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TRE  HISTORICAL  WORKS  of  the  Rev.  WIL- 
LIAM ROBERTSON,  D.D. ; comprising  his  HIS- 
TORY of  AM  ERICA ; CHARLES  V. ; SCOTLAND, 
and  INDIA.  In  3 vols.  8vo.  Embellished  with  Plates. 
vSlereolyped.) 

Harper’s  edition  of  these  valuable  standard  works  is  far  superior,  in 
every  respect,  to  any  other  edition  ever  published  in  this  country  ; and 
b to' be  preferred  to  Jones’s  University  edition,  ?s  the  type  is  larger, 
the  printing  and  paper  are  equally  good,  and  they  are  sold  for  leas 
than  the  cash  price  of  that  condensed  edition.  Each  volume  is  a 
separate  history  in  itself ; and  may  be  purchased  separately,  or  bound 
uniformly  with  the  other  volumes  in  sets. 

GIBBON’S  HISTORY  of  the  DECLINE  and 
FALL  of  the  ROMAN  EMPIRE.  In  4 vols.  8vo. 
With  Plates. 

Harper’s  edition  of  Gibbon’s  History  is  stereotyped,  and  great  care 
has  been  taken  to  reqder  it  correct  and  perfect.  The  dates.originally 
introduced  by  the  Author  are  preserved  in  the  Tables  of  Contents 
prefixed  to  the  Volumes,  and  also  imbodied  in  the  text.  This  vrill 
render  the  present  edition  decidedly  preferable  to  the  English  edition 
in  four  volumes,  as  in  the  latter  the  dates  aud  Tables  of  Contents  are 
entirely  omitted. 

THE  HISTORY  OF  MODERN  EUROPE  ; with  a 
View  of  the  Progress  of  Society,  from  the  Rise  of  the 
Modern  Kingdoms  to  the  Peace  of  Paris,  in  1763.  By 
William  Russell,  LL.D, ; and  from  the  Peace  of  Paris, 
in  1763,  to  the  Treaty  of  Amiens,  in  1802.  By  William 
Jones,  Esq.  In  3 vols.  8vo.  With  Engravings.  (Ste- 
reotyped. Uniform  with  the  works  of  Robertson  and 
Gibbon.) 

HOOPER’S  MEDICAL  DICTIONARY.  From 
the  last  London  Edition.  Witli  additions,  by  Samuel 
Akerly,  M.D.  8vo.  (Stereotyped.) 

In  order  to  render  this  stereotype  edition  of  Hooper’s  Medical  Dic- 
tionary more  accep  able  to  the  medical  public  of  the  United  States, 
considerable  ad.li'  have  been  made,  particularly  on  Materia 
Medica,  Mineralogj,  ilotany,  Chymistry,  Biography,  &c.  &c. 

GOOD'S  (Dr.  John  Mason)  STUDY  OF  MEDI- 
CINE. In  5 vols.  8vo.  A new  edition.  With  addi- 
tions by  Samuel  Cooper,  M.D. 

THE  BOOK  OF  NATURE ; being  a popular  Illus- 
tration of  the  general  Laws  and  Phenomena  of  Crea- 
tion, in  its  Unorganized  and  Organized,  its  Corporeal 
and  Mental  Departments.  By  John  Mason  Good,  M.D. 
and  F.R.S.  In  one  vol.  8vo.  (Stereotyped.) 

« —the  work  Is  certainly  the  best  philosophical  digest  of  the  kind 
which  we  have  seen.” — London  Monthly  Review. 

COOPER’S  DICTIONARY  of  PRACTICAL  SUR- 
GERY. Revised  and  Enlarged.  In  2 vols.  8vo. 
(Stereotyped.) 

BROWN’S  DICTIONARY  OF  THE  HOLY 
BIBLE.  From  the  last  genuine  Edinburgh  edition. 
Containing  the  Author’s  last  additions  and  corrections, 
and  further  enlarged  and  corrected  by  his  Sons;  with  a 
Life  of  the  Author ; and  an  Essay  on  the  Evidence  of 
Christianity.  Two  volumes  in  one,  8vo. 

A CONCORDANCE  to  the  HOLY  SCRIPTURES 
of  the  OLD  and  NEW  TESTAMENTS  ; by  the  Rev. 
’'ohii  Brown,  of  Haddington.  Printed  on  Diamond 
type,  in  the  32mo.  form.  (Stereotyped.) 

This  convenient  and  beautiful  little  pocket  volume  contains,  ver* 
batim,  the  same  as  the  original  duodecimo  edition. 

ENGLISH  SYNONYMES,  with  copious  Illustra- 
tions and  Explanations,  drawn  from  the  best  writers. 
By  George  Crahh,  M.A.  A new  Edition,  enlarged. 
0v().  (Stereotyped.) 

DOMESTIC  DUTIES;  or  Instructions  to  Young 
Married  Ladies,  on  the  Management  of  their  House- 
hold, and  the  Regulation  of  their  Conduct  in  the 
various  relations  and  duties  of  Married  Life.  By  Mrs. 
William  Parkks-  Fifth  American  from  the  last 
London  Edition,  with  Notes  and  Alterations  adapted 
to  the  American  Reader.  12mo.  (Stereotyped.) 

Dr.  Kitchiner’s  COOK’S  ORACLE  and  HOUSE- 
KEEPER’S MANUAL.  Containing  Receipts  for 
Cookery,  and  Directions  for  Carving,  &c..  &c. ; being 
the  Result  of  actual  Experiments' instituted  in  the 
Kitchen  of  William  Kitchiner,  M.D.  Adapted  to 
the  American  Public,  by  a Medical  Gentleman.  12mo. 
(Su-reotyped.) 


SERMONS  ON  IMPORTANT  SUBJECTS,  by  th« 
late  Rev.  and  pious  Samuel  Davies,  A.M.,  some  time 
President  of  the  College  of  New-Jersey.  To  which 
are  prefixed.  Memoirs  and  Character  of  the  Author ; 
and  two  Sermons  on  occasion  of  his  Death,  by  the 
Rev.  Drs.  Gibbon  and  Finley.  Fourth  American 
Edition, containing  all  the  Author’s  Sermons  overpaid 
lished.  In  3 vols.  8vo. 

ELEMENTS  OF  SURVEYING.  With  Copper- 
plate Engravings.  By  Charles  Davies,  Professor  of 
Matliematics,  U.  S.  Military  Academy.  8vo.  (The 
Tables  carefully  revised  and  stereotyped.) 

GIBSON’S  SURVEYING.  Improved  and  en- 
larged. ' By  James  Ryan,  Teacher  of  Mathematics, 
&c.  8vo. 

HISTORICAL  VIEW  of  the  LITERATURE  of 
the  SOU-BH  OP  EUROPE.  By  M.  De  Sismondi. 
Translated  from  the  Original,  with  Notes.  By  Thomas 
Roscoe,  Esq.  In  2 vols.  8vo. 

THE  WORKS  of  the  Rev.  JOHN  WESLEY,  A.M. 
With  his  LIFE.  Coinplele  in  10  vols.  8vo.  From  the 
last  London  Edition. 

WESLEY’S  MISCELLANEOUS  WORKS.  Con- 
taining his  Tracts,  Letters,  &c.  &c.  From  the  last 
London  Edition.  In  3 vols.  8vo. 

WESLEY’S  SERMONS  Containing  several  Ser- 
mons never  before  published  in  this  country.  In  3 vo- 
lumes. 8vo. 

THE  HISTORY  of  the  JEWS,  from  the  earliest 
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With  numerous  Maps  anu  Engravings.  In  3 vola 
18mo.  (Stereotyped.) 

THE  HISTORY  of  NAPOLEON  BUONAPARTE. 
With  numerous  Engravings.  In  2 vols.  18mo.  (Ste 
reotyped.) 

PELHAM;  or,  THE  ADVENTURES  OF  A GEN- 
TLEMAN. A Novel.  In  2 vols.  12mo.  (By  the  Au- 
thor of  “ The  Disowned,”  and  “ Devereux.”)  From 
the  second  London  Edition.  (Stereotyped.) 

THE  DISOWNED.  By  the  Author  of  “ Pelham,” 
and  “ Devereux.”  A Novel.  In  2 vols.  (Stereotyped.) 

DEVEREUX.  A Novel.  In  2 vols.  12mo  By  the 
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reotyped.) 

WAVERLEY ; or,  ’Tis  Sixty  Years  Since.  A 
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**•  Harper’s  stereotype  edition  of  Waverley  contains  upwards  of 
thirteen  thousand  words,  in  alterations  and  additions,  tort  in  say 
former  edition. 

LETTERS  FROM  THE  AEGEAN.  By  James 
Emerson,  Esq.  In  1 vol.  8vo. 

THE  LITERARY  REMAINS  OP  THE  LATE 
HENRY  NEELE,  Author  of  the  “ Romance  of  Hig- 
tory,”  See.  &c.— consisting  of  Lectures  on  English 
Poetry,  Tales,  and  otiier  Miscellaneous  Pieces  in  Prose 
and  Verse.  8vo. 

PRESENT  STATE  OF  CHRISTIANITY,  and  of 
the  Missionary  Establishments  for  its  Propagation,  in 
all  Parts  of  the  World.  Edited  by  Frederic  Scho- 
berl.  12mo. 

COMPLETE  WORKS  of  Dr.  SAMUEL  JOHN 
SON.  Comprising  the  Rambler — Idler— Rasselas — - 
Lives  of  the  Poets — Letters — Poems — Miscellanies, 
&c.  Witli  an  Essay  on  ins  Life  and  Genius,  by  Arthur 
Murphy,  Esq.  In  3 vols.  8vo.  [In  Press.] 

VAN  HALEN’S  NARRATIVE  of  his  Imprison 
ment  in  the  D’angeons  of  the  Inquisition,  his  Escape, 
his  Journey  to  Madrid,  &c.  &.c.  8vo. 

THE  REMINISCENCES  OF  THOMAS  DIBDIN. 
Author  of  the  “ Cabinet,”  <fec.  &c.  2 vols.  in  1.  8va 

THE  CONDITION  OF  GREECE,  in  1827  aiK 
By  J.  P.  Miller^  12mo. 

THE  RIVALS  OF  ESTE,  AND  OTHEP 
By  James  G.  Brooks  aud  Mary  K.  Brooks 


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THE  LIFE  OF  NELSON.  By  Robert  Southey, 
Esq.  18mo.  with  a Portrait.  (Stereotyped.) 

THE  LIFE  OF  ALEXANDER  THE  GREAT.  By 
Rev.  J.  Williams.  18mo.  with  a Map.  (Stereotyped.) 

, PAUL  CLIFFORD.  A Novel.  By  the  Author  of 
“ Pelham,”  &c.  In  2 vols.  12mo.  (Stereotyped.) 

O’NEIL.  A Poem.  With  several  Pieces  in  Prose. 
12mo.  (Stereotyped.) 

FALKLAND.  A Novel.  12mo.  By  the  Author  of 
“ Pelham,”  Ac.  (Steieotj-ped.) 

LIFE  OF  LORD  BYRON.  By  Thomas  Moore,  Esq. 
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LIVES  OF  THE  SIGNERS  of  iho  Declaration  of 
Independence.  By  N.  Dwight.  12mo.  (Stereotyped.) 

OVID  DELPHLNI,  and  SMART’S  HORACE.  Cor- 
rect Editions. 

THE  LIFE  and  REMAINS  of  Dr.  CLARKE.  8vo. 
An  inte-esting  and  useful  work. 

WALTER  COL YTON.  A Novel.  In  2 vols.  I2mo. 
By  the  Author  of  “ Brambletye  House,”  “ Zillah,”  Ac. 

THE  BARONY  A Novel.  In  2 vols.  12mo.  By 
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CLOUDESLEY.  A Novel.  In  2 vols.  12ma  By 
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DOOM  OF  DEVORGOIL;  and  AUCHINDRANE 
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THE  LOST  HEIR.  A Novel.  In  2 vols.  12mo. 
STORIES  OF  A BRIDE.  In  2 vols.  f2mo. 

THE  ENGLISH  AT  HOME.  A Novel.  In  2 vols. 
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‘ The  English  in  Fnince.” 

PERKIN  WARBECK.  A Novel.  In  2 vola  12mo. 
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APICIAN  MORSELS.  A Comical  Work.  With 
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THE  SUBALTERN’S  LOG  BOOK.  A NoveL  In 
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HAJJI  BABA.  A Novel.  In  2 vols.  12mo. 

DE  LISLE.  A Novel.  In  2 vols.  12mo. 

TRAITS  OF  TRAVEL.  A Novel.  In  2 vols.  12mo. 
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THE  NEW  FOREST.  A Novel.  In  2 vols.  12mo. 
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THE  LAST  OF  THE  PLANTAGENETS.  An 
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2 vols.  12mo. 

CO^^NG  OUT ; and  the  FIELD  OF  THE  FORTY 
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ROMANCES  OF  REAL  LIFE.  In  2 vols  12mo. 
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LAWRIE  TODD ; or.  The  Settlers  In  the  Wooo 
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tales  AND  SKETCHES.  By  a Country  School- 
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THE  EXCLUSIVES.  A Novel.  In  2 vols.  12ma 

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TALES  OF  A GRANDFATHER.  By  Sir  Walter 
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NEW  WORKS.— J.  & J.  Harpbr  are  publishing, 
weekly,  new  and  standard  works  by  the  best  authors, 
English  and  American.  Several  gentlemen,  of  high 
literary  acquirements  and  correct  taste,  having  been 
engaged  to  examine  all  new  works  as  they  emanate 
from  the  English  press,  and  also  such  original  works 
as  may  be  presented  in  manuscript,  the  public  may  rest 
assured  that  no  works  will  be  published  by  J.  A J.  H. 
but  such  as  are  Interesting,  instructive,  and  moral 


J.  Sc  J.  HARPER,  PRINTERS, 

Ab.  82  Clijffi-street,  JVew-Yorkf  have  recently  printed  for  the  Trade, 

GOOD’S  (Dr.  John  Mason)  STUDY  OF  MEDICINE.  In  5 vols.  8vo.  A 
new  edition  (Oct.  1829).  With  additions,  by  Samuel  Cooper,  M.D. 

“ Dr.  Good’s  extensive  reading  and  retentive  memory  enable  him  to  enliven  the  most  common  elementary  details,  by  interweav'ng 
cvious,  unconunon,  or  illustrative  examples  in  almost  eve^  page. — We  have  no  hesitation  in  pronouncing  the  work,  beyond  all  com 
parison,  the  best  of  the  kind  in  the  English  language.  With  the  naval,  the  military,  the  provincial,  and  the  colonial  practitioner,  the 
weife  before  us  ought  at  once  to  supersede  the  unscientific  compilation  of  Dr.  Thomas— and  it  will  do  so.”— Medico-Chirurg.  JievUvo. 

HOOPER’S  MEDICAL  DICTIONARY.  From  the  last  London  Edition. 
With  Additions,  by  Samuel  Akerly,  M.D.  In  2 vols.  8vo. 

In  order  to  render  this  ster.eotype  edition  of  Hooper’s  Medical  Dictionary  more  acceptable  to  the  medical  public  of  the  United 
States,  considerable  additions  have  been  made,  particularly  on  Materia  Medica,  Mineralogy,  Botany,  Chemistry,  Biography,  &c.  &c. 

THE  BOOK  OF  NATURE ; being-  a popular  Illustration  of  the  general 
Laws  and  Phenomena  of  Creation,  in  its  Unorganized  and  Organized,  its  Cor 
poreal  and  Mental  Departments.  By  John  Mason  Good,  M.D.  and  F.R.S. 
In  one  vol.  8vo. 

“ —the  work  is  ceitainly  the  best  philosophical  digest  of  the  kind  which  we  have  seen.”— London  Monthly  Review. 

THE  HISTORICAL  WORKS  of  the  Rev.  WILLIAM  ROBERTSON, 
D.D.;  comprising  his  HISTORY  of  AMERICA;  CHARLES  V.;  SCOT- 
LAND, and  INDIA.  In  3 vols.  8vo.  Embellished  with  Plates. 

H^er’s  edition  of  these  valuable  standard  works  is  far  superior,  in  every  respect,  to  any  other  edition  ever  published  in  this  country  . 
and  is  to  be  preferred  to  Jones’s  University  edition,  as  the  type  is  larger,  the  printing  and  paper  are  equally  good,  and  they  are  sold 
for  less  than  the  cash  price  of  that  condensed  edition.  Each  volume  is  a separate  history  in  itself ; and  may  be  purchased  separately,  or 
bound  uniformly  with  the  other  volumes  in  sets. 

GIBBON’S  HISTORY  of  the  DECLINE  and  FALL  of  the  ROMAN 
EMPIRE.  In  4 vols.  8vo.  With  Plates. 

H^er’s  edition  of  Gibbon’s  History  is  stereotyped,  and  great  care  has  been  taken  to  render  it  correct  and  perfect.  The  dates 
originally  introduced  by  the  author  are  preserved  in  the  Tables  of  Contents  prefixed  to  the  Volumes,  and  also  imbodied  in  the  text. 
This  wiU  render  the  present  edition  decidedly  preferable  to  the  English  edition  in  four  volumes,  as  in  the  latter  the  dates  and  Tables 
of  Contents  are  entirely  omitted. 

MOSHEIM’S  ECCLESIASTICAL  HISTORY.  A new  Edition,  in  which 
the  History  is  continued  down  to  the  Present  Time,  by  Charles  Coote,  LL.D. ; 
and  furnished  with  a Dissertation  on  the  State  of  the  Primitive  Church, by  the 
Rt.  Rev.  Dr.  Gleig,  of  Stirling.  In  4 vols.  8vo.  To  which  will  be  added, 
Historical  Sketches  of  the  various  religious  Societies  in  America. 

HISTORICAL  VIEW  of  the  LITERATURE  of  the  SOUTH  OF 
EUROPE.  By  M.  De  Sismondi.  Translated  from  the  Original,  with  Notes. 
By  Thomas  Roscoe,  Esq.  In  2 large  vols.  8vo. 

“ This  is  a valuable  and  interesting  work.  It  presents  a broad  and  general  view  of  the  rise  and  progress  of  modem  literature,  whlck 
will  be  read  by  those  who  are  uninformed  on  the  subject  with  equal  gratification  and  improvement.” — New  Times. 

ENGLISH  SYNONYMES,  with  copious  Illustrations  and  Explanations, 
drawn  from  the  best  Writers.  By  George  Crabb,  M.A.  From  the  last 
London  quarto  edition,  greatly  improved  and  enlarged.  8vo. 

ELEMENTS  OF  SURVEYING.  By  Charles  Davies,  Professor  ol 
Mathematics  U.  S.  Military  Academy.  Illustrated  by  nine  Copper-plate 
Engravings.  8vo. 

THE  HISTORY  OF  MODERN  EUROPE:  with  a View  of  the  Progress 
of  Society,  from  the  Rise  of  the  Modern  Kingdoms  to  the  Peace  of  Paris  in 
1763.  By  William  Russel,  LL.D.,  and  from  the  peace  of  Paris,  in  1763,  to 
the  treaty  of  Amiens  in  1802.  By  William  Jones.  In  3 vols.  8vo.  With 
Plates. 

THE  COMPLETE  WORKS  of  Dr.  SAMUEL  JOHNSON.  In  2 volt. 

8vo. 


RECOMMENDATIONS. 


The  Publishers  have  received  the  following  testimonials  from  the  only  pro- 
fessional gentlemen  to  whom  they  have  yet  had  an  opportunity  of  submitting 
this  American  edition : — 

To  Messrs.  J.  df  J.  Harper. 

Gentlemen, — We  have  e^jamined  your  new  and  accurate  edition  of  Cooper  s 
Surgical  Dictionary,  and  are  higlily  gratified  wdth  the  superiority  of  the  paper 
and  with  the  typographical  execution,  so  creditable  to  your  taste  and  libe- 
rality. 

The  numerous  arid  valuable  additions  of  our  fellow-practitioner.  Dr.  Reese  , 
embracing,  as  they  do,  most  of  the  surgical  improvements  which  have  originated 
in  our  country,  admirably  adapt  it  to  the  wants  and  wishes  of  American 
students ; who  will  find  all  the  greater  operations  performed  in  different  parts  of 
the  United  States,  suitably  noticed  in  the  body  of  the  work.  The  arduous  task 
of  condensing  so  much  practical  information  within  brief  limits,  has,  in  our 
opinion,  been  ably  and  impartially  performed,  and  entitle  Dr.  Reese  to  the 
thanks  of  the  profession. 

We  heartily  wish  you  success  in  the  laudable  efforts  you  are  making  to  ele- 
vate the  standard  of  American  literature  and  science ; and  hope,  that  so  far  as 
those  efforts  are  directed  to  our  department,  you  may  be  liberally  rewarded 
among  the  profession  by  extensive  patronage. 

DAVID  HOSACK,  M.D. 

President  of  Rutgers’  Medical  Faculty. 

VALENTINE  MOTT,  M.D. 

Professor  of  Surgery  in  Rutgers’  Medical  Faculty 

JOHN  WATTS,  JuN.  M.D. 

President  of  the  College  of  Physicians  and  Surgeons  for 
the  University  ofNew-York. 

JOHN  W.  FRANCIS,  M.D. 

Professor  of  Obstetrics  and  Forensic  Medicine  in 
Rutgers’  Medical  Faculty. 

DANIEL  L.  M.  PEIXOTTO,  M.D. 

President  of  the  Medical  Society  of  the  City  and 
County  of  New-York. 

New-York,  August  1830. 


The  sixth  edition  of  that  very  valuable  work,  entitled  Cooper’s  Surgical  Dic- 
tionary, has  been  reprinted  by  the  Messrs.  Harpers  in  a very  neat  and  accurate 
manner.  The  notes  by  Dr.  Reese  evince  great  research,  and  an  earnest  desire 
to  present  every  important  American  improvement  fairly  before  the  public. 
We  wish  them  success  in  their  undertaking,  and  cheerfully  recommend  the 
work  to  the  patronage  of  the  profession. 

ALEX.  H.  STEVENS,  M.D. 

Professor  of  Surgery  in  the  University  of  New-York. 

J.  AUGUSTINE  SMITH,  M.D. 

Professor  of  Anatomy,  &c.  in  the  College  of  Physicians 
and  Surgeons  for  the  University,  State  of  New-York. 


New-York,  August  21th,  1830. 


Harper^s  Stereotype  Edition^  uniform  with  Hooper^s  Medical  Dictionary. 


A 

DICTIONARY 

OF 

PRACTICAL  SURGERY: 

COMPREHENDING 

ALL  THE  MOST  INTERESTmO  IMPROVEMENTS,  FROM  THE  EARLIEST  TIMES  DOWN 
TO  THE  PRESENT  PERIOD;  AN  ACCOUNT  OF  THE  INSTRUMENTS 
AND  REMEDIES  EMPLOYED  IN  SURGERY  ; THE  ETY- 
MOLOGY AND  SIGNIFICATION  OF 

THE  PRINCIPAL  TERMS; 

AND 

NUMEROUS  REFERENCES  TO  ANCIENT  AND  MODERN  WORKS  : FORMING  A 
“CATALOGUE  RAISONNE”  OF  SURGICAL  LITERATURE. 

BY  SAMUEL.  COOPER, 

BVRQBON  TO  THE  KING’S  BENCH,  THE  BLOOMSBURY  DISPENSARY,  AND  HIS  MAJESTY’S  PRISON  OF  THE  FLEET 
MEMBER  OF  THE  COUNCIL  OF  THE  ROYAL  COLLEGE  OF  SURGEONS  IN  LONDON  ; SURGEON  TO 
THE  FORCES  ; HONORARY  MEMBER  OF  THE  ACADEMY  OF  NATURAL  SCIENCES 
AT  CATANIA  J THE  MEDICAL  SOCIETY  OF  MARSEILLES  ) &C. 


FROM  THE  SIXTH  LONDON  EDITION. 

REVISED,  CORRECTED,  AND  ENLARGED. 


WITH  NUMEROUS  NOTES  AND  -ADDITIONS, 

EMBRACING  ALL  THE  PRINCIPAL  IMPROVEMENTS  AND  GREATER  OPERATIONS 
INTRODUCED  AND  PERFORMED  BY  AMERICAN  SURGEONS. 

BY  DAVID  MEREDITH  REESE,  M.D. 

LICENTIATE  IN  SURGERY  AND  MIDWIFERY  ; HONORARY  MEMBER  OF  THE  MEDICAL  AND  CHIRURGICAL  FACULTY 
OF  MARYLAND,  AND  OF  THE  MEDICAL  SOCIETY  OP  MARYLAND  ; RESIDENT  FELLOW  OF  THE 
MEDICAL  AND  PHILOSOPHICAL  SOCIETY  OF  NEW'YORK  ; PRACTITIONER 
OF  PHYSIC  AND  SURGERY  IN  THE  CITY  OF  NKW-YORK,  &C. 


IN  TWO  VOLUMES. 

YOU.  I. 


NEW-YORK: 

PUBLISHED  BY  HARPER  & BROTHERS, 
NO.  82  CLIFF-STREET. 


1834. 


SODTHfiRN  DISTRICT  OF  JnCW-TORK,  i». 

Be  it  RE\tEMBERin),  That  on  the  16th  day  of  June,  A.  D.  1880,  in  fha  ISfW-fourth  year  of  the  independence  of  the  United  Staten 
of  America  J.  A J.  HARPl^I^  of  the  said  dittrict,  hare  deposit^  in  thia  office  the  title  of  a book,  the  right  whereof  they  claim 
ai  Proprietors,  in  the  words  following,  to  wit 

“ A Dictionary  of  Practical  Surgery . conaprehecding  all  the  most  interesting  ImprorementB)  from  the  earliest  times  down  to  the  preseo* 
period ; an  Account  of  the  Instruments  and  Remedies  employed  in  Surgery  ; the  Etymology  and  Signification  of  the  principal  Tejpi^s ; and 
numerous  References  to  ancient  and  modem  Works;  forming  a ‘ Caialogue  Raisonne’  of  surgical  Literature.  By  Samuel  Cooper,  Surgeon 
to  the  King's  Bench,  the  Bloomsbury  Dispensary,  and  his  Majestyts  Prison  of  the  Fleel ; Member  of  the  Conncil  of  the  Royal  College  of 
Surgeons  in  L/indoii ; Surge(>a  to  the  Forces : Honorary  Member  .of  the  Academy  of  Natural  Sciences  at  Catania,  the  Medical  Society  of 
Mai^illes ; Ac.  From  the  Sixth  I«ndon  Edition ; revised,  corrected,  and  enlarg^.  With  numerous  Notes  and  Additions,  embiasiOR  aK 
the  principal  Improvements  and  greater  Operations  introduced  and  performed  by  American  Surgeons.  By  David  Meredith  Reue,  M.^ 
Licentiate  in  Surgery  and  Midwifery  ; Honorary  Men  ber  of  the  Medical  and  Chirur^cal  Feculsy  of  Maryland,  aai  of  the  Medical  Soeid^ 
of  Maryland  ; Resident  Member  of  the  Medical  and  Philosophical  Society  of  New-Tork  j Practitioner  of  Physic  and  Surgery  in  the  city 
New-York,  Ac.-” 

In  conformity  to  the  Act  of  the  Congress  of  the  United  States,  entitled  An  Act  for  the  enooun^ement  of  Learning,  by  securing  the  ot^er 
of  maps,  chart^  and  books,  to  the  authors  and  proprietors  of  anch  copies,  during  the  times  therein  mentioned.”  And  also  to  an  Act,  entitles 
“ An  Act,  supplementary  to  an  Act.  entitled  an  Act  for  the  encouragement  or  Learning,  bx  securing  the  copies  of  maps,  charts,  and  book!,, 
to  the  authors  and  proprietors  of  such  copies,  during  the  times  thereu  mentioned,  and  extending  the  benefits  thereof  to  the  arts  of  designing, 
sngraviog,  and  etching  historicad  and  other  phnta  ” 

FREDERICK  J.  BETTS, 
Cletii  of  (Ac  ScnUhgm  Diitria  of  Ntw-'faiK 


PREFACE 


BY  THE  AMERICAN  EDITOR. 


The  exalted  reputation  acquired  by  this  Dictionary  having  obtained  for  it 
almost  exclusive  preference  in  Great  Britain,  on  the  Continent,  and  throughout 
the  United  States,  it  will  be  altogether  unnecessary  for  the  publishers  to  in- 
troduce the  work  or  its  distinguished  author  to  the  American  public  by 
any  new  testimonials.  Nor  will  it  be  expected  of  the  American  editor  to 
attempt  a laboured  commendation  of  this  compendium  of  surgical  literature, 
with  the  view  of  attracting  a larger  share  of  attention  from  the  profession  than 
it  has  already  received  in  its  former  publications  in  this  country.  It  has  long 
been  esteemed  a standard  work,  is  adopted  as  a text-book  in  our  universities, 
colleges,  and  schools  of  medicine  generally,  and  finds  a place  in  the  library 
of  every  surgeon  in  the  country. 

The  first  republication  in  this  country  was  edited  by  the  late  distinguished 
Dr.  Dorsey,  of  Philadelphia ; whose  valuable  improvements  carried  it  through 
a second  and  third  edition ; and  under  the  title  of  “ Dorsey’s  Cooper,”  it  rapidly 
gained  upon  public  favour.  The  author  availed  himself  of  most  of  the  Ameri- 
can additions  in  revising  his  -work  for  a fourth  edition,  from  which  it  was  again 
reprinted  in  America,  with  an  appendix,  by  Mr.  Wm.  Anderson,  of  New-York. 

Since  that  time,  Mr.  Cooper  has  published  a fifth,  and  recently  a sixth  edition, 
improving  and  enlarging  the  work  by  availing  himself  of  the  new  and  valuable 
discoveries  in  surgical  knowledge  to  which  he  has  access  ; and  from  this  last 
revision  of  1830,  the  present  stereotype  edition  is  republished.  And  as  it  has 
passed  through  two  revisions  by  the  author  since  it  was  printed  in  America, 
and  the  last  includes  all  that  is  novel  and  interesting  among  British  and  conti- 
nental surgeons  down  to  the  present  year  ; its  republication,  even  without  any 
semblance  of  improvement,  will  be  acknowledged  to  be  a desideratum  by  all 
who  would  keep  pace  with  their  improving  profession. 

As  in  eveiy^  species  of  human  science  our  highest  attainments  are  but  an 
approximation  towards  perfection,  so  in  the  science  of  surgery,  each  succeeding 
year  demonstrates  that  all  that  is  known  of  the  principles  or  practice  of  our 
art,  is  but  the  prelude  to  still  higher  exhibitions  of  science  and  skill,  alike 
honourable  to  the  profession,  and  valuable  to  the  cause  of  humanity.  To  con- 
'^ense  and  arrange  all  the  novel  and  interesting  facts  which  clinical  experience 
is  furnishing,  and  upon  which  alone  the  edifice  of  true  science  can  be  erected, 
is  a task  worthy  of  the  immense  labour  which  Mr.  Cooper  has  bestowed  on 
each  succeeding  reprint  of  his  Dictionary,  and  one  to  which  he  has  proved  him- 
self entirely  adequate.  The  extensive  and  multiplied  resources  to  which  he  has 
access,  furnish  him  with  facilities  possessed  by  few ; and  in  availing  himself  of 
these,  he  has  exhibited  an  industry,  and,  for  the  most  part,  an  impartiality, 
worthy  of  all  praise. 

A 2 


IV 


PREFACE. 


Within  the  last  few  years,  our  profession,  and  especially  the  department  of 
Chirurgery,  has  been  making  steady,  and  even  rapid  advances  in  almost  every 
country.  Many  diseases  forrnerly  among  the  opprobria  of  our  profession  have 
yielded  to  the  sciencea^  skill  of  modern  surgeons.  Besides  the  vast  improve 
ments  made  in  th^#^fe^ment  of  surgical  diseases,  operations  have  been  per- 
formed with  entire  success  for  the  relief  of  injuries,  but  a few  years  ago 
esteemed  irremediable  ; and  some  of  them  of  so  bold  and  difficult  a character,  that 
to  propose  them  would  have  been  a hazard  of  reputation  which  but  few  could 
have  then  survived. 

Learning  is  not  indigenous  to  any  country ; and  although  national  pride 
sometimes  prompts  to  exclusive  pretensions,  yet  the  history  of  surgery,  so  far 
as  this  is  concerned,  forbids  such  presumptuous  arrogance.  The  question, 
“ Who  hears  of  American  surgeons  ?”  is  no  longer  tauntingly  repeated  ; since 
the  discoveries  and  operations  of  some  of  them  have  extorted  a tribute  of  admi- 
ration from  almost  every  country  where  this  science  is  cultivated,  and  given  to 
their  names  professional  immortality.  In  this,  as  in  the  other  departments  of 
learning,  we  may  be  allowed  to  say,  without  the  imputation  of  vanity,  that  our 
countrymen  have  shown  to  demonstration,  that  when  the  tree  of  science  is  trans- 
planted across  the  Atlantic,  it  is  capable  of  taking  as  firm  a root  as  in  its  native 
soil. 

The  improvements  which  surgery  has  received  in  the  United  States,  and 
especially  within  a few  years,  although  highly  important  to  the  interests  of  the 
profession  and  to  the  cause  of  suffering  humanity,  are  far  from  being  generally 
known  even  in  our  own  country,  and  still  less  to  the  profession  abroad.  Our 
periodicals  containing  them  have  but  a limited  circulation,  and  local  views 
have  multiplied  their  number,  until  many  of  the  States,  and  most  of  our 
medical  institutions,  have  a vehicle  of  their  own ; thus  still  farther  contracting 
the  sphere  of  their  usefulness.  And  although  several  of  them  are  most  ably  con- 
ducted, and  are  adapted  to  general  circulation,  we  are  yet  without  the  advantages 
which  would  result  from  a periodical,  strictly  national,  in  which  the  whole  pro- 
fession might  combine  their  energies  for  the  promotion  of  science,  and  to  which 
all  might  have  free  and  equal  access. 

From  these  periodicals  our  European  brethren  obtain  their  information 
relative  to  the  state  and  progress  of  medical  and  surgical  science  among  us,  and 
some  of  them  never  find  their  way  either  into  Great  Britain,  France,  or  Ger- 
many. Hence  foreign  authors  are  so  often  charged  with  criminal  remissness 
in  their  notices  of  American  surgery.  But  when  we  advert  to  the  small  pro- 
portion of  the  surgical  improvements  of  this  country  which  have  ever  been 
published  at  all,  and  recollect  that  of  these  but  a few  are  ever  seen  by  our 
British  or  continental  brethren,  we  may  find  an  apology  for  much  of  the  neglect 
of  which  we  have  complained. 

That  there  has  been  a disposition  on  the  part  of  some  European  writers  to 
pass  over  in  silence  every  thing  American,  has  long  been  a subject  of  remon- 
strance ; and  in  relation  to  some  of  these,  there  is  doubtless  just  ground  of 
complaint.  How  far  Mr.  Cooper  will  be  found  in  the  same  condemnation  will 
be  estimated  by  those  who  peruse  the  present  edition,  and  who  will,  of  course, 
award  him  due  praise  for  so  much  as  he  has  said  of  American  surgery.  It 
is  difficult  to  believe  that  he  has  introduced  all  he  knew  on  this  subject,  and  it 
is  certain  that  he  might  have  known  much  more  equally  worthy  of  his  notice. 

In  preparing  the  present  edition  for  the  press,  the  publishers  have  desired  that 
it  might  include  all  that  is  novel  and  interesting  among  American  surgeons  ; and 


PREFACE. 


V 


have  committed  to  the  present  editor  the  task  of  collecting  and  arranging  the 
materials  furnished  by  our  periodicals  and  original  publications,  and  of  con- 
densing these  with  such  original  matter  as  he  might  be  able  to  obtain,  sufficiently 
important  to  merit  introduction  into  this  Dictionary. 

To  perform  this  duty  in  a manner  which  should  be  acceptable  to  the  profes- 
* sion  and  useful  to  the  community,  no  pains  or  labour  has  been  spared.  How 
far  he  has  succeeded  in  this  humble  task  of  compiling  from  the  productions 
of  his  fellow-countrymen  an  epitome  of  American  surgery,  remains  to  be  ad- 
judged by  those  for  whose  benefit  he  has  been  thus  employed.  He  claims  no 
merit  for  himself,  other  than  that  of  having  rendered,  as  far  as  possible,  equal  and 
exact  justice  to  the  claims  of  gentlemen  in  every  part  of  our  common  country, 
whether  living  or  dead ; and  for  this  purpose,  he  has  availed  himself  of  every 
accessible  means. 

He  has  corresponded  with  distinguished  surgeons  in  various  and  remote  parts 
of  the  land,  from  many  of  whom  he  has  received  communications  of  great 
merit  and  practical  importance.  To  the  periodicals  of  the  last  few  years  he 
has  had  frequent  recourse,  and  from  most  of  them  he  has  extracted  improve- 
ments and  inventions  which  cannot  fail  to  interest  and  instruct.  He  must  also 
acknowledge  his  obligations  to  Dr.  Gross’s  edition  of  Tavernier’s  Operative 
Surgery;  Dr.  Sterling’s  translation  of  Valpeau’s  Surgical  Anatomy  ; and  to  the 
late  Philadelphia  edition  of  Cooper’s  First  Lines,  with  notes  by  Professor 
Stevens,  of  New-York,  and  the  “ Philadelphia  Editor.” 

To  a number  of  his  professional  friends  in  New-York,  as  well  as  in  dis- 
tant parts  of  the  United  States,  the  editor  is  greatly  indebted,  not  only  for  the 
assistance  rendered,  but  for  the  encouragement  they  have  given  him  in  the 
performance  of  this  duty.  And  although  he  has  not  heard  from  some 
who  had  promised  communications,  yet  he  has  availed  himself  of  their  pub- 
lished works,  and  introduced  all  the  operations  they  claim,  so  far  as  his  limits 
would  permit. 

The  limits  assigned  him  by  the  publishers  for  enlarging  the  work,  have 
rendered  it  necessary  to  abbreviate  and  condense  many  new  and  important 
surgical  improvements  more  than  was  agreeable  to  his  own  wishes ; and  this 
must  be  his  apology  for  so  frequent  reference  to  the  works  and  periodicals  in 
which  they  are  recorded  at  length.  The  same  reason  will  account  for  the 
brevity  of  many  of  the  notes,  which  consist  of  mere  hints,  upon  which  some 
amplification  would  have  been  more  congenial  to  his  own  views,  and  perhaps 
more  acceptable  to  the  profession.  It  is  but  an  act  of  justice,  however,  on 
the  part  of  the  editor  towards  the  publishers  to  state,  that  they  have  sufiered 
him  to  transcend  their  limits  very  considerably,  and  allowed  him  a brief  ap- 
pendix for  the  purpose  of  introducing  some  articles  unavoidably  omitted  under 
their  appropriate  heads. 

It  will  be  perceived  by  those  who  have  the  opportunity  of  comparing  this 
with  the  late  London  edition,  as  revised  and  enlarged  by  the  author,  that  it 
contains  the  whole  of  the  matter  of  that  edition,  although  the  size  of  the  type 
has  somewhat  diminished  the  number  of  pages.  Although  many  of  the 
terms,  doctrines,  and  operations  are  now  obsolete,  and  might  very  plausibly 
be  omitted,  yet  as  Mr.  Cooper  has  seen  fit  to  retain  them,  it  has  been 
thought*  best  to  make  no  alteration  whatever  in  the  work,  and  hence  also 
the  long  catalogue  of  references  at  the  end  of  each  article  is  preserved, 
although  many  of  the  works  cannot  be  obtained  in  this  country. 

The  original  matter  introduced  by  the  American  editor  will  be  found  im-» 


vi 


PREFACE. 


bodied  in  the  text,  in  immediate  connexion  with  the  subject  to  which  it  refer  s, 
except  where  an  occasional  foot  note  for  obvious  reasons  has  been  preferred. 
To  distinguish  it  from  the  rest,  it  is  included  within  brackets,  and  at  the  close 
of  each  of  these  additions  will  be  found  the  surname  of  the  editor. 

This  method  of  making  mterpolations  in  the  body  of  the  work  may  ap- 
pear less  imposing  than  an  array  of  additions  in  an  appendix  at  the  end  of 
the  book,  or  a display  of  notes  at  the  foot  of  the  pages,  distinguished  by 
asterisks,  obelisks,  <fec. ; but  they  ^vill  certainly  be  found  niore  convenient 
to  the  student,  and  more  in  conformity  to  the  character  of  a dictionary.  It 
is  from  this  conviction  that  this  course  has  been  pursued  ; which,  it  is  hoped, 
will  be  satisfactory  to  the  profession. 

As  the  work  is  stereotyped,  it  will  be  necessary  in  future  editions  to 
enlarge  the  appendix,  which  can  be  done  to  any  desirable  extent,  and  the 
Dictionary  may  thus  keep  pace  with  the  steady  advancement  of  surgical 
knowledge  in  this  and  other  countries.  For  the  purpose  of  supplying  any' 
omissions  which  may  have  been  inadvertently  made,  it  is  intended  at  first  to 
publish  but  a small  edition,  sufficient  to  supply  the  present  demand,  and  any 
communications  from  American  surgeons  will  receive  respectful  notice  in  a 
future  edition,  by  being  included  in  the  appendix  at  the  close  of  the  second 
volume.  Such  communications  are  respectfully  solicited,  and  may  be  forwarded 
to  the  editor  without  delay. 

To  rescue  American  surgery  from  unmerited  neglect,  and  to  present  to  our 
transatlantic  brethren  a brief  epitome  of  what  is  doing  in  the  United  States  for 
the  promotion  and  improvement  of  surgical  science,  is  the  object  at  which  the 
editor  has  directed  this  effort.  That  his  task  has  been  imperfectly  performed 
he  is  fully  conscious,  nor  will  he  affect  to  conceal  his  own  misgivings  in  thus 
attempting  to  improve  upon  the  work  of  one  of  the  master-spirits  of  the  other 
hemisphere.  How  far  the  haste  with  which  the  work  has  been  hurried  through 
the  press,  to  supply  the  great  demand  which  is  every  where  felt  and  expressed, 
may  have  contributed  to  his  imperfections,  he  will  not  attempt  to  determine ; 
perhaps  his  inexperience  in  such  a vocation  may  be  more  plausibly  urged. 
His  design,  however,  is  now  completed ; and  he  submits  the  result  to  his  bre- 
thren in  the  profession,  and  to  students  of  this  noble  science,  with  po  other  wish 
than  that  it  may  contribute  to  elevate  our  national  character,  and  excite  to  the 
still  farther  cultivation  and  improvement  of  surgical  literature. 

DAVID  MEREDITH  REESE,  M.D, 


New-York,  August  22d,  1830. 


PREFACE 

TO  THE 

SIXTH  LONDON  EDITION. 


The  utility  of  this  Dictionary  to  students  and  all  classes  of  medical  practi- 
tioners, has  obtained  for  it  in  this  country  a larger  share  of  patronage  than  was 
perhaps  ever  conferred  upon  any  other  book  of  surgery ; while  its  translation 
into  the  French,  German,  Italian,  and  Russian  languages,  and  several  republi- 
cations of  it  in  America,  may  be  taken  as  proofs  of  its  being  deemed  worthy  of 
considerable  notice  in  various  other  parts  of  the  world.  At  Milan,  one  transla- 
tion of  it  was  produced  a few  years  ago  ; and  I learn  from  a letter,  with  which 
I have  lately  been  honoured  by  Dr.  Crescimbini,  president  of  the  Medico- 
Chirurgical  Society  of  Bologna,  that  he  is  preparing  another  Italian  translation, 
into  which  he  proposes  to  introduce  additional  subjects,  and  such  remarks  as 
are  founded  upon  his  own  researches  and  experience.  The  diligent  and  en- 
lightened Germans  were  not  only  the  first  to  undertake  and  complete  a transla- 
tion ; they  have  bestowed  still  greater  attention  upon  my  humble  endeavours  to 
promote  the  cultivation  and  diffusion  of  surgical  science ; for  they  have  fol- 
lowed up  their  translation  by  a series  of  well-executed  engravings,  expressly 
designed  to  illustrate  the  nature  of  the  diseases,  accidental  injuries,  and  curative 
metliods,  treated  of  in  this  Dictionary. — (See  Chirurgische  Kupfertafeln, 
Weimar,  1820 — 1829.)  Of  these  valuable  plates,  the  publication  of  which  I 
regard  as  an  honourable  compliment  to  my  surgical  labours,  nearly  fifty  numbers 
have  already  been  brought  out  at  an  extremely  moderate  price  ; and  it  is  with 
real  pleasure  that  I recommend  them  to  the  notice  of  every  surgeon  who  is  a 
German  scholar,  as  being  the  most  useful  collection  of  surgical  and  pathological 
plates  ever  offered  to  the  profession. 

In  preparing  this  edition,  which  is  enriched  with  an  account  of  all  the  latest 
improvements  in  surgery,  I have  conscientiously  endeavoured  to  deal  fairly  and 
impartially  with  every  individual  whose  name  I have  had  occasion  to  mention,  or 
whose  suggestions  form  subjects  of  consideration  in  the  ensuing  pages.  My  aim 
has  been  truth,  wherever  I could  find  her ; and  in  every  situation  where  any 
glimpse  of  her  beautiful  figure  presented  itself,  I have  ardently  courted  her,  re- 
gardless of  the  name,  school,  or  country  on  which  she  might  deign  to  shed  her 
glory.  By  steadily  adhering  to  this  principle ; by  zealously  marking  what  the 
book  of  nature  and  the  field  of  experience  unfolded ; by  renouncing  all  obse- 
quious submission  to  every  other  kind  of  authority ; and  by  taking  the  liberty  of 
sometimes  thinking  and  judging  for  myself ; I trust  that  the  most  likely  plan  has 
been  adopted  of  maintaining  the  character  of  this  book,  and  raising  my  own 
humble  reputation. 

According  to  my  usual  plan,  I subjoin  the  notice  of  a few  thmgs,  which  were  • 
either  inadvertently  omitted  in  the  articles  to  which  they  relate,  or  communi- 
cated to  me  after  such  articles  had  been  printed. 

[The  several  additions  which  follow  in  Mr.  Cooper’s  preface,  for  the  greater 
convenience  of  the  student  have  been  inserted  in  the  body  of  the  Dictionary, 
under  the  respective  articles  to  which  they  refer.  They  will  be  found  desig- 
nated by  the  abbreviation  Pref.  affixed  to  the  termination  of  each.] 


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SURGICAI.  DICTIONARY. 


ABD 

A BA.PTISTON.  (From  d,  priv.  and  Panr^uj,  im- 
mergo,  to  sink  under.)  Galen,  Fabricius  ab  Aqua- 
pendente,  and  especially  Scultetus,  in  his  Armamemta- 
riam  Chirurgicum,  so  denominate  the  crown  of  the 
trepan,  because  it  formerly  had  a conical  shape,  which 
kept  it  from  penetrating  the  cranium  too  rapidly, 
and  plunging  its  teeth  in  the  dura  mater  and  brain. 
While,  however,  it  is  admitted  by  modern  surgeons 
that  mischief  may  be  done  by  letting  the  saw  penetrate 
too  deeply,  they  do  not  find  it  necessary  to  obviate  the 
possibility  of  such  an  accident,  by  using  a conical  tre- 
pan, with  which  it  would  be  difficult  to  make  any  per- 
foration at  all ; but  they  guard  against  the  danger,  by 
observing  particular  rules  and  cautions  laid  down  in 
another  part  of  this  book.— (See  Trephine.) 

ABDOMEN.  The  Belly.  When  a surgeon  speaks 
of  the  cavity  of  the  abdomen,  he  confines  his  meaning 
to  the  space  included  witliin  the  bag  of  the  peritoneum. 
Hence,  neither  the  kidneys  nor  the  pelvis  viscera  are, 
strictly  speaking,  parts  of  the  abdomen. 

Anatomists  have  divided  the  abdomen  into  different 
regions,  the  terms  allotted  to  which  are  so  frequent  in 
the  language  of  surgical  books,  that  some  account  of 
them  in  this  Dictionary  seems  indispensable. 

The  middle  of  the  upper  pa^l  of  the  abdomen,  from 
the  ensiform  cartilage  as  low  down  as  a fine  drat^ 
directly  across  the  greatest  convexity  of  the  cartilages 
of  the  ribs,  is  called  the  epigastric  region. 

The  spaces  at  the  sides  of  the  epigastric  region  are 
termed  the  right  and  left  hypochondria  or  hypochon- 
driac regions. 

The  umbilical  region  extends  from  the  navel  up- 
wards to  the  line  forming  the  lower  boundary  of  the 
epigastric  region,  and  downwards  to  a line  drawn 
across  from  one  anterior  superior  spinous  process  to 
the  ileum  of  the  other. 

The  middle  space,  below  the  last  line,  down  to  the 
os  pubis,  is  named  the  hypogastric  region. 

The  parts  of  the  abdomen  situated  on  the  outside  of 
the  umbilical  region  to  the  right  and  left,  or  externally 
with  respect  to  two  perpendicular  lines  drawn  from 
the  greatest  convexities  of  the  cartilages  of  the  seventh 
true  ribs,  are  named  the  ilia  or  flanks.  On  each  side 
of  the  hypogastric  region  is  situated  the  inguinal  re- 
gion or  groin.  The  whole  of  the  back  part  of  the  ab- 
domen has  only  one  technical  appellation,  viz.  the  lum- 
bar region  or  loins. 

As  the  abdomen  is  the  frequent  situation  of  several 
important  surgical  diseases;  is  much  exposed  to 
wounds ; and  various  operations  on  different  parts  of 
it  are  often  indispensable ; it  claims  the  particular  no- 
tice of  every  practical  surgeon.  One  of  the  most  com- 
mon afflictions  to  which  mankind  are  subject,  is  that  in 
which  some  of  the  bowels  protrude.  This  disetise  is 
called  hernia,  and  ought  to  be  well  understood  by  every 
practitioner,  who,  however,  can  never  acquire  the  ne- 
cessary knowledge  without  being  minutely  acquainted 
with  the  anatomy  of  the  abdomen.  In  dropsical  cases 
it  is  frequently  proper  to  tap  the  abdomen ; and  this 
operation,  named  paracentesis,  simple  as  it  may  seem, 
requires  more  consideration  and  attention  to  the  ana- 
tomy of  the  parts  than  many  surgeons  bestow. — (See 
Hernia,  Paracentesis,  and  Wounds.) 

Abdomen,  Abscesses  of  the,  may  take  place  either 
within  the  cavity  of  the  belly,  or  at  some  point  of  its  cir- 
cumference, may  be  either  of  an  acute  or  chronic  nature. 
Women  are  generally  considered  more  liable  than  men 
to  abscesses  in  and  about  the  abdomen ; the  abscesses 
named  lumbar,  being  elsewhere  treated  of,  are  here  ex- 
cluded from  consideration.  Collections  of  purulent 
matter,  resembling  turbid  whey,  and  containing  whi- 
tish or  yellowish  flakes,  are  not  unfrequently  formed  in 


ABD 

the  cavity  of  the  peritoneum,  as  one  of  the  effects  of 
inflammation  accompanying  puerperal  fever.— (StoW, 
Rat.  Med.  t.  4,  p.  103  ; Lassus,  Pathologic  Chir.  t.  \,p 
137,  nouvelle  Mit.  8vo.  Paris,  1809.) 

In  lying-in  women,  abscesses  frequently  form  be- 
tween the  abdominal  muscles  and  the  peritoneum,  es- 
pecially just  above  the  groin.  They  are  cases  which 
have  been  very  correctly  described  by  Conradi.  Be- 
Ibre  the  integuments  project,  the  diagnosis  is  often 
attended  with  difficulty,  and  sometimes  an  obscurity 
prevails  several  weeks;  for  the  patients  seem  as  if 
affected  with  slight  colic  pains,  which  yield  to  com- 
mon treatment,  particularly  external  applications,  but 
soon  return.  Thus,  unless  the  vicinity  of  Poupart’s 
ligament  be  carefully  examined,  where  some  painful 
point,  hardness,  or  elevation  can  be  detected,  the  ab- 
scess may  remain  concealed  until  a large  prominence, 
or  the  extension  of  the  matter  down  the  thigh,  lame- 
ness, &c.,  makes  the  nature  of  the  case  completely  ma 
nifest.  As  the  peritoneum  adjoining  the  abscess  is 
always  thickened  by  the  preceding  inflammation,  Con- 
radi assures  us  that  there  is  no  danger  of  the  collection 
of  matter  bursting  inwards.  Some  abscesses,  indeed, 
have  been  so  enormous,  that  the  matter  actually 
pushed  the  viscera  out  of  their  places,  yet  all  this  hap- 
pened without  any  inward  bursting  of  the  disease. 
The  whole  danger  depends  upon  the  duration  of  the 
complaint  and  the  extent  to  which  the  matter  spreads. 
A timely  detection  of  the  nature  of  the  case,  the  use  of 
emollient  applications,  and  the  making  of  an  early  open- 
ing, generally  bring  the  disease  to  a speedy  and  favour- 
able termination. — (See  Arnemann's  Magazin  fur  die 
Wundarzneiwissenschqft,  b.  1,  p.  175, 8vo.  Gbtt.  1797.) 

Chronic  tumours  of  the  mesentery,  which  in  scrofu- 
lous children  sometimes  terminate  slowly  in  suppura- 
tion, and  diseases  of  the  ovary  and  other  abdominal 
viscera,  bringing  on  the  formation  of  matter,  are  often 
the  cause  of  purulent  extravasation,  great  emaciation, 
hectic  symptoms,  and  death.  . However,  sometimes 
salutary  adhesions  are  produced  between  the  viscera, 
by  which  means  an  OKtlet  is  obtained  for  the  matter 
through  the  bladder,  anus,  or  vagina.  Thus  (says 
Lassus)  in  the  case  of  a woman  who  had  had  for  a long 
while  pains  in  the  right  lumbar  region,  supposed  to 
proceed  from  suppuration  of  the  kidney,  because  pus 
was  voided  with  the  urine ; the  right  kidney  was  found 
after  death  in  the  natural  state ; but  there  was  an  ab- 
scess in  the  right  ovary,  which  was  adherent  to  the 
bladder,  into  which  the  pus  had  passed  through  an 
ulcerated  communication.  In  another  patient,  who 
had  voided  pus  by  the  anus,  the  right  kidney  was  sup- 
purated and  adherent  to  the  colon,  with  which  it  com- 
municated by  a preternatural  aperture.  For  many 
years  a woman  had  a hard  tumour  of  considerable 
size  in  the  abdomen : at  length  the  pain  of  it  became 
intolerable ; and  just  at  the  moment  when  her  death 
was  apprehended,  an  immense  quantity  of  pus  was  sud- 
denly discharged  from  the  vagina.  The  pain  abated ; the 
swelling  of  the  belly  subsided ; merely  the  remains  of 
the  induration  were  now  perceptible ; and  the  woman’s 
health  was  perfectly  re-established.— (Lossils,  Patho- 
logic Chir.  t.  \,p.  138.) 

The  abscesses  which  sometimes  form  between  the 
peritoneum  and  abdominal  muscles,  or  between  the 
layers  of  these  muscles,  or  under  the  integuments  of 
the  abdomen,  are  attended  with  considerable  variety, 
according  as  they  happen  to  be  chronic  or  acute,  cir- 
cumscribed or  diffused,  small  or  extensive.  Those 
of  the  acute  or  phlegmonous  kind,  sometimes  following 
stabs  and  contusions,  are  particularly  noticed  in  the 
article  Wounds.  They  are  cases  which  demand  es- 
1 pecial  care,  because  if  not  checked  they  may  prove 


iO 


ABDOMEN. 


fatal,  many  examples  of  wliich  arc  upon  record. — (Sec 
Cotumerc.  l^Uerar.  J^oric.  1741,  p.  100;  Eller,  Medic, 
and  Chir.  .^nvierkuvffen,  p.  108,  &c.)  As  for  chronic 
external  ab.scesses  of  the  abdomen,  they  should  be 
opened  early,  and  treated  on  the  principles  explained 
in  the  article  Lumbar  abscess. 

Hard,  indigestible  substances,  after  being  swallowed, 
are  not  unfrequently  discharged  from  abscesses  in  some 
of  the  abdominal  regions. — (See  De  l..a  Grange,  in 
Museum  der  HcUkunde,  b.  4,  p.  154  : a fish-bone,  which 
had  been  swallowed,  found  in  the  abscess  ; Petit,  Traili 
dc  Mai.  Chir.  t.  2,  ^.226  ; an  awl,  without  a handle,  ex- 
tracted from  an  abscess  of  the  abdomen ; and  many 
other  analogous  cases.) 

Encysted  tumours  are  sometimes  formed  between 
the  peritoneum  and  abdominal  muscles,  and  attain  an 
iinmense  size  before  they  burst ; a remarkable  specimen 
of  which  is  detailed  by  Gooch.— (CAir.  JVorks,  vol.  2, 
p.  144,  S,-c.  8vo.  Loud.  1792.;  In  this  case  the  sponta- 
neous opening  in  the  navel  was  enlarged  with  caustic, 
and  the  cyst  extracted ; but  before  a cure  could  be  ef 
fected  it  became  necessary  to  make  a depending  opening, 
and  introduce  a seton.  Swellings  of  this  nature,  how- 
ever, are  only  noticed  here  on  account  of  their  resem- 
blance to  circumscribed  chronic  abscesses  of  the  parie- 
les  of  the  abdomen. 

Abdomen,  pulsations  in  the.  From  the  article 
rism  the  reader  will  understand  that,  though  it  be  the 
common  nature  of  tliis  disease  to  be  attended  with 
throbbing,  it  is  not  everj'  jmlsating  tumour  that  is  an 
aneurism.  The  cases  usually  called  abdominal  or 
epigastric  ptdsations  often  furnish  a proof  of  the  cor- 
rectness of  the  preceding  remark.  'I'he  authors  who 
have  treated  of  the  latter  affection  with  the  greatest 
dLscrimination,  are  Dr.  Albers,  of  Hremeii,  and  Mr. 
Allan  Burns,  of  Glasgow,  two  gentlemen  whose  high 
reputation  and  useful  labours  will  long  survive  the  re- 
cent tenninatioii  of  their  meritorious  lives.  Some  of 
the  pulsations  here  referred  to  are  the  consequence  of 
organic  disease,  and  cajjable  of  demonstration  by  dissec- 
tion; while  the  rest  are  not  attended  with  any  such 
apiMjarance,  and  have  therefore  been  regarded  as  ner- 
vous. I'he  pulsation  is  not  always  produced  by  the 
impulse  communicated  to  some  solid  tumour  or  sub- 
stance between  the  hand  and  the  artery,  but  was  con- 
ceived by  Mr.  Burns  to  be  sometimes  dependent  on  a 
nervous  affection  of  the  vessel  itself. — (0«  the  Dis- 
eases of  the  Heart,  p.  263.)  Hippocrates,  in  his  book 
“ De  Morbis  I’opularibus,”  makes  mention  of  three 
patients  afi’ected  with  extraordinary  pulsations  in  the 
abdomen.  As  one  of  these  cases  seemed  to  depend 
ujion  obstructed  menses,  it  was  probably  not  the  re- 
sult of  any  organic  disease. — {Hippocratis  Opera  Om-  \ 
nia,  ex  edit.  Fwsii.  Francof.  1621,  lib.  5,  sect.l,  p.  1144.) 
In  order  to  remove  a difliculty  in  believing  how  an 
artery,  not  affected  with  aneurismal  enlargement,  can 
communicate  to  the  superincumbent  parts  such  move- 
ments as  are  frequently  remarked  in  cases  of  abdomi- 
nal pulsations,  a fact  pointed  out  by  Mr.  Hunter  shouid 
be  remembered  : in  speaking  of  the  actual  dilatation  of 
an  artery,  he  says,  that  when  the  vessel  is  “ covered 
by  the  integuments,  the  apparent  effect  is  much  greater 
than  it  really  is  in  the  artery  itself ; for  in  laying  such 
an  artery  bare,  the  nearer  we  come  to  it,  the  less  visi- 
ble is  its  pulsation ; and  when  laid  bare,  its  motion  is 
hardly  to  be  either  felt  or  seen.” — ( Treatise  on  the  Blood, 
6rc.  p.  1 /'S,  4to.  Lond.  1794.)  And  this  observation  will 
apply  to  all  tumours  and  indurations  situated  over  a 
large  artery.  In  the  epigastric  region  of  a certain  pa- 
tient Taberranus  felt  not  only  a pulsation,  but  a tumour 
as  large  as  the  fist,  with  all  the  other  usual  symptoms 
of  an  aneurism.  On  opening  the  body  after  death,  he 
was  therefore  surprised  to  find,  instead  of  this  disease, 
a considerable  scirrhous  tumour  in  the  middle  of  the 
mesentery,  so  closely  connected  to  the  large  vessels 
as  to  compress  the  aorta,  by  the  pulsations  of  which 
it  had  been  lifted  up.— ( Obs.  Anat.  ed.  2,  JVb.  9.) 

Dr.  Albers  quotes  an  extraordinary  case  from  Tul- 
pius ; the  patient,  a laborious  man,  but  subject  to  bi- 
lious attacks,  was  sometimes  affected  with  violent 
throbbings  of  the  spleen.  These  were  not  only  very 
painftil,  but  could  be  heard  at  a distance,  and  their 
number  distinctly  counted  when  the  hand  was  applied  to 
the  part.  What  seems  almost  incredible,  it  is  alleged 
that  Tulpius  could  hear  them  at  the  distance  of  thirty 
feet ! Their  violence  increased  or  diminished  accord- 
ing as  the  patient  was  more  or  less  bilious,  and  some- 


times they  entirely  ceased,  when  his  health  improved ; 
but  always  recurred  as  soon  as  the  chyloj>oietic  organs 
became  disordered  again.  After  the  patient’s  death, 
l)ermission  could  not  be  obtained  to  open  lus  body.— 

( Tulpii  Obs.  Medicee,  Arnst.  Um2,  lib.  2,  cap.  28.) 

According  to  Bonetus,  jmlsations  in  the  left  hypo- 
chondrium  are  not  unfrequent,  and  it  was  lus  belief 
that  they  were  produced  by  the  cmliac  artery.  He 
cites  several  cases  of  this  disorder  from  other  writers, 
the  tenour  of  wliich  is  to  prove  that  the  cceliac  artery 
and  mesenteric  vessels  must  have  been  affected,  as 
they  were  found  after  death  dilated  and  filled  with 
black  blood. — {Sepulchretum  Anatomicum,  lib.  1,  sect. 
9.  Obs.  9,  25,  27,  30, 38,  42,  44,  45,  and  46.,  The  conjec- 
ture of  Bonetus  and  others,  however,  respecting  the 
frequency  of  abdominal  pulsations  from  dilatation  of  the 
cteliac  and  mesenteric  arteries,  by  no  means  coincides 
with  the  results  of  modern  observations.  41r.  Wilson, 
whose  dissections  were  numerous,  met  with  only  one 
instance  of  true  aneurism  affecting  any  ofthe  branches  of 
the  aorta,  distributed  to  the  abdominal  viscera.  This 
case  was  an  aneurism  of  the  left  branch  of  the  hepatic 
artery. — (Lectures  on  the  Blood,  and  on  the  Anatomy, 
Physiology,  and  Surgical  Pathology  of  the  Vascular 
System,  S,-c.  p.  379,  8vo.  Lond.  1819.)  Bontius  was 
present  at  the  opening  of  an  inhabitant  of  Batavia, 
who  had  been  afflicted  three  years  with  a disease,  the 
exact  nature  of  which  could  never  be  made  out  during 
life.  When  the  hand  was  applied  above  or  below  the 
navel,  a pulsation  was  felt  like  that  of  the  heart  or  an 
artery,  and  as  forcible  as  the  motion  of  a child  in  the 
womb.  It  was  synclu-onous  to  the  pulsation  of  the 
heart  and  arteries.  Hence  Bontius. concluded,  that  the 
case  was  owing  to  sotne  affection  of  the  heart.  The 
vena  cava,  instead  of  containing  blood,  was  filled  with 
a medullary  substance,  which,  pressing  against  the 
aorta,  is  supposed  to  have  excited  the  extraordinary 
pulsa  ions  in  that  vessel.  The  heart  was  unusually 
dilated  and  flabby.  The  txvo  ventricles  were  very 
large,  and  filled  with  dark-coloured  blood.  The  liver 
was  of  nearly  twice  its  natural  size.  The  gall-bladder 
resembled  that  of  a bullock,  and  was  filled  with  viscid 
bile  nearly  as  thick  as  an  extract. — (Jacobi  Bontii  de 
Medicina  Indorum,  libri  4,  Lugd.  1718,  Obs.  8,  p.  101.) 

Lewenhoek  met  with  an  instance  of  a similar  pulsa- 
tion, which  he  imputed  to  irregular  action  of  the  dia- 
phragm, the  pulse  at  the  wrist  not  being  affected.  The 
disorder  lasted  three  days,  during  winch  the  functions 
of  the  alimentary  canal  were  so  much  disordered  that 
the  patient  was  expected  to  die. — (Philosoph.  Trans, 
from  1719  to  1733,  abr.  by  J.  Fames,  iS-c.  Lond.  1734, 
vol.  7,  p.  683.) 

j Dr.  Albers  has  described  the  particulars  of  a case 
recorded  by  Burggraf,  and  entitled  “ Diuturna,  magna, 
et  valde  molesta  pulsatio  in  epigastrio.” — ( Vid.  Acta 
Matur.  Cur.  JVorirnb.  1740,  vol.  6,  Obs.  131.)  Burg- 
graf gives  his  reasons  for  believing  that  in  this  in- 
stance, the  pulsation  arose  neither  from  the  aorta  nor 
from  the  cccliac  artery ; and  suspects  that  it  was  caused 
by  a dilatation  of  that  considerable  branch  of  the  in- 
ferior mesenteric  artery,  which  inosculates  with  the 
branch  of  the  superior  mesenteric.  This  idea,  how- 
ever, which  was  merely  surmise,  could  not  be  correct, 
as  the  patient  was  cured  by  taking,  every  morning  and 
evening,  half  a drachm  of  a mass  composed  of  equal 
parts  of  gum  ammoniac,  extr.  centaur,  minor,  and 
Venice  soap. 

In  an  example  recorded  by  Stork,  the  symptoms  were 
found  to  have  arisen  from  disease  of  the  pancreas,  which 
weighed  thirteen  pounds,  and  contained  a large  cyst 
filled  with  lamellated  blood. — (Annus  Medicus,  Vin- 
dob.  1760,  p.  245.) 

■ The  subsequent  case  somewhat  analogous  to  the 
former,  is  from  a different  author. 

A man,  aged  60,  complained  of  pain  in  the  left  side 
of  the  abdomen,  midway  between  the  umbilicus  and 
crista  of  the  ileum.  Emaciation,  weakness,  distress 
of  countenance,  anorexia,  constipation  succeeded  At 
length  a large  pulsating  tumour  was  discovered  in  the 
epigastric  region.  The  case  was  now  pronounced 
aneurism  of  the  abdominal  aorta.  There  was  no 
nausea  nor  vomiting,  except  that  some  days  before 
death  a quantity  of  fetid  blacKish  fluid  was  twice  or 
thrice  voided.  J^To  fever.  The  swelling  caused  a sense 
of  constriction  rather  than  pain,  and  the  throbbings 
became  more  perceptible.  The  pulse  was  feeble,  but 
slow  and  regtdar.  After  death,  the  stomach  was  found 


ABDOiMEN. 


11 


adhering  to  the  liver,  pancreas,  and  abdomen ; and  a 
cancerous  tumour  occupying  its  internal  surface  from 
the  duodenum  to  the  insertion  of  the  oesophagus,  the 
coats  of  the  stomach  being  an  inch  thick.  The  sur- 
face of  the  pancreas  was  also  diseased,  and  the  pylorus, 
situated  in  the  midst  of  the  cancerous  mass,  was  con- 
tracted by  the  thickening  of  the  parietes  of  the  stomach, 
and  obstructed  by  numerous  fungi.  The  liver  was 
large,  but  apparently  sound ; the  spleen  small.  The 
aorta.)  the  caliac  trunk)  and  its  branches,  were  quite  na~ 
turaZ.— (See  Journ.  de  Med.  per  Leroux,  Oct.  1815,  and 
Medico-Chir.  Journ.  vol.  1,  p.  289.) 

Morgagni  describes  the  case  of  a woman  44  years  of 
age,  who,  after  a simpression  of  the  menses  for  some 
months,  was  attaclred  with  palpitations  in  the  epigas- 
trium. Morgagni,  on  applying  his  hand  to  the  part, 
felt  a large  hard  body  moving  forcibly.  At  first,  it  was 
regarded  as  an  aneurism  in  the  abdomen ; but,  as  there 
were  no  similar  throbbings  in  the  chest,  and  there  was 
nothing  extraordinary  in  the  pulse  at  the  wrists,  Mor- 
gagni concluded  that  the  movements  in  question  could 
not  depend  upon  the  heart.  Neither  did  he  take  the 
disease  for  an  aneurism,  because  the  throbbings  did 
not  correspond  to  the  pulse.  As  for  the  large  indurated 
mass,  it  appeared  to  him  more  easy  to  say  what  it  was 
not,  than  what  it  was  : it  could  not  be  merely  a globus 
hystericus,  which  never  beats  like  an  aneurism.  Mor- 
gagni (ionsidered  the  case  as  an  hysterical  spasmodic 
complaint,  ordered  the  patient  to  be  bled,  and  the  fol- 
lowing day  the  pulsations  ceased. — {Morgagni,  de 
Sedibus  et  Causis  Morborum,  t.  2,  Epist.  39.  18.) 

Senac  has  spoken  of  these  abdominal  pulsations  as 
occurring  in  hypochondriacal  and  chlorotic  patients ; 
and,  as  they  frequently  subside  without  leaving  any 
vestige  behind,  he  sets  them  down  as  nervous  affec- 
tions.— ( Traiti  des  Mai.  da  Cceur.)  De  Haen  had 
under  his  care  a hypochondriacal  patient,  affected  with 
pulsations  in  the  abdomen ; which,  with  other  com- 
plaints, were  dispelled  by  means  of  brisk  opening 
medicines. — {Heilungs  Methode,  iibersetzt  von  Platt- 
ner,  Leipz.  1782,  b.  2,  s.  29.) 

Thilenius  observed  a flatulence  of  the  stomach,  which 
he  represents  as  having  been  epidemic,  and  attended, 
in  some  patients,  with  pulsations  at  the  scrobiculus 
cordis. — {Med.  Chir.  Bemerk.  Frankf.  1789,  s.  211—217.) 
My  friend  Mr.  Hodgson,  also,  in  speaking  of  pulsa- 
tions in  the  epigastrium,  which  are  not  the  consequence 
of  organic  disease,  and  occur  in  irritable  hypochondriac 
subjects,  states  his  opinion,  that,  in  some  instances, 
these  pulsations  were  a consequence  of  distention  of 
the  stomach  with  air,  which  was  thrown  against  the 
abdominal  muscles  by  the  pulsation  of  the  great  blood- 
vessels ; and  in  such  cases,  the  throbbing  was  dimi- 
nished by  the  eructations. — {On  the  Diseases  of  Arte- 
ries and  Veins,  p.  96.) 

Abdominal  pulsations  are  also  described  by  Zidiani, 
as  a symptom  of  hypochondriasis  and  hysteria. — {De 
Apoplezia,  JJps.  1790,  p.  79.)  They  also  happen  in 
certain  ferbrile  diseases. — {Versuch  iiber  den  Pemphy- 
gus und  das  BlasevJieber,von  C.  O.  C.  Braune,  I^eipz. 
1795,  s.  23;  and  Dr.  R.  Jackson  on  the  E'evers  of 
Jamaica,  8vo.  Fond.  1791.) 

In  a dissertation  on  cramp  in  the  stomach,  Haii  re- 
marks, “ Quin  immo,  ubi  diutius  vexavit  gastrodynia, 
continues  tegrotans  persentit  spasmos,  ut  et  baud  rare 
pulsationem  quandam  plane  singularem,  in  cardia  et 
ventriculo,  pulsui  autem  cordis  minime  synchrone.” — 
(Diss.  de  Gastrodynia,  Upsal,  1797.)  In  the  same 
essay,  there  is  an  account  of  a man,  who  had  violent 
palpitations  in  the  epigastric  region,  apparently  first 
excited  by  the  larvae  of  the  musca  pendula,  many  of 
which  were  vomited  up. 

Pinel  is  another  vmter  who  describes  these  abdo- 
minal pulsations  as  an  occasional  symptom  of  hypo- 
chondriasis. “Palpitations  du  cceur,  et  quelquefois 
une  sorte  de  pulsation  irreguliere,  dans  quelque  partie 
de  I’abdornen.” — {JToeographie  Philosophique,  t.  2,  p. 
25,  Paris,  an.  6.) 

Dr.  Albers  details  some  cases  which  fell  under  his 
own  notice.  A young  woman,  whose  menses  were 
upon  her,  and  who  had  been  for  some  days  constipated, 
was  seized  with  frequent  fainting  fits  and  febrile 
symptoms,  occasionally  voiding  from  the  bowels  a 
quantity  of  dark  matter,  each  evacuation  of  which  was 
followed  by  a swoon.  One  morning  at  five  o’clock 
Dr.  Albers  was  sent  for,  as  it  was  feared  the  patient 
was  about  to  die.  She  was  extremely  exhausted,  and 


the  fainting  fits  followed  each  other  with  hardly  any 
intervals.  She  could  just  say  “ I feel  a throbbing  in 
the  belly and,  when  Dr.  Albers  applied  his  hand  to 
the  part,  he  felt  a violent  pulsation  extending  from  the 
ensifonn  cartilage  down  to  about  the  bifurcation  of  the 
aorta.  The  action  of  the  heart  was  weaker  than  na- 
tural ; the  pulse  at  the  wrist  very  small,  but  not  quicker 
than  it  had  been  on  the  preceding  day,  and  not  synchro- 
nous to  the  throbbing  in  the  abdomen.  Dr.  Albers 
confesses,  that,  at  first,  he  took  the  case  for  an  aneu- 
rism. Dr.  Meyerhoflf  was  of  the  same  opinion.  An- 
other physician,  however.  Dr.  Weinholt,  entertained 
doubts  of  the  complaint  being  aneurismal,  saying,  that 
he  recollected  having  read  similar  cases  in  Morgagni. 
These  gentlemen  decided  to  persevere  in  the  employ- 
ment of  opening  medicines  and  clysters,  combining 
opium  with  the  former.  Under  this  plan,  the  pulsa- 
tions in  the  abdomen  and  tightness  of  the  chest  dimi- 
nished in  a few  days.  The  stools  were  at  first  of  the 
colour  of  chocolate,  but  afterward  resumed  their  natu- 
ral appearance.  The  throbbings,  in  a weakened  form, 
however,  were  perceptible  for  six  weeks  longer.  The 
patient  at  length  got  qiiite  well,  and  was  remaining  so 
four  years  afterward. 

A man  about  40,  severely  afflicted  with  hypochon- 
driasis, great  opi)ression  of  the  chest,  constipation,  and 
tension  of  the  abdomen,  tendency  to  fainting,  &c., 
complained  to  Dr.  Albers  that  he  felt  as  if  his  heart 
had  fallen  down  into  his  belly,  where  he  was  annoyed 
with  an  incessant  throbbing.  Indeed,  when  Dr.  Al- 
bers examined  the  abdominal  parietes  he  could  feel  a 
very  strong  pulsation,  and,  what  is  curious,  could  trace 
it  not  only  along  the  track  of  the  aorta,  but  in  the  course 
of  the  left  iliac  artery.  The  pulse  at  tire  wrist,  which 
was  small,  freejuent,  and  hard,  did  not  correspond  with 
the  abdominal  pulsations.  For  several  days  the  evacua- 
tions from  the  bowels  had  been  as  black  as  pitch. 
After  the  employment  of  gentle  purgatives,  all  the 
complaints  quickly  abated,  though  the  throbbings  were 
feebly  perceptible  for  nine  months  afterward. 

The  next  case  which  Dr.  Albers  met  with  is  very 
interesting.  A robust  sailor,  whose  bowels  were  so 
constipated,  that  hardly  the  strongest  purgative  could 
affect  them,  was  seized  with  constant  pain  in  the  left 
hypochondrium.  With  this  complaint  was  soon  joined 
great  pain  in  the  back,  and  a sensation  as  if  something 
alive  moved  about  in  the  belly  from  one  side  to  the 
other,  and  thence  extended  up  to  the  neck,  followed  by 
the  vomiting  of  a greenish  matter.  At  the  same  time, 
he  felt  in  the  left  side  a pulsation  which  he  took  for 
that  of  the  heart,  and  which  continued  the  whole  of 
his  illness.  The  pulse  at  the  wrist  was  natural,  and 
synchronous  with  that  in  the  abdomen.  In  <the  begin- 
ning of  the  disorder,  the  patient  was  obliged  to  sit  with 
his  body  very  much  inclined  forwards,  as  no  other  pos- 
ture could  be  endured.  For  the  first  week  opening 
medicines  afforded  so  much  relief,  that  he  was  some- 
times quite  free  from  pain  for  six  or  eight  hours.  After 
a time,  a round  swelling  formed  in  the  left  hypochon- 
driuin,  reached  to  the  navel,  and  attained  with  incre- 
dible quickness  the  size  of  a child’s  head.  Indeed,  it 
could  now  be  traced  beyond  the  umbilicus  to  the  right 
side.  The  motions  were  quite  of  a dark  colour,  or 
else  red  blood  and  a puriform  matter  were  discharged. 
Sometimes  the  blood  voided  was  of  a bright  red  colour, 
sometimes  it  was  dark,  coagulated,  and  mixed  with  bile. 
The  patient  was  at  length  worn  out  with  febrile  symp- 
toms, and  died.  On  opening  the  body.  Dr.  Albers  found  a 
swelling  in  the  middle  of  the  mesentery,  tjie  texture 
of  which  cannot  be  easily  described,  and  the  circumfe- 
rence of  which  was  16  French  inche.s.  The  stomach 
was  filled  with  coagulated  blood.  The  spleen,  pan- 
creas, and  liver  were  sound ; but  the  gall-bladder  was 
of  prodigious  size,  acid  contained  thick  viscid  bile.  The 
arteria  cceliaca,  arteria  coronaria  ventriculi,  and  the 
arteria  mesenterica  were  preternaturally  dilated,  and 
full  of  dark-coloured  blood.  He  speaks  of  them,  how- 
ever, only  as  being  in  an  enlarged,  not  an  aneurismal 
state  Dr.  Albers  thinks  it  highly  probable,  that  it  was 
one  of  these  vessels  by  wlrich  the  pulsations  had  been 
occasioned. 

Dr.  Albers  has  also  seen  these  abdominal  pulsations 
in  a paralytic  female ; and  in  a lunatic,  who  was  after- 
ward seized  with  apoplexy.  He  likewise  met  with 
a married  woman,  the  mother  of  several  children,  in 
whom  these  throbbings  took  place  invariably  at  the 
cpnunencement  of  proitoancy,  and  were  a surer  sign 


ABD 


ABS 


of  tlua  state,  tUau  other  common  effects,  as  stoppage 
of  the  menses,  <fcc.  After  the  third  mouth,  however, 
ttiey  used  to  cease  altogether. 

Many  valuable  practical  observations  on  cases  at- 
tende<l  with  hemorrliages  from  the  intestinal  canal,  my 
limits  here  oblige  me  to  pass  over.  According  to  Dr. 
Albers,  hemorrhoidal  patients,  especially  when  put  to 
inconvenience  by  compression  of  the  tumours,  often 
complain  of  throbbings  about  the  spleen,  which  are 
plain  even  to  the  hand. — (J.  F.  Albers,  Uber  Fulsa- 
tionen  im  Unterleibe,  8vo.  Bremen,  18tW.) 

Dr.  Parry  makes  a few  interesting  remarks  on  such 
abdominal  pulsations  as  excite  suspicion  of  aneurism. 
In  any  pensons  not  very  fat,  and  lying  upon  their  backs, 
he  says,  the  pulse  of  the  aorta  can  easily  be  felt,  if 
strong  pressure  be  made  a little  to  the  left  of  the  me- 
dian line,  about  half  way  between  the  navel  and  scro- 
biculus  cordis.  In  cenain  instances,  the  pulsation  is 
painfully  felt  by  the  patient  himself.  In  many  cases 
of  this  kind,  particularly  in  nervous  individuals,  the 
sense  of  pulsation  is  merely  the  effect  of  preternatural 
action  ol'  the  heart.  While,  in  other  examples,  it  is 
the  effect  of  the  pressure  of  some  hard  substance  upon 
llie  descending  aorta,  determining  a disproportionate 
quantity  of  blood  to  the  head,  “and  giving  to  the  hand 
placed  on  the  abdomen,  and  sometimes  even  to  the 
eye,  the  appearance  of  a beating  so  near  the  surface, 
as  to  lead  inexperienced  observers  to  conclude,  that 
the  aorta  is  morbidly  dilated.”  According  to  Dr.  Parry, 
the  most  common  causes  are  collections  of  feces  in 
the  colon,  requiring  repeated  and  active  purgatives, 
which  must  bring  away  almost  incredible  discharges 
of  stercoraceous  matter  before  the  aortal  pulsation  sub- 
sides.— (See  Parry's  Elements  of  Pathology,  (^c.  and 
fhe  Medico  Chir.  Joum.  and  Review,  vol.  1,  p.  157.) 

Another  cause  of  a temporary  appearance  of  pulsa- 
tion or  movement  in  the  abdomen,  not  mentioned  by 
any  of  the  preceding  authors,  is  the  power  which  some 
persons  have  of  putting  portions  of  the  recti  muscles 
separately  into  strong  convulsive  action.  1 have  seen 
a large  abocss  of  the  loins  attetided  w'ith  distinct 
and  forcible  pulsations,  corresponding  to  those  of  the 
aorta. 

According  to  Mr.  Allan  Bums,  a beating  is  generally 
felt  about  the  pit  of  the  stomach,  in  the  advanced  stage 
of  chronic  inflammation  of  the  heart : in  this  case,  when 
the  pericardium  is  closely  adherent  to  the  latter  organ, 
it  is  corrugated  at  every  contraction  of  the  ventricles, 
and  the  diaphragm  and  liver  are  elevated.  The  ven- 
tricle, however,  having  completely  emptied  itself,  is 
again  distended,  and,  in  proportion  to  the  degree  of 
dilatation,  the  liver  and  diapliragm  descend,  whereby 
an  impulse  is  communicated  in  the  epigastric  region. — 
(On  Diseases  of  the  Heart,  p.  263.)  This  valuable 
writer  cites  the  remark  of  Morgagni  {Papist.  17,  art.  28), 
that  sometimes,  in  dilatation  of  the  heart,  this  organ 
descends  so  far  as  to  push  the  diaphragm  into  the 
Jiypochondrium,  and  pulsate  in  that  situation,  so  that 
the  disease  is  mistaken  for  an  aneurism  of  the  cceliac 
artery.  In  Mr.  Bums’s  work,  a memorable  case  of  this 
description  is  related.  An  erroneous  judgment  is  the 
more  likely  to  be  formed  in  such  examples,  because 
the  pulsations  of  the  heart  and  tumour  are  not  exactly 
simultaneous;  for  it  is  not  the  heart  which  is  felt 
directly  beating,  but  the  liver,  which,  by  the  action 
of  the  heart,  is  thrown  forwards.  Hence  the  palpable 
interval  between  the  stroke  of  the  hetirt  and  the  move- 
ment of  the  liver. 

The  following  fact  shows  how  circumspect  a practi- 
tioner should  be  in  the  prognosis.  An  anonymous 
writer  informs  us,  that  he  attended  a gentleman,  in 
consultation  with  an  eminent  surgeon  and  lecturer  on 
anatomy,  where  the  most  distressing  palpitations  of 
the  heart,  and  loGd  pulsations  below  the  epigastrium, 
were  awful  symptoms.  The  pulsations  could  be  both 
seen  and  heard  at  a distance  on  entering  the  room  in 
which  the  patient  sat.  Several  physicians  were  in- 
clined to  suspect  some  organic  lesion  of  the  arterial 
system ; but  their  opinion  was  given  with  becoming 
diffidence : — not  so  the  surgeon’s ; his  impression  was, 
that  there  existed  an  aneurism  of  the  descending  aorta ; 
and  such  was  the  firm  persuasion  he  had  acquired  of 
the  reality  of  his  impression,  that  he  could  grasp  the 
aneurismal  sac  through  the  abdominal  coverings,  though 
nobody  else  could,  and  trace  its  magnitude  and  posi- 
tion. After  death,  the  heart  was  found  enlarged,  and 
its  left  ventricle  of  enormous  size.  The  inner  surface 


of  the  stomach  also  exhibited  traces  of  long  existing 
disease;  but  the  aorta  was  quite  sound. — ^See  Med. 
Intelligencer,  1821,  p.  71.) 

Preternatural  pulsation  about  the  epigastrium  is  also 
stated  by  Mr.  A.  Burns  to  be  sometimes  occasioned  by 
encysted  tumours,  attached  either  to  the  lower  surface 
of  the  diapliragm,  or  formed  between  the  layers  of  the 
pericardium  towards  the  diaphragm,  as  happened  in 
an  instance  recorded  by  Lancisi. 

Another  cause  specified  by  Mr.  A.  Burns,  is  enlarge- 
ment of  the  vena  cava,  or  of  the  right  auricle  of  the 
heart.  Senac  describes  a case  in  which  the  vena  cava 
w'as  as  large  as  the  arm,  and  there  had  been  a violent 
pulsation  in  the  epigastrium. 

The  next  cause  enumerated  by  the  same  gentleman 
is  increased  solidity  of  the  lungs,  more  especially  of 
their  lower  acute  margins,  where  they  overlap  the  peri- 
cardium. In  this  case  the  pulsation  is  about  the  scro 
biculus  cordis. 

Mr.  A.  Burns  likewise  notices  several  other  causes 
of  epig:astric  or  abdominal  pulsatiofis,  already  illus- 
trated in  the  foregoing  part  of  this  article,  indurations 
of  the  pancreas,  scirrhus  of  the  pylorus,  tumours  in  the 
mesentery,  or  any  solid  increase  of  substance  about 
the  abdominal  aorta,  or  its  principal  branches ; and, 
lastly,  a peculiar  affection  of  the  vascular  system  itself. 

The  following  observations  on  the  criteria  between 
various  abdominal  pulsations  and  those  of  aneurism, 
appear  interesting. 

According  to  Dr.  Albers,  an  internal  aneurism  origi- 
nates gradually,  and  the  pulsations  increase  in  strength 
by  degrees.  Other  abdominal  pulsations,  on  the 
contrary,  begin  suddenly,  and  are  most  violent  in 
the  beginning,  abating  after  they  have  lasted  some  time 

In  an  aneurism,  the  pulsation  is  synchronous  with 
the  stroke  of  the  artery  at  the  vvrist ; but  this  is  not  regu- 
larly the  case  wdth  other  pulsations. 

Should  the  patient  be  affected  with  melancholia, 
hypochondriasis,  hysteria,  or  other  nervous  complaintSv 
void  blood  from  the  stomach,  or  a black  matter 
from  the  bowels;  should  there  be  any  hardness  or 
swelling  of  any  of  the  abdominal  viscera  discoverable 
by  the  touch,  the  probability  is,  that  the  pulsations  are 
not  owing  to  an  internal  aneurism. 

With  the  exception  of  cases  in  which  these  pulsar 
tions  are  owing  to  mechanical  impediments  to  the  cir- 
culation, Dr.  Albers  believes,  that  they  are  mostly  a 
symptom  of  some  nervous  affection.  He  also  tliinks, 
that  the  surprise  excited  by  these  throbbings  arises 
only  from  their  strength  and  situation,  other  analogous 
strong  pulsations,  as,  for  instance,  those  of  the  heart, 
or  of  the  carotids  being  common  enough  in  hypochon- 
driacal and  hysterical  persons.  The  same  gentle- 
man adverts  to  the  increa.sed  action,  which,  in  in- 
flammation and  fevers,  is  often  more  conspicuous  in 
some  parts  of  the  sanguiferous  system,  than  in  others. — 
( Uber  Pulsationen  im  Unterleibe,  p.  36,  &lc.  Bremen, 
8vo.  1803.)  Much  important  additional  information  on 
this  subject  may  be  found  in  Observations  on  some  of 
the  most  frequent  and  important  Diseases  of  the  Heart  / 
on  Aneurism  of  the  Thoracic  Aorta ; on  Preternatu- 
ral Pulsation  in  the  Epigastric  Region,  <S-c.  By  Allan 
Burns,  p.  262,  cj-c.  8vo.  Edinb.  1809. 

ABSCESS.  A tumour  containing  pus,  or  a collection 
of  purulent  matter. 

Abscesses  are  divided  into  two  principal  kinds,  viz. 
acute  and  chronic.  For  information  relative  to  the  for- 
mer, see  Suppuration ; and  for  that  concerning  the 
latter,  refer  to  Lumbar  Abscess.  See  also  Abdomen, 
Antrum,  Anus  Abscesses  of.  Bubo,  Empyema,  Hypo- 
pium,  Mammary  Abscess,  fVhitlow,  ^c. 

ABSORPTION,  That  nature  has  Mly  provided  for 
the  due  execution  of  this  important  function,  is  u 
truth  of  which  no  doubt  is  entertained;  it  must  be 
immediately  manifest  to  every  person  who  reflects 
upon  the  mutation  which  is  continually  taking  place 
in  the  particles  of  every  texture  of  the  animal  body ; 
upon  the  gradual  and  harmonious  removal  of  the 
old  matter  in  proportion  as  the  new  is  deposited  by  the 
secerning  arteries ; or  upon  the  impossibility  of  ac- 
counting for  the  changes  produced  by  growth  in  the 
size  and  figure  of  different  organs,  and,  indeed,  of  the 
whole  body,  without  constantly  bringing  into  the  ex- 
planation this  interesting  process,  of  which  numerous 
and  even  the  most  essential  particulars,  it  is  true,  yet 
remain  obscure.  But,  besides  these  considerations  in 
proof  of  absorption,  many  others  must  strike  the  con- 


ABSORPTION.  13 


tetnplative  physidlogist.  By  the  action  of  the  secreting 
and  exhalent  arteries,  the  whole  mass  of  blood  would 
soon  be  so  lessened  that  life  would  unavoidable  cease, 
if  the  sanguiferous  system  were  not  duly  replenished 
in  some  way  or  another.  The  undiminished  quantity 
of  blood  in  the  circulation,  notwithstanding  the  con- 
stant deductions  from  it  by  secretion  and  exhalation ; 
the  regular  fulness  of  the  blood-vessels,  notwithstand- 
ing the  incessant  drain  from  them ; and  the  constant 
supply  of  materials  for  the  numerous  secretions ; all 
imply  the  existence  of  a certain  function,  one  principal 
design  of  which  is  to  counteract  the  effect  which, 
without  it,  would  be  r^idly  and  fatally  produced  upon 
the  quantity  of  blood  in  the  system.  As  M.  Magendie 
observes,  whenever  any  substance  in  the  form  of  a 
liquid,  gas,  or  vapour,  is  put,  for  a certain  time,  in 
immediate  contact  with  an  external  or  internal  surface 
of  the  body,  it  is  absorbed;  that  is  to  say,  it  passes 
Into  the  blood-vessels,  mixes  with  the  blood,  circu- 
lates with  it,  and  thus  occasions  either  salutary  or 
noxious  effects  upon  the  system.  This  is  particularly 
exemplified  in  the  action  of  certain  poisons ; a drop  of 
pure  hydrocyanic  acid,  put  on  a dog’s  tongue,  causes 
the  animal’s  death  in  a few  seconds,  in  consequence  of 
being  transmitted  with  the  blood  to  the  brain.  Food, 
drink,  medicines,  and  even  air  itself,  only  become  use- 
ful to  us,  after  having  been  absorbed.  Many  diseases, 
some  of  a very  dangerous  nature,  are  contracted  by 
absorption.  In  fact  our  existence  is  so  inseparably 
comiected  with  this  function,  that  the  susp^ension  of  it 
for  an  instant  would  produce  almost  immediate  death, — 
(See  Joum.  de  Physiol.  Expirim.  <.  1,  p.  L) 

The  office  of  the  absorbents,  as  a modern  writer  has 
remarked,  is  literally  expressed  by  their  name ; it  con- 
sists in  receiving  or  taking  up  certain  substances, 
and  in  transporting  them  from  one  part  of  the  body  to 
another.  The  substances  which  are  thus  taken  up, 
are  of  two  kinds,  the  chyle  and  the  lymph ; the  former 
being  received  by  the  lacteals,  and  the  latter  by  the 
lymphatics.  The  immediate  object  of  the  action  of  the 
two  sets  of  vessels,  he  observes,  is  also  essentially 
different ; that  of  the  first  being  to  convey  a fluid  from 
the  part  where  it  is  formed  into  the  blood,  in  order  that 
it  may  directly  serve  for  the  nutrition  of  the  body ; the 
latter  serving,  n the  first  instance,  to  remove  what  is 
useless  or  noxious,  and  to  dispose  of  it  in  such  a man- 
ner, that  it  may  either  be  applied  to  some  secondary 
purpose  of  utility,  or  be  finally  discharged  from  the 
system. — {Bostack,  in  Edenu  Syst,  of  Physiology,  vol. 
2,  p.  551.) 

The  uses  of  the  absorbent  system  are  far  more  nu- 
merous than  would  at  first  be  supposed  by  a person 
only  superficially  acquainted  with  physiology  and  the 
phenomena  of  disease.  If  we  wish  to  have  a just 
comprehension  of  all  the  various  purposes  which  this 
system  fulfils  in  the  animal  economy,  we  must  take 
the  same  enlarged  view  of  the  subject  as  Mr.  Hunter 
did.  We  must  contemplate  all  the  modifications  of 
absorption,  and  its  effects  both  in  health  and  disease, 
in  the  nutrition  and  growth  of  the  body,  as  well  as  in 
its  emaciation,  or  atrophy,  and  the  diminution,  or  even 
total  removal,  of  parts  of  it,  become  diseased  or  use- 
less. 

First,  According  to  Mr.  Hunter’s  explanation,  the 
absorbents  take  up  extraneous  matter,  in  which  is  in- 
cluded nourishment. — (On  the  Blood,  Sre.p.  439,)  By 
extraneous  matter  we  are  here  to  understand  matter 
not  originally  contained  within  any  texture  of  the  body, 
not  constituting  any  part  of  its  natural  structure,  but 
introduced  from  without.  Thus  the  absorption  of  mer- 
cury, arsenical  paint,  cantharides,  and  other  substances 
applied  to  the  skin,  furnishes  examples  of  the  absorp- 
tion of  extraneous  matter,  which  are  also  illustrated 
by  the  effects  of  the  venereal,  variolous,  vaccine,  and 
several  other  poisons.  Sometimes  the  passage  of  the 

oison  into  the  system  and  its  pernicious  operation, 

appen  so  rapidly,  that  suspicions  are  entertained  that 
it  must  have  a shorter  track  into  the  circulation  than 
through  the  lymphatic  vessels,  their  glands,  and  trunks. 
This  has  been  suspected  to  be  the  case  when  animals 
are  killed  with  hydrocyanic  acid,  the  nux  vomica,  the 
l)oison  of  certain  snakes,  the  upas  tiente,  &c.  How 
far  this  opinion  is  true  will  be  hereafter  considered. 
Such  is  the  rapidity  with  which  the  poisons  of  upas 
tiente,  nux  vomica,  and  St.  Ignatius’s  bean  are  absorbed 
and  carried  into  the  sanguiferous  system,  that  in  twenty 
seconds  after  being  put  into  the  cavity  of  the  perito- 


neum, their  action  reaches  the  spinal  marrow.— (Set) 
Magendie' s Journ.  de  Physioli  ExpMm.  i.  l,p.  18.) 

Secondly,  As  Mr.  Hunter  has  noticed,  the  absorbents 
take  up  superfluous  and  extravasated  matter,  whether 
natural  or  diseased.  Thus,  the  removal  of  the  old  par- 
ticles of  the  body,  after  they  have  become  unfit  to  con- 
tinue longer  in  their  respective  situations  and  textureSj 
— an  action  that  is  reciprocal  with  the  deposition  of 
new  matter  by  the  secerning  arteries ; and  the  inces- 
sant regulation  of  the  quantity  of  serous  fluid  in  the 
cavities  of  the  abdomen,  chest,  pericardium,  and  tunica 
vaginalis,  so  that,  though  the  arteries  unremittingly 
secrete  this  fluid,  the  absorbents  prevent  its  redundant 
accumulation,  and  combine  with  the  blood-vessels  in 
maintaining  a continual  renovation  of  it ; are  examples 
of  the  absorption  of  natural  but  superfluous  matter. 
On  the  contrary,  the  dispersion  of  extravasated  bloody 
of  the  fluid  of  ascites  and  anasarca,  of  coagulating 
lym])h,  or  air,  eflXised  in  the  cellular  tissue ; and  of  an 
infinite  number  and  variety  of  swellings  and  thicken- 
ings of  parts ; are  instances  of  what  Mr.  Hunter  has 
termed  the  absorption  of  superfluous  diseased  mat- 
ter, or,  as  I should  say,  of  superfluous  matter  from 
disease. 

Thirdly,  Mr.  Hunter  enumerates  the  absorption  of 
the  fat.  No  doubt  can  exist  respecting  the  continual 
change  which  is  taking  place  in  the  quantity  of  adi- 
pose matter  in  the  body,  according  to  the  state  of  the 
health,  the  degree  of  exercise,  fatigue,  or  labour  to 
which  the  body  is  exposed,  a disturbed  or  undisturbed 
condition  of  the  mind,  and  the  effects  of  different  kinds 
of  regimen  and  diet  on  the  whole  system.  Perhaps  it 
may  be  inquired  why  Mr.  Hunter  should  distinguish 
this  absorption  from  that  of  other  superfluous  matter 
in  the  body.  The  reason  does  not  appear  in  his  wri- 
tings ; unless  we  receive  as  such  the  observation,  that 
he  did  not  consider  the  fat  and  earth  of  bones  as  true 
animal  substances,  as  they  have  no  action  within  them- 
selves and  no  principle  of  life.  However,  this  would 
not  be  very  consistent,  because  other  superfluous  mat- 
ter, comprised  in  the  second  classification,  especially 
the  fluid  secreted  by  serous  membranes,  and  the  fluid  of 
anasarca,  are  likewise  quite  destitute  of  the  living  prin- 
ciple. At  the  same  time,  I admit  that  the  absorption 
of  the  fat  may  be  entitled  to  distinct  consideration  on 
other  grounds ; for  sometimes  its  absorption  seems  to 
be  retarded  in  a much  greater  degree  than  that  of  other 
substances  in  the  body ; or  at  all  events  its  absorption 
does  not  keep  pace  with  that  of  its  secretion,  so  tJiat, 
although  the  muscles  and  other  organs  remain  of  theif 
usual  bulk,  the  fat  may  acquire  the  thickness  of  several 
inches.  On  the  other  hand,  the  absorbents  sometimes 
act  upon  it  with  a quickness  that  does  not  always  ex- 
tend at  the  same  time  to  other  parts  of  the  body.  Thus 
in  fever  nearly  all  the  fat  may  be  absorbed  in  the 
course  of  a few  days  ; yet  the  size  of  the  muscles  may 
have  undergone  but  little  reduction. 

Fourthly,  Mr.  Hunter  enumerates  the  species  of  ab- 
sorption by  which  a waste  of  parts  is  produced,  and  in 
consequence  of  which  the  muscles  become  smaller, 
the  bones  lighter,  &c.  These  cases  we  find  exempli- 
fied in  the  ordinary  course  of  nature ; for  in  old  age 
such  changes  happen  in  the  bones  and  muscles,  and 
also  in  other  organs  like  the  absorbent  glands,  which 
become  so  diminished,  that  some  writers  erroneously 
assert  that  they  entirely  disappear.  Whenever  the  ac- 
tion of  a muscle  is  long  prevented  by  disease  of  a joint, 
a fractured  bone,  or  other  causes,  it  always  dwindles 
away  in  a greater  or  less  degree,  and  the  limb  com- 
pared with  the  sound  one  will  be  found  to  be  consider- 
ably reduced.  The  absorption  of  the  fat,  by  which  the 
bulk  of  parts  is  also  lessened  under  various  circum- 
stances of  disease,  I believe  is  not  generally  restricted 
to  a particular  limb  or  part,  like  the  absorption  which 
affects  the  muscles  in  similar  cases.  Thus,  when  a 
patient  becomes  hectic  from  disease  of  the  liip-joint, 
the  muscles  of  the  thigh  and  leg  on  the  same  side  as 
the  disea.se  undergo  a remarkable  diminution  of  their 
bulk,  while  those  of  the  sound  limb  are  little  or  not  at 
all  altered ; but  the  fat  of  the  whole  body  is  rapidly 
absorbed,  and  the  greatest  universal  emaciation  pre- 
vails. 

Before  the  period  of  Mr.  Hunter’s  inquiries,  the 
knowledge  of  all  the  different  purposes  of  absorption, 
by  whatever  organs  it  was  supposed  to  be  performed, 
whether  by  lymphatics  or  veins,  was  certainly  very 
limited  in  comparison  with  the  more  extensive  in- 


i4 


ABSORPTION. 


fonnution  wliich  now  prevails,  and  wliich  is  in  a 
great  measure  the  fruit  of  liis  industrious  researches. 
Speaking  of  the  absorbent  vessels,  which  he  consi- 
dered, witk  the  genendity  of  modern  physiologists,  as 
the  true  instruments  of  absorption,  he  says : “ From 
a farther  knowledge  of  these  vessels  we  shall  hnd  that 
they  are  of  much  more  consetiuence  in  the  body  than 
has  been  imagined,  and  that  they  arc  olten  taking  down 
what  the  arteries  have  built  up;  removing  whole  or- 
gans, becoming  modellers  of  the  form  of  the  body  in 
its  growth;  and  removing  many  diseased  and  dead 
pans,  wliich  are  beyond  the  jHiwer  of  cure.” 

As  these  vessels  are  productive  of  a great  variety  of 
changes  in  the  animal  economy,  which  are  very  dissi- 
nular  in  their  intention  anil  effect,  Mr.  Hunter  consi- 
dered them  in  ttvo  general  jHiints  of  view;  first,  as 
they  absorb  matter,  which  is  not  any  part  of  the  body 
itself;  secondly,  as  they  absorb  the  body  itself.  The 
first  of  the.se  uses,  the  absorption  of  matter  which  is 
no  part  of  the  macliiue,  he  observes,  is  well  known, 
and  of  two  kinds ; first,  that  of  e.xtenor  matter,  com- 
prising every  thing  applied  to  the  skin,  and  also  the 
chyle ; the  other  interior,  comprehending  that  of  many 
of  the  secretions,  the  fat,  the  earth  of  bone,  Ac.  'I'hese 
kinds  of  absorption  take  place  pnncii/aily  tor  the  nou- 
rishment of  the  body  ; but  they  also  answer  other  pur- 
poses, and  are  very  extensive ; for,  besides  their  salu- 
tary eU'ects,  they  are  frequently  the  cause  of  disease  in 
a thousand  forms. 

In  the  second  of  the  above-mentioned  views,  Mr. 
Hunter  considers  the  absorbents  as  removing  parts  of 
the  body  itself,  and  here  he  again  views  them  in  two 
lights.  The  first  is  where  only  a wasting  is  produced 
in  the  whole  body  or  some  particular  part  of  it ; to 
wliich  mode  of  absorption  he  apjilies  the  ciiithet  inter- 
stitial^ because  it  consists  in  the  removal  of  particles 
of  the  body  out  of  the  instcrstices  of  parts  which  yet 
reiiKun,  and  still  form  a jierfect  whole.  This  kind  of 
absorption,  Mr.  Hunter  says,  lias  always  been  admitted 
or  supposed,  whettier  performed  by  the  veins  or  lym- 
phatics. It  is  otleii  carried  farther  than  the  mere  wa.st- 
ing  of  the  part ; for  it  may  proceed  till  not  a vestige  of 
such  part  is  left,  as  is  sometimes  e.xemplified  in  the 
total  decay  of  a testicle.  Interstitial  absorption,  there- 
fore, may  be  understood  in  two  senses. 

Tlie  second  view  taken  by  Mr.  Hunter  embraces 
that  kind  of  absorption  by  wliich  whole  parts  of  the 
body  are  removed,  and  wliich  is  sometimes  a natural, 
sometimes  a diseased,  process.  It  is  a view  of  wliich 
he  particularly  claims  the  discoveryv  In  the  natural 
process,  he  says,  the  absorbents  are  to  be  considered  as 
the  modellers  of  the  original  construction  of  the  ody. 
No  alteration  can  take  place  in  the  original  fonnation 
of  many  of  the  parts,  either  in  the  natural  growth  or 
the  formation  arising  from  disease,  w ithout  the  action 
of  the  absorbents,  w-hich  always  have  a considerable 
share  in  the  production  of  the  changes.  This  he  terms 
modelling  absorption,  the  principle  of  w'hich  is  as  ex- 
tensive as  any  in  the  animal  economy.  Bones  and 
numerous  other  parts  cannot  be  fonned  w'itliout  it.  A 
part  which  is  of  use  in  one  stage  of  life,  but  becomes 
quite  useless  in  another,  is  thus  removed,  as  is  exem- 
plified in  the  thymus  gland,  tlie  ductus  arteriosus,  and 
the  membraha  pupillaris.  In  some  cases  the  absorp- 
tion of  whole  parts  in  consequence  of  disease  leads  to 
dissimilar  effects ; one  is  a sore  or  ulcer ; and  IMr.  Hun- 
ter therefore  calls  the  process  by  which  it  is  produced, 
ulcerative  absorption.  In  other  cases  no  ulcer  is  caused, 
although  whole  parts  are  removed.  Both  these  forms 
of  absorption,  he  thinks,  might  be  named  progressive. 

The  removal  of  a whole  solid  part  of  the  body,  or 
as  Mr.  Hunter  expresses  it,  “ that  power  which  the 
animal  economy  has  of  taking  a part  of  itself  into  the 
circulation,  by  means  of  the  absorbent  vessels,  when- 
ever it  is  necessar>',”  is  unquestionably  one  of  the  most 
curious  facts  wliich  can  present  themselves  to  the  no- 
tice of  the  physiological  inquirer.  In  Mr.  Hunter’s 
time  the  doctrine  was  a new  one ; but  he  informs  us, 
that  he  had  long  been  able  to  demonstrate  its  truth, 
and  that  he  received  the  first  hints  of  it  from  the  waste 
of  the  sockets  of  the  teeth  and  of  their  fangs  at  the  pe- 
riod of  their  being  shed. 

“ It  may  be  difficult  at  first  to  conceive  how  a part 
of  the  body  can  be  removed  by  itself;  but  it  is  just  as 
difficult  to  conceive  how  the  body  can  form  itself ;”  yet 
they  arc  both  equally  facts.  Without  dwelling  on  the 
exai't  mode  in  which  such  changes  happen,  he  gives  it 


as  his  belief,  that  “ whenever  any  solid  part  of  oar 
bodies  undergoes  a diminution,  or  is  broken  in  uixin, 
in  consequence  of  any  disease,  it  is  the  absorbmg  sys 
tern  wluch  does  it. 

“ When  it  becomes  necessary,  that  some  whole  liv- 
ing part  should  be  removed,  it  is  evident  that  nature, 
in  order  to  effect  this,  must  not  only  confer  a new  ac- 
ti\'ity  on  the  absorbents,  but  must  throw  the  part  to 
be  absorbed  into  such  a state  as  to  yield  to  this  opera- 
tion.”— See  Hunter  on  the  Blood,  <^c.  p.  439 — 442.) 
For  an  account  of  ulcerative  absorption,  vide  Ulcera- 
tion. 

With  regard  to  the  difficulty  which  there  may  be 
in  conceiving  how  such  small  tubes  as  the  Ijmphatics 
can  take  up  solid  substances,  Bichat  points  out  that 
the  distinction  between  the  solids  and  the  fluids  can 
only  be  said  to  prevail  when  they  fonn  a mass ; but 
that  when  reference  is  made  to  their  separate  particles, 
they  do  not  differ  from  each  other.  This,  he  says,  is 
so  pertectly  true,  that  the  very  same  particle  will  alter- 
nately enter  into  the  composition  of  a solid  and  a fluid, 
just  as  the  elements  of  water  are  the  same,  whether  it 
be  in  the  liquid  or  frozen  state.  Now  as  the  absorp- 
tion of  solid  substances  takes  place  by  the  removal  of 
these  separate  particles  or  atoms,  no  greater  difficulty 
can  present  itself  in  understanding  how  this  may  be 
elfected  than  in  conceiving  how  fluids  may  be  absorbed. 
— s^ee  Jinat.  Gen.  t.  2,  p.  92.) 

I come  now  to  a very  difficult  question,  and  one  that 
has  hitherto  received  no  satisfactory  answer ; not  be- 
cause the  subject  has  not  been  earnestly,  deeply,  and 
ably  considered,  but  because  its  difficulties  and  obscu- 
rity seem  to  defy  all  successful  investigation : the  ques- 
tion here  referred  to,  is.  On  what  principle  and  by 
what  power  are  the  lymphatics,  suppnsing  them  to  be  ab- 
sorbent vessels,  enabled  not  only  to  take  up  the  old  parti- 
cles of  various  organs  and  different  fluids  secreted  in 
different  textures  and  cavities,  but  to  convey  them 
frequently  with  considerable  velocity  and  through  a 
long  tract,  intercepted  also  by  those  complicated  organs, 
the  absorbent  glands,  into  the  venous  system  near  the 
heart?  In  other  words,  what  is  their  mode  of  action? 
As  Mr.  Hunter  has  observ'ed,  the  principle  of  capillary 
tubes  was  at  first  the  most  general  idea,  because  it  was 

familiar  one;  but  this  is  too  confined  a principle; 
nor  will  it  account  for  every  kind  of  absorption.  Capil- 
lar- i.'bes  can  only  attract  fluids;  but  as  solids  were 
often  absorbed,  such  as  firm  tumours,  coagulated  blood, 
the  earth  ofbones,  Ac.,  the  advocates  for  tliis  hyqiothesia 
were  compelled  to  suppose  the  existence  of  a solvent. 
“This  may  or  may  not  be  true ; it  is  one  of  those  hy- 
potheses that  can  never  be  proved  or  disproved,  and 
may  for  ever  rest  uixin  opinion.”  But  Mr.  Hunter’s 
conception  of  this  matter  was,  that  nature  leaves  as 
little  as  jiossible  to  chance,  and  that  the  whole  opera- 
tion of  absorption  is  performed  by  an  action  in  the 
mouths  of  the  absorbents  ; but  even  under  the  idea  of 
capillary  tubes,  physiologists  w'ere  still  obliged  to  have 
recourse  to  the  action  of  those  vessels  to  carry  the 
lymph  along  after  it  had  been  absorbed ; and  they  might 
as  well  therefore  have  extended  this  action  to  the 
mouths  of  the  vessels. — (On  the  Blood,  6,-c.  p.  443.) 

The  question  still  continues  without  satisfactory 
answer,  whether  Hunter’s  language  be  adopted,  and 
we  say  that  absorption  is  effected  by  an  action  of  the 
lymphatics  and  their  orifices ; or  whether  we  employ 
the  language  of  Bichat,  and  ascribe  the  performance 
of  the  functions  of  these  vessels,  and  the  circulation 
of  the  fluid  in  them,  to  what  he  ingeniously  (but  not 
much  to  the  edification  of  his  readers)  calls  organic 
sensibility  and  insensible  organic  contractility.  This 
imagined  kind  of  sensibility  confers  upon  every  ab- 
sorbent vessel  a power  of  feeling  quite  unconnected 
with  the  brain,  by  w'hich  it  is  presumed  to  be  sensible 
of  the  presence  of  matter  fit  for  removal,  which  is  then 
imbibed  and  conveyed  along  the  tube  by  the  insensible 
organic  contractility,  by  which  is  signified  a pow’er  of 
contraction,  not  admitting  of  demonstration,  not  ex- 
citable by  stimulation  or  irritation,  but  inferred  to  take 
place  in  some  inexphcablc  manner,  chiefly  because 
the  fluid  in  the  absorbents  is  knotvn  to  be  constantly 
in  motion,  and  always  flowing  towards  the  thoracic 
duct.  In  fact,  Bichat’s  explanation  is  merely  a reference 
to  two  principles,  which  are  themselves  hypothetical, 
and  more  calculated  to  amuse  a playful  fancy  than  t» 
satisfy  a sound  judgment.  Organic  sensibility,  and 
insensible  organic  contractility,  he  observes,  tire  the 


ABSORPTION. 


15 


Riore  remarkable  in  the  absorbent  system,  as  they  sur- 
vive for  a certain  time  death  itself.  A fluid,  injected 
while  the  animal  retains  some  degree  of  heat,  is  ab- 
sorbed both  on  serous  and  mucous  surfaces,  and  also 
in  the  cellular  tissue,  though  with  less  freedom.  This 
power  of  absorption  after  death,  he  says,  may  even 
be  lengthened  by  keeping  up  artificial  heat  by  means 
of  a bath,  though  the  plan  is  less  efficacious  than  he  at 
first  supposed,  vital  heat  seeming  to  be  essential. — 
(^nat.  Getu  t.  2,  p.  117.)  All  these  observations,  how- 
ever, merely  amyount  to  a recital  of  the  facts,  that  ab- 
sorption may  proceed  for  a short  time  after  death  (never 
later  than  two  hours  from  this  event,  p.  118),  and  that 
it  is  promoted  by  artificial  heat ; but  how,  or  by  what 
exact  mechanism  it  is  accomplished,  is  not  revealed 
to  us. 

The  lymphatics  are  not  regarded  by  Bichat  as  endued 
either  with  what  he  terms  animal  sensibility,  or  with 
animal  contractility.  His  proof  of  the  first  of  these 
statements  is,  that  when  a lacteal  vessel,  full  of  chyle, 
a lymphatic  filled  with  serosity  on  the  surface  of  the 
liver,  or  even  the  thoracic  duct,  is  punctured,  the  ani- 
mal betrays  no  mark  of  pain.  But  the  little  faith 
which  he  himself  put  in  the  doctrine,  may  be  conceived 
from  the  question  to  which  it  leads  him,  namely,  what 
inference  can  be  drawn  from  a circumstance  where, 
in  consequence  of  the  belly  being  laid  open,  the  many 
agonies  produced  would  comparatively  annihilate  any 
slight  sensation,  even  were  it  to  exist  ? He  also  ad- 
verts to  the  acute  sensibility  of  the  absorbent  vessels 
in  their  inflamed  state. — (P.  115,  t.  2.) 

Hunter  admitted  a vital  contractile  property  in  the 
lymphatics,  or,  as  Bichat  would  express  it,  sensible 
organic  contractility.  The  former  adopted  this  belief, 
because  those  vessels  readily  empty  themselves  of 
the  chyle  that  is  pervading  them,  and  contract  when 
sulphuric  acid  is  applied  to  them.  On  the  other  hand, 
Bichat  argues,  that  sulphuric  acid,  like  every  other 
concentrated  acid,  and  also  heat,  produce  the  same 
effect  upon  all  animal  substances,  even  afler  death, 
namely,  a shrinking  of  them.  When  the  absorbents, 
and  particularly  the  thoracic  duct,  are  touched  with 
the  point  of  a knife,  they  do  not  contract.  If  they  are 
capable  of  contraction,  Bichat  maintains  that  it  is 
when  they  cease  to  be  distended,  and  not  when  they 
are  irritated  ; consequently,  it  appears  to  him  to  be  by 
virtue  of  their  contractility  of  tissue.  The  opinion  at 
which  he  finally  arrives  is,  that  sensible  organic  con- 
tractility in  them  is  at  all  events  doubtful,  and  that,  if 
it  exist,  it  is  very  obscure,  and  at  most  not  greater 
than  that  of  the  dartos. — (T.  2,  p.  117.) 

This  last  inference,  and,  indeed,  the  whole  of 
Bichat’s  doctrine  respecting  the  non-existence  of 
sensible  organic  contractility  in  the  absorbent  ves- 
sels, are  very  difficult  to  reconcile  with  certain 
observations  made  by  himself,  in  other  parts  of  his 
work.  Thus,  he  informs  his  readers  (f,  2,  p.  95),  that 
he  had  frequently  noticed  in  living  animals,  especially 
in  dogs,  manifest  expansions  in  the  course  of  a lym- 
jfhatic,  and  containing  a limpid  fluid.  These  appear- 
ances were  mostly  met  with  on  the  concave  surface 
of  the  liver,  and  on  the  gall-bladder.  WTien  the  dilated 
portions  of  the  vessel  were  pricked  with  a lancet,  the 
fluid  ran  out,  and  they  immediately  disappeared.  “ On 
another  occasion,  I saw  two  or  three  of  these  small 
dilatations  on  the  gall-bladder,  and  having  then  let  the 
liver  descend  while  I examined  the  bowels,  I was  much 
astonished  the  next  instant  at  not  being  able  to  find 
them  again;  no  doubt  (says  he)  the  contraction  of  the 
vessel  had  made  them  disappear.'"  He  adds,  that  the 
liver  is  the  organ  on  which  these  vessels  can  be  best 
seen  in  living  animals ; but  its  concave  surface  must 
be  looked  at  the  instant  the  belly  is  opened,  for  the 
contact  of  air,  by  making  them  contract,  soon  hinders 
them  from  being  distinguished. — (See  Jinat.  Q6n.  t.  2, 
7>.  95,  96.)  And  in  another  place  he  says,  “in  drop- 
sies where  the  absorbents  are  full,  if  the  skin  be  lifted 
up,  they  may  easily  be  distinguished  by  their  transpa- 
rency; but  very  soon,  notwithstanding  their  valves, 
they  empty  themselves,  and  can  no  longer  be  discerned 
with  the  eye.”— ( V.  108.) 

The  fact  of  the  absorbents  expelling  more  or  less 
of  their  contents,  when  they  have  been  punctured, 
might  he  very  well  ascribed  to  what  Bichat  calls  con- 
trnctiUty  of  tissue,  or  even  to  elasticity ; but,  the 
propulsion  of  the  fluid  from  a dilated  portion  of  an 
unwounded  lymphatic  into  another  portion  of  the  same 


I vessel,  certainly  docs  not  admit  of  the  same  explana- 
tion. The  valves  may  determine  the  direction  which 
such  fluid  must  follow,  if  it  move  at  all ; the  anasto- 
moses may  facilitate  the  passage  of  it ; and  contrac- 
tility of  tissue,  or  elasticity,  may  have  an  auxiliary 
effect ; but  its  first  motion  can  only  be  accounted  for 
by  supposing  either  that  there  is  an  impelling  power 
in  the  vessels  themselves,  or  in  some  organ  or  organs 
with  which  they  are  connected  ; or  else  that  their  con- 
tents are  set  in  motion  by  external  pressure,  the  swell 
of  muscles  in  action,  or  the  pulsation  of  neighbouring 
arteries.  Now,  in  some  of  the  cases  mentioned  by 
Bichat,  no  doubt  can  be  entertained  that  the  impelling 
power  was  in  the  lymphatics  themselves,  because  he 
distinctly  adverts  to  the  contraction  so  speedily  excited 
in  them  by  exposure  to  the  air,  that  the  concave  sur- 
face of  the  liver  must  be  looked  at  immediately  on  the 
animal’s  belly  being  opened,  or  else  they  will  not  be 
distinguished. 

Dr.  Bostock  conceives,  that  “an  attraction  exists 
between  the  mouths  of  the  lacteals  and  the  chyle^ 
which  seems  to  be  analogous  to,  or  identical  with,  the 
elective  attraction,  which  unites  different  chemical 
substances ;”  and  “ that  the  lacteals,  as  well  at  theii* 
extremities  as  through  their  whole  extent,  are  pos- 
sessed of  contractility,  by  which  the  fluids,  when  they 
have  once  entered,  are  propelled  along  them ; an  effect 
which  is  probably  promoted  by  the  pressure  of  the 
neighbouring  parts,  while  the  numerous  valves  with 
which  they  are  finnished  prevent  the  retrograde  mo- 
tion of  their  contents.” — (Elem.  Syst.  of  Physiol.  voU 
2,  p.  580.)  The  principle  on  which  the  lacteals  im- 
bibe the  chyle  can  scarcely  be  referred  to  any  thing  so 
fixed  and  determinate  as  chemical  attraction,  or  so 
independent  of  life.  On  the  contrary,  the  absorption 
of  chyle  from  the  bowels  may  be  looked  upon  as  a pro- 
cess liable  to  be  accelerated,  or  retarded,  by  various  states 
of  the  constitution,  habits  of  life,  and  different  affections 
of  the  mind.  If  it  were  a chemical  operation,  and  the 
abundance  of  chyle  happened  to  exist  on  the  villous 
coat  of  the  small  intestines,  at  the  period  of  any  sud- 
den death,  the  process  would  be  expected  to  go  on  as 
long  as  that  fluid  and  the  villi  remained  in  contact ; 
yet  we  have  no  proof  of  this  being  the  case : indeed  I 
cannot  comprehend  any  similarity  between  elective 
attraction  and  the  absorption  of  chyle ; the  former  being 
an  operation  in  which  the  action  of  vessels  or  their 
orifices,  and  the  influence  of  life,  are  considerations 
totally  separated  from  the  subject;  whereas,  in  the 
latter,  they  form  in  reality  the  main  topics  of  inquiry. 
Elective  attraction,  however,  may  only  be  intended  as 
a comparison  applicable  to  the  disposition  which  the 
lacteals  have  to  take  up  certain  substances,  but  to  reject 
others:  though,  even  in  this  sense,  the  comparison 
would  be  very  imperfect. 

Dr.  Bostock’s  opinion  is  probably  true,  that  an  eluci- 
dation of  the  action  of  the  lymphatics  must  be  attended 
with  even  greater  difficulty,  than  what  presents  itself 
to  the  inquiry  into  the  principle  on  which  the  chyle  is 
taken  up  and  conveyed  into  the  system.  The  increased 
difficulty  chiefly  proceeds  from  our  having  no  positive 
information  respecting  the  extremities  of  the  lymphatic 
vessels,  or  the  mode  in  which  their  contents  are  first 
received;  “for  there  is  reason  to  suppose  that  the 
transmission  of  the  fluids  themselves  is  conducted  upon 
the  same  plan  with  that  of  the  lacteals.”  As  the  same 
author  remarks,  we  do  not  know  where  the  mouths  of 
the  lymphatics  are  situated ; with  what  parts  they  are 
connected;  how  they  are  brought  into  contact  with 
the  substances  which  they  receive ; nor  by  what  power 
they  are  enabled  to  take  them  \ip.—(Vol.  1,  p.  582.) 

The  source  of  the  lymph  is  also  less  certain  than 
that  of  the  chyle ; for,  even  at  the  present  day,  M.  Ma- 
gendie,  influenced  by  the  possibility  of  injecting  the 
lymphatics  from  the  arteries,  and  by  the  uniform  nature 
of  the  lymph,  and  its  analogy  to  the  blood,  proffesses  a 
belief,  which  was  common  many  years  ago,  that  it 
is  not  formed  by  the  decomposition  of  the  old  par- 
ticles of  the  body,  nor  by  fluids  absorbed  from  vari- 
ous surfaces;  but  that  it  is  composed  of  tlie  thin 
ner  parts  of  the  blood,  which,  instead  of  returning  by 
the  veins  to  the  heart,  pass  into  the  lymphatics,  and 
are  conveyed  to  that  organ  through  the  thoracic  duct. 
The  lacteals  certainly  have  little  disi)Osuion  to  take  up 
any  thing  but  chyle ; but,  as  Dr.  Bostock  has  explained,- 
“ the  lymphatics  are  capable  of  absorbing  a great  va- 
riety of  substances,  diflering  from  each  other  most 


16 


ABSORPTION. 


widely  in  their  nature,  so  that  it  would  almost  appear 
as  if,  by  a certain  inode  of  application,  any  substance 
might  be  forced  into  them.  Nor  (says  Dr.  Bostock)  is 
this  conclusion  affected  by  the  hypothesis  of  M.  Ma- 
gendie  ; for,  although  we  might  agree  with  him  in  sup- 
posing that  in  the  ordinary  operations  of  the  sj  stem, 
the  veins  are  the  pnncipal,  or  even  the  sole  instru- 
ments in  removing  the  materials  of  which  the  body  is 
compost^,  yet  we  have  unequivocal  evidence,  that 
when  certain  poisonous  or  medicinal  agents  are  applied 
to  their  extremities,  they  may  be  received  or  forced 
into  them,  and  conveyed  into  the  circulation.  The 
case  of  metallic  or  other  medicinal  substances  that  are 
taken  up  by  the  lymphatics,  may  apjiear  to  be  less 
difficult  to  explain,  because  the  absorption  is  generally 
produced  by  friction,  or  some  mechanical  process, 
which  may  be  supposed  to  force  the  substance  into 
the  mouths  of  the  vessels,  or  to  produce  an  erosion  of 
the  epidermis,  which  may  enable  the  substances  to 
come  into  more  iimnediate  contact  with  the  mouths 
of  the  vessels.  We  may  also  imagme  that  when  the 
component  parts  of  the  body  are  brought  into  close 
appro.ximation  with  their  capillary  extremities,  they 
are  then  taken  up  in  the  same  way  that  the  chyle  is 
absorbed  from  the  intestines.” — {F.Um.  Syst.  of  Physiol, 
vol.  2,  p.  583.)  For  my  own  part,  1 believe,  that  if  the 
modern  doctrine  of  absorption  can  be  effectually  de- 
fended and  retained,  the  general  presence  of  the  orifices 
of  the  lymphatics  at  every  point  of  the  variously  organ- 
ised textures  of  the  body  must  be  received  as  one  of 
its  leading  principles.  Many  physiologists  have  little 
difficulty  in  conceiving  how  fluids  can  be  taken  up  by 
the  lymphatics,  but  rather  stagger  at  the  notion  of  this 
being  also  the  case  with  the  hardest  solids.  Others, 
however,  accommodate  their  creed  to  both  hypotheses, 
reconciling  themselves  to  them  by  the  argument  that, 
if  the  minute  capillary  anerles  can  secrete  this  dense, 
hard  matter,  the  small  lymphatics  can  remove  it.  One 
example  is  not  more  difficult  to  comiirehend  than  the 
other.  Yet,  such  reasoning  throws  little  light  on  the 
questions,  how  are  the  solids  prepared  for  absorption, 
and  in  what  manner  are  they  taken  upJ  These  in 
fact  remain  completely  unanswered. 

“ What  (inquires  a judicous  physiologist)  are  we  to 
conceive  of  the  intimate  nature  of  this  ojieration  ? If 
solution  of  the  substance  be  necessary,  we  are  at  a 
loss  to  find  a proper  solvent ; many  of  the  substances 
are  insoluble  in  water,  or  in  the  serous  fluid  which  is 
found  in  the  vessels ; whue,  on  the  other  hanu,  it  is 
perhaps  not  easy  to  conceive  how  the  substances  can 
be  absorbed  without  being  previously  dis.solved,  and 
still  more  so,  how  the  solids  can  have  their  texture 
broken  down,  and  enter  the  vessels,  particle  by  particle, 
as  it  were,  and  be  suspended  in  the  lymph  in  a state 
of  extreme  communition  ?”  As  I have  already  men- 
tioned, these  difficulties  some  physiologists,  including 
Bichat,  endeavour  to  diminish  by  arguing  that  the  Ijin- 
phatics  must  be  supposed  to  act  only  upon  the  elements 
of  every  texture,  and  that,  on  this  principle,  the  ab- 
sorption of  solids  is  as  readily  intelligible  as  that  of 
fluids,  the  same  elements  frequently  contributing  to 
the  composition  of  both.  However,  it  must  be  ac- 
knowledged, that  all  this  kind  of  reasoning  is  entirely 
visionary. 

It  is  conjectured,  that  while  parts  retain  the  vital 
principle,  they  are  capable  of  resisting  the  action  of 
the  absorbents.  According  to  Dr.  Bostock,  dead  mat- 
ter is  more  easily  acted  upon  by  the  absorbents  than 
living ; and,  in  fact,  “ no  part  can  be  absorbed  until  its 
texture  is  destroyed,  and,  consequently,  until  it  is  de- 
prived of  life.  No  substance  can  possibly  enter  the 
absorbents,  while  it  retains  its  aggregation,  so  that  it 
necessarily  follows,  that  the  preliminary  step  to  the 
ibsorption  of  the  body  is  its  decomposition.” — (Elem. 
Syst.  of  Physiol.  voL  2,  p.  585.)  He  afterward  explains, 
that  by  the  death  of  a part  preceding  its  absorption,  is 
here  signified  only,  “ that  it  is  no  longer  under  the  influ- 
ence of  arterial  action.  It  therefore  ceases  to  receive 
the  supply  of  matter  which  is  essential  to  the  support 
of  all  vital  (living  ?)  parts,  and  the  process  of  decom- 
position necesseirily  commences.”  To  me  a better  ac- 
count of  the  subject  appears  to  be  that  which,  dismiss- 
ing all  metaphysical  and  chemical  reflections  upon  the 
supposed  death  and  decomposition  of  parts,  previously 
to  their  absorption,  represents  the  absorbents  as  acting 
directly  upon  the  individual  atoms,  particles,  or  ele- 
ments of  the  various  textures.  We  kiiow  nothing 


about  the  vitality  of  these  atoms,  or  elements,  in  their 
separate  capacity ; supposing  them  to  possess  it,  we 
know  nothing  of  the  moment  when  they  part  with  it 
previously  to  their  entrance  into  the  absorbent  system, 
just  as  we  are  completely  ignorant  both  of  the  manner 
in  which  such  elementary  materials  acquire  the  vital 
principle,  and  of  the  exact  moment  when  they  become 
thus  endued. 

With  regard  to  the  ijunphatic  glands,  their  use  is  not 
precisely  known,  though  various  conjectures  have  been 
offered  concerning  it.  As  Dr.  Bostock  observes,  we 
may  presume  that  they  seive  an  important  purpose, 
from  the  circumstance  of  every  absorbent  vessel,  in 
some  part  of  its  course,  passing  through  one  or  more 
of  these  glands,  as  was  first  remarked  by  Nuck. 

Mr.  Ilewson  in  one  subject  injected  the  lymphatic 
vessels  from  the  groin  to  the  neck,  without  filling  any 
lymphatic  gland,  so  as  to  prove  a fact  which,  he  says, 
is  contradictory  to  the  received  opinion,  that  such  ves- 
sels always  pass  through  glands  in  their  way  to  the 
blood-vessels.  He  found,  with  regard  to  the  abdomen, 
the  observation  not  strictly  true,  as,  besides  the  lym- 
phatic vessels  which  enter  glands,  there  are  others 
which  escape  them.  He  declares,  that  some  of  the 
lacteals  in  the  mesentery  do  not  p-ass  into  glands. — 
{Exp.  Inq.  vol.  2,  p.  44,  vol.  3,  p.  54.)  On  the  other 
hand,  Mascagni,  in  his  numerous  injections,  never  met 
with  the  circumstance  {Eas.  Lymph.  Hist.  pt.  1,  sect. 
4,  p.  25; ; and  Dr.  Bostock  refers  us  to  Gordon’s  Anat. 
p.  74,  in  confirmation  of  the  rarity  of  such  an  arrange- 
ment.—<£fem.  Syst.  of  Physiol,  vol.  2.  p.  548.) 

The  fact  of  every  lymphatic  vessel  commonly  entering 
a gland  m some  part  of  its  course,  seems  to  Dr.  Bostock 
to  warrant  the  inforence,  that  some  imiiortant  change 
is  effected  in  the  chyle  and  lymph  by  means  of  the 
lymphatic  glands.  “But  (says  he)  the  same  mode  of 
reasoning  might  lead  us  to  conclude,  that  although  the 
absorbent  glan.ds  are  necessary  to  the  existence  of  the 
higher  orders  of  animals,  they  are  not  so  for  the  pur- 
poses of  nutrition  and  growth  generally,  as  it  appears 
that  there  are  large  classes  of  animals,  which  resem- 
ble the  mammalia  m many  of  their  nutritive  functions, 
and  in  the  vascular  part  of  the  absorbents,  which  are 
without  any  lymphatic  glands,  or  are  very  sparingly 
furnished  with  them.  It  is  not  easy  to  point  out  any 
circumstances  that  belong  exclusively  to  the  mam- 
malia, which  can  assist  us  in  explaining  the  necessity 
for  these  appendages  to  their  lymphatic  system.” — 
{Eol.  l,p.  554.) 

Malpighi  fancied  that  the  Ijunphatic  glands  had  a 
muscular  covering,  which  enabled  them  to  act  as  or- 
gans for  propelling  the  IjTnph  from  their  cells  into  the 
vasa  efferentia,  and  thence  towards  the  thoracic  duct, 
so  that  they  were,  according  to  his  notions,  hke  so 
many  little  hearts  distributed  through  the  system.  This 
hypothesis,  which  is  contradicted  by  anatomy,  receives 
no  confinnation  from  observation  in  the  living  animal. 
If  it  were  true,  we  should  expect  to  find  the  ceils 
larger,  and  not  so  minute  as  to  render  even  their  exist- 
ence in  the  human  absorbent  glands  a questionable 
point ; some  pulsating  movement,  gentle  or  strong, 
would  be  perceptible  in  the  situation  of  every  super- 
ficial gland ; or,  if  the  contraction  were  of  a slower 
kind,  the  gland  would  sometimes  be  enlarged,  and 
sometimes  considerably  reduced.  Y'et  none  of  these 
circumstances  prevail.  It  is  likewise  to  be  remembered, 
that  no  jet  of  fluid  takes  place  from  the  vasa  eflferentia 
when  they  are  cut,  as  they  frequently  are  in  surgical 
operations. 

It  is  also  t©  be  taken  into  consideration  that  fishes 
are  destitute -of  IjTnphatic  glands  (see  Blumenbach's 
Comparative  Jinat.  by  Lawrence^  p.  256) ; yet  the  fluid 
in  their  lymphatic  vessels  must  be  presumed  to  have 
its  due  degree  of  motion.  In  the  mesentery  of  a turtle, 
no  glands  are  observable ; still,  “ in  this  animal,  na- 
ture does  her  business  as  well,  though  the  apparatus  is 
differently  constructed.”— (ifeicson’s  Exp.  Inq.  vol.  3, 

p.  60.) 

Malpighi’s  hypothesis  is,  therefore,  decidedly  untena- 
ble ; and  whatever  difficulty  we  may  feel  in  agreeing 
with  Bichat,  that  the  absorbent  vessels  are  destitute  of 
animal  contractUity,  we  can  have  no  hesitation  in 
adopting  this  conclusion  with  respect 'to  the  absorbent 
glands,  considered  as  entire  organs,  without  any  refer- 
ence to  the  nature  of  the  congeries  of  lymphatic© 
within  them. 

The  existence  oLa  white  thick  fluid  in  the  lymphatic 


ABS 


glands  was  noticed  by  Haller  in  the  following  terms  : 

“ Succum  glandulis  conglobatis  inesse,  album,  serosum, 
lacte  tenuiorem,  in  juniori  potissimum  animali  con- 
spicuum,  id  quidem  certum  est.  Eum  cremori  similem 
dixit  Thomas  Vi^arton,  cinerum  Malpighius,  diapha- 
num  Nuckius,  album  Morgagnius,  recte  et  ad  naturam, 
ut  puto  omnes. —(SZem.  Physiol,  t.  1,  p.  184.) 

According  to  Hewson,  the  fluid  formed  in  the  lym- 
phatic glands,  if  diluted  with  a solution  of  Glauber’s  * 
salts  in  water,  or  with  the  serum  of  the  blood,  and 
viewed  with  a len^  of  one  twenty-third  of  an  inch 
focus,  presents  numberless  small  white  solid  particles, 
resembling  in  size  and  shape  the  central  particles  found 
in  the  vesicles  of  the  blood. — (Ex;»er.  [nq.  vol.  3,  p.  67.) 

The  supposition  of  Ruysch  and  Nuck  adopted  also 
by  Haller;  that  one  use  of  the  Ij'mphatic  glands  is  to 
produce  a fluid  for  the  dilution  of  the  lymph,  is  desti- 
tute of  proof,  inasmuch  as  the  lymph  is  not  known  to 
be  thinner  after  its  egress  from,  than  previously  to  its 
entrance  into,  a gland  ; and  one  notion  sometimes  pro- 
mulgated is,  that  it  is  thicker.  The  investigations  of 
Dr.  Prout  certainly  show,  that  it  contains  a larger 
quantity  of  albumen  and  fibrine  in  proportion  to  its 
vicinity  to  the  subclavian  vein. — [See  Thomson's  Jln- 
nals  of  Philosophy,  1819.)  According  to  Mr.  Wilson, 
the  absorbent  glands  contain  numerous  arteries ; and, 
in  a horse,  this  vascularity  gives  to  the  inner  lining  of 
the  cells  the  usual  appearance  of  a secreting  membrane ; 
but  whether  it  does  actually  secrete,  or  what  it  se- 
cretes, we  have  no  means  of  thoroughly  knowing. — 

( On  the  Blood  and  Vascular  System,  p.  209.)  The 
appearance  of  the  lining  of  the  cells  of  the  lymphatic 
glands  of  the  whale,  is  in  favour  of  the  opinion,  that 
some  secretion  takes  place  from  it,  as  an  addition  to 
the  lymph. — ISee  Mernethy's  Obs.  in  Philos.  Trans. 
1796,  pt.  1.)  Other  speculators  imagined,  that  the  ab- 
sorbent glands  were  like  so  many  filters,  through 
which  the  lymph,  or  chyle,  was  strained.  Another 
idea  was,  that  they  drew  some  crude  liquid  from  the 
nerves  and  returned  it  to  the  blood. — (Glisson,  dc  He- 
pate,  p.  439.)  As  to  the  conglobate  glands,  they  were 
also  sometimes  contrasted  with  the  conglomerate,  and 
represented  as  organs  for  making  good  the  loss  pro- 
duced in  the  sanguiferous  system  b\"  the  secretions 
from  the  latter.  Another  suggestion  was,  that  their 
office  was  to  form  the  central  particles  of  the  globules 
of  the  blood.  But,  as  Mr.  Wilson  justly  observed, 
all  these  opinions  are  nierely  suppositions,  without  a 
shadow  of  proof. 

Dr.  Bostock  considers  it  most  probable  either  that 
these  glands  are  proper  secreting  organs,  and  intended 
to  prepare  a peculiar  substance,  which  is  mixed  with 
the  chyle  and  lymph,  or  that  they  offer  a mechanical 
obstruction  to  the  progress  of  these  fluids,  by  which 
means  their  elements  are  allowed  to  act  upon  each 
other,  and  thus  some  necessary  change  in  the  nature 
of  the  chyle  and  lymph  may  be  produced. — (See  Elem. 
System  of  Physiol,  vol.  2,  p.  554.)  Richerand’s  opi- 
nion embraces  both  these  views ; for  he  says  it  was 
necessary  that  the  lymph  should  be  retarded  in  the 
glands,  that  it  might  undergo  all  the  changes  which 
these  organs  had  to  communicate  to  it.  Although  he 
confesses  his  ignorance  of  what  these  changes  pre- 
cisely are,  he  represents  the  intention  of  them  to  be 
the  production  of  a more  intimate  mixture,  a more  per- 
fect combination  of  the  elements  of  the  lymph,  and  to 
give  it  a certain  degree  of  animalization,  as,  he  says, 
is  proved  by  the  greater  tendency  of  the  lymi)h  to  con- 
crete, taken  from  the  vasa  efferentia,  or  discharged 
from  the  glands.  He  also  supposes  that  another  use 
of  the  glands  is  to  deprive  the  lymph  of  its  heteroge- 
neous parts,  or,  at  least,  to  alter  them  so  that  they  may 
do  no  harm  by  passing  into  the  circulation.  The  yel- 
low colour  of  the  glands,  in  which  the  lymphatics 
fVom  the  liver  ramify ; the  black  colour  of  the  bron- 
chial glands ; the  redness  of  the  mesenteric  glands  in 
animals  fed  with  madder  or  beet-root ; their  whiteness 
at  the  period  when  the  chyle  is  pervading  them ; are 
circumstances  regarded  by  Richerand  as  proving  that 
the  glands  tend  to  separate  the  colouring  matter  from 
the  lymph,  though  their  action  in  this  respect  may  not 
always  be  completely  efficient.  He  adds  that,  from 
numerous  arteries  in  the  texture  of  c-onglohate  glands, 
a serous  secretion  occurs,  which  dilutes  the  lymph, 
incrca-scsits  (juantity,  and  at  the  same  time  animaiizes 
it.— (.VoMueaur  EUm.  t.  1,  p.  276,  ed.  5.)  These  obser- 
vations, however,  are  only  conjectures,  wluch  absurdly 


ACK  17 

enough  endeavour  to  blend  together  the  doctrine  of  tho 
glands  rendering  the  lymph  thinner,  yet  more  disposed 
to  concrete. 

Mr.  Wilson,  and  some  other  anatomists  prior  to  him, 
affirmed,  that  they- had  succeeded  in  tracing  filaments) 
of  nerves  into  the  substance  of  the  absorbent  glands ; 
the  possibility  of  which,  however,  is.  not  generally  ad- 
mitted. These  contradictory  statements  are  to  be 
reconciled  by  the  consideration,  that  one  anatomist 
would  set  dowji  as  a minute  nervous  filament,  appa- 
rently derived  from  a large  unequivocal  nerve,  what 
another  would  doubt,  or  deny,  to  be  a real  continua- 
tion of  such  nerve ; for  anatomy,  like  most  other  pur- 
suits, cannot  be  prosecuted  to  extreme  minuteness 
without  leading  to  conjectures,  difference  of  opinion, 
doubts,  and  obscurity.  According  to  Bichat,  when  the 
lymphatic  glands  are  irritated  in  various  ways,  which 
is  easily  done,  they  do  not  appear  to  be  endued  with 
animal  sensibility ; but  it  may  be  developed  in  them, 
as  well  as  in  the  absorbent  vessels,  by  inflammation, 
which  raises  their  organic  sensibility  to  a great 
height. — {See  .Mnat.  Gdn.  t.  %p.  116.) 

The  changes  in  the  structure  and  size  of  the  lym- 
phatic glands,  brought  on  by  the  progress  of  age,  jus- 
tify the  presumption,  that  the  action  of  the  lymphatic 
system  undergoes  modifications  at  different  periods  qf 
life ; but,  on  this  point,  as  M.  Magendie  has  remarked, 
no  precise  information  exists. — {See  Precis  El6m.  de 
Physiol,  t.  2,  p.  202.)  Halier  believed  that  the  absorbent 
glands  were  of  greater  consequence  to  young  than 
adult  animals ; and  Mascagni,  Bichat,  and  all  the  best 
modern  anatomists,  coincide  respecting  their  greater 
size  and  turgidity  in  children  than  in  grown-up  persons. 
Whatever  use  may  be  ascribed  to  them,  it  is  natural  to 
suppose,  as  Dr.  Bostock  remarks,  that,  during  the 
growth  of  the  body,  a larger  quantity  of  nutritive 
matter  will  be  conveyed  into  the  blood,  and  must  pass 
through  these  organs. — {Elem.  Syst.  vol.  2,  p.  554.) 

In  the  foregoing  observations  on  the  functions  of  the 
lymphatic  system,  its  vessels  have  been  presumed  to  be 
the  true  instruments  of  absorption ; by  which  is  meant, 
not  merely  that  they  contain  lymph,  and  transmit  it 
into  the  venous  system,  a fact  of  whicli.no  doubt  is 
entertained  by  any  class  of  physiologists;  but,  that 
such  lymph  is  really  produced  by  the  operation  of  these 
vessels  upon  the  various  kinds  of  matter  presumed  to 
be  taken  up  by  them,  and  to  consist  of  alt  the  old  par- 
ticles of  every  texture  of  the  body,  the  fat,  the  earth 
of  the  bones,  and  the  superfluous  quantity  of  many 
different  secretions,  naturally  undergoing  continual 
renovation,  besides  the  chyle  which  is  taken  up  by  the 
lacteals,  and  conveyed  to  the  thoracic  duct,  or  common 
trunk  of  both  descriptions  of  vessels.  To  this  view 
of  the  subject,  some  physiologists  of  eminent  talents 
do  not  accede,  and  even  if  it  should  hereafter  be  de- 
cidedly proved  that  the  lymphatics  possess  the  power 
of  absorption,  the  tendency  of  numerous  experiments 
performed  by  M Magendie,  Fodera,  and  others,  is  to 
show  that,  at  all  even:s,  they  are  not  the  only  ab- 
sorbents, and  that  the  veins  are  "■ery  actively  concerned 
in  the  function. 

As  the  doctrine  of  absorption  is  one  that  is  insepara- 
bly interwoven  with  the  theory  of  disease  in  general, 
and  always  has  a powerful  influence  on  practice,  and 
the  choice  of  remedies,  I have  considered  the  subject 
highly  deserving  of  notice  in  this  work ; but  my  thanks 
are  due  to  Professor  M'Kenzie,  of  Glasgow,  for  his  kind- 
ness in  having  suggested  the  want  of  such  an  article  in 
the  book. 

ACETIC  ACID.  Vinegar.  Distilled  Vinegar.  Vine- 
gar is  of  considerable  use  in  surgery- ; mixed  with  fari- 
naceous substances  it  is  frequently  applied  to  sprained 
joints,  and,  in  conjunction  v/ith  alcohol  and  water,  it 
makes  an  eiigible  lotion  for  many  ca.ses,  in  which  it  is 
desirable  to  keep  up  an  evaporation  from  the  surface 
of  inflamed  parts.  Vinegar  was  once  considered  useful 
in  quickening  exfoliations,  which  effect  was  ascribed 
to  its  property  of  dissolving  phosphate  of  lime.  Its 
application  to  this  purpose,  however,  seems  hardly  ad- 
missible, for  reasons  which  will  be  well  understood 
from  a perusal  of  what  is  said  on  the  subject  of  JSTecro- 
si.t.  The  good  eflects  of  vinegar,  as  an  application  to 
burns  and  scalds,  were  taken  particular  notice  of  by 
Mr.  Clegtiorn,  a brewer  in  Edinburgh,  whose  senti- 
ments were  deemed  by  Mr.  Hunter  worthy  of  publica- 
tion.— (See  Med.  Facts  and  Obs.  vol  2,  and  the  art. 
Barns.) 


18 


ACU 


ALV 


Diluted  vinegar  is  sometimes  applied  to  the  eye. — | 
(See  CoUyrium  .^cidi  Acelici.)  In  the  fonn  of  ac  ol- 
lyrinm  it  is  alleged  to  he  the  best  lotion  for  clearing  the 
eye  of  any  small  particles  of  lime  which  happen  to 
have  fallen  into  and  become  adherent  to  it  on  the  inside 
of  the  eyelids. — .See  T.  Thomson's  Dispensatory, 

p.  ed  2. 

Conc-entrated  vmegar  is  sometimes  employed  for 
stopping  violent  hemorrhage  from  the  nose.  With  tliis 
view  it  may  be  used  either  as  an  injection  or  a lotion,  in 
wnich  lint  is  to  be  dipped  and  introduced  up  the  nostril. 

Vinegar  is  sometimes  employed  for  obviating  the 
smell  of  sick  rooms.  The  strongest  acevic  acid  which 
can  be  made  is  found  also  to  be  one  of  the  most  certain 
and  convenient  applications  for  the  destruction  of 
wans  and  corns,  care  being  taken  not  to  injure  the  sur- 
rounding skin  with  it. 

Acetic  acid  has  occa-sionally  been  recommended  as 
an  antidote  to  the  narcotic  poisons ; but  the  proofs  of 
this  are  quite  unsatisfactory,  and  the  chemical  history 
of  opium  and  other  narcotics  by  no  means  sanctions 
the  practice. — (Brandt's  Jilanual  of  Pharmacy,  p.  9, 
8co.  Load.  1825. 

The  pyroligneous  acid,  which  i.s  merely  strong  acetic 
acid  impregnated  with  empyreumatic  oil  and  bitumen, 
is  much  used  by  Mr.  Buchanan,  of  Hull,  as  an  ingre- 
diciU  in  applications  to  the  ear  in  certain  cases  of  deaf- 
ness.— See  Illustrations  of  Acoustic  Surgery,  8vu. 
Land.  1825.1 

ACHILLES,  Tendon  of.  See  Tendons. 

AC’ID.  See  Acetic  Add}  Muriatic  Acid  ; and  JW 
trous  and  jYitric  Ands. 

ACTUAL  CAUTEllV.  A heated  iron,  formerly 
much  used  in  surgery  for  the  extirpation  and  cure  of 
diseases.  Its  shape  was  adapted  to  different  cases, 
and  the  instrument  was  of  tenapplied  through  a cannula, 
in  order  that  no  injury  might  be  done  to  the  surround- 
ing parts.  Actual  cauteries  were  so  called  in  opposi- 
tion to  other  applications,  which,  though  they  were  not 
really  hot,  produced  the  same  effect  as  fire,  and  conse- 
quently were  named  virtual  or  potential  cauteries. 
The  actual  cautery  is  still  in  uke  upon  the  continent ; 
and  by  foreign  surgeons  we  are  not  unfrequcntly  criti- 
cised for  our  general  aversion  to  what  they  distinguish 
by  the  appellation  of  an  heroic  remedy.  I’outeau, 
Percy,  Dupuytren,  Larrey,  Roux,  Deljiech,  and  Mau- 
noir  are  all  advocates  for  the  practice ; and  the  latter 
gentleman,  when  he  was  in  England,  took  the  opportu- 
nity of  reminding  British  surgeons  of  their  error,  in 
totally  abandoning,  as  they  now  do,  the  employment 
of  heated  irons  in  the  business  of  tiieir  profession. — 
(See  Obs.  on  the  Use  of  the  Actual  Cautery,  Med.  Chir. 
Trans,  vol.  13,  p.  364,  Ac.) 

ACUPUNCTURE.  ' From  acas,  a needle,  and  i>  nngo, 
to  prick.;  The  operation  of  making  small  punctures 
in  certain  parts  of  the  body  with  a needle,  for  the  pur- 
pose of  relieving  diseases,  as  is  practised  in  Siam,  Ja- 
pan, and  other  oriental  countries,  for  the  cure  of  head- 
aches, lethargies,  convulsions,  colics,  Ac. — See  1 hil. 
Trans.  JYo.  148;  and  If  .lh.  Ten.  Hhyne,  de  Arlhri- 
tide  Man  issa  Schcmatica,  (S-c.  8ci;.  J.ond.  1683.,  Dr. 
Elliotson  has  tried  acujiuncture  very  extensively,  and 
his  experience  coincide.s  with  that  of  Mr.  Churchill,  con- 
firming the  fact,  that  as  a remedy  for  chronic  rheuma- 
tism it  answers  best  where  the  disorder  is  seated  in 
fleshy  parts.  He  also  finds  that  one  needle,  allowed  to 
remain  an  hour  or  two  in  the  part,  is  more  eliicient 
than  several,  used  but  for  a few  minutes. — See  Med. 
Chir.  Trans,  vol.  13,  /<.  467.  i Neuralgia  is  a disease  in 
which  the  practice  may  deserve  trial.  Local  paralysis 
is  another.  In  a modern  French  work  it  has  been 
highly  commended;  but  the  author  sets  so  rash  an 
extunple,  and  is  so  wild  in  his  expectations  of  what 
may  be  done  by  the  thrust  of  a needle,  that  the  tenour 
of  his  observations  will  not  meet\\ith  many  approvers. 
For  instance,  in  one  case,  he  ventured  to  pierce  the 
epigastric  region  so  deeply,  that  the  coats  of  the  sto- 
mach were  supposed  to  have  been  perforated  : this  was 
done  for  the  cure  of  an  obstinate  cough,  and  is  alhtred 
to  have  effected  a cure  I But  if  this  be  not  enough  to 
excite  wonder,  1 am  sure  the  author’s  suggestion  to 
run  a long  needle  into  the  right  ventricle  of  the  heart, 
in  cases  of  asphyxia,  must  create  that  sensation. — 
(See  Berlioz,  Mint,  snrles  Maladie.‘i  Chroniques,  et  sur 
V Acupuncture,  p.  305 — 309,  8co.  Paris,  1816.  Churchill 
on  Acupuncture,  1824;  Duntu,  Traite  de  V Acupunc- 
ture, 1826.) 


[ ADHESIVE  INFLAMMATION.  That  kind  of  in- 
flammation  which  makes  parts  of  the  body  adhere  or 
grow  together.  The  process  by  which  recent  incised 
wounds  are  united  without  any  suppuration,  and  fre- 
quently s>Tionymous  with  union  by  the  first  intention. 
— See  Union  by  the  First  Intention.) 

iEGYLOPS.  ' From  a goat,  and  iSi//,  an  eye.) 
A disease  so  named  from  the  supposition  that  goats 
.were  very  subject  to  it.  The  term  means  a sore  just 
under  the  inner  angle  of  the  eye. 

The  best  modern  surgeons  seem  to  consider  the  ffigy- 
lops  only  as  a stage  of  the  fistula*  lachryinalis.  Mr. 
Pott  remarks,  when  the  skin  covering  the  lachrymal  sac 
has  been  (or  some  time  inflamed,  or  subject  to  fre- 
quently returning  inflammations,  it  most  commonly 
hapjiens  that  the  puncta  lachrymalia  are  aflTected  by  it, 
and  the  fluid,  not  having  an  opiKirtuiiity  of  passing  off 
by  them,  di.stcnds  the  inflamed  skin,  so  that  at  last  it 
becomes  sloughy,  and  bursts  externally.  This  is  the 
state  of  the  disease  which  is  called  jierfect  aigylops 
or  aegylops. 

il^lgylops  was  a common  tenn  among  the  old  surgi- 
cal writers,  who  certainly  did  not  suspect  that  obstruc- 
tion in  the  lachrymal  parts  of  the  eye  is  so  frequently 
the  cause  of  the  sore  as  it  really  is.  The  skin  over  the 
lachrymal  sac  must  undoubtedly  be,  like  that  in  every 
other  situation,  subject  to  inflammation  and  abscesses ; 
but  we  do  not  find  that  sores  unconnected  with  disease 
of  the  lachrymal  sac  are  here  so  frequent  as  to  merit  a 
distinct  appellation. 

AG.\RIU.  A species  of  fungus  growing  on  the  oak, 
and  formerly  much  celebrated  for  its  efficacy  in  stop- 
ping bleeding. — See  Hemorrhage.) 

ALBUGO.  (From  albus,  white.)  A white  opa- 
city of  the  cornea,  not  of  a sujierficial  kind,  but  affect- 
ing the  very  substance  of  this  membrane.  The  disease 
is  similar  to  the  leui;oma,  with  which  it  will  be  consi- 
dered.— See  I-eucoina.) 

ALFHON'SIN.  The  name  of  an  instrument  for  ex- 
tracting balls.  It  is  so  called  from  the  name  of  its  in- 
ventor, Alphonso  Ferricr,  a Neapolitan  physician.  It 
consists  of  three  branche.s,  wluch  separate  from  each 
other  by  their  elasticity,  but  are  capable  of  being  closed 
by  means  of  a tube  in  wliich  they  are  included. 

ALUM.  An  Arabic  word.)  Alum  either  in  its  sim- 
ple state,  or  deprived  of  its  water  of  crystallization  by 
being  burnt,  has  long  been  used  in  surgery.  The  in- 
genious author  of  the  Fhannacopoeia  C'hirurgica  re- 
marks that,  except  for  external  use  as  a dry  powder, 
the  virtues  of  alum  are  not  improved  by  exposure  to 
fire.  Ten  grains  of  alum  made  into  a bolus  with  con- 
serves of  roses  are  given  thrice  a day  at  Guy’s  Hospi- 
tal in  internal  hemorrhages,  gleets,  and  other  case» 
demanding  jiowerful  astringent  remedies.  In  a relaxed 
state  of  the  urinary  passages,  or  want  of  pow  er  of  the 
sphincter  vcsicie,  small  doses  of  alum  have  been  found 
of  ser\ice.  Alum  is  employed  as  an  ingredient  in 
several  astringent  lotions,  gargles,  injections,  and  col- 
lyria.  Ur.  Groshuis,  a Dutch  physician,  first  recom- 
mended its  use  in  colica  pictonum,  and  Dr.  Perceval 
subsequently  joined  in  the  advice.  The  principle  on 
which  it  acts  is  that  of  decomposing  the  common  pre- 
parations of  lead,  and  converting  them  into  sulphates, 
which  are  comparatively  innoxious.  Burnt  alum, 
which  is  a mild  caustic,  is  a principal  ingredient  in 
many  styptic  powders. 

ALMNE  CONCRETIONS.  Comprehending  under 
this  head  both  gall-stones  and  intestinal  concretions, 
an  interesting  subject  presents  itself,  certain  parts  of 
which  have  been  cltiefly  elucidated  in  modern  times, 
as  will  be  hereafter  explained.  When  the  concretions 
voided  are  very  numerous  they  are  generally  gall- 
stones. Thus  Dr.  Coe  relates  an  instance  in  which 
seventy  were  discharged  in  one  day.  In  the  same 
short  time  Petemiarm  knew  of  seventy-tw'o  being 
voided  from  one  individual ; Birch,  one  hundred ; Bar- 
bette, Sloane,  and  Vogel,  two  hundred ; and  Russell, 
four  hundred.  A patient  under  the  care  of  Van  Swie- 
ten  had  voided  two  hundred,  and  was  still  continuing 
to  expel  others.  Riverius  speaks  of  another  patient 
who  had  voided  calculi  from  the  bow'els  (or  several 
years  whenever  he  went  to  stool. — Obserz.  Cominun.) 
Femelius  likevzise  adverts  to  cases  in  which  the  con- 
cretions evacuated  were  innumerable. — Pathol,  lib  6, 
cap.  9.  If  we  take  a view  of  alvine  concretions  gene- 
rally, and  include  all  their  different  kinds,  we  shall 
\ find  that  they  are  of  various  sizes.  Most  of  them  aia 


ALVIN E CONCRETIONS. 


19 


not  target  than  a pea  or  nut ; but  others  are  as  large 
as  an  orange,  and  weigh  four  pounds. — tSee  Monro’s 
Morbid  Anat.  of  the  Human  Gullet,  &c.  and  Medico- 
Chir.  Journ.  vol.  4,  p.  188.)  Morgagni  saw  one  which 
equalled  in  size  a moderate  finger,  and  Gooch,  Guet- 
tard,  Heuermann,  Mar^schal  (M^m.  de  I’Acad.  Royalc 
de  Chir.  t.  3,  p.  55  i,  and  others,  have  seen  concretions 
of  this  nature  which  were  too  bulky  to  pass  out  of  the 
rectum  without  surgical  aid.  In  certain  examples,  re- 
corded by  Heuermann  and  Mar^schal,  the  passage  of 
the  concretion  outwards  lacerated  the  sphincter  ani. 
Horstius  speaks  of  one  concretion  which  was  as  large 
as  an  apple  (Epist.  1.  2,  sect.  2,  Opp.  2,  p.  237),  and 
Marcellus  Donatus,  Schwind  (Schmucker’s  Verm. 
Schriften,  b.  2,  p.  129  . Hooke,  Venette,  and  Hecquet 
give  the  particulars  of  other  examples  in  which  the 
concretions  discharged  were  as  large  as  a hen’s  egg. 
Mr.  C.  White  extracted  two  from  the  rectum,  which 
were  nearly  as  big  as  the  fist  (Cases  in  Surgery,  p.  18) ; 
and  in  a boy  who  had  died  in  an  emaciated  state,  after 
continued  pain  in  the  abdomen,  attended  with  frequent 
attacks  of  ileus,  Mr.  Hey  found  in  the  transverse  arch  of 
the  colon  so  large  a concretion  that  it  could  not  pass 
any  farther  along,  the  bowel,  and  appeared  to  have 
been  the  sole  cause  of  the  boy’s  death.— ^Practical  Obs. 
in  Surgery,  p.  509,  ed.  2.)  An  analogous  case  is  also 
reported  by  White  (p.  28).  It  is  stated  in  the  Mem.  de 
I’Acad.  de  Chir.  that  Duhamel  saw  a concretion  that 
had  been  discharged,  which  was  two  inches  and  a half 
in  length,  one  inch  and  a half  in  diameter,  three  inches 
and  a half  in  circumference,  and  the  weight  of  which 
was  three  drachms  and  a half.  But,  judging  by  their 
weight,  how  much  larger  those  must  have  been  which 
were  seen  by  Scroekius  and  Lettsom,  and  weighed  ten 
drachms;  that  reported  by  Dolaeus,  wliich  weighed 
two  ounces ; that  recorded  by  Orteschi,  which,  besides 
weighing  two  ounces  two  drachms  and  a half,  is  said 
to  have  been  eight  inches  in  circumference,  and  to  have 
been  taken  out  by  force;  that  recorded  by  Schaar- 
schmidt,  which  weighed  four  ounces ; and  lastly,  the 
specimen  cited  by  Plouquet  Literatura  Med.  Dig.  vol. 
1,  p.  171),  the  weight  of  which  is  alleged  to  have  been 
half  a pound.— (Samml.  Med.  Wahr.  nehm.  b.  9,  p.  231.) 
It  is  observed  by  Rubini,  that  although  examples  of 
alvine  concretions  being  discharged  by  vomiting  are 
not  so  frequent  as  the  foregoing  cases,  yet  they  are 
tolerably  numerous.  Many  of  them  have  been  col- 
lected by  Schenck,  and  others  are  collected  by  Breyn 
(Phil.  Trans.  No.  479) ; by  Orteschi  in  his  Journal ; 
by  Moreali,  Dell’  Uscita  di  una  Pietra,  per  la  Via  del 
Esophago,  Modena,  1781) ; by  Borsieri ; and  by  a long 
list  of  other  writers,  whose  names  and  publications 
are  specified  by  Plouquet.- Lit.  Med.  Dig.  art.  Calcu- 
lus, Vomitus,  &c.) — With  this  class  of  substances, 
says  Rubini,  may  also  be  arranged  those  concretions 
which  are  found  upon  dissection  either  in  the  intes- 
tines or  stomach,  whence  probably  in  time  they  might 
have  been  expelled.  Facts  of  this  description  are  re- 
corded by  Portal,  Vicq  d’Azyr,  Jacquinelle,  Chandron, 
&c.  The  ca-ses  recited  by  White  and  Hey,  in  which 
the  colon  was  completely  obstructed,  I have  already 
mentioned;  and  to  the.se  may  be  added  the  instance 
quoted  by  Rubini,  in  which  Meckel  found  the  jejunum 
entirely  blocked  up  by  a similar  substance.— See  Pen- 
sieri  sulla  varia  origine  e natura  de  corpi  calcolosi, 
che  vengono  talvolta  espulsi  dal  tubo  gastrico,  Merno- 
ria,  p.  5 and  6,  4to.  Verona,  1808.) 

Rubini  ob.serves  that,  with  respect  to  the  origin  of 
alvine  concretions,  whether  discharged  from  the  ali- , 
mentary  canal  upwards  or  downwards,  some  of  them 
appear  to  be  formed  in  that  canal  itself,  while  others 
pass  into  it  from  other  situations;  and  they  all  admit 
of  being  distinguished  according  to  the  place  of  their 
origin  and  formation  into  three  kinds : 1.  hepatic,  or 
biliary;  2.  gastric,  or  intestinal;  and  3.  (what  this 
author  tenns , mixed,  or  hepatico-gastric.  Hepatic  al- 
vine concretions,  as  the  name  implies,  are  derived 
from  some  point  of  the  hepatic  system ; the  gastric,  or 
intestinal,  are  formed  within  the  alimentary  canal ; ' 
and  the  mixed  commence  in  the  hepatic  organs,  but 
afterward  get  into  the  bowels,  where  they  acquire  an 
increased  size. 

On  the  subject  of  hepatic  concretions,  or  biliary  cal- 
culi, or  gall-stones  ^as  they  are  usually  named  , there 
is  no  iH)int  of  the  system  where  they  do  not  occasion- 
ally form.  Riedlin  found  them  in  the  surface  of  the 
liver.  Sorbait  met  with  a biliary  calculus  as  large  as 

B2 


a goose’s  egg,  adhering  to  the  peritoneal  covering  of 
the  liver,  and  a similar  case  is  recorded  by  Benivenio. 
Tallon,  Pomme,  Saurau,  and  Heberden  have  seen  cal- 
culi within  the  substance  of  the  liver ; while  Blasius, 
Fallopius,  Columbus,  Ruysch,  Henricus  ab  Heers,  and 
Morgagni  record  examples,  in  which  the  concretions 
were  in  the  parenchyma  of  that  organ.  Plater,  Rever- 
horst,  Glisson,  Morgagni,  and  Walter  have  seen  them 
in  the  biliary  ducts,  as  probably  were  those  which  Co- 
lumbus and  Camenicus  say  they  found  in  the  vena 
portae.  Walther  and  Dietrick  found  calculi  in  the 
ductus  hepaticus;  Ruysch  and  Soemmering  in  the 
ductus  cysticus ; and  Dietrick,  Galeazzi,  and  Richter, 
in  the  ductus  choledoclts.  Greisel,  Benivenio,  Eller, 
Morgagni,  Dargeat,  and  D’Hervillay  have  seen  calculi 
included  in  morbid  cysts,  attached  either  to  the  liver  or 
the  gall-bladder.  The  place,  however,  where  calculi 
are  found  in  the  greatest  number,  and  with  most  fre- 
quency, is  the  cavity  of  the  gall-bladder  itself.  Here 
they  are  sometimes  single,  their  size  varying  up  to  a 
magnitude  completely  filling  that  cavity,  as  Saye  ( Joum. 
des  Savans,  Sept.  1697;,  Halle,  and  Isenflamm  have 
noticed : while  sometimes  their  number  amounts  to  a 
hundred,  or  even  a thousand,  of  diflerent  sizes.  Rubini 
possesses  a gall-bladder,  which  contains  above  a hun- 
dred small  calculi,  and  formerly  I had  a similar  num- 
ber, which  I found  in  the  body  of  a female.  Van 
Swieten  met  with  a hundred  ; Haller,  a hundred  and 
Ibrty ; Stieber,  two  hundred ; F.  Plater,  three  hun- 
dred; Walther,  five  hundred;  Mentski,  seven  hundred; 
Bailiie,  a thousand ; Hunter,  eleven  hundred  ; Parb,  six- 
teen hundred ; Stork,  two  thousand ; and  Meckel,  several 
thousands. — Handb.  der  Pathol.  Anat.  b.  2,  p.  400.) 

All  hepatic  concretions,  however,  are  not  calculated 
to  pass  from  the  place  of  their  origin  into  the  intes- 
tines, but  only  such  as  are  situated  in  the  ductus  hepa- 
ticus, or  its  main  branches,  in  the  gall-bladder,  the 
ductus  cysticus,  or  the  ductus  choledocus.  When 
their  size  is  not  disproportionate  to  the  diameter  of  the 
ducts,  they  pass  with  facility;  but,  when  their  dimen- 
sions are  larger  than  those  ducts  can  naturally  athnit, 
the  latter  becomes  stretched  and  dilated,  whence  arise 
-the  sharp  pains  and  colic  which  attend  the  disorder, 
analogous  to  the  sufferings  produced  by  the  descent  of 
large  calculi  from  the  kidneys  to  the  bladder.  Tlie 
reality  of  these  dilatations  of  the  hepatic  ducts  is 
proved  by  dissection.  Heister  found  the  orifice  of  the 
ductus  choledocus,  which  is  usually  very  small,  so 
much  enlarged  that  it  could  receive  a finger;  and  Vita| 
d’Azyr  satv  this  duct  enlarged  through  its  whole  ex- 
tent in  a similar  degree. — Hist,  de  la  Sociitfe  Royale 
de  Medecine,  an.  1779,  p.  220.)  Galeazzi,  in  di.ssecting 
a body,  found  the  ductus  choledocus  so  dilated,  that  it 
resembled  a kind  of  bag,  in  which  several  calculi  were 
included.  Mr.  Thomas  has  likewise  seen  two  cases, 
in  which  the  point  of  the  fore-finger  readily  passed  from 
the  duodenum  into  the  gall-bladder.— i See  Med.  Chir. 
Trans,  vol.  6,  p.  105.  Morgagni  saw  this  duct  in  one 
instance  large  enough  to  hold  a coujile  of  lingers,  and 
he  quotes  many  similar  instances  from  Bezold,  Trew, 
V’erney,  and  others.  W’e  may  conceive  how  dilated 
this  tube  must  have  been  in  a case  recorded  by  Rich- 
ter, where,  though  it  was  not  completely  obstructed,  a 
calculus  weighing  three  ounces  and  a half  was  lodged 
within  it. — (Rubini,  op.  cit.  p.  7 — 10.) 

With  regard  to  those  concretions  tvhich  are  distin- 
guished by  the  epithet  gastric,  or  intestinal,  some 
are  formed  in  the  cavity  of  the  stomach ; the  rest  in 
one  or  other  of  the  intestines.  They  remain  for  a 
greater  or  less  period  in  the  place  of  their  formation, 
according  as  they  happen  to  be  lighter  or  heavier, 
smoother  or  rougher,  more  or  less  adherent,  or  as 
local  or  general  circumstances  are  more  or  less  favoura- 
ble to  their  retention  or  expulsion-  Sometimes,  they 
continue  undischarged  until  they  have  attained  a very 
considerable  size.  In  particular  instances,  instead  of 
remaining  constantly  in  one  place,  they  successively 
pass  through  the  whole  intestinal  tube,  lodging  at  dif- 
ferent points  for  a greater  or  less. time.  In  the  works 
of  Haller  and  (Jonradi  may  be  seen  representations  of 
the  fKiints  of  the  inte.stinal  canal,  where  these  concre- 
tioihs  have  been  found.  The  alvine  concretion,  of 
whi(;h  Mari'.schal  has  given  an  account,  was  some 
years  in  traversing  ali  the  convolutions  of  the  bowels. 
These  gastric  or  alvine  concretions,  which  are  very 
common  in  animals,  are  less  freciuent  in  the  hujnan 
subject,  as  is  proved  by  the  observations  of  Fourcroy 


20 


ALVIXE  COXCKETiOXS. 


and  Vauquelin,  inserted  in  their  valuable  essay  on  this 
subject  in  the  Aimales  du  Museum  Nationale  d’His- 
loire  Naturelle  de  Pans.  In  the  horse  they  are  some- 
times of  an  enormous  size,  as  we  may  learn  from  an  in- 
stance on  record,  in  which  the  concretion  weighed 
thirteen  pounds. — (Voigt,  .Magazin  Kir  das  Neueste  der 
Naturkunde,  b.  3,  p.  578.) 

As  for  the  third  species,  which  Rubini  names  mixed, 
or  hepatico-gastric,  they  have  their  beginning  m the 
hepatic  organs,  and  augment  in  the  intestinal  tube. 
Here,  if  the  extraneous  body  be  detained,  and  the  con- 
tents of  the  bowels  have  a di.sposition  to  become  thick- 
ened and  condensed  round  it,  as  a nucleus,  it  may  be 
rendered  larger  by  additional  strata  of  matter,  and 
would  increase  sine  fine,  it  a stop  were  not  put  to  the 
augmentation  by  the  narrowness  of  the  canal,  or 
an  efi'ort  made  for  the  expulsion  of  the  concretion. 
Morgaigni  cites  two  instances  of  this  sort  of  concre- 
tion; one  from  Gemma,  the  other  from  IJezold;  and 
he  gives  his  ojiinion  that  another  alvine  calculus, 
spoken  of  by  Vater,  must  have  been  of  the  same  nature. 
Dr.  Coe  describes  another  interc.sting  specimen;  and 
others  are  referred  to  by  Vandermonde,  (Moreali,  Por- 
tal, Ac.  Perhaps,  says  Rubini,  tlie  instances  ol  this 
kind  would  have  been  more  numerous  if  all  the  con- 
cretions discharged  from  the  bowels  had  been  noted 
with  greater  attention,  and  the  hepatico-gastric  sub- 
stances not  confounded  w ith  the  hcjiatic.  The  lodge- 
ment of  the.se  concretions  i’.i  trie  intestinal  cuiial  is  of 
uncertain  duration,  and  depends  ui>on  a vanety  of  cir- 
cumstances. Vandermonde  give.s  the  history  of  a cal- 
culus, wliich,  as  far  as  could  be  judged  of  by  the  pain 
in  the  right  hypochoiidrium,  and  the  change  of  symp- 
toms, must  have  passed  into  the  duodenum  in  the 
month  of  January,  and  then  continued  m the  bowels 
until  August,  when  it  was  discharged  from  the  rectum. 

The  crystallized  aiipearance  of  alvine  concretions  is 
generally  so  conspicuous,  that  it  has  not  escaped  the 
attention  of  several  of  the  old  writers,  as  we  may  con- 
vince ourselves  by  referring  to  the  works  of  Corn, 
Gemma,  Greisel,  Haglivi,  Scultctus,  Ac.  It  was  no- 
ticed by  Haller  in  his  Rleinenta  Physiologiae,  vol.  6, 
and  by  Morgagni  in  his  Episi.  3.,  de  Sedibus  ct  t'au- 
sis,  Ac.  If,  says  Rubini,  these  crystallizations  are  not ' 
always  plainly  visible,  distinct,  and  regular,  this  de- 
pends either  upon  their  imperfection,  th6  heteroge- 
neous nature  of  the  accumulated  matter,  or  particular 
unfavourable  circumstances,  which  wouid  equally  af- 
fect the  process  of  crystallization  out  of  the  body. 

Now,  as  all  crystallizatiotis  dej,end  u])on  the  fluids 
in  wlxich  they  form,  and  from  which  they  receive  their 
crystallizing  elements,  it  must  be  evident  that,  in- 
asmuch as  the  fluids  of  the  hepatic  organs  difler  in 
their  constituent  principles  from  the  fluids  contained 
m the  intestinal  canal,  the  concretions  produced  in  the 
first  system  must  differ  from  those  originating  in  the 
second;  while  tfie  hepatico-gastric  calculi  will  com- 
bine the  nature  and  jiroperties  of  both  togeixier. 

The  fluid  from  which  hepatic  concretions  are  fonned 
IS  unquestionably  the  bile,  either  some  or  all  its  ingre- 
dients entering  into  their  comiiosition.  Indeed,  pre- 
viously to  the  new  chemical  doctrines,  hepatic  calculi 
were  generally  considered  as  being  simply  condensed 
indurated  bile. 

From  investigations  made  in  more  modern  times,  how- 
ever, when  the  art  of  analysis  ha-s  attained  a precision 
of  which  the  old  chemistry  was  not  susceptible,  it  ap- 
pears, that  although  human  biliary  calculi  yield  the 
same  products  as  the  bile,  there  is  contained  in  them 
more  or  less  of  a peculiar  substance,  which  was 
named  by  the  celebrated  Fourcroy,  adi^cere. — M^m. 
de  I’Acad.  des  Sciences,  1789,  p.  323.  The  presence 
of  this  substance  in  the  concretion  is  of  such  import- 
ance, that,  when  it  is  abundant  and  in  large  propor- 
tion, the  calculus  is  regular  and  the  crysttdlization 
well  finished ; and,  when  it  is  in  small  quantity,  the 
crystallization  is  confused  and  disordered,  the  calculus 
only  exhibiting  an  irregular  misshapen  concretion,  more 
like  a clot  than  true  crystals.  The  kind  of  adipocere 
constituting  the  base. of  all  human  biliary  calculi,  has 
some  resemblance  to  spermaceti.  Both  Fourcroy  and 
Dr.  Bostock,  who  analyzed  it,  found  it  cornpo.sed  en- 
tirely of  carbon,  hydrogen,  ai;d  oxygen.  It  melts,  but 
requires  a heat  .superior  to  that  of  boiling  w'ater ; in 
fusion  it  has  a smell  like  wax,  and  on  cooling,  forms  a 
substance,  w’hich  breaks  into  crystalline  laminae.  It 
is  not  soluble  in  aicoaol  in  the  cold;  but  when  the  al- 


cohol is  boiled  on  it,  it  is  dissolved  in  a proportion,  ac- 
cording to  Fourcroy,  of  one  part  in  nineteen — accord 
ing  to  Dr.  Bostock,  one  m thirty. — .Nicholson’s  Jour- 
nal, 8vo.  vol.  4,  p.  137.)  The  solution,  when  it  cools, 
dejiosites  light  brilliant  scales.  It  is  soluble  in  ether  m 
the  cold,  and  more  abundantly  if  the  ether  be  heated. 
Oil  of  turpentine  generally  dissolves  biliary  calculi ; 
and,  according  to  Gren,  it  dissolves  those  which  con- 
sist almost  entirely  of  this  pecuhar  matter;  yet  Dr. 
Bostock  has  remarked,  that  oil  of  turpentine  acts  on  it 
with  dirticulty,  and  even  when  digested  with  it,  at  a 
boiling  heat,  dissolves  it  only  in  a small  degree.  Pure 
soda  and  potassa  dissolve  it  completely,  and  reduce  it 
to  a saponaceous  state.  Ammonia,  as  Dr.  Bostock  has 
remarked,  exerts  little  action  on  it,  except  w hen  boil- 
ing. Nitric  acid  dissolves  it,  and,  according  to  Four- 
croy, converts  it  into  a sjxscies  of  liquid  sniular  to  the 
oil  of  camphor.  This  becomes  concrete,  but  w ithout 
any  cry  stalline  structure,  and  is  more  soluble  in  ether 
and  the  alkalis  than  the  original  matter. 

“This  substance  Fourcroy  has  observed'  is  con- 
tained in  greater  or  less  quantity  in  nearly  all  human 
biliary  calculi,  more  or  le.ss  intermixed  with  other  mat- 
ter, but  sfill  so  far  predominant  as  to  form  their  basis. 
Hence,  they  iiarlake  of  its  jiroperties;  are  fusible,  in- 
flammable, and  more  or  less  -soluble  in  the  agents 
which  dissolve  it.” — See  Murray’s  Syst.  of  Chemist, 
vol.  4,  j).  591,  ed.  2.  Fourcroy,  on  exjiosing  the  above 
peculiar  substance  to  the  action  of  oxygenated  muria- 
tic acid,  saw  it  whitened,  and  afterward  resume  its 
former  silvery  hue.  However,  Jlubiiii  repeated  this 
exiieriment,  and  found  that  the  whiteness  which  was 
contracted  remained  penuaiient. 

While  the  hejiatic  system  contains  a fluid  which  is 
always  nearly  of  the  same  quality,  viz.  the  bile,  the 
alimentary  canal,  as  Rubini  observes,  contains  a hun- 
dred diflerent  fluids,  and  is  continually  occupied  by 
substances  of  various  natures,  kinds,  and  properties, 
consisting  of  food,  drink,  and  several  secretions.  All 
the  princijiles  which  are  to  serx'e  for  the  fonnation  and 
renewal  of  the  different  species  of  living  solids,  and  of 
the  many  kinds  of  fluids^  at  first  remain  more  or  less 
time  in  the  alimentary  canal,  and  there  undergo  pecu- 
liar changes.  All  the  princijiles  w liich,  under  different 
rircumsiances,  may  contribute  to  the  jiroduction  of 
morbid  concretions,  either  in  the  gall-bl.adder,  the  uri- 
nary bladder,  the  kidneys,  or  in  any  other  part  of  the 
body,  where  they  ever  occur,  pass  at  first  into  the  in- 
testinal canal,  where  they  continue  for  some  time. 
Such  a niultijilicity  of  principles,  disposed  to  crystal- 
lize, and  be  converted  into  calculi,  would  very  often, 
almost  daily,  produce  these  concretions  in  the  bowels, 
were  there  not  many  circumstances  wtiich  counter- 
act this  tendency,  as,  for  instance,  exercise,  the  in- 
ce.ssant  motion  of  the  matter  itself  along  the  intestinal 
tube,  the  variety  of  these  element-s,  whereby  their  re- 
quisite tendency  to  'onite  is  disturbed,  and  the  decom- 
posing and  reconijmsing  influence  of  the  gastric  secre- 
tions, whereby  parts  are  united,  disposed  of,  dissolved, 
and  analogous  matter  kept  divided,  Ac.  But  when- 
ver  these  circumstances  tire  not  actively  operating,  as 
may  be  the  case  in  a noose,  or  fold  of  the  bowels,  or 
in  some  preternatural  cyst  belonging  to  them ; when- 
ever the  intestinal  fluids  undergo  such  an  alteration 
that  the  production  of  these  concretions  cannot  be  pre- 
vented ; or,  lastly,  whenever  some  favourable  circum- 
stance, such  as  an  extraneous  nucleus,  forms  a centre 
of  reunion  for  particular  elements ; then  the  saline 
matter,  w liich  is  most  disjiosed  to  crystallize,  and  the 
earthy  and  mucilaginous  substances,  Ac.,  are  attracted 
together,  and  produce  more  or  less  perfect  crystalliza- 
tions. A chemical  analysis  of  some  intestinal  calculi, 
first  made  by  Konig,  and  aftenvard  by  Slare  Philo- 
sophical Transactions;,  proves,  that  when  they  are  ex- 
posed to  a strong  heat  in  distillation,  they  yield  water, 
ammonia,  and  a lixivious  salt,  a caput  mortuum  re- 
mtiining  behind.  Cadet,  in  analyzing  a similar  concre- 
tion, found,  in  addition  to  the  above  jiroducts,  phospho- 
ms.  The  muriate  of  ammonia  was  afterward  disco- 
•vered;  and  Gioberti,  Fourproy,  and  Vauquelin,  in  their 
histones  of  the  intestinal  concretions  met  with  in  ani- 
mals, describe  them  as  comjio.sed  of  the  acidulous 
phospate  of  lime,  phosphate  of  magnesia,  and  of  the 
ammoniacal-mague.sian  phosphate. 

Some  specimens  lontained  in  the  Edinburgh  mu- 
seum were  very  carefully  examined  by  Dr.  T.  Thom- 
s'c.a  : they  at  first  swam  in  v.  ater,  but  afterward  sunk ; 


ALViNE  CONCRETIONS. 


21 


the  specific  gravity  varying  from  1.376  to  1.540.  Cold 
water  acquired  from  them  a brownish  tinge,  and  took 
up  albumen,  wltich  separated  in  white  flakes  by  boil- 
ing. There  was  also  a peculiar  brown  substance,  at 
first  dissolving  in  water,  but  rendered  nearly  insoluble 
by  slow  evaporation ; soluble  in  alcohol ; and  most 
nearly  resembling  vegetable  extract.  The  specimens 
likewise  contained  muriate  of  soda,  crystallizing  on 
spontaneous  eva^toration  of  the  water;  phosphate  of 
lime,  precipitated  b7  ammonia;  sulphate  of  soda  in 
minute  proportion;  and,  perhaps,  sulphate  of  lime. 
Alcohol  dissolved  the  peculiar  brown  matter  and  some 
of  the  salts ; caustic  potash,  the  albumen,  brown  mat- 
ter, and  perhaps  some  of  the  salts ; and  muriatic  acid 
a proportion  of  phosphate  of  lime.  After  ail,  there  re- 
mained a peculiar  substance,  having  the  colour  and 
texture  of  the  calculus ; in  very  short  threads,  light, 
resembling  cork,  or  rather  agaric ; tasteless,  insoluble 
in  water,  alcohol,  other,  potash-ley,  and  muriatic  acid ; 
being  blackened,  and  partly  reduced  to  charcoal  by 
sulphuric  acid;  slowly  dissolving  by  heat,  without 
effervescence,  in  nitric  acid ; and  leaving  on  evapora- 
tion a whitish  residue,  of  bitter  taste,  and  imperfectly 
soluble  in  water;  burning  with  a bright  flame;  but 
differing  from  all  other  animal  and  vegetable  substances 
hitherto  examined,  and  distinguishable  from  wood, 
by  its  insolubility  in  potash-ley.  The  calculi  consisted 
of  alternate  layers,  or  intimate  mixtures  of  this  sub- 
stance and  phosphate  of  lime,  to  which  the  albumen 
and  brown  matter  served  as  a cement,  the  other  sub- 
stances being  in  small  proportions.  Phosphate  of  lime 
mixed  with  a brown  animal  matter,  formed  the  exter- 
nal crust  of  some  of  the  specimens.  On  the  surface 
of  a few  were  noticed  crystals  of  phosphate  of  ammonia 
and  magnesia.  The  presence  of  neither  potash,  am- 
monia, carbonate  of  lime,  uric  acid,  nor  urea  could  be 
detected. 

Varieties'  have  also  been  found  by  Dr.  Henry  and 
Mr.  Brande,  exclusively  composed  of  magnesia,  of 
which  the  patients  had  been  in  the  habit  of  taking  vast 
quantities. — See  Thomson’s  Obs.  in  Monro’s  Morbid 
Anatomy  of  the  Human  Gullet,  &;c.  p.  36,  or  in  Medico- 
Chir.  Journ.  voj.  4,  p.  188,  189.) 

From  observations  made  by  Dr.  Wollaston,  it  ap- 
pears probable,  that  the  above  fibrous,  light,  thready 
substance  is  derived  from  oats,  which  are  so  commonly 
taken  as  food  in  Scotland.  • 

If  the  oat-seed  be  divested  of  its  husk,  minute 
needles  or  beards,  forming  a small  brush,  are  seen 
planted  at  one  of  its  ends.  Dr.  Wollaston,  on  examin- 
ing these  needles  and  comparing  them  with  similar 
ones  detached  from  the  calculi,  and  forming  the  velvet 
substance  in  question,  satisfied  himself,  beyond  all 
doubt,  of  their  perfect  identity.” — Marcet  on  Calcu- 
lous Disorders,  p.  130,  8vo.  London,  1817.) 

The  specimen  analyzed  by  Dr.  Ure,  he  inferred  to  be 
a modification  of  ambergris. — Diet,  of  Chemistry,  art. 
Intestinal  Concretions,  j 

As  for  the  mixed  or  hepatico-gastric  calculi,  they 
have  for  their  nucleus  a biliary  concretion,  round  which 
other  substances  contained  in  the  bowels  adhere; 
hence,  it  is  evident,  that  as  they  are  formed  at  two  dis- 
tinct periods  in  two  different  situations,  and  among  va- 
rious fluids,  two  distinct  compositions  must  Be  the  re- 
sult. Although,  says  Kubini,  there  has  hitherto  been 
no  scientific  analysis  of  tliis  species  of  calculus,  ex- 
cepting the  very  imperfect  one  by  Moreali,  reason 
shows  clearly  enough,  that,  if  two  separate  analyses 
were  made,  one  of  the  nucleus,  the  other  of  the  sur- 
rounding matter,  there  would  be  obtained  from  the 
nucleus  the  same  elements  as  those  of  an  hepatic  cal- 
culus, and  from  the  rest  those  of  an  intestinal  concre- 
tion.— :See  Pensieri  sulla  Varia  Origine,  <kc.  de’  Corpi 
calcolosi  che  vengono  espulsi  dal  tubo  gastrico,  p.  15 — 
17..' 

As  the  same  author  remarks,  the  foregoing  princi- 
ples will  enable  us  to  determine  with  greater  precision 
than  formerly,  the  characters  which  appertain  to  the 
several  classes  of  calculi  liable  to  be  voided  from  the 
intestinal  canal ; characters,  by  means  of  which  there 
can  be  no  difficulty  in  deciding,  from  the  appearance 
of  one  of  the.se  concretions,  the  jilace  of  its  origin,  and 
its  peculiar  nature.  'I'he  hepatic  calculus  being  com- 
posed of  bile,  and  also  of  adipocere,  its  characters  will 
be  such  as  indicate  the  predominance  of  a uniform, 
oleaginous,  and  (what  Ilubini  terms,  a well-anirnalized 
principle.  The  gastric  or  intestinal  calculus,  arising 


I from  the  union  of  various  salts,  earths,  and  other  prin- 
ciples, which  happen  to  be  in  the  alimentary  canal, 
will  liave  very  different  characters,  generally  indicating 
its  earthy  saline  composition.  Lastly,  the  hepatico- 
gastric  calculus  will  present  a union  of  the  different 
characters;  viz  in  the  centre,  the  characters  of  the 
hepatic  calculus ; more  externally,  those  of  the  gastric. 

The  criteria  for  distinguishing  the  several  kinds  of 
calculi  from  each  other  may  be  divided  into  such  as 
may  be  termed  external,  being  derived  from  accidental 
circumstances  attending  the  foreign  body ; and  others, 
which  may  be  called  internal,  being  deduced  from  the 
inherent  characters  belonging  to  the  composition  and 
nature  of  these  concretions. 

The  first  of  these  external  criteria  is  the  age  of  the 
patient.  C.  Stephanus  Hoffmann,  Durande,  and  Mor- 
gagni all  agree,  that  biliary  calculi  seldom  occur,  ex- 
cept in  subjects  of  advanced  age,  and  never  in  youth. 
And  Haller  writes,  “Juniores  et  pueros,  quantum 
novi,  numquam  adlligit  morbus.”  Morgagni  met  with 
.sixty-one  old  persons  who  had  alvine  concretions,  but 
with  oijiy  eight  young  persons,  not  one  of  whom  was 
a child,  the  youngest  being  twelve  years  of  age,  and  the 
eldest  twenty-nine.  To  these  I may  add  the  instance 
reported  by  Saye,  in  which  a stone  as  large  as  a hen’s 
egg  was  found  in  the  gall-bladder  of  a young  female 
aged  only  twelve. — See  .lourn.  des  Savans,  Sept. 
1697.)  The  cause  of  this  difference  is  attempted  to  be 
explained  by  Morgagni ; but,  probably,  a more  rational 
explanation  than  that  suggested  by  him,  will  be  found 
in  the  analysis  of  the  bile  of  old  and  young  subjects, 
as  made  by  Fourcroy  and  other  modern  chemists. 
From  these  and  other  observations,  collected  by  Ru- 
bini,  it  is  rational  to  conclude,  that  when  an  alvine 
concretion  is  discharged  from  a young  subject,  the 
chances  are,  that  it  is  not  a biliary  one ; though  if  the 
patient  be  of  advanced  age,  it  is  not  to  be  inferred,  that 
the  foreign  substance  expelled  must  certainly  be  hepa- 
tic, because  gastric  or  intestinal  concretions  are  com- 
mon to  individuals  of  every  age.—  Rubini,  op.  cit.  p. 
18.)  Indeed,  with  the  latter  kiiid  of  calculi,  men  of 
advanced  age  and  women  are  said  to  be  most  frequently 
afllicted ; children  and  young  persons  rarely  suffering, 
unless  the  formation  of  such  bodies  has  been  produced 
by  the  presence  of  fruit-stones,  or  other  indigestible 
substances,  which  serve  as  nuclei. — Richerand,  Noso- 
graphie  Chir.  t.  3,  p.  433,  ed.  4.)  These  concretions  are 
also  sometimes  formed  in  patients  who  have  been 
confined  by  disease  a long  wlule  in  a recumbent  pos- 
ture. 

The  second  criterion  is  drawn  from  the  symptoms, 
which  precede  or  accompany  the  expulsion  of  the  cal- 
culus. Sense  of  heaviness,  irritation,  and  pain  in  the 
region  of  the  liver,  pain  about  the  ensiform  cartilage 
and  navel,  bilious  vomiting,  jaundice,  and  either  loose- 
ness of  the  bowels  or  constipation,  are  the  symptoms 
which  e.specially  when  they  frequently  occur;  indicate 
the  hejiatic  origin  of  the  calculus,  and  proceed  from  its 
passing  through  the  narrow  ducts  of  the  liver  or  gall- 
bladder towards  the  intestines.  The  most  careful  ob- 
servations have  proved,  however,  that  these  symptoms 
are  only  to  be  depended  upon  when  taken  collectively, 
and  that  no  single  one  gives  any  certain  information. 
Also,  if  their  presence  be  suificient  to  prove  the  hepa- 
tic origin  of  the  calculus,  their  absence  can  by  no 
means  be  regarded  as  a proof  of  the  concretion  being 
of  the  intestinal  kind. — Rubini,  p.  19.) 

Third  criterion.  A calculus  voided  may  be  set  down 
as  undoubtedly  hepatic,  if  accompanied  by  others  un- 
equivocally of  this  nature.  In  a case  recorded  by  Brun- 
ner, and  in  anothei  by  Vater,  the  absence  of  certain 
symptoms  in  the  first,  and  the  magnitude  of  the  calcu- 
lus in  the  second,  created  doubts  whether  the  concre- 
tions were  not  more  likely  to  be  of  the  intestinal  kind, 
than  of  the  hepatic.  At  length,  the  bodies  having  been 
opened,  the  presence  of  other  similar  calculi  in  the 
gall-bladders  afforded  an  adequate  criterion. 

Morgagni  lays  down  a fourth  criterion,  deduced  fVom 
the  number  of  the  calculi  voided;  which,  if  very  nu- 
merous, are  to  be  considered  as  biliary.  Rubini  points 
out,  however,  the  fallacy  of  this  test ; both  hepatic  and 
gastric  concretions  being  sometimes  single,  sometirnos 
in  various  numbers  even  up  to  a thousand;  and  he 
refers  to  a case  where  a very  large  number  of  concretions 
of  the  gastric  descri()tion  were  voided,  as  leported  by 
Ivoriig.  The  test  here  suggested,  however,  may  be 
consulered  as  generally  valid ; for,  the  number  of  in- 


22 


ALVLNE  CONCRETIOiXS. 


testinal  concretions  is  rarely  inore  than  two,  though 
Boinetiines  very  considerable. — ,T.  Thomson.  See 
Med.  Chir.  Jonrn.  vol.  4,  p.  189.) 

I shall  now  follow  Rubini,  and  notice  those  charac- 
ters of  alvine  concretions,  which  he  calls  internal,  and 
are  deduced  fVom  their  quality  and  composition,  begin- 
ning with  the  criterion  furnished  by  the  size  of  the  e.x- 
traneous  substance  voided.  As  the  biliary  ducts  are 
narrow,  it  is  obvious,  that  if  the  calculus  be  above  a 
certain  size,  it  cannot  have  passed  in  this  state  sud- 
denly through  those  narrow  tubes,  and  con.sequently 
must  be  either  of  the  gastric  description  or  mixed, 
having  quitted  the  hepatic  system  while  small,  and 
afterward  increa.sed  within  the  alimentary  canal.  Tn- 
questionably,  as  Rubini  admits,  this  criterion  has  con- 
siderable weight,  especially  whtni  the  discharge  of  the 
calculus  has  not  been  preceded  by  pain,  or  other  synij)- 
toms  indicating  such  violent  distention,  as  the  above 
ducts  must  have  suffered  from  the  passage  of  the 
foreign  body.  The.se  are  certainly  cajiable  of  being 
dilated  in  a remarkable  degree,  as  some  facts,  already- 
noticed  in  this  article,  sufficiently  prove;  but  such 
dilatation  can  never  hapjien  without  pain,  irritation, 
and  a serious  train  of  sympathetic  effects.  Rubini  re- 
marks, this  criterion  will  only  apply  to  large,  and  not 
to  diminutive  concretions.  A biliary  calculus,  of  pro- 
digious size,  was  found  by  Mr.  Brayne,  of  Banbury,  to 
have  passed  by  ulceration  directly  from  the  cavity  of 
the  gall-bladder  into  that  of  the  duodenum,  whence  it 
made  its  way  through  the  rest  of  the  bo\yels,  and  was 
voided  from  the  anus. — See  Med.  Chir,  Trans,  vol.  1‘2.) 

A second  criterion  is  the  colour  of  the  calculus ; 
a test  admitted  by  Moreau,  who  asserts,  that  biliary 
calculi  are  yellow  or  green,  and  intestinal  ones  gray- 
ish brown  or  black.  But,  says  Rubini,  one  need  only 
look  at  various  specimens  of  alvine  concretions,  and 
read  the  statements  of  authors  who  have  seen  a great 
many  of  then>,  particularly  Morgagni  and  Soemmer- 
ing, to  comprehend,  that  any  criterion  deduced  tVom 
their  colour  is  most  fallacious,  every  species  of  them 
presenting  great  variety  in  this  particular.  And  it  is  to 
be  remembered,  that  the  bile  and  the  intestinal  fluids, 
whence  these  concretions  arc  formed,  differ  in  colour 
in  different  individuals,  according  to  a variety  of  cir- 
cumstances, in  health  and  disease.  One  species  of 
hepatic  calculus  has  a white  colour,  but  is  sometimes 
yellow  or  greenish.  Another  is  of  a round  or  poly- 
gonal shajie,  and  often  of  a gray  colour  externally,  and 
brown  within.  A third  is  of  a deep  brown  or  green 
colour.— (See  Ure’s  Diet,  of  Chemistry,  art.  finll- 
stones.)  The  smaller  intestinal  concretions  examined 
by  Dr,  T,  Thomson,  destitute  of  coating,  resembled 
bad  yellow  ochre  ; the  larger  were  encrusted  with  an 
earthy  matter,  of  a coffee  colour,  and  puri)le  or  some- 
times white. — (See  Monro  on  the  Human  Gullet,  «fcc,, 
and  Med.  Chir.  .lourn.  vol.  4,  p.  188.) 

Third  criterion.  The  presence  or  absence  of  a nu- 
cleus will  enable  one  to  judge  w'hether  a calculus  be 
gastric  or  hepatic.  A biliary  concretion  has  no  nucleus, 
proper!*/  so  called ; that  is  to  say,  it  h;is  no  foreign 
body  in  its  centre.  When  a transverse  .section  is  made 
of  such  a calculus,  one'finds  either  a cavity  in  its  mid- 
dle, or  else  nothing  by  which  this  part  of  its  substance 
can  be  distinguished  from  the  rest;  or  if  a nucleus  dif- 
ferent from  the  other  part  of  the  concretion  be  apparent 
there,  it  consists  merely  of  bile,  either  grumous,  dif- 
ferently coloured,  or  more  or  less  fluid  than  the  rest  of 
the  calculus,  but  wliich  is  nevertheless  invariably  bile. 
On  the  contrary,  every  gastric  concretion  has,  as  it  were, 
an  extraneous  nucleus,  as  Fourcroy  and  Vauquelin  have 
explained  in  their  essay  upon  the  intestinal  calculi  met 
with  in  animals,  Ruysch  in  the  Phil,  Trans,  gives  an 
account  of  some  alvine  concretions  which  were  formed 
round  grains  of  seed,  Birch  records  an  example  of 
a crystallized  calculus  formed  round  a leaden  bullet. 
Haller  met  with  a calculus  in  the  centre  of  wiiich  was 
an  iron  nail.  Concretions  formed  upon  fruit-stones  are 
recorded  by  Clarice,  White,  and  Hey,  and  also  in  the 
Edinb.  Med.  Essays.  Instances  in  which  the  nucleus 
was  a small  portion  of  bone  are  related  in  the  latter 
work,  and  also  by  Hooke  and  Coe.  Homberg  and 
others  describe  alvine  concretions  formed  round  indu- 
rated excrementitious  matter ; and  many  similar  cases 
are  specified  by  Vallisnieri,  Van  Swieten,  and  others. 
In  the  hepatico-gastric  calculus  the  biliary  concretions 
serve  as  a nucleus  for  the  gastric.  According  to  Dr. 
T.  Thomson,  the  nucleus  is  commonly  a cherr^^-stone. 


a small  piece  of  l)onc,or  a biliary  calculus.— (See  Med, 
Chir.  .louni.  vol.  4,  p.  188.] 

A fourth  criterion  is  deduced  fVom  a certain  unctu- 
osity  which  belongs  to  biliarj-  calculi,  but  not  to  those 
of  the  gastric  class.  This  character  is  more  palpable 
w hen  the  calculus  has  been  recently  voided,  or  w hen  it 
is  handled  with  warm  fingers.  The  unctuasily  is  still 
more  evident  when  the  concretion  is  cut  or  sawn,  as  then 
the  knife,  saw,  or  fingers  become  smeared  with  saporm- 
ceous  particles,  which  adhere  to  them.  In  order  to 
denote  an  hepatic  calculus,  however,  the  umtuosity 
mu.si  per\’ade  its  whole  substance,  and  not  merely  ap- 
pear towards  its  outside ; for  a gastric,  earthy,  saline 
concretion  may  by  accident  become  coated,  as  it  passes 
through  the  bowels,  with  a stratum  of  bile  or  sapona- 
ceous matter.  When  the  unctuosity  is  deficient  exter- 
nally, or  in  the  outer  laminae  of  a calculus,  but  is  found 
in  its  interior,  it  is  a clear  indication  of  the  hepatico- 
gastric  formation  of  the  concretion. 

Fifth  criterion.  The  specific  gravity  of  a calculus, 
the  property  which  it  has  of  floating  or  sinking  in  wa- 
ter, has  been  long  considered  as  a test  of  its  species. 
The  hepatic  calculus  is  generally  specifically  lighter 
than  w ater,  as  most  oily  substances  are : on  the  con- 
trary. gastric  calculi  a:  sfiecifically  heavier  than  wa- 
ter, like  all  earthy  saline  matter,  and  of  course  sink  in 
that  fluid.  Tliis  criterion  was  often  employed  by  Re- 
verhorst,  Fernelius,  and  others,  for  distinguishing  va- 
rious concretions.  But  it  is  by  no  means  regular,  as 
many  hiiiary  calculi  swim  only  a little  w hile  and  then 
sink.  The  specific  gravity  of  that  analyzed  by  Dr, 
Ure,  of  Glasgow,  was  1.0135. — See  Med.  Chir.  Journ. 
vol.  4,  p.  179.)  As  Rubini  observes,  this  test  will  not 
answer  for  hepatico  gastric  calculi,  which  are  subject 
to  great  anomalies. — Pensieri,  A-c.  p.  22.)  Neverthe- 
less, the  most  correct  modem  examinations  prove,  that 
gastric  concretions  have  a specific  gravity  varying 
from  1.376  to  1.540  ; Dr.  T.  Thomson  in  Mpnro’s  Morb. 
.\iiat.  Ac.  , and  consequently  their  general  character  is 
to  be  heavier  than  biliary  calculi. 

A sixth  criterion  is  that  proposed  by  Vicq  d’Azyr  in 
the  .M^ni.  de  I’Acad.  Royale  de  Med.,  and  deduced  from 
the  figure  of  the  crystallization.  According  to  this 
writer,  intestinal  concretions  crystalli.;e  in  concentric 
laminte,  shaped  like  a cock’s  comb,  while  the  crystalli- 
zations of  biliary  calculi  are  radiated  and  needle-shaped. 
Although  this  criterion  is  ingeniously  founded  upon 
the  known  laws  by  which  ever)'  crystallized  substance 
assumes  a peculiar  and  determinate  shape,  yet  it  may 
be  generally  ohserx-ed  with  respect  to  the  mark  of  dis- 
tinction here  proposed,  that  the  concretions  of  which 
we  are  now  speaking  are  usually  too  compound,  and 
too  much  disturbed  in  their  crystallization  to  exhibit  a 
regularity,  for  which  simplicity  and  quietude  are  indis- 
pensable. Hence  many  of  these  concretions  do  not 
present  the  slightest  vestige  of  crystallization,  while 
others  scarcely  show  a trace  of  it,  in  the  midst  of  a 
large  misshapen  mass.  I'he  white-coloured  hejiatic 
calculus  when  broken  is  said  to  present  crystalline 
plates  or  stri®,  brilliant  and  white  like  mica.  The  round 
or  polygonal  one  which  is  often  of  a gray  colour  exter- 
nally, and  brown  within,  is  described  as  consisting  of 
concentric  layers  of  inspissated  bile,  msually  with  a 
nucleus  of  the  white  crystalline  matter  in  the  centre. 
Lastly,  the  hepatic  calculi,  of  a deep  brown  or  green 
colour,  when  broken,  are  said  to  exhibit  a number  of 
crystals  of  the  substance  resembling  spennaceti,  mixed 
with  inspissated  bile. — See  Ure’s  Diet,  art.  Gall-stones,) 
With  respect  to  the  special  shape  assigned  by  Vicq 
d’Azyr  to  the  two  classes  of  alvine  concretions,  it  may 
be  observed  that  his  specimens  were  taken  from  animals, 
and  that  consequently  the  inferences  made  from  them 
are  not  applicable  to  substances  of  an  analogous  nature 
discharged  from  the  human  body ; because,  as  the  bile 
varies  in  different  animals,  so  must  the  formative  prin- 
ciples of  the  calculous  crystallizations.  It  is  farther 
remarked  by  Rubini  that  the  substance  termed  adijio- 
cire,  which  is  the  basis  of  biliary  concretions,  was  not 
found  by  Poulletier  in  hepatic  calculi  taken  from  homed 
cattle. 

A seventh  criterion  is  founded  upon  the  inflammabi- 
lity of  an  alvine  calculus.  A biliary  concretion  being 
commonly  made  up  altogether  of  unctuous  matter, 
liquefies  when  subjected  to  heat,  smokes,  emits  a flame, 
and  burns.  When  this  experiment  is  made  in  close 
vessels,  the  products  are  hydrogen,  carbonic  acid  sas, 
oil,  and  ammonia  : some  carbon  and  eartii  remaining 


ALVINE  CONCRETIONS. 


23 


behind.  An  intestinal  concretion,  on  the  other  hand, 
decrepitates  or  turns  black,  but  generally  does  not  burn. 
One  specimen  examined  by  Dr.  Ure,  when  heated  to 
the  temperature  of  400°  F.,  fused  into  a black  mass, 
and  exhaled  a copious  white  smoke,  in  the  odour  of 
which  was  recognised  that  of  ambergris,  mixed  with 
the  smell  of  burning  fat.  Exposed  in  a platina  capsule 
to  a dull  red  heat,  it  burned  with  much  flame  and 
smoke,  leaving  no  appreciable  residuum. — See  lire’s 
Diet,  of  Chemistry,  art.  Intestinal  Concretions.) 

The  eighth  criterion  depends  upon  the  solubility  of 
calculi  in  an  oily  menstruum.  Haller  dissolved  biliary 
calculi  in  oil  of  turpentine;  Dietrick  found  them  solu- 
ble in  oil  of  sweet  almonds ; and  Gren  in  oils  in  gene- 
ral. But  intestinal  calculi  are  not  so  readily  dissolved 
by  any  of  these  menstrua. 

The  ninth  criterion  is  founded  upon  the  solubility  of 
the  calculus  in  alcoho'.  In  biliary  calculi  this  solubility 
is  not  always  the  same;  but  as  this  point  has  been 
already  spoken  of,  it  is  unnecessary  to  dwell  upon  it ; 
and  I shall  merely  add,  that  while  hepatic  concretions 
are  almost  always  more  or  less  dis.solved  by  alcohol, 
those  of  the  gastric  kind  resist  this  menstruum. 

Though  the  above  criteria  are  interesting,  as  tending 
to  establish  distinctions  between  the  different  species 
of  alvine  concretions,  it  merits  attention  that  not  one 
of  them  taken  separately  is  at  all  certain  and  pathogno- 
monic. It  may  happen,  says  Rubini,  that  some  pecu- 
liarity in  the  biliary  secretion,  and  an  irregularity  in 
the  crystallization  and  accumulation  of  the  matter,  may 
cause  salts  and  earths  to  predominate  in  hepatic  con- 
cretions, in  which  circumstance  their  usual  oily  quality 
will  be  defective.  On  the  other  hand,  in  the  formation 
of  an  intestinal  concrefion,  oily  adipooe  matter  may 
accidentally  adhere  to  it,  so  as  to  disguise  Its  wonted 
character.  If  uniformity  of  characters  and  physical 
properties  depend  upon  uniformity  of  elementary  con- 
stituent principles,  it  can  hardly  happen  even  in  the 
natural  healthy  state  of  the  secretions,  because  age, 
sex,  and  other  particular  circumstances  of-  the  indivi- 
dual will  always  make  a difference  in  the  proportions 
of  those  principles.  How  then  can  identity  of  results 
be  expected  in  a diseased  state  of  the  process  of  secre- 
tion?—Such  reflections  may  explain  how  Morgagni 
among  others  met  with  many  biliary  calculi  which 
were  not  inflammable;  with  others  which  did  not  give 
a yellow  tinge  to  water ; and  with  some  which  floated 
or  sunk  in  water,  according  as  they  had  been  recently 
or  long  discharged ; while  Gren  found  some  of  these 
calculi  insoluble  in  alcohol,  <fcc. — Rubini,  p.  24,  25.) 

Moreali  put  a piece  of  the  outer  part  of  an  alvine 
concretion  into  nitrous  acid,  whSn  a considerable  effer- 
vescence took  place,  and  the  substance  afterward  com- 
pletely dissolved.  Now  as  this  calculus  had  a nucleus, 
it  must  have  been  of  the  hei)atico-gastric  kind,  and  the 
experiment  was  therefore  made  only  with  the  intesti- 
nal part  of  it.  Should  the  experiment  be  o.len  repeated 
\vich  the  same  result,  says  Rubini,  it  would  furni.sh 
another  criterion  for  distinguishing  the  two  species  of 
calculi;  those  being  intestinal  which  effervesce,  and 
others  being  hepatic  which  do  not  effervesce,  but  yield 
globules  of  wax-like,  oily  matter. — P.  28.) 

For  additional  chemical  observations  on  biliary  and 
other  alvine  concretions,  the  reader  is  particularly  re- 
ferred to  Rubini’s  interesting  memoir,  Vicq  d’Azyr’s 
essay  in  the  Hist,  de  la  Soci^t^  Royale  de  Medecine,  an 
1779 ; the  writings  of  Fourcroy,  Vauquelin,  and  The- 
nard;  Thomson’s  account  of  the  subject  in  Monro’s 
Morbid  Anatomy  of  the  Human  Gullet,  <fec. ; Marcet 
on  Calculous  Disorders ; and  some  interesting  experi- 
ments by  Dr.  Ure,  related  in  a paper  by  Mr.  Kennedy, 
in  Medico-Chir.  .lourn.  vol.  4,  p.  177,  &c.  Also  Ure’s 
valuable  Diet,  of  Chemistry. 

With  respect  to  the  treatment  of  cases  of  biliary  cal- 
culi, the  subject  not  being  generally  one  for  which  any 
surgical  proceeding  is  advisable,  I may  be  very  brief. 
The  medicine  which  is  alleged  by  Durande,  a physician 
at  Dijon,  to  be  the  best  solvent  for  them,  consists  of 
three  parts  of  sulphuric  ether  and  two  parts  of  oil  of 
turpentine.  It  is  to  be  given  in  the  dose  of  3ij.  every 
morning ; purgatives  being  previously  exhibited  for  a 
few  days.  The  efficacy  of  this  medicine  is  also  corro- 
borated by  Soemmering  and  Richter.  T-'  these  state- 
ments, however,  some  doubts  must  be  c.:.ached  ; be- 
cause what  symptoms  and  circumstanc*'-'  will  ever 
unequivocally  prove,  that  there  were  biliary  calculi  in 
the  bowels,  and  that  they  have  been  dissolved  by  this 


medicine?  And  how  can  the  product  of  such  solution 
be  got  at  and  examined  ? But  admitting  the  authenti- 
city of  the  cases,  doubts  must  exist  of  the  solvent  ac- 
tion of  the  remedy  ; since  at  a temperature  below  that 
of  the  human  body,  the  ether  separates  from  the  tur- 
pentine and  is  volatilized. — ,See  Diet,  des  Sciences  M6d. 
t.  3,  p.  464,  465.^ 

A calculus  in  the  gall-bladder  or  one  of  the  bili^ 
ducts  sometimes  produces  so  much  irritation,  that  in- 
flammation and  suppuration  take  place,  and  if  the  ab- 
scess point  outwardly,  the  stone  may  escape  externally, 
and  a termination  be  put  to  the  patient’s  sufferings. 
Heberden  records  a case  of  this  description ; and  another' 
is  given  by  Mr.  Blagden. — See  Med.  Trans,  of  the  Col- 
lege of  Physicians,  vol.  5,  and  Thomas  in  Med.  Chir. 
Trans,  vol.  6,  p.  106.  And  for  other  instances,  the  follow- 
ing works  referred  to  by  Ploucquet : Acrel,  Diss.  de  Cho- 
lelithis,  Upsal,  1788,  p.  204  ; Act.  Natur.  Cur.  vol.  6, 
Obs.  09;  Barthoiiiius,  Act.  Kafn.  4,  Obs.  46;  Block, 
Med.  Benierk,  p.  27 ; Gooch’s  Works,  vol.  2,  157—161 ; 
.lohaston  in  Phil.  Trans,  vol.  50,  ]).  2,  548;  Petit,  M^m, 
de  I’Acad.  de  Chir.  1,  p.  182—185  ; Sandilbrt,  Tab.  Anat. 
Fasc.  3;  Schlichting  in  Bald.  N.  Magas,  b.9,  p.  210; 
Vogler  in  Museum  der  Heilkunde,  b.  4,  p.  91 ; Haller, 
Collect.  Diss.  Pract.  3,  No.  107.) 

It  was  J.  L.  Petit  who  first  suggested  the  bold  prac 
tice  of  making,  under  certain  circumstances,  an  incision 
into  the  gall-bladder,  in  order  to  extract  biliary  calculi. 
This  proceeding,  however,  is  liable  to  serious  objections, 
arising  not  only  from  the  usual  difficulty  of  knowing 
positively  whether  there  is  a calculus  in  the  gall-blad- 
der, but  also  from  the  difficulty  of  ascertaining  whether 
this  viscus  is  adherent  to  the  peritoneum,  without  which 
state  of  things,  the  operation  would  cause  an  extrava- 
sation of  bile,  enteriti.s,  and  death.  Petit  himself,  in- 
deed, mentions  three  cases  in  which  distention  of  the 
gall-bladder  was  mistaken  for  an  abscess,  and  punc- 
tured. In  two  of  these  examples  the  consequences 
were  fatal,  there  having  been  no  adhesion  between  that 
organ  and  the  peritoneum  to  prevent  the  bile  from  get- 
ting among  the  bowels  : the  other  patient  was  saved 
by  this  fortunate  circumstance. — See  Traits  des  Mai. 
Chir.  1. 1,  p.  262,  &c.)  However,  if  a case  wera  to  pre- 
sent itself  in  which  an  abscess  had  formed  and  broken, 
leaving  an  aperture  in  which  the  calculus  could  be 
plainly  felt,  the  surgeon  would  be  justified  in  attempt- 
ing to  make  a sufficient  opening  for  its  extraction. 

The  symptoms  induced  by  the  lodgement  of  large 
concretions  in  the  bowels  are  of  a formidable  descrip- 
tion; severe  pains  in  the  stomach  and  bowels,  diar- 
rhtea,  violent  vomitings  of  blood  and  mucus,  a dis- 
charge of  thin  fetid  matter  from  the  rectum,  a difficulty 
of  voiding  the  excrement,  an  afflicting  tenesmus,  extreme 
emaciation,  and  debility. 

That  the  foregoing  account  is  not  exaggerated,  may 
be  seen  by  a perusal  of  the  cases,  and  remarks  pub- 
lished by  Mr.  C.  White,  and  the  late  Mr.  Hey. 

In  cases  like  that  reported  by  Mr.  Hey  (Pract.  Obs. 
p.  509,  ed.  2),  where  the  colon  was  completely  ob- 
structed, surgeons  have  been  advised  to  cut  into  tiiat 
bowel,  and  extract  the  foreign  body.  Let  the  inexpe- 
rienced admirer  of  curious  feats  with  the  scalpel,  how 
ever,  pause  a little,  before  he  ventures  to  make  up  his 
mind  upon  this  matter ; and  at  all  events  let  him  know, 
that  some  serious  mistakes  have  nearly  been  made: 
“ upon  the  very  bold  operation  of  cutting  out  these 
concretions  when  lodged  in  the  colon,  proposed  by  Dr. 
Monro,  senior  (See  Monro’s  Morbid  Anatomy  of  the 
Human  Gullet,  <fec.  p.  63  , we  think  it  our  duty  to  state 
that  the  diagnosis  is  so  difficult,  that  in  one  case  where 
the  operation  was  strongly  advised,  it  turned  out  upon 
dissection  that  the  disease  was  a scirrhous  pylorus.” — 
(See  Edinb.  Med.  and  Surg.  Journ.  No.  33,  p,  112.) 

Sometimes  patients  ultimately  get  well  by  voiding 
the  concretions  either  by  vomiting  or  stool.  Mr.  C, 
White  gives  us  an  account  of  some  instances  of  this 
kind:  in  one,  fourteen  concretions  on  plumb-stones 
were  discharged  from  the  anus;  in  another,  twenty-one 
similar  bodies  were  ejected  from  the  stomach. 

When  such  concretions  are  not  particularly  large 
and  indurated,  they  sometimes  admit  of  expulsion  by 
doses  of  castor  oil,  oleaginous  clysters,  Ate.  But  in 
other  instances  their  extraction  must  be  attempted  if 
their  situation  in  the  rectum  will  i)ermit.  It  may  be 
done  with  a pair  of  lithotomy  forceps  or  with  the  sort 
of  scoop  used  for  taking  fragmerits  of  stone  out  of  the 
bladder.  In  this  manner  INIr.  C.  White  succeeded  In 


24 


AM  A 


AMA 


removing  two  alvine  concretions  from  the  rectum 
nearly  as  big  as  his  fist.  WTien  the  spincter  ani  will 
not  allow  the  concretion  to  be  taken  out,  the  muscle 
should  be  divided  at  its  posterior  angle.  According  to 
Richerand,  such  a division  does  not  permanently  weaken 
its  fibres  in  a perceptible  degree,  and  its  paralysis 
never  originates  from  this  cause. — Nosogr.  Chir.  t.  .I, 
p.  434.  edit.  4.)  Mar6schal,  after  a proi)er  dilatation 
withascalpel,  extracted  from  the  rectum  an  alvine  con- 
cretion which  weighed  two  ounces  and  a half,  and  was 
of  an  oval  form,  its  greatest  diameter  being  two  inches 
eight  lines,  and  its  smaller  one  inch  seven  lines. — ,See 
Mem.  de  I’Acad.  de  Chir.) 

A.  Petermann,  Scrutinium  Icteri  ex  calculis  vesiculae 
Fellis,  occasione  casus  cujusdarn  singularis.  Lijis. 
1696.  Alb.  Haller,  Ue  Calculis  Felleis  frequentioribus 
Observationes,  4to.  Cott.  1749.  T.  Coe,  A 'I'reatise  on 
Biliary  Concretions,  8vo.  Lond.  1757.  Imbert,  De  Va- 
riis  Calculorum  biliariurn  Speciehus,  <kc,  4to.  Monsji. 
1758.  De  Vries,  Diss.  de  Calculo  biliario,  et  sectione 
felleaB  vesiculae,  4to.  Traj.  ad  Rhen.  1759.  Walther 
de  Concrementis  Terrestribus  in  variis  partibus  cor- 
poris humani  repertis.  Fol.  Acrol.  1775:  the  most  va- 
luable work  on  the  subject  at  this  period.  Ilochstetter, 
De  Cbolelithis  Humanis,  4to.  Tub.  1763.  Vicq  d’Ar.yr, 
Hist,  de  la  Soci>  t6  Royale  de  Med.  1779.  A valuable 
production,  particularly  with  reference  to  the  kinds  of 
crystallization  obsers'able  in  hepatic  and  intestinal  cal- 
culi. Durande,  Memoire  sur  les  pi^rres  biliaires,  et 
sur  refficacitii  du  melange  d’ether  vitriolique  et  d'esprit 
de  t^rebinthine  dansle  colique  hepalique  produite  par 
ces  concretions,  vol.  1 des  M^m.  do  I’Acad.  de  Dijon, 
6vo,  p,  199,  an  1763.  S.  T.  Soemmering,  De  Concce- 
mentis  biliariis  corporis  humani,  8vo.  Traj.  ad  Rhen. 
1795.  B.  Brunie,  Essai  sur  les  Cafruls  biliaires,  4to. 
Paris,  1803.  Fourcroy,  Mem.  de  I’Acad.  des  Sciences, 
1789,  et  Syst.  des  Connoissances  Chim.  t.  10,  p.  53— 
60.  Dr.  Bostock,  in  .Nicholson’s  Journal,  vol.  4,  p.  137. 
Marcet’s  Chemical  History  and  Medical  Treatment  of 
Calculous  Disorders,  8vo.  Lond.  1317.  J.  F.  Meckel, 
Handbuck  der  Pathol.  Anat.  b.  “2,  p.  455,  Ac.  Leipz. 
1818.  P.  Riihini,  Pensieri  sulla  varia  Origine  e Natura 
de  Corpi  calcolosi  die  vengono  talvolta  espulsi  dal 
Tubo  Gastrico  Memona,  4to.  Verona,  1808.  James 
Kennedy,  An  Account  of  a .Morbid  Concretion  dis- 
charged from  the  Rectum,  and  in  its  Chemical  Charac- 
ters closely  resembling  .Vmbergris;  with  Historical  Re- 
marks: see  Medico-Chir.  Journal,  vol.  4,  p.  177,  Ac.  1817. 
Monro’s  Morbid  Anatomy  of  the  Human  Gullet,  Sto- 
mach, and  Intestines,  8vb.  Edinb.  1811.  The  account 
of  alvine  concretions  in  this  work  is  one  of  the  best 
and  most  comprehensive.  Diet,  des  Sciences  Med.  art 
Bezoard,  et  Calculs  biliaires.  Nothing  of  much  con- 
sequence in  either  of  these  articles.  Moscovius,  Diss. 
de  Calculorum  Anirnalium  eorumque  impnmis  bilioso- 
rum  origine  et  natura.  Berol.  1812.  Cases  in  Surgery, 
by  C.  White,  8vo.  Lond.  1770,  p.  17.  Philos.  Trans, 
abridged,  vol.  5,  p.  256,  et  seq.  Edinb.  Med.  Essays  and 
Obs.  vol.  1,  p.  301.  Ibid.  vol.  5,  p.  431.  Essays,  Phys. 
and  Literary,  vol.  2,  p.  345.  Leigh’s  Natural  History 
of  Lancashire,  plate  1,  fig.  4.  W.  Hay’s  Practical  Obs. 
in  Surgery,  p.  507,  ed.  2.  Richerand,  Nosographie  Chi- 
rurgieale,  t.  3,  p.  433,  ed.  4.  Thomas  in  Med.  Chir. 
Transactions,  vol.  6,  p.  98.  T.  Brayne,  An  Account 
of  Two  Cases  of  Biliary  Calculi  of  extraordinary  di- 
mensions : Med.  Chir.  Trans,  vol.  12.  lire’s  Chemical 
Diet,  articles.  Intestinal  Concretions  and  Gall-stones. 

AMAUROSIS.  (From  a^avpaij,  to  darken  or  ob- 
scure.) Gutta  serena.  Suffusio  nigra.  Fr.  L’Amau- 
rose ; Germ.  Schwarzer  Staar.  According  to  Beet , the 
term  amaurosis  properly  means  that  diminution  or  total 
loss  of  sight  which  immediately  depends  upon  a mor- 
bid state  of  the  retina  and  optic  nerve,  whether  this 
morbid  state  exist  as  the  only  defect,  or  be  complicated 
with  other  mischief ; whether  it  be  a primary  affection, 
or  a secondary  one  induced  by  previous  disease  of  other 
parts  of  the  eye.  Or  we  may  say,  Avith  a critical  wri- 
ter, that  the  terra  amaurosis  designates  all  affections 
of  the  nerves  of  vision,  which  produce  either  complete 
or  partial  loss  of  sight,  whether  this  arise  fiom  obvious 
or  inferred  organic  disease,  or  from  a diminution  or  loss 
of  sensibility  in  the  eye,  which  cannot  be  traced  to 
change  of  structure  or  any  other  evident  cause. — See 
Journ.  of  Foreign  Med.  and  Surgery,  vol.  4,  p.  166.) 

The  definition  given  by  Mr.  Lawrence  in  his  Lectures 
appears  to  be  correct  and  comprehensive.  Amaurosis 
an  1 gutta  serena,  he  remarks,  are  names  applied  indif- 


^ ferently  to  those  forms  of  blindness  which  result  from 
an  affection  of  the  nervous  structure  of  the  eye,  whether 
it  be  seated  in  the  retina,  optic  nerve,  or  sensorium ; or 
I whether  this  affection  be  produced  immediately  by  vas- 
, cular  congestion,  infiamrnation,  or  organic  change  ; or 
j indirectly  by  sympathy  with  other  organs. 

I From  these  definitions,  w'hich  comprehend  every 
I form  of  amaurosis,  it  is  evident  that  this  affection  does 
not  uniformly  take  jdace  as  a single  independent  disor- 
der ; hut  not  unfrequently  presents  itself  as  a symptom- 
atic effect  of  some  other  disea.se  of  the  eye ; a fact 
e.xemj)lified  in  cases  of  hydrophthalrnia,  cirsophthalmia, 
glaucoma,  Ac.  And,  a.s  Mr.  Wardrop  observes,  amau- 
rosis in  its  usual  acceptation  signifies  a symptom  of 
disease  as  well  as  a distinct  affection. — Essays  on  the 
.Morbid  Anatomy  of  the  Human  Eye,  vol.  2,  p.  165,  8vo. 
Lond.  Ibid.)  With  respect  to  the  mere  name  of  the 
kind  of  disease  here  implied  by  amaurosis,  its  correct- 
ness w ill  remain  the  same,  whether  the  iris  be  moveable 
or  immoveable ; whether  the  pupil  be  preternaturally 
enlarged  or  contracted;  and  whether  it  be  perfectly 
clear  and  transparent,  or  more  or  less  turbid  ; for  the 
name  only  refers  to  the  morbid  state  of  the  retina  and 
optic  nerve,  and  not  to  the  condition  of  the  sight  in 
general.  When  the  long-established  name  of  amauro- 
sis is  received  with  this  precise  meaning,  there  will  not 
be  the  slightest  danger  of  confounding  the  disease  with 
other  affections  of  the  eye.  How'ever,  when  it  is  wished 
to  make  out  the  very  different  fonqs  and  kinds  of  amau- 
rosis, the  foregoing  apjiearances  of  the  iris  and  pupil 
are  considerations  of  great  importance. — .See  Beer’s 
Lehre  von  den  Augeiikrankheiten,  b.  2,  p.  420,  Ac. 
Wien.  1817.) 

I think  it  also  of  importan«e  that  surgeons  should 
well  understand  what  Mr.  Travers  has  particularly 
mentioned,  that  the  tenn  “ amaurosis”  comprehends  all 
those  imperfections  of  vision  which  depend  upon  a 
morbid  condition,  whether  affecting  structure  or  func- 
tion of  the  sentient  apparatus  proper  to  the  organ. — 
(See  his  Synopsis  of  the  Diseases  of  the  Eye,  p.  293.) 

Beer  reckons  four  species  of  amaurosis. 

The  first  is  a genuine  uncomplicated  amaurosis,  the 
characteristic  symptom  of  wliich  consists  peculiarly 
and  entirely  in  an  impairment  or  loss  of  vision,  without 
any  morbid  change  in  the  organic  matter  of  the  eye. 
To  tliis  case  the  epithet  “proper  functional,”  used  by 
Mr.  Travers,  would  be  applicable. 

Secondly,  there  is  an  amaurosis,  which,  besides 
being  attended  with  a diminution  or  total  loss  of  vision, 
is  also  accompanied  with  appearances  of  di.sease  in  the 
organic  matter  of  the  ey  . 

Thirdly,  there  is  another  amaurosis,  in  which,  to- 
gether with  the  above  principal  symptom,  viz.  weak- 
ness or  loss  of  sight,  there  are  also  morbid  phenomena 
exhibited  in  the  form  of  the  eye  in  general,  or  its  parti- 
cular textures,  and  especially  in  the  action  of  its  irrita- 
ble parts. 

Lastly,  Beer  says,  he  can  offen  point  out  an  amau- 
rosis in  which  all  the  characteristic  symptoms  of  the 
three  preceding  cases  are  more  or  less  combined. — 
(See  Lehre  von  den  Augenkr.  b.  2,  p.  478,) 

The  genuine  uncomplicated  amaurosis,  consisting  of 
a mere  diminution  or  loss  of  sight,  without  the  appear- 
ance of  any  other  defect,  is  one  of  the  most  uncommon 
forms  of  complaint,  not  only  because  singly  operating 
causes  are  few,  but  because  they  can  rarely  operate 
directly  upon  the  optic  nerves. 

In  the  true  uncomplicated  amaurosis,  merely  the  vital 
qualities  of  the  optic  nerve  and  retina  are  affected,  and 
after  death  nothing  preternatural  can  be  traced  in  those 
parts  either  within  or  on  the  outside  of  the  eyeball.  It 
is,  in  short,  the  case  in  which  the  functions  of  the  retina 
have  become  imperfect  or  destroyed,  the  eye  appearing 
in  other  respects  sound. 

According  to  Beer,  this  simple  unmixed  form  of 
amaurosis  is  subdivisible  into  that  amaurotic  weak- 
ness of  sight  or  blindness,  which  depends  upon  the  vi- 
tality or  rather  sensibility  of  the  optic  nerve  and  retina 
being  too  highly  raised,  and  into  another  case,  the  proxi- 
mate cause  of  which  is  peculiarly  and  entirely  refera- 
ble to  depression  of  such  vitality  or  sen.sibility.  The 
first  example  is  much  less  common  than  the  second. 

Amaurosis  does  not  constantly  attack  both  eyes  at 
the  same  time ; frequently  one  is  attacked  some  time 
after  the  other,  and  it  is  not  unusual  even  for  one  eye 
to  remain  sound  during  life,  while  the  other  is  com- 
pletely blind.  This  depends,  in  part,  upon  the  dispoai- 


AMAUROSIS, 


25 


tion  to  the  disease  in  one  eye  being  quite  local,  and  in 
part  upon  the  causes  giving  rise  to  the  complaint  ex- 
tending their  operation  only  to  the  eye  affected.  Where 
also  the  origin  of  amaurosis  seems  to  depend  altogether 
upon  constitutional  causes,  one  eye  is  not  unfrequently 
attacked  much  sooner  than  the  other ; though  in  these 
examples,  it  is  more  rare  to  find  the  eye  which  does  not 
suffer  at  first  continue  perfectly  unaffected. — Beer,  b. 
2,  p.  422.)  As  a general  observation.  Mr.  Wardi'op 
thinks  it  may  be  remarked,  that  when  only  one  eye  be- 
comes at  first  amaurotic  from  a sympathetic  affection, 
there  is  little  danger  of  the  other  eye  becoming  blind  ; 
hut  that  when  amaurosis  is  produced  by  any  organic 
change  in  one  eye,  the  other  is  very  liable  to  be  sympa- 
thetically affected. — Essays  on  the  Morbid  Anatomy 
of  the  Human  Eye,  vol.  2,  p.  190.)  Amaurosis  may  not 
completely  hinder  vision,  a diminished  power  of  seeing 
often  remaining  during  life.  Hence  the  division  of 
cases  into  perfect  and  imperfect ; which  latter,  how- 
ever, sometimes  attain  a degree  in  which  the  patient  is 
only  just  able  to  distinguish  light,  the  direction  of  its 
rays,  and  its  degree. 

Imperfect  amaurosis,  besides  being  characterized  by 
a considerable  weakness  of  sight,  approaching  to  real 
blindness  (Amblyopia  Arnaurotica  , is  mostly  compli- 
cated with  a greater  or  less  number  of  other  morbid 
appearances,  which  merit  serious  attention. 

Among  the  most  important  of  these  symptomatic 
appearances  of  imperfect  amaurosis  is  a defective  in- 
terrupted vision  visus  interruptus).  For  instance, 
when  the  patient  is  reading,  single  syllables,  words,  or 
lines  cannot  be  seen,  unless  the  eye  be  first  directed  to 
them  by  a movement  of  the  whole  head,  and  greater 
or  less  portions  of  other  objects  are,  in  the  same 
manner,  indistinguishable.  Sometimes,  amaurotic  pa- 
tients can  see  only  the  upper  or  lower,  or  the  left  or 
the  right  half  of  objects  f Visus  dimidiatus;  Amau- 
rosis dimidiata ; Hemiopia;  Hemiopsia.) 

Sometimes  when  the  patient  shuts  one  eye,  he  can 
only  distingui.sh  the  halves  of  objects ; but  if  he  open 
both  eyes,  he  sees  every  thing  in  its  natural  form  In 
this  case,  according  to  Schmucker,  one  eye  is  sound, 
and  only  some  fibres  of  the  nerve  of  sight  are  injured 
in  the  other. — Vermischte  Chir.  Schrift.  b.  2,  p.  12.) 

There  are  likewise  some  not  very  uncommon  cases 
of  imperfect  amaurosis,  in  which  the  patient  can- 
not see  an  object,  unless  it  be  held  in  a particular 
direction  before  the  eye ; but  when  the  eye  or  head  is 
moved  in  the  least,  he  loses  all  view  of  the  thing, 
and  cannot  easily  get  sight  of  it  again. — Beer,  Lehre 
von  den  Augenkrankheiten,  b.  2,  p.  424.)  On  this  part 
of  the  subject,  it  is  remarked  by  Richter,  that  patients 
who  may  be  said  to  be  entirely  blind,  sometimes  have 
a small  part  of  the  retina  which  is  still  susceptible  of 
the  impression  of  light,  and  is  usually  situated  towards 
one  side  of  the  eye.  This  obliquity  of  sight  was  long 
ago  pointed  out  by  the  late  Mr.  Hey,  as  common  in  the 
present  disease. — See  Med.  Obs  and  Inquiries,  vol.  5.) 
Richter  mentions,  that  in  one  man,  who  was,  in  other 
respects,  entirely  bereft  of  vision,  this  sensible  point 
of  the  retina  was  situated  obliquely  over  the  nose,  and 
80  small,  that  it  was  always  a considerable  time  before 
its  situation  could  be  discovered ; he  adds,  that  it  was 
so  sensible,  as  not  only  to  discern  the  light,  but  even 
the  spire  of  a distant  steeple.  According  to  this  au- 
thor, it  is  the  centre  of  the  eye  that  seems  to  be  the  first 
and  most  seriously  affected.  Hence,  the  generality  of 
patients,  who  have  a beginning  imi^erfect  amaurosis, 
see  ^objects,  which  are  latterally  situated,  better  than 
such  as  are  immediately  before  them. — (Anfangsgr.  der 
Wundarzn.  b.  3,  kap.  14.) 

One  of  the  most  common  symptoms  of  a beginning 
amaurosis,  is  an  appearance  in  the  patient’s  fancy,  as 
if  gnats  or  flies  were  flying  about  before  his  eyes 
(Visus  Muscarum,  Myodesopsia).  Sometimes,  trans- 
parent, dark-streaked,  circular,  or  serpentine  diminu- 
tive bodies  appear  as  if  flying  in  greater  or  less  num- 
bers before  the  eyes,  often  suddenly  ascending,  and  as 
quickly  falling  down  again,  and  chiefly  annoying  the 
patient  and  confusing  his  sight  when  he  looks  at 
strongly  illuminated  or  white  objects.  The  substances 
thus  appearing  to  fly  about  before  the  patient’s  eyes,  are 
termed  Musete  volitantes  ; Mouches  volantes. — (Beer, 
Lehre,  <fec.  b.  2,  p.  42-4.  If  what  obstructs  the  sight  be 
a single  black  speck,  it  receives  the  name  of  scotoma. 

This  illusive  perception  of  various  substances  being 
In  rapid  motion  before  the  eye,  gradually  increases ; the 


substances  themselves  become  less  and  less  transpa- 
rent, and,  at  length,  are  so  connected  together,  that 
they  form  a kind  of  net-work  or  gauze,  by  which  all 
objects  are  more  or  less  obscured.  This  is  another 
symptom  of  amaurosis,  technically  called  visus  reti- 
culatus.  The  net-work  commonly  has  the  peculiarity 
of  being  black  in  very  light  situations,  or  when  white 
substances  are  before  the  eye ; wliile,  in  dark  places,  it 
is  quite  shining,  and,  as  it  were,  of  a bluish  white  hue, 
like  silver,  though  sometimes  of  a red-yellow  golden 
colour. 

A not  uncommon  symptom  of  imperfect  amaurosis 
is  the  patient’s  seeing  every  object  indistinctly  in  a 
rainbow-like,  sometimes  tremulous,  and  generally  very 
dazzling  light ; while,  in  the  dark  especially,  blue  or 
yellow  flashes,  or  fiery  balls  seem  suddenly  to  pass 
before  his  eyes  when  the  eyelids  are  shut,  and  excite 
considerable  alarm  (Visus  lucidus ; Marmoryge  Hip- 
pocratis ; Photopsia.) 

In  imperfect  amaurosis,  the  sensibility  of  the  retina 
may  be  so  augmented,  that  the  patient  shuns  all  very 
light  places,  particularly  those  in  which  the  light  is 
strongly  reflected  into  the  eye,  and,  in  order  yet  to  dis- 
cern in  some  measure  large  objects,  he  feels  himself 
obliged  always  to  seek  shady,  darkish  situations,  or  to 
screen  his  eyes,  out  of  doors,  with  a green  shade,  or 
green  glasses.  This  state  is  termed  by  Beer,  Licht- 
scheue  (Photophobia).  Under  these  circumstances,  it 
sometimes  happens,  that  the  patient  for  a very  short  time, 
for  example  a few  moments,  or  (what  is  very  un- 
common) for  a more  considerable  period,  is  able  of 
himself  to  discern  the  smallest  objects  in  a weak  light, 
more  plainly  and  accurately  than  the  best  eye  can 
hardly  do  in  a good  light.  Yet,  excepting  at  such  pe- 
riod, the  patient  with  the  above  degree  of  light  is  not 
capable  of  seeing  even  larger  objects.  This  infirmity 
of  sight  receives  the  name  of  oxyopia. 

Sometimes,  in  the  early  stage  of  amaurosis,  all  ob- 
jects seem  covered  with  a dense  mist ; while,  in  other 
instances,  this  mist  first  presents  itself  as  a simple, 
continually-increasing  scotoma,  and  rarely  in  the  fonn 
of  a net-work  or  gauze  ; but  to  the  patient,  when  his 
blindness  commences  with  the  visus  nebulosus,  the 
mist  usually  appears  for  a day  or  two  of  a light  gray 
colour,  and  then  for  another  day  or  two  very  black, 
every  thing  appearing  as  if  looked  at  through  a dense 
sooty  smoke.—  Beer,  Lehre  von  den  Augenkrankheiten, 
b.  2,  p.  422—426.) 

To  an  eye  affected  with  imperfect  amaurosis,  all  ob- 
jects frequently  appear  indistinct,  but  double  ' Visus 
duplicatus  ; Diplopia;.  It  is  remarked  by  Schmucker, 
that  in  the  gutta  serena,  which  comes  on  gradually, 
the  patient  sometimes  sees  double,  with  both  eyes.  He 
once  cured  a major  of  hussars,  who  saw  the  three 
lines  of  his  squadron  double  ; and  he  attended  another 
gentleman  similarly  afflicted.  Such  cases,  he  con- 
ceives, are  brought  on  by  a violent  di.stention  of  the 
vessels  of  the  choroides,  where,  he  thinks,  varices  may 
easily  arise,  in  consequence  of  the  weak  resistance  of 
that  membrane.  In  this  manner,  the  filaments  of  the 
retina  suffer  pressure,  and  the  rays  of  light  are  broken. 
Under  these  circumstances,  if  prompt  assistance  be 
not  afforded,  total  and  frequently  incurable  blindness 
may  be  the  consequence.  Schmucker  met  with  an  irre- 
mediable amaurosis  of  this  kind,  in  a young  man, 
twenty-six  years  of  age.  When  the  patient  made  ap- 
plication for  advice  he  had  been  blind  a year.  Before 
he  lost  his  sight,  he  remarked,  that  after  any  violent 
emotion,  his  sight  at  first  grew  weak,  and  that  objects 
afterward  appeared  double.  When  his  circulation  was 
at  all  hurried,  he  saw  black  spots  before  his  eyes,  and 
at  length  was  quite  blind.  The  vessels  of  the  cho- 
roides were  as  large  as  if  they  had  been  injected  with 
wax,  and  every  kind  of  surgical  assistance  proved  in- 
effectual.— Vermischte  Chir.  Schriften,  b.  2,  p.  12,  &c. 
8vo.  Berlin,  1786.)  In  some  cases,  according  to  Beer, 
double  vision  only  occurs  when  the  patient  looks  at 
objects  with  both  eyes,  and  it  ceases  as  soon  as  he 
shuts  either  the  diseased  or  the  sound  eye.  In  the  last 
of  these  circum.stai?  les,  double  vision  only  onginates 
fVom  the  deviation  of  the  unsound  eye  from  the  axis 
of  sight ; but,  in  the  first  instance,  it  arises  from  the 
morbid  state  of  the  retina  itself  of  the  diseased  eye. 
For  the  purpose  of  distinguishing  both  these  examples 
of  diplopia  from  every  other  sfiecies  of  symptomatic 
double  vi.sion.  Beer  applies  to  them  the  name  of  diplo- 
pia nervosa.  A degree  of  squinting  (strabismus),  there- 


26 


AMAUROSIS. 


fbre,  is  a very  common  sjTmptom  of  incipient  amauro- 
sis, panicularly  when  only  one  eye  is  atl'ected  ; for  this 
always  deviates  more  or  less  from  the  axis  of  vision. 
It  is  owing  to  this  loss  of  correspondence,  that  persons 
affected  with  an  imperfect  amaurosis  of  one  eye  oflen 
mistake  the  relative  distance  of  objects,  and  freiiuently 
see  them  reflected. — Traver’s  Synopsis,  p.  170.  It  is 
less  usual  for  imperfect  amaurosis  to  be  accompanied 
with  what  Beer  terms  oblujuity  of  the  eye  Luscita-s  ; 
either  a paralysis,  or  a ceaseless,  irregular  action  of  one 
or  more  of  the  muscles  of  the  organ,  being  evidently  a 
condition  of  this  symptomatic  appearance. — See  Beer’s 
Lehre  von  den  Augenkrankheiten,  b.  2,  p.  427.) 

Beer  has  oflen  met  with  patients  labounng  under 
imperfect  amaurosis,  who  could  plainly  distinguish  all 
objects  which  were  not  very  small ; but  saw  them  of  a 
diflerent  colour  from  their  real  one  ; for  instance,  yel- 
low, green,  purple,  «\ic.  (Visus  coloratus ; crujisia.) 
He  had  under  his  care  an  amaurotic  woman,  who  at 
midday  could  discern  even  the  smallest  objects  in  a 
strong  tight ; but  they  all  appeared  yellow,  though  no 
marks  of  jaundice  weie  perceptible. 

Sometimes,  in  the  early  stage  of  amaurosis,  all  ob- 
jects appear  quite  distorted,  bent,  shortened,  and,  in 
rarer  instances,  inverted  i Visus  defiguratis ; Meta- 
morphosiai.  Thus  the  flame  of  a candle  appears  very 
long,  but  all  awry.  This  is  said  by  Beer  to  be  c tii- 
Btantly  an  unfavourable  omen,  as  the  cause  of  it  lies 
in  the  brain  itself. 

Imperfect  amaurosis  is  sometimes  attended  with 
considerable  short-sightedness  Myopia  ; and  some- 
times with  the  opposite  affection  I’resbyopia  ; an  in- 
fallible proof  that  essential  changes  have  happened 
either  in  the  transparent  media  or  in  the  muscles  of  the 
eye. 

Many  patients,  when  first  attacked  with  amauro-sis, 
every  where  testify  a partiality  to  a great  quantity  of 
light,  employing  several  candles  at  night,  and  sitting 
in  the  daytime  with  their  backs  against  a sunshiny 
window,  in  order  to  let  whatever  they  are  reading  have 
a very  strong  light  ujion  it.  This  symptomatic  aj)- 
pearance  of  incipient  amaurosis  is  termed  by  Beer, 
Lichthunger. 

Amaurosis  may  either  take  place  in  an  instant,  even 
so  as  to  be  attended  with  entire  blindness  ; or  it  may 
come  on  quickly,  that  is,  it  may  be  complete  in  a few 
days  or  weeks  ; or  lastly,  what  is  most  ft-equently  the 
ca.se,  it  may  he  produced  gradually,  and  several  years 
elapse  before  it  attains  its  utmost  degree ; circumstances 
of  great  moment  in  the  diagnosis  and  treatment. 

The  type  which  the  disease  assumes  in  its  course 
and  developement,  is  also  subject  to  great  variety,  and 
claims  the  utmost  attention;  for  amaurosis  may  either 
be  permanent  or  temporary.  It  is  sometimes  an  in- 
termittent disorder,  making  its  appearance  at  regular 
or  irregular  intervals.  In  certain  examples  it  prevails 
at  particular  times,  commonly  all  day,  till  a certain 
hour ; or  fVom  one  day  till  the  next ; or  at  a stated  time 
every  month.  The  attacks  sometimes  take  place  at 
indeterminate  periods.  In  particular  cases,  another 
morbid  affection  is  associated  with  the  impairment  of 
sight.  Richter  mentions  a man  who  became  blind  at 
twelve  o’clock  in  the  day,  w'hen  the  upper  eyelid  used 
to  hang  down  paralytic.  The  attack  always  laste.d 
twenty-four  hours.  On  the  following  day  at  twelve 
o’clock,  the  sight  used  to  return,  and  the  patient  then 
suddenly  regained  the  power  of  raising  the  upper  eye- 
lid. He  would  continue  thus  able  to  see  for  the  next 
twenty-four  hours.  Whenever  he  took  bark,  the  dis- 
ease was  regularly  doubled ; that  is  to  say,  the  man 
then  alternately  remained  blind  forty-eight  hours,  and 
recovered  the  power  of  seeing  for  only  twenty-four. 
In  another  patient,  cited  by  the  same  writer,  the  aque- 
ous humour,  during  the  blindness,  always  became  dis- 
coloured, whitish,  and  turbid;  but  its  transparency 
regularly  returned  on  the  cessation  of  the  attack.  Ac- 
cording to  Richter,  the  periodical  amaurosis  commonly 
depends  upon  irritation  affecting  the  digestive  organs, 
the  stimulus  of  worms,  or  irregularity  in  the  men- 
strual discharge.  Sometimes  it  is  plainly  a symptom 
of  a confirmed  ague,  the  patient  being  attacked  with 
an  ordinary  intermittent,  and  blind  during  each  pa- 
roxysm, but  always  regaining  his  sight  as  soon  as  each 
fit  is  over. — Anfangsgr.  dcr  Wundarzn.  b.  3,  kap.  14.) 
Beer  believes  that  periodical  amaurosis  is  chiefly  ob- 
served in  chlorotic,  hemorrhoidal,  hysterical,  and  hypo- 
chondriacal subjects.  Day-blindness  (Cscitas  Diurna ; 


Nyctalopia'  and  night-blindness  '’Caecitas  Crepuscula- 
ris ; Hemeralopia  are  nothing  more  than  cas«e  of  pe- 
riodical amaurosis.  But  sometimes  the  frequently 
recurring  form  of  the  disease  confines  itself  to  no  de- 
terminate ty  lie  ; and,  on  account  of  its  irregularity,  it 
is  then  termed  by  Beer  “ amaurosis  vaga,”  which,  ho 
says,  is  often  of  spasmodic  origin,  and  therefore  prin- 
cipally met  with  in  persons  liable  to  hysteria,  hypo- 
chondriasis, convulsions,  or  epilepsy.  I’eriodical  amau- 
rosis, after  remaining  untured  a certain  time,  often  be- 
comes jiernianent. — Beer,  l.ehre,  Ac.  b.  2,  p.  429.) 

In  amaurosis  in  general,  but  particularly  when  no 
material  knowledge  can  be  acquired  of  causes,  and  the 
treatment  must  of  necessity  be  conducted  on  empirical 
principles,  it  is  of  the  highest  importance  to  recollect 
what  Richter  has  pointed  out ; namely,  that  amaurosis 
sometimes  coinmences  with  several  symptoms,  betray- 
ing an  increa.se  of  sensibility  in  the  eye,  or  some  irri- 
tation afl'ecting  this  organ.  In  moderately  light  places, 
the  patient  can  discern  things  very  well ; but  in  a 
great  light,  he  is  not  able  to  see  at  all.  The  eye  is 
sometimes  so  sensible,  that  a strong  light  will  make  it 
weep  and  become  painful.  Patients  of  this  description 
ought  always  to  wear  a shade,  however  bad  their  sight 
may  be. 

This  fonri  of  amaurosis  is  described  by  Beer  as  hav- 
ing two  stages  ; in  the  first,  the  patient  never  becomes 
blind  ; the  eyesight  not  being  lost  till  the  end  of  the 
second  stage.  'I'he  disease  always  forms  with  great 
quickness,  so  that  the  limits  between  the  two  stages 
are  frequently  very  indistinct. 

'I'he  first  stage  commences  with  a peculiar  sensation 
of  fulness  in  the  eyeball,  joined  with  continually  in- 
creasing, violent,  and  annoying,  luminous  appearances, 
and  a remarkable  weakness  of  sight.  These  symji- 
toiiis  are  soon  followed  by  a stupifying,  constantly  in- 
creasing headache,  duriiijg  which  the  jiower  of  vision 
manifestly  diminishes,  without  the  slightest  defect  be- 
ing perceptible  either  in  the  eye  itself,  or  its  surround- 
ing parts.  'I'he  patient,  however,  is  always  marked  by 
an  athletic  constitution,  or,  at  all  events,  by  such 
symptoins  of  general  and  local  plethora,  and  of  a 
phlogistic  diathesis,  as  cannot  be  mistaken. 

IJ  jion  the  advance  of  the  disorder  into  its  second  stage 
the  headache  becomes  irregular,  being  less  violent  at 
some  periods  than  others ; the  patient  feels  as  if  there 
were  before  his  eyes  a thick  net  or  gauze,  which,  in  a 
bright  light,  appears  quite  black,  but  in  the  shade, 
fiery  and  shining.  This  net  or  gauze,  when  there  is 
any  temporary  determination  of  blood  to  the  head  and 
eyes,  as  in  straining  at  stool,  is  immediately  rendered 
considerably  more  dense ; and  when  such  determina- 
tion of  blood  is  often  repeated,  or  long  maintained,  the 
density  at  length  remains  much  greater  than  before, 
and,  consequently,  the  patient  suddenly  grows' more 
blind,  and  is  very  quickly  entirely  bereft  of  vision. 
This  complete  loss  of  sight,  in  the  second  stage,  if 
efficient  assistance  be  not  given,  is  ultimately  produced 
by  the  progress  of  the  disease,  even  without  any  acci- 
dental determination  of  blood,  though  never  quite  sud- 
denly. At  last,  all  power  of  discerning  the  light  is 
abolished  under  incessant  stupifying  headaches,  which 
are  sometimes  weaker,  sometimes  stronger,  and  at- 
tended with  a sensation,  as  if  the  dimensions  of  the 
eye  were  increased,  and,  indeed,  it  really  feels  harder 
than  in  the  healthy  state. 

Sometimes  amaurosis  originates  writh  sy  mptoms  of 
weakness  and  diminished  irritability.  The  sight  is 
cloudy,  and  the  patient  finds  that  he  can  see  better  in 
a light  than  a dark  situation.  He  feels  as  if  some 
dirt  or  dust  w ere  upon  his  eyes,  and  is  in  the  habit  of 
frequently  wiping  them.  His  power  of  vision  is  greater 
after  meals  than  at  the  time  of  fasting.  His  sight  is 
always  plainer,  for  a short  time,  after  the  external  use 
of  tonic  remedies,  such  as  hartshorn,  cold  water,  <kc. 
Richter  informs  us  of  a person,  who  was  nearly  quite 
blind,  but  was  constantly  able  to  see  very  well  for  the 
space  of  an  hour,  after  drinking  champaign  wine.  He 
also  mentions . a woman  entirely  bereft  of  sight,  vvho 
was  in  the  habit  of  having  it  restored  again,  for  half 
an  hour,  whenever  she  walked  a quick  pace  up  and 
down  her  garden.  He  likewise  acquaints  us  with  the 
case  of  a lady,  who  had  been  blind  for  years,  but  ex- 
perienced a short  recovery  of  her  sight,  on  having  a 
tooth  extracted. — Anfangsgr.  &c.  b.  3,  kap.  14.) 

'Whether  the  benefit  arose  from  the  stimulus  of  the 
operation,  as  Richter  seems  to  imply,  or  from  the 


AMAUROSIS. 


27 


removal  of  an  irritating  cause,  doubts  may  rationally  be 
enteiiained.  A similar  fact  is  recorded  by  Mr.  Tra- 
vers, who  says,  that  he  has  seen  an  incipient  func- 
tional amaurosis  distinctly  arrested  by  the  extraction 
of  a diseased  tooth,  •when  the  delay  of  a similar  opera- 
tion h-ad  occasioned  gutta  serena  on  the  opposite  side 
two  years  before. — (Synopsis,  p.  299.) 

When  the  disorder  is  accompanied  with  diminished 
sensibility  in  the  eye  in  general.  Beer  joins  Richter, 
with  respect  to  the  temporary  improvement  of  the 
sight  after  a nourishing  meal,  or  drinking  spirituous  li- 
quors ; or  when  the  patient’s  mind  is  elated  with  joy, 
or  anger,  though  such  melioration  of  sight,  it  is  true, 
is  but  of  very  short  duration. — See  also  Vetch’s  Trea- 
tise on  the  Diseases  of  the  Eye,  p.  137  ; 

On  the  other  hand,  it  may  be  remarked,  that  every 
thing  which  tends  to  depress  the  passions  and  spirits, 
augments  the  imperfection  of  sight.  Where  marks  of 
increased  sensibility  prevail,  the  above-mentioned  cir- 
cumstances exercise  a transient  disadvantageous  opera- 
tion; the  patient  carefully  retires  from  every  strong 
light,  and  frequently  shelters  his  eye  with  his  hand, 
«&c.~  Lehre  von  den  Augenkr.  b.  2,  p.  430.) 

Mr.  Travers  also  knows  patients,  whose  vision  is 
benefited  in  a high  degree,  and  others,  in  whom  it  is 
much  deteriorated,  by  the  quickened  circulation  of  a 
full  meal,  and  a few  glasses  of  wine.  The  former,  he 
says,  are  persons  of  spare  and  meagre  habits ; the  latter 
plethoric. — Synopsis  of  the  Diseases  of  the  Eye,  p.  157. ) 

According  to  Beer,  this  amaurosis  differs  from  the 
preceding,  by  its  formation  being  usually  very  slow, 
and  its  not  exhibiting  any  traces  of  those  two  very  differ- 
ent stages  which  are  peculiar  to  the  other  case.  It 
also  invariably  commences  with  the  visus  reticulatus, 
or  nebulosus,  without  any  alternation  with  a -blinding 
glare  of  light ; and  the  eyesight  is  sometimes  considera- 
bly better,  and  sometimes  weaker,  which  always  de- 
pends upon  the  accidental  operation  of  the  above  in- 
ternal or  external  circumstances.  The  melioration  of 
the  eyesight  never  continues  long,  while  the  diminu- 
tion of  it  not  only  remains,  but  gels  worse  and  worse. 
It  is  not  at  all  uncommon  for  this  species  of  amaurosis 
to  make  its  appearance  as  a night-bimdtiess,  because 
common  artificial  light  is  much  too  feeble  to  make  due 
impression  upon  the  diminished  sensibility  of  the  optic 
nerve,  and  consequently  these  patients  always  show  a 
partiality  to  a very  strong  light.  To  such  weak-sighted 
individuals,  the  flame  of  a candle,  or  the  moon,  appears 
as  if  covered  by  a dense  veil,  with  an  expanded  halo 
round  it  of  various  colours.  There  is  no  complaint 
made  of  pain  in  the  head  or  eyes  ; and  no  sensation  of 
fulness  or  weight  is  experienced  in  the  eyeball ; much 
less  are  there  any  signs  of  the  disease  in  the  structure 
and  form  of  the  eye,  or  in  the  action  of  its  irritable 
textures;  but  when  it  has  been  long  complete,  it  is 
usually  conjoined  with  a debilitated  habit. 

Amaurosis  either  presents  itself  as  a genuine  un- 
complicated affection,  or,  at  least,  with  the  appearance 
of  such  a form  of  disease  of  the  eye,  depending  solely 
upon  a morbid  state  of  the  optic  nerve,  and  cognizable 
by  a diminution,  or  complete  abolition,  of  the  power  of 
vision ; or  the  disease  is  co-existeut  with  other  dis- 
eased appearances,  either  in  the  eye,  its  vicinity,  or 
some  other  organs  at  a distance  from  the  eye,  or  in 
the  general  constitution.  The.se  appearances  merit  the 
most  earnest  consideration,  because  they  are  for  the 
most  part  connected  with  the  catise  of  amaurosis.  Ac- 
cording to  this  statement  then,  there  is  a genuine  local 
amauro.sis,  and  a complicated  amaurosis,  which  last 
may  be  either  local,  or  general,  or  of  both  descriptions 
together,  and  therefore  named  by  Beer,  “perfectly 
complicated.” — Vol.  cit.  p.  43>.) 

The  general  symptoms  of  the  simple  uncomplicated 
species  of  amauro.sis,  putting  out  of  consideration  the 
morbid  increa.se,  or  diminution  of  the  sen.sibility  of 
the  optic  nerve,  are  thus  described  by  Beer.  In  the 
first  place,  all  morbid  appearances  are  absent,  which 
might  be  produced  in  the  amaurotic  eye  by  any  one 
preternatural  change  in  the  texture,  form,  or  state  of 
llal  organ.  Hence  we  are  obliged  to  trust  almo.st  ex- 
clusively to  the  patient’s  assertion  that  his  sight  is  bad, 
or  quite  gone ; and  not  unfrequently  it  is  necessary, 
especially  in  judicial  ctLses,  to  employ  political  artifices 
in  order  to  determine  whether  such  as.sertion  be  true, 
particularly  when  the  patient  affirms  that  the  blindness 
is  restricted  to  one  eye  Secondly,  wlien  the  amau- 
rusKs  n*  indeed  nearly  or  quite  formed  in  one  eye,  a 


slight  degree  of  strabl.smus  is  at  most  perceptible,  aris- 
ing from  the  circumstance  of  the  patient’s  not  fixing 
the  eye  affected  upon  any  object.  This  degree  of  stra- 
bismus is  noticed  by  Ackerman  and  Fischer  as  the 
surest  sign  of  amauro.sis. — <,See  Klinische  Annalen  von 
Jena  st.  1,  p.  144.)  And  it  is  particularly  pointed  out 
by  Richter  as  an  invariable  attendant  upon  amaurosis. 
The  patient,  says  he,  not  only  does  not  turn  either  eye 
towards  any  object,  in  such  a manner,  that  the  ob- 
ject looked  at  is  in  the  axis  of  vision,  but  he  does 
not  turn  both  his  eyes  towards  the  same  thing.  This 
was  regarded  by  Richter  as  the  only  symptom  which 
we  can  trust,  where  implicit  confidence  should  not  be 
put  in  the  mere  assurance  of  the  patient  that  he  cannot 
see,  while  all  the  coats  and  humours  of  the  eyes  pre- 
sent their  natural  appearance  — See  Anfangsgr.  der 
Wundarzn.  b.  3,  kap.  14.  i Provided  this  observation 
be  correct,  it  must  be  highly  interesting  to  the  military 
surgeon,  amaurosis  being  a common  affliction  of  sol- 
diers, many  of  whom,  liowever,  endeavour  to  avoid 
service  by  pretending  to  labour  under  a disqualification 
which  they  well  know  does  not  necessarily  produce  any 
very  considerable  alteration  in  the  natural  ajipearance 
of  the  part  affected.  Thirdly,  while  the  disorder  is 
only  in  the  stage  of  amblyopia,  the  patient  always  com- 
plains of  continually  multiplying  muscae  volitantes,  or 
of  the  visus  reticulatus,  or  nebulosus.  Fourthly,  lu- 
minous forms  appear  before  the  eyes,  especially  in  the 
dark,  even  when  the  patient  is  entirely  blind.  Fifthly, 
the  deer  ase  of  vision  goes  on  to  complete  blindness, 
without  any  material  interruption,  or  retrogression. 
Sixthly,  when  only  one  eye  is  quite  blind,  and  the  eye- 
sight on  the  other  side  is  perfectly  undisturbed,  there 
is  one  infallible  symptom  of  this  amauro.sis  ; namely, 
if  the  sound  eye  be  very  carefully  covered,  the  pupil 
of  the  blind  one  immediately  expands,  and  the  iris  be- 
comes quite  motionless,  notwithstanding  the  diseased 
eye  be  exposed  to  the  strongest  light  possible.  How- 
ever, this  criterion  is  mostly  wanting,  because  the 
amaurosis,  unattended  with  any  perceptible  effect,  ex- 
cept loss  of  vision,  is  seldom  confined  to  one  eye,  but 
usually  affects  both. — ^See  Lehre  von  den  Augenkr.  b. 
2,  p.  481,  482.) 

Mr.  I'ravers  divides  amaurotic  affections  into  two 
classes,  the  organic  and  the  functional.  The  first 
comp  eheuds  alterations,  however  induced,  in  the  tex- 
ture or  position  of  the  retina,  optic  nerve,  or  thalamus. 
The  second  includes  suspension,  or  loss  of  function  of 
the  retina  and  optic  organ,  depending  upon  a change, 
either  in  the  action  of  the  vessels,  or  in  the  tone  of  the 
sentient  apparatus. 

As  causes  of  organic  amaurosis,  Mr.  Travers  enu- 
merates; 1.  Lesion,  extravasation  of  blood,  inflamma- 
tory deposition  upon  either  of  its  surfaces,  and  loss  of 
transparency  of  the  retina.  2.  Morbid  growths  within 
the  eyeball,  dropsy,  atrophy,  and  all  such  disorganiza- 
tions as  directly  oppress  or  derange  the  texture  of  the 
retina.  3.  Apoplexy,  hydrocephalus,  tumours  or  ab- 
scesses in  the  brain,  or  in  or  upon  the  optic  nerve  or 
its  sheath,  and  thickening,  extenuation,  absorption,  or 
ossification  of  the  latter.  As  causes  of  functional 
amaurosis,  Mr.  Travers  specifies;  1.  Temporary  de- 
termination ; vascular  congestion,  or  vacuity,  as  from 
visceral  or  cerebral  irritation  ; suppressed  or  deranged 
or  excessive  secretions,  as  of  the  liver,  kidneys,  uterus, 
mammae,  and  testes;  various  forms  of  injury  and  dis- 
ease ; and  hidden  translations  of  remote  morbid  ac- 
tions. 2.  Paralysis  idiopathica,  suspension  or  ex- 
haustion of  sensorial  power  from  various  constitu- 
tional and  local  causes ; from  undue  excitement  or  exer- 
tion of  the  visual  faculty ; and  from  the  deleterious  action 
of  poisons  on  the  nervous  system,  as  lead,  mercury,  &c. 

From  this  description,  says  Mr.  Travers,  it  will  be 
understood  that  organic,  and  many  forms  of  functitwial 
amaurosis  are  incurable ; and  the  functional,  by  con- 
tinuance, lapses  into  the  organic  disease. 

Functional  amaurasis  is  subdivided  by  Mr.  Travers 
into,  1st,  the  Symptomatic,  or  that  which  is  only  a 
symptom  of  some  general  disease,  or  disorder  of  the 
system;  as,  for  example,  general  plethora,  general  de- 
bility ; 2dly,  the  Metastatic,  or  that  produced  by  the 
sudden  translation  of  the  morbid  action  from  another 
organ  of  the  body;  as,  for  example,  from  the  skin, 
the  testicle,  «kc.  : 3dly,  the  Proper,  or  that  which  de- 
pends upon  a peculiar  condition  of  the  retina ; as,  for 
example,  the  visus  nebulosus,  muscie  volitantes  — 
(9>'nopsi6,  p.  139—155.) 


28 


AMAUROSIS. 


On  the  whole,  genuine  local  amaurosis,  that  is  to 
say,  a diminution  or  total  loss  ol’  the  eyesight,  uiiat- 
teniled  with  any  other  apparent  local  or  constitutional 
defect,  may  be  said  to  be  a very  rare  case,  the  disorder 
being  usually  more  or  less  comiilicated. 

To  the  local  complications,  says  Beer,  belong  the  ca- 
taract ; glaucoma;  a general  varicose  state  of  the  eye- 
ball cirsophthalmia  ; exophthalmia ; atrophy  of  the 
eye  ; spasms  in  the  organ  and  surrounding  parts  ; para- 
lysis of  one  or  more  muscles  of  the  eye  oj)hthalmoi>- 
legia  ; paralysis  of  the  eyelids  ; ophthalmia  in  general, 
and  internal  ophthalmia  in  particular ; a scorbutic 
blood-shot  apiiearance  of  the  eye  ^hy^^oema  scorbuti- 
cum  ; and  finally,  wounds  or  contusions  of  the  eye  or 
adjacent  parts.  With  these  cases  should  also  be  men- 
tioned that  imiiortant  ca.se,  fungus  Inematodes  of  the  I 
eye.  From  this  siinjile  enumeration  of  local  complica-  j 
tioas  one  may  .see  how  frequently  amaurosis  is  only  a j 
symptomatic  effect  of  another  disorder  of  the  eye,  with  | 
which  it  is  conjoined,  and  how  ollen  it  is  connccteil  | 
with  the  same  common  causes  which  jiertain  to  another  i 
or  several  other  diseases  of  the  eye. 

Among  the  general  comjilications  Beer  enumerates  ' 
those  which  are  purely  nervous : impairment  of  the  I 
health  in  various  forms  by  infection,  contagion,  or  mias-  ' 
niata  ; a bad  habit  of  body  ; typhoid  fevers,  the  aniau-  i 
rotic  effects  of  which  Ujion  the  eye  the  author  of  tins  j 
work  has  frequently  noticed;  asthma  ; internal  and  ex- 
ternal hydrocephalus ; organic  defects  of  the  abdominal  ; 
viscera ; worms ; chlorosis;  consumption  ; old  ulcers  of  { 
the  legs;  organic  disease  of  the  brain  and  skull ; com-  i 
plaints  arising  from  pregnancy  ; hemorrhage,  Ac.  In  ! 
the.se  general  com|)licatioiis  Beer  remarks  that  the 
casual  connexion  between  amaurosis  and  some  remote  ^ 
disea.se  of  another  organ,  or  of  the  whole  constitution,  | 
cannot  be  mistaken;  and  in  these  cases  we  otlen  see 
the  disease  of  some  other  distant  part  Irom  the  eye  sud- 
denly Of  gradually  diminish,  and  immediately  ap|Miar 
again  as  a sympathetic  action  in  the  form  of  amaurosis, 
tif  which  the  most  remarkable  instance  is  seen  after  the 
sudden  healing  of  old  ulcers  of  the  legs. — (Beer,  Lehre 
von  den  Augenkr.  b.  2,  p.  133. 

From  the  above  general  remarks  upon  amaurosis  it  is 
<}uite  manifest  that  the  symptoms  of  the  disease  vary 
considerably  according  to  the  violence  of  its  causes, 
and  of  the  local  and  general  complications,  though  the  ! 
seat  of  the  disease  and  what  is  particularly  the  proximate  | 
cause  of  the  loss  of  vision  be  in  the  ojitic  nerve  ; and  it 
depends  esfiecially  on  the  nature  of  the  causes,  whether 
this  or  that  morbid  apiiearance  take  place  in  the  eye. 

One  may  consider  as  the  only  really  inseparable 
symptom  of  amaurosis  that  weakness  of  sight  ambly- 
opia , or  that  complete  blindness,  in  which  neither  wirh 
the  unassisted  or  assisted  eye  the  least  defect  can  be 
jierceived  in  the  structure  and  shape  of  the  alfected  or-  i 
gan.  Hence  Beer  names  such  impairment  of  vision,  or 
blindness,  amaurotic.  But  how  rarely  this  essential 
symptom  is  met  with  alone,  and  how  frequently  it  is  | 
obscured  by  some  other  defect  in  the  structure  and  i 
form  of  the  eye,  is  proved  by  daily  experience.  | 

The  incidental  symptoms  of  amaurosis  have  hitherto  | 
been  set  down  as  merely  consisting  of  a considerable 
dilatation  of  the  pupil,  and  immobility  of  the  iris,  be- 
cause these  appearances  are  indeed  the  most  freijuent ; 
but,  as  Beer  observes,  this  is  another  proof  what  igno- 
rance has  prevailed  respecting  the  true  mature  of  that 
disease  of  the  eye  and  its  modifications,  which  are 
usually  termed  amaurosis. 

The' incidental  symptoms  of  amaurosis  may  consist 
in  the  faulty  size  and  shape  of  the  pupil.  In  many 
cases  the  pupil  is  very  much  dilated,  immoveable,  and 
possesses  i;  s natural  black  colour  and  usual  transpa- 
rency. It  cannot  be  denied  that  this  Is  the  state  of 
numerous  cases,  but  it  is  etjually  true  that  there  are 
many  exceptions.  Sometimes,  according  to  Richter, 
in  the  most  complete  and  incurable  cases  the  pupil  is 
of  its  proper  size,  and  even  capable  of  free  motion 
(Turbes,  Recueil  Periodique,  &c.  t.  2,  p.  319  ; and  oc- 
casionally, it  is  actually  smaller  and  more  contracted 
than  natural.  This  aperture  often  continues  extraordi- 
narily large  in  the  .strongest  light ; but  in  some  instances 
it  is  unusually  small  in  every  kind  of  light. — Arra- 
chard,  Recueil  Period.  &c.  t.  1,  p.  273.  Richter,  An- 
fangsgr.  Ac.  b.  3,  p.  424.  Beer,  Lehre,  Ac.  b.  2,  d.  435.) 
According  to  the  latter  writer,  the  pupillary  edge  of  the 
ins  rarely  has  its  primitive  shape,  being  generally  more 
or  less  angular , either  at  some  indeterminate  point,  or 


above  and  below,  .so  as  to  resemble  in  some  measure 
the  pupil  of  the  cat  race ; or  towards  the  nose  or  tem- 
ple, so  as  to  have  some  similitude  in  its  form  to  the  pupil 
of  ruminating  animals.  These  apiiearances  are  highly 
imjiortant,  having  great  inftucnce  over  the  diagnosis. 

Frequently  not  only  the  size  and  shajic  of  the  pupil 
are  faulty,  but  the  position  of  that  opening  is  (luitc  un- 
natural, being  inclined  either  upwards  or  downwards, 
or  outwards  or  inwards  ; but  most  commonly  in  a dia- 
gonal line  between  inwards  and  upwards,  and  in  these 
cases  the  pupillary  margin  of  the  iris  never  describes  a 
regular  circle,  but  is  always  more  or  less  angular. — 
(Beer,  vol.  cit.  p.  436.) 

The  pupil  of  an  eye  affected  with  amaurosis  fre- 
quently does  not  exhibit  the  clear  shining  blackness 
w hich  is  seen  in  a healthy  eye.  In  general  it  is  of  a 
dull,  glassy,  honi-like  blackness,  which  symptom  alone 
is  frequently  enough  to  apprize  a well-infonneil  prac- 
titioner of  the  nature  of  the  disease.  It  is,  in  the  words 
of  Mr.  Travers,  “little  more  than  the  healthy  appear- 
ance of  the  humours  in  the  eye  of  a horse.” — Synop- 
sis, J).  Ifii.i  Sometimes  the  colour  of  the  pupil  has  an 
inclination  to  green  ; while  in  other  examples  this 
aperture  seems  to  be  dense,  white,  and  cloudy,  so  that 
the  complaint  might  ea.sily  be  mistaken  for  the  begin- 
ning of  a cataract.  This  error,  into  which  inexpe- 
henced  surgeons  are  liable  to  fall,  may  generally  be 
avoided  by  attention  to  the  following  circumstances : — 
The  mi.'ty  ajijicardnce  is  not  situated  close  behind  the 
pupil  in  the  place  of  the  crystalline  lens,  but  more 
deeply  in  the  eye.  iNor  is  it  in  proportion  to  the  im- 
painnent  of  sight,  the  patient  being  quite  blind,  while 
the  misty  apjiearance  is  so  trivial,  that  if  it  arose  from 
the  opacity  of  the  crystalline  lens,  it  could  at  most  only 
occa.sion  a slight  weakness  and  obscurity  of  vision ; at 
the  same  time  Richter  acknowledges  that  it  must  be 
more  dillicult  to  avoid  mistake  when  a beginning  amau- 
rosis is  accompanied  with  this  cloudiness  of  the  eye, 
and  consequently  when  the  degree  of  blindness  seems 
to  bear  .some  proportion  to  the  degree  of  mistiness  in 
the  pupil.  However,  in  this  case  he  maintains  that  the 
true  nature  of  the  disea.se  may  generally  be  known  by 
comparing  the  ordinary  symptoms  of  the  two  diseases. 
— Anfangsgr.  b.  3,  p.  14.)  And,  according  to  Beer, 
when  the  pupil  is  of  a true  dark-gray,  or  greenish-gray 
colour,  a lateral  inspection  of  the  eye  will  show  plainly 
enough,  that  the  cloudiness  is  in  the  vitreous  humour 
or  behind  it.  Sometimes  the  pupil  appears  reddish, 
quite  red.  or  of  a yellowish-white  colour  Lehre  von 
den  Augenkr.  b.  2,  ji.  436) ; while  in  other  ca.ses  the  inte- 
rior of  the  eye  a good  w'ay  behind  the  pupil  seems  quite 
white,  and  a concave  light-coloured  surface  may  be  ob- 
served, upon  which  the  ramifications  of  blood-vessels 
can  be  plainly  seen.  In  particular  instances  this  white 
surface  extends  over  the  whole  back  part  of  the  eye, 
while  in  other  ca.ses  it  only  occupies  a half  or  a small 
portion  of  it.  This  peculiar  appearance  has  been 
ascribed  to  a loss  of  transparency  in  the  retina  itself, 
and  a consequent  reflection  of  the  rays  of  light.—  (Hal- 
ler, Element.  Physiol,  tom.  5,  p.  409  ) Mr.  Travers  in- 
clines to  the  opinion,  that  it  arises  from  a deficient 
secretion  of  the  choroid  pigment,  a preternatural  adhe- 
sion between  the  choroid  coat  and  the  retina,  and  a 
discoloration  or  resplendent  appearance  of  the  latter 
from  this  cause. — (Synopsis,  p.  148.) 

One  of  the  strongest  characteristics  of  amaurosis  and 
an  incipient  cataract,  and  one  most  to  be  depended  upon 
in  practice,  is  reported  by  Mr.  Stevenson  to  be  the  dif- 
ference whii;h  the  flame  of  a candle  exhibits  in  the  two 
affections.  In  incipient  cataract  it  appears  as  if  it  were 
involved  in  a generally  diffused,  thin  mist  or  wbJte 
cloud,  which  increases  with  the  distance  of  the  light ; 
but  in  amaurosis  a halo  or  iris  appears  to  encircle  or 
emanate  from  the  mist,  the  flame  seeming  to  be  split, 
when  at  a distance. — vOn  the  Nature,  Ac.  of  Amauro- 
sis, Lond.  1821.) 

There  can  now  be  no  doubt  that  the  whitene.ss  be- 
hind the  pupil  must  sometimes  have  originated  flrom  the 
diseased  mass  which,  in  cases  of  fungus  haematodes  of 
the  eye,  grows  fVom  the  deeper  part  of  this  organ,  and 
gradually  makes  its  way  forwards  to  the  iris,  being 
always  attended  with  total  loss  of  sight.  Putting  out 
of  present  consideration  the  change  of  colour  within 
the  eye,  produced  by  fungus  htematodes,  the  othei 
palish  changes  behind  the  pupil  are  not  confined,  as 
Kieser  supposes,  to  very  old  cases  of  amaurosis,  be- 
cause the  alteration  is  described  by  Schmucker  as  taking 


AMAUROSIS.  29 


place  especially  in  examples  the  formation  of  which 
was  quite  sudden  t.Vermischte  Cltir.  Schrili.  b.  2 ; and 
Langenbeck  has  recorded  cases  in  which  the  same  ap- 
pearance happened  in  the  early  stage  of  the  disease. — 
(NeueBibl.  b.  1,  p.  64,  «fec.) 

Besides  the  above  appearances  in  the  pupil  itself, 
and  in  the  pupillary  margin  of  the  iris.  Beer  adverts  to 
several  important  phenomena  with  respect  to  the  mo- 
tion of  the  iris.  Sometimes  the  iris  moves  but  very 
inertly,  and  frequently  not  at  all,  though  the  light  be 
strong,  and  the  upper  eyelid  be  rubbed  over  the  eyeball. 
While  in  other  examples  a very  moderate  light  will 
bring  on  such  a rapid  contraction  of  the  iris  and  closure 
of  the  pupil,  as  are  never  witnessed  in  a healthy  eye. 

We  have  also  the  authority  of  Richter  for  asserting, 
that  in  particular  instances  the  iris  not  only  possesses 
the  power  of  motion,  but  is  capable  of  moving  with 
uncommon  activity,  so  that  in  a very  moderate  light,  it 
will  contract  in  an  unusual  degree,  and  nearly  close 
the  pupil. — vAnfangsgr.  der  Wundarzn.  b.  3,  p.  424, 
edit.  1795.) 

Two  or  three  remarkable  instances  of  the  active  state 
of  the  iris,  in  cases  of  amaurosis,  were  some  years  ago 
shown  to  me  by  Dr.  Albert,  then  staif-surgeon  at  the 
York  Hospital,  Chelsea,  and  1 have  seen  other  similar 
cases  in  St.  Bartholomew’s  Hospital.  Most  of  the  pa- 
tients in  question  had  not  the  least  power  of  distin- 
guishing the  difference  between  total  darkness  and  the 
vivid  light  of  the  sun,  or  a candle  placed  just  before 
their  eyes.  Janin  sometimes  found  the  pupil  capable 
of  motion  in  this  disease,  and  Schmucker  twice  noticed 
the  same  fact. 

Such  cases,  Mr.  Travers  thinks,  can  only  be  explained 
by  concluding  the  organ  to  be  sound,  and  the  cause  of 
the  amaurosis  remote  or  external  to  it.  Thus,  says  he, 
in  a case  of  circumscribed  tumour,  compressing  the 
left  optic  nerve,  immediately  behind  the  ganglion  op- 
ticum,  although  the  blindness  was  complete,  the  iris 
was  active.  In  two  young  ladies,  in  whom  the  eyes,  as 
in  the  former  case,  were  perfect,  and  the  blindness  com- 
plete, the  iris  was  even  vivacious ; and  there  was  the 
strongest  presumptive  evidence  from  the  symptoms 
that  the  amaurosis  was  in  the  cerebral  portion  of  the 
nerve. — (Synopsis,  p.  18H.) 

In  some  anomalous  cases,  when  the  strength  of  the 
light  is  suddenly  incretised,  the  pupil  expands  with 
more  or  less  celerity. 

I have  already  adverted  to  the  occasional  moveable- 
ness of  the  iris,  notwithstanding  the  insensible  state 
of  the  retina.  Let  me  next  take  notice  of  a case  which 
sometimes  presents  itself,  and  is  quite  the  reverse  of 
this  la.st.  The  nerves  of  the  iris  may  be  paralytic, 
while  those  of  sight  continue  unimpaired.  Schmucker 
was  ac<iuainted  with  a woman  whose  pupil  was  un- 
commonly distended,  and  totally  incapable  of  motion. 
Her  sight  was  very  weak,  and  spectacles  were  of  no 
use  to  her.  She  could  scarcely  discern  any  thing  by 
day  or  in  a strong  light,  but  she  could  see  rather  better 
at  night  and  in  dark  ])laces.  This  infirmity  of  sight 
depended  upon  the  dilated,  paralytic  state  of  the  pupil, 
by  which  too  many  rays  of  light  were  admitted  into 
the  eye  ; and  the  rea.son  why  the  patient  could  see  bet- 
ter at  night  was  because  the  pupil,  in  its  natural  state, 
always  becomes  widened  in  a dark  situation. — See  Ver- 
rnischte  Chirurgische  Schriften,  von  J.  L.  Schmucker, 
band  2,  p.  13,  14.) 

On  this  curious  part  of  the  subject  it  is  remarked  by 
Mr.  Travers,  that  if  the  retina  be  opaque,  cornpressecl, 
or  unsupported,  the  iris  mechanically  disordered,  or  the 
ciliary  nerves  palsied,  the  pupil  is  inactive,  indepen- 
dently of  the  state  of  vision.  In  the  first  of  these  cases 
it  is  evident  vi.sion  will  be  lost ; but  we  continually 
se.e  useful  vision  combined  with  the  second  and  third, 
as  after  operations  in  which  the  iris  has  been  half  de- 
stroyed or  has  become  preternaturally  adherent,  or  in 
malformations  where  it  is  half  wanting ; and  in  para- 
lysis of  the  ciliary  nerves  accompanying  ptosis.— (Sy- 
nopsis, p.  188.) 

Frequently  in  amaurosis,  when  the  sight  of  only  one 
eye  is  lost,  and  the  other  retains  its  full  power  of  vision, 
not  the  slightest  defect  can  be  discovered  as  long  as  the 
patient  keeps  both  of  them  open ; but  the  instant  the 
sound  eye  is  completely  covered,  the  iris  becomes  per- 
fectly motionless,  its  pupillary  margin  assumes  an  an- 
gular shape,  and  the  pupil  expands,  being  sometimes 
evidently  drawn  towards  the  edge  of  the  cornea. — 
(Beer,  Lehre  vbn  den  A-ugenkrank.  b.  2,  p.  438.)  This 


demonstrates  the  difference  between  the  independent 
and  the  associated  action  of  the  iris. 

Besides  the  above  appearances  of  the  pupil  and  iris, 
amaurosis  is  attended  with  other  characteristic  phe- 
nomena, which  occur  under  certain  circumstances,  in 
the  form,  texture,  and  state  of  other  parts  of  the  eye 
and  adjoining  organs.  Thus  the  patient  often  com- 
plains of  a peculiar  troublesome  dryness  of  the  eye,  or 
of  a sensation  as  if  the  eyeball  were  about  to  be  pressed 
out  of  its  socket ; and  indeed,  says  Beer,  one  may  some- 
times hear  a grating  noise,  and  distinguish  a fluctua- 
tion in  the  orbit  behind  the  eyeball,  when  this  organ  is 
pressed  upon  by  the  finger,  or  moved  in  various  direc- 
tions, though  neither  its  circumference  be  enlarged, 
nor  any  tendency  to  exophthalmia  be  really  present. 
Nor  is  It  very  uncommon  to  find  the  affected  eye  pre- 
ternaturally hard,  soft,  or  even  quite  flaccid  ; but  it  is 
less  common  to  find  the  dimensions  of  the  globe  of  the 
eye  increased,  or  the  organ  affected  with  atrophy.— 
(Beer,  vol.  cit.  p.  428.) 

However,  in  organic  amaurosis,  as  Mr.  Travers  no- 
tices, a peculiar  bluish-gray  tint  of  the  sclerotic  coat 
is  frequently  remarkable;  and  sometimes  even  a de- 
gree of  bulging  on  one  or  more  sides  of  the  eye,  or 
simply  a loss  of  .sphericity,  its  sides  appearing  flattened. 

A turgescence  of  the  superficial  vessels,  especially 
of  the  long  fasciculi  of  conjunctival  veins,  is  likewise 
another  symptom,  frequently  observed  in  cases  of  or- 
ganic amaurosis. — See  Travers’s  Synopsis,  p.  146.) 

The  same  gentleman  also  gives  the  particulars  of  a 
dissection,  in  which  a case  of  amaurosis  was  attended 
with  a collapse  of  the  retina  from  absorption  of  the 
vitreous  humour. — Op.  cit.  p.  150.) 

Some  of  the  principal  morbid  effects  of  amaurosis 
have  been  already  described  in  speaking  of  the  several 
defects  of  vision,  which  accompany  an  amaurotic  weak- 
ness of  sight.  Besides  these,  however,  there  are  others 
which  merit  attention.  For  instance,  the  patient  feels 
in  the  eye  and  surrounding  parts  an  irksome  sensation 
without  any  actual  pain,  and  complains  of  a remarkable 
sense  of  I'ulness  or  weight  in  the  organ.  Amaurotic 
patients  are  also  frequently  attacked  with  sudden  vio- 
lent giddiness,  usually  ending  in  a considerable  dimi- 
nution of  the  eyesight,  and  sometimes  in  severe  gene- 
ral headache.  Occasionally  they  fancy  that  small  atoms 
of  dust  are  lodged  under  the  eyelids,  and  are  fearful  of 
moving  these  parts  of  the  eye.  It  is  also  well  known, 
that  many  persons  become  amaurotic  while  labouring 
under  severe  hemicrania,  extending  from  or  to  the  dis- 
eased eye  ; while,  on  other  occasions,  the  most  violent 
pains  are  confined  particularly  to  the  region  of  the 
eyebrow,  and  have  the  appearance  of  being  strictly 
periodical.  In  certain  other  cases  the  pain  is  w'ander- 
ing,  and  shoots  in  every  direction  about  the  eyebrow. 
These  painful  feelings  often  precede  the  amaurotic 
blindness  a considerable  time,  and  often  first  take  place 
when  one  or  both  eyes  are  already  blind  ; but  the  pains 
and  loss  of  .sight  are  not  unfrequently  produced  toge- 
ther. Lastly,  some  patients  are  met  with,  in  whom 
the  worst  pains  only  last  until  the  amaurosis  is  per- 
fectly Ibrmed,  when  they  gradually  and  permanently 
cease.  In  all  these  painful-  cases  of  amaurosis,  the 
pain  and  the  blindness  chiefly  depend  upon  the  same 
cause,  and  one  is  seldom  the  occasion  of  the  other. 
Sometimes  amaurotic  patients  experience  such  violent 
pain,  that  they  lose  their  senses  and  grow  delirious ; 
but  in  these  cases,  if  we  can  credit  the  as.sertion  of 
Beer,  important  morbid  changes  in  the  bones  of  the 
skull,  or  the  brain  itself,  are  invariably  noticed  after 
death. — (See  Lehre  von  den  Augenkr.  b.  2,  p.  439.)  In 
some  amaurotic  patients  lethargic  symptoms  may  be 
remarked;  in  others,  restlessness  ; and  more  rarely  deli- 
rium in  all  its  degrees,  either  as  a transient  or  perma- 
nent affection. 

According  to  the  observations  of  Mr.  Travers,  pain 
affecting  the  forehead  and  temples  is  a percursory 
symptom  of  amaurosis,  diminishing  in  proportion  as  the 
dimness  increases.  When  the  amaurosis  is  perfect,  it 
usually  cea,ses  altogether,  if  the  disease  has  its  .seat  in 
the  eyeball.  But  when  the  pain  is  .severe,  remits  im- 
perfectly, and  is  (juickly  rendered  worse  by  exercise,  it 
is  usually  connected  with  organic  disease  of  the  brain. 
In  this  case  derangement  and  torpor  of  the  prim®  vi®, 
loss  of  strength  and  flesh,  disposition  to  stupor,  occa- 
sional confusion  oi'yitellect,  inajititude  to  exertion,  and 
paralysis  of  one  or  more  muscles  will  be  concomitant 
aymploms.— ,S3mopsis,  &,c.  p.  167.) 


30 


AMALROSIS. 


Paralytic  appearances  may  precede  amaurosis,  ekher 
in  the  vicinity  of  the  eye,  or  in  the  muscles  of  the  face, 
or  in  a distant  situation,  as  the  extremities.  Some- 
times they  accoiiijiaiiy  the  disease,  and  sometimes 
closely  follow  ihe  weakness  of  sight,  being  not  unire- 
quently  tiie  forerunners  of  a fatal  attack  of  apoplexy. 

In  the  s^nie  way  convulsive  symptoms  may  be  con- 
joined with  amaurosis,  and  when  the\  tirst  occur  in  the 
complete  stage  of  the  latter  disease^  Heer  pronounces 
them  a very  unfavourable  omen  for  the  patient’s  life. 

Put  according  to  the  same  experienced  oculist,  when 
in  a cause  of  perfect  amaurosis  several  of  the  other  ex- 
ternal senses  are  affected  ; and  lastly,  when  the  internal 
senses  begin  to  suffer,  when,  for  instance,  the  hearing, 
and  then  the  smell  and  taste  are  lost,  and  afterward 
the  memory  and  other  intellectual  jiowers  fail,  the  pa- 
tient’s speedy  dissolution  may  be  exjiected. — {See  Lclire 
von  den  Augeiikraiikh.  b.  2,  p.  4-11,  Wien,  1817.; 

As  Proles.sor  Peer  correctly  ob.serves,  age  cannot  be 
considered  a predisjiosmg  cause  o.’’  amaurcsis,  as  it  is 
of  catarac-t ; for  there  are  many  more  blind  jiersons 
who  have  been  deprived  of  their  sight  by  amaunisis 
in  their  best  days  than  old  persons  thus  atiacked 
Amaurosis  spares  no  age— not  even  the  new-born  in- 
fant. Mr.  Lawrence,  in  his  Lectures,  concurs  in  this 
statement,  adding  his  opinion,  however,  that  amaurosis 
is  very  frequent  during  the  active  middle  period  of  life, 
and  very  common  about  the  ces.sation  of  menstruation 
in  females,  and  the  corresiionding  age  in  the  male. 

Four  forms  of  congenital  organic  amaurosis  are  no- 
ticed by  Mr.  Travers.  One  in  which  tUe  eye  is  preter- 
naturally  small,  soft,  and  even  flaccid ; the  iris  tremu- 
lous, and  not  influenced  by  belladonna;  and  the  globe 
affected  with  tremor,  and  not  subject  to  the  control  of 
the  will.  A second,  dejicnding  on  a deficiency  ot  the 
pigmentum  nigrum;  the  organ  is  tremulous,  strong 
light  jiroduces  uneasine.ss,  and  vision  is  dazzled  and 
confused.  The  vessels  of  the  choroid  give  the  interior 
of  the  eye  a deep-red  tinge.  A third  case  is  that  in 
which  the  sclerotica  so  em'.roaches  upon  the  cornea, 
that  the  latter  i.s  scarcely  w ider  than  the  pupil.  In  the 
fourth  kind  of  congenital  amaurosis,  described  by  Mr. 
Travers,  the  eyas  move  in  concert,  as  if  attracted  by  a 
faint  perception  of  light ; but  the  infant  is  blind;  no 
marks  of  organic  derangement  can  be  seen ; but  Mr. 
Travers  apprehends  that  the  disease  must  be  coimected 
with  a morbid  state  of  the  thalanii  or  optic  nerve.— 
(Synopsis,  p.  153,  155.) 

Neither  does  sex  nor  race  appear  to  have  any  in- 
fluence over  the  origin  of  the  compiaint ; but  it  would 
seem  that  dark  eyes,  es|)ecially  those  w liich  are  called 
black,  are  more  disposed  to  amaurotic  blindness  than 
such  as  are  light-coloured.  According  to  Peer’s  expe- 
rience, for  every  gray  or  blue  eye  aflected  with  amau- 
rosis, there  are  five-and-twent  yor  tiiirty  brown  or 
black  ones  thus,  diseased.  In  the  peculiar  constitution 
of  the  eye,  then,  as  well  as  in  a sangmneous  and  cho- 
leric temperament,  there  exists  a tendency  to  the  dis- 
order. 

More  frequently  than  cataract,  amaurosis  is  found  to 
be  a true  hereditary  disease  ; — this  is  so  much  the  ca.se, 
that  most  of  the  members  of  a family  for  more  than 
one  generation  may  lose  their  sight  from  amaurosis  at 
a certain  period  of  life.  Peer  says  that  he  is  acquainted 
with  more  than  one  family  in  which  this  has  happened, 
and  what  merits  attention,  the  women  of  one  of  these 
families,  down  to  the  third  generation,  became  com- 
pletely and  permanently  blind  from  amaurosis  on  the 
cessation  of  the  menses,  w’hile  all  the  others  who  had 
had  children  were  unaffected.  But  the  males  of  this 
unfortunate  family,  who  tis  well  as  the  females  have 
very  dark-brown  eyes,  all  seem  to  be  weak-sighted, 
though  none  of  them  are  vet  blind. — (Lehre  von  den 
Augenkrankheiten,  b.  2,  p.  443.) 

In  women,  especially  those  vvith  black  eyes,  the  time 
when  the  menses  stop  is  a dangerous  ^riod  for  the 
commencement  of  amaurosis. 

According  to  the  same  writer,  patients  whose  piles 
used  to  bleed  periodically  for  a long  time,  but  are  now 
_ suddenly  stopped,  and  whose  eyes  are  dark,  are  very 
’liable  to  amaurosis. 

One  of  the  less  common  causes  of  amaurosis  is  an 
idiosyncrasy,  in  relation  to  this  or  that  sort  of  nutri- 
ment or  medicine,  or  this  or  that  particular  state  of  the 
body.  Here  is  to  be  reckoned  the  amaurotic  weakness 
of  sight,  or  the  perfect  amaurosis,  whicfli  comes  on  at  the 
very  commencement  of  pregnancy,  and  subsides  after 


deliver)-,  but  ahva)s  attended  with  dyspepsia  and  InsU* 
{H:rable  vomiting.  This  species  of  amaurosis,  however, 
should  be  carefully  distinguished  from  that  which  some- 
times first  originates  in  the  final  months  of  pregnancy, 
and  chiefly  from  strong  and  long-continued  determitia- 
tion  of  blijod  to  the  head  and  eyes,  particularly  when 
the  bowels  are  at  the  same  titne  loaded,  and  the  patient 
constipated.  I'his  latter  case  usually  ccniinues  till 
after  delivery ; or  if  the  labour  be  tedious,  difticult,  and 
attended  with  considerable  efforts,  the  blindness  may 
first  attain  its  complete  form  at  the  time  of  delivery, 
and  not  afterward  subside. 

Beer  saw  a young  Jewess,  who,  at  the  very  beginning 
of  her  first  three  pregnancies,  which  followed  each 
other  quickly,  regularly  lost  her  sight,  becoming  com- 
pletely amaurotic  between  the  third  atid  fourth  months, 
and  on  the  first  two  occasions  she  continued  blind  till 
after  delivery ; but  in  the  iliird  instance  the  jiower  of 
vision  never  returned  at  all.  Beer  twice  had  under  his 
care  another  woman,  who  was  attacked  with  amaurosis 
whenever  she  drank  chocolate ; but  uiion  leaving  off 
that  drink,  she  never  afterward  had  any  complaint  m 
her  eyes. 

If  we  are  to  believe  the  generality  of  writers  oti  this 
subject,  the  ahu.se  of  bitter  substances,  as  of  chicory 
in  coffee,  bitter  malt  liquors,  and  bitter  medicines,  es- 
pecially qua.ssia,  is  unquestionably  a predispositig  cause 
of  amaurosis. 

The  abuse  of  narcotic  poisonous  substances  may  in- 
duce amaurosis ; immoderate  dases  of  opium  ; hyoscy- 
amus;  belladonna,  Acc.  Lead  will  do  the  same  thing. 
Resiicciitig  the  operation  of  some  of  these  causes,  how- 
ever, .Mr.  laiwrence  entertains  a doubt.  The  narcotic 
vegetables  used  to  dilate  the  pupil,  he  observes,  are 
sujiiHised  to  give  a tendency  to  amaurosis.  He  has 
never  seeti  such  an  efl’cet  produced  by  the  belladonna; 
atid  he  adverts  to  one  ca.se  in  which  it  was  used  a great 
length  of  time.  I'lie  eflect  of  bitters  seems  to  him 
equally  problematic. 

Otie  not  unfrequentatidveryimportaiUcause  of  amau- 
rosis is  hysteria  and  hypochondriasis,  with  which 
must  be  mentioned  infarction,  atid  disca.se  of  one  or 
more  of  the  abdominal  viscera,  especially  the  liver. — 
(Beer,  Lehre,  A:c.  h.  2,  p.  444 — 446.) 

According  to  Kichter,  the  remote  causes  of  amauro- 
sis may  be  properly  divided  into  three  principal  classes, 
the  differences  of  which  indicate  three  general  methods 
of  treatment. 

The  first  class  of  causes  depends  upon  an  extraordi- 
nary plethora  and  turgidity  of  the  blood-vessels  of  the 
brain,  or  of  those  of  the  optic  nerves  and  retinae,  upon 
which  last  parts  a degree  of  pressure  is  thereby  sup- 
po.sed  to  be  o ca-sioned.  A considerable  plethora,  esjie- 
cially  when  the  patient  heats  himself,  or  lets  his  head 
hang  down,  will  frequently  excite  the  appearance  of 
black  specks  before  the  eyes,  and  sometimes  complete 
blindness.  A plethoric  jierson  says  Richter)  who 
held  his  breath,  and  looked  at  a white  wall,  was  con- 
scious of  discerning  a kind  of  net-work  which  alter- 
nately appeared  and  disapiiearcd  with  The  diastole  and 
systole  of  the  arteries. 

Richter  thinks  it  likely  that  the  disease  is  thus  pro- 
duced, when  it  proceeds  from  the  suiii)re.ssion  of  some 
habitual  discharge  of  blood,  not  being  bled  according 
to  custom,  the  stoppage  of  the  menses,  and  the  cessa- 
tion of  hemorrhage  from  piles.  In  the  same  manner 
the  complaint  may  be  brought  on  by  great  bodily  exer- 
tions, which  must  determine  a more  rapid  current  of 
blood  to  the  head.  Richter  informs  us  of  a man  wlia 
became  blind  all  on  a sudden,  while  carrying  a heavy 
burden  up  stairs.  He  tells  us  of  another  man,  w ho 
laboured  excessively  hard  for  three  days  in  succession, 
and  became  blind  at  the  end  of  the  third  day.  Preg- 
nant women  in  hke  manner  are  sometimes  bereft  of 
their  sight  during  the  time  of  labour.  Schmucker  has^ 
recorded  a remarkable  instance  of  this  in  a strong  young 
woman,  thirty  years  old,  and  of  a full  habit.  When- 
ever she  was  pregnant,  she  was  troubled  with  violent 
sicknes.s  till  the  time  of  delivery,  so  that  nothing  would 
stop  in  her  stomach.  She  w'as  bled  three  or  four  times 
without  effect.  Towards  the  ninth  month  her  sight 
grew  weak,  and  for  eight  or  ten  days  before  parturi- 
tion, she  was  quite  blind.  The  pupil  of  the  eye  was 
greatly  enlarged,  but  retained  its  shining  black  appear- 
ance. She  recovered  her  sight  immediately  after  deli- 
very, and  did  not  suffer  any  particular  complaints, 
Schmucker  assures  us  that  he  has  been  three  times  a 


AMAUROSIS, 


31 


\intness  of  this  extraordinary  circumstance.— (Ver- 
inischte  Chir.  Schriften,  band  2,  p.  6,  edit.  1786.)  Rich- 
ter speaks  of  a person  who  lost  his  sight  during  a vio- 
lent fit  of  vomiting.  Schmucker  acquaints  us  that  it  is 
not  uncommon  for  soldiers,  who  are  performing  forced 
marches  in  hot  weather,  to  become  blind  all  on  a 
sudden. 

Beer  also  coincides  with  Schmucker,  Richter,  and 
others,  in  regarding  as  a frequent  cause  of  amaurosis 
repeated  and  long-continued  determinations  of  blood  to 
the  head  and  eyes,  produced  by  various  circumstances, 
viz.  by  pregnancy  ; a tedious  and  difficult  labour;  lift- 
ing and  carrying  heavy  burdens,  especially  with  the 
arms  raised  up ; all  kinds  of  work,  in  which  the  eye- 
sight and  intellectual  faculties  are  intensely  exerted, 
with  the  head  bent  forwards,  and  the  abdomen  com- 
pressed, as  is  the  ca.se  with  shoemakers,  tailors,  &c.; 
every  sudden  stoppage  of  natural  or  preternatural 
long-established  discharges  of  blood,  as  that  of  the 
menses,  lochia,  or  hemorrhoids;  the  omission  of  habit- 
ual venesection  at  some  particular  season  of  the  year; 
severe  and  obstifiate  vomiting ; forced,  marches  in  hot 
dry  weather ; scrofulous  and  other  swellings  of  con- 
siderable size  in  the  neck,  pressing  upon  the  jugular 
veins,  and  obstructing  the  return  of  blood  from  the 
head;  the  use  of  a pediluvium,  or  warm  bath,  the 
water  of  which  is  of  high  temperature ; hard  drinking ; 
violent  gusts  of  passion ; frequent  and  obstinate  con- 
stipation ; and  hard  straining  at  stool.  These  causes 
are  more  likely  to  occasion  amaurosis  in  proportion  as 
the  individual  is  young  and  plethoric.  The  causes  of 
that  amaurosis  which  is  characterized  in  its  first  stage 
by  increased  sensibility  of  the  eye,  and  intolerance  of 
light,  are  referred  by  Professor  Beer  to  circumstances 
which  produce  a long  and  repeated  determination  of 
blood  to  the  head  and  eyes. — Beer,  Lehre  von  den 
Augenkr.  b.  2,  p.  446  and  483,  &c.) 

Mr.  Lawrence,  in  his  Lectures,  regards  amaurosis, 
in  its  most  frequent  and  important  form,  that  which  is 
seated  in  the  eye  itself,  as  generally  the  result  of  inflam- 
mation of  the  nervous  structure  ; including  under  that 
phrase,  all  degrees  of  increased  vascular  action, 
whether  designated  as  fulness,  turgescence,  determi- 
nation, congestion,  or  as  inflammation  in  its  more  limited 
sense ; and  the  usual  consequence  of  inflammatory  dis- 
turbance, that  is,  organic  change  permanently  destroy- 
ing the  function  of  the  part.  When,  says  Mr.  Law- 
rence, vve  advert  to  the  structure  of  the  retina,  we 
must  suppose  that  it  would  be  liable  to  such  affections ; 
we  find  it  composed  of  minute  ramifications  of  the 
arteria  centralis  retinae,  and  on  this  net-work  of  vessels 
the  nervous  pulp  is  expanded.  The  state  of  the  retina, 
when  examined  after  death,  in  amaurotic  eyes,  accords 
with  these  views ; it  exhibits  those  changes  which  long- 
continued  inflammatory  disturbance  would  produce; 
it  has  been  found  thickened,  opaque,  spotted,  buff-co- 
loured, tough,  and  in  some  cases  even  ossified.  The 
preceding  doctrine  is,  however,  j.udiciously  qualified  by 
its  restriction  to  the  disease  as  seated  in  the  eye  itself. 
The  retina  and  optic  nerve,  Mr.  Lawrence  admits,  with 
other  surgeons,  may  be  disordered  symjiathetically,  as 
the  stomach  may  be  disordered  without  any  change 
visible  on  dissection. 

The  second  class  of  cau.ses  are  supposed  to  operate 
by  weakening  either  the  whole  body  or  the  eye  alone,  and 
they  indicate  the  general  or  tojiical  use  of  tonic  reme- 
die.s.  In  the  first  case,  the  blindness  appears  as  a 
symptom  of  considerable  universal  debility  of  the 
whole  system ; in  the  second  case  it  is  altogether  local. 
Every  great  general  weakness  of  body,  let  it  pro- 
ceed from  any  c^use  whatsoever,  may  be  followed  by  a 
loss  of  sight.  Amaurosis,  if  we  can  give  credit  to  the 
statement  of  Richter,  is  sometimes  the  consequence  of 
a tedious  diarrhoea,  a violent  cholera  morbus,  profuse 
hemorrhage,  and  immoderate  salivations. — Also  Tra- 
vers’s Synopsis,  p.  144.)  Richter  informs  us  of  a 
dropsical  woman,  who  became  blind  on  the  water  being 
let  out  of  her  abdomen.  According  to  the  same  author, 
no  general  weakening  causes  operate  upon  the  eyes, 
and  occa-sion  total  blindness,  so  powerfully  and  often 
a.s  premature  and  excessive  indulgence  in  venereal 
pleasures.  Mr.  Lawrence,  in  his  Lectures,  does  not 
coincide  in  some  of  the  foregoing  views.  “Those,” 
says  he,  “ who  have  considered  amaurosis  to  arise  from 
debilitating  causes,  have  considered  that  debility  and 
atony  of  ttie  nerve  may  be  produced  by  all  those  cir- 
imn.-.idii<x-“s  wliich  debilitate  the  system  generally. 


such  as  loss  of  blood  from  profuse  hemorrhage,  diar* 
rhcea,  copious  salivation,  &c.  I have  never  seen  amau- 
rosis produced  by  such  causes.  7’hat  great  anxiety  and 
grief  may  favour  the  occurrence  of  amaurosis,  I am 
inclined  to  allow ; fof  it  is  not  improbable  that  severe 
impressions  of  that  kind  may  produce  inflammatory 
excitement  in  the  brain  or  eyes ; but  I think  we  cannot 
without  more  direct  proofs,  admit  the  influence  of 
debilitating  causes  generally  in  the  production  of  amau- 
rosis. The  most  clear  instance  of  any  directly  debi- 
litating cause  producing  amaurosis,  is  that  of  protracted 
suckling.” 

The  causes  which  operate  locally  in  weakening  the 
eyes  are  various.  Nothing  has  a greater  tendency  to 
debilitate  these  organs,  than  keeping  them  long  and 
attentively  fixed  upon  minute  objects.  But  however 
long  and  assiduously  objects  are  viewed,  if  they  are 
diversified,  the  eye  .suffers  much  less,  than  when  they 
are  all  of  the  same  kind.  A frequent  change  in  the 
objects  which  are  looked  at  has  a material  effect  in 
strengthening  and  refreshing  the  eye.  The  sight  is 
particularly  injured  by  looking  at  objects  with  only  one 
eye  at  a lime,  as  is  done  with  telescopes  and  magnifying 
glasses ; for  when  one  eye  remains  shut,  the  pupil  of 
that  which  is  open  always  becomes  dilated  beyond  its 
natural  diameter,  and  lets  an  extraordinary  quantity  of 
light  into  the  organ.  The  eye  is  generally  very  much 
hurt,  by  being  employed  in  the  close  inspection  of  bril- 
liant, light-coloured,  shining  objects.  Among  the 
occupations  enumerated  by  Mr.  Travers  as  particularly 
exposing  persons  to  amaurosis,  are  those  of  needle- 
workers,  writers,  draughtsmen,  inspectors  of  linen  and 
scarlet' cloths,  and  of  new  banknotes ; money  counters  j 
smiths,  stokers  in  iron-furnaces  and  glass-houses ; 
tavern-cooks;  watchmakers,  engravers,  philosophical 
instrument  makers,  sea  officers,  <fec. — Synopsis,  p. 
144.)  They  are  greatly  mistaken,  says  Richter,  who 
think  that  they  save  their  eyes,  when  they  illuminate 
the  object  which  they  wish  to  see  in  the  evening  with 
more  lights,  or  with  a lamp  that  intercepts  and  collects 
all  the  rays  of  light,  and  reflects  them  upon  the  body 
which  is  to  be  looked  at.  Richter  mentions  a man, 
who,  in  the  middle  of  winter,  went  a journey  on  horse- 
back, through  a snowy  country,  while  the  sun  was 
shining  quite  bright,  and  who  was  attacked  with  amau- 
rosis. He  speaks  of  another  person,  who  lost  his  sight 
in  consequence  of  the  chamber  in  which  he  lay  being 
suddenly  illuminated  by  a vivid  flash  of  lightning.  A 
man  was  one  night  seized  with  blindness,  while  his 
eyes  were  fixed  on  the  moon  in  a fit  of  contemplation. 
Richter  also  expresses  his  belief,  tnat  a concussion  of 
the  head  from  external  violence,  ma}'  sometimes  ope- 
rate directly  on  the  nerves,  so  as  to  weaken  and  render 
them  completely  paralytic. 

Beer  corroborates  the  foregoing  statement;  for,  he 
says,  among  the  most  frequent  causes  is  to  be  consi- 
dered every  abuse  of  the  eyesight,  especially  in  dark- 
eyed persons,  as  a long  and  close  inspection  of  one 
object  ])articularly  with  a microscope,  when  the  thing 
examined  is  very  brilliant,  or  reflects  back  much  light 
into  the  eye.  Hence  the  view  of  jewels  at  night,  and 
long  journeys  through  snowy  countries  «fcc.,  are  con- 
ducive to  the  dusease.  In  this  respect,  every  kind  of 
employment  which  strains  the  eyes  much,  and  requires 
a strong  reflected  light,  must  be  considered  injurious. — 
(See  also  Travers’s  Synopsis,  p.  144.)  Thus,  reverbe- 
rating lamps,  like  Argand’s;  the  view  of  a white  wall 
illuminated  with  tlie  sun’s  rays;  and  looking  a long 
while  at  the  moon,  or  more  especially  the  sun,  with  the 
unassisted  eye,  are  circumstances  likely  to  bring  on 
the  disease.  That  a flash  of  lightning,  especially  when 
it  suddenly  wakes  a person  in  the  night-time  out  of  a 
sound  sleep,  may  produce  an  amaurotic  amblyopia  in 
an  irritable  eye  or  even  perfect  blindness,  is  a well- 
known  fact,  and  it  is  on  the  same  principle  that  going 
suddeidy  out  of  a dark  bedroom,  immediately  after  wak- 
ing in  the  morning,  into  an  apartment  that  commands 
an  open  extensive  pro.spect,  must  be  hurtful  to  an  irrita- 
ble eye,  though  the  bad  eflects  may  only  be  very  slow. 
Here  is  also  to  be  included  every  kind  of  over-irritation 
of  the  eye  by  light,  as  hai)pens  to  typhoid  patients, 
when  they  lie  with  their  eyes  open  all  the  day  in  a large 
sunny  chamber. 

Very  often  the  cause  of  amaurosis  consists  in  local 
or  constitutional  debility,  proceeding  from  imi)airmetit 
of  the  nerves  in  genera!,  or  of  the  nerves  of  the  head, 
evpccuUly  those  of  the  forehead  and  eyebrow ; eitlier 


32 


AMAUROSIS. 


from  a concussion  of  the  spinal  marrow,  falls  from  a i Scarpa.  The  close  sympathy  between  the  stomach  and 
considerable  height  with  the  weight  of  the  whole  body  • the  eyes  is  well  illustrated  by  a case  recorded  in  one 
upon  the  heels ; concussions  of  the  eyeball,  sometimes  of  the  journals,  and  referred  to  by  Mr.  Lawrence  in  his 
caused  by  violent  sneez-ing,  but  more  generally  by  con-  , Lectures.  It  was  an  amaurosis,  with  fixed  pain  over 
tusions  of  the  eye  with  blunt  weapons,  <tc.  Some  of  ■ the  eyebrow,  in  a child.  It  was  not  relieved  by  purging 
the  cases  of  amaurosis  from  blows  on  the  temple  or  the  and  other  depletive  measures  ; an  emetic  was  at  last 
eye,  obsened  by  .Mr.  Travers,  were  attended  with  signs  given  ; and  under  its  action,  a bead  was  rejected  from 
of  disorganization ; some  were  superficially  intlamed ; the  stomach,  and  the  amaurosis  immediately  disap- 
and  others  presented  no  external  ajipearance  of  injury.  I peared. 

We  learn  also  from  the  same  authority,  that  it  is  not  : Amaurosis  sometimes  proceeds  from  mechanical  irri- 
always  the  eye  on  the  struck  side  of  the  head  that  is  tation.  A small  shot  pierced  the  ujiper  eyelid,  and 
aflTecled. — Synopsis,  A:c.  p.  152.  It  we  are  to  believe  , lodged  at  the  upper  part  of  the  right  orbit,  between  the 
Beer,  and  other  foreign  practitioners,  considerable  j eyelid  and  eyeball,  so  that  it  could  be  tell  extenially. 
direct  weakne.ss  may  arise  from  cholera,  iong-continued  . The  patient  shortly  afterward  became  blind  in  the  left 
diarrhtea,  salivation,  and  the  incessant  spitting  of  eye;  but  recovered  his  sight  after  the  excision  of  the 
tobacco  smokers ; bleedings;  injudicious  tapping  ot  the  ; shot. — Anfangsgr.  der  Wundarzii.  band  3,  p.  439.; 
abdomen;  exce.ssive  indulgence  in  veiiery,  and  the  mis- i According  to  Beer,  several  constitution^  disorders, 
employment  of  is.sues.  \ general  debility,  which  has  ^ but  more  especially  gout,  are  frequently  concerned  in 
the  worst  effect  on  the  eyes,  may  also  arise  from  long  the  production  of  amaurosis.  Whoever  reads  Beer’s 
trouble,  esjiecially  when  the  diet  is  poor  and  bad;  also  history  of  what  he  terms  gouty  amaurosis,  will  na- 
froin  a deficiency  of  proper  food  ; long  watching;  vio-  ! turally  doubt  the  correctness  of  the  name;  and  Mr. 
lent  and  sudden  fright;  imprudently  washing  the  i Lawrence  distinctly  aflimi.s,  in  his  Lectures,  that  ho 
eyes  with  very  cold  water,  especially  when  they  are  [ has  never  seen  gout  or  rheumatism  occasion  any  ten- 
already  weakish  and  irritable  ; and  keeping  them  long  j dency  to  afi'ections  of  the  nervous  structure  of  the  eye. 
in  a dark  plac.e,  particularly  when  they  are  also  exerted  ' It  is  not  because  amaurosis  sometimes  occurs  in  gouty 
a good  deal  in  some  particular  kinds  of  labour,  a case  | or  rheumatic  constitutions,  that  the  afl'ection  ol  the 
which.  Beer  sa\s,  is  very  frequent  in  Vienna.  The  1 sight  is  necessarily  of  a gouty  or  rheumatic  origin , 


amaurosis  following  typhus,  without  any  unusual  irri-  j for  the  fact  merely  proves,  that  such  constitutions  are 
tation  of  the  eye  by  light.  Beer  also  refers  to  general  j not  exempt  from  the  risk  of  being  attacked  by  disor- 


debility. — (Lehre  von  den  Augenkr,  b.  2,  p.  449.j 


ders  of  the  eye.  Mr.  Lawrence  has  also  never  seen 


Like  nervous  deafness  (.says  Mr.  Travers  , amaurosis  any  case,  in  which  the  origin  of  amaurosis  could  be 
sometimes  follows  tyjihus  and  scarlet  fever,  and  the  j referred  to  syphilis. 


various  forms  of  acute  constitutional  disea-e.  He  has 
several  times  met  with  it  as  a consequence  of  infantile 
fevers.  He  ob.serves  that  it  is  also  .sometimes  a con.se- 
quence  of  chronic  wasting  diseases,  in  which  organic 
changes  interrujit  the  nutntion  of  the  system.  He  has 
seen  a rapid  and  severe  salivation  instituted  for  a remote 
affection,  and  where  no  disea.se  had  previously  affected 
the  eyes,  terminate  in  gut ta  serenaof  both. — Synop.sis, 
p.  155.) 

With  regard  to  the  doctrine  that  certain  forms  of 
amaurosis  are  diseases  of  debility,  Mr.  Lawrence  ex- 
presses his  disbelief  in  its  correctness,  and  asserts, 
that  the  only  scientific  and  successful  treatment  of 
amaurotic  affections  is  found  to  be  antijihlogistic. 
Whether  the  amaurosis  resulting  from  t>phoid  fevers, 
of  which  I have  seen  several  instances,  jiroceed  from 
debility,  or  from  too  great  a determination  of  blood  to 
the  head,  ma>  admit  of  dispute;  but  I conceive,  that 
in  many  of  such  cases,  tonic  treatment  is  clearly  indi- 
cated, if  not  for  the  eye  itself,  certainly  for  the  generally 
enfeebled  state  of  the  healtii,  with  which  the  amaurosis 
is  connected.  Yet  Mr.  Lawrence’s  doctrine,  that  ful- 
ness and  congestion  of  the  vessels  originally  lead  to 
the  amaurotic  affection,  may  be  more  correct  than  the 
theory  which  refers  the  blindness  simply  to  weak- 
ness. How'ever,  as  the  amaurosis  generally  does  not 
show  itself  till  an  advanced  stage  of  fever,  or  that  of 
great  debility,  and  as  it  only  recedes  as  the  patient 
regains  strength,  it  can  hardly  be  considered  as  a ca.se 
in  which  any  other  treatment  than  tonic  can  be  avail 


Respecting  the  causes  of  amaurosis,  the  following 
remarks  by  Beer  claim  attention.  Various  swellings 
111  the  orbit,  as,  for  instance,  encysted  tumours,  tophi, 
hydatids  in  the  sheath  of  the  optic  nerve,  may  and 
must  gradually  produce  complete  amaurosis  by  their 
pressure  upon  the  optic  nerves  and  retina.  Some  of 
these  cases  are  usually  characterized  by  a protrusion 
of  the  eye  from  its  socket. — See  Exophthairnia.)  In 
Mr.  Langstaff’s  museum  is  a siiecimen  of  two  amau- 
rotic eyes,  in  which  the  optic  nerves  are  shrunk  to 
about  one-third  of  their  natural  size.  Similar  instances 
are  recorded  by  Dr.  Monteilh. — See  Weller’s  Manual.) 
According  to  Mr.  Lawrence,  Mr.  Langstaff  has  also 
some  interesting  sfiecinieiis  of  enlargement  in  front  of 
the  third  ventricle,  the  parietes  of  which  bulge  so  as 
to  jiress  111)011  the  optic  nerves,  and  thus  to  account  for 
the  amaurosis  under  which  the  patients  laboured. 

In  the  same  manner  dift'erent  morbid  changes  in  the 
brain  itself,  and  in  the  bones  of  the  cranium  in  par- 
ticular, may  be  the  direct  cause  of  amaurosis : for  ex- 
ample, h\  drocephalus  iiiternus,  caries,  and  exostoses 
at  the  basis  of  the  skull. 

.lust  as  amaurosis  is  frequently  a pure  symptomatic 
eftect  of  various  disordered  states  of  the  constitution, 
so  may  dift'erent  morbid  changes,  occasioned  in  the  eye 
by  those  suites  of  the  health,  become  the  proximate 
cause  of  amaurosis,  as  hydrophthalmia,  cirsophfhal- 
mia,  fungus  haematodes,  dissolution  of  the  vitreous 
humour,  glaucoma,  ice. 

From  a contagious  atmosphere,  which  is  generally 


Alt  «VlllV.tt  «I1J  V^AIIVt  ei  XlllAlt  IV/ttIV.  V.  lA  1 I I A 1 I 1 I AA  « Vr . I A < VT  AA  A * I I 41 V > . W 4 4 Ax . A 44.,  ^ Vx  .4  AX4  AA44  J 

ing.  It  is  right  to  state  that  Mr.  Law' rence*  himself,  | injurious  to  the  eyes,  an  amaurotic  blindness  may  origi- 


notwithstanding  his  belief  in  amaurosis  being  a kind 
of  inflammation  of  the  retina,  modifies  the  antiphlogistic 
treatment  according  to  the  state  of  the  constitution. 

The  third  class  of  causes  consists  of  irritations,  most 
of  which  are  asserted  to  lie  in  the  abdominal  viscera, 
whence  they  sympathetically  operate  upon  the  eyes. 
The  observations  of  Richter,  Scarpa,  and  Schmucker, 
all  tend  to  support  this  doctrine.  Many  amaurotic 
patients  are  found  to  have  suffered  much  trouble  and 
long  grief,  or  been  agitated  by  repeated  vexations,  anger, 
and  other  passions,  which  have  great  effect  in  disorder- 
ing the  bilious  secretion  and  the  digestive  functions  in 
general.  Richter  tells  us  of  a man  who  lost  his  sight, 
a few  hours  after  being  in  a violent  passion,  and  reco- 
vered it  again  the  next  day,  upon  taking  an  emetic,  by 
which  a considerable  quantity  of  bile  was  evacuated. 
A woman  is  also  cited,  who  became  blind  whenever 
she  vvas  troubled  with  what  are  termed  acidities  in  the 
stomach. — (See  Anfangs.  der  Wundarzn.  b.  3,  kap.  14.) 
However,  according  to  Beer,  imperfect  amaurosis  sel- 
dom depends  upon  disorder  of  the  gastric  organs, 
excepting  the  case  from  worms.  (Lehre  von  den 
Augenkr.  b.  2,  p.  456  ; a very  important  difference  from 
the  sentiments  entertained  by  Schmucker,  Richter,  and 


nate,  though  but  very  rarely,  and,  as  it  would  seem, 
only  through  the  powerful  iiitiuence  of  such  state  of 
the  air  over  the  whole  sanguiferous  and  nervous  sys- 
tem. Debilitated,  nervous,  weak-sighted  persons,  by 
remaining  long  in  the  atmosphere  of  a privy  iChomel, 
Mem.  de  Paris,  1711,  Obs.  Anat.  5,  and  Ramazzini, 
De  Morbis  Artificum,  c.  13  , that  of  a deep  cellar,  or 
exposed  to  other  e/Ruvia,  may  be  suddenly  attacked 
with  amaurosis ; and  Beer  assures  us,  that  his  expe- 
rience coufirms  the  truth  of  these  reports. — Lehre, 
&c.  b.  2,  p.  452.)  A sympathetic  affection  of  the 
nerves  of  the  eye,  with  a carious  grinder  in  the  upper 
jaw-bone,  is  one  of  the  most  uncommon  causes  of 
amaurotic  blindness. 

A case,  not  yet  duly  con.sidered,  and  very  like  the 
amblyopia  senilis,  consists  of  an  incessantly  diminish- 
ing secretion  of  the  pigmentum  nigrum  upon  the 
tunica  Ruyschiana.  choroidea,  and  uvea,  which  secre- 
tion indeed,  in  some  individuals  earlier,  and  more  con- 
siderably, in  others  later  and  in  a slighter  degree,  re- 
cedes with  other  secretions  of  a difiererit  nature. — (See 
Beer’s  Lehre  von  den  Augenkr.  b.  2,  p.  151,  <fcc.) 

As  Mr.  Travers  has  correctly  explained,  the  history 
and  concomitant  appearances  of  amaurosis,  usually 


AMAUROSIS. 


33 


denote  whether  the  ease  is  organic  or  functional. 
“ For  example,  diseased  changes  in  the  situation  or 
texture  of  the  eveball  or  in  the  hrain,  or  hemiplegia, 
or  partial  paralysis,  with  other  signs  of  apopletic  or 
hydrocephaUc  pressure,  whether  resulting  from  an 
injury  of  the  head  or  otherwise,  or  an  acute  ^eep-seated 
inflammation,  whether  accompanied  by  a visible  opa- 
city or  not,  point  out  the  organic  nature  of  the  affection. 

I have  seen  (continues  Mr.  Travers)  such  an  amau- 
rosis produced  by  abscess  in  the  cerebral  substance, 
and  by  the  medullary  fungus  of  the  cerebrum.  On 
the  other  hand,  I have  known  the  following  distinct 
sources  of  irritation  operating  to  produce  functional 
amaurosis,  viz.  a wound  of  the  scalp,  caries  of  the 
skull,  abscess  and  caries  of  the  antrum  maxillare,  with 
excessive  oedema  of  the  integuments  of  the  lids  and 
cheek,  a large  abscess  under  the  masseter  and  muscles 
of  the  cheek,  and  an  abscess  at  the  extremity  of  a 
molar  tooth,  while  the  crown  of  the  tooth  was  sound. 
In  all  these  cases,  it  is  to  be  understood,  that  the  eye 
was  sound,  and  the  orbit  was  untouched  by  the  dis- 
ease of  the  parts  in  the  vicinity,  to  which  the  amaurosis 
was  clearly  attributable.  In  like  manner,  an  excessive 
use,  or  rather  abuse,  of  the  visual  faculty,  the  disor- 
dered functions  of  the  stomach,  liver,  uterus,  &c.  sud- 
den and  alarming  depletion,  excessive  or  obstinately 
suppressed  secretions,  difficult  dentition,  the  presence 
of  worms  in  the  intestinal  canal,  and  the  deleterious 
effects  of  noxious  agents  upon  the  organ  or  the  sys- 
tem, are  sufficiently  obvious  causes  of  the  functional 
amaurosis.”—  Synopsis,  &c.  p.  142.)  For  a variety  of 
additional  facts  and  observations  respecting  the  causes 
of  amaurosis,  I would  advise  the  reader  to  consult 
Wardrop’s  Essays  on  the  Morbid  Anatomy  of  the  Hu- 
man Eye,  vol.  2,  chap.  45 ; and  Travers’s  Synopsis : 
works  replete  with  valuable  information. 

It  is  remarked  by  Beer,  that  amaurosis,  when  com- 
pletely formed,  has  hitherto  been  but  rarely  cured. 
This  (says  he)  may  depend  in  the  first  place  upon  our 
far  too  imperfect  knowledge  of  the  nerves,  and  of  their 
genuine  and  complicated  disorders.  Secondly,  it  may 
equally  depend  upon  the  present  very  defective  etiology 
of  amaurosis.  Tlurdly,  the  frequent  incurability  of 
amaurosis  also  very  materially  proceeds  from  the 
causes  of  the  disease  being,  in  most  instances,  not  only 
obscure,  but  exceedingly  complicated. 

In  amaurosis  the  difficulty  of  cure  is  naturally  in 
proportion  to  the  variety  and  number  of  <;auses  of  the 
complaint ; and  the  more  readily  the  surgeon  makes 
himself  acquainted  with  them,  and  the  more  certainly 
he  obviates  them,  the  more  surely  and  quickly  does 
the  cui^  follow. 

It  may  be  considered  as  generally  true,  that  every 
amaurotic  weakness  of  sight,  and  every  completely 
formed  amaurosis,  are  attended  with  the  greatest  pro- 
bability of  cure,  where  they  began  suddenly  and  were 
quickly  developed ; for  experience  proves,  that  in  these 
cases,  the  whole  of  the  causes  of  the  disease  arc  much 
more  frequently  and  earlier  comprehended,  than  when 
the  complaint  has  been  several  years  in  forming.— 
(Beer,  Lehre  von  den  Augenkr.  b.  2,  p.  454 — 456.)  This 
observation  perfectly  coincides  with  the  account  given 
bv  Schmucker,  who  says  that  many  of  these  suddenly 
formed  cases  fell  under  his  notice,  and  were  more  easy 
of  cure  than  when  the  disorder  had  come  on  in  a more 
gradual  way. — (See  Vermischte  Chir.  Schriften,  b.  2.) 

It  also  agrees  with  what  Mr.  Travers  has  stated ; 
namely,  that  slow  and  steadily  progressive  cases  of 
amatirosis  are  more  to  be  apprehended  in  the  result, 
that  is,  are  less  tractable,  than  either  the  sudden  or  the 
rapidly  advancing  disease,  supposing  all  to  be  alike 
free  from  unequivocal  signs  of  organic  change. — 
(Synopsis,  p.  298.) 

Respecting  suddenly  produced  cases,  Mr.  Lawrence, 
in  his  Lectures,  holds  out  less  encouragement  than  the 
preceding  authorities.  The  prognosis,  he  says,  is 
doubtful,  and  rather  unfavourable  than  otherwise,  as  to 
the  complete  recovery  of  vision,  if  the  affection,  even  in 
its  most  recent  state,  should  have  produce^!  complete  in- 
sensibility of  the  retina.  He  thinks  we  should  speak 
doubtfully  of  the  result  in  the  case  of  complete  insen- 
sibility to  strong  light,  even  if  it  had  only  lasted 
twenty-four  hours.  He  con.siders  it  difficult  to  say  in 
what  number  of  days  or  weeks  we  should  give  up  all 
hopes  of  recovery.  In  the  supposed  case  of  total  in- 
sensibility, or  even  of  a near  approximation  to  it,  there 
would  be  more  ground  for  apprehension  than  hope  at 

Vol.  I.— C 


the  end  of  a week,  though  sight  is  sometimes  restored 
under  these  circumstances ; but  the  lapse  of  a few 
weeks,  without  improvement,  makes  the  case  hopeless* 

A case  may  happen,  nay,  it  happens  not  unfrequently, 
says  Beer  (which,  considering  the  imperfect  etiology 
of  amaurosis,  cannot  be  wondered  at),  that  the  sur- 
geon, after  the  most  careful  .investigation,  can  abso-« 
lately  detect  no  particular  cause  of  the  existing  amau** 
rotic  blindness ; in  which  event,  the  prognosis  must  in 
every  respect  be  very  uncertain  and  unfavourable, 
since  oniy  empirical  treatment  can  be  tried,  which 
rarely  answers ; and  even  when  a cure  in  this  manner 
does  follow,  it  is  frequently  quite  accidental. 

As  will  be  seen  in  the  account  of  each  particular 
species  of  amaurosis,  the  affected  eye  is  sometimes  so 
conditioned,  that  the  complete  incurability,  sooner  or 
later,  may  be  prognosticated  with  entire  certainty,  and 
this  even  though  a degree  of  vision  may  now  be  en-* 
Joyed. 

There  are  amaurotic  patients  to  whom  every  treat-* 
ment  does  harm,  the  disease  making  uninterrupted  ad- 
vances to  perpetual  blindness  This  observation  es- 
pecially refers  to  local  remedies,  of  the  danger  of  which, 
under  certain  circumstances,  the  patient  should  be 
carefully  warned. 

In  general  the  more  complete  the  amaurosis  is,  and 
the  longer  the  patient  has  been  deprived,  not  only  of 
vision,  but  of  all  sensibility  to  light,  the  less  hope  is 
there  of  sight  being  ever  re-established. 

If  the  affection  be  partial,  and  the  case  seen  early, 
Mr.  Lawrence  says,  a complete  cure  may  be  expected. 
He  thinks  favourably  of  the  event,  when  amaurosis 
takes  place  in  conjunction  with  chronic  internal  inflam- 
mation, or  when  it  is  evidently  caused  by  active  conges- 
tion in  the  head  or  eye ; for  that  cause  can  be  removed  by 
suitable  treatment. 

When  one  eye  has  been  completely  bereft  of  sight 
by  amaurosis,  and  the  surgeon  can  find  out  little  or  no 
cause  fo'r  the  infirmity,  there  is  strong  reason  for  ap- 
prehending that  the  other  eye  will  sooner  or  later  be- 
come blind.  This  is  a fact  amply  proved  by  experi- 
ence, and  the  exceptions  are  very  rare. 

According  to  Beer,  the  idea  entertained  by  some 
writers  is  not  built  upon  experience,  that  amaurotic  pa- 
tients in  whom  the  iris  is  still  moveable,  and  the  pupil 
not  very  much  dilated,  are  more  easily  and  frequently 
cured  than  others  in  whom  the  iris  is  perfectly  mo- 
tionless, and  the  pupil  exceedingly  dilated.  For  some- 
times during  the  treatment,  or  even  spontaneously,  the 
iris,  after  being  quite  immoveable,  recovers  it  power 
of  motion,  yet  the  patient  may  not,  at  the  same  time, 
regain  the  slightest  degree  of  vision ; and,  on  the  other 
hand,  many  cases  of  perfect  amaurosis  are  cured, 
without  the  iris  recovering  any  of  its  mobility,  and  the 
pupil  remains  dilated  during  the  remainder  of  the  pa- 
tient’s life. — (Lehre,  von  den  Augenkr.  b.  2,  p.  468.) 
Richter  also  thinks,  that  the  moveable  or  immoveable 
state  of  the  pupil  can  neither  be  considered  as  a fa- 
vourable nor  unfavourable  circumstance.  Sometimes, 
sa  s he,  an  amaurosis  may  be  cured,  which  is  attended 
with  a pupil  extraordinarily  dilated,  and  entirely  mo- 
tionless ; and  sometimes  the  disorder  proves  incurable, 
notwithstanding  the  pupil  be  of  its  proper  size,  and 
capable  of  motion.  There  are  likewise  examples,  in 
which  the  pupil  recovers  its  moveableness,  in  the 
course  of  the  treatment,  although  nothing  will  succe^ 
in  restoring  the  eyesight. — (Anfangsgr.  der  Wundarzn. 
b.  3,  p 424,  8vo.  Gott.  1795.) 

In  some  very  rare  instances,  says  Beer,  amaurotic 
blindness  has  been  cured  by  some  apparently  acci- 
dental or  indeed  morbid  effect,  without  any  assistance 
from  art ; by  hemorrhage  from  the  nose,  an  intermittent 
fever,  a blow  on  the  head,  &c.  The  same  experienced 
writer  operated  successfully  upon  both  eyes  of  a patient 
with  cataracts,  which  had  been  previously  depressed 
too  far  against  the  retina,  so  that  their  jiressure  gave 
rise  to  amaurosis,  which,  after  continuing  eight  years, 
had  been  suddenly  removed  by  the  patient’s  accident- 
ally falling  out  of  bed,  and  pitching  upon  the  top  of  his 
head. — (Lehre  von  den  Augenkr.  b.  2,  p.  458.) 

The  following. observations  made  by  Beer,  respect- 
ing the  prognosis,  cannot  fail  to  prove  interesting. 
There  is  a species  of  amaurosis,  which  gradually 
diminishes  of  itself;  for  instance,  that  which  arise* 
from  hard  drinking,  or  the  effect  of  narcotic  poi.sons, 
belladonna,  opium,  hyoscyamus,  Ac. 

Sometimes  imperfect  amaurosis  goes  away  without 


34 


AMAUROSIS. 


any  assistance  from  art,  in  consequence  of  the  acces- 
sion of  some  other  disease,  as  an  eruption,  a discharge 
of  matter  from  the  ear,  bleeding  fVom  piles,  the  men- 
ses, <fec. 

Also,  in  most  cases,  when  the  surgeon  is  so  for- 
tunate as  to  cure  amaurosis,  either  by  scientific  or 
empirical  methods,  there  still  continues  for  life  a con- 
siderable degree  of  amblyopia,  more  especially  if  the 
amaurosis  has  been  complete. 

Sometimes,  by  successful  treatment,  vision  is  in  a 
great  measure,  or  even  entirely  restored  in  one  eye,  yet 
the  other  remains  completely  blind ; or  one  eye  sees 
again  much  sooner  than  its  fellow,  although  they  were 
both  affected  together  with  an  equal  degree  of  blindness. 

It  often  happens,  that  thougli  a material  degree  of 
vision  returns  in  the  course  of  the  treatment,  the  faculty 
is  restricted  to  a circumscribed  point  of  the  retina,  so 
that  the  jiatieiit  is  enabled  td  see  objects  plainly  only 
when  they  are  held  in  a particular  direction  before  him; 
while  in  other  directions,  they  are  either  quite  invisible, 
or  very  indistinct. — Jteer,  Lehre  von  den  Augeiikr.  b. 
2,  p.  45d,  460.) 

Amaurosis  following  an  injur>’  of  the  supra-orbitary 
nerve,  frequently  resist.s  every  endeavour  made  to  relieve 
it,  and  this,  whether  it  come  on  directly  after  the  blow 
or  some  weeks  subsequently  to  the  healing ‘of  the 
w'ouiid  of  the  eyebrow  ; but  it  is  not  always  ab.solutely 
incurable.  Scarpa  only  knows  of  one  such  cure,  viz. 
the  example  recorded  by  Valsalva. — ; Dissert.  2,  ^ 11.) 
But  additional  instances  are  reported  by  Iley  Med. 
Obs.  and  Inq.  vol.  5),  by  Larrey  M^m.  de  Cliir.  Mili- 
taire,  t.  4,  p.  181),  and  Dr.  liennen  Principles  of  Mili- 
tary Surgery,  p.  316,  ed.  2).  According  to  Mr.  War- 
drop,  it  is  only  when  this  nerve  is  wounded  or  injured, 
and  not  divided,  that  amaurosis  takes  place ; for  the 
blindness  may  sometimes  be  cured  by  making  a com- 
plete division  of  the  trunk  nearest  its  origin. — ^ Essays 
on  the  Morbid  Anatomy  of  the  Iluiiiaii  Eye,  vol.  2,  p. 
ISO.) 

Perfect  inveterate  amaurosis,  attended  with  organic 
injury  of  the  substance  constituting  the  immediate 
organ  of  sight,  says  Scarpa,  is  a disease  absolutely 
incurable.  Imperfect  recent  amaurosis,  particularly 
that  which  is  periodical,  is  usually  curable ; for  it  is 
mostly  dependent  ujion  causes  which,  though  they 
affect  the  immediate  organ  of  sight,  are  capable  of  being 
dispersed,  without  leaving  any  vestige  of  impaired  or- 
ganization in  the  optic  nerve  or  retina. 

When  amaurosis  has  prevailed  several  years,  in  per- 
sons of  advanced  age,  whose  eyesight  has  been  weak 
from  their  youth  ; when  it  has  come  on  slowly,  at  first 
with  a morbid  irritability  of  the  retina,  and  then  with 
a gradual  diminution  of  sense  in  this  part,  till  total 
blindness  was  the  consequence;  when  the  pupil  is 
motionless,  not  circular,  and  not  much  dilated;  when 
it  is  widened  in  such  a degree  that  the  iris  seems  as  if 
it  were  wanting,  and  the  margin  of  this  opening  is 
irregular  and  jagged ; and  when  the  bottom  of  the  eye, 
independently  of  any  opacity  of  the  crystalline  lens, 
presents  an  unusual  paleness  like  that  of  horn,  some- 
times partaking  of  green,  and  reflected  from  the  thick- 
ened retina,  the  disease  may  be  generally  set  down  as 
incurable.  Kieser  joins  Scarpa  in  representing  this 
alteration  as  an  unfavourable  omen,  adding,  that  it  only 
takes  place  in  examples  of  long  standing,  and  that 
when  it  is  considerable,  the  diseese  is  incurable.  Lan- 
genbeck  differs,  however,  from  both  these  authors,  and 
particularly  from  Kieser ; assuring  us,  not  only  that  he 
has  often  seen  this  discoloration  of  the  bottom  of  the 
eye  in  the  early  stage  of  amaurosis,  but  seen  patients 
in  this  state  soon  cured.  The  cases  which  he  has 
published  in  proof  of  this  statement,  I have  read  with 
care,  and  find  them  completely  satisfactory.  Langen- 
beck  agrees  with  other  writers  in  imputing  the  appear- 
ance to  a morbid  change  of  the  retina ; and  the  treat- 
ment which  he  prescribes  consists  in  the  internal 
exhibition  of  the  oxymuriate  of  mereuxy  in  small 
doses,  and  friction  with  mercurial  ointment  on  the  eye- 
brow and  temple. — iSee  Langenbeck’s  Neue  Bibl.  fur 
de  Chirurgie,  b.  1,  p.  64 — 69,  &c.  Gottingen,  1815.) 

Cases,  says  Scarpa,  attended  with  pain  all  over  the 
head,  and  a continual  sensation  of  tightness  in  the  eye- 
ball ; or  preceded  by  a violent,  protracted  excitement 
of  the  nervous  system,  and  then  by  general  debility,  I 
and  languor  of  the  constitution,  as  after  masturbation,  j 
premature  venery,  and  hard  drinking ; or  connected  i 
with  epileptic  fits,  or  frequent  spasmodic  hemicrania  ; ! 


or  which  are  the  consequence  of  violent,  long-continued, 
internal  ophthalmia,  may  be  set  down  as  incurable. 
Nor  can  any  cure  be  exjiected  when  amaurosis  pro- 
ceeds from  a direct  blow  on  the  eye ; foreign  bodies  in 
the  eyeball ; lues  venerea,  or  exostoses  about  the  orbit ; 
or  when  it  is  conjoined  with  a manifest  change  in  the 
figure  and  dimensions  of  the  eyeball. 

Recent,  sudden  cases,  in  which  the  pupil  is  not  exces- 
sively dilated,  and  its  circle  remains  regular,  while  the 
bottom  of  the  eye  is  of  a deep  black  colour ; cases  un- 
accompanied with  any  acute,  continual  pain  in  the  head 
and  eyebrow,  or  any  sense  of  constriction  in  the  globe 
of  the  eye  itself ; cases  which  originate  from  violent 
anger,  deep  sorrow,  fright,  gastric  disorder,  general 
plethora,  or  the  same  jiartial  affection  of  the  head,  sup- 
pression of  the  menses,  habitual  bleedings  from  the 
nose,  piles,  Ac.,  great  loss  of  blood,  nervous  debility, 
not  too  inveterate,  and  in  young  subjects,  are  all,  ge- 
nerally speaking,  curable.  Amaurosis  is  also  mostly 
remediable,  when  jiroduced  by  convulsions  or  the 
eflbrts  of  difficult  jiarturition ; when  it  arises  during 
the  course,  or  towards  the  termination  of  acute  or 
intermittent  fevers;  and  when  it  is  periodical. — (Scar- 
pa, Osservazioin  sulle  Mallatie  degli  Occhi,  cap.  20, 
Venez.  D02.) 

According  to  Mr.  Travers,  it  is  rather  the  degree 
than  the  nature  and  origin  of  the  symptomatic  ftme- 
tional  amaurosis,  that  stould  in  most  cases  influence 
our  jirognosis ; yet  the  latter  circumstances,  it  is  equally 
clear,  afford  more  or  le-ss  encouragement,  in  proportion 
as  the  pre-existing  states  of  disease  ordinarily  admit  of 
relief  or  not.  Thus,  says  he,  the  amaurosis  from  gas- 
tric di.scascs,  from  jilethora,  from  irritation,  are  all  of 
then,  rclievable,  and  if  treated  at  an  early  period,  reme- 
diable. Whereas  jiaralysis,  the  sequel  of  fever,  or  of 
ejiileiisy,  or  severe  constitutional  diseases,  whether 
acute  or  chronic,  or  depending  upon  habitual  cerebral 
congestions  combined  with  organic  visceral  disease,  or 
induced  by  the  ojieration  of  noxious  agents  on  the  system, 
is  a hopeless  form  of  the  malady. — tSynopsis,  p.  296  ) 
I may  remark,  however,  that  various  examples  of 
recovery  from  amaurosis  induced  by  fevers  have  fallen 
under  my  own  notice. 

In  general,  when  the  treatment  proves  successftil, 
the  return  of  the  power  of  vision  is  accompanied  with 
a regression  of  the  same  characteristic  effects,  which 
were  disclosed  in  the  gradual  advance  of  the  disorder, 
viz.  appearances  as  if  there  were  before  the  eyes  flashes 
of  light,  a cobweb,  net-work,  mist,  or  flaky  substances. 
— Beer,  Lelire  von  den  Augenkr.  b.  2,  p.  460.  Wien, 
1817.) 

Upon  the  commencement  of  the  cure,  there  is  also  a 
return  of  the  obliquity  of  sight ; one  of  the  most  con- 
stant symptoms  of  imperfect  amaurosis.  This  is  a 
circumstance  which  Hey  took  particular  notice  of ; he 
says,  that  it  was  most  remarkable  in  those  persons 
who  had  totally  lost  the  sight  in  either  eye ; for  in  them 
the  most  oblique  rays  of  light  seemed  to  make  the  first 
perceptible  impression  upon  the  retina;  and,  in  jiro- 
portion  as  that  nervous  coat  regained  its  sensibility,  the 
sight  became  more  direct  and  natural. — (See  Med.  Obs 
and  Inq.  vol.  5.) 

TREATMENT  OF  AMAUROSIS. 

When  amaurosis  is  to  b«  fundamentally  cured,  no! 
upon  empirical,  but  scientific  principles,  all  the  causes 
of  the  disorder  must  be  ascertained,  and,  if  possible, 
removed,  as  in  the  treatment  of  every  othei’  complaint. 
How  often,  however,  it  is  impossible  to  accomplish 
either  the  one  or  the  other  of  these  objects,  must  be 
clear  enough  from  the  preceding  observations,  particu- 
larly those  concerning  the  etiology  of  the  disease ; and 
hence  it  is  not  surprising,  that  amaurosis  should  so 
frequently  resist  every  endeavour  to  cure  it. 

The  plan  of  treatment  is  to  be  regulated,  first  by  the 
number  and  kinds  of  circumstances,  which  determine 
the  form  of  the  disorder  ; secondly,  by  its  presence, 
degree,  and  duration.  When  only  the  chief  causes  can 
be  ascertained,  a scientific  mode  of  treatment  may 
always  be  instituted ; though  here  it  is  very  necessary 
to  pay  the  utmost  attention  to  those  morbid  effects  in 
the  constitution,  and  in  the  eye  in  particular,  which 
appear  to  have  no  connexion  with  the  causes  of  amau- 
rosis, and  merely  exist  as  accidental  contemporary  de- 
fects. 

If  no  particular  circumstances  can  be  assigned  as 
the  cause  of  amaurosis,  the  surgeon  Ms  no  alternative 


AMAUKOrilS. 


35 


but  the  adoption  of  some  empirical  method  of  treat- 
ment ; but,  exclaims  Beer,  wo  to  the  patient  whose 
surgpon,  under  these  circumstances,  draws  from  a 
heap  of  what  are  considered  remedies  for  amaurosis, 
as  from  a lottery,  the  first  as  the  best ! 

In  order  to  avoid  this  erroneous  metliod,  and  not 
render  a half-blind  person  completely  blind,  instead  of 
improving,  or  at  least  preserving,  whatever  remnant  of 
vision  there  may  be,  the  surgeon  should  act  with  great 
caution,  and  constantly  bear  in  his  mind,  first,  the  con- 
stitution, sex,  and  age  of  the  patient ; secondly,  his 
ordinary  employments,  and  general  mode  of  living ; 
and  thirdly,  the  principal  morbid  appearances  under 
which  the  amaurosis  originated  and  was  developed. — 
(Beer,  Lehre  von  den  Augenkr.  b.  2,  p.  462.)  But 
what  will  be  the  greatest  assistance  is  a correct 
acquaintance  with  the  remedies  for  amaurosis  in 
general,  and  the  circumstances  under  which  the  use 
of  this  or  that  particular  means  is  likely  to  be  useful 
or  detrimental.  I know  of  no  writer  who  has  been  so 
minute  on  this  part  of  the  subject  as  Beer,  whose  sen- 
timents (be  it  also  remarked)  are  here  in  manyrespects 
different  from  those  of  Richter  and  Scarpa ; for,  like 
the  surgeons  of 'this  metropolis,  he  rarely  employs  the 
emetic  plan  of  treatment,  which,  according  to  his  prin- 
ciples, is  not  only  ineffectual,  but  hurtful,  whenever 
the  blindness  is  attended  witti  determination  of  blood 
to  the  head  and  eyes,  plethora,  an  accelerated  circula- 
tion, or  (what  is  understood  by)  a i)hlogistic  diathesis. 
Beer’s  opinions,  respecting  the  employment  of  emetics 
and  other  means  for  the  cure  of  amaurosis,  may  be 
partly  collected  from  the  sequel  of  this  article,  but 
more  especially  from  the  fuller  statement  which  will 
be  made  at  afhture  opportunity. — (See  Gutta  Serena.) 
In  the  mean  time,  I shall  endeavour  to  offer  a general 
account  of  the  practice  recommended  by  Schmucker, 
Richter,  Scarpa,  Travers,  and  Lawrence,  according  to 
the  arrangement  of  causes  adopted  by  the  second  of 
these  valuable  writers ; for  I need  not  repeat,  that 
whenever  the  method  of  cure  can  be  directed  against 
the  causes  of  the  disease,  it  is  the  most  proper  and  sci- 
entific. The  present  article  will,  then,  close  with  some 
practical  observations,  chiefly  taken  from  Professor 
Beer. 

In  that  species  of  amaurosis,  which  arises  from  the 
first  class  of  causes,  or  those  which  induce  the  disease, 
by  means  of  a preternatural  fulness  and  dilatation  of  the 
blood-vessels  of  the  brain  or  eye,  the  indication  is  to 
lessen  the  quantity  of  blood,  and  the  determination  of 
it  to  the  head.  For  this  purpose,  the  patient  may  be 
bled  in  the  arm,  temporal  artery,  or,  as  is  often  pre- 
ferred by  foreign  surgeons,  in  the  foot.  This  evacua- 
tion is  to  be  repeated  as  often  as  seems  necessary,  and 
it  will  be  better  to  begin  with  taking  away  from  twelve 
to  sixteen  ounces.  The  efficacy  of  bleeding,  in  the 
cure  of  particular  cases  of  gutta  serena,  is  strikingly 
exemplified  by  numerous  well-authenticated  obser- 
vations. Richter  informs  us  of  a woman,  who,  on 
leaving  off  having  children,  lost  her  sight;  but  reco- 
vered it  again  by  being  only  once  bled  in  the  foot.  A 
spontaneous  hemorrhage  from  the  nose  also  cured  a 
young  woman,  who  had  been  blind  for  several  weeks. 
— (Arffangsgr.  der  Wundarzn.  b.  3,  p.  442.) 

That  bleeding  is  sometimes  hurtfully  and  wrongly 
practised  in  amaurotic  cases,  is  a fact  which  admits  of  no 
doubt.  Mr.  TraVers  particularly  refers  to  one  descrip- 
tion of  cases  where  the  lancet  does  harm : these  are 
cases  of  undue  determination  of  blood  to  the  organ, 
which  are  especially  common  after  deep-seated  chronic 
inflammation  or  distress  from  over-excitement,  by  which 
its  vessels  have  lo.st  their  tone ; an  effect  decidedly  in- 
creased by  depletion.  In  one  interesting  ca.se  of  this 
kind,  a gradual  but  perfect  recovery  followed  a regti- 
lated  diet,  and  a course  of  the  blue  pill,  with  saline 
aperients. — (Synopsis,  p.  159.)  All  cases  of  direct  de- 
bility and  proper  paralysis  of  the  retina  (says  Mr.  Tra- 
vers are  aggravated  by  loss  of  blood,  and  the  great 
prevailing  mistake  in  the  treatment  of  amaurosis,  is 
the  indiscriminate  detraction  of  blood. — (Synopsis,  p. 
303.) 

When,  in  addition  to  general  bleeding,  topical  is  also 
necessary,  leeches  may  be  applied  to  the  temples,  or 
cupping-glasses  to  the  back  of  the  neck,  or  temples. 
Besides  bleeding,  purgatives,  blisters,  bathing  the  feet 
in  warm  water,  low  diet,  repose  of  the  organs,  <fec.  are 
fre(iuently  proper. 

In  .some  ca.ses,  the  foregoing  means  fail  in  producing 

02 


the  desired  benefit,  even  w'hen  followed  up  as  far  as 
the  pulse  and  strength  will  allow.  Here  the  continu- 
ance of  the  disease  may  depend  either  upon  the  stop- 
page of  some  wontfld  evacuation  of  blood,  or  else  upon 
some  other  cause  of  the  first  class.  In  the  first  of 
these  cases  (says  Richter)  experience  proves,  that  the 
disease  will  sometimes  not  give  way  before  the  accus- 
tomed discharge  Is  re-established.  A woman,  who  (as 
this  author  acquaints  us)  had  lost  her  sight  in  conse- 
quence of  a sudden  suppression  of  the  menses,  did 
not  recover  it  again  till  three  months  after  the  return 
of  the  menstrual  discharge,  notwithstanding  the  trial 
of  every  sort  of  evacuation.  He  also  tells  us  of  another 
woman,  who  had  been  blind  half  a year,  and  did  not 
menstruate,  and  to  whose  external  parts  of  generation 
leeches  were  several  times  applied.  As  often  as  the 
leeches  were  put  on  (says  Richter)  the  menses  in  part 
recommenced;  and  as  long  as  they  made  their  ap- 
pearance, which  was  seldom  above  two  hours,  the  wo- 
man always  enjoyed  a degree  of  vision. — (Anfangsgr. 
dor  Wundarzn.  b.  3,  p.  443.) 

For  the  amaurosis  arising  from  suppression  of  the 
menses,  Scarpa  recommends  leeches  to  the  pudenda, 
batliing  the  feet  in  warm  water,  and  afterward  exhi- 
biting an  emetic,  and  laxative  piUs,  made  of  rhubarb 
and  tartrate  of  antimony,  combined  with  gummy  and 
saponaceous  substances.  If  these  means  fail  in  esta- 
blishing the  men.strual  discharge,  he  says,  great  confi- 
dence may  be  placed  in  a stream  of  electricity,  con- 
ducted from  the  loins  across  the  pelvis,  in  every  direc- 
tion, and  thence  repeatedly  to  the  thighs  and  feet.  He 
enjoins  us  not  to  despair  at  want  of  success  at  first,  as 
the  plan  frequently  succeeds  after  a trial  of  several 
weeks. 

For  the  amaurosis  proceeding  from  the  stoppage  of 
an  habitual  copious  bleeding  from  piles,  Scarpa  recom- 
mends leeches  and  fomentations  to  the  hemorrhoidal 
veins,  then  an  emetic,  and  afterward  the  same  opening 
pills. — Osservazioni  sulle  principali  Malattie  degli 
Occhi,  cap.  19.) 

When  thb  disease  does  not  originate  from  the  stop 
page  of  any  natural  or  habitual  discharge  of  blood, 
and  does  not  yield  to  the  evacuating  plan,  Richter  thinks 
the  surgeon  justified  in  concluding,  that  the  preterna- 
turally  dilated  vessels  have  not  regained  their  proper 
tone  and  diameter,  and  that  topical  corroborant  reme- 
dies, particularly  cold  water,  ought  to  be  employed. 
In  this  kind  of  case,  he  is  an  advocate  for  washing  and 
bathing  the  whole  head  with  cold  water,  especially  the 
part  about  the  eyes ; a method,  he  says,  which  may 
often  be  practised  after  evacuations,  with  singular  and 
remafkable  efficacy. 

When  the  return  of  sight  cannot  be  brought  about 
in  this  manner,  Richter  advises  us  to  try  such  means 
as  seem  calculated  to  stimulate  the  nerves,  and  remove 
the  torpid  affection  of  the  ojitic  nerves  in  particular. 
Of  these  last  remedies,  says  he,  emetics  are  the  princi- 
pal and  most  effectual. 

The  principle  on  which  Mr.  Lawrence  directs  the 
treatment,  is  that  of  putting  a stop  to  vascular  excite- 
ment, with  the  view  of  preventing  the  permanent  in- 
jury of  altered  structure,  and  impaired  function  of  the 
retina.  Hence  he  is  a zealous  advocate  for  the  anti- 
phlogistic treatment,  in  the  early  stage  of  amaurosis. 

“ But,”  says  he,  “ if  this  treatment  be  not  found  to 
remove  the  change  which  has  been  produced  in  the  re- 
tina, we  must  have  recourse  to  mercury,  which  appears 
to  be  as  decidedly  beneficial  in  these  cases  as  in  iritis, 
or  general  internal  inflammation.  The  remark  which 
I made  respecting  the  use  of  mercury  in  those  affec- 
tions, applies  also  to  the  present  case ; namely,  that 
its  good  effect  mainly  depends  upon  the  promptitude 
with  which  it  is  employed.  The  alterative  form  is  in- 
sufficient ; we  give  it  with  the  view  of  arresting  in- 
flammation in  the  structure,  which  is  the  very  seat  of 
vision ; that  structure  is  easily  changed  by  the  inflam- 
matory process ; our  only  remedy  is  to  push  the  mer- 
cury in  a decided  manner,  and  if  we  do  so,  we  shall 
put  a stop  to  the  affection.”  When  the  antiphlogistic 
treatment  and  a fair  trial  of  mercury  have  failed,  Mr. 
Lawrence  contents  himself  with  recommending  such 
management  as  is  mo.st  conducive  to  general  health ; 
as  a residence  and  fretiuent  exercise  in  a pure  air ; 
plain  nutritious  diet ; mild  aperients,  with  the  occa- 
sional use  of  an  active  purgative ; and  repose  of  the 
affected  organ.  He  mentions  also  a trial  of  a seton,  or 
repeated  blisters  behind  the  ears,  or  at  the  side  or  back 


36 


AMAUROSIS. 


of  the  neck.  As  already  stated,  however,  Mr.  Law- 
rence does  not  wish  it  to  be  supposed,  that  all  amau- 
rotic patients  require  to  be  bled  and  salivated.  Amau- 
rosis, he  says,  often  comes  on  in  a slow  and  very  insi- 
dious manner  in  persons  of  enfeebled  constitution  : the 
organ  suffers  from  habitual  e.xcessive  exertion  at  the 
same  time  that  the  general  powers  are  depressed  by 
residence  in  confined  dwellings,  bad  air,  sedentary  oc- 
cupations, unwholesome  diet,  costiveness,  and  the  other 
injurious  intluences  of  such  causes.  If  you  should  see 
a thin,  pallid,  and  feeble  woman,  who  had  destroyed 
her  health  by  close  confinement  to  needle-work,  and 
whose  eyes  were  beginning  to  fail,  the  same  active 
measures  would  by  no  means  be  admissible.  You 
would  empty  the  alimentary  canal,  perhaps  take  a little 
blood  by  cupping,  or  by  leeches  to  the  temples,  and 
then  use  mercury  in  the  alterative  form,  together 
tvith  mild  aperients.  A few  grains  of  Plummer’s  pill 
may  be  given  every  night,  or  every  second  night,  and 
the  bowels  may  be  kept  ojien  with  electuary,  castor 
oil,  or  rhubarb  and  magnesia,  taken  occasionally.  The 
blue  pill  may  be  taken  in  combination  with  aloes  or 
colocynth.  It  may  be  necessary,  says  Mr.  Lawrence, 
to  persevere  with  the  mercury,  slowly  increaising  the 
dose  until  a slight  influence  is  visible  in  the  mouth.  A 
nutritious  diet  without  stimuli,  good  air,  and  exercise, 
and  rejiose  of  the  affected  organ,  are  imjiortant  auxilia- 
ries, and  a succession  of  moderi^te-siised  blisters  may 
be  advantageously  combined  witli  these  means.  Thus, 
observes  Mr.  Lawrenc.e,  you  see,  that  the  same  princi- 
ples regulate  our  treatment,  but  that  it  is  modified  in 
degree  according  lo  the  violence  of  the  symptoms,  and 
the  patient’s  strength.  In  the  latter  description  of 
cases,  after  mild  rntiphlogistic  means,  and  clearing  the 
alimentary  canal,  .’le  admits  that  it  may  be  expedient 
to  (xmiDine  tonics  with  aperients,  or  rhubarb  with 
bark,  columba,  or  cascarilla  : and  to  allow  a little  por- 
ter and  wine. 

We  come  now  to  the  consideration  of  that  species 
of  the  gutta  serena,  which  is  regarded  as  the  effect  of 
some  unnatural  irritation.  Here,  according  to  the  pre- 
cepts delivered  by  Richter,  we  should  endeavour  to 
discover  what  the  particular  irritation  is,  and  then  en- 
deavour to  effect  its  removal.  When  it  cannot  be  ex- 
actly detected,  we  are  recommended  generally  to  em- 
ploy such  remedies,  as  will  lessen  the  sensibility  of 
the  nerves,  and  render  them  less  apt  to  be  afi’ected  by 
any  kind  of  irritation. 

Sometimes  the  irritation  is  both  discoverable  and  re- 
moveable, and  still  the  effect,  that  is  to  say,  the  blind- 
ness, continues.  In  this  circumstance,  Richter  thinks 
that  the  surgeon  should  endeavour  to  obviate  the  im- 
pression which  the  irritation  has  left  upon  the  nerves, 
by  the  use  of  anodynes ; or  else  tr}'  to  remove  the  tor- 
por of  the  nerves  by  stimulants. 

But,  according  to  Schmuckcr,  Richter,  and  Scarpa, 
the  curable  imperfect  amaurosis  commonly  depends  on 
some  disease  or  irritation,  e.xisting  in  the  gastric  sys- 
tem, occasionally  complicated  with  general  nervous 
debility,  in  which  the  eyes  participate.  Hence,  in  the 
majority  of  cases,  we  are  assured  that  the  cliief  indi- 
cations are,  to  free  the  alimentary  canal  from  all  irri- 
tating matter,  improve  the  state  of  the  chylopoietic 
viscera,  and  invigorate  the  nervous  system  in  general, 
and  the  nerves  of  the  eye  in  particular. 

For  an  adult,  dissolve  three  grains  of  antimonium 
tartarizatum  in  four  ounces  of  water,  and  give  a spoon- 
ful of  this  solution  every  half  hour,  until  nausea  and 
copious  vomiting  are  produced.  The  next  day  some 
opening  powders  are  to  be  exhibited,  consisting  of  an 
ounce  of  the  supertartrate  of  potash,  and  one  grain  of 
antimonium  tartarizatum,  divided  into  six  equal  parts. 
The  patient  must  take  one  of  these  in  the  morning, 
another  four  hours  afterward,  and  a third  in  the  eve- 
ning, for  eight  or  ten  days  in  succession.  They  will 
create  a little  nausea,  rather  more  evacuations  from 
the  bowels  than  usual,  and  perhaps,  in  the  course  of  a 
few  days,  vomiting.  If  the  patient,  during  their  use, 
should  make  vain  efforts  to  vomit,  complain  of  bitter- 
ness in  his  mouth,  loss  of  appetite,  and  no  renovation 
of  sight,  the  emetic,  as  at  first  directed,  is  to  be  pre- 
scribed again  This  is  to  be  repeated  a third  and  fourth 
time,  should  the  morbid  state  of  the  gastric  system, 
the  bitter  taste  in  the  mouth,  the  tension  of  the  hypo- 
chondria, the  acid  eructations,,  and  the  inclination  to 
vomit,  make  it  necessary.  The  first  emetic  often  pro- 
duces (Vily  ail  evacuation  of  an  aqueous  fluid,  blended 


with  a little  mucus,  but,  if  it  be  repeated,  a few  day* 
after  the  resolvent  jiowders  have  been  administered,  it 
then  occasions  a discharge  of  a considerable  quantity 
of  a yellow,  greenish  matter,  to  the  infinite  relief  of 
the  stomach,  head,  and  eyes. 

The  stomach  having  been  thus  emptied,  the  follow- 
ing aperient  pills  are  to  be  ordered : 

R.  Gum.  sagapen.  1 

Galban.  >an.3j. 

Sap.  venet.  ) 

Rhei  optim.  3 iss. 

Tart.  emet.  gr.  xvi. 

Sue.  liquerit.  3 j.  fiant  pilulae  gran,  quinque. 

Three  are  to  be  taken  every  morning  and  evening, 
for  a month  or  six  weeks. 

When  the  state  of  the  stomach  has  been  improved, 
and  the  restoration  of  sight  partly  effected,  such  reme- 
dies must  be  employed,  as  strengthen  the  digestive  or- 
gans, and  excite  the  vigour  of  the  nervous  system  in 
general,  and  of  the  nerves  of  the  eye  in  particular. 
With  th^  intention  Scarjia  prescribes  bark  and  vale- 
rian in  powder,  and  recommends  a diet  of  tender  suc- 
culent meat,  and  wholesome  broths,  with  a moderate 
quantity  of  wine,  and  proper  exercise  in  a salubrious 
air.  For  exciting  the  action  of  the  nerves  of  the  eye, 
the- vapour  of  liquor  ammonise,  properly  directed 
against  the  eye,  he  says,  is  of  the  greatest  service. 
I'his  remedy  is  applied  by  holding  a small  vessel  con- 
taining it  sufilciently  near  the  eye  to  make  this  organ 
feel  a smarting,  occasioned  by  the  verj’  penetrating  va- 
pours with  which  it  is  enveloped,  and  which  cause  a 
copious  secretion  of  tears,  and  a redness,  in  le.ss  than 
half  an  hour  after  the  beginning  of  the  application.  It 
is  now  proper  to  stop,  and  repeat  the  application  three 
or  four  hours  afterward.  The  plan  must  be  thus  fol- 
lowed up  till  the  incomplete  amaurosis  is  quite  cured 

The  operation  of  these  vapours  may  be  promoted  by 
other  external  stimulants,  applied  to  such  other  parts 
of  the  body  as  have  a great  deal  of  sympathy  with  the 
eyes.  Of  this  kind  are  blisters  to  the  nape  of  the 
neck  ; friction  on  the  eyebrow  with  the  anodyne  liquor ; 
the  irritation  of  the  nerves  of  the  nostrils  by  sternuta- 
tive powders,  like  that  composed  of  two  grains  of  tur- 
beth  mineral,  and  a scruple  of  powdered  betony  leaves ; 
and,  lastly,  a stream  of  electricity.— (See  Gutta  Se- 
rena.) 

Bark,  which  is  efficacious  in  intermittent  fevers,  and 
other  periodical  diseases,  far  from  curing  periodical 
amaurosis,  seems  to  aggravate  it,  rendering  its  return 
more  frequent,  and  of  longer  duration.  On  the  other 
hand,  this  disease  is  most  commonly  cured,  in  a very 
short  time,  by  exhibiting,  first,  emetics,  then  the  above 
laxative  pills,  and  lastly,  corroborants,  and  even  bark, 
which  was  before  useless  and  hurtful. 

Such  is  Scarpa’s  statement,  w'hich  agrees  with  that 
of  Richter,  respecting  Ihe  effect  of  bark  in  periodical 
amaurosis.  As  if,  however,  practitioners  were  doomed 
alw'ays  to  differ,  and  learners  to  be  puzzled,  Beer  tells 
us,  that  he  has  seen  only  two  cases  of  periodical  inter- 
mittent amaurosis,  both  of  which  were  soon  perfectly 
cured  by  large  doses  of  bark.  Other  periodical  amau- 
rotic affections  he  has  seen,  how'ever,  attendant  on  in- 
termittent fever,  but  they  spontaneously  subsided  with 
the  febrile  paroxysms,  without  any  particular  treat 
ment  being  applied  to  the  eyes.  Somefimes,  when  the 
paroxysms  recurred  frequently,  a considerable  weak 
ness  of  sight  remained  after  them;  but  this  always 
went  off  of  itself,  except  in  a single  instance,  in  which 
the  functions  of  the  eyes  .were  perfectly  re-established 
by  the  exhibition  of  arnica  joined  with  bitters. — (Lehre, 
von  den  Augenkr.  b.  2,  p.  5S5.) 

In  the  two  cases,  which  \vere  unaccompanied  with 
fever,  the  vitreous  humour  had  the  appearance  of  be- 
ing turbid  during  the  attacks,  but  regained  its  natural 
clearness  on  each  return  of  vision,  the  loss  of  which 
used  to  be  complete.  Here  we  see  another  instance, 
in  W'hich  a cloudiness  behind  the  pupil  in  amaurosis  did 
not  impede  the  cure,  and  went  away  in  the  most  ready 
manner.  Possibly,  the  opacity,  which,  in  speaking  of 
the  prognosis,  I said  that  Langenbeck  had  not  found  to 
prevent  the  cure  of  certain  cases,  might  also  have  had 
its  seat  in  the  vitreous  humour,  and  not  depended  upon 
disease  of  the  retina. 

Cases,  in  the  formation  of  w'hich  manj  other  causes 
operate,  demand  the  employment  of  particular  curative 
means,  in  addition  to  those  which  have  been  already 
described.  Such  is,  for  example,  the  miperfect  aniau- 


AMAUROSIS, 


37 


rosis,  whic-h  occurs  suddenly  in  consequence  of  the 
body  being  excessively  heated,  or  exposure  to  the  sun, 
or  violent  anger  in  plethoric  subjects.  This  case  re- 
quires, in  particular,  general  and  topical  evacuations 
of  blood,  and  the  application  of  cold  washes  to  the 
eyes  and  whole  head.  An  emetic  should  next  be  given, 
and  afterward  a purge  of  potassae  tartras,  or  small  re- 
peated doses  of  antirnoaium  tartarizaturn.  Uy  means 
of  bleeding  and  an  emetic,  Schmucker  often  restored 
the  eyesight  of  soldiers  who  had  lost  it  in  making 
forced  marches,  with  very  heavy  burdens.  In  amau- 
rosis, suddenly  occasioned  by  violent  anger,  an  emetic 
is  the  more  strongly  indicated  after  bleeding,  as  the 
blindness,  thus  arising,  is  always  attended  with  a bit- 
ter taste  in  the  mouth,  tension  of  the  hypochondria, 
and  continual  nausea.  Richter  mentions  a clergyman, 
who  became  completely  blind  after  being  in  a violent 
passion,  and  whose  eyesight  was  restored  the  very 
next  day,  by  means  of  an  emetic,  given  with  the  view 
of  relieving  some  obvious  marks  of  bilious  disorder  in 
the  stomach. 

Scarpa’s  treatment  of  the  imperfect  amaurosis  brought 
on  by  fevers,  deep  sorrow,  great  loss  of  blood,  intense 
study,  and  forced  exertions  of  the  eyes  on  very  mi- 
nute or  brilliant  objects,  consists  also  in  removing  all 
irritation  from  the  stomach,  and  afterward  strengthen- 
ing the  qervous  system  in  general,  and  the  nerves  of 
the  eye  in  particular.  In  the  case  originating  from  fe- 
vers, the  emetic  and  opening  pills  are  to  be  given  ; then 
bark,  steel  medicines,  and  bitters ; while  the  vapour  of 
the  liquor  ammoniae  is  to  be  applied  to  the  eye  itself. 

When  the  disorder  has  been  brought  on  by  grief,  or 
fright,  the  stomach  and  intestines  are  to  be  emptied  by 
means  of  antimonium  tartarizaturn  and  the  opening 
pills  ; and  the  cure  is  to  be  completed  by  giving  bark 
and  valerian ; applying  the  vapour  of  liquor  ammonia) 
to  the  eyes ; ordering  nourishing,  easily  digestible  food  ; 
diverting  the  patient’s  mind,  and  fixing  it  on  agreeable 
objects,  and  recommending  moderate  exercise.  The 
amaurosis  from  fright  is  said  to  require  a longer  per- 
severance in  such  treatment,  than  the  case  from  sor- 
row.— (Scarpa’s  Osservaz.  cap.  19.) 

In  this  country,  the  emetic  practice,  wlfich  has 
proved  so  decidedly  efficacious  on  the  continent,  has 
not  been  attended  with  much  success ; Mr.  Travers 
even  states,  that  he  does  not  recollect  an  instance  of 
decided  benefit  from  it,  though  he  has  often  tried  it 
fairly.  He  agrees,  however,  in  tne  indication,  as  he 
remarks,  that  the  removal  of  an  irritating  or  oppress- 
ing cause,  will  often  effect  a sudden  and  marked  relief, 
as  by  clearing  the  intestinal  canal  of  vitiated  secre- 
tions, restoring  the  digestive  functions,  or  taking  away 
blood  where  the  necessity  is  indicated.  In  gastric 
cases  for  which  emetics  have  been  particularly  recom- 
mended, he  prefers  a long-continued  course  of  the  blue 
pill,  with  gentle  saline  purgatives  and  tonic  bitters. — 
(Synopsis,  p.  299—304.) 

Beer  is  also  a high  authority  against  the  use  of  eme- 
tics, even  in  the  amaurosis  from  disorder  of  the  gas- 
tric organs.  When,  says  he,  the  saburrse  have  a ten- 
dency to  be  discharged  upwards,  as  indicated  by  con- 
tinual nausea  and  disposition  to  vomit,  emetics,  which 
never  operate  without  some  violence,  are  to  be  most 
carefully  avoided  in  plethoric  individuals,  or  those  who 
have  a manifest  determination  of  blood  to  their  heads 
and  eyes,  or  any  acceleration  of  the  circulation.  The 
caution  here  given  must  be  observed,  even  though  eme- 
tics may  on  other  accounts  seem  advisable ; and,  ac- 
cording to  Beer,  the  determination  of  blood  and  the 
state  of  the  system  here  mentioned,  are  commonly  at- 
tendant upon  this  species  of  amaurosis.  Indeed  inoi- 
withstanding  the  testimony  of  Schmucker,  Richter,  and 
Scarpa,  in  favour  of  emetics  in  this  case).  Beer  posi- 
tively affirms,  that  the  violent  operation  of  an  emetic 
frequently  converts  this  sympathetic  amaurotic  weak- 
ness of  sight  all  on  a sudden  into  blindness.  Although 
1 apprehend  that  Beer  may  here  be  somewhat  preju- 
diced against  emetics,  candour  obliges  me  to  add,  that 
in  this  country,  their  efficacy  in  the  present  disease  is 
by  no  means  equal  to  the  representations  of  Richter 
and  Scarpa.  When  there  is  less  tendency  to  vomiting, 
but  the  case  is  attended  with  an  oppressive  sense  of 
weight  about  the  stomach,  freiiuent  eructations,  as  if 
arising  from  rotten  eggs,  an  infiated  belly,  and  terise 
hypochondria,  a gentle  aperient  clyster  may  be  ordered, 
especially  when  the  bowels  have  been  for  some  days 
confined,  in  which  circumstances  Beer  has  found,  that 


tolerably  brisk  purgatives  are  always  of  the  greatest 
service,  both  in  regard  to  the  general  complaints,  and 
the  amaurotic  weakjiess  of  sight ; the  removal  of  the 
offensive  matter  from  the  alimentary  canal  being  im- 
mediately tbllovved  by  a cessation  of  the  determination 
of  blood  already  mentioned.  Lastly,  when  this  amau- 
rosis originates  altogether  from  the  presence  of  worms 
in  the  bowels,  common  anthelmintics  are  to  be  pre- 
scribed. In  all  these  cases,  says  Beer,  mere  local 
treatment  is  quite  inapplicable,  and  may  do  mischief. — 
(.Beer,  Lehre  von  den  Augenkr.  b.  2,  p.  617—521.) 

The  third  species  of  gutta  serena,  or  that  which 
arises  from  debilitating  causes,  is  of  two  kinds; 
in  one,  the  disease  is  the  consequence  of  a general 
weakness  of  the  body ; in  the  other,  it  is  the  effect  of 
debility,  which  is  confined  to  the  eye  itself,  and  does 
not  extend  to  the  whole  constitution. 

According  to  Scarpa,  the  incomplete  amaurosis  from 
general  nervous  debility,  copious  hemorrhage,  convul- 
sions ab  inanitione,  and  long-continued  intense  study, 
especially  by  candle-light,  is  less  a case  of  real  amau- 
rosis, than  a weakness  of  sight  from  a fatigued  stale 
of  the  nerves,  especially  of  those  constituting  the  im- 
mediate organ  of  sight.  When  this  complaint  is  re- 
cent, in  a young  subject,  it  may  be  cured  or  diminished, 
by  emptying  the  alimentary  canal  with  small  repeated 
doses  of  rhubarb,  and  then  giving  tonic  cordial  reme- 
dies. At  the  same  time,  the  patient  must  abstain  from 
every  thing  that  has  a tendency  to  weaken  the  nervous 
system,  and,  consequently,  the  eyesight.  After  empty- 
ing the  stomach  and  l?ovvels,  it  is  proper  to  prescribe 
the  decoction  of  bark  wdth  valerian,  or  the  infusion  of 
quassia  with  the  addition  of  a few  drops  of  sulphuric 
ether  to  each  dose,  with  nourishing  easily'-digestible 
food.  The  aromatic  spirituous  vapours  (mentioned  in 
the  article  Ophthalmyi  may  then  be  tojiically  applied  ; 
or,  if  these  prove  ineffectual,  the  vapour  of  liquor  am- 
rnoniae.  The  patient  must  take  exercise  on  foot,  horse- 
back, or  in  a carriage,  in  a wholesome  dry  air,  in  warm 
weather,  and  avail  himself  of  sea-bathing.  He  must 
avoid  all  thoughts  of  care,  and  refrain  from  fixing  his 
eyes  on  minute  shining  objects.  The  impression  of  vivid 
light  on  the  retina  is  always  to  be  moderated  by  means 
of  flat  green  glasses. — iSaggio  di  Osservaz.  cap.  19.) 

One  case  of  temporary  palsy  of  the  retina  from 
over-excitement,  mentioned  by  Mr.  Travers,  yielded  to 
blistering  the  forehead,  and  a gentle  salivation  excited 
by  calomel  joined  wdth  opium. — (Synopsis,  p.  164.) 
Another  case,  brought  on  by  the  use  of  telescopes  and 
sextants,  gave  way  to  a copious  bleeding,  brisk  purg- 
ing with  jalap  and  calomel,  blisters  to  the  temples,  and 
a course  of  mercury. — (Op.  cit.  p.  166.) 

Mr.  Travers  remarks,  that  the  amaurosis  from  de- 
pletion is  sometimes  mistaken  for  the  opposite  case, 
viz.  that  from  plethoric  congestion : this  is  owing  to 
the  coincidence  of  a dilated  and  immoveable  pupil, 
muscae,  and  a deep-seated  pain  in  the  head,  with  occa- 
sional vertigo  ; and  its  frequent  occurrence  in  a corpu- 
lent* habit.  By  a cautious  use  of  tonics  (says  Mr 
Travers)  it  is  relieved  ; by  whatever  lowers  or  stimu- 
lates, whether  diet  or  medicine,  it  is  decidedly  aggra- 
vated. In  this  form  of  amaurosis,  vision  is  farther 
enfeebled  by  the  loss  of  as  much  blood  as  flows  from 
two  or  three  leech-bites. — (Synop.sis,  &c.  p.  160.) 

When  the  weakness  is  confined  to  the  eye,  Richter 
thinks  corroborant  applications  alone  necessary.  Bath- 
.ing  the  eye  with  cold  water,  says  he,  is  one  of  the  most 
powerful  means  of  strengthening  the  eye.  The  pa- 
tient should  dip  in  cold  w'ater  a compress,  doubled  into 
eight  folds,  and  sufficiently  large  to  cover  the  whole 
face  and  forehead,  and  this  he  should  keep  applied,  as 
long  as  it  continues  cold.  Or  else  he  should  frequently 
apply  cold  water  to  his  eyes  and  face  with  his  hand,  on 
a piece  of  rag. 

The  eye  may  also  be  strengthened  by  repeatedly  ap- 
plying blisters  of  a semilunar  shape  above  the  eye- 
brows, just  long  enough  to  excite  redness.  Richter 
likewise  speaks  favourably  of  rubbing  the  upper  eye- 
lid, several  times  a day,  with  a mixture  of  the  tinctura 
lyttae  and  spiritus  serpilli. — (Anfangsgr.  der  Wundarzn. 
b.  3,  p.452.) 

When  no  probable  cause  whatsoever  can  be  assigned 
for  the  disease,  the  .surgeon  is  justified  in  ernploying 
such  remedies,  as  have  been  proved  by  exjierience  to 
be  sometimes  capable  of  relieving  the  affection,  al- 
though upon  what  principle  is  utterly  unknown.— (See 
Gutta  Serena.)  To  this  article  I would  refer  the  reader, 


38 


AMAUROSIS. 


before  he  makes  up  his  mind  about  any  empirical 
method  of  treatment,  because  he  will  there  find  many 
cautions  and  instructions  given  by  Beer,  respecting  the 
remedies  for  amaurosis  in  general.  To  his  remarks,  I 
have  al.so  annexed  such  others,  on  the  same  topic,  as 
appeared  to  me  interesting. 

Cat-eye  amaurosis. 

This  species  of  the  disorder,  of  which  Beer  met  with 
but  one  form,  rarely  increases  to  complete  blindnes.s ; 
it  occurs  chietiy  in  very  old  persons,  and  it  is  i)erhaps 
this  affection  to  which  some  oculists  have  given  the 
unmeaning  name  of  ‘‘  amblyopia  senilis.”  Sometimes, 
however,  this  kind  of  amaurosis  takes  place  in  young 
persons  and  children  ; and  one  circumstance  that  de- 
mands particular  notice  in  its  nosology  is,  that  it  al- 
ways takes  place  either  in  tliin,  dwindled,  old,  gray- 
headed subjects,  nearly  in  the  state  of  marasmus  senilis, 
in  whom  consequently  the  exchange  of  organic  matter 
is  carried  on  but  tardily,  or  else  in  young  subjects,  who 
are  unhealthy,  and  disposed  to  consumption,  hectical 
adults,  emaciated  children,  and  as  a con.sequence  of 
severe  injuries  of  the  eye.  While  this  amaurosis  is 
not  perfectly  formed,  the  iris  retains  its  mobility,  and 
the  pupil  is  neither  preternaturally  dilated  nor  con- 
tracted; but  when  once  the  patient  is  quite  beretl  of 
vision,  the  motions  of  the  iris  are  slow,  and  the  pupil 
larger  than  in  a healthy  eye  in  at}  equal  degree  of  light. 
At  the  bottom  of  the  eye,  very  far  behind  the  pujiil,  a 
concave  pale-gray,  bright-yellowish,  or  variegated  red- 
dish opacity  is  develojied.  By  this  the  eyesight  is  not 
merely  weakened,  but  rendered  quite  confused,  since 
all  objects,  but  esjiecially  smallish  ones,  apjiear  to  be 
confounded  together,  particularly  when  the  patient 
tries  to  inspect  closely  any  determinate  body.  The  far- 
ther the  disease  advances,  the  brighter  and  more  visible 
m the  bottom  of  the  eye,  the  paler  is  the  colour  of  the 
iris  a thing  very  consjiicuous  in  dark-eyed  persons  ; 
gnd  when  once  the  amaurosis  is  complete,  so  that  no 
susceptibility  of  the  iinjire-ssion  of  light  is  left,  then, 
upon  an  attentive  e.xamination  of  the  eye,  one  can 
mo.stly  perceive,  at  the  troubled  deeper  pan  of  the  eye, 
a very  slender  vascular  plexus,  which  merely  consists 
of  the  ordinary  ramifications  of  the  central  artery  and 
yeiu,  which  are  now  visible  at  the  pale-coloured  bot- 
tom of  the  eye.  In  a half-darkened  place,  stich  an  eye 
resents  a shining  yellowish  or  reddish  appearance, 
ut  only  in  certain  positions  of  the  eyeball;  and,  in 
this  respect,  it  is  somewhat  similar  to  the  eye  of  a cat, 
whence  Beer  chooses  to  term  the  complaint  cat-eye 
amaurosis.  The  disorder  is  also  not  accompanied  with 
any  other  essential  morbid  appearances,  except  the  de- 
cline of  vision  or  complete  blindness. — (Lehre  von  den 
Augenkr.  b.  2,  p.  4%,)  Beer,  in  fig.  l,tab.  4 of  his 
second  vol,  has  given  from  nature  an  admirable  repre- 
sentation of  this  very  remarkable  species  of  amaurosis. 
The  differences  in  the  appearances  at  the  bottom  of 
the  eye,  in  this  case,  from  those  presented  in  the  early 
stage  of  fungus  hrematodes  of  that  organ,  will  be  best 
understood  by  referring  to  the  article  Fungus  Haema- 
todes.  On  this  point,  however,  I may  here  briefiy 
state,  that  in  the  cat-eye  amaurosis,  there  is  no  projec- 
tion, but,  on  the  contrary,  a concave  depression  in  the 
axis  of  vision.  Cat-eye  amaurosis  may  be  known 
from  incipient  cataract,  by  the  opacity  being  more 
deeply  situated,  and  having  a shining,  pearly  lustre, — 
(See  Journ.  of  Foreign  Med.  vol.  4,  p.  168.) 

Beer  observes  that  the  causes  of  this  species  of  amau- 
rosis are  so  obscure,  that  whatever  is  offered  upon  the 
subject  can  be  received  only  as  conjecture.  After  what 
has  been  said  jn  the  foregoing  paragraph  is  considered, 
about  the  particular  individuals  who  are  liable  to  be 
affected,  and  the  change  of  the  iris  to  a pale  colour,  as 
a constant  symptom  of  this  case,  a suspicion  may  be 
entertained  that  a deficiency  of  the  pigmentum  nigrum 
and  of  the  tapetum  of  the  uvea,  in  consequence  of  the 
stoppage  of  this  secretion,  may  be  the  cause  of  the  dis- 
ease. Beer  justly  remarks  that  much  might  be  learned 
on  this  iKiint  from  the  dissection  of  eyes  thus  affected; 
but  he  has  nevpr  met  with  the  opportunity. 

The  prognosis  cannot  but  be  very  unfavourable ; for, 
as  the  surgeon  is  ignorant  of  causes,  he  cannot  know 
what  means  ought  to  be  adopted  for  their  removal.  It 
is  fortunate,  however,  that  this  amaurosis  rarely  attains 
its  highest  degree,  but  almost  constantly  remains  in  the 
form  of  a more  or  less  considerable  amblyopia. 

J.USt  as  little  is  yet  known  respecting  any  well-regu- 


lated mode  of  treatment ; but  the  disease  may  some- 
times be  kept  from  getting  worse  by  the  careful  em- 
ployment of  such  general  remedies,  regimen,  and  diet, 
;ls  are  calculated  to  improve  the  health.  However,  in 
the  most  fortunately  managed  cases.  Beer  never  knew 
a step  made  towards  the  removal  of  the  disease.^ 
'.Lehre  von  den  Augenkr.  b.  2,  p.  497,  498.) 

.Amaurosis  produced  bybitte.rs,  certain  articles  of  food 
in  particular  constitutions,  or  the  poison  of  lead.  ■ 

The  reality  of  the  first  alleged  cause  is  sometimes 
doubted  in  this  country.  The  following  treatment  is 
recommended  by  Beer.  In  the  first  stage  he  advises 
gentle  antiphlogistic  means.  When  plethora  exists,  a 
few  ounces  of  blood  may  be  taken  away  by  venesection, 
or  leeches  applied  behind  the  ears,  when  after  bleeding  a 
determination  of  blood  to  the  head  and  eyes  still  continues 
in  full  habits,  or  there  is  any  tendency  to  infiamma- 
tion.  The  same  topical  bleeding  without  venesection, 
but  with  lukewarm  pediluvia,  containing  salt  or  mus- 
tard, is  proper  when  no  general  plethora  exists;  and 
merely  a determination  of  blood  to  the  head  and  eyes 
and  some  acceleration  of  the  circulation  prevail.  Inter- 
nally, lemon-juice  or  the  liquor  ammoniae  acet.  has  ex- 
cellent eftects ; and  externally,  poultices  composed  of 
bread-crumb  and  vinegar,  or  fomentations  containing 
oxycrat,  are  the  means  which  Beer  has  found  most  suc- 
cessftil  ill  the  first  stage  of  this  form  of  amaurosis. 

As  in  the  first  stage,  a moderate  antiphlogistic  gene- 
ral or  local  treatment  is  the  only  one  w’hich  can  be 
adopted,  and  which  in  urgent  cases  may  yet  save  the 
liatieiit  from  blindness,  so  in  the  second  stage  the  in- 
ternal and  external  emplo\inent  of  fluid  stimulants  is 
of  great  service  ; Ibr  example,  naphtha  combined  with 
camphor  inwardly,  liniments  to  the  eyebrow,  and  the 
vapours  of  ether  to  the  eye.  The  amaurosis  produced 
altogether  by  the  poi-son  of  lead,  and  complicated  with 
lead-colic  and  ileus,  will  require,  in  addition  to  the  fore- 
going means,  such  remedies  as  are  known  to  be  of 
service  in  these  latter  disorders. — (Beer,  Lehre  vou  den 
Augenkr.  b.  2,  p.  499—503.) 

Symptomatic  amaurosis  in  individuals  affected  with 
hysteria,  hypochondriasis,  epilepsy,  and  convulsions. 

This  amaurosis  is  rarely  permanent,  and  usually 
subsides  as  soon  as  the  spasmodic,  epileptic,  or  convul- 
sive attack  is  over.  However,  the  complaint  may  be- 
gin at  two  penod#,  viz.  either  during  such  an  attack, 
or  (what  is  more  uncommon)  afterward,  and  it  never 
loses  its  symptomatic  character.  The  pupil  always 
remains  perfectly  clear,  and  of  a shining  blackness, 
even  when  the  di.sease  has  induced  entire  blindness ; 
but  a slight  dull  pain  in  the  forehead,  especially  about 
the  eyebrow,  constantly  preceding  and  accompanying 
the  blindness,  generally  lasts  a good  while  after  the 
amaurosis  has  completely  subsided. 

Besides  the  foregoing  general  symptoms,  the  follow- 
ing  characteristic  appearances  present  themselves  in 
hysterical  and  hypochondriacal  patients,  who  suffer 
frequent  attacks  of  violent  spasm.  The  pupil  is  much 
dilated,  and  the  iris,  which  is  immoveable,  seems  evi- 
dently to  project  in  a convexity  forwards,  when  the 
eye  is  inspected  sidewise ; consequently,  the  anterior 
chamber  is  lessened.  The  eye  itself  does  not  move 
freely  in  its  socket,  the  patient  experiencing  an  annoy- 
ing and  sometimes  a truly  painftil  sensation,  as  if  the 
eyeball  w'ere  forcibly  compressed  (Ophthajmodymia). 
Every  attempt  which  the  patient  himself  makes  to  move 
the  eye,  or  the  surgeon  to  push  it  out  of  the  position 
which  it  has  assumed,  is  unavailing  and  excessively 
painftil.  The  eyelids  are  either  painftilly  shut,  or  in- 
capable of  being  shut  at  all ; the  eyesight  is  very  weak, 
but  seldom  quite  impeded ; and  at  the  termination  of 
each  attack  vision  returns,  though  every  paroxysm 
leaves  it  more  and  more  debilitated,  until  at  length  the 
spasmodic  attacks  of  bUndness  frequently  occurring, 
and  lasting  a long  wliile,  it  is  entirely  lost.  But  w’hen 
the  disorder  has  acquired  its  utmost  degree,  the  eye 
always  still  retains  the  power  of  discerning  the  light, 
and  it  seldom  happens  that  vision  is  abolished  by  the 
first  or  second  attack.  It  is  different  with  respect  to 
the  characteristic  phenomena  of  this  amaurosis,  in 
hysteric.al  or  hypochondriacal  patients,  especially  when 
often  affected  xvlth  spasms,  before,  ijuring,  or  after 
which  the  impairment  of  sight  originates  ; for  though 
the  pupil  may  continue  quite  clear,  it  cannot  escape  the 
notice  of  an  attentive  observer,  that,  together  wth  a 


AMAUROSIS. 


39 


pupil  of  diminished  diameter,  there  exists  a peculiar 
motion  of  the  iris,  a constant  fluttering  of  it  between 
expansion  and  contraction,  technically  called  hippus 
pupillae.  I'his  convulsive  state  of  the  iris  is  mostly 
accompanied  \vith  a similar  affection  of  the  eyelids, 
namely,  with  an  involuntary  blinking  (nictitatio; , and 
not  unfrequerttly  with  an  involuntary  pendulum-like 
rolling  of  the  eyeball  (nistagmus).  In  these  patients 
the  amaurotic  injury  of  sight  hardly  ever  proceeds  di- 
rectly to  complete  blindness,  but  more  commonly  re- 
mains as  a weakness  of  vision,  characterized  during 
the  rest  of  life  by  ceaseless  oscillations  of  the  eyeball, 
aversion  to  light,  and  frequent  sensations  as  if  there 
were  shining  fiery  objects  before  the  eyes. 

This  case  of  symptomatic  amaurosis  is  distingiiished 
by  an  untroubled,  but  very  expanded  pupil ; considera- 
ble diminution  of  the  motion  of  the  iris ; a dilated  state 
of  the  pupil,  even  under  the  .stimulus  of  the  strongest 
light,  and  tremulous  motions  of  the  eyeball,  which  con- 
tinue during  life,  after  the  epilepsy  and  amaurosis  are 
cured ; and  the  case  is  farther  characterized  by  ambly- 
opia, which  rarely  increases  to  complete  blindness. 

According  to  Beer,  the  amaurosis  connected  with 
convulsions  is  most  frequent  in  children.  The  first 
and  most  prominent  symptom  of  this  incomplete  or 
complete  amaurosis  consists  in  an  extremely  violent 
convulsive  rotation  of  the  eyeball,  especially  upwards, 
not  un  frequently  attended  with  the  most  violent  con- 
vulsive motions  of  the  eyelids.  The  pupil  is  exces- 
sively dilated,  and  scarcely  the  least  movement  of  the 
iris  is  distinguishable  on  exposing  the  eye  to  the 
strongest  light.  When  the  general  twitchings  are  over, 
and  only  an  amaurotic  weakness  of  sight  is  left,  stra- 
bismus occurs  in  both  eyes  in  various  directions,  though 
the  eyes  very  seldom  deviate  from  the  axis  of  vision  in 
the  direction  towards  the  inner  canthus.  When  the 
general  convulsions  happen  frequently,  and  are  violent 
and  of  long  duration,  the  amaurotic  weakness  of  sight 
usually  changes  into  perfect  blindness,  in  which  the 
pupil,  though  it  be  regularly  clear,  and  of  a shining 
blackness,  is  greatly  expanded,  and  the  eyes  constantly 
retain  their  faulty  position  and  pendulum-like  motion. 

With  respect  to  the  prognosis,  it  is  observed  by 
Beer,  that  even  when  merely  an  amaurotic  weakness 
remains,  the  prognosis  is  always  serious;  but  it  is 
naturally  still  more  unfavourable,  when  the  blindness 
is  complete,  and  when  the  loss  of  sight  has  suddenly 
recurred  after  violent  spasmodic,  epileptic,  or  convul- 
sive attacks,  without  such  attacks  them.selves  ever 
returning.  Under  these  circumstances.  Beer  has  not 
hitherto  seen  more  than  two  instances  of  such  blind- 
ness partially  cured.  Generally  some  hope  of  recovery 
may  be  entertained,  when  the  amblyopia,  or  even  com- 
plete amaurosis,  begins  with  these  attacks,  but  always 
terminates  with  them,  without  leaving  any  serious  im- 
pairment of  vision.  On  the  contrary,  it  is  a very  bad 
sign,  not  only  in  regard  to  the  removal  of  this  symptom- 
atic amaurosis,  but  likewise  to  the  cure  of  the  original 
disease,  when  the  amaurosis  invariably  precedes  these 
attacks,  and  lasts  a considerable  time  after  their  cessa- 
tion. As  yet.  Beer  says,  he  has  not  known  any  such 
patients  cured,  either  of  their  spasms,  epilepsy,  or  con- 
vulsions, much  less  of  their  blindness : on  the  contrary, 
after  three  or  four  attacks,  perfect  amaurosis  remains, 
and  some  of  the  patients  die  in  one  of  these  paroxysms. 

As  this  amaurosis  is  merely  a symptomatic  effect  of 
the  above  general  disorders,  its  removal  must  entirely 
depend  upon  the  success  with  which  their  treatment  is 
conducted.  Were  the  blindness  to  continue,  however, 
after  the  cure  of  the  original  disease,  the  surgeon  could 
do  nothing  more  than  try  an  empirical  mode  of  .treat- 
ment, and  ascertain  what  good  could  be  effected  with 
antispasmodic  and  tonic  medicines. — (.Beer,  Lehre  von 
den  Augenkr.  b.  2,  p.  606 — 510.) 

Rheumatic  amaurosis. 

According  to  Beer,  rheumatic  amaurosis  is  not  very 
uncommon,  and  is  so  plainly  denoted  by  certain  symp- 
toms, that  it  cannot  well  be  mistaken  ; namely,  a per- 
fectly clear  pupil  wavers  in  the  mid  state  between  con- 
traction and  dilatation,  the  iris  seeming  to  be  nearly 
motionless ; the  eyes  weep  from  the  slightest  causes, 
and  constantly  betray  more  or  less  aver.sion  to  light ; 
the  case  is  invariably  attended  with  wandering,  irrita- 
ting pains,  sometimes  affecting  the  eyeball  itself,  some- 
times the  vicinity  of  the  eye,  and  in  other  instances,  the 
teeth  or  neck.  Also  when  both  eyes  are  affected  to- 


gether, which  is  not  regularly  the  case,  a cast  of  the 
eye,  which  cannot  be  called  actual  squinting,  may  be 
remarked,  and  frequently  the  motion  of  the  eyeball  is 
chiefly  obstructed  O'nly  in  one  direction,  though  some- 
times a true  obliquity  of  the  organ  exists  (luscitas). 
In  nearly  every  instance  there  is  considerable  weak- 
ness of  the  levator  muscle  of  the  upper  eyelid,  and  not 
unfrequently  a complete  blepharoplegia ; but  total 
blindness  is  seldom  produced. 

According  to  Beer,  this  amaurosis,  which  is  to  be 
considered  as  chronic  rheumatism,  often  arises  from 
keeping  the  head  long  exposed  to  the  air,  and  is  chiefly 
met  with  in  individuals  who,  while  sweating  proftisely 
from  the  scalp  and  brow  in  warm  weather,  have  taken 
off  their  hats,  and  remained  with  their  heads  a long 
while  uncovered.  As,  however,  in  warm  weather,  the 
generality  of  persons  expose  themselves  in  this  man- 
ner, and  few  are  attacked  by  amaurosis,  I infer  that 
something  more  is  requisite  for  the  production  of  the 
disease. 

Under  certain  circumstances  the  prognosis  is  by  no 
means  unfavourable,  and  Beer  mostly  succeeded  in  ef- 
fecting a perfect  cure,  when  the  amaurosis  was  not 
completely  formed,  and  not  of  very  long  standing,  the 
patient  had  no  tendency  to  gout,  and  when  during  the 
treatment  every  thing  likely  to  bring  on  an  attack  of 
that  disease  was  avoided. 

The  treatment  consists  not  simply  of  local  means, 
which  indeed  are  always  needful,  but  likewise  of  ge- 
neral remedies.  With  regard  to  the  latter.  Beer  as- 
sures us  that  manifold  experience  has  convinced  him 
of  the  preference  which  ought  to  be  given  to  the  extract 
of  guaiacum  joined  with  camphor,  and  given  alternately 
with  the  compound  powder  of  ipecacuanha;  which 
remedies,  as  soon  as  the  wandering  pains  about  the 
eye  and  eyebrow  begin  to  be  milder,  and  more  fixed  to 
one  part,  are  to  be  succeeded  by  the  extract  of  aconi- 
tum,  antimonial  preparations,  and  flowers  of  sulphur. 
Externally,  the  most  powerful  operating  means  are  not 
to  be  omitted,  especially  blisters  applied  successively 
behind  the  ears,  to  the  temples,  and  eyebrows  ; and  as 
soon  as  the  pain  has  completely  subsided  in  these  last 
parts,  and  is  perhaps  more  concentrated  in  the  eye, 
frictions  are  to  be  made  on  the  eyebrow  with  liniments, 
containing  at  first  a moderate  quantity  of  opium,  and 
afterward  of  the  extractum  conii.  At  length,  when  the 
pain  in  and  about  the  eye  is  nearly  subdued,  but  some 
degree  of  amaurotic  weakness  of  sight  is  left,  frictions 
with  naphtha  and  a small  proportion  of  tinctura  lyttae 
and  tinctura  opii  will  be  found  exceedingly  beneficiat 
Afterward,  when  a considerable  time  has  transpired 
without  the  recurrence  of  the  slightest  rheumatic  pain 
in  the  eye,  its  vicinity,  or  the  head,  but  the  eyesight  is 
not  perfectly  re-established  by  perseverance  in  the  above 
general  and  local  treatment,  and  especially  when  the  pa- 
ralytic affection  of  the  levator  of  one  or  other  of  the  upper 
eyelids  continues  (as  often  happens),  galvanism  may  be 
tried,  with  the  cautions  elsewhere  premised. — (See 
Gutta  Serena.)  And  in  the  most  desperate  cases.  Beer 
approves  of  making  an  issue  in  the  depression  between 
the  angle  of  the  jaw  and  the  mastoid  process,  and  keep- 
ing it  open  for  a fortnight  after  the  recovery  seems 
complete. — (Lehre  von  den  Augenkr.  b.  2,  p.  526 — 529.) 

Traumatic  amaurosis. 

Beer  applies  the  epithet  “ traumatic”  to  such  cases  of 
amaurosis  as  are  the  consequence  of  a considerable 
wound  of  the  eye  itself,  its  surrounding  parts,  or  the 
skull.  Here,  consequently,  is  first  arranged  the  amau- 
ro.sis  produced  by  the  laceration  and  stretching  of  the 
branches  of  the  frontal  nerve  from  irregular  scars  about 
the  eyebrow.  Secondly,  Beer  reckons  the  amaurosis 
arising  from  external  violence  directed  in  such  a degree 
against  the  upper  or  lower  side  of  the  orbit,  that  the 
retina  is  torn,  and  many  of  the  internal  softer  textures 
of  the  eye  forced  out  of  their  natural  situations. 
Thirdly,  Beer  includes  every  weakness  of  sight  or  per- 
fect amaurosis,  which  is  the  result  of  such  injuries  of 
the  eyeball  itself  as  extend  to  the  retina,  so  as  either 
violently  to  bruise  or  lacerate  it,  or  cut  or  pierce  it.  For 
the  prognosis  and  treatment  of  all  these  cases,  he  refers 
to  his  observations  upon  mihthalmy.  Nor  does  he  choose 
here  to  treat  of  the  perfectly  complicated  amaurosis, 
which  is  a direct  consequence  of  a coup-de-.soleil,  be- 
cau.se  it  never  hapi)ens  unpreceded  by  a violent  general 
inflammation  of  the  eyeball,  and  therefore  is  to  be  re- 
gardeil  as  an  eflect  both  of  the  injury  and  the  infiain- 


40 


AMAUROSIS. 


mation  togetlier;  but  which,  like  the  symptomatic 
amaurosis,  Ibllowing  common  and  genuine  internal 
ophthalmy,  may  be  easily  knowm  by  the  total  insensi- 
bihty  to  light,  and  the  evident  changes  in  the  texture 
find  shape  of  the  eye ; and  is  quite  as  incurable  as  the 
other  example  to  w liich  we  have  alluded. — (Lchre  von 
den  Augenkr.  b.  2,  p.  542.) 

Gouty  amaurosis. 

According  to  Mr.  Travers,  gout  attacks  the  eye 
through  the  medium  of  the  stomach.  Vomiting  occurs 
with  pain  in  that  organ,  on  the  subsidence  of  an  in- 
flammation in  the  extremities,  and  is  succeeded  by  vio- 
lent jiain  in  the  head.  The  loss  of  sight,  he  adds,  is 
sudden  and  pennanent. — (Synopsis,  <kc.  p.  163.)  The 
gouty  amaurosis  described  by  Beer,  is  perhaps  badly 
named ; at  all  events,  there  are  some  circumstances  in 
its  history  which  must  create  doubts  on  the  subject. 
Gouty  amaurosis,  he  says,  has  two  forms  : the  first  is 
characterised  by  a very  considerable  dilatation  and  an- 
gular displacement  of  the  pupillary  edge  of  the  iris 
towards  the  c.anthi ; a confinually  increasing  slowness 
in  the  movements  of  the  iris,  and  final  immobility  of 
this  organ;  an  actual  change  of  colour  at  both  its  cir- 
cles; a dull,  glassy  blackness  of  the  pupil,  and  even  a 
tarnish  in  the  lustre  of  the  cornea ; an  alternate  ap- 
pearance of  the  gray  and  black  cloudy  substances  de- 
scribed in  the  account  of  the  general  symjiloms  of 
amaurosis,  which  effect  la.sts  while  the  patient  is  not 
totally  blind.  The  disorder  is  farther  indicated  by  a 
fleeting,  wandering,  irritating,  yet  not  very  severe  pain, 
all  about  the  vicinity  of  the  eye  ; a manifest  tendency 
to  a varicose  enlargement  of  the  blood-vessols  of  the 
conjunctiva  and  sclerotica ; a transient  melioration  of 
sight  after  meals,  or  any  accidental  excitement  or  sti- 
mulus ; a considerable  temporary  decrease  of  it  after  the 
operation  of  any  causes  which  depress  the  spirits  ; the 
excessively  slow  formation  of  tlfc  disease,  for  which 
several  years  are  usually  required ; and  lastly,  by  the 
nature  of  the  patient’s  constitution.  For,  in  general, 
thi.s  amaurosis  (if  we  are  to  beUeve  Beer)  always  at- 
tacks both  eyes  at  once,  and  is  confined  to  dark-eyed 
and  very  irritable,  slender,  weak,  maiden  females,  who 
oltUer  have  suifered  from  scrofula  in  their  childhood, 
or  from  severe  acute  or  chronic  diseases  at  a later  pe- 
riod of  their  lives ; who  are  not  yet  far  advanced  in 
years ; and  w hose  menses  have  never  been  very  irre- 
gular though  profuse. 

It  is  remarked  by  Beer,  that  although  the  second 
form  of  gotity  amaurosis  makes  its  attack  upon  males 
as  well  as  females,  the  latter,  on  the  whole,  are  most 
freijuemly  affected,  particularly  about  the  period  when 
the  menses  cease.  This  amaurosis,  which  is  seldom 
formed  quickly,  that  is  to  say,  in  a few  weeks  or  months, 
but  mostly  requires  years  for  its  production,  begins 
with  cloudy,  indistinct  vision  ; an  appearance  of  dif- 
ferent colours  before  the  eyes  ; and  a peculiar  sensation, 
as  if  insects  were  crawling  over  the  skin  around  the 
eye.  The  pupil  becomes  manifestly  dilated,  and  pre- 
sents a dull  greenish-gray  colour,  wliich,  however,  is 
easily  distinguished  from  the  colour  seen  behind  the 
pupil  in  the  amaurotic  cat-eye,  and  plainly  depends 
upon  some  defect  in  the  vitreous  humour  (glaucoma). 
Also  the  iris,  the  pupillary  edge  of  which  is  drawn 
towards  both  angles  of  the  eye,  as  in  the  first  form  of 
the  disorder,  undergoes  an  obvious  change  of  colour, 
first  at  its  less  circle,  w'hich  becomes  of  an  uncom- 
monly dark  hue,  and  then  at  its  greater  circle.  The 
alteration  of  colour  here  spoken  of  certainly  proceeds 
from  a general  varicose  state  of  the  blood-vessels  of 
the  eye,  which  affection  daily  augments,  and  is  at- 
tended with  vehement  pain  iti  the  organ  and  surround- 
ing parts,  or  even  in  the  whole  head,  or  one  side  of  4t, 
whether  the  blindness  attack  one  or  both  eyes  together. 
This  violent  pain,  however,  which  is  such  as  often  to 
distract  the  patient,  is  unsteady  and  irregular,  being 
immediately  aggravated  by  every  violent  mental  emo- 
tion, whether  of  the  exalting  or  depressing  kind,  every 
sud(ien  and  considerable  change  of  temperature,  every 
quick  accession  of  wet  cold  weather,  or  when  the  pa- 
tient stays  only  for  a short  time  near  a very  heated  fire- 
place, lies  on  feather  pilloxvs  with  the  affected  eye  rest- 
ing upon  them,  or  covered  with  flannel,  or  he  has  been 
eating  any  indigestible  food.  These  attacks  of  pain 
subside  without  any  medical  assistance,  in  the  dry, 
warm  season  of  the  year,  and  in  a mild,  not  too  hot,  cli- 
mate are  often  kept  oft'  for  several  years.  Upon  every 


such  attack  the  glaucoma  becomes  more  ex'ideiit,  the 
pupil  larger  and  more  angular,  and  the  eyesight  per- 
ceptibly weaker.  At  length,  during  one  of  these  jiuin- 
ful  exacerbations,  vision  is  completely  abolished,  not 
the  least  sensibility  to  hght  remaining  ; and  the  pupil- 
lary edge  of  the  iris,  together  with  the  less  circle  of 
the  same  organ,  then  entirely  di.sapjiears,  being  inverted 
towards  the  lens.  The  cirsophthalmia  also  gets  so 
much  worse,  that  the  sclerotica  acquires  a smutty,  gray- 
ish-blue colour;  and  at  length  the  bluish  windings  of 
vessels  may  be  noticed  at  various  points,  particularly 
about  the  place  where  the  tendons  of  the  muscles  are 
affixed.  Afterward  the  green,  or  w hat  may  be  more 
projierly  called  the  glaucomatous  cataract,  is  manifestly 
developed,  and  the  eye  Uien  generally  wastes  under 
the  most  violent  attacks  of  pain.  The  light  which  the 
jmtient  always  thinks  he  sees,  but  which,  according  to 
Beer,  is  produced  of  a reddish  or  bluish  colour  in  the 
interior  of  the  eye,  like  galvanism,  keeps  up  the  hope 
of  recovery ; but  all  consciousness  of  tliis  luminous 
appearance  ceases  as  soon  as  the  eye  begins  to  waste. 
The  first  degree  of  gouty  amaurosis  readily  changes 
to  the  second,  especially  in  persons  who  are  getting  into 
years,  or  are  near  the  pericsl  of  life  when  menstruation 
terminates. 

According  to  Beer,  the  apothecary’s  magatines  con- 
tain no  remedies  wliich  are  adequate  to  the  cure  of  the 
first  form  of  tliis  amaurosis.  A total  change  of  the 
whole  constitution  would  be  requisite,  ere  success 
could  be  expected,  and  such  change  it  is  not  in  the 
power  of  physic  to  accomplish.  In  one  single  exam- 
ple Beer  su.-ceeded  in  checking  the  disease,  by  per- 
su.nhng  the  patient  to  observe  a strict  regimen,  not  a 
grain  of  medicine  being  given;  but  the  patient  still  re- 
mains weak-sighted,  though  various  medicines  have 
latterly  been  tried. 

With  respect  to  the  treatment  of  the  second  form  of 
gouty  amaurosis.  Beer  observes  that  it  should  be  like 
that  of  gouty  iritis.  In  particular,  attention  must  be 
paid  to  the  attacks  of  pain,  and  palliative  means  adopt- 
ed. The  patient  should  not  lie  upon  feather  beds,  nor 
especially  feather  pillows,  but  only  employ  articles  of 
this  kind  which  are  stuffed  with  horse-hair.  Neither 
must  he  expose  himself  to  an  atmosphere  which  is  at 
the  same  time  both  cold  and  damp;  and  if  he  cannot 
altogether  take  care  of  himself  in  this  respect,  at  all 
events  let  him  keep  his  head  and  tect  warm  and  dry  ; 
shun  every  thing  which  tends  to  imjiede  the  functions 
of  the  skin ; and  avoid  pork-meat,  every  thing  cooked 
with  hogs’  lard,  and  all  acid  and  salt  dishes,  like  her- 
rings. With  what  are  usually  considered  as  gout  me- 
dicines, the  practitioners  should  act  very  circumspectly  ; 
and,  as  in  gouty  iritis,  he  should  pay  close  attention  to 
the  state  of  the  constitution,  rather  seeking  to  afford 
relief  by  means  of  a well-regulated  diet,  tlian  by  the 
employment  of  much  physic. 

Of  the  amaurosis  occa.'ioued  ly  the  sudden  cure  of 
cutaneous  diseases,  and  of  old  ulcers  of  the  leg. 

When  this  amaurosis  assumes  its  ordinary  form, 
Beer  has  not  yet  been  able  to  remark  in  it  any  peculiar 
characteristic  symptoms  by  which  it  can  be  effectually 
distinguished  from  the  second  form  of  gouty  amaurosis, 
excepting,  first,  that  it  originates  and  increases  very 
suddenly,  wliile  the  true  arthritic  amaurosis  is  a long 
time,  and  for  the  most  part  several  years,  in  forming. 
Secondly,  that  at  its  commencement  it  is  never  at- 
tended with  violent  pain  in  the  eyes  or  head.  Hence, 
the  diagnosis  will  depend  very  materially  upon  a cor- 
rect recollection  of  circumstances.  But,  according  to 
Beer,  there  are  some  cases  in  which,  besides  the  com- 
plete blindness,  unattended  with  the  slightest  power 
of  perceiving  light,  there  is  no  characteristic  symptom, 
but  extraordinary  enlargement  of  the  pupil,  total  im- 
mobility of  the  iris,  and  an  inanimate  projection  of 
the  eye. 

Respecting  the  causes  of  this  amaurosis.  Beer  says 
that  he  has  nothing  important  to  offer.  He  owns  that, 
after  the  sudden  cure  of  certain  cutaneous  diseases, 
and  of  old  ulcers  of  the  legs,  an  amaurotic  blindness 
does  not  always  ensue ; and  he  believes  that  the  reason 
why  the  bad  effects  ttie  place  in  other  organs,  some- 
times the  brain,  the  lungs,  or  the  bow'els,  &:c.,  may  pro- 
bably depend  upon  this  or  that  organ  happening  to  be 
most  predisposed  to  disease.  Here  the  discerning 
reader  w’lll  not  require  me  to  point  out  to  him  that  such 
a mode  of  accouniing  for  things  is  entirelj-  hypothetical, 


AMAUIIOSIS. 


41 


and  destitute  of  proof : it  is  indeed  so  convenient  a sort 
of  explanation  that  it  admits  of  being  extended  to  all 
diseases  without  exception.  If  we  are  to  believe  Beer, 
the  prognosis  is  very  uncertain,  and  in  many  cases 
highly  unfavourable;  first,  because  an  organic  part, 
namely,  the  optic  nerve,  is  directly  affected,  which,  by 
the  operation  of  external  and  internal  causes,  is  soon 
rendered  unfit  for  the  performtince  of  its  functions. 
Secondly,  because  in  the  majority  of  examples  impor- 
tant changes  immediately  take  place  in  the  organiza- 
tion of  the  whole  eye,  which  are  particularly  difficult 
of  removal  when  the  nervous  textures  are  affected. 
Thirdly,  because  it  is  impossible  to  know  whether  mor- 
bid changes  may  not  already  exist  in  the  retina  or 
course  of  the  optic  nerve. 

In  the  treatment.  Beer,  who  places  implicit  reliance 
upon  the  above  statement  of  causes,  is  an  advocate  for 
reproducing  as  quickly  as  possible  the  original  disease  ; 
and  if  that  cannot  be  done,  he  thinks  some  artificial 
disease  should  be  formed  in  lieu  of  it.  For  these  pur- 
poses, he  often  employs  blisters  and  friction  with  anti- 
monial  ointment.  His  treatment,  where  amaurosis 
happens  to  follow  the  cure  of  itch,  seems  very  ob- 
jectionable, as  it  consists  in  inoculating  the  poor  patient 
again  with  psoric  infection,  as  if  it  were  not  more  to- 
lerable to  remain  blind  than  live  perpetually  scourged 
with  the  other  disorder;  for  the  professor’s  theory 
leaves  us  uninformed  of  the  circumstances  under  which 
the  patient  whose  sight  is  restored  by  this  expedient 
could  ever  venture  to  have  a sound  skin  again  without 
the  risk  of  a fresh  attack  upon  his  eyes.  But  it  seems, 
even  from  Beer’s  account,  t.iat  the  patient’s  subjecting 
himself  to  the  itch  will  not  always  cure  Ins  eyes  ; for, 
says  he,  when  this  method  fails,  friction  with  antimo- 
nial  ointment  should  be  tried. 

When  amaurosis  follows  the  healing  of  old  sores, 
Beer  recommends  the  formation  of  them  again,  by 
applying  to  the  cicatrix  strong  mustard  cataplasms, 
and  the  muriate  of  soda ; and  if  the  new  ulcers  can- 
not be  made  to  discharge  properly,  he  praises  the  appli- 
cation of  issues  to  the  calves  of  the  legs,  and,  in  urgent 
cases,  to  the  thighs.  These  plans  are  to  be  aided  by 
such  medicines  as  act  specifically  upon  the  skin,  like 
antimonials,  especially  the  sulphur  auratum  antimonii. 
Beer  also  speaks  favourably  of  sulphur  baths  ; and  in 
cases  complicated  with  debility,  administers  tonics, 

Earticularly  the  calamus  aromaticus  and  bark. — (See 
,ehre  von  den  Augenkr.  b.  2,  p.  556—563.) 

Of  the  sympathetic  amaurosis  in  lying  in  women^  from 
suppression  of  the  secretion  of  milk. 

This  case  is  set  down  by  Beer  as  one  of  the  most 
uncommon  varieties  of  amaurosis.  It  comes  on  rapidly, 
after  sudden  stoppage  of  the  secretion  and  excretion  of 
the  milk,  with  violent  headache,  concentrated  about  the 
forehead  and  eyebrows  ; troublesome  luminous  appear- 
ances ; an  inconsiderable  dilatation  of  the  pupil ; and 
scarcely  any  perceptible  irregularity  in  the  pupillary 
edge  of  the  iris,  which  is  quite  motionless,  somewhat 
altered  in  colour,  and  swollen.  The  disease  is  also 
accompanied  with  great  aversion  to  light ; a palpable 
turgescence  of  all  the  blood-vessels  of  the  conjunctiva ; 
a slight  turbidness  of  the  transparent  media  of  the  eye  ; 
and,  at  first,  with  a mere  weakness  of  sight,  which,  in 
(he  end,  suddenly  changes  into  complete  amaurotic 
blindness.  The  breasts,  which  before  the  attack  were 
frill  of  milk,  are  now  empty,  and  hang  down  like  bags, 
but  are  quite  free  from  pain. 

From  tlie  few  cases  which  Beer  had  seen,  he  inferred, 
that  the  prognosis  is  always  unfavourable  when  the 
blindness  is  complete,  and  particularly  when  there  is  a 
manifest  diseased  change  in  the  transparent  parts  of  the 
eye  ; for,  in  the  latter  case,  he  has  known  patients 
remain  perfectly  blind,  though  the  secretion  of  milk 
had  been  most  successfully  and  expeditiously  re-esta- 
blished. In  one  instance,  the  remedies  applied  to  the 
breast,  instead  of  reproducing  the  secretion  of  milk, 
excited  in  the  part  a painfhl  inflammation  and  abscess, 
during  which  the  weakness  of  sight  subsided,  though 
it  was  very  considerable. 

In  considering  other  analogous  cases  of  amaurosis, 
enough  has  already  been  said  concerning  the  first  and 
most  important  indication,  namely,  the  re-establishment 
of  the  action  which  is  obstructed ; and  here  the  only 
question  is,  about  the  manner  in  which  that  object  can 
be  most  exjieditiously  and  safely  effected.  For,  says 
Beer,  it  should  be  distinctly  understood,  that  the  pre- 


vention of  a complete  amaurotic  blindness  essentially 
depends,  not  only  upon  the  renewal  of  the  secretion 
from  the  breasts,  but  upon  this  change  being  made 
without  delay.  The  remedies  which  Beer  has  found 
most  effectual  for  this  purpose  are  warm  poultices 
applied  to  the  breasts,  and  at  first  composed  of  simple 
emollients,  and  afterward  of  more  stimulating  ingre- 
dients, such  as  hemlock,  chamomile  flowers,  <fcc.  When 
the  breasts  have  more  of  a leucophlegmatic  appearance, 
than  that  indicative  of  a fulness  of  the  mammary 
gland,  and  disposition  to  a renewal  of  the  milk  secre- 
tion, Beer  strengthens  these  poultices  with' aromatic 
herb's,  and  applies  them  alternately  with  well-warmed 
bags,  full  of  dry  aromatic  plants,  and  sprinkled  with 
camphor.  These  last  means  are  very  useful  at  night, 
or  when  the  patient  is  asleep,  and  fresh  wann  poultices 
cannot  be  put  on  sufficiently  often.  In  the  daytime, 
the  breasts  should  be  frequently  and  gently  rubbed 
with  warm  flannels,  medicated  with  olibanum  and 
mastic.  This  plan  is  to  be  followed  up  until  the 
secretion  and  excretion  of  milk  are  renewed,  and  the 
amaurotic  amblyopia  has  subsided.  When  the  secretion 
either  cannot  be  restored  by  the  foregoing  means,  or 
the  eyesight  does  not  return  with  the  re-established 
secretion,  internal  remedies  must  be  tried,  especially 
arnica,  joined  with  calomel  and  camphor.  Issuen  or 
setons  should  also  be  formed,  and  kept  open  for  a con- 
siderable time. — ;,Lehre  von  den  Augenkr.  b.  2,  p.  572 
—575.) 

Of  the  symptomatic  amanrvsis  from  morbid  changes, 

either  in  the  optic  nerves  and  thdr  sheaths,  or  in  the 

bones  of  the  cranium,  or  the  brain  itself. 

Beer  says,  a very  considerable  number  of  cases  of 
this  form  of  amaurosis,  which  have  fallen  under  his 
notice,  have  enabled  him,  as  it  were,  not  only  to  know 
it  at  once,  but  to  describe  its  exact  symptoms. — 1st.  Its 
formation  is  constantly  very  slow,  and  in  all  cases  the 
patient  is  not  only  completely  deprived  of  vision,  but, 
for  more  or  less  time  previously  to  his  death,  rendered 
quite  incapable  of  distinguishing  light.  2dly.  A seennd 
peculiar  symptom  of  this  amaurosis  consists  in  morbid 
changes  in  the  structure  of  the  eye,  which  are  at  first 
scarcely  perceptible,  and  increase  very  slowly.  3dly. 
The  amaurosis  either  originates  during  an  attack  of 
violent  headache,  which  continues  almost  uninterrupt- 
edly until  death,  or  the  headache  does  not  come  on  until 
complete  blindness  has  taken  place ; or  the  patient  may 
have  no  pain  whatever  either  in  his  eyes  or  head. 
4thly.  In  the  progress  of  this  amaurosis,  objects  inva- 
riably seem  to  the  patient  to  be  perverted,  disfigured,  &c. 

Symptoms  when  the  disorder  proceeds  f com  disease  of 
the  optic  nerves  or  their  sheaths. 

This  case  comes  on  slowly,  and  rarely  attacks  both 
eyes  together.  It  always  commences  with  a black 
cloud,  which  grows  more  and  more  dense,  and  with  a 
troublesome,  alarming  perversion  and  disfigurement  of 
every  object,  without  the  least  painful  sensation  in  the 
eye  or  head.  The  patient  merely  complains  of  a slight 
sensation  of  dull  pressure  at  the  bottom  of  the  orbit,  as 
if  the  eyeball  w'ere  about  to  be  forced  from  its  socket, 
of  which  displacement,  however,  there  is  not  yet  the 
smallest  appearance.  In  the  very  beginning  of  the 
disease,  the  pupil  is  already  con.siderably  dilated,  and 
the  pupillary  edge  of  the  motionless  iris  presents  angles 
at  several  points,  the  pupil  sometimes  representing  an 
irregular  pentagon  or  hexagon.  By  degrees,  though 
very  slowly,  a glaucomatous  change  of  the  vitreous 
humour  ensues,  and  afterward  of  the  lens  itself;  the 
only  species  of  glaucoma  which  Beer  has  ever  noticed 
quite  unattended  with  a varicose  affection  of  the  blood- 
vessels of  the  eye.  At  last,  the  globe  of  the  eye 
becomes  perceptibly  smaller  than  natural ; but  a com- 
plete atrophy  does  not  ensue. 

Symptoms  when  the  case  proceeds  from  disease  of  the 
skull  or  brain. 

In  this  form  of  amaurosis,  which  usually  attacks 
both  eyes  together,  or  at  least  one  very  soon  after  the 
other,  the  blindness  also  commences  very  slowly,  with 
appearances  as  if  every  object  looked  at  were  perverted 
or  disfigured.  However,  there  is  no  black  cloud,  but 
rather  an  obscurity  or  confusion  of  every  object.  The 
disease  in  this  stage  is  also  accompanied  with  frequent 
giddines.s,  ugly  luminous  spectra,  and,  for  the  most  part, 


42 


AMAUROSIS. 


with  aversion  to  light,  uncommonly  lively  motions  of 
the  iris,  a contracted  pupil,  angles  in  the  upper  and 
lower  portions  of  th«  pujullary  margin  of  the  iris  ; an 
evident  turgescence  of  the  blood-vessels  of  the  eye, 
gradually  augmenting  with  most  violent  headache  into 
actual  cirsophthalmia ; frequent  convulsive  motions 
of  the  eyes  and  eyelids,  and  strabismus  of  one  or  both 
eyes,  ending  in  a true  deviation  of  one  or  both  of  these  . 
organs  from  their  natural  positions.  Under  these  symp- 
toms, vision  is  afterward  ciitirely  abolished ; and  the 
headache,  though  subject  to  remissions,  grows  so  much 
worse,  extending  back  to  the  spine,  that  the  patient  is 
often  nearly  frantic,  and,  indeed,  after  a time,  a de- 
struction ot  the  external  senses  ha})pens,  followed  by 
that  of  the  intellectual  faculties.  The  first  of  the  ex- 
ternal senses  which  is  lost  is  always  the  hearing, 
which  infirmity  is  next  followed  by  loss  of  the  smell, 
or  taste,  or  both  these  senses  together;  and  then  the 
memory  and  other  intellectual  powers  decline.  In  tliis 
stage  of  the  disorder,  the  eyeball  not  unfrequeiitly  pro- 
trudes from  the  orbit,  a pathognomonic  symiitoiri,  to 
which  Beer  attaches  great  importance,  because  it  is  an 
infallible  criterion  of  a diseased  state  of  the  bones  of 
the  orbit,  of  the  parts  which  invest  this  cavity,  and  of 
the  optic  nerve  and  dura  mater,  in  the  sella  turcica. 
In  such  cases,  complete  mania  now  usually  follows, 
and  this  sometimes  in  its  most  violent  form,  unless  the 
patient  happen  to  be  first  carried  off  by  paralytic  symii- 
toms;  life,  under  these  circumstances,  never  lasting 
any  considerable  time. 

As  far  as  our  external  senses  can  discover,  the  cause 
of  both  these  forms  of  amaurosis,  a.s  the  title  of  this 
section  specifies,  lies  in  certain  morbid  changes  in  the 
structure  of  the  optic  nerve  and  its  investments,  or  in 
disea-sed  alterations  of  the  bones  of  the  t;raniuin,  the 
dura  mater,  and  the  brain.  But  how  these  changes 
arise,  is  not  so  easy  of  explanation.  The  morbid 
changes  in  the  structures  above  mentioned,  which  Beer 
had  himself  ascertained  by  dissection,  consist  in  a real 
induration  of  the  optic  nerves,  and  an  adhesion  of  them 
to  their  sheaths,  while  within  the  skull  these  ash-co- 
loured, gray,  very  much  diminished  nerves  presented 
no  vestige  of  metlullary  structure  even  as  far  as  their 
origin  from  the  brain.  On  the  contrary,  the  optic  th.a- 
lamus  presented  externally  its  natural  appearance. 
The  retina  seemed  to  have  lost  its  pulpy  matter,  was 
tough,  not  easily  torn,  and  apjieared  to  consist  but  of  a 
vascular  membrane.  In  one  example,  although  both 
eyes  had  been  completely  deprived  of  sight  together. 
Beer  found  only  the  retina  and  optic  nerve  of  the  left 
side  in  this  state  of  atrophy  as  far  forwards  as  the  point 
of  union  in  the  sella  turcica.  On  the  other  hand,  the 
optic  nerve  of  the  right  eye  was  hard,  without  being  in 
the  lea-st  dwindled,  and  was  closely  adherent  to  its  ex- 
ternal coverings.  Anteriorly  to  their  decussation, 
nothing  at  all  preternatural  in  either  nerve  could  be 
discerned.  But  the  left  corpus  striatum  was  so  indu- 
rated, that  a very  sharji,  strong  scalpel  was  required 
for  its  division,  though  in  colour  and  shape  it  was  per- 
fectly natural.  On  this  side,  al.so,  the  plexus  choroides 
was  entirely  wanting.  In  three  amaurotic  patients  of 
this  kind.  Beer  found  hydatids  between  the  coverings 
of  the  optic  nerve,  and'where  such  hydatids  lay,  the 
medullary  matter  seemed  to  have  been  displaced  by 
their  pressure.  With  the  utmost  care,  he  could  not 
trace  the  ophthalmic  ganglion. 

Paw  also  found  in  the  optic  nerv'e  a large  hydatid, 
which  had  produced  amauro.sis. — (Obs.  Anat.  Rarior. 
Obs.  2.)  In  Mr.  Heaviside’s  museum,  there  is  a prepa- 
ration of  the  optic  nerve  of  an  amaurotic  eye,  where  a 
tumour  of  considerable  bulk  has  grown  from  the  neu- 
rilema. — 'See  Wardrop’s  Essays  on  the  Morbid  Ana- 
tomy of  the  Human  Eye,  vol.  2,  p.  157.)  In  this  work 
are  specified  examples  of  various  other  morbid  changes 
of  the  optic  nerve,  especially  calculous  concretions 
within  it,  the  presence  of  a viscid,  muddy,  gray  fluid 
in  the  thickened  neurilema,  instead  of  pulp,  a dwindling 
of  the  nerve,  <fec. 

To  the  present  description  of  cases.  Beer  refers  the 
instance  recorded  by  Haller  (Opusc.  Pathol.  Obs.  65, 
p.  172),  in  which  a calcareous  mass  w'as  found  between 
the  membrane  of  Ruysch  and  the  vitreous  humour. 
According  to  Beer,  there  is  preserved  in  the  patholo- 
gical and  anatomical  museum  of  the  general  hospital 
at  Vienna,  an  eye,  distended  with  a similar  osseous 
mass,  wuthout  the  capsule  of  the  lens  being  at  all 
affected.  Examples,  in  which  the  amaurotic  blindness 


arose  from  abscesses  in  the  brain,  are  reported  by  Bal- 
lonius  (Paradigmata  Hist.  7 , by  Pelargus  (Med. 
.lahrg.  3,  p.  198  , Peyronie  iM^m.  de  I’Acad.  Royalede 
Chir.  1,  p.  212/,  Schaarschmid  (Berlin  Nachrichte, 
1740.  No.  26),  Langenbeck  Neue  Bibl.  1,  p.  61),  and 
Mr.  Travers  (Synopsis,  p.  143).  The  latter  author  has 
recorded  an  instance  in  which  a firm  lardaccous 
tumour,  of  the  size  of  a garden  bean,  situated  on  the 
same  side  as  the  blindness,  compressed  the  optic  gan- 
glion and  nerve  at  its  origin  from  it.— (Synopsis,  p. 
151.)  I have  seen  a case  of  amaurosis,  in  which  a 
tumour  as  large  as  a middling-sized  apple  wjis  found  in 
the  anterior  lobe  of  the  brain,  attended  with  protrusion 
of  the  eye,  and  vast  destruction  of  the  bones.  Mr. 
Travers  has  seen  amaurosis  produced  by  a medullary 
fungus  of  the  brain.  A ca.se,  occasioned  by  disease  of 
the  thalamus,  is  related  by  Villeneuve  (Journ.  de  M^d. 
continue,  1811,  F4vr.  p.  98) ; another,  of  a tumour  of 
the  thalamus  on  the  same  side  as  the  blindness,  is 
recorded  by  Ford  iMed.  Commun.  vol.  1,  No.  4) ; and 
other  swellings  in  various  jiarts  of  the  brain  are  de- 
scribed in  Ephem.  Nat.  Cur.  Dec.  3,  Ann.  9,  and  10,  Obs. 
253 ; De  Haen’s  Ratio  Medendi,  P.  6,  p.  271  ; Journ. 
des  Savans,  1697 ; Muzell’s  Wahrnehm.  2,  No.  13  ; 
Plater,  Obs.  lib.  1,  p 108 ; Thomann,  Annalen  fur  1800, 
p.  400,  Ac.  On  this  part  of  the  subject,  1 beg  leave 
to  refer  also  i)articularly  to  my  friend  Mr.  Wardrop’s 
valuable  Essays  on  the  Morbid  Anatomy  of  the  Human 
Eye,  vol.  2,  p.  174,  Ac. 

The  morbid  alterations  of  the  bones  of  the  cavity  of 
the  skull  mostly  happen  at  its  basis,  and  not  only  may 
caries  take  place,  but  still  more  frequently  exostoses 
of  various  forms,  which  are  sometimes  so  small  that 
ihey  are  first  delected  by  the  bone  giving  the  feel  of  a 
rough  grater.  At  the  same  time  they  are  so  sharp, 
that  if  the  finger  be  passed  rudely  over  them,  it  will  be 
painfully  hurt.  In  these  cases  the  bones  of  the  cavity 
of  the  skull  are  always  found  extremely  thin ; the  diploe 
is  almost  entirely  wanting,  and  the  parietes  of  the 
orbit  are  preternaturally  diaphanous,  and  in  some  places 
imperfect.  Beer  speaks  of  a lady’s  skull  who  had  been 
comjiletely  blind,  and  for  some  weeks  previously  to 
her  death  insensible,  in  which  instance  scarcely  any 
part  of  the  cavity  of  the  skull  could  be  carelessly 
touched  without  risk  of  scratching  the  fingers  with 
si)icul{e.  Once  in  an  amaurotic  boy,  who  for  a short 
time  before  his  death  was  so  insane  that  he  used  to  de- 
vour his  own  excrement.  Beer  found  at  the  side  of  the 
sella  turcica  a long  considerable  spicula,  which  passed 
directly  through  the  optic  nerves  at  the  place  of  their 
decussation.  A case  of  amaurosis  produced  by  a spi- 
cula of  bone  injuring  the  opposite  side  of  the  brain  is 
related  by  Anderson. — See  Trans,  of  the  Society  of 
Edinb.  vol.  2.)  Sometimes  the  ethmoid  bone  has  been 
found  carious  i Ballonius,  Paradigmata,  No.  7) ; some- 
times other  i)arts  of  the  cranium. — (Mursirma,  Beobacht. 
1,  No.  6 ; Schmucker,  Vermischte  Schrift.  2,  p.  12.) 
Nor  is  it  unfreqnent  to  find  the  medullary  substance  of 
the  brain  itself  as  soft  as  pap,  while  the  cortical  sub- 
stance is  full  of  blood-vessels,  and  unusually  firm,  the 
convolutions  being  hardly  distingui.shable. 

Many  of  the  causes  of  amaurosis  are  of  such  a na- 
ture as  to  render  the  disease  totally  incurable.  Of  this 
description  is  fungus  haematodes,  in  which  the  struc- 
ture of  the  retina  and  optic  nerve  is  changed  in  a re- 
markable manner,  the  whole  cavity  of  the  eyeball  be- 
coming filled  with  a substance  resembling  medullary 
matter,  and  the  optic  nerve  changed  in  its  form,  colour, 
and  structure. — (See  Wardrop’s  Essays  on  the  Morbid 
Anatomy  of  the  Human  Eye,  vol.  2,  p.  156,  8vo.  Lond. 
1818.) 

On  the  authority  of  Ecker,  one  case  is  upon  record, 
where  the  cause  of  amaurosis  depended  upon  an  aneu- 
rism of  the  central  artery  of  the  retina. — (Pinel,  Noso- 
graphie  Philos,  vol.  2,  p.  122.) 

In  another  instance  the  macula  lutea,  which  is  natu- 
rally a yellow  spot  near  the  centre  of  the  retina,  was 
found  black. — (Mem.  de  la  Societe  Med.  d’Emulation, 
an  1798.) 

Bonetus,  in  his  Sepulchretum  Aiiatomicum,  lib.  1, 
sect.  18,  describes  various  cases  which  were  quite  in- 
curable : after  death  the  blindness  in  one  instance  was 
found  to  be  occasioned  by  an  encysted  tumour,  weigh- 
ing fourteen  drachms,  situated  in  the  substance  of  the 
cerebrum,  and  pressing  on  the  optic  nerves  near  their 
origin.  In  the  second,  the  blindness  was  produced  by 
a cyst  containing  water  and  lodged  on  the  optic  nerves 


AMA 


AMP 


43 


where  they  unite.  In  the  third,  it  arose  from  a caries 
of  the  os  frontis,  and  a consequent  alteration  in  the 
figure  of  the  optic  foramina.  In  a fourth,  the  cause  of 
the  disease  was  a malformation  of  the  optic  nerves 
themselves.  In  some  of  the  instances  in  which  no 
apparent  alteration  can  be  discovered  in  the  optic  nerve, 
the  late  Mr.  Ware  conjectured  that  a dilatation  of  the 
anterior  portion  of  the  circulus  arteriosus  may  be  the 
cause  of  the  affection.  The  circulus  arteriosus  is  an 
arterial  circle,  surrounding  the  sella  turcica,  formed  by 
the  carotid  arteries  on  each  side,  branches  passing  from 
them  to  meet  each  other  before,  and  other  branches 
passing  backwards  to  meet  branches  from  the  basilary 
artery  behind.  The  anterior  part  of  the  circulus  arte- 
riosus lies  directly  over,  crosses,  and  is  in  contact  with 
the  optic  nerves,  and  just  in  the  same  way  as  the  ante- 
rior branches  lie  over  the  optic  nerves,  the  posterior 
ones  lie  over  the  nervi  motores  oculorum.  Hence  Mr. 
Ware  attempted  to  refer  the  amaurosis  itself,  and  the 
paralytic  affection  of  the  eyelids  and  muscles  of  the 
eye,  sometimes  attendant  on  the  complaint,  to  a dilata- 
tion of  the  anterior  and  posterior  branches  of  the  circu- 
lu'S  arteriosus.  The  frequently  diseased  state  of  the 
trunk  or  small  branches  of  the  carotid  arteries  at  the 
side  of  the  sella  turcica  is  noticed  by  Dr.  Baillie  in  his 
useful  work  on  Morbid  Anatomy,  and,  he  says,  the 
same  sort  of  diseased  structure  is  also  found  in  the  ba- 
silary artery  and  its  branches. — ,See  Ware’s  Chir.  Obs. 
on  the  Eye.) 

In  1826,  M.  Magendie  related  to  the  French  Academy 
of  Sciences  various  facts  exemplifying  the  remarkable 
influence  of  the  fifth  nerves  over  all  the  senses ; and  with 
respect  to  the  sense  of  sight,  he  finds  that  the  action  of 
the  eyeball  and  optic  nerve  cease  immediately  they  are 
completely  deprived  of  the  influence  of  those  nerves. 
Thus  a state  of  the  eye  is  produced  that  has  the  greatest 
analogy  to  amaurosis.  Indeed,  when  the  fifth  nerves 
are  divided  in  an  animal,  it  is  instantly  bereft  of  sight 
on  the  side  on  which  the  nerve  has  been  cut,  notwith- 
standing the  eye  retains  at  the  moment  all  the  physical 
conditions  necessary  for  vision.  It  is  not  to  be  sup- 
posed, however,  that  the  fifth  nerves  perform  the  func- 
tion usually  referred  to  the  optic  one.s.  To  perceive 
the  light,  and  to  see,  as  Magendie  remarks,  are,  expe- 
rimentally speaking,  two  different  things.  An  animal 
whose  fifth  nerves  have  been  divided  does  not  see, 
neither  is  it  conscious  of  the  daylight  or  of  the  strongest 
artificial  light ; yet  it  decidedly  perceives  the  impression 
of  the  rays  of  the  sun  when  they  fall  directly  on  the  eye. 
Hence  a healthy,  sound  condition  of  the  optic  nerve 
on  the  one  part,  and  of  the  fifth  nerve  on  the  other,  is 
essential  to  perfect  vision ; and  M.  Magendie  therefore 
deems  it  highly  probable  that  there  are  two  kinds  of 
amaurosis , one  depending  on  a particular  affection  of 
the  optic  nerve  and  retina;  the  other  on  disease  of 
the  fifth  nerve,  and  the  defect  of  its  influence  on  the 
organ  of  vision.  These  reflections  led  him  to  make 
trial  of  a combination  of  acupuncture  and  galvanism 
for  the  cure  of  certain  cases  of  amaurosis.  Thus  in 
one  case,  having  introduced  one  needle  into  the  frontal 
nerve,  and  another  into  the  upper  maxillary,  he  brought 
the  needles  into  repeated  contact  with  the  two  poles  of 
a Voltaic  pile.  In  a fortnight  the  patient  had  received 
considerable  benefit  from  the  plan.  Other  facts  are 
also  recorded  in  favour  of  this  treatment. — i,See  Journ. 
Exp6r.  de  Physiol,  t.  6,  p.  156  et  seq.) 

//,  Heister,  ^jiologia  et  iiberior  JLlustratio  Systema- 
tis guide  Cataractd,(Tlaucuiiiatc,etAniaiirosi,  I'Ziiio.  Jil- 
torf.  1717.  J.  B.  O.  (Ehme,  de  Amaurosis  4tt).  Lips.  1748, 
in  Hallcri  Disp.  Chir.  2,  265.  Jos.  fVar7itr,  Descrip- 
tion of  Human  Eye.,  and  Diseases,  Quo,  Loud.  1754. 
Trnka  de  Krzowitz,  Historia  Aiiiauroseos,  8vo.  Vin- 
dob.  1781.  Gius.  Flajani,  Collezione  d'Osservaz. 
ifc.  t.4,p.  173,  187,  8«o.  Roma,  1803.  D.  G.  fCieser, 
Ueber  die  JTatur,  Ursachen,  Kennzeichen  und  Hedung 
dcs  schwarze  Staars,  8uo.  Giitt,  1811.  Dangenbeck, 
JVcite  Bibl.  fiir  die  Chirurgie,  b.  1,  Hanover,  1815. 
.T.  Beer,  Lehre  von  den  Augenkrankheiten,  b.  2,  Quo. 
fVien,  1817.  .James  fVardrop,  Essays  on  the  Morbid 
Anatomy  of  the  Human  Eye,vol.  2,  8vo.  Lond.  1818. 
The  two  latter  books  are  works  of  the  highest  merit ; 
and  as  we  have  no  translation  of  the  first,  I have 
thrown  a good  deal  of  the  information  which  it  con 
tains  on  amaurosis,  into  the  present  edition.  B.  A. 
fVtnkler,  De  Amaurosi,  12/«o.  Berol.  1818.  Eer- 
viischte  Chirurgische  Schriften  von  J.  D.  Schmucker, 
b.  2,  Berlin,  ed.  2,  1736.  Remarks  on  Ophthalmy,  4-c, 


by  James  Ware.  Inquiry  into  the  causes  preventing 
success  in  the  extraction  of  the  Cataract,  6rc.  by  the 
same.  Osservazioni  sulle  Malattie  degli  Occhi  di  A. 
Scarpa,  Venez.  1802.  This  book  has  gone  through 
many  editions  in  Italy.  The  last,  which  is  much  im- 
proved, has  been  well  translated  by  Mr.  Briggs.  W, 
Hey,  in  Practical  Observations  in  Surgery,  and  Med. 
Obs.  and  Inquiries,  vol.  5.  Schmucker' s Wahrneh- 
mungen,  b.  1,  p.  273.  Richter's  Anf angsgriinde  der 
Wundarzneykunst,  b.  3.  Frick  on  the  Diseases  of  the 
Eye,  by  Welbank,  8uo.  Lond.  ed.  2,  1826.  Some  scat- 
tered remarks  in  the  posthumous  work  on  the  Diseases 
of  the  Eye,  of  the  late  J.  C.  Saunders,  Src.  De  Wen- 
zel, Manuel  de  V Oculiste,  on  Dictionaire  Ophthalmolo- 
gique,8vo.  PaW.5,  1808.  J.  Stevenson,  On  the  Hature, 
drc.  of  the  different  Species  of  Amaurosis,  Sro.  1821. 
B.  Travers's  Synopsis  of  the  Diseases  of  the  Eye,  See. 
8vo.  Lond.  1820.  Also  Lawrence's  Lectures  on  Dis- 
eases of  the  Eye,  the  republication  of  which  in  a sepa- 
rate form,  with  references  to  the  best  works  and  autho- 
rities, would  make  one  of  the  most  useful  books  on  the 
subject. 

Many  additional  observations,  connected  with  the 
subject  of  amaurosis,  will  be  found  in  the  articles  Cata- 
ract, Diplopia,  Fungus  Haematodes,  Gutta  Serena,  He- 
meralopia, Hemiopia,  Nyctalopia,  Sight,  Defects  of,  &c. 

AMBE.  (From  ap6r],  the  projecting  edge  of  a rock.) 
An  old  chirurgical  machine  for  reducing  dislocations 
of  the  shoulder,  and  so  called  because  its  extremity 
projects  like  the  prominence  of  a rock.  Its  invention  is 
referred  to  Hippocrates.  The  ambe  is  the  most  ancient 
mechanical  contrivance  for  the  above  purpose  ; but  it 
is  not  at  present  employed.  Indeed,  it  is  scarcely  to 
be  met  with  in  the  richest  cabinets  of  surgical  appara- 
tus. It  is  composed  of  a piece  of  wood,  rising  vertically 
from  a pedestal.  With  the  vertical  piece  is  articulated, 
after  the  manner  of  a hinge,  a horizontal  piece,  with  a 
gutter  formed  in  it,  in  which  the  luxated  limb  is  laid 
and  secured  with  straps.  The  i)atient  places  himself 
on  one  side  of  the  machine ; his  arm  is  extended  in  the 
gutter  and  secured ; the  angle  formed  by  the  union  of 
the  ascending  piece  and  by  the  horizontal  branch  is 
lodged  in  the  armpit,  and  then  the  horizontal  branch  is 
depressed.  In  this  way  extension  is  made,  while  the  ver- 
tical part  makes  counter-extension,  and  its  superior 
part  tends  to  force  the  head  of  the  humerus  into  the 
articular  cavity.  But  there  is  notliing  to  fix  the  sca- 
pula, and  the  compression  made  by  the  superior  por- 
tion of  the  vertical  piece  of  the  machine  tends  to  force 
the  head  of  the  humerus  into  the  glenoid  cavity,  before 
it  is  well  disengaged  by  the  extension. — (See  Boyer  on 
Diseases  of  the  Bones,  vol.  2.) 

AMBLYOPIA.  (From  ap6\vi,  dull,  and  w^',  the 
eye.)  Hippocrates  means  by  this  word,  in  his  Aph. 
31,  Sect.  3,  the  dimness  of  sight  to  which  old  people  are 
subject.  Modern  writers  generally  understand  by  am- 
blyopia incomplete  amaurosis,  or  the  weakness  of 
sight  attending  certain  stages  and  forms  of  this  disorder. 

AMMONIA  MURIAS.  AMMONIA  MURIATA.  Sal 
ammoniac.  Its  chief  use  in  .surgery  is  as  an  external 
discutient  application. — (See  Lotio  Ammon.  Muriata 
cum  Aceto.) 

Mr.  Justamond  recommends  the  following  applica- 
tion to  milk  abscesses:  R.  Ammonia  muriata  5j- 
Spiritus  roris  marini  Ibj.  Misce.  Linen  rags  are  to 
be  wet  with  the  remedy,  and  kept  continually  applied 
to  the  part  affected. 

There  can  be  little  doubt  of  the  utility  of  this  lotion 
in  dispersing  the  induration  left  after  mammary  ab- 
scesses; but  while  these  cases  are  accompanied  with 
much  pain,  tension,  and  inflammation,  emollient  foment- 
ations and  poultices  are  to  be  preferred. 

If  muriate  of  ammonia  be  mixed  with  its  weight  of 
powdered  nitre,  and  dissolved  in  six  or  eight  parts  of 
water,  it  produces  a very  cold  lotion,  which  may  be 
used  as  a substitute  for  ice  in  cases  of  strangulated 
hernia. 

AMPUTATION.  The  operation  of  cutting  off  a limb, 
or  other  part  of  the  body,  as  the  breast,  penis,  <fec. 

Such  an  operation  frequently  becomes  indispensably 
proper,  on  the  principle  of  sacrificing  a branch,  as  it 
were,  for  the  sake  of  taking  the  only  rational  chance 
of  saving  the  trunk  itself.  Indeed  the  suggestion  of 
this  measure,  in  cases  of  mortification,  where  there  is 
no  chance  of  the  parts  recovering,  may  be  said  to  bo 
derived  from  nature  herself,  who,  by  a process  to  which 
I shall  advert  in  s])eaking  of  nf«)rtification,  detaches 


44 


AMPUTATION. 


the  dead  fVom  the  living  parts;  this  separation  is  fol- 
lowed by  cicatrization,  and  the  patient  recovers. 

The  necessity  for  amputation  has  always  e.xisted, 
and  ever  will  continue,  as  long  as  the  destructive 
effbcts  of  injuries  and  diseases  of  the  limbs  cannot  be 
obviated  in  any  other  manner.  As  Graefe  observes,  there 
was  once  a period  (I  should  say,  about  forty  years  ago) 
when  the  operation  was  more  fi-equently  practised 
than  at  present,  and  this  fact  is  to  he  imputed  less  to 
the  caprice  of  surgeons  than  to  the  imperfection  of  the 
means  which  used  to  be  employed  for  the  relief  of  local 
disea-ses.  For  then  aueurisms  of  the  limbs,  and  some 
other  cases,  at  present  treated  with  success,  were  al- 
ways deemed  incurable  without  amputation.  Boucher, 
Gervaise,  Faure,  and  Bilguer  inveighed  against  the 
fre<iuent  performance  of  amputation  on  the  held  of  bat- 
tle ; yet  their  arguments  must  prove  of  little  value ; 
unless  a path  were  at  the  same  time  traced  which 
would  conduct  us  to  the  method  of  remedying  the  cir- 
curnstaiuajs  which  form  the  necessity  for  the  operation. 
When  this  condition  is  fulfill  d,  and  more  etfectual 
modes  of  treatment  are  devised,  as  for  instance  with 
respect  to  the  giui-shot  wounds  specified  by  Bilguer, 
then  the  necessity  for  amputation  in  such  cases  would 
cease  of  itself. — Normen  tur  die  Abldsuiig  grdsserer 
Gliedmassen,  p.  13,  4to.  Berlin,  1812.) 

As  the  author  of  another  valuable  modern  work  has 
said,  it  is  an  excellent  observation,  founded  on  the 
purest  humanity,  and  justified  by  the  soundest  profes- 
sional principles,  that  to  save  one  limb  is  infinitely 
more  honourable  to  the  surgeon,  than  to  have  per- 
formed numerous  amputations,  however  successful; 
but  it  is  a remark,  notwithstanding  its  quaintness,  fully 
as  true,  that  it  is  much  better  for  a man  “ to  live  with 
three  limbs,  than  to  die  with  four.” — (liennen  on  Mili- 
tary Surgery,  p.  251,  ed.  2.) 

To  this  saying  should  be  atided  the  refiection,  that 
some  unfortunate  beings,  infiuenced  by  a relish  for 
life,  have  been  known  to  submit  to  the  loss  of  all  their 
legs  and  arms,  and  yet  recover.  In  the  llOtel  dcs  In- 
valides  at  Paris,  mutilated  objects  are  ^n  recollection, 
who  had  lost  all  their  thighs  and  arms,  so  that,  unless 
a.ssisted,  they  could  not  stir,  and  it  was  necessary  to 
feed  and  wait  upon  them  like  new-born  infants — ..Mo- 
rand,  Opusc.  de  Chir.  p.  183,  and  Graefe,  op.  cit.  p.  23.) 

The  amputation  of  the  large  limbs  was  aticienliy 
practised  under  many  disadvantages.  The  best  way 
of  making  the  incisions  was  unknown ; the  ignorance 
of  the  old  surgeons  about  the  right  method  of  stopping 
hemorrhage  was  the  death  of  a large  proportion  of  the 
patients  who  had  courage  to  submit  to  tlie  operation  ; 
the  mode  of  healing  the  wound  by  the  first  intention 
was  not  understood,  or  not  duly  appreciated ; and  the 
instruments  were  as  awkward  and  clumsy,  as  the 
dressings  were  irritating  and  improi>er. 

Modern  practitioners  have  materially  simplified  all 
£lie  cliief  operations  in  surgery ; an  object  which  has 
been  aci-omplished  not  merely  by  letting  anatomical 
science  be  the  main  guide  of  their  proceedhigs ; not 
siiiqily  by  devising  more  judicious  and  less  painful 
methods ; not  only  by  diminishing  the  number,  and 
improving  the  construction,  of  instruments ; but  also, 
in  a very  essential  degree,  by  abandoning  the  use  of  a 
multitmle  of  e.xternal  applications,  most  of  which 
were  useless  or  hurtful. 

The  Greek,  Roman,  and  Arabian  practitioners  ampu- 
tated limbs  with  feelings  of  alarm,  and,  in  general, 
with  the  most  melancholy  results;  while  modern  sur- 
geons proceed  to  the  operation  completely  fearless,  well 
knowing  that  it  mostly  proves  successful ; hence,  as 
Graefe  justly  remarks,  nothing  can  be  more  evident, 
than  that  the  patient’s  safety  must  depend  very  much 
upon  the  kind  of  practice. — (See  Normen  fur  die  Ablo- 
sung  gro.sserer  Gliedma.ssen,  p.  1.)  By  practice  is 
here  implied  the  mode  m which  the  operation  is  per- 
formed, the  way  in  which  the  wound  is  dressed,  and 
the  whole  of  the  aller-treatment. 

But,  much  improved  as  amputation  has  been,  it  can- 
not be  dissembled,  that  it  is  an  operation  at  once  terri- 
ble to  bear,  dreadM  to  behold,  and  sometimes  severe 
and  fatal  in  the  consequences  which  it  itself  produces, 
while  the  patient,  if  saved,  is  left  for  ever  afterward  in 
a crippled,  mutilated  state.  Hence  it  is  the  surgeon’s 
duty  never  to  have  recourse  to  so  serious  a proceeding 
without  a perfect  and  well-grounded  conviction  of  its 
necessity.  Amputation  should  be  generally  regarded 
as  the  last  expedient  to  which  a surgeon  ought  to  re- 


sort ; an  expedient  justifiable,  as  a late  waiter  says, 
only  when  the  part  is  either  already  gangrenous,  or 
the  seat  of  so  much  injury  or  disea.se,  that  the  attempt 
to  preserve  it  any  longer,  would  expose  the  patient’s 
lile  to  the  greatest  danger. — tDict.  des  Sciences  Med. 
t.  1,  p.  472.) 

Although,  says  a distinguished  modern  surgeon,  this 
amounts  to  a confession,  that  the  cure  of  some  local 
disorders  is  not  within  the  limits  of  our  art,  yet,  on  the 
other  hand,  it  furnishes  a proof,  that  surgery  may  be 
the  means  of  saving  life  under  circumstances  which, 
without  its  assistance,  would  infallibly  have  a fatal 
termination.  The  operation  is  adojited  as  the  safest 
measure : the  cause  is  removed  for  the  prevention  of 
consequences. — Graefe,  op.  cit.  p.  14.) 

Nothing  can  be  more  absurd  or  more  misapplied, 
than  the  censures  sometimes  passed  upon  amputation, 
because  the  body  is  mutilated  by  it,  «fcc.  Although,  as 
a modern  writer  remarks,  the  objection  proves  the 
limitation  of  human  knowledge  and  ability,  it  must  be 
very  unfair  on  this  account  to  tlnovv  blame  on  surgery, 
or  the  practitioner  who  thus  saves  the  patient’s  life. 
For,  without  dwelling  upon  the  fact,  that  a humane 
surgeon  w ould  never  amputate  through  a mere  love  of 
operating,  and  without  urgent  cause,  one  may  simply 
ask,  are  all  diseases  in  their  nature  curable  ? Does  not 
the  surgeon  cure  such  as  are  curable  without  mutila- 
tion ? And  are  not  cases,  wliich  were  in  the  begin- 
ning remediable,  often  first  brought  to  the  surgeon 
when,  from  neglect,  they  have  become  totally  incu- 
rable 1 Is  it  not  his  duty  then  to  employ  the  only  means 
left  for  saving  the  patient?  And  is  not  the  preserva- 
tion of  a long  and  healthy  life  a compensation  for  the 
sacrifice  ? Would  it  not  be  just  as  reasonable  to  blame 
an  architect,  when  the  irresistible  force  of  lightning  or 
a bomb  destroys  liis  building  ? Indeed,  is  it  not  rather 
a greater  honour  to  surgery,  that  even  when  death  has 
already  taken  possession  as  it  were,  of  a part,  and  is 
threatening  ineritable  destruction  to  the  whole,  a 
means  is  yet  furnished,  not  only  of  saving  the  patient’s 
life,  but  of  bringing  him  into  a state  in  which  he  may 
recover  his  former  good  health? — (Briinninghausen, 
Erfahrungen  und  Bemerkungen  fiber  die  Amputation, 
p.  11,  12mo.  Bamberg,  1818.) 

Though  amputation  is  in  eve^  respect  much  better 
than  in  former  times,  and  its  right  performance  is  by 
no  means  difficult,  I would  not  wash  to  be  thought  to 
say,  that  it  is  always,  or  even  usually  done  secundum 
ariem,  because  long  opportunities  of  observation  have 
convinced  me  of  the  contrary ; and  the  reason  of  the 
knife  being  yet  so  badly  handled  in  this  part  of  sur- 
gery, may  generally  be  imputed  to  carelessness,  slo- 
venly habits,  or,  what  is  as  bad,  a want  of  ordinary 
dexterity.  Tliere  are  several  egregious  faults  in  the 
method  of  amputating,  which  even  many  hospital  sur- 
geons in  tliis  metroiMilis  are  guilty  of;  but  these  w'e 
shall  find,  when  we  criticise  them,  are  for  the  most 
part  easily  avoidable,  without  any  particular  share  of 
skill  being  required.  A greater  difficulty  is  to  ascer- 
tain with  precision  the  cases  w'hich  demand  the  opera- 
tion, those  in  which  it  may  be  dispensed  with,  and  the 
exact  periods  at  which  it  should  be  practised.  These 
are  considerations  requiring  profound  attention,  and 
the  brightest  talents.  The  most  expert  operator  (as 
Mr.  O’Halloran  observes)  may  not  always  be  the  best 
surgeon.  To  do  justice  to  the  sick  and  ourselves,  we 
must,  in  many  cases,  rather  avoid  than  perform  capital 
operations ; and  with  respect  to  amputation,  if  we 
consider  the  many  cases  in  which  it  has  been  unneces- 
sarily undertaken,  or  done  at  unseasonable  periods,  it 
may  be  suspected,  that  this  operation,  upon  the  whole, 
may  have  done  more  mischief  than  good.  At  all 
events,  it  is  not  enough  for  a surgeon  to  know  how  to 
operate ; he  must  also  know  when  to  do  it. — (See 
O’Halloran  on  Gangrene  and  Sphacelus : preface.) 

For  such  reasons  I shall  first  take  a view'  of  the  cir- 
cumstances under  which  the  best  surgeons  deem  am- 
putation necessary ; though  it  may  be  proper  to  ob- 
serve, that  in  each  of  the  articles  relative  to  the  parti- 
cular diseases  and  injuries  which  ever  call  for  the  ope- 
ration, additional  information  will  be  oflfered. 

1.  Cnvipound  fractures. 

In  a compound  fracture  the  necessity  for  amputation 
is  not  altogether  proportioned  to  the  seriousness  of  the 
accident,  but  also  frequently  depends  in  part  upon 
other  circumstances.  For  example^  in  the  field,  and 


AMPUTATION. 


45 


on  board  of  a crowded  ship,  it  is  not  constantly  in  the 
surgeon’s  power  to  pay  such  attention  as  the  cases  de- 
mand, nor  to  procure  tor  the  patient  the  proper  degree 
of  rest  and  good  accommodation.  In  the  field,  there  is 
often  a necessity  for  transporting  the  wounded  from 
one  place  to  another.  Under  these  circumstances  it  is 
proper  to  have  immediate  recourse  to  amputation,  in 
numerous  cases  of  bad  compound  fractures,  some  of 
which,  perhaps,  might  not  absolutely  demand  the  ope- 
ration, were  the  patients  so  situated,  as  to  be  capable 
of  receiving  all  the  advantages  of  the  best  and  most 
scientific  treatment  in  a well-ventilated  quiet  house  or 
hospital,  furnished  with  every  desirable  convenience. 
At  the  same  time,  daily  experience  proves,  that  there 
are  many  other  cases,  in  which  it  would  be  improper 
to  have  recourse  to  the  knife,  even  under  the  most  un- 
favourable circumstances  of  the  above  description.  So, 
when  a compound  fracture  occurs,  in  which  the  soft 
parts  have  not  been  considerably  injured;  in  which 
the  bones  have  been  broken  in  such  a direction  that  they 
can  be  easily  set  and  kept  in  their  proper  position, 
or  in  which  there  is  only  one  bone  broken,  amputation 
would  be  unnecessary  and  cruel.  But  when  the  soft 
parts  have  been  more  extensively  hurt,  and  the  bones 
have  been  so  badly  broken,  that  perfect  quietude  and 
incessant  care  are  required  to  afford  any  chance  of  re- 
covery, it  is  a good  general  rule  to  amputate  whenever 
these  advantages  cannot  be  obtained. 

The  bad  air  in  crowded  hospitals  and  large  cities,  a 
circumstance  so  detrimental  to  wounds  in  general,  is 
another  consideration  which  may  seriously  lessen  the 
chances  of  saving  a badly  broken  limb,  and  should 
be  remembered  in  weighing  the  reasons  for  and  against 
amputation. 

On  this  part  of  the  subject,  I find  the  sentiments  of 
Graefe  interesting : besides  an  absolute,  says  he,  there 
is  a relative,  necessity  for  amputation ; it  is  the  most 
moum.ful,  and  proceeds  altogether  from  unfavourable 
external  circumstances,  though,  alas ! in  many  cases 
nearly  unavoidable,  when  life  is  to  be  preserved.  In 
war,  every  bloody  action  furnishes  proof  of  what  has 
been  stated.  The  number  of  the  w'ounded  is  immense ; 
the  number  of  surgeons  for  the  duty  too  limited.  The 
supplies  most  needed  are  at  a distance.  In  these  emer- 
gencies, though  the  military  surgeon  may,  from  routine 
and  genius,  be  able  to  suggest  the  quickest  method  of 
obtaining  what  is  wanted,  know  how  to  avail  himself 
of  every  advantage  which  circumstances  permit,  and 
contrive  tolerable  substitutes  for  such  things  as  are  de- 
ficient, yet  this  will  not  always  do.  Were  we  (says 
Graefe;  here  to  complain  of  the  government  not  pro- 
viding due  assistance  for  the  defenders  of  our  native 
soil,  to  many  the  remonstrance  would  only  appear  rea- 
sonable. Yet  they  who  manage  the  medical  affairs  of 
the  Prussian  army  may  not  constantly  have  it  in  their 
power  to  avert  the  inconvenience.  The  general  cannot 
foretel  the  number  and  nature  of  the  wounds  which 
may  happen,  so  as  to  enable  the  medical,  department  to 
take  with  them  exactly  the  apparatus  required,  without 
encumbering  the  army  with  a redundance  of  useless 
articles.  The  enemy,  perhaps,  captures  the' medical 
store.s,  or  the  rapid  movements  of  particular  corps  cut 
us  off  from  ihe  principad  depots.  Detachments  often 
skirmish  at  remote  points.  The  hospitals  may  lie  se- 
veral miles  in  the  rear  of  the  line;  and,  for  want  of 
means,  the  transport  of  the  imperfectly-d  ressed  wounded 
may  continue  night  and  day.  Hardly  are  the  sufferers 
brought  into  the  nearest  hospital,  in  the  most  pitiful 
state  from  pain,  anxiety,  and  cold,  when  an  order  is 
given  to  break  up,  and  they  must  be  conveyed  still  far- 
ther towards  their  grave ; ami  a thousand  other  circum- 
stances, as  Graefe  observes,  which  deprive  the  wounded 
of  the  requisite  attendance,  and  essential . number  of 
surgeons,  together  with  the  most  necessary  stores, 
make  it  desirable  to  simplify  every  wound  as  much  as 
possible  ; which,  indeed,  is  the  only  means  of  shunning 
the  reproach,  that,  while  we  are  eiideavouring  to  save 
one  man’s  limb,  we  let  anoftier  die. 

Who  doubts,  says  Graefe,  that  a soldier  with  a gun- 
shot wound,  complicated  with  a smashed  state  of  the 
bones,  may  sometimes  be  saved,  without  loss  of  his 
limb,  by  employing  all  the  means  wliich  the  resources 
of  surgery  offer  1 But  these  very  resources  are  often 
wanting  in  a campaign ; and  the  business  of  dressing 
the  patient  would  occupy  the  surgeon  several  hours 
daily,  during  which  his  useful  assistance  could  not  be 
extended  to  other  sufferers.  Notwithstanding  the  ut- 


most care,  the  removal  of  patients  from  one  place  to 
another  frequently  makes  their  wounds  extremely  dan- 
gerous, or  fatal ; and  we  now  lose  many  a man,  who,, 
had  he  undergone  amputation,  would  have  been  able  to 
bear  the  journey.— (See  Normen  flir  die  Ablosung 
grosserer  Gliedmassen,  p.  15, 16.) 

From  what  I have  seen  of  the  ill  effects  of  moving 
patients  with  bad  compound  fractures  of  the  lower  ex- 
tremity, produced  by  gun-shot  violence,  I am  convinced 
that,  as  a general  rule,  it  is  better  to  perform  amputa- 
tion ; but  if  this  be  not  done,  and  an  attempt  is  to  be 
made  to  save  the  member,  it  will  be  more  humane, 
when  the  army  is  retreating,  and  the  enemy  are  not 
savages,  to  leave  such  wounded  behind,  than  subject 
them  to  all  the  fatal  mischief  of  hastily  and  roughly 
transporting  them  in  such  a condition.  It  gives  me 
particular  pleasure  to  find  the  preceding  sentiment  con- 
firmed by  Dr.  Hennen,  whose  knowledge  and  experi- 
ence in  military  surgerj'  entitle  all  hi.s  opinions  to  the 
greatest  attention  : in  noticing  what  ought  to  be  done 
with  the  wounded,  when  the  amiy  is  compelled  to  re- 
treat, he  says,  “ it  then  becomes  the  duty  of  a certain 
proportion  of  the  hospital  staff  to  devote  themselves  for 
their  wounded,  and  become  prisoners  of  war  aloii|g 
with  them;  and  it  may  be  an  encouragement  to  theim 
experienced,  while  it  is  grateful  to  me,  to  observe,  that 
I have  never  witne.s6ed,  nor  traced,  on  inquiry,  an  act 
of  unnecessary  severity  practised  either  by  the  French 
or  English  armies  on  their  wounded  prisoners.” 

Compound  fractures  of  the  thigh,  produced  by  gun- 
shot violence,  too  often  have  an  unfavourable  termina- 
tion, especially  when  the  accident  has  been  caused  by 
grape-shot  oi-  eveti  a musket-ball,  fired  from  a mode- 
rate distance,  and  the  pati  nt  is  moved  from  one  place 
to  another  after  the  receipt  of  the  injury.  In  the  mili- 
tary hospital  at  Oudenbosch,  in  the  spring  of  1814, 1 
had  charge  of  about  eight  bad  compound  fractures  of 
the  thigh,  of  which  cases  only  one  escaped  a fatal  ter- 
mination. This  was  an  instance  in  which  the  femur 
was  broken  a little  way  above  the  knee.  Another  pa- 
tient was  extricated  by  amputation  from  the  perils 
immediately  arising  from  the  splintered  displaced  state 
of  the  bone,  the  serious  injury  of  the  muscles,  and 
enormous  abscesses,  but  was  unfortunately  lost  by  se- 
condary hemorrhage.  All  these  patients  had  not 
merely  been  struck  by  grape-shot,  or  else  by  balls  fired 
from  a short  distance,  but  they  had  been  moved  from 
Bergen-op-Zoom  into  my  hospital  five  or  six  days  after 
the  receipt  of  the  injury,  the  very  worst  period  possible 
on  account  of  the  inflammation  being  then  most  vio- 
lent. From  the  ill  success  of  these  cases,  many  a sur- 
geon who  saw  them  might  be  inclined  to  think  that 
immediate  amputation  ought  generally  to  be  performed 
for  all  compound  fractures  of  the  thigh  as  soon  after 
the  receipt  of  the  injury  as  possible.  And  such  is  my 
own  sentiment,  whenever  the  accident  has  been 
caused  in  the  violent  manner  above  si)ecified,  or  when- 
ever the  patient  must  be  moved  any  distance  in  a wa- 
gon after  the  occurrence  of  the  injury.  It  may  be  right 
to  state,  however,  that  I have  known  more  than  one 
compound  fracture  of  the  thigh  cured,  where  the  acci- 
dent had  not  been  occasioned  by  gun-shot  violence,  and 
I have  been  informed  of  one  or  two  .succe-ssful  cases 
where  the  bone  was  broken  by  a pistol-ball.  In  St. 
Bartholomew’s  hospital,  two  compound  fractures  of 
the  thigh  were  pointed  out  to  me  some  time  ago,  a& 
cases  likely  to  end  favourably.  However,  these  may 
only  have  been  lucky  escapes,  deviations  from  what  is- 
common,  and  not  entitled  to  any  stress,  with  the  view 
of  affecting  the  general  excellent  rule  ol’  amputating 
where  the  thigh-bone  is  broken  by  gun-shot  violence. 

As  Mr.  Guthrie  has  accurately  observed,  one  circum- 
stance winch  increases  the  danger  of  fractures  of  the 
femur  from  gun-shot  violence  is,  that  the  bone  is  very 
often  broken  obliquely,  the  fracture  extending  far  above 
and  below  the  point  immediately  struck  by  the  ball.— 
(On  Gun-shot  Wounds,  p.  189,  190.)  This  disposition 
of  the  thigh-bone  to  be  splintered  for  several  inches 
when  hit  by  a ball,  and  the  increased  danger  arising 
from  the  occurrence,  are  also  very  particularly  com- 
mented upon  by  (he  experienced  Schmucker,  who  was 
surgeon-general  to  the  Prussian  armies  in  the  cam- 
paigns of  Frederick  the  Great. — See  his  Vermischte 
Chirurgische  Schriften,  b.  1,  n.  39,  8vo.  Berlin,  1785.) 
In  several  of  the  cases  under  the  care  of  Dr.  Cole  and 
myself  in  Holland,  the  bone  was  split  longitudinally  to 
; tlie  extent  of  seven  or  eight  inches. 


46 


AMPUTATION. 


According  to  Schinucker,  all  fVactures  of  the  middle 
or  upper  part  of  the  femur  are  attended  with  great 
danger.  “ Bur  ,say.s  he;  if  the  fracture  be  situated  at 
the  lowest  part  of  the  bone,  the  risk  is  considerably 
less,  the  muscles  here  not  being  so  powerful ; in  such 
a case,  therefore,  amputation  sliould  not  be  performed 
before  every  other  means  lia-s  been  fairly  tried ; and 
very  frequently  I have  treated  fractures  of  this  kind 
with  success,  though  the  limb  sometimes  continued 
stiff.  But  says  Schmucker;  if  the  bone  be  completely 
fractured  or  splintered  by  a ball  at  its  middle,  or  above 
that  point,  I never  wait  for  the  bad  symptoms  to 
commence,  but  amputate  ere  they  originate ; and  when 
the  operation  has  been  done  early  enough,  most  of  my 
patients  have  been  saved,  lloweverj  when  some  days 
had  transpired,  and  inrtarnmation,  swelling,  and  fever 
had  come  on,  I must  candidly  confess  that  the  issue 
was  not  always  fortunate.  Yet  the  operation  should 
not  on  this  account  be  dispensed  wiili ; for  if  only  a 
few  can  thus  be  saved  out  of  many,  some  benefit  is  ob- 
tained, as,  without  this  step,  such  few  would  also  pe- 
rish.”— Vemuschte  C'hir.  richrifleii.  b.  1,  p.  42.)  What 
I saw  of  compound  fractures  of  the  thigh,  after  the  as- 
sault on  Bergen-op-Zoom,  we  may  remark,  coincides 
with  the  results  of  Schmucker’s  ample  experience ; for 
the  only  two  patients  who  survived  the  bad  symptoms 
proceeding  directly  from  the  fracture  were,  one  whose 
femur  was  broken  near  the  knee,  and  another  whose 
limb  I took  off  on  account  of  a Iracture  of  the  middle 
of  the  bone,  accompanied  with  abscesses  of  surjirising 
extent.  The  latter  was  a case,  however,  in  which  the 
limb  ought  to  have  been  removed  earlier.  The  follow- 
ing remarks,  by  Mr.  Guthrie,  1 consider  judicious  and 
correct. 

“ The  danger  and  dilficulty  of  cure  attendant  on  frac- 
tures of  the  femur  from  gun-shot  wounds,  deiiend  much 
on  the  part  of  the  bone  injured  ; and  in  the  considera- 
tion of  these  circumstances  it  will  be  useful  to  divide 
it  into  five  parts.  Of  these,  the  head  and  neck  in- 
cluded in  the  capsular  ligament,  may  be  considered 
the  first;  the  body  of  the  bone,  which  may  be  divided 
into  three  parts,  and  the  spongy  portion  of  the  lower 
end  of  the  bone  exterior  to  the  capsular  ligiunent,  form- 
ing the  fifth  part.  Of  these,  the  fractures  of  the  first 
kind  are,  I believe,  always  ultmiatelV  final,  although 
life  may  be  prolonged  for  some  time.  The  upper  third 
of  the  body  of  the  bone,  if  badly  fractured,  generally 
causes  death  at  the  end  of  six  or  eight  weeks  of  acute 
suffering.  I have  seen  few  escape,  and  then  not  with 
a useful  limb  that  had  been  badly  fractured  in  the  mid- 
dle part.  Fractures  of  the  lower  or  fifth  division  are 
in  the  next  degree  dangerous,  as  they  generally  affect 
the  joint ; and  the  least  dangerous  are  fractures  of  the 
lower  third  of  the  body  of  the  bone.  Of  these  even 
I do  not  mean  to  conceal,  that  when  there  is  much  shat- 
tered bone  the  dairger  is  great,  so  that  a fractured  thigh 
by  gun-shot,  even  without  particular  injury  of  the  soft 
parts,  is  one  of  the  most  dangerous  kinds  of  wounds 
that  can  occur.” — .See  Guthrie  on  Gun-shot  Womids, 
p.  190.) 

In  compound  fractures,  as  Mr.  Pott  has  correctly- 
pointed  out,  there  are  three  points  of  time  when  ampu- 
tation may  be  proper.  The  first  of  these  is  immedi- 
ately or  as  soon  as  possible  after  the  receijit  of  the  in- 
jury. The  second  is,  when  the  bones  continue  for  a 
great  length  of  time  without  any  disposition  to  unite, 
and  the  discharge  from  the  wound  has  been  so  long  and 
is  so  large  that  the  patient’s  strength  fails,  and  general 
symptoms  foreboding  dissolution  come  on.  The  tliird 
is,  when  a mortification  has  taken  such  complete  pos- 
session of  the  soft  parts  of  the  inferior  portion  of  the 
limb  quite  down  to  the  bone,  that  upon  the  separation 
of  such  parts  the  bone  or  bones  shall  be  left  bare  in  the 
interspace. 

The  first  and  second  of  these  are  matters  of  very  se- 
rious consideration.  The  third  hardly  requires  any. 

When  a compound  fracture  is  caused  by  the  pas- 
sage of  a very  heavy’  body  over  a limb,  such,  for  in- 
stance, as  the  broad  wheel  of  a wagon  or  loaded  cart,  or 
by  the  fall  of  a very  ponderous  body  on  it,  or  by  a can- 
non-shot, or  by  any  other  means  so  violent  as  to  break 
the  bones  into  many  fragments,  and  so  to  tear,  bruise, 
and  wound  the  soft  parts,  that  there  shall  be  good  rea- 
son to  fear  that  there  will  not  be  vessels  sufficient  to 
carry  on  the  circulation  with  the  parts  below  the  frac- 
ture, it  becomes,  as  Mr.  Pott  observes,  a matter  of  the 
most  serious  consideration,  whether  an  attempt  to  save . 


such  a limb  w ill  not  occasion  loss  of  life,  Tliis  consider- 
ation iniLst  he  before  any  degree  of  infiammation  has 
seized  the  part,  and  therefore  must  be  immediately  after 
tlie  accident.  When  inilammation,  tension,  and  a dispo- 
sition to  gangrene  in  the  limb  have  arisen,  the  period  is 
highly  disadvantageous  for  operating,  and  the  patient’s 
(diances  of  being  saved  by  amputation  under  these  cir- 
cumstances are  much  smaller  than  before  the  changes 
here  spoken  of  had  taken  place.  At  the  same  time,  there 
arc  certain  examples  of  mortification  from  external 
causes,  where,  as  far  as  one  can  judge  from  the  results 
of  later  exjierience  than  that  of  Mr.  Pott,  the  surgeon 
should  not  defer  amputation,  even  though  the  disorder  be 
yet  in  a spreading  state,  attended  with  considerable  swell- 
ing and  tension  reaching  far  up  the  limb.  This  is  a sub- 
ject, however,  which  will  require  more  explanation 
hereafter. — See  what  is  presently  said  on  Mortification.) 
Nor  are  the  cases  to  which  reference  is  made  meant  to 
aflect  the  general  truth  of  the  observation  delivered  by 
the  most  experienced  surgeons  of  every  age,  that  when 
a iimb  is  extensively  swelled  and  inflamed,  with  a part 
of  it  either  in  a state  of  spreading  mortification  or 
ready  to  become  gangrenous,  the  period  is  so  unfa- 
vourable for  amputation  that  very  few  patients  so  cir- 
cumstanced ever  recover  after  the  operation.  Nor  is 
it  meant  to  be  insinuated,  that  in  the  very  cases  which 
form  exceptions  to  the  general  rule  of  not  amputating 
before  the  tendency  to  gangrene  has  ceased,  the  pa- 
tient might  not  have  had  an  infinitely  better  chance  of 
his  life,  had  the  operation  been  done  immediately  after 
the  first  receipt  of  the  injury,  before  any  disposition 
to  gangrene  bad  had  time  to  be  produced. 

The  necessity  of  immediate  or  very  early  decision  in 
this  case  makes  it  a very  delicate  part  of  practice  ; for 
however  pressing  the  case  may  seem  to  the  surgeon, 
it  will  not,  in  general,  appear  in  the  same  light  to  the 
patient,  to  the  relations,  or  to  bystanders.  They  will 
be  inclined  to  regard  the  proposition  as  arising  from 
ignorance,  or  an  inclination  to  save  trouble,  or  a desire 
to  operate  ; and  it  will  often  require  more  firmness  on 
the  part  of  the  practitioner,  and  more  resignation  and 
confidence  on  the  part  of  the  patient,  than  is  generally 
met  with,  to  submit  to  such  a severe  operation  in  such 
a seeming  hurry,  and  upon  so  little  apparent  delibera- 
tion ; and  yet  it  often  happens,  that  the  suffering  this 
point  of  tune  to  pass  decides  the  patient’s  fate. 

This  necessity  of  early  deci.sion  arises  ft-om  the  quick 
tendency  to  mortification  which  ensues  in  tlte  injured 
limb,  and  too  often  ends  in  the  patient’s  death.  That 
tliis  is  no  exaggeration,  says  Pott,  melancholy  and  fre- 
quent experience  evinces,  even  in  those  whose  consti- 
tutions previous  to  the  accident  were  in  good  order ; 
but  much  more  in  those  who  have  been  heated  by  vio- 
lent exercise,  or  labour,  or  liquor,  or  who  have  led  very 
debauched  and  intemperate  lives,  or  who  have  habits 
naturally  inflammable  and  irritable.  This  is  often  the 
case  when  the  fracture  happens  to  the  middle  part  of 
the  bones,  but  is  much  more  likely  to  happen  when 
any  of  the  large  joints  are  concerned.  In  many  of 
these  cases  a determination  for  or  against  amputation 
is  really  a determination  for  or  against  the  patient’s  ex- 
istence. 

That  it  would  have  been  impossible  to  have  saved 
some  limbs  which  have  been  cut  off,  no  man  will  pre- 
tend to  say ; but  this  does  not  render  the  practice  in- 
judicious. Do  not  the  majority  of  those  who  get  into 
the  above  liazardous  condition,  and  on  whom  amputa- 
tion is  not  performed,  perish  in  consequence  of  their 
wounds  1 Have  not  many  lives  been  preserved  by  am- 
putation which,  from  the  same  circumstances,  would 
otherwise  most  probably  have  been  lost  1 

Pressing  and  urgent  as  the  state  of  a compoimd  frac- 
ture may  be  at  this  first  point  of  time,  still  it  will  be  a 
matter  of  choice  whether  the  limb  shall  be  removed  or 
not ; but  at  the  second  period  the  operation  must  be 
submitted  to,  or  the  patient  must  die. 

The  most  unpromising  appearances  at  first  do  not 
necessarily  or  constantly  end  unfortunately.  Some- 
times, after  the  most  threatening  first  symptoms,  after 
considerable  length  of  time,  great  discharges  of  mat- 
ter and  large  exfoliations  of  bone,  success  shall  ulti- 
mately be  obtained,  and  the  patient  shall  recover  his 
health  and  the  use  of  his  limb. 

But  sometimes,  after  the  most  judicious  treatment 
through  every  stage  of  the  disease;  after  the  united 
efforts  of  physic  and  surgery;  the  sore,  instead  of 
granulating  kindly,  and  contracting  daily  to  a smaller 


amputation. 


41 


«izG,  shall  remain  as  large  as  at  first,  with  a tawny, 
spongy  surface,  discharging  a large  quantity  of  thin 
sanies,  instead  of  a small  one  of  good  matter ; the 
fractured  ends  of  the  bones,  instead  of  tending  to  ex- 
foliate or  to  unite,  will  remain  as  perfectly  loose  and 
disunited  as  at  first,  while  the  patient  shall  loose  his 
sleep,  his  appetite,  and  his  strength;  a hectic  fever, 
with  a quick,  small,  hard  pulse,  profuse  sweats,  and 
colliquative  purging,  contributing  at  the  same  time  to 
bring  him  to  the  brink  of  the  grave,  notwithstanding 
every  kind  of  assistance : in  these  circumstances,  if 
amputation  be  not  performed,  Mr.  Pott  asks,  what  else 
can  rescue  the  patient  from  destruction  ? 

The  third  and  last  period  is  a matter  which  does 
not  require  much  consideration.  Too  often  the  inflam- 
mation consequent  upon  the  injury,  instead  of  producing 
abscess  and  suppuration,  tends  to  gangrene  and  morti- 
fication, the  progress  of  which  is  often  so  rapid,  as  to 
destroy  the  patient  in  a very  short  space  of  time,  con- 
stituting that  very  sort  of  case  in  which  amputation 
should  have  been  immediately  performed.  But  some- 
times even  this  dreadful  malady  is,  by  the  help  of  art, 
put  a stop  to,  but  not  until  it  has  totally  destroyed  all 
the  surrounding  muscles,  tendons,  and  membranes 
quite  down  to  the  bone,  which,  upon  the  separation  of 
the  mortified  parts,  is  left  quite  bare,  and  all  circulation 
between  the  parts  above  and  those  below  is  by  this 
totally  cut  off.  In  this  instance,  whether  the  surgeon 
saw  through  the  bare  bone,  or  leave  the  separation  to 
be  effected  by  nature,  the  patient  must  lose  his  limb. 
— (See  Pott’s  Remarks  on  the  Necessity,  &c.  of  Ampu- 
tation in  certain  Cases,  «fcc.  Chir.  Works,  vol.  3.) 

For  the  consideration  of  a variety  of  complicated 
cases  which  affect  the  question  of  amputation  in  com- 
pound fractures,  I must  refer  to  the  article  Gun-shot 
Wounds. 

2.  Extensive  contused  and  lacerated  wounds. 

These  , form  the  second  class  of  general  cases  re- 
quiring amputation.  Wounds  without  fracture  are  not 
often  so  bad  eis  to  require  this  operation.  When  a limb, 
however,  is  extensively  contused  and  lacerated,  audits 
principal  blood-vessels  are  injured,  so  that  there  is  no 
hope  of  a continuance  of  the  circulation,  the  immediate 
removal  of  the  member  should  be  recommended, 
whether  the  bones  be  injured  or  not.  Also,  since  no 
effort  on  the  part  of  the  surgeon  can  preserve  a limb  so 
injured,  and  such  wounds  are  more  likely  to  mortify 
than  any  others,  the  sooner  the  operation  is  undertaken 
the  better. 

In  these  cases,  as  in  those  of  compound  fractures, 
though  amputation  may  not  always  be  necessary  at 
first,  it  may  become  so  afterward.  The  foregoing 
observations,  relative  to  the  second  period  of  compound 
fractures,  are  equally  applicable  to  badly  lacerated 
wounds,  unattended  with  injury  of  the  bones.  Some- 
times a rapid  mortification  comes  on  ; or  a profuse 
suppuration,  which  the  system  can  no  longer  endure. — 
(Encyclop^die  M^thodique  ; partie  Chir.  t.  1,  p.  80.) 

3.  Cases  in  which  part  of  a limb  has  been  carried  away 
by  a cannon  ball. 

When  part  of  a limb  has  been  torn  off  by  a cannon- 
ball, or  any  other  cause  capable  of  producing  a similar 
effect,  the  formation  of  a good  and  serviceable  stump, 
the  greater  facility  of  heating  the  clean,  regular  wound 
of  amputation,  and  the  benefit  of  a far  more  expedi- 
tious, as  well  as  of  a sounder  cure,  are  the  principal 
reasons  which  here  make  the  operation  advisable. 

This  was  an  instance,  in  which  some  former  sur- 
geons disputed  the  necessity  of  amputation.  They 
urged  as  a reason  for  their  opinion,  that  the  limb  being 
already  removed,  it  is  better  to  endeavour  to  cure  the 
wound  as  speedily  as  possible,  than  increase  the  pa- 
tient’s sufferings  and  danger,  by  making  him  submit  to 
amputation.  It  mu.st  be  remembered,  however,  that 
the  hones  are  generally  shattered,  and  reduced  into 
numerous  fragments;  the  muscles  and  tendons  are 
unequally  divided,  and  their  ends  torn  and  contused. 
Now,  none  of  the  old  surgeons  questioned  the  absolute' 
necessity  of  extracting  the  splinters  of  bone,  and  cut- 
ting away  the  irregular  extremities  of  the  tendons  and 
muscles,  which  operations  would  require  a longer  time 
than  amputation  itself.  Besides,  we  should  recollect 
that,  by  making  the  incision  above  the  injured  part,  so 
as  to  be  enablfS  to  cover  the  bone  with  flesh  and  integu- 
ments perfectly  free  from  injury,  the  extent  of  the 


wound  is  so  diminished,  that  the  healing  can  be  accom- 
plished in  one-third  of  the  time  which  would  otherwise 
be  requisite,  and  a much  firmer  cicatrix  is  also  obtained. 
Such  reflefftions  mpst  convince  us,  that  amputation 
here  holds  forth  very  great  advantages.  It  cannot  in- 
crease the  patient’s  danger,  and  as  for  the  momentary 
augmentation  of  pain  which  he  suffers,  he  is  amply 
compensated  by  all  the  benefits  resulting  from  the  ope- 
ration.— (See  Gun-shot  Wounds.) 

4.  Mortification. 

Mortification  is  another  cause,  which,  when  ad- 
vanced to  a certain  degree,  renders  amputation  indis- 
pensably proper.  We  have  noticed,  that  bad  compound 
fractures  and  wounds  often  terminate  in  the  death  of 
the  injured  limb.  Such  surgeons  as  have  been  deter- 
minetl,*at  all  events,  to  oppose  the  performance  of  am- 
putation, have  pretended,  that  the  operation  is  here 
totally  useless.  They  assert,  that  when  the  mortifica- 
tion is  only  in  a slight  degree,  it  may  be  cured,  and  that 
when  it  has  spread  to  a considerable  extent,  the  patient 
will  perish,  whether  amputation  be  performed  or  not. 
But  this  way  of  viewing  things  is  so  contrary  to  facts, 
and  the  experience  of  every  impartial  practitioner,  that 
I shall  make  no  attempt  to  refute  the  assertion.  W’hile 
it  is  allowed  that  it  would  be  very  bad  practice,  to  am- 
putate on  every  slight  appearance  of  gangrene,  it  is 
equally  a fact,  that  when  the  disorder  affects  the  sub- 
stance of  a member,  the  operation  is  generally  the 
safest  and  most  advantageous  measure.  Nay,  there 
are,  as  we  shall  presently  see,  certain  forms  of  n)orti- 
fication,  in  which  the  early  performance  of  amputation 
is  the  only  chance  of  saving  the  patient. 

Practitioners  have  entertained  very  opposite  oiunions, 
concerning  the  period  when  one  should  operate  in  cases 
of  mortification.  Some  pretend,  that  whenever  the  dis- 
order presents  itself,  and  especially  when  it  is  the  effect 
of  external  violence,  we  shpuld  impntate  immediately 
the  mortification  has  decideaiy  begun  to  form,  and 
while  the  mischief  is  in  a spreading  state.  Others  be- 
lieve, that  the  operation  should  never  be  undertaken 
before  the  progress  of  the  disorder  has  stopped,  even 
not  till  the  dead  parts  have  begun  to  separate  from  the 
living  ones. 

The  advocates  for  the  speedy  performance  of  ampu- 
tation declare,  that  the  farther  progress  of  the  mortifi- 
cation may  be  stopped,  and  the  life  of  the  patient  pre- 
served, by  cutting  above  the  parts  affected.  However, 
according  to  the  reports  of  the  greater  number  of  emi- 
nent surgical  writers,  this  practice  is  highly  dangerous, 
and  undeserving  of  confidence.  Whatever  pains  may 
be  taken,  in  the  operation,  only  to  divide  sound  parts, 
there  is  no  certainty  of  succeeding  in  this  object, 
and  the  most  skilful  practitioner  may  be  deceived. 
The  skin  may  appear  to  be  perfectly  sound  and  free 
from  inflammation,  Avhile  the  muscles  which  it  covers, 
and  the  parts  immediately  surrounding  the  bone,  may 
actually  be  in  a gangrenous  state.  But  even  when  thq 
soft  parts  are  found  free  from  apparent  distemper,  on 
making  the  incision,  still,  if  the  operator  should  not 
have  waited  till  the  mortification  has  ceased  to  spread, 
the  stump  will  almost  always  be  attacked  by  gangrene. 
Surgeons  who  have  had  opportunities  of  frequently 
seeing  wounds  which  have  a tendency  to  mortify,  en- 
tertain the  latter  opinion.  Such  was  the  sentiment  of 
Pott,  who  says  that  he  has  often  seen  the  experiment 
made,  of  amputating  a limb  in  which  gangrene  had 
begun  to  show  itself,  but  never  saw  it  succeed,  and  it 
invariably  hastened  the  patient’s  death. 

The  operation  may  be  postponed,  however,  too  long. 
Mr.  S.  Sharp,  in  particular,  recommended  too  much 
delay,  advising  the  operation  never  to  be  done,  till  the 
natural  separation  of  the  mortified  parts  had  considera- 
bly advanced.  Mr.  Sharp  was  a surgeon  of  immense 
experience,  and  his  authority  carries  with  it  the  great- 
est weight.  But,  perhaps,  he  was  too  zealous  in  his 
opposition  to  a practice,  the  peril  of  which  he  had  sa 
often  beheld.  When  the  mortification  has  ceased  to 
spread,  there  is  no  occa.sion  for  farther  delay.  We  now 
obtain,  just  as  certainly,  all  the  benefits  of  the  operation, 
and  get  rid  of  a mass  of  putridity,  the  exhalations 
from  which  poison  the  atmosphere  which  the  patient 
breathes,  and  are  highly  detrimental  to  his  health. 
Nay,  according  to  the  reports  of  writers,  patients  in 
these  circumstances  may  actually  fall  victims  to  the 
absorption  of  the  putrid  matter  which  is  suffered  to 
remain  too  long.  However,  this  danger  would  not  be 


48 


AMPUTATlOxN. 


80  considerablfi  as  that  which  would  arise  from  too 
precipitate  an  operation  ; and  it  is  better  to  defer  ampu- 
tation a little  more  than  is  absolutely  re<]uisilc,  than 
run  any  risk  of  doing  the  oi)eralion  before  it  is  certain 
that  the  parts  have  lost  their  tendency  to  gangrene. 

In  the  article  Mortification,  we  have  noticed  particu- 
lar ca.ses  of  gangrene,  where,  according  to  Larrey’s 
e.xperience,  the  surgeon  is  not  to  wait  for  the  line  of 
separation  being  formed,  but  have  recourse  to  the  im- 
mediate performance  of  amputation.  The  e.xperience 
of  Mr.  Lawrence  tends  also  to  confirm  the  propriety 
of  such  practice. — (See  Medico-Cliir.  Trans,  vol.  6,  p. 
156,  &c.) 

In  an  example,  where  a large  part  of  the  arm  was 
deeply  affected  with  gangrene  from  external  violence, 
and  the  disorder  was  yet  making  rapid  progress,  I once 
recommeinled  the  performance  of  amputation  at  the 
shoulder-joint.  On  the  whole  this  instance  was  fa- 
vourable to  the  practice  ; for,  though  the  patient  died  at 
the  end  of  a fortnight,  probably  he  would  not  have  lived 
twenty-four  hours,  had  the  operation  not  been  done ; 
nor  was  the  stump  attacked  with  mortification,  a cir- 
cumstance worthy  of  attention,  because  it  is  a danger 
particularly  insisted  upon  by  the  opiionents  of  amputa- 
tion, under  the  preceding  circumstances;  and,  had  it 
not  been  for  a large  abscess,  which  formed  in  the  back, 
as  was  supposed,  from  a violent  blow  received  in  the 
fall  which  produced  the  original  injury,  there  were 
well-grounded  hopes  of  recovery.  The  patient,  here 
spoken  of,  was  attended  by  Dr.  Illicke,  of  Waltham- 
stow. 

There  is  likewise  a species  of  gangrene,  which  is 
pointed  out  by  xMr.  Guthrie  as  requiring  early  amputa- 
tion. “ A soldier  isays  he)  shall  receive  a flesh-wound 
from  a musket-ball  in  the  middle  of  the  thigh,  which 
passed  through  the  limb  apparently,  on  a superficial 
inspection,  without  injuring  the  main  artery ; or  it  shall 
pass  close  behind  the  femur,  where  the  artery  turns  to 
the  back  part  of  the  bone ; or  it  may  go  through  the 
middle  of  the  bone,  from  behind  forwards,  between  the 
condyles  of  the  femur,  into  the  knee-joint,  and  the 
patient  .shall  walk  to  the  surgeon  with  little  assistance, 
be  superficially  dre.ssed,  and,  in  many  ca.ses  be  consi- 
dered slightly  wounded ; yet  the  femoral  artery  and 
vein  of  the  whole  of  these  cases,  and,  indeed,  in  many 
others,  shall  be  wounded,  or  cut  across,  and  the  local 
Infl.'inmation  be  so  slight  as  to  obtain  little  aflention. 
On  the  third  or  fourth  day,  the  patient  shows  his  toes 
discoloured,  and  complains  of  pain  and  coldness  in  the 
limb  below  the  wound,  the  constitution  begins  to  sym- 
pathize with  the  injury,  and  the  surgeon  jirobably  thinks 
the  case  e.xtraordinary.  Terhaiis  he  suspects  the  real 
state  of  the  injury ; but  is  surprised  that  a wound  of 
the  femoral  or  popliteal  artery,  with  so  little  attendant 
injury,  could  cause  mortification,  &c.  lie  is  anxious 
to  do  something ; but  mortification,  or  at  least  gangrene, 
having  commenced,  he  must,  according  to  general  rule, 
await  the  formation  of  the  line  X)f  separation.  The 
temperature  of  the  leg,  a little  above  the  gangrene,  is 
good,  perhaps  higher  than  natural ; he  hopes  it  will  not 
extend  farther,  and  it  probably  does  remain  station- 
ary for  a little  time.  At  last,  the  parts  originally 
affected,  the  toes,  become  sphacelated,  and  gangrene 
quickly  spreads  up  the  leg  as  far  as  the  wounded  ar- 
tery, by  which  time  the  patient  dies.” 

For  the  purpose  of  preventing  such  a disaster,  where 
the  artery,  or  artery  and  vein,  have  been  dhided,  Mr. 
Guthrie  recommends  the  performance  of  amputation 
as  soon  as  the  gangrene  is  perceived  to  extend  beyond 
the  toes;  and  the  swelling  and  slight  attendant  inflam- 
mation, which  is  marked  more  by  the  tumefaction,  than 
the  redness  of  the  part,  has  passed  higher  up  than  the 
ankle. — (See  Guthrie  on  Gun-shot  Wounds,  p.  60,  61.) 

5.  White  stcellings. 

Scrofulous  joints,  xvith  diseased  bones,  and  distem- 
pered ligaments  and  cartilages,  is  another  case,  in 
which  amputation  may  become  absolutely  necessary. 
As  Mr.  Pott  remarks,  there  is  one  circumstance  attend- 
ing this  complaint,  often  rendering  it  particularly  un- 
pleasant, which  is,  that  the  subjects  are  most  frequently 
young  children,  so  as  to  be  incapable  of  determining 
for  themselves,  which  inflicts  a very  distressing  task 
on  their  nearest  relations.  All  the  efforts  of  physic 
and  surgery  often  prove  absolutely  ineffectual,  not  only 
to  cure,  but  eVen  to  retard,  the  disease  in  question. 
Notwnthstanding  many  cases  admit  of  cure,  tliere  are 


numerous  others  which  do  not  .so.  The  disease  often 
begins  in  the  very  inmost  recesses  of  the  cellular 
texture  of  the  heads  of  the  bones  forming  the  large 
articulations,  such  as  the  hip,  knee,  ankle,  and  elbow- ; 
the  bones  become  diseased,  in  a manner  which  we 
shall  exi>lain  in  the  article  Joints,  sometimes  w ith  great 
pain  and  symptomatic  fever ; sometimes  with  very  little 
of  either,  at  least  in  the  beginning.  The  cartilages 
covering  the  ends  of  these  bones,  and  designed  for  the 
mobility  of  the  joints,  are  totally  destroyed;  the  epi- 
physes in  young  subjects  are  either  partially  or  totally 
separated  from  the  said  bones ; the  ligaments  of  the 
joints  are  so  thickened  and  spoiled  by  the  distemper, 
as  to  lose  all  natural  appearance,  and  become  quite 
unfit  for  all  the  purposes  for  which  they  were  intended : 
the  parts  appointed  for  the  secretion  of  the  synovia 
become  disteiniiered  in  like  manner ; all  these  together 
ftirnish  a large  quantity  of  stinking  sanious  matter, 
which  is  discharged  either  through  artificial  openings, 
made  for  the  purpose,  or  through  small  ulcerated  ones 
These  openings  commonly  lead  to  bones  which  are 
diseased  through  their  wliole  texture.  When  the  dis- 
ease has  got  into  this  state,  the  constant  pain,  irritation, 
and  discharge  bring  on  hectic  symptoms  of  the  most 
destructive  kind,  such  as  total  loss  of  appetite,  rest, 
and  strength,  profuse  night-sweats,  and  as  proAiso 
purgings,  which  foil  all  the  efforts  of  medicine,  and 
bring  the  patient  to  the  brink  of  destruction. 

It  is  an  incontestable  truth,  that  unless  amputation 
be  i)erfonned,  a patient  thus  situated  must  perish ; and 
it  is  equally  true,  that  numbers,  in  the  same  circum- 
stances, by  submitting  to  the  operation,  have  recovered 
vigorous  health. — See  Pott  on  Amputation.; 

It  is  a fact,  highly  important  to  be  known,  that  in 
these  cases  amputation  is  attended  with  more  success, 
when  performed  late,  than  when  undertaken  at  an 
early  period,  before  the  disea.se  has  made  great  ad- 
vances. This  is  particularly  fortunate,  as  it  affords 
time  for  giving  a fair  trial  to  such  remedies  as  are  best 
calculated  to  check  the  progress  of  the  disorder,  and 
obviate  all  necessity  for  the  operation. — (Encyclop^die 
M^thodique,  tom.  1,  p.  83.  See  Joints,  White  Swell- 
ing-) 

6.  Exostoses. 

Here  it  will  be  sufficient  merely  to  mention,  that 
this  disease  may  render  amputation  necessary,  when 
the  tumour  becomes  hurtful  to  the  health,  or  insup- 
ponable,  on  account  of  its  weight  or  other  circum- 
stances, and  cannot  be  removed  by  any  of  the  plans 
specified  in  the  article  Exostoses, 

7.  J^ecrosis. 

Another  distemper,  sometimes  producing  a necessity 
for  amputation,  is  necrosis,  or  the  death  of  the  whole, 
or  of  a very  considerable  part,  of  the  bones  of  the  ex- 
tremities, accompanied  with  such  extensive  abscesses, 
such  disease  of  the  soft  parts,  such  disorder  of  the 
constitution  and  prostration  of  strength,  that  every 
hope  of  a cure  being  effected  by  a natural  process  must 
be  renounced.  By  necrosis,  is  here  meant,  not  merely 
some  disease  which  destroys  the  surface  of  a bone,  but 
one  which  extends  its  depredations  to  the  whole  of  the 
internal  substance,  and  that  from  end  to  end.  Por- 
tions of  the  bones  die  from  a variety  of  causes,  such  as 
struma,  lues  venerea,  deep-seated  abscesses,  pressure, 
&c. ; and  bones  in  this  state,  when  properly  treated, 
often  exfoliate  and  cast  off  their  dead  parts.  But 
when  the  whole  substance  of  a bone  becomes  diseased 
from  end  to  end,  frequently  no  means  will  avail.  In 
the  words  of  Mr.  Pott,  the  use  of  the  scalpel,  the  rasp- 
atory, and  the  rugine,  for  ti.e  removal  of  the  diseased 
surface  of  bones ; of  the  trephine,  for  perforating  into 
the  internal  texture  of  the  diseased  bone,  and  of  exfo- 
liating applications  if  there  be  any  such  which  merit 
the  name  ),  will  prove  in  many  instances  unavailing, 
and,  unless  the  whole  bone  be  removed  by  amputation, 
the  patient  will  die.  Mr.  Pott’s  refutation  of  Bilguer, 
who  asserts  that  amputation  is  not  requisite  in  these 
instances,  is  a masterly  and  most  convincing  produc- 
tion ; but  I would  not  exactly  do  as  the  former  of  these 
writers  has  done,  and  positively  affirm,  that  every  ex- 
tensive necrosis,  affecting  a bone  nearly  its  whole 
length,  must  inevitably  require  amputation.  The  power 
of  nature  in  restoring  the  bones  is  sometimes  wonder- 
ful, as  will  be  hereafter  explained  — (See  Necrosis.  i 

The  very  late  period  at  wluch  an  extensive  necro- 


AMPUTATION. 


49 


sis  may  follow  the  injury  of  a bone,  and  make  am- 
putation necessary,  is  sometimes  almost  incredible. 
Schmucker  details  the  case  of  a captain  who  received 
a musket-ball  through  the  left  arm,  four  or  five  inches 
above  the  elbow.  The  bone  was  violently  struck,  but 
not  broken;  several  exfoliations  followed,  aiid  after 
more  than  a year’s  treatment,  the  patient  appeared  per- 
fectly cured.  For  nine  years  this  officer  remained 
well ; but  at  the  end  of  this  time,  being  on  a journey, 
he  was  attacked  with  pain  and  inflammation  in  the 
wounded  part,  and  febrile  symptoms.  He  hastened  to 
Berlin,  and  put  himself  under  the  care  of  Theden  and 
Sctoucker,  who  found  an  abscess  in  the  situation  of 
the  former  wound,  and  as  an  opening  had  been  already 
made,  the  bone  could  be  felt  stripped  of  its  periosteum. 
At  length  a piece  of  bone  exfoliated,  and  became  loose, 
precisely  under  the  brachial  artery,  which  interfered 
with  its  removal.  Notwithstanding  the  discharge,  the 
elbow-joint  continued  swelled,  and  there  were  red 
points  observable,  not  only  above  that  joint,  but  also 
over  the  heads  of  the  ulna  and  radius,  indicating  disease 
of  those  bones.  Amputation  was  therefore  performed 
by  Theden,  and  the  patient  got  quite  well.  On  examin- 
ing the  os  brachii,  a splinter  was  found,  three  inches  in 
length,  and  one  in  breadth,  its  edges  being  thin  and 
sharp,  while  its  centre  was  more  than  three  lines 
thick.  The  bone,  every  where  about  the  place  where 
it  had  been  struck  by  the  ball,  seemed  to  consist  of 
callus  without  any  medullary  cavity,  and  the  whole 
of  it  dotvn  to  the  elbow  had  no  periosteum.  The  car- 
tilage appeared  also  dispose,d  to  separate,  and  the  peri- 
osteum was  detached  from  the  radius  and  ulna,  which 
were  likewise  affected  with  necrosis.— (See  Schmuck- 
er’s  Vermischte  Chir.  Schriften,  b.  1,  p.  23,  ed.  2.) 

8.  Cancerous  and  other  inveterate  diseases,  such  as 

fungus  hcematodes. 

Cancerous,  inveterate  diseases,  and  malignant  incura- 
ble ulcers  on  the  limbs,  sometimes  render  amputation 
a matter  of  necessity.  In  treating  of  cancer,  we  shall 
remark  that  little  or  no  confidence  can  be  placed  either 
in  internal  or  any  kind  of  topical  remedies,  and  that 
there  is  nothing,  except  the  total  separation  of  the  part 
affected,  upon  which  any  rational  hopes  of  cure  can  be 
built.  Cancer  is  not  frequently  seen  on  the  extremi- 
ties. Every  man  of  experience,  however,  must  occa- 
sionally have  seen,  in  this  situation,  if  not  actually 
cancer,  diseases  quite  as  intractable,  and  which  cannot 
be  cured  except  by  removing  the  affected  part.  This 
may  often  be  accomplished  without  cutting  off  the 
whole  limb.  But  when  the  disease  has  spread  beyond 
certain  bounds,  amputation  above  the  part  affected  is 
the  only  thing  to  which  recourse  can  be  had  with  any 
hope  of  success.  Sometimes,  when  the  operation  has 
been  delayed  too  long,  even  amputation  itself  will  not 
effect  a cure.  In  a few  cases  of  fungus  haematodes, 
the  operation  has  succeeded,  however,  after  the  dis- 
esise  had  reappeared,  and  a cure  had  been  seemingly 
achieved  by  the  excision  of  the  diseased  parts.  Yet, 
from  what  I have  seen  of  fungus  hajmatodes,  I should 
much  doubt  whether  the  benefit  obtained  by  amputation 
would  be  lasting ; as  when  this  disease  shows  itself 
only  externally,  internal  organs  are  mostly  at  the  same 
time  similarly  affected. — (See  Fungus  Hasrnatodes.) 

Besides  cancerous,  there  are  other  ulcers,  which  may 
render  amputation  indispensable.  Thus,  when  an  ex- 
tensive ulcer,  of  any  sort  whatsoever,  is  evidently  im- 
pairing the  health ; when,  instead  of  yielding  to  reme- 
dies, it  becomes  larger  and  more  inveterate ; when,  in 
short,  it  puts  life  in  imminent  danger;  amputation 
should  be  advised. 

9.  VarioxLS  tumours. 

That  there  are  numerous  swellings,  which  destroy 
the  texture  of  the  limbs,  rendering  them  useless ; caus- 
ing dreadful  sufferings,  and  bringing  the  patients  into 
the  most  debilitated  state,  no  man  of  observation  can 
fail  to  have  seen.  When  such  tumours  can  neither  be 
dispersed  nor  cut  out  with  safety,  amputation  of  the 
limb  is  the  only  resource. 

Mr.  Pott  has  particularly  described  a tumour  affect- 
ing the  leg,  for  which  the  operation  is  sometimes  re- 
quisite. It  has  its  seat  in  the  middle  of  the  calf  of  the 
leg,  or  rather  more  towards  its  upper  i)art,  under  the 
gastrocnemius  and  soleus  muscles.  It  begins  by  a 
small,  hard,  deep-seated  swelling,  sometimes  very 
painful,  sometimes  but  little  so,  and  only  hindering  the 

VoL.  l.-U 


patient’s  exercises.  It  does  not  alter  the  natural  colour 
of  the  skin,  at  least  until  it  has  attained  a considerable 
size.  It  enlarges  gradually,  does  not  soften  as  it  en- 
larges, but  continues  through  the  greatest  part  of  it  in- 
compressibly  hard,  and  when  it  is  got  to  a large  size^ 
it  seems  to  contain  a fluid,  which  may  be  felt  towards 
the  bottom,  or  resting,  as  it  were,  on  the  back  part  of 
the  bones.  If  an  opening  be  made  for  the  discharge  of 
this  fluid,  it  must  be  made  very  deep,  and  through  a 
strangely  distempered  mass.  This  fluid  is  generally 
small  in  quantity,  and  consists  of  a sanies  mixed  with 
grumous  blood ; the  discharge  of  it  produces  very  little 
diminution  of  the  tumour,  and  very  high  symptoms  of 
irritation  and  inflammation  come  on,  and,  advancing 
with  great  rapidity,  and  most  exquisite  pain,  very  soon 
destroy  the  patient,  either  by  the  fever,  which  is  high 
and  unremitting,  or  by  a mortification  of  the  whole 
leg.  If  amputation  has  not  been  performed,  and  the 
patient  dies  after  the  tumour  has  been  freely  opened* 
the  mortified  and  putrid  state  of  the  parts  prevents  all 
satisfactory  examination;  but  if  the  limb  was  re^ 
moved,  without  any  previous  operation  (and  which 
Mr.  Fott,  in  his  experience,  found  to  be  the  only  way 
of -preserving  the  patient’s  life),  the  posterior  tibial  ar- 
tery will  be  found  to  be  enlarged,  distempered,  and 
burst ; the  muscles  of  the  calf  to  have  been  converted 
into  a strangely  morbid  mass ; and  the  posterior  part 
of  both  the  tibia  and  fibula  more  or  less  carious.-- 
(Pott  on  Amputation.) 

It  seems  only  necessary  to  adduce  another  species 
of  tumour  to  illustrate  the  necessity  of  amputation^ 
The  following  case  is  related  by  Mr.  Abernethy.  A 
woman  was  admitted  into  St.  Bartholomew’s  Hospital 
with  a hard  tumour  in  the  ham.  It  was  about  four 
inches  in  length,  and  three  in  breadth.  She  had  also  a 
tumour  in  front  of  the  thigh,  a little  above  the  patella* 
of  less  size  and  hardness.  The  tumour  in  the  ham,  by 
its  pressure  on  the  nerves  and  vessels,  had  greatly  les- 
sened the  sensibility,  and  obstructed  the  circulation  of 
the  leg,  so  that  the  limb  was  very  cedematous.  As  it 
appeared  impossible  to  remove  this  tumour,  and  its  ori 
gin  and  connexions  were  unknown,  amputation  was 
performed.  On  examining  the  amputated  limb,  the 
tumour  in  the  ham  could  only  be  divided  with  a saw. 
Several  slices  were  taken  out  of  it  by  this  means,  and 
appeared  to  consist  of  a coagulable  and  vascular  sub- 
stance, in  the  interstices  of  which  a great  deal  of  bony 
matter  was  deposited.  The  remainder  of  the  tumour 
was  macerated  and  dried,  and  it  appeared  to  be  formed 
of  an  irregular  and  compact  deposition  of  the  earth  of 
bone.  The  tumour  on  the  front  of  the  thigh  was  of 
the  same  nature  as  that  of  the  ham,  but  contained  so 
little  lime,  that  it  could  be  cut  with  a knife.  The 
thigh-bone  was  not  at  all  diseased,  which  is  mentioned, 
because,  when  bony  matter  is  deposited  in  a limb,  it 
generally  arises  from  the  disease  of  a bone. — (Surgical 
Observations,  1804.) 

Before  the  late  facts  and  improvements  relative  to 
the  treatment  of  aneurisms,  these  cases,  on  the  extremi- 
ties, were  generally  set  down  as  requiring  amputation. 
Even  Mr.  Pott,  and  J.  L.  Petit,  wrote  in  recommenda- 
tion of  such  practice,  and  their  observations  on  this 
subject  are  among  .the  few  parts  of  their  writings 
which  the  enlargement  of  surgical  knowledge,  since 
their  time,  has  rendered  objectionable.  The  surgeon 
to  whom  the  honour  of  first  correcting  this  erroneous 
doctrine  belongs  is  A.  N.  Guenault,  who  opposed  the 
advice  delivered  on  this  subject  by  Petit. — (Haller, 
Disp.  Chir.  vol.  5,  p.  155.) 

I shall  conclude  these  remarks  on  the  cases  requir* 
ing  amputation,  with  advising  surgeons  never  to  un- 
dertake this  serious  operation,  without  consulting  the 
opinions  of  other  professional  men,  whenever  their  ad- 
vice can  be  obtained.  The  best  operators  are  often  de- 
ficient in  that  invaluable  kind  of  judgment  by  which 
the  cases  absolutely  demanding  amputation  are  dis- 
criminated firnm  others,  in  which  the  operation  may  be 
wisely  postponed,  and  a chance  taken  of  preserving 
the  limb. 

Historical  remarks  on  Jlmpvtation. 

The  history  of  amputation  evinces  that  the  steps  of 
surgery  to  perfection  are  slow,  and  that  they  even 
sometimes  deviate  from  the  straight  path,  though  upon 
all  essential  points  no  retrogration  has  ever  taken 
place.  Here  nature  has  acted  as  the  guide,  and  the 
surgeon’s  chief  merit  has  con.sisted  in  obeying  the 


50 


AMPUTATION. 


liinls  which  site  herself  has  thrown  out.  As  already 
mentioned,  r he  following  natural  occurren:e,  no  doubt, 
was  one  of  the  circumstances  which  first  led  to  the 
bold  preiclice  of  amputation  ; in  consequence  of  dis- 
ease and  grievous  local  injuries,  whole  limbs  were 
sometimes  seized  with  mortification.  In  the  majority 
of  cases,  this  was  attended  with  so  much  constitutional 
disturbance  that  the  patients  died ; byt  in  other  less 
numerous  instances,  the  mortification  was  confined  to 
the  part ; suppuration  was  established  between  the 
dead  and  living  parts ; the  whole  of  the  mortified 
limb  fell  oflT;  the  suppurating  surfaces  healed  up  ; and 
thus,  by  the  powers  of  nature,  the  patients  were  re- 
store to  health.  Here  was  clearly  proved  the  possi- 
bility of  recovery,  notwithstanding  the  loss  of  a limb. 
The  surgeon,  as  Brunninghausen  remarks,  viewed 
■with  surprise  this  course  of  nature,  and  hardly  ven- 
tured to  promote  it  by  the  feeble  means  formerly  em- 
ployed, which,  liowever,  were  not  really  needed.  But 
as  the  mortified  i)arts.  previously  to  their  detachment, 
caused  great  annoyance  hy  their  fetor,  a surgical  at- 
tempt was  at  length  made  to  get  rid  of  them  ; in  doing 
which  the  knife  was  always  kept  from  touching  the 
living  flesh,  on  account  of  a well-grounded  fear  of 
bleeding,  for  the  suppression  of  which  no  effectual 
methods  were  known.  Such  was  the  practice  that 
prevailed  from  Hippocrates  down  to  Celsus. — .Erfahr. 
dec.  iiher  die  Arnp.  p.  14.)  “ Partes  autem  corporis, 

qu®  infra  temiinos  denigrationis  fuerint,  ubi  jam  pror- 
sus  emortu®  fuerint  et  dolorem  non  senserint,  ad  ar- 
ticulos  auferend®  ea  cautione  ut  ne  vuluus  inferatur,” 
&c. — (De  Articulis,  sect.  6.)  Here  we  find  that  the 
earliest  mode  of  anipumtion  was  that  done  at  the  joints. 

A.  C.  Celsus,  who  lived  in  the  reign  of  Tiberius,  and 
whose  book,  Ue  Re  Medica,  should  be  read  by  every 
surgeon,  has  lefl  us  a short  description  of  the  mode 
of  amputating  gangrenous  limbs. — 'Lib.  7,  c.  33.)  It 
has  been  often  remarked,  that  Celsus  has  left  no  in- 
structions for  securing  the  divided  blood-vessels  ; but 
it  has  not  been  comnionly  noticed,  that  in  his  chapter 
on  wounds  he  directs  us  to  stop  hemorrhage  by  taking 
hold  of  the  vessels,  then  tj-ing  them  in  two  places  and 
dividing  the  intermediate  portion.  If  this  measure 
cannot  be  adopted,  he  advises  the  use  of  a cauterizing 
iron.  Several  hints  are  to  be  met  with  in  the  writings 
of  Celsus,  ft-oin  which  it  may  be  inferred  that  the  liga- 
ture of  bleeding  vessels  was  sometimes  practised  at 
the  early  age  in  which  he  lived ; and  this  supjiosi- 
tion  is  strengthened  by  a fragment  of  Archigenes  pre- 
served by  Cocchius,  on  the  subject  of  amputation, 
where  he  speaks  of  tying  or  sewing  the  blood-vessels. 
VVe  are  not,  however,  in  po.ssession  of  all  the  w ritings 
of  medical  authors  prior  to  the  time  of  Galen,  and  must 
therefore  remain  in  doubt  upon  this  point. — (Rees's  Cy- 
clop®dia,  art.  Amputation.) 

This  anonymous  writer  argues,  therefore,  with  some 
appearance  of  reason,  that  if  amputation  often  proved 
fatal  in  the  days  of  Celsus,  “ s®pe  in  ipso  opere,”  as 
the  expression  is,  it  was  owing  to  the  want  of  some 
efficacious  method  of  compressing  the  blood-vessels 
during  the  operation  itself ; for  whether  the  use  of  the 
ligature  were  known  to  the  ancients  or  not,  no  doubt 
exists  about  their  ignorance  of  the.tourniquet. 

But  admitting  that  the  ancients  were  not  altogether 
uninformed  of  the  plan  of  tying  arteries,  it  caimot  be 
credited  that  they  adopted  the  practice  to  any  extent ; 
for  if  they  had,  they  would  not  have  continued  so  par- 
tial to  the  cautery,  boiling  oils,  and  a farrago  of  as- 
tringent applications.  They  would  also  never  have 
had  recourse  to  the  barbarous  method  of  cutting  the 
flesh  with  a red-hot  knife,  with  the  view'  of  stopping 
the  hemorrhage  by  converting  the  whole  surface  of  the 
stump  into  an  eschar.  Painful  in  its  execution  and 
horrid  in  its  consequence  as  this  burning  operation 
was,  it  seldom  proved  a lasting  antidote  to  the  bleed- 
ing, which  generally  came  on  in  a fatal  manner,  as  soon 
as  the  sloughs  were  loose.  On  this  part  of  the  sub- 
ject my  own  ideas  fully  agree  with  those  of  a distin- 
guished foreign  surgeon,  who  says,  that  although  the 
document  left  us  may  prove  that  the  ligature  was  ^own 
to  the  ancients,  and  employed  in  cases  of  aneurisms 
and  wounded  blood-vessels,  nay,  that  the  arteries  were 
secured  with  a needle  and  ligature ; yet  the  practice 
could  not  have  been  extended  to  the  operation  of  ampu- 
tation, since,  with  the  custom  of  making  the  incisions  in 
the  dead  parts,  the  method  scarcely  admitted  of  being 
put  in  execution.  —(Briinninghausen,  Erfalir.  fiber  die 


Amput.  p.  29.)  Ambrose  Pare,  therefore,  seems  to  me 
.to  deserve  as  much  praise  for  the  introduction  of  the 
ligature  into  common  use,  as  if  no  allusion  to  this  me- 
thod whatsoever  had  existed  in  the  writings  of  Celsus 
and  other  ancients. 

The  diflerent  parts  of  the  operation  meriting  parti- 
cular attention  are,  the  choice  of  the  part  of  the  tiq)b 
where  the  incisions  are  to  begin ; the  measures  for 
guarding  against  bleeding  during  the  operation ; the 
dinsion  of  the  integuments,  muscles,  and  bones,  which 
is  to  be  accomplished  in  such  a manner  that  the  whole 
surface  of  the  stump  will  afterward  be  covered  with 
skin ; tying  the  arteries,  which  should  be  done  with- 
out including  the  nerves  or  any  other  adjacent  part ; 
jilacing  the  integuments  in  a projier  position  after  the 
oiieration;  and,  finally,  the  subsequent  treatment  of 
the  w oiiiid. 

At  the  period  of  making  the  incision,  the  ancients 
confenied  themselves  with  having  the  skin  forcibly 
drawn  upwards  by  an  a.ssistant ; they  next  divided, 
with  one  sweep  of  the  knife,  the  integuments  and  flesh 
down  to  the  bone,  and  afterward  sawed  the  bone  on  a 
level  with  the  soft  parts,  which  were  drawn  upwards, 
Celsus  considered  it  better  to  let  the  incision  encroach 
upon  the  living  flesh  than  leave  any  of  the  diseased 
parts  behind.  “ Et  potius  ex  sana  parte  aliquid  exci 
datur,  quam  ex  ®gra  relinquatur.” — (De  Medicina,  lib. 
7,  c.  33.) 

It  appears,  how'ever,  that  his  views  extended  farther 
than  those  of  most  of  his  contemporaries,  and  even  his 
followers,  almost  downto  modern  times.  After  cutting 
the  muscles  down  to  the  bone,  he  says  that  the  flesh 
should  be  reflected  and  detached  underneath  with  a 
scalpel,  in  order  to  denude  a portion  of  the  bone,  which 
is  then  to  be  sawn  as  near  as  possible  to  the*  healthy 
flesh  which  remains  adherent.  He  states,  that  when 
this  plan  is  pursued,  the  skin  around  the  wound  will  be 
.so  loose  that  it  can  almost  be  made  to  cover  the  extre- 
mity of  the  bone.  It  is  to  be  lamented  that  this  ad- 
vice, inculcated  by  Celsus,  should  not  have  been  com- 
prehended, or  that  it  should  have  been  so  neglected  as 
to  stand  in  need,  as  it  were,  of  a new  discoverer,  and 
that  a suggestion  of  such  importance  should  have  re- 
mained so  long  useless.  But  the  fact  is,  hemorrhage 
formerly  rendered  amputation  so  dangerous,  that  the 
ancient  surgeons  could  not  devote  much  attention  to 
any  thing  else  in  the  operation,  and  practitioners  am- 
putated so  seldom,  that  we  read  in  Albucasis  that  he 
positively  refused  to  cut  oflf  a person’s  hand,  lest  a fatal 
hemorrhage  should  ensue,  and  the  patient  did  it  him- 
self and  recovered.  Over  that  part  of  the  stump  which 
the  small  quantity  of  preserved  skin  would  not  cover, 
Celsus  recommended  compresses,  and  a sponge  dipped 
in  vinegar  to  be  laid. — fUe  Re  Medica,  lib.  7,  c.  33.) 

Archigenes,  who  was  bom  at  Apamia,  in  Syria,  was 
the  disciple  of  Aga'.hinus,  and  physician  to  Philip,  king 
of  that  countr>'.  He  repaired  to  Rome,  where  he  prac- 
tised physic  and  surgery  in  the  reign  of  the  emperor 
Trajan,  about  108  years  after  the  birth  of  Christ. — (Por- 
tal, Hist,  de  I’Anatomie  et  de  la  Chirurgie,  vol.  1,  p.  61.) 
In  the  history  of  amputation  the  name  of  Archigenes  is 
conspicuous,  not  only  because  he  is  supposed  to  have 
been  acquainted  with  the  use  of  the  needle  and  ligature 
for  the  stoppage  of  bleeding,  but  because  his  descrip- 
tion of  the  operation  is  in  some  respects  more  minute 
than  that  of  Celsus.  For  the  hindrance  of  loss  of 
blood  in  the  operation,  says  Sprengel  (Geschichte  der 
Chir.  b.  1,  p.  404,  Halle,  1805),  he  first  of  all  tied  up  the 
vessels,  and  often  the  whole  limb,  over  which  he  also 
sprinkled  cold  water.  The  integuments  w'ere  then 
drawn  upwards  from  the  wound,  and  confined  there 
With  a band ; and  after  the  limb  was  off,  he  cauterized 
the  stump,  and  applied  folded  compresses.  The  band 
was  now  loosened  and  a mixture  of  leeks  and  salt  laid 
on  the  stump,  to  which  were  also  applied  oil  and  ce- 
rate.—(Nicet,  Coll.  Chir.  p.  155.)  Such  was  likewise 
the  practice  of  Heliodorus,  who  thus  early  made  objec- 
tions to  the  plan  of  cutting  off  a limb  by  a single  stroke, 
a proposal  that  was  renewed  in  far  later  days.  The 
same  author  has  also  spoken  of  amputating  at  the 
joints ; a method  of  which  he  disapproves. — (Nicet, 
Coll.  Chir.  p.  155.)  However,  Galen  entertained  a fa- 
vourable opinion  of  it,  on  account  of  its  safety  and  ex- 
pedition.— (Comm.  4,  in  lib.  de  artic.  p.  650.)  Galen’s 
precepts  concerning  amputation  are,  upon  the  whole, 
very  like  those  given  by  Hippocrates ; for  he  directs 
only  dead  parts  to  be  cut,  and  the  stump  to  be  caute- 


AMPUTATION* 


51 


fized.— (i)e  Arte  Curativi  ad  GlaUconem,  lib.  2.)  By 
dll  the  old  writers,  amputation  was  entirely  restricted 
to  cases  of  mortification ; farther  they  Avere  afraid  to 
, go ; and  this  precept,  and  all  the  other  doctrines  of 
Galen,  may  be  said  to  have  been  the  guide  of  the  whole 
surgical  profession  for  full  fourteen  centuries. 

The  timid  Arabians  were  not  partial  to  amputation, 
and  even  in  cases  of  mortification  generally  preferred  a 
farrago  of  Useless  applications,  like  Armenian  bole,  (fee. 
Paulus  .a^ginet^  like  Galen,  deviated  from  Celsus’s 
good  rule  of  making  the  incisions  in  the  healthy  parts, 
and  only  approved  of  making  the  requisite  division  near 
them. — (Lib.  4,  c.  19,  p.  140.)  Avicenna,  however,  re- 
peated the  directions  left  by  the  Greek  writers  (Can. 
lib.  4.  Fen.  3,  tr.  1,  p.  454),  and  Abu’l  Kasem  proposed 
doing  the  operation  with  a red-hot  knife. — (Chirurg.  lib. 
1,  sect.  52,  p.  99.)  In  the  middle  ages,  little  was  done 
for  the  improvement  of  amputation.  In  the  14th  cen- 
tury gunpowder  Was  invented,  and  soon  applied  to  the 
purposes  of  war,  so  that  an  abundance  of  cases  must 
have  presented  themselves  in  which  the  wise  maxim 
of  not  deferring  amputation  until  mortification  had 
come  on,  but  of  preventing  the  mischief  by  the  opera- 
tion, ought  to  have  struck  an  intelligent  surgeon.  One 
might  also  expect  that  practitioners  would  now  have 
been  led  to  make  the  incisions  in  the  sound  flesh.  Unfor- 
tunately, the  invention  of  gunpowder  and  its  immediate 
consequences  in  surgery,  happened  at  a period  when 
practitioners  were  ill  qualified  to  profit  by  the  new  les- 
sons of  experience  set  before  them.  The  writings  of 
their  predecessors  furnished  them  with  no  directions 
how  they  ought  to  act,  and  they  were  themselves  too 
much  confounded  at  the  sight  of  the  mischief  for  which 
they  were  consulted,  to  be  able  to  form  any  correct 
opinion  about  causes  and  effects.  Their  first  idea  was, 
that  the  terrible  symptoms  proceeded  from  the  parts  be- 
ing actually  burned,  and  they  afterward  inclined  to 
the  belief  that  gun-shot  wounds  were  poisoned. 
Hence  the  most  absurd  modes  of  treatment  were  insti- 
tuted, and,  as  Briinninghausen  expresses  himself,  hu- 
man nature  groaned  under  a new  evil,  for  which  there 
were  for  some  time  no  true  plans  of  relief. — (Erfahr.  &c. 
fiber  die  Amp.  c.  19.)  This  deplorable  state  was  the 
natural  result  of  the  depression  of  science  in  general, 
and  of  the  healing  art  in  particular,  in  the  days  to  which 
I now  refer.  In  these  middle  ages,  as  they  are  called, 
the  population  of  all  Europe  was  plunged  in  the  deep- 
est ignorance ; and  whatever  little  knowledge  remained, 
either  of  the  arts  or  languages,  was  monopolized  by  the 
priesthood,  the  physicians  of  those  times,  who,  instead 
of  studying  the  volume  of  nature,  wasted  most  of  their 
time  in  discussing  the  doctrines  of  Galen.  Surgery 
itself  sunk  to  the  lowest  ebb,  as  may  be  well  conceived 
from  the  decrees  issued  at  Rheims  by  Pope  Boniface 
the  Eighth,  forbidding  any  of  the  clergy  to  do  any  thing 
themselves  which  drew  blood ; and  of  course  all  the 
operative  part  of  surgery,  that  which  required  the  most 
skill  and  science,  was  transferred  to  a set  of  illiterate, 
low-bred  mechanics,  far  inferior  to  the  worst  country 
farriers  of  modern  times.  Yet  the  clergy,  who  were 
here  scrupulously  averse  to  soiling  their  own  hands 
with  blood,  or  hurting  their  own  tender  feelings  by 
Alewing  the  agony  of  their  fellow-creatures  submitted 
to  operations,  had  no  hesitation  in  taking  the  chief  emo- 
luments and  honours  of  the  profession,  or  in  turning 
over  these  poor  sufferers  to  men  more  qualified  to  tor- 
ture and  murder  than  to  give  relief;  and,  what  nearly 
staggers  all  credulity,  the  same  professors  of  Christian- 
ity, who  shuddered  to  spill  a drop  of  blood  themselves 
on  a proper  occasion,  as  Haller  observes,  eagerly  had 
a hand,  and  acted  an  important  part,  in  every  sangui- 
nary war,  where  it  was  jmssible  for  them  to  interfere. 
In  these  dismal  days  of  surgery,  the  advice  delivered 
by  Celsus  was  renewed  by  Theodoricus,  who  used  to 
administer  opium  and  hemlock  previously  to  the  ope- 
ration, for  the  purpose  of  rendering  the  patient  less 
sensible  to  pain,  and  afterward  vinegar  and  fennel 
were  given,  with  the  view  of  dispersing  the  intoxica- 
ting effects  of  the  pre<;eding  medicines. — (Chirurg.  lib. 
3,  c.  10.) 

The  renowned  Guido  di  Cauliaco  was  the  inventor  of 
the  plan  of  taking  oiT  limbs  without  any  bloodshed. 
It  is  better,  says  he,  for  the  limb  to  drop  off  than  be 
cur  off ; as  in  the  latter  circumstance  the  conduct  of  the 
surgeon  is  viewed  with  spite,  because  it  is  supposed 
that  the  part  might  have  been  saved.  Guido’s  practice 
eoiwisted  in  covering  the  whole  membrane  with  pitch- 


plaster,  and  applying  round  one  of  the  joints  so  tight  a 
band,  that  the  parts  below  the  constriction  ultimately 
dropped  olf.— (Chirurg.  t^|[|6,  Doctr.  1,  cap.  8.)  As 
Sprengel  next  observes,  the  method  of  amputating  sug- 
gested by  Celsus  was  again  revived  by  Gersdorfj  who 
after  the  operation  not  only  drew  down  over  the  stump 
the  skin  which  had  been  retracted,  but  applied  a hog’s 
or  bullock’s  bladder  over  the  stump,  so  as  to  rend'ir  all 
burning  and  stitching  of  the  parts  needless. — (Feldbuch 
der  Wundarzn.  fol.  63.)  Bartholomew  Maggi  also  en- 
deavoured to  preserve  a considerable  flap  of  integu- 
ments for  covering  the  stump. — (De  Vulner.  bombard, 
et  sclopet.  4to.  Bonon.  1552 ; see  Sprengel’s  Geschichte 
der  Chirurgie,  p.  404.  406,  8vo.  Halle,  1805.) 

At  length,  in  the  15th  century,  the  revival  of  learning 
occurred  first  in  Italy.  Men  now  began  to  think  for 
themselves  again,  and  physicians  turned  from  compila- 
tions and  scholastic  nonsense  to  the  consideration  of 
nature.  Anatomy  was  cultivated  with  great  ardour* 
and  made  brilliant  progress  under  the  eminent  charac- 
ters of  the  time : De  la  Torre,  Berengarius  Carpi,  Ve- 
salius,  Fallopius,  Eustachius,  and  others,  who  were 
also  for  the  most  part  very  distinguished  surgeons. 
“ In  Italia  scientiarum  matre  medici  se  nunquam  chi- 
rurgia  abdicarunt.  Seculo  15  et  16,  professores  medici 
academiae  Bononiensis,  Patavinae,  et  aliarum  in  Italia 
illustrium  scholarum  et  manu  curaverunt,  et  consilio, 
et  inter  istos  viros  summi  chirurgi  exstiterunt.’  — (Hal- 
ler, Bibl.  Chir.  b.  1,  p.  161.)  Practitioners  now  ven- 
tured to  amputate  limbs  in  the  sound  part  for  other 
incurable  diseases  besides  mortifications ; but  the  art 
of  stopping  hemorrhage  after  the  operation  continued 
imperfect.  Though  the  method  of  applying  the  ligature 
in  cases  of  wounded  arteries  and  aneurisms  was  under- 
stood, yet  from  some  unaccountable  causes  the  practice 
was  never  thought  of  in  amputations.  Even  Fallopius 
knew  of  no  other  means  for  stopping  the  bleeding  but 
the  cautery. — (De  Turn,  praetern.  p.  665.)  On  the  whole, 
the  stoppage  of  bleeding  was  not  attended  with  a de- 
gree of  success  proportionate  to  the  advances  of  the 
healing  art  in  general.  Straps,  bands,  and  compresses 
were  indeed  put  round  the  member;  but  as  the  cir- 
culation of  the  blood  was  not  yet  correctly  known, 
they  were  not  applied  in  the  proper  places,  being  ar- 
ranged either  close  to  the  wound,  or  several  of  them 
put  at  random  round  the  limb.  The  effects  of  such 
immoderately  tight,  long-continued  constriction  could 
be  nothing  less  than  gangrene ; and  hence  the  actual 
cautery  was  still  chiefly  employed,  The  other  means 
for  suppressing  hemorrhage  scarcely  merit  the  name. 
Terrified  at  the  insecurity  and  ill  consequences  of  such 
expedients,  J.  de  Vigo  (Practica  in  Chirurgia  Copiosa, 
491,  Romae,  1514),  and  Fabricius  ab  Aquapendente  (Op. 
Chir.  Venet.  1619),  disapproved  of  amputating  in  the 
sound  flesh,  and  returned  to  the  principle  inculcated 
by  the  ancients,  of  making  the  incision  in  the  mortified 
parts.  Others  endeavoured  to  lessen  the  peril  of  the 
bleeding  by  the  rapidity  with  which  the  limb  was  re- 
moved, and  the  instantaneous  application  of  the  cau- 
tery. For  this  purpose  L.  Botalli  invented  a sort  of 
guillotine,  by  means  of  which  a member  was  severed 
from  the  body  in  an  instant  (De  Ciirandis  vulneribus 
sclopetorum,  Lugd.  1560),  while  others  laid  a sharp  axe 
upon  the  limb,  and  effected  the  dismemberment  by  the 
blow  of  a wooden  mallet.  An  example  of  this  barba- 
rous practice  is  recorded  by  Fabricius  Hildanus,  called 
by  his  countrymen  the  patriarch  and  ornament  of  the 
German  surgery.  In  consequence  of  this  fear  of  bleed- 
ing, before  he  knew  of  the  use  of  the  ligature,  he  was 
himself  accustomed  to  amputate  with  a red-hot  knife, 
the  representation  of  which  is  given  in  his  Avork. — (De 
Gangraena  et  Sphacelo,  Op. ) Hildanus  became  a better 
surgeon,  however,  as  he  grew  older,  and  in  the  end 
partly  contributed  to  the  improvement  of  amputation, 
inasmuch  as  he  made  the  incisions  completely  in  the 
sound  parts,  and  adopted  the  method  of  tying  the  arte- 
ries, as  then  recently  proposed  by  Pare ; but,  unfortu- 
nately, in  weak  persons  he  still  preferred  the  actual  cau- 
tery to  the  ligature. — (Op.  p.  814.)  One  of  his  inven- 
tions was  a linen  bag  or  cap  for  the  stump ; and  a sort 
of  retractor  for  holding  back  the  muscles.  According 
to  Sprengel  (Geschichte  der  Chir.  b.  1,  p.  407),  his  ob- 
serA’^atioiis  on  the  pain  folloAving  the  operation  are  in- 
teresting,— (Op.  p.  807.  814.)  ^ . 

Ambrose  Part;,  a French  surgeon,  who  flourished  in 
the  16th  century  (Opera,  Parisiis,  1582),  and  to  whom 
I have  already  alluded,  made  some  beneficial  innova- 


U.  OF  iUL  ua 


AMPUTATION. 


A2 

tions  with  regard  to  the  ojicration  of  amputation.  It  is 
to  his  industry,  good  sense,  and  skill  that  we  are  chiefly 
indebted  for  the  abolition  ^ cauterizing  instruments, 
and  the  general  use  of  a needle  and  ligature  for  the 
suppression  of  the  bleeding.— (Lib.  6,  c.  28,  p.  224.) 

An  anonymous  writer  has  given  the  following  ac- 
count of  the  practice  and  opinions  of  this  distingui-shed 
su.^,on  in  relation  to  amputation.  “ Pare  recommended 
to  cu  off  the  whole  of  the  gangrenous  part  if  the  limb 
be  mortified,  but  to  encroach  as  little  as  possible  upon 
the  living  flesh.  At  the  same  time,  he  laid  It  down  as 
a rule  not  to  leave  a very  long  stump  to  an  amputated 
leg ; because  the  patient  could  more  conveniently  make 
use  of  a wooden  leg,  with  the  stump  only  five  finger- 
breadths  long  below  the  knee,  than  if  much  more  of  the 
flesh  were  to  be  preserved.  In  the  arm,  however,  he 
left  the  whole  of  the  living  and  healthy  portion  of  the 
member,  only  separating  the  diseased  part  from  the 
sound. 

In  i»reparing  for  amputation,  he  directs  the  skin  and 
muscles  to  be  drawn  npward.s,  and  bound  tight  with  a 
broad  bandage  a little  above  the  jiart  where  the  incision 
is  to  be  made.  This  fillet  was  intended  to  answer  a 
threefold  purpose : — 1st,  to  afibrd  a quantity  of  flesh  for 
covering  the  bone,  and  facilitating  the  cure;  2dly,  to 
close  the  e.\tremities  of  the  divided  blood-vessels;  3dly, 
to  dull  the  patient’s  feelings  by  jiressure  on  the  subja- 
cent nerves.  When  this  linn  ligature  has  been  applied. 
Pare  directs  an  incision  to  be  made  down  to  the  bone, 
either  wth  a common  large  scalfiel  or  a curved  knife. 
Then  with  a smaller  curved  knife  we  are  carel'ull  v to 
divide  the  muscle  or  ligatneiu  remaining  between  the 
bones  of  the  forearm  or  leg;  after  which  we  may 
proceed  to  saw  oft’  the  bone  as  high  as  possible,  and  to 
remove  the  asperities  occasioned  by  the  saw. 

With  the  assistance  of  a curved  pair  of  forceps  he 
drew  out  the  extremities  of  the  bleeding  arteries,  either 
by  themselves  alone,  or  with  some  portion  of  the  sur- 
rounding flesh,  to  be  firmly  tied  with  a strong  double 
thread.  He  now  loosened  hia  bandage,  brought  toge- 
ther the  lips  of  the  wmund  over  the  face  of  the  stump, 
and  kept  them  as  clo.se  :ls  he  could  without  actual 
stretching,  by  means  of  four  stitches  or  sutures.  If 
the  larger  tied  vessels  should  accidently  become  loose, 
he  desires  the  ligature  or  bandage  to  be  again  passed 
round  the  limb  ; or  el.se,  what  is  better,  to  let  an  assist- 
ant grasp  the  limb  firm  with  both  hands,  and  press  with 
his  fingers  over  the  course  of  the  bleeding  ve.ssel,  so  as 
to  stop  the  hemorrhage  ; then  with  a square  edged  nee- 
dle, about  four  inches  long,  and  a thread  four  times 
doubled,  the  surgeon  must  .secure  the  artery  in  the  fol- 
lowing manner.  'Phrust  the  armed  needle  into  the 
outside  of  the  flesh,  half  a finger’s  breath  from  the  ves- 
sel which  bleeds,  and  bring  it  out  at  tlie  same  distance 
from  the  bleeding  orifice;  then  surround  tl»e  vessel 
with  the  ligature,  pass  it  back  again  to  within  one  nn- 
ger’s  breadth  of  the  place  where  it  first  entered,  and  tie 
a fast  knot  upon  a folded  slip  of  linen  rag  to  prevent  its 
hurting  the  flesh.  By  this  means,  says  Par6,  the  ori- 
fice of  the  artery  will  be  agglutinated  to  the  adjoining 
flesh  so  firmly,  as  not  to  yield  one  drop  of  blood ; but  if 
the  hemorrhage  were  not  considerable,  he  contented 
himself  with  the  application  of  astringent  powders,  <fec. 

Thus  did  this  famous  surgeon  endeavour,  by  his  sin- 
gle example  and  precepts,  to  exclude  the  barbarous  use 
of  hot  irons  in  amputation.  He  says,  he  knew  not  of 
any  such  practice  among  the  old  surgeons  ; except  that 
Galen  recommended  us  to  tie  bleeding  vessels  towards 
their  origin  in  accidental  wounds  :.and  he  thought  pro- 
per to  do  the  same  in  cases  of  amputation.  But  in  an 
apology  at  the  end  of  his  book,  Pare  has  iiuoted  in  his 
own  defence  a dozen  authors  who  employed  or  recom- 
mended the  ligature  before  him ; and  he  might  have 
cited  many  more. 

From  the  statement  we  have  here  given,  it  may  be 
seen  how  far  the  best  writers  of  almost  every  country 
have  erred  in  ascribing  the  original  invention  of  tying 
arteries  to  Ambrose  Pare.  Great  merit,  indeed,  was 
due  to  him  for  the  part  he  took  in  extending,  and  even 
reviving,  this  incomparable  practice : nay,  it  is  not  cer- 
tain whether  any  one  before  him  had  ever  applied 
the  needle  and  ligature  in  similar  cases,  that  is,  after 
amputation  ; but  how  very  wide  of  the  truth  Mr.  John 
Bell’s  recent  account  of  this  matter  is,  will  appear  to 
every  person  who  will  inquire  into  the  facts  them- 
selves ; for  not  only  were  ligatures  and  needles  in  use 
among  the  ancients,  but  likewise  the  tenacuhun  or 


I hook  to  lay  hold  of  the  bleeding  vessels,  when  they  had 
buried  themselves  in  the  muscles.  We  refer  our  in- 
quisitive readers  to  Avicenna,  .ffltius  Albucacis,  Bru- 
nus,  Theodoric,  Guido  di  Cauliaco,  John  de  Vigo,  L. 
Bertapaelia,  Tagaultius,  Petrus  Argillata,  Andreas  a 
Cruce,  <kc.  &c.,  where  they  will  find  enough  to  satisfy 
them  on  this  head.” — (Rees’s  Cyclopaidia,  art.  Ampu- 
tation.) 

1 shall  not  here  expatiate  upon  the  ill-treatment 
which  Par6  experienced  from  the  base  and  ignorant 
Gsunnelin ; nor  upon  the  slowness  and'reluctance  with 
which  the  generality  of  surgeons  renounced  the  cau- 
tery for  the  ligature.  These  circumstances  may  be 
conceived,  from  what  has  been  already  stated.  Suffice 
it  to  add,  upon  the  authority  of  Dionis,  that  almost  100 
j'ears  after  Pari^,  a butiun  of  vitriol  was  ordinarily  em- 
ployed in  the  116tel-Uieu  at  Paris  for  the  stoppage  of 
hemorrhage  after  amputations.  And  Uionis  was  the 
first  Frenchman  who  openly  taught  and  recommended 
Parc’s  method.  This  happened  towards  the  close  of 
the  17th  century,  while  Pare  lived  towards  the  end  of 
the  16th. — (Dionis,  Cours  d’Opcrat.  Paris,  1707.) 

As  Pan',  like  the  rest  of  the  old  surgeons,  used  to  cut 
directly  down  to  the  bone,  many  of  the  stumps  which 
he  made  must  have  been  badly  covered  with  flesh,  and 
ill-fitted  for  bearing  jiressure.  But  all  that  I have  read 
on  the  subject  of  amputation  imjiresses  me  with  a 
strong  conviction,  that  in  former  times  the  jiroj-'ction 
of  the  end  of  the  bone,  the  sugar-loaf  form  of  the  stump, 
the  frequent  exfoliations,  and  the  difficulty  in  healing 
the  jiart  and  keeping  it  healed,  were  as  much  owing  to 
the  mischief  done  with  the  cautery,  the  rude  way  of 
dressing  the  stump,  and  ignorance  of  the  right  method 
of  promoting  union  by  the  first  intention,  as  to  the 
mode  of  operating  or  any  other  circumstance. 

By  many  surgeons,  however,  the  tying  of  arteries  con- 
tinued to  be  deemed  too  trouble.some,  and  hence  they 
persisted  in  the  barbarous  use  of  the  actual  cautery  : of 
this  number  were  Ihgrai  (Epitome  des  Precejites  de 
Med.  et  de  Chir.  8vo.  Rouen,  1642),  F.  Plazzoni  (Ue 
Vuln.  Sclojiet.  4to.  Venet.  1618),  and  P.  M.  Rossi  (Con- 
sult. et  Observ.  8vo.  Fraiicof.  1616).  Nay,  so  difficult 
was  it  to  eradicate  the  blind  attachment  to  the  ancients, 
that  I’heodorus  Baronius,  a professor  at  Cremona,  pub- 
licly declared,  in  1601),  that  he  would  rather  err  with 
Galen  than  follow  the  advice  of  any  other  jierson  ; and 
Van  Hoorne  seems  even  to  have  countenanced  the  de- 
testable machine  of  Botalli. — (Mi>cpoTfxv>7,  p.  76.) 

What,  asks  Briinninghausen,  was  the  reason  why 
the  ligature  of  the  arteries,  which  is  now  regarded  by 
the  surgeons  of  all  civilized  nations  as  the  best,  easiest, 
and  safest  method  of  stopping  hemorrhage  after  ampu- 
tation, should  so  long  have  remained  unadopted  1 Be- 
sides the  prejudice  for  the  opinions  of  the  ancients, 
already  mentioned,  another  cause  was  undoubtedly  the 
imjjerfect  knowledge  of  the  circulation  of  the  blood,  a 
correct  description  of  which  was  first  delivered  by  the 
immortal  Harvey  early  in  the  17th  century. — (Exerci- 
tatio  Anat.  de  Motu  Cordis  et  Sanguinis  in  Animalibus, 
Francof.  1628.)  For  some  time  this  grand  discovery 
met  with  violent  opjiosition ; but  after  it  hud  been  ac- 
knowledged as  an  eternal  truth,  a hajipy  application 
of  it  was  made  to  surgery  by  a French  surgeon,  named 
Morell,  who,  at  the  siege  of  Besangon,  in  1674,  invented 
the  field  tourniquet,  by  means  of  which  more  certain 
pressure  was  made  on  the  trunk  of  the  artery.  By 
this  simple  invention,  founded,  however,  on  a know- 
ledge of  the  circulation,  the  surgeon  could  at  option  let 
the  blood  of  the  stump  spirt  out,  or  stop  its  jet  entirely  ; 
and  now  both  during  and  after  the  operation,  he  w'as 
first  enabled  to  command  the  hemorrhage,  and  coolly 
and  judiciously  employ  whatever  measures  were  indi- 
cated ; for  the  most  powerful  bandages  and  pressure 
previously  in  use  either  stojiped  the  circulation  in  the 
whole  limb,  or  could  not  be  made  to  have  the  right 
effect  with  sufficient  quickness. — (Briinninghausen, 
Erfahr.  &c.  fiber  die  Amp.  p.  36.)  Morell’s  tourniquet, 
however,  was  very  imperfect,  and  it  was  not  till  the  year 
1718,  that  J.  L.  Petit,  whose  name  shines  so  brightly 
in  the  history  of  surgery,  invented  the  kind  of  tourni- 
quet now  employed. 

Richard  Wiseman,  who  is  justly  considered  as  the 
father  of  good  English  surgery,  saw  the  necessity  of 
making  the  incision  in  the  sound  parts,  because  gan- 
grene does  not  always  spread  evenly,  but  frequently 
extends  much  higher  up  one  side  of  the  limb  than  the 
other.  He  deemed  the  actual  cautery  objectionable,  as 


..  AMPUTATION. 


53 


the  sloughs  were  so  long  in  being  thrown  off.  He  ap- 
plied a ligature  round  the  limb,  two  inches  above  the 
limits  of  the  mortification,  and,  drawing  up  the  mus- 
cles, made  the  incision  with  a large  curved  knife,  with 
the  back  of  which  he  scraped  off  the  periosteum.  The 
bag,  or  sort  of  retractor,  employed  by  Fabricius  Hilda- 
nus,  Wiseman  thought  unnecessary,  as  the  muscles 
spontaneously  drew  themselves  up  as  soon  as  divided. 
He  tied  the  blood-vessels  after  the  manner  of  Par6,  and 
deprecated  all  burning  of  the  stump.  After  the  opera- 
tion, he  drew  the  flaps  over  the  bone,  and  either  fastened 
them  in  this.position  with  stiches  or  a tight  bandage, 
though  he  generally  preferred  the  former,  as  the  surest 
means  of  keeping  the  end  of  the  bone  from  protruding. 
Across  the  slump  he  laid  a pledget  of  wax-cerate,  and 
over  this  a thick  layer  of  Armenian  bole  and  other 
styptics,  and  the  whole  was  covered  with  a bullock’s 
bladder  and  a roller,  applied  spirally  from  the  upper 
part  of  the  remaining  portion  of  the  limb  down  to  the 
extremity  of  the  stump.  On  the  third  day,  the  dress- 
ings were  taken  off,  and  a digestive  ointment  applied. 
— (Chirurg.  Treatises,  vol.  2,  p.  220,  8vo.  Lond.  1690.) 

From  this  time,  amputation  may  be  considered  as 
being  an  infinitely  safer  proceeding  than  what  it  used 
to  be ; for,  as  we  have  explained,  the  ligature  of  the 
arteries  was  now  practised  and  commended  in  Germany 
by  F.  Hildanus,  in  England  by  Wiseman,  and  in 
France  by  Dionis.  Much,  however,  remained  to  be  done. 
The  wound  was  large,  and  suppurated  long  and  pro- 
fusely ; the  healing  was  slow ; the  ends  of  the  bones 
perished,  and,  projecting  far  beyond  the  soft  parts,  re- 
tarded the  cure  so  long,  that  the  patient  was  not  unfre- 
quently  worn'  out.  Hence  the  best  surgeons  began 
seriously  to  consider  what  farther  could  be  done,  with 
a view  of  lessening  the  exposed  surface  of  the  wound, 
and  making  a better  covering  of  flesh  for  the  ends  of 
the  bones. 

According  to  Sprengel,  most  of  the  old  surgeons 
preserved  a flap  of  flesh,  and  he  is  therefore  by  no 
means  disposed  to  regard  our  countryman,  Lowdham, 
as  the  inventor  of  this  method,  though  it  is  acknow- 
ledged that  the  latter  surgeon’s  practice  was  novel, 
inasmuch  as  the  flap  was  formed  by  making  an  oblique 
incision  through  the  integuments  from  below'  upwards. 
—(See  James  Yonge’s  Currus  Triumphalis  e Terebintho, 
8vo.  Lond.  1679 ; and  Sprengel’s  Geschichte  der  Chirur- 
gie,  b.  1,  p.  408.)  Here,  if  Sprengel  means  that  many 
of  the  old  surgeons  endeavoured  to  preserve  a partial 
covering  of  flesh  for  the  bone,  there  can  be  no  doubt  of 
his  correctness ; because  we  find,  that  they  drew  back 
the  flesh  before  they  divided  it,  and  Celsus  and  some 
others  even  did  more,  for,  after  cutting  down  to  the  bone, 
they  detached  the  flesh  farther  from  it  upwards,  previ- 
ously to  taking  the  saw ; but,  on  the  contrary,  if  Spren- 
gel wishes  us  to  believe,  that  there  were  practitioners 
who,  previously  to  Lowdham,  in  the  operation  of  am- 
putation formed  what  in  England  is  usually  under- 
stood by  a flap,  that  is,  a portion  of  flesh,  generally  of 
a serriilunar  shape,  and  saved  particularly  from  one 
side  of  the  member  for  covering  the  bone,  I cannot  see 
any  reason  for  coinciding  with  Sprengel’s  observation. 
Upon  the  merit  of  Lowdham’s  suggestions,  and  the 
practice  and  principles  inculcated  by  J.  Yonge,  some 
reflections  lately  sent  me  by  Mr.  Carwardine  I insert 
with  great  pleasure,  as  perhaps  he  is  right  in  thinking 
that  the  third  edition  of  this  work  did  not  do  justice  to 
the  memory  of  the  latter  ^vriter. 

“At  the  time  Yonge  wrote  (1679),”  says  Mr.  Car- 
wardine, “ it  was  supposed  impossible  to  heal  a stump 
before  the  bone  had  exfoliated,  and  therefore  no  sur- 
geon would  venture  upon  an  attempt  at  uniting  the 
surface  by  the  first  intention.  Now  this  union  by  the 
first  intention  was  the  chief  object  of  Mr.  Yonge  in 
proposing  the  flap-operation,  and  it  is  to  him,  and  not 
to  Mr.  Alanson,  who  wrote  precisely  100  years  after 
him,  that  we  must  attribute  the  honour  of  tliis  improve- 
ment. It  is  related  in  a letter  addressed  to  his  friend 
Thomas  Hobs,  chirurgeon,  in  London,  dated  Plymouth, 
August  3,  1678,  and  published,  1679,  at  the  end  of  his 
Currus  Triumphalis  e Terebintho.  It  begins  thus : 

‘Sir,  I find  by  yours  that  you  are  surprised  with 
the  intimation  I gave  you,  of  a way  of  amputating 
large  members,  so  as  to  be  able  to  cure  them  per  sym- 
jihysin  in  three  weeks ; and  without  fouling  or  scaling 
the  bone.  It  is  a paradox  which  I will  now  evince  to 
you  to  be  a truth,  after  I have  first  taken  notice  of 
what  you  affirm,  that  there  is  a necessity  of  scaling 


the  ends  of  those  bones  left  bare  after  the  usual  manner 
of  dismembering,  before  the  stump  can  be  soundly 
cured  ; that  you  never  yet  found  it  otherwise,  but  that 
where  it  hath  been  attempted,  the  stumps  have  apostu- 
mated,  and  the  caries  come  off  thereby.’ 

Yonge  then  acknowledges,  that  it  was  from  an 
ingenious  brother,  Mr.  C.  Lowdham  of  Exeter,  that  he 
had  the  first  hint  thereof.  He  then  describes  the  ope- 
ration— the  laying  down  the  flap  over  the  face  of  the 
stump,  and  sewing  it  by  four  or  five  stitches,  &e.  After 
this,  Yonge  proceeds  with  a methodical  enumeration  of 
the  advantages  of  this  mode  of  operating  over  all 
others  then  in  use,  viz.  that  it  is  more  speedy — the 
cure  not  occupying  a fourth  of  the  usual  time — no  sup- 
puration—no  exfoliation — less  danger  of  hemorrhage 
— not  liable  to  break  open  again  from  slight  injury — 
and  lastly,  much  better  adapted  to  the  pressure  from 
an  artificial  leg,  &c. 

The  foregoing  abstract  will  show  (says  Mr.  Car- 
wardine) how  far  Mr.  O’Halloran’s  method,  presently 
to  be  described,  in  which  he  dresses  the  flap  and  the 
stump  as  distinct  surfaces,  can  be  regarded  as  a revival 
of  Lowdham’s  operation,  or  whether  it  has  been  super- 
seded or  improved  upon  by  the  mechanical  ingenuity  of 
the  Dutch  and  French  surgeons ; — the  apparatus  of 
M.  de  la  Faye  and  Verduin  appear  to  have  been  merely 
clumsy  and  unscientific  contrivances  for  the  suppres- 
sion of  hemorrhage.  Garengeot’s  operation  had  also  for 
its  object  to  supersede  the  use  of  the  ligature,  which, 
however,  after  twelve  years’  practice,  he  was  obliged 
to  give  up,  and  tie  the  vessel  before  he  laid  down  the 
flap  (the  particulars  of  all  these  methods  the  reader 
will  presently  meet  with' . Opinions,  therefore,  founded 
upon  the  practice  of  these  gentlemen,  I conceive,  can- 
not fairly  be  admitted  as  evidence  against  the  flap-ope- 
ration of  Lowdham,  which  nevertheless  appears  sinking 
in  the  estimation  of  the  best  modern  surgeons ; perhaps 
no  material  advantage  is  gained  by  it  over  the  common 
mode  of  operating  in  the  lower  extremities,  as  now 
practised — but  even  here  cases  may  occur  where  we 
are  glad  to  resort  to  it : a few  years  since,  I attended  a 
patient  in  consultation  with  a friend  at  Dunmow,  in 
Essex,  where  we  thought  it  necessary  to  remove  a 
man’s  leg  for  a caries  of  the  tibia.  An  ulceration  in 
front  extended  so  high,  that  no  integument  could  be 
saved,  and  the  limb  would  have  been  removed  above 
the  knee,  if  I had  not  suggested  the  propriety  of  making, 
a flap  from  the  calf  of  the  leg.  The  tibia  was  obliged 
to  be  sawed  as  high  as  possible,  but  the  flap  was  left 
sufficiently  long  to  cover  the  surface,  and  that  most 
important  object,  the  bend  of  the  knee,  was  preserved, 
to  bear  the  pressure  of  a wooden  leg.  In  the  removal 
of  the  arm  at  the  shoulder-joint,  doubtless  the  advan- 
tages of  making  a ffap  from  the  deltoid,  &c.  are  suffi- 
ciently established ; but  in  the  mode  of  dressing,  I pre- 
sume that  no  English  surgeon  will  admit,  that  the 
practice  of  M.  Larrey  (perhaps  the  most  eminent  sur- 
geon that  has  been  formed  by  the  wars  of  Buonaparte, 
and  whose  practice  will  be  hereafter  noticed)  can  super- 
sede the  method  of  Yonge  (or  Low'dhara),  who  wrote 
140  years  before  liim ! Larrey  introduces  cha'rpie 
beneath  the  dap  to  prevent  union  by  the  first  intention  1 
Lowdham’s  object  is  simply  to  lay  the  flap  over  the 
wound  to  prevent  exfoliation,  and  to  heal  the  surface 
‘ per  symphysin’  in  three  weeks.” — To  the  correctness 
of  these  sentiments  of  Mr.  Carwardine,  I believe  that 
every  impartial  surgeon  will  bear  witness;  and  it 
merely  remains  for  me  to  thank  him  for  his  obliging 
communication,  and  say,  that  I have  recently  looked 
over  the  copy  of  the  Currus  Triumphalis  e Terebintho, 
preserved  in  the  valuable  library  of  the  Medical  and 
Chirurgical  Society,  and  find,  that  what  he  had  stated  is 
fully  confirmed  by  the  contents  of  that  ancient  work. 
At  the  same  time,  I retain  the  belief,  that  the  example 
set  by  Mr.  Alanson,  with  respect  to  the  proper  method 
of  dressing  stumps  and  obtaining  a speedy  union  of 
the  wound,  is  entitled  to  the  praise  of  posterity ; because 
his  advice  was  so  well  enforced  that  it  soon  produced 
a revolution  in  practice,  while  the  correct  suggestions 
of  Lowdham  and  Yonge,  like  the  hint  in  Celsus,  of  the 
double  incision,  had  sunk  into  oblivion,  or  were  only 
known  to  a few  admirers  of  surgical  antiquities. 

As  Sprengel  remarks,  Purmann,  Dionis  (Cours 
d’Op6r.  de  Chir.  p.  611),  De  la  Vauguyon  (Trait6 
Compel,  des  Optr.  de  Chir.  p.  531),  and  most  other 
surgeons  of  the  seventeenth  century,  continued  the 
method  of  first  drawing  up  the  integuments,  and  then 


54 


AMPUTATION. 


applying  a baud  round  the  member.  Dion  is  also  took 
particular  pains  to  recommend  the  ligature  of  the  ves- 
sels, and  expresses  a strong  aversion  to  the  actual  cau- 
tery. Neither  did  he  approve  of  amputation  at  the 
knee-joint,  because  he  thought  that  the  patella,  which 
must  be  left  behind,  would  impede  the  healing  of  the 
stump,  and  he  was  apprehensive  of  the  articular  sur- 
face of  the  femur  becoming  diseased.  De  la  Vaugu^  on 
relied  ujion  the  styptic  properties  of  vitriol,  and  he 
praised  drawing  back  the  muscles  by  means  of  the 
kind  of  bag  invented  by  Fabricius  Hildanus. 

Taking  off  the  limbs  at  the  joints  was  first  com- 
mended again  in  modern  times  by  J.  M unnicks,  who 
was  more  partial  to  styptics  than  the  ligature ; and  for 
dressing  the  wound  employed  compresses  and  sticking- 
plaster. — (Chirurgia,  p.  101.) 

Mauquest  de  la  Mot  he  adopted  the  plan  of  operating 
recommended  by  Dionis  ; he  was  also  one  of  the  first 
who  made  common  use  of  the  tourniquet  in  amputa- 
tions, afterward  drawing  out  the  vessels  with  the 
forceps  and  tying  them.— iTraite  Compl.  de  Chir.  vol. 
3,  p.  171.)  Lowdham’s  original  suggestion  of  amputating 
with  a flap  has  been  briefly  noticed.  About  eighteen 
years  after  Yonge’s  publication,  I’eter  Vorduin,  an  emi- 
nent surgeon  at  Amsterdam,  submitted  to  the  judg- 
ment of  the  ])rofession  a new  kind  of  flap-amputation, 
which  he  had  put  in  practice. — (See  Dis.  Ejiistolica  de 
Nov4  Artuum  decurtandorum  rationo,  8vo.  Amst.  1090.) 
The  following  are  the  chief  particulars  of  Verduin’s 
flap-operation. 

Two  compresses  were  applieil,  one  under  the  ham, 
and  the  other  on  the  course  of  the  large  vessels.  The 
thigh  was  wrapped  in  a fine  linen  cloth,  which  was 
sustained  by  some  turns  of  a roller.  This  apparatus 
was  covered  with  a jiiece  of  leather,  six  inches  broad, 
fhrnished  with  tlu’ee  straps  with  buckles,  to  secure  it 
round  the  part.  The  tourniquet  was  placed  in  the 
usual  manner.  The  part  above  the  place  intended 
to  be  amputated  was  surrounded  with  a leather 
strap.  The  point  of  a crooked  knife,  which  was 
niade  to  pass  as  near  to  the  back  part  of  the  bones 
as  possible,  w as  thrust  in  on  one  side  of  the  leg,  and 
made  to  come  out  on  the  other.  The  knife  was  then 
carried  down  nearly  to  the  tendo  achillis,  and  thus  it 
separated  almost  the  whole  calf  of  the  leg.  The  flap 
being  formed,  the  operation  w'as  finished  in  the  ordi- 
nary manner.  The  wound  was  then  washed  with  a 
wet  sponge,  in  order  to  clear  it  from  the  fragments  of 
sawed  bone.  The  leather  strap,  which  served  to 
secure  the  flesh,  was  next  loosened,  and  the  flap  laid 
over  the  stump.  The  wound  was  dressed  with  lyco- 
perdon,  lint,  and  tow,  over  which  was  put  a bladder, 
sustained  by  strips  of  sticking-plaster,  Upon  this 
bladder  was  placed  an  instrument  called  a retinacu- 
lum, consisting  of  a compress,  and  a concave  plate, 
Avhich  were  made  to  press  upon  the  stump,  by  means 
of  two  straps,  which  crossed  each  other  and  were  at- 
tached to  the  broad  leather  strap  surrounding  the  thigh. 

In  1702,  Sabourin,  an  able  surgeon  at  Geneva,  gave 
an  account  of  Verduiii’s  practice  to  the  Royal  Academy 
of  Sciences,  which,  however,  decluied  to  pronounce 
any  judgment  about  it,  without  farther  experience. 

Though  this  method  of  amputation  was  objected  to 
by  CiJnerding,  in  a tract  published  at  Amsterdam  in 
1705,  it  was  afterward  highly  extolled  by  P.  Mas- 
suet,  on  account  of  the  quickness  with  which  the 
stump  healed,  the  safety  with  which  the  flap  served 
for  the  stoppage  of  the  hemorrhage,  and  the  avoidance 
of  exfoliation  by  the  non-exposure  of  the  bone.  He 
also  dwelt  upon  the  excellency  of  the  stump  for  the 
application  of  an  artificial  foot.— (De  I’Amputation  h 
lambeau,  8vo,  Paris,  1756.)  Heister  disapproved  of  the 
flap-amputation,  because  it  appeared  to  him,  that  the 
irritation  of  the  flesh  by  the  projecting  bonds  was  apt 
to  cause  pain  and  inflammation  : he  operated  himself 
after  the  manner  of  Dionis,  and  was-  strongly  in  favour 
of  the  use  of  ligatures. 

Some  excellent  precepts  were  delivered  by  J.  L. 
Petit  concerning  amputation.  He  improved  the  tour- 
niquet ; and,  instead  of  the  large  crooked  amputating 
knife  formerly  employed,  first  brought  into  use  the 
straight  more  moderate-sized  knives  with  sharp  backs, 
now  seen  in  the  hands  of  the  best  surgeons,  because 
much  better  calculated  than  crooked  knives  for  divi- 
ding the  flesh  by  a sawing  movement,  which  is  the 
only  right  and  surgical  way  of  attempting  to  cut  any 
part  of  the  human  body.  He  proved  that  making  the 


division  in  the  mortified  parts  was  (Vequently  followed 
by  hemorrhage ; and  for  the  suppression  of  bleeding 
he  thought  it  the  best  principle  to  promote  the  forma- 
tion of  acoagulum. — (M^m.  de  I’Acad.  des  Sciences,  an 
1732,  p.  285.  See  Hemorrhage.)  For  compressing  tlje 
vessels,  he  employed  an  instrument  wliich  covered  the 
stump,  like  Verduin’s  retinaculum,  and  made  pressure 
by  means  of  a screw.  His  only  objection  to  Verduin’s 
method  was,  that  the  extension  of  gangrene  up  the 
limb  frequently  hindered  the  formation  of  so  large  a 
flap.  He  laid  down  the  valuable  general  maxim  of  al- 
ways removing  as  much  bone,  and  as  little  flesh,  as 
possible ; for  which  purpose  he  invented  what  is 
termed  the  double  incision,  or  dividing  the  business  of 
cutting  through  the  soft  jiarts  into  two  stages.  About 
an  inch  higher  than  the  place  where  he  meant  to  saw 
through  the  bones,  he  first  made  the  circular  cut 
through  the  integuments  down  to  the  muscles;  the 
skin  was  then  pulled  up  so  as  to  leave  the  flesh  unco- 
vered to  the  extent  of  an  inch,  and  the  muscles  were  now 
divided  at  the  highest  point  of  their  exposure.  Lastly, 
the  flesh  was  held  out  of  the  way  with  a retractor,  and 
the  bone  was  sawed  through  high  enough  up  to  allow 
of  its  extremity  being  well  covered  with  flesh  and  in- 
teguments. The  greatest  defect  in  the  doctrine  of 
Petit,  relative  to  amimtation,  was  the  confidence  he 
put  in  pressure,  instead  of  the  ligature.— (Traits  des 
Malad.  (.'hir.  vol.  3,  p.  126.)  The  first  performance  of 
amputation  at  the  shoulder-joint,  by  Le  Dran,  and  the 
improvements  and  alterations  of  that  operation  sug- 
gested by  Garengeot,  De  la  Faye,  Desault,  &c.  I shall 
notice  in  a ftiture  section. 

In  chronological  order,  the  next  eveirt  claiming  no- 
tice in  the  history  of  amputation,  was  the  promulga- 
tion of  an  opinion  by  T.  R.  Gagtiier,  that  Verduin’s 
flap-amputation  might  be  traced  back  to  times  of  great 
antiquity,  the  method  described  by  Celsus  being  very 
similar. — (Haller,  Diss.  Chir.  vol.  6,  p.  161.)  On  this 
point,  with  reference  to  Lowdham,  the  true  inventor 
of  the  flap-operation,  I have  already  delivered  my  own 
sentiments. 

The  flap-amputation  of  the  leg,  after  Verduin’s  man- 
ner, was  tried  by  De  la  Faye,  who  found  that  the  pres- 
sure of  the  flap  was  not  enough  to  check  bleeding 
from  all  the  vessels,  as  it  only  operated  on  the  anterior 
tibial  artery,  and  by  pressing  the  flesh  more  firmly 
against  the  end  of  the  bones,  he  thought  the  risk  of 
mortification  would  be  occasioned. 

Verduin  and  iSabouriri,  as  we  have  seen,  made  only 
one  flap.  Two  French  surgeons,  Ravaton  and  Ver- 
male,  afterward  thought  that  it  would  be  better  to  save 
a flap  from  each  side  of  the  limb.  They  were  also  ad- 
vocates for  tying  the  vessels,  and  bringing  the  two 
flaps  into  contact,  so  as  to  procure  their  speedy  union, 
and  hinder  exfoliations  and  profuse  suppuration. 

However,  there  is  some  difference  in  their  methods 
of  forming  the  flaps.  Ravaton,  who  submitted  his 
plan  to  the  French  Academy  in  1739,  made  three  deep 
incisions  down  to  the  bone ; first,  a circular  one,  with 
a crooked  knife,  within  four  finger-breadths  of  the  bone 
intended  to  be  sawed ; and  then  with  a somewhat  larger 
knife,  the  two  others  perpendicularly  to  the  first,  one  at 
the  fore  part,  and  the  other  at  the  back  of  the  limb ; 
and,  taking  care  not  to  touch  the  principal  vessels,  he 
detached  the  two  flaps  from  the  bone. 

Verraale  formed  the  separate  flaps  by  two  incisions. 
After  applying  the  tourniquet,  he  surrounded  the  part 
with  two  red  threads,  at  the  distance  of  four  finger- 
breadths  from  each  other ; one  at  the  place  where  the 
bone  was  to  be  sawed,  the  other  at  the  place  where 
the  incision  of  the  flaps  was  to  terminate.  He  after- 
ward thrust  a long  bistoury  down  to  the  bone,  at  the 
fore  part  of  the  limb ; turned  it  round  the  circumfe- 
rence, so  that  it  might  come  out  at  the  opposite  part ; 
then,  directing  the  edge  of  the  knife  along  the  bone,  he 
cut  down  to  the  inferior  thread,  where  he  separated 
the  first  flap,  which,  as  the  author  says,  was  of  a round 
or  conical  figure  at  its  extremity.  The  second  flap  was 
made  in  a similar  way  on  the  interior  side  of  the  mem- 
ber.— (Traits  des  Playes  d’Armes  a feu,  par  Ravaton, 
8vo.  Paris,  1750.  De  la  Faye,  in  Mem.  de  I’Acad.  de 
Chir.  t.  5,  ed.  12mo.  Vermafe,  Obs,  de  Chir.  8vo.  Man- 
heim,  1767.) 

In  presence  of  M.  Quesnay,  Garengeot  performed 
the  flap-apiputation  according  to  the  method  of  Ver- 
duin and  Sabourin.  We  know  that  they  made  no  liga- 
ture on  the  vessels,  and  that  their  intention  was,  that  tlw 


AMPUTATION. 


55 


flap,  when  applied  to  the  stump,  and  sustained  by  a par- 
ticular apparatus,  should  reunite,  and  stop  all  bleeding. 

Garengeot’s  patient  died  on  the  third  day  after  the 
operation ; hemorrhage  having  had  a considerable  share 
in  producing  death. 

The  multiplicity  of  machines  described  by  Verduin, 
La  Faye,  &c.  had  no  other  end  but  that  of  keeping  the 
flap  near  the  orifices  of  the  vessels,  so  as  to  compress 
and  close  them.  In  consequence  of  the  difficulty  of 
making  this  compression  precisely  as  required,  the 
most ‘considerable  vessels  being  situated  between  the 
two  bones,  and  when  cut,  generally  becoming  retracted, 
Garengeot  determined  in  future  to  employ  ligatures. 

With  these  views,  twelve  years  after  the  foregoing 
case,  Garengeot  performed  a flap-amputation  of  the 
arm,  pre*rving  two  flaps,  according  to  the  method 
communicated  to  the  Academy  by  Ravaton.  The  bra- 
chial artery  was  tied,  and  the  patient  was  cured,  with- 
out any  exfoliations. 

Garengeot  made  a third  trial  of  this  operation  on  a 
soldier  dangerously  wounded  in  the  right  foot  by  the 
bursting  of  a bomb,  which  fractured  the  interior  part 
of  the  two  bones  of  the  leg,  and  several  of  the  foot : 
the  patient  recovered  in  twenty-seven  days. 

In  this  operation  one  single  flap  was  made.  Garen- 
goet  was  fearful,  however,  that  the  quick  union  might 
create  some  difficulty  in  withdrawing  the  ligatures, 
and  he  therefore  took  a means  of  hindering  adhesion 
where  they  were  situated;  but  of  tiffs  objectionable 
plan  I shall  not  speak.  He  rightly  preferred  dressing 
and  bandaging  the  stump  to  the  use  of  the  compressing 
machines  invented  by  Verduin  and  La  Faye ; and  his 
choice  of  a straight  knife,  instead  of  a crooked  one, 
was  equally  judicious. 

The  preceding  case  dictated  a truth,  which  will  last 
as  long  as  surgery  itself,  viz.  that  it  is  advantageous  to 
apply  the  ligatures  in  such  manner  as  to  embrace  no 
more  than  the  vessel,  so  that  they  may  fall  off  the 
sooner,  and  the  parts  more  quickly  unite.— (M.  de  Ga- 
rengeot, in  Memoires  de  I’Acad.  de  Chir.  t.  5,  12mo.) 

At  one  time,  an  objection  frequently  urged  against 
the  foregoing  methods  was,  that  when  the  fr^sh  cut 
flap  was  immediately  laid  over  the  stump,  inflamma- 
tion and  abscesses  were  apt  to  ensue.  Hence,  in  1765, 
Sylvester  O’Halloran,  a surgeon  at  Limerick,  was  led 
to  make  the  experiment  of  deferring  laying  down  the 
flap  till  the  end  of  the  first  eight  or  twelve  days  after 
the  operation,  when  it  was  conjectured  that  the  risk  of 
inflammation  and  abscesses  would  be  diminished.  The 
tenor  of  O’Halloran’s  book  is  apparently  corroborated 
by  the  facts  brought  forward.  Here  we  see  one  of  the 
grand  points,  insisted  upon  by  our  worthy  countryman 
James  Yonge,  viz.  the  chance  of  an  immediate  union 
of  the  wound  from  laying  down  the  flap  without  delay, 
suddenly  givon  up,  and  because  the  wound  could  not 
always  be  healed  without  suppuration,  it  was  deter- 
mined that  it  never  should  do  so.  However,  it  is  con- 
solatory to  find,  that  O’Halloran’s  suggestion  now  exists 
only  in  the  history,  and  not  in  the  practice,  of  surgery. 

Alexander  Monro,  senior,  was  a great  opposer  of  cer- 
tain methods  which  originated  among  the  French  sur- 
geons, and,  in  particular,  he  disapproved  of  the  tourni- 
quet : he  secured  the  vessels  with  needles  and  liga- 
tures ; and  was  the  inventor  of  a bandage,  which  has 
been  extensively  approved  of  under  the  name  of  Monro’s 
roller. — iMedical  Essays  of  EdinU.  vol.  4,  p.  257.) 

Bromfield,  like  Le  Dran,  restricted  amputation  to  a 
few  cases ; and  he  did  not  acknowledge  its  necessity,  as 
a matter  of  course,  in  every  case  of  gangrene,  much  less 
in  every  instance  of  white  swelling  or  caries.  From  a 
passage  which  I have  cited  from  Dr.  Rees’s  Cyclopae- 
dia, it  would  seem  that  the  tenaculum  was  known  to 
the  ancients ; yet,  according  to  general  opinion  (and 
I cannot  affirm  that  it  is  incorrect  from  any  passage  in 
my  recollection;,  Bromfield  is  allowed  to  be  the  first 
modem  surgeon  who  employed  this  very  useful  instru- 
ment.—(Chir.  Cases  and  Obs.  vol.  1,  p.  41,  8vo.  Lond. 
1773.) 

About  the  year  1742,  the  removal  of  thighs  without 
bloodshed  was  a subject  a good  deal  broached.  A sin- 
gle case  recorded  by  Schaarschmid,  where  a mortified 
thigh  separated  without  hemorrhage,  was  the  founda- 
tion of  the  scheme.  The  .arteries  were  completely 
blocked  up,  and  the  parts  insensible. — (Haller,  Diss. 
Chir.  vol.  5,  p.  155.)  A similar  occurrence  was  related 
by  Acrel  (Chir.  handels.  p.  557) ; and  Lalouette  pro- 
fessed himself  a believer  in  the  security  from  hemor- 


rhage, on  account  of  the  vessels  being  filled  with  coa- 
gula,  and  therefore  he  also  approved  of  letting  dead 
parts  be  removed,  or  rather  fall  off,  without  bloodshed. — 
(Haller,  Diss.  Chir.  vol.  5,  p.  273.) 

In  cases  where  the  projecting  bone  of  the  stump 
was  affected  with  necrosis,  Bagieu,  an  experienced 
military  surgeon,  ventured  to  amputate  a second  time, 
and  urged  a variety  of  arguments  in  defence  of  the 
practice. — (M6m.  de  I’Acad.  de  Chir.  t.  2,  p.  274.)  He 
coincided  \vith  Le  Dran  and  Bromfield,  however,  about 
the  propriety  of  restricting  amputation  to  few  cases, 
and  has  related  numerous  examples  of  limbs  being 
saved,  which,  according  to  the  doctrines  then  in  vogue, 
ought  to  have  been  cut  off — (Deux  Lettres  d’un  Chir. 
de  l’Arm6e,  12mo.  Paris,  1750.) 

M.  Louis,  a French  surgeon  of  extraordinary  talents, 
introduced  the  plan  of  diviffing  the  loose  muscles  first, 
and  lastly  those  which  are  closely  connected  with  the 
bone.  He  noticed  that  the  muscles  of  the  thigh,  after 
being  divided,  were  retracted  in  an  unequal  degree. 
He  observed  that  the  superficial  ones  extending  along 
the  limb,  more  or  less  obliquely,  without  being  attached 
to  the  bone,  were  drawn  up  with  greater  force,  and  in 
a greater  degree  than  others,  wlffch  are  deeply  situa- 
ted, in  some  measure,  parallel  to  the  axis  of  the  femur, 
and  fixed  to  this  bone  throughout  their  whole  length. 
The  retraction  begins  the  very  instant  when  the  miis- 
cles  are  cut,  and  is  not  completed  till  a short  time  has 
elapsed.  Hence,  the  effect  should  be  promoted,  and 
be  as  perfect  as  possible,  before  the  bone  is  sawed.  In 
the  amputation  of  the  thigh,  Mr.  I.ouis  was  always 
desirous  of  letting  the  muscles  contract  as  far  as  they 
could,  and  for  this  reason  he  was  rather  averse  to 
using  the  tourniquet,  as  the  circular  pressure  of  this 
instrument  in  some  measure  counteracted  what  he 
wished  to  take  place ; and  hence,  at  one  time  he  preferred 
letting  an  assistant  make  pressure  on  the  artery, 
though  he  subsequently  expressed  his  approbation  of 
the  tourniquet  proposed  by  M.  Pipelet  for  compressing 
the  femoral  artery. — (M6m.  de  I’Acad.  de  Chir.  vol.  4,  p. 
60,  4to.) 

Actuated  by  such  principles,  Louis  practised  a kind 
of  double  incision  different  from  that  of  Cheselden  and 
Petit,  and  different  also  from  Alanson’s  method,  which 
I shall  hereafter  notice.  By  the  first  stroke  he  cut,  at 
the  same  time,  both  the  integuments  and  the  loose  su- 
perficial muscles ; by  the  second,  he  divided  those 
muscles  which  are  deep  and  closely  adherent  to  the  fe- 
mur. On  the  first  deep  circular  cut  being  completed, 
Louis  used  to  remove  a band  which  was  placed  round 
the  limb,  above  the  track  of  the  knife.  This  was  taken 
off  in  order  to  allow  the  divided  nrascles  to  become 
retracted  without  any  impediment.  He  next  cut  the 
deep  adherent  muscles  on  a level  with  the  surfaces  of 
those  loose  ones  which  had  been  divided  in  the  first  in- 
cision, and  which  had  now  attained  their  utmost  state 
of  retraction.  In  this  way  he  could  evidently  saw  the 
bone  very  high  up,  and  the  painful  dissection  of  the  skin 
from  the  muscles  was  avoided.  Louis  was  conscious 
that  there  was  more  necessity  for  saving  muscle  than 
skin  ; and  he  knew  that  when  an  incision  was  made  at 
once  down  to  the  bone,  the  retraction  of  the  divided 
muscles  always  left  the  edge  of  the  skin  projecting  a 
considerable  way  beyond  them.  Hence  he  deemed  the 
plan  of  first  saving  a portion  of  skin  by  dissecting  it 
from  the  muscles  and  turning  it  up,  quite  unnecessary. 
As  the  bone  should  always  be  sawed  rather  higher  than 
the  division  of  the  soft  parts,  Louis,  like  J.  L.  Petit, 
and  most  other  judicious  surgeons,  highly  approved  of 
the  employment  of  a retractor.  He  was  likewise  the 
author  of  some  valuable  instructions  for  preventing  the 
protrusion  of  the  bone  after  the  operation.— (See  M6m. 
de  I’Acad.  de  Chir.  t.  2,  p.  268 — 410,  &c.  4to.)  The  im- 
partial reader,  who  takes  the  trouble  to  read  the  remarks 
on  amputation  published  by  this  greatest  of  all  the 
French  surgeons  of  the  last  century,  with  the  excep- 
tion perhaps  of  J.  L.  Petit  and  Desault,  will  be  im- 
pressed at  once  with  the  force  and  perspicuity  of  his 
matter,  and  with  the  evident  propriety  of  a good  deal  of 
the  practice  inculcated. 

In  England,  Cheselden,  and  not  J.  L.  Petit,  is  re- 
garded as  the  surgeon  who  revived  Celsus’s  method,  by 
proposing  to  divide  the  soft  parts  by  a double  incision, 
that  is,  by  cutting  the  skin  and  cellular  substance  first, 
and  then,  by  dividing  the  muscles  down  to  the  bone, 
on  a level  with  the  edge  of  the  skin,  so  that  the  bone 
miuht  be  sawed  higher  up,  and  its  end  be  more  com- 


56 


AMPUTATION. 


pletely  covered  with  skfn.  Wliether  Cheselden  had 
the  priority  in  this  impiovement,  I cannot  presume  to 
say ; but  he  gave  an  account  of  it  in  Gataker’s  transla- 
tion of  Le  Dran’s  treatise  on  the  operations,  as  early  as 
1749,  which  was  long  prior  to  the  appearance  of  Petit’s 
posthumous  writings ; and  Mr.  Cheselden  farther  men- 
tions, that  during  his  apprenticeship  to  Mr.  Fern  he  had 
communicated  to  that  gentleman  his  sentiments  about 
the  double  incision. 

In  order  to  hinder  the  stump  from  assuming  a pyra- 
midal or  sugar-loaf  shape,  which  sometimes  happened 
notwithstanding  every  improvement  hitherto  men- 
tioned, a circular  bandage  was  employed,  which  acted 
by  supporting  the  skin  and  muscles,  and  preventing 
their  retraction.  This  handage,  when  properly  applied, 
from  the  upper  part  of  the  limb  dowinvard,  fulfilled  in 
a certain  measure  the  end  proposed,  though  many 
stumps  yet  tunied  out  very  badly.  Mr.  Stiarp  was  in- 
duced, therefore,  to  revive  the  ancient  plan  of  bringing 
the  edges  of  the  skin  together  with  sutures ; but  the 
pam  and  other  inconveniences  of  this  method  were 
such  that  it  was  never  extensively  adopted,  and  Mr. 
Sharp  himself  ultimately  abandoned  it.  The  cro.s.s-  I 
bandage,  however,  which  he  used  to  put  over  the  end 
of  the  stump,  remains  in  fashion  even  at  the  jiresent 
day. — (Treatise  on  the  Oiier.  p.  210  , Critical  Inquiry, 
p.  268.)  It  is  to  be  regretted  that  an  excellent  modern 
surgeon,  the  late  Mr.  Iley,  should  have  commended  so 
much  as  he  has  done  the  use  of  sutures,  in  bringing  to- 
gether the  edges  of  the  wound  alter  amputation. — J’rac- 
tical  Observations  in  Surgery,  p.  534,  edit.  2.) 

in  opposition  to  Louis,  fhe  inefiiciency  of  his  method 
for  hindering  the  protrusion  of  the  bone  was  as.serted 
by  Valentin,  who  thought  the  object  might  be  better  at- 
tained by  dividing  the  parts  while  they  were  in  a state 
of  tension  ; for  which  purpose  he  recommended  chang- 
ing the  posture  of  the  limb,  according  to  the  parts 
which  he  was  about  to  cut. — Recherches  Critiques  sur 
la  Chirurgie  Modeme,  8vo.  Amst.  1772.)  Valentin’s 
proposal  seems  never  to  have  made  much  impre.ssion 
on  the  profession ; whether  on  account  of  its  incon- 
venience or  inelficacy,  I know  not ; certain  it  is,  many 
cases  present  themselves,  in  which  the  posture  of  a 
limb  absolutely  cannot  be  changed  during  the  operation, 
owing  to  the  nature  of  the  disease, -or  cannot  be  altered 
xvithout  extreme  agony. 

At  this  period  arose  the  celebrated  controv  ersy  about 
the  propriety  of  amputation  in  general.  As  Sprengel 
remarks,  several  French  surgeons  now  began  to  be 
convinc^,  with  Le  Dran  and  Bagieu,  that  the  operation 
was  undertaken  on  too  slight  grounds,  and  in  parti- 
cular that  many  bad  complicated  fractures  might  be 
cured  without  amputation.  Such  was  the  doctrine  of 
Boucher  (Mem.  de  I’Acad.  de  Chir.  t.  2,  p.  304),  Ger- 
vaise  (Anfangsgr.  der  Wundarzn.  8vo.  Strasb.  1755), 
and  Faure  iM6m.  qiti  out  concoum  pour  le  Prix  de 
I’Ac.  de  Chir.  vol.  i,  p.  100).  The  latter  especially 
urged  the  prudence  of  delay  in  gun-shot  wounds,  and 
comminut^  injuries  of  the  bones.  But  the  writer  who 
at  this  time  made  the  most  noise  in  the  world  by  his 
general  condemnation  of  amputation,  was  Bilguer 
(Diss.  de  Membrorum  Amputatione,  8vo.  Hal.  1761), 
whose  sentiments  received  a complete  refutation  from 
his  own  contemporaries,  Pott  (Chir.  Works,  vol.  2;, 
Morand  (Opusc.  de  Chir.  t.  1,  p.  232),  and  de  La  Mar- 
tini^re  (Mem.  de  I’Acad.  de  Chur.  vol.  4,  p.  1),  and  also 
from  later  writers,  to  whom  reference  will  be  made  in 
speaking  of  Gun-shot  Wounds.  Even  Bilguer  himself 
was  compelled  to  admit  the  necessity  of  amputation  in 
cases  of  gangrene. — (Anweis.  fiir  die  Feldwundarzie, 
8. 170.) 

Bilguer’s  colleague,  the  celebrated  Schmucker,  in- 
clined to  the  same  doctrines,  and  has  detailed  several 
cases,  where  limbs  were  not  only  shattered,  but  actu- 
ally carried  away  by  balls,  yet  where  a cure  followed 
xvithout  amputation.  One  of  his  maxims  was,  that  it 
was  better  for  the  member  to  be  taken  off  by  gun-shot 
than  by  the  surgeon’s  knife,  as  the  ball  operated  on  a 
healthy  subject,  and  the  knife  on  a person  debilitated  by 
an  hospital. — (Chir.  Wahrn.  th.  2,  s.  493.)  In  a later 
valuable  essay  on  this  subject,  he  restricts  amputation 
to  shattered  limbs  affected  with  gangrene.  His  mode 
of  operating  was  that  of  M.  Louis.  He  sanctioned 
joint-operatiotmi  on  the  hip  and  shoulder;  but  con- 
demned those  of  the  knee  and  elbow  as  never  answer- 
ing.— (Verm.  Schrift.  th.  1,  s.  3.) 

Soon  after  the  middle  of  the  last  century,  the  prac- 


tice of  amputating  at  the  joints  began  to  excite  Increased 
attention  ; but  as  this  is  a topic  to  wliich  I must  pre 
sently  return,  it  is  unnecessary  now  to  dwell  upon  it 
The  writings  of  Ihithod,  Wohler,  Brasdor,  Barbet,  Sa- 
batier, Park,  Moreau,  and  Vennandois,  in  relation  to  tliis 
subject,  deserve  particular  notice. 

I now  come  to  Mr.  Alanson,  whose  name  is  as  con- 
spicuous in  the  history  of  amputation  as  that  of  any 
surgeon  yet  mentioned.  His  chief  objects  were  to  hin- 
der a protrusion  of  the  bone,  and  to  promote  union  by 
the  first  intention.  He  rejectt*d  the  band  which  was 
formerly  put  round  the  limb  for  the  guidance  of  the 
knife,  as  altogether  useless,  and  an  impediment  to  the 
quick  performance  of  the  circular  incision  through  the 
skin.  Wlien  the  tourniquet  had  been  applied,  an  as- 
sistant grasped  the  integuments  with  both  bands,  and 
drew  them  and  the  muscles  firmly  upwards.  The  ope- 
rator then  fixed  his  eye  upon  the  proper  part  where  he 
was  to  begin  the  incision,  which  was  made  with  consi- 
derable facility  and  despatch,  the  knife  passing  xvith 
greater  quickness  in  consequence  of  the  tense  state  of 
the  integuments. 

After  the  incision  through  the  skin  had  been  made, 
the  assistant  still  continued  a steady  support  of  the 
parts,  while  Mr.  Alanson  separated  the  cellular  and 
ligamentous  attachments  xvith  the  point  of  his  knifie  till 
as  much  skin  had  been  drawn  up  as  would,  with  the 
muscles  divided  in  the  particular  way  hereafter  recom- 
mended, fully  cover  the  whole  surface  of  the  wound. 
Then,  instead  of  appljing  the  knife  close  to  the  edge  of 
the  integiunents,  and  dividing  the  muscles  in  a circular 
perjiendicular  manner  down  to  the  bone,  Mr.  Alanson 
proceeded  as  follows : when  operating  upon  the  tnigh, 
and  standing  on  the  outside  of  the  limb,  he  applied  the 
edge  of  his  knife  under  the  edge  of  the  supported  inte- 
guments, upon  the  inner  margin  of  the  vastus  intemus 
muscle,  and  cut  obliquely  through  that  and  the  adja- 
cent muscles  upwards  as  to  the  limb,  and  down  to  the 
bone,  so  as  to  lay  it  bare  about  three  or  four  finger- 
breadths  higher  than  is  usually  done  by  the  common 
perpendicular  circular  incision.  He  now  drew  the 
knife  towards  himself ; then  keeping  its  point  upon  the 
bone,  and  the  edge  in  the  same  oblique  line  already 
jiointed  out  for  the  former  incision,  he  divided  the  rest 
of  the  muscles  in  that  direction  all  round  the  limb  ; the 
point  of  the  knife  being  in  contact  with  and  revolving 
round  the  bone  through  the  whole  of  the  division. 

According  to  Mr.  Alanson,  the  speedy  execution  of 
the  above-directed  incision  will  be  much  expedited  by 
one  assistant  continuing  a firm  and  steady  elevation  of 
the  parts,  and  another  taking  care  to  keep  the  skin  from 
being  w’ounded  as  the  knife  goes  through  the  muscles, 
at  the  under  part  of  the  limb.  Mr.  Alamson  censures 
the  old  method  of  depriving  the  bone  of  its  periosteum 
to  a considerable  extent  above  and  below  t’...e  part  where 
the  saw  was  to  pass,  not  only  as  creating  unnecessary 
delay,  but,  since  the  periosteum  serves  to  support  the 
vessels  in  their  passage  to  the  bone,  as  apt  to  produce 
exfoliations  above  the  part  where  the  bone  is  to  be  di- 
vided with  the  saw.  Instead  of  this  practice  he  re- 
commends first  the  application  of  the  retractor,  as  ad- 
vised by  Gooch  and  Bromfield  ; and  then  denuding  the 
bone  at  the  part  w here  the  saw  is  to  pass,  whereby  the 
bone  may  be  sawed  off  higher  than  is  usually  practised ; 
a material  object  for  hindering  a projection  of  the  bone 
and  forming  a small  cicatrix. 

If  the  flesh  of  a stump  formed  in  the  thigh  agreeably 
to  the  foregoing  plan,  be  gently  brought  forwards  after 
the  operation,  and  the  surface  of  the  wound  be  then 
viewed,  it  may  be  said  to  resemble  in  some  degree  a 
conical  cavity,  the  apex  of  which  is  the  extremity  of 
the  bone;  and  the  thus  divided  Mr.  Alanson 

thought  the  best  calculated  to  prevent  a sugar-loaf 
stump. 

The  part  where  the  bone  is  to  be  laid  bare,  whether 
two,  three,  or  four  Anger -breadths  higher  than  the  edge 
of  the  retracted  integuments  ■;  or,  in  other  words,  the 
quantity  of  muscular  substance  to  be  taken  out  in  mak- 
ing the  double  incision,  must  be  regulated  by  considerr 
ing  the  length  of  the  limb,  and  the  quantity  of  skin  that 
has  been  previously  saved  by  dividing  the  membranous 
attachments.  The  quantity  of  skin  saved,  and  muscu- 
lar substance  taken  out,  must  be  in  such  exact  propor- 
tion to  each  other,  that  the  whole  strrface  of  the  wotmd 
w'ill  afterward  be  easily  covered,  and  the  limb  not  more 
shortened  than  is  necessary  to  obtain  this  end. 

After  the  removal  of  the  limb,  Mr.  Alanson  drew  each 


AMPUTATION. 


57 


bleeding  artery  gently  out  ■with  the  tenaculum,  and  tied 
it  as  nakedly  as  possible  with  a common  slender  liga- 
ture. When  the  large  vessels  had  been  tied,  the  tour- 
niquet was  immediately  slackened,  and  the  wound  well 
cleaned,  in  order  to  detect  any  vessel  that  might  other- 
wise have  remained  concealed  with  its  orifice  blocked 
up  with  coagulated  blood ; and  before  the  wound  was 
dressed,  its  whole  surface  was  examined  with  the  great- 
est accuracy ; by  which  means  Mr.  Alanson  frequently 
observed  a pulsation  where  no  hemorrhage  previously 
appeared,  and  turned  out  a small  clot  of  blood  from 
within  the  orifice  of  a considerable. artery.  He  is  very 
particular  in  recommending  every  vessel  to  be  secured 
that  is  likely  to  bleed  on  the  attack  of  the  s)Tnptomatic 
fever ; for,  besides  the  fatigue  and  pain  to  which  such 
an  accident  immediately  exposes  the  patient,  it  seriously 
interrupts  the  desired  union  of  the  wound.  He  used 
always  to  clean  the  whole  surface  of  the  wound  well 
with  a sponge  and  warm  water,  as  be  thought  that  the 
lodgement  of  any  coagulated  blood  would  be  a consider- 
able obstruction  to  the  quick  miion  of  the  parts. 

The  skin  and  muscles  were  now  gently  brought  for- 
wards ; a flannel  roller  was  put  around  the  body,  and 
carried  two  or  three  times  rather  tightly  round  the 
upper  part  of  the  thigh,  as  at  this  point  it  was  intended 
to  form  what  Mr.  Alanson  called  a sufficient  basis, 
which  materially  added  to  the  support  of  the  skin  and 
muscles.  The  roller  was  then  carried  down  in  a cir- 
cular direction  to  the  extremity  of  the  stump,  not  so  tight 
as  to  press  rudely  or  forcibly,  but  so  as  to  give  an  easy 
support  to  the  parts. 

The  skin  and  muscles  were  now  placed  over  the  bone 
in  such  a direction  that  the  wound  appeared  only  as  a 
line  across  the  face  of  the  stump,  with  the  angles  at 
each  side,  from  which  points  the  ligatures  were  left 
out,  as  their  vicinity  to  either  angle  might  direct.  The 
skin  was  easily  secured  in  this  posture  by  long  slips 
of  linen  or  lint  of  the  breadth  of  about  two  fingers, 
spread  with  cerate  or  any  cooling  ointment.  If  the 
skin  did  not  easily  meet,  strips  of  sticking-plaster  were 
preferred.  These  were  applied  from  below  upwards, 
across  the  face  of  the  stump,  and  over  them  a soft 
tow-pledget  and  compress  of  linen;  the  whole  being 
retained  with  the  many-tailed  bandage,  and  two  tails 
placed  perpendicularly,  in  order  to  retain  the  dressings 
upon  the  face  of  the  stump. 

Mr.  Alanson  censured  the  plan  of  raising  the  end  of 
the  stump  far  from  the  surface  of  the  bed  with  pillows, 
as  the  posterior  mhscles  were  retracted  by  it ; and  he 
considered  it  best  to  raise  the  stump  only  about  half  a 
hand’s  breadth  from  the  surface  of  the  bed,  by  which 
means  the  muscles  were  put  in  an  easy  relaxed  posi- 
tion. The  many-tailed  bandage  Mr.  Alanson  found 
much  more  convenient  than  the  woollen  cap,  frequently 
used  in  former  times  to  support  the  dressings  ; and  he 
observes,  that  though  thi,s  seems  well  calculated  to  an- 
swer that  purpose,  yet  if  it  be  not  put  on  with  particu- 
lar care,  the  skin  is  liable  to  be  drawn  backwards  from 
the  face  of  the  stump ; nor  can  the  wound  be  dressed 
without  first  lifting  up  the  stump  to  remove  the  cap.— (See 
Alanson’s  Tract.  Obs.  on  Amputation,  8vo.  Lond.  1779.) 

The  chief  peculiarity  of  Alanson’s  method  of  ope- 
rating, namely,  the  mode  in  which  he  recommended 
the  oblique  division  of  the  muscles  to  be  performed,  did 
not,  however,  meet  with  universal  approbation,  and 
his  extensive  dissection  of  the  skin  from  the  muscles 
was  complained  of  as  excessively  painful.  The  forma- 
tion of  a conical  wound  by  following  Alanson’s  direc- 
tions, was  regarded  by  several  as  impracticable. — (See 
Marten’s  Paradoxieen,  b.  1,  s.  88;  Loeffler,  Beytrage  1, 
No.  7 ; Wardenburg,  Briefe  eines  Arztes,  b.  2,  p.  20  ; 
Richter,  Anfangsgr.  vol.  7 ; Graefe,  Normen,  &c.  p.  8 ; 
Hey,  Pract.  Obs.)  In  my  opinion  there  can  be  no 
doubt  of  the  truth  of  some  of  the  criticisms  made  by 
these  and  some  other  writers  on  the  impossibility  of 
making  a wound  with  a regular  conical  ca-vity,  by  ob- 
serving the  directions  given  by  Alanson;  for  if  the 
knife  be  carried  round  the  member  with  its  edge  turned 
obliquely  upwards  towards  the  bone,  it  -will  pass  spi- 
rally, and  of  course  the  end  of  the  incision  will  be  con.si- 
derably  higher  than  the  beginning.  But  though  Alanson 
probably  never  did  himself  exactly  what  he  has  stated, 
1 am  sure  that  his  proposition  of  making  an  oblique 
division  of  the  muscles  all  round  the  member  has  been 
the  source  of  great  improvement  in  amputations  iti 
general,  and  is  what  is  usually  aimed  at  by  all  the  best 
mode/n  surgeons.  It  is  true  they  do  not  actually  per- 


form the  oblique  incision  all  round  the  limb  by  one 
stroke  or  revolution  of  the  knife  round  the  bone,  as 
Alanson  says  that  he  did ; but  they  accomplish  their 
purpose  by  repeated,  distinct,  and  suitable  applications 
of  the  edge  of  the  instrument  turned  obliquely  upwards 
towards  the  bone  or  bones. 

Among  others,  Mynors  found  fault  with  some  of  Alan- 
son’s instructions,  and  thought  every  desideratum 
might  be  more  certainly  attained  by  saving  skin  enough, 
and  then  cutting  through  the  muscles.  The  first  inci- 
sion, however,  he  directed  obliquely  upwards  through 
the  integuments,  wiiilo  they  were  drawn  up  by  an  as- 
sistant, and  he  then  cut  down  to  the  bone. — (Pract. 
Thoughts  on  Amputation,  8vo.  Birming.  1783.)  Spren- 
gel  considers  Mynors’s  plan  merely  as  a revival  of  Cel- 
sus’s  method,  as  it  had  in  view  only  the  preservation 
of  skin,  and  not  the  formation  of  a fleshy  cushion. — 
(Geschichte  der  Chir.  b.  1,  p.  426.) 

Kirkland  endeavoured  to  improve  Mynors’s  plan  by 
cutting  off  a piece  of  skin  at  each  angle  of  the  stump, 
so  as  to  keep  the  integuments  from  being  thrown  into 
folds ; and  in  opposition  to  Pott,  he  defended  the  .senti- 
ments of  Bilguer  concerning  the  successful  manage- 
ment of  desperate  cases  without  amputation. — (On  the 
present  State  of  Surgery,  p.  273,  and  Thoughts  on  Am- 
putation, 8vo.  Lond.  1780.) 

B.  Bell  used  to  operate  very  much  in  the  same  way 
as  Mynors ; and  when  it  seemed  advantageous  to  make 
a flap,  he  did  not  disapprove  of  the  plans  suggested 
by  Ravaton,  Verduin,  and  Alanson. — (Syst.  of  Surgery.) 

An  interesting  paper  on  amputation  was  some  years 
ago  published  by  Loder  ; its  chief  purport  was  to  de- 
fend Alanson’s  method  -with  some  slight  modifications. 
—(Chir.  und  Medic.  Beobacht.  b.  1,  p.  20,  8vo.  1794.) 
However,  the  alterations  suggested  by  Loder  do  not 
seem  to  Graefe  at  all  adequate  to  the  removal  of  the 
difficulties  with  which  the  mode  of  cutting  the  flesh  ex- 
actly after  Alanson’s  directions  is  complicated. — (No6- 
men  fiir  die  Abl.  grosserer  Gliedmassen,  p.  8,  4to.  Ber- 
lin, 1812.) 

The  removal  of  limbs,  without  bloodshed,  proposed 
by  Guido  di  Cauliaco  in  the  14th  century,  has  met  with 
modern  defenders  in  J.  Wrabetz  and  W.  G.  Plouquet. 
J.  Wrabetz,  with  a ligature,  which  was  daily  made 
tighter,  took  off  an  arm  above  the  elbow.  In  the  fissure 
he  sprinkled  a styptic  powder.  On  the  fourth  day,  the 
flesh  was  severed  down  to  the  bone,  which  was  sawed 
through. — (Geschichte  eines  ohne  Messer  abgesetzten 
Oberarms,  8vo.  Freyb.  1782.)  Plouquet  thought  the 
plan  suited  to  emaciated  timid  subjects,  but  not  well 
adapted  to  the  leg  or  forearm. — (Von  der  Unblutigen 
Abnehmung  der  Glieder,  8vo.  Tub.  1786.) 

Some  other  modes  of  doing  flap-amputations,  and  in 
particular  the  suggestions  and  improvements  made  by 
Hey,  Chopart,  Dupuytren,  Larrey,  Lisfranc,  and  other 
modern  practitioners,  will  be  noticed  in  the  description 
of  the  amputation  of  particular  members.  In  the  mean 
time,  I shall  conclude  this  section  with  mentioning  the 
laudable  attempts  made  at  different  periods  to  render 
the  patient  less  sensible  of  the  agony  produced  by  the 
removal  of  a limb.  Theodoricus,  as  we  have  said,  ad 
ministered  for  this  purpose  opium  and  hemlock,  and 
though  he  was  imitated  by  many  of  the  ancient  sur- 
geons, few  moderns  have  deemed  the  practice  worthy 
of  being  continued.  Guido  made  the  experiment  of 
benumbing  the  parts  with  a tight  ligature ; but  a ma- 
chine devised  a few  years  ago  in  England  expressly 
for  the  object  of  stupifying  the  nerves  of  a limb  pre- 
viously to  amputation,  is  perhaps  not  undeserving  of 
farther  consideration. — (See  J.  Moore’s  Method  of  pre- 
venting or  diminishing  Pain  in  several  Operations  of 
Surgery,  8vo.  Lond.  1784.)  The  great  reason  of  the 
latter  plan 'being  given  up  is,  that  some  patients  have 
made  more  complaint  of  the  sufferings  occasioned  by 
the  process  of  dulling  the  sensibility  of  the  nerves  than 
of  the  agony  of  amputation  itself  without  any  such  ex- 
pedient. Yet  daily  experience  proves  that  the  pressure 
caused  on  the  sciatic  nerve  by  sitting  with  the  pelvis 
in  a certain  position,  will  completely  benumb  the  foot 
and  leg,  and  this  with  such  an  absence  of  pain,  that 
the  person  so  affected  is  actually  unaware  of  his  foot 
being  asleep,  as  it  is  termed,  until  he  tries  to  walk. 
On  the  little  good  done  by  warming  and  oiling  the  cut- 
ting instruments,  a method  once  much  commended 
(Faust  und  Hunold  fiber  die  Anwendung des  Oehls  und 
der  Warine,  p.  3 — 23,  Leipsic,  1806),  I am  sure  it  is  un- 
necessary for  uio  to  comment. 


58 


AMPUTATION. 


AMPHTATIOS  OF  THK  THtOn. 

The  thigh  ought  always  to  be  amputated  as  low  as 
the  disease  will  allow,  so  that  as  little  of  the  limb  may 
be  cut  off  as  possible,  the  pain  may  not  be  greater  than 
necessary,  and  the  surface  of  the  wound  have  less  ex- 
tent than  would  otherwise  happen. — Sabatier,  Med. 
Obs.  p.  350,  t.  3,  ed.  2.)  The  patient  is  to  be  placed  on 
a firm  table,  with  his  back  properly  supported  by  pil- 
lows and  assistants,  who  are  ^so  to  hold  his  hands, 
and  keep  him  from  moving  too  much  during  the  ojie- 
ration.  The  ankle  of  the  sound  limb  is  to  be  fastened  by- 
means  of  a strong  band  or  garter  to  the  nearest  leg  of 
the  table. 

Here,  how'ever,  through  an  imprudent  solicitude  to 
obtain  the  above  advantages,  let  not  tlie  surgeon  ever 
be  unmindAil  of  the  great  axiom  in  surgical  operations, 
that  all  the  diseased  jiarts  should  be  removed;  but  let 
him  be  assured  of  the  truth  of  what  Graefe  inculcates, 
that  it  18  more  pardonable  to  cut  away  too  much  than 
too  little. — i.Normen  fiir  die  Abldsung  grdsserer  Gliedm. 
p 60.)  At  the  same  time,  I do  not  agree  with  some 
modern  writers,  who  deem  it  necessary  to  amputate 
beyond  the  limits  of  every  abscess  and  sinus,  wliich 
may  extend  very  far  above  a diseaseil  joint  or  compound 
fracture.  Many  of  these  suppurations  are  only  like 
ordinary  abscesses,  and  finally  gel  well  aAer  the  main 
disease  or  injury  is  removed,  as  I have  often  seen. 
Were  it  an  invariable  rule  to  cut  off  a limb  above  every 
collection  of  matter,  sometimes  five  or  six  inches  more 
of  the  thigh  -would  be  sacrificed  than  circumstances 
absolutely  demanded,  and  the  greater  danger  of  a high 
than  a low  amputation  would  be  encountered.  How- 
ever, in  all  cases  where  the  bone  is  susjiected  to  be  un- 
sound, or  the  muscles  are  affected  with  the  morbid 
changes  peculiar  to  fungus  htematodes  or  other  incurable 
diseases,  the  operation  should  be  practised  sulficiently 
high  to  take  aw  ay  all  the  distem}»ered  pans.  In  second- 
ary amputations,  where  there  has  been  much  suppura- 
tion in  the  limb,  an^  i sinus  runs  up,  Mr.  Guthrie  says, 
that  if  the  sinus  extend  only  a short  way  between  the 
muscles,  the  membrane  lining  it  may  be  dissected  out ; 
but  if  the  matter  has  lain  upon  the  bone,  this  will  have 
become  diseased,  and  amputation  should  be  done  high 
enough  to  remove  the  affected  part  of  it. — (On  Gun-shot 
Wounds,  p.  67.) 

Many  writers  disapprove  of  amputating  too  close  to 
the  knee  (Graefe,  Op.  cit.  p.  60) ; and  Langenbeck  urges 
one  objection  to  it  not  specified  by  any  other  author, 
viz.  that  if  the  operation  be  done  lower  dow  n than  tw'o 
hand-breadths  above  the  knee,  the  femoral  artery  shrinks 
into  the  aponeurotic  sheath,  which  it  here  receives 
from  the  vastus  internus  and  triceps,  and  cannot  be 
drawn  out  with  the  forceps,  so  as  to  be  separately  tied, 
without  first  slitting  up  that  sheath.  Hence,  he  recom- 
mends cutting  through  the  muscles  at  the  distance 
above  the  knee  already  mentioned. — (Bibl.  flirdie  Chir. 
b.  1,  p.  571,  12mo.  Gott.  1806.)  But  w hen  I come  to 
look  at  the  breadth  of  two  adult  hands,  and  see  how 
much  of  the  limb  would  be  sacrificed  at  all  events, 
only  to  save  a little  trouble,  1 cannot  bring  my  mind 
to  concur  with  Langenbeck — the  remedy  being  worse 
than  the  alleged  evil. 

The  next  tlung  is  the  application  of  the  tourniquet. — 
(See  Tourniquet.)  The  pad  should  be  placed  exactly 
over  the  femoral  artery  in  as  high  a situation  as  can 
be  conveniently  done.  When  the  tliigh  is  to  be  ampu- 
tated high  up,  it  is  better  to  let  an  assistant  (impress 
the  femoral  artery  in  the  groin  wath  any  commodious 
instrument,  furnished  with  a round  blunt  end,  calcu- 
lated for  making  direct  pressure  on  the  vessel  without 
injuring  the  integuments.  Some  authojs  indeed  give  a 
general  preference  to  this  method,  whether  the  thigh 
be  amputated  high  up  or  low  down. — (Paroisse,  Opus- 
cules de  Chir.  p.  188.  Briinninghause^  Erfahr.  fiber 
die  Amp.  p,  273.  Langenbeck,  Bibl.  Chir.  p.  564.  See 
also  Liston’s  Obs.  in  Ed.  Med.  and  Surg.  Joiim.  vol. 
20,  p.  43.)  Were  the-patient,  however,  in  a debilitated 
state,  and  unable  to  bear  loss  of  blood,  as  there  might, 
in  this  way,  be  some  considerable  bleeding,  by  reason 
of  the  anastomoses  with  the  branches  of  the  internal 
iliac  artery',  I should  feel  disposed  to  employ  the  tour- 
niquet whenever  circumstances  would  admit  of  its 
application.  In  amputations  of  the  thigh,  the  great 
objection  to  the  use  of  this  instrument  is,  that  it  im- 
pedes the  free  and  immediate  retraction  of  the  loose 
muscles  after  they  have  been  cut ; the  consequence  of 
which  is,  that  the  surgeon  cannot  divide  so  high  as  he 


otherwise  could  do,  the  deeper  muscles  which  are  more 
fixed  and  attached  to  the  bone.  Yet  in  order  to  have 
the  bone  well  covered  with  flesh,  and  no  danger  of  a 
sugar-loaf  stump,  the  latter  object  is  one  of  vast  im- 
portance. Perhaps  the  best  general  rule  is  to  abandon 
the  application  of  the  tourniquet  in  amputations  done 
a.s  high  as  the  middle  of  the  thigh,  except  where  the 
patient  is  remarkably  weak,  so  that  he  cannot  bear  the 
smallest  loss  of  blood,  and  no  steady  intelligent  assist- 
ant is  at  hand,  to  w hom  the  compression  of  the  artery 
in  the  groin  can  be  prudently  confided.  When,  how- 
ever, the  operation  is  to  be  done  much  higher  up,  of 
course  the  employment  of  a tourniquet  is  wholly  inad- 
missible. 

\N  hether  the  right  or  left  thigh  is  to  be  removed,  it  is 
customary  for  the  operator  to  stand  on  the  patient’s 
right  side.  The  great  advantage  of  this  situation  seems 
to  be,  that  the  surgeon’s  left  hand  can  be  thus  more 
conveniently  and  quickly  brought  into  use  than  if  he 
were  always  to  stand  oil  the  same  side  as  the  limb  he 
is  about  to  amputate.  This  seems  to  be  the  only  as- 
signable reason  for  this  habit ; for  w hen  the  left  thigh 
is  to  be  amputated,  it  is  certainly  some  inconvenience 
to  have  the  right  limb  between  the  operator  and  the  one 
that  is  to  be  removed.  But  this  is  found  less  inconve- 
nient than  not  ha-ving  the  left  hand  next  the  wound. 

Mr.  Guthrie,  in  speaking  of  amputations  on  the 
two  lower  thirds  of  the  thigh,  observes,  that  “ in 
these  cases  the  tourniquet  should  be  used  but  in  ope- 
rations high  up  the  thigh,  he  joins  all  other  surgeons 
in  recommending  the  inguinal  artery  to  be  compressed 
against  the  os  pubis. — (On  Gun-shot  Wounds,  p.  202.) 
The  utility  of  slackening  the  tourniquet  completely, 
however,  as  soon  as  the  principal  vessels  are  secured, 
a piece  of  advice  delivered  by  this  excellent  surgeon,  I 
presume,  cannot  be  right  on  the  ground  which  he  spe- 
cifies, vi/.  the  impediment  made  by  the  strap  of  the  in- 
strument to  the  retraction  of  the  muscles,  and  the  con- 
sequent difficulty  in  high  operations  of  sawing  the 
bone,  because  in  common  practice  the  bone  is  always 
sawed  before  any  of  the  vessels  are  secured ; and  loos- 
ening the  tourniquet  entirely,  while  any  arterial 
branches  still  require  the  ligature,  must  generally  be 
objectionable,  if  loss  of  blood  be  a disadvantage.  In 
flap-amputations  high  up  the  limb,  indeed,  where  the 
arteries  are  sometimes  tied,  before  the  division  of  the 
bone,  the  employment  of  a tourniquet  at  all  is  quite 
out  of  the  question. 

We  know  that  it  was  an  opinion  of  the  late  Mr.  J, 
Bell,  that  the  flow  of  blood  through  a large  artery 
could  not  be  cwnpletely  stopped  by  pressure ; and  the 
late  Mr.  Hey  adopted  a similar  notion,  in  consequence 
of  seeing  a case  in  w hich  the  application  of  two  tour- 
niquets to  the  thigh  did  not  restrain  the  hemorrhage 
from  a fungus  haimatodes  of  the  limb.  He  says,  the 
pressure  of  the  tourniquet  does  not  completely  obstruct 
the  passage  of  blood  in  the  arteries ; it  only  diminishes 
so  much  of  the  force  of  the  current  as  to  enable  the 
vessels,  in  a sound  state,  to  exert  their  natural  con- 
tractile power  so  effectually  tis  to  prevent  hemorrhage, 
(See  Hey’s  Pract.  Obs.  p.  257, 258,  ed.  2.)  Of  the  inac- 
curacy of  this  doctrine  no  man  can  doubt,  who  sees 
the  femoral  artery  with  its  open  mouth  on  the  face  of 
a stump  not  blee^ng,  while  the  tourniquet  is  tight,  or 
skilful  pressure  is  kept  up,  but  throwing  out  its  blood 
to  a great  distance  the  instant  the  pressure  is  disconti- 
nued. Nor,  I apprehend,  can  any  surgeon,  who  has 
amputated  at  the  shoulder,  and  seen  how  completely 
pressure  commands  the  flow  of  blood  through  the  open- 
mouthed  axillary  artery,  join  in  the  sentiment  of  John 
Bell  and  Hey  upon  this  particular  point.  Here  I can 
speak  with  confidence,  because  I have  myself  ampu- 
tated at  the  shoulder,  and  assisted  at  this  operation  seve- 
ral times,  and  found  the  statements  of  the  preceding 
writers  perfectly  and  clearly  contradicted.  Were  any 
farther  testimony  required,  I might  cite  that  of  Dr 
Hennen,  who  mentions,  among  other  facts,  that  in  a 
shoulder-joint  case,  operated  upon  by  Mr.  Dease,  the 
amount  of  blood  lost  from  the  principal  artery  was 
no  more  than  the  quantity  contained  between  the  point 
of  pressure  and  the  point  of  incision  through  the  ves- 
sels.—(Principles  of  Military  Surgery,  p,  257,  ed.  2.) 
The  same  fact  presented  itself  in  the  example,  where  I 
recently  assisted  Dr.  Biicke  in  private  practice. 

Mr.  Liston,  of  Edinburgh,  confirms  the  preceding 
statement,  observ'ing  that  pressure  complete  enough 
not  only  to  stop  the  pulsation  of  an  artery  in  a limb, 


AMPUTATION. 


69 


but  also  to  arrest  completely  the  flow  of  blood,  can  be 
easily  applied  by  means  of  the  fingers  only.  And,  in  or- 
der to  prove  the  correctness  of  this  remark,  he  has  re- 
peatedly, when  no  proper  assistant  was  at  hand,  com- 
pressed both  the  femoral  and  humeral  arteries  with  the 
fingers  of  one  hand,  while  with  the  other  hand  he  re- 
moved the  limb,  and  this,  as  he  affirms,  with  the  loss 
of  much  less  blood  than  if  he  had  followed  the  ordi- 
nary mode.  His  common  practice,  however,  is  to  let 
the  pressure  be  made  by  an  assistant,  and  to  employ 
no  tourniquet. — (See  Ed.  Med.  and  Surg.  Journ.  vol. 
20,  p.  44.) 

If,  then,  the  flow  of  blood  through  an  arterj'  can 
easily  be  commanded  by  pressure,  how  are  we  to  ex- 
plain the  occasional  continuance  of  bleeding,  notwith- 
standing the  pressure  of  one,  or  even  two,  tourniquets  ? 
Without  doubt,  by  the  fact  that  the  pads  of  these  in- 
struments, when  not  duly  arranged,  do  more  harm 
than  good,  by  raising  the  band  off  the  vessel,  and  per- 
haps also,  in  Mr.  Hey’s  example,  by  the  additional  con- 
sideration, that  tumours  of  the  fungus  haematodes  kind 
include  a large  quantity  of  blood,  and  will  bleed  pro- 
fusely, and  for  a considerable  time,  after  the  main  sup- 
ply of  blood  to  them  is  cut  off.  The  same  thing  hap- 
pens in  the  disease  called  aneurism  by  anastomosis,  as 
I have  had  several  opportunities  of  witnessing,  but  in  no 
instance  more  strikingly  than  in  one,  where,  some  time 
after  Mr.  Hodgson  had  tied  the  radial  and  ulnar  arte- 
ries, Mr.  Latvrence  divided  every  part  of  the  finger, 
excepting  the  tendons  and  bone,  and  yet  a considerable 
bleeding  went  on  from  the  farther  side  of  the  wound. — 
(See  Med.  Chir.  Trans,  vol.  9,  p.  216.) 

The  application  of  the  tourniquet  is  generally  left 
too  much  to  assistants  ; but,  as  far  as  my  judgment  ex- 
tends, no  operator  is  justified  in  commencing  his  inci- 
sions before  he  has  examined,  and  fully  satisfied  him- 
self that  the  instrument  is  correctly  applied.  Mr. 
Guthrie  candidly  tells  us,  that  he  once  lost  an  officer, 
in  consequence  of  hemorrhage  during  the  operation, 
although  the  tourniquet  was  in  the  charge  of  a sur- 
geon of  ability ; and  the  advice  with  which  he  follows 
this  statement  is  worth  recollecting : “ In  a case  of  this 
kind,  where  it  (the  tourniquet)  is  found  of  little  benefit, 
the  surgeon  should  not  continue  twisting  and  turning 
it,  while  his  patient  is  bleeding,  but  quit  it  altogether, 
and  compress  the  artery  against  the  pubes.”  This 
maxim,  I think,  cannot  be  too  highly  commended. 

The  shape  and  size  of  the  pad  of  the  tourniquet  are 
matters  of  importance.  At  St.  Bartholomew’s,  the 
pads  employed  are  very  firm,  being  composed  of  wood, 
or  cork  covered  with  leather,  and  rather  thicker  than 
the  thumb,  the  upper  surface  being  flat,  and  the  lower, 
which  is  put  against  the  thigh,  being  convex.  They 
are  about  an  inch  and  a half  in  length.  Such  pads  an- 
swer extremely  well,  as  I can  affirm  from  the  observa- 
tion of  some  hundreds  of  amputations  in  that  hospital. 
A common  fault  formerly  was  the  employment  of  pads 
which  were  too  large  and  soft,  and  not  judiciously 
shaped.  As  Mr.  C.  Hutchison  remarks,  the  principal 
objection  to  a large  pad  is,  that  the  band  of  the  tourni- 
quet is  so  much  raised  by  it,  that  a considerable  space 
is  left  on  each  side  of  it,  where  no  compression  is 
made  on  the  limb,  however  closely  the  instrument  may 
be  screwed,  and  thus  there  will  be  a risk  of  hemor- 
rhage from  such  vessels  as  happen  to  be  in  these  situa- 
tions. The  same  gentleman  uses  a pad  which  is  not 
thicker  than  a finger,  and  places  it  obliquely  over  the 
artery,  so  as  to  preclude  the  possibility  of  displace- 
ment.— (Pract.  Obs.  in  Surgery,  p.  21 — 23.)  Mr.  Guth- 
rie says,  “ the  pad  should  be  firm  and  rather  narrow, 
and  carefully  held  directly  over  the  artery,  while  the 
ends  of  the  bandage  in  which  it  is  contained,  are  pinned 
on  the  thigh.  The  strap  of  the  tourniquet  is  then 
to  be  put  round  the  limb,  the  instrument  itself  being 
directly  over  the  pad,  with  the  screw  entirely  free. 
The  strap  is  then  to  be  drawu  tight,  and  buckled  on  the 
outside,  so  as  to  prevent  its  slipping,  and  not  interfere 
with  the  screw,  which  is  to  be  turned  until  the  pres- 
sure is  sufficiently  forcible  to  stop  the  circulation.  If 
the  screw  require  to  be  turned  for  more  than  half  its 
number  of  turns  to  effect  this,  the  strap  is  not  suffi- 
ciently tight,  or  the  pad  has  not  been  well  applied,  and 
they  must  be  replaced.”— (On  Gun-shot  Wounds,  p. 
204.) 

In  two  amputations  at  St.  Bartholomew’s  Hospital, 
I saw  the  tourniquet  break  after  the  soft  parts  had  been 
divided,  and  as  in  one  of  these  cases  a good  deal  of 


blood  was  lost,  because  another  tourniquet  happened 
not  to  be  in  the  room,  and  i)ressure  on  the  artery  in  the 
groin  was  not  immediately  adopted,  I coincide  with 
such  writers  as  recommend  the  rule  of  always  having 
two  tourniquets  ready.  Graefe  even  goes  so  far  as  to 
advise  putting  both  of  them  round  the  limb  before  the 
operation  commences  (Normen  ftir  die  Ablosung  gros- 
serer  Gliedmassen,  p.  48) ; but  the  frequency  of  a tour- 
niquet breaking  is  not  so  great,  I believe,  as  to  demand 
such  precaution,  and  the  plan  would  be  very  objectiona- 
ble in  thigh-amputations,  where  it  is  a material  advan- 
tage to  have  plenty  of  room  between  the  place  of  the 
incision  and  the  band  which  goes  round  the  limb. 

An  assistant,  firmly  grasping  the  thigh  with  both 
hands,  is  to  draw  up  the  skin  and  muscles,  while  the 
surgeon,  beginning  with  that  part  of  the  edge  of  the 
knife  which  is  towards  the  handle,  makes  a circular 
incision  as  quickly  as  possible,  through  the  integu- 
ments down  to  the  fascia,  or,  as  Mr.  Guthrie  and  Dr. 
Hennen  recommend,  even  completely  through  it.  Ac- 
cording to  Mr.  Guthrie,  the  skin  cannot  be  sufficiently 
retracted,  unless  the  fescia  be  divided,  which  he  ap- 
pears to  think  ought  rather  to  be  drawn  up  with  the  in- 
teguments than  dissected  from  them. — (On  Gun-shot 
Wounds,  p.  205.  Also,  Hennen’s  Military  Surgery,  p. 
263.)  On  the  contrary.  Professor  Langenbeck  is  very 
particular  in  enjoining  surgeons  to  avoid  cutting 
through  the  fascia  by  the  first  sweep  of  the  knife,  be- 
cause he  finds  that  the  muscles  are  better  held  together, 
and  can  be  more  regularly  divided,  by  cutting  them  and 
the  fascia  at  the  same  time. — (Bibl.  fur  die  Chir.  b.  1, 
p.  004.;  Nor  does  M.  Roux  divide  the  fascia  by  the 
first  incision. — (M6m.  sur  la  Reunion  immddiate  de  la 
Plaie  apr^s  I’Amputation  circulaire,  p.  9,  8vo.  Paris, 
1814.)  At  St.  Bartholomew’s,  the  surgeons  rarely  or 
never  cut  through  the  fascia  with  the  integuments,  but 
aim  at  carrying  the  knife  perfectly  down  to  it  all  round 
the  limb.  This  at  least  ought  to  be  done  without  fear 
of  doing  rather  more  ; for,  as  Graefe  observes,  if  the 
outer  layers  of  the  muscles  be  here  and  there  a little 
touched,  this  occasions  less  pain  than  the  additional 
strokes  of  the  knife  for  dividing  any  portion  of  the 
skin  and  cellular  substance  not  completely  cut  through 
in  the  first  instance.  Graefe  also  dissents  from  My- 
nors  and  others,  who  are  advocates  for  cutting  the 
skin  obliquely  instead  of  perpendicularly,  because  he 
finds  the  thin  edge  of  the  integuments  thus  separated 
from  the  subjacent  cellular  membrane,  very  apt  to 
slough. — 'Normen  fiir  die  Abl.  grosserer  Gliedmassen, 
p.  102.)  In  a thigh  of  ordinary  dimensions,  the  first 
incision  should  be  made  four  inches  below  where  it  is 
intended  to  saw  the  bone.  When  the  thigh  is  bulky, 
the  large  amputation  knife  will  be  found  the  best.  Be- 
fbre  beginning  this  first  cut,  the  arm  is  to  be  carried 
under  the  limb,  till  the  knife  reaches  almost  round  to 
the  side  on  which  the  operator  stands.  With  one 
sweep  penetrating  at  least  to  the  fascia,  the  knife 
is  then  to  be  brought  round  to  the  point  where 
it  first  touched  the  skin.  Thus,  the  wound  is  more 
likely  to  be  regularly  made,  than  by  cutting  first 
on  one  side,  and  then  on  the  other,  while  the  patient  is 
saved  some  degree  of  pain,  in  consequence  of  the  un- 
interrupted quickness  with  wliich  the  incision  is  made. 
At  the  same  time,  I ought  to  confess,  that  the  late  Sir 
C.  Blicke,  and  some  other  surgeons,  whom  1 have  seen 
operate,  used  to  complete  the  circle  by  two  strokes  of 
the  knife,  so  well  and  expeditiously,  that  their  capri- 
cious attachment  to  this  plan  could  hardly  be  found 
fault  with. 

The  next  object  is  the  preservation  of  as  much  skin 
as  will  afterward,  conjointly  with  the  muscles,  cut  in 
an  oblique  direction,  cover  the  end  of  the  stump  with 
the  utmost  facility.  It  is  rather  difficult  to  lay  down 
any  other  general  principles  for  the  guidance  of  the 
surgeon  in  saving  integuments.  I am  disposed  to 
agree  with  several  modern  w'riters,  that  the  painful 
dissection  of  the  skin  from  the  muscles  has  been  re- 
commended and  practised  to  a very  unnecessary  extent, 
that  is  to  say,  unnecessary  if  the  division  of  the  mus- 
cles be  performed  in  the  most  advantageous  manner. 
Graefe,  one  of  the  best  surgeons  at  Berlin,  does  not 
dissect  the  skin  from  the  muscles  at  all  in  amimtating 
the  thigh,  but  takes  care,  after  making  the  cutaneous 
incision,  to  have  the  integuments  and  subjacent  flesh 
very  firmly  drawn  up  before  commencing  the  oblique 
division  of  the  muscles.  ’I’his  retraction  he  also  strongly 
advises  to  he  done  uniformly  and  smoothly  all  round 


60 


AMPUTATION. 


the  member,  lest  in  dividing  the  muscles  any  irregular 
projection  of  the  skin  interfere  with  the  requisite  move- 
ments of  the  knife. — (Normen  fiir  die  AbL  griisse- 
rer  Gliedmassen,  p.  103.)  Instead  of  dissecting  back 
the  skin,  Dupuytren  cuts  all  the  soft  parts  at  once  to 
the  bone,  which  he  next  removes,  after  retracting  the 
muscles. — Syme,  in  Edinb.  Med.  and  Surg.  Journal, 
voL  14,  p.  32.)  Ilowever,  Langenbeck,  another  of  the 
most  skUfttl  operators  on  the  continent,  prefers  detach- 
ing the  integuments  from  the  ftiscia  for  about  two  tin- 
ger-breadths  (Bibl.  fur  die  Chir.  b.  1,  p.  567),  as  is  per- 
haps the  most  common  practice  in  the  London  hospi- 
tals. Some  late  writers,  particularly  Mr.  Syme,  in  ex- 
pressing their  preference  to  muscle  as  a covering  for 
the  end  of  the  bone,  seem  to  forget  one  fact  which  I 
have  often  noticed,  viz.  that  the  muscular  cushion, 
though  at  first  thick  and  good,  soon  shrinks  to  a com- 
paratively small  mass.  This  is  con.sonant  to  a general 
law  in  the  animal  economy,  prevailing  whenever  the 
natural  action  of  a muscle  is  lost  or  prevented.  Sir 
Astley  Cooper  states,  that  the  covering  for  the  end  of 
the  bone  must  be  integuments  and  not  muscles ; for  if 
muscular  fibres  are  preserved  with  the  integuments 
they  will  contract,  and  retraction  of  the  skin  covering 
the  stump  will  be  the  result. — Lancet,  vol.  1,  p.  148., 
Briinninghausen  also  thinks  skin  a better  and  more 
durable  covering  for  the  end  of  the  bone  than  muscular 
fibres,  which  after  a time  dwindle  away ; and  hence  he 
computes  the  quantity  of  integuments  which  ought  to 
be  saved,  by  the  measure  of  the  circumference  and  dia- 
meter of  the  member.  Thus,  when  the  limb  Is  nine 
inches  in  its  circumference,  the  diamcici  in  ntiuui  three ; 
therefore,  one  inch  and  a half  of  skin  on  each  side  is  to 
be  saved.— (Erfahr.  &,c.  iiber  die  Amp.  p.  75.)  But 
this  atithor  cuts  the  muscles  perpendicularly,  so  that 
he  is  obliged  to  separate  much  more  skin  from  the  flesh 
than  is  necessary  when  the  incision  through  the  mus- 
cles is  carried  obhquely  upward.^.  Mr.  Iley’s  method  of 
calculation,  which  I shall  presently  notice,  appears 
more  adapted  to  ordinary  practice ; and  he  says,  “ the 
di^  ision  of  the  posterior  muscles  may  be  begun  at  half 
an  inch,  and  that  of  the  anterior  at  three  quarters,  above 
the  place  where  the  integuments  were  divided.” — 
(Pract.  Obs.  in  Surgery,  p.  528,  ed.  2.)  With  the  view 
of  preventing  the  necessity  of  dissecting  the  skin  from 
the  fascia,  Mr.  Guthne,  as  already  noticed,  commends 
the  plan  of  cutting  through  the  fascia,  together  with 
the  integuments,  by  the  first  stroke  of  the  kinfe,  and  re- 
tracting these  parts  at  the  same  time,  instead  of  de- 
taching them  from  each  other.  If  this  method  be  found 
perfectly  efficient,  and  it  be  not  objectionable,  as  ex})Os- 
ing  the  muscles  to  be  cut  unnecessarily,  I think  the 
reason  specified  against  it  by  Langenbeck,  and  ex- 
plained in  a preceding  page,  not  weighty  enough  to 
form  a just  ground  for  rejecting  a practice  which  comes 
with  the  alleged  advantage  of  superseding  the  neces- 
sity for  all  painful  dissection  of  the  skin  from  the 
muscles.  However,  in  secondary’  amputations  of  the 
thigh,  if  the  integuments  be  unsound  and  will  not  re- 
tract, Mr.  Guthrie  approves  of  their  being  dissected 
back  to  an  equal  distance  all  round. — (On  Gun-shot 
Wounds,  p.  205 — 208.)  Dr.  Hennen,  by  gi\’ing  an 
oblique  direction  to  all  the  incisions  through  the  mus- 
cles, obviates  the  necessity  for  much  dissection  of  the 
integuments,  and  he  says  that  in  a small  limb  he  has 
repeatedly  performed  the  operation  with  one  sweep  of 
the  knife,  cutting  obliquely  inwards  and  upwards  at 
once  to  the  bone.— (Principles  of  Mihtary  Surgery,  p. 
265,  ed.  2.)  This  author,  like  Mr.  Guthrie,  also  recom- 
mends carry’ing  the  knife  through  the  fascia  in  the 
first  circular  incision  ; and  so  does  Mr.  C.  Hutchison, 
who  makes  no  mention  of  dissecting  back  the  skin,  but 
simply  states,  that  the  “ integuments  and  fascia  being 
divided  by  a circular  incision,  and  retracted  upwards 
as  high  as  is  judged  necessary’,  the  superficial  muscles 
should  next  be  divided,”  &c. — (Pract.  Obs.  in  Surgery, 
p.  23,  8vo.  Lond.  1816.)  We  are  therefore  to  conclude, 
that  he  joins  Graefe  and  others  in  thinking  the  separa- 
tion of  the  skin  from  the  fascia  unnecessary.  My  own 
observations  in  practice  lead  me  to  believe,  that  the  dis- 
section of  the  integuments  from  the  subjacent  parts 
used  formerly  to  be  carried  to  an  extent  beyond  all  mo- 
deration and  necessity,  and  that,  as  it  is  a most  painful 
proceeding,  and  hurtful  by  forming  a large  loose  pouch 
for  the  lodgement  of  matter,  it  ought  to  be  abandoned 
by  every  surgeon  who  follows  the  method  of  sawing 
the  bone  considerably  higher  than  the  first  cut  through 


the  superficial  muscles.  I am  not,  however,  prepared 
to  assert,  that  no  dissection  at  all  is  generally  requisite, 
but  am  rather  disposed  to  believe  the  moderate  adop- 
tion of  it,  as  recommended  by  Mr.  Hey.  the  most  pru- 
dent. This  gentleman,  like  Desault  (CEuvres  Chir.  t. 
21,  p.  545),  is  an  advocate  for  amputating  with  a triple 
incision,  and  for  preserving  such  a quantity  of  muscular 
flesh  and  integuments  as  arc  proportionate  to  the  dia- 
meter of  the  limb.  By  a triple  incision,  he  means  first 
an  incision  through  the  integuments  alone ; secondly, 
an  incision  through  all  the  muscles,  made  somewhat 
higher  than  that  through  the  integuments  ; and  thirdly, 
another  incision  through  that  part  of  the  muscular 
flesh  which  adheres  to  the  bone,  made  round  that  point 
of  the  bone  where  the  saw  is  to  be  applied.  The  proper 
distance  of  these  incisions  from  each  other,  he  says, 
must  be  determined  by  the  thickness  of  the  limb  upon 
which  the  operation  is  to  be  performed,  making  allow’- 
ance  for  the  retraction  of  the  integuments,  and  of  those 
muscles  which  are  not  adherent  to  the  bone  Supposing 
the  circumference  of  the  limb  to  be  twelve  inches 
where  the  bone  is  to  be  divided,  the  diameter  is  about 
four  inches,  and  if  no  retraction  of  the  integuments 
were  to  take  place,  a sufficient  covering  of  the  stump 
would  be  afforded  by  making  the  first  incision  at  the 
distance  of  two  inches  from  the  place  where  the  bone 
is  to  be  sawed,  that  is,  at  the  thstance  of  the  semi-dia- 
meter of  the  limb  on  each  side.  But  as  the  integu- 
ments, when  in  a sound  state,  always  recede  after  they 
are  divided,  it  is  useful  to  make  some  allow’ance  for  this 
recession  ; and  to  make  the  first  incision  in  this  case  at 
least  two  inches  and  a half  or  three  inches  below  the 
place  where  the  bone  is  to  be  sawed.  As  the  posterior 
muscles  of  the  thigh  retract  a great  deal  in  the  process 
of  healing,  Mr.  Hey  advises  their  division  to  be  begun 
half  an  inch  above  the  place  where  the  integuments 
were  cut,  and  the  anterior  muscles  three  quarters  of 
an  inch.  The  integuments,  says  he,  will  retract  a lit- 
tle both  above  and  below  the  place  where  they  were  di- 
vided ; but  the  distance  from  that  place  must  be  com- 
puted from  the  mark  left  upon  the  surface  of  the  mus- 
cles in  dividing  the  integuments.  Thus,  in  fact,  in  a 
common  thigh-amputation,  Mr.  Hey  deemed  it  neces- 
sary to  detach  the  skin  from  the  muscles  merely  to  the 
extent  of  half  an  inch  at  the  back  part  of  the  limb,  and 
of  three  quarters  in  front ; a very  different  practice 
from  the  old  custom  of  making  quite  a bag  of  integu- 
ments, and  turning  them  back  as  the  upper  piece  of  a 
glove  is  turned  down,  or  rather  as  the  sleeves  of  a coal 
are  turned  up. 

In  common  amputations  of  the  thigh,  Roux  strongly 
disapproves  of  separating  the  skin  far  from  the  muscles, 
as  a circumstance  highly  unfavourable  to  the  healing 
of  the  wound  by  adhesion  ; he  divides  only  a few  of 
the  cellular  bands  between  the  integuments  and  fascia ; 
and  occasionally  he  has  imitated  M.  Louis  in  cutting 
through  the  skin  and  superficial  muscles  together. — 
(Mem.  sur  la  Reunion  de  la  Plaie  apres  1’ Amputation, 
&c.  p.  9.) 

I believe  the  generality  of  the  best  modem  operators 
are  now  con\’inced  of  the  impropriety  of  dividing  the 
muscles  exactly  in  the  manner  directed  by  Mr.  Alanson, 
viz.  by  letting  the  knife  revolve  unintenuptedly  all 
round  the  bone,  with  its  edge  turned  obliquely  upw’ards 
tow’ards  the  point  w’here  it  is  intended  to  apply  the  saw. 
It  is  a topic,  indeed,  to  which  I have  already  called  the 
reader’s  attention  in  the  foregoing  columns.  Langen- 
beck says,  that  he  is  perfectly  convinced  of  the  impos- 
sibility of  forming  a conical  wound  with  one  stroke  of 
a large  amputating  knife,  and  joins  Mr.  Hey  in  approv- 
ing of  the  triple  incision. — (Bibl.  ftir  die  Chir.  b.  1,  p. 
564.)  The  objections  first  urged  by  Wardenburgh 
against  Alanson’s  method  are  mathematically  correct, 
inasmuch  as  the  course  of  the  edge  of  the  knife,  in 
this  gentleman’s  method,  must  be  spiral,  and  the  end 
of  the  incision  be  considerably  higher  than  the  begin- 
ning of  it.  Such  must  be  the  result  of  performing  the 
division  of  the  muscles  all  round  the  limb  by  one  con- 
tinued stroke  of  the  knife,  w’ith  its  edge  directed 
obliquely  upwards ; for  the  idea  of  making  the  knife 
revolve  in  this  manner  while  its  point  is  confined  to  an 
imaginary’,  regular,  determinate  circle  on  the  bone,  I 
believe,  is  now  abandoned  as  not  really  practicable.  Yet 
with  the  exception  of  Desault,  who  confined  himself  to 
the  trinle  incision  conducted  on  the  principles  of  M 
Louis  (CEuvres  Chir.  t.  2,p.  547),  few  experienced  sur- 
geons refuse  to  acknowl^ge,  that  in  this  operation  im- 


AMPUTATION. 


6( 


mense  advantage  does  proceed  .from  the  oblique  divi- 
sion of  the  muscles,  the  honour  of  bringing  which  me- 
thod into  practice  Mr.  Alanson  still  unquestionably 
merits,  however  he  may  have  erred  in  recommending 
the  conical  wound  to  be  made  with  one  sweep  of  the 
knife.  Nor  are  there  many  living  surgeons  who  enter- 
tain a doubt  of  the  excellence  of  the  principle  incul- 
cated by  M.  Louis  respecting  the  utility  of  dividing  the 
loose  superficial  muscles  first,  and  then  such  as  are 
deeper  and  adherent  to  the  bone.  In  fact,  a combina- 
tion of  this  last  method  with  the  oblique  division  of 
the  muscles,  not  exactly  by  one  but  several  strokes  of 
the  knife,  constitutes  the  mode  of  amputating  at  pre- 
sent most  extensively  adopted,  and  sometimes  termed, 
as  already  mentioned,  amputation  by  a triple  incision. 
Thus,  after  the  skin  is  cut,  and  as  much  of  it  retracted 
and  saved  as  is  deemed  necessary,  the  operater  cuts 
through  the  loose  muscles  of  the  thigh  at  the  edge  of 
the  retracted  skin,  first  those  on  the  fore  part  of  the 
limb,  and  then  such  as  are  situated  behind.  For 
this  purpose  he  makes  two  or  more  sweeps  of  the 
knife,  as  may  be  found  necessary,  carefully  directing 
them  obliquely  upwards  towards  the  point  where  he 
means  to  saw  the  bone.  The  oblique  division  of  the 
muscles  does  not  merely  enable  the  operator  to  saw  the 
bone  higher  up  than  he  could  otherwise  do,  and  leaves 
at  the  same  time  more  muscle  for  covering  its  extremity, 
but  it  is  a preservation  of  sound,  undetached  integu- 
ments, which  assuredly  form  the  most  efficient  and 
durable  covering  to  the  stump.  I say  this  without  pre- 
cisely coinciding  with  Briinninghausen,  who,  trusting 
entirely  to  skin  for  covering  his  stumps,  makes  an 
extensive  detachment  of  it  from  the  muscles,  and  then 
cuts  straight  down  to  the  bone.  The  loose  muscles  ac- 
tually cut  through  now  retract  considerably,  leaving 
those  which  are  deeper  and  attached  to  the  bone  in  a 
condition  to  be  cut  higher  up  than  could  have  been  pre- 
viously done.  Lastly,  these  are  also  to  be  divided  with 
the  edge  of  the  knife  directed  obliquely  upwards  to- 
wards the  place  where  the  saw  is  to  be  applied.  Some 
operators  do  more  than  this;  for,  alter  cutting  down  to 
the  bone,  they  follow  the  plan  of  Celsus,  and  detach 
the  flesh  from  its  whole  circumference  upwards  with  a 
scalpel,  to  the  extent  of  about  another  inch,  in  order  to 
be  enabled  to  saw  the  bone  still  higher  up.  “ Inter  sa- 
nam  vitiatamque  partem  incidenda  scalpello,  caro  usque 
ad  08,  reducenda  ab  eo  sana  caro,  et  circa  os  subse- 
canda  est,  ut  eH  quoque  parte  aliquid  ossis  nudetur.” 
This  method,  I think,  deserves  commendation,  because 
it  may  have  considerable  effect  in  hindering  a protru- 
sion of  the  bone,  if  it  does  not,  in  conjunction  with  the 
foregoing  method  of  operating  and  judicious  dressings, 
render  this  disagreeable  event  quite  impossible.  As 
long  as  I live,  however,  I shall  never  forget  a poor  sol- 
dier, whose  thigh  had  been  amputated  in  Bergen-op- 
Zoom,  and  who  was  brought  about  ten  days  after  the 
operation  into  the  military  hospital  at  Oudenbosch,  un- 
der my  care.  Not  the  slightest  union  of  any  part  of 
the  wound  had  taken  place ; abscesses  had  formed  un- 
der the  fascia  on  every  side  of  the  stump ; the  loose 
skin  was  literally  a large  bag  of  purulent  matter ; the 
muscles  were  wasted  to  almost  nothing,  and  their  re- 
mains retracted  and  shrinking  still  farther  away  from 
the  extremity  of  the  bone,  which  protruded  at  least 
three  inches  beyond  the  soft  parts.  This  unfortunate 
man  had  been  attacked  with  chronic  tetanus  soon  after 
the  oj)eration,  and  probably  it  was  to  the  disturbance 
of  the  stump  by  the  effects  of  that  disease,  and  to  the 
strong  and  continual  tendency  of  the  muscles  to  retract 
thern-selves,  induced  by  this  state  of  the  system,  the 
deplorable  state  of  the  stump  was  to  be  attributed.  He 
lingered  nearly  a fortnight  in  the  hospital  before  he  died  ; 
previously  to  which  event  large  abscesses,  communi- 
cating with  the  hollow  of  the  stump,  surrounded  the 
greater  part  of  the  pelvis.  As  I had  every  reason  to 
believe  that  the  ojieration  had  been  skilfully  done,  per- 
haps when  I say  that  the  above  mode  of  amputating 
will  make  a protrusion  of  the  bone  impossible,  it  is  not 
exactly  correct,  as  the  occurrence  may  sometimes  ori- 
ginate from  causes  which  are  quite  independent  of 
the  particular  way  in  which  the  operation  has  been  ex- 
ecuted. 

'I'he  practice  of  detaching  the  bone  from  the  circum- 
jacent flesh  to  the  extent  of  about  an  inch,  after  the 
other  principal  incisions  are  completed,  as  advised  by 
t.'elsus  and  Louis,  I have  sometimes  seen  done  at  St. 
Bartholomew’s  Hospital,  and  have  practised  myself  on 


other  occasions,  with  the  decided  advantage  of  letting 
the  bone  be  sawed  higher  up  than  could  otherwise  have 
been  effected.  Mr.  Guthrie,  after  the  incisions  down 
to  the  bone,  even  recommends  dissecting  back  the  mus- 
cles from  it  “ for  the  space  of  two  or  three  inches,  as 
the  size  of  the  limb  or  other  circumstances  may  re- 
quire but  I should  be  reluctant  myself  to  imitate  the 
practice  to  this  extent,  though  inclined  to  think  most  fa- 
vourably of  it  within  more  moderate  limits.  If  we 
reckon  that  three  inches  of  the  member  lie  between 
the  first  circular  cut  in  the  skin  and  the  place  where 
the  knife  arrives  at  the  bone,  and  then  take  away  two 
or  three  inches  more  of  the  femur,  it  is  clear  that  in 
many  examples  we  should  be  getting  very  high  up  the 
limb,  and  if  a detachment  of  the  muscles  from  the  bone 
to  the  extent  of  two  or  three  inches  were  thus  made,  it 
would  at  all  events  be  of  no  service  unless  the  bone 
would  admit  of  being  sawed  at  this  great  distance  from 
the  termination  of  the  oblique  division  of  the  muscles. 
However,  if  this  were  truly  practicable  (a  point  which 
I leave  for  others  to  discuss),  it  would  certainly  be  con- 
sonant to  the  excellent  general  maxim  laid  down  by  J. 
L.  Petit,  that  in  amputation  as  much  of  the  bone  and 
as  little  of  the  flesh  should  be  taken  away  as  possible. — 
(See  Traits  des  Mai.  Chir.  t.  3,  p 150.)  When  this  final 
detachment  of  the  deep  muscles  from  the  bone  is  adopted, 
particular  care,  as  Roux  observes,  should  be  taken  al- 
ways to  dmde  the  thick  aponeurosis  connecting  the 
triceps  to  the  linea  aspera. — (M6m.  sur  la  Reunion  de 
la  Plaie  aprds  1’ Amputation,  p.  10.) 

With  respect  to  Desault’s  method  of  amputating  the 
thigh  by  a circular  incision,  already  mentioned,  he  con- 
sidered turning  the  knife  obliquely  upwards  quite  unne- 
cessary : his  plan  v/as,  to  cut  through  the  muscles, 
layer  after  layer,  with  the  precaution  of  retracting  the 
first  stratum  before  he  divided  the  second ; the  latter 
was  then  cut  through  on  a level  with  the  flesh  that  had 
been  previously  divided  and  retracted,  and  so  on  down 
to  the  bone.  This,  says  he,  is  the  right  way  of  forming 
a true  hollow  cone,  of  which  the  integuments,  which 
were  drawn  up  before  the  muscles  were  cut,  form  the 
base,  from  which  are  gradually  continued  the  various 
layers  of  muscles,  and  the  highest  point  of  which  is 
the  bone  itself.  Desault  owns,  that  this  method  is 
somewhat  tedious  and  painful,  but  in  his  opinion,  these 
disadvantages  are  more  than  counterbalanced  by  the 
benefits  procured  for  the  patient. — (CEuvres  Chir.  de 
Desault  par  Bichat,  t.  2,  p.  547.) 

All  the  muscular  fibres,  on  every  side,  having  been 
cut  doAvn  to  the  bone,  a piece  of  linen,  somewhat 
broader  than  the  diameter  of  the  wound,  should  be  torn 
at  one  end,  along  its  middle  part,  to  the  extent  of  about 
eight  or  ten  inches.  This  is  called  a retractor,  and  is 
applied  by  placing  the  exposed  part  of  the  bone  in  the 
slit,  and  drawing  the  ends  of  the  linen  upwards  on  each 
side  of  the  stump.  In  this  manner,  the  retractor  will 
obviously  keep  every  part  of  the  surface  of  the  wound 
out  of  the  way  of  the  saw,  Graefe  thinks,  that  in  am- 
putations of  parts,  where  there  is  only  one  bone,  the 
unslit  portion  of  the  linen  should  always  be  applied 
over  the  anterior  muscles,  as  these  ought  constantly  tch 
be  most  evenly  kept  back,  so  that  no  projection  of  them 
may  interfere  with  the  action  of  the  saw. — (Normere 
fur  die  Ablosung  grbsserer  Gliedm.  p.  105.)  This  is  a 
preference,  however,  which  may  not  be  of  great  import- 
ance, though  1 confess  that  there  appears  some  reason 
in  what  Graefe  has  stated.  That  meritorious  surgeon,- 
J.  L.  Petit,  whose  name  I always  mention  with  plea- 
sure, strongly  commends  the  use  of  the  retractor,  the 
ends  of  which  he  drew  over  the  anterior  muscles : he 
says  that  he  has  employed  this  simple  and  natural 
means,  but  that  it  did  not  suit  the  taste  of  every  body^ 
especially  of  those  who  consider  all  the  merit  of  an 
ojjeration  to  consist  in  the  quickness  of  its  performance, 
or  who  think  it  satisfactory  reasoning  to  say,  this  is 
not  their  way.— (Traite  des  Mai.  Chir.  t.  3,  p.  152.)  I 
have  seen  the  saw  do  so  much  mischief,  in  consequence 
of  the  operator  neglecting  to  use  the  retractor,  that  my 
conscience  obliges  me  to  censure  such  surgeons  as 
neglect  to  defend  the  soft  parts  by  this  simple  contri- 
vance. There  are  some  who  have  rejected  the  use  of 
the  retractor,  because  they  have  seen  it  get  under  the 
teeth  of  the  saw,  and  obstruct  the  action  of  the  instru- 
ment ; but  this  very  circumstance  adduced  against  the 
retractor  is,  when  considered,  the  strongest  one  that 
could  possibly  be  brought  forward  in  its  favour,  as  the 
surface  of  the  wound  itself,  and  particularly  the  edges 


62 


AMPUTATION. 


of  the  skin,  would,  in  all  probability,  suffer  the  same  | 
fate  as  the  linen,  by  getting  under  the  teeth  of  the  saw,  j 
if  no  retractor  were  employed,  in  attempting  to  saw  | 
the  bone  high  up,  as  closely  as  possible  to  the  soft 
{•arts.  1 think  no  ono  can  urge  any  but  the  most  frivo- 
lous objections  to  the  use  of  the  retractor,  and  I know 
that  many  who  have  been  with  myself  eye-witnesses 
of  the  mischief  frequently  done  by  the  saw  in  amputa- 
tions, are  deeply  impress^  with  an  aversion  to  the  ne- 
glect of  this  bandage.  I have  often  seen  the  soft  parts 
skilfully  divided,  and  I have,  in  these  same  instances, 
seen  the  operators  directly  afterward  lose  all  the 
praise  which  every  one  was  ready  to  bestow,  by  their 
actually  sawing  through  one-half  of  the  ends  of  the 
muscles  together  with  the  bone.  Men  who  have  had 
fortitude  not  to  utter  a sigh,  nor  to  let  a groan  be  heard, 
in  their  previous  sufferings,  have  now  had  their  invo- 
luntary cries  e.xtorteil  from  them  by  unneces.sary,  un- 
justifiable torture.  But  besides  defending  the  surface 
of  the  stump  from  the  teeth  of  the  saw,  the  retractor 
will  undoubtedly  enable  the  ojierator  to  saw  the  bone 
higher  up  than  he  could  otherwise  do. 

Mr.  Liston,  of  Edinburgh,  endeavours  to  show,  that 
the  saw  is  the  only  necessary  thing  in  the  case  of  am- 
putating instruments ; and  he  adds  (alluding,  as  1 
suppose,  to  operations  at  the  joints),  that  it  was  sel- 
domer  required  than  might  be  supposed ; and  he  par- 
ticularly declares  all  kinds  of  retractors  superfluous. 
Here  it  should  be  rememberetl.  that  this  gentleman’s 
practice  is  that  of  flap-amputation,  to  which  he  gives 
the  universal  preference ; a method  in  which  unques- 
tionably the  retractor  may  be  disfiensed  with,  as,  while 
the  saw  is  acting,  one  or  both  of  the  flaps  can  be  effect- 
ually held  out  of  the  way  by  an  assistant.  The  same 
preference  also  e.xplains,  in  some  measure,  this  sur- 
geon’s rejection  of  the  tourniquet,  the  apphcation  of 
which  is  inconvenient  in  certain  flap-amputations. — 
(See  Edinburgh  Med.  and  Surg.  Journ.  vol.  20,  p.  43 
— 45.)  Here,  however,  I am  treating  of  amputation  by 
the  circular  incision,  in  which  practice  I consider  both 
the  tourniquet  and  the  retractor  too  useful  to  be  com- 
monly relinquished. 

Another  proceeding,  which  seems  fit  for  reprobation, 
and  which,  indeed,  Mr.  Alanson  very  projierly  con- 
demned, is  the  practice  of  scraping  up  the  periosteum 
with  the  knife,  as  far  as  the  muscles  will  allow.  No- 
thing seems  more  probable,  than  that  this  may  be  the 
cause  of  the  exfoliations  which  occasionally  happen 
after  amputations.  At  all  events,  it  is  a superfluous, 
useless  measure,  as  a sharp  saw,  such  as  ought  to  be 
employed,  will  never  be  inqieded  by  so  slender  a mem- 
brane as  the  periosteum.  All  that  the  operator  ought 
to  do  is,  to  take  care  to  cut  completely  down  to  the 
bone  all  round  its  circumference.  Thus  a circular  di- 
vision of  the  periosteum  will  be  made,  and  upon  this 
precise  situation  the  saw  should  be  placed.  This  is 
the  method  which  was  approved  of  by  J.  L.  Petit. — 
(Traite  des  Mai.  Chir.  t.  3,  p.  159.)  It  is  what  I have 
always  done  and  recommended ; yet  it  must  be  con- 
fessed, that  differences  of  opinion  prevail  about  the  ne- 
cessity and  modes  of  dividing  the  periosteum.  Graefe, 
in  common  with  several  others,  entertains  considerable 
apprehensipn  of  the  effects  of  the  periosteum  being 
lorn  and  lacerated  by  the  saw,  exfoliations  of  the  bone 
and  abscesses  up  to  the  joint  being  possible  conse- 
quences of  the  rude  separation  and  inflammation  of 
this  membrane.  Hence  he  is  an  advocate  for  mtiking 
a circular  cut  through  at  the  place  where  the  saw'  is  to 
be  applied,  and  then  scraping  away  all  below  this  point 
in  the  direction  downwards. — (N’ormen  flir  die  Abl. 
grbsserer  Gliedm.  p.  105  and  165.)  Perhaps  no  very- 
great  objection  may  lie  against  this  mode,  which  is  not 
uncommonly  followed,  though  I have  some  doubts  of 
its  real  utility-,  as  it  scarcely  seems  practicable  in  the 
midst  of  the  oozing  of  biood  to  hit  with  the  saw  the 
precise  line  at  which  the  remains  of  the  periosteum 
terminate ; and  in  confirmation  of  the  safety  of  Petit’s 
practice,  Mr.  Guthrie’s  experience  may  be  adduced, 
who  says,  “I  have  often  sawed  through  the  bone, 
w-ithout  previously  touching  the  periosteum,  and  the 
stumps  have  been  as  soon  healed,  and  with  as  little  in- 
convenience as  any  others.” — ^On  Gun-shot  Wounds,  p. 
88.)  A very  modern  author,  impressed,  like  many 
others,  with  the  fear  of  tearing  the  periosteum  with 
the  saw,  differs  from  them,  in  thinking  it  best  to  scrape 
the  periosteum  upwards ; by  which  means,  he  says, 
that  at  least  half  an  inch  of  this  membrane,  and  a nro- 


portionate  quantity  of  muscular  fibres,  may  be  pt(U 
served  for  covering  the  end  of  the  bone,  ina.smuch  as 
the  muscular  fibres  adherent  to  the  periosteum  will 
remain  connected  with  it ; an  advantage  which  this 
author  deems  very  important  while  the  edges  of  the 
bone  are  sharp.  In  amputation  below  the  knee,  he  con- 
siders the  method  highly  useful,  as  the  sharp  edge  of 
the  tibia  may  be  not  merely  covered  with  skin,  but  peri- 
osteum and  the  cellular  membrane  connected  with  it. 
Since  his  adoption  of  tliis  practice,  he  assures  us  that 
he  has  not  for  a very  long  time  seen  any  exfoliation  of 
the  tibia,  and  never  any  protrusion  of  the  bone  of  a 
stump. — (Brunninghausen  Erfahr.  &c.,  fiber  die  Amp. 
p.  65,  66,  8vo.  Bamb.  1918.)  Such  are  the  sentiments 
of  a gentleman  who  has  published  a valuable  tract  on 
amputation,  as  well  as  some  other  works  of  deserved 
reputation.  His  opinion  is  unque-stionably  the  reverse 
of  what  is  most  prevalent  in  England ; and  I think  his 
practice  liable  to  the  objection,  that  the  disadvantages 
of  scraping  the  bone  at  all,  and  denuding  it,  may  exceed 
the  benefit  supposed  to  proceed  from  afterward  bringing 
down  the  detached  membrane  over  its  sharp  margin, 
even  admitting  this  to  be  always  practicable. 

But  in  no  part  of  the  operation  of  amputation  do  ope- 
rators in  general  display  more  awkwardness,  than  in 
sawing  the  bone ; though,  if  we  except  directing  the 
saw  against  the  flesh,  the  faults  are  here  less  yiemicious 
in  their  conseipiences  than  the  errors  already  noticed. 
At  the  time  of  sawing  the  bone,  much  depends  upon 
the  assistant  who  holds  the  limb.  If  he  elevate  the 
lower  jiortioti  of  the  thigh  bone  too  much,  the  saw 
becomes  so  pinched  that  it  cannot  work.  On  the  other 
hand,  if  he  allow  the  weight  of  the  leg  to  operate  too 
much,  the  thigh  bone  breaks  before  it  is  nearly  sawn 
through,  and  its  extremity  is  splintered.  It  is  one  of 
the  most  common  remarks  of  such  persons  as  are  in 
the  habit  of  frequently  seeing  amputations,  that  the 
part  of  these  operations,  which  a plain  carpenter  would 
do  well,  foils  the  skill  of  a consummate  surgeon,  and 
few  operators  acquit  themselves  w ell  in  the  manage- 
ment of  the  saw.  Many  of  them  begin  the  action  of 
this  instrument  by  moving  it  in  a direction  contrary 
to  the  inclination  of  its  teeth.  Many,  seemingly 
through  confusion,  endeavour  to  shorten  this  part  of 
the  o|<eration,  by  making  short,  very  rapid,  and  almost 
convulsive  strokes  with  the  saw.  Almost  all  opera- 
tors fall  into  the  error  of  bearing  too  heavily  on  the  in- 
strument. That  operator  will  saw  best,  who  makes 
the  first  stroke  of  the  saw  by  applying  its  heel  to  the 
bone,  and  drawing  the  instrument  across  the  part  to- 
wards himself,  so  as  to  make  a slight  groove  in  the 
bone,  which  serves  very-  materially  to  steady  the  future 
operations  of  the  instrument ; and  who  makes  long 
regular  sweeps  with  the  saw,  rather  slowly  than 
quickly,  rather  lightly  than  heavily.  But  there  is  often 
a fault  in  the  construction  of  the  saw-  itself,  which  im- 
pedes its  action,  quite  independently  of  any  fault  on  the 
part  of  the  surgeon.  I allude  to  the  edge  of  the  in- 
strument not  being  a little  broader  than  its  blade. 
When  the  saw  is  well  made,  the  teeth  edways  make 
plenty  of  space  for  the  movement  of  the  rest  of  the  in- 
strument. The  instrument,  as  Mr.  Guthrie  recom- 
mends, should  cut  with  both  edges,  backwards  and 
forwards,  which  expedites  the  operation,  and  (what  is 
of  more  consequence)  helps  to  prevent  splintering 
when  the  bone  is  nearly  divided,  because  the  division 
can  be  finished  by  the  backward  motions,  which  are 
the  most  gentle. — (On  Gun-shot  Wounds,  p.  89.) 

Graefe  commends  the  plan  of  oiling  the  saw,  for  the 
purpose  of  facilitating  its  action  (Normen  fur  die  Abl. 
grosserer  Gliedmassen,  p.  65) ; and  though  the  method 
is  innocent  enough,  the  best  operators  in  this  nietropo’d,9 
do  not  consider  it  sufficiently  important  for  adoption. 

If  the  bone  should  happen  to  break  before  the  saw- 
ing is  finished,  the  sharp-pointed,  projecting  spiculae, 
thus  occasioned,  must  be  removed  by  means  of  a strong, 
cutting  sort  of  forceps,  termed  bone-nippers.  The  per- 
pendicular division  of  the  bone,  leaves  a sharp  edge  at 
the  extremity  of  its  circumference.  It  is  not  the  com- 
mon practice  to  take  any  measures  for  the  removal  of 
such  sharpness ; vet  Graefe  recommends  filing  it  away 
(Op.  cit.  p.  66),  and  Mr.  C.  Hutchison  makes  it  an 
invariable  rule,  whether  there  be  any  occasion  to  use 
the  bone-nippers  or  not,  “ to  take  off  the  asperities^ 
and  scrape  or  endeavour  somewhat  to  round  the  sharp 
cut  edge  of  the  bone  with  a strong  blunt  scalpel,  in 
order  to  prevent  the  soft  parts  from  being  injured. 


AMPUTATION. 


63 


when  brought  over  the  end  of  the  bone  in  forming  the 
stump.”— (Pract.  Obs.  in  Surgery,  p.  24.)  Though  I 
have  not  followed  this  practice,  or  rather  the  part  of  it 
which  relates  to  cutting  off  the  edge  of  the  bone,  nor 
seen  it  adopted  in  London  in  amputation  of  the  thigh, 
1 know  of  no  objection  to  it,  unless  it  be  on  the  score 
of  its  inutility,  and  the  delay  which  it  occasions.  All 
projecting  points  of  bone,  it  is  the  ordinary  custom  to 
remove. 

After  the  removal  of  the  limb,  the  femoral  artery  is 
to  be  immediately  taken  hold  of  with  a pair  of  forceps, 
and  tied  with  a firm  round  small  ligature,  the  best  being 
that  kind  which  is  reconunended  and  used  by  my  friend 
Mr.  Lawrence. — (See  Ligature.)  Care  is  to  be  taken 
to  leave  the  accompanying  branches  of  the  anterior 
crural  nerve  out  of  the  noose.  None  of  the  surround- 
ing flesh  ought  to  be  tied,  though  the  ligature  should 
undoubtedly  be  placed  round  the  artery,  just  where  it 
emerges  from  its  lateral  connexions.  The  late  Mr. 
Hey  was  accustomed  to  tie  the  femoral  artery  twice, 
leaving  a small  space  between  the  ligatures.  Some 
reasons  against  this  plan  will  be  found  in  the  article 
Hemorrhage.  The  other  arteries  are  usually  taken 
up  with  a tenaculum.  After  tying  as  many  vessels  as 
require  it,  one-half  of  each  ligature  is  to  be  cut  off 
near  the  knot  on  the  surface  of  the  stump.  One  por- 
tion is  quite  sufiicient  for  withdrawing  the  ligature 
when  thus  becomes  loose,  and  the  other  being  only  an 
extraneous  body,  and  productive  of  irritation  and  sup- 
puration, should  never  be  allowed  to  remain. 

My  friend,  the  late  Dr.  Hennen,  in  his  excellent  pub- 
lication, ascribes  the  improvement  of  removing  one 
half  of  the  ligature  to  Mr.  James  Veitch,  a naval  sur- 
geon, who,  in  April,  1806,  published  some  valuable 
precepts  relative  to  the  mode  of  tying  the  arteries  in 
amputation. — (See  Edinb.  Med.  and  Surgical  Journal, 
vol.  2,  p.  176.)  But  highly  as  I approve  of  the  tenor  of 
the  anonymous  paper  here  referred  to,  it  is  impossible  for 
me  to  suppose  Mr.  Veitch  could  be  the  first,  or  nearly  the 
first,  who  suggested  such  improvement  When  I 
went  as  an  apprentice  to  St.  Bartholomew’s  Hospital,  in 
1797,  no  surgeon  of  that  hospital  ever  followed  any 
other  mode,  and  the  practice  was  then  so  far  from  be- 
ing new  there,  that  gentlemen  who  were  at  the  hospi- 
tal seven  years  before  myself,  had  seen  one-half  of 
each  ligature  regularly  cut  off  the  first  time  they  went 
into  the  operating  theatre  of  that  munificent  institu- 
tion. The  use  of  very  broad  ligatures,  and  the  inclu- 
sion of  a considerable  quantity  of  flesh  in  the  noose, 
together  with  the  vessel,  were  also  practices  quite  ex- 
ploded at  St.  Bartholomew’s  at  the  very  beginning  of 
my  apprenticeship.  Mr.  Veitch,  however,  seems  to 
merit  the  honour  of  having  been  perhaps  the  first  to 
set  the  example  of  tying  every  vessel,  the  femoral,  as 
well  as  the  smaller  arteries,  with  a single  silk  thread, 
taking  care  to  include,  as  far  as  was  possible,  nothing 
but  the  artery ; and  when  this  had  been  done,  he  took 
off  one-half  of  each  ligature,  as  near  as  possible  to  the 
knot,  “so  that  the  foreign  matter  introduced  was  a 
mere  trifle,  compared  with  what  I had  been  accus- 
tomed to  see.” — Edinb.  Med.  and  Surg.  Journ  vol.  2, 
p.  178.)  The  use  of  a single  silk  thread,  therefore, 
was  the  part  of  these  improvements,  probably  origina- 
ting with  Mr.  Veitch,  though  the  principles  which  led 
to  this  innovation  were  unquestionably  first  established 
by  Dr.  .Jones. 

Mr.  Alanson  directs  the  ends  of  the  ligatures  to  be 
left  hanging  out  at  the  two  extremities  of  the  wound, 
according  as  their  nearness  may  point  out  as  best. 
But  when  a ligature  is  situated  in  the  centre  of  the 
wound,  it  is  best  to  bring  it  out  between  the  strips  of 
adhe.sive  plaster,  at  the  nearest  part  of  the  surface ; 
otherwise  its  running  across  one-half  the  wound  to  get 
at  either  angle,  would  create  a great  deal  of  unneces- 
sary irritation  and  suppuration.  The  advantages  of 
this  method  of  placing  the  ends  of  the  ligatures  were 
well  explained  by  Mr.  Veitch ; but  his  practice,  like 
the  innovation  of  cutting  oft'  the  half  of  each  ligature, 
has  been  common  in  the  London  hospitals,  and  at  St.  Bar- 
tholomew’s in  particular,  many  years  earlier,  I presume, 
than  the  case  referred  to  by  this  gentleman ; since  it  has 
been  familiarly  adopted  in  those  institutions  ever  since 
1797,  as  I can  testify  from  my  own  personal  observa- 
tion. These  remarks  are  offered  without  the  slightest 
intention  of  detracting  ftorn  the  merits  of  the  above- 
mentioned  paper,  which  is  replete  with  valuable  ad- 
vice ; nor  am  I influenced  by  any  design  of  throwing 


honour  on  the  memory  or  character  of  any  other  indi-* 
vidual  at  the  expense  of  Mr.  Veitch,  being  at  this  time 
unacquainted  with  the  exact  periods  when  either  this 
improvement,  or  that  of  removing  the  half  of  each 
ligature,  commenced.  M.  Roux  is  one  of  the  few  re- 
maining modern  surgeons  who  declare  their  prefer- 
ence to  the  method  of.  bringing  out  all  the  ligatures  at 
the  lower  angle  of  the  wound  ; the  benefit  of  having 
them  brought  out  thus  low,  so  as  to  keep  up  a drain  for 
any  pus  that  may  form,  being  in  his  opinion  greater 
than  that  of  arranging  them  at  the  points  of  the  wound 
nearest  to  them. — (M6m.  sur  la  Reunion  de  la  Plaie 
aprds  I’Amp.  p.  12.) 

As  Dr.  Hennen  observes,  the  reducing  the  immode- 
rate size  of  ligatures,  the  separating  the  threads  of 
which  they  were  composed,  and  placing  them  at  con- 
venient points  along  the  face  of  the  stump  or  wound, 
and  the  actual  removal  of  one-half  of  each  ligature, 
were  amendments  very  slowly  made ; “ but,”  says  he, 
“ an  improvement  which  appears  to  me  of  great  conse- 
quence, was  the  last  of  introduction,  and  is  now  the 
slowest  of  adoption,  although  the  artery  once  secured, 
and  the  value  of  adhesion  duly  acknowledged,  it  is  the 
most  obvious  of  all.  I allude  to  the  plan  of  removing 
the  ends  of  the  ligature  altogether,  and  thus  leaving  to 
an  extensive  wound  the  greatest  possible  chance  of 
immediate  union,”  The  first  printed  mention  of  this 
practice,  as  far  as  Dr.  Hennen’s  investigations  have 
discovered,  was  in  a letter  written  by  Mr.  Haire,  dated 
Southminster,  Essex,  Nov.  1786.  “The  ligatures,” 
says  this  gentleman,  “ sometimes  became  troublesome 
and  retarded  the  cure.  An  intimate  friend  of  mine,  a 
surgeon  of  great  abilities,  proposed  to  cut  the  ends  of 
them  off  close  to  the  knot,  and  thus  leave  them  to 
themselves.  By  following  this  plan  we  have  seen 
stumps  healed  in  the  course  of  ten  days.  The  short 
ligature  thus  left  in  commonly  made  its  way  out  by  a 
small  opening  in  a short  time  without  any  trouble,  or 
the  patient  being  sensible  of  pain.” — (See  Lend.  Med, 
Journ.  vol.  7.)  Certainly,  considering  the  thickness  of 
the  ligatures  in  use  at  the  above  period,  this  testimony 
of  the  success  of  the  method,  as  Dr,  Hennen  remarks, 
is  very  satisfactory. — (Principles  of  Military  Surgery, 
p.  181,  ed.  2.)  In  a letter  received  by  me  from  Mr, 
Dunn,  surgeon  at  Scarborough,  and  dated  June  J,  1819, 
he  tells  me,  “ My  predecessor,  Mr.  J,  Wilson,  the  late 
partner  of  Mr.  Travis,  amputated  a hmb  in  1792  or 
1793,  and  cut  off  the  ligatures  close  to  the  arteries,  and 
no  trouble  ensued.  He  did  this  at  the  recommendation 
of  Dr.  Balcombe,  of  York,  who  had  seen  the  method 
practised  on  the  continent.”  In  September,  1813,  Dr, 
Hennen,  who  was  serving  with  the  army  in  Spain, 
began  the  adoption  of  this  plan,  which,  he  expected, 
would  not  only  prove  useful  in  promoting  immediate 
union,  but  in  obviating  any  accidental  violence  to  the 
ligatures,  and  the  wrong  interference  of  the  younger 
dressers  in  trying  to  pull  them  away.  Between  Sep- 
tember and  January,  thirty-four  cases  were  treated  in 
this  way  without  any  inconvenience  following,  or  the 
small  particles  of  silk  left  behind  giving  rise  to  any  ap- 
parent irritation.  Dr.  Hennen  also  presented  to  Sir 
J.  M‘Grigor  some  of  the  small  circles  of  silk,  a part  of 
which  had  come  away  with  the  dressings,  while  others 
had  floated  out  on  opening  the  little  pustules,  which 
formed  over  the  face  of  the  stump  at  the  points  where 
the  arteries  had  been  tied.  Some  few  of  the  ligature.^ 
never  made  their  appearance,  and  the  patients  com- 
plained of  no  uneasiness  whatever.  Convinced  of  the 
utility  of  the  method.  Dr.  Hennen  afterward  published 
an  account  of  it. — (See  Lond.  Med.  Repository,  vol.  3, 
p.  177,  and  vol.  5,  p.  221.)  Lhis  gentleman  subse- 
quently found  that  Dr.  Maxwell  of  Dumfries  had 
adopted  the  plan  as  far  back  as  1798 ; and  Dr.  Fergu- 
son, who  was  at  Stockholm  during  the  peace  of  Amiens, 
saw  it  also  then  followed  by  some  of  the  surgeons  of 
that  city,  without  any  ill  effects. — (Hennen’s  Military 
Surgery,  p.  175—178,  ed.  2.)  In  .July,  1814,  Mr.  Law- 
rence communicated  to  the  Medical  and  Chirurgical 
Society  of  London,  some  cases  and  observations  highly 
in  favour  of  the  practice,  and  the  particularity  which 
he  lays  much  stress  upon  is,  using  for  the  purpose  mi- 
nute firm  ligatures,  composed  of  what  is  called  den- 
tist’s silk. — (See  Med.  Chir.  Trans,  vol.  6,  p.  156.)  And 
in  a paper  of  later  date,  he  says,  his  farther  experience 
had  confirmed  the  usefulness  of  the  method,  “that 
this  plan,  by  diminishing  irritation  and  inflammation, 
and  simplilViiig  the  process  of  dressing,  very  mate- 


64 


AMPUTATION. 


rially  promotes  the  comfort  of  the  patient,  and  the  conve- 
nience of  the  8urj?eou,  while  it  has  not  produced  ill  con- 
sequences or  any  un|)leasant  effect,  in  the  cases  which 
have  come  under  his  own  observation.”  According  to 
Mr.  Lawrence,  the  small  knots  of  silk  generally  sepa- 
rate early,  and  c.ome  away  with  the  discharge ; that 
where  the  integuments  have  united  by  the  first  inten- 
tion, the  ligatures  often  come  out  rather  later,  with 
very  trifling  suppuration,  and  that,  in  some  instances, 
they  remain  quietly  in  the  part. — .Op.  cit.  vol.  8,  p. 
490.) 

A fter  the  battle  of  Waterloo,  it  was  tried  in  many  cases 
by  Mr.  (Jollier  and  by  myself,  though  our  ligatures  were 
certainly  not  so  minute  and  eligible  as  those  employed 
by  my  friend  Mr.  Lawrence,  whose  plan  essentially  re- 
quires the  use  of  minute  ligatures  made  of  dentist’s 
silk.  As  I joined  the  army  in  the  field  after  nine  days, 
and  was  therefore  obliged  to  leave  my  patients  at  llrus- 
sels  to  the  care  of  others,  I lost  the  opiKirtunity  of  wit- 
nessing the  effects  of  this  method.  Ent  from  Mr. 
Collier  I afterward  learned,  that  thb  new  plan  and  the 
common  one  appeared  in  his  judgment  to  answer 
about  equally  well ; which  report,  considering  hat  we 
did  not  use  the  smallest  ligatures,  must  be  regarded  as 
favourable.  When  the  plan  is  tried,  single  strong 
threads  and  silks,  or  rather  the  kind  of  ligature  which 
will  be  described  in  another  place  (see  Ligature),  should 
be  employed  ; for  otherwise,  the  knots  would  be  large, 
and  likely  to  create  suppuration  and  future  trouble. 
The  practice  has  likewise  been  tried  by  Delpech  at 
Montpellier ; but  it  is  not  explained  whether  he  used 
single  threads  or  silks,  or  whether  any  inconveniences 
resulted  from  the  method.— 'See  Relation  d’un  Voyage 
fait  d Londres  en  1814,  ou  I’aralldle  de  la  Chirurgie  An- 
glaise  avec  la  Chirurgie  Francaise  par  P.  .1.  Roux,  8vo. 
1815.)  Yet  candour  requires  me  to  state,  that  the  me- 
thod is  not  generally  adopted,  and  that  one  well-in- 
formed writer,  as  I shall  hereafter  notice  (see  Hemor- 
rhage), has  recited  a ca.se  and  some  experiments,  which 
are  unfavourable  to  the  jiractice. — (('ross,  in  Lond. 
Med.  Repository,  vol.  7,  p.  355.)  By  Sir  Astley  Cooper, 
the  practice  has  been  found  to  occasion  supimration, 
and  he  has  therefore  given  it  up. — (Lancet,  vol.  1,  p. 
149.)  Mr.  Guthrie,  in  two  or  three  instances,  has  also 
seen  some  ill-looking  abscesses  arise  from  the  presence 
of  the  bits  of  ligature,  though  he  approves  of  the  plan 
where  the  wound  will  not  unite  by  the  first  intention, 
which,  however,  can  rarely  be  known  beforehand. — 
(On  Gim-shot  Wounds,  p.  911.)  On  this  subject,  it 
merits  particular  attention,  that  no  cases  can  be  re- 
garded as  fair  trials  of  Mr.  Lawrence’s  method,  unless 
precisely  such  ligatures  as  he  himself  employs  be 
used. 

[Dr.  Koch,  Professor  of  Chemical  Surgery  at  the 
Hospital  of  Munich,  Bavaria,  after  performing  the  flap- 
operation  on  the  thigh,  contents  himself  with  approxi- 
mating the  flaps  without  securing  any  vessel ; thus  dis- 
ensing with  ligatures  altogether,  as  he  finds  that 

eeping  the  cut  surfaces  in  perfect  co-aptation  is  suffi- 
cient to  prevent  hemorrhage ; and  his  success  has  been 
truly  surprising.  Dr.  Wagner  has  long  since  proved 
in  this  country,  that  ligatures  may  be  dispensed  with  in 
cases  of  surgical  wounds,  in  which  they  are  not  only  ap- 
plied by  most  surgeons,  but  thought  indispensable.  See 
the  rejiort  of  his  operation  for  removing  the  lower  jaw, 
In  which  he  used  no  ligatures.  Many  surgeons  in  this 
country  are  satisfied  with  securing  tlie  larger  arteries 
only,  and  incur  the  risk  of  unimportant  hemorrhages 
from  the  smaller  vessels  rather  than  multiply  their 
ligatures.  Professor  Davidge,  of  Maryland,  fell  into 
the  opposite  extreme  ; from  having  encountered  terri- 
ble secondary  hemorrhages  in  the  early  part  of  his  prac- 
tice, he  would  never  leave  a single  artery  without  a 
ligature,  if  he  could  distinguish  it,  and  would  often 
wait  half  an  hour  after  amputation  before  closing  the 
stump.  He  operated  with  singular  success ; but  if  he 
had  used  animal  ligatures,  his  cases  would  not  have 
been  retarded  for  the  sloughing  of  their  pendent  ex- 
tremities. He  used  to  say  in  his  lectures,  that  arteries 
were  like  felons  and  murderers  ; there  is  no  safety  for 
us  without  we  rope  them. — ReKse.'] 

Sometimes  the  sawed  surface  of  the  bone  itself 
bleeds  rather  profusely.  When  this  happens,  it  is  an 
excellent  plan,  which  I have  often  seen  my  late  master 
Mr.  Ramsden  and  others  adopt  with  the  greatest  suc- 
cess, to  hold  a compress  of  lint  over  the  end  of  the  bone 
daring  the  time  requisite  for  securing  the  rest  of  the 


vessels.  At  the  end  of  this  period,  the  compress  may 
generally  be  taken  away,  the  bleeding  from  the  bone 
having  entirely  ceased.  As  Monro  remarks,  the  sur- 
geon ought  not  to  content  liimself  with  tying  only  such 
vessels  as  he  obser\'es  throwing  out  blood,  while  the 
patient  is  faint  with  pain ; he  should  endeavour  to 
rouse  him  from  that  faintish  state  by  a cordial,  and 
then  wiping  off  the  coagulated  blood  with  a sponge  wet 
in  warm  water,  he  should  examine  narrowly  all  the 
surface  of  the  stump,  for  otherwise  he  may  expect  to 
be  obliged  by  a fresh  hemorrhage  to  undo  all  the 
dressings. — (On  Amputation  of  the  larger  Extremities, 
p.  475,  Monro's  Works.) 

When  there  is  merely  an  oozing  from  small  vessels, 
Bromfield’s  advice  to  loosen  the  tourniquet  completely 
is  highly  proper,  as  this  measure,  and  washing  the  stump 
with  a little  cold  water,  will  put  an  entire  stop  to  such 
bleeding,  without  any  occasion  for  more  ligatures.  A 
good  deal  of  blood  is  sometimes  lost  from  the  mouths 
of  the  larger  veins,  and  where  they  bleed  much  in  de- 
bilitated subjects,  I think  Dr.  Hennen  is  right  in  re- 
commending them  to  be  tied. — (On  Military  Surgery, 
p.  264.)  There  is  no  necessity  for  doing  so,  however, 
in  ordinary  cases,  nor  should  I be  disposed  to  imitate 
Mr.  Hey,  who,  in  consequence  of  having  seen  a few  in- 
stances of  bleeding  from  the  femoral  vein,  generally 
enclosed  that  vessel  in  the  ligature  along  with  the  ar- 
tery.— 'Practical  Obs.  in  Surgery,  p.  530,  ed.2.)  This 
method  was  sanctioned  by  the  eminent  Desault,  who 
says,  that  if  the  vein  be  left  open,  and  the  bandage  at 
the  upper  part  of  the  limb  be  too  tight,  the  flood  regur- 
gitates downwards,  and  hemorrhage  takes  place,  as  this 
surgeon  assures  us  he  has  often  seen.  When  the  vein 
and  artery  lie  close  together,  as  often  happens,  one 
branch  of  the  forceps  is  to  be  introduced  into  the  ar- 
tery', and  the  other  into  the  vein,  which  being  done,  the 
two  vessels  are  to  be  drawn  out  together,  and  included 
in  one  ligature,  but  if  they  are  not  so  near  together, 
they  must  be  tied  separately. — ^Euvres  Chir.  de 
Desault  par  Bichat,  t.  2,  p.  550,  8vo.  Paris,  1801.)  At 
St.  Bartholomew’s,  it  is  not  the  usual  practice  to  tie  the 
femoral  vein  ; and  except  in  particular  cases,  I consider 
the  custom  wrong,  because  a ligature  on  a large  vein 
sometimes  excites  a dangerous  and  fatal  inflammation 
within  the  vessel,  while  the  intervention  of  the  vein 
between  the  one  side  of  the  circle  of  the  ligature  and 
the  artery,  must  rather  tend  to  liinder  the  thread  from 
operating  in  the  most  desirable  manner  upon  the  lat- 
ter vessel. 

The  wound  is  now  to  be  evenly  closed  with  strips  of 
sticking  plaster,  so  that  the  edges  of  the  skin  may  form 
a straight  line  across  the  face  of  the  stump.  This  was 
the  mode  commended  by  Alanson,  and  is  what  is  pre- 
ferred by  the  generality  of  surgeons  in  this  country. 
It  is  also  advised  by  Graefe — (Normen  fiir  die  Abl. 
grosserer  Gliedm.  p.  106.  Guthrie  on  Gun-shot  Wounds, 
p.  208.)  Over  these  plasters  and  the  ends  of  the  liga- 
tures it  is  best  to  place  some  pieces  of  lint,  spread  with 
the  unguentum  cetaceum,  in  order  to  keep  such  lint 
from  sticking,  which  becomes  an  exceedingly  trouble- 
some circumstance  when  the  dressings  are  to  be  re- 
moved. I am  decidedly  averse  to  the  general  plan  of 
loading  the  stump  with  a large  mass  of  plasters, 
pledgets,  compresses,  flannels,  «fec. ; and  I see  no  rea- 
son why  the  strips  of  adhesive  plaster  and  a pledget  of 
simple  ointment  should  not  suffice,  when  supported  by 
two  cross  bandages  and  a common  linen  roller,  applied 
spirally  round  the  limb  from  above  downwards.  The 
first  turn  of  the  roller,  indeed,  should  be  fixed  round 
the  pelvis,  while  the  lower  circles  secure  the  cross  ban- 
dages, often  called  the  Malta  cross,  over  the  end  of  the 
stump.  It  is  also  an  excellent  method  to  leave  some 
little  interspaces  between  the  plasters,  and  in  summer 
to  keep  the  linen  bandages  constantly  wet  with  cold 
water.  In  this  w'ay  any  discharge  will  readily  escape, 
and  the  parts,  being  kept  cool,  will  be  less  disposed  to 
hemorrhage  and  inflammation. 

Sir  Astley  Cooper  states,  that  he  has  seldom  suc- 
ceeded with  his  stumps  above  the  elbow  or  knee  when 
a roller  was  not  employed,  which,  he  says,  prevents 
retraction  of  the  muscles  and  extensive  suppuration. 
After  applying  the  roller,  and  bringing  the  integuments 
together,  he  merely  jiuts  three  strips  of  adhesive  plas- 
ter over  the  wound,  and  one  round  the  stump  to  keep 
the  ends  of  the  plaster  in  their  place:  in  hot  weather 
he  applies  a lotion  of  spirit  of  w'ine  and  water. — (Lan 
cet,  vol.  1,  p.  150, j 


AMPUTATION.  65 


I am  completely  of  opinion  with  Mr.  Alanson,  that 
the  elastic  woollen  cap,  sometimes  placed  over  all  the 
bandages  and  dressings,  if  not  put  on  with  a great  deal 
of  care,  has  a tendency  to  push  the  skin  backwards  from 
the  extremity  of  the  stump ; and  as  it  must  also  heat 
the  part,  its  employment  should  he  discontinued. 

If- possible,  the  dressings  should  never  be  removed 
before  the  fourth  day,  not  reckoning  the  one  on  which 
the  amputation  is  performed ; and  Sir  Astley  Cooper 
even  prefers  the  sjxth  or  eiglith  day,  merely  removing 
on  the  fourth  one  strip  of  plaster  in  order  to  let  out  any 
confined  matter. — (See  Lancet,  vol.  1,  p.  150.)  Monro 
also  set  down  the  fifth,  sirtn,  or  seventh  day  as  gene- 
rally soon  eni>'igh  for  the  change  of  the  dressings. 
He  allows,  however,  that  if  the  smell  of  the  wound 
snould  become  offensive,  the  outer  dressings  may  be 
removed  sooner.  Even  when  the  dressings  are  to  be 
taken  away,  it  will  frequently  be  found  useftrl  not  to 
remove  one  strip  of  plaster;  but  the  stump  must  be 
made  clean,  and  any  discharge  washed  away.  These 
and  other  valuable  precepts,  derived  from  the  eminent 
Dr.  A.  Monro  senior,  are  worthy  their  great  source, 
and  the  correctness  of  them  promises  to  be  acknow- 
ledged for  ever. 

The  imipner  of  renewing  the  dressings  of  stumps  is 
indeed,  a very  important  business,  which  should  never 
be  inti-usted  to  mere  novices;  for  in  taking  off  the 
straps  of  sticking  plaster,  if  great  care  be  not  taken, 
the  slight  and  newly-formed  adhesions  may  be  torn 
asunder.  Thus,  as  Mr.  A.  C.  Hutchison  lias  remarked, 
if  the  strap  be  pulled  off  by  holding  one  end  of  it  at 
nearly  a right  angle  with  the  adhering  part,  the  flap 
will  be  raised  up  with  it,  and  thus  a separation  of  the 
newly-united  parts  wall  be  produced.  “ My  plan,”  says 
he,  “ is  to  reflect  the  raised  end  of  the  strap  close  down 
upon  the  adhering  part,  and  to  bring  it  gently  forwards 
with  one  hand,  while  the  removing  part  of  the  strap  is 
followed  by  tw'o  fingers  of  the  other  placed  upon  the 
skin,  <fec. ; and  when  one  end  is  detached  from  its  ad- 
hesion, as  far  as  the  line  of  incision  on  the  face  of  the 
stump,  in  like  manner  the  other  end  is  brought  down 
and  wholly  removed.” — (Tract.  Obs.  p.  46.) 

In  order  to  facilitate  the  removal  of  the  plasters,  and 
save  the  patient  a great  deal  of  pain,  I have  always 
followed  the  plan  of  letting  warmish  water  drop  over 
them  from  a sponge  for  a few  minutes  previously  to 
the  attempt  to  remove  them.  In  the  early  part  of  the 
treatment,  it  is  also  a valuable  rule  never  to  let  every 
strap  of  plaster  be  off  at  once,  so  as  to  leave  the  flesh 
quite  unsupported.  Some  skill  and  care  are  also  inva- 
riably necessary,  to  avoid  pulling  away  the  ligatures 
with  the  dressings. 

At  the  end  of  five  or  six  days  the  surgeon  may  begin 
to  try,  in  a very  gentle  manner,  whether  any  of  the 
ligatures  are  loose ; observing  rather  to  twist  than  sud- 
denly pull  them  directly  outwards.  However,  he 
should  not  use  the  smallest  force,  nor  persist,  if  the  trial 
create  pain.  One  would  hardly  try  whether  the  liga- 
ture on  the  main  artery  were  loose  before  the  eighth  or 
ninth  day.  If  minute  ligatures  made  of  dentist’s  silk 
be  employed,  and  both  their  ends  cut  off  close  to  the 
knot,  of  course  this  delicate  business  of  trying  to  get 
rid  of  the  irritation  of  those  foreign  bodies  is  entirely 
superseded. 

Though  in  the  above  account  I have  directed  the 
edges  of  the  wound,  after  the  amputation  of  the  thigh, 
to  be  brought  together  in  such  a way  that  the  wotind 
shall  appear  as  a line  across  the  face  of  the  stump,  yet 
there  are  instances  in  which  the  bone  seems  most 
easily  and  conveniently  covered,  by  making  the  line  of 
the  wound  in  a perpendicular  direction. 

Mr.  B.  Bell,  indeed,  generally  approved  of  it,  as  af- 
fording a ready  outlet  for  matter ; it  is  likewise  directed 
by  Mr.  C.  Bell  (Op.  Surgery,  vol.  1),  by  Roux  (M^m. 
sur  la  Reunion  immediate  de  la  Plaie,  aprds  I’Amp. 
p.  1 1),  and  by  Dr.  Ilennen  (On  Military  Surgery,  p.  265, 
ed.  2). 

On  the  other  hand,  Mr.  C.  Hutchison  objects  to  it, 
because  it  seems  to  him,  tiiat  when  a stump  thus  put 
up  is  laid  on  a pillovi',  the  pressure  tends  to  sejtarate 
and  open  the  lower  part  of  the  wound. — (Tract.  Obs. 
on  Surgery,  p.  .37.) 

It  is  curious  to  remark,  however,  that  the  thing 
which  leads  this  gentleman  to  disapjtrove  of  the  plan, 
is  one  which  would  be  urged  in  its  favour  by  Roux  and 
some  other  surgeons,  who  actually  take  tlie  precaution 
of  never  closing  the  lower  angle  of  tlie  wound,  in  order 

Vol.  I.— E 


that  whatever  discharge  occurs  may  find  a ready  out 
let.— (Mem.  cit.  p.  14.) 

Mr.  Alanson  objected  to  this  method,  asserting  that 
the  cicatrix  afterward  became  situated  immediately 
over  the  end  of  the  bone,  the  pressure  of  which  was 
very  likely  to  make  the  part  ulcerate.  However,  in  St. 
Bartholomew’s  Hospital,  I have  seen  the  edges  of  the 
wound  occasionally  brought  together  in  the  perpendi- 
cular direction,  and  cajtital  stumps  made  in  this  man- 
ner. In  a case  in  which  I assisted  Mr.  Ramsden  at 
Christ’s  Hospital,  when  an  attempt  was  made  to  put 
up  the  wound  in  a common  manner,  the  bone  seemed 
to  make  considerable  pressure  against  the  skin,  which 
did  not  happen  when  the  line  of  the  wound  was  made 
in  the  other  direction,  which  of  course  was  immedi- 
ately adopted.  Mr.  Hey  has  noticed  this  subject  as 
follows : the  integuments  and  muscles  may  be  brought 
into  contact  by  pressing  either  the  anterior  and  poste- 
rior parts  or  the  sides  of  the  thigh  together.  The 
former  method,  by  the  gradual  retraction  of  the  poste- 
rior muscles,  causes  the  integuments  of  the  anterior 
part  of  the  stump  to  cover  more  completely  the  extre- 
mity of  the  bone.  The  latter  method  causes  the  inte- 
guments and  muscles  to  meet  each  other  the  more 
readily,  and  therefore  is  to  be  preferred  when  the  quan- 
tity of  soft  parts  preserved  is  somewhat  deficient. — 
(Tract.  Obs.  on  Surgery,  p.  533,  edit.  2.) 

The  plan  of  bringing  the  edges  of  the  wound  toge- 
ther after  amputation,  so  that  they  may  unite  by  tlie 
first  intention,  has  received,  for  many  years  past,  the 
universal  approbation  of  British  surgeons.  It  is  their 
general  practice  in  the  treatment  of  all  incised  wounds. 
It  may  be  said  to  be  the  pride  of  English  surgery ; for 
in  nothing  does  she  display  more  convincingly  her  su- 
periority. Baron  Larrey,  how'ever,  in  cases  of  ampu- 
tation, disapproves  of  the  attempt  to  unite  the  wound 
by  the  first  intention,  and  merely  brings  forward  its 
edges  somewhat  towards  each  other  with  a piece  of 
linen,  that  covers  the  whole  of  the  wound,  and  has 
small  holes  cut  in  it  for  the  passage  of  the  discharge. 
— (Mem.  de  Chir.  Mil.  t.  3,  p.  379.)  This  piece  of  linen 
is  supported  with  a moderately  tight  roller. 

M.  Roux,  on  his  arrival  in  this  country,  wondered 
to  see  British  surgeons  so  prejudiced  in  favour  of  union 
by  the  first  intention,  as  to  adopt  it  after  all  amputa- 
tions. “C’est  pareillement  abuser  de  la  reunion  im- 
mediate que  de  I’appliquer  en  toute  circonstance  a la 
plaie  qui  r^sulte  de  Tamputation  des  rnembres.  J’en- 
tends  parler  de  Tamputation  dans  la  continuite  des 
rnembres,  et  plus  particuli^rement  encore  de  I’amputa- 
tion  circulaire.” — (T.  128.  Tarallele  de  la  Chirurgie  An- 
glaise  avec  la  Chirurgie  Franqaise,  8vo.  Paris,  1615.) 
But  M.  Roux  has  curiously  omitted  to  explain  in  his 
book  w'hat  are  the  advantages  of  not  bringing  the  edges 
of  the  wound  together,  and  why  he  calls  prejudice  the 
partiality  to  a method,  the  superior  efficacy  of  which  is 
contijiually  demonstrated  in  every  hospital  of  London 
He  does  not  indeed  presume  to  condemn  the  practice 
altogether  ; on  the  contrary,  he  allows  it  to  be  proper 
in  certain  cases ; yet  he  contends  that  it  ought  to  be 
confined  within  particular  limits.— (P.  130.  See  also 
Mem.  et  Obs.  sur  la  Reunion  immediate  de  la  Plaie 
apr^s  TAmputation,  &c.  8vo.  Paris,  1814.) 

In  this  tract,  which  is  well  drawn  up,  Roux  proves 
most  convincingly  the  benefits  of  union  by  the  first  in- 
tention after  amputation  of  the  thigh  by  the  circular 
incision ; but,  strangely  enough,  his  prejudices  hinder 
him  from  advising  the  jjractice  to  be  extended  to  other 
amputations.  He  does  not  positively  condemn  it  in 
the  arm,  though  he  thinks  the  method  less  necessary, 
because  amputation  there  is  less  dangerous  than  in  the 
thigh,  &c. — (P.  45.)  To  such  futile  reasoning  is  this 
author  reduced  by  the  unsoundness  of  his  doctrine. 
He  also  deems  the  attempt  at  union  by  the  first  inten- 
tion counterindicated  where  limbs  are  amputated  for 
injuries  which  violently  contuse  and  crush  the  parts 
iP.  48),  and  where  the  limb  is  much  wasted. — (P.  50.) 
In  the  latter  condition,  however,  he  thinks  Desault’s 
flap-amputation  may  be  done,  and  an  elTort  made  to  heal 
the  wound  by  adhesion.  In  one  case  he  did  this  with 
success. — (P.  51.) 

Richerand  informs  us  that  Dubois  at  Paris  follows 
the  plan  with  a success  equal  to  that  of  the  London 
surgeons.  For  some  years  past,  he  has  himself  also 
constantly  endeavoured  to  accomplish  union  by  the 
first  intention,  after  alt  the  amimtations  which  he  has 
had  occasion  to  practise,  and  he  succeeds  at  least  in 


65 


AMrUTATION. 


fliree  out  of  four.  “ The  method  is  preferable,”  says 
he,  “ to  the  old  one,  in  whatever  point  of  view  ii  is  con- 
sidered. 'riiis  union  is  more  e.xpcditious ; a few  days 
being  sufficient  for  its  completion.  A woman,  whose 
thich  i took  off  in  1810,  was  very  well  in  a week,  <toc. 
liesides  the  advantage  of  a quick  cure,  and  such  quick- 
ness is  especially  of  great  iinjiortance  where  the  patient 
has  been  much  reduced,  so  that  he  would  hardly  be 
able  to  bear  a long  suppuration,  union  by  the  linst  in- 
tention has  the  recomineiidation  of  saving  the  patient 
tVoin  a great  deal  of  pain,  the  flap  of  integuments,  with 
wliicli  the  bleeding  surface  of  the  stump  is  covered, 
being  much  less  irritating  to  the  flesh  than  the  softest 
charpie  would  be,  Alc.  Three  years  have  elapsed  since 
the  publication  of  the  third  edition  of  this  book.  During 
(his  interval  I have  jierformed  more  than  a hundred 
and  filly  amputations,  and  the  utility  of  irriinedia^c 
union  has  been  more  and  more  proved  to  me.” — (>roso- 
graphie  Cliirurg.  p.  475.  477,  edit.  4.) 

Hut  notwithstanding  these  and  other  encomiums  on 
the  practice,  llicherand,  like  other  French  surgeons,  is 
not  an  advocate  for  it  in  certain  ca.ses  ; as,  fbr  instance, 
limbs  shattered  by  gun-shot  wounds,  or  affected  with 
hospital  gangrene.  Here,  he  maintains,  that  it  hardly 
ever  succeeihi. — (1*.  478.)  Hut  though  it  be  true  that 
amputations  afler  gun-shot  wound.s  do  not  generally 
heal  so  well  as  many  other  cases,  it  cannot  be  denied 
that  they  do  sometimes  unite  more  or  less  by  the  first 
intention  ; and  why  should  not  the  chance  be  taken  ? 
It  is  productive  of  no  danger;  there  is  nothing  better 
to  be  tried;  and  if  it  fail,  what  is  the  harm?  Why, 
the  wound  will  then  heal  by  suppuration  and  the  gra- 
nulating process,  just  as  soon  as  if  the  hollow  of  the 
stump  had  been  filled  w’ith  charpie  or  left  open ; it  will 
in  fact  heal  in  a way  which  is  less  advantageous  than 
union  by  the  first  intention,  but  which  is  the  best  which 
can  now  happen. 

From  what  has  been  said,  it  appears  that  the  practice 
of  healing  the  wound  by  the  first  intention  after  am- 
putation IS  less  general  in  I’Yance  than  it  is  in  Fngland  ; 
a circumstance  which  may  perhaps  be  explained  by 
Uie  fact  of  its  being  much  newer  to  the  French  than  to 
us.  Ever}'  improvement  must  eiiconuteT  fora  time  the 
opposition  of  prejudice ; but  one  so  important  as  that 
which  we  are  considering,  must  at  length  jirevail  and 
meet  with  universal  adoption.  Our  extraordinary  par- 
tiality to  union  by  the  first  intention  arises  from  a con- 
viction of  its  superior  efficacy,  and  is  a decisive  proof 
of  the  goodness  of  English  surgery  in  respect  to 
wounds.  The  observations  of  Roux  and  Richerand 
tend  to  prove,  that  they  are  not  altogether  unaware  of  its 
advantages,  and  they  therefore  recommend  it  for  certain 
cases  ; but  their  backwardness  to  extend  it  to  all  ampu- 
tations without  exception,  is  little  in  favour  of  the 
comparison  wdiich  they  are  so  fond  of  making  of 
French  with  English  surgery.  Even  the  justly  emi- 
nent Dupuytren  still  fills  the  hollow  of  the  stump  with 
charpie. — (Syme,  in  Edinb.  INIed.  and  Surgical  Journ. 
No.  78,  p.  32.) 

However,  that  stumps  may  fall  into  a state  in  which 
the  pressure  of  all  plasters  and  bandages  whatever 
should  be  most  carefully  avoided  and  emollient  poul- 
tices used,  is  a truth  of  which  every  surgeon  of  e.xpe- 
rience  must  be  fuljy  convinced.  This  happens  when- 
ever the  parts  are  affected  with  considerable  tension, 
inflammation,  and  swelling,  or  i)ainful  acute  abscesses. 
There  is  also  no  utility  in  keeping  the  edges  of  the 
■w'ound  very  closely  compressed  together  when  all 
chance  of  adhesion  is  past,  and  the  parts  must  heal  by 
the  granulating  process.  My  friend  Mr.  Guthrie,  afler 
amputations  performed  from  necessity  in  parts  not  in  a 
healthy  state,  as  in  most  secondary  amputations  after 
compound  fractures  of  the  thigh,  does  not  insist  upon 
the  edges  of  the  wound  being  brought  into  close  contact 
by  sticking  plaster,  compress,  and  bandage.  In  these 
cases,  he  also  recommends  the  bone  to  be  sawed  an  inch 
shorter  than  usual,  or  than  w'ould  be  necessray  under 
other  circumstances,  in  order  to  prevent  its  protrusion, 
and  the  ligatures  to  be  cut  off  close  to  the  knots,  so  as 
to  lessen  irritation.  The  integuments  and  muscles 
are  to  be  brought  forwards  and  retained  so  by  a mode- 
rately tight  roller,  but  not  laid  down  against  the  bone. 
Some  fine  lint,  smeared  xvith  cerate  or  oil,  is  to  be  put 
between  the  edges  of  the  wound  ; and  a piece  of  linen 
and  a Malta  cross  over  it,  supported  by  a few  light 
turns  of  the  roller.  “ In  some  cases,”  says  Mr.  Guth- 
rie, “ I have  put  one  and  even  two  straps  of  plaster 


over  the  stump  to  keep  the  edges  approximated  withtdie 
being  in  contact ; and  where  the  parts  are  but  little 
diseased,  this  may  be  attempted  ; but  if  the  stumi*  be- 
comes uneasy  they  should  be  cut,  and  a poultice  applied., 
When  only  a part  of  the  slump  has  appeared  to  slough, 
I have  found  the  spiritus  camphone,  alone  or  diluted  wntli 
a waterj’  solution  of  opium,  applied  with  the  lint,  very 
useflil.” — (On  Gun-shot  Wounds,  p.  K>4.) 

The  reasons  which  led  Mr.  Guthrie  to  incline  to  the 
plan  of  not  bringing  together  the  edges  of  the  wound 
in  cases  of  this  description,  must  be  learned  by  refer- 
ence to  his  own  valuable  work.  His  cases  and  ar- 
guments are  entitled  to  serious  consideration ; and 
t hough  they,  as  well  as  the  observations  of  Roux  (Mem. 
sur  la  Reunion  immediate  de  la  Plaie  apr^s  rAmimta- 
tion,  8vo.  Paris,  1814),  leave  me  unconvinced  of  the  use- 
fulness of  not  bringing  the  edges  of  the  wound  to- 
gether immediately  after  the  amputation  of  bad  com- 
IKiund  fractures,  tliere  are  some  of  liis  observations  re- 
specting the  injurious  effects  of  too  much  pressure  in 
certain  conditions  of  the  stump,  perfectly  agreeing  with 
my  own  sentiments.  At  preisent,  I have  never  seen  any 
case  of  amputation  in  which  I should  not  have  thought 
the  surgeon  wrong,  had  he  not  brought  the  sides  of  the 
wound  together  directly  afler  the  operation,  so  as  to  af- 
ford the  chance  of  union  by  the  first  intention 

[A  mode  of  amputating  the  thigli  with  two  flaps  was 
projKised  a few'  years  since  by  Profes-sor  .1.  H.  ?>avidge, 
of  the  University  of  Maryland,  which  combines  several 
iinportaiit  advantages. 

The  first  incision  is  made  with  the  large  knife  on  the 
outside  and  inside  of  the  thigh  through  the  integu- 
ment, so  as  to  surround  the  limb,  with  the  e.xception  of 
an  inch  or  more  in  the  centre  above  and  below.  The 
surgeon  having  calculated  the  size  of  the  flaps  required, 
which  are  to  be  as  long  as  the  semi-diameter  of  the 
limb, ’makes  with  a scalpel  a second  and  third  inci- 
sion through  the  skin,  in  form  of  the  letter  V,  com- 
mencing above  the  centre  of  the  space  left  vacant  on 
the  superior  and  inferior  surface,  and  continued  until 
its  lUverging  extremities  reach  the  ends  of  the  semi 
circular  cuts  first  mentioned.  The  flaps  of  integu- 
ment are  then  dissected  back  until  they  eijual  in  length 
a little  more  than  the  semi-diameter  of  the  limb,  to  al- 
low for  the  retraction  that  may  occur.  A circular  inci- 
sion is  then  made  through  the  muscles  down  to  the 
bone  with  the  large  knife.  The  bone  is  then  denuded  for 
an  inch  or  two,  the  retractor  employed,  and  the  bone 
sawed  off  at  the  edge  of  the  divided  flesh.  The  arte- 
ries are  then  secured,  the  muscles  drawn  down,  the 
ligatures  so  arranged  as  to  come  out  of  the  superior 
and  inferior  angles  of  the  wound,  and  the  flaps  are 
brought  together  and  kept  in  place  by  adhesive  straps, 
supported  by  a cross  bandage,  roller,  <fcc.  By  this  am- 
putation the  bone  is  cut  off  an  inch  or  more  within  the 
actual  face  of  the  stump,  and  the  flaps  of  integument 
having  the  angle  cut  out  above  and  below  do  not  pre- 
sent that  unnecessary  and  inconvenient  lump  or  puck- 
ering, formed  at  the  angles  after  the  common  circular 
amputation.  I have  seen  this  operation  performed  by 
Dr.  Davidge  and  others  with  singular  success.  The 
stump  heals  by  the  first  intention,  without  any  of  the 
delays  which  are  often  encountered  with  the  common 
flap-operation,  and  I prefer  it  for  the  arm  as  well  as  the 
thigh,  unless  the  limb  be  much  emaciated. — Reese.] 

HEMORRH.iGE  AFTER  AMPUTATION. 

Bleeding  after  the  operation  is  of  two  kinds  in  re- 
gard to  the  time  when  it  occurs.  The  first  takes  place 
within  twenty-fbur  hours  after  the  operation.  Hence 
an  assistant  should  always  be  left  with  the  patient, 
with  directions  carefully  and  repeatedly  to  look  at  the 
stump ; and  if  any  bleeding  should  arise,  to  apply  the 
tourniquet  until  farther  aid  be  obtained.  In  case  no 
assistant  can  be  spared  for  this  purpose,  as  must  fre- 
quently happen  in  country'  practice,  the  tourniquet  should 
be  left  slackly  round  the  limb,  and  the  nurse  or  patient 
himself  directed  to  turn  the  screw  of  the  instrument,  in 
order  to  tighten  it  in  case  of  need.  A slack  tourniquet 
left  round  the  limb  after  amputation  cannot  do  harm, 
and  its  not  having  been  ready  in  this  way  has  cost 
many  patients  their  lives,  as  I have  known  instances  of. 

This  kind  of  hemorrhage  has  often  been  known  to 
arise  from  the  pressure  of  a tight  bandage  round  the 
stump.  As  Monro  observes,  the  circular  turns  of  the 
bandage,  when  tight,  must  stop  the  return  of  blood  in 
the  cutaneous  veins,  and  thus  by  making  a greater  re- 


AMPUTATION. 


67 


Bistance  to  the  blood  in  the  arrt.y»  vhich  anastomose 
■with  them,  occasion  the  contracting'power  of  the  heart 
and  arteries  to  dilate,  and  force  more  blood  into  their 
other  branches,  but  these  being  cut  in  the  amputation 
•will  pour  out  their  blood,  and  so  hemorrhage  is  brought 
on.  Making  much  pressure  round  the  stump  is  highly 
deserving  of  reprobation ; and  whenever  there  is  an 
universal  oozing  of  blood  I would  recommend  the  ope- 
rator to  be  sure  that  the  circulation  in  the  superficial 
veins  is  not  impeded  by  the  tightness  of  any  bandage  or 
tourniquet. 

If  the  bleeding  should  not  be  from  an  artery  of  conse- 
quence, the  application  of  linen  dipped  in  cold  water  will 
sometimes  check  it,  and  the  disagreeable  necessity  for 
removing  the  dressings  and  opening  the  wound  may 
thus  be  avoided. 

But  it  often  happens  that  the  wound  miust  be  opened, 
and  the  bleeding  vessel  tied.  This  is  a very  painful 
proceeding,  and  when  the  dressings  have  been  applied 
some  hours,  so  that  the  stump  has  had  time  to  inflame, 
nothing  can  exceed  the  suffering  to  which  the  patient  is 
now  subjected.  Here  we  see  the  prudence  of  being 
particularly  careful  at  first  to  tie  every  suspicious 
vessel. 

The  second  sort  of  hemorrhage  after  amputation 
arises  from  ulceration  of  the  large  arteries,  and  may 
occur  a month  after  the  oi)eration,  when  the  ligatures 
are  all  away,  and  the  patient  seems  nearly  well. 

Two  such  cases  are  related  by  Mr.  Bromfield. — (Vol. 
i,  p.  307.)  Now  that  the  plan  of  covering  the  stump 
with  sound  skin  is  adopted,  this  kind  of  bleeding  is  less 
common  than  formerly.  When  the  bleeding  vessel  is 
large  there  is  no  chance  of  putting  the  patient  out  of 
danger,  except  by  cutting  down  to  the  vessel  and  tying 
it.  The  trunk  of  the  vessel,  however,  may  sometimes 
be  more  conveniently  tied  than  the  bleeding  branch 
itself. 

Mr.  Hey  makes  mention  of  a particular  sort  of  he- 
morrhage after  the  operation : “ I have  seen,”  says 
he,  “ a few  instances  of  the  integuments  becoming  so 
contracted  after  the  operation  as  to  compress  the  veins 
just  above  the  extremity  of  the  stump,  and  bring  on 
after  some  hours  a co])ious  hemorrhage.  When  it  has 
appeared  clear  to  me  that  the  hemorrhage  was  venous,  I 
have  made  a division  of  the  integuments  on  one  side 
of  the  thigh,  sufficient  to  remove  the  stricture,  and  this 
method  has  immediately  suppressed  the  hemorrhage.” 
— (P.  530,  edit.  2.) 

I have  never  yet  met  -with  a case  in  which  a hemor- 
rhage was  unequivocally  produced  by  a contraction  of 
the  integuments.  Dr.  Ilennen  says  that  he  has  seen 
only  one  example,  and  it  was  successfully  treated  by 
loosening  the  bandage  and  moistening  the  dressings 
with  cold  water.— (On  Military  Surgery,  p.  264,  ed.  2.) 
Doubts  may  therefore  be  entertained,  whether  the 
cause  was  the  pressure  of  the  integuments  or  of  the 
roller  on  the  veins. 

In  Mr.  Guthrie’s  truly  practical  work  there  are  some 
excellent  remarks  on  the  hemorrhages  which,  in  an 
irritable  and  sloughing  state  of  a stump,  frequently 
take  place  from  the  small  branches,  or  from  the  main 
trunks  of  the  arteries,  in  consequence  of  ulceration. 
It  is  (says  hej  not  always  easy  to  discover  the  bleeding 
vessel,  or,  when  discovered,  to  secure  it  on  the  face  of 
the  stump ; for,  as  the  ulcerative  process  has  not 
ceased,  and  the  end  of  the  artery,  which  is  to  be  se- 
cured, is  not  sound,  no  healthy  action  takes  place.  The 
ligature  very  soon  cuts  its  way  through,  or  is  thrown 
off,  and  the  hemorrhage  returns;  or  some  other  branch 
is  opened,  and  another  ligature  is  required  which  is 
equally  uncertain  ; and  under  this  succession  of  liga- 
tures and  hemorrhages  the  patient  dies.  Here  cutting 
down  to  the  principal  artery  in  preference  to  another 
amputation  has  often  succeeded ; but  under  certain  cir- 
cumstances it  fails,  and  amputation  becomes  ultimately 
necessary.  At  the  same  time  it  is  allowed  that  this 
oj)eration  may  also  fail.  On  the  wliole,  Mr.  Guthrie 
professes  himself  to  be  an  advocate  in  most  cases  for 
tying  the  artery  in  the  first  instance  ; and  if  this  pro- 
ceeding should  not  answer,  he  would  then  amputate. 
However,  the  practice  of  taking  up  the  artery,  he 
thinks,  should  not  be  adopted  indiscriminately,  the  doc- 
trines of  aneurism  not  being  here  applicable,  because 
there  is  a wounded  vessel  with  an  external  opening.  “ In 
the  thigh  the  operation  is  less  certain  than  in  the  arm, 
and  especially  if  it  is  not  the  main  artery  that  bleeds ; 
for  the  branch  from  which  the  hemorrhage  proceeds  may  j 


come  from  the  profunda,  and  tying  the  artery  in  the 
groin  on  'such  opinion  would  be  doing  a serious  ope- 
ration, and  one  which  probably  would  not  succeed  ; for 
the  anastomosing  -branches  would  restore  the  circula- 
tion in  the  sturnj)  in  a short  time,  and  again  establish 
the  bleeding.  If  it  is  the  femoral  artery  that  bleeds, 
and  the  ligature  is  applied  high,  it  is  very  liable  to  a 
return  of  hemorrhage.  To  obviate  these  difficulties,  the 
part  from  which  the  bleeding  comes  should  be  well 
studied,  and  the  shortest  distance  from  the  stump  care- 
fully noted,  at  which  compression  on  the  artery  com- 
mands the  bleeding ; and  at  tills  spot  the  ligature  should 
be  applied,  provided  it  is  not  witliin  the  sphere ’of  the 
inflammation  of  the  stump.” — (On  Gun-shot  Wounds, 
p.  105,  106.)  Thus  far  the  advice  .seems  to  me  correct 
and  valuable  j but  where  the  hemorrhage  could  be  re- 
strained by  taking  up  the  artery  in  the  grohi,  though  not 
lower  down,  I doubt  the  propriety  of  preferring  ampu- 
tation to  this  other  less  severe  operation,  provided  the 
efficiency  of  a ligature  above  the  profunda  be  proved 
in  the  manner  judiciously  fecommended  by  Mr.  Guth- 
rie, viz.  by  means  of  pressure. 

The  following  is  the  counsel  offered  by  Sir.  Hey; 
“ When  we  are  under  the  necessity  of  amputating  a 
limb  that  has  suffered  great  contusion,  though  the  ope- 
ration is  performed  upon  a part  apparently  sound,  the 
wound  sometimes  becomes  sloughy  and  ill-conditioned 
No  good  granulations  arise  to  cover  the  extremities  of 
the  arteries ; but  the  ligatures  cut  through  these  ves- 
sels, or  becoming  loose,  cease  to  make  a sufficient  pres- 
sure upon  them,  and  hence  repeated  hemorrhages  ensue. 
This  is  a dangerous  state  for  a patient ; for  if  the 
vessels  are  taken  up  afresh  with  the  needle,  the  he- 
morrhage will  now  and  then  return  in  the  course  of 
two  or  three  days.  In  such  cases,  the  application  of 
dry  sponge  cut  transversely,  as  directed  by  Mr.  White 
(Cases  in  Surgery),  has  been  found  singularly  useful, 
and  has  saved  the  life  of  the  patient.  But  a constant 
pressure  must  be  kept  upon  the  pieces  of  sponge  by  the 
fingers  of  a succession  of  assistants,  till  granulations 
begin  to  arise  upon  the  stump,  and  the  prospect  of  fu- 
ture hemorrhage  disajipears.  This  method  is  of  the 
greatest  importance  after  amputation  on  the  thigh  or 
leg,  where  the  great  vessels  are  deeply  seated.  In  the 
arm,  above  the  elbow,  where  the  vessels  are  more  su- 
perficial, the  great  artery  may  be  taken  up  with  a por- 
tion of  muscular  flesh  above  the  surface  of  the  stump, 
by  making  first  an  incision  through  the  integuments. 
My  colleague,  Mr.  Logan,  has  done  this  tivice  within 
the  last  year  with  complete  success,  when  repeated 
ligatures,  applied  in  the  usual  way,  had  failed. 

“ In  the  morbid  sloughy  state  of  the  stump 
above-mentioned,  the  apjilication  of  lint,  soaked 
in  a liquid  composed  of  equal  quantities  of  lemon- 
juice  and  rectified  spirit  of  wine,  has  been  found  very 
advantageous,  and  has  caused  it  to  put  on  soon  a 
healthy  aspect.”— (P.  536,  537,  edit.  2.) 

[When  tills  operation  is  necessary  in  crowded  hos- 
pitals, where  hospital  gangrene  is  prevailing,  Delpech 
recommends  the  practice  of  cutting  off  the  ligatures 
close  to  the  knots  on  the  vessels,  so  that  the  lips  of  the 
wound  may  be  more  completely  and  accurately  brought 
together. 

By  this  means,  as  his  experience  has  taught  him, 
the  risk  of  the  wound  being  affected  is  materially  les- 
sened. The  small  particles  of  the  ligatures  enclosed 
in  the  stump,  he  says,  are  discharged  at  a period  when 
the  jiatient  has  regained  strength  enough  to  be  moved 
into  a healthy  atmosphere,  little  openings  being  pro- 
duced for  their  escape,  and  healing  up  again  within 
twenty-four  hours.  He  assures  us  that  he  has  never 
seen  the  practice  give  rise  to  an  abscess.  Delpech  is 
led  by  the  view  he  takes  of  the  consequences  of  suppu 
ration,  and  the  contraction  of  cicatrices,  to  prefer 
bringing  the  sides  of  the  wound  together  after  ampu- 
tation of  the  thigh,  so  that  the  line  of  the  cicatrix  may 
be  transverse  and  not  perpendicular.  His  reason  is, 
that  most  of  the  ligatures  which  unavoidably  produce 
suppuration  are  placed  on  branches  of  the  profunda  in 
the  posterior  part  of  the  limb,  consequently  here  the 
greatest  contraction  follows  cicatrization,  and  the  ante- 
rior flap  is  thereby  drawn  over  the  extremity  of  the 
bone  in  the  most  advantageous  manner. — (Chirurg. 
Clinique,  t.  2,  p.  395.)  The  same  author  gives  an  in- 
stance of  the  failure  of  a seton  to  unite  a broken  thigh- 
bone, where  no  union  had  followed  a long  trial  of  com- 
mon means ; and  he  was  in  the  end  compelled  to 


68 


AMPUTATION. 


amputate  the  limb  at  the  hip  joint ; the  second  example 
of  his  performing  this  severe  operation. — .P.  4titi.) 
Under  certain  circumstances  he  is  an  advocate  for  the 
excision  of  diseased  joints  in  preference  to  amputa- 
tion ; and  refers  the  union  of  the  bones  in  this  case, 
not  to  the  same  process  by  which  fractures  are  united, 
but  to  the  production  of  a fibrous  substance  analo- 
gous to  that  of  a cicatrix.  Several  successful  ex- 
amples of  the  practice  are  recorded. — (P.  472.)  With 
respect  to  uncured  fractures,  1 have  now  one  under  my 
care  in  the  King’s  Bench.  The  accident  happened  two 
yearsiand  a half  ago,  and  I have  recommended  the  trial 
of  a seton.— Pref.j 

ON  PROTRUSION  OF  THE  BONK. 

It  is  clearly  proved  by  the  obser\'ations  of  M.  Louis, 
that  this  disagreeable  consequence  may  be  generally 
prevented  by  taking  care  to  divide  the  loose  muscles 
first,  and  (after  their  complete  retraction,  which  will 
be  favoured  by  no  band  or  tourniquet  being  ajtplied 
round  the  limb,)  by  observing  to  divide  with  a bistoury 
the  muscles  which  adhere  to  the  bone ; lor  itistance, 
the  crural  muscle,  and  the  adhesion  of  the  vasti  and 
triceps  to  the  spine  of  the  femur.  By  this  method,  the 
bone  may  be  sawn  three  finger-breadths  higher  than 
it  could  be  if  no  attention  were  paid  to  beginning  with 
the  division  of  the  loose  muscles,  and  concluding  with 
that  of  others  attached  to  the  bone. 

The  protrusion  of  the  bones  will  never  take  place 
so  long  as  they  are  immediately  encompassed  with  tlie 
rteshy  substance  of  the  muscles  : this  proposition  is 
incontestable.  The  state  of  the  skin,  w hether  longer 
or  shorter,  conduces  notliing  to  this  protrusion ; nor 
will  the  inconvenience  be  prevented  by  drawing  the 
skin  upwards  and  pre.serving  as  much  of  it  as  possible. 
— (See  Mem.  sur  la  Saille  de  I’Us  aprts  Tarnputation, 
in  Mem.  de  I’Acad.  de  Cliirurgie,  tom.  5,  p.  273,  edit,  in 
12mo.) 

As  Mr.  Guthrie  has  observed,  a protrusion  of  the 
bone,  after  sloughing  of  the  stump,  or  other  accidental 
circumstances,  will  sometimes  hapiien  without  any 
fault  on  the  part  of  the  ojierator ; but  he  thinks  it 
may  almost  always  be  prevented  by  attention  to  the 
following  rulds  : — l.To  leave  the  integuments  attached 
to  the  muscles,  instead  of  turning  them  back.  2.  When 
the  muscles  are  cut  through  in  a slanting  direction, 
upwards  and  inwards,  or  even  directly  downwards,  to 
separate  them  from  the  bone,  so  that  it  niay  appear  at 
the  bottom  of  the  cone  as  a depressed  point.  3.  To 
cut  the  bone  short,  and  to  keep  the  tliigh  constantly 
bandaged  from  the  trunk  during  the  cure,  so  as  to 
prevent  the  retraction  of  the  mtiscles.  If,  says  Mr. 
Guthrie,  a surgeon  find,  directly  after  the  operation, 
that  the  bone  cannot  be  well  covered,  he  should  imme- 
diately saw  ofl’  as  much  more  of  it  as  will  reduce  it 
to  its  proper  length.  The  error  may  be  remedied  at 
this  moment  w'ith  very  little  inconvenience  in  com- 
parison with  what  must  afterward  be  encountered  if 
the  opportunity  be  neglected. — (On  Gun-shot  Wounds, 
p.  109.)  For  .some  very  useful  directions  how  to  ban- 
dage and  support  the  soft  jiarts  with  adhesive  plasters, 
with  the  view  of  counteracting  the  tendency  of  the 
bone  to  protrude,  I refer  to  some  observations  by  Mr. 
Wright. — (See  Bromfield’s  Chir.  Gases,  Ac.  vol.l,  p.l77.) 

Having  explained,  that  the  surest  wav' of  preventing 
the  evil  is  to  save  a sufficiency  of  muscle,  especially 
of  that  muscular  substance  which  is  naturally  most 
near  and  adherent  to  the  bone,  we  shall  next  speak  of 
the  mode  of  relief. 

When  the  end  of  the  thigh-bone  protrudes,  it  of 
course  hinders  cicatrization  and  becomes  itself  affected 
with  necrosis.  By  the  process  ol'  exfoliation,  the  dead 
portion  of  bone  is  sometimes  throw  n off,  and  a cure 
follows.  But,  in  general,  this  desirable  change  is  ex- 
tremely tedious,  and  the  result  uncertain,  because  it 
frequently  happens  that,  after  the  piece  of  bone  has 
separated,  the  rest  yet  projects  too  much,  and  the 
stump  still  continues  too  conical  to  heal  firmly  enough 
to  be  capable  of  bearing  the  pressure  of  a wooden  leg. 
When,  however,  the  end  of  the  bone  forms  only  a slight 
projection,  and  the  stump  is  not  too  conical,  it  is  always 
best  to  leave  nature  to  throw  off  the  redundant  exfo- 
liating portion.  In  the  opposite  circumstances,  the  re- 
moval of  all  such  part  of  it  as  cannot  be  covered  by  the 
integuments  is  the  best  practice,  and,  if  well  executed, 
will  effect  a cure. 

Tliis  second  operation  is  exceedingly  unpleasant  to 


I the  surgeon,  because  patients  are  apt  to  suspect,  and 
! not  without  reason,  that  the  first  was  not  projierly 
managed.  Let  me  therefore  rejieat,  that  the  surest 
way  of  avoiding  the  evil  is  to  cut  the  deep  muscles 
rather  higher  than  the  superficial  ones,  a.s  inculcated 
by  M.  Louis,  by  which  means  the  bone  will  certainly 
lie  within  the  level  of  the  surface  of  the  divided  flesh. 
The  advice  delivered  by  my  friend,  Mr.  Guthrie,  I also 
consider  valuable. 

The  second  performance  of  amputation  is  a still 
more  severe  and  unpleasant  operation ; yet,  as  Dr. 
Hennen  has  explained,  it  sometimes  becomes  neces- 
sary for  osteo.sarcoma,  extensive  necrosis,  abscesses  of 
the  medulla,  unsuspected  fissure,  phagedena,  or  great 
protrusion  of  bone,  with  an  extensively  diseased  peri- 
osteum, where  the  powers  of  nature  are  inadequate  to 
the  cure.  “ If  ike  general  health  is  not  impaired,  and 
the  flesh  does  not  peel  off  from  the  bone,  as  if  it  were 
boiled,  the  eftbrts  of  nature  may  be  trusted  to,  aided  by 
proper  bandaging,  and,  in  some  cases,  by  the  employ- 
ment of  the  saw ; but  when  restless  nights,  intense 
pain,  flushings,  and  irregular  bowels,  with  great  tume- 
faction and  hardness  of  the  stump  take  place,  indi- 
cating ajiiiroaching  hectic,  and  there  is  evidence  of  an 
irregular  action  of  the  parts,  osseous  matter  becoming 
depiisited,  and  forming  a distinct  tumour  around  the 
stump,  our  best  plan  will  be  to  operate  again  near  the 
trunk.”— (Principles  of  Military  Surgerj',  p.  266,  ed.  2.) 
Sometimes  amputation  has  been  considered  necessary 
a second  time,  in  consequence  of  a morbid  protube- 
rance of  the  nerves  of  the  stump,  a change  noticed  by 
Molinelli,  Morgagni,  Lower,  Aniemann,  and  Procha.ska, 
and  alw  ays  attended  with  excruciating  pain  and  great 
irritability  of  the  part,  and  sometimes  with  retraction 
of  the  skin,  and  protnision  of  the  bone.  Sir  Astley 
Cooper,  in  his  Lectures,  relates  one  instance  of  such  a 
stump  high  up  the  arm,  where,  upon  examination  of 
the  part  near  the  axilla,  a tumour  was  felt,whith,when 
touched,  made  the  iiatient  jump  as  if  he  had  been  elec- 
trified. In  this  case,  as  the  bone  protruded,  amputa- 
tion at  the  shoulder  was  performed.  In  another  ex- 
ample, w here  a leg-stump  was  in  a painful  irritable 
state  from  a similar  cause,  Sir  Astley  Cooper  effectu- 
ally relieved  the  patient  by  removing  the  diseased  end 
of  the  posterior  tibial  nerve.  In  a third  instance,  am- 
putation was  repeated  at  the  patient’s  desire,  and  the 
nerve.s  were  found  enlarged,  fanning  a ganglion  which 
partly  rested  upon  the  extremity  of  the  bone.  Such  a 
degree  of  irritation  had  been  produced  by  it,  that  no 
part  of  the  stump  could  be  touched  without  exciting  a 
kind  of  electric  shock.  In  a case  that  occurred  in  the 
Middlesex  Hospital,  amputation  of  the  thigh  was  per- 
formed a second  time,  in  consequence  of  the  first 
stumj)  being  thus  diseased.  A complete  ganglion,  or 
plexus  of  nerves,  was  found  closely  adhering  to  the 
removed  portion  of  bone,  having  almost  the  appearance 
of  cartilage.  The  os  femoris  was  of  an  unusually 
small  size,  but  the  linca  aspera  larger  than  natural. 
— (See  Lancet,  vol.  1,  p.  115 ; vol.  2,  p.  192.) 

The  following  works  may  be  consulted  for  informa- 
tion on  diseases  of  the  bones  of  stumps : Bonn,  The- 
saurus Ossium  Morborum,  Amst.  1788;  Weidmann 
de  Necrosi  Ossium,  Francof.  1798  ; Macdonald,  de 
iMecrosi  ac  Callo,  Edinb.  1799 ; the  above-mentioned 
Essays  of  M.  Louis ; L6vCille  sur  les  Mai.  des  Os  aprds 
I’Amputation,  Mem.  de  la  Society  d’Emulation,  t.  1,  p, 
148  ; Von  Hoorn  De  iis,  quae  in  partibus  membri,  prae- 
sertim  osseis  amputatione  vulneratis,  notanda  sunt ; 
Lugd.  1803.  Roux,  de  la  resection  des  Os  Malades, 
Paris,  1812 ; MCm.  de  Physiologie,  &c.  par  Scarpa,  et 
Lev6ill6,  Paris,  1804.) 

SPASMS  OF  THE  STUMP. 

Spasmodic  contractions  of  the  muscles  of  the  stump 
is  another  very  afflicting  occurrence.  Such  spasms 
put  the  patient  to  the  greatest  agony,  tend  to  cause  a 
protrusion  of  the  bone  or  sugar-loaf  stump,  and  in 
some  cases  increase,  affect  the  whole  body,  and  ulti- 
mately prove  fatal.  But  this  unfortunate  affection, 
w’hich  was  rather  frequent  after  amputations  per- 
formed in  the  ancient  manner,  is  infinitely  less  so 
after  the  ruodern  improved  plans  of  operating,  tying 
the  vessels,  and  dressing  the  wound.  When,  how- 
ever, it  does  occur,  the  stump  must  be  kept  from  start- 
ing. by  fastening  it  to  the  pillow  and  bedding  on  which 
it  lies,  the  flesh  is  to  be  properly  supported  with  a 
bandage  applied  from  the  pelvis  downwards,  and 


AMPUTATION. 


69 


opium  and  the  camphor  mixture  should  be  liberally 
exhibited. — (Encyclopedie  M^thodique,  Partie  Chir. 
1. 1,  p.  93.  Latta’s  Surgery,  vol.  3,  &c.) 

FLAP-AMPUTATION  OF  THE  THIGH. 

Although  I concur  with  the  majority  of  surgeons  in 
regarding  the  operatiou  by  a circular  incision  the  most 
eligible  under  ordinary  circumstances,  no  doubt  can 
exist  about  the  preference  which  should  be  given  to 
amputating  with  a flap  in  particular  examples.  The 
choice,  as  Dr.  Bushe  has  well  remarked,  ought  to  de- 
pend on  the  state  of  the  limb  and  nature  of  the  malady 
requiring  amputation.  “ One  surgeon  is  so  devoted  to 
the  double  circular  incision,  that  he  performs  no  other 
(method),  though  his  coadjutor  in  the  same  hospital  is 
bigoted  to  the  double  flap-operation,  and  never  ampu- 
tates but  after  this  manner.  But  the  unprejudiced 
practitioner  will  look  to  the  nature  of  the  case,  and 
adjust  means  accordingly.” — (Lancet,  No.  246,  p.  204.) 
Notwithstanding  this  good  doctrine,  however.  Dr. 
Bushe  is  in  reality  very  partial  to  flap-amputations, 
affirming,  that  there  is  only  one  part,  viz.  the  upper 
third  of  the  leg,  where  he  would  recommend  the  double 
circular  incision  to  be  preferred.—  (Op.  cit.  p.  207.)  At 
the  same  time,  he  confesses,  that  when  the  arm  is  much 
emaciated  and  flaccid,  Dupuytren’s  mode,  with  a sin- 
gle circular  incision,  is  that  to  which  he  has  himself 
given  the  preference.  He  admits,  also,  the  frequency 
of  tedious  suppuration  and  sinuses  after  flap-amputa- 
tions, which  evils,  however,  he  ascribes  to  the  fault 
of  making  the  flaps  too  long. — (P.  206.)  Flap-ampu- 
tation of  the  thigh,  I believe,  has  the  important  advan- 
tage of  being  least  exposed  to  the  danger  of  a protrusion 
of  the  bone,  and,  hence,  I think  it  may  be  advisable, 
whenever  any  reasons  exist  in  the  state  of  the  parts, 
or  the  constitution,  for  apprehending  that  disagreeable 
occurrence.  An  experienced  military  surgeon  informs 
us,  that,  in  the  first  years  of  his  practice,  he  performed 
several  amputations  by  the  double  incision,  strictly 
according  to  the  precepts  of  Sabatier,  Desault,  Pelletan, 
and  Pott,  but  had  the  mortification  to  have  three  cases 
in  which  the  bone  protruded,  though  the  greatest  cir- 
cumspection was  used  in  the  operation  and  after- 
treatment.  Hence  he  was  induced  to  make  trial  of 
the  flap-amputation,  and  although  he  imitates  O’Hal- 
loran  in  not  attempting  to  bring  the  flaps  close  together 
for  the  first  six  or  eight  days,  he  reports  that  the 
stump  is  generally  healed  in  twenty  or  thirty  days, 
and  exfoliations  rarely  happen,  on  account  of  the  bone 
being  so  well  covered.  In  short,  he  s'ays,  that  this 
method  is  to  be  preferred  to  all  others. — (J.  B.  Paroisse, 
Opusc.  de  Chir.  p.  185 — ^203.  Paris,  1806.) 

Mr.  Syme  also  informs  us,  that  though  the  flap- 
amputations  seen  by  him  have  been  very  numerous, 
he  has  never  met  with  an  instance  of  the  bone  pro- 
truding or  exfoliating  after  them. — (Ed.  Journ.  vol.  14, 
p.  38.) 

A description  of  Desault’s  or  rather  Vermale’s  mode 
of  operating,  being  given  in  the  First  Lines  of  the 
Practice  of  Surgery,  I need  not  here  repeat  it,  nor  say 
by  how  many  respectable  names  the  practice  is  sanc- 
tioned. In  Guy’s  Hospital,  flap-amputation  of  the  thigh 
seems  now  to  be  mostly  preferred.  The  operation  is 
also  sometimes  adopted  by  my  friend  Mr.  Vincent  in 
St.  Bartholomew’s  Hospital,  who  showed  me,  some 
time  ago,  a capital  stump  which  he  had  made  in  this 
manner,  and  which  heated  with  great  expedition. 

By  Mr.  Guthrie  the  flap-operation  is  considered  pre- 
ferable to  the  circular  incision  at  the  upper  part  of  the 
tliigh,  “ as  it  permits  the  head  of  the  bone  to  be  re- 
moved if  found  necessary,  allows  it  to  be  examined 
and  cut  shorter  with  greater  ease,  and  makes  a much 
better  covering  afterward. — (On  Gun-shot  Wounds, 

p.  200.) 

In  military  surgery,  flap-amputation  of  the  thigh  is 
often  advantageous,  because  all  the  flesh  on  one  side 
of  the  limb  is  frequently  torn  away,  or  left  in  so  terri- 
bly a mangled  state  as  to  be  unfit  for  making  a cover- 
ing for  the  end  of  the  bone.  Here  a flap,  sufficient  to 
cover  the  whole  face  of  the  stump,  should  be  saved 
from  the  sound  flesh  on  the  other  side  of  the  limb. 
When  the  surgeon  chooses  the  flap-amputation,  not 
from  necessity,  as  under  these  last  circumstances,  and 
the  flesh  is  sound  all  round  the  member,  the  best  way 
is  to  save  a flap  on  each  side  of  the  limb,  by  making 
two  semicircular  cuts,  the  convexities  of  which  extend 
in  a parallel  manner  forwards,  and  the  terminations  of 


which  meet  at  the  upper  and  lower  surfaces  of  the 
limb.  The  skin  is  not  to  be  at  all  dissected  from  the 
muscles,  which  are,  to  be  obliquely  divided  as  high  as 
the  base  of  the  flap  on  each  side.  However,  though 
this  is  the  best  plan,  particular  cases  may  require  a 
flap  to  be  made  from  the  anterior,  or  even  the  posterior 
side  of  the  thigh.  The  latter  method  should  never  be 
followed  but  from  necessity. — (See  Hey’s  Pract.  Obs. 
in  Surgery,  p.  531.  ed.  2.) 

According  to  Mr.  Guthrie,  the  difference  between  the 
flap-operation  at  the  upper  part  of  the  thigh  and  that  at 
the  hip  consists  in  its  being  done  lower  down,  and  in 
the  flaps  being  saved  more  immediately  from  the  ex- 
ternal and  internal  sides  of  the  thigh,  the  inner  flap  be- 
ing the  largest,  in  order  to  prevent  the  inconvenience 
which  might  arise  from  the  external  one  being  tightly 
stretched  over  the  end  of  the  bone.  For  the  same  rea- 
son Mr.  Guthrie  also  recommends  the  bone  to  be  sawed 
off  close  tothe  lesser  trochanter,  even  when  the  nature 
of  the  injury  would  allow  of  its  being  left  an  inch 
longer. — (On  Gun-shot  Wounds,  p.  200.) 

Flap-amputation  of  the  thigh,  after  the  manner  of 
Verrnale,  is  now  preferred  by  Klein,  one  of  the  best 
operating  surgeons  in  Germany,  and  by  Messrs.  Liston 
and  Syme,  two  surgeons  of  great  merit  in  Edinburgh. 
— (See  Edinb.  Med.  and  Surg.  Journ.  vol.  14,  p.  36 — 46, 
«fec.)  It  is  also  sometimes  practised  in  several  of  the 
metropolitan  hospitals.  Of  seven  cases  in  winch  Klein 
adopted  this  method,  the  greater  number  were  healed 
in  ten  days,  and  the  rest  in  three  weeks ; and  this  suc- 
cess determined  him  in  future  always  to  practise  it. 
After  this  mode  he  finds  there  is  no  danger  of  the  mus- 
cles retracting  themselves,  and  leaving  the  end  of  the 
bone  protruding,  even  though  the  patient  be  transported 
from  one  place  to  another.  With  respect  to  the  occa- 
sional difficulty  of  taking  up  the  obliquely  cut  vessels, 
Klein  admits  this  objection,  but  thinks  that  it  equally 
applies  to  Alanson’s  method.  He  lays  great  stress  on 
the  utility  of  giving  due  support  to  the  flaps  with 
compresses  and  a roller. — (See  Practische  Ansichten 
der  bedeutendsten  chirurgischen  Operationen,  p.  35—38, 
4to.  Stuttgart,  1816.) 

In  one  instance,  where  a ball  had  broken  the  upper 
part  of  the  femur,  and  mortification  had  spread  so  far 
towards  the  great  trochanter  and  buttock,  that  it  was 
impossible  to  operate  except  by  the  flap-operation,  or  by 
taking  the  head  of  the  bone  out  of  the  joint,  Klein 
made  a broad  flap  six  inches  long  at  the  inner  and 
upper  part  of  the  thigh,  and  then  he  cut  the  soft  parts 
straight  across  just  below  the  great  trochanter,  so  as  to 
make  this  wound  meet  the  termination  of  the  incision 
by  which  the  inner  flap  was  formed.  This  patient  got 
perfectly  well  in  three  weeks  (Op.  cit.  p.  39) ; and  so 
die!  another  very  similar  case,  operated  upon  by  the 
same  gentleman. — (P.  43.)  ’ Wliere  the  bleeding  is  con- 
siderable, the  femoral  artery  and  profunda  should  be 
tied  previously  to  sawing  the  bone  ; but  if  the  vessels 
are  well  commanded  by  the  pressure  the  sawing  ought 
to  be  first  completed. 

At  the  middle  of  the  thigh,  Lisfranc  also  prefers  am- 
putating with  two  lateral  flaps ; pressure  is  made  on  the 
femoral  artery  as  it  passes  over  the  brim  of  the  pelvis ; 
and  the  vessel  is  tied  immediately  the  inner  flap  is 
formed.  Lisfranc  makes  the  flaps  with  a very  long 
narrow  two-edged  knife,  which  he  introduces  through 
the  limb  on  each  side,  and  then  cuts  obliquely  outwards, 
and  do-wnwards  with  it ; but  1 think  Mr.  Syme  is  right 
in  recommending  the  knife  used  by  Mr.  Liston,  and  the 
back  of  which  is  thin  and  blunt  except  for  an  inch 
from  the  point. — (Ed.  Med.  Surg.  Journ.  vol.  14,  p.  37.) 
Mr.  Hey  also  preferred  a knife  with  a blunt  back,  lest 
the  vessels  should  be  cut  with  it  in  a way  that  would 
render  the  securing  of  them  troublesome. 

AMPUTATION  BELOW  THE  KNEE. 

In  treating  of  amputation  of  the  thigh  I have  remarked 
that  as  much  of  the  limb  as  possible  should  be  preserved. 
The  longer  it  is  after  the  operation,  the  stronger  and 
more  useful  will  it  be  found.  But  when  the  leg  is  to  be 
amputated  writers  commonly  advise  the  operation  to  be 
performed  a little  way  below  the  knee,  even  though  the 
disease  for  which  the  limb  is  removed  may  be  situated 
in  the  foot  or  ankle,  and  would  allow  the  operation  to 
be  done  much  farther  down.  The  common  practice  is 
to  make  the  incision  through  the  integuments,  just  iow 
enough  to  enable  the  operator  to  saw  the  bones,  about 
four  inches  below  the  lowest  part  of  the  patella 


'0 


AMPUTATION, 


About  six  inches  bcilow  this  point  is  generally  an  elip- 
ble  place  for  the  first  circular  cut  through  the  skin. 
This  degree  of  lowness  is  usually  deeincd  necessary,  in 
order  not  to  deprive  the  stump  of  that  {lower  of  motion 
which  arises  from  the  flexor  tendons  of  the  leg  continu- 
ing undivided.  It  is  alleged  also  as  a reason  for  this 
mode  of  proceeding,  that  it  is  quite  sufficient  to  pre- 
serve a few  inches  of^^he  leg  in  order  to  afford  the  body 
a proper  surface  of  support  in  walking  with  a wooden 
leg ; whereas,  if  a larger  portion  was  saved,  the  super- 
fluous part  would  be  a great  inconvenience  both  in 
walking  and  sitting  down,  without  being  of  the  small- 
est utility  in  any  respect  whatever.  However,  as  I 
shall  jiresently  notice,  experience  proves  that  where, 
according  to  the.se  maxims,  an  injury  or  disease  would 
dictate  the  performance  of  amputation  above  the  knee, 
the  practice  of  amputating  below  tliis  joint,  but  much 
higher  than  is  generally  sanctioned,  may  be  followed 
xviih  advantage. 

The  tourniquet  should  be  apjilied  to  the  femoral  ar- 
tery about  two-thirds  of  the  way  down  the  thigh,  just 
liefore  the  vessel  perforates  the  tendon  of  the  triceps 
muscle.  This  place  is  much  more  convenient  than  the 
h im,  where  it  is  very  difficult  to  compress  the  vessel 
against  the  bone.  The  jiatient  is  to  he  placed  upon  a 
firm  table,  as  in  the  amputation  of  the  thigh,  and  the  leg 
being  proiierly  held  by  one  assistant,  while  the  integu- 
ments are  drawn  ujiwards  by  another,  the  surgeon  with 
one  quick  stroke  of  the  knife  is  to  make  a circular  in- 
cision through  the  integuments  all  round  the  limb. 
Some  recommend  the  operator  to  stand  on  the  inside  of 
the  leg,  ill  order  that  he  may  be  able  to  saw  both  bones 
at  once.  No  reflections  could  ever  make  me  perceive 
that  any  real  advantage  ought  strictly  to  be  imputed  to 
this  plan.  Many  suppo.se  that  it  diiiiiiii.shes  the  chance 
of  the  fibula  being  splintered,  this  bone  being  coin- 
jiletely  divided  rather  swnier  than  the  tibia.  But  .splin- 
tering the  bones  generally  ari.ses  from  the  assistant  de- 
pre.ssing  the  limb  too  much,  or  else  not  supporting  it 
enough.  If  the  assistant  were  to  be  guilty  of  this  mis- 
management, it  would  be  difficult  to  explain  why  the 
tibia  should  not  be  splintered  instead  of  the  fibula, 
when  a certain  thickness  of  it  had  been  sawed  through. 
At  the  same  time  it  must  be  admitted,  that  if  the  sur- 
geon prefer  standing  on  the  inside  of  the  limb,  there  is 
no  objection  to  it  at  the  time  of  using  the  saw ; but  be- 
fore this  period,  in  amjmtating  the  right  leg,  there  is 
great  convenience  in  having  the  left  hand  next  to  the 
wound,  as  is  the  case  when  the  surgeon  stands  on  the 
outside  of  the  right  limb.  Hence  I have  seen  many 
hospital  surgeons,  in  amputating  the  right  leg,  cut  the 
soft  parts  while  they  stood  on  the  outside  of  the  limb, 
and  having  done  this  part  of  the  o|)eration  they  pro- 
ceeded to  the  other  side  of  the  member  for  the  purpose 
of  applying  the  saw.  I have  only  to  repeat,  that  1 do 
not  think  any  particular  reason  exists  against  saw- 
ing the  two  bones  together,  yet  in  such  manner  as 
to  let  the  fibula  be  divided  entirely  through  the  first ; 
and  the  advantage  of  fixing  this  bone  against  the  tibia 
by  the  pressure  of  the  hands  of  the  assistants,  while 
the  surgeon  is  sawing  it,  is  another  circumstance  which 
influences  a great  many  writers  to  commend  the  latter 
plan.  Graefe,  who,  as  already  mentioned,  prefers  the 
true  flap-operation,  does  not  tliink  it  advisable  for  the 
surgeon  to  stand  on  the  inside  of  the  limb  in  his  me- 
thod of  operating,  because,  when  the  knife  is  intro- 
duced through  the  muscles  of  the  calf,  its  point  would 
be  apt  to  go  between  the  two  bones. — (Nonnen  fiir  die 
Abl.  griisserer  Gliedm.  p.  130.) 

A circular  cut  having  been  made  through  the  integu- 
ments, about  two  inches  below  the  place  where  it  is 
intended  to  saw  the  bones,  the  next  object  is  to  pre- 
serve skin  enough  to  cover  the  front  of  the  tibia  and 
the  part  of  the  stump  corresponding  to  the  situa- 
tion of  the  tibialis  anticus,  extensor  longus  pollicis  pe- 
dis, and  other  muscles,  between  the  tibia  and  fibula, 
and  those  covering  the  latter  bone.  Throughout  this 
extent  there  are  no  bulky  muscles  which  can  be  made 
very  serviceable  in  covering  the  end  of  the  stump,  and 
consequently  the  operator  mtist  take  care  to  preserve 
sufficient  skin  in  this  situation  by  dissecting  it  from  the 
parts  beneath  and  turning  it  up. 

On  the  back  part  of  the  leg,  on  the  contrary,  the  skin 
should  never  be  uselessly  detached  to  a great  extent 
from  the  large  gastrocnemius  muscle,  wliich,  with  the 
Boleus,  will  here  form  a sufficient  mass  for  covering  the 
stump.  However,  the  experience  which  I had  in  the 


army  taught  me  the  truth  of  a remark  made  by  Graefe, 
that  in  forming  the  posterior  flap  of  muscle  it  is  a mat- 
ter of  the  highest  importance  to  let  the  integuments  be 
somewhat  longer  than  it ; for  otherwise,  when  it  is 
turned  forwards,  as  it  must  be  for  the  purpose  of  cover- 
ing the  ends  of  the  bones,  its  front  edge  will  be  left  un- 
covered by  integuments  which,  being  the  outermost, 
describe  a greater  circumference  than  the  deeper  mus- 
cular flap. — (Norinen  fiir  die  Abl.  griisserer  Glied.  p. 
131.)  I was  fully  convinced  of  the  truth  of  this  ob- 
servation by  two  amputations  which  were  done  by  my- 
self one  in  the  neighbourhood  of  Antwerp,  in  1814,  and 
the  other  at  Bru.ssels  the  day  after  the  battle  of  Water- 
loo. Yet  Graefe,  who  performs  the  llaivamputation, 
strictly  so  called  (that  is  to  say,  the  operation  in  which 
a flap  of  skin  corresponding  in  shape  to  ilie  flap  of 
muscle  is  preserved),  does  not  himself  detach  the  skin 
from  the  muscles  of  the  calf  at  all,  but  at  the  time  of 
making  the  incision  in  that  situation  directs  one  as- 
sistant to  pull  up  the  integumenus,  wliile  another  bends 
the  foot  as  much  as  po.ssible,  which  maneeuvres  have 
the  effect  of  letting  the  muscles  be  cut  rather  shorter 
than  the  skin.  Unfortunately,  however,  in  many  cases, 
the  very  nature  of  the  disease  or  injury  for  which  the 
operation  is  performed,  would  not  admit  of  these  pro- 
ceedings. Nor,  in  a very  muscular  limb,  would  they 
be  likely  to  suffice,  as  Graefe  himself  confesses,  since 
in  such  cases  he  recommends  the  use  of  a knife  bent 
laterally  for  the  purpose  of  excavatitig,  as  it  were,  as 
the  incision  is  made,  the  thick  muscular  flap.^(Op. 
cit.  p.  134.)  In  the  common  method  with  the  circular 
incision,  I am  disposed  to  think  it  best,  therefore,  to  let 
a small  ijuantity  of  skin  be  detached  and  saved  at  the 
back  part  of  the  leg,  so  that  there  may  be  a certainty  of 
having  enough  to  cover  well  the  extremity  of  the  di- 
vided muscles  of  the  calf.  As  soon  as  the  skin  has 
been  separated  in  front  and  on  the  outside  of  the  leg, 
the  surgeon  is  to  detach  the  skin  from  the  calf  for 
about  an  inch,  and  having  reflected  or  drawn  this  pre- 
served portion  out  of  the  way,  he  is  to  place  the  edge 
of  the  knife  close  to  the  edge  of  the  retracted  or  reflected 
skin  at  the  back  of  the  limb,  and  cut  obliquely  upwards 
through  the  muscles  of  the  calf,  from  the  inner  edge  of 
the  tibia  quite  across  the  fibula,  supposing  the  operator 
to  be  on  the  outside  of  the  right  leg,  and  that  it  is  this 
member  which  is  undergoing  removal.  In  performing 
this  last  incision,  as  M.  Louis  well  observes,  it  is  es- 
sential to  incline  the  edge  of  the  knife  obliquely  up- 
wards. In  this  manner  the  skin  will  be  longer  than 
the  muscles,  and  the  cure  considerably  accelerated. — 
(Mem.  de  I’Acad.  de  Chir.  t.  5,  edit,  in  12mo.) 

In  the  leg,  the  necessity  of  dissecting  the  skin  from 
the  subjacent  parts  is  acknowledged  to  be  greater  than 
in  the  thigh : thus  Mr.  (Juthrie  says,  “ as  the  attach- 
ment of  the  skin  to  the  bone  will  not  readily  allow  of 
its  retraction,  it  must  be  dissected  back  all  round,  and 
separated  from  the  fascia,  the  division  of  which  in  the 
first  incision  would  avail  nothing,  from  its  strong  at- 
tachment to  the  parts  beneath.” — (On  Gun-shot 
Wounds,  p.  220.)  In  dissecting  the  skin,  however,  a 
much  greater  detachment  of  it  should  be  made  at  the 
front  and  outer  part  of  the  limb,  than  at  the  opposite 
points,  as  already  explained. 

The  flap  formed  of  the  integuments  and  muscles  of 
the  calf  is  then  to  be  held  back  by  one  of  the  assist- 
ants, while  the  surgeon  completes  the  division  of  the 
rest  of  the  muscles,  together  with  that  of  the  interos- 
seous ligament,  by  means  of  the  catling,  a kind  of  long, 
narrow,  double-edged  knife. 

In  amputating  below  the  knee,  very  particular  care 
must  be  taken  to  cut  every  fasciculus  of  muscular  fibres 
before  the  saw  is  used.  Every  part  except  the  bones 
being  divided,  the  soft  parts  are  next  to  be  protected 
from  the  teeth  of  the  saw  by  a linen  retractor,  made 
with  two  slits  to  receive  the  two  bones,  care  being 
taken  to  let  the  unslit  part  be  applied  to  the  muscles  of 
the  calf,  as  particularly  advised  by  Graefe. — (Op,  cit 
p.  136.) 

In  tho  leg  there  are  only  three  principal  arteries  re- 
quiring ligatures,  viz.  the  anterior  and  posterior  tibial, 
and  the  peroneal  or  fibular  arteries.  In  addition  to 
these,  however,  the  surgeon  is  sometimes  obliged  to 
tie  large  muscular  branches.  The  anterior  tibial  artery 
will  be  found  in  front  of  the  interosseous  membrane, 
and  between  the  extremities  of  the  bones ; the  fibular 
artery  behind  the  fibula ; and  the  posterior  tibial  situ- 
ated more  inwardly  than  tlie  last,  among  the  fibres  of 


AMPUTATION. 


71 


the  eoleas,  near  the  tibia.— (C.  Bell,  Oper.  Surgery,  vol. 
I,p.  385.) 

When  the  soft  parts  have  been  cut  in  the  preceding 
way,  the  bones  sawed,  and  the  arteries  tied,  the  wound 
is  to  be  closed  by  bringing  the  flap  of  skin  over  the 
front  and  external  parts  of  the  stump,  so  as  to  meet 
the  flap  composed  of  the  gastrocnemius,  soleus,  and 
integuments  on  the  opposite  side.  This  should  be  done 
without  letting  any  tight  strap  of  plaster  press  the 
skin  against  the  sharp  edge  of  the  tibia ; a serious  and 
hurtful  practice,  which  has  often  occasioned  ulcera- 
tion and  sloughing  of  the  integuments,  and  protrusion 
and  necrosis  of  the  bone.  It  is  this  danger  which 
leads  Mr,  Guthrie  to  prefer  closing  the  wound  vertically, 
or  nearly  so,  and  applying  the  adhesive  straps  from  side 
to  side.— (On  Gun-shot  Wounds,  p.  221.)  I think,  how- 
ever, the  above  mode  of  operating  almost  necessarily  re- 
quires the  wound  to  be  closed,  so  as  to  form  a line,  extend- 
ing in  a direction  from  the  tibia  to  the  fibula.  But  where 
a great  deal  of  skin  is  saved  all  round  the  limb,  and 
the  muscles  of  the  calf  are  not  chiefly  calculated  upon 
for  covering  the  bones,  the  perpendicular  line  of  the 
wound  wall  answer  very  well. 

Many  surgeons,  however,  operate  differently.  Thej”^ 
first  make  the  circular  incision  through  the  skin,  two 
inches  below  where  they  mean  to  saw  the  bones. 
They  next  detach  the  skin  from  the  muscles  and  bones 
equally  all  round  the  limb  to  the  extent  of  about  a 
couple  of  inches.  The  integuments  are  then  turned 
up,  and  a division  of  the  muscles  made  all  round  down 
to  the  bones,  on  a level  with  the  line  where  the  detach- 
ment of  the  skin  has  terminated.  The  parts  between 
the  bones  are  afterward  cut  through,  &c.  The  hemor- 
rhage having  been  stopped,  the  integuments  are  drawn 
down  over  the  stump,  and  the  line  of  the  wound  made 
perpendicular. 

In  the  army,  the  practice  has  sometimes  been  adopted 
of  sawing  off  the  sharp  upper  ridge  of  the  tibia;  but 
I can  offer  no  exact  judgment  on  the  merits  of  the  in- 
novation, which  has  made  but  slow  progress.  It  has 
been  done  a few  times  at  St.  Bartholomew’s,  and  I 
should  have  no  objection  to  giving  it  a fair  trial,  espe- 
cially ^ls  it  has  the  sanction  of  Mr.  Guthrie,  who  says, 
that  in  thin  persons,  where  the  spine  of  the  tibia  is 
very  sharp,  this  part  should  be  removed  with  the  saw. 
— (P.  222.) 

Occasionally  surgeons  have  also  removed  the  small 
remnant  of  the  fibula,  and  such  was  sometimes  the 
practice  of  Larrey,  when  he  amputated  nearer  the 
knee  than  common. — ’Mem.  de  Chir.  Mil.  t.  3,  p.  389.) 

Whether  the  above  plan  of  amputating  the  leg  so 
high  up,  when  the  foot  or  ankle  is  the  part  diseased  or 
injured,  be  on  the  whole  most  advantageous,  I cannot 
presume  to  determine.  By  some  clever  men  the  prac- 
tice has  been  condemned ; and  though  we  see  it  pur- 
sued by  the  best  surgeons  in  this  metropolis,  and  iny 
own  sentiments  incline  me  to  believe  they  are  right,  I 
will  not  say  that  the  matter  is  so  settled  as  not  to  re- 
quire farther  consideration. 

Mr.  White  of  Manchester,  in  a paper  dated  1769 
(Med.  Obs.  and  Inq.  vol.  4),  informs  us  that  he  took 
the  hint  to  amputate  a little  above  the  ankle,  from  see- 
ing a case  in  which  this  had  been  done  by  a simple  in- 
cision, with  such  success  that  the  patient  could  walk 
extremely  well,  though  with  a machine  that  was  very 
badly  constructed.  After  this,  Mr.  White  began  to 
operate  above  the  ankle  with  the  double  incision  ; and 
he  invented  a machine  much  better  calculated  for  the 
patient  to  walk  upon. 

In  1773,  Mr.  Bromfield  published  his  Chirurgical 
Cases  and  Observations,  wherein  he  mentions  his  hav- 
ing begun  about  the  year  1740  to  amputate  above  the 
ankle,  in  a case  of  gangrene  of  this  part  of  the  teg. 
The  patient  walked  so  well,  with  the  aid  of  a very 
simple  machine,  both  along  a level  surface,  and  in 
going  up  and  down  stairs,  that  it  was  difficult  to  per- 
ceive be  had  lost  his  toot.  Mr.  Bromfield  was  persua- 
ded, however,  to  give  up  this  practice,  until  he  learned 
that  in  1754,  a Mr.  Wright  had  thrice  amputated  in 
this  way  with  success,  when  he  again  had  recourse  to 
it  without  the  least  unpleasant  consequences. — (See 
Chir.  Cases  and  Obs.  vol.  1,  p.  189,  <fec.) 

The  advantage  of  amputating  a little  below  the  knee 
is,  that  the  pressure  in  walking  with  a wooden  log  is 
entirely  confined  to  the  front  of  the  limb,  the  cicatrix 
itself  not  being  subjected  to  irritation.  After  amputat- 
ing at  the  ankle,  the  pressure  in  walking  operates  di- 


rectly on  the  cicatrix.  According  to  Sabatier,  this  st 
plan  has  been  extensively  tried  in  France,  but  not 
found  to  answer,  the  stump  being  incapable  of  bearing 
pressure,  and  not  continuing  healed. — (Mttdecine  Op6- 
ratoire,  t.  3,  p.  377,  ^dit.  2.)  Baron  Larrey  also  speaks 
of  it  as  an  objectionable  operation,  not  merely  because 
some  patients,  as  for  instance  soldiers,  have  not  the 
means  of  providing  themselves  with  artificial  legs  ot 
the  above  description,  but  because  it  is  almost  always 
followed  .by  bad  symptoms,  owing  to  the  small  quantity 
of  cellular  substance  and  flesh,  and  the  thickness  of 
the  bone  at  this  part  of  the  leg,  whereby  cicatrization 
is  impeded.  A nervous  irritation  is  more  apt  to  be 
produced  by  this  than  the  common  mode  of  operating, 
and  the  suppuration,  which  is  always  sanious,  takes 
place  with  difficulty.  “ I have  (says  Larrey)  seen  many 
amputations  done  at  this  part,  but  nearly  all  the  pa 
tients  died  of  nervous  fever  or  tetanus.”— (Mem.  de 
Chir.  Mil.  t.  3,  p.  394.) 

In  the  foregoing  columns  I have  given  some  account 
of  the  flap-amputation  of  the  leg,  as  done  by  Lowd- 
ham,  Verduin,  Garengeot,  Vermale,  and  others,  and, 
in  particular,  the  practice  of  O’Halloran  has  been 
touched  upon,  whose  chief  peculiarity,  viz.  that  of  not 
laying  down  the  flap  until  ten  or  twelve  days  had 
elapsed,  was  unquestionably  his  greatest  error,  though 
the  idea  may  have  been  admired  and  followed  by  a few 
speculators  in  modern  times. — ’See  Paroisse,  Opusc. 
de  Chir.  p.  196,  &c.  Paris,  1806.)  This  last  author, 
who  is  a general  approver  of  flap-amputations,  leaves 
the  stump  unclosed  for  some  days  after  the  removal  of 
the  limb  ; but  it  surprised  me  to  hear,  that  in  one  of 
the  finest  hospitals  in  this  metropolis,  three  or  four 
trials  were  made  a few  years  ago,  of  a modification  of 
this  absurd  practice,  after  amputation  by  the  circular 
incision.  Instead  of  bringing  the  sides  of  the  wound 
together,  the  stumps  were  only  partially  closed,  and 
kept  for  a day  or  two  covered  with  wet  linen.  The 
last  patient  whom  I heard  of  as  having  been  treated  in 
this  manner,  died  a few  days  after  the  operation ; and 
it  gives  me  pleasure  to  hear,  that  all  farther  intention 
of  subjecting  more  patients  to  the  experiment,  in  the 
hospital  alluded  to,  is  given  up. 

In  flap-amputations  below  the  knee,  Alanson  and 
Lucas  conjectured  that  the  cure  might  be  rendered 
more  safe,  easy,  and  expeditious  by  applying  the  flap, 
with  the  view  of  uniting  it  by  the  first  intention. 

The  following  case  explains  Mr.  Alanson’s  flap-ope- 
ration. The  disease  was  in  the  left  leg,  the  patient, 
therefore,  lay  on  his  right  side,  upon  a table  of  conve- 
nient height,  so  as  to  turn  the  part  to  be  first  cut  fully 
into  view.  The  intended  line,  where  the  knife  was  to 
pass  in  forming  the  flap,  had  been  previously  marked 
out  w'ith  ink.  A longitudinal  incision  was  made  with 
a common  scalpel,  about  the  middle  of  the  side  of  the 
leg ; first  on  the  outside,  then  on  the  inside,  and 
across  the  tendo  Achillis : hence,  the  intended  flap  was 
formed,  first  by  incisions  through  the  skin  and  adipose 
membrane,  and  then  completed  by  pushing  a catling 
through  the  muscular  parts  in  the  upper  incised  point, 
and  afterward  carrying  it  out  below,  in  the  direction  of 
the  line  already  mentioned.  The  flap  w'as  thick,  con- 
taining the  whole  substance  of  the  tendo  Achillis.  The 
usual  double  incision  was  made  ; the  retractor  applied 
to  defend  the  soft  parts ; and  the  bone  divided  as  high 
as  possible  with  the  saw. 

The  flap  was  placed  in  contact  with  the  naked  stump, 
and  retained  there  at  first  by  three  superficial  stitches, 
between  which  adhesive  plasters  were  used.  Not- 
withstanding the  patient  caught  an  infectious  fever  a 
few  days  afterward,  the  slump  healed  in  three  w'eeks, 
except  half  an  inch  at  the  inner  angle,  where  the  prin- 
cipal vent  had  been.  In  another  week,  the  wound  was 
reduced  to  a spongy  substance,  about  the  size  of  a 
split  pea.  Tliis  being  touched  with  caustic  healed  in 
a few  days.  The  man  was  soon  able  to  use  an  artifi- 
cial leg,  with  which  he  walked  remarkably  well.  He 
went  several  voyages  to  sea,  and  did  his  business  with 
great  activity.  He  bore  the  pressure  of  the  machine 
totally  upon  the  end  of  the  stump,  and  was  not  trou- 
bled with  the  least  excoriation  or  soreness. 

In  the  next  instance,  in  which  Mr.  Alanson  operated, 
he  forme^d  the  flap  by  pushing  a double-edged  knife 
through  the  leg,  and  passing  it  downwards  and  then 
outwards,  in  a line  first  marked  out  for  the  direction  of 
the  knife.  In  tliis  way,  the  flaj»  was  more  quickly 
made. 


72 


amputation. 


The  leg  should  be  completely  extended  during  the 
operation  ; and  kept  in  that  jiosturc  till  the  wound  is 
perfectly  healed. 

We  shall  next  notice  Mr.  Iley’s  method.  He  was 
satisfied,  that  very  near  the  ankle  is  not  the  most  pro- 
per place  for  this  kind  of  amj)Utation. 

Some  cases  occurring  in  which,  from  a scrofulous 
habit,  the  wound  at  the  stump  would  not  heal  com- 
pletely, nor  remain  healed,  Mr.  Hey  detennined  to  try 
whether  amputation  in  a more  muscular  part  woidd  not 
secure  a complete  healing,  and  give  the  patient  an  op- 
portunity of  resting  his  knee  on  the  common  wooden 
leg,  or  using  a socket,  as  he  might  find  most  conve- 
nient. Mr.  Hey  latterly  preferred  this  method,  wliich 
he  reduced  to  certain  mea.surcs. 

It  had  been  customary  at  the  Leeds  Infirmary,  to 
make  the  length  of  the  flap  e<iual  to  one-third  of  the 
circumference  of  the  leg.  This  was  detennined  by 
the  eye  of  the  ojierator,  who  usually  jiushed  the  cat- 
ling through  the  leg  near  the  posterior  part  of  the 
fibula.  Mr.  Hey,  finding  the  flap  was  not  always 
of  the  proper  breadth,  began  to  determine  this  by 
measure,  and  then  operated  as  follows : to  ascertain 
the  jilace  where  the  bones  are  to  be  sawed,  together 
with  the  length  and  breadth  of  the  dap,  he  draws  upon 
the  limb  five  lines,  three  circular  and  two  longitudinal 
ones.  He  first  mea.sures  the  length  of  the  leg  from 
the  highest  part  of  the  tibia  to  the  middle  of  the  infe- 
rior protuberance  of  the  fibula.  At  the  mid-point  be- 
tween the  knee  and  ankle,  he  makes  the  first  or  highest 
circular  mark  upon  the  leg.  Here  the  bones  arc  to  be 
sawed.  Here  .Mr.  Hey  also  measures  the  circumfe- 
rence of  the  leg,  and  thence  determines  the  length  and 
breadth  of  the  flap,  each  of  which  is  to  be  equal  to 
one-third  of  the  circumference.  In  measuring  the  cir- 
cumference of  the  limb,  Mr.  Hey  employs  a piece  of 
marked  tape  or  riband,  and  places  one  end  of  it  on  the 
front  edge  of  the  tibia.  Supposing  the  circumference 
to  be  twelve  inches,  he  makes  a dot  in  the  circular 
mark  on  each  side  of  the  leg,  four  inches  from  the  an- 
terior edge  of  the  tibia.  These  dots  must,  of  course, 
be  four  inches  apart  behind.  From  each  of  these  dots 
Mr.  Hey  draws  a straight  line  downwards,  four  inches 
in  length,  and  parallel  to  the  front  edge  of  the  tibia. 
These  lines  show  the  direction  which  the  catling  is  to 
take  in  making  the  fl.ap.  At  the  tenninatiou  of  these 
lines,  Mr.  Hey  makes  a second  mark  round  the  limb, 
to  show  the  place  where  the  flap  is  to  end.  Lastly,  a 
third  circular  mark  is  to  be  made  an  inch  below  the 
upper  one,  first  made  for  the  purpose  of  directing  the 
circular  cut  through  the  integuments,  in  front  of  the 
limb.  The  catling  for  making  the  flap  should  be 
longer  than  those  commonly  employed  in  amputations. 
Mr.  Hey  u.ses  one  which  is  seven  inches  long  in  the 
blade,  and  blunt  at  the  back,  to  avoid  making  any  lon- 
gitudinal wound  of  the  arteries,  which  is  very  difficult 
to  close  with  a ligature  ; and,  for  the  same  reason,  he 
pushes  the  catling  through  the  leg  a little  below  the 
place  where  such  muscles  are  to  be  divided  as  are 
not  included  in  the  flap.  The  limb  being  nearly  hori- 
zontal, and  the  fibula  upwards,  he  pushes  the  catling 
through  the  leg  where  the  dot  was  made,  and  carries 
it  downwards  along  the  longitudinal  mark,  till  it  ap- 
proaches the  lowest  circular  mark,  a little  below  which 
the  instrument  is  brought  out.  The  flap  being  held 
back,  Mr.  Hey  divides  the  integuments  on  the  front  of 
the  limb  along  the  course  of  the  second  circular  mark. 
The  muscles  not  included  in  the  flap  are  then  divided 
a little  below  the  place  where  the  bones  are  to  be 
sawed.  No  great  quantity  of  these  muscles  can  be 
saved,  nor  is  it  necessary,  as  the  flap  contains  a suffi- 
cient portion  of  the  gastrocnemius  and  soleus  muscles 
to  make  a cushion  for  the  ends  of  the  bones.  After 
sawing  the  bones,  Mr.  Hey  advises  a little  of  the  end 
of  the  tendon  of  the  gastrocnemius  to  be  cut  off,  as  it 
is  apt  to  project  beyond  the  skin  when  the  flap  is  put 
down ; and  he  recommends  the  large  crural  nerve, 
when  found  on  the  inner  surface  of  the  flap,  to  be  dis- 
sected out,  lest  it  should  suffer  compression. 

As  strips  of  adhesive  plaster  cause  great  pressure  on 
the  end  of  the  stump,  Mr.  Hey  prefers  sutures  for  keep- 
ing the  flap  applied ; small  strips  of  court  plaster  being 
put  between  the  ligatures.  The  sutures  may  be  cut 
out  on  the  eighth  or  ninth  day,  and  the  flap  supported 
by  plasters. 

Mr.  C.  Bell  describes  another  sort  of  flap-amputation. 
The  operation  is  not  to  be  done  so  low,  as  there  will 


not  be  a sufficiency  of  muscle  to  cover  the  end  of  the 
bones.  An  oblique  cut  is  to  be  made  with  the  large 
amputating  knife  upwards,  through  the  skin  of  the  back 
part  of  the  leg.  The  assisuint  is  to  draw  up  the  skin, 
and  the  knife  is  to  be  again  applied  to  the  upper  mar- 
gin of  the  wound,  and  carried  obliquely  upwards  till  it 
reaches  the  bones.  The  knife,  without  being  with- 
drawn, is  next  to  be  carried  in  a circular  dire<-tion  over 
the  tibia  and  fascia,  covering  the  tibialis  anticus  until 
it  meets  the  angle  of  the  first  incision  on  the  outside  of 
the  limb.  The  surgeon  is  then  to  pierce  the  interos- 
.seous  membrane,  A:c.  The  sawing  being  completed, 
and  the  arteries  secured,  the  flap  is  to  be  laid  down, 
and  the  integuments  of  the  two  sides  of  the  wound  will 
he  found  to  meet. — (Operative  Surgery,  vol.  1 .)  Lan- 
genbeck.  disajiiiroves  of  the  plan  of  pushing  the  knife 
through  the  calf  of  the  leg,  as  practised  by  Alanson, 
Hey,  Graefe,  Liston,  Lisfranc,  Syme,  &;c.,  because  an 
inexperienced  surgeon  may  run  the  point  between  the 
two  bones,  and  in  this  way  the  wound  is  never  . lade 
evenly.  His  manner  of  tbnning  the  flap  is  very  simi- 
lar to  Mr.  C.  Bell’s,  exceiit  that  he  first  makes  three 
cuts  in  the  integiunents,  two  longitudinal  and  one 
transverse,  by  which  the  shape  of  the  tlaii  of  skin  is 
determined. — (Bibl.  tiir  die  (’hir.  b.  1,  p.  571.) 

The  regular  tlap-amputation  of  the  leg,  1 mean  that 
operation  in  which  the  circular  incision  is  abandoned, 
and  a semicircular  flap  both  of  skin  and  muscle  pre- 
served, is  often  considered  more  painthl  than  the  com- 
mon method.  Yet  when  we  come  to  see  what  respect- 
able names  are  recorded  in  its  favour,  how  soon  the 
stump  generally  heals,  how  w’ell  the  ends  of  the  bones 
are  covered,  and  how’  all  dissection  of  the  integuments 
from  the  fascia  is  avoided  in  this  mode  of  operating,  at 
least  as  far  as  the  flap  extends,  the  method  must  be 
allowed  to  possess  weighty  recommendations.  Indeed, 
in  its  present  improved  state,  and  with  the  peculiar 
fitness  of  such  a stump  for  adhesion,  this  operation,  I 
think,  is  again  rather  rising  in  the  estimation  of  the 
l)rofessioTi.  In  1816,  Klein  had  i)erformed  flap-amputa- 
tion of  the  leg  about  twenty  times.  If  the  flap  should 
happen  to  be  made  too  large,  he  i)articularly  dwells  on 
the  propriety  of  removing  part  of  it  at  once  ; and  when 
it  is  too  short,  he  enjoins  carrying  the  incision  a little 
farther  upwards  w ithout  delay.  He  confesses  that  the 
plan  is  attended  with  some  little  trouble  in  securing 
the  interosseous  arteries,  which  are  apt  to  retract  con- 
siderably ; but  sjuch  has  been  the  success  of  his  prac- 
tice, that  out  of  twenty  cases  seventeen  got  well,  and 
most  of  them  very’  soon,  without  the  least  exfoliation  ; 
and  the  other  three  died  of  typhus. — (Practische  An- 
sichten  der  bedeutendsten  Chir.  Op.  Iste  Heft,  p.  47.) 
In  the  same  work,  this  experienced  surgeon,  convinced 
how  much  more  quickly  and  certainly  the  Avound  heals 
after  amputations  w ith  two  flaps  than  those  with  one, 
has  suggested  a plan  of  amputating  below  the  knee,  so 
as  to  form  two  lateral  flaps.  Mr.  Syme,  of  Edinburgh, 
recommends  an  anterior  and  a posterior  flap.  On  the 
other  hand,  as  already  mentioned,  it  is  only  in  ampu- 
tating below  the  knee  that  Dr.  Bushe  conceives  the 
circular  incision  decidedly  preferable  to  the  flap-opera- 
tion. He  distinctly  declares,  that  he  “ never  saw  a 
case  Avhere  a flap  was  formed  from  the  calf  of  the  leg, 
in  which  considerable  retraction  of  the  remaining  mus- 
cles did  not  ensue,  attended  with  great  induration  of 
the  flap,  separation  of  its  edge  from  the  skin  on  the 
front  of  the  tibia,  sometimes  exfoliation  of  the  bone, 
and  generally  tedious  suppuration.  Nor  (says  he)  can 
I speak  much  in  favour  of  the  method  recommended 
by  Mr.  Syme,  viz.  that  of  fonning  an  anterior  and  pos- 
terior flap;  for  before  I saw  his  paper,  I once  per- 
formed this  operation,  and  regret  to  say  that  my  suc- 
cess w’as  so  indifferent,  that  I have  not  since  repeated 
it.” — (Lancet,  No.  246,  p.  208.)  I have  also  tried  the 
same  method,  and  coincide  with  Dr.  Bushe  respect- 
ing it. 

The  principal  reasons  have  already  been  specified 
which  have  established  the  common  custom  of  ampu 
tating  the  leg  about  four  inches  below  the  patella,  and 
if  the  disease  or  injury  will  not  admit  of  the  operation 
being  done  thus  low,  of  removing  the  limb  above  the 
knee-joint.  In  the  Egyptian  campaign,  however,  Baron 
Larrey  performed  two  amputations  very  near  the  knee- 
joint,  almost  on  a level  with  the  head  of  the  fibula, 
w’liich  he  judged  proper  to  extirpate.  The  successful 
result  of  these  operations  dispelled  the  fear  which  this 
experienced  surgeon  previously  entertained  about  am- 


AMPUTATION. 


73 


putating  in  the  thick  part  of  the  upper  head  of  the 
tibia ; for  no  caries  of  this  spongy  portion  of  the  bone, 
no  bad  effects  on  the  knee-joint,  and  no  anchylosis  of 
the  stump  ensued : and,  with  the  difference  of  a few 
days,  the  wound  healed  as  readily  as  that  made  in  the 
common  place  of  election,  viz.  three  or  four  finger- 
breadths  below  the  tuberosity  of  the  tibia.  Since  the 
above-mentioned  campaign,  Larrey  has  adopted  this 
practice  in  many  cases  where  it  was  impossible  to 
have  operated  at  the  usual  place,  and  he  assures  us, 
the  success  fully  equalled  what  attends  operations  done 
at  the  ordinary  distance  from  the  knee.  In  1806,  an- 
other French  military  surgeon,  who  had  tried  this  me- 
thod himself,  published  a dis.sertation,  in  which  he 
commended  operating,  where  circumstance  required  it, 
much  higher  than  the  point  allowed  by  generally-re- 
ceived rules.  Larrey  differs,  however,  from  Garrigues, 
in  forbidding  amputation  higher  than  the  level  of  the 
tuberosity  of  the  tibia,  the  thick  portion  of  which  may 
be  sawed,  but  not  above  the  insertion  of  the  tendon  of 
the  patella.  A transverse  line,  drawn  from  tins  point, 
usually  passes  below  the  articulation  of  the  fibula,  and 
over  the  lower  portion  of  the  uppermost  part  of  the 
condyles  of  the  tibia ; but  as  the  relative  positions  of 
the  heads  of  the  two  bones  to  each  other  differ  some- 
what in  different  individuals,  Larrey  makes  the  tube- 
rosity of  the  tibia  the  point  above  which  the  bone  should 
never  be  sawed.  By  cutting  higher,  the  ligament  of 
the  patella  is  separated  from  its  insertion  ; the  bursa 
mucosa,  situated  underneath  it,  is  wounded,  and  the 
ligaments  at  the  sides  of  the  joint  are  injured ; whence 
arise  retraction  of  the  patella,  effusion  of 'the  synovia, 
and  such  disease  of  the  knee-joint  as  may  render  an- 
other amputation  indispensable.  By  making  the  divi- 
sion on  a level  with  the  tuberosity  of  the  tibia,  the  at- 
tachment of  the  ligament  of  the  patella  is  preserved  as 
well  as  that  of  the  flexor  tendons  of  the  leg,  which  are 
requisite  for  the  motion  of  the  stump.  The  bursa  mu- 
cosa is  left  untouched  ; and  the  head  of  the  bone  is 
sawed  low  enough  to  avoid  creating  a risk  of  caries. 
But,  says  Larrey,  if  this  mode  of  amputating  below  the 
knee  be  compared  with  amputation  of  the  thigh,  as  re- 
commended by  authors  for  the  cases  in  which  the  new 
method  is  proposed,  the  advantages  of  the  latter  are 
considerable.  In  the  first  place,  life  is  less  endangered, 
because  a smaller  portion  of  the  body  is  removed.  The 
operation  is  as  easy  in  one  situation  as  the  other.  The 
stumps  heal  with  equal  facility.  Larrey  has  never 
seen  the  spongy  part  of  the  fibia  become  carious,  nor 
perceptibly  exfoliate.  When  the  remaining  portion  of 
the  fibula  is  very  short,  as  usually  happens,  it  ought 
to  be  taken  away,  as  it  is  a useless  body,  inconvenient 
for  the  employment  of  a wooden  leg..  Larrey  directs 
as  much  skin  as  possible  to  be  preserved,  and  making 
a perpendicular  incision  through  that  part  of  it  wliich 
covers  the  tibia,  in  order  to  hinder  the  bone  from  making 
its  way  through  it  by  ulceration. 

With  a stump  thus  formed,  comprising  the  knee  and 
one  or  two  finger-breadths  of  the  leg,  the  patient  has  a 
firm  point  of  support,  on  which  he  can  securely  walk 
without  a stick.  The  stump  admits  also  of  an  artificial 
leg  of  the  natural  shape  being  worn,  the  knee  being 
always  bent,  provided  the  length  of  the  stump  do  not 
exceed  the  diameter  of  the  calf  of  the  artificial  limb. — 
(M6m.  de  Chir.  Militaire,  t.  3,  p.  386 — 394.)  From  a 
passage  qtioted  by  Mr.  Guthrie,  it  would  seem  that 
Mr.  Bromfield  (Chir.  Obs.  and  Cases,  vol.  1,  p.  185) 
advised  amputating  as  near  to  the  knee  as  could  be 
done,  without  ri.sk  of  cutting  the  ligament  of  the  i)a- 
tella,  so  that  the  slump  might  not  extend  beyond  the 
wooden  leg.  On  the  whole,  Mr.  Guthrie’s  own  obser- 
vations are  very  favourable  to  this  practice;  but  he 
candidly  acknowledges  his  belief,  that  “ it  would  not 
succeed  when  indiscrirniiiately  done  in  the  hospitals  of 
large  cities,”  though  it  may  frequently  be  practised  in 
the  army  with  advantage,  provided  the  surgeon  saw 
through  the  tibia  below  its  tuberosity. — (On  Gun-shot 
Wounds,  p.  223  and  227.)  Upon  looking  over  the  de- 
tails of  the  cases  recorded  by  Larrey  in  confirmation 
of  the  above  statement,  I was  struck  with  one  impor- 
tant fact,  which  does  not  justify  a part  of  his  commen- 
dations ; viz.  most  of  the  stumps  were  above  four  months 
in  healing ; and  that  wliich  healed  most  quickly  was 
not  well  before  the  sixty-eighth  day.— iSee  M^m.  de 
Chir.  Mil.  t.  3,  p.  57.  397,  398,  &c.)  Hence,  unless  it 
be  supposed  that  the  wounds  produced  by  amjiutation 
below  the  knee  in  the  ordinary  manner  are  genei-ally 


thus  long  in  healing,  as  treated  by  the  French  surgeons, 
the  inference  is  rather  unfavourable  to  the  method  so 
highly  commended  by  Larrey,  though  I am  far  from 
wishing  to  assert  that,  even  if  the  stumps  cannot  usu- 
ally be  healed  in  less  time,  more  than  a full  compen- 
sation I'or  this  disadvantage  is  not  obtained  by  some  of 
the  benefits  above  enumerated.  However,  in  order  to 
be  able  to  pronounce  any  positive  judgment  on  the  me- 
rits of  this  mode  of  operating,  it  would  be  requisite  not 
only  to  «ee  two  or  three  successful  cases  just  after 
their  cure,  but  to  examine  the  state  of  a tolerable  num- 
ber of  stumps  some  time  after  they  had  been  subjected 
to  the  pressure  of  an  artificial  leg. 

AMPUT.VTION  OF  THE  ARM. 

The  structure  of  the  arm  is  very  analogous  to  that 
of  the  tliigh  : like  the  latter,  it  contains  only  one  bone, 
round  which  the  muscles  are  arranged.  The  interior 
muscles  are  attached  to  the  os  brachii,  while  the  more 
superficial  ones  extend  along  the  limb,  without  being 
at  all  adherent.  The  first  consist  of  the  brachialis  in- 
terims and  the  two  short  heads  of  the  triceps ; the 
second  of  the  biceps  and  long  head  of  the  triceps. 
Hence  amputation  is  here  to  be  done  in  the  same  way 
as  in  the  thigh,  unless  when  we  are  necessitated  to 
amputate  very  high  up  above  the  insertion  of  the  del- 
toid muscle.  In  the  arm,  says  Graefe,  the  incisions 
through  the  muscles  should  even  be  made  more  ob- 
liquely upwards  than  in  the  thigh,  where  the  muscles 
are  more  bulky,  by  which  means  two  inches  of  muscle 
may  be  saved,  besides  the  retracted  integuments ; an 
abundance  for  covering  the  stump,  were  the  arm  full 
ten  inches  in  cicumference. — (Normen  fiir  die  Abl. 
grosserer  Gliedm.  p.  109.) 

The  patient  being  properly  seated,  the  arm  is  to  be 
raised  from  the  side,  and,  if  the  disease  will  allow  it, 
into  a horizontal  position.  As  I have  seen  some  incon- 
veniences produced  by  the  patient’s  fainting  in  the 
midst  of  the  operation,  I join  Graefe  and  some  other 
practitioners  in  thinking  that  the  patient,  if  circum- 
stances will  allow,  should  be  placed  upon  a table  in 
the  recumbent  position. — (Normen  fiir  die  Ablosung 
grosserer  Gliedm.  p.  108  ) The  surgeon  is  to  stand  on 
the  outside  of  the  limb,  apply  the  tourniquet  as  high  as 
possible,  and  let  the  skin  and  muscles,  which  he  is 
about  to  divide,  be  made  tense  by  the  hands  of  an  as- 
sistant. The  soft  parts  are  next  to  be  divided,  as  much 
of  the  limb  being  preserved  as  possible.  The  retractor 
is  to  be  applied,  the  bone  sawed  with  the  usual  precau- 
tions, and  the  bleeding  stopped  in  the  ordinary  way,  care 
being  taken  to  leave  the  radial  nerve  out  of  the  ligature, 
which  is  put  round  the  brachial  artery.  The  wound 
is  then  to  be  closed  so  as  to  form  a transverse  line,  the 
dressings  are  to  be  applied,  and  the  patient  put  to  bed 
with  the  wound  a little  elevated  from  the  surface  of 
the  bleeding. 

In  taking  off  the  arm,  I entirely  coincide  with  Mr. 
Guthrie  with  regard  to  the  uselessness  of  dissecting 
back  the  integuments,  a plan  long  ago  renounced  by 
the  celebrated  Dupuytren,  their  effectual  retraction  by 
an  assistant  after  their  comidete  division  being  quite 
enough  (On  Gun-shot  Wounds,  p.  354)  ; but,  as  I 
have  invariably  imitated  Graefe  and  others,  in  making 
the  incisions  through  the  muscles  with  the  edge  of  the 
knife  turned  very  obliquely  upwards,  it  has  not  ap- 
peared to  me  necessary,  after  cutting  down  to  the 
bone  in  this  manner,  to  clear  away  the  muscles  from 
it  to  the  extent  of  an  inch  and  a half  or  two  inches 
higher.  Instead  also  of  attempting  to  perform  the  cir- 
cular oblique  incision  through  the  muscles  with  one 
stroke  of  the  knife,  the  objections  to  which  have  been 
noticed  in  the  description  of  amputation  of  the  thigh,  I 
have  made  it  a rule  to  divide  the  loose  biceps  muscle 
as  soon  as  the  integuments  have  been  cut  and  retracted, 
and  of  letting  it  fully  recede  before  the  division  of  the 
rest  of  the  soft  parts  is  begun. 

If  the  disease  should  require  the  arm  to  be  taken  off 
at  its  upper  part,  there  would  be  no  room  for  the  appli- 
cation of  the  touniicpiet.  Here,  instead  of  putting  a 
compress  in  the  axilla,  and  having  it  held  firmly  upon 
the  artery  by  a bystander,  as  advised  by  Sabatier,  it  is 
more  eligible  to  make  i)ressure  on  the  artery  as  it  passes 
over  the  lirst  rib,  of  which  method  I shall  speak  in  treat- 
ing of  amputation  at  the  shoulder-joint.  With  a straight 
bistoury  the  surgeon  is  now  to  make  a transverse  inci- 
sion down  to  the  bone,  a little  above  the  lower  extremity 
of  the  deltoid  muscle.  Two  other  longitudinal  incisions, 


74 


AMPUTATION. 


made  along  the  front  and  back  edge  of  this  muscle, 
now  form  a flap,  which  must  be  detached,  and  reflected. 
L:i.stly,  the  rest  of  the  soft  parts  of  the  limb  are  to  be 
divided  by  a circular  cut,  made  on  a level  with  the 
base  of  the  flap,  and  the  operation  finished  like  a com- 
mon amputation. — (Sabatier,  Medecine  Operatoire, 
t 3,  p.  375,  <kc.  ed.  2.) 

As  a matter  of  choice,  and  not  at  all  of  necessity,  the 
arm  may  be  amputated  with  two  flaps  ; one  anterior, 
the  other  posterior.  The  first  should  be  formed  of  the 
skin  and  biceps,  and  be  three  or  four  inches  in  length  ; 
the  other  is  to  be  of  the  same  size,  and  composed  of 
the  triceps  and  integuments.  The  muscular  flesh 
close  to  the  bone  is  now  to  be  divided  all  round,  and 
the  saw  used.  Klein  preferred  this  to  the  common  me- 
thod, and  adopted  it  in  nine  cases.  So  well  is  the  end 
of  the  bone  always  covered,  that  a protrusion  of  it  is 
impossible. — (l*ractische  Ansichten  der  Cliirurgischen 
Operationen,  p.  44.) 

When  the  arm  is  injured  very  high  up,  Baron  Larrey 
prefers  amputation  at  the  shoulder-joint  to  preserving 
a short  stump,  containing  the  upper  end  of  the  hume- 
rus ; for,  says  he,  if  this  bone  cannot  be  divided  at 
least  on  a level  with  the  tendinous  insertion  of  the 
deltoid,  the  stump  is  retracted  towards  the  armpit  by 
the  pectoralis  major  and  latissimus  dorsi ; the  ligatures 
on  the  vessels  irritate  the  brachial  plexus  of  nerves  ; 
great  pain  and  nervous  twitching.s,  often  ending  in 
teuuius,  are  produced  ; the  stump  continues  swelled ; 
and,  in  the  end,  the  humerus  is  fixed  by  anchylosis  to 
the  shoulder,  so  that  this  portion  of  the  arm  remains 
altogether  u.seless,  and  renders  the  patient  liable  to 
accidents.  “ I have  seen  (says  Larrey)  many  officers 
and  soldiers,  w'ho,  on  these  accounts,  were  sorry  that 
they  had  not  undergone  amputation  at  the  shoulder.” — 
(Mem.  de  Chir.  Mil.  t.  3,  p.  53.  400.) 

Mr.  Guthrie  al.so  states,  that  when  amputation  by 
the  circular  incision  is  attempted  at  the  insertion  of 
the  pectoralis  major,  the  bone  will  generally  protrude 
after  a few  dressings.  However,  he  entirely  dissents 
from  Larrey  respecting  the  necessity  of  taking  off  the 
limb  at  the  shoulder,  and  prefers  doing  it  from  half 
an  inch  to  an  inch  and  a half  below  the  tuberosities  of 
the  humerus,  as  the  state  of  the  injury  may  require. 
Two  incisions  are  to  commence  one  or  two  finger- 
breadths  below  the  acromion  ; and  the  inner  one  is  to 
be  extended  directly  across  the  under  side  of  the  limb, 
till  it  irieets  the  lower  point  of  the  outer  wound.  Thus 
the  under  part  of  the  arm  is  cut  by  a circular  incision ; 
the  upper  in  the  same  manner  as  it  sometimes  is  in 
removing  the  limb  at  the  shoulder-joint.  Without 
detaching  the  skin  from  the  muscles  these  are  cut 
through  ; the  soft  parts  are  held  out  of  the  way  of  the 
saw ; the  bone  is  sawed  ; the  vessels  secured;  and  the 
flaps  brought  together,  so  as  to  form  a line  IVom  the 
acromion  downwards. — (Gun-shot  Wounds,  p.  337,  &c.) 

I am  decidedly  of  opinion,  that,  in  the  description  of 
cases  referred  to,  either  this  method  or  Sabatier’s  ope- 
ration should  be  preferred  to  the  removal  of  the  whole 
limb  at  the  shoulder-joint. 

Dupuytren  sometimes  amputates  at  the  elbow-joint ; 
but  as  tlie  stump  is  not  more  useful  than  when  the 
operation  is  done  a little  higher  up,  and  the  wound  is 
frequently  long  in  healing,  the  method  appears  hardly 
to  merit  a description. 

AMPUTATION  OF  THE  FOREARM. 

The  wisest  maxim,  with  respect  to  the  place  for 
making  the  incision,  is  to  cut  off  as  little  of  the  limb 
as  possible.  This  fact  is  perfectly  established,  though 
it  is  true  that  Larrey,  in  consequence  of  his  mode  of 
dressing  the  stump,  has  not  experienced  success  in 
his  amputations  done  in  the  tendinous  part  of  the  fore- 
arm. The  foreann  is  to  be  held  by  two  assistants, 
one  of  whom  is  to  take  hold  of  the  elbow,  the  other  of 
the  wrist.  The  tourniquet  is  to  be  applied  to  the  lower 
part  of  the  arm,  and'the  assistant  holding  the  elbow 
should  draw  up  the  integuments,  so  as  to  make  them 
tense.  The  circular  incision  is  then  to  be  made  down 
to  the  fascia ; from  this  as  much  skin  is  to  be  detached, 
reflected,  and  saved,  as  is  necessary  for  covering  the 
ends  of  the  bones,  and  the  muscles  are  to  be  cut  on  a 
level  with  the  reflected  skin,  the  knife  being  at  the 
same  time  directed  obliquely  upwards.  As  many  of  the 
muscles  are  deeply  situated  between  the  two  bones  ot 
the  forearm,  too  much  attention  cannot  be  paid  to  di- 


viding all  of  them,  with  a double-edged  knife  intro- 
duced between  the  radius  and  ulna. 

The  soft  parts  are  to  be  protected  from  the  saw  by 
a linen  retractor.  It  is  generally  recommended  to  saw 
the  two  bones  together,  for  which  purpose  the  fore- 
arm should  be  placed  in  the  utmost  state  of  pronation. 
As  the  radius  at  the  lower  part  of  the  forearm  is 
larger  than  the  ulna,  it  should  perhaps  be  sawed  through 
first,  the  latter  bone,  in  consequence  of  its  connexion 
with  the  humerus,  being  better  adapted  to  bear  the 
weight  of  the  saw. — (Averill’s  Op.  Surgery,  p.  124.) 

The  ulnar,  radial,  and  two  interosseous  arteries  are 
those  which  usually  require  a ligature. 

Graefe  removes  the  forearm  by  making  a flap  from 
the  flesh  in  front  of  the  limb,  and  then  extending  the 
wound  quite  round  the  member. — (Normen  fiir  die  Ab- 
Idsung  grbsserer  Gliedm.  p.  138,  <kc.  4to.  Berlin,  1812.) 
Mr.  Guthrie  makes  two  flaps,  one  in  front,  the  other 
on  the  back  of  the  forearm  ; but,  above  the  middle  of 
this  jvirt  of  the  limb,  he  prefers  the  circular  incision. — 
(On  (iun-shot  Wounds,  p.  373,  374.)  Dr.  Hennen  also 
expresses  his  ajiprobation  of  amputating  the  forearm, 
so  as  to  make  two  semilunar  flaps  (Principles  of 
Military  Surgery,  p.  265,  edit.  2i  ; which  is  the  method 
recommended  and  practised  by  Klein. — (Practische  An- 
sichten bedeutendsten  Operationen,  Heft  1,  p.  45.)  Lis- 
franc  also  o|)erates  in  this  way  at  the  lower  third  of 
the  forearm.  These  flap-operations  of  the  forearm 
are  rather  proceedings  of  choice  than  of  necessity ; 
for  I have  seen  this  pan  of  the  limb  removed  in  num- 
berless instances  by  the  circular  incision,  and  can 
hardly  remember  a case  in  which  the  stump  turned 
out  badly.  In  making  the  inner  flap,  the  radial  and 
ulnar  arteries  must  obviously  be  in  danger  of  being 
wounded  higher  up  than  the  point  where  they  are 
quite  cut  through,  as  Mr.  Guthrie  candidly  acknow- 
ledges ; an  accident  which  I think  might  give  rise  to  a 
great  deal  of  trouble. 

With  respect  to  Larrey’s  preference  to  amputating 
in  the  fleshy  part  of  the  foreann,  though  the  case 
would  admit  of  the  operation  being  done  much  lower, 
I need  only  say,  he  would  find  no  reason  for  this 
choice  were  he  to  practise  union  by  the  first  intention 
at  every  opportunity,  as  is  the  custom  in  England. 

The  hand  may  be  amputated  at  the  joint  of  the  wrist 
whenever  the  disease  does  not  extend  too  high,  and  a 
flap  can  be  made  of  the  integuments  of  the  back  of  the 
hand.  Kicherand  thinks  such  an  operation  sometimes 
preferable  to  amputation  above  the  joint.— (Nosogr, 
(,'hirurg.  t.  4,  p.  566,  edit.  4.)  Lisfranc  saves  the  flap 
from  the  palm.  The  circumstances  of  the  case  should 
of  course  frequently  determine  the  choice.  The  am- 
putation may  also  be  done  by  the  circular  incision. 

AMPUTATION  AT  THE  HIP- JOINT. 

The  very  idea  of  this  formidable  operation  for  a long 
while  checked  the  hand  even  of  the  most  ready  advo- 
cate for  the  use  of  the  amputating  knife,  and  every 
mind  shuddered  at  so  extensive  a mutilation.  Still,  it 
could  not  be  denied,  that  the  chance  of  saving  life  oc- 
casionally depended  upon  a submission  to  the  greatest 
temporary  suffering,  and  that,  without  the  most  cruel 
of  sacrifices,  the  preservation  of  the  patient  was  totally 
impossible.  Dreadful  as  amputation  at  the  hip  ap- 
peared, both  in  respect  to  the  magnitude  of  the  part  of 
the  body  to  be  removed,  and  the  extent  of  the  wound 
caused  by  such  removal,  the  desperate  nature  of  some 
cases  at  length  began  to  incline  surgeons  to  view  more 
dispassionately  a scheme,  at  which  the  mind  at  first 
naturally  revolted.  Morand  is  the  earliest  practitioner 
who  made  this  severe  operation  the  subject  of  consi- 
derable attention  (Opuscules  de  Chir.  1. 1,  p.  176, 8vo. 
1768  );  and  in  the  year  1739,  two  essays  on  the  same 
topic  were  communicated  to  the  Royal  Academy  of 
Surgery  at  Paris,  by  two  of  his  pupils,  Volner  and  Pu- 
thod.  In  1743,  Ravaton  wished  to  have  perfonned  am- 
putation at  the  hip-joint  in  a case  of  gun-shot  fracture 
of  the  trochanter  major,  and  neck  of  the  thigh-bone, 
but  was  prevented  by  the  opposition  of  other  surgeons. 
— (Chir.  d’Arm.  p.  323,  &c.)  In  1748,  the  propriety  of 
attempting  the  operation  was  urged  by  I’Alouette. — 
(Disp.  Chii-.  Halleri,  t.  5,  p.  265.)  At  length,  the  Royal 
Academy  of  Surgery  at  Paris  thought  the  subject  highly 
deserving  of  farther  investigation,  as  it  appeared  to 
several  of  its  members,  that  there  were  circumstances 
under  which  its  performance  might  be  advisable.  In 
the  year  1756,  they  therefore  proposed  the  folloxving 


AMPUTATION. 


75 


^MCstion,  as  the  grand  prize  subject : In  the  case  in 
which  amputation  of  the  hip-joint  should  appear  to  be 
the  only  resource  for  saving  the  patient’s  life,  to  deter- 
mine whether  this  operation  ought  to  be  practised,  and 
what  would  be  the  best  way  of  performing  it  ? No 
satisfactory  memoirs  having  been  presented,  the  satpe 
subject  was  proposed  in  1759.  The  approbation  of  the 
Academy  was  now  conferred  on  a paper  written  by 
Barbet,  in  which  the  propriety  of  amputating  at  the 
hip-joint  was  defended,  and  some  of  the  cases  demand- 
ing the  operation  specified.  If,  for  instance,  a cannon- 
ball, or  any  other  violently  contusing  cause,  had  carried 
off  or  crushed  the  thigh,  so  as  to  leave  only  a few  parts 
to  be  cut  to  make  the  separation  complete,  he  thought 
a surgeon  ought  not  to  hesitate  about  doing  it.  The 
same  author  conceived  that  a sphacelus,  extending  to 
the  circumference  of  the  joint,  and  destroying  the 
greatest  part  of  the  surrounding  flesh,  might  also  ren- 
der the  operation  equally  necessary  and  easy. — iSee 
Sabatier,  Med.  Operatoire,  t.  3,  p.  271,  &c.)  Cases 
were  also  adduced,  where  the  surgeon  completed  the 
separation  of  the  dead  parts  with  a knife.  However, 
this  cannot  be  considered  as  amputation  at  the  hip- 
joint.  Dividing  a few  dead  fibres  was  a thing  of  no 
importance,  in  regard  to  the  likelihood  of  its  creating 
any  bad  symptoms.  The  proceeding,  in  fact,  seems  to 
me  to  have  no  analogy  at  all  to  the  bloody  operation  of 
taking  the  thigh-bone  out  of  the  socket.  It  is  quite  a 
diflferent  thing,  when  the  operator  has  to  cut  through 
parts  which  bleed  profusely,  and  are  endowed  with 
life  and  sensibility. 

In  addition  to  the  memoir  by  Barbet,  thirty-three 
other  essays  were  offered  to  the  academy,  the  majority 
of  which  were  filled  with  arguments  in  favour  of  the 
operation ; and,  besides  these  productions,  two  other 
memoirs  w'ere  published  at  Paris,  one  by  Goursaud  in 
1758,  explaining  a new  method  of  operating,  and  an- 
other by  Moublet  (see  Journ.  de  M^dec.  an  1759),  in 
which,  says  Professor  Thomson,  the  operation  is  very 
ably  considered  in  all  its  different  relations. — {Obs. 
made  in  the  Mil.  Hospitals  in  Belgium,  p.  260—263.) 

Some  of  the  best  surgeons  of  the  last  and  present 
century  condemn  the  proceeding.  The  following  are 
Mr.  Pott’s  sentiments  : “ M.  Bilguer  and  M.  Tissot  are 
the  only  people  whom  I have  met  with  or  heard  of 
in  the  proftssion,who  speak  of  an  amputation  in  the  joint 
of  the  hip  as  an  advisable  thing,  or  as  being  preferable  to 
the  same  operation  in  the  thigh.”  After  a quotation  or 
two,  he  continues ; “ that  amputation  in  the  joint  of 
the  hip  is  not  an  impracticable  operation  (although  it 
be  a dreadful  one)  I very  well  know.  I cannot  say  that 
I have  ever  done  it,  but  I have  seen  it  done,  and  am 
now  very  sure  I shall  never  do  it,  unless  it  be  on  a 
dead  body.  The  parallel  which  is  drawn  between  this 
operation  and  that  in  the  shoulder  will  not  hold.  In 
the  latter  it  sometimes  happens,  that  thevaries  is  con- 
fined to  the  head  of  the  os  huinferi,  and  that  the  scapula 
is  perfectly  sound  and  unaffected.  In  the  case  of  a 
carious  hip-joint,  this  never  is  the  fact ; the  acetabu- 
lum ischii,  and  parts  about,  are  always  more  or  less 
in  the  same  state,  or  at  least  in  a distempered  one,  and 
so  indeed  most  frequently  are  the  parts  within  the 
pelvis,  &c.— (Pott  on  Amputation.)  Here  it  may  be 
remarked,  that  Pott  was  right,  inasmuch  as  the  ope- 
ration is  totally  unjustifiable  in  disease  of  the  hip-joint, 
but  wrong  in  not  perceiving,  that,  though  unfit  for  such 
a case,  it  might  be  proper  for  others.  Callisen  had  dif- 
ficulty in  supposing  any  circumstances  in  which  the 
operation  could  be  undertaken  with  hopes  of  success. 
— ;Syst.  Chir.  Hod.  p.  418,  t.  2,  edit.  1800.)  And  Riche- 
rand  thinks,  that  unless  the  limb  be  nearly  separated 
by  the  disease  or  accident,  a prudent  surgeon  should 
decline  making  the  attempt. — (Nosogr.  Cliir.  t.4,  p.  519, 
edit.  4.) 

It  is  a remarkable  fact  in  the  history  of  surgery,  that 
an  operation  which  had  been  invented  in  France,  and 
concerning  which  so  much  had  been  written  in  that 
country,  should  have  been  first  actually  put  in  practice 
in  England.  “ I have  been  informed  (says  Professor 
Thomson),  that  the  operation  was  performed  in  Lon- 
don by  the  late  Mr.  H.  Thomson,  surgeon  to  the  Lon- 
don Hospital,  and  imagine  that  it  must  have  been  his 
operation  to  which  Mr.  Pott  alludes.” — (Obs.  made  in 
the  Mil.  Hospitals  in  Belgium,  p.  264.)  At  all  events, 
whether  this  was  the  identical  case  which  Mr.  Pott 
saw  or  not,  the  example  referred  to  by  this  distin- 
guished surgeon  is  the  earliest  instance  of  the  opera- 


tion being  actually  performed.  It  was  even  repeated 
in  this  country  before  it  was  ever  practised  on  the  con- 
tinent, as  far  as  can  be  made  out  from  the  records  of 
the  profession  ; for  it  xvas  performed  by  Mr.  Kerr,  of 
Northampton,  on  a girl  between  eleven  and  twelve 
ears  of  age,  in  a case  of  diseased  hip ; a case  in  which 
am  now  completely  satisfied  that  it  ought  never  to 
be  attempted,  for  the  reason  laid  down  by  Mr.  Pott.  In 
fact,  Mr.  Kerr,  after  removing  the  limb,  found  the  ace- 
tabulum, and  all  the  adjacent  parts  of  the  ossa  innomi- 
nata,  carious.  But  the  experiment  was  here  rendered 
still  more  hopeless  by  the  patient  being  consumptive. 
Yet  with  all  these  disadvantages,  the  girl  lived  till  the 
eighteenth  day  from  the  operation,  and  after  death  her 
lungs  were  found  to  be  a complete  mass  of  disease, 
one  of  them  being  totally  reduced  to  matter.— (See 
Duncan’s  Med.  Commentaries,  vol.  6,  p.  337,  8vo. 
Lond.  1779.)  Larrey  performed  this  operation  twice 
in  Egypt;  and  once  while  he  was  serving  vdth  the 
French  army  on  the  Rhine.  He  was  encouraged  to 
make  these  attempts  to  save  his  patients  by  the  consi- 
deration that  he  had  already  preserved  some  lives  by 
amputating  either  both  thighs,  both  legs,  or  both  arms, 
or  rerhoving  the  humerus  at  the  shoulder-joint.  Lar- 
rey has  also  the  true  merit  of  having  first  done  the 
operation  in  the  only  description  of  cases  in  which 
perhaps  (with  the  exception  of  bad  examples  of  ne- 
crosis of  the  higher  part  of  the  femur)  it  ought  ever  to 
be  performed  ; viz.  gun-shot  injuries  of  the  head,  neck, 
and  upper  part  of  the  femur,  with  or  without  injury 
of  the  femoral  artery,  or  where  the  limb  had  been  car- 
ried away  by  a shell  or  cannon-ball,  too  high  up  to  ad- 
mit of  amputation  in  the  ordinary  manner.  However, 
he  also  regards  as  fit  occasions  for  amputation  at  the 
hip-joint  circumstances  in  which,  from  gun-shot  vio- 
lence, the  limb  is  seized  or  threatened  with  gangrene 
nearly  up  to  the  hip. — Mem.  de  Chir.  Mil.  t.  2,  p.  185.) 

Severe  as  the  operation  is,  Larrey  contends  that  it  is 
an  act  of  humanity,  if  it  ever  is  the  means  of  saving 
lives  which  are  in  danger,  and  he  argues  that  it  is  jus- 
tifiable by  the  old  maxim  of  Hippocrates,  “ Ad  ex- 
tremes morbos  extrema  remedia.”  To  the  chief  objec- 
tions which  have  been  made  to  it,  he  replies,  1st,  That 
the  wound  is  more  alarming  than  dangerous.  The 
Caesarean  operation  (says  he)  has  been  successfully  per- 
formed on  the  living  female,  and  is  still  recommended 
by  many  practitioners.  L’Aumonier,  principal  surgeon 
of  the  Rouen  Hospital,  has  successfully  removed  a 
scirrhous  ovary  of  considerable  size.  Examples  are 
recorded  of  the  arm  and  scapula  being  torn  away,  and 
the  patients  soon  recovering.  Besides,  the  surgeon 
has  it  in  his  power  to  lessen  the  wound  produced  by 
the  operation.  2dly,  The  dangers  of  hemorrhage  may 
be  obviated  by  the  assistants  temporarily  placing  their 
fingers  on  the  mouths  of  the  cut  vessels,  until  liga- 
tures can  be  ai)plied. 

In  confirmation  of  his  sentiments  concerning  the 
propriety  of  the  operation,  Larrey  adverts  to  a fact  re- 
ported by  Morand,  where  a soldier  had  both  his  legs 
amputated  very  high  up,  and  also  both  his  arms  so  near 
the  shoulders  that  he  could  hold  nothing  in  his  armpits. 
Yet,  mutilated  as  he  was,  h^  enjoyed  good  health. — 
(Opuscules  de  Chir.  p.  183.)  And  Larrey,  in  his  own 
work  has  recorded  several  instances  in  which  the 
whole  of  a limb  was  removed,  or  more  than  the  halves 
of  both  the  upper  or  lower  extremities  of  the  same 
subject,  without  any  fatal  constitutional  disturbance. — 
(Mi  m.  de  Chir.  Mil.  t.  2,  p.  182 — 184.)  One  of  his  pa- 
tients above  alluded  to  survived  the  operation  a week, 
at  the  end  of  which  he  was  carried  off  by  the  plague ; 
and  the  others  died,  after  being  conveyed,  in  a very  un- 
easy manner,  during  the  precipitate  march  of  the  army. 
— (See  Relation  de  I’Expedition  de  I’Armee  d’Orient  en 
Egypte,  «kc.  p.  319,  8vo.  Paris,  1803.)  At  the  battle  of 
Wagram,  Larrey  operated  at  the  hip-joint  on  two  sol- 
diers of  the  imperial  guard,  under  very  unfavourable 
circumstances;  and  the  events  were  fatal  in  a few 
hours. — (Mem.  de  Chir.  Mil.  t.  3,  p.  349.) 

Larrey  used  to  operate  as  follows : he  began  with 
making  an  incision  in  the  track  of  the  inguinal  artery 
in  the  bend  of  the  groin,  and  after  carefully  excluding 
the  nerve,  which  is  more  externally  situated,  he  tied 
this  vessel,  with  the  aid  of  a semicircular  curved 
needle,  as  closely  as  possible  to  Poupart’s  ligament,  in 
order  that  the  ligature,  which  was  placed  above  the 
origin  of  the  circumflex  arteries  and  the  proftmda, 
might  obviate  all  inconvenience  lirom  the  bleeding 


76 


amputation. 


which  might  otherwise  happen  from  their  numerous  I 
branciies.  Tliis  being  done,  a straight  knife  was  per- 
pendicularly plunged  between  the  tendons  of  the  mus- 
cles attached  to  the  trochanter  minor  and  the  base  of  | 
the  neck  of  the  femur,  so  as  to  bring  out  its  point  at 
the  back  part  of  the  limb,  or  in  a iliametrically  opposite 
situation  to  its  first  entrance ; and  now.  by  directing  1 
the  knife  obliquely  inwards  and  downwards,  a flap, 
which  was  not  to  be  too  large,  was  made  of  the  soft 
parts  at  the  inner  and  upper  portion  of  the  limb.  This  I 
flap  was  now  drawn  towards  the  scrotum  by  an  as-  ; 
sistant,  and  the  articulation  was  brought  into  view.  I 
The  obturator  artery,  and  some  branches  of  the  pu- 
dendal, wounded  by  making  the  flap,  were  immediately  ‘ 
tied.  The  thigh  was  now  put  into  the  state  of  abduc-  j 
tion ; the  inner  part  of  the  orbicular  ligament  made 
tense  by  this  iwsition,  was  divided,  and  the  joint 
ojieneii.  The  ligamentum  teres  was  then  cut,  and  the 
bone  dislocated.  The  knife  was  ne.xt  brought  to  the 
out.side  of  the  great  trochanter,  anil  an  external  flap 
formed  of  the  soft  parts,  calculated  to  meet  that  which  i 
had  been  made  at  the  inside  of  the  limb.  In  proceed-  | 
ing  through  the  o[ieraiion,  Larrey  secured,  as  soon  as  ' 
they  were  divided,  the  obturator  arteries,  and  several  i 
branches  of  the  pudendal,  gluteal,  and  ischiatic  arte-  j 
ries.  The  two  flaps  were  brought  together  and  kept  in  ! 
this  position  with  strips  of  adhesive  plaster,  and  a '■ 
wo«)llen  spica  bandage. — ;See  Mem.  de  Chir.  Mil.  t.  2, 

p.  186—188.) 

In  the  Russian  campaign,  Larrey  had  two  more  oppor- 
tunities of  amputating  at  the  hip-joint.  In  the  first  in- 
stance he  operated  upon  a Russian  at  Witepsk,  whose 
thigh-bone  was  broken  to  pieces  up  to  the  trochanter, 
and  the  sort  parts  of  iwo-th.irds  of  the  tluckness  of  the 
limb  destroyed.  This  man  w'ent  on  as  favourably  as 
possible  until  the  25th  day  from  the  operation,  the 
parts  being  healed  except  at  two  points  where  the  liga- 
tures had  been  brought  out ; but,  unfortunately,  a 
scarcity  of  provisions  now  occurred  from  some  neglect 
or  another  ; and  the  patient  on  the  2yth  or  30th  day  fell 
a victim.  The  second  operation  was  done  on  a French 
dragoon,  at  the  battle  of  Mozaisk,  who  was  afterward 
seen  perfectly  cured  by  the  surgeon-major  at  Orcha, 
who  received  him  there,  and  made  a report  of  the  fact 
to  Larrey  by  letter. — ;8ee  .Mem.  de  C’hir.  Mil.  t.  4,  p. 
26 — 50,  51,  8vo.  Paris,  1817.) 

In  1812,  M.  Baflbs,  surgeon  to  the  Ilopital  des  En- 
fans  Maiades  at  Paris,  amputated  at  the  hip  nearly  m 
the  manner  of  Larrey,  except  that  he  only  compressed 
the  artery  in  the  groin,  and  did  not  begin  with  tying  it, 
a method  to  which  Larrey  himself  now  gives  the  pre- 
ference.— See  Mem  de  Chir.  Mil.  t.  4,  p.  434.)  The 
patient  was  a child  seven  years  old,  and  the  case  a 
diseased  hip.  The  patient  got  well  of  the  wound,  but 
died  of  scrofula  three  months  afterward.  The  co- 
n loid  cavity  was  found  full  of  fungous  flesh,  and  the  os 
Innominatum  carious.  As  the  latter  state  always  ex- 
IsUs  in  the  disea.sed  hip-joint,  the  whole  of  the  diseaise 
does  net  admit  of  removal  by  amputation,  and  conse- 
quently the  attempt  ought  never  to  be  made. — (See 
Joints,  Diseases  of.) 

The  plan  of  operating  adopted  by  Baffos  is  considered, 

I believe,  by  all  surgeons  of  the  present  day,  better  than 
4hat  formerly  advised  by  Larrey,  inasmuch  as  the  ob- 
jectionable and  unnecessary  preliminary  measure  of 
^king  up  the  artery  in  the  groin,  instead  of  simply 
compressing  it  against  the  os  pubis,  was  rejected.  Cut- 
•ting  down  to  the  artery  as  a precaution  against  he- 
morrhage, is  doing  a double  operation  and  putting  the 
patient  to  needless  suffering ; it  w'as  the  earliest  me- 
thod, having  been  proposed  by  Volther  and  Puthod. 
Who  was-the  first  jiroposer  to  press  the  artery  against 
4he  os  pubis,  instead  of  cutting  down  to  the  vessel,  I 
am  not  at  present  awmre ; but  I know  that  it  has  been 
publicly  recommended  by  Mr.  Abernethy,  in  his  anato 
mical  lectures,  for  the  last  thirty  years ; it  is  thirty- 
two  years  since  I began  to  attend  his  courses,  and  in 
the  exhibition  of  tliis  operation,  by  the  circular  inci- 
sion upon  the  dead  subject,  compression  of  the  artery  in 
the  groin  was  then  advised,  and,  as  I have  stated,  not 
for  the  first  time.  Lisfranc  is  /said  to  complete  ampu-  ' 
tation  at  the  hip-joint  upon  the  dead  subject  in  ten  se-  | 
conds : the  following  is  his  method,  as  described  by  a 1 
modern  writer  : — The  nates  of  the  patient  resting  on  1 
the  edge  of  the  table,  and  the  limb  being  supported  by  1 
an  assistant,  the  operator  draws  a line  an  inch  in  length, 
from  *he  anterior  and  superior  spinous  process  of  the  | 


ileum,  straight  down  the  thigh.  From  thi.s  point  ha 
marks  another  inwards  towards  the  pubes,  of  half  an 
inch,  so  as  to  Ibnn  a right  angle.  On  the  inner  ex- 
tremity of  the  last  he  places  the  point  of  a long-bladed 
catling,  and  pushes  it  perjiendicularly  downwards  till 
^ strikes  against  the  head  of  the  femur.  Then  passing 
it  on  the  outer  side  of  the  bone,  he  thru.sts  it  onwards 
till  it^irotrudes  at  about  an  inch  from  the  margin  of  ttie 
anu?.  He  now  cuts  outwards,  for  near  an  inch,  in  or- 
der to  clear  the  great  trochanter,  and  forms  the  exter- 
n.al  flap,  four  or  five  inches  in  length,  by  cutting  down 
the  limb  between  the  muscles  and  bone.  The  femoral 
arter)-,  which  muyt  now  be  seen,  is  to  be  compressed 
between  the  fingers  and  thumb  of  an  assistant,  while 
the  openitor  thrusts  the  knife  in  and  out  at  the  same 
{loint.s  as  before ; but  carrying  it  on  the  inner  side  of 
the  head  of  the  bone,  he  forms  a smaller  flap  on  that 
side  of  the  extremity.  He  then,  with  the  point  of  his 
knife,  cuts  through  the  capsular  ligament,  dislocates 
the  bone,  and  removes  the  limb  by  dividing  the  round 
ligament,  (fcc. — i.See  Averill’s  Operative  Surgery,  Lond. 
1823,  p.  153,  Ac. ; also  Maingault,  ISIed.  Operatoire,  fol. 
Paris,  lb22.  . It  is  obvious  (says  iSIr.  Syme),  that  as 
long  as  the  surgeon  merely  cuts  downwards,  and  keeps 
close  by  the  bone,  he  will  not  injure  the  femoral  artery, 
which  cannot  be  divided  till  the  knife  is  carried  out- 
wards. This  is  one  great  excellence  referred  by  Lis- 
franc to  his  operation  ; for  before  the  surgeon  cuts  the 
artery,  the  assistant  can  introduce  his  fingers  into  the 
wound  and  compress  the  vessel. 

The  disarticulation  is  accomplished  as  follows  : the 
surgeon,  seizing  the  limb  wath  his  left  hand,  while  the 
a.ssistant  holds  aside  the  flaps,  makes  a cut  half  round 
margin  of  the  acetabulum  at  its  fore  part.  The  limb 
is  then  put  in  the  posture  of  abduction,  the  bone  starts 
from  its  socket,  the  knife  is  carried  round  its  head,  and 
the  triangular  and  what  remains  of  the  capsular  liga- 
ment are  divided. — (See  Ed.  Med.  Surg.  Joum.  No.  78, 
p.  41.) 

A very  similar  method  of  operating  was  followed  by 
Professor  Von  Walther. — (See  Graefe  and  Walther’s 
Journ.  Also  Anderson’s  Quarterly  Jouni.  vol.  1,  p. 
630.) 

This  method  was  preferred  by  Mr.  Syme  in  the  very 
interesting  case  in  which  he  lately  amputated  at  the 
hip-joint  for  an  e.xtensive  necrosis  of  the  femur,  where 
the  neck  of  the  bone  was  itself  diseased.  Unfortu- 
nately, when  the  w’ound  was  nearly  healed,  the  jia- 
tient  became  dropsical,  and  died  at  the  beginning  of  the 
eighth  week  from  the  period  when  his  limb  was  taken 
olf.— lOp.  cit.  p.  25.) 

Langenbeck  begins  the  first  incision  on  the  outside 
of  the  femoral  artery,  and  forms  the  external  flap  by 
extending  the  wound  towards  the  tuberosity  of  the  is- 
chium. The  knee  is  then  mclined  inwards,  and  the 
head  of  the  femur  dislocated,  after  which  the  knife  is 
carried  to  the  inside  of  the  thigh,  and  the  inner  flap 
made. — (Bibl.  flir  die  Chir.  b.  4,  s.  512.) 

When  serving  with  the  army  in  Holland  in  1814, 1 
assisted  the  late  Dr.  Cole  in  the  performance  of  this 
operation.  The  plan  adopted  by  him  is  the  same  as 
that  which  has  been  taught  by  Mr.  Abernethy,  in  his 
lectures,  for  more  than  thirty  years.  The  flow  of  blood 
through  the  femoral  artery'  was  stopped  by  compress- 
ing the  vessel  in  the  groin  with  the  handle  of  a key 
covered  xvith  lint.  The  thigh  w'as  then  amputated  as 
high  as  possible,  close  below  the  trochanters.  The  fe- 
moral artery  was  immediately  secured,  and  afterward 
every  other  vessel  requiritig  ligature.  An  incision  was 
now  made  directly  on  the  acetabulum,  and  the  head  of 
the  bone  removed  with  the  utmost  facility  and  expedi- 
tion. The  patient  lost  even  less  blood  than  in  an  ordi- 
nary amputation,  and  the  wound  admitted  of  being 
brought  together  with  adhesive  pltister  in  the  best 
manner  possible,  so  as  to  represent  a transverse  line. 

I am  sorry  to  add,  that  the  patient  lived  only  till  the 
following  day.  In  one  dreadful  case  of  fracture  of  the 
upper  part  o”f  the  femiu:  by  a grape-shot,  where  the 
operation  had  been  delayed  too  long,  the  whole  limb 
being  inundated  with  matter,  and  the  upper  end  of  the 
lower  portion  of  the  bone  projecting  through  the  flesh 
backwards,  I ventured  to  perform  the  same  operation 
at  Oudenbosch  in  Holland,  a few  days  after  the  assault 
on  Bergen-op-Zoom ; and  here  happened  what  must 
often  occur ; immediately  the  soft  parts  had  beer,  di' 
vided,  as  the  bone  was  broken  to  pieces,  the  limb  came 
olf,  leaving  the  iiead  of  the  bone,  the  trochanters,  and 


AMPUTATION. 


77 


a small  piece  below  them  projecting.  Had  not  the 
man  appeared  in  a very  bad  way  by  the  time  the  ves- 
sels had  been  secured,  I should  now  have  removed  the 
head  of  the  bone ; but  the  shock  of  the  operation  was 
such,  that  he  survived  it  but  a few  minutes,  though 
scarcely  any  blood  was  lost.  The  mode  of  operating 
by  the  circular  incision  is  preferred  by  Graefe,  who 
unknowingly  considers  it  as  a new  method.— (Normen 
flir  die  Abl.  grosserer  Gliedm.  p.  118.)  It  has  also 
been  proposed  by  Mr.  Veitch,  with  the  modification  of 
leaving  an  inch  or  two  of  the  bone  projecting,  which  is 
done  without  giving  any  additional  pain,  by  dissecting 
off  the  soft  parts  below  the  first  incisions  down  to  the 
bone.  This  projecting  piece  is  intended  to  serve  as  a 
lever,  with  which  the  head  of  the  bone  is  to  be  got  out 
of  the  acetabulum. — (Edinb.  Med.  and  Surg.  .Tourn.vol. 
3,  p.  129.)  Ingenious  as  this  suggestion  may  be,  I do  not 
regard  it  as  an  important  practical  improvement ; 1st, 
because  in  almost  all  cases,  where  the  operation  is  ne- 
cessary, the  bone  is  so  fractured  that  its  division  is  al- 
ready made  by  the  injury ; 2dly,  because  the  scheme 
is  unnecessary ; for,  in  Dr.  Cole’s  case,  where  I as- 
sisted, the  head  of  the  femur  was  removed  from  the 
acetabulum  with  the  utmost  facility  by  merely  making 
an  incision  over  that  cavity,  cutting  the  ligaments,  and 
availing  ourselves  of  the  small  piece  of  bone  accident- 
ally projecting.  In  fact,  in  all  gun-shot  injuries,  requir- 
ing this  operation,  excepting  a few  instances  of  spread- 
ing gangrene  from  wounds,  the  bone  is  usually  broken 
too  high  for  Mr.  Veitch’s  method  to  be  practicable. 
With  the  same  view  of  facilitating  the  exit  of  the 
head  of  the  bone  from  the  acetabulum,  Graefe  (p.  123) 
recommends  dividing  the  transverse  ligament  which 
completes  the  brim  of  the  anterior  and  inferior  side  of 
the  socket.  From  my  having  once  seen  one  of  the 
first  anatomists  in  London,  with  a powerful  young  as- 
sistant, and  the  whole  length  of  the  unbroken  femur 
for  a lever,  baffled  for  nearly  half  an  hour  before  he 
tould  dislocate  the  head  of  the  bone,  I suppose  Graefe’s 
maxim  worth  recollecting. 

Sir  Astley  Cooper  commenced  his  operation  by  mak- 
ing an  incision  just  below  Poupart’s  ligament,  a little 
on  the  outside  of  the  femoral  artery.  The  wound  was 
then  carried  obliqrfcly  downwards  and  outwards  to  the 
back  of  the  thigh,  about  one-third  of  the  way  down 
it,  from  wliich  point  the  knife  was  carried  in  the  oppo- 
site direction,  obliquely  upwards  and  inwards  to  meet 
the  first  incision,  so  as  to  form  an  elliptical  curve.  The 
femoral  artery,  being  now  divided,  was  immediately 
tied.  The  muscles  were  next  cut  through,  another  ar- 
tery secured,  and  the  bone  taken  out  of  its  socket. 
Only  about  twelve  ounces  of  blood  were  lost. — (See 
Lancet,  vol.  2,  p.  95,  &c.) 

The  following  method  is  recommended  by  Mr.  Scout- 
teten.  The  patient  is  to  lie  on  the  opposite  side  of  the 
body  to  that  on  which  the  operation  is  to  be  done.  The 
inguinal  artery  is  to  be  compressed.  The  surgeon, 
standing  behind  the  limb,  is  to  put  the  thumb  or  fore- 
finger of  his  left;  hand  on  the  great  trochanter.  With 
the  right  he  introduces  the  point  of  the  knife  perpendi- 
cularly over  this  proce.ss,  and  then  depressing  the  han- 
dle, extends  the  incision  forwards  and  inwards  four  fin- 
ger-breadths below  the  groin.  He  then  carries  the 
knife  round  the  limb,  cutting  as  deeply  as  possible,  and 
bringing  the  knife  at  length  up  to  the  point  from  which 
the  wound  commenced.  All  the  muscular  fibres  are 
rarely  divided  by  this  first  incision,  and  hence  the 
knife  must  generally  be  applied  again,  ere  this  first 
stage  of  the  operation  can  be  completed. 

For  the  purpose  of  getting  at  the  capsule,  the  sides 
of  the  wound  must  be  kept  apart,  and  any  muscular 
fibres  not  yet  cut,  be  divided.  As  soon  as  it  is  per- 
ceived, it  is  to  be  cut  through  perpendicularly  on  the 
head  of  the  femur.  The  limb  is  now  to  be  somewhat 
depressed,  and  foot  turned  outwards,  whereby  the  head 
of  the  bone  is  forced  nearly  out  of  its  socKCt,  and  quits 
it  completely  as  soon  as  the  round  ligament  is  cut, 
which  is  the  only  part  by  which  it  is  confined.  The 
operator  then  raises  the  thigh-bone,  so  as  to  make  its 
head  project,  after  which  he  cuts  the  rest  of  the  cap- 
sule and  musctilar  fibres,  and  completes  the  separation 
of  the  limb.  When  the  operation  is  on  the  left  side, 
the  surgeon  stands  in  front  of  the  limb. — (See  Scout- 
teten,  Methode  Ovalaire,  ou  ISouvelle  Methode  pour 
amputer  dans  les  Articulations,  Paris,  1827,  4to.) 

The  vanety  in  the  mode  of  operating  is  now  very 
considerable.  Were  I to  offer  a particular  description 


of  every  method,  my  limits  would  be  greatly  exceeded 
It  may  suffice,  therefore,  to  refer  to  Graefe’s  Journal 
for  an  account  of  the  plan  which  he  adopted  on  the 
living  subject ; and  though  the  case  had  not  a fortunate 
result,  the  operation  itself  was  very  skilfully  per- 
formed. 

Several  cases  are  now  recorded,  in  which  amputa- 
tion at  the  hip-joint  proved  successful.  The  first  was 
that  under  the  care  of  Mr.  Brownrigg,  surgeon  to  the 
forces,  on  the  twelfth  of  December,  1812.  The  upper 
part  of  the  thigh-bone  had  been  broken  by  a gun-shot 
near  Merida,  in  Spain,  the  29th  of  December,  1811. 
Some  time  ago,  the  man  was  living  at  Spalding,  in  Lin- 
colnshire, in  perfect  health. 

The  second  successful  operation  was  that  performed 
by  Larrey,  at  Witepsk. 

The  third  was  done  by  Mr.  Guthrie  in  the  Nether- 
lands on  a French  prisoner  of  war,  who  completely  re- 
covered. The  fourth  is  the  example  in  which  Sir 
Astley  Cooper  amputated  at  the  hip  on  account  of  a 
disease  of  the  higher  part  of  the  femur.  As  the  pa- 
tient had  formerly  suffered  amputation  of  the  thigh,  it 
was  certainly  not  the  sudden  removal  of  nearly  a quar- 
ter of  him ; but  I cannot  presume  to  say,  what  differ- 
ence in  the  chances  of  success,  and  whether  any, 
would  be  connected  with  the  circumstance. 

In  June,  1824,  amputation  at  the  hip  was  done  by 
Professor  Delpech,  of  Montpellier,  on  account  of  a ne- 
crosis of  the  femur,  and  the  patient  was  completely 
well  in  the  following  September. — (See  Revue  Medi- 
cale.)  The  operation  was  also  performed  by  Dr.  Mott, 
of  New-York,  on  the  7th  of  October,  1824,  and  the 
whole  of  the  wound  had  healed  by  the  20th  of  Novem- 
ber. This  case  was  a bad  fracture  of  the  upper  part 
of  the  femur,  followed  by  abscesses  and  disease  of  the 
bone. — (See  Philadelphia  Journal,  No.  9,  vol.  5,  New 
Series.)  The  patient’s  age  was  favourable,  as  ha 
was  a boy  of  only  ten  years  of  age.  At  this  period  of 
life,  the  chances  of  success  will  always  be  greater  than 
in  adults,  not  only  in  consequence  of  the  remedial  power 
of  nature  being  then  particu*larly  great,  but  on  account 
of  the  smaller  dimensions  of  the  wound  necessary  for 
the  purposes  of  the  operation. 

[The  following  details  of  this  case  may  prove  service- 
able to  the  profession,  by  showing  that  the  operation 
may  be  advantageously  attempted  in  a patient  who 
would  otherwise  have  speedily  sunk  under  his  disease. 
It  is  moreover  interesting  from  the  circumstance  of  its 
being  the  fifth  instance  in  which  it  was  ever  successfully 
performed,  and  the  first  amputation  at  the  hip-joint  in 
this  country. 

“ George  Byles,  a healthy  boy,  ten  years  old,  broke 
his  thigh  about  two-thirds  of  its  length  from  the  hip- 
joint  ; two  days  after,  splints  and  bandages  were  firmly 
(and  injudiciously)  ai)plied,  which  produced  great 
distress,  and  were  removed  at  the  instigation  of  the 
boy.  Physick’s  modification  of  Desault’s  splint  was 
prei)ared  by  the  physician  then  called  in,  who  pointed 
out  to  the  father,  previous  to  its  application,  a project- 
ing point  on  the  outside  of  the  thigh,  which  was  the 
extremity  of  the  superior  fragment,  which  by  the  im- 
proper jnessure  was  nearly  forced  through  the  integji- 
ments.  The  hone  being  properly  coajkated,  the  long 
splint  was  then  aiiplied. 

About  three  weeks  subsequent  to  this  period  another 
physician  was  called  in,  who  recommended  the  em- 
ployment of  the  inclined  plane,  which  was  adopted, 
the  boards  farming  it  having  pegs  at  the  side.  The 
boy  stated  that  during  his  confinement  to  this  inclined 
plane  foe  several  weeks,  he  had  in  tossing  restlessly 
about,  injured  the  tliigh  on  the  inside  just  above  the 
condyle,  which  produced  a sinuous  opening  leading  to 
the  fractured  bone.  It  is  most  probable,  however,  that 
the  sinus  was  formed  and  pointing  when  it  was  struck 
against  the  peg  and  opened. 

. lie  was  brought  into  the  city  of  New-York  on  the 
7th  of  Sei)ternber,  1824,  at  which  time  we  first  saw  him. 
His  countenance  was  expressive  of  much  anguish, 
with  a white  tongue  and  feeble  pulse;  his  right  limb 
was  much  enlarged  oti  the  outside,  resembling  a case 
of  si)ina  ventosa.  To  the  touch  it  was  hard  and  irregu- 
lar, was  exceedingly  tender,  and  when  pressed  gave 
excruciating  pain.  The  sweiling  extended  to  the  great 
trochanter,  gradually  diminishing  towards  the  top  of 
the  thigh.  Opposite  to  the  greatest  enlargement  was  a 
sinus,  discharging  a thin  sanious  tluid,  leading  to  the 
middle  of  the  thigh  bone,  whii  h was  jierfectly  carious. 


78 


AMPUTATION. 


During  two  weeks  succeeding  his  arrival  in  the  city, 
medicines  were  administered  with  a view  of  allaying 
irritation,  and  imparting  tone  to  the  system,  but  hectic 
and  night  sweats,  notwithstanding,  supervened.  As 
ulcerations  began  to  occur  by  the  side  of  the  tibia,  and 
all  the  sjTnptoms  became  worse,  it  was  resolved  to 
amputate  at  the  hip-joint  as  the  only  chance  of  saving 
the  life  of  the  patient. 

On  the  7th  of  October,  1824,  the  patient,  after  having 
passed  a comfortable  night,  was  placed  upon  the  table 
in  order  to  be  operated  on.  An  incision  was  made 
over  the  femoral  artery  as  it  emerges  from  under  the 
femoral  arch,  and  the  vessel  secured  by  ligature. 
While  feeling  on  the  outside  of  the  artery  for  the  lesser 
trochanter,  the  pulsation  of  a vessel  apparently  but 
little  smaller  than  the  femoral  artery  immediately  be- 
low the  ligature,  convinced  us  that  in  this  case  the 
profunda  femoris  was  given  off  above  the  femoral  arch, 
as  we  occasionally  find  it.  This  vessel  was  taken  up. 

Lisfranc’s  knife  was  then  introduced  between  the 
artery  and  bone,  and  carried  through  close  by  the  neck 
of  the  femur  towards  the  tuber  ischii,  thus  forming  the 
inner  flap.  The  external  flap  was  formed  by  cutting 
from  without  inw’ards.  The  hemorrhage  from  the  veins 
and  small  arteries  was  considerable  when  the  incisions 
were  made,  and  numerous  vessels  were  taken  up : but 
comparatively  little  blood  was  lost  during  the  opera- 
tion, and  the  patient  was  put  to  bed  shortly  alter  it 
was  completed.  After  the  inner  flap  was  cut,  some  of 
the  surgical  attendants,  examining  the  lesser  trochanter, 
pronounced  that  the  head  of  the  bone  was  not  diseased. 
In  order  to  satisfy  the  doubts  expressed,  the  bone  was 
sawed  through  the  lesser  trochanter,  when  it  was 
found  to  be  of  the  consistence  of  cheese,  being  denuded 
of  periosteum  on  the  outer  side  up  towards  the  joint, 
and  requiring  to  be  removed,  which  was  afterward 
done,  as  originally  contemplated. 

It  is  scarcely  necessary  for  us  to  enter  into  the  detail 
of  symptoms  and  treatment  subsequent  to  the  opera- 
tion, as  nothing  occurred  worthy  of  note,  except  various 
degrees  of  irritation  of  the  stomach  and  whole  system, 
previous  to  the  coming  away  of  the  ligatures.  The 
treatment  consisted  in  regulating  the  diet,  and  admi- 
nistering anodyne  and  tonic  medicines  according  to 
circumstances. 

On  the  15th  of  October,  eight  days  from  the  opera- 
tion, two-thirds  of  the  stump  was  healed  by  the-  first 
intention.  Between  the  17th  and  31st  of  October,  all 
the  ligatures,  seventeen  in  number,  were  removed  ; 
and  by  the  20th  of  November  the  whole  stump  was 
effectually  healed,  and  the  boy  had  become  fat  and 
lusty.  There  can  be  no  doubt  but  that  this  limb  might 
have  been  saved  without  difficulty,  had  the  proper 
treatment  been  instituted  when  the  accident  occurred. 
When  it  came  under  our  charge,  nothing  short  of  the 
operation  above  related  could  have  saved  this  boy’s 
life.” — Rcest.'] 

Another  successful  amputation  at  the  hip  was  per- 
formed by  Mr.  Orten  ; the  disease  commenced  m the 
knee ; but  terminated  in  extensive  disease  of  the  thigh- 
bone, large  abscesses,  and  dislocation  of  the  knee,  the 
leg  being  fixed  in  the  bent  position,  and  drawn  under 
the  thigh.—  See  Med.  Chir.  Trans,  vol.  13,  p.  b()5.) 

On  the  other  hand,  the  failures  of  this  operation  are 
numerous,  though  undertaken  by  surgeons  of  reputa- 
tion and  ability.  Mr.  Guthrie,  Ur.  Emery,  Mr.  Brown- 
rigg,  Baron  Larrey,  Walther,  Graefe,  Mr.  Brodie,  Mr. 
Carmichael  (Trans,  of  the  Assoc.  Physicians,  vol.  3;, 
Drs.  Blick  and  Cole,  and  many  other  military  practi- 
tioners, have  had  opportunities  of  amputating  at  the 
hip  without  success. 

A calculation  has  been  made,  that  out  of  twenty  ex- 
amples of  hip-joint  amputation,  six  have  had  a favour- 
able termination. — (Chelius,  Haudb.  der  Chir.  b.  2,  p. 
763.)  According  to  my  computations,  this  account  is 
rather  too  favoura^e. 

No  one  can  expect,  however,  this  operation  not  to 
fail  in  a large  proportion  of  the  cases  in  which  it  is  at- 
tempted ; this  must  always  happen,  let  it  be  done  in 
the  most  skilful  manner  possible.  Yet,  as  there  are 
unquestionably  some  descriptions  of  injury,  where 
life  must  be  inevitably  lost,  if  this  proceeding  be  re- 
jected, and  experience  proves  that  it  sometimes  an- 
swers, an  important  consideration  is,  what  cases  are 
most  proper  for  it  ? Here  I am  decidedly  of  opinion 
with  Professor  Thomson,  that  the  e.xamples,  in  wliich 
it  is  particularly  called  for,  and  where  no  delay  should  i 


be  suffered,  are  those  in  which  the  head  or  neck  of  th« 
thigh-bone  has  been  fractured  by  a musket-ball,  grape- 
shot,  or  small  piece  of  shell.  Eight  or  ten  such  cases, 
where  amputation  ought  to  have  been  done  in  the  first 
instance,  were  brought  in  wagons  several  days  after 
the  assault  on  Bergen-op-Zoom,  into  the  hospital  su- 
perintended by  myself  at  Oudenbosch,  and  not  one  of 
these  patients  lived  ten  days  after  their  removal.  In 
the  whole  course  of  my  professional  life,  I have  never 
elsewhere  witnessed  so  much  suffering,  or  suppuration 
in  such  profusion.  From  each  limb,  I should  guess, 
that  at  least  three  or  four  pints  of  matter  were  dis- 
charged daily.  Had  amputation  at  the  hip  been  per- 
formed at  first,  some  of  these  patients  might  possibly 
have  been  saved ; at  all  events,  I am  certain  that  it 
was  their  only  chance. 

Larrey,  as  I have  stated,  tliinks  the  operation  pro- 
per, where  the  thigh  has  been  shot  off  high-up,  or 
where  the  femur  and  soft  parts  near  the  hip  have  been 
broken,  and  extensively  lacerated  by  a cannon-ball  or 
pieces  of  shell.  Here  the  operation  ithough  perhaps 
the  only  chance)  must  almost  always  fail,  because,  as 
Professor  Thomson  observes,  these  injuries  occasion 
a shock  to  the  constitution,  of  which  the  patient  mostly 
sinks  either  immediately,  or  in  a few  hours. — (Obs. 
made  in  the  Mil.  Hosp.  in  Belgium,  p.  274.)  The 
truth  of  this  observation  1 saw  exemplified  at  Merx- 
ham,  near  Antwerp,  at  the  bombardment  of  the  French 
fleet  in  that  port ; a shell  burst  between  the  thighs  of 
one  of  the  guards  ; tore  and  lacerated  tw'o-thirds  of 
the  thickness  of  the  upper  part  of  the  right  thigh; 
broke  the  ascending  ramus  of  the  ischium  ; lacerated 
the  perinaeum  and  scrotum ; and  fractured  the  higher 
part  of  the  femur.  There  was  no  hemorrhage  of  con- 
sequence ; but  the  exposed  lacerated  surface  of  the 
soft  parts  was  immense,  and  the  unfortunate  soldier, 
who  lay  with  his  hairs  standing  erect,  and  bereft  of  his 
intellectual  faculties,  sunk  in  the  course  of  a quarter  of 
an  hour  into  a state  of  insensibility,  and  was  quite 
dead  in  twenty  minutes.  However,  there  are  nume- 
rous cases  in  which  the  patients,  after  dreadful  injurieo 
of  the  upper  part  of  the  thigh,  are  less  depressed  and 
overcome,  and  live  several  weeks ; facts  clearly  prov- 
ing that  the  operation  ought  to  be  •attempted.  Many 
instances  of  this  kind  are  related  by  Mr.  Guthrie. — 
(On  Gun-shot  Wounds,  p.  134,  &;c.)  Bad  and  incura- 
ble disease  of  the  upper  part  of  the  femur  (not  the 
scrofulous  hip,  nor  any  other  example  m which  the 
pelvis  is  affected)  may  also  require  the  performance  of 
amputation  at  the  hip-joint,  as  was  recently  illustrated 
in  the  practice  of  Mr.  Syme,  of  Edinburgh,  and  in  that 
of  Sir  Astley  Cooper.  -The  case  in  which  Mr.  Car- 
michael amputated  at  the  hip,  was  what  is  termed  an 
osteosarcoma  ; tlte  patient,  a girl  19  years  of  age,  died 
on  the  fifth  day  — (SeeTfans.  of  the  King’s  and  Queen’s 
College  of  Physicians,  Ireland,  vol.  2,  p.  357,  &c.,  and 
vol.  3,p.  158.)  Dr.  Mott’s  case,  already  referred  to, 
was  one  of  fracture  of  the  upper  part  of  the  femur, 
ending  in  disease  of  the  bone  and  extensive  abscesses. 
The  disease,  for  which  Delpech  operated,  was  necrosis 
of  the  thigh-bone.  The  propriety  of  the  operation  in 
desperate  cases  is  now  perfectly  established. 

amputation  at  THK  SnOl’LDER-JOINT. 

H.  F.  Le  Dran  performed  the  first  operation  of  this 
kind,  of  which  the  particulars  are  recorded.  It  was 
in  a ca.se  of  caries  and  exostosis,  reaching  from  the 
middle  to  the  neck  of  the  humerus.  Le  Dran  began 
with  rendering  lumself  master  of  the  bleeding,  for 
which  purpose  he  introduced  a straight  needle  and  a 
strong  ligature  under  the  artery.  This  was  passed 
from  the  front  to  the  back  part  of  the  arm  as  closely  to 
the  axilla  and  bone  as  possible.  The  ligature  then,  in- 
cluding the  vessels,  the  flesh  surrounding  them,  and 
the  skin  covering  them,  was  tightened  over  a compress. 
Le  Dran,  with  a straight  narrow  knife,  then  made  a 
transverse  incision  through  the  skin  and  deltoid  muscle 
down  to  the  joint,  and  ihrough  the  ligament  surround- 
ing the  head  of  the  humerus.  An  assistant  now  raised 
the  arm  and  dislocated  the  head  of  the  bone  from  the 
cavity  of  the  scapula.  This  allowed  the  knife  to  be 
passed  with  ease  between  the  bone  and  the  flesh.  Le 
Dran  then  carried  the  knife  downwanls,  keeping  its 
edge  always  somewhat  inclined  towards  the  hone.  !n 
this  manner  he  gradually  cut  tiirough  all  the  parts,  as 
fir  as  a little  below  the  ligature.  As  there  was  a large 
) flap,  Lc  Dran  made  a second  ligature  with  a curved 


AMPUTATION. 


79 


needle, ‘which  ligature  included  a great  deal  of  flesh,  the 
redundant  portion  of  which  was  cut  oflf  together  with 
the  first  ligature,  which  had  become  useless.  The 
cure  was  completed  in  abouT  ten  weeks. — Obs.  de 
Cliir.  t.  1,  p.  ?15,  Paris,  1731  ; and  Tralte  de  Oper.  p. 
365.)  Le  Dran  (the  son),  who  published  this  memo- 
rable case,  does  not  state  that  the  operation  was  a new 
one,  and  it  appears  from  the  RechCrches  Critiques  sur 
rOrigine,  &c.  de  la  Chirurgie  en  France,  and  from  La 
Faye’s  notes  on  Dionis,  that  it  had  been  previously 
practised  by  Morand,  the  father. 

Garengeot  thought  that  the  ligature  might  be  applied 
by  means  of  a curved  needle,  with  sharp  edges ; and  in 
order  to  lessen  the  wound,  he  directs  the  incision  to 
begin  two  or  three  finger-breaths  below  the  acromion , 
across  the  deltoid  muscle,  so  as  to  form  one  flap ; then 
a lower  one  was  made  in  the  axilla ; and  after  the  se- 
cond ligature  had  been  applied,  the  two  flaps  were 
brought  into  contact.— (Traite  des  Oper.  de  Chir.  t.  3, 
p.  350 ; Mem.  de  Acad,  de  Chir.  t.  2,  p.  261.) 

La  Faye  extended  the  improvements  farther.  After 
placing  the  patient  in  a chair,  and  bringing  the  arm 
in  a horizontal  posicion,  he  made,  with  a common  bis- 
toury, a transverse  incision  into  the  deltoid  muscle 
down  to  the  bone,  four  finger-breadths  below  the  acro- 
mion. Two  other  incisions,  one  in  1‘ront,  the  other  be- 
hind, descended  perpendicularly  to  this  first,  and  made 
a large  flap  of  the  figure  of  a trapezium,  which  was  de- 
tached and  turned  up  towards  the  top  of  the  shoulder. 
The  two  heads  of  the  biceps,  the  tendons  of  the  supra- 
spinatus,  infra-spinatus,  teres  minor  and  subscapuiaris, 
and  the  capsular  ligament,  were  next  divided.  Now 
when  the  assistant  who  held  the  lower  part  of  the  limb 
made  the  bone  describe  the  motion  of  a lever  upwards, 
the  head  of  the  bone  was  easily  dislocated.  La  Faye 
next  carried  his  incision  downwards,  along  the  inner 
part  of  the  arm,  until  he  was  able  to  feel  the  vessels, 
winch  he  tied  as  near  the  axilla  as  possible.  The  se- 
paration of  the  limb  was  then  completed  a finger’s- 
breadth  below  the  ligature.  The  flap  was  then  brought 
down  over  the  glenoid  cavity,  and  the  wound  dressed. 
— See  Nouvelle  Methode  pour  faire  I’Operation  de 
I’Ainputation  dans  I’Articulation  du  Bras  avec  I’Omo- 
plate,  par  M.  La  Faye,  in  Mem  de  I’Acad.  de  Chirurgie, 
tom.  5,  p.  195,  edit,  in  12mo.)  With  respect  to  La  Faye, 
it  is  curious  to  remark  a coincidence  between  him  and 
Larrey : the  latter,  though  generally  averse  to  the  at- 
tempt of  uniting  stumps  by  the  first  intention,  is  an 
advocate  for  this  practice  after  hip-joint  amputations ; 
so  La  Faye,  who  was  fearful  of  laying  down  the  flap 
after  amputation  of  the  leg,  had  no  such  apprehension 
at  the  shoulder. 

La  Faye’s  method  is  yet  regarded  as  one  of  the  most 
approved  where  the  state  of  the  soft  parts  will  admit 
of  it.  But  it  is  absurd  to  think  of  applying  any  one 
plan  to  all  the  various  states  in  which  the  injured 
or  diseased  limb  may  present  itself.  It  is  advised  by 
Larrey  himself,  when  a wound  extends  through  the 
upper  part  of  the  arm,  breaking  the  bone,  and  injuring 
the  soft  parts.  Here,  says  h^,  it  would  be  impossible 
to  fonn  an  anterior  and  a posterior  flap,  for  the  soft  parts 
in  these  sil  nations  have  been  destroyed.  On  the  con- 
trary, when  the  deltoid  is  shot  away.  La  P’aye’s  plan 
is  inadmis.sible. — (Mem.  de  Chir.  Mil.  t.  2,  p.  167.) 

The  advantages  of  La  Faye’s  plan  are  obvious.  As 
only  one  ligature  was  ajjplied,  the  patient  was  saved  a 
great  deal  of  pain ; the  flap  connected  with  the  acro- 
mion was  capable  of  covering  the  whole  surface  of  the 
wound,  and  was  more  easily  apidied  and  kept  on  the 
stump  than  the  lowermost  of  the  two  flaps  which  Ga- 
rengeot recommended ; and  the  discharge  found  a ready 
outlet  downwards. 

Mr.  S.  Sharp  recommended  the  following  plan  : “ The 
patient’s  arm  being  held  horizontally,  make  an  incision 
through  the  rnernbrana  adiposa,  from  the  upper  part  of 
the  shoulder  across  the  pectoral  muscle  down  to  the 
armpit ; then  turning  the  knife  with  its  edge  upwards, 
divide  that  muscle  and  part  of  the  deltoid ; all  which 
may  be  done  without  danger  of  wounding  the  great 
vessels,  which  will  become  exposed  by  these  oiieniiigs. 

If  they  be  not,  cut  still  more  of  the  deltoid  muscle,  and 
carry  the  arm  backwards.  Then,  with  a strong  ligature, 
having  tied  the  artery  and  vein,  pursue  the  circular  in- 
cision through  the  joint,  and  carefully  divide  the  ve.s- 
sels  at  a considerable  distance  below  the  ligature  ; the 
Ollier  small  vessels  are  to  be  stopped,  as  in  other  cases. 

“ In  doing  this  operation,  regard  should  be  had  to  the 


saving  as  much  skin  as  possible,  and  to  the  situation 
of  the  processus  acromion,  which,  projecting  consider- 
ably beyond  the  joint,  an  unwary  operator  would  be 
apt  to  cut  upon.” — (Operations  of  Surgery.) 

Bromtield  used  to  press  the  artery  against  the  first  rib. 
His  incision  began  on  the  inside  of  the  arm,  by  the  edge 
of  the  deltoid  muscle,  as  high  up  as  where  the  pectoralis 
goes  over  the  axilla  to  its  insertion  into  the  humerus. 
Cutting  through  the  integuments  and  muscles,  he  con- 
tinued his  incision  obliquely  downwards  and  outwards, 
as  far  as  a little  below  the  termination  of  the  deltoid 
muscle.  Then  carrying  on  the  incision  transver.sely 
for  a small  space  in  a semicircular  direction,  the  wound 
was  next  extended  to  the  external  part  of  the  arm,  as 
high  up  as  the  fold  of  the  integuments  in  the  axilla. 
The  fla))  thus  shaped,  when  raised  from  the  humerus, 
was  intended  to  fill  up  the  axilla,  after  the  removal  of 
the  limb.  Bromfield’s  next  incision  began  at  the  acro- 
mion, and  being  carried  through  the  skin  and  deltoid 
down  to  the  bone,  terminated  in  the  semicircular  inci- 
sion above  described,  and  it  was  so  guided  that  it  left  the 
outer  portion  of  the  divided  flap  larger  than  the  inner 
one.  Bromfield  then  passed  his  knife  under  the  lower 
edge  of  the  internal  half  flap,  and  dissected  it  up  as 
high  as  possible.  The  tendon  of  the  pectoral  muscle 
was  thus  exposed,  under  which  he  now  passed  his  left 
fore-finger,  which  served  as  a conductor  to  a probe- 
pointed  curved  bistoury.  With  this  he  now  divided  the 
attachment  of  that  muscle  to  the  humerus.  If  the  ves- 
sels were  not  now  sufficiently  brought  into  view,  he 
cut  through  the  outer  head  of  the  biceps,  and  tied  them 
(artery  and  vein)  each  with  two  strong  ligatures  about 
half  an  inch  apart.  The  vessels  were  then  cut  throug’a 
in  the  interspace,  and  the  nerve  was  divided  much 
higher  than  the  artery.  The  external  flap  was  now 
raised  sutficiently  to  expose  the  joint ; and  the  muscles 
aitd  capsular  ligament  having  been  cut  through  in  the 
superior  and  lateral  parts,  the  humerus  slipped  out  of 
the  glenoid  cavity  immediately  the  arm  was  carried  a 
little  backwards.  Lastly,  the  ligatures  and  vessels  being 
held  out  of  the  way,  the  soft  parts  towards  the  axilla 
were  divided  in  a semicircular  direction. — (Chir.  Obs 
and  Cases,  vol.  1,  p.  249—252,  8vo.  London,  1773.) 
The  unnecessary  tediousness  and,  I may  add,  severity 
of  Bromfield’s  method  have  long  withdrawn  from  it 
the  approbation  of  modern  operators.  The  di%ision  of 
the  flap  into  two  portions,  its  extraordinary  length,  and 
the  painful  dissection  practised  to  get  at  the  artery, 
were  serious  faults  in  the  operation. 

In  1774,  Alanson  amputated  at  the  shoulder-joint  as 
follows  ; the  subclavian  artery  was  compressed  by  the 
fingers  of  an  assistant.  An  incision  was  made  about 
a hand’s  breadth  below  the  acromion,  and  carried 
through  the  integuments  all  round  the  limb.  The  del- 
toid and  posterior  muscles  were  then  obliquely  divided 
up  to  the  capsular  ligament.  The  tendon  of  the  biceps 
and  the  capsular  ligament  upon  the  anterior  and  pos 
terior  part  of  the  joint  were  now  cut  through.  One 
of  the  circumflex  arteries,  which  bled  a good  deal,  was 
next  tied.  The  great  pectoral  muscle,  the  rest  of  the 
capsule,  and  all  the  other  jiarts  except  the  vessels  and 
nerves  were  then  divided,  but  previously  to  cutting  the 
ves.sels  a temporary  ligature  was  put  around  them. 
Thus  the  separation  of  the  limb  was  completed.  The 
mouths  of  the  vessels  were  drawn  out  and  tied,  and 
the  tenqiorary  ligature  taken  away.  Lastly,  the 
aides  of  the  wound  were  brought  together  so  as  to 
make  a transverse  line.  Graefe,  seeming  not  to  recol- 
lect that  amputation  by  the  circular  incision  directed 
obliquely  upwards  had  been  practised  by  Alanson, 
mentions  it  as  a new  proposition.  In  one  ca.se,  after 
operating  in  this  manner,  his  patient  was  (juite  well  in 
three  weeks ; and  with  the  particular  sort  of  knife 
which  he  uses,  and  which  is  broadest  towards  its  point, 
he  jiretends  to  be  able  to  make  the  oblique  incision 
through  the  muscles  all  around  the  limb  with  one 
sweep.  Of  course  he  is  very  careful  to  make  pressure 
on  the  artery,  both  with  Mohrenheirn’s  compressor  ap- 
plied under  the  clavicle,  and  the  fingers  of  an  assistant 
above  it. — (See  Normen  fur  die  Abl.  grosserer  Gliedm. 
p.  110,  (fee.)  In  proof  of  the  possibility  of  making  the 
oblhpie  incision  (luite  evenly  with  one  stroke  of  his 
jiarticular  knife,  he  injected  a female  subject,  did  tlie 
operation,  and  caused  the  stump  to  be  drawn  Irorn  na- 
ture.— See  Plate  ii.  of  his  Work.) 

In  1760,  P.  II.  Halil  published  at  Gottingen  a disser- 
tation on  amputation  at  the  shoulder.  In  tliis  tract  a 


80 


AMPUTATION. 


tourniquet  was  proposed,  the  pad  of  which  was  calcu- 
lated to  press  upon  the  subclavian  arterj'  under  the 
clavicle,  and  enabled  the  operator  to  dispense  with 
tying  the  vessels  in  the  first  instance.  Camper  had 
observed,  that  if  the  scapula  were  pushed  backwards, 
and  the  axillary  artery  pressed  with  the  finger  between 
the  clavicle,  coracoid  process,  and  great  pectoral  mus- 
cle, the  pulse  at  the  wrist  might  be  instantly  stopped. 

Dahl’s  tourniquet  was  obviously  constructed  in  con- 
sequence of  what  Camper  had  observed.  It  is  made  of 
a curved,  elastic  plate  of  steel,  to  the  shortest  end  of 
which  a pad  is  attached,  capable  of  projecting  farther 
by  means  of  a screw.  The  instrument  embraces  the 
shoulder  from  beliind  forwards,  while  the  pad  presses  on 
the  hollow  under  the  clavicle,  between  the  margins  of/ 
the  deltoid  and  pectoral  muscles.  The  long  extremity 
of  the  steel  plate,  which  descends  behind  the  shoulder, 
is  fixed  to  the  body  by  a sort  of  belt.  The  pad  is  de- 
pressed until  the  pulsation  of  the  axillary  artery  is 
stopped. 

Farther  experiments  have  proved,  however,  that  this 
tourniquet  may  be  dispensed  with,  and  the  flow  of 
blood  in  the  axillary  artery  commanded,  by  properly 
compressing  this  vessel  with  a pad,  or  even  the  fingers 
alone,  as  some  operators  prefer,  at  the  place  where 
it  emerges  from  between  the  scaleni  muscles  above 
the  middle  part  of  the  clavicle.  Thus  the  artery  is 
p -ssed  between  the  pad  or  fingers  and  the  first  rib, 
across  which  it  runs.  In  certain  plans  of  operation, 
hereafter  to  be  described,  all  compression  of  the  artery 
either  above  or  below  the  cla\icle  is  dispensed  with. 

Some  practitioners,  forgetf  ul  of  the  horizontal  posture 
in  which  the  patient  is  usually  placed  after  the  opera- 
tion, have  feared  that  in  La  Faye’s  method  the  lower 
flap  may  sometimes  confine  the  discharge.  In  order  to 
avoid  this  inconvenience,  Desault  recommended  the 
formation  of  two  flaps,  one  of  which  was  anterior,  the 
other  posterior.  Tlie  axillary  artery  was  compressed 
from  above  the  clavicle,  at  its  coming  out  from  between 
the  scaleni  muscles,  while  the  integuments  and  flesh 
of  the  upper  and  internal  part  of  the  arm  were  pushed 
away  from  the  humerus.  A knife  was  plunged  be- 
tween these  and  the  other  soft  parts  behind,  to  make 
the  anterior  flap.  The  arm  being  inclined  backwards 
and  outwa'-ds,  the  humeral  artery  was  tied,  the  articu- 
lation opened,  and  the  liead  of  the  bone  dislocated. 
The  knife  was  then  carried  downwards  and  backwards 
so  as  to  form  the  posterior  flap,  the  incisions  meeting 
in  the  axilla. — (See  Sabatier’s  Medecine  Operatoire,  t. 
3,  p.  39:i— 399,  ed.  2.) 

Larrey,  who  had  frequent  opportunities  of  amputa- 
ting at  the  shoulder-joint,  aimed  at  the  same  object 
which  Desault  did ; but  in  his  earlier  operations,  he  was 
in  the  habit  of  beginning  with  the  formation  of  the  ex- 
ternal or  posterior  flap,  for  the  following  reason : by 
proceeding  in  this  way,  the  surgeon  can  tie  the  hume- 
ral artery  more  safely,  because  the  ligature  is  applied 
after  the  operation  is  entirely  finished,  and  conse- 
quently at  a time  Avheu  there  is  nothing  to  be  attended 
to  but  the  hemorrhage.  Thus,  the  patient  being  placed 
on  a stool,  and  w'ell  supported,  the  arm  is  to  be  raised 
from  the  side,  and  the  a.xillary  artery  compressed 
from  above  the  clavicle.  The  integuments  and  other 
soft  parts  of  the  upper  and  outer  parts  of  the  arm  are 
then  to  be  pushed  away  from  the  humerus,  and  the  e.x- 
ternal  flap  formed.  It  is  now  very  easy  to  cut  the  ten- 
dons of  the  infra-spinatus  and  teres  minor,  and  open 
the  outside  of  the  joint.  The  limb  is  to  be  carried  in- 
wards and  luxated  backwards.  The  tendons  of  the  su- 
pra-spinatus  and  biceps  are  to  be  divided,  and  as  soon 
as  the  head  of  the  bone  is  out  of  the  glenoid  cavity,  the 
knife  is  to  be  carried  along  the  internal  part  of  the 
head  and  neck  of  the  humerus,  with  its  edge  close  to 
the  bone.  An  internal  flap,  equal  to  the  external  one, 
is  to  be  formed,  consisting  of  a portion  of  the  deltoid, 
great  pectoral,  biceps,  and  coraco-brachialis  muscles, 
and  including  the  brachial  vessels  and  nerves.  The 
artery  is  to  be  taken  hold  of  with  a i)air  of  forceps, 
and  tied.  Any  other  vessels  which  require  a ligature 
are  also  now  to  be  secured.  Larrey  puts  some  charpie 
between  the  flaps,  and  brings  them  towards  each  other 
by  the  u.sual  means. — (See  Mim.  de  Chir.  Militaire,  t. 
2,  p.  170.)  Of  this  method  of  putting  charpie  to  pre- 
vent union  by  the  first  intention,  1 entertaui  the  most 
unfavourable  opinion. 

When  Larrey  published  his  campaign  in  Eg>’PL  he 
had  operated  in  this  way  on  nineteen  patients,  thirteen 


of  whom  recovered.  But,  at  a subsequent  period,  he 
and  his  colleagues  had  amputated  at  the  shoulder,  in 
the  above  manner,  in  upwards  of  a hundred  cases, 
more  than  ninety  of  which  recovered. — (M^m.  de  Chir. 
Mil.  t.  4,  p.  432,  8vo.  Paris,  1817.) 

In  his  latter  operations  he  adopted  the  innovation  of 
first  making  a longitudinal  incision  from  the  acromion 
to  about  an  inch  below  the  neck  of  the  humerus  down 
to  the  bone,  so  as  to  divide  the  fleshy  part  of  the  del- 
toid into  two  even  parts.  This  cut,  he  says,  facili- 
tates and  renders  more  exact  the  rest  of  the  operation. 
From  this  wound  the  incisions  for  the  flaps  are  con- 
tinued. Having  made  the  foregoing  incision,  “ I di- 
rect an  assistant  to  draw  up  the  skin  of  the  arm  to- 
wards the  shoulder,  and  I form  the  anterior  and  poste- 
rior flaps  by  two  oblique  strokes  of  the  knife  made 
from  within  outwards  and  doAvnwards,  so  as  to  cut 
through  the  tendons  of  the  pectoralis  major  and  latis- 
simus  dorsi.  There  is  no  risk  of  injuring  the  axillary 
vessels,  as  they  are  out  of  the  reach  of  the  point  of  the 
knife.  The  cellular  connexions  of  these  two  flaps  are 
to  be  divided,  and  the  flaps  themselves  raised  by  an  as- 
sistant, who,  at  the  same  time,  is  to  compress  the  two 
divided  circumflex  arteries.  The  whole  joint  is  now 
exposed.  By  a third  sweep  of  the  knife,  carried  circu- 
larly over  the  head  of  the  humerus,  the  capsule  and 
tendons  running  near  the  articulation  are  cut ; and  the 
head  of  the  bone  being  inclined  a little  outwards,  the 
knife  is  to  be  carried  along  its  posterior  part  in  order 
to  finish  the  section  of  the  tendinous  and  ligamentous 
attachments  in  that  direction.  The  assistant  now  ap- 
plies his  'fore-fingers  over  the  brachial  plexus,  for  the 
purpose  of  compressing  the  artery,  and  commanding 
the  current  of  blood  through  it.  Lastly,  the  edge  of 
the  knife  is  turned  backwards,  and  the  whole  fascicu- 
lus of  axillary  vessels  is  cut  through,  on  a level  with 
the  lower  angles  of  the  two  flaps,  and  in  front  of  the 
assistant’s  fingers.  The  patient  does  not  lose  a drop 
of  blood  ; and  ere  the  compression  is  remitted,  the  ex- 
tremity of  the  axillary  artery  is  readily  seen,  taken  up 
with  a pair  of  forceps,  and  tied.  The  circumflex  arte- 
ries are  next  secured,  wliich  completes  the  operation.” 
— (Mem.  de  Chir.  Mil.  t.  4,  p.  428,  Paris,  1817.)  In 
addition  to  these  important  deviations  from  his  earlier 
method,  he  subsequently  preferred  bringing  the  flaps 
together  with  two  or  three  straps  of  adhesive  plaster, 
and  interposes  no  charpie. — (P.  429.)  It  should  be  ob- 
served also,  that  he  lays  no  stress  on  first  making  the 
outer  flap,  though,  from  the  description,  it  does  not  ex- 
actly appear  which  flap  he  now  begins  with.  He  has 
changed  likewise,  on  another  point  of  importance,  viz. 
instead  of  preferring  La  Faye’s  plan  in  certain  exam- 
ples already  specified,  he  affirms  that  the  above-de- 
scribed way  of  operating  is  applicable  to  almost  every 
case  met  with  in  military  practice.  First,  because  ail 
gun-shot  wounds,  generally,  which  mutilate  the  arm 
so  as  to  create  the  necessity  for  the  operation,  partly 
or  entirely  destroy  the  centre  of  the  deltoid,  while 
there  is  always  enough  flesh  left  at  the  sides  for  mak- 
ing the  two  flaps.  Secondly,  because,  in  the  very  rare 
instances  where  the  lateral  parts  of  the  shoulder  are 
destroyed,  and  the  middle  untouched,  no  advantage 
would  be  gained  by  operating  in  La  Faye’s  manner,  as 
Larrey  conceives  that  the  detached  flap  would  slough, 
or  become,  as  he  terms  it,  disorganized.  He  now  prefers 
dividing  the  middle  piece  of  flesh,  and  giving  the  flaps 
the  same  shape  as  if  they  were  uninjured.  He  even 
asserts,  that  the  operation,  done  without  any  flaps  at 
all,  answers  better  than  any  method  in  which  the  sur- 
geon preserves  flaps  not  naturally  intended  for  the 
part.  Thus,  when  all  the  flesh  of  the  shoulder  has 
been  shot  away,  he  has  seen  surgeons  cover  the  gle- 
noid cavity  with  a flap  saved  from  the  soft  parts  of  the 
axilla ; but  such  flaps  invariably  sloughed,  hemor 
rhages  ensued,  and  the  patients  died.— (P.  430 — 431.) 
Some  of  these  latter  observations  are,  clearly  enough, 
the  result  of  great  partiality  to  a particular  method  of 
ojierating ; because  who  can  doubt,  when  the  lateral 
parts  of  the  shoulder  are  injured,  as  they  frequently 
are  (and  not  very  rarely,  as  Larrey  asserts),  by  the 
])assage  of  a musket-hall  through  the  shoulder,  from 
before  backwards,  that  the  right  method  is  that  of  La 
Faye ; or  the  same  operation,  with  the  slight  difler- 
ence  of  making  the  flap  of  a semicircular  shape  ? It 
was  for  cases  of  tliis  descriinion  that  Mr.  Collier  and 
1 operated  afler  La  Faye’s  plan,  with  perfect  success, 
after  the  battle  of  Waterloo;  and  a poor  fellow  of  the 


AMPUTATION. 


81 


rifle  brigade,  who  was  brought  in  too  late  for  operation, 
and  died  of  sloughing,  had  his  shoulder  injured  in  the 
same  way,  the  middle  of  the  deltoid  being  untouched, 
and  shot-holes  existing  behind,  and  in  front  of,  the  ar- 
ticulation. But  if  it  required  any  farther  arguments 
to  prove,  that  Larrey  is  wrong  in  wishing  to  extend 
his,  or  rather  Desault’s  method,  to  all  cases,  I might 
criticise  his  assertions  about  the  sloughing  of  the  flap, 
when  it  is  not  cut  into  two  portions,  and  its  preserva- 
tion by  the  singular  expedient  of  making  a division  of 
it,  and,  of  course,  injuring  it  still  more  than  it  may 
have  been  injured  underneath  by  the  bullet.  The 
cases,  however,  which  have  fallen  under  my  own  per- 
sonal observation,  and  numerous  others  on  record,  fur- 
nish an  adequate  proof,  that  excellent  as  Larrey’s  me- 
thod is  for  many  cases.  La  Faye’s  answers  very  well 
in  others.  Thus,  in  an  example  where  a Prussian 
hussar  had  had  his  arm  amputated,and  a projection  ofthe 
bone. took  place,  to  the  extent  of  three  inches,  with 
hospital  gangrene  commencing  in  the  stump,  Klein 
felt  obliged  to  remove  the  limb  at  the  shoulder.  He 
operated  in  La  Faye’s  manner;  the  separation  was 
finished  in  one  minute;  and  on  the  eighteenth  day  the 
stump  was  perfectly  healed. — (See  Praotische  Ansichte 
Chir.  op.  h.  1,  p.  1 — 10,  4to.  Stuttgart,  1816.)  The 
same  practitioner  had  five  other  secondary  amputations 
of  the  same  kind ; but  one  patient  was  afterward  carried 
off  by  hemorrhage,  and  another  by  hospital  gangrene. 
Klein,  however,  in  common  with  the  majority  of  army 
surgeons,  considers  the  idea  of  applying  any  one  plan 
of  operating  to  different  cases,  totally  absurd. — (P.  12.) 
After  the  storming  of  St.  Sebastian’s,  nine  shoulder-joint 
amputations  were  done  with  success  ; seven  of  them 
by  raising  the  deltoid  as  a flap. — (See  Guthrie  on  Gun- 
shot Wounds,  p.  108.) 

After  tlfb  battle  of  Waterloo,  1 adopted  La  Faye’s 
plan ; but  wnth  this  difference,  that  I did  not  cut  the 
brachial  artery  till  I made  the  last  stroke  of  the  knife, 
which  separated  the  limb  ; and  consequently  I did  not 
tie  that  vessel  till  the  time  when  I had  nothing  but  the 
hemorrhage  to  occupy  my  attention.  The  circumflex 
arteries,  however,  I tied  as  soon  as  the  external  flap 
was  made.  The  modification  of  thrusting  a knife 
under  the  deltoid,  quite  across  the  shoulder,  and  mak- 
ing the  flap  by  cutting  dow-nwards,  until  the  instru- 
ment comes  out  again  through  the  skin,  is  practised 
by  some  surgeons  of  eminence. — (Klein,  Lisfranc,  &c.) 
An  excellent  lithographic  plate  illustrative  of  this  last 
method  is  given  by  Maingault,  pi.  4,  fig.  17. — (See 
M6d.  Operat.  p.  24,  fol.  Paris,  1812.) 

When  the  state  of  the  integuments  will  permit  the 
choice,  Mr.  Guthrie  thinks  their  preservation  best  ef- 
fected by  Larrey’s  first  method;  but  he  particularly 
insists  upon  the  advantage  of  raising  the  shattered 
arm  or  stump  to  nearly  a right  angle  with  the  body 
before  the  operation  begins,  and  even  before  the  assist- 
ant makes  pressure  on  the  subclavian  artery,  as  some 
change  in  the  mode  of  accomplishing  the  latter  object 
might  be  rendered  necessary  by  elevating  the  limb  dur- 
ing the  operation  itself.  Mr.  Guthrie  commences  the 
first  incision  immediately  below  the  acromion,  and, 
with  a gentle  curve,  extends  it  downwards  and  in- 
wards, through  the  integuments  only,  a little  below 
the  anterior  fold  of  the  armpit.  The  second  incision 
outwards  is  made  after  the  same  manner,  but  is  car- 
ried rather  farther  down,  so  as  to  expose  the  long  head 
of  the  triceps  at  the  under  edge  of  the  deltoid.  The 
third  incision,  commencing  at  the  same  spot  as  the  first, 
but  following  the  margin  of  the  retracted  skin,  divides 
the  deltoid  on  that  side  down  to  the  bone,  and  exposes 
the  insertion  of  the  pectoral  is  major,  which  must  be 
cut  through.  This  flap  is  now  to  be  raised,  so  as  to 
expose  the  head  of  the  bone.  The  fourth  incision  out- 
wards divides  the  deltoid  muscle  down  to  the  bone, 
when  the  posterior  flap  is  to  be  well  turned  back,  so 
as  to  bring  into  view  the  teres  minor  and  infra-spina- 
tus  pas.sing  from  the  scapula  to  the  great  tuberosity  of 
the  humenis.  The  outer  and  inner  flap  being  now 
raised,  the  head  of  the  bone  may  be  rolled  a little  out- 
wards, the  teres  minor  and  infra-spinatus  cut,  and  an 
opening  made  into  the  joint.  The  capsular  ligament, 
supra-spinatus,  and  long  head  of  the  biceps  are  then 
divided.  The  inner  side  of  the  capsule  is  now  cut 
through,  together  with  the  subscapularis  muscle,  as  it 
approaches  its  insertion  into  the  lesser  tuberosity  of  the 
humerus.  The  long  head  of  the  triceps  is  next  divided, 
and  lastly,  with  one  sweep  of  the  knife,  the  rest  of  the 

Von.  I — F 


soft  parts  are  cut,  together  with  the  axillary  artery, 
veins,  and  nerve. — (On  Gun-shot  Wounds,  p.  274 — 
270.)  Larrey,  in  his  latest  method,  takes  no  measures 
in  the  first  stage  of  the  operation  for  commanding  the 
flow  of  blood,  as  the  assistant  merely  presses  the  ax- 
illary artery  between  his  fingers  just  before  it  is  di- 
vided. 

Some  of  the  modern  French  surgeons  were  earlier 
than  Larrey  in  dispensing  with  the  compression  of 
the  axillary  artery,  and  following  a method  which  ren- 
ders it  unnecessary.  Richerand,  for  instance,  describes 
nearly  the  same  plan  as  that  advised  by  La  Faye ; but 
after  making  the  deltoid  flap,  cutting  the  tendons,  and 
dislocating  the  bone,  he  dissects  down  close  to  the  in- 
side of  the  humerus,  so  as  to  enable  an  intelligent  as- 
sistant to  put  his  thumb  on  the  cut  surface  behind  the 
artery,  which,  with  the  aid  of  the  fingers  apjilied  to 
the  skin  of  the  axilla,  can  then  be  grasped  and  com- 
pressed so  as  to  command  the  flow  of  blood  through 
the  vessel.  The  operator  now,  fearless  of  hemorrhage, 
completes  the  internal  or  inferior  flap. — (Richerand, 
Nosographie  Chir.  t.  4,  p.  509 — 511,  edit.  4.) 

Baron  Uupuytren  amputates  at  the  shoulder,  in  a 
manner  which  seems  principally  commendable  on  ac- 
count of  its  celerity.  The  arm  being  raised  and  held 
at  a right  angle  with  the  trunk,  Dupuytren  stands  at 
the  inside  of  the  limb,  with  one  hand  grasps  and  ele- 
vates the  mass  of  the  deltoid  muscle,  and  plunges 
under  it  a two-edged  knife,  from  before  backwards, 
on  a level  with  the  end  of  the  acromion.  Gutting  in 
this  way  close  to  the  head  of  the  humerus,  he  con- 
tinues the  incision  downwards  between  this  bone  and 
the  deltoid,  and  at  length,  bringing  out  the  knife,  com- 
pletes the  external  or  superior  flap.  The  rest  of  the 
operation  does  not  essentially  differ  from  Richerand’s, 
except  that  Dupuytren  takes  hold  of  the  lower  flap  it- 
self, before  dividing  it,  and  compresses  the  artery 
until  he  has  cut  through  it  and  tied  it. 

Dupuytren’s  plan  would  be  difficult  on  the  left  side, 
unless  the  surgeon  were  an  ambidexter ; but,  in  other 
respects,  it  cannot  be  found  m\ich  fault  with.  This 
surgeon  has  also  proposed  making  one  flap  in  front, 
and  the  other  behind,  in  order  to  prevent  the  lodgement 
of  matter.  Richerand  justly  observes,  however,  that 
frequently  a good  deal  of  the  wound  unites  by  the  first 
intention,  and  that  as  the  patient  after  the  operation 
lies  in  the  recumbent  posture  on  an  oblique  plane,  he 
cannot  see  what  advantage  one  way  of  making  the 
flaps  has  over  another,  in  regard  to  affording  a ready 
issue  to  the  discharge. — (Op.  cit.  p.  515.) 

For  the  sake  of  celerity,  of  which  the  French  are 
rightly  admirers  in  all  capital  operations,  another  plan 
of  amputating  at  the  shoulder  has  been  proposed  by 
Lisfranc.  Supposing  the  left  extremity  is  to  be  re- 
moved, the  patient  is  placed  on  an  elevated  seat,  one 
assistant  pressing  the  artery  against  the  first  rib,  while 
another  draws  the  arm  forwards ; the  operator,  stand- 
ing behind  the  patient  with  a long-bladed  catling, 
pierces  the  integuments  on  the  inner  edge  of  the  latis- 
simus  dorsi  muscle,  opposite  the  middle  of  the  axilla, 
and  pushes  it  obliquely  upwards  and  forwards,  till  its 
point  strikes  against  the  under  surface  of  the  acromion  ; 
then,  by  raising  the  handle  of  the  knife,  its  point  is 
lowered,  and  protruded  just  in  front  of  the  clavicle  at 
its  junction  with  the  acromion.  By  ctitting  down- 
wards and  outwards,  he  then  forms  a flap  from  the 
superior  and  posterior  part  of  the  arm,  including  the 
whole  breadth  of  the  deltoid  muscle,  and  a part  of  the 
latissimus  dorsi.  This  being  held  back  by  the  assist- 
ant, the  joint  is  cut  through  from  behind  forwards, 
and  a corresponding  flap  is  formed  by  cutting  down- 
wards and  outwards,  between  the  muscles  and  bone, 
on  the  inner  side  of  the  arm.  When  the  operation  is 
on  the  right  side,  the  patient  should  be  seated  on  a low 
chair,  and  the  catling  thrust  from  above  downwards, 
from  the  part  just  in  front  of  the  point  where  the  clavi- 
cle is  connected  with  the  acromion,  the  surgeon  raising 
his  hand  as  the  instrument  proceeds  downwards  and 
backwards,  until  its  point  has  come  out  at  the  inner 
edge  of  the  latissimus  dorsi,  when  the  flap  is  to  be 
made,  and  the  operation  finished  as  above  directed.— 
(See  Averill’s  Operative  Surgery,  p.  135.  Also  Lis- 
franc de  St.  Martin,  et  Charnpesme,  Nouveau  Froc«';d6 
Op()ratoire  pour  I’amputation  du  bras  dans  son  articu- 
lation scapulo-hnmerale.  Paris,  1815.) 

Speaking  of  this  mode  of  operating,  Richerand  re- 
marks; “en  I’employant,  on  parvicut  ^ ddsarticuler 


82 


AMPUTATION. 


I’hurn^rus,  et  a s^parer  Ic  bras  en  aussi  peu  de  temps 
qu’en  met  un  habile  decoupeur  A detacher  I'aile  d’un 
perdrix.” — (P.  514.) 

The  last  method  which  I shall  describe  is  that  of  M. 
Scoutteten.  It  is  done  on  the  left  arm,  as  follows  : — 
The  surgeon  first  takes  hold  of  the  middle  of  the  arm 
with  his  left  hand,  and  raises  it  four  or  five  inches  from 
the  side.  With  his  right  hand  he  then  applies  the  point 
of  the  scalpel  immediately  below  the  acromion,  and 
passes  it  into  the  flesh  until  it  touches  the  head  of  the 
humerus.  He  then  depresses  the  handle,  and  forms 
the  first  incision,  which  extends  downwards  four 
inches  from  the  point  of  the  acromion,  and  divides  the 
posterior  third  of  the  deltoid,  and  the  greater  part  of  the 
fibres  of  the  Jong  portion  of  the  triceps  down  to  the 
bone.  The  second  incision  is  next  commenced  with 
the  point  of  the  knife  directed  downwards  upon  the 
inner  side  of  the  limb,  and  in  front  of  the  biceps,  on 
a level  with  the  place  where  the  first  incision  ended. 
The  wound  is  then  extended  inwards  and  upwards  to 
the  acromion,  where  it  terminates  by  joining  the  first. 
These  two  wounds  form  a triangle,  which  nartly  con- 
sists of  relinquished  integuments,  and  has  its  base 
downwards. 

In  order  to  find  the  joint  with  greater  ease,  the  sur- 
geon may  now  detach  a little  of  the  deltoid  from  the 
bone.  An  assistant  can  also  keep  the  edges  of  the  in- 
cision asunder,  so  that  the  operator  may  be  enabled  to 
see  and  divide  the  capsular  ligament,  and  the  tendons 
of  the  suprpi-spinatus,  infra-spinatus,  and  teres  minor, 
which  are  inserted  into  the  greater  tubercle  of  the  hu- 
merus, and  the  tendon  of  the  subscapularis,  which  is 
inserted  into  the  lesser  tubercle.  1 he  operator,  who 
constantly  keeps  hold  of  the  arm,  now  communicates 
to  it  some  rotatory  movements,  in  order  to  bring  the 
above  tendons,  one  after  another,  under  the  knife,  and 
dmde  them  with  the  capsule.  Iimnediately  the  cap- 
sule and  tendons  have  been  cut  through,  the  head  of 
the  bone  readily  quits  its  socket.  The  surgeon  luxates 
the  bone  by  pushing  it  a little  upw'ards,  and,  at  the 
same  moment,  inclining  the  condyles  towards  the  side. 
The  next  proceeding  is  to  divide  the  flesh  on  the  inner 
side  of  the  limb  as  closely  as  possible  dowm  to  the 
bone ; but  when  the  knife  approaches  the  artery,  this 
vessel  is  to  be  taken  hold  of  and  compressed  by  an  as- 
sistant, before  the  incision  is  completed.  In  this  way, 
no  hemorrhage  need  be  apprehended. 

When  it  is  the  right  limb,  the  only  difference  is,  that 
the  first  incision  is  made  at  the  inner  side  of  the  arm, 
and  extended  uj)  to  the  acromjon.  Scoutteten  consi- 
ders a single  assistant  sufficient,  and  compression  of 
the  subclavian  artery  unnecessary. — (II.  Scoutteten,  La 
M^thode  Ovalaire,  ou  Nouvelle  Methode  pour  amputer 
dans  les  Articulations,  Paris,  1827,  4to.) 

When  the  scapula  is  shattered,  of  course  the  loose 
fragments  should  be  taken  away,  and  if  the  acromion 
be  broken,  and  the  remnant  of  it  pointed  and  irregular, 
this  sharp  rough  portion  should  be  saw’ed  off,  as  tvas 
practised  longago  by  M.  Faure. — (See  Mem.de  I’Acad.  de 
Uhir.  t.  6,  p.  114.)  In  one  case,  indeed,  Larrey  found 
it  necessary  to  take  away  more  than  two-thirds  of  the 
scapula,  and  the  humeral  end  of  the  clavicle. — (M^m. 
de  Chir.  Mil.  t.  4,  p.  432.)  Sawing  off  part  of  the  acro- 
mion and  coracoid  process,  as  a general  rule,  seems  to 
me  quite  unnecessary  (see  Fraser  on  the  Shoulder-joint 
Operation,  8vo.  Loud.  1813)  and  improper,  not  only 
as  producing  delay,  but  wounding  other  parts  which 
should  not  be  at  all  disturbed. — (See  Guthrie  on  Gun- 
shot Wounds,  p.  235, 2St5,  <fcc.)  The  practice  of  scraping 
aw'ay  the  cartilage  of  the  glenoid  cavity,  except  when 
it  IS  diseased,  is  not  of  greater  value. 

Amputation  at  the  shoulder  has  been  partly  super- 
seded by  a preferable  operation,  even  in  cases  in  which 
it  would  formerly  have  been  deemed  quite  indispensa- 
ble ; such  as  considerable  gun-shot  fractures  of  the  head 
of  the  humerus,  a caries  of  the  substance  of  this  part, 
&c.  Boucher,  in  1753,  jiroved  that  considerable  wounds 
extending  into  the  shoulder-joint  might  be  success- 
fully treated  by  extracting  the  fragments  and  splinters 
of  bone. — (Mem.  de  I’Acaii.  de  Chir.  t.  2,  p.  287  et  461.) 
Instances  are  also  recorded,  in  which,  w hen  the  head 
and  neck  of  the  humerus  in  children  liad  been  totally 
disunited  from  the  body  of  that  bone,  a cure  was  ac- 
complished by  making  such  incisions  as  allowed  the 
portions  of  bone,  now  become  extraneous  bodies,  to  be 
taken  away.  The  earliest  case  of  this  kind  on  record 
is  that  in  which  M.  Thomas,  a surgeon  at  Pezenas  in  . 


Languedoc,  removed  the  separated  head  of  the  humerus 
in  1740,  which  in  a child  four  years  of  age  presented 
itself  loose  in  an  incision  which  had  been  previously 
made  tor  the  extraction  of  some  sequestra.  The  par- 
ticulars may  be  read  in  Guthrie’s  valuable  work. — (On 
Gun-shot  Wounds,  p.  215,  «fec.)  Mr.White  of  Manches- 
ter proceeded  farther,  for  he  made  a deep  incision  at  the 
upper  part  of  the  arm,  dislocated  the  head  of  the  hume- 
rus, which  he  knew  was  carious,  and  pushing  it 
through  the  wound  took  it  off  with  a saw.  He  began 
an  incision  at  the  orifice  of  a sinus  situated  just  below 
the  processus  acromion,  and  extended  the  wound  down 
to  the  middle  of  the  humerus,  by  which  all  the  subja- 
cent bone  was  brought  into  view\  He  then  took  hold 
of  the  patient’s  elbow,  and  easily  forcing  the  upper  end 
of  the  humerus  out  of  its  socket,  he  brought  it  so  en- 
tirely out  of  the  wound  that  he  readily  grasped  it  in 
his  left  hand,  and  held  it  there  till  he  had  sawed  it  off 
with  a common  amputation  saw,  having  first  applied  a 
pasteboard  card  between  the  bone  and  the  skin.  The 
patient  did  not  lose  more  than  two  ounces  of  blood, 
only  a small  artery  which  partly  surrounded  the  joint 
being  wounded,  w hich  was  easily  secured. 

In  about  five  or  six  weeks,  the  part  from  which  the 
bone  had  been  taken  had  acquired  a considerable  de- 
gree of  firmness,  and  the  boy  was  able  to  lift  a pretty 
heavyweight.  At  the  end  of  twm  months,  a large  piece 
of  the  whole  substance  of  the  humerus  was  ready  to 
separate  from  the  sound  bone,  and  with  a pair  of  forceps 
it  was  easily  removed.  After  this  exfoliation  the  wound 
healed  very  fast,  and  in  four  months  after  the  opera- 
tion, the  boy  was  discharged  perfectly  cured.  On  com- 
jiaring  this  arm  with  the  other,  it  was  not  quite  an 
inch  shorter ; the  boy  had  the  perfect  use  of  it,  and 
could  not  only  elevate  his  arm  to  any  height,  but  per- 
form the  rotary  motion  as  well  as  ever.  TMb  figure  of 
the  arm  was  not  at  all  altered.  -Mr.White  did  not  make 
use  of  any  splints,  machine,  or  bandage,  during  the 
cure,  in  order  to  confine  the  limb  strictly  in  one  certain 
situation,  nor  w^as  the  patient’s  arm  ever  dressed  in 
bed,  but  w'hile  he  was  sitting  in  a chair,  and  as  soon 
as  he  could  bear  it  standing  up.  To  this  method,  Mr. 
White  attributed  the  preservation  of  the  motion  of  the 
joint. 

“ As  this  is  the  first  operation  of  the  kind  that  has 
been  performed,  or  at  least  made  public  (says  Mr. 
White),  I thought  the  relation  of  it  might  possibly  con- 
duce to  the  improvement  of  the  art.  That  ingenious 
surgeon  Mr.  Gooch,  has  indeed  related  three  instances 
of  the  heads  of  bones  being  sawed  off  in  compound 
luxations.  In  one  of  these  cases  the  lower  heads  of 
the  tibia  and  fibula  were  sawed  off ; in  another,  that  of 
the  radius ; and  in  the  third,  that  of  the  second  bone  of 
the  thumb ; but  these  were  in  many  respects  different 
from  the  present  case.  I believe  it  will  seldom  happen, 
that  this  operation  will  not  be  greatly  preferable  to  am- 
putation of  the  arm  at  the  scapula,  as  this  last  is  gene- 
rally performed  for  a caries  of  the  upper  head  of  the  os 
humeri,  and  as  the  preservation  of  a limb  is  always  of 
the  utmost  consequence,  and  what  every  surgeon  of 
the  least  humanity  would  at  all  times  wish  for,  but 
particularly  where,  as  in  this  case,  the  whole  limb  and 
its  actions  are  preserved  entire,  the  cure  no  ways  pro- 
tracted, and  the  danger  of  the  operation  mo.st  undoubt- 
edly less.  For  though  amputation  is  often  indispen- 
sably necessary,  and  frequently  attended  with  little 
danger  or  inconvenience  when  only  part  of  a limb  is 
removed,  yet  when  the  whole  is  lost,  the  danger  is 
greatly  increased,  and  the  loss  irreparable.”  Mr.  White 
concludes  with  suggesting  an  analogous  operation  for 
removing  the  head  of  the  femur,  in  lieu  of  amputation 
at  the  hip.  Something  of  this  kind  is  indeed  reported 
to  have  been  actually  done  on  a girl  with  success. — 
See  Joannis  Mulder  Oratio  de  Mentis  P.  Camperi,  &c. 
p.  81.  Cases  in  Surgery,  by  C.  White,  p.  57 ; or  Phil. 
Trans,  vol.  59,  for  1769.) 

Here,  however,  the  acetabulum  and  ossa  innominata 
being  always,  or  generally,  more  diseased  than  the 
head  of  the  femur,  neither  of  these  operations,  1 think, 
ought  to  be  attempted.  Long  after  the  publication  of 
\N  bite’s  case,  viz.  in  1767,  an  example,  in  w hich  Viga- 
roux  adopted  the  same  practice,  in  1788,  was  communi- 
cated to  the  profession  : the  result,  however,  was  un- 
fortunate, the  patient,  a lad  seventeen  years  of  age, 
having  died  soon  after  the  experiment. — (See  CEuvn-a 
de  Chir.  Prat,  par  I.  M.  I.  Vigaroux  (fils),  Montp. 

IHIO) 


AMPUTATION. 


83 


Mr.  Bent,  of  Newcastle,  inserted  a similar  case  to 
Mr.White’s  in  the  64th  vol.  of  the  Philosophical  Trans- 
actions. White  made  only  one  incision,  from  the  vi- 
cinity of  the  acromion  down  to  the  middle  of  the  arm. 
Bent,  not  being  able  to  get  at  the  head  of  the  bone 
through  the  wound  which  he  had  made,  from  the  clavi- 
cle to  the  attachment  of  the  pectoral  muscle,  detached 
a portion  of  the  deltoid  where  it  is  connected  with  the 
clavicle,  and  another  part  where  it  is  adherent  to  the 
humerus.  A third  successful  case  is  also  reported  in 
the  69th  vol.  of  the  same  work,  p.  6.  Afterward, 
Bromfield  published  some  directions  for  the  guidance 
of  the  surgeon  in  such  operations. — (Cliir.  Obs.  and 
Cases.)  Sabatier  proposed  making  two  cuts  at  the 
upper  part  of  the  arm,  which  meet  below  like  the  letter 
V,  extirpating  the  flap,  dividing  the  inner  head  of  the 
biceps  and  capsular  ligament ; dislocating  the  head  ofV 
the  bone,  and  sawing  it  off. — (Medecino  Op6ratoire, 
t.3.) 

I think  the  cases  recorded  by  White  and  Bent  are 
truly  important,  inasmuch  as  they  are  the  earliest 
models  of  a practice  which  may  sometimes  supersede 
all  occasion  for  one  of  the  most  formidable  and  muti- 
lating operations  of  surgery.  To  military  and  naval 
surgeons,  these  cases  cannot  fail  to  be  highly  interest- 
ing, as  they  must  have  frequent  opportunities  of  avail- 
ing themselves  of  the  instruction  which  they  afford. 
Larrey,  who  was  surgeon-general  to  the  French  army 
in  Egypt,  employed  the  practice  with  the  greatest  suc- 
cess, in  cases  of  gun-shot  wounds.  He  thereby  saved 
limbs,  which,  according  to  ordinary  precepts  and  opi- 
nions, would  have  been  a just  ground  for  amputating 
at  the  shoulder ; and  when  it  is  considered,  not  only 
that  a most  dangerous  operation  is  avoided,  but  that 
an  upper  extremity  is  saved,  for  which  no  substitute 
can  be  applied,  we  must  allow  that  the  plan,  first  sug- 
gested and  practised  by  Mr. White,  cannot  be  too  highly 
appreciated.  When  the  arm  was  fractured  near  its 
upper  extremity  by  a musket-ball,  most  surgeons  for- 
merly deemed  it  necessary  to  amputate  the  limb.  Here, 
says  Larrey,  it  would  be  useless  to  dilate  the  entrance 
and  exit  of  the  ball,  because  a sufficient  opening  could 
not  be  prudently  made  in  this  way  for  the  extraction 
of  the  head  of  the  bone.  Yet  this  body  is  now  an  ex-  ■ 
traneous  substance,  having  lost  its  connexion  with  the 
shaft  of  the  humerus,  and  its  presence  exciting  irrita- 
tion and  inflammation  of  the  joint,  abscesses,  necrosis, 
&c.  Here  Larrey  seems  to  imply,  that  the  detached 
head  of  the  bone  cannot  unite  again  ; an  as.sertion 
which,  I have  no  doubt,  is  quite  incorrect,  as  I have 
attended  several  cases  in  which  the  humerus  was 
broken  very  high  up,  yet  united  without  difficulty. 
The  bad  symptoms,  which  he  so  emphatically  attri- 
butes to  the  detachment  of  the  head  from  the  body  of 
the  bone,  are  in  reality  the  effects  of  the  gun-shot  Vio- 
lence itself.  If,  therefore,  the  head  of  the  bone  were 
merely  broken  off,  and  it  and  the  neighbouring  part  of 
the  bone  not  splintered,  nor  the  flesh  not  more  exten- 
sively injured  than  w'ould  arise  from  the  passage  of  a 
rnusket-ball,  and  the  joint  itself  not  involved,  I should 
question  the  propriety  of  having  recourse,  at  once, 
either  to  the  extraction  of  the  head  of  the  bone,  or  am- 
putation at  the  shoulder.  When  the  bone  is  shattered 
the  case  is  often  very  different,  and  Larrey’s  practice 
is  then  commendable.  In  confirmation  of  these  senti- 
ments, I may  mention  Mr.  Guthrie’s  opinion,  who,  in 
reference  to  the  extraction  of  the  head  of  the  bone, 
says,  he  does  not  consider  a perfect  fracture  of  the  hu- 
merus an  inch  below  its  head  (although  there  be  evi- 
dent separation)  as  demanding  even  this  operation,  as 
he  has  known  such  cases  do  well  when  treated  as 
other  compound  fractures,  except  that  the  motion  of 
the  joint  was  nearly  lost.— (On  Gim-shot  Wounds,  p. 
329.)  However,  it  is  fair  to  mention  that  Mr.  Guthrie 
inclines  to  amputation  at  the  shoulder  when  the  body 
of  the  bone  is  splintered  or  has  long  fissures  in  it,  hi 
which  sentiment  he  is  probably  right.  The  other  ope- 
ration seems  principally  calculated  for  cases  in  which 
the  damage  is  restricted  to  the  head  and  uppemiost 
portion  of  the  bone. 

According  to  Mr.  Guthrie,  when  the  ball  passes  out 
with  little  injury  to  the  bone,  and  the  openings  already 
made  are  not  sufficient  to  admit  of  a moderate  exami- 
nation with  the  point  of  the  finger,  the  wound  should 
be  enlarged.  How’ever,  others  might  argue,  that  .such 
dilatation  should  be  made  only  when  the  bone  is  felt  to 
be  seriously  broken,  and  the  fragments  will  probably 


require  immediate  removal.  But  whatever  course  be 
adopted,  the  most  rigorous  antiphlogistic  treatment  will 
be  ])roper  ; and  if -abscesses  form,  depending  openings 
should  be  made  for  the  discharge. 

Larrey  says,  “ I have  had  the  good  fortune  on  ten 
different  occasions  to  supersede  the  necessity  for  am- 
putation at  the  shoulder,  by  the  complete  and  imme- 
diate extraction  of  the  head  of  the  humerus  or  its  splin- 
ters without  delay.  I perform  the  o])eration  in  the 
following  manner;  I make  an  incision  in  the  centre  of 
the  deltoid  muscle,  and  parallel  to  its  fibres,  carrying 
the  incision  as  low  dowm  as  possible.  I get  the  edges 
of  the  wound  drawn  asunder,  in  order  to  lay  bare  the 
articulation,  of  which  the  capsule  is  generally  opened 
by  the  fu|||[  incision,  and  by  means  of  a probe-pointcd 
bistourj^Retach  with  the  greatest  ease  from  their  in- 
sertionsB*  tendons  of  the  supra  and  infra-spinati,  of 
the  teres*niinor,  of  the  subs(;apularis,  and  of  the  long 
head  of  the  biceps ; then  I disengage  the  head  of  the 
humerus,  and  remove  it  through  the  wound  in  the  del- 
toid by  means  of  my  fingers  or  of  an  elevator.  I bring 
the  humerus  up  to  the  shoulder,  and  fix  it  in  a proper 
position,  with  the  aid  of  a sling  and  a bandage.  Such 
is  the  operation  which  I performed  on  ten  patients  in 
extirpating  the  head  of  the  humerus ; one  of  these  died 
of  the  hospital  fever,  two  of  the  scurvy  at  Alexandria, 
and  the  fourth,  after  he  was  cured,  died  of  the  plague 
on  our  return  to  Syria.  The  rest  returned  to  France 
in  good  health.  In  some  the  arm  became  anchylosed 
to  the  shoulder,  and  in  others  an  artificial  joint,  allow- 
ing of  motion,  was  formed.” — (See  Mem.  de  Chir.  Mili- 
taire,  t.  2,  p.  175.)  Another  successful  case  of  the 
same  kind  was  published  by  Mr.  Morel. — (See  Medico- 
Chirurg.  Trans,  vol.  7,  p.  161.) 

Mr.  Guthrie  thinks  it  not  sufficient  to  make  a simple 
incision  through  the  deltoid  muscle  into  the  capsular 
ligament,  and  take  away  the  fragments  of  bone,  but 
urges  the  removal  at  the  same  time  of  a considerable 
part  of  the  capsular  ligament,  lest  disease  still  go  on  in 
the  joint.  Also,  as  it  is  impossible  to  know  beforehand 
in  what  state  the  bone  may  be  below  the  fracture  (that 
is,  with  respect  to  fissures  running  more  or  less  down 
it),  he  advises  the  incision  designed  for  the  extraction 
of  the  splintered  head  of  the  bone,  to  be  made  in  a situa- 
tion where,  if  amputation  at  the  joint  be  found  indis- 
pensable, it  will  be  of  advantage.  Mr.  Guthrie  like- 
wise describes  the  manner  of  turning  out  the  head  of 
the  bone  in  these  cases,  and  sawing  it  off;  the  neces- 
sity of  which,  however,  I do  not  clearly  comprehend, 
unless  the  taking  away  of  any  sharp  spicula  of  the 
upper  end  of  the  body  of  the  bone  be  implied,  which 
may  be  right.— (On  Gun-shot  Wounds,  p.  333—335  ) 
My  ideas,  however,  chiefly  extend  to  the  removal  of 
loose  fragments  and  splinters ; and  with  respect  to  saw- 
ing off  the  head  of  the  bone,  this  is  a proceeding,  I sup- 
pose, necessarily  limited  to  the  kind  of  cases  reported 
by  Mr.  White  and  Mr.  Syme. — (Edinb.  Med.  and  Surgical 
•Tourn.  No.  88,  p.  49.) 

In  Mr.  Syme’s  example  the  head  of  the  humerus  was 
diseased.  A peri)endicular  cut  was  made  from  the 
acromion  through  the  middle  of  the  deltoid,  extending 
nearly  to  its  insertion.  A similar  incision  was  then 
made  ui)wards  and  backwards  from  the  lower  end  of 
the  first  wound,  and  a large  flap  formed  from  the  back 
portion  of  the  deltoid,  “ which  being  held  up,  exposed 
the  joint  so  far,  that  (says  Mr.  Syme)  I w as  able  to  in- 
sulate the  head  of  the  bone  by  means  of  my  finger,  and 
then  to  detach  the  scapular  muscles  from  their  con- 
nexions with  the  tuberosities,  wdien,  the  arm  being 
brought  forw'ards,  I easily  protruded  the  head  of  the 
humerus,  embraced  it  in  my  left  hand,  and  sawed  it 
off  without  any  injury  to  the  other  i)arts.” — (Op.  cit. 
p.  51.)  A portion  of  the  acromion,  being  diseased,  was 
removed  with  the  cutting  plyers.  From  w hat  has  been 
stated,  it  maybe  inferred,  that  when  the  object  is.  merely 
to  extract  splinters,  a single  j)eri)endicular  incision  will 
suffice;  but  that  when  the  joint  is  diseased,  and  the 
head  of  the  bone  requires  to  be  sawed  off,  the  ojteration 
will  be  much  facilitated  by  follotving  the  j)lan  adopted 
by  Mr.  Syme.  In  this  gentleman’s  case  the  i)atient  re- 
covered, and  the  shoulder  had  motion  in  every  direction. 

Walther  first  demonstrated  on  tlie  dead  body  the 
practicableness  of  amputating  the  .scapula ; and  in  one 
case,  where  this  bone  was  inseparably  connected  with 
a tumour,  the  greater  part  of  it  was  successfully  re- 
moved by  Haymann. — (See  Walther  in  .lourn.  fiir  Ghir. 
b.  5,  p.  274  ; and  Haymann,  vol.  cit.  p.  569.)  The  j)ar- 


84 


AMPUTATION. 


ticulars  are  also  detailed  by  Chelius. — (Handb.  der 
Chir.  b.  2,  p.  759.) 

amputation  of  the  heads  of  bones. 

In  a letter  to  Mr.  Pott,  dated  1782,  Mr.  Park,  .surgeon 
to  the  Liverpool  Hospital,  made  the  proposal  of  totally 
extirpating  many  diseased  joints,  by  which  the  limbs 
might  be  preserved,  with  a share  of  motion  that  would 
still  allow  them  to  be  very  useful. 

Mr.  Park’s  scheme,  in  short,  was  to  remove  entirely 
the  extremities  of  all  the  bones,  which  form  the  dis- 
eased joint,  with  the  whole  or  as  mitch  as  possible  of 
the  capsular  ligament ; and  to  obtain  a cure  by  means 
of  callus,  or  by  uniting  the  femur  to  the  tibia,  when  the 
operation  was  done  on  the  knee ; and  the  humerus  to  the 
radius  and  ulna,  when  it  was  done  on  the  elbow ; so 
as  to  have  no  moveable  articulation  in  those  situations. 

In  order  to  learn  wnether  the  popliteal  vessels  could 
be  avoided  without  much  difficulty  in  the  excision  of 
the  knee,  Mr.  Park  made  an  experiment  on  the  dead 
subject.  An  incision  was  made,  beginning  about  two 
inches  above  the  upper  end  of  the  patella,  and  extend- 
ing about  as  far  below  its  lower  part.  Another  one 
was  made  across  this  at  right  angles,  immediately 
above  the  patella,  down  to  the  bone,  and  nearly  half 
round  the  limb,  the  leg  being  in  an  extended  state. 
The  lower  angles  formed  by  these  incisions  were 
raised  so  as  to  lay  bare  the  capsular  ligament ; the  pa- 
tella was  then  taken  out ; the  upper  angles  were  raised, 
so  as  fairly  to  denude  the  head  of  the  femur,  and  to 
allow  a small  catling  to  he  passed  across  the  posterior 
flat  part  of  the  bone,  immediately  above  the  condyles, 
care  being  taken  to  keep  one  of  the  flat  sides  of  the 
point  of  the  instrument  quite  close  to  the  bone  all  the 
way.  The  catling  being  withdratvn,  an  elastic  spatula 
was  introduced  in  its  place,  to  guard  the  soft  parts 
while  the  femur  w'as  sawed.  The  head  of  the  bone, 
thus  separated,  w^as  carefully  dissected  out ; the  head 
of  the  tibia  was  then  with  ease  turned  out  and  sawed 
off,  and  as  much  as  possible  of  the  capsular  ligament 
dissected  away,  leaving  only  the  posterior  part  cover- 
ing the  vessels,  which  on  examination  had  been  in  very 
little  danger  of  being  wounded. 

The  next  attempt  was  on  the  elbow ; a simple  lon- 
gitudinal incision  was  made  from  about  two  inches 
above  to  the  same  distance  below  the  point  of  the  ole- 
cranon. The  integuments  having  been  raised,  an  at- 
tempt was  made  to  divide  the  lateral  ligaments,  and 
dislocate  the  joint ; but  this  being  found  difficult,  the 
olecranon  was  sawed  off,  after  which  the  joint  could 
be  easily  dislocated  without  any  transverse  incision, 
the  lower  extremity  of  the  os  humeri  sawed  off,  and 
afterward  the  heads  of  the  radius  and  ulna.  This  ap- 
peared an  easy  work ; but  Mr.  Park  conceives  the  case 
will  be  difficult  in  a diseased  state  of  the  parts,  and 
that  a crucial  incision  would  be  requisite,  as  well  as 
dividing  the  humerus  above  the  condyles,  in  the  way 
done  with  respect  to  the  thigh-bone. 

Mr.  Park  first  operated,  July  2,  1781,  on  a strong, 
robust  sailor,  aged  33,  who  had  a diseased  knee,  of  ten 
years’  standing.  The  man’s  sufferings  were  daily  in- 
creasing, ajid  his  health  declining.  Mr.  Park  wished 
to  avoid  making  the  transverse  incision,  thinking  that, 
after  removing  the  patella,  he  could  efiect  Ids  object  by 
the  longitudinal  one  ; but  it  was  found  that  the  differ- 
ence between  a healthy  and  diseased  state  of  parts 
deceived  him  in  this  expectation.  Hence  the  idea  w'as 
relinquished,  and  the  transverse  incision  made.  The 
operation  was  finished  exactly  as  the  one  on  the  dead 
subject  related  above.  The  quantity  of  bone  removed 
was  very  little  more  than  two  inches  of  the  femur,  and 
rather  more  than  one  inch  of  the  tibia.  The  only  ar- 
tery divided  was  one  on  the  front  of  the  knee,  and  it 
ceased  to  bleed  before  the  operation  was  concluded, 
but  the  ends  of  the  bones  bled  very  freely.  In  order  to 
keep  the  redundant  integuments  from  falling  inw'ards, 
and  the  edges  of  the  wounds  in  tolerable  contact,  a few 
sutures  were  used.  The  dressings  were  light  and  su- 
perficial, and  the  limb  was  put  into  a tin  case,  suffi- 
ciently long  to  receive  the  whole  of  it,  from  the  ankle 
to  the  insertion  of  the  glutaeus  muscle. 

I shall  not  follow  Mr.  Park  throughout  the  treatment. 
Suffice  it  to  remark,  that  the  case  gave  him  a great 
deal  of  trouble,  and  that  it  was  attended  with  many 
embarrassing  circumstances,  arising  chiefly  from  the 
difficulty  of  keeping  the  limb  in  a fixe.fl  position,  (he 
great  depth  of  the  wound,  and  the  abscesses  and  si- 


nuses which  formed.  On  the  other  hand,  however, 
the  first  symptoms  were  not  at  all  dangerous.  But 
the  patient  was  obliged  to  keep  his  bed  nine  or  ten 
w^eeks,  and  it  was  many  months  more  before  the  cure 
was  complete.  The  man  afterward  went  to  sea,  and 
did  his  duty  very  well.  . 

Subsequently  to  the  publication  of  the  letter  to  Mr. 
Pott,  another  excision  of  the  knee  was  done  by  Mr. 
Park,  on  the  22d  of  June,  but  the  event  was  unsuc- 
cessfffi,  as  the  patient  lingered  till  the  13th  of  October, 
and  then  died. 

In  1782,  P.  F.  Moreau  presented  to  the  French  Aca- 
demy of  Surgery  a memoir  proposing  the  excision  of 
caridUs  joints.  It  only  seems  necessary  to  notice  here 
the  difference  in  Moreau’s  plan  of  operating  from  that 
adopted  by  our  countryman.  Moreau,  the  son,  who 
has  published  the  account,  observes,  that  the  multipli- 
city of  flaps  is  unnecessary,  as  two  answer  every  pur- 
pose ; and  he  deems  Mr.  Park’s  direction  to  remove  the 
olecranon,  if  this  be  free  from  caries,  at  least  useless. 
Moreau  junior  operated  on  the  elbow  as  follows  : with 
a dissecting  scalpel  he  cut  down  to  the  sharp  edge  or 
spine  of  the  inner  condyle  of  the  os  humeri,  about  two 
inches  above  its  tuberosity ; and,  directed  by  the  spine, 
he  carried  the  incision  down  to  the  joint.  He  did  the 
same  on  the  other  side,  and  then  connected  the  two 
wounds  by  a transverse  incision,  which  divided  the 
skin  and  the  tendon  of  the  triceps  immediately  above 
the  olecranon.  The  flap  was  dissected  from  the  bone, 
and  held  out  of  the  way  by  an  assistant. 

The  flesh  which  adhered  to  the  front  of  the  bone 
above  the  condyles  was  now  separated,  care  being 
taken  to  guide  the  point  of  the  instrument  with  the  fore- 
finger of  the  left  hand,  and  when  the  handle  of  the 
scalpel  could  be  passed  through  between  the  flesh  and 
the  bone,  M.  Moreau  allowed  it  to  remain  there,  and 
sawed  the  bone  through  upon  it.  The  removal  of  the 
piece  of  bone  was  next  finished,  by  detaching  it  from 
all  its  adhesions.  The  removal  of  the  heads  of  the 
radius  and  ulna  remaining  to  be  done,  was  more  diffi- 
cult, and  the  first  flap  being  insufficient,  it  became 
necessary  to  make  another.  The  lateral  incision,  at 
1 the  outer  side  of  the  arm,  was  extended  downwards, 
along  the  external  border  of  the  upper  part  of  the  ra- 
dius. The  head  of  the  radius  was  separated  from  the 
surrounding  parts  ; its  connexion  with  the  ulna  de- 
stroyed, and  a strap  of  linen  was  introduced  between 
the  bones,  in  order  to  keep  the  flesh  out  of  the  way  of 
the  saw.  The  radius  was  sawed  through,  near  the  in- 
sertion of  the  biceps,  which  was  fortunately  preserved. 
Some  remaining  medullary  cells,  filled  with  pus,  were 
removed  with  a gouge.  The  ulna  was  now  exposed, 
by  extending  the  lateral  incision  on  the  inner  side  of 
the  arm.  Thus  another  flap  was  made,  and  detached 
from  the  back  part  of  the  forearm,  and  that  fiortion  of 
the  bone  which  it  was  wished  to  remove.  The  bone 
being  separated  from  every  thing  that  adhered  to  it, 
and  a strap  of  linen  put  round  it  to  protect  the  flesh, 
about  an  inch  and  a half  of  it  was  sawed  otf,  measuring 
from  the  tip  of  the  olecranon  downwards.  A few  dis- 
eased medullary  cells  w’ere  taken  away  with  the 
gouge.  Two  or  three  vessels  were  tied,  and  the  flaps 
were  brought  together  with  sutures.  In  a fortnight 
this  man  became  so  well,  that  he  was  allowed  to  go 
wherever  he  pleased,  with  his  arm  supported  in  a case. 
The  arm  was  at  first  powerless,  but  it  slowly  regained 
its  strength,  and  the  man  could  ultimately  thrash  com 
and  hold  the  plough  with  it,  &c. 

Seven  months  after  another  operation,  performed  in 
the  same  way  as  the  preceding  one,  by  Moreau  the 
father,  the  patient  was  completely  cured,  and  two  years 
after  this  period  the  flexion  of  the  forearm  on  the  arm 
w'as  very  distinct.  In  another  case  only  one  longitudi- 
nal incision  and  a transverse  one  w'ere  made,  the  flap 
being  of  course  triangular.  The  patient  got  well  in  six 
weeks,  and  in  three  months  more  joined  his  regiment. 

In  all  Moreau’s  cases,  the  flexion  and  extension  of 
the  Ibreami  were  preserved,  which  circumstance  no 
doubt  depended  very  much  on  the  insertion  of  the  bi- 
ceps not  being  destroyed.  After  the  excision  of  the 
knee,  however,  the  bones  grew  together. 

Moreau  junior’s  method  of  operating  diflTered  from  his 
father’s,  inasmuch  as  the  patient  was  in  a recumbent 
instead  of  a sitting  posture,  and  the  os  humeri  sawed 
before  it  was  dislocated. 

In  a knee-case,  Moreau  the  father  operated  as 
follows:— He  made  a longitudinal  incision  on  each 


AMPUTATION. 


85 


side  of  the  thigh,  between  the  vasti  and  the  flexors  of 
the  leg,  down  to  the  bone.  These  incisions  began 
about  two  inches  above  the  condyles  of  the  femur,  and 
were  carried  down  along  the  sides  of  the  joint  till  they 
reached  the  tibia.  They  were  united  by  a transverse 
cut,  which  passed  below  the  patella,  down  to  the  bone. 

The  flap  was  raised ; but  the  patella  attached  to  it, 
being  diseased,  was  dissected  out.  The  limb  was  then 
bent,  so  as  to  bring  the  condyles  of  the  femur  into 
view.  As  it  was  desired  to  cut  them  from  the  body  of 
the  bone  before  dislocating  them,  every  thing  adhering 
to  them  behind,  where  they  joined  the  body  of  the  bone, 
was  separated,  and  at  that  place  the  fore-finger  of  the 
left  hand  was  passed  through,  in  order  to  press  back 
the  flesh  from  the  bone  while  the  saw  was  used.  The 
kjiee  having  been  bent,  Moreau  drew  the  cut  piece  to- 
wards him,  and  easily  detached  it  from  the  flesh  and 
ligaments. 

The  head  of  the  tibia  was  laid  bare  by  an  incision 
nearly  eighteen  lines  long,  made  on  the  spine  of  that 
bone.  The  first  lateral  incision  on  the  outer  side  of 
the  knee  was  extended  nearly  as  far  down  on  the  head 
of  the  fibula.  Thus  were  obtained  one  flap  which  ad- 
hered to  the  flesh  filling  up  the  interosseous  space,  and 
another  triangular  flap  formed  of  the  skin  covering 
the  inner  surface  of  the  tibia,  which  bone  was  of  ne- 
cessity exposed  before  the  saw  could  be  applied. 

Upon  raising  the  outer  flap,  the  head  of  the  fibula 
came  into  view,  and  after  being  separated  I'rom  its  at- 
tachments was  cut  off  with  a small  saw.  The  inner 
flap  was  then  rtiised,  and  the  head  of  the  tibia  hav- 
ing been  separated  from  the  muscles  behind,  was 
sawed  off.— (See  Moreau  (Ic  fils),  Obs.  pratiques  rela- 
tives d la  resection  des  articulations  affectbes  de  carie. 
Paris,  an  xi.)  Some  cases  and  remarks,  in  favour  of 
the  excision  of  diseased  joints,  have  been  published 
by  Mr.  Crampton. — (.Dublin  Hospital  Reports,  vol.  4, 
p.  185,  &c.)  He  has  removed  with  success  one  knee 
and  one  elbow.  Another  knee-operation  may  be  set 
down  as  a failure,  no  union  having  taken  place,  and  a 
sinus  and  discharge  having  continued  in  the  ham  until 
the  patient’s  death,  three  years  and  two  months  after 
the  operation.  Respecting  the  plan  of  operating  on  the 
knee  he  concludes  thus  : “lam  satisfied,  from  repeated 
trials  on  the  dead  subject,  that  the  operation  can  be 
most  safely  and  rapidly  executed  by  separating  the 
condyles  from  all  their  attachments  previously  to  sawing 
the  bone.  As  soon,  therefore,  as  the  flap  containing 
the  patella  is  turned  upwards,  the  edge  of  the  knife 
should  be  carried  round  the  condyles  close  to  the  bone, 
so  as  to  divide  all  the  ligaments  W'hich  connect  the 
femur  with  the  tibia.  The  tibia  can  then  with  great 
ease  be  pushed  backwards,  and  as  much  of  the  pro- 
jecting condyles  can  be  removed  as  the  operator  may 
think  necessarj.” — i.Vol.  cir.  p.  213.) 

It  does  not  appear  necessary  to  insert  in  this  work 
the  account  of  cutting  out  the  ankle-joint,  an  operation 
which  will  never  be  extensively  adopted ; nor  shall  I 
add  any  thing  more  concerning  the  mode  of  removing, 
in  a similar  way,  the  shoulder-joint.  In  treating  of 
amputation  in  this  situation  I have  already  said  enough, 
and  whoever  wishes  for  farther  information  respecting 
this  practice,  must  refer  to  Dr.  .leffray’s  work,  entitled 
“ Cases  of  Excision  of  Carious  .Joints.”  (Glasgow,  1806.) 
This  publication  contains  all  that  was  then  known  on 
the  subject.  Dr.  Jeffray  has  recommended  a particu- 
lar, and  indeed  a very  ingenious,  saw,  for  facilitating 
the  above  operation.  The  saw  alluded  to  is  construct- 
ed with  joints,  like  the  chain  of  a watch,  so  as  to  allow 
itself  to  be  drawn  through  behind  a bone,  by  means  of 
a crooked  needle,  like  a thread,  and  to  cut  the  bone 
from  behind  forwards  without  injuring  the  soft  parts. 
An  instrument  of  this  kind  was  executed  in  London  by 
Mr.  Richards,  who  was  assisted  in  making  it  by  his 
nephew,  the  i)resent  Mr.  Richards,  of  Brick-lane.  In 
placing  the  saw  under  a bone,  its  cutting  edge  is  to  be 
turned  away  from  the  lle.sh.  Handles  are  afterward 
hooked  on  the  instrument. 

According  to  my  notions  of  the  treatment  of  diseased 
joints,  as  long  as  the  patient’s  strength  is  not  subdued 
by  the  irritation  of  the  local  disease,  humanity  dictates 
the  propriety  of  persevering  in  an  attempt  to  save  the 
affected  limb,  <fec.  Will  a patient,  greatly  reduced  by 
hectic  symptoms,  be  able  to  recover  from  so  bold  and 
bloody  an  operation  as  the  dissection  of  the  whole  of 
the  knee-joint  out  of  the  limb  ? If  some  few  should 
escape  with  life  and  limb  pre.served,  would  the  bulk  of 


persons  treated  in  this  manner  have  the  same  good 
fortune  ? I cannot  admit  that  the  extirpation  of  the 
whole  of  so  large"  an  articulation  as  the  knee  can  be 
compared  with  the  operation  of  amputation,  in  point  of 
simplicity  and  safety.  However,  it  is  not  on  the  diffi- 
culty of  practising  the  former,  that  I would  found  my 
objections  ; for  I believe  that  any  man  possessing  a 
tolerable  knowledge  of  the  anatomy  of  the  leg,  might 
contrive  to  achieve  the  business.  The  grounds  on 
which  I withhold  my  approbation  from  the  attempt  to 
cut  out  large  joints  are  the  following: — 1.  The  great 
length  of  time  which  the  healing  of  the  wound  re- 
quires. Whoever  peruses  the  case  of  Hector  M‘C’aghan, 
will  find  that  the  operation  was  performed  on  the  2d 
of  July,  1781,  and  that  it  was  February  2bth  of  tiie  fol- 
lowing year  before  all  the  subsequent  abscesses  and 
sores  were  perfectly  healed.  This  space  of  time  is 
very  nearly  eight  months  ! Mr.  Park  describes  the 
patient  as  a strong,  robust  sailor,  and  gives  no  farther 
particulars  concerning  the  state  of  his  constitution 
than  that  his  health  was  declining.  I entertain  little 
doubt,  that  if  the  excision  of  the  knee  had  been  per- 
formed in  that  state  of  the  health  in  which  amputation 
becomes  truly  indispensable,  this  man  would  not  have 
survived  the  illness  arising  from  the  operation.  The 
only  other  case  in  which  Mr.  Park  extirpated  the  knee 
ended  fatally.  In  the  instance  related  by  Moreau  there 
seemed,  indeed,  to  be  considerable  debility.  This  pa- 
tient escaped  the  first  dangers  consequent  to  so  severe 
an  operation ; and  after  three  months’  confinement, 
the  patient  w^as  in  such  a state  that  Moreau  expected 
he  would  be  able  to  walk  upon  crutches  in  another 
month  or  six  weeks  ! The  young  man,  in  the  mean 
time,  was  attacked  by  an  epidemic  dysentery  and  died. 
On  the  21st  of  October,  1809,  Mulder  extirpated  the 
knee-joint  of  a pregnant  woman  in  the  hospital  at  Gro- 
ningen ; but  she  died  of  tetanus  on  tluc  8th  of  the  fol- 
lowing February.  He  conceives  that  the  operation  is 
much  facilitated  by  removing  the  ends  of  the  femur 
and  tibia  in  their  connected  state. — (See  Diss.  de  Arti- 
culis  extiiq^andis  auctore  G.  H.  Wachter,  1810.)  2. 
Even  supposing  the  excision  of  the  knee  to  be  followed 
by  all  possible  succe.ss,  is  the  advantage  of  having  a 
mntilated,  shortened,  stiff  limb,  in  lieu  of  a wooden  leg, 
sufficiently  great  to  induce  any  man  to  submit  to  an 
operation,  beyond  a doubt  infinitely  more  dangerous 
than  amputation  ? I think  not.  The  practice  is  at  pre- 
-sent  nearly  exploded  in  this  country ; but  I hear  every 
now  and  then  of  its  being  adopted  at  Paris,  and  Mr, 
Crampton  has  thought  it  w'orthy  of  revival.  The  diffi- 
culties of  his  operations,  however,  and  tediousness  of 
the  after-treatment,  and  in  particular  the  general 
course  and  termination  of  one  of  his  two  knee-cases, 
as  represented  by  himself,  are  sufficiently  discouraging. 
No  doubt,  more  limbs  might  be  saved  by  this  practice 
than  by  that  of  amputation,  but  more  lives  would  be 
lost.  On  this  principle  I see  no  reason  for  preferring 
excision  to  amputation.  Many  interesting  obsen'^atious 
on  the  extirpation  of  various  diseased  joints  may  be 
found  in  the  above-mentioned  dissertation  by  Wachter, 
and  in  the  analysis  of  it  by  Langenbeck. — (Bibl.  fiir  die 
Chir.  b.  3,  Gottingen,  1811.) 

In  quitting  this  part  of  the  subject,  I may  just  notice 
the  interesting  case  recorded  by  Mr.  Dunn  of  Scarbo- 
rough, who  cut  out  several  of  the  tarsal  bones,  in- 
cluding the  diseased  surface  of  the  astragalus,  and  also 
some  of  the  metatarsal  bones  from  a boy’s  foot,  with 
complete  final  success.  The  hemorrhage,  however, 
was  profuse,  and  great  difficulty  experienced  in  stop- 
ping it.  Whether  this  bold  experiment  merits  imita- 
tion, I am  not  prepared  to  say  ; but,  be  this  as  it  may, 
the  fact  merits  attention. — (See  Med.  Chir.  Trans,  vol. 
11,  p.  337.)  Consult  also  White’s  Cases  in  Surgery; 
Sabatier,  Seances  publiques  de  I’Acad.  de  Chir.  Paris, 
1779,  p.  73  ; et  M^-m.  de  I’lnstitut  National,  vol.  5, 1805; 
Roux,  de  la  Resection,  &c.  de  portions  d’os  malades, 
&c.  Paris,  1812;  Ph.  Crampton,  in  Dublin  Hospital 
Reports,  vol.  4,  1827. 

AMPUTATION  OF  THE  FINGERS  AND  TOES,  AND  PART 
OF  THE  FOOT. 

The  best  surgeons  all  agree  with  Mr.  Sharp,  that  the 
amputation  of  the  fingers  and  toes  is  most  convenient- 
ly jierformed  in  their  articulations.  With  a common 
scalpel,  the  skin  is  to  be  cut  through  circularly,  not 
exactly  upon  the  joint,  but  a little  towards  the  extre- 
mity of  the  finger,  in  order  that  a suflicient  flap  may 


86 


AMPUTATION. 


be  preserved  for  covering  the  end  of  the  hone.  On 
taking  away  a finger  from  a metacarpal  bone,  Mr. 
Sharp  recommends  making  two  small  longitudinal  inci- 
sions on  each  side  of  the  joint,  as  a means  of  facilitating 
the  separation. 

In  amputating  the  fingers  and  toes,  the  operation  is 
greatly  facilitated  by  cutting  into  the  Joint  when  it  is 
bent.  Having  made  an  opening  in  the  back  part  of  the 
capsule,  one  of  the  lateral  ligaments  may  easily  be  cut, 
after  which  nothing  keeps  the  head  of  the  bone  from 
being  turned  out,  and  the  surgeon  has  only  to  cut 
through  the  rest  of  the  exposed  ligamentous  and  tendi- 
nous parts. 

Some  recommend  making  a small  semicircular  flap 
of  skin  to  cover  the  bone ; but  this  is  quite  unneces- 
sary if  care  be  taken  to  draw  the  skin  a little  up,  and 
to  cut  where  Mr.  Sharp  directs.  However,  as  making 
a small  flap  gives  little  pain,  I have  generally  followed 
this  method,  though  it  appears  to  me  nearly  a matter 
of  indifference  which  plan  is  adopted.  In  operating  at 
the  joints  between  the  phalanges  and  metacarpal  bones, 
a flap  should  alwaj-s  be  made,  either  on  the  upper  or 
under  part  of  the  fingers  to  be  removed. 

Although  it  is  generally  best  to  remove  the  fingers 
at  the  joints,  it  is  sometimes  thought  right,  where  the 
injury  just  includes  the  joint  and  no  more,  to  saw 
through  the  bone,  instead  of  operating  at  the  next  ar- 
ticulation.—(See  Guthrie  on  Gun-shot  Wounds,  p.  384.) 
The  division  can  also  be  readily  made  wuth  cutting 
plyers. 

It  may  happen,  that  the  bones  of  the  toes  and  only 
part  of  the  metatarsal  bones  are  carious,  in  which 
case  the  leg  need  not  be  cut  off,  but  only  so  much  of 
the  foot  as  is  disordered.  A small  spring  saw  is  here 
the  most  convenient.  When  this  operation  is  per- 
formed, the  heel  and  the  remainder  of  the  foot  wall  be 
of  great  service,  and  the  wound  heal  up  safely,  of 
which  Mr.  S.  Sharp  says,  he  had  in  his  time  seen  one 
example. — (Op.  of  Surgery,  chap.  37,  ed.  3.)  Mr. 
Hey  confirms  this  statement  of  Sharp’s  concerning  the 
impropriety  of  removing  the  whole  foot,  when  the  me- 
tatarsal bones  are  carious,  and  every  other  part  of  the 
leg  irs  sound,  as  the  remainder  of  the  foot  is  of  im- 
mense service  in  w alking,  the  use  of  the  ankle  not 
being  destroyed. 

Mr.  Hey  describes  a new  mode  of  removing  the  me- 
tatarsal bones,  wdiich  on  repeated  trial  has  fully  an- 
swered his  expectations.  By  the  term  new,  I here 
mean  a particular  method,  w'hich  had  not  been  pre- 
viously described,  though  it  may  have  been  performed 
by  others  sooner  than  by  IMr.  Hey  himself ; for  the 
merit  of  having  first  done  it  is  imputed  to  the  late  Mr. 
Turner,  of  North  Yarmouth,  who  did  it  with  success 
about  the  year  1787.— (See  Hutchison’s  Pract.  Obs.  p. 
70.)  Mr.  Hey  makes  a mark  across  the  upper  part  of 
the  foot,  to  denote  w^here  the  metatarsal  bones  are 
joined  to  those  of  the  tarsus.  About  half  an  inch 
from  this  mark,  nearer  the  toes,  he  makes  a trans- 
verse incision  through  the  integuments  and  muscles 
covering  the  metatarsal  bones.  From  each  extremity 
of  this  cut,  he  makes  an  incision  along  the  inner  and 
outer  side  of  the  foot  to  the  toes ; he  removes  all  the 
toes  from  the  metatarsal  bones,  and  then  separates  the 
integuments  and  muscles,  forming  the  sole  of  the  foot, 
from  the  inferior  part  of  the  metatarsal  bones,  keeping 
the  edge  of  the  knife  as  near  the  bones  as  possible,  in 
order  to  expedite  the  operation,  and  preserve  as  much 
muscular  flesh  in  the  flap  as  can  be  saved.  He  then 
separates  the  four  smaller  metatarsal  bones  at  their 
junction  with  the  tarsus,  and  divides,  with  a saw,  the 
projecting  part  of  the  first  cuneiform  bone,  which  sup- 
ports the  great  toe.  The  arteries  being  tied,  Mr.  Hey 
applies  the  flap,  which  had  formed  the  sole  of  the  foot, 
to  the  integuments  which  remain  at  the  upper  part,  and 
keeps  them  in  contact  with  sutures.  The  cicatrix  be- 
ing situated  at  the  top  of  the  foot,  is  in  no  danger  of 
being  hurt,  while  the  place  where  the  toes  were  situ- 
ated is  covered  with  such  strong  skin,  viz.  what  pre- 
viously formed  the  sole  of  the  toot,  that  it  cannot  be 
injured  by  any  moderate  violence. — (See  Practical  Ob- 
servations in  Surgery,  p.  535,  &c.) 

When  the  metatarsal  bone  of  the  great  toe  is  alone 
diseased,  Mr.  Hey  recommends  dissecting  it  out  from 
the  cuneiform  bone,  instead  of  sawing  it.  The  latter 
plan  cannot  be  easily  accomplished,  without  removing 
i>.art  of  the  integuments  and  muscles,  and  making  a 
transverse  as  Well  as  a longitudinal  incision.  These 


disagreeable  things  may  be  avoided  by  following  the 
method  of  Mr.  Hey,  or  that  of  Mr.  C.  Bell.  For  re- 
moving the  metatarsal  bone,  either  of  the  little  or  great 
toe,  the  latter  gentleman  directs  us  to  carry  a scalpel 
round  the  root  of  the  toe,  and  then  along  the  side  of 
the  foot.  The  flaps  are  then  to  be  dissected  back,  the 
metatarsal  bone  is  to  be  separated  from  the  next,  and 
its  square  head  is  to  be  detached  from  the  tarsus. — 
(Operative  Surgery,  vol.  1,  p.  390.) 

The  removal  of  the  central  metatarsal  and  metacar- 
pal bones  is  an  operation  of  much  difficulty,  and  the 
sawing  of  them  is  hardly  practicable,  without  injuring 
the  soft  parts.  Hence,  I am  decidedly  of  opinion  with 
Mr.  C.  Bell,  that  instead  of  a formal  amputation,  it  is 
better  to  extract  the  diseased  bones  from  the  foot  or 
hand,  as,  indeed,  Mr.  Hey  was  in  the  habit  of  doing. 

That  skilful  surgeon,  Langenbeck,  however,  has  de- 
vised a ready  mode  of  taking  away  the  middle  finger 
with  its  metacarpal  bone  from  the  os  magnum,  or  the 
ring-finger,  with  its  metacarpal  bone,  from  the  articu- 
lation of  the  latter  with  the  os  magnum  and  os  cunei- 
forme.  In  order  to  find  out  these  articulations,  he 
draws  a line  from  the  upper  head  of  the  metacarpal 
bone  of  the  thumb  straight  across  to  the  metacarpal 
bone  of  the  finger  to  be  extirpated,  and  at  this  place 
he  begins  his  first  incision,  which  runs  towards  each 
side  of  the  finger  like  an  inverted  V.  The  bone  is  then 
separated  all  round  from  the  soft  parts,  an'd  dislocated 
from  the  carpus,  when  nothing  remains  to  be  done  but 
to  cut  the  parts  towards  the  palm,  where  the  wound  is 
also  made  to  resemble  an  inverted  V,  but  does  not  ex- 
tend any  farther  than  is  necessary,  to  complete  the  se- 
paration.— See  Langenbeck’s  Bibl.  b.  1,  p.  575,  and 
plate  3,  f.  1.'  , This  is  unquestionably  a simple  and 
excellent  method  of  operating,  which  Langenbeck  also 
recommends  as  the  best  way  of  removing  such  bones 
of  the  metatarsus,  as  are  not  situated  at  the  sides  of 
the  foot ; care  being  taken  to  save  a flap  from  the  sole. 
It  is  often  difficult,  however,  to  know  with  certainty 
whether  the  disease  is  confined  to  the  metacarpal  or 
metatarsal  bones ; and  if  it  be  not,  and  the  carpus  or 
tarsus  be  affected,  the  operation  wall  not  answer,  and 
amputation  be  indispensable.  This  happened  in  one 
of  Langenbeck’s  cases,  in  which  he  had  removed  one 
of  the  metacarpal  bones. 

IModern  surgeons  never  amputate  the  whole  of  the 
foot  or  hand,  when  there  is  a reasonable  chance  of 
preserving  any  useful  portion  of  it,  though  the  rest 
may  be  most  severely  shattered.  Thus,  when  a sol- 
dier had  been  struck  by  a grape-shot,  which  shattered 
the  metacarpal  bones  of  the  little  and  ring-fingers, 
grazed  the  middle  finger,  and  tore  up  the  integuments 
on  the  palm  and  back  of  the  hand,  Mr.  Guthrie  suc- 
ceeded in  saving  the  two  fingers  and  thumb,  although, 
in  the  removal  of  the  other  parts,  no  regular  flaps 
could  be  made  for  covering  the  wound.— (On  Gun-shot 
Wounds,  p.  382.)  In  winter  campaigns,  the  toes,  and 
more  or  less  of  the  foot,  are  often  attacked  with  morti- 
fication from  cold.  In  this  circumstance,  when  the 
disorder  does  not  extend  beyond  the  middle  of  the  foot 
or  the  toes,  it  is  only  necessary  to  cut  away  the  gan- 
grenous part.  On  the  first  entrance  of  the  French 
army  into  Holland,  after  the  revolution,  Paroisse  met 
with  many  of  these  cases,  in  which  it  was  necessary* 
merely  to  take  away  ‘the  metatarsal  bones,  or  some- 
times those  of  the  tarsus.  All  the  patients  operated 
upon  in  this  maimer  for  the  effects  of  cold  were 
cured  ; walking  allerwartl  with  more  or  less  diffi- 
culty, according  as  the  portion  of  the  foot  taken  away 
had  been  greater  or  smaller. — (Opuscules  de  Chir.  p. 
218.) 

M.  Roux,  in  his  late  publication,  finds  fault  with  our 
ignorance  of  Chopart’s  method  of  removing  a part  of 
the  foot.  He  says,  “ I am  certain,  the  principal  sur- 
geons in  England  have  never  practised,  and  are  even 
totally  unacquainted  with,  the  amputation  of  the  foot 
at  the  junction  of  the  two  halves  of  the  tarsus,  or 
Chopart's  operation.” — (Voyage  fait  d Londresen  1814, 
ou  Paralltlle  de  la  Chirurgie  Angloise  avec  la  Chirur- 
gie  Franqoise,  p.  338.)  As  it  is  an  operation  of  consi- 
derable merit.  I think  it  will  be  useful  to  introduce  a 
description  of  it  in  the  present  work.  It  is  performed 
in  the  nearly  parallel  articulations  of  the  as  calcis  with 
the  os  cuboides,  and  of  the  a.stragalus  with  the  os  na- 
viculare.  Thus  the  heel  is  jireserved,  on  which  the 
patient  can  afterward  walk.  The  perl'orn  i a of  i.* 
i.s  simple.  The  tourniquet  having  been  ap^Ji.cd,  the 


AMrUTATlON. 


87 


surgeon  is  to  make  a transverse  incision  through  the 
skin  'W'hich  covers  the  instep,  two  inches  from  the 
ankle-joint.  He  is  to  divide  the  skin,  and  the  extensor 
tendons  and  muscles  in  that  situation,  so  as  to  expose 
the  convexity  of  the  tarsus.  He  is  next  to  make  on 
each  side  a small  longitudinal  incision,  which  is  to  be- 
gin below  and  a little  in  front  of  the  malleolus,  and  is 
to  end  at  one  of  the  extremities  of  the  first  incision. 
After  having  formed  in  this  way  a flap  of  integuments,  he 
is  to  let  it  be  drawn  upwards  by  the  assistant  who  holds 
the  leg.  There  is  no  occasion  to  dissect  and  reflect 
the  flap ; for  the  cellular  substance  connecting  the 
skin  with  the  subjacent  aponeurosis  is  so  loose,  that  it 
can  easily  be  drawn  up  above  the  place  where  the 
joint  of  the  calcaneum  with  the  cuboides,  and  that  be- 
tween the  astragalus  and  scaphoides,  ought  to  be 
opened.  The  surgeon  will  penetrate  the  last  the  most 
easily,  particularly  by  taking  for  his  guidance  the  emi- 
nence which  indicates  the  attachment  of  the  tibialis 
anticus  muscle  to  the  inside  of  the  os  naviculare. 
The  joint  of  the  os  cuboides  and  os  calcis  lies  pretty 
nearly  in  the  same  transverse  line,  but  rather  obliquely 
forwards.  The  ligaments  having  been  cut,  the  foot 
falls  back.  The  bistoury  is  then  to  be  put  down,  and 
the  straight  knife  used,  with  which  a flap  of  the  soft 
parts  is  to  be  formed  under  the  tarsus  and  metatarsus, 
long  enough  to  admit  of  being  applied  to  the  naked 
bones  so  as  entirely  to  cover  them.  It  is  to  be  main- 
tained in  this  position  with  three  or  four  strips  of  ad- 
hesive plaster,  which  are  to  extend  from  the  heel,  over 
the  flap,  to  the  inferior  and  anterior  part  of  the  leg. 

Chopart  used  to  tie  every  artery  as  soon  as  it  was 
diinded.  On  the  instep,  the  continuation  of  the  ante- 
rior tibial  artery  will  require  a,  ligature ; and  in  the 
sole,  the  internal  and  external  plantar  arteries,  in  the 
thickness  of  the  flap  of  soft  parts,  must  generally  be 
taken  up.  One-half  of  each  ligature  is  to  be  cut  away, 
and  the  other  one  is  to  be  left  hanging  out  between  the 
plasters,  at  the  nearest  and  most  convenient  jxiint. 

Walthei  and  Graefe  have  given  some  very  precise 
directions  for  the  performance  of  this  operation.  A 
cut  is  first  made,  beginning  half  an  inch  below  the 
outer  ankle,  and  extending  forwards  along  the  side  of 
the  foot  two  inches.  Another  similar  incision  is  then 
made  from  one  inch  below  the  inner  ankle.  The  foot  is 
now  to  be  bent  upwards,  and  the  first  two  cuts  united 
by  a transverse  incision,  two  finger-breadths  from  the 
front  of  the  tibia.  A flap  is  then  dissected  up,  as  far 
back  as  the  commencement  of  the  lateral  incisions,  or 
a line  corresponding  to  the  articulation  of  the  astraga- 
lus with  the  os  naviculare,  and  of  the  os  calcis  with 
the  os  cuboides.  An  assistant  now  checks  the  bleed- 
ing by  applying  the  points  of  his  fingers  on  the  mouths 
of  such  vessels  as  bleed  profusely,  and  holds  up  the 
flap.  The  extremity  of  the  foot  is  now  to  be  firmly  in- 
clined downwards,  so  as  to  stretch  the  ligaments  con- 
necting the  tarsal  bones  together.  The  ligaments  be- 
tween the  astragalus  and  os  naviculare  are  to  be  first  cut, 
when  the  foot  may  be  twisted  somewhat  outwards, 
and  the  ligaments  between  the  os  calcis  and  os  cu- 
boides divided.  The  division  is  lastly  completed  by 
cutting  through  the  soft  parts  regularly  from  above 
downwards,  with  the  precaution  of  directing  the  am- 
putating knife  so  as  to  leave  a flap  composed  of  jiart 
of  the  sole  of  the  foot. — See  Abhandl.  aus  dcm  Ge- 
biete  der  Prakt.  Med.  &c.  Landshut,  1810,  b.  1,  p.  152 ; 
aan  Graefe,  Normen  furdieAbl.  grcissr.  Gliedm.  p.  142.) 

Sometimes,  in  consequence  of  the  soft  parts  of  the 
instep  being  all  gangrenous  or  otherwise  destroyed,  it 
is  necessary  to  make  the  flap  entirely  from  the  sole  of 
the  foot,  a.s  Klein  was  obliged  to  do  in  one  of  his 
cases.— (Practische  Ansichten  bedeutendsten  Chir.  Ope- 
rationen,  h.  1,  p.  28.  t Indeed,  Richerand  thinks  this 
mode  generally  advantageous,  as  the  line  of  the  cica- 
trix is  not  placed  at  the  lower  end  of  the  stump, 
where  it  would  be  most  exposed  to  injury. — (Nosogr. 
Chir.  t.  2,  p.  502,  &c.  ed.  4.)  Langenbeck  and  Klein 
also  condemn  the  painful  and  unnecessary  measure  of 
dissecting  up  a flap  from  the  instep,  as  advised  by 
Walther  and  Graefe.  Chopart  himself,  as  we  have 
seen,  merely  drew  back  the  integuments  of  the  instep, 
without  making  any  detachment  of  them  from  the  sub- 
jacent parts.  When  the  ends  of  the  flexor  tendons  of 
the  toes  jiroject  too  much  from  the  inner  surface  of  the 
lower  flap,  they  are  to  be  cut  shorter,  as  Klein  particu- 
larly directs ; and  1 consider  his  advice,  not  to  use 
sutures  for  keeping  the  flap  applied,  but  merely  strips 


of  sticking-plaster,  perfectly  judicious.— (Op.  cit.  n 
33—34.) 

[For  amputation  of  the  lower  jaw  see  note  on  “ Jaw- 
Bone.”  For  amputation  or  excision  of  the  upper  jaw 
as  first  performed  in  this  country  by  Dr.  David  L.  Ro- 
gers, of  this  city,  see  note  on  “ Osteosarcoma or  for 
the  details  of  the  case,  reference  may  be  had  to  the 
N.  Y.  Med.  and  Phys.  Journal  for  1824,  vol.  3,  p.  301. 
For  amputation  or  exsection  of  the  clavicle,  an  opera- 
tion performed  for  the  first  time  by  Dr.  Mott,  in  1829, 
see  also  note  on  “ Osteosarcoma.” — Heesc.] 

The  following  sources  of  instruction,  on  the  subject 
of  amputation,  are  particularly  entitled  to  notice : L'el- 
sus  de  Re  MedicA.  tEnvres  de  Par^,  livre  12,  chap.  30 
et  33.  James  Yonge.,  Ctirrus  Triumphalis  e Terebin- 
tho,  8vo.  Lund.  1679.  R.  Wiseman.,  Chir.  Treatises^ 
4to.  Lund.  1692.  Sharp's  Operations  of  Surgery, 
chap.  37,  ayid  Critical  Inquiry  into  the  present  state  of 
Surgery,  chap.  8.  Ravaton,  Traite  des  Plaies  d'Jtr- 
mes  d Feu,  Paris,  1768.  Bertraudi,  Traite  des  Ope- 
rations de  Chirurgie,  chap.  23.  Le  Dran's  Obs. 
de  Chir.  Paris,  1731,  and  his  Traite  des  Opera- 
tions de  Chirurgie,  Paris,  1742,  and  the  English 
Translation  loith  the  additions  of  Cheselden,  by  Gata- 
ker.  Land.  1749  ; Heister's  Instit,  Chirurg.  pars  2, 
sect.  1.  JSTouvclle  MeUiode  pour  faire  V Operation  de 
I' Amputation  dans  V Articulation  du  Bras  avec  V Omo- 
plate,  par  M.  de  La  Faye.  P.  H.  Dahl,  Dis.  de  Hu- 
meri Amputatione  ex  Articulo.  Gott.  1760.  His- 
toire  de  V Amputation,  suivaiit  la  Meihode  de  Verduin 
et  Sabourin,  avec  ta  Description  d'un  nouvel  instru- 
ment pour  cette  Operation,  par  M.  De  la  P'aye.  P. 
H.  F.  Verduin,  Dis.  Epistolaris  de  JVova  Artuum  dc- 
curtandorum  Ratione,  l2mo.  Amst.  1696.  Moyens  de 
reudre  plus  simple  et  plus  sure  V Amputation  d Lam- 
beau,  par  M.  de  Garengeot.  Observation  sur  la  Re- 
section de  I' Os,  npres  V Amputation  de  la  Cinsse,  par 
M.  Veyret.  Me  moire  sur  la  Saillie  de  I' Os  apris 
L' Amputation  des  Membres ; ou  ion  examine  les 
causes  de  cct  inconvenient,  les  moyens  d'y  remedier,  et 
ceux  de  la  prevenir,  par  M.  IjOuis.  Seconde  Metnoire 
sur  i Amputation  des  Grandes  Extremites,  par  M. 
Louis.  The  foregoing  Essays  are  in  Mem.  de  I’Acad. 
de  Chirurgie,  t.  5,  edit.  12//io.  R.  de  Vermale,  Obs.  et 
Remarques  de  Chirurgie  pratique,  Manheim,  1767. 
Essai  sur  les  Amputations  dans  les  Articles,  par  M. 
Brasdor,  in  t.  15  Mem.  de  VAcad.  de  Chir.  J.  U.  Bil- 
guer  de  Membrorum  Amputatione  rarissime  adminis- 
tranda  aut  quasi  abroganda,  4fo.  Halce  Magd.  1761. 
White's  Cases  in  Surgery,  1770.  Brumfield's  Chirur- 
gical  Observations  and  Cases,  vol.  I,  chap.  2,  8vo. 
1773.  O' Halloran's  complete  Treatise  on  Gangrene, 
S,'c.,  with  a new  Method  of  Amputation,  8vo.  Dublin, 
1765.  Alanson's  Practical  Observations  on  Amputa- 
tion, ed.  2,  1782.  ./.  L.  Petit,  Traite  des  Maladies 
Chir.  t.  3,  Paris,  1774,  or  the  later  ed.  1790.  R.  My- 
nor's  Practical  Thoughts  on  Amputation,  Birmingh. 
1783.  T.  Kirkland,  Thoughts  on  Amputation,  S-c. 
8vo.  J.,ond.  1780.  I^oder,  Comment,  de  Mova  Alan- 
soiii,  Ampututiunis  Methodo,  Progr.  1,7,  Jen.  1784,  or 
Chir.  Med.  Beobachtungen,  8vo.  Weimar,  1794.  ./. 
F.  Tschrpius,  Casus  de  Amputatione  Femoris  non 
Cruenta,  Halw,  1742.  (^Haller,  Disp.  Chir.  5,  239.) 
Mtirsinna,  Mtue  Med.  Chir.  Beobacht.  Berlin,  1796; 
P.  F’.  Walther,  Abhandl.  aus  deni  Gebiete  der  Prakt. 
Medicin,  besonders  der  Chirurgie  and  Augenheil- 
kunde,  b.  1,  Landshut,  1810;  Kern.  Ueber  die  Hund- 
lungsweise  bey  der  Absetzung  der  Glieder.  Wien, 
1814 ; G.  Kloss,  De  Amputatione  Humeri  ex  Articulo, 
4to.  F'rancof.  1811;  W.  Fraser,  An  Essay  on  the 
Shoulder-joint  Operation,  8vo.  Lond.  1813.  H.  Robbi, 
De  Via  ac  Ratione,  qua  olim  membrorum  Amputatio 
instituta  est,  ito.  Lips.  1815.  J.  P.  Roux,  M^moire  et 
Obs.  sur  la  Riunion  Immediate  de  la  Plaie  apris 
V Amputation,  8vo.  Paris,  1814.  .7.  G.  Havse,  Ampu- 

tationis  Ossium  prweipua  queedam  momenta,  fJps. 
1801.  .7.  F.  D.  Evans,  Practical  Observations  on  Ca- 

taract and  closed  Pupil,  and  on  the  Amputation  of  the 
Arm  at  the  Shoulder,  frc.  8vo.  Lond.  1815.  H.  J. 
Brun nin ghausen,  Flrfahru ngen  und  B emerkn ngen  iiber 
die  Amputatiunen,  8vo.  Bamb.  1818.  J Aingenbeck,  Bibl. 
fiir  die  C.hirurgie,  b.  1,  p.  562,  (S'C.  8vo.  Gott.  1816. 
P.  G.  Van  Hoorn,  De  Us,  quee  in  partibus  Mernbri, 
prwsertim  osseis,  amputatione  vulneratis  notanda 
sunt.  Ato.  IjUgd.  1803.  Graefe,  Monnen  fiir  die  Ab~ 
losung  grbsserer  Gliedm..  Alo.  Berlin,  1813.  Klein, 
P r act ische  Ansichten  bedeutendsten  Chir.  Op.h.l,  4to. 


88 


ANA 


ANC 


Stuttg.  1816.  C.  Hutchison,  Practical  Observa- 
tions in  Surgery,  Svo.  Land.  1816.  And  farther  Obs. 
on  the  proper  Period  for  amputating  in  Gun-shot 
fVounds,  (S-c.  8«o.  Land.  1819.  Dr.  Hennen,  Princi- 
ples of  Military  Surgery,  2d  ed.  Suo.  Lond.  1820 ; a 
work  full  of  valuable  practical  information.  Pott's 
Remarks  on  Amputation.  Sabatier,  Medecine  Opera- 
toire,  t.  3,  cd.  2.  Hey's  Practical  Observations  in 
Surgery,  edit.  2.  Remarques  et  Observations  sur 
V Amputation  des  Membres,  in  CEuvres  Chir.  de  De- 
sault par  Bichat,  t.  2.  P.  J.  Roux,  De  la  resection,  ou 
du  retranchement  de  Portions  d'  Os  malades,  soit  dans 
les  Articulations,  soit  hors  des  Articulations,  Ato. 
Paris,  1812.  Rees's  Cyclopmdia,  art.  Amputation. 
Vermischte  Chirurgische  Schriften,  von  J.  1j.  Schmuc- 
ker,  band  1.  J.  Bell's  Principles  of  Surgery.  Cases 
of  the  Excision  of  carious  .Joints,  by  Park  and  Mo- 
reau, published  by  Dr.  Jeffray.  Operative  Surgery 
by  C.  Bell,  vol.  1.  Richter's  Anfangsgriinde  der 
Wundarzneykunst,  band  7.  Richerand,  JVosographie 
Chir.  t.  4,  edit.  4.  B.  Bell's  Surgery,  vol.  5.  Pelletan, 
Clinique  Chirurgicale,  t.  3.  Gooch's  Chirurgical 
Works, — various  parts  of  the  3 volumes.  Jjarrey, 
Relation  Chirurgicale  de  I'Armie  d'  Orient  en  Egypte 
et  Syrie  ; also  Mem.  de  Chirurgie  Militairc ; books 
which  should  be  in  the  library  of  every  surgeon.  Guth- 
rie on  Gun-shot  Wounds,  8vo.  I^ond.  1815 ; of  which 
a new  edition  has  since  appeared  : a publication  which 
cannot  be  too  attentively  studied  by  every  surgeon  who 
wishes  to  know  when,  as  well  as  how,  to  amputate  in 
cases  of  gun-shot  injury.  Roux,  Parallile  de  la  Chi- 
rurgie Angloise  avec  la  Chirurgie  Francoise,  p.  336, 
<S-c.  Paris,  1815.  Lawrence  on  a JVew  Method  of  ty- 
ing Arteries,  i^-c.  Medico-Chir.  Trans,  vol.  d,p.  156, 
<S-fi.  Report  of  Obs.  made  in  the  Military  Hospitals 
of  Belgium,  by  Professor  Thomson,  1817.  Diction- 
naire  des  Sciences  Medicales,  art.  Amputation.  C. 
Averill,  Operative  Surgery,  Lond.  1823.  Syme  and 
Liston,  in  Rdinb.  Med.  and  Surgical  Journ.  JVo.  78. 
Maingalt,  Mid.  Operaloire,  fol.  Paris,  1822,  contains 
excellent  lithographic  plates,  illustrative  of  amputa- 
tion. M.  J.  Chelius,  Handb.  der  Chirurgie.  b.  2, 
1827.  H.  Scoutteten,  IjU  Methode  Ovalaire,  ou  JSTou- 
velle  Methode  pour  amputer  dans  les  Articulations, 
Ato.  Paris,  1827. 

AMYLUM.  Starch.  Powdered  starch  is  sometimes 
used  as  an  external  application  to  erysipelas;  but 
chiefly  in  clysters  when  the  neck  of  the  bladder  is  af- 
fected with  spasm.  The  following  is  the  formula  used 
at  St.  Bartholomew’s  Hospital.  Ijl.  Mucilaginis  amyli, 
aquae  distillatae  ; sing.  1 ij.  Tinct.  opii  guttas  quadra- 
gin  ta:  Misce. 

ANASTOMOSIS.  (From  ava,  through,  and  aropa, 
a mouth.)  Anatomists  and  surgeons  imply  by  this 
term  the  communications  of  the  blood-vessels  with 
each  other,  or  their  running  and  opening  into  each  other, 
by  which  the  continuance  of  a free  circulation  of  the 
blood  is  greatly  ensured,  and  the  danger  of  mortifica- 
tion lessened.  The  immense  importance  of  this  part 
of  our  structure  in  all  cases  in  which  the  main  artery 
or  veins  of  a limb  are  obliterated,  is  particularly  conspi- 
cuous in  the  disease  called  aneurism. — (.See  Aneurism.) 

Nay,  such  has  been  the  providence  of  nature  in  this 
respect,  that  even  whore  the  thoracic  aorta  has  been 
completely  obstructed,  the  channels  for  the  conveyance 
of  the  blood  to  the  lower  extremities  have  yet  been 
found  adequate  to  that  purpose.  This  was  proved  in 
an  example  where  the  obstruction  had  been  gradually 
produced  by  disease,  and  the  anastomosing  vessels  of 
course  had  had  time  for  enlargement;  for  tliis  is  a 
very  different  case  from  that  in  which  a ligature  is 
suddenly  applied  to  the  aorta ; though,  as  far  as  can 
be  deduced  from  the  particulars  of  some  experiments 
made  on  dogs  by  Sir  Astley  Cooper,  and  of  one  opera- 
tion in  which  he  tied  the  human  abdominal  aorta  (Sur- 
gical Essays,  part  1,  p.  101),  blood  will  still  pass  to  the 
lower  extremities  in  sufficient  quantity  for  their  nutri- 
tion. At  least  this  inference  is  safely  deducible  from 
the  very  memorable  operation  to  which  I have  referred, 
subject  to  one  important  condition,  viz.  that  there  be  no 
additional  cause  of  impediment  to  the  passage  of  blood 
to  the  lower  extremities  be.sides  the  ligature  above  the 
bifurcation  of  the  aorta.  When  Sir  A.  Cooper  tied  the 
human  aorta  in  the  abdomen,  the  experiment  was  made 
as  the  only  possible  means  of  hindering  a man  from 
bleeding  to  death,  who  had  a large  aneurism  of  the  ex- 
ternal iliac  artery  actually  beginning  to  bleed,  and  ex- 


tending too  high  to  admit  of  any  thing  else  being  done. 
Now,  although  the  unfortunate  patient  was  not  saved, 
and  it  must  be  acknowledged  that  the  chances  of  any 
other  result  were  very  small,  the  case  furnished  the  im- 
portant proof,  that  if  the  abdominal  aorta  be  suddenly 
and  completely  obstructed,  the  blood  may  yet  pass  in 
adequate  quantity  to  the  lower  extremities,  provided 
there  exist  no  other  cause  of  impediment  to  the  passage 
of  the  blood  into  those  members  ; for  on  the  side  occu- 
pied by  the  aneurism  the  circulation  in  the  limb  was 
stopped,  while  in  the  opposite  limb  the  circulation  and 
natural  warmth  were  preserved.  To  this  subject  I shall 
hereafter  return.— (See  Aorta.) 

The  changes  which  take  place  in  the  arterial  system 
of  the  limb,  when  the  main  artery  is  rendered  im.per- 
vious  by  the  application  of  a ligature,  are  well  described 
by  Mr.  Hodgson : “ The  blood,  meeting  with  an  ob- 
stacle to  its  progress  through  the  accustomed  channel, 
is  thrown  in  greater  quantity  and  with  greater  force 
into  those  branches  which  arise  above  the  seat  of  the 
obstruction.  The  ramifications  of  these  branches,  in 
consequence  of  the  unusual  influx  of  blood,  undergo  a 
remarkable  dilatation  ; the  more  minute  vessels  also, 
by  which  they  anastomose  with  corresponding  ramifi- 
cations, arising  from  branches  given  off  below  the  ob- 
struction, are  from  the  same  cause  sufficiently  enlarged 
to  allow  a free  passage  of  the  blood  into  the  inferior 
trunks  of  the  limb.  At  first,  the  circulation  is  in  this 
manner  carried  on  through  a congeries  of  minute  anas- 
tomosing arteries ; In  a short  time  a few  of  these 
channels  become  more  enlarged  than  the  rest : as  these 
increase  in  size,  the  smaller  vessels  gradually  collapse, 
and  ultimately  a few  large  communications  constitute 
permanent  channels  through  which  the  blood  is  trans- 
mitted to  the  parts  that  it  is  destined  to  supply.  This 
is  one  mode  by  which  a collateral  circulation  is  esta- 
blished. 

“ But  in  some  situations  more  direct  and  ostensible 
inosculations  are  provided ; so  that  when  one  channel 
is  obstructed,  the  blood  passes  at  once  through  the  other 
in  a sufficient  stream  for  the  nourishment  of  the  part 
which  it  is  destined  to  supply.  Under  these  circum- 
stances no  dilatation  of  the  collateral  branches  is  ne- 
cessary : the  circulation,  in  such  instances,  may  be 
said  to  be  constantly  carried  on  through  inosculating 
trunks.  These  great  communications  principally  exist 
in  the  extremities  of  the  body  where  the  dilating  im- 
pulse which  the  blood  receives  from  the  heart  is  of 
course  diminished.  Thus  the  radical  artery  inosculates 
freely  with  the  ulnar  ; the  anterior  with  the  posterior 
tibial ; and  the  internal  carotid  with  the  vertebral  arte- 
ries. Two  modes  therefore  exist  by  w'hich  arteries 
communicate  with  each  other — the  anastomoses  of 
minute  ramifications  and  the  direct  inosculations  of 
trunks.” — (See  Hodgson  on  the  Diseases  of  Arteries 
and  Veins,  p.  234.)  Refer  also  to  Inosculation.  The 
best  general  account  of  the  inosculations  in  relation 
to  aneurism  is  contained  in  Scarpa’s  Treatise  on  Aneu 
rism ; more  especially  the  Italian  edition,  which  is  em- 
bellished with  beautiful  engravings. 

ANCHYLOPS.  (From  ayx'>  and  un/'>  eye.) 
Same  as  iEgylops. 

ANCHYLOSIS.  (From  ayvvXos,  crooked.)  This 
denotes  an  intimate  union  of  two  bones  w'hich  were 
naturally  connected  by  a moveable  kind  of  joint  All 
joints  originally  designed  for  motion  may  become  an- 
chylosed,  that  is,  the  heads  of  the  bones  forming  them 
may  become  so  consolidated  together  that  no  degree 
of  motion  whatever  can  take  place.  Bernard  Conner 
(De  stupendo  ossium  coalitu)  describes  an  instance  of 
a general  anchylosis  of  all  the  bones  of  the  human 
body.  A still  more  curious  fact  is  mentioned  in  the 
Hist,  of  the  Acad,  of  Sciences,  1716,  of  a child  23  months 
old  affected  with  universal  anchylosis.  In  the  ad- 
vanced periods  of  life  anchylosis  more  readily  occurs 
than  in  the  earlier  parts  of  it.  The  author  of  the  ar- 
ticle Anchylosis  in  the  Encycloptdie  Methodique,  men- 
tions a preparation  in  which  the  femur  is  so  anchylosed 
with  the  tibia  and  patella,  that  both  the  compact  and 
spongy  substances  of  these  bones  appear  to  be  common 
to  them  all  without  the  least  perceptible  line  of  sepa- 
ration between  them.  In  old  subjects  the  same  kind 
of  union  is  common  between  the  vertebraj  and  between 
these  and  the  heads  of  the  ribs. 

Anchylosis  is  divided  into  the  true  and  false.  In  the 
true,  the  bones  grow  together  so  completely  that  not  the 
smallest  degree  of  motion  can  take  place,  and  the  caso 


ANCHYLOSIS. 


89 


Is  positively  incurable.  The  position  in  which  the 
joint  becomes  thus  unalterably  fixed  makes  a material 
difference  in  the  inconvenience  resulting  from  the  oc- 
currence. In  false  anchylosis  the  bones  have  not  com- 
pletely grown  together,  and  their  motion  is  only  dimi- 
nished, not  destroyed.  True  anchylosis  is  sometimes 
termed  complete  ; false,  incomplete. 

In  young  subjects  in  particular,  anchylosis  is  seldom 
an  original  affection,  but  generally  the  consequence  of 
some  other  disease.  It  very  often  occurs  after  frac- 
tures in  the  vicinity  of  joints ; after  sprains  and  dislo- 
cations attended  with  a great  deal  of  contusion ; and 
after  white  swellings  and  abscesses  in  joints.  Aneu- 
risms, and  swellings,  and  abscesses  on  the  outside  of  a 
joint  may  aJ  so  induce  anchylosis.  In  short,  every  thing 
that  keeps  a joint  for  a long  timem  otionless  may  give 
rise  to  the  affection,  which  is  generally  the  more  com- 
plete the  longer  the  cause  has  operated. 

When  a bone  is  fractured  near  a joint,  the  limb  is 
kept  motionless  by  the  apparatus  during  the  whole  time 
requisite  for  uniting  the  bones.  The  subsequent  in- 
flammation also  extends  to  the  articulation,  and  attacks 
the  ligaments  and  surrounding  parts.  Sometimes  these 
only  become  more  thickened  and  rigid  : on  other  occa- 
sions, the  inflammation  produces  a mutual  adhesion  of 
the  articular  surlaces.  Hence  fractures  so  situated 
are  more  serious  than  when  they  occur  at  the  middle 
part  of  a bone.  After  the  cure  of  fractures,  a certain 
degree  of  stiffness  generally  remains  in  the  adjacent 
joints,  but  this  is  different  from  true  anchylosis;  it 
merely  arises  from  the  inactivity  in  which  the  muscles 
have  been  kept,  and  their  consequent  loss  of  tone. 

The  position  of  an  anchylosed  limb  is  a thing  of 
great  importance.  When  abscesses  form  near  the 
joints  of  the  fingers,  and  the  tendons  mortify,  the 
fingers  should  be  bent,  that  they  may  anchylose  in  that 
position,  which  renders  the  hand  much  more  useful 
than  if  the  fingers  were  permanently  extended.  On 
the  contrary,  when  there  is  danger  of  anchylosis,  the 
knee  should  always  be  kept  as  straight  as  possible. 
The  same  plan  is  to  be  pursued,  when  the  head  of  the 
thigh-bone  is  dislocated  in  consequence  of  a diseased 
hip.  When  the  elbow  cannot  be  prevented  from  be- 
coming anchylosed,  the  joint  should  always  be  kept 
bent.  No  attempt  should  ever  be  made  to  cure,  though 
every  possible  exertion  should  often  be  made  to  prevent 
a true  anchylosis.  The  attempt  to  prevent,  however, 
is  not  always  proper,  for  many  diseases  of  joints  may 
be  said  to  terminate  when  anchylosis  occurs. 

When  the  false  or  incomplete  anchylosis  is  appre- 
hended, measures  should  be  taken  to  avert  it.  The  limb 
is  to  be  moved  as  much  as  the  state  of  the  soft  parts  will 
allow.  Boyer  remarks,  that  this  precaution  is  much 
more  necessary  in  affections  of  the  ginglymoid  than  of 
the  orbicular  joints,  on  account  of  the  tendency  of  the 
former  to  become  anchylosed,  by  leason  of  the  great 
extent  of  their  surfaces,  the  number  of  their  ligaments, 
and  the  naturally  limited  degree  of  their  motion. 

The  exercise  of  the  joint  promotes  the  secretion  of 
the  synovia,  and  the  grating  first  perceived  in  conse- 
quence of  the  deficiency  of  this  fluid  soon  ceases.  A cer- 
tain caution  is  necessary  in  moving  the  limb  : too  violent 
motion  might  create  pain,  swelling,  and  inflammation, 
and  even  caries  of  the  heads  of  the  bones.  It  is  by  pro- 
portioning it  to  the  state  of  the  limb,  and  increasing  its 
extent  daily,  as  the  soft  parts  yield  and  grow  supple, 
that  good  effects  may  be  derived  from  it. — (See  Boyer, 
Mai.  des  Os,  t.  2.)  The  use  of  embrocations  and  pump- 
ing cold  water  on  the  joint  every  morning  have  great 
I)Ower  in  removing  the  stiffness  of  a limb  remaining 
after  the  cure  of  fractures,  dislocations,  <fec. 

Unreduced  dislocations  are  not  always  followed  by 
anchylosis.  Nature  often  forms  a new  joint,  especially 
in  persons  of  the  lower  order,  who  are  obliged  to  move 
their  limbs  a great  deal,  in  order  to  obtain  a livelihood. 
The  surrounding  cellular  substance  becomes  condensed, 
so  as  to  form  around  the  head  of  the  luxated  bone  a 
membrane  serving  the  purpose  of  a capsular  ligament. 
The  muscles,  at  first  impeded  in  their  action,  become 
so  habituated  to  their  new  state,  that  they  resume  their 
functions.  This  is  particularly  the  case  with  bones 
which  move  in  every  direction,  and  have  round  heads  ; 
but  in  ginglymoid  joints,  the  heads  of  the  bones  are 
only  imperfectly  dislocated,  and  the  motion  is  greatly 
restrained  by  the  extent  of  surface ; while  some  of  the 
numerous  ligaments  are  only  sprained,  not  ruptured. 
These  causes  promote  the  occurrence  of  anchylosis. 


Anchylosis  may  follow  sprains  and  contusions  of  the 
joints,  and  such  shocks  as  the  articular  surfaces  expe- 
rience in  leaping  og  falling  on  the  feet  from  great 
heights.  This  is  more  likely  to  happen  when  the  in- 
flammatory symptoms,  resulting  tfom  such  violence, 
have  not  been  properly  counteracted  by  bleeding  and 
other  general  remedies,  while  the  plan  of  beginning  to 
move  the  joint  gently  every  day,  as  soon  as  the  case 
will  allow,  has  been  entirely  neglected. 

When  certain  diseases  of  joints  end  in  complete  an- 
chylosis, it  is  sometimes  a desirable  event.  In  tact,  it  is 
as  much  a means  of  cure,  as  the  formation  of  callus  is 
for  the  union  of  broken  bones.  The  disease  of  the  ver- 
tebrae, described  by  Pott,  is  cured  as  soon  as  the  bones 
anchylose,  nor  can  the  patient  be  considered  well  be- 
fore this  event  has  taken  place. — fV.  H.  MUUer,  de 
Anchylosis  L,ugd.  1707,  U Encyclodedie  Methodiquti 
partie  Chir.  t.  I,  art.  Anchylose.  J.  A.  Petit.,  Ti  aite 
des  Mai.  d'  Os,  t.  2.  J.  T.  van  de  fVynpersse,  dt  An- 
chyloseos  Patkologia  et  Curatione  ; singularibus  el  Jig. 
illustr.  4to.  L,ugd.  1783.  Oentlevian' s Magazine, 
nS7,  universal  anchylosis,  ligaments  ossified.  fVurz, 
fVundarzn.  p.  224,  following  the  removal  of  the  patella. 
Sandifort,  Exercit.  Acad.  p.  1,  <S-c.,  anchylosis  of  the 
occiput  with  the  atlas,  and  of  the  atlas  with  the  denta- 
tus ; Sandifort,  Obs.  Pathol,  anchylosis  of  the  jaw. 
Dumas,  Recueil  Periodique  de  la  Societe  de  Med.  t.  10, 
p.  30,  and  1. 13,  p.  352.  Hennen's  Pnnciples  of  Mili- 
tary Surgery,  p.  161,  Src.  ed.  2.  The  examples  of  gene- 
ral anchylosis  are  numerous:  Ploucquetrefersto  Co- 
lumbus de  Re  Anatomied  ; Connor  de  stupendo  Ossium 
coalitu,  Oxon.  1695 ; Deslandes  in  Mem.  de  VAcad. 
des  Sciences,  1716 ; Frank,  Reise  vach  Paris,  London, 
Src.,  p.  127,  anchylosis  of  all  the  joints  except  those  of 
the  loioer  jaw  ; Olivier,  in  Journ.  de  Mid.  t.  12, /7.273; 
Voigt  Mug.fiir  den  JVeuesten  Zustund  der  JV* aturkunde, 
b 4,p.  412 ; Portal,  Cows  d'Anat.  Med.  t.  ],p.  14  ; Phil. 
Trans.  JSTo.  461  ; J.  C.  Smith,  J^at.  Hist.  Hibernim 
Comit.  1744.  Job  a Meckren's  Obs.  c.  64,  p.  297 
Callisvn's  Systema  Chir.  tJodiernce,  t.  2,  p.  edit. 
1800.  Boyer,  Mai.  des  Os,  t.  2,  et  Traite  des  Mala- 
dies Chir.  t.  4,  p.  553.  Verduc,  Traite  des  Bandages, 
chap.  35,  p.  172.  Richerand,  JVosogr.  Chir.  t.  3,p.  223, 
edit.  4.  Murray,  Diss.  de  Anchylosi,  Upsal.  1797. 

[A  highly  interesting  operation  has  been  performed 
by  Professor  Mott  for  the  cure  of  permanent  anchylosis, 
or  rather  “ immobility  of  the  lower  jaw,”  which  had 
existed  for  ten  years.  A report  of  this  case  is  pub- 
lished in  the  American  Journal  for  Nov.  1829 ; but  as 
the  disease  and  operation  are  of  so  novel  and  interesting 
a character.  Dr.  Mott,  at  my  request,  has  politely  fur- 
nished me  with  the  following  description  of  the  case, 
which  cannot  be  unacceptable  to  the  profession,  and  I 
therefore  insert  it  here. 

“ A young  man,  twenty-one  years  of  age,  from  North 
Carolina,  called,  with  the  lower  Jaw  almost  imnioveably 
fixed  to  the  upper.  No  motion  in  a downward  direction 
could  be  discovered,  nor  was  the  most  powerful  effort 
with  the  hand  upon  the  chin  able  in  the  slightest  de- 
gree to  alter  its  situation.  He  liad  been  in  this  deplora- 
ble state  for  ten  years.  Unable  to  chew  a mouthful 
of  food,  or  even  open  the  jaws  for  its  reception,  hia 
food  had  to  be  introduced  through  a small  opening,  oc- 
casioned by  an  irregularity  of  the  bicuspides  teeth  on 
the  right  side.  On  the  left  side,  just  within  the  angle 
of  the  mouth,  a very  firm  band,  of  more  than  ligament- 
ous hardness  was  to  be  seen  and  felt,  reaching  from 
this  point  along  the  alveolar  ridge  to  the  coronoid  process. 

Along  the  whole  course  of  this  adhesion  to  the  gum 
of  the  lower  jaw,  there  was  not  a vestige  of  a tooth, 
and  he  stated  that  from  this  part  the  jaw  had  been 
formerly  separated,  with  the  teeth  attached  to  it.  This 
morbid  adhe.sion  had  been  several  times  freely  divided; 
it  was  cut  from  within  the  mouth  in  different  direc- 
tions, but  never  permitted  the  least  motion  of  the  jaw. 

From  the  circumstance  that  he  could  give  a little 
lateral  motion  to  the  jaw,  I thought  that  his  mouth 
might  yet  be  opened,  and  the  deformity  removed.  I 
then  made  an  incision  from  the  angle  of  the  mouth 
on  the  left  side  through  the  cheek,  nearly  to  the  coro- 
noid process,  dividing  the  firm  cicatrix  within  com- 
pletely. The  jaws  being  relieved  by  dividing  all  the 
adhesions  between  them,  a piece  of  very  broad  tape 
was  placed  between  the  teeth  by  a probe  and  spatula, 
and  tied  some  distance  below  the  chin.  To  the  loop 
thus  formed  1 applied  all  the  strength  I could  command, 
but  not  the  least  yielding  of  the  jaw  could  be  discovered. 


90 


ANE 


ANE 


I then  applied  the  principle  of  the  screw  and  lever, 
by  an  instrument  prepared  for  the  purpose,  composed 
of  two  steel  plates  about  three  inches  in  length.  When 
applied  to  each  other,  they  were  of  a wedge-shape.  To 
the  large  end  was  attached  a screw,  which,  when  turned, 
caused  the  thin  extremity  of  the  plates  to  expand.  This 
instrument  enabled  me  to  open  the  mouth  completely. 

With  considerable  difficulty  this  vice  was  insinuated 
between  the  range  of  teeth  on  the  left  side,  resting 
along  their  whole  course.  It  was  then  expanded,  by 
turning  the  screw,  and  such  was  the  report  that  at- 
tended the  yielding  of  the  lower  jaw,  that  several  pre- 
sent thought  it  was  broken,  but  the  noise  was  like  that 
attending  the  laceration  of  ligaments  rather  than  such 
as  attends  the  fracture  of  a bone.  The  mouth  was  im- 
mediately opened  to  a sufficient  extent. 

The  wound  was  closed  with  the  interrupted  suture 
and  adhesive  plaster;  to  prevent  the  adhesion  of  the 
cheek  to  the  jaws  internally,  pieces  of  sponge  were  in- 
terposed. The  patient  was  enabled  to  chew  his  food, 
and.  to  converse  and  articulate  distinctly  as  the  result 
of  the  operation,  and  he  entirely  recovered.” 

Dr.  >Iott  has  since  repeated  the  operation  with  the 
same  success  on  a gentleman  from  Louisiana. 

In  the  North  Amer.  Med.  and  Surg.  .Journal  for  April, 
1828,  Dr.  J.  Rhea  Barton  has  published  a most  success- 
ful operation  performed  on  a case  of  anchylosis  at  the 
hip-joint,  attended  with  very  great  deformity,  after  it 
had  existed  for  more  than  eighteen  months.  The  object 
of  the  operation  was  to  substitute  an  artificial  joint  for 
the  loss  of  the  natural  articulation  at  the  hip,  and  it  is 
most  honourable  to  Dr.  Barton,  and  alike  gratifving  to 
the  profession  and  to  humanity,  to  record,  that  it  has 
been  most  completely  successful . An  abrid  ged  account 
of  this  novel  and  most  interesting  exhibition  of  consum- 
mate surgical  skill  is  given  in  the  Appendix  to  the  late 
Philadelphia  edition  of  Cooper’s  “ First  Lines,”  of  1828. 
It  was  performed  on  a sailor  at  the  Pennsylvania  Hos- 
pital in  Nov.  1826. 

In  Dr.  Francis’s  edition  of  Denman’s  Midwifery  is 
described  a peculiar  affection  of  the  hip-joint,  in  some 
respects  novel  and  important.  It  is  in  effect  an  anchy- 
losis, and  is  denominated  “ a displacement  of  bone 
without  fracture  or  dislocation,”  inducing  a morbid 
change  in  the  form  and  cavity  of  the  pelvis,  such  as 
might  wholly  defeat  the  process  of  natural  labour. 
The  patient,  an  adult  subject,  fell  on  the  right  hip ; the 
injury  done  to  the  external  parts  was  comparatively 
slight ; but  an  inflammatory  action  took  place  in  the 
bottom  ofthe  acetabulum,  which  caused  total  absorption 
of  the  bone,  and  the  protrusion  of  the  head  of  the  thigh- 
bone Itself  into  the  cavity  of  the  pelvis.  Nor  was  the 
diseased  action  limited  to  these  changes ; large  deposites 
of  osseous  matter  were  made  within  the  pelvis  sur- 
rounding the  absorbed  acetabulum ; and  the  head  of  the 
thigh-bone  was  by  the  same  material  augmented  to 
more  than  double  its  original  size.  The  neck  of  the 
bone  and  also  both  trochanters  were  considerably  in- 
creased in  bulk.  The  capacity  of  the  pelvis  was  dimi- 
nished about  two  inches  in  its  superior  and  lateral 
portion. — Reese.] 

ANEURISM,  or  ANEURYSM.  (From  avcvpvvo),  to 
dilate.)  The  tumours  which  are  formed  by  a preterna- 
tural dilatation  of  a part  of  an  artery,  as  well  as  those 
swellings  which  are  occasioned  by  a collection  of  arte- 
rial blood,  effused  in  the  cellular  membrane,  in  conse- 
quence of  a rupture  or  wound  of  the  coats  of  the  artery, 
receive  the  name  of  aneurisms.  According  to  these 
opinions,  aneurisms  are  of  two  kinds ; the  first  being 
termed  true ; the  second  spurious  or  false.  Some  mo- 
dern writers  have  ventured  to  reckon  another  form 
of  aneurism,  which  is  said  to  happen  when  the  exter- 
nal coats  of  an  artery  being  weakened  by  mechanical 
injury  or  disease,  the  internal  coat  protrudes  through 
the  breach  in  the  outer  coat,  so  as  to  form  a tumour 
distended  with  blood.  This  case  has  been  denominated 
the  internal  mixed  aneurism,  or  aneurisma  herniarn 
arteriae  sistens.  The  reality  of  this  form  of  disease 
was  believed  by  Dr.  W.  Hunter ; and  some  delicate 
experiments,  instituted  by  Haller  on  the  mesenteric  ar- 
teries of  frogs,  appear  to  have  been  the  first  ground  of 
the  opinion.  Such  an  aneurism,  however,  has  not  been 
universally  admitted,  not  that  any  body  doubted  the 
correctness  of  what  Haller  advanced,  but  because  there  I 
might  not  always  be  a perfect  analogy  between  the  I 
results  of  an  experiment  on  animals,  and  those  afforded 
by  the  observation  of  the  diseases  of  the  human  body,  j 


Wlien  Haller  asserted,  that  by  separating  the  mus- 
cular from  the  inner  coat  of  the  arteries  he  could,  when 
he  pleased,  produce  an  aneurism  in  these  animals ; 
and  when  Hunter  declared  that  such  an  experiment 
made  the  artery  firmer  than  ever,  in  consequence  of 
the  adhesive  inflammation  taking  place  ; the  character 
and  veracity  of  these  eminent  men  naturally  lead  to  the 
question,  whether  the  experiments  were  conducted  ex- 
actly in  the  same  manner.  Now,  says  Mr.  Wilson, 
w'hen  we  know  that  Haller  did  not  suffer  the  surround- 
ing parts  to  unite,  and  that  John  Hunter  did,  w^e  can 
no  longer  be  at  a loss  to  account  for  the  different  con- 
clusions— (See  Wilson’s  Anatomy,  Pathology,  <fec.  of 
the  Vascular  System,  p.  378.) 

However  this  may  be  with  respect  to  the  experiments 
made  on  certain  animals,  I am  disposed  to  consider  it 
fully  proved  by  Mr.  J.  Hunter,  Sir  E.  Home,  and  Pro- 
fessor Scarpa,  that  in  the  human  subject  an  aneurism 
will  not  arise  from  the  kind  of  weakness  which  is 
caused  by  cutting  or  even  stripping  off  the  external 
coat  of  a soimd  artery,  whether  the  wound  be  closed 
or  not. 

This  fact  would  at  least  appear  to  be  well  established, 
with  respect  to  the  generality  of  the  arteries  ; but  how 
far  it  is  so  in  relation  to  the  aorta,  is  another  question, 
the  inner  membrane  of  which  vessel  is  alleged  to  be 
more  elastic  than  that  of  common  arteries.  Dubois 
and  Dupujtren  in  fact  are  stated  to  have  presented  to 
the  Faculty  of  Medicine  at  Paris  preparations  which 
exhibit  the  lining  of  the  aorta  protruding  through  the 
middle  coat, -in  the  form  of  a sac  filled  with  blood. — 
See  Diet,  des  Sciences  Med.  art.  Aneurisme,  andBres- 
chet  in  Transl.  of  Mr.  Hodgson’s  work,  p.  130.) 

By  the  term  mixed  aneurism.  Dr.  A.  Monro  senior 
implied  the  state  of  a true  aneurism,  wffien  its  cyst  had 
burst,  and  the  blood  was  diffused  in  the  adjacent  cellu- 
lar substance  ; an  event  which  is  frequent.  Besides 
these  varieties  of  aneurism,  the  aneurismal  varix  or 
venous  aneurism,  and  the  aneurism  by  anastomosis, 
constitute  diseases  which  are  usually  regarded  as  cases 
pertaining  to  the  present  subject,  though  incapable  of 
being  comprised  under  the  ordinary  definition  of  an 
aneurism. 

Nothing  can  be  more  manifest  than  the  fact,  that  pre- 
viously to  the  discovery  of  the  circulation  of  the  blood, 
no  correct  nor  valuable  opinions  could  have  prevailed, 
re.specting  the  diseases  which  now  go  under  the  name 
of  aneurisms.  Indeed,  it  was  not  until  after  the  days 
of  Aristotle  that  any  distinction  was  made  between  the 
swellings  of  veins  and  those  of  arteries,  such  vessels 
not  having  been  at  that  early  period  distinguished  from 
each  other.  Their  differences  were  first  pointed  out  by 
Rufus  of  Ephesus. 

Down  to  Galen,  however,  nothing  lilje  consistency 
was  established  in  the  notions  respecting  aneurism. 
His  opinion  was,  that  all  tumours  of  this  nature  were 
produced  either  by  anastomosis  or  by  rupture ; and 
though  he  has  described  their  symptoms,  he  has  not 
informed  us  of  the  characters  by  which  each  of  these 
cases  was  distinguishable  one  from  the  other.  Paulus 
iEgineta  divides  aneurisms  into  two  sorts,  both  of 
which,  he  says,  are  attended  with  extravasation,  and  of 
course  with  rupture. 

Vesalius,  who  first  applied  anatomy  to  the  investiga- 
tion of  disease,  has  described  an  aneurism  arising  from 
the  rupture  of  a dilated  aorta  ; the  first  specimen,  I 
believe,  on  record  of  this  form  of  disease. — (Bonetus 
Sepulch.  Anat.  lib.  4,  sect.  2.) 

The  combination  of  rupture  with  dilatation  of  the  ar- 
tery was  afterward  more  particularly  noticed  by  Nuck. 
— lOpw.  Chir.,  «fec.  Lugd.  1692.) 

It  was  Fernelius  who  first  promulgated  the  doctrine 
that  aneurisms  were  always  dilated  arteries. — (Uni- 
versa  Medicina,  De  Extern.  Corp.  Affect,  lib.  7,  cap.  3, 
Venet.  1564.) 

This  opinion  was  espoused  by  Forrestus,  Diemer- 
broek,  and  others  ; but  at  length  the  inaccuracy  of  at- 
tempting to  refer  every  aneurism  solely  to  dilatation 
of  the  coats  of  the  vessel,  was  established  by  the  obser- 
vations of  Lancisi,  Freind,  Guattani,  and  Morgagni. 

In  short,  as  Mr.  Hodgson  has  stated,  these  authors 
proved  that  aneurism  may  be  produced  either  by  the 
rupture  or  the  dilatation  of  the  coats  of  an  artery,  or 
by  a combination  of  both  circumstances,  the  dilatation 
having  preceded  the  rupture. — (On  the  Diseases  of  Ar- 
teries, <fcc.  8vo.  Lond.  1815.) 

This  admission  of  aneurism  by  dilatation,  and  of 


ANEURTSIVT. 


91 


aneurism  iiy  rupture  of  the  coats  of  an  artery,  together 
with  the  frequent  combination  of  both  circumstances, 
was  indeed  the  prevailing  undisturbed  doctrine  of  every 
surgical  school,  until  Professor  Scarpa,  inclining  to  the 
tenets  of  Sylvaticus  (De  Aneurysmate.  Tract.  Venetiis, 
1600,  4to.i,  ventured  to  question  the  correctness  of  the 
common  opinion  about  the  dilatation  of  all  the  arterial 
coats.  However,  after  the  very  clear  and  satisfactory 
elucidation  of  this  disputed  point  by  my  friend  Mr. 
Hodgson,  the  accurate  views  of  the  subject,  first  taken 
by  Morgagni,  and  the  other  eminent  writers  specified 
above,  may  be  regarded  as  established  beyond  the  pos- 
sibility of  dispute.  At  the  same  time,  it  is  not  to  be 
supposed  that  Scarpa  means  to  say,  that  the  arteries 
are  not  subject  to  a morbid  dilatation ; on  the  contrary, 
he  gives  a particular  description  of  this  affection,  which 
he  carefully  discriminates  from  aneurism. 

Previously  to  offering  a more  particular  account  of 
the  doctrine  taught  by  Scarpa  respecting  the  formation 
of  aneurism,  as  well  as  of  the  chief  facts  which  may 
be  adduced  against  a part  of  such  doctrine,  it  seems 
proper  to  make  the  reader  acquainted  with  the  various 
species  of  the  disease,  their  ordinary  symptoms,  and  a 
few  other  circumstances. 

When  any  part  of  an  artery  is  dilated  (attended  with 
particular  circumstances  marking  its  difference  from 
another  form  of  dilatation  which,  as  I shall  explain, 
perhaps  ought  not  to  be  set  down  as  aneurismal;,  the 
swelling  is  commonly  named  a true  or  genuine  aneu- 
rism. In  such  cases  the  artery  is  either  enlarged  at 
only  a small  part  of  its  track,  and  the  tumour  has  a de- 
terminate border,  or  the  vessel  is  dilated  for  a consi- 
derable length,  in  which  circumstance  the  swelling  is 
oblong,  and  loses  itself  so  gradually  in  the  surround- 
ing parts,  that  its  margin  cannot  be  exactly  ascertained. 
The  first  case,  which  is  the  most  common,  is  termed 
the  circumscribed  true  aneurism  ; the  last  the  diffused 
true  aneurism  ; a case,  however,  which  would  be  looked 
upon  by  Scarpa  only  as  a specimen  of  dilatation  differ- 
ent in  several  particulars  from  aneurism,  as  will  be 
hereafter  noticed.  When  blood  escapes  from  a wound 
or  rupture  of  an  artery  into  the  adjoining  cellular  sub- 
stance, the  swelling  is  denominated  a spurious  or  false 
aneurism.  In  this  instance  the  blood  either  collects  in 
one  mass,  distends  the  cellular  substance,  and  con- 
denses it  into  a cyst,  so  as  to  form  a distinctly  circum- 
scribed tumour;  or  it  is  injected  into  all  the  cavities  of 
the  surrounding  cellular  substance,  and  extends  along 
the  course  of  the  great  vessels,  from  one  end  of  the 
limb  to  the  other,  thus  producing  an  irregular  oblong 
swelling.  The  first  case  is  named  a circumscribed 
false  aneurism  ; the  second  a diffused  false  aneurism. 
— (Richter’s  Anfangsgr.  b.  4.) 

These  appellations  are,  in  my  opinion,  preferable  to 
to  the  term  cylindrical,  applied  by  Sauvages  to  true 
aneurisms,  or  sacciform,  proposed  by  Morg^ni  for  false 
aneurisms. — lAdvers.  Anat.  2,  Aortse  Animadv.  38,  et 
Epist.  Anat.  17,  No.  27.)  Because,  as  we  shall  see  in 
the  coarse  of  this  article,  though  true  aneurisms  (in- 
cluding dilatations  of  all  the  arterial  coats  of  every 
kind;  do  mostly  affect  the  whole  circumference  of  the 
vessel,  and  must  therefore  partake  of  a cylindrical 
shape,  there  are  exceptions,  in  which  a distinct  circum- 
scribed sac,  composed  of  all  the  coats  of  the  vessel, 
projects  from  one  side  of  an  artery,  the  diameter  of 
which  may  not  be  at  all  increased.  Here  the  disease 
might  rather  be  named  sacciform,  the  very  appellation 
suggested  by  Morgagni  for  false  aneurisms,  in  which 
the  di.sease  generally  originates  in  this  shape,  from 
whatever  particular  side  of  the  vessel  the  inner  coats 
have  given  way.  We  see  also  that  the  subject  actually 
demands  more  numerous  distinctions,  since  aneurisms 
undergo  in  their  progress  various  changes,  which  some- 
times make  an  immense,  and  even  a very  sudden  dif- 
ference in  their  shape,  cases  which  were  at  first  cir- 
cumscribed afterward  becoming  diffused. 

The  symptoms  of  a circumscribed  true  aneurism 
take  place  as  follows;  the  first  thing  which  the  patient 
perceives  is  an  extraordinary  throbbing  in  some  par- 
ticular situation,  and  on  paying  a little  more  attention 
he  discovers  there  a small  pulsating  tumour  which  en- 
tirely disappears  when  compressed,  but  returns  again 
as  soon  as  the  pressure  is  removed.  It  is  commonly 
unattended  with  pain  or  change  in  the  colour  of  the 
skin.  When  once  the  tumour  has  originated,  it  con- 
tinually grows  larger,  and  at  length  attains  a very  con- 
sider ible  size.  In  proportion  as  it  becomes  larger,  its 


pulsations  become  weaker,  and  indeed  they  are  almost 
quite  lost  when  the  disease  has  acquired  much  magni- 
tude. The  diminution  of  the  pulsation  has  been  as- 
cribed to  the  coats  of  the  artery  losing  their  dilatable 
and  elastic  quality  in  proportion  as  they  are  distended 
and  indurated,  and,  consequently,  the  aneurismal  sac 
being  no  longer  capable  of  an  alternate  diastole  and  sys- 
tole from  the  action  of  the  heart.  The  fact  is  also  im- 
puted to  the  lamellated  coagulated  blood  deposited  on 
the  inher  surface  of  the  sac,  particularly  in  large  aneu- 
risms, in  which  the  motion  of  some  of  the  blood  is  al- 
ways interrupted.  Immediately  such  coagulated  blood 
lodges  in  the  sac,  pressure  can  only  produce  a partial 
disappearance  of  the  swelling.  This  deposition  of 
lamellated  coagulum  in  the  aneurismal  sac  is  a circum- 
stance of  considerable  importance  ; for  it  has  been  well 
explained  by  Mr.  Hodgson,  that  it  is  the  mode  by  which 
the  spontaneous  cure  of  the  disease  is  in  most  instances 
effected.  “ One  of  the  circumstances  which,  in  the 
most  early  stage,  generally  attend  the  formation  of 
aneurism  (says  this  author),  is  the  establishment  of  that 
process  which  is  the  basis  of  its  future  cure.  The 
blood,  which  enters  the  sac  soon  after  its  formation, 
generally  leaves  upon  its  internal  surface  a stratum  of 
coagulum,  and  successive  depositions  of  the  fibrous 
part  of  the  blood  gradually  diminish  the  cavity  of  the 
tumour.  At  length  the  sac  becomes  entirely  filled  with 
this  substance,  and  the  deposition  of  it  generally  con- 
tinues in  the  artery  which  supplies  the  disease,  forming 
a firm  plug  of  coagulum,  which  extends  on  both  sides 
of  the  sac  to  the  next  important  ramifications  that  are 
given  off  from  the  artery.  The  circulation  through  the 
vessel  is  thus  prevented,  the  blood  is  conveyed  by  col- 
lateral channels,  and  another  process  is  instituted, 
whereby  the  bulk  of  the  tumour  is  removed,”  &c. — 
(On  the  Diseases  of  Arteries  &c.  p.  114.)  Whether 
there  is  any  truth  in  Kreysig’s  conjecture,  that  some  of 
the  lymph  may  exude  from  the  inside  of  the  sac  itself, 
1 cannot  pretend  to  say : he  owns,  however,  that  the 
inner  concentric  layers  presenting  the  appearance  of 
being  deposited  last,  is  a circumstance  rather  against 
his  surmise,  though  he  adverts  to  some  other  circum- 
stances which  incline  him  to  look  upon  the  opinion  as 
possibly  correct.— (German  Transl.  of  Mr.  Hodgson’s 
Work,  p.  124.) 

In  a preceding  paragraph  I have  spoken  of  the  dias- 
tole and  systole  of  the  aneurismal  sac ; for  it  is  the 
general  belief  that  the  pulsation  of  the  tumour  is  pro- 
duced by  the  jet  of  blood  into  it  at  each  stroke  of  the 
heart.  This  opinion,  however,  is  disputed  by  an  emi- 
nent writer,  who  asks,  is  it  true  that  the  pulsation  of 
aneurisms  proceeds  from  the  entrance  of  a more  con- 
siderable stream  of  blood  into  the  sac,  and  the  dis- 
tention of  the  swelling  thereby  produced  ? In  aneu- 
risms, which  have  only  a narrow'  communication  with 
the  arterial  tube,  or  which  are  filled  with  laminated 
coagula,  the  idea,  says  he,  is  quite  inadmissible:  the 
aneurism  is  rather  shaken,  as  it  were,  like  other  differ- 
ent swellings  in  the  vicinity  of  an  artery,  by  the  stroke 
of  the  heart  occasioning  a stretching  of  the  whole  ar- 
terial system,  and  at  the  same  time  communicating  an 
impulse  to  the  column  of  blood.— (Kreysig,  Germ.  I'r. 
of  Mr.  Hodg.son’s  Work,  p.  14.3.)  Here,  however,  I 
am  by  no  means  disposed  to  coincide  with  this  distin- 
guished physician,  whose  sentiments  appear  to  me  to 
be  refuted  by  the  fact,  that  whenever  any  change  hap- 
pens, calculated  to  lessen  or  entirely  stop  the  influx  of 
blood  into  the  sac,  the  pulsation  either  diminishes  or 
ceases  in  proportion.  Thus,  when  Kreysig  adverted  to 
the  pulsation  of  aneurisms,  in  which  much  coagulated 
blood  was  deposited,  he  might  at  the  same  time  have 
mentioned  the  effect  which  such  deposition  has  in 
weakening  the  pulsation,  the  layers  of  coagulated  blood 
within  the  tumour  being  in  the  natural  mode  of  cure, 
as  Mr.  Hodgson  has  correctly  explained,  “ the  means 
by  which  the  force  of  the  circulation  is  removed  from 
the  sac,  and  the  fatal  termination  of  the  disease  by 
rupture  is  prevented.” — (On  Diseases  of  Art.  and  ’Veins, 
p.  126.)  In  proportion  as  the  aneurismal  sac  grows 
larger,  the  communication  of  blood  into  the  artery  be- 
yond the  tumour  is  lessened.  Hence,  in  this  state,  the 
pulse  below  the  swelling  becomes  weak  and  small,  and 
the  limb  frequently  cold  and  cedematous.  On  dissec- 
tion, the  lower  continuation  of  the  artery  is  found  pre- 
ternaturally  small  and  contracted.  The  pressure  of 
the  tumour  on  the  adjacent  parts  may  also  produce  » 
varietv  of  sjmptoiris,  ulceration,  absorption  of  bone*. 


92 


ANEURISM. 


&c.  Sometimes  (says  Richter)  an  accidental  contu- 
sion or  concussion  may  detach  a piece  of  coagulum 
from  the  inner  surface  of  the  cyst,  and  the  circulation 
through  the  sac  be  obstructed  by  it : nay,  he  asserts 
that  the  coagulum  may  possibly  be  impelled  quite  into 
the  artery  below,  so  as  to  induce  important  changes. 
The  danger  of  an  aneurism  arrives  when  it  is  on  the 
point  of  bursting,  by  which  occurrence  the  patient  usu- 
ally bleeds  to  death,  and  this  sometimes  in  a few  se- 
conds. The  fatal  event  may  generally  be  foreseen,  as 
the  part  about  to  give  way  becomes  particularly  tense, 
elevated,  thin,  soA,andof  a dark  purple  colour. — i; Rich- 
ter’s Anfangsgr.  band  1.) 

A targe  axillary  aneurism,  which  burst  in  St.  Bar- 
tholomew’s Hospital  some  years  ago,  did  not  burst 
by  ulceration,  but  by  the  detachment  of  a small  slough 
from  a conical,  discoloured  part  of  the  tumour;  and 
soon  after  this  ceise  fell  under  my  observation,  I had  an 
opportunity  of  seeing  the  process  by  which  an  inguinal 
aneurism  burst : at  a certain  point  the  tumour  became 
more  conical,  thin,  and  inflamed,  and  here  a slough 
about  an  inch  in  width  was  formed.  On  the  dead  part 
becoming  loose,  a profuse  bleeding  began,  which  was 
stopped  for  a short  time  by  pressure,  but  soon  returned 
with  increasing  violence,  and  put  an  end  to  the  patient’s 
misery.  We  are  then  to  conclude  that  external  atieu- 
risms  do  not  burst  by  ulceration,  but  by  the  formation 
and  detachment  of  a slough.  I believe  this  is  a fact  which 
was  first  particularly  pointed  out  in  the  early  editions 
of  my  work,  and  it  gives  me  pleasure  to  find  that  it  is 
a statement  which  entirely  coincides  with  that  subse- 
quently made  by  several  writers  of  eminence,  espe- 
cially Mr.  A.  Burns  (On  Diseases  of  the  Heart,  p.  225), 
and  Boyer  (Traits  des  Maladies  Chirurgicales,  t.  2, 
p.  98.) 

As  far  £is  my  information  extends,  Mr.  A.  Burns  first 
explained  the  very  different  mode  of  rupture  which 
happens  in  internal  aneurisms  ; these,  he  observed,  ge- 
nerally burst  by  actual  laceration,  and  not  by  sphace- 
lation of  the  cyst. — (On  Diseases  of  the  Heart,  p.  225.) 
But  a still  more  particular  account  of  the  process  by 
which  external  and  internal  aneurisms  burst,  is  deli- 
vered by  Mr.  Hodgson.  When  the  sac  points  exter- 
nally (says  this  gentleman),  it  rarely  or  never  bursts 
by  laceration,  but  the  extreme  distention  causes  the  in- 
teguments and  investing  parts  to  slough,  and  upon 
the  separation  of  the  eschar,  the  blood  issues  from  the 
tumour.  A similar  process  takes  place  when  the  dis- 
ease extends  into  a cavity  which  is  lined  by  a mucous 
membrane,  as  the  oesophagus,  intestines,  bladder,  <fec. 
in  such  cases,  the  cavity  of  the  aneurism  is  generally 
exposed  by  the  separation  of  a slough  which  has  formed 
upon  its  most  distended  part,  and  not  by  laceration. 
But  when  the  sac  projects  into  a cavity  lined  by  a se- 
rous membrane,  as  the  pleura,  the  peritoneum,  the  pe- 
ricardium, &c.,  sloughing  of  these  membranes  does  not 
take  place,  but  the  parietes  of  the  tumour  having  be- 
come extremely  thin  in  consequence  of  distention,  at 
length  burst  by  a crack  or  fissure,  through  which  the 
blood  is  discharged.— (On  the  Diseases  of  Arteries,  &c. 
p.  85.) 

When  the  aneurism  is  of  considerable  size,  the  col- 
lateral arteries,  which  originate  above  the  swelling,  are 
manifestly  enlarged.  Boyer  informs  us,  that  in  dissect- 
ing the  lower  extremity  of  a patient  on  whom  Desault 
had  operated  eight  months  previously  for  a popliteal 
aneurism,  he  found  in  the  substance  of  the  great  sci- 
atic nerve  an  artery,  whose  diameter  was  equal  to  that 
of  the  radial  at  the  wrist.  This  vessel  had  its  origin 
from  the  ischiatic  artery,  and  descended  to  the  back 
part  of  the  knee,  where  it  anastomosed  with  the  upper 
articular  arteries.  Boyer  had  also  noticed  in  the  same 
subject  before  the  operation,  that  one  of  the  branches 
of  the  upper  internal  articular  artery  was  so  much  en- 
larged that  its  pulsation  could  be  plainly  felt  on  the  in- 
ternal condyle  of  the  thigh-bone. — (Op.  cit.  p.  93.)  It 
is  such  enlargement  of  the  collateral  arteries  above  the 
disease,  which  ensures  to  the  limb  below  the  tumour 
an  adequate  supply  of  blood  when  the  obstruction  to 
its  passage  through  the  diseased  artery  becomes  consi- 
derable. or  when  this  vessel  has  been  rendered  totally 
impervious  by  a surgical  operation  performed  for  the 
cure  of  the  compl2unt. 

In  the  advanced  stage  of  an  aneurism,  the  skin  is 
fouitd  extremely  thin,  and  confounded,  as  it  were,  with 
the  aneurismal  sac.  The  cavities  of  the  cellular  sub- 
stance near  the  disease  are  either  filled  with  serum  or 


totally  obliterated  by  adhesion.  The  adjacent  muscles, 
whether  they  lie  over  the  aneurism  or  to  one  side  of  it, 
are  stretched,  displaced,  dwindled,  and  sometimes  con- 
founded with  other  parts.  It  is  the  same  with  the 
large  nervous  cords  situated  at  the  circumference  of 
the  tumour : they  are  pushed  out  of  their  natural  situ- 
ation, diminished  in  size,  sometimes  adherent  to  the 
outside  of  the  sac,  and  so  changed  as  scarcely  to  admit 
of  being  known  again.  Lastly,  the  cartilages  and  the 
bones  themselves  are  not  exempt  from  the  mischief 
which  the  aneurismal  swelling  produces  in  all  the  sur- 
rounding parts  : they  are  gradually  destroyed,  and  at 
length  not  the  least  trace  of  their  substance  remains, 
just  in  the  same  way  as  the  bones  of  the  cranium  are 
destroyed  by  fungous  tumours  of  the  dura  mater. — (See 
Dura  Mater.)  Even  the  cartilages  of  the  larynx  and 
rings  of  the  trachea  are  sometimes  destroyed ; this  tube 
is  pierced,  and  the  blood  escapes  into  it,  or  the  aneu- 
rism bursts  into  the  oesophagus. — (Boyer,  Traite  des 
Maladies,  Chir.  t.  2,  p.  99.)  As  I shall  hereafter  ex- 
plain, however,  the  pressure  of  an  aneurism.al  tu- 
mour more  quickly  produces  an  absorption  of  bone  than 
of  cartilage. 

Wliile  an  aneurism  is  small  and  recent,  it  does  not 
generally  cause  much  pain,  nor  seriously  impede  the 
functions  of  the  limb.  But  when  it  has  increased,  se- 
veral complications  are  produced.  Thus  the  dragging 
of  the  saphenal  nerve,  by  femoral  aneurisms,  frequently 
occasions  acute  pain  in  the  course  of  this  nerve  as 
far  as  the  great  toe.  The  distention  of  the  sciatic  nerve 
by  the  popliteal  aneurism  sometimes  brings  on  intole- 
rable pain,  which  extends  to  all  the  parts  to  which  this 
nerve  is  distributed,  and  which  can  hardly  ever  be  ap- 
peased by  the  topical  use  of  opiate  applications.  The 
compression  of  the  veins  and  lymphatics  gives  rise  to 
oedema,  numbness,  and  coldness  of  the  limb.  And, 
finally,  the  long-continued  pressure  of  the  aneurism  on 
the  neighbouring  bones  causes  their  de,«truction. — 
(Boyer,  t.  2,  p.  105.) 

In  true  aneurism,  the  coats  of  the  artery  are  not 
always  in  the  same  state,  the  kind  of  changes  observed 
depending  upon  the  progress  of  the  tumour.  In  the 
early  stage  of  the  disease,  either  the  whole  cylinder  of 
the  vessel,  or  only  a part  of  its  circumference,  is  di- 
lated ; but  this  period  is  generally  of  short  duration, 
especially  in  arteries  of  middling  size,  because  their 
middle  coat  is  capable  of  less  resistance  than  that  of 
the  larger  arteries,  like  the  aorta,  where  this  coat  is 
yellowish,  firm,  and  very  elastic.  As  Breschet  remarks, 
this  difference  of  resistance  in  the  middle  coat  of  the 
aorta  and  the  branches  given  off  from  it,  accounts  for 
the  rarity  of  true  aneurisms  either  in  the  small  arteries 
or  those  of  middling  size,  and  their  greater  frequency 
in  the  principal  trunk  of  the  arterial  system. 

At  length,  m consequence  of  the  increasing  disten- 
tion, some  of  the  coats  of  the  artery  possessing  the 
least  elasticity  give  way,  and  these  are  found  to  be  the 
internal  and  middle  coats,  while  the  external  one  still 
makes  resistance  and  continues  to  be  more  and  more 
dilated  by  the  lateral  impulse  of  the  blood. 

The  second  stage  of  true  aneurism  is  that  which  is 
mostly  met  with ; that  in  which  the  tumour  increases 
more  rapidly,  and  therefore  begins  to  excite  greater  at- 
tention. The  disease  when  it  has  attained  this  form 
is  in  point  of  fact  no  longer  a true  aneurism,  but  a 
case  which  Monro  distinguished  by  the  name  of  the 
consecutive  or  external  mixed  false  aneurism.  In  this 
stage  the  patient’s  life  is  endangered,  and  death  often 
brought  on  by  the  rupture  of  the  tumour.  Examinations 
of  the  dead  subject  under  these  circumstances  have 
frequently  led  to  mistaken  notions,  and  doubtless  if  va- 
rious swellings  of  this  kind  had  not  been  found  in 
different  degrees  or  stages  in  the  same  individual,  one 
might  be  disposed  to  join  Scarpa  in  the  belief,  that  no 
aneurism  consists  of  a dilatation  of  all  the  arterial 
coats. — (Breschet,  Fr.  transl.  of  Mr.  Hodgson’s  work, 
p.  128,  129.) 

The  false  aneurism  is  always  attended  with  at  least 
a rupture,  or  giving  way  of  the  inner  coat  of  the  vessel, 
and  usually  with  a breach  in  both  this  and  the  muscu- 
lar coat,  the  outer  elastic  tunic  forming  the  pouch  in 
which  the  blood  collects.  But  after  the  swelling  has 
attained  a certain  size,  this  coat  also  bursts,  and  then  the 
blood  either  becomes  diffused,  or  a large  circumscribed 
space  is  formed  for  it  by  the  condensation  of  the  sur- 
rounding cellular  membrane.  False  aneurisms,  when 
produced  by  a wound  or  puncture,  are  of  course  from  the 


ANEURISM. 


93 


first  attended  with  a division  of  all  the  coats  of  the 
vessel.  This  form  of  the  disease  is  often  seen  at  the 
bend  of  the  arm,  where  the  artery  is  exposed  to  injury 
in  venesection. — (See  Hemorrhage.)  In  this  circum- 
stance, as  soon  as  the  puncture  is  made,  the  blood 
gushes  out  with  unusual  force,  and  in  a bright  scarlet, 
irregular,  interrupted  current ; flowing  out,  however, 
in  an  even  and  less  rapid  stream  when  pressure  is  ap- 
plied higher  up  than  the  wound.  These  last  are  the 
most  decisive  marks  of  the  artery  being  opened ; for 
blood  may  issue  from  a vein  with  great  rapidity,  and 
in  a broken  current,  when  the  vessel  is  turgid  and 
situated  immediately  over  the  artery,  which  imparts  its 
motion  to  it.  The  surgeon  endeavours  precipitately  to 
stop  the  hemorrhage  by  pressure,  and  in  general  a 
diffused  false  aneurism  is  the  result.  The  external 
wound  in  the  skin  is  closed  so  that  the  blood  cannot 
escape,  but  this  does  not  hinder  it  from  passing  into 
the  cellular  substance.  The  swelling  thus  produced  is 
uneven,  often  knotty,  and  extends  upwards  and  down- 
wards along  the  track  of  the  vessel.  The  skin  is  also 
usually  of  a dark  purple  colour.  Its  size  increases  as 
long  as  the  internal  hemorrhage  continues;  and  if  this 
shotild  i)roceed  beyond  certain  bounds,  mortification  of 
the  limb  ensues.  Such  is  the  diffused  false  aneurism 
from  a wound. 

The  circumscribed  false  aneurism,  from  a wound  or 
puncture,  arises  in  the  following  manner.  When 
proper  pressure  has  been  made  in  the  first  instance,  so 
as  to  suppress  the  hemorrhage,  but  the  bandage  has 
afterward  been  removed  too  soon,  or  before  the  artery 
has  healed,  the  blood  passes  through  the  unclosed 
wound,  or  that  which  it  has  burst  open  again,  into  the 
cellular  substance.  As  this  has  now  become  aggluti- 
nated by  the  preceding  pressure,  the  blood  cannot  dif- 
fuse itself  into  its  cells,  and  consequently  a mass  of  it 
collects  in  the  vicinity  of  the  aperture  of  the  artery, 
and  distends  the  cellular  substance  into  the  form  of  a 
sac.  Sometimes,  though  not  often,  the  circumscribed 
false  aneurism  originates  immediately  after  the  opening 
is  made  in  the  artery.  This  chiefly  happens  when  the 
aperture  in  the  vessel  is  exceedingly  small,  and  conse- 
quently when  the  hemorrhage  takes  place  so  slowly 
that  the  blood,  which  is  first  effused,  coagulates,  and 
prevents  the  entrance  of  that  which  follows  info  the 
cavities  of  the  cellular  substance,  and  of  course  its 
diffusion.  False  aneurisms,  proceeding  from  the 
rupture  of  the  inner  coats  of  an  artery,  are  always  at 
first  circumscribed  by  the  resistance  of  the  outer  tunic. 

The  circumscribed  false  aneurism  consists  of  a sac 
composed  of  the  external  coat  of  the  artery,  or,  in  case 
this  has  given  way,  it  is  composed  of  an  artificial  pouch 
formed  among  whatever  parts  hapi)en  to  be  in  the 
vicinity  of  the  burst  artery.  This  cavity  is  filled  with 
blood,  and  situated  close  to  the  artery,  with  which  it 
has  a communication.  Hence  in  false  aneurisms  a 
throbbing  is  always  perceptible,  and  is  more  manifest 
the  smaller  such  tumours  are.  The  larger  the  sac  be- 
comes the  less  elastic  it  is,  and  the  greater  is  the  quan- 
tity of  laminated  coagula  in  it ; so  that  in  very  large  aneu- 
risms of  this  kind  the  pulsation  is  sometimes  vvholly  lost. 

The  tumour  is  at  first  small,  and  on  compression  en- 
tirely disappears ; but  returns  as  soon  as  this  is  re- 
moved. It  also  diminishes  when  the  artery  above  it  is 
compressed ; but  resumes  its  wonted  magnitude  im- 
mediately such  pressure  is  discontinued.  When  there 
is  coagulated  blood  in  the  sac,  pressure  is  no  longer 
capable  of  producing  a total  disaiipearance  of  ihe  tumour, 
which  is  now  hard.  The  swelling  is  not  painful,  and 
the  integuments  are  not  changed  in  colour.  It  con- 
tinually increases  in  size,  and  at  length  attains  a pro- 
digious magnitude. 

The  following  are  generally  enumerated  as  the  dis- 
criminating differences  between  circumscribed  true 
and  false  aneurisms ; the  true  aneurism  readily  yields 
to  pressure,  and  as  readily  recurs  on  its  removal ; the 
false  one  yields  very  gradually,  and  returns  in  the  same 
way  ; and  as  it  contains  laminated  coagula,  it  cannot 
be  reduced  in  the  same  degree  by  coniprcssiot)  as  an 
aneurism  formed  by  a dilatation  of  the  arterial  coats, 
where  such  strata  of  coagulated  blood  are  usually  ab- 
sent. Frequently  a hissing  sound  is  audible  when  the 
blood  gushes  into  the  sac.  The  pulsation  of  the  false 
aneurism  is  always  more  feeble,  and  as  the  tumour  en- 
larges is  sooner  lost  than  that  of  the  true  one,  which 
throbs  after  it  has  acquired  a considerable  volume. — 
(Sea  Richter’s  Anfangsgr.  b.  1. 


FORMATION  OF  ANEURISMS. 

If  the  doctrines  of  Scarpa,  published  in  1804,  had 
proved  correct,  the  grand  distinction  of  aneurism  into 
true  and  false  must  have  been  rejected  as  erroneous  : 
“ for,”  says  he,  “ after  a very  considerable  number  of 
investigations,  instituted  on  the  bodies  of  those  who 
have  died  of  internal  or  external  aneurisms,  I have 
ascertained,  in  the  most  certain  and  unequivocal  man- 
ner, that  there  is  only  one  kind  or  form  of  this  disease, 
viz.  that  caused  by  a solution  of  continuity  or  rupture 
of  the  proper  coats  of  the  artery,  with  effusion  of  blood 
into  the  surrounding  cellular  substance  ; which  solu- 
tion of  continuity  is  occasioned  sometimes  by  a wound, 
a steatomatous,  earthy  degeneration,  a corroding  ulcer, 
or  a rupture  of  the  proper  coats  of  the  artery,  I mean 
the  internal  and  muscular,  Avithout  the  concurrence 
of  a preternatural  dilatation  of  these  coats  being  es- 
sential to  the  formation  of  this  disease  ; and  there 
fore  that  every  aneurism,  whether  it  be  internal  or 
external,  circumscribed  or  diffused,  is  always  formed 
by  effusion.”— (On  Aneurism  : transl.  by  Wishart, 
Pref;) 

According  to  Scarpa,  it  is  an  error  to  suppose  that  the 
aneurism  at  the  curvature  or  in  the  trunk  of  the  aorta, 
produced  by  a violent  and  sudden  exertion  of  the  whole 
body,  or  of  the  heart  in  particular,  and  preceded  by  a 
congenital  relaxation  of  a certain  portion  of  this  artery, 
or  a morbid  weakness  of  its  coats,  ojight  always  to  be., 
considered  as  a tumour  formed  by  thef  distention  or  dila- 
tation of  the  proper  coats  of  the  artery  itself,  that  is, 
of  its  internal  and  fibrous  coats.  Scarpa  considers  it 
quite  demonstrable,  that  such  aneurisms  are  produced 
by  a corrosion  and  rupture  of  these  tunics,  and  conse- 
quently, by  the  effusion  of  arterial  blood  under  the 
cellular  sheath,  or  other  membrane  covering  the  vessel. 
If  ever  there  be  a certain  degree  of  preceding  dilatation, 
it  is  not  essential  to  constitute  the  disease,  for  it  is  not 
a constant  occurrence  ; most  aneunsms  are  unpre- 
ceded by  it,  and  in  those  rare  cases  in  which  an  aneu- 
rism is  preceded  and  accompanied  by  a certain  degree 
of  dilatation  of  the  whole  diameter  of  the  curvature  of 
the  aorta,  there  is  an  evident  difference  between  an 
artery  simply  enlarged  in  diameter,  and  a pouch  which 
forms  an  aneurismal  sac. 

Careful  dissections,  says  Scarpa,  will  prove  that  the 
aorta  contributes  nothing  to  the  formation  of  the  aneu- 
rismal sac,  and  that  this  is  merely  the  cellular 
membrane  which,  in  the  sound  state,  covered  the 
artery,  or  that  soft  cellular  sheath  which  the  artery 
received  in  common  with  the  neighbouring  parts. 
This  is  raised  by  the  blood  into  the  form  of  a tu- 
mour, and  is  covered  in  common  with  the  artery  by  a 
smooth  membrane. 

This  eminent  professor  does  not  deny  that  from  con- 
genital relaxation  the  proper  coats  of  the  aorta  may 
occasionally  yield  and  become  disposed  to  rupture  ; 
but  he  will  not  admit  that  dilatation  of  this  artery  pre- 
cedes and  accompanies  all  its  aneurisms,  or  that  its 
proper  coats  ever  yield  so  much  to  distention  as  to 
fonn  the  aneurismal  sac.  The  root  of  an  anetirism  of 
the  aorta  never  includes  the  whole  circumference  of 
the  artery ; but  the  aneurismal  sac  arises  from  one 
side  in  the  form  of  an  appendix  or  tuberosity.  On  the 
contrary,  the  dilatation  of  the  artery  always  extends  to 
its  whole  circumference,  and  therefore  differs  essen- 
tially from  aneurism.  Thus,  he  urges  that  there  is  a 
remarkable  difference  between  a dilated  and  aneuris- 
matic  artery,  although  these  two  affections  are  some- 
times found  combined  together,  especially  at  the  origin 
of  the  aorta.  If  we  also  consider  that  the  dilatation  of 
an  artery  may  exist  without  any  organic  affection,  the 
blood  being  always  in  the  cavity  of  the  vessel ; that  in 
an  artery  so  affected  there  is  never  collected  any  gru- 
mous  blood  or  polypous  layers  ; that  the  dilatation 
never  forms  a tumour  of  considerable  bulk ; and  that 
while  the  continuity  of  the  proper  coats  remains  unin- 
terrupted, the  circulation  of  the  blood  is  not  at  all,  or 
not  so  sensibly  changed ; we  shall  be  obliged  to  allow, 
that  aneurism  differs  essentially  from  one  kind  of  di- 
latation of  au  artery. 

Some  additional  remarks  on  this  topic  more  re- 
cently published  by  Scarpa  xvill  be  presently  consi- 
dered. 

Ry  dissections  of  arteries  both  in  the  sound  and  mor- 
bid state,  Scarpa  endeavours  to  demonstrate  what  share 
the  proper  and  constituent  coats  of  the  artery  have  in 
the  formation  of  the  aneurismal  sac,  and  what  belongs 


94 


ANEURISM, 


to  the  cellular  covering,  and  other  adventitious  mem- 
branes surrounding  the  artery. 

The  covering  of  an  artery  is  merely  an  adventitious 
sheath  which  the  vessel  receives  in  common  with  the 
parts  in  the  vicinity  of  which  it  runs.  On  cutting  an 
artery  across  in  its  natural  situation,  the  segment  of 
the  cut  vessel  retires  and  conceals  itself  in  this  sheath. 

This  cellular  covering  is  most  evident  round  the  cur- 
vature and  trunk  of  the  aorta,  the  carotid,  mesen- 
teric, and  renal  arteries : it  is  less  dense  round  the 
trunks  of  the  brachial,  femoral  and  popliteal  arteries. 
The  pleura  lies  over  the  cellular  sheath  of  the  arch  of 
the  aorta,  and  over  that  of  the  thoracic  a rta ; while 
that  of  the  abdominal  aorta  is  covered  by  the  perito- 
neum. Both  these  smooth  membranes  adhere  to  and 
surround  two-thirds  of  the  circumference  of  the  vessel. 
The  great  arteries  of  the  extremities  are  not  covered  in 
addition  to  the  cellular  substance  by  any  smooth  mem- 
brane of  this  sort,  but  by  a cellular  sheath,  which  is 
demonstrably  distinct  from  the  adipose  membrane,  and 
serves  to  enclose  the  vessels,  and  connect  them  with 
the  contiguous  parts. 

When  air  or  any  other  fluid  is  injected  by  a small 
hole,  made  artificially  between  the  cellular  covering  I 
and  the  subjacent  muscular  coat  of  the  artery,  the  in- 
jected matter  elevates  into  a tumour  the  cellular  mem-  | 
brane,  which  closely  embraces  the  artery',  without  pro-  | 
perly  destroying  its  cells,  which  it  distends  in  a re- 
dnarkable  manner.  When  melted  wax  is  injected  and 
pushed  with  much  force,  the  cellular  sheath  of  the  ar- 
tery is  not  only  raised  over  the  vessel  like  a tumour, 
but  the  internal  cells  of  that  covering  are  aLso  lacerated, 
and  on  examining  afterward  the  capsule  of  the  arti- 
ficial tumour,  it  appears  as  if  it  were  formed  of  several 
layers,  rough  and  irregular  internally,  smooth  and  po- 
lished externally.  The  same  tiling  happens  when  any 
injection  is  pushed  with  such  force  into  an  artery'  as  to 
rupture  the  internal  and  muscular  coats  at  some  point 
of  their  circumference.  Nicholls  performed  this  expe- 
riment several  times  before  the  Royal  Society. — (Phi- 
los. Trans,  an  1728.  ) As  soon  as  the  internal  coat  is 
ruptured,  the  muscular  one  ahso  gives  way ; but  the 
external  cellular  sheath  being  of  an  interlaced  texture, 
and  the  thin  laminte  of  which  it  is  composed  being  not 
simply  applied  to  one  another,  but  reciprocally  inter- 
mixed, is  capable  of  supporting  great  distention  by 
yielding  gradually  to  the  impulse  of  the  blood,  without 
being  torn  or  niptured. 

Scarpa  is  farther  of  opinion  that  the  same  pheno- 
mena may  be  observed  when  the  internal  coat  of  the 
aorta  becomes  so  diseased  as  to  be  ruptured  by  the  re- 
peated jets  of  blood  from  the  heart.  In  this  circum- 
stance, the  blood,  impelled  by  the  heart,  begins  imme- 
diately to  ooze  through  the  connexions  of  the  fibres 
of  the  muscular  coat,  and  gradually  to  be  effused  into 
the  interstices  of  the  cellular  covering,  forming  for  a 
certain  extent  a kind  of  ecchymosis  or  extravasation 
of  blood,  slightly  elevated  upon  the  artery.  Afterward, 
the  points  of  contact  between  the  edges  of  the  fibres  of 
the  muscular  coat  being  insensibly  separated,  the  ar- 
terial blood,  penetrating  between  them,  fills  and  ele- 
vates in  a remarkable  manner  the  cellular  covering  of 
the  artery,  and  raises  it  after  the  manner  of  an  incipi- 
ent tumour.  Thus  the  fibres  and  layers  of  the  muscu- 
lar coat  being  wasted  or  lacerated,  or  simply  separated 
from  each  other,  the  arterial  blood  is  carried  with  great 
force,  and  in  greater  quantity  than  before,  into  the  cel- 
lular sheath  of  the  artery,  which  it  forces  more  out- 
wards; and  finally,  the  divisions  between  the  inter- 
stices of  the  cellular  coat  being  ruptured,  it  is  converted 
intoa  sac,  which  is  filled  with  polypous  concretions  and 
fluid  blood,  and  at  last  forms,  strictly  speaking,  the 
aneurismal  sac.  The  internal  texture,  although  appa- 
rently composed  of  membranes  placed  one  over  the 
other,  is,  in  fact,  very  different  from  that  of  the  proper 
coats  of  the  artery,  notwithstanding  the  injured  vessel 
and  aneurismal  sac  are  both  covered  externally  in  the 
thorax  and  abdomen  with  a smooth  membrane. 

Scarpa  has  examined  a considerable  number  of  aneu- 
risms of  the  arch  and  of  the  thoracic  and  abdominal 
trunk  of  the  aorta,  without  finding  a single  .one  in 
which  the  rupture  of  the  proper  coats  of  tl^  artery  was 
not  evident,  and  in  which,  consequently,  the  sac  was 
produced  by  a substance  completely  different  from  the 
internal  and  muscular  coats. 

The  aneurismal  sac  never  comprehends  the  whole 
circumference  of  the  vessel.  At  the  place  where  the 


tumour  joins  the  side  of  the  tube,  the  aneurismal  sac 
presents  a kind  of  constriction,  beyond  which  it  be- 
comes more  or  less  expanded.  This  would  never  hap- 
pen, or  rather  the  contrary  circumstance  would  occur, 
if  the  sac  were  formed  by  an  equable  distention  of  the 
tube  and  proper  coats  of  the  affected  artery.  In  inci- 
pient aneurisms,  at  least,  the  greatest  size  of  the  tu- 
mour would  then  be  in  the  artery  itself,  or  root  of  the 
swelling,  while  its  fundus  would  be  the  least.  But 
whether  aneurisms  be  recent  and  small,  or  of  long 
standing  and  large,  the  passage  from  the  artery  is  al- 
ways narrow,  and  the  fundus  of  the  swelling  greater 
in  proportion  to  its  distance  from  the  vessel.  The  sac 
is  always  covered  by  the  same  soft  dilatable  cellular 
substance  which  united  the  artery  in  a sound  state  to 
the  circumjacent  parts.  Such  cellular  substance  in 
aneurisms  of  the  thoracic  aorta  is  covered  by  the  pleura, 
and  in  those  of  the  abdominal  aorta  by  the  peritoneum, 
which  membranes  include  the  sac  and  ruptured  artery, 
presenting  outwardly  a continued  smooth  surface,  juk 
as  if  the  artery  itself  were  dilated.  But  if  the  aorta 
be  opened  lengthwise  on  the  side  opposite  the  constric- 
tion or  neck  of  the  tumour,  the  place  of  the  ulceration  or 
rupture  of  the  proper  coats  of  the  artery  immediately 
appears  within  the  vessel,  on  the  side  opposite  to  that  of 
the  incision.  The  edge  of  the  fissure  which  has  taken 
place  is  sometimes  fringed,  often  callous  and  hard,  and 
through  it  the  blood  formed  for  itself  a passage  into  the 
cellular  sheath,  which  is  converted  into  the  aneurismal 
sac.  If,  as  sometimes  happens  in  the  arch  of  the  aorta 
near  the  heart,  the  artery,  before  being  ruptured,  has 
been  somew'hat  dilated,  it  seems  at  first  as  if  there  were 
two  aneurisms ; but  the  constriction  which  the  sac  next 
to  the  artery  presents  externally,  points  out  exactly  the 
limits  beyond  which  the  internal  and  muscular  coats 
of  the  aorta  had  not  been  able  to  resist  the  distention, 
and  where  of  course  they  have  been  ruptured.  The 
partition  which  may  always  be  seen  dividing  the  tube 
of  the  artery  from  the  aneurismal  sac,  and  which  is 
lacerated  in  its  middle,  consists  of  nothing  else  than 
the  remains  of  the  internal  and  muscular  coats  of  the 
ruptured  artery. 

By  carefully  dissecting  the  proper  coats  of  the  rup- 
tured aorta  in  its  situation,  and  comparing  them  with 
the  cellular  substance  forming  the  sac,  Scarpa  affirms 
that  the  truth  of  the  preceding  statement  may  be  in- 
disputably demonstrated. 

When  an  incision  is  made  lengthwise  in  the  side  of 
the  vessel  opposite  the  rupture,  its  proper  coats  are 
found  either  perfectly  sound,  or  a little  w'eakened  and 
studded  with  earthy  points,  but  still  capable  of  being 
separated  into  distinct  layers.  On  the  contrary,  in  the 
opposite  side  of  the  aorta,  where  the  rupture  is,  the 
proper  coats  are  unusually  thin,  and  are  only  separa- 
ble from  each  other  with  difficulty,  or  even  not  at  all ; 
they  are  frequently  brittle  like  an  egg-shell,  and  are 
disorganized  and  torn  at  the  place  where  they  form  the 
partition  between  the  ruptured  artery  and  the  mouth 
of  the  aneurismal  sac.  Continuing  to  separate  these 
coats  from  within  outwards,  we  arrive  at  the  cellular 
sheath  surrounding  the  aorta.  This  sheath  being  much 
thickened  in  large  aneurisms,  and  very  adherent  to  the 
subjacent  muscular  coat  of  the  artery  at  the  place  of 
the  constriction  of  the  sac,  is  very  apt  to  be  mistaken 
for  a dilated  portion  of  the  vessel  itself.  But  even  in 
such  cases  we  may  at  last  separate  it,  without  lacera- 
tion, from  the  tube  of  the  artery  above  and  below  the 
injury,  and  successively  from  the  muscular  coat  as  far 
as  the  neck  of  the  aneurism.  Then  it  is  clear  the  mus- 
cular coat  does  not  pass  beyond  the  partition  separa- 
ting the  cavity  of  the  artery  from  that  of  the  aneuris- 
mal sac,  over  which  it  is  not  prolonged,  but  terminates 
at  the  edge  of  the  rupture  like  a fringe,  or  in  obtuse 
points.  Errors  are  more  apt  to  occur  in  consequence 
of  the  aorta  and  sac  being  both  covered  by  the  pleura 
or  peritoneum. 

The  portion  of  the  aorta  within  the  pericardium  being 
only  covered  by  a thin  reflected  layer  of  this  membrane, 
such  layer  may  al.-^o  be  lacerated  when  the  proper  coats 
give  way,  and  blood  be  effused  into  the  cavity  of  the 
pericardium.  Examples  of  this  kind  are  related  by 
Walter,  Morgagni,  and  Scarpa  himself.  In  the  latter 
instance,  on  making  an  incision  into  the  concave  part 
of  the  aorta,  opposite  the  tumour  which  had  formed  un- 
der the  layer  of  the  pericardium,  which  had  also  burst 
by  a small  aperture,  its  internal  coat,  corresponding  to 
the  base  of  the  swelling,  was  quite  rough,  interspersed 


ANEURISM. 


95 


with  yellow  hard  spots,  and  actually  ulcerated  for  the 
space  of  an  inch  in  circumference.  The  preparation 
is  preserved  in  the  museum  at  Pavia. 

But  all  other  parts  of  the  aorta  having,  between  them 
and  the  pleura  and  peritoneum,  a cellular  sheath  of  a 
stronger  and  more  yielding  nature,  which  allows  itself 
to  be  distended  into  a sac,  and  being  strengthened  in- 
ternally by  polypous  layers,  and  externally  by  the 
pleura  or  peritoneum,  oppose  for  a long  while  the  fatal 
effusion  of  blood. 

Scarpa  believes  that  what  he  calls  the  slow,  morbid, 
steatomatous,  fungous,  squamous  degeneration  of  the 
internal  coat  of  the  artery  is  more  frequently  the  cause 
of  its  bursting  than  violent  exertions  of  the  whole  body, 
blows,  or  an  increased  impulse  of  the  heart.  This 
kind  of  diseased  change  is  very  common  in  the  curva- 
ture, and  in  the  thoracic  and  abdominal  trunks  of  the 
aorta.  In  the  incipient  state  of  such  disease  the  inter- 
nal coat  of  the  arterj’  loses,  for  a certain  space,  its 
beautiful  smoothness,  and  becomes  irregular  and 
wrinkled.  It  afterward  appears  interspersed  with  yel- 
low spots,  which  are  converted  into  grains  or  earthy 
scales,  or  into  steatomatous  and  cheese-like  concretions, 
which  render  the  internal  coac  of  the  artery  brittle,  and 
so  slightly  united  to  the  adjoining  muscular  coat,  that 
upon  being  merely  scratched  with  the  knife  or  point  of 
the  nail,  pieces  are  readily  detached  from  it,  and  on 
being  cut  it  gives  a crackling  sound,  similar  to  the 
breaking  of  an  egg-shell.  Tliis  ossification  cannot  be 
said  to  be  proper  to  old  age,  since  it  is  sometimes  met 
with  in  subjects  not  much  advanced  in  life.  The 
whole  of  the  side  of  the  artery,  in  that  portion  which 
is  occupied  by  the  morbid  affection,  is,  for  the  most 
part,  hard  and  rigid,  sometimes  soft  and  fungous,  and 
in  most  cases  the  canal  of  the  artery  is  preternaturally 
constricted.  In  the  highest  degree  of  this  morbid  dis- 
organization true  ulcerations  are  found  on  the  inside  of 
the  artery,  with  hard  and  fringed  edges,  fissures,  and  la- 
cerations of  the  internal  and  fibrous  coats  of  the  artery. 

Having  presented  the  reader  with  an  abridged  account 
of  the  most  important  remarks  made  by  Scarpa  in  sup- 
port of  the  doctrine  he  defends,  I now  annex  his  con- 
clusions. 1.  That  this  disease  is  invariably  formed 
by  the  rupture  of  the  proper  coats  of  the  artery.  2. 
That  the  aneurismal  sac  is  never  formed  by  a dilata- 
tion of  the  proper  coats  of  the  artery,  but  undoubtedly 
by  the  cellular  sheath  which  the  artery  receives  in  com- 
mon with  the  parts  contiguous  to  it ; over  which  cellu- 
lar sheath  the  pleura  is  placed  in  the  thorax,  and  the 
peritoneum  in  the  abdomen.  3.  That  if  the  aorta,  im- 
mediately above  the  heart,  appears  sometimes  increased 
beyond  its  natural  diameter,  this  is  not  common  to  all 
the  rest  of  the  artery,  and  when  the  aorta  in  the  vici- 
nity of  the  heart  yields  to  a dilatation  greater  than  na- 
tural, this  dilatation  does  not  constitute,  properly  speak- 
ing, the  essence  of  aneurism.  4.  That  there  are  none 
of  those  marks  regarded  by  medical  men  as  character- 
istic of  aneurism  from  dilatation,  which  may  not  be 
met  w'ith  in  aneurism  from  rupture,  including  even  the 
circumscribed  figure  of  the  tumour.  5.  That  the  dis- 
tinction of  aneurism  into  true  and  spurious,  adopted  in 
the  schools,  is  oidy  the  production  of  a false  theory  ; 
since  observation  shows  that  there  is  only  one  form  of 
the  disease,  or  that  caused  by  a rupture  of  the  j)roper 
coats  of  the  artery,  and  an  effu.sion  of  the  arterial 
blood  info  the  cellular  sheath  which  surrounds  the  rup- 
tured artery. — (See  Treatise  on  Aneurism,  by  A.  Scarpa, 
transl.  by  J.  H.  Wishart,  Edin.  1808.) 

Such  were  the  inferences  made  by  Scarpa,  in  1804, 
one  of  the  most  distinguished  anatomists  and  surgeons 
of  the  present  day  upon  the  continent.  It  has  been  al- 
ready stated,  that,  great  as  this  authority  is,  several 
eminent  modern  surgeons,  as  Richerand,  Boyer,  Du- 
bois, Uupuytren,  Sabatier,  Breschet,  <kc.,  did  not  yield 
to  it,  but  still  contended  that  in  some  aneurisms  the 
coats  of  the  artery  w'ere  dilated.  These  professors  in 
France  coincided  with  what  has  been  usually  taught 
upon  this  subject  in  the  surgical  schools  of  Great  Bri- 
tain. Every  lecturer  here  has  been  accustomed  to  de- 
scnbe  the  dkstinctions  of  aneurism  into  true  and  false, 
or  into  some  cases  which  are  accompanied  with  dilata- 
tion, and  into  others  which  are  attended  with  rupture 
of  the  arterial  coats.  A few  years  ago  Mr.  Hodgson, 
of  Birmingham,  published  a valuable  treatise  on  aneu- 
rism, ill  which  work  he  differs  from  Scarpa,  and  joins 
those  surgical  writers  who  believe  in  the  occa- 
sional dilatation  of  the  coats  of  the  arteries  in  this  dia- 


ease.  He  inquires,  “ Is  every  aneurism  produced  by  a 
destruction  of  the  internal  and  middle  coats  of  the  ves- 
sel, and  does  not  a partial  dilatation  of  these  coats  oc- 
casionally precede  and  give  rise  to  their  destruction  1 
I believe  that  this  is  frequently  the  case.  We  have 
seen  that  the  disorganization  of  the  coats  of  an  artery 
by  destroying  their  natural  elastipity,  will  give  rise  to 
permanent  dilatation  of  the  whole  circumference  of  the 
vessel ; and  there  is  every  reason  to  expect  that  a loss 
of  its  elasticity  in  a portion  only  of  the  diameter  of  the 
vessel,  will  give  rise  to  a partial  dilatation  of  its  coats. 
Indeed,  the  proofs  of  a partial  dilatation  of  the  coats  of 
an  artery,  particularly  of  the  aorta,  are  incontestably 
established  by  the  possibility  of  tracing  the  coats  of  the 
vessel  throughout  the  whole  extent  of  the  expansion, 
and  by  the  existence  of  those  morbid  appearances  in 
the  sac  which  are  peculiar  to  the  coats  of  the  arteries. 

“In  the  year  1811  (says  Mr.  Hodgson),  I dissected 
an  aneurism  of  the  aorta,  which  was  removed  from  the 
body  of  a young  woman  by  my  friend  Dr.  Farre.  The 
sac  was  as  large  as  a small  melon,  and  had  proved 
fatal  by  bursting  into  the  posterior  mediastinum,  and 
subsequently  into  the  cavity  of  the  thorax.  This  aorta 
exhibited  the  formation  of  aneurism  by  partial  dilata- 
tion in  three  distinct  stages.  The  internal  coat  was 
throughout  inflamed,  and  presented  a fleshy  and  irre- 
gular appearance.  At  the  arch  of  the  aorta  there  was 
a dilatation  not  larger  than  the  half  of  a small  pea. 
About  two  inches  lower  in  the  same  vessel  was  a se- 
cond dilatation,  which  would  have  contained  a hazel 
nut,  and  immediately  above  the  the  diaphragm  was  the 
large  aneurism  which  had  proved  fatal.  I removed 
that  portion  of  the  vessel  which  contained  the  smallest 
dilatation,  and  macerated  it  until  its  coats  could  be  se- 
parated without  violence.  I found  that  the  dilatation 
existed  equally  in  the  three  coats  of  the  vessel,  and, 
when  separated,  each  presented  the  appearance  of  a 
minute  aneurism.  The  second  dilatation  exhibited  the 
same  circumstances  in  a more  advanced  stage.  The 
coats  of  the  vessels  were  more  intimately  adherent  to 
each  other  than  in  a natural  state,  but  it  was  evident 
that  the  dilatation  consisted  in  a dilatation  of  the  inter- 
nal, the  middle,  and  the  external  coats  of  the  aorta.  In 
the  large  aneurism  the  disorganized  internal  and  mid- 
dle coats  could  be  traced  for  some  distaijce  into  the 
sac,  when  the  parts  contained  in  the  posterior  me- 
diastinum and  the  vertebrae  formed  the  remainder  of 
the  cyst.  There  can  be  little  doubt  that  the  sac  com- 
menced in  a dilatation  of  the  coats  of  the  vessel,  simi- 
lar to  those  appearances  which  existed  in  the  superior 
portion  of  the  dissection,  and  the  artery  appeared  to 
illustrate  the  formation  of  aneurism  by  partial  dilatation 
in  three  distinct  stages.” — Hodgson  on  the  Diseases 
of  Arteries  and  Veins,  p.  (ifi.  68.)  As  far  as  Kreysig’s 
information  extends,  nobody  before  Mr.  Hodgson  had  ex- 
amined the  structure  of  an  aneurismal  sac  in  this  accu- 
rate manner,  viz.  by  maceration  ; and  the  results,  he 
thinks,  are  not  liable  to  the  slightest  objections. — (See 
the  German  transl.  of  Mr.  Hodgson’s  work,  with  notes 
by  Kreysig  and  Koberwein,  p.  109.  Hanover,  1817.) 

Mr.  Hodgson  has  seen  this  partial  dilatation  in  almost 
all  the  arteries,  which  are  subject  to  aneurism;  at  the 
division  of  the  carotids  and  iliacs  ; in  the  arteries  of  the 
brain,  &c. ; and  he  agrees  with  Dr.  Baillie  ( Morbid  Ana- 
tomy, &c.),  I.aennec  (Cerattius,  Beschreib.  d.  Krankh. 
Preparate  d.  Anat.  Theatres  zu  Leip.  p.  408,  8vo.  1819), 
and  others,  that  aneurisms  at  the  origin  of  the  aorta 
are  generally  formed  by  dilatation  of  the  coats  of  the 
vessel . 

“ Partial  as  well  as  general  dilatation  Csays  Mr. 
Hodgson)  frequently  precedes  the  formation  of  aneu- 
rism in  the  arteries  of  the  extremities.  A gentleman 
had  a large  aneurism  in  the  thigh,  which  had  under- 
gone a spontaneous  cure.  Ujion  examining  the  limb 
after  death,  the  popliteal  artery  was  found  to  be  thick- 
ened and  covered  with  calcareous  matter.  A small 
pouch,  which  would  have  contained  the  seed  of  an 
orange,  originated  from  the  side  of  this  artery^.  This  lit- 
tle sac  was  evidently  formed  by  a dilatation  of  the  coats 
of  the  vessel.  A man  died  from  the  sloughing  of  an  aneu 
rism  in  the  ham ; in  the  femoral  artery  there  was  a 
small  aneurism  about  as  large  as  a walnut.  The  ex 
ternal  coat  was  dissected  from  the  surface  of  the  tu 
mour  to  a considerable  extent.  The  interna'  and  mid 
die  coats  were  evidently  dilated,  and  contri'/Uted  to  the 
formation  of  the  sac.  The  dilatation  ol  these  coats 
was  gradual,  and  they  continued  for  a considerable  dis 


ANEURISM. 


96 


tance  to  form  the  sac,  when  they  were  inseparably 
blended  with  the  surrounding  parts.” — (Op.  cit.  p.  70.) 

When  Mr.  A.  Bums  bears  testimony  to  the  fidelity 
and  accuracy  of  Scarpa’s  general  detail,  he  adds,  that 
perhaps  it  may  not  be  uniformly  found  that  “ the  root 
of  an  aneurism  never  includes  the  whole  circum- 
ference of  the  tube  of  an  artery.”  We  have,  says  he, 
a preparation  in  which  the  reverse  has  taken  place. 
In  this  case  the  whole  cylinder  of  the  vessel,  from  the 
heart  to  bevond  the  curvature,  is  equally  dilated ; and 
dilated  to  such  an  extent,  that  the  tumour  measures 
no  less  than  ten  inches  in  circumference.  Scarpa 
limits  dilatation,  says  Mr.  Burns,  to  that  state  of  an  ar- 
tery in  which  the  coats  remain  in  their  natural  relation 
to  each  other,  and  in  which  they  were  not  altered  in 
their  texture,  nor  lined  on  their  inner  surface  with 
“ polypous  layers.”  “ This,  however,  was  not  the  case 
in  the  instance  which  I have  brought  forward.  In  it 
you  have  seen  that  the  coats  were  much  dilated,  and 
also  very  much  altered  in  their  structure.  Externally 
and  internally  they  had  assumed  the  look  of  the  mem- 
branes of  the  fmtus,  only  they  w'ere  thicker  and  denser, 
but  they  were  equally  gelatinous  and  nearly  as  trans- 
parent ; and  on  their  inner  surface,  they  were  cmsted 
over  wth  the  laminae  of  coagulated  Ij-mph.  By  peeling 
off  this  incrustation,  after  the  sac  had  been  inverted, 
we  saw  plainly,  that  although  the  internal  coats  were 
round  the  complete  cylinder  of  the  vessel  much  dis- 
eased, and  considerably  dilated,  yet  they  were  not  di- 
lated in  the  same  degree  as  the  external  coverings  of 
the  artery.  At  irregular  distances,  longitudinal  rents 
were  formed  in  the  fibroHs  coats,  and  these  chasms 
were  filled  with  coagulating  hmiph.  The  internal 
coats  over  the  whole  circumference  of  the  vessel  had 
assumed  the  diseased  condition  which  in  aneurism  is 
generally  confined  to  a part  of  the  cylinder.  In  this 
tumour  all  the  coats  continued  for  a time  to  dilate 
equally,  but  at  length  the  internal  gave  way,  forming 
longitudinal  rents,  through  which  the  external  coats 
could  be  seen  after  the  Ijmiphatic  coating  had  been 
scraped  off.  In  this  instance,  had  the  sac  been  dis- 
sected in  the  early  stage,  it  would  have  presented  pre- 
cisely Che  same  appearances  as  those  described  by  Dr. 
Monro,  and  the  one  (the  aneurism  lately  examined  by 
the  surgical  editor  of  the  London  Med.  Re^new.”  Mr. 
Bums  afterward  expresses  doubts  whether  the  sac 
ever  acquires  a large  size  without  dilatation.  The  case 
reported  in  the  latter  periodical  work  was  the  largest 
that  he  knew  of,  in  which  all  the  coats  were  found  uni- 
formly dilated.  The  sac,  which  w'as  as  large  as  the 
fist,  was  lined  throughout  with  flakes  of  bone,  and 
thotigh  the  internal  coat  of  the  vessel  was  thus  patched, 
and  e.xtremely  thin  and  brittle,  it  did  not,  on  minute 
inspection,  any  w'here  exhibit  a solution  of  continuity. 
Mr.  A.  Burns  farther  states,  that  the  above  case,  re- 
ported by  himself,  was  the  only  one  out  of  fourteen 
which  did  not  corroborate  Scarpa’s  description. — (On 
Diseases  of  the  Heart,  &c.  p.  204.)  Mr.  Wilson,  after 
mentioning  the  frequency  of  aneurism  in  the  aorta, 
carotid,  subclavian,  and  axillary  arteries,  and  its  ra- 
rity in  the  brachial,  tells  us,  that  he  know's  of  no  ex- 
ample of  aneurism  below  the  elbow,  where  the  swell- 
ing could  not  be  traced  to  a Avound  of  the  coats  of  the 
artery.  He  adds,  that  true  aneurism  has  not  unfre- 
quently  occurred  in  the  internal  and  external  iliac 
arteries,  in  the  inguinal,  femoral,  and  very  frequently 
in  the  popliteal.  It  has  taken  place  in  the  posterior 
tibial  artery,  but  he  knows  of  no  instance  of  it  in  the 
anterior  tibial  or  peroneal  arteries.  “ I have  (says  he) 
met  with  only  one  instance  of  true  aneurism  aflecting 
any  of  the  branches  of  the  aorta  which  are  distributed 
to  the  abdominal  viscera.  In  the  year  1809,  on  inspect- 
ing the  body  of  a clergAunan,  in  the  presence  of  the  late 
Sir  W.  Farquahr,  a tumour  verA-  much  resembling 
the  heart  in  colour,  shape,  and  size,  api)eared  to  hang 
down  from  the  under  surface  of  the  left  lobe  of  the 
liver.  When  this  tumour  Avas  opened  and  carefully  in- 
spected, it  appeared  to  have  been  formed  by  the  left 
branch  of  the  hepatic  arterj'  having  become  very  much 
enlarged  and  aneurismal.  It  had  burst,  and  the  blood 
which  had  escaped  Avas  found  in  an  ini’terfect  cyst, 
panly  in  a fluid,  and  party  in  a coagulated  state, 
forming  a large  proportion  of  the  tumour.”  This  pre- 
paration is  in  Windmill-street. — See  Lectures  on  the 
Blood,  and  on  the  Anatomy,  Physiology,  and  Surgical 
Pathology  of  the  Vascular  System,  p.  379,  380,  8a’o. 
Lond.  1819.) 


The  facts  adduced  by  Mr.  Hodg.son  appear  sufficiently 
conclusive,  and  from  them  the  following  doctrine  is 
clearly  deducible. 

First,  That  numerous  aneurisms  are  formed  by  de- 
struction of  the  internal  and  middle  coats  of  an  artery, 
and  the  expansion  of  the  external  coat  into  a small  cyst, 
Avhich  giving  w'ay  from  distention,  the  surrounding 
parts,  whateA'er  may  be  their  structure,  form  the  re- 
mainder of  the  sac. 

Secondly,  That  sometimes  the  disease  commences  in 
the  dilatation  of  a portion  of  the  circumference  of  an 
arterA’.  This  dilatation  increases  until  the  coats  of  the 
vessel  give  Avay,  when  the  surrounding  parts  form  the 
sac,  in  the  same  manner  as  when  the  disease  is  in  the 
first  instance  produced  by  destruction  of  the  coats  of 
an  arter}-.—  P.  74.) 

The  conclusions  of  Mr.  Hodg.son,  as  he  himself  ex- 
plains, are  supported  by  the  observations  of  numerous 
writers. 

The  learned  Sabatier  says  there  can  be  no  doubt 
that  many  aneurisms  depend  upon  the  dilatation  of  the 
arterial  coats;  but  in  far  more  numerous  examples  the 
internal  tunics  are  ruptured,  and  it  is  the  cellular  coat 
alone  which  .separates  fiom  them,  and  enlarges  so  as 
to  form  the  aneurismal  sac  ; “ de  sorte  que  les  art^res, 
qui  sont  dans  ce  cas,  sont  diloriquees,  suivant  I’expres- 
sion  de  Lancisi.” 

It  is  difficult  to  conceive,  he  observes,  how  all  the 
coats  of  an  artery  can  dilate  and  yield  sufficiently  to 
form  the  investment  of  such  immense  tumours  as  some 
aneurisms  are.  Indeed,  that  verj'  tunic,  which  com- 
poses the  greater  part  of  the  thickness  of  the  vessel, 
and  which  is  termed  the  muscular  coat,  is  knowm  to 
consist  of  fibres  AA  hose  texture  is  firm,  and  little  capa- 
ble of  bearing  extension.  HoweA^er,  Haller,  in  descri- 
bing a very  large  aneurism,  situated  in  the  aorta,  near 
the  heart,  relates,  that  the  innermost  coat  of  this  A'essel 
Avas  ruptured  and  torn,  the  loose  jagged  edges  of  the 
laceration  being  Aisible  in  the  aneurismal  sac.  These 
were  squamous,  bony,  and  of  little  thickness ; while 
the  muscular  and  cellular  coats  were  quite  sound. 
Donald  Monro  noticed  the  same  thing  in  five  different 
aneurisms  in  the  course  of  the  femoral  and  popliteal  ar- 
teries of  a man  who  had  been  confined  a long  w hile  to 
his  bed  after  being  operated  upon  for  bubonocele. 
Monro  succeeded  in  tracing  the  fibres  of  the  muscular 
coat  over  the  swellings,  so  that  he  had  no  doubt  of  this 
tunic  being  dilated. — (See  Medecine  Op6ratoire,  t.  3, 
p.  160—162.) 

According  to  Richerand,  when  an  aneurism  is  recent 
and  of  small  size,  the  dissection  of  the  tumour  exhibits  a 
simple  di'atation  of  the  arterial  coats ; Avhile  in  the  other 
cases,  where  the  aneurism  is  large,  and  has  existed  a 
considerable  time,  the  internal  and  middle  coats  of  the 
vessel  are  inA-ariably  lacerated.  In  the  early  stage  of 
the  disease,  the  blood  which  fills  the  aneurismal  sac  is 
fluid,  and,  on  the  contrary,  m cases  AA'here  the  internal 
tunics  of  the  artery-  are  ruptured,  the  sac  contains 
more  or  less  coagulated  lATnph.  The  external  or  cellu- 
lar coat  composes  the  greater  part  of  the  cyst ; and  the 
coagulated  h-mph,  Avith  which  it  is  filled,  is  arranged 
in  layers,  the  density  of  which  is  described  as  being 
greater  in  proportion  to  the  length  of  time  AAhich  they 
haA’e  been  deposited.  Such  as  are  nearest  the  sac  are, 
therefore,  represented  as  being  most  compact,  and  con- 
taining the  smallest  quantity  of  the  colouring  matter  of 
the  blood ; more  deeply,  the  concretions  of  lymph  re- 
semble simple  coagula ; and  lastly,  the  blood  Avhich  is 
still  nearer  the  arterial  tube  retains  its  fluidity. 

After  the  aneurismal  sac,  has  been  cleansed  from  the 
lymph  and  coagulated  blood  which  it  contains,  its  pa- 
rietes  Avill  appear  to  be  almost  entirely  formed  of  the 
cellular  coat  of  the  arterj’.  Towards  the  bottom  may 
be  observ’ed  the  aperture,  arising  from  the  laceration 
of  the  internal  and  middle  coats,  Avhich,  being  much 
less  elastic  than  the  external,  are  ruptured  in  an  early 
stage  of  the  disea.se.  It  is  Avhen  these  tAAO  tunics  give 
Avay,  that  the  aneurismal  tumour  undergoes  a sudden 
and  considerable  increase  in  its  size ; for  then  the  cel- 
lular coat  alone  has  to  sustain  all  the  pressure  of  the 
blood,  which  noAV.  becoming  effused  into  a more  am- 
ple cyst,  loses  a great  deal  of  its  impetus,  coagulates 
and  forms  fibrous  masses ; circumstances  to  which 
may  be  ascribed  the  hardness  of  the  sAvelling,  the 
weakness  of  its  pulsation,  «kc. — (Nos.  Chir.  t.  4,  p 82, 
ed.  2.) 

But  this  author  seems  to  A'enture  far  bej'ond  the 


ANEURISM. 


bounds  of  accuracy,  when  he  represents  every  small 
aneurism  as  exhibiting  a dilatation  of  the  arterial  coats, 
unless  his  meaning  refer  more  particularly  to  the  outer 
coat  alone. 

The  reality  of  what  are  called  true  internal  aneurisms 
was  ably  urged  by  C.  F.  Ludwig,  in  a programma  written 
expressly  on  that  subject,— (Diagnostices  Chir.  Fragm. 
de  Aneurysmate  Interim ; Lips.  1805.)  But  an  inter- 
esting case,  exemplifying  an  aneurismal  dilatation  of  all 
the  coats  of  the  abdominal  aorta,  has  been  published 
by  Professor  N®gele  of  Heidelberg.  The  swelling  was 
as  large  as  a man’s  head,  and  weighed  about  five 
pounds.  The  aorta  began  to  be  dilated  at  the  point 
v/here  it  passes  into  the  cavity  of  the  abdomen  between 
the  crura  of  the  diaphragm.  This  dilatation  extended 
gradually  down  to  a point  about  four  finger-breadths 
from  the  bifurcation  of  the  aorta  into  the  iliac  arteries, 
at  which  point,  strictly  speaking,  the  large  aneurismal 
sac  commenced.  The  length  of  the  whole  dilated  part 
of  the  vessel  was  eleven  inches ; that  of  the  sac,  six  ; 
and  its  diameter  five  inches.  The  artery  was  not 
equally  dilated  in  every  direction,  the  expansion  being 
most  considerable  laterally  and  forwards.  Professor 
Nasgele  and  Ackermann  found  that  the  three  coats  of 
the  aorta,  the  internal,  muscular,  and  cellular,  were 
all  equally  dilated.  These  gentlemen  traced  the  mus- 
cular coat  with  the  scalpel  from  the  top  to  the  bottom 
of  the  tumour,  and  not  the  slightest  doubt  could  be 
entertained,  that  the  case  was  a true  aneurism. — (F. 
C.  Naegele,  Epistola  ad  T.  F.  Baltz,  qua  Historia  et 
Descriptio  Aneurysmatis,  quod  in  aorta  abdomiiiali  ob- 
servavit,  continetur.  Heidelb.  1816.) 

In  the  valuable  cases  collected  by  II.  F.  Janin,  very 
convincing  evidence  will  be  found  of  there  being  two 
kinds  of  aneurism ; one  attended  with  the  rupture  of 
the  coats  of  the  artery,  the  cellular  coat  alone  forming 
the  aneurismal  sac ; and  the  other,  consisting  in  an 
equal  dilatation  of  all  the  coats  of  the  artery.  Of  the 
latter  species  of  aneurism,  Janin  relates  three  very 
unequivocal  cases. — (.See  Annales  du  Cercle  Medical, 
t.  1,  Art.  2, 1820.; 

After  the  clear  demonstration  of  an  aneurismal  sac 
being  occasionally  comimsed  of  all  the  coats  of  an  ar- 
tery, as  afforded  in  the  dissections  and  pathological 
preparations  to  which  a reference  has  been  made,  the 
reader  will  be  better  prepared  to  judge  of  the  differ- 
ence existing  upon  this  subject  between  Scarpa  and 
other  modern  writers  ; and,  as  far  as  I can  judge,  the 
question  is  now  reduced  to  one,  whether  any  of  the  di- 
latations on  record,  said  to  comprise  all  the  arterial 
coats,  merit  the  name  of  aneurism.  We  have  seen, 
that  he  has  always  unequivocally  admitted  that  the 
arteries  may  be  dilated,  though  the  kind  of  dilatation  to 
which  he  alludes,  is  thought  by  him,  as  well  as  by  A. 
Burns,  and  my  friend  Mr.  Hodgson  'On  Di.seases  of 
Arteries,  »fec.  p.  58),  to  require  discrimination  in  a 
pathological  point  of  view.  “ It  is  proved  (says  Scarpa) 
by  dissection,  that  the  morbid  dilatation  is  circum- 
scribed by  the  proper  coats  of  the  diseased  artery  ; and 
that  the  inner  surface  of  the  sac,  formed  by  tlie  jiartial 
or  total  protrusion  of  the  arterial  tube,  is  never  filled 
with  polypous  lami[i;E,  or  layers  of  fibrine  disposed 
over  each  other  (a  fact  particularly  dwelt  upon  by 
Mr.  Hodg.son,  p.  82) ; which  layers  never  fail  to  be 
fonned  in  greater  or  smaller  quantity  in  the  cavity  of 
an  aneurism.”  The  opinion  that  these  lajers  of  coa- 
gula  are  not  met  wdth  in  small  dilatations  of  arteries, 
but  are  found  in  large  expansions  of  them,  he  says,  is 
contradicted  by  numerous  careful  observations,  and 
especially  by  a specimen,  actually  before  him  when  he 
was  writing,  where  a morbid  dilatation  of  the  arch 
of  the  aorta,  in  the  vicinity  of  its  origin  from  the 
heart,  six  inches  in  length,  and  five  in  breadth,  was 
entirely  free  from  any  of  the  larnellatcd  coagula  al- 
ways found  in  aneurisms.  On  the  contrary,  the  sac 
of  the  aneurism  is  formed  from  the  parts  surrounding 
the  wounded  or  ruptured  artery,  into  which  pouch, 
the  blood,  entering  as  into  a natural  receiver,  and  quite 
out  of  the  current  of  the  circulation,  moves  only 
slowly,  and  constantly  deposites  these  layers  of  fibrine, 
and  this  sometimes  in  such  quantity  as  to  fill  the  whole 
cyst.  Scarpa,  at  the  same  time,  particularly  explains, 
that  if  accidentally  furrows  or  fissures  exist  on  the 
inside  of  the  morbid  dilatation,  the  fibrine  may  be  de- 
jiosited  in  these  rough  places,  but  only  in  them.  These 
f.ssiires  and  inequalities  of  the  internal  surface  of  the 
morbidly  dilated  artery,  he  regards  strictly  as  so  many 
VoL.  1.— G 


beginnings  of  another  disease  of  the  vessel,  quite  dif- 
ferent from  dilatation,  that  is,  of  aneurism  subsequent 
to  dilatation. — (See  Mernoriasulla  Legatura  delle  prin- 
cipali  Arterie  degli  Arti,  con  una  Appendice  all’  Opera 
sulle  Aneurisma,  fol.  Pavia,  1817  ; or  the  Treatise  on 
Aneurism,  transl.  by  Wishart,  ed.  2,  p.  119,  Edinb 

In  this  manner,  no  doubt,  Scarpa  would  account  for 
the  presence  of  lamellated  coagula  in  the  case  reported 
by  Mr.  A.  Burns  (On  Diseases  of  the  Heart,  p.  306), 
though  the  latter  gentleman  himself,  for  reasons  al- 
ready detailed  in  the  foregoing  pages,  did  not  regard 
the  expansion  of  all  the  coats  of  the  artery,  as  corres- 
ponding to  the  morbid  dilatation  implied  by  Scarpa. 
Thus  Scarpa  farther  agrees  with  other  modern  writers, 
in  admitting  the  possibility  of  aneurism  becoming  in- 
grafted, as  it  were,  on  one  of  these  unnatural  dilata- 
tions, more  than  one  example  of  which  combination 
were  indeed  recited  in  his  first  work.  In  that  treatise 
he  has  asserted,  that  what  he  calls  morbid  dilatation, 
always  extends  to  the  whole  circumference  of  the 
vessel.  But  this  point  seems,  from  the  appendix,  to 
be  renounced,  as  he  now  observes,  “ Where  the  mor- 
bid dilatation  is  partial,  or  on  one  side  of  the  artery 
like  a tliimble  Tor  very  frequently,  even  in  the  arch 
of  the  aorta,  this  partial  dilatation  does  not  exceed  the 
size  of  half  a bean),  the  entrance  for  the  blood  into  this 
capsule  is  as  large  as  the  bottom  of  the  sac.”— (Transl. 
by  Wishart,  p.  120,  ed.  5.)  According  to  Scarpa, 
where  the  morbid  dilatation  occupies  the  whole  cir- 
cumference of  the  arterial  tube,  the  tumour  always  re- 
tain sa  cylindrical  or  oval  form ; and,  if  situated  in  such 
manner  that  it  can  be  compressed,  it  yields  very  readily 
to  pressure,  and  almost  disappears  ; and  after  death  is 
found  much  smaller  than  during  life.  On  the  contra- 
ry,  aneurism,  whether  preceded  by  dilatation  or  not, 
constantly  originates  from  one  side  of  the  ruptured 
artery.  The  entrance  for  the  blood  is  small,  compared 
with  the  size  of  the  fundus  of  the  sac  ; the  tumour  as- 
sumes an  irregular  shape;  }ields  with  difficulty  to 
pressure ; retains  nearly  the  same  size  in  the  dead  that 
it  had  in  the  living  body  ; and  its  sac,  instead  of  becom- 
ing thinner  as  the  swelling  enlarges,  as  the  coats  of  an 
artery  do  when  they  are  simply  affected  with  dilata- 
tion, attains  greater  thickness,  the  larger  the  aneurism 
grows.  These  essential  differences  between  the  two 
diseases  are  illustrated  by  an  interesting  case,  met 
with  by  Professor  Vacca,  where  a patient  died  with  an 
aneurism  of  one  subclavian  artery,  and  a simple  mor- 
bid dilatation  of  the  whole  circumference  of  the  other. 
— ^See  Sprengel,  Storia  delle  Operaz.  di  Chir.  trad. 
Ital.  Parte  2,  p.  294.) 

When  these  two  different  affections  are  situated  in 
the  thorax  or  abdomen,  it  is  impossible  to  discriminate 
them  from  each  other  before  death.  The  symptoms 
occasioned  by  the  pressure  of  the  tumour  on  the  vis- 
cera, must  be  nearly  the  same,  whether  caused  by  a 
morbid  dilatation  or  an  aneurism.  The  means  for  re- 
tarding their  fatal  termination  is  also  the  same  in  both 
forms  of  the  disease.  With  regard  to  the  pos.sibility 
of  cure,  however,  Scarpa  says,  that  there  is  great  dif- 
ference ; for  when  the  case  is  an  internal  aneurism, 
there  may  be  some  slight  hope  of  a radical  cure  by  the 
efforts  of  nature  and  art,  which  hope  can  never  be  en- 
tertained in  a case  of  morbid  dilatation ; a fact  which 
is  accounted  for  by  no  laminated  coagula  being  depo- 
sited in  the  latter  disease. — (On  Aneurism,  transl.  by 
Wishart,  p.  124,  ed.  2.)  A great  deal  of  the  latter 
statement  coincides  with  the  observations  of  Mr 
Hodgson,  who  particularly  notices,  that  he  has  never 
met  with  lamellated  coagula  in  such  sacs,  as  consist 
either  in  a general  or  partial  dilatation  of  the  coats  of 
the  vessel. — (On  Diseases  of  Arteries,  &c.  p.  82.) 
Whether  this  ever  takes  place  in  such  cases  may  still 
be  a question,  because,  if  Professor  Naegele  has  given 
a correct  description  of  the  aneurism  of  the  abdomi 
nal  aorta  already  mentioned,  which  aneurism  was  of 
a large  size,  and  consisted  of  a dilatation  of  all  the 
coats  of  the  vessel,  there  was  in  this  rare  example  a 
large  quantity  of  the.se  layers  of  coagulated  blood. 
Yet,  whether  the  Professor  actually  means  the  fibrine, 
arranged  in  lamina),  or  only  common  coagulated  blood, 
which,  as  every  one  knows,  may  be  found  either  in  the 
cy.sts  of  dilated  or  of  ruptured  arteries,  may  admit  of 
doubt.  ’I'he  statement,  therefore,  made  by  Hodgson 
and  Scarpa,  may  not  be  contrary  to  what  was  really 
seen  by  Ntegele  and  Ackermann.  The  following  case, 


98 


ANEURISM. 


however,  observed  by  Laennec,  and  quoted  by  a mo- 
dem writer,  must  (if  correctly  reported;  ati'ord  not 
only  an  unequivocal  specimen  of  aneurism  by  dilata- 
tion of  all  the  coats  of  the  aorta,  but  of  laminated  co- 
agula  within  its  cavity.  “ In  homine  enim,  qui  repente 
sub  atrocissimis  pectoris  doloribus  curruit,  praeter 
aortarn  adscendentem  in  aneurysma  ita  expansam,  ut 
neonati  infantis  caput  aequaret,  cystidam  aneurismati- 
cam  immediate  supra  arteriae  cceliacae  ortam  magnitu- 
dine  nusis  juglandis  invenit,  quae  luculenter  ostendit 
sinum  communicantem  cum  arteriae  cylindro  per  fora- 
men magmtudine  amygdalae,  diametro  toiius  arteriae 
illo  loco  non  mutato.  Saccus  hie  cultro  anatomico  ac- 
curate ac  subtilliter  subjectus,  eamdem  structuram, 
easdem  ostendit  membranas,  quibus  gaudebat  arteria, 
e cujits  latere  excreverat ; caeterum  massis  grumosis, 
sive  fibrosis  erat  impletus.  Inde  igitur  patet,  hoc  an- 
eurysma sacciforme  et  laterali  et  partiali  quidem  tuni- 
carum  aortae  dilatatione  ortum  esse.” — (J.  H.  G.  Ehr- 
hardt,  De  Aneurysmate  Aortae,  p.  13,  4to.  Lips.  1820.) 

From  what  has  been  stated,  then,  it  appears,  that  there 
is  only  one  principal  point  of  diflerence  between  Scarjia 
and  other  writers,  and  this  resolves  itself  into  the 
question,  whether  a dilatation  of  an  artery,  arising  at 
one  particular  side  of  the  vessel,  and  lined  by  its  in- 
ternal coat,  ought  not  to  be  regarded  as  an  aneurism, 
because  its  communication  with  the  tube  of  the  artery 
is  more  capacious  than  what  exists  in  other  aneurisms, 
where  the  inner  coat  has  given  way,  and  because  it 
rarely  (perhaps  never)  contains  laminated  coagula, 
unless  fissures  should  happen  to  exist  at  some  points 
of  the  inner  arterial  tunic  thus  expanded  1 

The  greater  number  of  aneurisms  increase  gradu- 
ally, and  sooner  or  later  incline  to  the  side  on  w'hich 
the  least  resistance  is  experienced.  De  Haen  men- 
tions an  aneurism  of  the  aorta,  which  first  made  its 
appearance  between  the  second  and  third  ribs  of  the 
left  side,  and  which,  instead  of  growing  larger,  as  is 
usual,  subsided,  and  could  neither  be  seen  nor  felt  for 
more  than  a month  before  the  patient's  decease,  al- 
though, on  opening  the  body,  a tumour  of  the  arch  of 
the  aorta  was  found,  three  times  as  large  as  the  first. 
De  Haen  imputes  the  sudden  disappearance  of  the 
swelling  to  its  weight,  the  yielding  of  the  parts  with 
which  it  was  connected,  and  to  its  gravitating  into  the 
chest,  when  the  patient  lay  on  his  right  side ; for  the 
difficulty  of  breathing,  and  other  complaints,  produced 
by  the  pressure  on  the  lungs,  underwent  a material 
increase  as  soon  as  the  tumour  ceased  to  protrude. 

The  pulsations  which  accompany  true  aneurisms 
continue  to  be  strong,  until  the  inner  coats  of  the  ves- 
sel give  way,  or  the  layers  of  coagulated  blood,  lodged 
in  the  sac,  are  numerous.  Hence,  when  soft  swell- 
ings, situated  near  any  large  arteries,  lose  their  pulsa- 
tory motion,  their  course,  precise  situation,  and  other 
circumstances,  ought  to  be  most  carefully  investigated, 
before  any  decision  is  made  about  the  mode  of  treat- 
ment. 

A few  years  ago,  I saw  a man  in  St.  Bartholomew’s 
Hospital,  who  had  a large  swelling  of  great  solidity, 
occupying  the  ham,  and  apparently  extending  a good 
way  forwards  round  the  condyles  of  the  femur.  Its  hard- 
ness, shape,  large  size,  and  entire  freedom  from  pulsa- 
tion not  only  then,  but  at  an  earlier  period,  as  far  as  could 
be  collected  from  the  patient’s  own  account,  led  to  the 
belief,  that  the  case  was  probably  a tumour  compli- 
cated with  exostosis  of  the  femur,  and  as  this  opinion 
seemed  to  be  confirmed  by  no  fluid  escaping  from  a 
puncture  made  with  a lancet,  amputation  was  per- 
formed. To  our  surprise,  however,  dissection  proved, 
fnat  the  disease  was  a large  diffused  popliteal  aneu- 
rism, in  which  the  spontaneous  cure  by  an  oblitera- 
tion of  the  sac  with  coagula  was  taking  place. — (See 
Med.  Chir.  Trans,  vol.  8,  p.  497.; 

In  many  instances  the  most  fatal  accidents  have 
happened,  in  consequence  of  incisions  having  been 
made  in  aneurisms,  which  were  mistaken  for  abscesses 
because  there  was  no  pulsation.  Vesalius  was  con- 
sulted about  a tumour  of  the  back,  which  he  pronounced 
to  be  an  aneurism.  Soon  afterward  an  imprudent 
practitioner  made  an  opening  in  the  swelling,  and  the 
patient  bled  to  death  in  a very  short  time.  Kuysch  re- 
lates that  a friend  of  his  opened  a tumour  near  the  heel 
not  supposed  to  be  an  aneurism,  and  the  greatest  diffi- 
culty w’as  experienced  in  suppressing  the  hemorrhage. 
De  Haen  speaks  of  a patient,  who  died  in  conseriuence 
of  an  opening  w’hich  had  been  made  in  a similar  swell- 


ing at  the  knee,  although  Boerhaave  had  given 
advice  against  the  performance  of  such  an  operation. 
Palfin,  Schlitting,  Warner,  and  others,  have  recorded 
mistakes  of  the  same  kind. — (Sabatier,  t.  3,  p.  167.) 
Ferrand,  head  surgeon  of  the  Hotel  Dieu,  mistook  an 
axillary  aneurism  for  an  abscess,  plunged  his  bistoury 
into  the  swelling,  and  killed  the  patient.  “ J’ai  ete 
temoin  d’erreurs  semblables,  commises  par  les  practi- 
ciens  non  moins  fameux  ; et  si  des  aneurismes  ex- 
ternes  on  passe  ^ ceux  des  artdres  placees  d l’int<^- 
rieur,  les  erreurs  ne  sont  ni  moins  ordinaires  ni  de 
moindre  consequence.” — (Richerand,  Nosogr.  Chir. 
t.  4,  p.  75,  4d.  2.) 

Notwithstanding  a pulsation  is  one  of  the  most 
prominent  symptoms  of  an  aneurism,  it  is  not  to  be 
inferred,  that  every  swelling  which  pulsates  is  un- 
questionably of  this  description;  for,  as  Mr.  W'arner 
has  explained,  it  does  happen  that  mere  imposthu- 
mations,  or  collections  of  matter,  arising  from  external 
as  well  as  internal  causes,  are  sometimes  so  imme- 
diately situated  upon  the  heart  itself,  and  at  other 
limes  upon  some  of  the  principal  arteries,  as  to  par- 
take in  the  most  regular  manner  of  their  contraction 
and  dilatation.  He  details  the  particulars  of  a boy, 
about  thirteen  years  of  age,  whose  breast-bone  had 
been  badly  fractured,  and  who  was  admitted  into  Guy’s 
Hospital  a fortnight  after  the  accident  had  happened. 

The  broken  parts  of  the  bone  were  removed  some 
distance  from  each  other.  The  intermediate  space  was 
occupied  by  a tumour  of  a considerable  size ; the  in- 
teguments were  of  their  natural  complexion.  The 
swelling  had  as.  regular  a contraction  and  dilatation 
as  the  heart  itself,  or  the  aorta,  could  be  supposed  to 
have.  Upon  pressure  the  tumour  receded ; upon  a re- 
moval of  the  pressure  the  tumour  immediately  resumed 
its  former  size ; all  these  are  allowed  to  be  distin- 
guishing signs  of  a recent  true  aneurism.  The  situa- 
tion and  symptoms  of  this  swelling  were  judged  suffi- 
cient reasons  for  considering  the  nature  of  the  disease 
as  uncertain  : on  which  account,  it  w'as  left  to  take  iw 
own  course. 

“ The  event  was  the  tumour  burst  in  about  three 
weeks  after  his  admission,  discharged  a considerable 
quantity  of  matter,  and  the  patient  did  well  by  very 
superficial  applications.” — (Cases  in  Surgery,  edit.  4, 
p.  155.) 

An  extraordinary  form  of  disease,  having  very  much 
the  appearance  of  an  aneurism,  sometimes  presents 
itself.  A sw'elling,  attended  with  considerable  pain 
and  a strong  pulsation,  is  gradually  produced  high  up 
the  arm,  and  at  length  attains  a verj’  large  size.  The 
strength  of  the  throbbings  at  first  leads  to  the  suspi- 
cion that  the  case  must  be  an  aneurism  ; but  on  care- 
ful examination  the  humerus  is  found  to  have  given 
way  at  a point  involved  in  the  disease,  and  here  to  be 
as  flexible  as  if  there  were  a fracture.  This  circum- 
stance, and  the  extension  of  the  swelling  too  far  away 
from  the  track  of  the  artery,  in  time  raise  doubts  about 
the  case  being  an  aneurism.  The  patient  ultimately 
falls  a victim  to  the  effects  of  the  disease  on  the  consti- 
tution, and  w'hen  the  arm  is  dissected  after  death,  the 
tumour  is  found  to  consist  of  a sarcomatous  or  medul- 
lary mass,  occupjing  the  central  portion  of  the  Umb, 
and  accompanied  with  a solution  of  continuity  extend- 
ing completely  through  the  whole  thickness  of  the 
bone.  Two  cases  of  this  description  were  admitted 
into  St.  Bartholomew’s  Hospital  m the  course  of  the 
year  1820.  One  of  these  patients,  a woman,  I had  an 
opportunity  of  seeing  ; and  after  her  death  the  real 
nature  of  the  disease  was  proved  by  dissection.  My 
friend  Mr.  Vincent  has  seen  a similar  disease  in  the 
leg,  resembling  aneurism  in  the  circumstance  of  pulsa 
tion,  but  attended  with  destruction  of  a part  of  the  tibia, 
and  a moveableness  of  the  separated  ends  of  the  bone. 

A few  years  ago,  I saw  a large  abscess  in  the  situa- 
tion of  the  quadrants  lumborum  muscle,  which  pul- 
sated so  strongly  that  the  case  was  supposed  by  several 
experienced  men  to  be  an  aneurism  of  the  abdominal 
aorta.  The  patient  w'as  a boy  belonging  to  Christ’s 
Hospital,  and  under  the  care  of  the  late  Mr.  Ramsden, 
surgeon  to  that  establishment,  by  whose  discernment 
the  real  nature  of  the  case  was  detected.  It  is  curious 
that  in  this  instance  the  pulsations  of  the  swelling 
suddenly  ceased,  after  having  continued  in  a very 
strong  and  manifest  way  and  without  interruption  for 
several  weeks,  during  which  it  was  under  the  observa- 
tion of  the  ajiove  eminent  practitioner. 


ANEURISM. 


99 


As  Mr.  Wilson  has  observed,  any  encysted  or  even 
solid  tumour,  situated  in  the  neighbourhood  of,  or  upon 
a large  artery,  may  have  a considerable  degree  of  mo- 
tion communicated  to  it  from  the  pulsation  of  the  artery. 
The  thyroid  gland,  when  a bronchocele  is  formed,  oc- 
casionally receives  a pulsatory  motion  from  the  carotid 
arteries.  This  may  be  mistaken  for  an  aneurism,  from 
which  disease,  however,  it  can  be  discriminated  by 
placing  our  fingers  behind  the  tumour  and  drawing  it 
forwards,  when  the  pulsation  ceases.  But  there  are 
other  criteria  for  distinguishing  a swelling  on  or  near 
an  artery  from  an  aneurism.  In  such  a case  the  whole 
tumour  moves  at  once,  without  any  alteration  of  size. 
In  an  aneurism  the  swelling  does  not  simply  move,  it 
expands.  A tumour  of  the  thyroid  gland,  having  ap- 
parently a pulsatory  motion,  may  be  known  not  to  be 
an  aneurism  of  the  carotid,  by  observing  that  from  its 
connexion  with  the  laryn.x  it  follows  the  movements 
of  the  latter  in  deglutition.  Aneurisms,  not  of  very 
long  standing,  and  not  containing  a large  mass  of  lami- 
nated coagula,  may  also  be  diminished,  or  rendered 
more  or  less  flaccid,  by  pressing  the  artery  leading  to 
the  disease. — (See  Wilson  on  the  Blood,  Anatomy,  Pa- 
thology, <fec.  of  the  Vascular  System,  p.  385  ; and  Burns 
on  the  Heart,  p.  257.)  In  cases  of  much  ambiguity, 
the  stethoscope  will  sometimes  convey  the  necessary 
information.  In  a doubtful  instance  of  aneurism  of 
the  groin  Mr.  Brodie  found  all  obscurity  cease  on  the 
application  of  this  instrument. — (Sir  A.  Cooper’s  Lec- 
tures, vol.  2,  p.  46.) 

The  following  case,  recorded  by  Pelletan,  shows, 
that  an  artery  running  more  superficially  than  natural, 
may  under  particular  circumstances  give  rise  to  th6 
suspicion  of  an  aneurism.  A strong,  robust  man, 
about  forty  years  of  age,  was  in  the  habit  of  going  on 
foot  to  dine  three  leagues  from  Paris  every  day,  on  the 
completion  of  his  business.  One  day  having  been  this 
distance  and  returned,  he  felt  an  acute  pain  along  the 
leg  and  in  the  right  ankle.  The  pain  did  not  subside, 
and  a tumour  appeared  at  the  lower  third  of  the  leg 
opposite  the  space  between  the  two  bones.  The  skin 
was  of  a yellowish  colour  from  effused  blood,  and  a 
pulsation  existed  by  which  the  hand  of  an  examiner 
was  lifted  up.  There  seemed  great  reason  for  con- 
cluding that  the  case  was  an  aneuri.smal  swelling.  In 
comparing  the  affected  limb  with  the  sound  one,  how- 
ever, Pelletan  perceived  in  the  latter  a similar  kind  of 
throbbing.  In  short,  in  both  legs  the  pulsation  of  an 
arterial  tube  could  be  felt  for  three  inches,  and  Pelletan 
distinctly  ascertained  that  in  the  diseased  member  the 
throbbing  did  not  extend  to  the  whole  of  the  tumour, 
but  only  lengthwise.  By  a particular  disposition  in 
this  individual,  the  anterior  tibial  artery,  which  usually 
runs  along  the  interosseous  ligament,  covered  by  the 
tibialis  anticus  and  extensor  communis  digitorum 
pedis,  came  out  from  between  these  muscles  at  the 
middle  of  the  leg,  and  lay  immediately  under  the  skin 
and  the  fascia. 

The  swelling  and  ecchymo.sis  gradually  dispersed, 
and  the  symptoms  were  supposed  to  originate  from 
the  rupture  of  some  muscular  fibres. — (Clinique  Chir. 
t.  1,  p.  101,  102.1 

Whenever  an  aneurismal  sac  of  immoderate  size 
beats  violently  and  for  a long  v hile  against  the  bones, 
as  the  sternum,  ribs,  clavicle,  and  vertebrae,  they  are  in 
the  end  invariably  destroyed,  so  that  the  aneurismal 
sac  elevates  the  integuments  of  the  thorax,  or  back, 
and  pulsates  immediately  under  the  skin.  Scarpa, 
with  the  best  modern  writers,  attributes  the  effect  to 
absorption  in  con.sequence  of  the  pressure. 

J.  L.  Petit  saw  the  condyles  of  the  femur  and  the 
upper  head  of  the  tibia  almost  destroyed  by  an  aneu- 
rism of  the  popliteal  artery  ; and  another  case  in  which 
the  caries  and  absorption  of  bone  were  very  extensive, 
is  reported  by  Rosenmiiller. — lAnhang  zu  Scarpa  iib. 
d.  Pulsadergeschwulste,  p.  364.)  According  to  Mr. 
Hodgson,  the  carious  and  corroded  state  of  the  bones 
in  aneurism  is  never  attended  with  the  fonnation  of 
pus  ; “ at  lea.st  the  di-scovery  of  pus  in  its  vicinity  has 
not  been  remarked  by  those  who  have  examined  such 
cases.  In  this  respect,  therefore,  it  differs  essentially 
from  common  caries  or  ulceration  of  the  bones.  Ex- 
foliation also  is  very  rarely  attendant  ujioii  it ; from 
which  circumstance  one  important  practical  observa- 
tion is  deducible,  namely,  that  if  the  aneurism  be  cured 
the  bones  will  recover  their  healthy  state,  without  un- 
dergoing those  jirocesses  which  take  place  in  the  cure 

G 2 


of  caries  or  necrosis.”— (On  the  Diseases  of  Arteries 
and  Veins,  p.  80.) 

The  same  author  confirms  the  remark  made  by  Dr. 
W.  Hunter  (Med.  Obs.  and  Inquiries,  vol.  1,  p.  384), 
Scarpa  (On  Aneurism,  p.  100,  ed.  2),  and  others,  that 
cartilage  is  less  rapidly  destroyed  by  the  pressure  of 
aneurism  than  bone.  This  fact  is  strikingly  illustrated 
in  a case  of  aneurism  of  the  thoracic  aorta  recorded  in 
another  modern  publication : the  bodies  of  the  vertebrae 
from  the  fourth  down  to  the  ninth  were  carious ; the 
four  lowest  in  particular : yet  the  intervertebral  car- 
tilages were  not  materially  affected. — IF.  L.  Kreysig, 
Die  Krankheiten  des  Herzens,  b.  3,  p.  176,  8vo,  Berlin, 
1817.) 

A case  is  related  by  Pelletan,  to  which  I refer  the 
reader,  as  exemplifying  not  only  the  degree  in  which 
internal  aneurisms  may  injure  the  vertebrae,  but  also 
the  occasional  possibility  of  such  diseases  being  mis- 
taken for  rheumatism  or  a lumbar  abscess. — (See  Cli- 
nique Chir.  t.  1,  p.  97—100.) 

CAUSES  OF  ANEURISM. 

In  many  instances  it  is  difficult  to  assign  any  cause 
for  the  commencement  of  the  disease.  Among  the  cir- 
stances  which  predispose  to  aneurisms,  however,  the 
large  size  of  the  vessels  may  undoubtedly  be  reckoned. 
Those  trunks  which  are  near  the  heart  are  said  to  have 
much  thinner  parietes,  in  relation  to  the  magnitude  of 
the  column  of  blood  with  which  they  are  filled,  than 
the  arteries  of  smaller  diameter ; and  since  the  lateral 
pressure  of  this  fluid  against  the  sides  of  the  arteries, 
is  in  a ratio  to  the  magnitude  of  these  vessels,  it  fol- 
lows that  aneurisms  must  be  much  more  frequent  in 
the  trunks  near  the  heart  than  in  such  as  are  remote 
from  the  source  of  the  circulation.— (Richerand,  No- 
sogr.  Chir.  t.  4,  p.  72,  edit.  2.)  The  whole  arterial 
system  is  liable  to  Aneurisms ; but,  says  Pelletan,  ex- 
perience proves  that  the  internal  arteries  are  much 
more  frequently  affected  than  those  which  are  external. 
— (Clinique  Chir.  t.  1,  p.  54.) 

The  curvatures  of  the  arteries  are  another  predis- 
posing cause  of  the  disease ; and,  according  to  Riche- 
rand, such  cause  has  manifest  effect  in  determining 
the  formation  of  the  great  sinus  of  the  aorta,  the  dilata- 
tion which  exists  between  the  cross  and  the  origin  of 
this  large  artery,  and  is  the  more  considerable  the  older 
the  person  is : Monro  even  thought  that  one-half  of 
old  persons  have  an  aneurism  at  the  beginning  of  the 
aorta.  And  with  respect  to  aneurisms  in  general, 
which  are  preceded  by  calcareous  depositions,  thicken- 
ing, and  disease  of  the  coats  of  the  vessel,  they  are 
most  frequently  met  with  in  persons  of  advanced  age. 
Aneurisms  from  wounds  are  of  cour.se  often  seen  in 
individuals  of  every  age.  In  old  people  the  coats  of 
the  arteries  are  subject  to  a disease  which  renders 
them  incapable  of  making  due  resistance  to  the  lateral 
impulse  of  the  blood.  The  disease  here  alluded  to  is 
what  is  described  in  a foregoing  part  of  this  article, 
one  common  effect  of  which  is  the  deposition  of  calca- 
reous matter  between  the  inner  and  muscular  coats  of 
the  arteries.  “ People  in  the  early  part  of  life,”  says 
Mr.  Wikson,  “ are  not  very  subject  to  these  calcareous 
depositions ; but  I have  occasionally  met  with  them  in 
the  arteries  of  very  young  people.  1 have  seen  a well- 
marked  deposition  of  the  phosphate  of  lime  in  the  arte- 
ries of  a child  under  three  years  of  age.”  He  adds, 
that  few  persons  above  the  age  of  sixty  are  free  from 
these  ossifications. — (On  the  Blood,  and  on  the  Anato- 
my, Pathology,  &c.  of  the  Vascular  System,  p.  375, 
Loud.  1819.) 

Though  spontaneous  aneurisms  are  most  common  in 
old  persons,  the  disease  is  not  absolutely  confined  to 
them ; for  I assisted  Mr.  Docker  at  Canterbury  in  an 
operation  for  the  cure  of  a popliteal  aneurism  in  a pos- 
tillion, whose  age  must  have  been  under  thirty;  and 
Mr.  Wilson  says  that  he  has  met  with  several  instances 
of  the  di.sease  in  the  aorta  and  other  vessels,  where  the 
patients  were  not  more  than  forty  years  of  age. — (Op. 
cit.  p.  376.) 

According  to  Sir  Astley  Cooper,  the  time  of  life 
when  aneurism  generally  occurs,  is  between  the  ages 
of  thirty  and  fifty ; an  age  when  exercise  is  consider- 
able and  strength  on  the  decline.  In  very  old  age  the 
disease  is  not  so  common.  However,  he  operated  suc- 
cessfully on  a ca.se  of  popliteal  aneurism  where  the  pa- 
tient was  eighty  four  or  eighty-five  years  old.  He  ope- 
rated  with  success  on  another  man  sixty-nine  years  of 


100 


ANEURISM. 


age.  He  has  also  seen  a boy  only  eleven  years  old 
with  aneurism  of  the  anterior  tibial  artery.  The  man 
of  more  than  eighty  is  the  oldest,  and  the  boy  of  eleven 
the  youngest,  aneurismal  patients  he  has  ever  seen. — 
(See  Lectures,  vol.  2,  p.  40.) 

Richerand  affirms,  that  out  of  twelve  popliteal  aneu- 
risms which  he  has  seen  in  hospital  or  private  prac- 
tice, ten  were  caused  by  a violent  extension  of  the  leg. 
This  statement,  he  says,  will  derive  confirmation  from 
the  following  experiment. 

Place  the  knee  of  a dead  subject  on  the  edge  of  a 
firm  table,  and  press  on  the  heel  so  as  forcibly  to  extend 
the  leg  far  enough  to  make  the  ligaments  of  the  ham 
snap.  Now  dissect  the  parts,  cut  out  the  artery,  and 
examine  its  parietes  in  a good  ligbi,  when  the  lace- 
rations of  the  middle  coat  will  be  observable  and  ren- 
dered manifest  by  the  circumstance  of  those  places  ap- 
pearing semitransparent  where  the  fibres  are  separated, 
the  parietes  at  such  points  merely  consisting  of  the  in- 
ternal and  external  tunics. — (Nosogr.  Chir.  t.  4,  p.  73, 
74,  edit.  2.)  But  the  insufficiency  of  this  explanation 
is  clear  enough  from  the  fact  that  such  violence  as  is 
requisite  to  break  the  ligaments  of  the  knee,  cannot  be 
imagined  to  happen  in  the  accidents  which  ordinarily 
bring  on  aneurism  in  the  ham. 

The  implicit  belief  also  which  Richerand  seems  to 
place  in  the  idea  that  the  laceration  of  the  middle  coat 
of  an  artery  will  bring  on  an  aneurism,  while  the  inner 
coat  is  perfect,  will  appear  to  be  unfounded,  when  it  is 
remembered  that  Hunter,  Home,  and  Scarpa  even  dis- 
sected off  the  external  and  middle  coats  of  arteries, 
without  being  able  in  this  manner  to  cause  an  aneu- 
rism. Nay,  where  the  experiment  has  been  made  of 
applying  a tight  ligature  to  an  artery,  and  immediately 
removing  it  again  in  order  to  determine  whether  the  di- 
vision of  both  the  inner  coats  of  the  vessel  would 
terminate  in  an  obliteration  of  the  tube  of  the  vessel, 
no  aneurism  has  been  the  consequence. 

Pelletan  accounts  for  the  frequency  of  popliteal 
aneurisms  somewhat  differently  from  Richerand : 
speaking  of  tho-two  principal  motions  of  the  knee,  viz ; 
extension  and  flexion,  he  remarks,  that  the  first  of  these 
is  so  limited  that  it  is  actually  an  incipient  flexion  ne- 
cessarily produced  by  the  curvature  backward  both  of 
the  condyles  of  the  femur  and  those  of  the  tibia.  This 
curvature,  which  would  seem  to  protect  the  popliteal 
artery  against  any  dangerous  elongation  that  might 
otherwise  be  caused  by  a forcible  extension  of  the 
joint,  becomes  the  very  source  of  such  an  elongation 
in  persons  who  are  accustomed  to  keep  their  limbs 
bent,  or  who  from  this  state  proceed  hastily  and  vio- 
lently to  extend  the  leg.  The  arterial  tubes  are  really 
shortened  when  the  limbs  are  in  the  state  of  flexion,  and 
lengthened  when  the  extension  of  the  members  renders 
it  necessary.  Hence,  says  Pelletan,  it  is  manifest  that 
an  habitually  shortened  state  of  these  vessels,  and  their 
suddeti  elongation,  must  be  attended  with  hazard  of 
runturing  their  parietes. — ^Clinique  Chirurgicale,  t.  1, 

p.  112.) 

The  opinion  of  Pelletan,  however,  is  quite  untenable ; 
because  Mr.  Hodgson  has  several  times  repeated  the 
experiment  mentioned  by  Richerand,  and  found,  as 
that  gentleman  did,  that  the  coats  of  the  artery  were 
never  lacerated  unless  the  degree  of  violence  had  been 
such  as  to  rupture  the  ligaments  of  the  knee. — ,On 
Diseases  of  Arteries,  &c.  p.  64.) 

Aneurisms  are  exceedingly  common  in  the  aoi  ta,  and 
they  are  particularly  often  met  with  in  the  popliteal  ar- 
tery. The  vessels  which  are  next  to  these  the  most 
usually  affected,  are  the  crural,  common  carotid,  sub- 
clavian, and  brachial  arteries.  The  temporal  .and  occi- 
pital arteries,  and  those  of  the  leg,  fool,  fore-arm,  and 
hand,  are  far  less  frequently  the  situations  of  the  pre- 
sent disease.  But  although  it  is  true  that  the  larger  ar- 
teries are  the  most  subject  to  the  ordinary  species 
of  aneurisms,  the  smaller  arteries  seem  to  be  more 
immediately  concerned  in  the  formation  of  one  pe- 
culiar aneurismal  disease,  now  well  known  by  the 
name  of  the  aneurism  by  anastomosis,  of  which  I shall 
hereafter  speak. 

According  to  surgical  WTilers,  the  causes  of  aneu- 
risms operate  either  by  weakening  the  arterial  parietes 
or  by  increasing  the  lateral  impulse  of  the  blood  against 
the  sides  of  these  vessels.  It  is  said  to  be  in  both  these 
ways  that  the  disease  is  occasioned  by  violent  contn-  ■ 
sions  of  the  arteries,  the  abuse  of  spirituous  drinks, 
fre(pient  mercurial  courses,  fits  of  anger,  rough  exer- 


cise, exertions  in  lifting  heavy  burdens,  &c.  In  certain 
persons  aneurisms  appear  to  depend  upon  a particular 
organic  disposition.  Of  this  description  was  the  sub- 
ject whose  arteries,  on  examination  after  death,  were 
found  by  Lancisi  affected  with  several  aneurisms  of 
various  sizes.  I have  known  a person  have  an  aneu- 
rism of  one  axillary  artery,  which  disease  got  sponta- 
neously well,  but  was  soon  afterward  followed  by  a 
similar  swelling  of  the  opposite  axillary  artery,  which 
last  affliction  proved  fatal.  I have  seen  another  instance 
in  which  an  aneurism  of  the  popliteal  artery  was  ac- 
companied with  one  of  the  femoral  in  the  other  limb. 
Boyer  mentions  a patient  who  died  of  femoral  aneurism 
in  La  Charite,  at  Paris,  and  who  had  also  another  aneu- 
rism of  the  popliteal  artery  equal  in  size  to  a walnut. 
— (Traite  des  Maladies  Chir.  &c.  p.  102,  t.  2.)  The 
greatest  number  of  aneurisms  that  Sir  Astley  Cooper 
has  seen  in  one  patient  is  seven ; and  it  is  a remark 
made  by  this  eminent  surgeon,  that  when  an  aneurism 
occurs  in  the  ham,  the  disease  is  frequently  of  a local 
nature  ; but  that  when  it  is  between  the  groin  and  ham, 
disease  of  other  arteries  is  ver>’  commonly  met  with. — 
(See  Lectures,  vol.  2,  p.  37.)  The  most  remarkable 
case,  however,  proving  the  existence  of  a disposition  to 
aneurisms  in  the  whole  arterial  system,  is  mentioned 
by  Pelletan  : “ J’ai  pourtant  vu  plusieurs  fois  ces  nom- 
breux  aneurismes  occupant  indistinctement  les  grosses 
ou  les  petites  artdres,  mais  surtout  celles  des  capacites : 
j’en  ai  comt6  soixante-trois  sur  un  seui  hoinme,  depuis 
le  volume  d’une  aveline  jusqu’a  celui  de  la  moitie  d’un 
ceuf  de  poule.” — (Clinique  Chir.  t.  2,p.  1.) 

Aneurisms,  and  those  diseases  of  the  coats  of  arte- 
ries which  precede  the  formation  of  aneurism,  are  much 
less  frequently  met  with  in  women  than  men. — (I.as- 
sus,  Pathologie  Chir.  t.  1,  p.  348.)  A few  years  before 
John  Hunter  died,  Mr.  Wilson  heard  him  remark,  that 
he  had  only  met  with  one  woman  affected  with  true 
aneurism. — (Anatomy,  Pathology,  &c.  of  the  Vascu- 
lar System,  p.  376.)  Mr.  Hodgson  drew  up  the  follow- 
ing table,  exhibiting  the  comparative  frequency  of 
aneurisms  in  the  two  sexes,  in  different  cases  of  this 
disease,  and  also  in  the  different  arteries  of  the  body, 
as  deduced  from  examples  either  seen  by  himself, 
during  the  lives  of  the  patients,  or  soon  after  their  death. 


Of  the  ascending  aorta,  the  arteria  in- 
nominata,  and  arch  of  the  aorta  . . 
Descending  aorta  ....... 

Carotid  artery 

Subclavian  and  tixillary 

Inguinal  artery 

Femoral  and  popliteal 


This  table  does  not  include  aneurisms  arising  from 
wounded  arteries,  nor  aneurisms  from  anastomosis. — 
(On  the  Diseases  of  Arteries  and  Veins,  p.  87.) 

Sir  Astley  Cooper  c-jnfirms  the  fact  of  the  much 
greater  frequency  of  aneurism  in  the  male  than  the  fe- 
male sex.  Women,  he  says,  rarely  have  aneurism  in 
the  limbs.  In  forty  years’ experience,  he  has  seen  only 
eight  cases  of  popliteal  aneurism  in  women,  but  an 
immense  number  in  men.  Most  of  the  aneurisms  which 
he  has  seen  in  females  have  been  in  the  ascending 
aorta,  or  the  carotids. — (Lectures,  vol.  2,  p.  41.) 

It  was  observed  by  Morgagni,  and  it  has  been  noticed 
in  this  country,  that  popliteal  aneurisms  occur  with 
particular  frequency  in  postillions  and  coachmen,  whose 
employments  oblige  them  to  sit  a good  deal  with  their 
knees  bent.  In  France,  the  men  who  clean  out  the 
dissecting  rooms  and  procure  dead  bodies  for  anato- 
mists, are  stud  almost  all  of  them  to  die  with  aneuris- 
mal  diseases.  Richerand  remarks,  that  he  never  knew 
any  of  these  persons  who  were  not  addicted  to  drink 
ing,  and  he  comments  on  the  debility  which  their  in- 
temperance and  disgusting  business  together  must  tend 
to  produce. — (Nosogr.  Chir.  t.  4,  p.  74,  < dit.  2.) 

Aneurisms  are  supposed  by  Roux  to  be  much  more 
frequent  in  England  than  France ; a circumstance 
which,  before  he  proves  it  to  be  a fact,  he  vaguely  re- 
fers to  the  mode  of  life  and  kind  of  labour  to  which  a 


5 

p- 

Males.  1 

Females. 

21 

16 

5 

8 

7 

1 

2 

2 

5 

5 

12 

12 

15 

14 

1 

63 

56 

7 

ANEURISM. 


101 


large  portion  of  the  population  of  England  is  subjected 
Indeed,  he  connects  this  surmise  with  a reason  for  the 
very  cultivated  state  of  this  part  of  knowledge  in  Eng- 
land : thinks  that  we  have  been  placed  in  favourable 
circumstances  for  perfecting  the  treatment  of  aneu- 
risms, and  acknowledges  that  we  have  contributed 
more  than  his  countrymen  both  in  the  last  and  present 
century  to  the  improvement  of  this  branch  of  surgery. 
— ;Roux,  Parall^le  de  la  Chirurgie  Angloise  avec  la 
Chirurgie  Frangoise,  &c.  p.  249.)  But  ere  M Roux 
ventured  into  such  conjectures,  he  ought  at  least  to 
have  specified  what  particular  occupations  and  kind  of 
labour  are  known  by  Englishmen  themselves  to  be  fre- 
quently conducive  to  aneurism;  for,  with  the  excep- 
tion of  postillions  and  coachmen,  of  v/hom  there  is  also 
abundance  in  France,  I am  not  aware  that  any  determi- 
nate class  of  persons  is  found  in  this  country  to  be  af- 
fected with  particular  frequency. 

In  some  instances  aneurisms  of  the  axillary  artery 
appear  to  have  arisen  from  violent  extension  of  the 
limb. — 'See  the  cases  recorded  byPelletan  in  Clinique 
Chir.  t.  2,  p.  49  and  83.)  In  other  examples  related  by 
the  some  practical  writer,  aneurism  arose  from  reite- 
rated contusions  and  rough  pressure  on  parts.— (Op. 
cit.  p.  10  and  14.) 

The  extremity  of  a fractured  bone  may  injure  an  ar- 
tery and  give  rise  to  an  aneurism,  instances  of  which  are 
recorded  by  Pelletan  (Op.  cit.  t.  1,  p.  178)  and  Durver- 
ney  (Traite  des  Mai.  des  Os,  t.  1).  In  Pelletan ’s  case, 
the  disease  followed  a fracture  of  the  lower  third  of  the 
leg.  An  aneurism  of  the  anterior  tibial  artery  from 
such  a cause,  is  also  described  by  Mr.  C.  White. — 
(Cases  in  Surgery,  p.  141.) 

The  following  case  of  an  aneurism  of  the  humeral 
artery  after  amputation  is  recorded  by  Warner : C.  D. 
was  afflicted  with  a caries  of  the  joint  of  the  elbow, 
which  was  attended  with  such  circumstances  as  ren- 
dered the  amputation  of  the  limb  necessary.  The  ope- 
ration was  performed  at  a proper  distance  above  the 
diseased  part,  and  the  vessels  were  taken  up  with 
needles  and  ligatures. 

In  a few  days  the  humeral  artery  became  so  dilated 
above  the  ligature  upon  it  as  to  be  in  danger  of  burst- 
ing. Hence  it  was  judged  necessary  to  perform  the 
operation  for  the  aneurism,  which  was  done,  and  the 
vessel  secured  by  ligature  above  the  upper  extremity  of  | 
its  distended  coats.  Every  thing  now  went  on  for  some 
time  exceedingly  well,  when  suddenly  the  artery  again 
dilated,  and  was  in  danger  of  bursting  above  the  second 
ligature.  These  circumstances  made  it  necessary  to 
repeat  the  operation  for  the  aneurism.  From  this  time 
every  thing  went  on  successfully  till  the  stump  was  on 
the  point  of  being  healed ; when,  quite  unexpectedly, 
the  artery  appeared  a third  time  diseased  in  the  same 
manner  as  it  had  been  previously,  for  which  reason  a 
third  operation  for  aneurism  was  determined  on  and 
performed. 

The  last  operation  was  near  the  axilla,  and  was  not 
followed  by  any  relapse. 

Could  the  several  aneurisms  of  the  humeral  artery 
(says  Mr.  Warner)  be  attributed  to  the  sudden  check 
alone  which  the  blood  met  with  from  the  extremity  of 
the  ves.sel  being  secured  by  ligature ; or  is  it  not  more 
reasonable  to  suppose  that  the  coats  of  the  artery  nearly 
as  high  as  the  axilla  were  originally  diseased  and 
weakened  ? ITie  latter,  in  the  opinion  of  this  judicious 
writer,  seems  the  most  probable  way  of  accounting  for 
the  successive  returns  of  the  disease  of  the  vessel; 
since  it  is  found  from  experience  that  such  accidents 
have  been  very  rarely  known  to  occur  after  amputa- 
tion, either  of  the  arm  or  thigh,  where  nearly  the  same 
resistance  must  be  made  to  the  circulation  in  every 
subject  of  an  equal  age  and  vigour,  who  has  undergone 
such  operation. 

If  it  should  be  supposed  that  the  several  dilatations 
of  the  coats  of  the  vessel,  continues  Mr.  Warner,  arose 
merely  from  the  chock  in  the  circulation,  it  will  not  be 
easy  to  account  for  the  final  success  of  this  operation  ; 
and  especially  when  we  reflect  that  the  force  of  the 
blood  is  increased  in  proportion  to  its  nearness  to  the 
heart.— (See  Cases  in  Surgery,  p.  1.39,  140,  edit.  4.) 
Ruysch  has  related  an  observation  somewhat  similar. 
— 'Obs.  Anat.  Chir.  t.  1,  p.  4.) 

Aneurisms  sometimes  follow  the  injury  of  a large 
artery  by  a gun-shot  wound.  The  passage  of  a bullet 
through  the  thigh,  in  one  example,  gave  rise  to  a femoral 
aneurism. — (See  Parisian  Chirurgical  Journal,  vol.  2,  p. 


109. ) The  same  cause  produced  an  aneurism  high  up  the 
thigh  of  a soldier  who  was  under  the  care  of  my  friend 
Mr.  Collier,  at  Brussels,  after  the  battle  of  Waterloo. 

PROGNOSIS. 

In  cases  of  aneurism  the  prognosis  varies  according 
to  a variety  of  important  circumstances.  The  disease 
may  generally  be  considered  as  exceedingly  dangerous ; 
for,  if  left  to  itself,  it  almost  always  terminates  in  rup- 
ture, and  the  patient  dies  of  hemorrhage.  There  are 
some  examples,  however,  in  which  a spontaneous 
cure  took  place,  and  aneurismal  swellings  have  been 
known  to  lose  their  pulsation,  become  hard,  smaller, 
and  gradually  reduced  to  an  indolent  tubercle,  which 
has  entirely  disappeared.  After  death  the  artery  in 
such  instances  has  been  found  obliterated,  and  con- 
verted into  a ligamentous  cord,  without  any  vestige  of 
the  aneurism  being  felt.  Aneurisms  are  also  some- 
times attacked  with  mortification  ; the  sac  and  adjacent 
parts  slough  away ; the  artery  is  closed  with  coagu- 
lum;  and  thus  a cure  is  effected.  Lastly,  tumours 
having  all  the  character  of  aneurisms  have  been  known 
to  disappear  under  the  employment  of  such  pressure 
as  was  certainly  too  feeble  to  intercept  entirely  the 
course  of  the  blood.  Such  examples  of  success,  how- 
ever, are  not  common,  and  whenever  they  happen,  it  is 
because  the  entrance  of  blood  into  the  sac  is  prevented 
by  the  coagulation  of  that  already  contained  in  it,  and 
because  the  artery  above  the  swelling  is  filled  with 
coagulum.  They  must,  in  fact,  have  been  cured  on 
the  very  same  principle  which  renders  the  surgical 
operation  successful. 

Nothing  is  subject  to  more  variety,  than  the  duration 
of  an  aneurism  previously  to  its  rupture ; the  tumour 
bursting  sooner  or  later,  according  as  the  patient  hap- 
pens to  lead  a life  of  labour,  or  ease,  temperance,  or 
moderation.  Even  the  bursting  of  an  internal  aneu- 
rism may  not  immediately  kill  the  patient ; a stone- 
cutter died  in  the  hospital  Saint  Louis  with  an  enor- 
mous aneurism,  situated  on  the  left  side  of  the  lumbar 
vertebrae.  The  body  was  opened  by  Richerand,  who 
found  that  the  external  tumour  consisted  of  blood, 
which,  after  making  its  way  through  the  muscles,  had 
been  effused  into  a cyst  formed  in  the  midst  of  the 
cellular  substance  of  the  loins.  The  track  through 
which  it  came  led  into  another  aneurismal  sac  con- 
tained in  the  abdomen,  and  situated  behind  the  peri- 
toneum, on  the  left  side  of  the  lumbar  vertebrae.  In 
endeavouring  to  discover  whence  the  extravasated 
blood  proceeded,  Richerand  found  that  the  abdominal 
aorta  was  entire,  though  in  .Contact  with  the  swelling. 
The  original  affection  consisted  of  an  aneurismal  dila- 
tation of  the  interior  portion  of  the  thoracic  aorta,  which 
had  burst  at  the  point  where  it  lies  between  the  crura 
of  the  diaphram.  Tiie  blood  had  probably  escaped  very 
slowly,  and  it  had  accumulated  in  the  cellular  sub- 
stance round  the  kidnej',  so  that  three  cysts  had  burst 
successively  before  the  patient  died. — (Nosogr.  Chir.  t. 
4,  p.  82,  edit.  2.) 

Every  aneurism,  so  situated  that  it  can  neither  be 
compressed  nor  tied  above  the  swelling,  has  generally 
been  considered  absolutely  incurable,  except  by  a natu- 
ral process,  the  establishment  of  which  is  not  suffi- 
ciently often  the  case  to  raise  much  expectation  of  a 
recovo’-y  on  this  principle.  But  it  should  be  recollected 
that  sometimes  the  size  of  the  swelling  appears  to 
leave  no  room  for  the  application  of  a ligature  above 
it,  while  things  are  in  reality  otherwise,  in  consequence 
of  the  communication  between  the  sac  and  the  ar- 
tery bearing  no  proportion  to  the  magnitude  of  the 
tumour  itself.  At  the  present  day,  also,  enlightened  by 
anatomical  knowledge,  and  encouraged  by  successftil 
experience,  surgeons  boldly  follow  the  largest  arteries, 
even  within  the  boundaries  of  the  chest  and  abdomen, 
as  we  shall  pre.sently  relate,  and  numerous  facts  have 
now  proved  that  few  external  aneurisms  arc  beyond 
the  reach  of  modern  surgery.  It  being  certain  that 
aneurisms  cannot  commonly  be  cured,  except  by  an 
obliteration  of  the  affected  artery,  it  follows  that  the 
circulation  must  he  carried  on  by  the  superior  and  infe- 
rior collateral  branches,  or  else  the  limb  would  mortify. 
Experience  proves  that  the  impediment  to  the  jiassage 
of  the  blood  through  the  diseased  artery  obliges  this 
fluid  to  pass  through  the  collateral  branches,  which 
gradually  acquire  an  increase  of  size.  It  is  therefore  a 
common  notion  that  it  must  be  in  favour  of  the  success 
of  the  operation,  if  the  disease  be  of  a certain  standing ; 


102 


ANEURISM. 


and  in  direct  opposition  to  the  sentiments  of  Kirkland, 
Boj  er  even  asserts  that  the  most  successful  operations 
have  been  those  performed  on  persons  who  have  had 
the  disease  a long  while.— (Maladies  Chirurg.  t.  2,p.  116.) 

There  is  this  objection  to  delay,  however,  that  the 
tumour  becomes  so  large,  and  the  effects  of  its  pres- 
sure so  e.xtensive  and  injurious,  that  after  the  artery 
is  tied,  great  inflammation,  suppuration,  and  sloughing 
often  attack  the  swelling  itself,  and  the  patient  falls  a 
victim  to  what  would  not  have  occurred  had  the  opera- 
tion been  done  sooner. 

The  large  size  of  an  aneurism,  as  Mr.  Hodgson  has 
rightly  observed,  is  a circumstance  which  materially 
prevents  the  establishment  of  a collateral  circulation. 
When  the  tumour  has  acquired  an  immense  bulk,  it 
has  probably  destroyed  the  parts  in  wliich  some  of  the 
principal  anastomosing  branches  are  situated ; or  by  its 
pressure  it  may  prevent  their  dilatation. — ;Oii  the  Dis- 
eases of  Arteries  and  Veins,  p.  259.)  The  practice  of 
permitting  an  aneurism  to  increase,  that  the  collateral 
branches  may  become  enlarged  (says  this  gentleman), 
is  not  only  unnecessary  but  injurious,  inasmuch  as  the 
increase  of  the  tumour  must  be  attended  with  a de- 
struction of  the  surrounding  parts,  which  will  render 
the  cure  of  the  disease  more  tedious  and  uncertain.— 
(P.  266.) 

The  most  successful  operations  which  I have  seen 
were  performed  before  the  aneurismal  swellings  were 
very  large.  However,  notwithstanding  the  great  dis- 
advantages of  letting  the  swelling  become  bulky  before 
the  operation,  the  fact  appears  scarcely  yet  to  have 
made  due  impression,  and  surgeons  are  yet  blinded 
with  the  plausible  scheme  of  giving  time  for  the  col- 
lateral vessels  to  enlarge ; at  least,  1 infer  that  things 
are  so,  from  having  lately  seen  a patient  who  has  been 
advised  to  let  the  operation  be  postponed  on  such  a 
ground,  though  the  swelling  in  the  ham  was  already 
as  large  as  an  egg. 

The  surgeon  should  not  be  afraid  of  operating,  al- 
though appearances  of  gangrene  may  have  taken  place 
on  the  tumour ; for,  as  Mr.  Hodgson  remarks,  should 
it  burst  afterward,  it  is  probable  that  both  extremities 
of  the  artery  in  the  sac  will  be  closed  with  coagulum. 
— (Hodgson,  p.  305.)  Sir  Astley  Cooper  tied  the  e.xter- 
nal  iliac  artery  in  two  cases  of  inguinal  aneurism, 
when  gangrene  existed,  and  though  the  tumours  burst 
no  hemorrhage  ensued.  The  coagulum  was  discharged  ; 
the  sac  granulated  ; and  the  sores  gradually  healed. — 
(Medico-Chir.  Trans,  vol.  4,  p.  431.) 

The  effects  of  the  pressure  of  aneurisms  upon  the 
bones  are  justly  regarded  as  an  unpleasant  complica- 
tion, when  they  take  place  in  an  extensive  degree,  and, 
according  to  writers,  they  may  sometimes  induce  a ne- 
cessity for  amputation. — (Boyer,  Traite  des  Mai.  Chir. 
t.  2,  p.  117.)  However,  1 have  never  seen  a case  of  this 
description  ; and  Mr.  Hodgson,  as  we  have  already  ex- 
plained, informs  us  that  the  aflection  of  the  bones  is 
hardly  ever  attended  with  exfoliations,  or  the  forma- 
tion of  pus,  so  that  if  the  aneurism  can  be  cured,  the 
bones  will  generally  recover  their  healthy  state,  with- 
out undergoing  those  processes  which  take  place  in 
the  cure  of  caries  or  necrosis. — (On  Diseases  of  Arte- 
ries and  Veins,  p.  80.)  At  the  same  time  there  can  be 
no  doubt,  that  where  the  tumour  has  been  allowed  to 
attain  a large  size  before  an  attempt  is  made  to  cure  it, 
and  where  from  this  cause  both  the  neighbouring  soft 
parts  and  the  bones  have  suffered  considerably,  the 
completion  of  a cure,  that  is  to  say,  the  full  restoration 
of  the  use  of  the  limb,  must  be  far  more  distant  than 
in  other  cases  where  the  cure  is  attempted  in  an  earlier 
stage.  Here  then  we  see  another  reason  against  the 
pernicious  doctrine  of  waiting  for  the  enlargement  of 
the  anastomising  vessels  in^  addition  to  that  which  has 
been  urged  above. 

The  age,  constitution,  and  state  of  the  patient’s 
health  are  also  to  be  considered  in  the  prognosis  ; for 
they  undoubtedly  make  a great  difference  in  the  chance 
of  success  after  the  operation. 

The  operation,  however,  should  not  be  rejected  on 
account  of  the  age  of  the  patient,  if  the  circumstances 
of  the  case  in  other  respects  appear  to  demand  it : for 
it  has  often  succeeded  at  very  advanced  periods  of  life. 
“ 1 have  seen  several  aneurisms  cured  by  the  modern 
operation  in  patients  above  sixty  years  of  age.” — 
(Ilodgson,  p.  304.)  Similar  cases  have  fallen  under 
my  own  notice.  Sir  Astley  Cooper,  already  noticed, 
has  operated  with  success  for  a popliteal  aneurism  on 


one  patient  aged  85,  and  on  another  69  years  old,  with 
the  same  favourable  result. 

When  an  aneurism  exists  in  the  course  of  the  aorta, 
the  violent  action  of  the  heart,  excited  by  an  operation 
in  the  extremities,  may  cause  it  to  burst,  and  prove  in- 
stantaneously fatal.  Two  cases  occurred  a few  years 
ago  in  this  metropolis,  in  which  the  patients  died  from 
such  a cause  during  operations  for  popliteal  aneurisms. 
— (See  Hodgson  on  Diseases  of  Arteries,  p.  306 ; Lon- 
don Med.  Review,  vol.  2,  p.  240  ; and  Burns  on  Dis- 
eases of  the  Heart,  p.  226.)  Were  the  co-existence  of 
the  internal  aneurism  known,  the  operation  for  the 
other  tumour  would  be  improper,  and  the  surgeon 
should  limit  the  treatment  to  palliative  means. 

Experience  proves,  however,  that  the  circumstance 
of  there  being  two  aneurisms  in  the  limb  should  not 
prevent  the  operation,  which  is  to  be  practised  at  sepa- 
rate periods.  Facts  in  support  of  this  statement  are 
quoted  by  Mr.  Hodgson. — (P.  310.) 

OF  THE  SPONTANEOUS  CURE  AND  GENERAL 
treatment  of  aneurisms. 

The  obliteration  of  the  sac  in  copsequence  of  a depo- 
sition of  lamellated  coagulum  in  its  cavity,  as  Mr. 
Hodgson  has  well  described,  is  the  mode  by  which  the 
spontaneous  cure  of  aneurism  is  in  most  instances  ef- 
fected. The  blood  soon  deposites  upon  the  inner  sur- 
face of  the  sac  a stratum  of  coagulum ; and  successive 
depositions  of  the  fibrous  part  of  the  blood  by  degrees 
lessen  the  cavity  of  the  tumour.  At  length,  the  sac  be- 
comes entirely  filled  with  this  substance,  and  the  de- 
position of  it  generally  continues  in  the  artery  on  both 
sides  of  the  sac  as  far  as  the  giving  off  of  the  next 
large  branches.  The  circulation  through  the  vessel 
is  thus  prevented  ; the  blood  is  conveyed  by  collateral 
channels ; and  another  jirocess  is  instituted  whereby 
the  bulk  of  the  tumour  is  removed. — (On  the  Diseases 
of  Arteries,  &;c.  p.  114.)  Such  desirable  increase  of 
the  coagulated  blood  in  the  sac  is  indicated  by  the  tu- 
mour becoming  more  solid,  and  its  pulsation  weak  or 
ceasing  altogether. 

Another  mode,  in  which  the  disease  is  spontaneously 
cured,  happens  as  follows : an  aneurism  is  sometimes 
deeply  attacked  with  inflammation  and  gangrene ; a 
dense,  compact,  bloody  coagulum  is  formed  within  the 
vessel,  shutting  up  its  canal,  and  completely  interrupt- 
ing the  course  of  the  blood  into  the  sac.  Hence,  the 
ensuing  sphacelation  and  the  bursting  of  the  integu- 
ments and  aneurismal  sac  are  never  accompanied  by 
a fatal  hemorrhage ; and  the  patient  is  cured  of  the 
gangrene  and  aneurism  if  he  has  strength  sufficient  to 
bear  the  derangement  of  the  health  necessarily  at- 
tendant on  so  considerable  an  attack  of  inflammation 
and  gangrene. 

When  a patient  dies  of  hemorrhage,  after  the  morti- 
fication of  an  aneurism,  it  is  because  only  a portion  of 
the  integuments  and  sac  has  sloughed,  without  the 
root  of  the  aneurism,  and  especially  the  arterial  trunk, 
being  similarly  affected.  For  cases  illustrative  of 
this  statement,  refer  to  Hodgson  on  Diseases  of  Arte- 
teries,  p.  103,  <fec. 

A third  way,  in  which  an  aneurism  may  be  sponta- 
neously cured,  is  by  the  tumour  compressing  the  ar- 
tery above,  so  as  to  produce  adhesion  of  its  sides,  and 
obliteration  of  its  cavity.  This  mode  of  cure  must  be 
uncommon  : it  has  been  adverted  to  by  Sir  E.  Home, 
Scarjia,  Dr.  John  Thomson,  and  others ; but  some 
facts,  tending  to  prove  it,  have  been  collected  by  Mr. 
Hodgson,  and  are  published  in  his  useful  work.— (See 
p.  107,  &c.) 

A fourth  mode  of  cure  is  illustrated  in  a case  related 
by  Sir  Astley  Cooper  : a man,  in  Guy’s  Hospital,  had 
an  aneurism  just  below  the  groin.  He  was  sitting  be 
fore  the  fire,  when  he  felt  something  burst  in  the  upper 
part  of  his  thigh.  On  examination  he  found  no  blootl 
had  escaped,  and,  in  fact,  the  aneurism  had  not  yet 
reached  the  skin,  so  as  to  be  adherent  to  it.  His  thigh, 
however,  was  enormously  swelled ; he  was  unable  to 
use  his  limb,  and  was  put  to  bed.  For  three  days  af- 
terward a pulsation  was  jierceptible  in  the  aneurism  ; 
but  it  then  ceased,  and  the  size  of  the  limb  began  to 
dimmish.  At  the  end  of  four  months,  the  aneurismal 
swelling  had  considerably  subsided,  he  could  use  the 
limb,  and  in  less  than  six  months  he  was  discharged 
from  the  hospital.  He  afterward  fell  a victim  to  the 
rupture  of  another  aneurism  in  the  abdomen.  On  ex 
amination  of  the  body,  it  was  found  that  the  aneurism 


ANEURISM. 


103 


in  the  thigh,  just  below  Poupart’s  ligament,  had  burst 
under  the  fascia  lata,  and  the  femoral  artery  had  been 
©bliterated  by  the  pressure  of  th& large  quantity  of- ef- 
fused blood. — (See  Lancet,  vol.  1,  p.  430.) 

“The  surgical  treatment  of  aneurism  (says  Mr. 
Hodgson)  consists  in  the  obliteration  of  the  cavity  of 
the  artery  communicating  with  the  sac,  so  that  the  in- 
gress of  the  blood  into  the  latter  is  either  entirely  pre- 
vented, or  the  stream  which  passes  through  it  is  sup- 
plied only  by  anastomosing  branches,  and  consequently 
the  force  of  the  circulation  is  so  much  diminished,  that 
the  increase  of  the  tumour  is  prevented,  and  the  deposi- 
tion of  coagulum  is  promoted.  By  the  absorption  of  its 
contents,  and  the  gradual  contraction  of  the  sac,  the  cure 
is  ultimately  accomplished.  The  blood  is  conveyed  to 
the  parts,  which  it  is  destined  to  supply,  by  collateral 
vessels,  some  of  which,  being  gradually  enlarged,  con- 
stitute permanent  channels  for  the  circulation.  The 
obliteration  of  the  artery  is  effected  by  the  excitement 
of  such  a degree  of  inflammation  in  its  coats  as  shall 
produce  adhesion  of  its  sides.  These  objects  have 
been  attempted  by  the  compression  or  the  ligature  of 
the  artery.  The  latter  method  constitutes  the  opera- 
tion for  aneurism.” — (P.  165.) 

Such  are  the  principles  of  the  ordinary  mode  of  cure ; 
but  it  appears  from  certain  facts,  recorded  by  Mr. 
Wardrop,  Dr.  Bush,  and  other  practitioners,  that 
some  aneurisms  may  be  cured  by  a surgical  operation, 
which  was  first  suggested  by  Brasdor,  and  the  design 
of  which  is  to  hinder  the  free  transmission  of  blood 
through  the  aneurismal  sac  by  tying  the  artery  on  that 
side  of  it  which  is  most  remote  fVom  the  heart.  This 
practice,  however,  is  only  allowable  in  certain  exam- 
ples, in  which  the  application  of  a ligature  in  the  com- 
mon way  is  no  longer  practicable,  because  its  success 
is  much  less  certain,  as  might  easily  be  anticipatsd, 
since  the  plan  does  not  comprise  the  very  desirable  ob- 
ject of  directly  preventing  the  entrance  of  blood  into 
the  aneurismal  sac.  To  this  subject,  however,  we 
shall  presently  return. 

According  to  Scarpa,  a complete  cure  of  an  aneu- 
rism cannot  be  effected,  in  whatever  part  of  the  body 
the  tumour  is  situated,  unless  the  artery  fl-om  which 
the  aneurism  is  derived  be,  by  nature  or  art,  oblite- 
rated, and  converted  into  a perfectly  solid  ligamentous 
substance,  for  a certain  extent  above  and  below  the 
place  of  the  ulceration,  laceration,  or  wound.  When 
aneurisms  are  cured  by  compression,  the  cure  is  never 
accomplished,  as  some  have  supposed,  by  the  pressure 
strengthening  the  dilated  proper  coats  of  the  artery, 
and  restoring,  especially  to  the  muscular  coat,  the 
power  of  propelling  the  blood  along  the  tube  of  the  ar- 
tery, as  it  did  previously  to  its  supposed  dilatation. 
Petit  and  Foubert  thought,  that  the  natural  curative 
process  sometimes  consisted  in  a species  of  clot,  which 
closed  the  laceration,  ulceration,  or  wound  of  the  artery, 
and  resisted  the  impulse  of  the  blood,  so  as  still  to  pre- 
serve the  continuity  of  the  coats  of  the  artery,  and  the 
pervious  state  of  the  vessel.  Haller  imbibed  a simi- 
lar sentiment  from  experiments  made  on  frogs. 

If  the  foregoing  statement  of  Scarpa,  respecting  the 
obliteration  of  the  tube  of  the  adjacent  portion  of  the 
artery,  when  an  aneurism  is  cured,  had  been  delivered 
merely  as  what  is  the  most  common  course  of  things, 
it  would  not  have  been  incorrect ; but  when  he  denies 
the  possibility  of  the  caliber  of  the  vessel  being  ever 
preserved,  whether  the  disease  be  cured  by  art  or  na- 
ture, he  is  exceeding  the  bounds  of  accuracy. 

Notwithstanding  aneurisms  cannot  in  general  be 
cured,  as  Scarpa  has  explained,  unless  the  artery  be 
rendered  impervious  for  some  extent  above  and  below 
the  tumour,  I believe  we  must  make  an  exception  to 
this  observation  with  respect  to  the  few  aneurisms  of 
the  aorta  (especially  those  of  its  arch)  which,  accord- 
ing to  the  records  of  surgery,  have  been  diminished 
and  cured  by  Valsalva’s  treatment.  In  such  examples, 
we  are  not  to  suppose  that  the  aorta  becomes  oblite- 
rated at  its  very  beginning ; but  that  the  diminution  of 
the  quantity  of  circulating  blood,  the  reduced  impetus 
of  this  fluid,  the  lessened  distention  of  the  aneurismal 
sac,  the  general  weakness  induced  in  the  constitution, 
and  the  increa-sed  activity  of  the  lymphatic  system,  all 
necessary  effects  of  Valsalva’s  method,  have  combined 
to  bring  about  a partial  subsidence  of  the  tumour. 

“It  is  a common  opinion  says  Mr.  Hodgson  i,  that 
the  radical  cure  of  an  aneurism  cannot  take  place 
without  the  obliteration  of  the  artery  from  which  the 


disease  originates.  It  is  probably  owing  to  this  idea, 
that  aneurisms  of  the  aorta  have  generally  been  consi- 
dered as  incurable  diseases,  and  consequently  that  so 
little  attention  has  been  given  to  their  treatment.” — 
(P.  118.)  The  facts,  however,  which  this  gentleman 
has  related  satisfactorily  prove,  1st,  that  a deposi- 
tion of  coagulum  may  take  place  in  an  aneurismal  sac, 
to  such  an  extent  as  entirely  to  block  up  the  communi- 
cation between  its  cavity  and  that  of  the  artery  from 
which  its  originates  ; secondly,  that  a sac  thus  filled 
with  coagulum  cannot  prove  fatal  by  rupture;  and, 
thirdly,  that  the  gradual  absorption  of  its  contents,  and 
the  consequent  contraction  of  the  sac,  may  proceed  to 
such  an  extent  as  to  effect  the  cure  of  the  disease, 
without  any  obstruction  taking  place  in  the  caliber  of 
the  vessel  from  which  it  originates.  See  cases  20,  21, 
22,  &c. — (Hodgson  on  Diseases  of  the  Arteries,  <fcc.  p. 
119,  &c.)  In  support  of  this  doctrine,  some  facts  are 
also  cited  from  Corvisart. — lEssai  sur  les  Maladies  du 
Cceur,  p.  313,  &c.) 

A part  of  these  cases,  it  is  true,  are  not  viewed  ex- 
actly in  this  light  by  Kreysig,  who  argues  (as  I think, 
without  much  probability),  that  they  might  have  been 
only  adipose  swellings,  connected  with  or  formed  in, 
the  parietes  of  the  artery,  a disease  described  by  Sten- 
zel. — (German  transl.  of  Mr.  Hodgson’s  book,  p.  174.) 

That  a punctured  artery  may  occasionally  be  healed 
in  this  manner,  Scarpa  himself  proves,  by  a case 
which  he  examined,  where  an  aneurism  took  place 
from  the  wound  of  a lancet  in  bleeding.  In  the  article 
Hemorrhage  we  shall  see  that  Jones’s  experiments 
show  the  same  thing,  and  the  particular  circumstances 
in  which  it  may  happen.  But  the  occurrence  is  rare, 
and  Scarpa  says  that  it  can  hardly  be  called  a radical 
cure,  as  the  cicatrix  is  always  found  in  a state  ready  to 
burst  and  break,  if  the  arm  be,  by  any  accident,  vio- 
lently stretched  or  struck  where  the  wound  was  situ- 
ated. 

In  the  spontaneous  cure  of  aneurisms,  arising  from 
arteries  of  inferior  size  to  that  of  the  aorta,  repeated 
examinations  have  proved,  that  the  deposition  of  coa- 
gulum does  not  in  general  merely  fill  up  the  sac,  but 
obliterates  the  tube  of  the  artery  above  and  below  the 
disease  to  the  next  important  ramifications.  Yet  even 
here,  exceptions  probably  take  place ; for  Mr.  Hodgson 
has  brought  forward  one  instance  in  which  a small 
sac,  which  originated  from  the  anterior  artery  of  the 
cerebrum,  was  completely  filled  with  firm  coagulum, 
which  did  not  extend  into  the  cavity  of  the  vessel. — 
(On  Diseases  of  Arteries,  p.  132.)  And  he  reports  the 
particulars  of  a true  femoral  aneurism,  communicated 
to  liim  by  Sir  A.  Cooper,  in  which,  after  the  patient’s 
death,  the  femoral  artery  was  found  dilated  into  a sac, 
which  was  lined  on  all  sides  with  very  firm  layers  of 
coagulum,  in  the  centre  of  which  was  an  irregular  ca- 
nal, through  which  the  circulation  was  continued.  As 
the  inside  of  this  canal  presented  a membranotis  ap- 
pearance, it  was  inferred  that  the  aneurism  had  been 
cured. — (Op.  cit.  p.  134.)  Here  I may  be  permitted  to 
remark,  that  if  this  case  be  correctly  reported,  viz.  if 
it  were  a true  aneurism  by  dilatation  of  all  the  arterial 
coats,  and  the  inside  of  it  was  every  where  lined  by 
firm  layers  of  coagulum,  it  amounts  to  a proof  that 
such  a deposition  is  not  entirely  confined  to  aneurisms 
by  rupture,  as  Scarpa  supposes.  And,  in  addition  to 
this  fact,  I may  mention,  as  referring  to  the  same 
question,  a case  of  aneurism  from  dilatation  of  the  ar- 
terial coats,  observed  by  Guattani,  where  the  same  pro- 
cess took  place.  “ Arterite  iliacae  ovalem  hanc  partem 
aneurysmaticam  polyposa  substantia  variae  densitatis 
adeo  infarctam  esse  denotebam,  ut  tunicarum  ejusdam 
forma  penitus  desiructa  in  unitbrmem  massam,  spongiai 
cera  imbutae  similem,  transformata  videretur.” — (Hist. 
17,  Gollect.  Lauth.  p.  158.) 

Whenever  the  ulcerated,  lacerated,  or  wounded  ar- 
tery is  accurately  compressed  against  a hard  body  like 
the  bones,  it  ceases  to  pour  blood  into  the  surrounding 
cellular  sheath,  because  its  sides,  being  kept  in  firm 
contact,  for  a certain  extent  above  and  below  the 
breach  of  continuity,  become  united  by  the  adhesive 
inflammation,  and  converted  into  a solid  ligamentous 
cylinder.  Molinelli,  Guattani,  and  White  have  given 
examples  and  plates  illustrative  of  this  fact.  When 
aneurisms  get  well  spontanexnzsly,  the  same  fact  is  ob- 
served after  death,  as  Valsalva,  Ford,  &,c.  have  demon- 
strated. I have  myself  seen,  in  St.  Bartholomew’s 
Hospital,  an  instance  in  which  a man  had  liad  a spon- 


104 


ANEURISM. 


taneous  cure  of  an  aneurism  in  the  left  axilla,  but  after- 
■u’ard  died  of  hemorrhage  from  another  aneurismal 
swelling  under  the  right  cla\'icle  : the  arterj'  on  the  left 
side  Avas  found  completely  impervious.  My  friend  Dr. 
Albert  had  under  his  care,  in  the  York  Hospital,  Chel- 
sea, a dragoon,  who  recovered  spontaneously  of  a very 
large  aneurism  of  the  external  iliac  artery : the  tumour 
sloughed,  discharged  about  tw'o  quarts  of  coagulated 
blood,  and  then  granulated  and  finally  healed  up.  Paoli 
relates  a similar  termination  of  a popliteal  aneurism. 
Moinichen  and  Guattani  relate  other  examples.  Hun- 
ter found  the  femoral  artery  quite  impervious  and  ob- 
literated at  the  place  where  a ligature  had  been  applied 
fifteen  months  before.  Boyer  noticed  the  same  fact  in 
a subject  eight  years  after  the  operation.  Petit  de- 
scribes the  spontaneous  cure  of  an  aneurism  at  the  bi- 
furcation of  the  right  carotid  ; the  subject  having  af- 
terward died  of  apoplexy,  the  vessel,  on  dissection, 
was  found  closed  up  and  obliterated  from  the  bifurca- 
tion as  far  as  the  right  subclavian  artery.  Desault  had 
an  opportunity  of  opening  a patient,  in  whom  a spon- 
taneous cure  of  a popliteal  aneurism  was  just  begin- 
ning ; he  found  a very  hard  bloody  thrombus,  which 
extended  for  three  finger-breadths  within  the  tube  of 
the  artery  above  the  sac,  and  was  so  firm  as  to  resist 
injection,  and  make  it  pass  into  the  collateral  branches. 

Both  the  spontaneous  and  surgical  cures  of  aneu- 
risms have  generally  two  stages  : in  the  first,  the  en- 
trance of  the  blood  into  the  aneurismal  sac  is  inter- 
rupted ; in  the  second,  the  parietes  of  the  artery  ap- 
proach each  other,  and  becoming  agglutinated,  the  ves- 
sel is  converted  into  a solid  cylinder.  This  doctrine  is 
corroborated  by  the  tumour  first  losing  its  pulsation, 
and  then  gradually  diminishing  and  disappearing. 

In  order  that  compression  may  make  the  opposite 
sides  of  an  artery  unite,  and  thus  produce  a radical 
cure  of  an  aneurism,  Scarpa  says,  the  degree  of  pres- 
sure must  be  such  as  to  place  these  opposite  sides  in 
firm  and  complete  contact,  and  such  as  to  excite  the 
adhesive  inflammation  in  the  coats  of  the  artery.  The 
point  of  compression  must  also  fall  above  the  lacera- 
tion or  wound  of  the  artery ; for  when  it  operates  be- 
low, it  hastens  the  enlargement  of  the  tumour:  and 
Scarpa  adds,  that,  in  practice,  band.ages  which  are  ex- 
pulsive and  compressive  are  more  useful  for  making 
pressure  than  any  tourniquets  or  instruments,  many 
of  which  are  contrived  to  operate  without  retarding 
the  return  of  blood  through  the  veins. 

In  order  that  pressure  may  succeed,  the  coats  of  the 
vessel  at  the  place  where  it  is  made,  must  be  sufficiently 
free  from  disease  to  be  susceptible  of  the  adhesive 
inflammation.  When  the  arterial  coats  round  the  root 
of  the  aneurism  are  much  diseased,  Scarpa  considers 
them  as  insusceptible  of  the  adhesive  inflammation, 
although  compressed  together  in  the  most  scientific 
manner,  and  even  when  tied  with  a ligature,  which 
only  acts  by  making  circular  pressure  on  the  vessel. 

This  statement  would  appear  to  derive  oonfirmation 
from  the  following  fact : Mr.  Langstaff  amputated  the 
thigh  of  a person  seventy-five  years  of  age ; but  the 
vessels  were  so  ossified  that  they  could  not  be  effect- 
ually tied,  and  the  patient  died  within  twenty-four 
hours.  It  is  generally  supposed,  says  Mr.  Law'rence, 
that  this  condition  of  the  arterial  coats  is  incompatible 
with  their  union  under  the  application  of  the  ligature. 
The  opinion  should  be  received,  however,  with  some 
limitation.  In  a man  fifty-nine  years  of  age,  bleeding 
took  place  nearly  a month  after  amputation  from  the 
ossified  femoral  arterv',  and  Mr.Lawrence  was  therefore 
obliged  to  expose  and  tie  that  vessel  again  for  the  sup- 
pression of  the  hemorrhage,  when  he  found  a hard  tube, 
which  cracked  immediately  the  ligature  was  tightened  : 
the  bleeding,  however,  never  returned.— (See  Med. 
Ciiir.  Trans,  vol.  6,  p.  193.)  This  case  is  mentioned, 
not  with  any  view  of  encouraging  surgeons  to  apply 
ligatures  round  diseased  portions  of  arteries,  a thing 
wliich  should  always  be  avoided  when  possible,  but 
to  let  them  be  aware  that  an  ossified  artery  is  some- 
times susceptible  of  being  permanently  closed,  when  a 
ligature  is  put  r.mnd  it.  With  respect  to  Scarpa's  idea 
of  making  pressure  operate  so  as  to  place  the  two  op- 
posite parietes  of  the  artery  at  the  mouth  of  the  ancu- 
nsmal  sac  completely  in  contact,  in  order  that  they 
may  be  united  by  the  adhesive  inflammation,  and  the 
cavity  of  the  vessel  be  obliterated,  I should  think,  with 
Pilr.  Hodgson,  that  if  jircssure  will  succeed  only  under 
these  circumstances,  it  will  answer  very  seldom,  be- 


cause, in  almost  al  auenrismal  sacs,  a sufficient  depo- 
sition of  coagulum  will  have  taken  place  to  prevent  the 
possibility  of  placing  the  opposite  side  of  the  artery  at 
the  mouth  of  the  aneurism  in  a state  of  complete  con- 
tact.— On  Diseases  of  Arteries,  dec.  p.  172.;  Possibly, 
how’ever,  Scarpa’s  directions  refer  to  a jicint  of  the  ves- 
sel rather  beyond  the  usual  limits  of  the  laminated 
coagula:  and  he  is  particular  in  recommending  the 
practice  only  wffiere  the  aneurism  is  soft  and  small. 

Some  ad'dse  trying  compression  in  every  case  of 
aneurism,  whether  small,  circumscribed,  soft,  flexible, 
indolent,  or  elevated,  diffused,  hard,  and  ptiinful.  But 
in  the  latter  case  Scarpa  represents  compression  as  de- 
cidedly hurtful.  He  says  also  that  every  bandage  which 
compresses  the  aneurism,  and  also  circularly  constricts 
the  affected  part,  is  always  injurious.  The  bandage, 
likewise,  which  compresses  only  the  aneurism  and  di- 
rects the  point  of  pressure  below  the  rupture  in  the 
vessel ; that  which,  on  account  of  the  great  size,  ex- 
quisite sensibility,  depth  ot  the  root  of  the  aneurism, 
and  fleshy  state  of  the  surrounding  parts,  cannot  ef- 
fectually compress  the  artery  against  the  bones,  so  as  to 
bring  the  opposite  sides  of  the  vessel  mto  contact ; and 
lastly,  the  compression  applied  to  a spontaneous  aneu- 
rism, attended  with  a steatomatous,  ulcerated,  earthy 
disease  of  the  arterial  coats,  ought  to  be  considered  as 
more  likely  to  do  harm  than  benefit.  In  cases  of  a 
completely  opposite  description,  bandages  have  pro- 
duced, and  may  produce,  a radical  cure,  and  should 
not  be  entirely  disused. — ^Scarpa  on  Aneurism,  ed.  2, 
P-221.) 

Guattani  first  employed  compression  systematically 
for  the  cure  of  aneurisms,  and  out  of  fourteen  cases  in 
w'hich  he  adopted  the  plan,  fo'or  were  cured  by  it.  Mr. 
Freer  details  other  examples ; but,  in  general,  pressure 
has  hitherto  been  applied  to  the  tumour  itself,  a me- 
thod less  likely  to  answ  er  than  that  of  making  pres- 
sure on  a sound  part  of  the  artery.  Mr.  Freer  recom- 
mends the  employment  of  Sennfio's  instrument,  or  the 
following  method ; first,  place  a bandage,  moderately 
tight,  from  one  extremity  of  the  limb  to  the  other ; then 
put  a pad  upon  the  artery,  a few  inches  above  the  tu- 
mour ; next,  surrounding  the  limb  with  a tourniquet, 
let  the  screw  be  fixed  upon  the  pad,  having  previously 
secured  the  whole  limb  from  the  action  of  the  instru- 
ment by  a piece  of  board  wider  than  the  limb  itself,  by 
which  means  the  artery  only  will  be  compressed  when 
the  screw  is  tightened.  The  tourniquet  shot ild  now  be 
twisted  till  the  pulsation  in  the  tumour  ceases.  In  a 
few  hours  the  limb  will  become  oedematous  and  swelled, 
when  the  tourniquet  may  be  removed,  and  the  pressure 
of  a pad  and  roller  will  afterward  be  enough.  By  ex- 
periments wliich  this  gentleman  made  on  the  radial 
arteries  of  horses,  these  ves.sels  were  found  to  become 
inflamed,  and  to  be  rendered  impervious  by  such  a pro- 
cess.— (Freer,  p.  112.)  In  a modern  wmrk  Dubois  is 
stated  to  ha\e  cured  an  aneurism  of  the  thigh  by  steady 
pressure  on  the  vessel  for  twenty-four  hours. — ,Med. 
Chir.  Trans,  vol.  4,  p.  437.) 

Sir  A.  Cooper  describes  another  machine  for  com- 
pressing the  femoral  artery  in  cases  of  popliteal  aneu- 
rism : it  was  used  by  Sir  W.  Blizard. 

‘‘  The  points  of  support  for  this  instrument  were  the 
outer  part  of  the  knee  and  the  great  trochanter,  a piece 
of  steel  passing  from  one  to  the  other ; and  to  the  mid- 
dle of  this  a semicircular  piece  of  iron  was  fixed,  which 
projected  over  the  femoral  artery,  having  a pad  at  its 
end  moved  by  a screw,  by  turning  which  the  artery 
ivas  readily  compressed,  and  the  pulsation  in  the  aneu- 
rism stopped  without  any  interruption  to  the  circulation 
in  the  smaller  vessels.”  But  although  the  patient  o.i 
whom  it  W21S  tried  possessed  unusual  tbrtitude,  he  wa  •: 
incapable  of  supporting  the  jjressureof  the  instrument 
longer  than  nine  hours. — (Med.  and  Fhys.  Journal,  vol. 
8.)  Few  patients,  indeed,  can  endure  the  pressure  of 
such  instruments  a quarter  of  this  time,  when  they  are 
put  on  sufficiently  tight  to  afford  any  chance  of  oblite- 
rating the  artery ; and  on  account  of  the  suffering 
which  they  produce,  they  are  rarely  used  by  modern 
surgeons. 

Whenever  the  treatment  by  pressure  is  attempted, 
the  plan  should  be  assisted  with  rejjeated  bleedings, 
spare  diet,  and  perfect  quietude  in  bed.  Digitalis  has 
al.so  been  sometimes  prescribed,  with  the  view  of  les- 
sening the  impetus  of  the  circulation.  It  is  likewise  a 
favourite  jilan  with  some  practitioners  to  apply  snow 
or  powdered  ice  to  the  tumour,  a.s  1 .shall  nonce  in  ue- 


ANEURISM. 


105 


scribing  Valsalva’s  treatment  of  aortic  aneurisms. 
These  last  applications  have  been  employed  for  the 
purpose  of  promoting  the  coagulation  of  the  blood 
within  the  aneurismal  sac,  and  the  consequent  oblite- 
ration of  the  cavity  of  the  aneurism  and  the  artery.  Va- 
rious examples  in  which  it  has  been  thought  to  have 
produced  a cure  are  recorded  by  Guerin. — (Recueil 
Period,  de  la  Soc.  de  Sante  de  Paris,  No.  3.  Pelletan, 
Clinique  Chir. ; and  Ribes,  Bulletins  de  la  Facnlte  de 
Med.  de  Paris,  1817,  No.  1 and  2,  p.  284.)  The  employ- 
ment of  ice,  however,  is  not  considered  proper  in  every 
case.  Breschet  says,  that  when  the  swelling  is  large, 
the  parts  very  tense,  their  texture  changed,  and  the 
skin  thin,  the  practice  is  likely  to  accelerate  the  forma- 
tion of  a slough;  and  he  confirms  a remark  made  by 
Mr.  Hodgson,  that  some  patients  cannot  continue  this 
treatment  longer  than  a tew  minutes,  whde  others  find 
it  absolutely  insupportable  — ,Fr.  Transl.  of  Mr.  Hodg- 
son’s Work,  t.  1,  p.  212—229.) 

The  grand  means  most  to  be  depended  upon  for  curing 
aneurisms,  is  tying  the  artery  above  the  tumour.  This 
more  certainly  prevents  the  great  ingress  of  blood  into 
the  sac,  and,  what  is  quite  as  important,  more  certainly 
excites  the  adhesive  inflammation  within  the  tied  part 
of  the  vessel,  and,  by  holding  the  opposite  sides  of  it 
steadily  in  contact,  brings  about  their  union,  and  an  obli- 
teration of  the  tube  of  the  vessel,  with  tolerable  regu- 
larity. The  chief  current  of  blood  into  the  sac  is  thus 
stopped,  the  contents  of  the  aneurism  are  afterward 
gradually  absorbed,  and  the  tumour  dwindles  away  in 
proportion.  The  natural  course  of  the  blood  being  now 
permanently  interrupted  in  the  arterial  trunk,  it  passes 
more  copiously  into  the  collateral  branches,  and  these 
enlarging  and  anastomosing  with  others  which  originate 
from  the  large  arteries  beyond  the  obstruction,  the  ne- 
cessary circulation  is  carried  on. — (See  Anastomosis 
and  Inosculation.) 

The  ligature  of  the  superficial  femoral  artery  may  be 
performed  with  the  same  confidence  of  success  as  the 
ligature  of  the  brachial  artery ; that  is,  without  any 
fear  of  destroying  the  circulation  or  depriving  the  sub- 
jacent limb  of  its  vitality.  Indeed,  the  numerous  and 
conspicuous  anastomoses  which  are  met  with  all  round 
the  knee,  correspond  exactly  with  those  which  are  ob- 
served round  the  elbow,  and  at  the  bend  of  the  arm. 
This  is  not  a peculiarity  of  the  arteries  of  the  extre- 
mities, but  it  is  a general  rule  which  nature  has  fol- 
lowed in  the  distribution  of  all  the  arteries,  that  the 
superior  trunks  communicate  with  the  inferior  by 
means  of  the  lateral  vessels.  After  the  principal  trunk 
of  an  artery  is  tied,  its  lateral  branches  not  only  carry 
on  the  circulation  in  the  parts  below  the  ligature,  but 
do  so  with  greater  quickness  and  activity  than  they  did 
previously,  while  the  course  of  the  blood  was  unim- 
peded through  the  principal  trunk.  This  evidently 
arises  from  the  increased  determination  of  blood  into  ^ 
the  lateral  vessels,  as  well  as  from  the  enlargement  of 
the  diameler  of  these  vessels.  After  the  amputation 
of  the  thigh,  while  the  blood  flows  in  a full  stream  from 
the  superficial  femoral  artery,  very  little  or  no  blood  is 
poured  out  of  the  lateral  vessels ; but  as  soon  as  that 
artery  is  tied,  the  blood  issues  with  impetuosity  from 
the  small  arteries  which  run  along  within  the  vasti  and 
cruriEUs  muscles  ; and  on  these  .smaller  arteries  being 
also  tied,  the  blood  immediately  oozes  out  from  the 
minute  arterial  vessels  of  the  muscles  and  cellular 
membrane.  When  the  principal  trunk  of  an  artery  is 
tied,  its  lateral  branches  gradually  acquire  a much 
larger  diameter.  After  amputation  of  the  thigh  on  ac- 
count of  a popliteal  aneurism,  the  size  and  situation 
of  which  could  not  fail  materially  to  impede  the  course 
of  the  blood  through  the  trunk  of  the  femoral  artery,  it 
has  often  been  remarked,  that,  although  both  the  trunk 
and  the  greater  and  smaller  branches  had  been  tied 
with  the  nicest  accitracy,  the  patients  have  been  in  dan- 
ger of  losing  their  lives  on  account  of  the  repeated  co- 
pious hemorrhages  from  the  innumerable  small  lateral 
vessels  that  had  become  unusually  enlarged.  In  several 
ca.ses,  during  the  treatment,  and  especially  after  the  ra- 
dical cure,  of  popliteal  aneurism  by  tying  the  superfi- 
cial femoral  artery  in  the  upper  third  of  the  thigh,  all 
the  ramifications  of  the  recurrent  popliteal  arteries 
have  been  felt  beating  strongly  round  the  knee.  We 
have  already  noticed  that  Boyer  found  in  a man  who 
some  years  previously  had  been  operated  on  for  a pop- 
liteal .aneurism,  but  had  afterward  died  from  a caries 
of  the  tibia,  that  au  arterial  branch  which  runs  in  the 


substance  of  the  sciatic  nerve  was  dilated  so  much  as 
to  be  equal  in  diameter  to  the  radial  artery.  White, 
in  dissecting  the  arm  of  a lady  who,  fifteen  years  be- 
fore, had  been  operated  on  for  an  aneurism  in  the  bend, 
of  the  arm,  found  the  brachial  artery  obliterated  and 
converted  into  a solid  cylinder  for  three  inches  below 
the  place  of  the  ligature,  and  as  far  as  the  division  into 
the  radial  and  ulnar  arteries  ; but  the  recurrent  radial 
and  ulnar  branches  had  become  so  much  enlarged  that 
taken  together,  they  exceeded  the  size  of  the  brachial 
artery  above  the  situation  of  the  ligature.  In  the  dead 
body,  it  is  found  that  an  anatomical  injection  will  pass 
more  freely  from  one  extremity  to  the  other  of  an  aneu- 
rismatic  than  of  a sound  limb,  and  this  even  when  no 
vessels  are  visibly  enlarged.  Although  it  be  self-evident 
that  the  circulation  through  the  collateral  vessels  ought 
to  be  much  more  easy  and  quick  the  lower  down  the  liga- 
ture is  applied  to  the  principal  trunk  ; yet  experience 
shows  that  this  difference  is  not  to  be  estimated  very 
high ; for  in  cases  of  popliteal  aneurism,  caeteris  paribus, 
the  success  is  the  same,  whether  the  femoral  artery  be 
tied  very  low  down  or  very  high  up  in  the  thigh.— 
(Scarpa.) 

This  facility  of  the  passage  of  the  blood  through  the 
lateral  vessels  is  not  the  same  in  subjects  of  all  ages  ; 
and  in  the  same  subject  it  is  not  the  same  in  the  infe- 
rior as  in  the  superior  extremity.  An  age  under  forty- 
five,  and  the  operation  being  done  on  the  arm,  which 
is  nearer  the  source  of  the  circulation  than  the  lower 
extremity,  increase  the  chance  of  success.  However, 
notwithstanding  these  are  the  opinions  of  Scarpa,  and 
as  general  ones  may  not  be  incorrect,  surgeons  in  Eng- 
land now  operate  for  aneurisms  of  the  lower  extremity, 
and  on  patients  much  older  than  forty-five,  with  a de- 
gree of  confidence  which  nothing  but  great  success 
could  inspire. 

According  to  Scarpa,  the  circumstances  chiefly  pre- 
ventive of  success,  especially  in  the  popliteal  and 
femoral  aneurisms,  are  the  following ; rigidity,  atony, 
or  disorganization  of  the  principal  anastomoses,  be- 
tween the  superior  and  inferior  arteries  of  the  harn 
and  leg  ; sometimes  depending  on  an  advanced  age,  or 
on  it  together  with  the  large  size  of  the  aneurism, 
which  by  long  continued  pressure  has  caused  a great 
change  in  the  neighbouring  parts ; or  sometimes  on 
steatomatous,  ulcerated,  earthy,  cartilaginous  disor- 
ganization of  the  proper  coats  of  the  artery,  not  con- 
fined to  the  seat  of  the  rupture,  but  extending  a great 
way  above  and  below  the  aneurism,  and  also  to  the 
principal  popliteal  recurrent  arteries,  tibial  arteries, 
and,  occasionally,  to  portions  of  the  whole  track  of  the 
superficial  femoral  artery.  Sometimes  the  pressure  of 
a large  aneurism  renders  the  thigh-bone  carious.  In 
such  circumstances,  the  ligature  is  apt  to  fail  in  closing 
the  trunk  of  the  artery  ; and,  if  it  should  succeed,  the 
state  of  the  anastomosing  vessels  will  not  admit  of  a 
sufficient  quantity  of  blood  being  conveyed  into  the 
lower  part  of  the  limb.  Hence,  when  the  patient  is 
much  advanced  in  life,  languid  and  .sickly  ; when  the 
internal  coat  of  the  artery  is  rigid,  and  incapable  of 
being  united  by  a ligature  ; when  the  aneurism  is  of 
long  standing  and  considerable  size,  with  caries  of  the 
os  femoris  or  tibia ; when  the  leg  is  weak  and  cold, 
much  swelled,  heavy,  and  (Edematous ; Scarpa  consi- 
ders the  operation  contra-indicated.  I must,  how’ever, 
declare  in  this  place  that  I have  seen  very  large  aneu- 
risms, as  well  as  aneurisms  in  persons  of  advanced 
age,  cured  by  the  Hunterian  plan  in  St.  Bartholomew’s 
Hospital ; and  with  respect  to  the  aftectiou  of  the 
bones,  though  it  may  be  an  unfavourable  circumstance, 
its  consequences  are  not  so  serious  as  those  of  ordi- 
nary caries,  as  I have  already  explained. 

It  appears,  then,  that  the  obliteration  of  the  artery 
for  a certain  extent  above  and  below  the  place  of  rup- 
ture, forms  the  primary  indication  in  the  radical  cure 
of  aneurism,  whether  compression  or  the  ligature  be 
employed  ; all  other  means  are  only  auxiliary.  Inter- 
nal remedies  may  be  useful,  inasmuch  as  they  tend  to 
moderate  the  determination  of  the  blood  towards  the 
place  where  the  artery  has  been  tied  or  compressed. 

In  the  articles  Hemorrhage  and  Ligature,  I have  re- 
lated in  detail  the  effects  of  the  ligature  upon  a tied  ar- 
tery, and  particularly  the  various  processes  which  arise 
from  its  application  and  terminate  in  the  iiermanent 
obliteration  of  the  vessel.  In  the  same  places  I have 
explained  what  an;  the  best  ligatures  for  use,  as  weP 
as  the  safest  manner  of  using  them.  Confining  myself, 


ANEURISM. 


106 


in  the  sequel  of  this' article,  to  what  expressly  relates 
to  aneurism,  I shall  here  merely  annex  the  following 
general  directions,  as  stated  by  Mr.  Hodgson. 

First,  The  cord  should  be  thin  and  round,  such  a 
ligature  being  most  likely  to  effect  a clean  division  of 
the  internal  and  middle  coats  of  the  vessel,  and  not 
liable  to  produce  extensive  ulceration  or  sloughing. 

Secondly,  The  ligature  should  be  tight,  in  order  to 
ensure  the  complete  division  of  the  internal  and  middle 
coats,  and  to  prevent  its  detachment,  it  being  almost 
impossible,  even  with  the  thinnest  ligature,  entirely  to 
cut  through  a healthy  arterj'. 

Thirdly,  The  vessel  should  be  detached  from  its  con- 
nexions only  to  such  an  extent  as  is  necessary  for  the 
passage  of  the  ligature  underneath  it. 

Fourthly,  The  immediate  adhesion  of  the  wound 
should  be  promoted  by  all  such  means  as  are  known 
to  promote  that  process  in  general. — (On  the  Diseases 
of  Arteries,  p.  225,  226.) 

In  the  course  of  his  experiments  upon  brutes,  to 
ascertain  the  operation  of  the  ligature.  Dr.  Jones  arrived 
at  a fact  which  offered  the  probability  of  leading  to  an 
improvement  in  the  operation  for  aneurism. — (Treatise 
on  Hemorrhage,  chap.  3.;  When  a small,  firm  ligature 
is  applied  to  an  artery,  it  causes  a division  of  the  inter- 
nal and  middle  coats ; and  if  it  be  afterw'ard  removed, 
an  effusion  of  lymph  takes  place  between  the  cut  sur- 
faces into  the  cavity  of  the  vessel.  If  several  divisions 
of  the  internal  and  middle  coats  be  thus  effected  in  the 
vicinity  of  each  other,  the  effusion  of  lymph  was  found 
by  Dr.  Jones  to  be  sufiiciently  extensive  to  obliterate 
the  cavity  of  the  vessel.  In  the  year  1800,  Mr.  C.  Hut- 
chison tied  the  brachial  arteries  of  two  dogs,  and  re- 
moved the  ligatures  immediately  after  their  applica- 
tion ; in  both  instances,  as  he  assures  us,  the  complete 
obliteration  of  the  canal  of  the  artery  was  the  conse- 
quence of  the  operation. — See  Practical  Obs.  in  Sur- 
gery, p.  103.)  If,  immediately  after  the  operation  for 
aneurism,  the  ligature  should  be  removed,  and  yet  the 
vessel  become  obliterated,  it  w'ould  be  highly  advanta- 
geous, as  there  would  then  be  left  in  the  wound  no 
extraneous  substance  to  prevent  its  union,  or  promote 
secondary  hemorrhage  by  extending  the  sloughing  or 
ulcerative  process  too  far.  It  is  to  be  regretted  that 
success  has  not  attended  the  repetition  of  the  experi- 
ment by  others.  Mr.  Hodgson  tried  it,  but  the  artery 
did  not  become  impervious. — See  Experiments  A and 
B,  p.  228,  229,  of  this  gentleman’s  work.)  Mr.  Dal- 
rymple  of  Norwich  made  the  experiment  not  less  than 
seven  times  on  horses,  and  three  times  on  sheep,  and 
failed  in  every  instance  to  obtain  the  same  result  as 
Dr.  Jones.  Not  only  was  no  coagulum  formed,  but 
even  when  the  animal  had  been  suffered  to  live  until 
the  tliirteenth,  fifteenth,  and  eighteenth  days  after  the 
operation,  the  canal  of  the  artery  was  not  found  oblite- 
rated. In  each  case,  indeed,  its  caliber  was  contracted ; 
but  it  was  still  capable  of  transmitting  a lessened 
column  of  blood. —[Travers,  in  Med.  Chir.  Trans,  vol.  4, 
p.  442.)  Thus  it  appears,  that  an  effusion  of  lymph  is 
an  invariable  consequence  of  the  operation,  and  as  Mr. 
Travers  has  observed,  the  w’ant  of  union  is  therefore 
©wing  t®  the  opposite  sides  of  the  vessel  not  being 
retained  in  a state  of  contact,  so  as  to  allow’  of  their 
adhesion.  The  presence  of  the  ligature  in  the  common 
mode  of  its  application  effects  this  object ; and  for  the 
success  of  Dr.  Jones’s  experiment  it  appe^ed  only  ne- 
cessary that  the  opposite  sides  of  the  wounded  vessel 
should  be  retained  in  contact,  until  their  adhesion  was 
sufficiently  accomplished  to  resist  the  passage  of  the 
blood  through  the  tube.  This  object  might  probably 
be  effected  by  compression  ; but  the  inconveniences 
attending  such  a degree  of  pressure  as  would  retain 
the  opposite  sides  of  an  artery  in  contact  at  the  bottom 
of  a recent  wound  are  too  great  to  admit  its  employ- 
ment. It  occurred  to  Mr.  Travers,  that  if  a ligature 
were  applied  to  an  artery,  and  suffered  to  remain  only 
a few  hours,  the  adhesion  of  the  wounded  surfaces 
would  be  sufficiently  accomplished  to  ensure  the  obli- 
teration of  the  canal ; and  by  the  removal  of  the  liga- 
ture at  this  period,  the  inconveniences  attending  its 
slay  would  be  obviated.  The  danger  produced  by  the 
residence  of  a ligature  upon  an  artery  arises  from  the 
Irritation  which  as  a foreign  body  it  produces  in  its 
coats.  Ulceration  has  never  been  observ’ed  to  com- 
mence in  less  than  twenty-four  hours  after  the  appli- 
ration  of  a ligature  ; while  it  is  an  ascertained  fact, 
that  lymph  is  in  a favourable  slate  for  organizatioji  in 


less  than  six  hours,  in  a wound  the  sides  of  which  arc 
preserved  in  contact.— (Jones,  ch.  4,  exp.  1.)  If  it  be 
sufficient,  therefore,  to  ensure  their  adhesion  that  the 
wounded  coats  of  an  artery  be  kept  in  contact  by  a 
ligature  only  three  or  four  hours,  ulceration  and  slough- 
ing may  in  a great  degree  be  obviated  by  promoting 
the  immediate  adhesion  of  the  wound.  Justified  by 
this  reasoning,  Mr.  Travers  performed  several  experi- 
ments, by  which  he  ascertained  that  if  a ligature  were 
kept  six,  two,  or  even  one  hour  upon  the  carotid  artery 
of  a horse,  and  then  removed,  the  adhesion  was  suffi- 
ciently advanced  to  effect  the  permanent  obliteration 
of  the  canal.  It  appeared  probable,  that  the  same  re- 
sult would  be  obtained  upon  the  healthy  artery  of  a 
human  subject. — (See  Travers’s  Obs.  in  Med.  Chir. 
Trans,  vol  4,  and  Hodgson  on  the  Diseases  of  Arteries 
and  Veins,  p.  228,  et  seq.) 

Sir  A.  Cooper  performed  one  operation  for  a popliteal 
aneurism,  with  the  view  of  ascertaining  the  efficacy 
of  such  a method  on  the  human  subject.  He  com- 
pletely stopped  the  flow  of  blood  for  thirty-two  hours, 
and  then  removed  the  ligature ; but  the  pulsations  of 
the  tumour  commenced  again.  He  next  applied  the 
ligature  forty  hours  longer,  at  the  end  of  which  time 
no  pulsation  recurred  on  the  ligature  being  taken 
away.  On  the  twelfth  day,  how’ever,  a considerable 
bleeding  look  place,  and  it  was  necessary  to  take  up 
the  vessel  anew. 

Mr.  C.  Hutchison  tried  this  method,  as  modified  by 
Mr.  Travers,  in  an  operation  which  he  performed  for  a 
popliteal  aneurism  in  a sailor,  in  Nov.  1813.  A double 
ligature  was  passed  under  the  femoral  artery.  The 
ligatures  were  tied  with  loops  or  slip  knots,  about  a 
quarter  of  an  inch  of  the  vessel  being  left  undivided 
between  them.  All  that  now  remained  of  the  pulsa- 
tion in  the  tumour  was  a slight  undulatory  motion. 
Nearly  six  hours  having  elapsed  from  the  application  of 
the  ligatures,  the  wound  was  carefully  opened,  and 
the  ligatures  untied  and  removed  without  the  slightest 
disturbance  of  the  vessel.  In  less  than  half  a minute 
afterward  the  artery  became  distended  with  blood, 
and  the  pulsations  in  the  tumour  were  as  strong  as 
they  had  been  before  the  operation.  Mr.  Hutchison 
then  applied  two  fresh  ligatures;  hemorrhage  after- 
ward came  on ; amputation  was  performed,  and  the 
patient  died. — (See  Practical  Obs.  in  Surgerj’,  p.  102, 
&c.)  Now,  as  Mr.  Hutchison  chose  to  apply  other 
ligatures  on  finding  that  the  pulsation  returned,  the 
above  case  only  proves  that  the  artery  is  not  oblite- 
rated in  about  six  hours,  and  we  are  left  in  the  dark 
respecting  the  grand  question,  namely,  whether  the 
vessel  would  have  become  obliterated  by  the  effusion 
of  coagulating  lymph  and  the  adhesive  inflammation, 
notwithstanding  the  return  of  circulation  through  it. 
As  for  the  hemorrhage  which  occurred,  I think  it  might 
have  been  expected,  considering  the  disturbance  and 
irritation  which  the  artery  must  have  sustained  in  the 
proceedings  absolutely  necessarj'  for  the  application  of 
not  less  than  four  ligatures,  and  the  removal  of  two  of 
them.  According  to  my  ideas  only  one  ligature  ought 
to  have  been  used,  and  none  of  the  artery  detached. 
We  also  have  no  description  of  the  sort  of  ligatures 
which  were  employed  ; an  essential  piece  of  informa- 
tion in  forming  a Judgment  of  the  merits  of  the  pre- 
ceding method.  The  application,  removal,  and  reappli- 
cation of  ligatures  are  not  consistent  with  the  wise 
principles  inculcated  by  the  late  Dr.  Jones,  and  have 
in  more  instances  than  that  recorded  by  Mr.  Hutchi- 
son, brought  on  ulceration  of  the  artery,  and  hemor- 
rhage. 

The  limits  of  this  work  prevent  me  from  entering 
into  the  particulars  of  the  very  interesting  experiments 
undertaken  by  Mr.  Travers,  upon  the  arteries  of  ani- 
mals, for  the  purpose  of  ascertaining  the  earliest  period 
when  a ligature  might  be  removed  from  an  artery, 
Avithout  any  risk  of  the  vessel  not  being  duly  oblite- 
rated. A full  detail  of  them  may  be  seen  in  another 
work  (See  Med.  Chir.  Trans,  vol.  4 and  6),  and  others, 
in  relation  to  the  same  question,  may  likewise  be  pe- 
rused in  Scarpa’s  ajipendix  to  his  great  Avork  on  aneu- 
rism.— (Memoria  sulla  Legatura  delle  principali  Arterie 
degli  Arti,  &c.  fol.  Pavia,  1817.)  The  cases  above 
related,  and  other  considerations,  long  ago  satisfied  me 
that  fiattering  as  the  suggestion  of  Dr.  Jones  Avas,  the 
plan  of  removing  the  ligature  previously  to  its  natural 
separation  would  never  answer  in  the  operation  for 
the  cure  of  aneurism,  unless  either  an  obliteration  of 


ANEURISM. 


107 


the  arterial  tube  would  follow  with  reasonable  cer- 
tainty the  taking  away  of  the  ligature  directly  after  it 
had  been  applied  and  it  had  divided  the  inner  coats  of 
the  vessel ; or,  at  all  events,  unless  the  ligature  could 
be  withdrawn  at  a determinate  period,  when  either  the 
same  obliteration  would  surely  ensue,  or  be  already 
complete  ; and  all  this  with  such  regularity  and  infal- 
libility in  every  case,  that  the  surgeon  would  have  no 
chance  of  being  called  upon  to  apply  another  ligature, 
do  a second  operation,  or  disturb  the  artery  in  any  kind 
of  way  whatsoever. 

Mr.  Travers,  in  the  prosecution  of  this  inquiry,  in 
which  he  evinced  a full  determination  to  be  guided  by 
no  motive  but  the  love  of  truth,  at  length  tried  the  tem- 
porary application  of  the  ligature  in  a case  of  brachial 
aneurism,  which  he  operated  upon  Feb.  14,  1817.  The 
artery  was  tied  an  inch  and  a half  above  the  bend  of 
the  elbow  with  a noose  ligature.  The  pulsation  in  the 
radial  artery  immediately  ceased.  On  the  16th,  at  four 
o’clock  in  the  afternoon,  the  ligature  was  rerhoved  with 
little  diiiiculty,  after  having  remained  on  the  artery 
fifty  hours.  No  pulsation  ensued  in  the  vessel  below 
the  iKtint  where  the  ligature  had  been  applied,  and  the 
ca.se  was  completely  successful. 

On  the  28th  November,  1817,  in  a case  of  popliteal 
aneurism,  Mr.  Travers  tied  the  femoral  artery  at  one 
o’clock.  On  the  29th,  at  four  in  the  afternoon,  the  liga- 
ture was  removed  without  difficulty  after  having  been 
on  the  vessel  twenty-seven  hours.  At  this  period  no 
pulsation  could  be  felt  in  the  sac;  but  at  seven  in  the 
evening  a faint  pulsation  was  perceptible.  On  the  30th, 
the  pulsation,  though  very  distinct,  was  less  strong 
than  before  the  operation.  On  the  2d,  3d,  and  6th  of 
December  the  pulsation  is  described  as  still  continuing. 
On  the  latter  day  pressure  was  applied  by  means  of  a 
roller  from  below  the  knee  to  the  groin,  and  was  con- 
tinued for  a month,  during  which  time  the  pulsation 
in  the  sac  evidently  became  more  feeble.  On  the  10th 
of  January  the  tumour  became  tense  and  severely  pain- 
ful, and  no  pulsation  in  it  could  be  distinguished.  The 
next  day  the  swelling  was  more  diffused  and  less  pro- 
minent ; and  on  the  12th,  as  the  disease  underwent 
no  amendment,  Mr.  Travers  tied  the  artery  again  about 
two  inches  above  the  place  where  the  former  ligature 
had  been  applied.  The  next  day  the  pain  had  dimi- 
nished. The  ligature  was  afterward  allowed  to  sepa- 
rate of  itself ; and  the  case  went  on  favourably  to  the 
cure.  According  to  Mr.  Travers,  the  first  of  these  cases 
tends  to  prove  that  the  continuance  of  the  ligature  upon 
the  artery  for  a period  of  fifty  hours,  as  certainlyand 
completely  answers  the  purpose  of  its  application,  as 
if  allowed  to  remain  until  thrown  off  by  the  natural 
process. 

In  the  second  case,  Mr.  Travers  infers  from  the  sus- 
pension of  pain,  and  the  diminished  strength  of  the  pul- 
sation, for  a month  after  the  application  of  the  tempo- 
rary ligature,  that  a degree  of  impediment  to  the  current 
of  blood  in  the  artery  had  been  produced ; circumstances 
which  once  led  him  to  entertain  hopes  that  the  cure 
of  the  aneurism  was  gradually  accomplishing.  At 
length,  however,  the  increase  of  the  tumour,  and  the 
aggravation  of  pain  and  inflammatory  symptoms,  dis- 
pelled such  expectation,  and  it  was  thought  necessary 
to  tie  the  femoral  artery  a second  time,  and  adopt  the 
common  mode. 

There  are  one  or  two  points  about  this  case  on  which 
the  author  does  not  particularly  dwell,  though  they 
require  consideration,  ere  one  can  form  a correct  judg- 
ment of  the  accuracy  of  one  of  his  positions,  “ that  non- 
pulsation of  the  sac  is  a sign  auspicious  or  otherwise, 
simply  as  it  stands  connected  with  increase  or  diminu- 
tion of  bulk  and  pain.” — (Med.  Chir  Trans,  vol.  9,  p. 
415.)  The  first  question  is,  how  are  we  to  account  for 
the  sudden  accession  of  pain,  the  absence  of  pulsation, 
the  increase  of  the  swelling,  and  the  other  changes 
which  happened  on  the  lOih  of  January  1 Judging 
from  the  j)articulars  given,  I should  say  that  at  this 
period  the  aneurisrnal  sac  gave  way,  and  the  disease 
changed  from  the  circumscribed  into  the  diffused  form ; 
an  alteration  which  would  account  for  the  pulsation 
being  entirely  lost,  the  increa.seof  pain,  and  the  extension 
of  the  swelling,  <fcc.  Now  although  the  circumstance 
of  the  sac  giving  way,  or  the  increase  of  pain,  swell- 
ing, <fec.  on  the  lOth  of  January,  may  be  taken  as  an 
argument,  that  the  application  of  the  ligature  for 
twenty-seven  hours  had  failed  in  producing  obstruction 
enough  in  the  vessel  to  retard  the  progress  of  the  dis- 


ease, we  ought  to  remember  tliut  at  tl.e  time  when 
these  changes  happened,  a trial  af  pressure  was  mak- 
ing to  which  one  might  impute  the  change  of  the  aneu- 
rism from  the  circumscribed  to  the  diffused  form  with 
quite  as  much  probability,  as  to  the  enlargement  of  the 
sac  by  blood  sent  into  it  through  the  imperfectly  obli- 
terated artery.  However  this  may  be,  certain  it  is,  that 
the  second  operation  was  done  when  no  pulsation  ex- 
isted ill  the  swelling;  and  perhaps,  therefore,  the  case 
would  have  been  doubly  interesting,  had  the  artery  not 
been  tied  a second  time  until  circumstances  had  un- 
equivocally proved  that  this  cessation  of  pulsation,  at- 
tended as  it  was  with  an  inflammatory  state  of  the 
tumour,  would  not  ultimately  have  ended  in  the  cure 
of  the  disease. 

Here,  however,  I may  be  speaking  rather  in  the 
spirit  of  an  experimenter  whose  curiosity  has  not  been 
fully  satisfied  than  as  a surgeon,  who  should  always 
be  governed  by  the  paramount  consideration  of  extri- 
cating his  patient  from  danger ; and  this  will  appear 
the  more  likely  when  I add  that  my  mind  has  long 
been  made  up  about  the  inexpediency  of  the  temporary 
ligature  as  an  innovation  in  surgery.  The  last  case 
induced  Mr.  Travers  to  relinquish  the  temporary  liga- 
ture; and  among  other  reflections  which  incline  him 
to  give  up  the  practice,  he  candidly  states,  “ that  the 
adhesive  union  is  prevented  by  the  enclosure  of  a fo- 
reign body  in  the  wound  long  before  suppuration  has 
commenced.  Suppuration  is  as  certain  to  take  place, 
though  the  ligature  be  removed  after  a few  hours,  as  if 
it  were  left  to  be  cast  off ; and  the  granulating  process 
is  more  languidly  performed  after  an  interruption  in 
its  early  stage,  for  the  purpose  of  removing  the  obstacle 
to  union,  than  where  no  such  interruption  has  been 
given,  and  the  obstacle  has  been  removed  by  nature’s 
own  means.  Hence  it  follows  that  the  theory  which, 
in  removing  the  ligature  within  a given  time,  propo.sed 
the  double  advantage  of  a quicker  as  well  as  a surer 
process,  fails  in  both  points  when  brought  to  the  test 
of  practice  upon  the  human  subject.” — (See  Med.  Chir, 
Trans,  vol.  9,  p.  416,  417.) 

We  have  seen  that  when  a temporary  ligature  which 
had  been  applied  to  the  brachial  artery  fifty  hours,  was 
withdrawn  by  Mr.  Travers,  pulsation  in  the  aneuris- 
mal  tumour  at  the  bend  of  the  elbow  did  not  return, 
and  the  disease  was  cured ; but  that  in  another  instance 
where  the  ligature  had  been  allowed  to  remain  on 
the  femoral  artery  only  twenty-seven  hours,  a feeble 
pulsation  was  renewed  a few  hours  afterward  in  a 
popliteal  aneurism,  and  as  the  swelling  became  painful 
and  more  diffused  some  weeks  after  this  experiment, 
though  no  pulsation  could  then  be  perceived,  the  femoral 
artery  was  tied  a second  time,  and  the  ligature  left  to 
separate  in  the  usual  manner. 

But  from  a case  more  recently  published  it  would 
seem  that  the  employment  of  a temporary  ligature  for 
only  twenty-four  hours  on  the  femoral  artery,  may 
obliterate  the  vessel,  and  accomplish  the  cure  of  a pop- 
liteal aneurism.  The  patient  was  a seafaring  man, 
aged  32  ; and  the  operator,  Mr.  Roberts,  of  Caernarvon  ; 
Mr.  Evans  and  Mr.  Carrey,  other  surgeons  of  that 
towm,  being  present  at  the  application,  and  also  at  the 
removal  of  the  ligature.  No  pulsation  recurred  in  the 
tumour ; the  edges  of  the  wound  were  brought  toge- 
ther with  adhesive  plaster  ; and  in  eleven  days  the 
part  was  quite  healed. — (Med.  Chir.  Trans,  vol.  11,  p, 
100.)  This  is  the  strongest  ca.«e,  I believe,  which  has 
been  adduced  in  support  of  the  use  of  the  temporary 
ligature,  whether  we  consider  the  little  time  which  il 
was  applied,  the  permanent  cessation  of  all  pulsation, 
the  quickness  with  which  the  wound  healed,  or  the 
complete  recovery  of  the  use  of  the  limb;  for  when 
the  patient  was  met  six  months  after  the  operation, 
“ he  could  go  to  the  mast  head  with  as  great  facility 
as  at  any  period  of  his  life.”  This  fact  proves  also 
that  there  is  a degree  of  irregularity  in  the  period  when 
the  temporary  ligature  may  be  removed  without  the 
jmlsation  in  the  tumour  below  the  constricted  part  ever 
returning.  Whether  the  variety  is  to  be  referred  to 
temperament,  the  kind  of  ligature  used,  its  greater 
tightness  in  one  case  than  another,  or  other  circum- 
stances, is  not  at  present  determined. 

The  greatest  advocate  which  this  practice  has  gained 
is  Scarpa,  whose  sentiments,  however,  about  the  most 
advantageous  form  of  ligatures,  and  mode  of  apjilying 
them  in  cases  of  aneurism,  are  very  muc.h  at  variance 
with  wliat  is  inculcated  by  the  best  and  most  expe- 


108 


ANEURISM. 


rienced  surgeons  in  this  country.  Instead  of  using  a 
fine  ligature,  composed  of  a single  piece  of  thread, 
twine,  or  silk,  he  employs  a cord  consisting  of  from 
four  to  six  threads,  accor^ng  to  the  size  of  the  artery 
which  is  to  be  tied  ; and  instead  of  aiming  expressly  at 
the  division  of  the  internal  coats  of  the  vessel  with  his 
ligature,  as  the  generality  of  English  surgeons  do,  for 
reasons  explained  in  another  part  of  this  work  (See 
Hemorrhage),  he  prefers  a largish  ligature,  and  inter- 
poses between  the  artery  and  the  knot  a small  cylinder 
of  linen  spread  with  ointment,  with  the  view  of  prevent- 
ing the  inner  coats  of  the  vessel  from  being  divided. 
His  reasons  for  this  practice  may  be  explained  in  a 
few  words  : he  admits  that  whenever  there  is  a concur- 
rence of  all  the  circumstances  capable  of  inducing  in 
the  tied  artery  the  proper  degree  of  adhesive  inflamma- 
tion, above  and  below  the  place  where  a single  circular 
ligature  has  been  applied,  this  method  is  adequate  to 
produce  a speedy  and  steady  closure  of  the  arterial  tube. 
But,  says  he,  it  sometimes  happens,  at  least  in  man,  that 
the  pressure  made  by  the  circular  ligature  produces  the 
ulcerative  process  more  quickly  in  the  artery  thdn  the 
adhesive  inflammation.  In  fact,  the  circular  ligature 
ulcerates  the  artery  in  general  about  the  third  day  after 
the  operation  ; and  the  adhesive  inflammation  does  not 
always  complete  its  course  in  this  period  of  time. 
During  this  delay  of  the  adhesive  inflammation,  the 
ulcerative  process,  occasioned  by  the  pressure  of  the 
ligature,  attacks  more  quickly  even  than  surgeons  ge- 
nerally suppose,  the  external  cellular  sheath  of  the 
artery,  and  penetrates  into  the  cavity  of  the  yet  per- 
vious vessel — and  this  of  course  with  increased  quick- 
ness, when  the  inner  coats  of  the  artery  are  already 
■divided  by  the  ligature.  The  dangers  of  non-adhesion 
and  too  rapid  ulceration  of  the  artery,  Scarpa  thinks, 
are  placed  at  the  greatest  distance  by  preserving  undi- 
vided all  the  three  coats  of  the  vessel  under  the  pres- 
sure of  the  ligature ; and  hence  his  partiality  to  larger 
ligatures  than  are  now  used  by  the  best  surgeons  in 
England,  and  to  the  interposition  of  a cylinder  of  linen 
between  the  knot  and  the  vessel,  as  recommended  by 
Pare,  Heister,  and  Platner.  If,  however,  he  has  had 
reason  to  suspect  that  a simple  circular  ligature  has 
frequently  failed  in  England,  because  other  innovations 
have  been  occasionally  substituted  for  it,  and  because 
we  should  not  have  sought  for  a better,  if  we  had  al- 
ready had  the  best,  how  much  more  vulnerable  is  his 
own  practice  on  a similar  principle ; since,  generally 
speaking,  it  has  not  retained  half  so  many  approvers 
as  they  who  still  express  their  preference  to  other 
methods,  and  more  especially  to  the  use  of  a single 
ligature,  uncomplicated  with  other  extraneous  sub- 
stances ! Is  it  probable,  he  asks,  that  the  single  cir- 
cular ligature,  which  was  formerly  used  with  doubtful 
success  by  the  greatest  surgeons,  should  not  have  be- 
come, as  is  pretended,  the  most  certain  means  of  pre- 
•venting  secondary  hemorrhage?  “It  is  now  wished 
(says  he)  to  ascribe  the  failures  of  Mr.  Hunter  and  of 
»many  other  operators,  not  to  the  circular  ligature,  but  to 
the  improper  treatment  of  the  wound  in  general,  and  in 
particular  to  the  introduction  into  it  of  lint,  and  more 
iespecially  to  the  irritation  occasioned  by  the  ligature  of 
.reserve.”  On  the  contrary,  it  is  argued  by  Scarpa, 
that  though  Mr.  Hunter,  after  his  first  trials,  simplified 
the  local  treatment,  though  all  skilful  surgeons  merely 
covered  the  wound  with  a pledget  of  soft  ointment,  and 
most  of  them  omitted  the  reserve-ligature,  yet,  notwith- 
standing these  reforms,  secondary  hemorrhage  after 
the  use  of  a simple  circular  ligature  was  not  rendered 
less  frequent. — (On  Aneurism,  p.  23,  ed.  2.)  With 
respect  to  the  latter  general  assertion,  its  incorrectness 
may  be  learned  by  reference  to  the  details  of  Mr.  Hun- 
ter’s own  operations,  and  by  going  into  the  principal  hos- 
pitals of  this  metropolis,  where  the  use  of  a simple  cir- 
cular ligature  for  tne  cure  of  aneurisms  very  rarely 
fails,  as  far  as  secondary  hemorrhage  is  concerned. 
Why  then  did  the  operation  more  frequently  fail  here 
in  former  times  ? The  answer  is  plain : the  kind  of 
ligature  now  employed  in  England  cannot  be  com- 
pared to  what  was  used  in  Mr.  Hunter’s  time,  or  even 
to  what  was  here  in  fashion  five-and-twenty  years  ago. 
And  besides  the  universal  rejection  of  ligatures  of 
reserve,  practitioners  now  have  a more  thorough  com- 
prehension of  what  ought  to  be  avoided  in  the  opera- 
tion, have  a just  fear  of  separating  and  disturbing  the 
artery  too  much,  know  how  to  appreciate  the  advan- 
tage of  closing  the  wound,  and  attach  due  importance 


to  the  choice  of  smaller  or  more  eligible  ligatures. — 
(See  Hemorrhage  and  Ligature.)  When,  therefore, 
Scarpa  siijiposes,  that  in  England  the  practice  with  the 
circular  ligature  in  the  treatment  of  aneurism  is  ma- 
terially the  same  now  as  heretofore,  and  that  secondary 
hemorrhage  is  as  frequent,  he  has  not  availed  himself 
of  all  the  information  on  tliis  subject,  which  he  might 
have  acquired  from  Mr.  Wishart,  the  able  translator 
of  his  writings  on  aneurism,  or  from  an  attentive  pe- 
rusal of  Mr.  Hodgson’s  valuable  treatise. 

In  an  equality  of  circumstances,  conducive  to  the 
success  of  the  Hunterian  operation,  Scarpa  thinks, 
that  the  fact  is  not  proved,  as  it  is  presumed  to  be,  that 
the  rupture  of  the  internal  and  middle  coats  of  the  ar- 
tery does  excite  the  adhesive  inflammation  and  union 
of  the  artery  more  effectually  than  is  done  by  the  sim- 
ple compression  and  close- contact  of  its  two  opposite 
internal  parietes  in  a sound  and  uninjured  state.  This 
remark  is  partly  true,  and  partly  incorrect,  at  the  same 
time  that  it  involves  a question  which  must  be  defer- 
red till  we  come  to  the  article  Hemorrhage.  The  truth 
in  the  observation  is,  that  an  artery  may  generally  be 
rendered  impervious  with  tolerable  certainty,  by  com- 
pressing its  opposite  parietes  steadily  and  firmly  to- 
gether for  a certain  time,  without  dividing  its  inner 
coats ; the  inaccuracy  of  it  depends  upon  the  fact,  that 
surgeons  have  no  instrument  nor  contrivance  inot  ex- 
cepting even  the  ligature  of  four  or  six  threads,  with 
the  interposition  of  the  cylinder  of  linen  spread  with 
ointment),  which  can  retain  the  opposed  undivided 
surfaces  of  the  inner  coats  of  the  vessels  closely  to- 
gether in  the  manner  commended  by  Scarpa,  and  for 
the  due  time,  without  the  objection  of  denuding  more 
of  the  artery  than  need  be  done  in  the  application  of 
a small  ligature ; or  without  the  serious  inconveni- 
ence and  risk  necessarily  attending  the  introduction 
of  a larger  quantity  of  extraneous  matter  into  the 
wound  than  is  desirable,  with  the  view  of  averting  all 
chance  of  the  ulceration  of  the  artery  reaching  beyond 
prudent  limits.  And  when  metallic  instruments  are 
used  for  the  same  purpose,  objections  not  less  real  are 
incurred,  as  will  be  hereafter  more  particularly  ex- 
plained. 

Scarpa  considers  that  his  mode  of  ligature  ought  to 
be  preferred,  as  combining  the  triple  advantage  of 
preserving  entire  all  the  three  coats  of  the  artery  ; of 
exciting  quickly,  and  in  a proper  degree,  the  adhesive 
inflammation  in  them  ; and  of  retarding,  as  much  as 
possible,  the  ulcerative  process  of  the  arterial  tube. 

Partly  impres.sed,  however,  with  tire  truth  of  the  te- 
nets laid  down  by  Dr.  Jones  (see  Hemorrhage),  Scarpa 
enjoins  a'ttention  to  the  following  rules:  1.  Not  to  in- 
I sulate  and  detach  the  artery  any  farther  than  is  neces- 
' sary  for  allowing  a ligature  to  be  passed  around  it. 
2.  Not  to  let  the  cylinder  of  linen  exceed  a line  in  length, 
or  a little  more,  above  and  below  the  breadth  of  the  tape 
which  is  about  a line  for  the  large  arteries  of  the 
extremities.  3.  That  the  ligature  be  not  too  tight. 
4.  And  that  it  be  never  applied  immediately  below  the 
origin  of  a large  lateral  branch. — ^See  Scarpa  on  Aneu- 
rism, p.  44,  ed.  2.) 

Some  farther  consideration  of  Scarpa’s  mode  of  ap- 
plying the  ligature  will  be  introduced  in  the  article 
Hemorrhage;  and  I now  proceed  to  notice  his  senti- 
ments concerning  the  advantage  which  may  be  derived 
from  removing  the  ligature  in  cases  of  aneurism,  as 
soon  as  the  tube  of  the  vessel  has  been  obliterated  by 
the  adhesive  inflammation.  From  the  facts  recorded 
by  Scarpa,  it  is  inferred,  that  with  the  kind  of  ligature 
and  the  cylinder  of  linen  used  in  his  practice,  the  clo- 
sure of  the  artery  by  the  adhesive  inflammation  and 
the  two  internal  coagula  is  sufficiently  far  advanced 
on  the  third  or  fourth  day  after  the  operation  to  resist 
the  impul.se  of  the  blood  ; and  hence  (says  he)  there  is 
no  rational  motive  for  waiting  beyond  this  time  for  the 
spontaneous  separation  of  the  ligature,  or  for  allowing 
it,  by  its  fartlier  presence,  to  ulcerate,  and  even  open 
the  artery  at  the  principal  point  of  adhesion.  He  then 
comments  on  the  advantages  to  the  wound,  derived 
from  the  removal  of  all  extraneous  matter  from  it  on 
the  third  or  fourth  day.  With  respect  to  the  general 
period  of  such  removal,  however,  he  makes  one  excep- 
tion, viz.  the  case  of  great  and  evident  debility  from 
sickly  constitution,  or  very  advanced  age,  as  it  is  ob- 
served, that  in  such  patients,  the  reunion  of  a simjile 
wound  is  frequently  protracted  to  the  sixth  day.  In 
cases  of  this  descrijition,  Scarpa  recommends  delaying 


ANEURISM. 


109 


the  removal  of  the  ligature  to  the  completion  of  the 
fifth  or  sixth  day,  but  under  the  express  condition  that 
the  ligature  has  been  applied  with  the  interposition  of 
a cylinder  of  linen ; as  it  is  proved,  that  a common 
circular  ligature  causes  ulceration  of  the  artery  before 
the  third  day,  and  it  is  not  till  the  sixth  day,  that  the 
external  coat  of  the  vessel  begins  to  ulcerate,  when 
the  other  modiftcation  of  the  ligature  is  adopted. — 
(P.  50.) 

Scarpa  supports  the  preceding  advice  by  four  cases, 
in  which  his  kind  of  ligature  was  applied,  and  with- 
drawn at  the  end  of  the  third  or  fourth  day,  and  the  ar- 
terial tube  obliterated.  However,  I do  not  tliink,  that 
in  England,  these  cases,  when  minutely  and  attentively 
considered,  will  be  regarded  as  inducements  to  per- 
severe in  the  use  of  temporary  ligatures.  In  every  in- 
stance the  wound  is  described  as  suppurating,  and 
sometimes  plentifully.  In  one,  the  foot  mortified,  and 
amputation  became  necessary.  In  another,  the  very 
day  after  the  disturbance  of  removing  the  ligature,  the 
thigh  was  attacked  with  erysipelas,  and  on  the  eighth 
day  the  wound  is  represented  ais  being  foul,  and  the  ery- 
sipelas not  yet  cured. 

Independently  of  the  uncertainty  of  the  period  when 
the  arterial  tube  is  closed  by  the  adhesive  inflamma- 
tion in  various  patients,  it  appears  to  me,  that  the  dis- 
turbance of  the  vessel  and  wound,  by  the  steps  neces- 
sary for  the  loosening  and  removal  of  the  ligature,  will 
ever  form  an  insuperable  objection  to  the  practice. 
Scarpa  appears  to  have  some  apprehension  of  this  kind 
himself ; for  he  remarks,  “ In  the  act  of  removing  the 
ligature,  there  can  be  no  doubt  it  is  of  great  conse- 
quence, that  the  artery  he  not  rudely  handled  or 
stretched.  And,  indeed,  if,  on  untying  the  running 
knot,  the  subjacent  knot  could  be  with  the  same  fa- 
cility untied,  we  could  not  wish  for  a better  mode  of 
performing  this  part  of  the  operation.  But  the  knot, 
although  a simple  one,  is  not  so  readily  untied  as  the 
running  knot,  on  account  of  the  moisture  with  which 
the  threads  forming  the  ligature  are  soaked,  or  because 
the  ligature  has  been  previously  waxed.” — (P.  64,  ed. 
2.)  In  fact,  his  apprehensions  then  lead  him  to  sug- 
gest the  scheme  of  placing,  previously  to  making  the 
knot,  a thread  longitudinally  on  each  side  of  the  cylin- 
der, and  at  the  time  of  removing  the  ligature,  the 
threads  are  to  be  drawn  in  opposite  directions,  in  order 
to  undo  the  knot,  without  displacing  or  stretching  the 
artery.  Thus,  instead  of  one  small  ligature,  which  is 
all  that  an  English  surgeon  leaves  in  the  wound, 
Scarpa  recommends  his  ligature  of  four  or  six  threads, 
a roll  of  linen,  and  two  other  threads  ; a quantity  of 
extraneous  substances,  which  cannot  fail  to  be  a source 
of  serious  irritation  and  mischief.  I shall  therefore 
take  leave  of  the  proposal  of  removing  the  ligature  on  | 
the  third  or  fourth  day,  or  any  other  particular  day, 
with  expressing  my  belief,  that  if  there  were  only  the 
following  objection  to  the  plan,  it  would  never  be 
adopted  in  this  country ; namely,  the  advocates  for 
this  practice  are  necessarily  obliged  to  renounce  the 
inflniie  advantage  of  bringing  the  edges  of  the  wound 
together  directly  after  the  operation.  Had  the  sug- 
gestion of  Dr.  .Tones  proved  invariably  correct,  and  the 
ligature  admitted  of  being  withdrawn  immediately 
aftf  r the  inner  coats  of  the  vessel  had  been  divided  by 
it,  the  case  would  have  been  very  dilTerent,  as  there 
would  then  have  been  no  foreign  body  at  all  left  in  the 
wound ; the  parts  might  have  been  immediately  brought 
together  with  the  greatest  chance  of  union  by  the  first 
intention,  and  no  subsequent  disturbance,  either  of  the 
artery  or  of  the  wound,  would  have  been  incurred. 

The  next  practiee  which  I shall  notice,  is  that  of  ap- 
plying two  ligatures  to  the  artery,  and  cutting  it 
through  in  the  interspace.  This  suggestion  may  be 
said  to  be  as  ancient  as  the  time  of  Celsus,  who  has 
advised  the  method  to  be  followed  in  the  treatment  of 
a wounded  arter>' ; ‘‘  Q.u:e  (arteriae)  sanguinem  fun- 
dunt  apprehendendae,  circaejue  id  (juod  ictum  est  duo- 
bus  locis  deligandae  intercidendmque  sunt,  ut  in  se  ii)sa3 
coeant,  et  nihilominus  ora  reclusa  habeant.” — (De  Me- 
dicine, lib.  5,  c.  26,  ^ 21.)  The  fact  is  curious,  though  I 
I mention  it  without  the  least  intention  of  detracting 
from  the  great  merits  of  several  modern  surgeons, 
that  the  Greeks  were  acquainted  with  the  practice, 
lately  recommended,  of  tying  and  dividing  the  trunk 
of  the  artery  high  above  the  tumour,  as  will  appear 
from  the  following  extract : — (.^hius,  4,  Serm.  Tetr.  4, 
cap.  10.;  At  vero  quod  in  cubiti  cavitate  fit  aneurisma. 


hoc  modo  per  chirurgiam  aggredimur : primum  arteria 
superne  ab  ala  ad  cubitum  per  internam  brachii  parte 
simplicem  sectionem,  tribus,  aut  quatuor  digitis  infra 
alam,  per  longitudinem  facimus,ubi  maxime  adtactum 
arteria  occurrit : atque  ea  paulatim  denudata,  dein- 
ceps  incumbentia  corpuscula  sensim  excoriamus  ac 
separamus,  et  ipsam  arteriam  caeco  uncino  attractam 
duobus  fili  vinculis  probe  adstringimus,  mediamque 
inter  duo  vincula  dissecamus;  et  sectionem  polline 
thuris  explemus,  ac  linamentis  inditis  congruas  deliga- 
tiones  adhibemns.  Afterward  we  are  directed  to  open 
the  aneurismal  tumour  at  the  bend  of  the  elbow,  and 
when  the  blood  has  been  evacuated,  to  tie  the  artery 
twice  and  divide  it  again.  If  the  ancients  had  only 
omitted  the  latter  part  of  their  operation,  they^would 
absolutely  have  left  notliing  to  be  discovered  by  the 
• moderns. 

This  method  of  applying  two  ligatures  to  the  artery, 
and  dividing  the  vessel  between  them,  was  revived  in 
France  about  sixty  years  ago  by  Tenon,  who,  as  well 
as  some  later  surgeons,  was  totally  unacquainted  with 
its  antiquity.— (See  Pelletan,  Clinique  Chir.  t.  1,  p 
192.)  At  one  time  it  had  also  modern  advocates  in 
Mr.  Abernethy  and  Professor  Maunoir  of  Geneva, 
each  of  whom  supposed  the  plan  an  invention  of  his 
own. — (See  Surgical  and  Physiol.  Essays,  part  3,  8vo. 
Lond.  1797  ; and  Memoires  Phisiologiques  et  Pratiques 
sur  I’Aiieurisme,  &c.  8vo.  Geneve,  1802.) 

When  an  artery  is  laid  bare  and  detached  from  its 
natural  connexions,  and  the  middle  of  such  detached 
portion  tied  with  a single  ligature,  as  was  Mr.  Hun- 
ter’s practice,  Mr.  Abernethy  conceived  that  the  vessel 
so  circumstanced  would  necessarily  inflame  and  be 
very  likely  to  ulcerate.  The  occurrence  of  bleeding 
from  this  cause  at  first  led  to  a practice,  which  this 
gentleman  justly  censures,  viz.  applying  a second  liga- 
ture above  the  first,  and  leaving  it  loose,  but  ready  to 
be  tightened  in  case  of  hemorrhage.  As  the  second 
ligature,  however,  must  keep  a certain  portion  of  the 
artery  separated  from  the  surrounding  parts,  and  must , 
as  an  extraneous  substance,  irritate  the  inflamed  ves- 
sel, it  must  make  its  ulceration  still  more  apt  to  follow. 
The  great  object,  therefore,  which  Mr.  Abernethy  in- 
sisted upon,  was  that  of  applying  the  ligature  close  to 
that  part  of  the  artery  which  lies  among  its  natural 
connexions ; a just  principle,  the  truth  and  utility  of 
Avhich  still  remain  incontrovertible,  though  there  may 
be  a better  way  of  accomplishing  what  Mr.  Abernethy 
intended  than  the  measures  which  this  gentleman  was 
led  to  recommend. 

The  peculiarity  in  Mr.  Abemethy’s  first  operation, 
consisted  in  applying  two  ligatures  round  the  artery, 
close  to  where  it  was  surrounded  with  its  natural  con- 
j nexions.  For  this  purpose,  he  passed  two  common- 
sized ligatures  beneath  the  femoral  artery,  and  having 
shifted  one  upwards,  the  other  downwards,  as  far  as 
the  vessel  was  detached,  he  tied  both  the  ligatures 
firmly. 

The  event  of  this  case  was  successful.  An  uneasy 
sensation  of  tightness,  however,  extending  from  the 
wound  down  to  the  knee,  and  continuing  for  many 
days  after  the  operation,  made  Mr.  Abernethy  deter 
mine,  in  any  future  case,  to  divide  the  artery  betweerr 
the  two  ligatures,  so  as  to  leave  it  quite  lax. 

Mr.  Abernethy  next  relates  a case  of  popliteal  aneu 
rism,  for  which  Sir  Charles  Blicke  operated,  and  divided 
the  artery  between  the  ligatures.  The  man  did  not 
experience  the  above  kind  of  uneasiness ; and  no  he- 
morrhage ensued  when  the  ligatures  came  away,  al- 
though there  was  reason  to  think,  that  the  whole  arte- 
rial system  had  a tendency  to  aneurism,  as  there  was 
also  another  tumour  of  this  kind  in  the  opposite  thigh. 

The  reasoning  which  induced  this  gentleman  to  re- 
vive this  ancient  practice  was  ingenious;  for  when 
the  artery  was  tied  with  two  ligatures,  and  divided  in 
the  foregoing  manner,  it  was  argued  that  it  would  be 
quite  lax,  possess  its  natural  attachments,  and  be  as 
nearly  as  possible  in  the  same  circumstances  as  a tied 
artery  upon  the  face  of  a stump.  Strictly  si»eaking, 

I however,  as  Mr.  Hodgson  first  pointed  out,  an  artery 
tied  in  two  places,  and  divided  in  the  intersjiace,  can- 
not be  regarded  as  placed  exactly  in  the  same  condi- 
tion, as  an  artery  tied  in  amputation.  In  the  latter 
case,  the  retraction  of  the  vessel  corresponds  with 
that  of  the  surrounding  parts,  which  are  divided  at  the 
same  instant,  and  therefore  its  relative  connexions 
stand  as  belbre  the  operation.  But  in  the  operation  for 


110 


ANEURISM. 


aneurism,  the  retraction  of  the  artery  takes  place, 
without  being  attended  with  a corresponding  retrac- 
tion of  its  connexions.  How  far  the  retraction  of  the 
artery  is  beneficial  or  injurious  is  by  no  means  evi- 
dent ; and  the  advantages  arising  from  it  may  in  most 
situations  be  obtained  without  dividing  the  vessel,  by 
placing  the  limb  in  a bent  jwsition.  One  important 
object,  however,  is  gained  by  the  divi.sion  of  the  artery  ; 
namely,  that  it  is  generally  in  that  case  tied  close  to  its 
connexions,  and  it  is  very  evident  how  liable  the  ap- 
plication of  the  ligature  in  the  middle  of  a denuded  ex- 
tent of  the  vessel  must  be  to  produce  ulceration  or 
sloughing  of  its  coats.  The  same  object,  however, 
will  be  gained  by  tying  the  undivided  artery  close  to 
its  connexions  at  the  end  nearest  to  the  heart ; and  the 
existence  of  a single  ligature  at  the  bottom  of  the 
wounJ  will  be  less  liable  to  give  rise  to  .suppuration 
and  the  formation  of  sinuses  than  the  employment  of 
two.  When  an  artery  is  divided,  the  portions  situated 
beyond  the  ligatures  must  slough,  and  prove  an  addi- 
tional cause  of  suppuration  in  the  wound.  Experi- 
ence has  amply  proved  the  safety  of  employing  a sin- 
gle ligature,  and  it  is  at  present  used  by  many  of  the 
most  experienced  operators  in  this  country. — (See 
Hodgson  on  the  Diseases  of  Arteries,  &c.  p.  221,  .fcc.) 

According  to  Scarpa,  numerous  examples  of  the  fail- 
ure of  the  plan  of  applying  two  ligatures,  and  cutting 
through  the  artery  in  the  interspace,  are  already  gene- 
rally known  to  the  profession,  and  there  are  many 
expert  and  ingenious  surgeons,  who  do  not  dissemble 
the  disadvantage  and  uncertainty  of  this  practice.  He 
speaks  of  one  failure  which  occurred  to  Mr.  Abernethy 
himself.  But  I entertain  doubts  how  far  any  inference 
against  the  method  can  be  drawn  from  Monteggia’s  in- 
stance, in  which  a ligature  of  reserve  had  been  used. 
Nor  can  I understand  how  a circumstance  which 
Scarpa  strongly  insists  upon,  can  be  well  founded ; I 
mean  the  danger  of  the  ligature  being  forced  off  the 
mouth  of  the  artery  by  the  impulse  of  the  blood.  Any 
risk  of  this  kind  cannot  exist  if  the  ligature  be  duly 
applied,  as  Dr.  Jones  has  particularly  explained ; and 
at  all  events,  how  can  it  be  greater  here  than  after 
amputation,  where  it  is  not  usually  made  a subject  of 
complaint  ? Indeed  the  several  examples  of  secondary 
hemorrhage  after  this  method,  quoted  by  Scarpa  from 
the  practice  of  Monteggia,  Morigi,  and  .\.ssalini,  may 
be  more  rationally  imputed  either  to  reserve-ligatures 
having  been  also  used,  or  the  common  fear  in  Italy  of 
applying  the  ligatures  tightly  ; in  which  event  one  can 
readily  suppose  that  the  ligature  might  really  slip,  or 
by  remaining  a long  time  on  the  vessel  might  give  rise 
to  dangerous  ulceration.  Thus  Morigi  speaks  of  one 
case  in  which  the  bleeding  occurred  on  the  nineteenth 
day. — (Scarpa  on  Aneurism,  p.  14,  ed.  2.)  On  the 
whole,  I am  disposed  to  believe,  that  when  this  method 
has  been  executed  precisely  according  to  Mr.  Aberne- 
thy’s  directions,  it  has  not  often  failed ; and  I am  ac- 
quainted with  only  one  case  in  London  in  which  it 
wras  followed  by  secondary  hemorrhage.  However,  in 
the  year  1807,  Mr.  Norman  of  Bath  tied  the  femoral 
artery  wth  two  ligatures,  and  divided  the  vessel 
between  them  ; the  upper  ligature  came  away  on 
the  sixteenth  day  after  the  operation ; the  lower 
one  on  the  fifteenth ; and  the  following  day  a pro- 
fuse hemorrhage  came  on,  the  patient  losing  a pound 
of  blood.  Pressure  with  a compress  and  wet  bandage 
was  continued  for  some  time,  and  the  wound  healed. — 
(See  Med.  Chir.  Trans,  vol.  10,  p.  123.)  This  is  the 
only  case  of  secondary  hemorrhage,  which  he  has  met 
with  after  operating  tor  aneurisms. 

Scarpa  very  properly  urges,  that  the  application  of 
two  ligatures  and  dividing  the  artery  in  the  interspace 
can  never  be  an  eligible  mode,  where  the  smallness  of 
the  space,  the  dejith  of  the  artery,  and  the  importance 
of  the  surrounding  parts,  do  not  permit  the  vessel  to  be 
separated  and  insulated  to  such  an  extent  as  is  re 
quired  for  dividing  it,  with  a probability  of  the  division 
of  it  being  sufficiently  distant  from  the  two  ligatures. 
Such,  for  example,  are  the  cases  of  ligature  of  the  caro- 
tid in  the  vicinity  of  the  sternum  ; of  the  iliac  above 
Poupart’s  ligament ; of  the  internal  iliac,  a little  below 
its  origin  from  the  common  iliac  ; of  the  axillary  artery 
between  the  point  of  the  coracoid  process  and  the 
acromial  portion  of  the  clavicle;  or  of  the  subclavian 
in  its  passage  between  the  scaleni  muscles.  Scarjia 
then  comments  on  the  difficulty  and  even  impossibility 
of  taking  up  the  end  of  the  truncated  artery  again  iii 


many  situations  were  hemorrhage  to  ensue ; and  he 
joins  Mr.  Hodgson  in  thinking  the  advantages  of  the 
method,  even  where  it  is  practicable,  by  no  means  de- 
monstrated. Nay,  he  goes  farther ; for  he  agrees  with 
Heister,  Callisen,  and  Richter,  in  setting  it  down  as 
worse  than  useless,  on  account  of  the  portion  of  the 
artery  between  the  ligatures  being  converted  into  a 
dead  and  putrid  substance,  which  rests  upon  the  bot- 
tom of  the  w'ound,  from  which  it  cannot  be  removed 
until  the  two  ligatures  are  separated.  Here,  deeply 
impressed  with  the  truth  of  principles  which  perhaps 
he  has  rather  lost  sight  of  in  speaking  of  his  own  par- 
ticular method,  he  comments  on  the  little  probability 
of  the  wound  uniting,  under  the  disadvantage  of  tw'o 
ligatures  hanging  out  of  it,  and  of  sloughs  at  its  bot- 
tom. He  argues  correctly,  that  the  laying  bare  and 
insulating  a large  portion  of  artery  would  often  be  ob- 
jectionable on  the  ground  that  it  could  not  be  done 
w ithout  the  surgeon  being  obliged  to  apply  the  prin 
cipal  ligature  too  near  the  origin  of  a large  lateral 
branch ; as,  for  example,  would  happen  in  a case  of 
inguinal  aneurism,  situated  an  inch  and  a quarter  be- 
low the  origin  of  the  profunda.  Thus  a coagiilum 
could  not  be  formed,  and  the  artery  would  be  in  dan- 
ger of  not  being  closed.  On  the  contrary,  by  employ- 
ing only  a single  ligature  at  an  inch  and  a quarter  be- 
low the  origin  of  the  profunda,  the  operation  would  be 
equally  simple  and  successful. — ^Scarpa  on  Aneurism, 
p.  19—21,  ed.  2.) 

ITie  above  considerations  would  certainly  lead  me 
to  avoid  the  practice  of  detaching  an  artery  from  its 
surrounding  connexions  any  more  than  is  absolutely 
necessary  for  the  conveyance  of  a single  ligature  under 
it ; but  I fully  concur  with  Sir  Astley  Cooper  in  the 
prudence  of  using  two  ligatures,  and  applying  them  in 
the  way  recommended  by  Mr.  Abernethy,  whenever 
the  artery  has  been  extensively  separated  from  its 
sheath  in  the  operation. — .See  Lancet,  vol.  1,  p.  433.) 

The  frequent  occurrence  of  accidents  after  the  intro- 
duction of  Mr.  Hunter’s  operation  might  have  been 
ascribed  to  more  probable  causes  than  the  condition  of 
an  undivided  artery,  upon  which  the  ligature  was  ap- 
plied. The  employment  of  numerous  ligatures  gradu- 
Mly  tightened,  or  the  introduction  of  extraneous  bodies 
into  the  wound,  were  alone  sufficient  to  produce  ulcer- 
ation of  the  artery ; and  such  practices  were  adopted 
in  most  of  the  cases  in  which  secondary  hemorrhage 
took  place. 

After  the  reasons  which  have  been  urged  against 
the  plan  of  tying  the  artery  vvith  two  ligatures,  and 
dividing  it  in  the  interspace,  it  may  appear  superfluous 
to  notice  a modification  of  this  practice,  intended  as  a 
security  against  the  slipping  of  the  ligature.  But  as 
the  proposal  has  had  the  approbation  of  some  men  of 
eminence,  and  I heard  of  an  instance  in  which  it  was 
practised  not  long  ago,  the  subject  may  still  be  worthy 
of  notice. 

Sir  Astley  Cooper  has  published  a case  of  popliteal 
aneurism,  in  which  the  femoral  artery  had  been  tied 
with  two  ligatures,  as  firmly  as  could  be  done  without 
ri.sk  of  cutting  it  through.  “But  (says  he,,  as  I was 
proceeding  to  dress  the  wound,  I saw  a stream  of 
blood  issuing  from  the  artery,  and  when  the  blood  was 
sponged  away  one  of  the  ligatures  was  found  detached 
from  the  vessel.  Soon  after,  the  other  was  also  forced 
off,  and  thus  the  divided  femoral  artery  was  left  with- 
out a ligature,  and  unless  immediate  assistance  had 
been  afforded  him,  the  patient  must  have  perished  from 
hemorrhage.”  The  same  kind  of  accident  has  occurred 
in  Mr.  Cline’s  practice.  For  the  prevention  of  it  Sir 
Astley  at  first  tried  the  method  of  conveying  the  liga- 
tures by  means  of  two  blunt  needles  under  the  arterj', 
an  inch  asunder  and  close  to  the  coats  of  the  vessel, 
excluding  the  vein  and  nerve,  but  passing  the  threads 
through  the  cellular  membrane  surrounding  the  artery. 
When  these  were  tied,  and  the  artery  had  been  divided 
between  them,  the  ligatures  were  prevented  from  slip 
ping  by  the  cellular  membrane  tlu-ough  which  they 
passed. 

Afterw'ard,  however,  he  preferred  a different  mode 
of  securing  the  ligature  suggested  to  him  by  Mr.  H. 
Cline,  and  it  was  imt  to  the  test  of  ex)>eriment  in  0]>e- 
rating  fora  popliteal  aneurism  on  Henry  Figg,  aged  29. 
“An  incision  being  made  on  the  middle  of  the  inner 
jiart  of  the  thigh,  and  the  femoral  artery  exposed,  the 
artery  was  sejiarated  from  the  vein  and  nerve  and  all 
the  surrounding  parts,  to  the  extent  of  an  inch ; an 


ANEURISM. 


Ill 


eyc-prooe,  armed  with  a double  ligature,  having 
a curved  needle  at  each  end,  was  conveyed  under 
the  artery,  and  the  probe  cut  away.  The  ligature 
nearest  the  groin  was  first  tied  ; the  other  was  sepa- 
rated an  inch  from  the  first  and  also  tied.  Then  the 
needles  were  passed  through  the  coats  of  the  artery, 
close  to  the  ligatures  between  them,  and  the  ends  of 
each  thread  were  again  tied  over  the  knots  made  in 
fastening  the  first  circular  application  of  the  ligatures. 
Thus  a barrier  was  formed  beyond  which  the  ligature 
could  not  pass.”  The  event  of  this  operation  was  suc- 
cessful.— (Med.  and  Phys.  Journ.  vol.  8.) 

A similar  proposal  appears  to  have  been  mentioned 
by  Dionis,  and  to  have  been  noticed  by  some  subse- 
quent writers.  In  the  13th  chapter,  in  Richter’s  An- 
fangsgriinde  der  Wundarzneykunst,  we  read  the  fol- 
lowing passage : 

“ The  artery  when  drawn  out,  is  to  be  twice  sur- 
rounded with  the  common  ligature.  This  is  to  be  tied 
in  a knot,  and,  when  the  artery  is  targe,  one  end  of  the 
ligature  is  to  be  passed  by  means  of  a needle  through 
the  vessel  before  the  knot,  then  both  ends  are  to  be 
tied  together  and  left  hanging  out  of  the  wound  as  in 
the  ordinary  way.”— (Ed.  3,  1799.) 

What  power  can  possibly  force  the  ligature,  when 
tied  with  due  tightness,  off  the  extremity  of  the  vessel  1 
No  action  of  the  heart  or  artery  itself,  no  turgid  state 
of  this  vessel,  could  do  so.  If  a piece  of  string  were 
tied  round  any  tube  for  the  purpose  of  preventing  a 
fluid  from  escaping  from  its  mouth,  provided  the  string 
were  applied  with  due  tightness,  and  the  knot  in  such 
a manner  as  not  to  yield,  no  fluid  could  possibly  escape, 
however  great  the  propelling  power  might  be,  as  long 
as  the  string  and  structure  of  the  tube  did  not  break. 
And  if  a ligature  were  applied  so  slackly  as  to  slip, 
who  can  doubt  that  hemorrhage  would  still  follow, 
even  though  the  ligature  were  carried  through  the  end 
of  the  vessel  and  tied  in  the  foregoing  way? 

Where  ligatures  have  slipped  off  very  soon  after 
being  applied,  I conclude  that  the  arteries  either  could 
not  have  been  tied  with  sufficient  tightness,  perhaps 
through  an  unfounded  fear  of  the  ligature  cutting  its 
way  completely  through  all  the  coats  of  an  artery,  or 
else  that  the  knot  or  noose  became  slack  from  causes 
which  will  be  understood  by  considering  what  is  said 
on  this  matter  in  the  article  Hemorrhage.  The  inner 
coats  of  the  artery,  we  know  from  the  experiments  of 
Dr.  Jones,  ought  to  be  cut  through  when  the  artery  is 
properly  tied,  because  the  circumstance  is  always  use- 
flil  in  promoting  the  effusion  of  lymph  within  the  ves- 
sel, and  the  process  of  obliteration  by  the  adhesive 
inflammation. 

The  preceding  method  is  so  contrary  to  the  grand 
principle  of  always  avoiding  the  detachment  of  the 
artery  from  its  surrounding  connexions,  and  is  so  in- 
consistent with  the  wise  maxim  of  doing  the  operation 
with  as  little  disturbance  of  the  vessel  as  possible,  that 
it  is  not  surprising  that  it  should  have  met  with  only  a 
small  number  of  followers.  In  fact,  it  is  not  only  liable 
to  every  objection  which  can  be  urged  against  the 
double  ligature  and  division  of  the  artery,  as  formerly 
proposed  by  Celsus  and  a few  of  the  moderns,  but  on 
account  of  its  greater  tediousness,  more  extensive  sepa- 
ration and  destruction  of  the  vessel,  and  other  reasons, 
is  still  less  worthy  of  imitation. 

With  respect  to  ligatures  of  reserve,  the  interposition 
of  agaric,  cork,  and  other  hard  substances  between 
the  knot  and  the  artery,  these  contrivances  are  now 
so  fully  rejected  by  all  good  surgeons,  for  reasons 
Avhich  will  be  quite  intelligible  after  the  perusal  of  an- 
other part  of  this  work  (see  Hemorrhage),  that  I shall 
not  at  present  detain  the  reader  with  animadversions 
on  their  danger.  As  for  several  kinds  of  metallic  com- 
pressors intended  to  be  applied  to  the  exposed  artery 
for  the  purpose  of  rendering  it  impervious,  they  are 
inventions  which  have  been  made  and  extolled  by  some 
surgeons  of  high  repute,  whose  names  would  give  im- 
portance even  to  a less  meritorious  proposition. 

Dubois  conceived  that  hemorrhage  might  sometimes 
proceed  from  the  circumstance  of  a ligature  making  its 
way  loo  fast  through  the  artery.  He  thought,  also, 
that  the  sudden  stoppage  of  the  current  of  blood  by  a 
tight  ligature  might  bring  on  gangrene  of  the  limb, 
particularly  when  the  aneurism  was  not  of  long  stand- 
ing, so  that  the  collateral  branches  had  not  had  time  to 
enlarge.  Dubois,  therefore,  proposed  a method  of 
gradually  stopping  the  flow  of  blood  through  the  artery ; 


and  by  tms  ingenious  imitation  of  the  process  of  na* 
ture,  to  promote  the  gradual  dilatation  of  the  collateral 
arteries,  and  obviate  all  risk  of  gangrene  in  the  lower 
part  of  the  limb.  This  gentleman  put  his  plan  in  exe- 
cution, and  two  instances  of  success  are  recorded. 
The  cases  were  popliteal  aneurisms.  A ligature  was 
passed  under  the  artery  in  the  manner  of  Hunter ; its 
two  ends  were  then  put  through  an  instrument  called 
a sorre-ncBud,  with  which  the  compression  was  gra- 
dually increased.  It  is  stated,  that  in  one  of  these 
cases  the  plan  made  the  artery  inflamVand  become  im- 
pervious in  the  course  of  the  first  night,  so  that  on  the 
following  day  the  throbbing  of  the  tumour  had  ceased. 
— (Richerand,  Nosogr.  Chir.  t.  4,  p.  109,  edit.  4.)  Here, 
however,  it  is  to  be  suspected  that  the  pressure  of  the 
apparatus  was  greater  than  was  calculated ; and  that 
the  stoppage  of  the  pulsation  was  more  owing  either 
to  this  cause,  or  to  the  coagulation  of  the  blood  in  the 
sac  and  adjoining  portion  of  the  artery,  than  to  the 
process  of  obliteration,  which  could  hardly  have  been 
so  rapidly  accomplished. 

Assalini’s  compressor  is  an  instrument  calculated, 
as  its  inventor  states,  to  produce  an  obliteration  of  the 
trunks  of  arteries,  without  dividing  or  injuring  their 
coats.  It  is  nothing  more  than  a small  pair  of  silver 
forceps,  the  blades  of  which  are  broad  and  flat  at  their 
extremities,  between  which  the  artery  is  compressed. 
A spring,  composed  of  a piece  of  elastic  steel,  is  at- 
tached to  the  inside  of  one  of  the  handles,  and  by 
pressing  against  the  opposite  handle  retains  the  flat 
ends  of  the  blades  in  contact.  This  spring  is  intended 
to  be  very  weak  in  its  operation ; but  by  means  of  a 
screw,  which  passes  through  the  handles,  the  pressure 
admits  of  being  regulated  and  increased  at  the  option 
of  the  surgeon. 

A representation  of  Assalini’s  compressor  may  be 
seen  in  his  Mannale  di  Chirurgia,  parte  prima,  p.  113. 
In  the  same  book,  or  in  my  friend  Mr.  Hodgson’s  valu- 
able Treatise  on  the  Diseases  of  Arteries  and  Veins, 
which  every  practical  surgeon  ought  to  possess,  a case 
may  be  perused  in  which  this  instrument  was  success- 
fully employed  by  Professor  Monteggla,  and  withdrawn 
entirely  as  early  as  sixty  hours  after  its  application. 
Tliis  last  distinguished  surgeon  also  used  the  compres- 
sor in  an  example  in  which  the  femoral  artery  was 
wounded  and  bled  in  an  alarming  degree.  After  forty 
hours  the  pressure  was  lessened,  and  in  four  hours 
more,  as  not  a drop  of  blood  issued  from  the  vessel, 
and  there  seemed  to  be  no  good  in  leaving  an  extra- 
neous body  in  the  wound  any  longer,  the  instrument 
was  taken  out  altogether.— (See  Assalini’s  Manuale  di 
Chirurgia,  p.  110.) 

When  Assalini  was  in  England,  he  acquainted  Mr. 
Hodgson  that  in  two  cases  of  popliteal  aneurism,  in 
which  he  had  himself  employed  this  means  gf  oblite- 
rating the  femoral  artery,  the  instrument  was  removed 
at  (he  expiration  of  twenty-four  hours ; no  pulsation 
returned  in  the  tumours  ; and  the  patients  were  speed- 
ily cured. 

With  respect  to  the  particular  merit  of  this  inven- 
tion, it  certainly  posse-^ses  the  recommendation  of  in- 
genuity ; but  it  operates  much  in  the  same  manner  as 
several  other  mechanical  contrivances,  the  serre-nceud 
of  Desault,  the  presse-art^re  of  Deschamps,  that  of  Mr. 
Crarnpton  (see  Med.  Chir.  Trans,  vol.  7),  the  pincers 
of  Baron  Percy,  &c.  If  there  be  a real  advantage  in 
the  division  of  the  internal  coats  of  an  artery  by  the 
ligature,  as  the  experiments  of  Jones  seem  to  prove, 
and  as  many  of  the  best  surgeons  in  this  country  in- 
culcate (.see  Hemorrhage  and  Ligature),  then  the  com- 
pressor cannot  be  an  eligible  means  of  obliterating  an 
artery.  It  may  be  said,  however,  that  experience  has 
proved  its  eflicacy ; but  let  it  be  recollected,  that  al- 
most every  method  of  operating  for  aneurisms  has 
sometimes  answered.  Farther  experience  is  requisite 
to  determine  whether  Assalini’s  compressor  would 
succeed  as  often  as,  or  more  frequently  than,  the  scien- 
tific application  of  the  right  kind  of  ligatures  (see  Liga- 
ture), which  may  perhaps  soem  slower  in  their  effect, 
only  because  they  are  not  in  general  removed  as  early 
as  Assalini’s  instrument.  In  fact,  the  experiments  of 
Mr.  Travers  have  now  proved  that  the  ligature  is  the 
quickest  in  its  pperatio'n. — (See  Med.  Chir.  Trans,  vol.  6, 
p 643,  &c.) 

In  1816,  some  ingenious  observations  were  publi.shed 
by  Mr.  Crarnpton,  on  the  effects  of  the  ligature  and  of 
compression  in  obliterating  arteries.  The  purport  of 


112 


ANEURISM. 


his  remarks  is  to  prove,  like  the  later  observations  of 
Scarpa:  1st,  That  the  obliteration  of  an  artery  can 
very  certainly  be  effected,  independently  of  the  rupture 
or  division  of  any  of  its  coats  ; 2dly,  That  this  operation 
the  ligature,  so  far  from  being  essential  to  the  process 
not  unfrequently  defeats  it— (See  Med.  Chir.  Trans, 
vol.  7,  p.  344,  345.) 

With  respect  to  the  first  of  these  assertions,  I pre- 
sume that  all  practical  surgeons  have  known  and  ad- 
mitted it,  especially  if  the  words  very  certainly  be  left 
out.  Every  system  of  surgery  for  half  a century  past, 
has  recorded  the  occasional  cure  of  aneurism  by  differ- 
ent modes  of  compression,  by  which  the  adhesive  in- 
flammation is  excited  in  the  artery,  or  the  coagulation 
of  the  blood  in  the  aneurismal  sac  brought  about.  As, 
however,  the  most  experienced  surgeons  have  found 
the  method  less  certain  than  the  use  of  the  ligature,  it 
is  not  represented  by  any  modern  writers  as  deserving 
equal  confidence ; though  there  are  circumstances,  in 
which  simple  pressure  may  be  sometimes  tried  with 
the  hope  of  doing  away  all  occasion  for  an  operation. 
The  cases,  however,  in  which  compression  is  applied 
directly  to  the  artery  itself  by  means  of  ligatures,  with 
the  intervention  of  other  substances  as  advised  by 
Scarpa,  &c.  or  by  various  contrivances,  like  those  of 
the  serre-nceud,  the  presse-artdre,  and  Assalini’s  for- 
ceps, all  require  the  exposure  of  the  artery  ; and  if 
commendable,  therefore,  cannot  be  so  on  the  principle 
of  saving  the  patient  the  pain  of  an  operation,  but  be- 
cause they  are  more  effectual  than  the  employment  of 
the  ligature.  This  last  point  remains  to  be  proved. 
From  the  comparatively  small  number  of  instances 
in  which  the  preceding  modes  of  compression  have 
been  practised,  several  examples  of  failure  might  be 
quoted. 

With  regard  to  Mr.  Crampton’s  second  assertion, 
that  the  division  of  the  inner  coats  of  the  vessel,  so  far 
from  being  essential  to  the  process  of  obliteration  not 
unfrequently  defeats  u,  I think  the  last  part  of  the  ob- 
servation is  altogether  unproved.  We  must  admit  that 
the  division  of  the  inner  coats  is  not  essential,  because 
arteries  sometimes  become  obliterated  under  a variety 
of  circumstances  in  which  such  division  is  not  made  ; 
but  still  the  great  question  remains  whether  it  renders 
the  process  more  certain.  Mr.  Crampton  founds  his 
conclusion,  that  it  not  unfrequently  prevents  the  oblite- 
ration and  gives  ri<e  to  secondary  hemorrhage,  upon  a 
few  very  uncommon  cases  in  which  aneurismal  swell- 
ings have  taken  place  above  the  ligature. — (See  War- 
ner’s Case,  p.  101  of  this  Dictionary.)  Here  Mr. 
Crampton  presumes,  without  proof,  that  the  occurrence 
happened  from  the  division  of  the  inner  coats  of  the 
artery,  though  Mr.  Warner  himself  suspected,  with 
more  probability,  that  it  proceeded  from  a diseased 
state  of  the  vessel.  Besides,  this  event  be  it  produced 
in  whatever  manner  it  may  is  so  rare,  that  I only  know 
of  three  examples  of  it  on  record,  and  have  never 
know'n  it  occur  during  the  last  30  years,  that  I have 
been  in  the  constant  habit  of  seeing  numerous  opera- 
tions performed.  In  Mr.  Warner’s  time  such  large 
ligatures  were  also  in  use  that  i.‘  appears  to  me  they 
were  more  likely  merely  to  press  the  sides  of  the  artery 
together,  like  Mr.  Crampton’s  presse-art<)re,  than  effect 
a complete  division  of  the  inner  coats  of  the  vessel, 
as  is  accomplished  by  the  small  ligatures  in  modern 
use. 

Those  metallic  instruments,  intended  to  be  applied 
directly  to  an  exposed  artery  for  the  j)urpose  of  oblite- 
rating it  by  compression,  are  liable  as  Scarpa  remarks, 
to  all  the  inconveniences  which  are  inseparable  from 
the  presence  of  hard  bodies,  introduced  and  kept  for 
several  days  in  the  bottom  of  a wound  ; especially 
when  this  is  recent,  in  which  case  they  cannot  be  re- 
tained in  a proper  direction  without  difficulty,  or  ex- 
actly at  such  a dej)th  as  will  not  be  attended  with 
hurtful  pressure  upon  the  wound  itself  and  important 
parts  in  its  vicinity.  And  with  regard  to  the  forceps 
of  As.salini,  Monteggia  has  observed,  “if  the  oblitera- 
tion of  the  artery  is  retarded,  the  forceps  eijually  di- 
vides the  artery  by  causing  the  death  of  the  included 
portion.  I also  saw  in  one  case,  the  extremity  of  the 
instrument  resting  at  the  bottom  of  the  wound  on  the 
subjacent  lemoral  vein,  rupture  its  anterior  half  also, 
although  we  were  sure  it  had  not  been  included  by  it.’’ 
— (Instituz.  di  Chir.  ed.  2,  t.  2.)  And  although  Cumano 
In  a case  of  popliteal  aneurism,  obtained  on  the  Iburth 
iay  tlie  closure  of  the  femoral  artery  by  means  of  As- 


salini’s forceps,  he  does  not  conceal  that  the  cure  of  the 
wound  was  rather  difficult ; and  in  comparing  the  liga- 
ture with  the  forceps  he  adds  his  belief,  that  if  an  equal 
result  is  derived  from  both  the  preference  will  be 
given  to  the  ligature,  unless  the  other  instrument  be 
brought  to  such  perfection  that  the  inconveniences  will 
be  removed  from  which  he  found  it  not  exempt,  though 
the  operation  succeeded.— (Annali  di  Med.  del  Dotlore 
Omodei,  Settembre,  1807,  p.  209,  and  Scarpa  on  Aneu- 
rism, p.  45,  ed.  2.)  Some  experiments  were  a few 
years  ago  instituted  by  Mr.  Travers,  in  order  to  deter- 
mine the  merit  of  Assalini’s  forceps  compared  with  the 
ligature  : and  his  conclusion  from  the  facts  elucidated 
in  the  investigation  is,  that  the  ligature  is  a more 
powerful  means  of  effecting  the  obliteration  of  the  tube 
of  an  artery. — (See  Med.  Chir.  Trans,  vol.  6,  p.  643,  Ac.) 

My  friend  Mr.  Lawrence,  a few  years  ago,  extended 
to  operations  for  aneurism  the  method  of  tying  the 
artery  with  a very  small  firm  silk  ligature,  the  whole 
of  which  is  immediately  afterward  cut  off  with  the 
exception  of  the  noose  and  knot,  and  an  endeavour 
then  made  to  heal  the  wound  by  the  first  intention.  In 
a case  of  popliteal  aneurism,  Mr.  Carwardine,  late  of 
Thaxted,  tied  the  femoral  artery  in  this  manner,  and 
the  wound  united  entirely  by  the  first  intention, 
not  a particle  of  pus  having  been  formed  at  any  time ; 
and  the  part  continued  perfectly  sound  at  the  distance 
of  some  months  from  the  operation.  On  the  29th  of 
March,  1817,  I saw  Mr.  Lawrence  try  the  practice  in  a 
similar  case:  with  the  exception  of  the  integuments, 
the  wound  united  by  adhesion.  However,  it  continued 
to  discharge  a small  quantity  of  matter  till  the  end  of 
May,  when  the  ligature  came  away,  and  it  healed 
firmly.  In  an  aneurism  of  the  humeral  artery,  Mr.  R. 
Watson,  of  Stourport,  Worcestershire,  tied  that  vessel 
and  cut  off  the  ends  of  the  ligature,  as  proposed  by  Mr. 
Lawrence.  The  operation  was  done  on  the  2d  of 
March,  and  the  wound  was  quite  healed  by  the  10th 
of  April.  On  the  3d  of  May,  a small  tubercle  which 
had  been  felt  under  the  skin  in  the  centre  of  the  cica- 
trix, appeared  above  the  skin,  and  proved  to  be  the 
knot  of  the  ligature.  There  was  no  inflammation  nor 
discharge ; but  the  ring  of  the  ligature  was  firmly  im- 
pacted in  the  centre  of  the  cicatrix.  In  about  a week 
from  this  time  the  whole  of  it  was  expelled.  In  an- 
other case,  where  Mr.  Hodgson  tied  the  ulnar  artery 
and  cut  off  the  ends  of  the  small  ligature,  the  skin 
healed  over  the  vessel,  but  a firm  almost  cartilaginous 
knot  gradually  formed,  from  the  centre  of  which  the 
bit  of  ligature  was  extracted  five  or  six  months  after 
ward,  by  a small  puncture.  For  additional  observa- 
tions on  this  part  of  the  subject,  see  Med.  Chir.  Trans, 
vol.  8,  p.  490,  Ac. 

Mr.  Carwardine’s  case  is  a strong  one  in  favour  of 
this  method  : but  I am  not  aware  that  sufficiently  nu- 
merous trials  of  it  have  been  made  to  enable  one  to 
form  a correct  estimate  of  its  merits.  With  the  excep- 
tion of  the  example  communicated  by  Mr.  Carwardine 
to  Mr.  Lawrence,  I apprehend  that  on  the  whole  the 
cures  on  record  cannot  be  said  to  have  been  completed 
sooner  than  others  generally  have  been,  in  which  one 
end  of  the  small  circular  ligature  was  left  for  the  re- 
moval of  the  noose.  Thus,  in  two  cases  where  the 
practice  was  tried  by  Mr.  Norman,  of  Bath,  the  results 
were  by  no  means  encouraging.  In  one  of  these  in- 
stances, a part  of  the  wound  appeared  to  have  united 
by  the  first  intention,  but  matter  afterward  formed, 
and  it  w'as  a considerable  time  before  the  ulcer  healed. 
The  ligature  was  never  seen  to  come  away  ; but  from 
the  circumstance  of  the  suppuration,  Mr.  Norman  ap- 
prehends that  it  must  have  been  voided.  In  a second 
e.xample,  the  attempt  to  procure  a permanent  adhesion 
of  the  p.arts  over  the  ligature  did  not  succeed ; a long 
and  troublesome  suppuration  ensued,  and  the  wound 
was  not  healed  till  the  latter  end  of  April,  though  the 
operation  was  done  on  the  7th  of  March. — .Norman,  in 
Med.  Chir.  Trans,  vol.  10,  p.  120—121.)  As  catgut, 
however,  was  employed  for  the  ligatures  in  these  two 
operations,  I do  not  know  that  it  is  fair  to  consider  the 
method  exactly  as  that  recommended  by  my  friend  Mr. 
Lawrence,  who  particularly  directs  very  small  liga- 
tures of  dentist’s  silk  to  be  used.  But  besides  the  dif- 
ferent material  employed,  we  are  left  uninformed  of 
the  thickness  of  the  catgut;  and  in  this  respect  also 
there  would  probably  be  no  greater  similarity  between 
tlie  ligatures  of  these  gentlemen,  than  there  is  in  regard 
to  the  substances  of  which  such  ligatures  were  made. 


ANEURISM. 


113 


tn  favour  of  catgut  as  a ligature,  when  the  ends  of  it  are 
to  be  cut  off,  a case  published  by  Sir  A.  Cooper  deserves 
particular  notice.  The  wound  was  found  completely 
united  on  the  fourth  day  after  the  operation,  notwith- 
standing the  patient  was  eighty  years  of  age.  The 
catgut,  previously  to  its  application,  was  softened  in 
warm  water.  The  recovery  was  complete  ; a fact 
strongly  proving  the  propriety  of  not  rejecting  an  ope- 
ration on  account  of  age,  if  no  other  objections  exist.— 
(See  Surgical  Essays,  part  1,  p.  120.) 

From  what  has  been  stated  in  the  Lancet,  however, 
it  seems  that  Sir  Astley  has  renounced  both  the  use  of 
catgut  ligatures,  and  the  plan  of  cutting  off  both  ends 
of  each  ligature.  With  respect  also  to  silk  ligatures 
in  particular,  if  we  take  into  the  account  the  little  ul- 
cerations, suppurations,  and  hard  knots,  which  occur- 
red even  after  their  use  in  this  manner,  I fear,  that 
though  these  complaints  might  be  attended  with  no  se- 
vere inconvenience,  they  will  deter  many  surgeons 
from  adopting  the  innovation ; unless  it  can  be  proved 
that  these  inconveniences,  slight  as  they  were,  are 
counterbalanced  by  the  quicker  healing  of  the  incision, 
or  some  other  decided  benefit.  As  a mode  attended 
with  the  least  possible  risk  of  being  followed  by  se- 
condary hemorrhage,  however,  I consider  it  inferior  to 
no  practice  which  has  yet  been  suggested ; nor  do  I 
know  of  any  serious  objections  to  it  in  any  point  of 
view,  provided  exactly  such  ligatures  are  used  as  Mr. 
Lawrence  recommends. 

In  cases  of  aneurism,  a single  small  ligature,  com- 
posed of  dentist’s  silk,  inkle,  or  twine,  is  now  usually 
preferred  by  the  majority  of  the  best  surgeons  in  Eng- 
land ; but  as  the  right  qualities  of  ligatures  are  else- 
where considered  (see  Hemorrhage  and  Ligature),  I 
need  not  here  dwell  upon  the  subject.  It  is  not  meant 
to  assert,  that  the  use  of  a single  ligature  is  never  fol- 
lowed by  secondary  hemorrhage ; for  this  would  be  un- 
true. The  accident  I believe  will  sometimes  happen 
after  this  or  any  other  mode,  under  certain  circum- 
stances, and  in  unfavourable  subjects.  A fact  of  this 
kind  we  find  recorded,  which  happened  in  the  practice 
of  a truly  eminent  and  experienced  surgeon  (see  A. 
Burns  on  Di.seases  of  the  Heart,  p.  230) ; but  from  the 
inquiries  which  I have  made,  it  appears  to  me  proved, 
that  cjEteris  paribus,  a single  small  ligature,  applied 
with  as  little  disturbance  and  detachment  of  the  artery 
as  possible,  will  be  more  rarely  Ibllowed  by  secondary 
hemorrhage,  abscesses,  sinuses,  «fec.  than  any  other 
known  method.  Thus,  in  the  several  cases  reported 
by  Mr.  Norman,  the  single  ligature  was  never  followed 
by  any  of  those  inconveniences,  which,  he  justly 
thinks,  will  be  rarer  after  this  practice  than  any  other, 
“ if  the  artery  be  not  removed  from  its  situation,  or 
more  detached  than  the  ligature  separates  it.” — (See 
Med.  Chir.  Trans,  vol.  10,  p.  123.) 

Before  entering  into  the  consideration  of  particular 
aneurisms,  I wish  to  mention  a few  other  circum- 
stances, worthy  the  attention  of  every  practical  sur- 
geon. The  first  is  the  partial  entrance  of  blood  into 
the  aneurismal  sac,  after  the  artery  has  been  tied  at 
.some  distance  from  the  tumour.  I'his  fact  was  first 
particularly  pointed  out,  and  its  reasons  explained  by 
.Sir  E.  Home,  who  published  three  examjiles  of  its 
occurrence. — (See  Trans,  for  the  Improvement  of  Med. 
and  Chir.  Knowledge,  vol.  1,  p.  173,  and  vol.  2,  p.  239.) 
But  the  circumstance  had  never,  I believe,  been  consi- 
dered with  due  attention,  until  Mr.  Hodgson  made  it 
one  of  the  subjects  of  his  reflections  in  his  valuable 
treati.se. 

“ When  an  artery  is  tied  close  to  an  aneurismal  sac, 
the  ingress  of  blood  into  the  latter  is  in  most  instances 
prevented  ; the  coagulum  which  it  cont.ains  is  absorbed, 
and  the  membranes  of  which  the  sac  is  composed,  gra- 
dually contract,  until  its  cavity  is  permanently  oblite- 
rated. But  when  the  artery  is  tied  at  a distance  from 
the  disease,  the  ingress  of  blood  into  the  latter  is  not 
altogether  prevented ; for  the  anastomosing  branches 
which  open  into  the  trunk,  below  the  seat  of  the  liga- 
ture, convey  a stream  which  passes  through  the  aneu- 
rism. The  impulse  of  this  current,  however,  is  so  tri- 
fling that  the  enlargement  of  the  sac  not  only  ceases, 
but  tlie  deposition  of  coagulum  in  it  increases,  in  c<«i- 
seijuence  of  the  languid  stale  of  the  circulation.  The 
coagulum  accumulates  until  the  cavity  of  the  sac,  and 
the  mouth  of  the  artery  leading  into  it,  are  obliterated,” 
Ac. — (See  Hodgson  on  the  Diseases  of  Arteries,  p. 
260.) 

Voc.  I.— H 


This  fact,  which  is  of  great  importance,  both  in  a 
practical  and  pathological  point  of  view,  is  proved 
(says  this  gentleman),  1st,  by  the  occasional  recur- 
rence of  pulsation  in  the  tumour  after  the  operation ; 
2dly,  by  cases  in  which  the  cavity  of  the  sac  has  been 
exposed,  and  hemorrhage  has  been  the  consequence ; 
and,  3dly,  by  dissection,  in  which  it  has  been  found, 
that  the  cavity  of  the  aneurism,  as  well  as  that  of  the 
artery  from  which  it  originated,  was  pervious,  from 
the  part  which  was  obliterated  by  the  direct  operation 
of  the  ligature. 

For  a detail  of  the  facts  relative  to  this  interesting 
point  the  reader  is  referred  to  Mr.  Hodgson’s  valuable 
publication.— (P.  267,  et  seq.) 

Some  very  uncommon  instances  are  recorded,  in 
which  the  return  or  continuance  of  pulsation  in  the 
tumour  is  said  to  have  prevented  the  cure ; the  aneu- 
rismal sac  having  begun  to  enlarge  again.  The  two 
cases  of  this  kind,  however,  which  happened  in  the 
practice  of  Pott  and  Guerin  (Trans,  of  a Soc.  for  the 
Impr.  of  Med.  and  Chir.  Know.  vol.  1,  p.  172;  and 
Joum.  de  ,1a  Soc.  de  Santd,  No.  3,  p.  197),  cannot  be 
well  depended  upon,  as  it  may  be  doubted,  whether  the 
artery  was  really  tied.  Some  better  established  facts, 
relating  to  this  part  of  the  subject,  have  been  very  re- 
cently published.  One  is  a case  by  Dr.  Monteath,  jun., 
of  Glasgow,  which  is  very  remarkable ; as  the  dis- 
ease, viz.  a popliteal  aneurism,  recurred  nine  months 
after  the  femoral  artery  had  been  unequivocally  tied  in 
the  upper  third  of  the  thigh.  On  the  27th  of  February, 
1819,  this  gentleman  performed  the  operation,  using  a 
single  ligature ; the  pulsation  of  the  tumour  in  the  ham 
instantly  ceased ; and  the  wound  healed  by  the  first 
intention,  except  where  the  ligature  was  situated, 
which  came  away  on  the  thirtieth  day.  By  this  time, 
the  tumour  was  diminished  to  one-half  of  its  original 
size,  and  in  two  months  more,  only  a hard  knot  was 
perceptible,  in  which  no  pulsation  whatever  could  be 
felt.  After  the  considerable  lapse  of  time  above  speci- 
fied, the  patient  informed  Dr.  Monteath,  that  the  tu- 
mour had  reappeared,  being  rather  larger  than  a plum. 
The  pulsation  in  it  was  distinct,  though  not  so  strong 
as  in  ordinary  aneurism.  As  the  size  of  the  swelling 
and  strength  of  the  pulsation  increased  gradually,  a 
compress  and  bandage  were  applied  without  confine 
ment ; but  as  this  treatment  was  ineftectual,  the  pa- 
tient v/as  afterward  kept  in  bed,  bled,  and  put  on  a 
spare  diet.  A thick  compress  was  placed  over  the  tu- 
mour, and  the  limb  was  firmly  bandaged  from  the  toes 
to  the  groin.  A trial  of  this  plan  for  three  days  not 
having  produced  any  benefit,  a tight  tourniquet  was 
applied  over  the  tumour ; but  the  pain  was  such  in 
half  an  hour,  that  the  instrument  was  taken  off,  from 
which  moment  no  pulsation  was  felt.  Next  day  the 
tumour  not  only  did  not  throb,  but  had  a firm  feel; 
and  the  bandage  being  continued,  the  cure  was  gradu- 
ally completed.  Had  the  disease  not  yielded  to  these 
means.  Dr.  Monteath  meant  to  have  tied  the  inguinal 
or  external  iliac  artery,  with  the  view  of  cutting  off  the 
s.upply  of  blood  to  the  sac,  through  the  anastomosing 
branches. — (Scarpa  on  Aneurism,  by  Wishart,  p.  510— 
512,  ed.  2.) 

The  following  cases  were  mentioned  by  Sir  Astley 
Cooper  : a man  underwent  the  operation  for  aneurism ; 
the  femoral  artery'  was  tied  ; the  pulsation  ceased ; and 
the  patient  in  a little  while  was  supposed  to  be  cured 
of  the  aneurism,  and  discharged.  Upon  his  return  to 
labour,  however,  a swelling  arose  in  the  ham,  with- 
out pulsation.  The  swelling  subsided  in  conse- 
quence ol’  rest ; but  afterward,  w hile  the  man  W'as  at 
work,  the  swelling  returned  with  great  pain.  At 
length,  as  Sir  Astley  conceived  that  there  was  no  pros- 
pect of  the  limb  becoming  useful  again,  it  was  ampu 
tated.  Upon  an  examination  of  the  parts,  he  found 
that  the  femoral  artery,  below  the  place  of  the  ligature, 
had  been  conveying  blood.  It  does  now  and  then  hap- 
pen (says  he)  that  a blood-vessel  will  arise  from  the 
artery  close  above  the  ligature,  and  pass  into  the  artery 
immediately  below  it,  by  which  means  the  circulation 

produced.  Sir  Astley  then  referred  to  a specimen  in 
the  hospital  museum,  where  this  fact  is  illustrated  in 
the  brachial  artery. — (See  Lancet,  vol.  1,  p.  298.)  - 

The  external  iliac  artery  was  taken  up  by  Mr.  Nor- 
man, of  Bath,  for  the  cure  of  an  inguinal  aneurism, 
and  when  the  collateral  circulation  was  fully  esta- 
blished a few  days  after  the  operation,  the  tumour  was 
again  supplied  with  blood  in  suflicient  quantity  to  pro- 


H4 


ANEURISM. 


duce  a distinct  pulsation ; **  a fact  (says  Mr.  Norman) 
of  practical  importance,  as  it  shows,  that  though  the 
ligature  on  the  iliac  artery  stops  the  direct  influx  of 
blood  into  the  tumour,  and  is  the  means  by  which  the 
disease  is  cured,  yet  that  there  exists  a necessity  for 
employing  strict  rest,  the  antiphlogistic  regimen,  and, 
in  some  cases,  the  abstraction  of  blood,  to  assist  na- 
ture in  her  operation  of  obliterating  the  aneurism.” 
And  in  another  instance,  after  the  same  gentleman  had 
tied  the  femoral  artery  for  the  cure  of  popliteal  aneu- 
rism, the  pulsation,  though  stopped  for  a time  in  the 
tumour,  allerward  recurred  in  such  a degree,  that 
much  doubt  was  entertained  whether  the  disease 
would  have  been  cured  by  the  ligature  on  the  femoral 
artery,  had  not  continued  and  rather  powerful  pres- 
sure been  adopted.— (Med.  Chir.  Trans,  vol.  10,  p.  99. 
118,  <&c.) 

M.  Roux,  in  a late  work,  has  offered  some  criticisms 
on  the  English  method  of  operating  for  aneurisms.  It 
would  hardly  be  fair  play  to  endeavour  to  offer  a seri- 
ous refutation  of  them,  because,  when  he  wrote,  it 
was  his  misfortune  not  to  be  duly  informed  of  all  the 
facts  and  experiments  recorded  in  the  inestimable  trea- 
tise on  hemorrhage  by  the  late  Dr.  Jones.  “ Still  less 
confident  than  we  are  (says  Roux)  in  the  treatment  by 
compression,  and  in  the  use  of  topical  remedies  for  the 
cure  of  external  aneurisms,  the  English  surgeons  have 
immediate  recourse  to  the  operation  with  the  ligature. 
Hunter’s  method  is  that  which  they  tmiversally  prac- 
tise. They  will  not  even  allow,  that  there  are  any 
cases  in  which  the  operation  by  opening  the  sac  should 
be  preferred,  &c.  And  it  is  singular,  the  very  same 
motive  which  would  incline  us  in  some  cases  of  aneu- 
risms, properly  so  called,  to  adopt  the  operation  of 
opening  the  sac,  is  alleged  by  the  English  surgeons  as 
a circumstance  in  favour  of  the  Hunterian  method. 
Let  us  suppose  an  aneurism  so  formed,  that  near  the 
centre  of  the  tumour  or  rather  near  the  opening,  by 
which  the  artery  communicates  with  the  swelling,  are 
situated  the  orifices  of  the  collateral  arteries, -which 
would  be  useful  for  the  re-establishment  of  the  circu- 
lation. Here  it  is  clear,  that  in  practising  the  opera- 
tion by  the  Hunterian  method,  that  is  to  say,  in  tying 
the  artery  above  the  tumour,  the  last  ramifications  are 
not  indeed  sacrificed  ; but  the  orifices  and  first  branches 
of  these  collateral  arteries.  Let  there  be,  for  example, 
at  the  upper  part  of  the  femoral  artery  an  aneurism, 
which,  though  formed  originally  below  the  origin  of 
the  profunda,  now  extends  above  it.  Here  it  is  mani- 
fest that  in  tying  the  femoral  artery  above  the  swell- 
ing, we  should  lose  the  important  resource  of  the  pro- 
funda for  re-establishing  the  circulation  in  the  lower 
part  of  the  limb.  The  desire  and  hope  of  saving  the 
profunda  would  in  such  a case  make  us  adopt  the  ope- 
ration of  opening  the  sac,  in  preference  to  the  Hunter- 
ian method  ; and  Scarpa  himself,  so  great  an  advo- 
cate for  this  last  mode,  Scarpa,  who  seems  only  to  have 
contposed  his  work  to  cry  up  this  method,  makes  an 
exception  of  the  case,  which  I have  just  been  suppos- 
ing. The  English  surgeons,  on  the  contrary,  would 
urge  the  following  objection  to  the  operation  by  open- 
ing the  sac  in  this  and  other  analogous  examples. 
They  contend  that  the  ligatures  would  be  applied  too 
near  to  the  origin  of  the  collateral  arteries,  which  are 
to  receive  the  blood  after  the  operation.  They  are  pre- 
possessed with  the  idea,  that  when  an  arterial  trUhk 
is  tied  at  a given  point,  the  too  great  proximity  of  the 
principal  collateral  arteries  disposes  to  subsequent  he- 
morrhage,” &c.  (p.  256,  257)  ; a circumstance  which 
Mr.  Roux  seetns  to  doubt. 

Now,  befovc  attempting  to  reply  to  these  observa- 
tions, we  ought  to  know  what  exact  distance  Roux 
means,  when  he  speaks  of  the  profunda,  or  a large  col- 
lateral artery,  originating  near  the  opening  by  which 
the  aneurism  communicates  with  the  tnain  artery. 
Here  he  is  not  at  all  precise  ; and  were  he  to  tie  the  fe- 
moral artery  immediately  below  the  point  where  the 
profunda  arises,  he  would  expose  his  i)atiem  to  great 
danger  of  bleeding.  I say  this,  well  aware  of  the  case 
which  he  has  adduced  to  prove  the  contrary.  In  the 
example  brought  forward,  he  applied  several  ligatures 
(p.  260),  some  of  which  were  the  ligatures  d’attente,  or 
loose  ligatures  left  ready  to  be  tightened  in  case  of  need. 
These  were  of  course  higher  up  than  the  ligature  which 
was  tightened.  It  is  therefore  impo.ssible,  that  this 
last  could  have  been  close  to  the  origin  of  the  profunda. 
There  must  have  been  room  left  for  the  aj)plicaiion  of 


! the  ligatures  d’attentc;  and  be  it  also  recollected,  that 
1 the  Erench  still  persist  in  the  use  of  large  flat  cords, 
and  not  small  firm  round  ligatures,  which  are  now 
found  to  be  most  advantageous. — (See  Hemorrhage.) 
In  tliis  part  of  the  Dictionary  we  shall  find  that  the 
nearness  of  a collateral  vessel  impede.s  the  formation 
of  the  internal  coagulum,  which  has  a material  share 
in  the  process  by  which  the  artery  is  closed. 

With  respect  to  the  circumstance  of  hemorrhage  be- 
ing more  likely  to  follow  when  the  ligature  is  placed 
close  below,  than  at  some  distance  from  a great  colla- 
teral artery,  tliere  cannot  be  a doubt  of  the  fact.  Roux 
when  in  London  saw  an  occurrence  of  this  kind  him*- 
self,  and  has  published  it  in  his  book.  It  was  a case  in 
which  Sir  A.  Cooper  tied  the  external  iliac  artery  ; but 
the  patient  died  of  hemorrhage  a fortnight  afterward, 
and,  on  ojjening  the  body,  it  was  ascertained  that  the 
obturator  artery,  which  usually  arises  either  from  the 
trunk  of  the  internal  iliac,  or  from  the  epigastric,  pro- 
ceeded from  the  external  iliac,  and  arose  immediately 
above  the  point  to  which  the  ligature  was  applied. — 
(See  Paralldle  de  la  Chir.  Angloise  avec  la  Chir.  Fran- 
goise,  «fec.  p.  278, 279.) 

From  a preparation,  spoken  of  by  Mr.  Travers,  and 
some  experiments  made  by  the  same  gentleman,  it 
would  appear,  that  the  presence  of  a collateral  branch 
hinders  the  formation  of  the  internfil  coagulum,  but 
will  not  always  prevent  the  closure  of  the  vessel  by 
the  adhesive  inflammation.  In  the  preparation  refer- 
red to,  a ligature  was  applied  to  the  external  iliac,  be- 
tween the  epigastric  and  circumflex  iliac  arteries, 
“ and  having  been  in  contact  with  the  former  at  the  an- 
gle Avhich  It  makes  at  its  origin  from  the  iliac,  ulcera- 
tion had  taken  place,  and  the  bleeding  had  proved  fa- 
tal. There  was  no  coagulum  formed  in  the  iliac  trunk, 
though  the  operation  had  been  performed  several  days, 
the  circulation  through  the  epigastric  having  continued. 
But  the  lymph-plug  at  the  seat  of  the  ligature  on  the 
iliac  artery  was  complete.” — (Med.  Chir.  Trans,  vol. 
6,  p.  656.)  Indeed,  it  must  be  allowed,  with  this  gen- 
tleman, that  the  fluidity  of  the  blood  does  not  prevent 
the  adhesive  process,  a fact  which,  he  observes,  is  also 
proved  in  the  indirect  obstruction  of  a vessel,  by 
means  of  a temporary  ligature  or  compressor.  When, 
therefore,  the  vicinity  of  a large  branch  to  the  ligature 
is  spoken  of  as  a circumstance  conducive  to  secondary 
hemorrhage,  I mean,  that  it  is  so  inasmuch  as  the  in- 
ternal coagulum  is  useful  in  promoting  the  closure  of 
the  vessel,  and  its  formation  is  prevented. 

Brasdor  fi^st,  and  afterward  Desault,  conceived,  that 
when  an  aneurism  was  so  situated  that  a ligature 
could  not  be  applied  to  the  artery  leading  to  the  swell- 
ing, a cure  might  possibly  arise  from  tying  the  vessel 
on  that  side  of  the  tumour  which  was  most  remote 
from  the  heart.  Desault  conjectured  that  by  this 
means,  the  circulation  through  the  sac  would  be  stop- 
ped, the  blood  in  it  would  coagulate,  that  the  circula- 
tion would  go  on  by  the  collateral  arteries,  and  that  the 
tumour  would  be  finally  absorbed.  Deschamps  tied 
the  femoral  artery  below  an  inguinal  aneurism;  but 
the  progress  of  the  di.sease,  instead  of  being  checked, 
seemed  to  be  accelerated  by  the  experiment.  The  ope- 
rator was  obliged,  as  a last  resource,  to  open  the  tu- 
mour, and  try  to  take  up  the  vessel.  In  this  attempt 
the  patient  lost  a large  quantity  of  blood,  and  died 
eight  hours  afterward. — (See  CEuvres  Chir.  de  Desault, 
par  Bichat,  t.  2,  p.  563 ; and  Recueil  Periodique  de  la 
Soci^tt?  de  Mcdecine  de  Paris,  t.  5,  No.  17.) 

The  operation  of  tying  the  artery  below  the  tumour 
was  repeated  by  Sir  A.  Cooper,  not  for  an  aneurism  of 
the  femoral  artery  in  the  groin,  but  for  an  aneurism  of 
the  external  iliac,  where  tying  the  artery  above  the 
swelling  was  impracticable.  The  femoral  artery  was 
therefore  tied  immediately  below  Poupart’s  ligament, 
between  the  origins  of  the  epigastric  and  the  profunda. 
The  pulsations  of  the  tumour  continued ; but  the  pro- 
gress of  the  disease  was  checked.  After  a time,  in- 
(leed,  the  swelling  decreased,  and  this  in  so  considera- 
ble a manner,  that  hopes  began  to  be  entertained  that 
perhaj)s  the  external  iliac  artery  might  soon  admit  of 
being  tied  above  the  disease.  The  ligatures  came 
away  without  any  unfavourable  occurrence,  and  when 
the  wound  was  healed,  the  patient  was  sent  into  the 
country  for  the  benefit  of  the  change  of  air.  After- 
ward, however,  the  tumour  gave  way  ; an  extravasa- 
tion of  blood  U)ok  place  in  the  abdomen  and  cellular 
membrane  of  the  pelvis,  and  the  jtatient  died.  Sir 


ANEURISM. 


115 


A.  Cooper  had  no  opportunity  of  seeing  the  case,  and 
as  the  body  could  not  be  opened,  farther  particulars 
were  not  obtained. 

I believe  no  additional  trials  of  this  practice  were 
made  in  any  part  of  the  world,  and  that,  in  fact,  the 
general  feeling  of  the  profession  was  decidedly  against 
it,  until  my  friend  Mr.  Wardrop  lately  directed  his 
particular  attention  to  the  subject,  and  both  by  reason- 
ing and  facts  exemplified  beyond  all  dispute,  that 
Brasdor’s  method  of  operating  ought  to  be  adopted  in 
certain  aneurisms,  the  circumstances  of  which  forbid 
the  application  of  a ligature  on  the  cardiac  side  of  the 
tumour.  Experience  has  amply  proved  what  I have 
already  repeatedly  mentioned,  that  after  the  Hunterian 
operation,  some  flow  of  blood  frequently  continues 
through  the  aneurismal  sac,  owing  to  the  anastomoses, 
but  that  the  impetus  of  the  stream  having  been  suffi- 
ciently reduced  by  the  effect  of  the  ligature,  the  cura- 
tive process  is  not  prevented  from  taking  place.  The 
pulsation,  which  is  sometimes  felt  for  the  first  few 
days,  at  length  subsides,  in  consequence  of  the  circula- 
tion being  stopped  by  the  increased  quantity  of  coagula, 
and  the  tumour  begins  to  diminish.  It  is  from  facts  of 
this  kind  that  Mr.  Wardrop  deduces  what  he  calls  “ a 
new  principle  for  operating  in  aneurisms  so  situated, 
as  hitherto  to  have  been  considered  beyond  the  reach 
of  art,  and  to  which  the  Hunterian  principle  of  opera- 
ting is  totally  inapplicable.” — 'On'  Aneurism,  p.  15, 
8vo.  Lond.  1828.)  Mr.  Wardrop  observes,  that  the 
changes  produced  by  Brasdor’s  method,  both  in  the  ar- 
tery and  the  sac,  are  precisely  those  which  nature  em- 
ploys when  she  cures  the  disease  by  a spontaneous 
process.  No  sooner  is  the  ligature  applied  on  the  dis- 
tal side  of  the  aneurismal  tumour,  than,  as  after  the 
Hunterian  plan,  the  anastomosing  vessels  dilate,  and 
perform  the  function  of  the  obliterated  or  obstructed 
trunk.  The  cases  in  which  the  operation  has  been  done 
prove  also  what  would  not  have  been  expected,  that  the 
tumour,  directly  after  the  application  of  the  ligature, 
diminishes  instead  of  undergoing  enlargement.  “ If  the 
circulation  be  turned  into  a new  channel,  and  if  that 
channel  completely  fulfil  the  purpose,  the  sac,  with  its 
contents,  as  well  as  the  portion  of  artery  extending 
between  the  aneurism  and  the  ligature,  and  also  the 
blood  contained  in  it,  will  now  be  in  a passive  state ; 
and  though  the  blood  will  continue  for  a certain  time 
to  be  influenced  by  the  impulse  of  the  circulation  car- 
ried on  in  that  part  of  the  vessel  which  passes  into  the 
tumour,  still  its  motion  must  become  not  only  languid, 
but  its  current  irregular,  a state  which,  we  know,  ad- 
mits of  its  speedy  coagulation.  Whenever  the  coagu- 
lation of  the  blood  does  take  place,  then  the  cure  of 
the  aneurism  may  be  said  to  be  accomplished ; the  sac 
will  contract ; the  coagulum  will  be  absorbed;  some 
portions  in  contiguity  with  the  sac  will  become  or- 
ganized, and  consolidate ; others,  if  the  quantity  be 
very  large,  wll  escape  by  a process  of  ulceration 
through  the  skin ; and  ultimately,  a gradual  coales- 
cence of  the  tumour  will  thus  take  place.” — (Wardrop, 

p.  20.) 

(In  the  Medical  Repository  for  1823,  vol.  7,  No.  4,  p. 
404,  Dr.  David  L.  Rogers,  then  Re.siderit  Surgeon  of 
the  N.  Y.  Hospital,  has  published  a paper  entitled  Ob- 
servations on  Aneurisms,  in  which  this  operation  is 
contended  for  as  being  applicable  to  the  carotid  artery, 
and  to  this  alone.  He  is  wrong,  however,  in  giving 
the  projection  of  this  operation  to  Desault,  for  although 
it  is  described  in  his  works  by  Bichat,  yet  it  was  pro- 
posed by  Brasdor.  And  as  this  seems  to  be  a controverted 
point,  I have  taken  some  pains  to  trace  the  progress  of 
this  improvement,  and  find  that  the  operation  was  first 
proposed  by  Brasdor  nearly  half  a century  ago,  so 
that  the  projection  of  the  plan  unquestionably  belongs 
to  him.  Bichat  next  gave  directions  for  its  perform- 
ance in  his  edition  of  Desault,  and  here  the  error  of 
Allan  Burns  probably  originated,  which  has  been  since 
repeated  by  so  many.  Deschamps  was  the  first  who 
performed  the  operation  in  a case  of  femoral  aneurism ; 
then  Sir  A.  Cooper  repeated  it  on  the  external  iliac, 
then  Mr.  Home’s  case  occurred,  all  of  wliich  were  un- 
successful. Mr.  Wardrop’s  first  ca.se  of  carotid  aneu- 
rism was  performed  in  1825,  by  tying  the  vessel  on  the 
anti-cardial  side  of  the  sac  with  complete  success. 
Mr.  Wardrop’s  secxtnd  trial  was  not  so  fortunate,  and, 
as  will  be  perceived,  it  is  questioned  whether  the  ar- 
tery was  tied  at  all.  See  ]\Tr.  ('ooper’s  remarks  on 
this  case,  inlrn.  Mr.  Lambert  next  operated  as  will  be 

H2 


sfeen  in  this  article,  without  success,  and  Dr.  Bushe’s 
and  Dr.  Evans’s  ,cases  were  the  only  successful  in- 
stances I can  find,  so  that  the  former  of  these  is  the 
second  and  the  latter  the  third  in  which  Brasdor’s 
method  has  succeeded.  Dr.  Mott’s  case  is  therefore 
the  fourth  successful  instance  on  record,  and  certainly 
the  only  one  in  which  it  has  been  attempted  in  Ame- 
rica. So  much  light  has  been  elicited  on  this  dark 
subject  by  the  cases  alluded  to,  that  there  can  be  little 
doubt  but  the  operation  on  the  distal  side  of  the  aneu- 
rism will  now  rescue  from  the  grave  many  valuable 
lives,  which  had  otherw  ise  been  lost  to  the  world,  and 
abandoned  as  beyond  Uie  resources  of  our  art. — ReeseJ] 
In  the  summer  of  1825,  Mr.  Wardrop  first  tried 
Brasdor’s  method.  The  case  was  a carotid  aneurism 
in  a female  75  years  of  age.  The  disease  was  so  close 
to  the  clavicle,  that  it  w as  quite  impracticable  to  tie 
the  vessel  on  the  cardiac  side  of  the  tumour.  Imme- 
diately the  artery  was  tied,  the  swelling  underwent  a 
diminution.  On  the  fourth  day  it  had  lessened  by  one- 
third.  Afterward  the  throbbing  continued  strong  for  a 
few  days,  at  the  expiration  of  which  it  became  ob- 
scure, and,  at  the  same  time,  the  tumour  began  to  di- 
minish again.  Previously  to  the  complete  cure,  ul- 
ceration occurred,  and  several  large  masses  of  coagu- 
lated blood  were  discharged,  along  with  some  healthy 
pus.  Three  years  after  the  operation,  the  patient  con- 
tinued to  enjoy  good  health. 

December  10, 1826,  Mr.  Wardrop  attempted  a similar 
operation  for  the  cure  of  a carotid  aneurism  in  another 
woman  aged  57.  Some  reduction  of  the  throbbing, 
and  other  relief,  are  stated  to  have  ensued ; but  the  pa- 
tient died  of  a complication  of  complaints  on  the  23d 
of  the  following  March,  1827.  “ Up  to  the  day  of  her 
death,  a tumour  remained  in  her  neck  of  about  the 
bulk  of  an  almond,  which  pulsated  strongly,  felt  very 
thin  in  its  coats,  and  its  contents  could  be  readily 
squeezed  out  of  it,  but  returned  rapidly,  when  the 
pressure  was  removed.” — (P.  33.)  In  the  dissection 
it  deserves  notice,  that  the  carotid  was  Ibund  completely 
pervious,  and  that  no  cicatrix  nor  other  appearance, 
enabled  Mr.  Bennet  to  ascertain  the  precise  point  to 
which  the  ligature  had  been  applied . — (P.  35.)  These 
circumstances  might  raise  a doubt  about  the  artery 
having  been  tied  at  all ; but,  supposing  the  ligature  to 
have  been  duly  applied,  they  prove  to  my  mind  the 
failure  of  the  operation,  inasmuch  as  the  tumour  and 
carotid  artery  were  probably  in  almost  the  same  state 
as  if  nothing  had  been  attempted.  The  blood  passed 
freely  through  them,  and  w'as  not  compelled  to  circu- 
late through  new  channels.  Without  wishing,  how- 
ever, to  enter  into  the  question  whether  the  artery  W'ere 
tied  or  not,  I shall  dismiss  this  example  with  two  plain 
inferences:  l-st,  that  if  the  artery  were  tied,  the  ope- 
ration failed  to  bring  about  the  desired  obliteration  of 
the  vessel  and  coagulation  of  the  blood  in  the  swell- 
ing; 2dly,  that  if  it  were  not  tied,  what  was  done  iS 
neither  favourable  nor  unfavourable  to  the  practice  of 
which  we  are  now  considering  the  merits.  A third 
example  of  the  operation  is  reported  in  vol.  12  of  the 
I.ancet.  The  carotid  was  tied  above  the  aneurism  by 
Mr.  Lambert,  March  1st,  1827,  in  the  presence  of  Mr. 
Wardrop,  Mr.  B.  Cooper,  and  Mr.  Callaway.  On  the 
third  day  the  tumour  seemed  much  consolidated,  and 
reduced  in  size.  On  the  tenth  day  there  was  some 
bleeding  from  the  wound ; but  it  was  suppressed  by 
the  application  of  a compress  wet  with  cold  water; 
and  in  a few  days,  the  swelling  had  entirely  disap 
peared,  and  all  that  could  be  felt  of  it  on  pressing  the 
finger  deeply  down,  was  a small  hard  tiunour,  having 
a very  faint  undulatory  thrill.  Unfortunately,  this  pa- 
tient, also  a female,  fell  a victim  to  hemorrhage  on  the 
1st  of  May,  in  consequence  of  ulceration  extending 
from  the  cicatrix  through  the  platisrna  myoides  to  the 
artery.  Without  detailing  other  appearances  noticed  in 
dis.section,  suffice  it  to  mention,  that  “ at  the  root  of  the 
right  common  carotid  artery  was  a consolidated  tumour 
of  a pyramidal  shape.  A probe  could  not  be  i)asBed 
upwards  from  the  arteria  innomuiata,  and  water  forci- 
bly injected  at  tliis  part  would  not  pass,  .so  completely 
and  effectually  closed  was  the  lower  part  of  the  carotid 
artery.  On  making  a longitudinal  section  of  the  tu- 
mour, we  observed  at  its  lower  part  a firm  coagulum 
of  blood,  of  about  the  size  of  a French  olive.  It  accu- 
rately closed  the  opening  at  the  base  of  the  carotid, 
and  it  was  this  which  afforded  the  resistance  to  the 
; probe  and  injection  of  water  passing  upwards  from  the 


116 


aneurism. 


arteria  innominafa.  The  coats  of  (be  artery,  surround- 
ing the  coagulum,  were  thickened  to  about  four  times 
their  natural  size,  and  lined  by  a thin  layer  of  fibrine. 
Above  the  coagulum,  the  coats  of  the  artery  were 
thickened  to  the  extent  of  at  least  six  times  theLr  natu- 
ral size,  and,  in  addition  to  a layer  of  fibrine  closely  ad- 
herent to  the  inner  surface  of  the  artery,  and  continu- 
ous with  that  surrounding  the  coagulum  at  the  lower 
part  of  the  tumour,  there  were  three  other  layers  of 
coagulated  lymph.— At  the  upper  part  of  the  thickened 
portion  of  the  artery,  and  just  above  the  omo-hyoideus, 
where  the  ligature  had  been  applied,  was  an  ulcerated 
opening  on  the  anterior  and  tracheal  surface  of  the  ca- 
rotid artery  a quarter  of  an  inch  in  length,  and  rather 
less  in  breadth,  covered  by  a coagulum  of  dark-co- 
loured lymph,  conununicating  with  the  opening  in  the 
inieguments.”  This  case,  according  to  my  judgment, 
must  "be  received  as  another  proof  that  Brasdor’s 
method  is  capable  of  producing  those  changes  in  the 
tumour,  artery,  and  circulation,  which,  if  not  suc- 
ceeded by  some  accidental  untoward  occurrence,  like 
the  ulceration,  leading  in  this  case  to  fatal  hemorrhage, 
may  bring  about  the  perfect  cure  of  the  disease. 

If  any  doubt  remained  of  this  fact  after  the  cases  al- 
ready cited,  it  would  be  dispelled  by  the  results  of 
some  other  trials  of  the  practice,  and  more  particularly 
by  the  history  of  the  case  of  Mary  Covis,  aged  36,  on 
whom  Dr.  Bushe  [now  Professor  of  Anatomy  and 
Surgery  in  Rutgers  Medical  Faculty  of  Geneva  College, 
New-York]  operated,  under  very  trying  and  difficult 
circumstances,  with  great  skill  and  complete  success. — 
(Lancet,  vol.  1,  1828.)  The  tumour  extended  from  the 
clavicle  on  the  right  side  upwards  nearly  to  the  os 
hyoides,  pressing  the  trachea  towards  the  opposite  side, 
and  paissing  under  the  sterno-mastoid  muscle  to  nearly 
an  inch  beyond  its  outer  border.  For  nine  days  pre- 
viously to  the  operation  the  patient  had  not  been  able 
to  swallow  any  thing  ; her  respiration  was  alarmingly 
obstructed,  and  her  voice  nearly  lost.  In  the  operation 
the  artery  immediately  above  the  aneurism  was  found 
dilated,  not  more  than  half  an  inch  of  its  extremity 
being  sound,  and  on  this  a single  silk  ligature  was 
placed.  As  soon  as  the  artery  was  tied,  the  tumour 
became  softer  and  less  prominent,  and  though  she  had 
not  swallowed  any  thing  for  nine  days,  she  took,  before 
the  wound  was  dressed,  about  ten  ounces  of  %vine  and 
water.  The  operation  was  performed  September  1 1 th, 
1827.  April  19th,  1828,  the  woman  was  in  perfect 
health.  There  was  then  scarcely  a remnant  of  the 
tumour  ; the  inordinate  action  of  the  heart  had  ceased; 
and  respiration  and  deghitition  were  natural.  As  Mr. 
War  drop  remarks,  the  facts  recorded  prove  beyond  all 
dispute,  that  the  future  groAvth  of  an  aneurismal  tu- 
mour may  be  arrested,  and  the  disease  cured,  by  placing 
a ligature  on  the  distal  side  of  the  sac,  especially  if  no 
branch  of  the  artery  intervene  between  the  sac  and  the 
ligature ; for  if  a considerable  branch,  and  one  that 
afterward  enlarged  sufficiently,  were  to  be  in  this  situa- 
tion, the  operation  would  have  little  or  no  effect  in  pro- 
ducing any  diminution  of  the  impetus  of  the  blood  in 
the  aneurism,  from  the  cavity  of  which  the  blood 
would  pass  as  freely  into  the  enlarged  branch  as  it 
previously  did  along  the  trunk  itself.  Hence  we  see 
why  Brasdor’s  operation  will  probably  be  attended  with 
greater  success  on  carotid  than  other  aneurisms,  the 
common  carotid  artery  giving  off  in  its  course  no 
branches  which  might  interfere  with  the  principles  of 
the  practice. 

[Professor  Bushe  being  now  engaged  in  teaching 
anatomy  and  surgerj’  in  this  city,  has  politely  acceded 
to  my  request  in  furnishing  me  from  his  note-book,  the 
following  case,  the  practical  importance  of  which  in 
relation  to  tliis  subject  entitle  it  to  a place  here.  It  is 
referred  to  in  the  Lancet,  No.  244,  vol.  2,  May  3d,  1828. 

“ As  every  fact  that  can  tend  to  piove  or  disprove  an 
unsettled  point  must  be  considered  more  or  less  valua- 
ble, it  may  not  be  useless  to  subjoin  a concise  account 
of  a patient  who,  in  the  summer  of  1823,  was  admitted 
into  the  Whitworth  Medical  Hospital,  Dublin,  under 
the  care  of  Dj.  Cuming,  llis  complaint  on  admission 
was  registered  as  paralysis  of  the  right  arm ; but  a 
large  tumour  being  discovered  in  the  axilla,  the  late 
Profe.ssor  Todd  was  called  to  see  the  patient  ’;  and  after 
careful  examination  he  gave  it  as  his  opinion  that  it  was 
an  aneurism,  which  from  its  magnitude  had  lost  its 
pulsation  ; but  to  settle  the  point,  he  punctured  it,  and 
Jlorid  blood  followed  the  insertion  of  a probe.  Whim  j 


passed  inwards  for  about  three  inches,  the  nature  of  (he 
case  being  decided,  the  man  was  removed  to  the  Rich 
mond  Surgical  Hospital ; where,  from  an  attack  of  ery 
sipelas  consequent  on  the  puncture,  he  died  in  a few 
days.  Mr.  Todd  requested  that  I might  examine  the 
body,  and  from  notes  made  after  the  dissection  I ab- 
stract the  following ; ‘ The  aneurism,  which  was  of 
large  size,  occupied  the  right  axilla ; the  sac  in  many 
places  was  almost  absorbed,  and  adhered  firmly  to  the 
upper  and  outer  part  of  this  cavity ; when  opened,  it 
contained  large  quantities  of  laminated  fibrine,  and  in 
its  centre  was  a cavity  holding  about  eight  ounces 
of  coagulated  blood ; communicating  with  the  cavity, 
there  was  an  opening  of  one-eighth  of  an  inch  in  the 
axillary  arterj',  below  which  the  vessel  was  obliterated 
for  the  space  of  half  an  inch,  corresponding  to  the  situa- 
tion where  the  sac  so  firmly  adhered.’ — Here  then  was 
a case  where  the  aneurism  was  undergoing  a sponta- 
neous cure  in  consequence  of  the  pressure  of  the  tu- 
mour having  obliterated  the  artery  on  its  distal  side ; 
and  I look  upon  it  as  a valuable  fact  towards  confirm- 
ing the  utility  of  reviving  the  operation  of  Brasdor  and 
Deschamps ; and  so  much  was  I impressed  with  this 
opinion,  that  before  Mr.  Wardrop  published  his  first 
essay,  I recommended  the  operation  in  a case  of  large 
carotid  aneurism  in  a public  hospital ; but  my  chance 
was  to  be  laughed  at.  However,  when  I again  meet 
the  two  surgeons  who  so  wantonly  ridiculed  me,  it 
will  be  my  turn  to  laugh  at  them.”— Reese.] 

Mr.  Wardrop  himself  regards  Brasdor’s  operation  as 
not  merely  applicable  to  examples  in  which  it  is  im- 
practicable to  place  a ligature  on  the  cardiac  side  of 
the  sac,  but  as  likely  to  merit  the  preference  when  the 
tumour  is  large,  and  likely  to  inflame  after  the  circula- 
tion through  the  sac  is  interrupted.  This  inference  he 
makes  from  the  fact  of  the  immediate  diminution  of  the 
swelling,  which  has  usually  followed  the  application 
of  the  ligature  on  the  distal  side  of  the  aneurism.  He 
also  deems  it  probable  that  in  this  method  there  is  less 
risk  of  hemorrhage  from  the  part  of  the  vessel  on  which 
the  ligature  is  applied  than  in  the  Hunterian  operation. 
On  the  principle  that  it  is  sufficient  for  the  cure  of 
an  aneurism,  that  the  impetus  of  the  blood  through  it  be 
diminished,  as  the  deposite  of  lamellated  coagula  within 
the  sac  will  then  increase,  Mr.  Wardrop  urges  the  pro- 
priety of  extending  Brasdor’s  method  to  aneurisms  of 
the  arteri^innominata ; but  the  very  interesting  and 
valuable  cases  which  he  has  adduced  in  confirmation 
of  his  views  of  these  particular  aneurisms  will  be  more 
conveniently  noticed  in  the  sequel.  As  an  admirer  of 
the  improvement  of  surgery,  I must  not  quit  this  part 
of  the  subject,  without  expressing  the  conviction  that  I 
entertain  of  the  ser\ice  which  Mr.  Wardrop  has  ren- 
dered the  profession  and  the  public  by  his  able  and  en- 
lightened view  of  a valuable  operation,  which  without 
his  exertions  and  example  might  long  have  remained 
quite  neglected,  or  briefly  mentioned  in  the  history  of 
surgery  as  a dangerous  proceeding,  unworthy  of  farther 
trials. 

[This  suggestion  of  Mr.  Wardrop  has  been  acted  upon 
by  D.  Evans,  Esq.,  surgeon  at  Belper,  Derbyshire, 
who  successfully  tied  the  carotid  for  aneurism  of  the 
innominata  and  root  of  the  carotid.  The  details  of 
this  splendid  operation  are  so  interesting,  that  I cannot 
withhold  from  the  profession  the  record  of  this  highly 
important  and  successful  triumph  of  modem  surgery 
over  this  most  horrible  disease.  It  is  e.xtracted  from 
the  Lancet,  No.  271,  vol.  1,  Nov.  8th,  182.-^. 

“ William  Hall,  aetat  30,  a butcher  and  horse-dealer, 
an  athletic  and, spirited  young  man,  about  five  feet  six 
inches  high,  has  been  accustomed  to  laborious  exer- 
cise, frequently  riding  from  70  to  100  miles  a day,  and 
has  always  enjoyed  excellent  headth  until  the  appear- 
ance of  the  following  symptoms ; — About  14  months 
ago  he  was  seized  with  shortness  of  breath,  trouble- 
some cough  and  tightness  over  the  chest  after  much 
exertion,  especially  in  wMking  fast  up  a hill. 

These  symptoms  continued  until  the  6th  of  March, 
when  he  had  an  attack  of  bronchitis,  which  he  attributed 
to  cold.  His  expectoration  was  copious,  consisting  of 
mucus  slightly  streaked  with  blood,  and  his  cough 
came  on  in  violent  paroxysms,  which  were  followed 
by  a sense  of  suffocatioin. 

On  the  10th  of  March,  after  a fit  of  coughing,  a soft, 
pulsating  tumour  about  the  size  of  a walnut  suddenly 
made  its  appearance  behind,  and  extending  a little 
j above,  the  right  sterno  clavicular  articulation,  and 


ANEURISM. 


117 


covered  externally  by  the  sternal  portion  of  the  sterno- 
mastoid  muscle.  The  tumour  was  greatly  diminished 
by  firm  pressure,  but  could  not  be  made  to  disappear 
entirely. 

The  pulsation  of  the  tumour,  which  was  synchro- 
nous with  that  of  the  heart,  was  increased  in  force  by 
pressure  upon  the  right  subclavian  artery,  and  was 
diminished  and  sometimes  completely  arrested  by  pres- 
sure upon  the  right  carotid  above  the  tumour. 

The  pulsations  of  the  right  carotid  and  subclavian 
arteries  were  stronger  tlian  those  of  the  left ; but  there 
was  no  apparent  difiTerence  in  the  pulsations  of  the 
radial  arteries. 

As  soon  as  the  tumour  made  its  appearance,  the 
cough  and  dyspnoea  ceased  to  be  troublesome,  and  his 
health  was  soon  re-established.  His  chest  sounded 
well  upon  percussion,  and  the  respiratory  murmur  was 
distinctly  heard  all  over  it.  No  unnatural  pulsation 
could  be  detected  by  the  use  of  the  stethoscope  between 
ttie  tumour  and  the  heart.  A loud  and  powerful  pul- 
sation was  heard  over  the  tumour,  unattended  with 
any  unusual  sound. 

In  taking  into  consideration  the  situation  of  the  tu- 
mour, its  sudden  appearance  after  a violent  jtaroxysm  of 
coughing,  and  its  soft,  pulsating  character,  together  with 
the  symptoms  above  enumerated,  little  doubt  could  be 
entertained  of  its  nature,  and  I concluded  that  the  root 
of  the  carotid  artery  was  the  seat  of  the  disease. 

Considering  this  a favourable  case  for  the  operation 
lately  revived,  and  so  ably  advocated  by  Mr.  Wardrop, 
I was  induced  to  obtain  the  opinion  of  two  eminent 
surgeons  in  London  respecting  its  propriety.  Both, 
however,  disapproving  of  the  operation,  it  was  there- 
fore determined,  with  the  approbation  of  my  friends, 
Mr.  Bennet  and  Mr.  Brown,  of  Derby,  that  a fair  trial 
should  be  made  of  Valsalva’s  plan  of  treating  aneu- 
risms. 

The  nature  of  the  disease  was  fully  explained  to  the 
patient,  who  fortunately  was  a man  of  strong  sense 
and  most  determined  resolution,  and  from  Ids  employ- 
ment leading  him  to  study  the  diseases  of  horses,  there 
v/as  no  difficulty  in  making  him  comprehend  the  dan- 
gerous tendency  of  the  disease.  He  therefore  submitted 
with  perfect  confidence  to  the  proposed  plan  of  treat- 
ment ; and  I cannot  sufficiently  adnnre  the  fortitude 
and  cheerfulness  with  which  he  bore  the  long  privation 
which  it  was  necessary  to  enforce,  and  the  implicit 
faith  which  he  placed  in  all  the  remedies  adopted  for  his 
relief. 

April  3.  He  was  accordingly  ordered  to  bed,  to  be 
bled  to  the  extent  of  eight  ounces  every  third  day ; his 
diet  to  consist  of  small  quantities  of  gruel,  broth,  and 
tea.  Small  doses  of  digitalis  were  likewise  adminis- 
tered. This  plan  of  treatment  was  continued  until  the 
13th  of  July.  During  the  first  month  there  appeared 
some  little  improvement ; his  pulse  was  frequently  as 
low  as  47  in  the  minute,  the  tumour  became  harder, 
its  pulsations  less  forcible  and  more  remote;  from 
wliich  it  was  supposed  that  coagula  might  be  forming. 
The  blood  hitherto  had  seemed  perfectly  healthy,  and 
it  was  noticed  that  if  the  bleeding  were  delayed  beyond 
the  usual  time,  the  symptoms  were  aggravated. 

In  the  beginning  of  May  a great  alteration  for  the 
worse  took  place,  which  was  supposed  to  be  owing  to 
his  taking  a small  quantity  of  animal  food.  The  blood 
after  each  bleeding  became  buffed ; pulse  80  in  the 
minute ; the  tumour  rapidly  increasing  in  the  course 
of  a few  days,  and  becoming  very  painful  upon  pres- 
sure. Twenty  leeches  were  applied  without  any  re- 
lief. A few  days  afterward  a diarrhoea  supervened, 
the  inflammatory  state  of  the  tumour  abated,  the  pain 
ceased,  and  the  swelling  in  some  degree  subsided.  After 
this  attack  his  pulse  was  never  less  than  80  in  a 
minute,  although  the  same  plan  of  treatment  was  rigidly 
adhered  to. 

From  this  time  until  the  1st  of  July  the  tumour  re- 
mained stationary  ; but  from  the  latter  date  until  the 
20th  he  gradually  got  worse;  the  tumour  increased, 
and  now  reached  as  high  as  the  cricoid  cartilage,  and 
by  its  pressure  upon  the  trachea  and  oesophagus  par- 
tially impeded  respiration  and  deglutition.  His  shirt- 
collar,  which,  prior  to  his  illness,  would  button  comfort- 
ably, could  not  now  be  made  to  meet  by  more  than  tlu-ee 
i nches  ; his  countenance  became  bleached  ; pulse  more 
feeble;  and  it  was  evident  that  the  lowering  system 
had  been  carried  as  far  as  it  could  with  safety. 

lindcr  these  circumstances  the  operation  was  recom- 


mended as  the  only  remaining  chance.  Its  advantages 
and  disadvantages  were  fairly  stated,  and  the  chance 
of  success,  although  small,  made  him  anxious  that  it 
should  be  performed.  Dr.  Bennet,  of  Derby,  saw  the 
patient  on  the  17th,  and  concurred  in  the  propriety  of 
the  operation  as  a last  hope. 

On  the  morning  of  the  22d  of  July,  the  day  proposed 
for  the  operation,  the  patient  became  so  agitated  that 
the  pulsation  of  the  tumour,  of  the  heart,  and  the  large 
arteries,  especially  the  abdominal  aorta,  was  percepti 
ble  to  the  eye.  The  operation  was  performed  in  the 
presence  of  Messrs.  Bennett  and  Brown,  of  Derby ; 
Mr.  Ingle,  of  Ashby-de-la-Zouch ; and  Mr.  Walne,  of 
Chancery  Lane,  surgeons. 

In  consequence  of  the  tumour  extending  so  high  up 
the  neck,  there  was  some  difficulty  in  getting  down  to 
the  sheath  of  the  artery,  which  was  opened  to  the  ex- 
tent of  half  an  inch.  The  artery  appeared  healthy,  and 
was  easily  secured  by  a single  ligature  of  strong  silk. 

Immediately  after  tightening  the  ligature  the  pulsa- 
tion in  the  different  branches  of  the  external  carotid 
artery  ceased,  except  a slight  fluttering  in  the  extreme 
branches  of  the  temporal.  The  pulsation  of  the  tu- 
mour continued  without  diminution. 

23d  and  24th.  He  went  on  well.  The  pulsation  in 
the  tumour  was  stronger  than  it  was  before  the  opera- 
tion, and  the  pulsation  of  the  right  radial  artery  was 
observed  to  be  more  forcible  than  that  of  the  left. 

25th.  He  became  feverish ; pulse  120,  and  full ; the 
right  lip  of  the  wound  swollen  and  painful.  Six  ounces 
of  blood  were  taken  away  from  the  arm,  and  some  sa- 
line medicine  administered.  The  blood  was  much 
buffed. 

26th.  Morning.  Much  better;  pulse  92,  stronger  in 
the  right  radial  artery  than  in  the  left ; pulsation  in 
the  tumour  still  very  forcible. 

Evening.  The  fever  and  pain  in  the  tumour  returned. 
He  was  again  bled.  Blood  still  bulTed. 

27th.  Better  again  tliis  morning.  He  was  taken 
worse  at  nine  o’clock  in  the  evening.  Pulse  100;  de- 
lirious ; anxious  countenance  and  sickness.  No  dimi- 
nution in  the  size  of  the  tumour. 

28th.  Much  better,  and  continued  so  all  day. 

29th.  At  seven,  a.  m.,  he  was  taken  suddenly  worse, 
and  appeared  to  be  dying  ; his  countenance  ghastly, 
and  covered  with  perspiration  ; tracheal  rattle,  and  in- 
ability to  swallow.  He  appeared  conscious,  but  could 
only  speak  in  a whisper ; pulsation  in  the  tumour  still 
forcible ; the  pulse  in  the  right  radial  artery  scarcely 
perceptible,  while  the  left  pulsated  as  strongly  as  it  did 
the  previous  day.  These  symptoms  were  accompanied 
with  a profuse  ptyalism.  He  remained  in  this  state 
for  several  hours,  at  the  expiration  of  which  time  he 
rallied ; and  by  the  evening  (with  the  exception  of  the 
salivation,  which  continued)  he  appeared  quite  as  well 
as  on  the  preceding  day. 

As  he  continued  to  improve  from  this  period,  it  will 
not  be  necessary  to  enter  into  a daily  report  of  the  case, 
I shall  therefore  content  myself  with  noticing  the  most 
prominent  symptoms  which  occurred.  One  of  the 
most  remarkable  was  the  obliteration  of  the  arteries  of 
the  right  arm  and  forearm,  wliich  was  first  observed 
in  the  arteries  of  the  forearm  on  the  29th  of  July,  the 
eighth  day  after  the  operation  ; for  until  that  day  the 
arteries  of  the  right  arm  pulsated  with  greater  force 
than  those  of  the  left.  The  process  of  obliteration  was 
attended  with  severe  paroxysms  of  pain,  chiefly  felt  in 
the  course  of  the  brachial  and  axillary  arteries. 

The  brachial  artery  after  its  obliteration  was  hard 
and  painful  to  the  touch,  and  felt  very  like  an  inflamed 
absorbent  vessel.  The  right  arm  wasted,  and  be- 
came partially  paralyzed,  and  continued  to  diminish  for 
three  weeks;  at  the  expiration  of  which  time  several 
anastomosing  branches  were  observed  pulsating  on 
the  back  part  of  the  arm.  As  these  vessels  enlarged, 
the  limb  improved  very  slowly,  not  having  yet  (Oct.  19) 
perfectly  acquired  sensation,  nor  its  muscles  the  power 
of  obeying  volition. 

On  the  11th  day  after  the  operation,  he  was  attacked 
with  intermitting  paroxysms  of  pain  in  the  right  side  of 
the  head  and  face,  of  the  same  character  as  the  pain  in 
the  right  arm,  though  not  so  violent ; this  pain  ceased 
within  a fortnight.  The  right  side  of  the  head  and 
face  became  ernaciated,  and  any  one  looking  at  him 
would  immediately  discover  that  the  right  half  of  the 
face  was  much  smaller  than  the  left.  The  blood  hav- 
ing since  found  its  way  into  the  temporal  and  facial 


118 


ANEURISM. 


arteries,  the  right  side  of  the  face  is  now  nearly  as 
plump  as  the  left. 

The  ptyalism,  winch  began  on  the  29th  of  July,  con- 
tinued until  the  middle  of  September,  during  which 
time  he  spit  daily  about  a pint  of  saliva ; a more  gene- 
rous diet  and  a small  quantity  of  ale  were  then  allowed, 
and  the  salivsition  subsided. 

Three  weeks  after  the  operation  he  was  able  to  sit 
up  to  his  meals.  The  first  time  that  he  got  out  of  bed, 
he  perceived  that  the  whole  of  the  right  side  was 
numbed,  and  weaker  than  the  left.  The  pulsation  in 
the  tumour,  which  had  hitherto  been  more  powerful 
than  it  was  before  the  artery  was  tied,  now  (Aug.  15) 
began  to  diminish  rapidly,  and  by  the  23d  of  August, 
the  thirty-third  day  after  the  operation,  had  so  much 
subsided,  that  it  was  doubtful  whether  it  arose  from 
the  passage  of  blood  into  the  tumour,  or  from  the  im- 
pulse given  to  it  by  the  subclavian  artery  beneath. 

In  five  weeks  after  the  operation,  he  was  sufficiently 
recovered  to  be  able  to  take  daily  exercise  in  a gig  or 
on  horseback,  and  from  this  time  he  has  continued  to 
improve  in  health  without  interruption. 

The  obliteration  of  the  right  brachial  artery  is  now 
complete,  and  above  the  insertion  of  the  latissimus 
dorsi  the  pulsation  of  the  axillary  artery  can  be  easily 
felt. 

The  pulse  in  the  radial  artery  is  scarcely  perceptible 
in  the  right  arm,  increases  daily,  but  is  yet  far  from 
being  of  the  size  of  the  left.  Sensation  and  susceptibi- 
lity of  the  influence  of  volition  are  more  perfect  on  the 
whole  of  the  right  side  of  the  bodj',  but  still  that  side 
is  more  feeble  than  the  left.  The  tumour  is  hard  and 
firm,  and  has  diminished  about  one-third  since  the  ope- 
ration. By  pressing  it  from  above  downwards,  a fee- 
ble, deep-seated  pulsation  is  felt,  but  in  grasping  the 
tum.our  and  using  lateral  pressure  no  pulsation  can  be 
perceived. 

On  the  13th  of  October  the  wmund  was  nearly  healed ; 
the  ligature  had  not  come  away,  and  as  it  acted  as  a 
source  of  irritation  to  the  small  wmund,  it  was  cut  off 
level  with  the  skin. 

The  most  peculiar  features  wffiich  this  interesting 
case  presented  were : — 1st,  The  obliteration  of  the  ar- 
teries of  the  right  arm;  2d,  The  profuse  salivation; 
3d,  The  disposition  to  paralysis  of  the  whole  of  the 
right  side  of  the  body. 

The  first  two  symptoms  commenced  on  the  8th  day 
after  the  operation;  and  I think  there  can  be  little 
doubt  that  the  obliteration  of  the  arteries  of  the  arm 
was  accomplished  by  inflammation  extending  from  the 
aneurisrnal  sac  to  the  internal  membrane  of  the  sub- 
clavian artery,  and  thence  to  the  brachial  artery. 
Might  not  the  active  obliteration  of  such  large  arteries 
as  those  of  the  arm  and  forearm,  be  the  cause  of  the 
unpleasant  train  of  symptoms  which  occurred  on>  the 
8th  day  after  the  operation  1 The  salivation  appeared 
to  be  connected  with  the  state  of  the  digestive  appara- 
tus ; for,  as  soon  as  ale  and  a generous  diet  were  al- 
lowed, it  gradually  subsided. 

I am  at  a loss  to  assign  the  cause  of  the  numbness 
and  debility  of  the  whole  of  the  right  side  of  the  body 
(which  were  only  observed  when  he  first  left  his  bed), 
unless  they  originated  in  a greater  quantity  of  blood 
circulating  in  the  left  hemisphere  of  the  brain  than  in 
the  right,  which  undoubtedly  would  be  the  case  after 
the  application  of  a ligature  to  the  common  carotid. 

What  tends  to  confirm  this  opinion  is,  that  now  (13 
weeks  after  the  operation)  the  balance  of  circulation  in 
the  brain  being  re-established,  the  numbness  and  debi- 
lity of  the  right  side  of  the  body  have  nearly  disappeared. 

In  conclusion,  it  is  worthy  of  notice,  that,  since  the 
operation,  he  has  become  more  irritable  in  temper,  and 
his  memory  is  evidently  weaker. 

So  far  as  this  ca.se  has  yet  proceeded,  it  amply  jus- 
tifies the  operation;  and  the  man  probabl ow'es  his 
life  to  Mr.  Wardro])*s  fortunate  suggestion  and  exam- 
ple. Should  any  untoward  circumstance  occur,  lead- 
ing to  any  other  conclusion,  it  shall  be  communicated. 

It  is  now  five  weeks  since  he  resumed  his  usual 
avocations,  and  he  regularly  attends  the  markets  and 
fairs  of  Derby,  a distance  of  seven  miles. — Reese.) 

That  Brasdor’s  operation  must  sometimes  fail,  and  par- 
ticularly that  it  should  have  failed  in  the  trials  made 
of  it  by  Deschamps  and  Sir  A.  Cooper,  is  not  at  all  sur- 
prising. These  cases  w’ere  both  inguinal  aneurisms  ; 
and  it  does  not  follow,  because  the  method  will  answer 
in  carotid  aneurisms,  that  it  will  answer  in  aneurisms 


in  every  other  situation.  I should  say,  indeed,  that 
unless  it  retard,  in  a certain  degree,  the  circulation 
through  the  sac,  it  will  never  answer  in  any  case; 
and  how  much  this  must  depend  upon  the  existence  or 
not  of  one  or  more  branches  between  the  sac  and  the 
ligature,  is  completely  obvious. 

The  memorable  instance  in  which  Sir  A.  Cooper  tied 
the  aorta,  in  a case  of  inguinal  aneurism,  extending 
very  high  up,  and  already  burst,  I shall  notice  under 
the  head  Aorta. 

I shall  finish  these  general  observations  on  the  treat- 
ment of  external  aneurisms,  or  such  as  admit  more 
particularly  of  surgical  treatment,  with  observing,  that 
in  England,  surgeons  now  lose  few  patients  either  from 
gangrene  in  the  limb  or  secondary  hemorrhage ; and 
this,  notwithstanding  they  may  sometimes  prefer  ap- 
plying a ligature  above  the  profunda  to  cutting  open 
the  aneurisrnal  tumour.  I firmly  believe,  that  such 
matchless  success  is  to  be  totally  ascribed  to  their  per- 
fections in  the  mode  of  operating;  the  choice  of  a 
proper  kind  of  ligature ; the  right  plan  of  applying  it ; 
the  rejection  of  the  employment  of  several  ligatures  at 
a time  ; and  the  great  care  which  is  taken  to  promote 
the  healing  of  a wound  as  quickly  as  possible ; the 
avoidance  of  all  unnecessary  and  hurtful  extraneous 
substances  in  the  wound ; and  above  all,  the  relin- 
quishment of  the  formidable  proceeding  of  cutting  open 
the  tumour. 

In  the  consideration  of  particular  aneurisms,  I shall 
begin  with  those  which  may  be  cured  by  a surgical 
operation  : and  here  we  shall  be  fully  satisfied  that 
“ Part  de  guerir  ne  triomphe  jamais  plus  heureusement 
que  lorsqu’il  peut  employer  la  mddecine  efficace,  e’est 
a dire,  les  moyens  chirurgicaux  ou  operatoires.’'-^^ei- 
letaii,  Clinique  Chir.  t.  l,p.  110.) 

OF  THE  POPLITEAL  ANEURISM,  AND  OPERATION 
FOR  ITS  CURE. 

Notwithstanding  the  solitary  example  in  wliich  M. 
A.  Severinus,  early  in  the  17th  century,  tied  the  femo- 
ral artery  near  Poupart’s  ligament  in  a case  of  aneu- 
rism {De  Efficac.  Med.  lib.  1,  p.  2,  c.  51),  the  practice  of 
tying  arteries  wounded  either  by  accident  or  in  the  per- 
formance of  surgical  operations,  and  even  the  plan  of 
tying  the  humeral  artery  for  the  cure  of  the  aneurism 
at  the  bend  of  the  arm,  were  known  long  before  the 
operation  for  the  relief  of  the  popliteal  aneurism  was 
attempted.  The  considerable  size  of  the  femoral  artery, 
its  deep  situation,  the  urgent  sjTnptoms  of  the  disease, 
and  ignorance  of  the  resources  of  nature  for  transmit- 
ting blood  into  the  limb  after  the  ligature  of  the  vessel, 
are  the  circumstances  which  appear  to  have  deterred 
former  surgeons  from  this  operation. 

Valsalva  treated  popliteal  aneurisms  on  the  debilita- 
ting method,  and  published  one  or  two  equivocal  proofs 
of  its  success.  In  Pelletan’s  first  memoir  on  aneuri.sm, 
and  in  the  third  vol.  of  Sabatier’s  Medecine  Operatoire, 
as  I shall  hereafter  notice  again,  are  two  cases  of  axil- 
lary aneurisms,  which  were  cured  by  Valsalva’s  treat- 
ment. But  encouraging  as  such  examples  may  be, 
experience  is  not  yet  sufficiently  favourable  to  this 
practice  to  allow  it  to  bear  a comparison  in  point  of 
efficacy  with  the  surgical  operation,  or  to  justifv  the 
general  rejection  of  this  last  more  certain  means  ol‘ 
cure.  As  Pelletan  admits,  Valsalva’s  treatment  is  ex- 
tremely severe ; the  event  of  it  doubtful ; and  should 
the  plan  fail,  the  patient  might  not  be  left  in  a condition 
to  bear  an  operation,  for  the  success  of  which  it  seems 
necessary  that  a certain  strength  of  vascular  action 
should  exist,  in  order  that  the  blood  may  be  freely 
transmitted  through  such  arterial  branches  as  are  to 
supply  the  places  of  the  main  trunk  after  it  has  been 
tied. 

The  time,  therefore,  has  not  yet  arrived  when  surgi- 
cal operations  for  the  relief  of  aneurisms  should  be  re- 
linquished.— {Clinique  Chir.  t.  l,p.  114.) 

The  cure  of  popliteal  aneurisms  by  means  of  com- 
pression is  occasionally  effected ; but  it  happens  too 
seldom  to  claim  a great  deal  of  confidence,  or  to  lessen 
in  any  material  degree  the  utility  and  importance  of 
operative  surgery  in  this  part  of  practice.  Pelletan 
records  the  cure  of  one  popliteal  aneurism  by  compres- 
sion and  absolute  repose  during  eleven  months  {t.  1, 
p.  115);  Boyer  relates  two  instances  ( TVaftc  des  J/af. 
Chh.  p.  204,  t.  2);  one  is  mentioned  by  llicherand 
Diet,  des  Scieiices  Mid.  t.  2,  p.  96);  the  practice  of 
Dubois  is  said  to  iKive  ftirnished  several  examples  of 


ANEURISM. 


119 


the  same  success  {vol.  cit.  p.  97) ; and  a case,  in  which 
Dupuytren  effected  a cure  by  compressing  the  femoral 
artery  by  means  of  an  instrument  applied  just  above 
the  place  where  the  vessel  perforates  the  tendon  of  the 
triceps  muscle,  is  detailed  by  Breschet. — {FV.  transl. 
of  Mr.  Hodgson's  work,  t.  1,  p.  249,  iSc.) 

The  circumstances  under  w'hich  the  employment  of 
compression  affords  the  best  chance  of  success  have 
been  already  mentioned,  as  well  as  the  prudence  of  as- 
sisting this  plan  with  perfect  quietude,  venesection, 
spare  diet,  and  cold  astringent  applications,  especially 
ice,  which  was  first  recommended  by  Donald  Monro, 
and  subsequently  highly  praised  by  Guerin. 

Aneurisms  in  general,  and  among  them  the  popliteal 
case,  are  all  attended  with  some  little  chance  of  a spon- 
taneous cure  ; yet  this  desirable  event  is  too  uncom- 
mon to  be  a judicious  reason  for  postponing  the  opera- 
tion, especially  as  it  is  the  usual  course  of  the  disease 
to  continue  to  increase ; while  in  the  early  stage  the 
cure  may  be  more  speedily  accomplished.  In  fact,  the 
experience  of  modern  operators  leaves  no  room  for  ap- 
prehending that  the  anastomoses  will  not  suffice  for  the 
due  nourishment  of  the  leg,  and  consequently  proves 
that  waiting  beyond  a certain  time  for  the  enlargement 
of  the  collateral  vessels  to  take  place  is  altogether  an 
unnecessary  and  disadvantageous  method.  Popliteal 
aneurisms,  as  well  as  other  external  tumours  of  the 
same  nature,  stand  the  best  chance  of  a spontaneous 
cure,  when  any  cause  induces  a general,  violent,  and 
deep  inflammation  all  over  the  swelling ; for  then  the 
communication  between  the  sac  and  the  artery  is  likely 
to  become  closed  with  coagulating  lymph,  and  the  pul- 
sation of  the  tumour  to  be  suddenly  and  permanently 
stopped.  If  in  this  state  the  disease  sloughs,  and  the 
patient’s  constitution  holds  out,  the  coagulated  blood 
in  the  sac  and  the  sloughs  are  gradually  detached,  leav- 
ing a deep  ulcer,  which  ultimately  heals.  An  example, 
in  which  a popliteal  aneurism  was  cured  by  such  a 
process,  is  related  in  the  Trans,  for  the  Improvement 
of  Med.  and  Chirurgical  Knowledge,  vol.  2,  p.  268. 

In  former  times,  when  all  hopes  of  curing  a popliteal 
aneurism  by  Valsalva’s  method,  by  compression,  or  a 
natural  process,  were  at  an  end,  amputation  of  the 
limb  was  considered  as  the  sole  and  necessary  means 
of  saving  the  patient’s  life.  But  about  fifty  years  ago, 
the  confidence  of  surgeons  in  the  sufficiency  of  the 
anastomosing  vessels  or  the  continuance  of  the  circu- 
lation began  to  increase,  and,  in  opposition  to  the  tenets 
of  J.  L.  Petit  and  Pott,  experience  soon  proved,  that  in 
general,  not  only  might  the  patient’s  life  be  saved,  but 
his  limb  also,  and  this  without  any  operation  that 
could  be  compared  with  amputation  in  regard  to  se- 
verity. On  looking  back  to  the  history  of  amputation, 
we  shall  find  that  A.  N.  Guenault  was  one  of  the  ear- 
liest writers  who  disapproved  of  amputation  as  not 
truly  indispensable  for  the  cure  of  popliteal  aneu- 
rism. 

It  is  alleged  that  Teislere,  Molinelli,  Guatlani,  Ma- 
zotti,  and  some  other  celebrated  Italian  surgeons,  were 
the  first  who  ventured  to  tie  the  popliteal  artery  for  the 
cure  of  aneurism.  The  path,  as  Pelletan  remarks,  had 
been  pointed  out  to  them  by  Winslow  and  Haller, 
whose  valuable  descriptions  and  plates  of  the  arterial 
anastomoses  about  the  knee-joint,  showed  by  what 
means  the  lower  part  of  the  limb  would  be  nourished, 
after  the  ligature  had  been  placed  on  the  principal  arte- 
rial trunk.  For  almost  thirty  years,  however,  the 
practice  of  tying  the  popliteal  artery  was  confined  to 
the  Italian  surgeons.  Pelletan  believes  that  he  was 
the  first  who  attempted  such  an  operation  at  Paris 
nearly  thirty  years  ago  (alluding  to  about  the  year 
1780,  the  Clinique  Chirurgicale  being  dated  1810). 

However,  this  operation  of  opening  the  tumour  and 
tying  the  popliteal  artery  itself,  was  a severe  and  ofien 
fatal  proceeding,  and  does  not  admit  of  being  compared 
with  the  Hunterian  operation,  in  point  either  of  sim- 
plicity, safety,  or  success,  as  I shall  explain,  after  the 
detail  of  a few  particulars  relating  to  the  popliteal 
aneurism. 

On  whatever  side  of  the  artery  the  tumour  is  pro- 
duced, it  can  be  plainly  felt  in  the  hollow  between  the 
hamstrings,  and  in  general  its  nature  is  as  easily  as- 
certained by  the  pulsation  in  every  jiart  of  the  tumour. 
Though  the  disease  may  not  occur  in  the  iiopliteal 
artery  so  often  as  in  the  aorta  itself,  U certainly  is  seen 
more  frequently  in  the  former  vessel  than  any  other 
branch  wliich  the  aorta  sends  off.  As  Sir  E.  Home 


has  observed,  this  circumstance  has  never  been  satis- 
factorily explained ; and,  what  is  rather  curious,  in 
many  recent  instances  of  this  disease  the  patients  have 
been  coachmen  and  postillions.  Morgagni  found  aneu- 
jsisms  of  the  aorta  most  frequent  in  guides,  postboys, 
and  other  persons  who  sit  almost  continually  on  horse- 
back ; a fact,  which  he  imputes  to  the  concussion  and 
agitation  to  which  such  persons  are  exposed.  Some 
allusion  to  this  subject  has  already  been  made  in  the 
foregoing  pages.  Whether  an  explanation  of  the  fre- 
quency of  popliteal  aneurisms  can  be  correctly  referred 
to  the  obstruction  which  the  circulation  in  the  artery 
must  experience  when  the  knee  is  in  a state  of  flexion, 
may  be  questioned,  though  it  is  on  a similar  principle 
that  the  great  frequency  of  aneurisms  of  the  curvature 
ol'  the  aorta  is  attempted  to  be  solved. — {Home  in 
Trans,  for  the  Improvement  of  Med.  and  Chir.  Know- 
ledge, vol.  1,  iS'C.  and  Monro  in  Ed.  Med.  Essays, 
vol.  5.) 

Were  this  the  only,  or  even  the  principal  cause, 
surely  one  would  have  reason  to  expect  aneurisms  to 
be  at  least  as  frequent  in  the  axilla,  and  in  the  bend  of 
the  elbow,  as  in  the  ham. 

The  popliteal  aneurism  was  generally  supposed  to 
arise  from  a weakness  in  the  coats  of  the  artery,  inde- 
pendently of  disease.  If  this  were  true,  we  might  rea- 
sonably conclude,  that  except  at  the  dilated  part  the 
vessel  would  be  sound.  Then  the  old  practice  of 
opening  the  sac,  tying  the  artery  above  and  below  it, 
and  leaving  the  bag  to  suppurate  and  heal  up,  would 
naturally  present  itself.  As  the  arterial  coats  were 
found  to  be  altered  in  structure  higher  up  than  the  tu- 
mour, and  the  artery  immediately  above  the  sac  sel- 
dom united  when  tied,  but,  when  the  ligature  came 
away,  the  patient  was  destroyed  by  hemorrhage,  Mr, 
Hunter  concluded,  that  some  disease  affected  the  coats 
of  the  vessel  before  the  actual  occurrence  of  aneurism,. 
Dissatisfied  with  Haller’s  experiments  on  frogs,  show.- 
ing  that  weakness  alone  could  give  rise  to  aneurism, 
he  tried  what  would  happen  in  a quadruped,  whose 
vessels  were  very  similar  in  structure  to  the  human. 
Having  denuded  above  an  inch  of  the  carotid  artery  of 
a dog,  and  removed  its  external  coat,  he  dissected  off 
the  other  coats,  layer  after  layer,  till  what  remained 
was  so  thin,  that  the  blood  could  be  seen  through  it. 
In  about  three  weeks  the  dog  was  killed,  when  the 
wound  was  found  closed  over  the  artery,  which  was 
neither  increased  nor  diminished  in  size. 

It  being  conjectured  that  the  prevention  of  aneurism, 
perhaps  arose  from  the  parts  being  immediately  laid 
down  on  the  weakened  jiortion  of  the  artery.  Sir  E. 
Home  stripped  off  the  outer  layers  of  the  femoral  artery 
of  a dog,  placed  lint  over  the  exposed  part  of  the  vessel 
to  keep  it  from  uniting  tp  the  sides  of  the  wound,  and  in 
six  weeks  killed  the  animal  and  injected  the  artery, 
which  was  neither  enlarged  nor  diminished,  its  coats 
having  regained  their  natural  thickness  and  appear- 
ance. 

These  experiments  strengthened  Mr.  Hunter’s  belief 
that  aneurismal  arteries  are  diseased  ; that  the  morbid 
affection  frequently  extends  a good  way  from  the  sac 
along  the  vessel  ; and  that  the  cause  of  failure  in  the 
old  operation  arose  from  tying  a diseased  artery,  which 
was  incapable  of  uniting  before  the  ligature  separated. 
These  reflections  led  him  to  propose  taking  up  the 
artery  in  the  anterior  part  of  the  thigh,  at  some  dis- 
tance from  the  diseased  portion,  so  as  to  diminish  the 
risk  of  hemorrhage,  and  be  enabled  to  get  at  the  vessel 
again  in  case  it  should  bleed.  The  stream  of  blood 
into  the  sac  being  stopped,  he  concluded  that  the  sac 
and  its  contents  v/ould  be  absorbed,  and  the  tumour 
gradually  disappear,  so  as  to  render  any  opening  of  it 
unnecessary. 

[Dr.  David  Hosack  was  the  first  surgeon  who  per- 
formed tliis  Qperation  in  America,  which  he  did  suc- 
cessfully as  early  as  1808.  Three  cases  of  aneurism 
were  cured  by  him,  by  the  ligature  of  the  femoral  arte- 
ry, and  will  be  found  reported  in  his  valuable  volume 
of  “ Essays  on  Medical  Science,”  by  which  it  will  be 
seen,  that  this  distinguished  gentleman  in  the  former* 
part  of  his  life  was  an  operative  surgeon  of  more  than 
ordinary  skill.  He  has  since  devoted  his  energies  to 
teaching  the  theory  and  practice,  and  in  the  less  osten- 
tatious character  of  a general  practitioner  has  acijuired 
a reputation  second  only  to  Rush,  with  whom  his 
name  will  be  transmitted  to  posterity  as  among  the 
most  eminent  in  their  profession  in  this  or  any  other 


120 


ANEURISM. 


country.  He  began  his  distinguished  career  as  a sur- 
geon, and,  like  many  others,  thus  laid  the  foundation 
of  professional  distinction. — Reese.] 

The  first  operation  of  this  kind  ever  done  was  per- 
formed on  a coachman  by  Mr.  Hunter,  in  St.  George’s 
Hospital,  December,  1785.  An  incision  was  made  on 
the  anterior  and  inner  part  of  the  thigh,  rather  below 
its  middle,  which  wound  was  continued  obliquely 
across  the  inner  edge  of  the  sartorius  muscle,  and 
made  large  in  order  to  facilitate  the  performance  of- 
whatever  might  be  necessary.  The  fascia  covering 
the  artery  was  then  laid  bare  for  about  three  inches, 
after  which  the  vessel  itself  could  be  felt.  A cut  about 
an  inch  long  was  then  made  through  the  fascia,  along 
tlie  side  of  the  artery,  and  the  fascia  dissected  off. 
Thus  the  vessel  was  exposed.  Having  disengaged  it 
from  its  connexions  by  means  of  the  knife  and  a thin 
spatula,  Mr.  Hunter  put  a double  ligature  under  it 
with  an  eye-probe.  The  doubled  ligature  was  then 
cut,  so  as  to  make  two  separate  ones.  The  artery  was 
now  tied  with  both  these  ligatures,  but  so  slightly  as 
only  to  compress  the  sides  together.  Two  additional 
ligatures  were  similarly  applied  a little  lower,  with  a 
view  of  compressing  some  length  of  artery,  so  as  to 
make  amends  for  the  want  of  tightness,  as  it  was 
wished  to  avoid  great  pressure  on  any  one  part  of  the 
vessel.  The  ligatures  were  left  hanging  out  of  the 
wound,  which  was  closed  with  sticking  jilaster.  On 
the  second  day,  the  aneurism  had  lost  one-third  of  its 
size,  and  on  the  fourth,  the  wound  was  every  where 
healed,  except  where  the  ligatures  were  separated.  On 
the.ninth,  there  was  a considerable  discharge  of  blood 
from  the  apertures  of  the  ligatures,  but  It  ceased  on 
applying  a tourniquet,  and  did  not  recur.  On  the  fif- 
teenth day  after  the  operation,  some  of  the  ligatures 
came  away,  followed  by  a small  quantity  of  matter  ; 
and  about  the  latter  end  of  January,  178G,  the  man 
went  out  of  the  hospital,  the  tumour  having  become 
still  less.  In  the  course  of  the  spring,  abscesses  in 
the  vicinity  of  the  cicatrix  followed,  and  some  pieces 
of  ligature  were  occasionally  discharged.  In  the  begin- 
ning of  July,  a piece  of  ligature  about  an  inch  long 
came  away,  after  which  the  swelling  went  off'  entirely, 
and  the  man  left  the  hospittd  again  on  the  8th,  per- 
fectly well,  there  being  no  appearance  of  swelling  in 
the  ham.  This  subject  died  of  a fever  in  March,  1787 ; 
and  oil  dissection,  the  femoral  artery  was  found  im- 
])crvious  from  the  giving  off"  of  the  arteria  profunda 
down  to  the  place  of  the  ligature,  and  an  ossification 
had  taken  place  for  an  inch  and  a half  along  the  course 
of  this  part  of  the  vessel.  Below  this  portion  the  ves- 
sel was  pervious,  till  just  before  it  came  to  the  aneu- 
rismal  sac,  where  it  was  again  closed.  'What  re- 
mained of  the  sac  was  somewhat  larger  than  a hen’s 
egg,  and  it  had  no  remains  of  the  lower  opening  into 
the  popliteal  artery.  The  rest  of  the  particulars  of 
this  dissection  are  very  interesting. — See  Trans,  for 
the  Improvement  of  Med.  and  Chir.  Knowledge,  vol.  1, 
p.  l.-iS.) 

This  celebrated  case  completely  established  the  im- 
portant fact,  that  simply  taking  off  the  force  of  the 
circulation  is  sufficient  to  cure  an  aneurism,  as  the 
tumour  is  afterward  diminished  and  renioved  by  the 
action  of  the  absorbent  vessels. 

In  order  to  confirm  the  same  fact,  Sir  E.  Home  re- 
lated a case  of  femoral  aneurism  which  got  well  with- 
out an  operation,  but  on  a similar  principle  to  what 
occurs  when  the  artery  is  tied.  A trial  of  pressure 
had  been  made  without  avail.  The  tumour  became 
very  large,  and  such  inflammation  took  place  in  the  sac 
and  integuments  that  mortification  was  impending: 
no  pulsation  .could  now  be  felt  in  the  timiour,  or  the 
artery  above  it.  The  correct  inference  of  Sir  E.  Home 
was,  that  a coagulum,  which  we  know  always  occurs 
in  an  artery  previously  to  mortification,  seemingly  to 
prevent  bleeding,  had  formed  in  this  instance,  and  in 
conjunction  with  the  effusion  of  coagulable  lymph 
about  the  root  of  the  aneurism,  had  kept  the  blood  from 
entering  the  sac. 

Mr.  Hunter’s  second' operation  was  on  a trooper. 
Instead  of  using  several  ligatures,  wliich  were  found 
hurtful,  he  tied  the  artery  and  vein  with  a single  strong 
one;  but  unluckily  the  experiment  was  made  of  dress- 
ing the  wound  from  the  bottom,  instead  of  attempting 
to  unite  it  at  once  ; and  the  event  was,  that  the  man 
died  of  hemorrhage. 

After  this  case  Mr.  Hunter’s  practice  was  to  tie  the 


artery  alone  with  one  strong  ligature,  and  unite  tha 
wound  as  speedily  as  possible. 

Having  recorded  Mr.  Hunter’s  cases,  which  first  es- 
tablished the  present  method  of  operating  for  tlic  cure 
of  popliteal  aneurisms,  I shall  not  repeat  the  strong 
reasons  which  exist  against  the  employment  of  reserve- 
ligatures  ; metallic  compressors  ; two  ligatures,  with 
the  division  of  the  vessel  between  them  ; the  interpo- 
sition of  pieces  of  linen,  wood,  cork,  agaric,  &c.  be- 
tween the  knot  and  the  vessel ; the  use  of  large  liga- 
tures ; and  other  contrivances,  the  merits  or  rather 
demerits  of  which  have  been  already  fully  considered 
in  the  preceding  section.  My  next  duty  is,  to  explain 
the  method  of  performing  the  Hunterian  operatioa,  as 
brought  to  its  modern  state  of  improvement,  and  adapt- 
ed to  the  M'ise  principles  which  first  emanated  from 
the  valuable  experiments  and  investigations  of  Dr. 
Jones. — (See  Hemorrhage.') 

In  the  arrangement  of  the  assistants,  one  of  them 
should  be  so  placed,  that  if  required,  in  consequence  of 
any  accidental  wound  of  that  vessel  in  the  operation, 
he  can  compress  the  femoral  artery  as  it  passes  over 
the  brim  of  the  pelvis : but,  as  Scarpa  justly  observes, 
no  pressure  of  this  kind  is  to  be  made,  unless  the  acci- 
dent referred  to  should  happen,  because  the  pulsations 
of  the  artery,  inasmuch  as  they  indicate  the  track  of 
the  vessel,  must  tend  materially  to  facilitate  the  opera- 
tion. The  surgeon  is  to  explore  with  his  fore-linger 
the  course  of  the  artery  from  the  crural  arch  down- 
wards, and  when  he  comes  to  the  place,  where  the 
vibration  of  this  vessel  begins  to  be  less  distinctly  felt, 
this  point  is  to  be  fixed  upon  for  the  lower  end  of  the 
external  incision.  This  angle  of  the  wound  will  fall 
nearly  on  the  inner  edge  of  the  .sartorius,  just  where 
this  muscle  crosses  the  track  of  the  femoral  artery, 
and  at  the  very  apex  of  the  triangle  formed  by  the  con- 
vergence of  tile  triceps  and  vastus  internus.  A little 
more  than  three  inches  above  the  place  here  fixed 
upon,  the  surgeon  is  to  begin  with  a convex -edged  bis- 
toury the  incision  through  the  integuments  and  cel- 
lular substance,  and  carry  the  wound  down  the  thigh 
in  a slightly  oblique  line  from  without  inwards,  so  as 
to  make  it  follow  the  course  of  the  artery,  as  far  as  the 
apex  of  the  above-mentioned  triangular  space,  or  the 
point  where  the  vessel  passes  under  the  inner  edge  of 
the  sartorius  muscle.  In  order  to  make  this  first  exter- 
nal incision  with  correctness,  I consider  it  a good  rule 
always  to  take  particular  notice  of  the  line  described 
by  the  sartorius  on  the  thigh,  the  inner  margin  of  which 
muscle  at  the  place  where  it  meets  the  artery,  as  we  have 
seen,  forms  at  once  the  lower  boundary  of  the  incision, 
and  an  important  guide  to  the  vessel  itself.  By  observing 
the  track  of  the  sartorius  attentively,  we  shall  likewise 
avoid  all^chance  of  making  the  wound  too  low  down, 
so  as  to  have  this  muscle  intervening  between  the  in- 
cision and  the  artery  ; a greater  source  of  embarrass- 
ment in  the  operation,  and  of  troublesome  consequences 
afterward,  than  perhaps  any  other  error ; for  when  this 
has  happened,  and  the  surgeon  has  not  room  enough 
afforded  by  the  higher  part  of  the  wound  to  get  at  the 
artery  above  the  sartorius,  he  is  compelled  to  dissect 
and  raise  up  this  muscle  from  its  natural  connexions, 
ere  he  can  plainly  discover  the  vessel.  This  inconve- 
nience made  a deep  impression  on  me  in  the  first  case 
where  I tied  the  femoral  artery ; for  the  intervention 
of  the  sartorius  in  a stout  soldier  upon  whom  the  ope- 
ration was  done,  threw  me  into  the  dilemma  of  either 
dissecting  at  the  outer  edge  of  this  muscle,  and  draw- 
ing it  inwards,  or  of  enlarging  the  wound  upwards. 
The  latter  proceeding  was  that  to  which  I gave  the  pre- 
ference, because  it  seemed  to  me  an  excellent  maxim  in 
this  ojjeration  to  avoid  making  any  farther  detachment 
of  parts  from  their  natural  connexions  than  is  abso 
lutely  necessary ; and  I knew  that  when  the  wound 
was  extended  a little  higher  up,  the  artery  would  pre- 
sent itself  more  superficially,  quite  unconcealed  by 
any  muscle  whatever.  Strongly,  therefore,  as  my  prin- 
ciples have  led  me  to  condemn  Scarpa’s  modification 
of  the  ligature,  his  use  of  from  four  to  six  threads,  and 
his  interposition  of  a roll  of  linen  between  the  knot 
and  the  vessel,  I feel  plea.surc  in  expressing  my  con- 
viction of  one  excellence  in  his  mode  of  operating  ; an 
improvement  which  is  now  obtaining,  if  it  has  hot  al- 
ready obtained,  the  universal  approbation  of  the  sur- 
gical profession.  This  amendment  consists  in  making 
the  incision  in  the  upper  third  of  the  thigh,  or  a little 
higher  than  the  place  where  Mr.  Hunter  used  to  make 


ANEURISM. 


121 


the  wound.  Scarpn’s  reason  for  this  practice  is  to 
avoid  the  necessity  of  removing  the  sartorius  muscle 
too  much  from  its  position,  or  of  turning  it  back,  to 
bring  the  artery  into  view,  so  as  to  be  tied.  I have 
seen  the  best  operators,  even  professors  of  anatomy, 
embarrassed  by  having  the  sartorius  muscle  imme- 
diately in  their  way  after  the  first  incision ; and  as  the 
vessel  is  more  superficial  a little  higher  up,  the  place 
is  farther  from  the  diseased  part  of  the  artery,  and 
there  is  no  hazard  of  the  anastomoses  failing  to 
keep  up  the  circulation : this  part  of  Scarpa’s  practice 
is  highly  deserving  of  imitation. 

“ The  part  of  the  limb  (observes  Mr.  Hodgson)  in 
which  the  femoral  artery  can  be  tied  with  the  greatest 
facility,  is  between  four  and  five  inches  below  Pou- 
part’s  ligament.  The  profunda  generally  arises  from 
the  femoral  artery  an  inch  and  a half  or  an  inch  and 
three-quarters  below  Pou  part’s  ligament ; it  very  rarely 
arises  so  low  as  two  inches.  If,  therefore,  the  ligature 
be  applied  to  the  femoral  artery  at  the  distance  of  four 
or  five  inches  below  Poupart’s  ligament,  the  surgeon 
will  not  be  embarrassed  by  meeting  with  the  profunda 
during  the  operation,  and  the  chance  of  causing  se- 
condary hemorrhage,  by  tying  the  artery  close  t(*  the 
origin  of  this  vessel,  will  be  obviated.” — (On  the  Dis- 
eases of  Arteries^  «S-c.  p.  434.) 

The  trouble  arising  from  cutting  too  low  down,  so 
as  to  have  the  sartorius  intervening  between  the 
outer  wound  and  the  artery,  may  be  more  accurately 
estimated,  when  it  is  known  that  Desault,  for  the  re- 
moval of  this  inconvenience,  considered  it  right  actu- 
ally to  make  a complete  transverse  division  of  that 
muscle,  a thing  which,  it  is  said,  may  be  done  without 
any  ill  consequences. — (Boyer,  Traiti  des  Mai.  Chir. 
t.  2,  p.  145.)  I shall  not  presume,  however,  to  second 
this  last  piece  of  advice,  because,  though  it  may  have 
been  done  by  Desault,  it  appears  to  me  that  the  artery 
can  always  be  taken  up  very  well  without  the  pro- 
ceeding here  recommeaided. 

A few  years  ago  Mr.  C.  Hutchison  published  a tract, 
in  which  he  is  an  advocate  for  the  practice  of  making 
the  incision  at  the  outer  edge  of  the  sartorius,  and  then 
raising  that  muscle  and  drawing  it  inwards,  in  order  to 
arrive  at  the  artery.  This  advice  proceeded  from  the 
apprehension  that  the  plan  of  taking  up  the  femoral 
artery  at  the  inner  edge  of  the  sartorius  was  attended 
with  risk  of  injuring  the  saphena  vein  and  large  lym- 
phatics.— (Letter  on  the  Operation  for  popliteal  Aneu- 
rism, 1811.)  The  same  method  is  commended  by  Boyer 
and  Roux  (Nouveaux  EUmetisde  Med.  Operatoire,  1. 1, 
p.  729),  when  the  operation  is  done  low  down  in  the 
thigh.  But  as  oprating  in  this  situation  is  liable  to 
the  several  objections  of  ajtproaching  too  near  the  dis- 
ease, of  aiming  at  taking  up  the  artery  where  it  lies 
more  deeply  than  it  does  higher  up,  and  of  every  in- 
convenience which  may  arise  from  the  interposition, 
dissection,  and  reflection  of  the  sartorius  muscle,  the 
method  must  be  rejected,  unless  it  can  be  proved  that 
so  many  disadvantages  are  fully  counterbalanced  by 
other  considerations.  If  the  plan  which  I shall  pre- 
sently recommend  be  adopted,  there  will  never  be  the 
slightest  risk  of  wounding  the  saphena  vein : and, 
therefore,  I do  not  consider  it  advisable  or  necessary, 
for  the  avoidance  of  this  accident,  to  make  the  wound 
precisely  upon  the  sartorius,  as  my  intelligent  friend 
Mr.  Hodgson  suggests ; a method  attended  with  the 
inconvenience  of  having  the  fibres  of  that  muscle  be- 
tween the  external  wound  and  the  artery,  and  perhaps 
inconsistent  with  the  excellent  directions  which  he  af- 
terward delivers  concerning  the  right  mode  of  per- 
forming the  external  incision,  when  he  says,  with 
Scarpa,  that  this  cut  should  be  “ continued  down  to 
the  fibres,  which  form  the  inner  margin  of  the  sarto- 
rius.”— (On,  the  Diseases  of  Arteries,  (Vc.  p.  436.) 

Now,  if  the  point  where  this  margin  first  lies  over 
the  artery  be  the  proper  place  for  the  lower  termina- 
tion of  the  external  incision,  we  shall  clearly  be  devi- 
ating from  the  precise  course  of  the  vessel  by  letting 
the  higher  portion  of  the  wound  be  over  the  fibres  of 
that  muscle.  And  when  it  is  farther  reflected,  that 
the  serious  evils  of  wounding  the  trunks  of  the  lym- 
phatics in  this  operation  are  not  demonstrated  in  mo- 
dern practice,  while  the  saphena  vein  may  always  be 
avoided  with  certainty  and  facility,  I cannot  admit, 
that  there  is  any  solid  reason  for  letting  the  situation 
and  direction  of  the  external  wound  be  determined  by 
such  apprehensions.  At  all  events,  for  the  motives 


above  explained,  it  should  be  a fixed  maxim  in  this 
operation  never  to  extend  the  wound  lower  than  the 
point  where  the  inner  margin  of  the  sartorius  crosses 
the  artery : and  then  all  detachment  and  displacement 
of  this  muscle  will  be  unnecessary,  and  every  embar- 
rassment which  might  proceed  from  its  interposition 
between  the  outer  wound  and  the  artery,  will  be  com- 
pletely avoided. 

With  the  view  of  preventing  injury  of  the  femoral 
vein,  Mr.  Cannichael  recommends  the  needle  to  be  in- 
troduced on  the  pubal  side  of  the  artery,  where  the 
vein  presents  itself  to  view,  and  can  be  most  easily 
avoided.  He  remarks,  that  the  only  part  of  the  thigh 
from  Poupart’s  ligament  to  the  tendon  of  the  triceps, 
in  which  the  femoral  vein  is  not  completely  covered  by 
the  artery,  lies  within  the  space  which  extends  from 
Poupart’s  ligament  to  the  point  where  the  artery  meets 
the  sartorius  muscle.  At  the  part  of  this  space  most 
distant  from  Poupart’s  ligament,  the  vein  begins  to 
disclose  itself  at  the  pubal  side  of  the  artery,  from  be- 
neath which  it  emerges  more  and  more  as  it  ascends. 
— (See  Trans.  S,-c.  of  the  Fellows,  4-c.  of  the  King's 
and  Queen's  College  of  Physicians,  Ireland,  vol.  2,  p. 
357.) 

The  skin  and  cellular  substance  are  to  be  divided  in  the 
situation  and  to  the  extent  above  specified,  down  to  the 
femoral  fascia,  under  which  the  artery  lies,  and  may  be 
felt  beating.  The  next  object,  therefore,  is,  to  divide 
the  fascia,  which  is  here  much  thinner  than  at  the 
outer  side  of  the  limb,  and  may  be  cut  with  another 
stroke  of  the  bistoury ; or  (what  is  safer,  with  the 
view  of  abstaining  from  all  chance  of  wounding  the 
artery),  a slight  cut  may  first  be  made  in  the  fascia, 
the  division  of  which  may  then  be  made  to  the  requisite 
extent  by  introducing  under  it  a grooved  director,  on 
which  the  farther  incision  may  be  made  with  perfect 
security.  Tlie  fascia  is  to  be  divided  in  the  direction 
of  the  external  wound  ; but  to  what  extent,  is  a point 
on  which  surgical  writers  differ,  and,  indeed,  they 
must  here  differ,  as  long  as  they  are  not  unanimous 
about  the  method  of  applying  the  ligature  round  the 
artery  ; because  if  it  be  intended  to  use  a broad  liga- 
ture, with  a cylindrical  piece  of  linen  interposed  be- 
tween it  and  the  artery,  or  especially  if  it  be  designed 
to  apply  two  ligatures  and  divide  the  vessel  in  the  in- 
terspace, more  of  the  artery  must  be  exposed,  and  of 
course  more  of  the  fascia  must  be  cut,  than  when  it  is 
simply  meant  to  surround  the  vessel  .with  a single 
small  ligature.  Such  operators  also  as  have  contracted 
the  pernicious  habit  of  insulating  the  artery  all  round 
sufficiently  far  to  let  them  thrust  their  fingers  under  it, 
will  likewise  require  an  extensive  opening  in  the  fascia. 
This  detachment  of  the  vessel  for  an  inch  or  more,  for 
the  purpose  of  placing  the  finger  under  it,  is  a mea- 
sure which  deserves  to  be  condemned  in  the  strongest 
terms,  as  it  is  the  very  thing  which  produces  some 
risk  of  injuring  the  saphena  vein,  and  has  a tendency 
to  bring  on  secondary  hemorrhage,  inasmuch  as  it  oc- 
casions unnecessary  handling,  stretching,  and  disturb- 
ance of  the  artery  and  surrounding  parts,  and  an  in- 
evitable division  of  the  vessels  by  which  the  arterial 
coats  are  supplied  with  blood. 

According  to  Mr.  Hodgson,  the  extent  of  the  cut  in 
the  fascia  should  be  about  an  inch;  for  he  wisely 
avoids  all  unnecessary  separation  of  the  artery  from 
its  surrounding  parts.  On  the  contrary,.^j^a,  who 
insulates  and  raises  the  vessel,  previously  tS^ying  it, 
insists  upon  the  prudence  of  cutting  the  fascia  the 
whole  length  of  the  external  wound  ; for,  says  he,  if 
this  practice  be  neglected,  it  most  frequently  happens, 
that  in  the  succeeding  inflammatory  stage,  the  bottom 
of  the  wound  swells  and  becomes  very  tense,  and  the 
matter  which  is  formed  under  the  fascia,  not  finding  a 
ready  exit,  occasions  abscesses  which  seriously  retard 
the  cure.  Btit  Scarpa,  instead  of  planning  a method  of 
relieving  the  consequences,  might  have  employed  him 
self  more  to  the  purpose  in  considering  how  they  were  to 
be  prevented,  and  why  in  his  method  they  most  fre- 
quently happen.  Now,  without  laying  any  stress  upon 
two  waxed  ligatures,  each  composed  of  six  threads, 
with  an  additional  extraneous  substance,  viz.  a roll  of 
linen,  in  the  noose,  we  should  be  more  surprised  to 
hear  that  the  wound  after  his  method  did  not  become 
affected  with  swelling,  tension,  and  suppuration,  than 
that  these  were  the  usual  effects.  After  describing 
the  division  of  the  fascia,  he  observes : “ IVith  the 
point  of  the  fore-finger  of  the  left  hand,  already  touch- 


ANEURISM. 


ing  the  femoral  artery,  the  surgeon  will  separate  it 
from  the  cellular  substance,  which  ties  it  laterally  and 
posteriorly  to  the  contiguous  muscles ; and  making 
the  point  of  the  same  finger  pass  gradually  uyider 
and  behind  the  femoral  artery  (supposing  the  sur- 
geon has  not  enormously  large  fingers),  he  will  raise 
it  alone  from  the  bottom  of  the  wound,  or  (when  it 
cannot  be  avoided)  along  with  the  femoral  vein.  If 
it  is  along  with  the  femoral  vein,  the  surgeon,  hold- 
ing the  artery  and  vein  thus  raised,  and  almost  out  of 
the  wound,  will  cautiously  sejmrate  the  vein  from  the 
artery  with  a bistoury  or  spatula,  or  simply  with  his 
fingers,"  &c.— (See  Scarpa  on  Aneurism,  p.  280, 
ed.  2.) 

\Vhen  we  combine  the  irritation  and  mischief  of  all 
this  work  with  the  ill  effects  of  filling  the  bottom  of 
the  wound  with  soft  lint,  I would  ask,  what  more  cer- 
tain plan  could  Scarpa  or  any  other  person  have  sug- 
gested for  bringing  on  the  unpleasant  state  of  the 
wound  which  he  describes  as  most  frequently  tak- 
ing place  1 

I shall  suppose  the  fascia  has  now  been  divided,  un- 
der which  the  surgeon  distinctly  fe'els  the  pulsations 
of  the  femoral  artery,  whiclj  is  still  invested  by  the 
cellular  sheath.  The  femoral  vein  lies  directly  under 
this  vessel,  while  the  branches  of  the  anterior  crural 
nerve,  separated  from  it  by  dense  cellular  substance, 
are  more  externally,  yet  somewhat  more  deeply  situ- 
ated. The  next  object,  therefore,  is  to  pass  a single 
ligature  round  the  artery,  without  including,  or  in  any 
manner  meddling  with,  the  subjacent  femoral  vein,  or 
detaching  and  disturbing  the  artery.  For  this  purpose 
the  best  direction  is  that  given  by  my  friend  Mr.  Law- 
rence, especially  when  combined  with  Mr.  Carmi- 
chael’s plan  of  letting  the  needle  be  introduced  on  the 
pubal  side  of  the  artery : “ after  dissecting  down  to 
the  artery,  a slight  scratch  or  incision  may  be  made 
through  the  sheath,  close  to  the  side  of  the  vessel. 
Then,  with  a narrow  aneurism-needle,  nearly  pointed 
at  the  end,  and  made  as  thin  at  its  edge  as  it  can  be 
without  cutting,  a single  silk  ligature  is  to  be  conveyed 
round  it,  the  point  of  the  needle  being  kept  in  contact 
with  the  artery.  A needle  of  this  form  makes  its  way 
easily  through  the  cellular  substance,  and  the  vessel 
is  detached  only  in  the  track  of  the  instrument.” — (See 
Med.  Chir.  Trans,  vol.  6.) 

Of  the  kind  of  ligature  to  be  emploj'ed,  I need  only 
say  here,  that,  it  should  be  a single  one  composed  of 
firm  materials,  in  order  to  avoid  the  necessity  for  in- 
creasing its  diameter  more  than  would  be  desirable  for 
reasons  elsewhere  considered. — (See  Hemorrhage  and 
Ligature.)  The  ligature  having  been  put  under  the 
artery,  one  end  of  it  is  to  be  drawn  completely  through 
the  track  made  for  it  by  the  needle,  which  instrument 
is  then  to  be  taken  away,  leaving  the  ligature  under 
the  vessel.  The  ligature  is  now  to  be  tied  in  a steady, 
firm  manner,  but  without  any  immoderate  force,  which 
can  never  be  necessary  even  for  the  division  of  the  in- 
ner coats  of  the  vessel.  In  this  part  of  the  operation, 
a few  practitioners  give  the  preference  to  what  is 
termed  the  surgeon's  knot ; and  commend  this  plan  of 
fastening  the  ligature ; a plan  which  consists  in  put- 
ting the  end  of  the  cord  twice  through  the  noose,  be- 
fore the  constriction  is  made.  The  only  good  of  the 
surgeon’s  knot  is,  that  it  does  not  so  readily  slip  and 
loosen  agjLcsmmon  one ; but  Scarpa  thinks  a simple 
knot  best,  as  it  does  not,  like  the  other,  prevent  the  sur- 
geon from  calculating  the  force  with  winch  the  artery 
is  constricted. — (On  Aneurism,  p.  281,  ed.  2.)  And 
besides  this  reason  against  the  surgeon’s  knot,  another 
objection  to  it  is  the  irregularity  with  which  a ligature 
in  this  form  will  lie  round  the  vessel.  A simjde  noose 
should  therefore  be  finst  made  and  tightened,  and  then  a 
second  one,  so  as  to  form  a common  knot ; and  now, 
as  a matter  of  precaution  against  the  possibility  of  the 
ligature  slipping  and  becoming  loose,  the  surgeon,  if  he 
pleases,  can  tie  the  knot  once  again.  One  end  of  the 
ligature  is  next  to  be  cut  off  near  the  knot ; and  the 
sides  of  Ihc  wound  are  to  be  brought  together  with 
strips  of  adhesive  plaster,  the  irritation  of  sutures  be- 
ing carefully  avoided.  The  remaining  end  of  the  liga- 
ture should  always  be  brought  out  at  the  nearest  point 
of  the  external  wound  to  the  knot  on  the  artery. 

The  effects  which  in  general  immediately  follow  the 
operation  are,  a total  cessation  of  the  pulsation  of  the 
aneurismal  tumour ; a manifest  sinking  and  flaccidity 
ol’  tlie  swelling ; a diminution  of  pain  in  the  seat  of 


the  disease  : and  a strong  vibration  of  the  articular  ar 
teries  round  the  knee.  As  Mr.  Hodgson  has  remarked, 
the  unusual  influx  of  blood  into  the  minute  ramifica- 
tions, when  a main  artery  is  suddenly  rendered  imper- 
vious, is  generally  attended  with  a remarkable  increase 
in  the  temperature  of  the  limb.  After  tying  the  femo- 
ral artery  for  the  cure  of  popliteal  aneurism,  the  same 
phenomenon  occurs,  at  least  after  a short  time,  during 
which  the  temperature  of  the  leg  and  foot  frequently 
coiitinues  lower  than  that  of  the  sound  limb.  But  in 
a few  hours  it  generally  rises,  and  is  sometimes  seve- 
ral degrees  higher  than  that  of  the  opposite  member. 
This  state  lasts  several  days,  at  the  end  of  which  time, 
the  heat  of  the  limb  which  has  been  operated  upon 
will  be  found  to  be  about  the  same  as  that  of  other 
parts  of  the  body. — (Hodgson  on  Diseases  of  Arteries, 
&,  c.  p.  256.)  It  is  only  while  the  limb  is  colder  than 
natural,  that  it  ought  ever  to  be  fomented  or  covered 
with  flannel.  In  particular  examples,  there  is  no  in- 
crease of  temperature  in  the  limb,  at  any  period  after 
the  operation ; a fact  which  Mr.  Hodgson  refers  to  the 
probability  of  a collateral  circulation  having  already 
been  established,  in  consequence  of  the  obstruction  to 
the  passage  of  the  blood  through  the  main  artery  by 
the  accumulation  of  the  coagulum  in  the  aneurismal 
sac.  Of  course,  unless  a collateral  circulation  be  es- 
tablished, the  operation  cannot  succeed,  as  the  limb 
will  mortify ; it  behooves  us,  therefore,  to  be  aware  of 
the  circumstances  which  may  prevent  the  due  transmis- 
sion of  the  blood  to  the  inferior  part  of  the  limb.  These 
are  ably  explained  and  commented  upon  in  Mr.  Hodg- 
son’s work  : 1st,  An  extensive  transverse  wound,  by 
which  the  principal  anastomosing  branches  are  divided. 
2dly,  Tight  bandages  and  pressure  operating  so  as  to 
obstruct  the  same  vessels.  3dly,  The  immense  bulk  of 
the  tumour,  and  the  pressure  upon  the  principal  colla- 
teral arteries.  4thly,  Calculous  depositions  in  the  coats 
of  the  arteries  of  the  limb.  5thly,  Advanced  age. 
6thly,  A languid  state  of  the  circulation ; a fact  indi- 
cating the  wrongness  of  venesection,  as  a general 
practice  after  the  operation,  though  it  may  yet  be 
right  to  adopt  this  treatment,  where  the  pulsations  re- 
turn in  the  tumour  with  unusual  strength,  and  appear 
to  stop  the  diminution  of  the  swelling,  as  already  men- 
tioned. 7thly,  The  abstraction  of  heat  from  the  limb 
by  cold  evaporating  lotions ; a plan  which  can  only  be 
right  when  there  is  a great  increase  of  heat  in  the 
limb,  a tendency  to  inflanunation, ora  return  of  strong 
pulsations  in  the  tumour. 

Sir  Astley  Cooper  saw  a case,  in  which  the  application 
of  whitewash  occasioned  mortification  and  the  patient’s 
death.  In  cold  weather,  he  always  covers  the  limb 
with  flannel  or  a stocking,  and  sometimes  puts  jars  filled 
with  hot  water  to  the  feet.— (See  Lancet,  vol.  2,  p.  42.) 

When  the  operation  is  done  according  to  the  princi- 
ples laid  down  in  this  article,  the  patient  is  not  too  old, 
nor  enfeebled,  and  the  after-treatment  is  properly  con- 
ducted, mortification  cannot  now  be  said  to  be  a fre- 
quent event.  In  one  case,  operated  upon  by  Sir  Astley 
Cooper  in  1823,  the  whole  of  the  foot  and  part  of  the 
leg  mortified ; but  it  should  be  noticed,  that  in  this  in- 
stance the  whole  limb  was  extremely  swollen  previ- 
ously to  the  artery,  being  taken  up.— (See  Lancet,  vol. 
1,  p.  436.)  In  all  his  extensive  practice,  he  has  seen 
but  three  or  four  instances  of  a failure  of  the  operation 
from  gangrene. -(Lectures,  S.  c.  vol.  2,  p.  60.)  Mr.  Liston 
has  related  one  example  which  he  ascribed  to  the  impro  • 
per  use  of  fomentations  with  hot  salt  water. — (See 
Edinb.  Med.  Jorum.  No.  90,  p.  3.)  As,  however,  the 
patient  seems  to  have  been  of  a very  phlogistic  diathe- 
sis, and  to  have  been  attacked  with  inflammation  of 
other  parts,  the  reality  of  the  alleged  cause  appears  ques- 
tionable. I have  seen  but  one  example  of  gangrene, 
and  in  that,  only  one  toe,  and  a portion  of  the  skin  of  the 
instep,  sloughed  in  a very  debilitated  subject.  This 
partial  gangrene  of  the  foot  has  been  particularly  no- 
ticed by  Deschamps  and  Scarpa,  the  latter  of  whom 
regards  it  as  an  unusual  thing,  only  likely  to  happen  in 
old,  weak,  or  unhealthy  subjects  ; and  “ at  any  rate 
(says  he)  if  this  should  happen  in  any  of  these  ener- 
vated individuals,  the  patients  may  console  theinselves 
for  the  loss  of  one  or  two  of  their  toes,  with  the  cure  of 
a popliteal  aneurism,  and  the  avoidance  of  a painftil  and 
dangerous  incision  in  the  ham,  and  of  the  tedious  sup- 
puration which  would  have  followed  it.” 

Sir  Ast.  Cooper  has  known  retention  of  urine  brought 
on  by  the  ojjerution  in  one  cr  two  examples,  and  the  use 


ANEURISM. 


m 


of  the'catheter  indispensable.— (Lecfiires,  ^c.  vol.  2,  p. 
58.)  Mr.  C.  Bell  met  with  a case  in  which  the  femoral 
artery  divided  below  the  profunda  into  two  equal 
branches,  the  most  superficial  of  which  was  alone 
noticed  and  tied  in  the  operation.  The  patient  died  of 
constitutional  disturbance,  arising  from  inflammation 
in  the  whole  course  of  the  sartorius.  After  two  or 
three  days,  the  pulsation  of  the  tumour,  which  had  been 
very  strong,  ceased,  in  consequence  of  the  coagulation  of 
the  blood  within  the  sac ; another  fact,  exemplifying 
that  this  desirable  change  will  not  be  prevented  by  a 
current  of  blood  being  still  propelled  through  theaneu- 
rismal  cavity.— (See  Quarterly  Joum.  vol.  3,  p.  607.) 

Mr.  Liston  has  recorded  a case,  in  which  the  pulsa- 
sation  and  tumour  returned  several  months  after  the 
operation.  “ On  consulting  with  Dr.  Thomson,  it  was 
agreed  to  try  the  effect  of  methodical  bandaging,  from  the 
points  of  the  toes  upwards,  and  a compress  over  the  j 
tumour,  with  rest,  cold  applications,  and  moderate 
diet.”  These  means  had  the  desired  effect ; and  the 
patient  did  not  complain  much  of  those  pains  which  so 
frequently  remain  after  the  operation  for  aneurism. 

According  to  Mr.  Liston,  these  pains  are  in  general 
distinctly  referable  to  the  sacro-ischiatic  nerve  and  its 
branches,  and  are  explained  by  the  state  of  the  ves- 
sels in  the  substance  of  the  nerve.  In  the  natural 
state  the  neurilemal  vessels,  when  injected,  are  not 
larger  than  sewing  threads  : but  when  the  enlargement 
of  the  collateral  branches  is  requisite,  owing  to  the  ob- 
struction of  the  trunk,  they  also  are  called  on  to  con- 
tribute their  share  in  the  new  circulation ; and  they 
become  enormously  distended.  In  one  remarkable 
specimen,  in  which  the  limb  was  injected  and  exa- 
mined fifteen  years  after  the  superficial  femoral  atery 
had  been  secured  for  aneurism  in  the  ham,  the  vessels  in 
the  sacro-ischiatic  nerve  had  attained  the  size  of  crow- 
quills,  and  were  convoluted  in  an  extraordinary  man- 
ner. The  pains  in  the  limb,  noticed  by  Mr.  Liston  as 
occurring  after  the  operation,  he  acknowledges,  how- 
ever, are  by  no  means  so  severe  as  those  experienced 
previously,  and  which  are  produced  by  the  compression 
and  stretching  of  the  nerves  by  the  sac. — {Edin.  Med. 
Journ.  No.  90,  p.  2.) 

WTien  the  operation  succeeds,  a considerable  portion 
of  the  artery  above  the  aneurismal  tumour  is  rendered 
impervious,  the  vessel  indeed  being  sometimes  con- 
verted into  a solid  cord  from  the  origin  of  the  profunda 
to  that  of  the  tibial  arteries. — (A.  Cooper,  Med.  Chir. 
Trans,  vol.  2,  p.  254.)  In  general,  however,  the  oblite- 
ration of  the  artery  is  less  extensive ; a fact  particularly 
noticed  in  one  of  Mr.  Hunter’s  cases  {Trans,  of  a Soc. 
for  the  Improvement  of  Med.  and  Chir.  Knowledge,  vol. 
1,  p.  153),  and  vaiidy  urged  by  Deschamps,  as  a proof 
of  the  insufficiency  of  the  new  method.— (See  Obser- 
vations et  inflexions  sur  la  Ligature  des  principales 
Attires  blesses,  et  particulierement  sur  VAneurisme  de 
VArtire  poplitie,  p.  76,  Paris,  1797.)  It  appears  from 
the  observations  of  Mr.  Hodgson,  that  the  artery  ge- 
nerally becomes  impervious,  for  the  space  of  three  or 
four  fingers’  breadth,  at  the  place  where  the  ligature 
is  applied ; below  whi<  h part  its  tube  is  unclosed,  and 
continties  so  for  some  distance,  when  the  obliteration 
again  commences,  and  descends  along  a considerable 
extent  of  the  popliteal  artery  to  the  origin  of  the  infe- 
rior articular,  or  tibial  arteries.  Thus,  says  this  author, 
uninsulated  portion  of  the  femoral  artery  preserves 
its  cavity,  from  each  extremity  of  which  considerable 
anastomosing  branches  arise  ; the  upper  branches  con- 
vey blood  into  the  vessel,  and  the  lower  transmit  it  into 
anastomosing  channels,  that  originate  below  the  knee. 
— {On  Diseases  of  Arteries,  Src.  p.  278.)  Now,  as  Mr. 
Hodgson  is  unacquainted  with  any  case,  except  that 
recorded  by  Sir  Astley  Cooper,  where,  after  the  mo- 
dern ojjeration,  the  artery  was  obliterated  from  the  seat 
of  disease  in  the  ham  to  the  part  at  which  the  ligature 
was  applied,  he  thinks  it  probable  that,  in  most  instan- 
ces, a double  collateral  circulation  exists  in  the  limb, 
after  this  method  of  cure. 

In  consequence  of  the  motion  of  the  blood  being  more 
or  less  impeded  in  the  aneurismal  sac  by  the  application 
of  the  ligature  to  the  femoral  artery,  the  aneurismal 
cavity  soon  becomes  completely  filled  with  coagula, 
which  even  block  up  the  adjoining  portion  of  the  arte- 
rial tube.  The  coagulated  blood  in  the  sac  is  afterward 
absorbed ; and  a gradual  diminution  and  final  dis- 
appearance of  the  aneurism  in  the  ham  ensue  ; with 
the  exception  of  a slight  induration,  which  sometimes 


remains,  composed  of  a remnant  of  the  sac  itself,  or  of 
the  fibrous  part  of  the  blood.  This  slight  hardness  in 
the  cavity  of  the  ham  Occasions  no  inconvenience,  and 
does  not  hinder  the  patient  from  performing  the  mo- 
tions of  the  knee  and  leg  with  quickness  and  safety. — 
{Scarpa,  p.  257,  edit.  2.) 

After  the  operation,  the  circulation  is  carried  on  prin- 
cipally by  the  arteria  profunda,  whose  branches  commu- 
nicate with  the  articular  arteries  of  the  poi)liteal,  and 
with  arteries  sent  to  the  knee  by  the  anterior  and  pos- 
terior tibial.  Large  branches  in  the  sciatic  nerve,  sent 
off  by  the  arteria  profunda,  communicate  very  freely 
with  the  popliteal  artery,  the  articular,  and  branches  of 
the  posterior  tibial.  As  Sir  Astley  Cooper  has  farther 
explained,  the  freedom  of  anastomosis  sometimes  leads 
to  a reproduction  of  an  aneurism.  The  femoral  artery 
was  tied  by  Mr.  Key,  and  the  patient,  after  being  dis- 
j charged  cured,  returned  with  a painful  tumour  in  the 
ham,  attended  with  an  obscure  pulsation.  The  limb 
was  amputated,  and  a large  artery,  passing  to  the  tu- 
mour, and  situated  nearly  in  the  usual  place  of  the  femo- 
ral, required  a ligature.— (Z/Cc^Mre.s,  Ac.  vol.  2,  p.  60.) 

When  the  advantages  of  the  foregoing  method  of 
operating  are  contrasted  with  the  dangers  and  seventy 
of  the  practice  of  laying  open  the  aneurismal  tumour, 
and  applying  ligatures  round  the  diseased  part  of  the 
vessel,  it  is  surprising  to  find  any  living  surgeons  still 
expressing  a preference  to  the  latter  mode  of  treatment 
under  any  circumstances  whatsoever.  Yet  Boyer, 
Roux,  and  a few  of  the  modern  French  surgeons,  are  in 
this  way  of  thinking,  which  reminds  me  of  their  slow- 
ness to  adopt,  at  every  opportunity,  union  by  the  first 
intention,  one  of  the  greatest  and  most  decided  advances 
to  perfection  ever  made  in  the  practice  of  surgery.  The 
severity  and  difficulties  of  the  old  method  of  operating, 
in  cases  of  politeal  aneurism,  are  most  faithfully  de- 
picted by  Scarpa.  In  the  ham,  says  he,  the  artery  lies 
very  deep.  The  space  is  limited  and  narrow,  within 
which  it  can  be  brought  into  view  and  tied,  without  risk 
of  tying  along  with  it,  or  of  destroying,  some  of  the 
principal  anastomoses  formed  by  the  articular  arteries 
of  the  knee.  On  account  of  the  depth  of  the  artery,  it  is 
difficult  to  pass  any  instrument  round  it,  vrithout  inclu- 
ding other  parts ; and  it  is  no  less  difficult  to  draw  the 
ligature  on  the  vessel  with  a proper  degree  of  tightness. 
Scarpa  then  comments  on  the  disadvantages  of  tying  the 
lacerated,  diseased  part  of  the  vessel,  which  is  some- 
times so  high  up,  that,  in  order  to  apply  the  ligature 
above  it,  it  is  necessary  to  cut  through  the  long  head  of 
the  triceps,  and  make  a passage  through  into  the  thigh. 
Or,  the  diseased  or  lacerated  part  of  the  artery  is  situa- 
ted so  low  down  in  the  calf  of  the  leg,  that  it  is  impos- 
sible to  avoid  including,  either  in  the  incisftn  or  the 
ligature,  the  lower  anastomosing  articular  arteries, 
on  the  preservation  of  which  the  circulation  and  life 
of  the  subjacent  part  of  the  limb  in  a great  measure 
depend.  We  must  add  to  all  this  the  violence  unavoid- 
ably done  to  the  great  sciatic  nerve,  which  an  assistant 
must  hold  drawn  to  one  side  of  the  wound  nearly  the 
whole  time  of  the  operation.  The  proceeding  is  also 
liable  to  other  great  difficulties,  as  may  be  seen  from  a 
case  reported  by  Masotti  {Dis.  sul  Aneurysma,  p.  54), 
where  the  popliteal  artery  was  so  firmly  united,  and,  as 
it  where,  confused  with  the  vein,  the  nerve,  the  tendons 
of  the  neighbouring  muscles,  and  the  periosteum,  that 
the  cavity  of  the  ham  presented  the  appearance  of  an 
intricate  mass  of  parts,  not  easily  separable  from  one  an- 
other. Lastly,  the  operation  leaves  a large  deep  wound, 
laying  open  the  whole  cavity  of  the  ham,  and  followed 
by  copious  suppuration,  sinuses  and  necrosis  of  the  heads 
of  the  femur  and  tibia.  If  the  patient  be  not  hurried  into 
the  grave  by  these  affections,  and  even  if  the  parts  in  the 
ham  heal,  he  is  almost  always  left  with  an  incurable 
contraction  of  his  knee,  and  perpetual  lameness.  Thus, 
Masotti  {Op.  cit.  p.  17)  relates  one  case,  where  the 
subsequent  effect  caused  such  destruction  of  the  soft 
parts  in  the  ham,  that  not  a vestige  of  artery,  vein,  or 
sciatic  nerve  was  left,  and  the  patient  remained  all  the 
rest  of  his  life  with  a paralytic  leg,  and  ulcers  and  fis- 
tul®  all  round  the  knee. — {Scarpa  on  Aneurism,  p.  251.) 

I shall  now  advert  to  a few  facts  in  the  history  of 
surgery,  which  eventually  led  to  the  bold  atid  success- 
ful operations  adopted  in  modern  times  for  the  cure  of 
aneurisms  of  the  femoral  and  popliteal  arteries  The 
earliest  case  of  which  the  particulars  are  recorded, 
amounting  to  df  satisfactory  proof  that  the  lower  ex- 
tremity might  be  duly  sujjplied  with  blood,  notwith- 


1S4 


ANEURISM. 


standing  the  femoral  artery  had  been  tied  mgn  [up  in 
the  thigh,  is  the  example  related  by  M.  A.  Severinus 
of  a false  aneurism  of  the  thigh,  about  eight  fingers’ 
breadth  below  the  groin,  caused  by  a musket-ball  wound. 
In  this  instance,  Severinus  tied  the  femoral  arterj’  above 
and  below  the  aperture  in  it,  and  not  only  was  the  pa- 
tient’s life  saved,  but  the  use  of  the  limb  also  preserved. 
— {Chirurgia  Ejficacis,  p.  2,  Enarratoria.)  The  next 
authentic  case  of  the  ligature  of  the  femoral  artery,  is 
that  reported  by  Saviard,  where  Bottentuit,  in  1688,  tied 
this  artery  on  account  of  a false  aneurism,  the  result 
of  a sword-wound,  at  the  inner  and  upper  part  of  the 
thigh.  The  surgeons  called  into  consultation  were 
immediately  convinced,  that  the  only  thing  to  be  done 
was  to  take  up  the  femoral  artery ; but  they  were  fear- 
Ail  lest  the  patient  should  perish  of  bleeding  ere  the 
opening  in  the  vessel  could  be  found ; and  in  case  the 
artery  were  secured,  they  apprehended  the  obstruction 
of  the  circulation  would  be  followed  by  mortification 
of  the  limb.  The  patient  was  therefore  first  prepared 
for  his  fate  by  the  administration  of  the  sacrament.  A 
band  was  then  applied  round  the  upper  part  of  the 
limb,  and  tightened  by  means  of  a stick  with  which  it 
was  twisted,  a piece  of  pasteboard  being  put  under  the 
knot,  in  order  to  render  the  constriction  less  painful. 
The  tumour  was  then  opened,  the  clotted  blood  ex- 
tracted, and  the  opening  in  the  artery  detected  by 
slackening  the  tourniquet.  A curved  needle,  armed 
with  a double  ligature,  was  then  introduced  under  the 
femoral  artery,  and  one  of  the  cords  was  tied  above, 
and  the  other  below  the  wound  in  the  vessel.  Then 
follows  a curious  passage,  showing  the  operator’s  judg- 
ment at  that  time,  respecting  the  impropriety  of  inter- 
posing any  cylinder  of  linen  between  the  knot  of  the 
ligature  and  the  artery,  as  some  of  the  old  surgeons  at 
that  time  used  to  do,  as  well  as  a few  of  the  moderns. 
“ On  ne  mit  point  de  petites  compresses  sur  le  corps 
de  Vartere  au-dessus  du  noeiul,  comme  font  quelques 
uns,  parceque  Von  jugea  qu'il  etoit  d'une  grande  con- 
sequence de  Her  tres-etroitement  une  drtere  si  consi- 
derable, ce  que  Von  n'auroit  pas  eti  sur  de  faire  en 
interposant  la  petite  compresse,”  &c.  For  greater  secu- 
rity, assistants  who  relieved  each  other  in  turn  kept 
ap  constant  pressure  on  the  tied  part  of  the  vessel  for 
twenty-four  hours.  In  six  weeks,  the  patient  recover- 
ed, and  afterward  enjoyed  such  good  health  that  he 
went  through  several  campaigns. — {Saviard,  Nouveau 
Recueild' Observations  Chir.  Obs.  63, 12mo.  Paris,  1702.) 

Now,  with  respect  to  these  two  cases,  it  merits  atten- 
tion, that  though  Heister,  Morgagni,  and  others,  en- 
deavoured to  explain  the  success,  by  supposing  that 
each  of  the  patients  in  question  must  have  had  two 
iemoral  arteries,  both  Severinus  and  Saviard  were  wise 
enough  to  avoid  making  any  such  erroneous  inference 
themselves.  At  a later  period,  Guattani  laid  bare  the 
femoral  artery,  as  it  passed  under  Poupart’s  ligament, 
■compressed  it  against  the  ramus  of  the  pubes,  by 
means  of  graduated  compresses  retained  with  a firm 
roller,  and  thus  obtained  the  speedy  obliteration  of  the 
vessel,  and  cured  the  aneurism,  which  had  been  first 
injudiciously  opened. — {De  Extemus  Aneurismatibus, 
Hist.  15,  4«o.  Romce,  1772.)  In  the  same  book  is  given 
the  case  of  an  inguinal  aneurism,  which,  when  it  had 
continued  three  months,  and  become  equal  in  size  to  a 
large  fist,  was  attacked  with  gangrene,  whereby  the 
nneurismal  sac  was  quickly  destroyed,  and  the  femoral 
artery  was  obliterated  for  a considerable  extent  from 
the  crural  arch  downwards.  The  sloughs  were  tlirown 
off,  however,  and  the  ulcer  had  in  a great  measure 
healed,  when  the  patient  fell  a victim  to  debility. — 
(Hist.  17.)  Here  it  is  to  be  remarked,  that  during  the 
jfive  weeks  this  man  lived  after  the  obliteration  of  the 
femoral  artery  above  the  origin  of  the  profunda,  not 
only  the  circulation  and  life  of  the  whole  limb  were 
preserved,  but  the  auxiliary  arteries,  coming  from 
within  the  pelvis,  proved  capable  of  limiting  the  progress 
of  the  mortification  of  the  parts  round  the  aneurism, 
and  of  commencing  the  healing  process  in  a manner 
which  raised  great  hopes  of  a cure.  A similar  fact  is 
also  recorded  by  Dr.  Clarke. — {Duncan's  Med.  Com- 
ment. vol.  3.) 

[In  cases  of  aneurism  in  the  thigh,  it  is  not  always 
practicable  to  decide  with  absolute  certainty  whether 
the  disease  is  situated  in  the  femoral  artery,  or  in  the 
profunda;  and  even  when  it  obviously  originates  with 
the  former,  the  latter  is  often  deeply  i^olved,  particu- 
larly when  the  disease  has  been  of  long  standing. 


Many  unsuccessful  cases  have  been  reported ; and  I 
know  of  one  which  has  failed  in  the  hands  of  a distin- 
guished surgeon,  the  aneurismal  tumour  still  remain- 
ing, although  the  femoral  artery  was  tied  above  the 
tumour.  In  this  case  the  disease  is  no  doubt  seated  in 
the  profunda. 

Many  surgical  WTiters  and  teachers  have  inculcated 
the  doctrine,  that  tvhen  the  aneurism  is  situated  in  the 
thigh,  the  ligature  must  always  be  applied  below  the 
bifurcation,  lest  the  circulation  of  the  limb  should  suf- 
fer. A distinguished  surgeon  of  Philadelphia,  prefer- 
red opening  the  sac  of  a femoral  aneurism,  and  apply- 
ing his  ligature  below  the  proftinda,  rather  than  ven- 
ture to  tie  the  artery  higher  up.  The  operation  failed, 
however,  and  the  tumour  still  remains.  That  such 
fears  are  wholly  groundless,  may  be  confidently  as- 
serted from  analogy,  furnished  as  we  are  with  the 
knowledge  that  the  innominata,  the  common  iliac,  and 
even  the  aorta  itself,  may  be  obliterated,  and  yet  the 
anastomosing  vessels  continue  the  circulation.  But 
Dr.  Whitridge,  an  accomplished  surgeon  of  Charles- 
ton, S.  C.,  has  afforded  a demonstration  in  a case  of 
aneurism  in  the  thigh  from  a gun-shot  wound,  in 
which  he  tied  the  femoral  artery  just  below  Poupart’s 
ligament,  and  of  course  above  the  point  at  which  the 
proftinda  goes  off.  This  case  has  been  completely  suc- 
cessful, and  the  patient  recovered  without  any  sensible 
interruption  in  the  circulation,  and  without  any  unto- 
ward symptom. 

The  cases  in  which  the  femoral  artery  divides  high 
up,  which  Professor  Godman  has  shown  are  by  no 
means  unfrequent,  may  account  for  the  occasional 
failures  of  this  operation,  and  should  not  be  lost  sight 
of  by  the  judicious  surgeon.  As  a general  rule,  how- 
ever, applicable  to  all  other  cases,  when  the  aneurism 
is  sittiated  immediately  below  the  bifurcation,  and  in 
the  vicinity  of  the  profunda,  it  is  safer,  and  also  better 
surgery,  to  apply  the  ligature  above.  The  action  of  the 
profunda  may  endanger  the  success  of  the  operation, 
and  the  most  profound  surgeon  may  sometimes  mis- 
take the  seat  of  the  disease. — Reese.] 

These  and  other  cases  which  might  be  quoted,  fur- 
nished ample  proof  of  the  efficiency  of  the  anasto- 
mosing vessels  in  the  support  of  the  limb,  though  the 
femoral  artery  had  been  tied,  or  obliterated  in  a very 
high  situation. 

Besides  these  facts,  surgeons  derived  every  encou- 
ragement to  attempt  the  cure  of  popliteal  aneurism,  by 
the  ligature  of  the  artery  above  the  tumour,  from  the 
elucidations  given  by  Winslow  and  Haller  concerning 
the  numberless  inosculations  which  exist  between  the 
upper  and  lower  articular  arteries.  Haller  even  drew 
the  conclusion,  that  if  the  course  of  the  blood  were  in- 
tercepted in  the  popliteal  artery,  between  the  origins 
of  the  two  orders  of  articular  branches,  such  anasto- 
moses would  suffice  for  carrying  on  the  circulation  in 
the  leg.  And  at  length,  Heister,  weighing  the  ana 
tomical  observations  of  Winslow  and  Haller,  and  the 
facts  recorded  by  Severinus  and  Saviard,  first  proposed 
applying  to  popliteal  aneurisms  an  operation,  which, 
with  the  exception  of  those  two  cases,  had  until  his 
time  been  restricted  chiefly  to  aneurisms  of  the  bra- 
cliial  artery. — {Dis.  de  Genuum  Structurd  eorumque 
Morhis.  Disp.  Chir.  Halleri,  t.  4.) 

It  was  in  Italy  that  the  earliest  operations  were  un- 
dertaken for  the  cure  of  popliteal  aneurisms,  by  Guat- 
tani, or  rather  by  a German  surgeon  named  Keysler, 
as  would  appear  from  a letter  written  by  Testa  to 
Cotunni. — (See  Pelletan,  Clinique  Chir.  t.  1.)  The 
success  obtained  by  those  surgeons  soon  led  others  to 
imitate  them,  and  by  degrees,  the  practice  of  tying  the 
femoral  artery  became  common  both  in  cases  of  aneu- 
rism and  wounds  ; and  from  the  observations  of  Heis- 
ter {Haller  Disp.  Chir.  t.  5),  Acrell  {Murray  de  Aneu- 
rysm. Femoris),  Leslie  {Edin.  Med.  Comment.),  Ham- 
ilton {B.  Bell's  Surgery,  vol.  1),  Burschall  {Med.  Obs. 
and  Inq.  vol.  3),  Leber  {Dehaen,  Ratio  Medendi,  t.  7), 
and  .Tussy  {Ancien  Joum.  de  Med.  t.  42),  if  was 
proved  beyond  the  shadow  of  a doubt,  that  the  circu- 
lation might  continue  in  the  limb  after  the  obliteration 
of  the  femoral  artery,  whether  such  obliteration  were 
effected  by  direct  pressure  or  the  ligature. 

The  exact  period  when  the  first  operation  of  laying 
open  the  tumour  and  tying  the  popliteal  artery  was 
performed  in  F.ngland,  is  not,  as  far  as  I know,  particu- 
larly specified.  However,  judging  from  the  observa- 
tions made  on  this  practice  in  the  writings  of  Fntt 


ANEURISM. 


(ftemarks  on  Palsy,  S,'C.  Svo.  Ixmd.  1779),  of  Wilmer 
(Cases  and  Remarks  in  Surgery,  8vo.  Lond.  1779),  of 
Kirkland  (Thoughts  on  Amputation,  8vo.  Lond.  1780), 
and  of  others,  it  is  clear  that  this  method  of  treatment 
had  been  often  done  in  this  country  earlier  than  the 
dates  of  those  works,  and  as  would  appear  with  little 
or  no  success.  The  earliest  attempt  of  this  kind  in 
FYance  was  made  by  Chopart  in  1781  (Rnux,  Nou~ 
veaux  Elimens  de  Mid.  Op^ratoire,  t.  1,  p.  556),  about 
five-and-tweuty  years  after  the  examples  set  by  Guat- 
tani  in  Italy;  but  Chopart  failed  in  his  endeavours  to 
repress  the  bleeding  from  the  exposed  cavity  of  the 
tumour,  and  was  therefore  obliged  to  amputate  the 
limb.  Subsequently  to  this  attempt,  the  operation  was 
undertaken  by  Pelletan  in  two  instances,  the  termina- 
tions of  which  were  successful : consequently,  this 
surgeon  may  be  regarded  as  entitled  to  the  honour  of 
having  proved  to  his  countrymen  the  possibility  of 
curing  the  popliteal  aneurism,  by  laying  open  the  tu- 
mour, and  securing  the  artery  in  the  ham. 

The  severity  and  frequent  ill  success  of  this  method 
of  operating  I have  already  noticed,  nor  shall  I repeat 
the  objections  to  it.  With  respect  to . the  Hunterian 
practice,  the  great  peculiarities  of  which  were  tying 
the  artery  at  some  distance  above  the  disease,  and  not 
opening  the  swelling  at  all,  Richerand  seems  offended 
that  Hunter’s  name  should  be  affixed  to  an  operation, 
which  he  conceives  was  in  reality  the  invention  of 
Guillemeau.  Here  we  observe,  ^Etius  again  puts  in  a 
prior  claim,  and  with  much  more  effect,  because  the 
method  of  which  he  speaks  truly  resembled  Mr.  Hun- 
ter’s, inasmuch  as  the  vessel  is  directed  to  be  tied  at 
some  distance  above  the  swelling,  while  Guillemeau 
only  tied  the  artery  close  above  the  disease,  and  opened 
the  swelling,  a serioits  deviation  from  the  Hunterian 
practice. 

Guillemeau,  a disciple  of  Ambrose  Par^,  having  to 
treat  an  aneurism  at  the  bend  of  the  arm,  the  conse- 
quence of  bleeding,  exposed  the  artery  above  the  tu- 
mour, tied  this  vessel,  then  opened  the  sac,  took  out 
the  coagulated  blood,  and  dressed  the  wound,  which 
healed  by  suppuration.  After  more  than  a century, 
Anel,  on  being  consulted  about  a similar  case,  tied  the 
artery  above  the  swelling,  which  was  left  to  kself. 
The  pulsation  ceased,  the  tumour  became  smaller,  and 
hard,  and  after  some  months  no  traces  of  the  disease 
were  perceptible. 

In  1785,  Desault  operated  in  the  same  manner  for  a 
popliteal  aneurism : the  swelling  diminished  by  one- 
half,  and  the  throbbings  ceased ; on  the  20th  day  it 
burst,  coagulated  blood  and  pus  were  discharged  in 
large  quantities,  and  the  wound,  after  continuing  a long 
time  fistulous,  at  length  healed.  Towards  the  end  of 
the  same  year,  says  Richerand,  Hunter  applied  the 
ligature  somewhat  differently  ; instead  of  placing  it 
close  to  the  swelling,  or  directly  above  it,  he  put  it  on 
the  inferior  part  of  the  femoral  artery. — (See  Nosogr. 
Chir.  t.  4,  p.  98,  99,  edit.  2.) 

Unquestionably,  Anel  did,  in  one  solitary  instance, 
tie  the  humeral  artery  immediately  above  an  aneurism 
at  the  bend  of  the  arm,  and  effected  a cure  without 
opening  the  swelling  (Suiti  de  la  Nouvetle  Mfthode 
dc  guerir  les  fstules  lachrymales,  p.  251,  Turin,  1714) ; 
but  he  did  not  think  of  applying  the  plan  to  the  femoral 
artery,  or  draw  the  attention  of  French  surgeons 
sufficiently  to  the  matter,  to  make  them  imitate  this 
operation ; on  the  contrary,  the  method  fell  into  obli- 
vion, and  was  never  repeated.  With  regard  to  De- 
sault’s operation,  said  to  have  been  done  in  an  earlier 
part  of  1785  than  Mr.  Hunter’s  first  operation,  it  is  only 
necessary  to  say,  that  Desault  tied  the  popliteal  artery 
it.self,  while  the  grand  object  in  Mr.  Hunter’s  method 
was  to  take  up  the  femoral  artery,  at  a distance  from 
the  disease,  and  that  it  is  this  last  mode  alone  which 
has  gained  such  approbation,  and  been  attended  with 
unparalleled  success. 

The  French  surgeons  have  not  practised  the  Hun- 
terian operation  \vith  the  same  degree  of  success  with 
which  it  is  now  perfonned  in  England,  and  conse- 
quently they  very  commonly  pursue  the  old  method  of 
opening  the  sac,  &c.  Even  Boyer  avers  his  relinqui.sh- 
ment  of  what  he  calls  Anel’s  plan. — (Traits  des  Mai. 
Chir.  t.  2,  p.  148.)  But  we  shall  not  be  surprised  at 
their  ill  success,  when  we  hear  that  they  neglect  the 
right  principles  on  which  ligatures  ought  to  be  applied 
to  arteries,  as  explained  by  Dr.  Jones  in  his  work  on 
hemorrhage.  Even  Baron  Dupuytren  adheres  to  the 


125 

use  of  ligatures  of  reserve ; and  Boyer  applies  four 
loose  ligatures  round  the  artery,  besides  two  tight  ones ; 
and  consequently,  a large  portion  of  the  vessel  lies 
separated  from  its  natural  connexions,  and  irritated  by 
these  e.xtraneous  substances.  Hunter’s  first  operation 
nearly  failed  also  on  account  of  so  many  ligatures, 
none  of  which  were  tightened  so  as  to  cut  through  the 
inner  coats  of  the  artery,  and  thus  promote  its  closure. 
—(See  Hemorrhage.)  With  reference  to  the  operation 
of  popliteal  aneurism,  Rosenmuller's  Chir.  Anat. 
Plates  deserve  to  be  consulted,  Part  3,  Tab.  8 iS*  9. 
Scarpa’s  and  Tiedemann’s  matchless  engravings,  and 
Haller’s  leones  should  likewise  be  examined. 

ANEURISMS  OF  THE  LEG,  FOOT,  FOREARM,  AND  HAND. 

Doubts  were  not  long  ago  entertained  respecting  the 
possibility  of  curing  an  aneurism  at  the  upper  part  of 
the  calf  of  the  leg  by  tying  the  femoral  artery  in  the 
middle  of  the  thigh. — (Instituto  di  Ital.  Scienze  ed 
Arti,  vol.  I, parte  2,  p.  266.)  The  author  here  referred 
to  was  led  by  this  uncertainty  to  have  recourse  in  one 
instance  to  the  severe  method  of  laying  open  the  tu- 
mour, in  order  to  get  at  the  vessel  lower  down.  On 
this  case,  Scarpa  makes  some  correct  reflections : the 
operator  (says  he)  assured  himself,  that,  on  compress- 
ing the  femoral  artery  at  the  upper  part  of  the 
thigh,  the  tumour  at  the  top  of  the  calf  ceased  to  pul- 
sate ; and  that,  when  the  compression  was  cooitinued 
for  some  time,  thv  swelling  partly  disappeared,  and 
became  softer.  It  ought  to  have  been  evident,  there- 
fore, that  the  aneurism  might  have  been  cured  by 
tying  the  trunk  of  the  femoral  artery,  as  described  in 
the  foregoing  section.  In  Scarpa’s  work  is  a case  in 
which  an  aneurism  at  the  bifurcation  of  the  popliteal 
artery  was  cured  by  the  ligature  of  the  femoral  artery, 
—(See  p.  451,  ed.  2.)  Mr.  Hodgson  has  seen  three  an- 
eurisms situated  at  the  commencement  of  the  tibial 
arteries,  cured  by  the  same  operation. — (On  Diseases 
of  Arteries,  drc.  p.  437.)  But,  as  Scarpa  remarks, 
though  the  Hunterian  operation  answers  in  the  cure 
of  aneurism  in  the  bend  of  the  arm,  and  at  ihe  upper 
part  of  the  calf  of  the  leg,  it  is  not  so  effectual  for 
aneurisms  situated  on  the  back  or  palm  of  the  hand,  or 
the  dorsum  or  sole  of  the  foot.  The  free  communi- 
cation which  the  ulnar  and  radial  arteries  keep  up 
with  each  other  in  the  hand,  and  the  tibial  arteries  have 
have  in  the  foot,  prevent  the  operation  from  succeeding 
whether  the  brachial  or  femoral  artery,  or  one  of  the  two 
large  arteries  of  the  forearm  or  leg,  be  tied.  In  proof 
of  this  statement,  Scarpa  cites  two  cases  of  aneurism 
seen  by  himself ; one  on  the  instep,  the  other  in  the 
sole  of  the  foot ; and  a third  case  of  the  same  dis- 
ease in  the  latter  situation  ; all  of  which  were  found 
to  be  incurable  by  the  ligature  of  the  anterior  tibial  artery. 
— (P.  311.)  He  thinks,  however,  that  the  operation  of 
tying  this  vessel  where  it  passes  over  the  dorsum  of  the 
foot  might  succeed,  if  aided  by  compression,  applied 
so  as  to  stop  the  current  through  the  other  main  chan- 
nel ; and  he  seems  to  approve  of  this  practice,  be- 
cause the  plan  of  tying  the  artery  above  and  below  the 
disease  (which  is  the  most  certain  means  of  cure) 
could  not  be  done,  without  extensive  incisions  in  the 
sole  of  the  foot.  In  an  aneurism  at  the  lower  part  of  the 
leg,  Mr.  Hodgson  judiciously  insists  upon  the  prudence 
of  tying  the  artery,  as  near  as  possible  to  the  tumour, 
because  the  recurrent  circulation  through  the  large 
inosculations  in  the  foot  might  still  cause  the  swelling 
to  enlarge,  in  consequence  of  the  blood  sent  into  the 
sac  from  the  lower  extremity  of  the  vessel,  passing 
through  the  aneurismal  cavity  into  branches  arising  from 
the  artery  between  the  aneurism  and  the  ligature. — (P. 
438.)  However,  in  one  case  of  aneurism  of  the  ante- 
rior tibial  artery,  Mr.  H.  Cline  applied  a ligature  just 
above  the  tumour  without  success,  and  Sir  Astley 
Cooper  expressly  recommends  making  an  incision  in  the 
sac,  and  applying  a ligature  both  above  and  below  the 
swcW'mg.— (Lectures,  S,-c.  vol.  2,  p.  63.)  When  an  aneu- 
rism arises  from  the  radial,  ulnar,  or  interrosseous  ar- 
teries near  the  elbow,  tying  the  brachial  will  suffice ; but 
if  the  disease  be  lower  down,  the  vessel  from  which  it 
proceeds  must  be  taken  up  near  the  swelling. — (Hodg- 
son, p.  393.)  A case,  strikingly  illustrative  of  this 
truth  is  recorded  by  Mr.Liston.  J.  M.  P.,  aged  19,  ap- 
plied to  him  on  the  28th  of  July,  on  account  of  an  an- 
eurism of  the  left  radial  artery,  about  the  middle  of  the 
forearm,  occasioned  by  a wound.  The  tumour  was  as 
Inrce  as  a walnut,  and  so  compressible,  that  it  could 


126 


ANEURISM. 


easily  be  made  to  disappear.  Pressure  was  tried  at 
first,  with  apparent  benefit ; but  as  it  did  not  succeed, 
the  humeral  artery  was  tied  on  the  8th  of  August,  and 
with  the  efifect  of  completely  removing  the  tumour. 
On  the  eighteenth  day  afterward,  however,  a small 
slough  was  detached  from  the  cicatrix,  and  about  three 
o’clock  next  morning,  a violent  hemorrhage  took  place. 
Mr.  Liston  then  deemed  it  necessary  to  lay  open  the 
sac,  and  tie  the  artery  above  and  below  the  wound  in 
it. — (See  Edinh.  Med.  Joum.  No,  90,  p.  4.) 

Scarpa  mentions  a case,  where  the  dorsal  artery  of 
the  thumb  was  wounded ; but  as  the  hemorrhage  re- 
turned several  times,  and  pressure  failed  in  suppress- 
ing it,  the  surgeon  took  up  the  radial  artery  at  the 
wrist.  After  cutting  off  this  direct  current  of  blood 
towards  the  injured  vessel,  pressure  on  the  wound 
proved  effectual.  Three  months  afterward,  the  pa- 
tient having  died,  the  radial  artery  was  found  impervi- 
ous for  three  fingers’  breadth  below  where  the  ligature 
had  been  applied,  and  the  dorsal  artery  was  likewise 
obliterated  from  the  root  of  the  thumb  to  the  begin- 
ning of  the  palmar  arch. 

Mr.  Todd  has  published  a case  in  which  he  cured  a 
large  aneurismal  swelling  of  the  posterior  side  of  the 
forearm,  by  tying  the  brachial  artery.  From  the  de- 
scription, I conclude  that  the  disease  w^as  an  aneurism 
by  anastomosis,  as  it  is  termed ; but  the  particulars 
given  by  the  author  leave  us  in  doubt  on  this  point. — 
(See  Dublin  Hospital  Reports,  vol.  3,  p.  135.) 

The  manner  of  exposing  and  tying  the  principal  ar- 
teries of  the  leg  and  forearm,  will  be  described  under 
the  term  Arteries. 

OF  ANEURISMS  HIGH  UP  THE  FEMORAL  ARTERY. 

Several  facts  already  specified  in  the  preceding  co- 
lumns as  having  occurred  many  years  before  the  ope- 
ration of  tjdng  the  external  iliac  artery  was  attempted, 
amounted  to  a full  proof,  that  the  circulation  might  go 
on  in  the  lower  extremity  notwithstanding  the  artery 
in  the  groin  were  tied  or  obliterated.  On  this  point, 
some  of  Guatfani's  cases  were  most  decisive. 

The  ligature  of  the  external  iliac  artery,  for  aneu- 
risms of  the  femoral  artery  in  the  bend  of  the  groin, 
has  now  been  practised  so  frequently,  and  the  instances 
of  success  are  so  numerous,  that  all  doubt  concerning 
the  propriety  and  utility  of  the  attempt  has  entirely 
ceased.  The  French,  who  have  evinced  great  back- 
wardness in  espousing  the  Hunterian  method  of  ope- 
rating for  aneurisms,  though  it  is  decidedly  one  of  the 
greatest  improvements  in  modem  surgery,  have  also 
shown  great  reluctance  even  to  believe,  much  less  to 
practice,  the  operation  of  tying  the  external  iliac  artery. 
A Parisian  surgeon,  however,  who  was  in  London  a 
few  years  ago,  saw  the  thing  done,  and  the  eyes  of  his 
brethren  in  the  capital  of  France  have  since  been  a 
little  more  open.  Still,  as  Roux  remarks,  “ We  can- 
not but  blame  the  indiflTerence  with  which  the  opera- 
tion is  mentioned  in  some  of  the  latest  French  surgical 
publications.  At  this  moment  (1815)  we  can  reckon 
twenty-three  facts  relative  to  tying  the  external  iliac 
artery,  and  on  fifteen  of  the  patients  it  has  perfectly  suc- 
ceeded. In  these  twenty-three  operations,  I compre- 
hend the  two  which  Avere  done  in  France ; one  at 
Brest,  by  Delaporte,  and  the  other  at  Lyons,  by 
Bouchet ; cases,  the  authenticity  of  which  cannot  be 
doubted.  In  the  number  of  successful  cases,  is  to  be 
comprised  Bouchet’s  operation,  since  the  patient  lived 
more  than  a year  afterward,  and  then  died  of  the  con- 
sequences of  an  inguinal  aneurism  of  the  opposite 
side.  Of  the  other  twenty-one  operations,  fifteen  were 
performed  in  London  only,  in  the  several  hospitals  of 
this  metropolis,  by  Abernethy,  Ramsden,  A.  Cooper, 
Brodie,  and  Lawrence ; gentlemen  who  would  never 
publish  forged  cases. 

“ Sir  A.  Cooper  alone  had  tied  the  external  iliac  ar- 
ery  six  times  before  my  journey  to  London,  and  dur- 
ing my  stay  there.  I saw  him  perform  the  operation 
once.  Four  of  his  patients  were  entirely  well ; one 
of  the  three  others  died,  the  thirteenth  week  after  the 
operation,  of  the  bursting  of  an  aneurism  of  the  aorta. 
At  this  period,  the  circulation  in  the  limb  had  been  re- 
established. I saw  the  limb  after  it  had  been  injected 
among  Sir  A.  Cof^per's  anatomical  prejtarations.  Large 
and  beautiful  anastomoses  exist(!d  round  the  pelvis, 
bctw'een  the  dilated  branches  of  the  internal  iliac  and 
femoral  arteries.  With  respect  to  the  sixth  patient, 
the  leg  mortified,  and  the  thigh  was  amputated  with- 


out success.  The  seventh  died  of  hemorrhage,  which 
took  place  the  fourteenth  or  fifteenth  day  after  the  ope- 
ration.”-— {ParalUle  de  la  Chir.  Angloise  avec  la  Chir. 
Francoise,  p.  275,  276.)  Sir  Astley  Cooper  has  now 
tied  the  external  iliac  artery  in  nine  cases.— (See  Lan- 
cet, vol.  2,  p.  44.) 

The  many  facts  already  published,  exemplifying  the 
propriety  of  this  operation,  must  be  highly  gratifying 
to  Mr.  Abernethy,  by  whose  judgment  it  was  first  sug- 
gested, and  by  whose  enterprising  hand  it  was  first 
practised. 

Mr.  Abernethy  has  been  called  upon  in  several  cases 
to  take  up  the  external  iliac  artery,  and  they  all  prove 
that  the  anastomosing  vessels  were  fully  capable  of 
conveying  blood  enough  into  the  limb  below,  and  that 
a vessel  even  of  this  size  could  become  permanently 
closed  after  being  tied.  Three  of  the  operations  done 
by  this  gentleman,  I was  an  eye-witness  of,  and  it  is 
therefore  with  confidence  that  I can  speak  of  the  ease 
and  simplicity  of  the  requisite  measures  for  securing 
the  external  iliac  artery.— (See  Abemethy's  Surg.  and 
Physiol.  Essays ; and  Surgical  Observations,  1804 ; 
Edin.  Med.  and  Surg.  Journal  for  January,  1807  ) 

In  Mr.  Abemethy’s  first  operation,  performed  in  1796, 
an  incision,  about  three  inches  in  length,  was  made 
through  the  integuments  of  the  abdomen,  in  the  direc- 
tion of  the  artery,  and  thus  the  aponeurosis  of  the  ex- 
ternal oblique  muscle  was  laid  bare.  This  was  next 
divided  from  its  connexion  with  Poupart’s  ligament,  in 
the  direction  of  the  external  wound,  for  the  extent  of 
aliout  tw'o  inches.  The  margins  of  the  internal  ob- 
lique and  tran.sverse  muscles  being  thus  exposed,  Mr. 
Abernethy  introduced  his  fingers  beneath  them  to  pro- 
tect the  peritoneum,  and  then  divided  them.  Next  he 
pushed  this  membrane,  with  its  contents,  upw’ards  and 
inwards,  and  took  hold  of  the  external  iliac  artery  with 
his  finger  and  thumb.  It  now  only  remained  to  pass 
a ligature  round  the  arter>q  and  tie  it ; but  this  required 
caution,  on  account  of  the  contiguity  of  the  vein  to  the 
artery.  These  Mr.  A.  separated  with  his  fingers,  and 
introducing  a ligature  under  the  artery  Avith  a common 
surgical  needle,  tied  it  about  an  inch  and  a half  above 
Ppupart’s  ligament. — (Surg.  Essays.) 

'The  folloAving  was  the  method  which  Mr.  Aber- 
nethy adopted,  the  second  tune  of  tying  the  external 
iliac  artery. 

An  incision  three  inches  in  length  w^as  made  through 
the  integuments  of  the  abdomen,  beginning  a little 
above  Poupart’s  ligament,  and  extending  upwards ; it 
was  more  than  half  an  inch  on  the  outside  of  the  up- 
per part  of  the  abdominal  ring,  to  avoid  the  epigastric 
artery.  The  aponeurosis  of  the  external  oblique  mus- 
cle being  exposed,  was  next  divided  in  the  direction  of 
the  external  wound.  The  lower  part  of  the  internal 
oblique  muscle  w’as  thus  uncovered,  and  the  finger 
being  introduced  beloAv  the  inferior  margin  of  it  and 
of  the  transversalis  muscle,  they  AA'ere  &vided  with 
the  crooked  bistoury  for  about  one  inch  and  a half.  Mr. 
Abernethy  now  introduced  his  finger  beneath  the  bag 
of  the  peritoneum,  and  carried  it  upAvards  by  the  side 
of  the  psoas  muscle,  so  as  to  touch  the  artery  about 
two  inches  above  Peupart’s  ligament.  He  took  care 
to  disturb  the  peritoneum  as  little  as  possible,  detach- 
ing it  to  no  greater  extent  than  was  requisite  to  admit 
his  tAvo  fingers  to  touch  the  vessel.  The  pulsations 
of  the  artery  made  it  clearly  distinguishable,  but  Mr. 
Abernethy  could  not  put  his  finger  round  it  Avith  fa- 
cility. In  order  to  be  able  to  do  so,  he  was  obliged  to 
make  a slight  incision  on  each  side  of  it.  Mr.  A.  now 
dreAv  the  artery  gently  down,  so  as  to  see  it  behind  the 
peritoneum.  By  means  of  an  eye-probe,  two  ligatures 
were  conveyed  under  the  vessel ; one  of  these  Avas 
carried  upAvards  as  far  as  the  artery  had  been  detached, 
and  the  other  downwards ; they  were  finnly  tied,  and 
the  vessel  was  divided  in  the  interspace  between  them. 
— (Surg.  Observ.  1804.) 

In  a third  instance  of  tying  this  vessel,  Mr.  Aber- 
nethy operated  exactly  as  in  the  foregoing  case,  and  with 
comj)lete  success. — (See  Edin.  Surg.  Joum.  Jan.  1807.) 

Mr.  Freer,  of  Birmingham,  Avho  may  be  said  to 
claim  the  honour  of  having  seconded  Mr.  Abernethy 
in  this  neAV  practice,  made  an  incision  about  one  inch 
and  a half  from  the  spine  of  the  ileum,  beginning 
about  an  inch  above  it,  and  extending  it  doAvniAards 
about  three  inches  and  a half,  so  as  to  form  altogether 
an  incision  four  inches  and  a half  long,  extending  to  the 
ba.se  of  the  tumour.  The  tendon  of  the  external  ob- 


liquc  being  exposed,  was  carefully  opened,  and  also 
the  internal  oblique,  when  the  finger  being  introduced 
between  the  peritoneum  and  transversalis,  served  as  a 
director  for  the  crooked  bistoury,  which  divided  the 
muscle.  Avoiding  all  unnecessary  disturbance,  Mr. 
Freer  separated  the  peritoneum  with  his  finger,  till  he 
could  feel  the  artery  beating,  which  was  so  firmly 
bound  down,  that  he  could  not  get  his  finger  under  it 
without  dividing  its  fascia.  The  vessel  having  been 
separated  from  the  surrounding  parts,  a curved  blunt 
needle,  armed  with  a strong  ligature,  was  put  under  it, 
and  tied  very  tight,  with  the  intention  of.  dividing  the 
internal  coats  of  the  vessel.  The  operation  led  to  a 
perfect  enre.— {Freer  on  Aneurism,  1807.) 

Mr.  Tomlinson,  of  the  same  town,  was  also  an  early 
performer  of  the  operation : he  applied  only  one  liga- 
ture, and,  of  course,  left  the  artery  undivided : the 
event  was  attended  with  perfect  success. 

The  following  is  Sir  Astley  Cooper’s  mode  of  ope- 
rating as  described  by  Mr.  Hodgson  : — A semilunar  in- 
cision is  made  “ through  the  integuments  in  the  direction 
of  the  fibres  of  the  aponeurosis  of  the  external  oblique 
muscle.  One  extremity  of  tliis  incision  will  be  situated 
near  the  spine  of  the  ileum  : the  other  will  terminate  a 
little  above  the  inner  margin  of  the  abdominal  ring. 
The  aponeurosis  of  the  external  oblique  muscle  will  be 
exposed,  and  is  to  be  divided  throughout  the  extent  and 
in  the  direction  of  the  external  wound.  The  flap 
which  is  thus  formed  being  raised,  the  spermatic  cord 
wdl  be  seen  passing  under  the  margin  of  the  internal 
oblique  and  transverse  muscles.  The  opening  in  the 
fascia  which  lines  the  transverse  muscle  through  which 
the  spermatic  cord  passes,  is  situated  in  the  midspace 
between  the  anterior  superior  spine  of  the  ileum  and  the 
symphysis  pubis.  The  epigastric  artery  runs  precisely 
along  the  inner  margin  of  this  opening,  beneath  which 
the  external  iliac  artery  is  situated.  If  the  finger, 
therefore,  be  passed  under  the  spermatic  cord,  through 
this  opening  in  the  fascia,  it  will  come  into  immedi5,e 
contact  with  the  artery  which  lies  on  the  outside  of 
the  external  iliac  vein.  The  artery  and  vein  are  con- 
nected together  by  dense  cellular  membrane,  which  must 
be  separated  to  enable  the  ojjerator  to  pass  a ligature 
by  means  of  an  aneurism-needle  round  the  former.”— 
(On  Diseases  of  Arteries,  p.  421,  422.) 

The  foregoing  incision,  the  convexity  of  which  is 
turned  outwards  and  downwards,  extends  from  within 
and  a little  above  the  anterior  superior  spinous  process 
of  the  ileum,  to  above  and  a little  within  the  middle 
part  of  Poupart’s  ligament.  As  soon  as  the  tendon  of 
the  external  oblique  muscle  has  been  divided,  the  knife 
may  be  put  down,  and  the  internal  oblique  and  trans- 
verse muscles  raised  from  Poupart’s  ligament  by  intro- 
ducing the  finger  behind  them.  Care  must  be  taken  to 
avoid  the  epigastric  arterj^  which  runs  from  the  pubis 
side  of  the  external  iliac  to  the  inner  side  of  the  inci- 
sion. Baron  Dupuytren,  when  performing  the  opera- 
tion at  the  Hdtel-Dieu  in  Paris,  in  the  autumn  of  1621, 
wounded  the  epigastric  artery.— (See  Averill’s  Opera- 
tive Surgery,  p.  37.)  The  hemorrhage  was  so  copious 
that  two  ligatures  were  required.  The  patient  aller- 
w'ard  died  of  peritonitis,  which,  in  all  probability,  was 
brought  on  by  the  disturbance  of  the  parts  in  the  pro- 
ceethngs  requisite  for  securing  the  ends  of  the  wounded 
vessel.  The  external  iliac  vein  must  also  not  be  in- 
cluded in  the  ligature,  as  such  a proceeding  would 
cause  a dangerous  interruption  to  the  return  of  the 
blood.  Wlien  little  of  the  artery  is  exposed,  one  liga- 
ture will  suffice ; in  the  contrary  circumstance  it  is 
best  to  apply  two.— (See  Lancet,  vol.  2,  p.  44,  45.) 

Mr.  Nonnan,  of  Bath,  who  has  tried  both  modes  of 
operating,  found  that  proposed  by  Sir  A.  Cooper  a more 
easy  way  of  finding  the  external  iliac  artery  than  the 
longitudinal  incision  practised  by  Mr.  Abernethy.  “ The 
objection  (says  Mr.  Norman)  to  Sir  A.  Cooper’s  mode 
of  operating  in  cases  where  the  tumour  extends  high 
up,  is  by  no  means  well  founded;  for  the  lower  part  of 
the  bag  of  the  peritoneum  lying  on  the  edge  of  Pou- 
part’s ligament,  must  in  every  case  be  exposed  and  de- 
tached, in  order  to  get  at  the  artery  which  lies  behind  the 
pasterior  part  of  that  membrane,  and  this  is  most  easily 
effected  by  an  incision  in  the  direction  of  Poujiart’s 
ligament;  while  two-thirds  of  the  longitudinal  incision 
are  made  on  a i»art  of  the  peritoneum,  which  lines  the 
abdominal  muscles,  and  the  lower  portion  only  of  the 
incision  reaches  that  part  of  the  membrane  which  is 
kO  be  separated.  The  consequences  of  this  are,  that 


KISM.  J27 

the  peritoneum  is  in  much  greater  danger  of  being 
wounded,  and  that  the  probability  of  a hernia  forming 
after  the  cure  is  much  increased  by  the  extensive  divi- 
sion of  the  oblique  muscles.”— (See  Med.  Chir.  Trans, 
vol.  10,  p.  101.)  As  far  as  I am  able  to  judge,  these  re- 
marks are  well  founded,  and  they  coincide  with  some 
observations  which  were  made  some  years  ago  by  Roux, 
who,  wliile  he  inclined  to  Mr.  Abernethy’s  method,  saw 
the  disadvantage  of  letting  the  direction  of  the  wound 
in  this  instance  correspond  to  the  course  of  the  artery. 
Hence,  after  many  trials  on  the  dead  subject,  he  laid 
down  the  rule  that  the  beginning  of  the  wound  should 
never  be  farther  than  half  an  inch  from,  and  a very 
little  higher  than,  the  anterior  superior  spine  of  the 
ileum,  and  that  it  should  be  carried  very  obliquely  down- 
wards to  the  middle  of  Poupart’s  ligament. — (See  Nou- 
veaux  Elemens  de  Med.  Op.  t.  1,  p.  747,  d c.) 

Mr.  Todd,  also,  after  repeated  trials  of  Mr.  Aberne- 
thy’s and  Sir  Astley  Cooper’s  methods  on  the  dead  sub- 
ject, concluded  that  the  plan  recommended  by  the  lat- 
ter afforded  the  greatest  facility  of  applying  the  ligature 
to  the  artery,  because  more  room  was  obtained  by  it, 
and  with  less  disturbance  of  ( he  peritoneum,  than  in 
the  other  way.  Where,  however,  it  becomes  necessary 
to  apply  a ligature  to  a higher  part  of  the  artery,  in 
consequence  of  secondary  hemorrhage,  Mr.  Todd  con- 
ceives that  Mr.  Abernethy’s  method  should  be  adopted 
—(See  Dublin  Hospital  Reports,  vol.  3,  p.  92.) 

In  a case  operated  upon  by  Mr  Kirby,  a hernia  fol- 
lowed in  the  situation  where  the  abdominal  muscles 
had  been  divided. — (Sec  Cases  with  Observations,  p, 
109,  8vo.  Land.  1819.) 

In  one  case.  Dr.  Post  found  the  peritoneum  so 
thickened  and  diseased  that  he  could  not  raise  it  from 
the  subjacent  parts,  and  he  was  obliged  to  make  an 
opening  in  it.  The  jjrotruding  viscera  were  then  pushed 
back,  and  with  a needle  a ligature  was  introduced  un- 
der the  artery,  the  peritoneum  being  also  included  in 
the  ligature.  Notwithstanding  the  disadvantageous 
method  of  operating,  and  the  return  of  pulsation  in  the 
swelling,  the  patient  had  so  far  recovered  in  three 
months  that  he  had  regained  the  use  of  the  limb.— (See 
American  Med.  and  Phil.  Reg.  vol.  4,  p.  443.) 

In  one  remarkable  case,  Mr.  Newbiggin,  by  tying 
the  external  iliac  artery,  cured  both  an  inguinal  and  a 
popliteal  aneurism  together.— (See  Edin.  Med.  and 
Surg.  Journal,  for  Jan.  1816,  p.  71,  <^c.) 

The  many  operations  which  have  now  been  done  on 
the  external  iliac  artery  have  impressed  me  with  a con- 
viction that  in  subjects  under  a certain  age  there  is  no 
reason  to  fear  that  the  anastomoses  will  not  generally 
suffice  for  the  supply  of  the  lower  extremity.  Out  of 
twenty-five  cases  I only  know  of  three  in  which  the 
limb  was  attacked  with  gangrene.  These  three  were 
patients  of  Sir  A.  Cooper,  Bouchet  of  Lyons,  and  Mr, 
Collier.  The  proportion  is  not  so  much  as  one  in 
eight.  The  three  instances  cf  gangrene  were  not  all 
in  the  circumstances  which  permitted  the  event  to  be 
imputed  to  the  anastomoses  not  having  had  sufficient 
time  to  enlarge,  though  perhaps  Mr.  Collier’s  case  was 
such.  On  the  other  hand,  we  are  to  notice  that  Dr. 
Cole’s  patient  was  operated  upon  a few  days  after  the 
wound,  and  yet  the  limb  w'as  duly  supplied  with  blood, 
and  did  not  become  gangrenous.  It  appears,  therefore, 
to  me,  that  the  occasional  occurrence  of  gangrene  cannot 
be  admitted  as  a just  reason  for  delay,  until  the  collate- 
ral vessels  have  had  time  to  enlarge.  I believe  that  in 
all  aneurismal  diseases,  early  operating  is  the  best  and 
most  judicious  practice.  This  was  one  principal  cause, 
as  Kirkland  observes,  which  occasioned  the  bad  suc- 
cess of  the  old  surgeons  in  the  treatment  of  popliteal 
aneurisms,  and  he  foretold,  many  years  ago,  that  ope- 
rations for  the  cure  of  aneurisms  would  answer  bet- 
ter if  not  deferred  so  long  as  formerly.— (See  Thoughts 
on  Amputation,  iS’-c.  8vo.  Lmd.  1780.)  I join  Kirkland 
in  this  sentiment,  not  without  recollecting  that  all 
aneurisms  are  attended  with  a chance  of  getting  well 
spontaneously  in  the  course  of  time.  In  saw  the  in- 
guinal aneurism  which  did  so  under  Dr.  Albert  in  the 
York  Hosi)ital ; but  as  this  also  is  a rare  incident,  I do 
not  believe  that  it  ought  to  influence  us  against  liaving 
speedy  roeourse  to  an  operation.  Besides,  the  cure  by 
inflammation  and  sloughing  appears  to  me  to  be  at- 
tended in  reality  with  more  peril  than  a well-executed 
operation,  and  consequently  has  less  recommendations 
than  many  may  imagine.  Had  not  Dr.  Albert’s  patient 
been  a very  strong  man,  he  would  certainly  have  fallen 


128 


ANEURISM. 


6 victim  to  the  extensive  disease  which  the  bursting 
and  sloughing  of  the  tumour  created.  Thus  Dela- 
porte’s  patient  died  of  the  mass  of  disease  which  the 
tumour  itself  made ; for  it  had  been  suffered  to  attain 
too  large  a size,  so  that  when  it  inflamed  the  effects 
were  fatal.— (See  Richer  and,  Nosogr.  Chir.  t.  4,  p. 
113,  edit.  4.) 

I believe  Dr.  Wilmot’s  observation  is  perfectly  cor- 
rect, that  if  a comparison  were  made  between  the  ope- 
ration of  tjnng  the  external  iliac  artery  and  that  of  ty- 
ing the  artery  in  the  thigh,  we  should  find  the  reco- 
veries ^lfter  the  first  more  frequent  in  proportion  to  the 
number  of  times  it  has  been  done,  than  after  common 
operations  lower  down.* — (See  Dublin  Hospital  Rep. 
6rc.  vol.  2,  p.  214.) 

The  greatest  artery  that  conveys  blood  into  the  lower 
extremity,  after  the  external  iliac  has  been  tied,  is  the 
gluteal;  but,  besides  it,  the  ischiatic,  the  obturator, 
and  the  external  pudic,  which  anastomoses  freely  with 
the  internal  pudic,  are  important  vessels  in  keeping  up 
the  circulation. 

I subjoin  a list  of  some  of  the  successful  examples 
of  this  operation.  Mr.  Abemethy,  2 cases  (Surgical 
Works,  vol.  1 ) ; Freer  and  Tomlinson,  2 (Freer  on  Aneu- 
rism, 1807) ; Sir  A.  Cooper,  4 (Hodgson  on  Diseases  of 
Arteries,  p.  417);  Goo^ad,  1 (Edin.  Med.  and  Surg. 
Journ.  vol.  8,  p.  32) ; Brodie,  1 (Hodgson,  op.  cit.  p. 
419) ; Lawrence,  1 (Med.  Chir.  Trans,  vol.  6,  p.  205) ; 
J.  S.  Soden,  1 (Same  work,  vol.  7,  p.  536):  G.  Nor- 
man, 1 (Same  work,  vol.  10,  p.  95,  d c.) ; E.  Salmon,  1 
(Same  work,  vol,  12) ; Bouchet,  1 (Roux,  Med.  Ope- 
ratoire,  t.  1,  p.  744);  J.  S.  Dorsey,  1 (Elements  of 
Surgery,  vol.  2,  p.  180,  Philadelphia,  1813) ; Mouland, 
i (Bulletin  de  la  Faculte  de  Medecine  de  Paris,  t.  5, 
p.  535) ; Dupuytren,  1 (French  Transl.  of  Mr.  Hodg- 
son's work,  t.  2,  p.  215);  Dr.  Cole,  1 (Rapport  des 
Travaux  de  la  Societe  dl Emulation  de  la  Ville  de  Cam- 
brai,  1817,  or  Land.  Med.  Repository) ; Dr.  Wilmot,  1 
(Dublin  Hospital  Reports,  vol.  2,  p.  208,  &c.) ; Kirby, 
1 (Cases  with  Observatioois,  6,-c.  Suo.  Lond.  1819) ; Dr. 
Post,  1 (American  Med.  and  Philos.  Register,  vol.  4); 
Newbiggin,  1 (Edin.  Med.  and  Surg.  Joum.  Jan.  1, 
1816);  J.  C.  Warren,  1 (New-England  Journal,  or 
Anderson's  Quarterly  Journal,  vol.  1,  p.  136).  In  this 
ctise  the  epigastric  arterj’  arose  from  the  anterior  and 
inner  part  of  the  sac,  and  gave  origin  to  the  obttuutor, 
while  the  circumflex  ilii  originated  from  the  outer  part 
of  the  sac.  Ail  these  vessels  were  greatly  enlarged, 
and  the  epigastric  rendered  the  necessary  detachment 
of  the  external  iliac  troublesome. 

Some  particulars  of  the  case  of  ruptured  inguinal 
aneurism,  in  which  Sir  A.  Cooper  tied  the  aorta,  tvill 
be  hereafter  noticed.— (See  Aorta.) 

Rosenmuller’s  Chir.  Anat.,  Tiedemann’s  and  Scarpa’s 
Plates,  in  illtistration  of  the  operation  of  tj-ing  the  ex- 
ternal iliac  artery,  merit  notice. 

CASES  or  GLUTEAL  ANEURISM  CURED  BY  TYING  THE 
INTERNAL  ILIAC  ARTERY. 

Tne  gluteal  artery  is  large ; from  its  situation  liable 
to  wounds;  from  its  size  subject  to  aneurism.  Dr. 
Jeffray,  of  Glasgow,  was  consulted  in  a case  where 
the  gluteal  artery  had  been  wounded.  He  urged  the 
propriety  of  mng  the  vessel  where  it  had  been  in- 
jured. Tills  sensible  advice  was  at  first  rejected,  and 
when  the  friends  at  last  consented,  tbe  operation  was 
too  late,  as,  while  preparation  was  making  for  it,  the 
tumour  burst,  and  the  patient  expired  in  a few  moments. 

Thenden  also  mentions  an  instance  in  which  the 
gluteal  artery  was  wounded  in  the  dilatation  of  a gun- 
shot wound,  and  the  patient  lost  his  life. — (See  Scarpa 
on  Aneurism,  p.  407,  ed.  2.) 

Mr.  John  Bell,  how'ever,  tied  the  gluteal  artery  in  a 
case  where  it  was  wounded,  and  the  patient  was  saved. 

[The  late  Dr.  Cocke  and  Davidge,  professors  in  the 
University  of  Maryland,  tied  the  gluteal  artery  for  an 
aneurism  of  immense  size,  with  entire  success.  The 
patient  was  one  whose  gluteal  muscles  were  exceed- 
ingly large,  and  the  extent  and  boldness  of  the  incision 
rivalled  the  herculean  case  reported  by  Mr.  Bell.  It 
wall  presently  be  seen  that  even  when  the  extent  of 
the  disease  forbids  tliis  attempt,  the  ligature  of  the  in- 
ternal iliac  will  afford  a means  of  relief.— Jfeesc.] 

Mr.  Stevens,  surgeon  in  Santa  Cruz,  the  gentleman 


[*  Dr.  Mott  has  tied  the  external  iliac  four  times  with 
complete  success.— iJce5e.] 


who  has  proved  the  practicableness  of  putting  a liga- 
ture round  the  internal  iliac  artery,  informs  Us  that 
“one  of  the  first  surgeons  in  London  had  a patient 
with  gluteal  aneurism.  The  tumour  was  large;  al- 
low'ed  to  burst ; and  the  person  bled  to  death. 

“ I sincerely  trust,”  says  he,  “ that  the  following  case 
may  be  the  means  of  preventing  such  tm  occurrence 
in  future. 

“ Maila,  a negro  woman  from  the  Bambara  country 
in  Africa,  was  imported  as  a slave  into  the  West  In- 
dies in  the  year  1790.  She  was  purchased  for  the  es- 
tate of  Enfield  Green ; now  the  property  of  the  heirs 
of  P.  Ferrall,  Esq.  I saw  her  first  in  the  beginning 
of  December,  1812.  She  had  a tumour  on  the  left  hip, 
over  the  sciatic  notch.  It  was  nearly  as  large  as  a 
child’s  head,  and  pulsated  very  strongly.  She  could 
assign  no  cause  for  the  disease.  It  had  commenced, 
about  nine  months  before,  with  slight  ptiin  in  the  part ; 
and  had  gradually  increased  to  its  present  size.  She 
was  now  much  reduced,  in  great  misery,  and  ready  to 
submit  to  any  operation.— (See  Medico-Chir.  Trans, 
vol.  5,  p.  425.)  Mr.  Stevens  had  tied  the  internal  iliac 
on  the  dead  body,  and  believed  that  it  might  be  done 
with  safety  on  the  living.  The  following  is  some  ac- 
count of  the  operation : “ On  the  27th  of  December, 
1812  (says  Mr.  Stevens),  I tied  the  arteiy  in  the  pre- 
sence of  Dr.  Lang,  Dr.  Van  Brackle,  Mr.  Nelthropp, 
and  Mr.  Ford,  the  manager  of  the  estate.  An  incision, 
about  five  inches  in  length,  was  made  on  the  left  side, 
in  the  lower  and  lateral  part  of  the  abdomen,  parallel 
with  the  epigastric  artery,  and  nearly  half  an  inch  on  the 
outer  side  of  it.  The  skin,  the  superficial  fascia,  and  the 
three  thin  abdominal  muscles,  were  successively  di- 
vided; the  peritoneum  was  separated  from  its  loose 
connexion  with  the  iliacus  intemus  and  psoas  magnus ; 
it  was  then  turned  almost  directly  inw^ards,  in  a di- 
rection from  the  anterior  superior  spinous  process  of 
the  ileum,  to  the  division  of  the  common  iliac  arterj'. 
In  the  cavity  which  I had  now  made,  I felt  for  the  in- 
ternal iliac,  insinuated  the  point  of  my  fore-finger  be- 
hind it,  and  then  pressed  the  artery  between  my  finger 
and  thumb.  Dr.  Lang  now  felt  the  aneurism  behind ; 
the  pulsation  had  entirely  ceased,  and  the  rumour  was 
disappearing.  I examined  the  vessel  in  the  pelvis ; it 
w'as  healthy  and  free  from  its  neighbouring  connex- 
ions. I then  passed  a ligature  behind  the  artery  and 
tied  it  about  half  an  inch  from  its  origin.  The  tumour 
disappeared  almost  immediately  after  the  operation, 
and  the  w'ound  healed  kindly.  About  tbe  end  of  the 
third  w'eek  the  ligature  came  away,  and  in  six  weeks 
the  woman  was  perfectly  well. 

This  is  the  first  example  in  which  the  internal  iliac 
was  tied.  The  operation  was  not  attended  with  much 
difficulty  or  pain,  and  not  an  ounce  of  blood  was  lost. 

Mr.  Stevens  had  no  difficulty  in  avoiding  the  ureter, 
which,  when  the  peritoneum  was  turned  inwards,  fol- 
low'ed  it.  Had  it  remained  over  the  artery,  Mr.  Ste- 
vens saj's  that  he  could  easily  have  turned  it  aside 
with  his  finger. — (See  a particular  history  of  this  case 
in  Medico-Chirurg.  Trans,  vol.  5,  p.  422,  i,-c.) 

A second  instance,  in  which  the  internal  iliac  artery 
W'as  tied,  was  some  time  ago  communicated  to  the  pub- 
lic. The  operation  w as  performed  by  ]\Ir.  Atkinson,  of 
York,  on  account  of  a gluteal  aneuri.'«m.  The  follow'- 
ing  are  a few  of  the  particulars,  as  related  by  this  gen- 
tleman : — Thomas  Cost,  aged  29,  presented  himself  at 
the  York  County  Hospital,  Apnl  29th,  1817.  He  w'as 
a tall,  strong,  active  bargeman,  not  corpulent,  but  very 
muscular.  He  was  enduring  great  pain  from  a large, 
renitent,  pulsating  tumour,  situated  under  the  glutehs 
of  the  right  side ; an  obvious  aneurism.  It  had  existed 
about  nine  months,  and  was  the  consequence  of  a blow 
from  a stone.  In  a consultation  with  Dr.  Lanson  and 
Dr.  Wake,  the  necessity  of  the  operation  w'as  deter- 
mined upon,  and  it  was  performed  on  the  12th  of  May 
w'ithout  any  material  difficulty  or  interruption,  except 
such  as  was  the  consequence  of  the  division  of,  and 
bleeding  from,  the  small  muscular  arteries.  Having 
got  command  of  the  internal  iliac  arterj'  within  the 
pelvis,  w'hich,  says  Mr.  Atkinson,  required  the  complete 
length  of  the  fingers  to  accomplish,  it  was  tied.  Suf- 
ficient proof  of  its  being  the  identical  artery  w'as  re- 
peatedly obtained  by  the  pressure  upon  it  stopping  the 
pulsation  and  causing  a subsidence  of  the  tumour. 
Dr.  Wake,  Mr.  Ward,  and  all  the  pupils  were  quite  sus- 
sured  of  the  circumstance.  The  arterj'  being  then  tied, 
the  pulsation  of  the  swelling  entirely  ceased.  Some 


delay  in  placing  the  ligature  arose  from  the  needle  not 
being  sufficiently  pliable  ; but  for  future  operations  of 
this  kind  Mr.  Atkinson  very  properly  recommends  the 
ligature  to  be  put  round  the  artery  by  means  of  an  in- 
strument resembling  a catheter,  the  wire  of  which  has 
a little  ring  at  its  extremity,  and  can  be  pushed  out 
some  way  beyond  the  end  of  the  tube. 

The  patient  went  on  tolerably  well  for  some  time  after 
the  operation ; the  pulse  never  exceeded  130,  and  after 
a time  sunk  to  85  or  90.  He  became  exhausted,  how- 
ever, partly  by  the  discharge,  and  partly  by  hemor- 
rhage, and  died  on  the  31st  of  May,  about  nineteen 
days  after  the  operation.  In  the  dissection,  the  cavity 
on  the  external  part  of  the  peritoneum,  in  the  situation 
of  the  incision,  was  completely  filled  with  coagulated 
blood.  “ The  ligature,  on  moving  a part  of  this^dood) 
with  a sponge,  readily  followed  it,  and  without  doubt 
had  been  disengaged  for  some  days.”  The  internal 
iliac,  which  appeared  to  have  been  tied,  had  separated 
ibout  an  inch  and  a half  from  the  bifurcation  with  the 
external  iliac.  By  “ separated”  I conclude  Mr.  Atkin- 
son means,  that  the  upper  part  of  the  internal  iliac  was 
separated  from  the  continuation  of  the  same  vessel. — 
(See  Medical  and  Phys.  Journ.  vol.  38,  p.  267,  A c.) 
A.lthough  this  gentleman  has  not  given  a very  dear- 
account  of  some  part  of  the  dissection,  and  he  has  also 
amitted  to  describe  the  place  of  his  external  incision, 
»r  the  exact  parts  which  he  divided  in  the  operation, 
Ket  I think  that  all  the  circumstances  of  the  case  taken 
•ogether  leave  not  the»  smallest  doubt  of  the  internal 
Hiac  artery  having  been  actually  tied.  The  complete 
stoppage  of  the  pulsation  as  soon  as  the  ligature  was 
tpplied,  and  the  testimony  of  several  respectable  prac- 
titioners who  were  present,  seem  indeed  to  remove  all 
ambiguity.  The  profession  is  much  indebted  to  Mr. 
Atkinson  for  this  important  communication,  which  was 
in  some  measure  required,  in  order  to  confirm  Mr.  Ste- 
vens’s similar  case,  as  it  is  well  known  that  some 
distinguished  anatomists  and  surgeons  in  this  metro- 
uolis  formerly  expressed  very  strong  doubts  of  the 
practicable  nature  of  the  operation. 

The  internal  iliac  artery  is  also  said  to  have  been  tied 
with  success  by  an  army  surgeon  in  Russia,  upon 
whom  the  late  Emperor  Alexander  settled  a pension  as 
a reward  for  the  skill  displayed  in  the  treatment  of  the 
case. — (See  AveriWs  Operative  Surgery,  p.  39.) 

[The  internal  iliac  has  also  been  tied  in  this  country 
successfully  for  the  (tiire  of  gluteal  aneurism  by  Pro- 
fessor White,  the  younger,  of  Berkshire  Med.  Institu- 
tion. This  case  is  published  in  the  second  number  of 
the  American  Journal  of  Medical  Sciences,  and  is  also 
referred  to  in  Johnson’s  Medico-Chirurgical  Review 
for  April,  1828.  It  is  the  fourth  instance  in  which  it 
has  been  ever  attempted  ; and  three  out  of  the  four 
have  been  successful.  The  only  time  it  was  ever  per- 
formed in  Great  Britain  is  the  only  instance  of  its 
failure. — Reese.] 

In  a modern  publication  are  given  a few  particulars 
of  a case,  which  was  supposed  to  be  an  aneurism  of 
the  gluteal  artery,  and  cured  by  means  of  pressure,  a 
light  vegetable  diet,  gentle  laxatives,  and  digitalis. — 
(8ee  Trans,  of  the  Fellows,  A-c.  of  the  King's  and 
Qv.een's  College  of  Physicians  in  Ireland,  vol.  1,  p.41, 
Svo.  Dub.  1817.)  From  the  very  imperfect  account  here 
given  of  the  tumour,  it  is  impossibl#  to  form  any  con- 
clusion respecting  its  nature. 

.Sandifort  has  recorded  an  instance  of  an  aneurism 
of  the  internal  iliac  artery  itself. — (See  Tabulcs  Ana- 
tomiccB,  ifC.  Prascedit  Ohs.  de  Aneurismate  ArterieB 
Iliacae  intenuB,  rariore  ischiadis  NervoscB  causa,  fol. 
Ltigd.  1804.) 

The  common  iliac  has  never  been  tied  in  any  case  of 
aneurism  of  tiie  external  or  internal  iliac  ; but  Pro- 
fessor Gibson  had  occasion  to  put  a ligature  round  it 
in  an  example  of  gun-shot  wound.  “ The  patient  lived 
fifteen  days  after  the  operation,  and  then  died  from  peri- 
toneal inflammation,  and  from  ulceration  of  the  artery. 
The  circulation  in  the  limb  of  the  injured  side  was  re- 
Bstablished  about  the  seventh  day  after  the  artery  was 
tied.” — (See  American  Med.  Recorder,  vol.  3,  p.  185 ; 
a>td  Gibson’s  Institutes  of  Surgery,  vol.  2,  p.  145. 
Philadelphia,  1825.) 

[As  an  act  of  justice  to  my  distinguished  fViend 
Profes.sor  Mott,  I here  insert  a detailed  account  of  this 
Herculean  operation,  which  Dr.  Cooper  admits  has  never 
before  been  performed.  It  is  alike  honourable  to  him, 
to  the  profession,  and  to  our  country.  It  is  introduced 
Vol.  I -I 


RISM.  129 

entire,  as  communicated  to  me  by  the  doctor  at  my  soli- 
citation. 

A detailed  account  of  the  first  operation  ever  per- 
formed upon  the  arteria  iliaca  communis  for  the  cure 
of  aneurism,  and  especially  of  the  first  attempt  to  apply 
the  ligature  to  so  great  a vessel,  without  dividing  the 
peritoneum,  may  prove  interesting  to  the  profession 
generally,  and  must  be  immediately  serviceable  to 
practitioners  of  surgery. 

“ On  the  15th  of  March,  1827, 1 was  requested  to  visit 
a patient  with  Dr.  Osborn  (of  Westfield,  New-Jersey, 
about  twenty-five  miles  distant  from  New-York),  whom 
we  found  labouring  under  a large  aneurism  of  the  right 
external  iliac  artery. 

Israel  Crane,  aged  thirty-three  years,  by  occupation  a 
farmer,  of  temperate  and  regular  habits,  having  gene- 
rally enjoyed  excellent  health,  says,  about  the  middle 
of  January  he  felt  some  pain  about  the  lower  part  of 
the  belly,  which  he  attributed  to  a fall  received  during 
the  winter.  He  is  in  the  habit  of  using  great  efforts 
in  lifting  heavy  logs  of  wood,  as  his  employment  at 
this  season  consists  in  carrying  wood  to  market.  It, 
however,  was  not  until  a fortnight  since  that  he  per- 
ceived any  tumour  about  the  lower  part  of  the  abdomen. 
Upon  examination,  the  abdomen  on  the  right  side  was 
considerably  enlarged  from  about  the  crural  arch,  as 
high  as  the  umbilicus.  When  the  hand  was  applied 
to  the  parietes  of  the  abdomen,  a pulsation  was  felt 
and  rendered  visible  to  some  distance.  To  the  touch 
the  tumour  beat  violently,  and  appeared  to  contain 
only  fiuid  blood.  It  commenced  a little  above  Pou- 
part’s  ligament,  and  reached,  judging  by  the  touch, 
from  without  near  the  navel,  inwards  almost  to  the 
linea  alba,  outwards  and  backwards  filling  up  all  the 
concavity  of  the  ileum,  and  reaching  beyond  the  poste- 
rior spinous  process  of  that  bone. 

The  rapid  increase  of  this  aneurismal  tumour  occa- 
sioned, as  the  countenance  of  our  patient  indicated, 
the  most  extreme  agony.  His  sufferings  at  times  were 
so  great  that  his  screams  could  be  heard  at  a distance 
from  the  house.  He  had  been  bled  several  times,  taken 
light  food,  and  was  kept  constantly  under  the  effect  of 
opium.  He  was  now  informed  of  the  serious  nature 
of  his  case,  and  that  without  an  operation  very  little 
chance  of  his  life  f emained ; with  great  composure  he 
immediately  consented  to  whatever  would  give  him 
the  best  prospect  of  saving  his  life. 

From  the  extent  and  situation  of  the  tumour  he  was 
apprized  of  the  uncertain  nature  of  the  operation,  as 
well  as  the  difficulty  of  performing  it,  and  indeed  that 
it  would  require  an  artery  to  be  tied,  which  never  had 
been  before  operated  upon  for  aneurism.  With  these 
views  of  his  situation,  he  cheerfully  submitted  to  be 
placed  upon  a table  of  suitable  height,  in  a room  which 
was  w’ell  lighted. 

Then,  in  the  presence  of  Dr.  Osborn,  Dr.  Liddle,  and 
Dr.  Cross,  the  following  operation  wa.s  performed  : — 

The  pubes  and  groin  of  the  right  side  being  shaved, 
an  incision  was  commenced  just  above  the  external 
abdominal  ring,  and  carried  in  a semicircular  direction 
half  an  inch  above  Poupart’s  ligament,  until  it  termi- 
nated a little  beyond  the  anterior  spinous  process  of 
the  ileum,  making  it  in  extent  about  five  inches.  The 
integuments  and  superficial  fascia  were  now  dmded, 
which  exposed  the  tendinous  part  of  the  external  ob- 
lique muscle  ; upon  cutting  which  in  the  whole  course 
of  the  incision,  the  muscular  fibres  of  the  internal  ob- 
lique were  exposed  ; the  fibres  of  which  were  cau- 
tiously raised  with  the  forceps  and  cut  from  the  upper 
edge  of  Poupart’s  ligament.  This  exposed  the  sper- 
matic cord,  the  cellular  covering  of  which  was  now 
raised  with  the  forceps,  and  divided  to  an  extent  suffi- 
cient to  admit  the  fore-finger  of  the  left  hand  to  pass 
upon  the  cord  into  the  internal  abdominal  ring.  The 
finger  serving  now  as  a director,  enabled  me  to  divide 
the  internal  oblique  and  transversalis  muscles  to  the 
extent  of  the  external  incision,  while  it  protected  the 
peritoneum.  In  the  division  of  the  last-mentioned 
muscles  outwardly,  the  circumflex  ilii  artery  was  cut 
through,  and  it  yielded  for  a few  minutes  a smart  bleed- 
ing. This,  with  a smaller  artery  upon  the  surface  of  the 
internal  oblique  muscle  between  the  rings,  and  one  in 
the  integuments  were  all  that  required  ligatures. 

With  the  tumour  beating  furiously  underneath,  I 
now  attempted  to  raise  the  peritoneum  from  it,  which 
we  found  difficult  and  dangerous,  as  it  was  adherent  to 
it  in  every  direction.  By  degrees  we  separated  it  with 


130 


ANEURISM. 


great  caution  from  the  aneurismal  tumour,  which  had 
now  bulged  up  very  much  into  the  incision.  But  we 
soon  found  that  the  external  incision  did  not  enable  us 
to  arrive  to  more  than  half  the  extent  of  the  tumour 
upwards.  It  was  therefore  extended  upwards  and 
backwards  about  half  an  inch  within  the  ileum,  to  the 
distance  of  three  inches,  making  a wound  in  all  about 
eight  inches  in  length. 

The  separation  of  the  peritoneum  was  now  continued, 
until  the  fingers  arrived  at  the  upper  part  of  the  tu- 
mour, which  was  found  to  terminate  at  the  going  oIT 
of  the  internal  iliac  artery.  The  common  iliac  was 
next  examined  by  passing  the  fingers  upon  the  pro- 
montory of  the  sacrum,  and  to  the  touch  appearing  to 
be  sound,  we  determined  to  place  our  ligature  upon  it, 
about  half  way  between  the  aneurism  and  the  aorta, 
with  a view  to  allow  length  of  vessel  enough  on  each 
side  of  it  to  be  united  by  the  adhesive  process. 

The  great  current  of  blood  through  the  aorta  made  it 
necessary  to  allow  as  much  of  the  primitive  iliac  to 
remain  between  it  and  the  ligature  as  possible,  and  the 
probable  disease  of  the  artery  higher  than  the  aneurism 
required  that  it  should  not  be  too  low  down.  The 
depth  of  this  wound,  the  size  of  the  aneurism,  and  the 
pressure  of  the  intestines  downwards  by  the  efforts  to 
bear  pain,  made  it  almost  impossible  to  see  the  vessel 
we  wished  to  tie.  By  the  aid  of  curved  spatulas,  such 
as  I used  in  my  operation  upon  the  innominata^  toge- 
ther with  a thin,  smooth  piece  of  board,  about  three 
inches  wide,  prepared  at  the  time,  we  succeeded  in 
keeping  up  the  peritoneal  mass,  and  getting  a distinct 
view  of  the  arteria  iliaca  communis,  on  the  side  of  the 
sacro-vertebral  promontory.  This  required  great  effort 
on  our  part,  and  could  only  be  continued  for  a lew  se- 
conds. The  difficulty  was  greatly  augmented  by  the 
elevation  of  the  aneurismal  tumour,  and  the  intercep- 
tion it  gave  to  the  admission  of  light. 

When  we  elevated  the  pelvis,  the  tumour  obstructed 
our  sight ; when  we  depressed  it,  the  crowding  down 
of  the  intestines  presented  another  difficulty.  In  this 
part  of  the  operation  I was  greatly  assisted  by  Dr.  Os- 
born and  my  enterprising  pupil,  Adrian  A.  Kissam. 

Introducing  my  right  hand  now  behind  the  perito- 
neum, the  artery  was  denuded  with  the  nail  of  the  fore- 
finger, and  the  needle  conveying  the  ligature  was  in- 
troduced from  within  outwards,  guided  by  the  fore-finger 
of  the  left  hand  in  order  to  avoid  injuring  the  vein. 
The  ligature  was  very  readily  passed  underneath  the 
artery,  but  considerable  difficulty  was  experienced  in 
hooking  the  eye  of  the  needle,  from  the  great  depth 
of  the  wound  and  the  impossibility  of  seeing  it.  The 
distance  of  the  artery  from  the  wound  was  the  whole 
length  of  my  aneurismal  needlq. 

After  drawing  the  ligature  under  the  artery,  we  suc- 
ceeded by  the  aid  of  our  spatulas  and  board  in  getting 
a fair  view  of  it,  and  w'ere  satisfied  that  it  was  fairly 
under  the  primitiva  iliac,  a little  below  the  bifurcation 
of  the  aorta.  It  was  now  tied  ; the  knots  were  readily 
conveyed  up  to  the  artery  by  the  fore-fingers ; all  pulsa- 
tion in  the  tumour  instantly  ceased.  The  ligature  upon 
the  artery  was  very  little  below  a point  opposite  the 
umbilicus. 

The  wound  was  now  dressed  with  five  interrupted 
sutures,  passing  them  not  only  through  the  integu- 
ments, hut  the  fibres  of  the  cut  muscles,  so  as  to  bring 
their  divided  edges  together  at  all  parts  of  the  incision 
which  was  muscular.  Adhesive  plaster  to  assist  the 
stitches,  lint  and  straps  to  retain  it,  completed  the 
dressing.  The  operation  leisted  rather  less  than  one 
hour. 

He  was  removed  from  the  table,  and  put  into  bed  upon 
his  back,  with  the  knee  a little  elevated  upon  pillows  to 
relax  the  limb  as  much  as  possible,  and  to  avoid  pressure 
upon  it.  It  was  considerably  cooler  than  the  opposite 
leg,  and  flannels  were  applied  all  over  it,  and  a bottle 
of  warm  water  to  the  foot.  From  the  habit  he  had 
been  in  of  taking  largely  of  anodynes,  a tea-spoonful 
of  the  tinct.  opii  was  administered,  with  directions  to 
repeat  it  in  an  hour  if  the  pain  should  be  severe. 

In  less  than  one  hour  from  the  operation,  considerable 
reaction  of  the  heart  and  arteries  took  place ; he  felt, 
as  he  stated,  eltogether  relieved  from  the  excruciating 
agony  he  had  suffered  since  the  aneurism  commenced. 
The  whole  limb  had  now  recovered  its  natural  tempe- 
rature. 

March  IQth.  The  day  after  the  operation,  pulse 
eighty ; skin  moist ; limb  warm  ae  the  other ; com- 


plains of  some  pain  at  the  ligature ; ordered  a purgative 
of  neutral  salts. 

nth.  Pulse  eighty,  and  ftiller  than  yesterday  ; took 
1 X.  of  blood  from  his  arm ; skin  moist ; tongue  brown  } 
considerable  uneasiness  m the  limb ; no  pain  at  the 
ligature ; leg  of  natural  heat ; salts  had  a good  effect. 

Pulse  seventy-five  ; skin  moist ; tongue  white ; 
pain  in  the  limb  considerable ; no  pain  at  the  ligature 
or  in  the  wound  ; limb  warm. 

19th.  Bled  him  to-day  ten  ounces,  the  pulse  being 
tense,  and  beating  eighty  strokes  in  a minute ; repeated 
the  cathartic ; suppuration  appearing  to  have  taken 
place,  the  dressings  were  removed. 

20th.  Pulse  seventy  and  soft ; skin  moist ; wound 
looks  ^vell ; pain  in  the  limb  continues;  leg  warm  as 
the  other ; cathartic  operated  well. 

Pulse  seventy  and  soft;  wound  looks  well; 
repeated  the  laxative ; pain  in  the  leg  rather  less ; con 
tinues  warm.  There  has  been  at  no  time  tension  of 
the  abdomen  or  any  particular  uneasiness  in  that  part. 
The  patient  thus  far  has  been  altogether  more  comfort- 
able than  could  have  been  imagined.  He  takes  more 
or  less  opium  daily,  from  the  long  habit  he  has  been  in 
of  taking  anodynes. 

26th.  No  unpleasant  symptom ; wound  looks  well ; 
bled  again  to  | xij.,  as  there  was  a little  tumefaction 
and  inflammation  about  the  wound. 

30th.  Our  patient  continues  to  do  well;  wound 
dressed  daily. 

April  3d.  Not  being  able  to  leave  the  city,  I requested 
Dr.  Prondfoot,  my  late  pupil,  ^nd  a most  promising 
young  surgeon,  to  visit  the  patient.  He  reports  that  he 
was  free  of  fever ; wound  all  healed  but  where  the 
large  ligature  was  passing.  The  ligature  appearing  to 
be  detached,  the  Dr.  took  hold  of  it  and  removed  it: 
this  was  on  the  eighteenth  day  from  the  time  of  its 
application.  Limb  of  the  natural  temperature ; en- 
joined upon  him  to  keep  very  quiet  and  in  bed. 

8th.  There  are  no  disagreeable  appearances  what- 
ever ; he  appears  to  be  doing  remarkably  well ; has 
been  bled  once  since  the  last  report ; takes  a purgative 
every  other  day,  and  an  opiate  every  night ; pulse  as 
in  health  ; no  pain ; says  he  is  entirely  comfortable ; 
wound  is  dressed  with  dry  lint. 

16th.  Has  improved  rapidly  since  the  last  report. 
Two  days  after  the  ligature  came  away  he  very  im- 
prudently got  out  of  bed,  without  experiencing  any  dif- 
ficulty except  weakness.  Rode  out  to-day;  wound 
perfectly  healed. 

April  26th.  He  has  been  using  crutches  for  a few 
days  to  favour  the  lame  leg,  which  as  yet  feels  rather 
weak.  General  health  greatly  improved. 

30th.  Is  perfectly  restored  in  health;  has  a little 
stoop  in  his  walk,  which  he  says  is  occasioned  by  the 
external  cicatrix.  Leg  is  not  yet  of  its  full  size,  nor 
quite  so  strong  as  the  other.  From  the  period  of  the 
operation  to  the  recovery  of  our  patient,  he  did  not  ap- 
pear to  suffer  more  pain,  or  have  more  unpleasant 
symptoms,  than  would  ordinarily  take  place  in  a flesh 
wound  of  equal  extent.  Much  of  this,  in  my  opinion, 
is  to  be  attributed  to  the  prompt  and  judicious  antiphlo- 
gistic treatment  pursued  by  Dr.  Osborn,  to  whom  I am 
indebted  for  the  daily  reports  of  the  case. 

Map  29th.  My  patient  visited  me  to-day,  having 
come  twenty-five  miles ; he  was  so  much  improved 
in  health  that  I did^iot  recognise  him.  Examined  the 
cicatrix,  and  found  it  perfectly  sound ; could  not  dis- 
cover any  remains  of  an  aneurismal  tumour;  felt  the 
epigastric  artery  much  enlarged  and  beating  strongly, 
and  a feeble,  though  distinct  pulsation  in  the  femoral 
artery  immediately  below  the  crural  arch.  The  leg 
has  its  natural  temperature  and  feeling,  and  he  says  it 
is  as  strong  as  the  other. 

Much  credit  is  due  the  patient  for  his  firmness  on  the  . 
occasion  ; although  apprized  of  the  great  danger  attend- 
ing so  formidable  an  experiment,  and  the  uncertainty  of 
its  result ; yet  with  a fortitude  unshaken,  and  a full  con- 
viction that  it  was  the  only  chance  of  prolonging  his  life, 
he  cheerfully  and  resolutely  submitted  to  the  operation 

The  gratification  his  visit  afforded  me  is  not  to  be 
imagined,  save  by  those  who  have  been  placed  under 
similar  circumstances.  The  perfect  success  of  so  im- 
portant and  novel  an  operation,  with  the  entire  restora- 
tion of  the  patient’s  health,  was  a rich  reward  for  the 
anxiety  1 experienced  in  the  case,  and  in  a measure 
compensated  for  the  unexpected  failure  of  my  opera- 
tion on  the  arteria  innominata." 


ANEURISM. 


131 


Professor  Bushe  has  lately  tied  common  iliac  in 
a child  less  than  two  months  old  for  a congenital  aneu- 
rism of  one  of  the  labia.  She  recovered  from  the  ope- 
ration, but  perished  a few  weeks  afterward  from  abscess 
Of  the  knee-joint. — Reese.] 

ANEURISMS  or  THE  BRACHIAL  ARTERY. 

Surgical  writings  contain  many  histories  of  aneu- 
risms in  the  bend  of  the  arm,  produced  by  the  punc- 
ture of  the  brachial  artery  in  venesection,  or  caused  by 
a deep  wound  inflicted  at  the  bend  of  the  arm  along  the 
inner  side  of  the  humerus  or  in  the  axilla.  Such  cases 
must  indisputably  be  formed  by  effusion.  Although 
Morand  and  others  have  found,  that,  along  with  aneu- 
risms caused  by  a wound  of  the  brachial  artery,  the 
diameter  of  the  vessel  is  sometimes  unusually  enlarged 
through  its  whole  length  above  the  seat  of  the  tumour, 
this  enlargement,  which  is  very  rare,  might  have  ex- 
isted naturally  before  the  puncture  occurred.  Even 
were  it  frequent,  such  an  equable  longitudinal  expan- 
sion of  the  tube  of  the  artery  could  not  explain  the  form- 
ation of  the  aneurismal  sac  in  the  bend  of  the  arm, 
along  the  inner  side  of  the  humerus,  or  in  the  axilla, 
after  wounds. — (Scarpa,  p.  160.) 

The  proximate  cause  of  these  cases  may  invariably 
be  traced  to  the  solution  of  continuity  in  the  two  pro- 
per coats  of  the  artery,  and  the  consequent  effusion  of 
blood  into  the  cellular  substance.  The  effect  is  the 
same,  whether  from  an  internal  morbid  affection,  ca- 
pable of  ulcerating  the  internal  and  fibrous  coats  of  the 
artery,  the  blood  be  effused  into  the  neighbouring  cel- 
lular sheath  surrounding  the  artery,  which  it  raises 
after  the  manner  of  an  aneurismal  sac ; or  the  wound 
of  the  integuments  having  closed,  the  blood  issue  from 
the  artery,  and  be  diffused  in  the  surrounding  parts. 
The  cellular  substance  on  the  outside  of  the  wounded 
vessel  is  first  injected,  as  in  ecchymosis ; the  blood 
then  distends  it,  and  elevates  it  in  the  form  of  a tumour, 
and,  the  cellular  divisions  being  destroyed,  converts  it 
at  last  into  a firm  capsule  or  aneurismal  sac. — (Scar- 
pa, p.  167.) 

The  circumscribed  or  the  diffused  nature  of  the  aneu- 
rism, and  the  rapidity  or  slowness  of  its  formation,  de- 
pend on  the  greater  or  less  resistance  to  the  impetus 
of  the  blood,  during  the  time  of  its  effusion,  by  the  in- 
terstices of  the  cellular  substance  surrounding  the  ar- 
tery, and  by  the  ligamentous  fasciae  and  aponeuroses, 
lying  over  the  sac.  The  aponeurosis  of  the  biceps 
muscle  being  only  half  an  inch  broad,  and  situated 
lower  than  the  common  place  for  bleeding,  cannot,  at . 
least  in  most  cases,  materially  strengthen  the  cellular 
substance  surrounding  the  artery,  as  is  commonly  sup- 
posed.—(Scar/ja,  p.  168 — 170.)  This  author  refers  the 
greatest  resistance  to  the  intermuscular  ligament, 
which,  after  having  covered  the  body  of  the  biceps 
muscle,  extends  over  the  whole  course  of  the  humeral 
artery,  and  is  implanted  into  the  internal  condyle.  This 
ligamentous  expansion  ha.s  a triangular  shape,  the  base 
of  which  extends  from  the  tendon  of  the  biceps  to  the 
internal  condyle,  while  the  apex  reaches  upwards  along 
the  inner  side  of  the  humerus  towards  the  axilla,  in  the 
course  of  the  artery.  The  humeral  artery  and  median 
nerve,  kept  in  their  situation  by  the  cellular  sheath  and 
this  ligamentous  expansion,  run  in  the  furrow  formed 
between  it  and  the  internal  margin  of  the  biceps. — 
(Scarpa,  p.  171.)  This  author  anatomically  explains 
many  circumstances  relative  to  the  diffu.sion,  circum- 
scription, shape,  &c.  of  brachial  aneurisms  by  this 
intermuscular  ligament.  While  aneurisms,  from  an 
internal  cause,  are  not  unfrequent  in  the  aorta,  thigh, 
and  ham,  they  are  very  rare  in  the  brachial  artery ; 
though  a few  such  instances  are  recorded. — (Scarpa, 
p.  174.  Pelletan,  Clinique  Chir.  t.  2,  p.  4.) 

The  mode  of  distinguishing  a wound  of  the  brachial 
artery  in  attempting  to  bleed,  a«d  the  method  of  trying 
to  effect  a cure  by  pressure  are  described  in  the  article 
Hemorrhage. 

Anel  was  the  first  who  tied  the  brachial  artery  for 
the  cure  of  the  aneurism  at  the  bend  of  the  arm,  in  the 
same  way  that  Hunter  did  the  femoral  for  the  cure  of 
aneurisms  in  the  ham,  viz.  with  one  ligature  above  the 
tumour,  without  making  any  incision  upon  or  into  the 
sac  itself. 

The  operation  is  performed  as  follows : — The  surgeon 
having  traced  the  course  of  the  brachial  artery,  and 
felt  it.s  pulsations  above  the  aneurism,  he  may  either 
cut  (low.'i  to  the  vessel  immediately  above  the  tumour. 

I 2 


or  much  higher  in  the  long  space  between  the  origins 
of  the  superior  and  inferior  collateral  arteries.  The 
integuments  are  to  be  divided  in  the  course  of  the  ar- 
tery, and  also  the  cellular  sheath  for  the  space  of  about 
two  inches  and  a half.  The  surgeon,  now  introducing 
his  left  fore-finger  to  the  bottom  of  the  wound,  will  feel 
the  denuded  vessel,  and  if  it  is  not  sufficiently  bare,  he 
must  divide  the  parts  which  still  cover  it,  observing  to 
introduce  the  edge  of  the  knife  on  the  side  next  to  the 
internal  margin  of  the  biceps,  to  avoid  dividing  any  of 
the  numerous  muscular  branches  which  go  off  from  the 
opposite  side  of  the  artery.  He  is  then  to  insulate  with 
the  point  of  his  finger  the  trunk  of  the  vessel,  alone  if 
he  can,  or  together  with  the  median  nerve  and  vein,  and 
raise  it  a little  from  the  bottom  of  tiie  wound.  He  is 
to  separate  the  median  nerve  and  vein  for  a small  space 
from  the  artery,  and  with  an  eyed  needle  is  to  pass  a 
ligature  under  the  latter,  and  then  tie  it  with  a simple 
knot. 

In  the  operation  it  should  always  be  recollected  that 
the  median  nerve  lies  on  the  inside  of  the  artery,  and, 
therefore,  that  the  instrument  used  for  putting  the  liga- 
ture under  the  vessel  should  be  passed  from  within 
outwards,  by  which  means  the  inclusion  of  the  nerve 
may  be  most  easily  avoided. — (Boyer,  Traite  des  Mala- 
dies Chirurgicales,  <V  c.  t.  2,  p.  193.) 

The  operation  is  wcH  described  by  Mr.  Hodgson: 
“ The  surgeon  divides  the  integuments  along  the  ulnar 
margin  of  the  biceps  muscle  by  an  incision  two  inches 
and  a half  in  length.  The  thin  fascia  which  surrounds 
the  arm  will  thus  be  exposed,  and  must  be  cautiously 
divided  in  the  direction  of  the  external  wound.  The 
artery  lies  immediately  under  the  fascia,  close  to  the 
margin  of  the  biceps.  The  median  nerve  is  situated 
on  the  ulnar  side  of  the  artery  which  lies  between  its 
two  venae  comites.  The  internal  cutaneous  nerve  is 
also  situated  under  the  fascia  in  the  middle  of  the  arm, 
and  lies  on  the  ulnar  edge  of  the  median  nerve.  The 
cellular  membrane  which  connects  these  parts  is  to  be 
divided,  until  the  coats  of  the  artery  are  fairly  exposed. 
This  part  of  the  operation  will  be  effected  with  facility, 
if  an  assistant  compress  the  artery  above  the  wound,  so 
as  to  stop  the  circulation  through  it,  and  render  it  in 
some  degree  flaccid.  The  point  of  an  aneurismal 
needle  is  then  to  be  introduced  close  to  the  ulnar,  and 
brought  out  on  the  radial  side  of  the  artery,  so  as  to 
avoid  including  the  median  nerve,  or  the  veins  which 
accompany  the  artery.”— (On.  Diseases  of  the  Arteries, 

4 c.  p.  391.) 

Whoever,  after  the  above  directions,  says  Scarpa,  shall 
have  the  treatment  of  a circumscribed  aneurism  in  the 
bend  of  the  arm,  w’ill  no  longer,  it  is  to  be  hoped,  follow 
the  method  of  those  who,  supposing  the  tumour  to  be 
formed  by  the  dilatation  of  the  artery,  used  first  to  di- 
vide the  integuments  over  the  tumour,  insulated  the 
sac,  and  sought  for  the  vessel  above  and  below  the 
aneurism,  in  order  to  tie  it  in  two  places ; and  then  en- 
deavour to  make  the  sac  slough  away.  The  operation 
is  now  reduced  to  the  greatest  simi)licity,  viz  tying  the 
artery  merely  above  the  tumour.— (See  Scarpa,  p.  358, 
359.) 

When  the  aneurism  is  diffused  and  accompanied 
with  violent  infiammation  and  swelling  of  the  whole 
ann,  from  the  excessive  distention  of  the  clots  of  effused 
blood,  Scarpa  recommends  the  old  operation  of  opening 
the  tumour,  and  tying  the  artery  at  the  bottom  of  the 
sac,  above  and  below  the  wound  made  by  the  lancet. 
In  this  method,  a tourniquet  must  be  applied  to  the 
upper  part  of  the  arm,  near  the  axilla;  or,  if  the  limb 
be  very  painful  and  swelled,  it  is  better  to  let  an  assist- 
ant compress  the  artery  from  above  the  clavicle,  against 
the  first  rib.  The  incision  having  been  made  into  the 
tumour,  and  the  blood  discharged,  a probe  is  to  be  in- 
troduced into  the  puncture  in  the  vessel,  from  below 
upwards,  so  as  to  raise  the  artery.  This,  being  sej)a- 
rated  from  the  parts  beneath  and  the  median  nerve,  for 
a small  extent,  is  to  have  two  ligatures  put  under  it, 
one  of  which  is  to  be  tied  above,  the  other  below,  the 
wound  in  the  vessel.  Then  the  tourniquet,  or  pressure, 
is  to  be  taken  off,  and  if  there  be  no  bleeding,  the 
wound  is  to  be  brought  together.— (See  Scarpa,  p.  359.) 
With  reference  to  this  operation,  Rosenmiillcr’s  (Jhir. 
Anat.  Plates,  part  2,  tab.  11,  Scarpa’s  plates,  Tiede- 
mann’s  beautiful  engravings  of  the  arteries,  and  Cam- 
per’s Demonstr.  Anat.  Pathol,  lib.  i.  are  worth  con- 
sulting. 

It  was  on  the  brachial  artery,  that  Mr.  Lambert 


133 


ANEURISM. 


(Med.  Obs.  and  Inquiries,  ool.  2)  made  the  experiment 
of  closing  the  puncture  in  the  vessel  by  means  of  the 
twisted  suture,  under  an  idea,  that  the  plan  would  not, 
like  compression,  obliterate  the  arterial  tube,  and  there- 
fore that  the  risk  of  gangrene  would  be  lessened. 
Now,  although  in  the  trial  which  was  made  the  bleed- 
ing was  permanently  stopped,  Lambert  was  mistaken 
in  supposing  that  the  previous  state  of  the  wounded 
part  of  the  artery  was  preserved  by  the  adoption  of  the 
twisted  suture,  instead  of  pressure  or  the  ligature. 
If  ever  a small  puncture  in  an  artery  heat,  so  as  to 
leave  the  tube  of  the  vessel  pervious,  it  is  under  the 
circumstances  pointed  out  by  Dr.  Jones.— (See  Hemor- 
rhage.) Had  Lambert  had  an  opportunity  of  examining 
the  state  of  the  vessel  some  time  after  the  above  opera- 
tion, he  would  have  found  its  canal  obliterated ; and 
had  he  known  the  freedom  with  which  the  collateral 
arteries  anastomose  with  the  recurrent  arteries  of  the 
forearm,  he  would  have  known  how  to  explain  more 
correctly  the  re-establishment  of  the  pulse.  I need 
merely  add,  that  as  the  false  idea  of  preserving  the  per- 
viousness of  the  artery  was  the  only  foundation  for 
the  method,  the  practice  ought  never  to  be  revived,  as 
not  affording  equal  security  from  hemorrhage  to  what 
is  obtained  by  the  ligature,  or  even  compression. 

AXILLARY  ANEURISMS. 

Aneurisms  occasionally  take  place  in  the  iixilla,  and 
make  it  necessary  to  tie  the  subclavian  artery.  A 
question  here  naturally  presenting  itself  is,  whether 
the  surgeon  should  attempt  the  operation  in  an  early 
period  of  the  disease,  or  wait  till  circuptistances  are 
urgent ; the  aneurism  large  and  far  advanced ; the  arm 
CEdematous  and  insupportably  painful,  from  the  stretch- 
ing of  the  axillary  plexus  of  vessels ; the  patient  worn 
out  by  suffering  and  loss  of  rest ; and  the  tumour  in 
danger  of  bursting?  In  all  cases  of  aneurisms,  un- 
questionably, there  is  a certain  chance  of  the  disease 
getting  well  spontaneously : and  one  axillary  aneurism, 
in  a man  in  St.  Bartholomew’s  Hospital  a few  years 
ago,  had  certainly  disappeared  of  itself,  as  was  proved 
by  the  account  which  the  patient  while  living  gave  of 
his  case,  and  by  the  obliteration  of  the  artery,  found 
on  inspection  after  death. 

I believe,  however,  we  ought  not  to  suffer  our  con- 
duct to  be  too  much  influenced  by  the  hope  of  so  un- 
frequent an  event,  and,  from  the  observaiions  v/hich 
I have  made  on  this  subject,  it  is  my  decided  opinion, 
that  the  operation  should  never  be  delayed,  so  as  to 
allow  the  tumour  to  actjuire  an  immoderate  size.  The 
operation  is  always  difficult ; but  the  difficulty  is  seri- 
ously increased,  when  the  swelling  has  extended  far 
towards  the  breast,  and  has  become  so  large  as  to  push 
the  clavicle  considerably  upwards.  The  several  ex- 
amples in  which  the  subclavian  artery  has  now  been 
successfully  tied  furnish  abundant  proof,  that  the  anas- 
tomoses are  fully  competent  to  the  supply  of  the  limb 
with  blood.  The  plan,  therefore,  of  delaying  the  ope- 
ration long,  with  the  view  of  allowing  the  inosculating 
arteries  to  enlarge,  must  be  as  questionable  here  as  in 
some  other  cases  of  aneurism,  and  at  all  events,  the 
maxim  may  be  safely  advanced,  that,  previously  to  the 
operation,  the  tumour  should  never  be  suffered  to  ac- 
quire an  enormous  size. 

That  the  limb  would  receive  an  adequate  supply  of 
blood  was  well  proved,  even  without  the  performance 
of  the  operation,  by  cases  in  which  the  axillary  and 
subclavian  arteries  had  been  rendered  impervious  by 
disease ; as,  for  instance,  by  the  pressure  of  an  aneu- 
rism of  the  aorta. — (For  an  account  of  such  facts,  the 
reader  is  particularly  referred  to  Hodgson's  Treatise  on 
the  Diseases  of  Arteries,  p.  Ill  ; Journal  de  MHecine 
by  Corvisart,  Leroux,  and  Boyer,  t.  2,  p.  21) ; Corvisart, 
Essai  sur  les  Maladies  du  Coeur.  p.  215.) 

“ In  these  cases  (says  Mr.  Hodgson),  the  only  un- 
usual circumstance  which  was  observed  during  the 
life  of  the  patients,  was  the  deficiency  of  the  pulse  at 
the  wrist.  The  limbs  were  well  nourished,  although  a 
considerable  extent  of  the  main  artery  (the  subclavian) 
was  obliterated  even  before  it  had  given  off  any 
branches.”— (P.  47.) 

This  vessel  was  tied  by  Mr.  Hall,  in  Cheshire,  when 
it  had  been  wounded  with  a scythe,  and  its  ends 
exposed ; the  arm  was  preserved,  though  it  remained 
somewhat  weakened,  which  might  be  owing  to  the 
division  of  some  large  nerve.— (See  J.  Bell  on  Wo2inds, 
p.  60,  edit.  3,  and  Scarpa,  p.  372.)  Mr.  White,  of  Man- 


chester, relates  another  instance  of  this  vessel  being 
tied,  in  the  case  of  a wound ; but  mortification  of  the 
limb  and  death  followed.  Three  of  the  nerves  were 
found  included  in  the  Ugature. — (Land.  Med.  Joum.  v. 
4.)  In  cases  of  wounds  of  the  axillary,  or  any  other 
large  arteries  of  the  extremities,  the  surgeon,  before 
proceeding  to  apply  a ligature,  should  first  ascertain 
the  precise  place  of  the  wound  in  the  artery ; and  for 
this  purpose,  it  may  sometimes  be  proper,  in  certain 
wounds  of  the  shoulder,  to  make  an  incision  in  the 
axilla  so  as  to  expose  the  Injured  part  of  the  vessel ; 
or,  if  circumstances  do  not  forbid  it,  the  external  wound 
may  be  dilated,  until  the  exact  part  where  the  artery 
has  been  wounded  is  discovered.  In  proof  of  the  pro- 
priety of  acting  in  this  manner,  and  applying  a ligature 
above  and  below  the  wound  in  the  vessel,  Scarpa  quotes 
a case,  in  which  such  practice  was  successful  on  a 
patient  under  M.  Maunoir,  of  Geneva : the  artery  had 
been  injured  with  a sabre  near  the  head  of  the  hume- 
rus; but  after  the  wounded  part  of  the  vessel  had 
been  traced,  and  secured  in  the  way  above  suggested, 
the  patient,  a boy  fourteen  years  of  age,  was  saved 
from  the  dangers  of  hemorrhage,  and  recovered  the 
use  of  his  arm,  as  fast  as  this  was  possible,  with  the 
loss  of  the  first  phalanges  of  the  last  three  fingers 
from  gangrene.— (See  Scarpa  on  Aneurism,  p.  412,  ed. 
2,  and  Journ.  de  Med.  t 40,  Mars,  1811.) 

There  are  two  modes  of  operating  for  axillary  aneu- 
risms : one,  by  cutting  below  the  clavicle,  in  order  to 
take  up  the  axillary  artery  itself ; the  other,  by  making 
the  wound  above  the  bone,  for  the  purpose  of  securing 
the  subclavian  artery  at  the  point  where  it  emerges 
from  behind  the  anterior  scalenus  muscle. 

The  first  of  these  methods  has  been  attempted  by 
Desault,  Pelletan,  the  late  Mr.  Keate,  Mr.  Chamber- 
laine,  <fcc.  It  was  in  a case  of  wound  of  the  axillary 
artery  that  Desault  operated.  An  incision,  six  inches 
long,  was  made  below  the  external  third  of  the  clavicle ; 
two  thoracic  arteries  cut  were  immediately  tied ; the 
two  lower  thirds  of  the  great  pectoral  muscle  were 
next  divided  with  a bistoury  guided  on  a director : a 
large  quantity  of  coagulated  blood  was  now  discharged ; 
and  the  artery  was  directly  taken  hold  of,  and  tied, 
together  with  the  brachial  plexus  of  the  nerves.  The 
arm  mortified,  and  the  patient  died  This  case,  we 
must  agree  with  Scarpa,  was  not  a fair  trial  of  the 
operation,  inasmuch  as  the  inclusion  of  the  plexus  of 
nerves  in  the  ligature  was  an  improper  measure,  and 
must  have  promoted  the  occurrence  of  sphacelus.  It 
seems  also  probable,  from  the  account,  that  the  vein 
was  likewise  tied;  another  serious  and  objectionable 
proceeding.  Besides,  it  is  worthy  of  notice,  that  the 
case  was  a wound  of  the  axillary  artery,  attended  with 
a copious  effusion  of  blood  in  the  cellular  membrane. 
In  ail  examples  of  this  kind,  gangrene  is  more  readily 
induced,  than  when  the  case  is  a mere  circumscribed 
aneurismal  tumour.— (See  (Euvres  Chir.  de  Desault, 
par  Bichat,  t.  2,  p.  553.)  As  for  Pelletan’s  example,  it 
hardly  deserves  recital,  because  the  operation  in  fact 
was  not  achieved.  His  colleagues  objected  to  dividing 
the  pectoral  muscle ; a random  thrust  was  made  with 
a needle  and  ligature ; but  the  artery  was  not  included, 
and  the  experiment  was  not  repeated.— (See  Clinique 
Chir.  t.  2,  Ohs.  7,  p.  49.) 

In  a case  of  axillary  aneurism,  which  had  actually 
burst,  and  the  hemorrhage  from  which  could  only  be 
stopped  by  pressing  the  artery  against  the  first  rib,  Mr. 
Keate,  the  surgeon-general,  practised  the  following  ope- 
ration, which  was  attended  with  complete  success. 
His  plan  was  to  take  up  the  artery,  above  the  diseased 
and  ruptured  part,  in  its  passage  over  the  first  rib. 
Accordingly  he  made  an  incision  obliquely  downwards, 
divided  the  fibres  of  the  pectoral  muscle  that  were  in  his 
way,  and,  when  he  came  to  the  artery,  passed  a curved, 
blunt-pointed  silver  needle,  armed  double,  as  he  con- 
ceived, under  the  artery,  and  tied  two  of  the  ends. 
After  a careful  examination,  finding  that  the  artery  pul- 
sated below  the  ligature,  he  determined  on  passing 
another  ligature  higher  up,  and  nearer  to  the  clavicle; 
he,  therefore,  passed  the  needle  more  deeply,  so  as  evi- 
dently to  include  the  artery.  In  a few  days  the  swell- 
ing of  the  arm  began  to  subside,  the  wound  suppurated, 
and  the  ligatures  came  away  with  the  dressings.  The 
arm  aftervyard  recovered  its  feeling,  and  the  patient 
regained,  in  a great  measure,  the  entire  motion  of  the 
shoulder,  &,c.— (See  Med.  Review  and  Magazine  for 
1801.) 


ANEURISM. 


133 


Mr.  Keate’s  operation  is  objectionable,  inasmuch  as 
it  was  a dive  made  with  a needle,  and  attended  with 
great  danger  of  wounding  and  tying  parts  which  should 
be  left  undisturbed. 

Mr.  R.  Chamberlaine,  of  Kingston,  Jamaica,  took  up 
the  axillary  artery  below  the  clavicle,  in  a patient  who 
had  an  aneurism  in  the  left  axilla,  occasioned  by  a 
wound  with  a cutlass  on  the  5th  of  October,  1814.  On 
the  10th  of  January,  the  tumour  had  considerably  in- 
creased, and  was  less  compressible  than  it  had  been 
when  first  seen  by  Mr.  Chamberlaine.  The  operation 
was  done  on  the  17th  of  January,  1815 : “ a transverse 
incision,  of  three  inches  in  length,  was  made  through 
the  skin  and  platysma  myoides,  along  and  upon  the 
lower  edge  of  the  clavicle,  three  finger’s  breadth  from 
the  sternal  end  of  that  bone,  and  terminating  about 
an  inch  from  the  acromion  scapulae.  Tliis  incision  di- 
vided a small  artery,  which  was  immediately  secured. 
A second  incision,  of  three  inches  in  length,  was  also 
made  obliquely  through  the  integuments  over  the  del- 
toid and  pectoral  muscles,  meeting  the  first  nearly  in 
the  centre.  The  cellular  membrane  and  fat  lying  be- 
tween them  at  the  upper  part  were  now  removed. 
The  next  step  consisted  in  detaching  the  clavicular 
portion  of  the  pectoralis  major,  and  taking  away  the 
fat  and  cellular  membrane  lying  over  the  subclavian 
vessels.  The  artery  was  now  brought  into  view,  and 
its  pulsations  made  it  clearly  distinguishable  from  the 
contiguous  parts.”  After  several  ineffectual  efforts, 
Mr.  Chamberlaine  succeeded  in  conveying  a ligature 
under  it,  by  means  of  an  eye-probe,  curved  for  the  pur- 
pose, and  the  point  of  which  was  brought  up  with  the 
aid  of  a pair  of  forceps.  On  the  22d  of  February,  the 
wound  was  completely  healed ; the  aneurismal  tumour 
reduced  to  the  size  of  a turkey’s  egg,  and  very  solid ; 
the  arm  smaller  than  its  fellow,  but  its  muscular  power 
improving. — (See  Medico-Chir.  Trans,  vol.  6,  p.  128, 
li  e.)  Mr.  Chamberlaine  expresses  his  conviction,  that 
the  operation  would  have  been  much  facilitated,  had 
he  been  furnished  with  the  instruments  described  in 
Mr.  Ramsden’s  work  for  passing  the  ligature  under  the 
artery : a still  better  invention,  however,  for  passing  a 
ligature  under  a deep  artery,  is  the  needle  lately  con- 
structed by  Mr.  Weiss,  surgeons’  instrument  maker,  in 
the  Strand.  An  engraving  and  description  of  this 
valuable  instrument  may  be  found  in  the  Edin.  Med. 
and  Surgical  Journal,  No.  76. 

The  subclavian  artery  might  be  got  at  below  the  cla- 
vicle as  follows : the  surgeon  is  to  begin  an  incision  in 
the  integuments  about  an  inch  from  the  sternal  end  of 
this  bone.  The  cut  is  to  run  towards  the  acromion,  de- 
viating a little  downwards  from  a line  parallel  to  that  of 
the  clavicle.  This  wound  will  bring  into  view  some 
fibres  of  the  great  pectoral  muscle  originating  from  the 
last-mentioned  bone.  These  are  next  to  be  divided. 
Some  cellular  substance  will  be  found  underneath, 
which  is  to  be  carefully  raised  with  a pair  of  dissect- 
ing forceps,  and  cut.  The  operator  will  thus  arrive 
at  the  great  subclavian  vein,  and  cephalic  vein  uniting 
with  it.  Under  the  subclavian  vein,  and  a little  farther 
backwards,  more  under  the  clavicle,  the  subclavian 
artery  may  be  felt  and  tied.— (See  C.  BelVs  Operative 
Surgery,  vol.  2,  p.  370.) 

On  the  whole,  however,  I think,  Mr.  Hodgson’s  direc- 
tions for  the  performance  of  this  operation  are  the  best 
which  have  been  given.  A semilunar  incision  through 
the  integuments,  which  is  to  have  its  convexity  down- 
wards, and  to  begin  about  an  inch  from  the  sterna]  end 
of  the  clavicle,  being  continued  towards  the  acromion  for 
the  extent  of  three  or  four  inches,  so  as  to  end  near  the 
anterior  margin  of  the  deltoid  muscle,  without  reaching 
into  the  space  between  the  deltoid  and  pectoral  muscle,  in 
order  to  avoid  wounding  the  cephalic  vein.  Tins  incision 
will  expose  the  fibres  of  the  pectoral  muscle,  which  are 
now  to  be  divided  in  the  direction  and  extent  of  the  ex- 
ternal wound.  The  flap  is  then  to  be  raised,  by  divid- 
ing the  loose  cellular  membrane  which  connects  the 
pectoral  muscle  to  the  parts  underneath  it.  The  pecto- 
ralis minor  will  now  be  seen  crossing  the  interior  pan 
of  the  wound  ; and,  by  introducing  his  finger  between 
the  upper  edge  of  this  muscle  and  the  clavicle,  the  sur- 
geon may  feel  the  pulsations  of  the  axillary  artery.  Here 
one  of  the  cervical  nerves  lies  above,  but  in  contact  with 
the  artery ; the  other  nerves  are  behind  it.  In  the  dead 
subject,  the  axillary  vein  is  situated  below  it ; but,  in 
the  living,  the  vein  is  distended,  and  conceals  the  artery. 
The  cellular  membrane  connecting  these  parts  is  to  be 


separated  by  careful  dissection,  or  by  lacerating  it  with 
a blunt  instrument.  A ligature  having  beeji  drawn 
under  the  artery  with  an  aneurism-needle,  the  ends  of 
the  cord  are  to  be  raised,  and  a finger  passed  down,  so 
as  to  compress  the  part  surrounded  by  the  ligature.  If 
the  artery  be  included,  the  pulsation  in  the  aneurism 
will  immediately  cease.  This  precaution  is  highly  ne- 
cessary, lest  one  of  the  cervical  nerves  should  be  tied, 
instead  of  the  artery. — (See  Hodgson  on  Diseases  of 
Arteries,  irc.  p.  362.) 

When  an  aneurism  extends  a certain  way  inwards, 
or  towards  the  trachea,  the  operation  below  the  clavicle 
becomes  impracticable,  and  it  is  now  requisite  to  make 
the  incision  above  that  bone,  and  take  up  the  subcla- 
vian artery  at  the  point  where  it  comes  out  from  be- 
tween the  scaleni  muscles  and  lies  on  the  flat  surface 
of  the  first  rib. 

In  the  dead  subject  without  any  tumour  under  the  cla- 
vicle, this  operation  is  ea*y  enough ; but  in  a living  pa- 
tient the  difficulty  is  much  increased  by  a large  axil- 
lary aneurism,  for  then  the  clavicle  is  sometimes  so 
much  elevated,  and  the  artery  lies  so  deeply,  that  a 
ligature  can  hardly  be  carried  under  it  without  a par- 
ticular needle  for  the  purpose.  This  was  the  case  in 
an  attempt  which  I once  saw  made  by  Mr.  Ramsden  to 
tie  the  artery,  and  in  which  one  of  the  cervical  nerves 
affected  by  the  pulsation  of  the  artery  was  mistaken 
for  it  and  tied,  so  that  the  aneurism  soon  afterward 
burst,  and  a fatal  hemorrhage  arose.  Hence  the  advice 
given  by  my  friend  Mr.  Hodgson,  always  to  operate  in 
this 'case  while  the  tumour  is  small,  cannot  be  too  well 
remembered.  A direction  given  by  Mr.  Liston  is  also 
important ; namely,  “ before  tightening  the  ligature, 
try  the  effect  of  compression  with  the  fingers  on  the 
pulsation,  as  by  taking  this  precaution  (says  Mr.  Lis- 
ton) I saved  myself  and  my  patient  the  pain  of  tying 
the.  nerve,  which  I got  hold  of  in  my  first  operation, 
in  place  of  the  artery.”— (Lance;;,  No.  195,  p.  234.) 
The  chief  difficulty  in  the  operation  is  that  of  passing 
the  ligature  round  the  artery ; but  it  may  be  done  either 
with  an  ingenious  needle  which  Mr.  Ramsden  has  de- 
scribed, and  which  is  exactly  similar  in  principle  to 
Desault’s  aiguille  d ressort,  or  with  the  still  preferable 
instrument  constructed  by  Weiss.  Another  very  inge- 
nious contrivance  for  tying  deep  arteries  has  also  been 
recently  proposed  by  Dr.  Prevost  of  Geneva. — (See 
Edin.  Med.  and  Surgical  Joum.  No.  79.)  The  instru- 
ments used  by  Dr.  Mott  when  he  took  up  the  arteria  in- 
nominata  will  be  presently  noticed. 

In  order  to  avoid  the  inconveniences  of  the  needles  or- 
dinarily used  for  conveying  ligatures  under  deep  arte- 
ries, Desault  (says  Bichat)  invented  “ une  aiguille  A 
ressort,”  composed  of  a silver  lube  or  sheath,  which 
was  straight  at  one  end  and  bent  at  the  other  in  a semi- 
circular form.  This  sheath  enclosed  an  elastic  wire, 
the  projecting  extremity  of  which  was  accurately  fitted 
to  the  end  of  the  sheath,  and  perforated  with  a trans- 
verse eye.  The  instrument  was  passed  under  the  ar- 
tery, and  as  soon  as  it  had  reached  the  other  side  of  the 
vessel,  the  sheath  was  kept  fixed,  while  an  assistant 
pushed  the  elastic  wire,  which,  rising  from  the  bottom 
of  the  wound,  presented  the  aperture  or  eye  to  the 
surgeon,  who  now  passed  the  ligature  through  this 
opening.  The  wire  was  next  drawn  back  into  its 
sheath  again,  and  the  whole  instrument  brought  from 
beneath  the  artery,  by  which  means  the  ligature  was 
conveyed  under  the  vessel. — (See  (Euvres  Chir.  de  De- 
sault, par  Bichat,  t.  2,  p.  560.)  Another  very  inge- 
nious method  of  passing  the  ligature  under  the  artery, 
is  that  practised  by  Mr.  Key ; but  as  the  comprehension 
of  it  is  difficult  without  the  plate,  I shall  here  merely 
refer  to  that  gentleman’s  description  of  it. — (See  Med. 
Chir.  Trans,  vol.  \^,p.  10.) 

The  invention  of  the  foregoing  instruments  makes  a 
material  diminution  in  the  difficulty  of  taking  up  the 
subclavian  arter>'  from  above  the  clavicle  ; nor  can  it 
be  wondered,  that  without  such  a.ssistance,  the  ope- 
ration should  have  baffled  even  so  skilful  a surgeon  as 
Sir  A.  Cooper. — (See  Bond.  Med.  Review,  vol.  2,  p.  200.) 

The  follov/ing  example  is  the  first  in  which  the  at- 
tempt to  tie  the  subclavian  artery  by  cutting  above  the 
clavicle  was  ever  accomplished. 

John  Townly,  a tailor,  aged  thirty-two,  addicted  to 
excessive  intoxication,  of  an  unhealthy  and  peculiarly 
anxious  countenance,  was  admitted  into  St.  Bartholo- 
mew’s Hospital  on  Tuesday,  the  2d  of  November,  1809, 
on  account  of  an  aneurism  in  the  right  axilla.  The 


134 


ANEURTSxM. 


prominent  part  of  the  tumour  in  the  axilla  was  about 
half  as  big  as  a large  orange,  and  there  was  also  much 
enlargement  and  distension  underneath  the  pectoral 
muscle,  so  that  the  elbow  could  not  be  brought  near 
the  side  of  the  body. 

“ The  temperature  of  both  arras,’*  says  Mr.  Rams- 
den,  “ was  alike,  and  the  pulse  in  the  radial  artery  of 
each  of  them  was  correspondent.  After  the  patient  had 
been  put  to  bed,  some  blood  taken  from  the  left  arm,  an^ 
his  bowels  emptied,  his  pulse,  which  on  his  admission 
had  been  at  130,  became  less  trequent ; his  countenance 
appeared  more  tranquil ; and  he  experienced  some  re- 
mission of  the  distressing  sensations  in  the  affected 
arm  : his  relief,  however,  was  of  short  duration.” 

The  pulsation  of  the  radial  artery  of  the  affected  arm 
gradually  became  more  obscure,  and  soon  after  either 
ceased  or  was  lost  in  the  oedema  of  the  forearm  and 
hand.  On  the  evening  of  the  twelfth  day,  a dark  spot 
appeared  on  the  centre  of  thp  tumour,  surrounded  by 
inflammation,  which  threatened  a more  extensive  de- 
struction of  the  skin.  A farther  jwstponement  of  the 
operation  being  deemed  inadmissible,  Mr.  Ramsden 
performed  it  the  next  day  in  the  following  manner. 

“ A transverse  incision  was  made  through  the  skin 
and  platysma  myoides,  along  and  upon  the  upper  edge 
of  the  clavicle,  about  two  inches  and  a half  in  length, 
beginning  it  nearest  to  the  shoulder,  and  terminating 
its  inner  extremity  at  about  half  an  inch  within  the 
outward  edge  of  the  stemo-cleido-mastoideus  muscle. 
This  incision  divided  a small  superficial  artery,  which 
was  directly  secured.  The  skin  above  the  cla%'icle  be- 
ing then  pinched  up  between  my  own  thumb  and  fin- 
ger and  those  of  an  assistant,  I divided  it  from  within 
outw’ards  and  upwards,  in  the  line  of  the  outward  edge 
of  the  stemo-cleido-mastoideus  muscle  to  the  extent  of 
two  inches. 

IVIy  object  in  pinching  up  the  skin  for  the  second 
incision,  was  to  expose  at  once  the  superficial  veins, 
and  by  dissecting  them  carefully  from  the  cellular  mem- 
brane, to  place  them  out  of  my  way  without  wounding 
them.  This  provision  proved  to  be  useful,  for  it  ren- 
dered the  flow  of  blood  during  the  operation  verj'  tri- 
fling, comparatively  with  what  might  otherwise  have 
been  expected  ; and  thereby  enabled  me  with  the  great- 
est facility  to  bring  into  view  those  parts  which  were 
to  direct  me  to  the  artery. 

My  assistant  having  now  lowered  the  shoulder, 
for  the  purpose  of  placing  the  first  incision  above  the 
clavicle  (which  I had  designedly  made  along  and  upon 
that  bone),  I continued  the  dis.section  with  my  scalpel,  i 
until  I had  distinctly  brought  into  sight  the  edge  of 
the  anterior  scalenus  muscle,  immediately  below'  the 
angle  which  is  formed  by  the  traversing  belly  of  the 
omo-hyoideus  and  the  edge  of  the  sterno-cleido-mastoi- 
deus;  and  having  placed  my  finger  on  the  artery  at  the 
point  where  it  presents  itself  betw'een  the  scaleni,  I 
found  no  difficulty  in  tracing  it,  without  touching  any 
of  the  nerves,  to  the  lower  edge  of  the  upper  rib,  at 
which  part  I detached  it  with  my  finger  nail,  for  the 
pur]tose  of  applying  the  ligature. 

liere,  however,  arose  an  embarrassment  which  (al- 
though I was  not  unprepared  for  it)  greatly  exceeded 
my  expectation.  I had  learned,  from  repeatedly  per- 
forming this  operation  many  years  since,  on  the  dead 
subject,  that  to  pass  the  ligature  under  the  subclavian 
artery  with  the  needle  commonly  used  in  aneurisms 
would  be  impracticable ; 1 had,  therefore,  provided  my- 
self with  instruments  of  various  forms  and  curvatures 
to  meet  the  difficulty,  each  of  w'hich  most  readily  con- 
veyed the  ligature  underneath  the  artery,  but  would 
serve  me  no  farther  ; for  being  made  of  solid  materials 
and  fixed  into  handles,  they  would  not  allow  of  their 
points  being  brought  up  again  at  the  very  short  curva- 
ture, which  the  narrowness  of  the  space  between  the 
rib  and  the  clavicle  afforded,  and  which,  in  tips  parti- 
cular case,  was  rendered  of  unusual  depth  by  the  pre- 
vious elevation  of  the  shoulder  by  the  tumour. 

After  trying  various  means  to  overcome  this  diffi- 
culty, a probe  of  ductile  metal  was  at  length  handed 
me,  w’hich  I passed  under  the  artery,  and  bringing  up 
its  point  with  a pair  of  small  forceps,  I succeeded  in 
passing  on  the  ligature,  and  then  tied  the  subclavian 
artery  at  the  part  where  I had  previously  detached  it 
for  that  j)urpose.  The  drawing  of  the  knot  w as  unat- 
tended with  pain ; the  wound  w as  clo.sed  by  the  dry 
suture,  and  the  patient  was  then  returned  to  his  bed.” 
— (See  Practical  Observations  on  the  Sclerocele,  h c.,  to 


which  are  added  four  cases  of  operations  for  Aneu 
risins,  p.  276,  ($-c.) 

It  only  seems  necessary'  for  me  to  add,  that  imme- 
diately the  artery'  w’as  tied  the  pulsation  of  the  swelling 
ceased ; that  the  arm  of  the  same  side  continued  to  be 
freely  supplied  with  blood,  and  was  even  rather  warmer 
than  the  opposite  arm  ; that  the  operation,  which  was 
severe  from  the  length  of  time  it  took  up,  w as  after  a 
time  followed  by  considerable  indisposition ; that  the 
patient  died  about  five  days  after  its  performance ; that 
after  the  artery  had  been  tied,  the  cedema  of  the  arm 
and  the  aneurismal  tumour  partly  subsided  ; and  that, 
on  examination  after  death,  nothing  but  the  vessel  was 
found  included  in  the  ligature. 

In  this  publication  are  descriptions  of  instruments 
which  will  be  of  great  service  to  any  future  perfonner 
of  this  operation.  The  chief  one  is  a needle,  resembling 
that  which  was  invented  and  used  by  Desault,  and  of 
which  I have  already  endeavoured  to  give  an  idea.  I’y 
means  of  this  instrument,  I conceive  that  the  main  dif- 
ficulty of  the  operation  will  in  future  be  avoided.  Had 
Mr.  Ramsden  had  its  assistance,  his  patient  would 
have  been  detained  a very  little  time  in  the  operating 
theatre,  and  the  event  of  the  case  might  have  been 
completely  successful.  Ha^ing  witnessed  all  the  cir- 
cumstances of  the  case,  the  inference  that  I drew'  from 
them  was,  that  if  the  operation  could  have  been  done 
in  a moderate  time,  which  now'  seems  practicable  with 
the  aid  of  the  aiguille  a ressort,  or  the  instrument  sold 
by  Mr.  Weiss,  the  case  in  all  probability  would  have 
ended  well.  The  preceding  ca.se  is  particularly  me- 
morable, as  being  the  first  instance  in  which  the  sub- 
clavian artery  was  scientifically  tied,  without  any  ran- 
dom thrust  of  a needle,  and  without  the  inclusion  of 
any  part  besides  the  artery  in  the  ligature.  It  fur- 
nished encouragement  to  repeat  the  experiment ; held 
out  the  hope,  that  axillary  aueurisms  might  be  cured 
as  well  as  inguinal  ones';  and  confirmed  the  compe- 
tency of  the  anastomosing  arteries  to  nourish  the  whole 
upper  extremity,  when  the  subclavian  is  tied  where  it 
emerges  from  beliind  the  anterior  scalenus  muscle. 

In  the  year  ISll,  the  subclavian  artery  was  tied  in 
the  London  Hospital,  in  a case  of  axillary  aneurism, 
by  Sir  W,  Blizard,  who  found  no  difficulty  in  getting 
the  ligature  under  the  artery,  with  a common  aneurism- 
needle.  A single  ligature  w'as  applied.  At  first  hopes 
of  recovery  w'ere  entertained;  but  the  patient,  who 
was  old  and  debilitated,  afterward  sunk  and  died  on 
the  fourth  day. — (See  HedgS'  n's  Treatise,  p.  375.) 

In  the  year  1815,  Mr.  Thomas  Blizard  tied  the  sub- 
clavian artery  in  the  same  hospital.  The  case  w'as  an 
aneurism  in  the  left  axilla,  and,  like  all  the  other  ex- 
amples of  this  kind  upon  record,  was  attended  with 
great  pain  in  the  tumour  and  limb.  There  was  no 
pulse  in  the  left  radial  artery,  though  there  was  scarce- 
ly any  difference  in  the  temperature  of  both  arms, 
“ An  incision  about  three  inches  in  length  was  made 
through  the  integuments  at  the  root  of  the  neck,  on 
the  acromial  side,  and  parallel  w'ith  the  external  jugu- 
lar vein.  The  platysma  myoides  being  divided,  the 
cellular  membrane  was  separated  with  the  finger,  until 
the  pulsation  of  the  subclavian  artery  was  felt  where 
the  vessel  passes  over  the  first  rib.  The  finger  being 
pressed  upon  this  part  of  the  artery,  the  cellular  sheath 
investing  it  was  carefully  opened  with  the  point  of  a 
knife.  A ligature  was  then  conveyed  underneath  the 
artery,  by  means  of  a common  aneurism-needle,  with 
the  greatest  facility.”  As  soon  as  the  ligature  was 
tied,  the  pulsation  in  the  tumour  ceased.  On  the 
second  day  after  the  operation  the  left  arm  began  to 
have  more  feeling,  and  was  as  warm  as  the  right. 
However,  difficulty  of  breathing,  twitchings,  delirium, 
<fec.  afterward  ensued,  and  the  patient  died  on  the 
evening  of  tlie  eighth  day,  previously  to  which  event 
the  ring  and  middle  fingers  turned  black.  On  opening 
the  boily,  the  pericardium  exhibited  the  efl'ects  of  a 
high  degree  of  inflammation,  and  the  heart  w as  covered 
with  fltdtes  of  lymph,  its  posterior  surface  being  of  a 
deep  red  colour.  The  inner  membrane  of  the  ascend- 
ing aorta  was  of  a bright  scarlet  hue,  much  diseased, 
and  studded  with  white  patches.  A reddisli  appear 
ance  was  also  noticed  in  the  lining  of  the  right  carotid, 
left  subclavian,  and  even  the  abdominal  aorta.  The 
boundaries  of  the  aneurismal  tumour  w ere  in  a state  of 
sphacelation.  These  are  all  the  circumstances  which 
I wish  here  to  notice ; but  more  particulars  may  be  jie- 
rused  in  Mr.  Hodgson’s  work,  p.  602. 


ANEURISM. 


135 


ft  Is  remarkable,  that  in  the  cases  operated  upon  in 
the  London  Hospital,  and  some  others  on  record,  no 
difficulty  was  experienced  in  passing  the  ligature  under  I 
the  artery  with  a common  aneurism-needle ; a circum- 
stance which  must  have  depended  upon  the  space  be-  | 
tween  the  clavicle  and  the  first  rib  having  been  less 
deep  in  these  instances  than  the  two  which  fell  under 
my  own  observation,  or  in  others  which  occurred  in 
the  practice  of  Dr.  Colles,  Sir  Astley  Cooper,  and  Mr. 
Liston. — (See  Land.  Med.  Review,  vol.  2,  p.  200 ; and 
Edin.  Med.  and  Surg.  Journal,  January,  1815,  No. 
6-1.)  In  Mr.  Key’s  case,  “ the  depth  of  the  angle  in 
which  the  artery  was  enclosed  rendering  it  impossible 
to  pass  a ligature  under  it,  about  three-quarters  of  an 
inch  of  the  clavicular  portion  of  the  sterno-mastoid  was 
divided,  which  afforded  sufficient  room,  and  rendered 
the  concluding  part  of  the  operation  easy  ; the  artery 
became  readily  exposed  to  view,  and  an  armed  aneu- 
rismal  needle  was  passed  with  facility  under  it.” — 
(Med.  Ckir.  Trans,  viol.  13,  p.  5.) 

In  Dr.  Colles's  first  case,  the  artery  was  tied  before 
it  reached  the  scaleni  muscles,  as  the  tu.mour,  which 
was  in  the  right  subclavian  artery,  extended  from  the 
sternal  origin  of  the  sterno-mastoid  muscle  along  the 
clavicle,  a little  beyond  the  arch  of  that  bone,  and  rose 
nearly  two  inches  above  it,  in  a conical  form,  the  apex 
of  the  cone  being  situated  at  the  outer  edge  of  the  fore- 
going muscle.  After  a tedious  dissection,  it  was  found 
that  only  a quarter  of  an  inch  of  the  .artery  was  sound, 
and  on  this  portion  the  ligature  was  placed.  Great 
difficulty  was  encountered  in  passing  it  round  the 
artery,  and  the  pleura  was  supposed  to  have  been 
slightly  wounded.  Before  tightening  the  ligature  the 
breathing  became  laborious,  and  the  patient  complained 
of  oppression  about  the  heart.  These  symptoms,  in- 
deed, were  so  violent,  that  it  was  judged  prudent  not 
immediately  to  tighten  the  ligature.  On  the  fourth 
day,  however,  the  artery  was  constricted,  when  the 
jiutse  at  the  wrist  ceased,  the  patient  not  seeming  to 
suffer  much  from  what  had  been  done.  The  patient 
then  went  on  pretty  well  till  the  ninth  day,  when  he 
was  seized  with  a sense  of  strangling,  and  pain  about 
his  heart,  and,  becoming  delirious,  died  nine  hours 
after  the  beginning  of  this  attack.  On  dissection  the 
aorta  was  found  diseased,  and  the  disease  extended 
into  the  subclavian  artery. 

In  another  instance.  Dr.  Colles  tied  this  vessel  at  the 
point  where  it  emerges  from  between  the  scaleni 
muscles,  without  any  particular  difficulty.  The  ope- 
ration, however,  was  soon  followed  by  a train  of  severe 
symptoms,  delirium,  and  mortification,  and  the  patient 
died  on  the  fifth  day.— (See  Edin.  Med.  and  Surg. 
Joum.  January,  1815.) 

The  first  case  in  which  complete  success  attended 
the  operation  of  tying  the  subclavian  artery,  where  it 
first  comes  from  behind  the  anterior  scalenus  muscle, 
was  that  under  the  care  of  Dr.  Post,  of  New-York. 
The  patient  tvas  a gentleman,  with  an  aneurism  in  the 
left  axilla.  Dr.  Post  performed  the  operation  on  the 
8th  of  September,  1817,  in  the  following  manner.  “An 
incision,  commencing  at  the  outer  edge  of  the  tendon 
of  the  mastoid  muscle,  was  carried  through  the  integu- 
ments about  three  inches  in  length,  in  a direction  de- 
viating a little  from  a parallel  line  with  the  clavicle. 
This  divided  the  external  jugular  vein,  the  bleeding 
from  which  required  a ligature  for  its  suppression  ; 
and  in  proceeding  with  the  operation,  three  or  four 
arterial  branches  were  cut,  which  it  was  also  neces- 
sary to  secure.  The  subclavian  artery  was  then  sought 
immediately  on  the  outside  of  the  scaleni  muscles,  and 
was  ea.sily  laid  bare.  Passing  over  the  artery  at  this 
place,  in  contact  with  it,  were  three  considerable 
branches  of  nerves,  running  downwards  towards  the 
chest  from  the  plexus  above.  These  were  separated, 
and  a ligature  passed  under  the  artery  with  great 
facility,  by  the  instrument  well  adapted  to  this  purpose 
invented  by  Drs.  Parish,  Hartshorn,  and  Hewson,  of 
I'hiladelphia.  On  tying  the  ligature,  all  pulsation 
ceased  in  the  limb.”  In  the  afternoon,  the  temperature 
of  the  limb  was  ob.served  to  be  rather  higher  than  that 
of  the  other  arm.  On  the  17th  of  September,  the  aneu- 
risrnal  tumour  burst,  and  about  three  ounces  of  dark 
coagulated  blood  were  discharged.  On  the  2f)th,  the 
ligature  came  away  from  the  subclavian  artery.  Oct. 
llth,  the  wound  was  entirely  healed  ; and  on  the  16th 
af  the  same  month,  the  patient  required  no  farther  at- 
tendance, his  only  complaint;!  being  now  a little  occa- 


I sional  pain  in  the  fingers,  and  a superficial  sinus  at 
the  part  where  the  tumour  burst. — (See  Med.  Chir. 
Trans,  vol.  9,  p.  185,  &c.) 

Mr.  Liston,  of  Edinburgh,  has  the  honour  of  being 
I the  surgeon  that  first  succeeded,  in  Europe,  in  curing 
an  axillary  aneurism,  by  taking  up  the  subclavian 
artery  from  above  the  clavicle,  on  the  3d  of  April,  1820 
The  particulars  of  the  case  are  verj"  instructing. 
They  prove  the  risk  there  always  is  of  tying  one  of 
the  axillary  nerves  instead  of  the  artery,  unless  great 
caution  be  employed ; and,  in  fact,  Mr.  I.isioh  himself 
first  passed  his  ligature  under  a nerve,  and  would 
have  tied  it,  had  he  not  wisely  tried  what  effect  con- 
stricting the  included  part  would  have  upon  the  pulsa- 
tion of  the  tumour.  As  the  subclavian  artery  seemed 
diseased  at  the  point  where  it  emerged  from  behind 
the  anterior  scalenus,  Mr.  Liston  cautiously  divided 
this  muscle  to  about  its  middle,  so  as  not  lo  injure  the 
phrenic  nerve.  At  length,  with  the  aid  of  an  aneurism- 
needle,  he  passed  a strong  round  silk  ligature  under 
the  artery,  and  laying  hold  of  the  loop  with  a small 
hook  withdrew  the  needle.  In  consequence  of  the 
great  depth  of  the  artery,  the  knot  could  not  be  made 
with  the  fingers ; but  with  the  assistance  of  a kind  of 
forceps,  each  extremity  of  which  had  a little  notch  in 
it,  the  business  was  accomplished. — (See  Edin.  Med. 
and  Surgical  Journ.  No.  64.) 

Several  other  successful  operations  of  this  kind  have 
subsequently  been  done  by  English  surgeons.  One  by 
Dr.  Gibbs,  in  the  General  Naval  Hospital  of  St.  Peters- 
burgh  (see  Med.  Chir.  Trans,  vol.  12,  p.  531) ; another 
by  Mr.  Bullen,  in  the  Lynn  Dispensary  (see  London 
Med.  Repository  for  Sept.  1823)  ; a third  by  Mr.Wishart 
at  Edinburgh  (see  Edin.  Med.  and  Surg.  Journ.  No. 
78) ; a fourth  by  Mr.  Key,  in  Guy’s  Hospital  (see 
Med.  Chir.  Trans,  vol.  13,  p.  1);  and  a fifth  by  Mr.  B 
Cooper,  in  the  same  establishment. 

[Professor  Gibson,  of  the  University  of  Pennsylvania, 
has  cured  a case  of  axillary  aneurism  occasioned  by 
the  reduction  of  an  old  luxation  of  the  humerus,  by 
tying  the  subclavian  artery. — (See  American  Journal, 
vol.  2,  p.  136.) — Reese.] 

The  instructions  delivered  by  Mr.  Hodgson  for  the 
performance  of  this  operation,  are  the  best  with  which 
I am  acquainted.  When  the  subclavian  artery  (says 
this  gentleman)  has  emerged  from  behind  the  anterior 
scalenus  muscle,  it  passes  obliquely  over  the  flat  sur- 
face of  the  first  rib,  with  which  it  is  in  immediate  con- 
tact. The  cervical  nerves  are  situated  above  and  a 
little  behind  the  artery;  the  subclavian  vein  passes 
before  it,  and  underneath  the  clavicle.  If  the  finger  be 
passed  down  the  acromial  margin  of  the  anterior  sca- 
lenus muscle,  the  artery  will  be  found  in  the  angle 
formed  by  the  origin  of  that  muscle  from  the  first  rib. 
The  shoulder  being  drawn  down  as  much  as  jtossible, 
the  skin  is  to  be  divided  immediately  above  the  clavicle, 
from  the  external  margin  of  the  clavicular  portion  of 
the  mastoid  muscle,  to  the  margin  of  the  clavicular  in- 
sertion of  the  trapezius.  No  advantage  whatever,  says 
Mr.  Hodg.son,  is  gained  by  cutting  the  clavicular  at- 
tachment of  the  sterno-cleido-mastoideus.  On  this 
point,  however,  there  is  some  difference  of  opinion  ; Mr. 
Key  having  found,  in  his  operation,  that  the  division 
of  the  clavicular  portion  of  that  muscle  greatly  facili- 
tated the  introduction  of  the  ligature  under  the  artery. 
— (See  Med.  Chir.  Trans,  vol.  13,  p.  5 and  10.)  The 
exposed  fibres  of  the  platysma  myoides  are  now  to  be 
carefully  divided,  without  wounding  the  external  jugu- 
lar vein,  which  lies  immediately  under  them,  near  the 
middle  of  the  incision,  and  should  be  detached,  and 
drawn  towards  the  shoulder  with  a blunt  hook.  The 
cellular  membrane,  in  the  middle  of  the  incision,  is 
then  to  be  cut,  or  separated  with  the  finger,  until  the 
surgeon  arrives  at  the  acromial  edge  of  the  anterior 
scalenus.  He  pas.ses  his  finger  down  the  margin  of 
this  muscle,  until  he  reaches  the  part  where  it  arises 
from  the  first  rib,  and  in  the  angle  formed  by  the  origin 
of  the  muscle  from  the  rib  he  will  feel  the  artery.  The 
ligature  is  now  to  be  conveyed  under  the  vessel  with 
an  aneurism-needle,  or  that  recommended  by  Desault. 
— (Hodgson  on  Diseases  of  Arteries,  ivc.  p.  376,  A-c.) 

Breschet  thinks  that  the  safest  and  easiest  method 
is  that  adopted  by  Dupuytren.  An  incision,  three  or 
four  inches  long,  is  to  be  made  at  the  lower  and  outer 
part  of  the  neck,  and  extended  to  the  clavicle.  I'his 
first  incision,  situated  behind  the  external  edge  of  the 
sterno-ma.stoid  muscle,  should  go  through  the  skin, 


136 


ANEURISM. 


the  cellular  membrane,  and  platysma  mj'oides.  Some 
venous  branches,  running  into  the  jugulars,  will  then 
be  met  wath,  which  should  be  surrounded  by  a double 
ligature,  and  divided  in  the  interspace.  A director  is 
then  to  be  introduced  under  the  omo-byoideus  muscle, 
in  order  to  facilitate  its  division,  and  the  surgeon  will 
at  length  reach  the  external  edge  of  the  anterior  sca- 
lenus. A curved  probe-pointed  bistoury  is  then  to  be 
gradually  and  cautiously  passed  behind  that  muscle, 
with  the  flat  surface  of  the  blade  against  it,  and  deeply 
enough  to  divide  the  external  third,  or  half  of  the  fibres 
of  the  same  muscle,  or  even  all  of  them  if  requisite. 
The  insulated  artery  will  then  be  felt  at  the  bottom  of 
the  wound,  situated  in  the  area  of  a triangle,  the  upper 
side  of  which  is  formed  by  the  braclual  plexus,  the 
lower  by  the  subclavian  vein,  and  the  inner  by  the 
scalenus.  A ligature  is  then  to  be  conveyed  under  the 
artery  by  means  of  the  needle  invented  by  Deschamps. 
— (See  French  transl.  of  Mr.  Hodgson's  work,  t.  2, 
p.  126.)  Whether  cutting  the  anterior  scalenus  and 
omo-hyoideus  will  facilitate  the  operation  is  question- 
able ; but  the  assertion  that  these  measures  increase 
its  safety,  is  what  I cannot  understand. 

With  respect  to  tying  the  subclavian  artery  on  the 
tracheal  side  of  the  scalenus,  we  have  seen,  that  it 
was  performed  by  Dr.  Colles,  and  the  event  was  fatal. 
Descriptions  of  the  operation  may  be  found  in  Mr. 
Hodgson’s  work,  p.  382.  When  I consider  the  man- 
ner in  which  the  subclavian  arterj',  before  it  passes 
behind  the  anterior  scalenus,  is  surrounded  by  parts 
of  great  importance,  I can  scarcely  bring  my  mind  to 
think,  that  the  measures  requisite  for  taking  up  the 
vessel  in  this  situation,  will  ever  leave  the  patient 
imuch  chance  of  recovery.  “ Between  the  aorta  and 
scaleni  muscles  (says  Mr.  A.  Burns)  the  subclavian 
arteries  are  connected  with  several  important  vessels 
and  nerves.  They  are  in  the  vicinity  of  the  nervus 
vagus,  of  the  recurrent  laryngeal  nerve,  of  the  sympa- 
thetic nerve,  of  the  phrenic  nerve,  and  the  subclavian 
vein ; and,  on  the  left  side,  the  subclavian  artery  is  in- 
timately connected  with  the  termination  of  the  tho- 
racic duct.  These  parts  are  all  grouped  together  in  a 
very  narrow  space,  and  the  perjilexity  of  their  dissec- 
tion is  farther  increased  by  the  interlacement  of  the 
different  nerves  with  one  another.  The  natural  con- 
nexions of  these  parts  are  best  shown  by  merely  rais- 
ing the  external  extremity  of  the  sterno-mastoid  mus- 
cle. If  this  be  done,  the  nervus  vagus  will  be  brought 
into  view,  lying  on  the  forepart  of  the  subclavian  ar- 
tery, almost  directly  behind  the  sternal  end  of  the  cla- 
vicle ; and  exactly  opposite  to  the  nervus  vagus,  but 
behind  the  artery,  the  lower  cervical  ganglion  of  the 
sympathetic  nerve  will  be  brought  into  view.  The  re- 
current nerve,  on  the  right  side,  hooks  round  the  sub- 
clavian artery,  and,  in  its  course  towards  the  larynx, 
ascends  along  the  tracheal  side  of  the  sympathetic 
nerve.  On  the  left  side,  it  twines  round  the  arch  of 
the  aorta,  and  in  mounting  upwards,  is  interposed  be- 
tween the  subclavian  artery  and  cesophagus.  The 
subclavian  vein  lies  anterior  to  the  artery,  and  in  the 
collapsed  state,  sinks  nearer  to  the  thorax but,  when 
distended  in  the  living  body,  it  overlaps  the  artery. 
The  thoracic  duct  enters  the  subclavian  vein,  about 
the  eight  of  an  inch  nearer  to  the  acromion  than  the 
point  where  the  internal  jugular  vein  empties  itself 
into  the  subclavian  vein.  The  termination  of  the  tho- 
racic duct  is  situated  between  the  sternal  and  clavicu- 
lar portions  of  the  sterno-mastoid  muscle. — {A.  Burns, 
on  the  Surgical  Anatomy  of  the  Head  and  Neck,  p.  28.) 

A case  in  which  an  axillary  aneurism,  unattended 
with  pulsation,  was  punctured,  and  the  child  bled  to 
death,  is  noticed  in  a modern  periodical  work. — (See 
Med.  Chir.  Journ.  vol.  4,  p.  78.) 

For  anatomical  views  of  the  parts  concerned  in  the 
operation  of  taking  up  the  subclavian  artery,  consult 
Rosenmiiller's  Chir.  Anat.  Plates,  part  2,  tab.  8 and 
9 ; Tiedemann's  evnd  Scarpa's  beautiful  engravings. 

Some  valuable  anatomical  remarks,  in  relation  to 
the  oiieration,  are  given  by  Mr.  A.  Burns.— (6’i4rg^icaZ 
Anatomy  of  the  Head  and  Neck,  p.  28,  c.) 

In  certain  cases  of  subclavian  aneurism,  it  has  been 
proposed  to  tie  the  arteria  innomiuata.  In  the  dead 
subject,  Mr.  Allan  Burns  applied  two  ligatures  to  it, 
and  after  cutting  through  the  vessel  in  the  interspace, 
he  injected  the  aorta,  when  the  injection  was  found  to 
ixirvade  the  anastomosing  vessels  of  the  right  arm, 
and  all  those  of  the  head.  But  notwithstanding  this  1 


fact,  and  others  noticed  by  Mr.  Hodgson,  tending  to 
show  the  probability  that  a ligature  upon  the  arteria 
innominata  would  not  prevent  the  arm  and  head  from 
receiving  an  adequate  supply  of  blood,  other  objec- 
tions were  made  to  the  practice.  The  principal  of 
these  were  founded  upon  the  difficulty  of  the  opera- 
tion in  the  living  body ; the  inflammation,  likely  to  be 
excited  by  it  in  neighbouring  important  organs ; the 
danger  of  hemorrhage  from  the  adhesion  of  the  vessel 
being  likely  to  be  broken  by  the  force  of  the  circula- 
tion ; and  the  equal  practicableness,  in  most  cases,  of 
tying  the  subclavian  artery  on  the  tracheal  side  of  the 
scalenus. 

Dr.  Mott,  an  eminent  surgeon  at  New-York,  im- 
pressed with  the  value  of  Mr.  .\llan  Burns’s  remarks 
upon  this  subject,  has,  ever  since  he  became  acquainted 
with  them,  maintained  in  his  lectures  the  propriety  of 
attempting  to  tie  the  arteria  innominata,  under  particu- 
lar circumstances  of  subclavian  aneurism.  At  length, 
Dr.  Mott  put  this  new  operation  to  the  test  of  experi- 
ence in  the  New-York  Hospital,  on  the  11th  of  June, 
1818.  The  case  was  a subclavian  aneurism  on  the 
right  side,  and  the  patient,  a sailor,  aged  fifty-seven,  to 
whom  seventy  drops  of  tinct.  opii  were  first  given. 
Dr.  Mott  began  the  first  incision  directly  over  the 
swelling  above  the  clavicle,  extended  it  along  this  bone 
and  ended  it  at  the  trachea,  just  above  the  upper  por- 
tion of  the  sternum.  Here  he  commenced  the  second 
incision,  of  about  the  same  length  as  the  first,  and 
reaching  along  the  inner  margin  of  the  stemo-cleido- 
mastoideus.  Dr.  Mott  next  detached  the  skin  from 
the  subjacent  platysma  myoides,  cut  through  the  lat- 
ter, and  cautiously  divided  the  sternal  portion  of  the 
mastoid  muscle,  in  the  direction  of  the  first  incision. 
The  internal  jugular  vein  now  presented  itself  close 
to  the  swelling,  and  adherent  to  it ; a circumstance 
that  rendered  the  subsequent  part  of  the  operation  very 
difficult.  After  detaching  a portion  of  the  latter  vein 
from  its  connexion,  Dr.  Mott  cut  through  the  sterno- 
hyoideus  and  sterno-thyroideus,  and  turned  them  back 
over  the  trachea.  The  carotid  was  now  exposed  a 
few  lines  above  the  sternum,  and  after  he  had  sepa- 
rated the  par  vagtim  and  internal  jugular  vein  from  it, 
they  were  drawn  towards  the  outer  side  of  the  neck. 
Dr.  Mott  then  laid  bare  the  subclavian  artery,  which 
part  of  the  operation  he  chiefly  accomplished  with  the 
handle  of  the  scalpel,  as  there  was  nothing  to  be  sepa- 
rated but  cellular  membrane.  The  subclavian  artery 
was  found  to  be  very  much  enlarged  and  diseased,  and 
as  Dr.  Mott  recollected  that  this  state  of  the  vessel 
had  seemingly  hindered  its  successftil  closure  in  the 
example  operated  upon  by  Dr.  Colles,  of  Dublin,  he 
decided  to  take  up  the  arteria  innominata  itself.  In 
detaching  the  cellular  membrane  from  the  lower  sur- 
face of  the  subclavian  artery,  a small  branch,  situated 
about  half  an  inch  from  the  innominata,  was  injured, 
and  the  wound  w’as  six  or  eight  times  filled  with  blood 
from  it.  The  hemorrhage  was  soon  suppressed,  how- 
ever, by  means  of  a little  pressure.  Had  not  the 
bleeding  been  so  easily  stopped.  Dr.  Mott  would  have 
concluded,  from  the  situation  of  the  vessel,  that  it  was 
the  internal  mammary;  but  if  it  were  not  this  branch, 
he  conceives  it  must  have  been  an  artery  not  regu- 
larly originating  in  this  situation ; perhaps  the  supe- 
rior intercostal. 

Dr.  Mott  continued  the  operation  with  a small,  round- 
ended,  sharp  scalpel,  until  he  came  to  the  division  of 
the  arteria  innominata,  which  great  vessel  he  traced 
below  the  sternum,  and  after  freeing  it  from  all  the  cel- 
lular membrane  with  the  handle  of  the  scalpel,  and 
drawing  aside  the  recurrent  and  phrenic  nerves,  he  tied 
it  with  a round  silk  ligature,  about  half  an  inch  from 
its  bifurcation. 

Most  surgeons,  says  Dr.  Mott,  complain  of  the  diffi- 
culty  of  tying  large  arteries  in  a deep  small  wound. 
Hence,  he  recommends  a set  of  instruments,  invented 
for  the  purpose,  in  Philadelphia,  by  Drs.  Parish, 
Hartshorn,  and  Kewson ; consisting,  1st.  Of  several 
blunt-pointed  needles,  of  various  sizes  and  curvatures, 
furnished  with  an  eye  at  each  end,  and  calculated  at 
one  end  to  screw  into  a strong  handle.  2dly.  Two 
strong  instruments,  with  handles,  having  at  one  end  an 
eye  or  hole ; they  resemble  those  sometimes  used  for  ap- 
plying a ligature  to  the  tonsils.  3dly,  A small  round 
pointed  scalpel.  4thly.  A small  hook,  flyed  in  a very 
strong  handle. — (Parish,  in  Eclectic  Rep.  vol.  3,  p.  229.) 

After  Dr.  Mott  had  introduced  the  ligature  into  tfic 


ANEURISM. 


137 


eye  of  one  of  the  above-described  needles,  and  screwed 
the  needle  into  a handle,  he  pressed  with  its  convexity 
the  cellular  membrane  and  pleura  carefully  down- 
wards, while  he  carried  it  from  below  upwards  round 
the  artery.  As  the  point  now  appeared  on  the  other 
bide  of  the  vessel,  the  above-mentioned  hook  was  passed 
into  its  eye,  and  the  handle  unscrewed  from  the  other 
end  of  it,  when  it  was  easily  drawn  out  from  under  the 
artery,  and  the  ligature  left  under  the  vessel. 

In  this  part  of  the  operation.  Dr.  Mott  urges  the  ne- 
cessity of  being  particularly  attentive  to  two  impor- 
tant circumstances;  one  is,  to  convey  the  ligature 
round  the  artery  from  below  upwards,  as  the  only  way 
to  prevent  injury  of  the  pleura ; and  the  other  is,  to 
fix  the  hook  in  the  eye  of  the  needle,  before  the  handle 
is  unscrewed  from  its  other  end,  because,  after  this 
has  been  done,  the  needle  loses  all  steadiness,  and  it 
is  then  difficult  to  get  the  hook  into  the  eye. 

With  respect  to  the  foregoing  instruments,  I may  ob- 
serve, that  they  are  superseded  by  the  needle  lately 
constructed  by  Mr.  Weiss. 

Dr.  Mott  now  made  a noose,  pressed  it  with  the 
fore-finger  down  to  the  artery,  and  tightened  it  very 
gradually,  in  order  not  to  stop  the  flow  of  blood 
through  the  vessel  all  at  once.  A moderate  constric- 
tion was  kept  up  some  seconds,  so  that  the  effect  of 
the  ligature  upon  the  heart  and  lungs  might  be  ob- 
served; and  as  no  disturbance  was  produced  in  the 
functions  of  these  organs.  Dr.  Mott  tightened  the  liga- 
ture, and  stopped  the  current  of  blood  through  the 
vessel.  At  this  instant,  the  pulsation  of  the  right  tem- 
poral and  radial  arteries  ceased.  The  noose  was 
tightened  still  more  with  the  above-mentioned  ligature 
irons,  and  then  a second  knot  was  made.  Dr.  Mott 
was  greatly  pleased  at  finding  his  patient’s  counte- 
nance remain  perfectly  unchanged,  and  no  complaint 
made  of  pain  in  any  other  part.  Immediately  after 
the  ligature  had  been  applied,  the  aneurismal  swell- 
ing lost  one-third  of  its  size,  and  the  clavicle  could  be 
felt  through  its  whole  extent.  The  divided  muscles 
and  detached  skin  were  now  brought  into  their  natu- 
ral situation,  the  wound  closed  with  three  sutures  and 
adhesive  pl2ister,  and  a compress  applied.  In  the  ope- 
ration three  small  arteries  were  tied : the  first  lay 
under  the  sternum,  and  seemed  to  be  a branch  of  the 
internal  mammary ; the  second  was  a descending 
branch  of  the  superior  thyroideal ; and  the  third  a 
branch  of  the  inferior  thyroideal.  From  two  to  four 
ounces  of  blood  were  lost,  most  of  which  came  from 
an  injured  small  branch  of  the  subclavian.  The  ope- 
ration took  up  about  ah  hour.  The  curved  spatulae 
recommended  by  Dr.  Colies,  were  found  very  useful 
for  holding  the  carotid  and  par  vagum  aside,  while,  by 
their  uniform  pressure,  they  materially  assisted  in  re- 
straining the  effusion  of  blood  from  small  vessels,  and 
as  taking  up  little  room,  were  infinitely  more  conve- 
nient in  a deep  narrow  wound,  than  the  fingers  of  an 
assistant. 

The  day  after  the  operation,  the  veins  of  the  right 
forearm  and  hand  had  a turgid  appearance.  When  the 
circulation  in  them  was  promoted  by  pressure,  they 
became  empty  for  some  distance  above  the  pressed 
part,  but  filled  again  immediately  the  pressure  was  re- 
moved ; a circumstance  that  seemed  to  show,  that  the 
circulation  in  this  arm,  notwithstanding  the  ligature 
of  the  arteria  innominata,  still  went  on  with  great  ce- 
lerity, though  no  pulse  could  be  felt  in  the  brachial  and 
radial  arteries.  On  the  contrary,  the  puise  was  very 
plain  in  the  front  branch  of  the  temporal  artery,  just 
above  the  outer  angle  of  the  orbit.  The  left  external 
carotid  beat  with  unusual  force.  In  a few  days,  how- 
ever, the  pulse  became  perceptible  again  at  the  right 
wrist. 

My  limits  will  not  allow  me  to  enter  into  all  the  de- 
tails of  this  interesting  ca.se  : suffice  it  to  mention,  that 
the  patient  suffered  considerable  febrile  disturbance 
at  some  periods  after  the  operation,  and  it  was  neces- 
sary twice  to  have  recourse  to  venesection.  He  was 
also  afflicted  with  a severe  cough.  The  discharge 
from  the  wound  was  copious  and  fetid.  The  main  liga- 
ture separated  on  the  fourteenth  day.  On  the  twen- 
tieth day,  the  patient  was  sufficiently  recover^  to 
walk  in  the  garden.  On  the  twenty-first  day,  the 
wound  was  almost  closed  ; the  patient  could  move  his 
right  arm  with  the  same  facility  as  his  left,  and  he 
was  gaining  such  strength,  that  no  doubts  were  enter- 
tained about  the  successful  result  of  the  operation. 


On  the  twenty-third  day,  hemorrhage  came  on  from 
the  wound  : it  was  stopped  by  the  introduction  of  lint 
and  the  employment  of  pressure.  About  twenty-four 
ounces  of  blood  were  lost,  whereby  the  patient  was 
so  depressed  that  the  pulse  was  no  longer  distinguish- 
able. On  the  twenty-fourth  day,  in  the  evening,  he 
lost  four  ounces  more  blood  ; on  account  of  his  rest- 
lessness and  the  painful  state  of  his  arm,  two  grains 
of  opium  were  administered  to  him.  After  one  or 
more  returns  of  bleeding,  he  died  on  the  twenty-sixth 
day. 

When  the  body  Avas  opened,  no  traces  of  inflamma- 
tion or  its  consequences  Avere  found  either  in  the  arch 
of  the  aorta,  the  origin  of  the  innominata  or  the  lungs. 
The  aorta  was  now  slit  open  longitudinally,  and  a 
probe  then  cautiously  passed  through  it  into  the  inno- 
minata, when  the  instrument  went  through  the  latter 
vessel  into  the  cavity  of  the  AA’ound.  The  inner  coat 
of  the  innominata  was  smooth  and  soft ; but  about 
half  an  inch  from  the  place  where  the  ligature  had  cut 
through  the  vessel,  marks  of  inflammation  were  no- 
ticed, and  a coagulum  adhered  to  the  sides  of  the  ar- 
tery Avith  considerable  firmness,  so  that  nature  had 
probably  endeavoured,  by  means  of  adhesive  inflam- 
mation, to  close  the  vessel,  but  had  been  prevented 
from  completing  the  salutary  process  by  the  destruc- 
tive ulceration.  One  portion  of  the  parietes  of  the 
innominata  was  thickened  by  inflammation,  and  an 
anomalous  branch,  as  large  as  a crow’s  quill,  arose 
from  this  artery. 

The  ulcer  was  tAAice  as  extensive  inwardly  as  it  was 
superficially,  reaching  laterally  to  the  trachea,  and  un- 
der the  clavicle  to  the  swelling.  The  tripod  of  great 
vessels,  viz.  the  innominata,  the  subclavian,  and  the 
carotid,  was  destroyed  by  ulceration  to  the  extent  of 
about  an  inch,  and  the  ends  of  both  the  last  vessels 
opened  into  the  wound.  At  this  place  the  pleura  was 
considerably  thickened  by  a layer  of  organized  lymph. 

The  inner  surface  of  the  carotid  was  covered  with 
a coagulum,  and  its  coats  so  much  thickened,  that  a 
probe  could  hardly  be  passed  into  it.  The  consolida- 
tion reached  up  to  the  division  into  the  external  and  in- 
ternal carotid.  The  subclavian  was  pervious  as  far  as 
the  situation  of  the  disease.  The  diameter  of  the  bra- 
chial and  other  arteries  of  the  right  arm  was  natural. 
The  external  mammary  artery  was  enlarged,  but  not 
the  internal.  The  clavicle  was  carious,  and  several 
lymphatic  glands  under  it  in  the  state  of  suppuration. 

Though  the  result  of  the  operation  was  unsuccess- 
ful, it  proves,  as  Dr.  Mott  correctly  remarks,  some  in- 
teresting points ; namely,  that  tying  an  artery  of  such 
magnitude,  and  so  near  the  heart,  may  be  done  with- 
out occasioning  any  disturbance  either  in  the  functions 
of  the  brain,  the  heart,.the  lungs,  or  the  right  arm. 

The  suppuration,  which  continually  extended  itself 
more  and  more  deeply,  is  set  down  by  Dr.  Mott  as  the 
cause  of  the  patient’s  death ; for,  as  no  bleeding  took 
place  for  several  days  after  the  detachment  of  the  prin- 
cipal ligature,  it  is  plain  that  this  must  have  fulfilled 
its  duty,  and  that  the  artery  had  been  closed.— (See 
New-Yark  Med.  and  Surgical  Register,  1818,  vol.  1.) 

[This  new  and  formidable  operation,  the  practicabi- 
lity of  which  Dr.  Mott  has  thus  demonstrated,  and  the 
safety  of  which  is  now  decided  in  any  future  aneu- 
rism in  which  it  may  become  necessary,  is  justly  con- 
sidered one  of  the  most  splendid  achievements  ever 
accomplished,  and  is  destined  to  give  the  author’s  name 
immortality ; and  this,  with  the  successful  case  of  liga-> 
ture  of  the  iliacus  communis,  confers  upon  American 
surgery  imperishable  laurels.  As  an  cAddence  of  the 
estimation  in  which  this  operation  is  held  in  Europe,  I 
feel  a national  pride  in  inserting  the  following  extract 
of  a letter  from  that  distinguished  surgeon.  Professor 
Colies,  of  Dublin,  Avritten  to  Dr.  Mott  soon  after  his 
case  of  ligature  on  the  innominata  had  reached  him. 

I think  this  tribute  to  the  able  operator  is  the  more  im- 
portant, since  efforts  have  been  made  by  the  envious 
to  detract  from  the  merit  of  the  operation ; and  it  has 
been  publicly  stated  that  the  same  operation  has  been 
performed  in  Europe,  and  even  by  Dr.  Codes  himself 
That  this  is  not  the  fact  will  be  obvious  from  the  ex- 
tract which  follows,  and  which  I introduce  without 
any  farther  comment. 

“ I shall  not  attempt  to  say  how  much  the  profession 
is  indebted  to  you  for  this  bold  and  splendid  operation. 
That  it  did  not  succeed  I lament  on  your  account ; that 
it  will  hereafter  succeed,  there  cannot  be  a doubt  in 


138 


ANEURISM. 


the  mind  of  any  reasoning  man.  Your  feelings  during 
the  first  twenty-two  days  after  the  operation  are  to  be 
envied.  The  hopes  of  success  continued  so  strong  and 
so  well  founded,  while  the  slight  degree  of  uncertainty 
as  to  the  issue  must  have  exalted  those  feelings  to  the 
liighest  intensity.  I have  never  read  the  account  of  an 
operation  in  which  I would  rather  have  been  the  ope- 
rator,”—Keesc.] 

The  arteria  innominata  was  also  tied  by  Graefe  on 
the  5th  of  March,  1822,  in  the  Clinical  Hospital  of  the 
University  of  Berlin,  on  account  of  a subclavian  aneu- 
rism. The  carotid  was  exposed  and  traced  down  to 
the  innominata,  to  which  a ligature  was  applied  by 
means  of  a blunt  tenaculum  constructed  for  the  pur- 
pose, the  vessel  being  tied  at  most  about  an  inch  from 
the  curvature  of  the  aorta,  ami  two  inches  from  the 
heart.  As  soon  as  the  ligature  was  tightened,  the  pul- 
sation of  the  arteries  of  the  right  arm,  right  caro- 
tid, and  right  temporal  artery  ceased;  at  the  same 
instant  the  throbbing  of  the  aneurism  stopped,  and 
the  tumour  became  flaccid.  The  constriction  of  the 
cord  produced  no  disturbance  of  any  function.  The 
patient  went  on  so  well  for  several  weeks  afterward, 
that  no  doubt  was  entertained  of  las  recovery.  How- 
ever, when  the  wound  was  nearly  healed,  hemor- 
rhage came  on,  and  though  it  was  suppressed,  and  hope 
began  to  be  again  indulged,  the  bleeding  recurred,  and 
the  patient  died  on  the  sixty-seventh  day.  Below  the 
ligature  the  innominata  was  (bund  closed  with  lymph. 
Graefe  has  written  a distinct  essay  on  the  method  in 
which  the  operation  was  done;  the  daily  particulars 
of  the  case,  and  preparation  from  it,  are  placed  in  the 
Royal  Anatomical  Museum  at  Berlin. — (See  Joum. 
der  Chirurgie  vcra  C.  F.  Graefe,  and  Ph.  v.  Walther, 
b.  3,  r-  596,  ^-c.,  b.  4,  p.  587.)  Of  Mr.  Wardrop’s  prac- 
tice of  tying  the  subclavian  artery  in  aneurism  of  the 
arteria  innominata  itself,  we  shall  presently  speak. 

CAROTID  ANEURISMS. 

There  is  no  part  of  the  body  where  the  diagnosis  of 
aneurisms  is  more  liable  to  mistake  than  in  the  neck. 
Here  the  disease  is  particularly  apt  to  be  confounded 
with  tumours  of  another  nature.  We  have  already 
cited  in  this  article  examples  in  which  aneurisms  of' 
the  arch  of  the  aorta  so  resembled  those  of  the  carotid 
as  to  have  deceived  the  surgeon  who  was  consulted. 
The  swelling  of  the  lymphatic  glands,  or  of  the  cellu- 
lar substance  which  surrounds  the  carotid  artery,  the 
enlargement  of  the  thyroid  gland,  and  especially  ab- 
scesses, may  resemble  an  aneurism  by  the  pulsations 
communicated  to  them  by  the  neighbouring  artery. 
On  the  other  hand,  aneurisms  of  long  standing,  which 
no  longer  throb,  and  the  integuments  over  which  are 
changed  in  colour  and  likely  to  burst,  may  the  more 
easily  be  mistaken  by  an  inattentive  practitioner  for 
chronic  abscesses,  as  the  neck  is  remarkably  often  the 
seat  of  such  diseases.— (Boyer,  Traite  des  Maladies 
Chirurgicales,  t.  2,  p.  185.) 

Scarpa  mentions  one  unfortunate  patient  who  was 
killed  by  a knife  being  plunged  in  a carotid  aneurism, 
on  the  supposition  that  the  case  was  an  abscess. 

I need  scarcely  observe,  that  by  opening  a carotid 
aneurism  a surgeon  would  expose  himself  to  the  dis- 
grace and  mortification  of  seeing  the  patient  die  under 
his  hands,  as  happened  in  the  example  cited  by  Har- 
derus.— (Apior.  Observationum,  Obs.  86.) 

The  possibility  of  tying  the  carotid  artery  in  cases 
of  wounds  and  aneurisms,  without  any  injurious  ef- 
fect on  the  functions  of  the  brain,  is  now  completely 
proved.  Petit  mentions  that  the  advocate  Vieillard  had 
an  aneurism  at  the  bifurcation  of  the  right  carotid,  for 
the  cure  of  which  he  was  ordered  a very  spare  diet, 
and  directed  to  avoid  all  violent  exercise.  Three 
months  afterward  the  tumour  had  evidently  dimi- 
nished ; and  at  last  it  was  converted  into  a small, 
hard,  oblong  knot,  without  any  pulsation.  The  patient 
having  died  of  apojilexy  seven  years  afterward,  the 
right  carotid  was  found  closed  up  and  obliterated  from 
its  bifurcation,  as  low  down  as  the  right  subclavian 
artery.— (Acrtd.  des  Sciences  de  Paris,  an  1765.)  Hal- 
ler dissected  a woman  whose  left  carotid  was  imper- 
vious.— (Opuscula  Pathol.  Obs.  19,  tab.  1.)  An  ex- 
ample of  the  total  closure  of  both  carotids  in  conse- 
^luence  of  ossification,  is  stated  by  Koberwein  to  be 
recorded  by  Jadelot.— (Ger/nara  transl.  of  Mr.  Hodg- 
son’s work,  p.  293.)  Hebenstreit,  vol.  4,  p.  266,  ed.  3, 
of  Ills  translation  of  B.  Bell’s  Surgery,  mentions  a case 


in  which  the  carotid  artery  ■was  wounded  in  thti  extir- 
pation of  a scirrhous  tumour.  The  hemorrhage  would 
have  been  fatal  had  not  the  surgeon  immediately  tied 
the  trunk  of  the  vessel.  The  patient  lived  many  years 
afterward.  This  is  probably  the  earliest  authentic 
instance  in  which  a ligature  was  applied  to  the  carotid 
artery.  Mr.  Aberncthy’s  case  is  perhaps  the  second  : 
and  that  in  which  Mr.  Fleming,  a naval  surgeon,  tied 
the  common  carotid  in  a sailor  who  attempted  suicide, 
and  who  was  saved  by  the  operation,  is  still  later,  not 
having  occurred  till  the  year  1803.— (See  Med.  Chir. 
Joum.  vol.  3,  p.  2.) 

Dr.  Baillie  knew  an  instance  in  which  one  carotid 
was  entirely  obstructed,  and  the  diameter  of  the  other 
considerably  lessened,  without  any  apparent  ill  effects 
on  the  brain.— (See  Trans,  for  the  Improvement  of 
Med.  and  Chir.  Knowledge,  vol.  \,p.  121.)  Sir  Astley 
Cooper  has  also  recorded  an  example  in  which  the  left 
carotid  was  obstructed  by  the  pressure  of  an  aneurism 
of  the  aorta ; and  yet  during  life  no  paralysis  nor  im- 
pairment of  the  intellects  had  occurred. — (See  Med. 
Chir.  Trans,  vol.  1,  p.  223.)  A similar  case  is  related 
by  Pelletan. — {Clinique  Chir.  t.  1,  p.  68.) 

Mr.  Abernethy  was  under  the  necessity  of  laying  the 
trunk  of  the  carotid  in  a case  of  extensive  lacerated 
wound  of  the  neck,  w'here  the  internal  carotid  and  the 
chief  branches  of  the  external  carotid  were  wounded. 
The  patient  at  first  went  on  well : hut  in  the  night  he 
became  delirious  and  convulsed,  and  died  about  thirty 
hours  after  the  ligature  was  applied.  This  case  fell 
under  my  own  notice,  and  the  inference  which  I drew 
was,  that  the  man  died  more  from  the  great  quantity  of 
blood  which  he  lost,  and  the  severe  mischief  done 
to  the  jiarts  in  the  neck,  than  from  any  efiect  of  the 
ligature  of  the  artery  on  the  brain. 

In  another  instance  in  which  the  common  carotid 
was  tied,  on  account  of  a wound  of  the  external  caro- 
tid by  a musket-ball,  complicated  with  fracture  of  the 
condyle  and  coracoid  process  of  the  lower  jaw,  every 
thing  went  on  favourably  until  the  seventh  day  after 
the  operation.  Neither  the  intellectual  faculties  nor 
the  functions  of  the  organs  of  sense  had  been  at  all 
disturbed.  But  at  that  period  stupor,  confusion  of 
ideas,  restlessness,  a small  unsteady  pulse,  discolor- 
ation of  the  face,  and  loss  of  strength  came  on,  fol- 
lowed in  the  evening  by  a violent  paroxysm  of  fever. 
On  the  eighth  day  three  copious  hemorrhages  took  place 
from  the  whole  surface  of  the  wound,  and  on  the  ninth 
the  man  died.  In  this  case,  however,  the  aflTection  of 
the  brain,  and  the  other  unfavourable  symptoms,  would 
be  ascribed  by  nobody  to  the  effects  of  the  ligature  on 
the  carotid,  but  every  one  would  see  the  cause  in  the 
severe  and  extensive  local  mischief  produced  partly  by 
the  rnusket-ball,  and  partly  by  the  mode  in  which  the 
operation  was  performed,  the  surgeon  having  extended 
his  incisions  from  the  parotid  gland  to  within  an  inch 
of  the  clavicle ! — (See  Joum.  General  de  Med.  <i  c.  par 
Sediltot.) 

That  the  carotid  maybe  tied  without  injuring  the 
functions  of  the  brain,  and  that  aneurisms  of  this  ar- 
tery admit  of  being  cured  by  the  operation,  is  now 
fully  proved.  The  folloiving  is  the  second  instance  in 
which  I have  been  present  at  the  operation  of  tjing 
the  carotid  trunk  on  account  of  a wound. 

A soldier  of  the  44th  regiment  was  wounded  in  the 
neck  with  a pike  at  the  battle  of  Waterloo,  and  was 
brought  to  Brussels.  After  he  had  been  some  little 
time  in  the  hospital,  the  bleeding,  which  had  stopped, 
recurred  with  great  violence,  both  from  the  mouth  and 
the  external  wound  itself ; and  it  was  therefore  judged 
necessary  to  tie  the  common  carotid,  which  was  done 
by  my  friend  Mr.  Collier.  The  operation  was  per- 
formed by  making  an  incision  along  the  inner  edge  of 
the  sterno-cleido-mastoideus,  raising  tliis  muscle  from 
the  sheath  including  the  artery,  &c.,  and  holding  aside 
the  jugular  and  lower  thyroid  veins,  which  swelled  up 
every  instant  to  a very  large  size,  so  as  to  overlap  the 
artery.  This  vessel  being  disengaged  from  the  nerve 
was  ttien  tied.  'Ihough  the  operation  was  done  by 
candle-light  it  was  skilfully  performed,  and  reflects 
great  credit  on  Mr.  Collier.  A detail  of  the  case  may 
be  ftftnd  in  a modern  work.— (Med.  Chir.  Trans,  vol. 

7,  p.  107.) 

Another  example  in  which  the  carotid  artery  was 
tied  and  the  patient  saved,  in  a case  where  it  was 
wounded  with  a penknife,  was  imblished  by  Dr.  John 
Brown,  surgeon  to  the  county  of  Meath  Infirmary.— 


ANEURISM. 


139 


XSee  Dublin  Hospital  Reports,  vol.  \,  p.  301,  Src.)  In 
xhis  instance,  the  internal  jugular  vein  “ did  not  ap- 
pear, nor  was  it  a source  of  the  slightest  inconve- 
nience during  the  operation.”— (P.  305.)  A case,  very 
analogous  to  the  foregoing,  is  recorded  by  Mr.  Hodg- 
son, and  the  event  equally  successful.  “ The  jugular 
vein  afforded  no  trouble  in  the  operation ; it  was  not 
even  seen.”  A gradual  improvement  of  the  power  of 
deglutition  marked  the  gradual  subsidence  of  the  tu- 
mour, which  pressed  against  the  pharynx.  Nor  was 
any  changed  perceived  in  the  state  of  the  patient’s 
mind  after  this  operation,  who  remained  as  she  had 
been  previously,  melancholy  and  dejected.— (P.  332.) 

Acrel  mentions  an  example  in  which  the  carotid  ar- 
tery was  wounded  by  a gun-shot,  and  the  hemorrhage 
permanently  stopped  by  compression.  A similar  case 
is  related  by  Van  Horne,  in  his  annotations  to  the  work 
of  Botallus. — {De  Vuln.  Sclopetus.)  Baron  Larrey  has 
likewise  related  a case  in  which  the  carotid  was 
wounded  by  a musket-ball,  and  life  saved  by  the  instant 
application  of  pressure. — (Mt'm.  de  Chir.  Mil.  t.  1,  p. 
309.)  However,  considering  the  size  of  the  vessel, 
and  its  unfavourable  situation  for  being  effectually  and 
steadily  compressed,  some  doubts  may  be  entertained, 
whether  the  vessel  wounded  might  not  rather  have 
been  one  of  its  branches. 

November  1,  1805,  Sir  Astley  Cooper  operated  on 
Mary  Edwards,  aged  forty-four,  who  had  an  aneurism 
of  the  right  carotid  artery  : the  tumour  reached  from 
the  vicinity  of  the  chin  to  beyond  the  angle  of  the  jaw, 
and  downwards  to  within  two  inches  and  a half  from 
the  clavicle. 

The  swelling  had  a strong  pulsatory  motion.  The 
woman  also  complained  of  a particular  tenderness  of 
the  scalp  on  the  same  side  of  the  head,  and  of  such  a 
throbbing  in  the  brain  as  prevented  her  from  sleeping. 

An  incision,  two  inches  long,  was  made  at  the  inner 
edge  of  the  sterno-cleido-mastoideus  muscle,  from  the 
lower  part  of  the  tumour  to  the  clavicle.  This  wound 
exposed  the  omo-hyoideus  and  sterno-hyoideus  mus- 
cles, which  being  drawn  aside  towards  the  trachea, 
the  jugular  vein  presented  itself  to  view.  The  mo- 
tion of  this  vein  produced  the  only  difficulty  in  the 
operation,  as,  under  the  different  states  of  breathing, 
the  vessel  sometimes  became  tense  and  distended 
under  the  knife,  and  then  suddenly  collapsed.  Sir 
Astley  Cooper  introduced  his  finger  into  the  wound  to 
keep  the  vein  out  of  the  way  of  the  knife,  and  having 
exposed  the  carotid  artery  by  another  cut,  he  passed 
two  ligatures  under  this  vessel  by  means  of  a curved 
aneurism-needle.  Care  was  taken  to  exclude  the  re- 
current nerve  on  the  one  hand,  and  the  par  vagum  on 
the  other.  Tlie  ligatures  were  then  tied  about  half  an 
inch  asunder ; but  the  intervening  portion  of  the  ar- 
tery was  left  undivided. 

The  pulsation  of  the  swelling  ceased  immediately 
the  vessel  was  tied ; and  on  the  day  after  the  operation, 
the  throbbing  in  the  brain  had  subsided,  while  no  dimi- 
nution of  nervo  is  energy  in  any  part  of  the  body  could 
be  observed. 

The  patient  was  occasionally  affiicted  with  bad  fits 
of  coughing,  but  upon  the  whole  went  on  at  first  pretty 
well.  On  the  eighth  day,  however,  a paralysis  of  the 
left  leg  and  arm  was  noticed,  attended  with  a great 
deal  of  constitutional  irritation.  November  8th,  the 
patient  could  move  her  arm  rather  better ; but  became 
unable  to  swallow  solids.  Nov.  12th,  the  palsy  of  her 
arm  had  now  almost  disappeared.  The  ligatures  came 
away.  Nov.  14th,  she  was  in  every  re.spect  better; 
she  swallowed  with  less  di^jieulty;  and  the  tumour 
was  smaller,  and  (juite  free  from  pain.  On  the  17th, 
she  became  very  ill ; the  tumour  increased  in  size,  and 
was  sore  when  pres.sed.  The  wound -was  as  large  as 
immediately  after  the  operation,  and  discharged  a sa- 
nio'js  serum.  Great  difficulty  of  swallowing,  and  a 
most  distressing  cough  were  ahso  experienced.  The 
pulse  was  ninety-six,  and  the  left  arm  again  very 
weak.  On  the  21st,  the  patient  died,  the  difficulty  of 
swallowing  having  previously  become  still  greater, 
attended  with  a farther  increase  of  the  tumour,  the 
skin  over  which  had  acquired  a brownish-red  colour. 

On  opening  the  swelling  after  death,  the  aneurismal 
sac  was  found  inflamed,  and  the  clot  of  blood  in  it  was 
surrounded  with  a considerable  quantity  of  pus.  The 
inflammation  extended  on  the  outside  of  the  sac,  along 
the  par  vagum,  nearly  to  the  basis  of  the  skull.  The 
glottis  was  almost  closed,  and  the  lining  of  the  trachea 


was  inflamed  and  covered  with  coagulating  lymph. 
The  pharynx  was  so  compressed  by  the  tumour,  which 
had  been  suddenly  enlarged  by  the  inflammation,  that 
a bougie  of  the  size  of  a goo.se-quill  could  hardly  be 
introduced  into  the  oesophagus  Sir  Astley  Cooper 
concludes  with  expressing  his  opinion  that  these  causes 
of  failure  may.,  in  future,  be  avoided  by  operating  be- 
fore the  tumour  is  of  such  size  as  to  make  pressure 
on.  important  parts;  or,  if  the  swelling  should  be 
large,  by  opening  it,  and  letting  out  its  contents,  as 
soon  as  inflammation  comes  on. — (See  Med.  Vhir. 
Trans,  vol.  1.) 

In  one  case  under  the  care  of  Mr.  Coates,  of  Salis- 
bury, the  making  of  an  opening,  about  a month  after 
the  operation,  gave  relief  by  discharging  seven  ounces 
of  fetid  blood  and  pus ; but  three  weeks  afterward, 
hemorrhage  came  on  from  the  sac,  and  the  jiatient  was 
carried  off  by  repeated  loss  of  blood.  On  dissection, 
an  artery  capable  of  admitting  a probe  was  found  to 
pass  into  the  cavity  of  the  sac. — (See  Med.  Chir. 
Trans,  vol.  11,  part  2.) 

In  June,  180M,  Sir  Astley  Cooper  operated,  in  Guy’s 
Hospital,  on  a man  aged  50,  who  had  a carotid  aneu- 
rism, attended  with  pain  on  one  side  of  the  head, 
throbbing  in  the  brain,  hoarseness,  cough,  slight  diffi- 
culty of  breathing,  nausea,  giddiness,  &c.  The  patient 
got  quite  well,  and  resumed  his  occupation  as  a porter. 
There  was  afterward  no  perceptible  pulsation  in  the 
facial  and  temporal  ‘ arteries  of  the  aneurismal  side  of 
the  face. 

On  the  opposite  side,  the  temporal  artery  became 
unusually  large.  The  tumour  was  at  last  quite  ab- 
sorbed, though  a pulsation  existed  in  it  till  the  begin- 
ning of  September.  The  man’s  intellects  remained 
perfect ; his  nervous  system  was  unaffected ; and  the 
severe  pain,  which  before  the  operation  used  to  affect 
the  aneurismal  side  of  the  head,  never  returned. 

The  swelling,  at  the  time  of  the  operation,  was  about 
as  large  as  a pullet’s  egg,  and  situated  on  the  left  side 
about  the  acute  angle  made  by  the  bifurcation  of  the 
common  carotid,  just  under  the  angle  of  the  jaw. 

Sir  Astley  Cooper  began  the  incision  opposite  the 
middle  of  the  thyroid  cartilage,  at  the  base  of  the  tu- 
mour, and  extended  the  wound  to  within  an  inch  of 
the  clavicle,  on  the  inner  side  of  the  sterno-cleido- 
mastoideus  muscle.  On  raising  the  margin  of  this 
muscle,  the  omo-hyoideus  could  be  distinctly  seen 
crossing  the  sheath  of  the  vessels,  and  the  nervus  de- 
scendens  noni  was  also  brought  into  view.  The 
sterno-cleido-mastoideus  was  now  separated  from  the 
omo-hyoideus,  when  the  jugular  vein  was  seen.  This 
vessel  became  so  distended  at  every  exjiiration  as  to 
cover  the  artery.  When  the  vein  was  drawn  to  one 
side,  the  par  vagum  was  manifest,  lying  between  that 
vessel  and  the  carotid  artery,  but  a little  to  the  outer 
side  of  the  artery.  The  nerve  was  easily  avoided. 

A double  ligature  was  then  conveyed  under  the  ar- 
tery with  a blunt  iron  probe.  The  lower  ligature  was 
immediately  tied,  and  the  upper  one  was  also  drawn 
tight,  as  soon  as  about  an  inch  of  the  artery  had  been 
separated  from  the  surrounding  parts  above  the  first  liga- 
ture, so  as  to  allow  the  second  to  be  tied  at  this  height. 
A needle  and  thread  were  passed  through  the  vessel  be- 
low one  ligature,  and  above  the  other.  The  arterj'  was 
then  divided.  In  a little  more  than  nine  weeks,  the 
wound  was  quite  healed,  and  the  patient  entirely  re- 
covered.— (See  Med.  Chir.  Trans,  vol.  1.) 

Another  successful  instance,  in  which  the  carotid 
was  tied  for  the  cure  of  an  aneurism,  is  related  in  a 
work  to  which  I always  have  the  greatest  pleasure  in 
referring. — (See  Hodgson's  Treatise  on  the  Diseases 
of  Arteries, _ p.  320.) 

Mr.  Travers  tied  the  carotid  artery  in  a woman,  who 
had  an  aneurism  by  anastomosis  in  the  left  orbit.  The 
disease  had  pushed  the  eye  out  of  its  socket.  Two 
small  ligatures  were  apidied,  which  came  away  on  the 
twenty-first  and  twetity-second  days.  No  hemorrhage, 
nor  impairment  of  the  function  of  the  brain  took  jilace, 
arid  the  disease  in  the  orbit  was  effectually  cured. — 
(See  Med.  Chir.  Trans,  vol.  2.) 

Another  highly  interesting  example,  in  which  an 
aneurism  by  anastomosis  in  the  orbit  was  eftectually 
cured  by  tying  the  carotid  artery,  is  recorded  by  Mi 
Dalrymple,  surgeon  at  Norwich.  This  gentleman  per 
formed  the  operation  on  the  12th  of  November,  1812. 
The  patient  was  a female,  aged  44.  The  protrusion  of 
the  eye  was  relieved  in  proportion  as  the  swelling 


140 


ANEURISM. 


diminished.  The  violent  headaches  also  subsided ; but 
the  eyesight  was  irrecoverably  lost. — (See  Med.  Chir. 
Trans,  vol.  6,  p.  111.) 

The  carotid  artery  has  sometimes  been  tied,  with 
the  vievv  of  enabling  the  surgeon  to  cut  away  swellings 
from  the  neck  and  side  of  the  face,  where,  from  par- 
ticular circumstances  in  the  cases  there  was  reason 
to  fear  a fatal  hemorrhage  without  that  preliminary 
measure.—  (See  Goodlad's  and  ArenaVs  Cases,  in  Med. 
and  Chir.  Trans,  vols.  7 and  12.) 

An  interesting  case,  in  which  my  friend  Mr.  Vincent 
tied  the  carotid  trunk  for  an  aneurism,  is  published  in 
the  10th  vol.  of  the  latter  work. — (P.  212,  &c.)  In  this 
example,  the  internal  jugular  vein  did  not  appear  to  be 
at  all  in  the  way  during  the  operation ; some  of  the 
fibres  of  the  omo-hyoideus,  however,  could  not  be  con- 
veniently drawn  aside,  and  were  therefore  divided.  A 
single  ligature  was  applied ; the  pulsation  in  the  tu- 
mour did  not  entirely  cease,  at  first,  when  the  artery 
was  tied,  but  it  did  so  two  days  afterward  ; and  the 
swelling  was  rapidly  diminishing.  The  ligature  came 
away  about  three  weeks  after  the  operation,  and  there 
was  every  hope  of  a cure  ; but,  between  the  fourth 
and  fifth  week,  a considerable  swelling  occurred  be- 
tween the  wound  and  the  jaw,  impeding  deglutition, 
but  not  the  breathing.  This  state  was  followed  by 
febrile  symptoms,  increased  difficulty  of  swallowing, 
an  attack  of  coughing,  and  impeded  respiration.  In 
the  hope  of  affording  relief,  an  incision  was  made  in 
the  tumour,  from  which  a small  quantity  of  pus  and 
coagulum  issued ; but  it  was  in  vain,  for  the  patient 
was  dying.  On  dissection,  the  carotid  artery  was 
found  perfectly  closed  as  far  as  the  division  of  the  ar- 
teria  innominata.  But  above  where  the  ligature  had 
been,  the  vessel  was  open  and  inflamed,  and  pus  was 
found  in  it.  The  most  remarkable  circumstance  no- 
ticed was  globules  of  air,  adhering  to  the  inner  surface 
of  the  aorta,  and  other  large  arteries,  and  found  also 
under  the  tunica  arachnoidea.  The  bulk  of  the  swell- 
ing in  the  neck  depended  upon  effusion  of  serum  in 
the  cellular  membrane. 

In  order  to  get  at  the  carotid  artery  in  the  safest 
manner,  Mr.  Abemethy  has  recommended  making  an 
incision  on  that  side  of  it  which  is  next  the  trachea, 
where  no  important  parts  are  exposed  to  injury,  and 
then  to  pass  a finger  underneath  the  vessel.  The  par 
vagum  must  be  carefully  excluded  from  the  ligature  ; 
for  to  tie  it  would  be  fatal. — {Surgical  Observations, 
1804.) 

The  cure  of  carotid  aneurisms  by  the  operation  has 
now  been  so  often  exemplified,  that  even  to  refer  to 
overy  case  upon  record  would  demand  more  space 
than  I can  affitrd.  A successful  instance  is  reported 
by  Macaulay  {Edin.  Med.  Surg.  Journ.  April,  1814) ; 
another  by  Dr.  Post,  who  used  two  ligatures,  and  di- 
vided the  artery  in  the  space  between  them  {New- 
England  Journ.  of  Medicine  and  Surgery,  vol.  3, 
p.  205,  Boston,  1814) ; another  by  Mr.  Giles  Lyford, 
proving  the  sufficiency  of  a single  ligature. — {Med. 
Chir.  Trans,  vol.  11,  p.  97,  <fec.)  The  case  in  w hich 
Mr.  Goodlad  tied  the  carotid,  in  order  to  prevent  he- 
morrhage in  the  removal  of  a tumour  involving  the 
parotid  gland,  is  contained  in  vol.  7,  p.  112,  &c.  of  the 
latter  book.  The  example  in  which  the  carotid  was 
tied  by  Dr.  Fricke,  in  the  hospital  at  Hamburgh,  for 
ithe  cure  of  a diseased  parotid,  is  reported  in  the  Lancet, 
No.  182.  Some  diminution  of  the  swelling,  and  in- 
creased power  of  swallowing  followed  ; but  suppura- 
tion took  place,  and  the  case  ended  fatally. 

The  best  anatomical  engravings  of  the  parts  con- 
cerned in  the  operation  of  taking  up  the  carotid  artery, 
are  those  by  Tiedemann  and  Roseiimuller.— (See  Chi- 
rurg.  Anatom.  Abbildungen,  th.  1,  tab.  7,  8,  90 

For  the  particulars  of  a carotid  aneurism  cured  by 
the  ligature  of  the  artery'  by  M.  Dumont,  see  Diss.  sur 
VAneurisme  de  VArtere  carotide,  par  P.  J.  Vander- 
hagen,  Paris,  1815.  Walther,  of  Landshut,  in  the  year 
1814,  tied  the  carotid  artery  for  the  cure  of  an  aneurism 
with  complete  success  : he  applied  only  a single  liga- 
tme.—  Breschet,  Fr.  transl.  of  Mr.  Hodgson's  work, 
t.  2,  p.  83.)  In  this  translation  are  reported  several 
instances,  in  which  Dupuytren  and  other  continental 
surgeons  applied  a ligature  to  the  carotid.  Dr.  Ilol- 
scher,  of  Hanover,  has  also  operated  with  success.— 
(See  Bond.  Med.  Repository,  vol.  16,  No.  94.) 

[Dr.  Bushe  has  lately  tied  the  common  carotid  for 
an  aneurism  situated  in  the  fauces,  with  complete  sue-  | 


cess.  Professor  Pattison,  of  the  University  of  London, 
when  resident  in  Baltimore,  cured  an  immense  aneu- 
rism of  the  internal  maxillary  by  tying  the  trunk  of  the 
carotid.  I w itnessed  this  operation,  and  saw  the  suc- 
cessful result. — Reese.] 

Of  the  plan  of  tying  the  carotid  above  the  aneurism, 
when  it  is  situated  so  low  that  the  ligature  cannot  be 
applied  below  it,  I have  also  spoken.  The  facts,  by 
which  the  propriety  of  this  practice  has  now  been  com- 
pletely established,  have  also  been  noticed : they  appear 
to  me  to  reflect  considerable  credit  on  Mr.  Wardrop,  by 
whom  this  method  of  operating  has  been  revived  and 
extended.  The  practice  of  tying  the  carotid  for  the 
cure  of  aneurism  of  the  arteria  innominata  will  be  no- 
ticed in  the  ensuing  section. 

NEW  OPERATION  FOR  ANEURISM  OF  THE  ARTERIA 
INNOMINATA. 

It  having  been  established,  that  aneurisms  may  be 
cured  by  simply  lessening  the  impetus  of  the  blood 
flowing  through  them,  and  that,  although  a circulation 
may  yet  continue  in  them  for  some  time,  the  layers  of 
coagulable  lymph  within  the  sac  will  augment,  and 
ultimately  bring  about  a complete  consolidation  of  the 
swelling,  it  occurred  to  Mr.  Wardrop,  that  in  aneurism 
of  the  arteria  innominata,  the  progress  of  the  disease 
might  be  arrested  by  tying  its  two  great  branches,  the 
carotid  and  subclavian.  Although  a certain  portion  of 
blood  w'ould  still  continue  to  pass  along  the  innominata 
to  those  branches  of  the  subclavian  on  the  cardiac  side 
of  the  ligature,  the  ligature  being  necessarily  placed  on 
the  subclavian  arter>'  after  it  emerges  from  between 
the  scaleni  muscles,  Mr.  Wardrop  conceived,  that  such 
would  yet  be  the  diminution  of  the  impetus  of  the  blood 
in  the  sac,  that  the  future  increase  of  the  tumour  would 
be  prevented,  and  even  a permanent  obliteration  of 
the  aneurismal  cavity  would  be  accomplished. — {On 
Aneurism,  p.  58.)  The  knowledge  of  this  principle, 
indeed,  he  thinks,  may  be  useful  in  the  cure  of  many 
aneurisms,  which  have  hitherto  been  considered  be- 
yond the  reach  of  an.  In  an  aneurism  of  the  innomi- 
nata,  Mr.  Mackelcan  found  that  nature  had  nearly 
completed  a cure  of  the  disease  on  this  principle.  The 
carotid  artery  was  plugged  up,  and  the  large  aneuris- 
mal swelling  was  filled  with  a coagulum,  leaving  only 
a comparatively  small  channel  for  the  passage  of  the 
blood  into  the  subclavian  artery. — (See  Appendix  to 
Wardrop  em  Aneurism.)  Mr.  Wardrop  has  seen  some 
cases,  and  several  are  on  record,  which  illustrate  the 
same  important  pathological  fact,  and  prove  beyond  a 
doubt,  that  blood  can  coagulate  in  an  aneurism  so  as 
to  strengthen  the  parietes  of  the  sac,  and  ultimately  fill 
its  cavity,  without  the  circulation  in  the  sac  being  in 
the  first  instance  either  suddenly  or  entirely  inter- 
rupted. 

It  was  the  knowledge  of  this  fact  that  led  Mr.  Ward- 
rop to  perform  the  operation,  which  he  has  related. 
Nature,  in  the  case  alluded  to,  had  already  instituted  a 
curative  process  by  diminishing  the  circulation  in  the 
carotid  artery ; and  when  he  found  this  alone  not  suffi- 
cient to  stop  the  enlargement  of  the  aneurism,  he  de- 
termined to  place  a ligature  on  the  subclavian.  In 
doing  this,  he  conceived  that  he  was  strictly  imitating  the 
process  which  nature  herself  had  commenced. — (P.  61.) 
The  case  of  Mrs.  Denmark,  aged  45,  in  whom  he  tied 
the  subclavian  tirterj’,  and  thus  cured  an  aneurism  of 
the  arteria  innominata,  is  highly  interesting.  The  par- 
ticulars may  be  read  in  his  own  publication,  or  in  the 
Lancet  for  1827.  Suffice  it  here  to  state,  that  the  dis- 
ease was  completely  cured.  In  the  appendix  to  Mr. 
Wardrop’s  publication,  and  in  the  Lancet  for  Novem 
her,  1828,  is  another  highly  important  case,  confirming 
the  accuracy  of  the  principles  explained  by  this  in- 
genious surgeon.  It  is  an  example  in  which  Mr. 
Evans,  of  Belper,  Derbyshire,  successfully  treated  an 
aneurism  of  the  innominata  mid  root  of  the  carotid,  by 
tying  the  latter  vessel.  In  the  end,  the  patient,  a but- 
cher and  horse-dealer,  thirty  years  of  age,  was  well 
enough  to  attend  regularly  the  markets  and  fairs  of 
Derby,  seven  miles  from  his  home.  In  the  course  of 
the  case,  three  remarkable  circumstances  occurred  ; 
1st,  An  obliteration  of  the  large  arteries  of  the  right 
arm.  2dly,  A profuse  salivation.  3dly,  A disposition 
to  paralysis  of  the  right  side,  supposed  by  Mr.  Evans 
to  have  arisen  from  a greater  quantity  of  blood  being 
sent  to  the  left  hemisphere  of  the  brain  than  to  the 
1 right.  However,  as  such  paralysis  has  not  attended 


ANEURISM. 


141 


other  operations  in  which  the  carotid  was  tied,  the 
truth  of  the  explanation  seems  doubtful.  The  palsy 
aAerward  nearly  subsided. 

[It  affords  me  high  gratification  to  record,  that  Pro- 
fessor Mott,  of  this  city,  has  lately  performed  this  ope- 
ration for  the  first  time  it  has  been  attempted  in  Ame- 
rica, by  tying  the  carotid  artery  for  aneurism  of  the 
arteria  innominata,  involving  the  subclavian  and  root 
of  the  carotid.  This  is  the  first  time  in  America  in 
which  aneurism  has  been  treated  by  tying  the  artery 
on  the  anticardial  side  of  the  tumour.  The  report  of 
the  case,  and  its  successful  result,  is  contained  in  the 
American  Journal  of  the  Medical  Sciences,  No.  10,  for 
February,  1830.  Since  that  report  was  published  the 
patient  has  died,  and  the  tumour  having  been  re- 
moved, fully  establishes  the  success  of  the  operation. 
I have  had  an  opportunity  of  examining  the  prepara- 
tion, and  found  the  carotid  entirely  obliterated  and  im- 
pervious above  the  aneurismal  sac,  although  the  liga- 
ture was  applied  very  high  on  that  vessel.  The  death 
was  occasioned  by  the  displacement  and  distortion  of 
the  trachea  and  larynx,  which  are  seen  lying  on  the 
side  of  the  neck,  and  in  no  wise  connected  with  the 
operation,  but  was  the  consequence  of  the  long  exis- 
tence of  the  disease  before  the  oper  tion  was  submitted 
to. — Reese.] 


OF  ANEURISMS  OF  THE  AORTA,  AND  VALSALVA’s 
TREATMENT. 

This  affhcting  and  fatal  disease  is  by  no  means  un 
frequent,  and  the  arch  of  the  aorta  is  its  most  com 
mon  situation.  Dr.  Hunter  was  of  opinion  that  th» 
latter  circumstance  depended  on  the  forcible  mannei 
in  which  the  blood,  propelled  from  the  left  ventricle  o 
the  heart,  must  be  driven  against  the  angle  of  the  cur- 
vature of  the  vessel. 

Mr.  A.  Burns  considered  aneurism  of  the  thoracic 
aorta  more  frequent,  perhaps,  than  that  of  any  othei 
vessel  in  the  body.  “ I have  had  (says  he)  an  oppor- 
tunity of  examining  fourteen  who  had  died  of  this  dis- 
ease, but  have  not  seen  more  than  three  instances  of 
external  anenrism.”— {On  Diseases  of  the  Heart,  6,-c.p. 

These  proportions,  however,  would  not  correspond 
to  common  observation,  external  aneurisms,  taken  col- 
lectively,  being  supposed  to  be  about  as  numerous  as 
those  of  the  aorta  alone,  a calculation  long  ago  made 
by  Dr.  A.  Monro,  primus. 

It  was  the  opinion  of  Dr.  W.  Hunter  that  the  aiieu- 
nsmal  sac  was  composed  of  the  dilated  coats  of  the 
artery,  which  parts  nature  thickened  and  studded  with 
ossifications  after  the  origin  of  the  disease,  for  the  pur- 
pose of  resisting  its  increase.  Mr.  Hodgson,  also,  in 
his  late  excellent  publication  declares  his  decided  belief 
and  adduces  facts  to  prove,  that  many  aneurisms  of  the 
aorta  are  formed  by  dilatation.  Scarpa  argues,  how- 
ever, that  the  generality  of  aneurisms  of  the  aorta  are 
the  consequence  of  a rupture  of  the  proper  coats  of  this 
large  vessel ; and  that  the  cellular  sheath  of  the  artery 
is  what  becomes  distended  into  the  thickened  and  os- 
sified aneurismal  sac. 

Dr.  W.  Hunter  considered  the  ossifications  of  the  sac 
as  consequences  of  the  disease:  but  Haller  looked 
upon  such  scales  of  bone  in  the  aorta  as  the  very  cause 
of  the  affection,  by  rendering  the  artery  inelastic,  and 
incapable  of  yielding  to  each  pulsation  of  the  heart. 

It  is  unquestionably  true  that  aneurisms  of  the  aorta 
are  most  common  in  persons  who  are  advanced  in  life 
and  it  is  equally  well  known,  that  the  aorta  of  everv 
old  subject,  whether  affected  with  aneurism  or  not  is 
almost  always  marked  in  some  place  or  another  wuth 
ossifications,  or  rather  with  calcareous  concretions 
Such  productions  appear  to  occasion  a decay  or  absorp- 
tion of  the  muscular  and  inner  coats  of  the  vessel,  so 
lliat  at  length  the  force  of  the  blood  makes  the  artery 
pve  way,  and  this  fluid,  collecting  on  the  outside  of  the 
laceration  or  rupture,  gradually  distends  the  external 
sheath  of  the  artery  into  the  aneurismal  sac,  which  it- 
self becomes  at  last  of  considerable  thickness,  and 
studded  with  ossified  specks. 

“ If  any  person  who  is  not  prejudiced  in  favour  of 
the  common  doctrine  with  regard  to  the  nature  and 
proximate  cause  of  this  disease  (says  Scarpa),  will  ex- 
amine, not  hastily  and  superficially,  but  with  care  and 
by  dissection,  the  intimate  structure  and  texture  of  the 
aneunsm  of  the  aorta,  unfolding  with  particular  atten- 
tion the  proper  and  common  coats  of  this  artery,  and 


in  succession  those  which  constitute  the  aneurismal 
sac,  in  order  to  ascertain  distinctly  the  texture  and 
limits  of  both,  he  will  clearly  see  that  the  aorta,  pro- 
perly speaking,  contributes  nothing  to  the  formation  of 
the  aneurismal  sac,  and  that,  consequently,  the  sac  is 
merely  the  cellular  membrane,  which  in  the  sound 
state  covered  the  artery,  or  that  soft  cellular  sheath 
which  the  artery  received  in  common  with  the  neigh- 
bouring parts.  This  cellular  substance,  being  raised 
and  compressed  by  the  blood  effused  from  the  corroded 
or  lacerated  artery,  assumes  the  form  of  a circum- 
scribed tumour,  covered  externally,  in  common  with  the 
artery,  by  a smooth  membrane,  such  as  the  pleura  in 
the  thorax  and  the  peritoneum  in  the  abdomen.” 

Scarpa  then  comments  upon  the  differences  of  mere 
dilatation  of  an  artery  from  aneurism,  a subject  which 
has  been  already  fully  considered  in  the  foregoing 
pages. — (Scarpa  on  the  Anatomy,  Pathology,  and 
Surgical  Treatment  of  Aneurism,  transl.  by 
hart,  p.  55,  56.) 

As  I have  already  explained  in  the  preceding  co- 
lumns, the  sentiments  of  this  eminent  anatomist  are 
not  adopted  by  the  generality  of  surgeons ; or  rather, 
his  doctrine  is  not  carried  by  others  to  the  extent  which 
he  has  insisted  upon  j and  it  would  be  useless  repeti- 
tion to  bring  before  the  reader  again  the  facts  which 
prove  that  his  statements  are  liable  to  many  exceptions. 
A case,  however,  recited  by  Roux,  which  I have  met 
with  since  the  foregoing  pages  were  printed,  merits  no- 
tice ; it  was  an  instance  in  which  a popliteal  aneurism, 
unattended  with  pulsation,  had  been  mistaken  for  an 
abscess  and  punctured,  whereby  the  patient  lost  his 
life.  On  dissecting  the  limb,  Roux  says,  “ the  three 
coats  of  the  artery  participated  in  the  dilatation,  and 
the  case  was  one  of  the  clearest  specimens  which  I 
have  ever  seen  of  a true  aneurism.”— (iVowueaiAr  EL~ 
mens  de  M-d.  Op,  ratoire,  t.  1,  p.  517.) 

All  arguments  brought  against  the  possibility  of  a 
dilatation  of  the  inner  coat,  and  founded  on  the  inelas- 
tic structure  of  that  membrane,  must  likewise  be  com- 
pletely refuted  by  another  fact  demonstrated  by  morbid 
preparations,  collected  by  Dubois  and  Dupuytren, 
where  the  inner  coat  of  the  aorta  is  alone  dilated,  pro- 
truding through  the  outer  tunics  in  the  form  of  a distinct 
swelling  somewhat  like  a hernia.— (Rowa?,  op.  cit.  p.  49.) 

In  whatever  manner  aneurisms  of  the  aorta  are 
formed,  there  are  no  diseases  which  are  more  justly 
dreaded,  or  which  more  completely  fill  the  surgeon  as 
well  as  the  patient  with  despair.  No  affliction,  indeed, 
can  be  more  truly  deplorable ; for  the  sufferings  which 
are  occasioned  hardly  ever  admit  even  of  palliation, 
and  the  instances  of  recovery  are  so  very  few,  that  no 
consolatory  expectation  can  be  indulged  of  avoiding  the 
fatal  end  to  which  the  disease  naturally  brings  the  mi- 
serable sufferer. 

The  existence- of  aneurisms  of  the  aorta  is  scarcely 
ever  known  with  certainty  before  they  have  advanced 
so  far  as  to  be  attended  with  an  external  pulsation  and 
a tumour  that  admits  of  being  felt  or  even  seen  In 
very  thin  subjects,  the  throbbing  of  the  abdominal 
aorta  is  sometimes  unusually  plain  through  the  inte<ni- 
rnents  and  viscera,  and  this  has  occasionally  given 
rise  to  the  suspicion  of  an  aneurism ; a circumstance 
which  deserves  to  be  rernembered  by  ever}'  surgeon  de-’ 
sirous  of  not  pronouncing  a wrong  opinion.  The  pre- 
ternatural pulsations,  however,  which  are  liable  to  be 
mistaken  for  those  of  aortic  aneurisms,  are  of  various 
kinds,  and  form  a subject  to  which  the  attention  of  Dr, 
Albep,  of  Bremen,  the  late  Mr.  A.  Burns,  and  others, 
usefully  directed.-(See  Abdomen.) 

While  thoracic  aneurisms  of  the  aorta  are  accompa- 
nied wth  no  degree  of  external  swelling,  the  symptoms 
are  all  equivocal,  and  might  depend  on  a disease  of  the 
heart,  angina  pectoris,  phthisis  pulmonalis,  »fec.  How- 
ever, some  difference  depends  upon  the  volume,  posi- 
tion,  and  nature  of  the  aneurism.  As  Laennec  oh- 
serves,  simple  dilatation,  when  in  a moderate  degree, 
hardly  produces  any  effect,  but  the  most  inconsiderable 
lalse  aneurisms  may  give  rise  to  verv  serious  disorder. 

I he  first  and  most  common  of  these  effects  is,  the 
compression  of  the  heart  and  lungs. — (See  Laennec  on 
Diseases  of  the  Che.st,  by  Forbes,  p.  676,  ed.  2.)  Vio- 
lent and  irregular  throbbings  frequently  occur  between 
the  fourth  and  fifth  true  ribs  of  the  left  side ; the 
same  irregularity  of  the  pulse  prevails  as  often  pro- 
ceeds from  organic  affections  of  the  heart ; a dissimi- 
larity ot  the  pulse  in  the  two  wrists ; the  respiration 


142 


ANEURISM. 


is  exceedingly  obstructed ; the  voice  altered  ; and  in  a 
moi'e  advanced  period  of  the  malady  the  patient  is  at 
times  almost  suffocated.  The  pressure  of  the  internal 
swelling  on  the  trachea,  bronchia,  and  lungs,  is  suffi- 
cient to  account  for  this  difficulty  of  breathing.  In 
many  instances  the  irritation  and  compression  pro- 
duced by  the  tumour  occasion  an  absorption  of  the 
greater  part  of  the  lungs,  and  abscesses  and  tubercles 
throughout  the  portion  which  remains.  Even  the 
function  of  deglutition  suffers  interruption  in  conse- 
quence of  the  pressure  made  on  the  oesophagus,  which 
may  even  be  in  a state  of  ulceration.  Thus,  in  an  ex- 
ample recently  published,  we  read  that  the  cavity  of 
the  windpipe  was  nearly  obliterated  from  the  pressure 
of  the  aneurism;  and  the  extremities  of  four  of  its 
cartilages  lay  in  the  oesophagus,  having  entered  that 
canal  through  an  ulcer  in  its  coat.” — {Trans,  for  the 
Improvement  of  Med.  and  Chir.  Knowledge,  vol.  3, 
p.  83.) 

AAer  what  has  been  stated,  it  cannot  be  surprising, 
that  ere  the  disease  manifests  itself  externally,  affec- 
tions of  the  lungs  or  strictures  of  the  oesophagus 
should  often  be  suspected.— (//odg6’on,  p.  91.) 

An  aneurism  of  the  arteria  innominata,  not  disco- 
vered till  after  the  patient  had  died  of  suffocation,  gave 
rise  to  great  difficulty  of  drawing  air  into  the  chest 
without  any  other  symiitom  calculated  to  throw  light 
on  the  nature  of  the  disease.  The  aneurismal  swell- 
ing was  situated  behind  the  first  bone  of  the  sternum, 
and  pressed  upon  the  trachea.  The  front  of  this  tube 
was  pushed  in  by  the  tumour  so  as  to  present  a con- 
vex prominence  on  the  inner  surface,  which,  however, 
diminished  its  area  in  a very  slight  degree.  Mr.  Law- 
rence adduces  tliis  f act  to  prove  that  spasm  of  the  air- 
cells  may  be  the  cause  of  great  distress  in  breathing. 
“ The  termination  of  this  case  (says  he)  is  the  more 
remarkable,  inasmuch  as  in  another  patient  an  aneu- 
rism rising  out  of  the  arch  of  the  aorta,  and  pressing 
on  the  corresponding  part  of  the  trachea,  so  as  to  pro- 
duce ulceration  of  the  internal  membrane,  under  which 
there  w’as  a slight  appearance  of  coagulated  blood, 
caused  no  affection  of  the  breath  at  all.  The  person 
died  of  a different  complaint,  and  the  discovery  of  the 
aneurismal  tumour,  which  was  very  small,  and  filled 
with  firm  laminated  coagula,  was  quite  accidental.” — 
{Med.  Chir.  Trans,  vol.  ti,  p.  227.) 

Thus  we  find  in  thoracic  aneurisms,  at  least  previ- 
ously to  their  attainment  of  a certain  size,  that  no  re- 
gularity prevails  even  with  regard  to  difficulty  of  breath- 
ing, the  symptom  which,  « priori,  one  might  suppose 
would  invariably  be  present. 

Few  diseases,  according  to  Laennec,  are  so  insidious 
as  aneurism  of  the  thoracic  aorta.  He  affirms,  that  “ it 
cannot  be  known  with  certainty  till  it  shows  itself  ex- 
ternally. It  can  hardly  be  suspected  even  when  it 
compresses  some  important  organ,  and  greatly  de- 
ranges its  functions.  When  it  produces  neither  of 
these  effects,  the  first  indication  of  its  existence  is  often 
the  death  of  the  individual,  as  instantaneously  as  if  by 
a pistol-bullet.”  One  case,  recorded  by  Mr.  Pattison, 
confirms  the  same  fact,  for  the  patient  had  only  symp- 
toms leading  to  a suspicion  of  rheumatism  in  the  neck, 
and  died  suddenly  of  apoplexy.— (jBwm.s  on  the  Head 
and  Heck,  ed.  by  Pattison.)  Laennec  has  known  per- 
sons cut  off  in  this  manner  who  were  believed  to 
be  in  the  most  perfect  health.  He  admits  that  jter- 
cussioa  will  sometimes  enable  us  to  detect  a tumour 
of  large  size  existing  within  the  mediastinum,  or  even 
in  the  back ; but  not  to  discriminate  the  nature  of  the 
swelling.  His  experience  had  not  been  .sufficient  to 
let  lum  pronounce  how  far  the  difficulty  of  diagnosis 
was  likely  to  be  removed  by  the  stethoscope.  How- 
ever, aneurisms  of  the  abdominal  aorta,  he  says,  are 
recognised  with  the  utmost  facility  by  means  of  this 
instrument.  In  this  case  we  are  sensible  of  tremen- 
dous pulsations  which  painfully  affect  the  ear,  and 
the  intensity  of  which  is  not  at  all  recognised  by  the 
hand,  even  when  sufficiently  perceptible  to  the  touch. 
As  high  up  as  the  cccliac  anery  the  contractions  of  the 
auricles  are  not  in  the  least  distinguishable.  The  sound 
of  the  pulsations  is  described  as  clear  and  loud.— (La- 
ennec  on  Diseases  of  the  Chest,  p.  ()78,  ^^c.) 

I have  mentioned  that  the  symptoms  of  thoracic  an- 
eurisms, previously  to  the  formation  of  any  outward 
swelling,  often  resemble  those  of  phthisis,  and  the  lat- 
ter IS  sometimes  actually  supposed  to  be  the  disease 
under  which  the  patient  is  labouring.  But  there  is 


one  distinction  betw'een  the  cases,  which  is  pointed  out 
by  Mr.  Hodgson,  and  may  be  of  use,  in  combination 
with  other  circumstances,  in  facilitating  the  diagnosis  ; 
“ in  phthisis,  the  expectoration  is  either  puriform  or 
thick  and  clotted  ; but  in  aneurisms  which  are  not 
accompanied  with  disease  in  the  lungs,  as  far  as  I have 
observed,  it  always  consists  of  a thin  frothy  mucus. — 
{On  Diseases  of  Arteries,  Ac.  p.  93.) 

According  to  Kreysig’s  experience,  the  cough  comes 
on  at  irregular  periods,  is  violent,  and  attended  with 
great  efforts,  the  expectorated  matter  being  forced  up 
by  the  vehemence.  He  agrees  with  Mr.  Hodgson  . t- 
specting  the  genertd  quality  of  what  is  expectorated, 
where  thoracic  aneurisms  are  not  complicated  w'ith  dis- 
eased lungs ; but  he  says  that  the  matter  coughed  up 
also  frequently  consists  of  masses  of  lymph  blended 
with  brick-red  particles  of  blood,  which  masses,  when 
thrown  into  water,  seem  as  if  they  were  composed  of 
a ball  of  stringy  substances — {German  transl.  of  the 
latter  work,  p.  137.) 

From  a review  of  many  cases  of  aortic  aneurisms, 
Mr.  A.  Burns  was  inclined  to  think,  that  when  the  as- 
cending aorta  is  aneurismal,  the  breathing  is  more  af- 
fected than  when  the  arch  of  the  vessel  is  enlarged, 
but  that  in  the  latter  case  the  impediment  to  degluti- 
tion is  greatest. — {On  Diseases  of  the  Heart,  Ac.  p.  244.) 

According  to  Laennec,  false  aneurisms  are  most 
common  in  the  descending  aorta;  and  true  ones  in 
the  ascending  portion  of  the  vessel  and  its  arch.  He 
has  never  met  with  any  species  of  false  aneurism  in 
the  latter  situation,  but  such  as  is  consequent  to  the 
true  or  simple  dilatation  of  the  artery. — (See  Laennec  on 
the  Diseases  of  the  Chest,  p.  676,  ed.  by  Forbes.) 

The  way  in  which  aneurisms  of  the  thoracic  aorta 
prove  fatal,  is  subject  to  considerable  variety.  These 
swellings  do  not  always  destroy  the  patient  by  hemor- 
rhage ; in  numerous  instances,  the  magnitude  of  the 
disease  so  impedes  respiration,  that  death  seems  in- 
duced by  suffocation,  and  not  a drop  of  blood  is  found 
internally  effused.  Frequently  (to  use  the  description 
of  Mr.  John  Bell),  before  the  awful  and  fatal  hemor- 
rhage has  had  time  to  occur,  the  patient  perishes  of  suf- 
ferings too  great  for  nature  to  bear.  The  aneurismal 
tumour  so  fills  the  chest,  so  oppresses  the  lungs,  com- 
presses the  trachea,  and  curbs  the  course  of  the  de- 
scending blood,  that  the  system  with  a poor  circulation 
of  ill -oxy dated  blood,  is  quite  exhausted.  And  thus, 
though  the  patient  is  saved  from  the  most  terrible  scene 
of  all,  he  suffers  great  miseries;  he  experiences  in  his 
chest  severe  pains,  which  he  compares  with  the  stab- 
bing of  knives ; terrible  palpitations  ; an  awful  sense 
of  sinking  within  him ; a sound  within  his  breast,  tis 
if  of  the  rushing  of  waters;  a continual  sense  of  liis 
condition ; sudden  startings  during  the  night ; fearful 
dreams  and  dangers  of  suffocation  ; until  with  sleep- 
less nights,  miserable  thoughts  by  day,  and  the  gra- 
dual decline  of  an  ill-supported  system,  he  grows  weak, 
dropsical,  and  expires. — (See  Anatomy  of  the  Hitman 
Body,  by  John  Bell,  vol.  2,  edit.  3,  p.  234,  235.) 

I\Ir.  A.  Burns  saw  two  examples,  in  which  the  pa- 
tients died  instantaneously,  though  their  aneurismal 
tumours  were  very  small  and  had  not  burst.  Both 
these  patients  were  in  the  early  stage  of  pregnancy. — 
{On  Diseases  of  the  Heart,  p.  236.) 

The  situations  in  which  aneurisms  of  the  curvature 
of  the  aorta  burst,  are  different  in  different  cases. 
Sometimes  the  swelling  bursts  into  the  cavity  of  the 
chest,  or  that  of  the  pericardium,  and  the  patient  drops 
suddenly  dowm.  According  to  Laennec,  the  left  cavity 
of  the  pleura  is  by  far  the  most  frequent  situation  in 
which  the  thoracic  aneurisms  of  the  aorta  burst. — {On 
Diseases  of  the  Chest,  p.  677.)  When  the  coats  of  the 
aorta  give  way  within  the  pericardium,  where  they 
only  receive  a slight  external  membranous  (■overing, 
this  is  apt  to  be  also  ruptured  at  the  same  time,  so  as 
to  bring  on  copious  effusion  of  blood,  which  oppresses 
the  action  of  the  heart,  and  produces  immediate  death. 
In  other  examples,  the  blood  is  effused  into  the  trai-hea 
or  bronchia,  and  the  patient,  after  violent  coughings 
and  ejections  of  blood  from  the  mouth,  expires.  Some- 
times, after  the  tumour  has  become  closely  adherent  to 
the  lungs,  it  bursts  into  the  air-cells,  through  wliich 
the  blood  is  w idely  diffused.  An  ex.ample  of  this  ter- 
mination of  the  disease  was ob.served  by  Laennec;  who 
also  saw  another  case,  in  which,  if  the  patient  had  lived 
a little  longer,  the  same  occurrence  in  all  probability 
would  have  happened.  Ehrhardt  says,  that  he  is  not 


ANEURISM, 


143 


aware,  that  this  mode  of'rupiture  has  been  noticed  by 
other  writers. — {De  Aneurijsinate  Aortcs,  p.  21,  4<o. 
Lips.  1820.) 

The  most  remarkable  local  effects  of  aneurisms  of 
the  aorta  are  those  on  the  vertebral  column.  They  of- 
ten destroy  it  to  a very  great  depth.  This  is  entirely 
the  work  of  interstitial  absorption,  there  never  being 
any  mark  of  suppuration.  On  the  side  next  the  verte- 
brae, the  sac  is  completely  destroyed,  and  the  circulat- 
ing blood  is  bounded  by  the  naked  bone.  In  certain 
cases,  the  swelling  beats  its  way  through  the  ribs ; 
even  the  spinal  marrow  may  be  injured,  and  the  pa- 
tient suffer  a species  of  death  somewhat  less  violent 
and  sudden.  In  one  case  of  an  enormous  aneurism  of 
the  abdominal  aorta,  reported  in  No.  259  of  the  Lancet, 
the  left  leg  and  thigh  were  much  wasted  and  quite  pa- 
ralytic. This  seemed  to  arise  from  the  pressure  on  the 
nerves  of  the  lower  extremity,  and  not  from  injury  of 
the  medulla  spinalis.  But,  although  aneurisms  in  the 
chest  do  sometimes  protrude  at  the  back,  a circum- 
stance that  depends  on  the  particular  situation  of  the 
disease  (see  Pelletan,  Clinique  Chir.  t.  1,  Ohs.  7,  p. 
84),  they  more  commonly  rise  towards  the  upper  part 
of  the  breast,  where  a throbbing  tumour  occurs,  which 
has  caused  an  absorption  of  the  oppo.sing  parts  of  the 
ribs  and  sternum ; and  sometimes  dislocated  the  cla- 
vicles. Corvisart  saw  an  instance,  in  which  an  aneu- 
rism of  the  aorta  had  dislocated  the  sternal  extremity 
of  the  clavicle ; and  Duverney  makes  mention  of  a 
case,  in  which,  besides  the  displacement  and  injury  of 
the  clavicle,  the  sternum  and  scapula  were  partially 
destroyed.  Guattani  speaks  of  an  example,  in  which 
the  clavicle  was  bent  by  a large  aneurism,  of  which  a 
l)ortion  as  large  as  a pigeon’s  egg  projected  above  the 
i)one. — {Lautk,  p.  168.)  And  Morgagni  has  described 
a case,  where  the  upper  bone  of  the  sternum,  the  ster- 
nal ends  of  the  clavicles,  and  the  adjoining  ribs  were 
destroyed  by  the  pressure  of  a large  aneurism  of  the 
front  of  the  curvature  of  the  aorta,  and  the  disease  pre- 
sented itself  externally  somewhat  in  the  form  of  a bile. 
—{Epist.  26,  art.  9.) 

The  swelling  now  pulsates  in  an  alarming  way.  The 
blood  is  only  retained  by  a thin  covering  of  livid  skin, 
which  is  becoming  thinner  and  thinner.  At  length  a 
point  of  the  tumour  puts  on  a more  conical,  thin,  and 
inflamed  ajipearance  than  the  rest ; a slough  is  formed, 
and  on  this  becoming  loose,  the  patient  is  sometimes 
instantaneously  carried  of  by  a sudden  gush  of  blood. 

An  extraordinary  case  of  aneurism  of  the  aorta  is 
related  by  Dr.  C.  W.  Wells.  The  disease  being  un- 
attended with  any  external  swelling,  it  seems,  was  not 
comprehended  during  the  patient’s  lifetime. 

The  following  is  an  abstract  of  the  case.  Mr.  A.  B., 
a gentleman,  thirty-five  years  of  age  and  temperate  in 
his  habits,  became  affected  in  1789  with  symptoms 
which  were  thought  to  denote  the  approach  of  pulmo- 
nary consumption.  These,  however,  after  some  time 
entirely  di.sappeared.  In  1798  he  was  attacked  with  a 
slight  hemiplegia,  from  which  he  also  recovered,  with 
the  exception  of  an  inconsiderable  sense  of  coldness  in 
the  foot,  which  had  been  paralytic.  In  March,  1804, 
he  complained  of  being  frequently  troubled  with  a noise 
in  his  ears,  flatulence  in  his  bowels,  and  pains  in  his 
hands  and  feet,  sometimes  attended  with  slight  swell- 
ing.s  in  the  same  parts.  From  one  or  more  of  these 
symptoms  he  was  never  afterward  quite  free ; but 
he  did  not  complain  of  any  unusual  feelings  in  his 
chest.  August  11,  1807,  he  fatigued  himself  consider- 
ably with  walking;  ate  rather  a hearty  dinner ; and, 
having  refreshed  mmself  with  some  sleep  afterward, 
he  played  about  with  his  children.  While  thus  amus- 
ing himself,  he  was  suddenly  seized,  between  eight 
and  nine  o’clock,  with  great  oppression  in  his  chest. 
He  soon  afterward  became  sick,  and  in  the  matter 
thrown  up,  some  streaks  of  blood  were  observed.  He 
now  went  to  bed  ; but,  though  the  weather  was  warm 
and  he  was  covered  with  bed-clothes,  his  skin  felt  cold 
to  the  attendants.  At  midnight  he  laboured  under  a 
constant  cough,  and  expectorated  mucus  tinged  with 
blood.  His  body  was  moistened  with  a cold  sweat, 
and  his  pulse  was  extremely  feeble ; sometimes  it  was 
scarcely  perceptible.  About  five  in  the  morning  his 
pulse  was  feeble  and  irregular ; his  breathing  difficult, 
his  skin  pale  and  cold,  and  covered  with  a clammy 
sweat.  He  frequently  tossed  and  writhed  his  body,  as 
if  he  was  suffering  great  pain  or  uneasiness.  The 
mental  faculties,  however,  seemed  unimpaired.  Shortly 


afterward  he  expired,  having  complained,  just  before 
his  death,  of  much  heat  in  his  chest,  and  thrown  off 
the  bed-clothes. 

The  most  remarkable  circumstance  found  on  open- 
ing the  body  is  thus  recorded ; — “ The  ascending  aorta 
was  distended  to  about  the  size  of  a large  orange.  The 
tumour  adhered  to  the  pulmonary  artery,  just  before 
its  division  into  the  right  and  left  branches.  Within 
the  circumference  of  this  adhesion  there  was  a narrow 
hole,  by  means  of  which  a communication  was  formed 
between  the  two  arteries.” 

Dr.  Wells  concludes  with  observing,  that  though 
such  a disease  might  easily  have  been  imagined,  he  had 
found  no  instance  of  it  in  books,  and  that  it  had  not 
been  observed  by  any  of  the  surgeons  or  anatomists  in 
London.  He  supposed,  that  the  communication  be- 
tween the  aorta  and  pulmonary  artery,  took  place  on 
the  evening  before  the  patient’s  death,  when  the  oji- 
pression  of  the  chest  was  first  felt ; and  that,  in  conse- 
quence of  the  superior  strength  of  the  left  side  of  the 
heart,  a part  of  the  blood  which  was  thrown  into  the 
aorta  must  have  been  forced  into  the  pulmonary  artery, 
from  which  circumstance  he  conjectures  most  of  tlie 
symptoms  originated. — {Trans,  of  a Society  fw  the 
Improvement  of  Med.  and  Chir.  Knowledge,  vol.  3, 
p.  85.) 

The  bursting  of  an  aneuri.sm  of  the  aorta  into  the 
pulmonary  artery,  is  then  another  possible  mode  in 
which  the  disease  may  prove  fatal. 

Besides  the  example  of  this  nature  reported  by  Dr. 
Wells,  several  others  are  detailed  by  writers. — (8ee 
Bulletin  de  la  Facvltn  de  MMecine,  No.  3,  in  which 
there, are  tioo  cases;  Siie,  in  Jovm.  de  Med.  continue, 
t.  24,  p.  124  ; and  in  Bulletin  de  la  FaculU,  c.  t.  17, 
p.  16.) 

Aneurisms  of  the  arch  of  the  aorta  are  stated  to  have 
adhered  to,  and  burst  into,  the  right  auricle  of  the 
heart,  and  thus  to  have  produced  instant  death. — (See 
Med.  Chir.  Jovrn.  vol.  6,  p.  617.  Bulletin  de  la  So- 
ciHe  de  Medecine  d Paris,  1810,  No.  3,  p.  38.) 

The  cases  recorded  in  which  aneurisms  of  the  tho- 
racic aorta  have  burst  into  the  cpsophagus,  are  begin- 
ning to  be  more  numerous  than  formerly.  Boiietus 
and  Morgagni  r.latc  no  examples  of  it ; nor  are  there 
any  in  the  comprehensive  treatises  of  Scarpa  and 
Hodgson.  Corvisart  speaks  of  an  instance  which  had 
been  seen  by  Dupuytren,  of  which,  however,  no  de- 
cription  is  given.  Yet  the  possibility  of  the  occurrence 
is  not  a matter  of  speculation  or  doubt. 

A case  of  this  descrijjtion  is  noticed  by  Matani  {De 
Aneurism.  PreBcordiorum  Morbis,  p.  120);  another  is 
alluded  to  by  Ehrhardt,  as  being  related  by  Copeland 
{Comment,  de  Aneurismate  Aortas,  p.  22,  et  Cerutti 
Catal.  Prop.  Pathol.) ; an  instance  is  described  by  Ber- 
tin  (See  Bulletins  de  la  Faculte  de  Med.  1810,  p.  14); 
and  a very  interesting  one,  attended  with  disease  of 
the  spinal  cord  and  paralysis,  is  given  by  Dr.  Molison. 
— (See  Edin.  Med.  Chir.  Trans,  vol.  3,  p.  173.) 

Sauvages  is  one  of  the  writers  who  have  adduced 
proofs  of  this  mode  of  rupture;  cadavere  aperto,  inveni 
ventriculum  septem  vel  octo  libris  sanguinis  disten- 
sum,  aorta7n  ad  brachii  magnitudinem,  per  spativm 
sqdem  vel  octo  pollicum  dilatatam,  et  mrificivm  de- 
narii magnitudine  aortw,  et  obso})hago  continuo  com- 
mune, quod  tamen  quinque  cristas,  cameos,  veluti  val- 
vulcB  ex  ambitu  orijicii  oriundw  et  circumpositw  po- 
tuerunt  obturare.  Per  hoc  orificium,  sanguis  ex 
aorta  Jluxerat  in  oesophagum.—  {Nov.  Method,  t.  2,  p. 
298.)  A similar  case  has  been  recently  published  by 
Bricheteau. — (See  Bulletin  de  VAthenie  de.Mdd.  de  Pa- 
ris, Dec.  1816.)  Laennec  met  with  three  examples  of 
death  from  this  cause. — {On  Dis.  of  the  Chest,  p.  677, 
ed.  by  Forbes.)  The  same  distinguished  professor  met 
with  an  aneurism  of  the  descending  aorta,  where  the 
tumour  had  made  such  pressure  on  the  thoracic  duct, 
that  this  tube  was  partly  destroyed,  and  all  the  lym- 
phatic vessels  were  found  uncommonly  turgid.  —{Journ. 
de  Med.  par  Corvisart,  t.  2,  p.  15.)  With  the  excejt- 
tion,  perhaps,  of  one  instance  given  on  the  authority  of 
Lancisi  {Lauthii  Collect,  p.  38),  no  other  example  of 
this  description  is  upon  record. 

All  instance  is  reported  by  Corvisart,  in  which  the 
pres.sure  of  an  aneurism  of  the  ascending  aorta  had 
nearly  obliterated  the  termination  of  the  lower  vena 
cava,  and  a final  attack  of  apoplexy  was  the  conse- 
(iuence. — {Mai.  du  Casur,  p 342.) 

It  is  well  worthy  of  notice,  that  aneurisms  of  the 


144 


ANEURISM. 


arch  of  the  aorta  may  occasion  a tumour  so  much  like 
that  of  a subclavian  aneurism,  as  to  be  iu  danger  of 
being  mistaken  for  the  latter  disease.  An  example  of 
this  kind  is  related  by  Mr.  Allan  Burns:  “a  case,’’ 
says  he,  “ on  which  several  of  the  most  distinguished 
practitioners  of  Edinburgh,  and  almost  every  surgeon 
in  Glasgow,  were  consulted.  The  nature  of  the  dis- 
ease appeared  to  be  so  decided,  and  its  situation  in  the 
subclavian  artery  so  clear,  that  on  that  subject  there 
was  no  difference  of  opinion.  Some  were,  however, 
of  opinion,  that  an  operation  might  be  performed,  while 
others  were  fully  convinced,  that  the  case  was  hope- 
less. For  myself,  I must  confess,  that  I was  firmly 
persuaded,  that  in  the  early  stage  of  the  disease,  an 
operation  might  have  been  beneficial,”  &c. — (Surgical 
Aruitomy  of  the  Head  and  Neck,  p.  30.)  After  death 
the  vessel  which  was  supposed  to  have  been  most  ma- 
terially affected,  was  found  perfectly  healthy. — (P.  39.) 

After  detailing  all  the  particulars  of  this  interesting 
case,  Mr.  A.  Burns  observes,  that  “it  corroborates 
Sir  Astiey  Cooper’s  remark,  that  aneurism  of  the  aorta 
may  assume  the  appearance  of  being  seated  m one  of 
the  arteries  of  the  neck  : an  inference  drawn  from  the 
examination  of  a case  which  came  under  his  own  ob- 
servation, and  of  which  he  had  the  goodness  to  trans- 
mit a short  history  to  me,  along  with  a sketch,  illus- 
trative of  the  position  of  the  tumour.  In  one  case, 
the  aneurism  w’as  attached  to  the  right  side  of  the 
aortic  arch,  and  involved  a part  of  the  arteria  innomi- 
nata : in  Sir  A.  Cooper’s,  the  tumour  arose  from  the 
lett  side  of  the  arch,  from  between  the  roots  of  the 
left  subclavian  and  carotid  arteries.  It  formed  a Flo- 
rence-flask-like  cyst,  the  bulbous  end  of  which  pro- 
jected at  the  root  of  the  neck,  from  behind  the  sternum, 
and  so  nearly  resembled  aneurism  of  the  root  of  the 
carotid  artery,  that  the  practitioner  who  consulted  Sir 
A Cooper  actually  mistook  the  disease  for  carotid  an- 
eurism.”— {Allan  Bums,  op.  cit.  p.  41.) 

The  preceding  statement  has  received  full  confirma- 
tion from  the  observation  of  an  intelligent  writer. 
“ I have  seen  (says  Mr.  Hodgson)  several  cases  of  an- 
eurism arising  from  the  superior  part  of  the  arch  of 
the  aorta,  which  protruded  above  the  sternum  and  cla- 
vicles, and  in  one  instance,  the  space  between  the  tu- 
mour and  the  sternum  was  so  considerable,  that  it  was 
proposed  to  tie  the  carotid  artery  for  an  aneurism, 
which  dissection  proved  to  arise  from  the  origin  of  the 
arteria  innominata  and  from  the  arch  of  the  aorta.”— 
{On  the  Diseases  of  Arteries  and  Veins,  p.  90.) 

As  we  have  already  noticed,  aneurisms  of  the  aorta 
are  most  frequent  at  its  curvature  ; but  they  are  also 
met  with  on  the  other  portion  of  this  vessel  in  the 
thorax,  and  likewise  on  that  part  of  it  which  is  below 
the  diaphragm.  In  subjects,  predisposed  to  aneurisms, 
such  swellings  are  frequently  seen  affecting  various 
pans  of  the  aorta  at  the  same  time. 

When  the  disease  occurs  in  the  abdominal  aorta,  a 
preternatural  pulsation  generally  becomes  perceptible 
at  some  particular  point.  The  pressure  of  the  tumour 
interferes  with  the  functions  of  the  viscera;  the  breath- 
ing is  rendered  difficult  by  the  swelling  resisting  the 
descent  of  the  diaphragm ; the  patient  suffers  at  times 
excruciating  internal  pains ; sometimes  he  is  affected 
with  cosiiveness ; sometimes  with  diarrhoea ; and  not 
unfrequently  with  incontinence  of  the  urine  and  feces. 
At  length,  an  immense  external  swelling  is  formed, 
which  pulsates  alarmingly,  and  if  the  patient  survives 
long  enough,  destroys  him  by  a sudden  external  or  in- 
ternal effusion  of  blood. 

Aneurisms  within  the  thorax  and  abdomen,  being 
entirety  out  of  the  reach  of  operative  surgerjq  have 
been  too  commonly  abandoned  as  unavoidably  fatal, 
and  when  any  thing  has  been  done  in  such  cases, 
it  has  generally  been  only  with  a view  of  palli- 
ation. Moderating  the  force  of  the  circulation  by 
b'eedings  and  low  diet,  avoiding  every  thing  that  has 
the  least  tendency  to  heat  the  body,  or  quicken  the  mo- 
tion of  the  blood,  keeping  the  bowels  well  open  with 
laxative  medicines,  and  lessening  pain  with  opiates, 
have  been  the  means  usually  employed.  Of  late  years, 
also  digitalis,  which  nas  a peculiar  power  of  diminish- 
ing the  action  of  the  sanguiferous  -system  and  impe- 
tus of  the  blood,  has  been  prescribed  with  every  ap- 
pearance of  benefit. 

That  the  diminution  of  the  force  of  the  circulation 
will  prevent  the  increase  of  an  aneurism,  Mr.  Hodg- 
son considers  illustrated  by  the  following  circumstance : 1 


I if  two  sacs  exist  in  the  course  of  the  same  artery, 
obstruction  which  is  caused  by  the  passage  of  blood 
into  the  upper  removes  the  force  of  circulation  from 
the  lower,  which  becomes  stationa^,  or  its  cavity  is 
I obliterated  with  coagulum. — {On  Diseases  of  Arteries, 
I d-c.  p.  149.) 

It  was  the  opinion  of  the  celebrated  Valsalva,  that 
the  utility  of  a lowering  plan  of  treatment  might  do 
more  than  merely  retard  the  death  of  aneurisnial  pa^ 
tients.  It  was  his  belief,  that  the  method  might  en- 
tirely cure  such  aneurisms  as  had  not  already  made 
too  fiiuch  progress  ; and  he  put  it  into  practice  with 
such  rigour  and  perseverance,  that  the  treatment  be- 
came considered  as  particularly  his  own.  The  plan 
alluded  to  is  not  described  in  his  writings,  but  was 
published  in  the  first  volume  of  the  Commentaries  of 
the  Academy  of  Bologna,  by  Albertini,  one  of  his  fel- 
low-students ; and  several  persons,  who  had  learned 
this  method  of  Valsalva,  afterward  imparted  it  to 
others.  Thus,  as  Morgagni  was  passing  through  Bo- 
logna, in  1728,  Stancazi,  a physician  of  that  place,  is 
said  to  have  informed  him  of  Valsalva’s  practice. — (See 
on  this  subject  Kreysig,  iiber  die  Herzkrankheiten,  h, 
2,  p.  728.) 

After  taking  away  a good  deal  of  blood  by  venesec- 
tion, Valsalva  used  next  to  diminish  the  quantity  of 
food  gradually,  till  the  patient  at  length  wtis  allowed 
only  half  a pint  of  soup  in  the  morning,  and  a quarter 
of  a pint  in  the  evening,  and  a very  small  quantity  of 
water,  medicated  with  mucilage  of  quinces,  or  with 
the  lapis  osteocolla.  When  the  patient  had  been  so 
reduced  tts  to  be  incapable  of  getting  out  of  his  bed, 
^’alsalva  used  to  give  him  more  nourislunem  till  tliis 
extreme  debility  was  removed.  Valsalva  was  sure, 
that  some  aneurisms,  thus  treated,  had  got  well,  be- 
cause every  symptom  disappeared,  and  his  conviction 
was  verified  by  an  opportunity  which  he  had  of  dis- 
secting the  body  of  a person  that  had  been  cured  of 
this  disease,  and  afterward  died  of  another  affection  ; 
for  the  artery  which  hail  been  dilated  was  found  con- 
tracted, and  in  some  degree  callous. 

Morgagni  relates,  that  this  method  of  treating  aneu- 
risms is  somewhat  like  the  plan  which  Bernard  Gen- 
gha  tried  with  success,  as  well  as  Lancisi,  and  he  re- 
fers us  to  the  24th  chapter  of  the  2d  vol.  of  the  Ana- 
tomy of  the  one,  and  to  lib.  2,  cap.  4,  of  the  Treatise 
on  the  Heart  and  Aneurisms,  of  the  other.  But  Saba- 
tier tells  us,  that  in  consequence  of  this  instruction, 
he  examined  both  these  works,  without  finding  any 
thing  on  the  subject.  However  this  may  be,  we  are 
informed  by  the  latter,  that  he  has  seen  the  good  effects 
of  the  practice  in  an  otficer,  who  had  an  alarming  an- 
eurism in  front  of  the  humeral  extremity  of  the  cla- 
vicle, in  consequence  of  a sword-wound  in  the  axilla. 
The  patient,  after  having  been  bled  several  times,  was 
confined  to  his  bed,  and  kept  to  an  extremely  low  diet. 
He  was  allow'ed  as  drink  only  a very  acid  kind  of  le- 
monade. He  took  pills  containing  alum,  and  the  swell- 
ing was  covered  with  a bag  full  of  tan-mill  dust, 
which  was  every  now  and  then  well  w'et  with  port 
wine.  By  a perseverance  in  this  treatment,  the  swell- 
ing was  reduced  to  a smallish  hard  tubercle,  having 
no  pulsation,  and  a perfect  cure  ensued. — (See  Saba- 
tier, Medecine  Operatoire,  tom.  3,  p.  170 — 172.) 

Guerin  recommended  the  application  of  ice  water  or 
pounded  ice,  to  aneurismal  swellings ; a plan  which 
he  represents  as  being  often  of  itself  sufficient  to  effect 
a cure.  This  topical  employment  of  cold  applications 
may  be  rationally  and  conveniently  adopted  in  con- 
junction with  Valsalva’s  practice. 

The  most  interesting  and  convincing  facts  in  proof 
of  the  efficacy  of  this  mode  of  treatment,  were  pub- 
lished a few  years  ago  by  Pelletan.  Indeed,  upon  the 
whole,  I have  no  hesitation  in  saying,  that  I have 
never  read  any  modern  collection  of  surgical  cases, 
which  have  appeared  to  me  more  valuable,  than  those 
w'hich  compose  the  Clinique  Chirurgicale  of  this  ex 
}ierienced  writer.  The  following  extract  from  a well- 
written  critique  on  this  work  will  serve  to  convey  to 
the  reader  some  idea  of  the  important  information  con- 
tained in  the  memoir  on  internal  aneurisms : — “ The 
intent  in  the  treatment  is  to  reduce  the  patient  gradu- 
ally to  as  extreme  a degree  of  weakness  as  is  possi- 
ble, without  immediately  endangering  life.  It  is  done 
by  absolute  rest,  a rigorous  diet,  and  bleeding  ; to  these 
means,  M Pelletan  adds  the  external  application  of 
ice,  or  cold  and  astringent  washes,  &c.  He  has  here 


ANEURISM. 


145 


detailed  many  cases  from  his  own  practice,  of  partial 
or  complete  success,  which  cannot  be  too  generally 
known,  as  they  may  be  the  means  of  creating  in  some, 
and  of  confirming  in  others,  a good  opinion  of  the  only 
method  of  treatment,  which  has  been  found  at  all  effica- 
cious in  a dreadful  and  not  unfrequent  organic  disease. 

Of  the  cases  here  recorded,  some  appear  to  have 
been  cured  ; in  others,  the  treatment  had  marked  good 
effects.  In  extreme  cases,  at  best,  it  afforded  but 
partial  and  temporary  relief.  We  can  notice  but  a 
few  of  these  cases,  which  are,  in  every  respect,  highly 
i.iteresting.  In  one,  a robust  man,  an  aneurism  at  the 
root  of  the  aorta,  with  a pulsating  tumour  of  the  size 
of  an  egg,  projecting  between  the  ribs  (the  edges  of 
which  were  already  partly  absorbed),  was  reduced  so 
as  to  recede  within  the  ribs  in  the  course  of  eight  days. 
At  the  end  of  this  time,  the  patient  refused  to  subm.it 
any  longer.  The  tumour  did  not  appear  again  for 
nearly  a year,  although  he  returned  to  very  drunken 
and  irregular  habits.  He  died  in  about  two  years  and 
a half,  with  the  tumour  again  appearing,  and  much  in- 
creased in  volume.  The  aneurismal  sac  communi- 
cated with  the  aorta,  by  a smooth  and  round  opening, 
opposite  to  one  of  the  sigmoid  valves.  There  can  be 
no  doubt  of  the  efficacy  of  the  treatment  in  this  case  ; 
and  it  is  highly  probable  that  his  health  and  his  life 
might  have  been  long  preserved,  but  for  his  own  in- 
discretion. In  a ca.se  somewhat  similar,  but  not  so 
far  advanced,  the  patient  appears  to  have  been  cured. 
There  was  a swelling  on  the  right  side  of  the  breast, 
about  six  inches  in  circumference,  with  a very  strong 
beating.  The  pulsation  was  accompanied  with  a pain 
which  stretched  towards  the  scapula  and  the  occiput. 
It  was  evident  that  the  disease  was  an  aneurism  of  the 
great  arch  of  the  aorta.  The  patient  was  a crier,  of  a 
strong  frame,  who  was  accustomed  to  drink  freely. 
In  the  first  four  days,  he  was  bled  eight  times,  draw- 
ing three  basins,  ‘ palettes,’  in  the  morning,  and  two 
in  the  evening.  On  the  fifth,  the  pains  and  the  beat- 
ing were  much  lessened,  but  the  pulse  was  still  full. 
He  was  again  bled  once.  The  pulse  was  in  a favour- 
able state  as  to  strength,  till  the  seventh  day,  when  it 
again  rose,  and  the  man  was  twice  bled. 

During  this  time  the  man  was  kept  to  a most  rigor- 
ous diet.  A cold  poultice  of  linseed  and  vinegar  was 
placed  on  the  tumour,  and  renewed  when  it  became 
warm.  At  the  end  of  eight  days,  the  good  effects  of 
this  plan  were  very  evident ; the  pain  and  the  pulsa- 
tion were  gone.  The  patient,  though  weak,  was  in 
health  and  tranquil.  He  was  now  allowed  more  food 
by  degrees.  At  the  end  of  four  weeks  from  the  com- 
mencement of  the  treatment,  he  left  the  Hotel-Dieu 
well.  He  afterward  led  a sober  life,  and  became  fat- 
ter, without  any  vestige  of  disease,  except  a slight  and 
deep  pulsation  at  the  part,  in  which  the  aorta  may  al- 
ways be  felt  beating  in  its  natural  state.  He  died  two 
or  three  years  after  of  another  complaint.  His  death 
was  not  known,  and  the  body  was  not  examined.” — 
(See  London  Med.  Revieiv,  vol.  5,  p.  123.) 

Pelletan  also  cured  by  similar  treatment  a large 
a.villary  aneurism,  which  was  deemed  beyond  the  reach 
of  operative  surgery.  On  the  thirteenth  day,  the  patient 
was  reduced  to  a degree  of  weakness  which  alarmed 
many  of  the  observers.  From  that  time,  all  pulsation 
in  the  tumour  ceased.  The  contents  were  gradually 
absorbed ; and  the  patient  returned  to  his  former  labo- 
rious life  with  his  arm  as  strong  as  ever.  The  pulse 
at  the  wrist  was  lost  in  consequence  of  the  obliteration 
of  the  axillary  artery,  and  the  limb  only  receiving  blood 
through  the  branches  of  the  subclavian  artery.  “ II  y 
a benucoup  d’exemples  d'aneurisines,  guSris  spontane- 
menit  et  sans  le  secours  de  Vart  (says  Pelletan) ; mais 
on  ne  pent  leur  comparer  le  cos  que  nous  venons  de 
d-.crire:  L'dat  extreme  de  la  maladie,  Venergie  des 
moyens  employes,  et  Veffet  immediat  et  success  if  qui  ern 
est  resulU  prouvent  assez  que  le  succis  a cte  dd  tout 
entier  a Vart." — {Clinique  Chirurgicale,  tom.  l,p.  80.) 

In  this  work,  we  find  not  less  than  three  cases,  in 
which  aneurism  of  the  aorta  is  stated  to  have  been 
effectually  cured.  One  instance  was  greatly  relieved; 
but  the  disease  returned  the  next  year,  in  con.sequence 
of  the  patient’s  intemperate  mode  of  life.  In  another 
example,  an  aneurism  at  the  origin  of  the  aorta  was 
cured ; but  the  disease  recurred  in  another  part  of  that 
vessel,  farther  from  the  heart.  Even  such  cases  as 
proved  incurable,  to  the  number  of  fourteen,  all  received 
various  degrees  of  palliation  from  the  treatment  adopted. 

Von.  1.--K 


In  a modern  work  of  great  merit,  several  other  in* 
stances  are  adduced,  in  which  the  utility  and  efficacy 
of  a debilitating  plan  of  treatment  are  illustrated.— (See 
HodgsorVs  Treatise  on  the  Diseases  of  Arteries,  p,  146, 
147,  <S-c.  Src.)  In  the  same  publication,  as  I have  pre- 
viously explained,  there  are  several  interesting  facts, 
which  tend  to  prove,  that  when  the  aneurism  of  the 
aorta  is  lessened  or  cured,  this  great  vessel  itself  may- 
remain  pervious.  The  progress  of  the  disease  is 
stopped  by  the  blood  coagulating  in  the  sac,  and  closing 
the  communication  between  the  cavity  of  the  aneurism 
and  that  of  the  artery. 

It  must  be  confessed,  in  regard  to  Valsalva’s  mode  of 
treatment,  that  some  experienced  men  do  not  place  con- 
fidence in  it.  Boyer  declares  himself  against  it,  as  not 
being  really  efficacious ; and  he  states,  that  some  time 
ago,  it  was  tried  twice  in  the  Hotel-Dieu  of  Paris. 
The  first  trial  was  made  on  a patient  with  an  axillary 
aneurism,  which  could  not  be  operated  upon  on  account 
of  its  situation ; the  second  on  a woman,  who  had  an 
aneurism  of  the  abdominal  aorta.  In  both  cases,  the 
tumour  was  large,  and  its  parietes  reduced  to  the  cel- 
lular coat,  and  the  surrounding  cellular  substance,  In 
these  two  pneurisms,  the  progress  of  the  swelling  was 
much  more  rapid,  and  its  rupture  ha])pened  precisely 
at  the  moment  when  the  treatment  had  been  pushed  to 
the  utmost,  and  there  ought  to  have  been  the  greatest 
hope.— (Trarfe  des  Maladies  Chir.  t.  2,  p.  121.) 

Sir  Astley  Cooper  declares,  that  he  has  seen  but 
little  benefit  result  from  the  treatment  of  this  disease. 
According  to  his  experience,  only  two  measures  are 
useful;  viz.  venesection  when  the  pulse  is  hard  and 
full ; and  the  administration  of  the  carbonate  of  soda 
in  considerable  doses,  which,  with  entire  rest,  seem  to 
prevent  the  increase  of  the  swelling.  But  he  adds, 
that  the  soda  is  at  length  unavoidably  given  up,  on 
account  of  its  producing  petechiai.  Sir  Astley  believes 
that  the  irritability  and  quickened  pulse,  produced  by 
antiphlogistic  treatment,  often  do  as  much  injury  as 
the  natural  force  of  the  circulation. — {Lectures,  ti  c., 
vol.  2,  p.  48.) 

Roux  expresses  his  entire  disbelief  in  the  possibility 
of  an  aneurism  of  the  aorta  being  ever  completely 
cured  by  Valsalva’s  mode  of  treatment,  because  he 
imagines,  that  such  change  could  not  happen  without 
the  tube  of  that  great  vessel  becoming  impervious,  and 
of  the  lower  parts  of  the  body  then  perishing  from 
stoppage  of  the  circulation.  But  he  bears  witness  to 
the  utility  of  such  treatment,  and  recites  a case  which 
he  attended  himself,  where  an  aneurism  made  a con- 
siderable projection  on  the  left  side  of  the  sternum, 
where  the  cartilages  of  the  third  and  fouth  ribs  were 
raised,  the  throbbings  very  forcible,  and  the  sense  of 
suffocation  such  that  the  patient  was  obliged  to  keep 
himself  constantly  quiet ; yet,  says  Roux,  though  the 
disease  now  exists,  it  forms  no  prominence  on  the 
chest;  the  pulsations  can  only  be  obscurely  felt  be- 
tween the  ribs ; the  respiratioais  but  slightly  oppressed ; 
and  the  patient  is  capable  of  attending  to  his  business. 
—{Nouveaux  Elemens  de  Mrdecine  Operatoire,  t.  I,  p. 
510,  Suo.  Paris,  1813.  Fr.  Torti,  De  Aortee  Aneurys- 
mate  Observationes  bines,  cum  animadv.  Pauli  Val- 
carenghi,  8vo.  Cremonae,  1741.  D.  Sommer,  Dis.  sis- 
tens  Aneurysmatis  Aortas  Pleuritydem.  mentientis 
Casum.  8vo.  Berol.  1816.) 

.\NEURISMAL  VARIX,  VARICOSE,  OR  VENOUS  ANEURISM. 

By  these  terms,  surgeons  mean  a tumour,  arising 
from  a preternatural  communication,  formed  between  a 
large  vein  and  a subjacent  artery.  Thus,  in  venesec- 
tion performed  immediately  over  the  artery  at  the  bend 
of  the  elbow,  if  the  lancet  be  carried  too  deeply,  it  may 
transfix  the  vein,  and  w'ound  the  artery,  in  which  event, 
the  arterial  bloody  in  consequence  of  the  i)roximity  of 
the  two  vessels,  instead  of  being  effused  into  the  cel- 
lular substance,  will  pass  directly  into  the  cavity  of  the 
vein,  which  will  become  dilated  in  the  form  of  a varix 
by  the  jet  of  arterial  blood  into  it. 

Although  Sennertus  probably  referred  to  an  instance 
of  this  disease  {Op.  t.  5,  Z.  5,  cap.  43),  Dr.  W.  Hunter 
is  undoubtedly  the  first  who  gave  an  accurate  descrip- 
tion of  it.  Scarpa  is  disposed  to  claim  a share  of  the 
merit  for  his  countryman  Guattaiii;  but,  as  Mr.  Hodg- 
son has  remarked.  Dr.  Hunter’s  observations  on  this 
disease  were  published  in  the  years  1757  and  1764; 
whereas,  Guattani  did  not  see  his  first  patient  until  the 


146 


ANEURISM. 


year  1769,  and  his  book  was  not  published  until  the 
year  1772. 

“ Does  it  ever  happen  in  surgery,”  says  Dr.  Hunter, 
“ that  when  an  artery  is  opened  through  a vein,  a com- 
munication, or  anastomosis,  is  afterward  kept  up  be- 
tween these  two  vessels  1 It  is  easy  to  conceive  tltis 
case,  and  it  is  not  long  since  I was  consulted  about 
one,  that  had  all  the  symptoms  that  might  be  expected, 
supposing  such  a tning  to  have  actually  happened,  and 
such  symptoms,  as  otherwise  must  be  allowed  to  be 
Very  unaccountable.  It  arose  from  bleeding ; and  was 
of  some  years’  standing,  when  I saw  it  about  two  years 
ago,  and  1 understand  very  little  alteration  has  happened 
to  it  since  that  time.  The  veins,  at  the  bending  of  the 
arm,  and  especially  the  basilic,  which  was  the  vein 
that  had  been  opened,  were  there  prodigiously  enlarged, 
and  came  gradually  to  their  natural  size,  at  about  two 
inches  above  and  as  much  below  the  elbows.  When 
emptied  by  ])ressure,  they  filled  again  almost  instanta- 
neously, and  this  happened,  even  w'hen  a ligature  was 
applied  tight  round  the  foreann,  immediately  belcw 
the  affected  part.  Both  when  the  ligature  was  made 
tight,  and  when  it  was  removed,  they  shrunk,  and  re- 
mained of  a small  size,  while  the  finger  was  kept  tight 
upon  the  artery,  at  the  part  where  the  vein  had  been 
opened  in  bleeding.  There  was  a general  swelling  in 
the  place,  and  in  the  direction  of  the  artery,  which 
seemed  larger,  and  beat  stronger  than  what  is  natural, 
and  there  was  a tremulous  jarring  motion  in  the  vein, 
which  was  strongest  at  the  part  which  had  been  punc- 
tured, and  became  insensible  at  some  distance  both 
upwards  and  dowmwards.”— (jT/ed.  Obs.  and  Inq.  vol.  1.) 

In  the  second  volume  of  this  work.  Dr.  Hunter  adds 
some  farther  remarks  on  the  aneurismal  varix. 

“In  the  operation  of  bleeding,  the  lancet  is  plunged 
into  the  artery  through  both  sides  of  the  vein,  and  there 
will  be  three  wounds  made  in  these  vessels,  viz.  two 
in  the  vein,  and  one  in  the  artery,  and  these  will  be 
nearly  opposite-  to  one  another,  and  to  the  wound  in  the 
skin.  This  is  wdiat  all  surgeons  know  has  often  hap- 
pened in  bleeding,  and  the  injury  done  the  artery  is 
commonly  known  by  the  jerking  impetuosity  of  the 
stream,  while  it  flows  from  the  vein,  and  by  the  diffi- 
culty of  stopping  it,  when  a sufficient  quantity  is  drawn. 

In  the  next  place,  we  must  suppose,  that  the  wound 
of  the  skin,  and  of  the  adjacent  or  ujiper  side  of  the 
vein,  heal  up  as  usual ; but  that  the  wound  of  the  ar- 
tery, and  of  the  adjacent  or  under  side  of  the  vein, 
remain  open  (as  the  wound  of  the  artery  does  in  the 
simrious  aneurism),  and,  by  that  means,  the  blood  is 
thrown  from  the  trunk  of  the  artery  directly  into  the 
trunk  of  the  vein.  Extraordinary  as  this  supposition 
may  appear,  in  reality  it  differs  from  the  common  spu- 
rious aneurism  in  one  circumstance  only,  viz.  the 
wound  remaining  open  in  the  side  of  the  vein,  as  well 
as  in  the  side  of  the  artery.  But  this  one  circumstance 
will  occasion  a great  deal  of  difference  in  the  symptoms, 
in  the  tendency  of  the  complaint,  and  in  the  proper 
method  of  treating  it:  upon  which  account,  the  know- 
ledge of  such  a case  will  be  of  importance  in  surgery. 

It  will  differ  in  its  symptoms  from  the  common 
spurious  aneurism  principally  thus: — 

The  vein  will  be  dilated,  or  become  varicose,  and 
it  will  have  a pulsating  jarring  motion  on  account  of 
the  stream  from  the  artery.  It  will  make  a hissing 
noise,  which  will  be  found  to  correspond  with  the  pulse 
for  the  same  reason.  The  blood  of  the  tumour  will  be 
altogether,  or  almost  entirely  fluid,  because  kept  in 
constant  motion.  The  arterjq  I apprehend,  will  become 
larger  in  the  arm,  and  smaller  at  the  wrist,  than  it  was 
in  the  natural  state ; which  will  be  found  out  by  com- 
paring the  size,  and  ttie  pulse,  of  the  artery,  in  both 
arms,  at  these  different  places.  The  reason  of  w^hich 
I will  speak  of  hereafter ; aqd  the  effects  of  ligatures, 
and  of  pressure  upon  the  vessels  above  the  elbow  and 
below  it,  will  be  wffiat  every  person  may  readily  con- 
ceive, who  understands  any  thing  of  the  nature  of  ar- 
teries and  veins  in  the  li’/ing  body. 

The  natural  tendency  of  such  a complaint  will  be 
very  different  from  that  of  the  spurious  aneurism. 
The  one  is  growing  xvorse  every  hour,  because  of  the 
resistance  to  the  arterial  blood,  and,  if  not  remedied  by 
surgery,  must  at  last  burst.  The  other,  in  a .short 
time,  comes  to  a nearly  permanent  state ; and,  if  not 
disturbed,  produces  no  mischief,  becaiise  there  is  no 
considerable  resistance  to  the  blood  that  is  forced  out 
of  the  arter)-. 


I The  proper  treatment  must,  therefore,  be  very  dif- 
ferent in  these  two  cases,  the  spurious  aneurism  re- 
quiring chirurgical  assistance,  as  much,  perhaps,  as 
any  disease  whatever;  wffiereas,  in  the  other  case,  I 
presume  it  will  be  best  to  do  nothing. 

If  such  cases  do  happen,  they  will  no  doubt  be 
found  to  differ  among  themselves,  in  many  little  cir- 
cumstances, and  particularky  in  the  shape,  &c.  of  the 
tumefied  parts.  Thus  the  dilatation  of  the  veins  may 
be  in  one  only,  or  in  several,  and  may  extend  lower  or 
higher  in  one  case  than  in  another,  &c.,  according  to 
the  manner  of  brandling,  and  to  the  state  of  the  valves 
in  different  arms.  And  the  dilatation  of  the  veins  may 
also  vary,  on  account  of  the  size  of  the  artery  that  is 
wounded,  and  of  the  size  of  the  orifice  in  the  artery 
and  in  the  vein. 

Another  difterence  in  such  cases  will  arise  from 
the  different  manner  in  which  the  orifice  of  the  artery 
may  be  united  or  continued  with  the  orifice  of  the  vein. 
In  one  case,  the  trunk  of  the  vein  may  keep  close  to 
the  trunk  of  the  artery,  and  the  very  thin  stratum  of 
cellular  membrane  between  them  may,  by  means  of  a 
little  inflammation  and  coagulation  of  the  blood  among 
its  filaments,  as  it  were,  solder  the  two  orifices  of  these 
vessels  together,  so  that  there  shall  be  nothing  like  a 
canal  going  from  one  to  the  other ; and  then  the  whole 
tumefaction  will  be  more  regular,  and  more  evidently 
a dilatation  of  the  veins  only.  In  other  instances,  the 
blood  that  rushes  from  the  wounded  artery,  meeting 
with  some  difficulty  of  admission  and  passage  through 
the  vein,  may  dilate  the  cellular  membrane,  between 
the  artery  and  vein,  into  a bag,  as  in  a common  spuri- 
ous aneurism,  and  so  make  a sort  of  canal  between 
these  two  vessels.  The  trunk  of  the  vein  will  then  be 
removed  to  some  distance  from  the  trunk  of  the  artery, 
and  the  bag  will  be  situated  chiefly  upon  the  under 
side  of  the  vein.  The  bag  may  take  on  an  irregular 
form,  from  the  cellular  membrane  being  more  loose 
and  yielding  at  one  place  than  at  another,  and  from 
being  unequally  bound  down  by  the  fascia  of  the  biceps 
muscle.  And  if  the  bag  be  very  large,  especially  if  it 
be  of  an  irregular  figure,  no  doubt,  coagulations  of 
blood  may  be  formed,  as  in  the  common  spurious  aneu- 
rism.” 

As  Scarpa  correctly  observes,  a concurrence  of  two 
circumstances  is  requisite  for  the  production  of  an 
aneurismal  varix : 1st,  the  incision  in  the  vein,  and  that 
in  the  artery  must  be  exactly  in  the  same  direction  ; 2d, 
the  solution  of  continuity  in  the  integuments  and  upper 
side  of  the  vein  must  heal,  while  the  wound  in  the 
deeper  side  of  that  vessel  and  the  puncture  in  the  upper 
surface  of  the  artery  remain  open,  and  communicate  so 
readily  that  the  arterial  blood  finds  greater  facility  in 
entering  from  the  artery  into  the  vein,  than  in  being 
effused  from  the  artery  into  the  surrounding  cellular 
substance. 

If  one  of  these  two  circumstances  be  wanting,  either 
because  the  wounding  instrument  has  entered  the  ar- 
tery a little  obliquely  from  the  vein,  or  because  the  vein 
has  not  been  sufficiently  near  to  the  artery,  on  account 
of  the  cellular  substance  between  them,  the  arterial 
blood  most  frequently  does  not  produce  the  aneurismal 
varix  ; or,  if  it  does,  the  disease  is  always  complicated 
with  effusion  of  arterial  blood  into  the  cellular  sub- 
stance, or  with  an  aneurism  and  aneurismal  varix 
at  the  same  time.  In  this  case  the  small  aneurismal 
sac  serves  as  a short  canal  of  communication  between 
the  artery  and  the  vein  {Med.  Facts  and  Obs.  vol.  4,  p. 
115);  two  distinct  diseases  in  fact  being  formed  from  the 
same  cause,  and  placed  one  over  the  other,  viz.  an 
aneurism  and  an  aneurismal  varix. — {Scarpa,  p.  421, 
ed.  2.)  The  following  marks  of  distinction  between 
aneurism  and  aneurismal  varix  are  pointed  out  by 
the  same  author : the  aneurismal  varix  always  forms 
a circumscribed  tumour ; aneurism  does  not  always  do 
so.  The  cellular  substance  which  constitutes  the  sac 
of  the  aneurism  does  not  always  resist  so  strongly  trie 
impetus  of  the  arterial  blood  as  the  coats  of  the  vein  do. 
Not  unfrequently,  therefore,  aneurism  from  being  cir- 
cumscribed at  first  becomes  diffused ; extends  along 
the  course  of  the  wounded  artery ; compresses  strongly 
the  surrounding  parts ; occasions  acute  pain  and  in- 
flammation ; and  the  parts  are  threatened  with  gan- 
grene. On  the  contrary,  the  aneurismal  varix  is  always 
circumscribed,  increases  very  slowly,  does  not  produce 
much  pain,  and,  as  it  augments,  it  always  extends 
more  or  less  above  or  below  the  place  w here  venesec- 


ANEIJUISM. 


147 


tion  has  been  done ; and  this  extension  is  in  proportion 
to  the  greater  or  less  force  with  which  the  arterial 
blood  is  thrown  from  the  artery  into  the  vein,  and  the 
greater  or  less  resistance  made  by  the  valves  situated 
til  the  vein  below  the  puncture,  and  according  to  the 
greater  or  less  number  of  veins  communicating  with 
the  aneurismal  varix.  The  seat  of  the  disease  is  gene- 
rally the  basilic  vein,  which  appears  dilated  in  an  un- 
usual manner,  forming  an  oblong  tumour  of  the  size 
of  a walnut,  if  the  disease  is  recent.  In  the  centre  of 
the  swelling  is  the  cicatrix  left  by  the  lancet.  The 
rein  is  less  dilated  the  farther  it  is  from  this  scar,  and 
in  general  at  the  distance  of  two  inches  and  a half 
above  and  below  this  point  the  vessel  resumes  its  natu- 
ral size.  The  small  tumour,  as  has  been  explained, 
pulsates  like  an  artery  with  a tremulous  motion  and 
iiissing  noise,  which  is  sometimes  so  great  that  the 
patient  cannot  sleep  if  he  is  lying  with  his  head  low, 
and  resting  on  the  injured  arm.  The  trunk  of  the  bra- 
chial artery,  from  the  axilla  doAvn  to  the  place  where 
it  has  been  wounded  with  the  lancet,  vibrates  with 
extraordinary  force.  There  is  no  change  of  colour  nor 
inflammation  of  the  skin ; and  the  pain  is  inconsiderable. 
The  swelling  is  compressible  and  yielding ; but  it  re- 
turns as  soon  as  the  pressure  is  removed  from  it. 
When  the  arm  is  kept  for  some  time  raised  up  towards 
the  head,  the  tumour  diminishes;  and  the  same  thing 
happens  when  pressure  is  made  on  the  communication 
between  the  artery  and  vein,  or  when  a tight  tourni- 
quet is  applied  near  the  axilla.  If  the  disease  be  com- 
plicated with  aneurism,  a second  pulsating  tumour  will 
be  found  lying  under  the  aneurismal  varix. — {Scarpa, 
p.  424,  ed.  2.) 

After  relating  two  cases,  illustrative  of  the  nature 
of  aneurismal  varix.  Dr.  W.  Hunter  proceeds  to  inquire, 
“ Why  is  the  pulse  at  the  wrist  so  much  weaker  in  the 
diseased  arm  than  in  the  other?  surely  the  reason  is 
obvious  and  clear.  If  the  blood  can  easily  escape  from 
the  trunk  of  the  artery  directly  into  the  trunk  of  the 
vein,  it  is  natural  to  think  that  it  will  be  driven  along 
the  extreme  branches  with  less  force  and  in  less  quan- 
tity. 

Whence  is  it  that  the  artery  is  enlarged  all  the  way 
down  the  arm  ? I am  of  opinion,  that  it  is  the  conse- 
quence of  the  blood  passing  so  readily  from  the  artery 
into  the  vein,  and  is  such  an  extension  as  happens  to 
all  arteries  in  growing  bodies,  and  to  the  arteries  of 
particular  parts  when  the  parts  themselves  increase  in 
their  bulk,  and  at  the  same  time  retain  a vascular  struc- 
ture.* It  is  well  known  that  the  arteries  of  the  uterus 
grow  much  larger  in  the  time  of  utero-gestation.  I 
once  saw  a fleshy  tumour  upon  the  top  of  a man's 
head  as  large  nearly  as  his  head ; and  his  temporal 
and  occipital  arteries,  which  fed  the  tumour,  were  en- 
larged in  proportion.  I have  observed  the  same  change 
in  the  arteries  of  enlarged  spleens,  testes,  &c.  so  that 
I should  suppose  it  will  be  found  to  be  universally 
true  in  fact,  and  the  reason  of  it  in  theory  seems  evi- 
dent.”— (See  Med.  Obs.  and  Inq.  vol.  2.) 

In  thin  subjects  the  median  basilic  vein  is  so  close  to 
the  brachial  artery,  the  track  of  which  it  crosses  at  a 
vei  y acute  angle,  that  it  is  almost  impossible  to  open  it 
at  this  point  without  risk  of  wounding  the  artery  at  the 
same  time.  The  bend  of  the  arm  indeed  is  the  very 
situation  in  which  this  disease  is  usually  noticed.  It 
is  easy  to  cx)nceive,  however,  that  a venous  aneurism 
may  happen  wherever  an  artery  of  a certain  diameter 
lies  immediately  under  a large  vein.  Thus,  Baron 
Larrey  informs  us  that  his  uncle,  surgeon  to  the  hospi- 
tal at  Toulouse,  saw  a case  of  aneurismal  varix,  which 
had  been  occasioned  by  a wound  of  the  popliteal  vein 
and  artery,  and  that  a history  of  the  disease,  accompa- 
nied with  the  pathological  preparation,  was  sent  to  the 
former  Royal  Academy  of  Surgery  at  Paris.  “ The 
varicose  swelling,  which  was  as  large  as  two  fists, 
occupied  the  whole  of  the  ham  in  a middle-aged  man, 
who  some  years  previously  had  been  wounded  with  a 
sword  in  that  part  of  the  limb.  At  a consultation,  ampu- 
tation was  deemed  necessary,  and  was  performed  with 
success.  At  the  bottom  of  the  varicose  pouch  the  com- 
munication between  the  popliteal  vein  and  artery  was 
observed.  The  sac  itself  was  evidently  composed  of 
the  vein,  the  parts  of  which,  adjacent  to  the  varicose 
swelling,  were  dilated,  especially  the  lower  continua- 
tion of  the  vessel.  The  popliteal  nerve  was  rendered 
flat,  like  a piece  of  tape,  and  adherent  to  the  out.side  of 
the  cy-st,” — (See  M^m.  de  CJiir.  MU.  t.  4,  p.  34fl,  Boyer,  I 


Traite  des  Mat.  Chir.  Src.  t.  2,  p.  177.)  Two  cases  are 
likewise  recorded,  by  Mr.  Hodgson.  In  one,  the  dis- 
ease was  caused  in  the  thigh,  about  four  inches  below 
Poupart’s  ligament,  by  the  point  of  a heated  iron  rod, 
v/hich  had  passed  through  the  femoral  artery  and  vein. 
In  the  other  example,  the  aneurismal  varix  was  situated 
in  the  ham,  and  was  the  consequence  of  a wound  in 
that  part  with  a pistol-ball. — {Treatise  on  the  Diseases 
of  Arteries,  p.  498.)  Larrey  records  one  example  of 
aneurismal  varix  situated  under  the  clavicle. 

P.  Cadrieux  was  wounded  with  a sabre  in  a duel,  on 
the  20tli  of  November,  1811 : part  of  the  attachment  of 
the  sterno-mastoid  muscle  was  divided,  the  anterior 
scalenus,  the  subclavian  artery  and  vein  at  a very  deep 
point,  and  probably  also  a portion  of  the  brachial  plexus. 
A most  violent  hemorrhage  took  place,  followed  by 
syncope.  Pressure  was  applied  to  the  wound,  and  the 
patient  conveyed  to  the  hospital  at  Gros-Caillou.  The 
external  wound,  which  was  small,  did  not  bleed  at  all 
the  following  morning  ; but  the  clavicle  was  quite  con- 
cealed by  a large  tumour,  which  throbbed  with  the  ar- 
teries, particularly  at  its  lower  part.  A peculiar  noise, 
like  that  of  the  passage  of  a fluid  through  tortuous 
metallic  tubes,  could  also  be  felt  more  deeply  in  the 
direction  of  the  axillary  vein.  The  arm  was  quite  cold, 
insensible,  motionless,  and  without  any  pulse  even  in 
the  axillary  artery  itself.  On  the  22d,  the  tumour  was 
not  larger,  but  its  throbbings  were  stronger ; the  jugu- 
lar vein  on  the  same  side  was  considerably  dilated ; 
and  the  pulsation  of  the  carotid  and  of  the  arteries  of 
the  op{)Osite  arm  had  augmented.  A vein  in  the  right 
arm  was  opened,  and  compresses  dipped  in  campho- 
rated vinegar,  mi/riate  of  ammonia,  and  ice  applied  to 
the  swelling.  It  would  be  superfluous  here  to  detail 
the  diet,  bleedings,  and  other  parts  of  the  treatment. 
On  the  8th  day,  the  outer  wound  was  quite  healed.  On 
the  10th,  the  veins  of  the  limb  were  observed  to  be 
swelled,  and  sensibility  and  warmth  were  returning  in 
it;  though  no  pulse  could  yet  be  felt.  The  tumour 
was  much  smaller,  and  restricted  to  a circumscribed 
place  behind  the  great  pectoral  muscle  ; but  the  hissing 
sound  was  still  plainer.  By  degrees  the  muscles  of 
the  arm  and  forearm  regained  their  power  of  motion. 
The  hand,  however,  continued  useless,  and  affected  with 
pricking  gains.  On  the  20th  day,  the  tumour  was  quite 
gone ; but  the  hissing  sound  was  unaltered,  and  the 
throbbings  were  still  evident  in  the  veins  of  the  neck 
and  ann.  The  arm  was  not  at  all  emaciated.  On  the 
55th  day,  a pulse  at  the  wrist  could  be  slightly  felt ; the 
hissing  sound  had  become  less  distinct ; the  veins  were 
less  turgid,  and  their  throbbing  diminished. 

A second  instance  of  aneurismal  varix,  or  rather 
perhaps  of  a varix  of  all  the  veins  of  the  arm,  caused 
by  a sword-wound  of  the  axilla,  is  also  recorded  by 
Larrey.  He  mentions,  however,  that  a pulsation  was 
observable  in  the  most  prominent  of  the  enlarged  ves- 
sels.—(See  Mem.  de  Chir.  Mil.  t.  4,  p.  341,  ^c.) 

Dr.  Dorsey,  of  Philadelphia,  published  a case  of  aneu- 
rismal varix,  which  is  in  several  respects  interesting. 
A patient  was  wounded  in  the  leg  with  buck-shot; 
and  after  the  cure  of  the  injury,  an  aneurismal  varix 
was  noticed  just  below  the  knee  ; and  in  a little  time 
the  superficial  veins  of  the  limb  became  dilated,  and 
the  hissing  noise,  characterizing  this  species  of  aneu- 
rism, could  be  plainly  distinguished.  The  patient  was 
seen  by  Dr.  Dorsey  twelve  years  affer  the  accident ; 
the  veins  were  then  considerably  distended  from  the 
toes  up  to  the  groin,  all  about  which  latter  part  pain 
was  constantly  experienced,  and  some  ulcers  situated 
on  the  foot  and  ankle  could  not  be  healed  by  any  of 
the  remedies  which  were  tried.  The  patient  was  un- 
der the  care  of  Drs.  Physick  and  Wistar.  The  enor- 
mous distention  of  the  vessels  of  the  leg,  and  the  un- 
certainty of  finding  out  the  communication  between 
the  artery  and  vein,  led  the.se  gentlemen  to  tie  the  first 
of  these  vessels  in  the  middle  of  the  thigh.  Gangrene 
soon  ensued,  and  in  this  state  the  patient  was  farther 
weakened  by  an  unexpected  hemorrhage  from  one  of 
the  distended  veins ; and  though  the  vessel  was  se- 
cured with  a ligature,  the  bleeding  recurred,  the  jiatient 
became  more  and  more  enfeebled,  and  at  length  ex- 
pired. When  the  limb  was  examined  after  death,  the 
whole  of  the  trunk  of  the  femoral  artery  was  found 
preternaturally  dilated  ; while  all  the  veins  of  the  limb 
were  considerably  distended ; a bougie  could  readily 
be  passed  from  the  poiiliteal  into  the  posterior  tibial 
artery,  which  particijiuted  in  the  dilatation,  and  from 


148 


ANEURISM. 


ttiis  last  artery  the  instrument  could  be  passed  into  the 
vein,  through  a cyst  situated  on  the  inside  of  the  leg 
below  the  knee. — (See  Dorsey's  Elements  of  Surgery, 
vol.  2,  p.  210,  Phiiadelphid,  1813.) 

Professor  Scarpa,  Dr.  Hunter,  Mr.  B.  Bell,  Pott,  and 
Garneri  mention  cases  of  the  aneurismal  varix  which 
remained  stationary  for  fourteen,  twenty,  and  thirty- 
five  years.  Several  cases  are  related  by  Brambilla, 
Guattani,  and  Monteggia,  of  a cure  having  been  ob- 
tained by  means  of  compression.  But  as  this  method 
of  cure,  if  it  does  not  succeed,  exposes  the  patient  to 
the  danger  of  a complication  of  the  disease  with  an 
aneurism,  it  ought  not  to  be  employed,  except  in  recent 
cases  where  the  tumour  is  small,  and  in  slender  pa- 
tients at  an  early  period  of  life,  and  where  both  of  the 
vessels  can  be  accurately  compressed  against  the  bone. 

Two  cases  are  recorded,  in  which  it  was  necessary' 
to  operate  in  consequence  of  the  disease  being  joined 
with  aneurism  of  the  artery,  and  even  bursting.  The 
sacs  were  opened,  and  a ligature  applied  both  above 
and  below  the  aperture  in  the  artery. — (See  Park,  in 
Medical  Facts  and  Obs.vol.  4,  p.  Ill ; and  Physick,in 
Medical  Museum,  vol.  1,  p.  65.)  The  latter  form  of 
the  disease,  which  is  particularly  noticed  by  Dr.  Hun- 
ter, and  also  by  my  friend  Mr.  Hodgson,  is  readily 
understood  by  recollecting  that  the  artery  and  vein, 
when  punctured  together,  do  not  always  unite  in  such 
a manner  as  to  let  the  arterial  blood  have  a direct  pas- 
sage into  the  vein ; but  they  may  be  separated  for  some 
distance  from  each  other,  so  that  the  blood  passes  from 
the  artery  into  the  adjacent  cellular  membrane,  where 
a sac  is  formed,  into  which  the  blood  is  poured  pre- 
viously to  its  entrance  into  the  vein. — (See  Gibson's 
Institutes  of  Surgery,  vol.2,p.  158,  Philadelphia,  1825.) 

In  the  winter  of  1819, 1 heard  a case  read  to  the  Me- 
dical and  Cliirurgical  Society  of  London,  from  Mr.  At- 
kinson, of  York,  who  had  found  it  necessary  to  take 
up  the  brachial  artery  on  account  of  the  large  and  in- 
creasing size  of  an  aneurismal  varix:  mortification 
of  the  limb  ensued.  When  the  aneurism,  joined  with 
an  aneurismal  varix,  is  circumscribed,  but  the  circum- 
stances such  as  to  require  the  brachial  artery  to  be  tied, 
this  vessel  should  be  exposed  and  tied  above  the  swell- 
iag  wfith  a single  ligature.  It  is  only  when  the  aneu- 
rism is  diflused  that  opening  the  swelling  ^ind  apply- 
ing a ligature  both  above  and  below  the  a perture  in 
the  artery  are  thought  necessary. — (See  Scarpa  on 
ineurism,  p.  433,  ed.  2 ; also  Guattani,  dc  Cubiti  flex- 
eurcB  aneurysmatibus,  in  Lauth's  Coll.  Scriptoruni, 
Sc.;  and  P.  Adelmann,  Tract.  Anat.  Chir.  de  Aneu- 
rismate  spurio  varicoso.  Wirceh.  1824.) 

ANEURISM  BV  ANASTOMOSIS. 

This  is  the  term  which  the  late  Mr.  .John  Bell,  of 
Edinburgh,  applied  to  a species  of  aneurism  resem- 
bling some  of  the  bloody  tumours  (yimvi  matemi) 
which  appear  in  new-born  children,  grow  to  a large 
size,  and  ultimately  bursting  emit  a considerable  quan- 
tity of  blood. 

Imperfect  descriptions  of  this  disea.<e  may  be  traced 
in  writers  ; though  before  the  publication  of  Mr.  John 
Bell’s  Principles  of  Surgery'  it  was  not  classed  with 
aneurisms.  Thus  Desault  has  recorded  a case  of  this 
affection  for  the  express  purpose  of  proving  that  pul- 
sation is  an  uncertain  sign  of  the  existence  of  an 
aneurism. — (See  Parisian  Chirurgical  Journal,  vol. 
2,  p.  73.) 

Aneurism  by  anastomosis  often  affects  adults,  in- 
creasing from  an  appearance  like  that  of  a mere  speck 
or  pimple  to  a formidable  disease,  and  being  composed 
of  a mutual  enlargement  of  the  smaller  arteries  and 
veins.  The  disease  originates  from  some  accidental 
cause;  is  marked  by  a perpetual  throbbing;  grows 
slowly  but  uncontrollably ; and  is  rather  irritated  than 
checked  by  compression.  The  throbbing  is  at  first  in- 
distinct, but  when  the  tumour  is  perfectly  fanned  the 
pulsation  is  very  manifest.  Every  e>«ertion  makes  the 
throbbing  more  evident.  The  occasionally  turgid  states 
of  the  tumour  produces  sacs  of  blood  in  the  cellular 
substance,  or  dilated  veins,  and  these  sacs  form  little 
tender,  hvid,  very  thin  iwints,  which  burst  from  time 
to  time,  and  then,  like  other  aneurisms,  tliis  one  bleeds 
so  profusely  as  to  induce  extreme  weakness. 

The  tumour  is  a congeries  of  active  vessels,  and,  ac- 
cording to  Mr.  John  Bell,  the  cellular  substance 
through  which  these  vessels  are  expanded,  resembles 
the  gills  of  a turkey-cock  or  the  sub.sfance  of  the  pla- 


centa, spleen,  or  womb.  The  irritated  and  incessant 
action  of  the  arteries  fills  the  cells  with  blood,  and  from 
these  cells  it  is  reabsorbed  by  the  veins.  Tlie  size  of 
the  swelling  is  increased  by  exercise,  drinking,  emo- 
tions of  the  mind,  and  by  all  causes  which  accelerate 
the  circulation. 

In  this  peculiar  disease  Dupuytren  regards  the  arte- 
ries as  being  in  an  aneurismal  state  ; but,  besides  this 
circumstance,  he  says,  their  extreme  ramifications  in- 
termix in  a thousand  different  ways,  intercepting 
spaces,  and  representing  cavities  like  those  which  are 
found  in  the  corpora  cavernosa ; and  he  imputes  the 
disease  to  increased  activity  of  the  capillary  circulation. 
— {Fr.  transl.  of  Mr.  Hodgson's  work,  t.  2,  p.  300.)  It 
is  obser\’ed  by  INIr.  Syme,  that  most  surgeons  have  fol- 
lowed John  Bell  in  believing  this  disease  to  consist  of 
a morbid  cellular  structure  through  which  the  blood 
passes  in  its  course  from  the  arteries  into  the  veins. 
However,  he  has  long  been  one  of  those  who  maintain 
that  the  apparent  cells  are  really  sections  of  enlarged 
vessels.— (See  Edin.  Med.  Joum.  No.  98,  p.  72.) 

In  the  dissection  of  a pulsating  tumour  of  the  scalp 
in  a patient  who  had  died  after  the  operation  of  tying 
the  carotid  artery.  Dr.  Maclachlan  found  the  branches 
of  this  vessel  on  the  head  “ degenerated  into  dilated 
tubes  of  extreme  thinness  and  transparency ; which, 
apparently  yielding  to  the  impetus  of  the  blood,  had 
become  elongated,  contorted,  and  ultimately  convoluted 
on  themselves,  so  as  to  form  by  this  species  of  dou- 
bling the  tumours  w hich  constituted  this  singular  dis- 
ease.” They  felt  like  placenta,  and  the  larger  portion 
immediately  over  the  ear  looked  precisely  like  a bundle 
of  earthworms  coiled  together. — (See  Glasgow  Me- 
dical Journ.  vol.  1,  p.  85.)  Two  cases  are  given  by 
Pelletan,  fully  confirming  the  view  taken  of  the  nature 
of  the  disease  by  Dr.  Maclachlan  and  Mr.  Syme. — (See 
Clinique  Chir.  t.  2.)  Boyer,  who  saw'  one  of  these 
cases,  describes  all  the  arteries  of  the  swelling  as  being 
dilated,  tortuous,  knotty,  and  though  very  large  in  some 
places,  in  others  contracted. — {Traite  des  Mai.  Chir.  t. 
2,  p.  295.)  In  the  tumour  described  by  Dr.  Maclachlan 
none  of  the  cells  spoken  of  by  Mr.  John  Bell  were 
found  ; no  parenchyma  as  in  the  spleen ; the  bulk  of 
the  tumour  w'as  formed  almost  entirely  by  convoluted, 
dilated  arterial  trunks,  the  veins  being  but  little 
changed  from  their  healthy  state.  He  adds,  that  these 
arteries  did  not  appear  to  communicate  more  freely 
than  by  their  ordinary  inosculations.  Some  of  these 
conclusions,  as  it  appears  to  me,  require  corroboration 
by  a careful  anatomical  injection  of  the  vessels. 

In  the  ff  male  subject  the  hemorrhage  from  the  aneu- 
rism by  anastomosis  is  sometimes  a substitute  for 
menstiTiation,  as  the  following  example  illustrates : 
Ann  Vachot,  of  St.  Maury,  in  Bresse,  was  born  with 
a tumour  on  her  chin,  of  the  size  and  shape  of  a small 
strawberry,  xvithout  pain,  heat,  or  discoloration  of  the 
skin.  As  it  produced  no  uneasiness  nor  inconvenience 
whatever,  it  excited  little  attention,  particularly  as  it 
did  not  seem  to  increase  with  the  growth  of  the  child. 
For  the  first  fifteen  years  there  was  but  little  alteration ; 
but  about  the  menstrual  period  it  increased  suddenly 
to  double  the  size,  and  became  more  elongated  in  its 
fonn.  A quantity  of  red  blood  was  observed  to  ooze 
from  its  extremity.  This  flux  became,  in  some  measure, 
periodical,  and  sometimes  was  sufficiently  abundant  to 
produce  an  alarming  degree  of  weakness.  Each  pe- 
riod of  its  return  was  preceded  by  a violent  pain  in  the 
head  and  numbness. 

Before  and  after  the  appearance  of  these  syTnptoms 
there  was  no  alteration  in  the  size  of  the  tumour ; the 
only  difference  was  a small  enlargement  of  the  cuta- 
neous veins,  with  an  increase  of  heat  in  the  part,  oc- 
casioning some  degree  of  tenderness. 

The  menses  at  length  took  place,  but  in  small  quan- 
tity and  at  irregular  periods,  without  influencing  the 
blood  discharged  from  the  tumour  or  the  frequency  of 
the  evacuation. 

The  breasts  were  not  enlarged  till  a late  period,  nor 
did  the  approach  of  puberty  seem  to  have  its  accus 
tomed  influence  on  those  glands,  &c. — (See  Parisian 
Chir.  Joum.  vol.  2,  p.  73,  74.) 

As  far  as  my  observations  extend,  the  true  aneurism 
by  anastomosis  is  a disea.se  with  which  a surgeon 
shoiild  never  tamper ; and  if  it  be  decided  to  try  any 
treat  nent  at  all,  the  only  prudeiv  plan  is  cither  a com- 
plete removal  of  the  di.sease  witi  i a knife,  or  tying  the 
chifi  arteries  which  supply  tlR  swelling  with’  blood. 


ANEURISM. 


149 


The  first  is  the  surest  mode  of  relief,  and  should  be 
preferred,  when  not  forbidden  by  the  magnitude  or  si- 
tuation of  the  tumour. 

In  performing  such  an  operation,  as  Mr.  Wardrop 
remarks,  the  surgeon  should  avoid  cutting  into  the 
substance  of  the  tumour ; for  if  this  be  done,  the  he- 
morrhage is  violent ; whereas,  by  making  the  incisions 
beyond  the  diseased  structure,  the  flow  of  blood  is 
much  more  moderate. — {Med.  Chir.  Trans,  vol.  9,  p. 
212.)  In  a few  nievi  pressure  may  be  safely  tried  ; but 
all  attempts  to  get  rid  of  a true  aneurism  from  anas- 
tomosis by  caustic  I should  think  by  no  means  advi- 
sable. 

“ This  aneurism,”  Mr.  John  Bell  observes,  “ is  a mere 
congeries  of  active  vessels,  which  will  not  be  cured  by 
opening  it ; all  attempts  to  obliterate  the  disease  with 
caustics,  after  a simple  incision,  have  proved  unsuccess- 
ful, nor  does  the  interception  of  particular  vessels 
which  lead  to  it  affect  the  tumour ; the  whole  group  of 
vessels  must  be  extirpated.  In  varicose  veins,  or  in 
aneurisms  of  individual  arteries,  or  in  extravasations 
of  blood,  such  as  that  produced  under  the  scalp  from 
blows  upon  the  temporal  artery,  or  in  those  aneurisms 
produced  in  schoolboys  by  pulling  the  hair,  and  also  in 
those  bloody  effusions  from  blows  on  the  head  which 
have  a distinct  pulsation,  the  process  of  cutting  up  the 
varix,  aneurism,  or  extravasation,  enables  you  to  obli- 
terate the  vessel  and  perform  an  easy  cure.  But  in 
this  enlargement  of  innumerable  small  vessels,  in  this 
aneurism  by  anastomosis,  the  rule  is,  ‘ not  to  cut  into, 
but  to  cut  it  out.’  These  purple  and  ill-looking  tu- 
mours, because  they  are  large,  beating,  painful,  co- 
vered with  scabs,  and  bleeding,  like  a cancer  in  the 
last  stage  of  ulceration,  have  been  but  too  often  pro- 
nounced cancers  ! incurable  bleeding  cancers ! and  the 
remarks  which  I have  made,  while  they  tend  in  some 
measure  to  explain  the  nature  and  consequences  of  the 
disease,  will  remind  you  of  various  unhappy  cases, 
where  either  partial  incisions  only  have  been  practised, 
or  the  patient  left  entirely  to  his  fate.” — {Principles  of 
Surgery,  vol.  1.) 

That  Mr.  John  Bell  has  comprised  in  his  account  of 
aneurism  by  anastomosis  certain  swellings  called  naevi 
cannot  be  doubted;  nor,  indeed,  are  the  differences 
between  this  kind  of  aneupism  and  some  naevi  at  all 
defined  even  by  the  best  writers  on  surgery.  To  the 
consideration  of  naevi,  however,  I have  allotted  an  ar- 
ticle, in  which  the  method  of  extirpating  particular 
forms  of  the  disease  by  means  of  a ligature  will  be  ex- 
plained. 

The  following  case,  recorded  by  Mr.  Wardrop,  af- 
fords a valuable  illustration  of  the  nature  and  struc- 
ture of  one  form  of  this  disease.  A child  was  born 
with  a very  large  subcutaneous  nsevus  on  the  back 
part  of  the  neck.  It  was  of  the  form  and  size  of  half 
an  ordinary  orange.  The  tumour  had  been  daily  in- 
creasing, and  when  Mr.  Wardrop  saw  it,  ten  days  after 
birth,  the  skin  had  given  way,  and  a profuse  hemor- 
rhage had  taken  place.  I’he  swelling  was  very  soft 
and  compressible;  when  squeezed  in  the  hand  it 
yielded  like  a sponge,  and  was  reducible  to  one-third 
of  its  original  size.  On  removing  the  pressure,  how- 
ever, the  tumour  rapidly  filled  again,  and  the  skin  re- 
sumed its  purple  colour.  “ Conceiving  the  immediate 
extirpation  of  the  tumour  the  only  chance  of  saving 
the  infant  (says  Mr.  Wardrop),  I removed  it  as  expe- 
ditiously as  possible,  and  made  the  incision  of  the  in- 
teguments beyond  the  boundary  of  the  tumour ; aware 
of  the  danger  of  hemorrhage,  where  such  tumours  are 
cut  into.  So  profuse,  however,  was  the  bleeding,  that 
though  the  whole  mass  was  easily  removed  by  a few  in- 
cisions, the  child  expired. 

The  tumour  having  been  injected  by  throwing  co- 
loured size  into  a few  of  the  larger  vessels,  its  intimate 
structure  could  be  accurately  examined.  Several  of 
the  vessels,  which,  from  the  thinness  of  their  coats  ap- 
peared to  be  veins,  were  of  a large  size,  and  there 
was  one  sufficiently  big  to  admit  a Ml-sized  bougie.” 
This  vessel  was  quite  as  large  as  the  carotid  artery  of 
an  infant.  The  boundaries  of  the  tumour  appeared 
distinct,  some  healthy  cellular  membrane,  traversed  by 
the  blood-vessels,  surrounding  it.  On  tracing  these 
vessels  to  the  diseased  mass,  they  penetrated  into 
a spongy  structure  composed  of  numerous  cells  and 
canals,  of  a variety  of  forms  and  sizes,  all  of  which 
were  filled  with  the  injection,  and  communicated  di- 
rectly with  the  ramifications  of  the  vessels.  These 


cells  and  canals  had  a smooth  and  polished  surface, 
and  in  some  parts  resembled  very  much  the  cavities 
of  the  heart,  fibres  crossing  them  in  various  directions 
like  the  columnae  teiidinae.  The  opening  in  the  skin, 
through  which  the  "blood  had  escaped  during  life,  com- 
municated directly  with  one  of  the  large  cells,  into 
which  the  largest  vessel  also  passed.” — {Wardrop,  in 
Med.  Chir.  Trans,  vol.  9,  p.  203.) 

In  the  section  on  Carotid  Aneurisms  I have  mentioned 
the  cases  in  which  Mr.  Travers  and  Mr.  Dalryinple 
cured  aneurisms  by  anastomosis  in  the  orbit  by  tying 
the  common  carotid  artery.  Professor  Pattison  also 
cured  an  immense  anastomosing  aneurism  of  the  cheek 
and  side  of  the  face  by  taking  up  the  carotid  artery. — 
(See  Med.  and  Phys.  Joum.  vol.  48,  July,  1822.)  These 
facts  prove  that  aneurism  by  anastomosis,  like  many 
other  diseases,  sometimes  admits  of  being  cured  on  the 
principle  of  cutting  off  or  lessening  the  supply  of  blood 
to  the  part  affected. 

However,  surgeons  must  not  be  too  confident  of  be- 
ing always  able  to  cure  the  disease  by  tying  the  main 
artery  from  which  the  swelling  receives  its  supply  of 
blood ; and  the  great  cause  of  failure  is  the  impossi- 
bility of  preventing  in  some  situations  the  transmis- 
sion of  a considerable  quantity  of  blood  into  the  tu- 
mour, through  the  anastomosing  vessels.  A case  is 
recorded  by  Maunoir,  in  wliich  he  applied  a ligature  for 
three  days  to  the  carotid  artery,  and  obliterated  it ; yet 
the  benefit  effected  seemed  to  be  only  temporary,  as 
in  a short  time  the  tumour  was  as  large  as  before.— 
(See  Med.  and  Phys.  Journ.  vol.  48.)  In  fact,  every 
vessel,  artery,  and  vein  around  the  disease  seems  to  be 
enlarged  and  turgid ; and  the  inosculations  are  so  in- 
finite that  no  point  of  the  circumference  of  the  swell- 
ing can  be  imagined  which  is  free  from  them.  Etienne 
Dumand  was  born  with  two  small  red  marks  on  the 
antihelix  of  the  right  ear.  Until  the  age  of  twelve 
years  the  chief  inconveniences  were,  a sensation  of  itch- 
ing about  the  part,  occasional  bleeding  from  it,  and  the 
greater  size  of  this  than  of  the  other  ear.  The  disease 
now  extended  itself  over  the  whole  antihelix,  and  to 
the  helix  and  concha;  and  the  upjter  part  of  the  ear 
became  twice  as  large  as  natural.  Slight  alternate 
dilatations  and  contractions  began  to  be  perceptible  in 
the  tumour,  which  was  of  a violet  colour,  and  covered 
by  a very  thin  skin.  Soon  afterw^ard  any  accidental 
motion  of  the  patient’s  hat  was  sufficient  to  excite  co- 
pious hemorrhages,  which  were  difficult  to  suppress, 
and  at  the  some  time  that  they  produced  great  weak- 
ness, caused  a temporary  diminution  of  the  tumour  and 
its  pulsations.  At  length  the  disease  began  to  raise 
up  the  scalp  for  the  distance  of  an  inch  around  the  me- 
atus auditorius,  and  the  hemorrhages  to  be  more  fre- 
quent and  alarming.  Pressure  was  next  applied  to  the 
temporal,  auricular,  and  occipital  arteries;  but  as  the 
patient  could  not  endure  it,  the  first  two  of  these  ves- 
sels were  tied,  the  only  benefit  from  which  was  a 
slight  diminution  in  the  pulsation  and  bulk  of  the  swell- 
ing. This  treatment  did  not  prevent  the  return  of  he- 
morrhage, and  therefore  forty-three  days  after  the  first 
operation  a ligature  was  applied  to  the  occipital  artery, 
which  {>ro  eedingwas  equally  ineffectual.  As  the  dis- 
ease continued  to  make  progress,  the  patient  entered 
the  H6tel-Dieu,  where,  on  the  8th  of  April,  1818,  Dupuy- 
tren  tried  what  ©fleet  tying  the  trunk  of  the  carotid  ar- 
tery would  produce  on  the  swelling.  As  soon  as  the  liga- 
ture was  applied,  the  throbbing  ceased,  and  the  tumour 
underwent  a quick  and  considerable  diminution.  On 
the  17th  day,  slight  expansions  and  contractions  of  the 
diseased  part  of  the  ear  were  again  perceptible,  though 
the  swelling  had  diminished  one-third.  An  attempt 
was  now  made  to  compress  the  tumour  by  covering  it 
with  plaster  of  Paris ;-  a plan  which  was  somewhat 
painful,  though  it  lessened  the  size  of  the  disease. 
After  being  sixty-three  days  in  the  hospital,  the  patient 
was  discharged,  at  which  period  the  tumour  was  dimi- 
nished one-tliird ; the  throbbings  had  returned,  but  no 
unpleasant  noises  continued  to  affect  the  ear.— (See 
BrescheVs  tr.  of  Mr,.  Hodgson's  work,  t.  2,  p.  296.) 

An  infant,  six  weeks  old,  was  brought  to  Mr.  Ward- 
rop, on  account  of  an  aneurism  by  anastomosis  (a  sub- 
cutaneous najvus)  of  a very  unusual  size,  situated  on 
1 the  left  cheek.  The  base  of  the  tumour  extended  from 
the  temple  to  beyond  the  angle  of  the  jaw,  completely 
enveloping  the  cartilage  of  the  ear.  At  its  upper  part 
there  was  an  ulcer,  about  three  inches  in  diameter, 
presenting  a sloughing  appearance.  The  tumour  waa 


150 


ANEURISM. 


soft  and  doughy ; its  size  could  he  much  diminished 
by  pressure ; there  was  a throbbing  in  it,  and  a strong 
pulsation  in  the  adjacent  vessels.  The  disease  was 
daily  increasing,  and  several  profuse  hemorrhages  had 
taken  place  from  the  ulcerated  part.  Mr.  Wardrop, 
knowing,  from  the  case  to  which  I have  already  ad- 
verted, the  danger  of  attempting  to  extirpate  so  large  a 
tumour  of  this  nature,  was  led  to  trj'  what  benefit 
might  be  obtained  by  tying  the  carotid  artery.  A few 
hours  after  this  operation,  the  tumour  became  soft  and 
pliable  ; its  purple  colour  disappeared,  and  the  tortuous 
veins  collapsed.  On  the  second  day,  the  skin  had  re- 
sumed its  natural  pale  colour,  and  the  ulceration  con- 
tinued to  extend.  On  the  third,  the  tumour  still  dimi- 
nished. On  the  fourth,  the  swelling  had  considerably 
increased  again ; the  integuments  covering  it  had  be- 
come livid,  and  the  veins  turgid.  The  inosculating 
branches  of  the  temporal  and  occipital  arteries  had 
become  greatly  enlarged.  A small  quantity  of  blood 
had  oozed  from  the  ulcer.  After  remaining  without 
much  alteration,  the  tumour  on  the  seventh  day  had 
again  evidently  diminished.  On  the  ninth,  the  ulcera- 
tion was  extending  itself  slowly,  and  the  tumour  was 
lessened  fully  one-half.  On  the  twellth,  the  child’s 
health  was  materially  improving.  The  auricular  por- 
tion of  the  swelling  had  now  so  much  diminished,  that 
the  cartilage  of  the  ear  had  fallen  into  its  natural  situ- 
ation. After  a poultice  had  been  applied  for  two  days, 
the  central  portion  of  the  swelling,  which  appeared 
like  a mass  of  hardened  blood,  was  softened,  and  Mr. 
Wardrop  removed  considerable  portions  of  it.  On  the 
thirteenth,  the  child  became  very  ill,  and  died  the  fol- 
lowing day,  exhausted  by  the  irritation  of  an  ulcer, 
which  had  involved  the  whole  surface  of  an  enormous 
tumour.  Mr.  Wardrop  thinks  the  advantages  likely  to 
occur  fl-om  the  plan  of  tying  the  main  arteries  supply- 
ing tumours  of  this  nature  tvith  blood  are,  the  diminu- 
tion of  the  size  of  the  disease ; the  lessening  of  the 
danger  of  hemorrhage,  if  the  ulcerative  process  has 
commenced  ; and  the  rendering  it  practicable  to  re- 
move the  swelling  with  the  knife,  though  the  operation 
may  previously  have  been  dangerous  or  impracticable. 
— (See  Med.  Chir.  Trans,  vol.  9,  p.  206 — 214,  <fec.)  In- 
stead of  endeavouring  to  promote  ulceration  in  any  of 
these  eases,  my  own  sentiments  would  incline  me  to 
leave  the  business  of  removing  the  diseased  mass 
quietly  to  the  absorbents,  or  at  most,  I would  only 
assist  them  with  pressure,  or  by  covering  the  tumour 
with  plaster  of  Paris. 

The  next  case  of  aneurism  by  anastomosis,  which  I 
shall  briefly  notice,  was  one  which  was  under  the  care 
of  my  friend  Mr.  Lawrence,  and  situated  on  the  ring 
finger  of  the  right  hand,  in  a young  woman  about 
twenty  years  of  age.  The  disease  was  attended  with 
painful  sensations  extending  to  various  parts  of  the 
limb  and  the  breast,  and  the  arm  was  disqualified  for 
any  kind  of  exertion.  In  January,  1815,  Mr.  Hodgson 
had  taken  up  the  radial  and  ulnai  arteries,  and  the  con- 
seauences  of  the  operation  were  an  entire  cessation  of 
of- beating,  collapse  of  the  swelling,  and  relief  from 
pain ; but  these  symptonis  all  recurred  in  a few  days. 
Finding  compression  unavailing,  and  the  sufferings  of 
the  patient  increasing,  Mr.  Lawrence  proposed  ampu- 
tation of  the  finger  at  the  metacarpal  joint ; but  as  this 
suggestion  was  not  approved  of,  he  recommended  the 
patient  to  try  the  effects  of  a division  of  all  the  soft 
parts,  by  a circular  incision  close  to  the  palm,  so  as  to 
cut  off  the  supply  of  blood.  This  operation  Mr.  Law- 
rence performed  in  the  presence  of  Mr.  George  Young 
and  myself,  in  as  complete  a manner  tis  can  possibly 
be  conceived.  All  the  soft  parts,  excepting  the  flexor 
tendons,  with  their  theca  and  the  extensor  tendoh, 
were  divided.  The  digital  artery,  which  had  pulsated 
so  evidently  in  the  palm  of  the  hand,  was  fully  equal 
in  size  to  the  radial  or  ulnar  of  an  adult,  and  was  the 
principal  nutrient  vessel  of  the  disease.  After  tying 
this  and  the  opposite  one.  we  were  surprised  at  finding 
so  strong  a jet  of  arterial  blood  from  the  other  orifices 
of  these  two  vessels,  as  to  render  ligatures  necessary. 

I can  here  only  add,  that  the  whole  finger  beyond  the 
cut  swelled  very  considerably  ; the  incision  healed 
slowly  ; the  swelling  subsided,  but  did  not  entirely 
disappear  ; the  integuments  recovered  their  natural 
colour  ; the  pulsation  and  pain  were  removed,  and  the 
patient  so  far  recovered  the  use  of  her  arm,  that  she 
could  work  at  her  needle  for  an  hour  together,  and  use 
the  arm  for  most  purposes. — -(See  Wardrop's  Obs. 


on  one  Species  of  Ncevus,  in  Med.  Chir.  Trans,  vol.  9, 

p.  216.) 

For  information  on  aneurism,  consult  O.  Amavd  on 
Aneurisms,  8vo.  S.  C.  Lucce,  De  Ossescentia  Arteria- 
rum  Senili,  4fo.  Marburgi,  1817.  A.  F.  Walther,  Pro- 
gramma  de  Aneurysmate,  Argent.  1738.  {Haller, 
Disp.  Chir.  5, 189.)  A.  de  Haller,  De  Aorta  Venaque 
Cava  gravioribus  guibusdam  Murbis  Observationes, 
4(0.  Qott.  1749.  Dauth,  Scriptorum  Datinorum  de 
Aneurysmatibus  Collectio,  4to.  Argent.  1785,  which 
work  contains  Asman's  Diss.  de  Aneui~ysmate,  1773  ; 
Cruattani,  de  Extemis  Aneurysmatibus,  4to.  Roma, 
1772;  Lancisi  de  Aneurysmatibus,  At  gent. \19i5',  Ma- 
tani  de  Aneurysmaticis  Pracordiorum  Morbis  Animad- 
versiones,  1785 ; Verbrugge,  Dissertatio  Anatumico- 
Chirurgica  de  Aneurysmate,  1773.  Penchienati,  Re 
cherches  Anat.  Pathol,  sur  les  Aneurysmes  des  Artires 
de  VEpaule  et  du  Bras  ; des  Arteres  crurales  et  pupli- 
tefes  ; in  Mim.  de  VAcad.  des  Sciences  de  Turin,  1784. 
Palletta,  iiber  die  Schlagadergeschwulst ; in  Kuhn’s 
and  Weigel’s  Ital.  Med.  Chir.  Bibl.  bd.  4.  R.  Caillot, 
Essais  sur  V Aneurysme,  Paris,  an  7.  Weltinus  de 
Aneurysmate  Kero.  Pectoris  Extemo  Hemiplegia  So- 
bole,  Basil,  1750.  Murray,  Observationes  in  Aneu- 
rysmata  Femoris,  1781.  Trew,  .Uneurysmatis  Spurti 
post  Vena  Basilica  Sectionem  Orti,  Historia  et  Cw- 
ratio.  See  also  an  account  of  Mr.  Hunter's  Method 
of  performing  the  Operation  for  the  Cure  of  the  Pop- 
liteal Aneurism,  by  Sir  £.  Home,  in  I'rans.  of  a So- 
ciety for  the  Improvement  of  Med.  and  Chir.  Know- 
ledge, vol.  1,  p.  138,  and  vol.  2,  p.  235.  Sabatier, 
Midecine  Opiratoire,  t.  3,  vol.  2.  The  several  volumes 
of  the  Medico- Chir urgi cal  7’ransactions.  Cases  in 
Surgery  by  J.  Warner,  p.  141,  Src.  ed.  4.  J.  B.  Heraud, 
De  Aneurysmatibus  Extemis,  Monsp.  1775.  J.  F.  L. 
Deschamps,  Obs.  et  Reflexions  sur  la  Ligature  des 
principales  Artires  blessis,  et  particular ement  sur 
I’ Aneurysme  de  I’Artire  poplitee,  8vo.  Paris,  1797. 
Richerand's  Mosographie  Chirurgicale,  t.  4,  ed,  4. 
Pelletan’s  Clinique  Chirurgicale,  t.  1 et  2.  A. 
Bum.s’s  Surgical  Anatomy  of  the  Head  and  Meek, 
8vo.  Edin.  1811,  and  Observations  on  Diseases  of  the 
Heart,  <S,-c.  8vo.  Edin.  1809.  Ramsden’s  Practical  Ob- 
servations on  the  Sclerocele,  with  four  cases  of  opera- 
tions for  Aneurism,  8vo.  Land.  1811.  lEuvres  Chir. 
de  Desault,  par  Bichat,  t.  2,  p.  553.  S.  C.  Lucm  qua- 
dam  Obs.  Anat.  circa  Mervos  Arterias  adeuntes  et 
comitantes,  4to.  Francof.  1810.  Wells,  in  Trans,  of 
a Soc.  for  the  Improvement  of  Med.  and  Chir.  Know- 
ledge, vol.  3,  p.  81 — 85,  Sre,  G.  P.  Scheid,  Obs.  Med, 
Chir.  de  Aneurysmate,  8vo.  Hardevici,  1792.  Corvi- 
sart,  Essai  sur  les  Maladies  et  les  Lesions  Organiques 
du  Caur  et  des  Grose  Vaisseaux,  edit.  2,  or  transl.  by 
C.  H.  Hebb,  8vo.  Land.  1813.  C.  Bell's  Operative 
Surgery,  vol.  1,  ed.  2.  John  Bell's  Principles  of  Sur- 
gery, vol.  1.  Richter's  Anfangsgr.  der  Wundanney- 
kunst,  6.  1.  A.  F.  Ayrer  iiber  die  Pulsadergeschwiilste 
und  ihre  Chir.  Behandlung,  Gott.  1800.  Abernethy’s 
Surgical  Works,  vol.  1.  Monro's  Observ.  in  the  Edin. 
Med.  Essays.  Various  productions  in  the  Med.  Ob- 
serv. and  Inquiries.  The  article  Aneurism  in  Rees’s 
Cyclopadia.  J.  P Maunoir,  Memoires  Physio logiques 
et  Pratiques  sur  V Aneurisme  et  la  Ligature,  8vo.  Ge- 
neve, 1802.  Freer's  Observations  on  Aneurism,  Ato. 
I.ond.  1807 ; and  a Treatise  on  the  .dnatomy.  Patholo- 
gy, and  Surgical  Treatment  of  Aneurism, by  A.  Scarpa, 
translated  by  J.  Wishart,  1808.  The  original  Italian 
was  published  1802.  Ant.  Scarpa,  Memoria  sulla  Le- 
gatura  della  Principali  Artcrie  delle  Arti,  con  una 
.Ippendice  all’  Opera  suit  Aneurisma,fol.  Pavia,  1817. 
This  tract,  and  a great  deal  of  valuable  additional 
matter,  are  contained  in  the  2d  edition  of  Scarpa's 
work  on  Aneurism,  by  Mr.  Wishart,  8vo.  Edin.  1819. 
Callisen's  Systema  Chirurgite  Hodiernw,  part  2,  p.  545, 
(S  c.  edit.  1791.  Boyer,  Traiti  des  Maladies  Chir.  t.  2, 
p.  84,  (S-c.  A.  C.  Hutchison,  Letter  on  Popliteal  Aneu- 
rism, 8vo.  Lond.  1811.  J.  Hodgson  on  the  Diseases 
of  Arteries  and  Veins,  Lond.  1815,  a work  of  the  great- 
est accuracy  and  merit.  Transl.  into  German  by  Dr. 
Koberwein,  with  additions  by  this  gentleman,  and  Dr. 
Kreysig,  8vo.  Hanov.  1817;  and  also  into  French,  with 
valuable  annotations  by  Breschet,  2 t.  8vo.  Paris,  1819. 
G.  A.  Spnngenbcrg,  Erfnhruvgev  iiber  die  Pulsader- 
jreschwulstr,  in  Horn' s Archil).  1815.  C.  H.  Ehrmann, 
la  Structure  des  Artires,  S,-c.  et  leiirs  allirations  or- 
gaviques,  Strasb.  1822.  Roux,  Muuveatix  Elemens  de 
Mcdecine  Operaloire,  t.  1.  .Ilsu,  Roux,  Voyage  fait 


ANT 


ANT 


151 


(i  Londres  en  1814,  ou  ParalUle  dc  la  Chirurgie  An 
gloise  avec  la  Chirurgie  Francoise^  p.  248,  iS-c.  1815. 
D.  Fried.  Lud.  K?-cystg,  Die  Krankketten  des  Herzens, 
4 bdnde,  8vo.  Berlin,  1814 — 17.  C.  D.  Kukln,  De 
Aneurysrnate  Externa,  ^tu.  Jence,  181G.  A.  J.  Ristel- 
hueber,  Mem.  sur  la  Ligature  et  V Applatissement  de 
I'Artere,  dans  V Operation  de  VAneurisme  Puplil^,8vo. 
A.  V.  Berlinghieri,  Memoria  sopra  I'Allacciatura  dell' 
Arterie,  8vo.  Pisa,  1819.  Lassus,  Pathologie  Chir. 
t.  1,  p.  347,  <J'C.  T.  F.  Baltz,  De  Ophthalmia  Catar- 
rhali  Bellica,  t^c.  pramittitur  F.  C.  Maegeli  Epistola, 
qud  Historia  ei  Descriptio  Aneurysm alis,  quad  in 
AoUa  abdominali  observavit,  4ta.  Heidelberg,  1816. 
J.  Cole,  Expas^  du  Traitement  d'un  Aneurisme  In- 
guinale par  la  Ligature  de  VArtire  Iliaque  Externe, 
8i)0.  Cambrai,  1817,  and  London  Medical  Repository 
for  May,  1820.  Hennen's  Military  Surgery,  p.  183 — 
185,  393,  Src.  ed.  2.  Edin.  1820.  J.  Kirby,  Cases,  S,  c. 
8oo.  Land.  1819.  C.  Fred.  Hubner  de  Aneurysmatibus , 
Gdtt.  1807.  Manuals  di  Chirurgia  del  Cao.  Assalivi, 
Milano,  1812.  The  author's  main  object  is  to  recom- 
mend his  compressor.  Todd's  Cases  in  Dublin  Hos- 
pital Reports,  voL  3.  He  is  an  advocate  for  trying 
compression  previously  to  the  operation,  with  the  view 
of  making  the  collateral  vessels  enlarge,  and  removing 
the  risk  of  gangrene  from  insufficient  circulation,  after 
the  ligature  is  applied.  C.  T.  Grdfe,  Angiektasie,  ein 
Beytrag  lur  rationellen  Cur  und  Erkentniss  der  Ge- 
fdss-ausdchnungen.  Valentine  Mott,  in  Mew- York 
Medical  and  Surgical  Register,  vol.  1,  1818:  the  first 
example  of  the  arteria  innominata  being  tied.  C.  F. 
Grdfe,  in  Journ.  der  Chirurgie,  b.  3,  1822,  and  b.  4, 
1823:  the  second  instance  of  the  arteria  innominata 
having  a ligature  applied  to  it.  Waltheruber  Ver- 
hartung,  Blutschwamm,  Teleangiektasie  und  Aneurys- 
ma  per  Anastomosin,  in  Jour,  fur  Chir.  b.  5.  Dr. 
Maclachlan,  On  a pulsating  Tumour  of  the  Scalp,  in 
Glasgow  Med.  .Journ.  vol.  1,  p.  81.  J.  Syme,  Case  of 
Aneurismal  Condition  of  the  Posterior  Auricular  and 
Temporal  Arteries,  Edin.  Med.  Journ.  Mu.  98.  Gib- 
son's Institutes  and  Practice  of  Surgery,  vol.  2,  p.  101, 
Src.  8vo.  Philadelphia,  1825.  Laennec  on  Diseases  of 
the  Chest,  transl.  by  Forbes,  ed.  2, 1827.  Sir  A.  Cooper's 
Lectures  on  the  Principles  and  Practice  of  Surgery, 
ed.  by  Tyrrell,  vol.  2,  8vo.  Lond.  1825.  Thomas  Tur- 
ner on  the  Arterial  System,  intended  to  illustrate  the 
importance  of  studying  the.  .Anastomoses  in  reference 
to  the  Rationale  of  the  Mew  Operation  for  Aneurisms, 
and  the  Surgical  Treatment  of  Hemorrhage,  Lond. 
1826.  Robert  Harrison,  Surgical  Anatomy  of  the  Ar- 
teries, 2 vols.  12ffJo.  Dublin,  1824 — 25.  A.  L.  M.  Vel- 
peau, Traitd  de  I'Anatomie  Chirurgicale,  Paris,  1825. 
L.  J.  Von  Bierkowski,  Ant.  Chir.  Abbildungen  nebst 
Beschreibung  der  Chir.  Operatiouen,  Berlin,  1826.  M- 
J.  Chelius,  Handb.  der  Chir.bd.  1,  Heidelb.  and  Leipz. 
1826.  ./.  War  dr  op  on  Aneurism,  1828. 

ANTHRAX  (av0o«^  a burning  coal),  Carbuncle. 

ANTIMONIAL  POWDER  ; pulvis  antimonialis. 
(Oxidum  Aniimonii  cum  Phosphate  Calcis.)  In  all 
cases  where  it  is  desirable  to  promote  the  secretions  in 
general,  and  those  of  the  kidneys,  skin,  and  aliment- 
ary canal,  in  particular,  it  is  proper  to  have  recourse 
to  antirnonial  medicines.  In  inflammation  of  the  brain 
and  its  membranes,  and  in  that  of  the  greater  number 
of  organs  of  high  importance  in  the  system,  antimony 
should  be  exhibited.  For  an  adtxlt,  from  two  to  five 
grains  of  pulv.  antim.  may  be  ordered,  and  the  dose, 
if  requisite,  may  be  repeated  three  or  four  times  a day. 
In  order  to  increase  its  action  on  the  bowels,  it  is  Ire- 
quently  conjoined  with  calomel. 

Of  late,  doubts  have  arisen  concerning  the  efficacy 
of  antirnonial  powder,  Dr.  Elliotson  having  prescribed 
it  even  in  the  dose  of  100  gr.  apparently  without  any 
effect.  Mr.  R.  Philips  has  attempted  to  explain  the 
circumstance  by  the  preparation  of  antimony  being 
the  peroxide,  which  is  known  to  be  inert. — (See  Annals 
of  Philosophy  for  Octob.  1822.  Pharmacologia  by 
Dr.  Paris,  p.  357,  vol.  2,  ed.  5, 1822.) 

ANTIMONIUM  MURIATUM.  {Butter  of  Anti- 
mony.) Employed  as  a caustic. 

ANTIMONII  SULPHURETUM  PR^CIPITATUM. 
An  ingredient  in  the  compound  calomel  pill,  and  sel- 
dom prescribed  in  any  other  form. 

ANTIMONIUM  TARTARIZATUM.  {Emetic  Tar- 
tar.) Of  this  useful  medicine,  the  best  prejiaration  is 
the  vinum  antim.  tart,  every  half  ounce  of  which 
contains  one  grain  of  antim.  tart.  Tartarized  anti- 


mony, in  the  dose  of  gr.  will,  if  the  skin  be  kept 
warm,  promote  a diaphoresis  ; gr.  i will  procure  some 
stools  first,  and  s\veating  afterward ; and  gr.  j.  will 
generally  excite  vomiting,  then  purging,  and  lastly 
perspiration.  In  very  minute  doses,  as  gr.  1-10  or  1-12, 
combined  with  squill  and  ammoniacum,  it  acts  as  an 
expectorant.  As  Dr.-  Paris  justly  remarks,  it  is  de- 
cidedly the  most  manageable,  and  the  least  uncertain 
of  all  the  antirnonial  preparations,  and  the  practitioner 
would  probably  have  but  little  to  regret,  were  all  the 
pther  combinations  of  antimony  discarded  from  our 
pharmacopteias.— (See  Pharmacologia  by  Dr.  Paris, 
vol.  2,  p.  67,  ed.  5.) 

Tartarized  antimony  is  sometimes  blended  with 
lard  or  spermaceti  ointment,  and  used  for  producing 
redness  and  pustules  of  the  integuments,  where  coun- 
ter-irritation is  indicated. — (See  Unguentum.) 

ANTRUM,  Diseases  of.  This  cavity  is  liable  to  a va- 
riety of  diseases.  Sometimes  its  membranous  lining 
inflames,  and  secretes  an  extraordinary  quantity  of 
mucus  or  pus ; at  other  times,  in  consequence  of  in- 
flammation or  other  causes,  it  is  the  seat  of  various 
excrescences,  polypi,  and  fungi.  Even  the  bony  parie- 
tes  of  the  antrum  are  occasionally  affected  with  exosto- 
sis or  caries.  Sometimes  it  contains  extraneous  bodies  ; 
and  it  is  even  asserted  that  insects  may  be  generated 
there,  and  cause,  for  many  years,  very  afflicting  pains. 

COLLECTIONS  OF  MUCUS  AND  PUS. 

Inflammation  of  the  membranous  lining  of  the  an- 
trum sometimes  produces  an  extraordinary  secretion 
of  mucus  within  it,  and  the  collected  fluid  being  con- 
fined, the  bony  parietes  of  the  cavity  become  expanded 
in  a surprising  degree.  This  disease,  says  Boyer,  is 
sometimes  ascribed  to  a blow  on  the  cheek,  to  caries 
of  the  teeth,  or  the  projection  of  one  of  their  fangs  into 
the  antrum.  But  in  general,  the  case  takes  place  un- 
preceded by  any  of  these  causes,  and  without  there  be- 
ing the  least  ground  for  suspecting  what  has  given  rise 
to  the  disorder.  It  is  remarked,  however,  that  collec- 
tions of  mucus  within  the  antrum  are  most  frequent 
in  young  subjects ; of  three  patients  seen  by  Boyer, 
the  eldest  was  not  more  than  twenty.— {Traite  des 
Mai.  Chir.  t.  6,  p.  139.)  As  Mr.  Hunter  has  noticed, 
whether  the  obliteration  of  the  duct  leading  to  the 
nose,  be  a cause  or  only  an  effect  of  the  disease,  is  not 
easily  determined  ; but  from  some  of  the  symptoms, 
there  is  great  reason  to  suppose  it  an  attendant.  “ If 
it  be  a cause,  we  may  suppose  that  the  natural  mucus 
of  these  cavities,  accumulating,  irritates,  and  produces 
inflammation  for  its  own  exit,  in  the  same  manner  as 
an  obstruction  to  the  passage  of  the  tears  through  the 
ductus  ad  nasum  produces  an  abscess  of  the  lachry- 
mal sac.” — (See  Hunter's  Natural  Hist,  of  the  Teeth, 
p.  174,  ed.  3.)  The  most  interesting  example  of  the 
effects  of  the  lodgement  of  mucus  in  the  antrum  is  that 
recorded  by  Dubois : a boy,  between  seven  and  eight 
years  of  age,  was  observed  to  have  at  the  base  of  the 
ascending  process  of  the  upper  jaw-bone,  on  the  left 
side,  a small,  very  hard  tumour  of  the  size  of  a nut. 
As  it  gave  no  pain,  and  did  not  appear  to  increase,  his 
parents  did  not  give  themselves  any  concern  about  it. 
When  he  was  about  sixteen,  however,  the  swelling 
began  to  increase,  and  to  be  somewhat  painful.  Before 
he  was  eighteen,  its  augmentation  was  so  considera- 
ble that  the  floor  of  the  orbit  was  raised  up  by  it ; the 
eye  thrust  upwards ; the  palpebrae  very  much  closed ; 
the  arch  of  the  palate  pushed  down  in  the  form  of  a 
tumour  ; and  the  nostril  almost  effaced.  Below  the 
orbit  the  cheek  made  a considerable  prominence  ; while 
the  nose  was  thrown  towards  the  opposite  side  of  the 
face,  and  the  skin  at  the  upper  part  of  the  tumour,  be- 
low the  lower  eyelid,  was  of  a purple  red  colour  and 
threatening  to  burst.  The  upper  lip  was  drawn  up- 
wards, and  behind  it  all  the  gums  on  the  left  side  were 
observed  to  project  much  farther  than  those  on  the  op- 
posite side  of  the  face,  and  at  this  point  alone  the 
thinness  of  the  bony  parietes  of  the  antrum  was  per- 
cei)tible.  I’he  patient  spoke  and  breathed  with  great 
difficulty;  he  slept  uneasily,  and  his  mastication  was 
painful.  The  case  was  first  supposed  by  Dubois,  Sa- 
batier, Pelletan,  and  Boyer,  to  be  a fungus  of  the  an- 
trum, and  an  operation  was  considered  advisable.  In 
proceeding  to  this  measure,  the  first  thing  which  at- 
tracted the  notice  of  Dubois  was  a sort  of  fluctuation 
in  the  situation  of  the  gum  behind  the  upper  lip;  a 
circumstance  which  led  him  to  give  up  the  idea  of  the 


152 


ANTRUM. 


case  being  a fungus,  though  he  expected  that,  on  mak- 
ing an  opening,  merely  a small  quantity  of  ichorous 
matter  would  escape,  affording  no  kind  of  information. 
In  this  place,  however,  he  determined  to  make  an  inci- 
sion along  the  alveolary  process,  whereby  a large 
quantity  of  a glutinous  substance  like  lymph,  or  what 
is  found  in  cases  of  ranula,  was  discharged.  A probe 
was  now  introduced,  with  wdiich  Dubois  could  feel  a 
cavity  equal  in  extent  to  the  forepart  of  the  tumour,  and 
in  moving  the  instrument  about,  with  the  view  .of 
learning  whether  any  fungus  was  present,  it  stmck 
against  a hard  substance,  which  felt  like  one  of  the 
incisor  teeth,  near  the  opening  that  had  been  made. 
Rve  days  after  this  first  operation,  Dubois  extracted 
two  incisors  and  one  grinder,  and  then  removed  the 
corresponding  part  of  the  alveolary  process.  As  the 
hemorrhage  was  profuse,  the  wmund  was  now  filled 
with  dressings,  which  in  two  days  came  away,  and 
enabled  Dubois  to  see  with  facility  all  the  interior 
of  the  cavity.  At  its  upper  part,  he  perceived  a white 
speck,  which  he  supposed  was  pus,  but  on  touching 
it  with  a probe,  it  turned  out  to  be  a tooth,  which  W'as 
then  extracted,  in  doing  which  some  force  was  requi- 
site. The  rest  of  the  treatment  merely  consisted  in 
injecting  lotions  into  the  cavity,  and  applying  common 
dressings.  In  about  six  weeks  all  the  hollow  disap- 
peared ; but  the  swelling  of  the  cheek  and  palate,  and 
the  displacement  of  the  nose,  still  continued.  In  the 
course  of  another  year  and  a half,  however,  every  ves- 
tige of  deformity  was  entirely  removed. — (Ihibois, 
Bulletin  de  la  Faculte  de  Mdd.  an  13,  A’o.  S.) 

With  respect  to  the  treatment  of  collections  of  mu- 
cus in  the  antrum,  by  means  of  injections,  thrown 
into  that  cavity  through  the  natural  opening  in  it, 
while  the  head  is  inclined  to  the  opposite  side,  for  the 
purpo.se  of  facilitating  the  escape  of  the  collected  fluid, 
as  proposed  by  Jourdain  in  1705  (Jltm.  de  VAcad.  de 
Chir.  t.  4,  p.  357),  Deschamps  and  Boyer  are  of  opi- 
nion, that  the  method  is  objectionable ; not  only  be- 
cause it  is  difficult  to  find  the  aperture,  wdiich,  ere  the 
disease  forms  an  outward  swelling,  is  probably  oblite- 
rated, but  also  because  the  thicfaiess  of  the  mucus 
collected  would  make  it  impossible  for  the  surgeon  to 
wash  it  out  with  injections.  Hence,  Boyer  approves 
of  the  practice  of  opening  the  tumour  in  an  eligible 
place,  and  to  an  extent  sufficient  for  the  discharge  of 
the  mucus. — {Deschamps,  Traite  des  Maladies  des 
Fosses  Nasales,  et  de  leur  Sinus,  p.  231,  Qvo.  Par. 
1804 ; Boyer,  Traite  des  Mai.  Chir.  t.  6,  p.  145,  Svo. 
Paris,  1818.)  Indeed,  that  Jourdain’s  proposal  was 
attended  with  too  much  difficulty  for  common  prac- 
tice, was  the  sentence  long  ago  pronounced  upon  it  by 
a committee  of  the  Royal  Academy  of  Surgeons  in 
France,  nominated  for  the  express  purpose  of  inquir- 
ing into  the  merits'  of  the  suggestion.  The  method 
of  making  an  opening  into  the  antrum,  w’ill  be  consi- 
dered in  the  sequel  of  this  article.  As  a general  rule, 
I may  here  remark,  that  except  when  a tumour  or  fun- 
gus requires  to  be  e.xtirpated,  or  a foreign  body  to  be 
extracted  from  the  antrum,  it  is  quite  unnecessary  to 
remove  any  part  of  the  alveolary  process,  or  cut  away 
any  of  the  bony  parietes  of  the  antrum ; the  drawing 
of  one  of  the  teeth  situated  below  this  cavity,  and 
making  a perforation  in  this  situation,  being  the  only 
kind  of  opening  required.  This  aperture  may  be 
preserved  as  long  as  necessary,  by  the  introduction  of 
a piece  of  elastic  gum  catheter,  which  is  to  be  fastened 
to  the  adjacent  teeth,  and  through  which  the  secretion 
in  the  antrum  may  escape,  or  lotions  be  injected. — (See 
Deschamps,  Traite  des  Mai.  des  Fosses  Nasales,  di  e. 
p.  234.)  However,  as  Hunter  remarks,  if  the  forepart 
of  the  bone  has  been  destroyed,  even  though  the  case 
be  merely  a collection  of  mucus  or  pus,  an  opening 
may  be  made  on  the  inside  of  the  lip ; but  on  account 
of  the  difficulty  of  maintaining  such  an  aperture,  he 
still  inclines  to  the  practice  of  drawing  one  of  the 
teeih.— {Natural  Hist,  of  the  Teeth,  p.  176,  ed.  3.) 

Of  all  the  above  cases,  abscesses  are  by  far  the  most 
common.  Violent  blows  on  the  cheek,  inflammatory 
affections  of  the  adjacent  parts,  and  especially  of  the 
pituitary  membrane  lining  the  nostrils,  exposure  to 
cold  and  damp,  and,  above  all  thing.s,  bad  teeth,  may 
bring  on  inflammation  and  suppuration  within  the 
hollow  of  the  upper  jaw-bone.  The  first  symptom  is 
a sensation  of  pain  at  first  imagined  to  be  a toothache, 
particularly  if  there  should  be  a carious  tooth  at  this 
part  of  the  jaw.  Such  pain,  however,  extends  more 


into  the  nose,  than  that  usually  does  which  arises  from 
a decayed  tooth ; it  also  affects,  more  or  less,  the  eye, 
the  orbit,  and  the  situation  of  the  frontal  sinuses. — 
(See  Hunter  on  the  Teeth,  p.  175,  ed.  3.)  But  even 
these  symptoms  are  insufficient  to  characterize  the  dis- 
ease, the  natiu-e  of  which  is  not  unequivocally  evinced 
till  a much  later  period.  The  complaint  is,  in  general, 
of  much  longer  duration  than  one  entirely  dependent 
on  a caries  of  a tooth,  and  its  violence  increases  more 
and  more,  until,  at  last,  a hard  tumour  is  perceptible 
below  the  cheek-bone.  By  degrees  the  swelling  ex- 
tends over  the  whole  cheek;  but  it  afterv.ard  rises  to 
a point,  and  forms  a very  circumscribed  hardness, 
which  may  be  felt  above  the  back  grinders.  This 
symptom  is  accompanied  with  redness,  and  sometimes 
with  inflammation  and  suppuration  of  the  external 
parts.  It  is  not  uncommon,  also,  for  the  outward  ab- 
scess to  communicate  with  that  within  the  antrum. 

The  circumscribed  elevation  of  the  tumour,  how- 
ever. does  not  occur  in  all  cases.  There  are  instances 
in  which  the  matter  makes  its  way  towards  the  palate, 
causing  the  bones  of  this  part  to  swell,  and  at  length 
rendering  them  carious,  unless  timely  assistance  be 
given.  There  are  other  cases  in  which  the  matter  es- 
capes between  the  fangs  and  sockets  of  the  teeth. 
Lastly,  there  are  certain  examples,  in  which  the  matter 
formed  in  the  antrum  makes  its  exit  at  the  nostril  of 
the  same  side,  wheu  the  patient  is  lying  with  his  head 
on  the  opposite  one  in  a low  position.  If  this  mode  of 
evacuation  should  be  frequently  repeated,  it  prevents 
the  tumour  both  from  pointing  externally  and  bursting, 
as  it  would  do  if  the  puru  ent  matter  could  find  no 
other  vent.  But  this  evacuation  of  pus  from  the  nos- 
tril is  not  very  common  ; for,  according  to  Mr.  Hunter, 
the  opening  between  the  antrum  and  cavity  of  the  nose  is 
generally  stopped  up.  He  even  seems  inclined  to  think, 
as  I have  already  observed,  that  the  disease  may  some- 
times be  occasioned  by  the  impervious  state  of  this 
opening,  in  consequence  of  which,  the  natural  mucus 
of  the  antrum  collects  in  such  quantity,  as  to  irritate 
and  inflame  the  membrane  with  which  it  is  in  contact, 
just  as  an  obstruction  in  the  ductus  nasalis  hinders  the 
passage  of  the  tears  into  the  nose,  and  causes  an  ab- 
scess in  the  lachrymal  sac.  This  is  a point,  however, 
on  which  even  Mr.  Hunter  would  not  venture  to  speak 
writh  certainty ; for  it  is  by  no  means  impossible,  that 
the  impervious  state  of  the  opening  is  rather  an  effect 
than  the  cause  of  the  disease,  since  inflammation  in  the 
antrum  is  often  manifestly  produced  by  causes  of  a 
different  kind,  and  since  the  opening  in  question  is  not 
invariably  closed. 

Abscesses  in  the  antrum  require  a free  exit  for  their 
contents,  and  if  the  surgeon  neglects  to  procure  such 
opening,  the  bones  become  mere  and  more  distended 
and  pushed  out,  and  finally  carious.  When  this  hap- 
pens, the  pus  makes  its  appearance,  either  towards  the 
orbit,  the  alveoli,  the  palate,  or,  as  is  mostly  the  case, 
towards  the  cheek.  The  matter  having  thus  made  a 
way  for  its  escape,  the  disease  now  becomes  fistulous. 

In  all  cases,  whether  the  pus  be  simply  confined  in 
the  antrum,  or  whether  the  case  be  conjoined  with  a 
carious  affection  of  the  bones,  the  principal  indication 
is  to  discharge  the  matter. 

The  ancients  seem  to  have  known  verj-  little  about 
the  treatment  of  diseases  of  the  antrum.  Drake,  an 
English  anatomist,  is  reputed  to  be  the  first  proposer 
of  a plan  for  curing  abscesses  of  this  cavity. — {Anthro- 
pologia  Nova.  Londini,  1727.)  However,  Meibomius 
was  much  earlier  in  proposing,  with  the  same  inten- 
tion, the  extraction  of  one  or  more  of  the  teeth,  in  order 
that  the  matter  might  have  an  opening  for  its  escape 
through  the  sockets.  This  plan  may  be  employed  with 
success.  The  pus  frequently  has  a tendency  to  make 
its  way  outwards  towards  the  teeth ; it  often  affects 
their  fangs;  and,  after  their  extraction,  the  whole  of 
the  abscess  is  seen  to  escape  through  the  sockets.  But 
this  very  simple  plan  will  not  suffice  for  all  cases,  as 
there  are  numerous  instances  in  which  there  is  no 
communication  between  the  alveoli  and  the  antrum. 

Drake,  and  perhaps  before  him,  Cowper,  took  no- 
tice of  the  insufficiency  of  Meibomius’s  method,  and 
hence  they  projwsed  making  a perforation  through  the 
socket  into  the  antrum  with  an  awl.  for  the  purpose  of 
letting  out  the  matter,  and  injecting  into  the  cavity  such 
fluids  as  were  judged  proper. 

.M.  .lourdain  recommended  to  the  French  Academy 
of  Surgery,  the  injection  of  detergent  lotions  into  the 


ANTRUM. 


153 


natural  opening  of  the  antrum,  by  means  of  a curved 
pipe  introduced  into  the  nostril ; but,  without  dwelling 
upon  the  difficulty  of  putting  this  method  in  practice, 
especially  where  the  opening  is  closed,  many  assert 
on  the  authority  of  the  French  surgeons  themselves, 
that  the  mere  employment  of  injections  is  not  in  these 
cases  an  effectual  mode  of  treatment. — (See  Diet,  ties 
Sciences  Med.  t.  51,  p.  383.) 

In  the  treatment  of  abscesses  of  the  antrum,  the  ex- 
traction of  one  or  more  teeth,  and  the  perforation  of  the 
alveoli,  being  generally  essential  steps,  we  must  con- 
sider what  tooth  ought  to  be  taken  out  in  preference  to 
others. 

A caries,  or  even  a mere  continual  aching,  of  any 
particular  tooth,  in  general,  ought  to  decide  the  choice. 
But  if  all  the  teeth  should  be  sound,  which  is  not  often 
the  case,  writers  direct  us  to  tap  each  of  them  gently, 
and  to  extract  that  which  gives  most  pain  on  this  being 
done.  When  no  information  can  be  thus  obtained, 
other  circumstances  ought  to  guide  us. 

All.  the  grinding  teeth,  except  the  first,  correspond 
with  the  antrum.  They  even  sometimes  extend  into 
this  cavity,  and  the  fangs  are  only  covered  by  the  pitu- 
itary membrane.  The  bony  lamella  which  separates 
the  antrum  from  the  alveoli,  is  very  thin  towards  the 
back  part  of  the  upper  jaw.  Hence,  when  the  choice 
is  in  our  power,  it  is  best  to  extract  the  third  or  fourth 
grinder,  as  in  this  situation  the  alveoli  can  be  more 
easily  perforated.  Though,  in  general,  the  first  grinder 
and  canine  tooth  do  not  communicate  with  the  antrum, 
their  fangs  approach  the  side  of  it,  and  from  their  socket 
an  opening  may  readily  be  extended  into  that  cavity. 

When  one  or  more  teeth  are  carious,  they  should  be 
removed,  because  they  are  both  useless  and  hurtful. 
The  matter  frequently  makes  its  escape  as  soon  as  a 
tooth  is  extracted,  in  consequence  of  the  fang  having 
extended  into  the  antrum,  or  rather  in  consequence  of 
its  bringing  away  with  it  a piece  of  the  thin  partition 
between  it  and  the  sinus.  Perhaps  a discharge  may 
follow  from  the  partition  itself  being  carious.  If  the 
opening  thus  produced  be  sufficiently  large  to  allow 
the  matter  to  escape,  the  operation  is  already  completed. 
But  as  it  can  easily  be  enlarged,  it  ought  always  to 
be  so  when  there  is  the  least  suspicion  of  its  being 
too  small.  However,  when  no  pus  makes  its  appear- 
ance after  a tooth  is  extracted,  the  antrum  must  be 
opened  by  introducing  a pointed  instrument  in  the  di- 
rection of  the  alveoli.  Some  use  a small  trocar  or 
awl,  others  a gimlet  for  this  purpose. 

The  patient  should  sit  on  the  ground  in  a strong 
light,  resting  his  head  on  the  surgeon’s  knee,  who  is 
to  sit  behind  him.  Immediately  the  instrument  has 
reached  the  cavity,  it  is  to  be  withdrawn.  Its  entrance 
into  the  antrum  is  easily  known  by  the  cessation  of  re- 
sistance. After  the  matter  is  discharged,  surgeons  ad- 
vise the  opening  to  be  closed  with  a wooden  stopper, 
in  order  to  prevent  the  entrance  of  extraneous  sub- 
stances. 

The  stopper  is  to  be  taken  out  several  times  a day, 
to  allow  the  pus  to  escape.  This  plan  soon  disposes 
the  parts  afiected  to  discontinue  the  suppuration,  and 
resume  their  natural  state.  Sometimes,  however,  the 
pus  continues  to  be  discharged  for  a long  time  after  the 
operation,  without  any  change  occurring  in  regard  to 
Its  quality  or  quantity.  In  such  instances,  the  cure 
may  often  be  accelerated  by  employing  injections  of 
brandy  and  w'ater,  lime-water,  or  a solution  of  the  sul- 
phate of  zinc. 

Some  surgeons  prefer  a silver  cannula,  or  a piece  of 
elastic  gum  catheter,  instead  of  the  stopper,  as  it  can 
always  be  left  pervious  except  at  meals.  The  exam- 
ples on  record,  where  the  extraction  of  a tooth  and 
the  jterforation  of  the  bottom  of  the  antrum  were  the 
means  of  curing  abscesses  of  that  cavity,  are  very  nu- 
merous.— (See  Farmer's  Select  Cases,  No.  9 ; Gooch's 
Cases, p.  03,  7ieiv  editiem;  Palfyn,  Anatomie,  dec.) 

If  no  opening  were  made  in  the  antrum,  the  matter 
would  make  its  way  sometimes  towards  the  front  of 
this  cavity,  which  is  very  thin  ; sometimes  towards  the 
mouth;  and  fistulous  openings  and  caries  would  in- 
evitably follow. 

When  the  bones  are  diseased,  the  abov  plan  will 
not  accomplish  a cure  until  the  affected  pieces  of  bone 
exfoliate.  A probe  will  generally  enable  us  to  detect 
caries  in  the  antrum.  The  fetid  smell  and  ichorous 
appearance  of  the  discharge,  also,  leave  little  doubt 
that  the  bones  arc  diseased ; and  in  projiorlion  as  the 


bones  free  themselves  of  any  dead  portions,  the  dis- 
charge has  less  smell  and  its  consistence  becomes 
thicker. 

When  there  are  loose  pieces  of  dead  bone  or  other 
foreign  bodies  to  be  extracted,  it  is  requisite  to  make 
a larger  opening  in  the  antrum  than  can  be  obtained 
at  its  lower  part.  Instances  also  occur  where  patients 
have  lost  all  the  grinding  teeth  and  the  sockets  are 
quite  obliterated,  so  that  a perforation  from  below  can- 
not be  effected.  Some  practitioners  object  to  sacri- 
ficing a sound  tooth.  In  these  circumstances,  it  has 
been  advised  to  make  a perforation  in  the  antrum  above 
the  alveolary  processes : a method  first  suggested  by 
I.amorier.  It  consists  in  making  a transverse  incision 
below  the  malar  process  and  above  the  root  of  the 
third  grinder.  Thus  the  gum  and  periosteum  are  di- 
vided, and  the  bone  exposed.  A perforating  instru- 
ment is  to  be  convej’ed  into  the  middle  of  this  incision, 
and  the  opetiing  in  the  antnam  made  as  large  as  requi- 
site.— (See  M<m.  de  VAcad.  de  Chir.  t.  4,  p.  35i ; 
Gooch's  Obs.  append,  p.  138.)  There  are  some  exten- 
sive exfoliations  of  the  antrum,  where  it  is  absolutely 
necessary  to  expose  a great  part  of  the  surface  of  the 
bone,  and  to  cut  away  the  dead  pieces  which  are  wedged, 
as  it  were,  in  the  livingones.  A small  trephine  may 
sometimes  be  advantageously  applied  to  the  malar 
process  of  the  superior  maxillary  bone. 

Surgeons  formerly  treated  carious  affections  of  the 
antrum  in  the  most  absurd  and  unscientific  way;  in- 
troducing setons  through  its  cavity,  and  even  having 
recourse  to  the  actual  cautery.  The  moderns,  how- 
ever, are  not  much  inclined  to  adopt  this  sort  of  prac- 
tice. It  is  now  known,  that  the  detachment  of  a dead 
portion  of  bone,  in  other  terms  the  jirocess  of  exfoli- 
ation, is  nearly,  if  not  entirely,  the  work  of  nature,  in 
which  the  surgeon  can  act  a very  inferior  part.  In- 
deed, he  should  limit  his  interference  to  preventing  the 
lodgement  of  matter,  maintaining  strict  cleanliness,  and 
removing  the  dead  pieces  of  bone  as  soon  as  tliey  be- 
come loose.  But  it  is  to  be  understood,  that  examples 
occasionally  present  themselves,  in  which  the  dead 
portions  of  bone  are  so  tedious  of  sepr  ration,  and  so 
wedged  in  the  substance  of  the  surrounding  living 
bone,  that  an  attempt  may  properly  be  made  to  cut 
them  away. 

TUMOURS  OF  THE  ANTRUM. 

Ruysch,  Bordenave,  Desault,  Abernethy,  Weinhold, 
and  others,  have  recorded  cases  of  polypous,  fungous, 
and  cancerous  diseases  of  the  antrum,  and  examples  of 
this  cavity  being  affected  with  exostosis. 

The  indolence  of  any  ordinary  fleshy  tumour  in  the. 
antrum,  while  in  an  incipient  state,  certainly  tends  to 
conceal  its  existence ; but  such  a disease  rarely  occurs 
without  being  accompanied  with  some  affection  of  the 
neighbouring  parts;  and  hence,  its  presence  may  ge- 
nerally be  ascertained  before  it  has  attained  such  a 
size  as  to  have  altered,  m a serious  degree,  the  natural 
shape  of  the  antrum.  This  information  may  be  ac- 
quired, by  examining  whether  any  of  the  teeth  have 
become  loose,  or  have  spontaneously  fallen  out ; whe- 
ther the  alveolary  processes  are  sound,  and  whether 
there  are  any  fungous  excre.scences  making  their  ap- 
pearance at  the  sockets ; whether  there  is  any  habitudl 
bleeding  from  one  side  of  the  nose;  any  sarcomatous 
tumour  at  the  Side  of  the  nostril,  or  towards  the  great 
angle  of  the  eye.  When  the  swelling,  however,  has 
attained  a certain  size,  the  bony  ]»arietes  of  the  antrum 
always  protrude,  unle.ss  the  body  of  the  tumour  should 
be  situated  in  the  nostril,  and  only  its  root  in  the  an- 
trum. This  case,  however,  is  very  uncommon. 

As  soon  as  a tumour  is  certainly  known  to  exist  in 
the  antrum,  the  front  part  of  this  cavity  should  be  open- 
ed, without  waiting  till  the  disease  makes  farther  pro- 
gress. In  a few  instances,  indeed,  we  may  avail  our- 
selves of  the  opening  which  is  sometimes  found  in  the 
alveolary  process,  and  enlarge  it  sufficiently  to  allow 
the  tumour  to  be  extirpated.  If  the  front  of  the  antrum 
were  freely  opened,  it  would  in  general  be  better  to  cut 
away  the  disease  in  its  interior. 

A swelling  of  the  parietes  of  the  antrum,  in  conse- 
quence  of  an  abscess,  or  a sarcomatous  tumour  in  its 
cavity,  may  lead  us  to  suppose  the  case  an  enlarge- 
ment of  the  bones,  or  an  exostosis.  The  symptoms  of 
the  first  two  affections  have  been  already  detailed. 
One  sign  of  an  exostosis,  besides  the  absence  of  tlie 
symptoms  characterizing  an  ab;jcess  or  a sarcoma,  is 


154 


ANTRUM. 


the  thickened  parietes  of  the  antnim  forming  a solid 
resistance ; whereas,  in  cases  of  mere  expansion,  the 
dimensions  of  the  surface  of  the  bone  being  increased, 
while  its  substance  is  rendered  proportionally  thinner, 
the  resistance  is  not  so  considerable. 

When  such  an  exostosis  depends  upon  a particular 
constitutional  cause,  and  especially  upon  one  of  a vene- 
real nature,  it  must  be  attacked  by  remedies  suited  to 
this  affection.  But  when  the  disease  resists  internal 
remedies,  and  its  magnitude  is  likely,  to  produce  an 
aggravation  of  the  case,  a portion  of  the  bone  may  be 
removed  with  a trephine  or  a cutting  instrument.  Such 
operations,  however,  require  a great  deal  of  delicacy 
and  prudence. 

Mr.  B.  Bell,  vol.  4,  describes  a kind  of  exostosis  of 
the  upper  jaw,  very  different  from  what  I have  men- 
tioned, since,  instead  of  its  being  distinguishable  from 
other  diseases  of  the  antrum  by  the  greater  firmness 
of  the  tumour,  the  substance  of  the  bpne  gradually  ac- 
quires such  suppleness  and  elasticity,  that  it  yields  to 
the  pressure  of  the  fingers,  and  immediately  resumes 
its  former  plumpness  when  the  pressure  is  discontinued. 
If  the  bone  be  cut,  it  is  found  to  be  as  soft  as  cartilage, 
and  in  an  advanced  stage  of  the  disease,  its  consistence 
is  almost  gelatinous.  The  swelling  increases  gradually, 
and  extends  equally  over  the  whole  cheek,  without 
becoming  prominent  at  any  particular  point,  or  only  so 
in  the  latter  periods  of  the  malady,  when  the  soft  parts 
inflame,  and  become  affected.  The  complaint  is  de- 
scribed as  totally  incurable.  Cutting  and  trephining 
the  tumour,  as  recommended  in  other  cases  of  exostosis, 
only  aggravate  the  patient’s  unhappy  condition. 

Mr.  Abernethy  published  an  account  of  a very  singu- 
lar disease  of  the  antrum.  The  patient,  who  was 
thirty-four  years  of  age  when  the  account  was  written, 
perceived,  when  about  ten  years  old,  a small  tumour  on 
his  left  cheek,  which  gradually  attained  the  size  of  a 
walnut,  and  then  remained  for  some  time  stationary. 
About  a year  afterward,  the  tumour  having  again  en- 
larged, a caustic  was  applied  to  the  integuments,  so  as 
to  expose  the  bone.  The  actual  cautery  was  next  ap- 
plied, and  an  opening  thus  made  into  the  antrum.  After 
the  exfoliation,  the  antrum  became  filled  with  a fungus, 
which  rose  out  upon  the  cheek,  and  could  not  be  re- 
strained by  any  applications.  Part  of  the  fungus  also 
made  its  way  into  the  mouth,  through  the  socket  of  the 
second  tricuspid  tooth,  the  other  teeth  remaining  natu- 
ral. The  disease  continued  in  this  state  nine  years, 
occasionally  bleeding  in  an  alarming  way.  When  the 
patient  was  in  his  twentieth  year,  the  whole  fungus 
sloughed  away  during  a fever,  and  never  returned. 
After  this,  the  sides  of  the  aperture  in  the  bone  began 
to  grow  outwards,  forming  an  exostosis,  wluch  rapidly 
attained  a great  magnitude.  A small  exostosis  took 
place  in  the  mouth,  but  became  no  larger  than  a horse- 
bean.  The  exostosis  of  the  maxillary  bone  was  of  an 
irregular  figure,  and  projected  from  the  whole  circum- 
ference of  the  aperture  a great  way  directly  forwards. 
Mr.  Abernethy  compared  its  appearance,  when  he  was 
writing,  with  that  of  a large  tea-cup  fastened  upon  the 
face,  the  bottom  of  which  may  be  supposed  to  commu- 
nicate with  the  antrum.  The  diameter  of  the  cup, 
formed  by  the  circular  edge  of  the  bone,  was  three 
inches  and  a half;  the  depth  two  inches  and  seven- 
eighths.  The  general  height  of  the  sides  of  the  exos- 
tosis, from  the  basis  of  the  face,  was  two  inches ; its 
walls  were  not  thick,  and  terminated  in  a tliin  circular 
edge.  The  integuments,  as  they  approached  this  edge, 
became  thinner,  and  they  extended  over  it  into  the  ca- 
vity. The  exostosis  now  reached  to  the  nose  in  front, 
and  to  the  masseter  muscle  behind  ; above,  it  included 
the  very  ridge  of  the  orbit,  and  below,  it  grew  from 
the  edge  of  the  alveolary  process.  A line,  that  would 
have  separated  the  diseased  from  the  sound  bone,  would 
have  included  the  orbit  and  nose,  and  indeed  one-half 
of  the  face.  Mr.  Abernethy  saw  no  means  of  affording 
the  man  relief. — {Trans,  of  a Soc.  for  the  Improvement 
of  Med.  and  Chir.  Knowledge,  vol.  2.)  See  also  a case 
related  by  Harri.son.— (iVeto-Z/Ond.  Med.  Journ.  vol.  1, 
p.  1.) 

In  a case  of  fungus,  which  had  distended  the  antnim, 
hindered  the  tears  from  passing  down  into  the  nose, 
raised  the  lower  part  of  the  orbit,  caused  a protrusion 
of  the  eye,  made  two  of  the  grinding-teeth  fall  out,  and 
occasioned  a carious  opening  in  the  front  of  the  antrum, 
through  which  opening  a piece  of  the  fungus  projected, 
Desault  operated  aa  follows ; the  cheek  was  first  de- 


tached from  the  os  maxillare,  by  dividing  the  internal 
membrane  of  the  mouth,  at  the  place  where  it  is  re- 
flected over  this  bone.  Thus  the  outer  surface  of  the 
bone  was  denuded  of  all  the  soft  parts.  A sharp  per- 
forating instrument  was  applied  to  the  middle  of  this 
surface,  and  an  opening  made  more  forwards  than  the 
one  already  existing.  The  plate  of  bone  situated  be- 
tween the  ^two  apertures,  was  removed  with  a little 
falciform  knife,  which,  being  directed  from  behind  for- 
wards, made  the  division  without  difficulty.  The  open- 
ing thus  obtained  being  insufficient,  Desault  endea- 
voured to  enlarge  it  below,  by  sacrificing  the  alveolary 
process.  This  he  endeavoured  to  accomplish  with  the 
same  instrument,  but  finding  the  resistance  too  great, 
he  had  recourse  to  a gouge  and  mallet.  A considerable 
piece  of  the  alveolary  arch  was  thus  detached,  without 
any  previous  extraction  of  the  corresponding  teeth, 
three  of  which  were  removed  by  the  same  stroke.  In 
this  manner  an  opening  was  procured  in  the  external 
and  inferior  part  of  the  antrum,  large  enough  to  admit 
a walnut.  Through  this  aperture  a considerable  part 
of  the  tumour  was  cut  away  with  a knife,  curved  side- 
ways, and  fixed  in  its  handle.  A most  profuse  hemor- 
rhage took  place,  but  Desault,  unalarmed,  held  a com- 
press in  the  antrum  for  a short  time ; this  being  re- 
moved, the  actual  cautery  was  applied  repeatedly  to 
the  rest  of  the  fungus.  The  cavity  was  dressed  with 
lint,  dipped  in  powdered  colophony. 

On  the  eighteenth  day,  the  swelling  was  evidently 
diminished,  the  eye  less  prominent,  and  the  epiphora 
less  visible.  But,  at  this  period,  a portion  of  fungus 
made  its  appearance  again.  This  was  almost  entirely 
destroyed  by  applying  the  actual  cautery  twice.  It 
appeared  again,  however,  on  the  twenty-fifth  day,  and 
required  a third  and  last  recourse  to  the  cautery.  From 
this  time,  the  progress  of  the  cure  went  on  rapidly. 
Instead  of  fungous  excrescences,  healthy  granulations 
were  now  formed  in  the  bottom  of  the  sinus.  The 
parietes  of  the  antrum  gradually  approaching  each  other, 
the  large  opening  made  in  the  operation  was  reduced 
to  a small  aperture,  hardly  capable  of  admitting  a 
probe.  Even  this  little  opening  closed  in  the  fourth 
month,  at  which  time  no  vestiges  of  the  disease  re- 
mained, except  the  loss  of  teeth,  and  a very  obvious 
depression  just  where  they  were  situated. 

In  all  fungous  diseases  of  the  antrum,  making  a free 
exposure  of  them  is  an  essential  part  of  the  treatment : 
if  you  neglect  this  method,  how  can  you  inform  your- 
self of  the  size,  form,  and  extent  of  the  tumour?  How 
could  you  remove  the  whole  of  the  fungus,  through  a 
small  opening,  which  would  only  allow  you  to  see  a 
very  little  portion  of  the  excrescence?  How  could  you 
be  certain  that  the  disease  was  extirpated  to  its  very 
root  t Even  when  the  antrum  is  freely  opened,  this 
circumstance  can  only  be  learned  with  difficulty ; and 
how  could  it  be  ascertained,  when  only  a point  of  the 
cavity  is  opened?  A portion,  left  behind,  very  soon 
gives  origin  to  a fresh  fungus,  the  progress  of  which 
is  more  rapid,  and  the  character  more  fatal,  in  conse- 
quence of  being  irritated  by  the  surgical  measures 
adopted.— ((Enures  Chir.  de  Desault,  par  Bichat,  t.  2.) 
See  also  other  cases,  recorded  by  Canolles  {Recueil  Pc- 
riodique  de  la  Soc.  de  Med.  t.  2,  No.  9) ; Eichom  {Diss. 
de  Polypis  in  Antro  Highmori,  Goett.  1814);  Sandi- 
fort  {Museum  Anat.  vol.  2,  tab.  30);  Leveilld  {Recueil 
de  la  Soc.,  (Sc.  t.  I,  p.  24)  ; Weinhold  {Von  dert.  Krank- 
heiten  der  Gesichtsknochen,  p.  27,  4to.  Halle,  1818). 

I imagine,  that  English  surgeons,  unaccustomed  to 
use  the  actual  cautery,  will  peruse  with  a degree  of 
aversion  this  means,  so  commonly  employed  in  P’rance. 
Nor  can  1 expect  that  they  will  altogether  approve  the 
use  of  the  mallet  and  gouge  for  making  a free  opening 
into  the  antrum.  Perhaps  it  might  be  better  to  trephine 
this  cavity  with  a small  instrument  for  the  purpose, 
and  then  cut  the  fungus  away.  After  removing  as 
much  of.it  as  possible  in  this  manner,  some  instrument 
of  suitable  shape  might  be  used  to  scrape  the  part 
where  the  tumour  has  its  root.  However,  if  there  be 
any  case  in  which  potent  and  violent  measures,  like 
those  of  Desault,  are  allowable,  it  is  the  one  of  which 
we  have  just  been  treating.  Inveterate  diseases  demand 
powerful  means,  and  tampering  with  them  is  generally 
more  hurtful  than  useful.  I have  lately  been  informed 
of  one  or  two  cases,  in  which  the  use  of  the  cautery 
was  found  necessary  in  this  countrj',  for  the  stoppage 
of  the  bleeding  after  the  removal  of  fungi  from  the 
antrum. 


ANT 


ANU 


155 


There  is  an  interesting  case  of  a fungus  in  the  maxil- 
lary sinus,  related  in  the  first  vol.  of  the  Parisian  Chir. 
Journal.  It  was  at  last  cured  by  opening  the  antrum, 
applying  the  cautery,  and  tying  the  portion  of  the  tu- 
mour which  had  made  its  way  into  the  nose.  In  the 
second  volume  of  the  same  work  is  an  excellent  case, 
exhibiting  the  dreadful  ravages  which  the  disease  may 
produce  when  left  to  itself. 

Professor  Pattison,  a few  years  ago,  suggested  the 
expedient  of  tying  the  carotid  artery,  as  likely  to  bring 
about  the  dispersion  of  fungous  diseases  of  the  antrum, 
without  the  necessity  of  meddling  wth  the  tumour 
itself.  He  adverts  to  three  cases,  the  results  of  which 
were,  on  the  whole,  favourable  to  the  practice.— (See 
Barns  on  Anat.  of  the  Head,  ^-c.  ed.  by  Pattison.)  I 
consider  that  this  p^roposal  merits  farther  trials,  inas- 
much as  the  operation  of  taking  up  the  carotid  artery 
is  an  infinitely  less  severe  proceeiling  than  that  of  ex- 
tirpating the  disease  in  the  cheek,  in  the  manner  prac- 
tised by  Desault. 

INSECTS  IN  THE  ANTRUM. 

It  is  said,  that  insects  in  this  cavity  may  sometimes 
make  it  necessary  for  the  surgeon  to  open  it.  This 
case,  however,  must  be  exceedingly  rare;  and  even 
what  we  find  in  authors  [Pallas,  de  insectis  Viventibus 
intra  viventia)  appears  so  little  authentic,  that  I should 
hardly  have  mentioned  the  circumstance,  if  there  were 
not,  in  a modern  work  [Med.  Comm.  vol.  1,,  a fact 
which  appears  entitled  to  attention.  Mr.  Heysham,  a 
medical  practitioner  at  Carlisle,  relates,  that  a strong 
woman,  aged  sixty,  in  the  habit  of  taking  a great  deal 
of  snuff,  was  subject,  for  several  years,  to  acute  pains 
in  the  antrum,  extending  over  one  side  of  the  head. 

These  pains  never  entirely  ceased,  but  were  more 
severe  in  winter  than  summer,  and  were  always  sub- 
ject to  frequent  periodical  exacerbations.  The  patient 
had  taken  several  anodyne  medicines,  and  others,  with- 
out benefit,  and  liad  twice  undergone  a course  of  mer- 
cury, by  which  her  complaints  had  been  increased. 
All  her  teeth  on  the  affected  side  had  been  drawn.  At 
length,  it  was  determindll  to  open  the  antrum  with  a 
large  trocar,  though  there  were  no  symptoms  of  an 
abscess,  nor  of  any  other  disease  in  this  cavity.  For 
four  days,  no  benefit  resulted  from  the  operation.  Bark 
injections  and  the  elixir  of  aloes,  were  introduced  into 
thesinus.  On  the  fifth  day,  a dead  insect  was  extracted, 
by  means  of  a pair  of  forceps,  from  the  mouth  of  the 
cavity.  It  was  more  than  an  inch  long,  and  thicker 
than  a common  quill.  The  patient  now  experienced 
relief  for  several  hours;  but  the  pains  afterward  re- 
curred with  their  former  severity : oil  was  next  injected 
into  the  antrum,  and  two  other  insects,  similar  to  the 
former,  were  extracted.  No  others  appeared,  and  the 
wound  closed.  The  pains  were  not  completely  re- 
moved, but  considerably  diminished  for  several  months, 
at  the  end  of  which  time  they  became  worse  than  ever, 
particularly  affecting  the  situation  of  the  frontal  sinus. 

Bordeiiave  has  published,  in  the  twelfth  and  thir- 
teenth volumes  of  the  M m.  de  VAcad.  de  Chir.  edit. 
12mo.  two  excellent  papers  on  diseases  of  the  antrum. 
In  the  thirteenth  volume,  he  relates  the  nistory  of  a 
case,  in  which  several  small  whitish  worms,  together 
with  a piece  of  fetid  fungus,  were  discharged  from  the 
antrum,  after  an  opening  had  been  made  on  account  of 
an  abscess  of  this  cavity,  attended  with  caries. — [P. 
381.)  But,  in  this  instance,  the  worms  had  probably 
been  generated  after  the  opening  had  been  made  in  the 
cavity ; for  when  they  made  their  appearance,  the  open- 
ing had  existed  nine  months.  Deschamps  refers  to 
another  ca.se,  in  which  M.  Fortassin,  his  colleague  at 
La  Charite,  found  in  the  antrum  of  a soldier,  whom  he 
was  dissecting,  a worm  of  the  ascaris  lumbricus  kind, 
four  inches  in  length.— (TVaitd  des  Mai.  des  Fosses 
Nasales,  isrc.  p.  107.)  Such  an  example  is  also  recorded 
in  one  of  the  volumes  of  the  Journ.  de  M6d.  Were  a 
case  of  this  description  to  present  itself  in  a living  sub- 
ject, it  would  be  advisable  to  inject  oil  into  the  cavity 
of  the  antrum,  and  then  endeavour  to  wash  out  the 
extraneous  substances,  by  throwing  into  the  sinus 
warm  water,  by  means  of  a syringe. — See  Precis 
d' Observations  sur  Its  Maladies  du  Stmts  Mazilluire, 
par  M.  Bordettave,  in  Mem.  de  VJlcad.  Rnyule  de  Chi 
rnrjf  ie,  t.  Vi,  edit,  in  Mom.  Also,  Suite  d'  Observations 
on  the  same  subject,  by  M.  Boi  denave,  t.  13,  of  the  said 
work;  Ij.  H.  Rmifre,  He  Morbis  Prcecipuis  Sinuum 
Ossis  Frontis  et  Maxilla  Superioris,^  e,  Rintelii,  1750; 


Haller,  Disp.  Chir.  1,  205.  Jourdahi,  in  Mem.  de 
VAcad.  de  Chir.  t.  4,  p.  357  ; also,  his  I'raite  des  D6 
p6ts  dans  le  Sinus  Maxillaire,  <lirc.  Vivio.  Pans,  1700 ; 
his  'Praite  des  Mai.  de  la  Bouche,  t.  2 ; and  .Journ.  de 
Med.  t.  21,  p.  57,  et  t.  27,  p.  52 — 157.  This  author,  who, 
in  1765,  suggested  to  the  Royal  Academy  of  Surgery 
the  method  of  injecting  fluid  into  the  antrum,  through 
the  natural  opening,  is  said  to  have  been  anticipated  in 
the  practice  by  Allouel,  who  first  conceived  the  plan  in 
1737,  and  tried  it  with  success  in  1739 ; see  Boyer, 
I'raite  des  Mai.  Chir.  t.  6,  p.  149.  Becker,  Hiss,  de 
Insolito  Maxillm  Superioris  tuniore  aliisyue  ejusdem 
morbis.  fVirceb.  1776.  Remargues  et  Observations  sur 
les  Maladies  du  Sinus  Maxillaire,  in  lEuvres  Chir.  de 
Desault,  par  Bichat,  t.  2,  p.  156.  Desault's  Parisian 
Chir.  Journal,  vols.  1 and  2.  Medical  Communica- 
tions, vol.  1.  Trans,  of  a Soc.for  the  Improvement  of 
AIed..and  Chir.  Knowledge,  vol.  2.  JWatural  History 
of  the  Human  Teeth,  by  John  Hunter,  p.  174,  175,  edit. 

3.  Gooch's  Chirurgical  fVorks,  vol.  2,  p.  61,  and  vol. 

3,  p.  161,  edit.  1792.  Callisen's  Systema  Chirurgiw 
Hodiernw,  t.  \,p.  346,  <S-c.  Dubois,  in  Bulletin  de  la 
Faculte  de  Medicine,  JVo.  8.  J.  L.  Desehamps,  'I'raite 
des  Maladies  des  Fosses  Masales,  et  de  leur  Sinus,  bvo. 
Paris,  1804.  Eichorn,  Diss.  de  Polypis  in  antro  High- 
mori,  Gott.  1804.  Liston,  Edin.  Med.  Journ.  JTu.  68. 
P.  V.  Leinicker,  de  Sinu  Maxillnri,  ejusdem  Morbis, 
<^c.  Hurceb.  ]80i).  C.  A.  fPeinhold,  Ideen  iiber  die  ab- 
nomien  Metamorphosen  der  Highmoreshble,  Leipz. 
1810.  C.  A.  Weinhold,  Von  den  Krankheiten  der 
Gesichtsknochen  und  Hirer  Schleimhaiite,  der  Ausrot- 
tung  eines  grossen  Polypen  in  der  linken  Oberkiefer- 
hbhle,  dem  Verhuten  der  Einsinkens  dcr  Gichtischen 
and  Venerischen  Mase,  und  der  Einsetzung  Kiinst- 
licher  Choanen,  Ho.  Halle,  1808.  Also,  an  account  of  a. 
Malignant  Tumour  removed  from  the  Antrum,  by  T. 
Irving,  in  Edin.  Med.  Journ.  JTos.  83  and  84. 

[A  case  of  aneurism  by  anastomosis,  situated  in  tho 
branches  of  the  internal  maxillary  artery,  and  cured 
by  tying  the  carotid,  is  recorded  by  Professor  Pattison, 
of  the  London  University.  The  centre  of  the  tumour 
occupied  the  antrum ; but  the  sides  of  this  cavity 
having  been  destroyed,  the  swelling  made  its  way  out 
of  it  in  every  direction  ; upwards  into  the  orbit,  from 
which  it  had  displaced  the  eye  ; laterally  into  the  nos- 
tril, which  it  completely  filled  ; and  against  the  septum 
narium,  so  as  to  produce  a considerable  distortion  of 
the  nose.  It  was  as  large  as  a new-born  child’s  head, 
and  attended  with  profuse  and  sometimes  nearly  fatal  • 
hemorrhages.  Immediately  after  the  performance  of 
the  operation,  the  appearance  of  the  tumour  in  the  nos- 
tril underwent  a remarkable  change ; just  before  the 
ligature  was  applied,  it  seemed  ready  to  burst  from 
distention ; but  as  soon  as  the  direct  circulation  was 
stopped,  its  distention  ceased,  and  its  surface  became 
shrivelled.  The  pulsatory  movement,  previously  per- 
ceptible in  it,  now  could  not  be  detected.  A daily  im- 
provement in  the  expression  of  the  countenance  fol- 
lowed. The  swelling  entirely  disappeared,  and  the 
cheek-bone  and  zygoma,  which  had  been  quite  con- 
cealed by  it,  again  became  evident.  At  the  end  of  two 
years  and  a half  from  the  operation,  there  had  been  no 
return  of  the  disease,  and  the  disfigurement  was  so 
trifling  that  it  was  scarcely  perceptible. — (See  A.  Burn's 
Surgical  Anatomy  of  the  Head  and  Neck,  p.  463,  ed.  2, 
with  additions  by  G.  S.  Pattisori,  Glasgow,  1824.)  In 
the  same  edition  the  efficacy  of  tying  the  carotid  for  the 
cure  of  fungous  diseases  of  the  antrum  is  proved  by 
several  interesting  cases.  This  is  a subject  which 
seems  to  me  to  demand  the  earnest  attention  of  surgi- 
cal practitioners. — Pref.] 

ANUS,  The  lower  termination  of  the  great  intes- 
tine named  the  rectum,  is  so  called,  and  its  office  is  to 
form  an  outlet  for  the  feces. 

The  anus  is  furnished  with  muscles  which  are  pecu- 
liar to  it,  viz.  the  sphincter,  which  keeps  it  habitually 
closed,  and  the  levatores  ani,  which  serve  to  draw  it 
up  into  its  natural  situation,  after  the  expulsion  of  the 
feces.  It  is  also  surrounded,  as  well  as  the  whole  of 
the  neighbouring  intestine,  with  muscular  fibres,  and 
a very  loose  sort  of  cellular  substance.  It  is  subject 
to  various  diseases,  in  which  the  aid  of  surgery  is  re- 
quisite : of  these  we  shall  next  treat. 

IMPERFORATE  ANUS. 

As  it  is  of  the  utmost  conseciuence  that  this  and 
other  malformations  should  not  remain  long  unknown. 


156 


ANUS. 


one  of  the  earliest  duties  of  an  accoucheur  after  deli- 
very should  be  an  examination  of  all  the  natural  out- 
lets of  new-born  infants. 

The  place  in  which  the  extremity  of  the  rectum,  or 
the  anus,  ought  to  be,  may  be  entirely  or  partly  shut 
up  by  a membrane  or  fleshy  adhesion.  In  other  in- 
stances, no  vestige  of  the  intestine  can  be  found,  as  the 
skin  retains  its  natural  colour  over  the  whole  space 
between  the  parts  of  generation  and  the  os  coccygis, 
without  being  more  elevated  in  one  place  than  another. 
In  these  cases,  the  intestine  sometimes  terminates  in 
one  or  two  culs-de-sac,  about  an  inch  upwards  from 
the  ordinary  situation  of  the  anus. — (See  Baillie’s  En- 
grravmgs,fasG.  4,  tab.  5.)  Sometimes  it  does  not  de- 
scend lower  than  the  upper  part  of  the  sacrum  ; some- 
times it  opens  into  the  bladder  or  vagina.  Dr.  Palmer 
dissected  a case  where  the  colon,  after  reaching  the 
vicinity  of  the  left  kidney,  began,  as  it  descended,  to 
form  a sigmoid  flexure ; but  previously  to  its  arrival  at 
the  concavity  of  the  left  ileum,  made  a sudden  turn  to 
the  right ; and  crossing  the  psoas  muscle,  reached  the 
projection  of  the  sacrum,  where  it  terminated,  without 
at  all  entering  the  pelvis.  With  this  malformation 
was  combined  an  imperforate  meatus  urinarius,  and 
other  considerable  deviations  of  the  genital  organs  from 
their  natural  structure. — (See  Medico-Chir.  Journ.  vol. 
1,  8vo.  Land.  1816.) 

Sometimes  the  colon  terminates  in  a sac,  and  the 
rectum  is  entirely  deficient. — (See  Beauregard,  in 
Joum.  de  M d.  1,  66.)  Instances  are  also  upon  record 
where  the  rectum  opened  into  the  urethra. — (Bresl. 
Samml.  1718,  p.  702 ; Hist,  de  PAcad.  Royale  des  Sci- 
ences, 1752,  p.  113;  Hochstetter,  in  Med.  Wochenhlatt, 
1780,  No.  18;  1783,  No.  10;  Kretschmar,  in  Horn's 
Archiv.  b.  I,  p.  350.) 

When  a surgeon  is  consulted  he  must  not  lose  much 
time  in  deliberation ; for  if  a speedy  opening  be  not 
made  for  the  feces,  the  infant  will  certainly  very  soon 
perish,  with  symptoms  similar  to  those  of  a strangu- 
lated hernia.  Mr.  C.  Hutchison  thinks  it,  however,  ad- 
vantageous not  to  operate  till  the  expiration  of  from 
twenty-four  to  sixty  hours  after  birth,  as  within  tliis 
period  no  great  inconvenience  will  arise,  and  the  dis- 
tention of  the  rectum  with  meconium  is  a guidance  to 
the  surgeon  in  making  the  incisions. — (See  Obs.  in 
Surgery,  ed.  2.)  After  ascertaining  the  complaint, 
which  is  an  easy  matter,  the  surgeon  should  endeavour 
to  learn  whether  the  anus  is  merely  shut  by  a mem- 
brane or  fleshy  adhesion,  or  whether  the  anus  is  alto- 
gether wanting,  in  consequence  of  the  lower  portion 
of  the  cavity  of  the  gut  being  obliterated  or  the  rectum 
not  extending  sufficiently  far  down. 

When  a membrane  or  production  of  the  skin  closes  the 
opening  of  the  rectum,  the  part  producing  the  obstruction 
is  somewhat  different  in  colour  from  the  neigbouring  in- 
teguments. It  is  usually  of  a purple  or  livid  hue,  in  con- 
sequence of  the  accumulation  of  the  meconium  on  its  in- 
ner surface.  The  meconium,  propelled  downwards  by 
the  viscera  above,  forms  a small  roundish  prominence, 
which  yields  like  dough  to  the  pressure  of  the  fingers  '; 
but  immediately  projects  again  when  the  pressure  is 
removed.  When  a fleshy  adhesion  closes  the  intes- 
itine,  the  circumstance  is  obvious  to  the  eye,  if  the  part 
protrude,  as  is  generally  the  case.  The  finger  feels 
gtreater  hardness  and  resistance  than  when  there  is  a 
mere  membrane,  and  the  livid  colour  of  the  meconium 
-cannot  be  seen  through  the  obstructing  substance. 

These  last  signs  alone  are  enough  to  convince  the 
surgeon  of  the  necessity  of  the  operation  ; but  they  do 
not  clearly  show  whether  the  intestine  descends  as  far 
as  it  ought  in  order  to  form  a proper  kind  of  anus. 
Complete  information  on  this  point  can  only  be  ac- 
quired after  the  membrane  or  adhesion  has  been  divided  ; 
or  else  after  the  child’s  death,  when  the  operation  has 
proved  ineffectual.  Though  there  be  no  mark  to  denote 
where  the  anus  ought  to  be  situated,  and  no  degree  of 
prominence,  yielding  like  soft  dough  to  the  pressure  of 
the  fingers,  and  rising  again  w'hen  such  pressure  is 
removed  ; yet  it  may  happen,  especially  on  our  being 
consulted  immediately  after  the  child  is  born,  that,  not- 
withstanding the  absence  of  such  symptoms,  denoting 
the  presence  of  the  meconium,  and  the  natural  extent 
of  the  intestine,  as  far  as  where  the  anus  ought  to  be, 
the  gut  may  exist  and  have  a cavity  as  far  as  the  mem- 
brane or  adhesion  closing  it. 

When  the  anus  is  simply  covered  with  skin,  and  its 
place  indicated  by  a prominence  arising  from  the  con- 


tents of  the  rectum,  we  have  only  to  make  an  opening 
with  a knife,  sufficient  to  let  out  the  meconium.  Lev- 
ret  recommends  a circular  incision  in  the  membrane; 
but  a transverse  one  is  sufficient.  A small  tent  of  lint 
is  afterward  to  be  introduced,  in  order  to  keep  the 
opening  from  closing.  If  the  anus  be  only  partly 
closed  by  a membrane,  the  opening  may  be  dilated  with 
tents  or  bougies ; but  if  the  aperture  be  very  small,  it 
is  preferable  to  use  the  bistoury  for  its  enlargement. 

When  no  external  appearance  denotes  where  the 
situation  of  the  anus  ought  to  be,  the  case  is  much 
more  serious  and  embarrassing  ; and  this,  whether  the 
intestine  be  stopped  up  by  a fleshy  adhesion  or  the 
coalescence  of  its  sides,  or  whether  a part  of  the  gut 
be  wanting. 

However,  it  is  the  surgeon’s  duty  to  do  every  thing 
in  his  j)ower  to  afford  relief.  For  this  purpose,  an  in- 
• cision  an  inch  long  or  rather  more  is  to  be  made  in  the 
situation  where  the  anus  ought  to  be,  and  the  wound 
is  to  be  carried  more  and  more  deeply  in  the  natural  di 
rection  of  the  rectum.  The  cuts  are  not  to  be  made 
directly  upwards,  nor  in  the  axis  of  the  pelvis,  for  the 
vagina  or  bladder  might  thus  be  wounded.  On  the 
contrary,  the  operator  should  cut  backwards,  along  the 
concavity  of  the  os  coccygis,  where  there  is  no  danger 
of  wounding  any  part  of  importance.  In  all  cases  of 
this  kind  the  surgeon’s  finger  is  the  best  director.  The 
operator,  guided  by  the  index  finger  of  his  left  hand, 
introduced  within  the  os  coccygis,  is  to  dissect  in  the 
direction  above  recommended,  until  he  reaches  the 
feces,  or  has  cut  as  far  as  he  can  reach  with  his  finger. 
If  he  should  fail  in  finding  the  meconium,  as  death 
must  unavoidably  follow,  one  more  attempt  ought  to 
be  made  by  introducing,  upon  the  finger,  a middle-sized 
trocar,  in  the  direction  best  calculated  to  reach  the 
rectum  without  danger  to  other  parts,  viz.  upwards  and 
backwards.  The  cannula  of  the  trocar  may  be  left 
in  the  puncture,  and  secured  there  by  tapes,  so  as  to 
afford  an  outlet  for  the  feces.  In  some  observations  on 
this  subject,  addressed  to  the  Medical  and  Chirurgical 
Society  by  Mr.  Copland  Hutchison,  he  recommends  an 
elastic  gum  catheter  to  be  substituted  for  the  cannula 
after  a week,  and  when  the  tube  can  be  dispensed  with, 
a sponge  tent  or  piece  of  bougie  to  be  w'orn  12  out  of 
the  24  hours. — (See  also  Obs.  in  Surgery,  ed.  2,  1826.) 

In  a very  interesting  case,  recorded  in  Langenbeck’s 
new  Surgical  Bibliotheca,  the  imperforate  state  of  (he 
anus  was  not  discovered  till  the  evening  of  the  12th 
day  from  the  child’s  birth,  when  hiccough  and  convul- 
sions had  come  on.  M.  Wolff  found  the  abdomen  pro- 
tuberant, hard,  and  painful  when  handled,  and  nausea, 
vomiting,  and  great  depression  of  strength  prevailed. 
Next  day,  he  introduced  a large  lancet  a few  lines  in 
front  of  the  os  coccygis  to  the  depth  of  an  inch  without 
finding  the  rectum.  The  puncture  was  then  carried  to 
the  depth  of  two  inches,  but  without  effect.  With  a 
pharyngotomus,  however,  he  now  succeeded  in  piercing 
the  rectum ; and  a glyster  was  administered,  which 
brought  away  some  meconium.  Under  the  use  of 
glysters  and  tents  the  child  soon  recovered. 

By  such  proceedings  many  infants  have  been  pre- 
served, which  would  otherwise  have  been  devoted  to 
certain  death.  Hildanus,  La  Motte,  Roonhuysen,  Mr. 
Copland  Hutchison,  and  others  have  successfully 
adopted  the  practice.  Mr.  B.  Bell  met  with  two  cases, 
in  which  the  intestine  was  very  distant  from  the  inte- 
guments, and  he  was  so  successful  as  to  form  an  anus, 
which  fulfilled  its  office  tolerably  well^  for  several  years ; 
but  he  found  it  exceedingly  difficult  to  keep  the  passage 
sufficiently  pervious.  As  soon  as  he  removed  the  dos- 
sils of  lint,  and  other  kinds  of  tents,  used  for  maintain- 
ing the  necessary  dilatation,  such  a degree  of  contrac- 
tion speedily  followed,  that  the  evacuation  of  the  intesti- 
nal matter  became  very  difficult  for  a long  while  after- 
ward. He  employed,  at  different  times,  tents  made  of 
sponge,  gentian  root,  and  other  substances,  which 
swell  on  being  moistened  But  they  always  produced 
so  much  pain  and  irritation  that  it  was  impossible  to 
persevere  m their  use. 

Tents  of  very  soft  lint,  dipped  in  oil,  or  rolls  of 
bougie-plaster,  cause  less  irritation  than  those  com- 
posed of  any  other  materials. 

Though  keeping  the  opening  dilated  may  seem  sim- 
ple and  easy  to  such  men  as  have  had  no  opportunities 
of  seeing  cases  of  this  description,  it  is  far  otherwise 
in  practice.  Mr.  B.  Bell  assures  us,  that  he  never  met 
with  any  disease  that  gave  him  so  much  trouble  aud 


ANUS. 


157 


enibarrassTTient  as  he  experienced  in  the  two  cases  of 
this  sort  which  occurred  in  his  practice.  Although  in 
both  instances  he  made  the  openings  at  first  sulRciently 
large,  it  was  only  by  very  a.ssiduous  attention  for  eight 
or  ten  months,  that  the  necessity  for  another  operation, 
and  even  repeated  d\ierations,  was  prevented.  When 
only  the  skin  has  been  divided,  the  rest  of  the  treatment 
is  doubtless  more  simple  ; for  then  nothing  more  is 
requisite  than  keeping  a piece  of  lint  for  a few  days  in 
the  opening  made  with  the  knife.  But  when  the  ex- 
tremity of  the  rectum  is  at  a certain  distance,  though 
we  may  generally  hope  to  effect  a cure,  after  having 
succeeded  in  giving  vent  to  the  intestinal  matter,  yet 
the  treatment  after  the  operation  will  always  demand 
for  a long  while  a great  deal  of  attention  and  care  on 
the  part  of  the  surgeon.  In  a highly  interesting  ex- 
ample, recorded  by  Mr.  Miller,  of  Methven,  such  was 
the  tendency  to  closure  of  the  new  opening,  that  he 
was  obliged  to  repeat  the  operation  ten  times  before 
the  child  was  eight  months  old. — (See  Edin.  Med. 
Journ.  No.  98,  p.  62.)  Notwithstanding  all  these  ope- 
rations. and  another  one  of  two  hours  and  three-quar- 
ters’ duration,  performed  several  years  afterward  for 
the  extraction  of  an  alvine  concretion  equal  in  size  to  a 
turkey’s  egg,  the  power  of  the  sphincter  was  perfect. 
The  difficulty  of  succe.ss  may  be  considered  as  in  some 
measure  proportioned  to  the  depth  of  the  necessary 
incision.  In  a case  like  that  recorded  by  Dr.  Palmer, 
to  which  I have  above  adverted,  the  inutility  of  any 
attempt  to  discharge  the  feces  by  an  operation  in  the 
usual  site  of  the  anus  must  be  sufficiently  obvious. — 
{Medico-Chir.  Journ.  vol.  I,;?.  181.) 

Sometimes,  while  the  anus  appears  pervious  and 
well  formed,  infants  suffer  the  same  symptoms  as  if 
there  were  no  anus  at  all.  The  reason  of  this  depends 
upon  the  intestine  being  occasionally  closed  by  a mem- 
branous partition  situated  more  or  less  upwards,  above 
the  aperture  of  the  antis  (Courtial,  Nouvelles  Obs.  sur 
les  Os,  p.  147 ; John  Wayte,  in  Edin.  Med.  and  Sur- 
ical  Joum.  April,  1821 ; and  Cases  in  Hutchison's 
Obs.  in  Surgery,  ed.  2),  and  sometimes  the  symp- 
toms are  owing  to  the  termination  of  the  gut  in  a cul- 
de-sac.  This  erroneous  formation  may  always  be  sus- 
pected when  an  infant,  whose  anus  is  externally 
open,  does  not  void  any  excrement  for  two  or  three  days 
after  its  birth,  and  especially  when  urgent  symptoms 
arise,  such  as  swelling  of  the  belly,  vomiting,  &c. 
We  are  now  to  endeavour  to  ascertain  whether  the 
rectum  is  impervious  above  the  anus,  by  attempting  to 
inject  glysters  or  to  introduce  a probe.  If  the  gut  be 
shut  up  there  is  nothing  to  be  done  but  having  recourse 
to  the  method  described  above,  and  forming  a commu- 
nication by  means  of  a bistoury  guided' on  the  finger, 
or  else  with  a pharyingotornus.  If  the  obstacle  should 
only  consist  of  a transverse  membrane,  the  operation 
will  be  easy  and  its  success  highly  probable.  But  if 
there  should  be  a strangulation  or  obstruction  of  the 
intestine,  the  case  is  infinitely  more  serious. 

In  the  case  recorded  by  Mr.  Wayte,  the  membranous 
septum  was  felt  by  the  finger  about  an  inch  from  the 
verge  of  the  anus.  It  w^as  pierced  with  a pointed  probe 
which  was  followed  by  a hydrocele  trocar,  and  after- 
ward by  a bougie  of  larger  dimensions.  On  with- 
drawing the  latter,  much  mecoiiium,  mixed  with  feces, 
escaped  and  continued  to  be  frequently  discharged. 
In  a week,  however,  the  opening  closed,  and  a fresh 
puncture  was  made,  which  was  maintained  by  the  fre- 
quent introduction  of  bougies.  The  child  proceeded 
tolerably  well  until  the  end  of  another  week,  when  the 
passage  was  again  much  contracted  and  the  abdomen 
jjropovtionably  distended.  On  the  20th  day  from  birth, 
a full-sized  trocar  was  used  for  restoring  the  opening, 
which,  however,  again  had  a tendency  to  close,  but 
was  afterward  dilated  by  introducing  twice  a day 
bougies,  which  were  increased  in  size  until  a rectum 
bougie  of  middle  size  could  be  passed.  The  boy  now 
rapidly  im))roved,  and  every  hope  of  a perfect  recovery 
was  entertained,  but  disease  of  the  os  coccygis  ensued, 
and  at  the  end  of  six  months  the  little  patient  died 
hectic. — (See  Edin.  Med.  and  Surg.  Joum.  vol.  17.) 

When  the  anus  is  imperforate,  the  intestine  some- 
times opens  into  the  vagina  or  bladder.— (DnTna-s,  in 
Rectieil  Piriodique  de  la  Soc.  de  MM.  t.  3,  No.  13. 
L'Eveille,  Rapport  des  Travavx  de  la  Soc.  Philom.  vol. 
1,  p.  145.  Murray,  Diss.  Atresis  Ani  ve.sicalis,  Ups. 
1794.  Act.  Nat.  Cur.  vol.  8,  Ob.s.  24,  vol.  9,  Obs.  11. 
Rocstcl,  ill  Mursinnu's  Journ.  fir  die  Chir.  b.  I,  v 


547.  Obs.  Med.  Decad.  2,  No.  2.)  The  first  case  is  tlio 
least  dangerous  of  such  malformations.  The  intestine 
may  also  terminate  at  two  places  at  the  same  time, 
viz.  at  the  usual  place,  so  as  to  form  a proper  anus 
more  or  less  perfect ; and  also  in  the  vagina. 

If  these  two  openings  should  be  ample  enough  for 
the  easy  evacuation  of  the  excrement.,  nothing  can  be 
done  at  so  tender  an  age  ; for  though  voiding  the  feces 
through  the  vagina  is  a most  unpleasant  inconvenience, 
yet  there  is  no  effectual  means  of  closing  the  opening 
of  the  intestine  in  this  situation,  nor  could  one  be  de- 
vised which  would  not  seriously  incommode  the  infant. 

But  when  the  two  openings  are  exceedingly  small, 
and  the  alvine  evacuations  cannot  readily  pass  out, 
even  with  the  aid  of  glysters,  the  opening  of  the  anus 
ought  to  be  dilated  by  cannulae  of  different  sizes.  If 
this  method  should  not  avail,  the  knife  must  be  em- 
ployed, and  the  wound  dressed  as  already  explained. 

For  the  most  part  the  intestine  has  only  one  opening 
in  the  vagina.  In  this  circumstance,  as  in  the  instance 
in  which  the  feces  have  no  vent  at  all,  we  must  make 
an  incision  in  that  place  which  the  anus  ought  to  oc- 
cupy. The  natural  course  of  the  feces  being  opened 
by  tills  operation,  which  in  such  a case  is  not  at  all  pe- 
rilous, much  less  excrement  will  pass  out  of  the  vagina, 
and  of  course  the  infirmity  will  be  diminished.  By  the 
introduction  of  a tube  into  the  new  anus,  the  communi- 
cation between  the  rectum  and  vagina  might  possibly 
be  obliterated,  and  a perfect  cure  accomplished.  The 
opening  between  the  intestine  and  vagina  may  also  be 
too  small  for  the  easy  evacuation  of  the  feces,  and 
even  expose  the  infant  to  the  same  sort  of  dangerous 
symiitoms  as  would  occur  if  the  rectum  had  no  open- 
ing at  all. 

In  male  infants  the  rectum  sometimes  opens  into  the 
bladder,  and  in  this  circumstance  there  is  generally  no 
anus.  The  case  is  easily  known  by  the  meconium 
being  blended  with  the  urine,  which  acquires  a thick 
greenish  appearance,  and  is  voided  almost  continually 
though  in  small  quantities.  Only  the  most  fluid  part 
of  the  meconium  is  thus  discharged.  The  thicker  part 
not  getting  from  the  rectum  into  the  bladder,  nor  from 
the  bladder  into  the  urethra,  greatly  distends  the  intes- 
tines and  bladder,  and  produces  the  same  symptoms  as 
take  place  in  cases  of  total  imperforation.  Hence, 
without  the  speedy  interference  of  art  to  form  an  anus 
capable  of  giving  vent  to  the  feces,  with  which  the 
urinary  organs  cannot  remain  obstructed,  the  infant 
will  inevitably  die.  This  case  must,  therefore,  be 
treated  like  the  foregoing  examples.  Though  we  can 
hardly  hope  to  prevent  altogether  the  inconveniences 
resulting  from  the  rectum  opening  into  the  bladder* 
since  even  a new  passage  will  not  completely  hinder 
the  feces  from  following  the  other  course;  yet  we 
shall  thus  afford  the  child  a very  good  chance  of  pre- 
servation, and  the  only  one  which  its  situation  will 
allow. 

In  cases  in  which  an  outlet  for  the  feces  cannot  be 
procured  by  any  of  the  methods  pointed  out  above* 
it  has  been  proposed  by  Littre  to  make  an  opening 
above  one  of  the  groins,  find  out  a portion  of  intestine* 
open  it,  fix  it  in  this  situation  with  a few  stitches,  and 
thus  form  an  artificial  anus.  Sabatier  was  only  ac- 
quainted with  one  case  in  which  this  proceeding  had 
been  actually  done,  viz.  the  example  where  Duret,  a 
French  naval  surgeon,  operated.  This  gentleman  cut 
into  the  abdomen  at  the  lower  part  of  the  left  iliac  re- 
gion, and  having  opened  the  sigmoid  flexion  of  the 
colon,  he  fixed  it  near  the  wound.  The  child  was  saved 
by  the  formation  of  an  artificial  anus ; but  at  the  age 
of  twenty-five  months  it  continued  to  be  troubled  with 
a sort  of  prolapsus  of  the  lining  of  the  bowel.— (See 
Recueil  Piriodique  de  la  Soc.  de  Med.  t.  4,  No.  19 ; and 
Sabatier.  Med.  Operatoire,  t.  3,  p.  336,  edit.  2.) 

An  instance  has  been  published  by  Mr.  Pring,  in 
which  he  made  an  opening  in  the  colon,  near  its  sig- 
moid flexure,  in  a lady,  who,  in  consequence  of  a scir- 
rhous disease  of  the  rectum,  was  afflicted  with  an  ob- 
stinate and  perilous  obstniction  of  the  intest!n'_.  canal. 
The  patient  survived  the  operation  nearly  sixteen 
months,  at  the  end  of  which  time  she  fell  a victim  to 
the  disease  of  the  rectum. — (See  London  Medical  and 
Physical  Journal,  vols.  45  and  47.)  I should  be  reluc- 
tant to  offer  any  remarks  encouraging  the  repetition  of 
this  practice,  against  which  various  considerations  pre- 
sent themselves,  particularly  in  cases  where,  besides 
a mere  difficultj  of  empLy'ng  the  bowels,  another  dis- 


158 


ANUS. 


ease  exists,  which  is  itself  likely  to  destroy  the  patient, 
and  is  of  a nature  not  capable  of  receiving  any  effect- 
ual benefit  from  the  bold  operation  practised  in  the  ex- 
ample related  by  Mr.  Pring. 

Oallisen  conceives  that  the  descending  colon  maybe 
most  conveniently  got  at  by  making  an  incision  in  the 
left  lumbar  region  along  the  edge  of  the  quadratus 
lumborum  muscle  ; and  he  prefers  this  mode  of  ope- 
rating to  that  of  making  the  incision  above  the  groin.— 
( Syst.  Chir.  Hodierrus,  t.  2,  p.  688,  689,  ed.  1800.)  Its 
advantages,  however,  are  not  obvious.— (See  Sabatier, 
Medccine  Operatoire,  t.  3,  p.  330.  PapperuioTj,  deAno 
infantum  imperforato,  Leipz.  1783.  Remarques  sur 
Differens  Vices  de  Conformation  que  les  Enfans  ap- 
portent  en  naissant,  par  M.  Petit,  in  Mim.  de  VAcad. 
Royale  de  Chir.  t.  2,  p.  236,  edit,  in  12mo.  H.  A. 
Wrisberg,  de  praiternaturali  et  raro  Intestini  Recti 
cum  vesica  urinaria  coalitu,  et  independente  Ani  de- 
fectu,  ito.  Gbtt.  1779.  Ford,  in  Med.  Facts  arid  Obs. 
vol.  1,  No.  10.  Chamberlaine,  in  Memoirs  of  the  Med. 
Soc.  of  Land.  vol.  5,  No.  23.  Richerand,  Nosographie 
Chir.  t.  3,  p.  437,  iVc.  ^dit.  4.  G.  Wayte,  in  Edin.  Med. 
Joum.  vol.  17.  Lancet,  vol.  1,  p.  434.  A.  C.  Hutchi- 
son, in  Pract.  Obs.  in  Surgery,  ed.  2,  1826.  Miller,  in 
Edin.  Med.  Joum.  No.  ^8,  p.  61.  Jolliet,  in  Journ.  de 
Mid.  par  Leroux,  t.  32,  p.  272.) 

ABSCESSES  OF  THE  ANUS. — FISTULA  IN  ANO. 

The  custom  of  giving  the  appellation  of  fistula  to 
every  collection  of  matter  formed  near  the  anus,  has, 
by  conveying  a false  notion  of  them,  been  productive 
of  such  methods  of  treating  them,  as  are  diametrically 
opjxisite  to  those  which  ought  to  be  pursued. 

A small  orifice  or  outlet  from  a large  or  deep  cavity, 
discharging  a thin  gleet  or  sanies,  made,  as  Mr.  Pott 
has  explained,  a considerable  part  of  the  idea  which 
our  ancestors  had  of  a fist'ilous  sore,  wherever  sealed. 
With  the  term  fistulous  they  always  connected  a no- 
tion of  callosity ; and  therefore,  whenever  they  found 
such  a kind  of  opening  yielding  such  sort  of  discharge, 
and  attended  with  any  degree  of  induration,  they  called 
the  complaint  a Jistiila.  Imagining  this  callosity  to  be 
a diseased  alteration  made  in  the  ver>'  structure  of  the 
parts,  they  had  no  conception  that  it  could  be  cured  by 
any  means  but  by  removal  with  a cutting  instrument, 
or  by  destruction  with  escharotics ; and  therefore  they 
immediately  attacked  it  with  knife  or  caustic,  in  order 
to  accomplish  one  of  these  ends;  and  very  terrible 
work  they  often  made. 

That  abscesses  formed  near  the  fundament  do  some- 
times, from  bad  habits,  from  extreme  neglect,  or  from 
gross  mistreatment,  become  fistulotis,  is  certain  ; but 
the  majority  of  them  have  not  at  first  any  one  charac- 
ter or  mark  of  a true  fistula ; nor  can,  without  the  most 
supine  neglect  on  the  side  of  the  patient,  or  the  most 
ignorant  management  on  the  part  of  the  surgeon,  de- 
generate or  be  converted  into  one. 

Collections  of  matter  from  inflammation  (wherever 
formed),  if  they  be  not  opened  in  time  and  in  a pro- 
per manner,  do  often  burst.  The  hole  through  which 
the  matter  finds  vent  is  generally  small,  and  not  often 
situated  in  the  most  convenient  or  most  dependent  part 
of  the  tumour : it  therefore  is  unfit  for  the  discharge 
of  all  the  contents  of  the  abscess  ; and  instead  of  clos- 
ing contracts  itself  lo  a smaller  size,  and  becoming 
hard  at  its  edges,  continues  to  drain  off  what  is  fur- 
nished by  the  undigested  sides  of  the  cavity. 

When  an  abscess  near  the  anus  bursts,  the  small- 
ness of  the  accidental  orifice  ; the  hardness  of  its  edges ; 
its  being  found  to  be  the  outlet  from  a deep  cavity  ; the 
daily  discharge  of  a thin,  gleety,  discoloured  kind  of 
matter ; and  the  induration  of  the  parts  round  about, 
have  all  contributed  to  raise  and  confirm  the  idea  of  a 
true  fistula. 

Abscesses  about  the  anus  present  themselves  In  dif- 
ferent forms. 

Sometimes  the  attack  is  made  with  sj-mptoms  of 
high  inflammation ; with  pain,  fever,  rigor,  &c.,  and 
the  fever  ends  as  soon  as  the  abscess  is  formed. 

In  this  case  a part  of  the  buttock  near  the  anus  is 
considerably  swollen,  and  has  a large  circumscribed 
hardness.  In  a short  time  the  middle  of  this  hardness 
becomes  red  and  inflamed ; and  in  the  centre  of  it  mat- 
ter is  formed. 

This  (in  the  language  of  our  ancestors)  is  called  in 
general  a phlegmon;  but  when  it  appears  in  tliis  parti- 
cular part,  a phyma. 


' The  pain  is  sometimes  great,  the  ftever  hlghj  the  tu- 
mour large  and  exquisitely  tender;  but  however  dis- 
agreeable the  appearances  may  have  been,  or  however 
high  the  symptoms  may  have  risen  before  suppuration, 
yet  when  that  end  is  fairly  and  fully  accom.plished,  the 
patient  generally  becomes  easy  and  cool ; and  the  mat- 
ter formed  under  such  circumstances,  though  it  may 
be  plentiful,  is  good. 

On  the  other  hand,  the  external  parts,  after  much 
pain,  attended  with  fever,  sickness,  »fec.,  are  sometimes 
attacked  with  considerable  inflammation,  but  without 
any  of  that  circumscribed  hardness  which  character- 
ized the  preceding  tumour ; instead  of  which  the  in- 
flammation is  extended  largely,  and  the  skin  wears  an 
erysipelatous  kind  of  appearance.  In  this  the  disease 
is  more  superficial ; the  quantity  of  matter  small,  and 
the  cellular  membrane  sloughy  to  a considerable  extent. 

Sometimes  instead  of  either  of  the  preceding  ap- 
pearances, there  is  formed  in  this  part  what  the  French 
call  une  suppuration  gangreneuse ; in  which  the  cel- 
lular and  adipose  membrane  is  affected  in  the  same 
manner  as  it  is  in  a carbuncle. 

In  this  case,  the  skin  is  of  a dusky  red  or  purple 
kind  of  colour ; and  although  harder  than  when  in  a 
natural  state,  yet  it  has,  by  no  means,  that  degree  of 
tension  or  resistance,  which  it  has  either  in  phlegmon 
or  in  ery  sipelas. 

The  patient  has  generally,  at  first,  a hard,  full,  jar- 
ring pulse,  with  great  thirst,  and  very  fatiguing  rest- 
lessness. If  the  progress  of  the  disease  be  not  stopped, 
or  the  patient  relieved  by  medicine,  the  pulse  soon 
changes  into  an  unequal,  low,  faltering  one ; and 
the  strength  and  the  spirits  sink  in  such  manner,  as  to 
imply  great  and  immediately  impending  mischief.  The 
matter  formed  under  the  skin,  so  altered,  is  small  in 
quantity,  and  bad  in  quality ; and  the  adipose  mem- 
brane is  gangrenous  and  sloughy  throughout  the  ex- 
tent of  the  discoloration.  This  generally  happens  to 
persons,  whose  habit  is  either  natunilly  bad,  or  has 
been  rendered  so  by  intemperance. 

Sometimes  the  disease  makes  its  first  appearance 
in  the  induration  of  the  skin,  near  to  the  verge  of  the 
anus,  but  without  pain  or  alteration  of  colour;  which 
hardness  gradually  softens  and  suppurates.  The  mat- 
ter, when  let  out,  in  this  case,  is  small  in  quantity, 
good  in  quality ; and  the  sore  is  superficial,  clean,  and 
well-conditioned.  On  the  contrary,  it  now  and  then 
happens,  that  although  the  pain  is  but  little,  and  the 
inflammation  apparently  slight,  yet  the  matter  is  large 
in  quantity,  bad  in  quality,  extremely  offensive,  and 
proceeds  from  a deep  crude  hollow. 

The  place  also  where  the  abscess  points,  and  where 
the  matter,  if  let  alone,  would  burst  its  way  out,  is 
various  and  uncertain.  Sometimes  it  is  in  the  buttock, 
at  a distance  from,  the  anus ; at  other  times,  near  its 
verge,  or  in  the  perinaeum ; and  this  discharge  is  made 
sometimes  from  one  orifice  only,  sometimes  from  seve- 
ral. In  some  cases  there  is  not  only  an  opening 
through  the  skin  externally,  but  another  through  the 
intestines  into  its  cavity  : in  others,  there  is  only  one 
orifice,  and  that  either  external  or  internal. 

Sometimes  the  matter  is  formed  at  a considerable 
distance  from  the  rectum,  which  is  not  even  laid  bare 
by  it ; at  others,  it  is  laid  bare  also,  and  not  perforated : 
it  is  also  sometimes  not  only  denuded,  but  pierced ; 
and  that  in  more  places  than  one 

All  consideration  of  preventing  .suppuration  is  ge- 
nerally out  of  the  question  : and  our  business,  if  called 
at  the  beginning,  must  be  to  moderate  the  symptoms ; 
to  forward  the  suppuration  ; when  the  matter  is  formed, 
to  let  it  out ; and  to  treat  the  sore  in  such  manner  as 
shall  be  most  likely  to  produce  a speedy  and  lasting 
cure. 

When  there  are  no  symptoms  which  require  particu- 
lar attention,  and  all  that  we  have  to  do  is  to  assist  the 
maturation  of  the  tumour,  a soft  poultice  is  the  best 
application.  When  the  disease  is  fairly  of  the  phlegmo- 
noid  kind,  the  thinner  the  skin  is  suffered  to  be- 
come before  the  abscess  is  opened,  the  better;  as  the 
induration  of  the  parts  about  will  thereby  be  the  more 
dissolved,  and,  consequently,  there  will  be  the  less  to 
do  after  such  opening  has  been  made.  This  kind  of 
tumour  is  generally  found  in  people  of  full,  sanguine 
habits;  and  who,  therefore,  if  the  pain  he  great,  and 
the  fever  high,  will  bear  evacuation,  both  by  phlebo- 
tomy and  g ntle  cathartics ; which  is  not  often  the 
case  of  those,  who  are  said  to  be  of  bilious  constitu- 


ANUS. 


159 


lions ; in  \Vhom  the  luflammation  is  of  a larger  ex- 
tent, and  in  whom  the  skin  wears  the  yellowish  lint 
of  the  erysipelas ; persons  of  this  kind  of  habit,  and 
in  such  circumstances,  being  in  general  seldom  capa- 
ble of  bearing  large  evacuation. 

Wh.eri  the  inflammation  is  erysipelatous,  the  quan- 
tity of  matter  formed  is  small,  compared  with  the  size 
and  extent  of  the  tumour;  the  disease  is  rather  a 
sloughy,  putrid  state  of  the  cellular  membrane  than  an 
imposthumation  ; and,  therefore,  the  sooner  it  is  opened 
the  belter:  if  we  wait  for  the  matter  lo  make  a point, 
we  shall  wait  for  what  will  not  happen  ; at  least,  not 
till  after  a considerable  length  of  time  : during  which 
the  disease  in  the  membrane  will  extend  itself,  and, 
consequently,  the  cavity  of  the  sinus  or  abscess  be 
thereby  greatly  increased. 

When,  instead  of  either  of  the  preceding  appearances, 
the  skin  wears  a dusky  purplish-red  colour ; has  a doughy 
unresisting  kind  of  feel,  and  very  little  sensibility ; 
when  these  circumstances  are  jouied  with  an  unequal, 
faltering  kind  of  pulse,  irregular  shiverings,  a great 
failure  of  strength  and  spirits,  and  inclination  to  doze, 
the  case  is  formidable,  and  the  event  generally  fatal. 

The  habit,  in  these  circumstances,  is  always  bad ; 
sometimes  from  nature,  but  much  more  frequently  from 
gluttony  and  intemperance.  What  assistance  art  can 
lend  must  be  administered  speedily ; every  minute  is 
of  consequence ; and  if  the  disease  be  not  stopped,  the 
patient  will  sink.  Here  (says  Pott)  is  no  need  for 
evacuation  of  any  kind ; recourse  must  be  immedi- 
ately had  to  medical  assistance;  the  part  affected 
should  be  frequently  fomented  with  hot  .spirituous  fo- 
mentations ; a large  and  deep  incision  should  be  made 
into  the  diseased  part,  and  the  application  made  to  it 
should  be  of  the  warmest,  most  antiseptic  kind. 

This  also  is  a general  kind  of  observation,  and 
equally  applicable  to  the  same  sort  of  disease  in  any 
part  of  the  body.  Our  ancestors  have  thought  fit  to 
call  it  in  some  a carbuncle,  and  in  others  by  other 
names  : but  it  is  (wherever  seated)  really  and  truly  a 
gangrene  of  the  cellular  and  adipose  membrane : it  al- 
ways implies  great  degeneracy  of  habit,  and,  most 
commonly,  ends  ill. 

Strangury,  dysury,  and  even  total  retention  of 
the  urine  are  no  very  uncommon  attendants  upon  ab- 
scesses in  the  neighbourhood  of  the  rectum  and  blad- 
der : more  especially  if  the  seat  of  them  be  near  the 
neck  of  the  latter. 

■ They  sometimes  continue  from  the  first  attack  of 
the  inflammation,  until  the  matter  is  formed,  and  has 
made  its  way  outwards ; and  sometimes  last  a few 
hours  only. 

The  two  former  most  commonly  are  easily  relieved 
by  the  loss  of  blood,  and  the  use  of  gum  arabic,  with 
nitre,  &c.  But  in  the  last  (the  total  retention),  they 
who  have  not  often  seen  this  case,  generally  have  im- 
mediate recourse  to  the  catheter  : but  the  practice  is  es- 
sentially wrong. 

7’he  neck  of  the  bladder  does  certainly  participate, 
m some  degree,  in  the  said  inflammation.  But  the 
principal  part  of  the  complaint  arises  from  irritation, 
and  the  disease  is,  strictly  speaking,  spasmodic.  The 
manner  in  which  an  attack  of  this  kind  is  generally 
made  ; the  very  little  distention  which  the  bladder  of- 
ten suffers;  the  small  quantity  of  urine  sometimes 
contained  in  it,  even  when  the  symptoms  are  most 
pressing ; and  the  most  certain  as  well  as  safe  me- 
thod of  relieving  it ; all  tend  to  strengthen  such  opi- 
nion. 

But  whether  we  attribute  the  evil  to  inflammation 
or  to  spasmodic  irritation,  whatever  can,  in  any  de- 
gree, contribute  to  the  exasperation  of  either,  must  be 
manifestly  wrong.  The  violent  passage  of  the  cathe- 
ter through  the  neck  of  the  bladder  (for  violent  in  such 
circumstances  it  must  be)  can  never  be  right. 

If  the  instrument  be  successfully  introduced,  it  must 
either  be  withdrawn  as  soon  as  the  bladder  is  emptied, 
or  it  must  be  left  in  it : if  the  former  be  done,  the  same 
cause  of  retention  remaining,  the  same  effect  returns; 
the  same  pain  and  violence  must  again  be  submitted  to, 
under  (most  likely)  increased  difficulties.  On  the  other 
hand,  if  the  catheter  be  left  in  the  bladder,  it  will  often, 
while  its  neck  is  in  this  state,  occasion  such  disturb- 
ance that  the  remedy  (as  it  is  called)  will  prove  an 
exasperation  of  the  disease,  and  add  to  the  evil  it  is  de- 
signed to  alleviate.  Nor  is  this  all  ; for  the  resistance 
wluch  the  parts  while  in  this  stale  make,  is  sometimes 


so  great  that  if  any  violence  be  used,  the  instrument 
will  make  for  itself  a new  route  in  the  neighbouring 
parts,  and  lay  the  foundation  of  such  mischief  as  fre- 
quently baffles  all  our  art. 

The  true,  safe,  and  rational  method  of  relieving  this 
complaint  (says  Pott)  is  by  evacuation  and  anodyne 
relaxation  : this  not  only  procures  immediate  ease,  but 
does,  at  the  same  time,  serve  another  very  material  pur- 
pose ; which  is  that  of  maturating  the  abscess.  Loss 
of  blood  is  necessary ; the  quantity  to  be  determined 
by  the  strength  and  state  of  the  patient : the  intestines 
should  also  be  emptied,  if  there  be  time  for  so  doing,  by 
a gentle  cathartic  ; but  the  most  effectual  relief  will  be 
from  the  warm  bath  or  semicupium,  the  application 
of  bladders  with  hot  water  to  the  pubes  and  perinaeum, 
and,  above  all  other  remedies,  the  injection  of  glysters, 
consisting  of  warm  water,  oil,  and  opium.  There  may 
have  been  cases  which  have  resisted  and  baffled  this 
method  of  treatment ; but  Pott  never  met  with  them. 

A painful  tenesmus  is  no  uncommon  attendant  upon 
an  inflammation  of  the  parts  about  the  rectum. 

If  a dose  of  rhubarb,  joined  with  the  confect,  opii, 
does  not  remove  it,  the  injection  of  thin  starch  and 
opium  or  linct.  thebaic,  is  almost  infallible. 

The  bearing  down  in  females,  as  it  proceeds,  in  this 
case,  from  the  same  kind  of  cause  (viz.  irritation),  ad- 
mits of  relief  from  the  same  means  as  the  tenesmus. 

In  some  habits,  an  obstinate  costiveness  attends  this 
kind  of  inflammation,  accompanied,  not  unfrequently, 
with  a painful  distention  and  enlargement  of  the  he- 
morrhoidal vessels,  both  internally  and  externally 
While  a large  quantity  of  hard  feces  is  detained  within 
the  large  intestines,  the  whole  habit  must  be  disor- 
dered ; and  the  symptomatic  fever  which  necessarily 
accompanies  the  formation  of  matter,  must  be  consi- 
siderably  heightened.  And  while  the  vessels  surround- 
ing the  rectum  (w'hich  are  large  and  numerous)  are 
distended,  all  the  ills  proceeding  from  pressure,  in- 
flammation, and  irritation  must  be  increased.  Phle- 
botomy, laxative  glysters,  and  a low,  cool  regimen 
must  be  the  remedies  : while  a soft  cataplasm  applied 
externally  serves  to  relax  and  mollify  the  swollen,  in- 
durated piles,  at  the  same  time  that  it  hastens  the  sup- 
puration. 

When  the  abscesses  have  formed,  and  are  fit  to  be 
opened,  or  when  they  have  already  burst,  they  may 
be  reduced  to  two  general  heads,  viz. 

1.  Those  in  which  the  intestine  is  not  all  interested : 
and, 

2.  Those  in  which  it  is  either  laid  bare  or  perfo- 
rated. 

In  making  the  opening,  the  knife  or  lancet  should  be 
passed  in  deep  enough  to  reach  the  fluid ; and  when  it 
is  in  the  incision  should  be  continued  upwards  and 
downwards  in  such  manner  as  to  divide  all  the  skin  co- 
vering the  matter.  By  these  means,  the  contents  of 
the  abscess  will  be  discharged  at  once ; future  lodge- 
ment of  matter  will  be  prevented ; convenient  room 
will  be  made  for  the  application  of  proper  dressings ; 
and  there  will  be  no  necessity  for  making  the  incision 
in  different  directions,  or  for  removing  any  part  of  the 
skin  composing  the  verge  of  the  anus. 

Notwithstanding  all  these  collections  of  matter  are 
generally  called  JistulcB,  and  are  all  supposed  to  affect 
the  rectum,  the  abscess  is  sometimes  really  at  such  a 
distance  from  the  gut,  that  it  is  not  at  all  interested 
by  it ; and  none  of  these  cases  either  are  or  can  be 
originally  JistulcB. 

In  this  state  of  the  disease,  w’c  have  no  more  neces- 
sarily to  do  with  the  intestine  than  if  it  were  not 
there  ; the  case  is  to  be  considered  merely  as  an  ab- 
scess in  the  cellular  membrane. 

A short  time  ago,  some  interesting  remarks  on  fis- 
tula in  ano  were  published  in  France  by  Hr.  Ribes, 
whose  opinions,  however,  like  those  of  many  other 
valuable  writers,  are  not  invariably  free  from  error ; 
and  I have  no  hesitation  in  extending  this  observation 
to  one  of  his  statements,  though  what  he  has  said  is 
alleged  to  be  deduced  from  the  dissection  of  not  less 
than  75  persons  who  had  died  with  fistulae.  No  man 
who  has  seen  much  of  this  part  of  surgery,  can  doubt 
that  the  most  frequent  form  of  the  di.sease  is  that 
in  which  the  abscess  has  only  an  external  opening, 
and  does  not  perforate  the  rectum  at  all,  from  which, 
indeed,  the  matter  is  sometimes  more  or  less  distant. 
Nor  can  any  experienced  surgeon  question  the  truth 
of  Mr.  I’ott’s  account  resitecUng  the  diversity  of  the 


160 


ANUS. 


nature  of  the  cases  of  fistui®,  some  being  phlegmo- 
nous, some  erysipelatous,  and  others  more  like  the 
carbuncle  in  their  origin,  progress,  and  consequences. 
But  besides  these  circumstances,  another  one  \vorth5' 
of  notice  is,  that  the  presence  of  fistula  in  ano  by  no 
means  implies  the  previous  or  present  existence  of 
piles.  However,  notwithstanding  these  considera- 
tions, the  doctrine  started  by  Dr.  Ribes  is,  that  a fis- 
tula is  formed  by  the  bursting  of  an  internal  pile  into 
the  rectum,  and  the  consequent  passage  of  a portion 
of  the  contents  of  the  bowel  into  the  orifice.  He  far- 
ther asserts  that  such  orifice  is  always  within  five  or 
six  lines  above  the  junction  of  the  internal  membrane 
of  the  bowel  with  the  external  skin,  and  that  it  may 
usually  be  seen,  if  the  patient  forces  the  gut  gently 
down,  as  in  going  to  stool.  The  only  correct  part  of 
these  statements  is,  I believe,  the  account  of  the  common 
situation  of  the  internal  opening,  when  the  abscess 
communicates  with  the  bowel,  which  is  not  always 
the  case. — (See  Recherches  sur  la  Situation  de  VOri- 
Jice  interne  de  la  Fistule  de  UAnus,  S,-c.  Quarterly 
Joum.  of  Foreign  Med.  No.  8.  Oct.  1820.)  Tliis  part 
of  the  account  is  confirmed  by  the  observations  of 
Larrey. — {Mem.  de  Chir.  Mil.  t.  3,  p.  415.) 

Suppose  a large  and  convenient  opening  to  have  been 
made  by  a simple  incision ; the  contents  of  the  abscess 
to  have  been  thereby  discharged  ; and  a sore  or  cavity 
produced,  which  is  to  be  filled  up. 

The  term  filling  up.  and  the  former  opinion,  that  the 
induration  of  the  parts  about  is  a diseased  callosity, 
have  been  the  two  principal  sources  of  misconduct  in 
these  cases. 

The  old  opinion,  with  regard  to  hollow  and  hard- 
ness, was  that  the  former  is  caused  entirely  by  loss  of 
substance ; and  the  latter,  by  diseased  alteration  in  the 
structure  of  the  parts. 

The  consequence  of  which  opinion  was,  that  as  soon 
as  the  matter  was  discharged,  the  cavity  was  filled 
and  distended,  in  order  to  procure  a gradual  regenera- 
tion of  flesh  ; and  the  dressings,  with  which  it  was  so 
filled,  were  most  commonly  of  the  escharotic  kind,  in- 
tended for  the  dissolution  of  hardness. 

On  the  other  hand,  the  surgeon  who  regards  the 
cavity  of  the  abscess  as  being  principally  the  effect  of 
the  gradual  separation  of  its  sides,  with  very  little  loss 
of  substance,  compared  with  the  size  of  the  said  cavity ; 
and  who  looks  upon  the  induration  round  about,  as 
nothing  more  than  a circumstance  which  necessarily 
accompanies  every  inflammation,  will,  upon  the  small- 
est reflection,  perceive  that  the  dressings  applied  to 
such  cavity  ought  to  be  so  small  in  quantity,  as  to 
permit  nature  to  bring  the  sides  of  the  cavity  towards 
each  other,  and  that  such  small  quantity  of  dressings 
ought  not  by  their  quality  either  to  irritate  or  de- 
stroy. 

If  the  hollow,  immediately  it  is  opened,  be  filled  with 
dressings  (of  any  kind),  the  sides  of  it  will  be  kept 
from  approaching  each  other,  or  may  even  be  farther 
separated.  But  if  this  cavity  be  not  filled,  or  have 
little  or  no  dressings  of  any  kind  introduced  into  it,  the 
sides  immediately  collapse,  and,  coming  nearer  and 
nearer,  do,  in  a very  short  space  of  time,  convert  a large 
hollow  into  a small  sinus.  And  this  is  also  constantly 
the  case,  when  the  matter,  instead  of  being  let  out  by 
an  artificial  opening,  escapes  through  one  made  by  the 
bursting  of  the  containing*  parts. 

True,  this  sinus  will  not  always  become  perfectly 
closed  ; but  the  aim  of  nature  is  not  therefore  the  less 
evident ; nor  the  hint,  which  art  ought  to  borrow  from 
her,  the  less  palpable. 

In  this,  as  in  most  othur  cases,  where  there  are  largo 
sores,  or  considerable  cavities,  a great  deal  will  deiiend 
on  the  patient’s  habit,  and  the  care  that  is  taken  of  it ; 
if  that  be  good,  or  if  it  be  properly  corrected,  the  sur- 
geon will  have  very  little  trouble  in  his  choice  of  dress- 
ings ; only  to  take  care  that  they  do  not  offend  either 
in  quantity  or  quality  ; but  if  the  habit  be  bad,  or  inju- 
diciously treated,  he  may  use  the  whole  farrago  of  ex- 
ternals, and  only  waste  his  own  and  his  patient’s 
time. 

By  light,  easy  treatment,  large  abscesses  formed  in 
the  neighbourhood  of  the  rectum  will  sometimes  be 
cured,  without  any  necessity  for  meddling  with  the  said 
gut.  But  it  much  more  frequently  happens,  that  the  in- 
testine, although  it  may  not  have  been  pierced  or  eroded 
by  the  matter,  has  yet  been  so  stripped  or  denuded,  i 
that  no  consolidation  of  the  sinus  can  be  obtained, 


but  by  a division ; that  is,  by  laying  the  two  cavifics, 
viz.  that  of  the  abscess  and  that  of  the  intestine,  into 
one. 

When  the  intestine  is  found  to  be  separated  from  the 
surrounding  parts  by  the  matter,  the  operation  of  di- 
viding it  had  better  (on  many  accounts)  be  performed 
at  the  time  the  abscess  is  first  opened,  than  be  deferred 
to  a future  one.  For,  if  it  be  done  properly,  it  will  add 
so  little  to  the  pain,  which  the  patient  must  feel  by 
opening  the  abscess,  that  he  will  seldom  be  able  to  dis- 
tinguish the  one  from  the  other,  either  with  regard  to 
time  or  sensation  ; whereas,  if  it  be  deferred,  he  must 
either  be  in  continual  expectation  of  a second  cutting, 
or  feel  one  at  a time  when  he  does  not  expect  it. 

The  intention  in  this  operation  is  to  divide  the  intes- 
tine rectum  from  the  verge  of  the  anus  uj)  as  high  as 
the  top  of  the  hollow  in  which  thematt-r  was  formed; 
thereby  to  lay  the  two  cavities  of  the  gut  and  abscess 
into  one ; and  by  means  of  an  open,  instead  of  a hol- 
low or  sinuous  sore,  to  obtain  a firm  and  lasting 
cure. 

For  this  purpose,  the  curved,  probe-pointed  knife, 
with  a narrow  blade,  is  the  most  useful  and  handy  in- 
strument of  any.  This,  introduced  into  the  sinus, 
while  the  surgeon’s  fore-finger  is  in  the  intestine,  will 
enable  him  to  divide  all  that  can  ever  require  division  ; 
and  that  with  less  pain  to  the  patient,  with  more  fa- 
cility to  the  operator,  as  well  as  with  more  certainty 
and  expedition,  than  any  other  instrument  whatever. 
If  there  be  no  opening  in  the  intestine,  the  smallest  de- 
gree of  force  will  thrust  the  point  of  the  knife  through, 
and  thereby  make  one ; if  there  be  one  already,  the 
same  point  will  find  and  pass  through  it.  In  either 
case,  it  will  be  received  by  the  finger  in  ano ; will 
thereby  be  prevented  from  deviating ; and  being  brought 
out  by  the  same  finger,  must  necessarily  divide  all  that 
is  between  the  edge  of  the  knife  and  the  verge  of  the 
anus  : that  is,  must  by  one  simple  incision  (w  hich  is 
made  in  the  smallest  space  of  time  imaginable)  lay 
the  two  cavities  of  the  sinus  and  of  the  intestine  into 
one. 

Authors  make  a very  formal  distinction  between 
those  cases  in  v/hich  the  intestine  is  pierced  by  the 
matter,  and  those  in  which  it  is  not ; but  although  this 
distinction  may  be  useful  when  the  different  states  of 
the  disease  are  to  be  described,  yet  in  practice,  when 
the  operation  of  dividing  the  gut  becomes  necessary, 
such  distinction  is  of  no  consequence  at  all : it  makes 
no  alteration  in  the  degree,  kind,  or  quantity  of  pair? 
which  the  patient  is  to  feel ; the  force  required  to  push 
the  knife  through  the  tender  gut  is  next  to  none,  and 
when  its  point  is  in  the  cavity,  the  cases  are  exactly 
similar.  In  this  statement  every  man  of  experience 
and  discernment  must  agree,  notwithstanding  the  pro- 
hibition to  the  operation,  delivered  by  Dr.  Ribes,  in 
every  case,  in  which  the  internal  opening  cannot  be 
fotind : a piece  of  advice  (as  it  seems  to  me)  fully  ad- 
mitting the  occurrence  of  cases  which  could  not  be 
formed  in  the  manner  in  which  he  conceives  all  fistulte 
in  ano  to  be  produced,  viz.  by  the  bursting  of  a pile, 
and  the  entrance  of  feces  into  the  orifice. 

Immediately  after  the  operation,  a soft  dossil  of  fine 
lint  should  be  introduced  (from  the  rectum)  between 
the  divided  lips  of  the  incision ; as  well  to  repress  any 
slight  hemorrhage,  as  to  prevent  the  immediate  reunion 
of  the  said  lips ; and  the  rest  of  the  sore  should  be 
lightly  dressed  with  the  same.  This  first  dressing 
should  be  permitted  to  continue,  until  a beginning  sup- 
puration renders  it  loose  enough  to  come  away  easily  ; 
and  all  the  future  ones  should  be  as  light,  soft,  and 
easy  as  possible;  consisting  only  of  such  materials  as 
are  likely  to  promote  kindly  and  gradual  suppuration. 
The  sides  of  the  abscess  are  large  ; the  incision  must 
necessarily,  for  a few  days,  be  inflamed  ; and  the  dis- 
charge will,  for  some  time,  be  discoloured  and  gleety  : 
this  induration,  and  this  sort  of  discharge,  are  often 
nustaken  for  signs  of  diseased  callosity  and  undis- 
covered sinuses ; upon  which  presumptions,  escharo- 
tics  are  freely  applied,  and  diligent  search  is  made  for 
new  hollows:  the  former  of  these  most  commonly  in- 
crease both  the  hardness  and  the  gleet ; and  by  the 
latter  new  sinuses  are  sometimes  really  produced. 
These  occasion  a repetition  of  escharotics,  and,  perhi»i).s, 
of  incisions ; by  which  means,  cases  which  at  first, 
and  in  their  own  nature,  were  simple  and  easy  of  cure, 
are  rendered  complex  and  tedious. 

To  quit  reasoning,  and  speak  to  fact  only : In  the 


ANUS. 


161 


great  number  of  these  cases,  which  must  have  been  in 
St.  I3artholomew’.s  Hospital,  within  these  ten  or  twelve 
years,  I do  aver  (says  Pott),  that,  I have  not  met  with  • 
one,  in  the  circumstances  before  described,  that  has 
not  been  cured  by  mere  sirhpie  division,  together  with 
light,  easy  dressings : and  that  I have  not,  in  all  that 
time,  used,  for  this  purpose,  a single  grain  of  precipi- 
tate, or  any  other  escharotic. 

Let  us  now  suppose  the  case  in  which  the  matter  is 
fairly  formed  ; has  made  its  point,  as  it  is  called ; and 
is  (it  to  be  let  out. 

Where  such  point  is,  that  is,  where  the  skin  is  most 
thin,  and  the  fluctuation  most  palpable,  the  opening 
most  certainly  ought  to  be  made,  and  always  with  a 
cutting  instrument,  not  caustic,  as  was  formerly  done. 

When  a discharge  of  the  matter  by  inei.sion  is  too 
long  delaj’ed  or  neglected,  it  makes  its  own  way  out, 
by  bursting  the  external  parts  somewhere  near  to  the 
fundament,  or  by  eroding  and  making  a hole  through 
the  intestine  into  its  cavity;  or  sometimes  by  both. 
In  either  case,  the  discharge  is  made  sometimes  by  one 
orifice  only,  and  sometimes  by  more.  Those  in  which 
the  matter  has  mad»  its  escape  by  one  or  more  open- 
ings through  the  skin  only  are  called  blind  external 
fstulae;  those  in  which  the  discharge,  has  been  made 
into  the  cavity  of  the  intestine,  without  any  orifice  in 
the  skin,  are  named  blind  internal ; and  those  which 
have  an  opening  both  through  the  skin  and  into  the 
gut  are  called  complete  fstulae. 

Thus,  all  these  cases  are  deemed  fistulous,  when 
hardly  any  of  them  ever  are  so ; and  none  of  them  ne- 
cessarily. They  are  still  mere  abscesses,  which  are 
burst  without  the  help  of  art ; and,  if  taken  proper  and 
timely  care  of,  will  require  no  such  treatment  as  a 
true  fistula  may  possibly  stand  in  need  of. 

The  most  frequent  of  all  are  w^hat  are  called  the 
blind  external,  and  the  complete.  The  method  where- 
by each  of  these  states  may  be  known  is,  by  ituro- 
ducing  a probe  into  the  sinus  by  the  orifice  in  the  skin, 
while  the  fore-finger  is  within  the  rectum:  this  will 
give  the  examiner  an  opportunity  of  knowing  exactly 
the  true  state  of  the  case,  with  all  its  circumstances. 

Whether  the  case  be  what  is  called  a complete  fistula 
or  not,  that  is,  wdiether  there  be  an  opening  in  the 
skin  only,  or  one  there  and  another  in  the  intestine,  the 
appearance  to  the  eye  is  much  the  suiue.  Upon  di.s- 
charge  of  the  matter,  the  externa!  swelling  subsides, 
and  the  inflamed  colour  of  the  skin  disappears;  tlie 
orifice,  which  at  first  was  sloughy  and  foul,  after  a 
day  or  two  are  passed,  becomes  clean  and  contracts  in 
size;  but  the  discharge,  by  fretting  the  parts  about, 
renders  the  patient  still  uneasy. 

As  this  kind  of  opening  seldom  proves  sufficient  for 
a cure  (though  it  sometimes  does),  the  induration,  in 
some  degree,  remains ; and  if  the  orifice  happens  not 
to  be  a depending  one,  some  part  of  the  matter  lodges, 
and  is  discharged  by  intervals,  or  may  be  pressed  out 
by  the  fingers  of  an  examiner.  The  disease,  in  this 
state,  is  not  very  painful ; but  it  is  troublesome,  nasty, 
and  offensive : the  continual  discharge  of  a thin  kind 
of  fluid  from  it  creates  heat,  and  cau.ses  excoriation  in 
the  parts  above ; it  daubs  the  linen  of  the  jiatient ; and 
is,  at  times,  very  fetid : the  orifice  also  sometimes  con- 
tracts so  as  not  to  be  sufficient  for  the  discharge ; and 
the  lodgement  of  the  matter  then  occasions  fresh  dis- 
turbance. 

The  means  of  cure  proposed  and  practised  by  our 
ancestors  were  three,  viz.  caustic,  ligature,  and  inci- 
sion. 

The  intention  in  each  of  these  is  the  same,  viz.  to 
form  one  cavity  of  the  sinus  and  intestines  by  laying 
the  former  into  the  latter.  The  first  two  are  now  com- 
pletely, and  most  properly,  exploded. 

Hitherto  wc  have  considered  the  disease  either  as  an 
abscess,  from  which  the  matter  has  been  let  out  by  an 
incision,  made  by  a surgeon ; or  from  which  the  con- 
tents have  been  discharged  by  one  single  orifice,  form- 
ed by  the  bursting  of  the  skin  somewhere  about  the 
fundament.  Let  us  now  take  notice  of  it,  when,  in- 
stead of  one  such  opening,  there  are  several. 

This  state  of  the  case  generally  happens  when  the 
quantity  of  matter  collected  has  been  large,  tlie  inflam- 
mation of  considerable  extent,  the  adipose  membrane 
very  sloughy,,  and  the  skin  worn  very  thin  before  it 
burst. — It  is,  indeed,  a circumstance  of  no  real  conse- 
quence at  all ; hut  from  being  misunderstood,  or  not 
properly  aiteiided  to,  is  made  one  of  additional  terror 

VoL.  I.  L 


to  the  patient,  and  additional  alarm  to  the  inexperienced 
practitioner ; for  it  is  taught,  and  frequently  believed, 
that  each  of  these  nrilices  is  an  outlet  from,  or  leads  to, 
a distinct  sinus,  or  hoilow  : whereas,  in  truth,  the  case 
is  most  commonly  quite  otherwise;  all  these  openings 
are  only  .so  many  distinct  burstings  of  the  skin  cover- 
ing the  matter ; and  do  all,  be  they  few  or  many,  lead 
and  open  immediately  into  the  one  single  cavity  of  the 
abscess  : they  neither  indicate,  nor  lead  to,  nor  are 
caused  by,  distinct  sinuses  ; nor  would  the  appearance 
of  twenty  of  them  (if  possible)  necessarily  imply  more 
than  one  general  hollow. 

If  this  account  be  a true  one,  it  will  follow,  that  the 
treatment  of  this  kind  of  case  ought  to  be  very  little, 
if  at  all,  ditferent  from  that  of  the  preceding;  and  that 
all  that  can  be  necessary  to  be  done,  must  be  to  divide 
each  of  these  orifices  in  such  manner  as  to  make  one 
cavity  of  the  whole.  . This  the  probe-knife  will  easily 
and  expeditiously  do;  and  afterward,  if  the  sore,  or 
more  properly  its  edges,  should  make  a very  ragged, 
uneven  appearance,  the  removal  of  a small  portion  or 
such  irregular  angular  jiarts  will  answer  all  the  pur- 
poses of  making  room  for  the  application  of  dressings, 
and  for  producing  a smooth  even  cicatrix  after  the  sore 
shall  be  healed. 

When  a considerable  quantity  of  matter  has  been  re- 
cently let  out,  and  the  internal  parts  are  not  only  in  a 
crude  undigested  state,  but  have  not  yet  had  time  to 
collapse  and  ajiproach  each  other,  the  inside  of  such 
cavity  will  appear  large ; and  if  a probe  be  pushed 
with  any  degree  of  force,  it  will  pass  in  more  than  one 
direction  into  the  cellular  membrane  by  the  side  of  the 
rectum.  But  let  not  the  unexperienced  practitioner  be 
alarmed  at  this,  and  immediately  fancy  that  there  are 
so  many  distinct  sinuses;  neither  let  him,  if  he  be  of  a 
more  hardy  disposition,  go  to  work  immediately  with 
liis  director,  knife,  or  scissors  : let  him  enlarge  the  ex- 
ternal wound  by  making  his  incision  freely ; let  him 
lay  ail  the  separate  orifices  open  into  that  cavity  ; let 
him  divide  the  intestine  lengthwise  by  means  of  his 
finger  in  ano;  let  him  dress  lightly  and  easily;  let  him 
pay  proper  attention  to  the  habit  of  the  patient ; and 
wait  and  see  what  a tew  days,  under  such  conduct, 
will  produce.  By  this  he  will  frequently  find,  that  the 
large  cavity  of  the  qbscess  will  become  small  and 
clean ; that  the  induration  round  about  will  gradually 
lessen ; that  the  probe  will  not  pass  in  that  manner  into 
the  cellular  membrane  ; and,  consequently,  that  his 
fears  of  a multiplicity  of  sinuses  were  groundless.  On 
the  contrary,  it  the  sore  be  crammed  or  dressed  with 
irritating  or  escharotic  medicines,  all  the  appearances 
will  be  difTerent : the  hardness  will  increase,  the  lips  of 
the  wound  will  be  inverted,  the  ca  vity  of  the  sore  will 
remain  large,  crude,  and  foul ; the  discharge  will  be 
thin,  gleety,  and  di.scoloured ; the  patient  will  be  un- 
easy and  feverish ; and,  if  no  new  cavities  are  tbnned 
by  the  irritation  of  parts  and  confinement  of  matter,  yet 
the  original  one  will  have  no  opporiunity  of  contracting 
itself,  and  may  very  possibly  become  truly  fistulous. 

Sometimes  the  matter  of  an  abscess,  formed  juxta 
anum,  instead  of  making  its  way  out  through  the  skin 
externally  near  the  verge  of  the  anus,  or  in  the  but- 
tock, pierces  through  the  intestine  only.  This  is  what 
IS  called  a blind  internal Jistula. 

In  this  case,  after  the  discharge  has  been  made,  the 
greater  part  of  the  tumefaction  subsides,  and  the  jm- 
tient  becomes  easier.  If  this  docs  not  produce  a cure, 
which  sometimes  though  very  seldom  hajqiens,  some 
small  degree  of  induraiioa  generally  remains  in  the 
place  where  the  original  tumour  was;  upon  pressure 
oil  this  hardness,  a small  discharge  of  matter  is  fre- 
quently made  per  anum;  and  sometimes  the  expulsion 
of  air  from  the  cavity  of  the  abscess  into  that  of  the  in- 
testine may  very  palpably  be  felt  and  clearly  heard ; 
the  stools,  particularly  if  hard,  and  requiring  force  to 
be  expelled,  are  sometimes  smeared  with  matter ; and 
although  the  patient,  by  the  bursting  of  the  abscess,  is 
relieved  from  the  acute  pain  which  the  collection  occa- 
sioned, yet  he  is  seldom  perfectly  free  from  a dull  kind 
of  uneasiness,  especially  if  he  sits  for  any  considerable 
length  of  time  in  one  posture.  The  real  difference  be- 
tween this  kind  of  case  and  that  in  which  there  is  an 
external  opening  (with  regard  to  method  of  cure),  is 
very  immaterial ; for  an  external  opening  must  be 
made,  and  then  all  ditlerence  ceases.  In  this,  as  in  the 
former,  no  cure  can  reasonably  be  expected  until  the 
cavity  of  the  abscess  and  that  of  the  rectum  are  made 


162 


ANUS. 


one ; and  the  only  difference  is,  that  in  the  one  case 
we  have  an  orifice  at  or  near  the  verge  of  the  anus,  by 
wliich  we  are  immediately  enabled  to  perform  that  ne- 
cessary operation ; in  the  other,  we  must  make  one. 

We  come  now  to  that  state  of  the  disease,  which 
may  truly  and  properly  be  called  fistulous.  This  is 
generally  defined,  sinus  angustus,  callosus,  profun- 
dus : acri  ganie  diffluens : or,  as  Dionis  translates  it, 
“ Un  ulcere  profond,  et  caverneux,  dont  I'entree  est 
itroite,  et  le fond  plus  large;  avec  ussue  d'un  pus  acre 
et  virulent ; et  accompagne  de  caUosites.” 

Various  causes  may  produce  or  concur  in  producing 
such  a state  of  the  parts  concerned  as  will  constitute  a 
fistula,  in  the  proper  sense  of  the  word ; that  is,  a deep 
hollow  sore,  or  sinus ; all  parts  of  which  are  so  hard- 
ened or  so  diseased,  as  to  be  absolutely  incapable  of 
being  healed  while  in  that  state;  and  from  which  a 
frequent  or  daily  discharge  is  made;  of  thin  discoloured 
sanies,  or  fluid. 

These  are  divided  into  two  classes,  viz.  those,  which 
are  the  effect  (rf  neglect,  distempered  habit,  or  bad  ma- 
nagement, and  w hich  may  be  called,  without  any  great 
impropriety,  local  diseases ; and  those  which  are  the 
consequence  of  disorders  whose  origin  and  seat  are 
not  in  the  immediate  sinus  or  fistula,  but  in  parts  more 
or  less  distant,  and  which,  therefore,  are  not  local  com- 
plaints. 

The  natures  and  characters  of  these  are  obviously 
different  by  description ; but  they  are  still  more  so  in 
their  most  frequent  event ; the  former  being  generally 
curable  by  proper  treatment,  the  latter  frequently  not 
so  by  any  means  whatever. 

Under  the  former  are  reckoned  ail  such  cases  as 
were  originally  mere  collections  of  matter  within  the 
coats  of  the  intestine  rectum,  or  in  the  cellular  mem- 
brane surrounding  the  said  gut ; but  w hich,  by  being 
long  neglected,  grossly  managed,  or  by  happening  in 
habits  which  w'ere  disordered,  and  for  w’hich  disorders 
n»  proper  remedies  w^ere  administered,  suffer  such  al- 
teration, and  get  into  such  state,  as  to  deserve  the 
appellation  of  fistulce. 

Under  the  latter  are  corriprised  all  those  cases  in 
which  the  disease  has  its  origin  and  first  state  in  the 
higher  and  more  distant  parts  of  the  pelvis,  about  the 
os  sacrum,  lower  vertebrae  of  the  loins,  and  parts  ad- 
jacent thereto;  and  are  either  strumous,  or  the  conse- 
quence of  long  and  much  distemperate  habits  ; or  the 
effect  of,  or  combined  with,  other  distempers,  local  or 
general ; such  as  a diseased  neck  of  the  bladder  or 
prostate  gland,  or  urethra,  &c.  <kc.  &c. 

Among  the  very  low  people,  who  are  brought  into 
hospitals,  we  frequently  meet  with  cases  of  the  for- 
mer kind : cases  which,  at  first,  were  mere  simple  ab- 
scesses ; but  which,  from  uncleanliness,  from  intem- 
perance, negligence,  and  distempered  constitutions, 
become  such  kind  of  sores  as  may  be  called  fistulous. 

In  these  the  art  of  surgery  is  undoubtedly,  in  some 
measure,  and  at  some  time,  necessary;  but  it  very  sel- 
dom is  the  first  or  princiiial  fountain  from  whence  re- 
lief is  to  be  sought : the  general  effects  of  intemperance, 
debauchery-,  and  diseases  of  the  habit  are  first  to  be 
corrected  and  removed,  before  surgery  can,  with  pro- 
priety, or  with  reasonable  prospects  of  advantage,  be 
made  use  of. 

The  surgery-  required  in  these  cases,  consists  in  lay- 
ing open  and  dividing  the  sinus  or  sinuses,  in  such  a 
manner  that  there  may  be  no  possible  lodgement  for 
matter,  and  that  such  cavities  may  be  fairly  opened 
lengthwise  into  that  of  the  intestine  rectum ; if  the  in- 
ternal parts  of  these  hollows  are  hard,  and  do  not  yield 
good  matter,  which  is  .sometimes  the  case,  more  espe- 
cially where  attempts  have  been  made  to  cure  by  inject- 
ing astringent  liquors,  such  parts  should  be  lightly- 
scratched  or  scarified  w-ith  the  point  of  a knife  or  lan- 
cet, but  not  dressed  w-ith  escharotics;  and  if,  either 
from  the  multiplicity  of  e.xternal  orifices,  or  from  the 
loose,  flabby,  hardened,  or  inverted  state  of  the  lips  and 
edges  of  the  wound  near  to  the  fundament,  it  seems  very 
improbaole  that  they  can  be  got  into  such  a state  as  to 
heal  smoothly-  and  evenly,  such  portions  of  them  should 
be  cut  off  as  may  just  serve  that  purpo.se.  The  dress- 
ings should  be  soft,  easy,  and  light ; and  the  whole  in- 
tent of  them  to  produce  such  suppuration  as  may  soften 
the  parts  and  bring  them  into  a state  fit  for  healing. 

If  a loose  fungous  kind  of  flesh  has  taken  possession 
of  the  inside  of  the  sinus  (a  thing  much  talked  of  and 
vc«y  seldom  met  with),  a slight  touch  of  the  lunar  caus- 


tic will  reduce  it  sooner,  and  with  better  effect  on  the 
sore,  than  any  other  escharotic  whatever. 

Modern  writers  also  speak  of  a smooth  adventitious 
membrane,  w liich  is  found  line  old  fistulae,  and  fre- 
quently to  hinder  the  success  of  the  operation  (see 
Quarterly  Joum.  of  Foreign  Medicine,  A c.  No.  8); 
a complication  which  would  undoubtedly  justify  the 
recourse  to  measures  for  the  extirpation  of  such  mem- 
brane. But  I ought  to  mention  my  own  belief,  that  a 
case  hindered  from  getting  well  by  this  cause  is  Very 
rare  in  comparison  with  others,  in  which  the  cure  is 
prevented  by  the  matter  being  still  more  or  less  con- 
fined, and  not  having  as  free  an  outlet  as  circumstances 
demand. 

The  method  and  medicines  by  which  the  habit  of 
the  patient  was  corrected,  must  be  continued  (at  least 
in  some  degree)  through  the  whole  cure;  and  all  the 
excesses  and  irregularities  which  may  have  contributed 
to  injure  it  must  be  avoided. 

By  these  means,  cases  which  at  first  have  a most 
disagreeable  and  formidable  aspect  are  frequently 
brought  into  such  state  as  to  give  very  little  trouble 
in  the  healing.  * 

If  the  bad  state  of  the  sore  arises  merely  from  its 
having  been  crammed,  irritated,  and  eroded,  the  me- 
thod of  obtaining  relief  is  so  obvious  as  hardly  to  need 
recital. 

A patient  who  has  been  so  treated  has  generally 
some  degree  of  fever ; has  a pulse  which  is  too  hard, 
and  too  quick;  is  thirsty,  and  does  not  get  his  due 
quantity  of  natural  rest.  A sore  w-hich  has  been  so 
dressed,  has  generally  a considerable  degree  of  inflam- 
matory hardness  round  about ; the  lips  and  edges  of  it 
are  found  full,  inflamed,  and  sometimes  inverted  ; the 
whole  verge  of  the  anus  is  swollen  ; the  hemorrhoidal 
vessels  are  loaded  ; the  discharge  from  the  sore  is  large, 
thin,  and  discoloured ; and  all  the  lower  part  of  the 
rectum  participates  in  the  inflammatory  irritation,  pro- 
ducing pain,  bearing  down,  tenesmus,  &c.  Contraria 
contrariis  is  never  more  true  than  in  this  instance : the 
painful,  uneasy  state  of  the  sore  and  of  the  rectum  is 
the  great  cau.se  of  all  the  mischief,  both  general  and 
particular ; and  the  first  intention  must  be  to  alter  that 
state.  All  escharotics  must  be  thrown  out  and  dis- 
used ; and  in  lieu  of  them,  a soft  digestive  should  be 
substituted,  in  such  manner  as  not  to  cause  any  disten- 
tion, or  to  give  any  uneasiness  from  quantity ; over 
which  a poultice  should  be  applied : these  dressings 
should  be  renew-ed  twice  a day ; and  the  patient  should 
be  enjoined  absolute  rest.  At  the  same  time,  atten- 
tion should  be  paid  to  the  general  disturbance  w-hich 
the  former  treatment  may  have  created.  Blood  should 
be  drawn  off  from  the  sanguine ; the  feverish  heat 
should  be  calmed  by  proper  medicines;  the  lan- 
guid and  low  shoitld  be  assisted  with  the  bark  and  cor- 
dials ; and  ease  in  the  part  must,  at  all  events,  be  ob- 
tained by  the  injection  of  anodyne  clysters  of  starch 
and  opium. 

If  the  sinus  has  not  yet  been  laid  open,  and  the  bad 
state  of  parts  is  occasioned  by  the  introduction  of 
tents  imbued  with  escharotics,  or  by  the  injection  of 
astringent  liquors  (the  one  for  the  destruction  of  cal- 
losity, the  other  for  the  drying  up  gleet  and  humidity), 
no  operation  of  any  kind  should  be  attempted  until 
bojh  the  patient  and  the  parts  are  ea-sy,  cool,  and  quiet ; 
cataplasms,  clysters,  rest,  and  proper  medicines  tnust 
procure  this;  and  w-hen  that  is  accomplished,  the  ope- 
ration of  dividing  the  sinus,  and  (if  necessary)  of  re- 
moving a small  portion  of  the  ragged  edges,  may  be 
executed,  and  w-ill,  in  all  probability,  be  attended  with 
success.  On  the  contrary,  if  such  operation  be  per- 
formed while  the  parts  are  in  a state  of  inflammation, 
the  pain  will  be  great,  the  sore  for  several  days  very- 
troublesome,  and  the  cure  prolonged  or  retarded,  in- 
stead of  being  expedited. 

Abscesses  and  collections  of  diseased  fluids  are  fre- 
quently formed  about  the  lumbar  vertebrae,  under  the 
psoas  muscle,  and  near  to  the  os  sacrum ; in  which 
ca-ses,  the  said  bones  are  sometimes  carious,  or  other- 
wise diseased.  These  sometimes  form  sinuses,  which 
run  down  by  the  side  of  the  rectum,  and  burst  near  to 
the  fundament. 

The  treatment  of  such  sores  and  sinu.ses  can  have 
little  influence  on  the  remote  situation  wdtere  the  col- 
lection of  mailer  is  originally  formed.— (See  Lumbar 
Abscess.) 

Fistulous  sores,  sinuses,  and  indurations  about  the 


ANUS. 


163 


anuSj  which  are  consequences  of  diseases  of  the  neck 
of  the  bladder  and  urethra,  called  fistulae  in  perinaeo, 
require  separate  and  particular  consideration. — (See 
Fistula  in  PerincBO.) 

A few  years  ago  M.  Roux  published  a critique  on 
the  preference  which  English  surgeons  invariably  give 
to  Pott’s  method  of  operating  for  the  fistula  in  ano. 
The  chief  peculiarity  in  the  French  plan,  on  which  he 
bestows  unqualified  praise,  consists  in  the  use  of  a 
kind  of  director  called  a gorget,  which  is  usually  made 
of  ebony  wood,  and  intended  to  be  introduced  within 
the  rectum,  with  its  concavity  turned  towards  the  fis- 
tula. A steel  inflexible  director,  slightly  pointed  and 
without  a cul-de-sac,  is  then  passed  through  the  fistula 
till  the  point  comes  into  contact  with  the  wooden  gor- 
get. A long,  narrow,  sharp-pointed,  straight  bistoury 
is  now  introduced  along  the  groove  of  the  steel  di- 
rector, till  its  point  meets  the  groove  of  the  ebony  gor- 
get, by  cutting  upon  which  all  the  parts  are  divided 
which  lie  between  the  internal  opening  of  the  fistula 
and  the  anus.  It  may  be  objected  to  this  method,  that 
it  is  not  always  easy  to  make  a director  pass  at  once 
through  the  fistula  into  the  rectum.  This  is  acknow- 
ledged by  Richerand,  who  adds,  that  in  this  circum- 
stance the  point  of  the  director  may  be  forced  into  the 
rectum  without  lessening  the  chance  of  the  success  of 
the  operation.— (iVosogr.  Chirurg.  t.  3,  p.  463, 464,  (dit. 
4.)  Why  then  does  it  matter  so  much  that  the  surgeon 
sometimes  pierces  the  rectum  with  the  point  of  his 
curved  bistoury?  Surely  th  s is  as  good  an  instru- 
ment for  making  the  puncture  as  the  pointed  director. 
Besides,  it  appears  to  me  that  a flexible  silver  director 
is  more  likely  to  follow  the  track  of  the  fistula  into  the 
rectum  than  an  unbending  iron  instrument.  I shall  say 
nothing  of  the  awkwardness  of  using  the  other  wooden 
director : the  finger  of  the  surgeon  can  always  do  the  oflice 
of  all  such  contrivances  with  greater  safety  and  conve- 
nience. M.  Roux  also  censures  us  for  not  cramining 
the  wound  with  charpie ; for  he  is  not  content  with 
merely  introducing  into  it  a dossil  of  lint.— (See  Paral- 
lile  de  la  Chir.  Angloise,  Ac.  p.  296,  (S  c.)  His  countrj^- 
man  Pouteau,  however,  knew  better  long  ago : for  he 
has  expressed  his  decided  conviction  of  the  inutility  of 
cramming  the  wound  with  dressings  to  its  very  bottom 
after  the  third  day,  when  superficial  dressings,  and  the 
renewal  of  them  as  often  as  cleanliness  requires,  will 
be  fully  sufficient. 

For  information  relative  to  former  opinions  concerning 
Jistula  in  ano,  refer  to  Cels  us ; Heister's  Surgery  ; Le 
D can's  Operations ; Sharpe's  Operations  ; Ca  Faye's 
J^otes  on  Dionis.  H.  Bass,  De  Fistula  Ani  f elicit er  cu- 
randa,  in  Halleri  Disp.  Chir.  4, 463.  J.  L.  Petit,  Traite 
des  Mai.  Chir.  1. 1 and  2,  p.  113.  Petit  is  an  advocate  for 
making  an  early  opening,  like  Pott,  and  all  the  best  wri- 
ters on  this  disease.  In  Kirkland' s Medical  Surgery, 
vol.  2,  may  be  found  an  account  of  the  opinions  and 
practice  of  many  former  celebrated  practitioners.  The 
best  modern  practical  remarks  are  contained  in  Pott's 
Treatise  on  the  Fistulain  Ano,  in  which  he  has  offered 
also  an  excellent  critique  on  some,  opinions  of  he  Dran, 
De  la  Faye,  and  Cheselden.  The  reader  may  also  con- 
sult with  advantage  Sabatier's  Medecine  Op&ratoire,  t. 
2.  J.  Howship,  Practical  Obs.  on  the  Diseases  of  the 
Lower  Intestines,  ire.  chap.  6,  ed.  3,  Loud.  1824.  T. 
IVhutely,  Cases  of  Polypi,  Src.,  with  an  appendix  de- 
scribing an  approved  instrument  for  the  fistula  in  ano, 
8oo.  hand.  1805.  .7.  T-  Oetzman,  De  Fistula  Ani, 
ito.  .lenm,  1812.  Richerand,  Mosographie  Chir.  t.  3, 
p.  446,  (J-c.  ^dit.  4.  Roux,  Voyage  fait  d Londres 
en  1814,  ou  Parallile  de  la  Chirurgie  Angloise  avec  la 
Chirurgie  Francoise,  p.  296,  &rc.,  Paris,  1815.  Callt- 
sen's  Syst.  Chirvrgice  Hodiernm,  1.  \,p.  470.  Schregcr, 
Chirvrgische  Versiiche,  b.  2,  iihe.r  die  Unterbindnng 
der  Mastda.rmfisteln,  p.  1,  131,  8iw.  JVurnberg,  1618. 
K'lthe,  Darstellung,  4-c.,  der  Cwnuethoden  der  .fiftcr- 
fisteln,  in  Ru.st's  Mag.  b.  1,  s.  259.  T.  Ribes,  Re- 
cherches  sur  la  Situation  de  V Orifice  interne  de  la  Fis- 
tule  de  I' Anus,  et  sur  les  parties  dans  I'ijiaisseur  dcs- 
qiielles  ces  vlcires  ont  leur  siige.  See  Quarterly 
.Jonrn  of  Foreign  Medicine,  JVo.  8.  Fr.  Reisingrr, 
Darstellung  eines  neuenn  Verf uhrens  die  .Mastdarm- 
fistel,  lu  unterbinden,Src.,8vo.  Augsb.  1816.  Into  the 
consideration  of  these  plans  of  curing  fist  alee  by  the  in- 
troduction of  a ligature  through  them  and  tying  them, 

I have  not  judged  it  advisable  to  enter,  because  every 
mefwd  of  this  kind  is  most  justly  banished  from  the 
practice  of  surgery  in  this  country. 


ANUS,  PROLAPSUS  OF. 

Prolapsus  ani,  technically  called  also  exania,  or  ar- 
choptosis.  In  this  case  the  rectum  protrudes  in  a greater 
or  less  degree  at  the  anus,  either  from  mere  relaxation 
of  the  internal  membrane  of  the  bowel,  or  from  a real 
displacement  and  inversion  of  its  upper  portion,  which 
presents  itself  as  an  external  tumour.  The  first  form 
of  the  disease  is  that  which  is  mo.st  common.  The 
inner  coat  of  the  rectum  being  connected  to  the  mus- 
cular by  a very  loose  elastic  cellular  substance,  natu- 
rally forms  several  folds,  the  use  of  which  is  to  let 
this  bowel  dilate  sufficiently  for  the  retention  of  the 
excrement.  The  swelling  occasioned  by  the  protrusion 
of  the  inner  coat  of  the  rectum,  or  by  the  actual  dis- 
placement of  the  greater  part  of  ttiis  bowel,  is  subject 
to  considerable  variety  in  respect  to  length  and#hick- 
ness  ; when  small  resembling  a mere  ring  ; when  large 
and  reaching  far  downwards,  having  an  oblong  globu- 
lar form.  The  tumour  sometimes  admits  of  reduc- 
tion with  ease ; sometimes  it  cannot  be  returned  with- 
out difficulty.  The  disease  occurs  in  persons  of  all 
ages ; but  it  is  most  common  in  infants  and  elderly 
subjects.  Such  examples  as  are  combined  with  thick- 
ening and  relaxation  of  the  inner  coat  of  the  rectum, 
internal  hemorrhoids,  or  other  tumours,  are  sometimes 
attended  with  a copious  discharge  from  the  anus,  and 
from  the  prolapsed  bowel,  of  a serous  and  mucous 
fluid  mixed  with  blood.  The  disease  may  originate 
from  various  causes ; 

J . From  circumstances  tending  to  relax  and  weaken 
the  parts  which  retain  the  rectum  or  its  inner  mem- 
brane in  its  situation. 

2.  From  various  kinds  of  irritation  and  pressure  on 
the  bowel  itself,  having  the  effect  of  increasing  the 
powers  by  which  it  is  liable  to  be  forced  outwards. 

3.  From  any  disease  or  irritation  in  the  adjacent 
parts,  and  affecting  the  rectum  sympathetically. 

Hence,  a prolapsus  ani  may  be  caused  by  long  habit- 
ual crying,  and  great  exertions  of  the  voice ; violent 
coughing ; sitting  long  at  stool ; hard  dry  feces,  and 
much  straining  to  void  them ; obstinate  diarrhoea  in 
infants,  kept  up  by  dentition  ; dysentery ; chronic  te- 
nesmus; various  diseases  of  the  rectum  itself;  the 
abuse  of  aloelic  medicines  and  emollient  clysters ; he- 
morrhoids ; excrescences  and  thickenings  of  the  inner 
membrane  of  the  rectum ; difficulty  of  making  water ; 
the  efforts  of  parturition;  the  stone  in  the  bladder; 
paralysis  of  the  sphincter  and  levatores  ani ; and  pro- 
lapsus vaginae. 

Considering  the  degree  of  the  disease,  and  the  occa- 
sional closeness  of  the  stricture,  the  symptoms  are 
sometimes  mild,  the  rectum  generally  bearing  pressure, 
exposure  to  the  air,  and  other  kinds  of  irritation  better 
than  any  other  bowel.  But  the  urgency  and  danger 
of  a prolapsus  ani  are  greater  when  the  swelling  is 
large,  recent,  and  conjoined  with  violent  pain,  inflam- 
mation, and  febrile  symptoms.  When  complicated 
with  strangulation,  the  consequences  may  be  a stop- 
page of  the  feces,  severe  pain,  swelling,  inflammation, 
and  even  gangrene  xvithin  the  cavity  of  the  abdomen 
In  short,  all  the  evils  may  arise  which  attend  strangu. 
lated  hernia.  The'  prognosis,  therefore,  varies  according 
to  tl^  different  degree,  species,  cause,  and  complica- 
tion of  the  disease.  The  recent,  small,  moveable  pro- 
lapsus ani,  the  cause  of  which  admits  of  being  at  once 
removed,  may  be  effectually  and  radically  cured.  It 
should  always  be  recollected,  however,  that  when  once 
the  rectum  has  been  affected  with  prolapsus,  a ten- 
dency to  protrusion  from  any  slight  occasional  cause 
generally  remains;  The  habitual  prolapsus,  which 
has  existed  for  years,  and  comes  on  whenever  the  pa- 
tient goes  to  stool,  is  the  case  which  is  most  difficult 
of  relief. 

The  treatment  of  prolapsus  ani  embraces  three  prin 
cipal  indications : 

1 . The  speedy  reduction  of  the  prolapsed  part. 

2.  The  retention  of  the  reduced  bowel. 

3.  The  removal  and  avoidance  of  the  causes  by 
which  the  disease  is  induced. 

In  general,  when  the  case  is  recent  and  the  tumour 
not  of  immoderate  size,  the  reduction  may  be  accom- 
plished with  tolerable  ease,  by  putting  the  patient  in  a 
suitable  posture,  with  the  buttocks  rai.sed  and  the  tho- 
rax depressed,  and  by  making  gentle  and  skilful  pres- 
sure either  with  the  palm  of  the  hand  or  fingers. 
When  difiicuUy  is  experitmeed,  the  patient,  if  young  or 
robust,  may  be  bled,  and  The  part  bii  fomented.  The 


164 


ANUS. 


large  intestines  may  also  be  emptied  by  means  of  a mild 
unirritating  clyster,  and  half  an  ounce  of  the  oleum 
ricini  should  be  exhibited.  In  the  habitual  prolapsus 
aiii  the  patient  himself  is  generally  accustomed  to  re- 
duce the  part,  or  it  goes  up  of  itself  when  he  lies  do^^^l. 
When,  however,  the  inllammation  and  swelling  are 
urgent,  the  part  ought  on  no  account  to  be  irritated 
by  repeated  attempts  at  reduction.  The  practitioner 
should  rather  have  recourse  to  the  antiphlogistic  plan, 
especially  leeches,  fomentations,  or  cold  washes,  and 
the  exhibition  of  the  oleum  ricini;  and  when  the 
swelling  has  been  lessened  the  reduction  may  be  again 
attempted.  When  the  reduction  is  prevented  by  a 
spasmodic  resistance,  the  use  of  an  anodyne  poultice 
or  fomentations,  a clyster  of  the  same  quality,  the 
wan*  bath,  and  the  internal  use  of  opium,  are  the 
best  means.  Should  the  complaint  not  give  way  to 
the  prece(hng  remedies,  and  the  symptoms  become  more 
and  more  pressing,  the  particular  situation  of  the  stric- 
ture should  be  examined  with  a probe,  and  divided 
either  tvith  a knife  and  director  or  with  a concealed 
bistoury.  Some  writers  speak  of  the  employment  of 
a speculum  ani ; but  on  account  of  the  globular  form 
of  the  disease,  it  must  be  difficult  ot  application. 
Cases  are  recorded  in  which  the  protruded  part,  either 
in  the  state  of  gangrene  or  of  chronic  hardness,  thick- 
ening, and  elongation,  has  been  removed  with  a knife 
or  ligature.— (See  CheseldeiVs  Anatomy,  A c.  1741 ; 
Kerstens,  Historia  Sedis  prociduce,  resectione  feliciter 
sa)iat(B,  Kilon,  1779;  Wtiately,  in  Med.  Tracts  and 
Observ.  vol.  8,  No.  16.) 

However,  I should  apprehend  that  in  the  circum- 
stance of  gangrene,  the  measures  best  calculated  for 
stopping  its  course,  detaching  the  sloughs,  and  keep- 
ing up  the  patient’s  strength,  must  always  be  more 
prudent  than  such  an  operation. 

The  reduction  having  been  effected,  it  is  proper  to 
introduce  the  fore-finger  up  the  rectum  in  order  to  as- 
certain that  no  intussusception  exists  above  the  anus 
v.'ithiii  the  spliincter.  The  bowel  is  then  to  be  kept  in 
its  place  by  quietude  and  the  recumbent  posture,  and 
if  there  be  a great  tendency  to  relapse  it  will  be  proper 
to  apply  to  the  fundament  a piece  of  sponge  or  com- 
presses, supported  w'ith  the  T bandage.  But  if  such 
means  shouid  not  answer,  and  an  habitual  prolapsus 
ani  should  recur  again  and  again,  wliich  is  not  unfre- 
quent when  the  disease  has  been  neglected,  or  its 
causes  have  long  remained  unremoved,  the  apparatus 
described  by  Mr.  Gooch  may  be  tried  with  more  hope 
of  success.— (CAir.  Works,  vol.  2,  />.•  150,  edit.  17l)2.) 
Others  have  used  perforated  balls  of  ivory.  Callisen 
found  the  introduction  of  a piece  of  sponge  wthin  the 
rectum,  fastened  to  a silver  probe,  give  effectual  sup- 
port. In  France,  instruments  made  of  elastic  gmn 
have  been  employed  with  advantage  for  supporting  the 
rectum. — {Richerarid,  Nosogr.  Chir.  t.  3,  p.  444,  cd.  4.) 

On  account  of  the  elasticity  and  unirritating  quality 
of  this  substance,  I conceive  it  is  better  calculated 
than  any  other  material  for  the  construction  of  such 
instruments.  It  cannot  be  denied,  however,  that  all 
foreign  bodies  in  the  rectum  create  serious  annoyance. 
In  the  female  sex,  a vaginal  pessary,  rather  prominent 
behind,  usually  hinders  the  recurrence  of  a prolpsus 
ani. 

The  late  Mr.  Hey  published  some  highly  interesting 
remarks  on  the  cure  of  the  procidentia  ani  in  adults. 
In  one  gentleman  the  disease  took  place  whenever  he 
had  a stool,  and  continued  for  some  hours,  the  gut  gra- 
dually retiring,  and  at  last  disappearing,  until  he  had 
occasion  to  go  to  the  privy  again,  .viler  each  stool,  he 
used  to  place  himself  in  a chair,  and  obtain  a little  re- 
lief by  making  pressure  on  the  prolapsed  part ; and  he 
then  was  in  the  habit  of  going  to  bed,  where  the  intes- 
tine by  degrees  regained  its  natural  situation.  While 
the  bowel  was  down  there  was  a copious  discharge 
from  it  of  a thin  mucous  fluid  blended  vvith  blood. 
When  the  part  was  up,  the  anus  was  constantly  sur- 
rounded by  a thin,  pendulous  flap  of  integuments,  ge- 
nerally hanging  down  to  the  extent  of  three-fourths  of 
an  inch.  Around  the  anus  there  were  also  several  soft 
tubercles  of  a bluish  colour,  situated  at  the  basis  and  at 
the  inner  part  of  the  pendulous  ilap.  These  were  evi- 
dently formed  by  the  extremity  of  the  rectum.  The 
patient,. previously  to  the  establisltrnent  of  these  habit- 
ual attacks  of  prolapsus  am,  had  been  afllicted  lor  se- 
veral years  with  pain  after  each  stool,  protuberances  at 
the  extremity  of  the  rectum,  and  di.-^chaigj  of  bl  md 


and  mucus.  For  these  complaints  he  applied  to  Mr. 
Sharp,  who  gave  him  an  ointment  to  be  applied  after 
each  stool,  some  soapy  pills  to  be  taken,  and  recom- 
mended the  use  of  a clyster  a little  before  the  time  of 
going  to  stool.  The  latter  remedy,  however,  could  not 
be  adopted,  and  no  material  benefit  was  derived  from 
the  others.  Some  years  afterward,  when  Mr.  Hey  was 
consulted,  the  foregoing  symptoms  continued ; in  addi- 
tion to  which  there  was  the  grievance  of  the  prolap- 
sus, which  came  on  at  every  time  of  going  to  stool, 
and  lasted  for  several  hours.  This  judicious  surgeon 
at  first  advised  the  patient  to  wash  the  prolajised  part 
with  a lotion  composed  of  an  infusion  of  oak-bark, 
lime-water,  and  spirit  of  wine,  and  keeping  on  the  tu- 
mour compresses,  wet  wiih  this  fluid,  and  supported 
by  the  T bandage.  The  disease,  however,  was  too  ob 
stinate  to  be  cured  by  this  treatment.  Nor  could  Mr. 
Hey  succeed  in  reducing  the  bowel  when  it  came  down. 
‘‘  Although,  (says  he)  the  prolapsed  part  of  the  intestine 
consisted  of  the  whole  inferior  extremity  of  the  rec- 
tum, and  was  of  considerable  bulk,  yet  the  impediment 
to  reduction  did  not  arise  from  the  stricture  of  the 
sphincter  ani ; for  I could  introduce  my  finger  with 
ease  during  the  procidentia;  but  it  seemed  to  arise 
from  the  relaxed  state  of  the  lowest  part  of  the  intes- 
tine and  of  the  cellular  membrane  which  connects  it 
with  the  surrounding  parts.  My  attempt  proved  vain 
as  to  its  immediate  object,  yet  it  suggested  an  idea 
which  led  to  a perfect  cure  of  this  obstinate  disorder. 
The  relaxed  state  of  the  part  which  came  down  at 
every  evacuation,  and  the  want  of  sufficient  stricture 
in  the  sphincter  ani,  satisfied  me  that  it  was  impos- 
sible to  afi’ord  any  effectual  relief  to  my  patient  unless 
I could  bring  about  a more  firm  adhesion  to  the  sur- 
rounding cellular  membrane,  and  increase  the  proper 
action  of  the  sphincter.  Nothing  seemed  so  likely  to 
etfect  these  purposes  as  the  removal  of  the  pendulous 
flap  and  the  other  protuberances  which  surrounded  the 
anus.”  This  operation  was  performed  on  the  13th  of 
November.  On  the  15th  the  gut  protruded  atid  did 
not  gradually  retire  as  it  used  to  do.  Mr.  Hey  at 
tempted  to  procure  ease  by  means  of  opiates  and  fo- 
mentations, and  avoided  immediately  trying  to  reduce 
the  prolapsed  part.  However,  the  prolapsus  conti 
nuedso  long  that  the  appearance  of  the  part  began  to 
alter,  and  therelbre,  on  the  16th  he  made  an  attempt  at 
reduction,  and  succeeded  vvith  great  ease.  However, 
as  a good  deal  of  pain  in  the  hypogastrium  was  still 
complained  of,  the  patient  was  bled  in  the  evening, 
and  gently  purged  with  the  oleum  ricini.  These  means 
gave  relief ; but  as  some  pain  in  the  belly  yet  continued, 
an  opiate  was  given.  A low  diet,  linseed  tea,  lac 
amygdalae,  Ac.  were  ordered,  and  a little  of  the  oleum 
ricini  every  morning,  or  every  other  morning,  with  an 
opiate  after  a stool  had  been  procured.  “ By  proceed- 
ing in  this  manner  lor  some  days,  regular  stools  were 
procured  without  any  permanent  inconvenience.  My 
patient  recovered  very  well,  and  was  freed  from  this 
distressing  complaint,  which  had  afllicted  him  so  many 
years.— (See  Hey's  Tract,  Obs.  p.  438,  A c.  ed.  2.) 

This  and  some  other  cases  which  this  gentlem.an 
has  related,  convincingly  exemplify  the  necessity  of 
paying  attention  to  the  removal  of  excrescences,  he- 
morrhoids, and  other  tumours,  situated  about  the  lower 
part  of  the  rectum,  in  cases  of  prolapsus  ani ; for  un 
less  this  object  be  accomplished,  the  disease  may  resist 
every  other  treatment.  Mr.  Howship  prefers  the  liga- 
ture for  the  extirpation  of  the  protuberances;  but 
heartily  commends  the  principle  of  the  treatment  pro- 
posed by  Mr.  Hey. — {Tract.  Obs.  on  Diseases  of  the 
Lower  Intestines,  p.  163,  ed.  3.)  An  elderly  gentleman, 
whom  I know,  was  troubled  for  many  years  with  a 
prolapsus  ani,  which  used  to  come  on  several  times  a 
week,  sometimes  at  the  privy,  and  sometimes  on  other 
occasions.  Several  of  the  first  surgeons  were  con- 
sulted, w'ho  failed  in  affording  permanent  benefit,  be- 
cause they  omitted  to  extirpate  some  hemorrhoidal  ex- 
crescences, situated  at  the  lower  part  of  the  rectum ; 
for,  w hen  thesb  were  afterward  removed,  the  prolapsus 
ani  entirely  disappeared. 

Hupuytren,  finding  that  the  excision  of  piles,  which 
so  often  accompany  prolapsus  ani,  commonly  prevented 
the  return  of  the  latter  complaint,  was  led  to  cut  olf 
more  or  less  considerable  portions  of  the  internal  mem- 
brane of  the  rectum.  However,  as  in  one  case  a juo- 
fuse  hemorrlnige  took  jilace,  and,  in  another,  a tedious 
snppuraiion,  he  ha.s  subsequently  adopted  tlie  plan  of 


ANUS. 


165 


removing  a certain  number  of  the  projecting  folds,  which 
may  be  seen  converging  from  the  circumference  to  the 
margin  of  the  anus.  He  lakes  hold  of  them  with  liga- 
ture-forceps, a little  flattened  at  osne  end,  and  cuts  them 
Oif  with  scissors  curved  on  their  flat  side.  This  prac- 
tice is  similar  to  that  employed  by  the  late  Mr.  Hey. 
Dupuytren,  in  his  first  method,  used  to  cut  away  the 
mucous  membrane  itself ; in  the  last,  only  the  folds  of 
skin  at  the  margin  of  the  anus  are  removed.  A woman 
had  had  a constant  prolapsus  ani  for  ten  years ; when 
she  was  in  the  upright  posture,  the  swelling  was  ten 
inches  in  one  diameter,  and  seven  in  the  other ; it  hin- 
dered her  froLn  walking,  and  continually  discharged  a 
mi.vture  of  blood  and  mucus.  Dupuytren  removed  five 
or  six  of,  the  projecting  folds  from  without  inwards. 
The  patient,  who  used  to  have  more  than  twenty  stools 
a day,  now  went  six  days  without  one ; on  the  seventh, 
however,  an  abundant  evacuation  took  place,  and  the 
prolapsus  never  returned.  ■ Merely  simple  dressings  are 
needed.  — ' See  Joum.  Universel  des  Sciences  M d.  No. 
81,  Sept.  1322.) 

The  last  indication  in  the  treatment  is  the  removal 
and  avoidance  of  all  such  causes  as  are  known  to  have 
a tendency  to  bring  on  the  complaint.  In  infants,  a 
fresh  protrusion  of  the  rectum  may  sometimes  be  pre- 
vented by  making  them  sit  on  a high  close-stool,  with 
their  feet  hanging  freely  down.  Every  thing  tending 
to  cause  either  diarrheea  or  costiveness  should  be 
avoided.  In  the  generality  of  cases,  however,  there  is 
an  inclination  to  costiveness,  which  must  be  obviated 
by  the  mildest  means.  For  this  purpose,  Mr.  Hey  used 
to  prescribe  half  an  ounce  of  the  oleum  ricini,  which 
is  to  be  taken  every  morning,  or  every  other  morning, 
as  circumstances  may  reiiuire.  The  same  practitioner 
sometimes  al  so  emiiloyed,  in  addition  to  this  medicine, 
a clyster  composed  of  a pint  of  water-gruel,  and  a large 
spoonful  of  treacle.  The  tone  of  the  relaxed  intestine 
is  to  be  restored  by  the  continued  use  of  cold  clysters, 
made  with  the  decoction  of  oak-bark,  alum,  and  vine- 
gar. In  one  obstinate  case,  under  the  care  of  Mr.  Hey, 
he  recommended  the  following  lotion  for  washing  the 
part  during  the  state  of  prolapsus,  and  he  also  advised 
its  application  to  the  anus  in  the  intervals,  by  means  of 
a thick  compress,  supported  by  the  T bandage.  E;. 
Aquie  calcis  simplicis  Ibij.  Cort.  quercus  contus.  ; iv. 
f.  infusum  per  hebdomadam,  et  colaturas  adde  sp.  vini 
reel.  3iv.  ft.  lotio.  — (See  Hey^s  Pract.  Obs.  p.  412, 
ed.  2.) 

Irritability  of  the  rectum  may  be  lessened  with  opium. 

The  intussusception  of  the  higher  part  of  the  bowel, 
especially  of  the  colon,  or  ccecum,  causing  a protrusion 
at  the  anus,  is  always  incurable,  as  it  is  not  in  the 
power  of  art  to  rectify  the  displacement.  Some  extra- 
ordinary cases  prove,  however,  that  large  portions  of 
the  intestinal  canal  thus  inverted,  may  be  separated  and 
voided,  and  the  patients  recover.— (See  Intussuscep- 
tion.) 

According  to  Mr.  Travers,  when  an  artificial  anus  is 
complicated  with  prolapsus,  the  case  very  rarely  ad- 
mits of  cure.— (See  Inquiry  into  the  Process  of  Nature 
in  repairing  Injuries  of  the  Intestines,  p.  374.) 

Surgical  writers  have  been  too  much  in  the  habit  of 
confounding  together  prolapsus  ani  and  intussusception. 
In  the  l.atter  dksease,  they  have  even  fallen  into  the 
error  of  supposing,  that  the  whole  of  the  rectum  be- 
comes everted,  in  consequence  of  the  relaxation  of  the 
sphincter  and  levatores  ani,  and  that  it  then  draws  after 
it  other  jiortions  of  the  intestinal  canal.  But  they  ought 
to  have  been  undeceived  by  the  strangulation,  which 
sometimes  occurs  under  such  circmnstances,  and  wlricli 
not  only  throws  a great  obstacle  in  the  way  of  the  re- 
duction of  the  displaced  part,  but  even  sometimes  brings 
on  mortification.  Besides,  the  connexions  of  the  rec- 
tum with  the  neighbouring  parts,  by  means  of  the  cel- 
lular substance,  which  surrounds  it,  and  the  attachment 
of  this  intestine  to  the  posterior  surface  of  the  urinary 
bladder,  render  the  above  origin  of  the  complaint  im- 
possible. Such  an  explanation  could  only  be  admitted 
with  regard  to  those  protrusions  of  the  rectum  which 
come  on  in  a very  slow  manner.  It  could  not  apply  to 
certain  cases,  in  which  the  everted  intestine  presents 
itself  in  the  form  of  an  enormous  tumour.  Fabricius 
ab  .Xquapendente  met  with  cases  of  prolapsus  of  the 
rectum,  where  the  tumour  was  as  long  as  the  forearm, 
a;id  as  large  as  the  fist.  In  the  M langes  des  Curicuv 
dr  la  Nafvre,  is  the  de«cription  of  a tumour  of  this 
sort,  wJiich  was  two  feet  long,  and  occurred  in  a 


woman  from  parturition.  Nor  is  a more  satisfactory 
reason  assigned  for  these  cases,  by  supposing,  that  they 
originate  from  a relaxation  of  the  villous  coat  of  the 
rectum,  and  its  separatioii  from  the  muscular  one.  We 
are  not  authorized  to  imagine,  that  such  a separation 
can  take  place  to  a considerable  extent,  nor  so  suddenly 
as  to  give  rise  to  the  pheiii>mena  sometimes  remarked 
in  this  disease. 

Accurate  observations  long  ago  removed  all  doubt 
upon  this  subject.  In  the  Memoires  de  VAr.ud  mie  de 
Chirurgie,  t.  II,  ed.  in  i2'/no.  is  an  account  of  a pre- 
tended prolapsus  of  Ihe  rectum,  which,  after  death, 
was  discovered  to  be  an  eversion  of  the  coccum,  the 
greater  part  of  the  colon  being  found  at  the  lovrer  end 
of  this  intestine,  and  most  of  the  rectum  at  its  upper 
part.  This  eversion  began  at  the  distance  of  more 
than  eleven  inches  from  the  anus,  and  terminated  about  ‘ 
five  or  sLv  from  this  opening,  the  tumour  formed  by 
the  disease  having  been  reduced  some  time  before  the 
child’s  death.  It  was  impossible  to  driw  back  the 
everted  jtart,  in  consequence  of  the  adhesions  which  it 
had  contracted.  Another  dissection  evinced  the  same 
fact.  A child,  having  suffered  very  acute  pain  in  the 
abdomen,  after  receiving  a blow,  had  a prolapsus  of 
intestine  through  the  anus,  about  six  or  seven  inches 
long.  This  was  taken  for  a prolapsus  of  the  rectum. 
After  death,  the  termination  of  the  protruded  bowel 
was  found  to  be  the  ccecum,  which  had  ])assed  through 
the  colon  and  rectum. — (See  Intussv.sception.) 

Schacher  de  Morbis  a Situ  Intestinorum  PreUrnatu- 
rali,  1721.  Luther,  de  Procidentia  Ani,  Erf.  1732. 
Heister,  Recti  Prolapsus  Anatome,  Helrnst.  1734. 
Gooch's  Chir.  Works,  vol.  2,  p.  150,  1702.  Rechcrches 
HUtoriques  sur  la  Gastrotomie,  ou  VOiivcrture,  du 
bus  Ventre,  dans  le  cas  du  Volvulus,  iS-c.,  par  M.  Hevin, 
in  Mm.  de  I'Acad.  Roy  ale  de  Chir.  t.  11,  p.  315,  ed.  in 
\2mo.  Mmteggia,  Ease.  Pathologici,  p.  91,  Tur.  1793. 
Jordan,  De  Prolapsu  ex  Ano,  Goett.  1793.  J,  Howship, 
Obs.  on  the  Diseases  of  the  Lower  Intestines,  c.  ed.  3, 
Land.  1821,  chap.  4.  Richter's  Anfangsgr.  der  Wun- 
darzn.  b.  6,  p.  403,  ed.  1802.  Callisen's  Syst.  ChirurgicB 
Hodiernae,  t.  2,  p.  521,  ed.  1800.  Hey's  Practical  Obs. 
in  Surgery,  p.  438,  c.  6vo.  ed.  2,  1810.  Jenirn.  Univ. 
des  Sciences  M'd.  No.  19,  Sept.  1822.  M.  J.  Chelius, 
Hanb.  der  Chir.  b.  I,  773,  Heiddb.  1826 

ANUS  ARTIFICIAL. 

This  signifies  an  accidental  opening  in  the  parietos  of 
the  abdomen,  to  which  opening  some  part  of  the  intes- 
tinal canal  tends,  and  through  which  the  feces  are, 
either  wholly  or  in  part,  discharged. 

An  artificial  anus  is  always  preceded  by  an  injury  of 
the  intestinal  canal,  either  a penetrating  wound  of  the 
abdomen,  ulceration  of  the  bowel,  and  the  bursting  of 
an  ab.scess  externally  ; an  operation,  in  which  the  pre- 
ternatural opening  is  jmrposely  made,  with  the  view  of 
savjng  life.,  in  particular  cases  of  imperforate  anus; 
an  accidental  wound  of  the  gut  in  the  operation  lor 
hernia;  or,  lastly,  and  most  commonly,  mortification 
of  the  bowel,  the  effect  of  the  violence  and  long  con- 
tinuance of  the  strangulation  of  the  part.  All  the.se 
cases  are  farther  divisible  into  such  as  are  attended 
with  a destruction  of  a portion  of  the  inte.stinal  tube ; 
and  into  those  which  are  not  accompanied  with  any 
such  loss  of  substance. 

Whatever  may  be  the  kind  of  injury  wliich  the  bow'el 
has  sustained,  one  thing  here  invariably  happens,  viz. 
the  adhesion  of  the  two  divided  portions  of  the  intes- 
tine to  the  edge  of  the  opening  in  the  parietes  cf  the 
abdomen.  This  occurrence,  which  has  the  most  salu- 
tary effect  in  preventing  extravasation  of  the  contents 
of  the  bowel  in  the  cavity  of  the  abdomen,  is  produced 
by  inflammation,  which  precedes  gangrene,  and  follows 
wounds.— (See  (Euvres  Chir.  de  Desault,  t.  2,  p.  352 — 
354.) 

When,  in  strangulated  hernia,  the  case  is  not  re- 
lieved by  the  usual  means,  or  when  the  necessary  ope- 
ration has  not  been  practised  in  time,  the  protruded 
bowel  sloughs  ; the  adjoining  part  of  it  adheres  to  the 
neck  of  the  hernial  sac  ; and  the  gangrenous  mischief 
spreads  from  within  outwards.  If  the  patient  live  long 
enough,  and  an  incision  in  the  tumour  be  not  now 
jiractised,  one  or  more  openings  soon  form  in  the  in- 
tegumentn,  and,  through  these  ajiertures,  the  feces  are 
discharge  1 until  the  separation  of  the  sloughs  gives  a 
freer  vent  to  the  excrement.  But  when  an  incision  is 
made,  the  feces  are  more  re.ndily  discharged,  and,  as 


166 


ANUS. 


Mr.  Travers  has  related,  this  is  sometimes  the  best 
mode  of  relief. 

“ 111  the  ordinary  situation  of  hernia  (as  this  gentle- 
man has  correctly  e.xplained),  the  portions  of  intestine 
embraced  by  the  stricture  occupy  a position  nearly 
parallel.  Their  contiguous  sides  mutually  adhere  ; in 
the  remainder  of  their  circumference  they  adhere  to 
the  peritoneum,  lining  or  Ibrming  the  stricture.  The 
existing  adhesion  of  the  contiguous  sides,  strengthened 
by  the  adhesion  of  the  parts  in  contact,  ensures  a par- 
tial continuity  uiion  the  separation  of  the  sphacelated 
part.  The  line  of  separation  is  the  line  of  stricture.  It 
commences  on  that  side  of  the  gut  which  is  in  • direct 
contact  with  the  stricture.  As  the  separation  advances, 
the  opposite  adhering  sides  may  perhaps  recede  some- 
what, and  a little  enlarge  the  angle  of  union.  But  it 
is  ever  afterward  an  angle;  and,  where  the  perito- 
neum is  deficient,  the  canal  is  simply  covered  in  by 
granulations  from  the  cellular  membrane  of  the  pa- 
rietes,  coalescing  with  those  of  the  external  or  cellular 
surface  of  the  peritoneum.”— (Om  the  Process  of  Na- 
ture in  repairing  Injuries  of  the  Intestines,  p.  360.) 
It  must  be  confessed,  that  few  surgeons  have  enter- 
tained sufficiently  accurate  ideas  of  the  changes  which 
happen  around  the  wounded  or  mortified  portion  of  in- 
testine, when  an  artificial  anus  is  produced  ; and, 
though  Desault’s  account  was  excellent,  as  far  as  it 
went,  it  was  not  until  the  year  1809,  when  Scarpa  pub- 
lished his  valuable  worjc  on  Hernia,  that  the  whole 
process  of  nature  on  such  occasions  was  completely 
elucidated.  The  hernial  sac  (says  he)  does  not  always 
partake  of  gangrene  with  the  viscera  contained  in  a 
hernia,  and  even  when  it  does  slough,  since  the  sepa- 
ration of  the  dead  parts  happens  on  the  outside  of  the 
abdominal  ring,  there  almost  always  remains  in  this 
situation  a portion  of  the  neck  of  the  hernial  sac  per- 
fectly sound.  It  may  be  said,  therefore,  that  in  all 
ca.ses,  immediately  after  the  detachment  of  the  morti- 
fied intestine,  whether  it  happen  within  or  on  the  out- 
side of  the  ring,  the  two  orifices  of  the  gut  are  en- 
veloped in  the  neck  of  the  hernial  sac,  which,  soon 
becoming  adherent  to  them  by  the  effect  of  inflamma- 
tion, serves  for  a certain  time  to  direct  the  feces  to- 
wards the  external  wound,  and  to  pre\ent  their  effu- 
sion in  the  abdomen.  In  proportion  as  the  outer  wound 
diminishes,  the  external  portion  of  the  neck  of  the  her- 
nial sac  also  contracts  ; but,  that  part  which  ernbraces 
the  orifices  of  the  intestine  gradually  becomes  larger, 
and  at  Lengm  forms  a kind  of  membranous,  funnel- 
shaped,  intermediate  cavity,  which  makes  the  commu- 
nication between  the  two  parts  of  the  bowel.  How- 
ever, according  to  Scarpa’s  investigation,  this  adhesion 
of  the  neck  of  the  hernial  sac,  round  the  two  orifices  of 
the  gut,  does  not  hinder  the  latter  from  gradually  quitting 
the  ring,  and  becoming  more  and  more  deeply  placed 
in  the  cavity  of  the  abdomen.  The  base  of  the  above- 
described  funnel-shaped  membranous  cavity  corres- 
ponds to  the  bowel,  and  its  apex  tends  towards  the 
wound  or  fistula. 

But  in  relation  to  this  part  of  the  subject,  there  are 
some  other  circumstances,  which  every  surgeon  should 
well  understand,  and  his  ignorance  of  them  would  not 
be  excusable,  on  the  ground  of  their  not  having  been, 
like  the  funnel-shaped  membranous  cavity,  forming 
the  communication  between  the  two  orifices  of  the 
bowel,  only  a discovery  of  recent  date  ; for  they  were 
fully  explained  many  years  ago.  I here  allude  to  the 
exact  position  of  the  two  portions  of  the  bowel,  with 
respect  to  each  other,  the  direction  of  their  orifices,  the 
angle  or  ridge  between  them,  and  the  difference  in  their 
diameters.  The  first  of  these  circumstances,  viz.  the 
position  of  the  two  parts  of  the  bowel,  was  correctly 
described  by  Morand,  and,  as  we  have  seen,  is  pointed 
out  by  Mr.  Travers,  who  represents  them  as  occupying 
a position  nearly  parallel,  and  cites  an  interesting  ob- 
servation recorded  by  Pipelet.  The  patient  was  a wo- 
man, 56  years  old;  the  loop  of  spoiled  gut  was  fiom 
five  to  six  inches  long ; fhe  contents  of  the  bowel  were 
discharged  through  the  wound  for  a considerable  time, 
and  an  artificial  anus  was  established.  Some  acci- 
dental obstruction  occurred  ; a purgative  was  given, 
which  operated  in  the  natural  way  ; and,  in  fifieen 
days,  the  wound  was  healed.  She  lived  in  perfect 
health  to  the  age  of  82,  when  she  died  of  a disease  not 
connected  with  this  malady.  Pipelet  examined  the 
body,  and  has  given  a figure  representing  the  union. 


The  line  of  the  intestine  formed  an  acute  angle,  where 
it  adhered  to  the  peritoneum,  opposite  to  the  crural  arch 
The  cylinder  is  evidently  much  contracted.  Pipelet 
particularly  dwells  upon  the  angular  position  and  con- 
striction of  the  tube  at  the  point  of  union.  The  lower 
continuation  of  fhe  intestinal  tube  was  also  remarked 
to  be  more  contracted  than  the  upper  portion  ; a cir- 
cumstance correctly  referred,  by  Mr.  Travers,  to  the 
undilated  state  of  the  bowels,  situated  between  the 
artificial  and  the  natural  anus.-^(See  Mem.  de  VAcad. 
de  Chir.  t.  4,  p.  164 ; and  Travers  on  Injuries  of  the 
Intestines,  p.  364)  The  two  ends  of  the  bowel,  as 
Scarpa  has  observed,  are  always  found  lying  in  a more 
or  less  parallel  manner  by  the  side  of  each  other ; the 
upper,  with  its  orifice  open,  and  directed  towards  the 
external  wound  by  the  feces,  which  issue  from  it, 
while  the  lower,  which  gives  passage  to  nothing,  be- 
comes less  capacious,  and  is  retracted  farther  into  the 
abdomen.  Hence,  the  breach  in  the  intestinal  canal  is 
never  repaired  by  the  orifices  of  the  upper  and  lowei 
portions  of  the  bowels  reuniting,  coalescing,  and  run- 
ning, as  it  were,  into  each  other.  Indeed,  they  meet  at 
•a  very  acute  angle ; the  axis  of  one  does  not  corres- 
pond to  that  of  the  other ; and  their  orifices  never  lie 
exactly  opposite  each  other.  It  is  in  short  by  means 
of  the  funnel-shaped  cavity,  formed  by  the  remains  of 
the  hernial  sac,  that  the  two  parts  of  the  bowel  com- 
municate, and  the  feces,  in  order  to  get  from  the  upper 
into  the  lower  continuation  of  the  intestine,  must  first 
pass  in  a semicircular  track  through  that  funnel-shaped 
cavity  ; there  being  between  the  orifices  of  the  bowel, 
directly  opposite  to  the  communication  between  the 
cavity  of  the  intestine  and  that  of  the  funnel-shaped 
membrane,  a considerable  projection,  or  jutting  angle, 
forming  a material  additional  obstacle  to  the  direct 
passage  of  the  feces  from  the  upper  into  the  lower  por- 
tion of  the  intestinal  tube. — (Scarpa  sulV  Ernie  Me- 
morie,  Nat.  Chirurgiche,  Milano,  1809.) 

Desault,  after  noticing  tlie  efficiency  of  the  adhesions, 
between  the  injured  part  of  the  bowel  and  the  edge  of 
the  opening  in  the  parietes  of  the  abdomen,  in  prevent- 
ing extravasation,  remarks,  that  if  such  adhesions  were 
entire,  the  abdominal  parietes  would  form  a substitute 
for  the  portion  of  the  canal  which  has  been  destroyed, 
and  the  contents  of  the  bowel  would  continue  to  pass 
as  usual  towards  the  anus,  if  the  portions  of  the  intes- 
tine, separated  and  adherent  to  the  neighbouring  parts, 
did  not  form  such  an  acute  angle  as  obstructs  the  pas- 
sage of  the  intestinal  matter.  The  more  acute  this 
angle  is,  the  greater  is  the  obstruction  ; when  the  two 
parts  of  the  bowel  lie  nearly  parallel,  the  entrance  into 
the  lower  portion  of  the  canal  is  completely  prevented ; 
but,  if  they  meet  at  a right  angle,  then  more  or  less  of 
the  contejits  of  the  upper  portion  may  be  transmitted 
into  the  lower.  The  first  disposition  chiefly  happens, 
when  a considerable  part  of  the  intestinal  canal  has 
been  destroyed,  or  when  the  tube  has  been  completely 
divided ; while  the  second  posture  is  principally  re- 
marked in  all  cases  where  the  injury  has  been  less 
extensive.  And  it  is  plain,  that  the  possibility  of  a 
cure  depends  materially  on  the  kind  of  angle  at 
which  the  two  portions  of  bowel  meet,  and  that  the 
projection  of  the  internal  fraenum,  or  jutting  membra- 
nous ridge  between  the  two  orifices,  is  always  a 
greater  or  less  obstacle  to  the  cure. 

With  respect  to  the  diminution  which  occurs  in  the 
diameter  of  the  part  of  the  intestinal  canal  between 
the  artificial  opening  and  the  natural  anus,  Desault 
admits  the  correctness  of  the  observation,  but  entirely 
dissents  from  such  authors  as  have  spoken  of  the 
change  as  sometimes  proceeding  so  far,  that  an  oblite- 
ration of  that  portion  of  the  intestinal  tube  is  the  con- 
sequence. The  mucus  secreted  within  it  suffices  for 
preventing  this  obliteration  ; a . secretion  which,  in 
these  cases,  is  copious,  and  is  partly  voided  from  the 
rectum  in  the  form  of  white  flakes.  And  if  any  far- 
ther proof  were  needed,  that  the  bowels  between  the 
artifioial  and  natilral  anus  remain  pervioiis,  it  is  fur- 
nished by  the  fact,  that  in  cases  of  artificial  anus,  the 
lower  continuation  of  the  tube  ftequently  becomes  in- 
verted, and  protrudes.  On  the  other  hand,  the  kind  of 
obliteration  above  spoken  of,  has  never  been  demon- 
strated by  dissection;  it  was  not  observed  by  Lecat,  in 
the  examination  of  the  body  of  a person,  who  died 
twelve  years  after  the  entire  cessation  of  the  passage 
of  feces  per  anum;  nor  was  it  found  to  exist  by  Do- 


ANUS. 


167 


sault,  when  he  opened  a patient  who  died  of  marasmus 
in  the  Hdtel-Dieu,  in  consequence  of  an  artiticial  anus, 
which  communicated  with  the  ileum,  and  had  lasted 
two  years. — {(F.uvr.  de  Default,  t.  2,  p.  354—356.) 

However  proper  the  formation  of  an  artilicial  anus 
may  be,  in  many  cases,  iri  which  the  patient’s  life  de- 
pends upon  the  event,  it  must  be  confessed  that  the 
consequence  is  a most  afflicting  and  disgusting  in- 
firmity. This  truth  cannot  be  denied  ; though  the  I'eces 
which  are  discharged,  from  not  having  been  so  long 
retained  in  the  bowels,  may  not  be  so  fetid  as  those 
which  are  evacuated  in  the  ordinary  way.  As  the 
opening,  which  gives  vent  to  the  excrement,  is  not  en> 
dued  with  the  same  organization  as  the  lower  end  of 
the  rectum,  and  as,  in  particular,  it  is  not  furnished 
with  any  sphincter  capable  of  contracting  and  relaxing 
itself  as  occasion  requires,  the  feces  are  continually 
escaping  without  any  knowledge  of  the  circumstance 
on  the  part  of  the  patient.  Hence  the  uncleanly  state 
of  the  parts  around  the  external  opening ; and  their 
frequently  excoriated  fungous  state.  Some  persons  in 
this  state,  among  the  number  of  those  whose  histories 
are  on  record,  made  use  of  a metal  box,  in  which  their 
excrement  was  received.  Schenckius  relates  the  case 
of  an  officer,  who  was  wounded  in  the  belly,  and  who 
allowed  his  feces  to  escape  into  a vessel  made  for  the 
purpose.  Dionis  mentions  a similar  case. 

Moscati  also  communicated  to  the  Academy  of  Sur- 
gery the  history  of  a wounded  man,  in  whom  an  artifi- 
cial anus  took  place,  in  consequence  of  a wound  in  the 
abdomen  below  the  right  hypochondrium.  His  excre- 
ment used  to  be  received  in  a tin  box,  fastened  to  him 
with  a belt.  The  wound  received  a leaden  cannula,  to 
which  the  tin  box  was  accommodated. 

Uncleanliness  is  not  the  only  inconvenience  of  an 
artificial  anus.  Persons  have  been  known  to  be  quite 
debilitated  by  the  affliction,  and  even  ultimately  to  die 
in  consequence  of  it.  This  is  liable  to  happen,  when- 
ever the  intestinal  canal  is  opened  very  high  up,  so  that 
the  aliment  escapes  before  chylification  is  completed, 
and  the  nutritious  part  of  the  food  has  been  taken  up 
by  the  lacteals.  In  this  circumstance,  the  patient  be- 
comes emaciated,  and  sometimes  perishes,  as  Desault 
had  an  opportunity  of  observing  ; and  examples  of 
which  are  al.so  recorded  by  Hoin  and  Le  Blanc.  In 
cases  of  this  description,  the  matter  voided  has  little 
fetor,  and  is  frequently  sourish.  In  all  instances,  the 
matter  is  evacuated  involuntarily,  because  there  is 
nothing  like  a sphincter.  But  when  the  opening  only 
interests  the  lower  convolutions  of  the  ileum,  or,  what 
is  more  frequent,  when  it  has  occurred  in  the  large  in- 
testines, the  danger  is  less  serious,  and  patients  in  this 
state  are  often  noticed  performing  all  their  functions 
very  well ; and,  with  the  exception  of  colic,  to  which 
they  are  subject,  enjoying  as  good  health  as  they  did 
previously  to  their  having  the  present  disease.  In  such 
examples,  the  matter  voided  is  more  fetid,  its  discharge 
does  not  follow  so  quickly  its  introduction  into  the 
stomach,  and  it  is  retained  for  a longer  time. 

Many  patients  afflicted  with  an  artificial  anus  void 
no  feces  at  all  from  the  rectum ; but  occasionally,  a 
thick  whitish  -substance,  which  is  the  mucous  secre- 
tion of  the  portion  of  the  large  intestines  nearest  to 
the  anus.  Under  certain  circumstances,  the  quantity 
of  this  mucus  discharged  is  more  copious. — {Desault, 
vol.  cit.p.  359.) 

The  most  grievous  occurrence  to  which  persons  with 
an  artificial  anus  are  exposed,  is  a prolapsus  of  the 
bowel,  similar  to  what  sometimes  happens  through 
the  anus,  with  respect  to  the  rectum.  The  descent  of 
the  bowel  is  sometimes  simple,  only  affecting  a portion 
of  the  intestinal  canal  just  above  or  below  the  opening. 
On  other  occasions  the  complaint  is  double,  the  bowel 
both  abovie  and  below  the  opening  being  prolapsed. 
This  descent  of  the  intestine  forms  a tumour,  the  dimen- 
sions of  which  vary  considerably  in  different  subjects. 
When  the  protrusion  is  caused  by  the  upper  part  of 
the  intestinal  canal,  the  feces  are  voided  at  the  extre- 
mity of  the  tumour,  and  when  the  swelling  consists 
of  the  lower  portion  of  the  bowel,  the  excrement  is 
evacuated  at  the  base  of  the  prolapsed  part.  By  ob- 
serving this  evacuation  when  the  tumour  is  double,  it 
is  easy  to  know  to  which  end  of  the  intestinal  canal 
each  protruded  portion  belongs.  This  consequence 
of  an  artificial  anus  is  very  serious,  because  it  greatly 
increases  the  inconvenience  which  the  patient  suffers. 
Sometimes  the  tumour  is  exquisitely  sensible ; and 


occasionally,  when  the  eversion  of  the  intestine  is  con- 
siderable, a strangulation  is  produced,  which  puts  the 
patient’s  life  in  danger. 

I apprehend  no  well-informed  surgeon  of  the  pre- 
sent day  can  doubt  that  formerly  the  frequency  of  arti- 
ficial ani  alter  hernia  was  seriously  increased  by  the 
absurd  measures  sometimes  adopted  for  the  express 
purjiose  of  preventing  them  ; and  as  Mr.  Travers  has 
rightly  observed,  the  cases  reported  by  the  old  surgeons, 
if  they  prove  any  thing,  prove  this  ; “ that  the  canal 
had  been  very  generally  restored,when  the  artificial  anus 
was  reckoned  upon  as  inevitable,  and  tuat  where  an  offi- 
cious solicitude  had  been  at  work  to  prevent  it,  showing 
itself  in  an  active  interference  with  the  arrangements 
of  nature,  the  case  has  terminated  in  artificial  anus ; 
so  that  the  event  either  way  has  been  a matter  of  sur- 
prise to  the  surgeon.  The  fear  of  doing  too  little,  or 
too  much,  applies  only  to  the  pernicious  customs  of  di- 
lating the  stricture,  displacing,  amputating,  and  sew- 
ing the  intestine  ; the  general  adoption  of  which  prac- 
tice fully  accounts  to  my  mind  for  the  number  of  arti- 
ficial ani,  which  are  the  sequelai  of  hernia.”— (Op.  cit. 
p.  367.) 

The  treatment  of  an  artificial  anus  is  either  pallia- 
tive or  radical.  The  first  consists  in  obviating  the  ha- 
bitual uncleanliness  produced  by  the  involuntary  dis- 
charge of  the  intestinal  matter,  and  in  relieving  such 
bad  symptoms  as  may  arise  from  the  disorder. 

The  first  indication  is  fulfilled  by  the  employment  of 
silver  or  tin  machines,  which  are  either  kept  applied 
to  the  external  opening  by  means  of  a spring,  or  form 
receptacles  jilaced  more  or  less  off  the  artificial  anus, 
from  which  the  intestinal  matter  is  transmitted  through 
a tube,  kept  constantly  in  the  opening.  In  general, 
says  Desault,  as  elastic  gum  is  supple,  light,  and  ca- 
pable of  taking  any  shape,  it  is  the  best  material  for 
the  construction  of  such  instruments,  which,  however, 
rarely  answer  their  purpose  completely,  and  always 
give  the  patient  a great  deal  of  trouble. 

As  for  the  second  indication,  Richter,  with  the  view 
of  hindering  the  too  quick  escape  of  the  intestinal  mat- 
ter, and  the  death  of  the  patient  from  this  cause,  pro- 
po.sed  covering  the  opening  for  a certain  time  with  a 
piece  of  sponge,  supported  by  an  elastic  bandage  or 
truss.  But  Loeffler  found  this  method  objectionable, 
as  it  was  apt  to  bring  on  colic,  constipation,  and  an 
inflamed  excoriated  state  of  the  skin. 

When  the  outer  opening  is  disposed  to  contract  too 
much,  and  inconveniences  arise  from  this  change,  Sa- 
batier is  an  advocate  for  preventing  such  closure  by 
means  of  a tent,  or  skein  of  silk,  introduced  into  the 
aperture,  and  changed  very  ofleii  for  the  sake  of  clean- 
liness ; while  others  prefer  a ring  of  ivory  for  the  pur- 
pose. But  the  irritation  produced  by  the  matter  im- 
bibed by  this  sort  of  tent,  and  in  particular  the  liability 
of  the  bowel  to  protrude,  and  be  strangulated  in  the 
opening  of  the  ivory  ring,  are  found  strong  objections 
to  these  practices ; and  according  to  Desault,  the  sponge 
employed  by  Richter  also  occasions  a great  deal  of  ex- 
coriation by  the  irritation  of  the  fluid  which  is  lodged 
in  it. 

For  the  purposes  of  hindering  a protrusion  of  the 
gut,  of  keeping  the  opening  suflicieiit'y  pervious,  of 
relieving  any  uneasiness  and  tenesmus,  of  hindering 
the  intestinal  matter  from  escaping  in  the  intervals  of 
dres-sitig,  and  confining  it  long  enough  for  the  adequate 
nourishment  of  the  patient,  Desault  preferred  a linen 
tent  or  stopper  covered  by  a pad  of  charpie,  compresses, 
and  a tight  bandage.  At  first,  says  he,  the  patient 
feels  some  uneasiness  from  this  plan,  and  slight  colics 
may  be  the  consequence  of  it ; but,  by  degrees,  the 
parts  become  habituated  to  their  new  state,  and  every 
thing  goes  on  well.  With  respect  to  the  employment 
of  tents  and  plugs  with  the  views  above  indicated,  I 
am  disposed  to  think  the  practice  can  rarely  be  advisa- 
ble ; and  that  any  necessity  for  it  may  be  obviated  by 
attention  to  diet,  and  the  occasional  exhibition  of  laxa- 
tive medicines  and  clysters,  as  will  be  hereafter  no- 
ticed. When  the  gut  protrudes,  its  reduction  is  to  be 
effected  in  the  same  way  as  a common  prolapsus  ani : 
but  serious  difficulty  will  occur  when  the  protruded 
part  is  inflamed,  thickened,  and  of  considerable  size. 
Indeed,  surgeons  have  usually  regarded  the  reduction 
as  impracticable  in  these  circumstances  ; but  accord- 
ing to  Desault  this  is  not  the  case,  as  compression  with 
a bandage,  kept  up  for  some  days,  will  succeed.  Care 
must  be  taken,  however,  to  leave  a sufficient  opening 


168 


ANUS. 


for  the  passage  of  the  feces.  \Miatever  may  be  the 
size  of  the  protrusion,  Desault  argues,  that  it  should 
be  the  invariable  rule  of  the  surgeon  to  endeavour  to 
return  the  part  by  the  means  here  suggested. — (See 
ULuvres  Chir.  de  Deaault,  t.  2,  p.  361 , .i  c.) 

The  radical  cure  is  what  is  next  to  be  considered. 
The  business  of  the  surgeon  is  to  prevent,  if  possible,  the 
formation  of  an  artificial  anus;  but  when  the  event  has 
occurred,  and  particularly,  when  the  whole  or  the  greater 
part  of  the  stools  is  discharged  in  this  way , no  attempt 
must  be  made  to  stop  up  the  opening  without  a great 
deal  of  consideration  ; for  any  eflbrt  of  this  kind, 
made  under  circumstances  which  do  not  justify  it, 
may  be  the  means  of  exposing  the  patient’s  life  to  the 
most  alarming  danger.  Sometimes,  indeed,  without 
any  interlereuce  of  the  surgeon,  the  outward  opening 
contracts,  and  the  issue  of  the  intestinal  matter  being 
obstructed,  pain  and  tene.smus  are  excited  ; and  the 
same  consequences  may  be  produced  by  any  swelling 
and  enlargement  of  the  projecting  ridge,  situated  be- 
tween the  two  portions  of  the  bowel.  In  two  cases 
Puy  found  this  sweliing  take  place  in  such  a degree, 
that  the  patiuuts  fell  victims  to  the  complete  stoppage 
of  the  intestinal  contents.  The  synnptoms  which  arise 
are  then  sunilar  to  those  which  happen  in  strangu- 
lated hernia.  Hoin,  Le  Blanc,  and  Sabatier  also  cite 
Instances,  in  which  the  patients  lost  their  lives  by  gan- 
grene, brought  on  by  this  species  of  strangulation. — 
(Desault,  vol.  cit.  p.  360.) 

There  is  a period  (say  s Mr.  Travers),  at  which  the 
function  of  the  lower  portion  of  the  canal,  tvith  a little 
assistance,  may  be  restored.  The  natural  order  of 
events  connected  with  this  recovery  has  been  mis- 
taken and  inverted.  Practitioners  have  closed  the 
wound  instead  of  conducting  tlie  matter  by  purga- 
tives and  clysters  into  the  large  intestines.  Now,  the 
wound  will  never  fail  to  heai,  when  the  matter  reco- 
vers its  accustomed  route ; but  this  condition  cannot 
be  reversed.  The  restoration  is  safest  when  most 
gradual;  when  there  is  evidence  of  an  existing  sym- 
pathy betw'een  the  repair  of  structure  and  the  return 
of  function.  According  to  the  same  gentleman,  there 
is  reason  to  believe,  that  the  well-timed  exhibition  of' 
a single  purgative  might  often  prove  effectual.  “ If' 
the  food  IS  rapid  and  little  changed  in  its  pa.ssage,  it 
should  be  pultaceous  and  nutritive,  and  given  in  mode- 
rate quantity  at  short  inten’als ; while  injections  of 
the  same  kind  should  be  administered  at  least  twice  in 
twenty-four  hours,  and  retained  as  long  as  possible.” 
He  states  that  by  such  means  patients  n.ay  be  nou- 
rished for  m?ny  weeks.  If  the  discharge  is  sparing, 
and  does  not  readily  escape,  he  recommends  an  occa- 
sional purgative  in  less  than  ordinary  quantity.  He 
disapproves  of  other  medicines,  especially^  stimulants, 
and  all  such  food  as  is  difficult  of  digestion,  giving  a 
general  preference  to  animal  food  in  a gelatinous  form. 
He  bestows  just  praise  on  strict  attention  to  cleanli- 
ness, and,  in  opposition  to  Desault  and  Sabatier,  con- 
demns the  employment  of  tents  and  sponges. — (Op. 
cit.  p.  371.  373.) 

Numerous  cases  on  record  furnish  abundance  of 
proof,  that  the  feces,  after  being  voided  for  several 
months  fro.m  the  wound  produced  by  the  operation  for 
hernia,  frequently  resume  their  natural  course.  Facts 
of  this  kind,  wliich  in  general  may  be  said  to  be  com- 
mon when  the  intestine  is  without  loss  of  .substance, 
are  not  very  rare  even  when  more  or  less  of  the  bowel 
has  been  destroyed  by  gangrene  ; and  many  illu.stra- 
tions  of  this  remark  may  be  found  in  the  writings  of 
De  la  Peyronie,  Louis,  Petit,  Pott,  Le  Dran,  &c.  The 
greater  number  of  the.se  instances  of  succes.s,  as  al- 
ready stated,  were  the  result  of  the  most  simple,  un- 
officious  treatment,  or  rather  of  the  undisturbed,  and 
yery  little  assisted,  efforts  of  nature. 

In  the  radical  cure  of  an  artificial  anus,  the  follow- 
ing are  the  general  indications  laid  down  by  Desault : 

1.  To  reduce  the  gut  when  it  protrudes  and  is  everted. 

2.  To  prevent  the  issue  of  the  feces  from  the  wound, 
so  that  they  may  be  obliged  to  pass  on  towards  the 
rectum,  at  the  same  time  that  the  healing  of  the  exter- 
nal opening  is  to  be  promoted.  3.  To  obviate  any  in- 
ternal impediments  to  the  passage  of  the  matter  into 
the  lower  part  of  the  intestinal  catial. 

How  the  first  of  these  objects  i.s  to  be  aecom.plished  in 
the  case  of  greatest  difficulty,  that  is,  when  the  pari- 
ctes  of  line  bowel  are  thickened,  has  been  already  ex- 
plained. Experience  proves,  says  Desault,  liiat  tho 


second  indication  cannot  be  lul  filled  by  metins  of  sn- 
tures.  The  best  thing  for  this  purpose  he  represents 
to  be  the  linen  stopper,  above  spoken  of  as  a means 
for  preventing  the  protrusion  of  the  bowel.  Here  it 
answers  the  double  object  of  hindering  such  a protru- 
sion, and  filling  up  the  fistulous  opening,  so  as  to  make 
the  contents  of  the  bowel  tend  towards  the  anus.  De- 
sault argues  that  the  surgeon  need  not  be  apprehen- 
sive of  the  tent  doing  harm  by  keeping  the  wound 
from  healing.  The  first  aim,  he  says,  shouid  be  to 
determine  the  feces  to  take  their  natural  route ; and 
when  this  has  been  done  by  closing  the  external  open- 
ing, the  tent  may  be  removed,  and  this  opening  will 
spontaneously  close. 

However,  when  the  internal  impediment  is  too  great, 
it  must  be  overcome  ere  such  treatment  can  be  suc- 
cessful. According  to  Desanlt,  the  most  frequent  im- 
pediment here  alluded  to,  is  the  angle  formed  by  the 
two  portions  of  the  intestine,  and  it  must  be  enlarged, 
and  rendered  less  acute,  in  order  that  the  feces  may 
continue  their  route.  This  desirable  change  he  re- 
commends to  be  effected  by  introducing  long  dossils  of 
charpie  into  the  two  ends  of  the  bowel,  and  gradually 
altering  their  direction  so  as  to  bring  it  into  one  same 
straight  line.  WTien  the  dilatation  is  sufficient,  and 
the  inner  angle  or  ridge  is  effaced,  the  long  dossils 
need  not  be  continued.  The  linen  tent,  with  the  pre- 
caution of  not  introducing  it  too  deeply,  lest  it  obstruct 
the  course  of  the  feces  itself,  will  then  suffice.  When 
this  plan  is  skilfully  managed,  Desault  says,  there 
will  be  a great  chance  of  its  succeeding,  and  its  bene- 
ficial effect  will  be  denoted  by  a rumbling  in  the  bow- 
els, and  frequently  by  slight  colics.  At  first  wind  is 
discharged  from  the  rectum,  and  soon  afterward,  the 
feces  begin  to  come  away.  On  the  contrary,  if  they 
should  not  pass  tvith  facility,  the  colic  be  violent,  and 
an  accumulation  happen  in  the  upper  iiortion  of  the 
inte.stinal  canal,  the  tent  must  be  withdrawn,  and  the 
other  cause  of  obstruction  be  considered,  and,  if  possi- 
ble, removed. — (Vol.  cit.  p.  355,  Ac.) 

In  the  preceding  columns,  I have  given  a ftill  ex- 
planation of  the  impediment  made  to  the  passage  of 
the  feces  into  the  lower  orifice  of  the  intestinal  canal, 
by  the  projecting  septum  or  ridge  between  the  two 
parts  of  the  bowel,  and  the  matter  havitig  to  traverse 
the  funnel-shaped  membranous  cavity  in  quite  a semi- 
circular track.  A representation  of  this  septum  may 
be  seen  in  Scarpa’s  work,  tab.  9,  fig.  1,  and  also  in  the 
sixth  plate  of  Mr.  Traver’s  Inquiry.  In  one  example 
in  which  this  septum  was  plainly  visible  in  the  w’ound, 
Dupuytren  introduced  into  the  orifice  of  the  upper  part 
of  the  bowel  a curved  needle,  and  passing  it  through 
the  projecting  septum,  brought  it  out  again  through 
the  orifice  of  the  lower  portion  of  the  gut.  Thus  he 
in  luded  a considerable  part  of  the  septum  in  a liga- 
ture, which  was  daily  made  thicker  with  a view  of 
first  exciting  inflammation  in  the  two  layers  of  this 
septum,  and  thus  ensuring  their  adhesion  together, 
and  his  next  plan  consisted  in  making  a division 
through  the  part  embraced  by  the  ligature,  whereby 
the  passage  for  the  feces  into  the  lower  jiortion  of  tha 
bow'el  was  made  quite  free.  But  as  the  section  made 
by  the  ligature  was  too  superficial,  Dupuytren  com- 
pleted the  division  of  the  septum  with  a knife ; but 
peritonitis  and  the  death  of  the  patient  ensued.  Ac- 
cording to  Dr.  Breschet,  the  ligature  also  proved  in- 
effectual, because  its  operation  was  so  slow,  that  adhe- 
sions and  cicatrization  took  place  behind  it  as  fast  as  it 
made  its  way  through  the  rest  of  the  septum.  Hence, 
the  expectation  that  the  feces  would  sufficiently  pass 
through  the  aperture  made  by  the  ligature  was  hot 
realized  ; and  in  one  case  quoted  by  Breschet,  though 
some  amendment  followed  the  operation,  still  the  cure 
was  far  from  being  accomplished,  as  only  some  of  the 
feces  passed  out  of  the  natural  anus,  w hile  th^remain- 
ing  and  greater  part  of  them  still  came  through  the  fis- 
tula.— (See  Graefe’s  Journ.  b.  2,  p.  300.)  In  another 
case,  Dupuytren  tried  to  render  the  layers  of  the  sep- 
tum adherent  by  compressing  them  between  the  blades 
of  a pair  of  forceps  of  particular  construction,  and  af- 
terward he  effected  the  division  of  the  part  by  augment- 
ing the  compression  by  means  of  a screw  traversing  the 
handles  of  the  instrument.  In  a case  which  followed  the 
operation  for  bubonocele,  attended  with  mortification  of 
the  bowel,  Dupuytren  began  w idi  tU.'ating  the  outer  open- 
ing with  a bistoury,  and  after  a.scei  tai  niug  the  position  of 
the  sfqiium,  bet  ween  the  two  orifices  of  the  bow  el,  he  in- 


ANUS, 


169 


troduced  one  of  the  blades  of  the  forceps  into  each 
portion  of  the  gut,  and  closed  the  instrument  with  the 
screw.  The  part  of  the  instrument  situated  externally 
to  the  ridge  or  septum,  he  covered  with  charpie  and  a 
compress.  The  constriction  was  soon  followed  by 
colic  pains  and  tendency  to  vomit,  complaints  which 
were  quickly  removed  by  fomenting  the  belly.  They 
recurred,  however,  the  instrument  became  loose,  and 
some  dLscharge  ensued.  On  examination,  the  septum 
was  found  to  be  partially  divided.  After  the  breadth 
of  the  instrument  had  been  lessened  it  was  applied 
again  ; but  when  the  screw  was  turned,  the  patient 
began  to  suffer  such  violent  pain  over  the  whole  of 
the  abdomen,  that  it  was  necessary  to  diminish  the 
pressure ; and  as  the  instrument  was  afterward  se- 
parated from  the  parts  in  a fit  of  vomiting,  it  was 
withdrawn.  A trial  was  now  tnade  to  determine  the 
feces  towards  the  rectum  by  pressure  on  the  externa) 
apening;  but  the  plan  could  not  he  endured,  and  the 
hindranc-e  to  the  egress  of  the  intestinal  matter  was  so 
oppressive  that  it  was  discontinued.  As  the  forceps 
used  on  the  foregoing  occasion  did  not  take  sufficient 
hold  of  the  septum,  nor  divide  it  properly,  the  in- 
strument was  somewhat  altered.  A particular  de- 
scription of  its  improved  make  has  been  inserted  by 
Breschet  in  G aefe's  Journal,  b.  2,  p.  302.  Dr.  Rei- 
singer  has  published  three  ca.ses  in  which  it  was  suc- 
cessfully employed  by  Dupuytren.  In  the  first  of 
these  examples,  when  the  instrument  had  been  applied, 
it  embraced  the  septum  so  well,  that  it  could  not 
be  displaced  from  it.  The  colic  attacks,  vomiting 
thirst,  furred  tongues,  and  loss  of  appetite,  which  en- 
sued, soon  gave  way  alter  the  belly  had  been  fo- 
mented; the  constriction  was  then  increased,  and 
found  to  produce  less  and  less  indisposition.  On  the 
29th,  very  little  of  the  feces  came  out  of  the  artificial 
anus,  and  after  a short  time,  five  natural  evacuations 
took  place.  The  blades  of  the  instrument  were  now 
completely  closed,  and  on  taking  it  out,  a slough  of 
membrane  was  found  between  the  blades ; a proof 
that  the  septum  was  destroyed.  On  the  30th,  the  pa- 
tient's health  was  undisturbed.  Clysters  were  now' 
administered  with  the  view  of  promoting  evacuations 
in  the  natural  manner  ; and  the  next  day,  the  patient 
had  a proper  motion  without  any  assistance,  and  a 
very  small  quantity  of  the  feces  jiassed  out  of  the  fis- 
tulous opening.  This  aperture  was  now  merely  co- 
vered with  charpie ; but  as  some  high  granulations 
were  rising,  the  powder  of  colophonium  was  sprin- 
kled on  them,  and  compresses  and  a bandage  were  ap- 
plied. The  use  of  clysters  was  also  daily  continued, 
though  the  patient  voided  his  feces  in  the  natural  way. 
On  discontinuing  the  external  pressure,  the  quantity 
of  discharge  from  the  fistulous  opening  increased ; 
and,  therefore,  on  the  first  of  October,  the  compresses 
vrere  again  aiiplied,  and  kept  on  the  part  with  a spring 
truss.  The  treatment  ended  in  a perfect  cure. 

In  another  ca.se,  Dupuytren  enlarged  the  low'er  an- 
gle of  the  outer  opening  with  a bistoury,  and  after  feel- 
ing with  his  finger  that  both  orifices  of  the  bowel  were 
close  to  that  ot>ening,  he  applied  the  forceps.  In  the 
eveninc,  the  constriction  was  increased,  which  was 
followed  by  severe  colic  pains  over  the  whole  abdo- 
men. They  subsided,  however,  the  following  day. 
From  the  outer  opening,  a great  deal  of  slimy  excre- 
ment was  discharged.  The  constriction  was  not  aug- 
mented. On  the  5th  day,  the  patient  was  attacked  in 
the  night  with  pain  and  vomiting.  The  following 
night  he  was  also  very  restless.  Though  the  belly  was 
not  tense,  it  could  not  bear  to  be  touched.  On  the  11th, 
and  12th  days,  the  patient  was  nearly  free  from  pain, 
and  by  means  of  clysters,  two  natural  motions  were 
procured;  and  on  the  13th,  as  the  patient  was  easy, 
Dupuytren  began  to  make  pressure  on  the  fistulous 
opening.  On  the  26th,  the  edges  of  the  aperture  were 
touched  with  lunar  caustic;  and  on  the  28th,  a com- 
press supported  by  a spring  truss  was  applied.  The 
patient  was  kept  constantly  in  the  horizontal  posture ; 
the  feces  began  to  be  voided  the  natural  way  regularly, 
and  the  opening  contracted  in  the  most  favourable 
manner. 

I think  the  generality  of  surgeons  will  agree  with 
Dr.  Rcisinger,  that  the  foregoing  treatment  cannot  be 
indiscriminately  adopted  in  all  descriptions  of  patients 
without  danger.  It  should  never  be  tried  too  soon  after 
the  formation  of  an  artificial  anus ; but  time  should 
be  allowed  lor  tiie  irriiabiluy  and  sensibility  of  the  gut, 


and  especially  of  the  septum,  to  be  lessened  by  the 
effect  of  the  air  and  the  pressure  of  the  feces.  Nor 
should  the  trial  ever  be  made  ere  it  has  been  fully  as- 
certained that  nature  cannot  herself  bring  about  the 
cure.  Breschet  mentions  an  example  in  which  the 
foregoing  method  could  not  have  been  practised,  in 
consequence  of  the  mouth  of  the  lower  portion  of  the 
bowel  having  been  obliterated  by  the  pressure  of  a. 
large  tent  three  inches  long,  which  had  been  worn  by 
the  patient  two  years,  and  the  projecting  ridge  could 
not  be  detected.-  (See  Grae/e’s  Joum.der  Chir.  b.  2, 
p.  298.)  Many  other  interesting  observations  on  this 
new  proposal  may  be  perused  in  the  memoir  by  Dr. 
Breschet,  and  in  Dr.  Reisinger’s  tract,  the  title  of 
which  is  given  in  the  list  of  works  at  the  end  of  the 
pre.sont  article.  In  order  not  to  incur  the  risk  of  ex 
travasation  of  the  feces  in  the  abdomen,  tiie  constric- 
tion of  the  septum  should  never  be  increased  with  im- 
prudent haste  before  the  adhesive  inflammatiori  has 
had  time  to  be  produced  between  the  layers  of  which 
that  part  is  composed. 

In  cases  of  artificial  anus,  the  appearance  of  the  mu- 
cous coat  of  the  bowel  undergoes  some  change,  in  con- 
sequence of  exposure  to  the  air  and  the  contact  of  ex- 
traneous bodies;  it  becomes  redder  and  less  villous, 
but  does  not  cea.se  to  secrete  a great  quantity  of  mu- 
cus : this  is  one  of  the  principal  reasons  why  it  is  so 
difficult  to  close  the  fistulous  opening,  even  when  the 
passage  for  the  feces  has  been  re.stored.  The  skin 
around  an  artificial  anus  is  also  generally  very  irritable, 
and  rendered  exceedingly  painful  by  the  contact  of  the 
excrement.--(Breschet,  in  Grae/e’s  Journ.  b.  2,  p.  303.) 

If  after  the  destruction  of  the  septum,  and  the  re-es- 
tablishment of  a free  communication  between  the  two 
portions  of  the  bow'el,  the  external  fistula  were  not  to 
admit  of  being  healed  by  pressure  and  other  ordinary 
means,  no  doubt  could  be  entertained  of  the  propriety 
of  revsorting  to  the  plan  ol'  attempting  to  cure  it  by  par- 
ing off  the  edges  and  bringing  them  together  with  su- 
tures, as  is  sometimes  done  by  Dupuytren,  or  on  the 
Taliacotian  principles,  as  successfully  exemplified  by 
Mr.  G.  F.  Collier. — (See  Med.  mui  Physical  Journ.  for 
June,  1820.)  Dupuytren.  for  the  purpose  ol'  making 
the  sides  of  the  fistula  remain  in  contact,  or  making 
them  approach  each  other,  occasionally  applies  an  in- 
genious little  instrument  consisting  of  two  pads,  which 
by  means  of  a screw  can  be  made  to  embrace  the  part. 
An  engraving  of  it  may  be  seen  in  Grae/e’s  Journ.  b.  3, 
tqf.  2,/g.  9.  For  the  closure  of  the  fistula,  Dupuy- 
tren  also  sometimes  has  recourse  to  the  actual  cau- 
tery. 

I shall  conclude  with  the  relation  of  an  interesting 
case  of  artificial  anus  complicated  with  prolapsus,  as 
recorded  -by  my  friend  Mr.  Lawrence. 

“ If  the  complaint  (a  mortified  hernia)  terminates  in 
the  formation  of  an  artificial  anus,  we  must  endeavour 
to  alleviate  those  distressing  inconveniences  which 
arise  from  the  involuntary  discharge  of  wind  and  feces 
through  the  new  opening,  by  supplying  the  patient 
with  an  aiiparatus  in  which  these  may  bo  received  as 
they  pass  off.  An  instrument  of  this  kind,  the  con- 
struction of  which  appears  very  perfect,  is  described 
by  Richter  (Anfangsgr.  der  Wundarzn.  vol.  5),  from 
the  Trait.  d'S  Bandages  of.]uville.  , The  patient  will 
be  best  enabled  to  adapt  any  contrivance  of  this  sort  to 
the  particular  circumstances  of  his  own  case.  It  has 
been  found  in  some  instances,  that  a common  elastic 
truss  with  a compress  of  lint  under  the  pad,  has  been 
more  serviceable  than  any  complicated  instrument 
(Parisian  Journal,  vol.  1,  p.  193)  in  preventing  the 
continual  flow  of  feculent  matter  from  the  artificial 
opening.” — (Treatise  on  Hernia,  p.  206.) 

“ 1 know,”  says  Mr.  Lawrence,  “ a patient  with  an 
artificial  anus,  in  whom  the  gut  often  protriules  to  the 
length  of  eight  or  ten  inches,  at  the  same  time  bleeding 
from  its  surface.  This  is  attended  with  pain,  and 
compels  him  to  lie  down  ; in  w’hich  position  tlie  intes- 
tine recedes.  The  patient  has  now  discharged  all  his 
feces  at  the  groin  for  fifteen  years,  and  has  enjoyed  to- 
lerable health  and  strength  during  that  time.  His 
evacuations  are  generally  fluid,  but  sometimes  of  the 
natural  consistence.  Whenever  he  retains  his  urine 
after  feeling  an  inclination  to  void  it,  a quantity  of 
clear  inoffensive  mucus  like  the  white  of  an  egg 
amounting  to  about  four  ounces,  is  expelled  from  the 
anus ; and  this  may  occur  twoor  three  times  in  the  day  ** 
—(P.  208.) 


170 


ANU 


AOR 


When  the  protruded  intestine  is  strangulated,  an 
operation  may  become  necessary  for  the  removal  of 
the  stricture. — {Schmucker,  Vermischte  Chirurgische 
Schri/ten,  t.  2.)  Two  cases  which  terminated  fatally 
from  this  cause  are  mentioned  by  Sabatier,  in  a me- 
moir in  the  5th  torn,  de  I’Acad.  de  Chir.  Mr.  Lawrence 
also  refers  to  Le  Blanc. — {Precis  d'Op  rations  de  Chir . 
tom.  2,  p.  445.)  We  should  always  endeavour  to  pre- 
vent such  protrusions  when  a disposition  to  their  form- 
ation seems  to  exist,  by  the  use  of  a steel  truss,  which 
should  indeed  be  worn  by  the  patient  independently  of 
this  circumstance.  If  the  tumour  has  become  irredu- 
cible by  the  hand,  an  attempt  may  be  made  to  replace 
it  by  keeping  up  a constant  pressure  on  the  part,  the 
patient  being  at  the  same  time  confined  to  bed.  By 
these  means,  as  we  have  already  noticed,  Desault  {Pa- 
risian Joum.  vol.  1,  p.  178)  returned  a very  large  pro- 
lapsus, and  by  pressure  on  the  opening,  the  ffeces  were 
made  to  pass  entirely  by  the  anus,  although  for  four 
years  they  had  been  voided  only  through  the  wound. — 
{Lawrence,  p.  209,  210.) 

In  cases  of  mortified  hernia,  the  wound  sometimes 
closes,  except  a small  fistulous  opening  which  dis- 
charges a tliin  fiuid  and  cannot  be  healed.  Mr.  Law- 
rence has  related,  in  his  excellent  treatise  on  hernia, 
a case  in  which  the  feces  came  from  the  wound  some 
time  after  an  operation,  although  the  bowel  did  not  ap- 
pear gangrenous  when  this  proceeding  was  adopted. 
— (P.  211.) 

In  the  appendix  to  this  work,  the  author  adds  some 
farther  account  of  the  case  of  artificial  anus  wdiich  he 
has  related.— (P.  208.)  The  man  is  sixty  years  of  age, 
and  appears  to  be  healthy,  active,  and  even  younger 
than  he  really  is.  He  had  had  a scrotal  hernia 
which  ended  in  mortification,  and  involved  the  testicle 
of  the  same  side  and  a large  portion  of  the  integuments 
in  the  destruction.  It  is  now  nearly  seventeen  years 
since  this  event,  and  the  feces  have  during  all  this 
time  been  discharged  from  the  groin.  He  has  never 
made  use  of  a truss,  nor  taken  any  step,  except  that  of 
always  keeping  a quantity  of  tow  in  his  breeches. 

The  prolapsed  portion  of  intestine  varies  in  length 
and  size  at  different  times.  It  was  four  inches  long 
when  Mr.  Lawrence  saw  it,  and  the  basis,  which  is 
the  largest  part,  measured  nearly  six  inches  in  circum- 
ference. The  prolapsus  never  recedes  entirely,  and  it 
has  occasionally  protruded  to  the  length  of  eight  or  ten 
inches,  being  as  large  as  the  forearm,  and  emitting 
blood.  This  occurrence  is  painful,  and  only  comes  on 
when  the  bowels  are  out  of  order.  Warm  fomentations 
and  a recumbent  position  afford  relief  and  accomplish 
a reduction  of  the  bowel. 

The  projecting  part  is  of  a uniform  red  colour,  simi- 
lar to  that  of  florid  and  healthy  granulations.  The 
surface,  although  wrinkled  and  irregular,  is  smooth, 
and  lubricated  by  a mucous  secretion.  It  feels  firm 
and  fleshy,  and  can  be  squeezed  and  handled  without 
exciting  pain.  The  man  has  not  the  least  pow'er  of  re- 
taining his  stools.  When  these  are  fluid,  they  come 
away  repeatedly  in  the  course  of  the  day,  and  with 
considerable  force.  When  of  a firmer  consistence, 
there  is  only  one  stool  every  one  or  two  days,  and  the 
evacuation  requires  much  straining.  Such  feces  are 
not  broader  than  the  little  finger.  When  the  patient  is 
purged,  the  food  is  often  voided  very  little  changed. 
This  is  particularly  the  case  with  cucumber.  In  this 
state  he  is  always  very  weak.  Ale  is  sometimes  dis- 
charged five  minutes  after  taken,  being  scarcely  at  all 
altered.  The  bowels  are  strongly  affected  by  slighf 
doses  of.porgatives. 

Consult  Sabatier,  in  Mem.  de  VJicad.  de  Chirvrgie, 
t.  5,  4t/i.,  and  m Medecine  Opiratoire,  t.  2.  Richter's 
yjvfangsgr.  der  fVundarzn.  b.  5.  J.  R.  Tieffcvbach, 
Vulnerum  in  intestinis  lethalitas  occasione  casus  ra- 
rissimi,  quo  colon  vulncratum,  inversum  per  14  antios 
ex  abdominepropendens  exhibetur ; Halleri  Disp.  Chir. 
5,  61.  Desault,  in  Parisian  Chir.  Journal,  u.  1,  or 
iEuvres  Chirurg.  par  Bichat,  t.  2,  p.  352,  ^c. 
Schmucker's  Chir.  Schnften,  vol.  2.  Jjowrence  on 
Hernia,  ed.  1.  Callisen's  Sijstema  Chirurgim  Hodi- 
ernoe,  t.  2,  p.  710,  Src.  B.  Travers,  Inquiry  into  the 
Process  of  Mature  in  repairing  Injuries  of  the  Intes- 
tines, chap.  8,  8vo.  Bond.  1812.  Scarpa  sull'  Krnir. 
Mernorie  Jinatomico- Chirurgiche,  fol.  Milano,  1809. 
F.  Reisinger,  jlnzeige  eiwr  von  dem  H.  Professor 
Dupuytren  erf undenen,  und  mit  dem  gliicklichst.cn 
Erfolge  aasgefiihrten  Operationsweise  zur  Ileilung 


des  Jinvs  Artijicialis,  nebst  Bemerknngen,  Jlugshurg, 
1817.  Brosse.  in  Rust’s  Mag.  b.  6,  p.  239.  Liordat^ 
Diss.  sur  le  Traitement  de  I'Anus  contre  Mature, 
Paris,  1819.  Breschet,  in  Journ.  der  Chirurgie  von  C. 
F.  Graife  und  Ph.  von  Walther,  b.  2,  p.  273.  479,  Ber- 
lin, 1821 : this  memoir,  containing  the  fullest  descrip- 
tion of  Dupuijtren's  practice,  well  deserves  the  careful 
perusal  of  every  surgeon  who  wishes  to  be  completely 
acquainted  with  the  present  subject.  Hennen’s  Mili- 
tary Surgery,  p.  407,  .J'c.  ed.  2,  8vo.  Edin.  1820.  Three 
cases  from  gun  shot  wounds;  the  cure  effictid  by 
aiding  nature  with  the  exhibition  of  occasional  laxa- 
tives and  clysters.  j9ll  irritating  plans  were  avoided. 
Scarpa  represents  the  artificial  ani  which  follow 
wounds,  as  far  more  difficult  of  cure  than  those  which 
are  the  consequence  of  hernia  with  mortification  ; yet  I 
have  known  many  of  the  first  description  of  cases  cured. 

AORTA.  Aneurisms  of  this  vessel  have  already 
been  treated  of ; but  there  are  a few  other  particulars 
relating  to  it  which  merit  notice  in  a dictionary  of  sur- 
gery. 

WOUND  OF  THE  AORTA  NOT  ALWAYS  FOLLOWED  BY 
INSTANTANEOUS  DEATH. 

A case  exemplifying  this  fact  was  recorded  by  M. 
Pelietan.  In  the  month  of  May,  1802,  a young  man 
was  brought  to  the  Hotel-Dieu.  In  a duel,  he  had 
been  run  through  with  a foil,  which  penetrated  above 
the  right  nipple,  and  came  out  at  the  left  loin.  The 
most  alarming  symptoms  were  apprehended ; but  se- 
veral days  elapsed  without  any  serious  complaints 
taking  place.  The  patient  was  bled  twice,  and  kept  on 
a very  low  regimen.  Every  thing  went  on  quietly  for 
a fortnight.  He  now  complained  of  severe  pains  in  his 
loins,  and  he  was  relieved  by  the  warm  bath.  He 
seemed  to  be  recovering,  got  up,  and  went  to  walk  in 
the  garden  allotted  for  the  sick ; but  the  pain  in  his 
loins  quickly  returned,  attended  with  difficulty  of  breath- 
ing, constipation,  and  wakefulness.  He  now  became 
very  impatient,  and  out  of  temper  with  the  surgeons 
for  not  relieving  him. 

On  the  15th  of  July,  two  months  after  the  accident, 
a deformity  of  the  spine  was  remarked  about  the  eighth 
dorsal  vertebra.  The  patient  grew  rapidly  worse,  and 
died  in  the  utmost  agony,  saying  that  he  felt  suffocated ; 
and  tearing  ofiT  his  shirt,  that  his  chest  might  be  free 
from  the  pressure  of  all  kinds  of  clothing. 

On  the  body  being  opened,  the  right  side  of  the  chest 
was  found  full  of  blood,  coagulated  in  various  degrees, 
and  an  opening,  the  diameter  of  which  was  equal 
to  that  of  a writing  pen,  was  detected  in  the  aorta 
above  the  crura  of  the  diaphragm.  All  the  adjacent 
cellular  substance  was  injected  with  blood,  and  three 
of  the  dorsal  vertebrae  were  found  carious.  No  mark 
of  injury  was  perceptible  in  any  of  the  thoracic  or  ab- 
dominal viscera. — {Pelietan,  Clinique,  Chir.  t.  1,  p. 
92—94.) 

THICKENING  AND  CONSTRICTION  OF  THE  AORTA. 

Meckel  met  with  two  cases  in  which  the  aorta  was 
thickened  and  considerably  constricted  just  below  its 
arch  ; yet  in  both  subjects  there  was  every  reason  to 
believe  that  the  abdominal  viscera  and  lower  extremi- 
ties had  been  duly  supplied  with  blood. 

This  fluid,  which  could  only  pass  from  the  heart 
with  great  difficulty  and  in  small  quantities,  had,  by 
regurgitating,  lacerated  the  semilunar  valves. — {Mem. 
de  I’Acad.  Royale  de  Berlin,  1756.  Ohs.  17  and  18.) 
A similar  example  is  recorded  by  Stoerck. — {Ann. 
Med.  11,  p.  171.)  An  instance,  in  which  a stricture 
was  met  with  in  the  aorta  opposite  to  the  termination 
of  the  canals  arteriosus,  is  described  by  Sir  Astley 
Cooper.  The  little  finger  could  hardly  pass  through 
the  constriction,  which  impeded  the  course  of  the  blood 
through  the  heart  and  lungs,  and  was  attended  with 
a considerable  dilatation  of  the  right  ventricle. — {Sur 
gical  Essays,  vol.  1,  p.  103,  Suo.  Land.  1818.) 

OBLITERATION  OF  THE  CAVITY  OF  THE  AORTA. 

It  is  observed  by  Professor  Scarpa,  that  the  whole 
body  may  be  regarded  as  an  anastomosis  of  vessels,  a 
vascular  circle ; and  he  contends  that  this  remark  is 
so  true,  that  even  an  obliteration  of  the  aorta  itself, 
immediately  below  its  arch,  may  take  place,  without 
the  general  circulation  of  the  blood  in  the  body  being 
stopped.  Such  a disease  of  the  aorta  was  seen  by 
Paris  in  the  body  of  a woman.  While  she  lived,  the 


AORTA. 


171 


Wood  which  was  expelled  from  the  heart  was  trans- 
mitted into  the  trunk  of  the  aorta  below  the  constric- 
tion, and  it  got  there  by  passing  through  the  subclavian, 
axillary,  and  cervical  arteries,  into  the  mammary, 
intercostal,  diaphragmatic,  and  epigastric  arteries. 
From  these  latter  arteries  the  blood  passed  into  the 
vessels  of  the  thoracic  and  abdominal  viscera  and 
those  of  the  lower  extremities. -(See  Desault's  Jour- 
nal,  t.  2,  p.  107.  Brasdor,  in  Recueil  Periodique  de  la 
Soc.  de  MU.  t.  3,  No.  18.) 

Dr.  Graham,  of  Glasgow,  published  another  example, 
in  which  the  aorta  was  completely  obstructed,  just  be- 
low the  canalis  arteriosus.  The  particulars  are  de- 
tailed in  the  Med.  Chir.  Trans,  vol.  5,  p.  287. 

Dr.  Goodison,  of  Wicklow,  in  examining  the  dead 
body  of  a woman  in  the  Hospice  de  la  Pitie  at  Paris, 
and  endeavouring  to  trace  the  origin  of  the  inferior 
jnesenteric  artery,  discovered  a hard  tumour  placed 
upon  the  aorta,  and  accompanied  with  an  obliteration 
of  that  vessel  from  the  origin  of  the  inferior  mesenteric 
artery  downwards  the  remainder  of  its  length ; the  let! 
iliac  being  also  rendered  impervious  down  to  its  bifur- 
cation, and  the  right  for  more  than  one-half  of  its  length. 
The  corpora  sesamoidea  of  the  semilunar  valves  of  the 
aorta  were  considerably  enlarged,  and  the  mitral  and 
tricuspid  valves  pre.sented  the  appearances  termed  by 
Corvisart  “ vegetations.”  The  arch  of  the  aorta  was 
greatly  enlarged,  and  internally  was  studded  with 
patches  of  bone.  The  vessels  given  off  from  the  trunk, 
and  especially  the  lumbar  arteries,  were  all  noticed  to 
be  considerably  increased  in  size.  At  the  obliterated 
part  of  the  abdominal  aorta,  there  was  a firm  bony 
sheath,  covering  the  vessel  for  about  two  inches,  and 
filled  with  a hard  fleshy  substance  which  extended 
farther  upwards,  and  was  firmly  adherent  to  the  coat 
of  the  artery.  It  was  the  inner  coat  itself  which  was 
ossified.  For  a particular  account  of  the  vessels  which 
were  chiefly  enlarged  for  the  purpose  of  continuing  the 
circulation,  I must  refer  to  Dr.  Goodison’s  description. 
The  general  appearance  of  the  body  was  not  unhealthy  ; 
and  the  lower  extremities,  which  were  not  emaciated, 
must  have  been  well  supplied  with  blood.  The  history 
of  the  case  could  not  be  traced.  Mr.  Crampton  having 
carefully  compared  Dr.  Goodison’s  narrative  with  the 
preparation  taken  from  this  subject,  refers  the  oblitera- 
tion of  the  aorta  to  the  effects  of  the  process  by  wdiich 
an  aneurism  had  been  spontaneously  cured  ; in  which 
particular  this  case  is  quite  different  from  those  re- 
ported by  M.  Paris  and  Dr.  Graham. — (See  Dublin 
Hospital  Reports,  vol.  2,  p.  193,  <^-e.  800.  1813.) 

The  next  case  which  I shall  notice  is  one  of  the 
most  memorable  in  the  annals  of  surgery,  since  it  was 
nothing  less  than  an  operation  in  which  a ligature  was 
applied  to  the  aorta  of  a living  subject,  under  circum- 
stances which,  at  a time  when  the  successful  repeti- 
tion of  Brasdor’s  operation  had  not  been  made  (see 
Wardrop  on  Aneurism,  1829),  perhaps  warranted  even 
this  desperate  attempt  to  preserve  life.  Sir  Astley 
Cooper  had  often  placed  ligatures  round  the  aorta  in 
dogs,  and  found  that  the  blood  was  readily  carried  by 
the  anastomoses  to  their  posterior  extremities  (see  Med. 
Chir.  Trans,  vol.  2,  p.  158),  and  he  has  ascertained, 
that  if  the  aortic  plexus  be  tied  with  the  artery,  the 
lower  extremities  are  rendered  paralytic,  and  the  ani- 
mal ultimately  dies ; but  if  care  be  taken  to  include 
only  the  vessel  in  the  ligature,  these  consequences  do 
not  take  place.— (See  Lancet,  vol.  2,  p.  47.) 

A porter,  aged  thirty-eight,  was  admitted  into  Guy’s 
Hospital,  April  9,  1817,  for  an  aneurism  in  the  left 
groin,  situated  partly  above  and  partly  below  Poupart’s 
ligament.  The  swelling  was  considerably  diffused, 
and  pressure  upon  it  gave  a great  deal  of  pain.  On 
the  third  day  from  his  entrance  into  the  hospital,  the 
tumqur  increased  to  double  its  former  size,  and  the 
pulsation  became  less  distinct.  The  blood  could  be  felt 
in  a fluid  state  within  the  sac,  which  was  so  large  that 
no  operation  was  practicable  without  opening  the  peri- 
toneum. Sir  Astley  Cooper  therefore  waited,  in  order 
to  let  the  man  have  the  chance  of  a spontaneous  cure. 
Notwithstanding  the  practice  of  venesection  and  com- 
pression, the  swelling  continued  to  increase,  and,  on 
the  20th  of  .lune,  a bleeding  took  ))lace  from  a point  of 
the  tumour,  where  a slough  had  formed.  The  bleed- 
ing recurred  from  time  to  time,  and  on  the  25th'he  was 
so  much  exhausted  by  loss  of  blood  that  his  feces 
passed  involuntarily,  and  his  immediate  death  was 
only  prevented  by  pressure  on  the  opening.  At  nine 


o’clock  in  the  evening,  this  experienced  surgeon  made 
a small  incision  into  the  sac  above  Poupart’s  I gament, 
and  introducing  his  finger,  tried  if  it  was  practicable  to 
pass  a ligature  round  the  external  iliac  artery  within 
the  cavity ; but  the  thing  was  found  impossible,  as  in- 
stead of  the  vessel,  “ only  a chaos  of  broken  coagula” 
could  be  perceived.  Ai  the  moment  of  withdrawing 
the  fiiig  r,  two  students  compressed  the  aorta  against 
the  spine,  and  the  incision  was  then  closed  with  a 
dossil  of  lint.  Sir  A.  Cooper  now  determined  to  apply 
a ligature  to  the  aorta  itself.  “ I made  (says  he)  an 
incision  three  inches  long  into  the  linea  alba,  giving  it 
a slight  curve  to  avoid  the  umbilicus.  One  inch  and 
a half  was  above,  and  the  remainder  below  the  navel,” 
the  cut  being  inclined  towards  the  left  side.  “ Having 
divided  the  linea  alba,  I made  a smalt  aperture  into  the 
peritoneum,  and  introduced  my  finger  into  the  ab- 
domen ; and  then  with  a probe-pointed  bistoury,  en- 
larged the  opening  into  the  peritoneum  to  nearly  the 
same  extent  as  that  of  the  external  wound.  Neither 
the  omentum  nor  the  intestines  protruded  ; and  during 
the  progress  of  the  operation  only  one  small  convolu- 
tion projected  beyond  the  wound.”  With  his  finger- 
nail he  scratched  through  the  peritoneum  on  the  left  side 
of  the  aorta,  and  then  gently  moving  his  finger  from  side 
to  side,  he  gradually  passed  it  between  the  aorta  and 
spine,  and  again  penetrated  the  peritoneum  on  the  right 
side  of  the  aorta.  A blunt  aneurismal  needle,  armed 
with  a single  ligature,  was  next  conveyed  under  that 
vessel,  and  tied,  with  the  precaution  of  excluding  the 
intestines  from  the  noose.  The  wound  was  then 
closed  by  means  of  the  quilled  suture  and  adhesive 
plaster.  During  the  operation  the  feces  were  dis- 
charged involuntarily,  and  the  pulse  both  immediately 
and  for  an  hour  after  the  operation  was  144.  An  opiate 
was  given,  and  the  involuntaty  passage  of  feces  soon 
ceased.  The  sensibility  of  the  right  leg  was  very  im- 
perfect. In  the  night,  the  patient  complained  of  heat 
in  the  abdomen  ; but  he  felt  no  pain  upon  pressure  ; and 
the  lower  extremities,  which  had  been  cold  a little  while 
after  the  operation,  were  regaining  their  heat,  but  their 
sensibility  was  very  indistinct.  At  six  o’clock  the  fol- 
lowing morning,  the  sensibility  of  the  limbs  was  still  im- 
perfect ; but  at  eight  o’clock  the  right  one  was  warmer 
than  the  left,  and  its  sensibility  returning.  At  noon 
the  temperature  of  the  right  limb  was  ninety-four; 
that  of  the  left  or  aneurismal  one,  eighty-seven  and  a 
half.  At  three  o’clock,  an  enema  was  ordered.  The 
heat  of  the  right  leg  was  now  ninety-six  ; that  of  the 
left  or  diseased  limb,  eighty-seven  and  a half.  It  is  un- 
necessary here  to  detail  all  the  various  circumstances 
.which  preceded  the  patient’s  death.  Vomiting,  pain 
in  the  abdomen  and  loins,  involuntary  discharge  of 
urine  and  feces,  a weak  pulse,  cold  sweats,  &c.  were 
some  of  the  most  remarkable  symptoms.  At  eight 
o’clock  on  the  second  morning  after  the  operation,  the 
aneurismal  limb  appeared  livid  and  cold,  more  particu- 
larly round  the  aneurism ; but  the  right  leg  was  warm ; 
and  between  one  and  two  o’clock  the  same  day,  the 
patient  died.  On  opening  the  abdomen,  there  was  not 
the  least  appearance  of  peritoneal  inflammation,  except 
at  the  edges  of  the  wound  ; and  the  omentum  and  in- 
testines were  of  their  natural  colour.  The  ligature, 
which  included  no  portion  of  intestine  or  omentum,  was 
placed  round  the  aorta  about  three-quarters  of  an  inch 
above  its  bifurcation.  When  the  vessel  was  opened, 
a clot  of  more  than  an  inch  in  extent  filled  it  above  the 
ligature;  and  below  the  bifurcation  another  clot  an 
inch  in  extent  occupied  the  right  iliac  artery,  while  the 
left  contained  a third,  which  extended  as  far  as  the 
aneurism.  The  neck  of  the  thigh-bone  was  also  found 
broken  within  the  capsular  ligament,  and  not  united; 
an  accidental  complication.  As  there  were  no  appear- 
ances of  inflammation  of  the  viscera.  Sir  Astley  Cooper 
refers  the  cause  of  the  man’s  death  to  the  want  of  cir- 
culation in  the  aneurismal  limb,  which  never  recovered 
its  natural  heat,  nor  any  degree  of  sensibility,  though 
the  right  leg  was  not  prevented  from  doing  so ; hence, 
says  this  experienced  surgeon,  “ in  an  aneurism  simi- 
larly situated,  tl  e ligature  must  be  applied  before  the 
swelling  has  acquired  any  considerable  magnitude. — 
{Surgical  Essays,  vol.  1,  p.  114,  Ac.) 

Indeed  the  most  important  conclusions  from  this  case 
are:— First,  that  where  no  other  impediment  exi-sts, 
the  circulation  will  continue  in  the  lower  extremities 
though  the  abdominal  aorta  be  tied  or  suddenly  ob- 
structed. Secondly,  that  sutfering  aneurismal  swell- 


172 


AOR 


APP 


ings  to  become  very  large  before  the  operation  is  done, 
exposes  the  patient  to  considerable  disadvantage,  on 
account  of  the  pressure  of  the  disease  upon  the  sur- 
rounding anastomoses,  Mdiereby  the  continuance  ol  the 
circulation  is  rendered  less  certain  than  it  would  be 
were  the  operation  done  at  an  earlier  period. 

Sir  Astley  Cooper  mentions,  that  if  he  were  to  per- 
form the  operation  again,  he  would  cut  olf  the  two  por- 
tions of  the  ligature  close  to  the  knot  on  the  vessel, 
because  the  irritation  of  the  bowels  by  them  seems  to 
him  a source  of  considerable  danger. 

[This  formidable  operation  of  tying  the  aorta  has 
again  been  performed  by  Mr.  James,  of  Exeter,  Eng., 
very  lately,  with  the  hope  of  preserving  the  life  of  an 
individual  afllicted  with  aneurism,  not  admitting  of  the 
common  mode  of  treatment;  but,  like  the  former,  it 
was  unsuccessful. 

“ For  cases  in  which  aneurismal  tumour  is  so  situ- 
ated as  not  to  admit  of  a ligature  being  applied  to  the 
artery  leading  to  the  disease,  Brasdor’s  proposal,  and 
the  facts  and  arguments  in  its  favour  related  by  Mr. 
Wardrop  and  others,  and  noticed  in  the  article  Aneu- 
rism of  tliis  Dictionary,  deserve  serious  reflection. 

In  weighing  the  various  reasons  both  for  and  against 
this  practice,  as  well  as  those  either  in  favour  or  con- 
demnation of  the  desperate  expedient  of  tying  the 
aorta,  the  judicious  surgeon  will  always  regard  the  oc- 
casional spontaneous  cures  of  aneurisms  as  facts  of 
much  importance.”— Fr^l 

The  numerous  cases  in  which  the  aorta  has  been 
found  obliterated  has  emboldened  Sir  Astley  (looper, 
Mr.  James,  and  others,  to  advocate  the  propriety  of 
tying  this  vessel  in  certain  cases,  and  to  maintain  that 
it  will  yet  succeed.  It  should  be  recollected,  however, 
that  in  all  these  cases  the  obliteration  of  the  vessel  was 
gradually  produced  by  disease,  and  the  anastomosing 
branches  became  enlarged  by  a slow  and  safe  process, 
because  one  that  is  perfectly  natural.  The  case,  how- 
ever, is  very  different  when  the  vessel  is  suddenly 
closed  by  a ligature  ; and  this  want  of  parallel  in  the 
cases  very  obviously  vitiates  the  argument  drawn  from 
analogy. 

Professor  Jamieson,  of  Baltimore,  in  a valuable  paper 
on  traumatic  hemorrhage,  published  in  the  American 
Med.  Recorder  for  January,  1829,  has  detailed  a number 
of  experiments  performed  on  inferior  animals,  in  some 
of  which  he  passed  a seton  through  large  vessels,  with 
a view  of  obstructing;  their  circulation,  and  thus  effect- 
ing their  gradual  obliteration.  His  success  was  cer- 
tainly encouraging,  and  Dr.  Webster,  of  Philadelphia, 
has  repeated  these  experiments  with  similar  results. 
The  latter  gentleman,  in  the  late  Philadelphia  edition 
of  “ Cooper’s  First  Lines,”  has  introduced  some  highly 
interesting  and  practical  remarks  on  this  subject  in  a 
note  on  the  subject  of  aneurism,  to  which  reference 
may  be  had,  as  containing  hints  of  the  most  invaluable 
importance. 

Future  experiments,  however,  will  be  necessary  to 
enable  the  surgeon  to  aiTive  at  definite  conclusions  on 
.this  most  interesting  subject. — Reese.^ 

RUPTURE  OF  THE  AORTX  WITHIN  THE  PERICARDIU.M . 

The  surgical  writings  of  Scarpa  in  relation  to  the 
formation  of  aneurisms  have  now  gained  extensive  ce- 
lebrity in  the  world.  It  is  well  known  that  this  author 
maintains  the  doctrine,  that  in  all  aneurisms  the  inter- 
jial  and  muscular  coats  of  the  artery  are  ruptured,  and 
that  the  aneurismal  sac  is  not  formed  of  the.se  tunics, 
'but  of  the  dilated  cellular  sheath  which  surrounds  the 
vessel.  When  a large  aneurism  bursts,  there  is  al- 
ways a double  rupture ; one  of  the  artery,  another  of 
the  aneurismal  sac.  The  last  is  that  which  is  the  im- 
mediate cause  of  the  patient’s  destruction,  by  altering 
the  circumscribed  state  of  the  aneurism  into  the  dif- 
fused.. 

There  are  some  exceptions,  however,  to  the  foregoing 
statement,  and  Scarpa  has  not  failed  to  point  them  out. 
When  the  internal  and  muscular  coals  of  the  aorta 
are  ruptured  in  a situation  where  the  outside  of  the 
vessel  is  only  covered  by  a thin,  tense,  closely  adherent 
membrane,  such  membrane  may  be  ruptured  at  the 
same  time  with  the  proper  coals  of  the  artery,  and  sud- 
den death  be  occasioned  by  the  effusion  of  blood  in  the 
cavity  of  the  thorax.  These  events  are  liable  to  hap- 
pen whenever  the  proper  coals  of  the  aorta  are  rup- 
tured within  the  iiericardium,  where  the  vessel  is  only 
covered  by  a thin  layer  reflected  from  this  membra- 


nous bag.  Waller  has  recorded  one  example  ol  this 
kind,  and  Morgagni  several  others.  A similar  case  is 
related  by  Scarpa. — (See  Haller,  Disput.  Chir.  tom.  5. 
Acta  Medic.  Berlin,  vol.  8,  p.  86.  Morgagni  de  Sed. 
et  Causis  Morb.  Epist.  26,  art.!.  17.  21.  Epist.  27, 
art.  28.  Scarpa  on  Aneurism,  transl.  by  Wish  art,  p. 
81.  Also,  Hodgson  on  the  Diseases  of  Arteries  and 
Veins.) 

STEATOMATOUS  TUMOURS  OF  THE  AORTA. 

Two  steatomatous  tumours  were  noticed  by  Stenzel 
in  the  body  of  a male  subject.  They  were  situated  in 
the  substance  in  the  membranes  of  the  aorta,  immedi- 
ately below  its  arch.  IXolwilhstanding  these  swellings 
rendered  the  vessel  almost  impervious,  the  man  had 
the  appearance  of  strength  and  of  having  been  well 
nourished.  Hrec  corpora  fere  cor  magnitudine  eequa- 
bant  ut  omnem  propemodum  exeunti  e sinistri  cordis 
thalamo  sanguini  spativm  preecluderent.  De  Slea- 
tomatibus  in  principio  arleriae  aortae,  &c.  Wittemb. 
1723. 

This  is  another  striking  fact,  illustrating  the  great 
power  of  the  inosculations  to  carry  on  the  circulation. 

Al'llJiRESIS.  (From  aiPuipio).  to  remove.)  Tliis 
term  was  formerly  used  in  the  schools  of  surgery  to 
signify  that  part  of  the  art  which  consists  in  taking  off 
any  diseased  or  preternatural  portion  of  the  body. 

APONEUROSIS.  Matter  often  collects  under  apo- 
neuroses, particularly  under  those  which  cover  the 
muscles  of  the  thigh,  leg,  and  forearm.  Abscesses 
are  also  sometimes  met  with  under  the  temporal,  the 
palmar,  and  the  plantar  fasciae ; in  the  tendinous  thecae, 
which  include  the  flexor  tendons  of  the  fingers  ; and 
occasionally  also  in  the  aponeurotic  sheath,  in  which 
the  rectus  abdominis  muscle  is  situated. 

One  particular  effect  of  an  aponeurosis,  or  any  kind 
of  tendinous  expansion  lying  between  a collection  of 
matter  and  the  skin,  is  materially  to  retard  the  progress 
of 'the  pus  towards  the  surface  of  the  body.  Hence,  if 
. the  case  be  allowed  to  take  iis  own  course,  the  quan- 
tity of  matter  increases,  the  pus  spreads  extensively 
under  the  aponeurosis  in  every  possible  direction,  se- 
parates the  rauscles  from  such  fascia  and  the  muscles 
from  each  other,  and  the  abscess  does  not  burst  till  a 
vast  deal  of  mischief  has  been  produced,  together  with 
more  or  less  sloughing  of  the  fascia,  tendons,  &c. 
These  circumstances  cannot  happen  without  a consi- 
derable degree  of  constitutional  disturbance,  and  a per- 
manent loss  of  the  use  of  certain  muscles.  Even 
when  a spontaneous  opening  is  formed,  and  some  of 
the  iiiafter  escapes,  it  is  often  only  a very  imperfect 
discharge  ; for  the  aperture  generally  occurs,  not  in  a 
depending  situation,  nor  over  in  the  main  collection  of 
pus,  but  at  a part  where  the  aponeurosis  is  thinnest, 
and  consequently  where  the  matter  has  the  least  re- 
sistance to  overcome  in  going  to  the  surface  of  the 
body. 

In  all  such  cases  the  cliief  indication  is  to  make  an 
early  and  a depending  opening  with  a lancet,  so  as  to 
prevent  the  extension  of  the  abscess,  and  to  let  the 
matter  escape  as  fast  as  it  is  formed.  If  a spontane- 
ous opening  should  have  occurred  in  an  unfavourable 
place,  a new  aperture  must  be  made  in  a proper  situa- 
tion ; or  if  the  former  should  be  sufliciently  depending 
and  near  the  principal  accumulation  of  matter,  but  too 
small,  it  must  be  rendered  larger  with  a curved  bis- 
toury and  a director.  Whenever  any  black  dead  pieces 
of  fascia  or  tendons  present  themselves  at  the  opening, 
they  must  be  taken  hold  of  with  a pair  of  forceps  and 
extracted. 

APPARATUS.  Every  thing  necessary  in  the  per- 
formance of  an  operation,  or  in  the  application  of  dress- 
ings. The  apparatus  varies  according  to  circum- 
stances. Instruments,  machines,  bandages,  tapes, 
compresses,  pledget.s,  dossils  of  lint,  tents,  sponges, 
basins  of  water,  towels,  «tc.  &c.  are  parts  of  the  a()pa- 
ratus,  as  well  as  any  medicinal  substances  used. 

It  is  a rule  in  surgery  to  have  the  apparatus  ready 
before  an  operation  is  begun.  All  preiiarations  of  this 
kind  should  be  made,  if  possible,  out  of  the  patient’s 
room  and  presence,  as  they  might  agitate  and  render 
him  timid. 

We  have  been  lately  censured  by  a French  surgeon 
for  our*  too  common  neglect  of  what  has  been  here  re- 
commended. “ In  France  (observes  M.  Roux)  we  are 
careful  not  to  let  a iiatient  who  is  to  undergo  a serious 
operation  see  any  of  the  requisite  preparations  lor  it. 


ARS 


ARS 


173 


Wo  haston  as  mucTi  as  possible  the  immediate  prepara- 
tory measures,  in  order  not  to  prolong  unnecessarily 
the  restlessness  and  moral  agitation  which  the  expect- 
ation of  an  operation,  and  sometimes  of  the  slightest 
one,  always  produces.  These  precautions  are  neglected 
by  the  English  surgeons,  at  least  by  most  of  those 
whom  1 saw  operate.  They  even  neglect  them  in  pri- 
vate practice,  where,  more  commonly  than  in  hospitals, 
we  have  to  deal  with  pusillanimous  individuals,  who 
are  easily  alarmed,  and  whose  extreme  susceptibility 
it  is  of  importance  to  spare.  It  was  in  the  very  room 
where  the  patient  lay,  of  course  under  his  eyes,  that 
the  table  and  all  the  necessary  instruments  for  litho- 
tomy were  arranged,  at  an  operation  which  I saw 
done  in  London,  during  my  stay  in  that  capital,  by  a 
gentleman  at  the  head  of  his  profession.”— (See  Parol- 
Ule  de  la  Chirurgie  Angloise  avec  la  Chirurgie  Fran- 
ioise,  p.  105.) 

M.  Roux,  in  his  visit  to  London,  had  also  too  good 
reason  to  complain  of  the  slovenly,  objectionable  prac- 
tice of  leaving  the  application  of  the  tourniquet  and 
the  dressing  of  the  wound,  after  a surgical  operation, 
to  mere  novices  and  students.  1 entirely  coincide  with 
him,  that,  in  respect  to  the  dressings  in  particular,  a 
surgeon  is  bound  to  extend  his  attention  and  solicitude 
a little  beyond  the  moment  when  the  operation  termi- 
nates. 

APPARATUS  MINOR;  APPARATUS  MA.TOR ; 
APPARATUS  ALTUS.  Three  ways  of  cutting  for 
the  stone.— See  Lithotomy.) 

AQUA  PICIS  LIQUIDS.  DuU.  Take  of  tar  two 
pints ; water  a gallon.  Mix  them  with  a wooden  rod 
for  a quarter  of  an  hour,  and  after  the  tar  has  subsided 
let  the  liquor  be  strained,  and  kept  in  well-corked  bot- 
tles. This  lotion  is  often  used  in  porrigo  and  ulcers 
surrounded  with  .scorbutic  redness.— (See 

ARGENTI  NITRAS.  {Nitrate  of  silver,  lunar 
caustic.)  One  of  the  best  caustics  Its  utility  in  sti- 
mulating indolent  ulcers,  and  keeping  granulations 
from  rising  too  high,  is  well  known  to  every  surgeon. 

Mr.  Hunter  sanctions  the  use  of  the  argentum  nilra- 
tum  on  the  first  appearance  of  a chancre,  before  absorp- 
tion can  be  supposed  to  have  taken  place.  He  directs 
the  caustic  to  be  scraped  to  a point,  like  a black  lead 
pencil ; so  that  when  it  is  applied  every  part  of  the 
surface  of  the  chancre  may  be  touched  with  it ; and 
he  advises  the  repetition  of  this  process  till  the  last 
slough  which  is  thrown  off  leaves  the  sore  florid  and 
healthy. 

This  treatment,  when  the  sore  is  very  small,  may 
sometimes  be  advisable  as  a means  of  lessening  the 
chance  of  the  constitution  being  infected  by  absorption. 
In  general,  surgeons  combine  with  the  plan  the  mode- 
rate use  of  mercury. 

The  important  use  of  the  argentum  nitratum,  in  the 
cure  of  numerous  diseases,  we  shall  have  occasion  to 
remark  in  various  articles  of  this  work ; particularly 
Cornea,  ulcers  of ; Iris,  prolapsus  of;  Ulcers  ; Ure- 
thra, strictures  of,  <S  c. 

ITie  argentum  nitratum  is  often  used  in  the  form  of 
a solution,  in  the  proportion  of  a drachm  of  the  caustic 
to  an  ounce  of  distilled  water.  In  general,  this  appli- 
cation ought  to  be  at  first  more  or  less  diluted  with  dis- 
tilled water.  Cancerous  ulcers  and  sores  about  the 
nose  and  neighbouring  parts  of  the  face,  being  exam- 
ples of  tuples,  or  noli  me  tangere,  are  often  consider- 
ably benefited  by  the  argentum  nitratum,  both  in  the 
solid  and  fluid  state.  The  solution  agrees  also  very 
well  with  certain  sores  which  occur  round  the  roots 
of  the  nails  .of  the  fingers  and  toes.  The  lotion  is 
sometimes  applied  with  a camel-hair  pencil ; but  in 
general  by  dipping  little  soft  bits  of  lint  in  the  fluid, 
laying  them  on  the  part,  and  covering  them  with  a 
pledget. 

ARSENIC  is  the  chief  ingredient  in  a secret  remedy 
which  has  long  possessed  very  great  celebrity  in  Ire- 
land for  the  cure  of  cancer,  and  is  now  well  known 
among  surgeons  by  the  name  of  Plunket’s  caustic. 
This  application  consists  of  the  ranunculus  acris,  the 
greater  crow-foot,  the  flammula  vulgaris,  and  the  less 
crow-foot,  in  the  proportion  of  an  ounce  of  each,  bruis- 
ed and  mixed  with  a drachm  of  the  white  oxide  of  ar- 
senic and  five  scruples  of  sulphur.  The  whole  is  to 
be  beaten  into  a paste,  formed  into  balls,  and  dried  in 
the  sun.  When  required  for  use,  these  balls  are  beaten 
up  with  yolk  of  egg  and  spread  upon  a piece  of  pig’s 
LiaJlor.  The  use  ol' the  ranunculi  us  is  to  destroy  the 


I cuticle,  upon  which  the  arsenic  would  have  no  effect ; 
for  it  is  to  be  ob.servcd,  that  Plunket’s  caustic  was  em- 
ployed for  the  dispersion  of  tumours  as  well  as  for  the 
relief  of  ulcerated  cancers.  The  application  is  to  re- 
main on  the  part  twenty-four  hours,  at  the  end  of 
which  time  the  slough  is  to  be  dressed  with  any  sim- 
ple unirritating  ointment.  When  arsenic,  was  first  re- 
commended as  an  application  for  cancers,  it  used  ge- 
nerally to  be  blended  with  opium.  When  Plunket’s 
caustic  is  employed  so  as  to  form  an  eschar  over  a scir- 
rhous tumour,  I conjecture,  that  if  it  ever  do  good,  it  is 
not  by  any  specific  effect  of  this  arsenical  application, 
but  simply  as  a slough  or  issue  formed  near  the  dis- 
ease in  any  other  manner.  It  is  highly  probable,  al.so, 
that  the  swellings  which  have  been  thus  dispersed, 
have  never  been  complicated  with  the  structure  cha- 
racteristic of  true  scirrhi.  With  respect  to  cancerous 
ulcers,  Pulnket’s  caustic  sometimes  evidently  produces 
a degree  of  amendment,  which,  however,  rarely  lasts 
for  any  considerable  time  ; but  there  are  many  invete- 
rate ulcerations  and  anomalous  sores  which  derive  per- 
manent benefit  from  the  application,  and  are  even  com- 
pletely cured  by  it.  t-  ome  examples  of  lupus,  ulcer- 
ations about  the  roots  of  the  nails,  and  reputed  carcino- 
matous sores  of  the  lips  are  of  this  description. 

At  Paris  an  arsenical  paste  is  often  used  by  Dubois 
and  other  surgeons  of  that  capital  for  cancerous  sores 
of  the  penis  and  other  malignant  ulcers.  It  is  com- 
posed of  seventy  parts  of  cinnabar,  twenty-two  of  san- 
guis draconis,  and  eight  of  the  white  oxide  of  arsenic 
formed  into  paste  with  saliva  at  the  time  when  it  is  to 
be  employed.  “ The  pain  and  inflammation  that  suc- 
ceed the  use  of  it  (says  Mr.  Cross)  cannot  be  equalled 
by  the  severest  operation  with  the  knife.” — {Sketches 
of  the  Medical  Schoots  of  Paris,  p.  45,  Bvo.  1815.) 
Even  death  may  be  occasioned  by  the  absorption  of 
the  poison,  as  appears  from  the  two  annexed  facts;  the 
first  of  which  is  recorded  by  M.  Roux  in  his  Medecine 
Op  ratoire.  “ The  day  after  the  paste  was  applied,  the 
patient  complained  of  colic  and  severe  vomiting,  and 
in  two  days  perished  in  convulsions,  et  les  plus  vives 
angoisses.  The  body  went  quickly  into  putrefaction. 
The  internal  coat  of  the  stom.ach  and  a great  part  of 
the  intestinal  canal  were  inflamed  and  marked  here 
and  there  with  dark  spots.”  Just  before  I visited  Pa- 
ris (adds  Mr.  Cross),  I dissected  in  I.ondon  a woman 
who  died  under  similar  circumstances,  and  where  the 
same  morbid  appearances  were  presented,  £lc. — {Op. 
cit.) 

Justamond’s  applications  to  cancer  were  generally 
combinations  of  arsenic  and  sulphur.  One  formula 
was  an  ounce  of  yellow  arsenic  with  half  that  quan- 
tity of  Armenian  bole,  and  sometimes  as  much  red  pre- 
cipitate. He  also  employed  a sulphuret  of  arsenic  and 
a combination  of  this  .sulphuret  with  crude  antimony. 
The  arsenical  preparation  selected  for  use,  was  scraped 
and  laid  on  the  middle  of  the  sore,  the  edges  of 
which  were  moistened  with  a combination  of  the  mu- 
riate of  iron  and  muriate  of  ammonia.  In  some  in- 
stances we  learn  that  the  effects  of  the  treatment  were 
the  correction  of  the  fetid  smeil,  melioration  of  the  ap- 
pearance of  the  sore,  and  separation  of  the  cancerous 
part. 

In  the  Pharmacopoeia  Chirurgica,  Justamond’s  arse- 
nical caustic  is  directed  to  be  made  in  the  following 
manner.  5k.  Antimonii  pulverizati  5j-  Arsenici  pul- 
verizati  ?ij.  These  are  to  be  melted  together  in  a 
crucible.  The  application  may  be  reduced  to  any  de- 
gree of  mildness  by  blending  with  this  pulverized  caus- 
tic a quantity  of  opium  in  the  form  of  powder,  which 
was  also  supposed  to  act  specifically  in  diminishing 
pain. 

The  powder  of  white  oxidd  of  arsenic,  unmixed  with 
other  substances,  has  sometimes  been  sprinkled  upon 
cancerous  and  other  inveterate  ulcers,  but  the  practice 
is  now  abandoned  by  every  judicious  surgeon,  on  ac- 
count of  the  violent  pain  resulting  from  it,  and  the  not 
unfrequently  fatal  consequences  of  its  absorption. 
Could  1 suppose,  that  a man  so  rash  and  ignorant  as  to 
revive  this  murderous  practice  yet  existed  in  the  pro- 
fession, I should  feel  disposed  to  lengthen  these  re- 
marks; but  I am  persuaded,  that  in  this  country  at 
least,  more  judgment  and  knowledge  every  where 
prevail.  The  white  oxide  of  arsenic,  however,  may 
be  applied  with  more  prudence  in  other  forms ; either 
in  one  of  those  already  specified,  or  as  a lotion,  com- 
posed of  eight  grains  of  the  oxide  and  the  same  qnan- 


174  ARSENIC. 


tity  of  subcarbonate  of  potash  dissolved  in  fot  ounces 
of  distilled  water ; or  as  an  ointment,  formed  . y rub- 
bing together  one  drachm  of  the  oxide  and  twelve 
drachms  of  spermaceti  ointment. — (See  A.  T.  Thom- 
son's Dispensatory,  p.  51.) 

Febure’s  celebrated  remedy  consisted  of  ten  grains 
of  the  white  oxide  of  arsenic  dissolved  in  a pint  of  dis- 
tilled water ; to  which  were  then  added  an  ounce  of 
the  extractum  conii,  three  ounces  of  the  liquor  plumbi 
subacetatis,  and  a drachm  of  laudanum.  With  this 
fluid  the  cancer  was  washed  every  morning.  Febure 
likewise  gave  arsenic  internally  ; and  his  prescription 
was  two  grains  of  the  white  oxide,  a pint  of  distilled 
water,  syrup  of  chichory  q.  s-  and  half  an  ounce  of 
rhubarb.  Of  this. mixture  a table-spoonful  was  given 
every  niglit  and  morning  with  half  a drachm  of  the 
syrup  of  poppies.  Each  dose  contained  about  one- 
twelfth  of  a grain  of  arsenic ; but  in  proportion  as  the 
patient  was  able  to  bear  an  increased  quantity,  the 
dose  was  gradually  augmented  to  six  table-spoonfuls 
of  the  solution. 

The  arseniate  or  rather  superarseniate  of  potash,  is 
an  excellent  preparation  for  internal  exhibition.  The 
Dublin  Pharmacopoeia  directs  it  to  be  made  as  follows ; 
take  of  white  oxide  of  arsenic,  nitrate  of  potassa,  each 
an  ounce.  Reduce  them  separately  to  powder ; then 
having  mixed  them,  put  them  into  a glass  retort  and 
place  it  in  a sand-bath  exposed  to  a gradually  raised 
heat,  until  the  bottom  of  the  retort  becomes  ob.scurely 
red.  The  vapours  arising  from  the  retort  should  be 
transmitted  through  distilled  water  by  means  of  a pro- 
per apparatus,  in  order  that  the  nitrous  acid  extri- 
cated by  the  heat  may  be  disengaged.  Dissolve  the 
residue  in  four  pounds  of  boiling  distilled  water,  and 
after  due  evaporation,  set  it  apart  in  order  that  crystals 
may  form.  This  preparation  has  long  been  known 
under  the  name  of  Macquer’s  arsenical  neutral  salt. 
It  may  be  given  in  the  following  way:  R.  Potassae 
superarseniatis  gr.  ij.  Aq.  menthae  viridis  | iv.  Spir. 
vinosi  tenuioris  |j.  M.  et  cola. 

Dosis  drachmae  duae  ter  quotidie. 

The  following  is  Dr.  Fowler's  method  of  preparing 
arsenic  for  internal  use : take  of  the  white  oxide  of 
arsenic  and  pure  subcarbonate  of  potash,  each  sixty- 
four  grains.  Boil  them  gently  in  a Florentine  flask  or 
other  glass  vessel,  with  half  a pound  of  distilled  water, 
until  the  arsenic  is  dissolved.  To  this  solution,  when 
cold,  add  half  an  ounce  of  the  compound  spirit  of  la- 
vender, and  as  much  water  as  will  make  the  whole 
Mual  to  a pint,  or  fifteen  ounces  and  a half  in  weight. 
Tlie  dose  of  this  solution,  of  which  the  liquor  arseni- 
calis  L.  P.  is  an  imitation,  is  as  follows : from  two 
years  old  to  four,  M.  ij  or  iij  to  v ; from  five  to  seven,  INL 
V to  vij ; from  eight  to  twelve,  M.  vij  to  x ; from  thir- 
teen to  eighteen,  M.  x to  xii ; from  eighteen  upwards, 
M.  xii.  These  doses  may  be  repeated  every  eight  or 
twelve  hours,  the  medicine  being  diluted  with  thick 
gruel  or  barley-water.  As  the  preparation  is  decom- 
posed by  the  infusion  and  decoction  of  cinchona,  it 
should  never  be  ordered  with  either  of  these  medicines. 

The  white  oxide  of  arsenic  may  be  given  in  the  form 
of  pills,  made  by  mixing  one  grain  of  it  with  ten  of  su- 
gar, and  then  beating  up  the  mixture  with  a sufficient 
quantity  of  the  crumb  of  bread  to  form  ten  pills,  one  of 
which  is  a dose.  It  will  only  be  in  my  power  to  spe- 
cify here  a few  of  the  numerous  surgical  cases  in 
which  the  internal  employment  of  arsenic  has  been 
proposed.  The  following  are  particularly  vvorthy  of 
attention  : tetanic  affections ; cancer ; lupus  ; elephan- 
tiasis; inert  cases  of  lepra  iSee  Bateman's  Tract.  Sy- 
nopsis of  Cutaneous  Diseases,  p.  33,  ed.  3);  various 
unnamed  malignant  ulcers  ; certain  forms  or  sequel* 
of  the  venereal  disea.se,  or  other  unintelligible  disea.ses 
which  cannot  be  subdued  by  mercury;  different  cuta- 
neous affections,  &c.  A longer  list  of  diseases  for 
which  a trial  of  arsenic  is  suggested,  may  be  seen  in 
some  papers  published  by  Mr.  IIill. — {Edin.  Med.  and 
Surg.  Journ.'vols.  5,  6.) 

Arsenic  has  also  been  recommended  by  Dr.  ,1.  Hun- 
ter for  the  prevention  of  hydrophobia. — (See  Trans,  of 
a Society  for  the  Improvement  of  Med.  and  Chir.  Know- 
ledge, voi.  1.)  Later  trials  of  the  medicine,  however,  in 
this  particular  ca.se,  do  not  appear  to  entitle  it  to  any  con- 
fidence. Dr.  Marcet  found  it  quite  unavailing,  though  not 
less  than  three  drops  of  Fowler’s  solution  were  taken 
every  other  hour  in  two  drachms  of  peppermint  or  sweet- 
ened water.— (See  Med.  Chir.  Trans,  vol.  1,  p.  141.  156.) 


After  the  symptoms  of  hydrophobia  have  once  began, 
arsenic  is  decidedly  useless. 

But  although  it  fails  in  hydrophobia,  some  facts  pub- 
lished by  Mr.  Ireland,  and  certain  observations  and  ex- 
periments detailed  in  Dr.  Russel’s  work  on  Indian  ser- 
pents, make  it  appear  a truly  valuable  remedy  for  the 
effects  of  the  bites  of  serpents.— (See  Med.  Chir.  Trans, 
vol.  2,  p.  393.) 

In  cases  of  poison  by  arsenic,  practitioners  univer- 
sally agree  respecting  the  first  indication,  which  is  to 
empty  the  stomach  as  quickly  as  possible  with  the 
stomach  pump  or  an  emetic.  In  this  country  the  com- 
mon practice  is  to  exhibit  an  emetic  of  sulphate  of  zinc 
or  sulphate  of  copper,  which  (it  is  said)  ought  to  be 
preferred ; first,  because  they  do  not  require  much  di- 
lution for  their  action  ; a circumstance  of  no  small  im- 
portance where  poisons  act  by  being  absorbed;  and  s»- 
condly,  because  they  are  extremely  expeditious  ; a dose 
of  fifteen  or  twenty  grains  producing  almost  instanta- 
neous vomiting,  without  exciting  that  previous  stage 
of  nausea  which  so  frequently  characterizes  other  eme- 
tics, and  which  produces  a state  of  the  vascular  sys- 
tem highly  favourable  to  the  functions  of  absorption. — 
(See  Pharmacologia,  by  Dr.  Paris,  p.  232,  vol.  1,  ed.  5.) 

On  the  other  hand,  instead  of  the  use  of  violent  eme- 
tics like  antimon.  tart,  and  sulphate  of  zinc,  which 
Orfila  says  always  increase  the  irritation  created  by 
the  poison,  he  prefers  exciting  vomiting  by  making  the 
patient  drink  large  quantities  of  warm  water,  milk, 
water  containing  sugar  or  honey,  linseed  tea,  and  other 
mucilaginous  fluids,  the  experiment  of  tickling  the 
throat  with  a feather  or  finger  not  being  omitted.  After 
as  much  of  the  poison  has  been  discharged  by  vomiting 
as  can  be  thus  evacuated,  the  stomach  may  be  me- 
chanically washed  out  with  the  stomach  pump  ; a plan 
first  proposed  by  Boerhaave  and  afterward  improved 
by  MM.  Dupuytren  and  Renault — (See  Orfila,  Toxico- 
logic Generate,  t.  1,  p.  132,  ed.  2,  1818.  See  also  Mr. 
Jukes's  Obs.  on  this  subject  in  Med.  and  Phys.  Journ. 
for  Nov.  1822,  and  June,  1823;  also  Lancet,  vol.  1.) 
By  this  means,  the  contents  of  the  stomach  may  either 
be  pumped  out  at  once,  or  any  fluid  may  be  first  in- 
jected and  then  drawn  out  again.  As  arsenic  produces 
its  fatal  effects  chiefly  by  being  absorbed,  an  important 
indication,  according  to  this  principle,  is  to  administer 
only  such  liquids  as  are  least  liable  to  dissolve  the  ar- 
senic in  the  stomach.  On  this  account  lime-water  has 
been  recommended  as  proper  to  be  drunk  after  the  sto- 
mach has  been  emptied  by  vomiting.  It  is  remarked 
by  Orfila,  that  lime-water  with  milk  offers  no  particular 
advantage  in  cases  of  poison  with  the  solid  arsenical 
acid ; but  where  this  acid  is  fluid,  he  admits  the  great 
utility  of  lime-water,  as  in  this  circumstance,  an  inso- 
luble arsenite  of  lime  is  formed,  the  action  of  which  is 
very  weak.  This  last  observation  is  confirmed  by  ex- 
periments on  dogs. — {Toxicologic  Genirale,  t.  1,  p.  233.) 

When  inflammation  of  the  abdomen  and  alarming 
nervous  symptoms  prevail,  the  means  of  relief  are, 
leeches,  venesection,  the  warm  bath,  fomentations, 
emollient  clysters  and  antispasmodic  narcotic  medicines. 

It  should  also  never  be  forgotten,  that  the  success 
of  the  treatment  will  depend,  in  a great  measure,  upon 
the  regimen  observed  during  the  patient’s  convales- 
cence, which  is  usually  tedious  ; and  he  should  be 
chiefly  nourished  with  milk,  gruel,  cream,  rice,  and 
beverages  of  a softening  mucilaginous  nature.— (See 
Orfila,  t.  cit.  p.  235.) 

[There  can  be  little  doubt  that  arsenic  is  the  basis 
of  the  active  ingredients  of  mo.st  of  the  popular  nos- 
trums of  the  day  which  are  set  forth  in  our  public 
papers  as  infallible  remedies  for  the  cure  of  cancerous 
affections,  as  tliey  are  termed  ; and  hence  the  manifold 
evils  which  we  often  witness  from  such  practice.  So 
long  ago  as  in  1786,  Dr.  Rush  favoured  the  public  with 
an  exposition  of  the  nature  of  the  famous  cancerous 
powder  of  Dr.  Martin;  its  base  was  arsenic,  though 
like  the  specifics  of  our  own  time  it  was  alleged  to  be 
of  a vegetable  nature.  The  consequences  arising  from 
applications  of  this  character  might  be  noticed  at  greater 
length  than  our  author  has  .seen  fit  to  do ; and  the 
caution  to  be  deduced  from  facts  of  this  sort  iriight  ope- 
rate more  forcibly  if  they  were  belter  understood.  The 
external  application  of  arsenic  ought  to  be  had  recourse 
to  only  after  the  severest  scrutiny  into  the  peculiar 
character  of  the  case  and  constitution  affected.  Even 
in  small  quantities  it  has  produced  apoplexy,  mental 
aberration,  organic  lesion  of  the  stomach,  paralysis. 


ART 


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175 


loss  of  motion,  enlargemertt  of  the  joints,  fatal  pete- 
chiae,  &c.  Arsenic,  in  fact,  may  be  enumerated  among 
that  class  of  poisons  which  induces  nearly  the  same  ef- 
fects externally  applied  as  well  as  when  taken  inwardly. 
The  experiments  of  Brodie,  as  well  as  those  of  other 
philosophers,  demonstrate,  that  its  influence  on  the 
system  is  no  less  rapid  and  dangerous  when  had  re- 
course to  as  an  external  application  to  denuded  sur- 
faces than  when  applied  directly  to  the  stomach.  An- 
other peculiarity  of  its  action  deserves  also  farther  to 
be  stated  : according  to  Professor  Francis  {Lectures 
on  Forensic  Medicine),  in  some  cases,  even  while  fa- 
vourable anticipations  from  the  operation  of  this  power- 
ful agent  locally  applied  are  indulged,  of  a sudden  the 
general  health  yields,  and  death  ensues  rapidly  and 
unexpectedly ; an  occurrence  of  much  consideration  in 
the  investigations  of  the  juridical  physician.— iJecA-e.] 

ARTERIOTOMY.  (From  dprypia,  an  artery,  and 
Tfpvu),  to  cut.)  The  operation  of  opening  an  artery, 
for  the  purpose  of  taking  away  blood  for  the  relief  of 
diseases.— (See  Bleeding^ 

ARTERIES.  The  process  by  which  a divided  or 
punctured  artery  is  healed  is  particularly  considered 
under  the  word  Hemorrhage ; while  the  general  prin- 
ciples, which  ought  to  be  observed  in  the  application 
of  the  means  for  the  stoppage  of  bleeding,  may  be  col- 
lected partly  from  the  remarks  contained  in  that  part 
of  the  work,  and  partly  from  what  is  stated  in  the  arti- 
cles Amputation,  Aneurism,  and  Ligature.  As  the 
condition  of  a bleeding  patient  admits  of  no  delay,  and 
the  preservation  of  his  life  entirely  depends  upon  proper 
measures  being  immediately  taken,  no  man  ought  to 
be  suffered  to  profess  surgery  who  is  not  competent 
to  the  treatment  of  wounded  arteries,  whether  injured 
by  accident  or  in  a surgical  operation.  As  Langen- 
beck  observes,  an  ignorant  practitioner,  when  called  to 
a case  of  serious  hemorrhage,  is  thrown  into  such 
consternation,  as  actually  deprives  him  of  the  power 
of  rendering  prompt  assistance.  Pale  as  a corpse,  and 
trembling,  he  beholds  the  jot  of  blood ; and,  for  the 
sake  of  appearing  to  do  something,  perhaps  he  applies 
spirit  of  wine,  or  a very  tight  bandage,  and  cries  out 
for  farther  aid ; while  simple  pressure  of  the  thumb 
upon  a certain  point  in  the  vicinity  of  the  injury  would 
prevent  all  this  confusion,  and  a dangerous  loss  oft 
blood.  No  part  of  surgery,  in  fact,  is  of  higher  import- 
ance than  the  treatment  of  wounded  arteries ; and  it 
deserves,  therefore,  to  be  earnestly  studied  by  every 
practitioner,  whether  he  move  in  the  higher  or  the 
tower  sphere  of  the  profession.  And  as  a proof  of  the 
necessity  of  country  surgeons  making  themselves  ac- 
quainted with  the  subject,  he  recites  the  case  of  a turf- 
cutter,  who  let  the  instrument  with  which  he  worked 
fall  against  the  lower  part  of  his  leg,  whereby  the  pos- 
terior tibial  artery  was  wounded.  The  blood  gushed 
out  profusely,  and  the  surgeon  who  was  sent  for  ap- 
plied a tourniquet  to  the  popliteal  artery,  and  thus 
stopped  the  bleeding  for  a time ; but,  unfortunately,  the 
tourniquet  was  kept  so  long  on  the  limb,  that  the  foot 
mortified  and  sloughed  away. — {Bill,  fur  die  Chir. 
b.  1,  p.  231,  232,  Giitt.  1806.)  From  the  explanations, 
delivered  in  the  article  Hemorrhage,  il  will  be  seen, 
that  in  all  bleedings  from  considerable  arteries,  nothing 
is  equal  to  the  ligature,  as  a means  of  preventing  the 
farther  loss  of  blood  ; and  it  may  be  laid  down  as  a 
standing  rule,  that  each  extremity  of  the  wounded  ves- 
sel should  be  tied  as  nearly  as  possible  to  the  wound 
in  its  coats.  As  Mr.  Hodgson  has  remarked,  “ the  ne- 
cessity of  tying  both  ends  of  a wounded  artery  is  evi- 
dent from  the  fact,  that  the  anastomoses  in  all  parts  of 
the  body  are  so  extensive,  as  to  furnish  a supply  of 
blood,  which  may  pass  through  the  lower  extremity  of 
the  wounded  vessel  in  a sufficient  stream  to  produce 
an  alarming,  and,  in  some  instances,  a fatal  hemor- 
rhage.”—(On  Diseases  of  Arteries,  Src.  p.  469.)  This 
correct  observation  is  followed  by  a case,  in  which  the 
bleeding  from  the  lower  end  of  a divided  brachial  ar- 
tery caused  the  patient’s  death.  Of  course  the  infer- 
ence is,  that  both  extremities  of  the  vessel  ought  to 
have  been  tied  directly  after  the  receipt  of  the  wound. 
With  regard  to  tying  the  trunk  of  an  artery  in  a part 
of  the  limb  where  it  cannot  be  exposed  with  facility, 
when  it  is  difficult  to  secure  its  bleeding  extremities, 
as  Mr.  Hodgson  remarks,  the  practice  “ was  falsely 
deduced  from  a knowledge  of  the  fact,  that  the  ligature 
of  an  artery  at  a distance  from  the  diseJi.se  will  effect 
the  cure  6f  an  aneurism.  But  a more  intimate  ac- 


quaintance with  the  condition  of  a limb  after  such  an 
operation,  and  the  processes  by  which  the  cure  of  an 
aneurism  is  effected  after  the  modern  operation,  afford  a 
complete  illustration  of  the  inefficacy  and  danger  of  this 
mode  of  treating  a wounded  artery;  for  it  is  now  fully 
proved,  that  when  an  artery  is  tied,  a stream  of  blood  con- 
tinues to  pass  through  it  below  the  ligature.” — (P.  471.) 
This  well-informed  surgeon  is  aware,  however,  that  in- 
stances do  occur,  in  which  only  the  upper  end  of  a 
wounded  artery  is  tied,  and  yet  the  patient  recovers 
without  hemorrhage  from  the  lower  orifice,  which  is 
closed  by  the  natural  processes. 

In  the  year  1814,  in  Holland,  I took  up  the  femoral 
artery,  in  the  middle  of  the  thigh,  in  a case  in  which 
the  popliteal  artery  had  given  way,  ten  days  after  the 
passage  of  a musket-ball  through  the  ham.  I employed 
only  one  smallish  ligature,  which  was  applied  with  the 
precaution  of  not  detaching  the  artery  from  its  natural 
connexions.  The  hemorrhage  was  effectnally  stopped, 
and  the  wound  healed  in  the  most  favourable  manner. 
Here,  no  doubt,  the  inflammation  in  the  ham  had  ob- 
literated the  portion  of  the  artery  immediately  below 
the  point  at  which  it  had  sloughed  or  ulcerated,  and 
there  might  even  have  been  from  the  same  cause  some 
deposition  of  lymph  within  the  upper  portion  of  the 
popliteal  artery,  contributing  to  the  success  of  the  ope- 
ration. But,  no  doubt,  it  was  the  diminution  of  the 
impulse  of  the  circulation  by  the  ligature  of  the  femoral 
artery,  which  enabled  nature  to  complete  the  oblitera- 
tion of  the  wounded  part  of  the  vessel.  Sometimes, 
says  Mr.  Hodgson,  when  hemorrhage  takes  place,  a 
few  days  after  the  bleeding  from  a w'ounded  artery  has 
been  stopped  by  compression,  one  extremity  of  the  ves- 
sel will  be  pervious,  while  the  other  will  have  closed 
by  the  natural  processes.  Cases  have  even  occurred, 
in  which  the  upper  end  of  the  artery  has  been  closed 
by  the  natural  processes,  while  those  processes  failed 
in  effecting  the  obi  iteration  of  the  lower  extremity  of 
the  vessel,  from  which  a serious  hemorrhage  took 
place.— (f/odg'son,  op.  cit.  475 ; and  Guthrie,  in  ISew 
Med.  and  Phys.  Journ.  vol.  4,  p.  177.)  Indeed,  in  the 
example  in  which  I took  up  the  femoral  artery  myself, 
it  was  impossible  to  say  positively,  whether  the  blood 
came  from  the  part  of  the  popliteal  artery  above  or 
below  the  slough  in  it,  as  no  incision  was  made  into 
the  ham. 

The  principle,  respecting  the  application  of  a liga- 
ture to  each  end  of  every  large  divided  artery,  is  to  be 
extended  also  to  punctured  arteries,  one  ligature  being 
placed  above  and  the  other  below  the  opening  in  the 
vessel. 

From  some  observations  in  the  article  Anetirism, 
p.  125,  it  will  be  seen,  that  when  the  impulse  of  the 
circulation  has  been  lessened  by  the  ligature  of  the 
main  trunk  of  an  artery,  some  distance  above  the 
wound,  the  hemorrhage  from  the  more  remote  portion 
of  the  vessel  may  sometimes  be  effectually  restrained 
by  pressure,  which,  previously  to  the  stoppage  of  one 
great  current  of  blood  to  the  part  had  proved  unavail- 
ing. This  fact  is  worth  remembering,  in  cases  in 
which  the  arteries  of  the  hand  or  foot  are  wounded. 

Mortification  is  observed  to  be  more  frequent  after 
the  ligature  of  an  artery  for  a wound,  than  for  an  aneu- 
rism. In  wounds,  Mr.  Hodgson  very  correctly,  I think, 
refers  the  difference  to  the  frequent  injury  of  the  sur- 
rounding parts,  and  particularly  of  the  veins  and 
nerves,  andtothe  loss  of  blood,  and  want  of  quietude  and 
proper  care  after  the  accident.  The  principal  anastomo- 
sing vessels  are  also  sometimes  divided.— (P.  479.) 

Having  given,  in  the  article  Aneurism,  the  necessary 
directions,  how  to  cut  down  to  and  tie  many  of  the 
principal  arteries,  I shall  conclude  the  present  subject 
with  a few  instructions  how  to  take  up  the  arteries  of 
the  forearm  and  leg,  as  delivered  by  Scarpa,  Mr.  C. 
Bell,  Mr.  Hodgson,  and  others.  Some  directions  how 
to  act  in  a case  of  wounded  axillary  artery  are  likewise 
subjoined. 

In  order  to  lay  bare  the  radial  artery  at  the  upper 
third  of  the  forearm,  a finger  is  to  be  put  on  the  in.ser- 
tion  of  the  tendon  of  the  biceps.  A little  below  this 
insertion,  an  incision,  about  two  inches  and  a half  in 
length,  is  to  be  made  in  the  integuments,  in  the  ob- 
lique direction,  denoted  by  the  inner  edge  of  the  supi- 
nator radii  longus.  The  subjacent  fascia  is  then  to  be 
divided,  and  the  inner  edge  of  the  supinator  muscle 
drawn  a little  from  the  outer  side  of  the  arm ; in  the 
spa  e between  that  muscle  and  the  flexor  carjM  ra- 


176 


ART 


AUS 


dialis  the  radial  arterj-  immediately  presents  itself, 
passing  over  the  tendon  of  the  pronator  radii  teres  and 
the  flexor  longus  pollicis,  and  it  then  runs  down  be- 
tween the  latter-named  tendon  and  the  flexor  carpi 
radialis. — (See  Camper's  Demons.  Anat.  Pathol,  lib.  1, 
tab.  I,  Jig.  2.)  A branch  of  the  musculo-spiral  nerve 
lies  on  the  radial  side  of  the  artery. 

At  the  wrist,  the  radial  artery  may  be  taken  up  by 
making  an  incision  a little  way  from  the  ulnar  margin 
of  the  flexor  carpi  radialis.  Here  the  artery  is  covered 
by  a fascia,  over  which  a small  branch  of  the  external 
cutaneous  nerve  runs ; but  the  vessel  is  now  unaccom- 
panied with  the  musculo-spiral  nerve,  which  quits  it, 
and  passes  under  the  supinator  radii  longus,  a little 
below  the  middle  of  the  forearm. 

After  the  radial  artery  leaves  the  forepart  of  the 
wrist,  it  may  be  taken  up  by  making  an  incision  “ on 
the  outside  of  the  insertion  of  the  extensor  primi  inter- 
nodii  pollicis,  and  the  inside  of  the  extensor  tertii  inter- 
nodii  pollicis.  Between  these  tendons  the  artery  lies 
very  deep,  and  over  it  is  the  extreme  branch  of  the 
muscular  spiral  nerve.  We  find  the  artery  going  close 
to  the  notch,  between  the  os  scaphoides  and  trapezium.” 
—(0.  Bell,  Op.  Surgery,  vol.  2,  p.  373.) 

For  bringing  into  view  the  ulnar  artery  at  the  upper 
third  of  the  forearm,  the  situation  and  breadth  of  the 
flexor  carpi  ulnaris  muscle  must  first  be  ascertained. 
An  incision  is  then  to  be  made  from  above  downwards, 
beginning  two  inches  below  the  inner  condyle  of  the 
humerus,  and  following  the  course  of  the  inner  margin 
of  the  above  muscle  to  the  extent  of  two  inches  and  a 
half.  The  fascia  is  then  to  be  divided : the  flexor  carpi 
ulnaris  is  to  be  drawn  a little  away  from  the  flexor 
sublimis.  In  this  opening,  rather  under  the  margin  of 
the  latter  muscle,  the  ulnar  artery  will  be  felt  with  the 
finger,  continuing  its  course  over  the  flexor  profundus. 
The  ulnar  nerve  is  situated  on  the  ulnar  side  of  the  artery. 

Below  the  middle  of  the  forearm,  the  ulnar  artery  is 
more  superficial,  and  may  easily  be  taken  up  by  making 
an  incision  upon  the  radial  side  of  the  flexor  carpi 
ulnaris,  between  the  tendon  of  which  muscle  and  that 
of  the  flexor  profundus  digitorum  the  vessel  is  situated. 
The  artery,  however,  will  not  be  reached  until  a thin 
aponeurosis  under  the  fascia  of  the  forearm  has  been 
divided.  The  nerve  is  rather  more  under  the  tendon 
of  the  flexor  carpi  ulnaris  than  the  artery  When  the 
ulnar  .artery  arises  from  the  brachial  above  the  elbow, 
it  runs  above  the  fascia,  and  is  easily  taken  up  in  any 
part  of  its  course. 

The  anterior  tibial  artery  passes  forwards  between 
the  bones  of  the  leg,  about  an  inch  below  the  upper 
head  of  the  fibula.  In  order  to  take  up  the  vessel  in 
this  situation,  a free  cut  must  be  made  through  the 
fascia,  extended  between  the  heads  of  the  tibia  and 
fibula.  The  incision  is  then  to  be  continued  more 
deeply  at  the  edge  of  the  peronaius  longus,  following 
the  fascia  between  this  muscle  and  the  origin  of  the  ex- 
tensor digitorum  communis.  The  artery  will  be  met  with 
on  the  interosseous  ligament.— (C.  Bell,  vol.  2,  p.  376.) 

In  order  to  lay  bare  the  anterior  tibial  artery,  a little 
above  the  middle  of  the  leg,  the  finger  is  to  be  passed 
along  the  outer  side  of  the  spine  of  the  tibia,  and  the 
breadth  of  the  tibialis  anticus  muscle  is  to  be  ascer- 
tained. Along  the  outer  margin  of  this  muscle,  an 
incision  is  to  be  made  through  the  integuments  and 
fascia,  two  inches  and  a half  in  length.  The  knife  is 
then  to  be  introduced  between  the  outer  margin  of  the 
tibialis  anticus  muscle  and  the  extensor  longus  of  the 
great  toe.  In  this  space,  at  the  depth  of  about  an  inch, 
he  anterior  tibial  artery  is  situated.— (Sec  Haller's 
Icon.  Annt.fasc.  5,  tab.  4.)  Cutting  down  to  this  ar- 
tery, near  the  tarsus,  where  the  vessel  passes  out  be- 
tween the  tendons  of  the  tibialis  anticus  and  extensor 
muscle  of  the  toes,  is  an  easy  operation. 

The  laying  bare  of  the  posterior  tibial  artery,  behind 
the  malleolus  internus,  is  also  quite  easy;  an  incision, 
about  two  inches  long,  is  to  be  made  between  the  in- 
ternal malleolus  and  the  tendo  achillis,  dowi  to  the 
posterior  surface  of  the  tuberosity  of  the  tibia.  At  this 
depth,  the  tendon  of  the  tibialis  posticus  muscle,  and 
that  of  the  fle.xor  communis  digitorum  pedis,  run  as  in 
a furrow.  Along  with  these  two  tendons,  but  a little 
nearer  to  the  os  calcis,  the  posterior  tibial  artery  de- 
scends to  the  sole  of  the  foot. 

On  the  contrary,  the  depth  of  the  posterior  tibial  ar- 
tery at  the  middle  or  in  the  upper  third  of  the  leg,  makes 
it  very  difficult  to  take  up  the  vessel  in  these  situations. 


And  the  difficulties  are  increased  by  the  spasmodic  con* 
tractions  of  the  gastrocnemius  and  soleus  muscles. 
When  necessary,  however,  the  artery  may  be  exposed 
and  tied  above  and  below  the  wound  in  it,  by  proceeding 
as  follows : an  incision  is  to  be  made  three  or  four 
inches  in  length,  along  the  inner  side  of  the  crest  of  the 
tibia,  and  the  origins  of  the  soleus  muscle  are  to  be 
detached  from  it  to  the  same  extent,  and  reflected.  Un- 
der the  soleus  muscle  is  found  the  aponeurosis,  which 
separates  the  muscle  of  the  calf  of  the  leg  into  super- 
ficial and  deep-sealed.  When  this  fascia  has  also  been 
divided,  the  posterior  tibial  artery  may  be  seen,  or  felt, 
deeply  situated,  running  on  the  tibialis  posticus  and 
fle.xor  muscle  of  the  toes.— (See  Haller,  Icon.  Anat. 
fasc.  5,  tab.  5.) 

In  taking  up  the  axillary  artery  when  it  is  wounded, 
Scarpa  believes  that  nothing  tends  more  to  embarrass 
the  surgeon,  than  an  injudicious  smallness  of  the  first 
incision  through  the  skin  and  such  other  parts  as  con- 
ceal the  w'ound  in  the  artery.  An  assistant  must  com- 
press the  vessel,  from  above  the  clavicle,  ^ls  it  passes 
over  the  first  rib.  When  the  weapon  has  penetrated, 
from  below  upwards,  directly  into  the  axilla,  the  surgeon 
is  to  make  a free  dilatation  of  the  wound  upon  a director 
or  his  finger.  This  must  be  done  to  a sufficient  height 
to  expose  a considerable  portion  of  the  artery,  and  the 
precise  situation  of  the  wound  in  it. 

When  the  weapon  has  pierced  obliquely,  or  from 
above  downwards,  through  a portion  of  the  great  pec- 
toral muscle,  into  the  axilla,  Scarpa  advises  the  surgeon 
to  cut  through  the  lower  edge  of  this  muscle,  and  en- 
large the  wound,  on  a director,  or  his  finger,  so  as  to 
bring  fairly  into  view  the  injured  part  of  the  artery. 
The  thoracic  arteries,  divided  in  this  operation,  must  be 
imm  -diately  tied.  The  clots  of  biooo  are  then  to  be 
removed,  and  the  bottom  of  the  wound  cleaned  with  a 
sponge,  by  which  means  the  opening  in  the  axillary 
artery  will  be  more  clearly  seen.  As  this  vessel  lies 
imbedded  in  the  brachial  plexus  of  nerves,  the  surgeon 
must  take  care  to  raise  it  from  these  latter  parts  with  a 
pair  of  forceps,  before  he  ties  it^  Two  ligatures  will 
be  required ; one  above,  the  other  below,  the  wound  of 
the  arteries. 

ASTRLNGENTS.  Substances  •w'hich  possess  the 
power  of  making  the  living  fibres  become  contracted, 
condensed,  and  corrugated.  They  are  employed  in  the 
practice  of  surgery  chiefly  as  external  applications, 
either  for  restoring  diminished  tonic  jiower,  or  checking 
various  discharges.  Astringent  lotions  are  deemed  eli- 
gible local  renieihes  for  phlegmonous  inflammation. 

ATHFiROMA.  (From  aQiipa,  pap.)  An  enqysted 
tumour,  so  named  from  its  pap-like  contents.-^See 
Tumours,  Encysted.) 

AUSCULTATION.  Mediate  auscultation,  or  the 
method  of  judging  of  the  nature  and  conditions  of  va- 
rious diseases  by  the  particular  sound  which  they  com- 
municate to  the  car,  through  the  medium  of  the  instru- 
ment called  the  stethoscope.  Thus,  in  diseases  of  the 
lungs  and  pleura,  the  practitioner  may  derive  important 
information  respecting  the  condition  of  those  organs, 
by  attending  minutely  to  the  changes  in  the  sound  of 
respiration,  to  the  sound  of  the  voice  and  coughing 
within  the  chest,  and  to  what  is  called  the  rattle,  and 
other  sounds  occasionally  heard  in  the  same  situation. 
The  stethoscope,  then,  in  many  ambiguous  cases,  must 
be  deemed  an  instrument  of  great  use  in  practice.  For 
a particular  descrijUion  of  it,  however,  I refer  to  Laen- 
nec's  invaluable  work  on  diseases  of  the  chest,  in  the 
translation  and  improvement  of  which,  by  numerous 
instructive  notes,  l)r.  Forbes  has  rendered  himself  a 
benefactor  to  medical  science.  In  surgery,  the  stetho- 
scope is  usefully  employed  in  detecting  the  real  nature 
of  various  doubtful  swellings,  particularly  those  of  an 
aneurismal  character.  By  M.  Lisfranc  it  has  been  found 
of  considerable  service  in  enabling  him  to  judge  with 
more  accuracy  of  the  collision  of  the  sound  against 
calculi,  or  other  substances  in  the  bladder,  in  the  opera- 
tion of  sounding.  M.  de  Kergaradec  has  used  the 
stethoscoj)e  with  much  success  (or  ascertaining  preg- 
nancy, where  the  history  was  obscure.  It  has  also 
been  found  of  great  utility  in  determining  the  existence 
and  state  of  various  collections  of  fluids,  and  particu- 
larly of  pus;  and  it  has  enabled  practitioners  to  ascer- 
tain with  certainty  the  communications  occasionally 
existing  between  abscesses  of  the  liver  and  the  interior 
of  the  lungs,  as  well  as  the  occasional  communication 
of  pulmonar}-  abscesics  xvith  tlie  abdominal  cavity.  In 


BAN 


BAN 


177 


cases  of  fracture,  where  the  crepitus  is  obscure,  the 
stethoscope  removes  all  ambiguity.  lu  all  diseases 
about  the  heart,  and  large  blood-vessels  near  this  organ, 
much  useful  information  may  be  derived  from  the  ap- 


plication of  the  stethoscope  ; but  the  method  of  using 
it,  and  the  circumstances  by  which  it  affords  instruction, 
must  be  gathered  from  a careful  perusal  of  Laennec’s 
work. 


B 


BALSAMUM  COPAIB.®.  Exhibited  by  surgeons 
principally  in  cases  of  gonorrhea,  gleet,  fiuor  albus, 
and  piles.  The  common  dose  is  from  ten  drops  to  half 
a drachm,  two  or  three  times  a day.  Mr.  Brande  gives 
the  following  formula:  If . Mucil.  acacias  3 iss.  Copaib® 
3 ss.  tere  simul  et  adde  gradatim  aq.  menth.  vir.  ^j. 
Tinct.  capsici  mv.  gutt.  ft.  Haustus  bis  vel  ter  quotidie 
sutnendus.— (See  Manual  of  Pharmacy, p.  70.) 

BANDAGE.  The  use  of  bandages  is  to  keeji  dress- 
ings, compresses,  remedies,  «fec.  in  their  proper  situa- 
tio°n ; to  compress  blood-vessels,  so  as  to  restrain  he- 
morrhage ; to  rectify  certain  deformities  by  holding  the 
deranged  parts  in  a natural  position ; and  to  unite  parts 
in  which  there  is  a solution  of  continuity.  As  the  ap- 
plication of  bandages  is  an  important  branch  of  sur- 
gery, authors  have  not  neglected  it.  Much  has  been 
written  on  the  subject,  and  almost  every  writer  has 
devised  new  bandages,  perhaps  without  much  benefit 
to  the  art.  Unfortunately,  it  is  next  to  impossible  to 
give  clear  ideas  of  the  numerous  sorts  of  bandages  by 
a printed  description  of  them.  The  surgeon  can  only 
acquire  all  the  necessary  instruction  from  experience 
and  practice.  Hence,  we  shall  confine  ourselves  to  a 
general  account  of  the  subject. 

Bandages  should  be  made  of  materials  possessing 
sufficient  strength  to  fulfil  the  end  proposed  in  applying 
them,  and  at  the  .same  time  they  should  be  supple  enough 
to  accommodate  themselves  to  the  parts  to  which  they 
are  applied. 

Bandages  are  made  of  linen,  cotton,  or  flannel.  If 
possible,  they  should  be  without  a seam  or  selvage, 
which  sometimes  causes  unequal  and  painful  pressure. 

There  are  cases  in  wliich  the  bandage  should  have  a 
degree  of  firmness  that  does  not  belong  to  the  materials 
usually  employed.  This  circumstance  is  obvious  in 
he'nia,  and  in  all  those  examples  in  which  there  is  oc- 
casion for  elastic  bandages.  As  we  have  already  ob- 
served, linen,  flannel,  and  cotton  (calico)  are  the  com- 
mon materials.  The  first  employment  of  flannel  band- 
ages is  imiiuted  to  the  Scotch  surgeons,  who  preferred 
them  to  linen  ones,  in  consequence  of  their  being  better 
calculated  for  absorbing  moisture,  while,  being  more 
elastic,  they  yield  in  a greater  degree  in  cases  requiring 
this  properly ; as  in  the  swelling  subsequent  to  dislo- 
cations, fractures,  &c.  It  has  been  asserted,  that  linen 
is  better  than  flannel,  because  more  cleanly ; but  neither 
one  nor  the  other  will  continue  clean,  unless  care  be 
taken  to  change  it  often  enough.  Where  the  indication 
is  to  keep  the  parts  warm,  flannel  is  of  course  prefera- 
ble both  to  linen  and  calico. 

In  applying  a bandage,  care  must  be  taken,  that  it  be 
put  oil  tight  enough  to  fulfil  the  object  in  view,  witliout 
running  any  risk  of  stopping  the  circulation,  or  doing 
harm  in  any  other  way.  If  it  be  not  sufficiently  tight 
to  support  the  parts  in  a proper  manner,  it  is  useless ; 
if  it  be  too  tense,  it  will  produce  swelling,  inflammation, 
and  even  mortification. 

In  order  to  apply  a roller  skilfully,  the  part  which  is 
to  be  covered,  must  be  put  in  its  proper  situation  ; the 
head  of  the  roller  held  in  the  surgeon’s  hand,  and  only 
so  much  unrolled  as  is  necessary  for  the  commencement 
of  the  application. 

In  general,  the  bandage  should  be  applied  in  such  a 
manner  as  will  admit  of  its  being  most  conveniently- 
removed,  and  allow  the  state  of  the  subjacent  parts  to 
be  examined,  as  often  as  occasion  may  require,  with  the 
least  possible  disturbance  of  them. 

For  this  reason,  in  fractures  of  Mie  leg  and  thigh,  the 
eighteen-tailed  bandage  is  generally  preferred  to  a sim- 
ple roller.  The  former  may  be  loosened  and  tightened, 
at  ideasure,  w-ithout  occasioning  the  smallest  disturb- 
ance of  the  affected  limb ; a thing  which  could  not  be 
done  were  a common  roller  to  be  employed. 

As  soon  a.s  the  bandage  has  fulfilled  the  object  for 
which  it  is  applied,  and  it  has  become  useless,  its  em- 
ployment should  be  discontinued  ; for,  by  remaining  too 
long  on  parts,  it  may  obstruct  the  circulation,  diminish 
VoL.  1.— M 


the  tone  of  the  compressed  fibres  and  vessels,  and  thus 
do  harm. 

Bandages  are  either  simple  or  compound.  They  are 
also  sometimes  divided  into  general  and  particular. 
The  latter  often  derive  their  names  from  the  pans  to 
which  they  are  usually  applied. 

A simple  bandage  is  a long  piece  of  linen  or  cotton, 
of  an  indefinite  length,  and  from  three  to  six  inches  in 
breadth.  When  about  to  be  applied,  it  is  commonly 
rolled  up,  and  the  roller  part  is  termed  its  head. 
When  rolled  up  from  each  end,  it  is  called  a double- 
headed roller  or  bandage. 

The  chief  of  the  simple  bandages  are  the  circular,  the 
spiral,  the  unitmg,  the  retaining,  the  expellent,  and  the 
creeping. 

The  circular  bandage  is  the  simplest;  consisting 
merely  of  a few  circles  of  a roller  covering  or  over- 
lapping each  other. 

The  spiral  bandage  is  the  most  frequently  used  of 
all ; for  it  is  this  which  is  seen  in  such  common  em- 
ployment on  the  limbs,  in  cases  of  ulcers,  varices,  dec. 
In  applying  a common  roller  to  the  whole  of  a limb,  the 
bandage  must  be  carried  round  the  part  spirally : for 
otherwise  the  whole  member  cannot  be  covered.  When 
the  leg  is  the  part,  the  surgeon  is  to  begin  by  surround- 
ing the  foot  with  a few  turns.  Then  carrying  the  head 
of  the  bandage  over  the  instep,  he  is  to  convey  it  back- 
wards, so  as  to  make  the  bandage  unroll,  and  apply 
itself  just  above  the  heel.  The  roller  may  next  be 
brought  over  the  inner  ankle ; thence  again  over  the 
instep,  and  under  the  sole ; and  the  surgeon  then  brings 
the  bandage  spirally  upwards  once  more  to  the  outer 
part  of  the  leg.  After  this,  every  circle  of  the  roller  is 
to  be  applied,  so  as  to  ascend  up  the  limb  in  a gradual, 
spiral  form,  and  cover  about  one-third  of  the  turn  of 
the  roller  immediately  below  it.  The  unequal  diameter 
of  the  limb  is  one  great  cause  which  brings  into  view 
the  unskilfulness  of  a surgeon  in  this  common  opera- 
tion; for  it  prevents  the  roller  from  lyi.ng  smoothly, 
although  spirally  ajiplied,  unless  a particular  artifice 
be  dexterously  adopted.  The  plan  alluded  to  is,  to 
double  back  the  part  of  the  roller  that  would  not  be 
even,  were  the  application  to  be  continued  in  the  common 
spiral  way,  without  this  manoeuvre.  When  the  bulk  of 
the  limb  increases  very  suddenly,  it  is  sometimes  neces- 
sary to  fold,  or,  as  it  is  termed,  reverse  everj'  circle  of 
the  bandage  in  the  above  manner,  in  order  to  make  it 
lie  evenly  on  the  limb.  It  is  manifest,  that  the  pressure 
of  the  roller  will  be  greatest  where  the  duplicatures 
are  situated ; and  hence,  wdien  it  is  an  object  to  com- 
press any  particular  part,  the  surgeon  should  contrive 
to  reverse  the  turns  of  the  bandage  just  over  the  situa- 
tion wffiere  most  pressure  is  desirable. 

Wlien  a roller  is  to  be  applied  to  the  forearm,  it  is 
best  to  put  a few  of  the  first  turns  of  the  bandage  round 
the  hand. 

Care  must  be  taken  not  to  make  the  bandage  very 
tight,  if  it  be  intended  to  wet  it  afterward  with  any 
lotion ; for  moisture  always  renders  it  still  more  tense. 

Mr.  John  Bell  describes  the  principal  purposes  for 
which  a roller  is  employed  as  follows ; “ Although  in 
recent  w'ounds  it  is  with  plasters  and  sutures  that  we 
unite  the  parts  point  to  point,  yet  it  is  with  the  bandage 
that  we  support  the  limb,  preserve  the  parts  in  con- 
tinual and  perfect  contact  with  each  other,  and  i/revent 
any  strain  upon  the  sutures,  with  wdiich  the  parts  are 
immediately  joined;  and  we  often  unite  parts  by  the 
bandage  alone.  But  it  is  particularly  to  be  observed, 
that,  in  gun-shot  wounds,  and  other  bruised  wounds, 
though  it  w'ould  be  imprudent  to  sew  the  parts,  since 
it  is  irniKissible  that  they  should  altogether  unite,  yet 
the  gentle  and  general  suiiport  which  we  give  by  a com- 
press and  bandage,  prevents  them  from  separating  tar 
from  each  other,  unites  the  deep  jiarts  early,  and  lessens 
the  extent  of  that  surface  which  must  naturally  fall 
into  suiipuration. 

In  the  hemorrhagy  of  wounds  we  cannot  alw-ays 


178 


BANDAGE. 


find  the  arterj' ; we  dare  not  always  cut  parts  for  fear 
of  greater  dangers  ; we  are  oilen  farmed  with  bleed- 
ings from  uncertain  vessels,  <fcc.,  or  from  veins  as  well 
as  arteries : these  hemorrhages  are  to  be  suppressed  by 
the  compress ; which  compress,  or  even  the  sponge 
itself,  is  but  an  instrument  of  compression,  serving  to 
give  the  bandage  its  perfect  effect.  Frequently,  in 
bleedings  near  the  groin  or  the  armpit,  or  the  angle  of 
the  jaw,  wherever  the  bleeding  is  rapid,  the  vessels 
tujcertain,  the  ca%'ity  deep,  and  the  blood  not  to  be  com- 
manded by  a tourniquet,  and  where  the  circumstances 
forbid  a deliberate  and  sure  operation,  we  trust  to  com- 
press and  bandage  alone. 

Bandage  is  very  powerful  in  suppressing  bleeding. 
At  one  period  of  surgery,  it  took  place  of  every  other 
meihtxl,  &:c.  If  a compress  be  neatly  put  upon  the 
bleeiUiig  arteries,  if  there  be  a bone  to  resist  the  com- 
press. or  even  if  the  soft  parts  be  firm  below,  and  the 
bandage  be  well  rolled,  the  patient  is  almost  secure. 
But  such  a roller  must  be  applied  smoothly  from  the 
very  extremities  of  the  fingers  or  toes ; the  member 
must  be  thoroughly  supported  in  all  its  lower  parts, 
that  it  may  bear  the  pressure  above.  It  is  partial  stric- 
ture alone  that  does  the  harm,  creates  intolerable  pain 
and  anxiety,  or  brings  on  gangrene.  Hemorrhagy  re- 
quires a very  powerful  compression,  which  must  there- 
fore be  very  general,  Ac.  It  must  not  be  made  only 
over  the  bleeding  arteries,  which  is  all  that  the  surgeon 
thinks  of  in  general,  Ac. 

In  abscesses,  where  matter  is  working  downwards 
along  the  limb,  seeking  out,  as  it  were,  the  weak  parts, 
undermining  the  skin,  and  wasting  it,  insulating  and 
surrounding  the  muscles,  and  penetrating  to  the  bones, 
the  bandage  does  every  thing.  The  expelling  bandage, 
the  propelling  bandage,  the  defensive  bandage,  were 
among  the  names  which  the  older  surgeons  gave  to  the 
roller,  when  it  was  applied  for  these  particular  pur- 
poses ; and  these  are  propenies  of  the  roller  which 
should  not  be  forgotten.” — (Principles  o/Surgery,vol.l.) 

Soon  after  this  description  of  some  of  the  chief  sur- 
gical uses  of  the  roller,  Mr.  John  Bell  proceeds  to  ex- 
plain in  what  manner  this  most  simple  of  all  band- 
ages may  be  put  on  a limb. 

“ Practice  v\nll  convince  you  that  the  firmness  and 
neatness  of  a bandtige  depend  altogether  upon  these 
two  points  ; first,  upon  the  turns  succeeding  each  other 
in  a regular  proportion ; and,  secondly,  upon  making 
reverses  wherever  t'ou  find  any  slackness  likely  to  arise 
from  the  varving  form  of  the  limb.  Thus,  m rolling 
from  the  foot  to  the  ankle,  leg,  and  knee,  you  must  take 
care,  first,  that  the  turns,  or,  as  the  French  call  them, 
doloires,  of  the  roller  lie  over  one  another  by  just  one- 
third  of  the  breadth  of  the  bandage  ; and,  secondly, 
that  at  every  difficult  part,  as  over  a joint,  you  turn  the 
roller  in  your  hand,  make  an  angle,  and  lay  the  roller 
upon  the  limb,  with  the  opposite  flat  side  towards  it ; 
you  must  turn  the  bandage  so  as  to  reverse  it,  making 
what  the  French  call  a rcnversee  of  the  roller  at  the 
ankle,  at  the  calf  of  the  leg,  and  at  the  knee.  You 
must  be  careful  to  roll  your  bandage  from  below  up- 
wards, and  support  the  whole  Umb  by  a general  pres- 
sure. That  you  may  be  able  to  supjtort  the  diseased 
part  with  a particular  pressure,  you  must  lay  com- 
presses upon  the  hollow's  and  upon  the  bed  of  each 
particnlar  abscess,  and  change  the  place  of  these  com- 
presses from  time  to  time,  so  as  now'  to  prevent  matter 
sinking  into  a particular  hollow,  now  to  press  it  out 
from  a place  where  it  is  already  lodged,  and  again  to 
reunite  the  surface  of  an  abscess  already  completely 
formed,  from  which  the  matter  has  been  discharged.” 
— (Principles  of  Surgery,  vol.  1.) 

In  the  article  Joints  we  have  taken  notice  of  the  good 
effects  of  the  pressure  of  the  roller  in  the  cure  of  some 
diseases  of  the  knee.  Here  v.’e  shall  just  introduce 
Mr.  John  Bell’s  sentiments  uj>on  the  subject : “ In  a dis- 
eased bursa,  as  in  a relaxation  of  the  knee-joint,  that 
disease  which,  with  but  a little  indulgence,  a very  Uttle 
encouragement  of  fomentations,  poultices,  bleeding,  and 
low  diet,  would  end  in  whites  welling  of  the  knee,  may 
be  stopf^  even  by  so  simple  a matter  as  a well-rolled 
bandage.”— ( Yof.  1,  p.  127.) 

The  uniting  bandage,  or  spica  descendens,  used  in 
rectilinear  wounds,  consists  of  a double-headed  roller, 
w'iih  a longitudinal  slit  in  the  middle  of  three  or  four 
inches  long.  The  roller,  h-aving  one  head  passed  through 
the  slit,  enables  the  surgeon  to  draw  the  lips  of  the 
wound  together.  The  wmole  must  be  manag^  so  that 


the  bandage  may  act  equally.  WTien  there  are  suturesq 
this  bandage  supports  the  stitches,  and  prevents  their 
tearing  through  the  skin.  When  the  wound  is  deep, 
writers  advise  a compress  to  be  applied  on  each  side,  in 
order  to  press  the  deeper  part  of  its  sides  together 
W hen  the  wound  is  veiy  long,  two  or  three  bandages 
should  be  employed,  and  great  care  t£iken  that  the 
pressure  be  perfectly  equable. 

Heister,  Henckel,  and  Richter  describe  a sort  of 
uniting  bandage  that  allows  the  surgeon  to  see  the 
wound,  over  w'bich  only  small  ligatures  cross.  This 
contrivance  will  be  best  understood  bv  reference  to  an 
engraved  representation  of  it  in  RichtePs  Elentents,  b.  1. 

W hen  we  make  use  of  a single-headed  roller  as  a 
retentive  bandage  only,  w'e  should  remember  always 
to  begin  the  application  of  it  on  the  side  opposite  the 
wound.  The  obvious  reason  for  so  doing  is  to  prevent 
a farther  separation  of  the  lips  of  the  wound,  as  the 
contrary  manner  of  applying  the  roller  would  tend  di- 
rectly to  divide  them.— (GoocA,  vol.  1,  p.  143.) 

The  intention  of  the  expellent  bandage  is  to  keep  the 
discharge  sufficiently  near  the  orifice  of  the  wound 
to  prevent  the  formation  of  sinuses.  In  general,  a 
compress  of  unequal  thickness  is  necessary ; the  thin- 
ner part  of  the  compress  being  placed  next,  and  imme- 
diately contiguous  to,  the  orifice  of  the  wound ; the 
thicker  part  below.  Before  the  bandage  is  applied  the 
pus  must  be  completely  pressed  out,  and  the  rolling  be- 
gin with  two  or  three  circular  turns  on  the  low'er  part  o< 
the  compress.  The  bandage  must  then  be  carried  spirally 
upwards,  but  not  quite  so  tightly  as  below.  It  is  after- 
w ard  to  be  rolled  downwards  to  the  place  where  it  began. 

The  creeping  is  a simple  bandage,  eveiy  succeeding 
turn  of  which  only  just  covers  the  edge  of  the  pre- 
ceding one.  It  is  employed  in  ca.ses  in  which  the  ob- 
ject is  merely  to  secure  the  dressings,  and  not  to  make 
any  considerable  or  equable  pressure. 

A bandage  is  termed  compound  when  several  pieces 
of  linen,  cotton,  or  flannel  are  sewed  together  in  differ- 
ent directions,  or  when  the  bandage  is  tom  or  cut  so  as 
to  have  several  tails.  Such  are  the  T bandage,  the  sus- 
peii.sory,  the  capistrum,  &c. 

The  eighteen-tailed  bandage  is  one  of  the  most  com- 
pound. It  is  now  in  general  use  for  all  fractures  of 
the  leg  and  thigh,  sometimes  for  those  of  the  forearm, 
and  frequently  for  particular  wounds.  Its  great  recom- 
mendation is  the  facility  with  which  it  can  be  undone 
so  as  to  allow  the  parts  to  be  examined,  and  its  not  cre- 
ating on  such  an  occasion  the  smallest  disturbance  of 
the  disease  or  accident. 

The  eighteeii-tailed  bandage  consists  of  a longitudi- 
nal portion  of  a common  roUer,  and  a sufficient  number 
of  transverse  pieces  or  tails,  to  cover  as  much  of  the 
part  as  is  requisite. 

Each  of  the  cross-pieces  is  to  be  proportioned  in 
length  to  the  circumference  of  the  part  of  the  limb  to 
w'hich  it  is  to  be  applied ; so  that  in  making  this  sort 
of  bandage  for  the  leg  or  thigh,  the  upper  tails  will  be 
tw'ice  as  Tong  as  the  lower  ones.  After  laving  the  long 
part  of  the  bandage  on  a table,  fix  the  upper  end  of  it 
in  some  way  or  another.  Then  arrange  the  tails  across 
it  in  sufficient  number  to  cover  such  part  of  the  limb 
3LS  requires  the  bandage.  Each  tail  must  be  long 
enough  tc  e.xtend  about  two  inches  beyond  the  oppo- 
site one,  when  they  are  both  applied.  The  tails  being 
all  arranged  across  the  longitudinal  band,  they  are  to 
be  stitched  in  this  position  with  a needle  and  thread. 
When  the  bandage  is  intended  for  the  leg,  a piece  of 
the  longitudinal  part  of  the  roller  below  is  to  extend 
beyond  the  tails.  Tliis  is  usually  brought  under  the 
sole  of  the  foot,  and  then  applied  over  the  inner  ankle 
directly  after  the  bandage  has  been  put  under  the  limb. 
Then  the  surgeon  lays  down  the  first  of  the  lower  tails 
and  covers  it  with  the  next.  In  this  way  he  proceeds 
upwards  till  all  the  cross-pieces  are  applied,  the  upper- 
most one  of  which  he  fastens  with  a pin.  This  band- 
age has  a very  neat  appearance.  The  tails  are  said 
to  lie  better  when  placed  across  the  longitudinal  piece 
a little  obliquely.— (Fo«.) 

The  T bandtige  is  for  the  most  part  used  for  covering 
parts  of  the  abdomen  and  back,  and  esiiecially  the  scro- 
tum, periiia-mn,  and  parts  about  the  anus.  Its  name  is 
derived  from  its  resemblance  to  the  letter  T,  and  it  is, 
as  Mr.  John  Bell  remarks,  the  peculiar  bandage  of  the 
body.  If  the  breast  or  belly  be  wounded,  we  make  the 
transverse  piece  which  encircles  the  body  very  broad ; 
and  having  split  the  tail  part  into  two  portions,  one  of 


BAN 


BEL 


179 


these  is  to  be  conveyed  over  each  side  of  the  neck  and 
pinned  to  the  opposite  part  of  the  circular  bandage,  so 
as  to  form  a suspensory  for  the  latter,  and  prevent  its 
slipping  down.  But,  says  Mr.  John  Bell,  if  we  have  a 
wound,  or  disease,  or  operation  near  the  groin  or  pri- 
vate parts,  the  tail  part  then  becomes  the  most  impor- 
tant part  of  the  bandage  : then  the  transverse  piece 
which  is  to  encircle  the  pelvis  is  smaller,  while  the  tail 
part  is  made  very  broad.  When  the  disease  is  in  the 
private  parts,  perinsum,  or  anus,  we  often  split  the  tail 
according  to  circumstances  ; but  when  the  disease  is  in 
one  groin  we  generally  leave  the  tail  part  of  the  band- 
age entire  and  broad. 

The  scissum  Imtmm,  or  split-cloth,  is  a bandage  ap- 
plied occasionally  to  the  head,  and  consists  of  a central 
part  and  six  or  eight  tails  or  heads,  which  are  applied 
as  follows  : 

When  the  cloth  has  six  heads,  the  middle  or  unsplit 
part  of  the  cloth  is  applied  to  the  top  of  the  head.  The 
two  front  tails  go  round  the  temples  and  are  pinned  at 
the  occiput ; the  two  back  tails  go  also  round  the  tem- 
ples, and  are  pinned  over  the  forehead  ; the  two  middle 
tails  are  usually  directed  to  be  tied  under  the  chin  ; but, 
as  Mr.  John  Bell  observes,  this  suffocates  and  heats 
the  patient,  and  it  is  better  to  tie  them  over  the  top  of 
the  head  or  obli4uely  so  as  to  make  pressure  upon  any 
particular  point.— (Principles Surfer f/,uoZ.  l,p.  131.) 

The  old  surgeons  usually  split  this  middle  tail  into 
tw'o  parts,  a broad  and  narrow  one.  In  the  broad  one, 
they  made  a hole  to  let  the  ear  pass  through.  This 
broad  portion  was  tied  under  the  chin,  while  the  nar- 
row ends  were  tied  obliquely  over  the  head.  As  Mr. 
John  Bell  has  observed,  though  this  gave  the  split-cloth 
the  effect  of  eight  tails,  yet  the  ancient  surgeons  did 
not  name  it  the  split-cloth  with  eight  tails.  When 
they  split  the  cloth  into  eight  tails,  and  especially  when 
they  tied  the  eight  tails  in  the  followdng  particular  man- 
ner, they  called  the  bandage  cancer,  as  resembling  a 
Srab  in  the  number  of  its  legs.  The  cancer,  or  split- 
cloth  of  eight  tails,  w'as  laid  over  the  head  in  such  a 
manner  that  four  tails  hung  over  the  forehead  and  eyes, 
while  the  other  four  hung  over  the  back  of  the  head. 
They  were  tied  as  follows ; first,  the  two  outermost 
tails  on  each  side  in  front  were  tied  over  the  forehead, 
while  the  two  middle  tails  in  front  were  left  hanging 
over  the  knot.  Then  the  two  outermost  or  lateral  tails 
behind  were  tied  round  the  occiput.  Next  the  middle 
tails  were  tied,  the  two  anterior  ones  being  made  to 
cross  over  each  other  and  pass  round  the  temples,  to  be 
pinned  at  the  occiput ; while  the  two  middle  tails  be- 
hind were  made  to  cross  each  other  and  pass  round  the 
temples  so  as  to  be  pinned  over  the  ears  or  near  the 
forehead.— (See  John  Bell's  Principles,  vol.  1,  p.  132.) 

The  triangular  bandage  is  generally  a handkerchief 
doubled  in  that  form.  It  is  commonly  used  on  the  head, 
and  now  and  then  as  a support  to  the  testicles  when 
swelled.  The  French  term  it  couvre-chef  en  triangle. 

The  nodose  bandage,  called  also  scapha,  is  a double- 
headed roller,  made  of  a fillet  four  yards  long,  and  about 
an  inch  and  a half  broad.  It  must  be  reversed  two  or 
three  times,  so  as  to  form  a knot  upon  the  part  which 
is  to  be  compres.sed.  It  is  employed  for  the  stoppage  of 
hemorrhage,  or  for  securing  the  compress  alter  the 
performance  of  arteriotorny  in  the  temples. 

The  most  convenient  bandage  for  the  forehead,  face, 
and  jaws,  is  the  four-tailed  one,  or  single  split-cloth. 

It  is  composed  of  a strip  of  cloth  about  four  inches 
wide,  which  is  to  be  torn  at  each  end,  so  as  to  leave 
only  a convenient  portion  of  the  middle  part  entire. 
This  unspht  middle  portion  is  to  be  applied  to  the  fore- 
head if  the  wound  be  there,  and  the  two  upper  tails  are 
carried  backw’ards  and  tied  over  the  back  part  of  the 
head,  while  the  two  lower  ones  are  to  be  ,tied  either 
over  the  top  of  the  head  or  under  th§  chin,  as  may  seem 
most  convenient. 

When  the  wound  is  on  the  top  of  the  head,  the  mid- 
dle of  the  undivided  part  is  to  be  applied  to  the  dress- 
ings. The  two  posterior  tails  are  to  be  tied  forwards, 
and  the  two  anterior  ones  are  to  be  carried  backwards, 
so  as  to  be  tied  behind  the  head.  This  is  sometimes 
called  Galen's  bandage.  It  is  curious,  that  writers  ou 
bandages  should  use  the  terms  Acad  and  ZaiZ,  synony- 
mously ; and  hence  this  fonr-tailed  bandage  is  often 
called  the  sling  with  four  heads.  Such  confu.sion  of 
language  is  highly  reprehensible,  as  it  obstructs  the 
comprehension  of  any,  the  most  simple  subject. 

If  the  upper  lip  be  cut,  and  a bandage  needed,  which 

M 2- 


is  seldom  the  case,  it  is  almost  superlluous  to  say,  that 
this  bandage  will  serve  the  purpose.  It  serves  also  in 
cuts  of  the  lower  lip,  though  in  them  a!.so  we  trust 
rather  to  the  twisted  suture  than  a bandage 

The  single  spht-cloth  is  particularly  useful  for  sup- 
porting a fractured  lower  jaw,  and  in  such  cases,  is 
the  only  one  employed  in  modern  surgery.  This  band- 
age, when  used  for  this  particular  purpose,  namely, 
supporting  the  lower  jaw,  is  named  capristrum  or  bri- 
dle, because  it  goes  round  the  part  somewdiat  like  a 
bridle. 

“ In  .some  cases  (says  Mr.  John  Bell),  the  circum- 
stances require  us  to  support  the  chin  particularly,  and 
then  the  unslit  part  of  the  bandage  is  applied  upon  the 
chin  with  a small  hole  to  receive  the  point ; but  where 
the  jaw  is  broken,  we  pad  up  the  jaw-bone  into  its 
right  shape  with  compresses  pressed  in  under  the  jaw, 
and  secured  by  this  bandage.  When  we  are  in  fear 
of  hemorrhage  after  any  wound  or  operation  near  the 
angle  of  the  jaw,  we  can  give  the  sling  a very  remark- 
able degree  of  firmness.  For  this  purpose,  we  tear 
the  band  into  three  tails  on  each  side,  and  we  stitch 
the  bandage  at  the  bottom  of  each  slit,  lest  it  should 
give  way  when  drawn  firm,”  «fcc. — {PriiLciples  of  Sur- 
gery, vol.  1.) 

We  have  already  described  one  way  of  ajiplying  a 
handkerchief  as  a bandage  to  the  head,  in  our  notice 
of  the  triangular  one,  or  couvre-chef  en  triangle. 
The  other  manner  of  applying  the  handkerchief,  called 
the  grand  couvre-chef,  is  as  follows : 

You  take  a large  handkerchief,  and  fold  it,  not  in  a 
triangular,  but  a square  form.  You  let  one  edge  pro- 
ject about  three  finger-breadths  beyond  the  other,  in 
order  to  form  a general  border  tor  the  bandage.  You 
lay  the  handkerchief  upon  the  head,  so  as  to  make  the 
lower  fold  to  which  the  projecting  border  belongs  lie 
next  the  head ; while  the  projecting  border  itself  is 
left  hanging  over  the  eyes  till  the  bandage  is  adjusted. 
The  two  corners  of  the  outermost  fold  are  first  to  be 
tied  under  the  chin  ; the  projecting  border  is  then  to  be 
turned  back  and  pinned  in  a circular  form  round  the 
face,  while  the  corners  of  the  fold  next  the  head  are 
to  be  carried  backwards  and  tied. 

After  the  outer  corners  of  this  bandage  have  been 
tied  under  the  chin  ; after  the  inner  corners  have  been 
drawn  out  and  carried  round  the  occiput ; and  after  the 
border  has  been  turned  back  and  pinned  ; the  doubling 
of  the  handkerchief  over  each  side  of  the  neck  hangs 
in  a loose,  awkward  manner.  It  remains,  theretbre, 
to  pin  this  part  of  the  handkerchief  up  above  the  ear  as 
neatly  as  can  be  contrived. — (See  J.  Bell's  Principles.) 

The  grand  couvre-chef  has  certainly  nothing  to  re- 
commend it,  either  in  point  of  utility  or  elegance.  A 
common  nightcap  must  always  be  infinitely  preferable 
to  It.  In  the  event,  however,  of  a cap  not  being  at 
hand,  it  is  proper  that  the  surgeon  should  know  what 
contrivances  may  be  substituted  to  fulfil  the  objects  in 
view. 

Having,  in  the  numerous  articles  of  this  Dictionary, 
noticed  the  mode  of  applying  bandages  in  particular 
cases,  and  allotted  a few  separate  descriptions  for  such 
bandages  as  are  not  here  mentioned,  but  which  are  of- 
ten spoken  of  in  books,  we  shall  conclude  for  the  pre- 
sent with  referring  the  reader  for  farther  information 
to  Rees's  CyclopcBdia ; John  Bell's  Principles  of  Sur- 
gery, vol.  1.  Diet,  des  Sciences  Med.  art.  Baiidage. 
Galen  and  Vidus  Vidius  are  reckoned  tHe  best  of  the 
old  writers  mi  the  subject ; M.  Sue,  Thillayc,  Heister, 
Juville,  Lombard,  Bernstein,  and  J.  Bell,  of  the  mo- 
dem ones. 

BARK,  Peruvian.  See  Cinchona. 

BELLADONNA.  {Deadly  Nightshade.)  A power- 
ful  sedative  and  narcotic.  The  leaves  were  first  u.sed 
externally  for  discussing  scirrhous  swellings,  and  they 
have  been  subsequently  given  internally  in  scirrhous 
and  cancerous  diseases,  amaurosis,  <kc.  Five  grains 
of  them  dried  are  reckoned  a powerful  dose  ; one  is 
enough  to  begin  with.  At  present  the  extract  in  doses 
of  one  grain  gradually  increased  to  five,  is  more  com- 
monly prescribed. 

It  is  said,  that  the  recent  leave.s  powdered,  and  made 
into  an  ointment  with  an  equal  weight  of  lard,  more 
efiectually  jirevent  priapism  and  relieve  chordee,  when 
rubbed  on  the  penis,  than  any  other  application.— (Pa- 
ris's  Pharmacologia,  vol.  2,  p.  110,  ed.  5.) 

From  the  power  which  belladonna  is  known  to  pos- 
sess of  lowering  the  action  of  tire  whole  arterial  sys- 


180 


BLA 


BLA 


tem,  it  seems  to  be  a fit  medicine  in  many  surgical 
cases  where  that  object  is  desirable,  particularly  in 
examples  of  aneurism. 

Beliadoaaa  has  the  power  of  producing  a dilatation 
of  the  pupil,  when  applied  to  the  eyebrovvaud  eyelids. 
The  late  Mr.  Saunders  tvas  in  the  habit  of  employing 
belladonna  a good  deal  for  this  express  purpose.  A 
little  while  before  undertaking  the  operation  for  the  , 
congenital  cataract,  he  was  accustomed  to  introduce 
some  dissolved  extract  of  belladonna  between  the  eye- 
lids, or  rub  the  eyebrow  and  skin  about  the  eye  freely 
with  the  .same  application.  The  consequence  was, 
that  if  there  were  no  adhesions  of  the  iris  to  other 
parts,  a full  dilatation  of  the  pupil  was  produced  in 
less  than  an  hour,  and  ilie  whole  of  the  cataract  was 
distinctly  brought  into  viewn  This  was  unquestiona- 
bly a considerable  improvement  in  practice,  as  the  iris 
wms  kept  out  of  danger,  and  the  operation  materially 
fiicilitated.  I allude  here  more  particularly  to  Mr. 
Saunders's  own  method,  in  which  be  introduced  the 
needle  through  the  cornea  in  front  oi'  the  iris,  and  then 
conveyed  it  to  the  cataract  through  the  enlarged  pupil. 
Belladonna  was  also  externally  applied  by  Mr.  Saun- 
ders after  the  operation,  with  the  view  of  prevenring 
the  edge  of  the  iris  Jrom  becoming  adherent  to  the 
edges  of  the  torn  capsule.  In  iritis  the  same  plan  is 
ail  important  part  of  the  treatment.  Whenever  the 
state  of  the  eye  behind  the  pupil  requires  to  be  mi- 
nutely examined,  the  plan  of  dilating  this  aperture  by 
means  of  belladonna  very  materially  facilitates  the 
examination.  Stramonium  is  found  to  have  the  same 
effect  upon  the  iris  as  belladonna.  Some  experiments, 
in  which  the  fact  is  clearly  proved,  w'ere  detailed  many 
years  ago,  by  a namesake  of  my  own  in  the  United 
States. — (See  A iJissei-tat.ion  on  the  Properties  and 
Iffccts  of  the  Datura  Stramonium,  i^-c.  by  Samuel 
Cooper,  Philadelphia,  1797.  C.  Himhly,  De  la  Para- 
lysie  de  V Iris  par  une  application  Locale  de  Jusquiame, 
<S-c.  2'i  ed.  iimo.  Altoiia,  1803.  J.  Bailey,  Observa- 
tions relative  to  the  Use  of  Belladonna  in  painful  Dis- 
ordfrs  of  the  Head  and  Face,  8vo.  Bond.  1818.) 

BINOCULUS.  (From  binits,  double,  and  oculus,  the 
eye.)  A bandage  for  keeping  dressings  on  bo  h eyes. 
Its  application  will  easily  be  understood  by  referring 
to  Monoculus, 

BISTOURY.  (Bistoire,  French.)  Any  small  knife 
for  surgical  purposes. 

BLADDER,  Puncture  of.  The  making  of  an  arti- 
ficial outlet  for  the  urine  is  an  operation  to  which  we 
are  obliged  to  have  recourse,  after  having  in  vain  em- 
ployed all  the  other  means  indicated  for  the  prevention 
of  the  bad,  and  even  fatal  consequences  of  a stoppage 
of  the  evacuation  of  this  fluid,  and  distention  of  the 
bladder.  Various  accidents  and  diseases,  both  acute 
and  chronic,  may  occasion  this  dangerous  state,  as 
will  be  more  particularly  noticed -in  the  article  Urine, 
Retention  of. 

The  bladder,  which  can  conveniently  hold  about  a 
pint  and  a half  of  urine,  is  no  sooner  dilated,  so  as  to 
contain  two  pints,  than  uneasy  sensations  are  experi- 
enced. The  desire  of  discharging  the  water  now  be- 
comes urgent,  and  if  the  inclination  be  not  gratified, 
and  the  bladder  is  suffered  to  be  dHated  beyond  its  na- 
tural state,  it  loses  all  -power  of  contraction,  and  be- 
comes paraljtic.  The  desire,  indeed,  continues,  and 
the  efforts  are  renewed  in  painful  paroxysms  ; but  the 
power  is  lost,  and  the  bladder  becomes  more  and  more 
distended.  WTien  this  viscus  is  dilated  in  the  utmost 
degree,  and  neither  its  own  structure  nor  the  space  in 
the  abdomen  can  allow  a farther  distention,  either  the 
bladder  must  be  lacerated,  which  it  never  is,  so  equally 
is  it  supported  by  the  pressure  of  the  surrounding 
parts,  or  its  orifice  must  expand  and  the  urine  begin  to 
flow.  After  the  third  day  of  the  retention,  the  urine 
often  really  begins  to  flow,  and  whatever  descends 
from  the  kidneys  is  evacuated  in  small  quantities  from 
time  to  time ; and  at  this  period,  the  bladder  is  distended 
in  as  great  a degree  as  it  ever  can  be,  however  long 
the  patient  may  survive.  This  dribbling  of  the  urine, 
which  begins  when  the  bladder  is  dilated  to  the  utmost, 
and  continues  till  the  eight  or  tenth  day,  or  till  the 
bladder  sloughs,  has  long  been  understood,  and  is 
named  by  the  French,  “ urine  par  regerrgement."  To 
practitioners  who  do  nor  understand  it,  tiie  occurrence 
is  most  deceitful.  The  friends  felicitate  themselves, 
that  the  urine  beguis  to  flow ; the  surgeon  believes  it ; 
basins  and  cloths  wet  with  urine  are  easily  produced ; 


but  the  patient  lies  unrelieved.  The  continued  disten- 
tion of  the  bladder  is  followed  by  universal  inflamma- 
tion of  the  abdomen.  The  iiisensibiJity  and  low  deli- 
riuin  of  incipient  gangrene  are  mistaken  for  that  re- 
lief which  was  expected  from  the  flow  of  urine,  till 
either  hiccough  comes  on,  and  the  patient  dies  of  fever 
and  inflammation,  or  the  urine  gets  into  the  abdomen 
through  an  aperture  fonned  by  mortification.  Let  no 
surgeon,  therefore,  trust  to  the  reports  of  nurses  and 
friends,  but  lay  liis  hands  upon  the  hypogastric  region, 
and  tap  with  his  finger,  in  order  that  he  may  distin- 
guish the  distended  bladder  and  the  fluctuation  of 
urine.  As  the  bladder  suffers  no  farther  distention 
after  the  third  day,  why  should  it  burst?  iNot 
from  laceration ; for  it  is  supported  by  the  uniform 
pressure  of  the  surrounding  viscera ; not  by  yielding 
suddenly,  for  it  is  distended  to  its  utmost  on  the  third 
day  of  the  retention,  and  j'et  seldom  gives  way  before 
the  tenth  ; not  by  attenuation,  for  it  becomes  thickened. 
The  term  laceration  was  never  more  wrongly  apjilied 
than  in  this  instance ; for  when  there  is  a breach  in 
the  bladder,  it  is  found  on  dissection  to  be  a small 
round  hole,  such  as  might  be  covered  with  the  point 
of  the  finger.  The  rest  of  the  viscus  and  the  adjacent 
bowels  are  red  and  inflamed,  while  this  single  point  is 
black  and  mortified  ! Delay  is  more  dangerous  than 
even  the  worst  modes  of  maixing  an  opening  into  the 
bladder,  and  while  life  exists,  the  patient  should  have 
his  chance. — (See  John  Bell’s  Principles  of  Surgery, 
vol.  2,  part  1,  p.  262,  Ac.) 

That  many  patients  die  after  paracentesis  of  the  blad- 
der is  an  undoubted  truth,  and  tliis  circumstance  has 
rather  intimidated  practitioners  against  the  operation. 
It  appears  to  me,  however,  that  in  general  death  may 
be  more  fairly  ascribed  to  the  effects  of  the  disease 
-than  to  the  puncture  of  the  bladder,  and  that  if  this 
last  measure,  or  the  making  of  an  outlet  for  the  urine 
in  some  way  or  another,  were  not  deferred  so  long  as 
it  often  is,  the  recoveries  would  be  more  numerous.  • 

Hence,  when  relief  cannot  be  obtained  by  the  treat- 
ment described  in  the  article  Urine,  Retention  of; 
when  no  urine  at  all  has  come  away  at  the  end  of  the 
third  day;  or  when  it  only  does  so  in  a dribbling  man- 
ner after  this  period,  while  the  bladder  continues  dis- 
tended, and  no  catheter  can  be  introduced ; the  opera- 
tion should  not  be  delayed.  Indeed,  in  urgent  cases, 
one  should  rather  operate  earlier. 

No  doiibt,  a man  who  is  exceedingly  skilful  in  the 
use  of  the  catheter,  and  knows  how  to  practice  with 
science  and  judgment  all  the  other  means  for  reliev- 
ing the  retention  of  urine,  will  not  frequently  find  it 
necessarj-  to  have  recourse  to  the  operation  of  punc- 
turing the  bladder.  This  is  said  to  have  been  so  much 
the  case  with  the  eminent  Desault,  that  in  the  course 
of  ten  years,  he  had  occasion  only  once  to  perform 
such  an  operation  in  the  Hotel-Dieu,  where  diseases 
of  the  urethra  are  always  extremely  numerous. — (See 
(Kuvres  Chir.  de  Desault,  purr  Bichat,  tom.  2,  p.  316.) 
When,  however,  this  superior  manual  dexterity  with 
the  catheter  is  not  the  acquirement  of  the  practitioner, 
the  timely  performance  of  the  paracentesis  of  the 
bladder,  or,  at  all  events,  the  making  of  an  outlet  for 
the  urine  in  some  w-ay  or  another,  should  not  be  ne- 
glected. It  is  gratifying  to  know,  however,  that  at  the 
present  day,  the  absolute  necessity  for  puncturing  the 
bladder  is  rendered  less  frequent,  not  only  by  the 
treatment  of  diseases  of  the  urethra  being  better  un- 
derstood than  formerly,  but  also  by  the  very  great  per- 
fection to  which  the  construction  of  elastic  gum  cathe- 
ters is  brought ; instruments,  from  which  the  most  es- 
sential assistance  may  frequently  be  derived.  Stric- 
tures in  the  urethra,  and  enlargement  of  the  prostate 
gland,  are  the  two  cases  most  frequently  producing  a 
retention  of  urine : and  in  both  of  them  Sir  Astley 
Cooper  considers  the  operation  of  puncturing  the  blad- 
der (with  very  few  exceptions)  entirely  unnecessary  ; 
an  opinion  with  which  my  own  observations  lead  me 
fully  to  concur.  In  cases  of  enlarged  prostate  gland, 
a skilful  surgeon  will  almost  always  succeed  in  intro- 
ducing a catheter  of  proper  shape  and  length  ; and  in 
examples  of  retention  from  stricture  when  relief  can- 
not be  afforded  by  ordinary  means,  the  best  plan,  gene- 
rally, is,  not  to  puncture  the  bladder,  but  to  make  a 
small  opening  in  the  part  of  the  uretlira  between  the 
stricture  and  neck  of  the  bladder;  a part  which  is 
most  commonly  much  dilated.  I shall  next  treat  of 
the  three  modes  of  punctunng  the  bladder 


BLADDER. 


181 


1.  Puncture  through  the  PerincBum. 

This  operation  is  said  to  have  been  first  done  by  M 
Tolet,  a French  surgeon,  the  author  of  a valuable  trea- 
tise, entitled,  “ TraiU  de  Lithotomie,  ou  de  V Extrac- 
tion de  la  Pierre  hors  de  la  Vessie,  troisieme  Edition, 
Paris,  1681.”  According  to  Sabatier,  it  ■w'as  customary 
at  the  time  of  Dionis  to  make  the  opening  with  a nar- 
row pointed  scalpel,  about  four  or  five  inches  long, 
which  wds  plunged  into  the  bladder  at  the  place  where 
the  incision  in  the  apparatus  major  terminated. — (See 
Lithotomy.)  The  escape  of  the  urine  indicated  when 
the  surgeon  had  reached  the  bladder.  A straight  probe 
was  conducted  along  the  knife,  and  then  a cannula  was 
passed  over  the  probe  into  the  bladder,  where  it  was 
allowed  to  remain  as  long  as  necessary,  care  being 
taken  to  fix  it  by  means  of  tapes  put  through  the  rings 
at  the  broad  part  of  the  instrument.  The  opening  was 
then  closed  with  a linen  tent.  Uionis  first  suggested 
the  method  of  opening  the  bladder  on  one  side  of  the 
perinaeum,  at  the  part  where  Frdre  Jacques  used  to 
perform  lithotomy.  Dionis  conceived  that  this  mode 
of  operating  had  advantages,  because  neither  the  urethra 
nor  the  neck  of  the  bladder  was  injured;  a narrow  scal- 
pel was  first  introduced,  so  as  to  make  a passage  for  the 
probe,  and  along  this  the  cannula  was  guided  into  the 
bladder.  The  idea  of  substituting  for  these  unsuitable 
instruments  a trocar  of  convenient  length  was  exceed- 
ingly simple,  and  for  this  improvement,  which  took 
place  in  1721,  surgery  is  indebted  to  Juncker  (see  Con- 
spectus ChirurgicB,  tab.  97,  p.  674),  unless  the  follow- 
ing passage  be  correct:  “In  the  year  1717  or  1718,  M. 
Peyronie  showed  in  the  king’s  garden  a long  trocar 
which  be  had  successfully  employed  in  a similar  punc- 
ture.”— (Desault’s  Parisian  Chir.  Journ.  vol.  2,  p.  267.) 

The  patient  having  been  placed  in  the  same  position 
as  for  lithotomy,  an  assistant  is  to  press  with  his  left' 
hand  on  the  region  of  the  bladder  above  the  pubes,  in 
order  to  propel  that  viscus  as  far  downward  into  the 
less  pelvis  as  possible,  vvhile  with  his  right  hand  he 
supports  the  scrotum.  The  surgeon  is  then  to  intro- 
duce the  trocar  at  the  middle  of  a line  drawn  from  the 
tuberosity  of  the  ischium  to  the  raphe  of  the  perinajum, 
two  lines  more  forwards  than  the  verge  of  the  anus. 
The  instrument  is  first  to  be  pushed  in  a direction  pa- 
rallel to  the  axis  of  the  body:  and  its  point  is  after- 
ward to  be  turned  a little  inw^ards.  Here,  according 
to  Bichat,  there  is  no  occasion  to  convey  the  cannula 
so  far  into  the  bladder  as  is  done  when  the  operation  is 
performed  above  the  pubes.  The  portion  of  this  viscus 
that  is  pierced,  being  incapable  of  changing  its  position 
with  regard  to  the  other  parts  in  the  perin®um,  if  the 
cannula  only  project  a few  lines  into  its  cavity,  it  will 
not  be  liable  to  slip  out.  It  would  be  wrong  indeed  to 
carry  it  in  farther ; for  the  pressure  of  its  end  against 
the  posterior  parietes  of  the  bladder  would  do  harm. 
Lastly,  the  cannula  is  to  be  fixed  in  its  place,  by  means 
of  the  T bandage. — (See  (Euvres  Chir.  de  Desault,  t.  3, 
p.  320.)  A silver  cannula,  w'hen  kept  introduced  too 
long,  becomes  covered  with  a thick  incrustation,  which 
renders  its  extraction  very  difficult  and  painful : care 
should  be  taken  to  prevent  the  inconvenience,  either  by 
withdrawing  it  entirely,  or  substituting  another  for 
it,  according  as  the  circumstances  of  the  case  may  de- 
mand. When  Dr.-  Ehrlich  visited  London,  Mr.  Chand- 
ler tapped  the  bladder  through  the  perinaeum,  and  in- 
troduced a cannula,  which,  after  remaining  in  the 
puncture  three  weeks,  was  .so  thickly  covered  with  an 
incrustation,  that  its  extraction  produced  considerable 
laceration  of  the  parts,  and  a great  deal  of  inflamma- 
tion, followed  by  a urinary  fistula.— (See  Diet,  des 
Sciences  Med.  t.  26,  p.  205.) 

Some  writers  recommend  the  introduction  of  the 
left  index  finger  into  the  rectum,  in  order  to  draw  this 
intestine  out  of  the  way  ; but  Sabatier  thinks  it  better 
to  use  this  finger  for  pressing  on  the  part  of  the  peri- 
naeum where  the  puncture  is  about  to  be  made,  so  as  to 
make  the  skin  tense,  and  assist  in  the  guidance  of  the 
trocar.  (Midecine  Op  ratoire,t.%p.  126.) 

The  parts  divided  in  the  puncture  are,  the  skin,  a 
good  deal  of  fat  and  cellular  substance,  the  levator  ani 
muscle,  and  that  portion  of  the  lower  part  of  the  blad- 
der which  is  situated  on  one  side  of  its  neck. 

The  following  is  the  judgment  which  Bichat  has 
passed  uiion  this  method:  In  the  track  which  the  tro- 
car has  to  pass,  there  is  no  part  the  puncture  of  which 
must  of  necessity  give  rise  to  bad  symptoms.  A surgeon 
moderately  exercised  in  the  practice  of  this  operation 


is  tolerably  sure  of  piercing  the  bladder,  which  is  opened 
in  the  most  depending  situation,  and  at  a point  which 
constantly  bears  the  same  relation  to  the  perinaeum.  B ut 
the  position  in  which  the  patient  is  placed  for  the  opera- 
tion is  a great  deal  more  disagreeable  than  that  for  the 
puncture  above  the  pubes.  Several  assistants  are  re- 
quired to  fix  him,  and  one  is  necessary  for  compressing 
the  bladder  in  the  hypogastric  region.  There  is  a possi- 
bility of  wounding  the  vessels  of  the  perinaeum,  and  of 
pricking  the  nerves  which  accompany  them.  If  the 
point  of  the  trocar  be  carried  too  much  outwards,  it  may 
glide  over  the  external  side  of  the  bladder.  If  it  be  in- 
clined forwards,  it  may  slip  between  this  viscus  and  the 
pubes.  If  it  be  turned  too  much  inwards,  it  may  pierce 
the  prostate  gland.  If  directed  too  much  backwards,  it 
may  wound  the  vasa  deferentia,  the  rectum,  the  extre- 
mity of  the  ureter,  and  the  vesiculae  seminales.  Also, 
while  the  cannula  is  introduced,  the  patient  can  neither 
walk  about  nor  sit  down ; but  must  continually  keep 
himself  in  bed.  Lastly,  this  mode  of  operating  is  fre- 
quently counter-indicated  by  tumours  or  other  common 
diseases  in  this  part  of  the  body  in  consequence  of  re- 
tentions of  urine.  — ( (Euvres  Chir.  de  Desault,  par  Bi- 
chat, t.  3,  p.  321.) 

The  puncture  of  the  bladder  from  the  perinaeum  is 
now  almost  universally  abandoned  by  British  surgeons. 
“ We  may  esteem  it  fortunate,”  says  Desault,  “ if  the 
trocar  penetrates  directly  into  the  bladder,  after  pierc- 
ing the  fat  and  the  muscles  situated  between  the  tube- 
rosity of  the  ischium  and  the  anus  ; and  as  this  viscus 
is  subject  to  much  variation  in  its  form,  the  surgeon 
will  often  be  defeated,  unless  he  be  perfectly  clear  in 
his  ideas  respecting  its  situation  and  figure.  This  dis- 
appointment is  not  without  example,  and  there  is  suf- 
ficient cause  to  deter  a practitioner  from  performing  this 
operation,  independently  ofthe  dangerof  wounding  with 
the  trocar  the  vasa  deferentia,  vesiculae  seminales, 
ureter,”  &.C.— (Parisian  Chir.  Journ.  vol.  2,  p.  267.) 

If  there  be  now  any  practitioners  who  are  not  averse 
to  the  total  relinquishment  of  this  method,  I think  the 
following  caution,  given  by  Sabatier,  may  be  of  service 
to  them  : perhaps  the  operation  would  be  more  safe  if 
the  surgeon  were  to  begin  with  making  a deep  incision 
in  the  perimeum,  as  is  practised  in  the  lateral  way  of 
cutting  for  the  stone,  and  if  he  were  to  desist  from 
plunging  the  trocar  into  the  bladder  until  he  has  as- 
sured himself  of  the  situation  oi  this  viscus,  and  felt 
the  fluctuation  of  the  urine. — (Medecine  Operatoire,  t. 
2,  p.  127.)  Sir  Astley  Cooper,  in  describing  this  me- 
thod, also  directs  an  incision  to  be  rnadein  the  perinaeum 
as  in  lithotomy  ; the  bulb  of  the  penis  to  be  pushed 
towards  the  patient’s  right  side;  the  knife  then  carried 
within  the  branch  of  the  ischium  till  it  reaches  the 
prostate  gland,  which  is  likewise  to  be  pushed  towards 
the  patient’s  right  side ; and  lastly,  the  instrument  to 
be  passed  obliquely  upwards  into  the  bladder,  the  ope- 
rator’s finger  resting  on  the  prostate  gland.— (Lectures, 
^ c.  vol.  2,  p.  314.) 

As  in  cases  of  inveterate  strictures  the  urethra 
between  the  obstruction  and  the  bladder  is  always  di- 
lated, I think,  with  Mr.  C.  Bell,  that  it  may  sometimes 
be  better  practice  to  cut  into  such  distended  portion  ofthe 
passage  than  puncture  the  bladder.  On  this  point 
many  useful  remarks  may  be  found  in  this  gentleman’s 
Surgical  Observations,  part  5,  (S'C.,  the  tenor  of  which 
I have  more  particularly  considered  in  the  5th  ed.  of 
the  First  Lines  of  the  Practice  of  Surgery.  The  prac 
tice  of  opening  the  urethra  behind  the  stricture,  in  pre- 
ference to  puncturing  the  bladder,  is  also  successftilly 
adopted  and  highly  commended  by  Sir  Astley  Cooper. 
— (See  Lectures,  Ji  c.  vol.  2,  p.  315.) 

2,  Puncture  above  the  Pubes. 

The  invention  of  the  method  of  tapping  the  bladder 
above  the  pubes  was  suggested  by  the  possibility  of 
extracting  calculi  from  that  viscus  by  what  is  usually 
denominated  the  high  operation.  The  first  performers 
of  the  puncture  above  the  pubes  are  said  to  have  em- 
ployed a straight  trocar,  the  very  same  instrument 
as  was  used  for  tapping  the  abdomen  in  cases  of  dropsy. 
The  consequence  was,  that  when  such  a trocar  was 
too  long,  its  cannula  was  apt  to  hurt  the  oppo.site  pa- 
rietes of  the  bladder,  so  as  to  occasion  intlammation 
and  a slough,  on  the  se()aration  of  which  the  urine  was 
liable  to  insinuate  itself  either  into  the  abdomen  or  rec- 
tum, as  happened  in  a case  mentioned  by  Mr.  Sharp, 
where  no  more  urine  was  discharged  through  the  can- 


182 


BLADDER. 


nula,  and  the  patient  died  of  a sort  of  diarrhoea.  When 
the  trocar  is  short,  the  bladder,  on  subsiding  and  con- 
tracting itself,  gradually  quits  the  cannula,  which  be- 
comes useless,  and  a necessity  for  making  another 
puncture  may  be  produced.  Whatever  pains  may  be 
taken  to  direct  the  trocar  obliquely  downwards  and 
backwards,  so  that  the  cannula  maybe,  in  sonne  degree, 
parallel  to  the  axis  of  the  bladder,  one  or  the  other  of 
these  accidents  cannot  always  be  prevented. 

Their  prevention,  however,  may  be'effected  by  merely 
employing,  instead  of  a straight  trocar,  a curved  one, 
v/hich  will  naturally  take  a suitable  direction.  This 
improvement  was  embraced  by  Frdre  Come,  the  in- 
vetitor  of  the  lithotome  cache,  who  also  de^^sed  a 
curved  trocar  for  the  paracentesis  of  the  bladder,  very 
superior  to  the  instrument  of  the  same  shape  previously 
in  use. 

To  this  way  of  operating  Mr.  Sharp  was  partial,  and 
Mr.  Abernethy  has  recommended  it  under  certain  cir- 
cumstances. The  former  remarks  that  it  is  an  opera- 
tion of  no  difficulty  to  the  surgeon,  and  of  little  pain  to 
the  patient,  the  violence  done  to  the  bladder  being  at  a 
distance  from  the  parts  affected.  It  is  equally  applica- 
ble, whether  the  disorder  be  in  the  urethra  or  the 
prostate  gland  ; and  when  there  are  strictures,  the  use 
of  bougies  may  be  continued,  while  the  cannula  re- 
mains in  the  bladder. — {Critical  htquiry,  p.  125,  erf.  4.) 

Some  writers  recommend  making  an  incision  about 
two  inches  long  through  the  linea  alba  a little  way 
above  the  pubes,  and  then  introducing  a trocar-  into 
the  bladder.  Others  deem  this  preliminary  incision 
quite  useless,  asserting  that  the  operation  may  be  per- 
formed with  equal  safety  and  less  pain  to  the  patient 
by  puncturing  at  once  the  skin,  the  linea  alba,  and  the 
bladder.  When  the  trocar  has  been  introduced,  the 
Btilet  must  be  withdrawn,  and  the  cannula  kept  in 
its  position  by  a riband  passed  through  two  little  rings, 
with  which  it  should  be  constructed,  and  fastened 
round  the  body.  The  orifice  of  the  cannula  should  be 
stopped  up  with  a little  plug,  so  as  to  keep  the  urine 
from  dribbling  away  involuntarily,  and  taken  out  as 
often  as  may  be  necessary  — {Encyclopedic  Metkodique : 
part.  Chirurg.  art.  Paracentise  de  la  Vessie.) 

The  trocar  should  be  introduced  in  a direction  ob- 
liquely downwards  and  backwards;  for  as  this  corres- 
ponds with  the  axis  of  the  bladder,  the  instrument  wall 
be  less  likely  to  injure  the  opposite  side  of  that  organ. 

Nearly  all  writers  advise  the  puncture  to  be  made 
an  inch  or  an  inch  and  a half  above  the  pubes.  The 
reasons  for  so  doing  are  the  following : “ If  the  punc- 
ture be  made  close  to  the  os  pubis,  the  bladder  in  that 
part,  often  rising  with  an  almost  perpendicular  slope, 
leaves  a chasm  between  it  and  the  abdominal  muscles, 
or,  to  speak  more  strictly,  a certain  depth  of  membrana 
cellularis  only,  so  that  if  the  trocar  penetrate  but  a 
little  way,  it  possibly  may  not  enter  into  the  bladder. 
If  it  penetrates  considerably,  it  may  pass  through  the 
bladder  into  the  rectum,  or  if  not  in  the  operation  itself, 
some  days  afterward,  when  by  the  course  of  the  ill- 
ness and  confinement  the  patient  is  more  wasted.  For 
the  abdominal  muscles,  shrinking  and  falling  in,  occa- 
sion the  extremity  of  the  cannula  to  press  against  the 
lower  part  of  the  bladder,  and  in  a small  time  to  make 
a passage  into  the  rectum.” — {Sharp,  in  Critical  In- 
qxiiry,  p.  127.)  Though  the  reasons  here  adduced  seem 
at  first  as  formidable  as  they  are  numerous,  does  not 
the  danger  of  injuring  the  peritoneum  form  an  objection 
to  plunging  in  a trocar  at  the  above  distance  from  the 
pubes  ? Certain  it  is,  peritonitis  would  be  more  apt  to 
be  induced  by  such  practice,  than  by  introducing  the 
instrument  immediately  above  the  pubes.  Richerand 
decidedly  condemns  the  plan,  principally  because  the 
higher  the  puncture  is  made,  the  more  apt  the  bladder 
will  be  to  (luit  the  cannula  on  the  urine  being  discharged. 
—(See  Nosogr.  Chir.  t.  3,  p.  472,  erf.  2.)  In  Desault’s 
works  by  Bichat,  the  puncture  is  al.so  advised  to  be 
made  immediately  above  the  pubes. — (T.  3,  p.  318.) 
Some  of  Mr.  Sharp’s  objections  are  removed  by  ta’xing 
care  to  pass  the  trocar  into  the  bladder  in  the  axis  of 
this  viscus,  and  employing  one  which  is  somewhat 
curved,  as  Hunter,  Frdre  Cdme,  Sabatier,  <fcc.  have 
advised.  Mr.  Sharp  confirms  the  danger  of  using  too 
long  a cannula,  by  mentioning  an  accident  which  oc- 
curred in  his  own  practice.  Though  he  introduced  the 
instrument  more  than  an  inch  and  a half  above  the  os 
pubis,  yet  having  pushed  it  full  two  inches  and  a half 
below  the  surface  of  the  skin,  its  extremity  in  six  or 


seven  days  insinuated  itself  into  the  rectum.— -{Criticai 
Inquiry,  p.  127.)  The  instrument,  says  an  excellent 
writer,  should  be  more  or  less  long,  according  as  the 
patient  is  fat  or  otherwise;  but  the  ordinary  length 
should  be  about  four  inches  and  a half  The  curvature 
should  be  uniform,  and  form  the  segment  of  a circle, 
about  eight  inches  in  diameter.— ((Futires  Chir.  de  De- 
sault, par  Bichat,  t.  3,  p.  317.) 

A catheter  left  in  the  bladder  longer  than  ten  days 
may  gather  such  an  incrustation  from  the  urine,  as  not 
only  to  render  the  extraction  of  it  painful,  but  even  im- 
practicable. Surgeons,  therefore,  should  never  leave 
the  cannula  in  the  bladder  quite  a fortnight;  or  if  it 
must  be  kept  introduced  so  long,  Mr.  Sharp  advises  a 
second  one  to  be  introduced,  made  with  an  end  like 
that  of  a catheter. — Critical  Inquiry,  p.  129.) 

Mursinna,  however,  has  reported  one  example  in 
which  a cannula  was  kept  in  for  a long  time  without 
inconvenience. — {Hecker,  Annales  der  Ges.  Medicin. 
1810,  Jul.  p.  39.)  I have  seen  one  myself,  and  two 
other  examples  of  the  same  kind  are  mentioned  by  Sir 
Astley  Cooper.— (2/ance^,  vol.  2,  p.  410.) 

Mr.  Abernethy  makes  an  incision  betw-een  the  pyra- 
midales  muscles,  passes  his  fingers  along  the  upper 
part  of  the  symphysis  pubis,  so  as  to  touch  the  distend- 
ed bladder,  and  introduces  a common  trocar  of  the  mid- 
dle size  in  a direction  obliquely  downwards.  On  with- 
drawing the  stilet,  he  passes  a middle-sized  hollow 
elastic  catheter  through  the  cannula  into  the  bladder. 
The  cannula  is  withdrawn,  and  the  catheter  left  in  till 
the  urine  passes  through  the  urethra.  After  a week, 
as  the  instrument  begins  to  be  stopped  up  w-ith  mucu.s, 
it  is  taken  out.  and  a new  one  introduced.— (.Stzrgicai! 
Observations,  1804.)  It  might  be  objected  to  this  plan 
of  employing  a hollow  bougie,  that  as  it  is  smaller 
than  the  wound,  the  urine  is  not  kept  from  passing 
between  the  instrument  and  parts  into  which  it  is  in- 
troduced, as  well  as  through  the  tube  itself.  This  hap- 
pened in  Mr.  Abernethy’s  case,  and  though  no  urine 
in  this  instance  got  into  the  cellular  membrane,  it 
might  sometimes  do  so,  because  it  is  not  till  after  in- 
flammation has  taken  place,  that  the  cavities  of  the 
cellular  substance  are  closed  with  coagulating  lymph. 
After  a day  or  two,  however,  the  cannula  of  the  trocar 
might  be  withdrawn  and  the  hollow  bougie  employed, 
which  would  be  less  likely  than  the  silver  one  to  cause 
ulceration  of  the  posterior  part  of  the  bladder. 

The  following  is  one  of  Sir  E.  Home’s  conclusions : 
“ When  the  puncture  is  made  above  the  pubes,  the  can- 
nula which  encloses  the  trocar  is  not  to  be  removed 
till  the  surrounding  parts  have  been  consolidated  by 
inflammation,  so  as  to  prevent  the  urine  in  its  passage 
out  from  insinuating  itself  into  the  neighbouring  parts ; 
for  wherever  the  urine  lodges  mortification  takes  place. 
Any  advantage,  therefore,  which  may  arise  from  a 
more  flexible  instrument  remaining  in  the  bladder,  is 
more  than  counterbalanced  by  its  not  filling  completely 
the  aperture  through  the  coats  of  the  bladder,  and 
allowing  the  urine  to  escape  into  the  cellular  mem- 
brane.”— {Trans,  of  a Soc.for  Med.  and  Chir.  Know- 
ledge, vol.  2.) 

There  is  much  truth  in  the  following  passage  : The 
abdomen  is  inflamed ; the  preliminary  incisions,  which 
prepare  for  the  introduction  of  the  trocar,  sometimes 
pass  through  several  inches  of  fat  and  cellular  sub- 
stance; the  incisions  must  be  wide  in  proportion  to 
their  depth;  the  cannula  is  no  sooner  lodged  here 
than  it  is  displaced,  in  some  degree,  by  the  contraction 
of  the  bladder,  which,  when  emptied,  subsides  under 
the  pubes.  The  cannula  stands  so  obliquely,  that  the 
urine  never  flows  with  ease,  but  by  running  out  upon 
the  wound,  and  by  being  injected  among  the  cellular 
substaiK-e,  it  causes  the  w-ound  to  inflame  ; the  wound 
by  its  proximity  to  the  inflamed  peritoneum  soon  mor- 
tifies, and  thus,  notwithstanding  the  temporary  relief 
produced  by  the  emptying  of  the  bladder,  the  patient 
dies  on  the  third  or  fourth  d&y.—{John  Belt’s  Princi- 
ples of  Surgery,  vol.  2,  p.  271.) 

That  this  operation  is  infinitely  better  than  that  of 
making  the  puncture  in  the  perinaeum,  is  indisputable. 
There  are  even  now  .some  good  surgeon.s,  who  seem 
to  prefer  it  to  the  method  of  tapping  the  bladder  from 
the  rectum.  In  the  CEuvres  Chirurgtcales  de  Desault, 
<.3,  p.  324,  it  has  received  the  preference;  and  at  p. 
319  of  the  .same  book,  a high  encomium  is  bestowed  on 
it  in  the  following  terms : “ This  operation  is  easy. 
The  little  thickness  of  the  parts  which  are  to  ^ 


BLADDER. 


183 


wounded,  renders  it  quick  and  triflingly  painful.  The 
surgeon  has  occasion  for  no  assistance.  The  patient 
is  neither  intimidated  nor  fatigued  with  the  posture  in 
which  he  is  put.  It  is  almost  impossible  to  miss  the 
bladder  except  it  he  exceedingly  contracted.  There  is 
no  risk  of  piercing  the  cavity  of  the  abdomen.  Ana- 
tomy proves,  that  here  the  bladder  is  in  immediate  con- 
tact with  the  recti  muscles,  and  that  when  this  viscus 
is  distended  with  urine,  it  pushes  the  peritoneum  up- 
wards and  backwards,  under  which  membrane  it  en- 
larges, and  thus  makes  the  point  of  the  trocar  become 
more  and  more  distant  from  the  cavity  of  the  abdomen. 
The  patient  may  easily  lie  on  his  side  or  abdomen,  so 
as  to  discharge  all  the  urine  contained  in  the  bladder. 
There  are  here  no  nerves  nor  vessels  of  which  the  in- 
jury cAn  be  dangerous.  No  difficulty  is  experienced 
in  hxing  the  cannula,  and  the  presence  of  this  instru- 
ment does  not  hinder  the  patient  from  sitting,  standing 
up,  or  even  walking  about  in  his  chamber.  When  the 
cannula  also  is  introduced  to  the  lower  part  of  the 
bladder,  this  viscus  cannot  possibly  quit  it.  Lastly, 
the  wound  heats  with  more  facility,  than  that  made  in 
any  other  method.” 

Respecting  this  advice  to  push  the  cannula  so  far 
into  the  bladder,  it  is  highly  objectionable,  for  the  rea- 
son already  explained.  The  writer  of  the  preceding 
commendation  seems  to  me  rather  too  partial.  He  has 
told  us  of  the  little  thickness  of  the  wounded  parts, 
and  yet  a little  before  bestowing  these  praises,  he  has 
acknowledged,  “ il  est  rare,  que  dans  cette  ponction, 
on  traverse  directement  la  ligne  blanche : on  passe 
presque  toujours  sur  ses  cotes,  et  Von  divise  le  peau, 
Vaponeurose  des  muscles  larges  du  has-ventre,  les 
muscles  droits,  quelquefois  Vun  des  pyramidales,  et  la 
paroi  anterieure  de  la  vessie." — (T.  3,  p.  318.) 

This  operation  (according  to  Sir  Astley  Cooper)  is 
very  easily  performed ; it  is  not  liable  to  the  objections 
which  were  formerly  made  to  it,  and  it  is  in  general 
safe.  In  the  female  it  is  the  only  proper  one  in  cases 
of  retention  of  urine  from  retroversio  uteri,  and  from 
an  obliteration  of  the  meatus  urinarius  by  cancerous 
disease ; for  (says  he)  opening  the  bladder  through  the 
vagina  is  a very  unsafe  and  disastrous  operation,  as 
the  urine  afterward  dribbles  into  ihat  passage,  where 
it  occasions  the  highest  degree  of  excoriation,  attended 
with  dreadful  suffering  and  constitutional  irritation. 
“ It  is  an  operation  which  ought  never  to  be  performed.” 
— {See  Lancet,  vol.  2,  p.  4If).) 

According  to  my  own  judgment,  the  plan  which  is 
about  to  be  described  is  the  safest  and  best,  when 
the  circumstances  of  the  case  afford  a choice;  and  I 
think,  that  it  would  be  for  the  benefit  of  the  afflicted  if 
the  puncture  above  the  pubes  were  only  performed  in 
cases  in  which  the  enormous  enlargement  of  the  pros- 
tate gland  and  disease  in  the  rectum  prevent  it  from 
being  safely  made  from  the  rectum. 

3.  Puncture  from  the  Rectum. 

This  method  is  more  generally  apjilicable  than  either 
of  the  two  plans  above  related.  It  is  not,  iike  the  punc- 
ture in  the  perin<eum,  liable  to  the  objection,  that  the 
w’ound  is  made  in  diseased  or  inflamed  parts  which 
afterward  become  gangrenous.  Nor  is  it,  like  the  punc- 
ture above  the  jiubes,  attended  with  a chance  of  the 
urine  diffusing  itself  in  the  cellular  membrane.  It  has 
also  the  advantage  of  emptying  the  bladder  completely. 
The  puncture  is  made  sufficiently  far  from  the  neck  of 
the  bladder  not  to  increase  any  inflammation  existing 
in  that  .situation;  and  the  operation  is  really  attended 
with  little  pain,  since  there  is  no  skin  nor  muscles  to 
be  wounded ; merely  the  coats  of  the  bladder  and  rec- 
tum, at  a point  where  these  viscera  lie  in  contact  with 
each  other.  In  cases  of  enlarged  prostate  gland  and 
of  disease  of  the  rectum,  however,  some  other  method 
should  be  chosen,  though  I am  of  opinion,  that  in  the 
first  of  these  cases,  puncturing  the  bladder  at  all  can 
seldom  be  absolutely  necessary,  as  the  catheter  may 
almost  always  be  introduced  by  a surgeon  who  under- 
stands the  nature  of  the  disease  and  its  alteration  of 
the  course  of  the  urethra. 

We  read  in  the  Philosophical  Transactions  for  1776, 
of  a case  of  total  retention  of  urine  from  strictures, 
where  the  bladder  was  successfully  punctured  from 
the  rectum.  The  plan  was  suggested  to  Mr.  Hamil- 
ton, who  did  the  operation  by  his  feeling  the  bladder 
exceedingly  prominent  in  the  rectum  when  his  finger 
was  in  the  bowel. 


The  patient  was  placed  in  the  same  position  as  that 
for  lithotomy ; a trocar  was  passed  along  the  finger 
into  the  anus,  and  pushed  into  the  lowest  and  most 
projecting  part  of  the  swelling,  in  the  direction  of  the 
axis  of  the  bladder.  A straight  catheter  was  imme- 
diately introduced  through  the  cannula,  lest  the  blad- 
der by  contracting  should  quit  the  tube,  which  was 
taken  away,  and  as  soon  as  the  water  was  discharged 
the  catheter  was  also  removed.  Notwithstanding  the 
puncture,  the  bladder  retained  the  urine  as  usual  until  a 
desire  to  make  water  occurred.  Then  the  opening 
made  by  the  instrument  seemed  to  expand,  and  the 
water  flowea  in  a full  stream  from  the  anus.  The 
urine  came  away  in  this  manner  two  days,  after  which 
it  passed  the  natural  way  with  the  aid  of  a bougie, 
which  had  been  passed  through  the  urethra  into  the 
bladder,  and  w'hich  was  used  till  all  the  disease  in  this 
canal  was  cured. 

The  method  is  said  to  have  been  originally  proposed, 
in  1750,  by  M.  Fleuxant,  surgeon  of  the  hospital  La  Cha- 
rite  at  Lyons ; and  Pouteau,  in  1760,  published  an  ac- 
count of  it  and  three  cases  in  which  Fleurant  had 
ojrerated.  It  was  also  the  feel  of  the  bladder  on  the 
introduction  of  a finger  intra  anum,  which  led  the  lat- 
ter surgeon  to  make  the  puncture  in  this  situation. 
The  urine  was  immediately  discharged  and  the  can- 
nula supported  in  its  place  with  the  T bandage,  until 
the  natural  passage  was  rendered  pervious  again. 
But  as  the  cannula  was  left  in  the  rectum,  it  annoyed 
the  patient  when  he  went  to  stool,  and  the  inconve- 
nience was  vastly  increased  by  the  continual  dribbling 
of  the  urine  from  the  mouth  of  the  instrument.  Hamil- 
ton avoided  both  these  inconveniences  by  withdraw- 
ing the  cannula  at  first.  In  another  instance,  how- 
ever, Fleurant  left  the  cannula  in  the  anus  and  blad- 
der thirty-nine  days,  without  the  least  inconvenience. 

In  order  to  lessen  the  tenesmus  and  other  inconve- 
niences attending  the  presence  of  the  cannula,  Fleurant 
suggested  that  it  would  be  better  to  employ  a tube 
made  of  a flexible  substance,  and  some  of  the  moderns 
approve  the  plan  of  passing  a flexible  catheter  through 
the  silver  one  into  the  bladder,  and  withdrawing  the 
latter  instrument. 

In  the  first  volume  of  the  Mem  . of  the  Medical  Society 
of  London  two  cases  are  related,  in  which,  after  tap- 
ping the  bladder  from  the  rectum,  the  cannula  was  im- 
mediately withdrawn  without  any  bad  effect ; and  a 
similar  fact  is  recorded  in  the  Medical  Communica- 
tions, vol.  I. 

A curved  trocar,  of  sufficient  length,  is  the  best  for 
performing  the  operation,  and  was  recommended  by 
Pouteau.  As  the  trocar  with  a lancet-point  may  cut 
blood-vessels  which  would  bleed  freely,  some  authors 
express  their  preference  to  one  made  with  a triangular 
point. — (Howship,  p.  215.)  It  should  be  introduced  into 
the  jirominence  made  by  the  distended  bladder,  a little 
beyond  the  prostate  gland,  exactly  in  the  centre  of 
the  front  of  the  rectum ; but  not  imprudently  far,  up 
the  intestine,  lest  the  peritoneum  be  injured.  For 
some  useful  cautions  on  this  head,  the  profession  are 
indebted  to  Mr.  Carpue,  who  has  very  properly  ad- 
verted to  the  very  low  point  to  which  the  portion  of 
peritoneum  reflected  over  the  rectum  descends.— (.Wiig. 
of  the  High  Operation,  ^ c.  p.  178,  Svo.  Land.  1819.) 

The  trocar  should  be  introduced  in  the  direction  of 
the  axis  of  the  bladder,  or  nearly  in  an  imaginary  line 
drawn  from  the  spot  to  be  punctured  to  the  middle 
point  between  the  navel  and  the  symphysis  pubis. 

The  patient  should  be  placed  nearly  in  the  same  pos- 
ture as  that  adopted  in  lithotomy  ; but  the  hands  and 
feet  need  not  be  bound  together,  it  being  sufficient  to 
let  the  assistants  sui)port  the  legs.  The  left  fore-finger, 
smeared  with  oil,  is  to  be  introduced  up  the  rectum, 
where  a portion  of  the  distended  bladder  will  be  felt 
behind  the  prostate  gland  and  between  the  converging 
vasadeferentia.  The  vesiculae  seminales,  which  are  on 
the  outside  of  the  va.sa  deferentia,  are  less  exposed  to 
injury.  Behind  the  prostate  gland,  as  Sir  Astley  Cooper 
correctly  explains,  there  is  a triangular  space  which 
affords  room  tor  the  instrument.  In  the  forepart  it  is 
bounded  by  the  meeting  of  the  vasa  deferentia,  which 
forms  the  apex  of  the  triangle  ; the  sides  are  formed  by 
the  vasadeferentia,  which  diverge  as  they  pass  from  the 
jirostate  backwards  ; while  the  basis  of  the  triangle  is 
formed  by  the  peritoneum,  which  is  reflected  from  the 
posterior  part  of  the  bladder  to  the  rectum.  Taking 
advantage  of  this  space  of  the  bladder,  which  is  not 


184 


BLADDER. 


covered  by  the  peritoneum,  the  trocar  is  introduced 
through  it  into  the  bladder  about  tliree-quarters  of  an 
inch  behind  the  prostate  gland.  The  instrument  must 
not  be  introduced  directly  behind  the  prostate,  as  the 
vas  deferens  on  one  side  or  the  other  would  certainly 
be  wounded.  If  the  trocar  be  carried  three-quarters 
or  half  of  an  inch  behind  the  prostate,  the  vasa  defe- 
rentia  will  be  {Lectures,  i-c.  vol.  2,  p.  311.)  Here 

the  surgeon  is  to  let  the  end  of  his  finger  continue, 
until,  with  his  right  hand,  and  under  the  guidance  of 
the  left  fore-finger,  he  has  brought  to  the  same  point  the 
extremity  of  the  curved  trocar,  the  concaAhty  of  which 
is  to  be  kept  forwards.  Great  care  must  also  be  taken 
not  to  let  the  stilet  project  out  of  the  cannula  too 
soon  ; that  is  to  say,  before  the  end  of  the  tube  has  been 
placed  exactly  upon  the  spot  at  w'hich  the  puncture  is 
to  be  made. 

It  is  not  necessary  to  retain  the  cannula  in  the  punc- 
ture after  the  inflammation  has  consolidated  the  sides 
of  the  wound,  and  there  is  no  danger  of  the  aperture 
closing  up  before  another  passage  is  made  for  the  urine. 
Sir  E.  Home  thinks  that  after  about  thirty-seven  hours 
the  cannula  may  be  taken  out. — {Trans,  of  a Soc.  for 
Med.  and  Chir.  Knowledge,  vol.  2.)  Indeed,  I am  not 
acquainted  with  any  fact  showing  the  ill  effect  of  re- 
moving the  cannula  early  ; for  here  the  urine  has  only 
to  pass  through  a mere  opening  without  any  longitu- 
dinal extent,  like  w'hat  remains  after  puncturing  abo  ve 
the  pubes.  The  general  safety  and  simplicity  of  tap- 
ping the  bladder  from  the  rectum  will  always  recom- 
mend this  method  to  impartial  practitioners.  The 
wound  is  made  at  a distance  from  the  peritoneum, 
passes  through  no  thickness  of  parts,  and  is  quite  un- 
attended with  any  chance  of  the  urine  becoming  extra- 
vasated  in  the  cellular  substance.  Whether  the  blad- 
der be  morbidly  contracted  and  thickened  ; whether 
the  neck  of  the  bladder  be  inflamed,  it  is  equally  ap- 
plicable. 

I am  happy  to  join  the  experienced  and  judicious  Mr. 
Hey  with  the  advocates  for  this  mode  of  performing 
the  operatioti ; and  as  his  opinion  on  this  subject  must 
have  considerable  influence,  I shall  quote  the  following 
passage  from  his  valuable  work,  particularly  as  the 
observations  confirm  some  other  points  adverted  to  in 
the  present  article.  “ It  is  sometimes  impossible,  from 
various  causes,  to  make  a catheter  pass  through  the 
urethra.  The  puncture  of  the  bladder  then  becomes 
necessary,  if  the  retention  of  urine  continues.  This 
operation  may  be  performed  either  above  the  pubes  or 
through  the  rectum.  I have  seen  it  performed  in  both 
these  methods,  but  give  the  preference  to  the  latter.  It 
is  more  easy  to  the  surgeon,  and  less  painful  to  the  pa- 
tient. Pouteau’s  curved  trocar  is  a very  convenient 
instrument,  and  may  be  used  with  safety  for  punc- 
turing the  bladder  through  the  rectum ; but  the  opera- 
tor should  cautiously  avoid  wounding  an  artery,  which 
may  be  felt  running  towards  the  anus  where  the  blad- 
der is  most  protuberant.  The  finger  tvhich  is  intro- 
duced into  the  rectum  to  guide  the  trocar,  may  be  con- 
veniently placed  a little  on  either  side  of  this  vessel. 
It  is  not  always  necessary  to  leave  the  cannula  in  the 
bladder,  as  the  urine  sometimes  begins  to  flow  through 
the  penis  within  a few'  hours  after  the  bladder  is  emptied. 
Perhaps  this  event  may  be  the  most  frequent  when 
the  introduction  of  the  catheter  has  been  prevented  by 
a stricture  in  the  urethra.  If  the  wound  becomes  closed 
before  the  power  of  expdlling  the  urine  is  regained,  re- 
course must  be  had  to  a repetition  of  the  operation, 
which  gives  very  little  trouble  to  the  patient ; neither 
is  he  much  inconrmioded  by  suffering  the  cannula  to 
remain  two  or  three  days  in  the  bladder.  This  is 
sometimes  necessary,  and  seldom  improper.” — {Hey's 
Practical  Observations  in  Surgery,  p.  430,  431, 
ed.  2.) 

The  objections  made  to  the  puncture  through  the  rec- 
tum are  three  : first,  the  annoying  tenesmus  sometimes 
produced  by  the  presence  of  the  cannula ; secondly, 
the  irritation  and  ulcerated  state  of  the  rectum  occa- 
sionally resulting  from  the  dribbling  of  the  urine 
through  it ; and  thirdly,  the  possibility  of  a sinus  be- 
ing formed  between  this  bow'el  and  the  bladder. — {A. 
Bonn,  Bemerkungen  ueber  der  Hamverhalt,  A c.  Leipz. 
1704.)  It  seems  that  Sir  Astley  Cooper  knows  of  some 
cases  in  which  such  inconveniences  have  followed, 
and,  in  particular,  one  instance  in  which  the  patient 
died  of  the  subsequent  diseased  state  of  the  rectum. 
Hence  the  puncture  of  the  bladder  from  the  rectum  is 


not  a practice  on  which  he  bestows  any  commenda- 
tion.—(See  Lancet,  vol.  2,  p.  412.) 

In  the  foregoing  columns  I have  briefly  adverted  to 
the  proposal  of  cutting  into  the  urethra  behind  the  ob- 
struction, instead  of  puncturing  the  bladder.  Mr. 
Grainger,  of  Birmingham,  a few  years  ago  also  recom- 
mended cutting  into  the  urethra  immediately  in  front  of 
the  prostate,  and  relieving  the  bladder  by  the  introduc- 
tion of  a female  catheter  through  the  gland,  or  (if  that 
could  not  be  accomplished)  by  the  division  of  its  sub- 
stance with  a scalpel.— (Med.  and  Surg.  Remarks,  A c. 
8vo.  Lond.  1815.) 

Women  rarely  stand  in  need  of  paracentesis  of  the 
bladder;  an  occasional  impossibility  of  introducing  the 
catheter  from  a retroversion  of  the  womb,  and  an  obli- 
teration of  the  meatus  urinarius  by  disease,  being  al- 
most the  only  cases  ever  placing  them  in  this  condition. 
The  only  method  applicable  to  them  is  the  puncture 
above  the  pubes,  with  the  exception  of  the  plan  of  in- 
troducing the  trocar  directly  from  the  vagina  into  the 
bladder ; a practice  which  Sir  Astley  Cooper  strongly 
condemns  on  account  of  its  leading  to  the  formation  of 
an  incurable  urinarj'  fistula  in  the  vagina,  and  a great 
deal  of  disease  and  irritation  in  that  passage  from  the 
contact  of  the  urine. 

Consult  Sharp  on  the  Operations,  chap.  15,  and  his 
Critical  Inquiry,  .dmbr.  Bertrandi,  Trattato  delle 
Operazioni  di  Chimrgia,  accresciuto  di  note,  A c.  dai 
Chirurghi  G.  Jl.  Penckienati  e O.  Brugnone,  8vo.  To- 
rino, 1802.  Bertrandi  was  an  approver  of  the  punc- 
ture from  the  rectum  ; so  was  Le  Blanc;  Opirat.de 
Chir.  t.l.  Melanges  de  Chirurgie,  Pouteau,  Lyon,  1760, 
p.  500.  L' Encyctopedie  Mithodique,  partie  Chirurgf- 
cale,  art.  Paracentese  de  la  Vessie.  Schmucker,  Chir. 
Wahmehmungen,  2 th.  Mo.  39:  puncture  from  the  rec- 
tum. Sabatier,  Medecine  Opiratoire,  t.  2.  Mursinna, 
Joum.  fur  die  Chirurgie,  &-c.  4,  p.  46.  67.  Cases  of 
puncture  from  the  rectum  and  above  the  pubes.  In  il- 
lustration of  the  operation  of  puncturing  the  bladder. 
Camper's  plates  are  the  best : see  his  Demonst.  Jinat. 
Pathol,  hb.  2.  In  this  work,  the  danger  of  letting  the 
end  of  any  long  instrument,  when  introduced,  press 
against  the  inside  of  the  bladder,  is  proved  by  a case 
in  which  that  organ  was  perforated  by  the  extremity 
of  a catheter,  p.  11.  Kloss,  Diss.  de  Paracentesi  Ve- 
sica Urinaria  per  intestinum  rectum,  Jen.  1791.  A. 
Bonn,  Anat.  Chir.  Bemerkungen  uber  die  Harnverhal- 
tung,  und  den  Blasenstich.  Leip.  1794,  prefers  the 
puncture  above  the  pubes.  J.  Howship,  in  Pract.  Obs, 
on  Diseases  of  the  Urinary  Organs,  p.  214,  8vo.  Lond. 
1816,  and  in  Treatise  on  Complaints  affecting  the  Se- 
cretion and  Excretion  of  the  Urine,  p.412,  Lond.  1823, 
thinks  the  operation  from  the  rectum  generally  supe- 
rior to  the  other  methods.  Sir  E Home,  in  Trans,  for 
the  Improvement  of  Med.  and  Chir.  Knowledge,  vol. ‘I. 
Abemeihy's  Surgical  Observations,  1804.  John  Bell's 
Principles  of  Surgery,  vol.  2.  (Euvres  Chir.  de  De- 
sault, par  Bichat,  t.  3,  p.  315,  cS'C.  TV.  Schmid  iiber  die 
Krankheiten  der  Harnblase,  &c.  8vo.  TVien,  1806. 
Richerand,  Mosogr.  Chir.  t.  3,  edit.  4.  Hey's  Practi- 
cal Observations  in  Surgery, p.  430,  edit.  2.  Parisian 
Chirurgical  .loumal,  vol.  2,  p.  156,  and  p.  265.  S.  T. 
Sbmmering  iiber  die  schnell  und  langsam  todtlichen 
Krankheiten  der  Harnblase,  A-c.  Frankfurt,  1809. 
The  author  is  an  advocate  for  the  puncture  above  the 
pubes  in  preference  to  that  through  the  rectum,  which 
he  thiziks  right  only  in  one  case,  viz.  when  the  bladder 
is  so  contracted  that  it  does  not  rise  out  of  the  less 
cavity  of  the  pelvis,  and  the  fluctuation  of  the  urine 
can  be  felt  in  the  rectum,  but  not  above  the  pubes.  In 
this  opinion  he  is  joined  by  Langenbeck  {Bibliothek,  b, 
‘S,p.  719).  Callisen,  Systema  Chirurgiw  Hodiernw,  t. 
2,  p.  277,  A-c.  Chirurgische  Versuche  von  B.  G.  Schre^ 
ger,b.  'l,p.2l\,S  c.8vo.  Mumberg,  1811,  gives  the  pre- 
ference to  the  puncture  above  the  pubes.  Edward 
Grainger,  Aled.  and  Surg.  Remarks,  &c.,  with  Gbs.on 
the  different  modes  of  opening  the  bladder  in  retention 
of  urine,  A-c.,  8eo.  I.ond.  1815.  Diet,  des  Sciences 
Med.  art.  Ischurie,  1818.  C.  Bell,  Surgical  Obs.  8vo. 
part  5,  Lond.  1818.  C.  Averill,  Short  Treatise  of 
Operative  Surgery,  p.  174,  A-c.,  Lond  1823.  Sir  A. 
Cooper's  Ij^ctures,  vol.  2,  p.  306,  Lond.  1825. 

Bladder.  T'umour  extirpated  from.  .Mr.  Wairu-r 
has  recorded  a ca.se  in  which  an  excrescence,  growing 
from  the  inside  of  a young  woman’s  bladder,  was  suc- 
cessfully removed.  Tlie  patient,  on  the  24th  of  .lu.  e, 
1747,  strained  herself  in  endeavouring  to  lift  a great 


BLA 


BLE 


185 


weight,  and  she  was  immediately  seized  with  a pain  in 
the  small  of  her  back,  and  a total  retention  of  urine.  In 
April,  1750,  she  applied  to  Mr.  Warner,  who  found  that 
she  had  never  been  able,  from  the  moment  of  the  acci- 
dent, to  void  a drop  of  urine  without  the  assistance  of 
the  catheter ; that  she  was  in  continual  pain,  and  had 
lately  been  much  weakened  by  having  several  times 
lost  considerable  quantities  of  blood,  occasioned  by  the 
Ibrce  made  use  of  in  introducing  the  instrument  into 
the  bladder. 

Mr.  Warner,  upon  examining  the  parts  with  his  fore- 
finger, whicii  he  had  great  difficulty  in  introducing  into 
the  meatus  urinarius,  discovered  a considerable  tumour, 
which  seemed  to  be  of  a fleshy  substance,  and  took  its 
rise  from  the  lower  i)art  of  the  bladder  near  its  neck. 
When  the  patient  strained  to  make  water,  and  the  blad- 
der was  full,  the  excrescence  protruded  a little  way 
out  of  the  meatus  urinarius  ; but  upon  ceasing  to  strain 
it  presently  returned. 

A purgative  having  been  given  the  day  before  the 
operation,  and  the  rectum  opened  by  means  of  an  emol- 
lient clyster,  Mr.  Warner  directed  the  patient  to  strain 
so  as  to  make  the  swelling  project.  He  then  hindered 
it  from  returning  into  the  bladder  by  passing  a ligature 
through  it,  and  endeavoured  to  draw  it  farther  out.  The 
latter  object  was  found  impracticable  on  account  of  the 
size  of  the  tumour.  Seeing  this,  Mr.  Warner  dilated 
the  meatus  urinarius  on  the  right  side  by  cutting  it  up- 
wards about  hal  f way  towards  the  neck  of  the  bladder, 
when,  by  pulling  the  swelling  forwards,  he  was  ena- 
bled to  tie  its  base,  which  was  very  large. 

For  three  days  after  the  operation,  a good  deal  of  pain 
was  felt  in  the  abdomen.  On  the  sixth  day  the  tumour 
dropped  off.  From  the  first  day  the  urine  came  away 
without  assistance,  and  the  patient  got  quite  well. 
The  tumour  resembled  a turkey’s  egg  in  shape  and 
size. — (See  Warner^s  Cases  in  Surgery,  edit.  4,  p.  303.) 

Perhaps  in  this  example  tying  the  tumour  was  pre- 
ferable to  cutting  it  away,  even  though  its  base  was 
large ; for  had  the  knife  been  used,  there  would  have 
been  some  danger  of  the  bladder  becoming  filled  with 
blood. 

For  an  account  of  other  tumours  of  the  bladder,  I 
refer  the  reader  to  “ A Practical  Treatise  on  the  most 
important  Complaints  affecting  the  Secretion  and  Ex- 
cretion of  Urine,  by  J.  Howship,  Svo.  Land.  1823.” 

[A  case,  in  which  large  quantities  of  hair,  mixed 
with  calculous  matter,  were  from  time  to  time  ex- 
tracted from  the  bladder  through  the  meatus  urinarius. 
The  disease  produced  severe  pain  in  making  water, 
and  other  complaints  resembling  those  of  stone.  At 
length,  Delpech,  suspecting  that  the  hairs  were  formed 
in  some  cyst,  communicating  with  the  bladder,  deter- 
mined to  divide  the  meatus  urinarius.  Previously  to 
this  measure,  every  information  which  could  be  de- 
rived from  sounding  was  obtained;  and  by  manual  ex- 
amination,a tumour,  as  large  as  an  egg,  was  felt  at  the 
point  where  the  bladder  and  uterus  touch  each  other. 
With  the  lithotome  cache,  the  meatus  was  cut  in  the 
direction  towards  the  symphysis  pubis,  care  being 
taken  not  to  divide  the  corpus  cavernosurn  of  the  cli- 
toris; and,  on  introducing  the  finger,  a calculus  of  the 
shape  of  a pigeon’s  egg  was  felt,  which  was  easily  ex- 
tracted. A large  mass  of  hair  and  calculous  matter 
was  also  detected,  projecting  at  the  back  and  right 
part  of  the  bladder  from  an  opening,  the  edges  of  which 
were  so  hard  and  contracted  that  the  extraneous  sub- 
stances required  the  polypus  forceps  for  their  extrac- 
tion. After  thus  clearing  the  aperture  of  the  cyst, 
Delpech  passed  his  finger  into  it,  when  a large  quan- 
tity of  fetid  pus  gushed  out  of  the  meatus.  It  was  al.so 
now  discovered,  that  the  swelling  made  a considerable 
prominence  within  the  bladder,  and  that  it  h'tJ  a cir- 
cular neck  which  might  be  tied.  This  was  afterward 
done  with  a piece  of  silver  wire,  conveyed  round  the 
part  by  means  of  the  ring  at  the  end  of  the  catheter. 
Five  days  afterw^ard,  what  had  been  tied  sloughed 
away,  and  to  the  surprise  of  Delpech  was  of  very  trivial 
size,  and  without  any  cavity.  In  short,  the  ligature 
had  only  destroyed  the  top  of  the  cyst,  and  the  finger 
conld  now  be  passed  into  a larger  opening,  and  through 
it  into  a cavity,  corresponding  to  the  swelling  felt  be- 
tween the  bladder  and  uterus.  The  cyst  was  found  in 
a state  of  complete  suppuration,  and  Delpech  conceived, 
that  the  best  chance  of  cure  would  result  from  letting 
an  injection  pass  from  a height  of  six  feet,  through  a 
pipe,  into  the  cyst,  so  as  to  wash  it  out  with  some 


force.  This  plan  created  pain  in  the  abdomen,  and 
fever,  so  that  it  could  not  be  continued  ; but,  after  the 
discharge  of  more  hair  and  calculous  matter,  and  a 
substance  as  large  as  a hen’s  egg,  which  was  covered 
by  scalp  and  contained  a molar  tooth,  the  patient  got 
well.  This  substance  in  fact  had  been  the  product  of 
conception,  and  the  sac  in  which  it  lay  extended  to  the 
uterus.  The  case  is  highly  interesting  to  the  practi- 
tioner.—(De/jjec/t,  Chirurgie  Clinique,  t.  2,p.  521,  ct  seq.) 
-Pref] 

Bladder,  Hernia  of.  See  Hernia. 

Bladder,  Insects  discharged  from.  The  instances 
in  which  worms  are  stated  to  have  been  discharged 
from  the  bladder  are  very  numerous.  Many  cases  of 
this  kind  are  referred  to  in  VoigteVs  Handbuch  der  Pa- 
thologischen  Anatomic,  b.  3,  p.  337-  342.  A few  years 
ago,  an  interesting  example  was  recorded  by  Mr.  Law- 
rence.—(See  Med.  Chir.  Trans,  v.  2,  p.  382,  A c.) 

Bladder,  Deficiency  of.  Numerous  examples  in 
which  this  deviation  from  the  natural  structure  has 
occurred  are  recorded  by  medical  writers.  The  pub- 
lications, however,  which,  as  far  as  I know,  contain 
the  most  ample  information  on  the  subject,  are,  a Got- 
tingen inaugural  dissertation,  entitled  “De  Vesicoe  Uri- 
nari(B  Prolapsu  Nativo,”  by  Dr.  Roose,  late  professor 
in  Brunswick,  and  a paper  called  “Ati  attempt  towards 
a systematic  account  of  the  appearances  connected 
with  that  malconformation  of  the  Urinary  Organs,  in 
which  the  ureters,  instead  of  terminating  in  a perfect 
bladder,  open  externally  on  the  surface  of  the  Abdo- 
men,'’ by  A.  Duncan,  jun.  in  Edin.  Med.  and  Surg. 
Journal,  vol.  1.  In  this  last  production,  may  be  seen 
references  to  all  the  most  noted  cases  on  record,  both 
male  and  female. — (See  alfio  Handbuch  der  Pathologis- 
chen  Anatomie  von  J.  F.  Meckel,  b.\,p.  650,  Svo.  Leip. 
1812.) 

Bladder,  Wounds  of.  See  Gun-shot  Wounds 
Many  cases  of  rupture  of  the  bladder  from  blows  or 
falls  are  recorded,  followed  by  fatal  extravasation  of 
urine  in  the  abdomen.  Two  such  instances  have  been 
recently  detailed  by  Dr.  Cusack.— (See  Dub.  Hospital 
Reports,  vol.  2,p.  312,  A c.  Svo.  1818.  Also,  C.  Montague 
in  Med.  Communications,  vol.  2,  p.  284,  1790.) 

BLEEDING.  By  this  operation  is  understood  the 
taking  away  of  blood  for  the  relief  of  diseases.  Bleed- 
ing is  called  general,  when  practised  with  a view  of 
lessening  the  whole  mass  of  circulating  blood ; topical, 
when  performed  in  the  vicinity  of  the  di.sease,  for  the 
express  purpose  of  lessening  the  quantity  of  blood  in  a 
particular  part. 

General  Blood-letting  is  performed  with  a lancet, 
and  is  subdivided  into  two  kinds ; viz.  the  opening  of 
a vein,  termed  phlebotorny,  or  venesection ; and  the 
opening  of  the  temporal  artery,  or  one  of  its  branches, 
termed  arteriotomy. 

Topical  Blood-letting  is  performed,  either  by  means 
of  a cupping-glass  and  scarificator,  or  leeches,  or  by 
dividing  the  visibly  distended  vessels  with  a lancet,  as 
is  frequently  done  in  cases  of  ophthalmy. 

[In  the  Southern  and  Western  States,  bleeding  is 
very  generally  perfoiTned  by  the  spring  lancet,  while 
in  -the  North  and  East,  the  tlmmb  lancet  is  almost  uni- 
versally in  use.  The  choice  of  instruments  must  of 
course  in  every  case  be  left  with  the  operator,  although, 
as  a matter  of  convenience,  it  may  sometimes  be  proper 
to  yield  in  this  respect  to  the  wishes  of  a sensitive 
patient,  and  hence  many  surgeons  have  both  at  hand, 
whether  they  individually  prefer  one  or  the  other.  The 
use  of  the  thumb  lancet  is  thought  by  some  to  require 
less  tact  than  the  other,  and  hence  they  advise  igno- 
rant and  awkward  operators  to  use  it;  but  confiding  in 
their  own  skill  in  the  use  of  the  spring  lancet,  they 
give  this  the  preference  in  their  own  hands.  From 
what  I have  seen,  however,  in  the  South,  where  the 
spnng  lancet  is  in  almost  every  body’s  hands,  and  in 
the  North,  where  it  is  seldom  seen  or  used  at  all,  I irt- 
cline  to  an  opposite  opinion,  although  from  long  habit 
1 employ  the  spring  lancet  myself  exclusively,  when 
the  prejudice  of  the  ])atient  does  not  forbid.  In  the 
hands  of  an  ignorant  or  awkward  phlebotomist,  I con- 
ceive the  thumb  lancet  to  be  a more  dangerous  instru- 
ment. There  is  first  the  risk  of  translixmg  the  vein, 
and  then  the  hazard  of  wounding  the  artery  beneath  it, 
both  the  one  and  the  other  being  greater  than  with  the 
spring  laticet.  This  latter  accident  of  wounding  the 
artery  in  the  act  of  bleeding  in  the  median  basilic  vein,  is 
known  to  be  a very  rare  occurrence  in  those  parts  of  the 


186 


BLEEDING. 


countrj'  where  the  spring  lancet  is  indiscriminately 
employed  by  the  most  illiterate  and  awkward.  Almost 
every  southern  plantation  has  one  or  more  negro 
bleeders  who  employ  this  instrument,  and  yet  the  ar- 
tery is  scarcely  ever  wounded;  while  the  thumb  lancet 
will  be  found  to  be  the  guilty  instrument  in  almost 
every  case  of  aneurism  from  this  cause,  and  hence  we 
find  this  accident  much  more  frequent  in  the  Northern 
and  Eastern  states. 

That  the  thumb  lancet  is  more  surgical  will  not  be 
questioned,  but  that  it  is  equally  safe  in  the  hands  of 
the  uninitiated  I cannot  believe.  And  the  reasons 
are  very  obvious : 1st,  The  cephalic  and  median  ce- 
phalic veins  are  easily  accessible  with  a spring  lan- 
cet, in  those  cases  where  the  basilic  or  median  ba- 
silic would  be  preferred  with  the  thumb  lancet,  be- 
cause close  to  the  skin,  and  often  much  larger.  2d, 
Even  when  the  latter  vein  is  near  the  artery  the 
oblique  direction  generally  preferred  for  the  incision 
secures  it  from  being  punctured : and,  3dly,  The  spring 
lancet  will  seldom  if  ever  transfix  a vein,  for  so  soon 
as  it  enters  the  cavity  of  the  vein,  the  non-resistance 
of  the  contained  blood  protects  the  inferior  coat  of  the 
vessel,  and  this  yields  without  being  wounded  by  the 
force  of  the  spring. 

The  only  accident  to  which  the  use  of  the  spring 
lancet  subjects  us  is,  the  occasional  fracture  of  the 
lancet  by  the  force  of  the  spring,  by  which  it  is  some- 
times left  in  the  arm,  and  thus  produces  disastrous 
consequences.  I have  more  than  once  had  to  remove 
the  fleam,  as  the  cutting  part  of  a spring  lancet  is 
called,  from  the  arm,  it  having  entered  the  vein,  and 
passed  up  to  the  next  valve,  requiring  the  slitting  up  of 
the  vein  itself  to  effect  its  removal.  This  accident, 
however,  never  occurred  under  my  notice,  except  with 
a German  fleam,  such  as  is  found  in  the  brass  lancets 
as  imported  ; and  being  made  to  sell,  should  always  be 
displaced  from  the  instrument,  and  substituted  by  a 
new  one  made  sufficiently  strong.— jReesc.] 

PHI.KBOTOMY,  OR  VKNESECTiON. 

The  mode  of  bleeding  most  frequently  practised  is 
that  of  opening  a vein ; and  it  may  be  done  in  the  arm, 
ankle,  jugular  vein,  frontal  vein,  veins  under  the  tongue, 
on  the  back  of  the  hand,  Acc.  In  whatever  part,  how- 
ever, venesection  is  performed,  it  is  always  necessary 
to  compress  the  vein,  between  the  place  where  the 
puncture  is  made  and  the  heart.  Thus  the  return  of 
blood  through  the  vein  is  stopped,  the  vessel  swells, 
becomes  conspicuous,  and  when  opened  bleeds  much 
more  freely  than  would  otherwise  happen.  Hence, 
according  to  the  situation  of  the  part  of  the  body  tvhere 
the  vein  is  to  be  opened  with  regard  to  the  heart,  the 
bandage,  or  other  means  for  making  the  necessary 
pressure  must  be  applied  either  above  ’or  below  the 
puncture. 

All  the  apparatus  essential  for  blood-letting,  on  the 
part  of  the  patient,  is  a bandage  or  fillet,  two  or  more 
small  pieces  of  folded  linen  for  compresses,  a basin  to 
receive  the  blood,  and  a little  clean  water  and  a towel. 
The  bandage  ought  to  be  about  a yard  in  length,  and 
nearly  two  inches  broad,  a common  riband  or  garter 
being  frequently  employed.  The  compresses  are  made 
by  doubling  a bit  of  linen  rag,  about  two  inches  square. 
On  the  part  of  the  surgeon,  it  is  necessary  to  have  a 
good  lancet  of  proper  shape.  He  should  never  bleed 
with  lancets  with  which  he  has  been  in  the  habit  of 
opening  any  kind  of  abscesses,  as  very  troublesome 
complaints  have  been  the  consetiuence  of  doing  so. 
The  shape  of  the  instrument  is  also  a matter  of  some 
importance.  If  its  shoulders  are  too  broad,  it  will  not 
readily  enter  the  vein,  and  when  it  does  enter,  it  inva- 
riably makes  a large  opening,  which  is  not  always  de- 
sirable. If  the  lancet  be  too  spear- pointed,  an  incau- 
tious operator  would  often  run  the  risk  of  transfixing 
the  vein,  and  wounding  the  artery  beneath  it.  More, 
however,  certainly  depends  on  the  mode  of  introducing 
the  lancet  than  on  its  shape. 

In  blood-letting  the  patient  may  fie  down,  sit  down, 
or  stand  up,  each  of  which  positions  may  be  chosen 
according  to  circumstances.  If  the  patient  be  apt  to 
faint  from  the  loss  of  a .small  quantity  of  blood,  and 
such  fainting  can  answer  no  surgical  purpose,  it  is 
best  to  bleed  him  in  a recumbent  posture.  liut  when 
the.  person  is  strong  and  vigorous,  there  is  little  occa- 
sion for  this  precaution,  and  a sitting  posture  is  to  be 
preferred,  as  the  most  convenient  both  (or  the  surgeon 


and  patient.  This,  indeed,  is  the  common  position,  m 
some  cases,  however,  particularly  those  of  strangu- 
lated hernia,  it  is  frequently  an  object  to  produce  faint- 
ing, in  order  that  the  bowels  may  be  more  easily 
reduced.  In  this  circumstance  the  patient  may  be  bled 
in  an  erect  posture,  and  the  wound  made  large,  as  a 
sudden  evacuation  of  blood  is  particularly  ajit  to  bring 
on  the  wished-for  swoon.  For  the  same  reason,  if  we 
wish  to  avoid  making  the  patient  faint,  we  should  then 
make  only  a small  puncture. 

Every  operator  should  be  able,  to  use  the  lancet  with 
either  hand,  and  thus  bleed  the  patient  in  the  right 
or  left  arm,  as  circumstances  may  render  most  eli- 
gible. 

At  the  bend  of  the  arm  there  are  several  veins  in 
which  a puncture  may  be  made,  viz.  the  basilic,  ce- 
phalic, median  basilic,  and  median  cephalic.  The  me- 
dian basilic  vein,  being  usually  the  largest  and  most 
conspicuous,  is  that  in  which  the  operation  is  mostly 
performed ; but  surgeons  should  never  forget,  that  it  is 
under  this  vessel  that  the  brachial  artery  runs,  with 
the  mere  intervention  of  the  aponeurosis  sent  off  from 
the  tendon  of  the  biceps  muscle.  In  very  thin  persons, 
indeed,  the  median  basilic  vein  lies  almost  close  to  the 
artery,  and  nothing  is  then  more  easy  than  to  transfix 
the  first  of  these  vessels  and  w'ound  the  last.  Hence 
Richerand  advises  all  beginners  to  prefer  opening  the 
median  cephalic,  or  even  the  trunk  of  the  cephalic  it- 
self, to  puncturing  either  the  basilic,  or  the  median 
basilic,  which  last  are  internally  situated,  and  nearer 
the  brachial  artery. — {Nosographie  Chirurgicale^  t.  3, 
p.  38,  edit.  2.) 

In  fat  subjects,  the  large  veins  at  the  bend  of  the 
arm  are  sometimes  totally  imperceptible,  notwithstand- 
ing the  fillet  is  tightly  applied,  the  limb  is  put  in  warm 
water,  and  every  thing  done  to  make  those  vessels  as 
turgid  as  possible.  In  this  circumstance,  if  the  sur- 
geon has  not  had  much  experience  in  the  practice  of 
venesection,  he  will  do  well  to  be  content  with  opening 
one  of  the  veins  of  the  back  of  the  hand,  after  putting 
the  member  for  some  time  in  warm  water,  and  apply- 
ing a ligature  round  the  wrist.  In  children,  a suffi- 
cient quantity  of  blood  cannot  always  be  obtained  by 
venesection ; and  in  this  event  the  free  application  of 
leeches,  and  occasionally  the  puncture  of  the  temporal 
artery,  are  the  only  effectual  methods. 

With  respect  to  the  choice  of  a vein  in  the  arm,  the 
most  experienced  operators  give  the  preference  to  one 
which  rolls  least  under  the  skin.  Such  a vessel, 
though  sometimes  less  superficial  than  another,  may 
commonly  be  opened  with  greater  facility.  The  sur- 
geon, however,  is  always  to  fix  the  vein  as  much  as 
he  can,  by  placing  the  thumb  of  his  left  hand  a little 
below  the  place  where  he  intends  to  introduce  the 
lancet. 

In  bleeding  in  the  arm,  the  fillet  is  to  be  tied  round 
the  limb,  a little  above  the  elbow,  with  sufficient  tight- 
ness to  intercept  the  passage  of  the  blood  through  all 
the  superficial  veins  ; but  never  so  as  to  stop  the  flow 
of  blood  through  the  arteries,  which  would  tend  to  pre- 
vent the  veins  from  rising  at  all.  The  veins  being 
thus  rendered  turgid,  the  surgeon  must  ^hoose  the  one 
which  seems  most  conveniently  situated  for  being 
opened,  and  large  enough  to  furnish  as  much  blood  as 
it  may  be  proper  to  take  away. 

Before  applying  the  fillet  round  the  arm,  however, 
the  operator  should  always  feel  where  the  pulsation  of 
the  artery  is  situated  ; and,  if  equally  convenient,  he 
should  not  open  the  vein  immediately  over  this  part. 
It  is  also  prudent  to  examine  where  a pulsation  is 
situated,  on  account  of  the  occasional  varieties  in  the 
distribution  of  the  arteries  of  the  arm.  The  ulnar 
artery  is  sometimes  given  off  from  the  brachial  very 
high  up ; and  in  tliis  case  it  frequently  proceeds  super- 
ficially over  the  muscles  which  arise  from  the  internal 
condyle,  instead  of  diving  under  them  in  the  ordinary 
manner. 

When  the  external  jugular  vein  is  to  be  opened,  the 
surgeon  generally  makes  the  necessary  pressure  with 
his  thumb.  The  orifice  should  be  made  in  the  direc- 
tion of  the  fibres  of  the  platysma  myoides  muscle ; and 
the  vein  is  not  so  apt  to  glide  out  of  the  way.  when  the 
surgeon  makes  the  puncture  just  where  it  lies  over  a 
part  of  the  steruo-cleido-inastoideus  muscle. 

When  blood  is  to  be  taken  from  the  foot,  the  ligature 
is  commonly  applied  a little  above  the  ankle. 

The  fillet  having  been  put  on  the  ann,  the  operato 


BLEEDING. 


187 


is  to  take  the  blade  of  the  lancet,  bent  to  a somewhat 
acute  angle,  between  the  thumb  and  fore-finger,  and, 
steadying  his  hand  upon  the  other  three  fingers,  he  is 
to  introduce  the  lancet  in  an  oblique  direction  into  the 
vessel,  till  the  blood  rises  up  at  the  point  of  the  instru- 
ment. Then  bringing  up  the  front  edge  in  as  straight 
a line  as  possible,  the  wound  in  the  skin  will  be  made 
of  just  the  same  size  as  that  in  the  vein.  The  operator 
next  takes  av/ay  the  thumb  of  his  left  hand,  with  which 
he  steadied  the  vessel,  and  allows  the  blood  to  escape 
freely,  till  the  desired  quantity  is  obtained.  The  arm 
ought  to  be  kept  in  the  same  position  while  the  blood 
is  escaping,  lest  the  skin  should  slip  over  the  orifice  of 
the  vein,  keep  the  blood  from  getting  out,  and  make  it 
insinuate  itself  into  the  cellular  substance. 

When  the  blood  does  not  issue  freely,  most  surgeons 
direct  the  patient  to  move  his  fingers,  or  turn  some- 
thing round  and  round  in  his  hand.  This  puts  the 
muscles  of  the  arm  into  action,  and  the  pressure  which 
they  then  make  on  the  veins  makes  the  blood  circulate 
more  briskly  through  these  vessels. 

The  proper  quantity  of  blood  being  discharged,  the 
fillet  is  to  be  untied.  The  flow  of  blood  now  generally 
ceases ; though  sometimes,  when  the  orifice  is  large 
and  the  circulation  very  vigorous,  it  still  continues.  In 
this  circumstance,  the  operator  may  immediately  stop 
the  bleeding,  by  placing  the  thumb  of  his  left  hand 
firmly  on  the  vessel,  a little  below  the  puncture. 

The  blood  is  next  to  be  all  washed  off  the  arm,  the 
sides  of  the  wound  placed  in  contact,  and  the  com- 
presses applied  and  secured  with  a fillet,  put  round 
the  elbow  in  the  form  of  a figure  of  8,  and  regularly 
crossing  just  over  the  compresses. 

The  patient  should  be  advised  not  to  move  his  arm 
much  till  the  fillet  is  removed,  wliich  may  be  done 
after  twenty- four  hours. 

In  order  to  open  the  external  jugular  vein,  the  pa- 
tient’s head  is  to  be  laid  on  one  side  and  properly  sup- 
ported. Then  the  operator  is  to  press  upon  the  lower 
part  of  the  vein  with  his  thumb,  so  as  to  make  the 
part  above  swell,  and  then  the  lancet  is  to  be  pushed 
at  once  into  the  vessel,  with  the  cautions  already 
stated. 

There  is  commonly  no  difficulty  in  stopping  the 
bleeding,  after  the  pressure  is  removed.  Some  practi- 
tioners divide  the  integuments  with  a scalpel,  before 
the  vein  itself  is  opened  ; but  this  is  quite  unnecessary. 
In  this  country,  the  fashion  of  opening  the  jugular  vein 
has  considerably  declined.  In  fact,  the  operation  is 
more  troublesome,  and  less  certain  of  succeeding,  than 
venesection  in  the  arm  ; while  the  principle  which  re- 
commended the  practice  to  the  old  surgeons,  namely, 
that  of  more  effectually  discharging,  in  this  manner, 
blood  from  the  minuses  of  the  brain,  is  erroneous  ; for 
it  is  only  the  external  jugular  vein  that  can  be  safely 
opened,  and  this  does  not  receive  the  blood  from  the 
interior  of  the  head. 

Blood-letting  in  the  feet  is  executed  on  the  same 
princijjle  as  in  other  parts ; but  as  the  blood  from  the 
veins  in  this  situation  generally  does  not  flow  with 
much  celerity,  it  is  customary  to  immerse  the  feel  in 
warm  water  to  promote  the  bleeding. 

ARTERIOTOMY. 

The  only  arteries  of  any  size  from  which  blood  is 
ever  taken  in  practice,  are  the  trunk  and  branches  of 
the  temporal  artery,  which  lie  in  such  a situation,  that 
they  may  easily  be  compressed  against  the  subjacent 
bones,  and  the  bleeding  stopped.  When  the  vessel 
which  the  surgeon  chooses  to  open  lies  very  near  the 
surface,  or  can  be  ascertained  by  feeling,  or  even  see- 
ing its  pulsation,  it  may  be  opened  at  once  with  a 
lancet.  But  in  many  instances  it  is  so  deeply  situated, 
that  it  becomes  necessary  in  the  first  place  to  make  a 
cut  in  the  skin,  and  then  puncture  (he  vessel. 

The  bleeding  generally  stops  without  any  trouble, 
and  may  always  be  suppressed  with  a compress  and 
bandage.  In  a very  few  cases,  the  blood  bursts  forth 
from  time  to  time,  and  more  is  lost  than  is  necessary. 
When  this  happens,  notwithstanding  pressure,  it  is  re- 
commended to  divide  the  vessel  completely  across, 
which  facilitates  the  process  of  nature  in  closing  the 
end  ol  the  vessel.  Sometimes  an  aneurism  follows, 
which  inust  be  treated  on  the  principles  explained  in  a 
foregoing  article. — (See  Aneurism.)  Cavallini  cured 
the  disease  by  dividing  the  vessel  and  compression. — 
Collez.  di  Casi  Chir.  t.  2,  Firenze^  1762.) 


TOPICAL  BLEEDING. — CUPPING. 

This  is  done  by  means  of  a scarificator  and  a glass 
shaped  somewhat  like  a bell.  The  scarificator  is  an 
instrument  containing  a number  of  lancets,  sometimes 
as  many  as  twenty,  which  are  so  contrived  that  when 
the  instrument  is  applied  to  any  part  of  the  surface  of 
the  body,  and  a spring  is  pressed,  they  suddenly  start 
out  and  make  the  necessary  punctures.  The  instru- 
ment is  so  constructed,  that  the  depth  to  which  the  lan- 
cets penetrate  may  be  made  greater  or  less,  at  the  option 
of  the  practitioner.  As  only  small  vessels  can  be  thus 
opened,  a very  inconsiderable  quantity  of  blood  would 
be  discharged,  w'ere  not  some  method  taken  to  promote 
the  evacuation.  This  is  commonly  done  with  a cup- 
ping-glass, the  air  within  the  cavity  of  which  is  rarified 
by  the  flame  of  a little  lamp  containing  spirit  of  wine, 
and  furnished  with  a thick  wick.  This  plan  is  prefer- 
able to  that  of  setting  on  fire  a piece  of  tow  dipped  in 
this  fluid,  and  put  in  the  cavity  of  the  glass  ; “ a clumsy 
expedient,  adding  unnecessarily  to  the  sufferings  of  the 
patient  by  cauterizing  the  skin ; doing  harm  also  by 
rarii  ying  the  air  more  than  necessary  within  the  glass, 
in  consequnnce^of  which  the  edges  of  the  cup  compress 
the  cutaneous  vessels  so  much  as  to  obstruct  the  influx 
of  blood.  The  larger  the  glass,  if  properly  exhausted, 
the  less  pain  does  the  patient  suffer,  and  the  more  freely 
does  the  blood  flow.”— (See  Mapleson's  Treatise  on  the 
Art  of  Cupping.,  p.  63 — 65,  \2ulo.  Land.  1813.)  When 
the  mouth  of  the  glass  is  placed  over  the  scarifications, 
and  the  rarified  air  in  it  becomes  condensed  as  it  cools, 
the  glass  is  forced  down  on  the  skin,  and  a consider- 
able suction  takes  place. 

This  professor  of  the  said  art  remarks,  that  when  the 
operation  is  about  to  be  done,  a basin  of  warm  water,  a 
piece  of  fine  sponge,  and  a lighted  candle  should  be 
provided.  As  many  of  the  cupping-glasses  as  may  be 
judged  necessary  are  to  be  put  in  the  basin.  If  six- 
teen or  twenty  ounces  of  blood  are  to  be  taken  away, 
four  glasses,  of  a size  adapted  to  the  surface  to  which 
they  are  to  be  applied,  will  generally  be  reiiuired.  Each 
glass  is  then  to  be  held  for  an  instant  over  the  flame 
of  the  spirit-lamp,  and  immediately  placed  upon  the 
skin.  Upon  the  quickness  with  which  this  is  done,  the 
neatness  and  efficacy  of  the  operation  will  depend.  If 
dry  cupping  be  only  intended,  the  glasses  may  be  al- 
lowed to  remain  on  the  skin  for  a few  moments,  and 
be  replaced  five  or  six  times,  with  a little  variation  of 
their  position,  in  order  to  prevent  the  skin  from  being 
hurt  by  their  pressure.  If  the  intention  be  to  scarify 
and  take  away  blood,  the  glass  ought  not  to  remain 
more  than  a minute,  when  the  scarificator  is  to  be  in- 
stantly applied  ; for  by  the  quickness  with  which  the 
application  of  the  scarificator  succeeds  the  removal  of 
the  glass,  the  patient  is  saved  a degree  of  pain,  which 
he  would  otherwise  suffer  from  the  making  of  the 
punctures.  When  the  glasses  are  so  full  as  to  be  in 
danger  of  falling  off,  or  the  blood  is  coagulated  in  them, 
they  should  be  removed,  emptied,  and  applied  again. 
For  the  sake  of  neatness,  care  should  be  taken  to  insert 
the  nail  under  the  upper  part  of  the  glass,  and  remove 
it  so  as  to  keep  its  bottom  downwards,  the  scarifica- 
tions being  at  the  same  time  wiped  with  a sponge  wet 
in  warm  water.  The  glasses  also,  previously  to 
each  application,  should  be  rinsed  in  warm  water,  but 
not  dried.  For  these,  and  some  other  useful  directions, 
see  Mapleson’s  Treatise,  p.  64,  <fec. 

Trials  have  been  made  of  syringes  calculated  for  ex- 
hausting the  air  from  cupping-glasses ; but  the  plan 
is  not  found  so  convenient  as  that  above  described. 

A common  pledget,  or  bit  of  rag,  is  usually  applied  as 
a dressing  for  the  punctures  made  with  a scarificator. 

If  a little  smarting  be  not  minded,  Mr.  Mapleson  pre- 
fers the  application  of  arquebusade  water  or  spirits  of 
wine,  as  it  immediately  stops  the  oozing  of  blood,  and 
prevents  subsequent  itching.— (P.  69.) 

lkei;hes. 

Leeches  are  often  preferable  to  cupping,  which  is  at 
tended  with  more  irritation  than  many  surfaces,  under 
particular  circumstances,  can  bear,  especially  when  the 
topical  bleeding  is  to  be  frequently  repeated  ; and  they 
can  be  used  in  cases  in  which  it  would  not  be  safe  or 
convenient  to  employ  the  lancet. 

Formerly  medicinal  leeches  were  very  abundant  in 
England,  but  owing  to  their  now  being  in  greater  re- 
quest, and  to  the  draining  and  cultivation  of  waste 
lands,  it  is  necessary  to  import  large  supplies  from  the 


l«8 


BLEEDING. 


continent,  chiefly  fVom  Bourdeaux  and  Lisbon.  As 
much  imposition  prevails  in  this  branch  of  commerce, 
it  should  be  understood,  that  unless  a leech  be  marked 
with  yellow  rings  or  spots,  or  with  variegated  lines 
running  the  whole  length  of  the  back,  it  will  generally 
be  found  useless. — (See  A Treatise  on  the  Medicinal 
Leech,  by  J.  R.  Johnson,  p.  133,  8wo.  Lond.  1816.) 
When  leeches  are  to  be  kept  in  any  considerable  quan- 
tity, this  gentleman  recommends  them  to  be  placed  in  a 
large  vessel  provided  with  a false  bottom,  so  perforated 
as  to  allow  them  a ready  passage.  “ Tliis  false  bottom 
should  be  raised  from  three  to  six  inches  above  the  real 
bottom,  or  to  such  an  extent  as  will  admit  of  a turf  of 
nearly  equal  dimensions  being  placed  between  them 
It  should  fit  closely  to  the  sides,  that  the  earth  may  not 
be  disturbed  by  the  frequent  introduction  of  fresh  wa- 
ter. It  is  necessary  that  the  vessel  be  also  furnished 
with  a stop-cock,  in  order  that  the  water  may  be  drawn 
off  as  often  as  may  be  considered  expedient.  But  pre- 
viously to  our  placing  the  leeches  in  this  vessel,  they 
should  be  singly  examined.  If,  on  being  handled,  they 
contract,  and  feel  hard  and  firm,  it  affords  the  best  in- 
dication of  their  being  healthy ; but  should  they  feel 
flabby,  or  exhibit  protuberances,  or  w'hite  ulcerous 
specks  on  the  surface,  they  should  be  kept  in  jars  by 
themselves,  the  water  and  the  turf  of  which  should  be 
frequently  renewed.”— (Op.  cit.  p.  138.) 

Sometimes  leeches  cannot  be  easily  made  to  fix  on  the 
part  to  which  they  ought  to  be  applied ; but  they  will 
do  so  if  the  place  be  first  cooled  with  a cloth  dipped 
in  cold  water,  or  if  it  be  moistened  with  cream  or  milk, 
and  they  be  confined  in  the  situation  with  a small  glass. 

According  to  Dr.  .lohnson,  the  part  on  which  they  are 
intended  to  fix  should  be  as  clean  as  possible ; it  should, 
therefore,  be  first  washed  with  soap  and  water,  and 
afterward  with  water  alone,  which  will  be  more  ne- 
cessary should  any  liniment  or  embrocation  have  been 
used.  Leeches  are  often  found  to  bite  better  when  re- 
moved from  the  water  at  least  an  hour  previously  to 
their  application.  In  the  common  practice  of  putting 
as  many  of  them  as  may  be  required  into  a wine-glass, 
and  inverting  it  upon  the  part  affected,  there  is  the  dis- 
advantage that  they  frequently  retire  to  the  upper 
part  of  the  glass,  and  cannot  be  got  down  again  with- 
out some  risk  of  displacing  those  which  have  already 
fastened.  To  remedy  this  inconvenience.  Dr.  Johnson 
recommends  glass  vessels  of  various  sizes  and  figtires, 
but  none  of  them  more  than  an  inch  deep.  But  in  his 
•own  practice  he  prefers  appl>ing  leeches  with  his  hand. 

Bring  a leech  towards  the  part  whereon  you  intend  to 
fix  it,  and  as  soon  as  it  begins  to  extend  the  head  to 
seek  an  attachment,  endeavour  that  it  may  affix  itself 
to  the  place  required.”  When  it  evinces  no  disposition 
to  bite,  a little  puncture  may  be  made  with  a lancet, 
when  the  animal  will  fix  itself.  “ When  the  patient  is 
fearful  of  the  lancet,  and  one  leech  only  shall  have  bit- 
-ten  where  several  are  required,  it  may  be  of  use  to  re- 
7move  it,  which  is  readily  done  by  inserting  the  nail  of 
fthe  finger  between  its  mouth  and  the  skin.  The  blood 
then  flowing  from  the  orifice  will  induce  the  remainder 
to  bite  with  the  greatest  avidity.  As  soon  as  the 
leeches  are  gorged  they  drop  off ; this  usually  happens 
within  ten  or  fifteen  minutes.  Sometimes  they  remain 
affixed  a considerable  time,  and  become  indolent ; but 
they  are  quickly  aroused  froin  this  state  by  sprinkling 
them  with  a few  drops  of  cold  water.” — {Johnson,  op. 
cit.  p.  141.)  When  they  fall  off,  the  bleeding  may  be 
promoted,  if  necessary,  by  fomenting  the  part.  When 
the  bleeding  continues  longer  than  is  desirable,  a slight 
compress  will  usually  stop  it ; but  in  more  troublesome 
cases  the  compress  must  be  dipped  in  brandy  or  spirits 
of  wine.  In  young  infants  the  hemorrhage  from  the 
bites  of  leeches  has  sometimes  proved  fatal,  and  the 
same  thing  may  happen  in  adults.  An  example  of 
each  fact  is  related  by  Beauchene  {Gazette  de  Sant.r, 
Sept.  1815).  When  the  bleeding  is  very  trouble.somc, 
Autenrieth  advises  pieces  of  charpie  to  be  pushed  into 
the  orifices  of  the  bites  a method  which  he  assures  j 
us  is  perfectly  effectual.— {Tubinffe?i  Blatter,  b.  2,  st. 
I,p.57.) 

In  order  to  make  a leech  disgorge,  it  is  usual  to  throw 
a little  salt  upon  it : in  a few  seconds  the  blood  is 
ejected,  the  leech  assumes  a coiled  form,  and  is  seldom  I 
found  fit  for  use  again  before  the  end  of  (bur  or  five  j 
days.  As  salt,  however,  frequently  blisters  the  leech,  | 
it  has  been  proposed  to  empty  the  animal  by  regular  . 
and  uniform  pressure ; but  though  Dr.  Johnson  consi-  j 


ders  this  plan  better  than  the  other,  he  admits  that  it  is 
scarcely  practicable  without  injuring  the  internal  struc- 
ture of  the  leech.  He  says,  the  best  method,  and  that 
from  which  the  animal  suffers  the  least  inconvenience, 
is  pouring  a small  quantity  of  vinegar  upon  its  head. 
Leeches  which  have  been  recently  applied  should  al- 
ways be  kept  by  themselves,  and  allowed  to  retain  for 
their  nourishment  about  one-third  of  the  blood  which 
they  extract.  For  a great  deal  of  valuable  information 
respecting  leeches,  see  Dr.  Johnson’s  work,  the  title 
of  which  is  above  specified. 

When  leeches  are  very  scarce,  their  tails  may  be 
snipped  off  while  they  are  sucking,  and  the  blood  will 
then  flow,  drop  by  drop,  from  the  artificial  opening,  as 
fast  as  the  animals  suck  it ; or,  with  the  same  view, 
an  incision  may  be  made  with  a lancet  close  to  the  tail. 
—{Johnson,  op.  cit.  p.  144.) 

SCARIF1C,\TI0N  WITH  A LANCET 

is  mostly  done  in  cases  of  inflamed  eyes.  An  assistant 
is  to  raise  the  upper  eyelid,  while  the  surgeon  himself 
depresses  the  lower  one,  and  makes  a number  of  slight 
scarifications  w'bere  the  vessels  seem  most  turgid,  try- 
ing particularly  to  cut  the  largest  completely  across. 

ILL  CONSEQUENCES  SO.METIMKS  FOLLOWING 
BLEEDING  IN  THE  ARM. 

1.  Ecchymosis. 

The  most  common  is  the  thrombus,  or  ecchyanosis,  a 
small  tumour  around  the  orifice,  and  occasioned  by  the 
blood  in.sinuating  itself  into  the  adjoining  cellular  sub- 
stance at  the  time  when  it  is  flowing  out  of  the  vessel. 
Changing  the  posture  of  the  arm  will  frequently  hinder 
the  thrombus  from  increasing  in  size,  so  as  to  obstruct 
the  evacuation  of  the  blood.  But,  in  some  instances, 
the  tumour  suddenly  becomes  so  large  that  it  entirely 
interrupts  the  operation,  and  prevents  it  from  being 
finished.  In  these  cases,  however,  the  most  effectual 
method  of  preventing  the  tumour  from  becoming  still 
larger  is  to  remove  the  bandage.  By  allowing  the 
bandage  to  remain,  a very  considerable  swelling  may 
be  induced,  and  such  as  might  be  attended  with  great 
trouble.’  If  more  blood  be  required  to  be  taken  away, 
it  ought  to  be  drawn  from  another  vein,  and,  what  is 
still  better,  from  a vein  in  the  other  arm. 

The  best  applications  for  promoting  the  absorption 
of  these  tumours,  are  those  containing  spirit,  vinegar, 
or  the  muriate  of  ammonia.  Compresses  wetted  with 
any  lotion  of  this  sort  may  be  advantageously  put  on 
the  swelling  and  confined  there  with  a slack  bandjige. 

2.  Ivjiammation  of  the  integnments  and  subjacent 
cellular  substance. 

According  to  Mr.  Abernethy,  the  inflammation  and 
suppuration  of  the  cellular  substance  in  which  the  vein 
lies,  are  the  most  frequent  occurrences.  On  the  subsi- 
dence of  this  inflammation,  the  tube  of  the  vein  is  free 
from  induration.  Sometimes  the  inflammation  is  ra- 
ther indolent,  producing  a circumscribed  and  slowly 
suppurating  tumour.  Sometimes  it  is  more  diffused, 
and  partakes  of  the  erysipelatous  nature.  On  other 
occasions  it  is  phlegmonous. 

When  the  lancet  has  been  bad,  sb  as  rather  to  have 
lacerated  than  cut  the  parts ; when  the  constitution  is 
irritable,  and  especially  when  care  is  not  taken  to  unite 
the  edges  of  the  puncture,  and  the  arm  is  allowed  to 
move  about,  so  as  to  make  the  two  sides  of  the  v ound 
rub  against  each  other,  inflammation  will  most  probably 
ensue.  The  treatment  of  this  case  consists  in  keeping 
the  arm  perfectly  at  rest  in  a sling,  applying  tlie  satur- 
nine lotion,  and  giving  one  or  two  mild  saline  purges. 
When  suppuration  takes  place,  a small  poultice  is  the 
best  application. 

3.  Absorbents  inflamed. 

Sometimes,  particularly  when  the  arm  is  not  kept 
properly  quiet  after  bleeding,  swellings  make  their  ap- 
pearance about  the  middle  of  the  ann,  over  the  large 
vessels,  and  on  the  forearm,  about  the  mid-space  l>e- 
tween  the  elbow  and  wrist,  in  the  integuments  covering 
the  flexor  muscles.  The  swelling  at  the  inner  edge  of 
the  biceps  is  sometimes  as  large  as  an  egg.  Before 
such  swmllings  take  place,  the  wound  in  the  vein  often 
inflames,  becomes  painful,  and  suppurates,  but  without 
any  perceptible  induration  of  the  venal  tube,  either  at 
this  time,  or  after  the  subsidence  of  the  inflammation. 
Pain  is  felt  shooting  from  the  orifice  in  the  vein,  ia 


BLEEDING. 


189 


lines  up  and  down  the  arm,  and  upon  pressing  in  the 
course  of  this  pain,  its  degree  is  increased  On  ex- 
amining the  arm  attentively,  indurated  absorbents  may 
be  plainly  felt,  leading  to  the  tumour  at  the  side  of  the 
biceps  muscle. 

The  pain  and  swelling  often  extend  to  the  axilla, 
where  the  glands  also  sometimes  enlarge.  Cord-iike 
substances,  evidently  absorbents,  may  sometimes  be 
felt,  not  only  leading  from  the  puncture  to  the  swelling 
in  the  middle  of  the  arm,  but  also  from  this  latter  situa- 
tion up  to  the  axillary  glands,  and  from  the  wound  in 
the  vein  down  to  the  enlarged  glands  at  the  mid-space 
between  the  eibow  and  wrist,  over  the  flexor  mus'^les 
of  the  hand. 

The  enlarged  glands  often  proceed  to  suppuration, 
and  the  patient  suffers  febrile  symptoms.  It  may  be 
suspected  that  the  foregoing  consequences  arise  from 
the  lancet  being  envenomed,  and  from  the  absorption 
of  the  viruient  matter ; but  the  frequent  descent  of  the 
disease  to  the  inferior  absorbents  militates  against  this 
supposition. 

When  the  absorbents  become  inflamed,  they  quickly 
communicate  the  affection  to  the  surrounding  cellular 
substance.  These  vessels,  when  indurated,  appear 
like  small  cords,  perhaps  of  one-eighth  of  an  inch  in 
diameter : this  substance  cannot  be  the  slender  sides 
of  the  vessels,  suddenly  increased  in  bulk^  but  an  in- 
duration of  the  surrounding  cellular  substance. 

The  inflammation  of  the  absorbents,  in  consequence 
of  local  injury,  is  deducible  from  two  causes  : one,  the 
absorption  of  irritating  matter  ; and  the  other,  the  effect 
of  the  mere  irritation  of  the  divided  tube.  When  viru- 
lent matter  is  taken  up  by  the  absorbents,  it  is  generally 
conveyed  to  the  next  absorbent  gland,  where  its  pro- 
gress being  retarded,  its  stimulating  qualities  give  rise 
to  inflammation,  and,  frequently,  no  evident  disease  of 
the  vessel  through  which  it  has  passed  can  be  dis- 
tinguished. 

When  inflammation  of  the  absorbents  happens,  in 
consequence  of  irritation,  the  part  of  the  vessel  nearest 
the  irritating  cause  generally  suffers  most,  while  the 
glands,  being  remotely  situated,  are  not  so  much  in- 
flamed. 

The  treatment  of  the  preceding  case  consists  in 
keeping  the  arm  perfectly  quiet  in  a sli'ng,  dressing  the 
puncture  of  the  vein  with  any  mild  simple  salve,  cover- 
ing the  situation  of  the  inflamed  lymphatics  with  linen 
wet  with  the  saturnine  lotion,  and  giving  some  gently 
purging  medicine. 

When  the  glandular  swelHngs  suppurate,  poultices 
should  be  applied,  and  if  the  matter  does  not  soon  spon- 
taneously make  its  way  outwards,  the  surgeon  may 
open  the  abscess. — (See  Abernethy's  Essays  on  this 
subject.) 

4.  Inflammation  of  the  Vein. 

When  the  wound  does  not  unite,  the  vein  itself  is 
very  likely  to  inflame.  This  affection  will  vary  in  its 
degree,  extent,  and  progress.  One  degree  of  inflam- 
mation may  only  cause  a slight  thickening  of  the  venal 
tube,  and  an  adhesion  of  its  sides.  Abscesses,  more 
or  less  extensive,  may  result  from  an  inflammation  of 
greater  violence,  and  the  matter  may  sometimes  be- 
come blended  with  the  circulating  fluids,  and  produce 
dangerous  consequences,  or  the  matter  may  be  quite 
circumscribed,  and  make  its  way  to  the  surface.  When 
the  vein  is  extensively  inflamed,  a good  deal  of  sympa- 
thetic fever  is  likely  to  ensue,  not  merely  from  the  ex- 
citement which  inflammation  usually  produces,  but 
also  from  the  irritation  continued  along  the  membra- 
nous lining  of  the  vein  towards  the  heart.  If,  how- 
ever, the  excited  inflammation  should  fortunately  pro- 
duce an  adhesion  of  the  sides  of  the  vein  to  each  other 
at  some  little  distance  from  the  wounded  part,  this  ad- 
hesion will  form  a boundary  to  the  inflammation,  and 
prevent  its  spreading  farther.  The  effect  of  tlie  adhe- 
sive inflammation  in  preventing  the  extension  of  in- 
flammation along  membranous  surfaces,  was  origin- 
ally explained  by  Mr.  Hunter.  In  one  case  Mr.  Hunter 
applied  a compress  to  the  inflamed  vein  above  the 
wounded  part,  and  he  thought  that  he  had  thus  suc- 
ceeded in  producing  an  adhesion,  as  the  inflammation 
was  prevented  from  spreading  farther.  When  the  in- 
flammation does  not  continue  equally  in  both  directions, 
but  descends  along  the  course  of  the  vein,  its  extension 
in  the  other  direction  is  probably  prevented  by  the  ad- 
hesion of  the  sides  of  the  vein  to  each  other.— (See  Obs. 


on  the  Inflammation  of  the  internal  coats  of  Veins, 
in  Trans,  of  a Soc.  for  the  Improvement  of  Med.  and 
Chir.  Knowledge,  vol.  I,  p.  18,  <^c.)  More  information 
on  this  subject  will  be  found  under  the  head  of  Veins. 

Mr.  Abernethy  ■mentions  his  having  seen  only  three 
cases  in  which  an  inflammation  of  the  vein  succeeded 
venesection.  In  neither  of  these  did  the  vein  suppu- 
rate. In  one  about  three  inches  of  the  venal  tube  in- 
flamed, both  above  and  below  the  puncture  The  in- 
teguments over  the  vessel  were  very  much  swollen, 
red,  and  painful,  and  there  was  a good  deal  of  fever, 
with  a rapid  pulse  and  furred  tongue.  The  vein  did 
not  swell  when  compressed  above  the  diseased  part. 
In  another  instance,  the  inflammation  of  the  vein  did 
not  extend  towards  the  heart,  but  only  downwards,  in 
which  direction  it  extended  as  far  as  the  wrist. 

The  treatment  is  to  lessen  the  inflammation  of  the 
vein  by  the  same  means  which  other  inflammations  re- 
quire, and  to  keep  the  affection  from  spreading  along 
the  membranous  lining  of  the  vessel  towards  the  heart, 
by  placing  a compress  over  the  vein  a little  w'ay  above 
the  puncture,  so  as  to  make  the  opposite  sides  of  the 
vessel  adhere  together. 

Mr.  Abernethy  conceives  a case  possible  in  which 
the  vein  may  even  suppurate,  and  a total  division  of 
the  vessel  be  proper,  not  merely  to  obviate  the  exten* 
sion  of  the  local  disease,  but  to  prevent  the  pus  from 
becoming  mixed  with  the  circulation.  Were  such  a 
proceeding  deemed  right,  I think  Mr.  Bmdie’s  method 
of  cutting  the  vessel  would  be  best.  However,  I 
have  never  heard  of  any  case  in  which  the  practice 
has  been  adopted.  As  for  the  scheme  of  tying  the  vein 
above  the  diseased  part  of  it,  the  severe  effects  fre- 
quently following  this  method  must,  as  Mr.  Dunn  has 
reminded  me,  render  it  iess  eligible  than  an  incision. 
In  the  case  of  an  inflamed  vein.  Dr.  Chapman  states 
that  nothing  is  so  efficacious  as  blisters ; a practice 
said  to  have  been  first  suggested  by  Dr.  Phy sick.— (See 
a fatal  case  of  Inflammation  of  the  vessel  from  Vene- 
section, in  Philadelphia  Journ.  Feb.  1824.)  I was 
lately  favoured  by  Mr.  Howship  with  a view  of  the 
state  of  the  parts  in  a case  where  a lady  had  died  after 
an  inflammation  of  the  veins  of  the  arm,  brought  on  by 
venesection  : they  were  considerably  thickened,  and  in 
some  cases  quite  soiid  and  impervious. — (See  Terns.) 

5.  Inflammation  of  the  Fascia  of  the  Forearm,  or  dif- 
fuse inflammation  of  the  cellular  membrane. 

Sometimes,  in  consequence  of  the  inflammation 
arising  from  the  wound  of  the  lancet  in  bleeding,  the 
arm  becomes  very  painful,  and  can  hardly  be  moved. 
The  puncture  often  remains  unhealed,  but  without 
much  inflammation  of  the  surrounding  integuments. 
The  forearm  and  fingers  cannot  be  extended  without 
great  pain.  The  integuments  are  sometimes  affected 
with  a kind  of  erj'sipelas  ; being  not  very  i»ainful  when 
slightly  touched,  but  when  forcibly  compressed,  so  as 
to  affect  the  inferior  parts,  the  patient  suffers  a good 
deal.  The  pain  frequently  extends  towards  the  axilla 
and  acromion  ; no  swelling,  however,  being  percepti- 
ble in  either  direction.  These  symptoms  are  attended 
with  considerable  fever.  After  about  a week,  a small 
superficial  collection  of  matter  sometimes  takes  place  a 
little  below  the  internal  condyle : this  being  opened,  a 
very  little  pus  is  discharged,  and  there  is  scarcely  any 
diminution  of  the  swelling  or  pain.  Perhaps,  after  a 
few  days  more,  a fluctuation  of  matter  is  distinguished 
below  the  external  condyle  ; and  this  abscess  being 
opened,  a great  deal  of  matter  gushes  from  the  wound, 
the  swelling  greatly  subsides,  and  the  patient^s  fottrre 
sufferings  are  comi)aratively  trivial. 

The  last  opening,  however,  is  often  inadequate  to 
the  complete  discharge  of  the  matter,  which  is  sometimes 
originally  formed  beneath  the  fascia,  in  the  course  of 
the  ulna,  and  its  pointing  at  the  upper  part  of  the  ann 
depends  on  the  thinness  of  the  fascia  in  this  situation. 
The  collection  of  pas  descends  under  the  lower  part  of 
the  detached  fascia,  and  a depending  opening  for  its 
discharge  becomes  necessary.  This  being  made,  the 
patient  soon  gets  well. 

In  these  cases  the  vein  is  not  inflamed ; but  some- 
times the  glands  of  the  armpit  and  just  above  the  elbow 
swell.  The  integuments  are  not  much  affected,  and 
the  patient  complains  of  a tightness  of  the  foreann. 
Matter  does  not  always  form,  and  the  pliability  of  the 
arm  after  a good  while  gradually  returns  again. 

Mr.  Watson  relates  a case  wliich  was  Ibllowed  by  a 


190 


BLE 


BLE 


permanent  contract  ion  of  the  forearm.  Mr.  Abernethy 
is  of  opinion  that  a similar  contraction  of  the  forearm, 
from  a tense  state  of  the  fascia,  may  be  relieved  by 
detaching  the  fascia  from  the  tendon  of  the  biceps,  to 
which  it  is  naturally  connected.  Mr.  Watson  seems 
to  have  obtained  success  in  his  first  case  by  having  cut 
this  connexion. 

In  the  treatment  of  an  inflammation  of  the  fascia,  or 
of  an  extensive  quantity  of  the  cellular  membrane,  in 
consequence  of  venesection,  general  means  for  the  cure 
of  inflammation  should  be  employed,  especially  nume- 
rous leeches,  cupping,  purgatives,  &c.  The  limb  should 
be  kept  quiet,  and  the  inflamed  part  relaxed.  As  soon  as 
the  inflammation  abates,  the  extension  of  the  forearm 
and  fingers  ought  to  be  attempted  and  daily  performed, 
to  obviate  the  contraction  which  might  otherwise  ensue. 

Mr.  C.  Bell  objects  to  calling  the  affection  an  inflam- 
mation of  the  fascia,  because  he  sees  no  proof  of  this 
part  being  inflamed ; and  he  conceives  that  the  symp- 
toms proceed  from  the  iHflammation  spreading  in  the 
cellular  membrane  and  passing  down  among  the  mus- 
cles and  under  the  fascia.  On  this  point  I believe  him 
to  be  quite  correct,  and  that  the  disorder  partakes 
of  the  character  of  diffuse  inflammation  of  the  cel- 
lular membrane  so  well  described  by  Dr.  Duncan. — 
(See  Edin.  Med.  Chtr.  Trans,  vol.  1.)  To  this  subject, 
however,  I shall  return  in  the  article  Erysipelas. 
The  fascia  acts  as  a bandage,  and  from  the  swelling  of 
the  parts  beneath  it  binds  the  arm,  but  is  not  itself  in- 
flamed and  contracted.  When  necessary  to  divide  the 
fascia,  Mr.  Charles  Bell  thinks  it  would  be  better  to 
begin  an  incision  near  the  inner  condyle  of  the  hume- 
rus, and  to  continue  it  some  inches  down  the  arm, 
rather  than  perform  the  nice  if  not  dangerous  opera- 
tion of  cutting  thp  fascia  at  the  point  where  the  expan- 
sion goes  off  from  the  round  tendon  of  the  biceps. 

When  the  elbow-joint  and  forearm  continue  stiff  after 
all  inflammation  is  over,  Mr.  C.  Bell  recommends  fric- 
tions with  camphorated  mercurial  ointment,  &c.,  and 
the  arm  to  be  gradually  brought  into  an  extended  state 
by  placing  a splint  on  the  forepart  of  the  limb, — \Ope- 
rative  Surgery,  vol.  1,  p.  65.)  • 

6.  Ill  Consequences  of  a Wounded  Nerve. 

Mr.  Pott  used  to  mention  two  cases  in  which  the 
patients  suffered  distracting  pains,  followed  by  con- 
vulsions and  other  symptoms,  which  could  only  be  as- 
cribed to  nervous  irritation,  arising  from  ^i  partial  divi- 
sion of  the  nerve,  and  he  recommended  its  total  divi- 
sion, as  a probable  remedy.  Dr.  Monro  related  simi- 
lar cases  in  which  such  treatment  proved  successful. 

Hence,  it  is  highly  necessary  to  know  the  charac- 
teristic symptoms  of  the  case,  particulariy,  as  all  the 
foregoing  cases  would  be  exasperated  by  the  treat- 
ment just  now  alluded  to.  It  is  to  Mr.  Abernethy  that 
we  are  indebted  for  several  valuable  remarks  elucidat- 
ing this  subject.  He  informs  us,  that  the  two  cutane- 
ous nerves  are  those  which  are  exposed  to  injury. 
Most  frequently  all  their  brain  hes  pass  beneath  the 
veins  at  the  bend  of  the  arm  ; but  sometimes,  although 
the  chief  rami  go  beneath  these  vessels,  many  small 
filaments  are  detached  over  them,  which  it  is  impossi- 
ble to  avoid  wounding  in  phlebotomy. 

Mr.  Abernethy  thinks  the  situation  of  the  median 
nerve  renders  any  injury  of  it  very  unlikely.  If,  how- 
ever, a doubt  should  be  entertained  on  this  subject,  an 
attention  to  symptoms  will  soon  dispel  it.  When  a 
nerve  is  irritated  at  any  part  between  its  origin  and 
termination,  a sensation  is  felt  as  if  some  injury  were 
done  to  the  parts  which  it  supplies.  If,  therefore,  the 
cutaneous  nerves  were  injured,  the  integuments  of  the 
forearm  would  seem  to  suffer  pain ; if  the  mediau 
nerve,  the  thumb  and  next  two  fingers  would  be  pain- 
fully affected. 

What  are  the  ills  likely  to  arise  from  a wounded 
nerve  ? If  it  were  partially  cut,  would  it  not,  like  a 
tendon  or  any  other  substance,  unite  1 It  seems  pro- 
bable that  it  would  do  so,  as  nerves  as  large  as  the  cu- 
taneous ories  of  the  arm  are  very  numerous  in  various 
situations  of  the  body,  and  are  partially  wounded  in 
operation.s,  without  any  peculiar  con.sequences  usually 
ensuing.  The  extraordinary  pain  sometimes  experi- 
enced in  bleeding,  may  denote  that  a cutaneous  nerve 
is  injured.  The  situation  of  (he  nervous  branches  is 
such,  that  they  must  often  be  partially  wounded  in  the 
operation,  though  they  probably  unite  again,  in  almost 
all  cases,  without  any  ill  consequences.  Yet,  says 


Mr.  Abernethy,  it  is  possible  that  an  inflammation'cf 
the  nerve  may  accidentally  ensue,  which  would  be 
aggravated  if  the  nerve  were  kept  tense,  in  conse- 
quence of  its  partial  division.  The  disorder,  he  thinks, 
arises  from  inflammation  of  the  nerve  in  common  with 
the  other  wounded  parts.  This  gentleman  supposes, 
rtiat  an  inflamed  nerve  would  be  very  likely  to  commu- 
nicate dreadful  irritation  to  the  sensorium,  and  that  a 
cure  would  be  likely  to  arise  from  intercepting  its 
communication  with  that  organ. 

I'he  general  opinion  is,  that  the  nerve  is  only  par- 
tially divided,  and  that  a complete  division  would 
bring  relief.  Mr.  Pott  proposed  enlarging  the  original 
orifice.  It  is  possible,  however,  that  the  injured  nerve 
may  be  under  the  vein,  and  if  the  nerve  be  inflamed, 
even  a total  division  of  it  at  the  aflected  part  would 
perhaps  fail  in  relieving  the  general  nervous  irritation, 
which  the  disease  has  occasioned.  To  intercept  the 
communication  of  the  inflamed  nerve  with  the  senso- 
rium, however,  promises  perfect  relief.  This  object 
can  only  be  accomplished  by  making  a transverse  inci- 
sion above  the  orifice  of  the  vein.  The  incision  need 
not  be  large,  for  the  injured  nerve  must  lie  within  the 
limits  of  the  original  orifice,  and  it  need  only  descend 
as  low  as  the  fascia  of  the  forearm,  above  which  all 
the  filaments  of  the  cutaneous  nerves  are  situated. 
As  the  extent  of  the  inflammation  of  the  nerve  is  un- 
certain, Mr.  Abernethy  suggests  even  making  a divi- 
sion of  the  cutaneous  nerve  still  farther  from  the 
wound  made  in  bleeding. 

Examples  are  recorded,  in  which  not  only  extraor- 
dinary pain  was  occasioned  by  the  prick  of  the  lancet, 
but  erysipelas  of  the  skin,  ending  in  gangrene  of  the 
whole  limb,  and  the  death  of  the  patient.— (/i/c^ierand, 
Nosogr.  Chir.  t.  2,  p.  390,  ed.  2.)  A ca.se  in  which  the 
greater  part  of  the  integuments  of  the  arm  had  been 
destroyed  by  erysipelas  thus  produced,  I once  saw  un- 
der the  care  of  Mr.  Vincent,  in  St.  Bartholomew’s  Hos- 
pital. 

In  former  times,  it  was  customary  to  refer  many  of 
the  bad  symptoms  occasionally  following  venesection 
to  a puncture  of  the  tendon  of  the  biceps ; but  this 
doctrine  is  now  in  a great  measure  renounced,  the  ex- 
periments of  Haller  having  completely  proved  that 
tendons  and  aponeuroses  are,  comparatively  speaking, 
parts  endued  with  little  or  no  sensibility. 

In  the  foregoing  account,  the  various  ill  conse- 
quences occasionally  arising  from  venesection  are  re- 
presented separately : no  doubt,  in  some  cases,  they 
may  occur  together. 

See  R.  Butler'. ‘i  Essay  concerning  Blood-letting,  4-c. 
Hoo.  Bond-  1734.  J\l.  Martin,  Traile  de  la  Phlebuto- 
niieetde  I'Jlrteriofonne,  8uo.  Paris,  1741.  Quesnapy 
Trnite  des  F.ffets  et  de  I'  Usage  de  la  Saignee,  l2mo. 
Pans.  Ci.  Vieusseux,  Dela  Saignee,  etde  son  Usage 
dans  laphtpart  des  Maladies,  8vo.  Pans,  1815.  J.  J. 
Walbauvi,  De  Venasectione,  Gott.  1749.  {Haller, 
Di.sp.  Chir.  5,  477.)  B.  Bell's  System  of  Surgery. 
E.ssay  on  the  ill  Consequences  sometimes  following 
Venesection,  by  J.  Mernethy.  R.  Carmichael  on  Va- 
rix  and  Venous  Inflammation,  in  Trans,  of  .^ssoc. 
Physicians,  vol.  2.  Duncan  on  Diffuse  Inflammation 
of  the  Cellular  Membrane,  in  Edin.  Med.  Chir.  Trans, 
vol.  1.  Medical  Communications,  vol.  2.  Richerand, 
Nosogr.  Chir.  t.  2,p.  416,  edit.  4.  J.  Hodgson  on  the 
Diseases  of  Jlrteries  and  Veins,  Svo.  J.,ond.  1815.  B. 
Travers,  in  Surgical  Essays,  part  l,8i'o.  Land.  1818. 
Chapman,  in  Philadelphia  .Journ.  Feb.  1824.  Freteau, 
sur  r Eniploi  des  EinDsiovs  Sanguines,  6rc.  8vo.  Pa- 
ris, 1816.  Mapleson  on  the  Jirt  of  Cupping,  12m<;. 
Dond.  1813;  and  Dr.  J.  R.  .Tohnson's  valuable  Trea- 
tise on  the  Medicinal  J^eech,  including  its  Medical  and 
Natural  History,  with  a description  of  its  .Anatomi- 
cal Sti'uctiire,  and  Remarks  upon  the  Diseases,  Preser- 
vation, and  Management  of  Beeches  8t'o.  Bond.  1816. 

BLEEDING.  See  Heviorrhage  and  Arteries. 

BLENORRHAGIA,  or  Blenorrhuco.  (From  fiXevva, 
mucus,  and  piw,  to  flow.)  A discharge  of  mucus. 
Swediaur.  who  maintains  that  gonorrhcea  is  attended 
with  a mucous,  and  not  a purulent  discharge  prefers 
the  name  of  blenorrhagia  for  the  disease.  However, 
in  treating  of  gonorrheea,  we  shall  find,  that  this  last 
appellation  is  itself  not  altogether  free  from  objec- 
tions. 

BLEPIIAROPTOSIS.  (From  |3>f(/>«pov,  the  eyelid, 
and  rrrwo-is,  a falling  down.)  Called  also  ptosis.  Au 
inability  to  raise  the  upper  eyelid.— (See  Ptosis.) 


BLI 


BOU 


191 


BLEPHAROTIS.  An  inflammation  of  the  eyelids. 

BLINDNESS.  This  is  an  effect  of  many  diseases 
of  the  eye.  See  particularly,  AmaMr-OA'ts;  Cafaraci  ; 
Cornea,  opacities  of;  Glaucoma;  Gutta  Serena, 
Hy  dr  ophthalmia ; Leucoma ; Ophthalmy ; Pterygium ; 
Pupil,  closure  of ; Staphyloma,  A c. 

BLISTERS.  Applications  which,  when  put  on  the 
skin,  raise  the  cuticle  in  the  form  of  a vesicle,  filled 
with  a serous  fluid.  Various  substances  produce  this 
effect ; but  the  powder  of  cantharides  is  what  ope- 
rates with  most  certainty  and  expedition,  and  is  now 
invariably  made  use  of  for  the  purpose.  The  blister 
plaster  is  thus  composed  : if.  Cantharidis  inpulv.  sub- 
tillissimum  tritas  tbj.  Emplastri  ceres,  Ibiss.  Adipis 
presp.  ibss.  The  wax  plaster  and  lard  being  melted, 
and  allowed  to  become  nearly  cold,  the  powdered  can- 
tharides are  afterward  to  be  added. 

When  it  is  not  wished  to  maintain  a discharge  from 
the  blistered  part,  it  is  sufficient  to  make  a puncture  in 
the  cuticle  to  let  out  the  fluid ; but  when  the  case 
requires  a secretion  of  pus  to  be  kept  up,  the 
surgeon  must  remove  the  whole  of  the  detached 
cuticle  with  a pair  of  scissors,  and  dress  the  excori- 
ated surface  in  a particular  manner.  Practitioners 
used  formerly  to  mix  powder  of  cantharides  with  an 
ointment,  and  dress  the  part  with  this  composition. 
But  such  a dressing  not  unfrequently  occasioned  very 
painful  affections  of  the  bladder,  a scalding  sensation 
in  making  water,  and  most  afflicting  stranguries.  An 
inflammation  of  the  bladder,  ending  fatally,  has  been 
thus  excited.  The  treatment  of  such  complaints  con- 
sists in  removing  every  particle  of  cantharides  from 
the  blistered  part,  w'hich  is  to  be  well  fomented,  and 
administering  freely  mucilaginous  drinks.  Camphor 
is  now  suspected  to  prove  more  hurtful  than  useful. 

These  objections  to  the  employment  of  salves,  con- 
taining cantharides,  for  dressing  blistered  surfaces,  led 
to  the  use  of  mezereon,  euphorbium,  and  other  irritat- 
ing substances,  which,  when  incorporated*  with  oint- 
ment, form  very  proper  compositions  forkeepingblisters 
open,  without  the  inconvenience  of  irritating  the  bladder. 

The  favourite  application,  however,  for  keeping  open 
blisters  is  the  powder  of  savine,  which  was  brought 
into  notice  by  Mr.  Crowther,  in  the  first  edition  of  his 
book  on  the  White  Swelling.  He  was  led  to  the  trial 
of  different  escharotic  applications  in  the  form  of 
ointment,  in  consequence  of  the  minute  attention 
which  caustic  issues  demand  ; and,  among  other  things, 
he  was  induced  to  try  powdered  savine,  from  observ- 
ing its  effects  in  the  removal  of  warts.  Some  of  the 
powder  was  first  mixed  with  white  cerate,  and  applied 
as  a dressing  to  the  part  that  had  been  blistered  ; but 
the  ointment  ran  off,  leaving  the  powder  dry  upon  the 
sore,  and  no  effect  was  produced.  Mr.  Crowther  next 
inspissated  a decoction  of  savine,  and  mixed  the  ex- 
tract with  the  ointment,  which  succeeded  better,  for  it 
produced  a great  and  permanent  discharge.  At  last, 
after  various  trials,  he  was  led  to  prefer  a preparation 
analogous  to  the  unguent um  sambuci  P.  L.  The  fol- 
lowing formula  answers  every  desirable  purpose  ; R. 
SahincB  recemtis  contuses  IbiJ.  Ceres  faces  ib].  Adi- 
pis suilleb  Ibiv.  Adipe  et  cera  liqucfeicta,  incoque 
sabinam  et  cola. 

The  difference  of  this  formula  from  that  which  Mr. 
Crowther  published  in  1797,  only  consists  in  using  a 
double  proportion  of  the  savine  leaves.  The  ceratum 
sabinae  of  Apothecaries’  Hall,  he  says,  is  admirably 
made : the  fresh  savine  is  bruised  with  half  the  quan- 
tity of  lard,  which  is  submitted  to  the  force  of  an  iron 
press,  and  the  whole  is  added  to  the  remainder  of  the 
lard,  which  is  boiled  until  the  herb  begins  to  crisp; 
the  ointment  is  then  strained  off,  and  the  proportion 
of  wax  ordered,  being  previously  melted,  is  added. 
On  the  use  of  the  savine  cerate,  immediately  after  the 
cuticle  raised  by  the  blister,  is  removed,  it  should  be 
observed,  says  Mr.  Crowther,  that  experience  has 
proved  the  advantage  of  using  the  application  lowered 
by  a half  or  two-thirds  of  the  unguetitum  ceraj.  An 
attention  to  this  direction  will  produce  less  irritation 
and  more  discharge,  than  if  the  savine  cerate  were 
used  in  its  full  strength.  He  found  fomenting  the 
part  with  flannel  wrung  out  of  warm  water,  a more 
easy  and  preferable  way  of  keeping  the  blistered  sur- 
face clean,  and  fit  for  the  impression  of  the  ointment, 
than  scraping  the  part,  as  has  been  directed  by  others. 
An  occasional  dressing  of  the  unguentum  resinaj  flavae, 
he  found  very  useful  in  rendering  the  sore  free  from 


an  appearance  of  slough,  or  rather  dense  lymph,  which 
is  sometimes  so  firm  in  its  texture,  as  to  be  separated 
by  the  probe  with  as  much  readiness  as  the  cuticle  is 
detached  after  blistering.  As  the  discharge  diminishes, 
the  strength  of  the  savine  dressing  should  be  propor- 
tionally increased.  The  ceratum  sabim*  must  be  used 
in  a stronger  or  w'eaker  degree,  in  proportion  to  the 
excitement  produced  on  the  patient’s  skin.  Some  re- 
quire a greater  stimulus  than  others  for  the  promotion 
of  the  discharge,  and  this  can  only  be  managed  by  the 
sensations  which  the  irritation  of  the  cerate  occasions. 

Mr.  Crowther  tried  ointments  containing  the  flowers 
of  the  clematis  recta,  the  capsicum,  and  the  leaves  of 
the  digitalis  purpurea.  The  first  two  produced  no  ef- 
fect; the  last  was  very  stimulating.  He  also  tried 
caustic  potassa  mixed  with  spermaceti  cerate,  in  the 
proportion  of  one  drachm  to  an  ounce ; it  proved  very 
stimulating,  but  produced  no  discharge.  One  grain  of 
the  oxymuriate  of  mercury,  blended  with  two  ounces 
of  the  above  cerate,  proved  so  intolerably  painful,  that 
at  the  end  of  two  hours  it  became  necessary  to  remove 
the  dressing;  and  the  patient  was  attacked  with  a se- 
vere ptyalism. — {Practical  Obs.  on  the  White  Swelling, 
■V  c.  2d  ed.  1808.) 

Instead  of  keeping  a blister  open,  it  is  frequently  a 
judicious  plan  to  renew  the  application  of  the  emjihis- 
trum  cantharidis,  after  healing  up  the  vesication  first 
produced,  and  to  continue  in  this  manner  a succession 
of  blisters,  at  short  intervals,  as  long  as  the  circum- 
stance of  the  case  may  demand.  Where  the  skin  is 
peculiarly  irritable,  and  particularly  in  young  chil- 
dren, where  the  emplastrum  cantharidis  sometimes 
acts  so  violently  as  to  produce  sloughing,  or,  in  any 
cases,  where  the  plaster  produces  strangury  and  irri- 
tation of  the  urinary  organs,  I am  informed,  that  the 
inconvenience  may  be  avoided,  and  the  cuticle  raised 
very  well,  if  a piece  of  silk  paper  be  interposed  be- 
tween the  plaster  and  the  integuments.  Dr.  A.  T. 
Thomson  recommends  for  the  same  purpose  a piece  of 
thin  gauze  wet  with  vinegar,  and  applied  smoothly  and 
closely  over  the  plaster. — {Dispensatory,  p.  717,  ed.  2.) 
For  infants,  a proportion  of  opium  has  sometimes  been 
added  to  the  plaster,  in  order  to  render  its  action  less 
violent ; a proposal  made,  I believe,  by  the  late  Mr. 
Chevalier.  Others  recommend  the  plan  of  not  letting 
the  blister  continue  so  long  applied  to  children  as  to 
other  patients. — (See  Paris’s  Pharmacologia,  vol.  2,  p 
186,  ed.  5.) 

BOIL.  See  Furunculus 

BONES,  iJiseases  of.  See  .Untrnm,  Caries,  Exos- 
tosis, ./onits,  ATollilies,  JVecrosis,  Osteosarcoma,  Rick- 
ets, and  Venereal  Disease.  The  following  works  re 
lative  to  the  pathology  of  the  bones,  deserve  notice 
F.  C.  Spoendli,  De  bensibilitate  Ossiniu  Alorbosa,  4to. 
Gott.  1814.  ji.  Murray,  De  Sensibilitate  Ossium  Mor- 
bosa  {Lndw.  Script.  Metir.  4).  O.  Murray,  Diss. 
Acad,  de  Sensibilitate  Ossium  Morbosa.  Frank.  Del 
Op.  12.  J.  G.  Sturmins,  De  Vulneribus  Ossium 
HelmsL.  1743.  A.  Bunn,  Pab.  Ossium  Morbosorum 
prescipue  Thesauri  Huviani,  fol.  Amst,  1785 — 1788. 
C.  F.  Clossius,  veher  die  Krankheitcn  der  Knorhen, 
12f«o.  Tubing.  1799.  A.  G.  Maumanu,  lie  Ostitide,  4to. 
Lips.  1818.  R.  ATesbitt,  Human  Osteogeny  ; two  I.,ec- 
tures  on  the  Mature  of  Ossification,  8oo.  Load.  1736. 
Siandifort,  Aiuseum  Anntomicum  Lugduno  Batavee 
Descriptum,  2 vol.  fol.  Lugd.  1793.  Weidmann,  De 
Mecrosi  Ossium,  fol.  Francof.  1793.  Brodie  on  Dis- 
eases of  Joints,  Svo.  Lund.  1818.  Howship,  in  Aled. 
Chir.  Trans.  Dr.  Cumin,  in  Edin.  Med.  and  Surgical 
.hrurn  Mo.  82 ; and  various  other  publications  speci- 
fied at  the  end.  of  the  article  Mecrosis. 

BOUGIE  is  a smooth  flexible  instrument  which  is 
introduced  into  the  urethra  for -the  cure  of  diseases  of 
that  passage  'see  Urethra)  ; and  is  .so  named  from  its 
generally  containing  wax  in  its  composition,  and  bear- 
ing some  resemblance  to  a wax  taper,  in  French,  bou- 
gie. However,  the  kinds  of  bougies  are  various,  and 
some  of  them  employed  in  modern  surgery,  so  far 
from  having  any  similitude  to  a wax  taper,  are  formed 
altogether  of  metal.  They  admit  of  being  divided  into 
those  which  are  solid,  and  others  which  are  hollow, 
and  are  more  commonly  named  catheters. — (See  Ca- 
theter.) 

The  exact  period  when  bougies  were  first  used,  is  a 
doubtful  jioint  in  the  history  of  surgery.  By  Andrew 
Lacuna,  a Spanish  physician,  the  invention  is  ascribed 
to  a Portuguese  empiric ; and  in  1551,  the  same  author 


192 


BOUGIE, 


published  what  had  been  communicated  to  him  upon 
this  subject.  In  the  year  1554,  Amaius  Lusitanus  pub- 
lished a work,  in  which  he  refers  to  several  witnesses 
to  prove,  that  the  empirical  practitioner  above  alluded 
to,  had  learned  from  him  the  use  of  bougies,  while,  on 
the  other  hand,  he  candidly  owns,  that  he  himself  was 
indebted  to  Aldereto,  of  Salamanca,  for  a knowledge  of 
these  instruments.  In  1553,  however,  Alph.  Ferri,  of 
Naples,  endeavoured  to  show,  that  his  acquaintance 
with  the  utility  of  bougies  reached  as  far  back  as  1548, 
and,  of  course,  that  he  had  anticipated  Lacuna,  and  per- 
haps even  Aldereto.  But,  instead  of  representing  him- 
self as  the  original  inventor  of  bougies,  he  mentions 
that  they  were  known  to  Alexander  of  Tralles,  which, 
if  true,  carries  back  the  invention  to  the  sixth  century. 
A.  Ferri,  also  before  describing  bougies  and  escharotic 
ointments,  mentions  various  means  of  examining  the 
state  of  the  urethra,  and,  among  other  things,  cylin- 
ders made  of  flexible  lead  and  of  dilferent  sizes.  Es- 
charotic ointments  for  what  were  termed  carnosities  of 
the  urethra,  and  bougies,  were  also  described  by  Petro- 
nius  in  1565,  and  afterward  by  A.  Pare.  The  oldest 
bougies,  which  were  wicks  of  cotton  or  thread,  covered 
with  wax  and  escharotic  plasters,  were  in  time  suc- 
ceeded by  those  composed  of  linen  smeared  with  wax. 
This  change  was  made  with  the  view  of  letting  them 
have  a hollow  construction;  an  improvement  which 
was  first  noticed  by  Fabricius  ab  Aquapendente. — (Op. 
Chir.  1617.) 

In  the  middle  of  the  ITth  century,  the  manner  of 
making  and  using  bougies  was  -tv’eU  known  to  Scul- 
tetus,  as  appears  from  his  Armamentarium  Chirurg. 
tab.  U,Jig.  9,  10. 

The  malting  of  bougies  has  now  become  so  distinct 
a trade,  that  it  may  be  considered  superfluous  to  treat 
of  the  subject  in  this  Dictionary.  However,  though  a 
surgeon  may  not  actually  choose  to  take  the  trouble  of 
making  bougies  himself,  he  should  understand  how 
they  ought  to  be  made.  Swediaur  recommends  the 
following  composition  ; R.  Cerae  flavae  Ibj.  Spennatis 
ceti  3 iij.  Cerussae  acetatae  3 v.  These  articles  are 
to  be  slowly  boiled  together,  till  the  mass  is  of  proper 
consistence.  Mr.  B.  Bell’s  bougie  plaster  is  thus  made : 
B;.  Emplastri  lythargyri  \ iv.  Cerae  fla\  a 3 iss.  Olei 
olivae  3 iij.  The  last  two  ingredients  are  to  be  melted 
in  one  vessel  and  the  litharge  plaster  in  another,  be- 
fore they  are  mixed.  In  Wilson’s  Pharmacopoeia  Chi- 
rurgica,  I observe  this  formula ; B.  Olei  olivae  tbiss. 
Cerae  flavae  tbj.  Minii  ibiss.  Boil  the  ingredients  to- 
gether over  a slow  fire  till  the  minium  is  dissolved, 
which  will  be  in  about  four  or  six  hours.  The  compo- 
sition for  bougies  is  now  very  simple,  as  modern  sur- 
geons place  no  confidence  in  the  medicated  substances 
formerly  extolled  by  Daran.  The  linen,  which  may 
be  considered  as  the  basis  of  the  bougie,  is  to  be  im- 
pregnated with  the  composition,  which  is  generally 
wax  and  oil,  rendered  somewhat  firmer  by  a proportion 
of  resin.  Some  saturnine  preparation  is  commonly 
added,  as  the  urethra  is  in  an  irritable  state,  and  the 
mechanical  irritation  might  otherwise  increase  it.  Of 
w'hatever  composition  bougies  are  made,  they  must  be 
of  different  sizes,  from  that  of  a knitting-kneedle  to 
that  of  a large  quill,  and  even  larger.  Having  spread 
the  composition  chosen  for  the  purpose  on  linen  rag, 
cut  this  into  slips  from  six  to  ten  inches  long,  and  from 
half  an  inch  to  an  inch  or  more  in  breadth.  Then  dex- 
terously roll  them  on  a glazed  tile  into  the  proper  cylin- 
drical form.  As  the  end  of  the  bougie,  which  is  'first 
introduced  into  the  urethra,  should  be  somewhat 
smaller  than  the  rest,  the  slips  must  be  rather  nar- 
row’er  in  this  situation,  and  when  the  bougies  are 
rolled  up,  that  side  must  be  outwards  on  which  the 
plaster  is  spread. 

Daran  and  some  of  the  older  writers,  attributed  the 
efficacy  of  their  bougies  to  the  composition  u.sed  in 
forming  them.  On  the  contrary,  Mr.  Sharp  appre- 
hended that  it  was  chiefly  owing  to  the  pressure  whicii 
was  made  on  the  affected  part;  and  Mr.  Aikin  adds, 
that  as  bougies  of  very  differeni  compositions  succeed 
equally  well  in  curing  the  same  diseases  in  the  ure- 
thra, it  is  plain  that  they  do  not  act  from  any  peculiar 
qualities  in  their  composition,  but  by  means  of  some 
common  property,  probably  their  mechanical  fonn. 

As  the  healthy  as  well  as  the  diseased  parts  are  ex- 
posed to  the  effects  of  bougies  made  of  very  active  ma- 
terials, modern  surgeons  always  prefer  such  as  are 
made  of  a simple  unirritating  composition. 


Plenck  recommended  bougies  of  catgut,  which  may 
be  easily  introduced  into  the  urethra,  even  when  it  is 
greatly  contracted,  their  size  being  small,  their  sub- 
stance firm,  and  dilatable  by  moisture.  It  is  objected 
to  catgut,  however,  that  it  sometimes  expands  beyond 
the  stricture,  and  gives  great  pain  on  being  withdrawn. 
Formerly,  catgut  bougies  were  sometimes  coated  with 
elastic  gum,  a valuable  material,  of  which  I shall  next 
speak. 

The  invention  of  elastic  bougies  and  catheters  origin- 
ated with  Bernard,  a silversmith  at  Paris,  who  in  the 
year  1779  presented  some  instruments  of  this  kind  to 
the  Academy  of  Surgery,  which  period  was  prior  to 
the  claim  made  by  Professor  Pickel  of  Wurzburg  to 
the  discovery. — (See  Jourti.  de  Med.  an  1785.) 

For  the  composition  of  bougies,  elastic  resin  or  gum 
is  thought  to  be  very  desirable,  as  it  unites  finnness 
and  flexibility.  Mr.  Wilson,  m \i\sPharmacopceia  Chi- 
mrgica,  is  inclined  to  think  that  the  ait  of  making 
these  instruments  consists  in  finding  a suitable  solvent 
for  the  Indian  gum.  As  this  substance,  if  dissolved  in 
ether,  completely  recovers  its  former  elasticity  upon 
the  evaporation  of  this  fluid,  it  is  supposed  that  ether, 
though  rather  too  expensive,  would  answer. 

I find  it  positively  asserted,  however,  in  a modem 
work  of  great  repute,  that  the  idea  of  elastic  gum  being 
the  substance  really  employed  is  a mistake,  as  the 
material  used  is  nothing  more  than  linseed  oil  boiled 
for  a considerable  time,  and  used  as  a varnish  for  the 
silk,  linen,  or  cotton  tube. — (See  Diet,  des  Sciences 
Mai.  art.  Bougie.) 

Very  cheap  and  good  elastic  gum  bougies  are  made 
by  Feburier,  No.  51  Rue  du  Bac,  at  Paris,  who  has 
twelve  different  sizes.  His  elastic  gum  catheters  are 
also  well  made,  though  for  smoothness  and  regularity 
1 think  they  are  not  equal  to  some  which  are  now^  con- 
structed in  London  : but  I believe  Feburier’s  smallest 
size  is  rather  less  than  any  w hich  are  made  in  this 
city;  an  ads’antage  which  no  doubt  our  artists  will 
soon  be  able  to  give  their  productions.  This  ingeni- 
ous mechanic  does  not  employ  catgut  in  the  composition 
of  the  elastic  gum  bougies,  for  which  he  is  so  cele- 
brated. These  bougies  are  most  excellent  when  you 
can  get  them  to  pass ; for  they  dilate  the  stricture  with 
the  least  possible  irritation.  But  sometimes  they  can- 
not be  introduced  when  a wax  bougie  can  ; and  from 
the  trials  which  I have  made  of  them.  1 conceive 
this  arises  from  their  elasticity  and  continual  ten- 
dency to  become  straight  when  they  reach  the  pe- 
rinaeum.  so  that  the  point  presses  on  the  lower  surface 
of  the  urethra.  Hence,  when  the  obstruction  is  on 
that  side,  it  must  be  verj'  difficult  to  get  the  end  of  the 
bougie  over  it. 

A few  years  ago,  Mr.  Smyth  discovered  a metallic 
composition  of  which  he  formed  bougies,  to  which 
some  practitioners  impute  very  superior  qualities. 
These  bougies  are  flexible,  have  a highly  polished  sur- 
face of  a silver  hue.  and  possess  a sufficient  degree  of 
firmness  for  any  force  necessary  in  introducing  them 
for  the  cure  of  strictures  of  the  urethra.  The  advocates 
for  the  metallic  bougies  assert,  that  such  instruments 
exceed  any  other  bougies  which  have  yet  been  invented, 
and  are  capable  of  succeeding  in  all  cases  in  which 
the  use  of  a bougie  is  proper.  They  are  either  solid  or 
hollow,  and  are  said  to  answer  extremely  welt  as  ca- 
theters; for  they  not  only  pass  into  the  bladder  with 
ease,  but  may  also  be  continued  there  for  any  conve- 
vient  space  of  time,  and  thus  produce  essential  benefit. 
— (U'.  Smyth,  Brief  Essay  on  the  Advantages  of  Flex- 
ible Metallic  Bougies,  8vo.  Lond.  1804.)  The  greatest 
objection  which  has  been  urged  against  them  is,  that 
they  are  attended  with  a risk  of  breaking.  I have 
heard  of  an  eminent  surgeon  being  called  upon  to  cut 
into  the  bladder,  in  consequence  of  a metallic  bougie 
having  broken,  and  a piece  of  it  passing  into  that  or- 
gan, where  it  became  a cause  of  the  severe  symptoms 
which  are  commonly  the  effect  of  a stone  in  the  blad- 
der. For  the  particulars  of  an  interesting  case,  in 
which  a metallic  bougie  broke  in  the  urethra,  the  read- 
er may  consult  London  Med  Repository,  vol.  9,  No. 
51.  The  manufacture  of  metallic  bdhgies,  however,  is 
now  brought  to  such  perfection,  that  though  they  are 
used  to  a great  extent  in  modem  practice,  we  rarely 
hear  of  their  breaking ; but  it  is  most  prudent  not  to 
be  too  bold  with  those  of  small  diameter. 

The  bougie,  with  its  application,  says  Mr.  Hunter,  is 
perhaps  one  of  the  greatest  improvements  in  surgery 


BRO 


BRO 


193 


which  these  last  thirty  or  forty  years  have  produced. 
“ When  I compare  the  practice  of  the  present  day 
with  what  it  was  in  the  year  1750,  I can  scarcely  be 
persuaded  that  I am  treating  the  same  disease.  I re- 
member, when  about  that  time  I was  attending  the 
first  hospitals  in  the  city,  the  common  bougies  were 
either  a piece  of  lead  or  a small  wax  candle ; and 
although  the  present  bougie  was  known  then,  the  due 
preference  was  not  given  to  it  nor  its  particular  merit 
understood,  as  we  may  see  from  the  publications  of 
that  time.” 

Daran  was  the  first  who  improved  the  bougie  and 
brought  it  into  general  use.  He  wrote  professedly  on  the 
diseases  for  which  it  is  a cure,  and  also  of  the  manner 
of  preparing  it ; but  he  has  introduced  much  absurdity 
into  his  descriptions  of  the  diseases,  the  modes  of  treat- 
ment, and  the  poAvers  and  composition  of  his  bougies. 

When  Daran  published  his  observations  on  the  bou- 
gie, every  surgeon  tried  to  discover  the  composition, 
and  each  conceived  that  he  had  found  it  out,  from  the 
bougies  which  he  composed  producing  the  effects  de- 
scribed by  Daran.  It  was  never  suspected,  that  any 
extraneous  body  of  the  same  shape  and  consistence 
would  do  the  same  thing. — (See  A IVeatise  on  the  Fe- 
nertal  Disease,  p.  IIG.  Sharp's  Critical  Inquirxy,,  ch. 
4.  Aikin  on  the  External  Use  of  Lead.  Daran,  Obs. 
Ckir.  sur  les  Maladies  de  U Uretre,  Vimo.  Paris,  1748 
and  1768.  Olivier,  Lettre  dans  laquelle  on  demontre 
les  avantages  que  I’on  peat  retirer  de  I'usage  des  bou- 
gies creases, S,-c.  Sec.  Paris,  1750.  Desault,  Journ.  de 
Chir.  t.  2,  p.  375,  and  t.  3,  p.  123,  1792.  Smijlh's  Brief 
Essay  on  Flexible  Metallic  Bougies,  8vo.  Loud.  1804. 
Diet,  des  Sciences  Medicates,  t.  3,».265,  Src.8vo.  Pa- 
ris, 1812.) 

Of  armed  bougies,  as  well  as  of  some  other  kinds, 
and  of  the  manner  of  using  bougies  in  general,  I shall 
speak  in  the  article  Urethra,  Strictures  of. 

BRAIN.  For  concussion,  compression  of,  &c.,  see 
Head,  Injuries  of.  For  the  hernia  of,  see  Hernia  Ce- 
rebri. 

BREAST.  See  Mammary  Abscess ; Mamma,  Re- 
moval if;  Cancer,  Src. 

BRONCHOCELE.  (From  ^p(5y%of,  the  windpipe, 
and  KtiXy,  a tumour.)  The  Swiss  call  the  disease  gotre 
or  goitre.  Heister  thought  it  should  be  named  tra- 
cheocele. Prosser,  from  its  frequency  in  the  hilly  parts 
of  Derbyshire,  called  it  the  Derbyshire  neck;  and  not 
satisfied  respecting  the  similitude  of  this  tumour  to  that 
observed  on  the  necks  of  women  on  the  Alps,  the  Eng- 
lish Bronchocele.  By  Alibert  the  disease  is  called  Thy- 
rophraxia. 

1.  The  .simple  bronchocele  or  thyrophraxia  is  the 
most  common  form  of  the  disease,  and  is  a mere  en- 
largement of  the  thyroid  gland.  The  integuments 
covering  the  part  are  quite  unchanged.  Women  are 
observed  to  be  more  subject  to  it  than  men.  It  is 
also  well  known  to  be  in  general  free  from  danger,  the 
office  of  the  thyroid  gland  not  being  of  stich  import- 
ance in  the  animal  economy  as  to  be  essential  to  the 
continuance  of  life.  Alibert  has  seen  one  example  in 
which  the  tumour  became  cancerous,  and  destroyed 
the  mother  of  a family. 

2.  The  compound  bronchocele  is  that  which  pre.sents 
the  greatest  variety,  and  astonishes  every  beholder. 
Sometimes  a more  or  less  voluminous  cyst  is  formed 
round  it,  filled  with  a pultaceous  or  purulent  matter. 
Sometimes  in  compound  bronchoceles,  calcareous  and 
other  heterogenous  substances  are  found.  In  tAvo 
cases  Alibert  found  on  the  outside  of  the  enlarged  gland 
a yellow  fatty  mass ; and  in  a third  instance  the  gland 
itself  formed  a true  sarcoma. —(iVo.s;o/o^ie  Naturelle, 
t.  \,p.  464,  folio,  Paris,  1817.) 

The  term  bronchocele  always  signifies  in  this  country 
an  enlargement  of  the  thyroid  gland,  Avhicli,  with  the 
di.sease  of  the  surrounding  parts,  sometimes  not  only 
occupies  all  the  space  from  one  angle  of  the  jaw  to  the 
other,  but  forms  a considerable  projection  on  each  side 
of  the  neck,  advancing  forwards  a good  way  beyond  the 
chin,  and  forming  an  enormous  mass,  Avhich  hangs 
down  over  the  chest.  The  swelling,  which  is  more  or 
less  unecjual,  in  general  has  a soft,  spongy,  elastic  feel, 
esiKicially  when  the  disease  is  not  in  a very  advanced 
state;  but  no  fluctuation  is  usually  perceptible,  and  the 
part  is  exceedingly  indolent.  The  skin  retains  nearly 
us  ordinary  colour ; but  when  the  tumour  is  of  very 
long  standing  and  great  size,  the  veins  of  the  neck  be- 
come more  or  less  varicose. 

VoL.  I.-N 


According  to  Prosser,  the  tumour  generally  begins 
between  the  eighth  and  twelfth  years.  It  enlarges 
sloAvly  during  a few  years ; but  at  last  it  augments 
rather  rapidly,  and  forms  a bulky  jiendiilous  tumour. 
Women  are  far' more  subject  to  the  disease  than  men. 
and  the  tumour  is  observed  to  be  particularly  apt  to  in- 
crease rapidly  during  their  confinement  in  childbed. 
Sometimes  bronchocele  affects  the  whole  of  the  thyroid 
gland,  that  is  to  say,  the  two  lateral  lobes  and  the  in 
tervening  portion  ; and  it  is  in  this  kind  of  case,  that  it 
is  not  unusual  to  remark  three  distinct  swellings,  for 
the  most  part  of  unequal  size.  Frequently  only  one 
lobe  is  affected  ; while  in  many  other  cases  the  three 
portions  of  the  thyroid  gland  are  all  enlarged  and  so  con- 
founded together,  that  they  make,  as  it  Avere,  only  one 
connected  globular  mass.  Finally,  in  some  dissections 
the  thyroid  gland  has  been  found  quite  unchanged,  the 
Avhole  of  the  tumour  having  consisted  of  a sarcomatous 
disease  of  the  adjacent  lymphatic  glands  and  cellular 
membrane. — {Postiglione,  p.  21.)  When  only  one  lobe 
of  the  thyroid  gland  is  affected,  it  may  extend  in  front 
of  the  carotid  artery,  and  be  lifted  up  by  each  diastole 
of  this  vessel,  so  as  to  have  the  pulsatory  motion  of  an 
aneurism. — (A.  Burns's  Surgical  Anatomy  of  the 
Head  and  Neck,  p.  195,  and  Parisian  Chirurgical 
Journ.  vol.  2,  p,  292,  293.)  Alibert  believes  that  he  first 
made  the  remark  that  the  right  lobe  was  more  fre- 
quently enlarged  than  the  left. — {Nosol.  Nat.  t.  1,  p. 
465.)  The  same  thing  was  invariably  noticed  in  every 
case  seen  by  Mr.  Rickwood  in  the  neighbourhood  of 
Horsham  in  Sussex.— (See  Med.  and  Phys.  Journ.  for 
Aug.  1823.) 

The  ordinary  seat  of  bronchocele,  as  Flajani  remarks, 
is  the  thyroid  gland  ; but  sometimes  cysts  are  formed 
in  the  cellular  membrane. — {Collez.  d’Oss.  t.  3,  p.  277.) 
And  Postiglione  also  observes,  that  the  sAvelling  is 
sometimes  encysted,  and  filled  with  matter  of  various 
degrees  of  consistence,  resembling  honey,  &c. ; in  some 
cases  it  is  emphysematous,  or  filled  with  air ; and  in 
other  instances  it  is  sarcomatous,  having  the  consistence 
of  a gland,  which  is  enlarged,  but  not  scirrhous.  These 
different  characters  prove,  says  he,  that  the  treatment 
ought  not  to  be  the  same  in  all  cases. — {Memoria  suUa 
Natura  del  Gozzo,  p.  20.) 

Bronchocele  is  common  in  some  of  the  valleys  of  the 
Alps,  Apennines,  and  Pyrenees.  Indeed,  there  are 
certain  places  where  the  disease  is  so  frequent,  that 
hardly  an  individual  is  totally  exempt  from  it.  Larrey, 
in  travelling  through  the  valley  of  Maurienne,  noticed 
that  almost  all  the  inhabitants  Avere  affected  with 
goitres  of  different  sizes,  Avhereby  the  countenance  was 
deformed,  and  the  features  rendered  hideous, — Mem. 
de  Chir, Mil.  t.  1,  p.  123.)  And  Postiglione  rejuarks  that 
in  Savoy,  Switzerland,  the  Tyrol,  and  Carinthia  there 
are  villages  in  Avhich  all  the  inhabitants  without  excep- 
tion have  these  swellings,  the  position  and  regularity 
of  which  are  there  considered  as  indications  of  beauty. 
— {Memoria  sulla  Natura  del  Gozzo,  p.  22.)  In  many 
the  swelling  is  so  enormous,  that  it  is  impossible  to 
conceal  it  by  any  sort  of  clothing.  A state  of  idiotism 
is  another  affliction  Avhich  is  sometimes  combined  with 
goitre,  in  countries  where  the  latter  affection  is  en- 
demic. However,  all  who  have  the  disease  are  not 
idiots,  or  cretins,  as  they  have  been  called ; and  in 
Switzerland  and  elsew'here  it  is  met  with  in  persons 
who  possess  the  most  perfect  intellectual  faculties. 
When  bronchocele  and  cretinism  exist  together,  Fodere 
and  several  other  writers  ascribe  the  affection  of  the 
mind  to  the  stateofthe  thyroid  gland. — (See  I'raitisur 
le  Goitre  et  le  Cretinisme,  8vo.  Paris,  an  ci.)  However, 
this  opinion  appears  to  want  foundation,  since  the  men- 
tal faculties  are  from  birth  weak,  and  in  many  the 
idiotism  is  complete  Avhere  there  is  no  enlargement  of 
the  thyroid  gland,  or  Avhere  the  tumour  is  not  bigger 
than  a walnut,  so  that  no  impediment  can  exist  to  the 
circulation  to  or  from  the  brain. — {Burns  on  the  Sur- 
gical Anatomy  of  the  Head  and  Neck,  p.  192.)  The 
direct  testimony  of  Dr.  Reeves  also  proves  that  in  coun- 
tries where  cretins  are  numerous  many  peojile  of  sound 
and  vigorous  minds  have  bronchocele. — (See  Dr.  Reeve's 
Paper  on  Cretinism  , Edin.  Med.  and  Surgical  Journal, 
vol.  5,  p.  31.)  Hence,  as  Mr.  A.  Burns  remarked,  the 
combination  of  bronchocele  and  cretinism  must  be  con- 
sidered as  accidental ; a truth  that  seems  to  derive  con- 
firmation from  the  fact  that  in  some  parts  of  this 
country  bronchocele  is  frequent,  where  cretinism  is 
seldom  or  never  seen. 


194 


BRONCHOCELE. 


Broncbocele  is  not  confined  to  Europe;  it  is  met  with 
in  almost  every  country  on  the  g obe.  Professor  Bar- 
ton, in  his  travels  among  the  Indians  settled  at  Oneida 
in  the  state  of  New-York,  saw  the  complaint  in  an  old 
•woman,  the  wife  of  the  chief  of  that  tribe.  From  this 
•wfoman  Barton  learned  that  bronchoceles  were  by  no 
means  uncommon  among  the  Oneida  Indians,  the  com- 
plaint existing  in  several  of  their  villages.  He  found 
also  that  the  disease  resembled  that  seen  in  Europe,  in 
respect  to  its  varieties.  He  did  not  indeed  himself  see 
the  pendulous  bronchocele  which  descends  over  the 
breast ; but  he  understood  that  it  was  not  uncommon 
among  the  women  on  the  banks  of  the  Mohawk  river, 
who  wore  a particular  dress  for  its  concealment.  In 
North  America  bronchocele  attacks  persons  of  every 
age ; but  it  is  most  frequently  seen  in  adults ; a dif- 
ference from  what  is  noticed  in  Europe.  Bronchocele 
is  said  to  be  frequent  in  Lower  Canada.  Bonpland, 
the  com[)anion  of  Humboldt,  intbrined  Alibert  that  the 
disease  was  endemic  in  New  Grenada,  and  that  it  pre- 
vailed in  such  a degree  in  the  little  towns  of  Honda 
and  Monpa,  on  the  banks  of  the  Magdalen  river,  that 
scarcely  any  of  the  inhabitants  were  free  from  it.  The 
blacks  and  those  who  led  an  active,  laborious  life,  how- 
ever, are  reported  to  escape  the  complaint.  Some  of 
the  natives  of  the  isthmus  of  Darien  are  said  to  be  ter- 
ribly disfigured  by  it. — {Alibert,  Nosol.  Nat.  t.  1,  p.469. 
Also,  Observations  sur  quelques  phinomencs  pen  con- 
nus  qn'offre  le  goitre  sous  les  tropiques,  dans  les 
plaines  et  sur  les  plateaux  des  Andes,  par  A.  de  Hum- 
boldt, in  Journ.  de  Physiologic  par  F.  Magendie,  t.  4, 
p.  109,  Paris,  1824.) 

In  European  women  bronchocele  usually  makes  its 
appearance  at  an  early  age,  generally  between  tlie 
eighth  and  twelfth  year,  and  it  continues  to  increase 
gradually  for  three,  four,  or  five  years,  and  is  said 
sometimes  to  enlarge  more  during  the  last  half  year 
than  for  a year  or  two  previously.  It  does  not  gene- 
rally rise  so  high  as  the  ears,  as  in  the  cases  mentioned 
by  Wiseman.  Sometimes,  however,  this  happens,  as 
we  see  in  the  case  of  Clement  Desenne,  of  whom  Ali- 
bert has  given  an  engraving.  In  this  patient,  a part 
of  the  tumour,  as  large  as  a hen’s  egg,  projected  into 
the  mouth. — {Nosol.  Nat.  t.  1,  p.  466.)  The  swelling 
extended  from  the  ears  to  the  middle  of  the  breast.  A 
seton  produced  a partial  subsidence  of  it ; but  when  it 
was  withdrawn  the  orifices  closed.  After  two  years 
more,  the  swelling  became  painful,  suppuration  took 
place,  and  fifteen  pints  of  matter  were  discharged ; and 
six  ounces  every  day  after  the  swelling  had  burst, 
came  away  with  the  dressings  for  three  months  ; but, 
notwithstanding  all  this  suppuration,  and  more  after- 
ward, the  tumour  was  only  pai’tially  lessened.  The 
disease,  mostly  has  a pendulous  form,  not  unlike,  as 
Albucasis  says,  the  flap  or  dewlap  of  a turkey-cock, 
the  bottom  being  the  largest  part  of  the  tumour.  Ali- 
bert mentions  a case  in  which  the  swelling  hung  down 
to  the  middle  of  the  sternum,  and  the  large  mass,  which 
was  quite  a burden  to  the  patient,  used  to  become  hard 
and,  as  it  were,  frozen  in  very  cold  weather.  This 
author,  however,  cannot  be  right,  when  he  adds,  that  it 
was  an  inert  body,  destiOite  (^vitality  ! — {Nosol.  Nat. 
t.  1,  p.  466.)  In  another  curious  instance,  the  tumour 
formed  a long  cylinder  which  reached  down  to  the  mid- 
dle of  the  thigh,  the  diameter  becoming  gradually 
smaller  downwards.— (P.  468.)  The  common  seat  of 
bronchocele  is  the  thyroid  gland ; but  freiiuently  the 
surrounding  cellular  membrane  is  more  or  less  thick- 
ened, and  contributes  to  the  swelling.  Sometimes  also 
the  neighbouring  lymphatic  glands  are  affected,  when 
its  base  is  widened  and  extends  from  one  side  of  the 
neck  to  the  other.  In  this  circumstance,  the  swelling 
gradually  loses  itself  in  the  surrounding  parts,  and  is 
not  circumscribed  as  in  ordinary  instances. — {Postig- 
lionc,  Mem.  sulla  Natura  del  Gozzo,  p.  20.)  It  is  soft, 
or  rather  flabby  to  the  touch,  and  somewhat  moveable; 
but  after  afew  years,  when  it  has  ceased  enlarging, 
it  becomes  firmer  and  more  fixed.  When  the  disease 
is  very  large,  it  generally  occasions  a difficulty  of 
breathing,  which  is  increased  by  the  patient’s  catching 
cold  or  attempting  to  run.  In  some  subjects  the  tu- 
mour is  so  large,  and  affects  the  breathing  so  much, 
that  aloud  whizzing  is  occasioned  ; but  there  are  many 
exceptions  to  this  remark.  Sometimes  when  the  swell- 
ing is  of  great  size,  patients  sufler  very  little  inconve- 
nience ; while  othens  are  greatly  incommoded,  though 
the  tumour  is  small.  In  general  the  inconvenience  is 


trivial.  The  voice  is  sometimes  rendered  hoarse,  and 
in  particular  cases  the  difficulty  of  speech  is  very  con- 
siderable.— (See  Flajani,  Collez.  d'Oss.  t.  3,  p.  271.) 

The  difficulty  of  respiration,  produced  by  the  pressure 
of  the  tumour  and  the  enlargement  of  other  glands,  as 
this  author  remarks,  is  the  most  dangerous  effect  of 
the  disease,  since  by  disordering  the  pulmonary  circu- 
lation, it  renders  the  pulse  irregular  and  intermittent, 
and  a strong  throbbing  is  excited  in  the  region  of  the 
heart,  followed  by  fatal  disease  of  the  lungs  themselves  ; 
consequences  often  not  suspected  to  have  any  connexion 
with  the  bronchocele,  though  it  is  in  reality  the  imme- 
diate cause  of  them. — {Vol.  cit.  p.  278.) 

The  causes  of  bronchocele  are  little  known.  To  the 
doctrine  that  bronchocele  is  caused  by  the  earthy  im- 
pregnation of  water  used  for  drink,  the  following  ob- 
jections offer  themselves ; 1.  The  water  of  Derbyshire, 
in  districts  where  this  disease  is  considered  endemic, 
contains  much  supercarbonate  of  lime ; but  that  in 
common  use  about  Nottingham,  where  the  disease  is 
also  prevalent,  is  impregnated  with  sulphate  of  lime. 
How  ever,  that  the  disease  is  not  produced  by  w ater 
impregnated  by  sulphate  of  lime  is  evident ; for,  as  Ali- 
bert observes,  the  waters  of  Saint  Jean,  Saint  Sulpice, 
and  Saint  Pierre,  where  bronchocele  is  frequent,  contain 
much  less  of  this  earth  than  the  waters  of  Upper  Mau- 
rienne,  where  the  disease  is  hardly  ever  noticed,  though 
the  bouses  are  built  upon  avast  quarry  of  gypsum.  The 
same  fact  was  observed  by  Bonpland  in  New  Grenada. 
— {Nosol.  Nat.  t.  1,  p.  471.)  Nor,  as  Fodere  explained, 
can  the  cause  of  the  disease  be  correctly  referred  to  the 
use  of  any  particular  kind  of  food.  Certain  localities, 
however,  seem  to  contribute  to  its  frequency  ; for  this 
author  observes,  that  the  disease  is  not  prevalent  in 
very  high  places  nor  in  open  plains ; but  that  it  be- 
comes more  and  more  common  as  we  descend  into 
deep  valleys  made  by  torrents,  where  there  is  a good 
deal  of  marsh,  and  abundance  of  fruit-trees.  The  air 
is  here  constantly  humid.  2.  Abstinence  from  un- 
boiled water  does  not  diminish  or  interrupt  the  gradual 
progress  of  the  disease.  3.  Patients  are  cured  of  the 
disease,  who  still  continue  to  drink  water  from  the 
same  source  as  before,  without  taking  any  precaution, 
as  boiling,  «fec.  4.  The  disease  in  this  country  is  less 
frequently  found  among  men.  5.  Many  instances  may 
be  related  of  a swelling  in  the  neck,  sometimes  very 
painful,  and  generally  termed  bronchocele,  being  pro- 
duced very  suddenly,  by  difficult  parturition,  violent 
coughing,  or  any  other  unusually  imverful  effort. — 
(See  Edin.  Med.  and  Surgical  Journ.  vol.  4,  p.  279.) 
When  the  gland  is  suddenly  enlarged  during  a violent 
e.xertion,  the  distention  is  said  to  be  produced  by  the 
passage  of  air  from  the  trachea  into  the  substance  of 
the  thyroid  gland  and  surrounding  cellular  membrane. 
But  w'hether  this  statement  be  a fact  or  not,  it  is  un- 
questionably true,  that  in  many  patients  the  tumour 
always  increases  when  they  speak  loud,  sing,  or  make 
any  effort. — {Flajani,  Collez.  (TOss.  4 c.  t.  3,  p.  276 ; 
and  Postiglionc,  p.  24.)  The  disease  is  sometimes 
seen  in  scrofulous  subjects  ; but  there  is  every  reason 
to  believe  that  it  is  quite  independent  of  the  other  dis- 
order, as  Prosser,  Wilmer,  and  Kortum  have  particu- 
larly explained.  The  following  are  some  points  of 
difference  between  bronchocele  and  scrofula,  as  indi- 
cated by  Dr.  Postiglione.  1.  The  true  bronchocele  is 
simply  a local  disease  of  the  neck,  the  constitution 
being  unaffected.  On  the  contrary,  scrofula  extends 
its  effects  to  the  whole  system,  attacking  not  only  the 
lymphatic  glands,  but  also  the  muscles,  cellular  mem- 
brane, ligaments,  cartilages,  and  bones.  2.  Both  dis- 
eases chiefly  occur  in  young  subjects;  but  bronchocele 
ollen  begins  at  a later  age  than  scrofula,  and  does  not, 
like  the  latter,  spontaneously  disappear  as  the  patient 
approaches  puberty  and  gains  strength.  3.  Scrofulous 
glands  often  suppurate  and  ulcerate ; bronchocele  rarely 
undergoes  these  changes.  4.  The  thickening  of  the 
tipper  lips  of  scrofulous  subjects  is  not  an  attendant  on 
bronchocele;  and  while  the  former  patients  generally 
enjoy  their  mental  faculties  in  perfection  as  long  as 
they  live,  the  latter  disease  in  certain  countries  is  often 
joined  with  cretinism.  Scrofula  is  likewise  alwajs 
hereditary,  while  bronchocele  is  not  so;  no  healthy 
persons  become  scrofulous  by  living  a long  while 
among  scrofulous  patients,  but  many  individuals  con- 
tract bronchocele  by  going  from  a country  where  this 
disease  is  unknown,  and  taking  up  iheir  residence  in 
places  w here  it  aboupds.  5.  Nature  alone  often  cure* 


BRONCHOCELB. 


195 


scrofula,  while  art  is  rarely  successful ; on  the  con- 
trary, bronchocele  is  seldom  cured  by  nature,  but  very 
frequently  by  art.  6.  The  muriate  of  lime,  recommended 
by  Fourcroy  for  the  cure  of  scrofula,  is  always  useless ; 
but  in  bronchocele  it  proves  a valuable  remedy. — 
{Postiglione,  Memoria  sulla  Natura  del  Gozzo,  &c. 
p.  25.)  The  error  of  confounding  bronchocele  with 
scrofula  is  now  generally  acknowledged.  At  the  Hos- 
pital St.  Louis,  says  Alibert,  scrofulous  patients  are 
numerous,  while  those  with  bronchocele  are  very  rare. 
(N’osol.  Nat.  t.  I,  p.  465.)  In  Derbyshire,  Genoa,  and 
Piedmont,  bronchocele  has  been  attributed  to  drinking 
water  cooled  with  ice.  To  this  theory  many  of  the 
objections  concerning  the  earthy  imi)regnation  of  water 
stand  in  full  force  ; with  this  additional  reflection,  that 
“ in  Greenland,  where  snow-water  is  commonly  used, 
these  unsightly  protuberances  are  never. met  with,  nor 
(says  Watson)  did  I ever  see  one  of  them  in  Westmore- 
land, where  we  have  higher  mountains  and  more  snow 
than  in  Derbyshire,  in  which  country  they  are  very 
common.  But  what  puts  the  matter  beyond  a doubt 
is,  that  these  wens  are  common  in  Sumatra,  where 
there  is  no  snow  during  any  part  of  the  year.” — (Wat- 
son’s Chemical  Essays,  vol.  2,  p.  157.)  The  above 
opinion  was  also  refuted  by  Fodere,  who  remarks,  that 
the  Swiss  who  reside  at  the  bottom  of  the  glaciers  are 
the  least  subject  to  the  disease.  Bronchoceles  are  also 
said  to  be  unknown  in  Lapland. 

Respecting  the  influence  of  particular  water  in 
bringing  on  the  disease.  Dr.  Odier  gives  credit  to  the 
opinion,  because  it  has  appeared  to  liim  that  distilled 
water  prevented  the  increase  of  the  tumour,  and  even 
tended  to  lessen  its  bulk. — (See  Manuel  de  Medecine 
Pratique,  8vo.  Genev.  1811.)  However,  that  every  e.x- 
planation  hitherto  devised  of  the  causes  of  broncho- 
cele is  quite  unsatisfactory,  is  fully  proved  by  the  ob- 
servations of  the  celebrated  Humboldt.  Persons  af- 
flicted with  bronchocele  (he  remarks)  are  met  with  in 
the  lower  course  of  the  Magdalen  river  (from  Honda 
to  the  conflux  of  the  Cauca) ; in  the  upper  part  of  its 
course  (between  Neiva  and  Honda) ; and  on  the  flat 
high  country  of  Bogota,  six  thousand  feet  above  the 
bed  of  the  river.  The  first  of  these  three  regions  is  a 
thick  forest,  while  the  second  and  third  present  a soil 
destitute  of  vegetation;  the  first  and  third  are  exceed- 
ingly damp,  the  second  is  peculiarly  dry ; in  the  second 
and  third  regions,  the  winds  are  impetuous ; in  the  first 
the  air  is  stagnant.  To  these  striking  ditferences,  we 
will  add  those  relative  to  temperature.  In  the  first  and 
second  regions,  the  thermometer  keeps  up  all  the  year 
between  22  and  33  centigrade  degrees;  in  the  third, 
between  4 and  17  degrees.  The  waters  drunk  by  the 
inhabitants  of  Mariquita,  Honda,  and  Santa  de  Bo- 
gota, where  bronchoceles  occur,  are  not  those  of  snow, 
and  issue  from  rocks  of  granite,  freestone  and  lime 
The  temperature  of  the  waters  of  Santa  Fe  and  Mom- 
pox,  drunk  by  those  who  have  this  disease,  varies  from 
nine  to  ten  degrees.  Bronchoceles  are  the  most  hideous 
at  Maricjuita,  where  the  symings  which  flow  over  gra- 
nite are,  according  to  my  experiments,  chemically  more 
pure  than  tho.se  of  Honda  and  Bogota,  and  where  the 
climate  is  much  less  sultry,  than  upon  the  banks  of  tlie 
Magdalen  river.  Perhaps  it  may  be  thought  that  the 
atony  of  the  glandular  system  (?)  depends  less  upon 
the  absolute  temperature  than  ujton  the  sudden  refri- 
geration of  the  atmosphere,  the  difference  of  tempera- 
ture in  the  night  and  day;  but  in  the  Magdalen  valley, 
where  the  constancy  of  low  tropical  regions  prevails, 
the  extent  of  the  scale  that  the  thermometer  pervades 
in  the  course  of  the  whole  year,  is  only  a small  num- 
ber of  degrees,  <fec. — (Humboldt,  in  Journ.  de  Physi- 
ologie  par  F.  Magendie,  t.  4,  p.  116.) 

The  same  distinguished  observer  confirms  previous 
accounts  of  the  variety  of  bronchoceles  among  the 
original  copper-coloured  natives  of  America  and  ne- 
groes. It  apiiears,  also,  that  in  South  Airierica  bron- 
choccle  is  progressively  extending  itself  from  the  lower 
provinces  to  the  flat  elevated  regions  of  the  ( lord iileras ; 
and  this  in  so  serious  a degree  that  in  1823  the  subject 
was  advened  to  in  a report  made  to  Congress  by  M. 
Restroppo,  one  of  the  Colombian  ministers. 

An  observation  lately  made  by  an  intelligent  writer 
would  lead  one  to  conclude,  that  cretinism  depends 
upon  malformation  of  the  head.  Speaking  of  goitre, 
as  it  appears  among  the  inhabitants  of  the  valley  of 
Maurienne,  Baron  Larrey  informs  u.s,  that  in  many  of 
these  people,  with  this  fr  ghtful  deformity  is  joined  that 

N2 


of  the  cranium,  of  which  the  smallness  and  excessive 
thickness  are  especially  remarkable.— (il/em  de  Chir. 
Mint.  t.  1,  p.  123.)  Dr.  Leake  thinks  that  tumours  of 
this  sort  may  be  owing  to  the  severity  of  the  cold  damp 
air,  as  they  generally  appear  in  winter,  and  hardly 
ever  in  the  warm  dry  climates  of  Italy  and  Portugal. 
The  latter  part  of  the  observation,  however,  is  not  cor- 
rect, for  Doct.  Postiglione,  and  other  Italian  writers, 
assure  us  that  the  disease  is  extremely  common  in  some 
of  the  warmest  parts  of  Italy.  “ Qvi  in  Napoli,  e per 
tutto  il  regno,  si  veggono  molt  gozzuti,  mai  non  m 
nnmero  tale,  come  in  Casoria,  ed  inpochi altri  villaggi.” 
—(P.  21.)  Prosser  is  inclined  to  consider  the  broncho- 
cele as  a kind  of  dropsy  of  the  thyroid  gland,  similar 
to  the  dropsy  of  the  ovary;  and  he  mentions  that 
Dr.  Hunter  dissected  one  thyroid  gland  which  had  been 
considerably  enlarged,  and  contained  many  cysts  filled 
with  water.  These,  he  erroneously  concludes,  must 
have  been  hydatids.  Dr.  Baillle  remarks,  that  when 
a section  is  made  of  the  thyroid  gland  aflected  with  this 
disea.se,  the  part  is  found  lo  consist  of  a number  of 
cells  containing  a transparent  viscid  fluid. 

In  all  probability  the  ordinary  bronchocele  is  entirely 
a local  disease,  patients  usually  finding  themselves  in 
other  respects  perfectly  well.  The  tumour  itself  fre- 
quently occasions  no  particular  inconvenience,  and  ia 
only  a deformity.  There  is  no  malignancy  in  the  dis- 
ease, and  the  swelling  is  not  prone  to  inflame  or  su])- 
purate,  though,  as  Dr.  Hunter  remarks,  abscesses  do 
occasionally  form  in  it.  Alibert’s  case  of  bronckocele 
becoming  cancerous  is  singular.  Mr.  Gooch  never 
knew  life  to  be  endangered  by  this  sort  of  tumour, 
however  large  ; a remark  very  much  at  variance  with 
the  observations  of  some  other  practitioners;  but  he 
had  seen  great  inconvenience  arise  from  it  when  com- 
bined with  quinsJ^  In  fact,  the  pressure  of  a large 
bronchocele  may  not  only  greatly  afflict  the  patient,  by 
rendering  respiration  difficult,  but  actually  cause  death 
by  suffocation.— (See  Obs.  svr  un  Goitre  volumineux, 
comprimant  la  Trachee-artere ; par  L.  Winslow,  in 
Bulletin  de  I’Athenee  de  Med.  (Si  c.)  “ Some  persona, 
as  Alibert  remarks^  have  the  disease  all  their  lives 
without  sufiering  any  inconvenience  from  it ; some  ex- 
perience a suffocating  oppression  of  the  breathing  ; 
and  in  others  there  is  an  impediment  in  the  circulation, 
and  a tendency  to  a})oplexy,  arising  from  the  strangu- 
lation which  afflicts  them.” — (Nosol.  Nat.  t.  I,  p.  466.) 
Dr.  Hunter  says,  that  the  bronchocele  frequently  ap- 
pears two  or  three  years  before  or  after  the  commence- 
ment of  menstruation,  and  that  it  sometimes  sponta- 
neously disa])pears,  when  this  evacuation  goes  on  iu 
a regular  manner.  Mr.  A.  Burns  affirms  the  same  thing. 
On  the  contrary,  according  to  Prosser,  this  change  in 
the  constitution  hardly  ever  affects  the  tumour. 

TREATMENT  OF  BRONCHOCELE. 

That  certain  localities,  perhaps  not  yet  correctly  un- 
derstood, contribute  to  the  origin  of  this  disease,  is  well 
proved  by  a fact  stated  by  Alibert,  viz.  that  change  of 
air  has  more  effect  on  the  complaint  than  medicines,  .as 
he  has  known  many  Swiss  ladies  who  came  to  Paris 
with  bronchoceles,  in  whom  the  tumour  subsided  after 
they  had  resided  some  time  in  that  city. — (Nosol.  Nat. 
t.  l,p.473.) 

A blister,  kept  open,  has  put  a stop  to  the  growth 
of  the  tumour;  but  this  method  is  not  much  fol- 
lowed at  present,  as  better  plans  of  treatment  have 
been  discovered.  A few  years  ago  the  favourite  mode 
of  curing  bronchocele  consisted  in  giving  internally 
burnt  sponge,  and  occasionally  a calomel  purge,  at  the 
same  time  that  frictions  v/ere  made  upon  the  tumour 
itself.  The  utility  of  burnt  sponge  in  the  treatment  of 
bronchocele,  as  Dr.  Coindet  and  others  have  now  fully 
jmoved,  depends  upon  the  iodine  in  its  compo.sition. 

The  efficacy  of  burnt  sjionge  was  thought  to  be  great- 
est, when  exhibited  in  the  form  of  a lozenge  compo.sed 
of  ten  grains  of  this  substance,  ten  of  burnt  cork,  and 
the  same  quantity  of  pumice-stone.  These  powders 
were  made  into  the  j)roi)er  form  with  a little  syrup,  and 
the  lozenge  was  then  {)ut  under  the  tongue  atul  allowed 
to  dissolve.  To  the  latter  circumstance  much  impor- 
tance was  attached.  Some  practitioners  gave  a scnii)le 
of  burnt  sponge  alone,  thrice  every  day,  while  others 
added  a grain  of  calomel  to  each  dose.  A purge  of  ca- 
lomel was  ordertal  about  oin-e  a week  or  fortnight,  at 
long  as  the  patient  persevered  in  the  use  of  the  cal- 
cined siiouge ; but  when  mercury  was  combined  with 


196 


BRONCHOCELE. 


ach  dose  of  this  medicine,  no  occasional  purgative  was 
deemed  requisite. 

External  means  may  very  materially  assist  the  above 
internal  remedies.  Frequently  rubbing  the  swelling 
with  a dry  towel ; bathing  the  part  with  cold  wafer ; 
rubbing  the  tumour  two  or  three  times  a day  \\ith  the 
liq.  animon.  acet.  or  the  camphor  liniment ; are  the 
best  steps  of  tliis  kind  which  the  surgeon  can  take. 

“ In  the  treatment  of  bronchocele,”  says  Mr.  A.  Burns, 
“ reiieated  topical  detraction  of  blood  from  the  tumour 
is  higliiy  beneficial.  Electricity  also  has  sometimes  a 
marked  effect ; but  there  is  no  remedy  which  I would 
more  strongly  advise,  than  regular  and  long-continued 
friction  over  the  tumour.  By  perseverance  in  this  plan, 
a bronchocele,  treated  in  London,  was  materially  re- 
duced in  the  course  of  six  weeks.  Its  good  effects  I 
have  likewise  witnessed  myself  ■,  and  it  is  a remedy 
highly  recommended  by  Girard  in  his  ‘ Traite  des 
Loupes.'  It  has  zdso  been  much  used  in  scrofulous  tu- 
mours by  Mr.  Grosvenor  of  Oxford,  and  by  Mr.  Rus- 
sell of  Edinburgh. — ^Surgical  Anatamy  of  the  Head 
and  Neck,  p.  204.) 

Mr.  A.  Bums  recommends  the  friction  to  be  made 
with  flannel  covered  with  hair-powder,  and  the  part  to 
be  rubbed  at  least  three  times  a day,  for  twenty  minutes. 

In  two  cases  of  bronchoode  related  by  Dr.  Clarke, 
the  patients  were  cured  by  “ the  steady  use  of  the 
compound  plaster  of  ammoniac  and  mercury,  con- 
joined with  the  internal  exhibition  of  burnt  sponge  and 
occasional  purgatives.”— (See  Edin.  Med.  and  Surgical 
Journal,  vol.  4,  p.  280.) 

We  learn  from  Professor  Odier,  that,  in  Geneva,  bron- 
chocele used  to  be  cured  by  burnt  sponge  exhibited  in 
powder  or  infused  in  wine',  and  combined  with  purga- 
tives to  prevent  the  cramps  of  the  stomach,  which  some- 
times accompany  the  disappearance  of  the  swelling. 
Muriate  of  barytes  has  likewise  been  recommended. — 
(See  Manuel  de  MMecme  Pratique.) 

Mr.  Wilmer,  credulously  imputing  great  influence  to 
the  changes  of  the  moon,  used  to  begin  with  an  emetic 
the  day  after  the  full  moon,  and  to  give  a purge  the 
ensuing  day.  The  night  following  and  seven  nights 
successively  he  directed  the  above-mentioned  lozenge 
to  be  put  under  the  tongue  at  bedtime,  and  adminis- 
tered every  noon  a bitter  stomachic  powder.  On  the 
eighth  day  the  purge  was  repeated,  and  in  the  Avane 
of  the  succeeding  moon,  the  whole  process,  except  the 
emetic,  wasrenew'ed. — {Cases  in  Surgery,  Appendix.) 
This,  which  is  often  called  the  Coventry  plan  of  treat- 
ment, is  said  to  be  greatly  assisted  by  rubbing  the  tu- 
mour with  an  ointment  containing  tartar  emetic. 

Prosser  succeeded  with  Ids  medicines,  though  the 
patient  was  nearly  twenty-five  years  old,  and  the  swell- 
ing had  existed  more  than  twelve  years.  It  is  said, 
that  no  instance  of  cure  has  been  known  after  the  pa- 
tient was  twenty-five.  Prosser  orders  one  of  the  fol- 
lowing pow’ders  to  be  taken  early  in  the  morning,  an 
hour  or  two  after  breakfast  and  at  five  or  six  o’clock  in 
the  evening,  every  day,  for  a fortnight  or  three  w’eeks. 
The  powder  may  be  taken  in  a little  syrup  or  sugar 
and  water : II.  Cinnab.  ant.  op.  levigat.  niilleped.  ppt.  et 
pulv.  aa  gr.  xv.  Spong.  calcin.  3J.  M. 

These  powders  should  be  taken  for  two  or  three  weeks, 
and  then  left  for  a week  or  nine  days  before  a repeti- 
tion. At  bedtime  everj"  night,  during  the  second  course 
of  the  powders,  some  purgative  pills  composed  of  mer- 
cury, the  extractum  colocynthid.  comp,  and  rhubarb,  are 
to  be  administered ; and  in  general  it  will  be  proper 
to  purge  the  patient  with  manna  or  salts,  before  be- 
ginning with  the  powders.  Prosser  put  no  faith  in 
external  applications. 

Some  have  recommended  giving  two  scruples  of 
calcined  egg-shells  every  morning,  in  a glass  of  red 
wine ; half  a drachm  of  the  sulphuret  of  potash  every 
day,  dissolved  in  water;  or  ten  or  fifteen  drops  of  the 
tinct.  digit,  twice  a day,  the  dose  being  gradually  in- 
creased. Muriated  barytes,  cicuta,  and  belladonna 
have  also  been  exhibited.  Postiglione  commends  the 
muriate  of  lime  as  a medicine  possessing  great  effi- 
cacy. The  reme.ly  is  made  in  a bolus  with  honey,  to 
which  is  sometimes  added  burnt  sponge,  with  cinna- 
mon in  powder.  He  employs  also  frictions  with  fian- 
nel,  liniments,  and  sometimes  purges  with  calomel. 
The  bolus  is  placed  under  the  longue,  and  allowed  to 
di.ssolve  there.— (P.  5'J,  vS  c.) 

Sir  .1.  Wylie,  physician  to  the  emperor  of  Russia, 
prescribes  throe  grains  of  the  submuriate  of  mcrcur}-. 


three  of  the  ammoniacal  muriate  of  iron,  four  of  burnt 
sponge,  and  ten  of  the  bark  of  laurns  cassia,  divided 
inm  twelve  doses,  one  of  which  is  given  twice  a week 
with  a gentle  anodyne  at  night.  He  also  directs  tw'enty- 
four  lozenges  to  be  made,  by  triturating  an  ounce  of 
burnt  sponge  with  an  equal  quantity  of  the  powder  of 
gum  arable,  and  fifteen  grains  of  cinnamon,  first  blended 
with  a sufficient  quantity  of  the  syrup  of  orange-peel. 
One  of  these  lozenges  is  put  under  the  longue  daily 
and  allowed  to  dissolve  there.  Lastly,  to  the  tumour 
Itself  he  applies  a piaster  composed  of  half  an  ounce 
of  litharge,  a drachm  of  the  submuriate  of  mercury, 
and  10  grains  of  antim.  tartariz. — {Alibert,  Nosol.  Hat. 
t.  1,  p.  474.) 

The  virtues  of  burnt  sponge  in  the  cure  of  certain 
forms  of  bronchocele  are  now  ascertained  to  be  owing 
to  the  iodine  which  it  contains.  Iodine  was  discovered 
in  1813  by  Courtois,  manufacturer  of  saltpetre  at  Paris ; 
but  six  years  elapsed  before  it  w-as  tried  as  a medicine. 
From  the  first  memoir  of  Dr.  Coindet,  addressed  in 
1820  to  the  Helvetian  Society  of  Natural  Sciences,  it 
appears,  that  as  he  was  searching  for  a formula  in  the 
work  of  Cadet  de  Gassicourt,  he  found  that  Russel  had 
recommended  the  ashes  of  the  fucus  vesiculosus,  or 
bladder  wrack,  under  the  name  of  aethiops  vegetabilis, 
for  the  cure  of  bronchocele ; and  he  was  led  from  ana- 
logy between  this  substance  and  burnt  sponge,  so  long 
celebrated  for  its  efficacy  in  the  treatment  of  broncho- 
cele, to  suspect  that  iodine  was  the  active  principle  of 
both.  “ The  great  and  unequalled  success  which  re- 
sulted from  its  use  in  the  treatment  of  bronchocele,  at 
once  indicated  the  power  of  iodine  as  a therapeutic 
agent,  and  encouraged  Dr.  Coindet  to  pursue  his  re- 
searches in  rendering  it  an  efficient  anicle  of  the  ma- 
teria medica;  and  about  the  close  of  the  same  year, 
when  Dr.  Coindet  had  employed  iodine  in  treating  goitre 
for  six  months  at  least,  his  conjecture  was  confirmed 
by  the  discovery  which  Dr.  Fyfe  of  Edinburgh  made, 
that  this  substance  was  actually  contained  in  the  ashes 
of  the  burnt  sponge,”  &c. 

“ It  has  been  generally  understood  among  the  pro- 
fe.ssion,  that  the  happy  conjecture  which  introduced 
iodine  into  medical  treatment,  originated  with  Dr.  Coin- 
det, of  Geneva;  yet  we  find  that  his  claim  to  this  ho- 
nour is  disputed  by  one  of  his  country  men.  Dr.  ,1.  C. 
Straub,  of  Hofwyi,  in  the  canton  of  Berne. 

Dr.  Straub,  whose  communication  is  found  in  Pro- 
fessor Meisner’s  Physical  Intelligence  of  the  General 
Helvetian  Society  for  1820,  states,  that  before  the  dis- 
covery of  iodine,  attempts  had  been  made  to  compound 
a substitute  for  burnt  sponge,  but  without  success; 
and  that  this  failure  and  his  observation  of  the  simi- 
larity of  siaell  between  iodine,  burnt  sponge,  and  other 
marine  productions,  led  him  to  suspect  the  existence 
of  iodine  or  its  salts  in  these  substances,  and  that  its 
absence  in  the  artificial  compounds  was  the  cause  of 
failure  in  these  experiments.  This  conjecture,  which 
appears  to  have  been  made  previously  to  1819,  led  Dr. 
Straub  to  examine  the  real  burnt  sponge,  and  he  in- 
forms us,  that  though  his  time  did  not  permit  him  to 
ascertain  exact  quantities,  yet  he  obtained  from  1^  oz. 
of  burnt  sponge  as  much  iodine  as  to  render  his  con- 
jecture probable,  and  to  be  astonished  that  the  ingre- 
dient should  have  escaped  notice.  He  was  therefore 
at  once  induced  to  think  of  its  use  in  medicine ; and  in 
the  same  paper  from  which  we  obtain  these  facts,  im- 
pressed with  the  poisonous  quality  ascribed  by  Orfila 
to  iodine,  he  recommended  first  the  trial  of  its  salts, 
especially  the  hydriodates  of  soda  and  lime,  and  then 
that  of  the  substance  itself. 

The  communication  of  Dr,  Straub  is  dated  Dec. 
1819,  and  was  actually  published  in  Professor  Meis- 
ner’s periodical  work  in  February,  1820,  five  months 
at  least  before  the  first  memoir  of  Dr.  Coindet  was 
communicated  to  the  Helvetian  Society  of  Natural 
Sciences  at  Geneva.  It  is  unnecessary  to  have  re- 
course to  any  supposition  of  injustice  done  to  Dr. 
Straub;  much  less  w'ould  it  be  right  to  deprive  Dr. 
Coindet  of  the  merit  of  originality  in  substituting  the 
direct  and  certain  action  of  iodine,  for  the  irregnlar  and  ‘ 
sometimes  inert  qualities  of  burnt  sponge  in  the  treat- 
ment of  goitre.  Coincidence  of  this  kind  is  not  uncom- 
mon in  science;  in  the  present  instance,  the  inge- 
nuity of  Dr.  Straub  does  not  diminish  the  merit  of  Dr. 
Coindet.”--(See  Edin.  Med.  and  Surg.  Journal,  No. 
80,  p.  210,  .t  c.) 

That  iodine  is  a medicine  ot  considerable  effit  .acy  in 


BRONCHOCELE. 


197 


brouchocele,  not  a doubt  can  be  entertaiited,  after  the 
many  cases  now  recorded  in  proof  of  the  fart ; and 
that  it  will  be  found  useful  in  some  other  chronic  tu- 
mours, especially  those  of  a scrofulous  nature,  seems 
highly  probable,  if  such  probability  be  no  already  con- 
verted into  certainty.  In  bronchocele,  friction  with 
the  ointment  on  the  swelling  may  often  be  advanta- 
geously conjoined  with  the  use  of  one  of  the  prepa- 
rations for  internal  exhibition. 

Ill  the  Archives  G n rales  de  M decine  for  July,  1823, 
Dr.  Coster  mentions  the  opportunity  which  he  had  had 
of  remaining  eight  months  at  Geneva  with  Dr.  Coin- 
det,  and  of  observing  correctly  the  good  effects  of  iodine 
in  enlargements  of  the  thyroid  gland  and  in  scrofulous 
tumours.  Dr.  Coiudet  first  of  all  employed  this  medi- 
cine under  the  form  of  alcoholic  tincture,  and  obtained 
very  surprising  effects  from  its  administration  in  goi- 
tre. He  next  tried  friction  on  the  tumour  itself  with  an 
ointment  composed  of  the  hydryodate'of  potass  and  lard ; 
and  the  success  of  tliis  practice  was  so  great, that  of  nearl  y 
one  hundred  individuals  affected  with  go5tre,whose  cases 
Dr.  Coster  collected,  more  than  two-thirds  were  com- 
pletely cured  by  it.  Soon  after  these  successful  results, 
iodine  was  employed  sometimes  internally  and  some- 
times in  the  fonn  of  friction  in  scrofula.  “ I shall  not 
affirm  (says  Dr.  Coster)  that  success  was  as  uniform  in 
the  latter  as  in  the  former  disease,  but  it  is  certain, 
that  scrofulous  tumours  yield  sooner  to  the  action  of 
iodine  than  to  that  of  any  other  remedy  at  present 
known:  when  the  tumours,  whether  of  the  thyroid 
gland,  or  of  the  lymphatic  glands,  are  hard  and  rcni- 
tent,  experience  proves,  that  the  effects  of  iodine  are 
much  more  prompt  when  the  frictions  are  preceded  by 
the  application  of  leeches  and  a low  regimen.  Not- 
withstanding these  precautions,  however,  the  tumour 
sometimes  continues  stationary.”  In  such  a case,  Dr. 
Coster  put  the  tumour  twice  a day,  for  ten  or  twelve 
minutes,  under  the  influence  of  the  positive  pole  of  the 
voltaic  pile,  taking  care  to  change  sides  each  time  of 
using  it ; so  that,  in  the  morning,  he  made  use  of  fric- 
tion with  iodine  on  the  right  side  and  the  action  of  the 
pile  on  the  left,  and  in  the  evening  applied  the  friction 
to  the  left  side  and  the  galvanism  to  the  right.  In 
twenty  days  not  the  least  trace  of  the  bronchocele  was 
left.  It  is  stated,  that  in  this  instance,  the  voltaic  pile, 
unassisted  with  the  frictions  of  iodine,  was  as  ineffec- 
tual as  the  friction  by  itself  had  been.  By  the  inter- 
nal and  external  use  of  iodine,  I lately  dispersed  a 
bronchocele  which  had  formed  in  the  neck  of  a young 
lady,  aged  about  12,  who  was  brought  to  my  house  by 
my  neighbour  Mr.  Blair.  The  disease  began  to  diminish 
in  less  than  a week  from  the  commencement  of  the 
treatment,  and  in  six  weeks  the  cure  was  complete. 
An  interesting  case,  in  which  a similar  plan  was  at- 
tended with  success,  is  recorded  by  Dr.  Roots. — (See 
Med.  Chir.  Trans,  vol.  12,  p.  810.)  Another  instance 
of  its  decided  efficacy  is  reported  by  Dr.  Barlow,  of 
Bath  (see  Edin.  Med.  Joum.  No.  79,  p.  337) ; but  who- 
ever wishes  to  have  a large  and  convincing  body  of 
evidence  on  this  point,  should  consult  the  cases  and 
observations  published  byDr.  Manson,  of  Nottingham, 
where  bronchocele  is  said  to  be  endemic.  He  gives 
the  results  of  one  hundred  and  twenty  cases  of  bron- 
chocele in  which  he  administered  iodine.  Fifteen  were 
in  males,  undone  hundred  and  five  in  females.  When 
the  disease  w.as  complicated  with  diseased  lymiihatic 
glands,  the  thyroid  gland  first  yielded  and  then  the 
others.  In  the  fourth  case  a scrofulous  swelling  of  the 
foot  yielded  during  the  use  of  iodine.  Of  the  hundred 
and  twenty  cases  referred  to,  eighty-seven  were  cured, 
ten  much  relieved,  and  only  two  or  three  discharged 
without  relief.  —(See  Manson's  Medical  Researches  on 
the  Effects  of  Iodine  in  Bronchocele,  Paralysis,  Chorea, 
Scrofula,  Fistula  Lachrymalis,  Deafness,  Dysphagia, 
White  Swellings,  and  Distortions  of  the  Spine.  Lond. 
1825.)  Some  farther  notice  of  this  gentleman’s  prac- 
tice, as  well  as  the  results  of  Mr.  Buchanan’s  expe- 
rience will  be  taken  in  the  articles  Ear,  Iodine,  Joints, 
Scrofula,  VertebrcB,  ^ c.  For  the  preparation  and  doses 
of  Iodine,  see  this  word. 

In  South  America,  a remedy  for  bronchocele  called 
aceyte  de  sal,  was  found,  by  M.  Roulin,  to  contain  a 
jiroportion  of  iodine.— (See  Magendie,  Journ.  de  Physi- 
ologie,  t.  5,  p.  273.)  The  same  gentleman  has  also 
proposed  the  trial  of  chlorine,  or  the  free  hydro-chloric 
arid. 

Petit,  Ileister,  and  Schmucker  make  mention  of  in- 


veterate bronchocelea  which  gradually  subsided  in 
consequence  of  suppuration.  Volpi  states,  that  such 
ulcerations  are  not  unfrequent.  He  has  published  two 
facts  of  this  kind- which  occurred  after  a nervous  fever; 
and  he  records  a third  case,  where  the  swelling  in 
flamed  in  consequence  of  a blow,  suppurated,  and 
sloughed  so  as  entirely  to  disappear.— (See  Ze?;e?7/,», 
Nouvelle  Doctrine  Chir.  t.  4,  p.  128.)  A similar  fact 
is  recorded  by  Zipp. — {Sicbold,  Samnd.  Chir.  Beob.  b 
2,  p.  229.) 

The  disease  in  its  inveterate  form  has  also  been 
sometimes  removed  by  the  application  of  caustic  {Mes- 
ny  in  Journ.  de  M decine,  t.  24,  p.  75  ; Timczus,  Cas. 
p.  283) ; the  establishment  of  issues  (Jeitteles,  Obs. 
Med.) ; the  making  of  an  incision  into  the  swelling,  or 
the  introduction  of  a setou  through  iX.—{Foder^,  Essai 
sur  le  Goitre  et  le  Crctinage,  p.  75  ; Klein,  in  v.  Sie- 
bold,  Sammlung  Chir.  Becbacht,  i».  2,  p.  11  ; Flajani, 
CoUezione  d’Osservazioni  di  Chirurgia,  t.  3,  p.  283.) 

Bronchoceles  have  sometimes  been  removed  by  the 
part  having  been  accidentally  or  purposely  burnt  to  a 
considerable  depth  {Motte,  in  Blegny,  Zodiac,  ann. 
2 Febr.  Obs.  11 ; Severinus  de  Effcaci  Mr.dicina,p.  220.) 
The  disappearance  of  bronchoceles  has  also  been 
known  to  folloAv  a wound.  — (Schmidrnuller  uher  die 
Ansfuhrungsgdnge  der  Schilddruse,  p.  37,  Landshut, 
1''05.)  A.  Burns  sometimes  employed  blisters,  and 
found  them  useful. — {Surgical  Anaiorry  of  the  Head 
and  Neck,  p.  204.)  With  respect  to  caustic,  which  is 
spoken  of  by  Celsus  {lib.  7,  cap.  13),  Flajani  states, 
that  its  operation  is  tedious  and  painful,  and  attended 
with  danger ; and  what  he  says  about  the  practice 
of  an  incision  is  not  more  encouraging.  When 
the  disease  contains  a cyst,  he  prefers  making  an 
opening  with  a trocar,  though  he  confesses  that 
this  plan  is  apt  to  be  followed  by  a relapse,  when 
the  cyst  is  very  thick  and  hard ; in  which  circum- 
stance, it  will  be  necessary  to  have  recourse  either 
to  an  incision  or  the  seton,  for  the  purpose  of  ex- 
citing suppuration.  Should  the  disease,  however, 
be  merely  composed  of  one  cyst  of  moderate  size,  Fla- 
jani recommends  its  entire  removal.  “ Of  all  these 
methods  (says  he)  proposed  for  the  extirpation  of  bron- 
clmceles,  the  seton  is  he  least  dangerous,  and  by 
means  of  it  a radical  cure  may  be  generally  effected 
without  any  severe  symptoms,  as  I have  found  by  ex- 
perience in  many  cases.  On  the  contrary  I have  been 
an  eye-witness  of  the  fatal  consequences  induced  by 
the  other  plans.  I was  called  to  assist  a gentleman, 
about  forty  years  of  age,  brought  to  death’s  door  by  a 
bleeding,  which  arose  from  the  application  of  caustic  to 
the  forepart  of  the  neck.  As  tourniquets,  bandages, 
«fcc.  proved  quite  ineffectual,  it  was  indispensable  to 
make  pressure  on  the  part  with  the  finger  of  an  assist- 
ant, for  twenty-four  hours,  ere  the  hemorrhage  could 
be  stopped ; a copious  suppuration  ensued  ; and  it  was 
three  months  before  the  parts  were  healed.  I was 
likewise  present  (says  he)  at  the  opening  of  a similar, 
but  larger  swelling  in  the  same  situation,  the  disease 
having  afflicted  an  elderly  respectable  patient  for  seve- 
ral years.  The  incision  caused  the  evacuation  of  a 
small  quantity  of  serum,  contained  in  the  cellular  mem- 
brane ; but  the  following  day  the  tumour  inflamed,  the 
difficulty  of  respiration  increased,  and  for  some  days 
the  jiatient  was  in  great  danger.  At  length  suppuration 
was  established,  followed  by  a destruction  of  a great 
deal  of  the  cellular  membrane  and  several  sinuses,  and 
in  five  months  the  patient  lost  his  life.  On  examina- 
tion of  the  body,  the  lungs  were  found  tuberculated, 
an  effect  of  the  impediment  to  the  circulation  of  the 
blood  through  the  smaller  vessels  of  those  organs.” — 
{Flajani,  CoUezione  d’Osserv.  t.  3,  p.  283,  6vo.  Roma, 
1802.) 

The  first  proposer  of  the  employment  of  setons  for 
the  cure  of  diseases  of  the  thyroid  gland,  is  perhajis 
not  exactly  known ; but  it  is  certain  that  the  method 
has  been  known,  and  occasionally  practised,  ever  since 
the  middle  of  the  last  century.  “ Dr.  Monro,  senior, 
(as  a well  informed  writer  has  observed)  mentions  in 
his  lectures  that  he  has  seen  a dropsy  in  the  centre  of 
the  gland,  complicated  with  bronchocele,  cured  by  a 
seton,  although  the  glandular  swelling  still  continued.” 
— {A.  Burns  on  the  Surgical  Anatomy  of  the  Head 
and  Neck,  p.  191.)  This  statement  is  given  on  the 
authority  of  some  MS.  notes  taken  by  Dr.  Brown,  from 
Dr.  Monro’s  lectures.  According  to  Girard,  many  cases 
in  hi-,  time  h;id  been  coinmuiacatetl  to  the  Rojul 


198 


BRONCHOCELE. 


Academy  of  Surgery  at  Paris,  in  which  the  disease  had 
been  got  rid  of  either  by  means  of  a seton,  drawn 
through  the  swelling,  or  the  application  of  an  issue.— 
{Litpiologie,  ivc.  8vo.  Paris,  1775.  The  occasional 
success  of  setons  was  also  adverted  to  by  Richter  in 
the  year  1788— (Bibliothek,  b.  9,  p.  478.)  And  the  plan 
is  spoken  of  in  another  work,  published  in  1790,  as  be- 
ing eligible  where  the  disease  is  conjoined  with  a cyst. 
— Encyclopedie  Method,  pnrtie  Chir.  t.  1,  p.  231.) 
The  practice  was  particularly  noticed  by  Foderb  in  bis 
valuable  treati.se  on  bronchocele ; and  Alibert  mentions 
the  seton  as  being  used  at  the  Hospital  St.  Louis. — 
(Nosol.  Nat.  t.  1,  p.  466,  fol.  Paris,  1817.) 

In  November,  1817,  Dr.  Quadri,  of  Naples,  tried  this 
practice,  which  he  erroneously  supi)Osed  to  be  quite 
new.  “ By  means  of  a trocar-pointed  needle,  six  and 
a half  inches  long,  I passed  (says  he)  a seton  from 
above  dowmwards  through  the  gland,  at  the  depth  of 
about  four  lines  from  its  surface.  Suppuration  took 
place  in  fort3--eight  hours.  On  the  18th  of  November 
the  seton  escaped,  when  the  matter  was  squeezed  out ; 
and  the  irritation  occasioned  by  replacing  it,  produced 
an  abscess  on  the  right  side  of  the  neck,  which  was 
opened  on  the  23d,  when  it  was  found  that  the  suppu- 
ration had  effected  the  destruction  of  nearly  the  whole 
gland.”  The  woman,  who  was  thirt\’-six  years  of 
age,  was  seen  by  Dr.  Somerville,  in  April,  1818,  with 
the  circumference  of  her  neck  lessened,  from  sixteen 
to  thirteen  inches,  French  measure.  In  another  case 
referred  to,  a seton  was  pa.ssed  through  each  side  of 
the  thyroid  gland,  and  the  result  was  a removal  of  the 
tumour  on  the  side  where  the  seton  was  maintained 
long  enough  ; but  on  the  opposite  side  the  seton  being 
withdrawn  too  early,  the  matter  collected  in  a sac ; 
and  at  the  end  of  four  months  a sinus  and  discharge 
stilt  continued,  the  patient  refusing  to  have  a counter 
opening  practised.  When  the  seton  does  not  prove 
stimulating  enough,  Dr.  Quadri  sometimes  enlarges  it, 
or  attaches  to  it  escharotic  or  irritating  substances. 
He  also  frequently  uses  two  setons.  In  one  example, 
in  endeavouring  to  perforate  the  gland  rather  deeply. 
Dr.  Quadri  appears  to  have  injured  the  larger  branches 
of  the  thyroid  arteries,  as  more  than  an  ounce  of 
blood  was  discharged,  and  the  tumour  swelled  as  if 
injected  with  blood.  The  bleeding,  however,  ceased 
spontaneously.  He  states  that  the  seton  has  been 
passed  through  the  tumour  not  less  than  sixteen  times, 
the  direction  being  varied  in  every  instance,  without 
untoward  accident ; and  he  is  confident,  that  unless 
the  needle  be  pushed  deep  enough  almost  to  touch  the 
thyroid  cartilage,  the  trunks  of  the  thyroid  arteries  will 
not  be  exposed  to  injtiry,  while  the  branches  in  the 
track  of  the  needle  will  not  cause  any  danger.  He 
insists  also  upon  the  propriety  of  retaining  the  seton 
in  the  tumour  a considerable  time ; and  observes,  that 
it  remains  to  be  ascertained  whether  this  practice  will 
answer  in  every  description  of  bronchocele  ? For  these 
and  several  other  cases  and  particulars,  the  profession 
is  indebted  to  Dr.  Somerville. — (See  Med.  Chir.  Tran*, 
vol.  10,  p.  16,  (^-c.) 

Mr.  Gunning  applied  a seton  in  a case  of  broncho- 
cele in  St.  George’s  Hospital ; but  in  this  instance  the 
irritation  brought  on  sloughing,  and  the  patient  after  a 
time  died.  The  particulars  of  this  case,  and  of  three 
successful  examples  of  the  practice  in  England,  have 
been  lately  recorded.  One  of  the  successful  cases  was 
treated  by  my  friend  Mr.  James,  of  Exeter,  another  by 
Mr.  A.  C.  Hutchison,  who  has  taken  the  trouble  to 
collect  the  history  of  them,  and  thb  third  by  Dr.  A.  T. 
Thomson. — (See  Med.  Chir.  Trans,  vol.  11,  p.  235.) 
Percy  and  Dupuytren  have  also  employed  setons  in 
bronchocele  with  success.  The  plan,  however,  is  some- 
times inefficient,  as  is  proved  by  two  cases  under  Dr. 
Kennedy,  of  Glasgow. — (See  London  Med.  Repository, 
No.  99,  Feb.  1822.)  The  exact  nature  of  cases  relieved 
by  this  practice,  and  their  difference  from  other  exam- 
ples, which  are  benefited  by  treatment  of  a different 
kind,  are  still  desiderata  in  surgery. 

The  diseased  thyroid  gland  has  been  successfhlly 
extirpated ; but  the  operation  is  one  of  so  much  danger, 
that  it  ought  never  to  be  attempted  except  under  the 
most  pressing  circumstances.  The  many  large  arte- 
ries naturally  distributed  to  the  gland  itself;  their  still 
greater  size  in  bronchocele ; and  the  vicinity  of  the 
carotid  arteries,  and  important  nerves,  render  the  un- 
dertaking a thing  of  no  common  difficulty. 

Mr.  Goo.h  relaies  two  case~,  which  d.r  not  encoti- 


j rage  practitioners  to  have  recourse  to  the  excision  of 
enlarged  thyroid  glands.  In  one,  so  copious  an  he- 
morrhage took  place,  that  the  surgeon,  though  equally 
j bold  and  experienced,  was  obliged  to  stop  in  the  middle 
of  the  operation.  No  means  availed  in  entirely  sup- 
pressing the  bleeding,  and  the  patient  died  in  a few 
days.  In  the  other,  the  same  event  nearly  took  place, 
the  patient's  life  being  saved  only  by  compressing  the 
wounded  vessels  with  the  hand,  day  and  night,  for  a 
whole  w'eek,  by  persons  who  relieved  each  other  in 
turn.  This  was  found  the  only  way  of  stopping  the 
hemorrhage,  after  many  fruitless  attempts  to  tie  the 
vessels. 

Hemorrhage  is  not  the  only  risk  ; Dujiuytren  re- 
moved a large  bronchocele  that  caused  dangerous  pres- 
sure upon  the  trachea ; the  whole  gland  vvas  taken 
away,  and  the  four  tly  roid  arteries  and  many  veins 
secured.  Only  a few  spoonfuls  of  blood  were  lost.  The 
woman,  however,  died  soon  after  the  operation,  with 
pale  face,  hurried  respiration,  cold  skin,  sickness,  <fec., 
denoting  injury  of  some  important  nerves. 

I do  not  mention  these  facts  to  deter  surgeons  from 
the  operation  altogether,  because  it  is  proved  by  modern 
experience,  and  esjiecially  by  six  cases  in  which  Dr. 
Hedeniis,  of  Dresden,  has  successfully  removed  the 
thyroid  gland,  that  not  only  it  is  occasionally  a neces- 
sary proceeding,  but  one  that  may  be  well  accom- 
plished by  a skilful  operator,  as  vvill  be  particularly- 
explained  in  a future  article. — (See  Thyroid  Gland.) 
When  bronchoceles  by  their  pressure  dangerously  ob- 
struct respiration,  deglutition,  and  the  return  of  blood 
from  the  head;  and  when  the  disease  resists  the  effi- 
cacy of  iodine,  a seton,  blisters,  and  every  other  plan 
of  treatment  found  deserving  of  trial ; what  can  be 
done  with  the  view  of  saving  the  patient,  but  the  bold 
operation  of  cutting  away  the  swelling,  or  that  of  ex- 
posing and  tying  one  or  both  of  the  upper  thyroid  arte- 
ries ? 

When  the  quantity  of  blood  flow  ing  into  a tumour  is 
suddenly  and  greatly  lessened,  the  size  of  the  swelling 
commonly  soon  undergoes  a considerable  diminution. 
The  experiment  was  once  made  by  Sir  W.  Blizard  ; he 
tied  the  arteries  of  an  enlarged  thyroid  gland,  and,  in  a 
week,  the  tumour  was  reduced  one-third  in  its  size. 
The  ligatures  then  sloughed  off,  repeated  bleeding  took 
place  from  the  arteries,  and  by  the  extension  of  hos- 
pital gangrene,  the  carotid  itself  was  exposed.  The 
patient  died ; yet,  as  Mr.  A.  Burns  observes,  this  does 
not  militate  against  a repetition  of  the  experiment ; as 
the  same  thing  might  have  happened  from  merely 
opening  a vein,  and,  in  the  confined  air  of  a hospital, 
has  actually  happened.— (Sui-^icaZ  Atiatomy  of  the 
Head  and  Neck,  p.  202.) 

In  fact,  the  rationality  of  the  experiment  prevented 
surgeons  from  being  intimidated  by  the  failure  in  ques- 
tion ; and,  with  that  laudable  spirit  for  the  improve- 
ment of  operative  surgery  every  where  diffusing  itself 
through  the  profession,  other  gentlemen  were  soon 
found  who  had  judgment  enough  to  make  farther  trials, 
of  the  practice.  In  a young  man,  twenty-four  years  of 
age,  whose  breathing  was  much  impeded  by  a bron- 
chocele, and  whose  upper  thyroid  arteries  were  very 
large,  and  affected  with  strong  pulsations,  Walther,  of 
Landshut,  tied  the  left  of  these  vessels,  the  left  side  of 
the  gland  being  the  largest.  The  operation  vvas  done 
on  the  3d  of  June,  1814.  An  incision,  an  inch  and  a 
half  in  length,  was  made  in  the  direction  of  the  inner 
edge  of  the  sterno-cleido-mastoid  muscle,  where  the 
throbbing  of  the  artery  was  quite  di.stinct.  By  a second 
stroke  of  the  knife,  the  platysrna-myoides  was  divided 
in  the  .same  direction,  and  to  an  equal  extent.  The 
vessel  was  then  exposed  by  a cautious  dissection,  and 
separated  from  the  surrounding  parts,  and  one  arterial 
branch  which  was  divided  was  immediately  secured. 
A ligature  composed  of  three  silk  threads,  was  then 
conveyed  with  an  aneurism-needle  under  the  left  thy- 
roid artery,  and  tied  with  two  simple  knots.  The 
wound  was  then  closed  with  adhesive  plaster,  and  the 
ends  of  the  ligatures  brought  out  at  the  angles.  The 
ligature  on  the  large  artery  came  away  on  the  12th 
day  ; and,  without  any  febrile  symptoms,  or  other  bad 
con.'iequcnces,  the  wound  was  perfectly  healed  on  the 
23d  day.  As  early  as  the  third  day  after  the  applica- 
tion of  the  ligature,  the  left  part  of  the  tumour  began 
to  be  less  tense,  and  the  throbbing  feel  in  it  soon 
ceased.  By  degrees  it  dwnmlled  away,  becoming  as  it 
le.s.sencd  harder,  and,  as  it  wei-e,  cartilaginous.  In  a 


BIIONCHOCEJ.E. 


199 


fortnight,  the  left  half  of  the  swelling  was  one-third 
smaller  than  before  the  operation  ; and,  at  lengtli,  only 
one-third  of  it  remained,  while  the  right  side  also  was 
somewhat  smaller.  On  the  17th  of  June,  Walther 
took  up  the  right  superior  thyroideal  artery,  which  was 
more  difficult  to  get  at,  as  it  lay  more  deeply,  and  was 
much  concealed  under  the  enlarged  gland,  which  had 
pushed  it  out  of  its  natural  situation.  The  operation 
lasted  three-quarters  of  an  hour,  and  several  large  and 
small  arteries  which  were  cut  were  tied.  With  re- 
spect to  the  thyroid  artery  itself,  it  could  not  be  tied 
without  including  a part  of  the  gland  in  the  ligature. 
No  unfavourable  symptoms  followed  this  second  ope- 
ration ; the  ligatures  were  detached  in  good  time,  and 
the  wound  healed  up  very  well.  The  right  portion  of 
the  bronchocele  also  now  diminished ; but  though  it 
was  originally  smaller  than  the  left,  it  did  not  dwindle 
away  so  completely  as  the  latter.  The  remains  of  the 
tumour,  however,  two  years  afterward,  produced  no 
inconvenience,  and  respiration  was  quite  easy.— (See 
Neue  Heilart  der  Kropfes,  iS  c.  von  Ph.  Fr.  von  Wal- 
ther, p.  25,  (S'C.  8vo.  Sulzbach,  1817.)  On  the  29th  of 
December,  1818,  Mr.  H.  Coates,  of  Salisburj',  took  up 
the  superior  thyroideal  artery  for  the  cure  of  a bron- 
chocele, which,  in  a young  woman  aged  seventeen, 
made  pressure  on  the  trachea  and  oesophagus,  attended 
with  a great  noise  in  breathing.  The  superior  thy- 
foideal  arteries  were  in  this  instance  large,  and  pul- 
sated strongly.  Mr.  Coates  cut  down  upon  the  left  of 
these  vessels,  separated  it  from  its  accompanying 
nerve,  and  passed  under  it  a small  round  ligature, 
which  was  drawn  moderately  tight  and  tied.  The 
ne.xt  day  there  was  headache,  and  some  swelling  of  the 
neck  and  side  of  the  head,  with  increased  difficulty  of 
swallowing  and  febrile  symptoms.  These  complaints, 
however,  were  relieved  by  bleeding  and  antiinonial 
medicines.  The  ligature  came  away  on  the  9th  day ; 
and  on  the  14th,  the  wound  was  completely  healed. 
On  the  14th  of  February,  the  breathing  being  much 
improved,  and  the  tumour  reduced  nearly  to  one-half 
of  its  former  size,  the  patient  was  well  enough  to  be 
discharged  from  the  infirmary. — (See  Med.  Ckir.  Trans, 
vol.  10,  p.  312.)  My  friend,  Mr.  Rose,  once  mentioned 
to  me  a case,  in  which  a similar  operation  done  by  Mr. 
Brodie,  did  not  produce  any  material  diminution  of  the 
tumour. 

Dr.  Parry  has  remarked  a frequent  coincidence, 
either  as  cause  or  effect,  between  enlargement  of  the 
thyroid  gland  and  cardiac  diseases. — {Elements  of  Pa- 
thology, Src.  p.  181.)  And  another  modern  writer 
mentions,  that  he  has  lately  seen  three  cases  of  this 
complication. — {Medico-Chir.  Journ.vol.  \,  p.  181.)  A 
case  is  detailed  by  Flajani,  where  the  disease  was  ac- 
companied wuth  extraoi  dinary  palpitations  of  the  heart. 
— (See  Collezione  d'Osservazioni,  S,  c.  di  Chirurgia,  t. 
3,  p.  270.)  In  the  instance  here  referred  to,  there  was 
great  irregularity  of  the  pulse,  and  the  oppression  of 
the  breathing  was  such,  that  the  patient  was  obliged 
to  submit  to  venesection  at  least  every  month,  whereby 
he  was  rendered  quite  emaciated. 

[The  prevalence  of  goitre  in  different  parts  of  the 
U.  States  is  stated  by  our  author,  and  several  American 
writers  have  described  the  disease  as  existing  in  vari- 
ous parts  of  our  country,  whose  geological  features 
very  widely  differ  in  many  respects.  In  Vermont,  in 
New-York,  in  Pennsylvania  and  Ohio,  the  disea.se  is 
by  no  means  unfrequent.  Professors  Barton  and  Gib- 
son, of  Philadelphia,  have  communicated  many  valua- 
ble observations  on  this  disease.  More  recently,  Pro- 
fes.sor  Francis,  of  New-York,  has  made  a series  of  ob- 
servations on  goitre  as  it  appears  in  the  western  part 
of  the  state  of  New-York.  From  the  communication 
with  which  he  has  politely  favoured  me,  the  following 
abstract  is  prepared.  I may  add,  that  agreeably  to  the 
facts  deduced  from  the  changes  which  our  country  un- 
dergoes in  the  progress  of  improvement,  we  have  the 
strongest  reasons  to  infer  that  as  the  climate  and  cul- 
tivation are  meliorated,  the  instances  of  the  existence 
of  this  disease  will  doubtless  become  less  freiiuent. 

However  frequent  cases  of  goitre  may  have  formerly 
been  in  the  state  of  New-York,  the  fact  is  certain,  that 
they  are  much  more  rare  at  pre.sent.  Even  the  repre- 
sentations of  the  late  L)r.  Dwight,  relative  to  the  great 
prevalence  of  the  disease,  though  among  the  mo.st  re- 
cent with  which  we  have  been  favoured,  are  to  be  re- 
ceived with  allowance.  That  in  particular  portions  of 
our  wesiern  country  repeated  examples  are  to  be 


found,  may  be  known  by  any  accurate  observer. 
But  “ in  the  village  of  Utica,  (says  Dr.  Francis)  which 
contains  between  4 and  5000  inhabitants,  no  case  of 
bronchocele  could,  be  pointed  out,  and  this  village  oc- 
cupies the  site  of  old  Fort  Schuyler,  on  the  Mohawk, 
the  vicinity  of  which  has  been  referred  to  as  the  spot 
where  goitre  was  peculiarly  prevalent.  I am  strength- 
ened in  the  accuracy  of  this  statement  relative  to  the 
almost  total  disappearance  of  goitre  in  this  neighbour- 
hood, by  the  testimony  of  Dr.  Coventry.  A similar  re- 
mark may  be  made  with  regard  to  the  former  fre- 
quency of  the  disease  throughout  the  extensive  region 
from  Utica  to  Buffalo.  The  late  Uriah  Tracy,  in  his 
excursion  through  this  country  some  years  since,  was 
led  to  believe  that  bronchocele  prevailed  in  the  old  set- 
tlements as  well  as  the  new,  and  thought  it  incidental 
to  the  country  at  large.  In  my  late  visit  I made  sjie- 
cial  inquiry  as  to  the  present  condition  of  the  health 
of  fhe  inhabitants,  and  am  persuaded  that  the  instances 
of  goitre  are  much  more  rare  than  at  the  period  of  Mr. 
Tracy’s  observations.  The  number  of  cases  which 
came  under  my  notice  during  the  tour  were  twenty- 
three.  These  were  at  Herkimer,  Manlius,  Syracuse, 
Onondaga,  Batavia,  Williamsville,  and  Buffalo ; and  I 
saw  more  cases  in  the  neighbourhood  of  Buffalo  than 
at  any  other  place.  In  other  parts  of  the  state  the 
disease  may  be  seen,  particularly  in  the  county  of  Alle- 
ghany.” 

To  assign  a satisfactory  cause  for  this  disease  is 
difficult,  perhaps  impossible.  Dr.  Barton  has  endea- 
TOured  to  show  that  goitre  and  intermittent  and  remit- 
tent fevers  have  one  common  origin,  and  argues  this 
opinion  from  the  simultaneous  prevalence  of  these  dis- 
eases, from  the  frequency  of  glandular  affections 
where  intermittents  abound,  and  from  the  opinion  that 
persons  afflicted  with  goitre  are  exempt  from  intermit- 
tents, though  in  the  midst  of  these  diseases.  Dr.  Co- 
ventry inclines  to  ascribe  it  to  drinking  water  impreg- 
nated with  alum.  Dr.  Dwight  advocates  the  more 
current  opinion  that  these  affections  originate  from  the 
lime  contained  in  the  water  drank  in  those  regions. 
Dr.  Francis  ascribes  the  production  of  the  disease 
chiefly  to  humidity,  and  hence  it  prevails  most  in  the 
vicinity  of  lakes  and  rivers  where  vegetation  abounds. 
He  says,  it  increases  with  the  rainy  seasons,  and  is  di- 
minished when  the  weather  becomes  cold  and  dry,  and 
hence  argues  the  reason  of  its  disappearance  as  the 
country  becomes  cleared.  He  however  does  not  alto- 
gether reject  the  agency  of  certain  waters  in  aggravat- 
ing if  not  producing  the  disease. 

Of  the  23  cases  examined  by  Dr.  Francis,  two  only 
were  in  male  subjects,  and  one  of  them  an  adult  In- 
dian, in  Niagara  county.  He  saw  it  in  an  infant  but 
a few  months  old,  and  he  subscribes  to  the  opinion 
that  it  often  depends  on  constitutional  causes,  and  is 
sometimes  hereditary. 

In  Oneida  county.  Dr.  Francis  learned  that  goitre 
prevailed  among  sheep,  and  Foderb  gives  us  a similar 
fact  of  its  occurrence  among  dogs.  The  doctrines  of 
Hunter  and  others,  in  considering  the  sexual  functions 
connected  with  thi.s  di.sease,  are  sustained  by  its 
greater  prevalence  among  women,  and  also  according 
to  Dr.  F.  by  some  well-Liown  facts  connected  with 
parturition. 

Dr.  Coventry  has  removed  several  cases  of  goitre  by 
the  simple  expedient  of  the  patient  wearing  the  muri- 
ate of  soda  about  the  neck.  The  recent  plan  of  Mr. 
Holbrook,  of  employing  steady  pressure,  has  been 
tried  in  this  country  with  some  success.  The  efficacy 
of  burnt  sponge  has  often  been  seen,  but  instances  of 
its  failure  are  not  unfrequent.  Tlje  iodine  has  been 
used  of  late  years  with  the  best  effects,  and  Dr.  Cong- 
don,  of  Buffalo,  has  reported  its  entire  success  in  a 
number  of  cases. 

Dr.  Francis  informs  me,  that  in  a subsequent  journey 
through  this  state,  he  found  a number  of  interesting 
cases,  and  that  the  disorder  in  every  instance  affliclca 
the  female  sex,  and  in  eight  or  ten  cases  it  was  obviously 
as.sociated  with  the  function  of  menstruation  and  par- 
turition. The  left  portion  of  the  gland  was  most  fre- 
quently the  seat  of  the  disease,  but  in  no  instance  was 
it  connected  with  idiocy.  lie  reports  one  instance  of 
the  entire  cure  of  a formidable  case  which  occurred  in 
a young  married  female,  who,  upon  leaving  the  neigh- 
bourhood of  Catskill  and  removing  to  the  southern 
states,  after  a residence  of  three  years,  was  cmirely 
relieved  of  h<.*r  goiire. 


200 


BRO 


BRO 


I can  add  my  own  testimony  to  the  value  of  the  iodiu  , 
having  witnessed  its  success  in  a number  of  cases 
which  had  resisted  the  other  remedies  ordinarily  em- 
ployed. 

The  ojieration  of  removing  the  gland  by  the  knife 
has  been  performed  in  this  country  with  success,  but  is 
seldom  advised,  and  will  not  be  often  repeated.— ilcese.] 

Jilbucasis  gaoe  the  first  good  account  of  broncko- 
crle.  Wihner's  Cases  and  Remarks  in  Surgery,  with 
an  Appendix  on  the  .Method  of  curing  the  Bronchoceli 
in  Coventry,  8vo.  Rond.  1779.  Prosser,  J3n  Account 
and  jMithod  of  Cure  of  Bronchocele,  or  Derby-neck, 
Boo.  Lond.MGQ.  Also,  “id  edit.  Ato.  J.,ond.  Yi&i.  Me- 
moirs of  the  Med.  Society  of  London,  vol.  1.  Gooch's 
Chirurgical  IVorks,  vol.  2,  p.  96  ',  vol.  3,  p.  157.  De- 
sault's Parisian  Chirurgical  Journal,  vol.  2,  p.  292. 
CEuores  Chirurgicales  de  Desault,  par  Bichat,  t.  2,  p. 
298.  V.  Malacarne,  Retire  sur  I'Etat  de  Cretin : 
{Frank,  Del.  Op.  6.)  Edin.  Med.  and  Surgical  ,/uurn. 
vol.  4,  p.^nQ.  Odier's  Manueldc  Medecine  Pratique, 
800.  Geneve,  1811.  Dr.  Reeves' s Paper  on  Cretinism, 
in  Edin.  Med.  and  Sin-g.  .Journal,  vol.  5.  Truite  du 
Goitre,  et  du  Cretinisme,  par  F.  E.  Fodo.  i,  8vo.  Pa- 
ris, an  8.  Richter's  Anfa.ngsgrunde  der  fVundarz- 
neykunst,  b.  4,  kap.  13,  wore  Kropfe.  Surgical  Ana- 
tomy of  the  Head  and  Meek,  by  A.  Burns,  p.  191,  <S'C. 
Rarrey,  Memoires  de  Chirurgie  Mditaire,  tom.  1,  p. 
123;  t.  3,  p.  199,  See.  .7.  F.  .dekermann,  uber  die  Kre- 
tinen,  eine  besondere  Menchenabart  in  d.ii  Alpen.  8vo. 
Gotha,  1790.  B.  S.  Barton,  A Memoir  concerning 
the  Disease  of  Goitre,  as  it  prevails  in  different  parts 
of  Morth  America,  Svo.  Philadelphia,  1800.  Memo- 
ria  Patologico  Practica  sulla  Malura  di  Gozio,  <S-c. 
del  Dottor  Prospero  Postiglione,  \2mo.  Firenze,  1811. 
Korium,  Comment,  de  Fitio  Scrofiiloso,  t.  2.  Giuseppe 
Flujani,  Collezione  d'  Ostervazioni  e Rifiessioni  di 
Chirurgia,  t.  3,  p.  270,  (S  c.  8vo.  Roma,  1802.  Quadri, 
in  Med.  Chir.  Trans,  vol  10,  p.  16.  Diet,  dcs  Sci- 
ences Med.  art.  Bronchocele.  Ph.  Fr.  JVallher,  Meuc 
Heilart  des  Kropfes  durch  die  Unterbindung  der  obern 
SchUdrusen  Schlagadern  nebst  der  Geschichte  eines 
durch  die  Operation  geheilten  Aneurisnids  der  Carotis 
Svo.  Sulzbach,  1817.  H.  Coates,  in  Med.  Chir.  Trans,  vol. 
10,  p.  312,  ij-c.  Gautieri  Tyrolicnsium,  Carynthiorum, 
Styriorumque  Struma;  Viennw,  1194.  Maas,  Diss. 
de  Glandula  Thyroidea  tarn  Sana  quam  Morbosa,  ire. 
Wirceb.  1810.  Hausleutncr,  uber  Erkenntniss,  i c. 
des  Kropfes,  in  Horn's  Archiv.  b.  13,  1813.  Muhli- 
bach  der  Kropf.  nach  seiner  Ursache,  Pehutung,  und 
Heilung.  Wien,  1822.  Hedenus,  Tractatus  de  Glan- 
dula Thyroidea,  ire.  Lips.  1822.  Lassus,  Pathologic 
Chirurg.  t.  1,  p.  408,  i-c.  Petit,  (Euvres  Posthumes, 
t.  l,p.  255.  Haller,  Opuscula  Pathologica,  Obs.  5,p. 
16.  J.  R.  Alibert,  JVosologic  JVuturelle,  t.  1,  p.  464, 
^c.fol.  Paris,  1817.  A.  C.  Hutchison,  Cases  of  Bron- 
chochcle,  or  Goitre,  treated  by  Scion : Med.  Chir. 
Trans,  vol.  11,  p-  235,  ire.  A.  de  Humboldt,  Observa- 
tions sur  quelques  Phenomines  peu  connus  qu'  offre 
le  Goitre  sous  les  Tropiques,  dans  les  Plaines  et  sur 
le.s  Plateaux  des  Andes  ; in  .Tourn.  de  Physiolngie  par 
F.  Magendie,  t.  4,p.  109,  Svo.  Paris,  1824.  Observa- 
tions on  the  remarkable  Effects  of  Iodine  in  Broncho- 
eele  and  Scrofula ; being  a translation  of  three  Me- 
moirs published  by  .1.  R.  Coindet,  M.  D.  Rond.  1821. 
J.  C.  Straub,  in  Maturwissenschaftlicher  Anzeiger  der 
Allgemeiner  Schweizerischer  Gesellschaft,  ire.  heraus- 
gegeben  von  Fr.  Meisner,4to.  Bern.  Feb.  1820.  Bra  a, 
Saggio  Clinico  still'  lodio,  ^c.  Padova,  1822.  W. 
Gairdner,  R.  D.,  Essay  on  the  Effects  of  Iodine,  with 
Practiced  Observations  on  its  use  in  Bronchocele, 
Scrofula,  irc.  Rond.  1824.  H.  S.  Roots,  in  Med.  Chir. 
Trans,  vol.  12,  310.  Coster,  in  Archives  Geuerales 

de  Medecine,  Juillet,  1823.  J.  Kennedy,  in  Rond.  Mi  d. 
Repository  for  Feb.  1822.  Dr.  A.  Maiison,  Medical 
Researches  on  the  Effects  of  Iodine  in  Bronchocele,  irc. 
Rond.  1825.  M.  Roulin,  Mote  sur  quelques  Faites  re- 
latifs  d V Histoirc  des  Goitres  ; in  Magendie' s Jotirn. 
de  Physiologic  Expir.  t.5,  p.  266.  J.  A.  W.  Hedenus, 
Ausrottung  der  Schildruse,  in  .Tourn.  der  Chir.  von 
C.  F.  Graefe  und  Ph.  Von  Walther,  b.2,  p.  237,  i-c.  or 
Journ.  of  Foreign  Medicine,  vol.  5,  p.  317,  i-c.  For 
the  best  plates  of  the  disease  see  Dr.  Baillie's  Series 
of  Entrravivir.s,  i^r.fasc.  2,  tub.  1. 

BRONCHOTOMY.  (From  ^pbyxo;,  the  windpipe, 
and  Tfpvw,  to  cut.)  This  is  an  operation  by  which  an 
onening  is  made  into  the  larynx  or  trachea,  either  for 
the  purpose  of  making  a passage  tor  the  air  into  and 


out  of  the  lungs,  when  any  disease  prevents  the  pa- 
tient from  breathing  through  the  mouth  and  nostrils ; 
or  of  extracting  foreign  bodies,  which  have  accident- 
ally fallen  into  the  trachea ; or,  lastly,  in  order  to  be 
able  to  inflate  the  lungs  in  cases  of  suspended  anima- 
tion. The  operation  is  also  named  tracheotomy.  Its 
practicable  nature  and  little  danger  are  Ibunded  on  the 
facility  w ith  which  certain  w ounds  of  the  windpipe, 
even  of  the  most  complicated  kind,  have  been  healed, 
and  on  the  nature  of  the  parts  cut,  which  are  not  tur- 
nished  with  any  vessel  of  consequence. 

When  the  incision  is  made  in  the  larynx,  the  opera- 
tion is  termed  laryngotomy.  With  respect  to  bron- 
chotomy,  its  performance  cannot  be  regarded  as  either 
difficult  or  dangerous  ; “ Dummodo  (says  Fabricius  ab 
Aquapendente),  qui  secat  sit  anatomes  per  it  us,  quia 
sub  hoc  medico  et  artifice  omnia  tutissimi  et  felicis- 
simi  peraguntur." 

Bronchotoniy  is  occasionally  practised  in  order  to 
enable  the  patient  to  breathe,  when  respiration  through 
the  mouth  and  nostrils  is  impeded  by  disease. 

Cynanche  laryngea  sometimes  creates  a necessity 
for  the  operation,  and  this  is  particularly  the  case  w hen 
the  disease  is  situated  in  the  edges  of  the  rima  gloiti- 
dis,  which  opening  becomes  so  contracted,  as  scarcely 
to  leave  the  smallest  spiace.  For  this  rea.son,  and  on 
account  of  the  tension  of  the  ligaments  of  the  glottis, 
the  voice  is  rendered  excessively  acute  and  hissing,  as> 
it  were.  The  suffocation  is  imminent ; the  lungs  not 
being  expanded,  the  blood  accumulates  in  them,  and 
the  return  of  the  blood  from  the  head  is  more  or  less 
impeded.  There  can  be  little  doubt,  that  many  pa- 
tients who  have  perished  under  these  circumstances, 
might  have  been  saved  by  a timely  incision  in  the 
trachea.  The  majority  of  writers  who  have  treated 
of  bronchotomy  as  a means  of  preventing  suffocation 
in  inflammatory  diseases  of  the  larnyx,  have  regarded 
this  operation  as  the  ultimate  resource.  Both  the 
Greeks  and  Arabians  were  of  this  sentiment;  and 
Avicenna  only  recommends  bronchotomy  in  violent 
cases  of  cynanche,  when  medicines  fail,  and  the  pa- 
tient must  evidently  die  from  the  unrelieved  state  of 
the  affection.  Rhazes  also  advised  the  operation  only 
when  the  patient  was  threatened  with  death.  Thus, 
in  former  times,  though  practitioners  were  aware  of 
the  principle  on  which  bronchotomy  became  necessary, 
they  generally  found  the  operation  fail,  because  it  was 
delayed  too  long,  and  rarely  done  ere  effusion  had 
commenced  in  the  lungs. 

Bronchotomy,  says  Louis,  will  always  be  done  too 
late,  when  only  practised  as  an  extreme  measure.  In 
cases  of  inflammation  about  the  throat,  the  danger  of 
perishing  by  suffocation,  as  this  author  remarks,  has 
been  known  from  the  very  dawn  of  medicine.  The 
advice  of  Hippocrates  to  remedy  this  urgent  symptom, 
is  a proof  of  it ; and  he  observes,  that  the  danger  is 
evinced  when  the  eyes  are  affected  and  prominent,  as 
in  persons  who  have  been  strangled,  and  when  there 
is  great  heat  about  the  face,  the  throat,  and  neck, 
without  the  appearance  of  any  external  defect.  He 
recommends  fistula  in  fauces  ad  maxillas  intru- 
denda,  qua  spiritus  in  pulmones  trahatur.  No  doubt 
he  would  have  advised  more,  had  it  not  been  for  the 
doctrine  of  his  time,  that  wounds  of  cartilages  were 
incurable. 

This  method,  defective  as  it  was,  continued  till  the 
time  of  Asclepiades,  who,  according  to  Galen,  was  the 
first  proposer  of  bronchotomy.  Since  Asclepiades, 
this  operation  has  always  been  recommended  and 
practised  in  case  of  quinsy  threatening  suffocation, 
notwithstanding  the  inculcation  of  Cielius  Aurelia- 
nus,  who  treated  it  as  fabulous.  The  mode  of  doing 
it,  however,  has  not  been  well  detailed  by  any  body 
who  put  it  in  practice,  except  Paulus  jEgineta,  who  is 
precise  and  clear.  “ We  must  (says  he)  make  the  in- 
cision in  the  trachea,  under  the  larynx,  about  the  third 
or  fourth  ring.  This  situation  is  the  most  eligible, 
because  it  is  not  covered  by  any  muscle,  and  no  ves- 
sels are  near  it.  The  patient’s  head  must  be  kept 
back,  in  order  that  the  trachea  may  project  more  for- 
wards. A transverse  cut  is  to  be  made  between  two 
of  the  rings,  so  as  not  to  wound  the  cartilage,  only  the 
membrane.”  The  knowledge  of  this  method,  and  its 
advantages  in  cases  of  the  angina  strangulans,  w hen 
practised  in  time,  ought,  according  to  Louis,  to  have 
rendered  its  perforniaiice  a general  jiraeiice. 

The  convulsive  angina  of  Boerhaave,  w hich  particu 


BRONCHOTOMY. 


201 


larly  affects  those  who  can  only  breathe  well  in  an 
upright  posture,  has  also  been  adduced  as  a case  de- 
manding the  prompt  performance  of  bronchotomy. 
Mead,  in  his  Precepta  et  Manila  Medica,  mentions  a 
case,  in  which  the  patient  had  been  bled  very  copiously 
twice  in  the  space  of  six  hours,  but  he  died  notwith- 
standing this  large  evacuation.  The  same  author  no- 
ticed in  Wales,  especially  on  the  seacoast,  an  epide- 
mic catarrhal  quinsy,  which  carried  the  patients  off  in 
two  or  three  days.  In  these  instances,  bleeding  was 
not  of  much  use,  and  bronchotomy,  which  was  not 
performed,  was  the  only  means  by’  which  the  patients 
might  have  been  saved. 

In  angina  and  croup,  some  modern  practitioners  are 
less  sanguine  in  their  expectation  of  benefit  from 
bronchotomy  than  Louis  was.  From  the  observa- 
tions of  Dr.  Cheyne,it  would  appear  that  in  croup,  the 
operation  cannot  be  necessary  for  the  j)urpose  of  ad- 
mitting air  into  the  trachea;  for  in  those  who  have 
died  of  the  disease,  he  has  found  a pervious  canal  of 
two-eighths  of  an  inch  in  diameter,  and  through  a tube 
of  such  diameter,  even  an  adult  can  support  respira- 
tion for  a considerable  time.  According  to  the  same 
writer,  bronchotomy  is  equally  unfitted  for  the  remo- 
val of  the  membrane  formed  by  the  effusion  of  lymph  ; 
for.  from  its  extent,  variable  tenacity,  and  adhesions, 
this  is,  in  almost  every  case,  totally  imjiracticable ; and 
even  could  the  whole  membrane  be  removed,  still  the 
function  of  respiration  would  be  but  little  improved, 
the  ramifications  of  the  trachea  and  bronchial  cells  re- 
maining obstructed. — (See  Cheyne's  Pathology  of  the 
Larynx  and  Bronchia.) 

No  doubt,  Ur.  Cheyne’s  statement  of  what  is  found  in 
the  dead  subject  is  correct ; and  yet  the  operation  may 
be  necessary  to  prevent  suffication,  which  might  other- 
wise be  induced,  partly  by  the  diminution  of  the  natural 
passage  for  the  air  by  disease,  and  partly  by  the  action  of 
the  muscles  of  the  glottis  ; a circumstance  to  which  Dr. 
Cheyne  has  not  assigned  sufficient  importance.  On  this 
point,  the  sentiments  of  Mr.  C.  Bell  are  more  correct ; 
speaking  of  the  membrane  of  croup,  formed  by  the  effu- 
sion of  coagulable  lymph,  and  of  the  cause  of  death  in 
these  cases,  he  says,  “ It  has  not  appeared  to  me  that  it 
was  the  violence  of  the  inflammation  which  destroyed 
the  patient,  nor  the  irritation  directly  from  the  inflamed 
membrane ; but  that  the  presence  of  this  secreted  mem- 
brane, acting  like  a foreign  bo  y,  at  the  same  time  occa- 
sions spasms  in  the  glottis,  obstructs  the  passage,  and 
confines  the  mucus.  But  I am  bound  to  state  in  the 
strongest  terms,  that  death  is  ultimately  a consequence 
of  effusion  in  the  lungs,  occasioned  by  the  continued 
struggle  and  difficulty  ; for  on  opening  the  chest  I have 
uniformly  found,  that  the  lungs  did  not  collapse,  and 
that  the  bronchiae  were  full  of  mucus.  This  corres- 
ponds with  the  symptoms ; for,  before  death,  the  vio- 
lence of  the  cough  and  struggle  has  given  place  to  cold- 
ness and  insensibility,  with  a pale  swelling  of  the  face 
and  neck,  and  when  the  child  has  fallen  into  this  state, 
giving  freedom  to  the  trachea  will  be  qf  no  avaiV’ — 
{Surg.  Obs.  p.  16.) 

In  the  cases  of  croup  which  Mr.  Chevalier  examined 
after  death,  he  found  the  trachea  obstructed  with  mucus, 
and  he  believed,  that  it  is  more  by  this  secretion  than 
by  that  of  coagulable  lymph  that  suffocation  is  finally 
produced.  At  all  events,  he  succeeded  in  saving  a boy- 
on  the  point  of  suffocation,  by  making  an  incision  in  the 
trachea,  and  letting  out  an  ounce,  or  an  ounce  and  a 
half,  of  reddish  brown,  frothy  mucus.  And  a case,  of  a 
very  similar  description,  in  which  the  same  practice  an- 
swered, I attended,  a few  years  ago,  with  Mr.  Lawrence 
and  Dr.  Blicke.  This  case,  however,  was  different 
from  Mr.  Chevalier’s,  in  the  circumstance  of  a tube  be- 
ing required  for  a couple  of  days  after  the  operation, 
when  the  removal  of  the  instrument  was  followed  by  no 
inconvenience. 

Pelletan  joins  several  modern  writers  in  representing 
bronchotomy  as  generally  useless  in  cases  of  croup; 
the  only  example  in  which  he  thinks  the  operation 
might  be  serviceable  being  that  in  whicht  he  disease  is 
confined  to  the  larynx ; a case  which  he  sets  down  as 
uncommon,  and  difficult  to  be  distinguished.  “ Kn  sup- 
yusant  enjin  I'angine  avec  concretion  bieii  curacterisee, 
on  .‘)e  tronvera  encore  entre  la  crainte  tie  pratiquer  une 
operation  inutile,  si  les  concretions  se  yrolongent  jus- 
qitc  duns  Ics  branches,  el  I'iiirpossibihlS  de  jnger  si  ces 
concretions  sunt  bornees  au  larynx.  C'esten  effe.tdans 
cc  scvl  cas  quet'oyeriUiov  pent  etre  fructuense ; elle  fa-  i 


cilitera  la  re.spiration  yrndant  que  la  nature,  aidec  de 
I’art,  trarnillera  a dis.soudre,  detacher,  et  faire  expec- 
torcr  les  fausses  mcnihranes  qui  obliterent  la  glutie  et 
le  larynx." — f Unique  I 'hir.t.  i,p.  28.) 

Of  course,  the  degree  of  success  which  will  attend 
the  practice  of  bronchotomy,  in  cases  of  this  nature, 
rnus’t  always  mainly  depend  upon  the  operation  being 
done  early  enough,  and  in  cases  where  the  lungs  are 
not  too  seriously  affected  ; for  if  the  effects  of  pneumo- 
nia are  far  advanced,  the  patient’s  chance  of  recovery 
will  be  hopeless,  whether  the  trachea  be  opened  or  not. 
In  order,  also,  to  have  a reasonable  chance  of  success, 
in  cases  threatening  suffocation  from  inflammation  of 
the  parts  about  the  fauces,  as  sometimes  happens,  the 
operation  must  not  be  deferr'^d  too  long.  We  see  this 
fact  exemplified  in  two  cases  recorded  by  Flajani ; in 
one,  where  the  operation  had  not  been  allowed  till  a 
late  period  of  the  disease,  the  patient  died  ; in  the  other, 
where  the  practice  was  adopted  earlier,  life  was  pre- 
served.—(CoZ^ezione  d' Osservazioni,  \ c.  t.  3,  p.  230 
—233.) 

A few  years  ago.  Dr.  Baillie  published  three  cases,  in 
which  death  was  produced  in  the  adult  subject,  and  in 
a very  few  days,  by  a violent  inflammation  of  the  la- 
rynx and  trachea.  The  disease  had  a strong  resem- 
blance to  croup ; yet  was  different  from  it.  There  was 
not  the  same  kind  of  ringing  sound  of  the  voice  as  in 
croup,  and  no  layer  of  coagulable  lymph  was  formed 
ujion  the  surface  of  the  inner  membrane  of  the  larynx 
and  trachea,  which,  according  to  Dr.  Baillie,  uniformly 
attends  the  latter  disease.  In  one  of  these  cases,  the  cavity 
of  the  glottis  was  found  to  be  almost  obliterated,  by  the 
thickening  of  the  inner  membrane  of  the  larynx  at  that 
part.  The  inner  membrane  of  the  trachea  was  likewise 
inflamed ; but  in  a less  degree.  The  lungs  were  sound. 
If,  in  thirty  hours,  no  relief  should  be  derived  from 
bleeding  ad  deliquium,  and  the  exhibition  of  opiates, 
Dr.  Baillie  conceives,  that,  in  this  sort  of  case,  it  might 
be  advisable  to  perform  the  operation  of  bronchotomy  at 
the  upper  part  of  the  trachea,  just  under  the  thyroid 
gland.  This  operation,  he  thinks,  would  probably  en- 
able the  patient  to  breathe  till  the  inflammation  in  the 
larynx,  more  especially  at  the  aperture  of  the  glottis, 
had  time  to  subside.— (See  Trans.for  the  Improvement 
of  Med.  and  Chir.  Knowledge,  vol.  3,  p.  275.  289.) 

An  acute  affection  of  the  membrane  of  the  glottis, 
proceeding  rapidly  to  a fatal  termination  by  suffocation, 
has  also  been  particularly  described  by  Drs.  Farre  and 
Fercival.— (See  Med.  Chir.  Trans,  vols.  3 and  4.)  In 
some  bodies,  which  Mr.  Lawrence  examined  after  death, 
he  found  appearances  analogous  to  those  mentioned  by 
the  above  physicians.  “ The  patients  died  of  suffocai- 
tion ; but  the  progress  of  the  complaint  was  much  slower 
than  in  those  cases;  the  syinjitoms  were  not  .acute,  nor 
did  the  inspection  of  the  parts  disclose  any  evidences  of 
active  inflammation.  The  membrane  covering  the 
chordag  vocales  was  thickened,  so  as  to  close  the  gloN 
tis,  and  a similar  thickening  extended  to  a small  dis» 
tance  from  these  parts,  accompanied  with  an  oedema- 
tons  effusion  into  the  cellular  substance  under  the 
membrane.  The  epiglottis  did  not  partake  of  the  disor- 
der. In  one  or  two  instances,  this  tliickened  state  of  the 
membrane  was  the  only  change  of  structure  observed ; 
but  in  others  it  was  attended  either  with  ulceration  of 
the  surface  near  the  glottis,  appearing  as  if  it  had  been 
formed  by  an  abscess,  which  had  burst,  or  with  a par- 
tial death  of  one  or  more  of  the  cartilages  of  the  larynx, 
viz.  the  arytenoid,  thyroid,  or  crycoid.  The  rest  of  the 
air-passages  and  the  lungs  were  healthy.” — {Med.  Chir. 
Trans,  vol.  6,  p.  222.) 

In  such  examples,  this  gentleman  is  a zealous  advo- 
cate lor  the  early  performance  of  bronchotomy,  and  he 
has  cited  several  instances  in  which  this  operation  was 
successfully  performed,  both  for  the  relief  of  quinsy  and 
the  extraction  of  foreign  bodies  from  the  trachea. 

What  Bayle  called  Voedeme  de  la  glotte,  no  doubt,  was 
the  same  kind  of  disease  as  that  noticed  by  Mr.  Law- 
rence ; one  case  of  it,  in  which  tracheotomy  was  per- 
formed with  success,  and  another  in  which  the  jiatient 
died  suddenly,  suffocated  in  consequence  of  the  operation 
not  being  done,  have  been  published  by  Liston. — (See 
Edin.  Med.  and  Surg.  Jowm.  vol.  19,  p.  568.) 

The  affections  of  the  larynx,  requiring  bronchotomy, 
would  seem,  indeed,  to  be  more  numerous  and  diversi- 
fied than  is  usually  supposed : thus,  Mr.  C.  Bell  men 
tions  the  case  of  a medical  student,  who  was  attacked 
with  shivering,  fever,  and  sore  throat,  and  in  tl„eedays 


202 


BROxNCHOTOxMY. 


died  of  suifocation.  On  dissection,  no  obstruction  in 
the  larynx  was  ohser^'ed,  but  only  an  inflammation  of 
its  membrane,  and  a spot  like  a small-iiox  pustule  upon 
the  margin  of  the  gloxtis.— {Surgical  Ohs.  part  1,  p.  M.)  j 

Children  sometimes  inadvertently  drink  boiling  water  | 
from  the  spout  of  a tea-kettle.  “ The  effects  of  this  ac-  , 
cident  (says  Dr.  Hail)  are  not,  as  might  be  supposed,  d ^ 
priori,  the  symptoms  of  inflammation  of  the  oesophagus  . 
and  stomach,  but  of  inflammation  of  the  glottis  and  la- 
rj'nx,  resembling  those  of  croup ; and  the  case  constitutes 
another  instance,  in  which  the  operation  ofiaryngotomy,  . 
or  of  tracheoiomy,  may  be  performed  with  the  effect  of 
preventing  impending  suffocation,  and  perhaps  of  saving 
Me.”— (Med.  Chir.7Vans.vol.  \2,p.  2.)  The  cases  and 
remarks  collected  by  Dr.  Hall,  Mr  Gilman,  and  Mr. 
Stanley,  on  this  new  subject,  cannot  fail  to  be  highly  in- 
teresting to  practitioners.  In  a case  of  the  foregoing  de- 
scription, Mr.  Wallace,  of  Dublin,  performed  tracheo- 
tomy with  success. — (See  Loud.  Med.  and  Phys.  Jnum. 
for  July,  1822.)  Mr.  Burgess,  who  has  seen  five  cases, 
in  which  boiling  water  was  taken  into  the  throat,  thinks 
that  death,  when  it  follows,  is  almost  always  produced 
by,  obstructed  respiration.  In  one  of  the  examples 
which  he  has  recorded,  bronchotorny  was  the  means  of 
saving  the  child.— (See  Dublin  Hospital  Reports,  vol.  3.) 

Great  mechanical  injury  of  the  larynx,  caused  by  a 
blow  or  fall,  may  create  the  necessity  for  bronchotorny, 
as  is  proved  by  a case  lately  reported  by  Mr.  Liston.— 
(See  Ed.  M d.  and  Surgical  Journ.  vol.  19,  p.  570.) 

[There  is  no  inconsiderable  diversity  of  opinion  among 
eminent  surgeons  as  to  the  propriety  of  performing 
bronchotorny  in  cases  of  croup  ; and  those  who  opixise 
the  operation,  very  plausibly  allege,  that  in  the  mem- 
branous stage  of  croup  no  advantage  can  result  from  | 
the  operation,  however  favourable  the  condition  of  the  j 
sufferer  may  be  in  other  respects.  The  views  of  the 
celebrated  Cheyne  would  seem  to  put  beyond  doubt  the 
inutility  of  the  operation  as  already  noticed  by  our  au-  j 
thor,  because  it  is  inadequate  to  the  removal  of  the  arti-  ' 
ficial  membrane  which  is  effused  in  the  advanced  stage  | 
of  cynanche  trachealis.  I am  not  jirepared,  from  my  ! 
own  experience,  wholly  to  decide  the  difficulty.  W’e  ! 
have  evidence  sufficient,  I think,  to  justify  an  occasional  I 
recourse  to  this  exercise  of  surgical  skill ; but  there  is  j 
still  another  means  of  relief,  not  stated  by  our  author,  | 
that  may  fitly  be  introduced  here,  which  wdll  often  ren-  | 
der  this  operation  unnecessary,  even  in  those  cases  in 
which  it  is  confidently  recommended  by  some,  and  cer- 
tainly ought  to  be  fully  tested  before  we  avail  ourselves 
of  so  doubtf ul  a remedy. 

In  that  stage  of  croup  which  has  been  aptly  termed 
the  fatal  stage,  from  its  so  generally  proving  such,  and 
which  is  characterized  by  the  existence  of  the  mem- 
brane, the  vitriolic  emetics  have  been  introduced  with 
decided  success. 

This  practice  was  first  introduced  by  Professor  Fran- 
cis, of  New-York,  in  1813  ; and  since  the  report  of  his 
success,  has  become  very  generally  adopted  in  this 
country,  and  with  .singular  success.  I have  now  in 
my  possession  a specimen  of  an  entire  membrane  lining 
the  trachea,  detached  and  thrown  up  under  the  power- 
ful emetic  action  of  the  blue  vitriol,  after  venesection, 
blisters,  calomel,  polygala  senega,  and  all  the  approved 
remedies  had  been  tried  ineffectually. 

I regret  that  the  limits  assigned  me  preclude  my  insert- 
ing the  interesting  detail  ofihe  cases  reported  by  Dr.  Fran- 
cis, in  his  valuable  paper  published  on  this  subject,  and 
have  to  content  myself  with  referring  to  the  i\".  Y.  Med. 
and  Phys.  Jaurn.  vol.  3,  p.  58,  et  seq.,  only  remarking, 
that  in  the  almost  hopeless  state  in  which  the  sequela  of 
inflammation  are  so  threatening,  calermel,  in  large  doses, 
is  among  the  most  efficient  auxiliaries  to  which  we 
can  have  recourse.  “ After  the  existence  of  the  mem- 
brane,” observes  Dr.  F.,  “ and  when  the  powers  of  life 
are  on  the  wane,  it  is  a judicious  and  sometimes  an 
available  resource and  he  admits,  that  in  the  cases  in 
which  he  found  the  vitriolic  emetics  successful,  their 
agency  was  probably  favoured  by  that  potent  mercurial. 

1 find  a similar  practice  has  been  adopted  by  Dr.  Hoff- 
mati,  of  Vienna,  who  first  used  the  vitriolic  emetics  in 
1820;  and  so  highly  does  he  estimate  them,  that  he 
declares  their  action  to  be  a specific  in  this  stage  of 
croup.  This  is  unquestionabh  saying  too  much  in  their 
behalf;  yet  certainly  they  are  entitled  to  high  consider- 
ation, and  ought  never  to  be  omitted  in^  these  almost 
hopeless  cases. — Reese.] 

2 Tbv  compression  of  the  trachea  by  foreign  bodies,  j 


lodged  in  the  pharvTix,  or  by  tumours,  formed  outwardly, 
and  of  sufficient  size  to  compress  the  windpipe,  but  not 
admitting  of  immediate  removal,  is  an  equal  reason  for 
operating  more  or  less  expeditiously,  according  to  the 
symptoms.  Mr.  B.  Bell  mentions  two  instances  of  suf- 
focation from  bodies  falling  into  the  pharynx.  Respira- 
tion was  only  stopped  for  a few  minutes  ; but  the  cases 
were  equally  fatal,  notwithstanding  the  employment  of 
all  the  usual  means.  This  author  thinks,  that  broncho- 
lomy  would  have  been  attended  with  complete  success, 
if  it  had  been  performed  in  time.  The  operation  should 
also  be  done,  when  the  trachea  is  dangerously  com- 
pressed by  tumours.  The  author  of  the  article  Bran- 
chotomie,  in  I'Encyclopidie  Methodique,  says,  that 
about  twenty  years  ago  he  opened  a man,  who  had  died 
of  an  emphysema,  which  came  on  instantaneously.  He 
had  had,  for  a long  while,  a bronchocele,  which  was  of 
an  enormous  magnitude  towards  the  end  of  his  life. 
The  cavity  of  the  trachea  was  so  obliterated,  that  there 
was  .scarce]  V room  enough  to  admit  the  thickness  of  a 
small  piece  of  money.  Doubtless,  bronchotorny,  per- 
formed before  the  emphysema  made  its  appearance, 
might  have  prolonged  this  man’s  days. 

In  cases  of  this  last  description,  Desault  would  have 
advised  the  introduction  of  an  elastic  gum  catheter  into 
the  trachea  from  the  nose,  in  order  to  facilitate  respira- 
tion. This  practice,  I believe,  has  not  hitherto  been 
attempted  by  English  surgeons. — (See  (Euvres  Chir. 
de  Desault,  t.  2,  p.  236,  <fcc.) 

Habicot  successfully  performed  this  operation  on  a 
lad  fourteen  years  old,  who,  having  heard  that  gold, 
when  swallowed,  did  no  harm,  attempted  to  swallow 
nine  pistoles,  wrapped  up  in  a piece  of  cloth,  in  order  to 
hide  them  from  thieves.  The  packet,  which  was  very 
large,  could  not  pass  the  narrow  part  of  the  phaiynx  ; 
and  here  it  lodged,  so  that  it  could  neither  be  extracted 
nor  forced  down  into  the  stomach.  The  boy  was  on 
the  point  of  being  suffocated  by  the  pressure  which  the 
foreign  body  made  on  the  trachea ; and  his  neck  and 
face  were  so  swollen  and  black,  that  he  could  not  have 
been  known.  Habicot,  to  whose  house  the  patient  was 
brought,  attempted  in  vain,  by  different  means,  to  dis- 
lodge the  foreign  body.  At  length,  perceiving  the  pa- 
tient in  evident  danger  of  being  suffocated,  he  resolved 
to  perform  bronchotorny.  This  operation  w as  no  sooner 
done,  than  the  swelling  and  lividity  of  the  face  and  neck 
disappeared.  Habicot  pushed  the  pieces  of  gold  down 
into  the  stomach  with  a leaden  probe,  and  the  pistoles 
w-ere,  at  different  times,  discharged  from  the  anus,  eight 
or  ten  days  afterward.  The  wound  of  the  trachea  .soon 
healed.— (See  M^m.  de  PAcad.  de  Chirurgie,  tome  12, 
p.  243,  dit  in  \2mo.) 

In  such  a case  Desault  would  have  introduced  an 
elastic  gum  catheter  into  the  larynx,  instead  of  perform- 
ing bronchotorny,  which  could  not  answer,  w'ere  the 
foreign  body  low-  down.— (See  (Euvres  Chirurg.  de  De- 
sault, t.  2,  p.  247.) 

3.  Foreign  bodies  in  the  trachea  may  render  it  neces- 
sary to  practise  bronchotorny.  Here  I ought  rather  to 
say,  perhaps,  larjuigotomy,  w'hich  by  several  modern 
surgeons  is  deemed  most  applicable.— (De^aiJf ; C. 
Bell,  Surg.  Obs.  part  1,  47,  <S-c.) 

Louis,  in  an  excellent  memoir  on  extraneous  sub- 
stances in  the  trachea,  has  proved,  more  convincingly 
than  all  other  preceding  writers,  the  necessity  of  the  ojie- 
ration  in  circumstances  of  this  kind.  The  following 
case  fell  under  his  observation. 

On  INIonday,  the  19th  of  March,  1759.  a little  girl,  seven 
years  of  age,  playing  with  some  dried  kidney-beans, 
threw'  one  into  her  mouth  and  thought  she  had  sv.-al 
low’ed  it.  She  w-as  immediately  attacked  with  a diffi- 
culty of  breathing  and  a severe  convulsive  cough. 
The  little  girl  said  she  had  swallowed  a bean,  and 
such  assistance  as  was  thought  proper  was  given  her 
Want  of  success  was  the  cause  of  several  surgeons 
being  successively  sent  for,  who  vainly  employed  the 
different  means  prescribed  by  art  for  extracting  foreign 
bodies  from  the  oesophagus,  or  forcing  them  into  the 
stomach.  A fine  sponge  cautiously  fiestened  to  the  end 
of  a whalebone  probang,  was  repeatedly  introduced 
through  the  whole  extent  of  the  oesophagus.  The  little 
girl,  who  made  a sign  with  her  finger,  that  the  foreign 
body  was  situated  in  the  middle  of  the  neck,  thought 
that  she  felt  some  relief  when  the  sponge  w as  conveyed 
below  the  place  which  she  pointed  out.  She  had  every 
now  and  then  a violent  cough,  the  efforts  attending 
which  produced  convulsions  in  all  her  limbs.  Degluti- 


BRONCHOTOMY. 


203 


tion  was  unobstructed ; and  warm  water  and  oil  of 
sweet  almonds  had  been  swallowed  without  difficulty. 
Two  whole  days  had  been  passed  in  sufferings,  when 
the  relations  called  in  Louis.  The  little  girl,  with  all 
po.ssible  fortitude  and  sense,  was  several  times  held 
in  her  friends’  arms  ready  to  die  of  suffocation.  Louis, 
well  aware  of  what  had  happened,  came  into  the  room 
where  the  patient  was.  She  was  sitting  up  in  her 
bed,  sufferiiig  no  other  symptom  than  a very  great 
difficulty  of  breathing.  Louis  inquired  where  she  felt 
pain,  and  she  made  such  a sign  in  reply,  as  left  no 
doubt  concerning  the  nature  of  the  accident.  She  put 
the  index  finger  of  her  left  hand  on  the  trachea,  be- 
tween the  larynx  and  sternum.  The  fruitless  attempts 
which  had  been  made  in  the  cesophagus  with  a view 
of  dislodging  the  foreign  body;  the  nature  and  the 
smallness  of  this  body,  which  was  not  such  as  would 
be  stopped  in  the  passage  for  the  food  ; and  the  facility 
of  swallowing,  were  negative  proofs  that  the  bean  was 
not  in  the  oesophagus.  Respiration  was  the  only  func- 
tion disturbed;  it  was  attended  with  difficulty  and  a 
rattling  in  the  throat.  The  little  girl  expectorated  a 
frothy  fluid,  and  she  pointed  out  so  accurately  the 
painful  point  where  the  object  producing  all  her  suf- 
ferings was  situated,  that  Louis  did  not  hesitate  to  de- 
clare to  the  relations,  from  this  single  inspection,  that 
the  bean  was  in  the  windpipe,  and  that  there  was  only 
one  way  of  saving  the  child’s  life,  which  was  to  make 
an  incision,  for  the  purpose  of  extracting  the  foreign 
body.  He  apprized  them,  that  the  operation  was  neither 
difficult  nor  dangerous,  that  it  had  succeeded  as  often 
as  it  had  been  practised,  and  that  the  very  pressing 
danger  of  the  case  only  just  allowed  time  to  take  the 
opinion  of  some  other  well-informed  surgeons,  respect- 
ing the  indispensable  necessity  for  such  an  operation. 
Louis  thought  this  precaution  necessary  in  order  to 
acquire  the  confidence  of  the  parents,  and  to  shelter 
himself  from  all  reproach  in  case  the  event  of  the  case 
should  not  correspond  with  his  hopes.  Louis  went 
home  to  prepare  all  the  requisites  for  bronchotomy, 
and  in  two  hours  he  was  informed  the  surgeons  who 
were  consulted  waited  for  him.  After  Louis  went 
away,  the  child  had  become  quiet,  and  was  now  lying 
on  its  side  asleep.  The  opinion  he  had  delivered  had 
been  ill  explained  by  the  friends  and  attendants,  and 
had  been  discu.ssed  before  his  return.  They  who  had 
been  rendering  their  assistance,  on  the  supposition  that 
the  foreign  body  was  in  the  oesophagus,  evinced  sur- 
prise at  the  proposal  of  extracting  by  an  operation  a 
substance,  the  presence  of  which  in  any  part  of  this 
tube  was  not  obvious.  Louis  explained  his  advice  in 
regard  to  bronchotomy,  and  did  not  expect  a doubt  to 
be  set  up  against  so  positive  a fact.  It  was  objected, 
that  a substance  as  large  as  a bean  could  not  insinuate 
itself  into  the  trachea.  He  brought  every  one  into 
his  sentiment  by  a short  explanation  of  cases  of  this 
sort  with  which  he  himself  was  acquainted.  The  lit- 
tle girl  was  examined;  she  was  better  than  when 
Louis  saw  her  before,  and  a very  jialpable  emphysema 
w'as  seen  above  the  clavicle  on  each  side  of  the  neck, 
n symptom  which  did  not  e.xist  two  hours  previously. 
This  swelling  made  Louis  conclude,  that  the  urgency 
for  the  operation  was  still  greater.  The  friends,  whose 
confidence  had  been  .shaken  by  the  opposition  he  had 
experienced  in  bringing  about  unanimity,  were  in  the 
greatest  embarrassment  when  they  were  told,  that  the 
child  might  die  of  an  operation  which  he  had  repre- 
sented as  only  a simple  incision  free  from  all  danger. 
Louis  was  repeatedly  asked,  if  he  would  be  respon- 
sible for  the  child's  life  during  the  operation,  and  he  in 
vain  replied,  that  if  there  were  any  thing  ro  fear  dur- 
ing the  operation,  it  would  be  from  the  accident  itself 
and  not  from  the  assistance  rendered.  'I'his  distinc- 
tion wa-s  not  perceived,  and  Louis  withdrew,  at  the 
same  time  refusing  his  consent  to  the  exhibition  of  two 
grains  of  emetic  tartar,  the  effect  of  which  would  be 
useless  and  might  be  dangerous.  Tiie  medicine  was 
given  in  the  night ; liie  child  was  fatigued  with  its 
operation  and  (juite  uiibenefited.  On  Tuesday  morn- 
ing, I.ouis  found  the  little  girl  very  quiet,  and  they  who 
had  paid  their  visits  earlier,  found  her  wonderfully 
well.  The  respiration,  how'ever,  continued  to  be  still 
attended  with  a rattling  noise,  which  Louis  had  ob- 
served in  the  evening  when  the  breathing  was  much 
more  laborious.  The  child  was  nearly  suffocated  seve- 
ral times  in  the  course  of  the  day,  and  died  in  the 
evening,  tli.-ce  days  after  the  accident. 


Bordenave,  who  had  seen  the  patient,  informed  Louis 
of  the  child’s  death  on  Friday.  The  body  was  opened 
before  a numerous  assembly  of  persons  After  mak- 
ing a longitudinal  Incision  through  the  skin  and  fat 
along  the  trachea,  between  the  sierno-hyoidei  muscles, 
Bordenave  slit  open  the  trachea,  cutting  three  of  its 
cartilages.  At  this  instant  every  one  could  see  the 
bean,  and  Louis  took  it  out  with  a small  pair  of  forceps. 
It  was  manifest,  from  the  ease  with  which  this  foreign 
body  was  extracted,  that  the  operation  would  have 
had  on  the  living  subject  the  most  salutary  effect.  The 
relations  had  to  regret  having  sacrificed  a child  which 
was  dear  to  them  to  an  irresolution  and  a timidity  which 
the  most  persuasive  arguments  could  not  remove. — 
{Mem.  de  VAcad.  Royale  de  Chirurgie,  1. 12,  p.  293,  4 c. 
edit,  in  \‘2mo.) 

This  case  strikingly  illustrates  the  symptoms  which 
result  Srom  the  presence  of  foreign  bodies  in  the  tra- 
chea, and  shows  the  only  surgical  proceeding  which  can 
be  of  use.  But  among  the  phenomena  apparently  dif- 
ficult of  explanation,  is  the  calm  which  at  intervals 
followed  the  afflicting  cough.— (See  Dr.  Hunfs  Case 
ill  Med.  Chir.  Trans,  vol.  12,  p.  27.)  Anatomy,  how- 
ever, has  dispelled  much  of  the  doubt  of  this  matter. 
It  is  known,  that  the  whole  canal  of  the  trachea  is 
much  less  sensible  than  the  rima  glottidis.  A foreign 
body,  like  a bean,  may  remain  a certain  time  in  that 
canal  without  much  inconvenience,  the  passage  being 
only  somewhat  obstructed,  according  to  the  position  of 
the  substance.  It  may  even  remain  several  days, 
months,  or  years,  without  producing  any  symptom  of 
its  presence,  except  a trivial  sensation  of  obstruction, 
and  this  is  what  happens  when  the  body  lodges  in  one 
of  the  ventricles  of  the  larynx.  Facts  of  this  kind  are 
to  be  found  in  Tulpius,  Bartholine,  and  many  other  ob- 
servers. But  when  the  extraneous  substance  quits  its 
situation  and  is  carried  into  the  trachea,  the  irritation 
which  it  produces  there,  and  particularly  about  the 
larynx,  occa.sions  coughing;  and  if,  in  the  fits,  the  fo- 
reign body  should  become  fixed  betw'een  the  lips  of  the 
glottis,  it  may  cause  instantaneous  death,  as  probably 
has  happened  in  many  of  the  cases  of  suffocation  from 
extraneous  substances. 

Another  remarkable  circumstance  which  deserves 
more  attention,  as  it  confirms  the  presence  of  a foreign 
body  in  the  trachea,  is  the  emphysema  which  ajipeared 
about  the  clavicle  towards  the  termination  of  the  case. 
Louis  did  not  believe  that  any  of  the  persons  who  saw 
the  patient  could  entertain  a just  idea  of  the  origin  of 
this  symptom.  The  suppo.sition  that  the  obstruction 
w’hich  the  foreign  body  caused,  for  two  days,  to  the 
free  passage  of  the  air,  might  have  occasioned  a 
forcible  distention  of  the  trachea,  and  a rupture  of  the 
membrane  which  connects  together  the  cartilaginous 
rings  of  this  tube,  was  dispelled  by  the  examination 
after  death.  The  windy  tumour  had  not  originated  in 
tile  circumference  of  the  trachea;  here  its  limits  were 
only  seen.  The  very  substance  of  the  lungs  and  the 
mediastinum  were  emphysematous.  The  air  confined 
by  the  foreign  body  had  ruptured  the  air-cells  during  the 
violent  fits  of  coughing,  and  thus  insinuated  itself  into 
the  interlobular  cellular  substance  of  the  lungs.  Thence 
it  had  passed  into  the  cellular  substance  of  the  lungs  ; 
and  afterward  into  that  connecting  the  pleura  pul- 
monalis  with  the  outer  surface  of  these  organs ; and 
by  the  communication  of  these  cells  with  each  other, 
it  had  produced  a prodigious  swelling  of  the  cellular 
substance  between  the  two  layers  of  the  mediastinum. 
The  emphysema,  in  its  progress,  at  length  made  its  ap- 
I»earance  above  the  clavicles.  The  swelling  of  the 
lungs  and  the  circumjacent  parts,  in  consequence  of 
the  insinuation  of  air  into  the  cellular  substance, 
is  a manifest  cause  of  suffocation.  The  tumefaction 
appears  to  be  so  natural  an  effect  of  the  presence  of  a 
foreign  body  in  the  trachea,  that  one  can  hardly  bwlieve 
it  is  not  an  essential  symptom,  though  before  Louis  no 
author  had  made  mention  of  it. 

Foreign  bodies  in  the  trachea,  however,  do  not  always 
cause  death  so  suddenly,  which  may  be  owing  to  their 
smallness,  their  smoothness,  or  the  situation  in  which 
they  are  fixed.  An  example  is  related  in  the  Kphemer. 
Cur.  Naluroe,  Decad.  2.  Ann.  13.  As  a monk  was 
swallowing  a cherry,  the  stone  of  the  fruit  passed  into 
the  trachea.  A violent  cough  and  excessive  effbrts,  as 
it  were,  to  vomit,  were  the  first  symptoms  of  the  acci- 
dent, and  of  these  the  patient  thought  he  should  have 
died.  A sleep  of  some  hours  followed  this  terrible 


204 


BRONCHOTOMY. 


agitation,  and  the  patient  afterward  d:i  not  feel  the 
least  inconvenience  during  a whole  year.  At  the  end 
of  this  time  he  was  attacked  by  a cough  attended  with 
fever.  These  symptoms  became  worse  ana  worse 
every  day.  At  length  the  patient  evacuated  a stone  as 
large  as  a nutmegT  It  was  externally  composed  of 
tartareous  matter,  to  which  the  cherry-stone  had 
served  as  a nucleus.  A copious  purulent  expecto- 
ration followed  the  discharge  of  the  foreign  body,  and 
the  patient  died  consumptive  some  time  afterward. 
No  mention  is  made  of  the  body  being  opened ; but 
from  the  symptoms,  there  is  every  reason  to  believe, 
that  an  abscess  must  have  arisen  in  the  substance  of 
the  lungs  from  the  presence  of  the  foreign  body.  That 
foreign  bodies  in  the  trachea,  even  when  they  do  not 
induce  pressing  symptoms  of  suffocation,  may  ulti- 
mately kill  the  patient  by  inducing  disease  of  the  lungs, 
is  proved  by  several  cases  on  record,  and  particularly 
by  one  which  occurred  to  Desault : a cherry-stone  was 
lodged  in  one  of  the  ventricles  of  the  larynx  ; the  pa- 
tient would  not  con.sent  lo  an  operation,  and  died  in 
two  years  iTutie  phthisie  laryuge. — (See  (l-uvrcs  Chir. 
de  Desault,  t.  2,  p.  25S.) 

Some  valuable  observations  confirming  the  neces- 
sity of  an  early  recourse  to  bronchotomy,  in  cases 
where  foreign  bodies  are  lodged  in  the  trachea,  have 
been  published  by  Pelletan.  In  one  ca.se,  in  which  a 
bean  had  fallen  into  a child’s  trachea,  and  in  which  the 
most  urgent  sy  mptoms  of  suffocaiion  had  prevailed  for 
four  days,  and  convulsions  during  the  last  thirty-six 
hours  of  this  space  of  time,  Pelletan  performed  the 
operation,  w'hich  a timid  practitioner,  under  whose  ma- 
nagement the  patient  was  first  placed,  had  neglected 
to  do  at  an  earlier  period.  Upon  the  incision  being 
made  into  the  trachea,  the  bean  was  immediately 
thrown  out  to  the  distance  of  two  feet,  and  the  child 
for  a time  was  relieved.  The  little  boy  was  so  ex- 
tremely weak,  that  if  was  at  one  time  supposed  he  was 
dead.  However,  with  some  assistance,  he  gradually 
revived,  even  regained  his  senses,  called  his  parents, 
and  asked  for  such  things  as  he  wanted. 

This  hopeful  state  lasted  eight  or  ten  hours,  after 
which  convulsions  came  on  again,  and  the  child  died 
fourteen  hours  after  the  operation. 

Notwithstanding  the  turgid  appearance  of  all  the 
blood-vessels  of  the  brain,  as  detected  after  death,  the 
little  boy  had  yet  received  a degree  of  relief  at  the  in- 
stant of  the  foreign  body  being  extracted.  Pelletan 
deems  it  unnecessary  to  insist  on  the  great  possibility 
.of  success  that  would  have  attended  the  operation  had 
it  been  performed  at  an  earlier  period. 

Of  sudi  success,  Pelletan  gives  us  the  following  ex- 
ample. 

In  the  month  of  May,  1798,  a child  about  three  years 
.old,  was  brought  to  the  Hotei-Dieu,  who,  in  playing 
.with  some  French  beans,  and  putting  them  into  its 
rniouth,  let  one  of  them  slip  into  the  trachea.  For 
.-^hree  days  the  child  was  afflicted  v/ith  a continued 
.cough,  and  sometimes  the  symptoms  of  suffocation 
•were  most  pres.sing.  The  time  had  been  spent  in  ad- 
ministering emetics,  introducing  instruments  into  the 
oesophagus  with  the  design  of  forcing  the  foreign  body 
.into  the  stomach,  and  in  inspiring  the  relations  with 
a pernicious  confidence,  arising  from  the  very  long 
intervals  of  repose  which  the  child  experienced,  during 
which,  however,  a rattling  in  the  throat  continued,  a 
characteristic  mark  of  the  accident.  Pelletan  imine- 
■diately  decided  to  perform  the  operation.  The  child 
was  very  fat,  and  this  circumstance,  together  with 
the  small  diameter  of  the  trachea  at  this  age,  rendered 
the  exposure  of  the  anterior  portion  of  the  tube  diffl- 
cult.  Pelletan  was  at  this  moment  struck  with  the 
.reflection,  that  bronchotomy  should  never  be  attempted 
except  by  men  of  .science,  coolness,  and  experience  in 
.operations.  The  rings  of  the  trachea,  however,  were 
at  length  cut,  and  there  was  no  sensible  interval  be- 
.tween  the  incision  and  the  expulsion  of  the  foreign 
body.  The  bean  had  swelled  considerably  with  the 
moisture.  The  child  seemed  restored  to  life;  it  spoke 
freely  ; it  was  only  troubled  with  coughing,  the  effect 
of  a small  quantity  of  blood  insinuating  it.self  into  the 
trachea,  which  fluid  was  instantly  rejected  again. 
This  event  has  the  appearance  of  convulsions,  and 
may  alarm  those  who  do  not  understand  it;  but  ac- 
cording to  Pelletan,  it  is  the  guarantee  of  the  patient’s 
life,  by  expelling  incessantly  and  without  difficulty, 
whatever  happens  to  get  into  the  trachea.  The  wound  j 


was  healed  in  twenty  days,  and  the  child’s  voice  wa.s 
not  perceptibly  altered. 

In  another  interesting  case  recorded  by  the  same  wri  • 
ter,  a pebble  was  lodged  in  the  windpipe,  and  the  case, 
not  being  understood,  was  treated  for  about  three  weeks 
as  a simple  inflammation  of  the  lungs.  At  last  bron- 
chotomy was  performed,  and  by  placing  the  child  in  a 
horizontal  position  the  stone  was  soon  discharged 
through  the  incision.  The  patient  was  immediately  re- 
lieved ; but  the  effects  of  the  inflammation  of  the  lungs, 
and  injury  which  these  organs  had  sustained,  could  ne- 
ver be  cured,  and  the  child  died  phthisical  eight  months 
afterward. 

Pelletan  details  other  cases  in  w'hich  the  foreign  body, 
being  fixed  in  the  trachea,  could  not  be  forced  out  by  the 
breath  as  soon  as  the  incision  had  been  made,  but  re- 
quired farther  means  to  disengage  it.  In  one  instance 
Pelletan  made  a long  cut  in  the  windpipe  of  a child; 
but  nothing  made  its  appearance.  A probe,  wrapped 
round  with  some  oiled  linen,  was  then  introduced  seve- 
ral times  U])  and  down  the  larynx  without  creating  a 
great  deal  of  uneasiness,  and  the  child  continued  to  re- 
siiire  very  well  through  the  opening  in  the  trachea.  The 
foreign  substance  was  presently  brought  to  the  wound 
and  extracted  : it  proved  to  be  part  of  the  jaw  of  a mack- 
erel, with  many  sharp  teeth  in  it.  This  child  soon  ex- 
perienced a perfect  recovery. 

In  another  instance,  a young  man  came  to  the  Hotei- 
Dieu,  in  consequence  of  being  afflicted  for  sLx  weeks 
with  a severe  cough,  frequently  accompanied  wdth  a 
sense  of  suffocation.  These  complaints,  on  inquiry, 
were  ascertained  to  arise  from  a button-mould  having 
fallen  into  the  trachea.  An  opening  was  therefore 
made  in  this  tube  ; btit  though  the  button  could  be  felt, 
it  could  not  be  extracted  with  the  finger.  The  cricoid 
cartilage  was  now  divided,  and  the  foreign  body  taken 
out  of  the  left  ventricle  of  the  larynx.  The  man  reco- 
vered. 

In  one  case  related  by  Pelletan,  a piece  of  tendon  of 
veal  got  down  the  glottis,  and  gave  rise  to  most  dan- 
gerous symptoms.  The  foreign  body  was  described 
as  being  so  large  that  this  surgeon  could  not  but  sup- 
pose that  the  complaints  were  owing  to  its  lodgement 
in  the  oesophagus,  as  it  seemed  to  be  incapable  of  en- 
tering the  glottis.  The  introduction  of  instruments 
down  the  pharynx,  however,  produced  do  relief ; but, 
on  dividing  the  thyroid  cartilage,  Pelletan  passed  his 
finger  within  the  larynx,  and,  wdthout  knowing  it, 
pushed  the  piece  of  tendon  towards  the  glottis,  when, 
with  the  aid  of  a probang,  it  was  forced  into  the  pha- 
rynx and  swallowed.  The  patient  experienced  imme- 
diate relief,  and  got  quite  well. — {Clinique  Chir.  t.  1.) 

With  respect  to  bronchotomy  or  laryngolomy,  for 
cases  in  which  extraneous  substances  are  supposed  to 
be  lodged  in  the  trachea,  one  imiiortant  caution  seems 
necessary,  viz.  whenever  the  foreign  bo<!y  is  above  a 
certain  size,  a probang  should  be  passed  down  the  oeso- 
phagus before  the  windpipe  is  opened,  for  very  simi- 
lar symptoms  to  those  which  proceed  from  extraneous 
substances  in  the  trachea  may  be  caused  by  the  lodge- 
ment of  foreign  bodies  in  the  tesophagus.  In  (act, 
bronchotomy  has  actually  been  performed,  while  the 
extraneous  substance  was  in  the  tesophagus,  from 
which  last  situation  no  attempt  was  made  to  displace 
it,  and  the  patient  lost  his  life. — See  (huvres  Chir.  de 
Desault,  t.  2,  p.  261.)  Examjiles  in  which  various  e,\- 
traneous  bodies  have  been  successfully  extracted  by 
means  of  bronchotomy,  are  recorded  by  Engel.— (6'end- 
schreiben  an  Schmid,  lVc.  Augsp.  1750;  Guinea  art, 
Joum.  de  Med.  vol.  12.  p.  44 ; Heister,  Wahmthmvn- 
ge'ti,  b.\,  p.  1026;  Wendt.  Hist.  TVacheotomKe,  iS  c., 
Urastisl.  1774.  Dr.  Hunt,  in  Med.  Chir.  Trans,  vol. 
12,  cvc.) 

4.  Bronchotomy  has  been  proposed  in  cases  in  which 
the  tongue  is  so  enlarged  as  totally  to  shut  up  the  ])as- 
sage  through  the  fauces  Richter  mentions  an  inflam- 
mation of  the  tongue,  in  which  it  became  four  times 
larger  than  in  the  natural  state.  Valescus  had  made 
the  same  observation  ; “ Ego  aliquando  vidi  itd  inagni- 
Jicatam  linguam  propter  humnres,  ad  ejus  substantiam 
venientes,  et  ipsam  i7nbibentes,quod  quasi  totum  os 
replebat,  et  aliquando  ex  ore  exibat."—{Lib.  2,  cap.  66.) 
Such  prodigious  swellings  of  the  tongue  are  said  somt^ 
times  to  occur  in  malignant  fevers  and  the  small-pox. 
'I'hey  are  also  sometimes  quite  accidental,  as,  for  in- 
stance, the  cases  which  happen  from  the  stings  of  in- 
sects, or  the  unskilful  einploynieiit  of  meicury.  Mr 


BRONCHOTOMY. 


205 


B.  Bell  gives  an  example  of  the  latter  sort.  He  says, 
that  the  patient  had  taken  in  a very  short  time  so  large 
a quantity  of  mercury,  that  the  part  became  alarmingly 
swollen  ina  few  hours,  and,  though  all  the  usual  reme- 
dies were  tried,  none  had  the  least  effect.  Broiicho- 
tomy  was  delayed  till  the  patient  was  nearly  suffoca- 
ted ; but  he  was  restored  as  soon  as  an  opening  wnis 
made  in  the  trachea.  Some  have  objected  to  thi.s  prac- 
tice, alleging  that  scarifying  the  tongue  will  bring  relief 
in  lime. i.ie  Methodique : partie  Chirur- 
gicale,  art.  Bronthotomie.)  Malle’s  observations  on 
the  swelling  of  the  tongue,  and  the  most  effectual 
means  of  relieving  it,  seem  to  confirm  the  latter  senti- 
ment.- -{Mem.  de  I’ Acad,  de  Chirurgie,  1. 14,  p.  408,  A c. 
edit,  in  \.‘Zmo.) 

In  cases  of  the  preceding  description,  Desault  would 
have  advised  the  introduction  of  an  elastic  gum  cathe- 
ter from  the  nose  into  the  trachea,  in  order  to  enable 
the  patient  to  breathe,  until  the  swelling  of  the  tongue 
had  subsided.— (See  ttuvres  Chir.  de  Desault,  t.  2, 
p.  246.) 

5.  Bronchotomy  has  been  recommended  when  both 
the  tonsils  are  so  enlarged  as  very  dangerously  to  im- 
pede respiration.  Here  the  inflammatory  swelling  is 
not  meant ; this  commonly  soon  suppurates,  and  the 
spontaneous  bursting  of  the  tumour,  or  the  opening  of 
it  with  a pharyngotomus,  generally  removes  all  neces- 
sity for  so  extreme  a measure.  But  even  in  acute  in- 
flammation and  great  enlargement  of  the  palate,  tonsils, 
«&c.  attended  with  imminent  danger  of  suffocation,  the 
practice  has  been  sometimes  deemed  necessary,  as  the 
cases  cited  from  Flajani  in  the  preceding  columns  are 
sufficient  to  prove.  The  disease,  however,  which  I 
here  wish  particularly  to  specify,  as  sometimes  render- 
ing bronchotomy  indispensable,  is  a chronic  enlarge- 
ment of  the  tonsils,  the  case  mentioned  in  the  article 
Tonsils.  From  the  remarks  on  the  disease,  however, 
it  will  be  seen  that  more  is  to  be  expected  from  the  ex- 
cision of  the  ton.sils  than  from  the  operation  now  in 
question.  Besides,  before  the  glands  are  so  large  as  to 
threaten  suffocation,  they  should  be  cut  away  m pre- 
ference to  performing  bronchotomy,  which  might  re- 
lieve the  urgency,  but  could  not  remove  the  cause  of 
the  difficulty  of  breathing.  In  general,  there  is  no  ur- 
gent dangerof  suffocation  till  the  swelling  is  such  as  not 
only  to  shut  up  the  posterior  aperture  of  the  mouth, 
but  also  the  posterior  openings  of  the  nostrils,  which 
is  exceeilingly  rare.  In  cases  of  obstructed  respiration 
from  enlargement  of  the  tonsils,  Desault  preferred  'he 
introduction  of  the  elastic  catheter  from  the  nose  into 
the  larynx,  to  the  operation  of  bronchotomy.  It  is  not 
common  for  a polypus  to  make  this  operation  neces- 
sarj'.  Boerhaave,  however,  mentions  a case,  in  which 
the  patient  was  suffocated  as  the  surgeon  was  going 
to  extirpate  a tumour  of  this  kind  ; no  doubt  this  pa- 
tient might  have  been  saved  if  bronchotomy  had  been 
previously  performed.  Polypi  growing  in  the  larynx 
itself  arc  very  rare,  but  examples  are  recorded;  and  if 
such  tumours  happen  to  obstruct  the  glottis  the  pa- 
tients are  instantly  suffocated.  Some  instances  of  this 
kind  are  related  by  Bichat.  The  only  mode  of  getting 
at  such  swellings  so  as  to  extirjiate  them,  is  by  per- 
forming bronchotomy.— (See  lEuvres  Chir.  de  Desault, 
t.  2,  p.  254,  255.) 

6.  Lastly,  bronchotomy  has  been  recommended  to 
be  done  on  persons  recently  suffocated  or  drowned. 
Detharding  is  the  first  author  who  has  treated  of  the 
necessity  of  this  operation  in  the  latter  case,  in  a letter 
addressed  to  Schroeck,  entitled  De  Methodo  suhveni- 
eiuti  SuOmersis  per  Larijngotomiam.  Haller  aiijiroves 
of  the  practice,  provided  the  mucous  secretion  with 
which  the  lungs  are  loaded  should  require  to  be  dis- 
charged in  tlii.s  manner.  Detharding  maintains  that 
drowned  persons  have  no  water  in  their  chests  or  air- 
vessels  of  the  lungs,  and  that  they  perish  suffocated 
for  want  of  air  and  respiration,  and  that  while  the 
person  is  under  water  the  epiglottis  ajiplies  itself  so 
closely  over  the  glottis,  that  not  one  drop  of  water  can 
pa.s.s.  But  these  as.sertions  are  quite  contrary  to  nu- 
merous experiments  made  by  Louis,  who  drowned  ani- 
mals in  coloured  fluids,  and  jiroved  that  such  as  are 
drowned  insjiire  water,  with  which  the  air-vessels  and 
cells  are  quite  filled.  Louis  also  ojiened  men  who  hud 
perished  under  water,  but  in  them  he  never  found  tlie 
epiglottis  applied  to  the  glottis  in  the  manner  described 
by  Detharding ; indeed,  anatomy  proves  the  iinpossi- 
bdilj  of  its  being  so.  Dotharding’s  theories  w'ere 


wrong,  and,  as  he  did  not  use  any  power  to  distend  the 
lungs  with  air,  his  mere  practice  of  bronchotomy  must 
have  been  useless.  When  there  is  a free  communica- 
tion betw'een  the  cells  of  the  lungs  and  the  atmosphere, 
the  air  will  not  expand  these  organs  if  the  inspiratory 
muscles  can  no  longer  act.  Hence,  after  opening  the 
trachea,  and  letting  as  much  w'ater  run  out  of  this  tube 
as  possible,  the  pipe  of  a pair  of  bellows  should  be  in- 
troduced, and  the  air  blown  into  the  lungs. 

Detharding  was  right  in  his  opinion,  that  drowning 
is  a species  of  suffocation,  and  that  the  privation  of 
oxygen  gas  is  the  cause  of  death.  Hence  the  propriety 
of  introducing  air  into  the  lungs  as  speedily  as  possible, 
whenever  animation  has  not  been  so  long  suspended 
that  every  hope  of  restoration  is  over.  Indeed,  it  is 
proper  to  distend  the  lungs  with  air  in  all  cases  in 
which  animation  has  been  recently  suspended  by  suf- 
focation, immersion  under  water,  or  by  noxious  va- 
pours and  gases.  This  measure  is  highly  proper,  m 
conjunction  with  electricity  or  galvanism;  the  com- 
munication of  warmth  to  the  body  ; the  application  of 
strong  volatiles  to  the  nostrils  ; rubbing  the  body  w’ilh 
warm  flannels ; and  the  injection  of  warm  wine  or 
brandy  and  water  into  the  stomach  through  a hollow 
bougie.  However,  tobacco  clysters,  which  have  had 
the  sanction  of  the  Royal  Humane  Society,  should  be 
reprobated,  as  the  qualities  of  this  plant  are  peculiarly 
destructive  of  the  vital  principle,  and  not  simply  sti- 
mulating. lam  sorry  to  find  this  last  means  com- 
mended by  so  respectable  a surgeon  as  Baron  Larrey, 
who  joins  the  rest  of  the  French  surgeons  in  condemn- 
ing electricity  and  bronchotomy.  He  speaks  in  favour 
of  opening  the  jugular  vein,  ex]iosing  the  body  to  the 
fire,  friction,  &c.  On  dissecting  the  bodies  of  some 
drowned  persons,  Larrey  found,  as  Louis  had  done  long 
since,  that  the  air-tubes  of  the  lungs  were  filled  with 
water  inst  ad  of  air,  and  that  the  epiglottis  was  rai.sed 
and  applied  to  the  os  hyoides.— (See  Mmoires  de  Chir 
Militaire,  t.  \,p.  83—85. 

There  are  many  modern  practitioners  wdio  consider 
bronchotomy  needless  in  cases  of  suspended  animation, 
because  it  is  contended,  that,  as  the  patient  is  always 
destitute  of  sensation,  a tube  may  easily  he  passed  into 
the  trachea  from  the  nose  or  mouth,  for  the  purpose 
of  inflating  the  lungs.  Either  the  curved  pipe  of  a 
pair  of  bellows  may  be  introduced  into  the  glottis 
through  the  mouth,  or  an  elastic  gum  catheter  may  be 
passed  into  the  trachea  from  the  nose.  “ On  pent 
inettre  ce  inuyen  a.  ea^cution  (.-ays  Pelleian)  c/iei  its 
asphijii^s,  ou  lc.s  evfans  vovveavx  lies,  quiverespi- 
rentpas ; pareeque,  dans  ccs  dijfcreiis  cas  non  stulc- 
ment  il  n'y  a pas  d'iiijlamwiition,  viais  ntime  ton  te  stn- 
sibilile  est  suspendiie,  et  la  cnniile  est  coniniude  pour 
suofficr  de  V air  dans  Ics  poumvns,  en  tneme  temps 
qid tile  pent  causer  une  irritation  sulutaire.  M.  Bua- 
deloque,  mon  cilebre  cunfiere,  m'a  temoigne  se  servir 
habituellement,ct  uvee  succis  de  ce  inayeu  pour  appeler 
a,  la  vie  les  nouveaux  nes  dont  la  respiration  ne  s'ct.a-. 
blitpas." — {Ciiiiique  Chir- t.  1,  p.'iQ.)  Desault  like- 
wise conceived,  that  the  lungs  might  be  easily  inflated 
wdthout  performing  bronchotomy.— (tAi/nm-  Chir.  t. 
2,  p.  339.)  Mr.  A.  Burns  adopts  the  same  sentiment. — 
(Surgical  Anatomy  of  the  Head  and  Neck,  p.  384.) 
My  own  individual  opinion  upon  this  subject  is,  that  if 
a surgeon  knows  that  he  can  inflate  the  lungs  as  coin- 
jiletely  and  expeditiously  without  perlbrrning  broncho- 
tomy, as  he  can  by  making  an  incision  in  the  trachea, 
he  is  right  in  dispensing  with  the  latter  operation.  But 
in  the  generality  of  cases  of  suspended  animation  (that 
of  new-born  infants  excepted,  where  bronchotomy 
would  be  an  objectionable  undertaking),  I much  doutg 
whether  in  actual  practice  bronchotomy  will  not  bo 
found  the  best  and  most  speedy  means  of  enabling  the 
surgeon  to  distend  the  lungs  with  air.  If  you  (bilow 
Desault’s  suggestion,  I contend  that  you  are  likely  to 
be  some  minutes  longer  in  getting  the  ela.stic  ciitlieu  r 
from  the  right  nostril  into  the  larynx,  than  you  wouid 
be  in  cutting  into  the  trachea  and  introducing  into  the 
incision  the  rnurale  of  a pair  of  bellows.  Supposing 
the  elastic  catheter  introduced,  will  you  now  be  ablcto 
distend  the  lungs  with  air  in  an  adeijuale  degree,  an 
object  of  the  highest  moment  ? A pair  of  bellows  .seein.s 
to  me  almost  es.sential  to  this  'purjiose.  I shall  say  no- 
thing on  the  probaliility  of  many  inactitioncrs  corning 
to  the  patient  unjirovided  with  the  requisite  sort  ol  tube. 

If  a pair  of  bellows  with  a curved  pipe  be  einjiloyed, 
many  surgeons  would  be  a considerable  time  in  getting 


£06 


BRONCHOTOMY. 


the  nozzle  into  the  glottis  ; and,  in  the  mean  while, 
every  spark  of  life  might  be  extinguished.  On  the 
other  hand,  bronchotomy  (performed  by  a m in  of  ordi- 
nary care  and  skill)  is  an  operation  free  from  danger. 
It  may  be  executed  with  a penknife  if  no  better  instru- 
ment be  at  hand  ; and  when  the  incision  has  been 
made,  a pair  of  common  bellows  will  suffice  for  the  in- 
flation of  the  lungs.  Did  I conceive  that  bronchotomy 
were  a perilous  operation ; that  the  lungs  could  be 
effectually  distended  without  the  employment  of  bel- 
lows ; that  the  object  could  generally  be  accomplished 
as  expeditiously  without  cutting  into  the  trachea  ; 1 
should  be  as  ready  to  join  in  the  condemnation  of  tliis 
last  proceeding  as  any  contemporary  writer.  Greatly, 
however,  as  I respect  most  of  the  authors  who  differ 
from  me  on  this  point,  the  reasons  I have  assigned  pre- 
vent me  from  subscribing  to  their  sentiment.  Desault, 
who  may  be  regarded  as  the  founder  of  the  doctrine, 
concerning  the  inutility  of  bronchotomy,  it  is  also  to  be 
observed,  spoke  only  from  theory,  and  not  actual  prac- 
tice, in  these  cases. 

With  respect  to  the  performance  of  the  operation,  no 
preparation  is  necessary,  as  delay  only  increases  the 
danger.  The  patient  being  seated  in  an  arm-chair,  or, 
what  is  better,  laid  on  a bed,  with  his  head  hanging 
backwards,  an  incision  is  to  be  made,  which  is  to  begin 
below  the  cricoid  cartilage,  and  to  be  continued  down- 
wards about  two  inches,  along  the  space  between  the 
sterno-thyroidei  muscles.  Care  should  be  taken  not 
to  cut  the  lobes  of  the  thyroid  gland,  lest  a trouble- 
some and  dangerous  bleeding  be  occasioned ; and,  as 
the  left  subclavian  vein  lies  a little  below  the  upper 
part  of  the  first  bone  of  the  sternum,  the  incision 
should  never  extend  so  low  as  this  point.  The  knife 
must  not  be  carried  either  to  the  right  or  left,  in 
order  to  avoid  all  risk  of  injuring  the  large  blood- 
vessels situated  at  the  sides  of  the  trachea.  The  inci- 
sion in  the  integuments  having  been  made,  the  sterno- 
thyroidei  muscles  are  to  be  pushed  a little  towards  the 
sides  of  the  neck,  so  as  to  bring  the  trachea  fairly  into 
view.  Many  authors  recommend  the  point  of  the  knife 
to  be  then  introduced  betw'een  the  third  and  fourth 
cartiltige  of  the  trachea,  and  the  opening  to  be  enlarged 
transversely.  It  is  true  that  in  this  w’ay  an  opening 
may  be  safely  made,  large  enough  to  allow  a small 
cannula  to  be  introduced.  It  is  safer,  however,  in  all 
cases,  to  enlarge  the  opening  in  the  perpendicular  di- 
rection, by  cutting  from  within  outwards.  There  is  no 
advantage  in  avoiding  a wound  of  the  cartilages  of  the 
trachea,  the  only  reason  assigned  for  cutting  the  mem- 
brane between  them,  in  a transverse  direction  ; while 
a sufficiently  large  opening  cannot  thus  be  safely  ob- 
tained, in  cases  m which  it  is  necessary  to  introduce 
the  nozzle  of  a pair  of  bellows,  in  order  to  inflate  the 
lungs.  In  short,  it  is  safer  and  better  in  every  in- 
stance, to  make  the  wound  in  the  trachea  in  a perpen- 
dicular manner. 

I have  stated,  that  bronchotomy  may  be  performed 
by  a man  of  ordinary  skill  without  hazard.  It  is  far 
otherwise  wnth  a careless  practitioner.  We  read  in 
Desault’s  work,  that  in  one  instance  the  carotid  artery 
was  wounded.  The  follownng  cautions,  given  by  Mr. 
A.  Burns,  seem  entitled  to  notice.  “ The  arteria  in- 
nominata  is  in  risk  in  some  subjects.  I have  seen  it 
mounting  so  high  on  the  forepart  of  the  trachea,  as  to 
reach  the  lower  border  of  the  thyroid  gland.  Even  the 
right  carotid  artery  is  not  always  safe.  I am  in  pos- 
session of  a cast,  taken  from  a boy  of  twelve  years  of 
age,  which  shows  the  right  c.arotid  artery  crossing  the 
trachea  in  an  oblique  direction.  In  this  subject,  that 
vessel  did  not  reach  the  lateral  part  of  the  trachea  till 
it  had  ascended  two  inches  and  a quarter  above  the 
top  of  the  sternum. 

Where  both  carotid  arteries  originate  from  the  ar- 
teria innominata,  there  is  considerable  danger  in  per- 
forming the  operation  of  tracheotomy  ; for  in  such 
cases,  the  left  carotid  crosses  the  trachea  pretty  high 
in  the  neck.  Professor  Scarpa  has  seen  a specimen  of 
this  distribution  in  a male  subject,  and  I have  met  with 
five. 

These  varieties  in  the  course  of  the  arteries  are 
worthy  of  being  known  and  remembered ; they  will 
teach  the  operator  to  be  on  his  guard,  since  he  can 
never,  « priori,  ascertain  the  arrangement  of  the  ves- 
sels with  any  degree  of  certainty.  It  will  impress  on 
his  mind  the  impropriety  of  using  the  knife  farther 
than  merely  to  divide  the  integuments  and  fasciae.  If 


he  then  clear  the  trachea  with  the  fingers,  he  wdil 
never  injure  any  of  the  large  arteries.  When  with  the 
finger  he  has  fairly  brought  the  trachea  into  view,  he 
ought  to  examine  carefully,  whether  any  of  the  large 
arteries  lie  in  front  of  it ; and  if  he  find  one,  he  ought 
to  depress  it  towards  the  chest,  before  he  penetrates 
into  the  windpipe. 

In  cutting  into  the  trachea,  the  preferable  plan  is 
to  cut  the  rings  from  below  upwards,  avoiding  injury 
of  the  thyroid  gland.”— (See  A.  Bums  on  the  Surgical 
Anatomy  of  the  Head  aiid  Neck,  p.  393,  394.) 

As  Mr.  Francis  \\  hiie,  of  Dublin,  was  performing 
tracheotomy  in  a case  of  cynanche  laryngea,  “on  sepa- 
rating the  edges  of  the  sterno-thyroid  muscles,  the  two 
thyroid  veins  were  exposed,  together  with  a considera- 
ble arterial  branch,  the  pulsation  of  which  was  quite 
perceptible,  directing  its  course  upwards  towards  the 
cross-slip  of  the  thyroid  gland.”  Mr.  White  stales, 
that  the  artery  here  spoken  of  was  the  branch  which 
Mr.  Harrison  in  his  work  on  the  Surgical  Anatomy  of 
the  Arteries,  describes  under  the  appropriate  name  of 
middle  thyroid  artery  ; and  though  looked  upon  as  an 
irregular  distribution,  it  is  sufficiently  frequent  to  make 
it  necessary  for  the  surgeon  to  be  upon  his  guard.— (See 
Dublin  Hospital  Reports,  vol.  4,  p.  563.) 

When  bronchotomy  is  performed  for  the  purpose  of 
inflating  the  lungs,  the  cut  in  the  windpipe  must  be 
made  somewhat  larger  than  when  an  opening  is  re- 
quired merely  to  enable  the  patient  to  breathe  through 
a small  cannula.  The  larger  size  of  the  pipe  of  the 
bellows  is  the  reason  of  this  circumstance. 

When  a cannula  is  introduced,  care  must  be  taken 
not  to  pass  it  too  far  into  the  wound,  lest  it  injure  tlie 
opposite  side  of  the  trachea.  This  is  a caution  on 
which  Fabricius  ab  Aquapendente  dwells  very  strongly, 
and  with  good  reason. 

When  tracheotomy  has  been  performed  in  a case 
where  mucus  is  secreted  in  such  abundance,  that  the 
patient  is  threatened  with  sufiocation  from  its  accu- 
mulation, and  his  inability  to  cough  it  up,  owing  to 
the  wound  in  the  wdiidpipe.  Dr.  Cullen  is  an  advocate 
for  the  use  of  a large  cannula  for  the  sake  of  permit- 
ting free  expiration,  the  only  substitute  for  coughing, 
which  the  patient  can  no  longer  effect.— (See  Edin. 
Med.  Journ.  No.  94,  p.  82.) 

Small  as  the  vessels  may  be  w'hich  are  divided  in 
bronchotomy,  they  occasionally  bleed  so  much  as  to 
create  apprehension,  and  even  prevent  the  continuance 
of  the  operation.  There  is  a case  in  Van  Swieten’s 
Commentaries  confirming  this  remark.  A Spanish 
soldier,  aged  tw’enty-three,  was  in  the  most  urgent 
danger  from  an  inflammation  of  his  throat.  It  was 
thought  nothing  could  save  him  except  bronchotomy. 
After  the  longitudinal  cut  in  the  skin,  and  the  separa- 
tion of  the  muscles,  the  trachea  was  opened  between 
two  of  the  cartilages;  but  the  blood  insinuated  itself 
into  this  canal,  and  excited  so  violent  a cough,  that  the 
cannula  could  not  be  kept  in  by  any  means,  though  it 
was  replaced  several  times.  Louis  remarks,  that  in 
this  instance  the  patient’s  head  should  have  been  turned 
downwards,  in  order  to  keep  the  Mood  from  flowing 
backwards  into  the  trachea.  It  is  asserted,  that  the 
opening  of  this  tube  was  not  always  opposite  the  ex- 
ternal wound,  in  consequence  of  the  convulsive  action 
of  the  muscles,  and  that  the  patient  on  this  account 
could  hardly  breathe.  Hence,  Vigili  was  induced  to 
slit  open  the  trachea,  dowm  to  the  sixth  cartilaginous 
ring ; and  it  was  only  then  that  he  inclined  the  pa- 
tient’s head  forwards.  The  bleeding  now  ceased,  the 
patient  breathed  whih  ease,  and  on  the  second  day 
the  inflammation  was  so  much  better,  that  respira- 
tion went  on  without  the  aid  of  the  opening  in  the 
trachea. 

The  most  simple  and  natural  mode  of  obviating  all 
trouble  from  the  entrance  of  blood  into  the  trachea,  is 
to  tie  any  bleeding  branch  of  the  thyroid  arterj’  or  vein 
before  the  windpipe  is  openeff. 

Sometimes  the  cannula  becomes  obstructed  with 
mucus  or  clots  of  Mood.  Such  an  accident  nearly  suf- 
focated a patient  at  Edinburgh.  An  ingenious  jierson 
happening  to  be  at  hand,  suggested  the  introduction  of 
a second  cannula  into  the  first ; the  second  one  being 
taken  out  and  cleaned  as  often  as  necessary,  and  then 
replaced. 

The  use  of  the  cannula  must  be  continued  as  long 
as  the  causes  obstructing  resiuraiion  remain.  Thus, 
in  one  very  interesting  case  of  cynanche,  detailed  in  a 


BRONCHOTOMY. 


207 


modern  publication,  the  patient,  thirteen  months  after 
the  operation,  had  not  been  able  to  discontinue  the 
tube. — (See  Med.  Chir.  Journ.  vol.  5,  p.  7.)  This  ex- 
ample was  attended  in  its  progress  with  a singular 
circumstance,  viz.  the  expulsion  through  the  cannula 
of  several  portions  of  calcareous  matter  or  bone.  In 
the  case  operated  upon  by  Mr.  F.  White,  the  tube  had 
been  worn  two  years ; and  in  the  well-known  case  of 
Mr.  Price  of  Plymouth,  the  instrument  had  been  worn 
ten  years.— (See  Dublin  Hospital  Reports,  vol.  4,  p.  5fi5, 
566.) 

When  respiration  is  suspended  by  the  presence  of  a 
foreign  body  in  the  trachea,  and  the  extraneous  sub- 
stance does  not  make  its  appearance  at  the  opening,  a 
trial  may  be  made  to  discover  its  situation  by  means 
of  a bent  probe.  When  it  lies  downwards,  which  it 
hardly  ever  does,  the  wound  in  the  trachea  may  be 
enlarged  in  this  direction,  and  the  body  extracted  with 
a pair  of  curved  forceps.  The  extraneous  substance  is 
mostly  forced  out  by  the  air,  as  soon  as  the  incision  in 
the  trachea  is  opened.  When  it  cannot  be  immediately 
found,  some  practitioners  (Heister  and  Raw)  have 
succeeded  by  keeping  the  lips  of  the  w'ound  asunder 
with  a leaden  cannula,  by  which  means  the  force  of 
the  air  m expiration  has  in  a few  hours  expelled  the 
foreign  body. 

Richter  gave  the  preference  to  a curved  cannula  ; 
and  since  his  time  many  surgeons  have  chosen  to  use 
such  an  instrument,  though  if  it  be  double  the  inner 
lube  cannot  be  so  easily  introduced  as  that  of  a straight 
one  ; and  no  doubt  the  chief  disadvantage  of  the  latter 
has  often  proceeded  from  its  having  been  made  of  too 
great  length. 

In  some  instances,  like  that  referred  to  above,  a can- 
nula has  been  borne  quietly  in  the  trachea;  while  in 
others,  it  has  produced  so  much  irritation,  cough,  and 
sense  of  choking,  as  to  render  its  immediate  removal 
necessary.  Mr.  Lawrence,  in  speaking  of  the  obstruc- 
tion of  the  glottis  from  the  disease  already  adverted  to 
in  this  article,  observes,  that  when  the  cannula  causes 
inconvenience,  he  should  advise  a longitudinal  inci- 
sion, of  about  half  an  inch,  in  the  middle  of  the  trachea, 
and  the  removal  of  a thin  slip  of  the  tube,  which  would 
leave  an  artificial  opening  for  respiration,  equal  in  size 
to  the  natural  one. — (See  Med.  Chir.  Trans,  vol.  6, 
p.  249.)  The  same  plan  was  Ibilowed  by  Mr.  F.  White, 
and  is  also  sanctioned  by  Mr.  Carmichael. — (See  Dub- 
lin Hospital  Reports,  vol.  4,  p.  563,  iS-c.,  and  Trans,  of 
Assoc.  Physicians,  vol.  3,  p.  174.)  When  this  prac- 
tice is  not  adopted,  Mr.  Carmichael  recommends  the 
use  of  as  large  a cannula  as  can  be  introduced. 

On  the  continent  the  operation  of  laryngotomy, 
which  was  first  advised  by  Vicq  d’Azyr,  and  recom- 
mended by  Desault,  is  frequently  preferred  to  trache- 
otomy. The  surgeon  makes  an  incision  over  the  ante- 
rior part  of  the  thyroid  cartilage,  punctures  the  cri- 
co-thyroid  membrane,  and,  if  it  be  necessary,  intro- 
duces a director  and  slits  the  thyroid  cartilage  up- 
wards. A single  opening  in  the  crico-lhyroid  mem- 
brane would  suffice  for  the  introduction  of  a cannula 
for  ihe  purpose  of  enabling  the  patient  to  breathe ; but 
for  the  extraction  of  foreign  bodies  it  would  be  neces- 
sary also  to  cut  the  thyroid  cartilage.  The  fact  that 
extraneous  substances,  when  they  are  loose,  are  almost 
always  lodged  at  the  upper  part  of  the  larynx,  proves 
that  laryngotomy,  in  such  cases,  must  commonly  be 
most  advantageous ; and  according  to  Desault,  even 
when  the  foreign  bodies  are  lower  down  in  the  tra- 
chea, they  may  in  general  be  most  easily  extracted  with 
the  aid  of  a pair  of  curved  forceps.  In  this  country 
laryngotomy  has  been  less  commonly  practised,  though 
commended  a few  years  since  by  Mr.  Coleman,  and 
more  recently  by  Mr.  C.  Bell. 

“ Of  the  three  situations  (says  Mr.  Lawrence),  in 
which  it  has  been  propo.sed  to  make  the  opening,  viz. 
in  the  thyroid  cartilage,  between  that  and  the  cricoid, 
or  in  the  trachea,  I consider  the  first  as  the  least  eligi- 
ble. Besides  the  objection  from  the  ossification  of  the 
cartilage,  and  the  danger  of  wounding  or  otherwise 
injuring  the  chorda?  vocales,  there  is  the  inconvenience 
in  the  case  of  angyna  laryngea,  arising  from  the  swollen 
and  thickened  stale  of  the  membrane,  which  may  ac- 
tually impede  the  passage  of  the  air.  I am  not  aware 
of  any  objection  to  a trarusverse  opening  between  the 
thynud  and  cricoid  cartilages.  The  prominence  of  the 
forroL-r  in  the  neck  serves  a.s  a guide  to  the  part  which 
should  be  opened.  Whether  bronchotomy  or  laryngo- 


tomy ought  to  be  selected,  must  of  course  depend  upon 
the  nature  of  the  case  : in  cases  of  cynanchc,  the  prox- 
imity of  the  inflamed  parts  w’ould  be  an  objection  to 
laryngotomy ; while  in  examples  of  foreign  bodies 
within  the  glottis  this  operation  may  generally  be  most 
advisable  for  reasons  already  explained.  It  is  absurd 
to  think  of  confining  one  mode  of  operating  to  differ- 
ent cases.” — (See  Medico-Chir.  Trans,  vol.  6,  p.  2-16.) 

Of  the  operation  performed  in  the  membranous  space 
Mr.  C.  Bell  entertains  a favourable  opinion.  He  directs 
us  to  slit  up  the  membrane  and  open  the  incision  with 
the  handle  of  the  knife,  when  the  patient  will  immedi- 
ately breathe  with  ease.  Here,  says  he,  there  is  no- 
thing to  alarm  the  most  timid  operator.  No  great  tur- 
gid veins  are  opened ; the  cut  is  made  above  the  thyroid 
gland,  and  above  the  anastomo.sing  branch  of  the  thy- 
roid arteries.  The  part  is  strongly  marked  by  the  pro- 
minence of  the  thyroid  cartilage  above,  and  the  ring 
of  the  cricoid  cartilage  below.  “ If  the  occasion  be 
temporary,  a simple  slit  of  the  membrane  will  be  found 
sufficient.  If  necessary,  a transverse  cut  will  afford 
any  degree  of  opening.  If  a round  bole  be  desired,  the 
four  comers  left  by  the  incisions  may  be  snipped  off,” 
or  the  edges  of  the  opening  may  be  kejit  asunder  by 
means  of  the  double  vrire  of  a catheter,  the  middle  part 
of  which  lies  on  the  wound,  w'hile  the  ends  are  bent 
round  the  neck  and  tied  by  a ligature  behind.  In  Mr, 
C.  Bell’s  cases,  less  annoyance  was  caused  by  this 
contrivance  than  by  a tube 

[Bronchotomy  is  frequently  performed  in  this  coun- 
try for  the  removal  of  foreign  bodies  from  the  trachea, 
but  seldom  with  any  other  intention.  The  situation 
most  generally  selected  is  between  the  thyroid  and 
cricoid  cartilages.  Sometimes  the  foreign  body  es- 
capes through  the  wound,  or  may  be  extracted  by  the 
forceps  ; at  other  times,  so  soon  as  the  air  is  admitted 
into  the  lungs,  the  fbree  of  the  respiration  expels  it 
through  the  mouth.  I have  known  several  cases  in 
which,  although  the  operation  afforded  immediate  relief 
to  the  respiration,  yet  the  escape  of  the  foreign  body 
did  not  take  place  for  several  hours ; and  in  one  in- 
stance days  had  elapsed,  when  it  was  coughed  up  with 
great  violence.— Reese.] 

Hevin  sur  les  Coips  Etravgers  qui  sont  arrSt^s 
dans  les  premieres  Votes,  ct  qu'il  font  tircr  pur  Inci- 
sion, in  Mem.  de  I'Jicad.  Ruyale  de  Chirurgie,  t.  3,  p 
131,  (Sc.  edit.  12/rto.  Eoais,  Mernoire  svr  une  Ques- 
tion Jinatomique  relative  d In  jurisprudence,  on  Von 
dtablit  les  prmcipes  pour  distinguer,  d Vinspection 
d'un  corps  trouvi  pendu,  les  signes  dv  suicide,  d'avec 
ceux  de  V assussinat.  Habicot,  Question  Chirurgi- 
cale,  par  loquelle  il  est  demnnti  ^ que  le  Chirurgjen 
doit  assurement  pratiquer  V Opei  ation  de  la  Broncho- 
tomie,  Src.,  12mo.  Pans  1620.  Louis,  AUmoire  sur 
la  Bronchotomie,  in  Mem.  de  VAcad.  de  Chirurgie,  t. 
12,  edit.  12me.  Second  Memoir  on  this  subject,  in- 
serted by  the  same  writer  in  the  said  volume.  De  la 
Rescission  des  Amygdales,  t.  14,  p.  263,  ;<S'C.  Precis 
d'  Observations  sur  le  Gouflement  de  la  J.,angue,  d c. 
par  M.  de  la  Alalle,  t.  14,  p.  408.  J^escure,sur  un  por- 
tion d'Amande  de  JVuyau  d'Ahricot  dans  la  Trachee 
Artere,  t.  14,  p.  427.  Suite  d'  Observations  sur  les 
Corps  Etravgers  dans  la  TraclUe  Artere,  t.  14,  p.  432. 
Experiences  sur  les  Cos,  par  M.  E'avier,  t.  14,  p.  445. 
De  la  Alartimere,  sur  les  Corps  Etravgers,  dans  la 
Trochee  Artire,  op.cit.t.  5,  4to.  Bertrandi,  'Jraite 
des  Operations  de  Chirurgie,  p.  402,  ifc.  edit.  1764. 
Sabatier,  de  la  Medecine  Opiratoire,  tom.  2,  p.  283, 
edit.  1.  (Eurres  Chir.  de  Desault,  par  Bichat,  t.  2,  p. 
236,  (S'C.  Pelletan,  Clinique  Chirurgicale,  t.  1,  first 
Memoir.  Che/yne,  Pathology  of  the  J.,arynx  and  Bron- 
chia, Edin.  1809.  A.  Burns,  Surgical  Anatomy  of 
the.  Head  and  JVeck,  p.3n~-40\.  .7.  E.  Double,  Traite 
du  Croup,  8vo.  Pans,  1811.  Richter's  An fangsgi  Unde 
dec  Wundarineylcunst,  b.  4,  p.  225,  dee.,  (i  bttivgev, 
1800.  Lawrence  on  some  affections  of  the  larynx 
which  require  the  operation  of  bronchotomy,  in  Alcdico- 
Chir.  Trans,  vol.  6,  p.  221,  Src.  Baillie,  in  Trans,  of 
a Society  for  the  Improvement  of  Med.  and  Chir. 
Knowledge,  vol.  3.  Trousscl  Drelincourt,  Corps 
Etravgers  a.rietSs  dans  les  Foies  aeriennes,  jCouveau 
.Inurn.de  Mid.  par  Bedard,  <Src.  t.  7,  p.  101.  Philos. 
Trans.  1730,  J\l'o.  416,  art.  5.  .Journal  de  Aledeeine  1. 
38,  7>.  358.  J.  A.  Albers,  Comm,  de  Trachitide  Infan- 
tum, vulgo  Croup  vocata,  4to.  Ups.  1816.  C'ase  of 
Chronic  Infi.  of  the.  Larynx,  in  winch  laryngotomy  was 
perfurnied.  See  AHd.  Chir.  ./ourn.  April,  1820.  E.  J. 


508 


BUN 


BUR 


Bourlant  de  Bronchntomia  Diss.  in  Coll-  Diss.  Lo- 
van.  2,  175.  G.  Detharding,  Epist.  Med.  de  Methodu 
subveniendi  Siibiner.iis  per  Laryugotomiam,  liostochii, 
1714.  Klein  in  Chir.  Beinerkungen,  Stuttgart.,  1801; 
in  V.  Siebold's  Chiron,  b.  2,  619;  in  Oraefe's.Journ. 

b.  \,p.  441,  and  b.  6,  p.  225.  Mtchaelir< , in  Huf  eland' .<1 
Journ.  b.  9,  p.  2,  and  b.  1 1,  p.  3.  Flnjani,  Osberim- 
zioni,  SrC;  di  Chirurgia,  t.  3,  Roma,  1802  R.  Col- 
lard,  Jlbhandlnng  iiber  den  Croup,  Soo.  Hannon.  1814. 
T.  Chevalier's  Case  of  Croup,  in  Med.  Chir.  Trans, 
vol  6,  p.  151,  Jindree's  Case,in  vol.  3,  same  work, 
p.  335,  with  the  Obs.  of  Dr.  Farre  on  Cynanche  in  the 
same  part  of  the  work  ; and  those  of  Dr.  Percival  on 
the  same  subject,  in  vol.  4,  p.  297.  C.  IV.  Eberhard, 
De  Musculis  Bronchialibus  in  Statu  et  Murbosa  Jic- 
tione.  Quo.  Marpurg.  1817.  R.  Sprengel,  Geschichte 
der  Chirurgie,  th-  1,  p.  177,  8vo.  Halle,  1805.  Diet, 
des  Sciences  Med.  art.  Broncholoniie,  t.  3,  1812.  Sur- 
gical Observations  by  C.  Bell,  part  1,  p.  14,  i^c.  Quo. 
Lond.  1816.  Case  of  Cynanche  Laryugea  requiring 
Tracheotomy,  and  the  continued  use  of  a Cannula, 
ever  since  the  Operation,  in  Med.  Chir.  .Journ.  vol.  5, 
p.  1,  Quo.  f^und.  1818.  W.  H.  Porter,  Case  of  Cynan- 
che Laryngea,  in  which  Tracheotomy  and  Mercury 
weie  successfully  employed',  Med.  Chir.  Trans,  vol. 
11,  p.  414.  R.  Ijiston,  two  Cases  in  which  Tracheo- 
tomy was  performed  with  success ; one  for  aedemo 
glottidis,  i,-c.,  the  other  on  account  of  an  injury  of 
the  larynx;  Edin.  Med.  and  Su  g.  .Journ.  vol.  19. 
Burgess,  in  Dublin  Hospital  Reports,  vol.  3.  Dr. 
Hall,  in  Med.  Chir.  Trans,  vol.  12.  JV.  J.  Hunt, 
Case  of  Bronchotoiny ; Med.  Chir.  Trans,  vol.  12,  p. 
27,  ij-c.  R.  Carmichael,  in  Trans,  of  Assoc.  Physi- 
cians, Ireland,  vol.  3,  p.  170,  Si-c.  F.  JVhite,  in  Dublin 
Hospital  Reports,  vol.  4.  Dr.  Cullen  on  Broncho- 
tomy,  ill  Edin.  Med.  .Journ.  Mo  94 

BUBO.  (Boufiwi/,  the  groin.)  Modern  surgeons 
mean  by  this  term  a swelling  of  the  lymphatic  glands, 
particularly  of  those  in  the  groin  and  a.xilla. 

The  disease  may  arise  from  the  mere  irritation  of  a 
local  disorder  ; from  the  absorption  of  some  irritating 
matter,  such  as  the  venereal  poison  ; or  from  constitu- 
tional causes. 

Of  the  first  kind  of  bubo,  that  which  is  named  the 
sympathetic  is  an  instance.  Of  the  second,  the  vene- 
real bubo  is  a remarkable  specimen. — (See  Venereal 
Disease.) 

The  pestilential  which  is  a s}Tnptom  of  the 

plague,  and  scrofulous  swellings  of  the  inguinal  and 
axillary  glands,  may  be  regarded  as  examples  of  buboes 
from  constitutional  causes. — (See  Scrofula.) 

The  inguinal  glands  often  become  affected  with  sim- 
ple phlegmonous  inflammation,  in  consequence  of  irri- 
tation in  parts  from  which  the  absorbent  vessels  pass- 
ing to  such  glands  proceed.  'I’hese  swellings  ought  to 
be  carefully  discriminated  from  others  which  arise 
from  the  absorption  of  venereal  matter.  The  first 
cases  are  simple  inflammations,  and  only  demand  the 
application  of  leeches,  the  cold  saturnine  lotion,  and 
the  exhibition  of  a few  saline  purges ; but  the  latter 
diseases  render  the  administration  of  mercury  ad- 
visable. 

Sympathetic  is  the  epithet  usually  given  to  inflamma- 
tion of  glands  from  mere  irritation  ; and  we  shall  adopt 
it  without  entering  into  the" question  of  its  propriety. 

The  sympathetic  bubo  is  mostly  occasioned  by  the 
irritation  of  a virulent  gonorrheea.  The  pain  which 
such  a swelling  gives  is  trifling  compared  with  that  of 
a true  venereal  bubo,  arising  from  the  absorjition 
of  matter,  and  it  seldom  suppurates.  However,  it 
has  been  contended  that  the  glands  in  the  groin  do 
sometimes  swell  and  inflame  from  the  actual  absorp- 
tion of  venereal  matter  from  the  urethra,  in  cases  of 
gonorrhoea,  and  if  this  were  true  the  swellings  would 
be  venereal ; but  this  doctrine  is  now  nearly  exploded. 
— {Hunter  on  the  Venereal,  p.  57.) 

The  manner  in  which  buboes  form  from  mere  irrita- 
tion will  be  better  understood  by  referring  to  the  occa- 
sional conseiiuences  of  venesection,  in  the  article 
Bleeding.  The  distinguishing  characters  of  the  vene- 
real bubo  are  noticed  in  the  article  Venereal  Disease. 

BUBONOCELE.  (From  jS  vBwu.  the  groin,  and 
Kr/Xn  a tumour.)  .species  of  hernia,  in  which  the 
bowels  protrude  at  the  abdominal  ring.  The  case  is 
often  called  an  inguinal  herma,  because  the  tumour 
takes  place  in  the  groin.— (See  Hernia.) 

BUNyON.  An  inflainiiiatioii  of  the  bursa  mucosa. 


at  the  inside  of  the  ball  of  the  great  toe.— (See  Brodie’s 
Pathological  and  Surgical  Obs.  on  the  Joints,  p.  356, 
ed.  2.) 

BURNS  are  usually  divided  into  three  kinds.  1st. 
Into  such  as  produce  an  inflammation  of  the  cutaneou-s 
texture,  but  an  inflammation  which,  if  it  be  not  im- 
properly treated,  almost  always  manifests  a tendency 
to  resolution.  2dly.  Into  those  which  occasion  the 
.separation  of  the  cuticle,  and  produce  suppuration  on 
the  surface  of  the  cutaneous  texture.  3dly.  Into  others 
in  which  the  vitality  and  organization  of  a greater  or 
less  portion  of  the  cutis  are  either  immediately  or  sub- 
sequently destroyed,  and  a soft  slough  or  hard  eschar 
produced. — (See  Thomson  on  Inflammation,  p.  585, 
586.) 

Suppuration  is  not  always  an  unavoidable  conse- 
quence of  the  vesications  in  burns  ; but  it  is  a common 
and  a troublesome  one.  “ In  severe  cases  it  may  take 
place  by  the  second  or  third  day  ; often  not  till  a later 
period.  It  often  occurs  without  any  apiicarance  of  ul- 
ceration ; continues  for  a longer  or  shorter  time  ; and 
is  at  last  stopped  by  the  formation  of  a new  cuticle 
In  other  instances,  small  ulcerations  appear  on  the  sur- 
face or  edges  of  the  burn.  These  spreading  form  ex- 
tensive sores,  which  are  in  general  long  in  healing, 
even  where  the  granulations  which  form  upon  them 
have  a healthy  appearance.”— (Op.  cit.  p.  595.) 

Burns  present  different  appearances,  according  to 
the  degree  of  violence  with  which  the  causes  producing 
them  have  operated,  and  according  to  the  kind  cf  cause 
of  which  they  are  the  effect.  Burns  which  only  irritate 
the  surface  of  the  skin  are  essentially  different  from 
those  which  destroy  it ; and  these  latter  have  a very 
different  aspect  from  wiiat  others  present  which  have  at- 
tacked parts  more  deeply  situated,  such  as  the  muscles, 
tendons,  ligaments, <fec.  Scalds,  which  are  the  elfect  of 
heated  fluids,  do  not  exactly  resemble  burns  occasioned 
by  the  direct  contact  of  very  hot  metallic  bodies,  or 
some  combustible  substance  on  fire.  As  fluids  are  not 
capable  of  acquiring  so  high  a temperature  as  many 
solids,  scalds  are  generally  less  violent  than  burns  in 
the  injury  which  they  produce ; but  in  consequence  of 
liquids  often  flowing  about  with  great  rajiidity,  and  be- 
ing suddenly  thrown  in  large  quantities  over  the  pa- 
tient, scalds  are  frequently  dangerous  on  account  of 
their  extent.  It  is  worthy  of  remark,  that  the  danger 
of  the  effects  of  fire  is  not  less  proiiortioned  to  the  size 
than  the  degree  and  depth  of  the  injury.  A burn  that 
is  so  violent  as  to  kill  parts  at  once,  may  not  be  in  the 
least  dangerous,  if  not  extensive  ; while  a scald,  which 
perhaps  only  raises  the  cuticle,  may  prove  fatal  if  very 
large.  The  degree  of  danger,  however,  is  to  be  rated 
from  a consideration  both  of  the  size  and  violence  of 
the  injury.  The  w'orst  burns  which  occur  in  practice 
arise  from  explosions  of  gunpowder  or  inflammable 
gases,  from  laihes’  dresses  catching  fire,  and  I'rom  the 
boiling  over  of  hot  fluids  in  laboratories,  manufacto- 
ries, «&c. 

Burns,  which  only  destroy  the  cuticle  and  irritate 
the  skin,  are  very  similar  to  the  effects  produced  by 
cantharides  and  rubefacients.  The  irritation,  which 
such  injuries  excite,  increases  the  action  of  the  arte- 
ries of  the  part  affected,  and  they  effuse  a fluid  under 
the  cuticle,  which  becomes  elevated  and  detached. 
Hence,  the  skin  becomes  covered  with  vesicles  or 
bladd-ers,  which  are  more  or  less  numerous  and  large, 
according  to  the  manner  in  w-hich  the  cause  has  ope- 
rated. But  w'hen  the  skin  or  subjacent  parts  are  de- 
stroyed, no  vesicles  make  their  appearance.  In  this 
circumstance  a black  eschar  is  seen ; and  when  the 
dead  [larts  are  detached,  there  remains  a sore  more  or 
less  deep,  according  to  the  depth  to  which  the  destruc- 
tive effects  of  the  fire  have  extended. 

The  parts  may  either  be  killed  at  the  moment  of  the 
injury  by  the  immediate  effect  of  the  fire,  or  they  may 
first  inflatne,  and  then  mortify. 

In  all  case.s  of  burns,  the  quantity  of  injury  depends 
on  the  degree  of  heat  in  the  burning  substance ; on  tiie 
duration  and  extetit  of  its  application  ; and  on  the  sensi- 
bility of  the  burnt  part. 

When  a large  surface  is  burnt,  mortification  some- 
times makes  its  apitearance  with  great  violence,  and 
very  quickly  after  the  accident;  but  in  general,  the 
.symptom  the  most  to  be  dreaded  in  such  cases  is 
inflammation.  'I'he  pain  and  irritation  often  run  to 
such  a intcli,  that,  notwithstanding  every  means,  there 
is  frequently  immense  trouble  in  kcejiiiig  down  the 


BURNS. 


209 


Inflammation.  When  the  burnt  surface  is  very  large, 
the  effects  of  the  inflammation  are  not  confined  to  the 
part  which  was  first  injured  ; but  even  cause  a great 
deal  of  fever  ; and  in  certain  cases,  a comatose  state, 
which  may  end  in  death. 

It  has  been  observed,  that  persons  who  die  of  severe 
burns  seem  to  experience  a remarkable  difficulty  of 
breathing  and  oppression  of  the  lungs.  These  organs 
and  the  skin,  are  both  concerned  in  separating  a large 
quantity  of  water  from  the  circulation,  and  their  par- 
ticipating in  this  function  may  perhaps  afford  a rea- 
son for  respiration  being  often  much  affected,  when  a 
large  surface  of  skin  is  burnt.  However,  the  kidneys 
perform  the  same  office,  and  they  are  not  particularly 
affected  in  burnt  patients ; so  that  the  asthmatic  symp- 
toms frequently  noticed  in  cases  of  burns,  are  i)roba- 
bly  owing  to  a sympathy  between  the  lungs  and  skin, 
or  else  to  causes  not  at  present  understood. 

According  to  Dupuytren,  extensive  and  deep  burns 
always  bring  on  inflammation  of  the  mucous  mem- 
brane of  the  alimentary  canal : a circumstance  said  to 
explain  those  curious  instances  of  death  which  so  of- 
ten occur  when  the  ulcers  are  on  the  point  of  healing. — 
(See  M decine  Op  ratoire  par  Sabatier,  edit,  de  MM. 
Sanson  et  Beguin.) 

Two  general  methods  of  treating  burns  have  at  all 
times  been  followed.  One  consists  in  the  application 
of  substances  which  produce  a cooling  or  refrigerant 
effect ; the  other  in  the  employment  of  calefacient  or 
stimulating  substances.  Dr.  Thomson  is  satisfied, 
that  each  of  these  different  modes  may  have  its  advan- 
tages in  particular  cases. — {Lect.  on  Inflammation,  p. 
588.) 

The  practice  mostly  resorted  to  in  this  country  some 
years  since,  is  explained  by  Mr.  B.  Bell.  When  the  skin 
is  not  destroyed,  but  seems  to  suffer  merely  from  irri- 
tation, relief  may  be  obtained  by  dipping  the  part  af- 
fected in  very  cold  water,  and  keeping  it  for  some  time 
immersed.  This  author  states,  that  plunging  the  in- 
jured part  suddenly  into  boiling  water  would  also  pro- 
cure ease  ; an  assertion,  however,  much  to  be  doubted, 
and  a practice  not  likely  to  be  followed.  In  some  cases, 
emollients  afford  immediate  relief ; but  in  general,  as- 
tringent applications  are  best.  Strong  brandy  or  alco- 
hol is  particularly  praised.  At  first  the  pain  is  in- 
creased by  this  remedy ; but  an  agreeable  soothing 
sensation  soon  follows.  The  parts  should  be  immersed 
in  the  spirit,  and  when  this  cannot  be  done,  soft  old 
linen  soaked  in  the  application  should  be  kept  con- 
stantly on  the  burn.  The  liquor  plumbi  superacetatis 
dilutus  is  recommended.  It  is  said  to  prove  useful, 
however,  only  by  being  astringent,  as  equal  benefit 
may  be  derived  from  a strong  solution  of  alum,  &c. 
Such  applications  were  frequently  made  with  the  view 
of  preventing  the  formation  of  vesicles ; but  Mr.  B. 
Bell  always  remarked,  that  there  was  less  pain  when 
the  blisters  had  already  appeared,  than  when  pre- 
vented from  rising,  by  remedies  applied  immediately 
after  the  occurrence  of  the  injury. 

The  applications  .should  be  continued  as  long  as  the 
pain  remains ; and  in  extensive  burns  creating  great 
irritation,  opium  should  be  prescribed.  The  stupor  with 
which  patients  so  situated  are  often  attacked,  receives 
more  relief  from  opium  than  any  thing  else. 

Some  recommend  opening  the  vesications  immedi- 
ately; others  assert,  that  they  should  not  be  meddled 
with.  Mr.  B.  Bell  thinks  that  they  should  not  be 
opened  till  the  pain  arising  from  the  burn  is  entirely 
gone.  At  this  period,  he  says,  they  should  always  be 
punctured  ; for  when  the  serum  is  allowed  to  rest  long 
upon  the  skin  beneath  it  has  a bad  effect,  and  even  in- 
duces some  degree  of  ulceration.  Small  punctures, 
not  large  incisions,  should  be  made.  All  the  fluid  hav- 
ing been  discharged,  a liniment  of  wax  and  oil,  with  a 
small  proportion  of  the  superacetate  of  lead,  is  to  be 
applied. 

On  the  subject  of  opening  the  vesications  in  burns, 
Dr.  Thomson  believes,  that  the  diversity  of  opinion 
arises  from  the  different  effects  resulting  from  the  par- 
ticular manner  in  which  the  opening  is  made.  “ If 
a portion  of  the  cuticle  be  removed  so  as  to  permit  the 
air  to  come  into  contact  with  the  inflamed  surface  of  the 
cutis,  pain  and  a considerable  degree  of  general  irritation 
will  necessarily  be  induced;  but  if  the  ve.sications  be 
opened  cautiously  with  the  point  of  a needle,  so  as  to 
allow  the  serum  to  drain  off  slowly,  without  at  the  i 
same  time  allowing  the  air  to  enter  between  the  cuticle  ! 

Von.  I.— O 


and  cutis,  the  early  opening  of  the  vesications  will  not 
only  not  occasion  pain,  but  will  give  considerable  re- 
lief, by  diminishing  the  state  of  tension  with  which 
the  vesications  are  almost  always,  in  a greater  or  less 
degree,  accompanied.  When  opened  in  this  manner, 
the  vesications  often  fill  again  with  serum ; but  the  punc- 
tures may  be  repeated  as  often  as  is  necessary,  with- 
out any  h azard  of  aggravating  the  inflammation . Great 
care  should  be  taken  in  every  instance,  to  preserve  the 
raised  portion  of  cuticle  as  entire  as  i)Ossible,”  &c. — 
(See  Lectures  on  Inflammation,  p.  595.) 

When  there  is  much  irritation  and  fever,  blood-let- 
ting, and  such  remedies  as  the  particular  symptoms 
demand,  must  be  advised.  On  account  of  the  pulse 
being  frequently  small,  quick,  and  vibratory,  bleeding 
is  at  present  not  often  employed.  As  Dr.  Thomson 
remarks,  however,  it  may  become  necessary  in  pa- 
tients of  a strong,  robust  constitution,  in  whom  the 
symptomatic  fever  assumes  an  inflammatory  type. 
He  has  often  seen  a single  bleeding  procure  great  re- 
lief in  these  cases  ; and  he  does  not  remember  a case 
where  bleeding  was  followed  by  injurious  effects. — (P. 
594.)  When  the  skin  ulcerates,  the  treatment  does 
not  differ  from  what  will  be  described,  in  speaking  of 
Ulcers. 

When  burns  are  produced  by  gunpowder,  and  the 
skin  more  or  less  destroyed,  cooling  emollient  applica- 
tions were  formerly  thought  most  effectual,  and  a lini- 
ment composed  of  equal*  proportions  of  lime-water 
and  linseed-oil  gained  the  greatest  celebrity.  Even  at 
this  day,  the  application  is  very  often  employed.  Mr. 
B.  Bell  advises  it  to  be  put  on  the  parts  by  means  of 
a soft  hair-pencil,  as  the  application  and  removal  of 
the  softest  covering  are  often  productive  of  much  pain. 
The  same  author  admits,  however,  that  there  are  some 
cases  in  which  Goulard’s  cerate,  and  a weak  solution 
of  the  sujieracetate  of  lead,  more  quickly  procure  ease 
than  the  above  liniment. 

The  sloughs  having  come  away,  the  sores  are  to  be 
dressed  according  to  common  principles. — (See  Ulcers.) 

When  bums  are  produced  by  gunpowder,  some  of 
the  grains  may  be  forced  into  the  skin  : these  sliould 
be  picked  out  with  the  point  of  a needle,  and  an  emol- 
lient poultice  applied,  which  will  dissolve  and  bring 
away  any  particles  of  gunpowder  yet  remaining. 

Burnt  parts  which  are  contiguous,  frequently  grow 
together  in  the  progress  of  the  cure.  The  fingens, 
toes,  sides  of  the  nostrils,  and  the  eyelids,  are  particu- 
larly liable  to  this  occurrence ; which  is  to  be  pre- 
vented by  keeping  dressings  always  interposed  be- 
tween the  parts  likely  to  become  adherent,  until  they 
are  perfectly  healed. 

The  sores  resulting  from  burns  are  perhaps  more 
disposed  than  any  other  ulcers  to  form  large  granula- 
tions, which  rise  considerably  above  the  level  of  the 
surrounding  skin.  No  poultices  should  now  be  used. 
The  sores  should  be  dressed  with  any  moderately 
stimulating,  astringent  ointment:  the  ceratum  cala- 
minae  or  the  unguentum  resinae  with  the  pulv.  hydrarg. 
nitrat.  rub.  is  now  generally  preferred : and  if  the  part 
will  allow  of  the  application  of  a roller,  the  pressure 
of  it  will  be  of  immense  service  in  keeping  down  the 
granulations,  and  rendering  them  more  healthy.  When 
these  methods  fail,  the  sores  should  be  gently  rubbed 
with  the  argentum  nitratum. 

In  the  dry  and  hot  state  of  the  skin  Dr.  Thomson  is 
an  advocate  for  diaphoretics.  “Laxatives  (says  he) 
are  often  necessary ; but  it  is  in  general  best  to  employ 
only  the  gentler  sort,  on  account  of  the  trouble  and 
pain  which  moving  always  gives  the  patient.  Ano- 
dynes are  often  required,  not  only  to  procure  sleep, 
but  even  a temporary  alleviation  of  the  pungency  of 
the  pain  which  the  burn  occasions.  A mild  vegetable 
and  farinaceous  diet  should  be  used  during  the  period 
of  the  symptomatic  fever.  Animal  food,  wine,  and 
other  cordials  may  be  required  in  the  progress  of  a 
suppurating  burn  ; but  they  are  not  nece.ssary  at  first, 
and  when  given  in  this  stage,  are  almost  always  inju- 
rious.”— (See  Lectures  on  Inflammation,  p.  594.) 

With  respect  to  the  topical  applications  recommended 
by  this  gentleman,  he  generally  prefers,  in  cases  of  su- 
perlicial  burns,  cooling  and  refrigerant  remedies.  When 
there  are  vesications,  and  suppuration  takes  place 
without  ulceration,  he  advises  us,  after  refrigerants 
have  ceased  to  produce  beneficial  effects,  to  use  the 
linimentum  aquae  calcis.  However,  where  the  pro- 
gress of  cic.atrization  is  slow,  he  recommends,  instead 


210 


BURNS. 


of  this  liniment,  ointments  containing  lead  or  zinc, 
particularly  the  ceratum  calaminae. 

In  the  ulcerating  state  of  suppurating  burns,  he  pre- 
fers emollient  cataplasms.  But  when  the  discharge 
continues,  or  becomes  more  profuse  under  the  use  of 
poultices,  they  are  to  be  left  off,  and  astringent  washes 
employed,  such  as  lime-water,  the  compound  decoction 
of  oak-bark,  a weak  solution  of  sulphate  of  copper,  «fec. 

Where  the  parts  are  destroyed  and  converted  into 
sloughs,  Dr.  Thomson  does  not  think  it  matters  much 
whether  vinegar,  oily  liniments,  turpentine,  spirits  of 
wine,  or  emollient  poultices  be  at  first  employed.  He 
acknowledges,  however,  that  the  poultice  is  the  remedy 
under  the  application  of  which  the  separation  of  the  j 
dead  parts  is  most  easily  and  agreeably  accomplished. 

“ The  question  (says  he)  at  present  most  deserving 
the  attention  of  medical  practitioners  with  regard  to 
the  use  of  the  warm  emollient  poultices  in  burns  is, 
whether  we  should  apply  it  immediately  after  the  burn 
has  been  received,  or  interpose  for  some  hours,  as  has 
been  so  strongly  recommended,  dressings  with  vine- 
gar, spirits  of  wine,  or  oil  of  turpentine.  My  own  ex- 
perience htis  not  been  sufficient  to  enable  me  to  deter- 
mine this  point  to  my  entire  satisfaction.  Yet  I think 
it  right  to  state  to  you,  that  in  a number  of  trials  made 
at  different  times,  I have  had  occasion  to  see  burns  to 
which  common  emollient  poultices  had  been  from  the 
first  applied,  slough  and  granulate  faster,  and  in  a more 
kindly  manner,  than  similar  burns  in  the  same  per- 
sons, to  which  in  some  instances  the  Carron  oil  (lin. 
aq.  calcis),  and  in  others  again  oil  of  turpentine,  were 
applied  at  the  same  time  with  the  poultices.”— (See 
Lectures  on  Injlammation,  p.  609.) 

MR.  CLKGHORN’S  plan. 

Tliis  gentleman,  who  was  a brewer  at  Edinburgh, 
was  induced  to  pay  great  attention  to  the  effects  of 
various  modes  of  treating  burns,  on  account  of  the 
frequency  of  these  accidents  among  his  own  workmen. 
Ilis  observations  led  him  to  prefer  the  immediate  ap- 
plication of  vinegar,  which  was  to  be  continued  for 
some  hours,  by  any  of  the  most  convenient  means, 
until  the  pain  abated  ; and  when  this  returned,  the 
vinegar  was  repeated.  If  the  burn  had  been  so  severe 
as  to  have  produced  a destruction  of  parts,  these,  as 
soon  as  the  pain  had  ceased,  were  covered  with  a 
poultice,  the  application  of  which  was  continued  about 
six  or,  at  mo.st,  eight  hours ; and  after  its  remo- 
val, the  parts  were  entirely  covered  with  very  finely 
powdered  chalk,  so  to  as  take  away  every  appear- 
ance of  moisture  on  the  surface  of  the  sore.  This 
being  done,  the  whole  burnt  surface  was  again  covered 
with  the  poultice.  The  same  mode  was  pursued  every 
night  and  morning  until  the  cure  was  complete.  If 
ihe  use  of  poultices  relaxed  the  ulcers  too  much,  a 
plaster  or  ointment,  containing  the  acetate  of  lead,  was 
applied ; but  the  chalk  was  still  sprinkled  upon  the  sore. 

With  respect  to  general  remedies,  Mr.  Cleghorn  al- 
lowed his  patients  to  eat  boiled  or  roasted  fowl,  or  in 
short  any  plainly  dressed  meat  which  they  liked.  He 
did  not  object  to  their  taking  moderate  quantities  of 
wine,  spirits  and  water,  ale,  or  porter.  He  never  had 
occasion  to  order  bark,  or  any  internal  medicines  what- 
ever, and  he  only  once  thought  it  necessary  to  let  blood. 
When  the  patient  was  costive,  Mr.  Cleghorn  ordered 
boiled  pot-barley  and  prunes,  or  some  other  laxative 
nourishing  food,  and  sometimes  an  injection,  but  nei}er 
any  purgative,  as  he  remarked  that  the  disturbance 
of  frequently  going  to  stool  was  distressing  to  a patient 
with  bad  sores.  Besides,  he  thought  that  a hurtful 
weakness  and  languor  were  always  more  or  less) 
brought  on  by  purgatives.  From  the'  effects  too  which 
he  felt  them  have  upon  himself,  and  observed  them  to 
have  upon  others,  they  did  not  seem  to  have  so  much 
tendency  to  remove  heat  and  feverish  symj)toms  as  is 
generally  supposed,  and  he  believed  that  they  more 
frequently  carried  off  useful  humours  than  hurtful  ones. 

Diluted  sulphuric  acid  was  not  found  to  answer  so 
well  as  vinegar,  and  the  latter  produced  most  benefit 
when  it  was  fresh  and  lively  to  the  taste. 

In  cold  weather  Mr.  Cleghorn  sometimes  warmed 
the  vinegar  a little,  placed  the  patients  near  the  fire, 
gave  them  something  warm  internally,  and  kept  them 
in  every  respect  in  a comfortable  situation.  His  object 
in  so  doing  was  to  prevent  the  occurrence  of  tremblings 
and  chilliness,  which  in  two  instances,  after  employing 
cold  vinegar,  took  place  in  an  alarming  degree. 


The  account  of  Mr.  Cleghom’s  plan  wa.s  published 
by  Mr.  Hunter. — (See  Med.  Facts  and  Observations, 
vol.  2.) 

SIR  JAMES  EARLE’s  PLAN. 

This  gentleman  was  an  advocate  for  the  use  of  cold 
water  or  rather  ice ; and  published  several  cases  of  ex- 
tensive burns,  in  which  this  method  was  employed 
with  the  best  effect.  Cold  water  was  enumerated  by 
Mr.  B.  Bell  among  the  applications  to  burns,  and  it 
was  not  uncommonly  used  long  before  Sir  James  Earle 
communicated  the  result  of  his  experience  to  the  pub- 
lic. The  method  indeed  is  very  ancient.  “ Cold  is  a 
remedy  (says  Dr.  J.  Thomson)  which  has  long  been 
employed  to  diminish  the  inflammation  of  superfii;ial 
burns.  Rhazes  directs,  that  in  recent  bums  cloths 
dipped  in  cold  water,  or  in  rose-water  cooled  with  snow, 
be  applied  as  soon  as  possible  to  the  parts  which  have 
been  injured,  and  that  these  cloths  be  renewed  from 
time  to  time ; and  Avicenna  says  that  this  practice 
often  prevents  the  formation  of  blisters.” — ^Lectures 
on  Inflammatimi,  p.  589.)  Sir  James  Earle’s  publica- 
tion, however,  had  the  good  effect  of  drawing  consider- 
able attention  to  the  subject,  and  of  leading  surgeons 
to  try  the  method  in  a great  number  of  instances  in 
which  other  more  hurtful  modes  of  treatment  might 
otherwise  have  been  employed.  The  burnt  parts  may 
either  be  plunged  in  cold  water,  or  they  may  be  covered 
with  linen  dipped  in  the  same,  and  renewed  as  often 
as  it  acquires  warmth  from  the  part.  The  application 
should  be  continued  as  long  as  the  heat  and  pain  re- 
main, which  they  will  often  do  for  a great  many  hours. 
— (See  Essay  on  the  means  of  lessening  the  Effects  of 
Fire  on  the  Human  Body,  8vo.  Lond.  1803.) 

Some  caution,  however,  in  the  application  of  cold 
becomes  necessary  when  a scald  is  of  very"  large  size, 
or  situated  upon  the  trunk  of  the  body.  In  extensive 
burns,  superficial  as  they  may  be,  the  patient  is  liable 
to  be  affected  with  cold  shiverings ; and  these  shiver- 
ings  may  be  greatly  aggravated  by  exposure  and  by  the 
application  of  cold.  Perhaps,  therefore,  in  these  exam- 
ples warm  applications  ought  to  be  preferred. — (Dr.  J. 
Thomson's  Lectures  on  Injlammation,  p.  591.) 

BARON  LARRKY’s  plan. 

It  seems  to  me,  that  on  the  subject  of  burns  there  Is, 
even  at  the  present  day,  as  much  contrariety  of  senti- 
ment as  in  any  part  of  surgery  whatsoever.  After  all 
the  praises  which  of  late  years  have  been  heard  of 
vinegar,  cold  applications,  oil  of  turpentine,  «fcc.,  a 
French  surgeon,  whose  talents  and  opportunities  of 
observation  entitle  his  opinion  to  the  highest  attention, 
has  recently  censured  the  employment  of  all  such  re- 
medies. Larrey,  though  a military  surgeon,  has  had 
occasion  to  see  numerous  burns,  in  consequence  of  e.\- 
piosioiis.  He  declares,  that  he  has  been  long  struck 
with  the  bad  effects  of  repellents,  such  as  fresh  water 
with  the  muriate  of  ammonia,  oxycrate,  the  liquor 
plumbi  subacetatis,  and  the  solution  of  opium  in  ice- 
water.  He  recommends  dressing  all  deep  burns  with 
fine  old  linen  spread  with  saffron  ointment,  which,  he 
says,  has  the  quality  of  diminishing  the  pain  and  pre- 
venting irritation,  by  keeping  the  nervous  papillae  from 
coming  into  contact  with  the  air,  or  being  pressed  by  the 
linen  and  clothes.  This  ointment  is  to  be  continued 
till  suppuration  takes  place,  after  which  Larrey  em- 
ploys the  ointment  of  styrax  for  promoting  the  detach- 
ment of  the  eschars,  and  checking  the  extension  of  the 
sloughing.  As  soon  as  the  dead  parts  have  separated, 
he  again  has  recourse  to  the  saffron  ointment,  for  which 
he  gradually  substitutes  dry  lint,  with  strips  of  linen 
spread  with  cerate.  When  the  vessels  exceed  the  level 
of  the  edge  of  the  sore,  he  touches  them  with  the  ar- 
gentum nitratiun,  and  he  occasionally  ajiplies  a weak 
solution  of  the  oxymuriate  of  mercury,  or  of  the  sul- 
phate of  copper. 

Larrey  prescribes  emollient  and  antispasmodic  beve- 
rages, which  are  to  be  taken  warm,  such  as  milk  of 
almonds,  containing  nitre,  and  properly  sweetened; 
hydromel,  rice  ptisan,  &c.  His  patients  are  never  de- 
prived of  light  nourishment,  such  as  broths,  jellies, 
eggs,  soups,  Ac.  He  has  found  this  simple  treatment, 
which  he  calls  soothing  and  gently  tonic,  almost  always 
successful. — (See  M^m.  de  Chir.  Militaire,  t.  l,p.  93.) 
nR.  Kentish’s  pi-an.. 

From  what  has  been  stated,  it  appears,  that  in  cases 
of  burns,  cold  -and  hot,  irritating  and  soothing,  astrin- 
gent and  emollient  applications  have  all  been  outwardij 


BURNS. 


211 


employed  without  much  discrimination.  But  the  in- 
ternal treatment  has  always  been  of  one  kind,  and  both 
the  ancients  and  moderns  agree  in  advising  blood-let- 
ting, cooling  purges,  and,  in  short,  the  whole  of  the 
antiphlogistic  plan.  If  we  except  Mr.  Cleghorn,  who 
condemned  purges,  and  allowed  stimulants  internally. 
Dr.  Kentish  has  been  almost  the  only  advocate  for  the 
latter  means. 

The  fanciful  theories  advanced  by  Dr.  Kentish,  lead 
him  to  believe,  that  as  burns  are  injuries  attended  with 
increased  action,  there  are  two  indications  for  restoring 
what  he  terms  tlie  unity  of  action : viz.  the  excitement 
or  action  of  the  part  is  first  to  be  gradually  diminished; 
secondly,  the  action  of  the  system  is  to  be  increased  to 
meet  the  increased  action  of  the  part,  holding  this  law 
as  the  system  in  view : That  any  part  of  the  system, 
having  its  action  increased  to  a very  high  degree, 
mvM  continue  to  be  excited,  though  in  a less  degree, 
either  by  the  stimulus  which  caused  the  increased  ac- 
tion, or  some  other  having  the  nearest  similarity  to  it, 
until  by  degrees  the  extraordinary  action  subsides  into 
the  healthy  action  of  the  part. 

With  this  view,  holding  the  part  to  the  fire  seems, 
to  Dr.  Kentish,  the  best  mode  of  relief ; but  as  parts  of 
the  body  are  injured  to  which  this  cannot  be  done,  the 
most  stimulant  applications  must  be  used  ; for  in  this 
class  there  is  little  fear  of  any  of  them  being  greater 
than  that  which  originally  caused  the  accident.  The 
strongest  rectified  spirits,  made  still  stronger  by  essen- 
tial oils,  are  proper,  and  may  also  be  healed  as  much  as 
the  sound  parts  can  bear.  These  and  many  other  ap- 
plications of  the  same  class,  says  Dr.  Kentish,  will 
give  the  most  speedy  relief.  They  are  to  be  continued 
only  for  a certain  time,  lest  they  cause  the  very  ill 
which  <hey  are  given  to  cure.  They  are  then  to  be 
succeeded  by  less  stimulant  applications,  until  the 
parts  act  by  common  natural  stimuli. 

The  internal  mode  of  relief  is  to  give  those  substances 
which  most  speedily  excite  the  system  to  great  action, 
such  as  ether,  ardent  spirits,  opium,  wine,  <fec.,  by 
which  means  the  solution  of  continuity  of  action  is  al- 
lowed to  last  the  shortest  time  possible,  and  the  unity 
of  action  is  restored,  which  constitutes  the  cure. 

Suppose,  for  instance,  as  a local  application,  we  at 
first  apply  the  strongest  alcohol,  heated  to  the  degree 
which  the  sound  part  would  bear  without  injury ; it 
should  afterward  be  gradually  diluted  until  it  becomes 
proof  spirit,  and  the  heat  should  be  diminished,  although 
gradually,  as  cold  is  always  pernicious,  bringing  on 
that  tendency  to  shiver  which  should  ever  be  conti- 
nually guarded  against,  as  being  a most  hurtful  symp- 
tom, and  the  forerunner  of  a violent  sympathetic  fever. 
To  prevent  this,  the  external  heat  should  be  kept  £it  a 
high  temperature,  and  the  action  of  the  whole  system 
raised  in  as  great  a degree  as  may  be  safe.  By  this 
means  the  action  of  the  whole  is  made  to  meet  the  in- 
creased action  of  the  part,  by  which  the  lessening  of 
the  increased  action  of  the  part  to  join  the  action  of 
the  whole  is  rendered  more  easy.  Thus  there  is,  says 
Dr.  Kentish,  a unify  of  intention  by  both  the  external 
and  internal  means,  leading  to  the  restoration  of  the 
unity  of  action,  and  the  cure  is  performed. 

It  may  be  said,  these  circumstances  can  only  take 
place  when  there  is  an  increased  action ; and  when 
the  parts  are  destroyed,  other  means  should  be  used, 
emollients,  &c.  In  replying  to  this  remark.  Dr.  Kent- 
ish distingui.shes  burns  into  two  kinds  ; one,  in  which 
the  action  of  the  part  is  only  increased  ; and  another, 
in  which  some  parts  have  increased  action,  while  other 
parts  are  destroyed.  It  is  of  little  consequence,  says 
Dr.  Kentish,  what  is  applied  to  the  dead  part,  as  the 
detachment  of  an  eschar  depends  upon  the  action  of 
parts  which  remain  alive,  and  not  upon  what  is  applied 
to  those  which  are  dead.  However,  he  never  saw  an 
instance  of  a burn  in  which,  though  some  parts  were 
totally  destroyed,  there  were  not  always  other  parts 
in  which  there  was  ordy  increased  action.  Now  as 
our  duty  is  always  to  save  living  parts,  our  mode  of 
cure  in  the  first  instance  will  always  be  the  same;  viz. 
to  cure  the  parts  which  have  only  an  increased  action, 
in  the  doing  of  which  the  dead  parts  will  not  be  the  | 
worse,  as  their  separation  is  a process  of  the  system 
which  requires  time,  and,  if  the  injury  is  to  any  extent,  . 
draws  forth  the  joint  efforts  of  the  system,  and  even, 
says  Dr.  Kentish,  calls  up  the  energy  of  its  powers  to  I 
violent  fever.  This  state  should  be  supported  by  every  I 
artificial  aid,  in  order  to  bring  the  parts  to  suppuration, 

O 2 


- otherwise  the  subject  falls  in  the  contest;  for  if  the 
i living  parts  have  not  the  power  to  throw  off  the  dead, 
■ the  dead  will  assimilate  the  living  to  themselves,  and 
; a mortification  ensue. 

> When  the  living'  parts  have  been  preserved  (conti- 
, nues  Dr.  Kentish),  which,  according  to  this  treatment, 
! will  be  in  the  course  of  two  or  three  days,  the  dead 
parts  will  be  more  plainly  observed,  and  the  beginning 
I of  the  process  to  throw  them  off  will  be  commencing. 
1 This  process  must  be  assisted  by  keeping  up  the  powers 
: of  the  system  by  stimulant  m^icines  and  a generous 
diet.  The  separation  of  the  eschars  will  be  greatly 
promoted  by  the  application  of  the  stimulus  of  heat  by 
I means  of  cataplasms  frequently  renewed.  These  may 
be  made  of  milk  and  bread,  and  some  camphorated  spirit 
, or  any  essential  oil  sprinkled  upon  the  surface.  Such 
, means  need,  only  be  continued  until  the  suppuration  is 
established. 

After  Dr.  Kentish  had  supported  the  system  to  sup- 
puration, he  then  found  that  gradually  desisting  from 
his  stimulant  plan  diminished  the  secretion  of  pus,  and 
wonderfully  quickened  the  healing  process. 

When  some  parts  are  destroyed,  there  must  be  others 
with  increased  action ; and  in  this  case,  according  to 
Dr.  Kentish,  the  foregoing  mode  will  be  the  best  for 
restoring  the  living  parts,  and  promoting  the  separation 
of  the  dead.ones.  Suppuration  having  taken  place,  the 
exciting  of  the  system  by  any  thing  stimulant,  either 
by  food  or  medicine,  should  be  cautiously  avoided. 
Should  the  secretion  of  pus  continue  too  great,  gentle 
laxatives  and  a spare  diet  are  indicated.  If  any  part, 
as  the  eyes  for  instance,  remain  weak,  with  a tendency 
to  inflammation,  topical  bleedings,  or  small  quantities 
of  blood  taken  from  the  arm,  are  useful.  For  the  pur- 
pose of  defending  the  new  skin,  camphorated  oil,  or 
camphorated  oil  and  lime-water  in  equal  parts,  are  good 
applications.  Wounds  of  this  kind  heal  very  fast, 
when  the  diminution  of  pus  is  prevented  by  attention 
to  diet ; if  the  patient’s  strength  require  support,  small 
doses  of  bark  taken  two  or  three  times  a day  in  some 
milk  will  answer  that  purpose,  without  quickening  the 
circulation  as  wine,  ale,  or  spirits  are  apt  to  do.  By 
attention  to  these  principles  (continues  Dr.  Kentish),  I 
can  truly  assert  that  I have  cured  very  many  extensive 
and  dangerous  burns  and  scalds  in  one,  two,  three,  and 
four  weeks,  which  in  the  former  method  would  have 
taken  as  many  months ; and  some  which  I believe  to 
have  been  incurable  by  the  former  method. 

After  explaining  his  principles.  Dr.  Kentish  takes  no- 
tice of  the  various  substances  which  have  commonly 
been  employed.  Of  these  he  would  chiefly  rely  on  alco 
hoi,  liquor  ammoniae  subcarbonatis,  ether  (so  applied  as 
to  avoid  the  cooling  process  of  evaporation),  and  spirit 
of  turpentine. 

In  applying  these,  we  are  directed  to  proceed  as  fol- 
lows: the  injured  parts  are  to  be  bathed,  two,  or  three 
times  over,  with  spirits  of  wine,  spirits  of  wine  with 
camphor,  or  spirit  of  turpentine,  heated  by  standing  in 
hot  water.  After  this  a liniment,  composed  of  the  cera- 
tum  resinae  softened  with  spirit  of  turpentine,  is  to  be 
spread  on  soft  cloth,  and  applied.  This  liniment  is  to 
be  renewed  only  once  in  twenty-four  hours,  and,  at  the 
second  dressing,  the  parts  are  to  be  washed  with  proof 
spirit,  or  laudanum,  made  warm.  When  the  secretion 
of  pus  takes  place,  milder  applications  must  be  made, 
till  the  cure  is  effected. 

The  yellow  ointment  stops  the  pores  of  the  cloth,  im- 
pedes evaporation,  and  thus  confines  the  effect  of  the 
alcohol  to  the  burnt  surface.  The  first  dressings  are 
to  remain  on  four-and-twenty  hours.  i)r.  Kentish  thinks 
it  of  importance,  that  the  injured  surface  should  be  left 
uncovered  as  little  as  possible.  It  is  therefore  recom- 
mended to  let  the  plasters  be  quite  ready,  before  the  old 
ones  are  removed,  and  then  only  to  take  oft'  one  piece  at 
a time. 

It  will  seldom  be  necessary  to  repeat  the  application 
of  alcohol,  or  that  of  oleum  terebinthinte.  The  inflam- 
matory action  will  be  found  diminished,  and,  according 
to  Dr.  Kentish’s  princijiles,  the  exciting  means  should 
therefore  be  diminished.  Warm  proof  spirits,  or  lauda- 
num, may  be  substituted  for  the  alcohol,  and  tb.e  un- 
guentum  resinae  flav;e  is  to  be  mixed  with  oleum  camph. 

. instead  of  turpentine.  If  this  should  be  found  too  irri- 
I fating.  Dr.  Kentish  recommends  ceraturn  plu.mbi  aceta- 
I tis,  or  cer.  calaminai.  Powdered  chalk  is  to  be  used 
I to  repress  the  growth  of  exuberant  granulations,  and  to 
absorb  the  pus.  In  the  cavities  of  separated  eschars, 


212 


BURNS, 


and  in  the  furrows  between  sloughs  and  living  parts, 
he  introduced  powdered  chalk.  Then  a plaster  is  ap- 
plied, and,  in  tedious  cases,  a poultice  over  the  plaster. 

With  respect  to  the  internal  treatment,  the  author  ob- 
serves, that  great  derangement  of  the  system  arises  in 
certain  persons  from  causes  which  in  others  produce 
no  etfect ; and  that  this  depends  on  a difference  in  the 
degree  of  strength.  Hence,  he  concludes  that  as 
strength  resists  the  sympathetic  irritative  actions  of 
parts,  and  weakness  induces  them,  we  should,  in  all 
cases,  make  the  system  tus  strong  as  we  can,  immedi- 
ately upon  the  receipt  of  the  injury.  In  considerable 
burns,  he  supposes  a disproportion  of  actio.a  to  take 
place  between  the  injured  parts  and  the  system  at 
large,  or  what  he  styles  a solution  of  the  continuity  of 
action  ; and  that,  by  a law  of  the  system,  a considera- 
ble commotion  arises,  for  the  purpose  of  restoring  the 
equilibnmn,  or  enabling  the  constitution  to  take  on  the 
action  of  the  part.  Hence,  Dr.  Kentish  is  of  opinion, 
that  the  indication  is  to  restore  the  unity  of  action  of 
the  whole  system,  as  soon  as  possible,  by  throwing  it  into 
such  a state  as  to  absorb  the  diseased  action,  and  then 
gradually  bring  down  the  whole  to  the  natural  stand- 
ard of  action  by  nicely  diminishing  the  exciting  powers. 
Ether  and  alcohol,  or  other  stimulants,  are  to  be  imme- 
diately given  in  proportion  to  the  degree  of  injury ; and 
repeated  once  or  twice  within  the  first  twelve  hours, 
and  afterward  wine  or  ale  is  to  be  ordered,  till  suppu- 
ration takes  place,  when  it  will  be  no  longer  necessary 
to  excite  the  system. 

In  a second  essay.  Dr.  Kentish  remarks,  that,  in  the 
first  species  of  burns,  in  which  the  action  of  the  part  is 
only  increased,  he  has  not  found  any  thing  better  for  the 
first  application  than  the  heated  oleum  terebintliinffi  and 
ceratum  resinte,  thinned  with  the  same.  In  superficial 
burns,  when  the  pain  has  ceased,  he  considers  it  advisa- 
ble to  desist  from  this  application  in  about  fbur-and- 
twenty  hours,  and  use  at  the  second  dressing  a digestive, 
sulficicntly  tliinned  with  common  oil,  beginning,  on  the 
third  day,  with  the  ceratum  lap.  calaminaris.  This 
author  has  frequently  seen  secondary  inflammation  ex- 
cited by  the  remedy.  The  most  certain  remedy  for  this 
unpleasant  symptom  is  a digestive  ointment  thinned 
with  oil,  or  a plaster  of  cerate,  and  over  that  a large 
warm  poultice.  The  cerate  will  finish  the  cure.  Should 
there  be  much  uneasiness  of  the  system,  an  anodyne, 
proportioned  to  the  age  of  the  patient,  should  be  given. 

The  growth  of  fungus,  and  the  profuse  discharge  of 
matter,  are  to  be  repressed,  as  already  mentioned,  by 
sprinkling  powdered  chalk  on  the  surface,  and  by  the 
use  of  purgatives,  in  the  latter  stages.  The  chalk  must 
be  very  finely  levigated. 

Dr.  Kentish’s  theories  are,  as  far  as  I can  judge,  vi- 
sionary : they  may  amuse  the  fancy,  but  can  never  im- 
prove the  judgment.  They  are  nearly  unintelligible ; 
they  are  unsupported  by  any  sort  of  rational  evidence ; 
and,  as  being  only  the  dreams  of  a credulous,  sportive 
imagination,  they  must  soon  decline  into  neglect,  if  not 
oblivion.  However,  in  making  these  remarks,  it  is  far 
from  my  intention  to  extend  the  same  animadversion  to 
the  mode  of  treatment  insisted  upon  by  Dr.  Kentish, 
which  forms  a question  which  cannot  be  determined  by 
reason,  but  by  experience. 

OF  DRESSING  BURNS  WITH  RAW  COTTON. 

In  America,  it  is  asserted  that  the  best  application  for 
superficial  burns  is  raw  cotton,  thinly  spread  out,  or 
carded,  and  put  directly  on  the  injured  part.— (See  Dal- 
lam on  the  Use  of  Cotton  in  Bums,  in  Potter's  Medical 
Lyceum,  p.  22 ; and  Gibson's  Institutes  and  Practice 
of  Surgery,  p.  62,  vol.  1,  8uo.  Philadelphia,  1824.) 
According  to  Professor  Gibson,  it  is  only  in  superficial 
bums  that  this  practice  answers ; but  Dr.  Anderson, 
of  Glasgow,  who  has  tried  it  on  a large  scale,  represents 
it  as  applicable  to  injuries,  whether  occasioned  by  scald- 
ing or  actual  fire,  whether  superficial  or  deep,  recent 
OT  old,  vesicated  or  sphacelated.  He  states,  that  it  has 
been  long  adopted  by  the  inhabitants  of  the  Greek 
islands.  One  of  its  advantages,  he  says,  is,  that,  except 
in  cases  of  deep  injury,  the  cure  is  always  accom- 
plished without  any  appearance  of  cicatrization. — (See 
Glasgtnju  Med.  Journ.  vol.  1,  p.  209.)  Another  is  the 
avoidance  of  the  pain  always  attending  the  frequent  re- 
newal of  other  kinds  of  dressing.^ ; for  this  is  left  un- 
changed a considerable  time.  Some  care,  says  Dr. 
Anderson,  is  necessary,  both  in  preparing  and  ap- 
plying the  cotton  For  this  purpose,  it  should  be 


finely  carded,  and  disposed  in  narrow  fleeces,’  so  thin  ttg 
to  be  translucent ; by  which  means  it  can  be  applied  in 
successive  layers,  and  is  thus  made  to  fill  up  and  pro- 
tect the  most  irregular  surfaces.  The  burnt  parts,  if  ve- 
sicated, are  to  be  washed  with  tepid  water,  and  the  fluid 
evacuated  by  small  punctures.  Or,  if  more  deeply 
scorched,  they  may  be  bathed  with  a spirituous  or  tur- 
pentine lotion.  The  cotton  is  then  applied,  layer  after 
layer,  until  the  whole  surface  is  not  only  covered,  but 
protected  at  every  point,  so  that  pressure  and  motion 
may  give  no  uneasiness.  On  some  parts,  it  will  ad- 
here without  a bandage,  especially  when  there  is 
much  discharge ; but,  in  general,  a support  of  this  kind 
is  useful.  Where  the  vesications  have  been  broken, 
and  the  skin  is  abraded,  or  where  there  is  sphacelus, 
more  or  less  suppuration  always  ensues  ; and,  in  such 
cases.  Dr.  Anderson  admits,  the  discharge  may  be  so 
great  as  soon  to  soak  through  the  cotton,  and  become 
olfensive,  particularly  in  summer,  so  that  it  may  be  ne- 
cessary to  remove  the  soiled  portions.  This,  however, 
he  advises  to  be  done  as  sparingly  as  possible,  care  be- 
ing taken  to  avoid  uncovering  or  disturbing  the  tender 
surface.— (Ojn  cit.  p.  213.)  According  to  Dr.  Ander- 
son, there  appears  to  be  a twofold  effect  from  this  kind 
of  treatment.  The  primary  effect  arises  from  the  ex- 
clusion  of  the  air,  and  the  slowly  conducting  power  of 
cotton,  by  which  the  heat  of  the  part  is  retained,  while 
a soft  and  uniformly  elastic  protection  from  pressure  is 
afforded.  The  secondary  effect,  he  says,  depends  en- 
tirely on  the  sheath,  or  case,  formed  by  the  cotton,  ab* 
sorbing  the  effused  serum  or  pus,  and  giving  the  best 
possible  substitute  for  the  lost  cuticle.  “ But  in  order 
that  the  full  benefit  may  be  derived  from  this  substitute, 
and  to  ensure  an  equable  and  continued  support  to  the 
tender  parts,  until  the  new  skin  is  foruied,  it  is  abso- 
lutely necessary  that  the  cotton  should  not  be  removed, 
except  under  particular  circumstances,  until  the  real 
cuticle  is  sufficiently  formed  to  bear  exposure.”— (P, 
217.)  As  Dr.  Anderson  admits,  the  theory  is  of  little 
consequence ; and  we  shall  not,  therefore,  criticise  it. 
The  merit  of  the  practice  can  be  determined  only  by  ex- 
perience. We  have  noticed,  that  Gibson  restricts  the 
plan  to  superficial  burns ; and  when  it  is  recollected, 
that  in  other  cases  the  discharge  would  soon  convert 
the  unchanged  cotton  into  a most  fetid  mass  of  scabs, 
putridity,  and  even  maggots,  one  can  hardly  doubt  that 
his  statement  is  correct.  It  is  true,  the  fetor  may  be 
counteracteU  by  wetting  the  cotton  in  a solution  of  chlo- 
ride of  lime ; but  directly  this  is  done,  the  soft  elastic 
property  of  that  substance  is  lost,  and  the  method  is  not 
essentially  different  from  that  in  which  linen  and  lint 
are  applied,  after  being  wet  with  thelinimentum  calcis, 
or  other  fluid  applications  ; and  would  equally  require 
frequent  change.  If  much  constitutional  irritation  be 
evinced  after  the  cotton  has  been  for  some  time  applied, 
Dr.  Anderson  confesses,  that  it  may  be  necessary  to  let 
out  the  discharge,  or  even  remove  the  cotton  altogether. 
“ We  are  then  to  be  guided  by  the  symptoms  and  ap- 
pearances, whether  to  reapply  the  same  dressings,  or 
first  restore  a more  healthy  action  in  the  constitution,” 
—{Op.  cit.  p.  218.) 

[The  “ exclusion  of  the  air"  is  the  tiue  indieatiem  in 
the  treatment  of  bums  ; but  it  is  imperfectly  fulfilled  by 
the  carded  cotton.  In  superficial  burns,  salt  has  long 
been  a domestic  application,  and  can  only  act  in  this 
way ; yet  when  the  part  is  completely  covered  with  a 
layer  of  salt,  the  relief  is  immediate,  and  in  superficial 
burns  is  permanent. 

Some  surgeons,  in  this  country,  treat  all  kinds  of 
burns  on  the  refrigerant  plan ; among  whom  Professor 
Davidge,  of  Maryland,  was  among  the  most  prominent. 
He  uniformly  directed  a saturnine  solution  to  be  applied 
to  all  recent  burns,  and  persevered  in  until  the  acute 
inflammation  was  subdued,  when  he  used  Turner's  ce 
rate  as  the  subsequent  dressing.  Dr.  Kentish’s  plan  is, 
however,  most  popular  in  this  country,  and  alcohol,  spi- 
rits of  turpentine,  and  the  mixture  of  linseed  oil  and 
lime-water  are  in  almost  universal  use. 

As,  however,  the  relief  afforded  in  burns  is  generally 
the  result  of  the  exclusion  of  the  air  from  the  raw  sur- 
face, the  modern  practice  introduced  on  the  continent 
of  covering  burns  with  wheat  flour,  or  other  farinaceous 
material,  will  be  found  by  far  the  most  immediate  in  its 
action,  and  the  most  successful  in  its  results  ; and  this 
application  is  adapted  to  every  species  of  burns,  “ whe- 
ther occasioned  by  scalding  or  actual  fire,  whether  su- 
perficial or  deep,  recent  or  old,  vesicated  or  sphaco- 


BUR 


BUR 


213 


lated.”  In  the  most  desperate  bums,  where  the  injury  i 
is  extensive  and  the  destruction  of  the  cutis  almost  uni- 
versal, the  patient  is  unable  to  sustain  either  the  refri- 
gerant treatment,  or  any  modification  of  Dr.  Kentish’s 
plan.  In  these  shocking  cases,  if  the  flour  be  applied 
all  over  the  injured  surface  until  the  air  is  entirely  ex- 
cluded, the  pain  is  almost  annihilated;  and  from  the 
most  excruciating  torture,  the  patient  is  instantly  placed 
under  circumstances  of  comparative  comfort.  The 
flour  should  be  repeatedly  applied,  and  persevered  in, 
until  the  acute  inflammation  is  removed,  or,  in  common 
parlance,  “ the  fire  is  out.”  No  other  application  or 
dressing  will  be  necessary  until  the  acute  stage  is  past ; 
and  then  the  plan  of  Dr.  Kentish,  modified  according  to 
the  circumstances  of  the  case,  will  be  found  adequate 
to  the  restoration  of  the  injured  surface,  however  ex- 
tensive. I can  confidently  recommend  this  practice, 
having  witnessed  its  success  in  the  most  hopeless 
cases. — Reese.] 

The  cicatrix  of  a burn  is  often  of  great  extent,  and,  on 
this  account,  the  subsequent  absorption  of  the  granula- 
tions on  which  the  new  skin  is  formed  (a  process  by  which 
the  magnitude  of  the  scar  is  afterward  lessened)  is  so  con- 
siderable, as  to  draw  the  neighbouring  parts  out  of  their 
natural  position,  and  occasion  the  most  unpleasant  kinds 
of  deformity.  Thus,  burns  on  the  neck  are  apt  to  cause 
a distortion  of  the  head,  or  even  draw  down  the  chin  to 
the  breast-bone ; and  in  the  limbs,  such  contractions  as 
fix  the  joints  in  one  immoveable  position.  Simply  di- 
viding these  contractions  again  mostly  fails  altogether, 
or  only  produces  very  partial  and  temporary  relief,  as, 
after  the  cicatrization  is  completed,  the  newly  formed 
parts  are  absorbed,  and  the  contraction  recurs.  A lew 
years  ago,  a proposal  was  made,  by  my  friend  Mr. 
Earle,  to  cut  away  the  whole  of  the  cicatrix,  and  then 
bring  the  edges  of  the  skin  as  much  towards  each  other 
as  possible,  in  the  transverse  direction,  with  strips  of 
adhesive  plaster.  In  one  case,  in  which,  from  the  fore 
part  of  the  upper  arm,  to  within  about  two  inches  of  the 
wrist,  a firm  tense  cicatrix  of  an  almost  horny  consist- 
ence extended,  which  kept  the  elbow  immoveably  bent 
to  a right  angle,  this  gentleman  performed  such  an  ope- 
ration. After  removing  the  cicatrix,  the  flexor  muscles 
at  first  made  some  resistance  to  the  extension  of  the 
limb ; but  by  degrees  they  yielded,  and  the  arm  was 
brought  nearly  to  a right  line.  The  whole  limb  was 
kept  in  this  position  by  means  of  a splint  and  bandage. 
In  the  end,  the  contraction  was  cured,  and  the  use  of 
the  limb  restored.”— (See  Med.  Chir.  Trans,  vol.  5,  p. 
96,  .S  c.) 

Probably,  as  this  patient  was  a young  growing  sub- 
ject, only  six  years  of  age,  the  operation  would  have 
proved  equally  successful,  if  a simple  division  of  the 
contracted  skin  had  been  made,  and  the  arm  kept  ex- 
tended for  a length  of  time  by  the  usd  of  a splint.  It  is 
hardly  necessary  to  observe,  that  cutting  a large  cica- 
catrix  entirely  away,  must  always  be  a severe,  and 
sometimes  a dangerous  operation ; therefore,  the  avoid- 
ance of  it,  if  possible,  cannot  but  be  desirable. — (See  B . 
Bell's  iiyslem  uf  isurirery.  Medical  Tacts  and  Observa- 
tions., vul.  2.  J.  Seddlot,  de  Jimbustiune  Theses,  4.io. 
Parisiis,  1781.  Richter's  Anfangsgriinde  der  IVun 
darzneyiiunst,  b.  1.  Earle' s Essay  on  the  Means  of 
lessening  the  Effects  of  Fire  on  the  Human  Body,  8vo. 
Load.  1799.  Kentish's  two  Essays  on  Burns,  the’ first 
of  which  was  published  in  1798.  Robert  By  all,  in  Edin. 
Med.  and  Hurg.  .Journ.  vol.  7.  p.  31.3.  Hedm,  Hiss, 
sistcns  Observationes  circa  vulnera  ex  combuslione, 
Src.  Ato.  Upsalice,  1804.  J^iUrrey,  M^moires  de  Chirur- 
gie  Militaire,  1. 1,  p.  93 — 96.  Boyer,  Traiti  des  Mala- 
dies Chir.  i.  l,p.  ICO.  Modes  Dickinson,  Remarks  on 
Burns  and  Scalds,  chiefly  in  reference  to  the  principles 
of  treatment  at  the  time  of  their  injliction,  suggested  by 
a perusal  of  the  last  edition  of  an  Essay  on  Burns,  by 
E.  Kentish,  M.  D.  8vo.  Bond.  1818.  Bectures  on  In- 
flammation, by  .John  Thomson, p.  5B5,  Src.  EiZ.'W.  1813. 
Bassos,  Pathologic  Chir.  t.  2,  p.  391.  Anderson,  in 
Olasgow  Medical  Journ.  vol.  1.  Pearson's  Principles 
of  Surgery,  p.  171,  edit.  1808.  (Jibson's  Institutes  of 
Suroery,  vol.  1,  Philadelphia.,  1824.) 

BUR.S^  MUCOSjE.  These  are  small  membranous 
sacs,  situated  about  the  joints,  particularly  the  large 
ones  of  the  upper  and  lower  extremities.  For  the  most 
part,  they  lie  under  tendons.  Mr.  Hrodie  comprehends 
also  under  the  same  head,  the  membranes  forming  the 
sheaths  of  tendons,  as  they  have  the  same  structure,  j 
and  perform  a similar  oflice.  The  celebrated  Dr.  A. 


Monro,  of  Edinburgh,  published  a very  full  account  of 
the  bursae  mucosae  and  their  diseases.  These  parts 
are  naturally  filled  with  an  oily  kind  of  fluid,  the  use 
of  which  is  to  lubricate  surfaces,  upon  which  the  ten- 
dons play  in  their  passage  over  joints.  In  the  healthy 
state,  this  fluid  is  so  small  in  quantity,  that  it  cannot 
be  seen  without  opening  the  membrane  containing  it ; 
but  occasionally  such  an  accumulation  takes  place, 
that  very  considerable  swellings  are  the  consequence. 
Tumours  of  this  sort  are  often  produced  by  bruises 
and  sprains ; and  now  and  then  by  rheumatic  affec- 
tions. They  are  not  often  attended  with  much  pain, 
though  in  some  cases  it  is  very  acute,  when  pressure 
is  made  with  the  fingers.  The  tumours  yield,  in  a 
certain  degree,  to  pressure;  but  they  rise  again,  with 
an  appearance  of  elasticity  not  remarked  in  other 
sorts  of  swellings.  At  first  they  appear  to  be  circum- 
scribed, and  confined  to  a small  extent  of  the  joint ; 
but  sometimes  the  fluid  forming  them  is  so  abundant 
that  they  extend  over  a great  part  of  the  circumference 
of  the  limb.  The  skin  when  not  inflamed  retains  its 
usual  colour. 

In  this  morbid  state  of  the  bursae  mucosae,  they  con 
fain  different  kinds  of  fluids,  according  to  the  cause  of 
the  disease.  When  the  tumour  depends  on  a rheumatic 
affection  the  contents  are  ordinarily  very  fluid.  They 
are  thicker  when  the  cause  is  of  a scrofulous  nature. 
When  the  disease  is  the  consequence  of  a bruise  or 
sprain,  the  effused  fluid  often  contains  hard  concre- 
tions, and  as  it  were  cartilaginous  ones,  which  are 
sometimes  quite  loose,  and  more  or  less  numerous. 
Mr.  Brodie  states,  that  they  have  the  appearance  of 
small  melon-seeds,  and  are  not  unusual  when  the  in- 
flammation is  of  long  standing.  Such  substances  may 
frequently  be  felt  with  the  fingers. 

In  the  greater  number  of  instances,  inflammation  of 
the  bursas  mucosae  occasions  an  increased  secretion  of 
synovia.  In  other  cases  the  bursa  is  distended  with  a 
somewhat  turbid  serum,  containing  floating  portions 
of  coagulable  lymph.  The  inflammation  sometimes 
leads  to  the  formation' of  an  abscess  ; and  occasionally 
the  membrane  of  the  bursa  becomes  thickened,  and 
converted  into  a grisly  substance.  Mr.  Brodie  has  seen 
it  at  least  half  an  inch  in  thickness,  with  a small  cellu- 
lar cavity  in  the  centre  containing  synovia.  In  other 
instances,  however,  though  the  inflammation  has  lasted 
a considerable  time,  the  membrane  of  the  bursa  retains 
nearly  its  original  structure.— (PafAoZog-fenZ  and  Sur- 
gical Obs.  on  the  Joints,  p.  351,  ed.  2.) 

According  to  the  same  authority,  the  disease  may  be 
the  consequence  of  pressure,  or  other  local  injury ; the 
abuse  of  mercury ; rheumatism,  or  other  constitutional 
affection ; and,  in  such  cases,  the  complaint  is  fre- 
quently joined  with  inflammation  of  the  synovial  mem- 
brane of  the  joints. — ^See  Joints.)  Sometimes  it  has 
the  form  of  an  .acute,  but  more  commonly  that  of  a 
chronic  inflammation. 

While  the  swellings  are  not  very  painful,  an  attempt 
may  be  made  to  disperse  them,  by  warm  applications, 
friction  (particularly  wdth  camphorated  mercurial  oint- 
ment), or  blisters,  kept  open  with  the  savin  cerate. 
But  if  these  tumours  should  become  very  painful,  and 
not  yield  to  the  above  methods,  Dr.  Monro  recommends 
opening  them.  This  author  was  continually  alarmed 
at  the  idea  of  the  bad  effects  of  air  admitted  into  cavi- 
ties of  the  body ; and  hence,  in  the  operation,  even  in 
opening  the  bursae  mucosae,  he  is  very  particular  in  di- 
recting the  incision  in  the  skin,  not  to  be  made  imme- 
diately opposite  that  made  in  the  sac, 

III  the  beginning,  Mr.  Brodie  recommends  the  use  of 
leeches  and  cold  lotions ; and  afterward,  that  of  blis- 
ters or  stimulating  liniments.  In  particular  cases,  he 
says,  these  means  should  be  combined  with  such  con- 
stitutional remedies  as  circumstances  indicate.  When 
the  disease  is  of  long  standing,  the  preternatural  secre- 
tion of  the  fluid  will  often  continue  after  the  inflamma- 
tion has  entirely  subsided.  If  blisters  now  fail  in  pro- 
curing its  absorption,  Mr.  Brodie  recommends  friction; 
and  if  this  be  unavailing,  he  considers  it  advisable  to 
discharge  the  fluid  by»a  puncture.  The  presence  of 
loose  substances  in  the  bursa,  he  thinks,  may  of  them- 
selves keep  up  a collection  of  fluid. 

Dr.  Monro  met  with  cases  in  which  amputation  be- 
came indispensable,  in  comsequcnce  of  the  terrible 
symptoms  brought  on  by  opening  a bursa  mucosa. 

On  account  of  such  evil  consequences,  which  are 
imputed  to  the  air,  though  they  would  as  often  arise 


214 


C^S 


CMS 


were  the  same  practice  pursued  in  a situation  in  which 
no  air  could  have  access  at  all,  it  has  been  recom- 
mended to  pass  a seton  through  the  swelling,  and  to  re- 
move the  silk,  after  it  has  remained  just  long  enough  to 
excite  inflammation  of  the  cyst,  when  an  attempt  is  to  be 
made  to  unite  the  opposite  sides  of  the  cavity  by  pressure. 

This  practice  is  sometimes  approved  of  by  Mr.  Bro- 
die  on  other  grounds : he  has  noticed,  that  after  the 
whole  cavity  of  tlie  bursa  has  been  converted  into 
an  abscess,  and  this  has  been  cured,  no  fluid  gene- 
rally collects  there  again.  Hence,  he  has  some- 
times been  induced  to  pass  into  the  puncture  a seton 
or  tent,  or  (what  he  deems  better)  the  blunt  end  of  a 
probe,  for  the  irritation  of  the  inner  surface  of  the 
bursa.  This  practice  I tried  very  successfully  on  a 
young  woman  who  was  under  my  care  last  year.  I 
punctured  the  bursa  below  the  patella,  and  discharged 
about  an  ounce  of  fluid,  resembling  white  of  egg.  The 
disease  had  existed  several  months,  and  the  bursa  was 
much  thickened.  I kept  the  puncture  open  about  ten 
days,  during  which  time  there  was  a discharge  from  it 
of  the  same  kind  of  fluid  without  any  tendency  to  sup- 
puration. I therefore  introduced  a tent  into  the  open- 
ing, by  which  means  the  necessary  degree  of  inflam- 
mation was  excited,  the  bursa  suppurated,  and  the  dis- 
ease was  soon  permanently  cured,  without  any  severe 
symptoms.  At  the  same  time,  I believe  Mr.  Brodie  to 
be  perfectly  right  in  cautioning  surgeons  against  the 
indiscriminate  adoption  of  this  practice.  Inflammation 
and  suppuration  of  a large  bursa  (he  says)  sometimes 
disturb  the  constitution  so  much,  that  it  might  be  pru- 


dent merely  to  make  a puncture,  and  keep  the  patient 
afterward  perfectly  quiet.  He  mentions  a diseased 
bursa  mucosa,  which  he  had  seen  between  the  lower 
angle  of  the  scapula  and  the  latissimus  dorsi,  and  which 
was  not  much  less  than  a man’s  head.  In  this  case, 
death  followed  the  constitutional  disturbance  excited 
by  a puncture  and  the  seton.  In  another  example,  seen 
by  this  judicious  surgeon,  where  the  patient  was  in 
bad  health,  and  the  due  observance  of  quietude  was 
neglected,  puncturing  a diseased  bursa  mucosa  was 
soon  followed  by  death.— (Op.  cit.  p.  360.) 

One  or  two  similar  cases,  which  happened  in  St. 
Bartholomew’s  Hospital,  have  also  been  communicated 
to  me.  In  some  instances,  the  making  of  too  free  an 
incision  into  the  bursa  mucosa  has  been  followed  by 
extensive  phlegmonous  erysipelas  of  the  whole  limb, 
ending  in  death. 

When  the  coats  of  a bursa  mucosa  are  much  thick 
ened,  and  cannot  be  restored  to  their  natural  condition, 
Mr.  Brodie  says,  that  the  bursa,  if  superficially  situ- 
ated, may  be  removed  with  as  much  facility  as  an  en- 
cysted tumour.  This  practice,  however,  he  has  only  as 
yet  applied  to  the  bursa  between  the  patella  and  the  skin, 
though  he  entertains  no  doubt  of  there  being  other  su- 
perficial bursae  which  would  also  safely  admit  of  removal. 

Consult  Muvro's  Description  of  all  the  Bursw  Mu- 
coS(e,&,-c.  with  remarks  on  their  accidents  and  diseases, 
(S-c.  fol.  Edin.  1788.  C.  Jl/.  Koch,  De  Morbis  Bnrsa- 
rum  t.evdinum  mucosarum.  And,  particularly,  B.  C. 
Brodie's  Pathological  and  Surgical  Observations  on 
the  Joints,  chap.  9,  ed.  2,  8>jo.  Land.  1822. 


c 


I^^SAREAN  OPERATION.  Called  also  Hystero- 
^ tomia,  from  varipa,  uterus,  and  ropy,  sectio. 
Pliny,  book  7,  chap.  9,  of  his  Natural  History,  gives  us 
the  etymology  of  this  operation.  “ Auspicatius  (says 
he)  enectd  parente  gignuntur,  sicut  Scipio  Africanus 
prior  natus,  primusque  CcBsar  a,  caeso  matris  utero 
dictus ; qua  de  causa  caesones  appellati.  Simili  modo 
natus  est  Manlius  qui  Carthaginem  cum  exercitu  in- 
travit.” 

From  this  passage  we  are  to  infer  that  the  Caesarean 
operation  is  extremely  ancient,  though  no  description 
of  it  is  to  be  found  in  the  works  of  Hippocrates,  Celsus, 
Paulus  .®gineta,  or  Albucasis.  The  earliest  accouni 
of  it  in  any  medical  work,  is  that  in  the  Chirurgia 
Guidonis  de  Cauliaco,  published  about  the  middle  of 
the  fourteenth  century.  Here,  however,  the  practice  is 
only  spoken  of  as  jiroper  after  the  death  of  the  mother, 
and  is  alleged  to  have  been  adopted  only  at  such  a 
conjunciure  in  the  case  of  Julius  Csesar.— (See  Cap.  de 
Extractione  Foetus.)  Vigo,  who  was  born  towards 
the  close  of  the  fifteenth  century,  takes  no  notice  of  the 
Caesarean  operation  ; and  Pare,  who  greatly  improved 
the  practice  of  midwifery,  thinks  this  measure  only 
allowable  on  women  who  die  undelivered. — (De  Homi- 
nus  Generatione,  cap.  31.)  Rousset,  who  was  contem- 
porary with  Par^,  collected  the  histories  of  several 
cases,  in  which  the  operation  is  said  to  have  been  suc- 
cessfully performed ; and,  after  the  publication  of  these, 
the  subject  excited  more  general  interest. 

By  the  Cassarean  operation  is  commonly  understood 
that  in  which  the  foetus  is  taken  out  of  the  uterus,  by 
an  incision  made  through  the  parietes  of  the  abdomen 
and  womb.  The  term,  however,  in  its  most  compre- 
hensive sense,  is  applied  to  three  different  proceedings. 
It  is  sometimes  employed  to  denote  the  incision  which 
is  occasionally  practised  in  the  cervix  uteri,  in  order  to 
facilitate  delivery ; but  this  particular  method  is  named 
the  vaginal  Caesarean  operation,  for  the  purpose  of 
distinguishing  it  from  the  former,  which  is  frequently 
called,  by  way  of  contrast,  the  abdominal  Cassarean 
operation.  With  these  cases  we  have  also  to  class 
the  incision  which  is  made  in  the  parietes  of  the  abdo- 
men for  the  extraction  of  the  *fof;tus,  when,  instead  of 
being  situated  in  the  uterus,  it  lies  in  the  cavity  of  the 
peritoneum,  in  consequence  of  the  rupture  of  the  womb, 
or  in  the  ovary,  or  Fallopian  tube,  in  consequence  of 
an  extra- uterine  conception. 

VAOINAL  C.1';SAREaN  OPERATION. 

Disease,  malformation,  or  a i)reternamral  position  of 


the  cervix  uten,  may  render  this  practice  indispensable. 
A scirrhous  hardness  of  the  neck  of  the  uterus  is  the 
most  frequent.  When  the  induration  is  such  that  the 
cervix  cannot  be  dilated,  and  the  patient  is  exhausting 
herself  with  unavailing  efforts,  the  parts  should  be 
divided  in  several  directions.  This  has  been  success- 
fully done  under  various  circumstances.  Cases  have 
been  met  with,  in  w'hich  the  cervix  uteri  presented  no 
opening  at  all ; and  yet  the  preceding  operation  proved 
quite  effectual.  Such  is  the  example  which  Dr.  Sim- 
son  l>as  inserted  in  the  third  volume  of  the  Edinburgh 
Essays.  A woman,  forty  years  of  age,  became  preg- 
nant, after  recovering  from  a difficult  labour,  in  which 
the  child  had  remained  several  days  in  the  passage. 
She  had  been  in  labour  sixty  hours  ; but  the  neck  of  the 
womb  had  no  tendency  to  dilate.  Dr.  Simson,  per- 
ceiving that  its  edges  were  adherent,  and  left  no  open- 
ing between  them,  determined  to  practise  an  incision, 
with  the  aid  of  a speculum  uteri.  The  bistoury  pene- 
trated to  the  depth  of  half  an  inch,  before  it  got  quite 
through  the  substance  which  it  had  to  divide,  and 
which  seemed  as  hard  as  cartilage.  As  the  opening 
did  not  dilate,  in  the  efforts  which  the  woman  made,  it 
became  necessary  to  introduce  a narrow  bistoury  on 
the  finger,  in  order  to  cut  this  kind  of  ring  in  various 
directions.  There  was  no  hemorrhage ; and  the  only 
additional  suffering  which  the  patient  encountered, 
arose  fVom  the  distention  of  the  vagina.  As  the  child 
was  dead.  Dr.  Simson  perforated  the  head,  in  order  to 
render  the  delivery  more  easy. 

Strong  convulsions  at  the  moment  of  partuntion, 
may  create  a necessity  for  the  vaginal  Caesarean  ope- 
ration. These  sometimes  subside  as  soon  as  the  mem- 
branes are  ruptured  and  the  waters  discharged,  so  as 
to  lessen  the  distention  of  the  womb.  However,  if  the 
convulsions  were  to  continue,  and  the  cervix  uteri 
were  sufficiently  dilated,  the  child  should  be  extracted 
with  the  forceps  or  by  the  feet,  according  to  the  kind 
of  presentation.  On  this  subject  Baudeloque  has  re- 
corded a fact,  which  was  cmnmunicaled  to  the  Academy 
of  Surgery  by  Dubocq,  professor  of  surgery  at  Tou- 
louse. The  woman  was  forty  years  of  age,  and  had 
been  in  convulsions  two  days.  She  was  so  alarmingly 
pale,  that  she  could  scarcely  be  known.  Her  pulse 
was  feeble  and  almost  extinct,  and  her  extremities 
were  cold  and  covered  with  a clammy  perspiration. 
The  edges  of  the  opening,  which  was  about  as  large 
as  a crown  piece,  felt,  as  it  were,  callous ; and  hardly 
had  this  a[)erlure  been  dilated,  when  delivery  took 
place  spontaneously.  The  child  was  dead.  The  sj  trip- 


CiESAREAN  OPERATION. 


215 


totns  were  appeased,  and  the  woman  experienced  a 
perfect  recovery.  Another  case,  in  which  the  indurated 
cervix  uteri  was  successfully  divided,  is  recorded  by 
Lambron,  a surgeon  at  Orleans. — (See  Diet,  des  Sci- 
ences Med.  L 23,  p.  297.) 

A considerable  obliquity  of  the  neck  of  the  womb, 
combined  with  a pelvis  of  small  dimensions,  may  also 
be  a reason  for  the  performance  of  the  vaginal  Cae- 
sarean operation.  Not  that  such  obliquity  always  oc- 
casions that  of  the  rest  of  the  uterus ; nor  is  the  neck 
of  this  viscus  invariably  directed  towards  that  side  of 
the  pelvis  which  is  opposite  to  its  fundus,  although 
this  is  sometimes  the  case.  In  the  latter  circumstance, 
as  the  contractions  of  the  uterus  do  not  produce  a dila- 
tation of  its  cervix,  which  rests  upon  the  bones  of  the 
pelvis,  the  adjacent  part  of  that  organ  is  dilated  and 
jiushed  from  above  downwards,  so  as  to  present  itself 
in  the  tbrm  of  a round  smooth  tumour,  without  any 
appearance  of  an  aperture.  Such  a case  may  have 
fatal  con-sequences.  Baudeloque  furnishes  us  with  an 
instance.  A woman  in  her  first  pregnancy,  not  being 
able  to  have  the  attendance  of  the  accoucheur,  whom 
she  wished,  put  herself  under  the  care  of'a  midvvrife, 
who  let  her  continue  in  labour-pains  during  three  dap. 
When  the  accoucheur  came,  on  being  sent  for  again, 
the  child’s  head  presented  itself  in  the  vagina  covered 
with  the  womb.  The  portion  of  the  uterus  which  in- 
cluded the  foetus,  was  in  a state  of  infiammation.  The 
os  tincae  was  situated  backwards  towards  the  sacrum, 
hardly  dilated  to  the  breadth  of  a penny-piece,  and  the 
waters  had  been  discharged  a long  time.  The  patient 
was  bled,  and  emollient  clysters  were  administered. 
All  sorts  of  fomentations  were  employed.  She  was 
laid  upon  her  back  with  the  pelvis  considerably  raised. 
The  a(Xoucheur  had  much  difficulty  in  supporting  the 
head  of  the  child,  and  keeping  it  from  protruding  at 
the  vulva,  enveloped  as  it  was  in  the  uterus.  Notwith- 
standing such  assistance,  the  patient  died. 

So  fatal  an  event,  says  Sabatier,  might  have  been  | 
prevented,  by  making  thie  woman  lie  upon  the  side  op- 
posite the  deviation  of  the  uterus,  and  employing  pres- 
sure from  above.  If  these  proceedings  had  failed  in 
bringing  the  os  tincae  towards  the  centre  of  the  pelvis, 
this  opening  might  have  been  brought  into  such  posi- 
tion by  means  of  the  finger,  in  the  interval  of  the  pains, 
and  kept  so  until  it  were  sufficiently  dilated  for  the 
membranes  to  protrude. 

This  is  what  was  done  by  Baudeloque  in  one  case, 
where  the  womb  inclined  forwards  and  to  the  right. 
The  os  tincae  was  situated  backwards.  The  waters 
escaped  and  the  head  advanced  towards  the  bottom  of 
the  pelvis,  included  in  a portion  of  uterus  The  whole 
of  the  spherical  tumour  which  presented  itself  could 
be  felt  with  the  finger;  but  no  opening  was  distinguish- 
able ; and  the  swelling  might  also  be  seen  on  separat- 
ing the  labia  from  each  other  and  opening  the  entrance 
of  the  vagina.  It  became  necessary  to  keep  the  patient 
continually  in  bed,  and  to  have  the  finger  incessantly 
introduced  ; but  she  was  not  sufficiently  docile  to  sub- 
mit to  such  treatment.  Fortunately,  the  unexpected 
appearance  of  two  officers  of  Justice,  forty-eight  hours 
after  the  commencement  of  the  labour,  had  the  effect  of 
making  her  more  manageable.  It  w-as  time  for  tier 
to  become  .so ; for  the  uterus  had  now  become  tense, 
red,  and  painful.  The  abdomen  was  also  so  tender, 
that  it  could  scarcely  bear  the  contact  of  the  clothes. 
Febrile  symptoms  had  begun,  and  the  ideas  were  be- 
ginning to  be  confused.  Baudeloque  made  her  lie 
down ; and  he  pressed  with  one  hand  on  the  abdomen, 
for  the  purpose  of  raising  the  uterus,  while  with  the 
other  he  pushed  the  head  a little  way  back,  in  order 
that  he  might  reach  the  os  tincse,  which  he  now 
brought  with  his  finger  towards  the  centre  of  the  pelvis, 
and  kept  there  for  some  time.  The  efforts  of  the  pa- 
tient being  thus  encouraged,  she  was  delivered  in 
about  a quarter  of  an  hour.  The  infant  was  of  a thriv- 
ing description,  and  the  case  had  a most  favourable 
termination. 

When  the  obliquity  of  the  uterus  is  such,  that  the  os 
tinea;  cannot  be  Ibund,  and  the  mother  and  feetus  are 
both  in  danger  of  perishing,  it  is  the  duty  of  the  prac- 
titioner to  open  the  portion  of  the  womb  that  projects 
towards  the  vulva.  Lauverjat  met  with  a case  of  this 
description  in  his  practice.  A woman,  pregnant  with 
her  first  child,  suffered  such  extreme  pain  in  her  labour, 
that  l.auverjat  was  solicited  to  ascertain  the  real  state  ! 
of  things,  lie  was  surprised  to  find  the  vulva  com- ^ 


pletely  occupied  by  a body  which  even  protruded  ex- 
ternally and  yielded  to  the  pressure  of  the  fingers,  e.x- 
cept  during  the  labour-pains.  In  examining  this  tumour 
Jie  could  only  find  .at  its  circumference  a cul-de-sac, 
half  an  inch  deep,  without  any  aperture  through  which 
the  child  could  pass.  Other  practitioners,  who  were 
consulted  about  this  extraordinary  case,  were  also 
anxious  to  learn  what  had  happened.  They  found  in 
the  tumour  a laceration,  which  only  affected  a part  of 
the  thickness  of  its  parietes.  This  laceration  was 
deemed  the  proper  place  for  making  an  incision.  The 
operation  having  been  done,  the  finger  was  passed  into 
the  cavity  in  which  the  child  was  contained.  A large 
quantity  of  turbid  fluid  was  discharged.  The  child 
presented  and  passed  thi'ough  the  opening,  with  a tri- 
vial laceration  on  the  right  side.  Lauverjat,  having 
passed  his  hand  into  the  utherus,  was  unable  to  find 
either  the  os  tineas  or  the  cervix.  No  particular  indis- 
position ensued,  and  the  lochia  were  discharged  through 
the  wound,  which  gradually  closed.  In  the  course  of 
two  months  the  os  tincae  and  neck  of  the  uterus  were 
in  their  natural  position  agam.— {Lauverjat,  Nouvelle 
M thode  de  pratiquer  I’Operation  Cesarienne.  Paris, 
1788.) 

When  the  case  is  a scirrhous  induration  of  the  cer- 
vix uteri,  or  a laceration  of  the  parietes  of  this  viscus 
at  the  place  where  it  projects  into  the  vagina,  the  va- 
ginal Cssarean  operation  is  attended  with  no  difficulty. 
It  is  performed  with  a blunt-pointed  bistoury,  the  blade 
of  which  is  wrapped  round  with  lint  to  within  an  inch 
of  the  point.  The  instrument  is  to  be  introduced,  un- 
der the  guidance  of  the  index  finger,  into  the  opening 
presented  by  the  uterus,  and  the  aperture  is  to  be  pro- 
perly enlarged  from  within  outwards,  in  various  direc- 
tions. But  when  the  scirrhous  hardness  of  the  cervix 
presents  no  oi)ening  at  all,  or  when  the  part  of  the  ute- 
rus projecting  in  the  vagina  is  entire,  the  incision 
should  be  made  from  without  inwards,  with  the  same 
I kind  of  knife.  Too  much  caution  cannot  be  used  in 
introducing  the  instrument,  in  order  that  no  injury 
may  be  done  to  the  child,  w'hich  lies  directly  beyond 
the  substance  which  is  to  be  divided.  No  general  di- 
rection can  here  be  offered,  except  that  of  proceeding 
slowly,  and  ot  keeping  the  index  finger  extended  along 
the  back  of  the  knife,  so  that  it  may  be  immediately 
known!  when  the  substance  of  the  womb  is  cut  through, 
into  the  cavity  of  which  the  finger  ought  to  pass  as 
soon  as  the  knife.  If  it  should  be  necessary  to  extend 
or  multiply  the  incisions,  the  cutting  instrument  should 
he  regulated  in  a similar  manner  with  the  same  finger. 
The  cerv'ix  uteri  having  been  divided,  the  expulsion  of 
the  child  is  either  to  be  left  to  nature,  or  to  be  pro- 
moted by  the  ordinary  means.  The  operation  that  has 
been  described  requires  no  dressings.  If  the  bleeding 
should  prove  troublesome,  we  are  recommended  to 
apply  to  the  inci.sion  a dossil  of  lint  wet  with  vinegar 
or  spirit  of  wine.— (See  Sabatier,  Medecine  Op^ratoire, 
t.  1.)  The  chief  object  would  here  be  to  prevent  adhe- 
sions between  the  cervix  of  the  uterus  and  the  upper 
part  of  the  vagina. — (Diet,  des  Sciences  Mid.  t.  23, 
p.  298.) 

AUrOMINAL  C^SSAREAN  OPERATION. 

This  is  a far  more  serious  operation  than  that  which 
has  just  now  been  treated  of,  and  is  the  proceeding  to 
which  the  term  Caesarean  operation  is  more  particularly 
applied. 

There  are  three  cases  in  which  this  operation  may 
be  necessary.  1.  When  the  feetus  is  alive  and  the  mo- 
ther dead,  either  in  labour,  or  the  last  two  months  of 
pregnancy.  2.  When  the  fetus  is  dead,  but  cannot  be 
delivered  in  the  usual  way,  on  account  of  the  deformity 
of  the  mother,  or  the  disproportionate  size  of  the  child, 
3.  When  both  the  mother  and  child  are  living,  but  de- 
livery cannot  take  place  from  the  same  causes,  as  in 
the  second  example. 

In  many  instances,  both  mother  and  child  have  lived 
after  the  C®sarean  operation,  and  the  mother  even  borne 
children  afterward.— (See  Heister’s  Jn-ttitutes  of  Si{r- 
gery,  chap.  113.  Mejyi.  de  VAcnd.  de  Chirurgie,  t.  \,  p. 
C23,  t.  2,  p.  308,  in  ito.  Edm.  Med.  Essays,  vol.  5,  art. 
37,  38.  Edin.  Med.  and  Surgical  Journal,  vol.  4,  p.  179. 
Med.  Chir.  Trans,  vol.  9 and  11,  ^V-c.)  Very  recently 
an  example  has  been  recorded,  in  which  Dr.  MiiUer,  of 
Lovvenburg,  in  Silesia,  performed  the  Cffisarean  sec- 
tion, and  saved  both  the  mother  and  the  child.— (jVfoira- 
zin/ur  die  gesanurJe  IkiUcunde,  1828;  b.  28,  p.  140.) 


216 


Ci?:SAREAN  OPERATION. 


An  instance  of  similar  success  is  reported  by  C.  H. 
Graefe. — {Journ.  fur  Chirurgie,  i^-c.  b.  9,  s.  1.)  Two 
successful  cases,  in  which  both  women  and  children 
were  operated  on  at  the  hospital  of  Maestricht,  by 
Bosch.— Med.  1823.)  And  in  a valuable  periodical' 
work,  one  e.xample  is  reported  from  Hufeland’s  Jour- 
nal, where  the  mother  and  twins  were  all  saved  by  the 
operation. — (See  Quarterly  Journ.  of  Foreign  Medicine, 
<i5-c.  vol.  4,  p.  625.) 

The  most  extraordinary  case  of  Caesarean  operation 
on  record,  is  one  performed  by  a negro  girl  on  herself, 
who  recovered. — (See  New-York  Med.  and  Physical 
Journ.  March,  1823.)  Dr.  Mosely  mentions  the  case 
of  a negro  woman  at  Jamaica,  who  opened  her  side 
with  a butcher’s  knife,  and  extracted  a child,  which 
died  of  locked-jaw.  The  woman  recovered.— (See  Ry- 
an's Manual  of  Midwifery,  p.  280.) 

In  England,  the  operation  has  been  attended  with 
remarkably  ill  success  ; and  perhaps  there  is  not  one 
unequivocal  example,  in  which  the  mother  has  here 
survived  the  true  Caesarean  operation.  In  the  tliird 
edition  of  this  work,  indeed,  I referred  to  the  case  re- 
corded by  Mr.  James  Barlow,  of  Chorley,  Lancashire, 
who  made  an  incision  into  the  abdomen,  extracted  a 
dead  child,  and  saved  the  mother’s  life.— (See  Medical 
Records  and  Researches,  p.  154,  1798  ; also,  J.  Barlow's 
Essays  on  Surgery  and  Midwifery.)  My  friend  Dr. 
Gooch,  however,  having  obligingly  communicated  to 
me  his  doubts,  and  those  of  Dr.  Hull,  respecting  the 
reality  of  an  incision  having  been  made  in  this  instance 
into  the  uterus,  I am  glad  to  have  the  opportunity  of  ex- 
pressing my  perfect  conviction  of  the  more  correct 
view  of  the  case  taken  by  these  physicians.  “ I sus- 
pected from  the  first  (says  Dr.  Hull),  that  Mr.  Barlow 
was  deceived  in  this  case,  from  the  account  he  gave  of 
the  remarkable  thinness  of  the  uterus.  And  I had 
formed  an  opinion,  that  the  child  had  escaped  through 
a laceration  of  the  uterus  into  the  abdomen,  enveloped 
in  the  secundines,  and  that  he  had  merely  divided  the 
membranes,  when  he  fancied  he  had  divided  the  uterus.” 
Dr.  Hull  then  proceeds  to  explain  the  confirmation  of 
his  own  sentiments  by  those  of  Mr.  Ho  warden,  a very 
intelligent  practitioner  at  Blackrod,  who  assisted  at  the 
operation.  In  fact,  the  particulars  stated  by  this  gen- 
tleman leave  no  doubt,  that  the  foetus  had  escaped 
through  a laceration  of  the  uterus  into  the  cavity  of  the 
abdomen.  —(See  Hull's  Defence  of  the  Caesarean  Ope- 
ration, Arc.  p.  72.)  The  case  also  referred  to  by  Mr.  D. 
Stewart  (see  Edin.  Med.  Essays,  vol.  5),  where  the 
labour  had  endured  twelve  days,  and  the  life  of  the 
mother  was  saved,  after  the  dead  fcetus  had  been  ex- 
tracted by  a midwife,  was  also  probably  of  the  same 
nature  : at  all  events,  the  want  of  authentic  particulars, 
and  the  circumstance  of  the  operation  having  been 
done  by  a woman,  leave  the  true  nature  of  the  case 
questionable. 

If,  therefore,  when  we  speak  of  the  Caesarean  ope- 
ration, we  mean  that  in  which  the  parietes  of  the  ab- 
domen and  those  of  the  uterus  are  divided  by  the  sur- 
geon, and  the  foetus  extracted,  I believe,  that  as  far  as 
the  history  of  the  practice  extends  in  this  country,  it 
cannot  be  said,  that  the  mother  has  ever  recovered 
after  such  a proceeding ; though,  some  years  ago,  a cal- 
culation was  made,  that  the  operation  had  been  done 
not  less  than  eighteen  times  in  Great  Britain ; and 
since  then  it  has  been  repeated  in  several  instances 
with  the  same  ill  success. — (See  Henderson's  Case,  in- 
Ed.  Med.  and  Surg.  Journ.  vol.  17.)  It  is  said  now, 
indeed,  to  have  been  performed  about  thirty  times  in 
the  British  dominions. — (See  Ryan's  Manual  of  Mid- 
wifery, p.  270.)  Several  of  the  children,  however,  are 
stated  to  have  been  saved.  And  in  the  case  operated 
upon  ill  April.  1826,  by  Mr.  Crichton,  of  Dundee,  the 
infant  was  preserved,  though  the  mother  sunk  eight 
hours  after  the  operation.— (See  Edin.  Med.  and  Sur- 
gical Journ.  No.  96,  p.  54.)  On  the  continent,  the 
practice  has  proved  infinitely  more  successful ; for 
of  231  cases  of  this  operation  to  be  found  in  the  records 
of  medicine,  139  are  said  to  have  terminated  success- 
fully.— {Kellie  in  Edin.  Med.  and  Surgical  Journ.  vol. 
8,  p.  17.)  No  doubt,  the  ill  success  of  the  Ctesarean 
operation  in  England  was  correctly  explained  by  Dr. 
Hull : “ In  France,  and  some  other  nations  upon  the 
European  continent,  the  Caesarean  operation  has  been, 
and  continues  to  be,  performed  where  Hritish  jiracti- 
tioners  do  not  think  it  indicated  ; it  is  also  had  recourse 
to  early,  before  the  strength  of  the  mother  ha-s  been 


exhausted  by  the  long  continuance  and  frequent  repe- 
tition of  tormenting,  though  unavailing  pains,  and  be- 
fore her  life  is  endangered  by  the  accession  of  inflam- 
mation of  the  abdominal  cavity.  From  this  view  of 
the  matter,  we  may  reasonably  expect,  that  recoveries 
will  be  more  frequent  in  France  than  in  England  and 
Scotland,  where  the  reverse  practice  obtains.  And  it 
is  from  such  cases  as  these,  in  which  it  is  employed 
in  France,  that  the  value  of  the  operation  ought  to  be 
appreciated.  Who  would  be  sanguine  in  his  expecta- 
tion of  a recovery  under  such  circumstances,  as  it  has 
generally  been  resorted  to  in  this  country,  namely, 
where  the  female  has  laboured  for  years  under  mala- 
costion  {mollities  ossium),  a disease  hitherto  in  itself 
incurable ; where  she  has  been  brought  into  imminent 
danger  by  previous  inflammation  of  the  intestines,  or 
other  contents  of  tlie  abdominal  cavity ; or  been  ex- 
hausted by  a labour  of  a week’s  continuance,  or  even 
longer  !”  *Dr.  Hull  thus  refutes  the  opinion  of  Mr.  W. 
Simmons,  that  our  ill  success  was  owing  to  climate, 
or  some  peculiarity  in  the  constitutions  of  the  females 
of  this  island.— (See  Hull's  Defence  of  the  Caesarean 
Operation,  p.  10.) 

The  general  readiness  of  continental  practitioners  to 
have  recourse  to  the  Caesarean  section  has  been  some- 
times censured,  because  they  have  even  operated  in 
cases  in  which  the  patients  had  previously  borne  chil- 
dren in  the  natural  way.  According  to  Dr.  Ryan,  how- 
ever, there  are  but  four  such  cases  on  record  : “ One 
by  Nagele  in  his  Erfakrungen  und  Abhandl.  aus  dem 
Gebiete  des  Krankheiten  des  Weiblichen  Geschlechts ; 
another  by  Henderson,  in  the  Edin.  Med.  and  Surg. 
Journ.  No.  66 ; a third  by  Meier,  in  Siebold's  Journ. ; 
and  a fourth  in  the  same  .lourn.  by  Berger.”—  (See  Ry- 
an's  Manual  of  Midwifery,  p.  279.)  Certainly,  if  a 
womgn  had  already  borne  children  in  the  natural  way, 
the  fact  should  be  received  as  a strong  argument  against 
the  necessity  of  the  operation,  but  perhaps  not  as  an 
absolute  prohibition,  since  every  thing  must  depend  on 
the  actual  dimensions  of  the  lower  aperture  of  the  pel- 
vis in  relation  to  the  size  of  the  existing  foetus. 

When  the  foetus  is  contained  in  the  womb,  and  can- 
not be  expelled,  by  reason  of  the  invincible  obstacles 
to  which  I have  already  referred,  and  embryotomy,  or 
the  practice  of  sacrificing  the  foetus  and  extracting  it 
it  piecemeal  by  the  vagina,  be  deemed  improper,  the 
Caesarean  operation  should  be  practised,  before  the 
mother  and  foetus  both  perish  from  the  violence  of  the 
pains,  hemorrhage,  convulsions,  &c. 

For  this  purpose  it  is  necessary  to  make  an  extensive 
incision  in  the  integuments  of  the  abdomen,  and  in  the 
uterus.  Some  have  thought  that  cutting  the  parietes 
of  the  belly  would  be  mortal ; while  others  have  be- 
lieved a wound  of  the  uterus  equally  dangerous. 
Hence  such  persons  have  condemned  the  operation  on 
the  principle  that  religious  reasons  do  not  authorize 
taking  one  life  to  save  another.  All  the  opponents 
of  the  Caesarean  operation  fear  the  hemorrhage  which 
they  say  must  follow.  Indeed,  if  the  uterus  were  not 
to  contract  sufficiently  when  the  foetus  and  after-birth 
had  come  away,  the  bleeding  would  really  be  perilous. 
But  when,  by  means  of  the  Caesarean  operation,  the 
foetus  is  extracted,  together  with  the  placenta  and  mem- 
branes, the  uterus  contracts  just  as  it  does  after  a na- 
tural labour.  Besides,  even  when  the  mother  is  alive, 
the  operation  is  not  commonly  done  till  the  uterus 
evinces  a propensity  to  deliver  itself,  and  begins  to 
contract.  The  womb  being  delivered  of  its  contents, 
the  incision  becomes  closed,  the  vessels  obliterated, 
and  there  is  no  fear  of  hemorrhage.  The  wound  must 
also  make  so  irritable  an  organ  more  disposed  to  con- 
tract ; but  whatever  arguments  may  be  adduced,  it  is 
enough  to  say  in  this  case,  Artem  experientia  fecit,  ex- 
emplo  monstrante  viam.  Roiisset,  in  1581,  published 
a work  in  French,  entitled  Hysterotomie,  ou  V Ac- 
couchement Cesarean.  This  book,  in  1601,  was  trans- 
lated into  Latin,  and  enlarged  with  an  appendix  by  the 
celebrated  Bauhin.  Even  then  the  practice  of  the  Cae- 
sarean operation  on  the  living  mother  had  its  defend- 
ers. Bauhin  relates,  that  in  the  year  1500  a sow-gelder 
performed  the  Caesarean  operation  on  his  wife,  tarn  fe- 
liciter,  ut  eaposted  gemellos  et  qvatuor  adhuc  infantes 
enixa  fuerit.  This  is  said  to  be  the  first  instance  in 
which  the  operation  was  ever  done  on  the  living  mother 
with  success.  Many  other  cases  were  afterward  col 
lected  and  published. 

'J'lie  possibility  of  operating  successfully  on  the 


CiESAREAN  OPERATION. 


217 


living  mother  was  proved  with  great  perspicuity  and 
accuracy  by  Simon,  in  theM  moires  de  I' Acad,  de  Chi- 
rurgie,  t.  1,  4to.  Here  we  are  presented  with  a col  ec- 
tion  of  sixty-four  Caesarean  operations,  more  than  a 
half  of  which  had  been  done  on  thirteen  women.  Some 
of  these  had  undergone  the  operation  once  or  twice  ; 
others  five  or  six  times.  There  was  one  woman  in 
particular  who  had  undergone  it  seven  times,  and  al- 
ways with  success.  This  seems  to  prove,  notwith- 
standing ail  assertions  to  the  contrary,  that  the  opera- 
tion for  the  most  part  succeeds.  But  if  the  life  of  the 
mother  should  not  invariably  be  preserved,  the  Caesa- 
rean operation  ought  not  to  be  rejected  on  this  account; 
it  ought  always  to  be  done  when  relief  cannot  be  ob- 
tained by  other  means  ; just  as  amputation  and  litho- 
tomy are  practised,  though  they  are  not  constantly  fol- 
lowed by  success.  Would  any  thing  be  more  cruel 
than  to  abandon  a mother  and  her  child,  and  leave  them 
to  perish  while  there  is  any  hope  of  saving  them  both  1 
It  is  true,  that  when  a pregnant  woman  dies  of  any  in- 
ward disorder,  and  not  from  the  pains  and  efforts  of 
labour,  the  foetus  is  sometimes  still  alive  in  the  uterus; 
but  in  cases  of  death  after  difficult  labours,  and  the 
great  efforts  made  by  the  uterus  to  overcome  the  ob- 
stacles to  parturition,  the  foetus  is  generally  dead  ; and 
the  operation  therefore  is  less  likely  to  be  availing. — 
(See  Bertrandi,  Traite  des  Operations  de  Chirurgic, 
chap.  5.) 

It  is  the  opinion  of  the  best  writers  upon  this  sub- 
ject, that  whenever  a woman  dies  at  all  advanced  in 
pregnancy  the  performance  of  the  Caesarean  opera- 
tion is  highly  proper.  The  propriety  of  this  practice 
in  such  circumstances  was  known  to  the  ancient  Ro- 
mans ; for  by  a decree  of  Nnma  Pompilius,  no  woman 
who  died  pregnant  was  suffered  to  be  buried,  ere  her 
body  had  been  opened,  with  the  view  of  preserving  the 
infant  for  the  use  of  the  state.— (Sprengel,  Geschichte 
derChir.th.  i,  p.  371.)  Experience  has  proved,  that 
when  the  foetus  has  not  attained  the  period  at  which 
parturition  commonly  happens,  it  will  sometimes  sur- 
vive the  operation  a considerable  time,  and  that  when 
it  is  full  grown  its  life  may  be  most  happily  preserved. 
Although  instances  are  cited,  in  which  the  foetus  in 
utero  has  been  found  alive  upwards  of  four-and  twenty 
hours  after  the  death  of  the  mother,  little  stress  should 
be  laid  on  such  prodigies.  The  operation  ought  to  be 
done  without  any  delay.  Even  then  we  are  not  certain 
of  saving  the  infant’s  life.  In  the  greater  number  of 
instances  the  foetus  perishes  at  the  same  time  with  the 
mother,  and  from  the  same  causes.  The  cases  which 
are  recorded  of  the  foetus  being  extracted  alive  after 
the  death  of  the  mother,  are  numerous : I shall  here 
only  refer  to  three,  two  of  which  rest  on  the  unim- 
peachable authority  of  Flajani,  whtr  was  himself  the 
operator. — {Collezione  di  Osservazioni,  <Src.  di  Chirur- 
gia,  t.  3,  p.  144 — 146.)  In  one  of  these  instances,  the 
operation  was  done  on  a woman  killed  by  violence  in 
the  ninth  month  of  pregnancy ; the  child  lived  six 
hours ; in  the  other,  a foetus  was  extracted  from  a wo- 
man who  had  died  of  typhus  fever  in  the  seventh 
month,  and  though  the  operation  was  not  done  till  she 
had  been  dead  about  an  hour,  the  child  was  taken  out 
alive,  and  continued  to  live  full  ten  minutes.  A living 
child  was  also  taker,  out  of  its  mother  by  Vesling, 
after  her  death  by  typhus.— (VTeisc/i.  Obs.  Med.  Epi- 
sagm.  No.  74,  p.  47 ; Sprengel,  Geschichte  der  Chir.  th. 

1,  p.  374.)  On  the  15th  of  April,  1820,  Mr.  Green,  of 
St.  Thomas’s  Hospital,  extracted  by  the  Caesarean  ope- 
ration, from  a woman  suddenly  killed  in  the  ninth 
month  of  pregnancy  by  the  passage  of  a stage  coach 
over  her,  a feetus  that  lived  34  hours  after  its  re- 
moval from  the  uterus. — (See  Med.  Chir.  Trans,  vol. 
12,  p.  46.)  With  respect  to  the  statements  of  Cangia- 
mila,  a Sicilian  practitioner,  I join  Si)rengel  in  consi- 
dering them  as  incredible  exaggerations  : five  instances 
are  given,  in  which  the  fretiis  was  taken  out  of  the 
mother  from  fifteen  to  twenty-four  hours  after  her 
death,  and  yet  it  continued  to  live.  Cangiamila  says, 
that  at  Syracuse,  in  tiie  course  of  eighteen  years,  the 
operation  had  been  practised  twenty  times  under  the 
same  circumstances ; that  at  Girgenti,  thirteen  chil- 
dren were  saved  out  of  twenty-two  women  who  had 
died  pregnant ; and  that  in  twenty-four  years,  at  Mon- 
tereali,  twenty-one  children  were  preserved  in  the  same 
Tnam\ex .—{Einbryologia  Sacro.  Venet.  1763,  fol.)  As 
Sprengel  remarks,  one  might  almost  suppose' from  this 
account,  that  in  Sicily  pregnancy  was  generally  fatal. 


If  the  mother  should  happen  to  die  in  labour,  .and  the 
neck  of  the  uterus  were  sufficiently  dilated,  or  dis- 
posed to  be  so,  an  attempt  should  be  made  to  accom- 
plish delivery  in  the  ordinary  w ay ; for  examples  have 
occurred  in  which  women,  supposed  to  be  dead  in  this 
circumstance,  were  in  reality  alive.  Hence  we  find 
that  the  Senate  of  Venice,  in  16u8,  enacted  a law,  by 
which  jiractitioners  were  liable  to  punishment  in  case 
they  neglected  to  operate  with  as  much  caution  on  a 
pregnant  woman  supposed  to  be  dead,  as  on  a living  sub- 
ject ; and  rules  to  be  observed  were  again  issued  by  the 
same  government  in  1120.— {Seb.  Melli,  La  Commare 
levatrice,p.  108, 4to.  Venez.  1721;  Persone,  Diss.  sopra 
VOperaz.  Cesar,  jx  15,  8?’o.  V.  nez.  1778.)  A law  to  the 
san.e  effect  was  likewise  made  in  1749,  by  the  king  of 
Sicily,  who  decreed  the  punishment  of  death  to  those 
medical  men  who  omitted  to  perform  the  Caesarean 
operation  on  such  women  as  died  in  the  advanced 
stages  of  pregnancy.  In  the  Journal  des  Sgavans  de 
Janvier,  1749,  the  following  case,  confirming  the  pro- 
priety of  such  caution,  was  inserted  by  Rigaudeaux, 
surgeon  to  the  military  hospital  at  Douay.  This  prac- 
titioner having  been  sent  for  to  a woman,  to  whose  re- 
sidence he  was  unable  to  proceed  till  two  hours  after 
her  apparent  death,  he  had  the  sheet  with  which  she 
was  covered  removed,  and  perceiving  that  the  body 
retained  its  suppleness  and  warmth,  he  tried  whether 
the  feetus  could  not  be  extracted  in  the  ordinary  way, 
which  was  easily  effected  as  soon  as  the  feet  were  got 
hold  of.  The  first  endeavours  to  save  the  child  were 
very  unpromising ; but  after  a few  hours  they  had  the 
desired  effect.  As  the  woman  continued  in  the  same 
state  five  hours  afterward,  Rigaudeaux  recommended 
that  she  might  not  be  buried  before  her  limbs  were 
(juite  cold  and  stiff.  He  afterward  had  the  satisfac- 
tion to  learn  that  she  was  also  restored  to  life.  This 
remarkable  case  happened  on  the  8th  of  June,  1745,  and 
both  the  mother  and  child  were  living  at  the  period 
when  Rigaudeaux  published  the  observation. 

Supposing,  however,  delivery  in  the  ordinary  man- 
ner to  be  impracticable,  at  all  events  the  Caesarean  ope- 
ration ought  to  be  performed  with  the  same  cautions  as 
if  the  mother  were  alive,  only  one  incision  being  made 
for  the  purpose  of  opening  the  uterus. 

Almost  all  the  insurmountable  obstacles  to  delivery 
originate  from  the  bad  conformation  of  the  pelvis,  de- 
pending upon  rachitis ; though  they  are  not  an  inva- 
riable consequence  of  it,  since  there  are  women  ex- 
tremely deformed,  in  whom  no  imperfection  of  the  pel- 
vis exists,  while  it  prevails  in  others  whose  shape  is 
but  trivially  disfigured.  An  examination  of  the  di- 
mensions of  the  pelvis  is  the  right  mode  of  ascertain- 
ing whether  there  is  really  such  an  impediment  to 
parturition.  In  order  that  the  dimensions  may  not  be 
an  obstacle  to  delivery,  the  distance  between  the 
upper  edge  of  the  sacrum  and  the  os  pubis  ought  to 
be  three  inches  and  a half ; and  the  distances  between 
the  tuberosities  of  the  i.schium  and  between  each  of 
these  protuberances  and  the  point  of  the  os  coccygis, 
three  inches.  Women  have  indeed  been  known  to  be 
delivered  without  assistance,  although  the  first  of  the 
above  distances  w'as  only  two  inches  and  a half;  but 
then  the  heads  of  the  children  were  so  elongated,  that 
the  great  diameter  was  nearly  eight  inches,  while  that 
which  extends  from  one  parietal  protuberance  to  the 
other  was  reduced  to  two  inches  five  or  six  lines,  and 
the  infants  were  lifeless.  If  they  are  to  be  born  alive, 
they  must  be  taken  out  of  the  womb  by  the  Caesarean 
operation ; but  the  latter  proceeding  should  never  be 
adopted  without  a certainty  that  they  are  actually 
living;  for  when  dead  they  may  be  extracted  in  a way 
that  is  attended  with  much  less  risk  to  the  mother. 

It  is  not  always  an  easy  matter  to  ascertain 
with  certainty  whether  a feetus  in  utero  be  liv- 
ing or  dead.  If  it  has  entirely  ceased  to  move,  after 
being  affected  with  a violent  motion,  the  probability  is 
that  it  is  no  longer  alive.  But  to  be  certain,  manual 
examination  is  necessary,  which  may  be  practised  in 
two  ways.  One  consists  in  pressing  upon  the  uterus, 
through  the  parietes  of  the  abdomen.  If  the  child 
lives,  .such  pressure  makes  it  move,  and  the  motion 
can  be  plainly  felt  and  distinguished.  In  the  other 
method,  one  hand  is  employed  in  j)ressing  upon  the 
uterus  externally,  while  with  the  fingers  of  the  other 
hand  passed  up  the  vagina,  corresponding  pressure  is 
also  to  be  made.  The  uterus  is  likewise  to  be  aJlowed 
to  de.scend  as  far  as  possible,  iii  order  to  induce  lUw 


^18 


CAESAREAN  OPERATION. 


foetus  to  move.  When  no  decisive  indications  can  be 
tiius  obtained,  it  becomes  necessary  to  rupture  the 
membranes,  if  they  have  not  already  given  way,  intro- 
duce the  hand  into  the  uterus,  and  put  a finger  into  the 
child’s  mouth,  for  the  purpose  of  making  it  move  its 
tongue.  The  finger  may  also  be  applied  to  the  region 
of  the  heart,  so  as  to  examine  whether  this  organ  is 
beating;  and  the  umbilical  cord  maybe  touched,  in 
order  to  ascertain  whether  there  is  still  a puLsation  in 
it.  When  none  of  these  proceedings  furnish  unequi- 
vocal information,  the  conclusion  is  that  the  child  is 
dead,  and  its  extraction  is  indicated,  unless  the  nar- 
rowness of  the  parts  be  such  that  the  hand  cannot  be 
passed  into  the  uterus,  in  which  case,  the  Caesarean 
operation  is  indispensable. 

But  how  are  we  to  form  a judgment  respecting  the 
dimensions  of  the  pelvis  1 And  how  can  we  know 
whether  that  diameter  which  extends  from  the  upper 
edge  of  the  sacrum  to  the  os  pubis,  is  long  enough  to 
allow  the  passage  of  the  child  1 The  proper  conforma- 
tion of  this  part  is  known  by  the  roundness  and  equal- 
ity of  the  hips,  both  in  the  transverse  and  perpendi- 
cular direction  ; by  the  projection  of  the  pubes  ; by  the 
moderate  depression  of  the  sacrum ; by  an  extent  of 
four  or  five  inches  from  the  middle  of  this  depression 
to  the  bottom  of  the  os  coccygis  ; by  an  extent  of  seven 
or  eight  inches  from  the  spinous  process  of  the  last 
lumbar  vertebra  to  the  highest  part  of  the  mons  ve- 
neris, in  a woman  moderately  fat ; and  by  there  being 
an  intersj)ace  of  eight  or  nine  inches  between  the  two 
anterior  superior  spinous  processes  of  the  ossa  ileum. 

These  general  calculations,  however,  are  insufficient. 
In  order  to  acquire  more  correct  opinions,  double  com- 
passes have  been  employed.  The  branches  of  the  first 
being  applied  to  the  top  of  the  sacrum  and  middle  of 
the  mons  veneris,  three  inches  are  to  be  deducted  from 
the  dimensions  indicated  by  the  instrument,  viz.  two 
inches  and  a half  for  the  thickness  of  the  upper  part 
of  the  sacrum  (which  is  said  to  be  constant  in  subjects 
of  every  size),  and  half  an  inch  for  that  of  the  os 
pubis.  In  women  who  are  exceedingly  fat,  some  lines 
must  also  be  deducted  on  this  account.  Hence,  when 
the  total  thickness  of  the  pelvis  measured  in  this  di- 
rection is  seven  inches,  there  will  remain  four  for  the 
distance  from  the  upper  part  of  the  sacrum  to  the  os 
pubis,  or  for  the  extent  of  the  lesser  diameter  of  the 
upper  aperture  of  the  pelvis. 

For  taking  the  measurement  internally,  a kind  of 
sector  was  invented  by  Coutouly.  It  bears  a consider- 
able resemblance  to  the  instruments  employed  by  shoe- 
makers for  measuring  the  feet.  It  is  passed  into  the 
vagina,  with  its  two  branches  approximated,  until  one 
arrives  opposite  the  anterior  and  upper  part  of  the  sa- 
crum, when  the  other  is  to  be  drawn  outwards,  so  as 
to  be  applied  to  the  pubes.  The  distance  between  the 
branches  is  judged  of  by  the  graduations  on  the  instru- 
ment. This  was  named  by  its  inventor  a pelvimeter. 
According  to  Sabatier,  it  is  not  always  easy  to  place  it 
with  accuracy  ; its  employment  is  attended  with  some 
pain ; and  there  are  particular  cases  in  which  it  can- 
not be  used. 

Instead  of  this  contrivance,  the  celebrated  Baude- 
loque  recommended  a means  which  seems  to  be  very 
safe  and  simple.  The  index  finger  of  one  hand  is  to 
be  introduced  into  the  vagina  to  the  upper  part  of  the 
projection  of  the  sacrum.  The  finger,  having  the  ra- 
dial edge  turned  forwards,  is  then  to  be  inclined  ante- 
riorly till  it  touches  the  arch  of  the  pubes.  The  point 
of  contact  being  then  marked  with  the  opposite  hand, 
the  length  from  the  point  in  question  to  the  end  of  the 
finger  is  to  be  measured.  This  length,  which  indicates 
the  distance  between  the  sacrum  and  the  bottom  of  the 
symphysis  pubis,  usually  exceeds  that  of  the  lesser  dia- 
meter of  the  pelvis  by  about  six  lines.  Baudeloque  ac- 
knowledges that  this  measurement  is  not  exactly  accu- 
rate ; but  he  believes  it  will  do  very  well,  because,  un- 
less the  narrowness  of  the  pelvis  be  extreme,  two  or 
three  lines  hardly  make  any  difference  in  the  facility 
of  parturition. 

The  following  is  the  description  of  the  pelvis  of  the 
woman  twice  oi)erated  upon  by  Dr.  Lochcr : the  ossa 
pubis,  which  should  be  on  the  same  level  with  the  pro- 
montory of  the  sacrum,  were  found  perpendicularly 
under  it;  so  that  the  child  nece.ssarily  extended  the  ab- 
dominal integuments  by  its  own  weight,  into  a pen- 
dulous bag  overhanging  tlie  thighs.  Fortlie  same  rea- 
tfou,  noiliing  could  be  felt  of  the  child  by  examination 


per  vaginam.  The  sacrum,  instead  of  closing  the  pel- 
vis behind  by  a semicircular  curve,  which  forms  a 
kind  of  conductor  for  the  child  in  parturition,  stretched 
nearly  horizontally  backwards.  A representation  of 
this  pelvis,  with  a few  other  particulars,  may  be  seen 
in  a modern  publication. — (Med.  Chir.  Trans,  vol.  11, 
p.  199.) 

The  pelvis  may  be  every  where  well  formed,  and  yet 
present  an  insurmountable  obstacle  to  delivery,  in  case 
an  exostosis,  lessening  its  dimensions,  should  exist  on 
one  of  the  bones  which  compose  this  part  of  the  skele- 
ton. Pineau  met  with  a case  of  this  description  in  a 
woman  who  died  undelivered.  The  tumour  originated 
from  one  of  the  ossa  pubis.  A steaiomatous  swelling, 
situated  with  the  head  of  the  child  in  the  upper  aper- 
ture of  the  pelvis,  might  produce  the  same  effect  unless 
it  were  detected,  and  could  be  pushed  out  of  the  way, 
so  as  to  make  room  for  the  fcetus  to  pass.  Baudeloque 
mentions  a swelling  of  this  kind.  It  was  six  or  seven 
inches  long,  and  an  inch  and  a half  in  width.  The  ex- 
tremity of  it,  which  was  as  large  as  half  a hen's  egg, 
had  a bony  feel,  and  contained  nine  well-formed  teeth, 
the  rest  of  the  mass  being  steatomatous.  It  had  de- 
scendedintothe  lesser  pelvis,  below  the  projection  of  the 
sacrum,  and  a little  to  one  side.  It  might  have  been 
taken  for  an  exostosis  of  this  last  bone.  The  labour- 
pains  continued  sixty  hours,  and  the  propriety  of  per- 
forming the  Cmsarean  operation  was  under  considera- 
tion. Baudeloque  was  averse  to  this  proceeding.  He  re- 
commended turning  the  child  and  extracting  it  by  the  feet, 
because  he  thought  that  the  pelvis  was  sufficiently  ca- 
pacious to  admit  of  delivery.  The  event  proved  that 
it  was  three  inches  nine  lines  from  before  backwards, 
and  four  inches  nine  lines  transversely.  The  foetus 
was  soon  easily  extracted.  The  assistance  of  the  for- 
ceps was  necessary  to  get  out  the  head.  The  child 
was  still-born.  The  mother,  exhausted  with  numerous 
unavailing  efforts,  only  survived  between  fifty  and 
sixty  hours.  Baudeloque  was  of  opinion  that  a de- 
fective regimen  also  tended  to  occasion  her  death. 

Among  the  insurmountable  obstacles  to  delivery  may 
be  reckoned  such  a displacement  of  the  uterus  that 
this  viscus  protrudes  from  the  abdomen  and  forms  a 
hernia.  The  records  of  surgery  have  preserved  some 
examples  of  this  extraordinary  occurrence.  Twice 
has  the  Caesarean  operation  been  performed,  and  in 
one  of  the  two  cases,  the  woman  survived  so  long  that 
hopes  were  entertained  of  her  recovery.  Indeed,  as 
Sabatier  observes,  why  should  not  the  operation  suc- 
ceed in  such  a case,  where  the  uterus  is  only  covered 
by  the  integuments,  and  there  is  no  occasion  to  cut  into 
the  abdomen,  just  as  well  as  other  instances  in  which 
it  is  indispensable  to  divide  the  muscles,  and  open  the 
cavity  of  the  belly  ? In  the  other  case  on  record,  de- 
livery was  effected  in  the  ordinary  way,  either  by 
raising  the  abdomen  and  keeping  it  in  this  position  with 
towels  skilfully  placed,  or  by  making  pressure  on  the 
, uterus,  which  had  the  beneficial  effect  of  making  this 
organ  resume  its  proper  situation. 

Having  shown  the  absolute  necessity  for  the  Caesa- 
rean operation  under  certain  circumstances,  it  remains 
to  consider  the  proper  time  for  performing  it,  the  re- 
quisite preparatory  means,  and  the  method  of  ope- 
rating. 

With  regard  to  the  time  of  operating,  practitioners 
do  not  agree  upon  tliis  point : some  advising  the  opera- 
tion to  be  done  before  the  membranes  have  burst  and 
the  waters  been  discharged ; others  not  till  afterward. 
The  arguments  in  favour  of  the  first  plan  are,  the  fa- 
cility with  which  the  uterus  may  be  opened  without 
any  risk  of  injuring  the  foetus,  and  the  hope  that  the 
viscus  will  contract  with  sufficient  force  to  prevent  he- 
morrhage. The  advocates  for  the  second  mode  believe, 
that  in  operating  after  the  discharge  of  the  waters, 
there  is  less  danger  of  the  uterus  falling  into  a state  of 
relaxation,  in  consequence  of  becoming  suddenly 
empty  after  being  fully  distended,  and  that  this  method 
does  not  demand  so  extensive  an  incision.  Hence 
they  recommend,  as  a preliminary  step,  to  open  the 
membranes.  Whatever  conduct  be  adopted,  it  is  es- 
sential that  the  labour  should  be  urgent  and  unequi- 
vocal, that  the  cervix  uteri  should  be  effaced,  and  that 
the  os  tine®  should  be  sufficiently  dilated  to  allow  the 
lochia  to  be  discharged  ; but  at  the  same  time,  says  Sa- 
batier, if  the  operation  is  not  to  be  done  till  after  the 
escape  of  the  waters,  there  ought  not  to  be  too  much 
delay,  lest  the  patient’s  strength  should  be  exhausted, 


C.?:SAREAN  OPERATION. 


219 


and  the  violent  efforts  of  labour  should  bring  on  an  in- 
flammatory state  of  the  parietes  of  the  uterus. 

The  propriety  of  emptying  the  rectum  and  bladder 
is  so  evident,  that  it  is  unnecessary  to  insist  upon  it. 
This  precaution  is  more  particularly  requisite  in  regard 
to  the  latter  of  these  viscera,  which  has  been  known 
to  rise  so  much  over  the  uterus  as  to  conceal  the 
greater  part,  of  it.  Baudeloque  had  occasion  to  remark 
this  circumstance,  in  a woman  upon  whom  he  was  ope- 
rating. The  bladder  ascended  above  the  navel,  and 
presented  itself  through  the  whole  extent  of  the  open- 
ing made  in  the  parietes  of  the  abdomen. 

The  instruments,  dressings,  &c.  which  may  be 
wanted,  are  two  bistouries,  one  with  a convex  edge,  the 
other  with  a probe-point ; s/onges,  basins  of  cold 
water  acidulated  with  a little  vinegar ; long  strips  of 
adhesive  plaster ; needles  and  ligatures ; lint ; long 
and  square  compresses  ; a bandage  to  be  applied  round 
the  body,  with  a scapulary,  &c. 

For  the  purpose  of  undergoing  the  operation,  the 
patient  should  be  placed  at  the  edge  of  her  bed,  well 
supported ; her  chest  and  head  should  be  moderately 
raised ; her  knees  should  be  somewhat  bent,  and  held 
by  assistants,  one  of  whom  ought  to  be  expressly  ap- 
pointed to  fix  the  uterus  by  making  pressure  laterally, 
and  from  above  downwards,  so  as  to  circumscribe,  in 
some  degree,  the  swelling  of  the  uterus,  and  prevent 
the  protrusion  of  the  bowels.  These  things  being  at- 
tended to,  the  integuments  are  to  be  divided  with  the 
convex-edged  bistoury  to  the  extent  of  at  least  six 
inches.  The  place  and  direction  of  this  incision  differ 
with  different  operators. 

In  the  most  ancient  method,  it  was  customary  to 
make  the  incision  between  the  outer  edge  of  the  rectus 
muscle,  and  a line  drawn  from  the  anterior  superior 
spinous  process  of  the  ileum,  to  the  junction  of  the 
bone  of  the  first  rib  with  its  cartilage.  This  cut  was 
begun  a little  below  the  umbilicus,  and  was  continued 
downwards  as  far  as  an  inch  above  the  pubes.  After 
the  integuments  had  been  divided,  the  muscles,  apo- 
neuroses, and  peritoneum  were  cut,  and  the  uterus 
cautiously  opened.  The  left  index  finger  was  then  in- 
troduced into  this  viscus,  the  wound  of  which  was 
dilated  by  means  of  the  probe-pointed  bistoury. 

This  manner  of  operating  is  subject  to  great  incon- 
veniences. The  place  where  the  incision  is  made  is 
the  situation  of  muscles,  the  fibres  of  which  have  a 
different  direction,  and,  on  contracting,  separate  the 
edges  of  the  wound,  and  make  it  gape.  The  consider- 
able blood-vessels  which  ramify  there,  may  be  the 
source  of  perilous  bleeding.  The  bowels  can  protrude 
in  that  situation  more  readily  than  any  where  else. 
When  the  position  of  the  uterus  is  oblique,  and  when, 
consequently,  the  edges  of  this  viscus  are  turned  for- 
wards and  backwards,  and  its  surfaces  to  the  right  and 
left,  the  incision  will  be  made  in  one  of  the  lateral  por- 
tions of  the  uterus,  where  the  trunks  of  its  blood-ves- 
sels are  known  to  be  situated,  and  sometime.s  even  the 
Fallopian  tube  and  ovary  may  be  cut.  The  fibres  of 
the  uterus  are  cut  transversely,  so  that  the  edges  of  the 
incision  are  apt  to  gape,  instead  of  being  in  contact. 
This  last  circumstance  may  the  more  readily  permit 
the  lochia  to  escape  into  the  abdomen,  inasmuch  as 
the  uterus  is  cut  nearly  through  its  whole  length,  and 
there  is  no  cavity  in  which  they  can  accumulate  in 
order  to  be  discharged  through  the  cervix  of  that 
organ. 

The  linea  alba  has  been  frequently  considered  the 
most  eligible  place  for  making  the  incision.  As  Saba- 
tier informs  us,  it  was  the  method  adojfted  by  Soleyrds 
and  Deleurye,  and  it  has  the  recommendation  of  Bau- 
deloque, because  there  are  fewer  parts  to  be  cut,  and 
when  the  uterus  is  expo.sed,  an  incision  parallel  to  its 
principal  fibres  may  be  made  in  its  middle  part.  So- 
leyrds  thought  that  this  plan  of  operating  originated 
with  Platner  and  Guerin,  a surgeon  at  Crepi  en  Valois 
Platner  says:  Incidentar  juxta  lineam  album,  plagd 
rnajore  qiicB  ab  umbilico  ad  ossa  pubis  feri  descmdit, 
turn  abdominis  musculi,  turn  per it,on(enm,ubi  tandem 
vitandum  ne  violetur  arteria  epigastrica.  Guerin,  in 
his  case,  made  an  incision  six  inches  long,  which  be- 
gan a little  above  the  umbilicus  and  extended  to  within 
an  inch  and  a half  of  the  pubes.  He  afterward  divided 
the  fat,  muscles,  and  peritoneum,  in  order  to  get  at  the 
uterus,  the  anterior  part  of  which  was  opened,  the 
wound  being  made  rather  in  the  body  than  the  fundus 
of  that  viscus.  Deleurye  will  not  admit  that  these  1 


writers  actually  divided  the  linea  alba,  because  they 
speak  of  having  cut  muscles  which  in  reality  do  not 
exist  in  that  situation ; and  he  attributes  the  honour 
of  the  invention  to  Varoquier,  a surgeon  of  Lisle,  in 
Flanders ; but  "the  method  was  known  to  Mauriceau 
as  we  may  be  convinced  of  by  the  following  passage, 
extracted  from  the  chapter  in  which  he  treats  of  the 
Caesarean  operation  : “ La  plupart  veulent  qu'on  in- 
cise au  c6U  gauche  du  ventre;  mais  Vouverture  sera 
mieux  au  milieu  entre  les  muscles  droits,  car  il  n'y  a 
en  ce  lieu,  que  les  t^gumens  et  les  muscles  d couper.” 
Lauverjat,  who  has  made  this  remark,  and  cited  the 
Latin  edition  of  Mauriceau,  page  247,  also  observes, 
that  the  incision  in  the  linea  alba  was  practised  by  a 
contemporary  of  La  Motte,  a circumstance  which  Sa- 
batier has  not  been  able  to  ascertain.— (M  decine  Ope- 
rntoire,  tom.  1.)  The  following  would  be  the  proper 
manner  of  operating  in  the  linea  alba  The  operator 
should  first  divide  the  integuments  perpendicularly,  so 
as  to  expose  the  linea  alba,  making  the  wound  about 
six  inches  long.  An  opening  should  then  be  carefully 
made  through  the  aponeurosis,  into  the  abdomen,  ei- 
ther at  the  upper  or  lower  part  of  the  linea  alba  in 
view,  A curved  bistoury  is  then  to  be  introduced  into 
the  opening,  and  the  tendon  and  peritoneum  cut  from 
within  outwards,  as  far  as  the  extent  of  the  wound  in 
the  integuments.  The  latter  cut  should  be  cautiously 
made  with  the  crooked  bistoury,  guided  by  the  fore-fin- 
ger of  the  left  hand,  lest  any  of  the  intestines  be  acci- 
dentally injured.  fThe  uterus  must  next  be  careftilly 
opened,  making  an  incision  in  it  of  the  same  length 
as  the  preceding  wound.  The  ftjetus  is  to  be  taken  out 
through  the  wound,  and  then  the  placenta  and  mem- 
branes. In  this  way,  M.  Artiste  lately  operated  so  as 
to  save  both  mother  and  child. — (See  Edin.  Med.  and 
Surg.  Journ.  vol.  4,  p.  178.) 

This  mode  of  operating,  as  Sabatier  observes,  gives 
more  hopes  of  success  than  the  plan  first  described  : 
but  he  argues,  that  such  hopes  have  not  been  realized 
by  experience.  Though  the  operation  may  have  been 
more  easy,  he  contends  that  the  edges  of  the  wound 
in  the  skin,  and  those  of  the  incision  in  the  uterus, 
have  had  no  tendency  to  remain  in  a state  of  proxi- 
mity to  each  other,  because  the  linea  alba  is  the  point 
on  which  all  the  large  muscles  of  the  abdomen  princi- 
pally act,  and  because  the  contraction  of  the  uterus 
invariably  takes  place  from  above  downwards.  Saba- 
tier alleges  that  the  wound  in  this  viscus  has  been 
found  to  incline  to  one  of  its  sides,  for  the  same  rea- 
sons as  occur  in  operating  at  one  of  the  sides  of  the 
abdomen.  He  also  states,  that  the  incision  has  been 
concealed  under  the  integuments  of  the  upper  part  of 
the  pubes,  and  that  the  presence  of  the  bladder  hin- 
ders the  wound  from  being  carried  sufficiently  far 
down.  Perhaps,  says  he,  a part  of  these  inconveni- 
ences which  depend  upon  the  contraction  of  the  ute- 
rus, and  the  return  of  this  organ  to  its  natural  state, 
might  be  avoided  by  extending  the  incision  to  its 
highest  part.  Baudeloque  has  advised  this  plan  with 
the  view  of  prevtjiiting  the  fatal  extravasations  in  the 
abdomen,  which  frequently  follow  this  operation.  Sa- 
batier, however,  has  doubts  whether  in  operating  in 
the  linea  alba,  the  wound  can  be  carried  high  enough. 
Besides,  he  maintains,  that  this  precaution  would  not 
prevent  the  wound  from  gaping,  nor  the  greater  ten- 
dency of  the  lochia  to  be  extravasated  in  the  abdomen 
than  to  accumulate  in  the  uterus,  and  be  discharged 
through  the  os  tincae. — (AI.  decine  Opaatoire,  tom.  1,  p 
274,  275.) 

In  this  country  (where,  indeed,  the  Caesarean  opera- 
tion has  proved  most  unsuccessful)  the  linea  alba  is 
preferred,  I believe,  by  the  majority  of  practitioners. 
That  the  method  is  not  always  attended  with  the  for- 
midable objections  urged  against  it  by  Sabatier,  is 
quite  certain  : the  case  lately  published  by  Dr.  Chis- 
holm is  a decisive  proof  of  this  assertion. — (See  Edin. 
Med.  and  Surgical  Journ.  vol.  4,  p.  178, 179.) 

There  is  a third  method  of  performing  the  abdominal 
Caesarean  ojieration.  It  consists  in  making  a tran^ 
verse  incision  five  inches  in  length,  through  the  pari- 
etes  of  the  abdomen,  between  the  rectus  muscle  and 
the  spine,  and  in  a situation  more  or  less  high,  ac- 
cording to  the  more  or  less  elevated  position  of  the 
uterus.  This  plan  was  recommended  by  Lauverjat, 
in  a publication  entitled,  Nouvelle  M thode  de  prati- 
quer  UOp  ration  C-  sarienne.  Paris,  8vo.  1788.  Lau- 
verjat acknowledges  that  the  method  had  been  sue- 


220 


CESAREAN  OPERATION. 


cessfully  practised  by  different  persons  before  himself ; 
and  especially  in  one  instance,  which  was  particu- 
larly remarkable,  as,  in  consequence  of  the  first  inci- 
sion having  been  made  too  high  up,  it  became  neces- 
sary to  make  a second  one,  which  extended  obliquely 
from  the  other.  However,  according  to  Sabatier, 
Lauverjat  has  as  much  merit  as  if  he  had  invented  the 
plan,  since  he  has  giv«n  a better  explanation  of  its  ad- 
vantages than  any  of  his  predecessors. 

The  side  on  which  the  operation  is  to  be  done  is  in 
itself  a matter  of  indifference.  But  if  the  liver  or 
spleen  were  to  project,  one  ought  to  avoid  it.  Also,  if 
the  uterus  were  to  incline  more  towards  one  side  than 
the  other,  it  would  be  proper  to  operate  on  the  side 
where  this  viscus  could  be  most  conveniently  exposed. 
The  patient  being  put  in  a proper  position  and  held  by 
assistants,  and  her  abdomen  kept  steady  by  an  at- 
tendant, who  must  apply  the  palms  of  his  hands  to 
the  sides  of  the  uterus,  the  integuments,  muscles,  and 
peritoneum  are  to  be  divided  with  the  usual  precau- 
tions. The  uterus  is  then  to  be  opened,  and  the  wound 
in  it  enlarged  in  the  requisite  degree,  by  means  of  a 
probe-pointed  bistoury.  Should  the  placenta  present 
itself,  care  must  be  taken  not  to  injure  it,  for  fear  of 
opening  one  of  the  arteries  of  this  mass  which  com- 
municate with  the  umbilical  arteries  of  the  child,  or  of 
leaving  a portion  of  it  in  the  uterus  ; but  it  should  be 
separated,  in  order  to  facilitate  breaking  the  membranes 
at  its  circumference.  The  child  is  next  to  be  extracted. 
This  part  of  the  operation  is  subject  to  no  general 
trule.  Delivery  being  accomplished,  we  are  recom- 
mended to  introduce  through  the  vagina  anodyne  injec- 
tions, in  order  to  lessen  spasm,  and  wash  out  the  co- 
agula.  This  method  is  preferable  to  that  of  clearing 
■out  the  uterus  with  the  hand.  Sabatier  most  properly 
condemns  the  plan  formerly  advised  by  Rousset  and 
Ruleau,  of  passing  up  the  neck  of  this  viscus  a cathe- 
ter for  the  purpose  of  washing  out  the  lochia,  as  well 
as  the  absurd  proposal  of  employing  a seton  to  pro- 
mote their  escape.  Should  the  lochia  not  pass  readily 
outwards,  we  are  recommended  to  introduce  the  finger 
occasionally  into  the  cervix  uteri,  so  as  to  free  it  from 
the  coagula  which  may  obstruct  it. 

Sabatier  observes,  that  nearly  all  authors  who  have 
spoken  of  the  Caesarean  operation,  whether  performed 
at  the  sides  of  the  abdomen,  or  in  the  linea  alba,  have 
advised  keeping  the  edges  of  the  wound  in  the  skin, 
muscles,  and  peritoneum  together,  by  means  of  the 
interrupted  or  twisted  suture,  care  being  taken  to  place 
at  the  lower  part  of  the  incision  a tent,  in  order  to 
prevent  adhesion,  and  leave  a free  issue  for  whatever 
discharge  may  take  place  from  the  abdomen.  Others 
have  been  content  with  recommending  the  use  of  ad- 
hesive plasters  and  the  uniting  bandage. 

Sabatier  condemns  sutures  as  painful  and  irritating, 
and  he  states  that  the  other  means  only  act  upon  the 
■skin,  without  fulfilling  the  object  in  view,  because  the 
snteguments  have  no  fixed  point,  and  the  divided  mus-  | 
■cles  tend  to  contract.  He  assures  us,  that  in  the  last  I 
inode  of  operating,  the  edges  of  the  wound  may  be  j 
brought  into  contact  by  merely  laying  the  patient  upo..  i 
her  side.  Besides,  he  remarks,  that  there  are  not  ' 
■many  muscular  fibres  cut,  those  of  the  traiisversalis  j 
being  only  separated  from  each  other.  He  affirms, 
that  this  manner  of  operating  also  favours  the  ap- 
proximation of  the  edges  of  the  wound  in  the  uterus, 
•in  consequence  of  this  organ  contracting  most  exten-  I 
sively  in  the  perpendicular  direction.  It  is  likewise  [ 
asserted,  that  as  the  uterus  has  only  been  opened  at  I 
.its  upper  part,  it  affords  in  its  middle  and  lower  por-  i 
tions  a large  cavity,  which  does  not  communicate  with  1 
the  abdomen,  and  in  which  the  lochia  may  easily  accu-  | 
mulate,  and  afterward  be  discharged  by  the  natural  j 
way.  The  only  dre.ssings  advised  by  Sabatier  are,  a 
large  pledget,  compresses,  and  a moderately  tight  band- 
,age  round  the  body.  These  are  to  be  changed  when  j 
soiled  with  the  matter  or  discharge.  In  this  country  ] 
practitioners  would  not  neglect  to  bring  the  edges  of 
the  wound  as  much  as  possible  together,  by  means  j 
of  strips  of  adhesive  jilaster ; for  though  they  may  i 
not  act  with  so  much  effect  in  this  situation  as  many  1 
-others,  they  undoubtedly  assist  in  promoting  the  main  ' 
aim  of  the  surgeon,  which  is  to  heal  at  least  all  the  upper  ' 
part  of  the  incision,  if  po.ssible,  by  the  first  intention.  ' 
I have  no  doubt  there  are  many  who  would  be  advo- 
cates for  sutures.  In  this  country,  the  last  method  of 
operating  has  also  been  tried.  i 


Mr.  Wood,  of  Manchester,  performed  the  Caesarean 
operation,  in  a case  in  which  parturition  was  pre- 
vented by  deformity  of  the  pelvis.  The  incision  was 
made  nearly  in  a transverse  direction,  on  the  lett  side 
of  the  abdomen,  about  five  inches  in  length,  beginning 
at  the  umbilicus.  This  part  was  fixed  upon  because 
the  nates  of  the  child  could  be  felt  there,  and  it  was 
evident  that  no  intestine  was  interposed  between  the 
abdominal  parietes  and  the  uterus.  There  was 
scarcely  any  effusion  of  blood,  either  from  the  external 
wound  or  from  that  of  the  uterus,  though  the  latter 
was  made  directly  upon  the  placenta.  Instead  of  di- 
viding the  placenta,  Mr-  Wood  introduced  his  hand 
between  it  and  the  uterus,  and  laying  hold  of  one  of 
the  child’s  knees,  extracted  the  feetus  with  ease.  His 
hand  readily  passed  between  the  placenta  and  uterus; 
this  produced  a hemorrhage,  but  not  in  any  considera- 
ble degree,  for  the  whole  quantity  of  blood  lost  did  not 
exceed  seven  or  eight  ounces.  After  the  uterus  was 
emptied,  the  intestines  and  omentum  protruded  at  the 
wound.  These  having  been  reduced,  the  integuments 
were  brought  into  contact  with  sutures  and  adhesive 
plaster.  This  operation,  however,  did  not  save  the 
woman’s  life ; she  died  on  the  fourth  day  after  its  per- 
formance.— (See  Med.  and  Physical  Joum.  vol.  6.) 
As  I have  already  explained,  the  ill  success  of  the  Cte- 
sarean  operation  in  England  has  been  such,  that  not 
a single  case  has  yet  happened  in  which  the  life  of 
the  mother  has  been  preserved  after  the  child  was 
truly  extracted  from  the  womb  by  incision.  The  pro- 
bable reason  of  this  circumstance  I have  also  noticed. 
Abroad,  however,  the  success  of  the  practice  forms 
quite  a contrast  to  what  has  occurred  in  this  country, 
the  operation  having  been  often  done  so  as  to  save  the 
lives  both  of  the  mother  and  child,  of  which  an  inte- 
resting example  was  recently  published  by  Dr.  Locher, 
of  Zurich.  -(See  Med.  Chir.  Trans,  vol.  9,  p.  11.)  And 
in  vol.  11  of  the  same  work,  may  be  read  a case  in 
which  Dr.  Meyer,  of  Minden,  lately  saved  a woman 
by  the  operation,  but  the  feetus  was  dead.  Likewise 
an  example  in  which  Dr.  Spitzbarth,  in  1819,  pre- 
served the  lives  both  of  the  infant  and  mother,  and 
another  interesting  relation  of  two  Caesarean  opera- 
tions performed  by  Lorinser,  on  a woman  still  living  at 
Nimes,  in  Bohemia.  - (See  also  Siebold's  Journ.  fur 
Geburtshulfe,  Src.  vol.  3,  part  1,  Frank/.  1819.)  In  1801, 
Dr.  Schlegel,  of  Merseburg,  likewise  operated  on  a 
woman  who  recovered,  notwithstanding  the  bowels 
became  strangulated,  and  she  is  still  living,  with  a 
hernia  in  the  situation  of  the  wound. — (Scliweighduser, 
Archiv.  des  Acrouchemens,  p.  135,  8vo.  Pans,  1797.) 
The  Caesarean  section  has  been  successfully  performed 
by  Graefe,  at  Berlin,  the  woman  and  child  both  having 
been  saved. — {Journ.  b.  9.)  And  besides  this  and  va- 
rious other  instances  of  success  already  referred  to, 
another  was  afforded  in  April,  1823,  in  the  practice  of 
Vanderfurh. — (See  Revue  M d.) 

[In  the  Western  Journal  of  Medical  and  Physical 
Sciences  for  April,  1830,  Dr.  Richmond,  of  Newton, 
Ohio,  reports  a successful  case  of  Caesarean  operation, 
performed  in  1827.  He  was  under  th«  necessity  of 
performing  the  operation  at  midnight,  on  the  spur  of 
the  moment,  without  a consultation,  and  under  most 
unfavourable  circumstances.  After  he  had  divided 
the  uterus  and  the  placenta,  which  was  attached  di- 
rectly under  his  inci.sion,  he  found  it  impossible  to  re- 
move the  feetus,  until  he  had  divided  the  muscles  of 
the  back,  near  the  upper  lumbar  vertebr®,  when  it  was 
extracted  with  facility.  The  mother  recovered  en- 
tirely in  four  weeks. 

The  necessity  for  the  operation  arose  from  malcon- 
formation  of  the  os  tincae  and  vagina.  On  examining 
the  patient  per  vaginam,  since  her  recovery.  Dr.  Rich- 
mond found  the  whole  depth  of  the  vagina  only  two- 
thirds  of  a finger’s  length,  its  anterior  coat  being  a 
kind  of  septum  passing  obliquely  upwards,  from  before 
backwards,  leaving  about  one  and  a half  inches  between 
it  and  the  fourchette,  and  the  abnormal  os  tincae  would 
not  be  discovered  by  the  most  minute  examiner.  He 
inclines  to  the  opinion,  that  it  is  an  unnatural  hymen, 
and  he  describes  a kind  of  tube  extending  from  the  os 
uteri  to  within  three-fourths  of  an  inch  of  the  meatus 
urinarius;  impervious  below,  but  probably  entering 
obscurely  into  the  vagina.  He  offers  no  theory  on  the 
manner  in  which  concejition  had  taken  place.  The 
woman  was  unmarried  at  the  time,  but  has  since  lived 
with  a hu.sband  two  years,  but  no  conception  has 


C.ESAREAN  OPERATION. 


221 


taken  place.  This  is  the  first  and  only  instance  of  the 
successful  performance  of  the  Caesarean  section  in  the 
United  States. — Reese.] 

OF  OPKRATING  WHEN  THE  FCETUS  IS  EXTRA-UTERINE. 

Delivery  cannot  possibly  happen  in  the  ordinary  way, 
when  the  fcetus  is  situated  in  the  ovaries,  or  Fallopian 
tube,  or  in  the  cavity  of  the  peritoneum.  However, 
there  are  many  •instances  recorded  of  ventral  preg- 
nancies, which  the  mothers  survived,  the  dead  foetus  hav- 
ing been  discharged  by  fragments  out  of  an  abscess  in 
the  parietes  of  the  abdomen.  A remarkable  case  under 
Mr.  Gunning,  in  St.  George’s  Hospital,  I had  an  op- 
portunity of  seeing  a few  years  ago,  in  which  the  child 
was  discharged  piecemeal  from  an  abscess  on  the  fore 
part  of  the  abdomen ; and  I have  lately  seen  another 
case  under  Dr.  Blicke,  of  Walthamstowe,  in  which 
portions  of  bone  and  a great  deal  of  matter  have  been 
voided  througH  the  vagina,  though  the  swelling  is 
altogether  on  the  right  side  of  the  abdomen. 

Practitioners  are  occasionally  called  upon  to  do  a 
very  similar  operation  to  the  C.Tssarean,  when  the  child 
has  passed  into  the  cavity  of  the  peritoneum,  in  conse- 
quence of  the  rupture  of  the  uterus.  Unfortunately, 
such  an  accident  is  not  uncommon,  and  though  the 
causes  of  it  may  not  be  obvious,  nothing  is  more  cer- 
tain than  that  the  fcetus  itself  is  entirely  passive,  and 
has  no  share  in  producing  the  misfortune.  The  symp- 
toms, by  which  the  event  can  be  known,  are  not  always 
easy  of  comprehension.  When,  however,  the  pains 
have  been  violent ; when  the  last,  after  being  exces- 
sively severe,  has  been  followed  by  a kind  of  calm  ; 
when  the  countenance  loses  its  colour,  the  pulse 
grows  weak,  and  the  extremities  become  cold  and  co- 
vered with  a cold  sweat ; when  the  abdomen  is  gene- 
rally flat  and  only  partially  affected  with  a swelling, 
occasioned  by  the  fcetus,  which  either  continues  to 
move,  or  is  dead  and  motionless;  when  the  patient 
complains  of  a moderate  degree  of  heat  about  the  belly ; 
and  lastly,  when  the  child  shrinks  from  the  touch  of 
the  accoucheur;  it  is  manifest  that  the  uterus  is  lace- 
rated. If  the  child  has  passed  completely  into  the  ab- 
domen, gastrotomy  is  the  only  resource.  Should  a 
part  of  it,  however,  yet  remain  in  the  uterus,  it  may 
be  extracted  with  the  aid  of  the  forceps,  if  the  head 
presents,  or  by  the  feet,  provided  only  the  upper  part 
of  the  body  be  in  the  abdomen. 

Baudeloque  quotes  three  instances  of  gastrotomy, 
performed  on  account  of  the  rupture  of  the  uterus. 
The  first  is  that  inserted  by  Thibaud  Dubois,  in  the 
Journal  de  Medecine,  for  May,  1760.  Every  prepa- 
ration was  made  for  a natural  labour,  when,  after  ex- 
cessively violent  pains  about  the  upper  and  left  part  of 
the  uterus,  the  child  disappeared.  Thibaud  opened  the 
abdomen,  though  not  till  some  hours  after  the  acci- 
dent The  infant  was  dead ; but  the  mother  expe- 
rienced no  ill  effects  after  the  operation,  except  such  as 
are  usual  after  ordinary  labours. 

The  second  and  third  cases  were  communicated  to 
the  French  Academy  of  Surgery  in  1775,  by  Lambron, 
a surgeon  of  Orleans.  He  practised  the  operation 
twice  on  the  same  woman  with  success.  In  the  first 
instance,  he  operated  eighteen  hours  after  the  rupture 
of  the  uterus.  The  child  was  dead.  An  ill-conditioned 
abscess  formed  near  the  wound;  but  the  patient  got 
quite  well  in  the  course  of  six  weeks.  She  was  preg- 
nant again  the  following  year,  and  the  uterus  was 
once  more  ruptured.  Lambron  now  had  recourse  to 
the  operation  without  delay.  The  child  betrayed  some 
signs  of  life,  but  soon  died.  The  mother  not  only  sur- 
vived ; but  afterward  became  pregnant  again,  and  had 
a favourable  delivery. 

In  a foregoing  column,  I have  adverted  to  the  case  in 
which  Dr.  Locher,  of  Zurich,  saved  both  the  mother 
and  child  by  the  Caesarean  operation,  performed  in  the 
linea  alba.  After  her  recovery,  a small  point  of 
the  wound,  not  exceeding  two  or  three  lines  in  length 
and  breadth,  required  a long  time  to  be  quite  healed, 
though  no  particular  inconvenience  was  experienced 
from  it.  Some  time  afterward  the  cicatrix  gave  way 
again,  and  a portion  of  omentum  protruded,  which  was 
reduced,  when  a piece  of  bowel  came  out,  and  was 
also  returned.  The  edges  of  the  wound  were  then 
brought  together;  but  a small  superficial  ulcer  con- 
tinued open  in  spite  of  every  effort  to  close  it.  In  1818, 
the  year  following  that  in  which  the  Caisarean  ope- 
ration had  been  performed  on  her,  she  became  pregnant 


again,  and  the  chief  particularity  which  happened  dur- 
ing gestation,  was  an  increase  in  the  size  of  the  pre- 
ceding ulcer,  which  became  three  inches  in  width.  The 
sore,  however,  was  covered  with  charpie,  and  the  in 
teguments  weft  supported  with  adhesive  plaster.  On 
the  23d  of  May,  she  was  seized  with  labour-pains;  and 
about  seven  in  the  evening,  she  complained  all  at 
once  of  a very  acute  pain,  and  at  the  same  moment 
voided  a considerable  quantity  of  blood  from  the  vagina. 
On  examining  by  this  passage,  nothing  was  discovered ; 
but,  when  the  hand  was  applied  below  the  navel,  in 
the  line  of  the  old  wound  and  under  the  ulcer,  a cir- 
cumscribed firm  swelling  was  felt,  caused  by  the 
child’s  head,  of  which  the  sutures  were  plainly  dis- 
cernible. Dr.  Locher  naturally  concluded,  that  the 
uterus  had  burst,  so  as  to  allow  the  child  to  escape, 
and  the  hemorrhage  was  thus  easily  explained.  A re- 
petition of  the  Caesarean  operation  was  deemed  indis- 
pensable. The  place  of  the  incision  was  determined 
by  the  round  swelling,  caused  by  the  child’s  head.  An 
incision,  six  inches  in  length,  was  made  into  the  ab- 
domen, where  a quantity  of  coagulated  blood  was 
found  When  this  had  been  removed,  the  membranes 
presented  themselves,  exhibiting  a bluish  hue,  and 
after  they  had  been  opened,  the  head  of  the  child  imme- 
diately appeared.  The  navel-string  passed  round  the 
neck,  which  was  also  compressed  in  the  opening  of  the 
uterus.  The  child  evinced  no  signs  of  life.  The  pla- 
centa came  away  during  the  attempts  to  reanimate  the 
child.  The  uterus  contracted,  and  there  was  little 
bleeding.  This  patient,  after  a good  deal  of  indisposi- 
tion, and  occasional  approaches  to  a perfect  recovery, 
was  at  length  attacked  with  inflammation  of  the  sto- 
mach and  bowels,  and  died  on  the  9th  of  July.  The 
uterus  was  found  contracted  to  a small  size,  with  an 
opening  of  about  the  size  of  an  almond,  on  its  anterior 
surface,  with  a rounded  callous  edge.  This  aperture, 
Dr.  Locher  thinks,  had  remained  ever  since  the  first 
operation,  and  had  allowed  the  escape  of  the  child  in 
the  second  labour;  a circumstance  which  may  be 
doubted,  as  the  hemorrhage  indicated  the  period  when 
the  uterus  had  been  lacerated,  as  this  gentleman  indeed 
has  in  one  place  particularly  noticed  himself.— (See 
Med.  Chir.  TVans.  vol.  11,  p.  182,  &c.)  An  almost  in- 
credible case  is  related  of  what  may  be  called  a Caesa- 
rean birth,  effected  solely  by  the  powers  of  nature,  and, 
as  would  appear,  by  a sudden  rupture  of  the  uterus 
and  parietes  of  the  abdomen,  after  the  patient  had  been 
in  labour  three  days. — (See  Essays  and  Obs.  Physical 
and  Literary,  vol.  2.) 

A laceration  in  the  uterus,  or  the  wound  made  in 
this  viscus  in  the  Caesarean  operation,  may  give  rise 
to  dangerous  and  even  fatal  symptoms  of  strangula- 
tion if  any  of  the  intestines  insinuate  themselves  into 
the  preternatural  opening.  When  such  an  occurrence 
happens  in  the  performance  of  the  preceding  operation, 
the  intestine  must  be  directly  withdrawn  and  replaced. 
If  the  accident  were  to  happen,  when  the  child  is  ex- 
tracted in  the  natural  way,  the  bowel  is  to  be  pushed 
back  into  the  abdomen  from  the  uterus.  Were  the  oc- 
currence to  take  place  several  days  after  the  operation, 
Sabatier  inquires,  what  ought  to  be  done  ? A surgeon 
is  said  to  have  pushed  back  the  intestine  from  the 
uterus  as  late  as  the  third  day.  Sabatier  thinks,  that 
later  it  could  not  be  done.  In  this  circumstance,  Bau- 
deloqne  advises  the  operation  suggested  by  Pigrai, 
namely,  that  of  opening  the  abdomen  and  withdrawing 
the  bowel  from  the  place  in  which  it  is  incarcerated. 
But  there  are  serious  objections  to  this  proceeding. 
There  is  no  certainty  that  the  intestine  is  strangulated, 
and  if  it  were  so,  the  adhesions  which  are  soon  formed,, 
would  frustrate  the  design  of  the  operator. 

Gastrotomy  has  not  only  been  recommended  for 
cases  where  the  child  has  passed  into  the  abdomen 
through  a rupture  of  the  uterus;  it  has  likewise  been 
advised  for  instances,  in  which  the  fcetus  has  grown 
in  the  Fallopian  tube,  ovary,  or  cavity  of  the  abdomen. 
Here,  indeed,  the  operation  deserves  to  be  called  Caisa- 
rean ; for,  in  addition  to  the  incision  in  the  skin  and 
muscles  of  the  abdomen,  it  is  necessary  to  open  the 
pouch  in  which  the  child  is  contained.  The  instances 
of  conception  in  the  Fallopian  tube  are  not  uncommon, 
'I'hose  in  the  ovary  and  cavity  of  the  peritoneuni  are 
more  rare.  Sabatier  conjectures,  that  most  of  the 
cases  reported  to  be  of  the  latter  kind,  if  attentively  ex- 
amined, would  have  been  found  to  be  in  renlitv  con- 
ceptions in  the  Fallopian  tube. 


222 


CESAREAN  OPERATION. 


Extra-uterhie  conceptions  hardly  ever  arrive  at 
maturity.  However,  the  foetus  formed  in  the  Fallo- 
pian tube  has  sometimes  been  known  to  attain  the 
term  of  nine  months,  and  then  die,  either  from  the  im- 
possibility of  its  expulsion,  or  from  the  insufficiency 
of  the  nourishment  afforded  it.  The  pouch  in  which  it 
was  contained,  and  the  neighbouring  parts,  have 
then  inflamed,  and  after  becoming  connected  together 
by  numerous  adhesions,  have  suppurated.  The  ab- 
scess has  burst,  partly  at  some  point  of  the  circum- 
ference of  the  belly,  and  partly  into  the  rectum;  and  the 
dead  foetus  has  been  discharged  piecemeal  with  the 
matter. 

In  other  examples,  the  foetus,  instead  of  giving  rise 
to  the  abscesses,  has  become  ossified  with  the  en- 
veloping membranes,  and  continued  in  this  state  many 
years,  without  any  other  inconvenience  to  the  patient 
than  what  depended  on  the  size  and  weight  of  the  tu- 
mour within  the  abdomen. 

Most  frequently,  however,  the  pouch  containing  the 
foetus  bursts  about  the  middle  of  the  ordinary  period 
of  gestation,  and  the  child  passes  into  the  cavity  of 
the  peritoneum.  At  the  same  moment,  the  blood-ves- 
sels ramifying  on  the  parietes  of  the  containing  parts 
usually  pour  forth  into  the  abdomen  so  much  blood, 
that  the  patients  generally  die  in  the  space  of  a few  , 
hours.— (See  a case  by  Dr.  Clarke  in  Trans,  of  a So- 
ciety for  the  Imyrovement  of  Medical  and  Chirurgical 
Knowledge.  Also  another,  adverted  to  by  Mr.  C.  Bell, 
in  Med.  Chir.  Trans,  vol.  4,p.  340.) 

Two  facts  of  this  kind  fell  under  Sabatier's  observa- 
tion. The  women  were  in  the  end  of  the  fourth  month 
of  pregnancy.  Excepting  a swelling,  which  affected 
only  one  side  of  the  abdomen,  and  frequent  dragging 
pains  in  this  cavity,  there  was  no  indication  of 
any  thing  extraordinary.  In  other  respects  the  pa- 
tients were  well.  They  were  both,  all  on  a sudden, 
attacked  w’ith  extremely  acute  pains  which  lasted  two 
or  three  hours.  A more  violent  suffering  than  the  rest 
was  followed  by  entire  ease.  The  abdomen  subsided, 
and  became,  as  it  were,  flat.  An  equal  moderate  w annth 
diffused  itself  over  this  part  of  the  body.  The  skin  lost 
its  colour.  Almost  continual  syncopes  occurred.  The 
pulse  was  feeble  and  concentrated.  The  whole  body 
was  covered  with  a cold  sw'eat,  and  the  w omen  died. 
The  rapid  course  of  these  symptoms  rendered  it  im- 
possible for  Sabatier  to  be  of  any  service.  The  pa- 
tients were  actually  dying  when  he  was  called  to  them. 
The  examination  of  their  bodies  evinced,  that  the  abdo- 
men contained  a large  quantity  of  blood ; that  the  foe- 
tuses lay  on  the  intestines,  connected  with  the  lace- 
rated Fallopian  tube  by  means  of  the  umbilical  cord ; 
and  that  the -tube  itself,  which  was  strongly  contracted, 
presented  no  other  tumour,  except  that  which  depended 
on  the  after-birth. 

There  is  nothing  that  announces  an  extra-uterine 
pregnancy  with  sufficient  certainty  to  justify  any  posi- 
tive conclusion  respecting  the  nature  of  the  case,  be- 
fore the  ordinary  time  of  parturition.  In  many  women 
the  gravid  uterus  inclines  to  one  side,  and  numerous 
pregnant  females  have  dragging  pains,  which  may 
depend  upon  other  causes.  Things,  however,  are  dif- 
ferent when  the  foetus  has  lived  to  the  ordinary  period 
of  parturition,  and  the  woman  is  attacked  with  labour- 
pains  ; because,  besides  the  unequivocal  signs  of  the 
presence  of  a child  in  the  abdomen,  the  womb  is  empty, 
and  is  little  changed  from  its  common  state.  Should 
we  now,  asks  Sabatier,  have  recourse  to  the  Caesarian 
operation,  just  as  if  the  foetus  were  in  the  womb? 
Can  we  be  sure,  that  the  pouch  which  contains  the 
child,  w'ill  contract  itself  like  the  uterus,  and  that  the 
incision  which  is  in  contemplation,  will  not  give  rise 
to  a fatal  hemorrhage  ? Would  it  be  easy  to  separate 
and  remove  the  whole  of  the  placenta  ? How  could 
the  discharge,  analogous  to  the  lochia,  find  an  outlet, 
and  would  not  its  extravasation  in  the  abdomen  be 
likely  to  prove  fatal  ? Sabatier  thinks,  that  the  risk 
which  IS  to  be  encountered,  is  much  less  when  things 
are  left  to  nature.  The  child,  indeed,  must  inevitably 
perish.  If  will  either  give  rise  to  abscesses,  with 
which  it  will  be  discharged  in  fragments,  or  it  will 
remain  for  a length  of  time  in  the  abdomen,  without 
any  urgent  symptoms.  Sabatier  also  calls  our  atten- 
tion to  the  great  precariousness  of  an  infant’s  life, 
and  expre.sses  his  ojiinion,  that  there  can  be  no  dilR- 
cvilty  in  deciding  what  conduct  ought  to  be  adopted. 
Happily,  practitioners  are  not  often  placed  in  circum- 


stances so  delicate,  and  extra-uterine  conceptions 
mostly  perish  before  the  end  of  the  common  period  of 
gestation.  We  have  then  only  to  second  the  efforts  of 
nature  ; either  by  promoting  suppuration,  if  it  should 
seem  likely  to  occur,  by  making  a suitable  opening,  or 
enlarging  one  that  may  have  formed  spontaneously; 
by  extracting  such  fragments  of  the  feetus  as  present 
themselves ; by  breaking  the  bones  when  their  large 
size  confines  them  in  the  abscess,  a%  Littre  did  in  an 
instance  where  the  abscess  burst  into  the  rectum; 
and  lastly,  by  employing  suitable  injections.— (Sai/atier, 
M decine  Operatoire,  t.  1.) 

An  extremely  uncommon  case  of  extra-uterine  con- 
ception was  related  a few  years  ago  by  Joseph! ; the 
feetus  having  at  length  passed  into  the  bladder  by  ul- 
ceration, and  caused  such  affliction  as  rendered  an  in- 
cision into  that  receptacle  indispensable,  with  the  view 
of  extracting  the  parts  of  the  feetus  lodged  in  it.  The 
operation  was  done  above  the  pubes  ; ^t  the  internal 
mischief  already  existing  was  so  great,  that  the  patient 
did  not  recover.— (Fe?>er  die  Schu  angerscheft  ausser- 
hall  der  Gebarmutter ; Rostock,  1803,  8v».) 

Govei,  p.  401,  relates  a case  of  ventral  conception,  in 
which  instance  the  Caesarean  operation  was  done,  and 
the  child  preserved.  A lady,  aged  twenty-one,  had  a tu- 
mour in  the  groin,  which  wais  at  first  supposed  to  be  an 
ejaplocele,  but  an  arterial  pulsation  was  perceptible  in 
it.  In  about  ten  weeks  the  swelling  had  become  as 
large  as  a pound  of  bread.  Govei,  solicited  by  the  lady, 
opened  the  tumour.  He  first  discovered  a sort  of  mem- 
branous sac,  whence  issued  a gallon  of  a limpid  fluid. 
The  sac  was  dilated,  and  a male  feetus  found,  about 
half  a foot  long,  and  large  in  proportion.  It  was  per- 
fectly alive,  and  was  baptized.  After  tying  the  umbili- 
cal cord,  the  placenta  was  found  to  be  attached  to  the 
parts  just  behind,  and  near,  the  abdominal  ring  ; but  it 
was  easily  separated.  Govei  does  not  mention  whether 
the  mother  survived ; but  the  thing  would  not  be  very 
astonishing,  considering  the  situation  of  the  foetus, 
Bertrandi  says,  he  was  unacquainted  with  any  other 
example  of  the  Cssarean  operation  being  done,  in  cases 
I of  extra- uterine  foetuses,  so  as  to  save  both  the  mother 
and  infant.  This  eminent  man  condemned  operating, 
in  ventral  cases,  on  the  ground  that  the  placenta  could 
not  be  separated  from  the  viscera,  to  which  it  might  ad- 
here, or,  if  left  behind,  it  could  not  be  detached,  w ithout 
such  inflammation  and  suppuration  as  would  be  mortal. 
But  if,  in  addition  to  such  objections,  says  Bertrandi, 
the  operation  has  been  proposed  by  many,  and  practised 
by  none,  w'e  may  conclude,  that  this  depends  on  the 
difficulty  of  judging  of  such  pregnancies,  and  of  the 
time  when  the  operation  should  be  attempted.  He  puts 
out  of  the  question  the  dilatations  which  have  been  indi- 
cated for  extracting  dead  portions  of  the  foetus,  and  also 
Govei’s  case,  who  operated  without  expecting  to  meet 
with  a feetus  at  all.— (Bertrandi,  TraiU  des  Operations 
de  Chirurgie,  chap.  5.) 

Whenever  the  Caesarean  operation,  or  gastrotomy, 
has  been  performed,  the  practitioner  is  not  merely  to 
endeavour  to  prevent  inflammation,  heal  the  wound, and 
appease  any  untow  ard  symptoms  which  may  arise ; he 
should  also  prevail  upon  the  mother  to  suckle  the  child, 
in  order  that  the  lochia  may  not  be  too  copious ; and, 
after  the  wound  is  healed,  she  should  be  advised  to 
wear  a bandage,  for  the  purpose  of  hindering  the  forma- 
tion of  a ventral  heniia,  of  which,  according  to  surgical 
w riters,  there  is  a considerable  risk. 

[The  following  case  of  extra- uterine  conception  is 
here  inserted  as  being  perfectly  unique  in  its  kind.  No 
such  case  is  to  be  found  referred  to  in  PloncqueVs  Lit. 
Med.  Digest,  nor  in  any  of  the  numerous  periodicals 
which  enrich  the  profes.sion.  It  occurred  in  the  prac- 
tice of  Drs.  Cotton  and  Harlow,  of  Georgia,  and  w as 
communicated  to  Prof.  Francis,  of  New-York.  The 
subject  was  a negro  woman,  aged  30  years.  On  the 
night  of  the  23d  of  .Tan.  1819,  she  was  taken  in  labour. 
There  apjieared  no  doubt  that  she  had  arrived  at  the 
full  time  of  labour.  Her  labour-pains  ceasing,  she  was 
attended  to  for  a few  days  for  drop-sical  symptoms,  un- 
der which  she  suffered  greatly.  On  the  4th  of  Febru- 
ary, she  was  again  taken  in  labour.  I’he  i)ains,  how- 
ever, shortly  after  entirely  ceased ; and  after  five  weeks 
she  expired.  On  examination  after  death,  the  following 
facts  i)resented  themselves.  In  the  first  place,  Drs. 
Harlow  and  Cotton  drew  off  from  the  abdomen  three 
and  a half  gallons  of  an  extremely  turbid  and  oflensive 
fluid.  On  opening  the  abdomen,  the  first  thing  that 


CESAREAN  OPERATION. 


presented  itself  was  the  child,  extending  itself  across 
the  abdomen  ; its  head  in  the  right,  its  fhet  in  the  left, 
hypochondriac  regions  ; its  back  immediately  to  the 
umbilicus  of  the  mother.  It  was  as  large  a child  as  ei- 
ther of  them  had  ever  seen  at  birth,  and  perfectly  formed. 
The  funis  ivas  of  the  usual  size,  about  six  inches  in 
length,  and  inserted  into  the  fundus  uteri  without  the 
intervention  of  a •placenta.  The  uterus  was  about  the 
size  of  an  orange ; its  coats  very  much  thickened  and 
indurated,  with  a small  quantity  of  a thin  glassy  fluid 
within  its  cavity.  The  abdominal  viscera  were  all 
diseased,  save  the  bladder.  The  liver  retained  its  ori- 
ginal shape  and  position,  but  looked  more  like  a mass 
of  glue  than  organized  animal  matter.  The  spleen  had 
gone  into  a state  of  complete  decomposition.  As  to  the 
omentum,  there  was  not  the  slightest  vestige  left. 
The  bladder  appeared  to  be  the  only  viscus  that  had 
escaped  tminjured  from  this  digression  in  nature.  The 
bowels  had  firmly  adhered  in  one  uniform  mass  from 
the  stomach  to  the  rectum,  and  to  the  posterior  and 
lateral  parietes  of  the  abdomen.— (See  New-York  Med. 
and  Phys.  Journal,  vol.  1.) 

The  case  of  extra-uterine  foetus  in  which  Dr.  Mac- 
Knight  of  New-York  operated  with  success,  is  often 
referred  to. — (See  Lond.  Med.  Society's  Trans,  vol.  4.) 
This  interesting  case  confirms  the  views  of  those  who 
believe  in  the  entire  production  and  perfection  of  the 
human  foetus  extra‘-uterum — {Thacher's  Med.  Biogra- 
phy.) But  even  this  operation  is  not  entitled  to  the 
epithet  Caesarean,  and  therefore  does  not  detract  from 
the  claims  of  Dr.  Richmond,  who  opened  the  uterus 
itself.— (See  the  preceding  note,  p.  221.) 

Gastrotomy  has  been  performed  for  the  removal  of 
extra-uterine  foeti  several  times  in  America,  with  com- 
plete success. 

Mr.  Wm.  Baynham,  of  Virginia,  member  of  the  Royal 
College  of  Surgeons,  London,  succeeded,  as  early  as 
1791,  in  removing  an  extra-uterine  foetus  from  the  ab- 
domen, after  it  had  lain  there  ten  years.  He  thus  pre- 
served the  life  of  a valuable  woman,  who  was  other- 
wise sinking  into  the  grave,  with  hectic  fever  and  the 
most  dangerous  symptoms. 

In  1799,  he  repeated  the  operation  with  the  like  suc- 
cess on  a servant  woman  of  Mrs. Washington’s,  Fairfax 
Co.,  Virginia.  In  the  publication  of  these  cases  in  the 
N.  Y.  Med.  and  Phys.  Journal,  vol.  1,  Mr.  B.  has  per- 
formed a valuable  service  to  the  profession,  in  the 
judicious  remarks  with  which  he  accompanies  the  re- 
port. 

In  the  same  work.  Dr.  J.  Augustine  Smith,  now  Pro- 
fessor of  Anatomy  in  the  University  of  New-York,  has 
published  a case  in  which  he  performed  this  same  ope- 
ration in  1808,  in  the  city  of  New-York,  with  the  most 
satisfactory  result.  I have  not  been  able  to  find  any 
other  cases  of  success  in  this  operation  in  this  country, 
except  those  of  Dr.  MacKnight,  Mr.  Baynham,  and  Pro- 
fessor Smith,  and  must  refer  to  the  journals  I have 
named  for  their  interesting  details. 

The  following  cases  of  Caesarean  operation  are  ex- 
tracted from  the  N.  Y.  Med.  and  Phys.  Journal,  vol.  2, 
for  1823 ; and  as  two  of  them  were  self-performed, 
and  the  other  accomplished  by  an  illiterate  female  ac- 
coucheur, they  will  be  found  interesting  in  a high  de- 
gree. The  recovery  of  these  women  should  be  regarded 
as  extraordinary  escapes,  rather  than  as  affording  en- 
couragement rashly  to  attempt  this  great  and  danger- 
ous achievement. 

“In  the  afternoon  of  Jan.  29th,  1822,  (says  Dr.  S. 
M‘Clel!en),  I was  called  upon  by  Mr.  Kipp,  of  Nassau,  to 
consult  with  Dr.  Bassett  on  the  case  of  his  servant  girl, 
who,  he  said,  was  in  a deplorable  situation . I immediately 
repaired  to  his  house,  and  found  the  patient  to  be  a girl 
fourteen  years  of  age,  one-fourth  black.  She  had  a 
firm  pulse,  and  complained  of  little  or  no  pain.  Dr.  B. 
informed  me,  that  she  had  a wound  in  her  abdomen, 
near  the  centre  of  the  epigastric  region,  from  which 
he  had  extracted  a full-grown  fuetus,  that  was  in  part 
protruded,  together  with  a considerable  portion  of  her 
intestines.  The  placenta  having  two  umbilical  cords 
attached  to  it,  he  had  removed  from  the  same  orifice, 
and  had  also  introduced  his  hand  into  the  uterus  per 
vaginam,  <kc. 

On  examination  I found  an  irregular  incision  of  about 
four  inches  in  length,  extending  in  a diagonal  direction, 
as  respects  the  abdomen,  about  two  inches  above  the 
umbilicus,  and  an  incision  of  about  two  inches  in 
length  at  nearly  a right  angle  with  the  former,  extcnd- 


223 

ing  towards  the  sternum.  The  lower  part  of  the  abdo- 
men was  considerably  distended  with  blood. 

Our  attempts  were  in  the  first  place  directed  to  the 
evacuation  of  the  blood  contained  in  the  abdomen, 
which  was  partly  effected  by  a change  of  posture  and 
slight  compression.  We  then  brought  the  lips  of  the 
wound  in  contact  by  the  interrupted  suture,  dressed  it 
with  lint  s})read  with  emollient  unguent,  and  secured 
the  whole  with  a broad  bandage.  After  administering 
an  anodyne,  we  left  her  for  the  night.  I did  not  see 
her  again,  but  was  informed  by  Dr.  B.  that  she  never 
had  any  very  violent  symptoms. 

The  second  day  he  bled  her,  gave  her  a cathartic, 
and  pursued  the  antiphlogistic  regimen  a few  days, 
when  the  febrile  excitement  subsided.  An  ordinary 
use  of  tonics  was  then  resorted  to,  and  in  a few  weeks 
the  patient  was  perfectly  recovered. 

The  circumstances  attendant  on  the  infliction  of  the 
wound  were  these.  While  the  family  was  at  dinner, 
she  went  a distance  of  perhaps  fifty  rods  from  the 
hou.se,  and  placed  herself  on  a snow-drift,  near  a fence, 
where  she  was  first  discovered  by  her  master  in  the 
act  of  covering  something  with  snow,  which  after- 
ward proved  to  be  a naked  child.  As  soon  as  she  per- 
ceived that  she  was  observed,  she  immediately  ran  to 
the  house,  with  the  second  child  hanging  ont  at  the 
wound,  together  with  a considerable  portion  of  her  in- 
testines ; laid  by  her  razor  and  large  needle,  which 
were  the  instruments  she  had  previously  prepared  for 
the  operation,  and  shortly  began  to  complain. 

I should  judge  from  the  api)earance  of  the  blood  upon 
the  snow,  there  being  three  several  places  where  she 
evidently  stopped,  that  the  incision  was  made  imme- 
diately preceding  the  rupture  of  the  membranes,  and 
that  the  first  child  was  delivered  per  vias  naturales, 
the  third  pain  after  the  rupture. 

As  some  of  the  greatest  discoverie.s  in  every  depart- 
ment of  science  are  made  by  accident,  or  without  any 
particular  previous  design,  may  not  the  conduct  of  this 
desperate  girl  give  a useful  hint  for  an  improvement  in 
the  Caesarean  operation,  consisting  in  a division  of  the 
uterus  diagonally,  near  the  fundus,  instead  of  the  ordi- 
nary method  ?” 

The  following  is  the  case  of  Alice  O'Neal,  inserted 
in  the  Medical  Essays  and  Observations  published  by 
a society  in  Edinburgh,  by  Mr.  Duncan  Stewart,  sur- 
geon in  Dungannon,  in  the  county  of  Tyrone,  Ireland. 

Alice  O'Neal,  aged  about  thirty-three  years,  wife  to 
a poor  farmer  near  Charlemont,  and  mother  of  several 
children,  in  Janua^',  1739,  took  her  labour-pains  ; 
but  could  not  be  delivered  of  her  child  by  several  wo- 
men who  attempted  it.  She  remained  in  this  condition 
twelve  days : the  child  was  judged  to  be  dead  after 
the  third  day.  Mary  Donally,  an  illiterate  woman,  but 
eminent  among  the  common  people  for  extracting  dead 
births,  being  then  called,  tried  also  to  deliver  her  in  the 
common  way : and  her  attempts  not  succeeding,  per- 
formed the  Caesarean  operation,  by  cutting  with  a 
razor,  first  the  containing  parts  of  the  abdomen,  and 
then  the  uterus ; at  the  aperture  of  which  she  took  out 
the  child  and  secundines.  The  upper  part  of  the  inci- 
sion was  an  inch  higher,  and  to  a side  of  the  navel, 
and  was  continued  about  six  inches  dowmwards  in  the 
middle  between  the  right  os  ileum  and  the  linea  alba. 
She  held  the  lips  of  the  wound  together  with  her  hand, 
till  one  went  a mile  and  returned  with  silk  and  the 
common  needles  which  tailors  use.  With  these  she 
joined  the  lips  in  the  manner  of  the  stitch  employed 
ordinarily  for  the  hare-lip,  and  dressed  the  wound  with 
whites  of  eggs,  as  she  told  me  some  days  after,  when, 
led  by  curiosity,  I visited  the  poor  woman  who  had 
undergone  the  operation.  The  cure  was  completed 
with  salves  of  the  midwife’s  own  compounding. 

In  about  twenty-seven  days,  the  patient  was  able  to 
walk  a mile  on  foot,  and  came  to  me  in  a farmer’s 
house,  where  she  showed  me  the  wound  covered  with 
a cicatrix ; but  she  complained  of  her  belly  hanging 
outwards  on  the  right  side,  where  I observed  a tumour 
as  large  as  a child’s  head  ; and  she  was  distressed  with 
the  flitor  alhiis,  tor  which  I gave  her  some  medicines, 
and  advised  her  to  drink  the  decoctions  of  the  vulne- 
rary plants,  and  to  supjjort  the  side  of  her  belly  with  a 
bandage.  The  patient  has  enjoyed  very  good  health 
ever  since,  manages  her  family  affair.^,  and  has  fre- 
quently walked  to  market  in  this  towm,  which  is  .six 
miles’ distance  from  her  own  house. — {Essays,  vol.  5.) 

In  the  year  1769,  a negro  woman  (belonging  to  Mrs 


224 


C^S 


CAL 


Bland,  a midwife)  at  Mr.  Campbell’s  grass  plantation 
at  the  Ferry,  between  Kingston  and  Spanish  Town,  in 
Jamaica,  being  in  labour,  she  performed  the  C(Bsarean 
operation  on  herself,  and  took  her  child  out  of  the  left  side 
of  her  abdomen,  by  cutting  boldly  through  into  the  uterus. 

She  performed  this  operation  with  a butcher’s  broken 
knife,  about  two  inches  and  a half  long— the  part 
which  joined  to  the  handle.  The  position  of  the 
child  was  natural  ; she  cut  through  near  the  linca 
alba,  on  her  left  side,  and  cut  into  the  child’s  right 
thigh,  which  presented  at  the  part,  about  three  lines 
deep,  and  two  inches  and  a half  long.  The  child 
came  out  by  the  action  of  its  own  struggling.  A negro 
midwife  was  sent  for  to  her,  who  cut  the  navel  cord 
and  freed  the  child ; and  returned  the  part  of  the  navel 
cord  adhering  to  the  placenta,  and  a considerable  ])or- 
tion  of  the  intestines  also,  into  the  abdomen,  which 
had  come  out  of  the  wound  with  the  child. 

The  surgeon  who  attended  the  plantation  was  sent 
for,  a few  hours  after  the  accident  happened  ; and 
judging,  from  the  situation  in  which  he  found  her,  that 
some  dirt  had  been  put  into  the  wound,  by  the  old 
midwife,  with  the  intestines,  he  cut  open  the  stitches 
that  had  been  made,  and  carefully  washed  the  parts 
clean,  extracted  the  placenta  at  the  wound,  and  then 
stitched  it  up  again. 

On  the  third  day,  after  she  had  recovered  from  her 
low  state  from  the  loss  of  blood,  which  was  considera- 
ble, a fever  came  on,  which  tvas  removed  by  coolmg 
medicines  ; she  then  took  bark  for  ten  days.  The 
wound  was  fomented  and  dressed  properly,  and  was 
soon  cured ; and  the  woman  was  well  in  six  weeks’ 
time  from  the  accident,  and  able  to  go  to  her  work. 

The  child  died  on  the  sixth  day,  with  the  Jaw-falling, 
as  it  is  called ; but  came  into  the  world  healthy  and  strong. 

The  woman  continued  perfectly  well,  menstruated 
regularly,  and  was  with  child  again  a year  or  two 
afterward.  She  attempted  the  same  operation  again ; 
but  was  watched  and  prevented,  and  had  a regular 
and  proper  labour.  She  had  borne  three  children  be- 
fore this  affair,  all  with  natural  and  easy  births.  She 
was  an  impatient  and  turbulent  woman,  whose  vio- 
lence of  temper  was  the  only  cause  assigned  for  her 
conduct. — [Mosely  on  Tropical  Diseases.)— Reese.] 

Ft.  Rousset ; Traite  J^oucean  de  V Hysterotomotn- 
hia.  Pans,  1581.  Lat.  C.  .Append.  Bauhini.  Basil. 
158‘i.  Also,  CtBsarei  Partus  Assertio  Historiologica, 
&-C.  8vo.  Paris,  1590.  Fr.  Roussetus,  Foetus  viiii  ex 
matre  viva  sate  alterutrius  perictilo  Ccesura  ; 12/no. 
Basil.  1591.  Theuph.  Raynaud,  l)e  Orta  Infantiam 
contra  J^aturam  per  Sectionein  Coesarenni,  6,-c.  12///0. 
J^agd.  1637.  A.  Cyprianus,  Epistola  Historiaiu  exhi- 
bens  Fmtus  humani  post  ill  ineyises  ex  uteri  tuba,  matre 
salna.  ac  superstite,  excisi.  8eo.  Tiigd.  Bat.  1700. 
This  is  the  celebrated  case,  related  by  Albosius  at  the 
end  of  Bauhhi's  Trans,  of  Rousset.  B.  Terduc, 
Traiti  des  Operations  de  Chirurgie;  nouvelle  edit. 
12/no.  Par.  1721.  Sabatier,  jMedecive  Operaioire,  t.  1, 
ed.  2.  Recherches  sur  V Operation  Cisarienne,  par  .i\I. 
Simon,  in  Jlletn.  de  VAcad.  Royule  de  Chirurgie,  t.  3, 
p.  210,  frc.  and  t.  5 p.  3l7,  Si-c.  edit,  in  12/no.  Bertrandi, 
Traite  des  Operations  de  Chirurgie,  chap.  5.  G.  TV. 
Stein,  Praktische  Anleitung  zur  Kaisergeburt.  Cassel, 
1775.  TVeissenborn,  Obs.  dure  de  Partu  Cresareo.  F.r- 
ford.  1792.  C.  Gaillardot,  sur  V Operation  Cesarienne, 
Strasb.  1799.  JV*.  Ansiaux,  Diss.  sur  V Operation  Ci- 
snrienne  et  la  Section  de  la  Symphyse  de  Pubis.  Paris, 
1803.  .7.  F.  JiTettmavn,  Specimen,  Sistens  Sectionis 

Ceesarea  historiam.  Hal.  1805.  Baudeloque,  Traite 
des  Accouchemens,  Paris,  1807.  Denman's  Introduc- 
tion to  Midwifery,  Ato.  1805.  Also,  Obs.  on  the  Rupture 
of  the  Uterus,  See.  8oo.  1810.  Hull's  Defence  of  the 
Coesarenn  Operation,  8vo.  Manchester,  1798.  Also, 
his  letters  to  Mr.  ./.  TV.  Simmons.  Haighton's  In- 
quiry concerning  the  true  and  spurious  Cmsarean  Ope 
ration.  P.  Berten,  du  Sectione  Sigaultiana  et  Ceesa- 
rea,  harumque  Sectionum  inter  se  Comparatione  : {Coll. 
Diss.  Lovan.  A.  321.)  G.  Ruellan,  Queestio,  Src.  .i)n 
ad  Servandam  pro  fmtu  rnatrem,  obstetricum  hamatile 
minus  anceps  et  tzque.  insons,  qtiam  ad  servandam  cum 
matre feetum  sectio  Ccesarea?  {Haller,  Disp.  Chir.3, 
525.  Paris,  1744.)  A.  Jjindemann,  De  Partu  Preter- 
naturali  quern  Sine  Matris  nut  Foetus  Sectione  absolvere 
non  licet.  Ato.  Gott.  1755.  j\led.  Obs.  and  Inquiries, 
vol.  4,  p.  274,  (S'c.  .7.  Vaughan,  Cases,  S-c.,  to  which  is 

annexed  an  Account  of  the  Cmsarean  Section,  ^,-c.  8vo. 
Land.  1778.  P.  J.  F.  TValckiers,  de  Hysterotomotocia, 


size  Sectione  Ocesarea.  /vouon.  1785.  Edin.  Jlled.  and 
Surgical  Journ.  vol.  A,  p.  178,  vol.  8,  p.  11.  Garth- 
shore's  Obs.  on  Extra-uterine  Cases,  inserted  in  the 
8th  vol.  Eond.  Med.  Journ.  Richter's  Ansfangsgr.  der 
TV undarzneykunst,  b.  7,  Aap,  5;  Gbtt.  1804.  C.  Bell, 
in  Medico- Chirurg.  Trans,  vol.  A,  p.  347,  S,-c. ; J.  J. 
I. ocher,  vol.  9 ; and  J..J.  J. ocher,  JV.  Mtyer,  F.  Spitzbarth, 
and  J.  Loriuser,  in  vol.  11  of  the  same  work.  J.  F. 
Freymann,  De  Partu  Coesareo,  12/no.  Marb.  Catt. 
1797.  .7.  Barlow,  in  Medical  Records  and  Researches, 
1798;  and  in  Essays  on  Surgery  and  Midwifery.  G. 
Josephi,  iiber  die  Schwangersekoft  ausserhalb  der  Ge- 
bdrmutter,\-c.  8vo.  Rostock,  XSTH.  Flojani,  Osserva- 
zioni.  See.  di  Chirurgia,  t.  3,  p.  144,  6i-c.  Roma,  1802. 
Rhode,  Relatio  de  Sectione  Ccesarca  feliciter  peracta. 
Ato.  Dorpati,  1803.  K.  Sprengel,  Geschichte  der  Chir. 
th.  1,  p.  369,  ^c.  8vo.  Halle,  1805.  M.  Baudeloque, 
Two  Memoirs  on  the  Cmsarean  Operation.  Transl. 
with  notes,  tl^c  by  John  Hull  ; 8vo.  Manchester,  1811. 
E.  L.  Heim,  E.7fahrungen,drc.  iiber  Schwangerschaften 
ausserhalb  der  Gebai-mutter,  8vo.  Berlin,  1812.  A.  J. 
A.  Stevens,  de  Conditionibus  qum  apud  parturientem 
Sectionem  Cmsaream,  vel  potius  illavi  Synchondrosis 
ossium  Pubis,  postulant,  Ato.  hugd.  1817.  Diction- 
na ire  des  Sciences  Med.  t.  17,  p.  419,  Paris,  1816;  and 
t.  23,  p.  293,  dec.  1818.  E.  Von  Siebold,  .Journal  fiir 
Geburtshiilfe,  Frauenzimmer  und  Kinder kr ankheiten , 
</.  3,  8//0.  Francof.  1809.  J.  H.  Green,  in  Med.  Chir. 
Trans,  vol.  12,  p.  46,  Src.  C.  F.  Oraefe  iiber  Minde- 
rung  der  Gefahr  beim  Kaiserschnitte,  nebst  der  Ges- 
chichte eines  Falles,  in  TVelchem  Mutter  und  Kind  er- 
halten  wurde.n  ; in  .Journ.  fiir.  Chir.  6,-c.  b.  9.  p.  1 

CALCULUS.  Calculi  form  in  the  ducts  of  the  sali- 
vary glands ; in  the  kidneys,  bladder,  urethra,  gall-blad- 
der, &c.  A paper  on  calculi  formed  in  the  lachrymal 
sac  is  contained  in  Graefe’s  new  Journal.— (/oar/i./wr 
die  Chir.  No.  1,  Berlin,  1820.)  For  an  account  of 
stones  in  the  bladder,  refer  to  Urinary  Calculi. 

[CALCULOUS  DEGENERATION  or  thk  SCRO- 
TUM. The  following  singular  case  is  communicated 
by  Professor  Mott.  It  was  first  published  in  the  Phi- 
ladelphia Journal  for  1827. 

“ In  the  practice  of  surgery  we  frequently  observe 
very  singular  morbid  alterations  of  texture,  which  are 
w'orthy  of  being  recorded  notwithstanding  our  inability 
to  account  for  their  production.  None  of  the  works 
that  we  have  examined  contain  a description  of  such  a 
degeneration  as  that  we  are  about  to  de.scribe,  nor  have 
we  ever  met  with  another  instance  of  a similar  kind. 
It  may,  therefore,  be  useful  to  state  the  fact,  as  a con- 
tribution towards  a more  complete  history  of  the  mor- 
bid anatomy  of  the  scrotum. 

In  the  summer  of  1824, 1 was  requested  to  visit  J.  R. 
aged  about  seventy-three,  a wealthy  farmer,  residing 
upon  Long  Island.  His  health  had  been  declining  for 
two  or  three  years  from  an  affection  of  his  stomach, 
accompanied,  as  he  stated,  with  an  uncommon  disease 
of  the  scrotum.  The  latter  complaint  had  so  far  in- 
creased within  the  last  year,  as  materially  to  injure  his 
health,  in  consequence  of  an  ulceration  and  very  fetid 
discharge  therefrom. 

The  constant  and  severe  burning  which  he  expe- 
rienced in  the  region  of  the  pylorus,  with  an  ejection 
of  the  contents  of  the  stomach  shortly  after  eating,  to- 
gether with  frequent  acrid  eructations  and  costiveness, 
led  to  the  fear  that  there  was  some  organic  derange- 
ment of  the  lower  orifice  of  the  stomach. 

As  the  disease  of  the  scrotum  was  the  particular 
object  of  my  visit,  I requested  permission  to  examine 
it.  It  exhibited  a monstrous,  and  to  me  a very  unique 
appearance,  reaching  fully  two-thirds  the  length  of  his 
thighs,  being  from  twelve  to  fifteen  times  its  ordinary 
bulk,  and  studded,  particulary  on  each  edge  (it  being 
flattened  anteriorly  aiid  posteriorly)  with  several  dozen 
tumours,  of  a stony  hardness,  covered  with  the  integu- 
ments, from  the  size  of  nutmegs  to  that  of  a large  pea. 
It  re.sembled  an  enormous  bunch  of  grapes,  or  more 
closely  some  morbid  conditions  of  the  pancreas  and 
spleen  w'hich  we  have  occasionally  met  with.  The 
tumours  had  all  a very  white  appearance,  and  the  inte- 
guments of  two  or  three  of  the  largest,*having  been  ul- 
cerated for  upwards  of  a year,  poured  forth  a constant 
and  very  fetid  discharge.  At  these  openings  white 
bodies  were  seen,  which,  wiien  touched  with  a probe, 
felt  of  a stony  hardness.  A white  substance  resem- 
bling mortar  was  discharging  from  these  openings, 
wliich  resulted  from  the  crumbling  away  of  the  calculi, 


CAL 


225 


CAL 

and  the  combination  of  this  substance  with  the  fluid 
from  the  ulcers. 

This  state  of  the  scrotum  was  of  upwards  of  twenty 
years’  duration,  and  had  been  frradually  increasing,  the 
tumours  multiplying  as  the  scrotum  augmented  in  size. 
The  patient  knew  of  no  cause  to  which  it  could  be 
ascribed. 

From  its  size  and  weight,  as  well  as  the  loathsome 
nature  of  the  discharge,  he  becam  desirous  to  have  it 
removed  if  practicable  and  proper.  His  health  being 
sufliciently  good,  and  the  testes  appearing  to  move 
freely  in  the  diseased  mass,  led  me  to  recommend  that 
the  operation  should  be  performed. 

An  incision  was  made  around  the  root  or  base  of  the 
scrotum,  beginning  on  each  side  of  the  under  part  of 
the  penis,  at  a point  a little  above  the  scrotum,  so  that 
some  integument  of  this  part  of  the  penis  in  a diseased 
state  was  also  removed,  and  carried  down  to  the  peri- 
naeum,  leaving  an  angular  portion  of  the  scrotum  below 
of  about  an  inch  in  length.  Cautiously  cutting  through 
the  diseased  integuments  and  the  subcutaneous  cellular 
structure,  the  vaginal  coat  of  each  testis  was  readily  dis- 
covered and  avoided.  The  whole  of  the  morbid  mass 
was  removed  by  cautious  dissection,  leaving  the  tunica 
vaginalis  on  each  side  sound  and  unopened.  Numerous 
arteries  were  secured  during  the  dissection  in  tlie  integu- 
ments, as  well  as  several  large  ones  in  the  septum  scroti. 

The  perinaeal  portion  of  the  scrotum  was  susceptible 
of  very  considerable  elongation,  but  it  was  altogether 
insufficient  to  cover  the  testes.  A new  covering  for  them, 
therefore,  could  only  be  looked  for  from  the  granulaiory 
process.  Light  dressings  of  lint,  compress,  and  a T 
bandage  were  applied  for  the  first  two  days,  followed  by 
emollient  poultices  to  favour  the  second  mode  of  healing. 

Suppuration  and  granulation  being  well  established, 
the  new  scrotum  was  increased  and  fashioned  by  the 
use  of  adhesive  straps. 

His  complete  recovery  from  the  operation,  and  the 
reproduction  of  a scrotum,  was  not  interrupted  by  any 
circumstance.  Three  years  have  now  elapsed,  and 
he  eryoys  excellent  health,  being  occasionally  obliged 
to  take  for  a week  or  two  a few  grains  of  the  subnitrate 
of  bismuth,  to  remove  the  affection  of  his  stomach, 
which,  before  the  operation  was  performed,  threatened 
to  become  an  organic  disease.” — Reese.] 

CALCULUS  IN  THE  INTERIOR  OF  THE  EYE. 
See  Eye,  c. 

CALLUS,  new  hone,  or  the  substance  which  serves 
to  join  together  the  ends  of  a fracture,  and  for  the  resto- 
ration of  destroyed  portions  of  bone. 

1.  The  old  surgeons  believed  callus  to  be  a mere  inor- 
ganic concrete,  a fluid  poured  out  from  the  extremities 
of  the  ruptured  vessels,  which  was  soon  hardened  into 
bone.  They  always  described  it  as  an  “ exudation  of 
the  bony  Juice,”  and  imagined  that  it  oozed  from  the 
ends  of  broken  bones,  as  gum  from  trees,  sometimes  loo 
profusely,  sometimes  too  sparingly.  The  reunion  of 
broken  bones,  and  the  hardening  of  callus,  they  com- 
pared with  the  glueing  together  of  tw'o  pieces  of  wood, 
or  the  soldering  of  a broken  iK)t.— (A.  Parc.)  They  also 
conreived,  that  callus  sometimes  flowed  into  the  joints, 
so  as  to  form  a clumsy,  prominent  protuberance.  I'hey 
imagined  that  callus  was  a juice  which  congealed  at  a 
determinate  period  of  time,  and  they  therefore  had  fixed 
days  for  undoing  the  bandages  of  each  particular  frac- 
ture. They  supposed,  that  its  exuberance  might  be 
suppressed  by  a firm  and  well-rolled  bandage,  and  its 
knobby  deformities  corrected  by  pillows  and  com- 
presses ; that  it  might  be  softened  by  frictions  and  oils, 
so  as  to  allow  the  bone  to  be  set  anew.  All  their  no- 
tions were  mechanical ; and  their  absurd  doctrines  have 
been  the  ajiology  for  all  the  contrivers  of  machines,  from 
Hildanus  down  to  Dr.  Aiken  and  Mr.  Gooch. 

2.  By  Galen  and  Duhamel,  however,  a second  doc- 
trine was  entertained,  which  imputed  the  formation  of 
callus  altogether  to  the  periosteum  and  medullary  tex- 
ture, which  were  suppo.sed  to  produce  two  solid  rings 
round  the  fracture,  the  interspace  between  them  being 
afterward  effaced. 

3.  A third  opinion,  maintained  by  Bordenave,  and  the 
best  modern  observers,  is,  that  the  process  of  nature,  in 
the  production  of  callus,  bears  a great  resemblance  to  the 
changes  which  take  place  in  the  reunion  of  the  soft  parts. 

A bone  is  a well-organized  part  of  the  living  body  ; 
that  matter,  which  keeps  its  earthy  parts  together,  is  of 
a platinous  nature.  The  phosphate  of  lime,  to  which 
a bone  owes  its  finnness,  is  deposited  in  tlie  interstices 

Vo..  I— P > 


of  the  gluten,  undergoing  a continual  change  and  reno- 
vation. It  is  incessantly  taken  up  by  the  absorbents, 
and  secreted  again  by  the  arteries.  It  is  this  continual 
absorption  and  deposition  of  earthy  matter  which  forms 
the  bone  at  first,  and  enables  it  to  grow  with  the  growth 
of  the  body.  It  is  this  unceasing  activity  of  the  vessels 
of  a bone  tvhich  enables  it  to  renew  itself  when  it  is 
broken  or  di.seased.  In  short,  it  is  by  various  forms  of 
one  secreting  process,  that  bone  is  formed  at  first,  is 
supported  during  health,  and  is  renewed  on  all  neces- 
sary occasions.  Bone  is  a secretion,  originally  depo- 
sited by  the  arteries  of  the  bone,  which  arteries  are  con- 
tinually employed  in  renewing  it.  Callus  is  not  a con- 
crete juice,  deposited  merely  for  filling  up  the  interstices 
between  fractured  bones,  but  it  is  a regeneration  of  new 
and  perfect  bone,  furnished  with  arteries,  veins,  and  ab- 
sorbents, by  which  its  earthy  matter  is  continually 
changed,  like  that  of  the  contiguous  bone.  Indeed,  there 
could  be  no  connexion  between  the  original  bone  and 
callus,  were  the  latter  only  the  inorganic  concrete,  as  it 
was  formerly  supposed  to  be. 

Notwithstanding  the  more  accurate  opinions  now  en- 
tertained concerning  callus,  the  supposition  is  still  very 
common,  that  the  slightest  motion  will  destroy  callus, 
while  it  is  being  formed.  But,  says  Mr.  John  Bell,  it  is 
an  ignorant  fear,  proceeding  merely  from  the  state  of 
the  parts  not  having  been  observed  ; for,  when  callus 
forms,  the  perfect  constitution  of  the  bone  is  restored ; 
the  arteries  pour  out  from  each  end  of  a broken  bone  a 
gelatinous  matter ; the  vessels  by  which  that  gluten  is 
secreted  expand  and  multiply  in  it,  till  they  Ibrm  be- 
tween the  broken  ends  a well-organized  and  animated 
mass,  ready  to  begin  anew  the  secretion  of  bone.  Thus, 
the  ends  of  the  bone,  when  the  bony  secretion  com- 
mences, are  nearly  in  the  same  condition,  as  soil  parts 
which  have  recently  adhered  ; and  it  is  only  when  there 
is  a want  of  continuity  in  the  vessels,  or  when  a want 
of  energetic  action  incapacitates  them  from  renewing 
their  secretion,  that  callus  is  imperfectly  formed.  This 
is  the  reason  why,  in  scorbutic  constitutions,  in  patients 
infected  with  syphilis,  in  pregnancy,  in  fever,  or  in  any 
great  disorder  of  the  system,  or  while  the  wound  of  a 
compound  fracture  is  open,  no  callus  is  generated.— 
{John  Belt's  Principles  of  Surgery,  vol.  1,  p.  500,  501.) 
How  far  some  of  the  latter  statement  is  correct,  or  not, 
will  be  seen  in  the  article  Fractures. 

For  some  time  the  secretion  of  earthy  matter  is  im- 
perfect ; the  young  bone  is  soft,  flexible,  and  of  an  or- 
ganization suited  for  all  the  purposes  of  bone ; but 
hitherto  delicate  and  unconfirmed ; not  a mere  con- 
crete, like  the  crystallization  of  a salt,  whicli,  if  inter- 
rupted in  the  moment  of  forming,  will  never  form ; 
not  liable  to  be  discomposed  by  a slight  accident,  nor  to 
be  entirely  destroyed  by  being  even  roughly  moved  or 
shaken.  Incipient  callus  is  soft  and  yielding;  it  is 
ligamentous  in  its  consistence,  so  that  it  is  not  very 
easily  injured ; and  in  its  organization  it  is  so  perfect, 
that  when  it  is  hurt,  or  the  bony  secretion  interrupted, 
the  breach  soon  heals,  just  as  soft  parts  adhere,  ajid 
thus  the  callus  becomes  again  entire,  and  the  process 
is  immediately  renewed. 

In  consequence  of  the  above  circumstances,  if  a 
limb  be  broken  a second  time  when  the  first  fracture  is 
nearly  cured,  the  bone  unites  more  easily  tlian  after 
the  first  accident ; and  Mr.  J.  Bell  even  asserts,  that 
when  it  is  broken  a third  and  a fourth  time,  the  union  is 
still  quicker.  In  these  cases  the  limb  yields,  it  bends 
under  the  weight  of  the  body  which  it  cannot  support ; 
but  without  any  snapping  or  splintering  of  the  bone, 
and  generally  without  any  over-shooting  of  the  ends  of 
the  i)art,  and  without  any  crepitation. 

Callus  is  found  to  be  more  vascular  than  old  bone. 
Mr.  J.  Bell  mentions  an  instance  of  a bone,  which  had 
been  broken  twelve  years  before  he  injected  it,  yet  the 
callus  was  rendered  singularly  red.  When  a recently 
formed  callus  is  broken,  many  of  its  vessels  are  rup- 
tured, but  some  are  only  elongated,  and  it  rarely  hap- 
pens that  Its  whole  substance  is  torn.  U is  easy  to 
conceive  how  readily  the  continuity  of  the  vessels  will 
be  renewed  in  a broken  callu.s,  when  we  reflect  on  its 
great  vascularity  and  the  vigorous  circulation  excited 
by  the  accident  in  vessels  already  accustomed  to  the 
secretion  ol  bone.  These  reasons  show  why  a broken  or 
bent  callus  is  moresj)et;dily  united  than  a fractured  bone. 

Vv  hile  the  ends  of  a broken  bone  are  connected  to- 
gether by  a flexible  substance  of  cartilaginous  consiM- 
ence,  liupuytrcn  calls  lliis  bond  ol'  union  the  proii- 


226 


CAM 


CAN 


sional  callus,  which  generally  lasts  nntil  the  thirtieth 
or  fortieth  day.  In  a later  stage  the  intervening  cartila- 
ginous matter  ossifies  ; the  swelling  of  the  soft  parts 
subsides  ; and  in  from  six  to  twelve  months  the  callus 
or  new’  bony  matter  filling  the  medullary  canal  is  ab- 
sorbed, whereby  the  latter  is  restored.  The  callus  re- 
maining after  the  completion  of  this  process,  Dupuy- 
tren  terms  dijinitive. 

Wtieu  bones  granulate,  says  Mr.  Wilson,  the  granu- 
lations at  first  appear  exactly  similar  to  those  of  the 
soft  parts,  and,  as  in  the  soft  parts,  take  place  to  restore 
any  loss  which  the  bones  may  have  suffered.  This 
process  is  very  similar  to  that  of  the  first  formation  of 
bone.  In  the  skull  membrane  was  first  formed;  and 
here,  also,  in  the  process  of  restoration  the  granulations 
change  into  membrane,  and  then  into  bone.  In  cylin- 
drical bones,  the  granulations  first  produce  a species  of 
cartilage,  and  this  is  afterward  converted  into  bone. 
Thus,  in  the  restoration  of  bone,  nature  is  guided  by 
the  same  laws  which  prevail  in  its  first  formation.  If 
the  granulations  thrown  out  on  the  surface  of  a bone  be 
viewed  in  a microscope,  they  appear  to  form  a number  of 
small  points  like  villi,  the  bases  of  which  first  become  si- 
milar to  cartilage,  and  then  to  bone.  “ The  preparations 
from  the  surface  of  granulating  stumps  show  the  ex- 
treme delicacy  of  the  first  bony  tlireads,  and  also  their 
mode  of  uniting  laterally  with  each  other.”— (On  the 
Structure,  Physiology,  and  Diseases  of  the  Bones,  i^-c. 
p.  197,  8uo.  Lond.  1820.) 

And  in  another  place  he  repeats,  “ I have  examined 
several  skulls  on  the  death  of  the  persons,  at  different 
periods,  from  days  to  years  after  pieces  of  bone  had 
been  removed,  and  before  vacancies  had  been  com- 
pletely filled  up  ; but  I never  could  in  any  of  them  dis- 
cover the  least  appearance  of  cartilage.”  A membrane 
here  always  precedes  the  formation  of  bone.--(P. 
210.)  For  additional  observations  on  callus  see  Frac- 
ture. AT.  M.  jyiuUer,  De  Callo  Ossium  ; 4fo.  JVorimb. 
1707 ; Duhamel  in  Jlem.  de  I' Acad.  Royale  des  Sci- 
ences, an  1741,  p.  92  et  222;  Boehmer,  De  Callo 
Ossium  i rubia  tinctorum  radicis  pa.<tii  infectoruni, 
Ato.  Lips.  1752;  Dethleef,  Diss.  exhibens  Ossium 
Calli  generationem  et  naturam  per  fracta  in  animali- 
bus  rubice  radicepastis  ossa  demonstratam.  Ato.  Goett. 
1753  ; A.  Marrigues,  Sur  la  Formation  du  Cal.  Paris, 
1783.  A.  McDonald,  de  J^ecrosi,  Src.  Edin.  1799. 
The  works  of  Trojd,  David,  Blumenbach,  and  Koeh- 
ler, as  specified  at  the  conclusion  of  the  article  Mccro- 
sis.  J.  F.  Meckel,  Handb.  der  Pathol.  Anatomic.  Leip- 
zig, 1818,  i.2,  p.62.  G.  Brescket,  Recherches  Histo- 
riques  et  Ezper.  sur  la  Formation  du  Cal.  Paris,  1819. 
J.  Wilson,  On  the  Structure,  Physiology,  and  Diseases 
of  the  Bones,  p.  208,  8vo.  4'C.  Lond.  1820. 

CALOMEL.  (Submuriate  of  mercury ; hydrargyTi 
submurias,  L.  P.)  Its  extensive  utility  in  numerous 
surgical  diseases  will  be  conspicuous  in  a large  pro- 
portion of  the  articles  in  this  w’ork.  When  prescribed 
as  an  alterative  the  common  dose  is  a grain  once  or  twice 
a day;  when  ordered  as  a purgative,  from  three  to 
eight  grains  may  be  given ; and  when  directed  w’ith 
the  view  of  exciting  salivation,  one  or  two  grains,  con- 
joined with  opium,  are  usually  administered  night  and 
morning. 

CAMPHOR  is  used  externally,  chiefly  as  a means  of 
exciting  the  action  of  the  absorbents,  and  thus  dispersing 
many  kinds  of  swellings,  extravasations,  indurations, 
&c.  Hence  it  is  a common  ingredient  in  liniments.  It 
has  also  the  property  of  rousing  the  action  of  the  nerves 
and  quickening  the  circulation  in  parts  on  w’hich  it  is 
rubbed.  For  this  reason,  in  paralytic  affections  it  is 
sometimes  employed.  Peiiiaps  there  is  no  composi- 
tion that  has  greater  power  in  exciting  the  absorption 
of  any  tumour  or  hardness  than  camphorated  mercu- 
rial ointment. 

In  cases  of  delirium,  depending  on  the  irritation  of 
local  surgical  diseases,  and  in  some  descriptions  of 
mortification,  camphor  is  occasionally  prescribed.  It 
has  also  been  recommended  as  singularly  useful  for  the 
relief  of  stranguries,  even  those  depending  on  the  ope- 
tion  of  caulharides.  But  although  it  may  occasionally 
have  succeeded,  w’hen  given  with  this  view,  it  not 
only  does  not  ahvays  do  so,  but  it  has  been  known  to 
cause  an  opposite  effect,  sometimes  producing  great 
scalding  in  voiding  the  urine,  and  sometimes  pains  like 
those  of  labour.— (Medico/  Trans,  xml.  l,p.  470.)  In 
chordee  its  utility  is  generally  acknowledged.  Persons 
wfvo  cannot  procure  rest  unless  they  take  verj-  large 


doses  of  opium,  sometimes  find  smaller  ones  answw', 
if  combined  with  camphor.— (See-Brandc’s  Manual  of 
Pharmacy,  p.  46.) 

CANCER.  (Derived  from  cancer,  a crab,  to  which 
a part  affected  wdth  cancer  and  surrounded  with  vari- 
cose veins  was  anciently  thought  to  have  some  resem- 
blance.) Carcinoma 

The  disease  has  two  principal  forms,  one  named  scir- 
rhus  or  occult  cancer  ; the  other,  ulcerated  or  open  can- 
cer. According  to  the  usual  definition,  as  Mr.  Pearson 
observes,  an  indolent  scirrhus  is  a hard  and  almost  in- 
sensible tumour,  commonly  situated  in  a glandular  part 
and  accompanied  with  little  or  no  discoloration  of 
the  surface  of  the  skin.  But  when  the  disease  has 
proceeded  from  the  indolent  to  the  malignant  state, 
the  tumour  is  unequal  in  its  figure,  it  becomes  painful, 
the  skin  acquires  a purple  or  livid  hue,  and  the  cutane- 
ous veins  are  often  varicose. — {Principles  of  Surgery, 
§ 331.  343.)  The  pain  is  remarked  to  be  acute  and  lan- 
cinating, and  its  attacks  recur  with  more  or  less  fre- 
quency. At  length  the  tumour  breaks,  and  is  con- 
verted into  cancer,  strictly  so  called,  or  the  disease  in 
the  state  of  ulceration. 

The  female  breast  and  the  uterus  are  particularly 
subject  to  the  disease.  The  breasts  of  men  are  but 
rarely  affected.  The  testes,  lips  (especially  the  lower 
one  of  male  subjects),  the  penis,  the  lachrj  mal  gland 
and  eye,  the  tongue,  the  skin  (particularly  that  of  the 
face),  the  tonsils,  the  pylorus,  the  bladder,  rectunrv, 
prostate,  and  a variety  of  other  parts,  are  recorded  by 
surgical  wTiters  as  having  frequently  been  the  seat  of 
scirrhus  and  cancer.  They  seem,  however,  to  have 
comprehended  an  immense  number  of  different  malig- 
nant diseases  under  one  common  name,  and  in  many 
of  the  cases  called  cancerous  there  are  no  vestiges  of 
the  true  scirrhous  structure. 

OF  SCIRRHUS,  OR  CANCER  NOT  IN  THE  IJLCER.CTED 
state. 

Mr.  Abemethy  has  given  a matchless  history  of  this 
affection  as  it  appears  in  the  female  breast,  where  it 
most  frequently  occurs,  and  can  be  best  investigated. 
Sometimes,  as  he  has  remarked,  it  condenses  the  sur- 
rounding substance  so  as  to  acquire  a capsule ; and 
then  it  appears,  like  many  sarcomatous  tumours,  to  be 
a part  of  new  formation.  In  other  cases  the  mam- 
mary gland  seems  to  be  the  nidus  for  the  diseased  ac- 
tion. In  the  latter  case  the  boundaries  of  the  disease 
cannot  be  accurately  ascertained,  as  the  carcinomatous 
structure,  hawng  no  distinguishable  investment,  is  con- 
fused W’ith  the  rest  of  the  gland.  Sir  Everard  Home 
also  remarks,  that  when  the  disease  originates  by  « 
small  portion  of  the  glandular  structure  of  the  breast 
becomhig  hard,  which  is  very  commonly  the  case,  it  is 
readily  distinguished  by  the  hard  part  never  having 
been  perfectly  circumscribed,  and  giving  more  the  feel 
of  a knot  in  the  gland  itself  than  of  a substance  dis- 
tinct from  it.  In  each  of  these  instances  carcinoma 
begins  at  a small  spot,  and  extends  from  it  in  all 
directions,  like  rays  from  a centre.  Tliis  is  one  fea- 
ture distinguishing  this  disease  from  many  others, 
which  at  their  first  attack  involve  a considerable  por- 
tion, if  not  the  whole,  of  the  part  in  which  they  occur. 
The  progress  of  carcinoma  is  more  or  less  quick  in  dif- 
ferent instances.  When  slow’,  it  is  in  general  unre- 
mitting. Mr.  Abemethy  thinks,  that  though  the  dis- 
ease may  be  checked,  it  cannot  be  made  to  recede  by 
the  treatment  which  lessens  other  sw’ellings.  On  this 
point,  however,  he  is  not  positive  ; for  surgeons  have 
informed  him,  that  diseases  which  eventually  proved 
to  be  carcinomatous,  have  been  considerably  diminished 
by  local  treatment.  With  great  deference  to  Mr.  Aber- 
nethy,  I may  be  allowed  to  remark  in  this  place,  that 
every  tumour  which  ends  in  cancer  is  not  from  the  first 
of  this  nature,  though  it  has  in  the  end  become  so ; 
consequently,  it  may  at  first  yield  to  local  applications, 
but  will  not  do  so  after  the  cancerous  action  has  com- 
menced. Hence  Mr.  Aberaethy’s  opinion,  that  a true 
carcinomatous  tumour  cannot  be  partially  dispersed,  at 
least  remtiins  unweakened  by  the  fhet  that  some  tu- 
mours have  at  first  been  lessened  by  remedies,  though 
they  at  la.st  ended  in  cancer.  Sir  E.  Home’s  observa- 
tions tend  to  prove  that  any  sort  of  tumour  may  ulti- 
mately become  cancerous. 

Without  risk  of  inaccuracy  we  may  set  down  the 
backw  ardness  of  a scirrhous  swelling  to  be  dispersed 
or  diminished,  as  one  of  its  most  confirmed  fcaiuM* 


CANCER. 


227 


This  obdurate  and  destructive  disease  excites  the  con- 
tiguous parts,  whatever  their  nature  may  be,  to  enter 
into  the  same  diseased  action.  The  skin,  the  cellular 
substance,  the  muscles,  and  the  periosteum,  all  become 
alfected  if  they  are  in  the  vicinity  of  cancer.  This 
very  strilung  circumstance  distinguishes  carcinoma, 
says  1^.  Abernethy,  from  several  other  diseases.  In 
what  this  author  calls  medullary  sarcoma,  the  disease 
is  propagated  along  the  absorbing  system ; but  the 
parts  immediately  in  contact  with  the  enlarged  glands 
do  not  assume  the  same  diseased  action.  Neither  in 
the  tuberculated  species  does  the  ulceration  spread 
along  the  skin,  but  destroys  that  part  only  which  co- 
vers the  diseased  glands.  According  to  Mr.  Abernethy, 
a disposition  to  cancer  existing  in  the  surrounding 
parts,  before  the  actual  occurrence  of  the  diseased  ac- 
tion, was  a circumstance  noticed  by  Mr.  Hunter. 
Hence  arose  the  following  rule  in  practice  : That  a 
surgeon  ought  not  to  be  contented  with  removing 
merely  the  indurated  or  actually  diseased  part,  but  that 
he  should  also  take  away  some  portion  of  the  surround- 
ing substance  in  which  a diseased  disposition  may 
probably  have  been  excited.  In  consequence  of  this 
communication  of  disease  to  the  contiguous  parts,  the 
skin  soon  becomes  indurated,  and  attached  to  a carci- 
nomatous tumour,  Which  in  like  manner  is  fixed  to  the 
muscles  or  other  part  over  which  it  is  formed. 

As  a carcinomatous  tumour  increases,  it  generally, 
though  not  constantly,  becomes  unequal  upon  its  sur- 
face, so  that  this  inequality  has  been  considered  as  cha- 
racteristic of  the  disease.  A lancinating  pain  is  com- 
mon ; but  it  is  not  experienced  in  every  case  without 
exception.  It  is  also  a symptom  attending  other  tu- 
mours, which  are  unlike  carcinoma  in  structure,  and  it 
cannot,  therefore,  be  deemed  an  infallible  criterion  of 
the  nature  of  the  disease.— (Afienie^/zi/’s  Surgical 
Works,  vol.  2,  p.  69,  &c.) 

A hard  and  painful  glandular  swelling,  having  a dis- 
position to  become  cancer,  says  Richter,  is  the  com- 
mon, but  inadequate  and  erroneous  definition  of  scir- 
rhus.  The  disease  is  not  regularly  attended  with 
swelling ; sometimes  scirrhous  parts  diminish  in  size 
and  shrink.  Hardness  is  not  a characteristic  property  ; 
for  many  tumours  which  are  not  scirrhous,  are  exceed- 
ingly indurated.  The  disease  is  not  always  situated 
in  a gland ; it  frequently  attacks  structures  which  can- 
not be  called  glandular ; and  hard  glandular  swellings 
are  often  seen  which  do  not  partake  of  scirrhus.  The 
disposition  to  cancer  cannot  be  enumerated  among  the 
marks  of  scirrhus,  since  it  is  not  discoverable  till  car- 
cinoma has  actually  commenced.  Its  termination  in 
open  cancer  is  not  an  invariable  occurrence ; and  other 
tumours  become  cancerous  to  which  no  one  would 
apply  the  term  scirrhi.— (An/angsgr.  der  Wundarzn. 
b.  1.) 

With  regard  to  (he  observation  that  tumour  is  not 
an  essential  character  of  carcinoma,  Mr.  C.  Bell  admits 
its  correctness  only  in  a certain  sense;  “It  is  true 
(says  he)  that  there  is  not  always  an  increase  of  the 
dimensions  of  the  whole  breast ; on  the  contrary,  true 
carcinoma  is  often  accompanied  with  a contraction  and 
diminution  of  tlie  general  bulk.  But  what  is  true  of 
the  breast  or  mamma  is  not  true  of  the  tumour ; for 
the  proper  structure  of  the  gland  either  shrinks  or  is 
compressed ; and  sometimes  the  surrounding  fat  is  di- 
minished by  absorption,  so  that  the  whole  mass  is  less 
than  the  natural  breast,  or  than  what  the  brea.st  was 
before  the  commencement  of  the  disease.  But  still 
the  diseased  jiart  is  properly  a tumour : there  we  sec 
an  increased  mass,  a preternatural  growth,  or  new 
matter,  corresponding  to  the  old  definition,  morbosum 
augmentum.  But  farther,  and  in  respect  to  the  adi- 
pose membrane,  the  fat  is  not'  always  diminished  in 
carcinoma  marnmie,  but  sometimes  quite  the  contrary  ; 
and  this  difference  in  it  will  sometimes  produce  a va- 
riety in  the  external  character,  when  there  is  none  in 
the  disease  actually  or  in  the  imernal  structure.  Some- 
tirne.s,  from  the  diminution  bf  fat,  the  irregular  tuber- 
culated structure  of  this  di.sease  will  be  apparent  to 
the  eye  and  to  the  touch  : while  in  another  patient  the 
oreast  will  be  large,  full,  and  smooth,  only  marked 
more  than  naturally  with  large  blue  veins,  and  having 
an  ulcer  like  a hole  dug  in  the  centre  of  the  breast.” — 
(C.  Bell,  in  Med.  Chir.  Trans,  vol.  12,  p.  220.)  These 
observations  fully  agree  with  those  which  some  atten- 
tion to  the  appearances  of  cancer  have  enabled  me  to 
make. 

P 2 


Scientific  surgeons  ought  undoubtedly  to  have  a de- 
finite meaning  when  they  employ  the  term  scirrhus ; 
the  word  is  generally  used  most  vaguely;  and,  per- 
haps, influenced  by  its  etymology,  surgeons  call  an  im- 
mense number  of  various  morbid  indurations  scirrhi, 
which  are  not  at  all  of  a malignant  or  dangerous  cha- 
racter. 

I have  always  considered  scirrhus  as  a diseased 
hardness,  in  which  there  is  a propefisity  to  cancerous 
ulceration,  and  a greater  backwardness  to  recede  than 
exists  in  any  other  kind  of  diseased  hardness,  although 
the  skin  may  occasionally  not  break  during  life,  and  a 
few  scirrhous  indurations  may  have  been  lessened. 

Though  Richter  states  that  this  disposition  cannot  be 
discovered  till  carcinoma  has  actually  taken  place ; 
though  Mr.  J.  Burns  and  Sir  E.  Home  affirm  that  other 
indurations  and  tumours  may  terminate  in  cancer; 
though  Mr.  Abernethy  shows  that  sarcomatous  and 
encysted  tumours  may  end  in  most  malignant  diseases, 
and  such  as  equal  cancer  in  severity  {Chir.  Works,  p. 
83)  ; yet  it  is  now  well  ascertained,  that  in  all  these 
instances,  the  changes  which  precede  cancerous  ul- 
ceration bear  no  resemblance  to  those  of  a true  malig- 
nant scirrhtis. 

The  puckering  of  the  skin,  the  dull,  leaden  colour  of 
the  integ'iments,  the  knotted  and  uneven  feel  of  the 
disease,  the  occasional  darting  pains  in  the  part,  its 
fixed  attachment  to  the  skin  above,  and  muscles  be- 
neath and  in  the  breast,  the  retraction  of  the  nipple, 
form  so  striking  an  assemblage  of  symptoms,  that 
when  they  are  all  present,  there  cannot  be  the  smallest 
doubt  that  the  tumour  is  a scirrhus,  and  that  the  dis- 
ease is  about  to  acquire,  if  it  have  not  already  acquired, 
the  power  of  contaminating  the  surrounding  parts  and 
the  lymphatic  glands  to  which  the  absorbents  of  the 
diseased  part  tend. 

As  Sir  Everard  Home  has  observed,  the  truly  scir- 
rhous tumour,  which  is  known  to  be  capable  of  chang- 
ing into  the  true  open  cancer,  when  allowed  to  increase 
in  size,  is  known  to  be  hard,  heavy,  and  connected 
with  the  gland  of  the  breast ; and,  when  moved,  the 
whole  gland  moves  along  with  it.  The  structure  of  a 
scirrhous  tumour  in  the  breast  is  different  in  the  va- 
rious stages  of  the  disease ; and  a description  of  the 
appearances  exhibited  in  the  three  principal  ones,  may 
give  a tolerable  idea  of  what  the  changes  are  which  it 
goes  through  previous  to  its  breaking,  or  becoming 
what  is  termed  an  open  cancer. 

When  a section  is  made  of  such  a tumour  in  an  early 
stage,  provided  the  structure  can  be  seen  to  advantage, 
it  puts  on  the  following  appearance ; the  centre  is  more 
compact,  harder  to  the  feel,  and  has  a more  uniform 
texture  than  the  rest  of  the  tumour ; and  is  nearly  of 
the  consistence  of  cartilage.  This  middle  part  does 
not  exceed  the  size  of  a silver  penny;  and  from  this, 
in  every  direction,  like  rays,  are  seen  ligamentous 
bands  of  a white  colour  and  very  narrow,  looking,  in 
the  section,  like  so  many  extremely  irregular  lines 
passing  to  the  circumference  of  the  tumour,  which  in 
blended  with  the  substance  of  the  surrounding  gland. 
In  the  interstices  between  the.se  bands  the  substance  is 
different,  and  becomes  less  compact  towards  the  outer 
edge.  On  a more  minute  examination,  transverse  liga- 
mentous bands,  of  a fainter  appearance,  form  a kind  of 
net- work,  in  the  meshes  of  which  the  new-formed  sub- 
stance is  enclosed.  This  structure  accords  with  what 
Dr.  Baillie  describes  as  presenting  itself  in  cancerous 
diseases  of  the  stomach  and  uterus. 

In  a more  advanced  stage  of  the  tumour,  the  whole 
of  the  diseased  part  has  a more  uniform  structure ; no 
central  point  can  be  distinguished ; the  external  edge 
is  more  defined  and  di.stinct  from  the  surrounding 
gland ; and  the  ligamentous  bands  in  different  direc- 
tions are  very  apparent,  but  do  not  follow  any  course 
that  can  be  traced. 

According  to  Mr.  C.  Bell,  it  is  the  ligamentous  bands 
which  produce  the  retraction  of  the  nipple,  by  extend- 
ing between  its  ducts  and  destroying  its  spongy  texture. 
-(Med.  Chir.  Trans,  vol.  12,  p.  233.) 

On  dis.section.  Sir  Astley  Cooper  observes,  that  the 
breast  is  one  solid  mass  like  cartilage,  with  very  little 
vascularity  except  at  its  edges,  and  internally  fibrous. 
When  the  breast  has  acquired  any  magnitude,  he  says, 
there  is  generally  an  opening  in  it,  in  which  case  it 
has  the  appearance  internally  of  being  worm-eaten  and 
spongy.  In  the  situation  of  the  ulceration  it  is  very 
vascular,  and  bloodv  serum  is  met  with,  ’fhe  ab.sorb- 


228 


CANCER. 


ent  glands  put  on  tlie  same  character  js  the  scirrhous 
breast.  The  cellular  membrane,  skin,  and  muscles 
are  also  affected.  Sometimes  the  diseased  glands 
above  the  clavicle  press  upon  the  thoracic  duct,  and  thus 
interrupt  the  transmission  of  chyle  into  the  blood. 
Hence  the  appetite  is  sometimes  voracious,  though  the 
patient  is  rapidly  wasting.  In  the  chest,  on  the  same 
side  as  the  disease,  hydrothorax  prevails,  and  the  ab- 
sorbents on  the  pleura  are  in  a morbid  state,  and  smalt 
white  spots,  like  pins’  heads,  are  visible.  Traces  of 
scirrhous  disorder  Sir  Astley  Cooper  likewise  repre- 
sents as  occasionally  existing  in  the  liver,  uterus,  &c. 
— (See  Lancet,  vol.  2,  f.  373.) 

When  the  tumour  has  advanced  to  what  may  be 
called  cancerous  suppuration  (which,  however,  does 
not  always  happen  in  the  centre  before  it  has  ap- 
proached the  skin  and  formed  an  external  sore),  it  ex- 
hibits an  appearance  totally  different  from  what  has 
been  described.  In  the  centre  is  a small  irregular  ca- 
vity filled  with  a bloody  fiuid,  the  edges  of  which  are 
ulcerated,  jagged,  and  spongy.  Beyond  these  there  is 
a radiated  appearance  of  ligamentous  bands,  diverging 
towards  the  circumference ; but  the  tumour  near 
the  circumference  is  more  compact,  and  is  made  up  of 
distinct  portions,  each  of  which  has  a centre,  sur- 
rounded by  ligamentous  bands,  in  concentric  circles. 

It  is  remarked  by  Sir  Everard  Home,  that  in  some 
instances  scirrhus  has  no  appearance  of  suppuration  or 
ulceration  in  the  centre,  but  consists  of  a cyst  filled 
with  a transparent  fluid  and  a fungous  excrescence, 
projecting  into  this  cavity,  the  lining  of  w'hich  is 
smooth  and  polished.  When  a large  hydatid  of  this  kind 
occurs,  a number  of  very  small  ones  have  been  found 
in  different  parts  of  the  same  tumour ; and  in  other 
cases  there  are  many  very  small  ones,  of  the  size  of 
pins’  hepds,  without  a large  one.  These  hydatids  are  by 
no  means  sufficiently  frequent  in  their  occurrence  to 
admit  of  their  forming  any  part  of  the  character  of  a 
cancerous  tumour.— (Oi^s.  on  Cancer,  p.  156,  S,  c.  8vo. 
Jj)nd.  1805.) 

In  the  fourth  chapter  of  this  work  the  author  relates 
two  cases  of  hydatids  found  in  the  breast.  In  the  first, 
the  contents  of  the  cyst  were  bloody  serum ; in  the  se- 
cond, a clear  fiuid.  These  two  cases  of  simple  hyda- 
tids in  the  breast,  unconnected  with  any  other  dis- 
eased alteration  of  structure,  led  Sir  E.  Home  to  con- 
sider more  particularly  the  nature  of  such  hydatids  as 
are  sometimes  found  in  cancerous  breasts ; he  believes 
that  they  form  no  real  part  of  the  disesise,  but  are  acci- 
dental complaints  superadded  to  it ; and  that,  tis  they 
occur  in  the  naturtil  slate  of  the  gland,  they  are  much 
more  likely  to  do  so  in  disease. — (Op.  cit.  p.  108. 159.) 
These  hydatid  or  encysted  swellings  of  the  breast  are 
not  always  regarded  as  true  scirrhi,  and  in  particular 
Sir  Astley  Cooper  and  Mr.  C.  Bell  describe  them,  ac- 
cording to  my  judgment  very  correctly,  as  a different 
form  of  disease. 

8ir  E.  Home  defines  what  he  means  by  cancer  as 
follows  “ As  cancer  is  a term  too  indiscriminately 
applied  to  many  local  diseases  for  which  we  have  no 
remedy,  though  they  differ  very  much  among  them- 
selves, it  becomes  necessary  to  state  what  the  com- 
plaints are  which  I include  under  this  denomination. 
The  present  observations  respecting  cancer  apply  only 
to  those  diseased  appearances  which  are  capable  of 
contaminating  other  parts,  either  by  direct  communi- 
cation or  through  the  medium  of  the  absorbents ; and 
when  they  approach  the  skin,  produce  in  it  small  tu- 
mours of  their  own  nature,  by  a mode  of  contamina- 
tion with  which  we  are  at  present  unacquainted. 

There  is  a disease,  by  which  parts  of  a glandular 
structure  are  very  frequently  attacked,  particularly 
the  os  tincae,  the  alas  of  the  nose,  the  lips,  and  the 
glans  penis.  This  has  been  called  cancer,  but  differs 
from  the  species  of  which  we  are  now  treating,  in  not 
contaminating  the  neighbouring  parts  with  which  it  is 
in  contact ; and  neither  affecting  the  absorbent  glands 
nor  the  skin  at  a distance  from  it.  It  is,  properly- 
speaking,  an  eating  sore,  which  is  uniformly  pro- 
gressive; whereas,  in  cancer,  after  the  sore  has  made 
some  progress,  a ridge  is  formed  upon  the  margin,  and 
the  ulceration  no  longer  takes  that  direction.  It  also 
differs  from  a cancer  in  admitting  of  a cure  in  many 
instances  and  under  different  modes  of  treatment. 

From  the  facts  whicli  have  been  stated  (.see  the  cases 
detailed  in  this  gentleman's  work),  it  appears  that  caii- 
err  IS  u disease  which  is  local  in  Us  origin.  In  tins 


resjiect  the  cases  (alluded  to)  only  confirm  an  opinlciT 
very-  generally  received  among  medical  practitioners  ; 
but  in  favour  of  which  no  series  of  facts  had  been  laid 
before  the  public  of  sufficient  force  entirely  to  establish 
the  opinion.” — (P.  145,  A c.) 

Sir  E.  Home  endeavours  to  establish  a second  point, 
that  cancer  is  not  a disease  which  immediately  takes 
place  in  a healthy  part  of  the  body ; bvX  one  for  the 
production  of  which  it  is  necessary  that  the  part  shoadd 
have  undergone  some  previous  change  connected  with 
the  disease.  In  proof  of  this,  the  first  two  cases  in 
his  work  are  brought  forward,  and  the  innumerable 
instances  in  which  a pimple,  small  tumour,  or  wart 
upon  the  nose,  cheek,  or  prepuce  may  remain  for  ten, 
fifteen,  or  thirty  years,  wiffiout  producing  the  smallest 
inconvenience  ; but  at  the  age  of  sixty  or  seventy, 
upon  being  cut  in  shaving,  bruised  by  any  accidental 
violence,  or  otherwise  injured,  assumes  a cancerous 
disposition. 

All  the  cases  of  induration  of  the  gland  of  thn 
breast,  or  of  indolent  tumours  in  it,  which  have  con- 
tinued for  years  without  producing  any  symptom,  and 
after  being  irritated  by  accidental  violence  have  as- 
sumed a new  disposition  and  become  cancerous,  admit 
of  the  same  explanation ; and  are  adduced  as  so  many 
proofs  of  the  truth  of  this  latter  position.— (P.  147,  A c.) 

With  regard  to  the  common  opinion,  that  the  pro- 
duction of  scirrhus  of  the  breast  is  connected  wdth 
the  cessation  of  the  menses.  Sir  Astley  Cooper  also- 
expresses  his  belief,  that  if  a person  has  a tumour^ 
not  originally  of  a mahgnant  nature,  in  the  breast,  an 
undue  action  may  afterward  be  excited  in  it  when  the 
change  of  life  takes  place ; and  the  disease  then  as- 
sumes the  character  of  scirrhus.— (Lancet,  vol.  2,  p 
376.) 

However,  the  doctrine,  that  certain  tumours  may 
change  their  nature  and  alter  into  cancer,  is  one  which 
is  sometimes  looked  upon  with  suspicion.  “ Improper 
treatment  may  without  doubt  exasperate  diseases,  and 
render  a complaint,  which  appeared  to  be  mild  and 
tractable,  dangerous  or  destructive ; but  to  aggravate 
the  sy  mptoms,  and  to  change  the  form  of  the  disease^ 
are  things  that  ought  not  to  be  confounded.  I do  not 
affirm  (says  Mr.  Pearson)  that  a breast  which  has 
been  the  seat  of  a mammary  abscess,  or  a gland  that 
has  been  affected  hy  scrofula,  may  not  become  can- 
cerous; for  they  might  have  suffered  from  this  dis- 
ease had  no  previous  complaint  e.xisted;  but  these 
morbid  alterations  generate  no  greater  propensity  to- 
cancer,  than  if  the  parts  had  always  retained  their  na- 
tural condition.  There  is  no  necessary-  connexion  be- 
tween cancer  and  any  other  disease  ; nor  has  it  ever 
been  clearly  proved  that  one  is  convertible  into  the 
other.” — (Pract.  Obs.  on  Cancerous  Complaints,  p.  8.) 
To  the  latter  way  of  thinking,  Mr.  Abemethy  also  in- 
clines ; for  in  speaking  of  the  occurrence  of  cancer  in 
parts  previously  diseased  in  another  manner,  he  con- 
fesses, that  his  owm  observations  have  not  led  him  to 
believe  that  this  change  is  common.  “ Cases  of  tu- 
mours, which  have  remained  indolent  for  twenty  or 
more  years,  becoming  cancerous  at  an  advanced  pe- 
riod of  life,  are  not  unfrequently  met  with but  (say.s 
Mr.  Abernethy)  the  patients  “ might  have  been  liable 
to  the  formation  of  a cancerous  disease,  even  if  00“ 
diseased  structure  had  previously  e.visted.”  A degree 
of  indecision,  liow-ever,  appears  to  be  thrown  ujam  this 
statement  by  the  admission,  that  cancer  is  more  likely 
to  begin  in  parts  previously  diseased. — {Surg.  Works, 
vol.  2,  on  Tumours,  p.  87.) 

The  following  are  some  of  the  most  distin^ishing 
characters  of  scirrhus.  A scirrhous  induration  sel- 
dom acquires  the  magnitude  to  which  almost  all 
other  tumours  are  liable  to  grow,  when  no  steps  are 
taken  to  retard  their  growth.  According  to  Sir  Astley 
Cooper,  the  swelling  gradually  grows  from  the  size  of 
a marble,  until  it  acquires  two  or  three  inches  in  dia- 
meter ; “ for  (says  he)  it  rarely  happens  that  the  true 
scirrhous  tubercle  increases  to  a very  considerable 
bulk,  and  this  circumstance  is  one  of  its  criteria.” — 
{Lectures,  A c.  vol.  2,  p.  177.)  Many  scirrlii  are  at- 
tended ex’en  with  a diminution  or  shrunk  stale  of  the 
part  affected. 

Scirrhi  are  generally  more  fixed  and  less  moveable 
than  other  sorts  of  tumours  ; esjiecially,  when  the  lat- 
ter have  never  been  in  a state  of  inflammation. 

With  the  e.xception  of  fungus  haunatodes,  other  dis- 
eases do  iKil  involve  in  their  ravages  indist  rimlnatclv 


CANCER. 


229 


every  kind  of  structure,  skin,  muscle,  cellular  sub- 
stance, &c.,  and  the  integuments  seldom  become  af- 
fected before  the  distention  produced  by  the  size  of 
such  swellings  becomes  very  considerable.  In  scir- 
rhous cases,  the  skin  soon  becomes  contaminated,  dis- 
coloured, and  puckered. 

Some  few  tumours  may  be  harder  and  heavier  than 
a few  scirrhi,  but  the  reverse  is  commonly  the  case. 

As  other  indurations  and  tumours  may  assume  the 
cancerous  action,  and  even  end  in  cancerous  ulcera- 
tion ; and  as  some  true  scirrhi,  when  not  irritated  by 
improper  treatment,  may  continue  stationary  for  years  ; 
the  occurrence  of  actual  carcinoma  cannot  prove  that 
the  preceding  -state  was  that  of  scirrhus.  The  only 
criterion  of  the  latter  disease  is  deduced  from  the  as- 
semblage of  characters  already  specified;  for  except 
the  peculiar  puckering,  and  speedy  leaden  discolora- 
tion of  the  skin,  no  other  appearances,  considered  se- 
parately, form  any  line  of  discrimination. 

The  white  ligamentous  bands  around  a scirrhus 
form  a very  characteristic  mark  of  the  complaint,  at 
least  as  it  presents  itself  in  the  female  breast ; but 
these  cannot  be  detected  till  the  disease  has  been  re- 
moved. Hence,  the  prudence  of  talung  away  a consi- 
derable portion  of  the  substance  surrounding  every 
scirrhous  tumour.  Were  any  of  these  white  bands 
left,  the  disease  would  inevitably  recur. 

Mr.  Pearson  has  never  yet  met  with  an  unequivocal 
proof  of  a primary  scirrhus  in  an  ab.sorbent  gland,  and 
(says  he)  “ if  a larger  experience  shall  confirm  this 
observation,  and  establish  it  as  a general  rule,  it  will 
afford  material  assistance  in  forming  the  diagnosis  of 
this  disease. — (Praci.  Obs.  on  Cancerous  Complaints^ 
p.  5.)  Sir  E.  Home,  however,  has  given  the  particu- 
lars of  one  case  which  seemed  to  him  to  have  com- 
menced in  one  of  the  lymphatic  glands,  situated  be- 
tween the  nipple  and  the  axilla.— (O/^s.  on  Cancer,  p. 
161.)  The  position  laid  down  by  Mr.  Pearson,  that 
when  the  disease  originates  in  those  glands,  it  w'ill 
rarely  be  found  to  be  of  a cancerous  nature,  may  yet 
be  generally  correct. 

OF  cancer  in  the  state  of  ulceration. 

According  to  the  observations  of  Mr.  Abernethy,  the 
diseased  skin  covering  a carcinomatous  tumour  of  the 
breast  generally  ulcerates  before  the  swelling  has 
attained  any  great  magnitude  ; a large  chasm  is  then 
produced  in  its  substance,  partly  by  a sloughing  and 
partly  by  an  ulcerating  process.  Sometimes,  when 
cells  contained  in  the  tumour  are  by  this  means  laid 
open,  their  contents,  which  are  pulpy  matter  of  differ- 
ent degrees  of  consistence  and  various  colours,  fall 
out,  and  an  excoriating  ichor  issues  from  their  sides. 
This  discharge  takes  place  with  a celerity  which 
would  almost  induce  belief,  that  it  can  hardly  result 
from  the  process  of  secretion.  When  the  diseased 
actions  have,  as  it  were,  exhausted  themselves,  an  at- 
tempt at  reparation  appears  to  take  place,  similar  to 
that  which  occur.s  in  healthy  parts.  New  flesh  is 
formed,  constituting  a fungus  of  peculiar  hardness,  as 
it  partakes  of  the  diseased  actions  by  which  it  was 
produced.  This  diseased  fungus  occasionally  even 
cicatrizes.  But  though  the  actions  of  the  disease  are’ 
thus  mitigated ; though  they  may  be  for  some  time  in- 
dolent and  stationary  ; they  never  cease,  nor  does  the 
part  ever  become  healthy. 

In  the  mean  while,  the  disease  extends  through  the 
medium  of  the  absorbing  vessels.  Their  glands  be- 
come affected  at  a considerable  distance  from  the  origi- 
nal tumour.  The  progress  of  carcinoma  in  an  absorb- 
ent gland  is  the  same  as  that  which  has  been  already 
described.  The  disease  is  communicated  from  one  [ 
gland  to  another,  so  that  after  all  the  axillary  glands  are  [ 
affected,  those  which  lie  under  the  collar-bone,  at  the  i 
lower  part  of  the  neck,  and  upper  part  of  the  chest,  ' 
become  disordered.  Occasionally,  a gland  or  two  be-  ! 
come  diseased  higher  up  in  the  neck,  and  apparently  j 
out  of  the  course  which  the  absorbed  fluids  would  | 
take.  As  the  disease  continues,  the  absorbent  glands, 
in  the  course  of  the  internal  mammary  vessels,  become  j 
affected.  In  the  advanced  stage  of  carcinoma,  a nurn-  I 
ber  of  small  tumours,  similar  in  structure  to  the  origi-  ^ 
rial  disease,  form  at  some  distance,  so  as  to  make  a j 
kind  of  irregular  circle  round  it.  j 

The  strongest  constitutions  now  sink  under  the  pain  I 
and  irritation  which  the  diseaso  creates,  aggravated  by 
the  ub.struc.tion  vvhicii  it  occasions  to  the  i’unclion  of 


absorption  i;i  those  parts  to  which  the  vessels  leading 
to  the  diseased  glands  belong.  Towards  the  conclu- 
sion of  the  disease  the  patient  is  generally  affected 
with  difficulty  of  breathing  and  a cough.— (See  Aber~ 
nethy's  Surgical  Works,  vol.  2,p.  72,  A c.) 

The  general  condition  of  the  patient  is  excellently 
described  by  Mr.  C.  Bell.  After  noticing  the  hectic  fe- 
ver wffiich  preys  upon  her,  he  observes,  “ the  counte- 
nance is  pale  and  anxious,  with  a slight  leaden  hue ; 
the  features  have  become  pinched,  the  lips  and  nostrils 
slightly  livid  ; the  pulse  is  frequent ; the  pains  are  se- 
vere. In  the  hard  tumours  the  pain  is  stinging  or 
sharp  ; in  the  exposed  surface  it  is  burning  and  sore. 
Pains  like  those  of  rheumatism  extend  over  the  body, 
especially  to  the  back  and  lower  part  of  the  spine ; the 
hips  and  shoulders,  &c.  Successively  the  glands  of 
the  axilla,  and  those  above  the  clavicle,  become  dis- 
eased. Severe  i)ains  shoot  down  the  arm  of  the  af- 
fected side : it  swells  in  an  alarming  degree,  and  lies 
immoveable.  At  length,  there  is  nausea  and  weakness 
of  digestion.  A tickling  cough  distresses  her.  Severe 
stitches  strike  through  the  side ; the  pulse  becomes 
rapid  and  faltering : the  surface  cadaverous ; the 
breathing  anxious  ; and  so  she  sinks  ”— (il/cd.  Chir. 
Trans,  vol.  12,  p.  223.) 

One  of  the  most  deplorable  efiects  occasionally  re- 
sulting from  cancer  is,  so  great  a fragility  of  the  bones 
that  those  of  the  limbs  are  broken  by  the  most  trifling 
causes,  as  merely  turning  in  bed,  &;c.  Sir  Astley 
Cooper  mentions  several  examples  of  this  fact.  In  the 
collection  of  St.  Thomas’s  Hospital  is  the  thigh-bone 
of  a Mrs.  Edge,  which  broke  on  her  merely  rising  in 
bed  ; and  also  the  thigh-bone  of  another  cancerous  pa- 
tient that  was  fractured  by  her  turning  in  heA.— {Lec- 
tures, ^ c.  vol.  2,  p.  184.)  Other  cases  are  recorded  by 
surgical  writers.— (See  Fragilitas  Ossium.)  It  seems 
that  the  scirrhous  substance  is  deposited  in  the  struc- 
ture of  the  bones,  as  the  sternum  of  Mrs.  Edge  above 
mentioned  fully  illustrates  ; and  in  the  museum  at  St. 
Thomas’s  are  two  curious  specimens  of  diseased  spine, 
in  which  much  of  the  bone  is  absorbed,  and  scirrhous 
tubercle.s  deposited  in  the  spaces  produced  by  absorp- 
tion. In  the  above  species  of  carcinoma,  described  by 
Mr.  Abernethy,  the  part  is  peculiarly  hard,  and  rarely 
attains  considerable  magnitude.  He  admits,  however, 
that  there  are  varieties,  and  speaks  of  another  case  in 
• which  the  integuments  sometimes  remain  pale  and  pli- 
ant ; “ and  a surgeon  who  first  sees  the  breast  in  this 
slate,  may  doubt  whether  the  disease  be  actual  cancer 
-or  common  sarcoma.  The  substance  of  the  tumour  is 
also  much  less  hard  than  in  the  specimen  first  de- 
scribed ; yet  it  is  more  compact  and  weighty  than  most 
other  diseases  of  the  same  bulk  which  are  not  carcino 
matous.  If  the  history  of  the  disease  accords  with 
tliat  of  carcinoma  ; that  is  to  say,  if  it  began  in  a small 
district,  and  regularly  and  unabatingly  attained  its  pre 
sent  magnitude  ; if  the  surface  of  the  tumour  be  un- 
equal, having  produced  in  various  jiarts  roundLsh  pro- 
jecting knobs,  the  disease  will  almost  invariably  be 
ibund  to  be  carcinoma.  The  skin  will  soon  adhere  to 
one  or  more  of  these  prominences ; it  will  ulcerate 
and  expose  the  subjacent  parts  ; and  the  future  pro- 
gress of  the  disease  will  accord  to  that  of  the  harder 
and  smaller  specimen,”  except  that  the  absorbents  are 
much  less  liable  to  be  affected.— (ToZ.  cit.  85.) 

The  edges  of  a cancerous  ulcer  are  hard,  ragged,  and 
unequal,  very  painful  and  reversed  in  different  ways, 
being  sometimes  turned  upwards  and  backwards,  and 
on  other  occasions  inwards.  The  whole  surface  of 
the  sore  is  commonly  une(iual ; in  some  parts  there  are 
considerable  risings,  while  in  others  there  are  deep  ex- 
cavations. The  discharge  for  the  most  part  is  a thin, 
dark-coloured,  fetid  ichor ; and  is  often  possessed  of 
such  a degree  of  acrimony  as  to  excoriate,  and  even 
destroy,  the  neighbouring  parts.  In  the  more  advanced 
stages  of  the  disease,  a good  deal  of  blood  is  often  lost 
from  the  ulcerated  vessels.  A burning  heat  is  univer 
sally  felt  over  the  ulcerated  surface ; and  this  is  the 
most  tormenting  symptom  that  attends  tiie  disorder. 
Those  shooting,  lancinating  pains,  which  are  generally 
very  distressing  in  the  occult  state  of  the  complaint, 
become  now  a great  deal  more  .so.  Notwithstanding 
cancerous  diseases  are  not  always  situated  in  glandu- 
lar parts,  the  situation  of  such  sores  affords  some  as- 
sistance in  the  diagnois  ; for  six  times  as  many  cancer- 
ous affections  occur  in  the  lijis  and  female  breasts,  u.s 
in  aU  tiie  rest  of  the  body  together.  {U.  Jhll.) 


230 


CANCER. 


According  to  Mr.  C.  Bell,  true  carcinoma  of  the 
breast  belongs  to  that  period  of  life  when  the  uterine 
Ainctions  cease.  Menstruation  becomes  irregular, 
both  in  respect  to  time  and  quantity.  .Long  intervals 
occur,  after  which  the  discharge  is  profuse,  with  un- 
usual disturbance  of  the  general  system.  The  mamma, 
in  particular,  sympathizes  with  the  condition  of  the 
uterus ; pains  shoot  through  it  and  it  swells ; and  when 
the  general  fulness  and  tension  subside,  a partial  hard- 
ness, an  indurated  lump,  is  left,  with  irregular  mar- 
gins, which  mL\  with  the  substance  of  the  breast. 
The  hardness  extends  until  the  whole  gland  is  unusu- 
ally firm,  the  disease  becoming  at  the  same  time  tuber- 
culated,  or  knobby  and  irregular.  The  veins  enlarge, 
and  assume  a deep  blue  colour.  In  the  mean  time,  the 
strength  declines,  and  the  patient  becomes  emaciated. 
The  nipple  is  now  not  only  drawn  in  and  incapable  of 
erection,  but  retracted  in  comparison  with  the  irregu- 
lar convexity  of  the  mamma.  In  a later  stage,  the 
skin  is  puckered  and  tucked  in.  These  parts  now 
firmly  adhere  to  the  subjacent  mass,  and  sometimes 
there  is  bleeding  from  the  nipple,  in  which  case,  the 
axillary  glands  are  affected  early. 

A true  carcinoma,  continues  Mr,  C.  Bell,  may  begin 
very  differently.  A small  hard  tumour  is  felt  deeply 
seated  in  the  mamma.  It  is  difficult  to  distinguish 
whether  or  not  it  is  a part  of  the  proper  gland.  Ii  be- 
comes painful,  approaches  the  surface,  becomes  at- 
tached to  the  mamma  and  to  the  skin,  and  is  gradually 
incorporated  with  them.  The  skin  becomes  discoloured, 
the  surface  moist,  and  the  patient  is  apprehensive  of 
the  occurrence  of  a sore.  At  length  the  part  does  ulcer- 
ate, and  begins  to  discharge.  The  bottom  of  the  sore 
is  foul  and  sloughy ; the  smell  is  offensive ; and  the 
constitution  sympathizes  with  the  state  of  the  sore. 
The  whole  gland  is  now  hard,  and  adherent  to  the  pec- 
toral muscle.  The  edges  of  the  sore  are  particularly 
hard,  and  present  a dark  red,  glazed  appearance.  They 
are  not  everted  and  curling,  but  rather  depressed  under 
the  general  convexity  of  the  tumour.  This  wll  cer- 
tainly be  the  appearance  in  a fat  woman.  The  chasm 
is  deep,  with  solid,  abrupt,  sharp  edges.  In  proportion 
as  its  depth  increases,  the  surrounding  hardness  ex- 
tends, and  the  whole  breast  feels  of  a stony  hardness. 

Cancer  of  the  breast  sometimes  assumes  another 
form,  which  is  also  well  described  by  Mr.  C.  Bell : al- 
though the  disease  commences  in  the  mamma,  it  rather 
propagates  itself  by  extending  its  peculiar  structure  to 
the  cutaneous  glandular  texture.  Around  the  nipple, 
tubercles  are  felt  in  the  skin,  which  extend  to  the  skin 
of  the  breast,  neck,  and  shoulders,  and  soon  become 
painful.  At  first  they  assume  a h^gh  red  colour ; then  a 
yellowish  transparency  in  the  centre.  They  do  not  sup- 
purate and  break  ; but  change  into  corroding  ulceration. 

It  is  a form  of  the  same  disease,  says  Mr.  C.  Bell, 
when  the  breast  presents  a tumour,  elevated,  tubercu- 
lated,  and  remarkably  firm,  without  any  elasticity,  but, 
on  the  contrary,  fixed  to  the  side,  and  presenting  one 
consolidated  mass.  The  surface  is  granular,  and  of  a 
deep,  or  rather  dark  red  colour,  with  a bluish  cast, 
somewhat  like  the  colour  of  a peach.  This  tumour  ul- 
cerates and  sloughs,  and  bleeds  profusely.  The  dis- 
ease is  propagated  by  tubercles  under  the  skin  towards 
the  sternum  and  clavicles  ; and  it  is  a case  soon  accom- 
panied with  effusion  in  the  chest. — (C.  Bell,  in  Med, 
Chir,  Trans,  vol.  12,  p.  21fi.  220.) 

By  some  of  the  old  writers  the  causes  of  cancer  were 
•eferred  to  the  presence  of  worms,  which  destroyed 
the  parts,  and  produced  all  the  local  mischief.  Strange 
as  this  doctrine  may  appear,  one  very  analogous  to  it 
was  adopted  by  the  late  Dr.  Adams. — {Obs.  on  Morbid 
Poisons.)  When  hydatids  found  their  way  into  a solid 
substance,  he  supposed  that  the  effect  would  be  cancer ; 
and  he  conjectured  that  the  success  of  an  operation 
would  depend  in  a great  measure  upon  these  animals 
being  confined  in  a common  cyst,  for  then  they  could 
be  entirely  removed  ; whereas  if  they  were  uncon- 
nected, some  of  the  smaller  ones  would  be  likely  to 
remain.  The  absurdity  of  this  doctrine,  however,  and 
the  eccentric  reasoning  by  which  it  is  supi)orted,  make  it  i 
quite  unnecessary  here  to  fatigue  the  reader  with  a i 
particular  explanation  of  it.  Though  hydatids  are  oc-  . 
casionally  found  in  tumours  which  have  been  called  I 
cancerous,  they  are  not  found  often  enough  to  make  i 
any  part  of  the  character  of  the  disease  ; and  they  are  I 
met  with  in  cases  in  which  there  is  not  the  least  ves-  i 
tige  of  such  disorder.  ]i 


j After  cancer  had  continued  some  time,  it  was  fbr- 
3 merly  believed  that  the  matter  -was  absorbed  into  the 
, blood,  and  all  the  humours  contaminated.  Hence  was 
3 explained  the  fatal  and  rapid  relapses  after  an  apparent 

- cure.  However,  the  effects  of  absorption  are  supposed 
, by  more  modern  writers  to  be  confined  to  the  lymphatic 
3 glands,  which  intervene  between  the  sore  and  the 
1 heart ; for  beyond  these  it  is  said  that  the  absorbed 

- matter  is  changed  in  its  properties. — {J.  Bums  on  In- 

- Jiammation,  vol.  2.) 

With  respect  to  the  causes  of  cancer,  the  disease  is 
■ very  frequently  imputed  to  blows,  pressure,  and  other 

- accidental  injuries ; but  there  are  almost  always  other 
, circumstances  concerned  which  have  ruore  influence 
: than  the  accidental  violence.  “ Although  (as  Sir  Astley 
. Cooper  remarks)  the  disease  operates  on  some  particu- 
r lar  part  of  the  body,  it  is  always  preceded  by  a state  of 
• constitution  which  has  excited  it.  He  who  looks  at 
! this  disease  in  the  light  merely  of  a local  affection, 
' takes  but  a narrow  view  of  it.  A blow  or  a bruise, 
I inflicted  on  a healthy  person,  would  be  followed  by 
I common  inflammation  only,  which  would  lead  to  the 

removal  of  the  matter  effused.  But  if  a blow  were 
1 received  on  the  breast  when  the  constitution  was  dis- 
posed to  the  formation  of  scirrhous  tubercle,  it  would 
be  the  cause  of  a particular  action  being  excited  in  the 
part  injured,  and  might  lay  the  foundation  of  this  com- 
plaint. Yet  the  formation  of  scirrhous  tubercle  does 
not  entirely  depend  on  constitutional  derangement ; 
there  must  be  also  a peculiar  action  excited  in  the  part.” 
In  order  to  prove  that  the  disease  mtist  depend  on  con- 
stitutional derangement  and  an  altered  action  in  the 
part  unitedly.  Sir  Astley  Cooper  observes,  that  if  a 
scirrhus  be  cut  into,  all  the  horrors  of  cancer  will  be  the 
result  of  the  injury ; but  if  the  cut  be  made  in  the 
healthy  parts  around  the  disease  no  cancerous  ulcera- 
tion follows,  and  the  wound  heals.  In  short,  he  argues 
that  the  disease  is  the  effect  of  a specific  action  in  the 
part,  preceded  by  a disposition  in  the  constitution  to  its 
production. — (See  Lancet,  vol.  2,p.  378.) 

In  the  breast  cancer  frequently  commences  without 
any  previous  accidental  injury  of  the  part ; a fact  tend- 
ing to  establish  the  correctness  of  such  writers  as  re- 
present the  disease  to  be  of  a constitutional  nature.  In 
these  cases  there  is  always  an  irregularity  or  disap- 
pearance of  the  menses ; and  the  affection  of  the 
mamma  may  be  supposed  to  depend  on  sympathy  be- 
tween it  and  the  uterus.  Certain  it  is,  that  cancer  is 
very  frequent  about  the  time  of  life  when  the  menstrual 
discharge  ceases. 

It  is  a commonly  received  opinion,  that  cancer  is  an 
hereditary  disease,  or  observed  to  prevail  a good  deal 
in  particular  families.  Sir  Astley  Cooper  has  know'n 
it  occur  in  three  sisters.— (Lectures,  S-c.  vol.  2,  p.  186.) 
Sir  Everard  Home  has  endeavoured  to  reconcile  this  to 
the  doctrine  of  the  disease  being  at  first  entirely  of  a 
local  nature  ; circumstances  which  seem  incompatible  ; 
“ It  is  now  universally  admitted  (says  he)  that  children 
take  after  their  parents  in  the  general  structure  of  their 
bodies,  and  therefore  will  be  more  or  less  liable  to  have 
the  diflferent  solids  of  which  they  are  composed,  dis- 
turbed by  the  same  causes  ; and  when  a violence  of  any 
kind  is  committed  upon  them,  it  may  be  productive  of 
the  same  diseases.  In  some  families,  the  venereal  dis- 
ease shall  always  appear  in  tlie  form  of  gonorrhoea  [?] ; 
in  others  again,  rarely  or  never  in  that  form,  but  in  that 
of  chancre  [?].  Strictures  in  the  urethra  are  common 
in  some  families  : they  have  taken  place  in  a father 
and  all  his  sons  from  vdly  slight  causes  ; such  indeed 
as  would  not  have  produced  the  disease  in  others.  Yet 
stricture  caunot  be  called  hereditary,  because  it  is  a 
local  complaint,  arising  from  a local  inflammation, 
differing  in  different  people,  according  to  the  natural 
irritability  of  the  parts  which  are  affected.  In  tins  way, 
and  this  only,  can  cancer  run  in  families,  and  be  an 
hereditary  disease,”  &c.—{Obs.  on  Cancer,  p.  150.)  The 
obseiv'alions  which  this  gentleman  has  published  re- 
specting cancer  are  unquestionably  some  of  the  most 
valuable  w'hich  have  yet  been  collected;  but  I am 
doubtful  about  the  correctness  of  one  term  which  is 
frequently  met  with  in  his  work,  viz.  cancerous  poison. 
At  all  events,  I am  not  at  present  acquainted  with  any 
facts  which  sjitisfactdrily  demonstrate  the  existence  of 
such  virus  ; and  from  some  circumstances  briefly  men- 
tioned in  the  First  Lines  of  the  Practice  of  Surgery,  the 
reality  of  a poison  of  this  nature  would  seem  at  least 
qticstionable.  In  sujiport  of  the  belief  m the  exisieiic# 


CANCER. 


231 


of  a cancerous  virns,  it  has  been  observed,  however, 
“ that  we  scarcely  ever  see  glands  diseased  out  of  the 
course  which  the  absorbed  matter  would  natural^  take, 
though  they  are  affected  in  this  manner  in  diseases 
which  can  be  propagated  by  irritation.”— (J.6erner/tJ/’i’ 
Surg.  Works,  vol.  2,  on  Tumours,  p.  75.) 

Undoubtedly  cancer  is  most  common  in  elderly  per- 
sons ; but,  according  to  some  writers,  no  age  is  exempt 
from  the  disease.  Mr.  J.  Burns  has  seen  it  distinctly 
marked  and  attended  with  a fatal  event  in  children  of 
five  years  old  : he  mentions  two  instances  of  the  eye 
being  affected  in  such  subjects : though,  from  the  late 
observations  of  Mr.  Wardrop,  we  may  now  reasonably 
suspect  that  these  examples  were  really  cases  of  fungus 
haematodes.  An  instance,  in  which  a cancerous  dis- 
ease of  the  breast  began  at  the  age  of  fifteen,  is  related 
by  SirE.  Home. — (Ol/s.  on  Cancer,  Src.  p.  50.) 

Sir  Astley  Cooper  has  frequently  seen  the  disease  at 
all  ages  between  thirty  and  seventy.  He  does  not  re- 
collect more  than  two  cases  in  which  the  nature  of  the 
tumour  was  decidedly  scirrhous  in  persons  under 
thirty  years  of  age.  He  has  seen  one  case  in  a patient 
aged  ninety-three  ; another  in  an  individual  of  eighty- 
six  ; and  he  has  removed  an  ulcerated  scirrhus  from  a 
person  seventy-three  years  old,  who  got  well.  Accord- 
ing to  Sir  Astley’s  experience,  the  disease  most  fre- 
quently occurs  about  the  age  of  fifty.  The  tumours 
met  with  in  women  under  thirty,  and  often  called 
scirrhi,  he  says,  are  only  simple  chronic  enlargements, 
not  disposed  to  malignant  action,  and  not  requiring 
removal. — {Lectures,  <S-c.  vol.  2,  p.  185.) 

Age  makes  a great  difference  in  the  whole  class  of 
carcinomatous  tumours ; and  as  Mr.  C.  Bell  has  re- 
marked, the  same  disease  distinguishable  by  obvious 
signs  will  run  its  course  rapidly,  and  with  every  symp- 
tom aggravated,  in  a woman  of  forty-five,  while  it  will 
remain  stationary  for  years  in  a woman  of  sixty  or 
seventy. — {Med.  Chir.  Trans,  vol.  12,  p.  216.)  Sir  Astley 
Cooper  also  states  that  when  it  occurs  in  very  advanced 
age,  it  is  slow  in  its  progress,  and  does  not  in  general 
shorten  life. — {Lectures,  <i  c.  p.  185.) 

According  to  Sir  Astley  Cooper,  married  women,  who 
bear  no  children,  and  single  women,  are  more  subject 
to  this  complaint  than  such  as  have  large  families. 
He  thinks  it  very  probable  that  the  natural  change 
which  the  breast  undergoes  in  the  secretion  of  milk  has 
some  power  in  preventing  this  disease.  But  he  admits 
that  the  circumstance  of  a woman  having  borne  chil- 
dren is  not  a perfect  security  against  the  complaint ; 
and  he  knew  one  individual  with  this  disease  who  had 
been  pregnant  seventeen  times.— {Lancet,vol.  2,p.  375.) 

This  gentleman’s  experience  confirms  a remark  made 
by  other  writers,  that  grief  and  mental  anxiety  seem 
frequently  to  have  a great  share  in  the  production  of 
scirrhus  of  the  breast.-^  Toi.  cit.  p.  379.) 

TREATMENT  OF  CANCER. 

Cancers  have  sometimes  been  supposed  to  be  a ge- 
neral disorder  of  the  system ; sometimes  merely  local 
affections.  This  is  a point  of  much  importance  in  prac- 
tice; for  if  cancers  are  originally  only  local  affections, 
no  objection  can  be  made  to  extirpating  them.  They 
who  think  that  cancer  is  a constitutional  di.sease, 
will  have  much  less  confidence  in  the  operation,  which 
they  may  even  regard  as  useless,  perhaps  hurtful,  inas- 
much as  it  may  convert  a scirrhus  into  an  open  cancer, 
or  bring  on  the  affection  in  some  other  part. 

Some  practitioners,  however,  reject  the  doctrine  of 
cancer  depending  on  constitutional  causes  ; and  Sir  E. 
Home’s  sentiments,  in  opposition  to  the  opinion,  have 
been  laid  before  the  reader.  When  cancer  breaks  out 
again  in  the  same  part,  after  the  performance  of  an 
operation,  it  is  often  owing  to  some  portion  of  the  dis- 
ease having  been  blameably  left  behind,  or  to  the  ope- 
ration having  beep  put  off  too  long.  How  likely  it  is 
that  some  of  the  cancerous  disease  may  be  left  unre- 
moved by  the  operator,  is  obvious  on  considering  the 
manner  in  which  the  white  bands,  resembling  ligament, 
shoot  into  the  surrounding  fat ; and  that  even  the  fibres 
of  the  muscles  beneath  a cancerous  disea.se  are  fre- 
quenUy  affected.  At  the  same  time,  it  must  be  allowed 
that  the  disease  is  sometime.s  to  all  appearances  so 
freely  and  completely  removed,  that  its  recurrence  may 
be  imputed,  perhaps  with  equal  probability,  to  the  con- 
tinued operation  of  the  same  unknown  cause  which 
onginally  produced  the  first  cancerous  mischief.  Sir 
A.stley  (kjoper  and  many  other  very  experienced  men. 


both  of  the  past  and  present  time,  consider  cancer  as 
decidedly  a complaint  connected  with  a peculiar  state 
of  the  constitution.  Bui  if  this  be  true,  it  may  be  asked, 
how  can  any  cure  be  expected  from  the  removal  of  the 
part,  as  the  continued  operation  of  the  same  constitu- 
tional causes  must  occasion  a relapse  ? And  so  they 
sometimes  do,  no  doubt,  independently  of  the  accident 
of  any  portion  of  the  disease  not  being  completely  re- 
moved with  the  knife.  However,  experience  proves 
that  the  operation  frequently  effects  a radical  cure,  and 
no  other  organ  is  afterward  attacked  ; which  is  analo- 
gous to  what  is  seen  after  the  amputation  of  a scrofulous 
limb  ; a case  in  which  frequently  no  other  part  is  after- 
ward attacked,  though  the  constitution  is  unsound. 

From  the  description  which  Sir  Astley  Cooper  has 
given  of  the  dissection  of  persons  destroyed  by  scirrhus, 
it  must  be  inferred,  not  only  that  the  disease  is  consti- 
tutional, but  that  the  hope  of  radically  curing  it,  either 
by  medicines  or  an  operation,  must  very  often  fail  in 
advanced  cases.  He  says,  that  a scirrhus  in  the  breast 
is  generally  accompanied  by  several  smaller  tumours 
of  the  same  character  in  different  parts  of  the  glandu- 
lar structure.  He  notices  the  deposition  of  the  scir- 
rhous matter  in  the  axillary  glands,  and  those  above 
the  clavicle.  On  the  left  side,  he  says,  the  latter  some- 
times press  upon  the  termination  of  the  thoracic  duct. 
According  to  his  observations,  the  glands  behind  the 
cartilages  of  the  ribs,  when  the  disease  is  on  the  sternal 
side  of  the  nipple,  are  generally  diseased.  The  axillary 
glands  on  the  other  side  of  the  body  he  has  also  seen 
in  the  same  state.  The  lungs  are  often  found  inflamed, 
and  adherent  to  the  pleura  ; serum  is  effused  in  the 
chest ; and  the  pleura  costalis  studded  with  scirrhous 
tubercles.  He  also  describes  the  liver,  uterus,  ovaries, 
and  bones  as  participating  in  the  morbid  changes. — 
(See  Lectures,  <S  c.  p.  182,  vol.  2.)  Under  such  cir- 
cumstances the  inutility  of  any  treatment  must  be  ob- 
vious. 

Until  late  years,  the  accounts  given  of  the  results  of 
operations  for  cancers  were  so  unpromising,  that  they 
deterred  many  patients  from  undergoing  a timely  ope- 
ration ; which,  for  cancerous  complaints,  is  the  only 
remedy  with  which  we  are  as  yet  acquainted  entitled 
to  much  confidence.  As  Mr.  B.  Bell  remarks,  the  great 
authority  of  Dr.  Alexander  Monro  must  have  had  no 
inconsiderable  influence  ’even  with  practitioners,  in 
making  them  much  more  backward  in  undertaking  the 
extirpation  of  cancers  than  they  otherwise  would  have 
been.  “ Of  near  sixty  cancers,”  says  he,  “ which  I 
have  been  present  at  the  extirpation  of,  only  four  pa- 
tients remained  free  of  the  disease  at  the  end  of  two 
years  : three  of  these  lucky  people  had  occult  cancers 
in  the  breast,  and  the  fourth  had  an  ulcerated  cancer 
on  the  lip.” — {Edin.  Med.  Essays,  vol.  5.)  Dr.  Monro 
also  observes,  that  in  those  in  whom  he  saw  the  dis- 
ease relapse,  it  was  always  more  violent,  and  made  a 
quicker  progress  than  it  commonly  did  in  others  on 
whom  no  operation  had  been  performed.  Hence, 
he  questions,  “ whether  ought  cancerous  tumours  to 
be  extirpated,  or  ought  the  palliative  method  only  to 
be  followed  ?”  and,  upon  the  whole,  he  concludes 
against  their  extirpation,  except  in  such  as  are  of  the 
occult  kind,  in  young  healthy  people,  and  have  been 
occasioned  by  bruises  or  other  external  causes. 

More  modern  experience,  however,  has  afforded  a 
very  different  result,  and  given  ample  encouragement 
to  the  early  performance  of  an  operation,  and  even  to 
making  an  attemjtt  to  cut  away  the  disease,  in  every 
instance,  both  of  the  occult  and  ulcerated  kind,  when 
such  a measure  can  be  so  executed  as  not  to  leave  a 
particle  of  the  cancerous  mischief  behind. 

Mr.  Hill,  in  1772,  published  some  valuable  remarks 
on  the  present  subject.  At  this  period,  he  had  extir- 
pated from  different  parts  of  the  body  eighty-eight 
genuine  cancers,  which  were  all  ulcerated,  except 
four;  and  all  the  patients,  except  two,  recovered  of  the 
operation.  Of  the  first  forty-fivq.  cases,  only  one 
proved  >msuccessful ; in  three  more  the  cancer  broke 
out  again  in  different  parts  ; and,  in  a fifth,  there  were 
threatenings  of  some  tumours,  at  a distance  from  the 
original  disease.  These  tumours,  however,  did  not 
appear  till  three  years  after  the  operation ; and  the 
woman  was  carried  off’  by  a fever  before  they  had 
made  any  progress.  All  the  rest  of  the  forty-five  con- 
tinued well  as  long  as  they  lived  ; or  are  so,  says  Mr. 
Hill,  at  this  day.  One  of  them  survived  the  ope- 
ration above  thirty  years ; and  fifteen  were  then 


232 


CANCER. 


alive,  although  the  last  of  them  was  cured  in  Msirch, 
1761. 

Of  the  next  thirty-three,  one  lived  only  four  months; 
and,  in  five  more,  the  disease  broke  out  afresh,  after 
having  been  once  healed.  The  reason  why,  out  of 
forty-five  cases,  only  four  or  five  proved  unsuccessful, 
and  six,  out  of  tliirty-three,  was  as  follows : “ The  ex- 
traordinary success  I met  with  (says  Mr.  Hill)  made 
cancerous  patients  resort  to  me  from  all  corners  of  the 
coimtry,  several  of  whom,  after  delaying  till  there  was 
little  probability  of  a cure,  by  extirpation  or  any  other 
means,  forced  me  to  perform  the  operation,  contrary 
both  to  my  judgment  and  inclination.” 

Upon  a survey,  in  April,  1764,  made  with  a view  to 
publication,  the  numbers  stood  thus ; Total  cured,  of 
different  ages,  from  eighty  downwards,  sixty-three  ; of 
whom  there  were  then  living  thirty-nine.  In  twenty- 
eight  of  that  number,  the  operation  had  been  performed 
more  than  two  years  before;  and,  in  eleven,  it  had 
been  done  in  the  course  of  the  last  tw’o  j^ears.  So  that, 
upon  the  whole,  after  thirty  years’ practice,  thirty-nine, 
of  sixty-three  patients,  were  alive  and  sound ; which 
gives  Mr.  Hill  occasion  to  observe,  that  the  different 
patients  lived  as  long,  after  the  e.xtirpation  of  the  can- 
cers, as,  according  to  the  bills  of  mortality,  they  would 
have  done,  had  they  never  had  any  cancers,  or  under- 
gone any  operation. 

The  remaining  twenty-five,  which  complete  the 
eighty-eight,  were  cured  since  the  year  1764.  Twenty- 
two  of  these  had  been  cured  at  least  two  years ; and 
some  of  them,  it  may  be  remarked,  were  seventy,  and 
one  ninety  years  old. 

In  the  year  1770,  the  sum  of  the  w'hole  stood  thus  : 
Of  eighty-eight  cancers,  extirpated  at  least  two  years 
before,  not  cured,  two ; broke  out  afresh,  nine  ; threat- 
ened with  a relapse,  one ; in  all,  twelve,  which  is  less 
than  a seventh  part  of  the  whole  number.  At  that 
time,  there  were  about  forty  patients  alive  and  sound, 
whose  cancers  had  been  extirpated  above  two  years 
before, 

Mr.  B.  Bell,  who  w'as  present  at  many  of  these  cases, 
bears  witness  to  Mr.  Hill’s  accuracy;  and  the  former 
very  judiciously  states,  that  “ from  these  and  many 
other  authenticated  facts,  which,  if  necessary,  might 
be  adduced,  of  the  success  attending  the  extirpation 
of  cancers,  there  is,  it  is  presumed,  very  great  rea- 
son for  considering  the  disease,  in  general,  as  a local 
complaint,  not  originally  connected  whth  any  disorder 
of  the  system.”  With  respect  to  Mr.  Bell’s  opinion, 
that  a general  cancerous  taint  seldom,  or  perhaps 
never,  occurs,  but  in  consequence  of  the  cancerous 
virus  being  absorbed  into  the  constitution  from  some 
local  affection,  much  doubt  attends  even  this  supposi- 
tion, though  the  practical  inference  from  it  is  w'hat 
cannot  be  found  fault  with,  viz.  in  every  case  of  real 
cancer,  or  rather  in  such  scirrhosities,  as  from  their 
nature  are  known  generally  to  terminate  in  cancer,  we 
should  have  recourse  to  extirpation  as  early  as  possi- 
ble ; and,  if  this  were  done  soon  after  the  appearance 
of  such  affections,  or  before  the  formation  of  matter 
takes  place,  their  return  would  probably  be  a very  rare 
occurrence.” — {System  of  Surgery,  vol.  7.) 

Sir  Astley  Cooper  admits,  that  the  operation  is  fol- 
lowed by  a return  of  the  disease  in  many  cases,  the 
average  number  of  which,  however,  he  does  not  state, 
though  he  says  that  they  do  not  amount  to  one-fourth. 
• -{Lancet,  vol.  2,  p.  383.) 

How  often  is  the  operation  determined  upon,  be- 
cause the  nipple  is  retracted,  and  true  cancer  thereby 
announced  ! Yet,  says  Mr.  Charles  Bell,  with  refer- 
ence to  the  cause  of  this  change,  as  previously  ex- 
plained, “it  is  quite  clear,  that  if  the  nipple  be  fully 
retracted,  and  if  this  has  been  evident  for  any  consider- 
able time,  the  operation  has  been  too  long  deferred  ” — 
— {Med.  Chir.  Trans,  vol.  12,  p.  233.) 

Sir  Astley  Cooper  is  adverse  to  the  performance  of 
the  operation  when  dyspnoea  is  present  ; for  he  has 
known  patients  die  in  two  or  three  days,  who  had  been 
operated  ui)on  while  labouring  under  that  symptom. 
On  examination  after  death,  water  was  found  in  their 
chests,  and  tubercles  in  the  pleura. — {Lancet,  vol.  2, 
p.  373.) 

The  same  experienced  surgeon  gives  it  as  his  opinion, 
that  a breast  should  never  be  removed,  unless  the  pa- 
tient has  undergone  a course  of  alterative  medicines, 
as  Plummer’s  pills  and  the  compound  decoction  of 
sarsaparilla,  or  (what  he  pn-fers)  the  inftision  of  gen- 


tian with  soda  and  rhubarb.  Thus  the  constitution 
may  be  improved,  and  the  danger  of  a relapse  dimi- 
nished.— {Vol.  cit.  p.  379.) 

After  comparing  the  different  accounts  of  success 
given  by  Monro  and  Hill,  well  might  Richter  say: 
“ Jure  sane  dixeris,  de  uno  eodemque  morbo  hos  viros 
loqui,  dviitari  fere  potest.”— {Obs.  Chir.fasc.  3.) 

.MEDICINES  AND  PLANS  WHICH  HAVE  BEEN  TRIED  FOR 
a HE  CURE  or  scirrhus  and  cancer. 

It  is  a contested  point,  whether  a truly  cancerous 
disease  is  susceptible  of  any  process,  by  wliich  a spon- 
taneous cure  can  be  effected.  It  appears  certain,  how- 
ever, that  a violent  inflammation,  ending  in  sloughing, 
may  sometimes  accomplish  an  entire  separation  of  a 
cancerous  affection,  and  that  the  sore  left  behind  may 
then  heal.  Facts,  confirming  this  observation,  are  oc- 
casionally exemplified  in  cases  where  caustic  is  used, 
and  accidental  inflammations  have  led  to  the  same 
fortunate  result,  as  we  may  be  convinced  of  by  ex- 
amples recorded  by  Sir  Everard  Home,  Richerand,  &c. 
The  latter  writer,  adverting  to  the  effort  which  nature 
sometimes  makes  to  rid  herself  of  the  disease  by  the 
inflammation  and  bursting  of  the  tumour,  takes  the 
opportunity  to  relate  the  following  case.  A woman, 
aged  forty-eight,  of  a strong  constitution,  was  admitted 
into  the  hospital  of  St.  Louis,  with  a cancerous  tumour 
of  the  right  breast.  The  swelling,  after  becoming 
softer,  and  affected  wth  lancinating  pains,  was  at- 
tacked with  an  inflammation,  which  extended  to  the 
skin  of  the  part,  and  all  the  adjacent  cellular  mem- 
brane. The  whole  of  the  swelling  mortified,  and  was 
detached.  A large  sore,  of  healthy  appearance,  re- 
mained after  this  loss  of  substance,  and  healed  in  two 
months. — {Nosographie  Chir.  t.  1,  p.  381,  edit.  2.) 

In  general,  however,  it  must  be  confessed  that  in 
flanimation  renders  things  worse  instead  of  better,  and 
by  converting  occult  cancers  into  ulcerated  ones,  has- 
tens the  patient’s  death,  or  at  all  events  renders  the 
cure  more  difficult,  and  forbids  any  attempts,  which, 
on  such  a principle,  might  be  made  for  his  relief. 

Of  the  general  remedies,  narcotics,  as  conium,  opium, 
belladonna,  &c  have  been  employed  with  most  hope. 

Cicuta,  or  conium  maculatum,  owed  its  reputation 
to  the  experimenting  talent  of  Storck,  who  has  written 
several  treatises  on  it.  According  to  him,  cicuta  pos- 
sesses very  evident  powers  over  cancer,  and  has  cured 
a great  many  cases ; but  in  less  prejudiced  hands  it 
has  not  been  found  successful ; and  even  in  many  of 
the  instances  adduced  by  Baron  Storck  of  its  utility,  it 
is  by  no  means  proved  that  the  disease  was  really 
cancer.  The  public  have  now  little  or  no  reliance  on 
this  medicine,  as  a means  of  relieving  cancer.  Mr.  J. 
Bums  declares,  that  in  cancerous  ulceration,  he  never 
knew  hemlock  produce  even  temporary  melioration. — 
(See  Conium.) 

Belladonna  was  highly  recommended  by  Lambergen 
During  its  use,  he  kept  the  bowels  open  with  clysters, 
administered  every  second  day.  The  dose  should  be, 
at  first,  a grain  of  the  dried  leaves,  made,  into  a pill. 
The  quantity  may  be  gradually  increased  to  that  of  ten 
or  twelve  grains!  The  extract  is  now  frequently  ex- 
hibited, the  dose  being  at  first  one  grain,  and  after- 
ward increased  by  degrees  to  five.  The  reputation  of 
belladonna  has  not  been  supported  by  any  decided 
success  in  cases  of  true  cancer. 

Hyosciamus  has  often  been  tried  in  cancerous  cases, 
and  was  held  in  great  estimation  by  the  ancients.  Mr. 
•T.  Burns  says,  he  has  employed  it  occasionally,  but 
with  little  effect.  The  common  dose,  at  first,  is  three 
grains  of  the  extract. 

Aconitum  has  also  been  given  ; and,  as  it  is  a veiy 
powerful  and  dangerous  narcotic,  a patient  usually  be- 
gins with  only  half  of  a grain  of  the  extract  night  and 
morning.  Solanum  dulcamara,  Paris  quadrifolia,  phy- 
tolacca,  &c.  have  also  been  recommended ; but  they 
are  now  hardly  ever  employed,  which  is  a sufficient 
proof  of  their  iiiefficacy.  Mr.  .1.  Burns  tried  the  hydro- 
sulphiiret  of  ammonia,  without  any  benefit.  Richter 
prescribed  the  laurus  cerasus,  but  without  any  decided 
success.  * 

Digitalis  lessens  vascular  action,  and  may  act  on 
scirrhi  like  abstinence,  bleeding,  &c.  It  has,  however, 
no  specific  virtue  in  curing  cant-erous  diseases. 

Opium  is  seldom  employed,  with  the  intention  of 
curing  cancer,  altuouvb  probably  it  has  just  as  much 
po'vcr  oftius  ».  • d a-  oihcr  . urcoius.  m u.lU  have  been 


CANCER. 


233 


more  frequently  used.  For  the  purpose  of  lessening 
the  pain  of  cancerous  diseases,  it  is  very  freely  pre- 
scribed. 

Tonics  sometimes  improve  the  general  health ; but 
they  never  produce  any  specific  etfect  on  the  local  dis- 
ease. 

.lustamond  thought  arsenic  a specific  for  cancers. 
Farther  experience  has  not,  however,  confirmed  the 
truth  of  this  opinion,  though  there  are  many  practi- 
tioners who  continue  to  think  highly  of  the  efficacy  of 
this  mineral  in  certain  forms  of  disease,  which  have 
sometimes  been  classed  with  cancer ; and  in  many 
cases  of  lupus,  and  malignant  ulcers  of  the  tongue  and 
ocher  parts,  it  may  really  po.ssess  greater  claims  to 
farther  trial  than  perhaps  any  other  medicine  yet  sug- 
gested. It  unquestionably  cures  numerous  ill-looking 
sores  on  the  face,  lips,  and  tongue,  and  is  one  of  the 
best  remedies  for  lupus.  Mr.  Hill  observes:  “Expe- 
rience has  furnished  me  with  some  substantial  rea- 
sons for  considering  arsenic  as  a medicine  of  consider- 
able merit,  both  with  regard  to  actual  cancer  and  scir- 
rhus.  w'hich  may  one  day  terminate  in  that  horrible 
species  of  ulcer ; and  although  I cannot  as  yet  say  it 
will  remove  the  one,  or  cure  the  other,  as  certainly 
and  safely  as  mercury  commonly  does  a syphilitic 
swelling,  or  open  sore,  yet  it  will,  in  a great  majority 
of  cases,  retard  the  progress  of  the  true  scirrhous  tu- 
mour, and  often  prevent  its  becoming  cancer.  In  some, 
it  has  appeared  to  dissipate  such  swellings  com- 
pletely.”—(See  Edin.  Med.  and  Surgical  Journ.  vol.  6. 
p.  58.) 

Mercury,  in  conjunctionwith  decoctions  of  guaiacum, 
sarsaparilla,  &c.,  has  been  recommended,  but  as  Mr. 
J.  Burns  remarks,  no  fact  is  more  certainly  ascertained, 
than  that  mercury  always  exasperates  the  disease, 
especially  when  in  the  ulcerated  state.  Plummer’s 
pills  and  the  other  alteratives  approved  of  by  Sir  Astley 
Coo()er,  as  medicines  to  be  given  previously  to  an  ope- 
ration, with  the  design  of  lessening  the  chances  of  a 
return  of  the  disease,  have  been  already  noticed. 

Sulphate  of  copper  has  been  tried ; but,  at  present, 
it  retains  no  character  as  a remedy  for  cancer.  The 
same  may  be  said  of  muriated  barytes. 

The  carbonate  (rust)  of  iron  was  particularly  recom- 
mended by  Mr.  Carmichael.  Besides  the  carbonate  of 
iron,  he  sometimes  prescribed  the  tartrate  of  iron  and 
potass,  and  the  phosphate,  oxyphosphate,  and  subnxy- 
phosphate  of  the  metal.  Some  constitutions  can  bear 
these  preparations  only  in  small  quantities ; they  affect 
most  patients  with  constipation,  and  many  with  head- 
ache and  dyspnoea.  These  circumstances,  therefore, 
must  be  attended  to  in  regulating  the  dose.  The  above 
gentleman  has  seldom  given  less  than  thirty  grains,  in 
divided  doses,  in  a day,  or  exceeded  sixty.  He  prefers 
the  suboxyphosphate  for  internal  use,  and  states,  that 
It  answers  best  in  small  doses  frequently  repeated.  It 
should  be  blended  with  white  of  egg,  have  a little 
pure  fixed  alkali  added,  and  then  be  made  into  pills 
with  powdered  liquorice.  Aloes  is  recommended  for 
the  removal  of  costiveness.  When  half  a grain  is  com- 
bined with  a pill  containing  four  grains  of  carbonate  of 
iron,  and  taken  thrice  a day,  the  constipation  will  be 
obviated.  When  the  internal  use  of  iron  brings  on 
headache,  difficult  respiration,  a quick,  sometimes  full 
pulse,  which  is  also  generally  hard  and  wiry,  excessive 
languor,  lassitude,  &c.,  and  such  sympfoms  become 
alarming,  the  iron  is  to  be  left  off,  and  four  grains  of 
camphor  given  every’  fifth  hour. 

At  the  same  time  that  preparations  of  iron  were  in- 
ternally administered,  Mr.  Carmichael  employed  exter- 
nally, for  ulcerated  cancers,  the  carbonate,  pho.sphate, 
oxyphosphate,  and  arseniate  of  iron,  blended  with  wa- 
ter, to  the  cx)n8istence  of  a thin  paste,  which  was  applieij 
once  every  twenty-four  hours.  To  occult  cancers,  the 
same  gentleman  applied  a solution  of  the  sulphate  of 
iron  ? j.  to  tlq.  of  water.  The  acetate  of  iron,  diluted 
with  eight  or  ten  times  its  weight  of  water,  was  also 
u.sed.  These  lotions  were  put  on  the  part  affected  by 
means  of  folded  linen,  wet  in  them,  and  covered  with 
a piece  of  oiled  silk  to  prevent  injury  of  the  clothes. — 
(8ce  An  Es.'iay  on  tlie  Effects  of  the  Carbonate  and  other 
preparations  of  Iron  upon  Cancer,  A c.  2d  ed.  8vo. 
Dnbhn,  18<i8.) 

Many  remedies  have  acquired  celebrity  in  cases  of 
cancer,  because  very  bad  and  malignant  di.seases,  only 
snpiKJ.sed  to  be  cancers,  have  got  well  under  their  use. 
teu.  u is  probably  the  case  with  the  curbonatc  of  iioii. 


The  only  mode  of  treatment  which  Mr.  Pearson  has 
ever  seen  do  any  particular  benefit  to  cancer,  is  that 
of  keeping  the  patient  on  a diet  barely  sufficient  for 
the  support  of  life,  such  as  barley-water  alone,  tea,  &c. 
A milk  diet  has  also  been  recommended. 

With  respect  to  the  effects  of  a very  low  diet,  Sir  A. 
Cooper  protests  strongly  against  the  plan  : if  the  pa- 
tient be  already  weak,  he  says,  you  will  thus  render 
her  still  weaker,  and  soon  bring  her  to  the  grave  : in 
proportion  as  the  strength  declines,  the  pulse  is  quick- 
ened. He  farther  declares,  that  w’e  possess  no  medi- 
cine which  has  any  specific  power  over  the  disease, 
though  the  state  of  the  constitution  may  sometimes  be 
improved  by  Plummer’s  pills  given  at  bedtime,  and  the 
following  draught  in  the  day.  Infus.  gentian,  I iss. 
Tinct.  columbae,  3j.  Ammon,  carbon,  gr.  v.  Sodae 
carbon.  3 ss.  Misce.  Climate  he  also  regards  as  hav- 
ing no  particular  effect  on  scirrhous  disease.  Sir  A. 
Cooper  only  sanctions  the  use  of  steel  medicines 
when  the  uterine  secretion  is  defective.  In  such  cases, 
he  recommends  the  compound  calomel  pill  at  night, 
and  the  following  draught  twice  a day.  B.  Vini  ferri 
3j.  Ammon,  carbon,  gr.  vij.  Aq.  menih.  vir.  5j. 
Tine,  cardam.  c 3 ss  He  also  approves  of  anodynes 
for  the  relief  of  the  suffering ; as  the  tinct.  opii.  the 
liquor  opii  sedativus,  or  the  black  drop,  combined  with 
the  camphor  mixture,  and  a little  of  the  spir.  letheris 
comp.  One  of  his  patients  derived  much  relief  from 
the  following  pill.  B-  Ext.  stramonii  gr.  Camph. 
gr.  ij.  M.  ft.  pil.  Bis  terve  in  die  sumend  — (See  Lec- 
tures, A c.  vol.  2,p.  193.) 

The  old  surgeons  commonly  dressed  cancerous  sores 
with  narcotic  applications.  Vesalius  used  cloths  dipped 
in  the  juice  of  the  solanum ; while  others  employed 
it  mixed  with  the  oil  of  roses  and  preparations  of  lead 
and  antimony.  Others  had  recourse  to  the  hyosciamus ; 
but  of  late  years  hemlock  poultices  have  been  the  fa- 
vourite narcotic  application ; and  in  many  cases,  as 
Mr.  J.  Burns  observes,  they  have  undoubtedly  abated 
pain  and  diminished  fetor ; but  this  is  all  which  can 
reasonably  be  expected.  He  thinks  carrot  poultices 
better  than  those  of  hemlock,  as  they  produce  as  much 
ease  and  more  powerfully  diminish  the  fetor. 

Sir  Astley  Coojier  has  no  confidence  in  the  utility  of 
evaporating  lotions.  Warm  applications  he  also  repre- 
sents as  improper.  The  dressing  which  he  mostly 
prefeis,  is  a plaster,  made  by  blending  3 j.  of  the  ex- 
tract of  belladonna  with  3 j.  of  soap  cerate.  When  in- 
flammation is  present,  he  does  not  object  to  the  use  of 
leeches.  All  local  applications,  as  well  as  internal 
medicines,  he  considers  as  merely  palliatives,  unpos- 
sessed of  any  power  of  curing  really  scirrhous  dis- 
eases. 

The  fetor  of  cancers,  having  been  thought  to  resem- 
ble that  of  the  sulphuret  of  potash  (liver  of  sulphur), 
and  the  oxygenated  muriatic  acid  being  the  best  agent 
for  decomposing  and  destroying  such  smell,  it  has 
been  recommended  as  an  application  to  cancerous 
sores.  It  may  correct  the  fetor  ; but  it  Avill  never  ac- 
complish a cure.  Carbonic  acid  has  been  said  not 
only  to  correct  the  fetor,  but  in  some  instances,  com- 
pletely to  cure  the  disease.  It  was  long  ago  proposed, 
says  Mr.  J.  Burns,  by  Peyrilhe,  and  was  again  brought 
forward  by  Dr.  Ewart.  Experience,  however  has  not 
shown  that  the  efficacy  of  carbonic  acid,  in  cases  of 
cancer,  is  very  great.  Fourcroy  remarks,  ‘‘  After  the 
first  applications,  the  cancerous  sore  appears  to  as- 
sume a more  favourable  aspect ; the  sanies  which  flows 
from  it  becomes  whiter,  thicker,  and  purer,  and  the 
flesh  has  a redder  and  fresher  colour ; but  these  flat- 
tering appearances  are  deceitful,  nor  do  they  continue 
long,  for  the  sore  speedily  returns  to  its  former  state, 
and  its  progress  goes  on  as  before  the  application.” 
I'he  best  method  of  applying  carbonic  acid  is  by  means 
of  a bladder,  the  mouth  of  which  is  fastened  round 
the  sore  with  adhesive  plaster.  The  air  is  introduced 
by  a pipe  inserted  at  the  other  end. 

Sometimes  the  fermenting  poultice  is  employed. 

Digitalis,  as  a local  application,  is  entitled  to  about 
as  much  confidence  as  cicuta. 

Tar  ointment,  gastric  juice,  absorbent  powders,  &c. 
have  been  tried,  but  without  any  evident  good.— (See 
J.  Bums  on  Infarnmation,  vol.  2.) 

Mr.  Fearon  rejected  all  internal  remedies,  as  inef- 
ficient in  the  treatment  of  cancer,  and,  in  the  early 
stages  of  the  complaint,  recommended  a method  of 
practice,  founded  on  Ins  idea  of  the  inflammatory  na- 


234 


CANCER. 


ture  of  the  disease.  “ In  the  beginning  of  scirrhous 
atfections  of  the  breast  and  testis,  the  mode  I have 
adopted  of  taking  away  blood,  is  by  leeches  repeatedly 
applied  to  the  parts.  In  this  course,  however,  I have 
often  been  interrupted  by  the  topical  inflammation 
produced  by  these  animals  around  the  parts  where 
they  fastened.  In  delicate  female  habits,  I have  often 
lost  a week,  before  I could  proceed  to  the  reapplicaiion 
of  them.  When  the  symptoms  lead  me  to  suspect  the 
stomach,  uterus,  or  any  of  the  viscera,  to  be  so  affected 
that  the  complaint  either  is,  or  most  probably  soon 
will  become  cancerous,  I then  have  recourse  to  general 
bleedings.  But  whether  topical  or  general,  perseve- 
rance for  a sufficient  length  of  time  is  necessary. 
Though  the  pulse  never  indicated  such  practice,  yet 
the  patients  have  not  suffered  by  repeated  bleedings ; 
on  the  contrary,  when  they  passed  a certain  time  with- 
out losing  blood,  they  felt  a return  of  their  symptoms, 
and  of  their  own  accord,  desired  to  be  bled  again.  To 
this  plan  of  repeated  bleedings,  I joined  a milk  and  ve- 
getable diet,  avoiding  wine,  spirits,  and  fermented 
liquors.”  Mr.  Fearon  used  also  to  keep  the  belly  open, 
and  employ  saturnine  applications. 

Of  the  method  of  treating  cancer  by  pressure,  I have 
spoken  in  another  work  (First  Lines  of  the  Practice  of 
Surgery,  vol.  1),  and  therefore  in  this  place  I need 
merely  repeat,  that  it  is  a practice,  which  none  of  the 
best  modern  surgeons  think  entitle  ! to  approbation. 

From  the  preceding  accounts,  we  may  infer  that 
scarcely  any  reliance  is  to  be  placed  on  any  known 
remedy  or  plan  in  any  cases  of  real  scirrhi,  and  ulcer- 
ated cancers.  The  operation  is  the  only  rational  means 
of  getting  rid  of  the  disease ; and  to  waste  time,  so  as 
to  allow  the  disorder  to  increase  in  a serious  degree, 
merely  for  the  sake  of  tr3dng  various  unpromising  me- 
dicines, is  conduct  unworthy  of  a wise  surgeon’s  imi- 
tation. 

Perhaps,  in  early  cases,  it  may  be  right  to  make  trial 
of  arsenic,  conium,  preparations  of  iron,  those  of.iodine, 
and,  in  particular,  of  the  ointment  of  the  hydriodate  of 
potass,  which  Dr.  Wagner  found  capable  of  dispersing 
one  swelling  reputed  to  be  cancerous. — (See  Revue 
Med.  Juin,  1823.)  In  France,  this  ointment  is  also 
applied  to  various  tumours.  Dr.  Wagner’s  contained 
only  eighteen  grains  of  the  hydriodate  of  potass  to  six 
drachms  of  lard ; but  in  France  the  proportions  are  as 
much  as  two  drachms  of  the  first  article  to  an  ounce  of 
the  second.  But  the  practitioner  should  beware  of 
devoting  too  much  time  to  medicines  which  will  in  all 
probability  prove  inadequate  to  the  object  for  which 
they  are  exhibited.  Graefe  is  also  alleged  to  have 
succeeded  in  bringing  about  an  absorption  of  the  whole 
of  the  diseased  breast,  by  applying  an  ointment,  com- 
posed of  3j.  of  hydriodate  of  potass,  and  sij.  of  lard. 
Mr.  Hill,  of  Chester,  has  recorded  one  case,  very  favour- 
able to  the  farther  .trials  of  iodine.  The  cancer  was  in 
the  ulcerated  state.  He  dressed  it  with  an  ointment 
consisting  of  3 j.  of  the  hydriodate  to  1 j.  of  lard  ; and 
gave  the  patient  internally  thirty  drops  at  a time  of  a 
solution  of  thirty-six  grains  of  the  hydriodate  in  an 
ounce  of  distilled  water.  The  result  was  such  amend- 
ment of  the  disease,  that  a cure  was  confidently  ex- 
pected ; but,  in  the  end,  the  ulcer  resumed  its  former 
dimensions  and  malignant  character.  — (See  Edin.  Med. 
Jourti.  No.  87,  p.  283.)  Upon  the  whole,  the  operation 
is  what  we  should  generally  adopt,  as  the  surest  and 
the  safest  means  of  getting  rid  of  cancerous  diseases. 
As  I have  before  remarked,  the  operation  is  alw'ays 
admissible,  when  every  particle  of  the  disease  can  be 
removed  by  it.  Even  large  open  cancers,  if  they  can 
be  entirely  cut  away,  are  often  capable  of  being  effec- 
tually cured. 

The  removal  of  cancerous  disorders,  even  in  the 
slightest  and  most  trivial  cases,  should  always  be  ef- 
fected with  the  scalpel,  in  preference  to  caustic ; the 
the  use  of  w'hich,  though  it  may  sometimes  succeed  by 
producing  a complete  destruction  of  the  diseased  parts, 
causes  severe  agony,  and  in  the  event  of  its  not  acting 
sufficiently  on  all  tlie  diseased  parts,  often  renders  the 
complaint  more  aggravated,  and  kills  the  patient,  and 
this  in  a very  short  space  of  time. 

In  cases  of  cancer,  the  irritation  generally  occasioned 
by  every  application  of  the  caustic  kind,  together  with 
the  pain  and  inflammation  which  commonly  ensue,  are 
strong  objections.  Flunket’s  remedy,  which  is  chiefly 
arsenic,  is  equally  objectionable.  Nor  can  you  at  once 
so  certainly  extirpate  every  atom  of  cancerous  mis- 


chief with  any  caustic,  as  you  can  with  the  knife ; for 
with  this  you  immediately  gain  an  ocular  inspection 
of  the  surface  surrounding  the  disease,  so  as  to  see  and 
feel  whether  the  disordered  parts  are  completely  re- 
moved, or  w'hether  any  portion  of  the  disorder  requires 
a farther  employment  of  the  instrument  With  re- 
spect to  the  pain,  that  of  caustics  is  infinitely  greater, 
more  intolerable,  and  more  tedious,  than  that  occasioned 
by  the  knife.  When  caustic  also  fails  in  destroying 
every  particle  of  the  disease  at  once,  it  almost  always 
tends  to  enlarge,  in  a very  rapid  way,  the  original 
boundaries  of  the  mischief.  For  an  account  of  the 
method  of  removing  scirrhi  and  ulcerated  cancers,  see 
Mamma,  Removal  of. 

[There  is,  perhaps,  no  disease  to  which  our  “ flesh  is 
heir,”  which  has  been  so  fruitful  of  empiricism,  or  has 
yielded  so  great  a harvest  of  wealth  and  reputation  to 
ignorant  and  mischievous  charlatans,  as  that  of  cancer. 
And  so  great  have  been  the  evils  of  malpractice  in  the 
treatment  of  this  disease,  and  so  fatal  have  been  the 
several  caustic  plasters  which  are  imposed  on  the  pub- 
lic, that  it  is  matter  of  surprise  that  such  impositions 
have  not  been  made  the  subjects  for  the  enforcement  of 
the  penalties  of  our  medical  pohee. 

Our  author  htis  given  us  a lucid  and  judicious  descrip- 
tion of  the  various  modifications  of  cancer,  and  one 
which  will  enable  the  young  surgeon  readily  to  make 
out  his  diagnosis.  But  his  chief  difficulty  will  be  to 
convince  his  patient  and  friends  that  every  indolent  tu- 
mour, tedious  ulcer,  irritated  gland,  or  protracted phleg- 
moid  or  erysipelatous  local  inflammation,  is  not  a cancer. 
Those  numerous  cancer-doctors  who  swarm  in  many  of 
our  cities,  gain  their  reputation  for  success  by  pronoun- 
cing all  such  local  affections  to  be  cancers,  and  then  ap- 
plying their  cancer-plaster  until  they  form  a new  sur- 
face which  soon  granulates  and  heals  by  cicatrization. 
The  cure  of  cancer  is  then  published,  and  thousands  of 
certificates,  under  oath,  are  deluging  the  country,  at- 
testing such  cures  in  patients,  many  of  whose  consti- 
tutions are  utterly  unsusceptible  of  cancerous  disease  in 
any  of  its  forms.  Hence  it  is  that  we  hear  of  more  cancers 
being  cured  in  New- York  by  these  empirics  than  there 
are  cases  of  the  genuine  disease  in  the  United  States; 
more  cures  in  a year  than  there  are  cancers  in  a century. 
Within  three  years  I have  known  more  than  a hundred 
instances  of  these  impositions.  Sometimes  in  cliildrea 
a niEvus  materni,  or  an  aneurism  by  anastomosis,  is 
treated  by  a cancer-plaster ; and  Dr.  Mott  mentioned  to 
me  a short  time  since,  that  he  saw  a child  with  ranula 
under  the  treatment  of  one  of  these  leeches,  who  had 
already  inserted  a caustic  plaster  beneath  the  tongue  by 
a complex  apparatus.  Very  often  an  indurated  gland, 
an  indolent  ulcer,  an  obscure  tumour,  has  come  under 
my  notice,  which  had  been  already  doomed  to  the  caus- 
tic as  the  worst  kind  of  cancer,  although  neither  pos- 
sessed any  specific  character  whatever. 

All  these  impositions,  however,  are  comparatively  in- 
nocent ; because,  for  the  most  part,  they  only  inflict  a 
scar  on  the  skin,  and  a w'ound  on  the  pockets  of  those 
who  become  their  victims.  But  they  stop  not  with  these 
lesser  crimes ; with  their  reputation  their  hardihood  in- 
creases, and  they  decide  every  morbid  alteration  in  the 
structure  of  the  female  breast  to  be  a cancerous  mam- 
ma, and  predict  the  surgeon  with  his  knife,  and  death 
in  the  rear,  as  the  certain  results  of  delay  in  eating  out 
tliis  cancer  and  its  roots.  I have  known  many  wives 
and  mothers  ruined  for  life  by  submitting  to  the  experi- 
ments of  ignorance  and  folly  on  diseases  of  the  glandu- 
lar structure,  which  required,  for  the  most  part,  no  me- 
dical attention.  And  in  one  instance  I saw  a patient 
die,  the  widowed  mother  of  a number  of  children,  of 
what  is  called  arsenical  fever,  produced  by  a plaster  ap- 
plied to  the  mamma,  for  an  ir  considerable  tumour  which 
had  e.xisted  for  years,  but  which  her  fears,  the  terror  of 
her  friends,  and  the  wickedness  of  one  of  these  cancer- 
doctors  had  magnified  into  a malignant  cancer.  She 
was  in  perfect  health  when  the  arsenic  w as  applied ; the 
eschar  formed  was  large  and  deep ; an  extensive  inflam- 
mation succeeded,  involving  the  other  breast  and  the 
axillary  glands,  from  which  she  was  soon  bedridden, 
and  lingered  eleven  months,  dying  of  the  remedy,  not 
the  disease.  This  }s  only  one  among  a number  of  in- 
stances in  which  death  has  resulted  in  this  city  from 
similar  means. 

It  will  perhaps  be  expected  that  I should  refer,  in  this 
place,  to  the  treatment  of  cancerous  mamma  by  conqiree- 
sion,  a remedy  which  some  years  since  attracted  a con- 


CAN 


CAN 


235 


fciderable  share  of  public  attention.  I know  not  with 
whom  the  practice  originated,  but  recollect  that  the  late 
Dr.  Ezra  Gillingham,  of  Baltimore,  wrote  a paper  on 
this  subject  a few  years  since,  in  which  he  extolled  the 
practice  of  compression,  and  seemed  to  anticipate  very 
important  results  from  tliis  mode  of  treatment.  He  ap- 
plied pressure  with  a piece  of  sheet  lead  and  a suitable 
bandage  in  the  case  of  his  mother,  and  thought  he  had 
effected  a cure ; but  a few  months  overthrew  his  hopes, 
the  disease  returned,  and  after  the  extirpation  of  one 
breast  by  the  knife,  she  died  of  the  disease  at  last. 

It  must  be  admitted  that  even  the  knife  affords  very 
equivocal  benefit  in  cases  of  well-marked  cancer,  and 
hence  in  this  countrya  prejudice  very  extensively  exists 
against  the  operation  of  removing  the  mamma.  The 
frequent  failures  of  the  operation  may  be  attributed  very 
frequently  to  its  long  postponement.  If  the  patient  re- 
fuse to  submit  to  the  knife  for  months,  and  even  years 
after  the  specific  characteristics  of  the  disease  are  plainly 
developed,  and  until  the  axilla  has  become  involved,  it 
would  be  surprising  indeed  if  recovery  should  ensue, 
especially  in  the  prostrated  condition  of  the  body  ordina- 
rily found  to  exist  under  such  circumstances. 

So  numerous  are  the  instances  of  the  return  of  the 
disease  in  other  and  even  remote  parts  of  the  body,  and 
this  too  after  the  best  advised  and  most  skilfully  per- 
formed operations,  that  many  surgeons  are  of  opinion 
that  cancer  is  always  a constitutional  disease,  and  they 
therefore  look  upon  the  operation  for  the  removal  of  can- 
cers as  altogether  palliative.  A more  probable  opinion, 
however,  is  that  expressed  in  the  note  on  Osteo  sarcoma, 
which  is  but  a modification  of  carcinoma,  that  the  dis- 
ease is  at  first  purely  local ; but  if  not  removed  in  its  inci- 
pient state,  very  soon  involves  the  whole  body,  and 
hence  the  success  of  early  operations.  But  although 
the  disease  may  be  most  generally  purely  local,  and  un- 
connected with  any  vitiated,  scrofulous,  or  scorbutic 
state  of  the  system,  yet  it  will  be  found  most  generally 
to  involve  the  whole  gland,  although  the  characteristic 
evidences  of  cancer  may  only  exist  in  a very  small  part 
of  the  structure.  Hence  when  any  portion  of  the 
mamma  is  affected  with  a disease  of  tins  kind  calling 
for  the  operation,  it  will  be  unsafe  to  extirpate  only  the 
art  diseased,  but  every  portion  of  the  entire  breast  must 
e removed,  else  the  disease  will,  in  a majority  of  in- 
stances, very  soon  return.  Some  surgeons  attribute  its 
return  to  the  inflarrunation  consequent  upon  the  opera- 
tion ; but  it  is  difficult  to  believe  that  an  affection  of  spe- 
cific character  can  result  from  any  ordinary  inflamma- 
tion after  a surgical  wound,  unless  there  be  some  portion 
of  the  diseased  structure  left  behind.  Either  this  must 
be  admitted,  or  else  it  will  follow  that  the  whole  system 
is  contaminated  with  the  specific  action,  for  otherwise  the 
inflammation  following  other  operations  might  be  ex- 
pected to  degenerate  into  cancer.  Dr.  Hosack  has  a 
paper  on  this  subject  in  vol.  2 of  his  Essays,  published 
in  1824. — Reese.] 

Much  additional  information  respecting  cancer  is  con- 
tained in  the  First  l.ines  of  the  Fraclicc  oj  Hurgcry,  ed.  5. 
A,c  JJrau's  Operations  in  Surgery ,p.  87,  &-c.  ed  2.  B 
Bell's  Surgery,  vol.  2.  .Juslarnond's  Jiccount  of  the  Me- 
thods pursued  in  the  Treatment  of  Cancerous  and  Scir- 
rhous J)isordtrs,8vo.  Land.  1780;  al.-o,  his  Surgical 
Tracts,  Src.  8vo.  Loud.  1789.  James  Hill,  Cases  in  Sur- 
gery,8vo.  F.din.  1772.  Vindungus  ab  Hai  ling,  l)e  Op- 
tima CancrumMamviarurnextir panda  rations.  Jllsdorf, 
1720.  {Haller,  Disp.  Chir.  2.  509.)  L.  Rouppe,  J)e 
Morbis  Mavigantium  liber,  accedit  Obs.de  Effcctu  Ex 
tracti  cicut/z  Storckianoin  Cancro,  8vo.  Lugd.  1704.  G. 
Dowman,  on  the  Mature,  &-c  of  a Scirrhus,  8oo.  Lond. 
v3.  Storck,  An  Essay  on  the  Medical  Mature  of  Hemlock, 
d'C.  8do.  Loud.  1760.  C.  MoUnarius,  Historia  Mulie- 
ris  a .Scirrho  curatce,  8vo.  Vindob,  1761.  G.  Tabor,  De 
Cancro  Mammarum,  eumque  novo  extirpandi  Mcthodo. 
'Jrojecti,  1721.  C.  Perry,  Mechanical  Account  of  the 
Hysteric  Passion,  A c.  with  an  Appendix  on  Cancer, 
Svo.  London,  175.5.  Sir  John  Hill,  Plain  and  Useful 
Directions  for  those  who  are  afflicted  with  Cancers,  2d 
ed.  Svo.  Land.  G.  A.  Langguth,  Programma  depotis- 
simis  Cancri  Mammarum  Caiisis  prudenter  occupandis, 
fViWmb.  1752.  Ph.  Fr.  Gmelin  et  Achat.  Gasriner, 
Specifica  Methodis  recentior  Cancrtim  sanandi,  Src. 
'J'ubingas,  1757.  M.  Zaffarini,  Storia  di  due,  Mam- 
melle  Demohte  nella  di  cui  Scirrosa  sostanza  sono 
stall  Irovnti  nove  Aghi.  8no.  Venez.  1761.  C.  Petrus, 
Jjiss.  sisleris  historiam  rariorem  mammte  cancfosie, 
sanguinem  menstruum  fuudentis,  methodo  simpliciore 


sanatw.  (Frank.  Del.  Op.  10.)  W.  Beckett,  Mew 
Discoveries,  relating  to  the  Cure  of  Cancers,  wherein 
a method  of  dissolving  cancerous  substance  is  recom- 
mended, Arc.  Svo.  Loud.  1711.  IV.  Morford,  Essay  on 
the  general  Method  of  treating  Cancerous  Tumours,  Src. 
\2mo.  Lond.llb'i,  R.  Guy,  An  Essay  on  Scirrhous  Tu- 
mours and  Cancers,  Svo.  Loud.  1759 ; also.  Practical 
Obs.  on  Cancers,  ^c.  Svo.  ./.  Burrows,  Practical  Es- 
say on  Cancers,  Svo.  Lond.  1767.  Chr.  C.  Lerche,  Obs. 
de  Cancro  Mammarum,  Ato.  Oott.  1777.  F.  Hopkins, 
Dc  Scirrho  et  Carcinomate,  Svo.  Edin.  1777.  B.  Pey- 
ril/ie,  Diss.  on  Cancerous  Diseases,  translated  from 
the  Latin,  with  Motes,  Svo.  Lond.  1777.  .T.  Andrte, 
Observations  upon  a Treatise  on  the  Virtues  of  Hem- 
lock, in  the  Cure  of  Cancers,  written  by  Dr.  Storck,  of 
Vienna,  wherein  the  Doctor's  Cases  in  favour  of  that 
vegetable  are  candidly  examined,  and  proved  insufficient 
rn  divers  instances;  with  some  practical  remarks  on 
Career  in  General,  drc.  Svo.  Lond.  1761.  P.  J.  F.  de 
Hameux,  De  Scirrho  et  Cancro,  Ocuderghern,  1788.  T. 
Clerke,  J)iss.  de  Cancro,  Svo.  Edin.  1784.  R.  Hamil- 
ton, on  Scrofulous  Affections,  with  remarks  on  Scirrhus, 
Ac.  Svo.  Land.  1791.  E.  Kentish,  Cases  of  Cancer; 
with  Obs.  on  the  use  of  Carbonate  of  Lime,  Svo.  Mew- 
castle,  1802.  C.  T.  Johnson,  a Practical  Essay  on 
Cancer,  Svo.  Lond.  1810.  Fearon  on  Cancers,  with  an 
Account  of  a new  and  successful  method  of  operating, 
particularly  in  Cancers  of  the  Breast  or  Testicle,  Svo. 
Lond.  \.7S&.  B.  Bell  on  Ulcers.  Adams  on  Cancerous 
Breasts,  Svo.  Lond.  1801 ; and  on  Morbid  Poisons,  2d 
ed.  1807.  Medical  Museum,  vol.  1.  Med.  T'rans.  vol.  1. 
Gooch's  Med.  Observations,  vol.  3.  L' Encyclopidie 
Mithodique,  partie  Chirurgicnle.  Article  Cancer,  in 
Rees's  Cyclopwdia.  Practical  Observations  on  Can- 
cer, by  J.  Howard,  8(;o.  I.ond.  1811.  Mimoire  renfer- 
mant  quclques  Vues  GeiUrales  sur  le  Cancer,  in  CEu- 
vres  Chir.  de  Desault,  par  Bichat,  t.  'd,p.  406,  Src.  Ri- 
cherand,  Mosographie  Chir.  t.  1,  p.  377,  A-c.  ed.  2. 
Lambe's  Inquiry  into  the  origin  and  cure  of  Constitu- 
tional Diseases,  Svo.  Land.  1805  ; and  Reports  of  the 
Effects  of  a peculiar  Regimen  in  Cancerous  Complaints, 
Svo.  Lund.  1815.  Baillie's  Morbid  Anatomy  of  some 
of  the  most  Important  Parts  of  the  Human  Body.  The 
(Queries  of  the  Society  for  investigating  the  Mature  and 
Cure  of  Cancer  may  be  seen  in  the  Edin.  Med.  and  Sur- 
gical Journal,  vol.  2,  p.  382,  A-c.  Diet,  des  Sciences 
Med.  art.  Cancer.  Alibert,  Mosol.  M aturelle,  t.  1,  fol. 
Paris,  1817.  Consult  also  War  drop  on  Fungus  Ha- 
viatodes,  in  which  may  be  seen  an  interesting  compara- 
tive view  of  this  last  affection  and  Cancer.  Denman's 
Observations  011  the  Cure  of  Cancer,  Svo.  Lond.  1810; 
and  Carmichael' s Essay  on  the  Effects  of  Carbonate  and 
other  preparations  of  Iron  upon  Cancers;  with  an  In- 
quiry into  the  Mature  of  that  and  other  Diseases,  to 
which  it  bears  a relation,  2d  ed.  Svo.  Dublin,  1809.  W. 
Thomas,  Commentaries  on  the  Treatment  of  Scirrhi 
and  Cancer,  Svo.  Lond.  1805,  1817.  S.  Young,  Inquiry 
into  the  Mature,  Ac.  of  Cancer,  Svo.  Lond.  1805.  Mi- 
nutes of  Cases  of  Cancer-  and  Cancerous  tendency,  Svo. 
Load.  1816  ; also,  farther  Reports  of  Cases  treated  by 
the  new  mode  of  pressure,  Svo.  Lond.  1818.  J.  Pear- 
son, Practical  Obs.  on  Cancerous  Complaints;  with  an 
account  of  some  Diseases  which  have  been  confounded 
with  Cancer ; also.  Critical  Remarks  on  some  of  the 
Operations  performed  in  Cancerous  Cases,  Svo.  Lond. 
1793.  Abernethy's  Surgical  Works,  vol.  2.  Lond.  1811. 
J.  Rodman,  A Practical  Explanation  of  Cancer  in  the 
Breast,  Svo.  J.,orid.  1815.  Sir  E.  Home,  Obs.  on  Can- 
cer, Svo.  Lond.  1805.  . C.  Bell  on  the  Varieties  of  Dis- 
eases comprehended  under  the  name  of  Carcinoma  Mam- 
mcB,  in  Med.  Chir.  Trans,  vol.  12,  Lond.  1822.  Sir  A. 
Cooper's  Lectures,  vol.  2;  1825.  Also,  Illustrations  of 
the  Diseases  of  the  Breast,  Lond.  1829.  Alo.  Hill  in 
Edin.  Med.  Jovrn.  Mo.  87. 

CANCER  SCROTI.  CHIMNEY-SWEEPERS^ 
CANCER.  See  Scrotum. 

CA  NCRUM  ORIS.  A deep,  foul,  irregular,  fetid 
ulcer,  with  jagged  edges,  on  the  inside  of  the  lips  and 
cheeks,  attended  with  a copious  flow  of  offensive  sa- 
liva. A(-cording  to  Mr.  Pearson,  this  di.sease  is  seldom 
seen  in  adults ; but  most  commonly  in  children  from 
the  age  of  eighteen  months  to  that  of  six  or  seven 
years.  The  gums,  as  well  as  the  lips  and  cheeks,  are 
sometimes  affected ; in  which  circumstance  the  teeth 
are  generally  carious  and  loose.  The  ulceration  is  oc- 
casionally attended  with  abscesses,  which  burst  either 
through  the  clieek,  lip,  or  just  below  the  jaw.  Exfo- 


236 


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nations  are  not  unfrequent,  and  when  the  disease  is 
neglected,  extensive  sloughing  sometimes  happens. 

Living  in  a marshy  situation,  unwholesome  food, 
and  inattention  to  cleanliness,  are  suspected  to  be  con- 
ducive to  this  disorder.  Its  causes  seem  not  to  be  un- 
derstood ; but  it  is  remarked  that  the  disease  prevails 
most  in  houses  where  children  are  crowded  together. 
The  complaint  is  sometimes  suspected  to  be  con- 
tagious. 

Though  children  are  the  usual  subjects  of  it,  grown- 
up persons  do  not  always  escape  its  attacks. 

The  treatment  consists  in  extracting  diseased  teeth 
and  loose  pieces  of  bone ; directing  a milk  and  vege- 
table diet,  v/ith  a prudent  quantity  of  fermented  li- 
quors ; and  prescribing  bark,  sarsaparilla,  and  elm 
bark  with  sulphuric  acid. 

I'lie  best  external  applications  are,  diluted  mineral 
acids ; burnt  alum ; the  decoctum  cinchonas,  with  sul- 
phate of  zinc;  tincture  of  myrrh;  lime-water,  with 
spirit  of  wine,  «fec.  — (See  Pearson's  Principles  of‘ Sur- 
gery, ed.  -2,  p.  287.) 

CANTHA  RIDES.  Spanish  or  French  flies,  with 
which  the  common  blistering  plaster  is  made.  In  sur- 
gery they  are  also  prescribed  in  incontinence  of  urine, 
gleets,  <fcc.  The  tincture  is  sometimes  added  to  sti- 
mulating liniments  to  increase  their  effect.  When  ap- 
plied to  the  skin  or  taken  into  the  stomach,  they  have 
a peculiar  tendency  to  act  upon  the  urinary  organs, 
and  especially  to  irritate  and  inflame  the  neck  of  the 
bladder,  and  occasion  strangury.  In  children,  these 
effects  are  particularly  frequent. — (See  Blisters.) 

[Under  the  article  Tincture  of  Cantharides  vcill  be 
found  some  practical  remarks  on  the  effects  of  this  re- 
medy in  severtil  diseases.  I would  therefore  only 
remark  in  this  place,  although  not  strictly  appertaining 
to  surgery,  that  the  inteinal  exhibition  of  cantharides 
will  be  found  to  possess  extraordinary  virtues  in  over- 
coming an  habitual  propensity  to  abortion  which  the 
female  constitution  sometimes  acquires.  I have  known 
this  remedy  succeed  after  thirteen  successive  abortions 
had  occurred,  notwithstanding  all  the  efforts  made  to 
prevent  its  repetition.  Its  use  should  be  continued  in 
increasing  doses  until  strangury  is  induced,  which  re- 
sult may  be  hastened  by  applying  a dilute  unguent  of 
cantharides  to  a blistered  surface.— Reese.] 

CAPELINA.  (From  capeline,  a woman’s  hat.) 
A double-headed  roller,  the  middle  of  which  is  applied 
to  the  occiput.  After  two  or  three  circles  the  rollers 
intersect  each  other  upon  the  forehead  and  occiput ; 
then  one  being  reflected  over  the  vertex  to  the  fore- 
head, the  other  is  continued  in  a circular  track.  They 
next  cross  each  other  upon  the  forehead,  after  which 
the  first  head  is  carried  back  obliquely  towards  the 
occiput,  and  reflected  by  the  side  of  the  other.  The 
last  is  continued  in  a circular  direction  ; but  the  first  is 
brought  again  over  the  sagittal  suture,  backwards  and 
forwards,  and  so  continued  till  the  whole  head  is  co- 
vered. By  the  ancients  this  bandage  was  sometimes 
applied  in  cases  of  hydrocephalus  : it  has  no  advan- 
tage, however,  and  is  now  hardly  ever  used. 

CAPILLARY  FISSURE.  A very  minute  crack  in 
the  skull.  The  term  came  into  use  from  its  presenting 
the  appearance  of  a hair. 

CAPISTRUM.  See  Bandage. 

CARBUNCLE.  (From  corfio,  a burning  coal.)  An- 
thrax. This  is  a very  common  symptom  in  the  plague ; 
but  comes  on  also  sometimes  as  a primary  disease. 
The  first  symptoms  are  great  heat  and  violent  pain  in 
some  part  of  the  body,  on  which  arise  one  or  several 
vesications,  attended  with  great  itching  and  a burning 
iieat;  below  which  a circumscribed  but  very  deep- 
seated  and  extremely  hard  tumour  may  be  felt.  In 
some  respects  it  resembles  the  furuncle ; but  differs 
from  it  in  having  no  central  core,  and  in  terminating 
in  gangrene  under  the  skin  instead  of  suppuration.— 
(See  Gibson's  Institutes,  vol.  1,  p.  50,  Philadelphia, 
1824.)  It  .soon  assumes  a dark  red  or  ptirple  colour 
about  the  centre,  but  is  considerably  paler  towards  the 
edges.  A blister  frequently  appears  on  the  apex, 
which,  as  it  occasions  an  intolerable  itching,  is  often 
scratched  by  the  patient.  The  blister  being  thus 
broken,  a brown  sanies  is  discharged,  and  an  eschar 
m akes  its  aitpearance.  Many  vesications  of  this  kind 
arc  sometimes  produced  upon  one  tumour.— (Rrowi- 
f eld's  Ohs.  vol.  1.) 

(’arbuncles  have  been  distinguished  into  the  benign 
and  malignant  kinds  ; but  as  far  as  the  disease  can  be 


judged  of  at  present  in  this  country,  the  distinctions 
are  only  founded  upon  the  different  degrees  of  violence 
with  which  it  makes  its  attack.  Some  carbuncles  are 
said  to  be  pestilential,  while  others  are  not  at  all  infec- 
tious. Fortunately,  all  cases  met  with  in  this  island 
are  of  the  last  sort ; for  no  opportunities  of  remarking 
the  pestilential  anthrax  have  occurred  in  England  since 
the  deplorable  periods  of  1665  and  1666. 

The  carbuncle  sometimes  appears  in  persons  affected 
with  typhoid  fevers,  in  which  case  it  is  attended  with 
great  weight  and  stiffness  of  the  adjacent  parts ; the 
patient  is  restless  and  pale,  the  tongue  white,  or  of  a 
deep  red,  and  moist ; the  pulse  low,  urine  sometimes 
pale,  sometimes  very  turbid,  with  all  the  other  symp- 
toms, in  an  exaggerated  degree,  which  attend  typhoid 
fevers.  The  patient  often  complains  much  of  his 
head,  either  from  pain  or  giddiness.  Sometimes  he  is 
drowsy ; at  other  times  he  cannot  get  the  least  sleep. 
Occasionally  he  is  delirious.  The  case  is  also  apt  to 
be  attended  with  chilliness  or  rigors,  and  profuse  per 
spirations.  The  patient  is  sometimes  costive,  some 
times  afflicted  with  a profusion  of  stools  ; he  generally 
complains  of  loss  of  appetite,  nausea,  and  vomiting, 
takes  but  little  nourishment,  complains  of  difficulty  of 
breathing,  and  is  extremely  low  with  palpitations  of  the 
heart,  and  sometimes  faintings.— (See  Bromfield's  Obs. 
vol.  1,  p.  122.) 

Sometimes  a little  slough,  of  a black  colour,  appears 
in  the  middle  of  the  tumour.  This  was  supposed  by 
the  ancients  to  be  a part  of  the  body  burned  to  a cinder 
or  hard  crust,  by  the  violence  of  the  disease.  By 
some  authors,  the  carbuncle  is  considered  as  a sort 
of  gangrenous  affection  of  the  cellular  substance.— 
{Latta.)  The  progress  of  carbuncles  to  the  gangre- 
nous Slate  is  generally  quick.  Their  size  is  various ; 
they  have  been  known  to  be  as  large  as  a plate.  Con- 
siderable local  pain  and  induration  always  attend  the 
disease.  The  skin,  indeed,  has  a peculiar  feel,  like 
that  of  brawn.  As  the  complaint  advances,  several 
apertuies  generally  form  in  the  tumour.  Through 
these  openings  there  is  discharged  a greenish,  bloody, 
fetid,  irritating  matter.  The  internal  sloughing  is 
often  very  extensive,  even  when  no  sign  of  mortifica- 
tion can  be  outwardly  discovered. 

The  constitution  is  often  so  low  and  exhausted,  that 
death  follows.  The  carbuncle,  indeed,  is  most  fre- 
quent in  old  persons,  whose  constitutions  have  been 
injured  by  voluptuous  living ; and  hence  w'e  cannot 
be  surprised  that  the  local  disease,  influenced  by  the 
general  disorder  of  the  system,  should  very  often  as- 
sume a dangerous  aspect. 

The  degree  of  peril  may  generally  be  estimated  by 
the  magnitude  and  situation  of  the  tumour,  the  num- 
ber of  such  .swellings  at  the  same  time,  the  age  of 
the  patient,  and  the  state  of  his  constitution. 

With  regard  to  the  local  treatment,  the  grand  thing 
is  to  make  an  early  and  free  incision  into  the  tumour, 
so  as  to  allow  the  sloughs  and  matter  to  escape  readily. 
Also,  with  the  view  of  facilitating  the  escape  of  the 
discharge  and  internal  sloughs  of  the  cellular  mem- 
brane, it  is  a good  plan  to  remove,  with  a pair  of  scis- 
sors, a part  of  the  dead  skin,  as  soon  as  its  detachment 
is  sufficiently  advanced. — (See  Diet,  des  Sciences 
MM.  t.  2,  p.  184.) 

As  much  of  the  contents  as  possible  is  to  be  at  once 
pressed  out,  and  then  the  part  is  to  be  covered  with  an 
emollient  poultice.  Indeed,  until  the  tumour  is  opened, 
no  applications  are  more  proper  than  emollient  poul- 
tices, and  when  an  incision  has  been  made  they  are 
far  preferable  to  any  detergent  antiseptic  injections, 
made  with  bark,  tincture  of  myrrh,  &c.,  or  to  any  lotions 
made  with  the  sulphates  of  copper  and  zinc,  nitrate  of 
silver,  &c.  Fomentations  also  aflbrd  considerable  re- 
lief, both  before  and  after  an  opening  has  been  made. 
As  the  discharge  is  exceedingly  fetid  and  irritating,  it 
will  be  necessary  to  put  on  a fresh  poultice  two  or  three 
times  a day.  The  use  of  the  poultice  is  to  be  continued 
till  all  the  sloughs  have  separated,  and  the  surface  of 
the  cavity  apjiears  red,  and  in  a granulating  state, 
when  soft  lint  and  a pledget  of  some  unirritating  oint- 
ment should  be  applied,  together  with  a compress  and 
bandage.  The  manner  in  which  the  disease  is  pro- 
tracted by  not  making  a proper  opening  in  due  time 
cannot  be  too  strongly  impressed  upon  the  mind  of 
every  practitioner,  and  it  may  justly  be  regarded 
as  a frequent  reason  of  the  fatal  terminations  of 
numerous  cases.  Mr.  Brumfield  forcibly  inculcates 


CAR 


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237 


the  necessity  of  making  a timely  opening  for  the  dis- 
charge of  the  sloughs ; for,  says  he,  in  case  you  rely 
on  the  opening  made  by  nature,  the  thin  matter  only 
will  be  discharged,  the  sloughy  membranes  will  re- 
main, and  the  orifice  close  up. — (See  vol.  1,  p.  128.) 

It  was  formerly  not  an  unconamon  custom  to  remove 
the  most  prominent  portions  of  carbuncles  with 
the  knife,  or  to  destroy  them  with  the  actual  and  po- 
tential cauteries.  The  French  in  particular  are  partial 
to  the  method  of  burning  the  swelling  with  a hot  iron, 
the  einployinent  of  which  is  sanctioned  by  Pouteau. — 
(See  Ins  (Euvres  Posthumes.)  Even  now  they  some- 
times touch  the  apex  of  the  swelling  with  boiling  oil, 
the  muriate  of  antimony,  or  the  actual  cautery,  espe- 
cially when  the  pain  is  excessively  severe;  and  the 
practice  is  alleged  to  be  the  mo.st  expeditious  mode  of 
relief.  In  America,  emollient  poultices  are  continued 
until  vesications  appear,  openings  form,  and  a bloody 
serum  begins  to  be  discharged;  the  surface  of  the 
tumour  is  then  freely  covered  with  caustic  vegetable 
alkali,  wliich  of  course  produces  a good  deal  of  pain, 
but  this  soon  subsides,  and  the  severe  burning  agony 
peculiar  to  the  complaint  is  now  quite  removed.  It 
was  Dr.  Physick  who  first  explained  the  proper  period 
for  the  application ; without  which  knowledge.  Profes- 
sor Gibson  says,  much  mischief  has  resulted  from  ill- 
timed  incisions,  and  the  actual  and  potential  cauteries. 
—{Institutes  of  Surgery,  vol.  1,  p.  52.) 

In  England  the  disorder  is  generally  subdued  by 
milder  means.  With  respect  to  the  constitutional 
treatment,  the  continental  surgeons,  in  the  beginning 
of  the  case,  before  a slough  has  formed,  usually  pre- 
scribe gentle  diaphoretic  drinks,  containing  a sufficient 
quantity  of  tartrate  of  antimony  to  open  the  bowels. 
After  this  stage,  they  have  immediate  recourse  to  tonics 
and  cordials.  It  should  always  be  remembered,  that 
the  disease  is  for  the  most  part  met  with  in  bad  con- 
stitutions, and  in  persons  who  are  weak  and  irritable. 
Hence,  it  is  only  when  there  is  a full  strong  pulse, 
and  the  complaint  is  just  beginning,  that  bleeding  is 
allowable.  Bark,  the  sulphate  of  quinine,  camphor, 
wine,  opium,  ether,  are  the  internal  medicines  most 
commonly  needed.  Iffie  diluted  sulphuric  acid  is  also 
highly  proper,  as  well  as  aromatics  and  a nourishing 
diet.  As  the  pain  is  very  severe,  opium  is  an  essential 
remedy.  The  constitutional  treatment  is  analogous  to 
that  of  mortification,  and  for  this  reason  I do  not  deem 
it  necessary  to  enlarge  the  present  article  by  expati- 
ating on  this  part  of  the  subject. — (See  Mortification.) 

In  many  of  the  southern  parts  of  Europe,  a malig- 
nant species  of  carbuncle  appears  to  be  endemic,  con- 
tagious, and  very  often  fatal. 

[In  the  United  States,  carbuncles  not  unfrequently 
occur,  and  occasionally  they  present  a most  malignant 
aspect.  They  are  for  the  most  part  seated  on  the  back 
near  the  spine ; varying  in  their  situation  from  the  cer- 
vical to  the  lumbar  vertebrae;  but  they  do  occur  on 
almo.st  every  part  of  the  body,  and  some  of  the  worst 
I have  ever  seen  existed  on  the  scalp. 

The  local  treatment  in  this  country,  when  the  dis- 
ease is  of  malignant  character,  is  most  generally  a 
poultice  or  cataplasm  of  bark  and  yest,  frequently  re- 
newed, washing  the  part  often  with  brandy.  At  the 
same  time  greater  reliance  is  placed  on  the  internal 
remedies,  which  are  designed  to  prevent  sphacelus, 
VIZ.  bark,  wine,  serpentaria,  porter,  and  other  tonics. 
In  the  2d  volume  of  l)r.  Hosack’s  essays  will  be  found 
the  narrative  of  the  successful  treatment  of  an  inte- 
resting case. — Reese.] 

f'or  an  account  of  this  form  of  this  disease,  I would 
particularly  advise  the  reader  to  consult  Hkhcrand 
J^’osugr.  Chir.  t.  1,  p.  210,  edit.  4,  and  Earrey, 
Mininires  de  Chirurgie  MUitaire,  1. 1,  p.  104,  <S-c.  Jint. 
To.si,  De  JInthrace  sea  Carbunculo  Tractatus,  4to. 
VevKtiis,\yiQ.  This  tract,  notwithstanding  its  anti- 
gui./i/,  is  said  to  contain  useful  precepts  : see  Did.  des 
•Sciences  Mid.  t.  2,  p.  184.  B rumfield' s Chirurgical 
Cases  and  Obs.  vol.  1.  D’ Encyclopidie  Methodique, 
panic  Chir.,  art.  Anthrax.  Pearson's  Principles. 
Richter's  Anfansgr.  der  Wundarin.  b.  1.  Boyer, 
Traiti  des  Maladies  Chir.  t.  2,  p.  50,  <S-c.  Physick's 
Case  of  Carbuncle,  with  Remarks  on  the  Use  of  Caustic 
in  that  Disease,  in  the  Philadelphia  Jovrn.  of  the  Med. 
and  Physical  Sciences,  vol.2,p.  172.  fV.  Gibson,  The 
Institutes  and  Practice  of  Surgery,  vol  1,  p.  50,  if-c. 
Philadelphia,  1824. 

CARCINOMA,  (From  xapxtvof,  a crab.)  See  Cancer. 


CARIES.  (From  to  abrade.)  Caries  is  a dis- 
ease of  the  bones,  supposed  to  be  very  analogous  to 
ulceration  of  the  soft  parts ; and  this  comparison  is  one 
of  great  antiquity,  having  been  made  by  Galen.  How-- 
ever,  by  the  generality  of  the  ancients,  caries  was  not 
discriminated  from  necrosis. 

It  was  from  the  surgeons  of  the  eighteenth  century, 
that  more  correct  opinions  were  derved  respecting 
caries.  Until  this  period,  writers  had  done  little  more 
than  mention  the  complaint  and  the  methods  of  treating 
it.  Some  new  light  was  thrown  upon  the  subject  by 
J.  L.  Petit,  in  his  remarks  upon  exostosis  and  caries. — 
(Mai.  des  Os,  t.  2,  chap.  16,  p.  27.)  But  as  he  only- 
spoke  of  the  disorder  as  one  of  the  terminations  of  ex- 
ostosis, he  has  not  entered  far  into  the  consideration  of 
it.  The  best  observations  on  caries  were  first  made  by 
Dr.  A.  Monro,  primus.— (Edin.  Med.  Essays,  vol.  5, 
art.  25.)  This  memoir  contains  the  earliest  correct 
ideas  of  dry  caries,  or  necrosis,  which  is  rightly  com- 
pared to  mortification  of  the  soft  parts,  and  named 
gangrenous  caries. 

The  bones,  like  other  parts  of  the  body,  are  composed 
of  arteries,  veins,  absorbent  vessels,  nerves,  and  a cel- 
lular texture ; they  are  endued  with  vitality ; they  are 
nourished,  they  grow,  waste,  are  repaired,  and  undergo 
various  mutations  according  to  the  age  of  the  indivi- 
dual ; and  they  are  subject  to  diseases  analogous  to 
those  of  the  soft  parts.  To  the  phosphate  of  lime, 
which  is  more  or  less  abundantly  distributed  in  their 
texture,  they  owe  all  their  solidity  ; and,  perhaps,  it  is 
to  the  same  earthy  substance,  that  the  difference  in 
their  vital  properties  and  in  their  diseases,  from  those 
of  the  rest  of  the  body,  is  to  be  referred.  In  fact,  this 
particular  organization  and  inferior  vitality  of  the 
bones  are  generally  supposed  to  account  for  the  small 
number,  peculiar  character,  and  generally  slow  j ro- 
gress  of  their  diseases.— (Dzef.  des  Sciences  Med.  t.  4, 
p.  80.) 

Bones  of  a spongy  texture  are  more  frequently  at- 
tacked by  caries  than  such  as  are  compact.  Hence 
the  vertebrae;  astragalus,  and  other  bones  of  the  tar- 
sus; those  of  the  carpus;  the  sternum;  the  bones  of 
the  pelvis,  and  the  heads  of  the  long  bones,  are  often 
affected;  and  the  bones  of  young  persons  are  unques- 
tionably more  frequently  the  seat  of  caries  than  those 
of  old  subjects. 

But,  as  a modern  writer  has  observed,  though  the 
soft  and  spongy  bones  are  most  subject  to  caries,  they 
sometimes  suffer  a degree  of  injury  sufficient  to  pro- 
duce the  death  of  a portion  of  their  texture.  This  re- 
mark is  illustrated  by  a case,  where  a musket-ball 
had  struck  the  head  of  the  tibia,  in  which  after  death  a 
sequestrum  was  found,  with  a cloaca  leading  down  to 
it.— (Liston,  in  Edin.  Med.  and  Surg.  Journ.  No.  78, 
p.  50.) 

According  to  the  observations  of  Mr.  Syme,  when 
caries  occurs  in  the  tables  of  the  skull,  or  the  cylindri- 
cal bones,  it  is  uniformly  preceded  by  a morbid  expan- 
sion of  the  compact  structure  into  a state  resembling 
that  which  naturally  belongs  to  those  where  the  dis- 
ease usually  resides.  He  notices,  that  the  shafts  of 
bones,  and  especially  that  of  the  tibia,  are  frequently 
enlarged  and  thickened,  in  consequence  of  chronic  in- 
flammation, and  at  the  same  time  loosened  in  their 
texture,  so  as  to  present  nearly  the  same  appearance 
as  that  of  the  spongy  articulating  extremities.  “ In 
bones  so  altered,  caries  occasionally  occurs,  or  I should 
rather  say,  a condition  resembling  caries,  since  it  dif- 
fers from  this  disease  in  one  important  feature,  viz, 
incorrigibleness.  I have  hardly  ever  known  this 
pseudo-caries  resist  the  local  application  of  blisters, 
and  internal  use  of  oxymuriate  of  mercury;  and  I 
have  felt  very  uncomfortable  in  seeing  extensive  inci- 
sions, rasping,  trephining,  actual  cauteries,  &c.  em- 
ployed ineffectually  to  cure  complaints  admitting  of 
such  easy  remedy.” — (See  Edin.  Med.  and  Surg.  Juum, 
vol.  31,  p.  257.) 

In  necrosis,  the  bone  is  entirely  dejirived  of  life;  in 
caries,  the  vital  principle  exists,  but  a morbid  action  is 
going  on,  w'hereby  the  texture  of  the  bone  is  altered, 
and  rendered  softer  and  lighter  than  rnttiral.  But 
though  these  disorders  .-rre  essentially  different  from 
each  other,  they  frequently  occur  together  in  the  same 
part,  as  Mr.  I.iston  has  correctly  explained.-  (Edm. 
Med.  and  Surg.  .Journ.  No.  78,  ]>.  50.) 

In  the  most  common  species  of  caries,  a loose  futi- 
gous  flesh  grows  out  of  the  interstue.s  formed  on  tho 


238 


CARIES. 


surface  of  the  diseased  bone,  and  bleeds  from  the 
slightest  causes;  while  in  the  soft  parts  a sinus  ge- 
nerally leads  down  to  the  caries,  and  emits  a very 
fetid,  dark-coloured  sanies.  These  symptoms,  how- 
ever, as  well  as  the  tendency  in  the  accompanying 
ulcer  or  sinus  to  produce  large  fungous  granulations, 
are  more  constant  in  cases  of  necrosis  than  in  those 
of  caries,  some  of  which  may  remain  a very  consider- 
able time  unattended  with  any  outward  sore,  abscess, 
or  sinus  as  we  see  illustrated  in  the  caries  produced 
by  various  diseases  of  the  joints.  And,  indeed,  par- 
ticular Ibrms  of  caries  (if  they  deserve  that  name)  are 
rarely  accompanied  with  suppuration : a fact  to  which 
I shall  again  advert. 

“ The  absorption  of  bone,  like  that  of  soft  parts  (says 
Dr.  Thomson),  may  be  distinguished  into  interstitial, 
progressive,  and  ulcerative.  We  have  ample  proofs  ol’ 
the  interstitial  absorption,  or  that  which  is  daily- 
hourly,  and  unceasingly  taking  place  from  every  part 
of  the  substance  of  bone,  in  the  deposition  and  removal 
of  phosphate  of  lime,  that  has  been  tinged  with  mad- 
der. If  too  much  earth  be  removed,  the  quantity  of 
animal  matter  will  be  relatively  increased,  and  a dis- 
position given  to  softness  of  the  bones — a state  which 
exists  in  the  bones  of  children,  in  the  disease  called 
the  rickets,  and  in  the  bones  of  older  people  in  that 
denominated  mollities  ossium,  or  the  rickets  of  grown 
people. 

I have  already  had  occasion  to  mention  the  effects  of 
the  progressive  absorption  of  bone,  as  manifested  in 
the  progress  of  aneurisms  and  other  tumours  to  the 
skin  ; but  the  formation  of  pus  is  by  no  means  a ne- 
cessary, constant,  or  even  frequent  attendant  on  the 
progressive  absorption  in  bone.  Hydatids  in  the  brains 
of  sheep,  tumours  growing  from  the  pia  or  dura  mater 
in  the  human  body  (see  Di/ra  Mater),  or  aneurism 
seated  over  the  cranium,  or  within  the  cavity  of  the 
chest,  are  often  the  cause  of  the  whole  substance  of  a 
bone  being  removed,  layer  after  layer,  by  progressive 
absorption,  without  the  formation  of  a single  particle 
of  pus.— (See  Aneurism.)  This  state  of  the  bone  has 
often  been  confounded,  but  improperly,  with  that  state 
of  the  bone  which  arises  from  ulcerative  absorption, 
the  state  which  is  properly  denominated  caries,  and 
in  which  one  or  more  solutions  of  continuity  may  be 
produced  upon  the  surface,  or  in  the  substance  of  the 
bones.  The  ulcerations  occasioned  in  bones  by  the 
venereal  disease  afford  by  far  the  best  marked  exam- 
ples of  the  effects  and  appearances  of  ulcerated  ab- 
sorption, or  caries  in  bones,”  <fcc. — (See  Thomson's 
Lectures  on  Inflammation,  p.  389.) 

Caries  has  bean  divided  into  three  kinds,  according 
to  the  nature  of  its  causes  ; 1.  Caries  from  external 
causes  ; 2.  From  an  internal  local  cause,  where  no  out- 
ward injury  of  the  bone,  and  no  internal  constitutional 
disease  can  be  suspected  to  have  produced  the  disorder, 
and  where  the  affection  can  be  removed  by  local  means. 
The  caries  of  the  finger-bones  from  whitlows  is  quoted 
as  a specimen  of  this  form  of  the  disease.  Perhaps, 
however,  the  case  is  generally  rather  an  instance  of 
necrosis.  3.  From  a general  internal  cause,  or  consti- 
tutional disease,  in  which  cases,  besides  local  remedies, 
it  is  necessary  to  employ  such  medicines  as  are  calcu- 
lated to  obviate  the  particular  affection  of  the  system, 
whence  the  diseased  state  of  the  bone  has  originated. 

But,  in  addition  to  these  general  divisions  of  the  sub- 
ject, there  are  many  circumstances  in  relation  to  the 
varieties  of  caries  which  may  be  said  yet  to  lie  in  ob- 
scurity. If,  as  a modern  witer  remarks,  the  situation 
of  the  bones,  the  nature  of  their  organization,  and  the 
slowness  of  their  diseases  would  let  an  attentive  ob- 
server trace  the  formation,  developement,  and  progress 
of  caries,  no  doubt  there  would  be  noticed  a diversity 
in  its  symptoms  corresponding  to  its  different  species  ; 
and  probably  it  would  be  found  that  a venereal  or  scro- 
fulous caries  would  vary  in  its  origin  and  progress  as 
much  from  a caries  arising  from  a purely  local  cause, 
as  a venereal  or  scrofulous  ulcer  differs  from  the  kind 
of  ulceration  that  follows  a common  abscess.— (D^c^ 
des  Sciences  Med.  t.  4,  p.  84.)  The  worm-eaten  caries, 
as  it  has  been  termed,  which  penetrates  the  whole  sub- 
stance of  a bone,  and  gives  it  an  appearance  as  if  it 
had  been  bored  in  hundreds  of  places,  is  a very  differ- 
ent affection  from  some  other  forms  of  the  disease, 
whether  superficial  or  extending  to  the  deeper  texture 
of  the  bone. 

Mr.  Syme  regards  the  distinction  of  caries  into  the 


dry,  moist,  worm-eaten,  &c.  only  as  the  result  of  the 
confusion  of  caries  with  other  morbid  states  of  the  os- 
seus  tissue.  The  drj’  is  in  reality  necrosis,  as  already 
noticed.  A carious  bone,  after  maceration,  according 
to  Mr.  Syme,  looks  as  if  it  had  been  burned ; being 
harder,  whiter,  and  more  brittle  than  usual,  and  always 
attended  with  more  or  less  excavation,  so  as  to  expose 
the  cellular  structure.  It  much  resembles  a piece  of 
loaf  sugar,  which  has  been  partially  dissolved  by  mo- 
mentary immersion  in  hot  water. — (See  Edin.  Med. 
and  Surg.  Joum.  vol.  31,  p.  257.) 

Abscesses  situated  in  the  \’icinity  of  bones  are  fre- 
quently thought  to  be  the  cause  both  of  necrosis  and 
caries.  This  was  the  ancient  doctrine,  and  it  has  found 
various  advocates  in  modern  times,  especially  Mr.  Lis- 
ton.— (See  Edin.  Med.  and  Surg.  Joum.  vol.  20.  p.  52.) 
Hence,  the  rule  to  open  such  abscesses  at  an  early 
period,  in  order  to  prevent  the  bone  from  being  affected. 
If  some  abscesses,  like  those  which  form  over  the  an- 
terior surface  of  the  tibia  and  mastoid  process  of  the 
temporal  bone,  be  frequently  attended  either  with  ca- 
ries or  necrosis,  the  latter  is  mostly  the  cause,  and  not 
the  effect  of  the  suppuration.  Pus,  which  is  a bland^ 
unctuous,  inodorous  fluid,  never  attacks  the  soft  parts 
with  which  it  is  in  contact  until  its  qualities  are 
changed  by  exposure  to  the  air.  When  an  abscess 
forms  in  the  anterior  part  of  the  parietes  of  the  abdo- 
men, the  peritoneum  of  that  part,  naturally  a thin  mem 
brane,  instead  of  being  destroyed,  becomes  tliick  and 
strong  enough  to  resist  the  extension  of  the  abscess 
towards  the  cavity  of  the  abdomen.  So  also  when  an 
abscess  is  formed  over  a bone,  not  originally  diseased 
or  hurt  by  the  same  causes  which  produced  the  ab- 
scess, and  not  injured  by  being  kept  exposed,  or  by  as- 
tringent escharotic  applications,  neither  caries  nor  ne- 
crosis is  likely  to  happen.  On  the  contrary,  the  perios- 
teum, like  the  peritoneum,  becomes  thickened,  and  gra- 
nulations are  formed  over  it.  In  the  opinion  of  Rlr. 
Syme,  caries  cannot,  like  necrosis,  be  induced  directly 
by  the  effect  of  violence.  It  depends,  he  says,  upon  a 
peculiar  morbid  action,  which  is  probably  in  all  cases 
preceded  by  inflammation.  “ Many  people  think  that 
pressure,  such  as  that  of  an  aneurism,  causes  absorption 
of  bone,  and  gives  rise  to  an  appearance  which  might 
b-  mistaken  for  caries  by  an  inexperienced  or  careless 
observer,  but  could  never  for  a moment  impose  upon 
any  one  acquainted  with  the  distinctive  characters  of 
the  disease.  The  surface  exjKised  by  simple  absorp- 
tion differs  in  no  respect  from  that  w^hich  would  have 
appeared  if  the  excavation  had  been  effected  by  vio- 
lence. We  do  not  here  perceive  the  hardness,  white- 
ness, and  brittleness  of  caries ; neither  is  there  any 
matter  secreted  from  it ; and  so  soon  as  the  caries  is 
removed  the  disease  ceases.  The  effect  of  pressure  in 
causing  absorption  without  inducing  caries,  is  w'ell 
seen  in  those  common  cases  of  necrosis  where  inter- 
nal exfoliation  occurs,  and  the  confined  pus  makes  a 
w'ay  for  its  escape,  since  the  sides  of  these  passages, 
so  produced,  the  cloacae  as  they  are  called,  are  in  no 
respect  carious,  or  unfit  for  healthy  action.  Deep- 
seated  collections  of  matter  ought  to  be  evacuated  early 
to  relieve  the  patient  from  pain,  or  prevent  exten- 
sion of  the  fluid,  but  no  apprehension  need  be  enter- 
tained of  caries  being  produced  by  its  pressure.” — 
(Syme,  vol.  cit.  p.  258.) 

But  though  this  gentleman  thinks  that  inflammation 
generally,  if  not  always,  precedes  caries,  he  represents 
this  consequence  as  not  invariably  following  inflam- 
mation or  even  suppuration.  “ In  cases  of  compound 
fracture,  amputation,  excision  of  joints,  &c.  we  every 
day  see  bone  sujipurate  and  grai;u!ate  in  the  most 
satisfactory  manner.  We  observe  the  same  thing  oc- 
casionally in  joints,  w’hich  become  anchylosed  after 
being  the  seat  of  abscess.”  At  the  .same  time,  Mr. 
Syme  believes  that  suppuration  of  bone,  which  either 
takes  place  spontaneously,  or  in  consequence  of  slight 
external  injury,  is  very  frequently  followed  by  caries, 
much  more  so  than  when  it  results  from  a wound 
which  does  not  heal  by  the  first  intention. 

Mr.  Syme  has  found  that  caries  seldom  affects  the 
bone  to  a great  depth.  “ Thus  we  often  .see  an  arti- 
culating extremity  carious  over  its  w hole  external  sur- 
face, and  sound  in  the  centre.  At  other  tnne.s  we  find 
it  hollowed  out  into  a cavity,  the  surface  of  which  is 
carious,  while  the  external  shell  is  sound.  The  very 
limited  extent  of  the  disease  often  contrasts  remarkably 
with  the  extreme  obstinacy  and  severity  of  the  symp- 


CARIES. 


239 


toms.  Thus  there  is  in  my  possession  a thigh-bone 
which  I took  from  the  body  of  a woman  who  had  1 1- 
boured  under  caries  of  tlie  trochanter  major  for  thir- 
teen years  ; yet  the  whole  disease  may  be  covered  by 
the  point  of  a finger,  and  is  not  thicker  than  a sixpence.” 
— (Syme,  in  Edin.  Med.  Journ.  v.  31,  jj.  257.) 

The  venereal  disease  is  sometimes  a cause  of  caries ; 
sometimes  of  necrosis  ; frequently  of  both  affections  j 
together,  and  in  other  instances  of  exostosis.  When 
it  attacks  the  bones  of  the  nose,  its  destructive  effects 
arise  partly  from  necrosis,  and  partly  from  caries,  and 
the  face  is  sadly  disfigured.  The  bones  of  the  palate 
are  sometimes  altered  in  the  same  manner;  but  on 
other  occasions  the  effect  upon  them  is  chiefly  necrosis. 

In  cases  of  cancer  of  the  breast  the  sternum  and  ribs 
are  sometimes  found  carious.  I believe  that  in  such 
cases  the  disease  of  the  bones  has  nothing  in  its  own 
nature  entitling  it  to  be  regarded  as  cancerous.  It  is 
a mere  effect  of  the  original  disorder ; and  if  the  cari- 
ous bone  could  be  removed  together  with  every  particle 
of  the  disease  of  the  soft  parts,  a cure  would  probably 
follow.  Or  supposing  the  carious  bone  were  the  only 
portion  of  the  disease  left,  it  is  conceivable  that  the 
case  might  yet  end  in  a cure.  At  the  same  time  it  is  pro- 
per to  recollect  what  has  been  mentioned  in  the  article 
Cancer,  that  Sir  Astley  Cooper  refers  in  his  Lectures 
to  some  bones  taken  from  cancerous  subjects,  where 
the  scirrhous  substance  is  deposited  in  their  structure. 

[Under  the  article  Treyhine  I have  noticed  a very  re- 
markable case  of  caries  from  syphilis  occurring  in  the 
cranium,  together  with  its  successful  treatment.  The 
celebrated  Richerand,  of  Paris,  has  several  times  re- 
moved carious  ribs,  and  this  operation  has  since  been 
repeated  by  Dr.  M‘Clellan,  of  Philadelphia,  and  by 
Dr  IVPDowell,  of  Virginia.— Reese  ] 

Caries  arising  from  syphilis  most  commonly  affects 
the  tibia,  cranium,  ossa  nasi,  ossa  palati,  and  sternum  ; 
and  I believe  is  mostly  complicated  with  a greater  or 
less  degree  of  necrosis. 

Caries  of  the  vertebrae  is  known  by  peculiar  symp- 
toms, among  which  a paralysis  of  the  inferior  extremi- 
ties and  lumbar  abscesses  are  the  most  remarkable. 

Caeteris  paribus,  caries  from  an  external  or  a local 
internal  cause  is  less  dangerous  than  that  which  pro- 
ceeds from  a constitutional  disease,  particularly  when 
the  latter  is  difficult  of  cure. 

Caries  of  the  spongy  part  of  the  bones  is  more  dif- 
ficult to  cure  than  a similar  affection  of  the  compact 
jjarts.  Caries  of  the  carpal  and  tarsal  bones  is  par- 
ticularly obstinate.  These  bones  being  in  close  contact, 
the  affection  cannot  easily  be  prevented  from  spreading 
from  one  to  the  other.  Amputation  is  often  the  only 
means  of  cure.  The  same  is  frequently  the  case  when 
the  spongy  heads  of  the  long  bones  forming  the  large 
joints  become  carious.  Even  this  mode  of  relief  is  not 
practicable  when  the  head  of  the  bone  lies  very  deeply, 
like  that  of  the  os  fernoris. 

Caries  of  the  ossa  ileum  is  also  observed  to  be  par- 
ticularly difficult  of  removal. 

Caries  from  scrofula,  the  most  frequent  case  of  all 
the  examples  of  this  disorder  of  the  bones  (WCvs- 
inan  i , is  more  difficult  of  cure  than  that  from  syphi- 
lis and  scurvy  ; for  some  efficacious  remedies  against 
the  latter  diseases  are  known  ; but  scrofula  cannot  be 
said  to  be  within  the  reach  of  medicine.  The  progno- 
sis is  less  favourable  in  old  than  young  subjects,  and 
much  depends  on  the  extent  of  the  disease,  the  pa- 
tient’s strength,  and  the  state  of  the  soft  parts. 

When  caries  arises  from  constitutional  disease,  inter- 
nal remedies  are  of  course  indicated.  Thus  mercurial 
and  sudorific  medicines  put  a stop  to  caries  from  syphi- 
lis ; while  vegetable  diet  and  acids  cure  both  the  scurvy 
and  the  caries  dependent  on  it. 

According  to  writers  the  indications  in  the  treatment 
of  caries  are,  either  to  produce  a change  in  the  action 
of  the  diseased  portion  of  bone,  whereby  it  may  regain 
a healthy  state,  or  to  destroy  it  altogether. 

In  the  caries  from  constitutional  causes,  the  first  ob- 
ject seems  to  be  brought  about  by  the  operation  of 
such  remeflies  as  remove  the  original  disca.se ; and  I 
should  much  doubt  whether,  in  these  cases,  any  very 
active  local  treatment  is  necessary  or  free  Irom  objec- 
tion. Of  course,  this  remark  is  meant  to  apply  only  to 
examples  in  which  we  possess  some  medicine  or  plan 
which  IS  known  to  be  a tolerably  sure  remedy  for  the 
general  disease.  This  is  not  the  case  in  caries  from 
Hjrol'uia,  and  here  issues,  blisters,  friction,  with  other 


local  means,  are  unquestionably  advantageous. — (See 
Joints  and  Vertehree.)  But  surgeons  ha^'e  proceeded  far- 
ther, and  not  content  with  issues,  blisters,  fomentations^ 
&c.  as  means  for  quickening  the  action  of  the  diseased 
bone,  they  have  commonly  recommended  applying  di- 
rectly upon  it  the  strongest  stimulants,  as  the  tincture 
of  aloes  or  myrrh,  a solution  of  the  argentum  nitratum, 

I concentrated  vinegar,  or  diluted  muriatic  acid. 

For  the  destruction  of  caries,  the  actual  and  poten- 
tial cauteries  and  cutting  instruments  have  been  enj- 
ployed. 

On  the  continent,  and  particularly  in  France,  the  plan 
of  touching  carious  parts  of  bones  with  the  actual  cau- 
tery, after  bringing  them  fairly  into  view  by  the  previous 
use  of  the  knife,  is  still  pursued.  It  is  thought  that 
the  burning  iron  acts  by  changing  the  caries  into  a ne- 
crosis, irritating  the  subjacent  sound  parts,  and  exciting 
that  action  of  the  vessels,  by  which  the  dead  or  dis- 
eased part  of  the  bones  must  be  thrown  otf.  Such  is 
the  doctrine  inculcated  by  Boyer,  and  such  is  the  prac- 
tice sanctioned  by  some  surgeons  of  the  present  day, 
among  whom  I find  Mr.  Liston. 

Mr.  Hey  succeeded  in  cutting  away  a carious  part  of 
the  tibia.  He  began  the  operation  by  dissecting  off  the 
granulations  of  flesh  which  had  arisen  from  the  bone, 
and  then  sawed  out,  by  means  of  a circular-headed  saw, 
a wedge  of  the  tibia  two  inches  in  length.  The  remo- 
val of  this  ponion  brought  into  view  a caries  of  the 
cancelli  almost  as  extensive  as  the  piece  already  re- 
moved. With  different  trephines,  suited  to  the  breadth 
of  the  caries,  Mr.  Hey  removed  the  diseased  cancelli  of 
the  bone  quite  through  to  the  0])posite  lamella.  As  the 
caries  extended  in  various  directions,  it  was  not  possi- 
ble to  remove  the  whole  of  it  with  a trephine  without 
removing  also  a large  portion  of  the  sound  part  of  the 
bone,  which  Mr.  Hey  wished  to  avoid.  By  the  assist- 
ance, therefore,  of  a strong  sharp-pointed  knife,  he  pur- 
sued the  caries  in  every  direction,  until  every  part  was 
taken  away  which  had  an  unsound  appearance.  The 
wound  was  simply  dressed  with  dry  lint ; the  whole 
.surface  was  speedily  covered  with  good  granulations ; 
and  a complete  cure  was  obtained  without  any  exfo- 
liation. 

Mr.  Hey  concludes  this  subject  as  follows : “ I have 
treated  some  other  cases  of  caries  of  the  tibia  in  the 
same  manner,  and  with  equal  success.  Where  the 
extent  of  the  caries  is  not  so  great  as  to  prevent  a 
comjilete  removal  of  the  morbid  part,  this  method  is 
extremely  useful,  and  far  superior  to  the  use  of  the  po- 
tential or  actual  cautery. 

The  trephine  is  not  wanted  where  the  cancelli  of 
the  bone  are  not  affected  with  the  caries.  The  dis- 
eased parts  of  the  lamella  may  be  removed  with  gouges 
or  small  chisels.  Granulations  of  flesh  will  then  arise 
from  the  sound  parts  of  the  bone,  and  become  united 
with  the  integuments,  which  ought  to  be  preserved  as 
far  as  is  possible.” — {Pract.  Obs.  on  Surgery.) 

Mr.  Syme  also  regards  excision  as  the  best  method 
of  destroying  carious  bone,  since  (he  says)  “ more  can 
be  done  by  the  gouge,  or  cutting  pliers,  in  a few 
seconds,  than  by  the  actual  cautery  in  as  many  weeks 
or  months  and  he  strongly  objects  to  the  application 
of  the  cautery  to  the  bone  after  the  excision  of  the 
carious  part. — {Edin.  Med.  Journ.  n.  31,  p.  260.)  On 
this  point,  every  judicious  surgeon  must,  I think,  agree 
with  him. 

Dr.  Nicol,  surgeon  to  the  Northern  Infirmary  of  In- 
verness, has  lately  published  the  lesult  of  his  expe- 
rience in  caries ; and  he  finds  that,  when  excision  is 
not  practicable,  the  next  most  effectual  treatment  con- 
sists in  applying  nitrate  of  silver  to  the  carious  part, 
and  exhibiting  the  compound  decoction  of  sarsaparilla- 
— (See  Edin.  Med.  and  Surg.  Journ.  No.  94.) 

In  the  treatment  of  caries,  particularly  of  that  form 
of  it  which  acconqianies  white  swellings,  Mr.  Liston 
considers  ointments  and  poultices  as  unlikely  to  be 
productive  of  much  good.  In  the  first  or  inflammatory 
stage,  he  (iraises  topical  bleeding,  practised  with  mode- 
ration, and  followed  by  issues,  sinapisms,  blisters,  or 
the  antimonial  ointment.  However,  he  thinks  the 
most  effectual  remedy  is  the  moxa.  “ In  all  deej)- 
seated  pains  of  the  joints  (.says  Mr.  Liston)  this  remedy 
affords  the  most  speedy  and  complete  relief,  at  the  ex- 
pense but  of  a trifling  pain  of  no  long  duration.  The  pain 
does  not  appear  to  be  greater  than  that  arising  from 
the  fonnation  of  an  eschar  by  potass,  or  any  (Mher  of 
the  potential  cauteries,  and  lasts  only  during  tive  lima 


240 


CARIES. 


of  the  application,  while  the  violent  pain  does  not  sub- 
side, perhaps,  fflr  twc.ve  liou  S after  the  employ iiie  .t 
of  the  potass.” — {Edi.a,  Med.  unci  Eurg.  Jounu.  Nu.  76, 

p.  54.) 

When  caries  is  fairly  established,  and  the  integu- 
ments have  given  way,  the  same  author  represents 
the  indications  to  be,  either  the  immediate  removal  of 
the  diseased  bone,  or  the  employment  of  means  calcu- 
lated to  make  it  be  thrown  off  by  the  constitution. 
“ The  first  indication  (he  says)  is  to  be  accomplished 
by  the  proper  use  of  trephines,  perforators,  gouges, 
gravers,  scoops,  saws,  and  forceps  of  different  kinds, 
for  dividing  or  extracting ; the  second,  by  cauteries,  ac- 
tual or  potential.  In  general,  a combination  of  both  is 
required. 

In  caries  of  the  long  bones,  it  becomes  in  general 
necessary  to  enlarge  the  openitig  through  the  outer 
lamella,  by  the  application  of  the  trephine,  and  per- 
haps by  the  use  of  a small  saw,  or  cutting  forceps,  so 
as  to  connect  the  different  perforations,  and  thus  obtain 
access  to  the  diseased  cancelli.  The  scoop,  or  graver, 
will  answer  well  for  the  rest  of  the  work.  In'  most 
instances  the  actual  cautery  is  next  applied  very  freely, 
by  which  means  the  whole  of  the  diseased  surface  will 
be  thrown  off,  and  healthy  granulations  fill  up  the 
breach.” — {Op.  cit.  p.  56.) 

In  the  Medico-Chirurgical  Trans,  cases  have  been 
recorded  by  Mr.  Dunn,  and  Mr.  C.  Hutchison,  in  which 
several  of  the  tarsal  bones  in  a state  of  caries  were  cut 
out,  and  the  foot  preserved.  The  same  practice  seems 
to  be  followed  by  Mr.  Liston,  with  the  addition  of  the 
cautery.  He  observes,  that  when  the  disease  is  seated 
in  one  of  the  tarsal  or  carpal  bones,  and  entirely 
limited  to  it,  its  simple  removal  will  be  sufficient. 
But  when  one  is  quite  destroyed,  and  the  surfaces  of 
others  with  which  it  is  articulated  are  affected,  these 
surfaces  must  also  be  cut  out,  and  the  operation 
finished  by  the  free  application  of  the  cautery.  The 
principle  which  Mr.  Liston  lays  down  is,  that  the 
cautery  is  indispensable,  whenever  the  cancellated  tex- 
ture of  a bone  is  encroached  upon.  The  knife  for 
such  operations,  he  says,  should  have  a strong,  sharp 
point  and  edge,  with  a thick  back  and  firm  handle. 
A scoop,  graver,  or  gouge,  and  strong  pliers,  with 
some  pairs  of  cutting  forceps,  will  (with  the  cauteries 
for  such  cases  as  require  them)  complete  the  appara- 
tus. The  bone-forceps,  with  the  cutting  edges  in  a 
line  with  the  handles,  as  used  by  Mr.  Liston  for  some 
years  in  these  operations,  as  well  as  amputation,  are 
strongly  commended,  more  especially  when  the  meta- 
carpal or  metatarsal  bones  are  to  be  in  part  removed. 
In  these  operations,  Mr.  Liston  has  never  found  saws 
of  the  least  use  ; and  in  several  trials  of  the  chain  saw 
which  he  witnessed,  it  either  broke,  or  got  so  wedged 
that  great  difficulty  was  experienced  in  disengaging  it, 
and  bringing  the  operation  to  a conclusion.  He  does 
not  approve  of  the  half-headed  trephine,  because  the 
bone  must  be  denuded  much  higher  than  where  the 
division  is  to  be  made,  in  order  to  let  the  centre  pin  be 
fixed.  The  annular  saw  he  also  disajmroves  of,  on 
account  of  the  extensive  division  of  the  integuments, 
which  its  use  requires.  He  does  not  enter  into  any 
particular  reasons  against  Hey’s  saws,  which  have 
been  found  so  useful  by  other  practitioners  ; and  the 
rotation  saw  lately  in%’ented  by  Professor  Thai,  of  Co- 
penhagen, is  mentioned,  but  its  merits  not  e.xamined. 
In  short,  whatever  some  surgeons  would  execute  with 
a saw  in  the  operations  under  consideration,  Mr.  Lis- 
ton would  perform  with  his  bone-forceps,  or  cutting 
pliers  and  other  means.  The  facts  which  lie  has  re- 
ported show  clearly  enough  that  the  forceps  used  by 
him  is  a very  efficient  instrument ; and  it  is  no  slight 
circumstance  in  its  favour,  tliat  Baron  Dupuytren 
strongly  commends  it,  and  has  iiuhlicly  used  it. — 
{Liston  in  Edin.  Med.  and  Snrg.  Journ.  No.  78.) 

If  surgeons  are  often  censurable  for  inert  measures 
in  a variety  of  diseases,!  believe  they  cannot  be  blamed 
for  the  same  kind  of  inactivity  in  the  treatment  of  caries, 
where  they  run,  perhaps,  into  the  opposite  extreme ; 
and,  too  confident  in  their  knowledge  of  the  causes  and 
nature  of  the  disease,  they  oflen  make  themselves  too 
officious,  and  rather  disturb  than  iiroiiioie  the  salutary 
processes  of  nature. — (See  ./  L.  I’l  tii,  '/'nine  ile.<  .M-ii. 
des  Os,  Pares,  1741.  .d.  Monro,  in  Eiiiu.  Mrd.  F.s- 

siiys,  vnl.  5.  (Vrhlmnnn  dr  Neernsi  Ossiuoi,  Frnneof. 
179U.  CnlUsrv,  Systnna  I'lnr  ririip.  / b'dir.rtiu,  lud.  I, 
V.  493  Boyer,  Traiit  des  Maladies  Lktr.  t.  3,  p.  453. 


ei  srq.  Pdri.s,  1814.  Richer  and,  Nu.sogr.  Chir.  t.  3, 
p.VJA,  rdti.A,  Fari.s,  1615.  Diet,  des  Scienc'S  Med. 
t 4,  p.  78,  d,-c.  J.  Wilson  on  Ihe  Structure,  Physio- 
<^>‘d  Diseases  of  the  Bones,  Spc.  p.  263,  Pi'o  Loud. 
16J0.  L.  iVtssmanv,  De  Rite  Cognoscendis  et  Cavan 
dts  Nudaiione,  Carie  et  M’ecrosi  Ossiuni,8ro.  R JJs- 
ton,  Ess:y  on  Cories,  in  Edin.  Med.  and  Surg.  .Joarii. 
No.  78.  ..d  good  description  of  the  different  kinds  of 

canes  is  yet  a desideratum.) 

[There  is  one  peculiar  and  somewhat  novel  species  of 
caries,  which  has  received  the  attention  of  several 
-American  writers,  and  to  which  some  European  wri- 
ters have  recently  referred.  I allude  to  the  caries  of 
the  jaw-bone  occurring  among  children,  and  which  has 
been  denominated  by  Marshall  Hall  a gangrenous 
ulcer,  affecting  the  jaw-bones  of  children.  This  dis- 
ease sdems  in  a variety  of  instances  to  be  preceded  by 
febrile  irritation,  and  derangement  of  the  digestive 
organs.  It  is  often  found  under  circumstances  in 
which  a great  number  of  children  occupy  the  same 
apartments,  as  in  workhouses,  alms-houses,  peniten- 
tiaries, <fec. ; but  it  sometimes  arises  spontaneously  or 
sporadically,  without  any  ostensible  cause.  It  has 
been  attributed  to  impoverished  or  bad  diet,  to  spoiled 
grain,  and  to  illy  ventilated  apartments.  In  some  in- 
stances it  has  been  supposed  to  originate  from  an  in- 
judicious use  of  mercurials,  and  I have  seen  several 
cases  of  the  disea.se  justly  attributed  to  this  agency  ; 
but  they  were  all  found  in  children  who  gave  une- 
quivocal evidences  of  scrofulous  diathesis,  where 
mercury  should  always  be  given  with  caution. 

But  it  often  occurs  without  any  mercurial  treat- 
ment having  been  premised.  Indeed,  Hall  asserts  that 
the  malign  effects  of  mercury  cannot  be  associated 
with  the  symptoms  of  this  species  of  caries  ; and  this 
opinion  was  probably  justified  by  his  observation  on 
the  cases  which  came  under  his  notice.  Dr.  Fran- 
cis says,  that  the  cases  occurring  in  his  practice, 
so  far  as  he  could  ascertain,  were  in  nowise  asso- 
ciated with  mercurial  treatment. 

In  1808,  a number  of  cases  of  this  disorder  appeared 
in  the  New-York  Alms-House,  and  were  described  by 
Dr.  Sherril.  It  also  occurred  again  in  the  New-York 
Penitentiary,  after  that  institution  was  removed  out  of 
the  city,  and  into  a pure  and  wholesome  air,  as  re- 
ported by  the  late  Dr.  Dyckman,  and  it  has  occasionally 
reappeared  since. 

.Sometimes  it  has  been  known  to  occur  among  the 
sequela  of  variola  and  scarlatina.  It  has  been  ob- 
served, that  the  children  most  liable  to  this  kind  of 
caries,  were  between  two  and  five  years  of  age,  and 
whose  constitutions  had  suffered  from  abdominal  or 
gastric  irritation.  When  it  prevailed  as  it  did  here  in 
1612  to  some  extent,  some  patients  were  found  to  labour 
under  it  much  older,  and  one  or  two  adults.  It  pre- 
vailed mo.st  in  cold  weather,  and  seemed  to  be  con- 
nected with  seasons  of  great  humidity.  The  rapidity 
of  t.he  disease  in  its  tendency  to  a fatal  termination, 
was  sometimes  truly  astonishing,  though  in  some  few 
instances  the  patients  lingered  out  from  ten  to  fourteen 
days,  and  now  and  then  cases  are  reported  as  having 
continued  twenty  and  even  thirty  days,  although  in 
a number  of  instances  it  did  not  last  as  many  hours; 
sphacelus  occurring  thus  suddenly  and  the  patient  sink- 
ing immediately. 

Sometimes  the  upper,  more  frequently  the  lower  jaw, 
and  occasionally  both,  seemed  to  be  involved  from  the 
commencement,  and  an  entire  necrosis  was  very  early 
found  to  exist.  “ The  disease.”  according  to  Dr.  Fran- 
cis, “ frequently  began  about  the  edge  of  the  gums,  in 
contact  with  the  incisor&s  teeth.  Tlie  soft  parts  be- 
came tumid  with  hardness  and  pain.  .Sometimes  the 
greater  part  of  the  side  of  the  face  assumed  an  erythe- 
uiatous  aspect,  without  any  premonitory  signs;  and 
this  was  subsequently  marked  by  spots  of  a dark  pur- 
ple or  brown  colour.  Sometimes  the  part  speedily  be- 
came sphacelated,  the  sloughing  commenced,  and 
emitted  a fetid  exhalation.  The  tongue  was  loaded 
with  a foul  sordes,  and  the  breath  exceedingly  offen- 
sive, when  coma  would  sujtervene,  and  death  suddenly 
ensue.  In  other  instances,  the  teeth  would  become 
loose  in  tlie  commencement  of  the  disease,  and  not  un- 
frciiuently  drop  out  on  the  slightest  exertion  or  motion 
of  the  jaw.  The  necrosi.s  would,  in  some  cases,  in- 
volve full  one  side  of  the  jaw,  and  the  ulceration  ex- 
tend eiiually  over  the  soft  parts,  and  affect  the  alw 
nasi,  the  nose  itself,  and  the  cheek  nearly  to  the  orbit 


CAS 


CAS 


241 


of  the  eye.  Very  soon  the  sphacelated  flesh  fell  in, 
and  the  internal  structure  of  the  mouth  would  be  ex- 
posed, while  the  lips  would  become  tumid,  painful, 
and  discoloured.  These  morbid  changes,  to  greater  or 
less  extent,  were  found  to  involve  very  speedily  the 
teeth,  alveolae,  mucous  surfaces,  and  cheeks.’’ 

In  the  account  of  this  caries  as  it  occurred  in  the 
Philadelphia  Alms-House  as  furnished  by  Dr.  Coates, 
of  that  city,  we  have  in  many  respects  a similar  narra- 
tion of  symptoms.  At  one  time,  when  the  disorder 
was  at  its  height,  threatening  several  patients  with  de- 
struction, Dr.  C.  found  upwards  of  70  children  out  of 
a population  of  240  were  more  or  less  afflicted  by  the 
ulcerations  characteristic  of  this  disease. 

I have  dwelt  thus  much  on  this  species  of  caries, 
because  our  knowledge  on  the  subject  is  chiefly  derived 
from  our  own  physicians  and  surgeons,  while  the  re- 
ports of  foreign  hospitals  are  almost  silent  on  the 
subject. 

The  treatment  of  this  disease  as  most  generally  re- 
commended is,  after  paying  due  attention  to  cleansing 
the  primae  vise,  to  rely  on  bark,  wine,  serpen taria,  and 
the  mineral  acids,  while  the  yest  and  bark  poultice  is 
constantly  applied  to  the  parts,  as  in  other  gangrenous 
affections.  But  the  external  means  most  useful  was 
found  to  be  a weak  solution  of  the  sulphate  of  copper 
applied  as  a wash  to  the  ulcerated  parts. — (See  Sher- 
rill on  the  Diseases  of  Dutchess  County.  Hall  in 
Edin.  Med.  and  Surg.  Journal,  vol.  15.  Coates  in  the 
Amer.  Med.  and  SuTg.  Journal;  and  Francis's  Let- 
ter on  Caries  of  the  Jaws  of  Children.) 

For  farther  valuable  information,  see  Cases  of  the  ex- 
cision of  Carioits  Joints,  by  H.  Park,  surgeon  in  the 
Liverpool  Hospital,  and  P.  F.  Moreau,  de  Bar-sur-Or 
mar,  M.  D.  de  l^ecole  de  Paris.  With  Observations  by 
James  Jeffrey,  M.  D.  Professor  offAnatomy  and  Sur- 
gery in  the  College  of  Glasgow. — Reese.) 

CASTRATION.  The  operation  of  removing  a tes- 
ticle. For  an  account  of  the  cases  rendering  this 
measure  necessary,  see  Testicle,  Diseases  of.  The 
manner  of  operating  is  as  follows  ; The  patient  being 
laid  on  a table  of  convenient  height,  the  integuments 
covering  the  spermatic  vessels  in  the  groin  are  to  be 
divided.  This  incision  should  begin,  as  nearly  as  pas- 
sible, opposite  to  the  opening  in  the  abdominal  muscle, 
and  should  be  continued  to  the  lower  part  of  the  scrotum. 

The  manner  of  beginning  this  incision  is  differently 
described  by  writers  : some  of  them  advLsing  that  the 
skin  be  held  up  by  an  assistant ; others  that  the  knife 
be  used  perpendicularly  in  this  as  in  other  parts.  The 
latter  mode  is  generally  preferred  by  English  surgeons. 
The  length  of  the  division  is  a more  important  con- 
sideration. A smalt  wound  will  indeed  serve  to  lay 
bare  the  spermatic  cord  ; but  it  will  not  permit  the 
operator  to  do  what  is  necessary  afterward  xvith  dex- 
terity or  facility ; and  as  the  scrotum  must  either,  at 
first  or  at  last,  be  divided  nearly  to  the  bottom,  it  had 
better  be  done  at  first.  The  spermatic  cord  is  next 
to  be  laid  bare  by  another  incision,  that  xvill  divide  the 
externa  pudendal  artery,  the  bleeding  from  which  may 
be  checked  by  an  assistant  putting  his  finger  on  it. 
The  spermatic  cord  having  been  detached  from  its 
surrounding  connexions,  the  operator,  with  his  finger 
and  thumb,  separating  the  blood-ves.sels  from  the-vas 
deferens,  must  pass  a ligature  between  them,  and 
having  tied  the  former  only,  must  cut  through  the 
whole  cord,  at  a quarter  or  half  inch  distance  from 
the  said  ligature,  according  as  the  state  of  the  process 
and  testicle  will  admit.  This  done,  he  is  then,  with 
the  same  knife  with  which  he  has  performed  the  for- 
mer part  of  the  operation,  to  dissect  the  testicle  out 
from  its  connexion  with  the  scrotum:  the  loose  tex- 
ture of  the  connecting  cellular  substance,  the  previous 
separation  of  the  testicle  from  the  spermatic  cord, 
and  the  help  of  an  assistant  to  hold  up  the  lips  of  the 
wound,  will  enable  him  to  do  this  xvith  very  little  pain 
to  the  patient,  and  great  facility  to  himself. 

Hesiiles  the  facility  which  a free  incision  in  the 
s'rotum  affords  to  removing  the  testicle,  the  division 
being  carried  quite  to  its  lower  part,  prevents  the  ac- 
cumulation of  matter  there,  which  would  seriously  re- 
tard the  healing  of  the  wound. 

.Mr.  S.  Sharji  once  castrated  a man,  vdiose  testicle 
weighed  above  three  pounds,  and  some  of  the  ves.sels 
were  so  varicose  and  dilated,  as  nearly  to  equal  the 
size  of  the  humeral  artery. — {Operalums  of  Surgery, 
chap.  10.) 

Vol.  I.— Q 


Desault  first  divides  the  cord,  and,  holding  its  upper 
end  between  the  index  finger  and  thumb  of  his  left 
hand,  he  then  takes  up  the  arteries  with  a pair  of  for- 
ceps, and  they  are  immediately  tied  by  an  assistant. — 
{(Euvres  Chir.  par  Bichat,  t.  2.)  The  spermatic  artery 
will  be  found  in  the  anterior  part  of  the  cord  ; and,  as 
soon  as  this  vessel  has  been  tied,  the  surgeon  is  to  se- 
cure another,  which  accomjianies  the  vas  deferens,  the 
latter  part  being  carefully  excluded  from  the  ligature. 
— (See  Sir  A.  Cooper’s  Lectures,  ^c.  vol.  2,  p.  161.) 

The  spermatic  artery,  and  any  scrotal  vessels  which 
require  to  be  taken  up,  should  be  tied  with  fine  silk 
ligatures,  as  recommended  by  my  friend  Mr.  Law- 
rence.— (See  Med.  Chir.  Trans,  vol.  6,  p.  197.) 

Pott  used  to  fill  the  cavity  of  the  wound  with  lint . 
but  Desault,  and  all  the  modern  surgeons  of  this 
country,  bring  the  edges  of  the  wound  together,  and 
endeavour  to  heal  as  much  of  it  as  possible  by  the 
first  intention.  Some,  with  this  view,  use  sutures  and 
sticking  plaster  ; others  only  the  latter,  aided  with 
compresses  and  a T bandage. 

The  plan  of  dressing  adopted  by  Mr.  Laxvrence, 
consists  in  retaining  the  edges  of  the  skin  in  apposi- 
tion with  two  or  three  sutures,  and  then  applying  a 
narrow  strip  of  simple  dressing.  A folded  cloth,  kept 
constantly  damp,  is  also  laid  over  the  wound. — (Med. 
Chir.  Trans,  vol.  6,  loc.  cit.)  Sir  A.  Cooper  also  em- 
ploys two  sutures  : one  opposite  the  end  of  the  cord  ; 
the  other  at  the  mid-point  between  the  first  suture 
and  the  termination  of  the  incision.— (Lecfwrc.y,  et  c. 
vol.%  p.  161.)  With  resjject  to  sutures,  unless  the 
sticking  plaster  be  wet,  so  as  to  loosen  it,  some  doubt 
may  be  entertained  of  their  utility ; and  I have  re- 
marked, that  considerable  irritation  and  an  extensive 
erysipelas  sometimes  follow  their  employment.  Roux 
also  noticed  their  bad  effects  in  a case  which  occurred 
during  his  visit  to  this  country.— (See  Parallele  de  la 
Chirurgie  Angloise  avec  la  Chirurgie  Francoise,  p.  121 .) 

It  is  somewhat  extraordinary,  that  Larrey  should 
condemn  the  plan  of  uniting  the  wound,  though,  in- 
deed, xve  cannot  be  surprised  at  his  delivering  this  ad- 
vice, when  we  recollect,  that  he  disapprox'es  of  healing 
the  stump  after  amputation  by  the  first  intention. 
The  passage  relative  to  dressing  the  wound  after  cas- 
tration, seems  to  be  a contrast  to  the  sensible  observa- 
tion which  generally  prevail  in  this  author’s  publica- 
tion : “ /Z  we  faut  pas  riunir  les  herds  de  la  plaie, 
comme  I'ont  conseilU  quelques  practiciens,  parcequ'ils 
doivent  suppurer,  et  que  la  suppuration  est  nices- 
saire  'f"—(Mim.  de  Chirurgie  Militaire,  t.  3,  p.  426.) 

Larrey  is  joined  by  Roux  and  the  rest  of  the  French 
surgeons  on  this  point.  The  main  reasons  stated  by 
the  latter  writer  for  not  bringing  the  wound  together 
are,  that  secondary  hemorrhage  cannot  be  well  guarded 
against,  except  by  filling  the  part  with  charpie ; that 
the  redundance  and  looseness  of  the  skin  render  it 
difficult  to  keep  its  edges  in  exact  contact,  without  re- 
moving a portion  of  it,  and  using  sutures,  which  are 
objectionable;  and  that  suppuration  cannot  commonly 
be  prevented,  because  there  is  a large  quantity  ofloo.se 
cellular  substance  in  the  wound,  which  substance 
readily  suppurates.— (ParaZ/^Ze  de  la  Chirurgie  An- 
gloise avec  la  Chirurgie  Francoise,  <S~c.  p.  119,  Ac.) 
By  applying  cold  water  and  gentle  compression  to  the 
part,  I believe,  however,  such  hemorrhage  may  gene- 
rally be  averted,  and  the  union  of  the  wound  materially 
expedited.  As  a judicious  writer  observes,  “ In  the 
London  ho.spitals,  complete  union  by  the  first  inten- 
tion is  seldom  or  never  accomplished : yet  by  attemjit- 
ing  it  the  wound  is  much  diminished,  and  the  cure  of 
it  rarely  delayed  later  than  three  or  four  weeks ; 
whereas  the  wound  when  stuffed  with  lint  is  usually 
not  healed  in  less  than  seven  or  eight  weeks.” — (See 
Sketches  of  the  Medical  Schools  of  Paris,  by  J.  Cross, 
p.  144.) 

Sometimes  one  or  more  vessels  begin  to  bleed  soon 
after  the  patient  is  in  bed,  although  they  effused  no 
blood  just  after  the  removal  of  the  te.sticle.  Keeping 
the  dressings  and  scrotum  continually  wet  with  the 
cold  saturnine  lotion  very  often  suffices  for  the  pre- 
vention and  suppression  of  such  hemorrhage:  if  not, 
the  wound  must  be  opened  again  and  the  vessels  tied. 

J.  L.  Petit  made  some  useful  remarks  on  this  opera- 
tion. I’he  vessels  of  the  scrotum,  says  he.  are  not 
the  only  ones  which  may  be  the  source  of  hemorrhage. 
Anatomists  know  that  the  septum  which  divides  this 
jiart  into  two  cavities,  is  furnished  with  an  artery  that 


242 


CASTRATION. 


is  not  censidterable,  but  which  becomes  materially  en- 
larged in  the  case  of  a sarcocele  or  other  tumour.  It 
is  sometimes  so  considerable  that  it  causes  a bleeding, 
which  makes  a surgeon  who  has  had  no  previous 
opportunity  of  seeing  the  occurrence  exceedingly  un- 
easy. Such  hemorrhage,  says  Petit,  may  be  easily 
suppressed  with  a ligature  ; and  lie  assures  us  that  he 
has  seen  a surgeon  dress  the  patient  three  times  with- 
out ever  suspecting  that  the  bleeding  for  which  the  ap- 
plications were  a third  time  removed,  proceeded  from 
this  anery.— {Petit,  Traite  des  Maladies  Chir.  t.  2,  p. 
524,  525.) 

The  same  experienced  and  able  surgeon  also  ac- 
quaints us,  that  he  has  more  than  once  extricated  from 
trouble  persons  who  knew  not  how  to  stop  the  bleed- 
ing after  the  operation.  He  has  seen  some  of  them 
take  off  the  dressings  several  times  without  discover- 
ing the  wounded  vessel.  As  they  imagined  that  the 
only  hemorrhage  which  could  follow  castration  must 
be  from  the  spermatic  artery,  they  contented  them- 
selves with  examining  the  ligature  on  the  cord  and  in- 
creasing the  compression,  in  order  to  stop  the  bleed- 
ing ; but  finding  their  attempts  fail,  they  were  com- 
pelled to  seek  assistance.  On  being  sent  for,  M.  Petit 
found  that  the  blood  did  not  issue  from  the  cord,  but 
from  a small  artery  under  the  skin,  at  the  inferior 
angle  of  the  wound.  He  easily  stopped  the  hemor- 
rhage, and  explained,  not  only  that  the  cord  had  no 
share  in  the  accident,  but  tliat  it  is  generally  suspected 
without  foundation.  Indeed,  says  he,  the  least  con- 
striction will  stop  the  bleeihng  from  the  spermatic  ar- 
tery ; it  is  not  essential  to  tie  it  :■ — “ I myself  am  con- 
tent with  cutting  the  cord,  so  as  to  leave  it  rather 
longer  than  usual,  and  apply  no  ligature  i I press  it 
against  the  os  pubis,  near  the  ring  of  the  external 
oblique ; I lay  over  it  a linen  compress,  half  as  thick 
as  the  finger,  two  inches  in  length,  suliiciently  broad 
to  cover  the  part,  and  yet  narrow  enough  to  be  placed 
entirely  within  the  wound.  Over  this  compress  I put 
dossils  of  lint ; I fill  the  scrotum  with  plain  lint,  and 
then  cover  the  whole  with  compresses,  observing  to 
put  one  which  is  thicker  than  the  rest  above  the  pubes, 
immediately  over  that  which  I have  laid  upon  the  cord, 
so  that  the  bandage  may  make  moderate  pressure  on 
this  last  part,  yet  sufficient  to  prevent  bleeding.”— (.Op. 
cit.  p.  526,  527.) 

This  quotation  is  not  made  with  the  view  of  inducing 
any  modern  operator  to  imitate  the  preceding  practice, 
which,  indeed,  the  advantages  of  the  present  mode  of 
dressing  the  wound  entirely  forbid,  as  well  as  the 
greater  security  of  the  ligature ; but  the  passage  is 
cited  for  the  express  purpose  of  impressing  on  the 
mind  of  the  young  surgeon,  that  in  general,  after  the 
removal  of  a diseased  testis,  there  is  more  risk  of  bleed- 
ing from  the  vessels  of  the  scrotum  than  those  of  the 
cord.  I have  never  seen  hemorrhage  from  the  sper- 
matic artery  give  trouble  after  the  operation,  but  have 
often  known  surgeons  obliged  to  take  off  the  dressings 
on  account  of  bleeding  in  the  scrotum. 

I believe  the  most  likely  way  of  avoiding  this  dis- 
agreeable occurrence  is  to  imitate  Mr.  Tyrrell,  “ always 
to  allow  the  patient  to  become  warm  in  bed  before  the 
dressing  is  completed for,  until  this  period,  it  is  not 
known  what  vessels  in  the  scrotum  will  bleed.— (See 
Sir  A.  Cooper's  Lectures,  S,-c.  vol.  2,  p.  161.) 

In  every  operation  in  which  a considerable  portion 
of  skin  is  to  be  divided,  and  particularly  in  this  and  in 
the  amputation  of  women’s  breasts,  it  should  always 
be  remembered  that,  as  the  division  of  the  skin  (the 
general  organ  of  sensation)  is  the  most  acute  and 
painful  part  of  what  Ls  done  by  the  knife,  it  cannot  be 
done  too  quickly,  and  should  always  be  done  at  once : 
the  scrotum  should  constantly  be  divided  to  the  bot- 
tom, and  the  circular  incision  in  the  skin  of  a breast 
always  m.ade  quite  round,  before  any  thing  else  be 
thought  of.  If  this  he  not  executed  properly  and  per- 
fectly, the  operation  will  he  attended  with  a great  deal 
of  pain  which  might  be  avoided,  and  the  operator  will 
be  justly  blameable.— (Pott.) 

When  the  diseased  testicle  is  exceedingly  large,  or  a 
part  of  the  scrotum  is  diseased,  the  surgeon  should 
take  care  to  remove  the  redundant  or  morbid  iwrtion 
of  the  skin,  by  including  the  piece  which  he  designs  to 
take  away  within  two  long  elliptical  incisions,  which 
are  to  meet  at  the  upper  and  lower  part  of  the  swell- 
ing. lu  this  manner,  as  Mr.  Samuel  Sharpe  lias  ob- 
served, the  hemorrhage  will  bo  much  less,  the  opera- 


tion greatly  shortened,  the  sloughing  of  the  distended 
skin  prevented,  and  the  recurrence  of  cancerous  dis- 
ease rendered  less  likely.— (See  Treatise  of  the  Opera-' 
tions,  chap.  10.) 

Mr.  Lawrence  concurs  with  M.  de  la  Faye  in  think 
ing  it  best  always  to  remove  a large  piece  of  the  scro- 
tum with  the  testicle,  bj*  which  means  the  surface  of 
the  wound  is  lessened. — (See  Med.  Chir.  Trans,  vol.  6^ 
p.  196.)  Sir  Astley  Cooper  approves  of  the  practice 
when  inflammation  has  rendered  the  testicle  adheren* 
to  the  scrotum,  as  being  preferable  to  a tedious  and 
painful  dissection  for  the  separation  of  the  parts.— (Se* 
Lectures,  Ac.  vol.  2,  p.  160.) 

If  the  tumour  be  of  a pyriform  figure,  perfectly 
smooth,  and  equal  in  its  surface  and  free  from  pain, 
notwithstanding  the  degree  of  hardness  mdy  be  great, 
and  the  surgeon  may,  in  his  own  opinion,  be  clear 
that  the  tumour  is  not  produced  by  water,  but  is 
a true  scirrhus,  it  is  an  excellent  rule  to  make  a small 
opening  through  the  scrotum  into  the  forepart  of  the 
tunica  vaginalis,  previously  to  the  commencement  of 
the  operation,  as  recommended  by  Mr.  Pott,  so  that  if 
the  case  be  one  of  water  or  blood,  its  nature  may  be 
ascertained,  and  perhaps  the  testicle  saved.  “My 
reason  for  giving  this  advice  (says  Mr.  Pott)  is,  that  I 
was  once  so  deceived  by  every  apparent  circumstance 
of  a true,  equal,  indolent  scirrhus,  that  I removed 
a testicle,  which  proved  upon  examination  to  be  so 
little  diseased,  that  had  I pierced  it  with  a trocar 
previous  to  the  operation,  I could,  and  certainly  should 
have  preserved  it.”  The  best  way  is  to  make  a small 
opening  with  a lancet  or  knife  ; and  not  to  introduce 
a trocar  in  the  manner  advis^  by  Pott,  because  it 
would  be  liighly  censurable  to  injure  the  testicle,  and 
put  the  patient  to  unnecessary  pain,^  even  though 
that  organ  might  be  found  diseased,  and  to  require 
removal. 

It  is  well  known  that  the  agony  of  tying  the  cord  is^ 
immensely  increased  by  including  the  vas  deferens  ; 
and  as  no  good  results  from  so  doing,  the  practice  de- 
serves the  severest  reprobation,  notwithstanding  (he 
opposite  opinion  of  Mr.  Pearson  (Pract.  Obs.  on  Can-' 
cer,  p.  74),  and  the  writer  of  the  article  Castration  in 
Rees’s  Cyclopaedia. 

Cases  are  even  recorded  in  which  the  inclusion  of 
the  whole  of  the  spermatic  cord  appears  to  have  occa- 
sioned severe  and  perilous  consequences,  and  these  in 
so  great  a degree,  that  it  was  found-  necessary  to  cut 
and  remove  the  ligature.  Sometimes,  says  Petit,  pa- 
tients on  whom  castration  has  been  performed,  suffer 
more  or  less  acute  pain  in  the  kidneys  t’he  suffering 
often  becomes  insupportable  and  highly  dangerous,  the 
belly  being  swelled,  tense,  and  painful;  the  patient 
being  affected  with  syncopes  and  attections  of  the. 
heart,  sometimes  with  vomiting  and  a retention  of 
urine : lastly,  a universal  inflammation  of  the  belly,, 
and  a violent  fever,  accompanied  with  delirium,  are 
occasionally  the  fatal  consequences  of  this  operation.. 
Petit  was  required  to  visit  a patient  who  had  been  in 
this  deplorable  state  for  twenty-four  hours,  after  hav- 
ing suffered  castration,  and  this  distinguished  surgeon 
could  impute  the  sudden  and  violent  symptoms  to  no- 
thing except  the  ligature  on  the  spermatic  cord ; con- 
sequently, he  advised  the  ligature  to  be  removed.  The 
patient  received  some  slight  relief  from  this  step,  and 
after  having  been  bled  twice  within  a short  space  of 
time,  he  found  himself  a great  deal  better ; but  as  the 
dressings  became  wet  with  blood,  apprehension  of 
bleeding  began  to  be  entertained.  Petit  therefore  had 
recourse  to  moderate  compression  of  the  cord,  in  the 
manner  above  related.  No  hemorrhage  ensued;  the 
case  afterward  went  on  well ; and  the  patient  recovered 
sooner  than  was  expected.— (TVaffe  des  Maladies  Chir. 
t.  2,  p.  527,  528.) 

In  the  operation  of  removing  a testicle,,  one  caution 
seems  particularly  necessary,  viz.  if  the  cord  should 
be  at  all  enlarged,  the  surgeon  ought  carefully  to  ex- 
amine whether  the  augmentation  of  its  size  may  not 
be  owing  to  a portion  of  intestine  or  omentum  that  is 
contained  within  it. — {Sabatier,  Medecine  Operatoire, 
t.  I,  p.  332,  idit.  1.)  In  one  case  of  extiiqiation  of  the 
testicle,  “ after  the  operation  was  completed  and  the 
wound  drcssiHl,  the  imtient  being  seized  with  a fit  ol 
coughing,  to  the  astonishment  and  dismay  of  the  sur- 
geon, the  dressings  were  forced  off  by  a protrusion  of 
several  convolutions  of  small  intestines ; from  this  it 
was  proved  that  the  patient  had  had  a hernia ; but  the 


CAS 


CAT 


243 


diseased  enlargement  of  the  testicle  had  acted  as  a 
truss,  and  prevented  the  rupture  from  coming  down.” 
— (See  Operative  Surgery,  by  C.  Bell,  vol.  1,  p,  226 ; 
also  p.  224.) 

There  is  another  circumstance  which  merits  atten- 
tion in  the  performance  of  this  operation  : when  there 
are  reasons  which  oblige  us  to  divide  the  cord  high  up, 
and  this  part  has  not  been  tied  before  such  division  is 
made,  it  may  be  drawn  up  by  the  cremaster  within  the 
abdominal  ring,  and  some  difficulty  may  be  experienced 
in  securing  the  spermatic  arteries.  Mr.  B.  Bell  saw 
this  happen  twice,  and  the  patients  lost  their  lives 
from  hemorrhage.  Hence,  when  it  is  necessary  to  cut 
through  the  cord  near  the  ring,  perhaps  it  may  be  best 
always  to  apply  the  ligature  first,  observing  not  to  in- 
clude the  vas  deferens.  However,  were  the  cord,  pre- 
viorusly  to  the  application  of  ligatures  to  its  arteries,  to 
happen  in  any  instance  to  be  drawn  up  within  the 
ring,  a surgeon  would  be  guilty  of  most  supine  neglect 
to  let  the  patient  die  of  bleeding  ; for,  as  Mr.  C.  Bell 
has  remarked,  we  may  follow  the  cord  vvith  perfect 
safety  even  to  the  origin  of  the  cremaster,  which  pulls 
it  up,  if  attention  be  paid  to  the  course  of  the  cord, 
obliquely  upwards  and  outwards  within  the  inguinal 
canal.  Mr.  Cline  was  present  at  the  removal  of  a tes- 
ticle, after  which  the  spermatic  could  not  be  found : he 
therefore  slit  up  the  inguinal  canal,  and  brought  it  into 
view  again.  In  order  to  avoid  this  inconvenience,  Sir 
Astley  Cooper  approves  of  the  practice  of  passing  a 
temporary  ligature  through  the  cord  as  soon  as  it  has 
been  exposed. — (See  Lectures,  S,-c.  vol.  2,  p.  61.) 

It  sometimes  happens  that  abscesses  form  in  the  re- 
mains of  the  spermatic  cord  after  the  operation  of  cas- 
tration. Such  suppuration  may  frequently  be  pre- 
vented by  the  employment  of  bleeding  directly  after  the 
operation,  and  repeating  the  evacuation  on  the  first  ac- 
cess of  the  inflammation  of  the  part  concerned.  Be- 
sides venesection,  low  diet,  neutral  salts,  diluents,  &c. 
are  indicated,  and  the  part  should  be  covered  with  an 
emollient  poultice.  When  pus  is  completely  formed, 
the  abscess  should  be  opened. 

When  the  symptoms  subside,  says  Petit,  they  who 
are  little  versed  in  practice  are  apt  to  fancy  the  abscess 
cured ; but  they  are  sometimes  mistaken.  The  matter 
is  not  always  sufficiently  near  the  surface  to  be  felt, 
and  in  this  circumstance  the  aponeurosis  of  the  exter- 
nal oblique  muscle  is  so  tense,  that  it  hinders  the  fluc- 
tuation from  being  distinctly  felt.  Indeed,  as  the  mat- 
ter finds  a lodgement  under  this  aponeurosis,  fbllowing 
the  course  of  the  sheath  of  the  vessels,  there  is  reason 
to  fear  that  it  may  lead  to  additional  inflammation  and 
suppuration,  and  extend  up  the  duplicature  of  the  pe- 
ritoneum to  the  loins.  In  these  cases,  the  abscess 
occasionally  makes  its  way  outwards,  and  the  dress- 
ings are  inundated  with  matter  ; but  if  this  should  not 
happen  quickly,  the  sooner  the  tumour  is  opened  the 
better.  The  opening  ought  unquestionably  to  be  made 
wherever  the  fluctuation  is  plainly  distinguishable; 
but,  as  Petit  has  remarked,  the  tension  of  the  aponeu- 
rosis of  the  external  oblique  muscle  makes  the  undnla- 
. tion  of  the  matter  less  readily  and  plainly  perceptible 
than  if  the  abscess  were  only  in  the  fat.  Therefore,  in 
order  to  avoid  mistake,  this  surgeon  advises  us  to  feel 
at  the  abdominal  ring,  as  in  general  the  pus  can  be 
more  readily  felt  here  than  in  other  situations.  If  matter 
is  felt  and  no  resistance  is  experienced.  Petit  advises  the 
finger  to  be  pa.ssed  into  this  opening  ; and  in  case  the 
seat  of  the  abscess  should  be  found  to  be  under  the 
aponeurosis,  we  are  recommended  to  divide  with  a 
probe-pointed  bistoury,  the  skin  and  fat  immediately 
covering  the  ring ; then  to  separate  the  fibres  of  this 
aperture,  as  it  were,  without  cutting  them.— (See  TraiU 
des  Maladies  Chir.  t.  2,  p.  529,  530.)  No  doubt  this 
surgeon  meant  that  the  division  of  the  tendon  ought  to 
be  made  in  the  direction  of  its  fibres.  A few  years 
ago,  the  operation  for  a bubonocele  was  performed,  and 
a-s  the  testicle  was  found  di.seased,  the  surgeon  made  a 
complete  division  of  the  spermatic  cord,  tied  the  sper- 
matic arteries,  and  tlien  left  the  testicle  in  its  natural 
situation.  After  a time,  the  absorbents  had  diminished 
the  part  to  a very  small,  inconsiderable  tumour.— (//. 
W einhold,  in  Journ.  der  Bract.  Heilkunde  von  C.  W. 
Huf eland  und  K.  Himley,  1812,  zehntes  stuck,  p.  112.) 
This  ca.se  merits  attention,  because  it  is  the  first  in- 
stance, I believe,  in  which  such  practice  was  ever 
l.'ied.  Subsequently  the  fbllowing  work  has  been  pub- 
lished; Nouvelle  Methods  de  trailer  le  Sarcocele,  saus 

Q2 


avoir  recours  d V Extirpation  du  Testicule ; par  C.  Th. 
Maunoir,  8vo.  Geneve,  1820.  The  new  plan  consists 
in  dividing  and  tying  the  spermatic  arteries,  and 
leaving  the  rest  of  the  cord  and  the  testis  undisturbed. 

When  disease,  not  merely  an  cedematous  swelling, 
extends  far  up  the  cord,  Pott,  and  the  best  surgeons 
of  the  present  day,  consider  the  operation  of  castra- 
tion as  too  late.  In  such  cases,  Lisfranc  has  seen  Du- 
bois pull  down  the  cord  and  then  divide  it,  and  Baron 
Dupuytren  cut  up  the  inguinal  canal  to  the  internal 
ring ; but  all  the  patients  died.— (C.  Averil,  Operative 
Surgery,  p.  103,  Lond.  1823.) 

Consult  Le  Dran’s  Operations.  Sharp’s  Operations 
of  Surgery,  chap.  10.  Pott  on  the  Hydrocele,  & c.  Sa- 
batier, Deda  Med.  Oper.  tom.  1.  Bertrandi,  Traite  des 
Oper.  de  Chirurgie,  chap.  11.  CEuvres  Chirurgicales 
de  Desault,  par  Bichat,  torn.  2,  p.  449.  Larrey,  Me- 
moires  de  Ohirurgie  Militaire,  tom.  3,  p.  423,  <S-c.  Pear- 
son on  Cancerous  Complaints.  J.  L.  Petit,  Traite  des 
Maladies  Chirurgicale,  tom.  2,  p.  519,  £rc.  C.  Bell’s 
Operative  Surgery,  vol.  1.  Richerand’s  Nosographie 
Chirurgicale,  tom.  4,  p.  281,  &rc.  ed.  2,  ^c.  A long 
account  of  the  particular  sentiments  of  several  emi- 
nent surgeons  is  to  be  found  in  Rees’s  Cyclopaedia,  art. 
Castration.  Roux,  Parallile  de  la  Chirurgie  An- 
gloise  avec  la  Chirurgie  Francoise,  p.  1 19,  Src.  Law- 
rence, in  Med.  Chir.  Trans,  vol.  6,  p.  196,  197. 
Sketches  of  the  Medical  Schools  of  Paris,  by  J.  Cross, 
p.  139,  (S'C.  Sir  A.  Cooper’s  Lectures  on  the  Prmciples 
and  Practice  of  Surgery,  vol.  2,  p.  159,  8vo.  London, 
1825. 

CATAPLASMA  ACETI.  Made  by  mixing  a suffi- 
cient quantity  of  vinegar  with  either  oatmeal,  linseed 
meal,  or  bread-crumb.  When  linseed  is  employed,  it  is 
best  to  add  a little  oatmeal  or  bread-crumb,  in  order  to 
keep  the  poultice  from  becoming  hard.  The  vinegar 
poultice  is  generally  applied  cold,  and  is  principally 
used  in  cases  of  bruises  and  sprains. 

CATAPLASMA  ACETOCiE.  Sorrel  poultice.  R. 
Acetosce  ftj.  To  be  beaten  in  a mortar  into  a pulp. 

CATAPLASMA  ALUMINIS.  Made  by  stirring  the 
whites  of  two  eggs  with  a bit  of  alum,  till  they  are 
coagulated.  In  cases  of  chronic  and  purulent  oph- 
thalmy,  it  has  been  applied  to  the  eye,  between  two  bits 
of  rag,  and  it  has  been  praised  as  a good  application  to 
chilblains  which  are  not  broken. 

CATAPLASMA  BYNES.  (Malt.)  B.  Farinae  bynes. 
Spumae  cerevisiae,  q.  s.  This  is  applied  to  cases  of 
gangrene  and  ill-conditioned  extending  sores.  It  is 
used  in  instances  similar  to  those  in  whish  the  cata- 
plasma  fermenti  is  employed,  and,  by  giving  out  carbonic 
acid  gas,  is  supposed  to  operate  as  a gentle  stimulus, 
and  as  a corrector  of  fetid  effluvia. 

CATAPLASMA  CARBONIS.  Made  by  mixing  pow- 
dered charcoal  with  linseed  meal  and  warm  water,  and 
is  applied  to  improve  the  condition  of  several  kinds  of 
unhealthy  sores. 

CATAPLASMA  CEREVISIB3.  Made  by  stirring 
some  oatmeal  or  linseed  meal  in  strong  beer  grounds. 
It  is  used  in  the  same  cases  as  the  cataplasma  fer- 
menti and  cataplasma  bynes. 

CATAPLASMA  CONH  VEL  CICUTiE.  R.  Her- 
bae  cicutae  exfoliatae  5 ij.  Aqiiae  fontanae  Ibij.  To  be 
boiled  till  only  a pint  remains,  when  as  much  linseed 
meal  as  necessary  is  to  be  added. 

Hemlock  poultice  is  an  excellent  application  to  many 
cancerous  and  scrofulous  ulcers,  and  other  malignant 
sores  ; firequently  producing  a great  diminution  of  the 
pain  of  such  diseases,  and  improving  their  appearance. 
Justamond  preferred  the  fresh  herb,  bruised, 

CATAPLASMA  DAUCI.  R.  Radicis  dauci  re- 
centis  ftj.  Some  bruise  the  carrots  in  a mortar  into  a 
pulp ; while  others  recommend  the  carrots  to  be  first 
boiled.  Carrot  poultice  is  employed  as  an  application 
to  ulcerated  cancers,  scrofulous  sores  of  an  irritable 
kind,  and  various  inveterate  malignant  ulcers. 

CATAPLASMA  DIGITALIS.  Made  by  mixing  lin- 
seed meal  with  a decoction  of  the  leaves  of  the  plant. 
It  is  said  to  have  great  sedative  virtues,  to  be  adapted 
to  the  same  cases  as  the  cicuta  poultice,  and  even 'to  be 
more  beneficial. 

CATAPLASMA  FARINACEUM.  The  bread  and 
milk  imultice,  made  by  putting  some  slices  of  bread- 
crumb in  milk,  and  letting  them  gently  simmer  over  the 
fire  in  a saucepan,  till  they  are  j)roperly  softened.  The 
mass  is  then  to  be  mixed  and  stirred  about  with  a 
spoon,  and  spread  on  linen,  in  order  to  be  a])plied.  I tlu 


244 


CAT 


CAT 


poultice,  which  is  of  the  emollient  kind,  is  with  many 
persons  the  common  one  for  all  ordinary  purposes. 
Most  surgeons,  however,  employ,  instead  of  it,  the  lin- 
seed poultice,  which  is  cheaper,  more  readily  made, 
not  apt  to  turn  sour,  and,  in  all  common  cases,  quite 
as  advantageous  in  everv  respect. 

CATAPLASMA  FERMENTI.  Fermenting  poul- 
tice. U . Farinae  tritici  Ibj.  Cereoisiae  sjmmce,  Yest 
dtcfft,  tbss.  These  are  to  be  mixed  together  and  ex- 
posed to  a moderate  heat,  till  the  effervescence  begins. 
In  cases  of  sloughing,  and  many  ill-conditioned  ulcers, 
this  is  an  application  of  great  repute. 

CATAPLASMA  LUST.  Linseed  poultice.  R-  Fa- 
rin(£  Uni  Ibss.  Aq.  ferventis  Ibiss.  The  powder  is 
to  be  gradually  sprinkled  into  ihe  hot  water,  while 
they  are  quickly  blended  together  with  a spoon. 

This  is  the  best  and  most  convenient  of  all  the 
emollient  poultices  for  common  cases,  and  it  has  nearly 
superseded  that  of  bread  and  milk,  which  was  Ibr- 
merly  much  more  frequently  employed. 

.Mr.  Hunter  speaks  in  the  following  terms  of  the  lin- 
seed poultice  and  its  uses. 

Poultices  are  commonly  made  too  thin  , by  which 
means,  the  least  pressure,  or  their  own  gravity,  re- 
moves them  from  the  part:  they  should  be  thick 
enough  to  support  a certain  form  when  applied. 

They  are  generally  made  of  stale  bread  and  milk. 
This  composition,  in  general,  makes  too  brittle  an  ap- 
plication ; it  breaks  easily  into  different  portions  from 
the  least  motion,  and  ollen  leaves  some  part  of  the 
wound  uncovered,  which  is  frustrating  the  first  inten- 
tion. 

The  poultice  which  makes  the  best  application,  and 
continues  most  nearly  the  same  between  each  dress- 
ing, is  that  formed  of* the  meal  of  linseed;  it  is  made 
at  once,  and  when  applied,  it  keeps  always  in  one 
mass. 

The  kind  of  wound  to  which  the  above  applica- 
tion is  best  adapted,  is  a wound  made  in  a sound  part, 
which  we  intend  shall  heal  by  granulation.  The  same 
application  is  equally  proper  when  parts  are  deprived 
of  file,  and  consequently  will  slough.  It  is  therefore  the 
very  best  dressing  for  a gunshot  wound,  and  probably 
for  most  lacerated  wounds  ; for  lint  ajiplied  to  a part 
that  is  to  throw  off  a slough,  will  often  be  retained 
till  that  slough  is  separated,  which  will  be  for  eight, 
ten,  or  more  days.” 

CATAPLAS.MA  MURIATIS  SOD^.  R.  Pulveris 
Lini,  Mic(B  panis  au.  partes  oequales.  Aq,  soda 
muriatoe  q.  s.  This  is  used  for  diminishing  scrofu- 
lous tumours  and  glands.  When  it  excites  too  much 
irritation  in  the  skin,  a linseed  poultice  may  be  substi- 
tuted for  it,  until  this  state  has  subsided. 

CATAPLASMA  PLUMBI  SUBACETATIS. 

R.  Liquoris  jilumbi  subacetatis  drach.  j. 

Aquae  distillatae  lib.  j. 

Micae  panis  q.  s. — Misce. 

Practitioners  who  place  much  confidence  in  the  vir- 
tues of  lead,  externally  applied,  often  use  tliis  poultice 
in  cases  of  inflammation. 

CATAPLASMA  CflJERCUS  MARINI.  This  is  pre- 
pared by  bruising  a quantity  of  the  marine  plant  com- 
monly called  sea  tang,  which  is  afterwards  to  be  ap- 
plied by  way  of  a poultice. 

Its  chief  use  is  in  cases  of  scrofula,  white  swellings, 
and  glandular  ttmiours. 

When  this  vegetable  could  not  be  obtained  in  its  re- 
cent state,  a common  poultice  of  sea-water  and  oat- 
meal was  substituted  by  the  late  Mr.  Hunter  and  other 
surgeons  of  eminence. 

CATARACT.  (From  Karaadaio,  to  confound  or  dis- 
turb ; because  the  disease  confounds  or  destroys  vision.) 
FAdincwpa.  Yndxopa.  Gutta  opaca.  Sujfusio.  Der 
Graue  Staar. 

A cataract  is  usually  defined  to  be  a weakness  or 
impediment  to  sight,  produced  by  opacity  of  the  crys- 
talline lens  or  ks  capsule.  Professor  Beer  applies  the 
term  to  every  perceptible  obstacle  to  vision,  situated  in 
tlie  j)osterior  chamber,  between  the  vitreous  humour 
and  the  uvea.— (Le//re  von  den  Augenkrankheiten,  b. 
3,  p.  279,  8fo.  Wien,  1817.) 

Ilippocrates  and  the  ancient  Greeks  described  the  ca- 
taract as  a disease  of  the  crystalline  lens,  tinder  the 
name  of  yXiivKWfia  ; but  no  .sooner  had  Galen  promul- 
gated the  doctrine  of  the  lens  being  the  immediate  or- 
gan of  sight,  than  the  correct  opinion  of  the  ancient 
Ibunder  of  medicine  began  to  decline,  and  for  many 


ages  afterward,  had  no  influence  in  practice.  In  fact, 
the  seat  of  the  cataract  was  entirely  forgotten,  till 
about  1656,  when  first  Lasnier,  and  afterward  Borel, 
Bonetus,  Blegny,  Geoffroi,  «Scc.  revived  the  truth  which 
had  been  so  long  extinct ; and  they  and  a few  others 
believed  that  the  disease  was  situated  in  the  crystal- 
line lens.  The  bulk  of  practitioners,  however,  re- 
mained ignorant  of  this  fact  eyen  as  late  as  the  begin- 
ning of  the  eighteenth  century,  when  the  several  pub- 
lications of  Maltre-Jan,  Brisseau,  St.  Ives,  and  Ileis- 
ter  combined  to  render  the  truth  universally  known. 
In  1708,  the  celebrated  M.  Mery,  who  had  hitherto 
joined  in  the  belief  that  the  cataract  was  not  a disease 
of  the  lens,  communicated  to  the  Academy  of  Sciences 
a memoir,  in  which  he  acknowledges  the  correctness 
of  the  statement  made  by  Brisseau  and  Maitre-.!an, 
that  vision  can  take  place  without  the  assistance  of  the 
crystalline  lens ; and  he  recommended  a clergyman 
who  had  a cataract  to  have  the  lens  extracted,  which 
was  successfully  done  by  M.  Petit. 

A cataract,  even  in  its  highest  degree,  does  not  al- 
ways produce  complete  blindness.  For  the  most  parr, 
its  Ibrmation  takes  place  slowly ; the  cases  in  which  it 
originates  very  quickly,  being  but  few,  and  those  in 
which  it  is  suddenly  produced  in  a complete  form  still 
more  unusual. 

The  characteristic  symptoms  commonly  remarked 
when  a cataract  is  slowly  formed  are  the  following : 
1.  All  objects,  especially  white  ones,  seem  to  the  pa- 
tient to  be  covered  by  a thin  smutty  or  dusty  cloud, 
which,  as  the  late  Mr.  Ware  observed,  is  gene- 
rally perceptible  by  the  patient  before  any  opacity  is 
visible  in  the  pupil.  2.  The  decline  of  vision  bears  an 
exact  proportion  to  the  increasing  opacity  distinguish- 
able behind  the  pupil.  3.  In  most  cases,  the  opacity  is 
first  discerned  behind  the  pupil,  most  plainly  also  at 
the  central  point,  the  instances  in  which  it  first  pre- 
sents itself  at  the  edge  of  the  pupil  being  less  frequent. 
4.  In  eyes  with  a light-coloured  iris,  the  greater  pro- 
gress a cataract  makes,  the  more  clearly  can  one  per- 
ceive at  the  edge  of  the  pupil  a blackish  ring,  tvhich 
partly  arises  from  the  shadow  of  the  iris  falling  on  the 
cataract,  but  chiefly  from  the  dark-coloured  pupillary 
edge  of  the  iris,  which,  in  a clear  pupil,  cannot  be 
seen,  biu  now  that  a grayish  surface  lies  behind  it,  is 
rendered  very  manifest.  This  blackish  ring  is  said  by 
Mr.  Guthrie  to  be  very  evident  in  cases  of  soft  cata- 
racts, and  to  arise  from  the  back  of  the  pupillary  edge 
of  the  iris  being  pushed  forwards  by  the  size  of  the 
lens.  But  if  the  dilatation  be  increased  to  its  full  ex 
tent,  by  the  application  of  the  extract  of  belladonna,  an 
interni  blacker  circle  w’ill  be  seen  to  surround  the 
turbid  or  muddy  part  behind  the  iris,  and  the  patient 
sees  better  for  a short  time.— (.Operative  Surgery  of 
the  Eye,  p.  197.)  5.  As  a cataract  generally  begins  at 
the  central  point  behind  the  pupil,  such  objects  as  are 
placed  directly  in  front  of  the  eye,  are  most  difticultly 
seen,  even  in  the  early  stage  of  the  disease,  but  those 
which  are  latterly  placed,  especially  when  the  light 
is  not  too  strong,  and  of  course  the  pupil  a good  deal 
dilated,  can  yet  be  seen  tolerably  well.  6.  Hence,* 
when  the  opacity  at  the  central  point  behind  the  pupil 
is  at  all  considerable,  the  patient  is  completely  blind  in 
a strong  4ight,  while,  on  the  contrary,  in  a moderately 
dark  room,  a degree  of  vision  is  yet  enjoyed.  When 
the  opacity  is  not  far  advanced,  the  eyesight  may  be 
improved  fbr  a short  time  bj  the  patient’s  turning  his 
back  to  the  light.  7.  Persons  with  incipient,  cataracts 
derive  the  greatest  palliative  aid  frwn  the  use  of  con- 
vex glasses,  because  objects  are  magnified  by  them ; 
but  they  only  answer  while  the  opacity  is  inconsidera- 
ble. 8.  To  such  patients,  the  flame  of  a candle  seems 
to  be  enveloped  in  a whitish  musty  halo  which  always 
becomes  broader  the  farther  the  patient  is  from  the 
light.  When  the  cataract  is  far  advanced,  the  flame 
of  the  candle  cannot  be  seen,  and  the  patient  can  only 
indicate  the  place  near  which  the  light  is,  or  say  whe- 
ther it  is  close  or  at  a distance  9.  Lastly,  a cataract 
which  forms  slowly  produces,  in  the  course  of  its  pro- 
gress, no  change  in  the  mobility  of  the  iris  ; and  if  tins 
effect  sometimes  takes  place  where  the  disease  is  very 
completely  developed,  the  nature  of  the  case  is  now  so 
manifest  that  no  surgeon  is  in  any  danger  of  mistak- 
ing the  complaint  for  amaurosis. 

The  characteristic  appearances  of  amaurosis  are  en- 
tirely difl'erent.  1.  The  opacify,  perceptible  behind  the 
pupil,  is  at  a consi  ic  able  distance  from  this  ojieiinig, 


CATARACT. 


245 


as  may  be  best  seen  when  the  eye  is  viewed  sideways. 
2.  The  opacity  is  somewhat  concave.  3.  Its  colour  in- 
clines rather  to  a greenish  or  reddish  cast  than  to  gray. 

4.  The  decline  of  the  eyesight  is  not  at  all  in  a ratio  to 
the  degree  of  opacity,  the  patient  being  almost  blind. 

5.  The  pupil  is  more  or  Ies» dilated;  the  iris  nearly  or 
quite  motionless,  its  pupillary  edge  being  here  and 
there  thrown  into  an  angle,  and  of  course  it  is  not  exactly 
circular.  6.  Even  the  cornea  itself  is  not  quite  so  clear 
and  transparent  as  in  the  natural  state.  7.  The  tempo- 
rary increase  or  diirrinution  of  blindness,  so  common  in 
patients  with  incomplete  amaurosis,  never  depends,  as 
in  those  with  cataracts,  upon  the  degree  of  dilatation  of 
the  pupil  or  the  degree  of  light,  but  upon  causes  which 
tend  either  to  depress  or  excita  the  system.  8.  The 
misty  halo  which  such  amaurotic  patients  perceive 
around  the  dame  of  a candle,  is  not  like  a whitish  cloud, 
but  has  all  the  hues  of  the  rainbow:  indeed,  the  flame 
itself  presents  these  colours,  and  when  the  patient  goes 
to  some  distance  from  it,  it  generally  seems  split.  9. 
At  no  period  of  the  complaint  are  spectacles  of  any  ser- 
vice in  enabling  the  patient  to  see  better.  Such  objects 
as  are  situated  to  one  side  cannot  be  seen  more  plainly 
than  those  which  are  directly  in  front  of  the  eye. — (See 
Beer’s  Lehre  von  den  Augenkr.  b.  2,  p.  281—284.)  10. 
The  sight  is  not  temporarily  improved  by  the  applica- 
tion of  belladonna.— (See  Guthrie’s  Operative  Surgery 
of  the  Eye,  p.  212.) 

According  to  this  author,  the  first  and  most  important 
division  of  cataract  is  into  the  genuine  and  spurious : 
for  the  obstacle  to  vision,  situated  in  the  posterior  ch  m- 
ber,  between  the  vitreous  humour  and  uvea,  and  mak- 
ing what  is  termed  a cataract,  may  be  either  within  the 
limit  of  the  capsule  of  the  lens,  or  between  the  ante- 
rior layer  of  that  capsule  and  the  uvea.  The  first  case 
is  the  genuine,  the  second  the  spurious  cataract. 

A genuine  cataract,  when  a primary  disease,  and  un- 
attended from  the  first  with  other  morbid  efffects  in  the 
eye,  is  mostly  a single  independent  affection ; on  the 
contrary,  as  the  spurious  cataract  is  generally  the  con- 
sequence of  internal  ophthalmy,  it  is  almost  alwa3’s 
more  or  less  combined  with  a partial  opacity  of  the 
anterior  layer  of  the  capsule,  and,  of  course,  with  a ge- 
nuine cataract. 

The  first  variety  of  genuine  cataract  noticed  by  Beer 
is  that  which  he  calls  lenticular:  it  always  begins  in 
the  centre  or  very  nucleus  of  the  lens,  mostly  present- 
ing a dull,  yellowish  gray  colour,  which  is  somewhat 
deeper  at  the  centre  than  at  the  margin  of  the  pupil ; a 
character  retained  even  when  the  disease  is  in  its  most 
complete  stage.  The  lenticular  cataract  is  always 
formed  very  slowly,  and,  except  when  the  iris  is  too 
dark-coloured,  it  is  more  or  less  attended  with  a black- 
ish ring  at  the  edge  of  the  pupil,  which  ring  becomes 
plainer  as  the  disease  advances.  A genuine  lenticular 
cataract  never  causes  any  alteration  in  the  expansion  or 
contraction  of  the  iris ; nor  does  it  even  in  its  highest 
degree  deprive  the  patient  of  all  power  of  vision,  who, 
in  shady  places,  or  when  the  jiupil  is  artificially  dilated 
with  hyosciamus  or  belladonna,  is  often  capable  of  dis- 
tinguishing pretty  well  many  objects  which  are  placed 
laterally  with  respect  to  the  eye.  A lenticular  cataract 
is  usually  at  some  distance  from  the  uvea,  so  that  the 
extent  of  the  posterior  chamber  is  manifest,  while  the 
opacity  presents  more  or  less  of  a convex  appearance, 
and  never  that  of  very  white  cloudy  specks.  Fre- 
quently, as  Beer  observes,  the  lenticular  cataract  is  un- 
attended with  any  change  in  the  capsule,  or  the  liquor 
of  MorgagnL  In  most  cases  of  senile  cataract,  not 
preceded  by  inflammation,  the  capsule  is  said  to  remain 
transparent.— (Trnuer^,  Synopsis  of  the  Diseases  of 
the  Eye,  p.  207,  8vo.  Land.  1820.) 

The  second  species  of  genuine  cataract  noticed  by 
Beer  is  the  capsular,  which  he  thinks  should  not  be 
called  membranous,  as  the  expression  may  lead  to  mis- 
laka  The  disease  seldom  commences  in  the  centre  of 
the  pupil,  and  usually  arises  at  its  margin  in  the  form 
of  distinct,  very  white,  shining  points,  streaks,  or  specks ; 
its  colour,  therefore,  is  always  very  light,  and  never  al- 
together uniform,  even  when  the  disease  is  completely 
formed.  The  dotted  or  mottled  apjiearance  of  this  ca- 
tamct  is  also  particularly  noticed  by  Mr.  Travers.— (8'^- 
nopsisof  the  Diseases  of  the  Eye,  p.  207.)  I'he  black- 
ish ring  which,  when  the  iris  is  light-coloured,  is  even 
more  evident  in  this  than  the  lenticular  cataract,  is  here 
not  owing  to  the  shadow  of  the  iris,  but  to  its  dark 
border ; for  this  cataract  is  too  near  the  iris  for  any  .sha- 


dow to  be  formed.  This  observation,  however,  is  some- 
what at  variance  with  what  Mr.  Travers  has  remarked ; 
for  when  a transparent  circumference  can  be  seen  on 
dilating  the  pupil  with  belladonna,  he  has  never  found 
the  capsule  opaque';  and  he  believes  that  the  black  rim 
may  be  considered  as  the  diagnostic  mark  of  the  trans- 
parency of  the  capsule.  But  when  the  opacity  of  the 
lens  is  diffused,  this  sign  is  of  course  absent.— (iVfpd. 
Chir.  Trans,  vol.  4,  p.  288.)  The  disease  also  has  some 
effect  on  the  motions  of  the  iris,  at  least  their  quickness. 
A capsular  cataract  never  remains  long  the  only  affec- 
tion, but  is  followed  by  disease  of  the  lens  itself ; a fact, 
says  Beer,  which  cannot  surprise  us,  when  we  consi- 
der that  it  is  through  the  medium  of  the  capsule,  that 
the  particles  of  the  lens  are  incessantly  undergoing  the 
changes  of  removal  and  reproduction. 

The  capsular  cataract  is  subdivided  by  Beer  into  the 
anterior  capsular  cataract,  the  posterior  capsulax  ca- 
taract, and  the  complete  capstdar  cataract,  in  which 
both  the  front  and  back  portions  of  this  membrane  are 
opaque. 

The  anterior  capsular  cataract,  which  is  not  at  all 
unfrequent,  does  not  continue  long  in  this  form  after  it 
has  attained  a high  degree,  but,  according  to  Beer,  be- 
comes combined  with  an  opacity,  and,  according  to  Mr. 
Travers,  with  a slow  absorption  of  the  lens  itself. — 
{Synopsis,  d c.  p.  207.)  “ When  the  capsule  is  com- 
pletely opaque  (says  Mr.  Travers),  we  can  hardly  judge 
of  the  texture  of  the  lens.”  But  in  such  examples, 
“the  lens  is  commonly  diminished  in  bulk ; it  undergoes 
a waste  after  the  opacity  of  the  capsule,  so  as  in  process 
of  time  to  become  a membranous  cataract.  This  I con- 
ceive to  be  owing  to  the  obliteration  of  the  vessels  of 
the  capsule,  from  which  those  of  the, lens  are  derived. 
When  the  capsular  opacity  is  congenital,  it  is  either 
purely  capsular  or  only  a very  small  piece  of  lens  re- 
mains. When  the  capsule  turns  opaque  from  injury, 
the  lens  is  soon  greatly  reduced  in  bulk,  as  apjiears  from 
the  falling  in  or  concavity  of  the  iris,  which  loses  its 
support,  and  is  demonstrated  in  the  operation.  This  ob- 
servation renders  the  operation  with  the  needle  appro- 
priate to  the  cataract  in  which  the  capsule  is  opaque,  in 
cases  which  are  not  very  recent.” — (Med.  Chir.  Trans, 
vol.  4,  p.  286.)  In  the  anterior  capsular  cataract,  ac- 
cording to  Mr.  Guthrie,  the  lens  does  not  generally  un- 
dergo any  diminution,  but,  for  the  most  part,  an  enlarge- 
ment, in  consequence  of  becoming  opaque  and  soft. 
But  he  admits,  that  the  reverse  is  frequently  the  case  in 
infants,  only  a small  portion  of  the  lens  being  left,  and 
the  rest  of  the  contents  of  the  capsule  fluid.— (See  Ope- 
rative Surgery  of  the  Eye,  p.  233.)  The  anterior  cap- 
sular cataract  may  be  known  by  its  light  gray  and,  in 
some  places,  completely  chalk-white  colour,  intersected 
by  shining,  mother-of-irearl-like  streaks  and  spots.  As 
the  capsule  is  at  the  same  time  thicker  than  natural,  the 
posterior  chamber  is  lessened,  and  the  cataract  is  not 
unfrequently  close  to  the  uvea,  especially  when  the  lens 
has  also  completely  lost  its  transparency.  In  this  stage, 
the  movements  of  the  iris  are  likewise  rendered  less 
quick,  and  the  shadow  at  the  margin  of  the  pupil  is  en- 
tirely absent.  Hence,  vision  is  not  only  hurt,  but  quite 
impeded,  in  regard  to  any  coiTect  sensation  of  light,  whe- 
ther the  patient  be  in  a light  or  shady  situation ; and 
frequently  a faint  light  is  completely  invisible  to  him. 
The  posterior  capsular  cataract  belongs  to  the  rarer 
forms  of  the  disease  of  the  eye ; but,  says  Beer,  when 
it  happens,  the  lens  always  participates  in  the  opacity 
much  more  quickly  than  occurs  in  the  anterior  capsu- 
lar cataract.  Hence,  the  disease  can  never  be  observed 
up  to  its  perfect  developement.  Respecting  the  state  of 
the  lens,  some  difference  prevails  between  the  state- 
ment of  Beer  and  that  of  Mr.  Travers : the  latter  gen- 
tleman infonns  us,  that  where  the  opacity  of  the  poste- 
rior capsule  is  met  with,  which  he  agrees  with  Beer  in 
considering  as  very  rare,  the  lens  and  anterior  capsule 
are  usually  transparent;  “and  when  this  is  not  tlie 
case,  and  the  cataract  escapes  with  a po.sterior  fold  of 
opaque  capsule,  it  is  always  accompanied  with  a coii- 
siderable  discharge  of  vitreous  humour.”— (8i/?wpsr.v  of 
the  Diseases  of  the  Eye,  p.  209.)  And  in  sj»eaking  of 
the  opacity  of  the  posterior  cajjsule,  in  another  work,  he 
informs  us,  that  he  has  not  ob.served  that,  in  this  ca.se, 
the  lens  undergoes  any  diminution.— (dfed.  Chir.  Trans, 
vol.  4,  p.  286.)  Like  the  anterior  cai).sular  caiaract,  it 
is  denoted  by  a whitish-gray,  unequal,  variegated  co- 
lour; but  no  light-coloured,  chalk-white  spots  and 
stre;tk.s  are  ever  discernible,  wliicn,  uiiili;  the  lens  re- 


246 


CATARACT. 


tains  its  transparency,  may  be  owing  to  the  distance  of 
the  cataract  from  the  pupil.  However,  the  opacity  si- 
tuated behind  the  pupil  always  seems  concave  when 
the  eye  is  inspected,  not  from  before,  but  from  every  side 
of  it  While  the  posterior  half  of  the  capsule  is  not 
completely  opaque,  the  lens  is  not  materially  affected ; the 
eyesight  is  only  more  or  less  weakened ; and  sometimes, 
especially  with  the  aid  of  a magnifying  glass,  a tolera- 
ble degree  of  vision  is  enjoyed,  notwithstanding  the  con- 
siderable opacity  behind  the  pupil.  This  species  of  ca- 
taract has  not  itself  any  influence  over  the  motions  of 
the  iris,  and  after  the  lens  becomes  opaque,  it  is  not 
softened. 

Though  the  complete  capsular  cataract  is  not  the 
rarest  species  of  genuine  cataract,  it  cannot  be  said  to 
be  very  common.  In  addition  to  the  symptoms  of  the 
anterior  capsular  cataract,  it  presents  few,  yet  decided, 
cliaracters  which  indicate  it  previously  to  an  operation: 
viz.  the  iris  is  nearly  motionless,  the  cataract  lying 
close  to  that  organ ; the  posterior  chamber  for  the  same 
reason  is  efl'aced;  and  an  inexperienced  surgeon  might 
really  suppose  the  anterior  portion  of  the  capsule  were 
adherent  to  the  uvea,  unless  he  convinced  himself  of 
the  contrary  by  producing  an  artificial  dilatation  of  the 
pupil  with  byosciamus  or  belladonna.  Sometimes  the 
iris  even  seems  thrust  out,  by  this  large  cataract,  to- 
wards the  cornea  in  a convex  form;  and  the  patient  can 
only  perceive  the  strongest  kinds  of  light.  Though 
such  is  the  statement  of  Beer,  I concur  with  Mr.  Guth- 
rie in  regarding  the  above  characters,  which  may  at- 
tend any  large  soft  cataract,  as  well  as  the  complete  cap- 
sular one,  as  by  no  means  a demonstration  of  the  exist- 
ence of  the  latter.— (Operative  Surgery  of  the  Eye,  p. 
235.) 

The  third  species  of  genuine  cataract  is  the  cataracta 
Morgagniana,  which  some  term  the  milk  cataract,  and 
others  confound  with  the  purulent  cataract.  It  is  one  of 
the  rarest  forms  of  the  disease ; so  rare,  indeed,  that 
Mr.  Travers  regards  the  case  as  purely  hypothetical. — 
{Synopsis  of  Diseases  of  the  Eye,p.  208.)  The  follow- 
ing is  the  form  of  disease  described  by  Beer  under  this 
name ; it  proceeds  from  a total  conversion  of  the  lens  into 
a milky  fluid,  or  thin  jelly,  frequently  attended  with  a 
complete  capsular  cataract.  Its  origin  is  said  to  be  al- 
ways quick,  and  an  immediate  eftect  of  chemical  injuries 
of  the  eye.  The  following  are  the  symptoms  of  the  case, 
while  it  is  uncomplicated  with  disease  of  the  lensand  cap- 
sule ; a state  which  can  never  continue  long.  Though 
the  colour  is  milk-white,  it  is  delicate  and  thin,  like  that  of 
diluted  milk.  The  whole  pupil  seems  cloudy,  but  when- 
ever the  eyeball  moves  suddenly  and  violently,  or  the 
eyelid  is  rubbed  over  the  eye,  the  opaque  substances 
change  their  shape  and  position.  The  posterior  cham- 
ber is  nearly  annihilated,  which  may  be  owing  to  the 
quantity  of  fluid  or  gelatinous  substance  collected. 
While  the  lens  and  capsule  are  not  materially  changed, 
the  sight  suffers  only  a diminution,  though  it  is  very 
cloudy,  and  small  objects  cannot  be  distinguished  at  all. 

When,  however,  the  lens  and  capsule  become  opaque, 
vision  is  quite  abolished,  a certain  power  of  knowing 
light  from  darkness  only  remaining.  Not  unfrequently, 
says  Beer,  when  the  lens  itself  is  in  a dissolved  state, 
the  capsule  is  i)artially  opaque,  the  eye  is  kept  quiet  for 
a few  minutes,  and  the  patient  stands  or  sits  in  an  up- 
right posture,  two  rows  of  opaque  matter  can  be  plainly 
seen ; the  upper  being  the  least  white  of  the  two ; the 
lower  presenting  a chalky  whiteness.  However,  as 
soon  as  the  patient  suddenly  or  violently  moves  his 
eye  or  head,  or  the  eyelid  is  rubbed  over  the  eye,  both 
these  rows  of  opaque  matter  disappear,  and  the  colour 
of  the  opacity  behind  the  pupil  again  seems  uniform. 

The  fourth  species  of  genuine  cataract  described  by 
Beer,  is  the  capsulo-lenticular  cataract,  to  which  he 
conceives  the  liquor  of  Morgagni  in  an  altered  state  may 
likewise  often  contribute,  as  may  be  inferred  from  the 
prodigious  size  of  this  cataract.  It  is  by  no  means  un- 
common, and  is  attended  with  the  following  character- 
istic symptoms.  The  colour  of  the  opacity,  close  to  the 
uvea,  is  partly  chalk-white,  partly  like  that  of  mother-of- 
pearl,  and  in  many  places  both  these  colours  can  be  evi- 
dently seen  disposed  one  over  the  other,  that  of  mother- 
of-pearl,  however,  being  always  most  sui)erficial.  Ex- 
posure of  the  eye  to  the  most  vivid  light  scarcely  causes 
any  motion  of  the  iris,  but  the  pupil  is  circular,  without 
any  angles  in  it.  After  the  application  of  the  extract  of 
henbane  or  belladonna,  the  iris  contracts  again  exceed- 
ingly slowly,  and  the  pupil  is  long  in  returning  to  its 


former  diameter.  Besides  the  obliteration  of  the  poste- 
rior chamber,  the  anterior  one  itself  is  mostly  dimi- 
nished, in  consequence  of  the  iris  being  pushed  towards 
the  cornea  by  the  very  large  size  of  the  cataract,  and 
hence  the  sensation  of  light  is  very  indistinct. 

The  capsulo-lenticular  cataract  is  not  unfrequently 
the  consequence  of  a slow  inflammatory  process  in  the 
iris,  the  lens,  and  its  capsule ; and  hence  several  varie- 
ties of  this  case,  and  its  not  unfVequent  combination 
vyith  a spurious  cataract ; all  which  different  modifica- 
tions, says  Beer,  should  be  correctly  undersi  lod  previ- 
ously to  an  operation,  in  order  to  form  a just  pn>gnosis 
of  Its  event,  and  to  know  what  method  of  oi)erating  ought 
to  be  adopted. 

Of  these  varieties  the  first  is  the  capsulo-lenticular 
cataract,  conjoined  with  slight  depositions  of  new  mat- 
ter upon  the  anterior  capsule  of  the  lens.  These  after- 
formations upon  the  front  layer  of  the  capsule,  as  Beer 
calls  them,  put  on  very  different  appearances,  and  ac- 
cordingly receive  various  appellations.  For  instance, 
the  marbled  capsulo-lenticular  cataract,  when  the  chalk- 
white  new-formed  substances  upon  the  anterior  layer  of 
the  capsule  are  so  arranged  as  to  resemble  the  varie 
gated  appearance  of  marble.  The  window  or  lattice 
capsulo-lenticular  cataract,  when  the  new-deposited 
substances  cross  each  other,  leaving  darker-coloured  in- 
terspaces. The  stellated  capsulo-lenticular  cataract, 
when  the  new  matter  runs  in  concentric  streaks  towards 
the  middle  of  the  pupil.  The  central  capsulo-lenticular 
cataract,  when  a single  elevated,  white,  shining  point 
is  formed  on  the  anterior  capsule,  while  the  rest  of  this 
membrane  is  tolerably  clear,  and  the  lens  not  com- 
pletely opaque.  The  dotted  capsulo-lenticular  cataract, 
when  the  front  layer  of  the  capsule  presents  several  dis- 
tuict  unconnected  depositions  on  its  surface.  The 
half-cataract,  or  cataracta  capsuio-lenticularis  dimidi 
ata,  when  one-hall  of  the  front  layer  of  the  capsule  is  co- 
vered with  a white  depbsite.  In  all  these,  and  some 
other  examples,  says  Beer,  the  lens  is  found  to  be  con 
verted  to  its  very  nucleus  into  a gelatinous  or  milky 
substance. 

The  second  variety  of  the  capsulo-lenticular  cataract 
pointed  out  by  Beer,  is  the  encysted,  indicated  by  its 
snow-white  colour;  sometimes  lying  so  close  to  the 
uvea  as  to  push  the  iris  forwards  towards  the  cornea ; 
and  at  other  times  appearing  to  be  at  a distance  from 
the  uvea.  These  circumstances,  as  Beer  remarks,  almost 
always  depend  upon  the  position  of  the  head ; for  when 
this  is  inclined  forwards,  the  cataract  readily  assumes  a 
globular  form,  and  projects  considerably  towards  the  an 
terior  chamber.  Frequently,  this  variety  of  the  capsu- 
lo-lenticular cataract  constitutes  the  kind  of  case  to 
which  the  epithets  tremulous  or  shaking,  and  swim- 
ming or  floating  are  applied.  According  to  Beer,  the 
reason  of  such  unsteadiness  in  the  cataract  is  owing 
to  the  broken  or  very  slight  connexion  of  the  capsule  of 
the  lens  with  the  neighbouring  textures.  The  same 
author  has  never  seen  any  case  of  this  kind,  which  had 
not  been  preceded  by  a violent  concussion  of  the  eye  or 
adjacent  part  of  the  head.  Both  layers  of  the  capsule 
are  opaque,  and  sometimes  considerably  thickened.  The 
third  variety  of  the  capsulo-lenticular  cataract  described 
by  Beer,  is  the  pyramidal  or  conical,  which  is  one  of 
the  rarer  forms  of  the  disease,  and  always  brought  on  by 
violent  internal  inflammation  of  the  eye,  especially  af 
fecting  the  lens,  its  capsule,  and  the  iris.  It  may  be 
known  by  a white,  almost  shining,  conical,  more  or  less 
projecting,  new-formed  substance,  which  grows  from 
the  centre  of  the  anterior  layer  of  the  capsule,  and  is  al- 
most in  close  contact  with  the  pupillary  margin  of 
the  iris.  Hence  the  iris  is  always  quite  motionless, 
and  the  pupil  angular.  Sometimes  this  growth  from 
the  capsule  extends  itself  so  far  into  the  anterior  cham- 
ber, as  nearly  to  touch  the  inner  surface  of  the  cornea, 
and  sometimes  actually  to  adhere  firmly  to  it : a cir- 
cumstance, says  Beer,  which  is  very  constant  in  the 
conical  staphyloma  of  the  cornea,  though  not  discover- 
able till  the  ojieration  is  performed.  The  power  of  dis- 
cerning light  is  feeble  and  indistinct,  and  sometimes 
entirely  abolished.  Mr.  Guthrie  (as  I think)  very  cor- 
rectly regards  this  case  as  an  advanced  degree  of  the 
disease  presently  described  under  the  name  given  to  it 
by  Beer,  of  lymph-cataract : it  ought,  indeed  to  be 
classed  as  a spurious  cataract. — (See  Guthrie’s  Opera- 
tive Surgery  of  the  Eye,  p.  246.) 

The  fourth  variety  of  the  capsulo-lenticular  cataract 
is  \hc  siliquoai.  Though  principally  met  with  in  yoimg 


CATARACT. 


247 


tWldren,  it  is  not  one  of  the  most  uncommon  affections 
in  adults,  and  in  the  former  it  is  often  falsely  regarded 
ns  a congenital  complaint.  When  this  cataract  is  ex- 
tracted either  from  children  or  grown-up  persons,  Beer 
says,  that  the  dried  shrivelled,  capsule  is  always  found 
round  the  equally  dry  nucleus  of  the  lens,  like  a husk, 
or  shell.  In  cliildren,  however,  he  says,  that  the  nu- 
cleus of  the  lens  is  often  scarcely  perceptible,  while  in 
adnlts  it  is  always  of  considerable  size,  and  this  may  be 
the  reason  why  this  cataract  in  children  does  not  pre- 
sent so  bright  a yellow- white  colour  as  it  does  in  grown- 
up persons.  In  infants,  in  which  it  is  frequently  seen 
in  the  first  weeks  of  their  existence,’ it  is  manifestly 
produced  by  a slow  and  neglected  inflammation  of  the 
lens  and  its  capsule,  arising  from  too  strong  light.  In 
<idults,  the  inflammation  exciting  this  form  of  cataract 
as  always  owing  to  external  violence;  yet  Beer  sup- 
poses, that  a considerable  diminution  of  cohesion  be- 
tween the  capsule  and  the  adjacent  textures  must  like- 
wise have  a principal  share  in  bringing  on  the  disease, 
which  in  grown-up  persons,  is  constantly  preceded  by 
a concussion  of  the  eyeball,  from  the  cut  of  a whip,  the 
lash  of  a horse’s  tail,  <fec.  Professor  Schmidt  had 
never  seen  this  kind  of  cataract,  except  in  boys  and  girls, 
who  in  their  early  childhood  had  been  afflicted  with 
convulsions ; and  hence,  he  thought,  that  the  cause  of 
the  disease  was  owing  to  a partial  loosening  of  the  cap- 
sule from  its  natural  connexions  by  the  violence  of  the 
convulsive  paroxysms. — {Abkandlung  iiber  Nachstaar 
und  Iritis  nach  Staar-Operationen.  Wien,  1801,  4io.) 
However,  Beer  assures  us,  that  he  has  seen  infants, 
scarcely  two  months  old,  affected  with  this  cataract, 
which  had  not  been  preceded  or  followed  by  any  con- 
vulsions ; while  a much  larger  number  of  children  with 
the  same  kind  of  cataract  had  fallen  under  his  notice, 
where  more  or  less  severe  blows  on  the  head  had  been 
received.  With  respect  to  the  convulsions,  spoken  of  by 
■Schmidt,  he  also  questioiis  whether  they  and  the  cataract 
might  net  be  owing  to  the  same  cause,  viz.  the  preced- 
ing inflammation  within  the  eye?  In  children,  says 
fleer,  this  form  of  cataract  may  be  known  by  its  light- 
gray,  whitish,  though  seldom  very  white  colour,  its  di- 
minutive size  and  considerable  distance  from  the  uvea, 
and  by  the  freedom  with  which  the  iris  moves  when  no 
adhesions  exist  at  any  points  between  this  organ  and 
the  cataract,  as  occasionally  happens ; a proof  of  the 
previous  inflammation  of  the  capsule,  lens,  and  neigh- 
bouring textures.  The  eyesight  is  never  quite  impeded, 
but  only  much  diminished.  On  the  contrary,  in  adults, 
as  Beer  has  remarked,  this  cataract  invariably  presents 
a dazzling  white  hue,  and  only  a few  points  of  it  are  of 
a smutty  yellowish-white  colour,  whence  the  case  has 
been  sometimes  termed  the  gypsum-cataract.  It  is  not 
convex,  but  rather  flat ; it  does  not  approach  the  iris  ; 
and  when  free  from  adhesions  to  the  uvea,  which  are 
more  likely  to  happen  in  adults,  it  has  no  effect  on  the 
motion  of  the  iris.  Vision  is  generally  entirely  lost, 
with  the  exception  of  the  power  of  discerning  the  light, 
and  even  this  faculty  is  sometimes  destroyed  in  conse- 
quence of  the  previous  violence  done  to  the  eye,  whereby 
not  merely  the  lens  and  its  capsule,  but  also  the  retina, 
have  suffered. 

According  to  Beer,  one  of  the  rarest  varieties  of  the 
capsulo-lenticular  cataract  is  that  accompanied  with  a 
cyst  of  purulent  matter.  It  is  indicated  by  a deep  le- 
mon colour,  very  slow  motion  of  the  iris,  manifest  abo- 
lition of  the  posterior  chamber,  slight  conve.xity  of  the 
ins,  trivial  perception  of  light,  and  the  weak,  unhealthy 
constitution  of  the  patient.  The  purulent  cyst,  which 
sometimes  contains  a very  fetid  matter,  and  was  therefore 
called  by  Schiferli  the  putrid  cataract,  {Theoretische- 
Praktische  Abhandlung  iiber  den  Grauen  Staar,  8vo. 
Jena  and  Leipz.  1797),  may  sometimes  be  taken  out,  with- 
out being  broken,  together  with  the  whole  capsule  of  the 
lens,  with  the  aid  of  the  forceps,  or  cataract-tenaculum, 
as  was  first  correctly  remarked  by  Professor  Schmidt. 
In  one  single  example.  Beer  found  the  cyst  of  matter 
between  tho  lens  and  the  anterior  portion  of  its  capsule. 
Mr.  Travers  has  likewise  seen  an  example  of  suppura- 
tion within  the  capsule,  which  projected  through  the 
pupil  in  a globular  form,  and  was  filled  with  pus.  The 
case  happened  in  a lad,  and  had  been  preceded  by  a 
severe  blow  on  the  eyt.— (^Synopsis  of  the  Diseases  of 
the  Eye,  p.  206.) 

The  sixth  and  la.st  variety  of  the  capsulo-lenticular 
cataract  mentioned  by  Beer,  is  the  well-known  case  de- 
scribed by  the  French  under  the  name  otcataracte  barr  t, 


the  bar-cataract,'and  by  Schmidt  under  the  appellation  of 
the  cataract  with  a girth  or  zone.  The  case,  says  Beef, 
is  one  of  the  least  frequent.  The  diagnosis  is  easy; 
for,  behind  the  diminished,  more  or  less  angular  pupil, 
the  cataract  can  bo  plainly  seen,  to  which  is  attached, 
either  in  a more  or  less  perpendicular  or  horizontal  di- 
rection, a chalk-white,  generally  very  shining,  and 
thickish  kind  of  bar  or  girth,  which  is  closely  adherent 
at  both  its  extremities  to  the  pupillary  margin  of  the 
uvea,  and  sometimes  reaches,  but  often  only  on  one 
side,  more  or  less  towards  the  ciliary  processes.  The 
iris  is  therefore  completely  motionless,  the  uvea  not  be- 
ing merely  adherent  to  the  substance  forming  what  is 
termed  the  bar  or  girth,  but  also  closely  connected  with 
the  whole  front  portion  of  the  capsule.  The  perception 
of  light  is  either  very  indistinct  or  quite  lost,  and  not 
unfrequently  the  globe  of  the  eye  is  somewhat  smaller 
than  natural.  Beer  says,  that  he  has  never  met  with 
this  variety  of  cataract,  except  after  violent  internal  in- 
flammation of  the  eye.  He  describes  the  substance  com- 
posing the  bar  or  girth  as  being  of  various  consistence, 
and  sometimes  firm  and  almost  cartilaginous.  In  two 
cataracts  of  this  sort,  which  he  extracted  from  a boy 
twelve  years  of  age,  he  found  the  bar,  strictly  speak- 
ing, ossified,  and  the  capsule,  which  was  nearly  cartila- 
ginous, was  adherent  to  a very  small,  firm  nucleus  of 
the  lens,  though  they  were  yet  capable  of  separation. 
In  a dead  subject  Beer  also  examined  such  a cataract, 
in  which  the  outer  end  of  the  bar  scarcely  extended  to 
the  greater  ring  of  the  uvea,  but  the  inner  end  reached 
over  the  ciliary  processes  to  the  ciliary  ligament,  from 
which  latter  part  it  was  inseparable.— (Z-eAre  von  den 
Augenkr.  b.  2,  p.  302.) 

OF  SPURIOUS  CATARACTS.  , 

The  most  frequent,  according  to  Beer,  is  what  he 
names  the  lymph-cataract.  It  is,  without  exception, 
the  effect  of  an  inflammation  which  is  chiefly  situated 
in  the  iris,  the  lens,  and  its  capsule.  Hence  it  is  fre- 
quently combined  with  a genuine  cataract.  The  na- 
ture of  the  disease  may  be  known  from  the  patient’s 
account,  that  the  present  blindness  has  been  preceded 
by  a painful  tedious  affection  of  his  eye  and  head ; 
and  from  an  examination  of  the  eye  itself,  in  wliich 
the  pupil  will  be  found  more  or  less  diminished  and 
angular ; the  iris  either  perfectly  motionless  or  nearly 
so;  the  eyesight,  and  even  sometimes  the  perception 
of  light,  more  or  less  impeded  or  lost,  and  this  not 
merely  in  proportion  to  the  quantity  of  lymph  observ- 
able immediately  behind  the  pupil,  but  also  in  propor- 
tion to  other  morbid  effects  produced  in  the  organ  of 
inflammation.  Lastly,  the  surgeon  may  notice,  di- 
rectly behind  the  pupil,  a plastic  lymph,  either  in  the 
fonn  of  a delicate  kind  of  net-work,  or  of  a thick  web 
of  a snow-white  colour.  Sometimes  in  this  variety  of 
spurious  cataract,  though  very  little  coagulating  lymph 
appears  upon  the  anterior  portion  of  the  capsule  of  the 
lens,  and  what  is  effused,  as  well  as  the  lens  itself,  is 
almost  clear  and  transparent,  yet  the  eyesight  is  con- 
siderably impaired ; and  on  more  careful  examination 
of  the  pupil,  something  of  a dark-brown  colour  is  per- 
ceived, which  often  projects,  at  several  points  behind 
the  pupillary  edge  of  the  iris,  a good  way  towards 
the  centre  of  the  pupil.  In  this  substance  one  may 
discern,  with  a good  magnifying-glass,  new  vesselsex- 
tending from  those  of  the  uvea,  and  formed  by  the 
previous  inflammation,  by  means  of  which  vessels 
this  mass  and  the  delicate  layer  of  lymph  are  con- 
nected with  the  capsule  of  the  lens.  According  to 
Beer’s  sentiments,  it  is  only  the  real  lymph  cataract 
which  rightly  deserves  the  epiidei  membranous,  which 
is  sometimes  wrongly  applied  to  the  capsular  cataract; 
for,  says  he,  the  lymph-cataract  alone  consists  of  an 
adventitious  membrane,  formed  by  injlammatum,  of 
a web  of  plastic  lymph,  which  may  be  very  thin,  and 
semi  transparent,  while  the  lens  and  its  capsule  are 
nearly  quite  clear,  though  the  patient  may  be  almost 
or  completely  blind,  when  the  effects  of  the  inflamma- 
tion have  extended  to  the  choroides  and  retina. 

The  spurious  purulent  cataract  is  much  le.ss  fre- 
quent than  the  lymph-cataract.  In  neglected  cases 
of  hy4)oi»ium  (see  this  word),  wlfere  the  pupil  is  already 
quite  covered  with  pus,  the  greater  part  of  the  effused 
matter  is  sometimes  absorbed,  and  the  pupil  can  be 
seen  again,  hut,  immediately  behind  it,  a quantity  of 
coagulating  lymph  can  be  discerned,  as  in  the  lymph- 
cataract,  sometimes  even  projecting  parti;  into  i.he  an- 


248 


CATARACT. 


terior  chamber,  but  blended  with  particles  of  purulent 
matter,  so  as  to  give  it  a light-yellowish  tinge  and  a 
clustered  appearance.  The  pupil  is  always  diminished, 
adherent  to  the  morbid  substance,  and  angular ; the 
motionless  iris  projects  towards  the  cornea ; and  not 
only  the  eyesight,  but  even  the  perception  of  light,  is 
completely  lost,  or  the  latter  at  least  much  dimi- 
nished. 

A rare  variety  of  spurious  cataract,  described  by 
Beer,  is  the  blood-cataract.  Either  from  some  con- 
siderable injury  of  the  eye,  a large  quantity  of  blood  is 
e-ttravasated  iii  the  chambers,  and  slowly  absorbed 
during  the  ophthalmy  caused  by  the  violence,  a part  of 
it,  however,  remaining  in  the  posterior  chamber,  in 
the  form  of  small  clots  encysted  in  the  lymph,  which 
was  effused  during  the  inflammation ; or  else  in  the 
course  of  a more  tedious  and  neglected  case  of  hypo- 
pium,  blood  is  effused  in  the  chambers  of  the  ej  e,  and 
not  mixing  with  the  pus,  still  continues  in  the  same 
form  behind  the  pupil,  after  the  matter  has  been  ab- 
sorbed. In  the  first  example,  this  cataract  looks  like 
a reddish  web,  interwoven  with  silvery  streaks  or 
threads;  the  pupil,  though  angular,  is  seldom  con- 
tracted; the  iris  nearly  or  quite  motionless;  and  not 
onli  is  the  light  clearly  distmguished,  but  a partial  de- 
gree of  vision  sometimes  retained.  On  the  contrary, 
in  the  second  instance,  the  opacity  behind  the  pupil  is 
very  dense,  white,  studded  with  reddish  or  brownish 
points  »r  specks,  having  a clustered  appearance,  and 
frequently  projecting  through  the  pupil  into  the  ante- 
rior chamber ; while  the  pupU  itself  is  very  small  and  an- 
gular, the  iris  quite  incapable  of  motion,  and  generally 
either  no  perception  of  light  remains,  or  only  a very 
confined  indeterminate  sensation  of  it.  Beer  says, 
that  this  cataract  may  easily  be  mistaken  for  lymph, 
and  that  its  difference  can  only  be  made  out  with  a 
good  magnifying  glass. 

The  dendritic  catarcLCt  of  Schmidt,  the  arborescent 
cataract  of  Richter,  or  the  choroid  cataract,  as  Beer  ob- 
serves, is  not  one  of  the  least  frequent  of  the  spurious 
cataracts,  and  is  invariably  the  consequence  of  a vio- 
lent concussion  of  the  globe  of  the  eye,  with  or  with- 
out a wound,  whereby  a portion  of  the  tapetum  of  the 
uvea  is  loosened,  and  becomes  placed  upon  the  ante- 
rior layer  of  the  cap.sule,  more  or  less  resembling  in  its 
appearance  the  arborescent  form  of  the  stone  termed  a 
dendritis.  Immediately  after  such  a concussion  of  the 
ej'eball,  the  patient  complains  of  a serious  diminution 
and  confusion  of  vi.sion.  Whoever  examines  the  eye 
only  superficially,  will  certainly  not  discern  the  pieces 
of  The  tapetum  lying  upon  the  yet  perfectly  transparent 
capsule  of  the  lens,  for  the  most  careful  inspection  will 
be  necessary  for  the  purpose,  atid  sometimes  the  aid 
of  a magnifying-glass  will  be  requisite.  But  as  the 
lens  and  its  capsule  are  mostly  at  the  same  time  loos- 
ened from  their  connexions,  they  likewise  generally 
become  deprived  of  their  transparency,  and  as  soon  as 
this  has  happened,  the  displaced  portion  of  the  tape- 
tmn  can  be  readily  seen.  When  inflammation  ensues, 
the  flakes  of  the  tapetum  become  closely  adherent  to 
the  front  layer  of  the  capsule  of  the  lens,  and  even  the 
pupillarj’  edge  of  the  uvea  acquires  the  same  kind  of 
connexion,  so  that  the  perception  of  light  is  diminished. 
But,  says  Beer,  when  inflammation  follows,  the  pupil- 
lar}’  margin  of  the  uvea  remains  free,  the  iris  is  per- 
fectly moveable,  the  light  clearly  distinguishable, 
though  the  lens  and  its  capsule  be  entirely  opaque,  and 
sometimes  the  flakes  of  the  tapetum  resembling  the 
arborescent  streaks  of  the  dendritis  alter  in  shape,  size, 
and  position,  but  never  comjjletely  disappear,  though 
they  may  not  closely  adhere  to  the  capsule.— (Xrf Are' 
von  den  Augenkr.  b.  2,  p.  303.  309.) 

A particular  case  is  described  by  Mr.  Guthrie,  as 
more  truly  deserving  the  name  of  choroid  cataract;  it 
arises,  without  any  blo%v  or  concussion  of  the  eye,  in 
consequence  of  a low  or  anomalous  inflammation  of 
the  iris.  The  pupil  closes  nearly  to  a point,  which 
remains  sufficiently  free  from  opacity  for  sight  to  take 
place  with  the  aid  of  spectacles.  “ On  the  subsidence 
of  the  inflammation,  the  iris,  by  the  natural  efforts  of 
the  part,  or  under  the  influence  of  belladonna,  is  drawn 
towards  its  outer  cirCle  or  circumference,  and,  the 
pupil  is  apjiarently  enlarged ; but  the  uvea,  in  retract- 
ing, does  not  keep  pace  with  its  anterior  part,  or  leaves 
attached  to  the  cajisule  of  the  lens  so  considerable  a 
portion  of  its  piirment  as  to  prevent  the  passage  of  the 
ra>s  of  light  tlirougli  it,  while  the  pu,  ii.  at  a du^tHiu-c, 


seems  to  be  of  its  natural  size  and  blackness.”  A mi- 
nute inspection,  however,  shows  that  the  pupil  is 
nearly  clo.sed.  Mr.  Guthrie  adds,  that  the  operation  for 
closed  pupil,  by  division  (the  only  proper  one),  is  not 
advisable  as  long  as  the  patient  can  see  well  enough 
for  the  common  purposes  of  life. — (See  Operative  Sur- 
gery of  the  Eye,  p.  249.) 

Another  classification  of  cataracts,  which  is  of  great 
importance  to  an  operator,  is  that  which  is  founded 
upon  their  consistence;  for,  as  Beer  remarks,  this 
makes  not  only  a great  ifference  in  the  prognosis,  but 
also  in  the  choice  of  a method  of  operating. 

When  the  opaque  lens  is  either  more  indurated  than 
in  the  natural  state,  or  retains  a tolerable  degree  of 
firmness,  the  case  is  termed  a firm  or  hard  cataract. 
When  the  substance  of  the  lens  seems  to  be  converted 
into  a whitish  or  other  kind  of  fluid,  lodged  in  the 
capsule,  the  case  is  denominated  a milky  or fiuid  cata- 
ract. W'hen  the  opaque  lens  is  of  a middling  consis- 
tence, neither  hard  nor  fluid,  but  about  as  consistent 
as  a thick  jelly  or  curds,  the  case  is  named  a soft  or 
caseous  cataract.  When  the  anterior  or  posterior 
layer  of  the  crystalline  capsule  becomes  opaque,  after 
the  lens  itself  has  been  removed  from  this  little  mem- 
branous sac  by  a previous  operation,  the  affection  is 
named  a secondary  cataract. 

The  harder  the  cataract  is,  the  thinner  and  smaller 
it  becomes.  In  this  case,  the  disease  presents  either 
an  ash-coloured,  a yellow,  or  a brownish  appearance  : 
according  to  Beer,  its  colour  is  very  dark.  The  inter- 
space between  the  cataract  and  pupil  is  considerable. 
The  patient  distinctly  discerns  light  from  darkness, 
and,  when  the  pupil  is  dilated,  can  even  plainly  per- 
ceive large  bright  objects.  In  the  dilated  state  of  the 
pupil,  a black  circle  surrounding  the  lens  is  ver>’  per- 
ceptible. The  motions  of  the  iris  are  free  and  prompt ; 
and  the  anterior  surface  of  the  cataract  appears  flat, 
without  any  degree  of  convexity  — {Richter^ s Anfangsg. 
der  Wundarzn.  p.  177,  b.  3.  Beer,  vol.  cit.  p.  309.) 

Beer  says,  that  it  is  only  the  genuine  lenticular  cata- 
ract which  can  be  hard,  and  it  is  chiefly  met  with  in 
thih,  elderly  persons ; but,  with  respect  to  the  opinion 
that  all  cataracts  in  old  persons  are  firm,  he  says,  this 
is  frequently  contradicted  by  experience.  In  c.ataract8 
extracted  from  thin,  aged  individutds,  the  lens  is 
sometimes  found  dwindled,  as  hard  as  wood,  nearly  of 
a chestnut-brown  colour,  and  with  its  two  surfaces  as 
flat  as  if  they  had  been  compressed.  This  esuse  has 
sonctimes  been  denominated  the  dark-gray  cataract, 
and  is  very  d fficult  to  make  out  previously  to  an  ope- 
ration, being  liable  to  be  mistaken  for  an  incipient 
amaurosis.  Hence,  in  order  to  judge  of  it  effectually, 
the  pupil  should  alwmys  be  dilated  with  hyosciamus 
or  belladonna. 

To  the  fimiish,  consistent  kind.  Beer  refers  several 
capsulo-lenticular  cataracts,  namely,  the  encysted  and 
conical,  or  pyramidal  cataracts,  that  to  which  he  ap- 
plies the  epithet  dry  siliquose,  the  gypsum  cataract  in 
particular,  and  the  bar  cataract,  which  at  least  is  always 
partly  firm,  as  well  as  all  the  varieties  of  spurious 
cataract. — {Beer,  b.  2,  p.  309.) 

The  fluid  or  milky  cataract  has  usually  a white  ap- 
pearance ; and  irregular  spots  and  stress,  different 
in  colour  from  the  rest  of  the  cataract,  are  often  ob- 
sersable  on  it.  These  are  apt  to  change  their  figure 
and  situation,  when  frequent  and  sudden  motions  of 
the  eyes  occur,  or  when  the  eyes  are  rubbed  and 
pressed  ; sometimes  also  these  spots  and  streaks  va- 
nish and  then  reappear.  The  lower  portion  of  the 
pupil  seems  more  opaque  than  the  upper,  probably 
because  the  untransparent  and  heavy  parts  of  the  milky 
fluid  sink  dowmwards  to  the  bottom  of  the  capsule. 
The  crystalline  lens,  as  it  loses  its  firmness,  coni- 
mordy  acquires  an  augmented  size.  Hence,  the  fluid 
cataract  is  thick,  and  the  opacity  close  behind  the  pupil. 
Sometimes,  one  can  perceive  no  space  between  the 
cataract  and  margin  of  the  pupil.  In  advanced  cases, 
this  aperture  is  usually  very  much  dilated,  and  the  iris 
moves  slowly  and  inertly.  This  happens  because  the 
cataract  touches  the  iris  and  impedes  its  action.  The 
fluid  cataract  is  sometimes  of  such  a thickness,  that  it 
protrude.s  into  the  pupil,  and  presses  the,  iris  so  much 
forwards  as  to  make  it  assume  a convex  ap|)earance. 
Patients  who  have  milky  cataracts,  general;,'  distin- 
guish light  from  darkness  very  indistinctly,  and  soma 
tunes  not  at  all ; ]mray.  because  tin-  cataract,  when  it 
IS  tiink,  lies  to  close  to  the  in.s  that  lew  or  no  rays 


CATARACT.  249 


of  light  can  enter  between  them  into  the  eye ; partly, 
because  the  fluid  cataract  always  assumes,  more  or 
less,  a globular  form,  and  therefore  has  no  thin  edge 
through  which  the  rays  of  light  can  penetrate.— (iiicA- 
ter's  Anfangsgr.  der  Wundarzn.  b.  3,  p.  174,  175.) — 
Mr.  Travers  believes,  that  fluid  cataracts  are  rarely 
contained  in  a transparent  capsule,  and  his  experience 
has  taught  him,  that  this  membrane  is  partially  opaque, 
presenting  a dotted  or  mottled  surface.  Tlie  opaque 
spots  are  most  distinguishable  when  viewed  laterally. 
— (See  Med.  Chir,  Trayis.  vol.  4,  p.  284.) 

According  to  Beer,  a fluid  cataract  is  mostly  con- 
joined with  a complete  opacity  of  the  capsule : its  diag- 
nosis, therefore,  is  commonly  very  ditficult,  and  some- 
times its  nature  cannot,  be  known  with  certainty, 
until  an  operation  is  undertaken.  When  the  capsule 
is  opaque  only  in  some  places,  he  states,  that  the  fol- 
lowing circumstances  may  be  noticed.  The  cataract 
lies  close  to  the  uvea,  and  when  the  patient  inclines 
his  head  forwards,  the  cataract  presses  the  iris  to- 
wards the  cornea,  and  the  anterior  chamber  becomes 
evidently  smaller;  but  when  be  lies  upon  his  back, 
the  cataract  recedes  in  some  degree  from  the  uvea. 
The  power  of  distinguishing  the  light  is  unequivocal. 
When  the  head  is  kept  quiet  for  a long  time,  a thick 
sediment  and  a thinner  part  can  be  plainly  remarked 
in  the  cataract;  during  which  state,  that  is,  while  the 
two  substances  are  undisturbed,  the  patient  can  some- 
times distinguish  large  well-lighted  objects,  as  through 
a deJise  mist;  but  when  the  head  or  eye  is  quickly 
moved,  these  two  substances  become  confused  together 
again,  and  the  cataract  again  presents  a uniform 
white  colour. — {Vol.  cit.  p.  312.)  It  cannot  be  denied, 
says  Beer,  that  what  is  called  the  congenital  cataract, 
and  which  presents  itself  in  infants  soon  after  birth, 
when  their  eyes  have  been  exposed  to  immoderate 
light,  is  not  unfrequently  fluid;  but,  in  such  cases, 
it  must  not  be  presumed,  that  the  lens  is  always 
in  this  state ; for,  in  fact,  the  cataract  is  often  of  that 
sort  which  Beer  describes  under  the  name  of  dry  sili- 
quose. 

Sometim*w  the  opaque  lens  is  of  a middling  consist- 
ence, neither  hard  nor  fluid,  but  about  as  consistent  as 
thick  jellj',  cunts,  or  new  cheese.  Cases  of  this  de- 
scription .ire  lermed  soft  or  caseous  cataracts.  The 
consistence  here  spoken  of  may  be  confined  to  the  two 
surfaces  of  the  lens,  or  may  exist  in  its  very  centre. 
The  first  case  is  the  most  frequent.  The  diagnosis  is 
not  difficult ; for  it  always  has  a light-gray,  grayish- 
white,  or  sea-green  colour.  When  it  is  far  advanced, 
it  quite  impedes  the  eyesight,  and  sometinles  consider- 
ably interferes  with  the  perception  of  light.— (Beer,  b. 
2,p.  310.)  As  the  lens  softens  in  this  manner,  it  com- 
monly grows  thicker  and  larger,  even  acquiring  a much 
greater  size  than  the  fluid.  It  is  not  unfrequent  to 
meet  with  caseous  cataracts  of  twice  the  ordinary  size 
of  a healthy  crystalline  lens.  The  motions  of  the  iris 
are  very  sluggish.— (Ric/ifcr’s  Anfangsgr.  der  Wun- 
darzn. p.  178,  b.  3.)  Indeed,  Beer  says  that  it  is 
sometimes  requisite  to  u.se  the  hyo.sciamus  (or  rather 
bell.idonna)  in  order  to  ascertain  that  no  adhesions  ex- 
ist between  the  uvea  and  the  cataract,  for  in  such  cases 
the  posterior  chamber  is  very  often  completely  abo- 
lished, as  the  more  caseous  the  lens  is,  the  larger  it  is  ; 
and  hence  likewise  the  black  ring  at  the  edge  of  the 
pujiil  is  not  at  all  owing  te  the  shadow  of  the  iris,  but 
entirely  to  the  dark  border  of  the  iris  at  the  margin  of 
that  opening.  According  to  Beer,  the  colour  of  such 
cataracts  is  never  uniform,  but  more  or  less  speckled ; 
the  spots,  however,  either  have  no  determinate  outline, 
or  they  seem  like  mother-of-pearl  fragments,  into 
which  the  cataract  crumbles  when  e.vtracted  or  couched, 
or  else  they  assume  the  appearance  of  clouds.  (Beer, 
6.  2,  p.  311.)  According  to  Mr.  Travers,  the  ca.seous 
cataract  has  a heavy,  dense  appearance,  uniformly 
opaque,  a clouded,  not  a fleecy  whiteness,  and  some- 
times a greenish  or  dirty  white  tinge.— (ilfed.  Chir. 
Trans,  vol.  4,  p.  285.)  He  farther  states,  that  what  he 
terms  the  Jlocculent  or  fieecy,  and  the  caseous  or 
doughy  cataracts,  are  most  frequently  met  with ; the 
fluid  or  vdlky  ca.ses.  and  tho.se  called  hard,  being  com- 
paratively rare.  -fOp.  et.  loc.  cit.) 

In  estimating  the  consistence  of  cataracts  it  is 
now  universally  admitted,  that  their  size  is  a better 
ciiicrion  of  it  than  their  colour;  and  “ the  larger  and 
mere  protuberant  the  lens  pressing  forwards  into  the 
pupd  and  against  the  iri-s,  the  grouter  i;i  Ihc  terlaiuty  1 


of  its  being  soft.”— (See  Guthrie's  Operative  Surgery 
of  the  Eye,  p.  209.) 

As  Beer  observes,  a cataract  which  is  recent  and  has 
originated  suddenly,  especially  in  young  subjects,  re- 
quires much  more  circumspection,  ere  an  operation  is 
determined  upon,  than  a cataract  which  has  already 
existed  a long  while,  and  the.  formation  of  which  has 
been  only  gradual,  particularly  in  an  old  subject ; for 
the  first  case  is  more  frequently  owing  to  a concealed 
slow  kind  of  inflammation  than  is  generally  supposed 
—(Vol.  cit.  p.  314.) 

Formerly,  cataracts  were  denominated  ripe  or  unripe ; 
tenns  which,  previously  to  the  time  of  Mr.  Pott,  who 
fully  exposed  their  impropriety,  often  led  to  the  error 
of  supposing  that  every  cataract  must  acquire  an  in- 
crease of  consistence  with  time,  a hardness  indicated 
by  a pearly  colour,  and  be  thereby  rendered  more  fit  to 
be  depressed  or  extracted.  “ This  opinion  (as  Mr. 
Guthrie  has  observed),  founded  on  the  hardness  or  soft- 
ness of  the  cataract,  as  dependent  upon  its  duration,  is 
contradicted  by  experience ; for  cataracts  of  fifteen  or 
twenty  years’  duration,  and  of  a pearly  colour,  have 
been  extracted  perfectly  soft,  while  others,  of  one 
year’s  standing  and  of  a milky  colour,  have  been  found 
hard.  Neither  is  the  relative  state  of  blindness  under 
these  particular  circumstances  a more  just  criterion  ; 
patients  having  been  found  almost  entirely  blind  with 
a soft  cataract,  while  through  a hard  one  they  could 
still  distinguish  objects  and  colours.  -(Operative  Sur- 
gery of  the  Eye,  p.  190.)  A cataract  was  also  called 
ripe  as  soon  as  it  was  in  a state  which  would  admit 
of  no  increase,  whether  the  eyesight  was  completely 
lost  or  only  diminished,  and  whether  the  pupil  was 
entirely  occupied  by  it  or  not.  Thus,  says  Beer,  the 
siliquose  cataract,  in  its  most  advanced  stage,  never 
totally  tills  the  pupil,  and  the  patient  can  sometimes 
even  discern  colours ; nor  does  the  floating  capsulo- 
lenticular  cataract  fill  the  pupil  in  a greater  degree ; 
and  yet  both  these  cases  are  completely  ripe  tor  an 
operation.  On  the  other  hand,  to  the  unripe  cataracts 
belong  the  central  cataract  of  the  capsule  and  lens, 
the  posterior  capsular  cataract  and  the  slight  degree  of 
lymph  cataract.  Most  of  these  cataracts,  after  perhaps 
remaining  for  years  in  this  state,  not  unfrequently  jdl 
of  a sudden  become  complete  upon  an  accidental  and 
slight  attack  of  ophthalmy  \ but  sometimes  they  remain 
unchanged  during  life.— (Beer,  b.  2,  p.  316.) 

Another  very  useful  and  practical  division  of  cata- 
racts is  into  those  which  are  called  simple  local,  and 
into  others  which  receive  the  name  of  complicated.  A 
simple  local  cataract  is  so  denominated  by  Beer  when 
the  patient  is  in  every  other  respect  perfectly  healthy, 
and  no  disease  prevails  in  any  other  part,  however  dis- 
tant from  the  eye.  A cataract  may  be  complicated  in 
three  ways  ; for  it  may  be  attended  either  with  other 
simultaneous  disease  in  the  eye  itself  or  its  appen- 
dages, when  the  case  is  termed  a local  complicated  ca- 
taract ; or  there  is  some  other  disease  prevailing  in  the 
system,  either  unconnected  or  connected  witti  the  pro-, 
duction  of  the  cataract,  which  then  has  the  epithets 
general  complicated  applied  to  it ; or.  lastly,  both  de- 
scriptions of  complication  exist  together,  the  complete 
complicated  cataract.  According  to  Mr.  Guthrie,  idio- 
pathic or  constitutional  cataract  generally  aflects  both 
eyes ; and  the  local  or  accidental  form  of  the  disease  is 
more  frequently  confined  to  the  organ  that  has  been 
injured  either  by  external  violence  or  active  inflamma- 
tion.—(Op.  cit.  p.  190.)  However,  from  my  being  ac- 
(juainted  with  several  cases  in  which  a cataract  arose 
in  one  eye,  without  any  previous  injury  or  inflamma- 
tion, and  continued  many  years  single,  in  one  case 
twenty  years,  I conclude  that  the  exceptions  to  a part 
of  the  foregoing  statement  are  by  no  means  unfrequent. 

Among  the  locally  complicated  cases  is  the  adhe'- 
rent  cataract.  The  preternatural  cohesion  may  be  one 
of  the  anterior  layer  of  the  capsule  with  the  uvea,  pro- 
duced by  effused  lymph;  it  may  consist  in  a very  firm 
connexion  of  the  posterior  laver  of  the  capsule  with 
the  membrana  hyaloidea;  or  it  may  he  an  unusually 
close  cohesion  of  the  whole  of  the  capsule  with  the 
lens ; or,  says  Beer,  all  the  three  species  of  adhesion 
may  exist  together.— (P.  318.) 

'I'lic  adhesion  of  the  capsule  of  the  lens  to  the  uvea 
(synechia  posterior)  is  generally  obvious  enough ; for, 
as  Beer  has  observed,  the  pupillary  margin  of  the  iris 
is  not  conqilelcly  circular,  and  is  more  angular  the 
stronger  tUc  light  is.  The  caturui’.t  lies  close  to  the 


250 


CATARACT. 


uvea,  and  is  very  white.  The  motions  of  the  iris  are 
more  or  less  obstructed,  and  when  the  adhesion  is  ex- 
tensive, are  quite  prevented.  The  perception  of  light 
is  indistinct,  often  very  faint,  and  .'■ometimes  entirely 
lost,  for  the  preternatural  adhesion  is  always  the  con- 
sequence of  previous  internal  ophthalmy,  which,  be- 
sides occasioning  opacity  of  the  lens  and  its  capsule, 
readily  produces  other  serious  effects  upon  the  retina, 
the  choroid  coat,  and  vitreous  humour,  quite  adequate 
to  account  for  the  loss  of  sight,  and  the  incapacity  of 
distinguishing  the  rays  of  light.  When  the  anterior 
layer  of  the  capsule  is  adlierent  only  at  a single  point 
to  the  uvea,  the  extent  of  the  adhesion  may  be  readily 
ascertained  by  artificially  dilating  the  pupil  with  hyo- 
sciamus  or  belladonna  ; and  the  information  thus  ob- 
tained will  have  great  weight  in  the  selection  of  a me- 
thod of  operating.— (Beer,  loco  cit.) 

Some  other  local  complications  of  cataract  are  so  ob- 
vious that  they  cannot  fail  to  be  understood  ; as,  for  in- 
stance, its  combination  with  an  adhesion  of  the  iris  to 
the  cornea  {synechia  anterior) ; with  closure  of  the 
pupil,  unattended  by  any  adhesion  of  the  uvea  to  the 
anterior  capsule  of  the  lens  (synechia  posterior)  •,  as  in 
watchmakers,  and  hysterical  and  hypochondriacal  sub- 
jects, the  complications  with  atrophy,  hydrophthal- 
mia,  cirsophthalmia,  specks  and  scars  upon  the  cornea, 
pterygium,  and  various  forms  of  ophthalmy. 

According  to  Beer,  the  combination  of  cataract  with 
glaucoma  is  also  readily  made  out  by  any  body  who 
has  once  seen  the  case ; for  the  cataract  always  pre- 
sents a greenish,  and  sometimes  quite  a sea-green  co- 
lour ; it  is  of  prodigious  size,  so  as  to  project  through 
the  pupil  towards  the  cornea ; the  colour  of  the  iris 
is  more  or  less  changed  nearly  in  the  same  manner  as 
after  iritis  ; the  iris  is  perfectly  motionless  ; the  pupil 
very  much  expanded  and  drawn  into  angles,  for  the 
most  part  towards  the  canthi ; the  lesser  circle  of  the 
iris  is  nowhere  visible,  because  it  lies  concealed  under 
the  far-projecting  soft  cataract;  the  light  cannot  be 
perceived,  though  the  blinded  patient  is  frequently  con- 
scious of  false  luminous  appearances  within  the  eye 
(photopsia) ; and,  lastly,  the  case  is  invariably  accom- 
panied with  more  or  less  of  a varicose  state  of  the 
blood-vessels  of  the  eye.  The  origin  of  this  sort  of 
cataract  is  constantly  attended  with  severe  obstinate 
headache. 

There  are,  says  Beer,  two  other  local  complications 
which  are  much  more  difficult  to  iearn  before  an  ope- 
ration. The  first  is  a cataract  combined  with  a disso- 
lution of  the  vitreous  humour  (synchysis),  the  diagno- 
sis of  w’hich,  indeed,  when  the  affection  prevails  m a 
considerable  degree,  is  tolerably  easy,  as  the  cataract 
trembles,  and  the  iris  alw'ays  swings  backwards  and 
forwards  ujwn  the  slightest  motion  of  the  eyeball ; the 
globe  itself  is  somewhat  affected  with  atrophy ; the  eye 
is  quite  spoiled,  and  feels  flaccid  and  unresisting ; the 
sclerotica  immediately  around  the  cornea  is  bluish,  as 
in  infants ; and  the  perception  of  light  is  uncertain. 
On  the  other  hand,  when  the  synchysis  is  not  far  ad- 
vanced, the  only  symptoms  are  a suspicious  softness 
of  the  eyeball,  and  a swinging  of  the  iris  when  the 
eye  is  suddenly  or  violently  moved. 

The  other  complication  of  cataract,  sometimes  very 
difficult  to  detect  previously  to  an  operation,  is  amauro- 
sis. When,  indeed,  the  pupil  is  extraordinarily  large, 
the  iris  nearly  or  quite  motionless,  and  the  patient 
cannot  distingui'-h  day  from  night,  and  of  course  not 
the  least  glimmer  of  lignt,  no  great  powers  of  divina- 
tion are  required  to  predict  with  certainty  that  no  ope- 
ration will  restore  the  eyesight,  wliich  is  abolished,  not 
by  the  cataract,  but  by  the  existing  amaurosis.  On  the 
other  hand,  when  the  motions  of  the  iris  are  nearly  as 
free  as  in  the  natural  state,  tne  pupil  as  small  as  it 
usually  is  in  a given  degree  of  light,  the  patient  capable 
of  judging  accurately  of  the  strength  of  the  light,  and 
yet  the  cataract  conjoined  with  amaurosis,  which,  with 
the  exception  of  the  faculty  of  perceiving  the  light, 
completely  impedes  vision,  it  is  then  only  by  a careful 
inquiry  into  the  his»ory  of  the  disease,  that  certain  cir- 
cumstances attending  the  origin  of  the  cataract,  and 
indicating  in  some  measure  the  prevalence  of  amauro- 
sis, can  be  traced;  some  imes  in  consequence  of  one 
eye  being  affected  with  amaurosis,  and  not  with  cata- 
ract, a reasonable  suspicion  may  be  deduced,  that  the 
eye  with  cataract  is  also  amaurotic ; yet,  says  Beer, 
in  such  a case  nothing  certain  can  be  known  before  an 
operation  is  done.  | 


He  considers  the  general  complications  of  cataract 
to  be  as  numerous  as  the  diseases  of  the  constitution 
itself,  or  as  the  affections  of  other  organs  besides  the 
eye ; but  the  most  common  are  scrofula,  gout,  syphilis, 
psora,  old  ulcers  of  the  leg,  and  an  unhealthy  constitu- 
tion. 

CAUSES,  PROGNOSIS,  &C. 

Persons  much  exposed  to  strong  fires,  as  blacksmiths, 
locksmiths,  glassmen,  and  persons  above  the  age  of 
forty,  have  been  reckoned  more  liable  to  cataracts  than 
other  subjects.— (Wenzel.)  In  young  persons  the  dis- 
ease is  by  no  means  unfrequent : even  children  are  often 
affected,  and  some  are  born  with  it.  Beer  assents  to 
the  general  correctness  of  the  opinion  that  old  age  is 
conducive  to  cataracts,  since  the  disease  is  most  fre- 
quently observed  in  old  persons.  Yet,  says  he,  that 
age,  nay,  a very  great  age,  cannot  be  deemed  a regular 
cause  of  cataract,  is  clear  from  the  circumstance  of 
many  very  old  and  even  decrepit  individuals  being  able, 
with  the  aid  of  spectacles,  to  read  the  smallest  print : 
and  it  would  seem  that  other  causes,  besides  old  age, 
are  essential  to  the  production  of  cataracts , as  for  in- 
stance immoderate  exenion  of  the  eye  during  youth, 
particularly  in  such  employments  as  expose  the  organ 
to  a strong  reflected  light.— (ie/tre  von  den  Augenkr. 
b.  2,p.  325.) 

Among  the  circumstances  which  promote  the  forma- 
tion of  cataracts.  Beer  enumerates  rooms  illuminated 
only  by  reflected  light ; and  all  kinds  of  work  in  which 
the  eyes  are  employed  upon  shining,  small,  microsco- 
pic objects,  especially  when,  during  such  labour,  a de- 
termination of  blood  to  the  head  and  eyes  is  kept  up 
by  the  compressed  state  of  the  abdomen,  the  cataract 
often  seeming  to  come  on  more  or  less  quickly  with 
inflammation  of  the  capsule  and  lens.  And,  accord- 
ing to  the  manifold  experience  of  the  same  author,  one 
of  the  most  important  though  least  noticed  causes  pro- 
moting the  formation  of  cataract,  is  allowing  very 
strong  light  suddenly  to  enter  the  eyes  of  a new-born 
or  very  young,  delicate  infant,  the  consequence  of  w Inch 
is,  that  the  cataracts  form  more  or  less  quickly,  with 
inflammation  of  the  capsule  and  lens,  or  remain  for 
life  incomplete,  as  is  the  case  in  the  central  capsulo- 
lenticular  cataract.  The  habitual  examination  of  mi- 
nute objects  in  a depending  position  of  the  head,  by 
which  an  undue  proportion  of  blood  is  thrown  upon 
the  organ,  is  said  frequently  to  bring  on  cataracts. — 
(See  Med.  Chir.  Trans,  vol.  4,  p.  279.)  In  the  majo- 
rity of  instances,  true  cataracts  arise  spontaneously, 
without  any  assignable  cause.  Sometimes,  however, 
the  opacity  of  the  lens  is  the  consequence  of  external 
violence ; a case  which  more  frequently  than  any 
other  gets  well  without  an  operation. 

Frequently  (says  a modem  writer)  the  cataract 
“ proceeds  from  an  hereditary  disposition  w hich  has 
existed  for  several  successive  general  ions ; while  in 
other  cases  it  attacks  several  members  of  the  same 
family  without  any  disposition  of  this  kind  being  re- 
cognisable in  their  progenitors.  Among  others,  Janin 
mentions  a whole  family  of  six  persons  who  laboured 
under  this  disease.” — (Ohs.  sur  VtKil,  p.  149.)  Richter 
extracted  the  cataract  from  a patient  whose  father  and 
grandfather  had  been  affected  with  the  same  malady, 
and  in  whose  son,  at  that  period,  it  had  begun  to  manifest 
itself.  He  adds,  that  he  had  seen  three  children,  all 
born  of  the  same  parents,  who  acquired  cataracts  at 
the  age  of  three  years.— (Oti  the  different  Kinds  of  Ca- 
taract, p.  3.)  “ During  my  apprenticeship  with  the 
late  Mr.  Hill,  of  Barnstable,  I was  present  when  he 
operated  on  two  brothers  and  a sister,  all  of  w hom 
were  adults,  and  who  stated  that  three  of  four  others 
of  their  family  were  affected  with  symptoms  not  unlike 
those  which  they  had  experienced  at  the  commence- 
ment of  the  complaint.  I myself  recently  operated  on 
two  gentlemen  advanced  in  years,  who  informed  me 
that  they  had  a brother  on  his  return  from  India,  who 
was  similarly  affected.” — (See  Adames  Fract.  Obser- 
vations on  Ectropium,  Artificial  Pupil,  and  Cataract, 
p.  101,  London,  1812.)  Beer  speaks  of  families  in 
which  the  children  all  became  afflicted  with  cataracts 
at  a certain  age ; cases,  says  he,  where  an  operation, 
though  done  by  the  most  skilful  practitioner,  haruly 
ever  succeeds.-^ Le/ire  von  den  Augenkr.  b.  2,  p.  331.) 

Long  exposure  of  the  head  and  eyes  lO  the  rays  of 
the  sun,  together  w'ith  a bent  position  of  the  body,  as 
1 in  some  kinds  of  ffeld  labour,  is  reckoned  by  Beer  a 


CATARACT. 


251 


cause  promoting  the  formation  of  cataracts  on  the  ap- 
proach of  age  ; also  hard  labour  near  strong  fires,  as 
near  evens  and  forges,  in  glass-houses,  &c.  In  Eng- 
land, little  credit  is  given  to  these  opinions. 

Beer  says,  that  he  has  also  learned  from  repeated  ob- 
servation, that  exposing  the  eye  to  the  vapour  of  con- 
centrated acids,  naphtha,  and  alcohol,  will  sometimes 
bring  on  a cataract ; a statement  which  will  be  re- 
ceived in  this  country  with  some  hesitation,  where  the 
vapour  of  ether  has  been  occasionally  recommended 
for  the  dispersion  of  opacities  of  the  lens  and  its  cap- 
sule. The  dust  of  lime  is  also  supposed  to  be  condu- 
cive to  the  disease,  cataracts  being  said  to  be  frequent 
among  the  workmen  in  lime-pits  and  kilns.  In  such 
cases,  I conceive  that  the  cataract  has  mostly  been  the 
result  of  inflammation. 

Wounds  of  the  eye,  where  the  weapon  has  pierced 
the  capsule  and  the  lens,  and  especially  violent  con- 
cussions of  the  forepart  of  the  globe  of  the  eye, 
though  no  wound  may  exist,  are  in  general  followed  by 
a cataract  as  an  immediate  consequence.  This  is  the 
case,  says  Beer,  even  when  no  inflammation  arises 
from  the  injury,  the  cataract  often  occurring  in  a few 
hours,  and  in  so  considerable  a degree  as  not  to  admit 
of  being  mistaken. 

The  cause  of  cataract  thus  rapidly  produced  must 
depend,  in  Beer’s  opinion,  upon  the  complete  separa- 
tion of  the  lens  from  its  connexions  with  the  capsule, 
and  not  unfrequently  in  part  upon  the  detachment  of 
the  capsule  itself  from  the  neighbouring  textures ; for 
in  such  cases  this  membrane  also  gradually  becomes 
opaque. 

According  to  Beer,  cataracts  frequently  arise  from  a 
slow,  insidious  inflammation  of  the  lens  and  its  capsule. 

With  respect  to  the  prognosis,  it  must  be  evident 
from  what  has  been  premised,  that  there  are  many  ca- 
taracts in  which  the  cure  is  highly  problematical,  and 
others  in  which  the  impossibility  of  restoring  vision, 
even  in  the  slightest  degree,  may  be  predicted  with  ab- 
solute certainty. 

With  the  little  positive  information  which  surgeons 
possess  concerning  the  causes  of  cataracts,  scarcely 
any  expectation  can  ever  be  entertained  of  curing  opa- 
cities of  the  lens  and  its  capsule,  by  means  of  medi- 
cine, so  as  to  supersede  all  occasion  for  an  operation. 
A possibility  of  success,  as  Beer  remarks,  can  exist 
only  when  the  cause  of  the  cataract  is  ascertained,  ad- 
mits of  complete  removal,  and  the  disease  is  in  an 
early  stage.  And  he  has  learned  from  manifold  and 
repeated  trials,  that  the  attempt  to  cure  an  incipient 
cataract  will  never  succeed,  except  when  some  deter- 
minate atid  obvious  general  or  local  affection  of  a cu- 
rable nature  has  had  a chief  share  in  the  production  of 
the  disease  of  the  eye  ; as,  for  instance,  scrofula  in  a 
mildish  form,  syphilis,  (?)  and  the  sudden  cure  of  erup- 
tions, or  old  ulcers  of  the  legs,  (?)  or  a slow  insidious 
inflammation  of  the  iris  and  capsule  of  the  lens.  In 
some  examples  of  this  kind.  Beer  could  only  check  the 
farther  progress  of  the  cataract,  and  even  when  the 
eyesight  w'as  improved,  it  was  never  rendered  per- 
fectly clear.  And  when  the  cataract  was  so  far  ad- 
vanced and  quite  developed,  with  the  exception  of  the 
general  melioration  of  the  health,  and  an  improved 
state  of  eye,  whereby  it  was  put  in  a better  condition 
for  the  operation,  not  the  slightest  benefit  was  de- 
rived from  medicine.— (Z>c/ire,  A c.  h.  2,  p.  333.) 

In  this  country  no  faith  is  put  in  these  notions  re- 
specting the  constitutional  influence  of  rheumatism, 
gout,  scrofula,  syphilis,  <fec.  in  the  production  of  cata- 
racts, except  where  such  general  di.sorders  directly  ex- 
cite inflammation  of  the  eye,  and  opacity  of  the  lens 
or  its  capsule  is  brought  on  as  a consequence  of  such 
inflammation.  Indeed,  Mr.  Guthrie  maintains  that 
scrofulous  inflammation  is  rarely  propagated  to  the  in- 
terior of  the  eye,  and  that  strumous  subjects  are  not 
more  subject  to  cataract  than  other  individuals ; an 
opinion  in  which  I perfectly  coincide.  He  also  re- 
marks, that  there  is  no  evidence  of  syphilitic  patients 
being  particularly  liable  to  cataracts,  and  this  even 
when  they  have  suffered  severely  and  frequently.  In 
ohort,  he  absolutely  denies  the  power  of  this  and  other 
constitutional  di.seases  to  jirornote  the  formation  of  an 
opacity  of  the  lens  and  its  capsule,  unless  inflamma- 
tion of  the  eye  be  excited  by  them  (see  Operative  Sur- 
gery of  the  Eye,  p.  191);  a sentiment  which  I think 
is  consonant  to  every  fhet  revealed  to  us  by  daily  ex- 
perience. 


The  principal  external  remedies  that  have  been  tried 
for  the  cure  of  the  cataract  are,  blbeding,  cupping, 
scarifications,  setons,  issues,  blisters,  and  fhmigations , 
' and  the  chief  internal  remedies  are  aperients,  emetics, 
cathartics,  sudorifics,  cephalics,  and  sternutatories. 
Formerly,  preparations  of  eyebright,  millepedes,  wild 
poppy,  henbane,  and  hemlock  were  credulously  ex- 
tolled as  specifics  for  the  disorder. 

Scultetus  asserts  that  he  checked  the  progress  of  a 
cataract  by  applying  to  the  eye  the  gall  of  a pike, 
mixed  with  sugar ; and  Spigelius  boasted  of  having 
successfully  used  for  this  purpose  the  oil  of  the  eelpout 
{mustela  JluviatUis). 

Cataracts  are  said  to  have  been  cured  in  venereal 
patients  while  under  a course  of  mercury.  Probably, 
however,  many  such  .cases  might  have  been  mere  opa- 
cities of  the  cornea,  or,  at  most,  only  transient  opacities 
of  the  capsule,  or  depositions  of  lymph  in  the  posterior 
chamber,  the  consequence  of  existing  or  previous  in- 
flammation. Wenzel  placed  no  reliance  whatever  on 
the  power  of  any  remedies  to  dissipate  a cataract,  and 
as  he  had  remarked  their  inefiicacy  in  numerous  in- 
stances, he  felt  authorized  in  declaring  that  internal 
remedies,  either  of  the  mercurial  or  any  other  kind, 
are  inadequate  to  the  cure  of  this  disorder ; and  equally 
so,  whether  the  opacity  be  in  the  crystalline  or  in  the 
capsule,  whether  incipient  or  advanced. 

Although  the  late  Mr.  Ware  coincided  with  Wenzel 
and  Beer  in  regard  to  the  uncertainty  of  all  known 
medicines  to  dissipate  an  opacity,  either  in  the  lens  or 
its  capsule,  or  even  to  prevent  the  progress  of  such 
opacity  when  once  begun,  yet,  according  to  his  obser- 
vations, many  cases  prove  that  the  powers  of  nature 
are  often  sufficient  to  accomplish  these  purposes.  The 
opacities,  in  particular,  which  are  produced  by  external 
violence,  Mr.  Ware  had  repeatedly  seen  dissipated  in 
a short  space  of  time,  when  no  other  parts  of  the  eye 
had  been  hurt.  In  such  cases  the  crystalline  lens  is 
generally  absorbed,  as  is  proved  by  the  benefit  which 
is  afterward  derived  from  very  convex  glasses.  In 
some  of  these  cases,  though  the  crystalline  had  been 
dissolved,  the  greater  part  of  the  capsule  remained 
opaque,  and  the  light  was  transmitted  to  the  retina 
only  through  a small  aperture  which  had  become  trans- 
parent in  its  centre.  Instances  are  also  recorded,  in 
which  cataracts,  formed  without  any  violence,  have 
been  suddenly  dissipated  in  consequence  of  an  acci- 
dental blow  on  the  eye.  The  remedies  which  Mr. 
Ware  found  more  effectual  than  others,  were  the  ap- 
plication to  the  eye  itself  of  one  or  two  drops  of  ether 
once  or  twice  in  the  course  of  the  day,  and  occasionally 
rubbing  the  eye  over  the  lid  with  the  point  of  the  fin- 
ger, first  moistened  with  a weak  volatile  or  mercurial 
liniment.  While  M*-.  Guthrie  admits  that  opacities 
perceptible  behind  the  iris  have  been  cured  under  a 
course  of  medicine,  he  considers  such  events  very 
rare,  and  to  have  been  accomplished  only  when  the 
opacity  arose  from  slight  depositions  in* the  capsule, 
the  result  of  simple  inflammation  rather  than  from  any 
affection  of  the  crystalline  itself.  A haziness  of  the 
capsule,  caused  by  the  extension  of  inflammation  of 
the  iris  to  it,  he  says,  may  almost  always  be  relieved 
under  the  treatment  proper  lor  the  cure  of  iritis ; but 
he  does  not  believe  that  an  opacity  of  the  lens,  dis- 
tinctly discerned  to  be  such,  has  ever  been  removed  by 
medicine.  He  expresse-s  his  decided  opinion,  that  if 
any  lenticular  cataracts  have  really  been  cured,  they 
were  caused  by  external  violence,  and  disappeared  in 
consequence  of  their  dissolution  in  the  aqueous  hu- 
mour, and  the  action  of  the  absorbents,  the  opacity  of 
the  lens  having  been  the  result  of  a rupture  of  its  cap- 
sule. Mr.  Ware,  who  at  one  time  supposed  that  inci- 
pient cataracts  might  be  cured  by  spirituous  applies 
tions,  and  particularly  the  sulphuric  ether,  latterly 
abandoned  the  opinion ; and  it  would  seem  from  a 
note  in  the  third  edition  of  his  book  on  the  cataract, 
that  the  cases  he  published  in  the  first  and  second,  and 
as  proceeding  from  an  external  injury,  were  of  the  lat- 
ter description. — {Operative  Surgery  of  the  Eye,  p. 
250.)  In  short,  the  operation  is  now  regarded  as  the 
only  means  affording  any  rational  hope  of  restoring 
the  eyesight  of  patients  afflicted  with  cataracts. 

Notwithstanding  al.so  the  perfection  to  which  the 
operation,  with  all  its  different  modifications,  is  really 
brought,  its  performance  will  not  always  re-establish 
vision  ; nay,  says  Beer,  it  is  frequently  conmerindi- 
cated  ; and  even  in  favourable  cases  the  result  of  the 


252 


CATARACT. 


operation  is  exposed  to  so  many  contingencies,  that  it 
is  rather  a matter  of  surprise  that,  on  the  whole,  so 
much  success  should  attend  it  as  is  found  to  happen. 

When  an  operation  for  a cataract  is  done  apparently 
under  favourable  circumstances,  and  its  event  is  un- 
expectedly very  incomplete  or  quite  unsuccessful,  sur- 
geons in  vain  ascribe  the  failure  to  the  particular  me- 
thod of  operating  which  they  have  hitherto  adopted, 
and  uselessly  abandon  it  for  another ; because  none  of 
these  methods,  including  that  which  is  preferred, 
brought  to  the  highest  state  of  perfection  possible,  can 
be  applicable  to  all  cataracts.  But,  says  Beer,  the  rea- 
son of  the  ill  success  is  generally  rather  owing  to  the 
operation  not  having  been  indicated,  or  to  a mode  of 
operating  not  we'l  calculated  for  the  particular  case 
having  been  selected  He  ridicules  the  idea  of  adher- 
ing exclusively  to  any  otie  plan  of  operating;  and 
whenever  the  question  was  put  to  him,  “ what  is  your 
plan  V'  he  answered,  that  his  custom  was  to  operate 
in  the  manner  which  appeared  to  him  the  best  adapted 
to  each  particular  case  about  which  he  v/as  consulted. 
A surgeon  should  be  able  to  distinguish,  first,  the  cases 
of  cataract  in  which  an  operation  may  be  done  with 
the  best  chance  of  success  ; secondly,  the  examples  in 
which  the  prognosis  is  more  or  less  doubtful;  and, 
lastly,  the  cases  in  which  there  is  a great  probability  or 
an  absolute  certainty  of  the  operation  failing,  in  which 
last  circumstance  the  practice  is  prohibited. 

According  to  Beer,  the  result  of  an  operation  will 
probably  be  favourable,  1.  When  the  cataract  is  a 
genuine  local  complaint,  perfectly  free  from  every  spe- 
cies of  complication.  2.  When  the  conformation  of  the 
eye  and  surrounding  parts  is  such,  as  to  allow  what- 
ever method  of  operating  may  be  most  advantageous 
for  the  particular  case,  to  be  done  without  ditficulty. 
3.  When  the  patient  is  intelligent  enough  to  behave 
himself  in  a manner  which  will  not  disturb  the  preci- 
sion and  safety  of  the  requisite  proceedings  in  the  ope- 
ration or  the  subsequent  treatment.  4 When  the  ope- 
rator not  only  possesses  all  requisite  medical  and  sur- 
gical knowledge  in  general,  but  is  capable  of  judging 
correctly  what  method  of  operating  suits  the  particular 
case ; and  when  besides  he  has  derived  from  nature 
and  acquirement  such  menial  and  corporeal  qualities 
as  are  essential  to  a skilful  operator  on  the  eye ; viz. 
an  acute  eyesight,  a steady,  but  light,  skilful  hand,  ex- 
cellently qualified  for  mechanical  artifice  in  general ; 
long,  pliant  fingers ; a delicate  touch ; a certain  ten- 
derness in  the  scientific  treatment  of  this  particular 
organ  ; complete  fearlessness  ; invincible  presence  of 
mind ; and  proper  circumspection.  5.  When  the  re- 
quisite instruments  are  not  loo  complicated ; but  w'ell 
adapted  to  the  purpose,  and  in  right  order.  6.  When 
the  domestic  condition  of  the  patient  is  such  as  not  to 
occasion  any  particular  disadvantages  during  or  after 
the  operation.  Yet,  says  Beer,  even  with  this  fortunate 
combination  of  circumstances,  uniform  success  must 
not  be  expecfed  ; for  a patient  whose  sight  is  quite  pre- 
vented by  this  disease,  and  who,  previously  to  its  ori- 
gin was  already  far-sighted,  will  be  still  more  so  after 
the  removal  of  the  diseased  lens,  aiid,  in  order  to  see 
distinctly  the  most  common  objects  wliich  are  near,  he 
will  be  obliged  constantly  to  employ  suitable  glasses. 
An  individual  of  this  description,  though  the  operation 
be  done  with  great  success,  is  apt  not  to  be  satisfied. 
But  such  patients  as  were  short-sighted  previously  to 
the  formation  of  their  cataracts,  are  more  pleased  with 
file  restoration  of  vision  ; as  before  the  operation  their 
eyesight  was  much  less  than  what  it  is  now,  and  in 
general  they  can  lay  aside  the  glasses  which  they  for- 
merly made  use  of,  without  having  occasion  for  any 
others.  Lastly,  as  Beer  remarks,  although  patients, 
who  before  the  origin  of  their  cataracts  were  neither 
far  nor  short  sighted,  are  sensible  of  the  important  bene- 
fit of  an  operation,  inasmuch  as  they  now  plainly  dis- 
cern .‘ill  objects  again,  yet  they  are  usually  obliged  to 
employ  spectacles  in  reading,  writing,  or  doing  any 
kind  of  fine  work. 

On  the  other  hand,  the  result  of  an  operation  Beer 
co.nsiders  always  more  or  less  doubtful,  1.  When  the 
cataract  is  only  locally  complicated,  as,  for  instance, 
with  pterygium,  which  may  not  form  any  absolute 
reason  against  the  experiment.  2.  When  the  conlbr- 
mation  of  the  eye  and  surrounding  parts  causes  .several 
hindrances  to  the  operator ; as  is  the  case  when  the 
eye  is  small,  and  deep  in  the  orbit,  and  the  fissure  of 
the  eyehd.s  very  narrow.  3.  When  the  patient  is  either 


very  stupid  and  obstinate,  rough-mannered,  particu- 
larly timid,  or  badly  fed.  4.  When  the  surgeon  knows 
how  to  operate  only  in  one  way,  in  which  perhaps  he 
has  also  not  had  sufiicient  experience,  and  when  pos- 
sibly he  is  also  deficient  in  the  qualities  specified  above 
as  essential  to  a good  operator  on  the  eyes.  5.  When 
the  instruments  are  bad.  6.  When  in  the  patient’s 
domestic  affairs  there  are  any  circumstances  which 
cannot  be  removed,  and  are  likely  to  have  a bad  effect 
upon  the  operation,  as  an  unwholesome,  damp  room, 
great  uncleanliness,  &c.  7.  When  the  origin  of  the 
cataract  was  attended  with  repeated  or  tedious  head- 
ache, though  this  may  have  subsided  a long  while. 
8.  Wlien  the  patient  is  particularly  subject  to  catarrhal 
and  rheumatic  complaints,  especially  affecting  the 
eyes.  9.  When  the  patient  has  often  had,  or  still  la- 
bours under,  an  attack  of  erysipelas,  notwithstan^ng 
the  parts  inflamed  be  remote  from  the  eye.  10.  When 
the  patient’s  skin  is  peculiarly  irritable.  11.  When  in 
his  childhood  or  youth  he  has  been  frequently  afflicted 
with  convulsions  or  epileptic  fits,  though  these  com- 
plaints may  have  ceased  many  years.  12.  When  there 
is  the  least  tendency  to  certeiin  constitutional  diseases, 
scrofula,  gout,  syphilis,  «fec.  Gout,  however,  does  not 
always  make  an  operation  fail,  as  we  learn  from  Mr. 
Travers,  who,  in  three  cases,  e.xtracted  the  cataract 
from  gouty  subjects,  and,  though  a smart  attack  of  the 
disease  followed  the  operation,  the  eyes  were  unaffected, 
and  the  sight  was  well  recovered. — {Synopsis  of  the 
Diseases  of  the  Eye,  p.  297.)  13.  When  the  patient’s 
habit  is  bad,  though  not  affected  with  any  definite  dis- 
order. 14.  When  the  patient  in  his  youth  has  often 
been  troubled  with  attacks  of  ophthalmy.  15.  When 
he  cannot  perceive  the  different  degrees  of  light,  and 
correctly  describe  them,  while  nothing  to  account  for 
this  state  can  be  detected  in  the  eye  itself.  16.  The  re- 
sult of  an  operation  is  always  very  doubtful,  when  there 
is  the  slightest  tendency  to  hysteria  or  hypochondriasis. 
17.  When  the  patient  is  subject  to  violent  mental  emo- 
tions, mania,  &c.  18.  When  the  eye  to  be  ojierated 
upon  can  still  discern  things,  however  feebly ; a state 
which  generally  produces  an  involuntary  resistance  to 
the  necessary  measures  in  the  operation.  19.  When 
the  cataract  is  the  consequence  of  a wound,  though 
free  from  complication.  20.  When  the  patient  is  in  the 
state  of  pregnancy.  21.  When  one  eye  has  been  already 
destroyed  by  suppuration.  22.  And  lastly,  when  One 
eye  has  already  been  operated  upon  without  success 
by  a man  whose  professional  judgment,  skill,  and  cau- 
tion are  unquestionable. 

According  to  Beer,  the  result  of  the  operation  will  be 
more  or  less  unfavourable,  1.  When  the  patient  is  af- 
fected with  gutta  or  acne  rosacea,  not  the  effect  of  hard 
drinking,  but  rather  of  scurvy.  2.  When  evident  traces 
of  some  general  disease  of  the  constitution  are  present. 
3.  When  the  patient  has  been  ill,  and  is  only  yet  conva- 
lescent. 4.  When  any  other  disease,  though  not  con- 
stitutional, is  present.  5.  When  the  cataract  is  adhe- 
rent for  a considerable  extent  to  the  uvea,  or  an  incur- 
able, though  not  very  severe,  chronic  inflammatory 
affection  of  the  eyelids  or  eyeball  prevails,  as,  for  in- 
stance, an  habitual  inflammation  of  the  Meibomian 
glands ; ectropium  of  the  lower  eyelid  ; the  remains  of 
a pannus ; or  a strong  aversion  to  light. 

Lastly,  as  Beer  observes,  every  operation  must  fail 
when  the  cataract  is  manifestly  joined  with  complete 
amaurosis,  a dissolution  of  the  vitreous  humour,  dropsy, 
or  atrophy  of  the  eye,  some  species  of  ophthalmy,  glau- 
coma, or  a general  varicose  affection  of  the  blood-ves- 
sels of  the  eye. 

The  capacity  of  distinguishing  light  from  darkness, 
and  in  a shady  place,  where  the  pupil  is  not  too  much 
contracted,  of  perceiving  bright  colours  and  the  shadows 
of  objects,  is,  as  Scarpa  has  particularly  noticed,  a very 
important  desideratum  in  every  case  selected  for  ope- 
ration. 

The  power  of  distinguishing  light  from  darkness  is 
even  more  satisfactory  than  motion  of  the  iris.  I saw, 
many  years  ago,  in  St.  Bartholomew’s  and  the  York 
Hospitals,  several  cases  of  complete  gutta  serena  in 
both  eyes,  in  which  there  was  the  freest  contraction 
and  dilatation  of  the  pupils.  Had  such  patients  been 
also  afflicted  with  cataract  (a  complication  by  no  means 
unfrequent),  and  a surgeon,  induced  by  the  moveable 
state  of  the  iris,  had  undertaken  an  operation,  it  mu.st 
of  course  have  proved  unavailing,  since  the  rays  of 
Lgiii  could  only  have  been  traiisiiiittcd  to  an  insens.u.o 


CATARACT. 


253 


relina.  Richter  and  Wenzel  make  mention  of  these 
peculiarities,  and  the  latter  refers  the  phenomenon  to 
the  iris  deriving  its  nerves  wholly  from  the  lenticular 
ganglion,  while  the  immediate  organ  of  sight  is  consti- 
tuted entirely  by  another  distinct  nerve.  Hence,  mo- 
tion of  the  iris  is  not  an  infallible  criterion,  as  authors 
have  stated  (Wat  A ere),  that  the  retina  is  endued  with 
sensibility.  Relating  to  this  subject,  Mr.  Lucas  has 
made  a curious  remark : he  attended,  in  conjunction 
with  Hey  and  Jones,  five  children  of  a clergyman  at 
Leaven,  near  Beverley,  who  were  all  born  blind.  He 
writes,  “ None  of  them  can  distinguish  light  from  dark- 
ness, and  although  the  pupil  is,  in  common,  neither  too 
much  dilated  nor  contracted,  and  has  motions,  yet 
these  do  not  seem  to  depend  upon  the  usual  causes, 
but  are  irregular.”— (Jfed.  Obs.  and  Jnq.  voL  6.) 

The  reciprocal  sympathy  between  the  two  organs  of 
sight  is  so  active,  that  no  one,  solicitous  to  acquire 
either  physiological  or  pathological  knowledge  respect- 
ing them,  ought,  for  a moment,  to  forget  it.  Hence,  in 
the  examination  of  cataracts,  it  is  of  the  highest  im- 
portance to  keep  one  eye  entirely  secluded  from  the 
light,  while  the  surgeon  is  investigating  the  state  of  the 
iris  in  the  other ; for  the  impression^f  the  rays  of  light 
upon  one  eye,  sensible  to  this  stimulus,  is  known  to 
be  often  sufficient  to  produce  corresponding  motions  of 
the  iris  in  the  opposite  one,  although  in  the  state  of 
perfect  amaurosis.  In  other  examples  of  cataract,  the 
pupil  may  be  quite  motionless,  and  yet  sight  shall  be 
restored  after  the  performance  of  an  operation.  {Wen- 
zel.) There  are  two  circumstances,  however,  which 
may  prevent  us  fr.jm  ascertaining  whether  the  retina  is 
sensible  to  light  or  not : the  first  is,  a circular  adhesion 
of  the  crystalline  capsule  to  the  iris.  Here  Richter 
thought  that  some  opinion  might  be  formed  of  the 
nature  of  this  case  by  observing  the  distance  between 
the  cataract  and  pupil ; inferring  that  when  Uie  space 
between  the  pupil  and  opaque  lens  was  inconsiderable, 
such  an  adhesion  had  happened  ; and  when  the  cata- 
ract did  not  seem  particularly  close  to  the  pupil,  and 
yet  the  patient  could  not  discern  light  from  darkness, 
that  it  was  complicated  with  amaurosis.  The  second 
circumstance,  sometimes  utterly  preventing  the  ingress 
of  any  light  to  the  healthy  retina,  is  the  roimd,  bulky 
form  of  the  cataract. 

But  although  the  power  of  distinguishing  light  from 
darkness  is  more  satisfactory  than  motion  of  the  iris, 
it  is  not  an  unequivocal  test  of  the  retina  bemg  per- 
fectly free  from  disease.  While  the  gutta  serena  is 
incomplete,  the  patient  can  yet  distinguish  light  and 
the  shadows  of  objects.  Dilatation  of  the  pupil  is  also 
a deceitful  criterion  of  the  complication  of  gutta  serena 
with  the  cataract  When  the  cataract  is  large,  or  ad- 
herent to  the  iris,  the  pupil  is  frequently  much  dilated, 
though  the  optic  nerve  may  be  natural  and  sound  : the 
pupil  often  continues  quite  undilated  in  a perfect  gutta 
serena.— (Ric/tter.) 

From  all  this  it  must  be  manifest,  Ist,  That  the  irre- 
gularity and  inconstancy  of  the  symptoms  of  gutta 
serena,  together  with  the  possibility  of  particular  states 
of  the  cataract  rendering  the  patient  utterly  uncon- 
scious of  the  stimulus  of  light,  make  it  necessary  for  the 
surgeon  to  be  particularly  attentive  to  the  appearance 
and  to  the  history  of  the  origin  and  progress  of  the  dis- 
ease, in  order  to  understand  the  real  condition  of  cer- 
tain causes.  2dly,  That  when  the  patient  can  distin- 
guish light  from  darkness,  though  the  iris  may  be 
motionless,  there  is  good  ground  for  trying  an  opera- 
tion. Possibly  in  this  circumstance  an  incipient  amau- 
rosis may  exist ; but  the  chance  of  the  defect  of  the 
iris  arising  from  other  causes ; the  certainty  that  the 
opaque  body  must  be  removed  from  the  axis  of  sight 
(even  if  the  di.iease  of  the  retina  be  cured),  ere  sight 
can  be  restored  ; and  the  improbability  that  an  opera- 
tion to  cure  the  cataract  will  render  the  otlier  complaint 
at  all  less  remediable,  fully  justify  the  attempt.  Fre- 
quently, the  patient  has  a fully-formed  cataract  in  one 
eye,  which  presents  the  signs  of  amaurosis,  while  an 
incipient  cataract,  or  one  as  much  advanced,  exists  in 
the  other,  which  at  present  is  free  from  these  symp- 
toms : in  this  case  (says  Mr.  Travers),  the  cataract  of 
the  latter  should  be  removed  witlioul  delay. — {Synop- 
sis, tsrc.  p.  314.) 

The  concurrent  testimony  of  almost  all  writers  upon 
the  subject  tends  to  prove,  that  the  restoration  of  sight 
has  sometimes  been  effected  in  the  most  hopeless  cases  ; 
u.id  I am  therefore  of  opinion  with  Mr.  Lucas,  that  in 


all  doubtful  cases  an  operation  should  be  tried  as  a 
remedy  by  no  means  violent  or  hazardous. — [^Med.  Obs. 
and  Inquiries,  vol.  6,  p.  257.) 

I shall  conclude  tliis  part  of  the  subject  with  annex- 
ing the  sentiment  of- Mr.  Travers,  viz.  that  it  would  be 
incorrect  to  say  that  the  operation  is  unadvisable  in  all 
cases  of  cataract  in  which  the  patient  has  no  sense  of 
light;  for  it  is  possible  that  the  density  of  the  lens 
may  be  such  as  absolutely  to  exclude  the  light,  and 
that  the  motions  of  the  iris  may  be  therefore  suspended ; 
or  from  some  degree  of  pressure  of  the  lens  or  ndhe  - 
sion  of  the  uvea  to  the  capsule,  that  the  pupil  may  be 
undilated,  and  the  circumference  of  the  lens  perma- 
nently covered.  But  undoubtedly,  says  Mr.  Travers, 
a case  of  this  description  is  unpromising.  “ A strong 
sense  of  light  by  which  at  least  to  know  the  direction 
in  which  it  enters  the  apartment,  to  be  sensible  of  its 
falling  on  the  eye,  and  of  a shade,  as  the  hand  for  ex 
ample,  intercepting  it,  with  a corresponding  freedom 
of  motion  of  the  pupil,  is  le  most  favourable  state  for 
the  operation.” — {Synopsis  of  the  Diseases  of  the  / ye, 
p.  315.) 

As  it  not  unfrequently  happens  that  cataracts  pro- 
duced by  external  violence  spontaneously  disappear 
{Pott,  Hey,A.  c.),  the  operation  should  never  be  too  hastily 
recommended  for  them. 

Respecting  the  question,  whether  an  operation  ought 
to  be  done  when  only  one  eye  is  affected  with  cataract, 
and  the  other  is  sound,  some  difference  of  opinion  pre- 
vails. 

One  reason  assigned  by  the  condemners  of  this  prac- 
tice, viz.  that  one  eye  is  sufficient  for  the  necessities 
of  life,  is  but  of  a frivolous  description  ; and  another, 
that  the  patient  would  never  be  able  to  see  distinctly 
after  the  operation,  by  reason  of  the  difference  of  the  fo- 
cus in  the  eyes,  is  (I  have  grounds  for  believing)  only 
a gratuitous  supposition,  inconsiderately  transmitted 
from  one  writer  to  another.  In  support  of  what  I have 
here  advanced,  and  to  prove  that  success  does  some- 
times, probably  in  general  (if  no  other  causes  of  fail- 
ure exist),  attend  the  practice  of  couching  and  extrac- 
tion, when  only  one  eye  is  affected  with  a cataract,  I 
refer  to  a case  reported  by  Malire-Jan. — {Trait<'  d.s 
Maladies  de  ViF.il,  tdit.  Paris,  IQmo.  Obs.  sur 
une  Cataracte  laiteuse,  p.  19C.) 

Baron  Wenzel  was  in  the  habit  of  extracting  cata- 
racts with  the  most  successful  result,  when  only  one 
eye  was  affected  with  the  disease,  as  may  be  learned 
by  referring  to  the  cases  here  specified. — {Cases,  6,  1.3, 
16,  19,  22,  25,  29, 30,  31,  34,  <kc.  Treatise  on  the  Cata- 
ract.) 

Richter  was  formerly  convinced,  that  the  advice  not 
to  operate  when  there  is  a cataract  only  in  one  eye, 
ought,  for  several  reasons,  to  be  disregarded  : he  re- 
minds us  of  the  wmnderful  consent  between  the  eyes, 
so  that  one  is  seldom  diseased  without  the  other, 
sooner  or  later,  falling  into  the  same  state ; and  hence 
he  questions  whether  it  may  not  be  possible  to  prevent 
the  loss  of  the  somid  eye  by  a\imely  operation  ? An 
non  caveri  possit  jactura  integri  oculi  tempestive  ex- 
trahendocataractam prions? — {Obs.  Chir.fascic.  1.)  He 
adverts  to  the  remarkable  case  related  by  St.  Ives, 
where  a man  was  wounded  in  the  right  eye  by  a small 
shot,  and  shortly  afterward  had  a cataract  in  it ; he 
then  gradually  became  blind  in  the  left,  but  soon  reco- 
vered his  sight  in  it,  after  the  cataract  had  been  ex 
tracted  from  the  right  one.  Here  let  us  notice,  that  St 
Ives,  {Maladies  des  Yeux,  chap.  15,  art.  3)  makes  no 
mention  of  any  confusion  in  vision,  in  consequence  of 
the  different  refracting  powers  of  the  two  eyes  in  ques- 
tion. From  .some  modern  publications,  indeed,  it  would 
appear,  that,  in  a lew  instances,  an  incipient  cataract 
in  one  eye  has  actually  disappeared  of  itself,  aller  the 
operation  had  been  performed  for  a complete  one  in  the 
other. — {Carmichael,  in  Med.  and  Physical  Joum.  vol. 
19 ; and  Stevenson,  in  Edin.  Med.  and  Surg.  Journ. 
No.  77,  p.  521.)  This  is  a circumstance  which  is 
urged  by  the  latter  gentleman,  not  only  as  a strong 
reason  for  disregarding  the  common  opinion,  that  a 
cataract  should  never  be  operated  upon  while  the  other 
eye  enjoys  useful  vision,  but  as  a powerful  motive  lor 
doing  the  operation  even  at  an  early  period  so ; that  if 
there  be  no  cataract  in  the  other  eye,  the  operation  may 
be  the  means  of  preventing  its  formation,  or  if  it  be 
already  beginning,  the  chance  of  its  dispersal  by  The 
effect  of  the  removal  of  the  other  cataract  may  h» 
taken.  In  the  Medical  and  Physical  Journ.  for  May, 


iiS4 


CATARACT. 


1808,  IS  also  an  ingenious  paper,  defending  the  practice 
of  operating  when  only  one  eye  is  affected.  Another 
reason,  judiciou-sly  assigned  by  Richter  {Obs.  Chirurg. 
fascic.  1),  for  disregarding  the  above  precept,  is,  that 
in  waiting  until  a cataract  forms  in  the  other  eye,  the 
existing  one,  which  is  at  this  moment,  perhaps,  in  the 
most  favourable  state  for  the  operation,  may  soon 
change  so  much  for  the  worse  (for  instance,  it  may- 
contract  such  adhesions  to  the  iris),  as  either  to  de- 
stroy all  prospect  of  relief,  or,  at  most,  afford  but  a 
very  precarious  and  discouraging  one.  The  length  of 
time  necessary  to  wait  is  also  uncertain  and  tedious. 
I once  saw  a man  in  St.  Bartholomew’s  Hospital,  who 
had  had  a cataract  in  one  eye  fifteen  years,  during 
all  which  time  the  other  continued  quite  sound ; and 
another  case  of  twenty  years’  standing  has  lately  been 
communicated  to  me.  It  is  right  to  state,  that  Richter 
latterly  inculcated  a contrary  opinion  to  what  he  for- 
merly espoused,  yet  without  specifying  the  particular 
facts  which  induced  him  to  revoke  his  former  senti- 
ments. The  principal  reason  stated  by  him  is,  that 
the  patient  not  only  does  not  see  much  more  acutely 
with  the  two  eyes  after  the  operation,  than  with  one 
before  it,  but  he  frequently  sees  more  confusedly,  be- 
cause the  eye  that  has  been  operated  on  cannot  see 
well  without  the  aid  of  a glass,  which  perhaps  the 
sound  one  does  not  r^qmre.—i^Anfangsgrunde  der 
Wundarzn.  Dritter.  b.  3,  p.  199.) 

When  I remember  that  no  cases  are  adduced  by  this 
author  to  contradict  the  rationality  of  his  former  sen- 
timents ; when  I also  refiect  ujton  the  facts  recorded 
by  Maitre-Jan,  St.  Ives,  and  Wenzel ; when  I contem- 
plate that  Callisen  mentions,  as  the  feeble  ground  of 
his  adopting  the  common  opinion,  that  in  one  single 
instance  of  this  description  he  w as  unsaccesslul,  with-* 
out  particularizing  from  what  immediate  cause  the 
failure  arose  ; there  appears  to  my  mind  strong  cause 
to  believe  that  the  advice  not  to  operate  when  there  is 
only  one  cataract,  and  the  other  eye  is  perfect,  is  at 
least  a subject  which  merits  farther  investigation. 
Warner’s  objection  is  similar  to  that  specified  by  Rich- 
ter : he  writes,  “ the  eye  from  which  the  crystalline 
lens  is  removed  cannot  be  restored  to  a degree  of  per- 
fection at  all  equal  to  that  of  the  sound  eye,  without 
the  assistance  of  a convex  glas'’  {Description  of  the 
Human  Eye,  and  its  Diseases,  p.  85) ; but  is  not  the 
power  of  using  both  eyes  at  the  same  time,  even  with 
the  inconvenience  of  being  necessitated  to  employ  a 
glass  tor  the  purpose,  preferable  lo  being  blind  of  one  ? 
The  cases  quoted,  ai  all  events,  prove,  tliat  confusion 
in  vision  is  not ‘alw'ays  the  result  of  the  practice; 
whether  the  fact  is  concordant  with  the  modern  theory 
of  vision  is  entirely  another  consideration  ; if  it  should 
be  found  incompatible  with  it,  we  must  infer  that  our 
knowledge  of  optics  still  continues  imperfect;  not  that 
such  well-attested  examples,  as  some  alluded  to,  are 
unworthy  ol  belief. 

When  there  is  a fqlly  formed  cataract  in  one  eye, 
and  vision  is  retained  in  the  other,  Mr.  Travers  thinks 
the  postponement  of  the  operation  wrong.  “I  am  sa- 
tisfied (says  he)  that  the  cataractous  eye,  if  it  becomes 
the  subject  of  an  accidental  inflammation,  is  strongly 
disposed  to  go  into  amaurosis ; and,  farther,  that  the 
retina  loses  its  vigour  by  the  permanent  exclusion  of 
light.  1 speak  from  repeated  observaiion  of  the  fact. 
The  objection  to  the  operation  on  the  ground  of  incon- 
venience, arising  from  the  difference  of  focus  of  the 
two  eyes,  when  one  only  is  the  subject  ol‘  disease,  is 
trivial,  and  a consideration  altogether  subordinate : 
such  a defect  may  aUvays  be  remedied  by  glasses  pro- 
perly adjusted.  In  several  cases  of  amaurosis  ensuing 
upon  cataract,  I have  been  disposed  to  regard  the 
change  in  consistence  and  volume  of  the  lens,  as  pro- 
ductive of  a destroying  inflammation ; in  others,  of  a 
partial  absorption  of  the  vitreous  humour.” — {Synop- 
sis of  Diseases  of  the  Eye,  p.  313.) 

For  some  decided  information  on  the  foregoing  inte- 
resting question,  I have  referred  to  Beer ; but  he  seems 
not  lo  have  entered  into  its  consideration  at  all.  The 
only  instance  in  which  he  approaches  the  subject  is, 
when  he  notices  the  custom  of  covering  the  eye,  which 
yet  possesses  more  or  less  vision,  w hen  the  other  alone 
has  a cataract  in  a fit  state  for  an  ojieration. — Lehre 
vormden  Augenkr.  b.  2,  p.  351.) 

The  reason  which  has  induced  me  to  allot  so  much 
space  for  the  consideration  of  the  question,  whether 
an  operation  should  be  undertaken  when  only  one  eye  J 


is  affected,  is  a conviction  of  the  importance  of  the  de- 
cision made  about  it.  Were  I to  judge  only  from  what 
has  been  said  by  writers,  I should  be  confident  that  a 
determination  in  the  negative  must  be  erroneous ; but 
when  I know  that  my  experienced  and  judicious  friend 
Mr.  Lawrence  joins  in  the  belief  that  the  practice  is 
not  productive  of  advantage,  the  only  inference  which 
1 venture  to  make  is,  that  the  subject  deserves  far- 
ther experiment. 

Mr.  Guthrie  even  declares,  that  he  has  ftiet  with 
several  “ ca.ses  in  which  great  inconvenience  was  sus- 
tained from  the  confusion  of  vision  caused  by  a suc- 
cessful operation and  in  one  instance,  the  patient 
actually  wished  him  to  destroy  the  sight  gained  by  the 
operation.  He  therefore  joins  in  the  opinion  that  the 
operation  should  not  be  attempted  on  one  eye  while 
the  other  is  sound. — {Operative  Surgery  of  the  Eye,  p. 
258.) 

On  the  other  hand,  however,  we  have  the  evidence 
of  Dr.  Andrew  Smith,  a gentleman  whose  observa- 
tions appear  to  be  deduced  from  considerable  experi- 
ence in  the  ophthalmic  hospital  at  Chatham.  He  ad- 
mits that  a slight  degree  of  double  vision  does  occur 
for  a short  time  after  the  lens  has  been  extracted.  In 
cases  where  the  lens  was  broken  up,  however,  this 
casual  imperfection  did  not  occur,  as,  before  the  lens 
was  absorbed,  the  eye  became  accustomed  to  its  pri- 
vation. “ The  following  (says  he)  were  the  remarks 
I made  on  the  cases  in  which  extraction  w'as  per- 
formed. Three  saw  objects  double  when  the  bandage 
was  first  removed,  and  for  nearly  twenty-lbur  hours ; 
and  then  singly.  Two  saw  double  for  about  three 
hours;  and  one  of  them,  two  days  afterward,  upon 
being  surprised,  and  opening  his  eyelids  suddenly,  ex- 
perienced lor  a few  seconds  the  same  imperfection.  A 
sixth  saw  constantly  double  for  four  day?,  and  after 
that  as  distinctly  as  ever  he  did  ; and  the  other  three 
cases,  as  above  remarked,  always  single.” — {Edin. 
Med.  and  Surgical  Joum.  No.  74,  p.  14.)  On  the 
whole,  I consider  this  question,  which  is  a very  impor- 
tant one  in  practice,  by  no  means  decidedly  settled ; 
and  as  far  as  the  evidence  of  various  writers  upon  it 
extends,  I think  those  who  are  in  favour  of  operating 
upon  a cataract,  though  the  other  eye  is  sound,  have 
the  best  of  the  argument. 

When  there  are  cataracts  in  both  eyes,  most  authors 
are  of  opinion  that  there  is  no  reason  w hy  one  should 
not  be  operated  upon  immediately  after  the  other.  As, 
however,  the  ophthalmy  is  likely  to  be  more  severe, 
ciBteris  f.aribus,  when  both  eyes  are  operated  upon  at 
the  same  time,  Scarpa,  who  gives  the  preference  to  the 
needle,  disapproves  of  this  mode  of  proceeding,  and 
assures  us,  that  in  patients  with  cataracts  in  both, 
eyes,  his  exj-erience  has  taught  him,  that  it  is  by  no 
means  advantageous  to  operate  upon  one  immediately 
after  the  other;  but  that  it  is  better  to  wait  till  one  eye 
is  well,  before  any  attempt  is  made  upon  the  other. — 
{Saggio  di  Osservaziovi,  <s  c.  p.  255.) 

On  this  point,  the  following  is  Beer’s  sentiment : — 
When  cataracts  are  completely  formed  in  both  eyes,, 
the  patient  willing,  and  every  thing  promises  a favour- 
able result,  both  eyes  may  be  operated  upon  at  the  same 
time.  On  the  contrary,  when  any  circumstances  are  pre- 
sent which  render  the  event  of  the  operation  very 
doubtful,  it  is  most  advisable  to  make  the  attempt  only  on 
one  eye,  even  though  the  patient  absolutely  wish  more 
to  be  done,  so  that  if  the  first  operation  should  fail,  but 
the  complication  of  this  cataract  afterward  change 
considerably  to  the  advantage  of  the  patient,  one  eye 
would  still  be  left  for  a second  more  favourable  at- 
tempt.—(LeAre  von  den  Augenkr.  h.  2,  p.  350.) 

With  regard  to  this  question,  I should  say,  with  Mr. 
Guthrie,  that  if  1 were  the  patient  myself,  I should  al- 
w ays  prefer  to  have  the  operation  done  only  on  one 
eye  in  the  first  instance. 

Some  years  ago,  it  was  the  common  doctrine,  that  no 
operation  should  be  undertaken  for  a cataract  before 
the  patient  had  attained  the  age  of  docility  and  reason, 
;*.id  in  a point  of  view  abstractedly  surgkal,  there  can 
be  no  doubt  of  the  rectitude  of  such  advice  ; but  when 
it  is  farther  considered  how  essential  sight  is  to  the  ac- 
quirement of  education ; that  youth  is  the  condition 
be.st  adapted  for  this  indispensable  pursuit ; that  w hen 
the  child’s  head  is  steadily  fixed,  the  needle  admits  of 
being  employed  ; that  with  the  aid  of  an  assistant,  this 
object  can  most  eflcctiially  be  accomplished  ; that  when 
the  operation  is  delayed,  the  cataract  may  acquire  adh^’ 


CATARACT. 


255 


sions ; that  persons  have  not  only  had  cataracts  suc- 
cessfully depressed  or  tirokeii,  at  a very  early  age,  but 
with  the  assistance  of  a speculum  oculi,  have  even 
had  them  extracted  (see  Ware's  note,  p.  90,  of  Wen- 
zel's treatise),  which  is  universally  acknowledged  to 
be  a far  more  difficult  process ; and  that  the  pupil  of 
the  eye  in  a young  suoject,  is  nearly  as  large  as  in 
an  adult  {Warner's  Description  of  the  Human  Eye, 
and  its  Diseases,  p.  34)  . I cannot  help  thinking,  with 
Mr.  Lucas,  that  after  a child  is  old  enough  to  bear  an 
operation,  the  attempt  to  cure  a cataract  with  the  needle 
may  be  proper  at  any  age.  Surgeons  do  not  refuse  to 
operate  for  the  hare-lip  as  early  as  two  years  of  age, 
or  even  earlier ; they  do  not  wait  for  docility  and  rea- 
son in  the  patient,  to  make  him  manageable,  and  sen- 
sible of  the  propriety  of  submitting  quietly  to  the  per- 
formance of  the  opera*  ion  ; they  render  him  trtictable 
by  force,  and  thus  they  wisely  succeed  in  making,  per- 
haps with  more  certainty  than  reliance  upon  the  forti- 
tude of  any  human  being  would  afford,  a very  precise 
incision,  such  as  the  nature  of  the  operation  demands : 
and  why  should  they  refuse  to  attempt  the  cure  of  ca- 
taracts in  children,  when  the  motives  are  more  urgent, 
and  it  is  equally  in  the  power  of  art  to  substitute 
means  quite  as  efectual  as  docility  and  reason  in  sur- 
gical patients?  What  experienced  operator  would 
trust  to  these  qualities,  when  he  undertakes  any  grand 
operation,  even  on  the  most  rational  and  firm  adult?— 
{Critical  Reflections  on  the  Cataract,  1805.) 

Of  late  years,  the  attention  of  surgeons  has  been  much 
drawn  to  the  subect  of  operating  on  the  cataracts  of  chil- 
dren, and  the  propriety  of  the  practice  seems  to  be  now 
firmly  fixed  on  the  basis  of  experience.  It  is  even  ascer- 
tained that  the  needle  may  be  successfully  employed  on 
children  of  the  most  tender  age.  The  late  Mr.  Saunders, 
surgeon  to  the  London  Infirmary  for  curing  diseases  of 
the  eye,  may  be  said  to  have  had  the  principal  share 
in  promoting  the  adoption  of  this  important  improve- 
ment. His  practice  confirmed  what  reason  had  long 
ago  made  probable,  and  the  judgment,  tenderness,  and 
skill  with  which  he  operated  on  the  eyes  of  infants, 
as  well  as  those  of  adults,  were  followed  by  a de- 
gree of  success  which  had  never  been  previously  wit- 
nessed, and  which  infused  quite  a' new  spirit  into  this 
most  interesting  branch  of  surgery.  Subjects  from 
eighteen  months  to  four  years  old  received  most  bene- 
fit from  Mr.  Saunders’s  operations ; and,  if  any  inter- 
mediate time  be  selected.  Dr.  Farre  (the  editor  of  this 
gentleman’s  publication)  is  inclined  to  recommend  the 
age  of  two  years.  “ The  parts  have  then  attained  a de- 
gree of  resistance  which  enables  the  surgeon  to  operate 
with  greater  precision  than  at  an  earlier  period ; yet 
the  capsule  has  not  become  so  tough  and  fie.xible  as  it 
does  at  a later  period,  aftfer  the  lens  has  been  more  com- 
pletely absorbed. 

But  this  is  not  the  greatest,  although  a consider- 
able advantage  of  an  early  operation  ; for,  in  cases  in 
which  the  patient  has  no  perception  of  external  objects, 
the  muscles  acquire  such  an  inveterate  habit  of  rolling 
the  eye,  that,  for  a very  long  time  after  the  pupil  has 
been  cleared  by  an  operation,  no  voluntary  effort  can 
control  this  irregular  motion,  nor  direct  the  eye  to  ob- 
jects with  sufficient  precision  for  the  purpose  of  distinct 
and  u.seful  vision.  The  retina,  too,  by  a law  common  to  all 
the  structures  of  an  animal  body,  tbr  want  of  being  ex- 
ercised, fades  in  power.  Its  sen.sibility,  in  many  of  the 
cases  cured  at  the  ages  of  four  years  and  under,  could 
not  be  surpassed  in  children  who  had  enjoyed  vision 
from  lurth;  but  at  eight  years,  or  even  earlier,  the 
sense  was  evidently  less  active ; at  twelve  it  was  still 
more  dull ; and  from  the  age  of  fifteen  and  upwards,  it 
was  generally  very  imperfect,  and  sometimes  the  mere 
perception  of  light  remained.  But  these  observations 
do  not  apply  to  those  congenital  cataracts  in  which  only 
the  centre  of  the  lens  and  capsule  is  opaque,  the  cir- 
cumference being  transparent;  for  in  those  the  retina  is 
exercised  by  a perception,  although  an  imperfect  one, 
of  external  objects,  the  motions  of  the  muscles  which 
direct  the  globe  are  associated,  and  an  absorption  of  the 
lens  does  not  take  place  : therefore,  in  this  variety  of 
the  disease,  the  argument  in  favour  of  an  early  operation 
is  not  so  much  a medical  as  a moral  one— it  is  prefer- 
able for  the  purposes  of  education  and  enjoyment.” — 
{Saunders  on  the  Diseases  of  the  Eye,  p.  153.  155.) 

Besides  Mr.  Saunders,  several  other  surgeons  of  the 
pre.sent  day  have  become  zealous  advocates  for  oi)erat- 
ing  upon  the  cataracts  of  children  Even  Mr.  Ware, 


before  his  death,  strongly  recommended  the  use  of  the 
needle  in  the  congenital  cataract  of  infants  and  children. 
Ilis  mode  of  operating  I shall  hereafter  notice.  The  late 
Mr.  Gibson,  of  Manchester,  likewise  urged  the  propri- 
ety of  couching  young  subjects,  and  fixed  on  the  age  of 
six  months  as  preferable  to  that  of  two  years.  “ What- 
ever objections  (says  he)  have  been  urged  against  the 
safe  and  effectual  use  of  the  couching-needle  in  infants, 
have  always  appeared  to  me  so  slight,  and  so  easily 
surmountable,  that  without  inquiring  particularly  into 
the  real  state  of  the  question,  I have  long  concluded' 
that  the  same  motives  which  would  induce  an  operator 
to  couch  a cataract  at  any  period  of  adult  life,  would 
equally  lead  him  to  perform  that  operation  at  any  ear- 
lier period  when  a cataract  existed.  Acting  upon  this 
presumption,  / have  operated  upon  children  of  all  ages' 
for  ten,  years  past." — (See  Edin.  Med.  and  Surgical 
Journal,  vol.  7,  p.  394.) 

Mr.  Gibson’s  paper  being  dated  June,  1811,  we  are  of 
course  given  to  understand,  that  he  pursued  this  practice 
from  the  year  1801,  and  he  asserts  that  his  experience 
had  embraced  a considerable  number  of  cases. 

“In  performing  the  operation  of  couching  infants,  it 
has  always  appeared  to  me  (says  this  geirtleman),  that 
the  advantages  to  be  gained  by  restoring  v'sion  at  so 
early  a period,  are  so  important  as  ,.0  bear  down  any 
obstacles  which  may  occasionally  be  opposed  to  the  safe 
use  of  the  needle.  Even  the  risk  of  deranging  the 
figure  of  the  pupil  forms  no  solid  objection  to  its  use; 
atid  may  always  be  avoided  by  steadiness  and  good 
management.  Should  even  a slight  change  in  its  figure 
be  produced,  it  is  seldom  in  the  least  detrimental  to  dis- 
tinct vision,  and  can  scarcely  be  considered  a blemish 
in  the  eye  of  any  one ; except  perhaps  in  that  of  a geo- 
metrician, who  may  easily  reconcile  to  himself  the  pre- 
sence of  an  oval  opening,  where  one  of  a circular  form 
should  exist.  It  may  farther  be  observed,  that  if  an 
operator  cannot  depend  upon  his  management  of  the 
eye,  so  as  to  render  it  steady  by  the  introduction  of  the 
couching-needle,  he  can  avail  himself  of  the  assistance 
of  a speculum  to  restrain  its  motions. 

The  following  observations  will  apply  principally  to 
infants  under  twenty  months  old.  The  advantages 
which  an  operator  possesses  in  operating  upon  a child 
of  this  age,  as  compared  with  a child  of  three  years  old 
or  upwards,  are  important.  An  infant  is  not  conscious 
of  the  operation  intended  : it  is  free  from  the  fears 
created  by  imagination,  and  can  opi)ose  very  feeble  re- 
sistance to  the  means  employed  to  secure  it  with  stea- 
diness. At  an  early  age  it  has  not  acejuired  the  pow^r 
of  retracting  the  eye  deep  in  the  socket,  so  that  the 
operator  has  always  a good  prospect  of  introducing  the 
couching-needle  with  ease  by  watching  a proper  oppor- 
tunity. The  eye  has  not  at  this  time  acquired  the  un- 
steady rolling  motion  which,  after  a few  years,  is  so- 
common  and  remarkable  in  children  born  blind,  or  re- 
duced to  that  state  soon  after  birth.  So  that  tliis  impe- 
diment to  the  easy  introduction  of  the  needle  does  not  ex- 
ist in  infants  a few  months  old.  The  operator  also  has  it 
in  his  power  to  administer  a dose  of  opium,  sufficient  to 
render  the  steps  necessary  to  expose  the  eye  almost  en- 
tirely disregarded  byhisj)atient.  With  respect  to  the  state 
of  the  eye  itself,  but  particularly  that  of  the  cataract, 
this  is  more  favourable  for  the  operation  than  at  any 
future  period  of  life.  In  infants,  the  cataract  is  gene- 
rally fluid,  and  merely  requires  the  free  rupture  of  its 
containing  capsule,  which  is  in  that  case  generally 
opaque.  The  capsule,  however,  is  tender  and  easily 
removed  by  the  needle,  so  as  to  leave  an  aperture  suf- 
ficiently large  for  the  admission  of  light.  The  milky 
fluid  which  escapes  from  the  capsule  is  soon  removed 
by  absorption.  If,  on  the  other  hand  (says  Mr.  Gibson), 
the  cataract  should  be  soft,  it  is  generally  of  so  pul])y  a 
softness  that  the  free  laceration  of  the  anterior  part  of 
its  capsule,  and  the  consequent  admission  of  the  aque- 
ous humour,  en.sure  its  speedy  dissolution,  and  disap- 
pearance, without  the  necessity  of  a second  operation 
Should  the  cataract  happen  to  be  hard,  there  will  be  no 
more  difficulty  in  depressing  it  than  in  an  adult. 

The  advantages  (says  Mr.  Gibson)  which  an  operator 
will  possess,  when  he  attempts  the  removal  of  a cata- 
ract in  a child  of  a few  months  old,  are  peculiar  to  that 
period.  In  proportion  as  the  age  of  the  i)atient  advances 
until  he  arrives  at  the  age  of  discretion,  and  can  esti- 
mate, in  some  measure,  the  value  of  sight  by  feeling  its 
loss,  the  difficulties  opi)osod  to  the  use  of  the  couching- 
needle  increase.  Ilis  fears  of  the  oiieralion,  the  unslea- 


256 


CATARACT. 


diness  of  the  eye,  and  his  power  of  retracting  it  within 
the  orbit,  present  considerable,  but  not  insuperable  ob- 
stacles ; such,  however,  as  every  surgeon  would  wil- 
lingly dispense  with,  if  he  had  it  in  his  power 

Before  an  operation  at  an  early  age  is  recommended, 
the  practitioner  ought  (as  at  any  other  age)  to  ascertain 
that  the  cataract  is  not  complicated  with  a defective 
state  of  the  retina,  or  with  a complete  amaurosis.  Such 
cases  are  by  no  means  uncommon.  Some  years  ago,  I 
recollect  to  have  seen  five  or  six  children,  the  families 
of  two  sisters,  who  were  all  totally  blind,  and  in  an  idio- 
tic state,  with  cataracts  accompanied  by  amaurosis.” — 
{Gibson,  op.  et  loco  cit.) 

I find  also  in  this  gentleman’s  paper  some  arguments 
which  have  been  repeated  in  Mr.  Saunders’s  work. 
“ Few  practitioners,  at  all  conversant  with  cases  of 
blindness  from  birth,  will  deny  that  it  is  highly  proba- 
ble that  the  eye  may  lose  a considerable  part  of  its  ori- 
ginal powers,  from  the  mere  circumstance  of  its  having 
so  long  remained  a passive  organ.  Hence,  probably,  it 
happens,  that  in  some  cases  of  congenital  cataract,  the 
only  benefit  conferred  on  the  patient  by  an  operation  is 
that  of  enabling  him  to  find  his  way  in  an  awkward  man- 
ner, and  to  discriminate  the  more  vivid  colours.  Such  pa- 
tients have  never  been  able  to  discern  small  objects,  or 
to  judge,  in  any  useful  degree,  of  figure  or  magnitude  : 
I am  well  aware,  however,”  says  Mr.  Gibson,  “ that  in 
some  rare  instances,  such  a defective  state  of  the  eye 
exists  from  birth. 

Another  circumstance  which  must  have  attracted  the 
attention  of  oculists  is,  that  in  a few  years,  the  eye  of 
a patient  born  blind  acquires  a restless  and  rolling  mo- 
tion, which  is  at  length  so  firmly  established  by  habit, 
that  he  has  little  control  over  it.  This  motion  unfortu- 
nately continues  for  a considerable  time  after  sight  has 
been  restored  to  such  a person,  and  is  a very  material 
obstacle  to  the  early  attainment  of  a knowledge  of  the 
objects  of  vision  He  cannot  fix  his  eye  steadily 
upon  one  point  for  a moment,  and  the  inconvenience 
which  arises  from  this  unsteadiness  is,  to  such  a per- 
son, occasionally  as  great  a bar  to  the  distinct  view  of 
an  object,  as  the  unsteady  motion  of  the  same  object 
would  be  to  one  whose  vision  is  perfect.  Tnis  incon- 
venience any  one  can  appreciate,  and,  as  far  as  I know, 
it  is  completely  avoided  by  restoring  sight  at  an  early 
age.” 

As  a motive  for  operating  on  infants,  Mr.  Gibson  also 
comments  on  the  loss  of  those  years  which  ought  to  be 
spent  in  education.— (See  Edin.  Med.  and  Surgical 
Journal,  vol.  7,  p.  3114.  400.) 

Mr.  Guthrie  also  joins  in  recommending  the  cure  of 
cataracts  in  children  : he  considers  the  period  of  denti- 
tion an  unsea.sonable  one  for  the  operation  ; but  except- 
ing the  time  of  this  process,  if  the  child  be  healthy,  he 
thinks  it  qualified  for  the  attempt  at  any  age,  reckoning 
from  that  of  six  months  ; and  that  “ even  if  the  opera- 
tion be  delayed  until  the  end  of  the  third  or  fourth  year, 
little  or  no  inconvenience  is  found  to  arise  from  it.” — 
{Operative  Surgery  of  the  Eye,  p.  362.) 

When  once  it  is  decided  to  operate  upon  a cataract, 
the  sooner  the  operation  is  generally  done  the  better, 
because  the  anxiety  of  the  patient  increased,  as  Beer 
says,  with  every  day,  nay,  with  every  hour  Just  be- 
fore the  operation,  care  must  be  taken  not  to  let  the  pa- 
tient eat  a great  deal,  nor  load  his  stomach  with  sub- 
stances difficult  of  digestion ; and  if  the  stomach  and 
bowels  should  already  be  disordered  by  what  they  con- 
tain, their  contents  ought  to  be  carefully  removed  pre- 
viously to  the  operation.  In  the  same  manner,  if  the 
surgeon  wish  to  keep  off  much  inflammation,  and  the 
patient  should  be  constipated,  this  state  must  be  obvi- 
ated by  suitable  medicines.  And,  lastly,  when,  at  the 
request  of  the  patient  himself,  the  operation  is  deferred 
for  a few  days,  the  greatest  caution  must  be  used  not  to 
let  him  expose  himself  to  any  causes  likely  to  bring  on 
catarrhal  or  rheumatic  complaints.  —(Beer,  b.  2,  p.  344.) 
The  following  advice,  delivered  by  Scarpa,  with  respect 
to  the  preparation  of  patients  for  operations  on  the  eye 
with  the  needle  is  valuable  : In  ordinary  cases,  there  is 
not  the  least  occasion  for  any  preparatory  treatment 
previous  to  the  operation ; all  that  prudence  requires  is, 
that  the  patient  should  abstain  from  animal  food  and 
fermented  liquors  for  a few  days  before  submitting  to 
it,  and  should  take  one  dose  of  a gentle  purgative.  But 
this,  like  every  other  general  observation,  is  liable  to 
particular  exceptions.  Hypochondnacal  men,  hysteri- 
cal women,  and  patients  subject  to  afl'ections  of  the 


stomach  and  nervous  system,  should  take,  for  two  or 
three  weeks  before  the  operation,  tonic  bitter  medicines, 
particularly  the  infusion  of  quassia,  either  with  or  with- 
out a few  drops  of  sulphuric  ether  to  each  dose  ; or,  in 
other  cases,  3j.  of  Peruvian  bark,  with  3j.  of  valerian, 
may  be  administered  two  or  three  times  a day  with  par- 
ticular benefit.  It  is  observed  by  the  most  accurate 
WTiters  upon  this  subject,  that  in  such  persons  the 
symptoms  consequent  to  operations  upon  the  eyes  are 
often  much  more  violent  than  in  common  cases ; and  it 
therefore  seems  proper  to  endeavour  previously  to  me- 
liorate their  constitutions.  Wlien  the  patient  is  timid, 
it  is  advisable  to  give  him,  half  an  hour  before  the  time 
of  operating,  about  fifteen  drops  of  the  tinctura  opii, 
with  a little  wine. 

Some  patients,  besides  being  afflicted  xvith  cataracts, 
have  the  edges  of  the  eyelids  swollen  and  gummy,  with 
relaxation  and  chronic  redness  of  the  conjunctiva.  In 
this  case,  before  undertaking  to  couch,  it  is  advisable 
to  apply  a blister  to  the  nape  of  the  neck,  and  to  keep 
it  open  for  two  or  three  weeks,  by  means  of  the  savin 
cerate,  and  to  insinuate,  every  morning  and  evening, 
between  the  palpebrae  and  globe  of  the  eye,  a small 
quantity  of  the  following  ointment,  the  strength  of 
which  is  to  be  gradually  increased;  B.  Unguenti  hy- 
drargyri  nitratis  5 iv.  Adipis  suillas  5 viij.  Olei  olivae 
3 ij.  When  this  ointment  does  not  produce  the  desired 
effect,  an  ointment  recommended  by  Janin  {Memoires 
sur  VlE.il)  should  be  substituted : it  consists  of  5 ss.  of 
hog’s  lard,  3 ij.  of  prepared  tutty,  3 ij.  of  Armenian  bole, 
and  3j.  of  the  white  precipitate  of  mercury.  At  first, 
care  should  be  taken  to  use  it  lowered  with  twice  or 
thrice  its  quantity  of  lard.  In  the  daytime,  a collyrium, 
composed  of  5 iv.  of  rose-water,  5 ss.  of  the  mucilage  of 
quince  seeds,  and  gr  v.  of  the  sulphate  of  zinc,  may 
also  be  frequently  used  with  considerable  advantage. 
By  such  means,  the  morbid  secretion  from  the  Meibo- 
mian glands,  and  membranous  lining  of  the  eyelids, 
will  be  checked,  and  the  due  action  of  the  vessels  and 
natural  flexibility  of  the  eyelids  restored.—  {Saggio  di 
Osservazioni,  >S-c.  suite  principali  malattie  degli  Oy.chi; 
Venez.  1802.) 

There  are  three  different  operations  practised  for 
the  cure  of  cataracts,  viz.  one  termed  couching,  or  de- 
pression, of  which  the  method  called  reclination  is  a 
modification,  as  will  be  hereafter  explained ; another 
named  extraction  ; and  a third  denominated  kera- 
tanyxis,  which  consists  in  puncturing  the  cornea  with 
a needle,  the  point  of  which  is  to  be  conveyed  through 
the  pupil,  so  as  to  reach  the  cataract,  which  is  to  be 
gently  broken  into  fragments.  As  Beer  observes,  each 
of  these  modes  has,  in  particular  cases,  manifest  ad- 
vantages over  the  other  two  but  no  single  method 
will  ever  be  exclusively  preferred,  and  invariably  fol- 
lowed, by  any  man  of  experience  or  judgment.  In  every 
operation  for  a cataract,  the  position  of  the  patient,  as- 
sistants, and  surgeon  is  of  great  importance.  In  order 
fo  enable  the  assistant,  who  stands  behind  the  patient, 
to  he  conveniently  near  the  head  of  the  latter.  Beer 
prefers  letting  the  patient  sit  on  a stool  which  has  no 
back.  However,  as  I shall  presently  notice,  some  emi- 
nent surgeons  have  urged  good  reasons  in  favour  of 
employing  a chair  which  is  completely  perpendicular. 
When  the  left  eye  is  to  be  operated  uj)on,  the  same 
assistant  is  to  apply  his  right  hand  under  the  patient’s 
chin,  and  press  the  head  of  the  latter  against  his 
breast,  at  the  same  time  that  he  inclines  it  and  himself 
mftre  or  less  forwards  towards  the  operator,  who  sits 
upon  rather  a high  stool,  in  front  of  the  patient.  In 
this  country,  a music-stool  is  commonly  prefen-ed,  the 
height  of  which  can  be  regulated  in  a moment,  by 
simply  turning  the  seat  round  to  the  right  or  left, 
whereby  the  screw,  with  which  it  is  connected,  is 
made  to  rise  or  descend,  as  may  be  found  most  desira- 
ble. The  same  assistant  then  places  his  left  hand  flat 
upon  the  left  side  of  the  patient’s  forehead,  with  the 
points  of  the  fore  and  middle  fingers  somewhat  under 
the  edge  of  the  ujiper  eyelid  ; and,  w'ith  the  fore-finger, 
he  is  now  to  raise  the  edge  of  this  eyelid  as  much  as 
possible,  following  that  finger  immediately  with  the 
middle  one,  so  as  to  fix  the  eyelid  with  greater  cer- 
tainty. The  ends  of  these  fingers,  however,  must  be 
so  applied  as  not  to  touch  the  globe  of  the  eye  in  the 
slightest  manner,  much  less  make  any  pressure  upon 
it,  yet  so  that  the  upper  part  of  the  eyeball  and  cornea 
may  be  gently  resisted  by  them,  when  the  eye  rolls 
tipwards  away  firom  the  instrument  about  to  be  intro- 


CATARACT. 


257 


^ced,  whereby  this  position,  which  is  extremely  in- 
convenient to  the  operator,  may  be  immediately  recti- 
fied. The  patient  should  also  sit  obliquely  opposite  a 
clear  window,  so  that  a sufficient  light  may  fall  ob- 
liquely upon  the  eyes,  without  any  rays  being  reflected 
to  the  cornea,  and  becoming  a hindrance  to  the  ope- 
rator. Nor  should  light  from  any  other  quarter  be 
ever  allowed  to  fall  upon  the  eyes.  The  stirgeon 
should  sit  in  front  of  the  patient,  whose  head  ought  to 
be  directly  opposite  the  operator’s  breast,  whereby  the 
latter  will  be  enabled  to  see  from  above,  with  the 
greatest  correctness,  every  thing  in  the  eye  during 
the  operation,  and  will  not  be  under  the  necessity  of 
raising  his  arms  too  considerably.  Supposing  it  to  be 
the  left  eye  which  is  to  be  operated  upon,  he  next  ef- 
fectually draws  down  the  lower  eyelid  with  the  left 
fore-finger,  the  end  of  which  must  be  planed  over  the 
edge  of  the  eyelid,  towards  the  globe  of  the  eye.  The 
middle  finger  is  then  to  be  applied  in  a similar  way 
over  the  caruncula  lachrymalis.  The  operator  now 
takes  in  his  right  hand  the  requisite  instrument  for  the 
operation,  viz.  the  needle  or  knife,  which  is  to  be  held 
like  a pen,  between  the  thumb  and  the  fore  and  middle 
fingers.  By  this  particular  arrangement  of  the  fingers 
of  the  assistant  and  operator,  which,  indeed,  is  partly 
ineffectual  where  the  fissure  of-the  eyelids  is  very  nar- 
row, and  the  eyeball  is  diminutive  and  sunk  in  the 
orbit,  the  restless  eye  of  the  timid  patient  is  fixed  ; for 
a point  of  the  finger  is  disclosed  on  every  side  to 
which  the  eye  can  possibly  turn  away  from  the  in- 
strument about  to  be  introduced,  and  when  the  cornea 
is  gently  touched  with  the  extremity  of  the  finger,  the 
wrong  position  which  the  eye  is  about  to  take  is  im- 
mediately prevented.  This  method  of  fixing  the  eye, 
says  Beer,  is  not  merely  indispensable  for  young  ope- 
rators, but  is  the  only  perfectly  unobjectionable  one 
which  can-  be  employed  on  this  delicate  organ,  since 
all  mechanical  inventions  for  this  purpose,  like  the 
speculum  oculi,  which  keeps  the  eye  steady  by  con- 
siderable pressure,  or  other  contrivances,  like  Rum- 
pelt’s  instrument,  which  does  the  same  thing  by  meank 
of  a short  pointed  instrumep'  attached  to  a kind  of 
thimble,  and  with  which  the  sclerotica  is  pierced  and 
held  motionless,  are  found  by  experience  to  be  worse 
than  useless.  And,  as  a proof  of  this  fact.  Beer  ad- 
verts to  the  numerous  patients  who  come  out  of  the 
hands  of  such  operators  as  employ  these  instruments, 
with  a more  or  less  hurtful  loss  of  the  vitreous  hu- 
mour, and  other  ill  consequences  ; a statement  which 
nearly  agrees  with  the  observations  of  Wenzel  and 
Ware. 

While  the  late  Mr.  Ware  coincided  with  Wenzel 
and  Beer,  respecting  the  general  objections  to  specula, 
he  remarks,  that  in  some  instances  of  children  born 
with  cataracts,  he  had  been  obliged  to  fix  the  eye  with 
a speculum ; without  the  aid  of  which,  he  found  it 
totally  impracticable  to  make  the  incision  through  the 
cornea  with  any  degree  of  precision  or  safety.  His 
speculum  was  an  oval  ring,  the  longest  diameter  of 
which  is  about  twice  as  long  as  the  diameter  of  the 
cornea,  and  the  .shortest  about  half  as  long  again  as 
this  tunic.  Annexed  to  the  upper  rim  of  (he  speculum 
is  a rest  or  shoulder,  to  support  the  ui)per  eyelid,  and 
by  its  lower  rim  it  is  fixed  to  a suitable  handle.  Beer 
entertained  no  higher  opinion  of  other  inventions,  made 
for  the  purpose  of  enabling  surgeons  to  operate  on  both 
eyes  with  the  right  hand ; for,  says  he,  the  right  eye 
should  always  be  operated  upon  with  the  left  hand, 
and  the  left  with  the  right,  and  he  who  cannot  learn  to 
be  equally  skilful  with  both  his  hands,  must  always 
remain  a bungler. — {Lehre  von  de)i  Augenkr.  b.  2, 
p.  347—350.) 

Mr.  Alexander,  whose  great  skill  in  operations  on 
the  eye  is  universally  acknowledged,  employs  no  as- 
sistant for  raising  the  upper  eyelid,  or  fixing  the  eye, 
which  objects  he  accomplishes  himself;  and  in  Ger- 
many, this  independent  mode  of  proceeding  has  been 
particularly  commended  by  Barth.— (£tit;a.9  uher  die 
Ausziehuag  des  grauen  Staare,  fur  den  geubten  Ope- 
rateur,  8vo.  Wu-n,  1797.) 

The  preceding  directions,  respecting  the  position  of 
the  a.ssistant,  the  seats  for  the  patient  and  surgeon, 
and  the  mode  of  fixing  the  eye,  are  chiefly  tho.se  of 
Professor  Beer.  Whether  these  instructions  arc  in 
every  respect  better  than  the  following,  which  com- 
bine the  sentiments  of  some  other  writers  of  exi»e- 
nencc,  the  impartial  reader  must  judge  for  himself. 

VoL  1.— R 


The  patient  should  be  seated  rather  low,  opposite  a 
window  where  the  light  is  not  vivid,  and  in  such  a 
manner,  that  the  rays  may  fall  laterally  upon  the  eye 
about  to  be  couched.  The  other  eye,  whether  in  a 
healthy  or  diseased  state,  ought  always  to  be  closed, 
and  covered  with  a handkerchief,  or  any  thing  con- 
venient for  the  purpose  ; for,  so  strong  is  the  sympathy 
between  the  two  organs,  that  the  motions  of  the  one 
constantly  produce  a disturbance  of  the  other.  The 
surgeon  should  sit  upon  a seat  rather  higher  than  that 
upon  which  the  patient  is  placed  ; and,  in  order  to  give 
his  hand  a greater  degree  of  steadiness  in  the  various 
manoeuvres  of  the  operation,  he  will  find  it  useful  to 
place  his  -elbow  upon  his  knee,  which  must  be  suffi- 
ciently raised  for  this  purpose,  by  a stool  placed  under 
the  foot.  The  chair  on  which  the  patient  sits  ought  to 
have  a high  back,  against  which  his  head  may  be  so 
firmly  supported,  that  he  cannot  draw  it  backwards 
during  the  operation.  Th^  back  of  the  chair  must  no( 
slope  backwards,  as  that  of  a common  one,  but  be 
quite  perpendicular,  in  order  that  the  patient’s  head 
may  not  be  too  distant  from  the  surgeon’s  breast. — 
(^Richter’s  Anfangsgr.  der  Wundarzn.  p.  207,  b.  3.) 

The  propriety  of  supporting  the  patient’s  head  rather 
upon  the  back  of  the  chair  on  which  he  sits,  than  upon 
an  assistant’s  breast,  as  Bischoff  has  observed,  is 
founded  upon  a consideration,  that  the  least  motion  of 
the  assistant,  even  that  necessarily  occasioned  by  re- 
spiration, causes  also  a synchronous  motion  of  the  part 
supported  on  his  breast,  which  cannot  fail  to  be  disad- 
vantageous, both  in  the  operation  of  extraction  and  of 
couching.  However,  as  this  is  not  at  present  the  com- 
mon practice,  the  inconvenience  of  having  the  back  of 
the  chair  between  the  assistant  and  the  patient  may 
more  than  counterbalance  the  circumstance  in  which 
it  seems  to  be  advantageous. 

In  certain  cases,  where  the  muscles  of  the  eye  and 
eyelids  are  incessantly  affected  with  spasm  ; or  where 
the  eye  is  peculiarly  diminutive,  and  sunk,  as  it  were-, 
in  the  orbit,  the  elevator  for  the  upper  eyelid,  invented 
by  Pellier,  and  approved  by  Scarpa,  may  possibly  prove 
serviceable  : in  young  subjects,  it  materially  facilitates 
the  operation. 

The  particular  sentiments  of  Wenzel  and  Ware,  con- 
cerning the  mode  of  fixing  the  eye,  will  be  farther  ex- 
plained in  the  description  of  the  extraction  of  the  cata^ 
ract. 

OF  COTJCHINO,  OR  DEPRESSION  OF  THE  CATARACT,  AND 
RECLINATION. 

The  operation  of  couching  was  once  supposed  to  con- 
sist altogether  in  removing  the  opaque  lens  out  of  the 
axis  of  vision,  by  means  of  a needle,  constructed  for 
the  purpose  ; but  it  is  well  known  to  be  frequently  ef- 
fectual on  another  principle,  even  when  the  nature 
and  consistence  of  the  cataract  do  not  admit  of  the 
depression  of  the  opaque  body.  Experience  fully 
proves,  that  the  diseased  lens,  when  broken  and  dis- 
turbed, with  the  needle,  and  especially  when  freely 
exposed  to  the  contact  of  the  aqueous  humour  by  a 
proper  laceration  of  its  capsule,  is  gradually  dissolved 
and  removed  by  the  action  of  the  absorbents. 

Indeed,  couching  now  means  a variety  of  operations ; 
for  it  comprehends  not  merely  the  depression  of  the 
cataract,  not  simply  its  displacement  in  any  direction 
whatsoever,  not  only  the  breaking  of  it  piecemeal  and 
thepushing  of  the  fragments  into  the  aqueous  humour, 
but  likewise  the  mere  disturbance  of  the  opaque  body, 
whereby  its  absorption  is  sometimes  affected,  xvithout 
any  kind  of  depression  or  displacement  of  it  at  all  with 
the  needle.  When,  therefore,  the  merits  of  couching 
are  investigated,  it  is  necessary  to  define  precisely 
wffiat  modification  of  it  is  meant,  and  for  what  parti- 
cular kind  of  case  its  application  is  designed ; for  no 
surgeon  of  the  present  day  would  confine  himself  ex- 
clusively to  one  method  of  operating;  and,  as  Mr 
Guthrie  has  remarked,  “ In  considering  the  advantages 
or  disadvantages  from  any  or  all  of  the  different  opera- 
tions for  cataract,  it  is  absolutely  necessary  to  recol- 
lecj,  that  no  individual  operation  is  ap])licable  to  every 
species  of  the  disea.se ; that  each  kind  requires  an  ope- 
ration for  its  relief  or  cure,  sometimes  of  a particular 
nature,  and  differing  es.sentially  from  that  which  is 
found  most  advantageous  in  another.  To  collect 
then  all  the  objections  which  can  be  urged  against  any 
of  the  operations,  from  a consideration  of  every  case 
of  cataract  to  which  it  is  and  is  not  aiiplicable,  is 


CATARACT. 


253 

merely  to  confuse  the  subject,  and  has  generally  been 
done  for  the  purpose  of  recommending  some  particular 
mode  of  proceeding,  rather  than  to  regulate  these  ope- 
rations by  the  general  principles  of  surgery.”— (Opem- 
tive  Surgery  of  the  Eye,  p.  365.)  In  this  respect,  the 
doctrines  of  Pott,  Callisen,  Hey,  and  Scarpa  arc  un- 
doubtedly wrong,  though  their  .sentiments  are  blended 
with  many  valuable  and  important  truths.  Beer,  who 
is  by  no  means  a great  advocate  for  depression,  ad- 
mits its  utility  in  particular  cases.  It  is  easily  com- 
prehensible, says  he,  that  in  this  way  a firm  and  large 
cataract  either  cannot  be  removed  without  injuring  the 
reting,  and  the  attachment  of  the  corpus  ciliare  to  the 
vitreous  humour,  or  not  far  enough  to  prevent  the 
opaque  body  from  rising  again  at  the  first  opportunity. 
Hence  the  former  complaints  about  the  frequent  re- 
turn of  the  cataract,  and  other  ill  consequences,  tinap- 
peaseable  vomiting,  suddenly  produced  amaurosis,  and 
severe  inflammation,  <fec.  put  while  Beer  acknow- 
ledges the  frequency  of  these  ill  effects  of  depression, 
he  condemns  the  universal  rejection  of  it,  attempted  at 
the  present  day,  and  the  unlimited  substitution  for  it 
of  reclination,  which  consists  in  applying  the  needle 
in  a certain  manner  to  the  anterior  surface  of  the  cata- 
ract, and  depressing  the  opaque  body  into  the  vitreous 
humour,  in  such  a way,  that  the  front  surface  of  the 
cataract  is  now  the  upper  one,  its  back  surface  the 
lower  one,  its  upper  edge  backwards,  and  its  lower 
edge  forwards  ; a change  which,  Beer  says,  cannot  be 
made  without  an  extensive  destruction  of  the  cells  of 
the  vitreous  humour.  Hence,  with  few  exceptions,  this 
author  thinks  the  common  mode  of  depression  should 
be  preferred. — {Lehre  von  den  Augmkr.  h.  2,p.  352.) 
And  in  this  sentiment  he  is  joined  by  Mr.  Travers, 
who  remarks,  that  the  real  objection  to  couching  is  the 
breaking  up  of  the  fine  texture  of  the  globe  of  the  eye, 
by  the  forcible  depression  of  the  lens.  “ Whether  it 
be  depressed  edgeways  or  breadthways,  makes  no  dif- 
ference in  the  result ; it  must  still  occupy  a breach  in 
the  cells  of  the  vitreous  humour,  and  must  derange  and 
disorder  that  delicate  texture  and  those  connected  with 
it.  A slow,  insidious  inflammation,  marked  by  a gra- 
dual developement  of  the  symptoms  of  disorganization, 
viz.  congestion  of  vessels,  turbid  humours,  flaccid  tu- 
nica, and  palsied  iris,  is  too  often  the  consequence. 
The  sight,  instead  of  improving  when  the  immediate 
effects  of  the  injury  are  passed  away,  remains  habit- 
ually weak  and  dim,  or  declines  and  fades  altogether. 
The  advocates  for  reclination  seem  to  forget,  that  the 
principle,  which  is  the  same  in  both  oj'erations,  is  the 
real  ground  of  objection.  As  to  the  position  of  the  lens, 

I suspect  less  mischief  is  done  by  the  old  method  of 
depression,  as  less  force  is  required  to  break  a space 
for  the  vertical  than  the  horizontal  lens,  provided  the 
depression  be  carried  to  no  greater  extent  than  is  ne- 
cessary to  clear  the  inferior  border  of  the  pupil.” — 
{Synopsis  of  the  Diseases  of  the  Eye,  p.  318.) 

The  form  of  couching-needles  should  vary  according 
to  the  object  designed  to  be  effected  by  the  operation. 
The  needle  used  by  the  late  Mr.  Hey,  that  recom- 
mended by  Scarpa,  and  another  employed  by  Beer,  are 
the  principal  ones. 

The  length  of  Mr.  Hey’s  needle  is  somewhat  less 
than  an  inch.  It  would  be  sufficiently  long  if  it  did  not 
exceed  seven-eighths  of  an  inch.  It  is  round,  except 
near  the  point,  where  it  is  made  flat,  by  grinding  two 
opposite  sides.  The  flat  part  is  ground  gradually  thin- 
ner to  the  extremity  of  the  needle,  which  is  semicir- 
cular, and  ought  to  be  made  as  sharp  as  a lancet.  The 
flat  part  extends  in  length  about  an  eighth  of  an  inch, 
and  its  sides  are  parallel.  From  the  part  where  the 
needle  ceases  to  be  flat,  its  diameter  gradually  increases 
towards  the  handle.  The  flat  part  is  one-fortieth  of 
an  inch  in  diameter.  The  part  which  is  nearest  the 
handle,  is  one-twentieth  of  an  inch.  The  handle,  which 
is  three  inches  and  a half  in  length,  is  made  of  light 
wood,  stained  black.  It  is  octagonal,  and  has  a little 
ivory  inlaid  in  the  two  sides  which  correspond  with 
the  edge  of  the  needle. 

Mr.  Hey  describes  the  recommendations  of  this  in- 
strument in  the  following  tc-rms : 

1.  “It  is  only  half  the  length  of  the  common  needle; 
and  this  gives  the  operator  a greater  c ommand  over 
the  motions  of  its  point,  in  removing  the  crystalline 
IVom  its  bed,  and  tearing  its  capsule.  It  is  also  of 
some  consequence  that  the  operator  should  know  how 
fer  tlie  point  of  the  needle  has  penetrated  the  globe  of  1 


the  eye,  before  he  has  an  oppcjrtunity  of  seeinf  it 
through  the  pupil ; as  it  ought  to  be  brought  forwards 
when  it  has  reached  the  axis  of  the  pupil.  Now  he 
may  undoubtedly  form  a better  judgment  respecting 
this  circumstance,  when  the  length  of  his  needle  does 
not  much  exceed  the  diameter  of  the  eye,  than  when 
he  uses  one  of  the  ordinary  length,  which  is  nearly 
two  inches.  The  shortness  of  the  needle  is  peculiarly 
useful  when  the  capsule  is  so  opaque  that  the  point 
cannot  be  seen  through  the  pupil. 

2.  As  this  needle  becomes  gradually  thicker  towards 
the  handle,  it  will  remain  fixed  in  that  part  of  the 
sclerotis,  to  which  the  operator  has  pushed  it,  while  he 
employs  its  point  in  depressing  and  removing  the  cata- 
ract. But  the  spear-shaped  needle,  by  making  a wound 
larger  in  diameter  than  that  part  of  the  instrument 
which  remains  in  the  sclerotis,  becomes  unsteady,  and 
is  with  difficulty  prevented  fiom  sliding  forwards 
against  the  ciliary  processes,  while  the  operator  is 
giving  it  those  motions  which  are  necessary  for  de- 
pressing the  cataract. 

On  the  same  account  the  common  spear-shaped 
needle  may  suffer  some  of  the  vitreous  humour  to  es- 
cape during  the  operation,  whereby  the  iris  and  ciliary 
processes  would  be  somewhat  displaced  and  rendered 
flaccid ; whereas  the  needle  which  I use.  making  but 
a small  aperture  in  the  sclerotis,  and  filling  up  that 
aperture  completely  during  the  operation,  no  portion  of 
the  vitreous  humour  can  flow  out  so  as  to  render  the 
iris  and  ciliary  processes  flaccid. 

3.  This  needle  has  no  projecting  edges ; but  the 
spear-shaped  needle,  having  two  sharp  edges,  which 
grow  gradually  broader  to  a certain  distance  from  its 
point,  will  be  liable  to  wound  the  iris,  if  it  be  introduced 
too  near  the  ciliary  ligament,  with  its  edges  in  a hori- 
zontal position.  Besides,  in  whatever  manner  the 
needle  be  introduced,  one  of  its  sharp  edges  must  be 
turned  towards  the  iris  in  the  act  of  depressing  the  ca- 
taract; and  in  the  various  motions  which  are  often 
necessary  in  this  operation,  the  ciliary  processes  are 
certainly  exposed  to  more  danger  than  when  a needle 
is  used  which  has  no  projecting  edge. 

4.  It  has  no  projecting  point.  In  the  use  of  e spear- 
shaped  needle,  the  operator’s  intention  is  to  bring  its 
broadest  part  over  the  centre  of  the  crystalline.  In  at- 
tempting to  do  this,  there  is  great  danger  of  carrying 
the  point  beyond  the  circumference  of  the  crystalline, 
and  catching  hold  of  the  ciliary  processes  or  their  in- 
vesting membrane,  the  membrana  nigra.” 

Mr.  Hey  asserts,  that  his  needle  will  pass  through 
the  sclerotis  with  ease ; depress  a firm  cataract  readily, 
and  break  down  the  texture  of  one  that  is  soft.  “ If 
the  operator  finds  it  of  use  to  bring  the  point  of  the 
needle  into  the  anterior  chamber  of  the  eye  (which  is 
often  the  case),  he  may  do  this  with  the  greatest  safety, 
for  the  edges  of  the  needle  will  not  wound  the  iris.  In 
short,  if  the  operator  in  the  use  of  this  needle  does  but 
attend  properly  to  the  motion  of  its  point,  he  will  do 
no  avoidable  injury  to  the  eye,  and  this  caution  becomes 
the  less  embarrassing,  as  the  point  does  not  project  be- 
yond that  part  of  the  needle  by  which  the  depression  i& 
made,  the  extreme  part  of  the  needle  being  used  for 
this  purpose.” — {Hey.) 

Scarpa  employs  a very  slender  needle,  possessing 
sufficient  firmness  to  enter  the  eye  without  hazard  of 
breaking,  and  having  a point  which  is  slightly  curved. 
The  curved  extremity  of  the  needle  is  flat  upon  its  dor- 
sum or  convexity,  sharp  at  its  edges,  and  haa  a con- 
cavity, constructed  with  two  oblique  surfaces,  forming 
in  the  middle  a gentle  eminence,  that  is  continued 
along  to  the  very  point  of  the  instrument;  there  is  a 
mark  on  that  side  of  the  handle  which  corresponds  to 
the  convexity  of  the  point.  The  surgeons  of  the  Leeds 
Infirmary  have  had  one  advantage  in  the  needle,  which 
they  have  used  in  imitation  of  Baron  Hilmer ; I mean, 
having  it  made  of  no  greater  length  than  the  purposes 
of  the  operation  demand.  A couching-needle  is  suffi- 
ciently long  when  it  does  not  exceed,  at  most,  an  inch 
in  length : this  affords  the  operator  a greater  command 
over  the  motions  of  the  point,  and  enables  him  to  judge 
more  accurately  how  far  it  has  penetrated  the  globe 
of  the  eye,  before  he  has  an  opportunity  of  seeing  it 
through  the  jmpil.  When  Scarpa’s  needle  is  preferred, 
it  should  therefore  be  of  no  greater  length  than  the 
operation  requires.  The  needle  here  described  will 
penetrate  the  sclerotic  coat  as  readily  as  any  straight 
one  of  the  same  diameter,  and  by  reason  of  its  sLendef 


CATARACT. 


259 


ness,  will  Impair  the  internal  structure  of  the  eye  less 
in  its  movements  than  common  couching- needles. 
When  cautiously  pushed  in  a transverse  direction, 
till  its  point  has  reached  the  upper  part  of  the  opaque 
lens,  it  becomes  situated  with  its  convexity  towards 
the  iris  and  its  point  in  the  opposite  direction ; and, 
upon  the  least  pressure  being  made  with  its  convex 
surface,  it  removes  the  cataract  a little  downwards,  by 
which  a space  is  afforded  at  the  upper  part  of  the  pupil, 
between  the  cataract  and  ciliary  processes,  through 
which  the  instrument  may  be  safely  conveyed  in  front 
of  the  opaque  body  and  its  capsule,  which  it  is  prudent 
to  lacerate  in  the  operation.  In  cases  of  caseous, 
milky,  and  membranous  cataracts,  the  soft  pulp  of  the 
crystalline  may  be  most  readily  divided  and  broken 
piecemeal  by  the  edges  of  its  curved  extremity ; and 
the  front  layer  of  the  capsule  lacerated  into  numerous 
membranous  flakes,  which,  by  turning  the  point  of  the 
instrument  towards  the  pupil,  may  be  as  easily  pushed 
through  this  apeiture  into  the  anterior  chamber,  where 
Scarpa  finds  absorption  takes  place  more  quickly 
than  behind  the  pupil. 

Beer,  and  many  other  skilful  operators,  give  the  pre- 
ference to  a straight  spear-pointed  needle.  Scarpa’s 
needle  made  quite  straight  is  a very  eligible  instru- 
ment, and  Beer’s  small  spear-pointed  needle,  which  is 
sold  at  almost  every  shop  for  surgical  instruments,  de- 
serves all  the  reputation  which  it  possesses. 

As  Mr.  Travers  has  observed,  m all  cases  of  operation 
with  the  needle,  the  employment  of  a solution  of  the 
extract  of  belladonna  in  an  equal  part  of  distilled  wa- 
ter, is  a point  of  the  first  importance.  “ The  space  in- 
cluded between  the  eyebrow  and  lash  should  be 
thickly  painted  with  the  solution  once,  or  oftener,  in 
the  twenty-four  hours,  and  this  varnish  should  be  pre- 
served moist  for  a period  of  half  an  hour,  in  order  to 
admit  of  its  absorption.  The  frequency  of  the  appli- 
cation must  be  determined  by  its  effect  upon  the  pupil. 
The  preternatural  dilatation  should  not  be  permanently 
maintained;  for  if  it  be,  the  pupil  will  in  all  probability 
be  misshapen,”  when  the  use  of  the  belladonna  is  sus- 
pended, and  the  iris  recovers  its  power. — {Synopsis  of 
the  Diseases  of  the  Eye,p.  322.) 

The  couching-needle  (if  the  curved  one  be  used)  is 
to  be  held  with  its  convexity  forwards,  its  point  back- 
wards, and  its  handle  i)arallel  to  the  patient’s  temple. 
The  surgeon,  having  directed  the  patient  to  turn  the  eye 
towards  the  nose,  is  to  introduce  the  instrument  boldly 
through  the  sclerotic  coat,  at  the  distance  of  at  least 
one  line  and  a half  from  the  margin  of  the  cornea,  for 
fear  of  injuring  the  ciliary  processes.  Most  authors 
advise  the  puncture  to  be  made  at  about  one  line,  and 
some  even  at  the  minute  distance  of  l-16th  of  an  inch 
(Hey)  from  the  union  of  the  cornea  with  the  sclerotica ; 
but  as  the  ciliary  processes  ought  invariably  to  be 
avoided,  and  there  is  no  real  cause  to  dread  wounding 
the  aponeurosis  of  the  abductor  muscle,  as  some  have 
conceived,  the  propriety  of  puncturing  the  globe  of  the 
eye,  at  the  distance  of  one  line  and  a half,  or  two,  from 
the  margin  of  the  cornea,  as  advised  by  Petit,  Platner, 
Bertrandi,  Beer,  &,c.,  must  be  sufficiently  manifest. 

Nor  is  it  a matter  of  indifference  at  what  height  the 
needle  is  introduced,  if  it  Be  desirable  to  avoid,  as  much 
a.s  possible,  effusion  of  blood  in  the  operation.  Anatomy 
reveals  to  us,  that  the  long  ciliary  artery  pursues  its 
course  to  the  iris,  along  the  middle  of  the  external  con- 
vexity of  the  eyeball,  between  the  sclerotic  and  choroid 
coats ; and  hence,  in  order  to  avoid  this  vessel,  it  is 
prudent  to  introduce  the  instrument  a full  line  below 
the  transverse  diameter  of  the  pupil,  as  Dudell,  Guntz, 
Bertrandi,  Beer,  Scarpa,  (fee.  have  directed.  If  the 
couching-needle  were  introduced  higher  than  the  track 
of  the  long  ciliary  artery,  it  would  be  inconvenient  for 
the  depression  of  the  cataract. 

The  exact  place  where  the  point  of  the  needle  should 
next  be  guided  is,  no  doubt,  between  the  cataract  and 
ciliary  processes,  in  front  of  the  opaque  lens  and  its  cap- 
sule : but  as  I conceive  the  attempt  to  hit  this  delicate 
invisible  mark  borders  upon  impossibility,  and,  perhaps, 
in  the  common  manner  of  bringing  the  needle  from  the 
posterior  chamber  to  the  upper  edge  of  the  lens,  is 
never  effected  without  injunng  those  processes,  as  Mr. 
Guthrie  positively  asserts  {Operative  Surgery  of  the 
Eye,  p.  270),  I cannot  refrain  from  expressing  my  dis- 
nent  to  the  common  method  of  passing  a couching-nec- 
dle  at  once  in  front  of  the  cataract.  Gn  the  contrary, 
it  .seems  safer  to  direct  the  extremity  of  the  instni- 

R 2 


ment  immediately  ovet  the  opaque  lens,  and  in  the  firfct 
instance  to  depress  it  a little  downwards,  by  means  of 
the  flat  surface  of  the  needle,  in  order  to  make  room  for 
the  safe  conveyance  of  the  instrument  between  the  ca- 
taract and  corpus  ciliare,  in  front  of  the  diseased  crys“ 
tallirie  and  its  capsule ; taking  care  in  this  latter  step  of 
the  operation  to  keep  the  marked  side  of  the  handle  for- 
wards, by  which  means  the  point  of  the  needle  will  be 
in  an  opposite  direction  to  the  iris,  and  will  come  into 
contact  with  the  diseased  body,  and  the  membrane 
binding  it  down  in  the  fossula  of  the  vitreous  humour. 
Wheii  this  has  been  done,  and  the  case  is  a firm  cata- 
ract, the  instrument  will  be  visible  through  the  pupil. 
Scarpa  now  pushes  its  point  transversely,  as  near  as 
possible  the  margin  of  the  lens,  on  the  side  next  the  in- 
ternal angle  of  the  eye,  taking  strict  care  to  keep  it  con- 
tinually turned  backwards.  He  then  inclines  the  han- 
dle of  the  in.strument  towards  himself,  whereby  its 
point  is  directed  through  the  capsule  into  the  substance 
of  the  opaque  lens ; and  on  making  a movement  of  the 
needle,  describing  the  segment  of  a circle,  at  the  same 
instant  inclining  it  downwards  and  backwards,  he  lace- 
rates the  former  and  convej^  it  in  the  generality  of 
cases  Avith  the  latter,  deeply  into  the  vitreous  humour.- 
Perhaps  the  greatest  inconvenience  of  Scarpa’s  method 
is  that  likely  to  arise  from  passing  the  point  of  the  nee- 
dle into  a firm  cataract,  whereby  the  opaque  body  may 
become  fixed  on  the  end  of  the  instrument,  and  follow 
it  when  it  is  withdrawn,  instead  of  remaining  below 
the  pupil.  Indeed,  Mr.  Guthrie  considers  it  a point  of 
great  importance  in  this  operation  never  to  pierce  the 
lens,  and  that  this  rule  should  even  be  followed,  “ ^ 
necessary,  at  the  expense  of  the  ciliary  processes,”  of 
which,  he  thinks,  the  principal  utility  terminates  with 
the  removal  of  the  lens. — {Operative  Surgery  of  the 
Eye,  p.  271.)  To  me,  who  prefer  Scarpa’s  manner  of 
depressing  the  cataract  a little  in  the  first  instance,  so 
as  to  make  room  for  the  passage  of  the  needle  between 
it  and  the  ciliary  processes  into  the  posterior  chamber,  the 
necessity  of  ever  wounding  those  processes,  for  the  pur- 
pose of  avoiding  to  pierce  the  lens,  seems  hardly  con- 
ceivable. At  the  same  time,  I believe,  with  Mr.  Guthrie,- 
that  in  the  common  practice  of  moving  the  needle 
from  the  posterior  chamber  to  the  upper  part  of  the  ca- 
taract, the  ciliary  processes  must  suffer  more  or  less 
injury. 

Beer,  as  I have  explained,  gives  the  preference  to  a 
spear-pointed  straight  needle,  one  flat  surface  of  which^ 
at  the  period  of  its  first  introduction  into  the  eye,  is 
turned  upwards,  the  other  downwards^^  one  edge  , di- 
rected towards  the  nasal,  the  other  towards  the  tempo- 
ral canthus,  and  the  point  towards  the  centre  of  the 
eyeball.  Beer  prefers  this  mode  of  proceeding,  in  order 
to  avoid  moving  the  lens  too  soon  out  of  its  natural  si- 
tuation, whereby  the  subsequent  manoeuvres  of  depres- 
sion or  reclination,  he  thinks,  would  be  rendered  very 
uncertain  and  incomplete.  He  also  recommends  the 
surgeon  to  support  his  hand  in  some  measure  on  the 
patient’s  cheek  by  means  of  the  little  finger,  so  as  to 
have  it  in  his  power  to  check  the  too  sudden  and  deep 
entrance  of  the  instrument  into  the  eye,  liable  to  hap- 
pen when  the  broadest  part  of  the  spear-point  has 
passed  through  the  sclerotica. — {Lehre,  iVc.  b.  2,  p.  354.) 

It  happened,  unfortunately  for  the  credit  of  the  ope- 
ration of  depression,  that  Petit  admonished  surgeons 
to  beware  of  wounding  the  anterior  layer  of  the  crys- 
talline capsule : he  had  an  idea,  that  Avhen  this  caution 
was  observed,  the  vitreous  humour  would  afterward 
fill  up  the  space  previously  occupied  by  the  lens,  and 
that  thus  the  refracting  powers  of  the  eye  might 
become  as  strong  as  in  the  natural  state,  and  the  neces- 
sity for  using  spectacles  be  considerably  obviated.  But 
we  are  now  apprized,  that  leaving  this  very  membrane, 
from  which  Petit  anticipated  such  great  utility,  even 
were  it  practicable  to  leave  it  constantly  uninjured  in 
its  natural  situation,  would  be  one  of  the  worst  incul- 
cations that  could  possibly  be  established  ; for,  in  many 
cases  where  extraction  j)roves  fruitless,  in  .some  where 
depression  fails,  the  want  of  success  is  owing  lo  a sub- 
sequent oj)acity  of  the  crystalline  capsule ; m short, 
blindness  is  rej)roducod  by  the  secondary  membranous 
cataract.  It  seems  more  than  probable,  that  in  some  of 
the  instances  where  the  ojjaqne  lens  has  been  said  to 
have  risen  again,  nothing  more  has  happened  than  the 
disea.se  in  question.  Therelbre,  notwithstanding  the 
whole  capsule  in  the  mtijority  of  cases  may  be  depressed 
with  the  lens  out  of  the  axts  of  vision,  as  it  is  not  rt 


260 


CATARACT. 


(lonstant  occurrencei  I cannot  too  strongly  enforce  the 
propriety  of  extirpating,  as  it  were,  ever'^  source  and 
seat  of  »he  cataract  in  the  same  operation  , and  in  imita- 
tion of  the  celebrated  Scarpa,  who  is  entitled  to  the  ho- 
nour of  having  first  pointed  out  the  gre,it  importance 
of  this  practice,  I shall  presume  to  recommend,  as  a ge- 
neral rule  in  couching,  iways  to  lacerate  the  fl'oni  layer 
of  the  capsule,  whether  m an  opaque  or  transparent 
state. 

The  capsule  of  the  lens  may  retain  its  usual  transpa- 
rency, while  the  lens  itself  is  in  an  opaque  state.  In 
this  case,  an  inexperienced  operator  might,  from  the 
blackness  of  the  pupil,  suppose,  not  only  that  he  had  re- 
moved the  lens,  but  also  the  capsule  from  the  axis  of 
sight , and  having  depressed  the  cataract,  he  might  un- 
intentiottaUy  leave  this  membrane  entire  in  its  natural 
situation.  Therefore,  if  there  should  be  any  reason  for 
suspecting  that  the  anterior  lajer  of  the  capsule  has  es- 
caped laceration  ; if,  in  other  words,  the  resistance  made 
to  moving  the  convexity  of  the  instrument  forwards,  to- 
wards the  pupil,  should  give  rise  to  such  a suspicion; 
for  the  sake  of  remo^dng  all  doubt,  it  is  proper  to  com- 
municate to  the  needle  a gentle  rotatory  motion,  by  which 
its  point  will  be  turned  forwards  and  disengaged  through 
the  transparent  capsule  opposite  the  pupil ; then,  by  re- 
peating a few  movements  downwards  and  backwards,  it 
will  be  so  freely  rent  wiin  the  needle,  as  to  occasion  no 
future  trouble. 

Beer  divides  both  the  operations  of  couching  and  re- 
clination  into  three  stages  : the  first  is  that  in  which  the 
needle  is  introduced  into  the  eye ; the  second  that  in 
which  it  is  passed  into  the  posterior  chamber  and  placed 
across  the  anterior  surface  of  the  cataract ; and  the  third 
that  in  which  the  depression  or  reclination  of  the  cata- 
ract is  accomplished. 

If  a straight,  slender,  spear-pointed  needle  be  used, 
Hid  the  second  stage  of  the  operation  be  completed  by 
the  introduction  of  the  extremity  of  the  instrument  into 
the  posterior  chamber  (which  I particularly  recommended 
to  be  done  in  the  manner  directed  by  Scarpa),  then  accord- 
ing to  the  directions  given  by  Professor  Beer,  when  de- 
pression is  indicated,  the  needle  is  to  be  immediatelj* 
carried  to  the  uppermost  part  of  the  cataract,  with 
its  point  directed  somewhat  obliquely  dowmwards; 
and  with  that  surface,  which,  in  the  first  instance,  was 
applied  to  the  front  of  the  lens,  now  placed  upon  its  su- 
perior edge  ; then  the  opaque  body  is  to  be  pushed  rather 
obliquely”  dowaiwards  and  outwards,  so  far  below  the 
pupil  that  it  can  no  longer  be  distinguished.  After  this 
ha^  been  done,  the  needle  is  to  be  gently  raised,  in  order 
to  see  whether  the  cataract  will  continue  depressed,  and 
if  it  be  found  to  do  so.  the  needle  is  to  be  withdratvu  in 
the  same  direction  in  which  it  was  introduced. 

On  the  other  hand,  says  Beer,  when  reclination  is  to 
be  practised,  the  needle,  after  being  apphed  to  the  front 
surface  of  the  cataract,  is  not  to  be  moved  fanher  out  of  j 
the  position  of  the  second  stage  of  the  operation,  but  its  ; 
handle  is  merely  to  be  raised  diagonally  forwards,  where-  i 
by  the  cataract  wiU  be  pressed  downwards  and  outwards  ! 
towards  the  bottom  of  the  vitreous  humour,  and  turned  j 
in  the  manner  already  specified.  Beer  has  delivered  | 
what  appears  to  me  one  valuable  piece  of  advice  for  i 
operators  on  the  eye  with  the  needle : whether  depres-  j 
Sion  or  reclination  is  to  be  done,  says  he,  a surgeon  can  j 
only  use  this  instrument  without  injurious  consequences  i 
on  the  principle  of  a lever  ; and  every  attempt  to  press  j 
with  the  whole  length  of  the  instrument  is  not  only  in-  ; 
effectual,  with  respect  to  the  progress  of  the  operation, 
but  so  hurtful  to  the  eye  that  bad  effects  must  follow,  as 
may  be  readily  conceived,  when  it  is  recollected  how  , 
violently  the  cihaiy  nerves  must  be  stretched. 

As  for  the  modifications  of  the  manoeuvres  rendered 
necessary  by  the  varieties  of  cataracts,  they  are  (says 
Beer)  so  unimportant  m all  cases  of  depression,  that  a ‘ 
young  operator  will  easily  understand  them  himself 
But  things  are  far  otherwise  in  the  practice  of  rechna-  ' 
tion ; for  when  the  case  is  a completely  formed  capsiilo-  , 
lenticular  cataract,  and  the  opaque  capsule  is  so  thin 
as  to  be  tom  during  the  turning  of  the  lens,  the  latter 
body  tvill  indeed  be  placed  in  the  intended  position  at  the  i 
bottom  of  the  eye,  but  the  capsule  itself,  which  has 
merely  been  lacerated,  must  form  a secondary  cataract,  : 
unless  the  surgeon,  with  a sharp  double-edged  needle,  , 
immediately  di\ide  it  in  ever}*  ihrection,  and  remove 
it  as  far  as  possible  from  the  pupil,  ^^^len,  during 
reclination,  a snftLsh  lens,  or  one  w hich  is  pulpy  to  its 
ver>- nudeus,  breaks  into  several  pieces,  it  is  necessary. 


in  order  not  to  have  afterward  a considerable  second* 
ary  lenticular  cataract,  to  put  the  larger  fragments  sepa- 
rately in  a state  of  reclination,  while  the  smaller  ones 
may  either  be  depressed,  or  (if  the  pupil  be  not  too  much 
contracted)  they  may  be  pushed  into  the  anterior  chamber, 
where  they  will  soon  be  absorbed.  When  the  cataract 
is  partially  adherent  to  the  uvea.  Beer  recommends  an 
endeavour  to  be  first  made  with  the  edge  of  the  needle 
(which  is  to  be  introduced  flat  between  the  cataract  and 
the  uvea,  above  or  below  the  adhesion)  to  separate 
the  adherent  qltrts  before  the  attempt  at  rechnation 
is  made.  Should  it  be  a cataract  which  always  rises 
^ain  as  soon  as  the  needle  is  taken  from  it,  though  the 
instrument  has  not  pierced  it  at  all,  the  case  is  temied 
the  elastic  cataract,  in  which  the  lens  is  not  only  firmly 
adherent  to  its  own  capsule,  but  this  also  to  the  mem- 
brana  hyaloidea.  Here  Beer  thinks  that  the  best  plan 
is  first  to  carry  the  needle  to  the  uppemiost  point  of  the 
posterior  surface  of  the  lens,  and,  by  means  of  perpendi- 
cular movements  of  the  cutting  part  of  the  instrument, 
to  endeavour  completely  to  loosen  this  preternatural  ad- 
hesion of  the  cataract  to  the  vitreous  humour,  when  re- 
clination may  be  tried  again,  and  will  perhaps  succeed. 
But,  says  Beer,  w'hen  the  continual  rising  of  the  cata- 
ract is  caused  by  the  operator's  running  the  needle  into 
it,  the  instrument  must  either  be  withdrawn  far  enough 
out  of  the  eye  to  let  it  be  again  properly  brought  into  the 
posterior  chamber,  when  reclination  may  be  effectually 
repeated ; or,  if  the  cataract  be  firmly  fixed  on  the  nee- 
dle at  the  bottom  of  the  eye,  the  instrument  should  not 
be  raised  again,  but  previously  to  being  withdrawn,  it 
should  bcTOtated  a couple  of  times  on  its  axis,  whereby 
the  pierced  lens  will  be  more  easily  disengaged  from  the 
needle,  and  at  last  continue  depressed.— (LeAre  ton  den 
Ajj-gernkr.  b.  2,  p.  356  358.) 

In  addition  to  Beer’s  directions  for  couching  and  re- 
clination, the  following  observations  seem  to  me  to 
merit  attention. 

^Mien  the  case  is  a fluid  or  milky  cataract,  the  ope- 
rator frequently  finds,  that  on  passing  the  point  of  the 
couching-needle  through  the  anterior  layer  of  the  cap- 
sule, its  white  milky  contents  instantly' flow  out,  and, 
spreading  like  a cloud  over  the  two  chambers  of  the 
aqueous  humour,  completely  conceal  the  pupil,  the  iris, 
and  the  instrument  from  his  view ; who,  however, 
ought  never  to  be  discouraged  at  this  event.  Although 
it  seems  to  me  most  prudent  to  postpone  the  comple- 
tion of  operations  with  the  needle,  m the  example  of 
blood  concealing  the  pupil,  in  the  first  step  of  couching, 
and  not  to  renew  any  attempt  before  the  aqueous  hu- 
mour has  recovered  it's  transparency ; I am  inclined  to 
adopt  this  sentiment,  chiefly  because  the  species  of  ca- 
Uiract  is,  in  this  circiunstance,  generally  unknown  to 
the  operator ; consequently,  he  must  be  absolutely  inca- 
pable of  emplojdng  that  method  of  couching  which  the 
peculiarities  of  the  case  may  demand.  Speaking  of 
this  case,  however.  Beer  says,  “ the  surgeon  must  has- 
ten the  completion  of  e-xtraction  or  reclination,  though 
possibly  the  operation  may  not  always  admit  of  being 
continued,  or,  if  gone  on  with,  it  must  be  done,  as  it 
were,  blindfold.”— (I/cAre,  <S-c.  b.  2,  p.  361.)  ^Mien  a 
milky  fluid  blends  itself  writh  the  aqueous  humour,  and 
prevents  the  surgeon  from  seeing  the  iris  and  pupil  t 
this  event  is  itself  a source  of  mformation  to  hun,  inas- 
much as  it  gives  him  a perfect  insight  into  the  nature  of 
the  cataract  which  he  is  treating ; and  instructs  him 
what  method  of  operating  it  is  his  duty  to  adopt.  The 
surgeon,  guided  by.  his  anatomical  knowledge  of  the 
eye,  should  make  the  curved  point  of  the  needle  desenbe 
the  segment  of  a circle,  from  the  inner  towards  the  outer 
can  thus,  and  in  a direction  backwards,  as  if  he  had  to  de- 
press a finn  cataract. — (Scarpa.)  Thus  he  will  succeed 
in  lacerating,  as  much  as  is  necessary,  the  anterior 
layer  of  the  capsule,  upon  which,  in  a great  measure,  the 
perfect  success  of  the  operation  depends ; and,  not  only 
in  the  milky,  but  almost  every  other  species  of  cataract. 

The  extravasation  of  the  milky  fluid  in  the  chambers 
of  the  aqueous  humour  spontaneously  disappears 
very  soon  after  the  operation,  and  leaves  the  pupil  of 
its  accustomed  transparency.  In  twelve  casts  of  a 
dis-solved  lens,  on  which  I have  operated,”  says  I.atta,. 
“ the  dissolution  was  so  complete,  that  on  entering  th^ 
needle  into  the  capsule  of  the  lens,  the  whole  was 
mixed  with  the  aqueous  humour,  and  all  that  could  be 
done  wa.s  to  de.siroy  the  capsule  as  comptelely  as  pos- 
sible. that  all  the  milky  matter  might  be  evacuated.  Itr 
ten  of  these  ca.ses.  \neion  was  almost  completely  r*- 


CATARACT. 


261 


stored  in  four  weeks  from  the  operation.”  Mr.  Pott, 
in  treating  of  this  circumstance,  viz.  the  effusion  of 
the  fluid  contents  of  the  capsule  into  the  aqueous  hu- 
mour, observes,  that  so  far  from  being  an  unlucky  one, 
and  preventive  of  success,  it  proves,  on  the  contrary, 
productive  of  all  the  benefit  which  can  be  derived  from 
the  most  successful  depression  or  extraction,  as  he  has 
often  and  often  seen. 

When  the  cataract  is  of  a soft  or  caseous  description, 
the  particles  of  which  it  is  composed  will  frequently 
elude  all  efforts  made  with  the  needle  to  depress  them, 
and  will  continue  behind  the  pupil  in  the  axis  of  vi- 
sion. This  has  been  adduced  as  one  instance  that  baf- 
fles the  efficacy  of  couching,  and  may  really  seem  to 
the  inexperienced  an  unfortunate  circumstance.  It 
often  happens  in  the  operation  of  extraction,  that  frag- 
ments of  opaque  matter  are  unavoidably  overlooked 
and  left  behind  ; yet  Richter  confesses  that  such  mat- 
ter is  frequently  removed  by  the  absorbents.  Supposing 
a caseous  cataract  were  not  sufficiently  broken  and  dis- 
turbed in  the  first  operation,  and  that  consequently  the 
absorbents  did  not  completely  remove  it,  such  a state 
might  possibly  require  a reapplication  of  the  instru- 
ment ; but  this  does  not  generally  occur,  and  is  the 
worst  that  can  happen.  It  is  quite  impossible  to  de- 
termine, d priori,  what  effect  will  result  from  the  most 
trivial  disturbance  of  a cataract ; its  entire  absorption 
may,  in  some  instances,  follow,  while,  in  others,  a re- 
petition of  the  operation  becomes  necessary  for  the 
restoration  of  sight.  Even  where  the  whole  firm  lens 
has  reascended  behind  the  pupil,  as  Latta  and  Hey  con- 
firm, the  absorbents  have  superseded  the  necessity  for 
couching  again.  The  disappearance  of  the  opaque  par- 
ticles of  cataracts  was,  in  all  times  and  in  all  ages,  a 
fact  of  such  conspicuousness,  that,  as  appears  from  the 
authority  of  Barbette  and  others,  it  was  recorded  even 
previously  to  the  discovery  of  the  system  of  lymphatic 
vessels  in  the  body.  Indeed,  the  modern  observations 
of  Scarpa  and  others  so  strongly  corroborate  the  ac- 
count which  I have  given  of  the  vigorous  action  of  the 
absorbents  in  the  two  chambers  of  the  aqueous  hu- 
mour, and  particularly  in  the  anterior  one,  that  from 
the  moment  the  case  is  discovered  to  be  a soft  or 
caseous  cataract,  it  seems  quite  unnecessary  to  make 
any  farther  attempt  to  depress  it  into  the  vitreous  hu- 
mour. Mr.  Pott  sometimes  in  this  circumstance  made 
no  attempt  of  this  kind,  but  Contented  himself  with  a 
free  laceration  of  the  capside,  and  after  turning  the 
needle  round  and  round  between  his  finger  and  thumb 
within  the  body  of  the  crystalline,  left  all  the  parts  in 
their  natural  situation,  where  he  hardly  ever  knew 
them  fail  of  dissolving  eo  entirely  as  not  to  leave  the 
smallest  vestige  of  a cataract.  This  eminent  sur- 
geon even  practised  occasionally  what  Beer  sanctions 
and  Scarpa  so  strongly  recommends  at  this  day; 
for  he  sometimes  pushed  the  firm  part  of  such  cata- 
racts through  the  pupil  into  the  anterior  chamber, 
where  it  always  disappeared,  without  producing  the 
least  inconvenience;  we  must  at  the  same  time  add, 
that  he  thought  this  method  wTong,  not  on  accouTit  of 
its  inefticacy,  but  an  apprehension  that  it  would  be 
apt  to  produce  an  irregularity  of  the  pupil,  one  of  the 
worst  inconveniences  attending  the  operation  of  extrac- 
tion. But  the  deformity  of  the  pupil  after  extraction 
seems  to  proceed  either  from  an  actual  laceration  of  the 
iris,  or  a forcible  distention  of  the  pupil,  by  the  passage 
of  large  cataracts  through  it,  a kind  of  cau.se  that 
would  not  be  present  in  pushing  the  broken  portions 
of  a caseous  lens  into  the  anterior  chamber.  Hence, 
it  does  not  seem  warrantable  to  reject  this  very  effica- 
cious plan  of  treatment.  It  is  well  deserving  of  notice 
that  Mr.  Hey,  who  has  several  times  seen  the  whole 
opaque  nucleus  and  very  frequently  small  opaque  por- 
tions fall  into  the  anterior  chamber,  makes  this  re- 
mark : “ Indeed,  if  the  cataract  could,  in  all  cases,  be 
brought  into  the  anterior  chamber  of  th»  eye  without 
injury  to  the  iris,  it  would  be  the  best  method  of  per- 
forming the  operation."  What  the  same  author  al.so 
observes,  in  a subsequent  part  of  his  work,  is  strik- 
ingly corroborative  of  the  efficacy  of  Scarpa’s  practice. 
The  practice  of  the  Italian  professor  consists  in  lacerat- 
ing the  anterior  portion  of  the  crystalline  capsule  to 
the  extent  of  the  diameter  of  the  pupil,  in  a moderately 
dilated  state ; in  breaking  the  pappy  substance  of  the 
diseased  lens  piecemeal ; and  in  pushing  the  fragments 
through  the  pupil  into  the  anterior  chamber,  where 
they  are  gradually  absorbed. 


One  great  advantage  of  coucliing  insisted  upon  by 
Scarpa  depends  upon  its  generally  removing  the  cap- 
sule at  the  same  time  with  the  lens,  from  the  passage 
of  the  rays  of  light  to  the  retina.  Sometimes,  how- 
ever, this  desirable  eVent,  by  which  the  patient  is  ex- 
tricated from  the  danger  of  a secondary  membranous 
cataract,  does  not  take  place.  What  most  frequently 
constitutes  the  secondary  membranous  cataract  is  the 
anterior  half  of  the  capsule,  which,  not  having  been 
removed,  or  sufficiently  broken  in  a previous  opera- 
tion, continues  more  or  less  entire  in  its  natural  situa- 
tion, afterward  becomes  opaque,  and  thus  impedes  the 
free  transmission  of  the  rays  of  light  to  the  seat  of 
vision.  Sometimes  the  secondary  membranous  cata- 
ract presents  itself  beyond  the  pupil,  in  the  form  of 
membranous  flakes,  apparently  floating  in  the  aqueous 
humour  and  shutting  up  the  pupil ; at  other  limes,  it 
appears  in  the  form  of  triangular  membranes,  with 
their  bases  affixed  to  the  membrana  hyaloidea,  and 
their  points  directed  towards  the  centre  of  the  pupil. 
When  there  is  only  a minute  membranous  flake  sus- 
pended in  the  posterior  chamber,  Scarpa  thinks  it  by 
no  means  necessary  for  the  patient  to  submit  to  an- 
other operation  ; vision  is  tolerably  perfect,  and  in  time 
the  small  particle  of  opaque  matter  will  spontaneously 
disappear.  But  when  the  secondary  membranous 
cataract  consists  of  a collection  of  opaque  fragments 
of  the  capsule,  accumulated  so  as  either  in  a great  de- 
gree or  entirely  to  close  the  pupil ; or  when  the  disease 
consists  of  the  whole  anterior  half  of  the  opaque  cap- 
sule, neglected  in  a prior  operation,  and  continuing 
adherent  in  its  natural  situation,  it  is  indispensable 
to  operate  again ; for  although,  in  the  first  case,  there 
may  be  good  reason  to  hope  that  the  collection  of 
membranous  fragments  might  in  time  disappear,  yet  it 
would  be  unjustifiable  to  detain  the  patient  for  weeks 
and  months  in  a state  of  anxiety  and  blindness,  when 
a safe  and  simple  operation  would  restore  him,  in 
a very  short  space  of  time,  to  the  enjoyment  of  this 
most  useful  of  the  senses.  In  the  second  case,  says 
Scarpa,  it  is  absolutely  indispensable ; for  while  the 
capsule  remains  adherent  to  its  natural  connexions,  the 
opacity  seldom  disappears,  and  may  even  expand  over  a 
larger  portion  of  the  pupil.  He  advises  the  operation 
to  be  performed  as  follows  : when  the  aperture  in  the 
iris  is  obstructed  by  a collection  of  membranous  flakes 
detached  from  the  membrana  hyaloidea,  the  curved 
needle  should  be  introduced  with  the  usual  precaution 
of  keeping  its  convexity  forwards,  its  point  backwards, 
until  arrived  behind  the  mass  of  opaque  matter ; the 
surgeon  is  then  to  turn  the  point  of  the  needle  towards 
the  pupil,  and  is  to  push  through  this  opening  regularly, 
one  after  another,  all  the  opaque  particles  into  the  ante- 
rior chamber,  where,  as  we  have  before  noticed,  ab- 
sorption seems  to  be  carried  on  more  vigorously  than 
behind  the  pupil.  All  endeavours  to  depress  them  into 
the  vitreous  humour  Scarpa  has  found  to  be  in  vain  ; 
for  scarcely  is  the  couching-needle  withdrawn  when 
they  all  reappear  at  the  pupil,  as  if  (to  use  his  own 
phrase)  carried  thither  by  a current ; but  when  forced 
into  the  anterior  chamber,  besides  being  incapable  of 
blocking  up  the  pupil,  they  lie  without  inconvenience 
at  the  bottom  of  that  cavity,  and  in  a few  weeks  are 
entirely  absorbed. 

When  the  secondary  membranous  cataract  consists 
of  the  whole  anterior  layer  of  the  crystalline  capsule, 
or  of  several  portions  of  it  connected  with  the  mem- 
brana hyaloidea,  Scarpa,  after  cautiously  turning  the 
point  of  the  needle  towards  the  pupil,  pierces  the  opaque 
capsule : or,  if  there  be  any  interspace,  he  passes  the 
point  of  the  instrument  through  it ; then,  having  turned 
it  again  backwards,  he  conveys  it  as  near  as  pos.sible 
to  the  attachment  of  the  membranous  cataract,  and 
after  piercing  the  capsule,  or  each  portion  of  it  succes- 
sively, and  sometimes  carefully  rolling  the  handle  of  the 
instrument  between  his  finger  and  thumb,  so  as  to 
twist  the  capsule  round  its  extremity,  he  thus  breaks 
the  cataract,  as  far  as  it  is  practicable,  at  every  point 
of  its  circumference.  The  portions  of  membrane  by 
this  means  separated  from  their  adhesions,  are  next 
cautiously  pushed,  with  the  point  of  the  couching 
needle  turned  forwards,  through  the  pupil  into  the  ante 
rior  chamber.  In  these  manoeuvres  the  operator  must 
use  the  utmost  caution  not  to  injure  the  iris  and  ciliary 
processes,  for  upon  this  circumstance  depends  the 
avoidance  of  bad  symptoms  after  the  operation,  not- 
withstanding it.s  duration  may  be  long,  and  the  uece*? 


CATARACT. 


sary  movements  of  the  needle  frequently  repeated.  If 
a part  of  the  membranous  cataract  be  found  adherent 
to  the  iris  (a  complication  that  will  be  indicated  w'hen, 
upon  moving  it  backwards  or  downwards  with  the 
needle,  the  pupil  alters  its  shape,  and,  from  being  cir- 
cular, becomes  of  an  oval  or  irregular  figure),  even 
more  caution  is  required  than  in  the  foregoing  case,  so 
-as  to  make  repeated  but  delicate  movements  of  the 
needle,  to  separate  the  membranous  opacity  without 
injuring  the  iris.  Beer’s  mode  of  proceeding  in  such  a 
case  I have  already  described. 

Scarpa  doss  not  deem  it  necessary  to  vary  the  plan 
of  operating  above  explained,  if  occasionally  the  cata- 
ract be  formed  of  the  posterior  layer  of  the  capsule. 
And,  according  to  this  author,  the  same  plan  also  suc- 
ceeds in  those  rare  instances  where  the  substance  itself 
of  the  crystalline  wastes,  and  is  almost  completely  ab- 
sorbed, leaving  the  capsule  opaque,  and  including,  at 
most,  only  a small  nucleus  not  larger  than  a pin’s  head. 
Scarpa  terms  it  the  primary  membrancms  cataract,  and 
describes  it  as  being  met  with  in  cliildren  or  young  peo- 
ple under  the  age  of  twenty  ; as  being  characterized  by 
a certain  transparency  and  similitude  to  a cobweb  ; by 
a whitish  opaque  point  either  at  its  centre  or  circumfe- 
rence ; and  by  a streaked  and  reticulated  appearance : 
he  adds,  that  whosoever  attempts  to  depress  such  a ca- 
taract is  baffled,  as  it  reappears  behind  the  pupil  soon 
after  the  operation  : he  recommends  breaking  it  freely 
with  the  curved  extremity  of  the  couching-needle,  and 
pushing  its  fragments  into  the  anterior  chamber,  where 
they  are  gradually  absorbed  in  the  course  of  about  three 
weeks. 

No  other  topical  application  is  generally  requisite  after 
the  operation,  but  a small  compress  of  fine  linen  upon 
each  eye ; and  the  patient  ought  to  be  kept  in  a quiet, 
moderately  darkened  room.  On  the  following  morning 
a dose  of  some  mild  purgative  salt,  such  as  the  sulphate 
of  soda  or  magnesia,  may  usually  be  administered  with 
advantage.  I shall  not  enlarge  upon  the  method  of 
treatment  when  the  inflammation  subsequent  to  couch- 
ing exceeds  the  ordinary  bounds  ; in  hypochondriacal, 
hysterical,  and  irritable  constitutions  this  is  more  fre- 
quently met  w'ith,  and  I have  already  touched  upon  the 
propriety  of  some  j)reparatory  measures  before  operat- 
ing upon  these  unfavourable  subjects. 

Beer  remarks,  that  although  after  extraction  very 
cautious  trials  of  the  sight  are  indispensable,  they  are 
by  no  means  proper  after  depression  or  reclination ; 
for  the  action  of  the  muscles  of  the  eye,  in  the  inspec- 
tion of  objects  at  various  distances,  is  very'  liable  to 
make  the  opaque  body  rise  again.  Hence,  as  soon  as 
the  pupil  is  clear.  Beer  recommends  covering  both  eyes 
(even  when  one  only  has  been  operated  upon)  with  a 
plaster,  and  simple  linen  compress,  which  last  is  to  be 
fastened  on  the  forehead  with  a common  bandage.  The 
same  experienced  operator  also  enjoins  perfect  quiet- 
ude of  the  body  and  head  for  some  days.  The  patient, 
he  says,  may  either  lie  in  bed,  or  sit  in  an  arm-chair,  as 
may  be  most  agreeable,  care  being  taken  to  avoid  all 
sudden  motions.  The  most  proper  food  for  the  patient 
is  such  as  is  easily  digested,  not  too  nutritious,  and  does 
not  require  much  mastication.  Every  thing  must  be 
avoided  wfliich  has  a tendency  to  excite  inflammation 
in  the  eye.  On  the  third  or  fourth  day,  the  eye  should 
be  opened,  and  afterward  be  merely  protected  by  a green 
silk  eye-screen,  which  should  also  be  gradually  dis- 
pensed v/ith.  The  patient  should  be  careful  to  do  what- 
ever is  agreeable  to  the  eye  which  has  been  operated 
upon,  and  as  carefully  avoid  every'  thing  which  irritates 
it,  or  causes  a disagreeable  sensation  in  it,  a difficulty 
of  opening  the  eyelids,  or  keeping  them  open,  a dis- 
charge of  tears,  or  a redness  of  the  white  of  the  eye,  &lc. 

Of  the  thrombus  under  the  conjunctiva,  sometimes 
caused  by  the  prick  of  the  needle,  and  of  the  readily- 
bleeding  granulations  w'hich  occasionally  shoot  up  at 
the  puncture,  I need  not  here  particularly  speak.  For 
relieving  the  obstinate  vomiting  sometimes  excited  by- 
injury  of  the  ciliary  nerves,  or  that  of  the  retina.  Beer  re- 
commends castor,  musk,  and  opium,  except  w-hen  the 
eye  is  in  a state  of  inflammation,  in  which  circumstance 
the  antiphlogistic  treatment  is  preferable.  8uch  vomit- 
ing, Beer  joins  other  writers  in  believing,  is  often  pro- 
duced by  a firm  lens  being  depressed  too  far,  so  as  to 
injure  the  retina ; a case,  however,  which  is  usually 
c(  mbined  with  a suddenly  ])roduced  conqileu  or  in- 
c(jmplete  amaurosis.  Here,  unless  the  position  of  the 
lens  can  be  changed  by  a sudden  movement  of  the  head. 


the  above  class  of  medicines  will  be  of  no  use.  Thi* 
kind  of  amaurosis  may  also  take  place  without  any 
vomiting,  and,  as  Beer  has  had  oi)portunitiesof  remark- 
ing, it  will  not  alw'ays  subside,  even  though  the  cata- 
ract be  made  to  rise  again.  The  same  amaurotic  afiec- 
tion  may  also  result  from  the  surgeon  hurting  the 
retina  by  pushing  the  needle  too  deeply  against  this 
membrane.  According  to  Beer,  the  ophtlialmy  liable  to 
happen  in  these  cases,  as  well  as  after  extraction  and 
keratonyxis,  is  always  most  severe  in  the  iris  and 
neighbouring  textures. — (Von  den  Augenkr.  b.  2,  p. 
361—363.) 

I cannot  help  remarking  how  judicious  it  is  never  to 
attempt  too  much  at  one  time  in  any  mode  of  couching. 
It  happens  in  this,  as  in  most  other  branches  of  opera- 
tive surgery,  that  celerity  is  too  often  mistaken  for 
skill : the  operator  should  not  only  be  slow  and  delibe- 
rate in  achieving  his  purpose ; he  should  be  taught  to 
consider,  that  the  repetition  of  couching  may,  like  the 
puncture  of  a vein,  be  safely  and  advantageously  put  in 
practice  again  and  again  ; and  with  far  greater  security, 
than  i'f,  for  the  sake  of  appearing  expeditious,  or  avoid- 
ing the  temporary  semblance  of  failure,  a bolder  use  of 
the  couching-needle  should  be  made  than  the  delicate 
structure  of  the  eye  warrants.  We  read,  in  Mr.  Hey’s 
Practical  Observations  on  Surgery,  that  he  couched 
one  eye  seven  times,  before  perfect  success  was  ob- 
tained : had  he  been  less  patient,  and  endeavoured  to 
effect  by  one  or  two  rough  applications  of  the  instru- 
ment what  he  achieved  by  seven  efforts  of  a gentler 
description,  it  is  highly  probable  that  the  structure  of 
the  eye  would  have  been  so  impaired,  as  well  as  the 
consequent  ophthalmy  so  violent,  as  to  have  utterly  pre- 
vented the  restoration  of  sight. 

All  the  various  methods  of  couching  having  now 
been  described,  I subjoin  the  sentiments  of  Beer,  re- 
specting the  circumstances  by  which  the  choice  of  de- 
pression or  reclination  ought  to  be  regulated.  Accord- 
ing to  this  author,  when  the  cataract  is  very  firm,  or 
moderately  so,  w-ith  a scabrous  surface,  or  the  case  is 
what  has  been  already  described  under  the  name  of  en- 
cysted cataract,  or  when  the  cataract  consists  of  any 
tough  membrane,  both  depression  and  reclination  can 
only  be  a palliative  remedy  ; for,  says  he,  none  of  these 
cataracts  after  the  operation  can  be  dissolved  and  ab- 
sorbed, but  must  remain  in  the  eye,  as  a foreign  unor- 
ganized body,  ready  at  everj-  opportunity  to  rise  again, 
and  partially  or  completely  blind  the  patient  anew 
Beer  assures  us,  that  he  has  carefully  examined  the 
eyes  of  persons  after  death,  on  w hom  depression  or  re- 
clination had  been  practised,  in  some  instances,  tw  enty 
or  more  years  previously ; but  in  almost  all  the  ex- 
amples, the  lens  was  found  firm  and  undissolved,  or  at 
most  only  diminished,  with  or  w'ithout  its  capsule. 
Membranous  cataracts  were  very  trivially  lessened ; 
though  they  had  quite  lost  their  rough  consistence,  and 
were  changed  into  a firmish  white  niass.  In  a living 
person,  Beer  says,  he  saw  an  instance,  in  which  a ca- 
taract rose  again  after  it  had  been  depressed  by  Hilmer 
thirty  years  previously : it  w as  small,  angular,  and 
w'hen  the  pupil  w'as  dilated,  it  floated  from  one  chamber 
of  the  eye  into  the  other.  ^Vhen  extracted,  w hich  w as 
done  with  complete  success,  it  was  found  to  be  almost 
ossifled.  In  1805,  Beer  extracted  from  a woman,  forty 
years  of  age,  a very  large,  hard,  yellowish-white  lenti- 
cular cataract,  which  had  been  in  the  anterior  chamber 
tw-enty-si.x  years.  The  lens  had  been  thus  disjdaced  by 
a blow  received  on  the  eye  from  the  branch  of  a tree. 
Nor  has  Beer  ever  yet  seen  a case  in  w hich  a cataract 
of  a semi-firm  consistence  w-as  dissolved  and  absorbed. 
—(Von  den  Augenkr.  b.  2,p.  363.)  Had  Beer  confined 
his  statements  to  what  happens  to  certain  cataracts,  on 
which  depression  or  reclination,  strictly  so  called,  had 
been  practised,  I should  have  been  disposed  to  accede 
to  the  general  assertion,  respecting  the  great  length  of 
time  which  a ^rm  or  tough  capsular  cataract  remains 
in  the  vitreous  humom  uiidissolved  and  unabsorbed 
But  if  he  mean  that  the  same  thing  is  generally  the  case 
with  cataracts  broken  piecemeal,  and  placed  in  the 
aqueous  humour,  we  know  that  such  a representation 
is  coiitradicted  by  the  experience  of  an  infinite  number 
of  the  highest  authorities  in  surgery.  Nay,  notwith- 
standing the  case  adduced  of  a bony  lens  having  re- 
mained in  the  aijueous  humour  twenty-six  years,  1 am 
disjiosed  to  think  that  Beer  himself  does  not  intend  to 
question  the  absorption  of  the  fragments  of  cataracts  in 
the  aqueous  humour,  particular! j as  at  />.  35T,  it.2,  Us 


CATARACT, 


263 


sanctions  pushing  the  fragments  of  semi-firm  cataracts 
through  the  pupil  into  the  anterior  chamber,  where,  he 
confesses,  that  they  are  soon  absorbed. 

Beer  thinks  that,  in  general,  depression  and  reclina- 
tion  are  indicated  only  in  cases  in  which  extraction  is 
absolutely  impracticable,  or  attended  with  too  great  dif- 
ficulty, as  will  be  better  understood  when  this  operation 
is  considered.  As  examples  of  this  kind,  Beer  specifies 
an  extensive  adhesion  of  the  iris  to  the  cornea ; a very 
flat  cornea,  and,  of  course,  so  small  an  anterior  chamber, 
that  an  incision  of  proper  size  in  the  cornea  cannot 
be  made;  a broad  arcus  senilis;  an  habitually  con- 
tracted pupil  (incapable  of  being  artificially  dilated) ; an 
eye  much  sunk  in  the  orbit,  with  a small  fissure  be- 
tween the  eyelids ; eyes  affected  with  incessant  convul- 
sive motions ; a partial  adhesion  of  the  cataract  to  the 
uvea  ; unappeasable  timidity  in  the  patient ; and  an  im- 
possibility of  managing  him  during  and  after  the  opera- 
tion, in  consequence  of  his  childhood  or  stupidity. 

With  regard  to  the  question  whether  depression  or 
reclination  should  be  preferred.  Beer  is  of  opinion  that 
the  first  method  is  indicated  only  when  the  dimensions 
of  the  cataract  are  small,  and,  consequently,  when  there 
is  room  enough  for  it  to  be  placed  below  the  pupil,  with- 
out the  ciliary  processes  being  torn  from  the  annulus 
ciliaris.  Such  cases  are  the  dry  siliquose  cataract  (the 
primary  membranous  cataract  of  Scarpa),  when  per- 
fectly free  from  adhesions  to  the  uvea  ; the  true  lenticu- 
lar secondary  cataract,  produced  by  the  small  but  firm 
fragments  of  the  lens  having  been  left,  or  risen  again ; 
and  the  genuine  secondary  membranous  or  capsular 
cataract.  On  the  other  hand,  reclination  is  to  be  pre- 
ferred, when,  together  with  the  above  objections  to  ex- 
traction, the  surgeon  has  to  deal  with  a fully  formed, 
very  hard  lenticular,  or  capsulo-lenticular  cataract ; or 
with  a case  of  the  latter  kind,  complicated  with  partial 
adhesions  to  the  uvea ; or  when  the  case  is  a secondary 
capsular  cataract,  similarly  circumstanced ; a second- 
ary cataract  of  lymph ; a gypsum  cataract ; or  there 
is  reason  to  apprehend  a considerable  tendency  in  the 
blood-vessels  of  the  interior  of  the  eye  to  become  vari- 
cose.— (Lehre  von  den  Augenkr.  b.  2,p.  365.) 

The  manner  of  operating  with  the  needle  upon  the 
congenital  cataracts  of  children  will  be  hereafter  ex- 
plained. 

EXTRACTION  OF  THE  CATARACT. 

From  some  passages  in  the  works  of  Rhazes,  Haly, 
and  Avicenna,  specified  by  Mr.  Guthrie,  it  is  suffi- 
ciently clear,  that  the  practice  of  opening  the  cornea  for 
the  removal  of  cataracts  was  not  unknown  to  the  an- 
cients. Rhazes  says,  that  about  the  end  of  the  first  cen- 
tury, Antyllus  opened  the  cornea,  and  drew  the  cataract 
out  of  the  eye  with  a fine  needle,  in  which  practice  he 
was  followed  by  Lathyrion.  However,  while  doubts 
were  entertained  respecting  the  true  seat  of  the  cata- 
ract, it  is  hardly  to  be  supposed,  that  this  mode  of  treat- 
ment could  have  been  frequently  adopted ; but  as  soon 
as  it  was  fully  proved  that  the  true  cataract  was  an 
opacity  of  the  crystalline  lens ; that  the  loss  of  sight 
wouid  not  be  occasioned  by  the  removal  of  this  body ; that 
the  cornea  might  be  divided  without  danger;  and  that 
the  aqueous  humour  would  be  quickly  regenerated ; the 
mode  of  cure  by  extracting  the  cataract  out  of  the  eye 
would  naturally  present  itself. — {Wenzel.) 

Freytag  is  perhaps  the  first  in  modem  times  who 
made  an  attempt  to  extract  the  cataract : this  was  about 
the  close  of  the  17th  century.  After  him,  Lotterius,  of 
Turin,  performed  the  operation.  But  nobody  has  so 
strong  a claim  as  M.  Daviel  to  the  honour  of  bringing 
the  merits  of  the  practice  before  the  public ; and  he  not 
only  adopted  it  himself,  but  published  the  first  good  de- 
scription of  it. — {Sur  une  Nouvelle  Mdthode  de  guerir 
la  Catnracte  par  V Extraction  du  Cristallin,  1747.  Also, 
M' moires  de  VAcad.  Royale  de  Chirurgie,  t.  2,  4to. 
1753.)  Two  cases  in  which  the  cataract  had  accident- 
ally slipped  through  the  pupil  into  the  anterior  chamber, 
whence  they  were  extracted  in  the  years  1707  and  1708 
by  MM.  Mery  and  Petit,  as  related  by  St.  Ives,  seem  to 
have  had  considerable  itifiuencc  in  bringing  about  the 
regular  performance  of  this  method  of  removing  the  ca- 
taract ; for  they  served  as  an  encouragement  to  Daviel, 
by  whom  the  practice  was  completely  established.  The 
operation  was  afterward  brought  considerably  nearer 
to  perfection  by  the  ingenuity  and  industry  of  Wenzel. 
—{Itrarnbilla,  Jnstrumentarium  Chir.  Austriacum, 
J782.P.71.) 


Indeed,  with  the  valuable  Instructions  which  Ware 
and  Beer  have  still  more  recently  furnished,  the  extrac- 
tion of  the  cataract  may  now  be  regarded  as  brought  to 
the  highest  state  of  improvement.  According  to  Beer, 
it  admits  of  division  into  three  stages,  the  first  of  which, 
as  in  depression  and  reclination,  is  the  most  important, 
because,  unless  it  be  performed  exactly  as  it  ought  to 
be,  the  operation  will  be  very  liable  to  fail,  and  it  is  ex- 
ceedingly difficult  to  make  amends  for  any  fault  com- 
mitted in  this  early  part  of  the  proceedings.  The  first 
stage  consists  in  making  an  effectual  opening  in  the 
cornea  with  a suitable  knife.  The  second,  in  dividing 
the  anterior  layer  of  the  capsule,  which,  says  Beer, 
should  not  be  merely  punctured,  or  torn  with  a bluntish 
instrument,  but  cut  with  a sharp  two-edged  lance- 
pointed  needle ; and,  as  much  as  possible,  annihilated. 
In  the  third  stage,  the  expulsion  of  the  cataract  from  the 
eye  is  effected  either  by  the  well-regulated  action  of  the 
eyeball  itself,  or  by  the  assistance  of  art.  But,  as  Beer 
remarks,  they  who  have  learned  the  manner  of  effect- 
ually and  skilfully  cutting  the  cornea,  wdll  frequently 
have  the  pleasure  to  find  the  last  two  stages  beneficially 
converted  into  one,  and  the  operation  in  general  soon 
and  expeditiously  completed. — ( Von  den  Augenkr.  b.  2, 
p.  366.) 

The  knives  used  by  Richter,  Wenzel,  Ware,  and 
Beer  are  all  of  them  more  or  less  different ; but  they 
agree  in  the  common  quality  of  completely  filling  up  the 
wound,  as  it  is  extended,  so  that  none  of  the  vitreous 
humour  can  escape  before  the  division  of  the  cornea  is 
finished. 

Wenzel’s  knife  resembles  the  common  lancet  employed 
in  bleeding,  excepting  that  its  blade  is  a little  longer, 
and  not  quite  so  broad.  Its  edges  are  straight,  and  the 
blade  is  an  inch  and  a half  (eighteen  lines)  long,  and  a 
quarter  of  an  inch  (three  lines)  broad,  in  the  widest  part 
of  it,  which  is  at  the  base.  From  this  part  it  gradually 
becomes  narrower  towards  the  point ; so  that  this 
breadth  of  a quarter  of  an  inch  extends  only  to  the  space 
of  about  one-third  of  an  inch  from  the  base ; and  for  the 
space  of  half  an  inch  from  the  point,  it  is  no  more  than 
one-eighth  of  an  inch  broad. 

The  knife  employed  by  the  late  Mr.  Ware  is,  in  re- 
gard to  its  dimensions,  not  unlike  that  employed  by 
Wenzel.’  The  principal  difference  is,  that  Mr.  Ware’s 
knife  is  less  spear-pointed  ; in  consequence  of  which 
when  this  latter  instrument  has  transfixed  the  cornea, 
its  lower  or  cutting  edge  will  sooner  pass  below  the 
inferior  margin  of  the  pupil,  than  the  knife  used  by 
Wenzel.  On  this  account,  Mr.  Ware  believed  that  the 
iris  would  be  less  likely  to  be  entangled  under  the 
knife  which  he  recommended,  than  under  Wenzel’s, 
when  the  instrument  begins  to  cut  its  way  down- 
wards, and  the  aqueous  humour  is  discharged.  Mr. 
Ware  particularly  advises  great  care  to  be  taken  to  let 
the  knife  increase  gradually  in  thickness  from  the 
point  to  the  handle  ; by  which  means,  if  it  be  con- 
ducted steadily  through  the  cornea,  it  will  be  next  to 
an  impossibility,  that  any  part  of  the.  aqueous  humour 
can  escape,  before  the  section  is  begun  downwards : 
and,  consequently,  during  this  time,  the  cornea  will 
preserve  its  due  convexity.  But  if  the  blade  should 
not  increase  in  thickness  from  the  point ; or  if  it  be  in- 
curvated  much  in  its  back  or  edge,  the  aqueous  humour 
will  unavoidably  escape  before  the  puncture  is  com- 
pleted ; and  the  iris,  being  brought  under  the  edge  of 
the  knife,  will  be  in  great  danger  of  being  wounde;!  by 
it.  But  a better  knife  than  any  other  which  has  yet 
been  proposed,  is  that  emiiloyed  by  Beer.  A very  in- 
genious double  cataract-knife  is  used  by  Jaeger.  “ The 
instrument  is  composed  of  a Beer’s  blade  affixed  to  a 
handle  ; a smaller  blade  of  the  same  form,  having  its 
flat  side  in  contact  with  the  other  knife ; and  a button 
screw.  When  not  in  use,  the  second  blade  is  situated 
within  the  outline  of  the  first,  with  which  the  cornea 
is  transfixed.  It  is  introduced  in  the  same  way  as 
Beer’s  knife,  not  parallel,  but  nearly  perpendicular  to 
the  cornea,  and  afterward  carried  across  the  eye,  ex- 
actly like  the  single  knife,  with  the  posterior  surface 
of  the  fixed  blade  imrallel  to  the  iris,  at  the  usual  dis- 
tance from  the  junction  of  the  cornea  with  the  sclero- 
tica. When  the  point  of  the  greater  knife  has  trans- 
fixed the  cornea  at  the  inner  side,  pressure  is  made  on 
the  button  head  of  the  smaller  blade,  which  slides  in  a 
groove  in  the  upper  part  of  the  handle  with  the  thumb, 
with  which  it  it  pushed  steadily  Ibrwards,  while  the 
greater  blade  keeps  the  bull  firmly  fixed,  and  thus  the 


264 


CATARACT. 


section  of  the  cornea  is  completed,”  &c.— (See  Lou- 
don's Short  Inquiry  into  the  Principal  Causes  of  the 
Unsuccessful  Termination  of  Extraction,  <^c.  1826.) 
Among  the  advantages  imputed  to  Jaeger’s  knife  are 
those  of  not  injuring  parts  at  the  inner  angle  ; of  not 
making  the  incision  too  small  for  the  extraction  of  the 
lens ; and  of  less  of  the  aqueous  humour  being  dis- 
charged previously  to  the  iris  being  out  of  danger. 
The  sentiments  of  Richter,  Scarpa,  Beer,  and  others, 
about  the  position  of  the  patient  in  the  operation,  and 
the  mode  of  fixing  the  eye,  have  been  already  noticed 
in  a foregoing  section. 

The  operator  is  to  sit  in  front  of  the  patient,  but 
upon  a considerably  higher  stool  or  chair  than  the  lat- 
ter, as  already  explained,  and  his  legs  are  to  be  placed 
on  each  side  of  the  patient,  and  his  right  foot  suffl- 
.ciently  raised  by  a stool  for  his  elbow  to  rest  upon  his 
knee,  while  the  knife  is  on  a level  with  the  patient’s 
eye.— (See  Guthrie's  Operative  Surgery  of  the  Eye,  p. 
295.) 

When  the  right  eye  is  to  be  operated  upon,  and  the 
operation  is  to  be  done  according  to  the  preceding  di- 
rections, the  surgeon  must  of  course  use  his  left  hand ; 
but  if  he  be  not  an  ambidexter,  “ the  patient  must  be 
placed  on  his  back  on  a table,  or  on  a mattress,  or  a 
firm  bedstead  vtdth  a head,  so  that  the  operator  can 
stand  behind  without  inconvenience.  The  head  being 
supported  on  a cushion,  the  operator  raises  the  upper 
eyelid  himself  and  fixes  the  eyeball,  Avhile  an  assistant 
depresses  the  lower  lid,  if  nece*ssary.  The  incision  is 
then  to  be  made  with  the  same  precaution  as  in  the 
other  method,  the  knife  being  held  with  its  edges  to- 
wards the  thumb,  and  the  httle  finger  towards  the 
temple  instead  of  the  cheek.  The  division  of  the  cor- 
nea upwards  in  this  manner  is  the  operation  generally 
preferred  by  ]\Ir.  Alexander  for  both  eyes,  when  not 
specially  contra-indicated.” — (^Guthrie,  p.  318.) 

Baron  Wenzel,  fearful  of  the  bad  consequences  of 
undue  pressure,  made  no  endeavour  to  fix  the  eye  at 
all  at  the  period  of  cutting  the  cornea. 

The  late  Mr.  Ware  did  not  approve  of  this  plan  of 
leaving  the  eye  unfixed.  The  danger  likely  to  arise 
from  undue  pressure,  he  observes,  can  only  take  place 
after  the  instrument  has  made  an  opening  into  the 
eye ; but  the  pressure  which  he  recommended  is  to  be 
removed  the  instant  the  knife  is  carried  through  the 
cornea,  and  before  any  attempt  is  made  to  divide  this 
tunic  downw'ards.  To  understand  this  subject  better, 
however,  the  reader  should  know,  that  Mr.  Ware  di- 
vided the  incision  of  the  cornea  into  two  distinct  pro- 
cesses ; the  first  of  which  may  be  called  punctuation, 
and  the  second  section.  So  long,  says  Mr.  Ware,  as 
the  knife  fills  up  the  aperture  in  which  it  is  inserted, 
that  is,  until  it  has  passed  through  both  sides  of  the 
cornea,  and  its  extremity  has  advanced  some  way  be- 
yond this  tunic,  the  aqueous  humour  cannot  be  dis- 
charged, and  pressure  may  be  continued  with  safety. 
The  punctuation  of  the  cornea  being  completed,  the 
purpose  of  pressure  is  fully  answered ; and  if  such 
pressure  be  continued  when  the  section  of  the  cor- 
nea begins,  instead  of  being  useful,  it  will  be  hurtful. 
To  avoid  all  bad  defects,  Mr.  Ware  recommends  the 
cornea  to  be  cut  in  the  following  way. 

The  operator  is  to  place  the  fore  and  middle  fingers 
of  the  left  hand  upon  the  tunica  conjunctiva,  just  be- 
low and  a little  on  the  inside  of  the  cornea.  At  the 
same  time,  the  assistant  who  supports  the  head  is  to 
apply  one  or,  if  the  eye  projects  sufficiently,  two  of  his 
fingers  upon  the  conjunctiva,  a little  on  the  inside, 
above  the  cornea.  The  fingers  of  the  operator  and  as- 
sistant thus  opposed  to  each  other,  will  fix  the  eye, 
and  prevent  the  lids  from  closing.  The  point  of  the 
knife  is  to  enter  the  outside  of  the  cornea  a little  above 
its  transverse  diameter,  and  just  before  its  connexion 
with  the  sclerotica.  Thus  introduced,  it  is  to  be  pushed 
on  slowly,  but  steadily,  without  the  least  intermission, 
and  in  a straight  direction,  with  its  blade  parallel  to 
the  iris,  so  as  to  pierce  the  cornea  towards  the  inner 
angle  of  the  eye  on  the  side  opposite  to  that  which  it 
first  entered,  and  till  about  one-third  part  of  it  is  seen 
to  emerge  beyond  the  inner  margin  of  the  cornea. 
When  the  knife  has  reached  so  far,  the  punctuation  is 
completed.  The  broad  part  of  the  blade  is  now  be- 
tween the  cornea  and  the  iris,  and  its  cutting  edge  be- 
low the  pupil,  which  of  course  is  out  of  all  danger  of 
being  wounded.  As  every  degree  of  pressure  must 
now  r»e  taken  off  the  eyeball,  the  fingers  both  of  the  1 


operator  and  his  assistant  are  instantly  to  be  removed 
from  this  part  and  shifted  to  the  eyelids.  These  are  to 
be  kept  asunder  by  gently  pressing  them  against  the 
edges  of  the  orbit ; and  the  eye  is  to  be  left  entirely  to 
the  guidance  of  the  knife,  by  which,  says  Mr.  Ware,  it 
may  be  raised,  depressed,  or  drawn  to  either  side,  as 
may  be  found  necessary.  The  aqueous  humour  being 
now  partly,  if  not  entirely,  evacuated,  and  the  cornea 
of  course  rendered  flaccid,  the  edge  of  the  blade  is  to 
be  pressed  slowly  downwards,  till  it  has  cut  its  way 
out,  and  separated  a little  more  than  half  the  cornea 
from  the  sclerotica,  following  the  semicircular  direction 
marked  out  by  the  attachment  of  the  one  to  the  other. 
—{Ware.) 

In  the  eyes  of  some  persons,  the  iris  is  so  convex, 
that  it  almost  impossible  to  complete  the  section  of 
the  cornea  without  entangling  the  iris  under  the  edge 
of  the  knife,  unless  the  cornea  be  gently  rubbed  down- 
wards with  the  finger ; one  of  the  most  important  di- 
rections, according  to  Mr.  Ware,  in  Wenzel’s  whole 
book. 

If  the  edge  of  the  knife  should  incline  too  much  for- 
wards, and  its  direction  be  not  altered,  the  incision  iu 
the  cornea  will  be  too  small,  and  terminate  almost  op- 
posite the  pupil.  In  this  case,  there  will  be  great  dif- 
ficulty in  extracting  the  cataract,  and  the  cicatrix 
afterward  may  obstruct  sight.  If,  on  the  contrary,  the 
edge  of  the  instrument  be  inclined  too  much  back- 
wards, and  its  direction  be  not  changed,  the  incision 
will  approach  too  near  the  part  where  the  iris  and  scle- 
rotica unite,  and  there  will  be  great  danger  of  wound- 
ing them.  These  accidents  may  be  prevented  by  gently 
rolling  the  instrument  between  the  fingers,  until  the 
blade  takes  the  proper  direction.— (WcrizeZ.) 

The  late  Mr.  Ware  had  seen  operators,  through  a 
fear  of  wounding  the  iris,  introduce  and  bring  out  the 
instrument  at  a considerable  distance  before  the  union 
of  the  cornea  and  sclerotica  ; in  consequence  of  which 
the  incision  from  one  side  of  the  cornea  to  the  other 
was  made  too  small  for  the  easy  extraction  of  the  ear- 
taract,  although  from  above  downwards  it  was  fully 
large  enough  for  this  purpose.  Mr.  Ware  also  some- 
times observed,  that  though  the  punctuation  of  the 
cornea  from  side  to  side  had  been  properly  conducted, 
and  its  section  afterward,  to  all  appearance,  effectu- 
ally completed,  yet,  on  account  of  the  frictions  em- 
ployed to  disengage  the  iris  from  the  edge  of  the  in- 
strument, the  knife,  in  cutting  downwards,  was  carried 
between  the  layers  of  the  cornea,  and,  consequently, 
though  the  incision  appeared  externally  to  be  of  its 
proper  size,  internally  it  w^ls  much  too  small  for  the 
cataract  to  be  easily  extracted.  In  this  case,  the  inci- 
sion must  be  enlarged  by  means  of  a pair  of  curved 
blunt-pointed  scissors,  w'hich  should  be  introduced  at 
the  part  where  the  knife  first  entered  the  cornea. — 
{Ware.) 

Beer  subdivides  the  first  stage  of  this  operation  into 
four,  each  of  which,  he  says,  claims  the  utmost  atten- 
tion, if  it  be  wished  to  make  the  incision  in  the  cornea 
in  every  respect  proper  ; the  first  is  the  introduction  of 
the  knife  through  the  cornea  into  the  anterior  chamber; 
the  second  is  directing  the  knife  towards  the  place 
where  its  point  is  to  be  brought  out  again  ; the  third  is 
bringing  out  the  point  and  guiding  the  knife  in  con- 
tinuing the  incision  in  the  cornea ; and  the  fourth  is 
the  finishing  of  that  incision.  As  Beer  states,  a com- 
pletely well-made  incision  in  the  cornea  must,  in  the 
first  place,  be  of  sufficient  size  to  let  the  cataract  es- 
cape from  the  eye  without  the  slightest  impediment ; 
and  it  will  be  large  enough,  if  care  be  taken  to  open 
one-half  of  the  cornea  near  its  edge.  Secondly,  it  must 
be  of  a proper  shape,  its  margin  not  being  triangular, 
nor  notched,  but  evenly  rounded.  In  general,  says 
Beer,  no  greater  disadvantage  can  happen,  than  that 
of  having  too  small  an  incision  in  the  cornea ; for,  even 
when  the  cataract  is  pressed  out  of  such  an  opening, 
portions  of  it  are  always  left  behind  which  afterward 
cannot  be  extracted  without  trouble ; and  though  the 
sight  may  be  at  the  moment  restored,  it  will  be  fortu- 
nate if  the  eye  be  not  afterwasd  spoiled  by  the  effects 
of  inflammation.  When  the  incision  is  triangular  or 
notched,  its  edges  cannot  be  put  smoothly  together  so 
as  to  be  healed  by  the  first  intention,  which,  however, 
is  highly  necessary,  and  the  conseijuence  is  a white 
ugly  scar,  which  is  slowly  produced  with  inflamma- 
tion, and  forms  a greater  or  less  permanent  impediment 
to  vision  downwards,  though  the  patient  be  capable  of 


CATARACT. 


265 


seeing  the  smallest  objects  which  are  straight  before  I 
him.  I 

According  to  Beer,  when  the  knife  is  to  be  intro-  i 
duced,  its  point  should  enter  the  cornea,  about  one- 
eighth  of  a line  from  its  edge,  and  one-fourth  of  a line 
above  its  transverse  diameter,  directed  obliquely  to- 
wards the  iris,  with  its  edge  turned  downwards,  by 
which  means  the  point  will  pass  immediately  into  the 
anterior  chamber.  As  soon  as  it  has  arrived  there, 
which  is  indicated  partly  by  its  bright  extremity  being 
seen  within  the  space  in  question,  and  partly  by  the 
tactus  eruditus,  such  a direction  is  to  be  given  to  it, 
that  its  point  may  project  from  the  place  of  its  entrance 
nearly  in  a direct  line  towards  the  intended  place  of  its 
exit  out  of  the  cornea,  but  a little  higher ; while  the 
posterior  surface  of  the  blade  is  to  be  conveyed  across 
the  anterior  chamber  exactly  parallel  to  the  iris.  The 
knife  is  to  be  cautiously  pushed  on,  neither  too  quickly 
nor  too  slowly,  with  its  point  continually  directed 
somewhat  upwards  above  the  part,  where  it  is  to  pass 
out  again,  until  the  point  arrives  near  the  inner  edge 
of  the  cornea ; but  in  the  transverse  passage  of  the 
knife,  its  edge  should  not  be  suffered  either  to  go 
nearer  to  or  farther  from  the  ins,  as  every  turn  of  the 
blade  backwards  or  forwards  opens  the  upper  angle 
of  the  wound,  when  the  aqueous  humour  immediately 
escapes,  and  the  iris  not  only  falls  close  against  the 
posterior  surface  of  the  blade,  but  sometimes  even  un- 
der the  edge,  so  as  to.  throw  the  young  operator  into 
the  greatest  embarrassment.  If  the  point  of  the  knife 
has  now  been  favourably  brought  out,  the  surgeon  is 
to  continue  to  push  it  on  without  pressing  it  down- 
wards, or  making  a sawing  motion  with  it,  until  the 
last  stage  of  the  operation,  viz.  that  in  which  the  inci- 
sion is  finished.  However,  as  soon  as  the  point  of  the 
knife  has  passed  out  of  the  cornea  and  reached  the 
inner  canthus,  attention  must  be  paid,  first,  to  that  part 
of  the  blade  wliich  is  yet  in  the  anterior  chamber,  so 
that  the  iris  may  not  fall  under  its  edge,  and  the  knife 
may  not  take  an  erroneous  direction  ; secondly,  to  the 
point  of  the  knife,  which  continually  projects  more 
and  more,  so  that  the  inner  canthus  may  not  be 
wounded,  which  accident,  though  trivial  in  itself, 
would  make  the  unprepared  patient  suddenly  and  in- 
voluntarily draw  back  his  head.  The  only  way  of 
preventing  this  injury,  says  Beer,  is  regularly  to  in- 
cline the  handle  more  backwards  and  downwards,  in 
proportion  as  the  point  passes  farther  out  of  the  ante- 
rior chamber.  Thirdly,  at  the  period  when  the  last 
piece  of  the  cornea  is  to  be  cut,  the  knife  should  be 
pushed  on  very  slowly,  for  otherwise  the  lens,  and 
with  it  a part  of  the  vitreous  humour,  may  be  discharged, 
as  now  the  muscles  of  the  eye  are  acting  and  com- 
pressing this  organ  with  the  greatest  force,  and,  in  old 
persons  especially,  the  loose  conjunctiva,  after  the  cor- 
nea is  cut  through,  comes  against  the  knife,  and  is  apt 
to  be  wounded.  At  the  time  when  the  operator  finishes 
the  incision  in  the  cornea,  the  assistant  is  to  let  the 
upper  eyelid  cover  the  eye,  and  a few  seconds  are  to 
be  allowed  for  the  patient  to  recoverfrom  his  fright. 

In  the  second  stage  of  the  operation.  Beer  directs 
the  assistant  again  steadily  to  hold  the  patient’s  head 
in  the  same  manner  as  during  the  cutting  of  the  cor- 
nea; but  the  upper  eyelid,  he  says,  must  be  carefully 
and  effectually  raised,  without  touching,  the  eyeball  in 
the  least,  or  letting  the  ends  of  the  fingers  project  be- 
yond the  edge  of  the  tarsus.  The  operator  is  to  de- 
press the  lower  eyelid  with  his  fore-finger,  which  is 
not  to  be  removed  away  from  the  eye,  but  gently  ap- 
plied to  the  lower  part  of  it  with  the  intervention  of 
the  eyelid,  by  which  means  the  cataract-lance  or  cap- 
sule-needle may  be  more  readily  and  easily  introduced 
under  the  flap  of  the  cornea  into  the  pupil,  while  the 
gentle  pressure  and  the  projection  of  the  cataract 
thereby  jiroduced  considerably  enlarge  the  pupil,  and 
facilitate  the  proper  division  of  the  capsule.  In  order 
to  complete  the  latter  object,  the  surgeon  introduces 
one  of  the  sharp  edges  of  the  capsule-needle,  with  the 
point  directed  towards  the  inner  canthus,  between  the 
cornea  and  the  iris,  the  wound  in  the  former  of  these 
membranes  being  opened  as  little  as  possible,  lest  the 
atmospheric  air  enter  the  eye ; a circumstance  of  which 
Beer  entertains  great  apprehension.  After  the  cap- 
sule-needle has  been  cautiously  passed  to  the  inferior 
margin  of  the  pupil,  its  lower  sharp  edge  is  to  be  ap- 
plied to  the  capsule  of  the  lens  with  its  point  directly 
upwards,  and  one  of  its  flat  surfaces  towards  the 


I inner,  and  the  other  towards  the  outer  canthus.  The 
I operator  is  now  strictly  to  cut  through  the  capsule,  by 
i making,  at  small  distances  from  one  another,  repeated 
perpendicular  strokes  with  the  edge  of  the  needle. 
Then  the  handle  of  .the  instrument  is  to  be  half  turned 
round  on  its  axis,  and  similar  strokes  are  to  be  made 
with  its  edge  in  a somewhat  oblique  direction,  by 
which  means  the  anterior  layer  of  the  capsule  will  be 
cut  into  many  squarish  fragments,  some  of  which,  in 
the  third  stage  of  the  operation,  are  taken  out  of  the 
eye  together  with  the  cataract,  and  the  risk  of  a se- 
condary cataract  of  the  anterior  layer  of  the  capsule  is 
in  a great  measure  removed.  When  the  capsule- 
needle  has  done  its  business,  it  is  to  be  withdrawn 
from  the  eye  in  the  same  position  in  which  it  was  in- 
troduced, and  the  second  stage  of  the  operation  is  thus 
finished.— (Beer,  b.  2,  p.  369.) 

I believe  no  better  instructions  than  the  foregoing 
can  be  delivered,  respectir  g the  most  advantageous 
method  of  dividing  the  capsule.  They  are  infinitely 
better  than  those  given  by  Wenzel  and  Ware.  As  soon 
as  the  point  of  the  cornea-knife  had  arrived  opposite 
the  pupil,  Wenzel  used  to  incline  it  gently  backwards, 
and  thus  puncture  the  capsule  ; but  Mr.  Ware  very  pro- 
perly objected  to  this  plan,  which,  however  it  might 
serve  to  exhibit  the  dexterity  of  the  operator,  was  at- 
tended with  no  advantage  to  the  patient,  and  could  not 
be  so  efficient  and  safe  as  the  mode  of  making  the  di- 
vi.sion  of  the  capsule  a distinct  part  of  the  operation. 

Indeed,  Wenzel  himself  did  not  recommend  opening 
the  capsule  of  the  crystalline  in  this  way  when  the 
pupil  was  much  contracted,  and  the  muscles  of  the 
eye  and  eyelids  easily  thrown  into  convulsions,  or  when 
the  posterior  chamber  was  large. 

For  dividing  the  capsule  after  the  division  of  the  cor- 
nea, Wenzel  and  his  father  used  to  employ  a flat 
needle,  one  line,  that  is,  one-twelfth  part  of  an  inch,  in 
diameter,  having  its  cutting  extremity  a little  incur- 
vated.  This  needle,  which  they  advised  to  be  made  of 
nealed  gold,  in  order  that  its  pliability  may  allow  the 
operator  to  bend  it  in  different  directions  as  occasion 
requires,  is  fixed  in  a handle  two  inches  and  a half  in 
length,  and  similar  to  that  of  the  cornea-knife.  At  the 
other  extremity  of  the  same  handle  a small  curette  or 
scoop  is  fixed,  made  also  of  nealed  gold,  which  is  of 
use  for  extracting  the  cataract. 

The  late  Mr.  Ware’s  method  of  opening  the  capsule 
will  be  hereafter  noticed. 

When  the  incision  in  the  cornea  has  been  completed, 
and  the  capsule  effectually  divided,  the  cataract,  as 
Beer  observes,  advances  into  the  pupil  immediately 
behind  the  capsule-needle,  and  if  there  be  the  least  ac- 
tion in  the  eye  itself,  it  is  generally  at  o.nce  discharged, 
Under  these  very  favourable  circumstances,  however, 
it  sometimes  happens  that  a portion  of  the  gelatinous 
or  scabrous  surface  of  the  cataract  is  detached  at  the 
margin  of  the  pupil,  as  the  opaque  body  is  passing  out, 
and  therefore  in  the  second  stage  of  the  operation, 
Beer  recommends  having  Daviel’s  scoop  always  ready, 
which  is  to  be  substituted  for  the  capsule-needle,  and 
employed  for  preventing  the  loose  fragments  from  fall-, 
ing  back  into  the  posterior  chamber,  in  the  following 
manner : as  soon  as  the  operator  remarks  that  in  the 
passage  of  the  cataract  out  of  the  pupil,  a portion  of  it 
will  be  scraped  off  by  the  edge  of  that  opening,  he 
should  introduce  the  scoop  at  the  lov/er  and  outer 
edge  of  the  cataract  upwards,  between  the  cornea  and 
the  iris,  so  as  to  be  able  to  keep  the  part  of  the  cata- 
ract which  is  ready  to  break  off,  close  up  behind  the 
rest  of  it,  and  bring  the  whole  out  of  the  eye. 

But,  says  Beer,  when  the  third  stage  of  the  opera? 
tion,  viz.  the  removal  of  the  cataract  from  the  eye, 
cannot  be  so  readily  accomplished ; a circumstance  not 
always  owing  to  an  imperfection  in  the  incision  in  the 
cornea  or  in  the  division  of  the  capsule,  but  sometimes 
proceeding  from  a want  of  proper  action  in  the  eye  it- 
self; the  operator,  if  he  feels  convinced  that  the  fault 
does  not  lie  in  the  first  or  second  stage  of  the  opera- 
tion (in  which  case  it  would  be  necessary  to  endeavour 
to  rectify  what  is  wrong),  should  assist  in  promoting 
the  discharge  of  the  cataract.  There  are  tvyo  manners 
of  doing  this,  and  it  is  not  a matter  of  iridifi'erence 
which  is  selected ; for  the  second  should  be  adopted 
only  when  the  first  will  not  answer.  Hence,  says 
Beer,  the  operator,  like  a skilful  accoucheur,  must  first 
trust  to  the  action  of  the  organ  itself,  which  he  should 
in  a certain  degree  excite,  and  not  proceed  immediately 


266 


CATARACT. 


to  fhe  use  of  a scoop,  hook,  or  forceps.  The  eye  is  to 
be  suffered  to  turn  quickly  a few  times  upwards,  and  in 
general,  during  these  movements,  the  surgeon  will 
perceive  that  the  lower  edge  of  the  cataract  advances 
farther  through  the  pupil,  and  at  length  slips  out  of  the 
eye  without  the  aid  of  instruments.  If  at  this  period 
a portion  of  the  cataract  were  found  to  be  likely  to 
break  off,  the  employment  of  David’s  scoop  in  the  way 
already  explained  would  be  proper.  On  the  other 
hand,  if,  during  the  protracted  movements  of  the  eye 
upwards,  this  organ  evince  little  energy  of  its  own, 
the  cataract  will  not  enter  the  pupil,  or  scarcely  do  so, 
much  less  pass  out  of  the  eye,  and  the  operator  is 
under  the  necessity  of  resorting  to  manual  assistance, 
and  with  the  end  of  the  finger,  used  for  keeping  the 
lower  eyelid  depressed,  he  is  gently  to  press  the  lid 
against  the  lower  part  of  the  eyeball . Such  pressure 
should  be  gradually  increased  until  the  greatest  diame- 
ter of  the  cataract  has  passed  into  the  pupil,  at  which 
moment  the  pressure  must  not  be  discontinued  before 
the  cataract  is  completely  out  of  the  eye,  which  object 
may  be  promoted  by  supporting  the  lower  part  of  the 
lens  with  David’s  scoop,  and  then  the  pressure  is  to 
be  diminished  in  the  same  gradual  way  in  which  it 
has  been  previously  augmented.  Immediately  the  ca- 
taract is  completely  out  of  the  eye,  and  the  surgeon 
has  paid  due  attention  to  the  removal  of  any  fragments 
left  behind,  the  assistant  is  to  let  the  upper  eyelid  de- 
scend, the  patient  is  to  be  desired  to  keep  both  his 
eyes  shut  and  perfectly  still,  and  his  head  and  eyes  are 
to  be  covered  with  a clean  white  piece  of  linen,  so  that 
the  effect  of  the  light  may  be  moderated. 

When  the  patient  has  recovered  from  the  alarm, 
which,  according  to  Beer,  the  passage  of  the  cataract 
outwards,  especially  when  it  is  large  and  firm,  always 
produces  in  a greater  or  less  degree,  he  is  to  be 
placed  with  his  back  towards  the  window,  and  the 
linen  is  to  be  rai.sed  a little  from  the  eye,  which  is  to 
be  very  slowly  opened,  while  the  other  eye,  which  has 
not  been  operated  upon,  is  to  be  kept  well  covered. 
Beer  says  that  the  patient  should  then  be  shown  some 
objects,  not  of  a shining  or  very  bright  description,  at 
different  distances;  and  if  he  is  able  to  see  them 
plainly,  the  surgeon  may  proceed  to  apply  the  dressings 
without  delay. 

Beer  confesses,  that  if  possible  it  would  be  better  to 
dispense  altogether  with  making  any  trials  of  the 
power  of  the  eye  which  has  just  been  operated  upon, 
because  such  attempts  must  tend  to  increase  the  sub- 
sequent inflammation  in  the  organ ; yet  he  is  of  opi- 
nion that  these  trials  of  the  eyesight  are  necessary 
after  extraction  of  the  cataract.  First,  because  the  ca- 
pability of  seeing  immediately  is  a thing  always  ex- 
pected by  the  patient  and  liis  friends,  and  leaving  them 
in  ignorance  on  this  point  would  keep  up  an  anxiety 
likely  to  have  a bad  effect  in  rendering  ophthalmy 
more  severe.  Secondly,  Beer  urges  as  a stronger  mo- 
tive for  the  custom,  the  circumstance  of  the  patient 
seeing,  when  his  eye  is  first  opened,  all,  even  the 
smallest  objects,  though  he  suddenly  loses  the  fa- 
culty of  distinguishing  them  at  all,  or  sees  them  very 
obscurely ; and  now,  if  he  be  half  turned  with  his  face 
towards  the  window,  one  will  find  in  the  pupil,  which 
directly  after  the  passage  of  the  cataract  was  perfectly 
clear,  some  soft  or  firm  fragments  of  the  lens,  which 
are  first  dislodged  from  within  the  capsule*  by  the  va- 
riations in  the  eye,  produced  by  the  inspection  of  dif- 
ferent objects  at  different  distances,  and  which,  with- 
out these  trials  of  vision,  would  be  long  in  being 
loosened  by  the  aqueous  humour,  and  might  form  a 
secondary  lenticular  cataract ; which  will  not  now'  be 
the  case,  as  the  surgeon  can  and  ought  at  once  to  re- 
move them. — {Lehre  von  den  Augenkr.  h.  2,  p.  373.) 

The  preceding  mode  of  operating,  as  Beer  observes, 
will  not  answer  for  every  case  of  cataract  adapted  to 
extraction  ; but  the  plan  sometimes  requires  to  be  mo- 
dified according  to  circumstances.  Thus,  according  to 
the  same  writer,  when  the  eye  is  very  prominent,  and 
particularly  when  at  the  same  time  the  fissure  of  the 
eyelids  is  extremely  narrow,  the  incision  in  the  cor- 
nea must  not  be  made  horizontally,  but  obliquely  out- 
wards ; for  otherwise  the  edge  of  the  lower  eyelid  will 
retard  the  healing  of  the  wound,  and  an  ugly  cicatrix, 
more  or  less  injurious  to  the  eyesight,  be  the  conse- 
quence. 

When  the  cataract  is  of  middling  consistence,  nei- 
Uier  very  hard  nor  soft,  Beer  assures  us  that  the  at- 


tempt ought  to  be  made  to  extract  the  cataract  and  the 
capsule  together.— (il/efftode  den  grauen  Staar  Sammt 
der  Kapsel  aiLszuziehen,  Ac.  Wien,  1799.)  In  such  a 
case,  he  says,  the  experiment  will  mostly  succeed  if 
properly  conducted,  and  if  it  should  not,  it  causes  not 
the  slightest  detriment  to  the  eye,  nor  the  least  ob- 
stacle to  the  effectual  completion  of  the  operation. 
The  capsule-needle  is  to  be  introduced  into  the  pupil, 
as  in  the  second  stage  of  the  operation,  and  its  point  is 
then  to  be  slowly  pushed,  as  far  as  its  greatest  diame- 
ter, into  the  centre  of  the  lens,  so  that  one  surface  of 
the  needle  may  be  upwards,  the  other  downwards ; 
one  of  its  cutting  edges  turned  towards  the  inner  can- 
thus,  the  other  towards  the  outer  one.  And  now  the 
needle,  with  the  impaled  cataract,  is  to  have  sudden 
but  short  perpendicular  jerks  communicated  to  it,  by 
which  means  the  upper  and  lower  connexions  of  the 
capsule  with  the  neighbouring  textures  will  be  in  part 
loosened.  The  needle  is  next  to  be  suddenly  ro- 
tated without  withdrawing  it  from  the  cataract,  so 
that  one  of  its  flat  surfaces  may  face  the  inner  canthus, 
the  other  the  outer  one  ; and  one  of  its  edges  may  be 
turned  upwards,  the  other  downwards  ; and  then  the 
short  sudden  jerks  of  the  needle  in  the  horizontal  di- 
rection may  be  repeated,  for  the  purpose  of  breaking,  as 
much  as  possible,  the  lateral  connexions  of  the  cap- 
sule. Lastly,  the  capsule-needle  is  to  be  quickly  with- 
drawn from  the  eye,  when  it  is  mostly  followed  by  the 
lens  and  the  capsule,  or  the  cataract  comes  away  fixed 
on  the  point  of  the  instrument,  at  which  moment  the 
pupil  becomes  perfectly  clear  and  black.  When  the 
cataract  does  not  follow  the  withdrawing  of  the  needle, 
the  surgeon  is  to  proceed  with  the  usual  cautions  to 
the  third  stage  of  the  operation.  Great  as  the  advan- 
tage would  always  be  of  extracting  the  cataract, 
together  with  its  capsule,  it  is  plain  that  the  attempt  is 
not  practicable  when  the  case  is  a very  hard  len- 
ticular cataract,  because  the  capsule-needle  cannot 
be  effectually  introduced  into  the  body  of  such  a lens, 
situated  upon  the  yielding  vitreous  humour.  Nor 
would  the  plan  answer  if  the  cataract  were  very  soft, 
as  the  movements  of  the  needle  in  it  could  have  no  ef- 
fect in  breaking  the  connexions  of  the  capsule.  Mr. 
Lawrence  has  often  expressed  to  me  his  decided  opi- 
nion that  the  foregoing  method  will  rarely  succeed,  and 
ought  not  to  be  attempted ; which  is  also  Mr.  Guth- 
rie’s judgment.— (Operative  Surgery  of  the  Eye,  p.  308.) 

In  the  case  described  by  Beer  under  the  name  of  en- 
r.y.<it.ed  cataract,  the  capsule  must  not  be  opened  ; but 
after  properly  opening  the  cornea,  if  the  cataract  does 
not  escape  of  itself  at  this  moment  from  the  eye,  the 
operator  must  immediately  introduce  the  small  cataract- 
tenaculum,  with  its  point  turned  dow'iiwards,  between 
the  cornea  and  the  iris,  into  the  pupil.  The  cataract 
should  then  be  firmly  taken  hold  of  with  the  hook,  and 
slow'ly  and  steadily  drawn  out  of  the  eye  with  its  thick, 
tough  capsule.  Beer  says,  that  extraction  should  be 
performed  in  the  same  way  in  the  dry  siliquose  capsulo- 
lenticular  cataract  of  children  and  adults,  except  that 
in  all  the.<e  cases  a fine,  elastic,  sharp,  silver  or  golden 
spatula,  fixed  at  the  lower  ])art  of  David’s  curette  or 
scoop,  should  be  ready  at  hand  to  assist  in  separating 
the  cataract  from  the  vitreous  humour,  immediately 
the  opaque,  substance  is  disposed  to  pass  out  of  the  eye. 
Also  in  the  completely  fluid  cataract,  when  the  capsule 
is  partially  opaque  and  thickened,  a circumstance  easily 
knowm  by  appearances,  the  same  mode -of  extraction 
must  be  attempted.  But  if  the  hook  should  tear  its 
way  out,  and  the  capsule  empty  itself,  the  extraction 
must  be  performed  altogether  with  the  forceps.  The 
latter  instrument  is  to  be  cautiously  introduced,  in  the 
same  manner  as  the  capsule-needle,  into  the  pupil ; one 
of  the  largest  and  thickest  portions  of  the  capsule  is  then 
to  be  taken  hold  of,  and  suddenly  drawn  out  towards 
the  opposite  side,  by  which  means  generally  the  whole 
anterior  layer,  and  sometimes  also  the  posterior  layer, 
of  the  capsule  will  be  detached,  and  the  j)upil  imme- 
diately cleared.  On  the  contrary,  in  what  Beer  has 
called  the  bar-cataract,  which,  he  says,  is  seldom  fit 
for  an  operation  as  soon  as  the  cornea  has  been  opened, 
the  bar  must  first  be  separated  by  means  of  the  cap- 
sule-needle from  the  uvea,  in  whatever  way  is  found 
most  practicable  and  then  it  is  to  be  extracted  with  the 
small  cataract-tenaculum,  or  teeih-forceps  : when  this 
has  been  done,  the  cataract  itself  must  be  taken  out  of 
the  eye  in  the  same  manner  as  the  encysted  cataract,— 
(B.  2,  p.  377.) 


CATARACT. 


267 


When  extraction  has  been  completed,  the  next  object 
Is  to  dress  the  eye : while  the  patient  turns  this  up- 
wards the  lower  eyelid  is  to  be  drawn  downwards  with 
the  fore-finger,  and  steadily  held  so  until  the  patient 
has  shut  his  eye  as  much  as  possible. 

Mr.  Ware  found  that  a dossil  ol'  lint,  steeped  in  plain 
water,  or  brandy  and  water,  and  covered  with  the  sper- 
maceti or  saturnine  cerate,  and  removed  once  every  day, 
is  the  most  easy  and  convenient  dressing  that  can  be 
applied  after  the  operation.  The  cerate  over  the  lint 
prevents  the  latter,  when  impregnated  with  the  dis- 
charge, from  becoming  stiff  and  irritating  the  lids.  Mr. 
Ware  thought  the  mooe  of  applying  the  compress  and 
bandage  over  the  eye,  a circumstance  of  no  small  im- 
portance, because  if  too  loose  the  dressings  are  very 
apt  to  slip  off,  and  consequently  to  press  unequally  and 
injuriously  on  the  eye  ; and  if  too  tight,  the  undue  pres- 
sure will  excite  pain  and  inflammation,  and  even  force 
out  some  of  the  vinpous  humour.  Mr.  Ware’s  com- 
press is  made  of  soft  linen  folded  two  or  three  times, 
wide  enough  to  cover  both  eyes,  and  sufficiently  long 
to  extend  from  the  upper  part  of  the  forehead  to  the 
lower  part  of  the  nose.  This  he  pins  at  the  top  of  the 
patient’s  nightcap  ; and  its  lower  part,  which  is  divided 
in  the  middle,  to  allow  the  nose  to  come  through  it,  he 
lays  loosely  over  the  eyes.  The  bandage,  also  made 
of  old  linen,  and  as  broad  as  six  fingers,  he  carries 
round  the  head  over  the  compress,  and  pins  to  the  side 
of  the  nightcap  moderately  tight.  A slip  of  linen  is 
afterward  carried  under  the  chin,  and  pinned  at  each 
end  to  the  side  of  the  bandage,  so  as  to  prevent  it  from 
slipping  up  wards.— (Ware.)  Mr.  Guthrie  recommends 
an  elastic  net- work  nightcap  which  fits  the  head  closely 
to  be  put  on,  and  a piece  of  roller  to  be  fastened  by  its 
middle  to  the  centre  of  the  cap  behind.  “ A small 
piece  of  lint,  on  which  some  ung.  cetacei  has  been 
spread,  is  to  be  applied  over  the  closed  eyelids,  a com- 
press of  fine  linen  is  to  be  placed  over  it,  and  another 
over  the  opposite  eye,  when  each  end  of  the  roller  is  to 
be  brought  forwards,  made  to  secure  the  compress  of 
its  own  side,  and  then  passed  over  to  the  other.” — 
{Operative  Surgery  of  the  Eye,  p.  314.) 

Beer  recommends  the  patient  to  lie  upon  his  back, 
with  his  head  not  too  low,  and  in  a chamber  which  is 
not  too  light,  and  to  remain  in  this  way  at  least  until 
the  wound  in  the  cornea  is  closed.  As  during  the  first 
two  days  after  the  operation,  the  doubled  piece  of  linen, 
which  Beer  places  over  the  eye,  is  repeatedly  wet 
through  with  the  discharged  aqueous  humour,  it  is  to 
be  changed  several  times  a day.  He  also  enjoins  the 
observance  of  every  thing  which  has  been  already 
pointed  out  as  proper  after  depression  and  recli- 
nstion  ; and  in  particular  while  the  wound  in  the  cor- 
nea is  not  firmly  healed,  and  the  eye  cannot  be  kept 
open,  the  patient  must  refrain  from  taking  snuff  and 
smoking  tobacco.  According  to  the  same  author,  no 
thoughts  should  be  entertained  of  opening  the  eye  again 
till  two  or  three  days  after  the  discharge  of  the  aqueous 
humour  has  completely  ceased  ; a circumstance  indi- 
cated by  slight  prickings  in  the  eye  itself,  by  a burning, 
though  not  very  severe  pain  attending  the  escape  of  that 
fluid  from  the  inner  canthus,  and  in  irritable,  nervous, 
debilitated  subjects,  even  by  the  sensation  of  transient 
luminous  appearances.  Therefore,  Beer  says,  the  eye 
should  seldom  be  ojiened  before  the  fifth  or  sixth  day. 
When  this  is  first  done,  the  light  should  be  very  mo- 
derate, and  the  patient  placed  with  his  back  towards  it, 
all  unnecessary  lateral  light  being  kept  from  the  eye 
by  the  linen  attached  to  the  forehead  while  the  daily 
trials  of  the  newly  recovered  powers  of  the  eye  should 
be  made  with  the  utmost  caution.  On  the  8th,  9th,  or, 
at  latest,  on  the  10th  day.  Beer  recommends  leaving 
the  eye  open,  hut  screened  above  by  a green  eye-shade, 
in  a halftdarkened  chamber,  and  the  patient  is  after- 
ward to  be  treated,  until  his  eye  is  perfectly  well,  ac- 
cording to  the  rules  already  laid  down  as  proper  to  be 
observeil  after  couching.  And  especially  when  the  i)a- 
tient  has  had  cataracts  in  both  eyes.  Beer  thinks  it  as  well 
to  apprize  him,  in  order  to  prevent  unnecessary  alarm, 
that,  upon  first  going  out  into  the  open  air,  jiarticulariy 
in  the  evening,  he  will  be  for  some  moments  almost 
blinded,  and  then  begin  to  see  again,  but  every  object 
will  now  appear  covered  with  a white,  shining  circle, 
which  at  length  goes  off ; though,  in  the  open  air,  it 
will  sometimes  continue  forseveral  days.— (B.  2,  p.  380.) 

A few  hours  after  the  operation,  Mr.  Guthrie  always 
Oleeds  the  patient,  whether  pain  come  on  or  not ; and 


if  it  continue,  or  afterward  take  place,  he  repeats  the 
evacuation.  In  another  few  hours,  if  no  amendment 
occur,  he  has  recourse  even  to  a third  bleeding.  For 
the  first  twenty-four  hours  he  does  not  wish  the  patient 
to  be  disturbed  with  purgative  medicines,  so  as  to  pro- 
duce any  risk  of  the  edges  of  the  cornea  being  displaced; 
but  after  this  period  he  exhibits  saline  aperients,  and 
when  much  inflammation  is  expected,  he  prescribes 
calomel,  combined  with  opiate  confection ; and  if  the 
inflammation  continue,  he  gives  two  grains  of  calomel 
with  or  2 of  a grain  of  opium,  three  or  four  times  in 
the  course  of  tw^enty-four  hours,  so  as  to  affect  the 
system,  and  prevent  the  bad  consequences  of  the 
inflammation  of  the  iris  and  internal  parts  of  the  eye. 
— (See  Guthrie's  Operative  Surgery  of  the  Eye,  p.  315, 
316.) 

The  late  Mr.  Ware  published  an  inquiry  into  the 
causes  preventing  the  success  of  extraction  of  the  cata- 
ract. 

The  first  which  he  considers  is  making  the  incision 
through  the  cornea  loo  small.  In  this  circumstance,  a 
degree  of  violence  will  be  required  to  bring  the  cataract 
through  the  wound  ; and  if  the  eataract  be  not  altered 
in  its  figure,  the  wound  will  be  forcibly  dilated,  and 
the  edge  of  the  iris  compressed  between  the  cornea  and 
the  cataract.  In  this  way  either  some  of  its  fibres 
may  be  ruptured,  or  it  may  be  otherwise  so  much  in- 
jured as  to  excite  a considerable  degree  of  inflammation, 
and  even  induce  in  the  end  a closure  of  the  pupil. 

This  accident  may  arise  from  the  operator’s  cutting 
the  cornea,  without  being  able  to  see  exactly  the  posi- 
tion of  this  membrane,  in  consequence  of  the  eye  having 
turned  inwards,  owing  to  its  not  being  properly  fixed. 
The  fault  may  also  proceed  from  the  incision  having 
been  begun  below  the  transverse  diameter  of  the  cor- 
nea. In  this  manner  nine-sixteenths,  or  rather  more 
than  half,  of  the  circumference  of  this  membrane  will 
not  be  divided  ; which  extent  the  incision  ought  always 
to  occupy,  in  order  to  allow  the  cataract  to  be  extracted 
with  facility. 

When,  however,  the  cornea  is  remarkably  flat,  and 
the  iris  projects  unusually  forwards  in  the  anterior 
chamber,  Mr.  Ware  recommends  including  only  one- 
third  of  the  cornea  in  the  first  incision,  and  afterward 
enlarging  the  aperture  on  the  outer  side  by  means  of 
curved  scissors. 

Taking  care  to  fix  the  eye  in  Mr.  Ware’s  way  is  re- 
presented by  this  author  as  being  of  great  consequence 
in  hindering  the  wound  in  the  cornea  from  being  made 
too  small. 

Whenever  the  wound  in  the  cornea  is  made  too 
small,  it  should  always  be  enlarged  before  proceeding 
farther  in  the  operation  ; and,  according  to  Mr.  Ware, 
this  can  be  best  accomplished  with  a pair  of  curved 
blunt-pointed  scissors,  on  the  outer  side  of  the  cornea, 
where  the  knife  first  made  its  entrance. 

For  doing  this  Beer  recommends  the  use  of  Daviel’s 
scissors,  which  are  to  be  introduced  with  their  conca- 
vity towards  the  operator,  and  their  point  directed  to- 
wards the  pupil.  Beer  also  introduces  the  point  of 
the  inner  blade  into  the  middle  of  the  wound  of  the 
cornea,  under  the  flap  already  made,  and  passes  it 
somewhat  higher  than  the  place  to  which  it  is  neces- 
sary to  enlarge  the  incision.  Then  he  first  conveys  the 
instrument  to  the  inner  or  outer  angle  of  the  wound, 
where  the  dilatation  is  to  be  made,  keeping  the  blade, 
which  is  within  the  cornea,  not  parallel  to  the  iris,  but 
in  an  oblique  position  with  respect  to  it,  for  otherwise 
the  best  scissors  will  fail  to  make  a clear  division. 
The  scissors  also  must  not  be  opened  more  than  is 
absolutely  necessary,  and  they  should  be  very  quickly 
shut,  and  in  such  a manner  that  the  outer  blade  ought 
only  to  move  towards  that  within  the  cornea,  lest  the 
eye  sufler  injury.  Beer  says,  that  it  is  hardly  ever 
necessary  to  enlarge  the  incision  in  the  cornea  at  both 
its  angles : and  in  these  cases  he  confesses  that  all 
idea  of  shajjing  the  wound  altogether  as  it  ought  to  be, 
must  be  renounced. — (Lehre  von  den  Augenkr.  b.  2, 
p.  382.)  As  already  explained,  Jaeger  uses  a double 
knife,  with  which  it  is  alleged  the  incision  in  the  cornea 
may  always  be  made  of  due  size<^(.See  Loudmi’s  Short 
inquiry,  \ c.  1826.) 

Wounding  the  iris  with  the  cornea-knife  is  the  se- 
cond accident  which  Mr.  Ware  considers.  The  princi- 
pal cause  seems  to  him  to  be  a discharge  of  the  aqueous 
humour  before  the  knife  has  passed  through  the  cornea 
low  enough  to  hinder  the  lower  part  of  the  iris,  which 


268 


CATARACT. 


forms  the  inferior  rim  of  the  pupil,  from  getting  be- 
neath the  edge  of  the  instrument.  According  to  Mr. 
Ware,  the  escape  of  the  aqueous  humour  may  be 
owing  to  some  inaccuracy  in  the  shape  of  the  knife,  or 
unsteadiness  in  introducing  it.  The  falling  of  the 
lower  part  of  the  iris  under  the  edge  of  the  knife,  Mr. 
Ware  believes,  cannot  always  be  prevented  by  the 
utmost  skill  or  precaution  of  the  operator.  Happily, 
however,  says  he,  we  have  been  taught  that  the  iris 
may  be  reinstated  after  it  has  been  thus  displaced,  and 
without  suffering  any  injury,  by  making  gentle  frictions 
on  the  cornea  with  the  point  of  the  finger. 

By  unsteadiness  in  passing  the  knife,  Mr.  Ware 
means,  that  the  knife  may  not  only  be  suffered  to  make 
a punctuation  through  this  tunic,  but  that  its  edge  may 
at  thesanie  time  be  unintentionally  jtressed  downwards, 
so  as  to  make  an  incision  likewise ; in  consequence  of 
which  downward  motion  of  the 'knife,  an  aperture  must 
unavoidably  be  left  in  the  cornea,  through  which  the 
aqueous  humour  will  escape.  If  the  cornea-knile  in- 
crease through  itswhole  length, both  in  width  and  thick- 
ness, and  if  it  be  merely  pushed  through  the  cornea,  no 
space  will  be  left  through  which  any  fluid  can  escape. 

According  to  Beer,  the  escape  of  the  aqueous  hu- 
mour, as  the  knife  passes  across  the  anterior  chamber, 
may  happen  with  or  without  any  fault  on  the  part  of 
the  operator,  and  the  iris  fall  not  merely  against  the 
posterior  surface  of  the  knife,  but  even  project  under 
its  edge  and  over  its  back.  When  this  happens.  Beer 
joins  Ware  in  recommending  the  end  of  the  nnddle 
finger,  situated  at  the  inner  canthus,  to  be  gently 
pressed  without  delay  upon  that  part  of  the  cornea 
which  is  in  front  of  the  knife,  and,  at  the  moment 
when  this  is  done,  the  iris  will  recede  from  the  edge  of 
the  instrument,  and  the  operator,  by  being  very  quick, 
may  proceed  again  without  a'ny  risk  of  injuring  that 
part  of  the  eye.  But  if  the  iris  should  be  found  to  pro- 
ject again  above  and  below  the  knife  immediately  the 
point  of  the  finger  is  removed  from  the  cornea,  such  re- 
moval should  not  be  made,  and  the  knife  be  boldly 
pushed  on  until  its  point  pierces  the  other  side  of  the 
cornea ; or,  if  the  point  has  already  passed  some  way 
out  of  the  cornea  towards  the  inner  canthus,  the  blade 
is  to  be  pushed  on  so  far  that  no  protrusion  of  the  iris  is 
possible.  For,  says  Beer,  while  the  fitiger  continues  to 
make  gentle  pressure  upon  the  cornea,  the  iris  will  not 
fall  under  the  knife.  Should  the  eye  chance  to  with- 
draw itself  from  the  knife,  after  this  has  penetrated  the 
anterior  chamber,  a circumstance  which  may  easily 
happen  in  restless,  timid  patients,  the  greater  part  or  the 
whole  of  the  aqueous  humour  is  immediately  discharged, 
,'md  the  iris  comes  in  contact  with  the  empty  cornea.  In 
this  case.  Beer  says,  that  the  operator  should  find  out  the 
wound  with  another  knife,  and  with  a wriggling  mo- 
tion of  the  instrument,  conduct  it  between  the  iris  and 
the  cornea,  twisting  and  turning  the  point  about  until 
it  has  successfully  passed  beyond  the  external,  then  be- 
yond the  inner  pupillary  margin  of  the  iris,  and  has 
finally  come  out  of  the  cornea  again.  Now  the  incision 
in  the  cornea  may  be  properly  finished,  in  doing  which 
it  is  always  necessary  to  keep  the  middle  finger  applied 
to  this  membrane,  in  consequence  of  the  disposition  of 
-the  iris  to  fall  against  the  knife.  Beer  mentions  it  as  a 
•curious  fact,  that  most  of  the  patients  who  are  restless 
and  unmanageable  at  the  first  introduction  of  the  knife, 
and  who  themselves  cause  that  disagreeable  occurrence 
now  spoken  of,  are,  on  the  contrary,  very  quiet  during 
the  foregoing  manceuvres.— (Z/eAre  von  den  Augenkr. 
b.  2,  p.  381.) 

The  third  actident  noticed  by  Mr.  Ware  is  the  es- 
cape of  the  vitreous  humour.  The  common  cause  of 
this  occurrence  is  the  undue  application  of  pressure.  It 
may  take  place,  either  when  the  incision  is  made 
through  the  cornea,  or  at  the  time  of  extracting  the  ca- 
.taract.  Some  eyes  are  subject  to  spasm,  which  renders 
them  much  more  liable  to  this  accident.  To  prevent  it, 
Mr.  Ware  recommends  every  kind  and  degree  of  pres- 
sure to  be  taken  from  the  eye,  before  the  knife  has  com- 
pletely cut  its  way  through  the  cornea.  And  as  soon 
as  the  knife  has  jiroceeded  sufliciently  low  to  secure 
•the  iris  from  being  wounded  the  operator  should  not 
only  take  heed,  that  his  own  fingers  do  not  touch  the 
«ye,  but  should  also  direct  the  a.ssistant,  who  supports 
the  upper  lid,  to  remove  his  fingers  entirely  from  this 
part.  The  assistant  seldom  need  make  any  pressure 
on  the  globe  of  the  eye ; however,  when  there  is  room 
/or  onr  of  his  fingers  to  be  jdaced  on  the  inner  and  up- 


per part  of  the  globe,  without  interfering  with  (hose  of 
the  operator,  the  method  may  be  followed  in  order  to 
make  the  eye  still  more  fixed.  But  immediately  the 
punctuation  of  the  cornea  is  completed,  the  assistant’s 
finger  should  always  be  entirely  removed  both  from  the 
eyelids  and  eye  itself. 

Notwithstanding  the  upper  lid  is  left  thus  free,  theie 
will  be  sufficient  space  between  it  and  the  lower  lid  to 
allow  the  progress  of  the  knife  to  be  seen ; and,  in 
finishing  the  wound,  the  operator  should  depress  the 
lower  lid  with  great  gentleness. 

With  Jaeger’s  double  knife,  the  risks  arising  from  a 
very  early  escape  of  the  aqueous  humour  are  said  to  be 
avoided. 

The  vitreous  humour  may  also  be  lost  in  consequence 
of  ojiening  the  capsule  of  the  lens  nearer  the  circumfe- 
rence than  the  centre  of  the  pupil.  As  the  crystalline 
is  both  thinner  and  softer  at  that  part,  the  instrument 
will  be  liable  to  pass  through  bothsides  of  the  capsule, 
and  enter  the  vitreous  humour.  This  humour,  having 
no  longer  any  barrier  to  its  escape,  is  liable  to  be  forced 
out  by  the  action  of  the  eyelids  alone ; and  when  pres- 
sure is  afterward  made,  to  bring  the  cataract  through, 
a much  greater  quantity  will  be  lost,  and  the  cataract, 
instead  of  coming  forwards,  will  recede  from  the  pupil. 
The  only  way  to  extract  it  now  is,  by  letting  the  upper 
lid  be  gently  raised  by  an  assistant  (a  rare  instance,  in 
which  this  is  necessary  after  cutting  the  cornea),  while 
the  operator,  either  with  the  fore-finger  of  the  left  hand, 
or  with  the  blunt  end  of  the  curette,  applied  beneath  the 
incision  in  the  cornea,  prevents  the  cataract  from  sink- 
ing farther.  Then  with  his  right  hand  let  him  intro- 
duce a hook  under  the  flap  of  the  cornea,  and  with  its 
point  carefully  entangle  the  cataract  and  bring  it  away. 

To  prevent,  however,  such  difficulties,  Mr.  Ware 
never  attempted  to  puncture  the  capsule,  until  the 
Avhole  pupil  was  in  view.  He  was  in  the  habit  of 
opening  the  capsule  with  a gold-pointed  needle,  arched 
towards  its  extremity.  Wenzel’s  needle  for  this  pur- 
pose was  flat  in  its  extremity ; Mr.  Ware’s  pointed ; 
and  this  is  their  only  difference.  The  latter  introduced 
his  instrument  under  the  flap  of  the  cornea,  with  its 
arched  part  uppermost,  until  its  point  was  on  a level 
with  the  centre  of  the  jiupil.  The  end  of  the  instru- 
ment was  then  turned  inwards,  and  gently  rubbed  on 
the  capsule  of  the  crystalline  until  it  pierced  it.  In  a 
few  instances  Mr.  Ware  found  the  capsule  so  tough, 
that  the  point  of  the  gold  needle  would  not  enter  it,  and 
he  was  obliged  to  use  a sharp  steel  instrument  of  the 
same  shape  as  that  with  a gold  point.  As  already  ex- 
plained, Beer  was  much  bolder  with  the  capsule  than 
Ware,  and  there  can  be  little  doubt,  that  both  his  cap- 
sule-needle and  mode  of  using  it  are  better  than  those 
of  Wenzel  and  Ware. 

The  vitreous  humour  may  also  be  lost  at  the  time  of 
extracting  the  cataract,  and  the  usual  cause  is  an  un- 
due application  of  pressure.  All  violent  pressure  is 
quite  unnecessary  for  forcing  out  the  cataract,  when 
the  wound  in  the  cornea  is  sufficiently  large.  When 
the  wound  is  too  small,  it  should  be  enlarged  as  above 
directed.  If  pressure  be  continued  at  all  after  the  ca- 
taract is  extracted,  the  capsule  of  the  vitreous  humour 
will  certainly  be  ruptured,  and  .some  of  this  part  of  the 
eye  protrude.  Pressure  may  even  rupture  the  capsule 
of  the  vitreous  humour,  before  the  cataract  is  brought 
through  the  incision  in  the  cornea;  the  same  conse- 
quences will  ensue,  and  the  same  practice  be  necessary, 
as  in  the  case  in  which  the  operator  has  unskilfully 
opened  the  capsule  of  the  vitreous  humour  with  the 
needle  in  attempting  to  open  that  of  the  lens. 

In  taking  away  fragments  of  opaque  matter  from  the 
pupil  by  means  of  the  curette,  great  care  is  requisite  to 
avoid  vvounding  the  posterior  part  of  the  capsule  of  the 
crystalline  with  the  end  of  the  instrument,  so  as  to 
open  a way  for  the  escape  of  the  vitreous  humour. 

The  vitreous  humour  may,  indeed,  be  forced  out, 
after  the  extraction  of  the  cataract,  merely  by  a spas- 
modic action  of  the  eyelids.  On  this  subject,  Mr.  Ware, 
after  hinting  his  suspicion,  that  in  a case  of  this  kind, 
which  he  saw,  the  assistant’s  keeping  up  the  lid  con- 
tributed to  the  event,  repeats  his  advice,  “that  after  the 
cornea  hi?s  been  cut,  the  upper  eyelid  should  be  raised 
solely  by  the  fingers  of  the  left  hand  of  the  operator.” 

Mr.  Ware  seems  to  think,  that  more  evil  has  resulted 
from  the  operator’s  being  deterred,  by  the  readiness  with 
which  the  vitreous  humour  continues  to  start  out,  froni 
ascertaining  that  all  the  fragments  of  the  cataract  are 


CATARACT. 


269 


femoted,  and  that  the  whole  of  the  iris  has  resumed  its 
position,  than  from  the  mere  loss  of  the  vitreous  hu- 
mour which  is  quickly  regenerated. 

When  a portion  of  the  vitreous  humour  protrudes, 
Beer  thinks  that  the  safest  practice  is  not  to  meddle 
with  it,  though  he  owns  that  in  this  circumstance  the 
wound  heals  slowly,  and  is  always  followed  by  a more 
or  less  perceptible  whitish  scar,  the  pupil  being  gene- 
rally drawn  towards  it,  and  deformed,  while  the  iris 
and  the  partly-emptied  membrana  hyaloidea  become  ad- 
herent to  the  edges  of  the  incision  in  the  cornea.  But, 
says  Beer,  the  ej'esight  will  be  but  little  or  not  at  all 
impaired,  notwithstanding  one-eighth  or  one-fourth  of 
the  vitreous  humour  may  be  lost.  However,  he  ob- 
serves, that  when  one-third  or  half  of  it  has  escaped,  a 
good  degree  of  vision  afterward  cannot  be  expected; 
and  when  more  than  half  has  been  lost,  the  operation 
will  have  a still  less  successful  result.  He  states  also, 
that  when  two-thirds  have  been  lost,  though  the  eye 
may  recover  its  natural  form,  the  pupillary  edge  of  the 
iris  will  remain  contracted  round  the  empty,  light-gray 
membrana  hyaloidea,  which  projects  into  the  anterior 
chamber,  consequently,  the  pupil  will  be  closed,  and 
that  state  of  the  iris  ensue,  which  is  aptly  termed  a 
sinking  of  the  pupil,  subsidentia  pupillae,  or  synizesis. 

Mr.  Ware  notices  the  accident  of  extracting  only  a 
part  of  the  cataract,  and  leaving  the  remainder  behind. 
He  is  an  advocate  for  removing  all  opaque  substances 
from  the  pupil,  except  an  extreme  degree  of  irritability, 
to  which  some  eyes  are  subject,  should  render  the  in- 
troduction of  every  sort  of  instrument,  after  the  cata- 
ract is  extracted,  difficult  and  dangerous.  Mr.  Ware 
usually  removed  opaque  portions  of  the  cataract  by 
means  of  a curette ; and  occasionally,  when  the  opaque 
substance  was  large,  and  adherent  to  the  capsule,  he 
was  obliged  to  extract  it  with  small  forceps.  Before 
finishing  the  operation,  Mr.  Ware  approves  of  always 
rubbing  the  end  of  the  finger  gently  on  the  forepart  of 
the  eye  over  the  eyelids;  which  proceeding  tends  to 
bring  into  view  any  opaque  matter,  which  may  pre- 
viously lie  behind  the  iris.  Mr.  Ware  relates  a case, 
proving  that  such  opacities  as  cannot  be  removed  in  the 
operation  are  capable  of  being  absorbed. 

When,  notwithstanding  the  observance  of  the  direc- 
tions laid  down  by  Beer,  as  explained  in  the  previous 
columns,  some  of  the  pultaceous  or  scabrous  surface 
of  the  cataract  is  detached,  and  continues  behind  in  the 
po>tcrior  chamber.  Beer  says,  that  it  ought  to  be  imme- 
diately removed,  lest  the  patient  be  left  with  a second- 
ary lenticular  cataract,  which,  he  observes,  is  not  al- 
ways so  certain  of  being  dissolved  and  absorbed  as 
some  imagine.  The  fragments  may  be  removed  in  two 
ways;  and  first,  the  experiment  of  rubbing  the  upper 
eyelid  over  the  eye  should  be  made,  because  it  not  un- 
frequently  brings  the  remains,  especially  when  they 
are  gelatinous,  completely  through  the  pupil,  and  out 
of  the  incision  in  the  cornea.  But  if  such  manoeuvre 
should  not  be  effectual.  Beer  recommends  cautiously  in- 
troducing Daviel’s  curette  to  the  outer  pupillary  edge 
of  the  iris,  with  its  concavity  towards  the  inner  sur- 
face of  the  flap  of  the  cornea,  without  raising  this  flaj) 
unnecessarily  high,  and  then  the  operator  is  to  endea- 
vour to  scoop  out  at  once  as  much  of  the  opaque  mat- 
ter as  he  can,  and  bring  it  to  the  inner  surface  of  the 
cornea.  He  says,  that  it  will  rarely  be  necessary  fre- 
quently to  repeat  the  introduction  of  the  curette.— 
kB.  2,  p.  3S7.) 

According  to  Mr.  Ware,  an  opacity  of  the  capsule  can 
be  the  only  reason  for  reinoving  it.  Tlte  anterior  part,  he 
says,  can  alone  become  the  object  of  the  operator’s  at- 
tention ; its  posterior  part  is  necessarily  hidden,  while 
the  cataract  remains  in  the  eye,  and  afterward,  if  disco- 
vered to  be  opaijue,  it  is  so  closely  connected  with  the 
capsule  of  the  vitreous  humour,  that  Mr.  Ware  believes 
it  cannot  be  removed  by  any  instrument,  without  ha- 
zarding a destructive  effusion  of  this  humour. 

When,  however,  the  opaque  lens  is  accompanied 
with  an  opacity  in  the  front  part  of  the  capsule,  the 
late  Mr.  Ware  recommended  the  following  plan.  After 
cutting  the  cornea,  as  usual,  a fine-pointed  instrument, 
somewhat  smaller  in  size  than  a round  couching-needle, 
and  a little  bent  towards  the  point,  should  be  introduced 
under  the  flap  of  the  cornea,  with  its  bent  part  up- 
wards, until  its  point  is  parallel  with  the  aperture  of 
the  pupil.  The  point  should  then  be  turned  towards 
the  opaque  capsule,  which  is  to  be  punctured  by  it  in 
a circular  direction,  as  near  td  the  rim  of  the  pupil  as 


the  instrument  can  be  applied  without  hurting  the  iris. 
Sometimes  the  part  included  within  the  punctures  may 
be  extracted  on  the  point  of  the  instrument ; and  if  this 
cannot  be  done,  it  should  be  removed  with  a small  pair 
of  forceps.  The  lens,  whether  opaque  or  transparent, 
should  next  be  extracted,  by  making  a slight  pressure 
with  the  curette,  either  above  or  below  the  circumfe- 
rence of  the  cornea. 

On  the  preceding  subject  Beer  remarks,  that  when 
none  of  the  lens  itself  is  left  behind,  but  there  is  a slight 
degree  of  opacity  in  the  anterior  layer  of  the  capsule, 
easily  distinguishable  from  the  cut  flakes,  and  pro- 
ducing the  least  obstacle  to  vision,  the  opaque  mem- 
brane should  be  taken  away  with  the  forceps,  in  the 
manner  described  in  the  preceding  pages ; for,  other- 
wise, a secondary  capsular  cataract  will  follow,  which 
will  become  of  a snow-white  colour,  and  if  only  a tri 
vial  degree  of  iritis  takes  place  after  the  operation,  it 
will  become  adherent  to  the  iris,  and  the  pupil  become 
contracted  and  disfigured.— (B.  2,  p.  388.) 

Beer  does  not  agree  with  Ware  in  condemning  all 
attempts  to  remove  the  posterior  layer  of  the  capsule,^ 
when  found  opaque,  after  the  extraction  of  the  lens. 
The  case,  he  says,  is  indicated  by  the  light-gray  speckled 
appearance  of  tlie  whole  pupil,  and  by  the  patient  see- 
ing nothing  at  all,  or  objects  only  indistinctly  in  a thick 
mivSt.  Beer  advises  a cataract-tenaculum  to  be  passed 
into  the  pupil,  in  the  same  way  as  the  capsule-needle 
is  introduced  in  the  second  stage  of  extraction,  directing 
its  point  downwards  as  it  enters,  and  upwards  when  it 
is  brought  out  again.  After  it  has  entered  the  pupil,  it 
is  to  be  made  to  divide  and  annihilate,  by  repeated 
turns  of  the  tenaculum,  the  back  layer  of  the  capsule, 
and  also  the  membrana  hyaloidea  directly  behind  if, 
which,  in  such  a case,  is  always  adherent  and  opaque. 
Of  these  membranes  a considerable  part,  closely  wound 
round  the  hook,  may  be  taken  out  of  the  eye,  though 
never  without  some  slight  loss  of  the  vitreous  humour. 
In  cases  of  this  kind,  the  patient  ought  to  be  informed, 
that  though  his  sight  will  be  restored,  a part  of  the  ca- 
taract must  be  left,  and  will  be  visible  behind  the 
pupil,  particularly  when  it  is  dilated ; for  otherwise 
suspicions  may  arise,  that  the  operation  has  been  badly 
done,  and  a relapse  apprehended. — {B.  2,  p.  388.) 

The  late  Mr.  Ware  published  some  remarks  on  the 
bad  consequences  of  allowing  foreign  bodies  of  any 
kind,  after  the  operation,  to  press  unequally  on  the 
globe  of  the  eye ; comprehending  under  this  head,  the 
intervention  of  the  edge  of  the  lower  eyelid  between 
the  sides  of  the  divided  cornea ; the  inversion  of  the 
edge  of  the  lower  eyelid ; and  the  lodgement  of  one  or 
more  loose  eyelashes  on  the  globe  of  the  eye. 

To  prevent  the  first  accident,  every  operator,  before 
applying  the  dressings,  should  carefully  depress  the 
lower  eyelid;  and  before  he  suffers  it  to  rise  again^ 
should  take  care  that  the  flap  of  the  cornea  be  accu- 
rately adjusted  in  its  proper  position  ; and  that  the 
upper  lid  be  dropped,  so  as  completely  to  cover  it. 
After  this,  the  eyelids  should  not  be  opened  again  for 
three  or  four  days,  (hat  is,  until  there  is  a good  reason 
to  suppose  the  wound  in  the  cornea  closed. 

The  inversion  of  the  lower  eyelid  is  hurtful,  in  con- 
sequence of  its  making  the  eye-lashes  rub  against  the 
eye.  These  should  be  extracted  the  day  before  the 
operation.  For  the  mode  of  effecting  a permanent 
cure,  .see  Trichiasis. 

Besides  the  danger  to  which  the  eye  is  exposed 
from  the  inversion  of  the  edge  of  the  lid,  the  eye  may 
receive  injury  from  the  improper  position  of  the  eye- 
lashes alone;  one  or  more  of  which,  during  the  ope- 
ration, may  happen  to  bend  inwards,  or,  becoming 
loose,  may  afterward  insinuate  themselves  between 
the  inside  of  the  lid  and  the  eye.  An  eyelash  bent  in- 
wards should  be  rectified ; if  broken  off  and  loose,  it 
should  be  removed. 

Lastly,  Mr.  Ware  considers  prematurely  exposing 
the  eye  to  a strong  light.  He  censures  the  plan  of 
ojiening  the  eyelids  within  the  first  two  or  three  days 
after  the  operation,  because  the  stimulus  of  the  light 
increases  the  ophtlialmy,  and  the  method  is  ajit  to  dis- 
turb the  wound  in  the  cornea  before  it  is  closed.  Mr. 
Ware,  however,  wishes  it  not  to  be  inferred,  that  he  is 
an  advocate  for  long  conlinemcMt  after  the  operation. 
His  mode  is  to  keep  the  patient  wholly  in  bed,  and  to 
direct  him  to  move  his  head  as  little  as  possible,  for 
the  first  three  days  after  the  operation.  During  this 
time,  a dossil  of  wet  lint  is  kept  on  his  eyes,  covered 


270 


CATARACT. 


■with  a saturnine  plaster,  compress,  and  bandage,  as 
already  described.  The  dressing  is  renewed  once  every 
day,  and  the  outsides  of  the  eyelids  washed  with  warm 
water  in  winter  and  cold  in  summer.  At  each  time  of 
dressing,  the  skin  of  the  lower  lid  is  drawn  gently 
down,  to  prevent  any  tendency  to  an  inversion.  Ani- 
mal food  is  prohibited,  and  the  patient  enjoined  not  to 
talk  much.  On  the  fourth  day  he  is  permitted  to  sit 
up  for  two  or  three  hours,  and  if  he  has  had  no  stool 
since  the  operation,  a mild  opening  medicine  is  now 
administered.  On  the  fifth,  the  time  of  his  getting  up 
is  lengthened,  and  presuming  that  the  wound  in  the 
cornea  is  now  closed,  Mr.  Ware  usually  examines  the 
state  of  the  eye.  After  this,  no  dressing  need  be  ap- 
plied in  the  daytime,  care  being  taken  to  defend  it 
from  a strong  light  by  a pasteboard  hood  or  shade,  and 
by  darkening  the  room,  so  that  no  inconvenience  is 
felt.  The  patient  may  now  also  look  for  a short  time 
at  targe  objects.  The  following  part  of  the  treatment 
need  interfere  very  little  with  the  wishes  of  the  patient, 
unless  unexpected  accidents  occur. — (Ware.) 

As  Beer  observes,  if  the  patient  be  very  restless, 
make  frequent  attempts  to  open  his  eyes  in  the  least, 
and  partly  lie  upon  the  eye,  or  if  in  changing  the  com- 
presses the  greatest  caution  be  not  used,  the  eye  will 
perhaps  be  roughly  pressed  upon,  and  the  iris  protrude 
between  the  displaced  and  half-opened  edges  of  the  in- 
cision in  the  cornea,  to  which  it  will  become  adherent 
during  a slow  and  seldom  very  violent  inllammation. 
From  the  moment  when  'he  iris  thus  interposes  itself 
between  the  sides  of  the  wound,  the  aqueous  humour 
begins  to  collect,  and  at  length  pushes  the  iris  consi- 
derably forwards.  In  this  case.  Beer  recommends  care- 
fully opening  the  eye  in  a very  moderate  light,  and 
adopting  the  expedients  formerly  mentioned,  for  the 
purpose  of  making  the  iris  recede.  The  dressings 
should  be  reapplied,  and  the  eye  kept  closed  and  very 
quiet  for  at  least  eight  or  ten  days,'  so  as  to  hinder  a 
recurrence  of  this  disagreeable  accident.  But  if  the 
iris  should  be  already  adherent  to  the  edges  of  the 
wound  in  the  cornea j the  eye  incapable  of  bearing 
light,  and  the  aqueous  humour  more  or  less  accumu- 
lated in  the  anterior  chamber.  Beer  says,  every  thing 
must  be  left  to  time,  while  the  eye  is  kept  lightly  co- 
vered for  about  a fortnight,  and  the  existing  inrtamma- 
tion  properly  treated.  Then,  if  the  protrusion,  or  sta- 
phyloma of  the  iris  should  not  be  diminished  by  the 
means  calculated  for  lessening  the  inflammation,  caus- 
tic or  the  knife  must  be  employed.— (Beer,  b.  '2,  p.  391.) 
The  same  causes  which  have  been  above  specified,  as 
conducive  to  a protrusion  of  the  iris,  may  also  produce 
a discharge  of  the  vitreous  humour. 

The  following  observations  by  Beer  are  interesting : 
when  the  dressings  have  been  unskilfully  applied; 
when  the  incision  in  the  cornea  has  been  made  hori- 
zontally upon  a large  prominent  eye ; when  the  fissure 
of  the  eyelids  is  exceedingly  narrow  ; or  the  patient  is 
restless;  a proper  cicatrization  of  the  wound  in  the 
cornea  may  not  follow.  Though  the  aqueous  humour 
may  collect  in  the  anterior  chamber,  the  partially  united 
lamellae  of  the  cornea  may  be  incapable  of  duly  resist- 
ing the  distention  of  that  fluid,  and  consequently  pro- 
trude in  the  form  of  a light-gray,  semi-tran.sparent, 
oval  vesicle,  extending  nearly  the  whole  length  of  the 
wound  in  the  cornea,  and  . being  most  prominent  in  the 
centre.  The  patient  complains  of  an  annoying  sense 
of  pressure  in  the  eye.  as  in  cases  of  protrusion  of  the 
iris  ; but  the  discharge  of  the  aqueous  humour  has 
completely  stopped,  and  therefore  the  anterior  cham- 
ber presents  its  natural  appearance,  and  the  pupil  its 
regular  round  shape,  though  the  edges  of  the  wound  in 
the  cornea  are  whitish  and  swollen.  This  case  was 
formerly  regarded  as  a prolapsus  of  the  membrane  of 
the  aqueous  humour ; but  Beer  considers  it  as  a sort  of 
hernia  of  the  cornea,  termed  ceratocele.  Merely  punc- 
turing or  cutting  away  the  cyst  is  of  no  service ; for 
though  the  aqueous  humour  immediately  flows  out,  the 
wound  soon  closes  again  and  the  tumour  reappears, 
attended  also  with  some  risk  of  the  iris  falling  into 
the  cyst,  and  becoming  adherent  to  it.  EflTectual  relief 
cannot  be  obtained,  unless  the  tumour  be  removed,  with 
David’s  scissors,  as  close  as  possible  to  the  wound ; 
the  dressings  skilfully  arranged  ; and  the  eye  kept 
closed  and  quiet  for  eight  days  or  a fortnight.  In  such 
a case,  a whitish  scar  is  always  permanently  left. — 
(Beer,  b.  2,  p.  393.) 

Beer  observes,  that  when  the  pupil  contracts  very 


considerably  after  the  incision  in  the  cornea  is  made, 
and  the  cataract  at  the  same  time  remains  at  some  dis- 
tance from  the  uvea,  too  small  an  opening  has  gene- 
rally been  made,  and  it  ought  to  be  enlarged.  But  if 
the  cataract  cannot  be  forced  though  the  pupil  with- 
out making  pressure  on  the  lower  part  of  the  eyeball, 
and  the  closure  of  the  pupd  should  still  continue,  the 
circumstance  proceeds  from  the  loss  of  the  aqueous 
humour,  and  the  second  stage  of  extraction  must  be 
deferred  a little  while,  until  the  pupil  dilates  again,  and 
the  operation  must  then  be  finished  in  a very  moderate 
light. — (Also  Guthrie’s  Operative  Surgery  of  the  Eye^ 
p.  305.) 

When,  in  the  second  stage  of  the  operation,  the  an- 
terior layer  of  the  capsule  has  been  properly  divided, 
and  yet  the  cataract  will  not  pass  into  the  pupil,  though 
the  eye  itself  acts  with  energy.  Beer  says,  that  it  is 
indispensably  necessary  to  make  pressure  upon  the 
lower  part  of  the  eyeball,  as  already  advised,  and  to 
continue  it  either  until  the  cataract  with  its  lowermost 
edge  efiectually  projects  through  the  pupil  and  out  of 
the  eye,  or  until  it  is  moved  so  far  directly  upwards 
(without  entering  the  pupil)  that  its  lower  margin  is 
brought  into  view,  and  quite  a black  semilunar  inter- 
space is  seen  between  it  and  the  inferior  pupillary  edge 
of  the  iris.  At  this  moment  the  operator,  without  in- 
creasing the  pressure  of  the  finger  on  the  eyeball,  lest 
the  vitreous  humour  burst,  and  a great  part  of  it  be 
lost,  and  without  lessening  the  pressure,  lest  the  cata- 
ract sink  back  into  the  eye,  should  introduce  Daviel’s 
curette  into  the  above  interspace,  with  its  hollow  sur- 
face applied  against  the  back  surface  of  the  cataract, 
which  is  to  be  gently  pushed  out  of  the  eye.  In  do- 
ing this.  Beer  owns  that  a small  part  of  the  vitreous 
humour  is  almost  always  lost,  but  the  quantity  is  not 
at  all  comparable  to  what  is  lost  when  the  hyaloid 
membrane  gives  way  before  Daviel’s  curette  is  intro- 
duced, which  can  then  only  be  passed  into  the  eye 
through  the  protruded  vitreous  humour  for  the  pur- 
pose of  pushing  out  the  cataract. 

Beer  notices  the  occasional  protrusion  of  the  iris, 
in  the  third  stage  of  the  operation,  more  or  less  between 
the  edges  of  the  incision  in  the  cornea,  immediately 
after  the  exit  of  the  cataract.  Here,  says  Beer,  the  iris 
should  be  reduced  without  the  least  delay,  and  the 
pupil,  which  is  completely  oval,  made  round  again  ; a 
thing  which  the  operator  may  easily  perform,  by  ap- 
plying his  hand  flat  upon  the  patient’s  forehead,  letting 
the  latter  shut  his  eye,  rubbing  the  upper  eyelid  quickly 
yet  gently  with  the  thumb,  and  then  suddenly  opening, 
the  eye,  by  which  means  a moderate  light  will  at  once 
strike  it,  and  produce  an  expansion  of  the  iris. 

In  all  patients  who  have  been  operated  upon  for  cata- 
racts, the  edges  of  the  eyelids  become  glued  together 
with  mucus  on  the  first  night  after  the  operation ; yet, 
according  to  Beer,  in  individuals  particularly  subject 
to  copious  secretions  of  mucus,  it  is  not  unusual  for 
the  puncta  lachrymalia  and  lachrymal  ducts  to  be 
blocked  up  with  thickened  mucus,  whereby  the  tears 
are  prevented  from  duly  passing  down  into  the  no.se, 
so  that  from  time  to  time  they  are  discharged  from  the 
inner  angle  of  the  eye,  and  collect  under  the  eyelids. 
In  this  case,  the  patient  soon  begins  to  complain  of  a 
violent,  continual,  and  increasing  sense  of  pressure  on 
the  eye,  and  the  upper  eyelid  swells,  unattended  with 
any  redness.  Irritable  persons  also  experience  a stu- 
pifying  dull  headache.  These  inconveniences  may  be 
immediately  removed  by  clearing  away  the  mucus 
with  a little  lukewarm  milk  from  the  inner  canthus, 
and  letting  a stream  of  clean  water  fall  over  the  cheek. 
Care  must  also  be  taken  to  hinder  a recurrence  of  the 
circumstance,  and  to  remove  it  if  it  should  happen. 

The  inflammation  consequent  to  extraction  chiefly^ 
affects  the  iris  and  neighbouring  textures.  Beer  refers 
its  origin  principally  to  the  entrance  of  air  into  the 
interior  of  the  eye;  which,  owing  to  the  size  of  the 
wound,  he  says,  is  not  entirely  to  be  prevented.  But 
another  cause  is  the  introduction  of  different  instru- 
ments into  the  eye ; and  hence  the  inflammation  is  ge- 
nerally severe  when  it  has  been  necessary  to  remove 
fragments  of  the  cataract  with  Daviel’s  curette,  or  to 
take  away  the  capsule  with  forceps,  or  destroy  it  with 
the  tenaculum-needle.  However,  Beer  is  of  opinion, 
th.it  a surgeon  who  knows  how  to  operate  well  m every 
mode,  will  not  find  the  inflammation,  under  these  cir- 
cumstances, more  violent  after  extraction  than  other 
methods ; and  therefoio  he  thinks  that  when  no  con- 


CATARACT.  271 


ftlderable  impediment  exists,  it  should  be  preferred. 
Beer,  who  considers  extraction  as  a radical  mode  of  re- 
moving a cataract,  thinks,  that  when  there  are  no  great 
and  insurmountable  obstacles  to  its  performance,  and 
the  operator  can  execute  it  as  well  as  all  other  methods, 
and  with  the  requisite  skill,  it  ought  to  be  preferred. 
But  when  he  is  deficient  in  skill,  he  is  himself  the 
greatest  impediment  to  the  success  of  the  operation. 
The  particular  cases  in  which  the  methods  of  depres- 
sion and  reclination  are  indicated,  have  been  already 
specified,  and  in  these,  of  course,  extraction  is  not  ad- 
vantageous. There  are  also  some  examples,  as  Beer 
remarks,  in  which  the  latter  operation  must  be  hazard- 
ous for  a beginner,  and  therefore,  in  respect  to  such  an 
orperator,  by  no  means  eligible,  as  in  cases  of  har-cata- 
ract  and  capsulo-lenticular  cataracts  with  a cyst  of 
purulent  matter— {Beer,  b.  2,  p.  3‘J6.) 

OF  KERATONYXIS. 

Gleize,  having  commenced  an  operation  by  extrac- 
tion, was  prevented  from  completing  it  by  a sudden 
movement  of  the  patient’s  head : instead  of  enlarging 
the  opening  in  the  cornea  with  scissors,  he  intro- 
duced a needle  through  it,  and  depressed  the  lens.  This 
case  led  to  the  invention  of  the  new  method  of  opera- 
ting by  keratonyxis,  as  it  is  now  termed,  a description 
of  which  Gleize  published  in  1786.  Gleize’s  method 
was  simplified  by  Conradi,  who  merely  opened  the  cor- 
nea and  capsule  of  the  lens  with  a lance-shaped  knife, 
and  left  the  removal  of  the  cataract  to  be  effected  by  the 
absorbents.  Several  improvements  were  subsequently 
made  in  this  method  by  Dr.  H.  Buchhorn,  who  first 
gave  it  the  name  of  Keratonyxis  (see  this  word),  and 
adopted  the  practice  of  dividing  the  lens,  as  well  as  the 
capsule,  and  of  bringing  the  fragments  forwards  into  the 
anterior  chamber.  About  the  same  time  Mr.  Saunders, 
in  England,  perfected  a similar  operation,  and  applied  it 
particularly  to  congenital  cataracts.— (See  Guthrie's 
Operative  Surgery  (f  the  Eye,  p.  331,  332.) 

This  operation  requires  the  pupil  to  be  first  artificially 
dilated.  The  belladonna  (says  Mr.  Guthrie)  should  be 
applied  the  day  before,  and  on  the  morning  of  the  ope- 
ration, in  order  that  the  pupil  may  be  completely  di- 
lated, and  a few  drops  of  a solution,  in  the  proportion  of 
five  grains  of  the  extract  to  a drachm  of  water,  should 
be  dropped  into  the  eye  half  an  hour  before  its  com- 
mencement, so  as  to  prevent  a contraction  of  the  pupil 
during  the  operation. — {Op.  cit.  p.  333.)  Keratonyxis 
admits  of  being  divided  into  two  stages ; first  the  intro- 
duction of  the  needle  through  the  cornea  and  pupil  as 
far  as  the  cataract;  and  secondly,  the  breaking  of  the 
lens  to  pieces,  and  the  division  and  laceration  of  its 
capsule.  For  these  purposes  Beer  prefers  a common, 
straight,  spear-shaped,  sharp-edged  couching-needle 
to  any  curved  one,  however  fine  it  may  be  made ; first, 
because  it  pierces  the  cornea  with  greater  facility  ; se- 
condly, because  both  a soft  cataract  and  the  capsule  can 
be  more  effectually  cut  with  it,  a larger  opening  being 
made,  through  which  the  aqueous  humour  may  flow 
over  the  fragments  of  the  lens,  and  the  dissolution  of 
the  cataract  be  thus  rendered  more  certain ; whereas, 
with  a curved  needle,  Beer  says,  the  lens  can  only  be 
disturbed  and  the  capsule  torn,  under  which  circum- 
stances inflammation  and  a secondary  capsular  cata- 
ract are  likely  to  be  juoduced.  He  directs  the  instru- 
ment to  be  introduced  either  at  the  lower  or  at  the  ex- 
ternal part  of  the  cornea,  one  line  and  a half  from  its 
margin,  the  point  being  directed  obliquely  towards  the 
pupil,  and  the  capsule  is  to  be  effectually  cut  by  moving 
the  extremity  of  the  needle  laterally  in  various  ways-; 
and,  above  all  things,  it  is  necessary  at  the  time  of 
breaking  the  lens  piecemeal,  not  to  let  the  instrument 
continue  always  within  this  body,  but  at  every  stroke 
to  lift  it  completely  out  of  the  lens  and  capsule,  and 
then  introduce  it  into  them  again  in  different  direc- 
tions. 

Dr.  Jacob  prefers,  for  the  performance  of  this  opera- 
tion, a fine  sewing-needle  curved  at  the  point.  He 
says,  that  it  rarely  or  never  leaves  the  slightest  mark  in 
the  cornea.  ‘The  cajjsule  can  be  opened  to  any  extent ; 
a soft  or  friable  lens  can  be  actually  broken  up  into  a 
pulp,  by  pushing  the  curved  extremity  of  the  needle 
into  its  centre,  and  revolving  the  handle  between  the 
fingers ; large  fragments  can  be  taken  up  on  the  point 
of  ihe  needle  ffom  the  anterior  chamber,  and  forced 
back  out  of  the  way  of  the  iris  ; or,  if  sufficiently  soft, 
may  be  divided  by  pressing  them  against  the  back  of 


the  cornea  with  the  convexity  of  the  neeefie,”  <fec.— 

(See  Dublin  Hospital  Reports,  vol.  4,  p.  224.) 

As  Beer  observes,  keratonyxis  must  soon  have  been 
found  as  little  adapted  to  all  cataracts  as  any  other 
mode ; for  otherwise  the  suggestion  would  not  have 
been  made  to  practise  reclination  through  the  cornea. 
To  this  form  of  reclination,  however,  Beer  adduces 
great  objections  ; for  he  says  that  in  thi,s  manner  either 
the  cataract  cannot  be  properly  turned  if  the  iris  be 
duly  spared,  but  it  will  continue  to  lie  obliquely,  bejng 
always  quite  evident  below  the  pupil,  and  very  apt  to 
rise  again  from  the  slightest  cause ; or  it  is  indeed  de- 
pressed far  enough  towards  the  bottom  of  the  eye,  but 
however  much  the  pupil  may  be  artificially  dilated, 
the  pupillary  edge  of  the  iris  is  more  or  less  injured, 
especially  at  the  convexity  of  the  curved  needle.  In 
addition  to  these  con.siderations.  Beer  urges  against 
this  method  all  the  objections  which  apply  to  the  prac- 
tice of  reclination  through  the  sclerotica. 

After  the  lens  and  capsule  have  been  effectually  cut 
in  pieces,  the  same  light  mode  of  dressing  and  the 
same  after-treatment  are  proper,  which  are  adopted  in 
cases  of  depression  and  reclination.  Beer  also  parti- 
cularly objects  to  any  trials  being  immediately  made 
of  the  eyesight.  At  the  same  time  be  assures  us,  that 
he  has  not  met  with  any  of  the  instances  so  frequently 
mentioned  in  books,  of  persons  on  whom  keratonyx’s 
has  been  done,  seeing  perfectly  well,  and  having  quite 
a clear  pupil  in  a few  days : under  the  most  favourable 
circumstances,  several  weeks,  and  sometimes  as  many 
months  elapsed  before  the  pupil  became  quite  transpa- 
rent. 

According  to  Beer,  keratonyxis  is  not  liable  to  many 
accidents.  Sometimes,  says  he,  the  artificially  dilated 
pupil  contracts  as  soon  as  the  needle  has  pierced  the  ^ 
cornea  and  reached  the  cataract : in  this  circumstance  ^ 
the  operator  must  wait  quietly,  until  the  pupil  gradually 
expands  again,  a change  which  may  be  promoted  by 
screening  the  eye  with  the  hand.  If  the  operation 
were  to  be  continued  without  delay,  either  the  pupillary 
edge  of  the  iris  would  be  seriously  and  dangerously 
hurt  by  the  needle,  o"  the  cataract  could  not  be  effect- 
ually divided.  When,  contrary  to  expectation,  the 
nucleus  of  the  cataract  is  too  hard  to  be  broken  piece- 
meal, reclination  and  depression  should  be  done  through 
the  cornea,  as  well  as  circumstances  will  allow,  and 
these  objects  can  be  more  easily  effected  with  a part 
than  with  the  whole  of  the  lens.  When  the  lens  is 
found  completely  fluid,  but  the  capsule  opaque  only  at 
som,e  points.  Beer,  with  the  view  of  preventing  a sc 
condary  capsular  cataract,  recommends  cutting  the 
membrane  in  all  directions,  and  annihilating  it  as  much 
as  possible.  Keratonyxis  may  be  followed  by  the  same 
evils  which  occasionally  take  place  after  depression 
and  reclination,  and  which  will  require  similar  treat- 
ment. But,  according  to  Beer’s  experience,  one  of  the 
most  frequent  consequences  is  a secondary  capsular 
cataract,  which  often  ensues  even  though  the  pupil 
was  quite  clear  at  the  time  of  the  operation ; and 
though  it  may  not  quite  blind  the  patient,  it  consider- 
ably lessens  his  power  of  vision,  and  renders  the  ope- 
ration very  incomplete. 

When  the  sole  object  of  keratonyxis  is  to  break  and 
cut  the  cataract  and  its  capsule  piecemeal,  and  the  frag- 
ments are  to  be  left  to  dissolve  and  be  absorbed,  the 
operation  can  be  indicated  only  where  this  division, 
breaking,  dissolution,  and  absorption  of  the  cataract 
can  be  successfully  wrought.  Hence  Beer  sets  down 
the  method  as  not  calculated  for  firm,  hard,  lenticular 
cataracts  ; nor  for  those  which  are  softish  and  scabrous 
only  upon  their  suiface;  and  he  says  that  it  is  not 
suited  for  capsulo-lenticular  cataracts,  nor  for  any 
cases  termed  false  cataracts,  which  are  of  a membra- 
nous nature.  Keratonyxis,  he  observes,  may  be  ex- 
pected to  answer  only  in  fluid  or  gelatinous  cataracts, 
when  the  capsule  is  either  little  or  not  at  all  opaque 
and  thickened,  and  of  course  can  be  easily  opened  and 
cut  to  pieces,  as  in  the  case  described  under  the  naino 
of  encysted  cataract.  For  the  above  reasons,  the  me- 
thod is  well  adapted  for  children  and  young  subjects, 
in  whom  the  origin  and  general  complications  of  a cata 
ract  involve  the  case  in  susj)icious  circumstances. 

After  keratonyxis,  the  dilatation  of  the  pupil  should 
be  kept  up  by  means  of  belladonna  until  all  symptoms 
of  inflajnmation  have  subsided. — (See  Guthrie's  Opera- 
tive Surgery  of  the  Eye,  p.  336.) 

Langenbeck,  who  has  practised  keratonyxis  to  a con* 


CATARACT. 


m 


siderable  extent,  and  uses  the  curved,  two-edged,  lan- 
cet-shaped needle,  thinks  extraction  preferable  to  it 
only  when  the  whole  cataract  can  be  brought  out  at 
once  by  means  of  gentle  pressure  on  the  eye,  and 
with  the  aid  of  Daviel’s  curette,  as  in  the  case  of  a firm 
cataract;  while  he  represents  keratonyxis  as  most  ad- 
vantageous where,  by  the  manoeuvre  of  opening  the 
capsule,  the  mass  of  the  cataract  would  be  so  divided 
by  the  instrument  as  not  to  admit  of  being  extracted 
altogether ; but  would  require  the  use  of  a scoop,  for- 
ceps, or  hook  for  bringing  out  the  fragments,  as  in  ex- 
amples of  soft,  milky,  and  capsular  cataracts.  Lan- 
genbeck  also  urges,  as  a reason  against  extracting  soft 
cataracts,  their  greater  size,  whereby  in  their  passage 
through  the  pupil  in  an  entire  state,  they  may  injure 
the  iris. — {Neue  Bibliothek  fur  die  Chir.  b.  1,  p.  461.) 
Valuable  information  on  keratonyxis  has  been  pub- 
lished by  the  same  author  in  the  4th  vol.  of  his  first 
Bibliothek;  in  the  1st  vol.  of  his  ne.'N  Bibl.  p.  1, 
1815  ; and  in  a tract  entitled,  “ Prufung  der  Kerato- 
nyxis, einer  Methode  den  grauen  Staar  durch  die  Horn- 
haut  zu  recliniren,  Oder  zuzurstuckeln  nebst  erlau- 
ternden  Operations  geschichten,  Gottingen,  1811.  See 
also  Conradi,  in  Arnemarm's  Magazin,  b.  1,  p.  95, 
1791.  Gleize,  Nouvelles  Obs.  Pratiques  sur  les  Mala- 
dies de  ViFAl,  p.  118,  1812.  G.  H.  Buchhorn's  Diss. 
de  Keratonyxide,  Hales,  1806.  Die  Keratonyxis,  6rc. 
1811. 

[The  several  operations  enumerated  by  Mr.  Cooper 
for  the  removal  of  this  disease  have  all  found  strenu- 
ous advocates  in  this  country.  That  no  one  operation 
is  adapted  to  every  kind  of  cataract  is  admitted  by  all 
experienced  oculists ; and  the  refinement  of  the  art 
consists  in  distinguishing  each  from  the  o'her.  I have 
known  very  many  erroneous  decisions  made  by  gentle- 
men of  great  skill  and  experience,  in  their  diagnosis 
of  cataract ; and  after  the  operation  was  I'.ommenced, 
the  true  character  of  the  cataract  was  ascertained  to  be 
very  different  from  what  had  before  been  supposed. 
This  liability  to  error  arises  from  the  very  imperfect 
descriptions  given  of  the  characteristics  of  each  kind 
of  cataract,  and  yet,  imperfect  as  they  are,  they  are  too 
often  presented  as  infallible. 

It  will  not  be  found  easy  to  decide  in  all  cases  with 
absolute  certainty  whether  the  cataract  be  hard,  soft, 
caseous,  or  fluid,  nor  to  assert  positively  whether  the 
opacity  is  in  the  capsule  or  the  body  of  the  crystalline 
lens,  by  merely  looking  into  the  eye ; nor  should  any 
decision  be  made  in  any  case  until  the  pupil  is  fully 
dilated  by  the  belladonna,  stramonium,  or  some  similar 
agent ; for  this  will  be  found  greatly  to  facilitate  the 
diagnosis. 

The  operation  most  frequently  performed  in  this 
country,  is  that  of  passing  the  needle  of  Adams,  Scarpa, 
Saunders,  or  Hey  through  the  sclerotic,  immediately 
behind  the  iris,  and  then  lacerating  the  capsule  or  the 
lens  itself,  and  permitting  the  aqueous  humour  to  act 
upon  it,  either  by  pressing  the  fragnients  of  the  lens 
through  the  pupil  into.the  anterior  chamber,  or,  where 
this  is  impracticable,  by  suffering  the  lacerated  mem- 
brane or  fragments  to  remain  in  situ,  which  will  often 
be  found  sufficient. 

One  of  the  most  successful  operators  in  this  country 
is  Doct.  John  Harper,  of  Baltimore,  and  he  seldom 
adopts  any  other  operation  than  this,  which  he  repeats 
as  often  as  necessary  on  the  same  eye.  When  the 
opacity  is  in  the  anterior  portion  of  the  capsule,  which 
is  frequently  the  case,  a single  operation  of  this  kind 
will  succeed.  I have  often  witnessed  the  satisfactory 
results  of  this  method  in  his  practice  and  in  my  own. 
Inone  instance  T performed  it  on  both  eyes  at  once,  on 
the  person  of  a young  lady,  and  to  promote  absorption 
kept  her  on  the  use  of  the  blue  pill ; and  in  three  weeks 
her  vision  was  restored,  although  she  had  been  blind 
twelve  years. 

The  operation  of  keratonyxis  is  now  very  often  per- 
formed, and  is  well  spoken  of  by  many  surgeons,  who 
think  it  adapted  to  more  kinds  of  cataract  than  any 
other  Some,  however,  after  passing  the  needle  through 
the  cornea,  have  the  tactus  eruditus  to  bring  forward 
the  lens  into  the  anterior  chamber,  and  ilius  accom- 
plish the  same  object  as  by  the  posterior  operation. 

Couching  or  depression  has  now  but  few  advocates 
amon-T  us,  although,  from  its  simplicity  and  the  facility 
of  its  performance,  it  was  formerly  very  generally  prac- 
tised in  America.  The  freiiuent  instances  of  amauro- 
eis  by  injury  of  the  retina,  and  the  return  of  the  leiui 


to  the  axis  of  the  eye  after  its  depression,  have  brought 
it  into  disrepute. 

The  operation  of  extraction  is  not  often  preferred,  even 
for  hard  cataract,  whether  from  any  real  or  supposed 
difficulty  in  its  performance,  as  insinuated  by  its  ad* 
vocates,  I am  not  prepared  to  decide.  If,  however,  the 
lens  be  first  brought  into  the  anterior  chamber,  the 
difficulty  will  be  amiihilated,  and  very  often  absorption 
will  render  the  latter  operation  unnecessary  if  the 
former  be  premised.  I know  this  fact  from  my  own 
experience,  as  well  as  from  the  observation  of  other 
surgeons. 

When  the  cataract  exists  only  in  one  eye,  the  pro- 
priety of  an  operation  is  not  only  questionable,  but 
should  never  be  admitted.  I have  a valuable  friend,  a 
clergyman,  in  this  city,  who  has  liad  an  entire  opacity, 
situated  in  the  capsule  of  one  lens,  for  many  years, 
while  the  other  eye  has  always  possessed  an  uncom- 
mon acuteness  of  vision.  And  I once  knew  the  ope- 
ration of  extraction  attempted  by  an  European  sur- 
geon, in  the  city  of  Baltimore,  on  a man  who  had 
one  sound  eye,  and  by  some  mishap  iritis  came  on,  and 
this  attempt  to  cure  one  eye  has  resulted  in  the  loss 
of  both,  and  he  is  totally  blind  to  this  day.  One  such 
occurrence  in  a century  should  prevent  the  repetition 
of  so  hazardous  an  experiment. 

When,  however  there  is  a well- formed  cataract  on 
one  eye,  and  another  begins  to  form  on  the  other  eye, 
then  the  operation  should  not  be  delayed  on  the  eye 
first  diseased  ; and  in  very  many  cases  the  cataract  in 
its  forming  state  will  be  removed  by  the  operation  on 
its  fellow.  This  I have  seen  in  several  instances,  and 
is  one  of  the  most  satisfactory  results  which  can  fol- 
low in  this  department  of  operative  surgery. — Reese.] 

OF  THE  CONGENITAL  CATARACT,  AND  OPERATING 
UPON  CHILDREN. 

I shall  not  stop  here  to  inquire  whether  the  expres- 
sion congenital  cataract  is  generally  used  with  strict 
propriety  ; but  it  is  worth  noticing,  that  the  term  is  re- 
probated by  Beer  as  being  in  general  incorrectly  ap- 
plied. 

So  much  has  been  already  said  in  a preceding  sec- 
tion of  this  article,  concerning  the  propriety  and 
striking  advantages  of  operating  for  the  cataracts  of 
children,  that  to  expatiate  farther  upon  this  point  would 
be  a mere  waste  of  time. 

We  have  noticed  the  case  which  Scarpa  terms  the 
primary  membranous  cataract,  and  which  is  men- 
tioned by  that  distinguished  professor  as  being  met 
with  in  children,  or  young  people  under  the  age  of 
twenty,  the  substance  of  the  crystalline  itself  being 
almost  entirely  absorbed,  while  the  capsule  is  left  in 
an  opaque  state,  including  at  most  only  a small  nu- 
cleus, not  larger  than  a pin’s  head.  This  disease  is  de- 
scribed by  Scarpa  as  exceedingly  rare,  and  character- 
ized by  a certain  transparency,  and  similitude  to  a cob- 
web : by  a whitish  opaque  point,  either  at  its  centre  or 
circumference;  and  by  a streaked  and  reticulated  ap- 
pearance. Now  this  example,  which  is  represented  by 
Scarpa  as  being  rare,  appears,  from  the  experience  of 
Mr.  Saunders,  to  be  by  no  means  uncommon,  since, 
at  the  London  Infirmary  for  diseases  of  the  eye,  it 
was  found  that  the  majority  of  congenital  cataracts 
were  capsular  or  membranous.  This  last  statement 
is  also  at  variance  with  that  of  the  late  Mr.  Gibson, 
who  has  asserted,  that  in  infants  the  cataract  is  gene- 
rally fluid.— (Edm.  Med.  and  Surgical  Journal,  vol.  7,  p. 
397.)  Mr.  Ware  also  asserts,  that  in  children  bom  with 
cataracts  the  crystalline  humour  has  generally,  if  not 
always,  been  found  either  in  a soft  or  fluid  state.— (Oft^. 
on  the  Cataract  and  Gutta  Serena,  vol.  2,  p.  380.)  We 
learn  from  Mr.  Saunders’s  publication,  that  in  the  con- 
genital cataract,  after  the  crj'stalline  lens  is  converted 
into  an  opaque  substance,  it  is  gradually  absorbed  ; and 
in  proportion  to  the  progress  of  absorption  the  ante- 
rior lamella  of  the  capsule  approaches  the  posterior, 
until  they  form  one  membrane,  which  is  white,  opaque, 
and  very  elastic.  This  process  is  commonly  completed 
long  before  the  eighth  year,  and  the  operator  will  now 
find  a substance  which  he  will  in  vain  endeavour  either 
to  extract  or  depress.  But  there  is  one  form  of  the 
congenital  cataract  in  which  the  ab-sorjition  of  the  lens 
does  not  proceed,  viz.  when  the  centre  of  the  crystal- 
line is  opaque,  and  its  circumference  is  perfectly  trans- 
parent. Should  the  capsule  and  lens  be  penetrated, 
however,  with  any  instrument,  the  opacity  soon  be- 


CATARACT. 


273 


comes  complete,  and  from  this  moment  the  substance 
of  the  lens  begins  to  be  absorbed. 

The  experience  of  Mr.  Saunders  proves,  that  in  the 
congenital  cataract,  the  lens  may  be  either  solid,  soft, 
or  fluid,  but  that  more  frequently  it  is  partially  or  com- 
pletely absorbed,  and  the  cataract  is  capsular. 

The  circumstance  of  Mr.  Gibson’s  never  having  met 
■with  a simple  membranous  cataract  in  an  infant,  a fact 
so  much  at  variance  with  Mr.  Saunders’s  account,  is 
conceived  by  Mr.  Guthrie  to  admit  of  satisfactory  ex- 
planation by  the  inference,  that  Mr.  Gibson,  in  Man- 
chester, probably  saw  all  the  children  there  with  con- 
genital cataract  soon  after  they  were  born,  and  before 
the  absorption  of  the  lens  had  proceeded  far  ; while  a 
great  number  of  Mr.  Saunders’s  congenital  cases  were 
brought  to  him  in  London  from  distant  places,  and  not 
seen  by  him  till  the  children  were  older,  and  the  disease 
had  made  greater  ^yrogreas.— {Operative  Surgery  of  the 
Eye,  p.  359.)  Indeed,  Mr.  Gibson  states  himself,  that 
simple  membranous  cataracts  are  by  no  means  uncom- 
mon at  the  age  of  eight  or  ten,  as  well  as  in  adults  who 
have  been  born  blind.— (See  Edin.  Med.  and  Surg.  Jour, 
vol.  8,  p.  399.) 

The  following  table  of  forty-four  cases  is  given  m Mr. 
Saunders’s  work,  for  the  purpose  of  showing  in  what 
proportion  each  species  of  cataract  has  been  found  to 


prevail  in  congenital  cases. 

Solid  opaque  lens,  with  or  without  opacity  of  the 

capsule.  Three  single,  two  double  cataracts 5 

Solid  lens,  opaque  in  the  centre,  transparent  in  the 
circumference,  with  capsule  in  the  same  state. 

Five  double 5 

Soft  opaque  lens,  with  or  without  opacity  of  the  cap- 
sule. Two  single,  two  double 4 

Soft  opaque  lens,  with  solid  nucleus.  One  single, 

two  double 3 

Soft  opaque  lens,  with  dotted  capsule,  the  spots 

white,  the  spaces  transparent.  Two  double 2 

Fluid  cataract,  with  opacity  of  the  capsule.  Two 

single 2 

Fluid  cataract,  with  opacity  of  the  capsule,  and 

closed  pupil.  Two  double 2 

Opaque  and  thickened  capsule,  the  lens  being  com- 
pletely absorbed,  or  the  remains  of  it  being  thin 

and  squamose.  Six  single,  tw’elve  double 18 

Opaque  and  thickened  capsule,  with  only  a very 
small  nucleus  of  the  lens  unabsorbed  in  the  centre. 

Two  single 2 

Opaque  and  thickened  capsule  in  the  centre,  remains 
of  the  lens  in  the  circumference.  One  double.  • . 1 


Here  the  corresponding  character  of  congenital  cata- 
racts in  the  eyes  of  each  individual  is  exhibited  by  the 
number  of  double  cases,  and  we  are  informed  that  the 
same  character  was  preserved  in  the  cataracts  of  several 
children  of  the  same  family.— on  Diseases 
of  the  Eye,  edit,  by  Dr.  Farre,  p.  135,  136.) 

The  congenital  cataract  appears  frequently  to  afflict 
several  children  of  the  same  parents.  In  the  course  of 
the  present  article,  I have  already  had  occasion  to  advert 
to  two  striking  examples  of  this  fact.  The  first  is  re- 
lated by  Mr.  Lucas,  who  attended  five  children  of  a 
clergyman  at  Leaven,  near  Beverley,  all  born  with  cata- 
racts.— (See  Med.  Ohs.  and  Inquiries,  vol.  6.)  The 
second  is  mentioned  by  Mr.  Gibson,  who,  some  years 
ago,  .saw  five  or  six  children,  the  families  of  two  sisters, 
who  were  all  totally  blind,  and  in  an  idiotic  state, 
having  cataracts  accompanied  with  amaurosis. — {Edin. 
Med.  and  Surgical  Journal,  vol.  8,  p.  398.)  Several 
instances  occurred  to  the  late  Mr.  Saunders.  In  one 
family,  two  brothers  were  thus  afflicted.  In  a second 
family,  two  brothers,  twins,  became  blind  with  cataracts 
at  the  age  of  twenty-one  months,  each  within  a few 
days  of  the  other.  It  is  remarkable,  that  the  four  cata- 
racts had  precisely  the  same  character.  In  a third 
family,  a brother  and  two  sisters  were  bom  with  this 
disease.  The  eldest  sister  was  affected  with  it  only  in 
one  eye,  the  brother  and  youngest  sister  in  both  eyes. 
In  a fourth  family,  three  brothers  and  a sister  had  all 
congenital  cataracts. — {Saunders  on  the  Diseases  of  the 
Eye,  p.  134,  135.) 

Children  with  congenital  cataracts  possess  various 
degrees  of  vision  ; but  when  they  are  totally  blind, 
their  eyes  not  being  attracted  by  external  objects,  voli- 
tion is  not  exercised  over  the  muscles  of  these  organs, 
which  roll  about  with  an  irregular,  rapid,  and  trembling 
motion. 

Vi>L.  1.-6 


I I shall  now  pfoceed  to  speak  of  the  manner  of  operas 
ting  upon  children.  Until  the  time  of  Mr.  Pott,  the 
intention  of  surgeons,  in  couching  or  depressing  the 
cataract  (as  indeed  the  expression  itself  implies),  was 
to  push  the  opaque  crystalline  downwards,  away  from 
the  pupil.  Mr.  Pott,  conscious  that  the  cataract  often 
existed  in  a fluid  or  soft  state,  was  aware  that  it  could 
not  then  be  depressed  ; and  therefore,  in  such  cases,  he 
recommended  using  the  couching-needle  for  the  express 
purpose  of  breaking  down  the  cataract,  and  of  making 
a large  aperture  in  the  capsule,  so  that  the  aqueous  hu- 
mour, which  he  believed  to  be  a solvent  for  the  opaque 
crystalline,  might  come  into  immediate  contact  with 
this  body.  This  operation,  subsequently  to  Mr.  Pott, 
has  been  strongly  and  ably  recommended  by  Mr.  Hey, 
of  Leeds,  and  Professor  Scarpa,  of  Pavia.  In  the  cases 
of  children,  it  even  received  the  approbation  of  the  late 
Mr.  Ware. — {On  the  Operation  of  Puncturing  the  Cap' 
sule  of  the  Crystalline  HuJnnur,  p.  9.) 

But,  notwithstanding  the  utility  and  efficacy  of  lace- 
rating the  front  layer  of  the  crystalline  capsule  had  been 
so  much  insisted  upon  by  Scarpa  and  others,  their  observ- 
ations were  confined  to  the  cataract  in  the  adult  subject, 
and,  before  the  example  set  by  the  late  Mr.  Saunders, 
no  one  (excepting,  perhaps,  Mr.  Gibson  of  Manchester) 
ventured  to  apply,  as  a regular  and  successful  practice, 
such  an  operation  to  the  eyes  of  infants  and  children. 
Indeed,  it  seems  highly  probable  that  even  Mr.  Gibson 
himself  would  have  remained  silent  upon  the  subject, 
had  not  his  attention  been  roused  by  the  reports  of  the 
London  Institution  for  curing  diseases  of  the  eye,  which 
reports,  he  says,  were  dispersed  and  exhibited  in  the 
public  news-rooms  of  Manchester.  For  the  creation 
and  perfection  of  this  beneficial  practice,  therefore,  I am 
disposed  to  give  the  memory  of  Mr.  Saunders  great 
honour.  The  propriety  of  operating  for  the  cataracts  of 
children  had  long  ago  been  insisted  upon  by  a few 
writers,  and  the  attempt  even  now  and  then  made  ; but 
tlie  method  never  gained  any  ground,  until  Mr.  Saunders 
led  the  way. 

It  only  remains  for  me  to  describe  the  plans  of  opera- 
ting, as  executed  by  Mr.  Saunders,  Mr.  Gibson,  and 
Mr.  Ware. 

The  principle  on  which  Mr.  Saimders  proceeded  in 
his  operations  on  the  congenital  cataract,  was  founded 
on  the  opinion,  that  the  only  obstacle  to  the  absorption 
of  the  opaque  lens  is  the  capsule ; and  that,  as  the  latter 
also  is  most  generally  opaque,  “ the  business  of  art  is 
to  effect  a permanent  aperture  in  the  centre  of  this 
membrane.  This  applies  to  every  case  of  congenital 
cataract  which  can  occur.”  Mr.  Saunders  used  to  over- 
come the  difficulty  of  operating  upon  children,  by  fixing 
the  eyeball  with  Pellier’s  elevator,  having  the  patient 
held  by  four  or  five  assistants,  dilating  the  pupil  with 
belladonna,  and  employing  a very  slender  needle,  armed 
with  a cutting  edge  from  its  shoulders  to  its  point,  and 
furnished  with  a very  sharp  point,  calculated  to  pene- 
trate with  the  utmost  facility. 

Before  the  operation,  the  extract  of  belladonna,  diluted 
with  water  to  the  consistence  of  cream,  is  to  be  dropped 
into  the  eye,  or,  to  avoid  irritation,  the  extract  itself 
may  be  smeared  in  considerable  quantity  over  the  eye- 
lid and  brow.  In  less  than  an  hour,  if  there  be  no  ad- 
hesions, it  produces  a ftill  dilatation  of  the  pupil,  ex- 
posing to  view  nearly  the  whole  anterior  surfhee  of  the 
cataract.  The  application  should  then  be  washed  from 
the  appendages  of  the  eye. 

In  u.sing  the  needle,  Mr.  Saunders  most  carefully  ab- 
stained from  doing  any  injury  to  the  vitreous  humour, 
or  its  capsule,  and  it  was  an  essential  point  with  him  to 
avoid  displacing  the  lens.  In  directing  the  extremity  of 
the  instrument  to  the  centre  of  the  capsule,  he  passed  it 
either  through  the  cornea,  near  the  edge  of  this  mem- 
brane (the  operation  now  called  Areraf 077  or  through 

the  sclerotica,  a little  way  behind  the  iris.  By  the  first, 
which  is  called  the  anterior  operation,  Mr.  Saunders 
conceived  that  less  injury  w'ould  be  inflicted,  and  less 
irritation  excited,  than  by  introducing  the  needle  behind 
the  iris,  through  all  the  tunics  of  the  eye.  In  every 
case,  the  first  thing  aimed  at  was  the  permanent  de- 
struction of  the  central  portion  of  the  capsule  to  an 
extent  equal  to  that  of  the  natural  size  of  the  pupil.  If 
the  capsule  contained  an  opaque  lens,  Mr.  Saunder.s 
used  next  to  sink  the  needle  gently  into  the  body  of  the 
crystalline,  and  moderately  open  its  texture ; cautiously 
observing  not  to  move  the  lens  at  all  out  of  its  natural 
situation. 


S74 


CATARACT. 


When  the  case  was  a fluid  cataract,  Mr.  Saunders 
Was  content  in  the  first  operation  with  simply  lace- 
rating the  centre  of  the  capsule,  being  desirous  of 
avoichng  to  increase  the  irritation  following  the  diffusion 
of  the  matter  of  the  cataract  in  the  aqueous  humour. 

When  the  cataract  was  entirely  capsular,  Mr.  Saun- 
ders acted  with  rather  more  freedom,  as  he  entertained 
in  this  case  less  fear  of  inflammation : but  in  other  re- 
spects, he  proceeded  with  the  same  objects  in  view 
w'hich  have  been  already  related,  and  of  which  the 
principal  consisted  in  effecting  a permanent  aperture  in 


For  the  purpose  of  fixing  the  eye,  Mr.  Ware  const- 
dered  Pellier’s  elevator  requisite  in  operating  upoh 
infants.  When  the  patient,  however,  had  advanced 
beyond  the  age  of  infancy,  Mr.  Ware  sometimes  fixed 
the  eye  by  means  of  the  fingers  alone.  For  the  purpose 
of  puncturing  the  capsule,  and  breaking  dow  n the  cata 
ract,  this  gentleman  gave  the  preference  to  an  instru 
ment  which  resembles  one  recommended  by  Cheselden, 
for  the  purpose  of  making  an  artificial  pupil ; but  it  is 
somewhat  narrower.  Its  blade,  indeed,  is  so  narrow, 
that  it  nearly  resembles  a needle.  Its  extremity  is 


the  centre  of  the  capsule,  without  detaching  this  mem-  | pointed,  and  it  cuts  on  one  side  for  the  space  of  about 
brane  at  its  circumference;  for  then  the  pupil  would  i the  eighth  of  an  inch,  the  other  side  being  blunt.  It  is 
have  been  more  or  less  covered  by  it,  and  the  operation  | perfectly  straight,  is  an  inch  long  in  the  blade,  and 


imperfect,  “ because  this  thickened  capsule  is  never 
absorbed,  and  the  pendulous  flap  is  incapable  of  pre- 
senting a sufficient  resistance  to  the  needle  to  admit  of 
being  removed  by  a second  operation.’’ — (P.  145.) 

I have  already  explained,  that  Mr.  Saunders  found 
that  the  greatest  success  attended  the  operation  between 
the  ages  of  eighteen  months  and  four  years.  One  ope- 
ration frequently  accomplished  a cure  ; as  many  as  five 
were  seldom  requisite. 

The  only  particularity  in  Mr.  Saunders’s  treatment  of 
the  eye  after  the  operation,  was  that  of  appl>ing  the 
belladonna  externally,  for  the  purpose  of  making  the 
pupil  remain  dilated,  till  the  inflammation  had  ceased, 
so  as  to  keep  the  edge  of  the  iris  from  contracting  aohe- 
sions  with  the  margin  of  the  torn  capsule.  This  last 
practice  is  found  to  be  so  important,  that  it  is  never 
neglected  by  any  good  operator  of  the  present  day.  In 


forms  a complete  wedge  through  its  whole  length. 
Upon  one  side  of  the  handle  is  a coloured  spot ; by  at- 
tending to  which,  the  operator  may  always  ascertain 
the  position  of  the  instrument  in  the  eye. 

Mr.  W'are  dilated  the  pupil  with  the  extractum  bella- 
donnas, softened  with  a little  water,  and  applied  about 
half  an  hour  before  the  lime  of  operating.  He  believed 
that,  in  operating  upon  infants,  the  surgeon  might  per- 
form the  operation  wth  more  composure,  if  the  patient 
were  laid  upon  a table,  wflththe  head  properly  raised  on 
a pillow.  The  bent  end  of  Pellier’s  elevator  should  be 
introduced  under  the  upi)er  eyelid,  and  the  instrument 
conunitted  to  the  care  of  an  assistant  If  the  right  eye 
is  to  undergo  the  operation,  and  the  surgeon  operate 
with  his  right  hand,  he  must  of  course  sit  or  stand 
behind  the  patient ; and,  in  this  case,  he  will  himself 
manage  the  speculum  with  his  left  hand.  The  eye 


leaving  this  part  of  the  subject,  I must  advise  every  being  thus  fixed,  Mr.  Ware  passed  the  point  of  the 

trv  inttiir*acsf  in /t  Tl  firTrWJir-Hl  Irnif^  nn£>nf 


surgeon  to  read  the  interesting  account  of  Mr . Saunders’s 
practice,  published  by  his  friend  and  colleague.  Dr. 
Farre.  Many  minute  particulars  ^vill  be  found  in  this 
work,  highly  worthy  of  the  practitioner’s  attention  and 
imitation. 

Mr.  Gibson  appears  to  have  been  unacquainted 
with  the  useftjlness  of  the  extract  of  belladonna  in 
preparing  the  eye  for  the  operation.  A few  hours 
before  operating,  he  was  in  the  habit  of  ordering  an 
opiate,  sufficient  to  produce  a considerable  degree  of 
drowsiness,  so  that  the  infant  generally  allowed  its 
eyelids  to  be  opened  and  properly  secured  without  re- 
sistance, and  was  little  inclined  to  offer  any  impediment 
to  the  introduction  of  the  couching-needle ; but,  on  the 
contrary,  presented  the  sclerotica  to  view,  naturally 
turning  up  the  white  of  its  eye.  If  the  infant  was 
more  than  a year  old,  and  whenever  it  was  necessary, 
Mr.  Gibson  used  to  introduce  its  body  and  arms  into  a 
kind  of  sack,  open  at  both  ends,  and  furnished  with 
strings  to  draw  round  the  neck,  and  tie  sufficiently  tight 
round  the  legs,  so  that  its  hands  were  effectually  se- 
cured, and  the  assistants  had  only  to  steady  its  body, 
and  fix  its  head,  while  the  child  was  laid  on  a table, 
upon  a pillow.  Mr.  Gibson  never  found  it  necessary 
to  use  a speculum,  having  uniformly  experienced  that, 
after  the  couching-needle  was  introduced,  he  had  no 
difficulty  in  commanding  the  eye,  aided  by  a slight  de- 
gree of  pressure  upon  the  eyeball  with  the  index  and 
middle  fingers  of  his  left  hand,  w'hich  were  employed 
in  depressing  the  lower  eyelid.  He  admits,  however, 
that  the  speculum  can  easily  be  applied,  if  an  operator 
prefer  it.  He  generally  used  Scarpa’s  needle,  because, 
in  infants,  the  free  rupture  of  the  capsule  of  the  lens 
ought  commonly  to  be  aimed  at,  in  order  '.hat  the  milky 
cataract  may  escape,  and  mix  with  the  aqueous  hu- 
mour; or,  if  the  cataract  be  soft,  that  the  aqueous 
humour  may  be  freely  admitted  to  its  pulpy  substance 
which  has  been  previously  broken  down  with  the  needle. 
He  thinks  that  no  peculiarity  is  necessary  in  depressing 
the  hard  cataract  of  infants.  Before  Scarpa’s  needle 
was  knowu  in  this  countrj’,  Mr.  Gibson  used  Mr.  Hey’s, 
which  was  generally  effectual,  and,  as  he  conceives, 
possesses  the  recommendation  of  being  less  liable  to 
have  its  points  entangled  in  the  iris.  He  says,  that 
when  a milky  cataract  has  been  thus  evacuated,  it  ren- 
ders the  aqueous  humour  turbid ; but  that  within  the 
space  of  two  days,  the  eye  generally  acquires  its  natural 
transparency,  and  vision  commences.  When  the  cap- 
sule and  substance  of  the  soft  cataract  have  been  broken 
down,  and  the  aqueous  humour  has  come  into  contact 
with  the  lens,  the  solution  and  disappearance  of  the 
cateiract,  in  all  the  cases  upon  which  Mr.  Gibson  has 
operated  have  uniformly  taken  place  in  a short  time. 
— (See  Edin.  Med.  and  Suro:icalJoitrn.al,vol.8,  p.  31)8, 
399.) 


narrow-bladed  knife  above  mentioned  through  the  scle- 
rotica, on  the  side  next  to  the  temple,  about  the  eighth 
of  an  inch  from  the  union  of  that  membrane  to  the 
cornea,  the  blunt  edge  being  turned  downwards.  The 
instrument  was  pushed  forwards  in  the  same  direction, 
until  its  point  had  nearly  reached  the  centre  of  the 
crystalline.  The  point  was  then  brought  forwards, 
until  it  had  passed  through  the  opaque  crystalline  and 
its  capsule,  and  was  plainly  visible  in  the  anterior 
chamber.  If  the  cataract  was  fluid,  eind  the  anterior 
chamber  became  immediately  filled  with  the  opaque 
matter,  Mr.  Ware  deemed  it  advisable  to  withdraw  the 
instrument,  and  defer  farther  measures  until  the  matter 
w'as  absorbed,  which  absorption  usually  took  place  in 
the  course  of  a few  days,  and  sometimes  of  a few 
hours.  If  no  visible  change  were  produced  in  the 
pupil,  the  point  and  cutting  edge  of  the  instrument  were 
applied  in  different  directions,  so  as  to  divide  both  the 
opaque  crystalline  and  its  capsule  into  small  portions, 
and,  if  possible,  bring  them  forw  ards  into  the  anterior 
chamber.  This  may  require  the  instrument  to  be  kept 
in  the  ej  e for  a minute  or  two ; but  if  the  operator  pre- 
serve his  steadiness,  he  may  continue  it  there  a much 
longer  time,  w'ithout  doing  the  least  injury  to  the  iris, 
or  to  any  other  part.  If  the  cataract  be  found  of  a firm 
consistence  (though  this  rarely  happens  in  young  per- 
sons), it  may  be  advisable  to  depress  it  below  the  pupil ; 
and  in  such  a case,  particular  care  should  be  taken  to 
perforate  largely  the  posterior  part  of  the  capsule,  and 
to  withdraw  the  instrument  immediately  after  the  cata- 
ract has  been  depressed,  in  order  to  hinder  it  from 
rising  again.  If  the  opacity  be  in  the  capfsule,  the 
instrument  will  not  act  so  easily  upon  it  as  it  does 
on  the  opaque  crj’stalline ; but,  notwithstanding  this, 
the  capsule,  as  well  as  the  crystalline,  may  be  divided 
by  it  into  larger  or  smaller  portions,  which,  when  thus 
divided,  wall  be  softened  by  the  action  of  the  aqueous 
humour ; and  though  in  the  first  operation  on  such  a 
case,  says  Mr.  Ware,  it  may  not  be  possible  to  remove 
the  opacity,  -yet,  on  the  second  or  third  attempt,  the 
divided  portions  may  be  brought  • forwards  into  the  tin- 
terior  chamber,  in  wffiich  place  they  will  then  be  gradu- 
ally absorbed,  and  soon  disappear.  After  the  opera- 
tion, Mr.  Ware  seldom  found  it  necessary  to  take  away 
blood  from  children  or  persons  under  the  age  of  twenty. 
He  continued  a cooling  antiphlogistic  treatment  a few 
days.  After  this,  if  any  opaque  matter  remained,  he 
expedited  its  absorption  by  dropping  a small  i)ortion  of 
powdered  sugar  into  the  eye  once  or  twice  a day. 
When,  at  the  end  of  a week  or  ten  days,  the  inflamma- 
tion was  over,  and  the  pupil  obstructed  with  opaque 
matter,  Mr.  Ware  advised  a repetition  of  the  operation. 
After  a similar  interval,  the  operation,  he  says,  may  be 
requisite  again.  In  most  cases,  Mr.  Ware  was  obliged 
to  operate  twice;  in  a few'  instances,  ouce  proved  suftv 


CAT 


CAT 


275 


hient ; and  only  in  three,  oUt  of  the  last  twenty,  did  he 
find  it  necessary  to  operate  a fourth  time.— (On.  the  Ope- 
ration of  puncturing  the  Capsule  of  the  Crystalline 
Humour.) 

I think  any  impartial  man,  who  considers  the  prac- 
tice of  the  three  preceding  operators,  will  find  great 
cause  to  admire  the  superior  gentleness  and  skill  which 
predominate  in  the  operations  of  the  late  Mr.  Saunders. 
For  my  own  part,  I am  so  fully  convinced  of  the  mis- 
chief which  has  been  done  to  the  eyes  by  the  rash 
boldness,  awkwardness,  and  unsteadiness  of  numerous 
operators,  that  it  appears  to  me  the  inculcation  of  gen- 
tleness and  forbearance,  in  all  operations  for  the  cata- 
ract, is  the  bounden  duty  of  every  man  who  has  occa- 
sion to  Write  upon  the  subject.  Great  manual  skill  and 
invariable  gentleness,  indeed,  seem  to  me  to  have  had 
more  share  in  rendering  Mr.  Saunders’s  operations  suc- 
cessful, than  any  particularity  either  in  liis  method  or 
his  instrument.  I have  no  hesitation  in  declaring  my 
own  partiality  to  the  principles  on  which  his  practice 
was  founded,  and  my  belief  that  they  are  well  calcu- 
lated to  improve  most  materially  this  interesting  branch 
of  surgery.  In  conclusion,  I shall  mention  Mr.  Guth- 
rie’s general  opinion  respecting  the  kinds  of  operation 
suited  for  the  three  classes  of  cataracts,  into  which  he 
arranges  them  for  the  consideration  of  this  important 
point.  The  hard  admit  only  of  extraction  or  displace- 
ment ; the  soft  seldom  of  displacement  or  of  extraction, 
but  usually  of  division;  the  capsular  neither  of  dis- 
placement, extraction,  nor  division,  purely  considered 
as  such,  but  b^'  laceration,  and  removal  of  the  opaque 
body  from  the  axis  of  vision  by  different  operations, 
which,  although  they  may  partake  of  the  nature  of  all, 
are  yet  not  precisely  either.  All  intermediate  states  of 
disease,  such,  for  instance,  as  the  caseous  and  fluid 
cataracts,  admit  of  some  slight  deviations  from  these 
rules,  but  are  still  regulated  by  the  same  principles. — 
{Operative  Surgery  of  the  Eye,  p.  365.) 

With  respect  to  extraction,  also,  it  deserves  careful 
recollection,  that  it  is  a method,  which,  though  the 
cataract  may  be  of  a hard  consistency,  is  often  prohi- 
bited by  various  unfavourable  circumstances,  which  I 
have  taken  notice  of  in  the  foregoing  pages.  Consult 
P.  Brisseau,  Nouvelles  Ohs.  sur  la  Cataracte,  propo- 
sftes  d VAcad.  des  Sciences,  1705.  Tournay,  1706.  Ant. 
Maitre-Jan,  Traiti  des  Maladies  de  I'lEil,  Mo.  Paris, 
1707.  Charles  de  St.  Ives,  Nouveau  Traite  des  Mala- 
dies des  Yeux,  \2mo.  Paris,  1722.  J.  H.  Frey  tag,  De 
Cataracta,  Argent.  1721 . A.  Petit,  Lettre,  dans  laquelle 
il  demontre  que  le  Crystallin  est  fort  pris  de  V Uvee,  et 
rapporte  de  nouvelles  Preuves,  qui  concement  VOpera- 
tion  de  la  Cataracte.— {Haller,  Disp.  Chir.  5,  570.) 
L.  Heister,  De  Catara  -ta,  <Cc.  tract.  Alt.  1713;  Vin- 
dicicB  de  Cataracta,  <^c.  Alt.  1713;  and  Apologia  et 
uberior  Illustratio  Systematis  s^ti  de  Cataracta,  Glau- 
comate,  et  Amaurosi,  \2mo.  Altorf.  1717.  PotVs  Re- 
marks on  the  Cataract,  vol.  3 of  his  Chirurgical  Works. 
Daviel,  Sur  une  Nouvelle  Methods  de  Guirir  la  Cata- 
racte par  r Extraction  du  Crystallin,  1747;  avA  in 
M m.  de  VAmd.  de  Chirurgie,  t.  b,p.  369,  edit.  \2mo. 
A.  B'schoff,  A Treatise  on  the  Extraction  of  the  Cata- 
ract, 8vo.  Land.  1793.  Wenzel's  Treatise  on  the  Cata- 
ract, by  Ware,  Svo.  bond.  1791.  W.  H.  J.  Buchhorn, 
Die  Keratonyxis,  Eine  neuc  gefahrlosere  Methode  den 
grauen  Staar  zu  operiren,  <!rc.  8vo.  Hal  re  Magd.  1811. 
Richter's  Treatise  on  the  Extraction  of  the  Cataract, 
transl.  Svo.  bond.  1791 ; and  Anfangsgr.  der  Wun- 
darzneykunst,  b.  3.  Jon.  Wathen,  A Diss.  on  the  The- 
ory and  Cure  of  the  Cataract,  in  which  the  Practice  of 
Extraction  is  supported,  S,-c.  Svo.  1785.  Ph.  F.  Walther, 
Abhandlungen,  S,-c.  bandshut,  1810.  Also  in  Quar- 
terly Joum.  of  Foreign  Med.  No.  6.  Kupfer,  Diss.  de 
Utilitate  BelladonncB  in  sananda  constrictione  nimia 
iridis,  Erlangae,  1803.  Himley,  Ophthalmologische, 
Bibl.  1,  5.  2,  No.  3,  the  Use  of  Hyosciamus  for  dilating 
the  Pupil  proposed.  J.  Wathen,  A New,  I\  c.  Method  of 
Curing  the  Fistula  bachrymalis,  ^c.  with  an  Appendix 
on  the  Treatment  after  the  Operation  for  the  Cataract, 
Svo.  bond.  1792.  J.  A.  Schmidt,  in  Abhandlungen  der 
K.  K.  Josephs  Acad.  b.  2,  p.  209.  273 ; and  Ueber  Nach- 
stanr  and  IritisnachStaaroperationem,Mo.Wien,  IFOl; 
one  of  the  most  valuable  works  ever  published  <m  Dis- 
eases of  the  Eye.  War^s  Chirurgical  Observations  on 
the  Eye,  2 vol.  edit.  3.  Scarpa's  Observ/itions  on  the 
Principal  Diseases  of  the  Eyes,  edit.  2.  Hey's  Practical 
Observations  in  Surgery,  edit.  2.  G.  Ch.  Conrndi, 
Bemerkungen  i/ber  einige  Gegenstdnde  des  Giauen 

S2 


Staars,  beipz.  1791;  and  in  ArnemamOs  Magazin,  b. 

I.  Saunders,  on  Diseases  of  the  Eye,  by  Farre,  edit.  3. 
G.  J.  Beer,  Practische  Beobachtungen  iiber  den  grauen 
Staar,  frc.  Wien,  1791.  Methode  den  grauen  Staar 
sammt  der  Kapsel  auszuziehen,  Wien,  8vo.  1729 ; 
behre  von  den  Augenkr.  b.  2,  Wien,  1817.  Karl  Aug. 
Wienhold's  Anleitung  zur  Reclination  des  Giauen 
Staars  mit  der  Kapsel,  1809.  Gibson's  Practical  Ob- 
servations on  the  E’ormation  of  an  Artificial  Pupil, 
and  Remarks  on  the  Extraction  of  Soft  Cataracts,  6,  c. 
Svo.  bond.  1811.  C.J.M.  bangenbeck,  Prufung  der 
Keratonyxis,  einer  Methode  den  grauen  Staar  durch 
die  Hornhaut  zu  recliniren  Oder  zu  zerstuckeln  nebst 
erldutemden  operation  geschichten,  Svo.  Gott.  1811 ; 
and  several  papers  in  his  Bibliothek  of  later  date.  B. 
Travers,  tn  Medico-Chir.  Trans,  vols.  4 and  5 ; and  A 
Synopsis  of  the  Diseases  of  the  Eye,  Svo.  bond.  1802, 
and  later  editions.  J.  Wardrop,  Essays  on  the  Morbid 
Anatomy  of  the  Human  Eye,  2 vols.  Svo,  bondon,  1818. 

J.  Vetch,  A Practical  Treatise  on  the  Diseases  of  the 
Eye,  p.  109,  <S-c.  Svo.  bond.  1820.  Gleize,  Nouvelles 
Obs.  Pratiques  sur  les  Maladies  de  I'lEil,  1812.  De- 
mours,  Traite  des  Maladies  des  Yeux.  Andrew  Smith, 
in  Edin.  Med.  and  Surg.  Journ.  vol.  19,  p.  13.  John 
Stevenson,  On  the  Advantage  of  an  Early  Operation 
for  the  Different  Species  of  Cataract,  Edin.  Med.  Joum. 
vol.  19,  p.  513.  Also,  his  Treatise  on  the  Nature,  Src.  of 
Cataract,  Svo.  1824.  Wendz,  Ueber  den  Zustand  der 
Augenheilkunde  in  Frankreich,  nebst  Kritischen  Be- 
merkungen iiber  denselben  in  Deutschland,  Numberg, 
1815.  Also,  Quarterly  Journ.  of  Foreign  Med.  No.  4. 
Sir  W.  Adams,  On  the  Diseases  of  the  Eye,  1812.  Prac- 
tical Inquiry  into  the  Causes  of  the  Frequent  Failure 
of  Depression  and  Extraction;  with  New  and  Improved 
Operations,  Svo.  bond.  1817.  G.  J.  Guthrie,  bectures 
on  the  Operative  Surgery  of  the  Eye,  Svo.  bond.  1823 
G.  Frick,  Treatise  on  the  Diseases  of  the  Eye,  p.  155,  <^c. 
edit.  2,  with  notes  by  R.  Welbank,  bond.  1826.  C.  bou 
don.  Inquiry  into  the  Principal  Causes  of  the  Unsuc- 
cessful Termination  of  Extraction  by  the  Cornea,  with 
the  view  of  showing  the  Superiority  of  Dr.  F.  Jaeger's 
Double  Knife,  &,  c.  bond.  1826.  Arthur  Jacob,  On  a 
Cataract-Needle  of  a Particular  Description ; Dublin 
Hospital  Reports,  vol.  4,  p.  214,  1827. 

CATHETER.  (From  KadirjiM,  to  thrust  into.)  A 
tube  which  is  introduced  through  the  urethra  into  the 
bladder,  for  the  purpose  of  drawing  off  the  urine. — 
(See  Urine,  Retention  of.)  Of  course  there  are  two 
kinds  of  catheters ; one  intended  for  the  male,  the 
other  for  the  female  urethra.  With  respect  to  cathe- 
ters, three  things  are  to  be  considered  : 1st,  the  instru- 
ment itself ; 2d,  the  manner  of  introducing  il ; and  3d, 
the  conduct  to  be  pursued  after  its  introduction. 

Catheters  were  anciently  composed  of  copper ; Cel- 
sus  knew  of  no  other  kind.  As  these,  however,  had 
the  inconvenience  of  becoming  incrusted  with  verdi- 
gris, they  at  length  fell  into  disuse,  and  others,  made 
of  silver,  were  substituted  for  them.  This  change, 
which  was  made  as  early  as  the  time  of  the  Arabian 
practitioners,  still  receives  the  approbation  of  the  best 
modern  surgeons.  The  common  catheter  is  a silver 
tube,  of  such  a diameter  as  will  allow  it  to  be  intro- 
duced with  ease  into  the  urethra,  and  of  various  figures 
and  lengths,  according  as  it  is  intended  for  the  young 
or  adult,  the  male  or  female  subject.  For  an  adult  fe- 
male subject  it  should  be  aboufsix  inches  long,  and  for 
young  girls,  Ibur  or  five.  For  men,  the  length  ought 
to  be  from  ten  inches  and  a half  to  eleven  inches.  Ilut 
as  the  instrument  need  not  enter  far  into  the  bladder, 
Mr.  John  Bell’s  advice  to  avoid  too  great  a length  me- 
rits observance.— (Prmcip/e5  of  Surgery,  vol.  2,  p. 
193.)  As  the  urethra  in  some  instances  is  narrow,  and 
in  others  wide,  surgeons  should  be  furnished  with  ca- 
theters of  different  diameters.  The  choice  of  the  in- 
strument, with  respect  to  its  width,  is  likewise  deter- 
mined very  much  by  the  nature  of  the  disease  of  the 
meUna.— {bangenbeck,  Bibl.  b.  1,  p.  1177.)  For  a wo- 
man, the  diameter  ought  to  be  at  least  two  lines  ; and 
for  girls,  a line  and  a half.  For  male  adult  subjects, 
Desault  recommends  the  thickness  of  two  lines  and 
one-third ; and  for  boys,  that  of  a line  and  a half.  In 
general,  whenever  the  urethra  is  pervious,  il  is  better 
to  follow  the  advice  of  Desault,  and  employ  a largish 
catheter,  which  will  enter  the  passage  more  easily,  and 
not  be  entangled  in  the  folds  of  the  membranous  lining 
of  the  canal,  w’liilc  it  wilt  afford  a more  ready  outlet 
for  the  urine  On  the  other  hand,  a small  catheter 


276 


CATHETER. 


should  be  preferred  when  there  are  obstructions  in  the 
passage.  Catheters  also  ditfer  in  shape : those  which 
Desault  used  for  male  subjects  had  only  a slight  curva- 
ture of  one-third  of  their  length  : a curvature  wliich 
began  insensibly  from  their  straight  part,  and  was 
continued  to  the  very  end  of  their  beaks.  The  curva- 
ture was  also  regular,  so  as  to  form  the  segment  of  a 
circle  of  six  French  inches  in  diameter.  Amussat  re- 
commends the  use  of  straight  catheters,  which  are 
passed  as  far  as  the  pubes,  while  the  penis  is  drawn 
upwards,  which  is  then  brought  down  between  the 
thighs,  so  as  to  lessen  the  bend  of  the  urethra.  One 
advantage  imputed  to  a straight  catheter  is,  that  it  may 
be  rotated  between  the  surgeon's  fingers,  w'hereby  the 
chance  of  its  surmounting  any  obstacle  will  be  in- 
creased.— {Archives  Gen.  de  Med.  t.  4.  Also,  P.  Ecot, 
Diss.  du  Catherisme  exercie  avec  la  Sonde  droite, 
Strasb.  1825,  ito.)  As  the  course  of  the  healthy  ure- 
thra in  the  male  subject  is  regular,  the  caprice  evinced 
by  surgeons  in  the  different  curvatures  of  their  cathe- 
ters, cannot  be  founded  on  any  correct  anatomical  prin- 
ciples, and  the  bend  of  the  instrument  (at  least  for  sub- 
jects of  the  same  age  and  stature)  should  generally  not 
vary  at  all,  but  be  strictly  adapted,  as  Langenbeck  re- 
marks, to  the  natural  track  of  the  urethra.— (FiiZ.  1,  p. 
1177.)  The  female  catheter,  however,  has  only  a slight 
curvature  towards  its  beak ; a shape  adapted  to  the  di- 
rection of  the  meatus  urinarius.  Desault  also  improved 
silver  catheters,  by  causing  them  to  be  made  with  ellip- 
tical openings,  or  eyes,  at  the  sides  of  the  beak,  with 
rounded  edges,  instead  of  the  longitudinal  slits  pre- 
viously in  use,  in  which  the  lining  of  the  urethra  was 
frequently  entangletl,  pinched,  and  lacerated,  so  that 
acute  pain  and  profuse  hemorrhage  were  the  conse- 
quences. With  the  view'  of  preventing  these  evils,  he 
also  filled  up  the  openings  with  lard. — (See  CEuvres 
Chir.  de  Desault,  t.  3,  p.  118.) 

Besides  silver  or  inflexible  catheters,  surgeons  now 
frequently  employ  flexible  ones  made  of  elastic  gum. 
These  last,  indeed,  are  of  so  much  importance,  that 
they  may  be  said  to  constitute  one  of  the  greatest  im- 
provements in  modern  surgery.  I shall  not  here  in- 
quire whether  they  were  first  invented  by  Theden, 
Pickel  of  Wurzburg,  or  Bernard  of  Paris:  this  is  a 
point  which  the  Germans  and  French  must  settle 
themselves.  Imperfect  attempts  had  been  made  by 
others  at  earlier  periods  to  invent  catheters  possessing 
the  property  of  flexibility.  Van  Helmont  proposed  the 
use  of  catheters  made  of  horn ; but  this  substance  was 
found  to  be  too  stifiT,  and  to  be  very  quickly  coated  with 
depositions  from  the  urine.  Fabricius  ab  Aquapen- 
dente  employed  leather  catheters,  which  were  objec- 
tionable, inasmuch  as  they  were  soon  softened  by  the 
urine  and  mucus  of  the  urethra,  when  they  shrivelled 
and  became  impervious.  Other  flexible  catheters  were 
also  formerly  tried,  comjiosed  of  spiral  springs  of  sil- 
ver wire,  covered  with  the  skins  of  particular  animals. 
These  last,  however,  were  very  quickly  spoiled  by  pu- 
trefaction ; and  when  left  in  the  urethra  any  consider- 
able time,  the  beak  sometimes  entirely  separated  from 
the  rest  of  the  instrument,  and  was  left  behind  in  the 
bladder. 

The  elastic-gum  catheters  now  in  use  are  liable  to 
none  of  the  preceding  inconveniences ; they  are  formed 
of  silk  tubes,  woven  for  the  purpose,  and  covered  with 
a coat  of  elastic  gum  ;*they  are  sufficiently  flexible  to 
accommodate  themselves  to  the  different  curvatures  of 
the  urethra  ; they  are  not  softened  by  the  urine ; and 
they  constantly  remain  with  their  cavity  unobliterated. 
Their  smooth  and  polished  surface  makes  them  con- 
tinue a long  while  free  from  incrustations  deposited 
from  the  urine.  Sometimes  they  are  introduced  with  a 
Btilet  or  wire,  which  is  passed  into  their  canal,  in  order 
to  give  them  a certain  curvature,  and  a greater  degree 
of  firmness  : but  in  general  it  is  withdrawn  as  soon  as 
the  tube  is  in  the  bladder. 

Elastic  catheters  are  less  irritating  to  the  urethra, 
and  less  apt  to  become  covered  with  calculous  incru.s- 
tations  than  silver  tubes  ; they  can  also  be  frequently 
introduced  when  a metallic  one  will  not  pass. 

The  selection  of  good  bougies  and  catheters,  espe- 
cially in  operations  upon  the  male  subject,  is  a business 
of  the  first-rate  importance,'  for  by  employing  such  as 
are  disposed  to  break,  “ many  a practitioner  has  doomed 
his  patient  to  years  of  dreadful  and  perhaps  hopeless 
aufibring,  and  brought  down  irreparable  disgrace  upon 
hiaown  head.”— (A/erf.  Chir^  Journ  vol.  5.  p.  7.5.)  M. 


Nicod,  in  performing  the  operation  of  lithotomy  tipon 
a male,  found  the  stone,  which  was  very  brittle,  one 
inch  and  a half  long,  and  eight  or  nine  lines  thick,  tra- 
versed in  the  direction  of  its  greater  diameter,  by  a 
piece  of  elastic  gum  catheter,  which  had  acted  as  a 
nucleus  for  the  deposition  of  calcareous  matter. — (See 
Obs.  sur  le  danger  iT employer  de  mauvaises  sondes  de 
gomme  dastique ; Joum.  de  Mtdecine,  par  Leroux, 
Oct.  1816.) 

Formerly,  the  best  elastic  catheters  used  to  be  fabri- 
cated at  Paris  ; but  such  as  are  new  made  in  London 
are  in  some  respects  better  than  French,  being  gene 
rally  much  smoother  and  more  regular,  though  I be- 
lieve our  smallest  size  is  not  yet  so  .small  as  theirs. 
The  gum  catheters  made  at  Paris  are  of  twelve  differ- 
ent sizes,  wliich  correspond  to  twelve  holes  in  a plate 
of  brass.  “ Each  catheter,  therefore  (says  a late  intel- 
ligent visiter  to  that  capital),  has  its  size  designated  by 
its  number,  which  greatly  facilitates  the  ascertaining 
of  the  progress  of  the  case  towards  a cure.  Numbers 
1 and  2 are  smaller  than  can  be  procured  in  England, 
and  are  so  slender  that  I thought  there  might  be  dan- 
ger of  their  breaking  until  I was  convinced,  by  seeing 
the  method  of  making  them,  that  there  is  no  reason  for 
fearing  any  such  thing.  A firm  tissue  of  silk  is  woven 
upon  a brass  stilet,  of  the  size  of  the  cavity  of  the  in- 
strument to  be  made.  In  weaving  this  tissue,  the  ori- 
fice or  eye  is  left,  and  the  whole  therefore  consists  of 
one  entire  thread.  The  successive  layers  of  varnish 
are  deposited  on  the  outer  surface  of  the  silken  tissue, 
their  number  depending  on  the  size  of  the  instrument ; 
and  each  coating  of  varnishing  undergoes  a long  pro- 
cess of  scouring  before  the  next  is  put  on,  for  which 
purpose  women  are  employed  by  Feburier.” — (See 
Sketches  of  the  Medical  Schools  of  Paris,  by  J.  Cross, 
1815,;?.  122, 123.) 

According  to  this  gentleman,  however,  the  English 
gum  catheters  po.ssess  advantages  ; “ they  retain  their 
curve  better  without  the  stilet,  are  less  liable  to  crack, 
and  have  eyes  more  smooth  and  better  formed.”— (P. 
124.)  . 

When  the  object  of  passing  a catheter  is  merely  to 
empty  the  bladder,  without  any  design  of  leaving  the 
instrument  afterward  in  its  passage,  Langenbeck  al- 
ways prefers  an  inflexible  one  made  of  silver.— (Bift/, 
fur  die  Chir.  b.  l,p.  1176.) 

Sometimes  spasm  about  the  perinaeum  renders  the 
introduction  of  a catheter  difficult.  In  this  case,  a do.se 
of  opium  should  be  administered  before  a second  at- 
tempt is  made.  When  inflammation  prevails  in  the 
passage,  the  introduction  may  often  be  facilitated  by  a 
previous  bleeding. 

The  operation  of  introducing  the  catheter  may  be 
performed  either  when  the  patient  is  standing  up,  sit- 
ting, or  lying  down,  which  last  posture  is  the  most  fa- 
vourable. In  order  to  pass  a catheter  with  ease  and 
dexterity,  the  following  circumstances  must  be  ob- 
served : the  instrument  must  be  of  suitable  shape  and 
size : a just  idea  of  the  perinaeum  and  curvature  of  the 
urethra  must  be  entertained  ; the  catheSf  must  be  in- 
troduced with  the  greatest  care  and  delicacy ; and  the 
relaxation  of  the  abdominal  muscles  has  been  insisted 
upon  {Langenbeck,  Bibl.  1,  p.  1177),  though  I confess 
that  it  does  not  appear  to  me  how  this  circumstance  ie 
of  importance. 

One  of  the  most  important  maxims  is,  never  to  force 
forward  the  instrument  when  it  is  stopped  by  any  ob- 
stacle. If  there  are  no  strictures,  the  stoppage  of 
the  catheter  is  always  owing  to  one  of  the  following 
circumstances.  Its  beak  may  be  pushed  against  the 
os  pubis.  Tliis  cliiefly  occurs  when  the  handle  of  the 
instrument  is  prematurely  depressed.  Here  the  em- 
ployment of  force  can  obviously  do  no  good,  and  may 
be  productive  of  serious  mischief.  The  beak  of  the 
catheter  may  take  a wrong  direction,  and  push  against 
the  side  of  the  urethra,  especially  at  its  membranous 
part,  which  it  may  dilate  into  a kind  of  pouch.  In 
this  circumstance,  if  force  were  exerted,  it  would  cer- 
tainly lacerate  the  urethra,  and  occasion  a false  pas- 
sage. The  end  of  the  catheter  may  be  entangled  in  a 
fold  of  the  lining  of  the  urethra,  and  here  force  would 
be  equally  wrong.  Lastly,  the  point  of  the  instrument 
may  be  stopped  by  the  prostate  gland,  in  which  ca.se 
force  can  be  of  no  service,  and  may  do  great  harm. 
Hence  it  is  alw  ays  proper  to  w'itlidraw  the  instrument 
a little,  and  then  push  it  on  gently  in  aditTerent  position. 

There  are  two  methods  of  introihicing  a male  ca^lv^' 


CATHETER. 


277 


ter,  viz.,  with  the  concavity  turned  towards  the  abdo- 
men, or  with  the  concavity  directed  downwards,  in  tiie 
lirst  stage  of  the  operation.  Of  course,  the  latter  plan 
requires  the  instrument  to  be  turned  so  as  to  place  its 
concavity  upwards,  as  soon  as  the  beak  has  arrived  in 
the  perinaeum  ; and  hence  the  French  surgeons  call  this 
method  the  “ tour  de  maitre.”  This  method  is  disap- 
proved of  by  some  practitioners,  who  prefer  beginning 
the  operation  in  corpulent  persons  with  the  handle  of 
the  catheter  placed  towards  the  left  groin.— (See  Che- 
lius,  Handb.  der  Chir.  b.  2,  p.  158,  Heidelb.  1827.) 

The  operation  may  be  divided  into  three  stages.  In 
the  first,  the  catheter  passes,  in  the  male  subject,  that 
portion  of  the  urethra  which  is  surrounded  by  the  cor- 
pus spongiosum,;  in  the  second,  it  passes  the  membra- 
nous part  of  the  canal,  situated  between  the  bulb  and 
the  prostate  gland ; and  in  the  third,  it  enters  the  gland 
and  the  neck  of  the  bladder. 

In  the  first  stage,  little  trouble  is  usually  experienced ; 
for  the  canal  is  here  so  supported  by  the  surrounding 
corpus  spongiosum,  that  it  cannot  easily  be  pushed  into 
the  form  of  a pouch,  in  which  the  end  of  the  instru- 
ment can  be  entangled. 

When  the  catheter  is  to  be  introduced  with  its  con- 
cavity towards  the  abdomen,  and  the  patient  is  in  the 
recumbent  posture,  the  thighs  are  to  be  separated,  and 
the  legs  moderately  bent.  The  surgeon  is  to  draw 
back  the  prepuce,  and  to  hold  the  penis  between  the 
thumb  and  fore-finger  of  his  left  hand,  which  are  to  be 
applied  on  each  side  of  the  corona  glandis,  and  not  at 
all  to  the  under  surface  of  the  penis,  so  as  to  avoid 
pressing  upon  the  commencement  of  the  urethra. 
After  the  catheter  has  been  well  oiled,  its  handle  is  to 
be  held  between  the  thumb  and  fore-finger  of  the  right 
hand,  and  to  rest  with  the  back  of  the  little  finger  upon 
the  patient’s  abdomen,  in  the  vicinity  of  the  navel. 
Now,  while  the  handle  is  parallel  to  the  axis  of  the 
body,  the  beak  is  to  be  introduced  into  the  urethra ; the 
penis  being  extended  and  drawn  forwards,  as  it  were, 
over  the  instrument,  while  the  latter  is  gently  pushed 
on  until  its  beak  has  reached  the  arch  of  the  pubes. 
Wlien  the  penis  cannot  be  drawn  farther  over  the  ca- 
theter, the  beak  has  arrived  in  this  situation,  where  it 
stops  in  front  of  the  arch,  and  is  pressing  against  the 
posterior  side  of  the  urethra.  At  this  particular  moment, 
the  handle  is  to  be  depressed  towards  the  patient’s 
thighs,  and  the  manoeuvre  well  managed  generally  di- 
rects the  end  of  the  catheter  at  once  through  the  pros- 
tatic portion  of  the  urethra  into  the  cavity  of  the  blad- 
der. In  short,  as  soon  as  the  beak  of  the  instrument 
has  passed  under  the  arch  of  the  pubes,  and  the  sur- 
geon very  slowly  brings  the  handle  forwards  or  down- 
wards, the  beak  is  elevated  and  glides  into  the  bladder. 
In  this  stage  of  the  operation,  the  penis  must  be  al- 
lowexi  to  sink  down,  and  not  be  kept  tense,  as  this 
would  only  render  the  passage  of  the  instrument  more 
difficult. 

The  operation,  however,  is  not  always  successfully 
accomplished  in  this  manner.  The  beak  of  the  cathe- 
ter may  be  slopped  by  the  os  pubis ; it  may  take  a 
wrong  direction,  so  as  to  push  the  membranous  part 
of  the  urethra  to  one  side  or  the  other ; or  it  may  be 
stopped  by  a fold  of  the  lining  of  the  passage. 

The  first  kind  of  impediment  is  best  avoided  by  not 
depressing  the  handle  of  the  catheter  too  soon  ; that  is, 
before  the  point  has  passed  beyond  the  arch  of  the 
pubes.  When  the  membranous  part  of  the  urethra  is 
pushed  to  one  side  or  the  other,  the  instrument  ought 
to  be  withdrawn  a lUtle,  and  then  pushed  gently  on  in 
a different  direction  ; but  if  this  expedient  is  unavail- 
ing, the  index  finger  of  the  left  hand  may  be  introduced 
into  the  rectum,  for  the  purpose  of  supporting  the  mem- 
branous part  of  the  urethra,  and  guiding  the  extremity 
of  the  catheter.  The  passage  of  the  catheter  through 
the  membranous  part  of  the  urethra,  and  e.speciatly 
the  attempt  to  hit  the  entrance  of  the  prostate,  are  the 
most  difficult  things  in  the  operation,  and  also  the  only 
ones  attended  with  risk  of  mischief,  which  is  fre- 
quently produced  by  rough,  unskilful  surgeons  when 
they  u.se  violence,  and  rupture  this  yielding,  weak  por- 
tion of  the  canal. 

When  the  prostate  gland  is  enlarged,  the  urethra,  just 
aa  it  approaches  the  bladder,  makes  a more  sudden 
turn  upwards  than  is  natural.  The  end  of  the  cathe- 
ter, therefore,  should  be  more  bent  upwards  than  in 
(Other  cases. 

In  the  third  stage  of  the  operation,  the  beak  of  the 


instrument  has  to  pass  the  prostate  gland  and  neck  of 
the  bladder.  The  principal  obstacles  to  its  passage  in 
this  situation  arise  from  spasm  of  the  neck  of  the 
bladder  and  muscles  in  the  perinsurn,  and  from  the  in- 
strument being  pushed  against  the  prostate  gland,  in- 
stead of  into  the  continuation  of  the  urethra  through 
it.  The  first  impediment  may  generally  be  obviated 
by  waiting  a few  moments,  and  gently  rubbing  the 
perinaeum,  before  attempting  to  push  the  catheter  far- 
ther into  the  passage.  The  hinderance  caused  by  the 
prostate  is  best  eluded  by  using  an  instrument  the 
point  of  which  is  more  curved  than  its  other  part. 
Sometimes  the  surgeon  himself  presses  the  prostate 
towards  the  os  pubis,  by  means  of  his  finger  in  the 
rectum,  and  thus  prevents  the  passage  of  the  catheter, 
by  increasing  the-  sudden  curvature  at  this  part  of  the 
urethra.  Hence,  as  Richter  observes,  it  is  a very  im- 
portant maxim,  never  to  introduce  the  finger  so  far 
into  the  rectum  as  to  press  on  the  prostate  gland  itself. 

When  the  catheter  has  turned  round  the  pubes,  and 
is  just  about  to  enter  the  neck  of  the  bladder,  is  the 
critical  moment  at  which  may  be  seen  whether  a sur- 
geon can  or  cannot  manage  the  operation  with  skill ; 
for  if  he  knows  how  to  pass  the  instrument,  he  sud- 
denly, but  not  violently,  changes  its  direction.  He  de- 
presses the  handle  with  a particular  kind  of  address, 
and  raises  the  point,  which,  as  if  it  had  suddenly  sur- 
mounted some  obstacle,  starts  into  the  neck  of  the 
bladder,  and  the  urine  bursts  out  in  a jet  from  the 
mouth  of  the  catheter. 

They  who  are  unskilful  press  the  tube  forwards,  and 
persist,  as  they  first  began,  in  drawing  up  the  penis,  on 
the  supposition  that  by  stretching  this  part,  they 
lengthen  the  urethra  and  make  it  straight,  whereas 
they  elongate  only  that  part  of  the  canal  into  which  the 
catheter  has  already  passed. — {John  Bell’s  Principles 
of  Surgery,  vol.  2,  p.  213.) 

When  the  catheter  is  to  be  introduced  with  its  con- 
cavity downwards,  or  by  the  “ tour  de  maitre,”  the 
beak  is  to  be  passed  into  the  urethra,  and  the  penis 
drawn  over  it,  as  it  were,  as  in  the  foregoing  method. 
In  other  words,  the  instrument,  well  oiled,  is  to  be  in- 
troduced, w'ith  its  convexity  uppermost,  as  far  as  it  can 
be  without  using  force.  As  soon,  however,  as  the  end 
of  the  catheter  has  reached  the  point  at  which  the  ca- 
nal begins  to  form  a curve  under  the  pubes,  the  sur- 
geon is  to  make  the  penis  and  the  instrument  perform 
a simicircular  movement,  by  inclining  them  towards 
the  right  groin,  and  then  towards  the  abdomen.  In  the 
execution  of  this  manceuvre,  care  is  to  be  taken  to 
keep  the  beak  of  the  catheter  stationary,  so  that  it  may 
be  the  centre  of  the  movement,  and  simply  revolve 
upon  itself.  This  part  of  the  operation,  the  object  of 
which  is  to  turn  the  concavity  of  the  catheter  upwards, 
ought  to  be  done  very  slowly,  a large  sweep  being 
made  with  the  handle,  while  particular  care  is  taken 
not  to  retract  nor  move  the  beak  from  its  position. 
The  handle  is  then  to  be  depressed,  and  the  operation 
finished  exactly  in  the  same  manner  as  when  the  first 
plan  is  pursued.  As  Desault  properly  observes,  the 
only  circumstance  in  which  the  two  methods  differ  is, 
that  in  one  the  same  thing  is  performed  by  two  move- 
ments, which  is  done  in  the  other  by  one ; so  that 
the  operation  is  rendered  more  difficult  and  painful. 
Hence,  many  judicious  modern  surgeons  never  prac- 
tice the  “ tour  de  maitre,”  except  when  their  patients 
are  very  corpulent,  or  placed  in  the  position  usually 
chosen  for  lithotomy,  when  other  modes  of  introducing 
the  catheter  would  be  less  convenient. 

The  depth  to  which  the  catheter  has  entered,  the 
cessation  of  any  feeling  of  resistance  to  the  motidns 
of  the  beak  when  revolved  upon  its  axis,  and  the  issue 
of  the  urine,  are  the  circumstances  by  which  the  sur- 
geon knows  that  the  instrument  has  passed  into  the 
bladder. 

According  to  the  experience  of  Desault,  the  practice 
of  gradually  letting  out  a part  of  the  urine,  after  the 
catheter  has  been  introduced,  is  by  no  means  advan- 
tageous. He  also  disapproves  of  running  into  the  oppo- 
site extreme,  that  is  to  say,  of  letting  the  urine  flow 
out  of  the  catheter  as  fast  as  it  is  secreted ; for  then 
the  bladder  is  kept  constantly  relaxed,  and  the  detrusor 
muscle  will  not  be  likely  to  recover  its  tone.  When 
the  bladder  is  continually  empty,  it  is  liable  to  come 
into  contact  with  the  end  of  the  catheter  ; a circum- 
stance which  has  sometimes  caused  considerable  irri- 
tation, pain,  and  even  ulceration  of  that  viscua.  Be- 


278 


CATHETER. 


sides  these  inconveniences  there  are  some  others  ; the 
catheter  is  sooner  obstructed  with  mucus,  and  covered 
with  incrustations,  than  when  it  is  closed  with  the 
etilet.  The  patients  are  likewise  obliged  to  remain  in 
bed,  where  they  are  either  wet  with  their  urine,  or 
compelled  to  have  incessantly  a pot  for  its  reception. 
The  best  practice,  therefore,  seems  to  be  that  of  letting 
out  all  the  urine  as  soon  as  the  catheter  is  introduced, 
and  then  closing  the  instrument  until  the  bladder  has 
become  moderately  distended  again;  for  experience 
proves,  that  such  moderate  distention  and  relaxation  of 
the  muscular  fibres  of  the  bladder,  alternately  kept  up, 
have  the  same  good  effects  upon  that  organ  as  mode- 
rate exercise  has  upon  other  parts  of  the  body  When 
a catheter  is  to  be  left  in  the  urethra,  it  should  always 
be  properly  fixed  with  a narrow  piece  of  tape,  or  else 
it  is  apt  to  slip  out,  or  even  pass  too  far  into  the  pas- 
sage. For  this  purpose,  some  surgeons  use  cotton 
thread,  which  they  fasten  to  the  rings,  or  round  the 
external  end  of  the  catheter.  The  two  extremities  of 
the  thread  are  then  carried  some  way  along, the  dor- 
sum of  the  penis,  when  they  are  tied  together,  and 
afterward  conveyed  in  opposite  directions  round  the 
part  till  they  meet  underneath  it,  where  they  are  tied 
in  a bow.  When  a silver  catheter  is  employed,  a tape 
or  narrow  riband  is  passed  through  each  of  the  rings, 
and  conveyed  to  each  side  of  the  pelvis,  where  it  is 
fastened  to  a circular  bandage.  Mr.  Hunter  remarks, 
that  the  common  bag-truss  for  the  scrotum  answers 
extremely  well,  when  two  or  three  rings  are  fixed  on 
each  side  of  it  along  the  side  of  the  scrotum,  and  the  ring 
of  the  cannula  is  fastened  to  any  of  them  with  a piece 
of  tape.— (O/i  the  Venereal  Disease,  ed.  2,  p.  159.)  He 
also  notices  another  method  ; when  the  catheter  (says 
he)  is  fairly  in  the  bladder,  the  outer  end  is  rather  in- 
clined downwards  nearly  in  a line  with  the  body.  To 
keep  it  in  this  position,  we  may  take  the  common  strap 
or  belt  part  of  a bag-truss  with  two  thigh  straps,  ei- 
ther fixed  to  it  or  hooked  to  it,  and  coming  round  each 
thigh  forwards  by  the  side  of  the  scrotum,  to  be  fast- 
ened to  the  belt,  where  the  ears  of  the  bag  are  usually 
fixed.  A small  ring  or  two  may  be  fixed  to  each  strap 
just  where  it  passes  the  scrotum  or  root  of  the  penis ; 
and  with  a piece  of  small  tape  the  ends  of  the  catheter 
may  be  fixed  to  those  rings,  which  will  keep  it  in  the 
bladder.  It  seems  Mr.  Hunter  did  not,  like  Desault, 
disapprove  of  leaving  the  catheter  unclothed,  and  he 
adds,  therefore,  “ a bit  of  rag  about  four  or  five  inches 
long,  with  a hole  at  the  end  of  it,  passed  over  the  ex- 
terior end  of  the  catheter,  and  the  loose  end  allowed  to 
hang  in  a basin  placed  between  the  thighs,  will  catch 
the  water,  which  cannot  disengage  itself  from  the  ca- 
theter, and  keep  the  patient  dry ; or  if  another  pipe  is 
introduced  into  the  catheter,  it  will  answer  the  same 
purpose.” — (Op.  cit.p.  191.)  The  following,  which  is 
the  French  method  of  retaining  the  catheter  in  the 
bladder,  is  the  most  convenient  with  which  I am  ac- 
quainted : “ A metallic  ring,  the  circumference  of 
which  should  be  more  than  sufficient  to  encircle  the 
penis,  is  to  be  covered  with  cloth,  and  four  long  pieces 
of  tape,  with  the  same  number  of  short  ones,  attached 
to  it.  This  ring,  enclosing  the  penis,  is  fixed  against 
the  pubes  by  the  long  pieces  of  tape,  which,  surround- 
ing the  pelvis  in  different  directions,  meet  and  are  tied 
posteriorly.  One  of  the  short  pieces  is  carried  through 
the  ring  or  round  the  groove  of  the  catheter,  on  each 
side,  and  being  tied  to  its  fellow,  fixes  the  instrument 
securely  in  the  bladder.”--  -(See  AverilVs  Operative  Sur- 
gery, p.  195.)  But  there  are  numerous  modes  of  fixing  a 
catheter  which  need  not  be  specified ; for  although 
they  are  of  importance,  the  principles  which  should  be 
observed  in  adopting  them  are  the  main  things  to  be 
understood.  These  are,  first,  never  to  fix  a catheter 
in  such  a way,  that  too  much  of  the  instrument  pro- 
jects into  the  cavity  of  the  bladder  (Lallemand,  Per- 
foration de  la  Vessie  par  les  Sondes  fixes  ; Revue  MH. 
Nov.  1822,  p.  299) ; and  secondly,  to  be  careful  that 
the  thread  or  tape  which  is  applied  will  not  chafe  and 
irritate  the  parts. 

Mr,  Hey  has  offered  some  good  practical  remarks  on 
the  introduction  of  the  catheter.  If,  says  he,  the  point 
of  the  catheter  be  less  turned  up  than  the  urethra,  the 
point  will  be  pushed  against  the  posterior  part  of  the 
passage,  instead  of  following  the  course  of  the  canal. 
The  posterior  part  of  the  urethra  has  nothing  contigu- 
ous to  it  which  can  support  it ; and  no  considerable 
degree  of  force  will  push  the  point  of  the  catheter 


through  that  part  between  the  bladder  and  the  rectum. 
If  this  accident  is  avoided,  still  the  point  will  be 
pushed  against  the  prostate,  and  cannot  enter  the  blad- 
der. Mr.  Hey  tells  us,  that  the  truth  of  this  is  illus- 
trated by  the  assistance  which  is  derived,  whenever 
the  catheter  stops  at  the  prostate,  from  elevating  the 
point  of  the  instrument  with  a finger  introduced  into 
the  rectum. 

Mr.  Hey  takes  notice  of  the  impropriety  of  pushing 
forwards  the  point  of  the  catheter  before  its  handle  is 
sufficiently  depressed,  as  the  point  would  move  in  a 
horizontal  direction,  and  be  likely  to  rupture  the  poste- 
rior side  of  the  urethra. 

The  difficulty  arising  from  the  inflamed  and  dry  state 
of  the  passage  (w^hich  difficulty  I should  conceive  can 
never  be  great),  Mr.  Hey  says,  may  be  obviated  by  the 
previous  introduction  of  a bougie  well  covered  with 
lard. 

In  order  to  pass  the  catheter.  Hr.  Hey  places  his  pa- 
tient on  a bed,  in  a recumbent  posture,  his  breech  ad- 
vancing to,  or  projecting  a little  beyond,  the  edge  of  the 
bed.  If  the  patient’s  ffeet  cannot  rest  upon  the  floor, 
Mr.  Hey  supports  the  right  leg  by  a stool  or  by  the 
hand  of  an  assistant.  The  patient’s  head  and  shoul- 
ders are  elevated  by  pillows  ; but  the  lower  part  of  the 
abdomen  is  left  in  a horizontal  position.  Mr.  Hey 
commonly  introduces  the  catheter  with  its  convexity 
towards  the  abdomen,  and  having  gently  pushed  down 
the  point  of  the  instrument,  till  it  becomes  stopped  by 
the  curvature  of  the  urethra,  under  the  symphysis  pu- 
bis, he  turns  the  handle  towards  the  navel,  pressing  at 
the  same  time  its  point.  In  making  the  turn  he  some- 
times keeps  the  handle  at  the  same  distance  from  the 
patient’s  abdomen,  and  sometimes  makes  it  gradually 
recede;  but  in  either  method,  he  avoids  pushing  for- 
wards the  point  of  the  catheter  any  farther  than  is  ne- 
cessary to  carry  it  just  beyond  the  angle  of  the  sym- 
physis pubis.  When  he  feels  that  the  point  is  beyond 
that  part,  he  pulls  the  catheter  gently  towards  him, 
hooking,  as  it  w'ere,  the  point  of  the  instrument  upon 
the  pubes.  He  then  depresses  the  handle,  making  it 
describe  a portion  of  a circle,  the  centre  of  which  is 
the  angle  of  the  pubis.  When  the  handle  of  the  ca- 
theter is  brought  into  a horizontal  position,  with  the 
concave  side  of  the  instrument  upwards,  he  pushes 
forwards  the  point,  keeping  it  close  to  the  interior  sur- 
face of  the  symphysis  pubis  ; for  when  passing  in  this 
direction  it  will  not  hitch  upon  the  prostate  gland,  nor 
injure  the  membranous  part  of  the  urethra. 

If  the  surgeon  uses  a flexible  catheter,  covered  with 
elastic  gum,  it  is  of  great  consequence  to  have  the  stilet 
made  of  some  firm  metSllic  substance,  and  of  a proper 
thickness.  Mr.  Hey  always  makes  use  of  brass  wire 
for  the  purpose.  If  the  stilet  is  too  slender,  the  catheter 
will  not  preserve  the  same  curvature  during  the  ope- 
ration ; and  it  will  be  difficult  to  make  the  point  pass 
upwards  behind  the  symphysis  pubis  in  a proper  direc- 
tion. If  the  stilet  is  too  thick,  it  is  withdrawn  with 
difficulty. 

When  the  stilet  is  of  a proper  thickness,  this  instru- 
ment has  one  advantage  over  the  silver  catheter,  which 
is,  that  its  curvature  may  be  increased  while  it  is  in 
the  urethra,  which  is  often  of  great  use  when  the 
point  approaches  the  prostate  gland.  In  all  cases 
where  an  elastic  gum  catheter  is  preferred,  care  must 
be  taken  that  it  does  not  pass  imnecessarily  far  into 
the  bladder ; and,  if  it  be  too  long,  a part  of  it  ought  to 
be  cut  off",  or  a shorter  one  employed. 

In  many  cases  elastic  catheters,  formed  with  a per- 
manent curvature,  so  as  to  admit  of  being  introduced 
without,  a stilet,  are  advantageous. — (jlf.  J.  Chelius, 
Handb.  der  Chirurgie,  b.  2,  p.  \57,  Heidelb.  1827.) 

Wlien  the  proper  manoeuvres  with  a silver  catheter 
do  not  succeed,  the  surgeon  must  change  it,  taking  a 
bigger  or  more  slender  one,  with  a greater  or  less 
curve,  according  to  such  observations  as  he  may  have 
made  in  his  first  attempt.  But  if  the  catheter  has  been 
of  a good  form  or  commodious  size,  yet  has  not  passed 
easily,  he  should,  instead  of  choo.sing  a rigid  catheter 
of  another  size  or  form,  take  a flexible  one  for  his  second 
attempt.  The  flexible  catheter  is  generally  slender, 
and  of  sufficient  length,  and  its  shaiie  may  be  accommo 
dated  to  all  occasions,  and  to  all  forms  of  the  urethra ; 
for,  having  a stiff  wire,  wc  can  give  that  wire,  either 
before  or  after  it  has  passed  into  the  catheter,  what- 
ever shape  we  please ; and  what  is  of  still  greater  im- 
portance, we  can  introduce  the  inswument  without  or 


CATHETER. 


279 


with  the  wire,  as  circumstances  may  require ; or  wliat 
as  more  advantageous,  we  can  introduce  the  wire  par- 
ticularly so  as  not  quite  to  reach  the  point  of  the  cathe- 
ter, but  only  to  within  two  inches  or  a little  more  of 
this  part,  by  which  contrivance  the  point,  if  previously 
warmed  and  wrought  in  the  hand,  has  so  much  elasti- 
city, that  it  follows  the  precise  curve  of  the  urethra, 
and  yet  has  sufficient  rigidity  to  surmount  any  slight 
resistance.  If  this  too  fail,  and  especially  if  there  be 
the  slightest  reason  to  suspect  that  the  resistance  is  not 
merely  spasmodic,  but  arises  from  stricture  near  the 
neck  of  the  bladder  in  a young  man,  or  swelling  of  the 
prostate  in  an  old  one,  we  may  take  a small  bougie, 
ttirn  up  the  extremity  of  it  with  the  finger  and  thumb, 
so  as  to  make  it  incline  towards  the  pubes,  and  allow- 
ing no  time  for  the  wax  to  be  softened,  pass  it  quickly 
down  to  the  obstruction,  turn  it  with  a vertical  or 
twisting  motion,  and  make  it  enter  the  constricted  part. 
On  withdrawing  it  in  about  ten  minutes  or  a quarter 
of  an  hour,  the  urine  generally  escapes,  or  the  catheter 
may  now  be  introduced. — {John  Bell's  Principles  of 
Surgery,  vol.  2,  215.) 

Mr.  Hey  found,  that  in  withdrawing  the  stilet  of  an 
elastic  gum  catheter,  the  instrument  becomes  more 
curved  ; and  he  availed  himself  of  this  information  by 
withdrawing  the  stilet,  as  he  introduced  the  catheter 
beyond  the  arch  of  the  pubes,  by  which  artifice  the 
point  was  raised  in  the  due  direction.  He  says,  you 
may  sometimes,  though  not  always,  succeed  in  intro- 
ducing an  elastic  gum  catheter,  by  using  one  which 
has  acquired  a considerable  degree  of  curvature  and 
firmness  by  having  had  a curved  stilet  kept  in  it  a long 
while.  Introduce  this  without  the  stilet,  with  its  con- 
cavity towards  the  abdomen,  taking  care  not  to  push 
on  the  point  of  the  instrument,  after  it  has  reached  the 
symphysis  pubis,  until  its  handle  is  depressed  into  a 
horizontal  position. 

When  it  is  necessary  to  draw  off  the  urine  frequently, 
and  the  surgeon  cannot  attend  often  enough  for  this 
purpose,  a catheter  must  be  left  in  the  urethra  till  an 
attendant  or  the  i)atient  himself  has  learned  the  mode 
of  introducing  the  instrument. 

Mr.  Hey  imputes  the  formation  of  a false  passage, 
or  the  rupture  of  the  membranous  part  of  the  urethra, 
genereilly  to  the  method  of  pushing  forwards  the  cathe- 
ter before  its  handle  has  been  depressed.  In  this  man- 
ner, the  course  of  the  instrument  crosses  that  of  the 
urethra,  and  the  point  of  the  catheter,  pressing  against 
the  posterior  side  of  the  membranous  part  of  the  urethra, 
is  easily  forced  through  the  coats  of  that  canal.  The 
want  of  due  curvature  in  the  catheter,  and  of  sufficient 
bluntness  in  its  point,  greatly  contributes  to  facilitate 
the  injury.  When  it  has  once  happened,  the  point  of 
the  instrument  passes  more  readily  into  the  wound, 
than  along  the  urethra  against  the  symphysis  pubis  ; 
and  a great  deal  of  skill  is  requisite  to  prevent  this  dis- 
advantageous occurrence  from  repeatedly  taking  place, 
and  rendering  the  case  more  and  more  serious. 

Mr.  Hey  surmounted  a difficulty  of  this  kind,  by 
bending  upwards  the  point  of  a silver  catheter,  so  as  to 
keep  it  more  closely  in  contact  with  the  anterior  part 
of  the  urethra,  and  thereby  pass  over  the  w^ound  made 
in  the  posterior  side  of  the  canal.  In  the  instance  al- 
luded to,  as  it  was  necessary  to  leave  an  elastic  gum 
catheter  in  the  urethra,  Mr.  Hey  procured  some  brass 
wire  of  a proper  thickness,  with  which  he  made  a stilet, 
and  having  given  it  the  same  curvature  as  that  of  the 
silver  catheter,  he  introduced  it  about  four  hours  after 
the  preceding  operation,  and  fixed  it  by  tying  it  to  a 
bag-truss.  Mr.  Hey  sometimes  succeeded  by  partly 
writhdrawing  the  stilet  at  the  moment  when  he  wished 
to  increase  the  curvature  of  the  catheter. 

In  an  instance  in  which  the  urethra  had  suffered  a 
violent  contusion,  Mr.  Hey  drew  off  the  urine  with  a 
silver  catheter  of  unusual  thickness,  after  he  had  failed 
with  instruments  of  a smaller  bore.  He  suspected  that  I 
the  urethra  was  ruptured,  and  was  obliged  to  raise  the 
point  of  the  catheter  by  a finger  introduced  into  the 
rectum,  and  to  use  bleeding,  purgatives,  the  wurm 
bath,  and  opium  before  it  could  be  made  to  pass.  The 
elastic  gum  catheter  was  afterward  employed.  It  is  an 
unsettled  point,  whether  it  is  best  to  leave  the  catheter 
in  the  urethra  until  the  power  of  expelling  the  urine  is 
regained,  or  to  draw  off  the  urine  twice  a day,  and 
withdraw  the  catheter  after  each  operation.  Mr.  Hey 
thinks  that  no  general  rule  can  be  laid  down  ; some 
iwtients  cannot  bear  the  catheter  to  remain  introduced;  i 


others  seem  to  suffer  no  inconvenience  from  it.  On  the 
whole,  however,  Mr.  Hey  commonly  prefers  removing 
the  catheter.  In  this  manner,  he  is  of  opinion,  that 
the  power  of  expelling  the  urine  again  is  soonest  ac- 
quired. 

The  preceding  question  is  often  determined  by  the 
nature  of  the  disease,  and,  as  Mr.  Hunter  observes,  in 
cases  of  debility  of  the  bladder,  and  where  a catheter 
passes  with  difficulty,  or  with  great  uncertainty,  as 
well  as  in  other  instances  in  which  it  must  be  used 
frequently  and  for  a length  of  time,  it  will  be  necessary 
to  keep  it  introduced,  so  as  to  allow  the  water  to  pass 
freely  through  it.— (0?i  the  Venereal  Disease,  edit.  2, 
p.  191.) 

In  France,  a conical  silver  catheter  (sonde  conique) 
is  frequently  employed  in  difficult  cases  by  Boyer, 
Roux,  &c.  This  instrument  has  a very  slight  curva- 
ture, and  an  extremity  almost  pointed.  By  force,  regu- 
larly applied,  it  is  introduced  ^to  the  bladder  in  spite 
of  all  opposition.  Care  is  taken  to  keep  it  in  the  cen- 
tre of  the  passage,  and  the  direction  of  its  point  is 
judged  of  by  the  position  of  the  lateral  rings.  The  rule 
mentioned  by  Roux,  for  commencing  the  great  depres- 
sion of  the  outer  extremity  of  the  instrument,  is  when, 
by  the  finger  in  the  rectum,  the  point  can  be  felt  to 
have  reached  the  apex  of  the  prostate.— (See  Sketches 
of  the  Medical  Schools  of  Paris,  by  J.  Cross,  p.  112.) 
In  bad  cases  the  conical  catheter  is  usually  allowed  to 
remain  introduced  three  or  four  days,  and  on  being 
withdrawn,  a small  flexible  gum  catheter  generally 
admits  of  being  used. 

The  forcible  manner  in  which  the  French  surgeons 
employ  the  conical  silver  catheter  must  often  do  great 
and  dangerous  mischief.  Thus,  in  two  examples,  which 
were  witnessed  and  examined  by  Roux  himself  after 
the  decease  of  the  patients,  a false  passage  had  been 
made,  no  flexible  gum  catheter  could  be  passed,  the 
urine  was  effused  in  the  cellular  membrane,  and  the 
parts  were  gangrenous. — (See  p.W&of  the  above  ivork.) 
According  to  the  observation  of  Mr.  Cross,  the  French 
surgeons  employ  the  conical  silver  catheter  with  too 
little  discrimination,  and  “in  their  practice  they  seem 
to  make  no  nice  distinctions  between  impediments  to 
the  flow  of  urine  from  spasm,  irritable  and  inflamed 
state  of  the  canal,  disease  of  the  prostate  gland,  and 
cartilaginous  stricture  of  long  duration.  If  the  conical 
catheter  be  admissible  at  all,  it  is  in  the  last  of  these 
cases,  particularly  when  combined  with  fistula  in  pe- 
rinspo ; and  here  all  surgeons  who  are  familiar  with 
the  treatment  of  diseases  of  the  urethra,  occasionally 
use  means  which  approach  very  closely  to  the  forcing 
method  of  the  French.  I have  heard  of  instances,  in 
which  John  Hunter  employed  great  force  with  the  sil- 
ver catheter,  and  overcame  the  obstruction.  I have 
seen  Mr.  Pearson  (who  generally  treats  strictures  as 
mildly,  and,  I need  hardly  say,  as  successfully  as  any 
man)  take  a steel  sound,  and  pass  it  gradually  and  forci- 
bly on  into  the  bladder,  at  the  same  time  feeling  his 
way,  as  it  were,  by  keeping  one  finger  in  the  rectum  : 
the  relief  of  the  patient,  and  the  ultimate  cure  of  the 
disease,  were  the  results  of  this  practice.” — (P.  118.)  It 
appears  farther,  that  the  conical  silver  catheter  has 
been  used  by  Sir  A.  Cooper.  Without  altogether  con- 
demning the  occasional  employment  of  this  instrument, 
I perfectly  coincide  with  Mr.  Cross,  that  it  is  one  with 
which  young  men,  of  little  caution  and  no  experience, 
may  do  more  harm  in  the  first  few  cases  they  meet 
with,  than  the  rest  of  their  life  will  afford  them  oppor- 
tunities of  doing  good 

Mr.  Hunter  refers  to  instances  in  which  the  com- 
mon catheter  had  been  pushed  through  the  projecting 
part  of  the  prostate  gland  into  the  bladder,  and  the 
water  then  drawn  off;  but,  “ in  one  patient,  the  blood 
from  the  wound  passed  into  the  bladder,  and  increased 
the  quantity  of  matter  in  it.  The  use  of  the  catheter 
I was  attemjjted  a second  time ; but  not  succeeding,  I 
was  sent  for.  I passed  the  catheter  till  it  came  to  a 
stop,  and  then  suspecting  that  this  part  of  the  prostate 
projected  forwards,  I introduced  my  finger  into  the 
anus,  and  found  that  gland  very  much  enlarged.  By 
depressing  the  handle  of  the  catheter,  which  of  course 
raised  the  point,  it  passed  over  the  projection  ; but  un- 
fortunately the  blor)d  had  coagulated  in  the  bladder, 
which  filled  up  the  holes  in  the  catheter,  so  that  I waa 
obliged  to  withdraw  it,  and  clear  it  repeatedly.  Thia 
I ))racti.sed  several  da)  s ; but  suspecting  that  the  co- 
1 agulum  must  in  the  end  kill,  I proposed  cutting  him 


280 


CAU 


CER 


(the  patient)  for  the  stone  ; but  he  diet!  before  it  could 
be  conveniently  done,  and  the  dissection  after  death 
explained  the  case,”  &c. — {On  the  Venereal  Disease, 
ed.  2,  p.  172.) 

To  a surgeon  dulv  acquainted  with  anatomy,  the  in- 
troduction of  the  female  catheter  is  exceedingly  simple. 
From  motives  of  delicacy,  the  instrument  should  be 
passed  without  anj'  exposure.  The  surgeon  should 
hold  the  catheter  in  his  right  hand,  while  he  introduces 
the  fore-finger  of  his  left  hand  between  the  nymphae, 
so  as  to  feel  upon  the  upper  surface  of  the  passage  the 
little  papilla,  w'hich  surrounds,  and  denotes  to  the 
touch  the  precise  situation  of  the  orifice  of  the  meatus 
urinarius.  Holding  the  concavity  of  the  catheter  for- 
wards, the  surgeon,  guided  by  the  fore-finger  of  his  left 
hand,  is  then  to  introduce  the  instrument  upwards  into 
the  bladder.  A female  catheter  should  always  be  fur- 
nished with  some  contrivance  for  preventing  its  slip- 
ping completely  into  the  bladder : the  following  case, 
mentioned  in  a respectable  periodical  work,  fully 
proves  the  truth  of  this  remark : 

Some  years  ago,  a surgeon,  practising  in  the  coun- 
tiy,  was  required  to  introduce  the  catheter  for  a lady 
labouring  under  retention  of  urine.  During  the  opera- 
tion he  was  observed  to  exhibit  signs  of  confusion,  and 
to  quit  his  patient  in  considerable  embarrassment.  The 
same  day  he  abruptly  left  his  home,  and  was  never 
seen  afterward.  The  lady  passed  several  years  of 
dreadful  suflering,  attributed  by  herself  and  the  pro- 
fessional gentleman  on  w'hom  the  treatment  of  the  case 
devolved,  to  aggravation  of  the  original  complaint. 
At  length  an  abscess  presented  itself  in  the  sacral  re- 
gion, and  the  surgeon  punctured  it,  when  his  instru- 
ment came  in  contact  with  some  unusually  hard  sub- 
stance imbedded  in  the  centre  of  the  abscess.  With  a 
pair  of  forceps  he  now  extracted,  to  his  utter  astonish- 
ment, a blackened  female  catheter.  From  this  period 
the  lady’s  sufferings  all  terminated.  A similar  acci- 
dent nearly  happened  in  the  practice  of  another  gentle- 
man.— (See  Urine,  Retention  of.)  See  iledico~Chir. 
Joum.  vol.  5,  p.  75,  Lond.  1818.  J.  Hunter,  Treatise 
on  the  Venereal  Disease,  ed.  2,  in  various  places. 
Hey's  Practical  Obs.  in  Surgery,  ed.  3.  John  BelVs 
Principles,  vol.  2.  Sketches  of  the  Medical  Schools  of 
Paris,  by  J.  Cross,  p.  Ill,  ifrc.  Jos.  M'Sweeny,  Obser- 
vations on  the  Catheter,  Edin.  Med.  and  Surgical 
Joum.  No.  58,  p.  52.  Richter's  Anfangsgr.  der  Wun- 
darzneykunst.  Lnllemand,  Perforation  de  la  Vessie 
par  les  Sondes  fix  s.  Revue  Med.  Nov.  1822.  Langen- 
beck,  Bibl.fur  die  Chir.  b.  l,p.  175,  12mo.  Gbtt.  1806. 
Desault,  LEuvres  Chir.  t.  3.  Amussat,  Archives  Gen. 
de  Med.  t.  4.  Berton,  op.  cit.  Mai,  1826.  The  Obser- 
vations on  the  Catheter,  by  Desault,  Richter,  J.  Hun- 
ter, and  Hey  are  the  best  with  which  I am  acquainted. 

CATLING,  often  spelled  in  surgical  books  catlin,  is 
a long,  narrow,  double-edged,  sharp-pointed,  straight 
knife,  which  is  chiefly  used  in  amputations  of  the  leg 
and  forearm,  for  dividing  the  interosseous  ligaments 
and  the  muscles,  <kc.  situated  between  the  two  bones. 
It  is  frequently  made  too  wide  and  large,  so  that  it 
cannot  execute  its  office  with  the  right  degree  of  ease. 

CAUSTICS.  (From  xaiw,  to  burn.)  Medicines, 
which  destroy  parts  by  burning  or  chemically  decom- 
posing them.  The  potassa  fusa,  the  potassa  cum  ctdce, 
the  antimoninm  muriatum,  the  argenti  nitras,  the  by- 
drargyri  nitrico-oxydum.  the  acidum  sulphuricum,  and 
the  eupri  sulphas,  are  the  caustics  in  most  frequent 
use. 

CAUTERY.  (From  Kaiw,  to  \>um.)  Cauteries  are 
of  two  kinds,  viz.  actual  and  potential.  By  the  first 
term  is  implied  a heated  iron  ; by  the  second,  surgeons 
understand  any  caustic  application. 

The  high  opinion  which  the  ancients  entertained  of 
the  efficacy  of  the  actual  cautery,  may  be  well  con- 
ceived from  the  following  passage.  “ Quoscunique 
morbos  medicamenta  non  sanant,  ferrum  sanat ; quos 
ferrbm  non  sanat,  ignis  sanat ; quos  vero  ignis  non 
sanat,  insanabiles  exislimare  oportet.”— (Hipp.  sect.  8, 
aph.  6.)  The  actual  cautery  has  been  employed  for  the 
stoppage  of  bleeding,  where  the  vessels  could  neither 
be  tied  nor  compressed.  It  has  been  also  employed  for 
the  destruction  of  carcinomatous  tumours  and  ulcers, 
fistulas,  polypi,  and  a variety  of  fungous  diseases. 
Whoever  looks  over  the  writingstof  Hippocrates  wfil 
discover,  that  the  actual  cautery  was  a principal  means 
of  relief  in  several  chronic  afiections,  as  dropsies,  dis- 
eased joints,  &c. 


In  modern  times,  the  actual  cautery  has  been  more 
and  more  relinquished,  in  proportion  as  surgery  has 
attained  a higher  state  of  improvement.  On  the  conti- 
nent, however,  it  still  retains  advocates.  In  France, 
all  the  professors  recommend  and  employ  it  in  particu- 
lar cases.  Hospital  gangrene,  a peculiar  disorder, 
much  more  frequently  seen  in  foreign  and  military 
hospittils  than  in  the  charitable  institutions  for  the 
reception  of  the  sick  poor  in  England,  is  said  to  be 
little  affected  by  any  internal  remedies.  “ Vegetable 
and  diluted  mineral  acids  are  the  local  means  employed 
with  effect  in  mild  cases.  I have  (says  Mr.  Cress)' al- 
ready alluded  to  a case  of  Pelletan’s,  where  carbon 
was  applied,  and  the  progress  of  the  disease  impeded. 
But  the  actual  cautery  is  the  only  means  that  has  been 
found  effectual  in  stopping  the  fatal  progress  of  bad 
cases  of  hospital  ulcer,  and  the  iron  is  applied  red-hot, 
so  as  to  produce  an  eschar  on  eveiy  point  of  the  sur- 
face of  the  sore.” — (See  Sketches  of  the  Medical  Schools 
of  Paris,  p.  84,  and  the  article  Hospital  Gangrene.) 

Desault  often  employed  the  actual  cauterv’  to  destroy 
fungous  tumours  of  the  antrum. — (See  Antrum.)  The 
same  practice  is  still  followed  by  Pelletan  and  other 
eminent  surgeons  in  France.  Mr.  Cross  saw  it  adopted 
in  one  such  case  with  good  effect. — {P.  86.)  That  part 
of  the  fungus  which  can  be  cut  away  is  to  be  so  re- 
moved, and  the  deeper  portion,  out  of  the  reach  of  the 
knife,  is  to  be  cauterized.  If  there  be  any  case  in  sur- 
gery justifying  the  use  of  a red-hot  iron,  it  is  a fungus 
of  the  antrum.  But  even  in  this  instance,  I should 
prefer  any  other  certain  mode  of  destroying  the  root  of 
the  disease,  and  stopping  the  profuse  bleeffing. 

[The  actual  cautery  has  been  found  exceedingly  use- 
ful in  the  treatment  of  the  hip-joint  disease,  though  it 
is  seldom  employed  in  tltis  countiy  for  any  other  pur- 
pose. It  is  not  easy  to  perceive,  however,  in  what 
respects  it  is  to  be  preferred  for  the  formation  of  an 
eschar,  which  is  its  chief  design,  to  the  potassa  fusa, 
or  other  caustics.  Even  in  the  hip-joint  disease,  as 
deep  and  extensive  a destruction  of  the  integument  can 
be  effected  by  some  of  these,  as  by  the  red-hot  iron ; 
without  exciting  that  mental  horror  which  the  latter 
often  produces,  both  in  the  patient  and  friends.  And 
although  the  sloughing  is  not  so  early,  yet  ultimately 
the  effect  is  the  same. 

In  fungus  of  the  antrum,  which,  according  to  Mr. 
Cooper,  is  the  only  case  in  surgery  “ justifying  the 
use  of  the  red-hot*  iron,”  I have  known  the  caustic 
pottish  fully  adequate  for  the  destruction  of  this  dis- 
ease, after  the  operation  with  the  knife ; and  it  always 
arrests  the  hemorrhage  as  suddenly  and  effectually. 

The  use  of  fire  in  surgery  as  an  agent  for  the  pur- 
poses to  which  it  has  been  applied  from  time  immemo- 
rial. has  gradually  fallen  into  disrepute.  But  in  cases 
of  suspended  animation,  or  sudden  injury  to  the  powers 
of  life  from  casualty,  poison,  or  hemorrhage,  in  which 
other  means  fail,  and  yet  a faint  hope  is  indulged  of 
resuscitation,  I apprehend  we  are  perfectly  justifiable 
in  resorting  to  this  potential  agent. 

I have  employed  boiling  water  to  the  extremities  in 
cases  in  which  there  was  no  sign  of  life,  after  hanging, 
and  hemorrhage  from  a wound  in  the  throat,  and 
poisoning  with  opium,  and  in  each  of  these  have  met 
with  entire  success,  although  other  means  offered  no 
hope  whatever.  The  actual  cautery  applied  to  the  ex- 
tremities in  like  manner,  had  this  been  convenient, 
would  doubtless  have  produced  the  same  result. 

In  these  and  other  cases  of  suspended  animation,  in 
which  the  signs  of  death,  although  present,  are  equivo- 
cal, it  may  often  be  advisable  to  try  this  means,  for  if 
any  portion  of  vitality  remain,  fire  will  find  it,  and 
other  appropriate  means  may  be  then  superadded.  I 
believe  resuscitation  might  often  be  effected  by  this 
agent,  when  other  remedial  agents  are  unsuccessful. 
See  article  Moxa  in  this  Dictionary,  for  the  farther  u.se 
of  fire.  Dr.  Cogswell,  of  Hartford,  recommends  the 
use  of  boiling  water  instead  of  cantharides,  where  ve- 
sication is  important,  and  where  an  immediate  effect 
is  desirable. — K/ v.^e.J 

CERATOTOME.  (From  sipai,  a horn,  and  rinvw, 
to  cut.)  The  name  given  by  Wenzel  to  the  knife 
with  w hich  he  divided  the  cornea,  or  homy  coat  of  the 
eye. 

CERATUM  CALAMINiE.  (L.)  A good  simide 
dressing. 

CERATI  M CANTH.\RID18,  (T..)  lately  called  the 
cerate  of  lyttffi,  was  once  much  used  for  stimulaiiug 


CHE 


CHI 


281 


blistered  surfaces,  in  order  to  maintain  a discharge. 
The  ceratum  sabinae,  however,  which  answers  much 
better,  and  is  not  attended  with  danger  of  bringing  on 
strangury,  inflammation  of  the  bladder,  &c.,  has  almost 
superseded  the  ceratum  cantharidis. 

CERATUM  CETACEI.  (L.)  The  spermaceti  ce- 
rate. A mild,  unirritaiing  salve  for  common  purposes. 

CERATUM  CONII.  R.  Unguenti  conii 
Unguentum.)  Cetacei  |ij.  CercealbcB  ^iij.  M.  One 
of  the  formulae  at  St.  Bartholomew’s  Hospital,  occa- 
sionally applied  to  cancerous,  scrofulous,  and  phage- 
daenic  sores. 

CERATUM  HYDRARGYRI  SUBMURIATIS.  R. 
Hydrarg.  submuriatis  3 i.  Cerati  lapid.  calamin. 
5 ss.  M.  Some  practitioners  are  partial  to  this  as  a 
dressing  for  chancres. 

CERATUM  PLUMBI  ACETATIS.  (L.)  A mild, 
astringent,  unirritating  salve. 

CERATUM  PLUMBI  COMPOSITUM.  (L.)  An 
excellent  gently  astringent  salve  for  common  pur- 

pOS6S 

CERATUM  SABIN.dE.  R.  Sabinae  foliorum  re- 
centium  contiLsorum  Ibj.  Cerae  Jlavae  Ibss.  Adipis 
praeparatae,  tbij.  Mix  the  savin  with  the  melted  wax 
and  hog’s  lard,  and  strain  the  composition. 

The  common  application  for  keeping  open  blisters, 
on  the  plan  recommended  by  Mr.  Crowther.— (See 
Blisters.) 

CERATUM  SAPONIS.  R.  Plumbi  oxydi  semi- 
vitrei  lib.  j.  Aceti  cong.  j.  Saponis  unc.  viij.  Olei 
olivae,  cerae  Jlavce,  sing.  lib.  j. 

The  soap  cerate  of  St.  Bartholomew’s  Hospital.  In 
preparing  it,  the  utmost  caution  must  be  used.  The 
first  three  ingredients  are  to  be  mixed  together  and 
boiled  gently  till  all  the  moisture  is  evaporated  ; after 
which  the  wax  and  oil,  previously  melted  together, 
must  be  added.  The  whole  composition,  from  first  to 
last,  must  be  incessantly  and  eflectually  stirred,  with- 
out which  the  whole  will  be  spoiled.  This  formula 
was  introduced  into  practice  by  Mr.  Pott,  and  is  found 
to  be  a very  convenient  application  for  fractures  and 
sometimes  a good  dressing  for  ulcers;  being  of  a con- 
venient degree  of  adhesiveness,  and  at  the  same  time 
possessing  the  usual  properties  of  a saturnine  remedy. 

In  applying  this  cerate,  spread  on  linen,  to  frac- 
tures of  the  leg  or  arm,  one  caution  is  necessary  to  be 
observed,  namely,  that  it  be  in  two  distinct  pieces ; 
for  if,  in  one  piece,  the  limb  be  encircled  by  it,  and  the 
ends  overlap  each  other,  it  will  form  a very  indbnve- 
nient  and  partial  constriction  of  the  fractured  part,  in 
consequence  of  the  subsequent  tumefaction.— (P/iam. 
Chirurg.) 

CERU'MEN  AURIS.  A degree  of  deafness  is  fre- 
quently produced  by  the  lodgement  of  hard  dry  pellets 
of  this  substance  in  the  meatus  auditorius.  The  best 
plan,  in  such  cases,  is  to  syringe  the  ear  with  warm 
water,  which  should  be  injected  with  moderate  force. 

In  some  instances,  deaf^ness  seems  to  depend  on  a 
defective  secretion  of  the  cerumen,  and  a consequent 
dryness  of  the  meatus.  Here,  a drop  or  two  of  sweet 
oil  may  now  and  then  be  introduced  into  the  ear,  and 
fomentations  applied. 

CERUSSA  ACETATA.  Sugar  of  lead.  Superace- 
tate of  lead.  This  preparation  is  well  known  as  an 
ingredient  in  a variety  of  lotions  and  collyria.  It  has 
the  qualities  of  preparations  of  lead  in  general,  being 
highly  useful  in  diminishing  inflammation. 

CHALAZIUM.  (From  xoAu^a,  a hailstone.)  A lit- 
tle tubercle  on  the  eyelid,  which  has  been  whimsically 
supposed  to  resemble  a hailstone.  When  the  hordeo- 
lum or  stye  does  not  suppurate,  but  changes  into  a 
hard  fleshy  tumour,  it  receives  this  appellation.— (See 
Hordeolum.) 

CHAMOMILE.  The  flowers,  which  are  bitter  and 
aromatic,  are  used  in  surgery  for  making  fomenta- 
tions. 

(JHANCRE.  (From  KaoKivog,  cancer  venereus.)  A 
sore  which  arises  from  the  direct  application  of  the 
venereal  poison  to  any  part  of  the  body.  Of  course  it 
almost  always  occurs  on  the  genitals.  Such  venereal 
sores  as  break  out  from  a general  contamination  of  the 
system,  in  consequence  of  absorption,  never  have  the 
term  chancre  applied  to  them.  {For  an  account  of  the 
nature  and  treatment  of  chancres,  see  Venereal  Dis- 
ease. ) 

CHRMOSIS.  (From  xalcw,  to  gape.)  When  oph- 
Bialrny  or  inflammation  of  the  eye  is  exceedingly  vio- 


lent, it  frequently  happens,  that  IjTinph  or  blood  is 
effused  in  the  cellular  membrane,  which  connects  the 
conjunctiva  with  the  anterior  hemisphere  of  the  eye. 
Hence,  the  latter  membrane  is  gradually  elevated  upon 
the  eyeball,  and  projects  towards  the  eyelids,  so  as  to 
conceal  within  it  the  cornea,  which  appears  as  if  it 
were  depressed.  In  this  way  the  middle  of  the  eye 
assumes  the  appearance  of  a gap  or  aperture. 

It  is  observed  by  Mr.  R.  Welbank,  that  inflammatory 
chemosis  is  generally  dependent  on  the  fungous  swell- 
ing of  the  mucous  tissue,  but  that  it  may  also  partly 
arise  from  effusion.  He  notices  a very  firm,  but  pale 
chemosis,  as  occasionally  produced  by  effusion,  and 
resembling  a solid  cedema,  or  fat.  In  one  case  of  this 
sort  which  fell  under  his  own  observation,  there  were 
numerous  white  aphthae  on  the  mucous  surface. — (See 
FVick  on  Diseases  of  the  Eye,  note,  p.  15.) 

The  time  has  exjtired  when  surgeons  had  faith  in 
the  application  of  the  vapour  of  ether,  or  of  an  inspis- 
sated decoction  of  the  lactuca  sissilis,  to  ah  inflamed 
eye,  for  the  relief  of  chemosis,  as  recommended  by  the 
late  Mr.  Ware.  In  this  kind  of  case,  more  benefit  will 
result  from  general  treatment  than  from  any  local 
measures.  I here  particularly  refer  to  the  inflamma- 
tory chemosis  ; for,  in  certain  chronic  cases,  like  that 
spoken  of  by  Mr.  Welbank,  topical  remedies  may  un- 
doubtedly promote  the  cure. 

Acute  ophthalmy,  attended  with  chemosis,  demands 
the  most  rigorous  employment  of  the  antiphlogistic 
treatment.  Both  general  and  topical  bleeding  should 
be  speedily  and  copiously  put  in  practice,  with  due  re- 
gard, however,'  to  the  age  and  strength  of  the  patient. 
Leeches  should  be  applied  to  the  vicinity  of  the  eyelids ; 
or,  what  is  preferable,  the  temporal  artery  should  be 
opened.  When  chemosis  is  very  considerable,  Scarpa 
approves  of  making  an  incision  in  the  conjunctiva, 
near  its  junction  with  the  cornea,  for  the  discharge  of 
the  lymph  or  blood  lodged  under  the  distended  mem- 
brane.— (See  Ophthalmy.) 

CHEVASTER,  or  Cheva'stre.  A double-headed 
roller,  the  middle  of  which  was  applied  to  the  chin  ; 
the  bandage  then  crossed  at  the  top  of  the  head,  and 
passed  on  each  side  to  the  nape  of  the  neck,  where  it 
crossed  again.  It  was  next  carried  up  to  the  top  of 
the  head,  and  so  on,  till  all  the  roller  was  exhausted. 

CHIA'STRE.  A bandage  for  stopping  hemorrhage 
from  the  temporal  artery.  It  is  double-headed,  about 
an  inch  and  a half  wide,  and  four  ells  long.  Its  middle 
is  applied  to  the  opposite  side  of  the  head : the  bandage 
is  carried  round  to  the  bleeding  temple,  and  there 
made  to  cross  over  a compress  on  the  wound.  The 
roller  is  then  continued  over  the  coronal  suture,  and 
under  the  chin,  care  being  taken  to  make  the  bandage 
cross  upon  the  compress.  In  this  way,  the  rest  of  it 
is  applied  round  the  head. 

CHILBLAINS  are  the  effect  of  inflammation  arising 
from  cold.  A chilbljiin,  in  its  mildest  form,  is  attended 
with  a moderate  redness  of  the  skin,  a sensation  of 
heat  and  itching,  and  more  or  less  swelling,  which , 
symptoms,  after  a time,  spontaneously  disappear.  The 
intolerable  itching  and  sense  of  tingling,  accompanying 
the  inflammation  of  the  milder  description  of  chilblains, 
are  observed  to  be  seriously  aggravated  by  exposure  to 
heat.  In  a more  violent  degree,  the  swelling  is  larger, 
redder,  and  sometimes  of  a dark-blue  colour ; and  the 
heat,  itching,  and  pain  are  so  excessive,  that  the  pa- 
tient cannot  use  the  part.  In  the  third  degree,  small 
vesicles  arise  upon  the  tumour,  which  burst  and  leave 
excoriations.  These  often  change  into  ill-conditioned 
sores,  which  sometimes  penetrate  even  as  deeply  as  the 
bone,  discharge  a thin  ichorous  matter,  and  generally 
prove  very  obstinate.  As  Dr.  John  Thomson  has  re- 
marked, “when  the  serum  contained  in  the  vesica 
tions  is  let  out  by  a small  opening,  a portion  of  new 
cuticle  is  usually  formed  to  supply  the  place  of  that 
which  has  been  separated;  but  when  the  inflamma- 
tion is  severe,  and  the  affection  neglected,  or  improperly 
treated,  the  parts  which  are  the  seat  of  vesication  are 
liable  to  pass  into  the  state  of  vitiated  ulcers.  In  this 
state,  they  yield  a thin  ichorous  or  sanious  discharge, 
and  are  in  general  brought,  only  after  a long  time,  and 
with  much  difliculty,  to  a healthy  suppuration.  In 
neglected  cases,  these  ulcers  not  unfrcquently  become 
covered  with  foul  sloughs.  Ulceration  often  super- 
venes, and  the  soft  parts  covering  the  bones  are  de- 
stroyed.”— (On  Injlammatkm,  p.  f)38.)  Tlie  worst 
stage  of  chilblains  is  attended  with  sloughing. 


282 


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CIC 


Chilblains  are  particularly  apt  to  occur  in  persons 
who  are  in  the  habit  of  going  immediately  to  the  fire, 
when  they  come  home  in  winter,  with  their  fingers  and 
toes  very  cold  ; they  are  also  frequent  in  persons  who 
often  go  suddenly  into  the  cold,  while  very  warm. 
Hence  the  disease  most  commonly  affects  parts  of  the 
body  which  are  peculiarly  exposed  to  these  sudden 
transitions ; for  instance,  the  nose,  ears,  lips,  toes,  heels, 
and  fingers.  Richter  remarks  that  they  are  still  more 
frequently  occasioned  when  the  part,  suddenly  exposed 
to  cold,  is  in  a moist,  perspiring  state,  as  well  as  warm. 
Young  subjects  are  much  more  liable  to  this  trouble- 
some complaint  than  adults  ; and  females  brought  up  in 
a delicate  manner  are  generally  more  afflicted  than  the 
other  sex. 

Tile  most  likely  plan  of  preventing  chilblains  is  to 
accustom  the  skin  to  moderate  friction;  to  avoid  hot 
rooms  and  making  the  parts  too  warm ; to  adapt  the 
quantity  and  kind  of  clothing  to  the  state  of  the  constitu- 
tion, so  as  to  avoid  extremes,  both  in  summer  and  win- 
ter ; to  wash  the  parts  frequently  with  cold  water ; to 
take  regular  exercise  in  the  open  air  in  all  weathers ; 
and  to  take  particular  care  not  to  go  suddenly  into  a 
warm  room,  or  very  near  the  fire,  out  of  the  cold  air. 

Although  chilblains  of  the  milder  kinds  are  only  local 
inflammations,  yet  they  have  some  peculiarity  in  them ; 
for  they  are  not  most  benefited  by  the  same  antiphlogis- 
tic applications  wliich  are  most  eflTectual  in  the  relief  of 
inflammation  in  general. 

One  of  the  best  modes  of  curing  chilblains  of  the 
milder  kind  is  to  rub  them  with  snow,  or  ice-cold  wa- 
ter, or  to  bathe  them  in  the  latter  several  times  a day, 
keeping  them  immersed  each  time  till  the  pain  and  itch- 
ing abate.  After  the  parts  have  been  rubbed  or  bathed 
in  this  way,  they  should  be  well  dried  with  a towel,  and 
covered  with  flannel  or  leather  socks. 

This  plan  is  perhaps  as  good  a one  as  any ; but  it  is  not 
that  which  is  always  congenial  to  the  feelings  and  ca- 
price of  patients  ; and  with  the  constitutions  of  some  it 
may  even  disagree.  In  such  cases,  the  parts  agitated 
may  be  rubbed  with  spirits  of  wine,  liniinentum  sapo- 
Bis,  a mixture  of  tincture  of  opium  and  hartshorn,  tinc- 
tura  myrrhae,  or  a strong  solution  of  alum  or  vinegar. 
A mixture  of  oleum  terebinthinae  and  balsamum  co- 
paibae,  in  equal  parts,  is  a celebrated  application.  A 
mixture  of  two  parts  of  camphorated  spirit  of  wine,  and 
one  of  the  liquor  plumbi  subacetatis,  has/  also  been 
praised.  Mr.  Wardrop  speaks  highly  of  one  part  of  the 
tincture  of  cantharides,  with  six  of  the  soap  hnunent. — 
{Medico~Chir.  Trarts.  vol.  5,p.  142.) 

With  respect  to  vesications,  their  occurrence  is  al- 
ways hastened,  and  the  inflammation  upon  which  they 
depend  greatly  aggravated,  by  the  action  of  external  heat ; 
and  hence  the  propriety  of  continuing  cold  applications 
to  frost-bitten  parts,  so  long  as  their  temperature  conti- 
nues above  the  natural  standard,  or  the  inflammation 
excited  seems  to  retain  an  acute  character.  From  the 
tendency  which  the  inflammation  excited  has  to  pass 
into  gangrene,  the  more  stimulating  applications,  such 
as  spirit  of  wine,  diluted  ammonia,  or  oil  of  turpentine, 
may  be  required.  But  should  these  applications  prove 
too  stimulating,  their  strength  may  be  weakened  by  ad- 
ditions of  greater  or  less  portions  of  the  liiiimentum  ex 
aqua  calcis. — {Thomson  on  Inflammation,  p.  648.) 

When  chilblains  suppurate  and  ulcerate,  they  require 
stimulating  dressings,  such  as  lint  dipped  m a mixture 
of  the  liquor  plumbi  subacetaiis  dilutus,  and  liquor  cal- 
cis ; tinctura  myrrhee,  or  warm  vuiegar.  If  a salve  be 
employed,  one  which  contains  the  hydrargyri  nitrico- 
oxydura,  or  the  ungueiitum  zinci  with  myrrh,  camphor, 
opium,  or  the  Peruvian  balsam,  will  be  found  most  be- 
neficial. Ulcers  of  this  kind  frequently  require  to  be 
touched  with  the  nitrate  of  silver,  or  dressed  wuth  a so- 
lution of  it. 

Chilblains,  attended  with  sloughing,  should  be  poul- 
ticed till  the  dead  parts  are  detached.  The  sores  should 
then  be  first  dressed  with  some  mildly  stimulating  oint- 
ment, such  as  the  unguentum  resin®  flav®,  or  unguen- 
tum  zinci.  With  the  first  of  these,  in  a day  or  two,  a 
little  of  the  hydrargyri  nitrico-oxydum  may  be  mixed  ; 
but  the  surgeon  should  not  venture  on  the  employment 
of  very  irritating  applications,  till  he  sees  what  the 
parts  will  bear,  and  whether  such  will  be  requisite  at 
ail ; for  were  he  too  bold,  immediately  he  leaves  off  the 
poultices,  he  might  bring  on  sloughing  again. 

Rees's  CydopcBdia,  art.  Chilblains.  Richter's  An- 
fa/ig.<!^r.  d-:r  Wundarm.  b.  1.  Thomson's  Lectures  on 


Inflammation,  p.  637,  Src.  Lassus,  Patholope  Cht- 
rurg.  t.  2,  p.  388,  Src.  Leveille,  Nouvelle  Doctrine  Chir. 
t.  4,  p.  352,  it  c.  Callisen's  Sy sterna  Chirurgice  Hodier- 
TUB,  vol.  1,  p.  304,  it-c.  ed.  1798.  Psarson's  Principles  of 
Surgery,  p.  153,  <S-c.  ed.  1808.  M.  J.  Chelius,  Handb. 
der  Chir.  b.  1,  p.  72.  Heidelb.  1826. 

CHIMNEY-SWEEPER’S  CANCER.  See  Scrotum. 

CHORDEE.  (French,  from  xopdi),  a cord.)  When 
inflammation  is  not  confined  merely  to  the  surface  of  the 
urethra,  but  affects  the  corpus  spongiosum,  it  produces 
in  it  an  extravasation  of  coagulable  lyunph,  as  in  the  ad- 
hesive inflammation,  which,  uniting  the  cells  together, 
destroys  the  power  of  distention  of  the  corpus  spongio- 
sum urethr®,  and  makes  it  unequal  in  this  respect  to 
the  corpora  cavernosa  penis,  and  therefore  a curvature 
takes  place  at  the  time  of  an  erection,  which  is  called  a 
chordee.  The  curvature  is  generally  in  the  lower  part 
of  the  penis.  When  the  chordee  is  violent,  the  inner 
membrane  of  the  urethra  is  so  much  upon  the  stretch, 
that  it  may  be  torn,  and  a profuse  bleeding  from  the  ure- 
thra excited,  that  often  relieves  the  patient,  and  even 
sometimes  proves  a cure. 

This  is  the  inflammatory  chordee : there  is  another 
kind,  which  has  been  named  spasmodic. 

In  the  beginning  of  the  inflammatory  chordee,  bleed- 
ing from  the  arm  is  often  of  service ; but  it  is  more  im- 
mediately useful  to  take  blood  from  the  part  itself  by 
leeches  ; for  we  often  find  that  when  a vessel  gives  way, 
and  bleeds  a good  deal,  the  patient  is  greatly  relieved. 
Exposing  the  penis  to  the  steam  of  hot  water  frequently 
gives  great  relief.  Poultices  have  also  beneficial  effects ; 
and  both  fomentations  and  poultices  will  often  do  most 
good  when  they  contain  camphor.  Opium,  given  inter- 
nally, is  of  singular  service ; and  if  it  be  joined  with 
camphor,  the  effect  will  be  still  greater. 

When  the  chordee  continues  after  all  uiflammation 
has  terminated,  no  evacuations  are  required ; for  the 
consequences  of  the  inflammation  will  gradually  cease 
on  the  absorption  of  the  extravasated  coagulating  lymph. 
Mercurial  ointment,  rubbed  on  the  part,  will  consider- 
ably promote  this  event.  When  the  common  methods 
of  cure  aj-e  unavailing,  hemlock  is  sometimes  very  use- 
ful. Electricity  may  be  of  service.  A chordee  is'  often 
longer  in  going'off  than  any  other  consequence  of  a go- 
norrhoea, but  in  the  end  it  disappears. 

For  bringing  about  the  removal  of  the  extravasated 
lymph,  camphorated  mercurial  ointment  is  better  than 
the  simple  unguentum  hydrargyri.  According  to  Mr. 
Hunter,  the  spasmodic  chordee  is  much  benefited  by 
bark. — (See  his  Treatise  on  the  Venereal  Disease,  ed.  2.) 
The  recent  leaves  of  belladonna,  powdered  and  made 
into  an  ointment  with  an  equal  weight  of  lard,  and  rub- 
bed over  the  penis,  are  stated  to  hinder  priapism,  and 
relieve  chordee  more  effectually  than  any  other  applica- 
tion hitherto  ppoposed. — (J.  A.  Paris,  in  Pharmacolo- 
gia,  vol.  2,  p.  110,  ed.  5.) 

Last  summer  (1828)  I attended,  with  Dr.  Langmore, 
of  King  Street,  Finsbury,  and  Mr  Holt,  of  Compton 
Street,  Brunswick  Square,  a gentleman  attacked  with 
gonorrhoea,  w'hose  case  was  remarkable  on  account  of 
the  situation  and  quantity  of  the  effused  lymph  ; for  it 
occupied  the  portion  of  the  corpus  spongiosum  towards 
the  glans,  and  produced  so  considerable  a swelling  and 
pressure  on  the  corresponding  portion  of  the  urethra, 
that  the  patient  required  the  use  of  a catheter  for  nearly 
a fortnight,  as  well  as  the  most  active  antiphlogistic 
treatment.  The  irritability  of  the  bladder,  without  the 
power  of  emptjing  it ; the  suffering  from  tenesmus ; 
and  the  high  degree  of  fever,  made  this  really  a very- 
severe  case,  demanding  the  utmost  attention.  I have 
never  seen  any  other  instance  in  which  the  effused 
lymph  was  half  so  copious. 

CICATRIX.  A scar:  the  mark  left  after  the  healing 
of  a wound  or  ulcer. 

CICATRIZATION.  The  process  by  which  w'ounds 
and  sores  heal.  Granulations  having  been  formed,  the 
next  object  of  nature  is  to  cover  them  with  skin.  The 
parts  which  had  receded  by  their  natural  elasticity,  in 
consequence  of  the  breach  made  in  them,  now  begin  to 
be  brought  together  by  the  contraction  of  the  granula- 
tions. The  contraction  takes  place  at  every  point,  but 
principally  from  edge  to  edge,  bringing  the  circumference 
towards  the  centre  of  the  sore,  which  thus  becomes 
smaller  and  smaller,  even  although  httle  or  no  new  skin 
be  formed. 

The  contracting  tendency  is  in  some  degree  propor- 
tioned to  the  general  healing  disposition  of  the  sore,  and 


CIC 


283 


looseness  of  the  parts.  When  granulations  are  formed 
upon  a fixed  surface,  their  contraction  is  mechanically 
impeded;  as  for  instance  on  the  skull,  the  shin,  &c. 
Hence,  in  all  operations  on  such  parts,  as  much  skin 
should  be  saved  as  possible. 

The  shape  of  a sore,  as  well  as  its  situation,  makes 
also  a considerable  difference  in  its  readiness  to  heal ; 
thus,  as  Sir  Astley  Cooper  has  remarked,  a sore  of  a cir- 
cular form,  cateris  paribus,  will  be  longer  in  cicatrizing 
than  another  of  much  greater  length  but  less  diameter. 
— (Lancet,  vol.  1,  p.  225.) 

When  there  has  been  a loss  of  substance,  making  a 
hollow  sore,  and  the  contraction  of  the  granulations  has 
begun,  and  made  a good  deal  of  progress,  before  they 
have  had  time  to  rise  as  high  as  the  skin,  then  the 
edges  of  the  skin  are  generally  drawn  down,  and  tucked 
in  by  it,  in  the  hollow  direction  of  the  surface  of  the  sore. 

The  contraction  of  the  granulations  continues  till  the 
healing  is  complete ; but  it  is  greatest  at  first.  That 
there  is  a mechanical  resistance  to  such  contraction,  is 
proved  by  the  assistance  wliich  may  be  given  to  the 
process  by  the  application  of  a bandage. 

Besides  the  contractile  power  of  the  granulations, 
there  is  also  a similar  power  in  the  surrounding  edge 
of  the  cicatrizing  skin,  which  assists  the  contraction  of 
the  granulations,  and  is  generally  more  considerable 
than  that  of  the  granulations  themselves,  dravihng  the 
mouth  of  the  wound  together  like  a purse.  The  con- 
tractile power  of  the  skin  is  confined  principally  to  the 
very  edge  where  it  is  cicatrizing,  and,  as  Hunter  be- 
lieved, to  those  very  granulations  which  have  already 
cicatrized;  for  the  natural  or  original  skin  surrounding 
this  edge  does  not  contract,  or  at  least  not  nearly  so 
much,  as  appears  by  its  having  been  thrown  into  folds 
and  plaits,  while  the  new  skin  is  smooth  and  shining. 

The  uses  of  the  contraction  of  granulations  are  vari- 
ous. It  facilitates  the  healing  of  a sore,  as  there  are  two 
operations  going  on  at  the  same  time,  viz.  contraction 
and  skinning. 

It  avoids  the  formation  of  much  new  skin,  the  advan- 
tage of  which  is  evident ; for  it  is  with  the  skin  as  with 
all  other  parts  of  the  body,  viz.  that  such  as  are  origin- 
ally formed  are  much  fitter  for  the  purposes  of  life  than 
those  which  are’  newly  formed,  and  not  nearly  so  liable 
to  ulceratiotL 

When  the  whole  surface  of  a sore  has  skinned  over, 
the  substance,  the  remains  of  the  granulations  on  which 
the  new  skin  is  formed,  still  continues  to  contract,  till 
hardly  any  thing  more  is  left  than  what  the  new  skin 
stands  upon.  This  is  a very  small  part,  in  comparison 
with  the  first  formed  granulations,  and  it  in  time  loses 
most  of  its  apparent  vessels,  becoming  white  and  liga- 
mentous. All  newly  healed  sores  are  at  first  redder 
than  the  common  skin,  but  in  time  they  become  much 
whiter. 

As  the  granulations  contract,  the  surrounding  old 
skin  is  stretched  to  cover  the  part  which  is  deprived  of 
skin. 

When  a sore  begins  to  heal,  the  surrounding  old 
skin,  close  to  the  granulations,  becomes  smooth,  and 
rounded  with  a whitish  cast,  as  if  covered  with  some- 
thing white.  This,  Mr.  Hunter  supposed  to  be  a be- 
ginning cuticle,  and  it  is  as  early  and  sure  a symptom 
of  healing  as  any.  While  the  sore  retain.?  its  red  edge 
all  round,  for  perhaps  a quarter  or  half  an  inch  in 
breadth,  we  may  be  certain  that  it  is  not  in  a healing 
state. 

Skin  is  a very  different  substance,  with  respect  to 
texture,  from  the  granulations  upon  which  it  is  formed ; 
but  it  is  not  known  whether  it  is  a new  substance 
formed  by  the  granulations  or  a change  in  the  surface 
of  the  granulations  themselves. 

The  new  skin  most  commonly  takes  its  rise  from  the 
surrounding  old  skin,  as  if  elongated  from  it ; but,  ac- 
cording to  Mr.  Hunter,  not  always.  In  very  large  sores, 
but  principally  old  ulcers,  in  which  the  edges  of  the 
surrounding  skin  have  but  little  tendency  to  contract, 
and  the  cellular  membrane  underneath  to  yield,  or  the 
old  skin  to  become  drawn  over  the  ulcerated  surface, 
the  nearest  granulations  do  not  acquire  a cicatrizing 
disposition.  In  such  ca-ses,  new  skin  forms  in  different 
parts  of  the  ulcer,  standing  on  the  surface  of  the  gra- 
nulations like  little  islands. 

'I'his  power  of  the  centre  of  a sore  to  form  new  skin, 
however,  is  not  universally  admitted ; and  while  Sir 
Astley  Cooper  acknowledges  the  fact  of  insulated  por- 
tion.? of  skin  being  sometimes  seen  in  the  nruddle  of 


CIN 

sores,  he  maintains,  that  such  appearance  is  produced  in 
consequence  of  the  whole  of  the  skin  not  having  been 
destroyed  by  ulceration,  and  granulations  having  arisen 
from  the  part  of  the  skin  which  was  left.  This,  he 
says,  only  happens  in  irregularly  formed  sores,  where, 
after  the  healing  process  has  gone  on  to  the  centre,  the 
sore  breaks  out  again  at  the  circumference — (See  Lan- 
cet, vol.  1,  p.  225.) 

Whatever  change  the  granulations  undergo  to  form 
new  skin,  they  are  generally  guided  to  it  by  the  sur- 
rounding skin,  which  gives  this  disposition  to  the  sur- 
face of  the  adjoining  granulations. 

The  new-formed  skin  is  never  so  large  as  the  sore 
was  on  which  it  is  formed,  owing  to  the  contraction  of 
the  granulations,  and  the  yielding  of  the  surrounding 
old  skin.  If  the  sore  is  situated  where  the  adjoining 
skin  is  loose,  as  in  the  scrotum,  then  the  contractile 
power  of  the  granulations  being  quite  free  from  ob- 
struction, a very  little  new  skin  is  formed;  but  if  the 
sore  is  situated  where  the  skin  is  fixed  or  tense,  the 
new  skin  is  nearly  as  large  as  the  sore. 

The  new  skin  is  at  first  commonly  on  the  same  level 
with  the  old.  This,  however,  is  not  the  case  with 
scalds  and  burns,  which  frequently  heal  with  a cicatrix 
higher  than  the  skin,  although  the  granulations  may 
have  been  kept  from  rising  higher  than  this  part. 

The  new-formed  cutis  is  neither  so  yielding  nor  so 
elastic  as  the  original  is ; it  is  also  less  moveable.  It 
gradually  becomes,  however,  more  flexible  and  loose. 
At  first  it  is  very  thin  and  tender,  but  it  afterward  be- 
comes firmer  and  thicker.  It  is  a smooth  continued 
skin,  not  formed  with  those  insensible  indentations 
which  are  observed  in  the  natural  or  original  skin,  and 
by  which  the  latter  admits  of  any  distention  which  the 
cellular  membrane  itself  will  allow  of. 

This  new  cutis,  and  indeed  all  the  substance  which 
had  formerly  been  granulations,  is  not  nearly  so  strong, 
nor  endowed  with  such  lasting  and  proper  actions,  as 
the  originally  formed  parts.  The  living  principle  itself 
is  less  active ; for  when  an  old  sore  breaks  out,  it  con- 
tinues to  yield,  till  almost  the  whole  of  the  new-formed 
matter  has  been  absorbed,  or  has  mortified. 

The  young  cutis  is  extremely  full  of  vessels;  but 
they  afterward  disappear,  and  the  part  becomes  white. 
Hence  the  white  appearance  of  the  cicatrices  or  marks 
of  small-})Ox. 

The  surrounding  old  skin  being  drawn  towards  the 
centre  by  the  contraction  of  the  granulations,  is  thrown 
into  loose  folds,  while  the  new  skin  itself  seems  to  be 
upon  the  stretch,  having  a smooth  shining  appearance. 

The  new  cuticle  is  more  easily  formed  from  the  cutis, 
than  the  cutis  itself  from  granulations.  Every  point  of 
the  surface  i-f  the  cutis  is  concerned  in  forming  cuticle, 
so  that  this  s forming  equally  every  where  at  once  ; but 
the  formation  of  the  cutis  is  principally,  if  not  entirely, 
progressive  from  the  adjoining  skin. 

The  new  cuticle  is  at  first  very  thin,  and  rather  pulpy 
than  horny.  As  it  becomes  stronger,  it  looks  smooth 
and  shining,  and  is  more  transparent  than  the  old  cu- 
ticle. 

The  rete  mucosum  is  later  in  forming  than  the  cuticle, 
and  in  some  cases  never  forms  at  all.  In  blacks,  who 
have  been  wounded  or  blistered,  the  cicatrix  is  a con- 
siderable time  before  it  becomes  dark ; and  in  one 
black  whom  Mr.  Hunter  saw,  the  scar  of  a sore,  which 
had  been  upon  his  leg  when  young,  remained  white 
w'hen  he  was  old.  This  case,  however,  must  have 
been  an  unusual  one ; for  it  is  now  ascertained  that  the 
new  skin  of  a negro  does  not  become  white,  but  is  at 
first  red,  and  after  a little  time  turns  blacker  than  the 
original  skin. — (Sir  A.  Cooper,  Lancet,  vol.  1,  p.  227.) 
According  to  this  gentleman’s  observations,  muscle  and 
cartilage  are  the  only  two  parts  of  the  body  incapable 
of  being  reproduced  in  the  processes  of  cicatrization : 
when  a muscle  is  divided,  it  unites  by  means  of  a ten- 
dinous substance ; and,  except  in  very  young  subjects, 
the  cartilages  of  the  ribs  invariably  unite  with  the  in- 
tervention of  bone.— (Hunter,  On  the  Blood,  Inflamma- 
tion, iS-c.  Thomson's  Lectures  07t  Injlammativn,  p.  3U9, 
.U.) 

CICUTA.  See  Conium  Maculatum. 

CINCHONA.  As  one  of  the  designs  of  this  Diction- 
ary is  to  embrace  the  subjects  of  a surgical  pharmaco- 
peia, Peruvian  bark,  which  is  administered  in  a very 
great  number  of  surgical  cases,  cannot  be  pas.sed  over 
in  silence. 

Its  great  repute  for  its  virtues  in  stopping  mortiflea- 


284 


CINCHONA. 


lions,  and  accelerating  the  separation  of  the  sloughs, 
every  person,  whether  of  the  medical  profession  or 
not,  has  frequently  heard  of.  Indeed,  so  high  is  the 
character  of  the  medicine,  that  many  practitioners  or- 
der it  in  some  stage  or  another  of  almost  every  distem- 
per, often  prescribe  it  when  it  is  totally  useless,  give  it 
Avhen  it  actually  does  harm,  and  make  their  patients 
swallow  such  quantities  as  operate  perniciously,  when 
smaller  doses  would  effect  striking  benefit.  Some  men 
are  credulous  enough  to  think,  that  from  the  Peruvian 
bark  vigour  and  strength  are  directly  extricated  and  in- 
fused into  the  constitution,  in  exact  proportion  to  the 
quantity  of  the  medicine  which  the  stomach  will  keep 
down  and  digest. 

While  a doctrine  of  this  sort  prevails,  we  must  ex- 
pect to  see  indiscriminate  and  erroneous  practice.  The 
generality  of  diseases  will  always  be  attended  with  an 
appearance  of  languor  and  weakness,  and  certainly, 
while  there  exists  a supposition  that  a drug  is  at  hand, 
possessing  the  quality  of  evolving  and  communicating 
strength,  it  would  be  absurd  to  fancy  that  so  important 
an  article  will  not  be  largely  exhibited  in  a multiplicity 
of  surgical  cases.  I shall  not  pre.sume  to  hazard  an 
idea  of  the  powers  of  the  Peruvian  bark  in  the  practice 
of  physic;  but  I have  not  the  least  doubt  that  they 
have  been  unwarrantably  exaggerated  in  surger>',  so  as 
to  blind  and  prejudice  many  a practitioner  of  good  abi- 
lities, and  lead  him  to  adopt  injudicious  and  hurtful  me- 
thods of  treatment. 

Under  particular  circumstances,  bark  has  undoubtedly 
the  quality  of  increasing  the  tone  of  the  digestive  or- 
gans; and,  of  course,  whenever  the  indication  is  to 
strengthen  the  system  by  nourishing  food,  and  the  ap- 
petite fails,  this  medicine  may  prove  of  the  highest  uti- 
lity, provided  it  be  given  in  moderate  doses,  and  it  be 
found  to  agree  with  the  stomach  and  bowels.  But  the 
plan  of  making  the  patient  swallow  as  much  of  it  as 
can  be  got  into  his  stomach,  must,  in  my  opinion,  be 
invariably  followed  by  bad  instead  of  good  effects. 
How  can  it  be  reasonably  expected  that  the  stomach, 
which  is  already  out  of  order,  can  be  set  right  by  hav- 
ing an  immoderate  quantity  of  any  drug  whatever 
forced  into  it  ? In  fact,  if  the  alimentary  canal  were  in 
a healthy  state,  must  not  such  practice  be  likely  to 
throw  it  into  a disordered  condition  1 

Bark  is  an  excellent  medicine  when  judiciously  ad- 
ministered ; but,  like  every  other  good  medicine  in  bad 
hands,  it  may  be  the  means  of  producing  the  worst 
consequences.  How  much  good  does  mercury  effect  in 
an  infinite  number  of  surgical  diseases,  when  prescribed 
By  a surgeon  of  understanding ; what  a poison  it  be- 
comes under  the  direction  of  an  ignorant  practitioner ! 
With  respect  to  cases  of  mortification,  bark  is  often 
most  strongly  indicated  when  the  sloughing  is  not  sur- 
rounded with  active  inflammation,  when  the  patient  is 
•debilitated,  and  his  stomach  cannot  take  nutritious  food. 

I have  always  regarded  the  notion  of  giving  bark  as  a 
-specific  for  gangrene  as  totally  unfounded  and  absurd. 
I have  watched  its  effects  in  these  cases,  and  could 
never  dis-  ern  that  it  had  the  least  peculiar  pow’er  of 
/Operating  directly  upon  the  parts  which  are  distempered. 
Whatever  good  it  does  is  by  its  improving  the  tone  of 
fhe  digestive  organs,  and  making  them  more  capable  of 
conveying  nourishment,  and  of  course  strength  into  the 
constitution. 

I should  feel  myself  guilty  of  a degree  of  presump- 
ion  in  speaking  thus  freely  upon  this  subject,  were  not 
..ny  sentiments  in  some  measure  supported  by  those  of 
certain  surgical  writers,  the  remembrance  of  whom  will 
always  be  hailed  with  unfeigned  veneration  and  esteem. 
Mr.  Samuel  Sharp  was  not  bigoted  to  bark,  and  wlfile 
he  allowed  it  to  possess  a share  of  efficacy,  he  would 
not  admit  that  it  was  capable  of  miraculously  accom- 
plishing every  thing  which  the  ignorant  or  prejudiced 
alleged.  “ i know,”  says  he,  “ it  will  be  looked  upon 
by  many  as  a kind  of  skepticism,  to  doubt  the  efficacy 
of  a remedy  so  well  atte.stcd  by  such  an  infinity  of  cases"; 
and  yet  I shall  frankly  own  I have  never  clearly  to  my 
satisfaction  met  with  any  evident  proofs  of  its  prefer- 
ence to  the  cordial  medicines  usually  prescribed;  though 
I have  a long  a time  made  experiment  of  it  with  a view 
to  search  into  the  truth. 

Perhaps  it  may  seem  strange  thus  to  dispute  a 
doctrine  established  on  what  is  called  matter  of  fact ; 
but  I shall  here  observe,  that  in  the  practice  of  physic 
and  surgery  it  is  often  exceedingly  difficult  to  ascertain 

fact.  Prejudice  or  w'ant  of  abilities  sometimes  mis- 


leads us  in  our  judgment,  where  there  is  evidently  a 
right  and  a wrong ; but  in  certain  cases  to  distinguish 
how  far  the  remedy  and  how  far  nature  operate,  is  pro- 
bably above  our  discernment.  In  gangrenes  particu- 
larly, there  is  frequently  such  a complication  of  un 
known  circiunstances  as  cannot  but  tend  to  deceive  an 
unwary  observer.  Mortifications  arising  from  mere 
cold,  compression,  or  stricture,  generally  cease  upon  re- 
moving the  cause,  and  are,  therefore,  seldom  proper 
cases  for  proving  the  power  of  the  bark.  However, 
there  are  two  kinds  of  gangrene  where  internals  have 
a fairer  trial ; those  are  a spreading  gangrene  from  an 
internal  cause,  and  a spreading  gangrene  from  violent 
external  accidents,  such  as  gun-shot  wounds,  compound 
fractures,  «kc.  Yet  even  hcK  we  cannot  judge  of  their 
effect  w ith  absolute  certainty ; for  sometimes  a morti- 
fication from  internal  causes  is  a kind  of  critical  disor- 
der. There  seems  to  be  a certain  portion  of  the  body 
destined  to  perish,  and  no  more ; of  this  we  have  an  in- 
finity of  examples  brought  into  our  hospitals,  where 
the  gangrene  stops  at  a particular  point  without  the 
least  assistance  from  art.  The  same  thing  happens  in 
the  other  species  of  gangrene  from  violent  accidents, 
where  the  injury  appears  to  be  communicated  to  a cer- 
tain distance  and  no  farther;  though,  by-the-way,  I 
shall  remark  in  this  place,  contrary  to  the  received  opi- 
nion, that  gangrenes  from  these  accidents  (where  there 
has  been  no  previous  straitness  of  bandage)  are  as  often 
fatal  as  those  from  internal  causes. 

As  I have  here  stated  the  fact,  we  see  how  difficult 
it  is  to  ascertain  the  real  efficacy  of  this  medicine ; but 
had  bark  in  any  degree  those  w onderful  effects  in  gan- 
grenes which  it  has  in  periodical  complaints,  its  pre- 
eminence would  no  more  be  doubted  in  the  one  case 
than  in  the  other.  What,  in  my  judgment,  seems  to 
have  raised  its  character  so  high,  are  the  great  numbers 
of  single  observations  published  on  this  subject,  the  au- 
thors of  which,  not  having  frequent  opportunities  of 
seeing  the  issue  of  this  disorder  under  the  use  of  cor- 
dials, &;c.,  and  some  of  them,  perhaps,  prejudiced  with 
the  common  supposition,  that  every  gangrene  is  of  it- 
self mortal,  have  therefore  ascribed  a marvellous  influ- 
ence to  the  bark,  when  the  event  has  proved  success- 
ful.”— (Sharp's  Crit.  Inq.  chap.  8,  <m  Amputation.) 

Some  farther  remarks  on  this  subject  will  be  reserved 
for  the  article  Mortijicatmi. 

According  to  Mr.  Bromfield,  bark  is  a specific  for  old 
ulcers,  where  the  inflammation  seems  circumscribed 
at  the  distance  of  an  inch  round  the  sore,  the  surface 
of  the  ulcer  looks  glossy,  and  the  discharge  is  extremely 
thin  and  very  offensive,  with  little  or  no  sleep  from 
the  violence  of  the  pain.  He  farther  observes,  that  the 
addition  of  opium,  as  circumstances  may  require,  wlU 
often  be  found  necessary. — (Chirurgical  Observations 
and  Cases,  vol.  1,  p.  132.) 

Bark  is  given  so  extensively  in  the  practice  of  sur- 
gery, that  there  are  few  important  cases  in  which,  in 
certain  circumstances,  and  at  some  period  or  another,  it  is 
not  indicated.  When  persons  have  been  weakened  by 
a course  of  mercury,  or  by  the  effects  of  any  disease  what- 
soever, moderate  doses  of  bark  will  frequently  be  found 
of  great  service.  But  it  only  becomes  so  on  the  princi- 
ples above  suggested,  and,  as  far  as  my  judgment  ex- 
tends, this  medicine  should  never  be  prescribed  in  any 
surgical  cases  in  excessive  and  unreasonable  quantities. 

[The  use  of  charcoal,  in  combination  w ith  one-fourth 
part  of  pulverized  myrrh,  is  found  of  essential  service 
as  a tonic  in  the  debility  and  constitutional  irritation 
which  are  induced  in  some  habits  by  the  excessive  use 
I of  mercury,  and  I learn  from  my  friend  Dr.  Francis, 
that  he  has  recently  tested  its  efficacy  to  his  entire  sa- 
tisfaction. In  the  mercurial  sore-throat  of  long  stand- 
ing, it  has  proved  an  effective  remedy,  and  its  use  may 
be  alternated  or  combined  with  bark  and  other  corrobo- 
rants In  fulfilling  the  indications  required  in  the  eczema 
mercuriale.— Reese.] 

The  yellow'  bark,  or  the  cortex  cinchonse  cordifoliae  of 
the  new  pharmacopoeia,  is  said  to  possess  more  efficacy 
than  the  other  kinds.  One  desirable  result  of  the  com- 
plete establishment  of  the  modem  doctrine,  that  the  vir- 
tues of  the  various  kinds  of  cinchona  reside  in  tw'o  sa- 
lifiable bases,  or  alkaline  elements,  termed  cinchonine, 
and  quinine,  is  that  of  being  able  to  prescribe  prepara- 
tions which  will  concentrate  all  the  efficacy  of  the  me- 
dicine in  formulae  of  moderate  bulk,  not  likely  at 
least  to  disorder  the  alimentar>'  canal  by  the  mechanical 
effects  of  quantity. 


CIR 


COL 


28^ 


The  sulphate  of  quinine,  or  quina,  as  Dr.  Paris  terms 
It,  “appears  to  be  the  most  efficient  of  ail  the  salts  of 
bark.  We  must  be  careful  not  to  combine  it  with  sub- 
stances that  form  insoluble  compounds  with  it.  The 
infusum  rosae  comp,  is  objectionable  as  a vehicle,  on  ac- 
count of  the  astringent  matter  wliich  it  contains,  and 
which  therefore  precipitates  the  quina  from  its  solution.” 
The  form  in  wliich  Dr.  Paris  prefers  to  prescribe  it  is 
that  of  solution,  with  a minim  of  sulphuric  acid  to 
every  grain  of  the  sz.\\..—{Pharmacologia,  vol.  2,  p.  163.) 
It  is  frequently  made  into  pills,  with  the  conserve  of 
roses,  or  joined  with  hyosciamus,  squills,  opium,  and 
other  medicines.  Professor  Brande  does  not  agree  with 
Dr.  Paris,  respecting  the  compound  infusion  of  roses 
being  an  unfit  vehicle  for  sulphate  of  quinine,  and  re- 
commends tli^  subjoined  formula;  fit.  Quiniae  sulpha- 
tis  gr.  ij.  Infus.  rosae  comp.  3 xi.  Tinct.  cort.  aurant. 
syrupi  ejusdem  a a 3 ss.  M.  ft.  haustus  bis  in  die  su- 
mendus. 

CINNABAR,  ARTIFICIAL  {Hydrargyri  sulphu- 
return  rubrum),  is  cMefly  employed  by  surgeons  for  fu- 
migating venereal  ulcers.  An  apparatus  is  sold  in  the 
shops  for  this  purpose.  The  powder  is  thrown  upon  a 
heated  iron,  and  the  smoke  is  conducted  by  means  of  a 
tube  to  the  part  affected. 

CIRCUMCISION.  (From  circumcido,  to  cut  round.) 
The  operation  of  cutting  off  a circular  piece  of  the  pre- 
puce, sometimes  practised  in  cases  of  phymosis. — (See 
Phymosis.) 

CIRSOCELE.  (From  Kipcrog,  a varix,  and  X1/X77,  a tu- 
mour.) Cirsocele  is  a varicose  distention  and  enlarge- 
ment of  the  spermatic  vein ; and  whether  considered  on 
account  of  the  pain  which  it  sometimes  occasions,  or  on 
account  of  a wasting  of  the  testicle,  which  now  and 
then  follows,  it  may  truly  be  called  a disease.  It  is  fre- 
quently mistaken  for  a descent  of  a small  portion  of 
omentum.  The  uneasiness  which  it  occasions  is  a dull 
kind  of  pain  in  the  back,  generally  relieved  by  suspen- 
sion of  the  scrotum.  It  has  been  fancied  to  resemble  a 
collection  of  earth-worms ; but  whoever  has  an  idea  of 
a varicose  vessel,  will  not  stand  in  need  of  an  illustra- 
tion by  comparison.  It  is  most  frequently  confined  to 
that  part  of  the  spermatic  process,  which  is  below  the 
opening  in  the  abdominal  tendon ; and  the  vessels  ge- 
nerally become  rather  larger  as  they  approach  the  tes- 
tis. Mr.  Pott  never  knew  good  eflects  arise  from  exter- 
nal applications  of  any  kind. 

In  general  the  testicle  is  perfectly  unconcerned  in, 
and  unaffected  by,  this  disease ; but  it  sometimes  hap- 
pens, that  it  makes  its  appearance  very  suddenly,  and 
with  acute  pain,  requiring  rest  and  ease ; and  sometimes 
after  such  sjuiptoms  have  been  removed,  Mr.  Pott  has 
seen  the  testicle  so  wastd'd  as  hardly  to  be  discernible. 
He  has  also  observed  the  same  effect  from  the  injudi- 
cious application  of  a truss  to  a true  cirsocele ; the  ves- 
sels, by  means  of  the  pressure,  became  enlarged  to  a 
prodigious  size,  but  the  testicle  shrunk  to  almost  no- 
thing.—( Pot<’5  Works,  vol.  2.) 

Morgagni  has  remarked,  that  the  disease  is  more  fre- 
quent in  the  left  than  in  the  right  spermatic  cord ; a 
circumstance  which  he  refers  to  the  left  si)ermatic  vein 
terminating  in  the  renal.— (De  Sedibus  et  Cans.  Morb. 
Epist.  43,  art.  34.) 

Cirsocele  is,  more  frequently  than  any  other  disorder, 
rnistaken  for  an  omental  hernia.  As  Sir  Astley  Cooper 
'ernarks,  when  large  it  dilates  upon  coughing ; and  it 
Ewells  in  an  erect,  and  retires  in  a recumbent  posture 
of  the  body.  There  is  only  one  sure  method  of  distin- 
guishing the  two  complaints : place  the  patient  in  a ho- 
rizontal posture,  and  empty  the  swelling  by  pressure 
upon  the  scrotum;  then  put  the  fingers  firmly  upon  the 
upper  part  of  the  abdominal  ring,  and  desire  the  patient 
to  rise : if  it  is  a hernia,  the  tumour  cannot  reappear,  as 
long  as  the  pressure  is  continued  at  the  ring ; but  if  a 
cirsocele,  the  swelling  returns  with  increased  size,  on 
account  of  the  return  of  blood  into  the  abdomen  being 
prevented  by  the  pressure. — {A.  Cooper  on  Inguinal 
Hernia.) 

Cirsocele  can,  for  the  most  part,  only  be  palliated,  and 
seldom  radically  cured.  When  the  complaint  is  at- 
tended with  pain,  cold  saturnine  and  alum  lotions  may 
be  applied  to  the  testicle  and  spermatic  cord.  At  the 
same  time,  blood  should  be  repeatedly  taken  away  by 
means  of  leeches ; the  bowels  should  be  kept  gently 
open ; the  patient  should  be  placed  in  a horizontal  pos- 
ture, and  the  testicle  should  be  supported  in  a bag- 
tnws. 


In  general,  the  patient  only  finds  it  necessary  to  keep 
up  the  testicle  with  this  kind  of  suspensory  bandage. 

[I  learn  from  Dr.  H.  G.  Jameson,  of  Baltimore,  that  he 
has  been  favoured  with  singular  success  in  treating  cir- 
socele, by  tying  the  .spermatic  artery.  He  has  thus 
proved  that  tliis  painful  and  disagreeable  disease  may 
be  radically  cured  by  this  simple  operation.  The  first 
public  account  I can  find  of  this  operation,  is  that  per- 
formed by  Dr.  J.  in  1821,  and  published  in  the  Arn.  Med. 
Recorder  for  1825.  He  reports,  that  in  neither  of  the 
cases  in  which  tlus  operation  was  performed,  did  the 
patient  suffer  in  the  integrity  of  the  testis,  nor,  so  far  as 
could  be  ascertained,  did  the  ligature  interfere  with  the 
important  functions  of  that  organ,  although  both  these 
effects  had  been  feared,  and  even  predicted. 

Dr.  Stephen  Brown,  of  New-York,  has  succeeded  In 
curing  varicocele  by  a similar  operation,  viz.  tying  the 
spermatic  vein.  Although  no  evil  consequences  resulted 
in  this  case  from  the  ligature,  yet,  after  the  facts  before 
the  profession,  of  the  dangerous  and  fatal  results  of 
tying  the  veins,  the  propriety  of  performing  this  opera- 
tion for  the  cure  of  varicocele  may  be  justly  questioned, 
unless  in  cases  of  so  much  suffering  and  danger  as  to 
warrant  this  hazard.— (See  N.  Y.  Med.  and  Phys.  Jour- 
nalfor  1824.)— Reci-e.] 

Gooch  and  other  writers  have  related  cases  of  cir- 
socele, in  which  the  pain  was  so  intolerable  and  incura- 
ble, that  nothing  but  castration  could  afford  the  patient 
any  relief.— (7.  A.  Murray  de  Cirsocele,  Upsal,  1784.. 
Pott  on  Hydrocele,  A-c.  Richter  in  Nov.  Comment, 
Goett.  No.  4,  and  in  Obs.  Chir.  Ease.  2,  p.  22.  Gooch,- 
Chir.  Works.  Most,  Diss.  de  Cirsocele,  Halos,  1796.) 

CIRSOPHTHALMIA.  (From  Kipaos,  a varix,  and 
6(pdaXpdi,  the  eye.)  A general  varicose  affection  of  the 
blood-vessels  of  the  eye. 

CLAP.  See  Gonorrhoea. 

CLOACA.  The  openings  leading  through  the  new 
bony  shell,  in  cases  of  necrosis,  down  to  the  enclosed 
dead  bone  are  termed  cloacae. 

COLLYRIIJM  ACIDI  ACETICI.  R.  Aceti  distil- 
lati,  |j.  Spiritus  vini  tenuioris,  ^ss.  Aq  rosae, 
5viij.  Misce. 

COLLYRIUM  ALUMINIS.  R.  Aluminis  purif.  3j. 
Aq.  rosae,  ; vj.  Misce. 

COLLYRIUM  AMMONIA  ACETATE.  R.  Liq 
ammon.  acet.,  aq.  rosae  sing.  | j.  M. 

COLLYRIUM  AMMON  I.E  ACETATE  CAMPHO- 
RATUM.  R.  Collyrii  ammon.  acet.  misturae  campho- 
ratae  sing.  1 ij.  M. 

COLLYRIUM  AMMONIA  ACETATE  OPIATUM. 
R.  Collyrii  ammon.  acet.  | iv.  Tinct.  opii  gutt.  xl.  M. 

COLLYRIUM  CUPRI  SULPHATIS  CAMPHORA- 
TUM.  R.  Aq.  cupri  suljffiatis  camphoratae,  3 ij.  Aq 
distillatae,  5iv.  M.  Recommended  by  the  late  Mr 
Ware,  for  the  purulent  ophthalmy  of  children. 

COLLYRIUM  HYDRARGYRI  OXYMURIATIS. 
R.  Hydrarg.  oxymuriatis,  gr.  ss.  Aq.  distillat.  |iv.  M» 
This  collyrium  is  fit  to  be  employed  after  the  acute  stage 
of  oidithalmy  has  subsided,  and  it  will  disperse  many 
superficial  opacities  of  the  cornea. 

COI.LYRIUM  OPIATUM.  R.  Opii  extracti  gr.  x. 
Camphorae  gr.  vj.  Aquae  distillatae  ferventis,  ?xii. 
Beat  the  first  two  ingredients  together  in  a mortar,  and 
mix  the  hot  water  gradually,  and  strain  the  fluid. 

This  collyrium  is  recommended  in  some  ophthalmies 
attended  with  great  pain  and  swelling. — (See  Wilson's 
Pharrn.  Chir.  p.  70.) 

COLLYRIUM  PLUMBI  ACETATIS.  R.  Aqu» 
rosae,  jvj.  Plumbi  acetatis,  3 ss.  Misce;  or,  R.  Aq, 
distillatae,  5 iv.  Liq.  plumbi  acetatis  gutt.  x.  M.  This 
is  a good  application  to  the  eyes,  when  one  of  a gently 
astringent,  cooling  quality  is  indicated. 

COLLYRIUM  ZINCI  SULPHATIS.  Zinci  sulpha- 
tis,  gr.  V.  Aq.  distillatae,  | iv.  M.  This  is  the  most 
common  collyrium  of  all : it  may  be  made  gradually 
stronger. 

COLLYRIUxM  ZINCI  SULPHATIS  CUM  MUCI- 
LAGINE  SEMINIS  CIDONII  MALI.  R.  Aq.  planta- 
ginis,  ?iv.  zinci  sulphatis,  gr.  v.  et  mucil.  sem.  cydon. 
trial.  5 ss.  M.  In  order  to  check  the  morbid  secretion 
from  the  eyelids,  in  cases  of  fistula  lachrymalis,  or 
what  Scarpa  calls  il/tusso  palpebrale  puriforme,  this  ce- 
lebrated Professor  re»onimends  a few  drojis  of  the  above 
collyrium  to  be  insinuated  between  the  eyelid  and  the 
eye. 

COLPOCELE.  (From  xdXffoj.  the  vagina,  and 
a tumour.)  A tumour  or  hernia  situated  in  Uic  vagina 


m 


CON 


CON 

COLPOPTOSIS.  (From  /f<5X7rof,  the  vagina,  and 
ni-nru),  to  fall  down.)  A bearing  or  falling  down  of  the 
Vagina.— (See  Vagina,  Prolapsus  of.) 

COxMMINUTED.  (From  comminuo,  to  break  in 
pieces.)  A fracture  is  termed  comminuted  when  the 
bone  is  broken  into  several  pieces. 

COMPRESS.  (From  comprimo  to  press  \ipon.) 
Folded  linen,  lint,  or  other  materials,  making  a sort  of 
pad,  which  surgeons  place  over  those  parts  of  the  body 
on  which  they  wish  to  make  particular  pressure  ; and 
for  this  purpose  a bandage  is  usually  applied  over  the 
compress.  Compresses  are  also  frequently  applied  to 
prevent  the  ill  effects  which  the  pressure  of  hard  bodies 
or  tight  bandages  would  otherwise  occasion. 

COMPRESSION  OF  THE  BRAIN.  See  Head,  In- 
juries of. 

CONCUSSION  OF  THE  BRAIN.  See  Head,  Inju- 
ries of. 

CONDYLOMA.  (From  K6vhv\oi,  a tubercle  or  knot.) 
A small,  very  hard  tumour.  The  term  is  generally  ap- 
plied to  excrescences  of  tliis  description  about  the  anus. 
The  practitioner  may  either  destroy  them  with  caustic, 
tie  their  base  with  a ligature,  or  remove  them  at  once 
with  a knife ; the  first  is  generally  the  worst,  the  last 
the  best  and  most  speedy  method. 

CONIUM  MACULATUM.  Hemlock.  Cicuta.  This 
is  a medicine  to  which  my  observations  in  practice  in- 
cline me  to  impute  considerable  eflicacy  in  several  sur- 
gical diseases*  However,  there  is  no  doubt,  that  when 
it  is  represented  as  a certain  cure  for  cancer  and  scro- 
fula, exaggeration  is  employed.  It  is  an  excellent  re- 
medy for  irritable  painful  sores  of  the  scrofulous  kind, 
and  it  will  complete  the  cure  of  many  ulcers  in  which 
the  venereal  action  has  been  destroyed  by  mercury, 
though  the  healing  does  not  proceed  in  a favourable 
way.  Hemlock  is  likewise  beneficial  to  several  inve- 
terate malignant  sores,  particularly  some  which  are 
every  now  and  then  met  with  upon  the  tongue.  It  is  an 
eligible  alterative  in  cases  of  noli  me  tangere,  porrigo, 
and  various  herpetic  affections.  I have  seen  several 
enlargements  of  the  female  breast  give  way  to  hemlock 
conjoined  with  calomel.  Some  swellings  of  the  testes 
also  yield  to  the  same  medicines.  Hemlock  certainly  has 
not  the  power  of  curing  cancer ; but  its  narcotic  ano- 
dyne qualities  tend  to  lessen  the  pain  of  that  distemper, 
so  as  to  render  it  by  no  means  a contemptible  remedy 
in  that  intractable  kind  of  case. 

Respecting  hemlock,  Mr.  Pearson  observes,  that  the 
extract  and  powder  may  be  sometimes  given  with  evi- 
dently good  effect  in  spreading  irritable  sores ; whether 
they  are  connected  with  the  active  state  of  the  venereal 
virus,  or  whether  they  remain  after  the  completion  of 
the  mercurial  course ; and  it  would  seem,  that  the  be- 
nefit conferred  by  this  drug  ought  not  to  be  ascribed 
solely  to  its  anodyne  qualities,  since  the  same  advan- 
tages cannot  always  be  obtained  by  the  liberal  exhibi- 
tion of  opium,  even  where  it  does  not  disagree  with 
the  stomach.  He  states  that  cicuta  is  almost  a spe- 
cific for  the  venereal  ulcers  which  attack  the  toes 
at  their  line  of  junction  with  the  foot,  and  which  fre- 
quently become  gangrenous.  Also,  in  spreading  sores 
which  are  accompanied  with  great  pain,  and  no  appear- 
ance of  remarkable  debility,  hemlock  will  often  do  more 
than  bark,  vitriol,  or  cordials.  The  common  mode  of 
exhibiting  hemlock  is  in  the  form  of  pills,  made  of 
the  extractum  conii,  five  grains  to  each.  However,  I 
have  always  thought  three  grains  sufficient  to  begin 
with,  the  dose  being  afterward  gradually  augmented. 

It  is  curious  how  large  a quantity  may  at  last  be  taken 
in  this  manner.  Mr.  .1.  Wilson,  in  his  Pharmacopoeia 
Chirurgica,  informs  us  of  a remarkable  case  of  cancer- 
ous ulcer,  for  which  the  patient  took  a hundred  and 
twenty  pills,  each  consisting  of  five  grains  of  the  ex- 
tractum conii,  in  twenty-four  hours,  and  this  without 
any  benefit  being  produced, or  any  inconvenience  to  the 
patient. 

The  stomach  being  a little  disordered,  and  the  head 
somewhat  giddy,  is  a sign  of  the  dose  being  sufficiently 
strong. 

“According  to  some  writers,  but  more  particularly 
Dr.  Withering,  there  are  several  ways  in  which  the 
views  of  a medical  practitioner,  in  prescribing  this 
remedy,  may  be  frustrated.  The  plant  chosen  for  pre- 
paring the  extract  may  not  be  the  true  conium  macula- 
turn,  which  is  distinguished  by  red  spots  along  the 
stalk.  It  may  not  be  gathered  when  in  perfection, 
namely,  when  beginning  to  flower.  The  inspissation 


of  the  juice  may  not  have  been  performed  in  a water* 
bath,  but,  for  the  sake  of  despatch,  over  a common  fire. 
The  leaves,  of  which  the  powder  is  made,  may  not  have 
been  cautiously  dried  and  preserved  in  a well-stopped 
bottle;  or,  if  so,  may  still  not  have  been  guarded  from 
the  ill  effects  of  exposure  to  light.  Or  lastly,  the  whole 
medicine  may  have  suffered  from  the  mere  effects  of 
long  keeping.  From  any  of  these  causes,  it  is  evident, 
the  powers  of  cicuta  may  have  suffered ; and  it  hajjpens, 
no  doubt,  very  frequently,  that  the  failure  of  it  ought,  in 
fact,  to  be  attributed  to  one  or  other  of  them.” — {Phar- 
macopoeia Chirurgica,  published  in  lb02,  p.  174.) 

'Phe  activity  of  hemlock  is  now  found  to  reside  in  a 
resinous  element,  obtained  separately,  by  evaporating 
an  ethereal  tincture  of  the  leaves  on  the  surface  of 
water.  A dose  of  half  a grain  will  prodiuie  vertigo  and 
headache.  The  watery  extract  of  this  plant  has  been 
proved  by  Orfila  to  have  but  little  power. — {J.  A.  Paris, 
in  Pharmacologia,  vol.  2,  p.  180,  ed.  6.) 

I have  sometimes  prescribed  as  an  alterative,  with 
manifest  benefit  in  several  surgical  diseases,  a pill  con- 
taining three  grains  of  extractum  conii,  or,  what  is 
preferable,  the  dried  leaves,  one  of  hydrargyri  submu- 
rias  (calomel),  and  one  of  antimonii  sulphuretum  prae- 
cipitatum.  In  various  cases  of  scrofulous  diseases,  and 
also  in  several  very  painful  irritable  ulcers  and  swell- 
ings, it  is  occasionally  employed  in  the  form  of  foment- 
ations and  poultices.  The  latter  are  generally  made  by 
mixitig  the  powder  with  the  common  bread  and  water 
cataplasm.  F.  Hoffman,  Of  Hemlock,  8vo.  Lovd.  1763. 
A.  Storck,  Libelltcs,  quo  demonstratur  cicutam  non 
solum  usu  intemo  tutissimi  exhiberi,  sed  st  esse  simul 
remedium  valde  utile,  &'C. ; editio  altera,  8vo.  Vindob. 
1761.  Also,  Supplementum  Necessarium  de  Cicuta, 
8vo.  Vindob.  1761.  J.  Pearson,  On  Various  Articles  of 
the  Materia  Medica,  &,-c.  2d  edit.  8vo.  London,  1807.  J. 
A.  Paris,  Pharmacologia,  ed.  6. 

CONJUNCTIVA,  GRANULAR.  The  following  ac 
count  of  this  subject  is  given  by  Dr.  Frick.  This  dis 
ease  is  mostly  the  sequel  of  purulent  ophthalmy.  It  is 
characterized  by  a rough,  scabrous,  or  granulated  state 
of  the  palpebral  conjunctiva,  with  a gleety  or  puriform 
discharge  from  its  surface.  The  constant  friction  of 
the- eyelids  upon  the  globe  brings  on  a varicose  state  of 
the  sclerotic  conjunctiva,  and  a dusky  apjjearance  of 
the  cornea.  The  patient  complains  of  a sensation  simi- 
lar to  that  produced  by  sand,  or  other  extraneous 
matter,  under  the  eyelids ; the  eye  cannot  endure  the 
light,  and  there  is  a troublesome  epiphora.  In  the  re- 
cent stage,  a cure  is  easily  accomplished  by  the  applica- 
tion of  a few  leeches  to  the  eyebrows,  and  pencilling 
the  part  once  or  twice  a day  with  the  vinous  tincture  of 
opium,  or  the  ung.  hydrarg.  nitrat.  When  these  means 
fail,  the  sulphate  of  copper  or  nitrate  of  silver  may  be 
used,  though  not  so  freely  as  to  produce  a slough,  but 
only  to  change  the  diseased  condition  of  the  part. — (See 
Frick,  On  Dis.  of  the  Eye,  p.  240,  ed.  2.)  Mr.  R.  Wel- 
bank  recommends  the  use' of  these  means  to  be  followed 
by  ablution  with  tepid  water,  and  the  application  of  a 
few  leeches.  He  also  recommends  counter-irritation 
and  active  aperients.  The  upper  eyelid,  he  says,  should 
be  completely  everted  in  examination,  as  there  is 
sometimes,  at  the  angle  where  the  conjunctiva  passes 
from  the  globe  to  the  lid,  a crescentic  fVinged  fold,  not 
unlike  a cock’s  comb,  apt  to  keep  up  a tedious  inflam- 
mation of  the  cornea.  Dr.  Frick  considers  excision  of 
the  granular  surface  proper  only  when  it  is  hard,  insen- 
sible, and  prominent,  or  the  excrescences  hang  like 
peduncles  from  the  surface  of  the  eyelids.  In  this  state. 
Dr.  Vetch  recommends  the  application  of  a little  burnt 
alum,  or  verdigris,  and  then  washing  it  off  with  a 
syringe.— (See  the  article  Cornea,  and  Frick,  Vetch,  and 
Travers  on  Diseases  of  the  Eye.) 

CONTUSED  WOUNDS.  See  Wounds. 

CONTUSION.  (From  conrimdo,  to  bruise.)  A bruise. 

Slight  bruises  seldom  meet  wth  much  attention ; but 
when  they  are  severe,  very  bad  consequences  may 
ensue;  and  these  are  the  more  likely  to  occur,  when 
such  cases  are  not  taken  proper  care  of. 

In  all  severe  bruises,  besides  the  inflammation  which 
the  violence  necessarily  occasions,  there  is  an  instanta- 
neous extravasation,  in  consequence  of  the  rupture  of 
many  of  the  small  vessels  of  the  part.  In  no  otlier  way 
can  we  account  for  those  very  considerable  tumours, 
which  often  rise  immediately  after  injuries  of  this  na- 
ture. The  black  and  blue  appearance  instantly  follow- 
ing many  bruises  can  only  be  explained  by  there  being 


COP 


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287 


an  actual  effUsion  of  blood  from  the  small  arteries  and 
veins  which  have  been  ruptured.  Even  largish  vessels 
are  frequently  burst  in  tliis  manner,  and  considerable 
collections  of  blood  are  the  consequence.  Blows  on 
the  head  very  often  cause  a large  effusion  of  blood 
under  the  scalp.  I have  seen  many  ounces  thus  extra- 
vasated. 

Besides  the  rupture  of  an  infinite  number  of  small 
vessels,  and  an  extravasation  of  blood,  which  attend  all 
bruises  in  a greater  or  less  degree,  the  tone  of  the 
fibres  and  vessels  which  have  suffered  contusion  is 
considerably  disordered.  Nay,  the  violence  may  have 
been  so  great,  that  the  parts  are  from  the  first  deprived 
of  vitality,  and  must  slough. 

Parts  at  some  distance  from  such  as  are  actually 
struck  may  suffer  greatly  from  the  violence  of  the  con- 
tusion. This  effect  is  what  the  Fench  have  named  a 
contrecoup. 

The  bad  consequences  of  bruises  are  not  invariably 
proportioned  to  the  force  which  has  operated ; much 
depends  on  the  nature  and  situation  of  the  part.  When 
a contusion  takes  place  on  a bone  which  is  thinly 
covered  with  soft  parts,  the  latter  always  suffer  very 
severely,  in  consequence  of  being  pressed,  at  the  time 
of  the  accident,  between  two  hard  bodies.  Hence, 
bruises  of  the  shin  so  frequently  cause  slojughing  and 
troublesome  sores.  Contusions  affecting  the  large 
joints  are  always  serious  cases ; the  inflammation  oc- 
casioned is  generally  obstinate;  and  abscesses  and 
other  diseases,  which  may  follow,  are  proper  grounds 
for  serious  alarm. 

In  the  treatment  of  bruises,  the  practitioner  has  three 
indications,  which  ought  successively  to  claim  his 
attention. 

The  first  is  to  prevent  and  diminish  the  inflamma- 
tion which,  from  the  violence  done,  must  be  expected 
to  arise.  The  bruised  parts  should  be  kept  perfectly  at 
rest,  and  be  covered  with  linen,  constantly  wet  with 
the  liquor  plumbi  acetatis  dilutus,  or  the  lotio  ammon. 
acetatis.  When  muscles  are  bruised,  they  are  to  be 
kept  in  a relaxed  position,  and  as  quiet  as  possible. 

If  the  bruise  be  very  violent,  it  \vill  be  proper  to 
apply  leeches,  and  this  repeatedly ; and  even  in  some 
cases,  particularly  when  the  Joints  are  contused,  to  take 
blood  from  the  arm.  In  every  instance,  the  bowels 
should  be  kept  well  open  with  saline  purgatives. 

A second  object  in  the  cure  of  contusions  is  to  pro- 
mote the  absorption  of  the  extravasated  fluid  by  discu- 
tient  applications.  These  may  at  once  be  employed  in 
all  ordinary  contusions,  not  attended  with  too  much 
violence : for  then  nothing  is  so  beneficial  as  maintain- 
ing a continual  evaporation  from  the  bruised  part,  by 
means  of  the  cold  saturnine  lotion,  and  at  the  same 
time  repeatedly  applying  leeches.  In  common  braises, 
however,  the  lotio  ammonia!  rnuriata:  (see  this  article) 
is  an  excellent  discutient  application ; but  most  sur- 
geons are  in  the  habit  of  ordering  liniments  for  all  or- 
dinary contusions ; and  certainly  they  do  so  much  good 
in  accelerating  the  absorption  of  the  extravasated  blood, 
that  the  practice  is  highly  praiseworthy.  The  lini- 
men'um  saponis  or  the  lininientum  camphor®  are  as 
good  as  any  that  can  be  employed. — (See  Linimen- 
tum.) 

In  many  cases  unattended  with  any  threatening 
appearances  of  inflammation,  but  in  which  there  is  a 
good  deal  of  blood  and  fluid  extravasated,  bandages  act 
very  beneficially,  by  the  remarkable  power  which  they 
have  of  exciting  the  action  of  the  lymphatics,  by  means 
of  the  pressure  which  they  produce. 

A third  object  in  the  treatment  of  contusions  is  to 
restore  the  tone  of  the  parts.  Rubbing  the  parts  with 
liniments  has  a good  deal  of  effect  in  this  way.  But 
notwithstanding  such  ajiplications,  it  is  often  observed, 
that  brui.sed  parts  continue  for  a long  while  weak,  and 
even  swell  amf  become  oedcmatous,  when  the  patient 
takes  exercise,  or  allows  them  to  hang  down,  as  their 
functions  in  life  may  require.  Pumping  cold  water 
two  or  three  times  a day  on  a part  thus  circumstanced, 
is  the  very  best  measure  which  can  be  adopted.  A 
bandage  should  also  be  worn,  if  the  situation  of  the 
pan  will  permit.  These  steps,  together  with  perseve- 
rance in  the  use  of  liniments,  and  in  exercise  gradually 
increased,  will  soon  bring  every  thing  into  its  natural 
state  again. 

COPPER.  The  subacetate  and  sulphate  are  used  in 
surgery.  The  first,  often  called  aerugo,  or  prepared 
verdigris,  is  employed  as  an  escharotic.  Mixed  with 


an  equal  quantity  of  powdered  cantharides,  it  is  some- 
times applied  for  the  removal  of  warts  and  other  ex- 
crescences. At  present,  the  old  practice  of  destroying 
the  surface  of  chancres  with  it,  with  the  view  of  hin- 
dering the  absorption  of  venereal  matter,  and  rendering 
the  exhibition  of  mercury  needless,  may  be  said  to  be 
completely  abandoned. 

CORNEA.  (From  cornn,  a horn.)  The  anterior 
transparent  convex  part  of  the  eye,  which  in  texture  is 
tough,  like  horn.  It  has  a structure  peculiar  to  itself, 
being  composed  of  a number  of  concentric  cellular 
lainell®,  in  the  cells  of  which  is  deposited  a particular 
sort  of  fluid.  It  is  covered  externally  by  a continuation 
of  the  conjunctiva,  which  belongs  to  the  class  of  mu- 
cous membranes : and  it  is  lined  by  a membrane,  the 
tunica  humoris  aquei,  which  seems  to  belong  to  the 
serous  class. 

FLESHY  EXCRESCENCES  OF  THE  CORNEA. 

Mr.  Wardrop,  in  his  Essays  on  the  Morbid  Anatomy 
of  the  Human  Eye,  has  published  an  excellent  chapter 
on  this  subject.  Besides  pterygia,  which  are  treated  of 
in  another  part  of  this  Dictionary,  Mr.  Wardrop  states 
that  the  cornea  is  subject  to  two  kinds  of  caruncles,  or 
fleshy  excrescences.  One  appears  at  birth,  or  soon 
after  it,  and  resembles  the  n®vi  materni,  so  frequent 
on  the  skin  of  various  parts  of  the  body.  The  second 
is  described  as  having  a greater  analogy  to  the  fungi 
which  grow  from  mucous  surfaces,  and  being  in  gene- 
ral preceded  by  ulceration. 

Of  the  congenital  excrescence  of  the  cornea,  Mr. 
Wardrop  has  seen  two  remarkable  instances.  The 
first  was  in  a girl  eight  or  ten  years  of  age,  on  whose 
left  eye  there  was  a conical  mass ; the  base  of  which 
grew  from  about  two-thirds  of  the  cornea,  and  a small 
portion  of  the  adjoining  sclerotic  coat. 

The  second  example  occurred  in  a patient  upwards 
of  fifty  years  old.  The  tumour  had  been  observed  from 
birth,  was  about  as  large  as  a horse-bean,  and  only  a 
small  portion  of  it  seemed  to  grow  from  the  cornea. 
The  other  part  was  situated  on  the  white  of  the  eye, 
next  the  temporal  angle  of  the  orbit.  From  the  middle 
of  the  excrescence,  upwards  of  twelve  long  firm  hairs 
grew,  and  hung  over  the  cheek. 

Mr.  Wardrop  acquaints  us,  that  a similar  tumour, 
with  two  hairs  growing  out  of  it,  was  seen  at  Lisbon 
by  Dr.  Barron,  of  St.  Andrew’s.  Mr.  Crampton  also 
mentions,  that  he  once  saw  a “ tuft  of  very  strong  hairs 
proceeding  from  the  sclerotica.” — (Essay  on  the  Entro- 
peon,  p.  7.)  And  De  Gazelles  met  with  an  instance,  in 
which  a single  hair  grew  from  the  cornea..— (Journ.  de 
M^decine,  tom.  24.)  According  to  Mr.  Wardrop,  this 
species  of  excrescence  of  the  cornea  greatly  resem- 
bles the  spots  covered  with  hair,  which  are  frequent 
on  various  parts  of  the  surface  of  the  body. 

With  regard  to  the  second  kind  of  tumour  growing 
from  the  cornea,  a fungus,  proceeding  from  an  ulcer  of 
this  part  of  the  eye,  is  stated  to  be  very  uncommon. 
However,  it  is  said  that  when  a portion  of  the  iris 
protrudes  through  an  ulcer  of  the  cornea,  the  growth  of 
a large  excrescence  from  the  projecting  part  is  not  so 
unusual.  Of  such  a disease,  Mr.  Wardrop  has  cited 
examples  from  Maitre- Jean’s  Traiti  des  Maladies  des 
Yeux,  Voigtel,  Beer,  and  Plaichner.  Excrescences 
growing  from  the  cornea  are  also  quoted  from  the  fol- 
lowing works : Handbuch  der  Pathologischen  Anato- 
mie,  von  F.G.  Voigtel,  Halle,  1804.  Praktische  Beo- 
bachtungen  uber  den  grauen  Staar  und  die  Krankheiten 
der  Hornhaut,  von  Joseph  Beer,  Wien,  1791.  Plaich~ 
ner's  Dissertatio  de  Furigo  Oculi. — (See  Wardrop's 
Essays  on  the  Morbid  Anatomy  of  the  Human  Eye, 
vol.  1,  chap.  4.)  Others  are  likewi.se  de.scribed  by 
Mery,  in  M:  m.  de  V Acad,  des  Sciences,  1703 ; by  Dupre, 
in  Phil.  Trans,  vol.  19;  and  Home,  in  the  same  work, 
vol.B\. 

The  only  treatment  which  excrescences  of  the  cor- 
nea admit  of,  is  that  of  removing  them  with  a scal- 
pel and  a pair  of  forceps,  or  destroying  them  with 
caustic. 

ABSCESSES  OF  THE  CORNEA. 

When  the  matter  is  collected  between  the  lamellae 
of  thd  cornea,  it  first  appears  tike  a small  spot ; and 
instead  of  resembling  a speck  in  colour,  it  is  of  the 
yellow  hue  of  common  pus.  As  the  quantity  of  the 
matter  increases,  this  spot  becomes  broader,  and  it 
does  not  alter  its  situation  from  the  position  of  the 


288 


CORNEA. 


head.  If  it  be  situated  among  the  external  layers  of 
the  cornea,  or  immediately  below  the  corneal  conjunc- 
tiva, a tumour  is  formed  anteriorly,  and  if  touched 
with  the  point  of  a probe,  the  contained  fluid  can  be 
felt  fluctuating  within,  or  if  fhe  eye  be  looked  at  side- 
ways, an  alteration  m the  form  of  the  cornea  may  be 
readily  perceived. 

When  the  matter  collects  between  the  interior  la- 
mellae, it  does  not  produce  any  evident  alteration  in  the 
external  form  of  the  cornea ; but  if  it  be  touched  with 
the  point  of  a probe,  a fluctuation  can  be  more  or 
less  distinctly  perceived,  and  the  spot  alters  its  form, 
and  becomes  somewhat  broader. 

Such  collections  of  matter  appear  on  every  part  of 
the  cornea.  Sometimes  they  alter  their  situation  by 
degrees,  and  sink  downwards ; and  sometimes  they 
change  both  their  situation  and  form.  They  very  sel- 
dom cover  more  than  one-fourth  or  one-third  of  the 
cornea. 

When  the  quantity  of  matter  is  small,  it  is  often 
completely  absorbed  during  the  abatement  of  the  in- 
flammatory symptoms,  and  it  generally  leaves  no  ves- 
tige behind  it.  In  other  cases,  the  cornea  is  eroded  ex- 
ternally, producing  an  ulcer  and  subsequent  opacity. 
In  some  few  instances,  the  internal  lamellte  of  the  cor- 
nea give  way,  and  the  matter  escapes  into  the  anterior 
chamber.  When  an  artificial  opening  is  made,  the 
matter  often  does  not  readily  flow  out ; and  it  is  some- 
times so  tenacious,  and  contained  in  a cavity  so  irre- 
gular, that  it  neither  escapes  spontaneously,  nor  can  it 
be  evacuated  by  art. 

It  is  particularly  to  the  cases  in  which  matter  col- 
lects between  the  layers  of  the  cornea,  that  the  terms 
unguis  and  onyjr  are  applied. — (See  Wardrop's  Essays 
on  the  Morbid  Anatomy  of  the  Human  Eye,vol.  1, 
chap.  6.)  According  to  a late  writer,  these  words 
should  be  restricted  to  what  he  names  “ crescentic  in- 
terlamellar  depositions.” — {Travers's  Synopsis  of  the 
Diseases  of  the  Eye,  p.  115.)  Where  the  cornea  is  af- 
fected with  onyx,  this  gentleman  commends  antiphlo- 
gistic treatment. — (P.  278.)  And  with  respect  to  a 
large  collection  of  matter  in  the  cornea,  whether  the 
puriform  onyx  or  central  abscess,  he  observes,  that  it 
requires  “ a supporting  constitutional  treatment,  mild 
cathartics,  and  the  application  of  blisters;  calomel 
should  be  avoided,  and  the  cornea  can  seld'im  be  punc- 
tured with  advantage.”— (P.  280.) 

OPACITIES  OF  THE  CORNEA. 

Opacity  of  the  cornea  is  one  of  the  worst  conse- 
quences of  obstinate  chronic  ophthalmy.  The  term 
opacity  is  used  when  the  loss  of  transparency  extends 
over  the  whole  or  the  greater  part  of  the  cornea ; while 
other  cases  of  a more  limited  kind  are  named  specks. 
The  distinction,  as  Beer  observes,  is  chiefly  important 
in  respect  to  the  prognosis.— (Pe/ire  V07i  den  Augenkr. 
b.  2,  p.  77.) 

Scarpa  distinguishes  the  superficial  and  recent  spe- 
cies of  opacity  from  the  albugo  and  leucoma  (see  these 
words),  which  are  not  in  general  attended  with  inflam- 
mation, assume  a clear  and  pearl  colour,  affect  the  very 
substance  of  the  cornea,  and  form  a dense  speck  upon 
this  coat  of  the  eye.  The  nebjila,  or  slight  opacity, 
here  to  be  treated  of,  is  preceded  and  accompanied  by 
chronic  ophthalmy ; it  allows  the  iris  and  pupil  to  be 
discerned  through  a Kind  of  cloudiness,  and  conse- 
quently does  not  entirely  bereave  the  patient  of  vision, 
but  permits  him  to  distinguish  objects,  as  it  were, 
through  a mist.  The  nebula  is  an  effect  of  protracted 
or  ill-treated  chronic  ophthalmy.  The  veins  of  the 
conjunctiva,  much  relaxed  by  the  long  continuance  of  the 
inflammation,  become  preternaturally  turgid  and  pro- 
minent; afterward  they  begin  to  appear  irregular  and 
knotty,  first  in  their  trunks,  then  in  their  ramifications, 
near  the  union  of  the  cornea  with  the  sclerotica,  and 
lastly  in  their  most  minute  ramifications,  returning 
from  the  delicate  layer  of  the  conjunctiva,  spread  over 
the  cornea.  It  is  only,  however,  in  extreme  relaxation 
of  the  veins  of  the  conjunctiva,  that  these  very  small 
branches  of  the  cornea  become  enlarged. 

When  this  happens,  some  reddish  streaks  begiij  to 
be  perceptible,  in  the  interspaces  of  which,  very  soon 
afterward,  a thin,  milky,  albuminous  fluid  is  effused, 
which  dims  the  diaphanous  state  of  the  cornea.  The 
whitish,  delicate,  superficial  speck  thence  resulting 
forms  precisely  what  is  termed  nebula,  or  the  kind  of 
opacity  here  to  be  considered.  And  since  this  extrava- 


sation may  happen  only  at  one  point  of  the  cornea,  of 
in  more  places,  the  opacity  may  be  in  one  speck  or  in 
several  distinct  ones,  but  which  altogether  diminish 
more  or  less  the  transparency  of  this  membrane. 

The  cloudiness  of  the  cornea,  which  sometimes  takes 
place  in  the  inflammatory  stage  of  violent  acute  oph- 
thalmy, especially  differs  from  the  species  of  opacity 
expressed  by  the  term  nebula.  The  first  is  a deep  ex* 
travasation  of  coagulating  lymph  in  the  internal  cel* 
lular  texture  of  the  cornea,  or  else  the  opacity  pro- 
ceeds from  an  abscess  between  the  layers  of  this  mem- 
brane about  to  end  in  ulceration.  On  the  other  hand, 
the  nebula  forms  slowly  upon  the  superfices  of  the 
cornea,  in  long-protracted  chronic  ophthalmy ; is  pre- 
ceded first  by  a varicose  enlargement  of  the  veins  in 
the  conjunctiva,  next  of  those  in  the  delicate  lamina  of 
this  tunic,  continued  over  the  front  of  the  cornea ; and 
finally  it  is  followed  by  an  effusion  of  albuminous 
lymph  in  the  texture  of  this  thin  layer,  expanded  over 
the  transparent  part  of  the  eye.  This  effusion  never 
elevates  itself  in  the  shape  of  a pustule.  Wherever 
the  cornea  is  affected  with  nebula,  the  part  of  the  con- 
junctiva corresponding  to  it  is  constantly  occupied  by 
net- work  of  varicose  veins,  more  knotty  and  prominent 
than  other  vessels  of  the  same  description;  and 
though  the  cornea  be  clouded  at  more  points  than  one, 
there  are  distinct  corresponding  fasciculi  of  varicose 
veins  in  the  white  of  the  eye.  Scarpa  injected  an  eye 
affected  with  chronic  ophthalmy  and  nebula,  and  he 
found  that  the  wax  easily  passed,  both  into  the  enlarged 
veins  of  the  conjunctiva,  and  those  of  that  part  of  the 
surface  of  the  cornea  where  the  opacity  existed ; the 
inosculations  all  round  the  margin  of  the  cornea  were 
beautifully  variegated,  without  trespassing  that  line 
which  bounds  the  sclerotica,  except  on  that  side  where 
the  cornea  was  affected  with  the  species  of  opacity. 

Mr.  Travers  does  not  adopt  precisely  the  same  defi- 
nition of  nebula  as  Scarpa;  for  he  describes  it  as  a 
thickening  of  the  conjunctiva,  and  an  effusion  of  adhe- 
sive matter  between  it  and  the  cornea,  or  betxveen  the 
lamellcB  of  the  latter,  commonly  the  product  of  acute 
strumous' ophthalmy. —(Synopsis,  A c.  p.  118.) 

According  to  Scarpa,  the  superficial  opacity,  which 
alone  he  calls  nebula,  demands,  from  its  very  origin, 
active  treatment ; for  though  at  first  it  may  only  oc- 
cupy a small  portion  of  the  cornea,  when  left  to  itself 
it  advances  towards  the  centre  of  this  membrane,  and 
the  ramifications  of  the  dilated  veins  upon  this  coat 
growing  still  larger,  at  length  convert  the  delicate  con- 
tinuation of  the  conjunctiva  upon  the  surface  of  the 
cornea,  into  a dense  opaque  membrane,  obstructing 
vision. 

The  curative  indication  in  this  disease  is  to  make 
the  varicose  vessels  resume  their  natural  diameters,  or 
if  that  be  impracticable,  to  cut  off  all  communication 
between  the  trunk  of  the  most  prominent  varicose 
veins  of  the  conjunctiva,  and  the  ramifications  coming 
from  the  surface  of  the  cornea,  the  seat  of  the  opacity. 
The  first  mode  of  treatment  is  executed  by  means  of 
topical  astringents  and  corroborants,  especially  .lanin’s 
ophthalmic  ointment,  and  success  attends  it  when  the 
opacity  is  in  an  early  state,  and  not  extensive.  But 
when  advanced  to  the  centre  of  the  cornea,  the.  most  in- 
fallible treatment  is  the  excision  of  the  fasciculus  of 
varicose  veins  near  their  ram i/icat ions,  that  is,  near 
the  seat  of  the  opacity.  By  means  of  this  excision, 
the  blood  retarded  in  the  dilated  veins  of  the  cornea  is 
voided ; the  varicose  veins  of  the  conjunctiva  have  an 
opportunity  to  contract  and  regain  their  tone,  no  longer 
having  blood  impelled  into  them ; and  the  turbid  secre- 
tion effused  in  the  texture  of  the  layer  of  the  conjunc- 
tiva continued  over  the  cornea,  or  in  the  cellular  sub- 
stance connecting  these  two  membranes,  becomes  ab- 
sorbed. The  celerity  with  which  the,  nebula  disai)- 
pears  after  this  oi)eration  is  surprising,  commonly  in 
twenty-four  hours.  The  extent  to  which  the  excision 
of  the  varicose  veins  of  the  conjunctiva  must  be  per- 
formed depends  ujion  the  extent  of  the  opacity  of  the 
cornea.  Thus,  should  there  be  only  one  set  of  varicose 
vessels,  corresponding  to  an  opacity  of  moderate  ex- 
tent, it  is  sufficient  to  cut  a portion  of  them  away. 
Should  there  appear  several  dim  specks  upon  the  cor- 
nea, with  as  many  distinct  sets  of  varicose  vessels,  ar- 
ranged round  upon  the  white  of  the  eye,  the  surgeon 
must  make  a circular  incision  into  the  conjunctiva, 
near  the  margin  of  the  cornea,  by  which  he  will  cer- 
tainly divide  every  plexus-  of  varicose  vessels.  But  let 


CORNEA, 


289 


ft  be  observed,  that  a simple  incision  through  the  vari- 
cose vessels  is  not  permanently  effectual  in  destroying 
all  direct  communication  between  the  trunks  and  rami- 
fications of  these  vessels  upon  the  cornea,  after  such 
an  incision  made,  for  instance,  with  a lancet ; though 
it  be  true  that  a separation  of  the  mouths  of  the  di- 
vided vessels  follows  in  opposite  directions,  it  is  lio 
less  true,  that  in  the  course  of  a few  days  after  the  in- 
cision, the  mouths  of  the  same  vessels  approximate 
each  other,  and  inosculate,  so  as  to  resume  their  for- 
mer continuity.  Hence,  to  derive  from  this  operation 
all  possible  advantage,  it  is  essential  to  extirpate  with 
the  knife  a small  portion  of  the  varicose  plexus,  to- 
gether with  the  adherent  particle  of  the  tunica  con- 
junctiva. 

The  eyelids  are  to  be  separated  from  the  affected  eye 
by  a skilful  assistant,  who  is,  at  the  same  moment,  to 
support  the  patient’s  head  upon  his  breast.  The  sur- 
geon is  then  to  take  hold  of  the  varicose  vessels  with 
a pair  of  small  forceps,  near  the  edge  of  the  cornea, 
and  to  lift  them  a little  up,  which  the  lax  state  of  the 
conjunctiva  renders  easy ; then,  with  a pair  of  small, 
curved  scissors,  he  is  to  cut  away  the  plexus  of  vari- 
cose vessels,  together  with  a small  piece  of  the  con- 
junctiva, making  the  wound  of  a semilunar  form,  and 
as  near  as  possible  to  the  cornea.  If  it  should  be  ne- 
cessary to  operate  upon  more  than  one  plexus  of  vari- 
cose vessels,  situated  at  some  distance  apart,  the  sur- 
geon must  elevate  them  one  after  the  other  with  the 
forceps,  and  remove  them.  But  when  they  are  very 
close  together,  and  occupy  every  side  of  the  eye,  he 
must  make  ,an  uninterrupted  circular  incision  in  the 
conjunctiva,  guiding  it  closely  to  the  margin  of  the  cor- 
nea all  around,  so  as  to  divide  with  the  conjunctiva  all 
the  varicose  vessels. 

This  being  done,  he  may  allow  the  cut  vessels  to 
bleed  freely,  even  promoting  the  hemorrhage  by  fo- 
menting the  eyelids  until  the  blood  discontinues  to 
flow.  Scarpa  then  covers  the  eye  with  an  oval  piece 
of  the  emplastrum  saponis  and  a retentive  bandage. 
The  eye  ought  not  to  be  opened  till  twenty-four  hours 
after  the  operation,  when,  usually,  the  opacity  of  the 
cornea  will  be  found  completely  dispersed ; and,  dur- 
ing the  ensuing  days,  the  patient  is  to  be  enjoined  to 
keep  the  eye  shut,  atid  covered  with  a bit  of  fine  rag. 
A collyrium  of  milk  and  rose-water,  warm,  may  be  ap- 
plied two  or  three  times  a day.  When  the  inflamma- 
tion of  the  conjunctiva  happens,  about  the  second  or 
third  day  after  the  operation,  particularly  in  cases  in 
which  the  incision  is  made  all  round,  while  the  greater 
part  of  the  sphere  of  the  eye  reddens,  a whitish  circle, 
in  the  place  of  the  incision,  forms  a line  of  boundary 
to  the  redness  which  does  not  extend  farther  upon  the 
cornea.  This  inflammation  of  the  conjunctiva,  with 
the  aid  of  internal  antiphlogistic  remedies  and  topical 
emollients,  abates  in  a few  days,  and  then  pus  is  se- 
creted along  the  track  of  the  incision  in  the  conjunc- 
tiva. The  wound  contracts,  and,  growing  smaller  and 
smaller,  soon  cicatrizes.  Bathing  the  eye  with  warm 
milk  and  rose-water  is  the  only  local  treatment  neces- 
sary in  this  stage  of  the  complaint. 

Thus,  not  only  the  transparency  of  the  cornea  is  re- 
vived, but  also  the  preternatural  laxity  of  the  conjunc- 
tiva is  diminished,  or  even  removed.  When  the  con- 
junctiva subsequently  appears  yellowish  and  wrinkled, 
the  use  of  topical  astringents  and  corroborants,  and  of 
Janin’s  ophthalmic  ointment,  may  be  highly  beneficial 
in  preventing  the  recurrence  of  the  varicose  state  of  the 
ve.s8els.— {.Scarpa  sulle  Malattie  degli  Occhi,  c.  8.) 

According  to  the  experience  of  Dr.  Vetch,  Scarpa’s 
plan  of  removing  the  plexus  of  varicose  vessels,  toge- 
ther with  a portion  of  the  conjunctiva,  produces  no 
good  effect,  “ except  in  cases  of  great  relaxation  of  the 
membrane  covering  the  eye.”  He  asserts,  that  new 
vessels  immediately  appear  in  the  room  of  those  re- 
moved, and  the  good  derived  from  the  bleeding  does 
not  compensate  for  the  irritation  produced  by  the  ope- 
ration.—(A  Practical  Treatiae  on  the  Diseases  of  the 
Eye,  p.  86.)  However,  when  it  is  reflected,  that  Scarpa 
advises  this  practice  only  for  advanced  cases,  and  jiar- 
licularly  recommends  topical  astringents  for  the  more 
recent  stages  of  the  disease,  he  nearly  agrees  with  Dr. 

» etch,  as  far  as  this  point  is  concerned.  But  Scarpa’s 
account  of  the  disease  and  its  treatment  is  left  im- 
perfect by  the  omission  of  any  notice  of  the  connexion 
frequently  existing  between  opacity  of  the  cornea,  and 
• rough,  scabrous,  granulated  state  of  the  lining  of  the 

VoL  I.— T 


eyelids.  Yet,  perh^s,  Scarpa  was  not  to  be  expected 
to  treat  of  this  combination  in  his  chapter  on  nebula, 
because  his  definition  of  this  superficial  opacity  wilk 
not  altogether  suit  the  affection  of  the  same  membrane 
referred  to  in  the  following  observations.  It  is  re- 
marked by  Dr.  Vetch,  that  after  the  complete  cessation 
of  conjunctival  ophthalmia,  as  far  as  regards  that  por 
tion  of  the  membrane  which  covers  the  eye,  the  villous 
elongation  of  the  vessels  of  the  lining  of  the  eyelids, 
instead  of  recovering  their  natural  state,  acquire  a 
farther  increase  of  size,  so  as  to  produce  a rough,  sca- 
brous, or  granulated  surface,  with  a secretion  ofpuri- 
form  matter.  The  irritation  of  this  unequal  surface 
gradually  induces  an  inflammatory  state  of  the  sclerotic 
vessels,  and,  consequently,  a greater  flow  of  blood  to- 
wards the  cornea:  the  superficial  vessels  become  va- 
ricose ; the  conjunctiva  assumes  a dusky  and  loaded 
.'ippearance ; and  the  cornea  becomes  opaque,  not  par- 
tially, but  throughout  the  whole  extent  of  its  structure. 
This  affection,  says  Dr.  Vetch,  is  essentially  different 
from  those  nebulous  or  partial  opacities  which  take 
place  in  primary  sclerotic  inflammation,  and  which 
consist  in  slight  extravasations,  accompanied  by  in- 
tolerance of  light,  and  in  which  any  affection  of  the  pal- 
pebral linings  is  a secondary  instead  of  a primary  cir- 
cumstance. The  cornea  is  of  the  green  colour  pre- 
sented by  a broken  gun-flint;  and  while  it  is  sufficiently 
diaphanous  to  permit  the  perception  of  light,  it  is  yet 
too  opaque  to  allow  the  patient  to  discern  external  ob- 
jects, except  by  their  shades.  Nor  can  the  colour  of 
the.  iris  and  limits  of  the  pupil  be  seen.  Dr.  Vetch  also 
describes  the  conjunctiva  as  being  sometimes  so  much 
relaxed,  and  its  vessels  so  generally  loaded,  as  to  give 
it  a dusky  appearance  similar  to  that  of  the  cornea; 
and,  in  other  instances,  without  much  alteration  of  its 
thickness  or  transparency,  it  is  said  to  lose  for  a con- 
siderable extent  its  close  attachment  to  the  subjacent 
lamina  of  the  cornea.  Along  with  the  opaque  state  of 
the  cornea,  there  is  more  generally  an  enlargement  of 
individual  vessels,  which  penetrate  almost  to  its  cen- 
tre, increase  as  they  come  outwards,  and  terminate  in 
trunks,  which  run  to  the  duplicature  of  the  conjunc- 
' tiva.  Dr.  Vetch  represents  this  di.sease  of  the  pal- 
pebrae  as  consisting  at  first  in  a highly  villous  state  of 
their  membranous  lining.  This  state,  if  not  rectified 
by  proper  treatment,  gives  birth  to  granulations,  which 
in  time  become  more  deeply  sulcated,  hard,  or  warty, 
accompanied  by  an  oozing  of  purulent  matter.  Dr. 
Vetch  has  explained,  that  the  use  of  the  actual  cautery, 
excision,  and  friction,  for  the  purpose  of  curing  the  dis- 
eased state  of  the  eyelids,  may  be  traced  back  to  Hip- 
pocrates, who  prefers  escharotics.  Dr.  Vetch  ascribes 
their  first  employment  in  these  cases  to  St.  Ives.  Mr. 
Saunders,  he  observes,  took  au  early  and  a just  view 
of  the  relations  existing  between  the  diseased  conditions 
of  the  palpebral  linings,  and  the  opaque  state  of  the 
cornea;  and  he  succeeded  in  establishing  the  cure  of 
the  latter  by  the  removal  of  the  former.  In  short,  Dr. 
Vetch  admits,  that  in  the  case  which  more  especially 
formed  the  claim  of  Mr.  Saunders  to  the  discovery  of 
the  nature  of  the  disease,  the  practice  of  excision  was 
attended  with  complete  success.  Dr.  Vetch  contetids, 
however,  that  this  method  is  for  the  most  part  inade- 
quate to  the  cure  of  the  disease ; and  that  there  are 
very  few  cases,  in  which  the  more  certain  and  consis- 
tent process  of  gradually  repressing  the  diseased  sur- 
face by  escharotic  substances  will  not  produce  a more 
complete  and  permanent  cure.  After  giving  a fair 
trial  to  a great  variety  of  escharotics  made  into  oint- 
ments, and  applied  to  the  inside  of  the  upper  eyelid, 
Dr.  Vetch  found  the  direct  application  of  the  escha- 
rotic substances  themselves  was  preferable.  When 
there  is  too  much  increased  action  of  the  vessels  of  the 
sclerotic  coat.  Dr.  Vetch  recommends  the  use  of  escha- 
rotics to  be  preceded  by  cupping  the  temples;  or,  when 
there  is  any  risk  of  a slough,  the  application  of  a leech 
to  the  inside  of  the  lower  eyelid.  Whatever  will  bring 
on  a determination  of  blood  to  the  head  is  to  be  avoided, 
and  a low  regimen  observed. 

The  escharotics  preferred  by  Dr.  Vetch,  are  the  sul- 
phate of  copper  and  nitrate  of  silver,  scraped  in  the  form  of 
a pencil  and  fixed  in  a portcrayon.  In  this  way.  Dr.  Vetch 
says,  they  should  be  applied,  not,  as  some  have  con- 
ceived, with  the  view  of  producing  a slough  over  the 
whole  surface,  but  with  great  delicacy,  and  in  so  many 
points  only  as  will  produce  a gradual  change  intlxecondi 
lion  and  dispo.sition  of  the  part.  As  long  as  there  is  any 


200 


CORNEA. 


aecretion  of  pus,  the  above  application  may  be  mate- 
rially assisted  by  the  daily  use  of  the  undiluted  liquor 
plumbi  acetatis.  When  the  disease  resists  these  reme- 
dies, and  its  surface  is  hard  and  warty.  Dr.  Vetch  ap- 
plies to  the  everted  surface  powder  of  verdigris  or  burnt 
alum,  finely  levigated;  or  even  lightly  touches  the  dis- 
eased surface  with  the  kali  purum.  In  employing 
these  remedies,  he  enjoins  confining  their  operation  to 
the  point  of  contact,  so  as  to  prevent  them  from  hurting 
the  eye.  Hence,  they  are  to  be  applied  in  very  minute 
quantities  with  a fine  camel’s  hair  pencil,  and  to  be 
washed  off  with  an  elastic  gum  syringe,  before  the 
eyelid  is  returned.  Of  the  employment  of  astringent 
collyria  in  conjunction  with  escharotics.  Dr.  Vetch  dis- 
approves.— (See  A Practical  Treatise  on  the  Diseases  of 
the  Eye,  p.  67,  <S'C,)  With  re.spec.t  to  the  treatment  by 
excision,  as  first  practised  by  Mr.  Saunders  with  scis- 
sors, and  afterward  by  Sir  W.  Adams  with  a knife, 
the  principle  of  cure  does  not  ajtpear  to  me  (Merent 
from  that  aimed  at  with  escharotics,  unless  these  latter 
be  supposed  not  always  to  destroy,  but  sometimes  to 
cause  an  absorption  of  the  fungous  granulations.  At 
present,  the  last  method  is  considered  most  effectual, 
and  during  the  operation  the  eyelids  should  be  everted 
over  a probe. 

For  the  form  of  disease  termed  by  Mr.  Travers 

strumous  nebula,  with  vessels  overshooting  the  cor- 
nea,” this  gentleman  recommends  ptyalism.  He  says, 
that  “ the  hydrargyrus  cum  creta  or  oxymuriate,  in 
small  but  frequent  doses,  will  sometimes  succeed  bet- 
ter in  this  case,  than  the  other  forms  of  mercury,  and 
the  combination  of  calomel  with  antimony,  better  than 
that  with  opium.”  When  the  internal  exhibition  of 
mercury  either  disorders  the  bowels  or  has  no  effect 
on  the  constitution,  frictions  are  to  be  preferred. — {Sy- 
nopsis of  the  Diseases  of  the  Eye,  p.  282.)  In  the  par- 
ticular form  of  opacity,  to  which  he  alludes,  he  disap- 
proves of  dividing  the  vessels  of  the  conjunctiva  be- 
fore the  inflammation  has  declined. — (P.  285.) 

From  some  observations  published  by  Mr.  Wardrop, 
it  would  appear,  that  certain  opacities  of  the  cornea  are 
produced  by  an  increase  in  the  quantity  of  the  contents 
of  the  eyeball,  and  not  by  the  deposition  of  an  albu- 
minous fluid  in  the  texture  of  the  cornea,  as  takes 
place  in  the  common  speck.  He  considers  this  fact 
proved,  by  cases  in  which  the  cornea  regained  its 
transparency  the  instant  the  aqueous  humour  was 
evacuated.  Some  cases  are  detailed  by  this  gentleman, 
with  the  view  of  recommending  the  practice  of  punc- 
turing the  cornea,  and  discharging  the  aqueous  humour, 
for  the  relief  of  the  kind  of  opacity  to  which  we  have 
here  alluded. — (See  Med.  Chir.  Trans,  vol.  i,p.  180, i-c.) 

For  other  ojiacities  of  the  cornea,  refer  to  Albugo, 
Leucoma,  and  Staphyloma. 

ULCERS  OF  THE  CORNEA. 

An  ulcer  is  a common  consequence  of  the  bursting 
of  a small  abscess,  which  not  unfrequently  forms  be- 
neath the  delicate  layer  of  the  conjunctiva  continued 
over  the  cornea,  or  in  the  very  substance  of  the  cornea 
itself,  after  violent  ophth'almy.  At  other  times,  the 
ulcer  is  produced  by  the  contact  of  corroding  matter,  or 
sharp  pointed  bodies  insinuated  into  the  eyes,  such  as 
quicklime,  pieces  of  glass  or  iron,  thorns,  &c.  As  Dr. 
Vetch  has  observed,  ulceration  of  the  cornea  is  a very 
frequent  consequence  of  purulent  ophthaimy.  Tlie 
little  abscess  of  the  cornea  is  attended  with  the  same 
symptoms  as  the  severe  acute  ophthaimy ; especially 
with  a troublesome  sensation  of  tension  in  the  eye, 
eyebrow,  and  nape  of  the  neck ; w’ith  ardent  heat ; co- 
pious secretion  of  tears;  aversion  to  light ; intense  red- 
ness of  the  conjunctiva,  particularly  near  the  point  of 
suppuration.  The  inflammatory  pustule,  compared 
with  similar  ones  in  any  other  part  of  the  body,  is 
slovv  in  bursting  after  matter  is  formed.  Scarpa  deems 
it  improper,  however,  to  puncture  the  small  abscess ; 
for,  though  it  assumes  the  appearance  of  being  per- 
fectly maturated,  the  matter  contained  in  it  is  so  tena- 
cious and  adherent  to  the  substance  of  the  cornea,  that 
not  a particle  issues  out  of  the  artificial  aperture,  and 
the  wound  exasperates  the  disease,  increases  the  opa- 
city of  the  cornea,  and  often  occasions  another  small 
abscess  to  form  in  the  vicinity  of  the  first.  Indeed,  if 
the  observations  of  Mr.  Travers  be  correct,  “ the  ulcer 
of  the  cornea  begins  not  in  abscess,  but  in  a cir- 
cum.scribed  deposite  of  lymph,  or  in  pure  ulcerative  ab- 
sorption without  pus.” — (Synopsis  of  the  Diseases  of  | 


the  Eye,  p.  106.)  And  Dr.  Vetch  takes  notice,  that  thet 
observation  with  respect  to  fluid  matter  never  forming 
in  the  cornea,  he  invariably  found  true  in  sevend 
cases,  where  the  whole  of  the  eyeball  had  been  de- 
stroyed by  inflammation. — {Practical  Treatise  on  the 
Diseases  of  the  Eye,  p.  52.)  This  author  differs  from 
Scarpa,  however,  respecting  the  question  of  opening 
pustules  or  abscesses  of  the  cornea ; for  he  remarks, 
that  whenever  the  matter  or  slough  is  removed,  the 
ulcer,  however  deep  and  extensive,  will  fill  up  with- 
out leucoma  behig  the  consequence.  By  a little  ad- 
dress, he  says,  it  may  in  most  instances  be  removed 
In  a mass  upon  the  point  of  a lancet  or  couching- 
needle. — (Op.  cit.  p.  50.)  This  remark  applies  both  to 
cases  where  lymph  or  tenacious  matter  more  or  less 
protrudes,  and  to  instances  in  which  it  is  quite  con- 
fined between  the  lamellae  of  the  cornea.  Scarpa 
thinks  that  the  safest  plan  is  to  temporize,  until  the 
pustule  spontaneously  bursts,  promoting  it  by  means 
of  frequent  fomentations,  batliing  the  eye  with  warm 
milk  and  water,  and  applying  emollient  poultices. 
The  spontaneous  bursting  of  the  little  abscess  is 
usually  denoted  by  a sudden  increase  of  all  the  symp- 
toms of  ophthaimy;  particularly  by  an  intolerable 
burning  pain  at  the  ^int  of  the  cornea,  where  the  ab- 
scess first  began,  greatly  increased  by  motion  of  the 
eye  or  eyelid.  The  event  is  confirmed  by  ocular  in- 
spection, and  at  the  spot  where  the  white  pustule  ex- 
isted a cavity  appears,  as  may  best  be  seen  whep  the 
eye  is  viewed  in  the  profile.  Extraneous  bodies  in  the 
eye,  which  have  simply  divided  a part  of  the  cornea, 
or  lodged  in  it,  when  soon  extracted  do  not  in  general 
cause  ulceration,  as  the  injured  part  heals  by  the  first 
intention.  Those  which  destroy  or  burn  the  surface 
of  this  membrane,  or  which,  when  lodged,  are  not  soon 
extracted,  excite  acute  ophthaimy,  suppuration  at  the 
injured  part,  and  at  length  ulceration. 

As  Dr.  Vetch  has  observed,  the  appearance  of  ulcer- 
ation varies  according  to  the  degree  of  a][¥)Stemation, 
or  tendency  towards  it  in  the  surrounding  cornea : 
when  this  part  is  clear,  the  case  is  doing  well,  but 
when  opacity  comes  on,  the  ulcer  is  increasing.  The 
soft  middle  lamina,  he  says,  is  destroyed  with  great 
rapidity  when  the  inflammation  is  violent,  but  as  soon 
as  the  ulcer  reaches  the  internal  coat,  it  often  proceeds 
no  farther. — {Practical  Treatise  on  Diseases  ofthe  Eyef 
p.  52.) 

The  ulcer  of  the  cornea,  as  Scarpa  remarks,  has  this 
in  common  with  all  solutions  of  continuity  in  the  skin, 
where  this  is  delicate,  tense,  and  endowed  with  exqui- 
site sensibility,  that  at  its  first  appearance,  it  is  of  a 
pale  ash  colour;  has  its  edges  high  and  irregular; 
creates  sharp  pain ; discharges,  instead  of  pus,  an  acrid 
serum,  and  tends  to  spread  widely  and  deeply.  Such 
is  the  precise  character  of  ulcers  upon  the  cornea,  and 
such  is  the  nature  of  those  upon  the  nipples  of  the 
mammae,  the  glans  penis,  lips,  apex  of  the  tongue,  the 
tarsi,  the  entrance  of  the  meatus  auditorius-  externus ; 
nostrils,  &c.  Ulcers  of  this  description,  neglected  or 
ill-treated,  speedily  enlarge,  make  their  way  deeply,  and 
destroy  the  parts  in  which  they  are  situated.  If  they 
spread  superficially  upon  the  cornea,  the  transparency 
of  this  membrane  is  destroyed ; if  they  proceed  deeply 
and  penetrate  the 'anterior  chamber  of  ^the  aqueous 
humour,  tliis  fluid  escapes,  and  a fistula  of  the  cornea 
may  ensue ; and  if  it  should  form  a larger  opening  in 
it,  besides  the  exit  of  the  aqueous  humour  it  occasions 
another  more  grievous  malady  than  the  ulcer  itselJ^ 
namely,  a prolapsus  of  a portion  of  the  iris ; an  escape 
of  the  crystalline  lens  and  vitreous  humour;  in  short, 
a total  destruction  of  the  whole  organ  of  sight.  It  ia 
therefwe  of  the  highest  importance,  as  soon  as  an  ulcer 
appears  upon  the  cornea,  to  impede  its  growing  larger 
as  much  as  the  nature  of  it  will  permit ; the  morbid 
process  should  be  converted  into  a healing  one,  and 
the  surgeon  must  exert  Ms  skill  with  more  attention, 
the  more  extensively  and  deeply  the  ulceration  has 
proceeded.  According  to  Scarpa,  the  cicatrix  of  a 
larger  ulcer  impairs  the  texture  of  the  cornea  so  much, 
that  the  injury  is  irreparable.  Yet  Dr.  Vetch  assures 
u.s,  that  when  a slough  covers  an  ulcer  of  considerable 
extent,  and  is  taken  off  with  great  caution,  so  as  not  to 
wound  the  inner  tunic  of  tho  cornea  ; or  when  it  can- 
not be  removed,  if  it  be  slightly  scarified  and  divided, 
the  cornea  may  recover  its  transparency  after  two- 
thirds  ofit  have  been  in  this  state.— (FmeritaZ  Treatise 
1 on  Diseases  of  the  Eye,  p.  51.) 


CORNEA. 


291 


They  who  inculcate  that  no  external  application  can 
be  adopted  with  benefit  for  the  cure  of  this  disease,  be- 
fore the  acute  ophthalmy  has  been  subdued,  or  at  least 
chminished,  are,  in  Scarpa’s  opinion,  deceived.  Expe- 
rience teaches  that  local  remedies  ought,  in  the  very 
first  instance,  to  be  applied  to  the  ulcer ; such  as  are  ap- 
propriate to  lessen  the  increased  morbid  irritability  and 
stop  the  destructive  process  going  on : afterward  such 
means  should  be  taken  as  will  cure  the  ophthalmy  if  it 
does  not  subside  gradually,  as  the  ulcer  heals.  It  is  a 
fact,  confirmed  by  repeated  observation,  that  it  is  the 
ulcer  which  keeps  up  the  ophthhalmy,  not  the  ophthalmy 
the  ulcer.  The  case,  however,  is  to  be  excepted  in 
which  the  ulcer  makes  its  appearance  in  the  height  of 
a severe  ophthalmy.  Here  the  first  indication  is  to 
abate  inflammation  before  attempting  to  heal  the  sore. 

It  is  true,  that  when  the  little  abscess  of  the  cornea 
breaks,  the  symptoms  of  acute  ophthalmy  are  aggra- 
vated ; the  redness  of  the  conjunctiva  is  increased,  as 
^vell  as  the  turgid  state  of  its  vessels ; but  it  is  equally 
certain,  that  it  happens  from  no  other  cause  than  an 
increased  inflammation  in  the  part,  in  consequence  of 
the  augmented  sensibility  in  the  ulcerated  spot  of  the 
cornea.  As  soon  as  this  increase  of  sensibility  in  the 
ulcer  of  the  cornea  ceases  or  abates  in  violence,  the 
ophthalmy  retreats  with  equal  speed ; and  finally,  when 
the  ulcer  heals,  the  inflammation  disappears  gradually, 
or,  at  most,  requires  only  the  use  of  an  astringent  and 
corroborant  collyrium  for  a few  days.  Analogous  exam- 
ples every  day  occur  in  practice,  in  ulcers  of  other  parts 
besides  the  cornea;  particularly  in  little  foul  ulcers 
on  the  inside  of  the  lips,  on  the  apex  of  the  tongue,  on 
the  nipples,  on  the  glans  penis,  wliich,  as  was  described 
above,  at  their  first  appearance  assume  an  ash-coloured 
surface,  excite  infiammation  of  the  part  in  which  they 
are  seated,  and  cause  a very  troublesome  itching  and 
ardent  heat  in  the  part  affected.  To  subdue  this  in- 
flammation we  do  nothing  more,  and  the  vulgar  do  the 
same,  than  repel  the  excessive  irritability  in  these 
ulcers,  and  convert  the  ulcerative  process  into  cicatri- 
zation : this  done,  the  surrounding  inflammation  imme- 
diately disappears  of  itself. 

Such  speedy  and  good  effects  may  be  obtained  by 
caustic.  It  inmiediately  destroys  the  naked  extremi- 
ties of  the  nerves  in  the  ulcerated  part,  and  soon  re- 
moves the  diseased  irritability  in  the  part  affected  ; it 
converts  the  ash-coloured  surface  of  the  ulcer,  and  the 
serous  discharge  upon  it,  into  an  eschar  and  scab, 
which,  as  a kind  of  epidermis,  moderate  the  contact  of 
the  neighbouring  parts  upon  the  ulcer,  and  at  length 
convert  the  process  of  ulceration  into  that  of  granula- 
tion and  cicatrization. 

For  cauterizing  the  ulcer  of  the  cornea,  the  caustic 
to  which  Scarpa  gives  the  preference  is  the  argentum 
nitratum.  It  must  be  scraped  to  a point,  like  a crayon 
pencil,  and  the  eyelids  being  opened  perfectly,  and  the 
upper  eyelid  suspended,  by  means  of  Pellier’s  elevator, 
the  ulcer  of  the  cornea  is  to  be  touched  with  the  apex 
sufficiently  to  form  an  eschar.  Should  any  of  the  caus- 
tic dissolve  in  the  tears,  the  eye  must  be  copiously 
bathed  with  warm  milk.  At  the  instant  the  caustic  is 
applied,  the  jiatient  complains  of  a most  acute  pain; 
but  this  aggravation  is  amply  compensated  by  the  ease 
experienced  a few  minutes  after  the  operation ; the 
burning  heat  in  the  eye  ceases,  as  it  were  by  a charm; 
the  eye  and  eyelids  become  capable  of  motion  without 
pain  ; the  flux  of  tears  and  the  turgidity  of  the  vessels 
of  the  conjunctiva  decrease ; the  patient  can  bear  a 
moderate  light,  and  enjoys  repose.  These  advantages 
last  while  the  eschar  adheres  to  the  cornea 

On  the  separation  of  the  eschar,  ■ometimes  at  the 
end  of  two,  three,  or  four  days  after  the  application  of 
the  caustic,  the  primary  symptoms  of  the  disease  recur, 
esjiecially  the  smarting  and  burning  pain  at  the  ulcer- 
ated part  of  the  cornea  ;'the  effii.sion  of  tears ; the  re- 
straint in  moving  the  eye  and  eyelids ; and  the  aversion 
to  light ; but  all  these  inconveniences  are  less  in  degree 
than  before.  At  their  recurrence  the  surgeon,  without 
delay,  must  renew  the  application  of  the  argentum  ni- 
traturn,  making  a good  eschar,  as  at  first,  upon  the  whole 
surface  pf  the  ulcer,  which  will,  as  before,  be  followed 
by  perfect  ease  in  the  eye.  The  application  of  the 
caustic  is,  if  reijuired,  to  be  repeated  a third  time ; that 
is,  if,  upon  the  separation  of  the  eschar,  the  extreme 
irritability  in  the  ulcer  is  not  exhausted,  and  its  pro- 
gressive miscliief  checked.  When  the  case  goes  on 
lavourably,  it  is  a constant  phenomenon  in  the  cure 

T 2 


of  this  disease,  that  at  every  separation  of  the  eschar, 
the  diseased  sensibility  of  the  eye  is  decreased;  the 
ulcer  also,  abandoning  its  pale  ash-coJour,  assumes  a 
delicate,  fleshy  tint,  a certain  sign  that  the  destructive 
process  which  prevailed  is  turned  into  a healing  one. 
The  turgid  stale  of  the  vessels  of  the  conjunctiva,  and 
the  degree  of  ophthalmy,  disappear  in  proportion  as  the 
ulcer  draws  near  to  a cure.  At  this  epoch,  when  the 
formation  of  granulations  has  begun,  the  surgeon 
would  act  very  wrongly  were  he  to  continue  the  use 
of  the  argentum  nitratum;  it  would  now  reproduce 
pain,  effusion  of  tears,  and  inflammation  of  the  eye ; 
and  the  ulcer  would  take  on  that  foul,  ash-coloured 
aspect,  with  swelled  and  irregular  edges,  which  it  had 
in  the  beginning.  Plainer  has  noticed  this  fact.  Ne- 
cp.9sfi  est,  ut  hoc  temperatd  manu,  nec  crehrius  fiat,  ne 
nova  infiam-inatio,  novnque  lackrymatio  hie  acrioribus 
concitetur.-  -{Inst.  Chirurg.  ^314.)  As  soon  as  ease  is 
felt  in  the  eye,  and  granulations  begin  to  rise,  whether 
after  the  first,  second,  or  third  application  of  the  caus- 
tic, the  surgeon  must  refrain  from  the  use  of  every 
strong  caustic,  and  use  only  the  following  collyrium  : 
3;.  Ziaci  sulphatis  gr.  iv.  Aq.  roscB,  ^iv.  Mucil.  sem. 
cydon  mali  | ss.  M.  This  is  to  bemused  every  two 
hours,  the  eye  in  the  intervals  being  defended  from  the 
air  and  light  by  means  of  a gentle  compress  and  retentive 
bandage.  When,  besides  the  ulcer  of  the  cornea,  a 
slight  relaxation  of  the  conjunctiva  remains,  Janin’s 
ointment,  towards  the  end  of  the  treatment,  introduced 
between  the  eye  and  eyelids,  morning  and  evening, 
proved  serviceable.  It  must  be  adapted  in  strength 
and  quantity  to  the  particular  sensibility  of  the  pa- 
tient. 

To  cure  those  superficial  excoriations  of  the  cornea 
which  make  no  excavation  in  the  substance  of  this 
membrane,  and  which,  in  reality,  are  only  a detach- 
ment of  the  cuticle,  covering  the  layer  of  the  conjunc- 
tiva continued  over  the  cornea,  the  use  of  caustic  is 
not  requisite.  The  same  collyrium,  combined  with  mu- 
cilage, is  sufficient.  The  symptoms  which  accompany 
these  slight  excoriations  or  detachments  of  the  cuticle 
are  unimportant,  and  when  the  patient  takes  care  to 
bathe  his  eye  every  two  or  three  hours  with  the  solu- 
tion of  sulphate  of  zinc,  and  to  avoid  too  much  light 
and  exposure  to  the  air,  they  soon  get  well. 

According  to  Dr.  Vetch,  when  the  ulcerative  process 
is  likely  to  destroy  the  membrane  which  lines  the  cor- 
nea, it  can  only  be  checked  by  measures  calculated  to 
subdue  the  inflammation  upon  which  it  depends.  “As 
long,  therefore,  as  there  is  an  appearance  of  activity  in 
the  disease,  or  recurrence  of  pain,  local  blood-letting 
by  cupping  or  leeches  must  be  steadily  adhered  to. 
The  indication  of  the  ulcer  healing  is  easily  seen  in 
the  diminished  activity  of  the  inflammation,  relief  from 
pain,  and  the  clean  aspect  of  the  ulcerated  part.  The 
injection  of  vegetable,  tepid,  astringent  infusions  may 
be  used,  or  milk  and  water  only.  When  called  upen 
in  extreme  cases,  where  the  immediate  perforation  of 
the  inner  membrane  is  threatened,  we  may,  with  great 
propriety,  resort  to  the  operation  of  puncturing  the  cor- 
nea at  a place  as  remote  as  possible  from  the  ulcer. 
Next  in  imj)ortance  to  a diminution  of  the  action  on 
which  the  ulcer  depends,  is  the  removal  by  scarification 
of  any  slough  thrown  out  from  its  surface,  or  imbed- 
ded in  the  adjoining  part  of  the  cornea.  Sometimes, 
but  always  subordinate  to  these  indications,  we  may 
add  some  topical  applications  to  the  ulcer ; a solution 
of  nitrate  of  silver,  the  infusion  of  tobacco  or  calomel 
in  powder,  applied  with  a camel’s  hair  pencil.”— (Prac- 
tical  Treatise  ov.  Diseases  of  the  Eye,  p.  57.)  In  inci- 
pient protrusions  of  the  inner  membrane  of  the  cornea, 
this  author  decidedly  condemns  the  use  of  the  argen- 
•tum  nitratum  in  the  free  manner  proposed  by  Scarpa ; 
observing  that,  “ if  the  caustic  touches  by  accident  the 
edge  of  the  ulcer,  or  any  part  but  the  a])ex  of  the  pro- 
jecting vesicle,  it  will  often  produce  much  mischief.” 

Thus  far  of  ulcers  of  the  cornea,  and  the  best  me- 
thod of  curing  them  in  ordinary  cases.  How’ever, 
sometimes,  says  Scarpa,  in  consequence  of  ill-treat- 
ment, the  ulcer,  already  very  extensive,  assumes  the 
fonn  of  a flingous  excrescence  upon  the  cornea,  ap- 
pearing to  derive  its  nourishment  from  a band  of 
blood-vessels  of  the  conjunctiva;  and  on  this  account 
it  occasions,  not  unfrequently,  a .serious  mistake  in 
being  taken  for  a real  pterygium.  Left  to  itself,  or 
treated  with  slight  astringents,  it  produces,  in  general, 
a loss  of  the  whole  eye.  It  requires  the  speedy  adop- 


292 


CORNEA. 


tion  of  some  active  and  efficacious  plan  to  destroy  all 
the  fungus  upon  the  cornea,  to  annihilate  the  vessels 
of  the  conjunctiva  tending  to  it,  and  to  impede  the  pro- 
gress of  ulceration.  This  consists  first  in  cutting  away 
the  fungus  with  a pair  of  small  scissors  to  a level  with 
the  cornea,  continuing  the  incision  far  enough  upon  the 
conjunctiva  to  remove  with  the  excrescence  that  string 
of  blood-vessels  from  wliich  it  seems  to  derive  its  sup- 
ply. Having  effected  tliis,  and  allowed  the  blood  to  flow 
freely,  Scarpa  applies  the  argentum  nitratum  to  all  the 
space  of  the  cornea  which  appears  to  have  been  the 
seat  of  the  fungus,  so  as  to  make  a complete  eschar ; 
and  if,  upon  its  separation,  the  whole  morbid  surface 
should  not  be  destroyed,  he  repeats  the  caustic  tmtil 
the  ulcerative  process  changes  into  a healuig  one.  To 
execute  commodious!  y such  a full  applkation  of  the 
caustic,  it  is  not  in  general  enough  to  have  the  upper 
eyelid  raised  by  an  assistant,  and  the  lower  one  de- 
pressed ; it  is  also  farther  re(iuisite,  that  the  operator 
should  evert  the  upper  eyelid  completely,  and  keep  it 
so,  while  a deep  eschar  is  made  with  the  caustic. 

The  action  of  the  caustic  cannot  always  be  calculated 
with  precision,  and  therefore  a portion  of  the  whole 
thickness  of  the  coniea  may  be  destroyed  with  the 
fungus,  which  never  fails  to  be  followed  by  a prolapsus 
of  the  part  of  the  iris  through  the  aperture  made  in  the 
cornea.  This  accident  may  seem  grievous,  yet  it  is  not 
irreparable,  as  will  be  shown  in  the  article  Iris,  Pro- 
lapsus of;  and  when  the  surgeon  can  produce  a firm 
cicatrix  at  the  point  where  the  excrescence  was  situ- 
ated, which  prevents  a reproduction  of  the  fungus  and 
a total  destruction  of  the  eye,  he  has  fulfilled  the  indi- 
cations required.— (Scarpa,  suUe  Malattie  degli  Occhi.) 

In  a late  publication,  tw'o  cases  of  ulcer  of  the  cornea 
are  recorded,  which  were  benefited  by  Mr.  Wardrop’s 
operation  of  puncturing  the  cornea  and  discharging  the 
aqueous  humour.  In  the  first  example,  there  was  an 
ulcer  on  the  central  part  of  the  cornea,  and  a cluster 
of  blood-vessels  passing  towards  it.  The  whole  eye- 
ball was  also  much  inflamed.  The  puncture  was  made 
art;  the  place  where  the  vessels  passed.  The  patient’s 
severe  headache  was  relieved,  and  under  the  use  of  fo- 
mentations and  the  vinous  tincture  of  opium,  all  the 
other  symptoms  rapidly  subsided.  In  the  second  case, 
there  were  two  or  three  erosions,  with  a good  deal  of- 
muddiness  of  the  cornea,  headache,  &c.  The  obscu- 
rity of  this  membrane  instantly  disappeared,  and  the 
headache  subsided,  upon  the  aqueous  humour  being  dis- 
charged. With  the  help  of  bleeding  and  fomentations, 
the  symptoms  abated,  the  ulcer  healed  in  a few  days, 
and  the  ey'e  reco-vered.— (See  Med.  Chir.  Trans,  vol.  4, 
p.  ISfi,  187,) 

hi  superficial  ulcers  of  the  cornea,  attended  with 
mtich  inflammation  of  the  conjunctiva,  Mr.  Travers 
recommends  opium,  combined  so  as  to  operate  upon 
the  skin,  and  keeping  the  bowels  well  open.  Here  he 
differs  from  Scarpa,  in  specifying  the  use  of  the  nitrate 
of  silver  as  the  best  local  treatinent.  Warm  fomenta- 
tions, he  says,  aflbrd  temporary  relief ; and  when  the 
inflammation  of  the  sclerotica  is  intense,  he  advises  the 
exhibition  of  mercury. — {Synopsis  of  the  Diseases  of 
the  Eye,iK27S.) 

With  regard  to  the  treatment  of  indolent  and  deep 
sloughing  ulcers  of  the  cornea,  Mr.  Travers  praises,  in 
addition  to  the  employment  of  the  nitrate  of  silver,  the 
occasional  use  of  leeches,  and  the  administration  of 
tonics  and  sedatives. 

The  same  author  has  also  noticed  chronic  interstitial 
tdeers,  where  the  cornea  is  transparent,  “ but  indented 
like  a bonce  when  stuck  upon  a marble  hearth,  or  pit- 
ted, according  as  the  ulcers  are  diffused  or  circum- 
scribed.” These  axe  said  to  succeed  acute  inflamma- 
tion, when  large  quantities  of  blood  have  been  lost, 
and  to  occur  frequently  in  children  imperfectly  nou- 
rished, or  in  adults  who  are  very  debilitated.  With  the 
aid  of  good  diet,  tonics,  and  moderate  topical  stimulants, 
like  vinum  opii,  or  the  zinc  collyrium,  they  become 
hazy,  which  denotes  the  commencement  of  the  adhesive 
inflammation.— (Op.  czt.p.  117.) 

OSSIFICATION  OF  THE  CORNEA. 

Mr.  Wardrop  has  seen  only  one  instance  of  ossifica- 
tion of  the  coniea ; and  in  that  ca.se  the  whole  eye  w^as 
changed  in  its  form,  and  the  corriea  had  become  opaque. 
On  macerating  the  latter  part,  a piece  of  bone,  weighing 
two  grams,  oval-shajied,  hard,  and  with  a smooth  sur- 
face, was  found  between  its  lamella*.  .V  piece  of 


bone  was  also  found  between  the  choroid  coat  and 
retina. 

The  same  gentleman  informs  us,  that  Walter  had, 
in  his  museum,  a piece  of  cornea,  taken  from  a man 
sixty  years  of  age,  containing  a bony  mass,  which  was 
three  lines  long,  two  broad,  and  weighed  two  grains. 

In  Mr.  Wardrop’s  publication  there  is  also  recorded 
a curious  case,  in  which  a portion  of  bone  was  formed, 
either  in  the  substance  of  the  cornea,  or  immediately  be- 
hind it,  and  which  was  extracted  from  the  eye  by  Mr.  An- 
derson, surgeon  at  Inverary.  The  patient  was  a woman 
thirty-one  years  of  age,  and  the  formation  of  the  bony 
substance,  which  was  about  half  as  large  as  a six- 
pence, is  said  to  have  been  occasioned  by  a fall  against 
the  root  of  a tree,  fifteen  years  before  the  operation,  by 
which  accident  the  eye  was  struck,  though  not  cut.— 
(See  Wardrop's  Essays  on  the  Morbid  Anatomy  of 
the  Human  Eye,  vol.  1,  chap.  10.) 

ALTERATION  IN  THE  FORM  OF  THE  CORNEA, 

This  is  the  last  subject  which  I shall  take  notice  of 
in  the  present  article.  It  is  well  known  that  the  con- 
vexity of  the  cornea  varies  in  different  persons,  and  in 
the  same  individual  at  different  periods  of  life,  this  part 
of  the  eye  being  naturally  most  convex  in  young  sub- 
jects. It  appears  also  from  the  experiments  of  the 
late  Mr.  Ramsden,  and  those  of  Sir  E.  Home,  that  the 
sphericity  of  the  cornea  is  altered  according  to  the  dis- 
tance at  which  objects  are  viewed. 

Sometimes  the  cornea  projects  or  collapses  so  consi- 
derably, without  its  transparency  being  affected,  that 
sight  is  much  impaired  or  quite  destroyed.  The  first 
ease  has  been  called  by  some  authors  the  Staphyloma 
pellvcidum ; the  second,  Rhytidosis. 

Leveille,  the  French  translator  of  Scarpa’s  book  on 
the  diseases  of  the  eye,  has  described  a case  in  which 
the  cornea  of  both  eyes  became  of  a conical  form.  Mr. 
Wardrop  met  with  two  examples  of  a similar  disease; 
but  only  one  eye  was  affected  in  each  of  them.  In  both 
cases,  the  conical  figure  of  the  cornea  was  very  remark- 
able, and  the  apex  in  the  cone  was  in  the  centre  of  the 
cornea.  When  the  eye  was  -viewed  laterally,  the  apex 
resembled  a piece  of  solid  crystal ; and  when  looked  at 
directly  opposite,  it  had  a transparent  sparkling  appear- 
ance, which  prevented  the  pupil  and  iris  from  being 
distinctly  seen. 

One  of  these  cases  occurred  in  a lady  upwards  of 
thirty  years  of  age,  and  the  changes  produced  in  her 
vision  were  very  remarkable.  At  the  distance  of  an 
inch,  or  an  inch  and  a half,  she  could  plainly  distin- 
guish small  objects  when  held  towards  the  temporal 
angle  of  the  eye,  although  it  required  considerable  ex- 
ertion ; but  the  sphere  of  vision  was  very  limited. 

On  looKing  through  a small  hole  in  a card,  she  could 
distinguish  objects  held  very  close  to  the  ej  e,  and  could 
even  retul  a book. 

At  any  distance  greater  than  two  inches,  vision  was 
very  indistinct ; and  at  a ifew  feet  she  could  neither 
judge  of  the  distance  nor  the  form  of  the  object. 

When  she  looked  at  a distant  luminous  body,  such 
as  a candle,  it  was  multiplied  five  or  six  times,  and  all 
the  images  w'ere  more  or  less  indistinct.  She  could 
never  find  any  glass  sufficiently  concave  to  assist  her 
vision.  She  did  not  remark  this  complaint  in  her  eye 
until  she  was  about  sixteen  years  of  age,  and  she  does 
not  think  it  has  undergone  any  change  since  that  time. 

In  Mr.  Wardrop’s  publication  may  be  read  a letter 
from  Dr.  Brewster,  giving  an  explanation  of  the  pheno- 
mena of  the  foregoing  case. 

It  appears  that  >Ir.  Phipps  had  opportunities  of 
watching  the  progress  of  several  cases  in  which  the 
cornea  had  become  conical,  and  that  he  never  saw  the 
disease  in  persons  under  the  age  of  founeen  or  sixteen. 
The  same  gentleman  also  observed,  that  when  the  cone 
is  once  complete,  the  disease  seldom  makes  any  farther 
progress,  except  that  the  apex  sometimes  becomes 
opaque. 

Burgman  saw  a remarkable  case  where  the  cornea 
of  both  the  eyes  of  a persoHj  who  had  been  hanged, 
were  so  prodigiously  extended,  that  they  reached  down 
to  the  mouth  like  two  horns. — {Haller,  Disputationes 
Chirurg.  tom.  2.)  The  chapter  of  Mr.  Wardrop  on  the 
preceding  subject  will  be  found  highly  interesting  to 
such  as  are  desirous  of  farther  information  concerning 
this  curious  disease  of  the  eye.— (See  Wardrop's  Es- 
says on  the.  Morbid  Anatomy  of  the  Eye,  vol.  I,  chap. 
13.)  For  information  relative  to  diseases  of  the  cornea. 


CORNEA. 


293 


see  M.  Geiger,  De  Fistula  Corne<B,  Tub.  1742.  C.  F. 
Giffiheil,  De  Ulceribus  Corneee,  Tub.  1744.  J.  W. 
Baury,  De  Maculis  CornecB,  <S-c.  Tub.  1743.  G.  H.  Vol- 
ger,  De  Maculis  Come<B,  ito.  Giitt.  1778.  A.  G.  Richter, 
Anfangsgr.  der  Wundarzn.  b.  3,  kap.  4.  8vo.  Gott. 
1795.  Ant.  Scarpa,  Trattato  delle  Malattie  degli 
Occhi,  ed.  2,  8vo.  Pavia,  1816,  chap.  8.  10.  J.  Beer, 
Praktische  Beobacht.  uber  den  graue^i  Staar,  und  die 
Krankheiten  der  Homhaut,  Wien,  1799,  und  Lehre  von 
den  Augenkr.  b.  2,  Wien,  1817.  M.  J.  Chelius,  Ueber 
die  durchsichtige  Hornhaut  d.es  Auges,  ihre  Function, 
und  ihre  Krankhqften  Veranderungen,  8vo.  Karls- 
ruhe, 1818.  A.  Clemens,  Diss.  sistens  Tunicas  Cornea: 
et  Humoris  Aquei  Monographiam  Physiologico-patho- 
logicam,  Mo.  Giitt.  1816.  J.  Wardrop’s  Essays  on  the 
Morbid  Anatomy  of  the  Human  Eye,  vol.  1,  8vo.  edit. 
1808.  B.  Travers^ Synopsis  of  the  Diseases  of  the  Eye, 
8vo.  Bond.  1820.  J.  Vetch,  A Practical  Treatise  on  the 
Diseases  of  the  Eye,  8vo.  Bond.  1820.  The  sections 
of  this  work  on  opaque  cornea  and  ulceration  of  the 
cornea  are  highly  interesting. 

CORNS.  {Clavi,  Spinas  Pedum,  Colli,  Condylo- 
mata,  d-c.)  A corn,  technically  called  claxus,  from  its 
fancied  resemblance  to  the  head  of  a nail,  is  a brawn- 
like hardness  of  the  skin,  with  a kind  of  root  sometimes 
extending  deeply  into  the  subjacent  cellular  substance. 
When  this  is  the  case,  the  indurated  part  is  fixed ; but 
while  the  hardness  is  more  superficial,  it  is  quite 
moveable.  Some  corns  rise  up  above  the  level  of  the 
skin  in  the  manner  of  a flat  wart.  They  are  hard, 
dry,  and  insensible,  just  like  the  thickened  cuticle  which 
forms  on  the  soles  of  the  feet,  or  on  the  hands  of  la- 
bouring people. 

Corns  are  entirely  owing  to  repeated  and  long-con- 
tinued pressure.  Hence  they  are  most  frequent  in  such 
situations  as  are  most  exposed  to  pressure,  and  where 
the  skin  is  near  bones,  as  on  the  toes,  soles  of  the 
feet,  &c.  However,  corns  have  occasionally  been  seen 
over  the  crista  of  the  ileum  from  the  pressure  of  stays, 
and  even  on  the  ears  from  the  pressure  of  heavy  earrings. 

Corns  of  the  feet  are  usually  owing  to  tight  shoes, 
and  consequently  they  are  more  common  in  the  higher 
classes,  and  in  women,  than  other  subjects.  In  females, 
indeed,  the  ridiculous  fashion  of  wearing  high-heeled 
shoes  was  very  conducive  to  this  affliction ; for  cer- 
tainly it  merits  the  appellation.  In  shoes  thus  made 
the  whole  weight  of  the  body  falls  i)rlacipally  on  the 
toes,  which  become  quite  wedged,  and  dreadfully  com- 
pressed in  the  end  of  the  shoe. 

Thouiih  some  persons  who  have  corns  suffer  very- 
little,  others  occasionally  endure  such  torture  from 
them,  that  they  are  quite  incapable  of  standing  or 
walking.  Doubtless  the  great  pain  proceeds  from  the 
irritation  of  the  hard  corn  on  the  tender  cutis  beneath, 
which  is  frequently  very  much  inflamed  in  consequence 
of  the  pressure.  It  is  observed  that  every  thing  which 
accelerates  the  motion  of  the  blood,  which  heats  the 
feet,  which  increases  the  pressure  of  the  corn  on  the 
subjacent  parts,  or  the  determination  of  blood  to  the 
feet,  or  which  promotes  its  accumulation  in  them,  ex- 
asperates the  pain.  Hence,  the  bad  effects  of  warm 
stockings,  tight  shoes,  exercise,  long  standing,  d.-inking, 
(fee.  The  pain  in  warm  weather  is  always  much  more 
annoying  than  in  winter. 

If  a person  merely  seeks  temporary  relief,  it  may  be 
obtained  by  pulling  off  his  tight  shoes,  sitting  down,  plac- 
ing his  feet  in  a horizontal  posture,  and  becoming  a little 
cool : the  prominent  portion  of  the  corn  should  be  cut 
off,  as  far  as  it  can  be  done  without  exciting  pain  or 
bleeding,  and  the  feet  should  be  bathed  in  warm  water. 

The  radical  cure  essentially  requires  the  avoidance  of 
all  the  above  causes,  and  particularly  of  much  walking 
or  standing.  Wide,  soft  shoes  should  be  worn.  Such 
means  are  not  only  requisite  for  a radical  cure,  but 
they  alone  very  often  effect  it.  How  many  women  be- 
come spontaneously  free  from  corns  in  childbed  and 
other  confinements ! Though  the  radical  cure  is  so 
easy,  few  obtain  it,  because  their  perseverance  ceases 
as  soon  as  they  experience  the  wished-for  relief. 

When  business  or  other  circumstances  jirevent  the 
patient  from  adopting  this  plan,  and  oblige  him  to  walk 
or  stand  a good  deal,  .still  it  is  possible  to  remove  all 
pressure  from  the  corn.  For  this  purpose,  from  eight 
to  twelve  pieces  of  linen,  smeared  with  an  emollient 
ointment,  and  having  an  aperture  cut  in  the  middle, 
exactly  adapted  to  the  size  of  the  corn,  are  to  be  laid 
over  each  other,  and  so  applied  to  the  foot  that  the  corn 


is  to  lie  in  the  opening  in  such  a manner  that  it  cannot 
be  touched  by  the  shoe  or  stocking.  When  the  plaster 
has  been  applied  some  weeks,  the  corn  commonly  disap- 
pears without  any  other  means.  Should  the  corn  be  in 
the  sole  of  the  foot,  it  is  only  necessary  to  piit  in  the  shoe 
a felt-sole,  wherein  a hole  has  been  cut,  corresponding 
to  the  situation,  size,  and  figure  of  the  induration. 

A corn  may  also  be  certainly,  permanently,  and 
speedily  eradicated  by  the  following  method,  especially 
when  the  plaster  and  felt-sole  with  a hole  in  it  are  em- 
ployed at  the  same  time.  The  corn  is  to  be  rubbed  twice 
a day  with  an  emollient  ointment,  such  as  that  of 
marshmallows,  or  with  the  volatile  liniment,  which  is 
still  bettor ; and  in  the  interim  is  to  be  covered  with  a 
softening  plaster.  Every  morning  and  evening  the 
foot  is  to  be  put  for  half  an  hour  in  warm  water,  and 
while  there  the  corn  is  to  be  well  rubbed  with  soap. 
Afterward  all  the  soft,  white,  pulpy  outside  of  the  corn 
is  to  be  scraped  off  with  a blunt  knife ; but  the  scraping 
is  to  be  left  off  the  moment  the  patient  begins  to  com- 
plain of  pain  from  it.  The  same  treatment  is  be  per- 
sisted in  without  interruption  until  the  corn  is  totally 
extirpated,  which  is  generally  effected  in  eight  or  twelve 
days.  If  left  off  sooner,  the  corn  grows  again. 

A multitude  of  other  remedies  for  curing  corns  are 
recommended . They  all  possess,  more  or  less,  an  emol- 
lient and  discutient  property.  The  principal  are  green 
wax,  soap,  mercurial  and  hemlock  plasters,  a piece  of 
green  oil-skin,  &c.  They  are  to  be  applied  to  the  corn, 
and  renewed  as  often  as  necessary.  A very  successful 
composition  consists  of  two  ounces  of  gum  ammonia- 
cum,  the  same  quantity  of  yellow  wax,  and  six  drachms 
of  verdigris.  In  a fortnight,  if  the  corn  yet  remain,  a 
fresh  plaster  is  to  be  applied. 

It  is  frequently  difficult  and  hazardous  to  cut  out  a 
corn.  The  whole  must  be  completely  taken  away,  or 
else  it  grows  again  ; and  the  more  frequently  it  is  i)ar- 
tially  cut  away,  the  quicker  is  its  growth  rendered. 
When  the  skin  is  moveable,  and  consequently  the  corn 
not  adherent  to  the  subjacent  parts,  its  excision  may 
be  performed  with  facility  and  safety,  but  not  without 
pain.  But,  in  the  opposite  case,  either  leaving  a piece 
of  the  corn  behind,  or  wounding  the  parts  beneath,  can 
seldom  be  avoided.  The  latter  circumstance  may  ex- 
cite serious  mischief. 

A person  entirely  cured  of  corns  is  sure  to  be  affected 
with  them  again,  unless  the  above-mentioned  causes  be 
carefhlly  avoided.  Some  subjects  are  indeed  particu- 
larly disposed  to  have  the  complaint.  There  are  per- 
sons who  for  life  wear  tight  shoes,  and  take  no  care  of 
their  feet,  and  yet  are  never  incommoded  with  corns. 
On  the  contrary,  others  are  constantly  troubled  with 
them,  though  they  pay  attention  to  themselves.  Many 
are  for  a time  vexed  with  corns,  and  then  become  quite 
free  from  them,  though  they  continue  to  wear  the  same 
kind  of  shoes  and  stockings. 

Mr.  Wardrop  recommends  cutting  or  tearing  away 
as  much  of  the  corn  as  can  be  done  with  safety  ; then 
keeping  the  toe  for  some  time  in  warm  water ; and  af- 
ter the  adjacent  skin  has  been  well  dried,  rubjing  the 
exposed  surface  of-the  corn  with  the  argentum  nitratum, 
or  wetting  it,  by  the  means  of  a camel-hair  pencil,  with 
a solution  of  the  oxymuriate  of  mercury  in  spirit  of 
wine.  Either  of  these  applications,  two  or  three  times 
repeated,  he  says,  will  mostly  effect  a cure. — (See  Med. 
Chir.  Trans,  vol.  5,p.  140.)  However,  the  use  of  caus- 
tic for  the  cure  of  corns  is  not  a new  proposal.— (See 
Callisen’s  Syst.  Chir.  Hodiemae,  part  2,  p.  200.) 

The  above  account  is  partly  taken  from  Richters 
Anfangsgriinde  der  Wundarzneykunst,  b.  1. 

COUCHING.  The  depression  of  a cataract  out  of  the 
axis  of  sight,  or  the  displacement,  breaking,  and  dis- 
turbance of  the  opaque  lens  in  various  ways  with  a kind 
of  needle  for  these  purposes,  so  as  to  bring  about  the 
dispersion  and  absorption  of  the  cataract. — (See  Car 
tar  act.) 

COUVRE  CHEF.  The  name  of  a bandage.— (See 
Bandage.) 

CRANIUM.  For  an  account  of  its  fractures,  see 
Head,  Injuries  of. 

CREMOR  LITHARGYRI  ACETATI.  R.  Cremoris 
laefis  Ij.  Liq.  plumbi.  acet.  3j.  M.  Employed  by 
Kirkland  in  ophthalmies,  and  other  inflammations. 

CREPITUS.  The  grating  sensation  or  noise  occa- 
sioned by  the  ends  of  a fracture,  when  they  are  moved 
and  rubbed  against  each  other;  one  of  the  me.'^t  positive 
symptoms  of  the  existence  of  such  an  a -rj 


294 


DEC 


DIP 


CUPRI  SULPHAS  (Sulphate  of  Copper)  is  an  es- 
charotic,  and  an  ingredient  in  several  astringent  fluid 
applications,  lotions  for  ulcers,  collyria  for  the  eyes,  and 
injections  ibr  the  urethra. 

CURETTE.  (French.)  An  instrument  shaped  like 
a minute  spoon  or  scoop,  invented  by  Daviel,  and  used 
in  the  extraction  of  the  cataract,  for  taking  away  any 
opaque  matter,  which  may  remain  behind  the  pupil,  im- 
mediately after  the  lens  has  been  taken  out. 

CURVATURE  OF  THE  SPIXE.  See  Vertebra, 
Disease  of 


CLTPING.  Bleeding. 

CYSTITOME.  (From  »fi;(TTif,and  rf/iV(«),to  cut.)  An 
instrument  made  on  the  same  principle  as  the  pharjii- 
gotomus,  and  invented  b^-  M.  de  la  Faye,  for  opening 
the  capsule  of  the  cr>'stalline  lens. 

CYSTOCELE.  (From  xt'oris.  the  bladder,  and  KrfXii, 
a tumour.)  A hernia  formed  by  a protrusion  of  the 
bladder. — (See  Hernia.) 

CYSTOTO^HA.  (From  Kvang,  the  bladder,  and 
Teiivu),  to  cut.)  The  operation  of  opening  the  bladder,  for 
the  extraction  of  a stone  or  calculus. — (See  Lithotorny.j 


D 


D.\CRY0!VIA.  (From  SaKovco,  to  weep.)  An  imper- 
vious state  of  one  or  both  the  puncta  laclir3Tnalia, 
preventing  the  tears  from  passing  into  the  lachrymal  sac. 
DAUCUS.  See  Cataplasma  Baud. 

DECOCTUM  CHAMCEMELI.  R.  Florurn  chamce- 
meli,  3 ss.  Aquae  distillatae,  Ibj.  Boil  ten  minutes, 
and  strain  the  liquor.  A common  decoction  for  foment-  1 
aUons. — (See  Fomentvm.)  \ 

DECOC-TUM  DULCAMAR.T:.  R.  Dulcamarae  cau-  i 
lis  concisse  unciam,  aquae  eclarium  cum  semisse.  De-  j 
coque  ad  octarium,  et  cola.  I 

ilie  decoction  of  bittersweet,  or  woody  nightshade,  is  I 
recommended  for  some  cutaneous  diseases,  proceeding  | 
from  scrofula,  lepra,  and  lues  venerea.  The  dose  is  I 
one  or  two  table  spoonfuls,  three  times  a day.  An  aro- 
matic tincture  should  be  added. 

DEC0CTI:M  HELLEBORI  ALBI.  (Xow  the  Be- 
eoctum  Veratri.)  R.  Pulveris  radicis  hellebcri  albi,  3). 
Aquae  distillatae,  Ibj.  Spiritus  vinosi  rectificati,  3 ij. 
Boil  the  water  and  powder  till  only  one-half  the  fluid 
remains,  and  when  cold  add  the  spirit. 

This  is  used  as  a lotion  for  curing  psora,  porrigo,  and 
some  herpetic  affections. 

DECOCTUM  LOBELIA.  (Blue  Cardinal  Flmcer 
of  Virginia.)  R.  Radicis  lobeliae  sj-philiticae  siccae  ma- 
nip.  j.  Aqu®  distillatae,  Ibxij.  This  is  to  be  boded  till 
only  four  quarts  remain.  The  lobelia  once  gained  re- 
pute as  an  antivenereal,  though  little  reliance  is  now 
put  in  it.  The  patient  is  at  first  to  take  half  a pint  twice, 
and  afterward  four  times  a day.  It  operates,  however, 
as  a purgative,  and  the  doses  must  be  regtdated  accord- 
ing as  the  bowels  appear  to  bear  them. 

DECOCTUM  MEZEREI.  R.  Corticis  radicis  me2e- 
rei  recentis,  3 ij.  Radicis  glycirrhiz®  contusae,  3j. 
Aqu®  (hstdlat®,  Ibiij.  Bod  the  mezereon  in  the  water 
till  only  two  pints  remain;  and  when  the  boiling  is 
nearly  firushed,  add  the  liquorice  root. 

The  decoction  of  mezereon  has  been  much  prescribed 
for  venereal  nodes  and  nocturnal  pains  in  the  bones,  in 
dases  of  from  four  to  eight  ounces,  three  times  a day. 

DECOCTUM  PAPAVERIS.  R.  Papaveris  soiimi- 
feri  caps ’Icurnm  concisarum,  yiv.  Aqu®,  Ibiv.  Boil 
for  a quarter  of  an  hour,  and  strain.  In  cases  attended 
with  great  pain  and  inflammation,  this  decoction  is  used 
as  a fomenting  fluid. 

DECOCTUM  QUERCUS.  R.  Quercus  corticis,  ij. 
Aqu®,  feij.  Bod  down  to  a pint,  and  strain  the  fluid. 

'This  decoction  forms  a very  astringent  injection, 
which  is  sometimes  used  for  stopping  gleets  from  the 
vagina.  It  also  makes  a lotion  which  is  of  consiilcrable  | 
use  in  cases  of  prolapsus  ani.  It  may  be  applied  to  some  ; 
slight  rheumatic  white  swellings,  which  it  wdl  some-  | 
times  cure,  particularlv  when  a little  alum  is  put  into  it. 

DECOCTUM  SARSAPARILLA.  R.  Sarsapardl® 
radicis  concis®,  3 iv.  Aqu®  ferventis,  Ibiv.  The  sar- 
saparilla is  to  be  macerated  for  four  hours,  near  the  fire, 
in  a vessel  lightly  closed.  The  root  is  then  to  be  taken  1 
out,  bruised,  and  put  into  the  fluid  again.  The  mace- 
ration is  to  be  continued  two  hours  longer,  after  which  1 
the  liquor  is  to  be  boiled  tUl  only  two  pints  remain.  ; 
Lastly  it  is  to  be  strained.  ! 

DECOCTUM  SARSAPARILLA  COMPOSITUM. 
R.  Decocti  sarsaparills.ferventis,  Ibiv.  Sassafras  radi-  ' 
cis  concis®,  guaiaci  ligni  rasi,  glycirrhiz®  radicis  con-  ] 
lus  e,  singulorum  3j.  Mezerei  radicis  corticis.  3 iij.  | 
These  are  to  be  boiled  together  for  a quaner  of  an  ' 
hour,  and  then  strained,  j 

This  and  the  preceding  decoction  of  sarsaparilla  are  ; 
much  prescribed  in  cases  of  venereal  nodes  and  pains  ; ■ 


but  while  some  surgeons  hold  them  in  high  repute  in 
such  cases,  others  entertain  an  opposite  opinion  of  them. 
They  are  also  commonly  given  in  several  cutaneous  dis- 
eases, and  in  scrofula. 

Tlie  simple  decoction  is  frequently  directed  for  the 
restoration  of  the  constitution  after  a course  of  mercurj', 
sometimes  mLxed  with  an  equal  quantity  of  milk. 

The  common  dose  of  both  the  decoctions  is  from  four 
to  eight  ounces,  three  times  a day. 

The  compound  one  possesses  similar  qualities  to  those 
of  the  famous  Lisbon  diet  drink,  for  which  it  is  now  a 
common  substitute. 

DECOCTUM  ULiH.  R.  Ulmi  corticis  recentis  con- 
tus.  3 iv.  Aqu®,  Ibiv.  Boil  to  two  pints,  and  then 
strain  the  liquor. 

The  decoction  of  elm  bark  is  often  prescribed  in  cuta- 
neous diseases.  Its  operation  is  frequently  promoted 
by  giving  with  it  the  hvdrargxri  submurias. 

DECOCTUM  ^'ERATRI. ' See  Becoctmn  Hellebori 
Albi. 

DEPRESSION  OF  THE  SKULL.  See  Head,  In- 
juries of. 

DEPRESSION  OF  THE  CATARACT.  See  Ca- 
taract. 

DETERMINATION.  WTien  the  blood  flows  into  a 
ptirt  more  rapidly  and  copiously  than  is  natural,  it  is 
said,  in  the  language  of  surgery,  that  there  is  a deter- 
miiiation  of  blo^  to  it. 

DIARESlSs.  (From  6iaipio),  to  divide.)  A division 
of  substance ; a solution  of  continuity.  This  was  for- 
merly a sort  of  generic  term  applied  to  everj-  part  of  sur- 
gery, by  which  the  continuity  of  parts  was  divided. 

DIGESTION.  (From  digero,  to  dissolve.)  By  the 
digestion  of  a wound,  or  ulcer,  the  old  surgeons  meant 
bringing  it  into  a state  in  which  it  formed  healthy  pus. 

DIGESTIV  ES.  Applications  which  promote  this 
object. 

DIORTHOSIS.  (From  ciop0du,  to  direct.)  One  of  the 
ancient  divisions  of  surgery : it  signifies  the  restoration 
of  parrs  to  their  proper  situations. 

DIPLO  PIA.  (From  5tT,\oCs,  double,  and  a)(^  , the 
e\e,  or  drropai,  to  see.)  Vis^es  duplicatus  is  of  two 
kinds.  For  instance,  the  patient  either  sees  an  object 
double,  treble,  Ac.  only  when  he  is  looking  at  it  wnth 
both  his  eyes,  and  no  sooner  is  one  eye  shut  than  the 
object  is  s^n  single  and  right ; or  else  he  sees  every 
object  double,  whether  he  surveys  it  with  one  or  both 
his  eyes.  The  disorder  is  observed  to  affect  persons  in 
different  degrees.  Patients  seldom  see  the  two  appear- 
ances which  objects  present  with  equal  distinctness ; 
but  generally  discern  one  much  more  plainly  and  per- 
fectly than  the  other.  The  first  distinct  shape  which 
strikes  the  eye  is  commonly  that  of  the  real  object, 
while  the  second  is  indistinct,  false,  and  visionary 
Therefore  patients  labouring  under  this  affection  sel- 
dom  make  a mistake,  but  almost  always  know  which 
is  the  true  and  real  object.  However,  there  are  cases 
in  which  the  patient  sees,  with  equal  clearness,  the  two 
appearances  which  things  assume,  so  that  he  is  incapa- 
ble of  distinguishing  the  real  object  from  what  is  false 
and  only  imaginary. 

The  disorder  is  sometimes  transitorj'  and  of  short  du- 
ration. and  may  be  brought  on  in  a healthy  eye  by  some 
accidental  cause,  getieraily  an  irritation  affecting  the 
organ.  .Sometimes  the  complaint  is  continual,  some- 
times periodical.  In  j^articular  instances  the  j>aiient 
only  sees  objects  double,  when  he  has  been  straining  his 
sight  for  a considerable  time,  as,  for  e\an!n'e.  when  no 
I has  been  reading  a small  print  for  a long  while  by  can* 


DIPLOPIA. 


295 


^le-light.  In  this  case,  the  disorder  becomes  lessened 
by  shutting  the  eyes  for  a few  moments.  There  are 
also  instances  in  which  the  objects  have  a double  ap- 
pearance only  at  a particular  distance,  and  not  either 
when  they  are  nearer  or  farther  off.  Sometimes  the 
patient  sees  objects  double  only  upon  one  side ; as,  for 
example,  when  he  turns  his  eyes  to  the  right-hand, 
while  nothing  of  this  sort  is  experienced  in  looking  in 
any  other  direction.  In  certain  cases,  objects  appear 
double,  in  whatever  way  the  eyes  are  turned  and  directed. 

The  causes  of  double  vision  may  be  divided  into  four 
classes.  Namely,  the  object  which  the  patient  looks  at 
may  be  represented  double  upon  the  retina ; which  is 
the  effect  of  the  first  class  of  causes.  Or,  the  object 
may  be  depicted  in  one  eye  differently  from  what  it  is 
in  the  other,  in  regard  to  size,  position,  distance,  clear- 
ness, &c.  This  is  the  effect  of  the  second  class  of 
causes.  Or,  the  object  may  appear  to  one  eye  to  be 
in  a different  place  from  that  which  it  seems  to  the  other 
to  occupy  : the  effect  of  the  third  class  of  causes.  Or, 
lastly,  the  sensibility  of  the  optic  nerves  is  defective,  so 
that  the  image  of  an  object,  though  it  may  appear  single 
to  one  eye  as  well  as  the  other,  yet  in  one  identical 
situation  will  seem  double  to  both  of  them.  When  the 
complaint  originates  from  causes  of  the  first  and  fourth 
class,  the  patient  sees  things  double,  whether  he  is 
using  only  one  or  both  eyes  ; liut  when  it  proceeds  from 
the  second  and  third  class  of  causes,  the  patient  sees 
objects  double  only  when  he  is  looking  at  them  with 
both  eyes,  and  no  sooner  does  he  shut  one  than  objects 
put  on  their  natural  single  appearance. 

The  following  are  the  chief  causes  of  the  first  class 
of  a single  object  being  depicted  upon  the  retina  as  if 
double.  1.  An  unevenness  of  the  cornea,  which  is  di- 
vided into  two  or  more  convex  surfaces.  There  are 
cases,  which  show  that  such  an  uneven  sha{)e  may 
actually  be  the  cause  of  double  vision.— (i/aZZcr,  Ele- 
nient.  Physiol,  t.  5,  p.  85.)  According  to  Beer,  this 
conformation  of  the  cornea  is  mostly  a result  of  several 
preceding  ulcers  of  that  membrane;  in  which  circum- 
stance, the  patient  sees  with  the  affected  eye  not  merely 
double,  but  treble,  and  quadruple,  of  which  facts  Beer  has 
met  with  some  examples. — {Lehre  von  den  Augenkr. 
A2,p.  31.)  However,  it  must  not  be  dissembled  that 
in  a far  greater  number  of  instances,  such  unevenness 
of  the  cornea,  though  equally  considerable,  does  not  occa- 
sion this  defect  of  siglu.  We  have  principally  an  oppor- 
tunity of  observing  cases  of  this  sort  after  the  operation 
of  extracting  the  cataract.  Hence,  it  would  seem  that 
the  inequalities  must  be  of  very  particular  shape  to 
produce  double  vision.  The  diagnosis  of  this  cause  is 
easy  enough,  but  the  removal  of  it  is  impracticable ; 
for  how  is  it  possible  to  restore  the  original  shape  of 
the  cornea  ? On  this  case;  however.  Beer  delivers  a 
more  favourable  prognosis  than  Richter ; for  he  states, 
that  when  the  patient  is  not  decrepit,  the  double  vision, 
from  altered  shape  of  the  cornea,  will  gradually  disap- 
pear of  itself,  when  proper  care  is  taken  of  the  consti- 
tution, and  in  particular  of  the  eye.— (R.  2,  p.  32.) 
2.  \n  inequality  of  the  anterior  surface  of  the  crystalline 
lens,  whereby  the  same  is  divided  into  several  distinct 
surfaces,  it  is  suggested,  may  akso  be  the  occasion  of 
diplopia.  Such  an  inequality  may  possibly  produce  the 
di.sorder;  but  it  is  exceedingly  doubtful,  whether  any 
case  of  this  sort  has  ever  been  met  with,  and,  as 
Richter  properly  remarks,  the  investigation  is  not  worth 
u;idertaking,  as  the  diagnosis  and  cure  would  be  equally 
impracticable.  The  only  possible  method  of  cure 
would  be  the  e.xtraction  or  depre.ssion  of  the  crystalline 
lens ; yet  with  the  uncertainty  respecting  the  nature 
of  the  cause,  what  man  would  be  justified  in  per- 
forming an  operation,  in  which  the  patient  is  not  wholly 
Hxemin  from  the  danger  of  losing  his  sight  altogether  1 
\ flouble  aperture  in  the  iris,  or,  as  the  ca.se  is  termed, 

» double  pupil,  and  a deviation  of  the  pupil  from  its 
natural  position,  have  been  enumerated  as  causes  of 
diplopia  —{Haumer,  in  Act.  Soc.  Hassiac.  t.  \,No.  27.) 
However,  Richter  deems  the  reality  of  the  first  of  these 
causes  doubtful ; lor  cases  have  been  noticed,  where 
double  vision  was  not  the  effect  of  there  being  two 
openings  in  the  iris.— (7anm,  Mim.  sur  ViKil.)  But 
were  the  disorder  actually  to  originate  in  this  way,  the 
experiment  might  be  made  of  converting  the  two  aper- 
(ures  into  one. 

The  causes  of  the  second  class,  by  the  effect  of 
which  the  object  is  represented,  in  regard  to  its  size, 
vwsiuoii,  <lisian;;e,  Ac.,  differently  in  one  eye  from  what 


it  is  in  the  other,  are  for  the  most  part  rather  possible, 
than  such  as  have  been  actually  observed.  The  causes 
which  make  objects  assume  an  appearance  contrary  to 
the  real  one,  may  sometimes  be  confined  to  one  eye,  to 
which  things  are  depicted  diversely  from  what  they  are 
to  the  other  healthy  eye,  so  that  the  patient  sees,  as  it 
were,  double.  Thus,  for  example,  there  may  be  a 
stronger  refraction  of  the  rays  of  light  in  one  eye  than 
the  other ; the  patient  may  be  a my  ops  with  one  eye, 
and  a presbyops  with  the  other ; and  then  the  object 
will  seem  to  one  eye  large,  to  the  other  small ; to  one 
eye  distant,  to  the  other  plainly  near.  This  state  of  the 
sight,  indeed,  is  said  to  have  occurred  after  opeiating 
upon  a cataract  in  one  eye — {Heuermatm.)  However, 
that  this  is  not  a common  consequence  of  operating 
upon  a cataract  in  one  eye,  while  the  other  is  perfect,  is 
sufficiently  clear  from  what  has  been  said  upon  tins 
subject  in  a foregoing  part  of  this  v/ork.— (See  Cataract.) 
In  particular  examples,  objects  which  are  perpendicular 
seem  to  the  patient  to  have  a slo])ing  posture.  When 
it  is  considered  that  only  one  eye  is  thus  affected,  and 
that  to  it  things  will  appear  sloping,  and  to  the  other 
straight,  double  vision  must  be  the  effect.  A few  re- 
marks ('onnected  with  this  subject  will  be  introduced 
hereafter.— (See  Sight,  Defects  of.) 

When  both  eyes  are  so  directed  to  an  object,  that  it 
becomes  situated  in  the  axis  of  vision  of  each  of  these 
organs,  such  object  is  represented  in  both  at  the  same 
place,  that  is,  it  is  depicted  upon  that  part  of  the  retina 
on  which  the  axis  of  sight  falls.  Thus  the  object  seems 
to  both  eyes  to  be  in  the  same  place ; and  though  the 
two  organs  discern  the  thing,  it  only  communicates 
a single  appearance.  But  when  one  eye  is  turned 
to  any  object  in  a different  direction  from  that  of  the 
other  ; that  is  to  say,  when  one  eye  is  turned  to  an  ob- 
ject in  such  a way  that  the  object  is  situated  in  the  axis 
of  vision  of  this  eye,  while  the  opposite  eye  is  so  turned 
that  the  same  object  is  placed  on  one  side  of  its  axis  of 
vision ; in  other  words,  when  a person  squints,  the 
object  is  depicted  in  one  eye  u})on  a diflerent  part  of  the 
retina  from  what  it  is  in  the  other ; consequently,  the 
object  appears  to  the  two  respective  organs  to  be  dif- 
ferently situated,  and  the  patient  is  affected  with  diplo- 
pia. This  is  the  third  species  of  this  disorder,  which 
arises  from  strabismus,  as  a third  kind  of  occasional 
cause.  Such  patients  naturally  see  objects  double  only 
when  they  behold  them  with  both  eyes.  A lady,  whom 
I frequently  see,  is  much  annoyed  with  diplopia,  the 
effect  of  deep-seated  disease  in  the  orbit,  whereby  the 
eye  is  forced  out  of  its  natural  position. 

A person  who  squints  usually  has  one  eye  stronger 
than  the  other,  and  the  weakness  of  one  of  those  organs 
is  the  common  cause  of  the  strabismus.  Such  a person 
does  not  see  objects  double,  because  he  only  sees  with 
one  eye  well,  and  with  the  other  so  faintly  and  imper- 
fectly, that  scarcely  any  impression  is  made.  Hence, 
every  case  of  strabismus  is  not  necessarily  combined 
Avith  diplopia ; indeed,  the  common  kind  of  squinting 
isnot  joined  with  it.  A person  affected  with  strabismus 
only  sees  double  when  the  sight  of  each  eye  is  etiually 
strong,  and  when  the  squinting  does  not  depend  upon 
any  weakness  of  one  of  the  eyes,  but  upoii  some  other 
occasional  causes.  The  principal  causes  of  the  latter 
sort  are  of  a spasmodic  nature,  viz.  an  irritation 
affects  some  muscle  of  the  eye  in  such  a manner,  (hat 
the  patient  is  incajiacitated  from  moving  both  his  eyes 
according  to  his  will,  and  from  directing  them  to  any 
ob  ject,  so  that  such  object  may  be  at  once  in  the  axis  of 
vision  of  both.  On  this  case,  the  observations  of  Sir 
'E.  Home  are  interesting,  who  has  made  many  accurate 
reflections  on  the  effect  of  an  irregular  action  of  the 
straight  muscles  of  the  eye  in  producing  double  vision. 
— {Phil.  Trans.  1797.) 

Richter  states  that  in  the  majority  of  cases,  the  irri- 
tation alluded  to  is  seated  in  the  gastric  organs,  though 
he  thinks  that  any  other  species  of  irritation  may  ope- 
rate upon  the  eyes  in  a similar  manner.  This  kind  of 
diplopia  is  frequently  attendant  on  other  spasmodic 
diseases  as  a symptom.  It  often  accomiianies  hypo- 
chondriasis. Sometimes  it  is  the  consciiuencc  of  vio- 
lent pain.  Richter  informs  us  of  a man  who  saw 
double,  and  sijuintcd,  during  a severe  headache.  He 
stales  that  another  xvas  affected  in  the  same  way  during- 
a toothache.  Sometimes  the  dijilopia  is  owing  to  a para- 
lysis of  one  of  the  muscles  of  the  eye  {Morgagni  d* 
Seilihns  et  Cansis  Morhorum,  epist.  13,  art.  20,  a para 
lysis  of  the  abductor  muscle) ; sometimes  to  a tumour  in 


296 


DIP 


DIS 


the  orbit.  The  diagnosis  of  this  kind  of  diplopia  is  free 
from  difficulty ; the  patient  having  been  affected  with 
squinting  ever  since  things  appeared  double  to  him. 

The  views  which  Sir  E.  Home  took  of  diplopia  from 
irregular  action,  spasm,  or  weakness  of  any  particular 
muscle  of  the  eye,  led  him  to  propose  a plan  of  treat- 
ment, the  principle  of  which  is  to  keep  the  muscle 
affected  for  a time  perfectly  at  rest,  which  is  easily  done 
by  covering  the  eye  wth  a bandage,  and  not  aJtowing 
the  organ  to  be  at  all  employed. 

The  fourth  class  of  causes  are  such  irritations  as  act 
upon  the  optic  nerves,  changing  their  sensibility  in  such 
a way  that  objects  do  not  make  tiiat  sort  of  impression 
upon  them  which  they  ought  to  do.  Thus  things  some- 
times have  the  appearance  of  being  coloured,  when  they 
are  really  not  so ; immoveable  objects  seem  in  motion, 
straight  objects  appear  oblique,  and  in  the  cases  which 
we  are  now  treating  of,  single  things  seem  to  the  eye 
double,  treble,  &c.  This  faulty  kind  of  sensibility  may 
also  be  produced  by  irritation  in  eyes  which  are  per- 
fectly sound  ; but  it  is  most  readily  occasioned  in  eyes 
which  are  pretematurally  w eak  and  irritable.  In  these, 
very  trivial  and  inconsiderable  irritations  wilt  often 
excite  it.  In  the  treatment,  the  common  indication  is  to 
discover  and  remove  whatever  irritation  conduces  to 
this  effect ; but  the  attempt  frequently  fails.  In  irritable 
eyes,  the  disorder  is  often  brought  on  by  very  slight  irri- 
tations, which  cannot  always  be  diminished  or  removed. 
Here  the  grand  indication  is  to  cure  the  weakness  and 
irritability  of  the  organs. 

According  to  Richter,  the  fourth  class  of  causes  of 
diplopia  is  the  most  frequent.  The  irritations  are  oC ' 
various  lands,  and  generally  seated  in  the  abdominal 
viscera.  Diplopia  is  sometimes  the  consequence  of  ine- 
briety, foulness  of  the  stomach,  intermitting  fevers, 
hypochondriasis,  worms,  &c.  However,  the  complaint 
is  occasionally  excited  by  other  sorts  of  irritation.  It 
has  frequently  followed  a violent  fright.  It  may  be 
connected  with  spasmodic  and  painful  diseases  of  se- 
veral kinds.  Severe  headaches  and  toothaches  are 
sometimes  joined  with  this  affection  of  the  sight. 
Richter  mentions  a boy,  who,  being  in  the  woods,  was 
struck  by  the  bough  of  a tree  over  the  eye,  and  in  con- 
sequence of  the  accident  became  affected  with  diplopia. 
He  informs  us  of  a man,  who  rode  a journey  on  horse- 
back along  a snowy  road  on  a very  sunshiny  day,  and 
was  affected  in  the  same  manner.  This  affection  of 
the  eyes  is  sometimes  the  effect  of  injuries  of  the  head. 
—(See  J/ill's  Cases  in  Surgery,  p.  108.  Schmucker, 
Med.  Chir.  Bemerk.  b.  1,  No.  26.  Hennen's  Principles 
of  Military  Surgery,  p.  345,  ed.  2.)  Persons  who  have 
weak  eyes,  are  apt  to  become  double-sighted,  whenever 
they  look  attentively  for  a long  w'hile  at  any  light  shining 
objects.  Patients  in  fevers  are  also  sometimes  double- 
sighted. — {Gooch's  Cases,  i,-c.  vol.  2.) 

The  irritation,  productive  of  diplopia,  may  lead  to 
other  serious  complaints  of  the  eye,  when  it  operates 
with  great  violence.  Indeed,  it  frequently  happens  that 
diplopia  terminates  in  some  other  disorder  of  the  eyes, 
and  is  often*  the  forerunner  of  the  worst  diseases  oi* 
these  organs,  particularly  the  gulta  serena.  The  diffi- 
culty or  casb  of  the  cure  partly  depends  upon  the  nature 
of  the  remote  cause,  and  partly  upon  the  condition  of 
the  eye.  Some  of  the  causes  are  easy,  others  difficult 
of  removal.  When  the  eye  is  very  weak  and  irritable, 
the  disorder  frequently  continues,  notwithstanding  the 
irritation  has  been  removed.  Also,  when  the  complaint 
is  relieved,  it  is  exceedingly  difficult  to  prevent  a relapse, 
for  on  verj'  irritable  eyes,  slight  irritations,  which  can- 
not be  hindered,  are  apt  to  produce  a return  of  the 
affection.  Therefore,  the  indication  is  to  remove  the 
existing  defect  of  sight,  and  take  means  for  the  preven- 
tion of  its  return,  or  the  commencement  of  any  other. 
The  weakness  and  preternatural  irritability  of  the  eye 
should  be  removed,  as  well  as  every  sort  of  irritation, 
things  which  are  often  difficult  of  accomplishment. 

The  chief  business  of  the  surgeon  in  the  treatment 
of  this  kind  of  diplopia,  consists  in  endeavouring  to  find 
out  and  remove  the  irritation  occasioning  the  disorder. 
The  majority  of  such  irritations  are  of  the  same  nature 
as  those  which  give  rise  to  the  gutta  serena.— (See 
Amaurosis.)  Indeed,  both  the  rx)mp]aints  are  often 
only  different  effects  of  the  same  cause,  and  of  course 
require  a similar  mode  of  treatment.  The  boy  wliom 
Richter  has  mentioned  as  having  become  double-sighted 
in  consequence  of  being  struck  over  the  eye  with  the 
bough  of  a tree,  was  cured  by  the  c.xterna!  use  of  the 
infu-sum  radicis  valcrianae  and  spiritus  vini  crocatu.s. 


with  which  the  eyelids  and  adjacent  parts  were  rubbed 
several  times  a day.  A diplopia,  which  followed  a vio- 
lent fright,  was  cured  by  valerian,  preceded  by  a few 
doses  of  cream  of  tartar.  The  case  recorded  by  Dr. 
Hennen,  as  proceeding  from  a gun-shot  wound  of  the 
soft  parts,  covering  the  root  of  the  nose  and  right  eye- 
brow, yielded  to  abstinence,  occasional  emetics,  and 
cold  collyria.— (PrmcipZes  of  Mil.  Surgery, ed.^p.  345.) 
A hj-pochondriacal  patient  got  rid  of  the  disorder  by 
means  of  the  warm  bath.  A diplopia,  supposed  to  arise 
from  disorder  of  the  biliary  secretion  was  cured  by  means 
of  pills  made  of  grmi  galbanum,  guaiacum,  rhubarb,  and 
Venice  soap,  assisted  with  emetics  and  purgatives. 

When  the  irritation  exciting  the  disorder  is  only  of 
temporary  duration,  as,  for  instance,  looking  at  shining 
objects ; when  the  disorder  continues  after  the  removal 
of  the  irritation  ; or,  lastly,  w'hen  the  irritation  cannot 
be  w'ell  detected  ; the  surgeon  is  to  endeavour,  by 
means  of  nervous  and  soothing  medicines,  either  to 
remove  the  impression  which  the  irritation  has  left 
upon  the  nerves,  or  to  render  the  nerves  insensible  to 
the  continuing  irritation.  According  to  Richter,  the 
following  remedies  have  proved  useful  in  cases  of 
diplopia : hartshorn,  dropped  into  the  hand,  and  held 
before  the  eyes ; the  external  use  of  the  spiritus  vini 
crocatus ; warm  bathing  of  the  eye,  particularly  in  a 
decoction  of  white  poppy  heads;  bathing  the  eye  in 
cold  collyria ; the  internal  administration  of  bark,  va- 
lerian, small  doses  of  ipecacuanha,  flowers  of  zinc,  and 
oleum  cajeput.  In  one  instatice,  in  which  it  was  im- 
possible to  detect  the  cause,  Richter  states,  that  soluble 
tartar  with  ox’s  gall,  and  castoreum  was  found  of  ser- 
vice ; that,  in  another  similar  case,  rhubarb,  ox’s  gall, 
and  asafeetida ; and,  in  a third,  liquor  ammoniae  ace- 
tatae  with  ox’s  gall  proved  useful.  This  author  farther 
observes,  that  in  all  cases  in  which  the  particular 
cause  of  the  disorder  cannot  be  precisely  determined, 
we  may  conjecture,  that  such  cause  has  its  seat  in  the 
abdominal  viscera ; and  that  much  benefit  may  often 
be  derived  from  mild  resolvents,  evacuants,  and  ano- 
dyne medicines.— (RicAter’s  Anfangsgr.  der  Wun- 
darzn.  b.  3,  kap.  15.) 

According  to  Beer,  the  diplopia  wffiich  is  not  an 
effect  of  the  continuance  of  another  disease -after  in- 
flammation of  the  eye,  but  probably  depends  upon  in- 
jurj^  of  the  retina  caused  by  such  inflammation,  usually 
diminishes  without  the  assistance  of  art,  if  the  eye  be 
not  abused. — {Lehre  von  den  Augernkr.  b.  2,  p.  32.) 
For  the foregoing  account  of  diplopia,  I am  chiefly  in- 
debted to  Richter.  See  also  A.  Vater  et  J.  C.  Heinickery 
Vis%is  Vitia  duo  rarissima;  alterum  duplicati,  alte- 
TTum  dimidiati,  &-c.  Wittemb.  1723.  {Haller,  Diss.  ad 
Morb.  t.  1,  p.  305.)  J.  J.  Klauhold  de  Visu  duplicato, 
Mo.  Argent.  1746.  Buchner  de  Visione  simplici  et 
duplici.  Mo.  Argent.  1753.  Euler,  Recherches  Phy- 
siques sur  la  diverse  refrangibiliU  des  rayons  de 
lumiere. ; Mem.  de  VAcad.  des  Sciences,  S,  c.  BerUuy 
p.  200,  1754.  Klinke  de  Diplopia,  Mo.  Goett.  1774.  Sir 
E.  Home's  Obs.  on  the  Straight  Muscles  of  the  Eye, 
and  the  structure  of  the  Cornea,  in  Phil.  Trans,  for 
1797  ; B.  Gooch,  Chir.  Cases,  St  C.  vol.  2,  p.  42,  df  c.  8vo. 
Lond.  1792.  Keghellini,  Lettera  sopra  Voffera  della 
cista  in  una  Donna,  <^-c.  8vo.  Venet.  1749  ; an  instance 
of  Dipl opia  from  double  pupil.  Diet,  des  Sciences  Med. 
t.  9,p  497.  J.  Wardrop,  Essays  on  the  Morbid  Anatomy 
of  the  Human  Eye,  vol.  2,  p.  216,  <!i  c.  8vo.  Lond.  1818.) 

DIRECTOR.  (From  dirigo,  to  direct.)  One  of  the 
most  common  instruments  of  surgery  ; it  is  long,  nar- 
row, grooved,  and  made  of  silver,  in  order  that  it  may 
be  bent  into  any  desirable  shape.  Its  use  is  to  direct 
the  knife,  and  protect  the  parts  underneath  from  the 
edge  or  point  of  the  latter  instrument.  The  surgeon 
introduces  tlie  director  under  the  parts  which  he 
means  to  divide,  and  then  either  cuts  down,  along  the 
groove  of  the  instrument,  with  a common  bistoury,  or 
cuts  upwards  with  a narrow',  curs’ed,  pointed  bistoury, 
the  point  of  w’hich  is  turned  upwards,  which  he  care- 
fully introduces  along  the  groove.  This  instrument 
and  the  crooked  bistoury  are  commonly  employed  for 
opening  sinuses,  for  cutting  fistulie  in  ano,  and  fistula 
in  other  situations,  and  for  dilating  the  stricture  in 
cases  of  hernia. 

DISLOCATION.  (From  disloco,  to  put  out  of  place.) 
A Luxation.  W'hen  the  articular  surfaces  of  the 
bones  are  forced  out  of  their  proju-r  situation,  the  acci- 
dent is  termed  a dislocation  or  li/xotion. 

Sir  Astley  Cooper  has  ju.stly  remarked,  that  of  the 
various  accidents  which  hapi>cu  to  the  bodv , there  ar# 


DISLOCATION. 


207 


few  which  require  more  prompt  assistance,  or  in  which 
the  reputation  of  the  surgeon  is  more  at  stake,  tliaii 
cases  of  luxation  ; for  if  much  time  be  lost  prior  to  the 
attempt  at  reduction,  there  is  great  additional  difficulty 
in  accomplishing  it,  and  it  is  often  entirely  incapable 
of  being  effected.  If  it  remains  unknown,  and  conse- 
quently unreduced,  the  patient  becomes  a living  me- 
morial of  the  surgeon’s  ignorance  or  inattention.  Hence 
this  experienced  surgeon  forcibly  inculcates  the  careful 
study  of  anatomy ; the  want  of  an  accurate  knowledge 
of  the  structure  of  the  joints  being  the  cliief  cause  of 
the  many  errors  which  happen  in  the  diagnosis  and 
treatment  of  dislocated  bones.  The  following  passage 
cannot  be  too  deeply  impressed  upon  the  surgeon’s 
mind:  “A  considerable  share  of  anatomical  knowledge 
is  required  to  detect  the  nature  of  these  accidents,  as 
well  as  to  suggest  the  best  means  o f reduction  ; and 
it  is  much  to  be  lamented,  that  our  students  neglect  to 
inform  themselves  sufficiently  of  the  structure  of  the 
joints.  They  often  dissect  the  muscles  of  a limb  with 
great  neatness  and  minuteness,  and  then  throw  it 
av/ay,  without  any  examination  of  the  ligaments,  the 
knowledge  of  which,  in  a surgical  point  of  view,  is  of 
infinitely  greater  importance ; and  from  hence  arise 
the  numerous  errors  of  which  they  are  guilty,  when 
they  embark  in  the  practice  of  their  profession ; for  the 
injuries  of  the  hip,  elbow,  and  shoulder  are  scarcely  to 
be  detected  but  by  those  who  possess  accurate  ana- 
tomical information.  Even  our  hospital  surgeons,  who 
have  neglected  anatomy,  mistake  these  accidents  ; for 
I have  known  the  pulleys  applied  to  an  hospital  patient 
in  a case  of  a fracture  of  the  neck  of  the  thigh-bone, 
which  had  been  mistaken  for  a dislocation,  and  the  pa- 
tient cruelly  exposed,  through  the  surgeon’s  ignorance, 
to  a violent  and  protracted  extension.  It  is  therefore 
proper,  that  the  form  of  the  ends  of  the  bones,  their 
mode  of  articulation,  the  ligaments  by  which  they  are 
connected,  and  the  direction  in  which  the  larger  mus- 
cles act,  should  be  well  understood.”— Es- 
says, part  1,  p.  2.) 

The  most  important  differences  of  luxations  are : 1. 
With  respect  to  the  articulation  in  which  these  acci- 
dents take  place ; 2.  The  extent  of  the  dislocation  ; 3. 
The  direction  in  which  the  bone  is  displaced  ; 4.  The 
length  of  time  the  displacement  has  continued  ; 5.  The 
circumstances  which  accompany  it,  and  which  make  the 
injury  simple  or  compound ; 6.  And  lastly,  with  respect 
to  the  causes  of  the  accident. 

1.  Every  kind  of  joint  is  not  equally  liable  to  dislo- 
cations. Experience  proves,  indeed,  that  in  the  greater 
part  of  the  vertebral  column,  luxations  are  absolutely 
impossible,  the  pieces  of  bone  being  articulated  by  ex- 
tensive numerous  surfaces,  varying  in  their  form  and 
direction,  and  so  tied  together  by  many  powerful  elas- 
tic means,  that  very  little  motion  is  allowed.  Expe- 
rience proves,  also,  that  the  strength  of  the  articula- 
tions of  the  pelvic  bones  can  scarcely  be  affected  by 
enormous  efforts,  unless  these  bones  be  simultaneously 
fractured.  Boyer  has  therefore  set  down  luxations  of 
joints  with  continuous  surfaces  as  unpossible. — [Traite 
des  Maladies  Chirurg.  t.  4,  p.  17.)  And  Sir  A.  Cooper 
observes,  that  in  the  spine,  the  motion  between  any 
two  bones  is  so  small,  that  dislocations  hardly  ever 
occur,  except  between  the  first  and  second  vertebrte, 
although  the  bones  are  often  displaced  by  fracture.— 
{Surgical  Essays,  p.  14.) 

In  the  articulations  with  contiguous  surfaces,  the 
facility  with  which  dislocations  happen,  depends  upon 
the  extent  and  variety  of  motion  in  such  joints.  Thus 
in  the  short  bones  of  the  carpus,  and  particularly  of 
the  tarsus,  and  at  the  carpal  and  tarsal  extremities  of 
the  metacarpal  and  metatarsal  bones,  where  flat  broad 
surfaces  are  held  together  by  ligaments,  strong,  nu- 
merous, and  partly  interarticular,  and  where  only  an 
obscure  degree  of  motion  can  take  place,  dislocations 
are  very  unfrequent,  and  can  only  be  produced  by  un- 
common violence. 

The  loose  joints,  which  admit  of  motion  in  every  di- 
rection, are  those  in  which  dislocations  most  frequently 
occur ; such  is  that  of  the  humerus  with  the  scapula. 
On  the  contrary,  the  ginglymoid  joints,  which  allow 
motion  only  in  two  directions,  are,  comparatively 
sjieaking,  seldom  dislocated.  The  articular  surfaces 
of  the  latter  are  of  great  extent,  and  consequently  the 
heads  of  the  bones  must  be  pushed  a great  way  in 
order  to  be  completely  dislocated ; and  the  ligaments 
are  numerous  and  strong. 


2.  With  respect  to  the  extent  of  the  dislocation,  luxa* 
tions  are  either  complete  or  incomplete.  The  latter 
term  is  applied,  when  the  articular  surfaces  still  re- 
main partially  in  contact.  Incomplete  dislocations  only 
occur  in  ginglymoid  articulations,  as  those  of  the  foot, 
knee,  and  elbow.  In  these,  the  luxation  is  almost  al- 
ways incomplete  ; and  very  great  violence  must  have 
operated,  when  the  bones  are  completely  dislocated. 
In  the  elbow,  the  dislocation  is  partial,  with  respect 
both  to  the  ulna  and  radius.  In  the  orbicular  articula- 
tions, the  luxations  are  almost  invariably  complete. 
However,  “ the  os  humeri  sometimes  rests  upon  the 
edge  of  the  glenoid  cavity,  and  readily  returns  into  its 
socket.” — (.n.  Cooper,  Essays,  part  ' I,  p.  14.)  The 
lower  jaw  is  sometimes  partially  dislocated  in  a man- 
ner different  from  what  is  commonly  meant  by  this 
expression,  viz.  one  of  its  condyles  is  luxated,  while 
the  other  remains  in  its  natural  situation. 

As  Sir  A.  Cooper  has  explained,  a partial  dislocation 
sometimes  occurs  at  the  ankle-joint.  “An  ankle  (says 
he'  was  dissected  at  Guy’s,  and  given  to  the  collection 
of  St.  Thomas’s,  which  was  partially  dislocated : the 
end  of  the  tibia  rested  still  in  part  upon  the  astragalus, 
but  a large  portion  of  its  surface  was  seated  on  the 
os  naviculare,  and  the  tibia,  altered  by  this  change 
of  place,  had  formed  tv\m  new  articular  surfaces, 
with  their  faces  turned  in  opposite  directions  towards 
the  two  bones.  The  dislocation  had  not  been  re- 
duced.” 

3.  In  the  orbicular  joints,  the  head  of  the  bone  may 
be  dislocated  at  any  point  of  their  circumference ; and 
the  luxations  are  named  accordingly  upivards,  down- 
wards, forwards,  and  backwards.  In  the  ginglymoid 
articulations,  the  bones  may  be  dislocated  either  late- 
rally, or  forwards,  or  backwards. 

4.  The  length  of  time  a dislocation  has  existed  makes 
a material  difference.  In  general,  recent  dislocations 
may  be  easily  reduced  ; but  when  the  head  of  a bone 
has  been  out  of  its  place  several  days,  the  reduction 
becomes  exceedingly  difficult,  and  in  older  cases  very 
often  impossible.  The  soft  parts  and  the  bone  itself 
have  acquired  a certain  position;  the  muscles  have 
adapted  themselves  in  length  to  the  altered  situation 
of  the  bone  to  which  they  are  attached,  and  sometimes 
cannot  be  lengthened  sufficiently  for  it  to  be  reduced. 
Indeed,  I believe  ihat  Sir  Astley  Cooper’s  statement  is 
quite  correct,  that  the  difficulty  in  the  reduction,  arising 
from  the  muscles,  is  proportioned  to  the  length  of  time 
that  has  elapsed  from  the  period  of  the  accident. — 
{Treatise  on  Dislocations,  p.  26.) 

Desault  and  Boyer  believe,  that  frequently  the  open- 
ing in  the  capsular  ligament  soon  becomes  closed,  and 
hinders  the  return  of  the  head  of  the  bone  into  its 
original  situation.  However,  with  regard  to  the  doc- 
trine of  the  reduction  being  prevented  by  the  capsular 
ligaments,  it  is  considered  by  Sir  Astley  Cooper  as 
destitute  of  foundation. — {Surgical  Essays,  part  1, 
p.  18 ; and  Treatise,  S,  c.  p.  25  ) Lastly,  the  head  of 
the  bone  may  become  adherent  to  the  parts  on  Avhich 
it  has  been  forced. 

5.  The  difference  is  immense,  in  regard  to  the  dan- 
ger of  the  case,  arising  from  the  circumstance  of  a dis- 
location being  attended  or  unattended  with  a wound, 
communicating  internally  with  the  joint,  and  externally 
with  the  air.  When  there  is  no  wound  of  this  kind, 
the  danger  is  generally  trivial,  and  the  dislocation  is 
termed  a simple  one  ; when  there  is  such  a wound,  to- 
gether with  the  dislocation,  the  case  is  denominated 
compound,  affd  is  frequently  accompanied  with  the 
most  imminent  peril.  Indeed,  the  latter  kind  of  acci- 
dent sometimes  renders  amputation  necessary,  and  in 
too  many  instances  has  a fatal  termination. 

6.  The  causes  of  dislocations  are  externa!  and  in- 
ternal. A predisposition  to  such  accidents  may  depend 
on  circumstances  natural  or  accidental.  The  great 
latitude  of  motion  which  the  joint  admits  of;  the  little 
extent  of  the  articular  surfaces  ; the  looseness  and 
fewness  of  the  ligaments  ; the  lowness  of  one  side  of 
the  articular  cavity,  as  at  the  anterior  and  inferior  part 
of  the  acetabulum  ; and  the  shallowness  of  the  cavity, 
as  of  that  of  the  scapula;  are  natural  predisposing 
causes  of  luxations. 

A paralytic  affection  of  the  muscles  of  a joint,  and  a 
looseness  of  its  ligaments,  are  also  predisposing  causes. 
When  the  deltoid  muscle  has  been  paralytic,  the  mere 
weight  of  the  arm  has  been  known  to  cause  such  a 
lengthening  of  the  capsular  ligament  of  the  shoulder- 


S93 


DISLOCATION. 


joint,  that  the  head  of  the  os  brachii  descended  two 
or  three  inches  from  the  glenoid  cavity. 

Two  cases  strikingly  illustrative  of  the  tendency  to 
dislocation  from  a weakened  or  paralytic  state  of  the 
muscles,  are  recorded  by  Sir  A.  Cooper.  The  first  is  that 
of  a junior  officer  of  an  India  ship,  who,  for  some  triffing 
offence,  had  been  placed  with  his  foot  upon  a small 
projection  on  the  deck,  wliile  his  arm  was  kept  forcibly 
drawn  up  to  the  yard-arm  for  an  hour.  “ When  he 
returned  to  England,  he  had  the  power  of  readily- 
throwing  that  arm  from  its  socket,  merely  by  raising  it 
towards  his  head;  bur  a very  slight  extension  reduced 
it.  The  muscles  were  wasted,  also,  as  in  the  case  of 
paralysis.”  The  other  example  happened  in  a young 
gentleman,  troubled  with  a paralytic  affection  of  his 
right  side  from  dentition.  “ The  muscles  of  the  shoul- 
der were  wasted,  and  he  had  the  power  of  throwing 
his  03  humeri  over  the  posterior  edge  of  the  glenoid 
cavity  of  the  scapula,  from  whence  it  became  easily 
reduced.”  In  these  cases,  no  laceration  of  the  liga- 
ments could  have  occurred,  and  the  influence  of  the 
muscles  in  preventing  dislocation  and  in  impeding  re- 
duction is  exemplified.— (Sur^ica?  Essays,  part  1,  p. 
10.)  Mr.  Brindley,  of  Wink  Hill,  communicated  to  Sir 
A.  Cooper  an  account  of  a dislocation  of  the  os  fern  oris, 
which  the  patient,  a man  of  50,  is  able  to  produce  and 
reduce  whenever  he  chooses. — {Treatise  on  Disloca- 
tions, Prefax:e.) 

The  looseness  of  the  ligaments  sometimes  makes  the 
occurrence  of  dislocations  so  easy,  that  the  slightest 
causes  produce  them.  Some  pei^ons  cannot  yawn  or 
laugh  without  running  the  risk  of  having  their  lower 
jaw  luxated.  On  this  account,  collections  of  fluid 
within  the  knee,  causing  a relaxation  of  the  ligament  of 
the  patella,  are  often  followed  by  a dislocation  of  that 
bone.  And  whenever  a bone  has  been  once  dislocated, 
it  ever  afterward  has  a tendency  to  be  displaced  again, 
by  a slighter  cause  than  what  was  first  necessary  to 
produce  the  accident.  This  tendency,  indeed,  increases 
with  every  new  displacement. 

Diseases  which  destroy  the  cartilages,  ligaments, 
and  articular  cavities  of  the  bones,  may  give  rise  to  a 
dislocation.  The  knee  is  sometimes,  but  not  frequently, 
partially  luxated,  in  consequence  of  a white  swelhng  ; 
the  thigh  is  often  dislocated,  in  consequence  of  the 
acetabulum  and  Ugaments  being  destroyed  by  disease. 
Such  dislocations  are  termed  spontaneous. 

In  the  anatomical  collection  at  St.  Thomas's  Hospi- 
tal, there  is  a preparation  of  a knee  dislocated  in  con- 
sequence of  ulceration,  and  in  the  state  of  anchylosis ; 
the  leg  forming  a right  angle  with  the  femur  directly 
forwards.— (See  Sir  A.  Cooper’s  Surg.  Essays,  part  1, 
p.ll.) 

An  enarthrosis  joint  can  only  be  dislocated  by  exter- 
nal violence,  a blow,  a fall,  or  the  action  of  the  muscles, 
w-hen  the  axis  of  the  bone  is  in  a direction  more  or  less 
oblique  with  respect  to  the  surface  with  which  it  is 
articulated. 

Any  external  force  may  occasion  a dislocation  of 
ginglymoid  Joints,  which  case  is  generally  incomplete ; 
but  in  the  ball  and  socket  articulations  the  action  of 
the  muscles  constantly  has  a share  in  producing  the 
accident.  So,  when  a person  falls  on  his  elbow,  wdiile 
his  arm  is  raised  outwards  from  his  side,  the  force 
thus  applied  wdll  undoubtedly  contribute  very  much  to 
push  the  head  of  the  os  brachii  out  of  the  glenoid 
cavity,  at  the  low-er  and  internal  part.  Still,  the  sudden 
action  of  the  pectoralis  major,  latissimus  dorsi,  and 
teres  major,  -vhich  alw'ays  takes  place  from  the  alarm, 
will  also  tud  in  pulling  dow-nwards  and  inwards  the  head 
of  the  bone.  Under  certain  circumstances,  the  violent 
action  of  the  muscles  alone  may  produce  a dislocation, 
without  the  conjoint  operation  of  any  outward  force. 
But  when  the  patient  is  aw-are  in  time  of  the  violence 
which  is  about  to  operate,  and  his  muscles  are  pre- 
pared for  resi.stanee,  a dislocation  cannot  be  produced 
without  the  greatest  difficulty  {Sir  .d.  Cooper,  op.  cit. 
p.  15),  unless  the  posture  of  the  member  at  the  moment 
be  such  as  to  render  the  action  of  the  strongest  muscles 
conducive  to  the  displacement  instead  of  preventive 
of  it,  as  is  frequently  the  case  in  luxations  of  the 
shoulder. 

Dislocations  are  constantly  attended  with  more  or  less 
laceration  or  elongation  of  the  ligaments ; and  in  the 
shoulder  and  hip,  the  capsules  are  always  tom,  when 
the  accident  has  been  produced  by  violence.  Some 
instances,  in  wliich  the  ligaments  are  only  lengthened  , 


and  relaxed,  I have  already  quoted.  Sometimes  a <!is* 
location  is  attended  with  a fracture.  The  ancle  is 
seldom  luxated,  without  the  fibula  being  broken ; and 
in  dislocation  at  the  hip,  the  acetabulmn  is  also  occa- 
sionally fVactured. — {Sir  A.  Cooper's  Treatise  on  Dis 
locatioTis,  i'C.  p.  15.) 

SYMPTOMS  OF  DISLOCATIONS. 

As  Boyer  justly  observes,  every  dislocation  produces 
pain  and  incapacity  in  the  limb ; but  these  are  only 
equivocal  symptoms,  and  cannot  distinguish  the  case 
from  a fracture,  nor  even  from  a simple  contusion.  A 
severe  but  obtuse  pain  arises  from  the  pressure  of  the 
head  of  the  bone  upon  the  muscles;  sometimes  the 
pain  is  rendered  more  acute  by  the  pressure  being 
made  upon  a large  nerve. — {Sir  A.  Cooper’s  Treatise, 
p.  5.) 

In  order  that  a dislocation  may  happen,  there  must 
be  a particular  attitude  of  the  limb  during  the  action  of 
the  external  violence.  Indeed,  the  displacement  can 
hardly  occur  from  the  direct  action  of  the  cause  on  the 
articulation  itself.  The  action  of  the  luxating  cause  is 
the  more  efficient  the  farther  it  is  from  the  joint,  and 
the  longer  the  lever  is  w^hich  it  affects.  Thus,  in  a fall 
on  the  side,  when  the  arm,  rmsed  considerably  from 
the  trunk,  has  had  to  sustain  all  the  w-eight  of  the  body 
on  a point  at  its  inner  side,  the  probability  of  a disloca- 
tion is  evident,  and  even  that  the  head  of  the  bone  has 
been  forced  through  the  lower  portion  of  the  capsular 
ligament. 

But  the  symptoms  which  Boyer  terms  positive,  or 
actually  present,  are  numerous  and  clear. 

1.  In  dislocations  of  orbicular  joints  and  complete 
luxations  of  ginglj-moid  joints,  the  articular  surfaces 
are  not  at  all  in  contact,  and  the  point  where  the  dislo- 
cated bone  is  lodged  cannot  be  upon  the  same  level 
with  the  centre  of  the  cavity,  from  which  it  has  been 
forced.  Hence,  a change  in  the  length  of  the  limb.  In 
the  ginglymoid  joints,  such  alteration  can  only  be  a 
shortening  proportioned  to  the  extent  of  the  displacement, 
for  there  is  then  an  overlapping  of  the  bones,  similar 
to  that  of  the  fragments  of  a fracture  longitudinally 
displaced.  But  in  the  orbicular  joints,  the  bone  may 
be  displaced,  and  earried  above  or  below  the  articular 
cavity ; so  that,  in  the  first  event,  a shortening,  in  the 
second,  an  elongation,  of  the  limb  will  be  produced. 
But  as  the  direction  of  the  member  is  at  the  stone  time 
altered,  it  is  not  always  practicable  to  place  the  limbs 
parallel  together,  nor  to  bring  them  near  the  trunk,  for 
the  purpose  of  judging  w'hether  they  are  lengthened  or 
shortened.  A comparison,  however,  made  without  this 
advantage,  will  generally  enable  the  surgeon  to  form  a 
correct  opinion.  The  proper  length  of  a dislocated 
limb  cannot  be  restored,  except  by  putting  the  bone 
back  into  the  cavity  from  which  it  has  shpped.  In 
general,  this  cannot  be  accomplished  without  consider- 
able efforts,  while  a slight  exertion  is  usually  sufficient 
to  obtain  the  same  effecl  in  cases  where  the  shortening 
of  the  limb  depends  upon  a fracture.  It  is  also  particu- 
larly worthy  of  notice,  that  when  once  the  natural 
length  of  the  limb  has  been  restored  in  dislocations,  it 
remains ; whUe  there  are  a great  many  fractures,  in 
which  the  shortening  of  the  member  recurs  after  it  has 
been  made  to  disappear.  The  surgeon  must  also  recol- 
lect, that  an  elongation  of  the  limb  can  never  happen  in 
cases  of  fracture  as  it  does  in  certain  dislocations. 

2.  In  almost  all  complete  luxations,  the  direction  of 
the  axis  of  the  limb  is  unavoidably  altered.  This  cir- 
cumstance arises  from  the  resistance  of  that  portion  of 
the  articular  ligaments  which  has  not  been  ruptured,  as 
well  as  from  the  action  of  the  muscles.  In  complete 
lateral  dislocations  of  ginglymoid  joints,  the  direction 
of  the  axis  of  the  limb  is  not  altered,  on  account  of  the 
total  rupture  of  the  ligaments,  and  even  of  a part  of  the 
surrounding  muscles.  Neither  is  this  observable  in 
incomplete  dislocations  of  such  articulations,  on  account 
of  the  e.xtent  of  the  articular  surfaces.  But  it  is 
strongly  marked  in  complete  luxations  of  these  joints, 
where  the  displacement  has  happened  in  the  direction 
of  the  articular  movements,  although,  in  ca.ses  of  this 
description,  the  ligaments  must  be  totally  ruptured. 
The  muscles,  which  have  suffered  less,  are  in  a state 
of  extreme  tension,  and  must  necessarily  alter  the  axis 
of  the  limb.  The  tension  of  certain  muscles,  and  the 
pre.servation  of  some  of  the  ligaments,  especially  m the 
orbicular  joints,  are  also  a cause  of  a rotator>-  movenient 
of  the  dislocated  limb  at  the  moment  of  the  displace- 


DISLOCATION. 


299 


nent,  and  which  it  afterward  retains.  Thus,  in  luxa- 
tions of  the  thigh,  the  toes  and  knee  are  turned  outwards 
or  inwards,  according  as  the  head  of  the  thigh-bone 
happens  to  be  situated  at  the  inside  or  outside  of  the 
joint.  These  two  kinds  of  alteration  in  the  direction  of 
the  limb  are  permanent,  when  they  depend  upon  a dis- 
location ; a circumstance  quite  different  from  what  is 
observable  in  fractures,  where  the  same  changes  occur, 
but  can  be  made  to  cease  at  once,  without  any  particu- 
lar effort. 

3.  The  absolute  immobility  of  a limb,  or,  at  least,  the 
inability  of  performing  certain  motions,  is  among  the 
most  characteristic  symptoms  of  a dislocation.  In 
some  complete  luxations  of  particular  ginglymoid 
joints,  the  dislocated  limb  is  absolutely,  or  very  nearly, 
incapable  of  any  motion.  Thus,  in  the  dislocation  of 
the  forearm  backwards,  the  particular  disposition  of  the 
bones,  and  the  extreme  tension  of  the  extensor  and 
fle.xor  muscles,  confine  the  limb  in  the  half-bent  state, 
and  at  the  same  time  resist  every  sjKtntaneous  motion, 
and  likewise  almost  every  motion  which  is  communi- 
cated. In  the  orbicular  joints,  the  painful  tension  of 
the  muscles  which  surround  the  luxated  bone  nearly 
impedes  all  spontaneous  movements ; but,  in  general, 
analogous  motions  to  that  by  which  the  displacement 
was  produced  can  be  communicated  to  the  limb,  though 
not  without  exciting  pain.  Thus,  in  the  dislocation  of 
the  humerus  downwards,  the  elbow  hardly  admits  of 
being  put  near  the  side,  nor  of  being  carried  forwards 
and  backwards ; but  it  can  be  raised  up  with  ease.  In 
the  dislocation  of  the  acromial  end  of  the  clavicle,  the 
patient  can  bring  the  arm  towards  the  trunk,  separate 
it  a little  from  the  side,  or  carry  it  forwards  or  back- 
wards ; but  he  cannot  raise  it  in  a direct  way.  Lastly, 
in  complete  lateral  dislocations  of  such  joints  as  have 
alternate  motions,  the  patient  has  the  power  of  per- 
forming no  motion  of  the  part;  but  the  complete  de- 
struction of  all  the  means  of  union  allows  the  limb  to 
obey  every  species  of  extraneous  impulse;  and  this 
symptom,  which  is  besides  never  single,  makes  the 
nature  of  the  case  sufficiently  manifest. 

Sometimes,  as  Sir  A.  Cooper  has  remarked,  a consi- 
derable degree  of  motion  continues  for  a short  time  after 
a dislocation  : thus,  in  a man,  brought  into  Guy’s  Hos- 
pital, whose  thigh-bone  had  just  been  dislocated  into  the 
foramen  ovale,  a great  mobility  of  the  femur  still  re- 
mained ; but,  “ in  less  than  three  hours,  it  became 
firmly  fixed  in  its  new  situation,  by  the  contraction  of 
the  muscles. — {Surgical  Essays,  part  1,  p.  3.) 

4.  In  dislocations  attended  with  elongation  of  the 
limb,  the  general  and  uniform  tension  of  all  the  muscles 
arranged  along  it,  gives  to  these  organs  an  appearance 
as  if  they  lay  nearer  the  circumference  of  the  bone,  and 
the  limb  were  smaller  than  its  fellow.  The  muscles, 
however,  which  belong  to  the  side,  from  which  the 
dislocated  bone  has  become  more  distant,  appear  more 
tense  than  the  others,  and  form  externally  a prominent 
line.  This  is  very  manifestly  the  case  with  the  deltoid 
muscle,  when  the  arm  is  luxated  downwards.  On  the 
contrary,  in  dislocations  where  the  limb  is  shortened, 
the  muscles  are  relaxed  ; but,  being  irritated,  they  con- 
tract and  accommodate  themselves  to  the  shortened  I 
state  of  the  limb.  Hence  the  extraordinary  swelling  of 
their  fleshy  part,  and  the  manifestly  increased  diameter 
of  the  portion  of  the  member  to  which  tltey  belong.  We 
have  a striking  example  of  this  in  the  dislocation  of  the 
thigh  upwards  and  outwards,  where  the  muscles  at  the 
inside  of  the  limb  form  a distinct  oblong  tumour. 

The  parts  which  surround  the  affected  joint  also  ex- 
perience alterations  in  their  form,  whenever  muscles 
connected  with  the  dislocated  bone  occupy  that  situa- 
tion. Thus,  in  dislocations  of  the  thigh,  the  buttock 
on  the  same  side  is  flattened,  if  the  bone  is  carried  in- 
wards ; but  it  is  more  prominent,  when  the  thigh-bone 
is  carried  outwards ; and  its  lower  edge  is  situated 
higher  or  lower  than  in  the  natural  state,  according  as 
the  luxation  may  have  taken  place  upwards  or  down- 
wards. In  the  complete  luxation  of  the  forearm  back- 
wards, the  triceps  is  tense,  and  forms  a cylindrical  ])ro- 
minence,  owing  to  the  displacement  of  the  olecranon 
bacikwards,  in  which  displacement  it  is  obliged  to  jiarti- 
cipatc. 

5.  The  circumference  of  the  joint  itself  presents  al- 
terations of  shape  well  deserving  attention,  and  in  or- 
der to  judge  rightly  of  this  symptom,  correct  anatomi- 
cal knowledge  is  of  high  importance. 

The  form  of  the  joints  principally  depends  upon  the 


shape  of  the  heads  of  the  bones.  Hence,  the  natural 
relation  of  the  bones  to  each  other  cannot  be  altered 
without  a change  being  immediately  produced  in  the 
external  form  of  the  joint.  The  changes  which  the 
muscles  passing  over  the  luxated  joint  at  the  same 
time  undergo  in  their  situation  and  direction,  contribute 
likewise  to  the  difference  of  shape,  by  destroying  the 
harmony  of  what  may  be  called  the  outlines  of  the 
limb. 

When  the  head  of  a bone  articulated  by  enarthrosis, 
has  slipped  out  of  the  cavity,  instead  of  the  plumpness 
which  previously  indicated  the  natural  relation  of 
parts,  fhe  head  of  the  dislocated  bone  may  be  distin- 
guished at  some  surrounding  point  of  the  articulation, 
while  at  the  articulation  itself  may  be  remarked  a flat- 
ness, caused  by  one  of  the  neighbouring  muscles 
stretched  over  the  articular  cavity,  and  more  deeply 
may  be  perceived  the  outline  and  depression  produced 
by  this  cavity  itself.  The  bony  eminences  situated 
near  the  joint,  and  whose  outlines  were  gradually 
effaced  in  the  general  form  of  the  member,  are  ren- 
dered much  more  apparent  by  the  displacement,  and 
project  in  a stronger  degree  than  in  the  natural  state. 
On  this  part  of  the  subject  Sir  A.  Cooper  is  particu- 
larly correct,  when  he  observes,  that  the  head  of  the 
bone  can  generally  be  felt  in  its  new  situation,  except- 
ing in  some  of  the  dislocations  of  the  hip,  and  its  rota- 
tion is  often  the  best  criterion  of  the  accident.  Tht 
natural  prominences  of  bone  near  the  joint  either  dis- 
appear or  become  less  conspicuous,  as  the  trochante} 
at  the  hip- joint.  Sometimes  the  reverse  occurs;  for 
in  dislocations  of  the  shoidder,  the  acromion  projects 
more  than  usual. — {Surg.  Essays,  part  1,  p.  4.) 

The  lines  made  by  the  contour  of  the  limb  and  the 
natural  relation  of  the  bones,  are  so  manifestly  broken 
in  dislocations  of  ginglymoid  joints,  that  when  there 
is  no  inflammatory  swelling  the  case  is  at  once  mani- 
fest. More  certain  knowledge,  however,  and  more 
correct  information  respecting  the  kind  of  displace- 
ment, are  to  be  obtained,  by  attentively  examining  the 
changes  of  position  which  the  bony  prominences  form- 
ing the  termination  of  the  bones  articulated  together 
have  undergone,  and  which  are  the  more  obvious  in 
these  joints,  inasmuch  as  they  give  attachment  to  the 
principal  muscles.  The  natural  relations  of  these  pro- 
cesses being  known,  the  least  error  of  situation  ought 
to  strike  the  well-informed  practitioner.  Thus,  in  the 
elbow-joint,  a considerable  difference  in  the  respective 
height,  and  in  the  distances  between  the  olecranon  and 
internal  and  exterital  condyles,  can  be  easily  distin- 
guished. But  the  thing  is  less  easy  when  the  sur- 
rounding parts  are  so  swelled  and  tense  as  to  make  the 
bony  projections  deeper  from  the  surface  and  less  ob- 
vious to  examination.  Even  then,  however,  a good 
surgeon  will  at  least  find  something  to  make  him  sus •• 
pec'  the  dislocation,  and  the  suspicion  will  be  con- 
firmed when  he  again  examines  the  part  after  the 
swelling  has  begun  to  subside.  It  is  of  the  utmost 
consequence  to  make  out  what  the  OBse  is  as  early  as 
possible;  for  the  unnatural  state  in  which  the  soft 
parts  are  placed  keeps  up  the  swelling  a long  while ; and 
if  the  surgeon  wait  till  this  has  entirely  subsided  before 
he  ascertains  that  the  bones  are  luxated,  he  will  have 
waited  till  it  is  too  late  to  think  of  reducing  them,  and 
the  patient  must  remain  for  ever  afterward  deprived 
of  the  free  use  of  his  limb. — {Boyer,  TraiU  des  Mala- 
dies Chir.  t.  5,  p.  45,  c.)  It  is  not  only  the  inflam- 
matory swelling  which  may  tend  io  conceal  the  state 
of  the  ends  of  the  bone  ; sometimes  a quicker  tumour 
arises  from  the  effusion  of  blood  in  the  cellular 
membrane,  and  causes  an  equal  ditficulty  of  feeling 
the  exact  position  of  the  heads  of  the  bones.— (See 
Treatise  on  Dislocation,  by  Sir  A.  Cooper,  p.  5.) 

Dislocations  are  also  sometimes  attended  with  parti- 
cular symptoms,  arising  altogether  from  the  pressure 
caused  by  the  head  of  the  luxated  bone  on  certain 
parts.  The  sternal  end  of  the  clavicle  has  been  known 
to  compress  the  trachea  and  impede  respiration  : the 
head  of  the  humerus  may  press  upon  the  axillary 
plexus  of  nerves,  and  produce  a paralytic  affection  of 
the  whole  arm.  In  one  instance  cited  by  Sir  A.  Cooper, 
a dislocated  clavicle  iircssed  upon  the  (esophagus  and 
endangered  life.— ( Surg.  Essays,  part  1,  p.  4.) 

As  Kirkland  has  observed,  there  are  some  luxations 
which  are  far  worse  injuries  than  fractures ; of  thia 
description  are  dislocations  of  the  vertebrae,  cases, 
which,  indeed,  can  hardly  happen  without  fracture, 


300 


DISLOCATION. 


and  are  almost  always  fatal ; dislocations  of  the  long 
bones,  with  protrusion  of  their  ends  through  the  mus- 
cles and  skin,  and  severe  inflammation,  extensive  ab- 
scesses, attended  with  great  risk  of  being  followed  by 
large  and  tedious  exfoliations,  and  not  unfrequently 
gangrene. 

According  to  Sir  A.  Cooper,  young  persons  are  rarely 
subjects  of  dislocations  from  violence ; but  he  admits 
that  they  do  sometimes  experience  them,  and  relates 
an  instance  which  happened  in  a child  seven  years  of 
age.  In  general,  their  bones  break,  or  their  epiphyses 
give  way,  much  more  frequently  than  the  articular 
surfaces  are  displaced. — (,Surg.  Essays,  part.  1,  p.  16  ; 
and  Treatise,  Src.  p.  23.)  Suspected  luxations  of  the 
hip  in  children  commonly  turn  out  to  be  disease  of  the 
joint,  one  instance  of  which  is  given  by  the  preceding 
author,  and  an  example  of  which  I was  lately  con- 
sulted about  myself.  Also,  when  a dislocation  of  the 
elbow  is  suspected  In  a child,  because  the  bone  appears 
readily  to  return  into  its  place,  but  directly  to  slip  out 
of  it  again,  the  case,  according  to  Sir  A.  Cooper,  is  an 
oblique  fracture  of  tlie  condyles  of  the  humerus.  Old 
persons  are  also  much  less  liable  to  dislocations  than 
individuals  of  middle  age ; a fact  which  is  accounted 
for  by  the  extremities  of  bones  in  old  subjects  being  so 
softened  that  the  violence  sooner  breaks  than  luxates 
them.— (Sir  Astley  Cooper,  Treatise,  <fec.  p.  23.) 

PROGNOSIS. 

In  general,  every  unreduced  dislocation  must  deprive 
the  patient  more  or  less  completely  of  the  use  of  the 
limb ; for  nature  cannot  re-establish  the  natural  rela- 
tions which  are  lost.  There  is  indeed  an  effort  made 
to  restore  some  of  tlie  motions  and  the  use  of  the 
limb  in  a certain  degree  ; but  it  is  always  very  imper- 
fectly accomplished,  and  in  the  best  cases,  only  a con- 
fined degree  of  motion  is  recovered.  Nature  cannot 
in  any  way  alter  the  lengthened  or  shortened  state  of 
the  limb  ; and  she  can  only  correct  in  a very  imperfect 
manner  its  faulty  direction.  There  are  even  some 
cases  in  which  no  amendment  whatsoever  can  be 
effected;  as  in  complete  dislocations  of  ginglymoid 
joints. 

There  are,  however,  a few  exceptions  to  this  general 
rule.  The  arthrodia  joints  are  seldom  extensively  dis- 
placed ; and  as,  in  the  natural  state,  their  motions  are 
very  limited,  the  loss  of  these  motions  in  consequence 
of  the  natural  relations  not  having  been  res  tored,  is  of  less 
importance.  Thus,  the  bones  of  the  carpus,  those  of 
the  tarsus,  and  the  acromial  end  of  the  clavicle,  may 
be  dislocated,  and  be  reduced  either  imperfectly  or  not 
at  all,  without  the  functions  of  the  limb  to  which  they 
belong  being  materially  impaired. — {Boyer,  TraiU  des 
Maladies  Chir.  t.  4,  p.  54.) 

Dislocations  of  enarthrosis  joints  are  generally  much 
Jess  dangerous  than  those  of  ginglymoid  ones ; for  the 
action  of  the  muscles  has  a great  share  in  producing 
the  former;  the  violence  done  to  the  external  parts  is 
Jess;  and  the  laceration  of  the  soft  parts  is  not  so 
eonsiderable.  Even  in  the  same  kind  of  joints,  the 
seriousness  of  the  case  depends  on  the  largeness  of  the 
articular  surfaces,  and  the  number  and  strength  of  the 
muscles  and  ligaments. 

Dislocations  of  ginglymoid  joints,  however,  are  more 
easily  reduced  than  those  of  enarthrosis  ones,  the  mus- 
cles of  which  are  frequently  very  powerful,  and  capa- 
ble of  making  great  resistance  to  the  efforts  of  the 
surgeon.  Tins  is  frequently  seen  in  luxations  of  the 
shoulder  and  thigh. 

It  may  be  saU,  however,  of  the  luxations  of  enar- 
ihrosis  joints,  that  if  they  happen  the  most  easily, 
Jhey  are  attended  with  less  injury  ; and  that  although 
their  reduction  may  require  considerable  efforts,  yet  it 
can  be  accomplished,  and  the  accident  leaves  no  ill 
effects.  On  the  contrary,  in  dislocations  of  ginglymoid 
joints,  the  same  reason  which  renders  them  more  un- 
frequent, makes  them  also  more  serious.  The  solidity 
of  these  joints  prevents  the  uniting  means  from  being 
destroyed  except  by  great  violence  ; and  the  extent  of 
the  articular  surfaces  does  not  permit  a considerable 
displacement,  especially  a complete  one,  without  ex- 
tensive injury  of  the  ligaments  and  surrounding  soft 
parts.  It  is  for  these  reasons,  no  doubt,  that  compound 
luxations  and  jirotrusions  of  the  heads  of  the  bones 
are  most  commonly  seen  in  the  ginglymoid  articula- 
lions. 

The  more  recent  a luxation  is,  the  more  easy  it  is  to 


reduce,  and,  therefore,  cezteris  paribus,  the  less  grave 
is  the  injury.  In  this  point  of  view,  dislocations  of 
ginglymoid  joints  are  the  most  serious,  because  they 
soon  become  irreducible. 

Simple  dislocations  are  much  less  dangerous  than 
those  which  are  complicated  with  contusion,  the  injury 
of  a large  nerve  or  blood-vessel,  inflammatory  swell- 
ing, fracture,  wound,  and,  especially,  a protrusion  of 
one  of  the  articular  surfaces.— (Boyer,  Traite  des  Mala- 
dies, Chir.  t.  4,  p.  55,  56.) 

Dislocations  from  ulceration  and  suppuration  in 
joints,  termed  spontaneous  luxations,  cannot  admit 
of  reduction  : when  they  arise  from  the  hip-disease,  it 
is  not  merely  in  consequence  of  the  ligaments  being 
destroyed,  the  brim  of  the  acetabulum  itself  is  often 
annihilated.  However,  there  are  other  spontaneous 
dislocations  from  preternatural  looseness  of  the  liga- 
ments, where  reduction  may  be  accomplished  with  the 
greatest  facility ; though  the  displacement  generally 
recurs  from  the  slightest  causes. 

TREATMENT  OF  DISLOCATIONS  IN  GENERAL. 

Mr.  Pott  observes ; — By  what  our  forefathers  have 
said  on  the  subject  of  luxations,  and  by  the  descriptions 
and  figures  which  they  have  left  us  of  the  means  they 
used,  of  what  they  call  their  organs  and  machinemata, 
it  is  plain,  that  force  was  their  object,  and  that  what- 
ever purposes  were  aimed  at  or  executed  by  these  in- 
struments or  macliines,  were  aimed  at  and  executed 
principally  by  violence.  Many  or  most  of  them  are 
much  more  calculated  to  pull  a man's  joints  asunder 
than  to  set  them  to  rights.  Hardly  any  of  them  are  so 
contrived  as  to  execute  the  purpose  for  which  they 
should  be  used,  in  a manner  most  adapted  to  the  na- 
ture or  mechanism  of  the  parts  on  which  they  are  to 
operate.  The  force  or  power  of  some  of  the  instru- 
ments is  not  always  determinable,  as  to  degree,  by  the 
operator,  and  consequently  may  do  too  little  or  too 
much,  according  to  different  circumstances  in  the  case, 
or  more  or  less  caution  or  rashness  in  the  surgeon. 
If,  in  the  diagnosis  of  these  accidents,  an  exact  know- 
ledge of  the  ligaments  is  of  the  highest  importance,  a 
familiar  acquaintance  with  the  muscles  is  not  less  es- 
sential in  the  treatment. 

In  dislocations,  as  in  fractures,  says  Pott,  our  great 
attention  ought  to  be  paid  to  the  muscles  belonging  to 
the  part  affected.  These  are  the  moving  powers,  and 
by  these  the  joints,  as  well  as  other  moveable  parts, 
are  put  into  action : while  the  parts  to  be  moved  are 
in  right  order  and  disposition,  their  actions  will  be  re- 
gular and  just,  and  generally  determinable  by  the  will 
of  the  agent  (at  least  in  what  are  called  voluntary  mo- 
tions) ; but  when  the  said  parts  are  disturbed  from 
that  order  and  disposition,  the  action  or  power  of  the 
muscles  does  not  therefore  cease ; far  from  it ; they  still 
continue  to  exert  themselves  occasionally,  but  instead 
of  producing  regular  motions  at  the  will  of  the  agent, 
they  pull  and  distort  the  parts  they  are  attached  to, 
and  which,  by  being  displaced,  cannot  perform  the 
functions  for  which  they  were  designed. 

“ Hence  principally  arise  the  trouble  and  difficulty 
which  attend  the  reduction  of  luxated  joints.  The 
mere  bones  composing  the  articulations,  or  the  mere 
connecting  ligaments,  would  in  general  afford  very 
little  opposition ; and  the  replacing  the  dislocation 
would  require  very  little  trouble  or  force,  was  it  not 
for  the  resistance  of  the  muscles  and  tendons  attached 
to  and  connected  with  them;  for  by  examining  the 
fresh  joints  of  the  human  body,  w e shall  find,  that 
they  not  only  are  all  moved  by  muscles  and  tendons, 
but  also,  that  although  w'hat  are  called  the  ligaments 
of  the  joints  do  really  connect  and  hold  them  together, 
in  such  manner  as  could  not  well  be  executed  without 
them,  yet  in  many  instances  they  are,  when  stripped 
of  all  connexion,  so  very  weak  and  lax,  and  so  dilata- 
ble and  distractile,  that  they  do  little  more  than  connect 
the  bones  and  retain  the  synovia ; and  that  the  strength 
as  well  as  the  motion  of  the  joints,  depends  in  great 
measure  on  the  muscles  and  tendons  connected  with 
and  passing  over  them;  and  this  in  those  articulations 
which  are  designed  for  the  greatest  quantity,  as  well 
as  for  celerity  of  motion.  Hence  it  must  follow,  that 
as  the  figure,  mobility,  action,  and  strength  of  the 
principal  joints  depend  so  much  more  on  the  muscles 
and  tendons  in  connexion  with  them  than  on  their 
mere  ligaments,  that  the  former  are  the  parts  which  re- 
quire our  first  and  greatest  regard,  these  being  the 


DISLOCATION. 


301 


parts  which  will  necessarily  oppose  us  in  our  attempts 
for  reduction,  and  whose  resistance  must  be  either 
eluded  or  overcome  ; terms  of  very  different  import, 
and  which  every  practitioner  ought  to  be  well  apprized 
of.”— (See  Pott’s  Chir.  Works,  vol.  1.) 

That  the  muscles  are  the  chief  cause  of  resistance  is 
strongly  evinced  by  cases  in  which  the  dislocation  is 
accompanied  with  injury  of  a vital  organ ; for  then  the 
bone  may  be  reduced  by  a very  slight  force.  Thus,  in 
a man  who  had  an  injury  of  his  jejunum,  and  a dislo- 
cation of  his  hip,  the  bone  was  most  easily  replaced.— 
{Sir  A.  Cooper,  Surgical  Essays,  part  1,  p.  20.)  In 
short,  any  thing  which  produces  faintness  or  weak- 
ness facilitates  the  reduction,  as  intoxication,  nausea 
and  sickness,  paralysis,  <fec. 

The  following,  which  are  some  of  the  principles  laid 
down  by  Mr.  Pott,  merit  attention. 

1 . Although  a joint  may  have  been  luxated  by  means 
of  considerable  violence,  it  does  by  no  means  follow 
that  the  same  degree  of  violence  is  necessary  for  its 
reduction. 

2.  When  a joint  has  been  luxated,  at  least  one  of  the 
bones  of  which  it  is  composed  is  detained  in  that  un- 
natural situation  by  the  action  of  some  of  the  muscu- 
lar parts  in  connexion  with  it ; which  action,  by  the 
immobility  of  the  joint,  becomes  as  it  were  tonic, 
and  is  not  under  the  direction  of  the  will  of  the  pa- 
tient. 

3.  That  all  the  force  used  in  reducing  a luxated  bone, 
be  it  more  or  less,  be  it  by  hands,  towels,  ligatures,  or 
machines,  ought  always  to  be  applied  to  the  other  ex- 
tremity of  the  said  bone,  and  as  much  as  possible  to 
that  only.  Mr.  Pott  argues,  that  if  the  extending  force 
were  applied  to  a distant  part  of  the  limb,  or  to  the 
bone  below  or  adjoining,  it  would  necessarily  be  lost 
in  the  articulation  which  is  not  luxated,  owing  to  the 
yielding  nature  of  the  ligaments,  and  be  of  little  or  no 
service  in  that  which  is  dislocated.  This  remark, 
though  made  by  Pott  and  generally  received  as  true,  is 
very  incorrect ; for  it  tends  to  state  that  if  you  pull  at 
the  ankle  or  wrist,  the  force  does  not  operate  on  the 
hip  or  shoulder. 

4.  That  in  the  reduction  of  such  joints  as  are  com- 
posed of  a round  head,  received  into  a socket,  such  as 
those  of  the  shoulder  and  hip,  the  whole  body  should 
be  kept  as  steady  as  possible. 

5.  That  in  order  to  make  use  of  an  extending  force 
with  all  possible  advantage,  and  to  excite  thereby  the 
least  pain  and  inconvenience,  it  is  necessary  that  all 
parts  serving  to  the  motion  of  the  dislocated  joint,  or 
in  any  degree  connected  with  it,  be  put  into  such  a 
state  as  to  give  the  smallest  possible  degree  of  resist- 
ance. 

6.  That  in  the  reduction  of  such  joints  as  consist  of 
a round  head,  moving  in  an  acetabulum  or  socket,  no 
attempt  ought  to  be  made  for  replacing  the  said  head, 
until  it  h8us  by  extension  been  brought  forth  from  the 
place  where  it  is,  and  nearly  to  a level  with  the  said 
socket.  This  will  show  us,  says  Mr.  Pott,  a fault  in 
the  common  ambi,  and  why  that  kind  of  ambi  which 
Mr.  Freke  called  his  commander,  is  a much  better  in- 
strument than  any  of  them,  or  indeed  than  all ; be- 
cause it  is  a lever  joined  to  an  extensor ; and  that 
capable  of  being  u.sed  xvith  the  arm  in  such  position  as 
to  require  the  least  extension  and  to  admit  the  most ; 
besides  which  it  is  graduated,  and  therefore  perfectly 
under  the  dominion  of  the  operator.  It  will  show  us 
why  the  old  method  by  the  door  or  ladder  sometimes 
produced  a fracture  of  the  neck  of  the  scapula ; as  Mr. 
Pott  saw  it  do  himself.  Why,  if  a sufficient  degree  of 
extension  be  not  made,  the  towel  over  the  surgeon’s 
shoulder,  and  under  the  patient’s  axilla,  must  prove  an 
impediment  rather  than  an  assistance,  by  thru.sting  the 
head  of  the  humerus  under  the  neck  of  the  scapula, 
in.stead  of  directing  it  into  its  socket.  Why  the  bar, 
or  rolling-pin,  under  the  axilla  produces  the  same  ef- 
fect. Why  the  common  method  of  bending  the  arm 
(that  is,  the  os  humeri)  downwards,  before  sufficient 
extension  has  been  made,  jirevcnts  the  very  thing 
aimed  at,  by  pushing  the  head  of  the  bone  under  the 
scapula,  which  the  continuation  of  the  extension  for  a 
few  seconds  only  would  have  carried  into  its  proper 
place.  To  the  observation  that  mere  extension  only 
draws  the  head  of  the  bone  out  from  the  axilla  in  which 
It  is  lodged,  but  docs  not  replace  it  in  the  acetabulum 
Scapulae,  >Ir.  Pott  replies,  that  when  the  head  of  the 
08  humeri  is  draxvn  forth  from  the  axilla,  and  brought 


to  a level  with  the  cup  of  the  scapula,  it  must  be  a 
very  great  and  very  unnecessary  addition  of  external 
force,  that  will  or  can  keep  it  from  going  into  it.  All 
that  the  surgeon  has  to  do  is  to  bring  it  to  such  level ; 
the  muscles  attached  to  the  bone  xvill  do  the  rest  for 
him,  and  that  whether  he  will  or  not. 

7.  Another  of  Pott’s  principles  is,  that  whatever 
kind  or  degree  of  force  may  be  found  necessary  for  the 
reduction  of  a luxated  joint,  that  such  force  be  em- 
ployed gradually ; that  the  lesser  degree  be  always  first 
tried,  and  that  it  be  increased  gradatim.— (See  PotVs 
Chir.  Works,  vol.  1.) 

The  supposition  of  the  reduction  being  sometimes 
prevented  by  the  capsular  ligaments.  Sir  A.  Cooper 
considers  erroneous : he  as.sures  us,  that  in  disloca- 
tions from  violence,  those  ligaments  are  always  exten- 
sively lacerated ; and  that  the  idea  of  the  neck  of  the 
bone  being  girt  or  confined  by  them,  is  altogether  un- 
true.—(Sizi-g.  Essays,  part  1,  p.  18.)  But,  in  addition 
to  the  resistance  of  the  muscles,  there  are,  in  old  dis- 
locations, three  circumstances  pointed  out  by  him  as 
causes  of  the  difficulty  of  reduction.  1.  The  extre- 
mity of  the  bone  contracts  adhesion  to  the  surrounding 
parts,  so  that  in  dissection,  even  when  the  muscles  are 
removed,  the  bone  cannot  be  reduced.  In  this  state, 
he  found  the  head  of  a radius,  which  had  been  long 
dislocated  upon  the  external  condyle,  and  which  is 
preserved  in  the  collection  of  St.  Thomas's  Hospital. 
In  a similar  state  he  has  also  seen  the  dislocated  head 
of  the  humerus.— (071  Dislocations,  p.  28.)  2.  The 

socket  is  sometimes  filled  up  with  adhesive  matter.  3. 
A new  bony  socket  is  sometimes  formed,  in  which  the 
head  of  the  bone  is  so  completely  confined  that  it  could 
not  be  extricated  without  breaking  its  new  lodgement, 
—{Surgical  Essays,  part  1,  p.  21  ; and  Treatise,  <S-c, 

p.  10.) 

Dislocations  in  general  cannot  be  reduced  without 
trouble ; but  alter  the  reduction  is  accomplished,  it  is 
easily  maintained.  On  the  contrary,  fractures  are  for 
the  most  part  easy  of  reduction ; but  cannot  be  kept  in 
this  desirable  state  without  difficulty.  The  moment 
extension  is  remitted,  the  muscles  act,  the  ends  of  the 
broken  bone  slip  out  of  their  proper  situation  wtih  re- 
spect to  each  other,  and  the  distortion  of  the  limb 
recurs.  As  a modern  writer  has  observed,  the  reduc- 
tion is  only  a small  part  of  the  treatment  of  fractures : 
the  most  essential  point  of  it  is  the  almost  daily  care 
which  a fracture  demands  during  the  whole  time  re- 
quisite for  its  consolidation.  The  contrary  is  the  case 
in  luxations.  Here,  in  fact,  the  reduction  is  every 
thing,  if  we  put  out  of  consideration  the  less  frequent 
cases  in  which  the  dislocation  is  complicated,  and  at- 
tended with  such  grave  circumstances  as  render  it 
indispensably  necessary  to  continue  Ibr  .a  length  of 
time  the  utmost  surgical  care.  But  even  then  the  pro- 
tracted treatment  is  less  for  the  dislocation  itself  than 
for  the  extraordinary  circumstances  with  which  it  is 
accompanied.— (See  Roux,  Parallile  de  la  Chirurgie 
Angloise  avec  la  Chirurgie  Francoise,  p.  207.) 

All  the  ancient  writers  recommend  the  extending 
force  to  be  applied  to  the  luxated  bone ; for  instance,, 
above  the  knee  in  dislocations  of  the  thigh-bone,  and 
above  the  elbow  in  those  of  the  humerus.  We  have  stated 
that  Pott  advised  this  plan,  and  the  same  practice, 
which  is  approved  by  J.  L.  Petit,  Duvemey,  and  Calli- 
sen,  is  almost  generally  adopted  in  this  country. 

How'ever,  many  of  the  best  modern  surgeons  in 
France,  for  instance,  Fabre,  D’Apouy,  Desault,  Boyer, 
Richerand,  and  Leveillt^,  advise  the  extending  force 
not  to  be  applied  on  the  luxated  bone,  but  on  that  with 
which  it  is  articulated,  and  as  far  as  possible  from  it. 
It  is  said  that  this  plan  has  two  most  important  advan- 
tages : first,  the  muscles  which  surround  the  dislocated 
bone  are  not  compressed,  nor  stimulated  to  spasmodic 
contractions,  which  would  resist  the  reduction ; se- 
condly, the  extending  force  is  much  more  considerable 
than  in  the  other  mode ; for,  by  using  a long  lever,  we 
obtain  a greater  degree  of  power. 

In  Pott’s  remark.s,  we  find  even  him  influenced  by 
the  prevailing  jirejudice  against  the  above  practice, 
that  part  of  the  extending  force  is  lost  on  the  joint  in- 
tervening between  the  dislocation  and  the  jiart  at  which 
the  extension  is  made.  This  notion  is  quite  unfounded, 
as  every  man,  who  reflects  for  one  moment,  must  soon 
perceive.  When  extension  is  made  at  the  wrist,  the 
ligaments,  muscles,  <fcc.  which  connect  the  bones  of 
the  forearm  with  the  os  bracliii,  have  the  whole  of  ilic 


302 


DISLOCATION. 


extending  force  operating  on  them,  and  they  must  ob- 
viously transmit  the  same  degree  of  extension  which 
they  receive  to  the  bone  above,  to  which  they  are  at- 
tached. Indeed,  this  matter  seems  so  plain,  that  I 
think  it  would  be  an  insult  to  the  reader’s  understand- 
ing to  say  any  more  about  it,  than  that  such  eminent 
surgeons  as  have  contrary  sentiments  can  never  have 
taken  the  trouble  to  reflect  for  themselves  on  this  par- 
ticular subject.  Whether  the  force  necessary  to  be  ex- 
erted in  some  instances  would  have  a bad  effect  on  the 
intervening  joint,  may  yet  be  a question ; but  as  De- 
sault’s practice  was  very  extensive,  and  he  did  not 
find  any  objection  of  this  kind,  perhaps  we  have  no 
right  to  conclude  that  such  would  exist. 

If,  however,  the  common  objection  to  Desault’s  plan 
of  applying  the  extending  force  be  unfounded,  the  ques- 
tion still  remains  to  be  settled,  whether  this  practice  is 
most  advantageous  on  the  grounds  above  specified? 
This  is  a point  which,  perhaps,  cannot  be  at  once  pe- 
remptorily decided  altogether  in  the  negative  or  the  af- 
firmative, since  what  may  be  best  in  one  kind  of  dislo- 
cation may  not  be  so  in  another.  Thus,  Sir  A.  Cooper 
states,  that  as  far  as  he  has  had  opportunity  of  observ- 
ing, it  is  generally  best  to  apply  the  extension  to  the 
bone  which  is  dislocated ; but  that  dislocations  of  the 
shoulder  are  exceptions  in  which  he  mostly  prefers  to 
reduce  the  head  of  the  bone,  by  placing  his  heel  in  the 
axilla,  and  drawing  the  arm  at  the  wrist  in  a line  with 
the  side  of  the  body,  whereby  the  pectoralis  major  and 
latissimus  dorsi  are  kept  in  a relaxed  stsile.— {Surgical 
Essays,  part  1,  p.  25.) 

Extension  may  either  be  made  by  means  of  assist- 
ants, who  are  to  take  hold  of  napkins  or  sheets  put 
round  the  part  at  which  it  is  judged  proper  to  make 
the  extension ; or  else  a multiplied  pulley  may  be  used. 
In  cases  of  difficulty.  Sir  A.  Cooper  thinks  the  pulley 
should  always  be  preferred.  “When  assistants  are 
employed,  their  exertions  are  sudden,  violent,  and  often 
ill-ffirected,  and  the  force  is  more  likely  to  produce  la- 
ceration of  parts,  than  to  restore  the  borje  to  its  situa- 
tion. Their  efforts  are  also  often  uncombined,  and 
their  muscles  are  necessarily  fatigued,  as  those  of  the 
patient,  whose  resistance  they  are  employed  to  over- 
come.” In  dislocations  of  the  hip-joint,  and  in  those 
of  the  .shoulder  which  have  been  long  unreduced,  pul- 
leys should  always  be  employed. — (Surgical  Essays, 
part  1,  p.  24.)  But  whether  pulleys  be  used  or  not, 
nothing  more  need  be  added  to  what  Mr.  Pott  has 
stated,  concerning  the  propriety  of  u.sing  moderate 
force  in  the  first  instance,  and  increasing  the  extending 
power  very  gradually. 

The  extension  should  always  be  first  made  in  the 
same  direction  in  which  the  dislocated  bone  is  thrown  ; 
but  in  proportion  as  the  muscles  yield,  the  bone  is  to 
be  gradually  brought  back  into  its  natural  position. 
Thus  the  head  of  the  bone  becomes  disengaged  from 
the  parts  among  which  it  has  been  placed,  and  is 
brought  back  to  the  articular  cavity  again  by  being 
made  to  follow  the  same  course  which  it  took  in  escap- 
ing from  it. 

Extension  will  prove  quite  unavailing,  unless  the 
bone,  with  which  the  dislocated  head  is  naturally  ar- 
ticulated, be  kept  motionless  by  counter-extension,  or  a 
force  at  least  equal  to  the  other,  but  made  in  a con- 
trary direction. 

The  mode  of  fixing  the  scapula  and  pelvis,  in  luxa- 
tions of  the  shoulder  and  thigh,  will  be  hereafter  de- 
scribed. 

In  dislocations  of  ginglymoid  joints,  exten.sion  and 
counter-extension  are  only  made  for  the  purpose  of  di- 
minishing the  friction  of  the  surfaces  of  the  joints,  so 
that  the  reduction  may  be  rendered  more  easy. 

When  the  attempts  at  reduction  fail,  the  want  of  suc- 
cess is  sometimes  owing  to  the  extension  not  being  pow- 
erful enough,  and  the  great  muscular  strength  of  the 
patient,  which  counteracts  all  efforts  to  replace  the  bone. 

In  the  latter  case,  the  patient  may  be  freely  bled,  and 
put  into  awannbath,  so  as  to  make  him  faint.  The  open- 
ing in  the  vein  .should  be  made  large,  because  a sudden 
evacuation  of  blood  is  more  likely  to  produce  weakness 
and  swooning,  than  a gradual  discharge  of  it ; and  the 
patient,  for  the  same  reason,  may  be  bled  as  he  stands 
up.  In  very  difficult  cases,  the  expedient  of- intoxica- 
tion ha.s  been  recommended,  as,  when  the  jiatient  is  in 
this  stale,  his  muscles  are  incapable  of  making  great 
resistance  to  reduction.  IJndor  these  circumstances, 
opium  is  also  frecpaently  administered  xviih  advantage. 


“ The  means  to  be  employed  for  the  deduction  of  dis- 
locations (says  Sir  Astley  Cooper)  are  both  constitu- 
tional and  mechanical.  It  is  generally  wrong  to  em- 
ploy force  only,  as  it  becomes  necessary  to  use  it  in 
such  a degree  as  to  occasion  violence  and  injury ; and  it 
will  be  shown  in  the  sequel,  that  the  most  powerful 
mechanical  means  fail,  when  unaided  by  constitutional 
remedies.  The  power  of  the  muscles,  in  the  first  in- 
stance, is  to  be  duly  appreciated;  as  this  forms  the 
principal  cause  of  resistance.  The  constitutional  means 
to  be  employed  for  the  purpose  of  reduction  are  those 
which  produce  a tendency  to  syncope,  and  this  neces- 
sary St  te  may  be  best  induced  by  one  or  other  of  the 
following  means,  viz.  by  bleeding,  warm  bath,  and 
nausea.  Of  these  remedies,  I consider  bleeding  the 
most  powerful ; and  that  the  effect  may  be  produced  as 
quickly  as  possible,  the  blood  should  be  drawn  from 
a large  orifice,  and  the  patient  kept  in  the  erect  posi- 
tion ; for  by  this  mode  of  depletion,  syncope  is  produced 
before  so  large  a quantity  of  blood  as  might  injure  the 
patient  is  lost.  However  the  activity  of  this  practice 
must  be  regulated  by  the  constitution  of  the  person  ; for 
as  the  accident  happens  to  all  the  varieties  of  constitu- 
tion, it  must  not  be  laid  down  as  a general  rule ; but 
when  the  patient  is  young,  athletic,  and  muscular,  the 
quantity  removed  should  be  considerable,  and  the  me- 
thod of  taking  it  away  that  which  I have  described. 

Secondly,  in  those  cases  where  the  warm  bath  may 
be  thought  preferable,  or  where  it  may  be  considered 
improper  to  carry  bleeding  any  farther,  the  bath  should 
be  employed  at  the  temperature  of  100°  or  110°;  and 
as  the  object  is  the  same  as  in  the  application  of  the 
last  remedy,  the  person  should  be  kept  in  the  bath  at 
the  same  heat  till  the  fainting  effect  is  produced,  when 
he  should  be  immediately  placed  in  a chair,  wrapped  in 
a blanket,  and  the  mechanical  means  emjtloyed. 

Of  late  years,  I have  practised  a third  mode  of  lower- 
ing the  action  of  the  muscles,  by  exhibiting  nauseating 
doses  of  tatarized  antimony ; but  as  its  action  is  uncer- 
tain, frequently  producing  vomiting,  which  is  unneces- 
sary, I rather  recommend  its  application,  merely  to 
keep  up  the  state  of  syncope,  already  produced  by  the 
two  preceding  means,  which  its  nauseating  efects 
will  most  readily  do,  and  so  powerfully  overcome  the 
tone  of  the  muscles,  that  dislocations  may  be  reduced 
with  much  less  effort,  and  at  a much  more  distant  pe- 
riod from  the  accident  than  can  be  effected  in  any  other 
way.”- (Sir  ./?.  Cooper  on  Dislocations,  <S-c.  p.  29,30, 
Also,  Surgical  Essays,  part  1,  p.  22.)  In  cases  of  un- 
usual difficulty,  the  use  of  antimonium  tartar.,  together 
with  the  warm  bath  and  bleeding,  seems  rational  and 
judicious ; but  except  in  cases  of  that  description,  I 
should  prefer  long-continued,  unremitting,  not  too  vio- 
lent, extension,  which  will  at  last  overcome  the  mus- 
cles of  the  most  athletic  man.  Sometimes  the  resist- 
ance made  to  reduction  by  muscles,  acting  in  obedience 
to  the  will,  may  be  eluded  by  the  patient’s  attention 
being  suddenly  taken  from  the  injured  part,  at  which 
moment  the  action  of  those  muscles  is  suspended,  and 
a very  little  effort  on  the  part  of  the  surgeon  will  re- 
duce the  bone.  A case,  illustrating  tliis  circumstance, 
is  recorded  by  Sir  A.  Cooper,  (Surgical  Essays,  part 
1,  p.  25;  and  Treatise,  <S  c.  p.  34.) 

Dislocations  of  orbicular  joints  can  seldom  be  re- 
duced after  a month,  though  by  means  of  great  vio- 
lence Desault  used  to  succeed  at  the  end  of  three  or 
four.  Dislocations  of  ^nglymoid  articulations  gene- 
rally become  irreducible  in  twenty  or  twenty-four  days, 
in  consequence  of  anchylosis. 

The  reduction  of  a dislocation  is  known  by  the  limb 
recovering  its  natural  length,  shape,  and  direction,  and 
being  able  to  perform  certain  motions,  not  possible 
while  the  bone  was  out  of  its  place.  T^e  patient  ex- 
periences a great  and  sudden  diminution  of  pain  ; and 
very  often  the  head  of  the  bone  makes  a noise  at  the 
moment  when  it  turns  into  the  cavity  of  the  joint. 

Sir  Astley  Cooper  believes,  that  much  mischief  is 
produced,  by  attempts  to  reduce  dislocations  of  long 
standing  in  very  muscular  persons.  He  has  seen  great 
contusion  of  the  integuments,  lacenation,  and  bruises 
of  the  muscles,  and  stretcliing  of  the  nerves,  leading 
to  an  insensibility  and  paralysis  of  the  hand,  follow  an 
abortive  attempt  to  reduce  a dislocation  ol’  the  shoul- 
der. He  is  of  opinion  that  three  months  for  the  shoul- 
der, and  eight  weeks  for  the  hip,  may  be  set  down  as 
the  period  from  the  accident  when  it  would  be  impru- 
dent to  make  the  attempt,  except  m persons  of  very  rev 


DISLOCATION. 


303 


laxed  ribre,  or  advanced  age.— (See  Tr  eatise  on  Dislo- 
cations, Src.  p.  35.)  I have  seen  two  cases,  in  which 
very  great  force  was  exerted  witli  pulleys,  to  reduce 
the  thigh-bone  at  the  end  of  three  or  four  weeks ; but 
the  attempts  completely  failed.  However,  the  assist- 
ance to  be  derived  from  properly  lowering  the  strength 
of  the  muscles  previously,  by  means  of  nauseating 
doses  of  antimony,  the  warm  bath,  &c.,  was  not  here 
taken  advantage  of.  A dislocation  of  the  upper  head 
of  the  radius,  of  about  a fortnight’s  standing,  I have 
known  resist  all  the  efforts  of  two  of  the  most  eminent 
surgeons  in  London. 

[I'he  mischiefs  resulting  from  violence  done  to  the 
structure  of  the  neighbouring  parts  in  attempts  at  dislo- 
cation, are  often  much  greater  than  those  to  which  Mr. 
Cooper  alludes  in  the  preceding  paragraph.  The  fol- 
lowing extract  is  taken  from  the  last  edition  of  the  ‘ First 
Lines,’  and  may  be  found  in  a note  by  the  Philadelplua 
editor,  vol.  2,  p.  469. 

“ In  the  third  volume  of  the  Repertoire  d\dnatomie, 
several  cases  of  long-continued  lu.xation  of  the  hu- 
merus, in  which  severe  mischief  arose  from  the  at- 
tempt to  reduce  the  parts,  are  reported  by  M.  Flaubert, 
M.D. ; in  one  case,  one  of  the  axillary  nerves  was 
torn  from  the  spinal  marrow ; and  in  others,  paralysis 
of  the  arm  wtis  the  result.  After  having  succeeded 
completely  in  several  previous  instances.  Professor 
Gibson  has  within  a few  years  met  with  two  instances 
in  which  the  axillary  artery,  having  formed  unnatural 
adhesions,  was  torn  across,  and  the  death  of  the  pa- 
tients consequently  resulted  from  the  attempts  at  re- 
duction. 

One  of  these  cases  is  reported  in  the  third  number  of 
the  Am.  Journal  of  the  Med.  Sciences.  The  patient,  a 
strout,  muscular,  athletic  man,  about  six  feet  high,  ap- 
plied to  Professor  Gibson  on  account  of  a luxation  of  the 
left  os  humeri  at  the  shoulder-joint,  of  nine  weeks’ 
standing.  He  was  admitted  into  the  Alms-House  In- 
firmary on  the  6th  of  March ; the  antiphlogistic  system 
was  pursued  until  the  15th,  when  attempts  at  reduc- 
tion were  made,  in  the  presence  of  the  surgeons  and 
students  of  the  house,  which  was  not  accomplished 
until  after  the  lapse  of  an  hour  and  three-quarters  from 
the  commencement  of  the  operation. 

On  the  16th,  there  was  a general  swelling  over  the 
deltoid  and  pectoral  muscles,  with  a distinct  pulsa- 
tion of  an  aneurismal  character.  On  the  morning  of 
the  17th,  it  had  increased  considerably,  and  in  consulta- 
tion it  was  decided  that  the  subclavian  artery  should 
be  tied  without  delay.  This  was  accordingly  done  by 
Professor  G.” 

This  patient  died  on  the  tenth  day  after  the  ligature 
of  the  subclavian.  The  details  of  the  case,  and  the  dis- 
section, which  was  highly  interesting,  may  be  found 
in  the  3d  No.  of  the  Ajh.  Joiumal  of  the  Med.  Sciences. 
The  writer  then  adds,  “ Those  who  are  acquainted  with 
the  professional  skill  of  Professor  G.  must  attribute  the 
failure  in  this  case  to  the  proper  cause,  the  ‘ firm  adhe- 
sion of  the  artery  to  the  head  of  the  bone and  a like 
result  must  necessarily  have  Ibllowed  its  reduction  in 
the  hands  of  any  other  surgeon.  As  the  result  of  Ifis 
exp'.irience.  Prolessor  G.  has  drawn  some  conclusions 
of  immense  practical  value,  and  to  which  we  think  too 
much  attention  cannot  be  paid.  ‘If,” says  Professor 
G.,  ‘the  patient  is  young,  not  very  muscular,  the  luxa- 
tion not  complicated  with  fracture — if  no  attempts  have 
previously  been  made  to  accomplish  the  reduction,  and 
the  head  of  the  bone  has  not  been  out  of  its  natural 
situation  beyond  five  or  six  weeks,  I should  advise  the 
attenqit  to  replace  it.  But,  on  the  contrary,  if  the 
patient  is  very  robust  and  vigorous,  advanced  in 
years,  accustomed  to  labour  and  to  the  free  use  of  ar- 
dent spirits,  and  the  head  of  the  bone  has  been  long 
out,  I should  discountenance  any  attempt  at  reduction.’  ” - 
— Reese.] 

In  ordler  to  keep  the  bone  from  slipping  out  of  its 
place  again,  we  have  only  to  hinder  the  limb  from  mov- 
ing. When  splints  will  act  powerfully  in  supporting 
the  joint,  they  are  very  often  u.scd,  as  in  dislocations  of 
the  ankle,  wrist,  <kc.  As  the  humerus  cannot  be  lu.x- 
ated,  except  when  at  some  distance  from  the  body,  a 
return  of  its  dislocation  will  be  prevented  by  confining 
the  arm  close  to  the  side  in  a sting.  The  spica  band- 
age, applied  after  such  an  accident,  is  more  satislactory 
to  the  patient,  than  really  efficacious.  Whatever  band- 
age is  used  to  keep  the  arm  from  moving,  should  be 
put  on  the  lower  end  of  the  bone,  as  far  as  possible  from 


the  centre  of  motion.  According  to  Sir  Aslley  Cooper, 
the  hip  is  rarely  dislocated  a second  time ; but  the  hu- 
merus and  the  lower  jaw  very  frequently  slip  again 
from  their  sockets,  which  are  shallow.  Bandages  for 
the  prevention  of  this  return  of  displacement  are,  there- 
fore, in  such  cases,  particularly  necessary.  Rest  is  re- 
quired for  some  time  after  the  reduction,  in  order  that 
the  ruptured  ligaments  may  unite.  The  strength  of  the 
muscles,  &c.  will  also  be  greatly  promoted  by  friction, 
and  pouring  cold  water  over  the  limb. — {On  Disloca- 
tions, p.  35.) 

When  a bone  is  broken  and  dislocated,  an  endeavour 
should  be  made  to  reduce  the  dislocation  without  loss 
of  time,  and  then  pay  attention  to  the  fracture.  Also, 
if  there  be  a compound  fracture  of  the  leg,  and  a dis- 
location of  the  shoulder,  the  fractme  is  to  be  secured 
in  splinrs,  and  the  dislocation  then  reduced.— (Sir  A. 
Cooper  on  Dislocations,  p.  16.)  The  case  of  a bone, 
dislocated  and  fractured  at  the  same  time,  might  be  at- 
tended with  considerable  difficulty  of  reduction:  for- 
tunately, it  is  a very  uncommon  accident. 

COMPOUND  DISLOCATIONS. 

Compound  Dislocations  are  those  which  are  attended 
with  a wound  communicating  with  the  cavities  of  the 
injured  joints.  Some  joints  are  much  more  disposed 
than  others  to  compound  dislocations.  The  accident 
scarcely  ever  takes  place  at  the  hip.  Sir  Astley  C’oojier 
has  known  one  instance  of  it  at  the  shoulder,  and  he 
has  seen  one  of  the  knee;  but  the  case  isvery  fre- 
quent in  the  ankle,  elbow,  and  wrist. — {On  Disloca- 
tions, p.  19.)  In  most  instances,  the  opening  in  the 
skin  is  caused  by  the  protrusion  of  the  bone,  but  some- 
times by  the  part  having  struck  against  a hard  or  an 
irregular  body.  Cases  of  this  description  are  frequently 
attended  with  great  danger;  and  the  same  nicety 
of  judgment  is  requisite  in  determining,  whether  am- 
putation ought  to  be  immediately  perfonned,  or  an  ef- 
fort made  to  preserve  the  limb,  as  in  compound  frac- 
tures, and  bad  gun-shot  injuries ; and  many  of  the  ob- 
servations which  I shall  have  to  offer  upon  the  latter 
subjects,  will,  for  the  most  part,  be  applicable  to  the 
present. 

When  the  luxation  of  a large  joint  is  conjoined  with 
an  external  wound,  leading  into  the  capsular  ligament, 
it  is  a circumstance  that  has  a particular  tendency  to 
increase  the  danger.  In  many  cases,  injuries  of  this 
description  are  followed  by  violent  and  extensive  in- 
flammation, abscesses,  mortification,  fever,  delirium, 
and  death.  When  the  patient  is  advanced  in  years, 
much  debilitated,  or  of  an  unhfealthy  irritable  constitu- 
tion, a compound  luxation,  especially  if  attended  with 
much  contusion  and  other  injury  of  the  sore  parts,  and 
wrongly  treated,  very  often  has  a fatal  termination. 
This,  however,  is  not  the  general  event  of  compound 
dislocations ; and  whatever  may  have  happened  in  for- 
mer times,  we  now  know,  that  in  the  present  improved 
state  of  surgery,  these  accidents  mostly  admit  of  cure. 
This  statement  may  be  made,  without  any  censure  be- 
ing cast  upon  every  instance  of  amputation  performed 
in  such  cases.  1 know  that  this  operation  is  sometimes 
indispensable  directly  after  the  accident,  and  I am 
equally  aware,  that  it  may  become  necessary  in  a fu- 
ture stage,  when  extensive  abscesses  or  sloughing 
joined  with  threatening  constitutional  symptoms  have 
taken  place.  My  only  design  is  to  recommend  the  en- 
deavour to  cure  the  generaUty  of  compound  luxations. 
But  if  a case  were  to  present  itself,  attended  with  se- 
rious contusion  and  laceration  of  the  soft  parts,  I 
should  be  as  earnest  an  advocate  lor  amputation  as  any 
surgeon. 

Mr.  Hammick,  surgeon  to  the  Royal  Naval  Hospital, 
Plymouth,  in  speaking  of  compound  dislocations  of  the 
ankle,  advises  amputation,  “ where  the  lower  heads  of 
the  tibia  and  fibula  are  very  much  shattered ; where, 
together  with  the  compound  dislocations  of  these  bones 
some  of  the  tarsal  bones  are  displaced  and  injured ; 
where  any  large  vessels  are  divided,  and  cannot  be  se- 
cured without  extensive  enlargement  of  the  wound 
and  disturbance  of  the  solt  parts ; where  the  common 
integuments,  with  the  neighbouring  tendons  and  luus- 
cles,  are  considerably  tom;  where  the  protruded  tibia 
cannot  by  any  means  be  reduced;  and  where  the  con- 
stitution is  enfeebled  at  the  time  of  the  accident,  and 
not  likely  to  endure  pain,  discharge,  and  length  of 
confinement.”— (W.  Cooper's  Surgical  Essays,  part  2, 
p.  146.)  Perhaps,  as  general  remarks,  these  may  not 


304  dislocation. 


be  inaccurate ; but  there  are  exceptions  to  them.  Thus, 
we  find  in  Sir  A.  Cooper’s  publication,  several  cases  in 
which  compound  dislocations  of  the  ankle  terminated 
well,  notwithstanding  the  displacement  and  removal 
of  the  astragalus,*  other  instances  of  which  kind  of 
success  are  to  be  found  in  the  records  of  surgery. — 
(See  Laumonier,  in  Fourcroy,  M^d.  Eclair- e;  Percy j 
in  Journ.  de  Med.  continue,  Nov.  1811,  p.  348.)  How- 
ever, if  the  ends  of  the  tibia  and  tarsal  bones,  especi- 
ally the  astragalus  and  os  calcis  are  broken,  the  opera- 
tion of  amputation  is  recommended  on  high  authority 
—{Sir  A.  Cooper's  Surg.  Essays,  part  2,  p.  181.)  But 
with  regard  to  the  division  of  large  blood-vessels,  Sir 
A.  Cooper  states,  that  he  would  hot  at  once  proceed 
to  amputation  on  that  account.  “The  case  from  Mr. 
Sandford,  of  Worce.ster,  sent  me  by  Mr.  Carden,  clearly 
shows,  that  the  division  of  the  anterior  tibial  artery- 
does  not,  if  it  be  well  secured,  prevent  the  patient’s  re- 
covery. I also  once  saw  a compound  fracture,  close  to 
the  ankle-joint,  accompanied  by  a division  of  that  ar- 
tery ; and,  although  the  patient  was  in  the  hospital,  and 
a brewer’s  servant,  who  possessed  the  worst  constitu- 
tion to  strugle  against  severe  injuries,  yet  this  man  re- 
covered without  amputation.”  Nor,  in  Sir  A.  Cooper’s 
opinion,  would  all  hope  be  precluded,  even  if  the  pos- 
terior tibial  artery  were  injured. — {Vol.  cit.p.  186.)  For 
the  method  of  securing  these  vessels,  see  Arteries. 

The  following  are  the  circumstances,  which  Sir  A. 
Cooper  has  known  give  rise  to  the  necessity  for  ampu- 
tation in  compound  dislocations  of  the  ankle.  1.  The 
advanced  age  of  the  patient.  2.  A very  extensive  la- 
cerated wound.  3.  Difficulty  of  reducing  the  ends  of 
the  bones  he  considers  rather  as  a reason  for  sawing 
them  off,  than  for  amputation.  4.  The  extremely  shat- 
tered state  of  the  bones.  5.  Dislocations  of  the  tibia 
outwards  cause  greater  injury  of  the  bones  and  soft 
parts  than  those  inwards,  and  more  frequently  require 
amputation.  6.  Sometimes  the  bone  cannot  be  kept 
reduced,  owing  to  the  tibia  in  the  dislocation  outwards 
being  obliquely  fractured.  7.  Division  of  a large  blood- 
vessel, attended  with  extensive  wound  of  the  soft 
parts.  8.  Mortification.  9.  Excessive  contusion.  10. 
Extensive  suppuration.  11.  Necrosis,  where  the  se- 
questra do  not  admit  of  removal.  12.  Very  great  and 
permanent  deformity  of  the  foot.  13.  When  teta- 
nus comes  on.  Sir  A.  Cooper  does  not  approve  of  the 
operation.  14.  A very  irritable  state  of  constitution, 
such  as  is  often  met  with  in  very  fat  subjects,  who 
take  no  exercise. — {On  Dislocations,  ^ c.  p.  332,  i-c.) 

The  treatment  of  a compound  dislocation  requires 
the  reduction  to  be  effected  without  delay,  and  with  as 
little  violence  and  disturbance  as  possible.  When  the 
extremity  of  the  bone  protrudes,  and  is  smeared  with 
sand  or  dirt,  as  frequently  hajjpens  from  its  having 
touched  the  ground,  “ it  should  be  washed  with  warm 
water,  as  the  least  extraneous  matter  admitted  into  the 
joint  will  produce  and  support  a suppurative  process, 
and  the  utmost  care  should  be  taken  to  remove  every 
portion  of  it  adhering  to  the  end  of  the  bone.  If  the 
bone  be  shattered,  the  finger  is  to  be  passed  into  the 
joint,  and  the  detached  pieces  are  to  be  removed ; but 
this  is  to  be  done  in  the  most  gentle  manner  possible,  so 
as  not  to  occasion  unnecessary  irritation;  and  if  the 
wound  be  so  small  as  to  admit  the  finger  with  difficulty, 
and  small  loose  pieces  of  bone  even  be  felt,  the  integu- 
ments should  be  divided  with  a scalpel,  to  allow  of  such 
portions  being  removed  without  violence.'-’ — {Sir  A. 
Cooper  On  Dislocations,  p.  254  ) If  any  difficulty  of 
reduction  should  arise  from  the  bone  being  girt  by  the 
integuments,  the  opening  in  them  should  be  dilated 
with  a scalpel.  The  limb  is  then  to  be  placed  in  splints, 
with  the  necessary  pads,  eighteen-tailed  bandage,  <fec. 
Sir  A.  Cooper  judiciously  recommends  the  portions  of 
this  bandage  not  be  sewed  together,  “ but  passed  under 
the  leg,  so  that  one  piece  may  be  removed  when  it  be- 
comes stiff;”  and  by  fixing  another  to  its  end,  before  it 
is  withdrawn,  the  fresh  piece  may  be  applied  without 
any  disturbance  of  the  limb.— (Si/rg-.  Essays,  part  2, 
p.  120.)  The  wound  is  to  be  freed  from  any  dirt,  clots 
of  blood,  or  other  extraneous  matter,  and  its  lips  are  to 
be  accurately  brought  togellier  with  strips  of  adhesive 
plaster.  Sir  A.  Cooper  considers  lint  dipi)ed  in  the 


[*  Professor  Stevens,  of  New-Vork,  removed  the  as- 
tragalus in  a case  of  irreducible  compound  dislocation 
of  the  ankle-joint,  and  the  case  had  an  early  and  most 
happy  termination. --Eeese.] 


blood  which  oozes  out  the  best  kind  of  first  dressing# 
The  joint  is  to  be  covered  with  linen  kept  constantly- 
wet  with  the  liquor  plumbi  acetatis  dilutus,  or  with, 
what  is  better,  spirit  of  wine  and  water ; the  bandage 
is  to  be  loosely  laid  down,  and  the  splints  fastened  on 
the  limb  with  their  proper  straps  or  pieces  of  tape,  and 
the  limb  is  to  be  kept  perfectly  at  rest  in  an  eligible 
posture.  The  patient,  if  strong  and  young,  is  to  be 
bled.  This  last  practice  may  be  more  freely  adopted  in 
the  country  than  in  London,  or  large  hospitals.  An 
anodyne  the  first  night  or  two  will  be  liighly  proper. 
Saline  draughts,  antimonials,  and  a low  regimen  are 
also  indicated  during  the  first  few  days  of  the  symptom- 
atic fever,  which  commonly  follows  so  serious  an  ac- 
cident. 

According  to  Sir  A.  Cooper,  purgatives  should  be 
used  with  the  utmost  caution ; “ for  (says  he),  there 
cannot  be  a worse  practice,  when  a limb  has  been 
placed  in  a good  position,  and  adhesion  is  proceeding, 
than  to  disturb  the  processes  of  nature  by  the  frequent 
changes  of  position  which  purges  produce ; and  I am 
quite  sure,  that  in  cases  of  compound  fracture,  I have 
seen  patients  destroyed  by  their  frequent  administra- 
tion. That  which  is  to  be  done  by  bleeding  and  empty- 
ing the  bowels  should  be  effected  within  an  hour  or  two 
after  the  accident,  before  the  adhesive  infiammation 
anses.”— {Surgical  Essays,  part  l,p.  121.)  Here  the 
fracture-bed,  invented  by  Mr.  Earle,  would  allow  pur- 
gatives to  be  used  without  any  disturbance  of  the  limb. 

If  the  case  takes  a favourable  course,  the  constitu- 
tional fever  will  not  be  excessive,  nor  will  the  pain  and 
infiammation  of  the  limb  be  immoderate.  Sometimes 
the  wound  unites  more  or  less  without  suppuration;  a 
circumstance  particularly  desirable,  as  tending  more 
than  any  thing  else  to  lessen  the  danger,  by  changing 
the  case,  as  it  were,  from  a compound  into  a simple  one. 
In  other  cases  the  wound  is  not  united,  but  the  infiam- 
mation and  suppuration  are  not  violent  nor  extensive, 
the  constitution  is  not  dangerously  disturbed,  and 
hopes  of  ultimate  success  may  be  reasonably  enter- 
tained. When  the  wound  is  disposed  to  heal  favour- 
ably, adhesive  plaster,  with  or  without  lint,  or  a pled- 
get of  soft  soap  cerate  is  the  best  dressing.  In  other 
instances,  while  the  suppuration  is  copious,  and  the 
parts  are  tense  and  painful,  emollient  poultices  are  the 
most  eligible. 

When  the  symptomatic  fever  and  first  inflammatory 
symptoms  are  over,  and  much  discharge  prevails,  at- 
tended with  marks  of  approaching  weakness,  the  pa- 
tient is  to  be  allowed  more  food,  and  directed  to  take 
bark,  cordials,  porter,  wine,  &c.  If  his  nights  are  rest- 
less, he  must  have  opiates ; if  he  sweats  profusely, 
sulphuric  acid ; and,  in  short,  all  such  medicines  a.s  his 
particular  complaints  may  require  are  to  be  prescribed. 

When  the  inflammation  of  a compound  dislocation  is 
violent  or  extensive,  general  bleeding,  the  application  of 
leeches,  and  the  use  of  fomentations  and  poultices,  are 
the  most  likely  means  of  lessening  the  mischief.  Yet 
it  is  only  in  strong  habits  that  venesection  to  any  ex- 
tent can  be  prudently  practised  in  large  cities  or  crowded 
hospitals. 

The  following  are  the  instructions  delivered  by  Sir 
A.  Cooper  on  the  subject  of  dressings.  “ If  the  patient 
complain  of  considerable  pain  in  the  part,  in  tour  or 
five  days  the  bandage  may  be  raised  to  examine  the 
wound ; and  if  there  be  much  inflammation,  a comer 
of  the  lint  (or  other  dressing)  should  be  lifted  from  the 
wound,  to  give  vent  to  any  matter  which  may  have 
formed ; but  this  ought  to  be  done  with  great  circum- 
spectioii,  as  there  is  danger  of  disturbing  the  adhesive 
process,  if  that  be  proceeding  without  suppuration. 
By  this  local  treatment,  it  will  every  now  and  then 
happen,  that  the  wound  will  be  closed  by  adhesion* 
but  if  in  a few  days  it  be  not,  and  suppuration  take 
place,  the  matter  should  have  an  opportunity  of  escap- 
ing; and  the  lint  being  removed,  simple  dressings 
should  be  applied.  After  a week  or  ten  days,  if  there 
be  suppuration  with  much  surrounding  inflammation, 
poultices  should  be  applied  upon  the  wound,  leeches  in 
its  neighbourhood,  and  upon  the  limb  at  a distance  the 
evajiorating  lotion  should  still  be  employed;  but  as 
soon  as  the  inflammation  i.s  le.ssened,  tne  poultices 
should  be  discontinued.”— (iJurg-ica/  Essays,  part  2, 

p.  121.) 

In  certain  examples,  the  most  skilful  treatment  is 
unavailing.  The  joint  and  limb  become  affected  with 
considerable  pain  and  swelling,  the  fever  rune  high, 


DISLOCATION. 


delirium  comes  on,  and  the  patient  may  even  perish 
ft-om  the  violence  of  the  first  symptoms,  the  limb  being 
generally  at  the  same  time  attacked  by  gangrene.  If 
these  first  dangers  are  avoided,  tlie  wound  may  yet  not 
heal  favourably,  the  inflammation  may  be  considerable, 
or  of  an  erysipelatous  nature,  large  abscesses  under  the 
fasciee  may  be  formed,  the  bones  may  be  affected  with 
necrosis,  and  the  hectical  symptoms  and  sinking  state 
of  the  patient  may  make  the  only  chance  of  recovery 
depend  upon  amputsUion.  But  even  this  operation  is 
sometimes  deferred  till  too  late,  and  the  patient  must 
be  left  to  his  miserable  fate. 

Whoever  gives  the  smallest  reflection  to  the  nature 
of  compound  luxations,  will  perceive  that  it  is  often 
a matter  of  the  highest  importance  to  make  a right  de- 
cision at  the  very  beginning,  whether  amputation 
should  be  immediately  done,  or  an  attempt  made  to 
save  the  limb.  In  some  instances,  the  patient’s  sole 
chance  depends  upon  the  operation  being  performed  at 
once,  without  the  lea^  delay,  and  the  opportunity  of 
doing  it  never  returns.  The  surgeon  should  take  off 
the  limb  as  soon  as  he  has  seen  the  nature  of  the  in- 
jury, and  not  wait  till  .i  general  tendency  to  swelling 
and  gangrene  has  spread  through  the  member,  and 
every  action  in  the  system  is  disturbed.  Amputation 
under  these  circumstances  is  undoubtedly  done  with  a 
very  diminished  chance  of  success ; and,  until  certain 
facts  were  adduced  by  Baron  Larrey,  Mr.  Lawrence, 
Mr.  A.  C.  Hutchison,  and  others,  was  of  late  j ears  al- 
together prohibited.— (See  Amputation  and  Mortifica- 
tion.) 

But,  besides  this  first  critical  period,  the  surgeon  often 
has  to  exercise  a nice  degree  of  Judgment  in  a future 
stage  of  the  case ; I mean  when  the  suppuration  is  co- 
pious, the  wound  open,  the  bones  carious,  and  the 
health  impaired.  Here  the  practitioner  may  sometimes 
err,  in  taking  off  a limb  that  might  be  saved;  or  he 
may  commit  a worse  fault,  and  make  the  patient  lose  his 
life,  in  a fruitless  attempt  to  save  the  member.  No 
precepts  can  form  the  right  practitioner  in  this  delicate 
part  of  surgery ; genius  alone  cannot  do  it : the  oppor- 
tunity of  making  observations,  and  the  talent  of  profit- 
ing by  them,  are  here  the  things  which  make  the  con- 
summate surgeon. 

It  should  ever  be  recollected,  in  regard  to  bad  com- 
pound dislocations,  that  in  young  subjects,  and  in  a sa- 
lubrious air,  many  cases  will  do  well,  which  in  old 
persons,  and  in  the  polluted  atmosphere  of  London,  and 
crowded  hospitals,  would  be  fatal  without  amputation. 

The  constitutions  of  some  individuals  are  so  irrita- 
ble, that  whether  an  attempt  be  made  to  save  the  limb, 
or  amputation  be  at  once  performed,  the  case  has  a ra- 
pid and  fatal  termination.  According  to  Sir  A.  Cooper, 
persons  who  are  much  loaded  with  fat  “ are  generally 
irritable,  and  bear  important  accidents  very  ill ; indeed,” 
says  he,  “ they  generally  die,  whichever  plan  of  treat- 
ment be  pursued.” — However,  he  adds  thart  such  corpu- 
lent people  as  take  a great  deal  of  exercise,  form  excep- 
tions to  the  foregoing  remark. — {Surgical  Essays, 
part  2,  p.  195.) 

There  is  a practice  in  regard  to  compound  dislocations, 
which  I think  ought  at  all  events  to  be  adopted  only  in 
a very  few  cases ; I mean  the  plan  of  sawing  off  the 
head  of  the  luxated  bone.  According  to  Leveille,  this 
method  is  recommended  by  Hippocrates,  as  a means  of 
accelerating  and  perfecting  the  cure. — {Nouvelle  Doc- 
trine Chirurgicale,  t.  2,  p.  44.)  However,  it  seems  not 
to  have  done  sufficient  good  in  ancient  times  to  have 
obtained  a lasting  reputation.  In  fact,  when  it  was 
mentioned  by  the  late  Mr.  Gooch,  it  had  sunk  into  such 
oblivion,  that  it  was  received  as  an  entirely  new  pro- 
posal. “ Compound  luxations  (says  this  author)  are 
of  a more  dangerous  nature  than  compound  fractures, 
for  very  plain  reasons;  but  if  a surgeon  should  Judge 
it  advisable  to  attempt  saving  a limb  under  such 
threatening  circumstances,  I am  inclined  to  think, 
from  what  I have  observed,  he  will  be  more  likely  to 
succeed  by  sawing  off  the  head  of  the  bone,  especially 
if  it  has  long  been  quite  out,  and  exposed  to  the  air.” 

Mr.  Gooch  afterward  takes  notice  of  a case  in  which 
Mr.  Cooper,  of  Bungay,  sawed  off  the  heads  of  the  tibia 
and  fibula,  and  preserved  the  limb,  the  patient  being 
able  to  walk  and  work  for  his  bread  for  many  years 
afterward.  Other  examples  are  also  briefly  mentioned, 
in  which  the  lower  head  of  the  radius  was  sawn  off, 
■nd  the  head  of  the  second  bone  of  the  thumb. 

I'he  late  Mr.  Hey,  of  Leeds,  was  induced  to  make 

VoL.  L— U 


30f> 

trial  of  this  plan  in  a compound  luxation  of  the  ankle. 
The  example,  however,  which  he  published,  is  decidedly 
unfavourable  to  the  practice,  as  the  following  passage 
will  show : “ 1 was  in  hopes  that  this  patient  would 
have  been  able  to  walk  stoutly ; but  in  this  I was  disap- 
pointed. He  walked  indeed  without  a crutch ; but  his 
gait  was  slow,  his  leg  remaining  weak,  and  his  toes 
turning  outwards,  which  rather  surprised  me,  as  hi^ 
leg  was  very  straight  when  I ceased  attending  him.”  • 

Mr.  Hey  did  not  recite  this  case  with  the  view  of  re- 
commending a similar  practice  in  all  cases  of  this  ac- 
cident ; for  he  had  not  always  adopted  it,  nor  was  he 
of  opinion,  that  the  same  mode  of  treatment,  whether 
by  replacing  the  bones,  sawing  off  their  extremities,  or 
amputating  the  limb,  ought  to  b'e  universally  practised. 
When  the  laceration  of  the  capsular  ligament  and  in- 
teguments is  not  greater  than  is  sufficient  to  permit  the 
head  of  the  tibia  to  pass  through  them ; and  when,  at 
the  same  time,  the  joint  or  contiguous  parts  have  suf- 
fered no  other  injury;  Mr.  Hey  recommends  the  re- 
placing of  the  bone,  and  a union  of  the  integumenta 
by  suture,  with  the  treatment  adapted  to  wounds  of 
the  joints. — {Practical  Obs.  in  Surgery,  chap.  11, 
edit.  2.) 

That  in  a few  cases  recorded  by  Mr.  Gooch  and  Mr. 
Hey  the  patients  recovered  with  a new  sort  of  joint,  only 
proves  to  my  mind  the  great  resources  and  activity  of 
nature,  and  her  occasional  triumph  over  the  opposition 
she  meets  with  from  bad  and  injudicious  surgery.  A 
limb  so  treated  must  ever  afterward  be  shorter  than  its 
fellow,  and  consequently  the  patient  be  more  or  less  a 
cripple.  We  have  seen,  that  in  the  only  instance  pub- 
lished by  Mr.  Hey,  considerable  deformity  was  the 
consequence  of  the  practice.  I cannot  help  adding  my 
belief,  that  this  gentleman  would  have  experienced 
more  success  in  the  treatment  of  compound  dislocations, 
had  he  relinquished  the  objectionable  method  of  sewing 
up  the  wound.  In  such  accidents  every'  kind  of  irrita- 
tion should  be  avoided  as  much  as  possible,  and  that  the 
wound  may  be  conveniently  closed  with  sticking  plaster, 
the  observation  of  numerous  cases  in  St.  Bartholomew’s 
Hospital  has  perfectly  convinced  me.  In  this  munifi- 
cent institution,  under  the  disadvantage  of  the  air  of 
London,  and  an  hospital,  compound  luxations  used,  at 
the  period  when  I was  an  apprentice  there,  to  be  treated 
with  marked  success;  and  I feel  warranted  in  ascrib- 
ing the  circumstance  to  the  mode  of  treatment,  which 
was  conducted  on  the  principles  explained  in  tliis  sec- 
tion of  the  Dictionary. 

The  most  ingenious  arguments  which  have  yet  been 
urged  in  behalf  of  the  practice  of  sawing  off  the  ends 
of  the  bones  in  compound  dislocations  of  the  ankle, 
are  those  recently  published  by  Sir  A.  Cooper.  How- 
ever, he  does  not  advise  the  plan  without  restrictions. 
If  the  dislocation  (says  he)  can  be  easily  reduced, 
without  sawing  off  the  end  of  the  bone ; if  it  be  not 
too  obliquely  broken  to  remain  firmly  upon  the  astra- 
galus after  being  reduced ; if  the  end  of  the  bone  be 
not  shattered,  for  then  the  small  loose  pieces  of  bone 
should  be  removed,  and  the  surface  of  the  bone  be 
smoothed  by  the  saw ; if  the  patient  be  not  excessively 
irritable,  and  the  muscles  affected  with  violent  spasms, 
impeding  reduction,  and  causing  a displacement  of  the 
bones  after  they  have  been  reduced ; Sir  Astley  Cooper 
advises  the  immediate  reduction  of  the  parts,  and  uni- 
ting the  wound  by  adhesion..  In  the  opposite  circum- 
stances, rather  than  amputate  the  limb  he  would  saw 
off  the  ends  of  the  bones. — {Surgical  Essays,  part  1, 
p.  154.  Treatise,  p.  302.) 

The  only  case  in  which  the  plan  of  sawing  off  the 
head  of  the  bone  can  be  at  all  proper,  is  when  a com- 
pound dislocation  cannot  be  reduced,  notwithstanding 
the  enlargement  of  the  wound  in  the  skin,  and  every 
other  possible  means.  There  is  no  other  mode  of  pre- 
venting the  formidable  symptoms  which  would  ensue 
were  the  bone  left  in  a state  of  protrusion  through  the 
integuments ; nor  is  there  any  better  way  of  alleviating 
such  symptoms  after  they  have  actually  begun.  M. 
Roux  gives  much  praise  to  the  English  surgeons  for  the 
judicious  boldness  which  they  have  evinced  in  cases 
of  this  description.  Although  Fabricius  Hildanus,  Fer- 
rand,  Desault,  Laumonier,  and  several  other  French 
surgexms,  have,  like  many  British  practitioners,  ven- 
tured to  remove  the  whole  of  the  astragalus,  when 
this  bone  was  totally  separated  from  the  scaphoides, 
and  protruded  in  compound  luxations,  yet  M.  Roux 
acknowledges  that  the  bold  practice  of  sawing  off  the 


DISLOCATION. 


m 


Tower  end  of  the  hnmeras,  the  lower  end  of  the  radius, 
the  lower  end  of  the  tibia,  and  also  of  the  fibula,  at  the 
same  time,  originated  with,  and  was  first  executed  by, 
English  surgeons.— {ParalMe  de  la  Chirurgie  An- 
gloise  avec  la  Chirurgie  Francoise,  p.  208,  209.) 

DISLOCATIONS  OF  THE  LOWER  JAW. 

• The  low’er  jaw  can  only  be  luxated  forwards,  and 
either  one  or  both  of  its  condyles  may  become  displaced 
in  this  direction.  Every  dislocation  except  that  for- 
wards is  rendered  impo.ssible  by  the  formation  of  the 
parts.  The  lower  jaw  cannot  even  be  dislocated  for- 
wards, unless  the  mouth,  just  before  the  occurrence  of 
^he  accident,  be  very  much  open.  Whenever  the  chin 
i.s  considerably  depressed,  the  condyles  slide  from  be- 
hind forwards  under  the  transverse  root  of  the  zygoma- 
tic processes.  The  cartilaginous  cap  which  envelopes 
the  condyles,  and  follows  them  in  all  their  motions, 
still  affords  them  an  articular  cavity ; but  the  depres- 
sion of  the  bone  continuing,  the  ligaments  give  way, 
the  condyles  glide  before  the  eminentice  articulares, 
and  slip  under  the  zygomatic  arches.  Hence  a dislo- 
cation mostly  happens  while  the  patient  is  laughing, 
gaping,  <fcc.  A blow  on  the  jaw,  when  the  mouth  is 
wide  open,  may  easily  cause  the  accident.  The  case 
has  occasionally  arisen  from  the  exercise  of  great  force 
hi  drawing  out  the  teeth.  Sir  Astley  Ccroper  has  known 
a complete  lu.xation,  that  is  to  say,  of  both  condyles, 
produced  by  a boy  suddenly  putting  an  apple  into  his 
mouth  to  keep  it  from  the  reach  of  a play-fellow. — 
(On  Dislocations,  p.  389.)  Whenever  the  jaw  has  once 
been  dislocated,  the  same  causes  more  easily  reproduce 
the  occurrence.  In  certain  individuals  the  ligaments 
are  so  loose,  and  the  muscles  so  weak,  that  a di.sloca- 
tion  is  produced  by  any  slight  attempt  to  yawn,  laugh, 
or  (as  Lamotte  has  observed)  to  bite  any  substance 
which  is  rather  large. — {Leveilli,  Nouvelle  Doctrine 
Chirurgicale,  tom.  2,  p.  54.)  There  have  been  persons 
who  could  scarcely  ever  laugh  heartily  without  their 
lower  jaws  being  luxated.  But  of  all  the  causes  of 
this  occurrence,  yawning  alone,  even  without  the  com- 
bination of  any  external  force,  is  by  far  the  most 
common. 

When  the  jaw  is  depressed,  and  its  angles,  to  the  ex- 
ternal sides  of  which  the  masseters  are  attached,  are 
carried  upwards  and  backwards,  if  these  muscles  con- 
tract, the  greater  part  of  their  force  tends  to  bring  the 
condyles  irtto  the  zygomatic  depression. — {Boyer.) 

Dislocations  of  the  lower  jaw  are  attended  with  a 
great  deal  of  pain,  which  Boyer  imputes  to  the  pressure 
produced  by  tne  condyles  on  the  deep-seated  temporal 
nerves,  and  those  going  to  the  masseters,  w^hich  nerves 
pass  before  the  roots  of  the  zygomatic  process.  The 
mouth  is  wide  open,  and  cannot  be  shut.  It  is  more 
open  in  recent  dislocations  than  in  those  which  have 
continued  for  some  time.  An  empty  space  is  felt  be- 
fore the  ear  in  the  natural  situation  of  the  condyles. 
The  coronal  process  forms  under  the  cheek-bone  a pro- 
minence, which  may  be  felt  through  the  cheek  or  from 
within  the  mouth.  The  cheeks  and  temples  are  flat- 
tened by  the  lengthening  of  the  temporal,  masseter, 
and  buccinator  muscles.  The  saliva  flows  in  large 
quantities  from  the  mouth,  the  secretion  of  which  fluid 
is  greatly  increased  by  the  irritation  of  the  accident. 
The  arch  formed  by  the  teeth  of  the  lower  jaw  is  situ- 
ated more  forward  than  that  formed  by  the  teeth  of  the 
upper  jaw.  During  the  first  five  days  after  the  acci- 
dent, the  patient  can  neither  speak  nor  swallow.— 
{Boyer.)  When  only  one  condyle  is  dislocated,  the 
mouth  is  distorted,  and  turned  towards  the  opposite 
side,  while  the  fellow’-teeth  of  he  jaws  do  not  corres- 
pond. However,  Mr.  Hey  asserts,  that  frequently  the 
position  of  the  chin  is  not  perceptibly  altered.  —{Prac- 
tical Observations,  p.  322.)  The  mouth  cannot  be  shut ; 
but  it  is  not  so  widely  open  as  in  the  complete  luxation. 
—{Sir  A.  Cooper  on  Dislocations,  p.  392.) 

When  a dislocated  jaw  has  remained  unreduced  for 
several  days  or  w’eeks,  the  symptoms  are  not  so  well 
marked.  In  such  instances,  the  chin  becomes  gradu- 
ally approximated  to  the  upper  jaw ; the  patient  reco- 
vers by  degrees  the  faculty  of  speaking  and  swallow- 
ing ; but  he  stammers,  and  the  saliva  dribbles  from  his 
mouth.  The  sufferings  induced  by  a dislocated  jaw, 
it  is  said,  may  even  prove  fatal  if  the  case  continue 
unrectified;  but  wc  are  not  to  believe  Hippocrates 
v.hcn  he  positively  declares  the  accident  mortal  if  not 
reduced  before  the  tenth  day.  Indeed,  Sir  ikstley 


Cooper,  in  noticing  the  severity  of  the  psin,  assures  Vfy 
that  he  has  never  seen  any- dangerous  effect  produced  J 
on  the  contrarv’,  that  in  time  the  jaw  becomes  more 
closed,  and  a considerable  degree  of  its  motion  is  re- 
stored.—(On  Dislocations,  p.  389.) 

Moiiteggi  attended  a man,  two  months  after  such  a 
bixation,  which  had  not  been  understood,  and  Fabri- 
cius  ab  Aquapendente  assures  us,  that  he  had  never 
seen  the  prognostic  of  Hippocrates  verified,  though  he 
had  had  many  patients  of  this  sort  under  his  care. — 
{Leveille,  Nouvelle  Doctrine  Chir.  t.  2,  p.  58.) 

Dislocations  of  the  lower  jaw  may  be  reduced  in  the 
following  manner : The  surgeon  is  first  to  wrap  some 
linen  round  his  thumbs,  to  keep  them  from  being  hurl 
by  the  patient’s  teeth,  and  then  introduce  them  into 
the  mouth,  as  far  as  possible  along  the  grinding  teeth. 
At  the  same  time  he  is  to  place  his  fingers  under  the 
chin  and  base  of  the  jaw,  and  while  he  depresses  the 
molares  with  his  thumbs,  he  raises  the  chin  with  his 
fingers,  by  which  means  the  condyles  become  disen- 
gaged from  their  situation  under  the  zygomas;  at 
which  instant  the  muscles  draw  those  parts  so  rapidly 
back  into  the  articular  cavities  again,  that  the  surgeon’s 
thumbs  might  sometimes  be  hurt,  did  be  not  immediately 
move  them  QUtwards  between  the  cheek  and  the  jaw. 

The  reduction  being  accomplished,  a fresh  displace- 
ment is  to  be  prevented  b^'  applying  a four-taiied  band- 
age, as  recommended  for  the  fractured  jaw  For  a few 
days  the  patient  should  avoid  such  food  as  requires 
much  mastication. 

The  ancients  used  to  place  between  the  grinding 
teeth  two  pieces  of  stick,  and  while  they  used  them  as 
levers  to  depress  the  back  part  of  the  bone,  they  raised 
the  chin  by  means  uf  a bandage.  The  late  Mr.  Fox, 
the  dentist,  had  a patient  whose  jaw  was  dislocated  on 
both  sides  in  the  extraction  of  a tooth : the  reduction 
was  first  effected  on  one  side  by  placing  a piece  of 
wood  a foot  long  upon  the  grinders,  and  then  raising 
the  part  of  it  which  was  held  in  the  hand.  Mr.  Fox 
next  reduced  the  other  condyle  in  the  same  manner. 
Sir  Astley  Cooper,  in  reducing  a complete  luxation  of 
the  lower  jaw,  prefers  putting  the  patient  in  the  recum- 
bent posture,  introducing  two  corks  behind  the  molar 
teeth,  and  then  elevating  the  chin.— (On  Dislocations, 
p.  391.)  When  only  one  condyle  is  dislocated,  what- 
ever method  of  reduction  be  followed,  it  need  only  be 
applied  to  the  side  affected. 

DISLOCATIONS  OF  THE  VERTEBR.*. 

What  have  been  called  ^slocations  of  the  spine  are 
considered  by  Sir  Astley  Cooper  as  really  fractures  of 
the  vertebrae,  with  displacement  of  the  bones  but  not 
of  the  intervertebral  substance.  The  only  true  disloca- 
tions 01  the  spine  admitted  by  him,  are  those  of  th* 
first  and  second  cervical  vertebrae.— ^ On  Dislocations, 
•Sc.  p.  17.) 

The  large  surfaces  with  wnich  the  vertebrae  support 
each  other ; the  number  and  thickness  of  their  liga- 
ments ; the  strength  of  their  muscles ; the  little  degree 
of  motion  which  each  vertebra  naturally  has ; and  ths 
vertical  direction  of  the  articular  processes,  are  gene- 
rally supposed  to  make  dislocations  of  the  dorsal  and 
lumbar  vertebrae  impossible,  unless  there  be  also  a frac- 
ture of  the  above-mentioned  processes.  Thus  Sir  Ast- 
ley Cooper,  in  his  very  extensive  experience,  has  nevei 
witnessed  a separation  of  one  vertetra  from  another, 
through  the  intervertebral  substance,  without  fracture 
of  the  articular  processes ; or,  if  those  processes  re- 
mained unbroken,  without  a fracture  through  the  bodies 
of  the  vertebrae.  Of  the.se  cases,  I shaM  merely  re- 
mark, that  they  can  only  result  from  immense  violence  ; 
that  the  symptoms  w’ould  be  an  irregularity  in  the  dis- 
position of  the  spinous  processes,  retention  or  inconti- 
nence of  the  urine  and  feces,  paralysis  and  a motion- 
less state  of  the  lower  extremities,  the  effects  of  the 
pressure  or  other  injury,  to  which  the  spinal  marrow 
would  be  subjected.  Similar  symptoms  may  also  arise 
w'hen  the  spinal  marrow  has  merely  undeigone  a vio- 
lent concussion,  without  any  fracture  or  dislocation 
whatever;  and  it  is  certain,  that  most  of  the  cases 
mentioned  by  authors  as  dislocations  of  the  lumbar  and 
dorsal  vertebrae,  have  only  been  concussions  of  the  spi- 
nal marrow,  or  fractures  of  those  bones. 

The  cervical  vertebrte,  however,  not  having  such  ex- 
tensive articular  surfaces,  and  having  more  motion, 
are  occasionally  luxated.  The  dislocation  of- the  head 
from  the  first  vertebra,  and  of  the  first  vertebra  troto 


DISLOCATION. 


31.7 


ttle  second,  particularly  the  last  accident,  is  the  most 
common ; but  luxations  of  the  cervical  vertebra  lower 
down)  though  very  rare,  are  possible.  Indeed,  accord- 
ing to  Boyer,  many  examples  have  happened,  in  which 
one  of  the  inferior  oblique  or  articular  processes  of  a 
cervical  vertebra  has  been  dislocated,  so  as  to  cause  a 
permanent  inclination  of  the  neck  towards  the  side  op- 
posite to  that  of  the  displacement.— (TraiW  des  Mol. 
Chir.  t.  4,  p.  114.) 

Whether  the  case  published  by  Mr.  C.  Bell  under  the 
name  of  a subluxation  of  the  spine,  ought  to  be  re- 
ceived as  an  uneqivocal  specimen  of  a displacement  of 
the  last  ceffvical  from  the  first  dorsal  vertebra,  I cannot 
presume  to  determine.  This  author  speaks  of  an  evi- 
dent loosening  between  these  two  bones  ; of  a consi- 
derable space  between  them ; of  the  destruction  of  the 
intervertebral  substance ; and  of  an  immense  quantity 
of  pus  around  the  injured  part  of  the  spine,  as  circum- 
stances seen  in  the  dissection.  “ On  the  back  part,  the 
pus  had  e.xtended  under  the  scapulte,  and  on  the  fore 
part  was  bounded  by  the  cesophagus,”  and  in  the  spinal 
canal  it  had  ascended  through  the  whole  length  of  the 
sheath  to  the  cauda  equina.— (C.  Bell,  Surg.  Ohs.  vol. 
l.p.  148.) 

Rust  declares,  however,  that  even  the  lumbar  and 
dorsal  vertebra?  may  be  dislocated. — (^Jirthrokakologie, 
p.  71.)  Mr.  Bell  also  describes  a case  of  complete  dis- 
location of  the  last  dorsal  from  the  first  lumbar  ver- 
tebrte,  with  entire  division  of  the  spinal  cord.  A small 
portion  of  bone  was  broken  off.— (On  Injuries  of  the 
Spine  and  Thigh-heme,  p.  25,  pi.  %Jig.  2 and  3.)  We 
learn  from  Mr.  Lawrence,  that  in  the  museum  of  St. 
Bartholomew’s  Hospital,  there  are  specimens  of  luxated 
cervical  vertebrje.  In  one  of  these,  the  right  inferior 
articular  process  of  the  fifth  vertebra  is  dislocated  for- 
wards. The  portion  of  the  vertebral  column  above  the 
seat  of  the  injury  is  twisted  to  the  left,  and  the  body  of 
the  fifth,  having  been  partially  displaced,  projects  be- 
yond that  of  the  sixth  vertebra.  This  displacement 
could  not  have  been  effected  without  considerable  in- 
jury of  the  fibro-cartilage.  The  upper  and  anterior 
part  of  the  body  of  the  sixth  and  seventh  vertebrae  has 
been  slightly  fractured  on  the  left  side.  In  another 
case,  the  inferior  articular  processes  of  the  fifth  cer- 
vical vertebra  are  partially  separated  from  those  of  the 
sixth.  The  bodies  of  the  same  bones  are  partially  se- 
parated behind.  A third  specimen  exhibits  a disloca- 
tion of  the  sixth  from  the  seventh  cervical  vertebra. 
The  inferior  articular  processes  of  the  sixth  are  com- 
pletely dislocated  forwards,  and  its  body  projects  over 
that  of  the  seventh.  Mr.  Lawrence  has  recorded  one 
case,  proving  that  complete  dislocation  both  of  the  ar- 
ticular processes  and  body,  without  fracture,  may  oc- 
cur in  the  cervical  region  of  the  spine.— (See  Med.  Chir. 
Trans,  vol.  13,  p.  391.  394.) 

DISLOCATION  OF  THtt  HEAD  FROM  THE  FIRST 
VERTEBRA,  OR  ATLAS. 

The  OS  occipitis  and  first  cervical  vertebra  are  so 
firmly  connected  by  ligaments,  that  there  is  no  instance 
of  tneir  being  luxated  from  an  external  cause,  and 
were  the  accident  to  happen,  it  would  immediately 
prove  fatal,  by  the  unavoidable  compression  and  in- 
jury of  the  spinal  marrow. 

Five  examples  of  displacement  of  the  atlas  by  dis- 
ease are  in  the  museum  at  Leyden,  and  are  described 
by  Sandifort.  Boyer  has  seen  one  at  La  Charitb ; and 
a very  interesting  description  of  a similar  case,  illus- 
trated by  engravings,  has  been  recently  published  by 
Schupke. — (J)e  Luxatione  Spontanea  Atlantis  et  Epis- 
trophei, 4to.  Btrol.  1816.)  In  this  tract  is  collected, 
from  the  writings  of  J.  P.  Frank  {Delect.  Opusc.  vol.  5), 
from  those  of  Reil  {Feiberlehre,  b.  2,  § 102),  and  of  Rust, 
<fcc.,  an  exact  detail  of  the  symptoms  of  the  disease ; an 
important  topic,  on  which  Boyer  confesses  his  inabi- 
lity to  give  any  information.  The  symptoms  have:  been 
described  from  Rust,  by  Mr.  Lawrence  as  follows: 
“ Pain  in  the  neck,  becoming  more  severe  at  night,  or 
in  swallowing  a large  mouthful,  or  drawing  a deep 
breath,  is  the  first  symptom.  This  pain  affects  one 
side  of  the  neck,  especially  when  the  head  is  moved  to- 
wards the  shoulder;  it  extends  from  the  larynx  towards 
the  nape,  and  often  to  the  scapula  of  the  pained  side. 
No  external  alteration  is  perceptible ; but  firm  pressure 
on  the  region  of  the  first  and  second  vertebrae  produces 
considerable  pain,  and  thus  points  out  the  seat  of  dis- 
ease. The  dilBculty  of  swallowing  and  breathing,  and 


hoarseness,  increase,  alternating  with  pain  in  the  neck, 
which  seems  to  fix  about  the  back  of  the  head,  and  be- 
comes intolerable  on  moving  that  part.  The  head 
sinks  towards  one  shoulder,  the  face  being  turned  a 
little  down;  for,  in- general,  the  articulations  are  af- 
fected on  one  side  only,  and  that  was  the  left  in  seven 
out  of  nine  examinations  after  death.  If  both  sides  are 
affected,  the  head  incline  directly  forwards.  In 
this  state  things  continue  for  several  weeks  or  months ; 
and  before  worse  symptoms  come  on,  there  is  often 
apparent  improvement,  freer  motion,  and  more  natural 
situation  of  the  head.  But  the  uneasiness  in  speaking 
and  SAvallowing  returns ; the  pain  becomes  more  se- 
vere and  extensive ; the  head  falls  a little  backwards, 
and  sinks  towards  the  opposite  side  The  patient  feels 
as  if  the  head  were  too  heavy,  and  he  carefully  stlp- 
ports  it  with  his  hands,  when  he  moves  from  the  sit- 
ting to  the  lying  position,  or  vice  versa.  This  may  be 
considered  a pathognomonic  symptom  of  the  affection. 
Another  symptom,  which,  at  this  period,  shows  the  true 
nature  of  the  disease,  is  a peculiar  expression  of  pain  in 
the  countenance,  which,  combined  with  the  position  and 
stiffness  of  the  head,  constitutes  so  Aiharacteristic  an 
assemblage  of  appearances,  that  it  is  enough  to  have 
seen  it  once,  in  order  to  recognise  it  again  immediately. 
In  the  I'arther  progress  of  the  case,  noise  in  the  head, 
deafness,  giddiness,  cramps  and  convulsions,  partial 
paralysis,  particularly  of  the  upper  limbs,  loss  of  voice, 
purulent  expectorations,  and  hectic  symptoms  super- 
vene. Generally,  no  external  change  is  observable, 
either  in  the  neck  or  in  the  nape ; and  Rust  observed, 
in  one  case  only,  swelling  of  the  affected  side,  which 
broke  and  left  fistulous  ulcers.  But  the  slightest  pres- 
sure in  the  region  of  the  three  upper  vertebrae  is  acutely 
painful,  and  sometimes  in  the  advanced  period  of  the 
disease,  a grating  of  rough  surfaces  is  distinctly  per- 
ceptible Avhen  the  head  is  turned.  The  patient  may 
continue  for  months  in  this  helpless  and  painful  state, 
and  then  dies,  either  from  exhaustion  and  debility,  or, 
which  is  more  frequent,  suddenly  and  unexpectedly.” — 
{Lawrence,  in  Med.  Chir.  Trans,  vol.  13,  p.  406.)  These 
spontaneous  displacements  of  the  atlas  may  depend 
upon  caries  and  scrofulous  disease  of  its  articular  sur- 
faces, or  upon  an  exostosis  of  its  transverse  process, 
or  a similar  tumour  growing  from  the  neighbouring 
portion  of  the  os  occipitis,  or  petrous  portion  of  the 
tem.poral  bone.  By  these  causes,  the  anterior  or  pos- 
terior arch,  or  one  of  the  sides  of  the  atlas,  has  been 
made  to  intercept  a third,  the  half,  and  even  two-thirds 
of  the  diameter  of  the  foramen  magnum.  Notwith- 
standing these  changes,  life  may  be  carried  on,  and  the 
nutritive  functions  performed  sufficiently  w'ell  to  afford 
time  enough  either  for  the  exostoses  to  attain  a large 
size,  or  for  the  anchylosis,  binding  together  the  head 
and  most  of  the  cervical  vertebrse,  to  acquire  great 
solidity.  The  size  of  the  foramen  magnum,  and  the 
dimensions  of  the  vertebral  canal  in  the  neck,  are  con- 
siderably beyond  what  would  be  necessary  for  simply 
containing  the  spinal  marrow,  so  that  the  free  lateral 
movements  of  the  head  and  atlas  can  be  executed 
without  any  risk  of  pressure  on  that  important  part. 
Hence  spontaneous  displacement  can  occur  in  these 
cases  to  a considerable  degree,  without  impairing  the 
functions  of  the  spinal  cord. — {Latvrence,  in  Med.  Chir. 
TYans.  vol.  13,  p.  411.)  According  to  Boyer,  the  atlas 
is  never  found  free  and  distinct  when  thus  displaced, 
but  is  confounded  at  least  with  the  os  occipitis,  and 
mostly  with  five  or  six  of  the  subjacent  vertebrae.  And 
another  interesting  fact  is,  that  in  cases  of  this  descrip- 
tion, the  joint  between  the  atlas  and  occiput  is  never 
the  only  one  which  is  displaced  and  deformed,  unless 
the  disease  be  very  slightly  advanced;  for  the  articu- 
lation of  the  processus  dentatus  with  the  atlas,  and 
sometimes  that  of  the  point  of  the  same  process  with 
the  occiput,  are  considerably  affected.  Sometimes  the 
processus  dentatus  and  the  occiput  retain  their  natural 
position  with  respect  to  each  other,  and  the  atlas  alone 
seems  to  be  displaced  between  them.  Sometimes  the 
second  vertebra  is  out  of  its  place  with  respect  to  the 
os  occipitis,  in  the  same  direction  as  the  atlas,  but  not 
in  quite  so  great  a degree.  Lastly,  in  some  other  in- 
stances, the  two  vertebra?  are  twi.sted  in  opposite  di- 
rections, as,  for  instance,  one  to  the  left,  the  other  to 
the  right ; or  vice  versa.  In  one  of  the  cases  recorded 
by  Sandifort,  this  kind  of  lateral  displacement  in  oppo- 
site directions  was  so  extensive,  that  an  interspace, 
only  six  lines  in  breadth,  was  left  between  their  ap- 


308 


DISLOCATION. 


roxi mated  annolar  margins.  An  instance  was  seen 
y Duverney,  where  the  displacement  of  the  two 
vertebrae  was  from  before  backward,  and  where 
the  processus  dentatus  was  approximated  to  the 
posterior  arch  of  the  atlas  to  the  extent  of  two-thirds 
of  the  annular  opening  in  this  vertebra.  In  these 
cases,  nothing  can  be  more  obvious,  than  that  there 
must  be  a destruction,  or  at  all  events  a thoroughly 
diseased  state  of  the  ligaments  between  the  atlas  and 
dentatus,  and  of  those  connecting  the  dental  process  to 
the  occiput. — {Boyer,  voL  cit.p.  105.) 

As  for  the  treatment  of  the  preceding  forms  of  dis- 
ease, experience  has  hitherto  furnished  little  satisfac- 
tory knowledge.  But  as  an  analogy  is  seen  between 
these  cases  and  the  scrofulous  aiid  carious  affections 
of  other  joints,  blisters,  setons,  and  issues  have  been 
proposed  and  tried.  Rust  found  these  remedies  only 
capable  of  retarding  the  progress  of  the  disease,  and  of 
producing  an  abatement  of  the  symptoms.  The  pain, 
often  reaching  from  the  back  of  the  head  to  the  fore- 
head, was  rendered  less  severe ; and  the  difficulty  of 
swallowing  was  considerably  lessened.  But,  the 
means  here  specified  were  not  found  adequate  to  arrest 
the  morbid  change  in  the  bones.  However,  Rust 
thinks,  that  greater  benefit  might  be  expected,  if  a case 
were  to  present  itself  arising  altogether  from  a local 
cause,  without  its  origin  being  connected  with  ccnsti- 
tutional  disease. — {Salzburger  Med.  Chir.  Zeitung, 
jahrgang  1813,  b.  3,  p.  108.)  In  a later  work  he  ad- 
verts to  some  examples,  in  which  a cure  was  effected 
by  nature.  Indeed  the  occasional  termination  of  the 
disease  by  anchylosis  is  a full  pxooL—{Arthrokakolo- 
gie,^\\%.) 

nSLOCATlONS  OF  THE  FIRST  CERVICAL  VERTEBRA 
FROM  THE  SECOND. 

The  rotatory  motion  of  the  head  is  chiefly  performed 
by  the  first  vertebra  moving  on  the  second.  When 
this  motion  is  forced  beyond  its  proper  limits,  the  liga- 
ments which  tie  the  processus  dentatus  to  the  edge  of 
the  foramen  magnum  are  torn,  and  supposing  the  head 
to  be  forced  from  the  left  to  the  right,  the  left  side  of 
the  body  of  the  vertebra  is  carried  before  its  corres- 
ponding articulating  surface,  while  the  right  side  falls 
behind  its  corresponding  surface.  Sometimes  the  pro- 
cessus dentatus,  whose  ligaments  are  ruptured,  quits 
the  foramen  formed  for  it  by  the  transverse  ligament 
and  the  anterior  arch  of  the  first  vertebra,  and  presses 
on  the  medulla  oblongata.  But,  according  to  Boyer, 
the  processus  dentatus  may  be  displaced  in  two  ways  : 
1st,  It  may  be  carried  directly  backwards,  the  trans- 
verse and  other  ligaments  being  broken.  This  mode 
cff  displacement  Boyer  considers  as  the  most  difficult 
and  uncommon,  as  it  can  hardly  take  place,  except 
from  a fall  from  a great  height  upon  the  back  of  the 
head,  while  the  spine  is  bent  forwards. — {TraM  des 
Mai.  Chir.  t.  4,  p.  109.)  However,  the  accident  may 
happen  in  another  manner,  as  in  Mr.  C.  Bell’s  instance 
where  it  occurred  from  the  chin  striking  against  a curb 
stone.— {Surg.  Obs.  vol.  1,  p.  150.)  2dly,  In  a violent 
rotation  in  which  the  face  is  carried  sideways  beyond 
the  proper  limits,  the  lateral  and  accessory  ligaments 
of  the  processus  dentatus  may  be  stretched  and  twisted 
spirally  round  this  process.  The  force  operates  en- 
tirely upon  them,  and  not  at  all  upon  the  transverse 
ligament.  Now  when  the  lateral  and  accessory  liga- 
ments of  the  processus  dentatus  have  given  way,  and 
an  effort  to  incline  the  head  to  one  side  is  kept  up, 
one  of  the  sides  of  the  space,  bounded  by  the  transverse 
ligament,  may  present  itself  near  the  point  of  the  pro- 
cessus dentatus,  which  mav  then  pass  below  the  trans- 
verse ligament  without  rupturing  it. 

In  chddren,  where  the  processus  dentatus  is  not 
folly  developed,  and  the  ligaments  are  weaker  than  in 
the  adult,  a perpendicular  impulse  may  break  the  late- 
ral and  accessory  ligaments,  and  then  force  the  pro- 
cessus dentatus  under  the  transverse  ligament,  without 
rupturing  this  latter  part;  as  Boyer  conceives  must 
have  been  the  case  in  the  child,  which  J.  L.  Petit  men- 
tions as  having  been  instantaneously  killed  by  being 
lifted  up  by  the  head. 

Lastly,  when  the  transverse  lateral  and  other  liga- 
ments are  capable  of  making  very  great  resistance 
a force  tending  to  rupture  them  all,  and  to  throw  the 
processus  dentatus  directly  backwards,  this  process, 
if  more  slender  than  common,  may  be  broken  near  its 
base,  and  this  portidn  of  it  forced  back  upon  the  spinal 
marrow. 


A case  exemplifying  the  occurrence,  used  to  »c  re- 
lated by  Mr.  Else  in  his  lectures,  and  is  recorded  by 
Sir  Astley  Cooper. — {On  Dislocations,  p.  348.  Boyer^ 
vol.  cit.  p.  110.) 

Patients  can  hardly  be  expected  to  survive  mischief 
of  this  kind  in  so  high  a situation  ; when  the  trans- 
verse ligament  is  broken,  and  the  processus  dentatus 
is  thrown  directly  backwards  against  the  medulla  ob- 
longata, the  effect  must  be  instant  death,  as  happened 
in  the  case  recorded  by  Mr.  C.  Bell,  {Surg.  Obs.  vol.  1, 
p.  150.)  and  in  that  mentioned  by  Mr.  Else. 

According  to  surgical  writers,  the  causes  which  may 
produce  this  formidable  accident  are  various : a fall  on 
the  head  from  a high  place ; the  fall  of  a heavy  body 
against  the  back  of  the  neck  ; a violent  blow ; a forci- 
ble twist  of  the  neck;  tumbling;  standing  upon  the 
head ; the  rash  custom  of  lifting  children  up  by  the 
head,  &c.  Louis  found  that  the  first  vertebra  was  dis- 
located from  the  second  in  the  malefactors  hanged  at 
Lyons  ; at  wliich  place,  the  executioner  used  to  give  a 
sudden  twist  to  the  body,  at  the  moment  of  its  suspen- 
sion, and  then  bear  with  all  his  weight  upon  it.  Under 
such  circumstances,  Boyer  conceives,  that  the  proces- 
sus dentatus  might  pass  under  the  transverse  ligament, 
without  any  rupture  of  the  latter. 

Dislocations  of  the  cervical  vertebrae  are  said  not  to 
be  always  fatal,  as  when  they  occur  at  the  third,  fourth, 
fifth,  or  sixth  of  these  bones,  and  only  one  articular 
process  is  luxated.  In  these  instances,  the  vertebral 
canal  is  not  so  much  lessened  as  to  compress  the  spinal 
marrow,  and  occasion  immediate  death. 

With  regard  to  the  prognosis  and  treatment  of  all 
luxations  in  which  the  processus  dentatus  is  displaced 
suddenly  by  violence,  and  not  gradually  by  disease,  the 
reader  need  only  hear  that  such  cases  are  immediately 
fatal.  Mistaken  notions  have  been  entertained  upon 
this  point,  in  consequence  of  particular  dislocations  of 
the  neck  having  been  successfully  treated. 

A child  was  brought  to  Desault,  with  its  neck  bent, 
and  its  chin  turned  towards  the  right  shoulder.  Tlie 
accident  had  been  a consequence  of  the  head  having 
been  fixed  on  the  ground,  while  the  feet  were  up  in  the 
air.  A surgeon  happened  to  be  with  Desault  at  the 
time,  and  they  agreed  to  make  an  attempt  to  reduce  the 
luxation,  and  to  apprize  the  mother,  that  though  the 
child  might  be  cured,  there  was  a possibility  of  its 
perishing  under  their  hands.  Being  permitted  to  do 
what  they  judged  proper,  they  fixed  the  shoulders,  and 
the  head  w'as  gently  raised,  and  gradually  turned  into 
its  natural  position.  The  child  could  now  move  freely, 
the  pain  ceased,  and  a considerable  swelling  in  the  situ- 
ation of  the  luxation  yet  left,  was  dispersed  by  the 
application  of  emollient  poultices.— (LeuciW^,  Nouvelle 
Doctrine  Chir.  t.  2,  p.  C2.) 

Another  alleged  instance  of  the  reduction  of  a dislo- 
cation of  the  neck  is  also  recorded  by  Dr.  Settin. — 
{Schmucker’s  Vermischte  Chirurgische  Schriften,  b.  1.) 
However,  both  in  this  case  and  that  related  by  Desault, 
there  can  now  be  little  or  no  doubt,  that  the  accident 
was  not  a dislocation  of  the  dentata  from  tlie  atlas,  but 
only  a luxation  of  one  of  the  oblique  processes  of  a cer- 
vical vertebra  lower  down.  Whenever  the  processus 
dentatus  is  suddenly  displaced,  or  fractured,  the  effects 
on  the  medulla  spinalis  are  inevitably  fatal.  A case, 
indeed,  was  attended  by  Mr.  Cline,  in  which  the  pro- 
cessus dentatus  had  lost  a part  of  its  natural  support,  in 
consequence  of  a transverse  fracture  of  the  first  verte- 
bra, and  in  which  the  child  suriiived  the  accident  a year. 
— (See  d.  Cooper,  On  Dislocations,  p.  649.  T.  E. 
Schmidt,  De  Luxatione  Nuchoe.  Haller,  Disp.  Chir.  t. 
2,  p.  351.  7’u5. 1747.  S.  T.  Soemmering,  Bemerkungen 
iiber  Verrunkung  und  Bruch  des  Riickgrats,  8do.  Ber- 
lin, 1793.  Bayer,  Traiti  des  Mai.  Chir.  t.  4,  p.  100, 
&-C.  8vo.  Paris,  1814.  d.  E.  Schupke,  De  Luxationt 
Spontanea  dtlantis  et  Epistrophei,  4fo.  Berol,  1816 
C.  Bell,  Surgical  Ohs.  vol.  1,  p.  145, 149,  iS  c.  8vo.  Ixmd. 
1816.  Observations  on  Injuries  ojf  the  Spine,  irc.  4to. 
Lond.  1824.  Sir  d-  Cooper,  Treatise  on  Dislocations, 
Src.  p.  548—551,  <S'C.  4to.  Land.  1822.  Laurence,  in 
Med.  Chir.  Trans,  vol.  13.) 

DISLOCATIONS  OF  THE  CLAVICLE. 

These  are  much  less  common  than  fractures,  which 
are  said  to  occur  six  times  more  frequently.  In  Ihct, 

. as  Sir  Astley  Cooper  has  truly  remarked,  the  clavicle  is 
so  strongly  articulated  both  with  the  sternum  and  sca- 
pula. that  its  dislocations  are  rare  in  compuriseo 


DISLOCATION.  309 


with  those  of  many  other  joints.— (On.  Dislocations, 
p.  395.) 

The  clavicle  may  be  luxated  at  its  sternal  extremity, 
forwards,  backwards,  and  upwards,  but  never  down- 
wards, on  account  of  the  situation  of  the  cartilage  of  the 
first  rib.  The  luxation  forwards  is  the  most  frequent ; 
dislocations  backwards  and  upwards  are  very  unusual ; 
and  one  directly  backwards  is  still  more  rare.  This  last 
case  Sir  Astley  Cooper  has  never  known  arise  from 
violence ; but  he  conceives  that  it  might  happen  from  a 
blow  on  the  fore  part  of  the  bone,  rupturing  the  capsu- 
lar ligament  and  that  between  the  clavicle  and  rib.  The 
only  instance  of  the  dislocation  backwards,  with  which 
this  experienced  surgeon  is  acquainted,  proceeded  from 
great  deformity  of  the  spine.  In  this  extraordinary 
case,  the  bone  gradually  slipped  behind  the  sternum, 
and  produced  so  much  inconvenience  by  its  pressure 
on  the  oesophagus,  that  the  late  Mr.  Davie,  of  Bungay, 
in  Suffolk,  was  obliged  to  remove  its  sternal  extremity. 
—(A.  Cooper  on  Dislocations,  p.  401.) 

If  the  dislocation  be  forwards,  a hard,  circumscribed 
tumour  is  felt,  or  even  seen,  on  the  front  and  upper 
part  of  the  sternum.  According  to  Boyer,  when  the 
shoulder  is  carried  forwards  and  outwards,  the  tumour 
disappears ; but  in  Sir  Astley  Cooper’s  account,  it  is 
said,  that  the  projection  on  the  sternum  will  subside,  if 
the  shoulder  be  drawn  backwards.  The  shoulder  being 
elevated,  the  projection  descends ; if  it  be  drawn  down- 
wards, the  dislocated  extremity  of  the  bone  becomes 
elevated  to  the  neck.  The  motions  of  the  clavicle  are 
painful,  and  the  patient  moves  the  shoulder  with  diffi- 
culty. The  point  of  the  injured  shoulder  is  less  distant 
from  the  central  line  of  the  sternum  than  usual.  Ac- 
cording to  the  same  authority,  the  dislocation  forwards 
is  sometimes  incomplete,  only  the  front  of  the  capsular 
ligament  being  torn.  The  dislocation  forwards  is  ge- 
nerally produced  by  a fall  upon  the  point  of  the  shoul- 
der, when  the  force  pushes  the  clavicle  imvards  and 
forwards;  but  it  also  frequently  hapi)ens  from  falls 
upon  the  elbow,  when  this  is  separated  from  the  side, 
and  thus  the  clavicle  is  propelled  violently  inwards 
and  forwards  against  the  anterior  portion  of  the  capsu- 
lar ligament. — Cooper  on  Dislocations,  p.  399.) 

When  the  luxation  is  upwards,  the  distance  between 
the  sternal  ends  of  the  clavicles  is  diminished. 

When  the  dislocation  is  backwards,  there  is  a de- 
pression where  the  end  of  the  clavicle  ought  to  be,  and 
the  head  of  the  bone  forms  a projection  at  the  front  and 
lower  part  of  the  neck,  which,  as  J.  L.  Petit  remarks, 
may  compress  the  trachea,  oesophagus,  jugular  vein, 
carotid  artery,  and  nerves.  The  head  is  inclined  to- 
wards the  side  on  which  the  accident  itself  is  situated. 

In  reducing  dislocations  of  the  sternal  end  of  the 
clavicle,  we  are  to  make  a lever  of  the  arm,  by  means 
of  which  the  shoulder  is  brought  outwards ; and  when 
thus  brought  outwards,  it  is  to  be  pushed  forwards,  if 
the  dislocation  be  in  that  direction ; backwards,  if  the 
dislocation  be  behind ; and  upwards,  if  the  dislocation 
be  above. 

The  same  position  of  the  arm,  and  the  same  appara- 
tus as  in  fractures  of  the  clavicle,  are  to  be  employed. 
The  wedge-like  pad,  with  its  thick  part  towards  the 
axilla,  for  the  purpose  of  inclining  the  shoulder  out- 
wards, a sling  for  the  support  of  the  weight  of  the  arm, 
and  a bandage  judiciously  applied,  are  especially  neces- 
sary. In  consequence  of  the  obliquity  and  smoothness 
of  the  articular  surfaces,  the  reduction  is  easy,  but 
great  attention  is  requisite  to  prevent  a return  of  the 
displacement. 

Dislocation  of  the  scapular  end  of  the  clavicle  from 
the  acromion.  The  luxation  upwards  is  almost  the 
only  one  that  ever  occurs.  It  is  possible,  however,  for 
the  accident  to  take  place  downwards,  and  for  the  end 
of  the  clavicle  to  glide  under  the  acromion.  The 
rarity  of  dislocations  of  the  scapular  end  of  the  clavicle 
is  owing  to  the  strength  of  the  ligaments  tying  the 
clavicle  and  acromion  together.  While  Desault  and 
Boyer,  however,  represent  these  cases  as  much  less 
common  than  displacements  of  the  sternal  end  of  the 
bone.  Sir  Astley  Cooper’s  experience  pronounces  them 
to  be  more  frequent.— (Cbi  Dislocations,  p.  405.) 

A fall  on  the  top  of  the  shoulder  may  cause  the  dis- 
location upwards.  The  scapular  end  of  the  clavicle 
then  slides  upwards  on  the  acromion,  and  the  shoulder 
is  drawn  inwards  by  the  muscles  which  approximate 
the  arm  to  the  body.  It  has  been  a.S8ened,  that  the  vio- 
lent action  of  the  trapezius  muscle,  in  pulling  the 


clavicle  upwards,  may  tend  to  produce  the  accident ; 
but,  as  Sir  Astley  Cooper  has  remarked,  the  mere  ac- 
tion of  this  muscle,  without  the  simultaneous  operation 
of  great  violence,  could  never  tear  both  the  ligaments 
of  the  coracoid  process,  which  must  be  broken  ere  this 
dislocation  can  happen.  When  the  projection  is  but 
slight,  as  Sir  Astley  Cooper  has  sometimes  noticed,  the 
circumstance  indicates  that  the  internal  ligament  is  not 
ruptured. — {On  Dislocations,  p.  406.)  Pain  at  the  top 
of  the  shoulder,  a projection  of  the  end  of  the  clavicle 
under  the  skin  covering  the  acromion,  and  a depression 
of  the  shoulder,  are  symptoms  indicating  what  has 
happened.  The  patient  also  inclines  his  head  to  the 
affected  side,  and  avoids  moving  his  arm  or  shoulder. 

This  dislocation  is  reduced  by  carrying  the  shoulder 
outwards,  putting  a thick  cushion  in  the  axilla,  and 
applying  Desault’s  bandage  for  fractures  of  the  clavicle 
(see  Fractures),  making  the  turns  ascend  from  the 
elbow  to  the  shoulder,  so  as  to  press  the  luxated  end  of 
the  bone  downwards  and  keep  it  in  its  due  situa- 
tion, at  the  same  time  that  the  elbow  is  confined  close 
to  the  side,  and  supported  in  a sling ; by  which  means, 
the  shoulder  will  be  kept  raised  and  inclined  outwards. 
This  plan,  which  is  advised  by  Boyer,  is  more  efficient 
than  the  common  practice,  which  consists  in  applying 
a compress,  the  figure  of  8 bandage,  and  supporting 
the  arm  in  a sling.  However,  the  exact  maintenance 
of  the  reduction,  by  any  apparatus  whatever,  is  found 
to  be  a matter  of  the  greatest  difficulty,  and  some  slight 
deformity  will  remain ; though  it  is  agreeable  to 
know  that,  notwithstanding  this  disadvantage,  the  use 
of  the  limb  returns  very  well.  In  the  course  of  my 
time,  I have  seen  several  cases  in  proof  of  this  state- 
ment, and  one  example  was  shown  me  by  my  friend, 
Mr.  Vincent,  in  St.  Bartholomew’s  Hospital.  The 
same  observations  are  applicable  to  luxatioiis  of  the 
sternal  end  of  the  bone. 

[Dr.  James  Cocke,  of  Baltimore,  has  reported  in  vol. 
1,  of  the  New-York  Med.  and  Phil.  Joum.  the  success- 
ful reduction  of  a dislocation  of  the  clavicle  at  its  scapu- 
lar articulation. — Reese.] 

DISLOCATIONS  OF  THE  OS  BRACHII. 

Nature,  which  varies  according  to  the  necessities  of 
different  animals,  the  number  of  their  joints,  has  also 
been  provident  enough  to  vary  the  structure  of  these 
parts,  according  to  the  use  of  the  different  portions  of 
their  economy.  To  great  moveableness,  some  unite 
considerable  solidity ; for  instance,  the  vertebral  co- 
lumn. Others  are  very  strong,  but  only  admit  of  a 
slight  yielding  motion,  as  we  observe  in  the  carpus, 
tarsus,  &c.  Lastly,  other  joints  admit  of  a great  lati- 
tude of  motion;  but  their  strength  is  easily  over- 
powered by  the  action  of  external  bodies.  Such  are  in 
man  the  shoulder-joint,  and  that  between  the  sternum 
and  clavicle. 

The  last  kinds  of  articulation  are  particularly  subject 
to  dislocation,  and,  of  all,  not  one  is  so  often  luxated  as 
the  shoulder -joint.  Bichat  mentions,  that  it  appears 
from  a comparative  table,  that  in  some  years,  this  acci- 
dent at  the  Hotel-Dieu  has  been  as  frequent,  and  even 
more  so,  than  dislocations  of  all  the  other  bones  taken 
collectively. 

Here  every  thing  seems  to  facilitate  the  escape  of 
the  bone  from  its  natural  cavity.  An  oval  shallow 
cavity,  surrounded  by  a margin  of  little  thickness, 
receives  a semi-spherical  head,  which  is  twice  as  broad 
as  the  cavity  in  the  perpendicular  direction,  and  three 
times  as  extensive  from  before  backward.  With  respect 
to  the  ligaments,  the  joint  is  only  strengthened  by  a 
mere  capsule,  which  is  thin  below,  where  nothing  op- 
poses a dislocation ; but  thicker  above,  where  the  acro- 
mion, coracoid  process,  and  triangular  ligament  form 
an  almost  insurmountable  obstacle  to  such  an  accident. 
With  regard  to  the  muscles  and  motions  of  this  joint, 
strong  and  numerous  fa.sciculi  surround  the  articular 
surfaces,  make  them  easily  move  in  all  directions,  and, 
pushing  the  head  of  the  os  brachii  against  the  different 
points  of  the  capsule,  distend  this  ligamentous  bag ; 
and  when  their  power  exceeds  the  resistance,  actually 
lacerate  it.  As  for  external  bodies,  what  bone  is 
more  exposed  than  the  os  brachii  to  the  eflect  of  their 
force  ? 

Thus  subjected  to  the  influence  of  these  predisposing 
causes,  the  os  brachii  would  be  in  continual  danger  of 
being  dislocated,  if  the  scapula,  which  is  as  moveable 
as  itself,  did  not  furnish  a point  ol  support  tor  it,  by 


310 


DISLOCATION. 


accompanying  all  its  motions  This  jwint  of  support  | 
accommodates  itself  to  the  variations  in  the  position 
of  the  head  of  the  os  brachii,  so  that  to  the  moveable- 
ness of  the  articular  surfaces  their  strength  is  in  a 
great  measure  owing. 

The  shoulder-joint,  which  is  very  liable  to  luxations 
in  a general  sense,  is  not  equally  so  at  all  points. 
There  are  some,  where  a dislocation  cannot  occur ; 
there  are  others,  where,  though  possible,  such  an  acci- 
dent has  never  been  observed. 

Desault  divided  dislocations  of  the  humerus  into 
primitive,  which  are  the  sudden  eifect  of  external  vio- 
lence, and  into  consecutive,  which  follow  the  first  by 
the  influence  of  causes  presently  to  be  expltiined.  In 
order  to  simplify  the  comprehension  of  the  various  di- 
rections in  which  the  head  of  the  humerus  is  luxated, 
he  supposed  the  genoid  cavity  to  be  bounded  by  four 
lines : one  representing  its  upper  edge ; another  its 
lower;  a third  its  inner;  and  a fourth  its  external 
one. 

The  head  of  the  humerus  cannot  be  displaced  to- 
wards the  upi)er  edge.  Here  are  situated  the  acromion 
and  coracoid  process,  the  triangular  ligament  stretched 
between  them,  the  tendons  of  the  triceps,  supraspina- 
tus,  and  the  fleshy  portion  of  the  deltoid,  insurmount- 
able obstacles  to  the  luxation  of  the  head  of  the  bone, 
propelled  by  any  force  upwards.  Besides,  what  power 
could  this  be  T Supposing  there  were  such  a force,  the 
head  of  the  bone  must  necessarily  be  driven  outwards 
as  well  as  upwards,  ere  its  head  w’ould  be  displaced. 
This  is  impossible,  because  the  trunk  prevents  the 
lower  part  of  the  arm  from  being  directed  sufficiently 
inwards  to  produce  this  effect. 

On  the  contrary,  at  the  other  margins  there  is  little 
resistance.  At  the  inferior  one,  the  long  portion  of  the 
triceps ; at  the  internal  one,  the  tendorf  of  the  subsca- 
pularis ; and  at  the  extemtil  edge,  those  of  the  infra- 
spinatus and  teres  minor,  will  readily  yield  to  any  power 
directed  against  them,  and  allow  primitive  luxations  to 
take  place  downw'ards,  inwards,  or  outwards.  Down- 
wards, between  the  tendon  of  the  long  portion  of  the 
triceps  and  the  tendon  of  the  subscapularis,  which 
last,  in  a case  dissected  by  Sir  A.  Cooper,  was  rup- 
tured {Snrg.  Essays,  part  I,  p.  7 ; and  on  Disloca- 
tions, 421,  422);  inwards,  between  the  fossa  subscapu- 
laris and  muscles  of  tliis  name;  outwards,  between 
the  fossa  infraspinata  and  infraspinatus  muscle. 

According  to  Sir  Astley  Cooper,  the  os  humeri  is 
liable  to  be  thrown  from  the  glenoid  cavity  of  the  sca- 
pula in  four  directions : three  of  these  luxations  are 
complete;  the  other  is  only  partial.  The  first  is 
downwards  and  inwards,  the  dislocation  into  the  ax- 
illa, as  it  is  usually  called,  in  which  case  the  head  of 
the  bone  rests  upon  the  inner  side  of  the  inferior  costa 
of  the  scapula.  The  second  is  forwards  under  the  pec- 
toral muscle,  the  head  of  the  bone  being  placed  below 
the  middle  of  the  clavicle,  and  on  the  sternal  side  of 
the  coracoid  process.  The  third  is  the  dislocation 
backwards,  in  which  the  head  of  the  bone  can  be 
plainly  felt  and  seen,  as  a protuberance  at  the  back  and 
outer  part  of  the  inferior  costa  of  the  scapula,  upon  the 
dorsum  of  this  bone.  The  fourth,  which  is  only  par- 
tial, is  when  the  front  of  the  capsular  ligament  is 
torn,  and  the  head  of  the  bone  rests  against  the  outer 
side  of  the  coracoid  process.  “ Of  the  dislocation  in 
the  axilla  (says  Sir  Astley  Cooper),  I have  seen  a mul- 
titude of  instances ; of  that  forwards  on  the  inner  side 
of  the  coracoid  process,  several ; although  it  is  much 
less  frequent  than  that  in  the  axilla : of  the  dislocation 
backwards,  I have  seen  only  two  instances  during  the 
practice  of  my  profession  for  38  years.”— (On.  Disloca- 
cations,  Src.p.  416.) 

Sometimes,  after  the  head  of  the  bone  has  escaped 
from  the  internal  or  inferior  part  of  the  capsule,  it  is 
carried  behind  the  clavicle,  forming  a case  of  consecu- 
tive dislocation  upwards ; a specimen  of  which  was 
preserved  in  Desault’s  museum.  But  here  the  second- 
ary displacement  only  takes. place  slowly,  and  when 
it  occurs  a reduction  can  rarely  be  effected,  on  account 
of  the  strong  adhesions  contracted  by  the  surfaces  of 
the  bone.  Thus,  in  the  specimen  referred  to,  a new 
cavity  was  formed  behind  the  clavicle,  and  the  hu- 
merus adhered  by  new  ligaments  to  the  surrounding 
parts. 

The  action  of  external  bodies  directed  against  the 
arm,  but  particularly  falls,  in  which  this  part  is  forced 
against  a resisting  body,  give.s  rise  to  primitive  dislo- ' 


\ cations,  and  then  the  different  species  of  the  accident 
are  determined  by  the  particular  position  of  the  hume- 
rus at  the  instant  w'hen  the  injurj'  takes  place. 

Should  this  bone  be  raised  from  the  side  without  be- 
ing carried  either  forwards  or  backwards  ; should  (he 
elbow  be  elevated  and  the  fall  take  place  on  the  side, 
then  the  weight  of  the  trunk,  almost  entirely  supported 
by  this  bone,  forces  downwards  its  upper  part,  which 
stretches  and  lacerates  the  lower  part  of  the  cap.sula’’ 
ligament.  Thus  a luxation  downwards  is  produced 
and  its  occurrence  may  also  be  facilitated  by  the  com- 
bined action  of  the  latissimus  dorsi,  pectoralis  major, 
and  teres  major  muscles,  as  Fabre  has  judiciously  re- 
marked ; for  being  at  this  period  involuntarily  con- 
tracted to  support  the  trunk,  they  act  with  the  power 
of  a considerable  lever ; the  resistance  being  the  head 
of  the  bone,  which  they  draw  dowmwards,  while  the 
fixed  point  is  the  lower  end  of  the  bone,  resting  against 
the  ground.  Some  authors  also  consider,  as  the  im- 
mediate cause  of  a dislocation  downwards,  the  strong 
action  of  the  deltoid,  which  is  supposed  to  depress  the 
head  of  the  bone,  and  push  it  downwards  through  the 
capsular  ligament.  In  support  of  this  opinion,  Bichat 
mentions  the  well-known  case  of  a notarj'  who  lux- 
ated his  arm  downwards  in  lifting  up  a register. 

The  rationale  of  the  primitive  luxation  inwards  dif- 
fers very  little  from  that  of  the  jireceding  case.  The 
elbow  is  both  separated  from  the  side  and  carried  back- 
wards ; in  falling,  the  weight  of  the  body  acts  on  tbe 
humerus,  the  front  part  of  the  capsule  is  lacerated,  and 
a luxation  takes  place  in  this  direction. 

The  dislocation  outwards  (or,  as  Sir  Astley  Cooper 
calls  it,  backwards)  is  produced  in  the  same  sort  of 
way.  The  elbow  is  carried  forwards  towards  the  op- 
posite shoulder ; the  capsule  is  stretched  outwards, 
and  if  a sufficient  force  act  on  the  limb,  it  is  lacerated. 
But  how  could  such  a force  arise  ? In  a fall,  the  arm 
being  pushed  against  the  trunk  and  kept  there,  cannot 
move  extensively  enough  to  cause  such  a laceration. 
Hence  a luxation  outwards,  or  rather  backwards,  under 
the  spine  of  the  scapula,  must  necessarily  be  exceed- 
ingly rare,  and  Desault,  in  all  his  experience,  never 
saw  such  an  accident.  Besides,  when  in  a fall  the 
arm  is  raised  from  the  side  and  inclined  forwards  or 
backwards,  the  weight  of  the  body  only  operates  upon 
it  obliquely,  and  the  limb  is  very  little  exposed  to  the 
action  of  the  latissimus  dorsi,  pectoralis  major,  and 
teres  major  muscles.  However,  a few  instances  of  a 
dislocation  of  the  head  of  the  humerus  in  this  direction 
have  been  recorded.  Sir  Astley  Cooper,  in  the  course 
of  38  years,  has  met  with  two  examples.  In  a dead 
subject,  Boyer  remarked  a singular  inclination  of  the 
glenoid  cavity  backwards,  its  articular  surface  also 
presenting  on  this  side  an  extraordinary  elongation, 
and  the  humerus  readily  slipping  under  the  spine  of  the 
scapula.— (TVaftedes  Mai.  Chir.  t.  4,  p.  176.) 

In  the  patient  whose  history  was  published  by  M. 
Fizeau,  and  in  whom  a dislocation  of  the  humerus 
outwards  and  backwards  was  seen  both  by  that  gen- 
tleman and  Boyer,  there  was  also  the  particularity 
that  the  luxation  was  readily  reproduced.-^/oum.  de 
Med.  par  Corvisart,  dS-c.  t.  10,  p.  3S6.)  Hence  Boyer 
suspects  that  this  ver>-  rare  kind  of  displacement  must 
have  been  facilitated  by  some  preternatural  disposition 
of  the  articular  surfaces,  especially  that  of  the  glenoid 
cavity.  No  dislocation  must  occur  more  ft-equently 
than  that  downwards,  in  which  the  influence  of  the 
weight  of  the  body,  and  of  the  action  of  the  muscles, 
is  direct.  However,  the  luxation  inwards,  or,  as  Sit 
Astley  Cooper  and  others  call  it,  forwards,  is  common. 

In  all  primitive  dislocations  from  violence,  and  not 
from  paralysis  of  the  deltoid,  and  a gradual  yielding  of 
the  capsule,  I believe  the  latter  part  is  always  exten- 
sively lacerated.  In  general  authors  have  paid  too  lit- 
tle attention  to  this  circumstance,  which  dissections 
have  repeatedly  demonstrated.  Desault  had  two  spe- 
cimens made  of  wax  ; one  of  a dislocatton  inwards  ; 
the  other  of  one  downw'ards ; both  of  which  were  met 
with  in  subjects  who  died  at  the  H6tel-Dieu.  Bell 
also  makes  mention  of  similar  facts,  and  another  Eng- 
lish surgeon,  says  Bichat,  has  observed  the  same  oc- 
currence. I suppose  Bichat  here  alludes  to  Mr.  Tliomp- 
son,  who  long  ago  noticed  the  laceration  of  the  cap- 
sule, and  particularly  called  the  attention  of  surgeons 
to  the  subject.— (See  Med.  Obs.  and  Inquines.) 

Desault  conceives  that  the  capsule  may  be  suffi- 
' ciently  torn  to  let  the  head  of  the  bor.e  escape ; but 


DISLOCATION.  311 


that  the  opening  may  afterward  form  a kind  of  con- 
striction round  the  neck  of  the  humerus,  so  as  to  pre- 
vent the  return  of  the  head  of  the  bone  into  the  place 
which  It  originally  occupied.  The  correctness  of  this 
statement,  however,  is  positively  denied  by  Sir  A. 
Cooper,  who  remarks,  that  they  who  entertain  this  be- 
lief must  forget  the  inelastic  structure  of  the  capsular 
ligament,  and  never  witnessed  by  dissection  the  exten- 
sive laceration  which  it  suffers  in  dislocations  from 
violence. — (Surgical  Essays,  part  1,  p.  18.) 

Several  causes  may  lead  to  a consecutive  luxation. 
If  a fresh  fall  happen  while  the  arm  is  separated  from 
the  trunk,  the  head  of  the  humerus,  which  nothing 
confines,  obeys,  with  the  utmost  facility,  the  power 
displacing  it  in  this  manner,  and  is  again  pushed  out 
of  the  situation  which  it  accidentally  occupies. 

A man,  going  down  stairs,  meets  with  a fall,  and 
dislocates  the  humerus  downwards;  he  immediately 
sends  for  Desault,  who  defers  the  reduction  till  the 
evening.  In  the  mean  time,  the  patient,  in  getting 
upon  a chair,  slips  and  falls  again.  The  pain  was 
more  acute  than  when  the  first  accident  occurred,  and 
Desault,  on  his  return,  instead  of  finding  the  head  of 
the  humerus  as  it  was  in  the  morning,  in  the  hol- 
low of  the  axilla,  finds  it  behind  the  pectoralis  major 
muscle. 

The  action  of  muscles  is  a permanent  cause  of  a 
new  dislocation.  When  the  humerus  is  lujtated  down- 
wards, the  pectoralis  major  and  the  deltoid  draw  the 
upper  part  of  this  bone  upwards  and  inwards,  which, 
only  making  a weak  resistance  to  their  action,  changes 
its  position,  and  takes  one  in  the  above  double  di- 
rection. 

The  various  motions  imparted  to  the  arm  may  also 
produce  the  same  effect,  according  to  their  direction. 
Thus,  in  consequence  of  unskilful  efforts  to  reduce  the 
bone,  a luxation  inwards  frequently  follows  one  down- 
wards. By  the  French  surgeons,  a great  deal  of  im- 
portance has  been  attached  to  the  division  of  disloca- 
tions of  the  humerus  into  primary  and  consecutive ; 
and  perhaps  some  of  their  statements  on  the  secondary 
change  in  the  position  of  the  head  of  the  bone  may  be 
exaggerated.  That  a subsequent  alteration  in  the  situ- 
ation of  the  bone  may  happen,  from  the  causes  spe- 
cified by  Desault,  can  hardly  be  questioned.  The  ob- 
servations of  Petit,  Hey,  and  others,  confirm  the  fact ; 
and  I have  myself  seen  a dislocation  in  the  axilla 
change  into  one  forwards,  under  the  pectoral  muscle. 
However,  Sir  Astley  Cooper  believes  that,  excepting 
from  violence  and  the  effect  of  absorption,  the  nature 
and  direction  of  a dislocation  are  never  changed  after 
the  muscles  have  once  contracted.— (Du  Dislocations, 
p.  416.)  Perhaps,  with  the  latter  qualification,  no  great 
difference  prevails  between  him  and  other  writers. 

SYMPTOMS. 

In  general,  the  diagnosis  of  dislocations  of  the  hu- 
merus is  attended  with  no  difficulties. 

Whatever  may  be  the  mode  and  situation  of  the  dis- 
location, there  always  exists,  as  Hippocrates  has  re- 
marked, a manifest  depression  under  the  acromion, 
which  forms  a more  evident  projection  than  in  the  na- 
tural state.  Almost  all  the  motions  of  the  arm  are 
painful ; some  cannot  be  performed  in  any  degree ; 
and  they  are  all  very  limited.  The  arm  cannot  move 
without  the  shoulder  moving  also,  because  the  articu- 
lation being  no  longer  able  to  execute  its  functions, 
both  it  and  the  shoulder  fbrm,  as  it  were,  one  body. 
When  the  limb  is  moved,  a slight  crepitus  may  some- 
times be  felt,  probably  in  consequence  of  the  synovia 
having  escaped  through  the  laceration  of  the  capsule. 
— (A.  Cooper  on  Dislocations,  p.  418.) 

To  these  symptoms,  generally  characteristic  of  every 
sort  of  dislocation  of  the  humerus,  are  to  be  added 
such  as  are  peculiar  to  each  particular  case.  When 
the  luxation  is  downwards,  the  arm  is  a little  longer 
than  in  the  natural  state ; the  natural  roundness  of 
the  shoulder  is  lost  in  consequence  of  .the  deltoid  mus- 
cle being  drawn  down  with  the  head  of  the  bone ; and 
the  patient  cannot  use  the  arm.  The  elbow  is  more  or 
less  removed  from  the  axis  of  the  bo<ly  by  the  action 
ef  the  deltoid,  the  long  head  of  the  biceps  and  supra- 
spinatus  muscle  being  aiso  stretched,  and  tending  to 
draw  the  bone  outwards.  The  pain  which  arises  from 
^is  position  compels  the  patient  to  lean  towards  the 
dislocated  limb,  to  keep  the  forearm  half  bent,  and  the 
o-bow  supported  on  Ins  hip>  in  such  a way  that  the 


arm,  having  a resting-place,  may  be  sheltered  from  all 
painfhl  motion,  especially  that  of  the  elbow  inwards. 
By  this  posture  alone  Desault  often  recognised  the  ac- 
cident. The  head  of  the  humerus  may  be  felt  in  the 
axilla;  but  “ only  when  the  elbow  is  considerably  re- 
moved from  the  side.”— (Sir  A.  Cooper  on  Dislocations, 
p.  417.)  This  last  circumstance  is  worthy  of  particu- 
lar notice,  as  the  inability  to  feel  the  head  of  the  bone 
has  led  to  mistakes. 

With  the  general  symptoms  of  dislocations  of  the  hu- 
merus, a luxation  inwards  has  the  following ; the  elbow, 
separated  from  tne  axis  of  the  body,  is  inclined  a little 
backwards ; the  humerus  seems  to  be  directed  towards 
the  middle  of  the  clavicle;  motion  backwards  is  not  very 
painful,  but  that  forwards  is  infinitely  so ; a manifest 
prominence  under  the  great  pectoral  muscle ; the  arm 
is  said  by  Desault  to  be  a very  little  longer  than  in  the 
natural  state  ; by  Sir  Astley  Cooper  it  is  described  as  be- 
ing somewhat  shortened  (Ort  Dislocations,  p.  435),  and 
the  posture  is  the  same  as  in  the  foregoing  case.  The 
coracoid  process  is  on  the  outer  side  of  the  headof  tlie  bone. 

Were  a dislocation  outwards  to  present  itself,  it  would 
be  particularly  characterized  by  a hard  tumour  under 
the  spine  of  the  scapula ; by  the  direction  of  the  elbow 
forwards  ; and  by  the  somewhat  increased  length  of  the 
arm.  The  motions  of  the  arm  would  be  impaired,  but 
not  in  so  great  a degree  as  in  the  foregoing  cases.  In  one 
example,  related  by  Mr.  Toulmin,  of  Hackney,  the  arm 
could  be  moved  considerably  either  upwards  or  dowm- 
wards ; but  motion  forwards  or  backwards  was  very 
limited.  And  from  the  observations  of  Mr.  Coley,  of 
Brulgenorth,  it  would  seem  that  this  dislocation  may 
be  attended  with  the  peculiarity  of  the  arm  lying  close 
to  the  side.— (A.  Cooper  on  Dislocations,  p.  441—443.) 

Many  authors,  particularly  B.  Bell,  speak  of  an  cede- 
matous  swelling  of  the  whole  upper  extremity  as  a fre- 
quent consetiuence  of  a dislocation  inwards.  In  the  time 
of  Desault  and  Bichat,  this  occurrence  was  not  often  no- 
ticed at  the  Ilotel-Dieu,  except  in  very  old  luxations ; 
and  when  it  was,  very  beneficial  effects  were  obtained, 
in  certain  instances,  by  applying,  for  a few  days,  a mo- 
derately tight  bandage  from  the  fingers  up  to  the  axilla. 
Bichat  relates  a case  in  which  the  cedema  did  not  dis- 
appear with  the  cause,  but  even  rather  increased  ; but 
the  day  alter  a bandage  had  been  applied,  the  swelling 
was  found  diminished  by  one-half.  Considerable  sw'ell- 
ing,  which  sometimes  takes  place  very  rapidly,  may 
render  the  nature  of  the  accident  too  obscure  for  a prac- 
titioner imperfectly  acquainted  with  all  its  signs  to  de- 
tect it  with  certainty ; and  hence  the  patient  may  not 
have  the  benefit  of  right  treatment  in  due  time ; the 
bone  at  length  cannot  be  reduced ; a permanently  crip- 
pled state  of  the  arm  is  the  consequence ; the  surgeon 
is  sued  for  heavy  damages ; and  his  reputation  and  pros- 
pects are  ruined. 

There  is  another  consequence,  to  which  authors  have 
paid  but  little  attention ; though  it  was  known  to  Avi- 
cenna, and  was  several  times  observed  by  Desault. 
This  is  a palsy  of  the  upper  extremity,  arising  from  the 
pressure  made  by  the  head  of  the  bone,  when  dislocated 
inwards,  upon  the  axillary  plexus  of  nerves,  and  some- 
times resisting  every  means  of  relief. 

Indeed,  when  the  nerves  have  been  long  compressed, 
the  affection  is  very  difficult  of  cure.  Desault  several 
times  applied  the  moxa  above  the  clavicle.  The  success 
which  he  at  first  experienced  in  some  patients  did  not 
invariably  follow  in  others.  But  when  the  head  of  the 
humerus  has  only  made,  as  it  were,  a momentary  pre.s- 
sure  on  the  nerves,  and  the  reduction  has  been  effected 
soon  after  the  appearance  of  the  symptoms,  the  para 
lytic  affection  often  goes  off  of  itself,  and  its  dispersion 
may  always  be  powerfully  promoted  by  the  use  of  vola- 
tile liniments. 

OF  THE  REDUCTION. 

We  may  refer  to  two  general  classes  the  infinitely 
various  number  of  means  proposed  for  the  reduction  of 
a dislocated  humerus.  The  first  are  designed  to  push 
back,  by  some  kind  of  rftechanical  force,  the  head  of  the 
bone  into  the  cavity  from  which  it  is  displaced,  either 
with  or  without  making  previous  extension.  The 
others  are  merely  intended  to  disengage  the  head  of  the 
bone  from  the  place  which  it  accidentally  occupies, 
leaving  it  to  be  put  into  its  natural  situation  by  the  ac- 
tion of  the  muscles. 

By  the  first  means  art  effects  every  thing ; by  the 
second,  it  limits  its  interference  to  the  suitable  dircc- 


312 


DISLOCATION, 


tion  of  the  powers  of  nature.  In  the  first  method,  the 
force  externally  applied  always  operates  on  the  bone  in 
the  diagonal  of  two  powers,  which  resist  each  other  at  a 
more  or  less  acute  angle ; in  the  last  the  power  is  only 
in  one  direction. 

All  the  means  intended  to  operate  in  the  first  way,  act 
nearly  in  the  followng  manner.  Sometlung  placed 
under  the  axilla  serves  as  a fulcrum,  on  which  the  arm 
is  moved  as  a lever,  the  resistance  being  produced  by 
the  dislocated  head  of  the  humerus,  while  the  power  is 
applied  either  to  the  lower  part  of  this  bone,  or  the  wrist. 
The  condyles  of  the  humerus  being  pushed  downwards 
and  inwards,  the  head  of  the  bone  is  necessarily  moved 
in  the  opposite  direction,  towards  the  glenoid  cavity, 
into  which  it  slips  with  more  or  less  facilitj'. 

Thus  operated  the  machine  so  celebrated  among  the 
ancients  and  moderns,  under  the  name  of  the  anibi  of 
Hippocrates;  whether  used  exactly  in  the  form  described 
by  him,  or  with  the  numerous  corrections  devised  by 
Paul  of  iEgina,  Ambrose  Par6,  Duverney,  Freke,  &;c. 
By  this  machine  a double  motion  is  communicated  to 
the  head  of  the  humerus,  as  above  explained. 

The  extension  usually  moves  the  bone  from  its  un- 
natural situation,  and  is  executed  in  different  ways. 
Sometimes  the  weight  of  the  body  on  one  side,  and  the 
dragging  of  the  end  of  the  dislocated  bone  on  the  other, 
tend  to  produce  this  effect.  Such  was  the,  action  of  the 
ladder,  door,  &c.  described  in  Hippocrates’s  Treatise 
on  Fractures,  and  repeated  in  modern  works.  Some- 
times the  trunk  is  fixed  in  an  unchangeable  manner, 
while  the  arm  is  powerfully  extended,  as  is  practised 
in  employing  the  machine  of  Oribasius,  one  of  the  me- 
thods formerly  adopted  in  the  public  places  where 
wrestlers  combated. 

Sometimes  no  extension  is  sensibly  executed,  and 
while  the  end  of  the  humerus  is  pushed  outwards  by  a 
body  placed  under  the  axilla,  the  surgeon  pushes  it  up- 
wards into  the  glenoid  cavity. 

The  following  are  the  objections  common  to  all  these 
contrivances. 

However  well  covered  the  body  placed  under  the 
axilla  may  be  to  serve  as  a fulcrum,  there  is  always  a 
more  or  less  inconvenient  chafing,  frequently  dreadful 
stretching  and  laceration  of  parts  in  consequence  of  its 
application  when  the  trunk  is  suspended  upon  it,  as  in 
the  instance  of  the  door,  &;c.  In  this  way  Petit  saw  a 
fracture  of  the  neck  of  the  humerus  ])roduced,  and  even 
a laceration  and  aneurism  of  the  axillary  artery. 

Few  surgeons  have  the  different  kinds  of  apparatus 
at  hand.  Hence  trouble  and  loss  of  time  in  getting 
them ; time,  which  is  of  so  much  moment,  as  the  re- 
duction is  always  more  easy  the  sooner  it  is  accom- 
plished. 

When  the  luxation  is  consecutive,  how  can  mecha- 
nical means  bring  back  the  head  of  the  bone  through 
the  track  it  has  taken  ■?  For  instance,  if  to  a dislocation 
downwards  one  inwards  has  succeeded,  the  head  of  the 
bone  ought  to  be  brought  down  before  it  can  be  re- 
placed. The  above  means  often  do  not  co-operate  with 
the  muscles,  which  are  the  chief  and  essential  agents 
in  the  reduction. 

Perhaps,  however,  they  might  be  advantageously 
employed,  when  a primitive  luxation  downwards  is 
quite  recent,  and  when  the  head  of  the  bone  is  very 
near  the  cavity.  Then  the  inferior  costa  of  the  scapula 
presents  an  inclined  plane,  along  which  the  end  of  the 
bone  can  easily  glide,  when  propelled  by  any  kind  of  ex- 
ternal fgrce. 

Desault  very  often  employed  the  following  method 
with  great  success.  While  the  patient  was  seated 
upon  a chair  of  moderate  height,  he  took  hold  of  the 
hand  on  the  affected  side,  placed  it  between  his  knees, 
which  he  moved  downwards  and  backwards,  in  order  to 
make  the  extension  and  disengage  the  head  of  the  bone, 
while  an  sissistant  held  back  the  trunk  to  effect  the 
counter-extension.  This  was  sometimes  executed  by 
the  weight  of  the  body  and  effort  of  the  patient.  At  the 
same  time  the  surgeon’s  hands,  being  applied  to  the 
arm  in  such  a way  that  the  four  fingers  of  each  were 
put  in  the  hollow  of  the  axilla,  and  the  thumbs  on  the 
outer  part  of  the  arm,  pushed  upwards,  and  a little  out- 
wards, the  head  of  the  humerus,  which  usually  returned 
with  ease  into  its  natural  cavity. 

Petit  describes  this  plan,  but  complicated  with  the  | 
use  of  a napkin,  passed  under  the  patient’s  axilla,  and 
over  the  surgeon’s  neck,  who  contributes  to  raise  the 
dislocated  end  of  the  bone,  by  lifting  up  his  head. 


When  the  luxation  downwards  was  ver>’  recent,  De- 
sault occasionally  reduced  it  by  a still  more  simple  pro- 
cess. Marie-Louise  Favert  fell  in  going  down  stairs,  dis- 
located her  arm  downwards,  and  was  conveyed  immedi- 
ately after  the  accident  to  the  Hotel-Dieu.  Desault  hav- 
ing recognised  the  disorder,  placed  his  left  hand  under  the 
axilla,  to  serve  as  a fulcrum,  while  with  the  right,  applied 
to  the  lower  and  outer  part  of  the  arm,  he  depressed  the 
humerus  towards  the  trunk,  and  at  the  same  time  raised 
the  upper  part  of  the  bone.  The  head  of  the  humerus, 
directed  upwards  and  outwards  by  this  double  motion,  re- 
turned into  the  glenoid  cavity  without  the  least  resistance. 

Reduction  by  means  of  the  surgeon’s  heel  in  the  pa- 
tient’s axilla  is  a well-known  method,  which  is  com- 
mended by  Sir  Astley  Cooper  as  the  best  in  three- 
fourths  of  recent  dislocations.  The  patient  (he  observes) 
should  be  placed  in  the  recumbent  posture,  upon  a ta- 
ble or  a sofa,  and  near  its  edge.  “ The  surgeon  then 
binds  a wetted  roller  round  the  arm,  immediately  above 
the  elbow,  upon  which  he  ties  a handkerchief.  Then, 
with  one  foot  resting  upon  the  floor,  he  separates  the 
patient’s  elbow  from  his  side,  and  places  the  heel  of  his 
other  foot  in  the  axilla.”  The  arm  is  then  steadily 
drawn  with  the  handkerchief  for  three  or  four  minutes, 
at  the  end  of  which  the  bone  in  common  cases  is  easily  re- 
placed. If  more  force  be  required,  a long  towel  can  be 
used,  with  which  several  persons  may  pull.  Sir  Ast- 
ley Cooper  generally  bends  the  forearm  nearly  lo  a 
right  angle  with  the  os  humeri,  because  this  position 
relaxes  the  biceps,  and  lessens  its  resistance  ; in  many 
cases,  however,  he  makes  the  extension  at  the  wrist ; 
a plan  in  which  he  finds  more  force  requisite,  but  the 
bandage  is  less  apt  to  slip. 

Another  simple  mode  of  reduction,  which  Sir  Astley 
Cooper  considers  proper  for  recent  dislocations,  delicate 
females,  and  very  old,  relaxed,  emaciated  persons,  is  that 
by  means  of  the  surgeon’s  knee,  as  a fulcrum,  in  the 
patient’s  axilla.  The  patient  is  placed  on  a low  chair, 
on  the  side  of  which  the  surgeon  rests  his  foot,  while 
he  takes  hold  of  the  os  humeri  just  above  the  condyles, 
and  applies  his  other  hand  to  the  acromion.  The  arm 
is  then  drawn  down  over  the  knee,  and  the  head  of  the 
bone  returns  into  its  place. — {On  Dislocationns,  p.  432.) 

In  some  cases  the  preceding  methods  are  inadequate, 
and  greater  extension  must  be  made.  The  following 
was  the  practice  of  Desault. 

The  patient  is  laid  upon  a table  covered  with  a mat- 
tress ; a thick  linen  compress  is  applied  to  the  axilla, 
on  the  side  affected,  and  upon  this  compress  the  middle 
of  the  first  extenduig  bandage  is  placed,  the  two  heads 
of  which  ascend  obliquely  before  and  behind  the  chest, 
meet  each  other  at  the  top  of  the  sound  shoulder,  and 
are  held  there  by  an  assistant,  so  as  to  fix  the  trunk  and 
make  the  counter-extension.  The  action  of  this  band- 
age does  not  affect  the  margin  of  the  pectoralis  major 
and  latissimus  dorsi,  in  consequence  of  the  pad  project- 
ing over  them.  If  this  were  not  attended  to,  these  mus- 
cles, being  drawn  upwards,  would  pull  the  humerus  ie 
this  direction,  and  thus  destroy  the  effect  of  the  exte'.,- 
sion,  which  is  to  be  made  in  the  following  manner. 

Two  assistants  take  hold  of  the  forearm,  above  the 
wrist ; or  else  the  towel,  doubled  several  times,  is  to 
be  appUed  to  this  part.  The  two  ends  are  to  be  twisted 
together,  and  held  by  one  or  two  assistants,  who  are  to 
begin  pulling  in  the  same  direction  in  which  the  hum» 
rusis  thrown.  After  this  first  proceeding,  which  is  de- 
signed to  disengage  the  head  of  the  bone  from  its  /’.cci- 
dental  situation,  another  motion  is  to  be  employed,  which 
differs  according  to  the  kind  of  luxation.  If  this  should 
be  downwards,  the  arm  is  to  be  gradually  brought  near 
the  trunk,  at  the  same  time  that  it  is  gently  pushed  up- 
wards. Thus  the  head  of  the  bone  being  separated  from 
the  trunk,  and  brought  near  the  glenoid  cavity,  usually 
glides  into  this  situtation  with  very  little  resistance. 

When  the  luxation  is  inwards,  after  the  extension  has 
been  made  in  the  direction  of  the  humerus,  the  end  of 
this  bone  should  be  inclined  upwards  and  forvs  ards,  in 
order  that  its  head  may  be  guided  backwards;  and 
vice  versa,  when  the  luxation  is  outwards. 

’When  the  head  of  the  bone  has  been  disengaged  by 
the  first  extension,  the  motion  imparted  to  it  by  the 
rest  of  the  extension,  should  in  general  be  exactly  con- 
trary to  the  course  which  the  head  of  the  bone  has 
I taken  after  quitting  the  glenoid  cavity.  When  there  is 
I difficulty  experienced  in  replacing  the  head  of  the  bone, 
j we  should,  after  making  the  extension,  move  the  bone 
1 about  in  various  mhuners  according  to  the  differeiH 


DISLOCATIOxN. 


313 


direction  of  the  dislocation,  and  the  principle  just  no- 
ticed. This  plan  often  accomplishes  what  extension 
alone  cannot ; and  the  head  of  the  bone,  brought  by 
such  movements  towards  its  cavity,  returns  into  it 
during  their  execution. 

When  the  dislocation  is  consecutive,  it  is  the  first  ex- 
tension made  in  the  direction  of  the  displaced  bone, 
which  brings  back  its  head  to  the  situation  where  it 
was  primitively  lodged,  and  the  case  is  then  to  be 
managed  just  as  if  it  were  a primitive  dislocation. 

Thus  we  see  that,  except  in  a few  cases,  where  the 
beneficial  operation  of  the  muscles  had  been  prevented 
by  the  oldness  of  the  dislocation  or  by  adhesions,  and 
where  it  was  necessary  to  employ  means  to  force,  as  it 
were,  the  head  of  the  bone  into  its  cavity,  to  which  the 
muscles  could  not  bring  it,  Desault  only  employed  exten- 
sion variously  diversified,  till  he  had  put  the  muscles 
in  a state  favourable  for  accomplishing  reduction. 

When  the  muscles  are  very  powerful,  or  the  displace- 
ment has  continued  several  days.  Sir  Astley  Cooper, 
instead  of  the  treatment  by  the  heel  in  the  axilla,  re- 
commends the  patient  to  be  put  upon  a chair,  and  the 
.scapula  to  be  fixed  by  means  of  a bandage  which  allows 
the  arm  to  pass  through  it,  and  is  buckled  on  the  top 
of  the  acromion,  so  that  it  cannot  slip  downwards. 
A wetted  roller  is  next  applied  round  the  arm  just 
above  the  elbow,  and  over  the  roller  a strong  worsted 
tape,  fixed  with  what  the  sailors  term  the  dove-hitch 
knot.  The  arm  should  now  be  raised  to  a right  angle 
with  the  body,  and,  if  much  difficulty  be  experienced, 
even  above  the  horizontal  line,  in  order  to  relax  more 
completely  the  deltoid  and  supraspinatus  muscles. 
iSvo  persons  are  then  to  pull  the  worsted  tape,  and 
two  the  scapula  bandage,  in  opposite  directions,  with  a 
steady,  equal,  and  combined  force.  After  the  exten- 
sion has  been  kept  up  a few  minutes,  the  surgeon  is  to 
place  his  knee  in  the  axilla,  with  his  foot  resting  upon 
the  patient’s  chair ; he  now  raises  his  knee,  while  he 
ushes  the  acromion  downwards  and  inwards,  and  the 
ead  of  the  bone  usually  slips  into  the  glenoid  cavity. 
Sometimes  Sir  Astley  Cooper  has  seen  a gentle  rotatory 
motion  of  the  limb,  made  during  the  extension,  bring 
about  the  reduction. 

In  old  cases,  and  others  attended  with  great  difficulty 
from  the  powerful  contraction  of  the  muscles,  Sir  Ast- 
ley prefers  making  the  extension  with  pulleys,  because 
with  them,  when  the  resistance  is  likely  to  be  long, 
jerks  and  unequal  force  are  more  likely  to  be  avoided 
than  in  the  preceding  method  of  reduction ; and  the 
assistants  less  apt  to  be  fatigued.  The  patient  sits 
between  two  staples,  which  are  screwed  into  the  sides 
of  the  room ; the  bandages  are  then  applied  precisely 
in  the  same  way  as  when  the  extension  is  made  with- 
out pulleys ; and  the  force  is  applied  in  the  same  direc- 
tion. The  surgeon  is  to  pull  the  cord  of  the  pulley 
gemly  and  steadily  until  pain  is  complained  of,  when 
he  is  to  maintain  the  extension  already  made,  but  not 
increase  it.  During  this  stop,  he  should  converse  with 
the  patient,  and  direct  his  mind  to  other  subjects.  In 
two  or  three  minutes,  more  force  should  be  applied, 
and  very  gently  increased,  until  pain  be  again  com- 
plained of,  when  another  stop  should  be  made.  The 
surgeoh  should  proceed  in  this  way  for  a quarter  of  an 
hour,  at  intervals  slightly  rotating  the  limb.  When 
the  extension  seems  great  enough,  an  assistant  should 
hold  the  cord  of  the  pulley,  and  keep  up  the  degree  of 
extension,  while  the  surgeon  puts  his  knee  into  the 
axilla,  and  resting  his  foot  upon  the  chair,  gently  raises 
and  pushes  back  the  head  of  the  bone  towards  the 
glenoid  cavity,  into  which  it  generally  returns  without 
the  snap  usually  heard  when  the  reduction  is  effected 
by  other  means.  Sir  Astley  Cooper  precedes  the  use 
of  the  pulleys  with  venesection,  the  warm  bath,  and  a 
grain  of  tartarized  antimony  every  ten  minutes,  until 
faintness  is  produced,  as  already  noticed  in  our  general 
remarks. — (Cbi  Dislocations,  p.  429.) 

When  the  head  of  the  humerus  is  dislocated  forwards, 
or  undir  the  middle  of  the  clavicle,  Sir  Astley  Cooper 
recommends  the  biceps  to  be  .relaxed,  and  the  extension 
to  be  made  obliquely  downwards  and  a little  back- 
wards. In  most  instances  of  this  kind,  he  says,  the 
plan  of  reduction  by  means  of  the  heel  in  the  axilla 
will  succeed,  care  being  taken  to  apply  the  foot  rather 
more  forwards  than  in  a dislocation  into  the  axilla,  so 
that  it  may  press  on  the  head  of  the  bone.  However, 
when  the  dislocation  has  continued  several  days,  he 
,con8iderH  gradual  extension  xvith  pulleys  necessary. 


As  soon  as  the  head  of  the  bone  has  been  drawn  below 
the  level  of  the  coracoid  process,  it  is  to  be  pressed 
backwards  with  the  surgeon’s  heel  or  knee,  and  the 
elbow  at  the  same  moment  pulled  forwards.— (Op.  cit. 
p.  439.) 

The  dislocation  on  the  dorsum  of  the  scapula  ap- 
pears, from  some  cases  in  Sir  Astley  Cooper’s  work,  to 
be  reducible  by  nearly  the  same  mode  of  extension  as 
hat  employed  for  the  reduction  of  the  dislocation  in 
the  axilla.  Mr.  Coley,  of  Bridgenorth,  who  has  met 
with  two  cases  of  luxation  backwards,  advises  the  re- 
duction to  be  effected  by  elevating  the  arm  and  rotating 
it  outwards,  so  as  to  roll  the  head  of  the  humerus  to- 
wards the  axilla,  when  it  is  to  be  kept  in  this  po.sition, 
while  the  arm  is  brought  down  into  a horizontal  direc- 
tion; on  the  extending  force  being  now  applied,  the 
bone  is  easily  reduced. — (Op.  cit.  p.  444.) 

In  the  partial  dislocation  forwards,  or  that  where  the 
head  of  the  bone  lies  at  the  scapular  side  of  the  coracoid 
process,  the  moder  of  reduction,  according  to  Sir  Astley 
Cooper,  is  the  same  as  that  employed  in  the  complete 
dislocation  forwards ; but  it  is  necessary  to  draw  the 
shoulders  backwards,  and  as  soon  as  the  reduction  is 
accomplished,  the  bone  is  to  be  kept  from  slipping  for- 
wards again  by  maintaining  the  shoulders  in  that  posi- 
tion with  a bandage.— (Op.  cit.  p.  449.)  The  elbow  and 
forearm  should  also  be  supported  as  much  forwards  as 
possible  in  a sling. 

In  the  museum  of  St.  Thomas’s  Hospital  is  a prepa- 
ration, exhibiting  a dislocation  of  the  humerus  into  the 
axilla,  complicated  with  a separation  of  the  greater  tu- 
bercle by  fracture.  In  Sir  Astley  Cooper’s  valuable 
work  on  this  subject  is  also  recorded  a case  of  com- 
pound dislocation  of  the  shoulder,  which  was  under 
the  care  of*  Messrs.  Saumarez  and  Dixon,  of  Newing- 
ton, and  was  cured  by  anchylosis. — (P.  450.)  Such  an 
accident  must  be  treated  on  the  same  principles  as  other 
severe  compound  dislocations. 

For  the  purpose  of  preventing  the  head  of  the  bone 
from  slipping  out  of  its  place  again,  the  arm  should  be 
kept  for  some  days  quiet,  the  elbow  bandaged  close  to 
the  side,  and  supi)orted  in  a sling.  Sir  Astley  Cooper 
recommends  a cushion  to  be  put  in  the  axilla,  and  a 
stellate  bandage  and  sling  to  be  applied. — (O/i  Disloca- 
tions, p.  432.)  After  the  reduction  of  a dislocation 
which  has  happened  downwards,  the  facility  of  a fresh 
displacement  is  said  to  depend  very  much  upon  the 
extent  to  which  the  tendon  of  the  subscapularis  muscle 
has  been  lacerated.— (A.  Cooper's  Surgical  Essays, 
part  1,  p.  7.) 

OF  SOME  CIRCUMSTANCES  RENDERING  THE 
REDUCTION  DIFFICULT. 

I.  Narrowness  of  the  Opening  of  the  Capsule. 

While  Desault  considers  this  circumstance  as  one 
of  the  chief  impediments  to  the  return  of  the  head  of 
the  humerus  into  the  glenoid  cavity,  Pott  and  Sir  Ast» 
ley  Cooper  are  of  opinion  that  the  capsular  ligament 
can  never  create  any  such  difficulty.  According  to  De- 
sault, the  obvious  indication  is  to  enlarge  such  an  open- 
ing by  lacerating  its  edges.  This  is  fulfilled  by  moving 
the  bone  about  freely  in  every  direction,  particularly 
in  that  in  which  the  dislocation  has  taken  place.  Now 
by  pushing  the  head  of  the  bone  against  the  capsule 
already  torn,  the  latter  becomes  lacerated  still  more, 
in  consequence  of  being  pressed  between  two  hard 
bodies.  The  reduction,  which  is  frequently  impracti- 
cable before  this  proceeding,  often  spontaneously  fol- 
lows immediately  after  it  has  been  adopted.  In  the 
Journal  de  Chirvrgie  are  two  cases,  by  Anthaume  and 
Faucheron,  establishing  this  doctrine. 

Mr.  C.  White,  of  Manchester,  also  believed  that  the 
reduction  was  sometimes  prevented  by  the  head  of  the 
bone  not  being  able  to  get  through  the  laceration  in  the 
capsule  again.  He  succeeded  in  reducing  some  cases 
which  he  supposed  to  be  of  this  nature,  in  the  following 
mannPr : having  screwed  an  iron  ring  into  a beam  at 
the  top  of  the  patient’s  room,  he  fixed  one  end  of  the 
pulleys  to  it,  and  fastened  the  other  to  the  dislocated 
arm  by  ligatures  attached  to  the  wrist,  placing  the  arm 
in  an  erect  position.  In  this  way,  he  drew  up  the  pa- 
tient till  his  whole  body  was  suspended  ; but  that  too 
much  force  might  not  be  sustained  by  the  wnst,  Mr. 
White  at  the  same  time  directed  two  other  persons  to 
support  the  arm  above  the  elbow.  He  now  used  to 
try  with  his  hands^to  conduct  the  arm  into  its  place,  if 
the  reduction  had  not  already  happened,  as  was  some- 


314 


DISLOCATION. 


times  the  ease.  Occasionally,  a snap  might  be  heard 
as  soon  as  the  patient  was  drawn  up  : but  the  reduc- 
tion could  not  be  completed  till  he  was  let  down  again, 
and  a trial  made  with  the  heel  in  the  armpit.  When 
no  iron  ring  was  at  hand,  Mr.  White  used  to  have  the 
patient  raised  from  the  ground  by  three  or  four  men 
who  stood  upon  a table.— (Cases  in  Surgery,  p.  95.) 

2.  Oldness  of  the  Dislocation. 

When  the  head  of  the  bone  has  lodged  a long  while 
in  its  accidental  situation,  it  contracts  adhesions  to  it. 
The  surrounding  cellular  substance  becomes  con- 
densed, and  forms,  as  it  were,  a new  capsule,  which 
resists  reduction,  and  which,  when  such  reduction 
cannot  be  accomplished,  supplies  in  a certain  degree 
the  office  of  the  original  joint  by  allowing  a consider- 
able degree  of  motion. 

In  such  cases,  the  common  advice  used  to  be  that  no 
attempt  at  reduction  should  be  made,  as  it  would  be 
useless  in  regard  to  the  dislocation,  and  might  be  inju- 
rious to  the  patient  from  the  excessive  stretching  of 
parts.  This  was  for  some  time  the  doctrine  of  Desault ; 
but  in  his  latter  years  experience  led  him  to  be  bolder. 

Complete  success  obtained  in  dislocations  wliich  had 
existed  from  fifieen  to  twenty  days,  encouraged  him  to  at- 
tempt reduction  at  the  end  of  thirty  and  thirty-five  days  ; 
and  in  the  two  years  preceding  his  death  he  succeeded 
three  or  four  times  in  reducing  dislocations  which  had 
existed  two  months  and  a half,  and  even  three  months, 
both  when  the  head  of  the  bone  \vas  situated  at  the 
lower  and  at  the  internal  part  of  the  scapula. 

In  these  cases  it  is  necessary,  before  making  the 
extension,  to  move  the  bone  about  extensively  in  all 
directions  for  the  purpose  of  first  breaking  its  adhesions, 
lacerating  the  condensed  cellular  substance  which 
forms  an  accidental  capsule,  and  of  producing,  as  it 
were,  a second  dislocation,  in  order  to  remove  the  first. 
Extension  is  then  to  be  made  in  the  ordinary  way,  but 
with  an  additional  number  of  assistants. 

The  first  attempts  frequently  fail,  and  the  dislocated 
head  of  the  bone  continues  unmoved  notwithstanding 
the  most  violent  efforts.  In  this  case,  after  leaving  off 
the  extension,  the  arm  is  to  be  again  moved  about  very 
extensively.  The  humerus  is  to  be  carried  upwards, 
downwards,  forwards,  and  backwards ; and  every  re- 
sistance overcome.  Let  the  arm  describe  a large  seg- 
ment of  a circle  in  the  place  where  it  is  situated.  Let 
it  be  once  more  rotated  on  its  axis  ; then  let  the  exten- 
sion be  repeated,  and  directed  in  every  way.  Thus  the 
head  of  the  bone  will  first  be  disengaged  by  the  free 
motion,  and  afterward  reduced. 

In  these  cases,  when  the  dislocation,  in  consequence 
of  being  very  old,  presents  great  obstacles  to  reduction, 
even  though  the  attempts  made  for  this  purpose  should 
fail,  they  are  not  entirely  useless.  By  forcing  the  head 
of  the  bone  to  approach  the  glenoid  cavity,  and  even 
placing  it  before  the  cavity,  and  making  it  form  new 
adhesions  after  the  destruction  of  the  old  ones,  the  mo- 
tions of  jthe  arm  are  rendered  freer.  Indeed,  they  are 
always  the  less  obstructed,  the  nearer  the  head  of  the 
bone  is  to  its  natural  situation.  Notwithstanding  the 
encouragement  given  by  Desault  to  making  attempts  to 
reduce  old  dislocations  of  the  humerus,  experience 
proves  that  when  the  bone  has  been  out  of  its  place 
more  than  a month,  success  is  rarely  obtained.  And 
as  for  the  danger  which  may  arise  from  long-protracted, 
immoderate  force,  a case  which  I have  elsewhere  cited 
proves  that  caution  is  here  a virtue  which  cannot  be 
too  highly  commended.— (See  First  Lines  of  Surgery, 
vol.  2,  p.  465.)  Another  instance,  in  which  a woman 
died  from  the  violence  used  in  the  extension,  is  reported 
by  Sir  Astley  Cooper. — (On  Dislocations,  p.  422.) 

[The  late  Dr.  Colin  Mackenzie,  of  Baltimore,  several 
years  since  reduced  a dislocation  of  the  humerus,  of 
nearly  six  months’  duration,  in  the  Maryland  Hospital, 
with  entire  success ; and  Dr.  James  Cocke,  also  of 
Baltimore,  reduced  a luxated  humerus  after  it  h^  been 
displaced  120  days.— Reese.] 

3.  Contractions  of  the  Muscles. 

A third  impediment  to  the  reduction  of  every  kind  of 
dislocation  is  the  power  of  the  muscies,  which  is  aug- 
mented beyond  the  natural  degree,  in  consequence  of 
their  being  on  the  stretch.  Sometimes  this  power  is  so 
considerable,  that  it  renders  the  head  of  the  bone  im- 
moveable, though  the  most  violent  efforts  are  made. 
Here  the  means  to  be  adopted  are  such  as  weaken  the 


patient ; bleeding,  the  warm  bath,  nauseating  dose.s  of 
tartarized  antimony,  as  advised  by  Loder,  Sir  Astley 
Cooper,  &c. ; opium,  &c.  Should  the  patient  happen 
to  be  intoxicated  at  the  time  of  his  being  first  seen  by 
the  surgeon,  the  opportunity  would  be  verj'  favourable 
to  reduction,  as  the  muscles  w ould  then  be  capable  of 
less  resistance.  Extension  unremittingly,  but  not  vio- 
lently, continued  for  a length  of  time,  will  ultimately 
fatigue  the  resisting  muscles,  and  overcome  them  with 
more  safety  and  efficacy,  than  could  be  accomplished  by 
any  sudden  exertion  of  force.  In  all  cases  of  difficulty, 
pulleys  should  be  preferred. 

The  swelling  about  the  joint,  brought  on  by  the  acci- 
dent, usually  disappears  without  trouble. 

Another  consequence,  which  seldom  occurs  in  prac- 
tice, but  which  Desault  saw  twice,  is  a considerable 
emphysema,  sudenly  originating  at  the  time  of  reduc- 
tion. In  the  middle  of  sucli  violent  extension,  as  the 
long  standing  of  the  dislocation  requires,  a tumour  sud- 
denly makes  its  appearance  under  the  great  pectoral 
muscle.  Rapidly  increasing,  it  spreads  towards  the 
armpit,  the  whole  extent  of  which  it  soon  occupies.  It 
reaches  backwards,  and  in  a few  minutes  sometimes 
becomes  as  large  as  a child’s  head.  A practitioner  un- 
acquainted with  this  accident,  might  take  it  for  an 
aneurism,  occasioned  by  the  sudden  rupture  of  the 
axillary  artery,  by  the  violent  extension.  But  if  atten- 
tion be  paid  to  the  elasticity  of  the  tumour,  its  fluo- 
tuation,  the  situation  where  it  first  appears,  commonly 
under  the  great  pectoral  muscle,  and  not  in  the  axilla ; 
the  continuance  of  the  pulse  ; and  the  unchanged  colour 
of  the  skin  ; the  case  may  easily  be  discriminated  from 
a rupture  of  the  artery.— (CEuvres  Chir.  de  Desault, 
par  Bichat,  t.  1.) 

For  dispersing  the  above  kind  of  swelling,  the  lotio 
plumbi  acetatis,  and  gentle  compression  wdth  a bandage, 
are  recommended. 

I shall  conclude  the  subject  of  luxations  of  the 
shoulder  wdth  the  following  singular  observation,  re- 
corded by  Baron  I.arrey. 

“ Among  the  curious  anatomical  preparations  (says 
he)  w'hich  I saw  in  the  cabinet  of  the  university  of 
Vienna,  there  was  a dissected  thorax,  shown  to  me  by 
Professor  Prokaska,  in  which  the  whole  orbicular  mass 
of  the  head  of  the  right  humerUs,  engaged  between  the 
second  and  third  true  ribs,  projected  into  the  cavity  of 
the  chest.  This  singular  displacement  was  the  result 
of  an  accidental  luxation,  occasioned  by  a fall  on  the 
elbow,  while  the  arm  was  extended  and  lifted  from  the 
side.  The  head  of  the  humerus,  after  tearing  the  cap- 
sular ligament,  had  been  violently  driven  into  the  hollow 
of  the  a.\illa,  under  the  pectoral  muscles,  so  as  to  sepa- 
rate the  two  corresponding  ribs,  and  pass  between 
them.  The  diameter  of  the  head  of  the  bone  sur- 
mounted this  obstacle,  and  penetrated  entirely  into  the 
cavity  of  the  thorax,  pushing  before  it  the  adjacent 
portion  of  the  pleura.  Every  possible  effort  was  made 
in  vain  to  reduce  this  extraordinary  dislocation.  The 
urgent  symptoms  which  arose  were  dissipated  b.y 
bleeding,  warm  bathing,  and  antiphlogistic  remedies. 
The  arm,  however,  remained  at  a distance  from  the 
side,  to  which  condition  the  patient  became  gradually 
habituated,  and  after  several  years  of  suffering  and 
oppression,  he  at  length  experienced  no  inconvenience. 
The  patient  was  about  sixteen  or  seventeen,  when  he 
met  with  the  accident ; and  he  lived  to  the  age  of  thirty- 
one,  when  he  died  of  some  disease,  which  had  no  con- 
cern with  the  dislocation.  His  physicians  were  anxious 
to  ascertain  the  nature  of  this  curious  case,  of  which 
they  had  been  able  to  form  only  an  imperfect  judgment. 
They  were  much  surprised  to  find, -upon  opening  the 
body,  the  head  of  the  humerus  lodged  in  the  chest,  sur- 
rounded by  the  pleura,  and  its  neck  closely  embraced 
by  the  two  ribs  above  specified.  They  were  still  more 
astonished  to  find,  instead  of  a hard  spherical  body  co- 
vered with  cartilage,  only  a very  soft  membranous 
ball,  which  yielded  to  the  slightest  pressure  of  the 
finger.  The  cartilage  and  osseous  texture  of  the  whole 
portion  of  the  humerus,  contained  within  the  cavity  of 
the  chest,  had  entirely  disappeared.  Les  absorbans 
s’en  etaient  empar^s  (says  Mr.  Larrey ),  et  comme  autant 
de  gardiens fdiles.  Us  avaient  cherchi  d ditruire  par 
portions,  n'ayant  pu  Vexpulser  en  masse,  un  ennemt 
qui  s'etait  furtivement  introduit  dans  un  domicile  ou 
sa  presence  devait  itre  importuve  et  nuisible.  Of  the 
humerus,  there  only  remained  some  membranous  rudi- 
ments of  its  head,  and  a great  part  of  these  seemed  to 


DISLOCATION, 


315 


belong  to  the  pleura  costalis.” — {Mimoires  de.  Ckirurgie 
Militaire,  t.  2,  p.  405 — 407.) 

DISLOCATIONS  OF  THE  FOREARM  FROM  THE 
HUMERUS. 

Notwithstanding  the  extent  of  the  articular  surfaces 
of  the  radius  and  ulna,  the  strength  of  the  muscles  and 
ligaments  surrounding  the  joint,  and  the  mutual  recep- 
tion of  the  bony  eminences,  rendering  the  articulation 
a perfect  angular  ginglymus,  a dislocation  of  both  the 
radius  and  ulna  from  the  humerus,  is  an  accident  for 
which  a surgeon  is  sometimes  consulted.  The  radius 
and  ulna  are  most  frequently  luxated  backwards ; some- 
times laterally,  but  very  rarely  forwards  : the  latter 
luxation  cannot  occur  without  a IVacture  of  the  ole- 
cranon. Indeed,  it  is  so  uncommon,  that  neither  Petit 
nor  Desault  ever  met  with  it.  The  luxation  backwards 
is  facilitated  by  the  small  size  of  the  coronoid  process, 
which,  when  the  humerus  is  forcibly  pushed  down- 
wards and  forwards,  may  slip  behind  it,  and  ascend  as 
high  as  the  cavity  which  receives  the  olecranon  in  the 
extended  state  of  the  forearm. 

Sir  Astley  Cooper’s  experience  has  made  him  ac- 
quainted with  five  different  luxations  of  the  elbow;  1. 
That  of  the  radius  and  ulna  backwards.  2.  That  of 
both  these  bones  laterally.  3.  That  of  the  ulna  alone. 
4.  That  of  the  radius  alone  forwards.  5.  That  of  the 
radius  backwards.— (On.  Dislocations,  p.  467.) 

In  the  luxation  backwards,  the  radius  and  ulna  may 
ascend  more  or  les.s  behind  the  humerus ; but  the  coro- 
noid process  of  the  ulna  is  always  carried  above  the 
articular  pulley,  and  is  found  lodged  in  the  cavity  des- 
tined to  receive  the  olecranon.  The  head  of  the  radius 
is  placed  behind  and  above  the  external  condyle  of  the 
humerus.  The  annular  ligament,  which  confines  the 
superior  extremity  of  the  radius  to  the  ulna,  may  be  la- 
cerated ; in  which  case,  even  when  the  bones  are  re- 
duced, it  is  difficult  to  keep  them  in  their  proper  places, 
as  the  radius  tends  constantly  to  quit  the  ulna. 

This  accident  always  takes  place  from  a fall  on  the 
hand ; for  when  we  are  falling,  we  are  led  by  a me- 
chanical instinct  to  bring  our  hands  forwards  to  protect 
tlie  body.  If,  in  this  case,  the  superior  extremity, 
instead  of  resting  vertically  on  the  ground,  be  placed 
obliquely  with  the  hand  nearly  in  a state  of  supination, 
the  repulsion  which  it  receives  from  the  ground  will 
cause  the  two  bones  of  the  forearm  to  ascend  behind 
the  humerus,  while  the  weight  of  the  body  pressing  on 
the  humerus,  directed  obliquely  downwards,  forces  its 
extremity  to  pass  down  before  the  coronoid  process  of 
the  ulna. 

The  forearm  is  in  a state  of  half  flexion,  and  every 
attempt  to  extend  it  produces  acute  pain.  The  situa- 
tion of  the  olecranon,  with  respect  to  the  condyles  of 
the  humerus,  is  changed.  The  olecranon,  which,  in  the 
natural  state,  is  placed  on  a level  with  the  external 
condyle,  which  is  itself  situated  lower  than  the  internal, 
is  even  higher  than  the  latter.  Posteriorly  a consider- 
able projection  is  formed  by  the  ulna  and  radius.  On 
each  side  of  the  olecranon,  a hollow  appears.  A con- 
siderable hard  swelling  is  felt  on  the  fore  part  of  the 
joint,  arising  from  the  projection  of  the  lower  end  of 
the  humerus.  The  hand  and  forearm  are  supine,  and 
the  power  of  bending  the  joint  is  in  a great  measure 
lost. — {Sir  Astley  Cooper  on  Dislocations, p.  468.) 

The  swelling,  which  supervenes  in  twenty-four  hours 
after  the  accident,  renders  the  diagnosis  more  difficult ; 
but,  notwithstanding  the  assertion  of  Boyer,  I believe 
the  olecranon  and  internal  condyle  are  never  so  ob- 
scured that  the  distance  between  them  cannot  be  felt  to 
be  increased.  It  is  true  that  the  rubbing  of  the  coro- 
noid process  and  olecranon  against  the  humerus  may 
cause  a grating  noise,  similar  to  that  of  a fracture;  and 
some  attention  is  certainly  requisite  to  establish  a diag- 
nosis between  a fracture  of  the  head  of  the  radius  and 
a dislocation  of  the  forearm  backwards.  “ This  dislo- 
cation (says  Sir  Astley  Cooper)  is  at  first  sometimes 
undiscovered,  in  consequence  of  the  great  tumefaction, 
which  immediately  succeeds  the  injury  ; but  this  cir- 
cumstance does  not  prevent  the  reduction,  even  at  the 
period  of  several  weeks  after  the  accident ; for  I have 
known  it  thus  reduced  by  bending  the  limb  over  the 
knee,  even  without  great  violence  being  employed.” 
— {On  Dislocations,  S,  c.}i.  A70.) 

A luxation  backwards  must  be  attended  with  serious 
injur>'  of  the  surrounding  soft  parts.  The  lateral  liga- 
ments are  constantly  ruptured,  and  sometimes  the  an- 


nular ligament  of  the  radius.  In  a case  dissected  by 
Sir  Astley  Cooper  the  annular  ligament  was  entire. 
The  biceps  muscle  was  only  slightly  put  upon  the 
stretch ; but  the  brachialis  was  excessively  so.  Pro- 
bably the  lower  insertions  of  the  biceps  and  brachialis 
internus  would  likewise  be  more  frequently  lacerated 
by  the  violent  protrusion  of  the  head  of  the  humerus 
forwards,  were  it  not  that  their  attachments  are  at  some 
distance  from  the  joint.  This  mischief,  however,  occa- 
sionally takes  place,  and  then  the  forearm  is  observed 
to  be  readily  placed  ip  any  position,  and  not  to  retain 
one  attitude,  as  is  generally  the  case  in  dislocations. 
The  lower  end  of  the  humerus,  indeed,  has  been  known 
rtbt  only  to  lacerate  these  muscles,  but  to  burst  the 
integuments  and  present  itself  externally  ; an  instance 
of  which  is  recorded  by  Petit,  and  two  such  cases  I saw 
myself,  during  my  apprenticeship  at  St.  Bartholomew’s. 
Boyer  justly  remarks,  that  it  is  difficult  to  conceive 
how,  under  these  circumstances,  the  brachial  artery 
and  median  nerve  can  escape.  In  fact,  this  vessel  has 
sometimes  been  ruptured,  and  mortification  of  the  limb 
been  the  consequence  ; but  this  injury  of  the  artery, 
and  the  laceration  of  the  muscles  and  skin,  are  rare 
occurrences.- {Tiaitd  des  Mai.  Chir.  t.  4,  p.  215.)  Nor 
if  the  artery  were  wounded,  would  gangrene  be  inva- 
riably the  result;  for  if  my  memory  is  correct,  an 
instance  in  which  the  limb  was  saved,  notwithstanding 
such  a complication,  is  mentioned  by  Mr.  Abemethy  in 
his  lectures,  though  no  doubt  the  risk  would  be  great. 

The  following  method  of  reducing  the  case  is  advised 
by  Boyer:— The  patient  being  seated,  an  assistant  is  to 
take  hold  of  the  middle  of  the  humerus,  and  make 
counter-extension,  while  another  assistant  makes  ex- 
tension at  the  wrist.  The  surgeon,  seated  on  the  out- 
side, grasps  the  elbow  with  his  two  hands,  by  applying 
the  fore-fingers  of  each  to  the  anterior  part  of  the  hu- 
merus, and  the  thumbs  to  the  posterior,  with  which  he 
presses  on  the  olecranon,  in  a direction  downwards  and 
forwards.  This  method  will  generally  be  successful 
If  the  strength  of  the  patient,  or  the  long  continuance 
of  the  luxation,  render  it  necessary  to  employ  a greater 
force,  extension  is  to  be  made  with  a towel  applied  on 
the  wrist,  and  a cushion  is  to  be  placed  in  the  axilla, 
and  the  arm  and  trunk  fixed  as  is  done  in  cases  of  luxa- 
ticn  of  the  humerus. 

In  Sir  Astley  Cooper’s  method,  the  patient  sits  in  a 
chair.  The  surgeon  places  his  knee  on  the  inner  side 
of  the  elbow-joint,  in  the  bend  of  the  arm,  and  taking 
hold  of  the  patient’s  wrist,  bends  the  arm.  At  the 
same  time  he  presses  on  the  radius  and  ulna  with  his 
knee,  so  as  to  separate  them  from  the  os  humeri.  Thus 
the  coronoid  process  is  pushed  out  of  the  posterior  fossa 
of  the  humerus;  and  while  the  pressure  is  kept  up  with 
the  knee,  the  arm  is  to  be  forcibly  but  slowly  bent,  and 
the  reduction  is  soon  eflTected.  According  to  the  same 
authority,  the  bones  may  also  be  reduced  by  bending  the 
arm  over  a bedpost,  or  by  bending  it  while  it  is  engaged 
in  the  opening  of  the  back  of  the  elbow-chair  in  which 
the  patient  sits. — {On  Dislocations,  p.  469.) 

A bandage  may  afterward  be  applied  in  the  form  of 
a figure  of  8,  evaporating  lotions  used,  and  the  arm 
kept  in  a sling.  The  swelling  which  follows  is  to  be 
combated  by  antiphlogistic  means. 

At  the  end  of  seven  or  eight  days,  when  the  infiam- 
malion  has  subsided,  the  articulation  is  to  be  gently 
moved,  and  the  motion  is  to  be  increased  every  day,  in 
order  to  prevent  an  anchylosis,  to  which  there  is  a 
great  tendency. 

In  this  luxation,  the  annular  ligament  which  con- 
fines the  head  of  the  radius  to  the  extremity  of  the 
ulna  is  sometimes  torn,  and  the  radius  passes  in  front 
of  the  ulna.  In  such  cases,  pronation  and  supination 
are  difficult  and  painful ; though  the  principal  luxa- 
tion has  been  reduced,  the  head  may  be  easily  replaced 
by  pressing  it  from  before  backwarcte,  and  it  is  to  be 
kept  in  its  place  by  a compress,  applied  to  the  superior 
and  external  part  of  the  forearm.  The  bandage  and 
compress  are  to  be  taken  off  every  two  or  three  days, 
and  the  joint  gently  bent  and  extended,  in  order  to 
prevent  anchylosis. 

In  a modern  publication,  an  instance  of  a dislocation 
of  the  heads  of  the  radius  and  ulna  backwards  is  rela- 
ted, where  the  lower  end  of  the  humerus  protruded 
through  the  integuments,  and,  as  it  could  not  be  re- 
duced, it  was  sawed  off.  The  patient,  a boy,  recovered 
the  full  use  of  his  arm. — (Evans,  Pract.  Obs.  on  Cata- 
ract, Compound  Dislocations,  iS-c.  p.  101 


316 


DISLOCATION. 


A luxation  forwards  should  be  treated  as  a fracture 
of  the  olecranon,  with  which  it  would  be  inevitably 
accompanied.  Here,  on  account  of  the  great  injury 
done  to  the  soft  parts,  it  would  also  be  right  to  bleed 
the  patient  copiously,*and  put  him  on  the  antiphlo- 
gistic regimen. 

With  respect  to  lateral  luxations,  either  inwards  or 
outwards,  they  are  always  incomplete  and  easily  dis- 
covered. In  the  case  outwards,  the  coronoid  process 
is  situated  on  the  back  part  of  the  external  condyle. 
The  projection  of  the  ulna  backwards  is  even  greater 
than  in  the  dislocation  of  both  bones  directly  back- 
wards, and  the  radius  forms  a protuberance  behind 
and  on  the  outer  side  of  the  os  humeri.  By  moving 
the  hand,  the  rotation  of  the  head  of  the  humerus  can 
be  distinctly  felt  In  the  lateral  dislocation  inwards, 
the  ulna  may  be  thrown  upon  the  internal  condyle,  so 
as  to  produce  an  apparent  hollow  above  it,  and  the  ro- 
tation of  the  head  of  the  radius  can  be  distinctly  felt. 
Sometimes  when  the  ulna  is  throwm  upon  the  internal 
condyle,  it  still  projects  backwards,  as  in  the  external 
lateral  dislocation,  in  which  circumstance  the  head  of 
the  radius  is  in  the  posterior  fossa  of  the  humerus, 
and  the  outer  condyle  forms  a considerable  projection. 
— (.4.  Cooper,  op.  cit.  p.  471.)  Boyer  advises  the  re- 
duction of  lateral  dislocations  to  be  effected  by  ex- 
tending the  humerus  and  forearm,  and  at  the  same 
time  pushing  the  extreihity  of  the  humerus  and  the 
heads  of  the  ulna  ^md  radius  in  opposite  directions. 

According  to  Sir  Astley  Cooper,  in  each  of  the  late- 
ral dislocations,  the  reduction  may  be  performed  by 
bending  the  arm  over  the  knee  ; but  in  a recent  case, 
as  one  which  he  relates  proves,  he  considers  that  the 
business  may  be  most  readily  accomplished  by  forcibly 
extending  the  arm ; for  when  this  is  done,  the  biceps 
and  brachialis  draw  the  heads  of  the  radius  and  uliia 
into  their  right  places  again.— (P.  472.) 

These  luxations  cannot  be  produced  without  consi- 
derable violence;  but  when  the  bones  are  reduced, 
they  are  easily  kept  in  their  place.  It  will  be  sufficient 
to  pass  a roller  round  the  part,  to  put  the  forearm  in  a 
middle  state,  neither  much  bent  nor  extended,  and  to 
support  it  in  a sling.  But  much  inflammation  is  to  be 
expected  from  the  injury  done  to  the  soft  parts.  In 
order  to  prevent,  or  at  least  mitigate  it,  the  patient  is 
to  be  bled  two  or  three  times  and  put  on  a low  diet, 
and  the  articulation  is  to  be  covered  with  the  lotio 
plumbi  acet.  or  an  emollient  poultice.  It  is  scarcely 
necessary  to  repeat  that  the  arm  is  to  be  moved  as 
soon  as  the  state  of  the  soft  parts  will  admit  of  it. — 
{Boyer,  sur  les  Maladies  des  Os,  t.  2.) 

A dislocation  of  the  forearm  backwards  is  said  to 
/)ccur  ten  times  as  frequently  as  lateral  luxations ; and 
those  forwards  are  so  rare,  that  no  comparison  what- 
.ever  can  be  drawn. — {(Euvres  Chir.  de  Desault,  1. 1.) 

All  recent  dislocations  of  the  elbow  are  easily  re- 
xiuced  and  as  easily  maintained  so  ; for  a displacement 
is  prevented  by  the  reciprocal  manner  in  which  the  ar- 
ticular surfaces  receive  each  other,  and  by  their  mutual 
.eminences  and  cavities.  This  consideration,  however, 
should  not  lead  us  to  omit  the  application  of  a bandage 
in  the  form  of  a figure  of  8,  and  supporting  the  arm  in 
.a  sling. 

DISLOCATION  OT  THE  RADIUS  FROM  THE  ULNA. 

The  majority  of  writers  on  dislocations  of  the  fore- 
arm have  not  separately  considered  those  of  the  radius. 
The  subject  was  first  well  treated  of  by  Duverney. 
However,  dislocations  of  its  lower  end  remained  unno- 
Jiced,  until  Desault  favoured  the  profession  with  a par- 
ticular account  of  them. 

The  radius,  the  moveable  agent  of  pronation  and 
supination,  rolls  round  the  ulna,  which  forms  its  im- 
moveable support,  by  means  of  two  articular  surfaces ; 
one  above,  slightly  convex,  broad  internally,  narrow 
outwardly,  and  corresponding  to  the  little  sigmoid  ca- 
vity of  the  ulna,  in  which  it  is  lodged ; the  other  below, 
concave,  semicircular,  and  adapted  to  receive  the  con- 
vex edge  of  the  ulna.  Hence,  there  are  two  joints, 
differing  in  their  motions,  articular  surfaces,  and  liga- 
ments. 

Above,  the  radius  in  pronation  and  supination  only 
moves  on  its  own  axis  : below,  it  rolls  round  the  axis 
of  the  ulna.  Here,  being  more  distant  from  the  centre, 
its  motions  must  be  both  more  extensive  and  powerful 
than  they  are  above.  The  head  of  the  radius,  turning 
on  its  own  axis  in  the  annular  or  coronary  ligament. 


cannot  distend  it  in  any  direction.  On  the  contrary, 
below,  the  radius,  in  performing  pronation,  stretches 
the  posterior  part  of  the  capsule,  and  presses  it  against 
the  immoveable  head  of  the  ulna,  which  is  apt  to  be 
pushed  through,  if  the  motion  be  forced.  A similar 
event,  in  a contrary  direction,  takes  place  in  supina- 
tion. ITie  front  part  of  the  capsule  being  rendered 
tense,  may  now  be  lacerated. 

Add  to  this  disposition  the  difference  of  strength  be- 
tween the  ligaments  of  the  two  joints.  Delicate  and 
yielding  below  ; thick  and  firm  above ; their  difference 
is  very  great.  The  upper  head  of  the  radius,  sup- 
ported on  the  smaller  immoveable  articular  surface  of 
the  ulna,  is  protected  from  dislocation  in  most  of  its 
motions.  On  the  contrary,  its  lower  end,  carrying 
along  with  it  in  its  motions  the  bones  of  the  carpus, 
which  it  supports,  cannot  itself  derive  any  solid  sta- 
bility from  them. 

From  what  has  been  said,  the  following  conclusions 
may  be  drawn  ; 1.  That  with  more  causes  of  luxation, 
the  lower  articulation  of  the  radius  has  less  means  of 
resistance  ; and  that  under  the  triple  consideration  of 
motions,  ligaments  tying  the  articular  surfaces  toge- 
ther, and  the  relations  of  these  surfaces  to  each  other, 
this  joint  must  be  very  subject  to  dislocation.  2.  That, 
for  opposite  reasons,  the  upper  joint  must,  according 
to  Desault,  be  rarely  exposed  to  such  an  accident.  He 
here  excludes  from  consideration  cases  in  which  the 
annular  ligament  of  the  radius  is  lacerated  in  a luxa- 
tion of  both  heads  of  the  radius  and  ulna  backwards ; 
and  particularly  confines  his  reasoning  to  a dislocation 
of  the  upper  head  of  the  radius  from  the  lesser  sig- 
moid cavity  of  the  ulna,  as  a single  and  uncomplicated 
injury,  suddenly  produced  by  an  external  cause,  and, 
therefore,  neither  to  be  confounded  with  the  cases 
above  specified,  nor  with  other  examples  in  which  the 
displacement  happens  slowly,  especially  in  children, 
in  consequence  of  a diseased  or  relaxed  state  of  tha 
ligaments. 

However,  some  instances  of  dislocation  of  the  upper 
head  of  the  radius,  suddenly  produced  by  external 
causes,  are  recorded  by  Duverney  ; the  particulars  of 
another  case  were  transmitted  to  the  French  Academy 
of  Surgery;  and  I have  been  informed  of  four  exam- 
ples which  were  met  with  in  this  country. 

Two  of  these  cases  occurred  in  the  practice  of  Mr. 
Dunn,  of  Scarborough ; one  in  that  of  Mr.  Lawrence ; 
and  the  other  was  attended  by  Mr.  Earle.  Sir  Astley 
Cooper  has  himself  seen  six  examples  of  the  disloca- 
tion of  the  head  of  the  radius  forwards.  Baron  Boyer 
says,  that  many  instances  are  now  known  in  which 
the  upper  head  of  the  radius  was  dislocated  backwards ; 
indeed,  ir  opposition  to  what  Desault  has  stated,  he  as- 
serts, that  dislocations  of  the  lower  joint  between  the 
radius  and  ulna  are  more  rare  than  those  of  the  upper 
joint  between  the  same  bones.  The  latter  accident  he 
has’  twice  seen  himself.— (ilfaZ.  Chir.  t.  4,  p.  248.) 

The  displacement  backwards  is  descnbed  by  this 
author,  as  occurring  more  readily  and  frequently  in 
children  than  in  adults  or  old  subjects.  The  reason 
of  this  circumstance  is  ascribed  to  the  less  firmness 
both  of  the  ligaments  and  of  the  tendinous  fibres  of 
the  exterior  muscles,  which  fibres,  in  a more  advanced 
age,  contribute  greatly  to  strengthen  the  external  la- 
teral ligament.  In  a child,  also,  the  little  sigmoid  ca- 
vity of  the  ulna  is  smaller,  and  the  annular  ligament, 
extending  farther  round  the  head  of  the  radius,  is  longer, 
and  more  apt  to  give  way.  Hence,  in  a subject  of 
this  description,  efforts,  which  may  not  at  first  produce 
a dislocation,  if  frequently  repeated,  cause  a gradual 
elongation  of  the  ligaments,  a change  in  the  natural  po- 
sition of  the  bones,  and  at  length,  a degree  of  displace- 
ment as  great  as  in  a case  of  luxation  suddenly  and 
immediately  efliected.— (IVaite  des  Mol.  Chir.  t.  4,  p. 
239.) 

Another  fact  mentioned  by  Boyer  is,  that  the  dislo- 
cation of  the  upper  head  of  the  radius  backwards  is 
always  complete,  its  articular  surfaces  being  perfectly 
separated  both  from  the  lower  end  of  the  humerus, 
and  from  the  little  sigmoid  cavity  of  the  ulna.  The 
usual  cause  of  the  accident  is  a pronation  of  the  fore- 
arm, carried  with  great  violence  beyond  the  natural 
limits. 

In  a dislocation  of  the  head  of  the  radius  backwards, 
the  forearm  is  bent,  and  the  hand  fixed  in  the  slate  of 
pronation.  Supination  can  neither  be  performed  by 
the  action  of  the  mu.scles,  nor  by  external  force ; and 


DISLOCATION. 


317 


every  attempt  to  execute  this  movement  produces  a 
considerable  increase  of  pain.  The  hand  and  fingers 
are  moderately  bent,  and  the  upper  head  of  the  radius 
may  be  observed  forming  a considerable  projection  be- 
hind the  lesser  head  of  the  humerus.  In  the  case 
which  was  mentioned  to  me  by  my  friend  Mr.  Law- 
rence, the  head  of  the  radius  lay  upon  the  outside  of 
the  external  condyle. 

Sir  Astley  Cooper  has  never  seen  a dislocation  of 
the  upper  head  of  the  radius  backwards  in  the  living 
subject ; but  a man  was  brought  for  dissection  into  the 
theatre  of  St.  Thomas’s  Hospital,  who  had  such  a dis- 
location which  had  never  been  reduced.  The  head  of 
the  radius  was  thrown  behind  the  external  condyle, 
and  rather  to  the  outer  side  of  the  lower  extremity  of 
the  humerus.  The  fore  part  of  the  coronary  ligament 
was  torn  through,  as  well  as  the  oblique  one,  and  the 
capsular  was  partially  lacerated. 

In  the  kind  of  case  described  by  Sir  Astley  Cooper, 
where  it  seems  the  limb  was  extended,  this  experienced 
surgeon  conceives,  that  the  bone  would  be  easily  re- 
duced by  bending  the  arm. 

The  reduction  is  to  be  accomplished  by  extending 
the  forearm,  and  endeavouring  to  bring  it  into  the  su- 
pine posture  at  the  same  time  that  the  surgeon  tries  to 
press  with  his  thumb  the  head  of  the  radius  forwards 
towards  the  lesser  tubercle  of  the  humerus,  and  into 
the  little  sigmoid  cavity  of  the  ulna  again.  Success  is 
indicated  by  the  patient  being  now  able  to  perform  the 
supine  motion  of  the  hand,  and  to  bend  and  extend  the 
elbow  with  freedom 

For  the  purpose  of  preventing  a return  of  the  dis- 
placement, and  giving  nature  an  opportunity  of  repair- 
ing the  torn  ligaments,  measures  must  be  taken  to 
hinder  the  pronation  of  the  hand.  Boyer  recommends 
with  this  view  a roller,  compresses,  and  a sling ; but 
it  appears  to  me,  that  a splint,  extending  nearly  to  the 
extremity  of  the  fingers,  and  laid  along  the  inside  of 
the  forearm  with  a pad  of  sufficient  thickness  to  keep 
the  hand  duly  supine,  would  be  right,  in  addition  to  the 
sling,  roller,  &c. 

In  the  dislocation  of  the  head  of  the  radius  forwards, 
this  part  is  thrown  into  the  hollow  above  the  external 
condyle,  and  upon  the  coronoid  process  of  the  ulna. 
According  to  Sir  Astley  Cooper,  the  forearm  is  sli^tly 
bent,  but  cannof  be  bent  to  a right  angle,  nor  com- 
pletely extended.  When  it  is  suddenly  bent,  the  head 
of  the  radius  strikes  against  the  fore  part  of  the  os 
humeri.  The  hand  is  in  the  prone  position,  and  if 
rotated,  the  corresponding  motion  of  the  head  of  the  ra- 
dius can  be  felt  at  the  upper  and  front  part  of  the  el- 
bow-joint. The  coronary  or  annular,  the  oblique  liga- 
ment, the  front  of  the  capsular,  and  a portion  of  the 
interosseous  ligament,  are  torn. 

Sir  Astley  says,  that  the  cause  of  this  accident  is  a 
fall  upon  the  hand  when  the  arm  is  extended ; in 
which  event,  the  radius  receives  the  weight  of  the  body, 
and  is  forced  up  by  the  side  of  the  ulna,  and  thrown 
over  the  external  condyle  upon  the  coronoid  process. 
In  two  of  the  cases  recorded  by  him,  the  reduction 
could  not  be  accomplished  : in  the  third  it  was  affected 
during  a syncope  by  extending  the  forearm,  while  the 
olecranion  rested  on  Sir  Astley’s  foot.  In  the  fourth, 
the  patient  was  placed  on  a fofa,  and  hi.s  arm  bent 
over  the  back  of  it,  in  which  state  extension  was 
made  from  the  hand,  without  including  the  ulna.  The 
sofa  fixed  the  os  humeri,  and  the  reduction  was  ac- 
complished in  a few  minutes.  The  chief  things  to  be 
observed  are,  to  let  the  extension  act  upon  the  radius 
alone,  without  the  ulna,  and  during  the  extension  to 
let  the  hand  be  supine.— (Dislocations,  p.  474—477.) 
Ill  the  latter  posture  the  forearm  should  also  be  kept 
by  means  of  a splint,  pad,  and  bandage,  until  the  torn 
parts  are  healed. 

DISLOCATION  OF  THE  LOWER  END  OF  THE  RADIUS. 

The  causes  are,  I.  Violent  action  of  the  pronator  and 
supinator  muscles.  Thus,  Desault  has  published  the 
case  of  a laundress,  who  dislocated  the  lower  end  of 
the  radius  forwards,  by  a powerful  pronation  of  her 
hand  in  twisting  a wet  sheet.— (Boyer,  Traiti  desMal. 
Chir.  t.  4,  p.  249.) 

2.  External  force,  moving  the  radius  violently  into  a 
state  of  pronation,  and  rupturing  the  back  part  of  the 
capsule ; or  into  a state  of  supination,  and  breaking  its 
fore  part. 

Hence  there  are  two  kinds  of  dislocation:  one  of 


the  radius  forwards ; the  other  backwards.  The  firs! 
is  very  frequent;  the  second  is  much  less  so.  The 
latter  case  is  not  mentioned  by  Sir  Astley  Cooper,  and 
never  presented  itself  to  Desault  but  once  in  the  dead 
body  of  a man,  both  of  whose  arms  were  dislocated, 
and  of  whom  n-  particulars  could  be  learned.  The  head 
of  the  ulna  was  placed  in  front  of  the  sigmoid  cavity 
of  the  radius,  and  in  contact  with  the  os  pisiforme,  to 
which  it  was  connected  by  a capsular  ligament. — 
(Boyer,  Traite  des  Mai.  Chir.  t.  4,  p.  249.)  The  latter 
writer  has  also  recorded  one  Instance  of  this  rare  acci- 
dent.—(VoZ.  cit.  p.  253.; 

In  the  dislocation  of  the  lower  head  of  the  radius 
forwards,  described  by  Sir  Astley  Cooper,  this  part  is 
thrown  upon  the  front  of  the  carpus,  and  lies  upon  the 
os  scaphoides  and  the  os  trapezium. 

The  luxations  of  the  lower  head  of  the  radius,  de- 
scribed by  Desault,  are  the  same  as  those  named  by 
Sir  Astley  Cooper  dislocations  of  the  lower  end  of  the 
ulna  from  the  radius,  and  differ  Irom  the  case  called  by 
him  a luxation  of  the  radius  only  at  the  wrist,  inas- 
much as  the  hand  is  not  thrown  in  the  opposite  direc- 
tion to  that  of  the  radius ; but  this  bone  is  merely  dis- 
placed from  the  convex  articular  surface  of  the  ulna, 
the  hand  going  along  with  it.  This  circumstance 
makes  a material  difference  in  the  mode  of  reduction, 
with  reference  to  the  direction  in  which  the  hand  is  to 
be  pushed.  In  the  luxation  of  the  lower  head  of  the 
radius  forwards,  described  by  Desault,  the  symptoms 
are,  constant  pronation  of  the  forearm ; an  inability  to 
perform  supination,  and  great  pain  on  its  being  at- 
tempted ; an  unusual  projection  at  the  back  of  the 
joint,  in  consequence  of  the  protrusion  of  the  little 
head  of  the  ulna  through  the  capsule ; the  position  of 
the  radius  is  more  forward  than  natural ; constant  ad- 
duction of  the  thumb,  which  is  almost  always  extended; 
a half  bent  state  of  the  forearm,  and  very  often  of  the 
fingers,  which  posture  cannot  be  changed  without  con- 
siderable pain.  The  outer  side  of  the  hand  is  twisted 
backwards,  and  the  inner  forwards.  The  protuberance 
made  on  the  fore  part  of  the  wrist  by  the  head  of  the 
radius  is  very  evident,  and,  as  Sir  Astley  Cooper  ob- 
serves, the  styloid  process  of  the  radius  is  no  longer 
situated  opposite  to  the  os  trapezium.  This  case,  he 
says,  usually  happens  from  a fall  while  the  hand  is 
bent  back. — (On  Dislocations,  p.  503.) 

Sometimes  the  lower  head  of  the  radius  is  driven 
through  the  skin  at  the  inside  of  the  wrist,  between 
the  radial  artery,  and  the  mass  formed  of  the  flexor 
tendons  of  the  wrist  and  fingers.  Cases  of  this  de- 
scription, when  well  managed,  generally  have  a favour- 
able termination,  as  we  see  in  the  case  reported  by  M. 
Thomassin. — [Jourv,.  de  Med.  t.  39.) 

If  the  smallness  of  the  opening  in  the  skin  cause  an 
impediment  to  reduction,  the  integuments  should  be 
divided  with  a knife. 

A luxation  of  the  radius  backwards  is  characterized 
by  symptoms  the  reverse  of  those  above  mentioned. 
They  are,  a violent  supination  of  the  limb  ; inability  to 
put  it  prone;  pain  on  making  the  attempt ; a tumour 
in  front  of  the  forearm  formed  by  the  head  of  the  ulna; 
a projection  backwards  of  the  large  head  of  the  radius; 
and  adduction  of  the  thumb. 

When  he  dislocation  is  forwards,  an  assistant  is  to 
take  hold  of  the  elbow,  and  raise  the  arm  a little  from  the 
body  ; while  another  is  to  support  the  hand  and  fingers. 

The  surgeon  is  to  take  hold  of  the  end  of  the  fore- 
arm with  both  his  hands ; one  applied  to  the  inside, 
the  other  to  the  outside,  in  such  a manner  that  the  two 
thumbs  meet  each  other  in  front  of  the  limb,  between 
the  ulna  and  radius,  while  the  fingers  are  applied  to 
the  back  of  the  wrist.  lie  is  then  to  endeavour  to 
separate  the  two  bones  from  each  other,  pushing  the 
radius  backwards  and  outwards,  while  the  ulna  is  held 
in  its  proper  place.  At  the  same  time,  the  assistant 
holding  the  hand  should  try  to  bring  it  into  a state  of 
supination,  and  consequently  the  radius,  which  is  its 
support.  Thus  pushed,  in  the  direction  contrary  to  that 
of  the  dislocation,  by  two  powers,  the  radius  is  moved 
outwards,  and  the  ulna  returns  into  the  opening  of  the 
capsule,  and  into  the  sigmoid  cavity. 

Sir  A.  Cooper,  who  describes  this  case  under  the 
name  of  a dislocation  of  the  lower  end  of  the  ulna 
backwards,  reduces  it  by  pressing  the  bone  forwards, 
and  maintains  the  reduction  with  splints  well  padded, 
and  a compress  of  leather  over  the  end  of  the  ulna.— 
(On  Dislocations,  p.  505.) 


318 


DISLOCATION. 


If  chance  should  present  a dislocation  of  the  lower 
head  of  the  radius  backwards,  or,  in  other  words,  of  the 
lower  head  of  the  ulna  forwards,  the  same  kind  of  pro- 
ceeding, executed  in  the  opposite  direction,  would  serve 
to  accomplish  the  reduction. — (See  CEuvres  Chir.  de 
Desault,  <.  1.) 

In  the  luxation  of  the  lower  head  of  the  radius  for- 
wards, upon  the  carpus,  Sir  Astley  Cooper  effects  the 
reduction  by  extending  the  hand,  while  the  forearm  is 
fixed. — {On  Dislocations,  p.  504.) 

DISLOCATIONS  OF  THE  WRIST. 

The  carpal  hones  may  be  luxated  from  the  lower 
ends  of  the  radius  and  ulna  forwards  or  backwards : 
The  case  backwards  is  the  most  frequent.  It  is  facili- 
tated by  the  direction  of  the  convex  articular  surfaces 
of  the  scaphoid,  lunar,  and  cuneiform  bones,  which 
slope  more  backwards  than  forwards.  According  to 
Sir  Astley  Cooper,  the  direction  of  the  force  determines 
the  direction  in  which  the  carpal  bones  are  thrown : 
thus  if  a person  in  falling  put  out  his  hand  to  save 
himself,  and  fall  upon  the  palm,  a dislocation  is  pro- 
duced, the  radius  and  ulna  are  forced  forwards  upon 
the  annular  ligament,  and  the  carpal  bones  are  thrown 
backwards.  A considerable  swelling  is  produced  by 
the  radius  and  ulna  on  the  fore  part  of  the  wrist,  and  a 
similar  protuberance  upon  the  back  of  the  wrist  by  the 
carpus,  with  a depression  above  it,  and  the  hand  is 
bent  back. 

When  the  carpal  bones  are  dislocated  forwards  under 
the  flexor  tendons,  and  the  radius  and  ulna  backwards 
upon  the  posterior  part  of  the  carpus,  the  accident  has 
been  caused  by  a fall  on  the  back  of  the  hand. 

In  each  of  these  cases,  two  swellings  are  produced  ; 
one  by  the  radius  and  ulna ; the  other  by  the  bones  of 
the  carpus.  Sprains  will  often  cause  a great  swelling 
over  the  flexor  tendons,  and  give  rise  to  the  suspicion 
of  a luxation,  from  which  they  may  always  be  known 
by  the  swelling  being  single,  and  its  not  having  made 
its  appearance  directly  after  the  injury. 

Dislocations  inwards  or  outwards  are  never  com- 
plete. The  projection  of  the  carpal  bones  at  the  inner 
or  outer  side  of  the  joint,  and  the  distortion  of  the 
hand,  make  such  cases  sufficiently  evident. 

Recent  dislocations  of  the  wrist,  particularly  such  as 
are  incomplete,  are  easy  of  reduction : but  when  the 
displacement  has  been  suffered  to  continue  some  time 
more  difficulty  is  experienced,  and  in  a few  days  all 
attempts  are  generally  unavailing.  This  observation 
applies  to  all  dislocations  of  ginglymoid  joints  ; and  I 
cannot,  therefore,  loo  strongly  condemn  the  waste  of 
time  in  trials  to  disperse  the  swellings  of  the  soft  parts 
ere  the  bones  are  replaced  ; an  absurd  plan,  which,  I 
am  sorry  to  say,  is  sanctioned  by  Boyer. — {Mai.  Chir. 
t.  4.  p.  260.) 

For  the  purpose  of  reducing  the  dislocated  bones, 
gentle  extension  must  be  made,  while  the  two  surfaces 
of  the  joint  are  made  to  slide  on  each  other  in  a direc- 
tion contrary  to  what  they  took  when  the  accident  oc- 
curred. 

In  dislocations  of  the  wrist,  numerous  tendons  are 
always  seriously  sprained,  and  many  ligaments  lace- 
rated ; consequently,  a good  deal  of  swelling  generally 
follows,  and  the  patient  is  a long  time  in  regaining  the 
perfect  use  of  the  joint.  Hence  the  propriety  of  bleed- 
ing, low  diet,  and  opening,  cooling  medicines ; while 
the  hand  and  wrist  should' be  continually  covered  with 
linen  wet  with  the  lofio  plumbi  acetatis,  or  spirit  of 
wine  and  water,  and  the  forearm  and  hand  kept  in 
splints,  which  ought  to  extend  nearly  to  the  end  of  the 
fingers,  so  as  to  prevent  a return  of  the  displacement. 
The  linab  must  also  remain  quiet  in  a sling. 

When  the  ruptured  ligaments  have  united,  liniments 
will  tend  to  dispel  the  remaining  stiffness  and  weak- 
ness of  the  joint. 

DISLOCATION  OF  THE  CARPUS,  METACARPUS,  FINGERS, 
AND  THUMB. 

A simple  dislocation  of  the  carpal  bones  from  each 
other  seems  almost  impossible.  The  os  magnum, 
however,  has  been  known  to  be  partially  luxated  from 
the  deep  cavity  formed  for  it  in  the  os  scaphoides  and 
os  lunare.  This  displacement  is  produced  by  too  great 
a flexion  of  the  bones  of  the  first  phalanx  on  those  of 
the  second,  and  the  os  magnum  forms  a tumour  on  the 
back  of  the  hand.— <CAopari ; Boyer;  Richerand.) 

Chopart  once  met  with  a partial  luxation  of  the  os 


magnum  in  a butcher.  Baron  Boyer  has  seen  several 
examples  of  the  accident,  which,  he  says,  is  more  com- 
mon in  women  than  men ; a circumstance  which  he 
imputes  to  the  ligaments  being  looser  in  females,  and 
to  the  bones  of  the  carpus  in  them  having  naturally  a 
greater  degree  of  motion.  The  tumour  increases  when 
the  hand  is  bent,  and  diminishes  when  it  is  extended. 
The  case  does  not  produce  any  serious  inconvenience. 
If  the  wrist  be  extended,  and  pressure  be  made  on  the 
head  of  the  os  magnum,  the  reduction  is  easily  accom- 
plished ; though  a renewal  of  the  displacement  cannot 
be  prevented,  unless  the  extension  and  compression 
be  kept  up  by  means  of  a suitable  apparatus,  during 
the  whole  time  requisite  for  the  healing  of  the  tom  liga- 
ments. As  the  inconveniences  of  the  accident  are  slight, 
few  patients  will  submit  to  any  tedious,  irksome  treat- 
ment ; and  sometimes  the  surgeon  is  never  consulted, 
till  it  is  too  late  to  think  of  replacing  the  bone.  In 
general,  therefore,  he  is  obliged  to  be  content  with 
treating  the  case  as  a sprain  or  contusion. 

Sir  Astley  Cooper  has  seen  two  cases  of  displace- 
ment of  the  os  magnum  in  females : the  accidents  pro- 
duced a weakened  state  of  the  limb,  and  arose  from 
relaxation  of  the  ligaments.  One  example  is  also  given 
of  a dislocation  of  the  os  scaphoides,  which  was  thrown 
backwards  upon  the  carpus,  with  the  lower  portion  of 
the  broken  radius.— (On,  Dislocations,  p.  514,  515.) 
Compound  dislocations  of  the  carpal  bones  are  not  un- 
common, and  generally  arise  from  gun-shot  violence, 
or  other  great  mechanical  injury.  In  these  cases,  it  is 
sometimes  necessary  to  takeaway  the  displaced  bones 
altogether ; and  too  frequently  the  accident  is  such  as 
to  require  amputation. 

The  connexion  of  the  metacarpal  bones  with  one  an- 
other, and  with  those  of  the  carpus,  is  so  close,  and  the 
degree  of  motion  so  slight,  that  a disloc?ition  can  hardly 
take  place.  Thus,  Sir  Astley  Cooper,  in  his  vast  expe- 
rience, has  never  seen  them  dislocated,  except  by  the 
bursting  of  guns,  or  by  the  passage  of  heavy  carriages 
over  the  hand ; cases  frequently  demanding  amputa- 
tion.— {On  Dislocations,  p.  519.)  The  first  metacarpal 
bone,  which  is  articulated  with  the  os  trapezium,  and 
admits  of  the  movements  of  flexion,  extension,  abduc- 
tion, and  adduction,  is  capable  of  being  luxated  ; but 
the  accident  is  uncommon,  for  reasons  explained  in 
my  other  work. 

Although  from  the  nature  of  the  joint,  between  the 
first  metacarpal  bone  and  the  trapezium,  one  might 
infer  that  a dislocation  is  possible  in  the  four  directions, 
backwards,  forwards,  inwards,  and  outwards,  yet  if 
we  are  to  believe  Boyer,  the  first  case  is  the  only  one 
which  has  been  observed.  The  accident  is  produced 
by  the  application  of  external  force  to  the  back  of  the 
metacarpal  bone,which  is  suddenly  and  violently  thrown 
into  a state  of  flexion,  the  case  usually  arising  from  a 
fall  on  the  outer  edge  of  the  hand.  In  this  circum- 
stance, the  upper  head  of  the  bone  is  forcibly  driven 
backwards,  the  capsular  ligament  is  lacerated,  the  ex- 
tensor tendons  of  the  thumb  are  pushed  up,  and  the 
head  of  the  bone  slips  behind  the  trapezium. 

For  an  account  of  the  symptoms  and  treatment  of 
this  accident,  I must  refer  to  the  fifth  edition  of  the 
First  Lines  of  the  Practice  of  Surgery. 

The  first  phalanges  of  the  fingers  may  be  dislocated 
backwards  off  the  heads  of  the  metacarpal  bones.  A 
luxation  forwards  would  be  very  difficult,  if  not  impos- 
sible, because  the  articular  surfaces  of  the  metacarpal 
bones  extend  a good  way  forwards,  and  the  palm  of 
the  hand  makes  resistance  to  such  an  accident.  The 
first  phalanx  of  the  thumb,  in  particular,  is  often  dis- 
located backwards  behind  the  head  of  the  first  meta- 
carpal bone,  in  which  case  it  remains  extended,  while 
the  second  phalanx  is  bent. 

These  dislocations  should  be  speedily  reduced ; for 
after  eight  or  ten  days  they  become  irreducible.  In 
a luxation  of  the  first  bone  of  the  thumb  which  was 
too  old  to  be  easily  reduced,  and  where  the  part  was 
thrown  behind  the  head  of  the  metacarpal  bone,  De- 
sault proposed  cutting  down  to  the  dislocation,  and 
pushing  the  head  of  the  bone  into  its  place  with  a spa- 
tula. Even  in  cases  which  are  quite  recent,  this  kind 
of  dislocation  frequently  cannot  be  reduced  without 
the  utmost  difficulty,  and  the  different  proiiosals  which 
have  been  made  respecting  this  particular  accident,  by 
Mr.  Evans,  the  late  Mr.  Hey,  Mr.  C.  Bell,  and  Bo)er, 
deserve  the  notice  of  the  surgical  practitioner,  who  will 
find  them  explained  in  my  other  work.  On  lliis  sub- 


DISLOCATION. 


319 


Ject,  however,  Sir  Astley  Cooper  remarks,  that  he  has 
seen  too  much  mischief  arise  from  injury  to  the  ten- 
dons and  ligaments,  ever  to  recommend  their  division, 
in  order  to  facilitate  their  reduction,  when  extension 
will  not  succeed.— (On  Dislocation,  p.  523.)  Disloca- 
tions of  the  thumb  and  little  finger  inwards,  and  that 
of  the  thumb  outwards  (which  are  possible  cases),  and 
luxations  of  the  first  phalanges  of  the  other  fingers 
backwards,  and  of  their  second  phalanges  forwards,  are 
all  reduced  by  making  extension  on  the  lower  end  of 
the  affected  thumb  or  finger,  and  at  the  same  time 
pressing  the  head  of  the  bone  towards  its  natural  situ- 
ation. 

After  the  reduction,  the  thumb  or  finger  should  be 
rolled  with  tape,  and  surrounded  and  supported  with 
pasteboard,  till  the  lacerated  ligaments  have  united ; 
care  being  taken  to  keep  the  hand  and  forearm  in  a 
sling.  The  luxation  of  the  first  phalanx  of  the  thumb 
behind  the  metacarpal  bone,  requires  peculiar  treatment, 
as  I have  elsewhere  explained. 

DISLOCATIONS  OF  THE  BONES  OF  THE  PELVIS. 

Experience  proves,  that  the  bones  of  the  pelvis,  not- 
withstanding the  vast  strength  of  their  ligaments,  may 
be  dislocated  by  violence : thus  the  os  sacrum  may  be 
driven  forwards  towards  the  interior  of  the  pelvis ; 
the  ossa  ileum  may  be  displaced  forwards  and  up- 
wards ; and  the  bones  of  the  pubes  may  be  totally  se- 
parated at  the  sympyhsis,  and  an  evident  degree  of 
moveableness  occur  between  them.  For  the  produc- 
tion of  these  accidents  the  operation  of  enormous  force 
is  requisite ; and,  in  fact,  their  usual  causes  are  falls 
from  a great  height;  the  fall  of  a very  heavy  body 
against  the  sacrum,  at  a period  when  the  body  is  fixed ; 
and  the  pressure  of  the  pelvis  between  a wall  or  post 
and  the  wheel  of  a carriage  or  wagon.  Hence,  the 
dislocation  is  generally  the  least  part  of  tlie  mischief 
occasioned  by  such  kinds  of  violence,  and  the  case  is 
commmonly  attended  with  concussion  of  the  spinal 
marrow,  injury  of  the  sacral  nerves,  extravasation  of 
blood  in  the  cellular  substance  of  the  pelvis  or  cavity 
of  the  peritoneum,  injury  of  the  kidneys,  and  fracture 
of  one  or  more  of  the  bones  of  the  pelvis.  As  Sir  A. 
Cooper  has  remarked,  some  of  these  cases  complicated 
with  fracture,  are  liable  to  be  mistaken  for  dislocations 
of  the  thigh “ When,”  says  this  gentleman,  “ a frac- 
ture of  the  os  innominatum  happens  through  the  aceta- 
bulum, tne  head  of  the  femur  is  drawn  upwards,  and 
the  trochanter  somewhat  forwards,  so  that  the  leg  is 
shortened,  and  the  knee  and  foot  are  turned  inwards. 
Such  a case,  therefore,  may  be  readily  mistaken.  If 
the  os  innominatum  is  disjointed  from  the  sacrum,  and 
the  pubes  and  ischium  are  broken,  the  limb  is  slightly 
shorter  than  the  other ; but  the  knee  and  foot  are  not 
turned  inwards.  These  accidents  may  generally  be 
detected  by  a crepitus  perceived  in  the  motion  of  the 
thigh,  when  the  surgeon  applies  his  hand  to  the  crista 
of  the  ileum,  and  there  is  greater  motion  than  in  a dis- 
location of  the  Xhigh..''~{Surgical  Essays, part  l,p.49.) 

In  addition  to  the  complications  which  may  attend  a 
dislocation  of  the  bones  of  the  pelvis,  and  arise  imme- 
diately from  the  external  .violence,  the  case  is  always 
followed  by  inflammation,  which  may  be  very  serious, 
not  only  on  account  of  the  extent  of  the  articular  sur- 
faces affected,  but  because  such  inflammation  may  ex- 
tend to  the  peritoneum  and  viscera  of  the  abdomen  and 
pelvis,  as  I have  myself  seen  in  two  or  three  instances. 

Louis  relates  a case  in  which  the  os  ileum  of  the 
right  side  was  found  separated  from  the  sacrum  so  as 
to  project  nearly  three  inches  behind  it.  This  accident 
wa-s  caused  by  a heavy  sack  of  wheat  falling  on  a la- 
bourer. — {Mem.  de  PAcad.  de  Chir.  t.  4,  Mo.) 

In  a case  recorded  by  Sir  A.  Cooper,  the  posterior 
part  of  the  acetabulum  was  broken  off,  and  the  head 
of  the  thigh-bone  had  slipped  from  its  socket ; the  frac- 
ture extended  across  the  os  innominatum  to  the  pubes, 
the  bones  of  which  were  separated  at  the  symphysis 
nearly  an  inch  asunder.  The  ilia  were  separated  on 
each  side,  and  the  left  os  pubis,  ischium,  and  ileum 
broken. — {Surgical  Essays,  part  l,p.  50.)  In  the  same 
work  may  also  be  perused  another  case  of  fracture  of 
the  body  of  the  os  pubis  and.  ramus  of  the  ischium, 
combined  with  a luxation  of  the  right  os  innominatum 
from  the  sacrum  and  laceration  of  the  ligaments  of  the 
symphysis  of  the  pubes. 

When  these  cases  do  not  prove  fatal  from  the  direct 
effect  of  the  great  violence  •oinmitted  on  many  parts, 


or  from  peritonitis,  the  same  unpleasant  event  some- 
times follows  rather  later  from  suppuration  of  the  ar- 
ticular surfaces  taking  place,  and  abscesses  Ibrming  in 
the  cellular  membrane  of  the  pelvis.— (5oi/cr,  TraiU 
des  Mai.  Chir.  t.  4,  p.  147.) 

A case  in  which  a dislocation  of  tlie  left  os  innomi- 
natum upwards  had  a successful  termination,  was  at- 
tended by  Enaux,  Hoin,  and  Chaussier,  and  is  pub- 
lished in  a modern  work. — {M  m.de  PAcad.  des  Sci- 
ences de  Dijon.)  As  the  reduction  could  not  be  accom- 
plished at  first,  antiphlogistic  treatment  was  followed 
for  some  days,  when  new  attempts  to  replace  the  bone 
were  made,  but  could  not  be  continued,  as  they  caused 
a recurrence  of  pain  and  other  bad  symptoms.  A third 
trial,  made  at  a later  period,  was  not  more  effectual ; 
and  all  thoughts  of  reduction  were  then  abandoned. 
After  the  patient  had  been  kept  quiet  some  time, 
though  not  so  long  as  was  wished,  he  quitted  his  bed 
and  began  to  walk  about  on  crutches.  1 do  not  under- 
stand, however,  as  is  asserted,  how  the  weight  of  the 
body  could  now  bring  about  the  reduction  which  had 
been  previously  attempted  in  vain.  Be  this  as  it  may, 
the  result  was  the  patient’s  recovery.  The  fact  clearly 
proves,  as  Boyer  observes,  that  in  cases  of  this  descrip- 
tion the  most  important  object  is  not  to  aim  at  the  re- 
duction, but  rather  to  oppose,  by  every  means  in  our 
power,  inflammation  and  its  consequences.  Frequently 
the  use  of  the  catheter  is  necessary,  and  sometimes 
an  incontinence  of  urine,  or  the  involuntary  discharge 
of  the  feces,  demands  the  strictest  attention  to  clean- 
liness. In  these  ceises,  if  the  patient  live  any  time,  there 
is  also  another  source  of  danger,  consisting  in  a ten- 
dency to  sloughing  in  the  soft  parts,  on  which  the  pa- 
tient lies,  and  which,  when  they  have  been  bruised, 
require  still  greater  vigilance. 

The  os  coccygis  is  not  so  easily  dislocated  as  frac- 
tured. Boyer  has  seen  it  displaced  in  a man  who  was 
greatly  emaciated  by  disease.  This  subject  had  consi- 
derable ulcerations  about  the  coccyx,  and  the  bone 
itself  was  bare.  There  was  an  interspace  of  nearly 
two  inches  between  the  sacrum  and  base  of  the  os  coc- 
cygis. In  proportion  as  the  man  regained  his  strength, 
the  bone  recovered  its  right  position,  and  at  length 
united  to  the  os  sacrum,  notwithstanding  the  action  of 
the  levatores  ani,  which  are  inserted  into  it.  This  case, 
however,  was  not  an  accidental  luxation ; and  it  clearly 
arose  from  the  destruction  of  the  ligaments  by  disease. 

Authors  mention  two  kinds  of  dislocation  to  which 
the  os  coccygis  is  liable  ; one  inwards,  the  other  out- 
wards. The  first  is  always  occasioned  by  external  vio- 
lence ; the  second  by  the  pressure  of  the  child’s  head 
in  difficult  labours.  Pain,  difficulty  of  voiding  the 
feces  and  urine,  tenesmus,  and  inflammation,  some- 
times ending  in  abscesses  which  interest  the  rectum, 
are  symptoms  said  to  attend  and  follow  dislocations  of 
the  os  coccygis. 

The  best  authors  now  regard  all  schemes  for  the  re- 
duction useless,  as  the  bone  will  spontaneously  return 
into  its  place  as  soon  as  the  cause  of  displacement 
ceases : and  the  introduction  of  the  finger  within  the 
rectum,  and  handling  of  the  painful  and  injured  parts, 
are  more  likely  to  increase  the  subsequent  inflamma- 
tion, and  produce  abscesses,  than  have  any  beneficial 
effect.  In  short,  the  wisest  plan  is  to  be  content  with 
enjoining  quietude,  and  adopting  antiplilogistic  mea- 
sures. 

DISLOCATION  OF  THE  RIBS. 

J.  L.  Petit  was  silent  on  this  subject,  as  he  thought 
such  cases  never  occurred.  Since  his  death,  a French 
surgeon,  Buttet,  has  related  an  instance  which  he  sup- 
posed to  be  a dislocation  of  the  posterior  extremity  of 
the  rib  from  the  vertebrae ; but  Boyer  clearly  proves, 
that  there  were  no  true  reasons  for  this  opinion,  and 
that  the  case  was  only  a fracture  of  the  neck  or  end  of 
the  bone  near  the  spine.— {Traite  de  Mai.  Chir.  t.  4,  p. 
123.) 

Ambrose  Pard,  Biurbette,  Juncker,  Platner,  and  Heis- 
tcr  not  only  admit  the  occurrence  of  luxations  of  the 
ribs,  but  describe  different  species  of  them.  I.ieutaud 
also  extended  the^erm  luxations  to  cases  in  which  the 
head  of  the  rib  is  separated  by  disease,  the  pressure  of 
aneurisms,  &c. 

In  a modem  work  may  be  read  the  particulars  of  a ^ 
case  where  all  the  ribs  are  said  to  have  been  dislocated 
from  their  cartilages.  The  accident  arose  from  the 
chest  being  violently  comprassed  between  the  beam  of 


320 


DISLOCATION. 


a mill  and  the  wall.  In  such  a case  there  is  no  means 
of  reduction  except  the  effect  produced  by  forcible  in- 
spirations; nor  are  there  any  modes  of  relief  but 
bleeding,  and  the  application  of  a roller  round  the  chest. 
— <See  C.  BelVs  Surg.  Obs.p.  171.) 

DISLOCATIONS  OF  THE  THIGH-BONE. 

The  head  of  the  thigh-bone  may  be  dislocated  up- 
wards on  the  dorsum  of  the  ileum  ; upwards  and  for- 
wards on  the  body  of  the  os  pubis ; downwards  and 
forwards  on  the  foramen  ovale;  and  backwards  on  the 
ischiatic  notch. 

The  dislocation  upwards,  and  that  downwards  and 
forwards,  are  the  most  frequent. 

The  dislocation  of  the  thigh-bone  upwards  on  the 
dorsum  of  the  ileum  is  attended  with  the  following 
symptoms.  The  limb  is  from  one  inch  and  a half  to 
two  inches  and  a half  shorter  than  its  fellow,  the  thigh 
a little  bent  and  carried  inwards.  The  knee  inclines 
more  forwards  and  inwards  than  the  opposite  one  ; the 
leg  and  thigh  are  turned  inwards,  and  the  foot  points 
in  this  direction  ; the  toe  resting,  as  Sir  A.  Cooper  re- 
marks, against  the  tarsus  of  the  other  foot.— (Siirg-icai 
Essays,  part  4,  p.  27.)  There  is  an  approximation  of 
the  trochanter  major  to  the  anterior  superior  spinous 
process  of  the  ileum,  and  at  the  same  time  it  is  ele- 
vated and  carried  a little  forwards.  It  is  also  less  pro- 
minent than  that  on  the  opposite  side,  and  the  natural 
roundness  of  the  hip  has  disappeared.  The  natural 
length  of  the  limb  cannot  be  restored  without  reducing 
the  luxation : the  foot  cannot  be  turned  outwards,  and 
any  attempt  to  do  so  causes  pain ; but  the  inclination 
of  the  foot  inwards  may  be  increased.— (jBoyer.) 

WTien  an  attempt  is  made  to  draw  the  leg  away  from 
the  other,  it  cannot  be  accomplished ; but  the  thigh  may- 
be slightly  bent  across  its  fellow. 

A dislocation  on  the  dorsum  of  the  ileum  is  generally 
at  once  readily  discriminated  from  a fracture  of  the 
neck  of  the  thigh-bone  within  the  capsular  ligament,  by 
the  rotation  of  the  limb  inwards ; a position  which  is 
unusual  in  a fracture  of  any  part  of  the  os  femoris. 
“ In  a fracture  of  the  neck  of  the  thigh-bone  (says  Sir 
A.  Cooper),  the  knee  and  foot  are  generally  turned  out- 
wards ; the  trochanter  is  drawm  backwards : the  limb 
can  be  readily  bent  towards  the  abdomen,  although 
with  some  pain ; but,  above  all,  the  limb  which  is  short- 
ened from  one  to  two  inches  by  the  contraction  of  the 
muscles,  can  be  made  of  the  length  of  the  other  by  a 
slight  extension,  and  when  the  extension  is  abandoned 
the  leg  is  again  shortened.  If,  when  extended,  the  limb 
is  rotated,  a crepitus  can  often  be  felt,  which  ceases 
when  rotation  is  performed  under  a shortened  state  of 
the  limb.  The  fractured  neck  of  the  thigh-bone,  \vithin 
the  capsular  ligament,  rarely  occurs  but  in  advanced 
age,  and  it  is  the  effect  of  the  most  trifling  accidents, 
owing  to  the  absorption  which  this  part  of  the  bone 
undergoes  at  advanced  periods  of  life.  Fractures  ex- 
ternal to  the  capsular  ligament  occur  at  any  age,  but 
generally  in  the  middle  periods  of  life ; and  these  are 
easily  distinguished  by'  the  crepitus  which  attends 
them,  if  the  limb  is  rotated  and  the  trochanter  is  com- 
pressed with  the  hand.  The  position  is  the  same  as  in 
fractures  within  the  ligament.  The  proportion  of  frac- 
tures of  the  neck  of  the  thigh-bone  which  I have  seen, 
is  at  least  four  CEUses  to  one  of  dislocation.” — (A. 
Cooper,  Surg.  Essays,  part  \,p.  28.) 

The  rotation  of  the  limb  inwards,  in  cases  of  fracture 
of  the  neck  of  the  thigh-bone,  is  uncommon,  though 
sometimes  met  with.  Sir  A.  Cooper  .saw  one  example 
of  it,  under  the  care  of  Mr.  Langstaff.— (On  Disloca- 
tions, Preface.)  To  reduce  this  dislocation,  the  patient 
should  be  placed  on  his  opposite  side  ujwn  a table 
firmly  fixed,  or  a large  four-posted  bedstead.  A sheet 
folded  longitudinally  is  first  to  be  placed  under  the  pe- 
rinseiun ; and  one  end  being  carried  behind  the  patient, 
the  other  before  him,  they  are  to  be  fastened  to  one  of 
the  legs  or  posts  of  the  bed.  Thus  the  i)elvis  will  be 
fixed,  so  as  to  allow  the  neces.sary  extension  of  the 
thigh-bone  to  be  made.  Great  care  must  be  taken 
during  the  extension  lo  keep  the  scrotum  and  testicles, 
or  the  pudenda  in  women,  from  being  hurt  by  the  sheet 
passed  under  the  perinaeum.  The  patient  must  be  far- 
ther fixed  by  the  assistants. 

The  best  practitioners  of  the  pre.sent  day  in  France 
advise  the  extending  force  to  be  applied  to  the  inferior 
part  of  the  leg,  in  order  that  it  may  be  as  far  as  possible 
tVom  the  parts  which  resist  the  return  of  the  head  of 


the  bone  into  its  natural  situation.  In  this  country# 
surgeons  generally  prefer  making  the  extension  by 
means  of  a sheet,  or  fhe  strap  of  a pulley,  fastened 
round  the  limb,  Just  above  the  condyles  of  the  os 
femoris.  The  direction  in  which  Sir  A.  Cooper  makes 
the  extension  is  in  the  line  made  by  the  limb,  when  it 
is  brought  across  the  other  thigh  a little  above  the  knee. 
As  soon  as  the  head  of  the  bone  has  been  brought  on  a 
level  with  the  acetabulum  by  the  assistants  who  are 
making  the  extension,  the  surgeon  is  to  force  it  into 
this  cavity  by  pressing  on  the  great  trochanter,  or  by 
rotating  the  knee  and  foot  gently  outwards,  as  practised 
by  Sir  A.  Cooper. 

The  extension  should  always  be  made  in  a gradual 
and  unremitting  manner ; at  first  gently,  but  afterward 
more  strongly ; never  violently.  The  difficulty  of  re- 
duction arises  from  the  great  power  and  resistance  of 
the  muscles,  especially  the  glutei  and  triceps,  which 
will  at  length  be  fatigued,  so  as  to  yield  to  the  extend- 
ing force,  if  care  be  taken  that  it  be  maintained  the 
necessary  time,  without  the  least  intermission.  Some- 
times, when  there  is  difficulty  in  bringing  the  head  of 
the  bone  over  the  lip  of  the  acetabulum.  Sir  A.  Cooper 
raises  it  by  placing  his  arm  under  it  near  the  joint. 

The  disappearance  of  all  the  symptoms,  and  the 
noise  made  by  the  head  of  the  bone  when  it  slips  into 
the  acetabulum,  denote  that  the  reduction  is  effected. 
This  noise,  however,  is  not  always  made  when  pulleys 
are  tised.  The  bone  is  afterward  to  be  kept  from 
slipping  out  again,  by  tying  the  patient’s  thighs  toge- 
ther with  a bandage  placed  a little  above  the  knees. 
The  patient  should  be  kept  in  bed  at  least  three  w'eeks, 
live  low,  and  rub  the  joint  with  a CEunphorated  lini- 
ment. Due  time  must  be  given  for  the  lacerated  liga- 
ments to  unite,  and  the  sprained  parts  to  recover. 
Premature  exercise  may  bring  on  irremediable  disease 
in  the  joint. 

Mr.  Hey  gives  the  following  description  of  the  way 
in  which  he  reduced  a case  of  tliis  kind. 

“ The  extension  of  the  limb  must  be  made  in  a right 
line  with  the  trunk  of  the  body  ; and,  during  the  exten- 
sion, the  head  of  the  bone  must  be  directed  outwards 
as  well  as  downwards.  A rotatory  motion  of  the  os 
femoris  on  its  own  axis,  towards  the  spine  (the  patient 
lying  prone),  seems  likely  to  elevate  the  great  trochan- 
ter, bring  it  nearer  to  its  natural  position,  and  direct 
the  head  of  the  bone  towards  the  acetabulum.  These 
circumstances  led  to  the  following  method ; a folded 
blanket  was  wrapped  round  one  of  the  bed-posts,  so 
that  the  patient,  lying  in  a prone  position,  and  astride 
of  the  bed-post,  might  have  the  affected  limb  on  the 
outside  of  the  bed.  The  bed  was  rendered  immoveable 
by  placing  it  against  a small  iron  pillar,  which  had 
been  fixed  for  the  purpose  of  supporting  the  curtain- 
rods.  The  leg  was  bent  to  a right  angle  with  the 
thigh,  and  was  supported  in  that  position  by  Mr.  Lucas, 
who,  when  the  extension  should  be  brought  to  a proper 
degree,  was  to  give  the  thigh  its  rotatory  motion,  by 
pushing  the  leg  inwards ; that  is,  towards  the  other 
interior  extremity.  Mr.  Jones  sat  before  the  patient’s 
knee,  and  was  to  assist  in  giving  the  rotatory  motion, 
by  pushing  the  knee  outwards  at  the  same  moment.  I 
sat  by  the  side  of  the  patienf,  to  press  the  head  of  the 
bone  downwards  and  outwards  during  the  extension. 
Two  long  towels  were  wrapped  round  the  thigh,  just 
above  the  condyles ; one  towel  passing  on  the  inside 
of  the  knee,  the  other  on  the  outside.  Three  persons 
made  the  extension ; but  when  we  attempted  to  give 
the  thigh  its  rotatory  motion,  we  found  it  i:onfined  by 
the  tow’el,  w'hich  pjissed  on  the  inside  of  the  knee  and 
leg.  We  therefore  placed  both  the  towels  on  the  out- 
side ; and  in  this  jKisition,  the  extending  force  concurred 
in  giving  the  rotatory  motion.  The  first  effort  that  was 
made,  after  the  towels  were  thus  placed,  had  the  de- 
sired effect ; and  the  head  of  the  bone  moved  down- 
wards and  outwards  into  the  acetabulum.” — {Hey's 
Practical  Observations,  p.  313.) 

For  the  purpose  of  facilitating  the  reduction,  many 
surgeons  endeavour  to  produce  a temporary  faintness 
by  a copious  venesection,  immediately  before  the  exten- 
sion is  begun ; a practice  which,  when  the  patient's 
state  of  health  docs  not  forbid  it,  is  advisable,  as  less- 
ening very  materially  the  resistance  of  the  muscles. 
Sir  A.  Cooper  gives  it  his  general  approbation,  as  well 
as  the  warm  bath,  and  nauseating  doses  of  tartarized 
antimony.  After  taking  away  lYom  twelve  to  twenty 
ounces  of  blood,  this  gentleman  places  the  patient  in  • 


DISLOCATION. 


321 


bath  heated  to  100  degrees,  and  gradually  raised  to  110 
degreesj  until  faintness  is  induced.  While  in  the 
bath,  the  patient  is  also  to  take  a grain  of  tartarized 
antimony  every  ten  minutes,  until  nausea  is  excited ; 
w'hen  he  is  to  be  removed  from  the  bath,  put  in  blan- 
kets, and  placed  between  two  strong  posts,  in  each 
of  wtiich  a staple  is  fixed  ; or  he  may  be  placed  on  the 
floor,  into  which  two  rings  may  be  screwed.  The 
manner  in  which  Sir  A.  Cooper  performs  the  reduction 
with  pulleys,  and  by  making  the  extension  with  the 
thigh  slightly  bent,  having  been  detailed  in  the  last 
edition  of  the  First  Lines  of  Surgery , I shall  not  here 
repeat  it.  Of  Mr.  Hey’s  plan,  especially  the  direction 
of  the  limb  in  it,  he  entertains  an  unfavourable  opinion, 
as  little  calculated  to  answer  where  the  reduction  has 
been  at  all  delayed.— (0?i  Dislocations,  p.  45.)  In  this 
sentiment  I fully  concur.  In  all  cases  of  difficulty,  the 
above-mentioned  debilitating  means,  the  intoxicating  ef- 
fect of  a liberal  do.se  of  opium,  and  the  use  of  pulleys,  for 
the  reduction,  appear  to  me  to  deserve  recommendation. 

An  instance  of  dislocation  of  the  thigh- oohe  on  the 
dorsum  of  the  ileum,  with  fracture  of  the  same  bone, 
is  recorded  by  Sir  Astley  Cooper : the  dislocation  was 
not  at  first  detected,  and  afterward  no  attemjit  to  re- 
duce the  bone  was  considered  prudent.  “ The  probabi- 
lity is,  that  dislocations,,  thus  complicated  with  fracture, 
will  generally  not  admit  of  reduction,  as  an  extension 
cannot  be  made  until  three  or  four  months  have  elapsed 
flrom  the  accident,  and  then  only  with  strong  splints 
upon  the  thigh,  to  prevent  the  risk  of  di.suniting  the 
fracture.” — {On  Dislocations,  <S"C.  p.  62.) 

' Luxations  of  the  thigh-bone,  downwards  and  for- 
wards, upon  the  obturator  foramen,  are  the  next  in  f re- 
quency. to  those  upon  the  dorsum  of  the  ileum.  The 
accident  is  facilitated  by  the  great  extent  to  which  the 
abduction  of  the  thigh  can  be  carried  ; by  the  notch  at 
the  inferior  and  interned  part  of  the  acetabulum ; by  the 
weakness  of  the  orbiculafr  ligament,  which  on  this  side 
is  tom  through ; and  by  the  ligamentum  teres  not  oppos- 
ing, or  being  necessarily  ruptured  by  it ; that  is  to  say, 
it  is  only  broken  when  the  head  of  the  femur  has  been 
carried  with  great  violence  a certain  distance  from  the 
acetabulum.  On  this  point,  however,  I mention  with 
great  respect  the  statement  of  Sir  Astley  Cooper : “ The 
dislocation  in  the  foramen  ovale  happens  while  the 
thighs  are  widely  separated,  during  which  the  ligamen- 
tum teres  is  upon  the  stretch;  and  when  the  head  of 
the  bone  is  thrown  from  the  acetabulum,  the  ligament 
is  tom  through  before  it  entirely  quits  the  cavity.”— (On 
Dislocations,  <S-c.  p.  65.)  That  the  ligamentum  teres  is 
frequently  ruptured  admits  of  no  doubt.  It  seems  also 
that  the  pectinalis  and  adductor  brevis  muscles  are 
sometimes  lacerated.— (See  Case,  vol.  cit.  p.  66.)  The 
head  of  the  bone  is  thrown  between  the  obturator  liga- 
ment and  obturator  externus  muscle. 

The  symptoms  are  as  follows;  the  injured  limb  is 
two  inches  longer  than  its  fellow,  the  head  of  the  femur 
being  lower  than  the  acetabulum ; the  trochanter  ma- 
jor, which  is  less  prominent  them  natural,  is  removed 
to  a greater  distance  from  the  anterior  superior  spinous 
proc'jss  of  the  ileum,  and  the  thigh  is  flattened  in  con- 
sequence of  the  elongation  of  the  muscles.  A hard, 
round  tumour,  formed  by  the  head  of  the  femur,  is  felt 
at  the  inner  and  superior  part  of  the  thigh,  towards  the 
perinaeum.  The  leg  is  slightly  bent ; and,  according  to 
Sir  A.  Cooper's  experience,  the  foot,  though  widely  .sepa- 
rated from  the  other,  is  generally  turned  neither  out- 
wards nor  inwards ; but  he  has  seen  a little  variation 
in  this  respect  in  different  instances.  Hence,  he  pre- 
fers as  the  diagnostic  symptoms,  the  bent  position  of 
the  body,  caused  by  the  psoas  and  iliacus  muscles  being 
on  the  stretch  ; the  separated  knees ; and  the  increased 
length  of  the  limb.— (jEssaz/s,  part  1,  p.  37.)  The  lat- 
ter symptom  alone  is  a sufficient  indication  of  the 
case  not  being  a fracture. 

Dislocations  on  the  obturator  foramen  are  very  easy 
of  reduction.  The  pelvis  having  been  fixed,  the  exten- 
sion is  to  be  made  downwards  and  outwards,  so  as 
just  to  dislodge  the  head  of  the  bone.  The  muscles 
then  generally  draw  it  into  the  aeetabulum,  on  the  ex- 
tending force  being  gradually  relaxed,  if  the  upper  part 
of  the  bone  be  pulled  outwards  with  a bandage,  and  the 
ankle  be  at  the  same  instant  inclined  inwards.  Thus 
the  limb  is  used  as  a lever,  with  very  considerable 
power. 

Mr.  Hey  says,  that  “in  this  species  of  dislocation 
(downwards  and  forwards),  as  the  head  of  the  bone  is 

VoL.  I._X  • 


situated  lower  than  the  acetabulum,  it  is  evident,  that 
an  extension  made  in  a right  line  withthe  trunk  of  the 
body  must  remove  the  head  of  the  bone  farther  from  its 
proper  place,  and  thereby  prevent,  instead  of  assisting, 
reduction.  The  extension  ought  to  be  made  with  the 
thigh  at  a right  angle,  or  inclined  somewhat  less  than  a 
right  angle  to  the  trunk  of  the  body.  When  the  exten- 
sion has  removed  the  head  of  the  bone  from  the  exter- 
nal obturator  muscle,  which  covers  the  great  foramen 
of  the  os  innominatum,  the  upper  part  of  the  os  femoris 
must  then  be  pushed  or  drawn  outwards ; which  motion 
will  be  greatly  assisted  by  moving  the  lower  part  of  the 
os  femoris,  at  the  same  moment,  in  a contrary  direction ; 
and,  by  a fotatory  motion  of  the  bone  upon  its  own 
axis,  turning  the  head  of  the  bone  towards  the  aceta- 
bulum.”—(Hey,  p.  316.) 

The  ensuing  case  illustrates  Mr.  Hey’s  practice. 
“ The  lower  bed-post,  on  the  right  side  of  the  bed  on 
which  the  patient  lay,  was  placecf  m contact  with  a 
small  immoveable  iron  piftar  (about  an  inch  square  in 
thickness),  such  as  in  our  wards  are  used  for  support- 
ing the  curtain-rods  of  the  beds.  A folded  blanket  be- 
ing wrapped  round  the  bed-post  and  pillar,  the  patient 
was  placed  astride  of  them,  with  his  lett  thigh  close  to 
the  post,  and  his  right  thigh  on  the  outside  of  the  bed. 
A large  piece  of  flannel  was  put  between  the  blanket 
and  the  scrotum,  that  the  latter  might  not  be  hurt  dur- 
ing the  extension. 

The  patient  sat  upright  with  his  abdomen  in  contact 
with  the  folded  blanket  which  covered  the  bed-post. 
He  supported  Irmself  by  putting  his  arms  round  the 
post,  and  an  assistant  sat  behind  him  to  prevent  him 
from  receding  backwards.  He  was  also  su])ported  on 
each  side. 

Two  long  toAvels  were  put  round  the  lower  part  of 
the  thigh,  after  the  part  had  been  well  defended  from 
excoriation  by  the  application  of  a flannel  roller.  The 
knot  which  the  towels  form  was  made  upon  the  ante- 
rior part  of  the  thigh,  that  the  motion  intended  to  be 
given  to  the  leg  might  not  be  impeded  by  the  towels. 

The  thigh  being  placed  in  a horizontal  position,  or 
rather  a little  elevated,  with  the  leg  hanging  dowji  at 
right  angles  to  the  thigh,  I sat  down  upon  a chair  di- 
rectly fronting  the  patient,  and  directed  a gentle  exten- 
sion to  be  made  by  the  assistants  standing  at  my  left 
side.  This  was  done  with  the  view  of  drawing  the 
head  of  the  bone  a little  nearer  to  the  middle  of  the 
thigh,  and  the  extension  had  this  effect.  I then  placed 
the  two  assistants  who  held  the  towels  at  my  right 
side,  by  which  means  the  extension  would  be  made  in 
a direction  a little  inclined  to  the  sound  limb.  Mr.  Lo- 
gan stood  on  the  right  side  of  the  patient,  with  his 
hands  placed  on  the  upper  and  inner  side  of  the  thigh, 
for  the  purpose  of  drawing  the  head  of  the  bone  to- 
wards the  acetabulum,  when  the  extension  should  have 
removed  it  sufficiently  from  the  place  in  which  it  now  lay. 

I desired  the  assistants  to  make  the  extension  slowly 
and  gradually,  and  to  give  a signal  when  it  arrived  at 
its  greatest  degree.  At  that  moment  Mr.  Logan  drew 
the  upper  part  of  the  bone  outwards,  while  I ptished 
the  knee  inwards,  and  also  gave  the  os  femoris  a con- 
siderable rotatory  motion,  by  pushing  the  right  leg  to- 
wards the  left.  By  these  combined  motions,  the  head 
of  the  os  femoris  was  directed  upwards  and  outwards, 
or,  in  other  words,  directly  towards  the'  acetabulum, 
into  which  it  entered  at  our  first  attempt  made  in  this 
manner.— (Hey,  p.  318.) 

The  thigh-bone  is  sometimes  luxated  upwards  and 
forwards  on  the  pubes.  The  whole  limb  is  turned  out- 
wards, and  cannot  be  rotated  inwards : it  is  shortened 
by  one  inch ; the  trochanter  major  is  nearer  the 
anterior  superior  spinous  process  of  the  ileum  than 
natural ; the  head  of  the  bone  forms  a tumour  in  the 
groin  above  the  level  of  Poupart’s  ligament,  on  the 
outer  side  of  the  femoral  artery  and  vein,  where  it  can 
be  perceived  to  move  when  the  thigh-bone  itself  is 
moved.  By  the  stretcliing  of  the  anterior  crural  nerve, 
which  lies  over  the  neck  of  the  bone  (see  A.  Cooper  on 
Dislocations,  p.  95),  great  pain,  numbness,  and  even 
paralysis,  are  liable  to  be  produced.  The  knee  is  gene- 
rally carried  backwards. 

In  the  account  of  the  position  of  the  limb,  however, 
authors  vary ; and,  in  opposition  to  what  Boyer  has 
stated.  Sir  A.  Cooper  remarks,  that  there  is  a sUght 
flexion  forwards  and  outwards.— (Surgical  Essays, 
part  1,  p.  45.) 

The  head  of  the  bone  felt  in  the  groin,  and  the  i n- 


S22 


DISLOCATION. 


possibility  of  rotating  the  limb  inwards,  distinguish 
this  case  from  a fracture  of  the  neck  of  the  bone. 

Ill  reducing  this  dislocation,  Sir  A.  Ckioper  recom- 
mends the  extension  to  be  made  in  a line  behind  the 
axis  of  the  body,  so  as  to  draw  the  thigh-bone  back- 
wards ; and,  when  such  extension  has  been  continued 
some  time,  a napkin  is  to  be  put  under  the  upper  part 
of  the  bone,  and  its  head  lifted  over  the  pubes  and 
edge  of  the  acetabirium. 

The  last  dislocaticai  of  the  thigh  remaining  to  be 
spoken  of,  is  that  backwards. 

In  this  case,  according  to  the  valuable  description 
of  it  given  by  Sir  A.  Cooper,  the  head  of  the  thigh- 
bone is  placed  on  the  pyrifornus  muscle,  between  the 
edge  of  the  bone  which  forms  the  upper  part  of  the 
ischiatic  notch  and  the  sacrosciatic  ligament,  being  be- 
hind the  acetabulum,  and  a liitle  above  the  level  of  the 
middle  of  tliat  cavity.  The  limb  is  generally  not  more 
than  h^f'an  inch  shorter  than  its  fellow;  and  the 
knee  and  foot  are  turned  inwards,  but  not  nearly  in  so 
great  a degree  as  in  the  dislocation  on  the  dorsum  of  the 
ileum.  The  thigh  inclines  a little  forwards,  the  knee 
is  slightly  bent,  and  the  limb  is  so  fixed  that  flexion  and 
rotation  are  in  a great  measure  prevented. 

Sir  A.  Cooper  considers  this  dislocation  as  the  most 
difficult,  both  to  detect  and  reduce : difficult  to  detect, 
because  the  length  of  the  limb  and  the  position  of  the 
knee  and  foot  are  but  little  changed ; difficult  to  re- 
duce, because  the  head  of  the  bone  is  placed  deeply 
behind  the  acetabulum,  and  requires  to  be  dra%vn  over 
the  edge  of  the  socket,  as  well  as  towards  it.  In  thin 
.subjects,  a hard  tumour  is  felt  at  the  ,x)sterior  and  in- 
ferior part  of  the  buttock,  and  the  great  trochanter  is 
removed  farther  from  the  spine  of  the  ileum. 

The  pelvis  being  fixed,  the  extension  is  to  be  made 
dowmwards  and  forwards  across  the  middle  of  the 
other  thigh,  so  as  to  dislodge  the  head  of  the  bone, 
whUe  the  surgeon,  with  a napkin  placed  just  below 
the  trochanter  minor,  pulls  the  upper  part  of  the  femur 
towards  the  acetabulum.  In  tliis  case,  pulleys  are  pre- 
ferable for  making  the  extension. 

[congenital  dislocation  or  the  hip-joint. 

M.  Dupujtren,  of  Paris,  has  divided  dislocations 
into  three  kinds,  viz.  primitive,  consecutive,  and  con- 
genital. In  the  course  of  eighteen  years  he  'has  met 
with  twenty  cases  of  the  congenital  kind,  seventeen  of 
which  were  females. 

The  following  extract  is  made  from  his  work,  to 
which  I must  refer  the  readen  for  much  valuable  in- 
formation. 

“ The  signs  w’hich  characterize  it  are,  shortening  of 
the  limb ; presence  of  the  head  of  the  femur  on  the 
dorsum  ileum ; prominence  (saillie)  of  the  trochanter 
major ; retraction  of  almost  all  the  muscles  of  the 
up^r  part  of  the  thigh  towrards  the  crest  of  the  Ueum, 
where  they  form  around  the  head  of  the  femur  a kind 
of  cone,  the  base  towards  the  os  innominatum,  the  apex 
towards  the  trochanter ; the  almost  entire  denudation 
in  consequence  of  the  tuber  ischii ; the  rotation  of  the 
limb  inwards ; the  obliquity  of  the  thigh,  proportioned, 
of  course,  to  the  age  and  developement  of  the  pelvis ; 
the  meagreness  of  the  limb,  out  of  all  proportion  to  the 
trunk  and  upper  extremities,  which  are  really  well  de- 
veloped ; and  the  imperfect  motions,  particularly  of  ab- 
duction and  rotation.  The  upper  part  of  the  trunk  of 
the  persons  thus  affected  is  thrown  backwards,  while 
the  lumbar  portion  of  the  column  projects  as  much  for- 
wards ; the  pelvis  is  placed  almost  horizontally  on  the 
femurs,  and  the  ball  of  the  foot  alone  touches  the 
ground.  In  wEdking,  we  observe  them  incline  the  body 
strongly  towards  the  limb  which  is  to  support  the 
weight,  at  which  mcwnent  the  head  of  the  femur  of  that 
side  is  seen  distinctly  to  rise  on  the  dorsum  ilei,  in  con- 
sequence of  the  superincumbent  weight  and  sinking  of 
the  pelvis,  and  then  they  drag  painAilly  forwards  the 
opposite  limb,  the  head  of  the  femur  of  which  is  per- 
ceived not  to  rise,  but  to  sink,  in  consetiuence  of  its 
own  weight  drawing  it  down.  This  series  of  pheno- 
mena, then,  is  reflated  each  step  the  patient  takes,  and 
although  locomotion  to  him  is  not  so  painful  as  it  ap- 
pears, still  he  is  incapable  of  making  any  thing  like  a 
long  journey. 

In  the  recumbent  posture,  most  of  the  sj-mptoms  of 
the  dislocation  in  a great  measure  disappear,  in  conse- 
quence, no  doubt,  of  the  relaxation  of  the  muscles, 
and  removal  of  the  weight  of  the  trunk.  In  this  posi- 


tion of  the  body,  the  surgeon  can,  by  a slight  effbri, 
elongate  the  limb,  and  shorten  it  again ; that  is,  he  can 
pull  the  head  of  the  femur  downwards,  or  press  it 
again  upwards  to  the  extent  of  two,  or  even  three 
inches,  according  to  circumstances. 

Let  us  look  to  the  history  of  this  complaint.  Even 
at  birth,  the  prominence  of  the  haunches,  the  obliquity 
of  the  femurs,  &c.,  are  perceptible,  but  in  these  cases, 
the  attention  of  the  parents  is  seldom  much  directed  to 
the  malformation,  till  the  child  begins  to  walk,  and,  in- 
deed, even  then  its  awkward  efforts  are  attributed  in 
general  to  weakness,  <fcc.,  till  the  end  of  the  third  or 
fourth  year,  when  the  parent  is  at  last  convinced  there 
must  be  something  wrong.  As  the  pelvis  begins  to  be 
developed  (for  it  is  a curious  fact  that  the  growTh  of  the 
pelvis  is  never  affected  in  these  patients),  the  symp- 
toms which  we  have  enumerated  above  become  more 
marked,  esi^cially  in  females;  and  a person  not  ac- 
quainted with  the  true  nature  of  the  malady,  would 
consider  it  the  consequence  of  scrofulous  disease  of  the 
joint.  But  the  previous  history,  the  absence  of  all 
pain,  swelling,  abscess,  fistula,  or  cicatrix,  and  the  si- 
multaneous affection  of  both  sides,  are  sufficient  to 
correct  this  error.  At  the  same  time,  it  must  be  re- 
marked, that  these  individuals  are  fort^  most  part  of  a 
lymphatic  and  scrofulous  habit. 

As  the  age  of  the  person  increases,  and  the  su- 
perincumbent weight  becomes  of  course  greater, 
the  heads  of  the  femurs  rise  on  the  dorsum  ilei,  till  at 
last  they  almost  touch  the  crista,  the  obhquity  of  the 
bones  is  increased,  and  the  difficulty  of  motion  pro- 
ceeds at  last  so  far,  as  to  incapacitate  the  patient  from 
all  active  exercise. 

In  the  cases  which  he  has  examined,  M.  Dupuytren 
has  found  the  acetabulum  almost  entirely  obliterated, 
or  even  entirely  wanting ; the  head  of  the  femur  a 
little  flattened  on  its  internal  and  anterior  surface,  and  a 
sort  of  cotyloid  cavity  to  lodge  it,  formed  on  the  dor- 
sum of  the  ileum,  as  happens  in  unreduced  accidental 
dislocations.  In  one  or  two  instances,  he  has  seen  the 
ligamentum  teres  elongated,  and,  in  some  places,  worn 
apparently  from  the  pressure  and  friction  of  the  head 
of  the  femur. 

On  the  treatment,  which  of  course  can  be  but  pal- 
liative,” says  M.  D.,  “ as  the  weight  of  the  trunk  is  the 
main  agent  in  aggravating  the  displacement,  repose  is 
obviously  indicated  ; but  it  is  not  necessarv’  to  confine 
patients  to  the  recumbent  posture ; for,  in  the  act  of  sit- 
ting, there  is  no  stress  on  the  femurs,  the  body  resting 
entirely  on  the  tuberosities  of  theischia.  Let  these  in- 
dividuals. then,  choose  a profession  which  they  can 
exercise  when  seated.  Our  author  advises,  likewise, 
the  use  of  the  cold  bath,  and  the  application  of  a band- 
age which  encircles  the  pelvis,  con  tines  the  trochan- 
ters, and  keeps  them  of  a imiform  height,  thus  binding 
the  ill-adapted  parts  together,  and  preventing  that  con- 
tinual motion  to  which  they  are  exposed.  This  prac- 
tice, though  it  certainly  will  not  cure  the  complaint, 
will  give  a great  degree  of  support  to  the  hip-joints,  and 
prevent  the  progress  of  the  displacement.”— iieese.] 

dislocations  or  the  patella. 

The  patella  may  be  luxated  outwards,  or  even  in- 
w'ards,  when  violently  pushed  in  this  direction.  It  is 
also  liable  to  a displacement  upwards,  in  consequence 
of  its  ligament  being  sometimes  ruptured  by  the  action 
of  the  extensor  muscles.  The  luxation  outwards  is 
the  most  frequent,  because  the  bone  more  easily  slips 
in  this  direiction  off  the  outer  condyle  of  the  femur  than 
inwards.  The  assertion  made  by  some  authors,  that 
the  dislocation  inwards  is  the  most  common,  is  quite 
erroneous,  as  I have  elsewhere  more  particularly  con- 
sidered.— (See  First  Lines  of  Surgery,  5th  ed.)  In 
confirmation  of  what  is  here  observed,  I may  mention 
the  opinion  of  Sir  A.  Cooper,  who  states,  that  the  bone 
is  most  frequently  thrown  on  the  external  condyle, 
where  it  produces  a projection  ; and  this  circumstance, 
w^th  an  incapacity  of  bending  the  knee,  is  evidence  of 
the  nature  of  the  injury.— (SurgiraZ  Essays,  part  \,p. 
66.)  The  accident  is  most  common  in  persons  whose 
knees  incline  inwards  ; a circumstance  that  accounts 
for  the  tendency  of  the  patella  to  be  drawn  outwards 
by  the  action  of  the  extensor  muscles.  The  di-slocation 
inwards,  which  is  much  less  frequently  met  with,  is 
produced  either  by  a fall  upon  a projecting  body,  which 
stnkes  the  outer  edge  of  the  patella,  or  by  the  foot  b*- 
ing  turned  inwardh  at  the  time  of  the  fall. 


DISLOCATION. 


323 


In  each  case,  if  there  be  no  previous  morbid  relaxa- 
tion of  the  parts,  a portion  of  the  capsular  ligament 
will  be  torn.— (^.  Cooper,  on  Dislocations,  ifC.  p.  179.) 
The  generality  of  cases  are  easily  reduced  by  pressure 
when  the  extensors  of  the  leg  have  been  completely 
relaxed ; but  owing  to  a lax  state  of  the  ligament  of 
the  patella  or  other  predisposing  causes,  the  bone  is 
sometimes  difficultly  kept  in  its  proper  situation,  un- 
less a roller  be  applied.  The  inflammatory  affection  of 
the  joint  is  to  be  opposed  by  bleeding,  purging,  and  the 
use  of  the  lotio  plumbi  subacetatis.  The  joint  must 
be  kept  quiet  a few  days,  and  then  gently  moved  in 
order  to  preVent  stiffness.  When  the  relaxation  of  the 
ligaments  is  such  that  a relapse  is  likely  to  ensue  from 
slight  causes,  a laced  kneecap,  with  a strap  and  buckle 
above  and  below  the  patella,  should  be  worn,  as  re- 
commended by  Sir  Astley  Cooper.— (On.  Dislocations, 
p.  181.)  The  luxation  of  the  patella  upwards,  from  a 
rupture  of  its  ligament,  is  a case  fbllowed  by  a con- 
siderable degree  of  inflammation.  Hence  Sir  Astley 
Cooper  particularly  recommends  early  depletion  ; the 
use  of  evaporating  lotions  from  four  to  seven  days,  and 
then  a roller  to  the  foot  and  leg.  The  leg  is  to  be  kept 
extended  by  means  of  a splint  behind  the  knee ; a lea- 
ther strap  is  to  be  buckled  round  the  lower  part  of  the 
thigh,  and  to  it,  on  each  side,  another  is  buckled,  which 
extends  from  the  sole  of  the  foot,  and  is  carried  up 
each  side  of  the  leg.  Thus  the  patella  is  kept  down, 
and  an  opportunity  is  afforded  for  the  ligament  to 
unite.  In  a month,  the  knee  may  be  gently  moved 
every  day. — {On  Dislocations,  p.  182.) 

DISLOCATIONS  OF  THE  KNEE. 

The  tibia  may  be  luxated  forwards,  backwards,  or  to 
either  side.  As  Boyer  observes,  complete  dislocations 
of  the  upper  head  of  the  tibia  are  exceedingly  rare,  be- 
cause the  articular  surface  of  the  condyles  of  the  fe- 
mur is  so  extensive  that  the  tibia  cannot  be  entirely 
removed  from  it  without  a prodigious  laceration  of  the 
ligaments,  tendons,  and  all  the  rest  of  the  soft  parts. 

The  condyles  of  the  femur  are  disposed  in  such  a 
manner,  that,  in  the  extreme  flexion  of  the  leg,  the  ar- 
ticular cavities  of  the  upper  head  of  the  tibia  are  still 
in  contact  with  those  bony  eminences  ; and  this  cir- 
cumstance, together  with  the  resistance  made  by  the 
ligament  of  the  patella,  the  patella  itself,  and  the  ten- 
don of  the  extensor  muscles  of  the  leg,  renders  a sud- 
den dislocation  of  the  tibia  backwards  so  difficult,  that 
Boyer  seems  even  to  question  the  possibility  of  the  ac- 
cident, notwithstanding  the  case  recited  by  Heister. — 
{Traiti  des  Mai.  Chir.  t.  4,p.  366.)  That  this  accident, 
however,  sometimes  really  happens,  nqjonger  admits 
of  dispute : the  case  is  noticed  l^||VA.  Cooper  as 
producing  the  following  appearafl^K  a shortened 
state  of  the  limb  ; a projection  of  tSKiondyles  of  the 
os  femoris ; a depression  in  the  situation  of  the 
ligament  of  the  patella  ; and  a bending  of  the  leg  for- 
wards : which  last  statpjnent  differs  from  that  of  Boyer, 
who  declares  that  the  leg  is  bent  to  a very  acute  angle, 
and  cannot  be  extended  a.ga.\n.~{Ma(.  Chir.  t.  4,  p. 
369.)  It  appears  farther,  from  the  particulars  of  the 
example  of  this  accident  seen  by  Dr.  Walshman,  that 
the  dislocation  may  even  be  complete,  the  head  of  the 
tibia  being  thrown  behind  the  condyles  of  the  femur 
into  the  ham.  The  tendinous  connexion  of  the  patella 
to  the  rectus  muscle  was  ruptured  ; and,  probably, 
without  alaceration  of  that  tendon,  or  of  the  ligament  of 
the  patella,  such  a degree  of  displacement  could  scarcely 
have  happened. — {Surgical  Essays,  part  2,  p.  74.) 

But  if  a sudden  dislocation  of  the  tibia  from  the  fe- 
mur backwards  is  uncommon,  the  sqme  remark  can- 
not be  made  respecting  a displacement  in  that  direc- 
tion, gradually  produced  by  the  effects  of  disease.  Se- 
veral cases  of  the  latter  kind  have  fallen  under  my 
own  observation. 

A di.slocation  of  the  head  of  the  tibia  forwards,  from 
the  condyles  of  the  femur,  cannot  happen  without  the 
greate.st  difficulty  ; for  the  accident  would  be  likely  to 
be  attended  with  a laceration  of  the  lateral,  crucial,  and 
oblique,  or  posterior  ligaments,  all  which  tend  to  pre- 
vent the  leg  from  being  too  far  extended  ; and,  in  addi- 
tion to  all  this  injury,  Boyer  calculates  that  the  head 
of  the  gastrocnemius,  the  popliteus,  and  the  extensor 
tendons  of  the  leg,  would  be  immoderately  stretched, 
and  even  tom.  However,  it  deserves  notice,  that  in 
one  compound  luxation  of  the  knee,  where  the  os  fe- 
moris  was  thrown  behind  the  outer  side  of  the  head 

X 2 


of  the  tibia,  the  external  condyle  being  dislocated  back- 
wards and  outwards,  and  the  internal  one  thrown  for- 
wards upon  the  head  of  the  tibia,  the  dissection  proved 
that  “ neither  the  sciatic  nerve,  the  popliteal  artery  and 
vein,  the  lateral,  nor  the  crucial  ligaments  were  rup- 
tured.”— {A.  Cooper,  on  DLslocations,  p.  197.)  Both 
heads  of  the  gastrocnemius  were  lacerated,  and  the 
back  portion  of  the  capsula»  ligament  extensively 
torn.  In  1802,  an  instance  of  a luxation  of  the  tibia 
forwards  was  seen  In  Guy’s  Hospital.  According  to 
Sir  Astley  Cooper,  while  the  tibia  projects  forwards 
the  thigh-bone  is  depressed,  and  throivn  somewhat  la- 
terally as  well  as  backwards.  The  os  femoris  makes 
such  pressure  on  the  popliteal  artery  as  to  prevent  the 
pulsation  of  the  anterior  tibial  artery  on  the  instep ; and 
the  patella  and  tibia  are  drawn  forwards  by  the  rectus 
muscle. — {Surgical  Essays,  part  2,  p.  73.  ) 

Dislocations  inwards  or  outwards,  though  more  fre- 
quent than  the  foregoing  cases,  are  still  to  be  consi- 
dered as  rare,  and  are  always  incomplete.  In  the  dis- 
location inwards,  the  condyle  of  the  os  femoris  is  thrown 
upon  the  external  semilunar  cartilage,  and  the  tibia 
projects  at  tile  inner  side  of  the  joint,  so  as  at  once  to 
disclose  the  nature  of  the  accident ; and  a depression 
may  be  felt  under  the  external  condyle.  In  the  luxa- 
tion of  the  head  of  the  tibia  outwards,  the  condyle  of 
the  os  femoris  is  thrown  upon  the  inner  semilunar 
cartilage,  or,  as  Sir  Astley  Cooper  says,  rather  behind 
it.  In  both  these  cases,  this  gentleman  thinks  that  the 
tibia  is  rather  twisted  upon  the  os  femoris,  so  that  the 
condyle  of  the  latter  bone  is  thrown  somewhat  back- 
wards as  well  as  outw^ards  or  inwards. 

I have  stated  that  lateral  luxations  of  the  tibia  from 
the  femur  are  almost  always  incomplete  : but  the  pos- 
sibility of  a complete  dislocation  inwards  seems  to  be 
established  by  the  402d  Obs.  of  Lamotte. 

Whenever  the  tibia  is  dislocated  from  the  femur,  the 
accident  has  generally  happened  either  while  some 
force  was  operating  upon  that  bone,  at  a period  when 
the  femur  was  fixed  and  immoveable,  or  else  while  the 
thigh-bone  was  propelled,  or  twisted  with  great  vio- 
lence, while  the  leg  itself  was  firmly  fixed. 

These  accidents  are  all  most  easily  reduced  by  mak- 
ing gentle  extension,  and  pushing  the  head  of  the  tibia 
in  the  proper  direction.  The  grand  object,  after  the 
reduction,  is  to  avert  inflammation  of  the  knee,  and 
promote  the  union  of  the  torn  ligaments.  The  first  de- 
mands the  rigorous  observance  of  the  antiphlogistic 
plan — bleeding,  leeches,  low  diet,  opening  medicines, 
and  a cooling  evaporating  lotion;  both  require  the 
limb  to  remain  perfectly  motionless.  With  respect  to 
splints,  I conceive  that  their  pressure  would  be  ob- 
jectionable. As  soon  as  the  ligaments  have  grown 
together,  and  the  danger  of  inflammation  is  over,  which 
will  be  in  about  three  weeks,  the  joint  should  be  gently 
bent  and  extended  every  day,  in  order  to  prevent  stifiT- 
ness.  Liniments  will  now  also  be  of  service. 

In  this  section,  we  must  notice  the  cases  which  were 
first  described  by  the  late  Mr.  Hey,  and  are  named  by 
Sir  A.  Cooper  partial  luxations  of  the  thigh-bone  from 
the  semilunar  cartilages.  Mr.  Hey  observes,  that  the 
disorder  may  happen  either  with  or  without  contusion. 
When  no  contusion  has  occurred,  or  the  effects  of  it 
are  removed,  the  joint,  with  respect  to  shape,  appears 
uninjured.  If  there  is  any  difference  from  its  usual 
appearance,  it  is  that  the  ligament  of  the  patella  seems 
rather  more  relaxed  than  that  of  the  sound  limb.  Thc 
leg  is  readily  bent,  or  extended  by  the  hands  of  the 
surgeon,  and  without  pain  to  the  patient : at  most,  the 
degree  of  uneasiness  caused  by  this  flexion  and  exten- 
sion is  trifling.  But  the  patient  himself  cannot  freely 
bend,  nor  perfectly  extend  the  limb  in  walking;  and 
he  is  rompelled  to  walk  with  an  invariable  and  small 
degree  of  flexion.  Yet  though  the  leg  is  stiff  in  walk- 
ing, it  may  be  freely  moved  while  the  patient  is  sitting 
down. 

Mr.  Hey  ascribes  this  complaint  to  any  causes  which 
had  the  effect  of  hindering  the  condyles  of  the  os  femo- 
ris from  moving  truly  in  the  hollow  formed  by  the 
semilunar  cartilages,  and  articular  depressions  of  the 
tibia;  an  unequal  tension  of  the  lateral  or  crucitd  liga- 
ments ; or  some  slight  derangement  of  the  semilunar 
cartilages. — {Pract.  Obs.  p.  333,  ed.  2.)  Sir  A.  Cooper 
says,  the  most  frequent  cause  of  the  accident  is  the 
point  of  the  foot,  while  averted,  striking  against  any 
projection,  when  pain  is  immediately  felt  in  the  knee, 
and  the  patient  becomes  incapable  of  perfectly  extend- 


324 


DISLOCATION. 


ing  the  leg.  Me  has  also  known  the  case  produced  by 
a person  suddenly  turning  in  bed,  and  the  clothes  not 
suffering  the  foot  to  turn'as  quickly  as  the  rest  of  the 
body.  A sudden  twist  of  the  knee  inwards  may  also 
displace  the  semilunar  cartilages. 

Sir  A.  Cooper  gives  the  following  explanation  of  the 
case.  The  semilunar  cartilages  are  united  to  the  tibia 
by  ligaments,  which,  when  relaxed,  allow  the  carti- 
lages to  be  easily  pushed  from  their  natural  situation 
by  the  condyles  of  the  femur,  which  then  come  into 
contact  with  the  head  of  the  tibia  ; and  now,  upon  an 
attempt  being  made  to  extend  the  leg,  a complete  move- 
ment of  this  kind  is  prevented  by  the  edges  of  the 
semilunar  cartilages.-^Siir^tcaf  Essays,  part  .2,  p. 
76.)  In  several  examples  recorded  by  Mr.  Hey,  a 
cure  was  effected  by  placing  the  patient  upon  an  ele- 
vated seat,  extending  the  joint,  while  one  hand  was 
placed  above  the  knee,  and  then  suddenly  mpving  the 
leg  backwards  so  as  to  make  as  acute  an  angle  with 
the  thigh  as  possible. — {Pract.  Ohs.  p.  337,  &c.)  This 
manoeuvre  seems  to  have  the  effect  of  restoring  the 
semilunar  cartilages  to  their  natural  position.  Some- 
times, however,  it  will  not  answer;  and  *in  one  such 
case,  mentioned  by  Sir  A.  Cooper,  the  patient  used  to 
accomplish  the  reduction  by  sitting  upon  the  ground, 
and  then  bending  the  thigh  inwards  and  pulling  the 
foot  outwards.  A knee-cap,  laced  tightly,  and  fur- 
nished with  a strong  leather  strap  just  below  the 
patella,  was  requisite  in  this  instance  for  preventing  a 
retinn  of  the  displacement.  In  another  case,  subject 
to  frequent  relapses,  these  were  at  length  hindered  by 
a bandage  with  four  rollers  attached  to  it,  which  were 
tightly  applied  above  and  below  the  patella. — (A.  Cooper, 
Surgical  Essays,  part  2,  p.  77.) 

Compound  dislocations  of  the  knee  generally  demand 
immediate  amputation. 

DISLOCATIONS  OF  THE  FIBULA. 

According  to  Sir  A.  Cooper,  luxations  of  the  upper 
head  of  the  fibula,  from  relaxation  of  the  ligaments, 
are  more  frequent  than  those  from  violence.  The  head 
of  the  bone  is  thrown  backwards.  The  bone  is  easily 
replaced,  but  immediately  slips  behind  the  tibia  again. 
When  the  case  is  attended  with  disease,  repeated  blis- 
ters are  recommended ; and  afterward  a strap  to  con- 
fine the  bone  in  its  natural  situation. — (Surg.  Essays, 
part  2,  p.  105.)  In  other  instances,  a roller,  a compress 
applied  over  the  head  of  the  fibula,  and  a splint  along 
this  bone,  would  be  proper. — (Boyer,  Mai.  Chir.  t.  4,  p. 
374.)  The  latter  author  has  seen  a displacement  of  the 
whole  fibula  upwards,  accompanying  a dislocation  of 
the  foot  outwards.  This  case  must  be  exceedingly  un- 
frequent, as  it  is  resisted  not  only  by  the  ligaments  of 
the  upper  joint  of  the  fibula,  but  also  by  those  very 
strong  ligamentous  bands  which  bind  the  malleolus 
externus  to  the  astragalus  and  os  calcis.  In  all  the 
cases  which  I have  seen,  the  pressure  of  the  astraga- 
lus, when  driven  outwards,  has  broken  the  fibula.  In 
the  instance  mentioned  by  Boyer,  the  double  luxation 
of  the  fibula  was  readily  reduced,  by  rectifying  the  po- 
sition of  the  foot,  and  bringing  the  astragalus  into  its 
proper  place  again  with  respect  to  the  tibia. 

DISLOCATION  OF  THE  FOOT. 

The  tibia  may  be  dislocated  from  the  astragalus  in- 
w^ards  or  outwards,  forwards  or  backwards;  and 
either  of  these  luxations  may  be  complete  or  incom- 
plete. The  dislocation  inwards  is  the  most  common ; 
the  foot  being  thrown  outwards,  and  its  inner  edge 
resting  upon  the  ground,  wliile  the  fibula  is  broken 
about  two  or  three  inches  above  the  ankle.  Upon  dis- 
section, as  Sir  A.  Cooper  observes,  the  end  of  the  tibia 
is  fbund  resting  upon  the  inner  side  of  the  astragalus, 
and,  if  the  accident  heis  been  produced  by  a jump  from 
a considerable  height,  the  lower  end  of  the  tibia,  where 
it  is  connected  to  the  fibula  by  ligament,  is  split  off, 
and  remains  attached  to  the  latter  bone.  The  broken 
end  of  the  fibula  itself  is  carried  down  upon  the  astra- 
galus, occupying  the  natural  situation  of  the  tibia.  The 
malleolus  externus  remains  in  its  natural  situation, 
with  two  inches  of  the  fibula,  and  the  piece  of  the  tibia 
which  is  split  off.  The  capsular  ligament  attached  to 
the  fibula,  and  the  three  strong  fibular  tarsal  ligaments 
are  uninjured.— (Surg-fcaf  Essays,  part  2,  p.  107.) 

One  thing  very  essential  to  be  understood  in  this 
ctLse  is,  that  the  fracture  of  the  fibula  is  here  the  tirst 
rmschieP,  without  which  the  dislocation  could  not  have 


happened.  The  fibula  may  easily  be  fractured  'W'iluacrf 
j any  luxation  of  the  foot,  but  the  above-described  dislo- 
cation can  never  take  place  unpreceded  by  a fracture  of 
the  fibula ; and  grave  and  serious  as  the  displacement 
of  the  joint  is,  it  is  always  a secondary  event. — (Du- 
puytren,  Annuaire,  M6d.  Chir.  1819,  p.  3.) 

It  was  to  this  particular  case,  joined  with  the  fracture 
of  the  fibula,  that  Mr.  Pott  drew  the  attention  of  sur- 
geons as  affording  a striking  example  or  the  benefit  de- 
rived from  relaxing  the  muscles ; the  instance,  in  which 
“ by  leaping  or  jumping,  the  Hbula  breaks  within  two 
or'  three  inches  of  the  lower  extremity.  When  this 
happens,  the  inferior  fractured  end  of  the'  fibula  falls 
inwards  towards  the  tibia,  that  extremity  of  the  bone 
which  forms  the  outer  ancle  is  turned  somewhat  out- 
wards and  upwards,  and  the  tibia  having  lost  its  pro- 
per support,  and  not  being  of  itself  capable  of  steadily 
preserving  its  true  perpendicular  bearing,  is  forced  off 
from  the  astragalus  inwards;  by  which  means,  the 
weak  bursal  or  common  ligament  ofthe  joint  is  violently 
stretched,  if  not  torn,  and  the  strong  ones  which  fasten 
the  tibia  to  the  astragalus  and  os  calcis,  are  always 
lacerated ; thus  producing,  at  the  same  time,  a perfect 
fracture  and  a partial  dislocation,  to  which  is  some- 
times added,  a wound  in  the  integuments,  made  by  the 
bone  at  the  inner  ankle.  By  this  means,  and  indeed 
as  a necessary  consequence,  all  the  tendons  which  pass 
behind  or  under,  or  are  attached  to  the  extremities  of 
the  tibia  and  fibula,  or  os  calcis,  have  their  natural  di- 
rection and  disposition  so  altered,  that  instead  of  per- 
forming their  appointed  actions,  they  all  contribute  to 
the  distortion  of  the  foot,  and  that  by  turning  it  out- 
wards and  upwards.” 

When  this  accident  is  accompanied,  as  it  sometimes 
is,  with  a wound  of  the  integuments  of  the  inner  ankle, 
and  that  made  by  the  protrusion  of  the  bone,  the 
danger  and  difficulties  of  the  case  are  seriously  in- 
creased. 

“ By  the  fracture  of  the  fibula,  the  dilatation  of  the 
bursal  ligament  of  the  joint,  and  the  rupture  of  those 
which  should  tie  the  end  of  the  tibia  firmly  to  the 
astragalus  and  os  calcis,  the  perpendicular  bearing  of 
the  tibia  on  the  astragalus  is  lost,  and  the  foot  becomes 
distorted ; by  this  distortion,  the  direction  and  action 
of  all  the  muscles  already  recited  are  so  altered,  that  it 
becomes  (in  the  usual  way  of  treating  this  case)  a 
'difficult  matter  to  reduce  the  joint ; and  the  support  of 
the  fibula  being  gone,  a more  difficult  one  to  keep  it 
in  its  place  after  reduction.  If  it  be  attempted  with 
compress  and  strict  bandage,  the  consequence  often  is 
a very  troublesome,  as  well  as  painful  ulceration  of 
the  inner  ankle^vhich  very  ulceration  becomes  itself 
a reason  why^B||j^ind  of  pressure  and  bandage  can 
be  no  longer  ce^^ped ; and  if  the  bone  be  not  kept  in 
its  place,  the  laHriess  and  deformity  are  such  as  to  be 
very  fatiguing  to  ihe  patient,  and  to  oblige  him  to  wear 
a shoe  with  an  iron,  or  a laced  buskin,  or  something 
of  that  sort,  for  a great  while,  or  perhaps  for  life. 

All  this  trouble,  pain,  difficulty,  and  inconvenience 
are  occasioned  by  putting  and  keeping  the  limb  in  such 
position  as  necessarily  puts  the  muscles  into  action,  or 
into  a state  of  resistance,  which  in  this  case  is  the 
same.  This  occasions  the  difficulty  in  reduction,  and 
the  difficulty  in  keeping  it  reduced  ; this  distorts  the 
foot,  and,  by  pulling  it  outwards  and  upwards,  makes 
that  deformity  which  always  accompanies  such  acci- 
dent ; but  if  the  position  of  the  limb  be  changed,  if  by 
laying  it  on  its  outside,  with  the  knee  moderately  bent, 
the  muscles  forming  the  calf  of  the  leg,  and  those 
which  pass  behind  the  fibula  and  under  the  os  calcis, 
are  all  put  into  a state  of  relaxation  and  non-re.sistance, 
all  this  difficulty  and  trouble  do  in  general  vanish  im- 
mediately ; the  foot  may  easily  be  placed  right,  the  joint 
reduced,  and  by  maintaining  the  same  disposition  of 
the  limb,  every  thing  will  in  general  succeed  very  hap- 
pily, as  I have  many  times  experienced.— (Pott.) 

I think  the  profession  are  much  indebted  to  Sir  A. 
Cooper,  for  his  application  of  terms  to  dislocations  of 
the  ankle,  which  are  liable  to  no  mistake  or  confusion. 
Thus,  when  he  speaks  of  a dislocation  of  the  tibia  in- 
wards or  outwards,  backwards  or  forwards,  the  case 
spoken  of  is  immediately  known.  On  the  contrary, 
when  authors  write  about  dislocations  of  the  ankle  or 
foot,  in  any  named  direction,  their  meaning  may  be 
various  and  misinterpreted.  We  find  this  exemplified 
in  Unpuvtrcn’s  valuable  memoir  on  fractures  ol  the 
lower  cnil  of  the  fibula ; for,  instead  of  ternung  the 


DISLOCATION. 


325 


above  case  a dislocation  of  the  foot  outwards,  as  the ' 
generality  of  writers  have  done,  he  thinks  it  should  be 
named  a dislocation  of  the  foot  inwards,  on  account  of 
the  direction  in  which  the  astragalus  is  carried.— (.4n- 
nuaire,  Med.  Chir.p.  3,  1819.) 

With  respect  to  the  treatment  of  the  preceding  case, 
Dupuytren  admits,  that  Pott’s  method  easily  effects  a 
reduction;  though  incapable  of  maintaining  it ; but,  as  I 
have  endeavoured  to  explain  in  the  last  edition  of  the 
First  Lines  of  Surgery,  the  practice  recently  proposed 
at  the  Hotel-Dieu,  it  would  .be  useless  repetition  to  en- 
ter into  the  subject  again.  Sir  A.  Cooper  appears  to 
prefer  the  rpode  of  treatment  on  Mr.  Pott’s  principles ; 
but  gives  one  very  essential  piece  of  advice,  which  is, 
that  the  splint  upon  which  the  outer  part  of  the  limb 
rests  may  have  a foot-piece,  “ to  give  support  to  the 
foot,  prevent  its  eversion,  and  preserve  it  at  right  angles 
with  the  leg.  If  much  inflammation  succeeds,  leeches 
are  to  be  applied  to  the  parts,  and  the  constitution  will 
require  relief  by  taking  blood  from  the  (^Surgical 

Essays,  part  2,  p.  108.) 

When  the  tibia  is  dislocated  outwards,  the  internal 
lateral  ligaments  are  always  ruptured,  or  pulled  away 
from  the  bones,  and  the  inner  malleolus  broken  pre- 
viously to  the  fracture  of  the  fibula.  On  a part  of  this 
statement,  however,  Dupuytren  and  Sir  A.  Cooper  dif- 
fer, as  the  latter,  mentions  that  the  deltoid  ligament 
remains  unbroken.  In  some  cases,  he  says,  the  frac- 
ture is  not  confined  to  the  malleolus,  but  passes  ob- 
liquely through  the  articular  surface  of  the  tibia,  which 
is  thrown  forwards  and  outwards  upon  the  astragalus, 
in  front  of  the  malleolus  externus.  Sometimes  the  as- 
tragalus is  fractured,  and  the  lower  extremity  of  the 
fibula  broken  into  several  splinters.  He  states  also, 
that  when  the  fibula  is  not  broken,  the  external  lateral 
ligaments  are  ruptured.  The  foot  is  thrown  inwards, 
its  outer  edge  resting  upon  the  ground ; while  a consi- 
derable projection  is  made  by  the  malleolus  externus 
under  the  skin.  The  accident  is  generally  caused  by 
the  passage  of  a wheel  of  a carriage  over  the  leg,  or  a 
violent  twist  of  the  foot  inwards  in  jumping  or  falling. 
— (./3.  Cooper,  vol.  cit.p.  113.) 

The  reduction  is  accomplished  by  relaxing  the  mus- 
cles of  the  calf,  making  extension  in  the  axis  of  the 
leg,  and  pressing  the  lower  head  of  the  tibia  inwards 
towards  the  astragalus.  “ The  limb  is  to  be  laid  upon 
its  outer  side,  resting  upon  a splint  with  a foot-piece, 
and  a pad  is  to  be  placed  upon  the  fibula  just  above  the 
outer  angle,  and  extending  a few  inches  upwards,  so 
as  in  some  measure  to  raise  that  portion  of  the  leg,  and 
prevent  the  tibia  and  fibula  slipping  from  the  astraga- 
lus, as  well  as  lessen  the  pressure  of  the  malleolus  ex- 
ternus upon  the  integuments.” — (Surg.  Essays,  part  2, 
p.  113.)  Sir  A.  Cooper  also  enjoins  paying  the  strict- 
est attention  to  hindering  the  foot  from  being  twisted 
inwards  or  pointed  downw'ards. 

Dupuytren’s  manner  of  treating  this  case  is  described 
in  the  last  edition  of  the  First  L-nes  of  Surgery. 

A complete  dislocation  of  the  lower  head  of  the  tibia 
forw'ards  cannot  happen  without  the  fibula  being  first 
broken,  and  either  the  base  of  the  malleolus  internus 
fractured,  or  its  point  torn  away.  The  foot  being  then 
acted  upon  by  the  extensor  and  flexor  muscles,  and  un- 
retained by  the  malleoli  and  their  ligaments,  yields  to 
the  powerful  operation  of  the  muscles  of  the  calf,  the 
astragalus  passing  behind  the  tibia,  while  this  projects 
forwards  under  the  tendons  and  skin  of  the  instep. — 
{Dupuytren,  Jlnnuaire  Med.  Chir.  p.  187,  4to.  Paris, 
1819.)  The  foot  of  course  is  much  shortened,  the  heel 
lengthened,  and  firmly  fixed,  and  the  toes  point  down- 
wards. Upon  dissection,  the  tibia  is  found  to  rest 
upon  the  upper  surface  of  the  os  naviculare,  and  os 
cuneifbrme  internum.  The  anterior  part  of  the  ca 
sular  ligament  is  torn  through;  the  deltoid  liga- 
ment is  only  partially  lacerated ; and  the  three  liga- 
ments of  the  fibula  remain  unbroken. — («4.  Cooper,  vol. 
eif.  p.  109.) 

This  case  is  much  more  difficult  of  reduction  than 
the  instance  in  which  the  foot  is  thrown  inwards;  and 
the  cause  is  owing  to  the  powerful  mannef  in  which 
the  muscles  resist  the  extension  of  the  parts,  and  plac- 
ing them  in  their  natural  position  again.  As  Dupuy- 
tren observes,  it  is  true  that  such  resistance  may  be 
lessened  by  relaxing  the  muscles,  and  drawing  the  pa- 
tient’s attention  from  his  limb  ; plans,  which  fully  an-  - 
swer  for  the  reduction  of,  the  other  above-mentioned  i 
ca.';e;  yet,  in  that  now  under  consideration,  they  are  in-  i 


! sufficient,  and  here  a greater  effort  is  required  to  bring 
the  foot  from  behind  forxvards,  and  to  place  the  astraga- 
’ lus  under  the  tibia.  And  a still  greater  difficulty  is  to 
keep  the  parts  reduced  during  the  time  necessary  for 
the  fibula  and  torn  ligaments  to  be  firmly  united.  In 
fact,  the  upper  surface  of  the  astragalus,  which  is  con- 
vex from  behind  forwards,  is  so  slippery  that  it  is  hard 
to  make  the  tibia  rest  securely  on  the  articular  pulley 
of  that  bone,  which  is  itself  incessantly  acted  upon  by 
the  extensor  muscles  of  the  leg,  so  as  to  have  a ten- 
dency to  slip  behind  the  lower  head  of  the  tibia.  In 
addition,  therefore,  to  the  bent  posture,  Dupuytren 
deems  it  necessary  here  to  employ  an  apparatus,  which 
propels  the  foot  forwards,  and  the  lower  head  of  the 
tibia  backwards.— (.-3nnitaire  M d.  Chir.  p.  188.) 
As  this  apparatus  has  been  described  in  the  last  edi- 
tion of  the  First  Lines  of  Surgery,  I need  not  explain  it 
again. 

Sir  A.  Cooper  prefers  keeping  the  limb  upon  the  heel, 
resting  upon  a pillow.  A splint,  with  a suitable  pad 
and  a foot-piece,  is  to  be  applied  to  each  side  of  the 
leg,  care  being  taken  to  keep  the  foot  well  supported  at 
a right  angle  with  the  \eg.— {Surgical  Essays,  part  2, 
p.  HO.) 

Besides  the  complete  dislocation  of  the  tibia  forwards, 
a partial  case  is  sometimes  met  with,  where  one 
half  of  the  artipular  surface  of  the  bone  rests  upon  the 
os  naviculare,  and  the  other  on  the  astragalus.  Ac- 
cording to  Sir  A.  Cooper,  the  fibula  is  broken ; the  foot 
appears  but  little  shortened ; nor  is  there  any  consider- 
able projection  of  the  heel.  The  foot  points  down- 
wards, it  cannot  be  put  flat  on  the  ground,  and  is 
nearly  stiff,  and  the  heel  continues  draxvn  up.  The  ac- 
cident, if  not  detected  and  rectified  in  its  early  stage, 
afterward  admits  of  no  relief,  the  change  in  the  state 
of  the  muscles,  and  the  position  in  which  the  fibula 
has  united,  not  suffering  any  reduction,  even  though 
great  force  be  emplo3^ed. 

Dislocations  of  the  tibia,  forwards  or  backwards,  are 
not  common  ; during  fifteen  years,  Dupuytren  has 
scarcely  met  with  two  or  three  cases ; though  he  has 
seen  .some  hundreds  of  lateral  dislocation.  It  must  be 
obvious  to  every  body,  says  he,  that  when  the  foot  is 
violently  bent,  or  extended,  many  poxverful  muscles  re- 
sist the  movement  in  question,  and  prevent  the  mis- 
chief with  which  the  articulation  is  threatened. — {Jin- 
nuaire  MM.  Chir.  des  H pitaux  de  Paris,  p.  34.)  A 
luxation  of  the  tibia  from  the  astragalus  backwards, 
Sir  A.  Cooper  has  never  had  an  opportunity  of  observ- 
ing ; a proof  of  the  rarity  of  the  accident. 

A luxation  of  the  astragalus,  either  simple  or  com- 
plicated with  a laceration  of  the  integuments,  as  Mr. 
Hey  has  remarked,  is  an  accident  which  does  not  often 
occur.  Above,  the  astragalus  is  articulated  with  the 
tibia  and  fibula;  below,  it  is  united,  by  means  of  a cap- 
sular ligament,  to  the  os  calcis  ; while  in  front,  it  is  con- 
nected to  the  os  naviculare  by  a capsular  and  broad  in- 
ternal lateral  ligament.  Thus  situated,  it  is  evident 
that  its  displacement  is  not  likely  to  happen  with  great 
frequency;  and  yet  this  observation  must  be  received 
only  as -a  conijiarative  one;  for  the  cases  of  disloca- 
tion of  the  astragalus,  now  upon  record,  are  rather  nu- 
merous. 

When  a dislocation  of  the  lower  head  of  the  tibia  is 
combined  with  one  of  the  astragalus  from  the  os  calcis 
and  os  naviculare,  and  the  ligaments  which  kept  these 
bones  together  are  nearly  destroyed,  while  a consider- 
able portion  of  the  astragalus  itself  protrudes  through 
the  wound  in  the  integuments,  if  it  be  judged  prudent 
to  attempt  the  preservation  of  the  limb,  it  is  best  per- 
haps to  imitate  Desault,  Ferrand,  Trye,  and  Evans,  and 
extract  the  astragalus  altogether. 

A luxation  of  the  astragalus,  unattended  with  a 
wound  in  the  skin,  is  a serious  and  embarrassing  acci- 
dent ; for,  in  general,  the  reduction  is  so  difficult,  that 
it  is  not  many  years  since  the  case  was  deemed  a 
ground  for  antputation. — (8ee  Gooch's  C hir.  Cases, 
tV  c.)  When  the  displacement  in  que.stion  b.ippens,  the 
astragalus  is  generally  thrown  fbrwards  upon  the  os 
naviculare,  forming  a tumour  on  the  instep  and  inclin- 
ing a little  either  to  the  outer  or  inner  side  of  the  foot. 
In  many  cases  of  this  description,  the  reduction  is  found 
to  be  impracticable.  Here,  as  Boyer  observes,  the  im- 
pediment does  not  depend  upon  the  head  of  the  bone 
-being  constricted  in  the  narrow  opening  of  the  cap- 
sule ; but  rather  uiion  the  impossibility  of  making  the 
extending  force  and  the  pressure  of  the  surgeon’s 


326 


DIS 


hands  operate  with  much  effect  upon  the  displaced 
bone.  However,  an  example  is  recorded  by  Desault, 
where  the  reduction  was  accomplished  by  dividing  the 
skin,  and  then  extending  the  incision  through  a part  of 
the  ligaments.  In  the  Joum.  de  Cfiir.  another  case  is 
also  related  of  a simple  dislocation  of  the  astragalus 
from  the  os  calcis  and  os  naviculare,  where  the  reduc- 
tion was  easily  performed  by  common  means.  Boyer 
conceives  it  probable,  that  in  these  cases,  most  of  the 
ligaments  uniting  the  a.stragalus  to  the  os  calcis  and 
os  naviculare  were  ruptured,  and  that  the  first  of  those 
bones  was  therefore  sufficiently  moveable  to  admit  of 
being  replaced  by  the  pressure  of  the  fingers.  But  the 
luxated  astragalus  may  be  so  wedged  between  the  tibia, 
os  calcis,  and  os  naviculare,  that  its  reduction  is  impos- 
sible, as  Boyer  has  actually  seen.  In  the  case  here  re- 
ferred to,  things  were  left  to  take  their  course,  except 
that  every  possible  means  was  employed  to  keep  off 
inflammation.  The  result  was,  that  the  skin  covering 
the  projection  of  the  astragalus  at  the  inner  and  upper 
part  of  the  foot  sloughed,  and  amputation  vvas  at  length 
deemed  necessary. — (Mai.  Chir.  t.  4,  j).  400.)  A simi- 
lar example  is  recorded  by  Sir  Astley  Cooper. — (On 
Dislocations,  p.  360.)  In  another  case,  recorded  by.Mrl 
Hey,  pressure  was  made  with  a tight  bandage  on  the 
prominence  of  the  astragalus,  and  the  soft  parts  over  it 
became  gangrenous ; yet  a recovery  followed  without 
amputation,  all  the  projecting  portion  of  the  astragalus 
having  gradually  come  away  in  fragments.— (He t/’s 
Pract.  Obs.p.  3&4,.cd.  2.)  In  an  instance  recently  pub- 
lished by  Dupuytren,  a person  dislocated  the  astraga- 
lus by  alighting  with  great  violence,  upon  the  heel,  the 
bone  being  driven  forwards  by  the  pressure,  which  it 
had  sustained  between  the  tibia  and  os  calcis,  so  as  to 
form  a protuberance  under, the  skin  of  the  instep.  As 
the  reduction  was  found  impracticable,  a cut  was  made 
down  to  the  displaced  bone  with  the  intention  of  ex- 
tracting; but  Dupuytren  found  that  he  could  not  re- 
move it  so  readily  as  he  expected ; nor  could  he  replace 
it ; and  it  was  not  till  after  a tedious  operation  that  he 
succeeded  in  taking  it  away.  The  difficulty  arose  from 
the  upper  surface  of  the  bone  being  turned  downwards, 
while  the  back  projection  of  what  was  naturally  the 
lower  part  of  it  took  hold  of  the  tibia  in  the  manner  of 
a hook.— (j^nnuaire  Med.  Chir.  desHopitaux  de  Paris, 
1819,  p.  28.) 

In  another  modern  valuable  publication,  two  cases  of 
dislocation  of  the  astragalus  are  related.  One  was  a 
simple  luxation  of  the  astragalus  inwards,  the  os  cal- 
cis and  rest  of  the  foot  being  thrown  outwards.  The 
reduction  was  easily  performed  by  fixing  the  knee,  then 
extending  the  foot  gently  and  directly  from  the  leg,  by 
laying  hold  of  the  heel  with  one  hand  and  placing  the  other 
on  the  dorsum  of  the  foot ; and  lastly,  by  pressing  the 
foot  inwards,  while  counter-pressure  was  made  with 
the  knee  upon  the  opposite  side  of  the  lower  extremity 
of  the  tibia.  The  other  instance  alluded  to,  w as  a com- 
pound luxation,  in  which  the  astragalus  was  displaced 
outwards,  and  the  other  tarsal  bones  throwm  inwards. 
Reduction  was  accomplished,  first  by  bending  the  leg 
so  as  to  relax  the  muscles,  and  then  by  extending  the 
foot,  as  above  explained,  and  rotating  it  outwards. — (A. 
Cooper,  Surgical  Essays,  par  t 2,  p.  297.) 

By  heavy  weights  falling  upon  the  foot,  a dislocation 
is  sometimes  produced  at  the  transverse  joint  between 
the  astragalus  and  os  calcis  behind,  and  the  os  navicu- 
lare and  os  cuboides  in  front. 

Sir  A.  Cooper  has  twice  seen  the  os  cuneiforrae  in- 
ternum dislocated,  and  in  both  cases,  the  head  of  the 
bone  naturally  connected  to  the  os  naviculare  projected 
inwards  and  somewhat  upw'ards.  being  drawn  in  this 
direction  by  the  action  of  the  tibialis  anticus  muscle. 
In  neither  instance  was  the  reduction  accomplished ; 
and,  in  one,  the  patient  had  so  trivial  a lameness  that 
the  functions  of  the  foot  were  expected  to  be  in 
time  perfect  again. — (Surgical  Essays,  part  2,  p.  209.) 
With  regard  to  the  treatment.  Sir  A.  Cooper  recom- 
mends, first,  confining  the  bone  in  its  place  with  a 
roller,  kept  wet  with  spirits  of  wine  and  water,  and 
when  the  inflammation  is  subdued,  he  directs  a lea- 
ther strap  to  be  buckled  round  the  foot,  so  as  to  main- 
tain the  bone  in  its  right  situation.— (On-  Dislocations, 
p.  384.) 

The  phalanges  of  the  toes  are  sometimes  dislocated, 
and  the  first  bone  of  the  great  toe  is  frequently  luxated 
from  the  first  metatarsal  bone;  but  I am  not  aware 
that  those  cases  are  attended  wth  any  particular  dif- 


DUR 

Acuity  in  the  reduction,  like  some  dislocations  of  th« 
thumb. 

On  the  subject  of  Dislocations,  consult  jS.  Flatch,  de 
Luxatione  Ossis  Femoris  rariore,  fi^equentiore  Colli 
fractura,  Disp.  Argent.  1723.  H.  Linguet,  QiuBstio, 
Ac.  An  in  Humeri  Inixationi  Ambi  potius  quam 
Scala,  Janua,  Polyspastusque  iterato  renovata?  Pa- 
ris, 1732.  G.  C.  Reickel,  Ihss.  de  Epiphysium  ab  Os- 
sium  Diaphysi  Diductione,  Lips  1759.  J.  L.  Petit, 
Traite  des  Maladies  des  Os,  1725 ; et  Traite  des  Mai. 
Chir.  1783.  Duvemey,  IVaiti  des  Maladies  des  Os. 
Richerand,  Nosographie  Chir.  t.  3,  p.  193,  Ac.  idit.  4. 
(Euvres  Chir.  de  Desault,  par  Bichat,  1. 1.  Potfs  Re- 
marks on  Fractures  and  Dislocations,  1775.  Kirk- 
IcmtTs  Observations  upon  Mr.  Pott's  General  Remarks 
on  Fractures,  Ac.  }^ite's  Cases  in  Surgery.  Medi- 
cal Observations  and  Inquiries,  vol.  2.  Bromjield's 
Chirurgical  Cases  and  Observations,  1773.  J.  F.  P. 
Castella,  Sur  les  Fractures  du  Peroni,  Landshut,  1808. 
C.  Bell,  A System  of  Operative  Surgery,  1809.  J.  How- 
ship,  Pract.  Obs.  in  Surgery  and  Morbid  Anatomy,  8vo. 
Bond.  1816.  Callisen,  Systema  Chirurgia  Hodiemoe,  t. 
2.  Desault,  Journ.  deChirurgie.  Boyer,  Traite  des  Alal- 
Chir.  t.  4,  Paris,  1814.  Trye's  Illustrations  of  some  of 
the  Injuries  to  which  the  lower  Limbs  are  exposed,  Ac. 
W.  Hey,  on  Dislocations  and  internal  Derangement  of 
the  Knee-joint,  in  Practical  Obs.  in  Surgery,  ed.  2. 
Dupuytren,  sur  la  Fracture  de  VExtremite  infirieure 
du  P^on^,  les  Luxasions,  et  les  Accidens,  qui  en  sont 
la  Suite,  in  Annuaire  Medico-Chir.  des  Hdpitaux  de 
Paris,  4to.  Paris,  1809.  The  observations  in  this  Me- 
moir are  highly  interesting,  and  afford  new  and  in- 
structive views  of  the  subject.  G.  F.  D.  Evans, 
Practical  Obs.  on  Cataract,  Closed  Pupil,  Amp.  at  the 
Shoulder,  Ac.,  and  Compound  Dislocations,  8vo.  Wel- 
lington, 1815.  Astragalus  removed ; shattered  end  of 
the  fibula  sawed  off;  protruded  lower  end  of  the  hume- 
rus similarly  removed;  a compound  dislocation  of  the 
shoulder-joint,  and  head  of  the  metacarpal  bone  of 
the  thumb  dislocated  in  two  instances  towards  the 
palm,  and  on  account  of  the  difficulty  of  reduction, 
exposed  by  an  incision  and  sawed  off.  Surgical  Es- 
says ; also,  a Treatise  on  Dislocations  and  Fractures 
of  the  joints,  by  Sir  A.  Cooper,  Bart. : a work 
ivhich  abounds  in  practical  information,  and  does  in- 
finite credit  to  the  talents  and  industry  of  its  experi- 
enced author. 

DISTICHIA,  or  distichiasis.  (From  Fi;,  twice,  and 
errixos,  a row.)  Gorrhaeus,  Heister,  and  St.  Ives  ap- 
ply this  term  to  an  affection  in  w'hich  each  tarsus  has  a 
double  row  of  eyelashes,  w'hich,  inclining  inwards,  irri- 
tate the  eye,  and  keep  up  ophthalmy.  Such  authors 
speak  of  this  as  a very  frequent  complaint ; but  the  au- 
thor of  the  present  article,  in  the  Encyclop^die  Method- 
ique,  partie  Chirurgicale,  remarks,  that  he  has  never 
met  with  U at  all,  though  in  ulceration  of  the  ej  elids  he 
has  often  seen  a certain  number  of  the  eyelashes  in- 
-line inwards,  and  cause  a good  deal  of  disturbance  to 
the  eye,  already  in  a state  of  inflammation.  This  dis- 
order cannot  properly  be  called  distichiasis.  However 
it  may  be,  all  writers  recommend  plucking  our  such 
eyelashes  as  assume  an  unnatural  direction.  Some  of 
the  hairs  are  first  to  be  taken  out  one  after  the  other, 
and  a few  days  are  allowed  to  elapse  before  the  opera- 
tion is  repeated.  In  order  that  the  eyelashes  may  be 
more  completely  extirpated,  and  that  others  may  not 
grow  in  the  same  situation,  the  places  from  which  they 
grow  are  usually  touched  with  the  argentum  nitratum. 
— (See  Trichiasis.) 

DURA  MATER,  FUNGOUS  TUMOURS  OF.  The 
dura  mater,  the  outer  membrane  of  the  brain,  was  so 
named  by  the  ancients  on  account  of  its  hardness,  and 
its  being  formerly  supposed  to  be  the  source  of  all  the 
other  membranes  of  the  body. 

Fungous  tumours  of  the  dura  mater,  the  true  nature 
of  which  was  ascertained  late  in  the  last  century,  did 
not  escape  the  notice  of  the  ancient  writers ; but  the 
disease  is  ver>'  imperfectly  described  by  them,  and  un- 
der an  erroneous  denomination.  They  supposed  that 
the  swelling  was  of  the  encysted  kind,  or  what  they 
termed  matia,  talpa,  testudo,  and  that  it  gradually  al- 
tered and  destroyed  the  cranium.  They  sometimes 
mistook  the  fungous  or  sarcomatous  tumour  of  the 
dura  mater  for  coagulated  blood,  or  for  ill-conditioned 
excrescences,  like  those  ,which  make  their  appearance 
on  ulcers  attended  with  caries.  Such  are  the  ideas 
which  seem  to  be  conveyeif  by  some  imperfectly  dp 


DURA  MATER. 


327 


tailed  cases  in  the  writings  of  Lanfranc,  Guido  di  Cau- 
liaco,  Theodoricus,  and  other  authors  of  the  thirteenth 
and  fourteenth  centuries.  Amatus  Lusitanus  has  given 
the  appellation  of  lupus  with  caries  to  a fungous  tu- 
mour of  the  dura  mater.  The  swelling  occurred  in  a 
child  eight  years  old,  who  died  in  convulsions,  two 
days  after  an  opening  had  been  made  in  it. — {Centur, 
5,  obs.  8.)  Another  similar  case  which  happened  in  a 
child,  and  was  noticed  by  Camerarius  at  Paris,  is 
styled  a singular  bony  excrescence. — (Ephemer.  curios, 
natur.  decad.  2,  ann.  6,  1687,  obs.  99.)  Lastly,  Cattier, 
a physician  of  Montpellier,  has  recorded  the  history  of 
a lady  who  died  from  the  consequences  of  a fungous 
" tumour  of  the  dura  mhter.  The  disease  was  so  acutely 
painful,  as  to  compel  the  patient  to  cry  out.  The  swell- 
ing was  opened  with  caustic.  Pimprenelle,  a Parisian 
surgeon,  recommended  the  trepan  to  oe  employed;  but 
his  advice  was  overruled.  After  death  a fungus  of  the 
dura  mater,  with  a perforation  in  the  skull,  was  de- 
tected, and  it  is  described  by  the  author  as  a hard, 
stony  substance,  accompanied  with  points  and  aspe- 
rities.— {Obs.  Mid.  obs.  15,  p.  48.  See.  Lassus,  Patho- 
logic Chirurgicale,  tom.  1,  p.  498,  id.  1809.) 

The  old  surgeons,  ignorant  of  the  real  character  of 
ftingous  tumours  of  the  dura  mater,  used  often  to  com- 
mit the  most  serious  and  fatal  mistakes  in  the  treat- 
ment. These  diseases  are  of  a chronic  nature,  and 
make  their  appearance  gradually,  in  the  form  of  a tu- 
mour, which  makes  its  way  through  the  bones  of  the 
cranium,  rises  up,  and  insensibly  blends  itself  with  the 
integuments,  which  seem,  as  it  were,  to  make  a part  of 
it.  Such  fungous  tumours  of  the  dura  mater  may  ori- 
ginate spontaneously  at  any  part  of  this  membrane ; 
but  they  are  particularly  apt  to  grow  on  the  surface, 
which  is  adherent  to  the  upper  part  of  the  skull,  or  to 
its  basis.  They  are  firm,  indolent,  and  chronic,  seem- 
ing as  if  they  were  the  consequence  of  slow  inflamma- 
tion, affecting  the  vessels  which  supply  the  dura  mater, 
and  inosculate  with  those  of  the  diploe.  It  is  very  dif- 
ficult, one  might  say  impossible,  to  determine  whether, 
in  an  affection  of  this  kind,  the  disease  begins  in  the 
dura  mater  or  the  substance  of  the  bone  itself.  The 
general  belief,  however,  is,  that  the  bone  is  affected  se- 
condarily, and  that  the  disorder  originates  in  the  dura 
mater.  The  patient,  who  is  the  subject  of  the  first 
case,  related  in  a memoir  by  M.  Louis,  had  received  no 
blow  upon  the  head,  and  could  only  impute  his  com- 
plaint to  a fall  which  he  had  met  with  four  or  five 
months  previously,  and  in  which  the  head  itself  had 
not  received  any  violence ; but  from  this  time  he  expe- 
rienced a stunning  sensation,  which  continued  till  he 
died.  The  cranium  and  dura  mater  were  found  both 
equally  diseased.  Though  this  case  may  tend  to  prove 
that  fungous  tumours  of  the  dura  mater  may  form 
spontaneously,  yet  it  is  not  the  less  confirmed  by  the 
examination  of  a vast  number  of  cases,  that  this  af- 
fection more  frequently  follows  blows  on  the  head, 
than  any  other  cause.  Hence  a slow  kind  of  thicken- 
ing of  the  dura  mater  is  produced,  which  ends  in  a sar- 
comatous excrescence,  the  formation  of  which  always 
precedes  the  destruction  of  the  bone.  In  the  memoir 
published  by  M.  Louis  in  the  fifth  volume,  4to.  of  those 
of  the  Royal  Academy  of  Surgery,  there  is  a very  in- 
teresting case,  illustrating  the  nature  of  the  present 
disease. 

The  subject  was  a young  man,  aged  twenty-one, 
Who  had  a considerable  tumour  on  the  left  side  of  the 
head,  which  was  taken  for  a hernia  cerebri.— (See  this 
article.)  The  swelling  had  begun  in  the  region  of  the 
temple,  and  had  gradually  acquired  the  magnitude  of 
a second  head.  The  external  ear  was  displaced  by  it, 
and  pushed  down  as  low  as  the  angle  of  the  lower 
jaw.  At  the  upper  part  of  the  circumference  of  the 
base  of  the  tumour  the  inequalities  of  the  perforated 
bone  and  the  pulsations  of  the  brain  could  be  distinctly 
felt.  Some  parts  of  the  mass  were  elastic  and  hard, 
others  were  soft  and  fluctuating.  A plaster  which  had 
been  applied  brought  on  a suppuration  at  some  points, 
from  which  an  ichorous  matter  was  discharged.  Shi- 
verings  and  febrile  symptoms  ensued,  and  the  man  died 
in  less  than  four  nlonths,  in  the  year  1764.  On  dissection 
a sarcomatous  tumour  of  the  dura  mater  was  detected, 
together  with  a destruction  of  the  whole  iiortion  of  the 
skull  corresponding  to  the  extent  of  the  disease. 

When  a tumour  of  this  nature  has  decidedly  formed, 
it  makes  its  way  outwards  through  all  the  parts  soft  or 
hard  which  are  opposed  to  it.  The  swelling,  in  be- 


coming circumscribed,  is  partly  blended  'mth  the  dura 
mater,  and  its  pressure  produces  an  absorption  of  such 
parts  of  the  skull  as  oppose  its  enlargement.  It  unex- 
pectedly elevates  itself  externally,  confounding  itself 
with  the  scalp,  and,  presents  itself  outwardly  in  the 
form  of  a preternatural,  soft,  yielding  swelling,  which 
even  sometimes  betrays  an  appearance  of  a decided 
fluctuation  or  a pulsation  which  may  make  it  be  mis- 
taken for  an  aneurismal  tumour.  When  once  the 
swelling  has  made  its  exit  from  the  cavity  of  the  cra- 
nium, it  expands  on  every  side  under  the  integuments, 
which  readily  make  way  for  its  growth.  The  scalp 
becomes  distended,  smooth,  and  cedematous  over  the 
extent  of  the  tumour,  and  lastly  it  ulcerates.  The 
matter  discharged  from  the  ulcerations  is  thin  and  sa- 
nious ; the  outer  part  of  the  tumour  is  confounded  with 
the  integuments  and  edges  of  the  skull  on  which  it 
rests,  so  that  in  this  state  it  is  easy  to  mistake  the  tu- 
mour for  one  whose  base  is  altogether  external.  While 
the  swelling  thus  increases  in  size  externally,  it  also 
enlarges  internally.  The  latter  change  takes  place  in 
particular,  while  the  oi»ening  in  the  cranium  is  not 
large  enough  to  admit  the  whole  mass  of  the  tumour, 
which  then  depresses  the  brain,  and  lodges  in  an  ex- 
cavation which  it  forms  for  itself.  But  this  cavity 
quickly  diminishes,  and  becomes  reduced  almost  to  no- 
thing, as  soon  as  the  tumour  projects  outwardly.  The 
tables  of  the  skull  are  absorbed  to  let  the  swelling  ar- 
rive externally ; but  it  is  remarked,  that  the  internal  or 
vitreous  table  is  alw'ays  found  much  more  extensively 
destroyed  than  the  external  one.  Sometimes  new  bony 
matter  is  found  deposited  around  the  opening  in  the 
cranium. 

It  is  asserted,  that  whatever  may  be  the  situation  of 
a fungous  tumour  of  the  dura  mater,  the  outer  layer  of 
this  membrane,  upon  which  the  disease  forms,  is  alone 
altered,  the  inner  layer  and  the  pia  mater  being  always 
unchanged.-  (Lassus,  Pathologic  Chirurgicale,  tom.  1, 
p.  501,  id.  1809.) 

In  one  of  these  cases,  detailed  by  Walther,  the  inner 
layer  of  the  dura  mater  was  quite  natural,  though  one- 
half  of  the  tumour,  which  was  very  large,  was  within 
the  skull,  where  it  had  formed  for  itself  a deep  excava- 
tion in  the  posterior  lobe  of  the  brain.  And,  what  is 
remarkable,  notwithstanding  this  latter  change,  the 
patient,  the  day  before  her  death,  retained  all  her  in- 
tellectual faculties,  and  the  power  of  voluntary  motion. 
— (Joum.  fur  Chirurgie  von  C.  Graefe  und  Ph.  v. 
Walther,  b.  \,p.  64,  65,  Svo.  Berlin,  1820.) 

According  to  surgical  writers,  fungous  tumours  of 
the  dura  mater  have  been  caused  by  contusions  on  the 
skull,  falls  on  the  buttocks,  concussions  of  the  head  or 
whole  body,  lues  venerea,  scrofula,  inveterate  rheuma- 
tism, &c.  The  three  last  of  the  alleged  causes,  how’^- 
ever,  seem  to  be  little  better  than  mere  conjecture ; and 
the  same  may  be  said  of  Walther’s  idea,  that  the  dis- 
ease is  of  a similar  nature  to  white  swelling  of  the 
joints  (Grae/e’s  Journ.  b.  1,  p.  104),  beginning  rather 
in  the  bone  than  in  the  dura  mater. 

Even  children  of  the  most  tender  years  are  liable  to 
the  disease.  M.  Louis  has  related,  that  a child,  two 
years  of  age,  died  of  a fungus  of  the  dura  mater,  which 
had  produced  a swelling  above  the  right  ear,  attended 
with  a destruction  of  a portion  of  the  parietal  and  tem- 
poral bones. — (Mem.  de  VAcad.  de  Chirurgie,  tom.  5, 
4^0.  p.  31.) 

Though  the  common  opinion  is,  that  these  fungi 
grow  entirely  from  the  dura  mater,  Sandifort  asserts 
that  the  vessels  of  the  diploe  have  a considerable  share 
in  their  production.— Musei  Anat.  Acad. 
Lugd.  t.  l,p.  152.) 

A similar  belief  was  entertained  by  Heister  and 
Kaufmann,  and  is  espoused  by  Siebold  and  Walther, 
the  latter  imputing  the  disease  to  a simultaneous  affec- 
tion of  the  vessels  of  the  dura  mater  and  pericranium, 
attended  with  an  absorption  of  the  earthy  part  of  the 
bone. — (Journ.  fur  Chir.  xion  C.  Graefe,  &,-c.  p.  91 — 93.) 

The  existence  of  a fungous  tumour  of  the  dura  mater 
cannot  be  ascertained,  as  long  as  there  is  no  external 
change.  The  effects  produced  may  originate  from  so 
many  causes,  that  there  would  be  great  risk  of  a gross 
mistake  in  referring  them  to  any  particular  ones.  This 
is  not  the  case  when  there  is  an  opening  in  the  skull. 
Then  a hardness  felt  from  the  very  first  at  the  circum- 
ference of  the  tumour,  denotes  that  it  comes  from 
within.  When  the  swelling  is  carefully  handled,  such 
a crackling  sensation  is  perceived,  as  would  arise  from 


328 


DURA  MATER. 


touching  dry  parchment  stretched  over  the  skin.  On 
making  much  pressure  pain  is  occasioned,  and  some- 
times a numbness  in  all  the  limbs,  stupefaction,  and 
other  more  or  less  afflicting  symptoms.  The  tumour 
in  some  measure  returns  inwards,  especially  when  not 
very  large,  and  gradually  rises  up  and  outwards  again, 
when  the  pressure  is  discontinued.  Sometimes  there 
is  pain ; at  other  times  there  is  none ; which  may  be. 
owing  to  the  manner  in  which  the  tumour  is  affected 
by  the  edges  of  the  bone  through  which  it  passes.  The 
pain  is  often  made  to  go  off  by  compression,  but  returns 
as  soon  as  this  is  taken  off.  The  tumour  has  an  alternate 
motion,  derived  from  the  pulsation  of  the  brain,  or  of 
the  large  arteries  at  its  base.  This  throbbing  motion 
has  led  many  practitioners  to  mistake  the  disease  for 
an  aneurism,  as  happened  in  the  second  case  related  in 
the  memoir  of  M.  Louis.  When  the  tumour  is  pushed 
sideways,  and  the  finger  carried  between  it  and  the 
edge  of  the  bone,  through  which  the  disease  protrudes, 
the  bony  edge  may  be  felt  touching  the  base  of  the 
swelling,  and  more  or  less  constricting  it.  This  symp- 
tom, when  distinguishable,  added  to  a certain  hardness 
and  elasticity,  and  sometimes  a facility  of  reduction, 
forms  a pathognomonio  mark,  whereby  fungous  tu- 
mours of  the  dura  mater  may  be  discriminated  IVom 
herniae  of  the  brain,  external  fleshy  tumours,  abscesses, 
exostosis,  and  other  affections  wlUch  at  first  resemble 
them. 

Probably,  however,  some  variety  in  the  symptoms 
prevails  in  different  instances  ; fbr  in  the  cases  recorded 
by  Walther  there  was  no  pulsation,  strictly  so  called, 
but  merely  an  obscure  movement,  or  an  alternate  dis- 
tention and  flaccidity,  arising  from  the  influx  of  blood 
into  the  vessels  of  the  diseased  mass  ; the  tumours 
could  not  be  pushed  within  the  cranium,  in  the  slight 
est  degree  ; nor  did  the  attempt  cause  any  of  the  effects 
usually  observed  to  proceed  from  pressure  on  the  brain. 
No  aperture  could  be  felt  in  the  skull,  much  less  could 
the  irregular  edges  of  the  bone  around  the  tumour  be 
distinguished.— (Jour/i. /ttr  Chir.  b.  1,  p.  57—61,  4-c. 
6vo.  Berlin,  1820.) 

Whatever'  movements  also  were  perceptible  in  the 
swellings,  Walther  is  convinced  could  not  be  commu- 
nicated to  them  by  the  pulsations  of  the  subjacent 
brain ; because  they  were  wedged,  as  it  were,  in  an 
aperture  in  the  skull,  and  adherent  to  the  dura  mater 
beneath  them,  and  to  the  superincumbent  periosteum, 
so  that  even  in  the  dead  subject  they  did  not  admit  of 
being  pushed  in  the  least  more  outwards  without  diffi- 
culty, and  the  employment  of  strong  pressure. — {Vol. 
cit.  p.  57.) 

Indeed,  this  tight  constriction  of  the  tumour  not  only 
explains  why  stupor,  paralysis,  <fec.  were  not  brought 
on  in  these  particular  examples  by  external  pressure, 
but  also  why  the  edges  of  the  hole  in  the  skull  could 
not  be  felt ; and  the  small  size  of  the  same  opening,  in  re- 
lation to  the  magnitude  of  the  swelling,  fully  accounts, 
in  my  opinion,  for  the  swelling’s  not  sinking  inw'ards 
under  pressure.  But  1 am  far  from  being  convinced, 
with  Walther,  that  fungi  of  the  dura  mater  are  in  their 
nature  always  irreducible  (see  vol.  cit.  p.  82)  ; a belief, 
which  he  grounds  upon  the  connexion  of  the  diseased 
mass  with  the  vessels  of  the  diploe  ; its  constriction  by 
the  bone ; and  its  exjjansion  under  as  well  as  above  the 
cranium.  Here  I think  Walther  is  as  wrong  in  say- 
ing that  none  of  these  fungi  can  possibly  be  reduced,  as 
others  would  be  in  asserting  that  it  is  their  invariable 
character  to  be  reducible.  These  differences  must 
chiefly  depend  upon  the  size  of  the  swelling,  in  relation 
to  that  in  the  aperture  in  the  skull. 

Generally  speaking,  fungous  tumours  of  the  dura  ma- 
ter are  very  dangerous,  as  well  on  account  of  their  na- 
ture as  of  the  difficulty  of  curing  them  in  any  certain 
manner,  and  of  the  internal  and  external  disorder 
which  they  may  occasion.  Such  as  have  a pedicle,  the 
base  of  which  is  not  extensive ; wffiich  are  firm  in  their 
texture,  without  much  disease  in  the  surrounding  bone, 
are  moveable,  not  very  painful,  and  in  persons  who  are 
in  other  respects  quite  well,  are  in  general  reputed  to 
be  the  least  perilous.  These  are  the  cases  in  which  a 
cure  may  be  attempted  with  a hops  of  success,  though 
the  event  is  always  e.xceedingly  doubtful. 

When  the  contrary  of  what  has  been  just  related  oc- 
curs, when  the  disease  is  of  long  continuance,  and  the 
brain  already  affected,  nothing  favourable  can  be  ex- 
pected. 

Compression  is  the  most  simple  means  of  cure,  and 


that  which  has  naturally  occurred  to  such  practitioners 
as  have  mistaken  the  disease  for  an  anerurism,  or  a 
hernia  cerebri.  The  ellicacy  of  this  method  has  been 
further  misconceived,  because  the  tumour,  when  not 
very  large,  has  sometimes  been  partly,  or  even  wholly, 
reduced,  without  any  bad  consequences.  This  had  no 
httle  share  in  leading  to  errors  concerning  the  true  cha- 
racter of  the  disease..  But,  as  might  be  conceived,  this 
reduction  only  being  attended  with  temporary  success, 
and  having  no  effect  whatever  on  the  original  cause  of 
the  affection,  the  s>Tnptoms  returned,  and  the  tumour  rose 
up  again  the  moment  the  compre.ssion  was  discontinued. 
There  is  a fact  in  the  memoir  of  M.  Louis,  which  seems 
to  evince  that  good  effects  may  sometimes  be  produced 
by  compression  judiciously  employed.  A woman 
brought  to  the  brink  of  the  grave  by  symptoms  occa- 
sioned by  a tumour  of  the  above  kind,  having  rested 
with  her  head  for  some  time  on  the  same  side  as  the 
tumour,  found  the  swelling  so  suddenly  reduced,  with- 
out any  ill  effects,  that  she  thought  herself  cured  by 
some  miracle.  Compression,  artfully  kept  up  by  means 
of  & piece  of  tin  fastened  to  her  cap,  prevented  the  pro- 
trusion of  the  tumour  again.  The  pressure,  however, 
not  having  been  always  very  exact,  the  symptoms  every 
now  and  then  recurred,  while  the  tumour  was  in  the 
act  of  being  depressed  again,  and  they  afterward  ceased, 
on  the  swelling  having  assumed  a suitable  position. 
The  symptams  were  doubtless  occasioned  by  the  irrita- 
tion which  the  tumour  suffered,  in  passing  the  ine- 
qualities around  the  opening  through  which  it  pro- 
truded. The  patient  lived  in  this  state  nine  years, 
having  every  now  and  then  fits  of  insensibility,  in  one 
of  which,  attended  with  hiccough  and  vomiting,  she 
perished. 

As  compression  cannot  be  depended  upon,  the  follow- 
ing safer  method  may  be  tried.  It  consists  in  exposing 
the  tumour  with  a knife,  which  is  certainly  preferable 
to  caustics,  the  action  of  which  is  very  teffious  and 
painful,  and  can  never  be  limited  or  extended  with  any 
degree  of  precision.  A crucial  incision  may  be  made 
through  the  scalp  covering  the  tumour,  and  the  flaps 
dissected  up,  and  reflected  so  as  to  bring  all  the  bony 
circumference  into  view.  Then  with  trephines  re- 
peatedly applied,  or  with  what  would  be  better,  Mr. 
Hey’s  saws,  all  the  margin  of  the  bone  should  be  care- 
fully removed.  Now,  if  it  be  true,  that  the  vessels  of 
the  diploe  are  chiefly  concerned  in  the  supply  of  the  dis- 
eased mass,  we  see  that  this  source  of  its  growth  must 
be  destroyed  by  the  foregoing  proceeding. 

The  tumour,  thus  disengaged  on  all  sides,  may  he  cut 
off  with  a scalpel ; and  such  arteries  as  bleed  much 
should  be  tied.  Then  instead  of  applying  caustic,  as 
sometimes  advised,  perhaps  it  wcuild  be  better  to  re- 
move every  part  of  both  layers  of  the  dura  mater  im 
mediately  under  the  situation  of  the  excrescence.  By 
this  means,  and  the  removal  of  the  surrounding  bone 
and  diploe,  all  chance  of  the  regeneration  of  the  tumour 
would  be  prevented.  In  attempting  the  excision  of  a 
fungus  of  the  dura  mater,  it  is  certainly  an  interesting 
point  to  know  whether  the  tumour  has  an  intimate  vas 
cular  connexion  with  the  diploe  and  pericranium,  as  as- 
serted by  Siebold,  Walther,  and  some  other  respectable 
authorities ; though  the  importance  of  the  information 
on  this  subject  to  the  practitioner  is  somewhat  lessened 
by  his  being  aware  that  it  is  necessary  alwmys  to  begin 
with  sawing  away  the  bone  in  the  immediate  vicinity 
of  the  diseased  mass.  In  the  dissection  of  one  case; 
Walther  found  the  pericranium  thickened  for  a consider- 
able extent  around  the  disease,  and  closely  connected 
with  the  tumour  by  vessels. — {Vol.  cit.  p.  100.) 

When  the  tumour  is  sarcomatous,  and  its  pedicle 
small  and  narrow,  as  sometimes  happens,  one  should 
not  hesitate  to  cut  it  off. 

This  method  is  preferable  to  tying  its  base  with  a 
ligature:  a plan  which  could  not  be  executed  without 
dragging  and  seriously  injuring  the  dura  mater;  and 
the  fatal  effects  of  wliich  I saw  exemplified  in  one  case 
that  occurred  many  years  ago  in  St.  Bartholomew’s 
Hospital,  and  was  operated  uikmi  by  the  late  Mr.  Ramsr 
den.  Excision  is  also  preterable  to  caustics,  which 
cause  great  pain,  and  very  often  coninilsions.  In  per- 
forming the  extirpation,  we  should  remove  the  whole 
extent  of  the  tumour,  and,  if  possible,  ita  root,  even 
though  it  may  extend  as  deeply  as  the  internal  layer  of 
the  dura  mater.  This  step  must  not  be  dtlayed,  for  the 
disease  wdl  continue  to  increa.se  so  ns  to  alfeet  the 
brain,  become  incurable,  and  even  mortal.  It  us  to  such 


EAR 


EAR 


329 


decision  that  we  must  impute  the  success  which 
atipuded  the  treatment  of  the  Spaniard  Avalos,  of  whom 
Marcus  Aurelius  Severinus  makes  mention.  The  above 
nobleman  was  afflicted  with  intolerable  headaches,  which 
no  remedy  could  appease.  It  was  proposed  to  him  to 
trepan  the  cranium,  an  operation  to  which  he  consented. 
I'his  proceeding  brought  into  view,  under  the  bone,  a 
fungous  excrescence,  the  destruction  of  which  proved 
a permanent  cure  of  the  violent  pains  which  the  disease 
had  occasioned.  It  is  not  mentioned  in  this  case  whether 
the  internal  layer  of  the  dura  mater  was  healthy  or  not ; 
but  there  is  foundation  for  believing  that  if  the  extirpa- 
tion of  these  tumours  be  undertaken  in  time,  and  bold 
measures  be  pursued,  as  in  the  instance  just  cited,  suc- 
cess would  often  be  obtained.  Indeed,  reason  would 
support  this  opinion  ; for  when  the  disease  is  not  exten- 
sive, it  is  necessary  to  expose  a much  smaller  surface 
of  the  dura  mater. 

It  appears  to  me,  however,  that  trepanning  can  never 
be  warrantable,  unless  the  disease  can  be  indicated  by 
some  external  changes.  I saw  my  late  master,  Mr. 
Ramsden,  trepan  a man  for  a mere  fixed  pain  in  one 
part  of  the  head,  on  the  supposition  that  there  was  a tu- 
mour under  the  bone ; but  no  tumour  was  found,  and 
the  operation  caused  inflammation  of  the  dura  mater, 
and  proved  fatal. 

No  doubt,  in  some  cases,  the  hemorrhage  will  be  con- 
siderable, as  was  exemplified  in  the  instance  in  which 


Walther  made  an  incision  at  the  base  of  one  of  these 
fungi,  in  order  to  ascertain  its  nature : two  pints  of 
blood  being  lost  from  several  vessels  of  very  large  size 
ere  tliey  could  be  secured  ; and  the  farther  use  of  the 
knife  discontinued.  • 

M.  Louis  has  described  other  tumours,  which  grow 
from  the  surface  of  the  dura  mater,  when  this  mem- 
brane has  been  denuded,  as  after  the  application  of  the 
trephine.  They  only  seem  to  differ  from  the  preceding 
in  not  existing  before  the  opening  was  made  in  the 
skull.  Tumour  of  the  dura  mater  should  not  be  con- 
founded with  hernia  cerebri.—  (See  this  article.)  See, 
on  the  preceding  subject,  Mem  sur  les  Tumeurs  fon- 
gueuses  de  la  Dure-Mere,  par  M.  Louis,  in  M<lm.  de 
I’Acad.  de  Chir.  t.  5,  Ato.  Encyclopidie  Methodique, 
partie  Chir.  art.  Dure-Mire.  J.  P.  Kaufmann,  de  Tu- 
more  Capitis  fungoso  post  Cariem  Cranii  exorto. 
Helmst.  1743.  Lassus,  Pathologie  Chir.  t.  I,  p.  497,  ed. 
1809.  J.  and  C.  Wenzel,  uber  die  Schwammigen  Aus- 
wuchse  auf  der  aussem  Himhaut.  Fol.  Mainz.  1811 
In  this  work,  the  sentiments  of  M.  Louis  are  espoused. 
Ph.  V.  Wolther  in  Joum.fdr  Chir.  von  C.  Graefe,  <S  c. 
b.  1,  p.  55,  A c.  8vo.  Berlin,  1820.  The  latter  writer 
criticises  the  opinions  of  the  Wenzels,  and  of  course 
differs  considerably  from  Louis  on  several  points,  some 
of  which  I have  noticed  in  the foregoing  pages. 

For  inflammation  of  the  dura  mater,  see  Head,  In- 
juries  of. 


EAR,  DISEASES  OF. 

A N organ  so  valuable  and  necessary  to  the  perfec- 
tion  of  our  existence  as  the  ear  should  have  all 
the  resources  of  surgery  exerted  for  the  preservation  of 
its  integrity,  and  the  removal  of  the  diseases  with  which 
it  may  be  affected.  What,  indeed,  would  have  been  our 
lot,  if  nature  had  been  less  liberal,  and  not  endued  us 
with  the  sense  of  hearing  ? As  Leschevin  has  observed, 
we  should  then  have  been  ill  qualified  for  the  receipt  of 
instruction ; a principal  inlet  of  divine  and  human 
knowledge  would  have  been  closed : and,  there  being 
no  reciprocal  communication  of  ideas,  our  feeble  reason 
could  never  have  approached  perfection.  Even  our  life 
itself,  being  as  it  were  dependent  upon  all  such  bodies  as 
surround  us,  would  have  been  incessantly  exposed  to 
dangers.  The  eyesight  serves  to  render  us  conscious 
of  objects  which  present  themselves  before  us,  and 
when  we  judge  them  to  be  hurtful,  we  endeavour  to 
avoid  them.  But  to  say  nothing  of  our  inability  of  look- 
ing on  all  sides  at  once,  our  eyes  become  of  no  service 
to  us  whenever  we  happen  to  be  enveloped  in  darkness. 
The  hearing  is  then  the  only  sense  that  watches  over 
our  safety.  It  warns  us  not  only  of  every  thing  which 
is  moving  about  us,  but  likewise  of  noises  which  are 
more  or  less  distant.  Such  are  the  inestimable  advan- 
tages which  we  derive  from  this  organ.  Its  importance 
when  healthy  makes  it  worthy  of  the  utmost  efforts  of 
Hurger>'  when  diseased. — (^Leschevin  in  Mem.  sur  les 
Sujets  proposes  pour  le  Prix  de  I'Jlcad.  Roy  ale  de  Chi- 
rurgie,  t.  9,  p.  Ill,  112,  id.  \2mo.) 

It  is  not  many  years  since  the  diseases  of  the  ear 
were  a subject  on  which  the  greatest  ignorance  and  the 
most  mistaken  opinions  prevailed ; and  indeed  bow 
could  any  correct  pathological  information  be  expected, 
while  anatomists  had  not  given  a complete  and  accu- 
rate description  of  the  organ  itself?  Also,  notwith- 
standing what  has  now  been  made  out  respecting  dis- 
orders of  the  ear,  it  is  generally  admitted  that  they 
still  require  farther  investigation  and  renewed  industry. 
Though  Duverney,  Valsalva,  Morgagni,  &c.  dispelled 
some  of  the  darkness  which  covered  this  branch  of 
Burger>',  they  left  a great  deal  undone.  Since  their 
time,  science  has  been  enriched  with  the  valuable  dis- 
coveries of  Ootunni,  Meckel,  Scarpa,  and  Cornparetti ; 
the  first  two  of  whom  demonstrated  that  the  labyrinth 
is  filled  with  a limpid  fluid,  and  not  (as  was  pretended) 
w’ith  confined  air ; while  the  last  two  distinguished 
anatomists  favoured  the  public  with  the  first  very  accu- 
rate description  of  the  parts  composing  the  labyrinth, 
especially  the  semicircular  canals. 

In  1763,  the  French  Academy  of  Surgery  offered  a 


prize  for  the  best  essay  on  diseases  of  the  ear,  and  two 
years  afterward  the  honour  was  adjudged  to  that  of 
Leschevin,  senior  surgeon  of  the  hospital  at  Rotien. 
Thft  memoir  is  still  of  great  value,  few  modem  trea- 
tises being  more  complete.  The  most  useful  contri- 
butors to  our  stock  of  information  on  the  pathology  of 
the  ear,  subsequently  to  M.  Leschevin,  have  been 
Britter  and  Lenten  ( Ueber  das  schWere  Gehoer.  Leipz. 
1794) ; Trampel  (Amemann’s  Magaz.  b.  2,  1798) ; 
Pfingsten  {Vieljahrige  Erfahrung  ueber  die  Gehoer- 
fehler,  Kiel,  1802) ; Alard  {Sur  le  Catarrhe  dl  Oreille, 
Hvo.  Paris,  1807,  tdit.  2);  Sir  A.  Cooper  (Phil.  Trans. 
1802) ; Portal  (Anat.  Mtd.  1803) ; J C.  Saunders  (Jinat. 
and  Dis.  of  the  Ear,  1806) ; Baron  Boyer  (Mai.  Chir. 
t.  6) ; Itard  ( Traiti  des  Mai.  de  V Oreille,  &uo.  2 tomes) ; 
Saissy,  in  an  essay  which  received  the  approbation  of 
the  Medical  Society  of  Bourdeaux  ; and  Professor  Rosen- 
thal, in  a short  but  sensible  tract  on  the  pathology  of 
the  ear. — (See  Joum.  Complem.  t.  6,  1820.) 

But  notwithstanding  the  laudable  endeavours  of  so 
many  men  of  eminence,  the  pathology  of  the  internal 
ear,  and  the  treatment  of  its  diseases,  are  far,  I may- 
say,,  very  far,  from  a high  state  of  improvement.  To 
farther  advances  indeed  some  discouraging  obstacles 
present  themselves : theauditory  api)aratus is  extremely 
complicated  ; the  most  important  parts  of  it  are  en, 
tirely  out  of  the  reach  of  ocular  inspection  ; the  ana- 
tomy of  the  organ  is  perhaps  not  yet  completely  unra 
veiled  ; the  exact  uses  and  action  of  several  parts  of  it, 
anatomically  known,  are  still  involved  in  mystery  ; the 
opportunities  of  dissecting  the  ear  in  a state  of  disease 
are  neither  frequent  nor  duly  watched  ; and  even  when 
they  are  taken,  and  when  vestiges  of  disease  or  imper- 
feetjon  are  traced  to  particular  parts  of  the  organ,  the 
utmost  difficulty  is  experienced  in  drawing  any  usefql 
practical  conclusion,  because  the  natural  uses  of  those 
parts,  and  the  precise  manner  in  which  they  contribute 
to  the  perfection  of  the  ear,  are  not  known  to  tlie  most 
enlightened  physiologists.  We  are  here  nearly  in  tlie 
same  helpless  dilemma  as  a watchmaker  would  be,  were 
he,  in  examining  the  interior  of  a watch,  to  find  parts 
broken  and  out  of  order,  the  exact  uses  of  which,  in  Bie 
perfection  of  the  instrument,  he  had  not  first  stumljd 
and  comprehended.  In  fact,  the  physiology  of  the  ear 
is  but  very  imperfectly  understood  ; and,  gis  Rosenthal 
remarks  (Journ.  CompUm.  t.  0,  p.  17),  if,  notwithstand- 
ing the  progress  made  in  optics,  and  the  complete 
knowledge  of  the  structure  of  the  eye,  a perfect  expla- 
nation has  not  yet  been  given  of  the  phenomena  of 
this  organ  as  an'instrument  of  vision,  we  cannot  won- 
der that,  with  far  more  circumsenbed  informatiq;; 


330 


EAR. 


about  acoustics,  and  the  greater  difficulty  of  unravelling 
the  structure  of  the  ear,  so  little  progress  should  have 
been  made  in  the  physiology  of  the  latter  organ.  Were  it 
practicable  in  acoustics  to  arrive  at  that  precision  and 
certainty  which  would  enable  us  to  establish  laws  in 
the  theory  of  sound  as  fixed  as  those  which  relate  to 
light,  this  void  in  physiological  science  might  perhaps 
be  obviated.  But  Rosenthal  justly  argues,  that  hitherto 
the  approach  to  perfection  has  not  been  made,  and  this 
notwithstanding  the  learned  and  valuable  labours  of 
Chladni.  — ( AArastiA:.  4fo.  Leipz.  1802.)  Some  facts, 
however,  are  admitted  to  be  well  ascertained,  and  the 
researches  of  Autenrieth  and  Kerder  {ReWs  Jirchiv. 
fur  die  Physiol,  t.  9,  p.  SIS'— 376)  are  honourably  men- 
tioned ; for  though  they  only  elucidate  the  function  of 
the  conductor  part  of  the  ear,  they  are  of  unquestion- 
able importance  to  the  medical  practitioner.  It  is  clearly 
proved  that  the  difference  in  the  length  and  breadth  of 
the  meatus  auditorius,  form  of  the  membrana  tympani, 
and  the  make  of  the  cavity  of  the  tympanum  modify 
sound ; that  is  to  say,  that  the  differences  of  structure 
of  the  auricle  and  the  meatus  auditorius  externus,  which 
merely  receive  and  concentrate  the  sonorous  undula- 
tions, as  these  emanate  from  a vibrating  body,  can 
only  influence  the  degree  of  force  or  weakness  of  the 
sound  ; while,  on  the  contrary,  the  differences  of  struc- 
ture in  the  membrane  and  cavity  of  the  tympanum  are 
not  limited  to  this  effect,  but  ihe  greater  or  less  tension 
of  the  one,  and  the  more  or  less  considerable  capacity 
of  the  other  appear  to  alter  in  a greater  or  less  degree 
the  particular  character  of  the  sound. — {Joum.  Com- 
pUm.  t.  6,  p.  20.) 

1.  Wov.nds  and  Defects  of  the  external  Ear. 

The  external  ear,  which  is  a sort  of  instrument  cal- 
culated for  concentrating  the  undulations  or  waves  of 
sound,  may  be  totally  cut  off  without  deafness  being 
the  consequence.  For  a few  days  after  the  loss,  the 
hearing  is  rather  hard;  but  the  infirmity  gradt^glly 
diminishes,  the  increased  sensibility  of  the  auditory 
nerve  compensating  for  the  imperfection  of  the  organic 
apparatus.— (RicAerand,  Nosogr.  Chir.  t.  2,  p.  122,  ed.  2.) 

Dr.  Hennen  says,  that  he  has  met  with  a case  where 
the  external  ear  was  completely  removed  by  a cannon- 
shot,  and  yet  the  sense  of  hearing  was  as  acute  as  e-v  er. 
— {Principles  of  Military  Surgery,  p.  348,  ed.  2.)  An- 
other case,  recorded  by  Wepfer,  also  proves  that  a total 
loss  of  the  auricle  may  not  cause  any  material  injury 
of  hearing,  for  the  patient  of  whom  he  speaks  had  had 
the  whole  of  the  .external  ear  destroyed  by  ulceration, 
and  yet  could  hear  as  well  as  before  the  loss. — {Kriter 
und  Lentin  uber  das  schwere  Gehoer,p.  19,  Leipz.  1794.) 

However,  if  we  are  to  credit  the  statement  of  other 
writers,  the  recovery  is  generally  far  less  complete. 
Thus  Leschevin  notices,  that  they  who  have  lost  the 
external  ear,  or  have  it  naturally  too  flat  oi  ill-shaped, 
have  the  hearing  less  fine.  The  defect  can  only  be  re- 
medied by  an  artificial  ear  or  an  ear-trumpet,  w'hich, 
receiving  a large  quantity  of  the  sonorous  undulations, 
and  directing  them  towards  the  meatus  auditorius, 
thus  does  the  office  of  the  external  ear.—  {Prix  de  VAcad. 
Roy  ale  de  Chir.  t.  9,  p.  120,  edit.  ]2mo.) 

Wounds  are  not  the  only  causes  by  which  the  exter- 
nal ear  may  be  lost : its  separation  is  sometimes  the 
consequence  of  ulceration,  and  sometimes  the  effect  of 
the  bites  of  horses  and  other  animals.  In  cold  climates 
it  is  frequently  -frozen,  and  afterward  attacked  with 
inflammation  and  sloughing.  When  the  external  ear 
is  not  totally  separated  from  the  head,  the  surgeon 
should  not  despair  of  being  able  to  accomplish  the  re- 
union of  it.  This  attempt  should  always  be  made, 
however  small  a connexion  the  part  may  have  with 
the  skin  ; for  m w'ounds  of  this  kind,  the  efforts  of  sur- 
gery have  occasionally  succeeded  beyond  all  expec- 
tation. 

Wounds  of  the  external  ear,  whatever  may  be  their 
size  and  shape,  do  not  require  different  treatment  from 
that  of  the  generality  of  other  wounds.  The  reunion 
of  the  divided  part  is  the  only  indication,  and  it  may  be 
in  most  instances  easily  fulfilled  by  means  of  method- 
ical dressings.  Such  writers  as  have  recommended 
sutures  for  wounds  in  the  ear  (says  Leschevin),  have 
founded  this  advice  upon  the  difficulty  of  applying-  to 
the  part  a bandage  that  will  keep  the  edges  of  the 
wound  exactly  together.  The  cranium,  however,  af- 
fords a firm  and  equal  surface,  against  which  the  ex- 
ternal ear  may  be  conveniently  fixed.  Certainly,  d is 


not  more  easy  to  secure  dressings  on  the  nose  than  the 
ear ; and  yet  cases  are  recorded  in  which  the  cartilagi- 
nous part  of  the  nose  was  wounded  and  almost  entirely 
separated,  and  the  union  was  effected  without  the  aid 
of  sutures.— (See  Mem.  de  M.  Pibrac  sur  VAbus  des 
Sutures,  in  Mem.  de  I’.dcad..  de  Chir.  tom.  3.) 

In  wounds  of  the  ear,  then,  we  may  conclude  that 
sutures  are  generally  useless  and  unnecessary.  As 
examples  may  occur,  however,  in  which  the  wound 
may  be  so  irregular  and  considerable  as  not  to  admit 
of  being  accurately  united,  except  by  this  means,  it 
should  not  be  absolutely  rejected.  An  enlightened 
surgeon  will  not  abandon  altogether  any  curative  plans ; 
he  only  points  out  their  proper  utility,  and  keeps  them 
within  the  right  limits.  When  sticking  plaster,  sim- 
ple dressings,  and  a bandage  that  makes  moderate 
pressure  appear  insufficient  for  keeping  the  edges  of  a 
wound  of  the  ear  in  due  contact,  the  judicious  practi- 
tioner will  not  hesitate  to  employ  sutures. 

When  a bandage  is  applied  to  the  external  ear,  it 
should  only  be  put  on  with  moderate  tightness,  since 
much  pressure  gives  considerable  uneasiness,  and  may 
induce  sloughing.  In  order  to  prevent  these  disagree- 
able Effects,  I,eschevin  advises  us  to  fill  the  space  be- 
hind the  ear  with  soft  wool  or  cotton,  against  which 
the  part  may  be  compressed  without  risk.— (Op.  cit. 
p.  119.) 

Baron  Boyer  remembers  a medical  student  who  was 
compelled  by  an  ulcer  on  the  sacrum  to  lie  for  a long 
time  on  his  side,  in  which  posture  the  pressure  on  the 
ear  caused  a slough  of  the  antihelix,  and  after  the  sepa- 
ration of  the  dead  part,  an  aperture,  large  enough  to 
receive  the  end  of  the  little  finger,  was  left  in  the 
pinna  or  auricle. 

In  the  application  of  sutures  to  the  ear,  the  ancients 
caution  us  to  avoid  carefully  the  cartilage,  and  to  sew 
only  the  skin.  They  were  fearful  that  pricking  the 
cartilage  would  make  it  mortify,  “ ce  qui  est  souvente- 
fois  arrive,"  says  Pare.  But,  notwithstanding  so  re- 
spectable an  authority,  as  Leschevin  has  remarked,-  the 
moderns  make  no  scruple  about  sewing  cartilages. 
In  wounds  of  the  nose,  Verduc  expressly  directs  the 
skin  and  cartilage  to  be  pierced  at  once,  and  the  success 
of  the  plan  is  put  out  of  all  doubt  by  a multitude  of 
facts.  The  same  treatment  may  also  be  safely  extended 
to  the  ear. 

Celsus,  lib.  3,  c.  6,  speaks  of  fractures  of  the  carti- 
lages of  the  ear ; but  such  an  accident  seems  hardly 
possible,  unless  the  part  be  previously  ossified.  Les- 
chevin and  Boyer  have  never  met  with  such  a case, 
either  in  practice  or  in  the  works  of  surgical  writers. 

In  this  section,  a few  malformations  of  the  external 
ear  require  notice.  Sometimes  the  orifice  of  the  mea- 
tus auditorius  is  diminished  by  the  tragus,  antitragus, 
and  antihelix  being  depressed  into  it.  Here  the  excision 
of  these  wrongly  formed  eminences  has  been  recom- 
mended as  a surer  means  of  perfecting  the  sense  of 
hearing  than  the  use  of  any  tube  or  dilating  instru- 
ments. The  tyagus  has  been  known  to  project  consi- 
derably backwards,  and  to  apply  itself  most  closely 
,over  the  orifice  of  the  meatus,  which  was  also  a mere 
slit  instead  of  a round  opening.  In  one  case  of  this 
description  relief  was  obtained  by  the  introduction  of 
tubes,  calculated  to  maintain  the  tragus  in  its  proper 
position.— (Diet,  des  Sciences  Med.  t.  38,  p.  28.) 

Sometimes  the  outer  ear  is  entirely  w'anting.  Thus 
Fritelli  has  given  an  account  of  a child  in  this  condition, 
whose  physiognomy  at  the  same  time  strongly  resem- 
bled that  of  an  ape. — {Orteschi  Giom.  di  Med.  t.  3,  p.  80.) 
Oberteuffer  has  also  recorded  an  example  of  a total  de- 
ficiency of  the  auricles  in  an  adult,  who  yet  heard  very 
well. — {Stark's  Neues  ..drehiv.  b.  2,  p.  638.  J.  F. 
Meckel,  Handbuch  der  Pathol.  Jlnat.  h.  1,  ».  400,  Leipz. 
1812.) 

I remember  a child  which  was  exhibited  many  years 
ago  in  London  as  a curiosity  ; it  was  entirely  destitute 
of  external  ears,  and  no  vestiges  of  the  meatus  auditorii 
could  be  seen,  these  openings  being  completely  covered 
by  the  common  integuments.  Yet  the  child  could  hour 
a great  deal,  though  the  sense  was  certainly  dull  and 
imperfect.  I recollect  that  the  circumstance  of  the 
patient  hearing  so  well  as  he  did,  was  what  excited 
considerable  surprise.  I am  sorry  I do  not  more  parti- 
cularly recollect  at  the  present  time  the  degree  in  which 
this  sense  was  enjoyed,  and  several  other  circum- 
stances, such  as  the  child’s  age  power  of  speech,  dec. 
The  example,  however,  is  interesting,  inasmuch  as  U 


EAR. 


331 


proves,  that  even  a deficiency  of  the  auricles,  combined 
with  an  imperforate  condition  of  both  ears,  may  be  un- 
attended with  complete  deafness,  provided  the  internal 
and  more  essential  parts  of  these  organs  are  sound  and 
perfectly  formed. 

Baron  Boyer  attended  a youtig  man,  the  lobule  of  one 
of  whose  ears  extended  in  a very  inconvenient  manner 
over  the  cheek;  the  redundant  portion  was  removed 
with  a pair  of  scissors,  and  the  wound  soon  healed. 

The  auricle  not  being  a very  irritable  part,  is  not 
often  inflamed,  and  when  it  is  so,  the  affection  is  gene- 
rally of  an  erysipelatous  character.  Portal  has  seen 
the  part  nearly  an  inch  thick  ; and  he  takes  notice  of 
the  prodigious  thickness  which  the  lobe  of  the  ear 
sometimes  acquires  in  women  Who  wear  very  heavy 
earrings,  which  keep  up  constant  irritation.  Small 
encysted  and  adipose  swellings  occasionally  grow  un- 
der the  skin  of  the  external  ear,  and  demand  the  same 
treatment  as  swellings  of  the  same  nature  in  other 
situations. — (See  Tumours.)  Lastly,  the  external  ear 
is  frequently  the  seat  of  scrofulous  and  other  ill- 
conditioned  ulcers.  These  cases  generally  require 
cleanliness,  alterative  medicines,  and  to  be  dressed 
with  the  ung.  hydrarg.  nitrat.  or  a solution  of  the  ni- 
trate of  silver ; and  sometimes,  when  the  sores  resist 
for  a long  time  the  effects  of  medicine  and  the  usual 
dressings,  they  will  soon  heal  up,  if  the  treatment  be 
assisted  with  a blister  or  seton,  kept  open  on  the  nape 
of  the  neck.— (See  Diet,  des  Sciences  Mid.  t.  38,  'p.  28, 
29.) 

2.  Of  the  Meatus  Jluditorius,.  and  its  Imperfections. 

This  is  the  passage  which  leads  from  the  cavity  of 
the  external  ear  called  the  concha,  down  to  the  mem- 
brane of  the  tympanum.  It  is  partly  cartilaginous,  and 
partly  bony,  and  has  an  oblique  winding  direction,  so 
that  its  whole  extent  cannot  be  easily  seen.  There  are 
circumstances,  Jiowever,  in  which  it  is  proper  to  look 
as  far  as  possible  into  the  passage.  Such  is  the  case, 
when  the  surgeon  is  to  extract  any  foreign  body,  to  re- 
move an  excrescence,  or  to  detect  any  other  occasion 
of  deafness.  Fabricius  Hildanus  gives  a piece  of  ad- 
vice upon  this  subject,  not  to  be  despised  ; namely,  to 
expose  the  ear  to  the  rays  of  the  sun,  in  order  to  be 
enabled  to  see  the  very  bottom  of  the  passage.' 

Mr.  Buchanan  recommends  the  patient  to  be  placed 
upon  a low  seat,  with  the  ear  exposed  to  the  rays  of 
the  sun.  The  surgeon  should  then  lay  hold  of  the  au- 
ricle with  the  left  hand,  by  placing  the  thumb  in  the 
concha,  and  with  the  index  and  middle  finger  of  the 
same  hand  placed  behind  the  cartilage,  take  hold  of  the 
cavity,  and  pull  it  outwards  and  upwards,  so  as  to 
elongate  the  cartilaginous  part  of  the  meatus.  With 
the  help  of  a slightly  curved  probe,  by  which  the  tragus 
is  to  be  drawn  a little  outwards,  and  the  diameter  of 
the  tube  increased,  the  whole  of  the  meatus  and  mem- 
brana  tympani  may  then  be  distinctly  seen.-7(See 
Buchanan’s  Illustrations  of  .ficoustic  Surgery,  p 1.) 
When  the  assi.stance  of  sunshine  cannot  be  obtained, 
and  in  the  evening,  Mr.  Buchanan  finds  great  advan- 
tage from  the  use  of  an  ingenious  kind  of  lantern 
which  he  has  invented  for  examining  the  ear,  and 
which  he  terms  an  inspector  auris.  When  it  is  used, 
the  room  is  darkened,  and  the  focus  from  the  lantern 
directed  into  the  meatus. 

The  surgical  operations  practised  on  the  meatus  au- 
ditorius  are  confined  to  opening  it,  when  preternatu- 
rally  closed,  extracting  foreign  bodies,  washing  the 
passage  out  with  injections,  and  removing  excres- 
cences. 

The  case  which  we  shall  next  treat  of,  is  the  imper- 
foration  of  the  meatus  auditorius  externus,  a defect 
with  which  some  children  are  born. 

When  the  malformation  e.xists  in  both  ears,  it  gene- 
rally renders  the  subject  dumb  as  well  as  deaf,  for,  as 
he  is  incajiable  of  imitating  sounds  which  he  does  not 
hear,  he  cannot  of  course  learn  to  speak,  although  the 
organs  of  speech  may  be  perfect,  and  in  every  respect 
rightly  disposed.  In  this  case  the  surgeon  has  to  rec- 
tify the  error  of  nature,  and  (to  use  the  language  of 
Leschevin)  he  has  to  give,  by  a double  miracle,  hearing 
and  speech  to  an  animated  being,  who,  deprived  of 
these  two  faculties,  can  scarcely  be  regarded  in  society 
as  one  of  the  human  race.  How  highly  must  such  an 
operation  raise  the  utility  and  excellence  of  surgery  in 
the  estimation  of  the  world  1 

When  the  meatus  auditorius  externus  is  -merely 


closed  by  an  externa]  membrane,  the  nature  of  the  ease 
is  evident,  and  the  mode  of  relief  equally  easy.  But 
when  the  membrane  is  more  deeply  situated  in  the 
passage,  near  the  tympanum,  the  diagnosis  is  attended 
with  increased  difficulty,  and  the  treatment  with  greater 
trouble. 

If  the  preternatural  membrane  be  external,  or  only  a 
little  way  within  the  passage,  it  is  to  be  divided  with  a 
bistoury ; the  small  flaps  are  to  be  cut  away ; a tent  of 
a suitable  size  is  to  be  introduced  into  the  opening ; 
and  the  wound  is  to  be  healed  secundum  artem,  care 
being  taken  to  keep  it  constantly  dilated,  until  the  cica- 
trization is  completed. 

When  the  obstruction  is  deeply  situated,  we  must 
first  be  sure  of  its  existence,  which  is  never  ascer- 
tained, or  even  suspected,  till  after  a long  while.  It  is  not 
till  after  children  are  pa.st  the  age  at  which  they  usually 
begin  to  talk,  that  any  defect  is  suspected  in  the  organ 
of  hearing,  because  until  this  period,  little  notice  is 
taken  whether  they  hear  or  not.  As  soon  as  it  is  clear 
that  this  sense  is  deficient,  the  ears  should  always  be 
examined  with  great  attention,  in  order  to  discover,  if 
possible,  the  cause  of  deafness.  Sometimes  the  in- 
firmity depends  upon  a malformation  of  the  internal 
ear,  and  the  cause  does  not  then  admit  of  detection. 
The  most  convenient  method  of  making  the  examina- 
tion is  to  expose  the  ear  which  is  about  to  be  examined 
to  the-  light  of  the  sun.  In  this  situation,  the  surgeon 
will  be  able  to  see  beyond  the  middle  of  the  bony  part 
of  the  meatus,  if  he  places  his  eye  opposite  the  orifice 
of  the  passage,  and  takes  care  to  efface  the  curvature 
of  the  cartilaginous  portion  of  the  canal,  by  drawing 
upwards  the  external  ear.  If  the  passage  has  been 
carefully  cleansed  before  the  examination,  the  skin 
forming  the  obstruction  may  now  be  seen,  unless  it  be 
immediately  adherent  to  the  tympanum. 

When  the  preternatural  septum  is  not  closely  united 
to  the  tympanum,  its  destruction  should  be  attempted  ; 
and  hopes  of  effecting  the  object  either  suddenly  or 
gradually  may  reasonably  be  entertained.  According 
to  Leschevin,  the  particular  situation  of  the  obstruction 
is  the  circumstance  by  which  the  surgeon  ought  to  be 
guided  in  making  a choice  of  the  means  for  this  opera- 
tion. If  the  membranous  partition  is  so  far  from  the 
tympanum,  that  it  can  be  pierced  without  danger  of 
wounding  the  latter  part,  there  can  be  no  hesitation  in 
choosing  the  plan  to  be  adopted.  In  the  contrary  state 
of  things,  Leschevin  is  an  advocate  for  the  employment 
of  caustic,  not  only  on  account  of  the  risk  of  injuring 
the  tympanum  with  a cutting  instrument,  but  also 
because  if  the  puncture  were  ever  so  well  executed,  a 
tent  could  not  be  introduced  into  it,  so  as  to  prevent  it 
from  closing  again. 

In  the  first  case,  a very  narrow  sharp-pointed  bis- 
toury should  be  used  ; after  its  blade  has  been  wrapped 
round  with  a bit. of  tape  to  within  a line  of  the  point,  it 
is  to  be  passed  perpendicularly  down  to  the  preternatu- 
ral membrane,  which  is  to  be  cut  through  its  whole 
diameter.  The  instrument  being  then  directed  first  to- 
wards one  side,  then  the  other,  the  crucial  incision  is 
to  be  completed.  As  the  flaps,  which  are  small  and 
deeply  situated,  cannot  be  removed,  the  surgeon  must 
be  content  with  keeping  them  separated  by  means  of  a 
blunt  tent.  The  wound  will  heal  just  as  favourably  as 
that  occasioned  by  removing  the  imperforation  of  the 
concha,  or  outer  part  of  the  meatus  auditorius. — {Prix 
de  V./icad.  de  Chir.  p.  124 — 126,  t.  9.)  In  the  second 
case,  that  is  to  say,  when  the  risk  of  wounding  the 
tympanum  leads  us  to  prefer  the  employment  of  caustic, 
the  safest  and  most  commodious  way  of  putting  the 
plan  in  execution  would  be  that  of  touching  the  ob- 
struction, as  often  as  circumstances  may  require,  with 
the  extremity  of  a bougie  armed  with  the  argentum  ni- 
tratum.  In  the  intervals  of  the  applications,  no  dressings 
need  he  introduced,  except  a bit  of  clean  sort  cotton,  for 
the  purpose  of  absorbing  any  discharge  which  may  take 
pkice  within  the  passage. 

It  is  manifest,  that  if  the  whole  or  a considerable 
part  of  the  meatus  auditorius  externus  were  wanting, 
the  foregoing  measures  would  be  insufficient.  The 
following  observations  of  Leschevin  merit  attention  : 
“ I do  not  here  allude  to  cases,  in  which  a malforma- 
tion of  the  bene  exists.  I know  not  whether  there  are 
any  examples  of  such  an  imperforation  ; but  it  is  clear 
that  it  would  be  absolutely  incurable.  I speak  of  a 
temporal  bone  perfectly  formed  m all  its  parts,  and  the 
meatus  auditorius  of  which,  instead  of  being  merely 


332 


EAR, 


lined  by  a membrane,  as  in  the  natural  state,  is  blocked 
up  by  the  cohesion  of  the  parietes  of  this  membrane, 
throughout  a certain  extent  of  the  canal ; just  as  the 
urethra,  rectum,  or  vagina  is  sometimes  observed  to 
be  not  simply  closed  by  a membrane,  but  by  a true  ob- 
literation of  its  cavity. 

Such  a defect  in  the  ear  may  be  congenital,  and  it 
may  also  arise  from  a wound  or  ulceration  of  the  whole 
circumference  of  the  meatus  auditorius  externus,  lliis 
canal  having  become  closed  by  the  adhesion  of  its  pa- 
rietes, on  cicatrization  taking  place. 

Such  an  imperforation,  whether  congenital  or  acci- 
dental, must  certainly  be  more  difficult  to  cure  than 
the  examples  treated  of  abov? ; but,”  says  Leschevin, 
‘‘  I do  not  for  this  reason  believe  that  the  case  ought  to 
be  entirely  abandoned.  Yet  I would  not  have  the  ciure 
attempted  in  all  sorts  of  circumstances.  For  instance, 
if  the  defect  only  existed  in  one  ear,  and  the  other  were 
sound,  I would  not  undertake  the  operation,  because 
as  the  patient  can  hear  tolerably  well  on  one  side,  the 
advantages  which  he  might  derive  from  having  the 
enjoyment  of  the  other  ear,  would  not  counterbalance 
the  pain  and  bad  s>  mptoms  occasioned  by  such  an  ex- 
periment, the  success  of  which  is  extremely  uncertain. 
I would  not  then  run  the  risk  of  making  a perfora- 
tion, except  in  a case  of  complete  deafness ; and  I 
propose  this  means  only  as  a dubious  one,  upon  the 
fundamental  maxim,  so  often  laid  down,  that  it  is 
preferable  to  employ  a doubtful  remedy,  than  none 
at  all 

With  respect  to  the  mode  of  executing  this  opera- 
tion,” says  Leschevin,  “ the  trocar  seems  the  most  eli- 
gible instrument.  I would  employ  one  that  is  very 
short,  and  the  jxiint  of  which  is  bluntish,  and  only  pro- 
jects out  of  a cannula  as  little  as  possible.  This  con- 
struction would  indeed  make  the  instrument  less 
adapted  to  pierce  any  thing ; but  still,  as  the  parts  to 
be  perforated  are  firm,  their  division  might  be  accom- 
plished sufficiently  well ; and  the  inconvenience  of  a 
trivial  difficulty  in  the  introduction  of  the  trocar  is  com- 
paratively much  less,  than  that  which  would  attend 
the  danger  of  wounding  tvith  a sharper  point  the  mem- 
brane of  the  tympanum.  I would  plunge  the  point  of 
the  instrument  into  the  place  where  the  opening  of  the 
meatus  auditorius  externally  ou^t  naturally  to  be,  apd 
which  would  be  denoted,  either  by  a slight  depression, 
or  at  all  events  by  attending  to  the  different  parts  of 
the  ear,  especially  the  tragus,  which  is  situated  directly 
over  this  passage.  I would  push  in  the  trocar  gently, 
in  the  direction  of  the  canal  formed  in  the  bone,  until 
the  point  of  the  instrument  felt  as  if  it  had  reached  a 
vacant  space.  Then,  withdrawing  the  trocar  and  leav- 
ing the  cannula,  I would  try  whether  the  patient  could 
hear.  I would  then  introduce  into  the  cavity  of  the 
.cannula  itseif  a small,  rather  firm  tent  of  the  length  of 
the  passage,  or  a small  bougie.  By  means  of  a probe  I 
would  push  it  to  the  end  of  the  cannula,  which  I would 
now  take  out,  observing  to  press  upon  the  tent,  which 
is  to  be  left  in.  The  rest  of  the  treatment  consists  in 
keeping  the  canal  pervious,  making  it  suppurate,  and 
healing  it  with  common  applications.  One  essential 
caution,  however,  would  be  that  of  keeping  the  part 
dilated  long  after  it  had  healed  : otherwise  it  might 
dose  again,  and  a repetition  of  the  operation  become 
necessary.  This  happened  to  Heister,  as  be  himself 
apprizes  us,  and  it  occurred  to  Roonhuysen  in  treating 
imperforations  of  the  vagina. 

If  the  cohesion  of  the  parietes  of  the  meatus  audi- 
^orius  externus  were  to  extend  to  the  tympanum  in- 
clu.sively,  the  operation  would  be  fruitless ; but  as  it  is 
impossible  to  ascertain  this  circumstance  before  the 
attempt  is  made,  the  surgeon  would  incur  no  disgrace 
b>  relinquishing  the  operation,  and  giving  up  the  treat- 
ment of  an  incurable  di.sease.  If,  then,  after  the  trocar 
were  introduced  to  about  the  depth  of  the  tympanum, 
the  situation  of  which  must  be  judged  of  by  our  ana- 
tomical knowledge,  no  cavity  were  met  with,  the  ope- 
ration should  be  abandoned;  and  if,  in  these  circum- 
stances, any  one  were  to  impute  the  want  of  success 
to  the  iuefficacy  of  surgery,  or  the  unskilfulness  of  the 
surgeon,  he  would  act  very  unfairly. 

It  is  also  i)lain,  that  such  an  operation  could  cure  a 
congenital  deafness,  only  inasmuch  a.s  it  might  dej)end 
upon  the  imperforation;  for  if  there  should  exist,  at 
the  same  time,  in  the  internal  ear  any  malformation, 
destructive  of  the  jiower  of  the  organ,  the  remedying 
of  the  external  defect  would  be  quite  useless.”— (Lcs- 


chevin,  in  Prix  de  V^cad.  de  Chirurgie,  tom.  9,  v.  127. 

132. ) 

We  find  that  this  author  entertains  a great  dread  of 
wounding  the  tympanum,  and  certainty  he  is  right  in  ge- 
nerally insisting  upon  the  prudence  of  avoiding  such  an 
accident.  It  will  appear,  however,  in  the  sequel  of  this 
article,  that  under  certain  circumstances  puncturing  the 
tympanum  has  been  successfully  practised,  as  a mode 
of  remedying  deaf  ness.  The  operation,  however,  de- 
mands caution;  for,  if  done  so  as  to  injure  the  con- 
nexion of  the  malleus  with  the  membrana  tympani, 
the  hearing  must  ever  afterward  be  very  imperfect. 

3.  Unusual  Smallness  of  the  Meat'iis  Auditgrius 
Externus. 

Imperforation  is  not  the  only  congenital  imperfection 
of  the  meatus  auditorius ; this  passage  is  occasionally 
too  narrow  for  the  admission  of  a due  quantity  of  the 
sonorous  undulations,  and  the  sense  is  of  course  weak- 
ened. Leschevin  mentions  that  M.  de  la  Metric  found 
this  canal  so  narrow  in  a young  person  that  it  could 
hardly  admit  a probe.  What  has  been  observed  con- 
cerning the  imperforation  is  also  applicable  to  this  case. 
If  it  depends  upon  malformation  Of  the  bone  it  is  mani- 
festly incurable ; but  if  it  is  owing  to  a thickening  of 
the  soft  parts  within  the  meatus,  hopes  may  be  indulged 
of  doing  good  by  gtadually  dilating  the  passage  with 
tents,  which  should  be  increased  in  size  from  time  to 
time,  and  lastly  making  the  patient  wear,  for  a consi- 
uerable  time,  a tube  adapted  to  the  part  in  shape.— (Les- 
chevin  in  Prix  de  PA  cad.  de  Chh'urgie,  t.  9,p.  132.) 

Mr.  Earle  has  published  a case  in  which  the  diame- 
ter of  the  meatus  auditorius  was  considerably  lessened 
by  a thickening  of  the  surrounding  parts,  and  espe- 
cially of  the  cuticle,  attended  with  a discharge  from  the 
passage,  and  great  impairment  of  hearing.  A cure  was 
effected  by  injecting  into  the  passage  a very  strong  so- 
lution of  the  nitrate  of  silver,  which  in  a few  days 
was  followed  by  a detachment  of  the  thickened  por- 
tions of  cuticle.  This  evacuation  was  assisted  by 
throwing  warm  water  into  the  passage.— (See  Med.  Chir. 
TVans.  vol.  10,  p.  411,  <(  c.)  Boyer  was  consulted  fora 
deafness,  which  arose  from  a malformation  w hich  con- 
sisted of  a flattening  of  the  meatus,  its  opposite  sides 
being  for  some  extent  in  contact.  The  patient  was 
advised  to  wpar  in  the  ear  a gold  tube  of  suitable  shape 
by  which  means  he  was  enabled  to  hear  perfectly  well. 

4.  Faulty  Shape  of  the  Meatus  Auditorius  Externus, 

Anatomy  informs  us  that  this  passage  is  naturally 

oblique,  and  somewhat  winding  ; and  natural  philoso- 
phy teaches  us  the  necessity  of  such  obliquity,  which 
multiplies  the  reflections  of  the  sonorous  waves,  and 
thereby  strengthens  the  sense.  This  theory,  says  Les- 
chevin is  confirmed  by  experience ; for  there  are  per- 
sons in  whom  the  meatus  auditorius  is  almost  straight, 
and  they  are  found  to  be  hard  of  hearing.  If  there  is 
any  means  of  correcting  this  defect,  it  must  be  that  of 
substituting  for  the  natural  curvature  of  the  passage  a 
curved  and  conical  tube,  which  must  be  placed  at  the 
outside  of  the  organ,  just  like  a hearing  trumpet.  The 
acoustic  instrument  invented  by  Deckers,  which  is  much 
more  convenient,  might  also  prove  useftil.— (Ow.  cit.  p. 

133. ) 

5.  Extraneous  Substances,  Insects,  drc.  in  the  Meatus 

Auditorius  Externus. 

Foreign  bodies  met  with  in  this  situation  are  inert 
substances  w'hich  have  been  intioduced  by  some  exter- 
nal force;  in.sects,  which  have  insinuated  themselves 
into  the  passage;  or  the  cerumen  itself,  hardened  in- 
such  a degree  as  to,  obstruct  the  transmission  of  the 
.sono  ous  undulations.  Worms  which  make  their  ap- 
pearance in  the  meatus  auditorius  are  always  produced 
subsequently  to  ulcerations  in  the  passage,  or  in  the 
interior  of  the  tympanum,  and  very  often  .such  insects 
are  quite  unsuspected  causes  of  particular  symptoms. 
In  the  cases  of  surgerj'  published  in  17T8  by  Acrel, 
there  is  an  instance  confirming  the  statement  just  of- 
fered It  is  the  case  of  a w'oman  who,  having  been  long 
afflicted  with  a hardness  of  hearing,  was  suddenly 
seized  w’ith  violent  convulsions  without  any  apparent 
cause,  and  soon  afterward  complained  of  an  acute 
pain  in  the  car.  This  affection  was  followed  by  a re- 
currence of  convulsions,  which  were  still  more  vehe- 
ment. A small  tent  of  fine  linen  moistened  with  a mix- 
ture of  oil  and  laudanum,  was  introduced  into  the  meu- 


EAR. 


333 


tusauditorius,  and  on  removing  it  the  next  day  several 
small  round  worms  were  observed  upon  it,  and  from 
that  period  all  the  symptoms  disappeared.  To  this  case 
■we  shall  add  another  from  Morgagni.  A young  woman 
consulted  Valsalva,  and  told  him  that  when  she  was  a 
girl  a worm  had  been  discharged  from  her  left  ear; 
that  another  one  about  six  months  ago  had  also  been 
discharged  very  much  like  a small  silkworm  in  shape. 
This  event  took  place  after  very  acute  pain  in  the  same 
ear,-  the  forehead,  and  temples.  She  added,  that  since 
this  she  had  been  tormented  with  the  same  pains  at  dif- 
ferent intervals,  and  so  severely  that  she  often  swooned 
away  for  two  hours  together.  On  recovering  from  this 
state,  a small  worm  was  discharged,  of  the  same 
shape  as,  but  much  smaller  than  the  preceding  one,  and 
she  was  now  afflicted  with  deafness  and  insensibiltiy 
on  the  same  side.  After  hearing  this  relation  Valsalva 
no  longer  entertained  any  doubt  of  the  Inembrane  of  the 
tympanum  being  ulcerated.  He  proposed  the  employ- 
ment of  an  injection  in  order  to  destroy  such  worms  as 
yet  remained.  For  this  purpose  distilled  water  of  St. 
John’s  wort,  in  which  mercury  had  been  agitated,  was 
used.  In  order  to  prevent  a recurrence  of  the  incon- 
venience, Morgagni  recommends  the  aflected  ear  to  be 
closed  up  when  the  patient  goes  to  sleep,  in  autumn 
and  summer.  If  this  be  not  done,  flies,  attracted  by 
the  suppuration,  enter  the  meatus  auditorius,  and  while 
the  patient  is  unconscious  deposite  their  eggs  in  the 
ear.  Acrel,  in  speaking  of  tvorrns  generated  in  the 
meatus  auditorius,  observes,  that  there  is  no  better  re- 
medy for  them  than  the  decoction  of  ledum  palus- 
tra  injected  into  the  ear  several  times  a day.  How- 
ever, as  this  plant  cannot  always  be  procured,  an  in- 
fusion of  tobacco  in  oil  of  almonds  may  be  used,  a 
few  drops  of  which  are  to  be  introduced  into  the  ear 
and  retained  there  by.  meads  of  a little  bit  of  cotton. 
This  application,  which  is  not  injurious  to  the  lining 
of  the  passage,  is  fatal  to  insects,  and  especially  to 
worms.  When  caterpillars,  ants,  earwigs,  and  other 
insects,  have  insinuated  themselves  into  the  meatus 
auditorius,  they  may  be  removed  with  a piece  of  lint 
smeared  ■with  honey ; and  when  they  cannot  be  extract- 
ed by  this  simple  means,  they  may  sometimes  be  taken 
out  with  a small  pair  of  forceps.  In  general,  however, 
the  most  safe  and  expeditious  practice  for  the  removal 
of  small  insects,  peas,  beads,  and  other  extraneous 
bodies  from  the  meatus  auditorius,  is  to  throw  tepid 
water  into  the  passage  with  a proper  syringe,  by  which 
means  they  are  forced  out  with  the  fluid.  When  the 
bead  or  globular  substance  is  small  (according  to  Mr. 
Buchanan),  the  best  mode  of  extraction  will  be  by- 
means  of  a syringe  and  injection  of  tepid  w-ater.  For 
this  purpose  the  point  of  the  syringe  ought  to  be 
pressed  gently  against  the  edge  of  the  meatus,  so  that 
it  may  occupy  as  little  of  the  diameter  of  the  tube  as 
possible,  and  when  the  injection  arrives  at  the  mem- 
brana  tympani,  the  regurgitation  will  force  the  bead 
or  Other  substance  outwards.  If  this  be  rather  large, 
it  may  perhaps  remain  at  the  entrance  of  the  meatus, 
w'hence  it  ought  to  be  extracted  by  means  of  a pair  of 
forceps.— (See  Buchanan's  Illustrations  of  Jlcoustic 
Surgery,  p.  40.) 

A few  days  ago  (May,  18-29)  I was  called  to  a child 
about  two  years  and  a half  old,  into  one  of  who.se  ears 
a pebble,  and  into  the  other  a French  bean,  had  been 
pushed  by  another  child,  and  remained  there  for  ten 
months,  causing  complete  deafness  and  extreme  sufler- 
ing.  By  throwing  tepid  water  forcibly  into  the  ear,  I 
soon  dislodged  these  foreign  bodies,  which  lay  close 
against  the  tympanum,  entirely  hidden  by  the  swollen 
state  of  the  lining  of  the  ear,  indurated  wax  and  dried 
discharge.  With  a bent  probe  their  extraction  was 
then  readily  effected.  Several  surgeons,  previously 
consulted,  had  failed  in  their  endeavours  to  remove  the 
Kubstance.s  by  other  methods. 

The  presence  of  foreign  bodies  in  the  ear  often  occa- 
sions the  mo.st  extraordinary  symptoms,  as  we  may' 
see  in  the  fourth  observation  of  Fabricius  Hildanus, 
(lent.  13  After  four  surgeons,  who  had  been  succes- 
sively consulted,  had  in  vain  exerted  all  their  industry 
to  extract  a bit  of  glass  from  the  left  ear  of  a young 
girl,  the  patient  found  herself  abandoned  to  the  most 
excruciating  pain,  which  soon  extended  to  all  the  side  i 
of  the  head,  and  which,  after  a considerable  lime,  was  ' 
followed  by  a paralysis  of  the  left  side,  a dry  cough, 
suppression  of  the  menses,  epileptic  convulsions,  and  i 
at  length  an  atrophy  of  the  left  arm  Hildanus  cured  < 


1 her  by  extracting  the  piece  of  glass  w liich  had  rr- 
I mained  eight  years  in  her  ear,  and  had  been  the  cause 
! of  all  this  disorder.  Although  the  extraction  must 
1 have  been  very  difficult,  it  does  not  appear  that  Hilda- 
I nus  found  it  necessary'  to  practise  an  incision  behind 
; the  ear,  as  some  authors  have  advised,  and  among 
them  Duvemey,  'W'ho  has  quoted  the  foregoing  case. 
We  must  agree  with  Leschevin  that  such  an  incision 
does  not  seem  likely  to  facilitate  the  object  very  ma- 
terially ; for  it  must  be  on  the.  outside  of  the  extrane- 
ous substance,  w’hich  is  in  the  bony  part  of  the  canal. 
The  incision  enables  us.  in  some  measure  to  avoid  the 
obliquity  of  the  passage,  as  Duverney  has  observed ; 
but  it  is  not  such  obliquity  of  the  cartilaginous  portion 
of  the  canal  that  can  be  a great  impediment ; for  as  it 
is  flexible  it  may  easily  be  made  straight  by  drawing 
• the  external  ear  upwards.  Hence  Fabricius  ab  Aqua- 
pendente  rejected  this  operation  first  proposed  by  Pau- 
lus  jEgineta  ; and  it  is  justly  disapjjroved  of  by  Lesche- 
vin.— {Prix  de  I’Acad.  de  Chir.  t.  9,  p.  147,  edit.  l2mo.) 

Sabatier  relates  a case  in  which  a paper  ball,  which 
had  been  pushed  into  the  meatus  auditorius,  made  its 
way  by  ulceration  into  the  cavity  of  the  tympanum, 
where  an  abscess  formed,  w'hich  communicated  with 
the  interior. of  the  cranium. — 'Diet,  dcs  Sciences  Mid, 
t.  7,  p.  8.) 

6.  Meatus  Jluditorius  ohstmeted  with  thickened  or 
hardened  Cerumen. 

The  cerumen  secreted  in  the  meatus  auditorius  by 
the  sebaceous  glands  frequently  accumulates  there  in 
large  quantities,  and,  becoming  harder  and  harder,  at 
length  acquires  so  great  a degree  of  solidity  as  en- 
tirely to  deprive  the  patient  of  the  power  of  hearing. 
Galen. has  remarked,  e numero  eorum  quae  meatum 
obstruunt,  sordes  esse  qua:  in  auribus  coUigi  solent 
This  species  of  deafness  is  one  of  those  kinds  which 
are  the  most  easy  of  cure,  as  is  confirmed  by  observers, 
especially  Duverney.  Formerly,  frequent  injections 
either  with  simple  olive  oil  or  oil  of  almonds  were  re- 
commended. The  injection  was  retained  by  a piece  of 
cotton,  and  w'hen  there  was  reason  to  believe  that  the 
matter  was  sufficiently-  softened,  an  attempt  was  made 
to  extract  it  by  means  of  a small  scoop-like  instru- 
ment. Various  experiments  were  made  by  Haygarth, 
at  (Chester,  in  1769,  from  which  it  ajjpears  that  warm 
water  is  preferable  to  oil.  The  w'aier  dissolves  the 
mucous  matter  which  connects  together  the  truly  ceru- 
minous particles,  and  w hich  is  the  cause  of  their  tena- 
city ; other  applications  only  succeeding  by  reason  of 
the  water  which  they  contain. 

The  lodgementof  hard  pellets  of  tvax,  if  neglected, 
may  ultimately  produce  ulceration  of  the  tympanum 
and  other  serious  mischief.  Thus,  in  one  case,  Ribes 
and  Chaussier  found  the  handle  of  the  malleus  sepa- 
rated from  its  head,  partly  destroyed  and  covered  with 
the  hardened  cerumen  that  had  made  its  way  into  the 
tympanum. — (See  Diet,  des  Sciences  Mid.  t.  38,  p.  30.) 

‘‘ The  symptoms  (says  Mr.  Sau.nders)  whicli  are  at-, 
tached  to  the  inspissation  of  the  cerumen  are  pretty 
v'ell  known.  The  patient,  besides  his  inability  to 
hear,  complains  of  noises,  particularly  a clash  or  con- 
fused sound  in  mastication,  and  of  heavy  sounds,  like 
the  ponderous  strokes  of  a hammer. 

The  practitioner  is  led  by  the  relation  of  such  symp- 
toms to  suspect  the  existence  of  wax ; but  he  may  re- 
duce it  to  a certainty  by  examination. 

Ahy  means  capable  of  removing  the  inspissated 
wax  may  be  adopted ; but  syringing  the  meatus  with 
warm  water  is  the  most  speedy  and  effectual,  and  the 
only  means  necessary.  As  the  organ  is  sound,  the  pa- 
tient is  instantaneously  restored.” — {Anatomy  of  the 
human  Ear,  with  a Treatise  on  its  Diseases,  by  J.  C. 
Saurulers,  1806,  p.  27,  28.) 

In  order  to  throw  an  injection  into  the  ear  •vvith  effect, 
a syringe  capable  of  holding  from  four  to  six  ounces, 
should  be  emi)loyed  ; and  the  fluid  injected  with  a good 
deal  of  force,  care  being  taken  to  let  it  enter  in  the  na- 
tural direction,  and  not  against  one  of  the  sides  of  the 
passage.  The  surgeon  must  also  avoid  pressing  the 
pipe  too  deeply  into  the  car,  .so  as  to  hurt  the  tyiri|)anum. 
As  the  fluid  regurgitates  with  con.siderable  rapidity,  a 
small  basin  is  to  be  held  close  up  to  the  ear  at  the  time 
of  using  the  syringe,  so  as  to  catch  the  water  and 
hinder  it  from  wetting  the  patient’s  clothes;  for  the 
surer  prevention  of  w hich  a napkin  is  also  to  be  laid 
over  the  shoulder.  In  general,  it  is  necessary  to  throw 


334 


EAR. 


the  water  into  the  ear  six  or  seven  times,  or  more,  ere 
the  pellets  of  wax  are  loosened  and  entirely  brought 
out ; and  sometimes  the  injections  will  not  completely 
succeed  the  first  day  on  which  they  are  employed. 
The  evening  before  the  syringe  is  to  be  used,  it  may 
occasionally  be  best  to  drop  a little  sweet  oil  into  the  ear. 

7.  Imperfect  Secretion  of  Wax. 

When  the  wax  is  deficient  in  quantity,  Mr.  Bucha- 
nan recommends  warmth  and  stimulant  applications. 
He  advises  two  drops  of  the  following  mixture  to  be 
introduced  into  the  meatus  auditorius,  every  night  at 
bedtime.  Acid,  pyrolygn.,  spir.  aetheris  sulphur., 
Ol.  terebinth,  a a M.  One  tablespooiiful  of  the  fol- 
lowing medicine  is  also  to  be  taken  at  the  same  time. 
R.  Tinct.  colchici  3 iij.  Aq.  distillat.  I vj.  M.  If  cos- 
tiveness prevail,  the  pilulte  rhei  comp,  are  to  be  given. 
— (See  Buchanan^ s Jicorastic  Surgery, p.  60.) 

When  the  quality  of  the  secretion  requires  improve- 
ment, the  meatus  is  to  be  frequently  washed  out,  and  a 
little  of  the  infusion  of  quassia  with  rhubarb  and  mag- 
nesia given  once  or  twice  a day.  The  warm  bath  is 
to  be  occasionally  used  at  bedtime,  and  the  (bllowing 
powder  exhibited.  U.  Hydrarg.  subraur.  gr.  ij.  Pulv. 
ipecac,  comp.  3j.  ft.  Pulv.  Hora  decubitus  sutnend. 
In  cases  where  the  ear  is  preteriiaturally  dry,  and  the 
cuticle  of  the  meatus  peels  off,  the  ensuing  injection  is 
to  be  used  every  second  or  third  day.  It.  Acid,  pyro- 
lign.  3ij.  AqufB  distillalae  3Vj.  ft.  lofio;  or  the  vapour 
of  a mixture  of  equal  parts  of  distilled  water  and  pyro- 
ligneous acid  might  be  introduced'  three  times  a week 
into  the  meatus  with  the  aid  of  a glass  retort.  A little 
cotton  should  afterward  be  put  into  the  ear.— (See 
Buchanan's  Acoustic  Surgery,  p.  62.) 

8.  Discharges  from  the  Meatu?  Auditorius. 

Purulent  discharges  from  the  ear  either  come  from 
the  meatus  auditorius  externus  itself,  or  they  originate 
from  suppuration  in  the  tympanum,  in  consequence  of 
blows  on  the  head,  abscesses  after  malignant  fevers, 
the  small-pox,  or  the  venereal  disease.  In  such  cases, 
the  little  bones  of  the  ear  are  sometimes  detached,  and 
escape  externally,  and  complete  deafness  is  most  fre- 
quently the  consequence.  However,  in  a few  instances, 
total  deafness  does  not  always  follow  even  this  kind  of 
mischief,  as  I myself  have  witnessed  on  one  or  two 
occasions.  There  is  greater  hope  when  the  disorder  is 
confined  to  the  meatus ; as  judicious  treatment  may 
now  avert  the  most  serious  consequences.  In  Acrel’s 
surgical  cases,  there  is  a case  relative  to  the  circum- 
stance of  which  w^e  are  speaking.  Suppuration  took 
place  in  the  meatus  auditorius  externus,  in  conse- 
quence of  acute  rheumatism,  which  was  Ibllowed  by 
vertigo,  restlessness,  and  a violent  headache.  The  mat- 
ter discharged  was  yellowish,  of  an  aqueous  consist- 
ence and  acid  smell.  The  meatus  auditorius  was 
filled  with  a spongy  fiesh.  On  introducing  a probe, 
our  author  felt  a piece  of  loose  rough  bone,  which  he 
immediately  took  hold  of  with  a pair  of  forceps  and 
extracted.  From  the  time  when  this  was  accom- 
plished the  discharge  diminished ; and  with  the  aid  of 
proper  treatment,  the  patient  became  perfectly  well. 

The  meatus  auditorius,  like  all  other  parts  of  the 
body,  is  subject  to  inflammation.  This  is  frequently 
produced  by  exposure  to  cold.  It  is  hardly  necessary 
to  say,  that  generally  topical  bleeding  and  antiphlo- 
gistic means  are  indicated.  The  meatus  auditorius 
should  also  be  protected  from  the  cold  air,  particularly 
in  the  winter  season,  by  means  of  a piece  of  cotton. 

Mr.  .Saunders  observes,  “ When  the  means  employed 
to  reduce  the  inflammation  have  not  succeeded,  and 
matter  has  formed,  it  is  generally  evacuated,  as  far  as 
I have  observed,  between  the  auricle  and  mastoid  pro- 
cess or  into  the  meatus.  If  it  has  been  evacuated  into 
the  meatus,  the  opening  is  most  commonly  smali,  and 
the  spongy  granulations,  squeezed  through  a small 
ajierture,  assume  the  appearance  of  a polypus.  Some- 
times the  smalt  aperture  by  which  the  matter  is  eva- 
cuated is  in  this  manner  even  closed,  and  the  patient 
suffers  the  inconvenience  of  frequent  returns  of  pain 
from  the  retention  of  the  discharge.  When  the  parts 
have  fallen  into  this  state,  it  will  be  expedient  to  hasten 
the  cure  by  making  an  incision  into  the  sinus,  between 
the  auncle  and  mastoid  process. 

It  occasionally  happens  that  the  bone  itself  dies  in 
consequence  of  the  sinus  being  neglected,  or  the  origi- 
nal extent  of  the  3Ui)puration.  The  exfoliating  parts 


are  the  meatus  externus  of  the  os  temporis,  or  the  e36« 
ternal  lamina  of  the  mastoid  process.”— (P.  24,  25.) 

In  some  examples  of  purulent  discharge  from  the 
ear,  and  particularly  in  scrofulous  patients,  Mr.  Bucha- 
nan employs  alterative  medicines,  as  calomel,  the 
tincture  of  iodine,  and  the  compound  rhubarb  ihlls  of  the 
Edinb.  Pharmacopoeia.  He  also  sometimes  has  re- 
course to  the  pyroligneous  injection.— (See  Illustra- 
tions of  Acoustic  Surgery,  p.  93,  &c.)  Some  addi- 
tional cases  in  favour  of  the  efficacy  of  iodine,  in  cer- 
tain forms  of  deafness  may  be  found  in  Dr.  Manson’s 
work. — {See-Medical  Researches  07i  the  Effects  of  Iodine, 
8vo.  London,  1825.) 

9.  Excrescences  in  the  Meatus  Auditorius. 

Though  the  membrane  lining  the  meatus  auditorius 
is  very  delicate,  it  is  not  the  less  liable  to  become 
thickened,  and  to  form  polypous  excrescences.  This 
case,  however,  is  not  common.  As  such  tumours  are 
ordinarily  firmer  in  their  texture  than  polypi  of  the 
nose,  they  are  sometimes  not  so  easily  extracted  with 
forceps.  When  they  are  situated  near  the  external 
orifice,  and  admit  of  being  taken  hold  of  with  a small 
pair  of  forceps  or  a hook,  and  drawn  outwards,  they 
may  easily  be  cut  away.  When  the  tumours  are 
more  deeply  situated,  Mr.  B.  Bell  recommends  the  use 
of  a ligature.  Here  the  same  plan  may  be  pursued  as 
will  be  explained  in  the  article  Polypus.  But  it  some- 
times happens,  that  the  excrescences  cannot  be  re- 
moved in  this  manner ; as,  instead  of  being  adherent 
by  a narrow  neck,  they  have  a broad  ba.se,  which  oc- 
cupies a considerable  extent  of  the  passage.  In  such 
cases,  the  use  of  escharotics  has  been  proposed  ; but 
they  cannot  be  used  without  risk  of  injuring  the  tym- 
panum. Mr.  Buchanan  prefers  the  practice  of  remov- 
ing polypi  of  the  meatus  with  forceps,  and  afterward 
touching  the  part  from  which  they  grew  with  the  ung. 
hydrarg.  nitrat.,  or  tinct.  ferrt  muriati. — {.dcoustic  Sur- 
gery, p.  74.)  lie  also  recommends  washing  out  the 
l)assage  every  day  with  the  injection,  ht.  Acid,  pyro- 
lign.  3 ij.  Aq.  distillatae  svj.  ft.  Ictio. 

. 10.  Herpes  of  the  Meatus  Auditorius. 

An  herpetic  ulcerous  eruption  sometimes  affects  the 
meatus  auditorius  and  auricle,  producing  considerable 
thickening  of  the  skin,  and  so  great  an  obstruction 
of  the  passage  that  a good  deal  of  deafness  is  the 
consequence.  Mr.  Saunders  remarks,  that  in  this 
case,  “ the  ichor  which  exudes  from  the  pores  of  the 
ulcerated  surface,  inspissates  in  the  meatus,  and  not 
only  obstructs  the  entrance  of  sound,  but  is  accompa- 
nied with  a great  degree  of  fetor.  This  disease  is  not 
unfrequent.  I have  never  seen  it  resist  the  effect  of  al- 
terative medicines,”  the  use  of  injections  containing 
the  oxymuriate  of  quicksilver,  and  the  application  of 
the  unguentum  hydrargyri  nitrati.  Mr.  Saunders  ex- 
hibited calomel  as  the  alterative,  and  in  one  instance, 
employed  a solution  of  the  argentum  nitratum  as  an 
injection. — (Pag^e  25,  26.)  Whenthedisea.se  is  obsti- 
nate, a seton  should  be  made  on  the  nape  of  the  neck, 
or  a blister  be  applied  behind  the  ear.  The  tincture  of 
iodine  should  also  be  tried. 

11.  Affections  of  the  Tympanum. 

The  ear  is  sometimes  affected  with  apuriform  ichor- 
ous discharge,  attended  with  a loss  of  hearing,  pro- 
portionate to  the  degree  of  disorganization  which  the 
tympanum  has  sustained.  Frequently,  on  blowing 
the  nose,  air  is  expelled  at  the  meatus  auditorius  ex- 
ternus; and  when  this  is  the  case,  it  is  evident  that 
the  discharge  is  connected  xvith  an  injury  or  destruc- 
tion of  the  ihembrana  tympani.  However,  when  the 
Eustachian  tube  is  obstructed  with  mucus  or  matter, 
or  when  it  is  rendered  impervious,  and  permanently 
closed  by  inflammation,  the  membrana  tympani  may 
not  be  perfect,  and  yet  it  is  clear,  no  air  can  in  this 
state  be  forced  out  of  the  external  ear  in  the  above 
manner.  An  examination  with  a blunt  probe  or  with 
the  eye,  while  the  rays  of  the  sun  fall  into  the  passage, 
should  therefore  not  be  omitted.  If  the  membrane 
have  any  aperture  in  it,  the  probe  will  jiass  into  the  ca- 
vity of  the  tympanum,  and  the  surgeon  feel  that  his  in- 
strument is  in  coiitact  with  the  ossicula. 

In  this  manner  the  affection  may  be  discriminated 
from  an  herpetic  ulceration  of  the  meatus  auditorius 
externus.  The  causes  are  various : In  scarlatina  ma- 
ligna, the  membrana  tympani  occasionally  inflamc.s, 
and  slouglis;  all  the  ossicula  are  discharged,  and  if  the 


EAR. 


335 


patient  live,  he  often  continues  quite-deaf.  An  earache, 
111  other  words,  acute  inflammation  of  the  tympanum, 
is  the  most  common  occasion  of  suppuration  in  this 
cavity,  in  which,  and  the  cells  of  the  mastoid  process, 
a good  deal  of  pus  collects.  At  length  the  membrana 
tympani  ulcerates,  and  a large  quantity  of  matter  is 
discharged;  but  as  the  secretion  of  pus  still  goes  on, 
the  discharge  continues  to  ooze  out  of  the  external  ear. 

Instead  of  stimulating  applications,  inflammation  of 
the  tympanum  demands  the  rigorous  employment  of 
antiphlogistic  means.  Unfortunately,  it  is  a too  com- 
mon practice  in  this  case  to  have  recourse  to  acrid  spi- 
rituous remedies.  Above  all  things,  the  repeated  ap- 
plication of  leeches  to  the  skin  behind  the  external  ear 
and  over  the  mastoid  process,  should  never.be  neglected. 
As  soon  as  the  inflammation  ceases,  the  degree  of  deaf- 
ness occasioned  by  it  will  also  disappear.  This,  how- 
ever, does  not  always  happen. 

When  an  abscess  is  situated  in  the  cavity  of  the 
tympanum,  Mr.  Saunders  thinks  that  the  membrana 
tympani  should  not  be  allowed  to  burst  by  ulceration, 
but  be  opened  by  a small  puncture. — (P.  31 .)  However, 
unless  there  were  the  strongest  ground  for  believing  that 
the  Eustachian  tube  were  impervious,  this  advice,  I 
think,  ought  not  to  be  followed,  more  especially  as  the 
symptoms  are  generally  too  vague  to  afford  any  degree 
of  certainty  in  the  diagnosis. 

Sometimes  the  disease  of  which  we  are  treating,  is 
more  insidious  in  its  attack;  slight  paroxysms- of  pain 
occur,  and  are  relieved  by  slight  discharges.  The  case 
goes  on  in  this  way,  until,  at  last,  a continual  dis- 
charge of  matter  from  the  ear  takes  place.  The  dis- 
order is  destructive  in  its  tendency  to  the  faculty  of 
hearing,  and  it  rarely  stops  until  it  has  so  much  disor- 
ganized the  tjnnpanum  and  its  contents,  as  to  occasion 
total  deafness.  Hence,  Mr.  Saunaers  insists  upon  the 
propriety  of  making  attempts  to  arrest  its  progress, — 
attempts  which  are  free  from  danger ; and  he  censures 
the  foolish  fear  of  interfering  with  the  complaint, 
founded  on  the  apprehension,  that  bad  constitutional 
effects  may  originate  from  stopping  the  dis(;harge. 

If  the  case  be  neglected,  the  tympanum  is  very  likely 
to  become  carious  ; before  which  change,  the  disease, 
says  Mr.  Saunders,  is  mostly  curable. 

Mr.  Saunders  divides  the  complaint  into  three  stages : 
1.  A simple  puriform  discharge.  2.  A puriform  dis- 
charge complicated  with  fungi  and  polypi.  3.  A puri- 
form discharge  with  caries  of  the  tympanum.  ' As  the 
disease  is  local,  direct  applications  to  the'  parts  affected 
are  chiefly  entitled  to  confidence.  Blisters  and  setons 
may  also  be  advantageously  employed.  Mr.  Saun- 
ders’s practice  consisted  in  administering  laxative  medi- 
cines and  fomenting  the  ear,  while  inflammatory  symp- 
toms lasted,  and  afterward  injecting  a solution  of  the 
sulphate  of  zinc  or  cerussa  acetata. 

In  the  second  stage,  when  there  were  fungi,  he  re- 
moved or  destroyed  them  with  forceps,  afterward 
touched  their  roots  with  the  argentum  nitratum,  or  in- 
jected a solution  of  alum,  sulphate  of  zinc,  or  argen- 
tum nitratum. 

Writers  describe  a relaxed  state  of  the  membrana 
tympani  as  a cause  of  deafness.  If,  says  a late  author, 
after  a discharge  fiom  the  meatus  auditorius  externus, 
or  cavity  of  the  tympanum,  or  a dropsy  of  the  latter  ca- 
vity, the  hearing  remains  hard,  there  is  reason  to  sus- 
pect that  the  infirmity  may  depend  upon  relaxation  of 
the  membrane  of  the  tympanum  or  paralysis  of  the 
internal  muscle  of  the  malleus.  This  suspicion  will 
be  strengthened  if  the  deafness  should  increase  in 
damp  and  lessen  in  dry  weather;  and  particularly,  if 
it  be  found  that  the  hearing  is  benefited  by  introdu- 
cing into  the  ear  dry  warm  tonic  applications,  such  as 
the  smoke  of  burning  juniper-berries  or  other  astrin- 
gent vegetable  substances.  The  decoction  of  bark, 
used  as  an  injection,  is  also  said  to  have  done  good. 

The  relaxation  of  the  tympanum,  alleged  to  proceed 
from  a rupture  of  the  muscle  of  the  malleus,  is  deemed 
incurable  ; but  it  is  not  so  with  the  case  which  depends 
upon  paralysis  of  this  muscle.  Here  tonic  injections 
into  the  tympanum,  through  the  Eustachian  tube,  are 
recommended.— (Hict.  des  Sciences  Med,  t 38,  p.  50.) 
Electricity,  stimulating  liniments,  gargles,  and  a blis- 
ter, might  also  be  tried. 

Imperfect  hearing  is  supposed  sometimes  to  arise 
firom  preternatural  ten.sion  of  the  membrane  of  the  tym- 
panum, indicated  by  the  patient  hearing  better  in  wet 
than  dry  weather,  and  by  his  hearing  what  is  spoken 


in  a low  tone  near  his  ear  better  than  any  thing  said  in 
a loud  manner.  The  opinions  delivered  by  writers  on 
the  causes  of  this  affection  are  only  uncertain  con- 
jectures. The  local  treatment  recommended  consists 
of  injecting  into  the  meatus  auditorius  emollient  de- 
coctions or  warm  milk,  or  introducing  into  the  passage 
a dossil  of  soft  cotton,  dipped  in  oil  of  sweet  almonds. 
Nothing  certain  is  known  respecting  the  proper  con- 
stitutional treatment,  as  must  be  clear  from  our  igno- 
rance of  the  causes  of  this  form  of  disease  of  the  ear. 

Hardness  of  hearing  appears  sometimes  to  be  caused 
by  a chronic  thickening  of  the  membrane  of  the  tym- 
panum ; and  it  is  alleged,  that  there  are  cases  of  this 
description  wliich  proceed  from  syphilis,  and  require 
mercury.  An  issue  in  the  arm  nearest  the  affected 
ear,  the  tincture  of  iodine,  and  emollient  and  slightly 
stimulant  injections,  are  likewise  commended.  When 
the  tympanum  was  so  considerably  thickened,  that 
there  was  no  chance  of  restoring  it  to  a healthy  sta>3. 
Portal  questioned  whether  it  might  not  be  advisable  to 
make  a small  opening  in  ill— {Precis  de  Cliir.  Pratique, 
t.  2,  p.  430.)  This  operation  which  is  said  to  have  been 
first  suggested  by  Cheselden,  wilt  be  considered  in  tlte 
ensuing  section'. 

Morgagni  found  the  cavity  of  the  tympanum  inter- 
sected by  numerous  membranes,  which  impeded  the 
movements  of  the  ossicula. — {Epist.  an.  6,  ^ 4.) 

Meckel  does  not  mention  any  example  ol'a  deficiency 
of  all  the  ossicula.— des  Pathol.  Anat.  b.  \,p. 
402.)  Mersanni,  however,  found  the  incus  wanting. — 
{Bonet  Sepulch.  1. 1,  sect.  ID,  obs.  4,  ^ 1.)  Catdani,  the 
malleus  and  incus.— (Epist.  ad  Haller,  t.  6,  p.  142.) 
The  latter  case  was  unattended  with  any  bad  effect  on 
the  hearing  ; the  first  with  deafness.  In  a deaf  child 
three  years  of  age,  Bailly  found  the  ossicula  of  only  one- 
third  their  proper  size.—  (Bonet  Sepulch.  t.  I,.<?gct.l9,  obs. 
4,  3.)  In  an  example  where  the  fenestra  rotunda  was 

obstructed,  Cotunni  found  the  ossicula  twice  as  large 
as  natural. — {De  Labyrinthi  Auris  contentis,  $ 72,  and 
Meckel's  Handb.  des  Pathol.  Anat.  6.  1,  p.  402.)  A 
case  in  which  all  the  ossiculi  were  wanting,  is  now  on 
record. — (See  Diet,  des  Sciences  Med.  t.  38,  p.  1 14.) 

12.  Obstruction  of  the  Eustachian  Tube. 

■ This  is  often  a cause  of  a considerable  degree  of  deaf- 
ness, because  it  is  necessary  for  perfect  hearing,  that 
air  should  be  conveyed  from  the  mouth  through  this 
passage  into  the  cavity  of  the  tympanum,  which  now 
can  no  longer  happen. 

A degree  of  deafness  generally  attends  a severe  cold, 
which  is  accounted  for  by  the  Eustachian  tube  being 
obstructed  with  thickened  mucus.  Mr.  Saunders  tells 
us.  that  the  obstruction  mo.st  frequently  arises  from 
syphilitic  ulcers  in  the  throat,  or  sloughing  in  the 
cynanche  maligna.  The  deafness  comes  on  when 
such  sores  are  healed ; that  is,  when  the  obstruction  is 
complete.  The  descent  of  a nasal  polypus  into  the 
pharynx,  and  enlarged  tonsils,  have  also  been  known 
to  close  the  tube.— (P.  42.) 

When  the  Eustachian  tube  is  obstructed,  the  patient 
cannot  feel  the  membrana  tympani  crackle,  as  it  were, 
in  his  ear,  on  blowing  forcibly  with  his  nose  and 
mouth  stopped.  Previous  ulceration,  or  disease  of  the 
throat  will  sometimes  facilitate  the  diagnosis. 

When  the  Eustachian  tube  is  obstructed  with  mu- 
cus, it  has  been  proposed  to  employ  injections,  which 
are  to  be  thrown  by  means  of  a syringe  and  catheter,  ‘ 
into  the  guttural  orifice  of  that  canal.  This  operation’ 
however,  is  alleged  to  be  always  attended  with  trouble; 
and,  when  the  os  spongiosum  inferius  happens  to  be 
situated  near  the  floor  of  the  orbit,  the  introduction  of 
any  instrument,  like  a female  catheter,  would  be  im- 
practicable.— {Richerand,  Nosogr.  Chin  t.  2,  p.  131, 
td.  2.) 

Sir  A.  Cooper  had  noticed,  that  hearing  was  only  im- 
paired, not  lost,  when  suppurations  in  the  tympanum 
had  injured  and  even  destroyed  the  membrana  tympani, 
and  that  the  degree  of  deafness  by  no  means  equalled 
what  resulted  from  ati  obstruction  of  the  Eustachian 
tube.  Hence,  when  the  tube  was  permanently  ob- 
literated, he  conceived  that  a small  puncture  of  the 
membrana  tympani  mig’it  be  the  means  of  enabling 
the  patient  to  hear.  This  gentleman  reports  four 
cases,  in  which  the  experiment  w'as  made  wilh  success. 

The  operation  consists  in  introducing  an  instrument, 
resembling  a hydrocele  trocar,  but  curved,  into  the 
meatus  auditorius  externus,  and  pushing  it  through 


336 


EAR. 


the  anterior  and  inferior  part  of  the  membrana  tym- 
pani ; a place  rendered  most  eligible  on  account  of  the 
situation  of  the  corda  tympani  and  manubrium  of  the 
malleus,  parts  which  should  be  left  uninjured.  The 
instrument  must  not  be  introduced  far,  lest  it  wound 
the  vascular  lining  of  the  tjTnpanum,  and  cause  a tem- 
porary continuance  of  the  deafness,  by  an  effusion  of 
blood.  When  the  puncture  is  made  in  proper  cases 
and  in  a judicious  manner,  hearing  is  immediately 
restored.  A small  hole  in  the  membrana  t5'mpani  now 
conveys  the  air  into  the  cavity  of  the  tympanum,  an- 
swering the  same  purpose  tis  the  Eustachian  tube. 

The  surgeon  will  be  able  to  operate  with  more  ease, 
if  he  take  care  to  lessen  the  curvature  of  the  meatus 
auditorius  by  drawing  upwards  the  external  ear. 

There  is  some  chance  of  a relapse  in  consequence  of 
the  opening  closing  up.  This  consideration  led  Riche- 
rand  to  propose  making  the  aperture  vrith  caustic,  so 
as  to  destroy  a part  of  the  membrane.— (A’osogr.  Chir. 
t.  2,  p.  132,  ed.  2.)  The  suggestion  is  not  likely  to  be 
adopted,  on  account  of  the  inconveniences  of  applying 
caustic  within  the  ear.  Mr.  Saunders  is  an  advocate 
for  making  the  opening  large.  However,  perhaps  the 
best  method  of  doing  the  operation  both  effectually  and 
safely  is  that  lately  described  by  Mr.  Buchanan,  of 
Hull,  the  chief  peculiarity  of  whose  mode  con.sists  in 
drilling  the  perforation.  The  quadraugubar  point  of 
his  perforator  cuts  the  fibres  of  the  membrana  tym- 
pani across ; they  retract ; the  wound  assumes  an  oval 
shape;  and  there  is  less  danger  of  its  closure  again, 
than  after  the  common  plan  of  making  a single  punc- 
ture. “ A room  (says  Mr.  Buchanan),  with  a window 
fronting  the  south,  should  be  chosen  for  the  place  of 
the  operation ; and  the  patient  placed  on  a low  seat, 
80  that  the  rays  of  the  sun  may  fall  into  the  meatus. 
The  manubrium  or  handle  of  the  malleus,  will  then  be 
distinctly  seen,  pointing  downwards  and  inwards ; oc- 
cupying the  superior  half  of  the  membrana  tympani. 
The  surgeon  being  seated  on  a high  chair,  should  lay 
his  left  hand  on  the  head  of  the  patient,  and  tvith  the 
right  take  hold  of  the  instrument  in  the  same  manner 
as  he  would  a pen  when  writing;  he. should  then  cau- 
tiously and  steadily  enter  the  point  of  the  perforator 
into  the  membrana  tympani,  about  half-way  between 
the  centre  and  its  lower  edge,  and  with  the  thumb  and 
index  finger,  give  the  instrument  half  a turn  one  way 
and  then  half  a turn  the  other,  and  in  this  manner 
gently  push  the  point  about  a line  through  the  mem- 
brane.”— (See  Engraved  Represerdation  of  the  ^dna- 
tomy  of  the  Ear,  p.  33.)  Mr.  Saunders,  by  puncturing 
the  tympanum,  instantaneously  restored  the  hearing 
of  one  patient,  who  had  been  deaf  thirty  years  in  con- 
sequence of  a destruction  of  a part  of  his  palate  by  sy- 
philis.— (P.  45  ) 111  an  instance  where  a young  man 
had  been  deaf  for  eight  years,  apparently  from  obstruc- 
tion of  the  Eustachian  tube  by  swellings  and  disease 
about  the  throat,  Paroisse  also  restored  the  hearing 
directly,  by  perforating  the  anterior  and  inferior  part 
of  the  tympanum. — r,Opuscides  de  Chir.  p.  309^  Suo. 
Paris,  1806.)  The  practice  has  also  been  successfully 
adopt^  by  Michaelis  in  one  case,  and  Hunold  has 
tried  it  in  a vast  number  of  examples,  two-thirds  of 
which  succeeded. — (Diet,  des  Sciences  Med.  t.  38,  p.  63.) 
Sir  A.  Cooper's  ca-ses  are  in  the  Phil.  Trans,  for  1802. 

Puncturing  the  membrana  tympani  has  been  attended 
with. some  degree  of  success  in  France,  where  it  has 
been  tried  by  Itard,  Celliez,  and  Maunoir,  Ac.  It  is 
•not  to  be  dissembled,  however,  that  it  is  liable  to  fail- 
ure. Dubois  performed  the  operation  in  four  instances, 
without  success. — (Richerand,  Nosogr.  Chir.  t.  2,  p. 
132.)  ■ 

In  most  cases  the  patients  benefited  are  said  to  have 
experienced  pain  just  after  the  trocar  was  withdrawn 
The  organ,  not  being  accustomed  to  sound,  had  become 
so  e.xtremely  sensible,  that  it  could  not  bear  the  gentlest 
impression  of  the  sonorous  vibrations ; and  the  patient’s 
first  request,  after  the  perforation- had  been  made,  was, 
that  persons  near  him  might  speak  softly.  This  ex- 
cessive tenderness  of  the  sense  gradually  subsides. 

The  two  principal  objections  made  to  the  foregoing 
practice  are,  the  risk  of  injuring  that  jiart  of  the  tym- 
panum which  is  connected  w iih  the  malleus,  and  the 
tendency  of  the  puncture  to  heal  up  again. — (See  Diet, 
des  Sciences  M d.  t.  38,  p.  57  ; Mavnmr  in  Journ.  de 
Mid.  t.  13 ; Sabatier,  Trait-  cT.^natomie,  t.  2,  p.  186.) 
Tlie  author  of  the  article  Oreille  in  the  latter  dictionary, 
who  cannot,  however,  be  deemed  at  all  partial  to  tlie 


operation,  delivers  the  following  judgment  conccniing 
it;— 1.  It  is  the  only  operation  which  is  likely  to  an- 
swer where  the  tympanum  is  cartilaginous  or  ossified, 
and  the  rest  of  the  organ  is  sound.  2.  It  will  be  attended 
with  some  success  where  the  Eustachian  tube  is  closed, 
and  this  defect  cannot  be  otherwise  removed.  3.  It  will 
be  useless  where  the  cavity  of  the  tj-mpanum  is  filled 
with  matter,  which  is  too  thick  to  escape  through  the 
puncture.  4.  WTien  deafness  depends  on  paralvsis  of 
the  auditory^  nerve.  5.  When  the  infinnity  arises  from 
inflammation  of  the  ear  or  nervous  irritation.  6.  From 
fevers,  the  Eustacliian  tube  being  pervious. 

The  limits  of  this  work  will  not  allow  me  to  intro- 
duce the  directions  given  by  various  authors  for  in- 
jecting fluids  into  the  Eustachian  tube.  Wathen,  Ba- 
ron Boyer,  Itard,  Buchanan,  and  the  latest  surgeons 
who  have  considered  this  operation,  seem  to  agree,  that 
it  is  more  easily  performed  by  passing  the  tube  through 
one  of  the  nostrils  than  the  mouth.  Wathen’s  instru- 
ments are  described  in  Phil.  Trans.  1794;  those  of 
Baron  Boyer  in  Traite  des  Mai.  Chir.  t.  6,p.  391 ; those 
of  M.  Itard,  wltich  deserve  particular  notice,  in  his 
Traite  des  Mai.  de  V Oreille ; and  tliose  of  another  mo- 
dern advocate  for  this  operation,  in  Diet,  des  Sciences 
Med.  t.  3S,p.  108.  The  latter  author,  after  stating  how 
his  tubes,  which  are  four  French  inches  in  length,  and 
shaped  somewhat  like  an  italic  S,  are  introduced,  enu- 
merates the  following  as  the  advantages  derived  from 
their  emplojment.  1.  Fluid  applications  may  be  con- 
veyed into  the  Eustachian  tube,  the  cavity  of  the  tym- 
panum, and  the  mastoid  cells,  and  deeply  seated’ ob- 
stinate ulcerations  within  these  parts  cured.  2.  The 
same  parts  can  be  cleared  from  any  mucus  by  which 
they  are  obstructed.  3.  Blood  extrav^asated  wijhin  the 
ttmpanum  from  blows  on  the  head,  can  be  washed  out. 

4.  Chalky  substances,  which  sometimes  form  in  the 
tvmpanum,  may  be  brought  out  in  the  same  manner, 

5.  Through  the  tube  a stilet  can  be  passed  into  the 
Eustachian  tube,  so  as  to  perforate  a congenital  sep- 
tum, or  any  cicatrix,  obstructing  the  entrance  of  that 
passage.  6.  ^\’hen  the  sensibility  of  the  auditory  nerve 
is  dull,  the  effect  of  fluids  thrown  into  the  tympanum 
can  be  tried. — (See  also  T.  Buchanan’s  engraved  Re- 
presentation of  the  Jlnatomy  of  the  Human  Ear,  p.  28, 
fol.  Hull,  1823.) 

13.  Of  perforating  the  Mastoid  Process. 

Of  all  the  cases  of  deafness  for  which  Arnemann 
and  others  have  recommended  this  operation,  that 
attended  with  an  ab.scess  and  caries  of  this  process  is 
the  only  one  in  which  the  practice  is  now  at  all  sanc- 
tioned. An  instance  is  related  by  Jasser,  in.  which  the 
carious  surface  of  the  right  mastoid  process  was  ex- 
posed by  an  incision,  and  an  opening  detected  with  a 
probe.  An  injection  was  thrown  into  the  aperture 
with  a syringe,  when,  to  the  astonishment  of  .Tasser  and 
his  patient,  the  fluid  gushed  out  of  the  right  nostril. 
The  plan  was  repeated  for  a few  days,  and  at  the  end 
of  three  w eeks,  the  part  was  healed,  and  the  hearing 
greatly  improved.  This  success  induced  Jasser  to 
make  a perforation  in  the  left  mastoid  process,  the  ear 
on  that  side  being  deaf,  and  to  employ  the  injection, 
which  was  also  discharged  from  the  left  nostril.  The 
hearing,  however,  was  not  so  completely  restored  in 
this  as  it  had  been  in  the  right  ear;  but  the  wound 
healed  up  without  any  exfoliations.— </o7/r7?.  de  Mrd. 
Fev.  1793.)  The  idea  of  perforating  the  mastoid  process 
was  suggested  long  before  the  time  of  Jasser.  Riolan, 
in  various  parts  of  his  works,  suggests  the  propriety  of 
making  a small  perforation  in  several  cases  of  deaf- 
ness, and  tinnitus  aurium,  attended  with  obstruction 
of  the  Eustachian  tube.  Rolfincius  also  advised  a 
similar  opening  to  be  made  in  the  mastoid  process  with 
a trocar,  in  cases  of  dropsy  of  the  cavity  of  the  tym- 
panum and  of  the  mastoid  celts.  Jasser,  however,  was 
the  first  w ho  actually  made  the  experiment,  and  his 
example  was  followed  by  Hagstroem,  whose  attempt 
did  not  succeed,  the  completion  of  the  operation  having 
been  interrupted  by  profuse  hemorrliage,  and  no  be- 
nefit done  to  the  hearing.  The  injections  also  appear 
to  have  caused,  in  this  instance,  alarming  symptoms, 
violent  pain  in  the  head,  loss  of  vision,  sense  of  suffo- 
cation, and  sjmeope.  The  fluid  entered  the  mastoid 
cells  without  any  of  it  issuing  either  by  the  nostrils  or 
mouth. — (Op.  cit.) 

The  operation  was  successfully  tried  by  Ixifller.  The 
injection  did  not  pass  into  tbc  mouth,  yei  the  hearing 


EAR. 


S37 


•was  restored,  though  it  •was  lost  again  when  the  wound 
closed.  Hence  a new  opening  was  made,  and  kept 
from  healing  by  means  of  a piece  of  catgut.  The 
patient  was  afterward  able  to  hear  when  his  mouth 
was  open. 

The  perforation  of  the  mastoid  process  was  not  ap- 
proved of  by  Morgagni ; indeed,  it  must  often  fail,  as 
both  Morgagni  and  Hagstroem  have  observed,  on  ac- 
count of  complete  bony  partitions  preventing  all  com- 
munications between  the  mastoid  cells ; and  sometimes 
the  mastoid  process,  instead  of  being  cellular,  is  per- 
fectly solid ; an  instance  of  which  is  recorded  by  A. 
Murray. 

14.  Diseases  of  the  Labyrinth. 

These  are  much  more  diversified  than  might  at  first 
be  supposed ; and  if  we  admit  the  two  doubtful  cases 
said  to  depend  upon  the  state  of  the  lymph  of  Cotunni, 
there  are  not  less  than  seven  different  species  of  disease 
affecting  the  labyrinth:—!.  Disease  of  the  fenestra 
ovalis  and  fenestra  rotunda,  as  ulceration,  thickening, 
(fee.  2.  Malformation  of  these  apertures.  3.  Mal- 
formation of  the  labyrinth.  4.  Inflammation  of  the 
nervous  membrane  which  lines  its  cavities.  5.  Alter- 
ation of  the  liquor  of  Cotunni.  6.  Deficiency  of  the 
same  fluid.  7.  Affections  of  the  nerve  of  hearing. 

No  doubt  deafness  (and  that  kind  of  it  which  so  fre- 
quently foils  the  most  skilful  men)  often  arises  from  an 
insensible  state  of  the  portio  mollis  of  the  auditory 
nerve,  or  of  the  surfaces  on  which  its  filaments  are 
spread.  This  affection  is  analogous  to  the  amaurosis, 
or  gutta  serena,  in  which,  though  every  part  of  the  eye 
may  seem  to  possess  its  natural  structure,  sight  is  lost, 
because  the  rays  of  light  only  strike  against  a paralytic 
or  insensible  retina.  Mr.  Saunders  dissected  the  ears 
of  two  deaf  patients  with  the  greatest  care,  but  could 
not  discover  the  least  deviation  from  the  natural  struc- 
ture. In  the  commencement  of  deafness  from  a para- 
lytic affection  of  the  auditory  nerve.  Sir  A.  Cooper 
remarked,  that  the  secretion  of  cerumen  was  dimi- 
nished, and  when  the  deafness  became  worse,  was 
totally  suppressed.  And  another  particular  symptom 
of  paralysis  of  the  auditory  nerve,  pointed  out  by  the 
same  author,  is  the  patient’s  inability  to  hear  the  sound 
of  a watch  placed  between  the  incisor  teeth. 

With  respect  to  the  causes  of  a paralytic  affection  of 
the  auditory  nerve,  they  are  mostly  buried  in  great 
obscurity,  and  some  of  them  probably  depend  upon 
congenital  imperfection  of  the  nerve  or  brain  itself.  It. 
seems,  however,  that  a part  of  the  causes  to  which  we 
allude  act  mechanically,  as  an  extravasation  of  blood, 
a steatoma,  or  an  exostosis ; while  others  operate  on 
the  ear  by  sympathy,  as  is  the  case  when  deafness  is 
produced  by  the  presence  of  worms  in  the  bowels. 

Mr.  Saunders  remarks,  that  all  the  diseases  of  the 
internal  ear  may  -be  denominated  nervous  deafness ; 
the  term,  in  this  sense,  embracing  every  disease,  the 
seat  of  which  is  in  the  nerve,  or  parts  containing  the 
nerve.  Nervous  deafness  is  attended  with  various 
complaints  in  different  cases,  noises  in  the  head  of 
sundry  kinds,  the  murmuring  of  water,  the  hissing  of  a 
boiling  kettle,  rustling  of  leaves,  blowing  of  wind,  &c. 
Other  patients  speak  of  a beating  noise,  corresponding 
with  the  pulse,  and  increased  by  bodily  exertion,  in  the 
same  degree  as  the  action  of  the  heart.— (Sawreders, 
p.  47.) 

According  to  this  author,  there  is  a syphilitic  species 
of  nervous  deafness,  attended  with  a sensation  of  some 
of  the  above  peculiar  noises ; and  one  case  is  related,  in 
which  the  hearing  was  completely  restored  in  five 
weeks,  by  a mercurial  course. 

Mr.  Saunders  relieved  several  cases  of  nervous  deaf- 
ness, by  confining  patients  to  low  diet,  giving  them 
calomel  freely,  repeated  doses  of  sulphate  of  soda, 
magnesia,  sometimes  twice,  sometimes  thrice  a week, 
or  according  to  circumstances,  and  applying  blisters 
behind  the  ears,  at  intervals  of  a week.  The  plan  re- 
quires perseverance. 

Electricity  has  been  highly  recommended  for  the  cure 
of  nervous  deafness,  though  the  prospect  of  benefit 
from  it  must  entirely  depend  upon  the  nature  of  the 
cause  of  the  infirmity.  It  is  allowed  to  be  sometimes 
useful  in  ca.ses  of  incomplete  paralysis  of  the  auditory 
nerve ; but  it  cannot  be  of  any  service  where  the  Eus- 
tachian tube,  the  cavity  of  the  tympanum;  or  the  mas- 
toid cells  are  obstructed.  It  is  set  down  as  hurtful , 
when  the  patients  are  very  irritable  and  subject  to 

Vui..  I.-Y 


vertigo,  bleeding  from  the  nose,  great  determination  of 
blood  to  the  head,  &c. — {Diet,  des  Sciences  Mid.  t.  38, 
p.  124.)  The  evidence  in  favour  of  the  efficacy  of  gal- 
vanism is  still  more  scanty  and  questionable. 

Whether  in  certain  cases  of  deafness  from  torpor 
of  the  auditory  neri?e  the  introduction  of  tonic  injections 
into  the  cavity  of  the  tympanum,  through  the  Eusta- 
chian tube,  will  answer  m the  manner  stated  by  a late 
WTiter,  future  experience  must  determine.— (Dfcf.  des 
Sciences  Med.  t.  38,  p.  120,  121.)  The  effect  of  the  tinc- 
ture of  iodine,  in  some  of  these  cases,  may  also  merit 
farther  trial. 

This  article,  I think,  may  be  usefully  concluded  with 
a few  general  but  sensible  observations  on  the  various 
kinds  of  deafness,  made  by  a modem  writer.  Accord- 
ing to  Professor  Rosenthal,  all  the  disorders  of  the 
sense  of  hearing  may  be  comprised  under  three  princi- 
pal forms. 

1.  Deafness  {Surditas,  Cophosis),  in  which  the 
faculty  of  hearing  articulated  sounds  is  completely 
annihilated. 

2.  Hardness  of  hearing  (Dyscecia),  in  which  this 
faculty  is  so  diminished,  that  articulated  sounds  cannot 
be  heard,  without  the  assistance  of  a particular  appa- 
ratus. 

3.  Alteration,  or  diminution  of  hearing  {Paracusis), 
in  which  the  faculty  of  hearing  articulated  sounds  in 
the  natural  way  is  imperfect  for  want  of  precision. 

1.  Deafness  Rosenthal  distinguishes  into  two  de- 
grees ; the  first  of  which  is  marked  by  an  absolute 
impossibility  of  hearing  at  all ; the  second,  by  a power 
of  still  distinguishing  certain  sounds,  as  whistling,  the 
vowels,  die.  The  first  is  usually  congenital,  and  a 
cause  of  dumbness. 

The  discrimination  of  these  two  degrees  Rosenthal 
considers  of  great  importance  in  practice,  and  especially 
in  institutions  for  the  deaf  and  dumb ; because  the  ex- 
ceedingly fine  sense  of  touch  with  which  dumb  persons 
are  sometimes  gifted,  is  apt  to  be  mistaken  for  the 
faculty  of  hearing.  This  fact  is  illustrated  by  some 
interesting  experiments  made  by  Pfingsten  on  deaf  and 
dumb  persons. — {Vieljahrige  Erfahrung  uber  die 
Gehoerfehler  der  Taub.stummen,  Kiel,  1802,  p.  32.)  A 
deaf  and  dumb  girl,  who  was  at  needle-work  in  a room 
near  the  house-door,  regularly  gave  notice  whenever  it 
was  opened  or  shut.  As  the  door  was  furnished  with 
a little  bell,  which  rung  loud  enough  whenever  the 
door  moved  to  be  plainly  heard  in  the  neighbouring 
room,  and,  with  the  excejjtion  of  this  noise,  no  other 
impulse  nor  shock  could  be  distinguished,  Pfingsten 
was  surprised  at  the  circumstance.  Desirous  of  ascer- 
taining how  the  girl  really  knew  about  the  movements 
of  the  door,  he  caused  the  bell  to  be  rung  with  great 
force  without  the  door  being  opened ; the  child  was 
perfectly  unconscious  of  the  noise.  The  bell  was  after- 
ward kept  still,  while  a person  opened  and  shut  the 
door  so  softly,  that  Pfingsten  himself  could  not  hear  it ; 
yet  the  child  instantly  gave  warning  that  somebody  had 
entered.  The  inference  was,  that  the  chair  on  which 
she  sat  communicated  to  her  legs  and  back  a certain 
impulse,  which  made  her  conscious  of  the  motion  of  the 
door. 

The  dissection  of  the  ears  of  deaf  and  dumb  persons 
has  evinced  some  facts  explanatory  ot  the  cause  of  the 
loss  of  hearing.  Among  other  things,  it  appears,  that 
complete  deafness,  whether  congenital  or  acquired, 
more  frequently  depends  upon  morbid  alterations  of 
the  soft  parts,  than  upon  any  irregularity  in  the  form- 
ation of  the  bones.  Thus,  in  the  body  of  a person  who 
had  been  deaf  and  dumb  while  living,  Hoffman  found 
the  auditory  nerve  diminished  in  size,  while  every  other 
part  of  the  organ  was  perfectly  natural.  Arnemann 
found  the  nerve  harder  than  common.  Dr.  Haighton 
met  with  an  instance,  in  which  the  vestibulum  was 
filled  with  a caseous  substance. — {A  case  of  original 
Deafness,  in  Mem.  of  the  Med.  Society,  vol.  3,  p.  1 — 15.) 
Duverney  and  Sandifort  found  the  auditory  nerve 
strongly  compressed  by  a steatoma.  In  one  case,  Itard 
found  every  part  of  the  ear  apparently  so  natural,  that 
the  deafness  could  not  be  ascribed  to  paralysis  of  the 
nerve.  In  another,  the  infirmity  depended  upon  ob- 
struction of  the  passages.  In  a third,  the  cavity  of  the 
tympanum  and  the  vestibulum  contained  small  portions 
of  calcareous  matter.  He  has  also  seen  the  tympanum 
filled  with  a thick,  yellow  lymph,  or  a thin  fluid  en- 
closed in  membranous  cells.  In  the  dissection  of  the 
body  of  a deaf  and  dumb  person,  Ro.senthal  noticed. 


338 


EAR. 


among  other  remarkable  circumstances,  a greater 
hardness  of  the  auditory  than  of  the  facial  nerve,  and 
preternatural  firmness  of  the  medulla  oblongata ; thick- 
ening of  the  membrane  of  the  tj-mpanum ; the  bony 
roof  of  the  cavity  of  the  tympanum  not  thicker  than 
paper;  and  just  over  the  junction  of  the  malleus  with 
the  incus  the  bony  substance  was  so  absorbed,  that  an 
appearance  like  that  of  membrane  alone  remained.  The 
mastoid  cells,  cavity  of  the  tympanum,  and  the  Eusta- 
chian tubes,  contained  a limpid  yellow  fluid.  In  the 
tympanum,  the  periosteum  was  thickened,  forming 
small  cells  around  the  ossicula,  which  were  of  their 
natural  structure.  Nothing  particular  was  remarked 
in  the  labyrinth. 

In  a small  proportion  of  instances,  the  above  degree 
of  deafness  has  been  traced  to  anomaly  in  the  structure 
of  the  solid  parts.  Thus,  Mundini  found  the  cochlea 
composed  of  only  one  circle  and  a half.— (0/>?4Sc.  Acad. 
Boiioti,  1791,  t.  7,p.  422.)  Valsalva  found  the  stapes 
adherent  to  the  fenestra  ovalis  {De  Aure  Humana,  cap. 
11) ; and  Reimarus  relates  a case  in  which  the  ossicula 
were  entirely  wanting.— der  Tliiere,  p.  57.) 

In  the  first  degree  of  deafness  above  described, 
which,  when  congenital,  must  excite  suspicion  of  serious 
malformation  of  the  organ  and  abolition  of  the  nervous 
influence;  and  when  acquired,  indicates  a complete 
injury  of  the  functions  of  the  nerve,  the  prognosis,  as 
Rosenthal  observes,  must  be  unfavourable.  Nor  can 
it  be  otherwise  in  the  second  congenital  degree  of  the 
disease,  though  only  a partial  imperfection  of  the  organ 
and  nerve  can  here  be  supposed.  On  the  other  hand, 
when  the  latter  degree  is  acquired,  there  is  more  pros- 
pect of  relief,  because  merely  a partial  alteration  in  the 
soft  parts  is  to  be  suspected. 

2.  Hardness  of  hearing.  Rosenthal  also  distin- 
guishes several  degrees  of  what  is  termed  hardness  of 
hearing.  In  the  first,  the  patient  cannot  hear  a distant 
noise,  and  especially  high  tones ; but  he  can  perceive, 
though,  it  is  true,  not  in  a very  distinct  manner,  articu- 
lated sounds,  when  the  voice  is  a good  deal  raised.  In 
the  second  degree,  he  hears  and  distinguishes  both  high 
and  low  tones  very  well,  and  also  words,  but  only  when 
the  voice  is  somewhat  raised. 

These  two  cases  are  better  understood,  inasmuch  as 
it  is  tolerably  well  ascertained  that  the  immediate  cause 
of  the  infirmity  is  some  alteration  in  that  part  of  the 
organ  which  serves  as  a conductor  for  the  vibrations 
of  sound,  or  else  an  increased  sensibility  of  the  nerve, 
all  the  internal  ear  being  in  other  respects  right. 

Among  alterations  of  the  conducting  parts  of  the 
organ,  Ro.senthal  comprehends : 

1.  A total  obliteration  of  the  meatus  auditorius  ex- 
temus,  its  imperforation,  or  complete  absence.  These 
cases  may  almost  always  be  detected  by  a superficial 
examination,  the  patient  only  hearing  when  some  solid 
bodies  are  placed  between  his  teeth,  while  his  dull  per- 
ception of  sounds  does  not  appear  to  be  much  lessened 
when  the  ear  is  covered. 

2.  Diseases  of  the  cavity  of  the  tympanum,  as  inflam- 
mation of  its  membranous  lining,  caries  of  its  parietes, 
or  collections  of  blood,  pus,  or  other  fluid,  in  its  cavity. 
Rosenthal  thinks  there  can  be  no  doubt  that  inflamma- 
tion and  suppuration  in  the  tj*mpanum  are  much  more 
Ibequent  than  is  generaily  supposed ; the  fonner  afiec- 
tion  being  often  mistaken  for  a slight  attack  of  rheuma- 
tism. In  dissecting  aged  subjects,  he  has  frequently- 
found  the  membrane  of  the  tympanum  thickened  and 
opaque,  and  he  could  only  impute  this  appearance  to 
previous  inflammation. 

After  detailing  a case  illustrative  of  the  symptoms 
of  inflammation  within  the  tympanum,  and  a few 
ob.sers-aftoiis  on  caries  and  collections  of  fluid  in  that 
cavity,  Rosenthal  notices  the  hardness  of  hearing  con- 
nected  ivith  nervous  irritability,  in  the  treatment  of 
which  case,  he  insists  upon  the  advantage  that  would 
result  from  a knowledge  of  the  particular  species  of 
morbid  excitement  p-evailing  in  the  patient.  But  as 
notV.ing  very  certain  can  be  made  out  on  this  point, 
and  only  conjectures  can  arise  from  dissections  of  bo- 
dies, that  the  affection  consists  either  in  a determina- 
tion of  blood  to  the  part,  or  in  a partial  para’^sis  of 
the  auditory  nerve,  the  exact  nature  and  form  ct  which 
are  quite  incomprehensible,  it  is  absoluiely  necessary 
to  att-nd  solely  to  the  diagnosis  of  the  nervous  affcc- 
tio'.-  in  general.  Th.s  diagnosis  will  be  fa.  ilitated,  Isi, 
If  the  patient  has  been  previously  very  sensible  to  the 
impression  of  certain  tones,  or  sound  in  general ; 2dly, 


If  the  power  of  hearing  has  been  lost  all  on  a sudden, 
without  any  mark  of  inflammation  ; 3dly,  If  the  aflec- 
tion  coincides  with  other  nervous  disorders. 

3.  Alteration  or  Diminution  of  Hearing.  Between 
the  most  perfect  hearing,  congenital  or  acquired,  and 
this  point  of  diminution  of  the  faculty  of  hearing,  Ro- 
senthal observes  there  are  a great  many  degrees,  the 
cause  of  which  is  the  more  difficult  to  comprehend,  a» 
the  circumstances  of  structure,  which  enable  every 
part  to  perform  its  functions  with  freedom  and  perfec- 
tion, are  not  yet  made  out.  If,  says  he,  it  were  in  our 
power  to  determine  what  is  truly  the  regular  structure 
of  each  part,  we  should  then  be  furnished  with  a means 
of  judging  correctly  of  the  anomalies  of  function,  the 
changes  in  which  would  be  indicated  quite  as  clearly 
as  in  the  eye,  by  shades  of  organization,  absolutely  in 
the  same  way  as  we  judge  of  the  modifications  which 
the  image  of  objects  must  undergo  at  the  bottom  of  the 
ocular  mirror,  by  the  greater  or  less  convexity  of  the 
cornea  or  lens,  or  the  consistence  of  the  other  humours. 

In  the  present  st^te  of  physiological  and  patholo- 
gical knowledge  of  the  ear,  therefore,  Rosenthal  con- 
ceives that  little  can  be  attempted  with  respect  to  a 
scientific  classification  of  these  cases  of  altered  or  dimi- 
nished hearing.  As  the  cavity  of  the  tympanum  and  its 
contents  are  the  parts  which  have  principal  influence  over 
the  intensity  of  sound,  and  a great  share  in  the  propagation 
of  articulated  sounds,their  faulty  condition  must  here  be 
chiefly  the  subject  for  consideration.  And  among 
their  numerous  defects,  traced  by  dissection,  and  al- 
ready specified  in  the  foregoing  columns,  Rosenthal  par- 
ticularly calls  the  attention  of  the  reader, 

1 . To  alterations  of  the  membrane  of  the  tympanum, 
whether  proceeding  from  congenital  malformation  or 
Situation,  or  from  thickening,  ossification,  perforation, 
or  laceration  of  the  same  part. 

2.  The  lodgement  of  some  fluid  in  the  cavity  of  the 
t3Tnpanum,  more  frequently  produced  than  is  com- 
monly supposed  by  obstruction  of  the  Eustachian  tube. 
In  most  new-born  infants,  Rosenthal  has  also  found  the 
cavity  of  the  tympanum  filled  with  a thick,  almost  gela 
tinous  fluid,  which  for  some  days  is  not  absorbed,  and 
is  probably  the  cause  of  the  indifference  evinced  by 
new-born  children  to  sounds,  which  are  even  so  in- 
tense as  to  be  offensive  to  the  ears  of  an  adult. 

3.  Alterations  Of  the  membrane  of  the  fenestra  ro- 
tunda, such  as  its  imperfect  formation,  or  erroneous  si- 
tuation, its  thickened  state,  &c. 

But  it  is  remarked  by  Rosenthal,  that  as  the  differ- 
ence in  the  intensity  of  sound  may  occasion  a modifi- 
cation in  the  sensations  of  the  ear,  the  merely  con 
ducting  parts  of  the  auditory  apparatus  must  not  be 
forgotten,  as  the  external  ear  and  the  meatus  audito- 
rius externus,  which  regulate  the  quantity  of  sonorous 
waves  striking  the  auditory  nerve.  However,  the  mal- 
formations 01  the  meatus  and  the  state  of  the  cerumi- 
nous secretion  within  it,  are  observed  by  Kritter  and 
Lentin  {Ueber  das  schuere  Gehoere,  1.  10,  Leipz.  1794) 
to  have  more  effect  on  the  hearing  than  defects  of  the 
auricle  itself,  the  whole  of  which,  as  we  have  stated, 
may  be  lost  without  any  material  deafness  being  pro- 
duced. Lastly,  Rosenthal  calls  our  attention  to  the 
nervous  action  or  influence,  which,  whether  too  much 
raised  or  depressed,  may  equally  render  the  hearing 
dull ; and  some  useful  information  may  for  the  most 
part  be  derived  from  attemling  to  the  patient's  general 
sensibility.— (See  Joum.  Complan.  t.  6,  p.  21,  Ac.  Du~ 
vemey,  de  rOrgande  de  rOuie,  12mo.  1683.  P.  Ken- 
nedy, A Treatise  on  the  Eye,  and  on  some  of  the  Dis- 
eases of  the  Ear,  8vo.  Loiid.  1713.  A.  D.  Dieiiert, 
Quaestio,  i^c,  an  absque  MembraiuB  Tympani  Aper- 
tura  topica  injiri  in  Concham  possint,  Paris,  1748. 
Meracire  sur  la-Theorie  des  Maladies  de  rOreille,  et 
sur  les  Moyens  que  la  Chirurgie  pent  employr  pour 
leur  Curation,  in  Prix  de  VAcad.  de  Chir.  t.  9,  p.  Ill, 
<S-c.  ed.  12/no.  I.  D.  Arnnnann,  Bemerkungen  uher 
die  Dvrchborung  des  Processus  Ma.’stoideus  i.n  geuns- 
sen  Fallen  der  Tavbheit,  Suo.  Gbtt.  1792.  G.  R.  Tram- 
pel  von  dm  Krankheiten  des  Ohres,  in  Amemann’s 
Magazin  fur  die  Wundarzneiwi.ssenschaft,  b.  2,  p.  17, 
(S-c.  buo.  Gott.  1798.  Riclarand,  Mosogr.  Chir.  t.  2.  p. 
135,  .?c.  edit.  4.  .4.  Cooper,  in  the  Phil.  Trans,  for 
1802.  Saunders  on  the  Analenny  and  Diseases  of  the 
Ear,  1806.  Desmonceaux,  Traits  des  Maladies  des 
Yeux  et  des  Oreille s,  2 torn.  Svo,  Paris.  1806.  Lass^ts, 
Pntnalogie.  Chtnirgicale,  1,  p.  84.  idit.  1809.  ft'. 
Wright,  An  Essay  on  the  Human  Ear,  its  anaio.ni.al 


ECT 


ECT 


039 


Structure,  and  incidental  Complaints,  8vo.  Land. 
1817.  Diet,  des  Sciences  M d.  art.  Oreille,  t.  38, 
Paris,  1819.  Rosenthal,  Essai  d’une  Pathologic  de 
VOrgane  de  VOuie,  in  Journ.  Complimentaire  du  Diet, 
des  Sciences  MM.  t.  6,  p.  17,  8vo.  Paris,  1820.  J.  M. 
G.  Itard,  Traiti  des  Maladies  de  VOreille  et  de  V Audi- 
tion, 2 tom.  8vo.  Paris,  1821.  T.  Buchanan,  An  En- 
graved Representation  of  the  Anatomy  of  the  Human 
Ear,  fol.  Hull,  1823.  Also,  Illustrations  of  Acoustic 
Surgery,  8vo.  1825.  And,  Munson’s  Med.  Researches 
on  Iodine,  8vo.  Bond.  1825.  For  an  account  of  mal- 
formations of  the  organ,  see  Meckel’s  Handbuch  der 
Pathol.  Anat.  b.  1,  p.  400,  <S-c.  8vo.  Leipz.  1812.)  [See 
also  .fin  Essay  on  Diseases  of  the  Internal  Ear,  by  J. 
R.  Saissy,  M.D.  Translated  by  Professor  Smith,  of 
Maryla7ui,  with  Additions  on  the  External  Ear.] 

ECCHYMOSIS.  (From  ekxvo),  to  pour  out.)  A 
superficial,  soft  swelling,  attended  with  a livid  or  blue 
colour  of  the  skin,  produced  by  blood  extravasated  in 
the  cellular  substance. 

The  causes  of  ecchymosis  are  falls,  blows,  sprains, 
&c.,  which  occasion  a rupture  of  the  small  vessels  on 
the  surface  of  the  body,  and  a consequent  effusion  of 
blood,  even  without  any  external  breach  of  continuity. 
Ecchymosis  is  one  of  the  symptoms  of  a contusion. — 
(See  Contusion.)  A considerable  ecchymosis  may  ori- 
ginate from  a very  slight  bruise,  when  the  ruptured 
vessels  are  capable  of  pouring  out  a large  quantity  of 
blood,  and  particularly  when  the  parts  contain  an 
abundance  of  loose  cellular  substance.  In  general, 
ecchymosis  does  not  make  its  appearance  immediately 
after  the  blow  or  sprain,  and  sometimes  not  till  several 
hours  after  the  application  of  the  violence;  at  least,  it 
is  not  till  this  time  that  the  black,  blue,  and  livid  colour 
of  the  skin  is  most  conspicuous.  A black  eye,  which 
is  only  an  ecchymosis,  is  always  most  disfigured  six 
or  eight  hours  after  the  receipt  of  the  blow. 

In  the  article  Bleeding,  we  have  noticed  how  an  ec- 
chymosis may  arise  from  the  blood  getting  out  of  the 
vein  into  the  adjacent  cellular  substance. 

Common  cases  of  ecchymosis  may  generally  be 
easily  cured,  by  applying  discutient  lotions,  and  ad- 
ministering one  or  two  doses  of  any  mild  purgative 
salt.  The  best  topical  applications  are  vinegar,  the 
lotio  muriatis  ammonia;,  spirit,  vin.  camph.  and  the 
liquor  ammon.  acet. 

The  object  is  to  avert  inflammation,  and  to  promote 
the  absorption  of  the  extravasated  fluid. 

In  cases  of  ecchymosis,  I have  seen  such  success 
attend  the  practice  of  dispersing  collections  of  extra- 
va.sated  blood,  by  means  of  absorption,  that  the  plan 
of  evacuating  it  by  an  incision  seems  to  me  to  be  sel- 
dom necessary.  When  an  opening  is  made  and  air  is 
admitted,  the  portion  of  blood  which  cannot  be  jiressed 
out  soon  putrefies,  and  extensive  inflammation  and 
suppuration  are  the  frequent  consequences. 

The  quick  and  powerful  action  of  the  absorbent  ves- 
sels in  removing  extravasations  of  blood  can  now  be 
no  longer  called  in  question,  when  we  daily  see  it 
jiroved  in  modern  practice,  that  the  largest  aneurismal 
swclhngs  are  thus  speedily  diminished  and  removed, 
after  the  operation  of  tying  the  aiteries,  from  which 
such  tumours  arise. 

I wish,  how’ever,  the  preceding  observations  merely 
to  convey  a general  condemnation  of  the  practice  of 
opening  swellings  containing  extravasated  blood;  for 
no  surgeon  is  more  assured  than  I am,  that  there  are 
particular  exceptions,  in  which  the  plan  is  highly 
projier  and  necessary.  Thus,  whenever  a case  of  ex- 
tensive ecchymosis,  or  a large  tumour  of  extravasated 
blood  either  excites  suppuration  or  creates  excessive 
pain  from  distention,  it  is  better  to  practise  a free  ojien- 
ing.  tin  it  sometimes  happens  in  cases  of  aneurism, 
that  the  skin  breaks  after  the  artery  has  beenftied,  and 
some  of  the  blood  escapes;  but  the  remainder  putrefies 
and  soon  becomes  blended  with  purulent  matter  in  the 
sac.  Here  the  making  of  a free  incision  for  the  dis- 
charge of  the  irritating  contents  of  the  swelling,  with 
due  attention  to  every  caution  delivered  in  the  article 
Aneurism,  will  often  be  followed  by  beneficial  effi'cts. 

ECTIIOPIUM.  (Froin  f«rpf7ra>,  to  turn.)  A turn- 
ing out  or  an  eversion  of  the  eyelids. 

Accurding  to  Scar[»a  there  are  two  species  of  this 
disease ; one  produced  by  an  unnatural  swelling  of 
the  lining  of  the  eyelids,  which  not  only  pustics  their 
edees  from  the  eyeball,  but  also  presses  them  so  for- 
cibly that  they  become  everted  ; the  other,  arising  from 

Y 2 


a contraction  of  the  skin  of  the  eyelid,  or  its  vicinity, 
by  which  means  the  edge  of  the  eyelid  is  first  removed 
for  some  distance  from  the  ej  e,  and  afterward  turned 
completely  out,  together  with  the  whole  of  the  affected 
eyelid. 

The  morbid  swelling  of  the  lining  of  the  eyelids, 
which  causes  the  first  species  of  ectropium  (putting 
out  of  present  consideration  a similar  affection  inci- 
denttd  to  old  age),  arises  mostly  from  a congenital 
laxity  of  this  membrane,  afterward  increased  by  obsti- 
nate chronic  ophthalmies,  particularly  that  of  a scro- 
fulous nature,  in  relaxed,  unhealthy  subjects  ; or  else 
the  disease  originates  from  the  small-pox  affecting  the 
eyes. 

While  the  disease  is  confined  to  the  lower  eyelid,  as 
it  most  commonly  is,  the  lining  of  this  part  may  be 
observed  rising  in  the  form  of  a semilunar  fold,  of  a 
pale  red  colour,  like  the  fungous  granulations  of 
wounds,  and  intervening  between  the  eye  and  eyelid, 
which  latter  it  in  some  measure  everts.  When  the 
swelling  is  occasioned  by  the  lining  of  both  the  eye- 
lids, the  disease  assumes  an  annular  shape,  in  the 
centre  of  which  the  eyeball  seems  sunk,  while  the  cir- 
cumference of  the  ring  presses  and  everts  the  edges 
of  the  two  eyelids  so  as  to  cause  both  great  uneasiness 
and  deformity.  In  each  of  the  above  cases,  on  press- 
ing the  skin  of  the  eyelids  with  the  point  of  the  finger, 
it  becomes  manifest  that  they  are  very  capable  of  being 
elongated,  and  would  readily  yield,  so  as  entirely  to 
cover  the  eyeball,  were  they  not  prevented  by  the  inter- 
vening swelling  of  their  membranous  lining. 

Besides  the  very  considerable  deformity  which  the 
disease  produces,  it  occasions  a continual  discharge  of 
tears  over  the  check,  and,  w'hat  is  worse,  a dryness  of 
the  eyeball,  frequent  exasperated  attacks  of  chronic 
ophthalmy,  incapacity  to  bear  the  light,  and,  lastly, 
opacity  and  ulceration  of  the  cornea. 

The  second  species  of  ectropium,  or  that  arising 
from  a contraction  "of  the  integuments  of  the  eyelids 
or  neighbouring  parts,  is  not  unfreqiiently  a conse- 
quence of  puckered  scars  produced  by  the  confluent 
small-pox  ; deep  bums  ; or  the  excision  of  cancerous 
or  encysted  tumours,  without  saving  a suflicient  quan- 
tity of  skin  ; or,  lastly,  the  disorder  is  the  eflect  of  ma- 
lignant carbuncles,  or  any  kind  of  wound  attended 
with  much  loss  of  substance.  Each  of  these  causes 
is  quite  enough  to  bring  on  such  a contraction  of  the 
skin  of  the  eyelids  as  to  draw  these  parts  towards  the 
arches  of  the  orbits,  so  as  to  remove  them  from  the 
eyeball  and  turn  their  edges  outwards.  No  sooner  has 
this  circumstance  happened,  than  it  is  often  followed 
by  another  one  equally  unpleasant,  namely,  a swelling 
of  the  internal  membrane  of  the  affected  eyelids,  which 
afterward  has  a great  share  in  completing  the  ever- 
sion. The  lining  of  the  eyelids,  though  trivially 
everted,  being  continually  exposed  to  the  air  and  irrita- 
tion of  extraneous  substances,  soon  swells,  and  rises 
up  like  a fungus.  One  side  of  this  fungus-like  tumour 
covers  a part  of  the  eyeball ; the  other  pushes  the  eye- 
lid so  considerably  outwards,  that  its  edge  is  not  un 
frequently  in  contact  w ith  the  margin  of  the  orbit 
The  complaints  induced  by  this  second  species  of  ec 
tropium  are  the  same  as  those  brought  on  bj-  the  first ; 
it  being  noticed,  however,  that  in  both  cases  whenever 
the  disease  is  inveterate,  the  fungous  swelling  of  the 
inside  of  the  eyelids  becomes  hard,  coriaceous,  and,  as 
it  were,  callous. 

Although  in  both  species  of  ectropium  the  lining  of  the 
eyelids  seems  equally  swollen,  yet  the  surgeon  can  easily 
distinguish  to  wliich  of  the  two  species  the  disease  be- 
longs. For  in  the  first  the  skin  of  tlie  eyelids  and  ad- 
joining parts  is  not  deformed  with  scars,  and  by  ja-ess- 
ing  the  everted  eyelid  with  the  point  of  the  finger,  the 
part  would  with  ease  cover  the  eye,  were  it  not  for  the 
intervening  fungous  swelling.  But  in  the  second  spe- 
cies of  ectropium,  besides  the  obvious  cicatrix  and  con- 
traction of  the  skin  of  the  eyelids  or  adjacent  parts, 
when  an  effort  is  made  to  cover  the  eye  with  the  everted 
eyelid,  by  pressing  ui;on  the  latter  part  with  the  point 
of  the  finger,  it  does  not  give  way,  so  as  completely  to 
cover  the  globe,  or  only  yields,  as  it  ought  to  do,  for  a 
certain  extent ; or  it  does  not  move  in  the  least  fi  om  its 
unnatural  position,  by  means  of  the  integuments  of  the 
eyelids  liaving  been  so  extensively  destroyed  that  their 
margin  has  become  adherent  to  the  arch  of  the  orbit. 

In  addition  to  the  forms  of  the  disea.se  mentioned  by 
Scarpa,  Mr.  tJuthrie  enumerates  a case  depending  on 


340 


ECTROPIUM. 


chronic  inflammation,  accompanied  with  contraction  of 
the  integuments  of  the  eyelid,  but  xiitfiont  any  manifest 
sicatrix.  It  is  described  by  him  as  usually  taking 
place  after  a long  continuance  of  li^rpitudo,  and  proceed- 
ing from  the  excoriation,  contraction,  and  hardening  of 
the  skin,  “ the  result  of  the  passage  of  the  vitiated  secre- 
tions over  it,  and  which,  by  dropping  on  it,  increase  the 
irritation.” — {On  the  Oyerative  Surgery  of  the  Eye,p. 
50—55.)  This  form  of  the  disease,  according  to  Mr. 
Guthrie,  is  rarely  attended  t^th  such  a thickening  of  the 
inner  membrane  of  the  eyelid,  as  to  require  removal 
with  the  knife  or  scissors  ; for  it  subsides  with  the  re- 
moval of  the  complaint. — (P.  60.) 

According  to  Scarpa,  the  cure  of  ectropium  cannot  be 
accomplished  with  equal  perfection  in  both  its  forms, 
the  second  species  being,  in  some  cases,  absolutely  in- 
curable. For,  as  in  the  first  species  of  ectropium  the 
disease  only  depends  upon  a morbid  thickening  of  the 
internal  membrane  of  the  eyelids,  and  the  treatment 
merely  consists  in  removing  the  redundant  portion,  art 
possesses  many  efficacious  means  of  accomplishing 
what  is  desired.  But  in  the  second  species  of  ectropium, 
the  chief  cause  of  which  arises  from  the  loss  of  a por- 
tion of  the  skin  of  the  eyelids  or  adjacent  parts,  which 
loss  no  knoAvn  artifice  can  restore,  surgery  is  not  capa- 
ble of  effecting  a perfect  cure  of  the  malady.  The 
treatment  is  confined  to  remedying,  as  much  as  possi- 
ble, such  complaints  as  result  from  this  kind  of  ever- 
sion, and  this  can  be  done  in  a more  or  less  satisfactory 
manner,  according  as  the  loss  of  skin  of  the  eyelid  is  lit- 
tle or  great.  Cases  in  which  so  much  skin  is  deficient, 
that  the  edge  of  the  eyelid  is  adherent  to  the  margin  of 
the  orbit,  Scarpa  abandons  as  incurable.  How  far  the 
case  can  be  rectified,  he  thinks,  may  always  be  estimated 
by  remarking  to  what  point  the  eyelid  admits  of  being 
replaced,  on  being  gently  pushed  with  the  end  of  the 
finger  towards  the  globe  of  the  eye,  both  before  and  af- 
ter the  employment  of  such  means  as  are  calculated  to 
effect  an  elongation  of  the  skin  of  the  eyelid  ; for  it 
is  to  this  point,  and  no  farther,  that  art  can  reduce  the 
everted  part,  and  permanently  keep  it  so  replaced. 

When  the  first  species  of  ectropium  is  recent,  the 
fungous  swelling  of  the  lining  of  the  eyelid  not  consi- 
derable, and  consequently  the  edge  of  the  eyelid  not 
much  turned  out,  and  in  young  subjects  (for  in  old  ones 
the  eyelids  are  so  flaccid,  that  the  disease  is  irremedi- 
able), Scarpa  prefers  destroying  the  fungous  surface  of 
the  internal  membrane  of  the  eyelid  by  the  repeated 
application  of  the  argentum  nitratum.  Mr.  Guthrie 
touches  the  fungous  portion  of  the  conjunctiva  every 
four  days  with  a probe  dipped  in  sulphuric  acid,  and 
gently  applies  every  day,  or  every  second  day,  the  sul- 
phate of  copper,  at  the  same  time  not  omitting  some 
minor  remedies,  which  he  also  employs  in  cases  pro- 
ceeding from  contraction  of  the  skin  independent  of  any 
cicatrix,  and  which  I shall  presently  notice. — {On  the 
Operative  Surgery  of  the  Eye,  p.  70.)  In  recent  cases, 
M'here  the  patient  is  weak  and  irritable  (or  a child). 
Beer  commences  the  treatment  W'ith  simply  applying 
every  day  the  tincture  of  opium,  which  after  a time  is  to 
be  strengthened  by  the  addition  of  naphtha.  To  the  re- 
laxed conjunctiva  he  rfterward  applies  escharotic  eye- 
salves,  and  last  of  all  the  nitrate  of  silver  and  muriate 
of  antimony.  When  the  part  is  hard  and  callous,  the 
employment  of  caustic  is  preceded  by  scarifications. — 
(Lehre,  .H.  b.  2,  p.  136.) 

For  remedying  the  considerable  and  inveterate  form 
of  the  first  species  of  the  disease.  Beer  and  Scarpa  are 
sdvocates  for  cutting  away  the  whole  of  the  fungous 
swelling  closely  from  the  muscular  substance,  on  the 
inside  of  the  eyelid.  The  following  is  Scarpa’s  descrip- 
tion of  the  operation. 

The  patient  being  seated  with  his  head  a little  inclined 
backwards,  the  surgeon,  with  the  index  and  middle  fin- 
ger of  his  left  hand,  is  to  keep  the  eyelid  steadily 
everted,  and  holding  a small  pair  of  curved  scissors  with 
convex  edges  in  his  right,  he  is  completely  to  cut  off  the 
whole  fungosity  of  the  internal  membrane  of  the  eyelid 
as  near  as  possible  to  its  base.  The  same  operation  is 
then  to  be  repeated  on  the  other  eyelid,  should  that  be 
affected  with  the  same  disorder.  If  the  excrescence 
Bhould  be  of  such  a shape  that  it  cannot  be  exactly  in- 
cluded within  the  scissors,  it  must  be  raised  as  much  as 
possible  with  forceps,  or  a double-pointed  hook,  and  dis- 
sected off  at  its  base,  by  means  of  a small  bistoury  with 
a convex  edge.  This  last  mode  is  preferred  by  Beer 
to  the  use  of  scissors,  and  I confess  that  it  has  always 


appeared  to  me  the  most  convenient.  The  bleeding', 
which  seems  at  the  beginning  of  the  operation  as  if  it 
would  be  copious,  stops  of  itself,  or  as  soon  as  the  eye 
is  bathed  with  cold  water.  The  surgeon  is  then  to  ap- 
ply the  dressings,  which  are  to  consist  of  two  small 
compresses,  one  put  on  the  upper,  the  other  on  the 
lower  arch  of  the  orbit,  and  over  these  the  uniting  band- 
age, in  the  form  of  the  monoculus,  or  so  applied  as  to 
compress  and  replace  the  edges  of  the  everted  eyelids, 
in  order  to  make  them  cover  the  eye.  On  the  first  re- 
moval of  the  dressings,  which  should  take  place  about 
twenty- four  or  thirty  hours  after  the  operation,  the  sur- 
geon will  find  the  whole,  or  almost  the  whole,  of  the 
eyelid  in  its  natural  position.  The  treatment  should 
afterward  consist  in  washing  the  ulcer  on  the  inside  of 
the  eyelid  twice  a day  with  simple  water,  or  barley 
water,  and  confect,  rosae,  until  it  is  completely  well. 
If  towards  the  end  of  the  cure  the  wound  should  assume 
a fungous  appearance,  or  the  edge  of  the  eyelid  seem  to 
be  too  distant  from  the  eyeball,  the  wound  on  the  inside 
of  the  eyelid  must  be  rubbed  several  times  with  the  ar- 
gentum nitratum,  for  the  jmrpose  of  destroying  a little 
more  of  the  membranous  lining,  so  that  when  the  cica- 
trization follows,  a greater  contraction  of  it  may  take 
place,  and  the  edge  of  the  eyelid  be  drawn  still  nearer 
the  eye.  Proper  steps  must  be  taken,  however,  for  re- 
sisting the  principal  cause  on  which  the  ectropium  de- 
pends, particularly  chronic  ophthalmy,  a relaxed  and 
varicose  state  of  the  conjunctiva,  &c.— (See  Oph- 
thalmy.) 

In  England  the  excision  of  the  fungous  thickened 
portion  of  the  conjunctiva,  in  cases  of  ectropium,  has 
been  very  much  relinquished  for  the  employment  of 
caustic.  The  difficulty  and  almost  total  impossibility  of 
dissecting  off  every  particle  of  the  fungus  render  the 
practice  of  excision  much  less  certain  than  the  treat- 
ment with  caustic.  Thus  we  see  that  Scarpa  con- 
fesses its  occasional  failure,  and  the  necessity  of  then 
having  recourse  to  the  latter  plan.  Demours  also  lets  the 
employment  of  caustic  follow  the  use  of  the  knife. — 
{Mai.  des  Yeux,  p.  98.)  In  the  ectropium  from  a re- 
laxed fungous  state  of  the  conjunctiva,  the  consequence 
of  purulent  ophthalmia.  Dr.  Vetch  begins  with  a light 
careful  application  of  the  argentum  nitratum  to  the 
whole  granulated  villous  surface.  The  everted  part  is 
then  to  be  returned,  and  secured  in  its  place  with  a 
compress,  and  straps  of  plaster  and  a bandage.  Every 
time  the  eye  is  cleaned,  the  same  things  are  to  be  re- 
peated, and  in  the  course  of  a few  days  the  tendency  to 
protrude  will  disappear. — {On  Diseases  of  the  Eye,p. 
228.) 

In  the  second  species  of  ectropium,  or  that  produced 
by  an  accidental  contraction  of  the  skin  of  the  eyelids, 
or  neighbouring  parts,  Scarpa  observes,  that  if  a con- 
traction of  the  integuments  has  proved  capable  of  evert- 
ing the  eyelid,  the  excision  of  a piece  of  the  internal 
membrane  of  the  part,  and  the  cicatrix  which  will  fol- 
low must  also  be  capable,  for  the  same  reason,  of  bring- 
ing back  the  eyelid  into  its  natural  position.  But  since 
nothing  can  restore  the  lost  skin,  the  shortened  state  of 
the  whole  eyelid,  in  whatever  degree  it  exists,  must  al- 
wa5's  continue,  even  after  any  operation  the  most  skil- 
fully executed.  Hence  the  treatment  of  the  second  spe- 
cies of  ectropium,  he  says,  will  never  succeed  so  per- 
fectly as  that  of  the  first,  and  the  replaced  eyelid  will 
always  remain  shorter  than  natural,  in  proportion  to 
the  quantity  of  integuments  lost.  It  is  true  that,  in 
many  cases,  the  eversion  seems  greater  than  it  actually 
is,  in  regard  to  the  small  quantity  of  skin  lost  or  de- 
stroyed ; for  when  the  disease  has  once  begun,  though 
the  contraction  ofthe  skin  may  be  trivial  in  consequence 
of  the  little  quantity  of  it  deficient,  still  the  swelling  of 
the  lining  of  the  eyelid,  which  never  fails  to  increase, 
at  last  brings  on  a complete  eversion  of  the  part.  In 
these  cases  the  cure  may  be  accomplished  with  such 
success  as  is  surprising  to  the  inexperienced  ; for  after 
the  fungous  swelling  of  the  internal  membrane  of  the 
eyelid  has  been  cut  off,  and  the  edge  of  the  part  approxi- 
mated to  the  eyeball,  the  shortening  of  (he  eyelid  re- 
maining after  the  operation  is  so  trivial,  that  it  may  be 
considered  as  nothing  in  comparison  with  the  deformity 
and  inconvenience  occasioned  by  the  ectropium.  When- 
ever, therefore,  the  retraction  of  the  skin  of  the  everted 
eyelid,  and  the  consequent  shortness  of  it,  are  such  as  not 
to  prevent  its  rising  again  and  covering  the  eye,  if  not 
entirely,  at  least  moderately,  Scarpa  directs  the  surgeon 
to  cut  away  the  internal  membrane  of  the  everted  eye- 


ECTROPIUM. 


341 


lid,  as  already  explained,  so  as  to  produce  a loss  of  sub- 
stance on  the  inside  of  the  everted  eyelid.  In  invete- 
rate cases  of  ectropium,  in  which  the  lining  of  the 
eyelids  has  become  hard  and  callous,  Scarpa  applies  to 
t'he  everted  eyelid,  for  a few  days  before  the  operation, 
a soft  bread-and-milk  poultice,  in  order  to  render  the 
part  flexible,  and  more  easily  separated  than  it  could  be 
in  its  former  rigid  state. 

The  division  of  the  cicatrices  which  have  given  rise 
to  the  shortening  and  eversion  of  the  eyelid,  as  Scarpa 
observes,  does  not  procure  any  permanent  elongation 
of  this  part,  and  consequently  it  is  of  no  avail  in  the 
cure  of  the  presept  disease.  We  see  the  same  circum- 
stance occur  after  deep  and  extensive  burns  of  the  skin 
of  the  palm  of  the  hand  and  fingers : whatever  pains 
may  have  been  taken,  during  the  treatment,  to  keep  the 
hand  and  fingers  extended,  no  sooner  is  the  cicatriza- 
tion thus  completed,  than  the  fingers  become  irremedi- 
ably bent.  The  same  thing  happens  after  extensive 
burns  of  the  skin  of  the  face  and  neck.  Fabricius  ab 
Aquapendeiite,  who  well  knew  the  inutility  of  making  a 
semilunar  cut  in  the  skin  of  the  eyelids,  for  the  purpose 
of  remedying  their  shortness  and  eversion,  proposes,  as 
the  best  expedient,  to  stretch  them  with  adhesive  plas- 
ters, applied  to  them  and  the  eyebrow,  and  tied  closely 
together.  Whatever  advantage  may  result  from  this 
practice,  the  same  degree  of  benefit  may  be  derived  from 
using,  for  a few  days,  a bread-and-milk  poultice,  after- 
ward oily  embrocations,  and  lastly,  the  uniting  band- 
age, so  put  on  as  to  stretch  the  shortened  eyelid  in  an 
opposite  direction  to  that  produced  by  the  cicatrix ; a 
practice  which  Scarpa  thinks  should  always  be  care- 
fully tried  before  the  operation  is  determined  upon. 

The  surgeon,  with  a small  convex-edged  bistoury,  is 
to  make  an  incision  of  sufficient  depth  into  the  internal 
membrane  of  the  eyelid,  along  the  tarsus,  carefully 
avoiding  the  situation  of  the  puncta  lachryrnalia.  Then 
with  a pair  of  forceps  he  should  raise  the  flap  of  the  di- 
vided fungous  membrane,  and  continue  to  detach  it 
with  the  bistoury  from  the  subjacent  parts  all  over  the 
inner  surface  of  the  eyelid,  as  far  as  where  the  membrane 
quits  this  part,  to  be  reflected  over  the  front  of  the  eye, 
under  the  name  of  conjunctiva.  The  separation  being 
thus  far  accomplished,  the  membrane  is  to  be  raised 
still  more  with  the  forceps,  and  cut  off  with  one  or  two 
strokes  of  the  scissors,  at  the  lowest  part  of  the  eyelid. 
The  compresses  and  bandage,  to  keep  the  eyelid  replaced, 
are  to  be  applied  as  above  directed.  On  changing  the 
dressings,  a day  or  two  after  the  operation,  the  eyelid 
will  be  found,  in  a great  measure,  replaced,  and  the  dis- 
figurement which  the  disease  caused  greatly  amended. 
The  operation  is  rarely  followed  by  bad  symptoms, 
such  as  vomiting,  violent  pain,  and  inflammation. 
However,  should  they  occur,  the  vomiting  may  be  re- 
lieved by  means  of  an  opiate  clyster ; and  as  for  the 
pain  and  inflammation,  attended  with  a great  tumefac- 
tion of  the  eyelid  operated  upon,  these  complaints  may 
be  cured  by  applying  a poultice,  or  bags  filled  with 
emollient  herbs,  at  the  same  time  applying  internal  an- 
tiphlogistics,  until  the  inflammation  and  swelling  have 
subsided,  and  suppuration  has  commenced  on  the  in- 
side of  the  eyelid  on  which  the  operation  has  been  done. 
After  this  the  treatment  is  to  consist  in  washing  the 
part  twice  a day  with  barley-water  and  confect,  rosas, 
and  lastly,  in  touching  the  wound  a few  times  with  the 
argentum  nitratum,  in  order  to  keep  the  granulations 
within  certain  limits,  and  to  form  a permanent  cicatrix, 
proper  for  maintaining  the  eyelid  replaced. — {Scarpa 
suite  Mallattie  degli  Occlii.)  / 

In  cases  in  which  the  eversion  is  considerable.  Sir 
W.  Adams  has  never  found  the  simple  incision  of  the 
fungus,  as  practised  by  Scarpa,  sufficient  to  effect  a ra- 
dical cure,  and  he  therefore  tried  a new  mode  of  opera- 
ting. In  his  first  attempts,  he  employed  a very  small 
curved  bistoury,  the  point  of  which  he  carried  along  the 
inside  of  the  eyelid,  at  its  outer  angle,  downwards  and 
outwards,  as  far  as  the  point  of  reflection  of  the  con- 
junctiva would  admit.  He  then  pushed  it  through  the 
whole  substance  of  the  everted  eyelid  and  its  integu- 
ments, and  cut  upwards  through  the  tarsus,  making  an 
incision  nearly  half  an  inch  in  length.  With  a curved 
pair  of  scissors,  he  next  snipped  off  a piece  of  the  edge 
of  the  tarsus,  about  one-third  of  an  inch  in  width,  and 
he  afterward  removed  with  the  same  instrument  the 
whole  of  the  diseased  conjunctiva.  When  the  bleeding 
had  ceased,  Sir  W.  Adams  passed  a needle  and  ligature 
fhrougli  the  whole  substance  of  the  two  divided  por- 


tions, and  brought  them  as  accurately  into  contact  as 
possible.  Finding,  however,  that  too  much  integument 
had  been  left  at  the  lower  part  of  the  incision,  he  em- 
ployed in  future  operations,  instead  of  the  sealpel,  a 
pair  of  straight  scissors,  with  which  he  cut  out  an  an- 
gular piece  of  the  lid,  resembling  the  letter  V.  Latterly 
Sir  W.  Adams  has  found  it  advantageous  to  leave  about 
a quarter  of  an  inch  of  the  lid  adjoining  its  external 
angle,  and  after  shortening  the  part  as  much  as  neces- 
sary he  brings  the  edges  of  the  incision  together  with  a 
suture.— (See  Practical  Observations  on  the  Ectropium, 
iS-c.  p.  4 and  5,  Land.  1812.) 

On  the  subject  of  the  foregoing  proposal,  M.  Roux 
' observes,  “ What  Sir  W.  Adams  says,  with  a view  of 
enhancing  the  value  of  his  own  method,  about  the  fre- 
quent recurrence  of  ectropium,  when  the  conjunctiva 
is  simply  cut  out,  is  a gratuitous  assertion,  contradicted 
by  experience.  I have  already  in  a very  great  number 
of  cases  undertaken  the  cure  of  ectropium  in  the  com- 
mon way : the  operation  always  succeeded  as  much  as 
the  degree  or  other  circumstances  of  the  disease 
allowed ; and  I have  not  yet  observed  an  instance  of  a 
relapse.” — ( Voyage  fait  a Londres  en  1814,  ou  Parallele 
de  la  Chirurgie  Angloise  avec  la  Chirurgie  Francoise, 
p.  291.)  If  this  new  operation,  however,  will  cure  the 
ectropium,  caused  by  the  contraction  of  cicatrices,  a.s 
its  inventor  describes,  or  produce  great  improvement,  aa 
the  experience  of  Mr.  Travers  confirms  {Synopsis  of 
the  Diseases  of  the  Eye,  p.  235),  it  is  clear  that  though 
it  may  not  be  necessary  in  ordinary  cases,  its  usefulness 
will  not  be  entirely  lost.  Mr.  Guthrie  acknowledges 
that  it  may  be  highly  useful  in  the  ectropium  from  the 
contraction  of  a cicatrix.— (On,  the  Operative  Surgery 
of  the  Eye,  p.  71.)  The  contracted  scar  must  of  course 
be  divided,  in  addition  to  the  other  proceedings. 

In  the  form  of  ectroinum  described  by  Mr.  Guthrie 
as  arising  from  a hardened  and  contracted  state  of  the 
integuments  of  the  eye,  but  without  any  cicatrix,  he 
observes  that  the  indications  are,  1st,  to  relieve  the 
contraction  of  the  skin  externally ; 2dly,  to  restore  and 
retain  the  eyelid  in  its  proper  situation,  until  the  unna- 
tural curvature  of  the  cartilage  has  been  overcome,  and 
the  chronic  inflammation  removed.  For  fulfilling  the 
first  indication  he  recommends  washing  the  external 
parts  with  warm  water,  so  as  to  leave  the  skin  as  clean 
as  possible.  It  is  then  to  be  carefully  dried,  and  re- 
peatedly anointed  with  the  ung.  zinci,  for  three  or  four 
days.  Being  thus  protected  from  the  irritation,  it  be- 
comes softer,  and  in  a favouralde  state  to  yield  to  mild 
extension.  For  accomplishing  the  second  indication, 
Mr.  Guthrie  applies  the  sulphuric  acid  : the  eyelid 
having  been  cleansed  so  as  to  prevent  its  slipping,  the 
conjunctiva  is  to  be  gently  wiped  dry  and  everted  as 
much  as  possible,  so  that  the  part  where  it  begins  to  be 
reflected  over  the  eyeball  may  be  seen.  An  assistant  is 
to  raise  the  upper  eyelid  a little,  and  the  patient  to  look 
upwards.  The  blunt  end  of  a common  silver  probe  is 
then  to  be  dipped  in  the  sulphuric  acid  and  rubbed  over 
the  conjunctiva,  so  that  every  part  of  it  may  be  touched 
with  the  acid.  The  round  point  of  the  probe  is  to  be 
carried  as  tar  as  where  the  membrane  begins  to  be  re- 
flected over  the  eyeball,  but  no  farther.  The  punctum 
lachrymale,  caruncle,  and  semilunar  fold  are  to  be 
avoided  ; but  the  external  angle,  as  well  as  every  other 
part,  except  what  is  reflected  over  the  eye,  is  to  be  care- 
fully rubbed.  The  acid  will  turn  the  touched  portion 
of  the  conjunctiva  white;  and  in  order  to  prevent  the 
acid  from  affecting  the  eyeball,  a stream  of  water  is 
now  to  be  directed  over  the  eyelid  with  an  elastic  gum 
syringe.  If  the  conjunctiva  should  not  be  turned  suffi- 
ciently white,  its  application  may  be  repeated.  The  use 
of  the  acid  is  to  be  repeated  every  fourth  day ; ‘‘  and  when 
applied  in  the  manner  directed  it  does  not  cause  a slough, 
but  a general  contrai  tiou  of  the  part,  which  is,  however, 
only  perceptible  after  two  or  three  applications,  by  its  ef- 
fect in  inverting  the  lid,  which  gradually  begins  to  take 
place.  After  six  or  eight  applications,  the  cure  will 
be  more  tlian  half  accomplished,  and  in  most  cases  of 
this  species  of  eversion,  the  thickening  of  the  con- 
junctiva will  have  subsided.”  The  ung.  zinci  is  to 
be  constantly  applied  to  the  skin,  and  the  ung.  hydrarg. 
nilr.  in  the  proportion  of  one  part  to  four  or  six  of  the 
ung.  cetacei,  to  the  edge  of  the  eyelid.  After  the  eye- 
lid has  reriirned  two-thirds  ol  the  way  towards  its  na- 
tural position,  the  intervals  between  the  applications 
of  the  acid  must  be  longer,  lest  the  contraction  within 
Lhi  eyel.d  be  carried  too  far,  and  an  inversion  of  it  pro- 


342 


EMB 


EMP 


duced.  After  the  eversion  is  cured,  the  lippitudo  may 
yet  partly  remain,  and  demand  the  use  of  the  ung.  hy- 
drarg.  nitr.  or  other  gentle  stimulants. — (See  Scarpa's 
Osservazioni  suLle  Malattie  degli  Occhi ; ed.  5,  cap.  6. 
Richter's  Avfangsgr.  der  Wuadarzneykunst,  b.  2,  p. 
473,  A,-c.  Wenzd's  Manuel  de  I'Oculiste.  Pellier,  Re- 
cueil  d'Obs.  sur  les  Maladies  des  Yeux.  Sir  W.  Adams, 
Pract.  Observ.  on  Ectropium,  or  Eversion  of  the  Eye- 
lids, with  a Description  of  a nesu  Operation  for  the 
Cure  of  that  Disease ; on  the  modes  of  forming  an 
artificial  Pupil;  and  on  Cataract,  Svo.  Load.  1812. 
M.  Bordenave,  Mimoire  dans  lequel  on  propose  un 
nouveau  ProcMo  pour  traiter  le  Renversement  des 
PaupUres,  in  Mem.  de  I'Acad.  Royale  de  Chirurgie,  t. 
13,  p.  156,  et  seq.  edit.  12/no.  It  was  in  this  memoir, 
that  the  proposal  of  removing  a portion  of  the  inside 
of  the  eyelid  for  the  cure  of  ectropium  was  first  made. 
Here  may  also  be  found  the  best  historical  account  of 
the  different  methods  of  treatment,  which  have  prevailed 
from  the  earliest  periods  of  surgery.  Consult  also 
Parallele  de  la  Chirurgie  Angloise  avec  la  Chirurgie 
Francoise,  par  P.  J.  Roux,  p.  289—292,  Paris,  1815. 
G.  J.  Beer,  Lehre  von  den  Augenkrankheiten,  b.  2,  p. 
133,  SfC.  Svo.  Wien,  1817.  Benj.  Travers,  Synopsis  of 
the  Diseases  of  the  Eye,  p.234.  356,  iV  c.  Svo.  Lond.  1820. 
Demoairs,  Traiti  des  Mai.  des  Yeux,  p.  98.  G.  J. 
Guthrie,  Lectures  on  the  Operative  Surgery  of  the  Eye, 
Svo.  Loud.  1823.) 

ECZEMA,  or  Eczk'sma  (from  ekI^Iu),  to  boil  out),  is 
characterized  by  an  eruption  of  small  vesicles  on  va- 
rious parts  of  the  skm,  usually  close  or  crowded 
together,  with  little  or  no  inflammation  round  their 
bases,  and  unattended  by  fever.  It  is  not  contagious. 
— (Bateman's  Synopsis,  p. ‘250,  ed.  3.)  There  are  se- 
veral varieties  of  this  disease,  the  most  remarkable  of 
which  is  the  eczema  rubrum  from  the  irritation  of  mer- 
cury. This  form  is  attended  with  quickened  pulse  and 
a white  tongue ; but  the  stomach  and  sensorium  are 
not  materially  disturbed.— (See  Mercury.) 

EFFUSION,  in  surgery,  means  the  escape  of  any 
fluid  out  of  the  vessel  or  viscus  naturally  containing 
it,  and  its  lodgement  in  another  cavity  in  the  cellular 
substance,  or  in  the  substance  of  parts.  Thus,  when 
the  chest  is  wounded,  blood  is  sometimes  effused  from 
the  vessels  into  the  cavity  of  thd  pleura  ; in  cases  of 
false  aneurisms,  the  blood  passes  out  of  the  artery  into 
the  interstices  of  the  cellular  substance ; in  cases  of 
fistul®  in  perinaeo,  the  urine  flows  from  the  bladder  and 
urethra  into  the  cellular  membrane  of  the  perinaeum 
and  scrotum ; and  when  great  violence  is  applied  to  the 
skull,  blood  is  often  effused  even  in  the  very  substance 
of  the  brain. 

Effusion  also  sometimes  signifies  the  natural  secre- 
tion of  fluids  from  the  vessels ; thus  surgeons,  fre- 
quently speak  of  the  coagulable  lymph  being  effused  on 
Afferent  surfaces.— (See  Extravasation.) 

ELECTRICITY.  Among  the  aids  of  surgery,  elec- 
tricity once  held  a conspicuous  and  important  situation. 
It  has,  however,  met  with  a fate  not  unusual  with  reme- 
dies too  much  cried  up  and  too  indiscriminately  em- 
ployed ; that  of  having  fallen  into  an  undeserved  degree 
of  neglect. 

Whatever  its  effects  may  be  on  the  system,  it  cer- 
tainly possesses  this  advantage  over  other  topical  reme- 
dies, that  it  may  be  made  to  act  on  parts  very  remote 
from  the  surface. 

Electricity,  as  a topical  remedy  for  surgical  diseases, 
is  chiefly  used  in  amaurosis,  deafness,  some  chronic 
tumours  and  abscesses,  weakness  from  sprains,  or  con- 
tusions, paralysis,  &c. 

In  cases  of  suspended  animation,  electricity  is  some- 
times an  important  auxiliary  for  the  restoration  of  the 
vital  functions.— (See  J.  Curry's  Obs.  on  Apparent 
Death.  &rc.  ed.  2,  1815.) 

ELEVATOR.  An  instrument  for  raising  depressed 
portions  of  the  skull. 

Besides  the  common  elevator,  now  generally  pre- 
ferred by  all  the  best  operators,  several  others  have 
been  invented;  as,  for  instance,  the  tripod  elevator,  and 
another  which  was  first  devised  by  M.  J.  L.  Petit,  and 
afterward  improved  by  M.  Louis. 

EMBROCATIO  ALUMINIS.  Jk-  Aluminis  ^ij. 
Aceti,  spiritus  vinosi  tenuioris,  sing.  Ibss.  For  chil- 
blains and  disea.sed  joints.  . 

EMBROCATIO  AMMONIA.  R.  Liq.  ammon.  5 i. 
.Athens  >aulphurici  5 ss-  Spir.  lavanduls  5>j-  M. 
For  sprains  and  bruises. 


EMBROCATIO  . AMMONIiE  ACETATE  CAM- 
PHORATA.  ft.  Linim.  camph.,  liq.  ammon.  acet 
sing.  3 vj.  Liq.  ammon.  ? ss.  M.  For  sprains,  bruises 
and  chilblains,  not  in  a state  of  suppuration 

EMBROCATIO  AMMONIAC  ACETATtE.  ft.  Liq 
ammon.  acet.,  lin.  sapon.  sing.  sj.  M.  For  bruises 
with  inflammation. 

EMBROCATIO  CANTHARIDIS  CUM  CAM- 
PKORA.  ft.  Tinct.  canth.,  spirit,  camph.  sing.  3j. 
M.  This  may  be  used  in  any  case  in  which  the  object 
is  to  stimulate  the  skin.  It  should  be  remembered, 
ho  wever,  that  the  absorption  of  cantharides  will  some- 
times bring  on  strangury. 

EMBRYOTOMIA.  (From  spSpvov,  a foetus,  and 
TEpvu),to  cut.)  The  operation  of  cutting  into  the  womb, 
in  order  to  extract  the  foetus.— (See  Caesarean  Opera 
tion.) 

EMPHYSEMA.  ('KpipyayiJia,  fronupvadu),  to  inflate.) 
A swelling  produced  by  air  in  the  cellular  substance. 
The  common  cause  is  a fractured  rib,  by  which  the 
vesicles  of  the  lungs  are  wounded,  so  that  the  air  es- 
capes from  them  into  the  cavity  of  the  thorax.  But  as 
the  rib  at  the  moment  of  its  being  fractured  is  pushed 
inwards  and  wounds  the  pleura,  which  lines  the  ribs 
and  intercostal  muscles,  part  of  the  air  most  commonly 
passes  through  the  pleura  aiid  the  lacerated  muscles 
into  the  cellular  membrane  on  the  outside  of  the  chest, 
and  thence  is  diffused  through  the  same  membrane 
over  tile  whole  body,  so  as  to  inflate  it  sometimes  in  an 
extraordinary  degree.  This  inflation  of  the  cellular 
membrane  has  been  commonly  looked  upon  as  the  most 
dangerous  part  of  the  disease  ; but  very  erroneously,  as 
will  appear  in  the  sequel. — (Hewson,Med.  Obs.  and  In- 
quiries,vol.  3.) 

Emphysema  is  most  frequent  after  a fractured  rib, 
because  there  is  a wide  laceration  of  the  lungs,  and  no 
exit  for  the  air;  it  is  less  fre»iuent  in  large  wounds 
with  a knife  or  broadsword,  because  the  air  has  an 
open  and  unimpeded  issue;  it  is  again  more  frequent  in 
deep  stabs  with  bayonets  or  small  swords;  but  it  is  not 
so  peculiarly  frequent  in  gun-shot  wounds  as  the  late 
Mr.  John  Bell  supposed  (On  Wounds  of  the  Breast, 
p.  265,  ed.  3),  and,  in  fact,  is  not  nearly  so  common  in 
them  as  in  cases  of  stabs,  particularly  where  the  ribs 
are  not  splintered. 

Emphysema  has  also  been  known  to  arise  from  a 
rupture  of  the  larynx  and  trachea,  produced  by  a blow 
or  kick,  as  we  find  exemplified  in  the  case  reported  by 
Dr.  L.  O’Brien. — (See  Edin.  Med.  and  Surg.  Joum. 
No.  72.) 

The  symptoms  attending  emphysema  are  generally 
of  the  following  kind.  The  patient  at  first  complains 
of  a considerable  tightness  of  the  chest,  with  pain, 
chiefly  in  the  situation  of  the  injury,  and  great  difficulty 
of  breathing.  This  obstruction  of  respiration  gradually 
increases,  and  becomes  more  and  more  insupportable. 
The  patient  soon  finds  himself  unable  to  lie  down  in 
bed,  and  cannot  breathe,  unless  when  his  body  is  in  an 
upright  posture,  or  he  is  sitting  a little  inclined  for- 
wards. The  countenance  becomes  red  and  swollen. 
The  pulse,  at  first  weak  and  contracted,  becomes  after- 
ward irregular.  The  extremities  grow  cold,  and,  if  the 
patient  continue  unrelieved,  he  soon  dies,  to  every  ap- 
pearance suffocated. 

The  emphysematous  swelling,  wheresoever  situated, 
is  easily  distinguished  from  oedema  or  anasarca,  by  the 
crepitation  which  occurs  on  handling  it,  or  a noise  like 
that  which  takes  place  on  comp'^essing  a dry  bladder 
half  filled  with  air. 

The  tumour  is  colourless  and  free  from  jmin.  It  does 
not  of  itself  descend  into  depending  parts,  though  by 
jiressure  it  may  be  made  to  change  its  situation.  It  is 
elastic,  that  is  to  say,  it  may  be  pressed  down,  but  it 
rises  up  again  as  soon  as  the  pressure  is  discontinued 
The  swelling  never  retains  the  impression  of  the  end 
of  the  finger,  or,  in  the  language  of  surgery,  never  pits. 
The  iiart  affected  is  not  heavy.  The  tumour  first 
makes  its  appearance  in  one  particular  jilace;  but  it 
soon  extends  over  the  whole  body,  and  causes  an  ex- 
traordinary distention  of  the  skin.— (Ric/ifer’s  An 
fiugsgr.  der  W undarzn.  b.  \,p.  451.) 

The  wound  of  the  pleura  and  intercostals  may  some- 
times be  too  small  to  suffer  the  air  to  get  readily  into  the 
cellular  membrane,  and  inflate  it,  but  may  confine  a part 
of  it  in  the  cavity  of  the  thorax,  so  as  lo  compress  the 
lungs,  prevent  their  expan.sion,  and  cause  the  same 
symptoms  of  tightness  of  the  chest,  quick  breathing, 


EMPHYSEMA. 


343 


and  j^nse  of  suffocation,  which  water  does  in  the  hy- 
drops pectoris,  or  matter  in  empyema. — {Hewsmrv.) 

To  understand  why  the  air  passes  at  all  out  of  the 
wound  of  the  lungs,  we  must  advert  to  the  manner  in 
which  inspiration  and  expiration  are  naturally  carried  on. 
It  is  well  known,  that  in  the  perfect  state,  the  surface  of 
the  lungs  always  lies  in  close  contact  with  the  membrane 
lining  the  chest,  both  in  inspiration  and  expiration.  The 
lungs  themselves  are  only  passive  org^ins,  and  are 
quite  incapable  by  any  action  cf  their  own  of  expand- 
ing and  contracting,  so  as  to  maintain  their  external 
surface  always  in  contact  with  the  in.side  of  the  thorax, 
which  is  continually  d.idergoing  an  alternate  change 
of  dimensions.  Every  muscle  that  has  any  share  in 
enlarging  and  diminishing  the  capacity  of  \he  chest, 
must  contribute  tc  the  effect  of  adapting  the  volume  of 
the  lungs  to  the  cavity  in  which  thsy  are  contained, 
as  long  as  there  is  no  communication  between  the  ca- 
vity of  the  pleura  and  the  exterr.al  air.  In  inspiration 
the  thorax  is  enlarged  in  every  direction,  the  lungs  are 
expanded  in  the  same  way,  and  the  air,  entering  through 
the  windpipe  into  the  air-cells  of  these  organs,  prevents 
the  occurrence  of  a vacuum. 

But  in  cases  of  wounds,  when  there  is  a free  com 
munication  between  the  atmosphere  and  inside  of  the 
chest,  no  sooner  is  this  cavity  expanded,  than  the  air 
naturally  enters  it  at  the  same  time,  anu  for  the  same 
reasons,  that  the  air  enters  the  lungs  througii  the  tra- 
chea, and  the  lung  itself  remains  proportionally  col- 
lapsed. When  the  thorax  is  next  contracted  in  expira- 
tion the  air  is  compressed  out  of  .he  lung,  and  also  out 
of  the  bag  of  the  pleura  through  the  externa)  wound,  if 
there  be  a direct  one ; in  which  circumstance  the  em- 
physematous swelling  is  never  extensive. 

But  in  the  case  of  a fractured  rib,  attended  with  a 
breach  in  the  pleura  cosialis,  pleura  pulmonalis,  and 
air-cells  of  the  lungs,  there  is  no  direct  communication 
between  the  cavity  of  the  chest  and  tlie  external  air ; in 
ocher  words,  there  is  no  outward  wound  in  the  parietes 
of  the  thorax.  There  is,  however,  a preternatural 
opening  formed  betvveen  the  air-cells  of  the  lungs  and 
the  cavity  of  the  chest,  and  also  another  one  between  the 
latter  space  and  the  general  cellular  substance  of  the 
body,  through  the  breach  in  the  pleura  costalis.  The 
consequence  is,  that  when  the  chest  is  expanded  in  in- 
spiration, air  rushes  from  the  wound  in  the  surface  of 
the  lungs,  and  insinuates  itself  between  them  and  the 
pleura  costalis.  The  lungs  collapse  in  proportion,  and 
the  place  which  they  naturally  occupied  when  dis- 
tended, is  now  occupied  by  the  air.  When  in  expira- 
tion the  dimensions  of  the  chest  are  every  where  di- 
minished, the  air  now  lodged  in  the  bag  of  the  pleura 
cannot  get  back  into  the  aperture  in  the  collapsed  lung, 
because  this  is  already  full  of  air,  and  is  equally  com- 
pressed on  every  side,  by  that  which  is  confined  in  the 
thorax.  Were  there  no  breach  in  the  pleura  costalis, 
this  air  could  not  now  become  diffused ; the  muscles  of 
inspiration  would  next  enlarge  the  chest,  remove  the 
pressure  from  the  surface  of  the  wounded  lung,  more 
air  would  be  sucked  out  of  it,  as  it  were,  into  the  space 
between  the  pleura  costalis  and  pleura  pulmonalis,  and 
this  process  would  go  on  till  the  lungs  of  the  wounded 
side  were  completely  collapsed.  But  in  the  case  of  a 
fractured  rib  or  narrow  stab,  in  which  there  is  also  a 
breach  in  the  pleura  co.stalis,  without  any  free  vent  out- 
wards for  the  air  which  gets  out  of  the  lung  into  the 
cavity  of  the  pleura,  as  soon  as  the  expiratory  powers 
lessen  the  capacity  of  the  chest,  this  air,  not  being 
able  to  pass  back  through  the  breach  in  the  collapsed 
lung,  is  forced  through  the  laceration  or  wound  in  the 
pleura  costalis  into  the  common  cellular  substance. 

It  is  through  the  communicating  cells  of  this  struc- 
ture that  the  air  becomes  most  extensively  diffused 
over  the  whole  body,  in  proportion  as  the  expiratory 
mmscles  continue  in  their  turn  to  lessen  the  capacity  of 
the  chest,  and  pump  the  air,  as  it  were,  through  the 
breach  in  the  pleura  costalis,  immediately  after  it  has 
been  drawn  out  of  the  wound  of  the  lung  in  inspiration, 
— iSee  John  Bell,  On  Wounds  of  the  Breast,  and  Hal- 
liday.  On  Emphysema,  1807.) 

To  prove  that  the  confinement  of  air  in  the  chest  is  the 
cause  of  the  dangerous  symptoms  attending  emphy- 
sema, Ilewson  adverts  to  the  histories  of  some  re- 
markable cases,  published  hy  Littre.  Mery,  W.  Hunter, 
and  Cheslon.— (See  Mem.  de  I' Acad.  Royale  des  Sci- 
ences, frjr  1713;  Med.  Obs.  and  Inquiries,  vol.  2;  and  \ 
Pathoioffical  Inquiries.) 


In  Littre’s  case,  the  patient,  who  had  been  wounded 
in  the  side  with  a sword,  could  not  breathe  without 
making  the  most  violent  efibris,  especially  during  the 
latter  part  of  his  disease ; he  died  on  the  fifth  day. 

In  Mery’s  instance,  the  fourth  and  filth  true  ribs  were 
broken  by  a coach  passing  over  the  chest ; the  patient’s 
respiration  was  much  impeded  from  the  first,  and  be- 
came more  and  more  difficult  till  he  died,  which  was  on 
the  fourth  day  after  the  accident. 

In  Dr.  Hunter’s  case,  the  patient  had  received  a con- 
siderable hurt  on  his  side  by  a fall  from  his  horse.  He 
had  adifficultv  of  breathing',  which  increased  Ui  propor- 
tion as  the  skin  became  elevated  and  tense , it  was  la- 
borious as  well  as  frequent.  Ills  inspiration  was 
short  and  almost  instantaneous,  and  ended  with  a 
catch  in  the  throat,  which  was  produced  by  the  .shutting 
oft  he  glottis;  after  this  lie  strained  to  expire  for  a moment 
without  £ny  noise,  then  suddenly  opeiiidg  the  glo.tis, 
forced  out  his  breath  with  a sort  of  groan,  anu  in  a hui  '-y, 
and  then  quickly  inspired  agam ; so  that  his  end'uvours 
seemed  to  be  lo  keep  Ids  lungo  always  full ; inspiration 
succeeded  expiration  as  fast  as  possible.  He  said,  his 
difficulty  of  breathing  was  owing  to  an  oppre.ssion  or 
tig’nness  across  his  breast,  near  the  pit  of  the  stomach. 
He  hac  a little  cough,  which  exasperated  his  pain,  and 
he  brouglit  up  blood  and  phlegm  from  his  lungs.  He 
was  relieved  by  scarifications,  and  recovered. 

In  Mr.  Cheston’s  car  s,  the  man  had  received  a blow 
on  the  chest.  He  had  a constant  cough,  bringing  up, 
after  many  ineffectual  efforts,  a frothy  discharge,  lightly 
tinctured  with  blood ; he  seemed  to  be  in  the  greatest 
agonies,  and  constantly  threatened  will)  sufibcation. 
His  pulse  was  irregular,  and  .sometimes  scarcely  to  be 
felt,  his  face  livid,  ar.d  when  he  was  sensible,  which 
was  only  now  and  then,  he  complained  of  a pair,  in  his 
head.  On  passing  a bandage  round  his  chest,  with  a 
proper  compress  to  prevent  the  discharge  of  air  into  the 
cellular  membrane,  and  to  confine  tiie  inotioii  of  the 
thorax,  the  patient  cried  out  th.at  he  could  not  siifier  it. 
A strong  compression  by  the  baud  alone  affected  him 
in  the  same  way.  Notwitlistaiidiiig  bieeumg,  repeated 
scarifications,  and  other  means,  his  sense  of  suffoca- 
tion and  dilficulty  of  breathing  increased.  On  the 
fourth  day,  the  air  no  longer  passed  into  the  cellular 
membrane,  when  on  a sudden  inclining  his  head  back- 
wards, as  it  were,  for  the  admission  of  more  air  than 
usual,  his  breathing  became  more  difficult  and  inter- 
rupted, he  turned  wholly  insensible,  and  soon  afterward 
died. 

Littre,  Mery,  and  Cheston  opened  their  patients  after 
death. 

Besides  a wound  of  the  lungs  and  fractured  rib, 
Littre  found  a considerable  quantity  of  blood  in  the 
cavity  of  the  thorax,  and  was  sensible  of  some  fetid 
air  escaping  on  his  first  puncturing  the  intercostals  and 
pleura.  The  wounded  lobe  was  hard  and  black,  and 
the  other  two  of  the  same  side  were  inflamed. 

In  Mery’s  patient  no  blood  was  extravasated,  nor  was 
there  any  thing  preternatural,  except  the  fractured  ribs, 
the  wound  of  the  pleura,  and  that  of  the  lungs. 

Clieslon  found  a fracture  of  the  tenth  and  eleyenth 
ribs,  and  a wound  of  the  lungs.  The  lungs  below  the 
wound  were  livid,  and  more  compact  than  usual ; but 
every  thing  else  was  natural,  no  extravasation,  iio  in- 
flammation, no  internal  emphysema. 

Hewson  made  several  experiments  on  animals,  tend- 
ing to  prove,  that  air  in  their  chests  produced  great  diffi- 
culty in  breathing,  such  as  occurs  in  cases  of  emphy- 
sema ; and  in  one  case  which  he  examined  after  death, 
air  was  actually  discharged  on  puncturing  the  thorax. 

The  object  of  Mr.  Hewson’s  paper  is  to  recommend 
making  an  opening  in  the  chest,  for  the  purpose  of 
giving  vent  to  the  air  confined  in  that  cavity,  just  as  is 
done  for  the  discharge  of  pus  in  cases  of  empyema  or 
of  water  in  those  of  hydrops  pectoris. 

In  wounds  of  the  lungs,  says  this  author,  w'hether 
occ^asioned  by  fractured  ribs  or  other  causes,  when 
symptoms  of  tightness  and  suffocation  come  on,  so  far 
should  we  be  from  dreading  the  emphysematous  swell- 
ing of  the  cellular  membrane,  that  we  should  rather 
consider  it  as  a favourable  symptom,  showing  that  the 
air  is  not  likely  to  be  confined  in  the  thorax ; and  so  far 
should  we  be  from  compressing  the  wound  to  prevent 
the  inflation  or  emphysema,  that  we  should  rather  di- 
late it  (if  not  large  enough  already)  or  perform  the  pa- 
racentesis thoracis.  We  may  judge  of  the  necessiiy 
of  this  operation  from  the  violence  of  the  symptoms. 


344 


EMPHYSEMA. 


such  as  the  oppressed  breathing,  dtc.  For  when  these 
are  not  considerable,  and  the  air  passes  out  of  the  chest 
with  sufficient  freedom,  the  operation  is  then  unue- 
cessarj'. 

If  the  disease  is  on  the  right  side,  the  best  place  for 
performing  the  operation,  says  Mr.  Hewson,  will  be  on 
the  fore  part  of  the  chest,  between  the  fifth  and  sixth 
ribs ; for  there  the  integuments  are  thin,  and  in  the  case 
of  air  no  depending  drain  is  required.  But  if  the  dis- 
ease is  on  the  left  side,  it  will  be  more  advisable  to 
make  the  opening  between  the  seventh  and  eighth,  or 
eighth  and  ninth  ribs,  in  order  that  we  may  be  sure  of 
avoiding  the  pericardium.  As  large  penetrating  wounds 
are  inconvenient  on  account  of  the  air  entering  by  the 
aperture  in  such  a quantity  as  to  prevent  the  expcmsion 
of  the  lungs,  a small  wound  \%ill  be  eligible,  espe- 
cially as  air  does  not  require  a large  one  for  its  escape. 
Mr.  Hewson  recommends  dissecting  cautiously  with  a 
knife,  in  preference  to  the  coarse  and  hazardous’  method 
of  thrusting  in  a trocar. 

There  is  one  error  prevailing  in  Mr.  Hewson’s  paper, 
for  which  he  has  been  justly  criticised  by  Mr.  John 
Bell ; viz.  the  idea  that  it  is  possible  and  proper  to  make 
the  collapsed  lung  expand  by  making  an  opening  in  the 
chest.  Bromfield  and  B.  Bell  have  both  imbibed  the 
same  erroneous  opinions,  and  proposed  plans  for  ex- 
hausting the  air  and  expanding  the  lung.  It  is  very- 
certain  that  it  is  impracticable  to  make  the  collapsed 
viscus  expand,  until  the  breach  in  it  is  closed,  and  this 
closure  is  greatly  promoted  by  the  quiet  state  in  which 
the  collapsed  lung  remains;  a state  also  the  most 
favourable  for  the  stoppage  of  any  bleeding  from  the 
pulmonary  vessels. 

The  true  object  then  of  making  an  opening  in  the 
thorax,  when  the  symptoms  of  suffocation  are  violent, 
is  not  to  obtain  an  expansion  of  the  lung  on  the  affected 
side,  nor  to  take  the  pressure  of  the  air  from  it ; but  to 
remove  the  pressure  caused  on  the  opposite  lung  by 
the  distention  of  the  mediastinum,  and  at  the  same  time 
to  diminish  the  pressure  of  the  air  on  the  diaphragm. 
The  lung  on  the  affected  side  must  continue  collapsed, 
and  it  is  most  advantageous  that  it  should  do  so.  The 
opposite  lung  is  that  which  for  a time  must  of  itself 
carry  on  respiration,  and  it  is  known  to  be  fully  ade- 
quate to  this  function,  provided  the  quantity  of  air  on 
the  other  side  of  the  chest  does  not  produce  too  much 
pressure  on  the  mediastinum  and  diaphragm. 

Mr.  John  Bell  concludes  his  remarks  on  this  subject 
with  advising  the  following  practice  : 

1st.  When  the  crackling  tumour  begins  to  form  over 
a fractured  rib,  small  punctures  should  be  made  with 
the  point  of  a lancet,  as  in  bleeding  ; and  if  the  point 
be  struck  deep  enough,  the  air  will  rush  out  audibly. 
But  as  (supposing  the  lung  is  not  adherent  to  the  inside 
of  the  chest)  this  air  was  in  the  thorax  before  it  came 
into  the  cellular  substance,  it  is  plain  that  the  thorax  is 
still  full,  and  that  the  lung  of  that  side  is  already  col- 
lapsed and  useless,  and  must  continue  so.  The  pur- 
pose, therefore,  of  making  these  scarifications,  and  es- 
pecially of  making  them  so  near  the  fractured  part,  is 
not  to  relieve  the  lungs,  but  merely  to  prevent  the  air 
spreading  more  widely  beneath  the  skin. 

2d.  If  the  air  should  have  spread  to  very  remote 
parts  of  the  body,  as  to  the  scrotum  and  do^vn  the  thighs, 
it  will  be  easier  to  make  small  pui^ctures  in  those  parts 
to  let  out  the  air  directly,  than  to  press  it  along  the 
whole  body  till  it  is  brought  up  to  the  punctures  made 
on  the  chest  over  the  wounded  part. 

3d.  If,  notwdihstanding  free  punctures  and  pressing 
out  the  air  in  this  way,  you  should  find  by  the  oppres- 
sion that  either  air  or  blood  is  accumulating  within  the 
cavity  of  the  thorax,  so  as  to  oppress  not  the  wounded 
lung  only,  which  was  of  course  collapsed  and  useless 
from  the  first,  but  the  diaphragm,  and  through  the 
diaphragm  to  affect  also  the  sound  lung  ; then  a freer 
incision  must  be  made  through  the  skin  and  muscles, 
and  a small  puncture  should  be  cautiously  made  through  ‘ 
the  pleura,  in  order  to  let  out  the  air  or  blood  confined 
in  the  thorax.-^/o/in,  Bell,  op.  cit.  p.  278.) 

In  all  these  cases  copious  and  frequently  repeated 
venesection  is  generally  proper. 

After  a few  days  the  wound  in  the  collap.sed  lung  is 
closed  by  the  adhesive  inflammation,  so  that  the  air  no 
longer  passes  out  of  it  into  the  cavity  of  the  chest,  and 
the  outer  wound  may  therefore  be  healed.  W^hat  air  I 
is  already  there  is  ultimately  absorbed,  and  the  lung, 
expanding  in  proportion,  resumes  its  original  ftinctions.  I 


[ The  application  of  a bandage  round  the  chest  is  some- 
‘ times  practised  in  cases  of  emphysema  ; and  its  utility 
i when  the  ribs  are  broken  has  been  highly  spoken  of 
by  Mr.  Abemethy. — “ Pressure  by  bandage  (says  he) 
not  only  hinders  the  air  from  diffusing  itself  through 
the  cellular  substance,  but  serves  to  prevent  it  from 
escaping  out  of  the  wounded  lung,  and  of  course  facili- 
tates the  healing  of  the  wound,  w-hich  would  be  pre- 
vented by  the  constant  transmission  of  air.  Its  early 
application,  therefore,  will  often  prevent  a very  trou- 
blesome symptom,  while,  at  the  same  time,  by  keeping 
the  fractured  bones  from  motion  it  greatly  lessens  the 
sufferings  of  the  p&lient.”— {Abemethy' s Surgical 
Works,  vol.  2,  p.  179.)  Where  emphysema  is  compli- 
cated with  a fractured  rib,  the  latter  injury-  is  unques- 
tionably a reason  in  favour  of  a bandage.  But  whether 
the  pressure  of  the  roller  will  be  useful  or  hurtful  with 
respect  to  the  emphysema  itself,  or  the  state  of  the  lungs 
and  respiration,  may  be  questionable.  As  for  its  ten- 
dency to  resist  the  diffusion  of  air  in  the  common  cellu- 
lar membrane,  this  circumstance  does  not  appear  to 
me  important,  because  the  air  thus  diffused,  much  as 
it  disfigures  the  patient,  is  nearly  harmless,  at  least  as 
long  as  the  interlobular  texture  of  the  lungs  remains 
uninflated  ; a danger  also  which  no  bandaging,  as  far 
as  I can  judge,  has  any  tendency  to  prevent.  Neither 
will  a bandage  have  so  much  effect  in  hindering  the 
diffusion  of  air  eis  scarifications,  with  this  important 
additional  consideration,  that  punctures  or  small  inci- 
sions, made  over  the  broken  rib,  prevent  the  spreading 
of  the  air  by  letting  it  escape,  while  a bandage  can  only 
do  so  by  more  or  less  resisting  its  escape  from  the 
cavity  of  the  pleura ; which  mode  of  operation  in  some 
cases  w'ould  dangerously  interfere  with  the  continua- 
tion of  respiration  by  the  lung  of  the  opposite  side.  At 
the  same  time,  I believe,  that  when  the  air  extravasated 
within  the  injured  side  of  the  chest  is  not  in  such  quan- 
tity as  to  oppress  the  sound  lung,  and  a rib  is  broken, 
a bandage  will  generally  afford  great  relief.  Indeed, 
it  is  but  justice  to  Mr.  Abemethy  to  state,  that  he  does 
not  recommend  the  employment  of  a bandage  in  all 
cases  of  emphysema.  “Patients  (says  he)  will  not 
always  be  able  to  wear  a bandage  w'hen  one  lung  is  • 
collapsed,  particularly  if  any  previous  disease  has  ex- 
isted in  the  other,  as  it  equally  confines  the  motions  of 
the  ribs  on  both  sides,  and  as  every  possible  enlarge- 
ment of  the  chest  becomes  necess^'  for  the  due  admis- 
sion of  the  air  into  the  lung  which  still  executes  its 
functions.  Under  these  circufhstances,  if  the  emphy- 
sema continues  (and  its  continuance  must  alw'ays  de- 
note that  the  w’ound  in  the  lung  is  not  closed),  I should 
esteem  it  the  best  practice  to  make  a small  opening 
into  the  chest,  so  that  the  external  air  might  have  a 
free  communication  with  that  cavity ; and  then  the  in- 
jured lung  must  remain  motionless  till  its  wound  is 
healed,  tmd  the  mediastinum  will,  in  ever}-  state  of  the 
thorax,  preserve  its  natural  situation.” — {JJbemethy, 
vol.  cit.  p.  183.) 

The  utility  of  a free  incision  and  scarifications  is  w'ell 
illustrated  in  a case  recorded  by  Larrey.  The  emphysema 
arose  from  a wound  of  the  lungs  by  a lance.  The 
whole  body  w^as  prodigiously  swelled,  the  integuments 
so  distended  that  the  limbs  were  inflexible,  the  eyes 
buried,  and  the  lips  so  enlarged  that  nothing  could  be 
introduced  into  the  mouth.  TTie  pulse  and  respiration 
were  scarcely  perceptible,  and  the  voice  feeble  and  in- 
terrupted. The  lance  had  entered  obliquely  under  the 
lower  angle  of  the  scapula,  and  though  the  external 
and  internal  orifices  of  the  wound  were  not  parallel, 
the  surgeon  had  applied  adhesive  straps,  and  closed 
the  external  one.  Hence  the  air,  as  it  escaped  from 
the  lungs,  distended  the  cellular  texture.  Larrey  im- 
mediately removed  the  dressings,  and  w’ith  a bistoury 
made  the  openings  in  the  pleura  and  skin  parallel. 
Cupping-glas.ses  were  then  applied  over  the  wound, 
and  quickly  filled  with  air  and  blood.  The  lips  of  the 
wound  were  now  brought  together,  and  kept  so  w ith 
a suitable  bandage.  Cupping-glasses  and  scarificators 
w ere  applied  to  various  parts  of  the  body,  and  in  others 
incisions  were  made  with  a scalpel.  The  patient  revX>- 
vered. — (See  M m.  de  Chir.  Militaire,  t.  4.) 

Emphysema  has  been  known  to  arise  from  the  burst- 
ing of  a vomica,  and  ulceration  of  the  surface  of  the 
lungs  ; but  the  air  which  escapes  in  this  instance  c.hu- 
not  find  its  way  into  the  cavity  of  the  thorax,  because 
the  inflammation  which  precedes  the  abscess  and  ul- 
ceration of  the  air-cells  clo.ses  tho.se  which  are  adja- 


EMPHYSEMA. 


345 


cent,  and  produces  an  adhesion  of  the  edges  of  the 
vomica  or  ulcer  to  the  inner  surface  of  the  chest,  so  as 
entirely  to  separate  the  two  cavities.  We  are  not  ac- 
quainted with  any  instance  of  the  symptoms  imputed 
to  the  continement  of  air  in  the  chest  originating  from 
suppuration  and  ulceration  of  the  surface  of  the  lungs ; 
but  Palfyn,  Dr.  Hunter,  and  the  author  of  the  article 
Emphysema  in  the  Encyclop  die  Mdthodique,  partie 
Chirurgicale,  have  seen  cases  in  which  emphysema 
originated  from  abscesses  of  the  lungs,  attended  with 
adhesion  to  the  pleura,  and  ulcerations  in  the  situation 
of  such  adhesion.  In  these  instances,  the  pus  having 
made  its  way  through  the  pleura  and  intercostal  mus- 
cles, the  air  escapes  also  through  the  same  track,  so  as 
to  pass  into  the  cellular  membrane  on  the  outside  of 
the  chest. 

A violent  effort  of  respiration  has  sometimes  produced 
a certain  degree  of  emphysema,  which  first  makes  its 
appearance  about  the  clavicles,  and  afterward  spreads 
over  the  neck  and  adjacent  parts.  The  efforts  of  labour 
have  been  known  to  occasion  a similar  symptom  ; but 
no  bad  consequences  followed.— (MedtcaZ  Communi- 
cations, vol.  1,  p.  176 ; Blackden,  in  Med.  Facts  and 
Experiments,  vol.  2 ; and  Wilmer's  Obs.  in  Surgery 
p.  143.) 

Louis  has  described  an  emphysema  of  tliis  sort,  which, 
on  account  of  its  cause,  and  the  indication  furnished  by 
it  to  the  practitioner,  is  highly  important.  It  took  place 
in  a young  girl,  who  died  suffocated  from  a bean  falling 
into  her  windpipe,  and  he  considers  it  as  a pathogno- 
monic symptom  of  such  an  accident,  concerning  the 
existence  of  which  it  is  so  essential  not  to  commit  any 
mistake. — (See  Bronchotomy.)  It  made  its  appearance 
on  both  sides  of  the  neck  above  the  clavicles,  and  came 
on  suddenly  on  the  third  day  after  the  accident.  Tite 
inspection  of  the  body  proved  that  the  lungs  and  medi- 
astinum were  also  in  an  emphysematous  state.  The 
retention  of  the  air,  confined  by  the  foreign  body,  pro- 
duced, says  Louis,  at  each  attempt  to  expire,  and  espe- 
cially when  the  violent  fits  of  coughing  occurred,  a 
strong  propulsion  of  this  fluid  towards  the  surface  of 
the  lung  into  the  spongy  substance  of  this  viscus. 
Thence  the  air  passed  into  the  cellular  texture  which 
unites  the  surface  of  the  lung  to  the  pleura  pulmonaris ; 
and  by  communications  from  cells  to  cells  it  caused  a 
prodigious  swelling  of  the  cellular  substance  between 
the  two  layers  of  the  mediastinum.  The  emphysema 
increasing,  at  length  made  its  appearance  above  the 
clavicles.  This  tumefaction  of  the  lung  and  surround- 
ing parts,  in  consequence  of  air  getting  into  their  spongy 
and  cellulai  texture,  is  an  evident  cause  of  suffocation, 
and  the  swelling  seems  so  natural  an  effect  of  the  pre- 
sence of  a foreign  body  in  the  trachea,  that  one  can 
hardly  fail  to  think  it  an  essential  symptom,  though  no 
author  has  made  mention  of  it. — {Mem.  de  VAcad.  de 
Chir.  t.  4,  in  4to.)  The  emphysematous  swelling, 
sometimes  formed  in  the  axilla  in  the  reduction  of  a 
dislocated  shoulder  (see  Dislocation),  was  accounted  for 
by  Desault  and  Bichat  on  the  same  principle  as  the 
foregoing  case,  viz.  a rupture  of  one  of  the  air-cells  by 
the  patient’s  efforts  to  hold  his  breath  during  the  reduc- 
tion of  the  bone.  How  far  the  explanation  of  the  cause 
may  be  true  has  been  questioned  (see  Diet,  des  Sciences 
Med.  t.  12,  p.  15) ; the  fact  itself  admits  of  no  doubt, 
and  is  both  curious  and  interesting. 

The  example  lately  recorded  by  Dr.  Ireland  as  one 
of  idiopathic  emphysema  following  pneumonia,  bears 
so  strong  a resemblance  to  the  case  above  cited  from  M. 
Louis,  that  I cannot  refrain  from  suspecting  that  it 
may  have  been  one  of  the  same  nature. — (See  Trans, 
of  the  King’s  and  Queen’s  College  of  Physicians,  vol. 
3,  art.  4.) 

An  emphysematous  swelling  of  the  head,  neck,  and 
chest  has  also  been  noticed  in  typhoid  fevers.  Dr. 
Huxarn  relates  an  instance  of  this  sort  in  a sailor  of  a 
scorbutic  habit. — {Medical  Observations  and  Inquiries, 
vol.  3,  art.  4.)  Another  example  in  a case  of  bilious 
fever  is  recorded  in  a periodical  work  — (See  London 
Med.  Repository,  No.  73.)  A case  of  spontaneous  em- 
physema is  likewise  described  by  Dr.  Baillie.— (See 
Trans,  for  the  Imjrrove^ncnt  of  Med.  and  Chir.  Know- 
ledge, vol.  1,  p.  202.) 

A curious  example  of  what  has  been  called  a spon- 
taneous emphysema  is  recorded  by  Mr.  Allan  Bums; 
“ The  patient  was  a strong,  athletic  man,  who,  about 
six  years  previous  to  his  application  at  the  Royal  In- 
firmarj',  had  received  a smart  blow  on  the  neck  from 


the  keel  of  a boat.  This  injury  was  soon  followed  by 
the  formation  of  a firm,  tense  tumour  on  the  place 
which  had  been  hurt.  The  swelling  increased  very 
slowly  during  the  five  years  immediately  succeeding 
its  commencement',  but  during  the  sixth  it  received  a 
very  rapid  addition  to  its  bulk.  At  this  time  it  mea- 
sured nearly  six  inches  in  diameter,  seemed  to  be 
confined  by  a firm  and  dense  covering,  and  the  morbid 
parts  had  an  obscure  fluctuation.  From  the  first  to  the 
last  the  tumour  had  been  productive  of  very  little  pain. 

Judging  from  the  apparent  fluctuation  that  the  tu- 
mour was  encysted,  it  was  resolved  at  a consultation 
to  puncture  the  swelling,  draw  off  its  contents,  and 
then  pass  a seton  through  it.  By  plunging  a lancet 
into  it,  only  a very  small  quantity  of  blood,  partly  co- 
agulated, and  partly  fluid,  was  discharged— a quantity 
so  trifling  that  after  its  evacuation,  the  size  of  the  tu- 
mour was  not  perceptibly  reduced.  A seton  was 
passed  through  the  swelling.  At  this  time  the  man 
was  in  perfect  health. 

About  ten  hours  after  the  operation,  the  patient 
was  seized  with  extremely  violent  rigors,  followed  by 
heat,  thirst,  pain  in  the  back,  excessive  pain  in  the 
tumour,  and  oppressive  sickness. 

An  emetic  was  prescribed,  but  instead  of  producing 
vomiting  it  operated  as  a cathartic.  To  remove  the 
irritation  the  seton  was  withdrawn.  The  pain  in  the 
tumour,  however,  and  the  general  uneasiness  continued 
to  increase,  and  thirty  hours  subsequent  to  making  the 
puncture,  air  began  to  issue  from  the  track  of  the 
seton ; and  afterward  the  cellular  membrane  of  the 
neck,  and  of  the  other  parts  of  the  body  in  succession, 
became  distended  with  a gaseous  fluid.  In  the  course 
of  a few  hours  after  the  commencement  of  the  general 
emphysema  the  man  died. 

Twelve  hours  after  death,  when  the  body  was  free 
from  putrefaction,  it  was  inspected.  The  emphysema 
was  neither  increased  nor  diminished  since  death,  and 
some  idea  may  be  formed  of  its  extent,  when  the  scro- 
tum was  distended  to  the  size  of  the  head  of  an  adult. 
Even  the  cavities  of  the  heart,  and  the  canals  of  the 
blood-vessels,  contained  a considerable  quantity  of  air. 
We  could  discover  no  direct  communication  between 
the  tumour  and  the  trachea  or  lungs,  although  such 
was  carefully  sought  for.”— (A.  Burns  on  the  Surgical 
Anatomy  of  the  Head  and  Neck,  p.  51 — 53.) 

From  such  cases  we  may  infer,  with  the  preceding 
writer,  that  from  the  mere  rupture  of  a few  of  the  bron- 
chial cells,  occasioned  by  irregular  action  of  the  lungs, 
or  by  some  other  internal  cause,  a spontaneous  diffu- 
sion of  air  may  take  place  in  the  cellular  texture  of  the 
body.  Such  examples  are  dependent  on  the  same 
cause  as  the  emphysema  from  injury  of  the  lungs; 
only  the  rupture  of  the  bronchial  cells  in  the  former 
cases  is  less  obvious. 

A partial  emphysema  is  sometimes  seen  in  cases  of 
gangrene.  Here,  however,  it  is  hardly  necessary  to 
observe,  the  air  is  the  product  of  putrefaction,  and  the 
disorder  has  not  the  smallest  connexion  with  any  in- 
jury, or  disease  of  the  air-cells  of  the  lungs. 

( That  very  extensive  emphysema  does  occur  during 
the  parturient  process,  without  fractured  rib,  or  punc- 
tured wounds  of  the  lung,  is  a fact  familiar  with  every 

01. stetric  jiractitioner  whose  opportunities  are  consi- 
derable ; and  it  is  equally  well  known,  that  this  kind  of 
emphysema  is  not  attended  with  any  dangerous  conse- 
quences. It  doubtless  arises  from  a rupture  of  one  or 
more  of  the  air-cells  by  the  efforts  of  the  patient  to  hold 
her  breath. 

In  the  Maryland  Medical  Recorder  for  January,  1830. 
a case  of  spontaneous  emphysema  is  reported  by  Dr. 
Yeates,  occurring  in  a child  of  4 years  old,  which 
proved  fatal  in  a few  days.  It  is  to  be  regretted  that 
punctures  and  scarifications  were  not  resorted  to,  re- 
liance being  placed  on  ipecacuanha  and  squills,  which 
failed  to  produce  any  impression  on  the  stomach  or  the 
disease.  Dr.  .Jameson  suggests  that  probably  the  dis- 
ease arose  from  an  accidental  opening  of  tlie  bronchia 
and  investing  membrane  of  the  lungs,  by  which  the  air 
escaped  and  thus  found  its  way  throughout  the  body. — 
Reese.] 

C.  C.  Pruysch,  De  Emphysemate.  Haller,  Disp.  Chir. 

2,  567.  Hahe,  1733.  H.  A.  Nies,  De  Miro  Emphysemate, 
Mo.Duisb.  ad  Rheen.  1751.  Hewson's  Paper,  in  Med. 
Ob.servations  and  Inquiries,  vol.  3.  Mem.  de  I’ Acad. 
Royale  des  Sciences,  for  1713.  Dr.  Hunter,  in  M L 
Ohs.  and  Jnquirie.s,  vol.  2.  Cheston,  in  Pathological 


346 


EMP 


EMP 


Inquiries.  Abernethy's  Surgical  Works,  vol.  2.  Rich- 
ter, von  der  Windgeschwulst,  in  Anfangsgr.  der  Wun- 
darzneykunst,  b 1,  451,  A c.  John  Bell  on  WouJids, 

edit.  3,  Edin.  1812.  Halliday  on  Emphysema,  1807. 
Allan  Bums  on  the  Surgicd  Anatomy  of  the  Head 
and  Neck,  p.  52,  u-c.  Trans,  of  a Society  for  the  Im- 
provement of  Aledmal  and  Chir.  Knowledge,  vol.  1, 
p.  262.  WilmeHs  Observations  in  Surgery,  p.  143.  F. 
C.  Waltz.  De  Emphysemate,  ito.  Lips.  1803.  Riche- 
rand,  Nosographie  Chir.  t.  4,  p.  164,  ^dit.  2.  Lassus, 
Pathologic  Chir.  t.2,p.  321,  ^-c.  Mit.  1809.  Diet,  des 
Sciences  M d t.  12,  7?.  1,  A-c.  J.  Hennen,  Principles 
of  lALhtary  Surgery,  p.  376,  edit.  2,  Src.  Edin.  1820. 
C.  Bell.  Surgical  Obs.  vol.  1,  p.  161,  A c. 

EMPLASTRUM  AMMONI4CI  CUM  ACETO.  R. 
Ammoniaci  putiC  | ij.  Acidi  acetici.  ?iij.  Ammo- 
niacum  in  ac«to  liquefactu.n  vapora  in  .ase  ferreo  ad 
emplastri  crassitudinem. 

EMPLASTRITM  AMMONIACI  SCILLITICUM.  R. 
Gumm.  ammoniaci,  |j.  Aceti  scilliiici,  q.  s.  ut  fiant 
emplastrum,  quo  pars  affacta  tegatur. 

Mr.  Ford  found  this  last  plaster  useful  in  some  scro- 
fulous affections.  If  may  be  rendered  more  stimulating 
by  sprinkling  it  with  squills. — (Ford  on  the  Hip-joint, 
p.  59.)  It  was  recommended  by  Swediaur. — (London 
AJedical  Journal,  vol.  1,  p.  198.) 

EMPLASTRUM  AMxdOMACI  CUM  HYORAR- 
GYRO.  Discutient. 

EMi^LASTRUM  AMMONIACI  CUM  CICUTA.  R. 
Gum.  ammon.  3 iij.  Extract!  conii,  3 ij.  Liq.  plumb, 
acet.  3j. 

Dissolve  the  ammoniacum  in  a little  vinegar  of 
squills,  then  add  the  other  ingredients,  and  boil  them 
all  slowly  to  the  consistence  of  a plaster.  Discutient. 

EMPLASTRUM  AMMONL4E.  R.Sapon.  3ij.  Em- 
plastr.  plumbi  3 ss.  Ammon,  rnur.  3j. 

The  first  two  articles  are  to  be  melted  together,  and 
when  nearly  cold,  the  muriated  ammonia,  finely  pow- 
dered, is  to  be  added.  This  plaster  stimulates  the  skin, 
excites  the  action  of  the  absorbents,  and  disperses  many 
chronic  swellings  and  indurations. 

EMPLASTRU.M  CANTHARIDIS.  Bee  Blister. 

EMPLASTRUM  GALBANI  COMPOSITUM.  L.  P. 
{Olim  emplastrum  lithargyri  comp.)  Properties  dis- 
cutient. 

EMPLASTRUM  HYDRARGYRI.  L.  P.  {Olim 
emplastrum  litharg.  cum  hydrargyro.)  Properties  dis- 
cutient. 

EMPLASTRUM  PLUMBI.  L.  P.  (Olim  emplas- 
trum lithargyri  cum  resina.)  The  cormnon  adhesive 
or  sticking  plaster. 

E.MPLA5TRUM  SAPONIS.  The  plaster  commonly 
used  for  fractures.  It  is  also  frequently  applied  to 
bruised  parts,  and  to  many  indurations  of  a chronic 
nature. 

EMPYEMA.  (From  h,  loithin,  and  rvov,  pus,  or 
matter.)  A collection  of  purulent  matter  in  the  cavity 
of  the  chest. 

The  ancients  made  use  of  the  word  “ empyema”  to 
express  every  kind  of  internal  suppuration.  It  wms 
.®tius  who  first  restricted  the  term  to  collections  of 
matter  in  the  cavity  of  the  pleura,  or  membrane  lining 
the  chest ; and  all  the  best  modern  surgeons  invariably 
attach  this  meaning  alone  to  the  expression. 

The  operation  for  empyema  properly  means  the 
making  of  an  opening  into  the  thorax,  for  the  purpose 
of  giving  vent  to  the  matter  collected  in  the  cavity  of 
the  pleura,  though  the  phrase  with  several  writers  de- 
notes making  an  incision  into  the  chest,  in  order  to  let 
out  any  effused  or  confined  fluid,  whether  matter, 
blood,  an  aqueous  fluid,  or  even  air.  The  necessity  of 
having  recourse  to  such  an  operation,  however,  does 
not  often  present  itself  I would  not  wish  to  be  suj)- 
posed  to  assert,  that  inflammation  of  the  lungs,  pleura, 
mediastinum,  diaphragm,  and  even  of  the  liver,  does 
not  sometimes  terminate  in  suppuration.  Certainly, 
the  latter  event  is  occasionally  produced ; but  w'hen  it 
does  happen,  the  matter  does  not  always  make  its  way 
into  the  cavity  of  the  chest : frequently  external  ab- 
scesses form,  or  the  pus  is  either  coughed  up,  or  dis- 
charged with  the  stools. 

Acute  and  chronic  abscesses  not  unfrequentK  form 
in  the  cellular  substance  between  the  pleura  and  the 
ribs  and  intercostal  muscles.  A swelling  occurs  be- 
tween two  of  those  bones ; the  skin  does  not  undergo 
anv  change  of  colour  ; a fluctuation  is  distinguishable, 
a 1 sometimes  an  extensive  cedema  is  observable. 


With  respect  to  abscesses  formed  in  the  cellular 
substance  connecting  the  pleura  costalis  to  the  inter- 
costal muscles,  they  rarely  burst  into  the  chest,  the 
pleura  always  being  considered  thickened.  However, 
in  order  to  keep  them  from  spreading  extensively,  as 
well  as  to  obviate  any  possibility  of  their  breaking  in- 
wards, the  best  rule  is  to  make  an  early  and,  if  pos- 
sible, a depending  opening.  The  motions  of  respi- 
ration then  both  promote  the  exit  of  the  matter,  as  well 
as  the  coairaction  of  the  cavity  in  which  it  wa*  lodged ; 
and  the  disease,  if  unattend^  with  canes,  generally 
tenninares  favourably. 

It  often  happens,  however,  that  the  ribs  are  carious, 
and  then  the  cure  is  more  tedious  and  difficult.  A 
modem  writer,  indeed,  informs  us,  that  when  the  in- 
side of  the  rib  is  extensively  carious,  or  when  the  caries 
is  near  the  junction  of  the  bone  to  the  spine,  the  fistula 
is  incurable. — {Lassus,  Pathologie  Chirurgicale,  t.  1, 
p.  129,  iulit.  1809.)  On  the  other  hand,  another  sur- 
geon of  vast  experience  recommends  us  to  endeavour 
to  separate  the  diseased  bone,  either  by  cutting  it  away 
or  emplo)ing  the  trepan. — {Pelletan,  Clinique  Chir. 
t.  3,  p.  2.' 3.)  Were  a jiart  of  a diseased  rib  to  admit  of 
being  sawed  away,  Mr.  Hey's  convex  saw  would  be  a 
more  proper  instrument  for  the  purpose  than  a trepan. 

An  abscess  of  the  preceding  kind  may  be  so  situated, 
and  attended  with  such  a pulsation,  as  greatly  to  re- 
semble an  aneurism  of  the  origin  of  the  aorta.  An  in- 
tere.sting  case  of  this  description  is  detailed  by  Pelletan 
{Clinique  Chir.  t.  3,  p.  254) ; and  another  was  seen  by 
Baron  Boyer  {Traite  des  Mai.  Chir.  t.  7,  p.  333). 

When  the  surface  of  the  lungs  and  that  of  the  pleura 
costalis  have  become  adherent  to  each  other,  in  the 
situation  of  the  abscess,  so  as  to  constitute  what  is 
termed  encysted  empyema,  the  pus,  disposed  by  a law 
of  nature  to  make  its  way  to  the  surface  of  the  body, 
generally  occasions  ulceration  of  the  intercostal  mus- 
cles, and  collects  on  the  outside  of  them.  An  abscess 
of  this  kind  comes  on  with  a deep-seated  pain  in  the 
part  affected ; an  tedematous  swelling,  which  retains 
the  impression  of  the  finger  ; and  a fluctuation,  which 
is  at  first  not  verj-  distinct,  but  from  day  to  day  be- 
comes more  and  more  palpable ; and  at  length  leads 
the  surgeon  to  make  an  opening. 

If  this  be  not  done  when  the  fluctuation  becomes 
perceptible,  the  abscess  may  possibly  insinuate  itself 
into  the  cavity  of  the  pleura,  in  consequence  of  the  ad- 
hesion being  in  part  destroyed  by  ulceration.  Sabatier 
affirms  that  the  case  may  take  this  course,  even  when 
the  ab.scess  has  been  punctured,  and  while  a free  ex- 
ternal opening  exists;  and  this  experienced  surgeon 
has  adduced  a fact  in  confirmation  of  such  an  occur- 
rence.— (See  Mcdecine  Operatoire,  tom.  2,  p.  249.) 

In  a few'  instances,  the  surface  of  the  lung  ulcerates, 
and  the  matter  is  voided  from  the  trachea.  But  in  the 
majority  of  examples,  the  pus  makes  its  way  outw  ards 
through  the  pleura  costalis.  If  inflammation  occurs  in 
the  anterior  mediastinum,  and  ends  in  suppuration,  the 
abscess  ma;-  possibly  burst  imp  neither  of  the  cavities 
of  the  chest,  but  make  its  way  outwards,  after  render- 
ing the  sternum  carious,  as  happened  in  the  example 
recorded  by  Van  Sw'ieten. — {Comment  on  BoerhaavRs 
895th  Aphorism.) 

But  though  collections  of  matter  in  the  anterior  me- 
diastinum are  influenced  by  the  general  law,  whereby 
abscesses  in  general  tend  to  the  surface  of  the  body, 
and  though  it  be  true  that  they  rarely  burst  inwardly 
into  the  cavity  of  the  pleura,  the  contrary  may  happen, 
as  is  proved  by  the  9th  case  in  La  Martini^res’s  me- 
moir on  the  operation  of  trepanning  the  sternum.  Here 
the  event  was  the  more  extraordinary,  as  there  was 
already  an  external  opening  in  the  abscess. 

External  injuries,  such  as  the  perforation  of  the  ster- 
num with  a sword  {Vanderwel,  Obs.  29,  Cent.  1),  a 
contusion,  a fracture,  or  a caries  of  this  bone  may  give 
rise  to  an  ab.scess  in  the  anterior  mediastinum.  Galen 
has  recorded  a memorable  example,  where  the  abscess 
was  the  consequence  of  a wound  of  the  fore  part  of  the 
chest.  After  the  injury,  which  was  in  the  region  of 
the  sternum,  seemed  quite  well,  an  abscess  formed  in 
the  same  situation,  and  being  opened  healed  up.  The 
part,  however,  soon  inflamed  and  suppurated  again. 
The  abscess  could  not  now  be  cured.  A consultation 
was  held,  at  which  Galen  attended.  As  the  sternum 
was  obviously  carious,  and  the  pulsation  of  the  heart 
was  visible,  every  one  was  afraid  of  undertaking  the 
■ treatment  of  the  case,  since  it  was  conceived  t^i  it 


EMPYEMA. 


347 


■would  be  necessary  to  open  the  thorax  itself.  Galen, 
however,  engaged  to  manage  the  treatment,  without 
making  any  such  opening,  and  he  expressed  his  opinion 
that  he  should  be  able  to  effect  a cure.  Not  finding 
the  bones  .so  extensively  diseased  as  was  apprehended, 
he  even  indulged  considerable  hopes  of  success.  After 
the  removal  of  a portion  of  the  bone,  tne  heart  was  quite 
exposed  (as  is  alleged),  by  reason  of  the  pericardium 
having  been  destroyed  by  the  previous  disease.  After 
the  operation,  the  patient  experienced  a speedy  recovery. 

J.  L.  Petit  met  with  an  abscess  in  the  anterior  me- 
diastinum, in  consequence  of  a gun-shot  wound  in 
the  situation  of  the  sternum.  The  injury  had  been 
merely  dressed  with  some  digestive  application ; no  di- 
latation, nor  any  particular  examination  of  the  wound 
had  been  made.  The  patient,  after  being  to  all  ap- 
pearance quite  well,  and  joining  his  regiment  again, 
was  soon  taken  ill  with  irregular  shivcrings,  and  other 
febrile  symptoms.  Petit  probed  the  wound,  and  found 
the  bone  affected.  As  there  -was  a difficulty  of  breath- 
ing, he  suspected  an  abscess  either  in  the  diploe  or  be- 
beliind  the  sternum ; and,  consequently,  he  proposed 
laying  the  bone  bare  and  applying  the  trepan.  The 
operation  gave  vent  to  some  sanions  matter ; and  as 
soon  as  the  inner  part  of  the  sternum  was  perforated, 
a quantity  of  pus  was  discharged.  The  patient  was 
■relieved,  and  afterward  recovered.— Traite  des 
Mai.  Chir.  t.  p.  80.) 

Another  instance,  in  which  an  abscess  behind  the 
sternum  was  cured  by  making  a perforation  in  that 
bone  opposite  the  lower  part  of  the  cavity  in  which  the 
matter  collected,  is  recorded  by  De  la  Martinidre. — 
{Mdm.  de  I'Acad.  de  Chir.  t.  12,  idit.  12/rto.) 

When,  in  consequence  of  inflammation,  an  abscess 
forms  deeply  in  the  substance  of  the  lungs,  the  pus 
more  easily  makes  its  way  into  the  air-cells,  and  tends 
towards  the  bronchi®,  than  towards  the  surface  of  the 
U’lgs.  In  this  case  the  patient  spits  up  purulent  mat- 
ter. When  the  opening  by  which  the  abscess  has  burst 
Internally  is  large,  and  the  pus  escapes  from  it  in  con- 
siderable quantity  at  a time,  the  patient  is  in  some  dan- 
ger of  being  suffocated.  However,  if  the  opening  be 
not  immoderately  large,  and  the  pus  which  is  effused 
be  not  too  copious,  a recovery  may  ensue.  Abscesses 
in  the  substance  of  the  diaphragm,  and  collections  of 
matter  in  the  liver  may  also  he  discharged  by  the  pus 
being  coughed  up  from  the  trachea,  when  the  parts  af- 
fected become  connected  with  the  lungs  by  adhesions, 
and  the  abscesses  of  the  liver  are  situated  on  its  con- 
vex surface.  When  the  collection  of  matter  in  the 
liver  occupies  any  other  situation,  the  abscess  fre- 
quently makes  its  way  into  the  colon,  and  the  pus  is 
discharged  with  the  stools.  Several  cases  of  this  kind 
are  related  by  authors ; Sabatier  has  recorded  two  in 
his  M dicine  Operatoire,  Le  Dr.an  makes  mention  of 
others,  and  Pemberton,  in  his  book  on  the  Diseases  of 
the  Abdominal  Viscera,  p.  36,  relates  additional  in- 
stances of  a similar  nature. 

I shall  now  proceed  to  the  consideration  of  empyema 
strictly  so  called.  Sometimes  it  is  a consequence  of  a 
penet rating  wound  of  the  chest ; occasionally  it  pro- 
ceeds from  the  bursting  of  one  or  more  vornic®;  in  a 
few  examples  it  arises  from  the  particular  way  in  which 
abscesses  of  the  liver  burst  {Journ.  de  MM.  t.  3,  p.  47 ; 
M'irqagni,  epist.  30,  art.  4 ;)  but  in  the  greater  number 
of  instances  it  originates  from  pleuritic  inflammation, 
especially  that  of  the  chronic  kind. — {Boyer,  Traite  des 
Mai.  Chir.  t.  7,  p.  352.)  Empyema  very  rarely  take-s 
place  in  both  sides  of  the  chest,  but  is  almost  always 
limited  to  one  cavity  of  tVe  pleura. 

According  to  Baron  Boyer,  when  empyema  arises 
from  thoracic  inflammation,  pleuritis,  or  pneumonia, 
the  symptom.s  characterizing  it  are  always  preceded  by 
those  of  the  disease,  of  which  the  effusion  of  pus  upon 
the  diaphragm  is  the  effect.  Inquiry  must,  therefore, 
be  made  whether  the  patient  has  fdeurisy  or  peripneu- 
inony,  the  symptoms  of  which  have  lasted  longer  than 
a fortnight ; and  whether,  after  a transient  amendment, 
there  have  been  frequent  shiverings,  followed  by  a low, 
continued  fever,  with  nightly  exacerbations.  Now, 
these  first  circumstances  justify  the  belief,  that  the  in- 
fl  imrnatory  disorder  has  terminated  in  suppuration,  and 
that  the  symptoms  afterward  experienced  depend  upon 
elfusioTi  of  matter  in  the  chest.  Some  of  these  arise 
from  tlie  mechanical  action  of  the  pus  upon  the 
lungs,  heart,  and  parietes  of  the  chest,  and  belong 
also  to  other  efthsions  in  the  thorax ; the  rest  may  be 


said  to  be  the  effects  of  ulceration  and  suppuration  of 
the  parts  on  the  animal  economy,  and,  therefore,  parti- 
cularly belong  to  empyema. 

First,  of  the  common  symptoms,  respiration  is  diffi- 
cult, short,  and  fteqhent ; the  patient  suffers  great  op- 
pression, and  experiences  a sense  of  suffocation,  and 
of  weight  upon  the  dia  phragm.  He  cannot  move  about, 
even  for  a short  time,  without  being  quite  out  of  breath, 
and  threatened  with  syncope.  He  has  an  almost  in- 
cessant and  very  fatiguing  cough,  which  is  sometimes 
dry,  sometimes  attended  with  expectoration.— (Boyer, 
Traite  des  Mai  Chir.  t.  7,  p.  356.) 

No  surgical  writer  with  whom  I am  acquainted  has 
treated  with  more  discrimination  than  Mr.  Samuel 
Sharp,  of  the  symptoms  produced  by  collections  of 
matter  in  the  chest.  He  remarks,  that  it  has  been  al- 
most universally  taught,  that  when  a fluid  is  extrava- 
sated  in  the  thorax,  the  patient  can  only  lie  on  the  dis- 
eased side,  the  weight  of  the  incumbent  fluid  on  the 
mediastinum  becoming  troublesome,  if  he  places  him- 
self on  the  sound  side.  For  the  same  reason,  when 
there  is  fluid  in  both  cavities  of  the  thorax,  the  patient 
finds  it  most  easy  to  lie  on  his  back,  or  to  lean  for 
wards,  in  order  that  the  fluid  may  neither  press  upon 
the  mediastinum  nor  the  diaphragm.  But  it  is  noticed 
by  Mr.  Sharp,  that  however  true  this  doctrine  may 
prove  in  most  instances,  there  are  a few  in  which,  not- 
withstanding the  extravasation,  the  patient  does  not 
complain  of  more  inconvenience  in  one  posture  than 
another,  nor  even  of  any  great  difficulty  of  breathing. 
—(See  Le  DratVs  Ohs.  217,  and  Marchetti,  65.) 

On  this  account,  ob.serves  Mr.  Sharp,  it  is  sometimes 
less  easy  to  determine  when  the  ojieration  is  requisite, 
than  if  we  had  so  exact  a criterion  as  we  are  generally 
sujiposed  to  have.  But,  says  he,  though  this  may  be 
wanting,  there  are  some  other  circumstances  which 
will  generally  guide  us  with  a rea.soriable  certainty. 
He  states,  that  the  most  infallible  symptom  of  a large 
quantity  of  fluid  in  one  of  the  cavities  of  the  thorax, 
is  a preternatural  expansion  of  that  side  of  the  chest 
where  it  lies;  for,  in  proportion  as  the  fluid  accumu 
lates,  it  will  necessarily  elevate  the  ribs  on  that  side, 
and  prevent  them  from  cciitractiiig  so  much  in  expira- 
tion as  the  ribs  on  the  other  side.  This  change  is  said 
to  be  most  evident  when  the  surgeon  views  the  back  of 
the  chest.- (Boyer,  vol.  cit.  p.  357.)  Mr.  Sharp  also  re- 
fers to  Le  Bran's  Obs.  211,  vol.  1,  in  order  to  prove  that 
the  pre.ssure  of  the  fluid  on  the  lungs  may  sometimes  be 
so  great,  as  to  make  them  collapse,  and  almost  totally 
obstruct  their  function.  When,  therefore,  says  Mr. 
Sharp,  the  thorax  becomes  thus  expanded  after  a pre- 
vious pulmonary  disorder,  and  the  case  is  attended  with 
the  symiitoms  of  a suppuration,  it  is  probably  owing  to 
a collection  of  matter.  The  patient,  he  observes,  will 
also  labour  under  a continual  low  fever,  and  a particular 
anxiety  from  the  load  of  fluid. 

Besides  this  dilatation  of  the  cavity  by  an  accumula 
tion  of  the  fluid,  the  patient  will  be  sensible  of  an  un- 
dulation, which  is  sometimes  so  evident,  that  a by 
slander  can  plainly  hear  it  in  certain  motions  of  the 
body.  Mr.  Sharp  adds,  that  this  was  the  case  with  a 
patient  of  his  own,  on  whom  he  performed  the  opera- 
tion ; but  the  fluid  in  this  instance,  he  says,  was  very 
thin,  being  a serous  matter  rather  than  pus.  Some- 
times, ■when  the  practitioner  applies  his  ear  close  to  the 
patient’s  chest,  while  this  is  agitated  a noise  can  be 
heard  like  that  produced  by  shaking  a small  cask  not 
(juite  full  of  water.— (See  Dr.  Archer's  Case.^  in  Trans, 
of  the  Fellows,  A c.  of  the  King's  and  Queen's  College 
of  Physicians  in  Ireland,  vol.  2,  p.  2.)  In  this  instance 
the  fluid  resembled  whey. 

According  to  the  same  author  it  will  also  frequently 
happen,  that  though  the  skin  and  intercostal  muscles 
are  not  inflamed,  they  will  become  oedematous  in  certain 
parts  of  the  thorax ; or,  if  they  are  not  tedeiiiatoiis,  they 
will  be  a little  thickened  ; or,  as  Boyer  states,  the  inter- 
costal sjiaces  are  widened,  and,  when  the  empyema  is 
considerable,  instead  of  being  dejiresscd,  as  they  are  in 
thin  persons,  they  project  beyond  the  level  of  the  ribs. 
—{Mai.  Chir.  t.  7,  p.  357.)  These  symptoms,  joined 
with  the  enlargement  of  the  thorax,  and  the  preceding 
affection  of  the  pleura  or  lungs,  seem  unqucstionatdy  to 
indicate  the  projiriety  of  the  oiieraiion.  But,  observes 
Mr.  Sharp,  among  other  motives  to  recommend  it  upon 
such  an  emergency,  this  is  one,  that  if  the  ojierator  should 
mistake  the  case,  an  incision  of  the  intercostal  muscles 
would  neither  be  very  paintXil  nor  dangerous.— (See 


348 


EMPYEMA, 


Critical  Inquiry  into  the  Present  State  of  Surgery, 
sect,  on  Empyema.) 

“ The  difficulty  of  lying  on  the  side  opposite  to  the 
.collection  of  pus,”  says  Le  Dran,  “ is  always  accounted 
a sign  of  an  empyema.  This  sign,  indeed,  is  in  the  af- 
firmative; but  the  want  of  it  does  not  prove  the  nega- 
tive ; because,  when  there  is  adhesion  of  the  lungs  to 
the  mediastinum,  the  patient  may  lie  equally  on  both 
sides.” — {Le  Dran's  Obs.  p.  108,  edit.  2.)  The  expla- 
nation of  this  circumstance  offered  by  Le  Uran  is, 
that  when  the  cyst,  in  which  the  matter  is  contained, 
is  between  the  mediastinum  and  the  lungs,  the  medias- 
tinum gradually  yields  to  the  volume  of  the  pus  in 
proportion  as  it  is  formed,  and  the  cyst  in  which  it  is 
contained  becomes  dilated ; “ whence  habitude  becomes 
a second  nature.”  Whereas,  in  an  empyemal  person, 
in  whom  the  lung  is  not  adherent  to  the  mediastinum, 
and  who  lies  on  the  side  opposite  to  that  on  which  the 
collection  of  pus  is  situated,  the  mediastinum  is  on  a 
sudden  loaded  with  an  unusual  weight  of  fluid. — (P. 
111.) 

Richerand  contends,  that  the  difficulty  of  breathing 
which  patients  with  extravasated  fluid  in  the  chest  ex- 
perience in  lying  upon  the  side  opposite  to  that  on 
which  the  disease  is  situated,  never  originates,  as  has 
been  commonly  taught  and  believed,  from  the  fluid 
pressing  upon  the  mediastinum  and  opposite  lung. 
•“  I have  (says  he)  produced  artificial  cases  of  hydro- 
thorax, by  injecting  water  into  the  thorax  of  several 
dead  subjects,  through  a wound  made  in  the  side.  This 
experiment  can  only  be  made  on  subjects  in  which  the 
lungs  are  not  adherent  to  the  parietes  of  the  chest. 
In  this  way  from  three  to  four  pints  of  water  were  in- 
troduced. I then  cautiously  opened  the  opposite  side 
of  the  chest ; the  ribs  and  lungs  being  removed,  the 
mediastinum  could  be  distinctly  seen,  reaching  from  the 
vertebr®  to  the  sternum,  and  supporting,  without  yield- 
ing, the  weight  of  the  liquid,  in  whatever  position  the 
body  was  placed. 

It  is  evident,  then,  that  patients  with  thoracic  extra- 
vasations lie  on  the  diseased  side,  in  order  not  to  ob- 
struct the  dilatation  of  the  sound  side  of  the  respiratory- 
organs,  one  part  of  which  is  already  in  a state  of  inac- 
tion. It  is  for  the  same  reason,  and  in  order  not  to  in- 
crease the  pain  by  the  tension  of  the  inflamed  pleura, 
that  pleuritic  patients  lie  on  the  diseased  side.  The 
same  thing  is  observable  in  peripneumony ; in  a word, 
in  all  affections  of  the  parietes  of  the  chest. — {Riche- 
rand, Nosogr.  Chir.  t.  4,  p.  168,  169,  edit.  2.) 

It  appears  to  me,  that  there  may  be  some  truth  in  the 
foregoing  statement ; but  the  experiments  are  far  from 
being  conclusive  with  respect  to  the  assertion,  that  in 
cases  of  empyema,  hydrothorax,  &c.  the  fluid  on  one 
side  of  the  chest  does  not  compress  the  opposite  lung. 
In  the  first  place  the  quantity  of  fluid  is  frequently 
much  larger  than  that  which  Richerand  injected. 
Secondly,  although  the  mediastinum  may  not  be  apt  to 
yield  at  once  to  the  weight  of  a liquid  suddenly  injected 
into  one  side  of  the  thorax,  yet  it  may  do  so  by  the 
gradual  effect  of  disease.  Thirdly,  many  of  the  pheno- 
mena of  empyema  seem  adverse  to  Richerand’s  infer- 
ence. 

Although  surgeons  should  be  aware,  that  patients 
with  empyema  can  sometimes  lie  in  any  position,  with- 
out particular  aggravation  of  the  difficulty  of  breathing, 
yet  it  ought  to  be  distinctly  understood,  that  the  gene- 
rality of  patients  with  this  disease  cannot  place  them- 
selves on  the  side  opposite  to  that  on  which  the  collec- 
tion of  pus  is  situated,  without  their  respiration  being 
■very  materially  obstructed.  Another  circumstance  also 
which  deserves  to  be  mentioned  while  we  are  treating 
of  the  symptoms  of  empyema  is,  that  the  oedema  of  the 
integuments  is  sometimes  not  confined  to  the  thorax, 
but  extends  to  more  remote  jiarts,  on  the  same  side  of 
the  body  as  the  collection  of  matter.  Both  the  forego- 
ing remarks  are  confirmed  by  an  interesting  case  which 
was  published  by  Mr.  Hey. 

Sept.  3,  1788,  Mr.  Hey  was  desired  to  visit  John  Wil- 
kin.son,  who  had  been  ill  ten  days  of  the  influenza. 
The  patient  was  found  labouring  under  a fever,  attended 
with  cough,  difficulty  of  breathing,  and  pain  in  the  left 
side  of  the  thorax.  He  was  bled  once,  blisters  were 
repeatedly  applied  to  the  chest,  and  he  took  nitre  and 
antimonials,  with  a smooth  linctus  to  allay  his  cough. 
“ He  was  repeatedly  relieved  by  these  means,  espe- 
cially by  the  apiilication  of  the  blisters ; but  repeatedly 
relapsed.  At  last  he  became  so  ill,  that  he  breathed 


with  the  utmost  difficulty,  and  could  not  lie  on  the 
right  side  without  danger  of  immediate  suffocation.” 

Mr.  Hey  found  the  patient  in  the  state  just  now  de- 
scribed on  the  17th  of  September.  “ His  face,  and  es- 
pecially his  eyelids,  were  a little  swollen  on  the  left 
side.”  The  left  side  of  the  thorax  was  larger  than  the 
right,  and  its  integuments  were  cedematous.  Upon 
pressing  the  intercostal  muscles,  they  felt  distended ; 
they  yielded  a little  to  a strong  presstu-e,  but  rebounded 
again.  The  abdomen,  especially  at  its  upper  part,  ap- 
peared to  be  fuller  than  in  the  natural  state. — (See 
Hey's  Practical  (%s.  in  Surgery,  p.  476.)  This  last 
symjjtom  is  also  particularly  noticed  by  Boyer. — {Mol. 
Chir.  t.  7,  p.  357.) 

Another  remarkable  symptom  which  is  occasionally 
produced  by  collections  of  matter  in  the  chest,  is  an 
alteration  in  the  position  of  the  heart.  1 have  seen  a 
patient  in  St.  Bartholomew’s  Hospital,  who  had  so 
large  a quantity  of  matter  in  the  left  bag  of  the  pleura, 
that  it  completely  displaced  the  heart,  which  pulsated 
against  the  inside  of  the  chest  at  a considerable  dis- 
tance to  the  right  of  the  stei-num.  This  man’s  life 
might  perhaps  have  been  saved  had  paracentesis  tho- 
racis been  performed  in  time.  Some  suspected  an 
aneurism  from  the  throbbing  on  the  right  of  the  ster- 
num : and  the  case  was  not  fully  understood  till  after 
death,  when  the  body  was  opened.  A little  attention 
to  the  symptoms,  however,  might  have  convinced  any 
man  of  moderate  understanding,  that  it  was  an  empy- 
ema, and  that  making  an  opening  for  the  discharge  of 
the  matter  afforded  the  only  rational  chance  of  pre- 
serving life.  There  had  been  pain  and  inflammation 
in  the  chest,  followed  by  shiverings  ; there  was  very 
great  difficulty  of  breathing ; the  heart,  which  pre- 
viously used  to  beat  in  the  usual  place,  no  longer  did  so ; 
but  now  pulsated  on  the  right  side  of  the  thorax. 

That  the  heart  should  be  displaced  in  this  manner  by 
any  large  collection  of  fluid  in  the  right  cavity  of  the 
thorax,  one  would  naturally  expect ; but  it  is  an  occur- 
rence that  has  not  been  much  noticed  by  surgical  wri- 
ters. Baron  Larrey,  however,  has  related  a higlily  in- 
teresting case,  where  the  heart  was  not  only  pushed 
considerably  to  the  right  of  the  sternum,  but  its  action 
was  so  much  impeded  by  the  derangement  of  its  posi- 
tion, that  the  pulse  in  the  large  arteries  was  thereby 
rendered  extremely  feeble.  In  this  instance,  also,  the 
diaphragm  had  descended  so  low  down  as  to  force 
some  of  the  small  intestines  into  the  cavity  of  the 
pelvis. — {M^oires  de  Chirurgie  Militaire,  t.  3,  p.  447, 
Ac.)  Pelletan  has  also  recorded  an  example  in  which 
a collection  of  fluid  in  the  left  cavity  of  the  chest  dis- 
placed the  heart,  the  pulsations  of  which  were  per- 
ceptible between  the  third  and  fourth  ribs  of  the  right 
side,  near  the  sternum. — {Clinique  Chir.  t.  Z,p.  276.) 
Baron  Boyer  speaks  of  one  case  in  which  the  displace- 
ment of  the  heart  was  so  extensive  that  its  pulsations 
were  felt  near  the  right  axilla. — {Traits  des  Mai. 
Chir.  t.  7,  p.  357.)  In  the  anatomical  collection  at 
Strasburg  is  also  a preparation  exhibiting  the  displace- 
ment of  the  heart  into  the  right  side  of  the  chest,  by 
matter  in  the  left  pleura,  the  left  lung  being  nearly  an- 
nihilated.— {Lohstein,  Compte  de  son  Museum  Anat. 
p.  39,  Hvo.  1820.)  The  heart  is  sometimes  thrust 
downwards  by  collections  of  fluid  in  the  chest,  and  its 
pulsation  is  distinguishable  in  the  epigastrium. — 
{Hodgson  on  the  Diseases  of  Arteries  and  Veins, 
p.  95.) 

When  the  cavity  of  the  pleura  contains  fluid,  and 
the  surgeon  strikes  the  thorax  repeatedly  with  the 
ends  of  his  fingers,  a dull  sound  is  said  to  be  produced, 
quite  different  from  what  would  occur  were  the  chest 
in  its  natural  state.  But,  as  Boyer  remarks,  this 
symptom,  to  which  so  much  importance  has  of  late 
been  attached,  being  common  to  extravasations  in  the 
thorax  and  several  other  diseases,  will  not  denote  em- 
pyema, unless  combined  with  other  signs  of  this  af- 
fection. Nor  will  any  useful  information  be  derived 
from  the  above  percussions,  except  the  practitioner  has 
had  a good  deal  of  experience  in  them,  and  they  are 
repeatedly  practi.sed  with  the  patient  in  difl'ercnt  posi- 
tions.— {Mai.  Chir.  t.  7,  p.  357.) 

The  symptoms  of  empyema  are  frequently  very 
equivocal,  and  the  existence  of  the  disease  is  generally 
somewhat  doubtful.  Panarolius  opened  a man  whose 
left  lung  was  destroyed,  at  the  same  time  that  the 
thorax  contained  a considerable  quantity  of  pus.  .Al- 
though the  patient  had  been  ill  for  two  months,  he  had 


EMP 


ENC 


349 


unffercu  ilo  difficulty  of  breathing,  and  had  had  only  a 
slight  cough.  Le  Dran  met  with  a case  of  nearly  the 
same  kind.  A patient  who  had  been  for  three  days  af- 
fected with  a considerable  oppression  and  an  acute 
pain  on  the  left  side  of  the  chest,  got  somewhat  bet- 
ter. He  felt  no  material  difficulty  of  breathing  on 
whatever  side  he  lay.  The  only  thing  which  he  com- 
plained of,  was  the  sense  of  a fluctuation  in  his  tho- 
rax, and  a little  obstruction  of  his  respiration  when  he 
was  in  a sitting  posture.  These  symptoms  did  not 
seem  sufficiently  decided  to  justify  the  operation,  and 
it  was  delayed.  The  febrile  symptoms  continued,  with 
cold  sweats,  and  the  patient  died  on  the  eighth  day. 
Five  pints  of  pus  were  found  collected  in  the  chest. — 
(See  Le  Dr  art's  Observations  in  Surgery,  p.  109,  110, 
edit.  2.) 

The  symptoms  more  particularly  depending  upon 
empyema  itself,  that  is  to  say,  upon  the  disease  and 
suppuration  within  the  chest,  are  nearly  the  same  as 
those  which  accompany  all  large  deep-seated  ab- 
scesses. The  fever  attending  the  thoracic  inflarrtraa- 
tion  which  ends  in  suppuration,  gradually  diminishes, 
but  does  not  entirely  cease.  On  the  contrary,  it  soon 
changes  into  hectic,  attended  witlL  flushings  of  the 
cheeks,  heat  of  the  palm  of  the  hands,  and  exacerba- 
tions every  evening  and  after  meals.  In  the  night,  the 
upper  parts  of  the  body  are  covered  with  perspiration  ; 
the  patient  is  tormented  with  insatiable  thirst ; his  ap- 
petite quite  flails  ; his  debility  becomes  extreme ; he  is 
suhjpct  to  frequent  fainting  fits  ; diarrhcea  ensues  ; and 
the  ii  :.  r nails  become  curved,  shining,  and  of  the  yel- 
low til  iTe  observable  all  over  the  body.  At  length 
the  utmost  emaciation  and  the  facies  Ilippocratica 
come  on,  frequently  attended  with  dilated  pupils  and 
enfeebled  vision,  and  indicating  the  approach  of  death. 

As  the  operation  of  empyema  and  some  other  par- 
ticulars relating  to  this  subject,  are  treated  of  in  an- 
other part  of  tms  Dictionary  (see  Paracentesis  of  the 
Thorax),  it  will  only  be  necessary  for  me  here  to^sub- 
join  a list  of  works,  which  may  be  advantageously 
consulted  for  information  on  empyema.  A.  Vater,  et 
J.  E.  Mutillet,  Empyema,  e vomica  pulmonis,  rupta  in 
cavitatem  pectoris  dextram  effusa,  indeqv.e  pulmo 
hujus  lateris  compressus  petiitusque  ab  officio  remo- 
tus,  Wittemb,  1731. — (^Haller,  I)isp.  ad  Morh.  2,  4031.) 
Gerardus  le  Maire,  Diss.  de  Empyemate,  4<o.  Lugd. 
1735.  Sharp's  Critical  Inquiry  into  the  Present  State 
of  Surgery,  sect,  on  Empyema.  Le  Dran's  Observa- 
tions in  Surgery.  J.  L.  Petit,  Traite  des  Maladies 
Chirurgicales,  t.  1,  chap.  3.  Des  Plaies  de  la  Poitrine. 
Warner's  Cases  in  Surgery,  chap.  6,  edit.  4.  Memoire 
sur  I'Op  ration  du  Trdpan  au  Sternum,  par  M.  de  la 
Martiniire,  in  Mem.  de  I' Acad.  Royale  de  Chirurgie,  t. 
12,  P.-342,  edit.  l2mo.  L.  G.  Van  Malcote,  De  Empye- 
mate, Teneramund.  1783.  Sabatier,  M^dccine  Opera- 
toire,  t.  2,  p.  247,  <^-c.  edit.  1 . A.  O' Flaherty,  De  Em- 
pyemate, Montp.  1774.  Andouard  de  I'Empyeme,  Cure 
Radicate  obtenue  par  I'Op  ration,  S,  c.  8vo.  Paris,  1808. 
Cnllisen,  Sy sterna  Chirurgiae  HodierneB,  vol.  2,  p.  363, 
edit.  1798.  Flajani,  Collezione  d'Osservazioni,  (S,-r.  di 
Chirurgia,  t.  3,  p.  185,  li'C.  8vo.  Roma,  1802.  Riche- 
rand,  Nosogr.  Chir.  t.  4,  sect,  des  Maladies  de  PAppa- 
reil  respiratoire.  Leveilld,  Nouvelle  Doctrine  Chir.  t. 
2,  p.  575,  S,-c.  Hey's  Practical  Obs.  in  Surgery,  ed.  3. 
Lassus,  Pathologic  Chir.  t.  \,p.  122,  <i-c.  Larrey,  Mc- 
moires  de  Chirurgie  Militaire,  t.  3,  p.  442  ; et  t.  4,  p. 
356,  d-c.  Pelletan,  Clinique  Chir.  t.  3,  p.  236,  Ac.  J. 
Hennen,  Principles  of  Military  Surgery,  p.  384,  ^ c. 
ed.  2,  8vo.  Edinb.  1820.  Boyer,  Traite  des  Mai.  Chir. 
t.  7,  p.  351,  Ac.  8vo.  Paris,  1821. 

[A  most  singular  case  of  empyema  occurred  under 
my  own  observation,  which  was  reported  at  length  in 
the  Med.  Recorder  for  1823.  The  patient  had  been 
treated  by  a number  of  physicians  for  abscess  of  the 
liver,  from  the  circumstance  of  large  quantities  of  pus 
pas.sing  off  from  the  stomach  and  bowels  at  short  in- 
tervals, and  the  pulmonic  symptoms  were  attributed 
to  the  displacement  of  the  diaphragm  by  the  pressure 
of  the  enlarged  hepar.  On  dissection,  however,  the 
case  was  found  to  be  empyema,  and  an  opening  for  the 
escape  of  the  matter  had  taken  place  through  the  oeso- 
phagus near  the  canliac  orifice  of  the  stomach,  whereby 
the  abscess  emptied  itself  into  that  viscus,  and  the 
matter  was  thrown  up  from  the  stomach  or  passed  off 
by  the  bowels. 

I have  now  a patient  in  this  city  under  medical  treat- 
ment, who,  I doubt  not,  is  suffering  under  empyema, 


which  somehow  or  other  finds  its  way  into  the  sto- 
mach, probably  by  a similar  route.  Large  quantities 
of  pus  are  passing  periodically  from  the  bowels  or  are 
ejected  from  the  stomach,  which  I am  satisfied  does  not 
come  from  the  liver,  and  I have  no  doubt  this  is  the 
case  with  many  cases  treated  as  hepatic  abscess. — 
Reese. ^ 

ENCANTIIIS.  (From  iv,  and  kuvOos,  the  angle  of 
the  eye.) 

The  encanthis,  at  its  commencement,  is  nothing 
more,  says  Scarpa,  than  a small,  soft,  red,  and  some- 
times rather  livid  excrescence,  which  grows  from  the 
caruncula  lachrymalis,  and,  at  the  same  time,  from  the 
neighbouring  semilunar  fold  of  the  conjunctiva.  The 
inveterate  encanthis  is  ordinarily  of  considerable  mag- 
nitude ; its  roots  extend  beyond  the  caruncula  lachry- 
malis and  semilunar  fold,  to  the  membranous  lining  of 
one  or  both  eyelids.  The  patient  experiences  very  se- 
rious inconvenience  from  its  origin,  and  interposition 
between  the  commissure  of  the  eyelids,  which  it  ne- 
cessarily keeps  asunder,  on  the  side  towards  the  nose. 

The  encanthis  keeps  up  a chronic  ophthalmy,  im- 
pedes the  action  of  the  eyelids,  and,  in  particular,  pre- 
vents the  complete  closure  of  the  eye.  Besides,  partly 
by  compressing  and  partly  by  displacing  the  orifices  of 
the  puncta  lachrymalia,  it  obstructs  the  free  passage 
of  the  tears  into  the  nose. 

According  to  Scarpa,  this  excrescence,  on  its  first 
appearance,  is  commonly  granulated  like  a mulberry, 
or  is  of  a ragged  and  fringed  structure.  Afterward, 
when  it  has  acquired  a certain  size,  one  part  of  it  re- 
presents a granulated  tumour,  while  the  rest  appears 
like  a smooth,  whitish,  or  ash-coloured  substance, 
streaked  with  varicose  vessels,  sometimes  advancing 
as  far  over  the  conjunctiva  covering  the  side  of  the  eye 
next  to  the  nose,  as  where  the  cornea  and  sclerotica 
unite.  In  this  advanced  state,  the  encanthis  constantly 
interests  the  caruncula  lachrymalis,  the  valvula  semi- 
lunaris, and  the  membranous  lining  of  one  or  both 
eyelids.  In  addition  to  the  roots,  which  in  such  cir- 
cumstances connect  the  excrescence  with  the  carun- 
cula lachrymalis,  the  semilunar  fold,  and  the  conjunc- 
tiva of  the  globe  of  the  eye,  the  encanthis  emits  an  ap- 
pendage, or  prominent,  firm  elongation,  along  the  inside 
of  the  upper  or  lower  eyelid,  in  the  direction  of  its 
edge.  The  middle  or  body  of  the  encanthis  divides 
near  the  cornea,  as  it  were,  like  a swallow’s  tail,  to 
form  two  appendages  or  elongations,  one  of  which  ex- 
tends along  the  inner  surface  of  the  upper  eyehd  by 
the  margin  of  which  it  is  covered,  while  the  other 
shoots  in  a direction  from  the  internal  towards  the  ex- 
ternal angle,  along  the  inside  of  the  lower  eyelid, 
which  also  conceals  it  beneath  its  edge. 

The  body  of  the  encanthis,  or  that  middle  portion  of 
the  whole  excrescence  which  reaches  from  the  carun- 
cula lachrymalis  and  semilunar  fold,  inclusively,  over  the 
conjunctiva  almost  tojhe  junction  of  the  sclerotica  with 
the  cornea,  sometimes  forms  a prominence  as  large  a» 
a small  nut  or  chestnut.  At  other  times  it  is  of  consider- 
able size,  but  depressed  and  broken  down,  as  it  were, 
at  its  centre.  Still,  however,  the  body  of  the  encanthis 
preserves  that  granulated  ajipearanee  which  prevailed 
at  first ; while  one  or  both  the  appendages  on  the  in 
side  of  the  eyelids  appear  rather  like  a fleshy  than  a 
granulated  substance. 

On  turning  out  the  inside  of  the  eyelids,  these  appen- 
dages or  elongations  of  the  encanthis  form  a very 
manifest  jiromirience.  When  both  eyelids  are  equally 
affected,  and  turned  inside  out,  the  appendages  con- 
jointly represent,  as  it  were,  a ring,  the  back  of  which 
rests  on  the  globe  of  the  eye. 

Sometimes  the  encanthis  assumes  a cancerous  ma- 
lignancy. This  character  is  evinced  by  the  dull  red, 
leaden,  or  (as  Beer  says)  the  bluish  red  colour  of  the  e.x- 
crescence  ; by  its  excessive  hardness,  and  the  lancinat- 
ing pains  which  occur  in  it,  and  extend  to  the  forehead, 
the  whole  eyeball,  and  the  temple,  especially  when  the 
tumour  has  been  slightly  touched.  It  is  also  evinced 
by  the  propensity  of  the  excrescence  to  bleed,  by  the 
partial  ulcerations  on  its  surface,  which  emit  a fungous 
substance,  and  a thin  and  exceedingly  acrid  discharge. 
The  disease  is  constantly  attended  with  epiphora,  and 
preceded  by  a scirrhous  induration  of  the  caruncle. 
The  eyeball  and  neighbouring  bones,  which  are  of  a 
spongy  texture,  are  said  to  particiimte  very  soon  in  the 
disease,  the  lower  eyelid  also  becoming  evcri.ed.— (Beer, 
Lehre  von  den  AugenJer.  b.  2,  p.  187,  188.)  This  font* 


350 


ENC 


ENE 


of  encanthis  only  admits  of  palliative  treatment ; un- 
less, indeed,  an  effort  be  made  to  extirpate  it  entirely, 
together  with  the  whole  of  what  is  contained  in  the 
orbit,  and  even  then  the  event  is  dubious. 

Beer  joins  Scarpa  in  the  statement  that  the  opera- 
tion rarely  proves  successful,  and  adds,  that  it  is  al- 
ways followed  by  an  incurable  weeping,  and  a con- 
siderable eversion  of  the  lower  eyelid. — {Vol.  cit.  p. 
189.)  Fortunately,  the  truly  cancerous  encanthis  is 
uncommon ; Mr.  Guthrie  has  not  seen  it  (^Operative 
Surgery  of  the  Eye,  p.  117);  and  Mr.  Travers,  who 
was  a surgeon  to  the  London  Eye  Infirmary  several 
years,  never  met  with  an  instance  of  it. — {Synopsis  of 
Diseases  of  the  Eye,  p.  103.) 

The  benign  encanthis,  how  large  soever  it  may  be,  is 
always  curable  by  extirpation.  Those  instances  which 
are  small,  incipient,  and  granulated,  like  a mulberry, 
or  of  a fringed  structure,  which  originate  either  from 
the  caruncula  lachrymalis,  or  the  semilunar  fold  of  the 
conjunctiva,  or  from  both  these  parts  together,  and 
even  in  part  from  the  internal  commissure  of  the  eye- 
lids, may  be  raised  by  means  of  a pair  of  forceps,  and 
cut  off  from  the  whole  of  their  origin  closely  to  their 
base,  with  the  curved  scissors  with  convex  edges.  In 
the  performance  of  this  operation,  it  is  unnecessary  to 
introduce  a needle  and  thread  through  this  little  ex- 
crescence, as  some  are  wont  to  do,  for  the  purpose  of 
raising  it,  and  destroying  more  accurately  all  its  ori- 
gins and  adhesions.  The  same  object  is  fulfilled  by 
means  of  forceps,  without  inconveniencing  the  patient 
with  a puncture  of  this  kind,  and  drawing  a thread 
through  the  part  in  order  to  make  a noose.  However, 
in  cutting  out  an  encanthis  of  this  small  size,  care 
should  be  taken  not  to  remove,  together  with  that  por- 
tion of  the  excrescence  which  originates  from  the  ca- 
runcula lachrj  malis,  any  more  of  this  tatter  body  than 
what  is  absolutely  necessary  for  the  precise  eradica- 
tion of  the  disease,  in  order  that  no  irremediable  weep- 
ing may  be  occasioned. 

When  the  little  excresence  has  been  detached  from 
all  its  roots,  says  Scarpa,  the  eye  must  be  washed  se- 
veral times  with  cold  water,  in  order  to  cleanse  it  from 
the  blood,  and  then  it  is  to  be  covered  with  a piece  of 
fine  linen,  and  a retentive  bandage.  On  the  5th,  6th, 
or  7th  day,  the  inflammation  arising  from  the  operation 
entirely  ceases,  and  the  suppuration  from  the  wound 
is  accompanied  with  the  mucous  appearance  already 
described.  The  little  wounds  are  then  to  be  touched 
with  a piece  of  altim,  scraped  to  a point  like  a crayon, 
and  the  vitriolic  collyrium,  containing  the  mucilage  of 
quince  seeds,  is  to  be  iisjected  into  the  affected  eye 
several  times  a day.  If  these  means  should  not  bring 
about  the  wished-for  cicatrization,  but,  on  the  contrary, 
the  small  wounds  situated  on  the  caruncula  and  inter- 
nal commissure  of  the  eyelids  should  become  station- 
ary and  covered  with  proud  flesh,  the  argentum  nitra- 
tum  ought  to  be  applied  to  them.  The  conjunctiva, 
however,  should  be  avoided  as  much  as  possible,  espe- 
cially if  at  all  w'ounded.  When  the  fungous  granula- 
tions have  been  destroyed,  the  cure  may  be  perfected 
by  the  collyrium  already  mentioned,  or  rather  by  intro- 
ducing thrice  a day,  betw’een  the  eyeball  and  the  inter- 
nal angle  of  the  eyelids,  the  powder  of  tutty  and  the 
Armenian  bole.  Bidloo  recommends  powdered  chalk, 
either  alone  or  in  conjunction  with  burnt  alum.— (Ex- 
ercit.  .^nat.  Chir.  dccad.  2.) 

Excision  is  equally  applicable  to  the  inveterate  en- 
canthis, which  is  of  considerable  size,  and  broken 
down  at  its  body,  or  which  forms  a prominence  as 
large  as  a nut  or  chestnut,  with  two  fleshy  append- 
ages extending  along  the  inner  surface  of  one  or  both 
eyelids.  The  application  of  a ligature  to  such  an  ex- 
crescence ought  never  to  be  regarded  as  a method  of 
cure ; for  the  large  inveterate  encanthis  never  has  a 
sufficiently  narrow  neck  to  admit  of  being  tied.  On 
the  contrary,  when  the  tumour  is  volutninous,  its  roots 
invariably  extend  to  the  caruni-ula  lachrymalis,  the 
semilunar  fold,  and  the  conjunctiva  covering  the  eye- 
ball, oftentimes  nearly  as  far  as  the  cornea.  In  this 
state  also,  the  encanthis  has  one  or  two  fleshy  append- 
ages, which  reach  along  the  membranous  lining  of  one 
or  both  eyelids.  Hence,  though  the  ligature  were  to 
produce  a separation  of  the  body  of  the  encanthis,  one 
or  both  the  appendages  would  still  remain  to  be  ex- 
tirpated. This  second  operation  could  only  be  accom- 
plished with  the  knife.  In  this  disease,  there  is  no 
foundation  for  the  fear  of  hemorrhage,  to  which  the 


advocates  for  the  ligature  attach  so  much  import 
ance ; for  cases  are  recorded  of  considerable  inve- 
terate encanthes  being  removed,  without  the  least 
untoward  occurrence  from  loss  of  blood.  To  these, 
Scarpa  observes,  he  could  add  a great  number  of  his 
own,  so  that  no  doubt  can  now  be  entertained  on  this 
point. 

Pellier  relates  a case,  in  which  an  encanthis  was 
followed  by  a dangerous  hemorrhage,  though  it  had 
been  cut  out  by  an  expert  oculist.  He  enters,  however, 
into  no  detail  concerning  the  nature  of  the  complaint, 
nor  the  w ay  in  which  the  operation  was  performed ; 
circumstances  from  which  one  might  deduce  the  reason 
of  this  unusual  accident.  Indeed,  the  same  author  adds, 
“ I have  often  performed  this  operation  for  such  ex- 
crescences, and  have  never  met  with  a similar  occur- 
rence.”—(.RecrtefZ  d’Oftsern.  sur  les  Maladies  de  V CEil 
part  2,  obs.  118.) 

When  the  encanthis  is  large  and  inveterate,  with  twm 
extensive  fleshy  elongations,  one  on  the  inside  of  the 
upper  eyelid,  and  the  other  on  that  of  the  low'erone,  we 
are  to  proceed  in  the  following  manner.  The  patient 
being  seated,  an  assistant  is  to  turn  out  the  inside  of 
the  upper  eyelid,  so  as  to  make  one  of  the  appendages 
of  the  encanthis  project  outwards.  By  means  of  a 
small  bistoury,  a deep  incision  is  next  to  be  made  into 
the  elongation,  in  the  direction  of  the  margin  of  the 
eyelid ; and  then  having  taken  hold  of  aiul  drawn  it 
forwards  with  a pair  of  forceps,  w e are  to  separate  it 
throughout  its  whole  length,  from  the  inside  of  the 
upper  eyelid,  proceeding  from  the  external  towards  the 
internal  angle  of  the  eye,  as  far  as  the  body  or  middle 
of  the  encanthis.  We  are  then  to  do  the  same  to  the 
lippomatous  appendage  on  the  inside  of  the  lower  eye- 
lid. Afterward  the  body  of  the  encanthis  is  to  be  ele- 
vated, if  possible,  with  a pair  of  forceps ; but  when  this 
instrument  will  not  answer  the  purpose,  a double  hook 
must  be  employed.  This  middle  portion  is  now  to  be 
detached,  partly  with  the  bistoury,  and  partly  wflth  the 
curvla  scissors,  from  the  subjacent  conjunctiva,  on 
the  globe  of  the  eye,  from  the  semilunar  fold,  and  from 
the  caruncula  lachrymalis;  dividing  the  substance  of 
this  last  part  more  or  less  deeply,  according  to  the 
depth  and  hardness  of  the  large  inveterate  encanthis. 
Here  it  is  proper  to  state  distinctly,  that  when  we  have 
to  deal  with  an  old  large  tumour  of  this  nature,  deeply 
rooted  in  the  caruncula  lachrymalis,  it  is  not  regularly 
in  our  power  to  preserve  a sufficient  quantity  of  the 
substance  of  this  part,  to  prevent  the  tears  from  drop- 
ping over  the  cheek  after  the  wound  is  healed. 

The  eye  is  to  be  repeatedly  washed  w’ith  cold  water. 

The  rest  of  the  treatment  consequent  to  the  extirpa 
tion  of  a large  encanthis,  is  almost  the  same  as  what 
w’as  explained  in  speaking  of  the  small  incipient  case. 
Bathing  the  eye  very  frequently  in  the  lotion  of  mal- 
lows, and  employing  anodyne,  detergent  collyria,  are 
the  best  local  means,  until  the  mucous  appearance, 
preceding  suppuration,  has  taken  place  on  the  surface 
of  the  wound.  Then  we  may  have  recourse  to  mild 
astringent  ointments  and  colljTia.  The  mildest  topical 
applications  are  generally  the  best,  both  in  the  first 
stage  of  suppuration,  as  well  as  afterward,  parti- 
cularly when,  together  with  the  encanthis,  we  have 
removed  a considerable  piece  of  the  conjunctiva  which 
covered  the  eyeball  tow'ards  the  nose,  and  was  inti- 
mately connected  with  the  body  of  the  excrescence. 

Consult  Scarpa  suite  Malattie  degli  Occhi,  ed.  5,  cap. 
12;  Richter,  Anfangsgr.  der  Wundarzn.  band  2,  p. 
473,  i^-c.  edit.  1802.  G.  J.  Beer,  Lehre  von  den  j9u- 
srenkr.  b.  2,  p.  187,  8ro.  Wien,  1817.  B.  Travers,  Ji 
Synopsis  of  the  Diseases  of  the  Eye,  p.  103,  A c.  G.  T. 
Guthrie,  Lectures  on  the  Operative  Surgery  of  the  Eye, 
8vo.  Land.  1823,  p.  117,  A c. 

ENX'EPHALOOELE.  (From  h'Ki6a\og,  the  brain, 
and  Kr/Xy,  a tumour.)  A hernia  of  the  brain. — (See  Her- 
nia Cerebri.) 

ENCYSTED  TUMOURS.  See  Tumours,  En- 
cysted. 

ENEMA.  The  following  are  some  of  the  most  use- 
ful glysters  employed  in  the  practice  of  surgery. 

Cathartic. 

Decocti  hordei  tbj. 

Sodae  muriatis  ? j. — Misce. 

51.  Decocti  aven<e  ftij. 

Olei  olivaj  7 ii. 

Magnesia;  Suiphatis  i j. — Misce. 


EPl 


Anodyne. 

5;.  Mucilagnisamyli,  aquae  distillatae,  sing.  2 ij.  Tinc- 
tura  opii  guttas  vi.. — Misce. 

Olei  olivaesiv.  Tinctura  opii  guttas  xl. — Misce. 

The  two  latter  are  particularly  useful  when  great 
irritation  exists  about  the  rectum,  bladder,  or  urethra. 
They  have  great  effect  in  diminishing  spasmodic  affec- 
tions of  this  canal  and  the  neck  of  the  bladder. 

Tobacco. 

Employed  in  cases  of  strangulated  hernia. 

ft.  Nicotianae  3 j.  Aq.  ferventis  tbj.  The  plant  is 
to  be  macerated  ten  minutes,  and  the  liquor  then 
strained  for  use.  One  half  should  be  first  injected,  and 
soon  afterwads  the  other,  unless  the  glyster  operate 
with  dangerous  violence,  as  it  sometimes  does  in  par- 
ticular constitutions. 

ENTEROCELE.  (From  evrepa,  the  bowels,  and 
KijXy,  a tumour.)  A hernia,  the  contents  of  which  are 
intestine. 

ENTERO-EPIPLOCELE.  (From  svrepa,  the  bow- 
els, f-n'mXoov,  the  omentum,  and  a tumour.)  A 

hernia,  the  contents  of  which  are  both  intestine  and 
omentum. 

[ENTEROTOMY.  As  Mr.  Cooper  has  not  introduced 
this  operation  into  his  Dictionary,  it  may  be  safely  pre- 
sumed that  it  has  not  been  performed,  at  least  with 
success,  in  Great  Britain  or  on  the  continent. 

To  Professor  White,  senior,  of  Berkshire  Medical 
Institution,  belongs  the  honour  of  having  first  per- 
formed this  operation,  and  with  entire  success,  as 
early  as  the  year  1806,  for  the  extraction  of  a teaspoon 
from  the  intestine.  This  case,  so  novel  and  important, 
and  standing  as  it  does  alone  in  this  country  as  well  as 
in  Europe,  will  be  found  recorded  in  the  Med.  Repos,  of 
New-  York,  Hexade  2,  vol.  4,  p.  367. — Reese.] 

ENTROPIUM.  (From  iv,  and  rpeiw),  to  turn.)  An 
inversion  of  the  eyelids. — (See  Trichiasis.) 

EPIGLOTTIS  SHOT  AWAY.  The  practice  of  Ba- 
ron Larrey  furnishes  a curious  examjile,  in  which  the 
epiglottis  of  a French  sohUer  was  shot  ofi’  at  the  battle 
of  Alexandria,  on  the  21st  of  March,  1801.  The  ball 
entered  at  the  angle  of  the  jaw,  crossed  the  throat  ob- 
liquely, and  came  out  at  the  opposite  side  of  the  neck. 
The  base  of  the  tongue  was  grazed,  and  the  ejiiglottis 
shot  away ; the  patient  spit  it  up  after  the  accident, 
and  showed  it  to  the  surgeon  who  first  saw  him. 

The  patient  was  not  in  much  pain ; but  his  voice 
was  hoarse,  feeble,  and  scarcely  audible. 

When  he  first  attempted  to  swallow,  he  was  seized 
with  a convulsive  suffocating  cough,  attended  with 
vomiting.  Annoyed  by  thirst,  which  the  extreme  heat 
of  the  weather,  and  the  irritation  of  the  wound  excited, 
he  incessantly  repeated  his  attempts  to  drink;  but 
always  with  the  same  result.  Four  days  were  jiassed 
in  this  deplorable  condition.  He  already  experienced 
Violent  complaints  in  his  stomach,  continual  loss  of 
sleep ; he  had  a small  accelerated  pulse ; and  was  be- 
ginning to  look  thin. 

Such  was  the  state  of  this  wounded  soldier,  when 
Larrey  saw  him  on  the  fifth  day.  After  making  a few 
inquiries  about  what  had  jiassed  after  the  accident, 
attempting  to  make  the  patient  drink,  and  examining 
tile  interior  of  the  mouth,  Larrey  was  convinced  that 
the  paroxysms  of  suffocation  and  the  inability  to  swal- 
low, depended  upon  the  permanent  opening  of  the  glottis, 
the  lid  of  which  had  been  shot  away.  The  prognosis 
of  the  injury  was  exceedingly  unfavourable,  and  there 
can  be  no  doubt,  that  if  tiie  patient  had  been  abandoned 
to  the  resources  of  nature,  he  w'ould  have  died  in  the 
course  of  a few  days.  The  imlications  were  equally 
dillicult  to  fulfil : the  most  urgent  was  (o  appease  the 
hunger  and  thirst  with  which  this  jioor  soldier  was 
alllK-ted.  J.arrey  fortunately  was  provided  with  en 
elastic  gum  tube,  constructed  for  the  cesophagus.  This 
inst'.unient  was  introduced,  with  the  u.sual  precautions, 
into  the  pharynx,  and  by  irn-ans  of  it  the  patient  was 
given  some  drink,  which  relieved  him  much,  and  afler- 
ward  some  rich  broth.  The  patient  w'as  fed  in  tiiis 
manner  Ibr  six  weeks,  at  the  end  of  which  time  he  was 
ab.e,  without  the  assistance  of  the  tube,  to  swallow 
tliick  panado,  and  thickened  rice  made  i’do  little  balls. 
1 he  powers  of  speech  and  deglutition  in  time  became 
much  more  perteci ; in  consequence,  as  Larrey  ima- 
gines, of  an  enlargement  of  the  artenoid  cartilages, 
and  an  expansion  of  tiiat  part  of  the  base  of  the  tongue 
wh.ch  lies  next  to  the  glottis,  having  formed  a sort  of 


ERY  351 

substitute  for  the  epiglottis.— (Af^moiVc«  ae  Chirurgie 
Militaire,  L2,  p.  145.— 149.) 

The  foregoing  ca.se  illustrates,  in  a convincing  man- 
ner, the  importance  and  utility  of  elastic  gum  tubes  for 
conveying  nourishment  and  medicines  down  the  ceso- 
jihagus  in  wounds  about  the  throat.  All  practitioners, 
and  especially  military  surgeons,  should  be  duly  im- 
pressed with  the  necessity  of  having  such  instruments 
always  at  hand.  The  patient,  whose  case  is  above  re- 
cited, owed  his  preservation  altogether  to  this  means, 
without  which  he  must  have  been  starved  to  death. 

In  the  4th  vol.  of  the  above  work,  p.  247,  is  recorded 
another  case,  in  which  a gun-shot  wound,  that  took 
away  the  epiglottis  and  broke  the  os  hyoides,  was  suc- 
cessfully treated. 

EPIPHORA.  (From  iirKpepo),  to  carry  with  force  ) 
By  this  term  is  meant  an  accumulation  of  tears  on  the 
anterior  part  of  the  eye  ; in  consequence  of  which,  the 
person  affected  is  not  only  under  the  necessity  of  fre- 
quently wiping  them  away,  but  vision  is  injured  by  the 
morbid  refraction  which  they  produce  of  the  rays  of 
light  that  enter  the  pupil.  StUlicidium  lachrymarum 
is  distinguished  by  modern  writers  from  epiphora  : the 
cause  of  stillicidium  lies  in  some  obstacle  to  the  ab- 
sorption and  conveyance  of  the  tears  from  the  lacus  la- 
chrymarum into  the  sac.  Epiphora,  on  the  other  hand, 
consists  in  a superabundant  secretion  of  tears,  and  is 
a disease  of  the  secreting,  not  of  the  excreting  parts  of 
the  lachrymal  organs.— (See  W.  MlKenzie's  valuable 
Essay  on  the  Diseases  of  the  Lachrymal  Organs,  p.  47, 
Svo.  Land.  1819;  and  Beer,  Lehre  von  den  Jlugenkr. 
b.  2.) 

EPIPLOCELE.  (From  hhXoov,  the  omentum,  and 
KyXy,  a tumour.)  A hernia,  formed  by  a protrusion  of 
the  omentum. — (See  Hernia.) 

EPULIS.  (From  hi,  upon,  and  ouAa,  the  gums.)  A 
small  tubercle  on  the  gums.  It  is  said  sometimes  to 
become  cancerous.  The  best  plan  of  cure  is  to  extir- 
pate it  with  a knife. 

ERETHISMUS.  (From  fp£0t^w,  to  irritate.)  The 
slate  of  irritation,  attending  the  early  stage  of  acute 
diseases.  Mr.  Pearson  has  described  a state  of  the 
constitution  produced  by  mercury  acting  on  it  as  a 
I)oison.  He  calls  it  the  mercurial  erethismus,  and  men- 
tiotfs  that  it  is  characterized  by  great  depression  of 
strength,  anxiety  about  the  praecordia,  irregular  action 
of  the  heart,  frequent  sighing,  trembling,  a small,  quick, 
sometimes  intermitting  pulse,  occasional  vomiting,  a 
pale,  contracted  countenance,  a sense  of  coldness ; but 
the  tongue  is  seldom  furred,  nor  are  the  vital  and  natu- 
ral functions  much  disturbed.  In  this  state,  any  sudden 
exertion  will  sometimes  prove  fatal.  Mr.  Pearson  ad- 
vises, with  a view  of  preventing  the  dangerous  ten- 
dency of  this  affection,  the  immediate  discontinuance 
ofthe  use  of  mercury,  and  exiiosing  the  patient  to  a 
dry,  cool  air.  The  incipient  erethismus  may  often  be 
averted  by  the  camphor  mixture  and  large  doses  of 
ammonia,  if  mercury  be  also  left  off.  Sarsaparilla  is 
also  beneficial,  when  the  stomach  will  bear  it.— (Pe«r- 
son  on  Lues  Venerea,  p.  156,  4 c.  edit.  2.) 

ERYSIPELAS.  (From  fpiiw,  to  draw,  and  irAaf, 
adjoining.)  St.  Anthony’s  fire;  so  called,  from  its 
tendency  to  draw  the  neighbouring  jiarts  into  the  same 
state,  or,  in  other  words,  from  its  propensity  to  spread. 

Erysipelas  may  be  defined  to  be  a cutaneous  inflam- 
mation, attended  wdth  redness,  which  disappears,  and 
leaves  a while  spot  for  a short  time  aller  being  touched 
with  the  end  of  the  finger;  and  the  affection,  which  is 
irregularly  circiiinscribcd  by  a defined  line,  is  charac 
terized  by  a remarkable  propensity  to  sjiread. 

The  part  is  generally  of  a bright  red  colour,  clear, 
and  shining.  'I'he  disorder  is  not  accompanied  by 
throbbing;  and  a burning  heat  and  tingling  are  felt 
rather  than  acute  pain.  If  the  skin  alone  be  ailerted, 
there  is  hardly  any  perceptible  swelling,  and  no  ten- 
sion; “yet  some  difference  is  perceived  between  the 
sound  and  the  inflamed  part  by  passing  the  finger  over 
it.”  In  many  instances,  vesications  ari.se;  a circum- 
stance which  led  Dr.  Willan  to  include  the  disease  in 
the  order  BuUcb.  However,  if  we  mean  this  arrange- 
ment to  extend  to  what  is  named  local  or  accidental 
erysipelas,  as  vreU  us  to  the  idiopathic  forms  of  the 
disorder,  there  cannot  be  a doubt  of  its  inaccuracy  ; 
many  examples  cf erysipelas  from  local  irritation  being 
characterized  neither  by  fever  nor  vesications. 

Desault  preferred  the  division  of  erysipelas  into 
phlegmonous,  bilious,  unA  local. — {Vhir.  Journ.  vol.  2.} 


352 


ERYSIPELAS. 


Mr.  Pearson  divided  the  complaint  into  three  forms, 
viz.  phlegmonous,  oedematous,  and  gangrenous.— 
(Principles  of  Surgery,  chap.  10.)  Burserms  notices, 

1.  The  idiopathic,  or  primitive  erysipelas,  or  that  which 
arises  spontaneously  from  an  internal  cause,  unpre- 
ceded by  any  other  disease.  2.  Symptomatic,  or  se- 
condary  erysipelas,  depending  on  another  affection,  by 
which  its  progress  is  completely  influenced.  3.  Acci- 
dental erysipelas,  or  that  which  is  casually  excited  by 
some  external  manifest  cause. — (Instit.  Med.  Prac.  t. 

2,  c.  2,  8vo.  Lips.  1798.) 

The  division  adopted  by  Mr.  LaAvrence  is  into  ery- 
thema, simple,  oedematous,  and  phlegmonous  erysipe- 
las. By  erysipelas,  he  understands  “ inflammation  of 
the  skin,  either  alone,  or  in  conjunction  with  that  of 
the  subjacent  adipous  and  cellular  tissues.  Like  other 
inflammations  (he  says;,  it  varies  in  degree.  When  it 
affects  the  surface  of  the  skin,  which  is  red,  not  sensi- 
bly swelled,  soft,  and  without  vesication,  it  is  called 
erythema.  Simple  erysipelas  is  a more  violent  cuta- 
neous inflammation,  attended  with  effusion  into  the 
cellular  substance,  and  generally  with  vesication. 
Phlegmonous  erysipelas  is  the  highest  degree  of  the 
affection,  involving  the  cellular  and  adipous  membrane, 
as  well  as  the  skin,  and  causing  suppuration  and  mor- 
tification of  the  former.”— (See  Med.  Chir.  Trayis.  vol. 
14,  p.  2.)  When  erysipelas,  however,  is  defined  to  be 
inflammation  of  the  skin,  a peculiar  kind  of  inflamma- 
tion must  be  implied ; for  the  skin,  like  all  other  parts, 
is  often  the  seat  of  common  inflammation.  My  views 
of  the  subject  lead  me  to  consider  erysipelas  as  a com- 
plaint of  an  inflammatory  nature. 

In  the  phlegmonous  erysipelas,  the  skin  is  more 
raised  than  in  the  simple  form  of  the  complaint,  the 
swelling  is  harder  and  deeper,  and  of  a darker  colour. 
The  redness  has  often  a brownish  or  dark  livid  tint ; 
and  the  discoloration  is  sometimes  irregular,  giving  to 
the  part  a marbled  appearance.  The  tumefaction  is 
more  considerable  than  in  simple  erysipelas,  the  whole 
depth  of  the  adipous  and  cellular  textures  being  loaded 
with  effusion,  so  that  the  arm  or  leg  appears  of  twice 
the  natural  size.  The  sensation  of  heat  and  pain,  at 
first  sight,  is  aggravated  to  a very  severe  degree,  and 
may  be  accompanied  with  throbbing.  The  swollen  part 
at  first  yields  slightly  to  the  pressure  of  the  finger,  -but 
subsequently  becomes  tense  and  firm.  Vesications, 
often  minute  and  miliary,  form  on  the  surface  with 
purulent  contents ; but  sloughing  of  the  cellular  mem- 
brane soon  comes  on,  and  the  febrile  symiitoms  are  ag- 
gravated. According  to  Mr.  Law  rence  s late  observa- 
tions, these  dangers  are  not  attended  Avith  increased 
swelling,  elevation,  and  pointing,  as  in  phlegmon ; on 
the  contrary,  there  is  rather  a diminution  of  tension,  a 
subsidence,  and  a feel  of  softness  in  the  part.  At  first, 
the  cellular  texture  contains  a whey-like  or  whitish 
serum.  The  fluid  gradually  becomes  yellow  and  pu- 
rulent, and  we  often  find  it  presenting  all  the  characters 
of  good  pus,  and  very  thick.  The  serum  is  diffused 
through  the  cells  at  an  early  period,  and  a mixture  of 
serum  and  pus  often  fills  a considerable  portion  of  the 
cellular  texture,  Avithout  any  distinct  boundary.  Fre- 
quently matter  is  deposited  in  small,  separate  portions, 
forming  a kind  of  little  abscesses,  which  often  run  irre- 
gularly in  the  cellular  texture.  The  substance  turns 
gray,  yellowish,  or  tawny  ; and  sometimes  appears  like 
a dirty,  spongy  substance,  filled  with  a turbid  fluid ; 
thus  losing  its  vitality  altogether,  it  is  conA’erted  into 
more  or  less  considerable  fibrous  shreds,  of  various 
size  and  figure,  w'hich  come  away  soaked  with  matter 
like  a sponge.  The  integuments  over  a large  slough 
of  this  kind  being  deprived  of  their  vascular  supply, 
become  livid,  and  often  lose  their  vitality.  The  sup- 
purating and  sloughing  processes  go  on  to  a great  ex- 
tent when  an  entire  limb  is  affected,  sometimes  com- 
pletely detaching  the  skin,  and  often  separating  it 
through  a large  space  ■,  occasionally  penetrating  deeper, 
passing  bctAveenthe  muscles,  causing  inflammation  of 
them,  suppuration  between  them,  and  often  sloughing 
of  the  tendons.  When  the  substance  of  a limb  is  thus 
generally  inflamed,  the  joints  do  not  escape ; inflam- 
mation of  the  synovial  membranes,  effusion  of  matter 
into  the  joint,  and  ulceration  of  the  cartilage  take 
place. — (See  Hutchison's  Practical  Obs.  p.  115,  ed.  2; 
and  Bihl.  Med.  Sept.  1827,  p.  331,  as  cited  by  Lawrence.) 
An  inflammation  of  such  extent  and  violence  cannot 
fail  to  produce  the  most  serious  disturbance  of  the 
nervou.s  system,  typhoid  symptoms,  inflammation  of 


the  lungs,  or  pleura,  of  the  intestinal  mucous  mem- 
brane, «fcc. ; and  the  case  is  speedily  fatal.  If,  hoAv- 
ever,  says  Mr.  LaAvrence,  the  patient  should  recover 
after  tedious  suppurations  and  discharge  of  slough,  the 
parts  which  have  been  inflamed  are  so  changed  in  struc- 
ture, and  the  skin,  fascia,  muscles,  tendons,  and  bones 
are  so  materially  agglutinated  and  fixed  after  the  exten- 
sive destruction  of  the  connecting  cellular  texture,  that 
the  motions  of  the  part  are  permanently  and  seriously 
injured.— (See  Lawrence,  in  Med,  Chir.  Trans,  vol.  14, 

p.  12.) 

The  following  is  Mr.  LaAvrence’s  description  of 
simple  erysipelas.  The  skin  is  pretematurally  red  and 
shining,  having  a light  or  rosy  tint  in  the  early  stage 
and  slighter  cases  of  the  affection ; whence,  in  some 
languages,  it  has  received  the  popular  appellation  of 
the  rose;  while,  in  other  instances,  it  is  of  a bright 
scarlet,  or  even  a deep  and  livid  red.  The"  colour  dis- 
api)ears  on  pressure,  returning  as  soon  as  the  pressure 
is  removed.  If  the  skin  alone  be  affected,  there  is 
hardly  any  perceptible  swelling,  and  no  tension ; yet 
some  difference  is  perceived  between  the  sound  and 
the  inflamed  part,  by  passing  the  finger  over  it.  Ery- 
sipelas, however,  is  found  by  Mr.  Lawrence  to  be  sel- 
dom confined  to  the  skin,  except  in  the  slightest  cases ; 
effusion  soon  takes  place  into  the  cellular  texture, 
causing  a soft  SAvelling  ; and  this  may  be  considerable, 
together  with  much  tension  and  a sliining  surface, 
when  a large  part  of  the  body  or  an  entire  limb  is  ui- 
volved.  The  inflamed  pan  is  hot  and  painful ; at  first, 
a stinging  or  itching  is  felt,  which  soon  becomes  a sharp, 
smarting,  and  burning  sensation,  with  acute  pain  on 
pressure.  The  pain  is  not  so  intense  and  unremitting 
as  in  phlegmon,  nor  is  it  attended  with  throbbing. 
This  kind  of  inflammation  often  ends  by  resolution  ; 
the  redness  and  other  symptoms  disappearing,  and  the 
skin  recovering  its  natural  state,  AA'ith  or  without  de- 
squamation of  the  cuticle.  Frequently  serous  effusion 
takes  place  from  the  inflamed  surface,  elevating  the 
cuticle  into  smaller  or  larger  vesicles,  or  into  bullte, 
like  those  produced  by  blisters ; or  raising  it  by  a soft, 
yellow,  jelly-like  deposite,  which  remains  slightly  adhe- 
rent to  both  the  cutis  and  cuticle.  The  contents  of  the 
vesicles  or  bullae  are  transparent,  sometimes  nearly 
colourless,  but  more  commonly  yellowish ; sometimes 
they  consist  of  a thin  pus,  or  they  may  exhibit  a bloody 
or  livid  discoloration.  The  fluid  loses  its  clearness, 
becoming  thicker,  opaque,  and  whitish  or  yelloAvish. 
The  cuticle  gives  Avay ; the  fluid  escapes,  and  incrusta- 
tions form,  which  soon  fall  off,  leaving  the  skin  sound  ; 
or  they  may  lead  to  superficial  ulcerations.  Erysipelas 
sometimes  produces  gangrene,  but  this  is  of  compara- 
tively rare  occurrence.  So  long  as  this  inflammation 
is  confined  to  the  skin,  it  does  not  produce  suppura- 
tion ; and  the  affection  of  the  cellular  structure  is  too 
slight  for  that  termination  in  most  cases  of  simple 
erysipelas.  It  may,  however,  become  more  severe  at 
one  point ; and  thus  we  occasionally  see  the  formation 
of  abscess  under  the  skin  towards  the  decline  or  after 
the  disappearance  of  the  general  erysipelatous  redness. 
This  inflammation  generally  attacks  a considerable 
surface  of  the  skin,  the  inflamed  part  being  irregularly 
circumscribed  by  a defined  line.  It  spreads  quickly  to 
the  neighbouring  skin,  declining  and  disappearing  in 
the  part  first  affected.  Thus,  we  commonly  see  the 
various  stages  of  erysipelas  existing  together  at  the 
same  time  in  different  parts  of  the  skin.  The  portion 
last  affected  is  red  and  swelled ; another  part  is  vesi- 
cated; Avhile  others  exhibit  incrustation  and  desqua- 
mation. Sometimes  it  leaves  the  part  first  affected,  tc 
apjiear  in  a distant  situation.  Its  origin,  developement, 
and  complete  termination  seldom  take  place  in  one  and 
the  same  spot.  The  neighbouring  absorbent  glands 
are  frequently  inflamed,  and  red  streaks  are  sometimes 
seen  leading  to  them. — (Laivrence,  in  Med.  Chir.  Trans, 
vol.  14.) 

A little  before  the  appearance  of  the  redness,  and 
sometimes  during  several  previous  days,  the  patient 
experiences  considerable  indisposition,  loses  his  appe- 
tite, has  shiverings  and  violent  pains  in  his  head,  ac- 
companied sometimes  Avith  vomiting,  and  always  Avith 
weakness  and  dejection.  Frequently  bilious  complaints 
occur,  attended  with  a bitter  taste  in  the  mouth,  and 
fetid  eructations  from  the  stomach.  The  tongue  is 
moist,  and  covered  Avith  a yellow  mucus.  The  patient 
afterward  has  a dry,  parched  skin,  constipation,  an 
accelerated  pulse,  thirst,  and  other  common  symptoms 


ERYSIPELAS. 


f?53 


of  fever.  Blood  drawn  from  a vein  exhibits  in  a greater 
or  less  degree  tlie  inflammatory  character.  “Often, 
particularly  when  the  head  is  the  seat  of  erysipelas, 
the  sensorium  is  principally  affected,  and  symptoms 
are  of  the  kind  called  nervous,  such  as  pain  and  oppres- 
sion of  the  head,  sleepiness,  coma,  or  delirium.  The 
tongue  in  such  cases  becomes  dry  and  brown ; but, 
according  to  Mr.  Lawrence,  this  state  of  the  organ  is 
often  owing  principally  to  the  circumstance  of  the  pa- 
tient breathing  entirely  through  the  mouth  ; the  pulse  is 
rapid  and  feeble,  and  there  is  great  loss  of  muscular 
strength  ; in  short,  the  symptoms  at  length  are  those 
called  typhoid.  In  other  cases,  the  circulation  and  the 
nervous  system  are  not  much  affected;  but  there  is 
pain  in  the  epigastric  region,  fout  tongue,  with  bad 
taste  in  the  mouth,  nausea,  and  constipation ; that  is, 
so  many  indications  of  disordered  stomach  and  intesti- 
nal canal,  to  which,  as  its  cause,  the  local  affection 
must  be  referred.”— (jVfea.  C/iir.  Trans,  obs.  14,  p.  6.) 
This  last  Ibrm  of  the  complaint  has  been  termed  by 
Desault  and  others  bilious  erysipelas. 

The  following  is  a description  of  phlegmonous  ery- 
sipelas, as  it  sometimes  appears  when  it  attacks  the 
head. 

The  attack  is  mostly  preceded  by  shiverings,  com- 
plaints about  the  region  of  the  heart,  and  other  symp- 
toms very  similar  to  those  which  indicate  the  approach 
of  an  intermittent  fever.  The  heat  is  often  accompa- 
nied with  a little  delirium,  and  almost  always  with 
drowsiness  of  a more  or  less  evident  kind.  The  swel- 
ing  generally  makes  its  appearance  on  the  second 
night  or  third  day  of  the  fever,  attacking  the  forehead, 
the  cheeks,  the  nose,  or  eyelids.  This  swelling  is 
elastic  and  smooth : but  it  is  not  distinctly  circum- 
scribed, and  it  gradually  si)reads  over  such  parts  of  the 
face  as  were  not  at  first  affected.  The  skin  becomes  of 
a bright  red  coiour ; occasionally  having  a tendency  to 
a livid  hue;  in  other  instances  having  a mixture  of 
yellow.  These  colours  disappear  when  pressure  is 
made  on  the  part  affected,  but  very  soon  reappear  when 
such  pressure  is  discontinued.  The  patient  experiences 
a burning  heat  and  a disagreeable  pricking  in  the  part, 
rather  than  any  acute  pain  ; sometimes  he  complains 
of  a very  trouble.sonie  itching.  The  surface  of  the  tu- 
mour is  shining,  and,  as  it  were,  semi-transparent ; but 
without  hardness,  tension,  or  any  sensation  of  throb- 
bing. The  eyelids  are  often  so  swollen  that  the  patient 
cannot  see,  and  the  whole  countenance  is  exceedingly 
disfigured.  On  more  or  less  of  the  erysipelatous  tu- 
mour vesications  arise  about  the  fourth  or  fifth  day ; 
they  are  filled  with  a transparent  serous  fluid,  and  bear 
a great  resemblance  to  those  which  are  occasioned  by 
boiling  water.  They  commonly  burst,  or  subside,  on 
the  fifth  or  sixth ; the  fluid  which  is  discharged  some- 
times excoriating* the  neighbouring  parts.  Frequently 
there  is  even  a slight  ulceration  at  their  base,  which 
ulceration,  in  the  worst  sort  of  cases,  assumes  a gan- 
grenous ajipearance,  and  falls  rapidly  into  a state  of 
complete  mortification.  When  the  disease  takes  a 
more  favourable  course,  the  fever  now  begins  to  abate  ; 
the  vesications  dry  up  ; and  at  the  end  of  eight  or  twelve 
Jays  the  cuticle  peels  off,  and  the  scabs  situated  in 
plac.e.s  which  were  occupied  by  the  vesications  fall  off. 
The  degree  of  danger  depends  materially  on  the  deli- 
rium and  other  symptoms  indicating  an  affection  of  the 
brain.  When  phlegmonous  erysipelas  attacks  the  face, 
the  termination  of  the  disorder  in  suppuration  is  very 
rare.  —{Bateman,  vol.  cit.  p.  127.)  Mr.  Lawrence  re- 
pre.sents  phlegmonous  as  differing  from  simide  erysi- 
pelas, merely  in  the  higher  degree  and  deeper  extent  of 
the  intlammation,  which  not  only  occupies  the  whole 
thickness  of  the  skin,  and  subjacent  adipous  and  cellular 
tissues,  but  soon  proceeds  in  the  latter  to  suppuration 
and  sloughing,  the  skin  itself  being  often  involved  se- 
condarily in  the  mortification.  Other  writers,  however, 
regard  as  examples  of  phlegmonous  erysipelas  .cases 
winch  jierhaps  would  not  be  comprehended  in  the 
above  view  ; and  in  fact,  the  exact  line  that  should 
divide  one  form  of  erysipelas  from  another  does  not 
always  admit  of  being  drawn.  The  affected  part, 
wliich  is  at  first  firm,  becomes  softer,  when  diffused 
supjiuration  and  matter  mixed  with  slouglns  are  under 
the  skin.  Exjierience  proves  that  the  .seat  of  phlegmo- 
nous erysipelas  is  in  the  .skin  and  cellular  substance, 
and  that  the  disease  does  not  generally  extend  beneath 
thp  fascia.  Mr.  Lawrence  differs  from  Mr.  Hutchison, 
111  haviiiir  always  found  the  ajioneuroscs  unaffected  ni 

\ OL.  1.—  Z 


examination  after  death,  and  seen  no  symptoms  refer- 
able to  such  an  inflammation  during  life.  “ They  may 
indeed  become  involved  in  the  disease  W'hen  it  is  vio- 
lent, and  they  must  suffer  partially  when  it  extends  to 
the  intermuscular  cellular  texture,  but  they  are  not  pri- 
marily affected  in  these  cases,  wdiile  in  the  majority  of 
instances  they  do  not  suffer  at  all.” — {Lawrence,  Med. 
Chir.  Trans,  vol.  14,  p.  16.) 

According  to  several  writers,  the  seat  of  erysipelas 
in  the  greater  number  of  cases  is  the  very  surface  of 
the  cutis  : its  most  vascular  and  nervous  part.— (DicL 
des  Sciences  M6d.  t.  13,  p.  255.)  Perhaps  it  may  be 
true,  that  the  disorder  commences  here,  and  is  most 
intense ; yet  there  can  be  no  doubt  that  the  affection 
generally  extends  more  deeply,  and  affects  the  subja- 
cent cellular  membrane,  particularly  in  cases  of  phleg- 
monous erysipelas.  The  researches  of  Mr.  Lawrence 
have  taughr  him,  as  already  noticed,  that  erysipelas  is 
seldom  confined  to  the  skin,  except  in  the  slightest 
(•ases ; effusion  soon  takes  place  into  the  cellular  tex- 
ture, causing  a soft  swelling  ; and  this  may  be  consi- 
derable, together  with  much  tension  and  a shining  sur- 
face, when  a large  part  of  the  body  or  an  entire  limb  is 
involved. — (See  Med.  Chir.  Trans,  vol.  14,  p.  3.)  The 
affection  of  the  cellular  membrane,  however,  is  very 
different  from  what  happens  in  phlegmonous  inflam- 
mation. In  true  erysipelas,  healthy  pus  is  rarely  found 
enclosed  in  a circumscribed  cavity  ; and  when  there  is 
any  secretion  of  purulent  matter,  a feel  is  communi- 
cated on  compressing  the  part,  almost  like  that  which 
a sponge  would  give.  In  such  cases,  the  cellular  sub- 
stance is  freipiently  gangrenous. 

It  does  not  appear  to  me  that  any  very'  exact  informa- 
tion has  yet  been  established  respecting  the  causes  of 
erysipelas.  We  absolutely  know  nothing  about  the 
anrnediate  cause;  the  prevailing  ideas  concerning  the 
predisposing  causes  are  vague  ; and  only  those  causes 
termed  exciting  appear  entitled  to  much  confidence. 

Every  surgeon  is  well  aware,  that  one  cause  of  ery 
sijielatous  inflammation  is  a fever  of  a determinate 
atid  peculiar  nature,  one  feature  of  which  is  the  inva- 
riable production  of  this  kind  of  inflammation  upon  the 
surface  of  the  body. 

With  respect  to  the  causes  of  erysipelas,  it  is  the 
opinion  of  Mr.  Lawrence  that  no  difference  prevails  on 
this  point  between  erysipelas  and  other  inflammations. 
“ The  habitual  excitement  of  the  vascular  system,  or 
the  long-continued  disturbance  of  the  stomach,  ali- 
mentary canal,  and  liver,  consequent  on  intemperance 
and  excess,  lay  the  foundation  of  inflammation  gene- 
rally, and  it  depends  on  individual  peculiarity,  or  on 
local  causes,  w'hether  the  skin  or  other  parts  shall  be 
the  seat  of  the  disease.  In  most  cases  of  erysipelas, 
the  bilious  and  digestive  systems  are  more  or  less 
actively  disordered,  such  disorder  appearing  sometimes 
to  jiroduce  the  cutaneous  affection,  sometimes  to  be 
excited  sympathetically  by  it.  Hence  Desault  esta- 
blished the  denomination  of  bilious,  in  contradistinction 
to  phlegmo7ious,  erysipelas  ; on  which  division  it  may 
be  observed,  that  the  symptoms  called  bilious  are  com- 
monly found  also  in  phlegmonous  cases.” — {Med.  Chir. 
Trans,  vol.  14,  p.  36.)  Erysipelas  may  arise  from  ex- 
ternal irritants  of  all  kinds  ; from  heat  or  cold  ; blis- 
ters, issues,  setons,  caustics,  or  other  acrid  matters 
applied  to  the  skin  ; from  wounds,  jiunctures,  bruises, 
surgical  operations,  and  all  kinds  of  injury.  The  me- 
chanical or  chemical  irritatiott  of  wounds,  ulcers,  or 
other  local  diseases  will  cause  it.  “ Neglect  of  previous 
{ireparation,  inattention  to  diet,  injudicious  modes  of 
dressing,  continued  exercise  of  the  affected  part,  and 
ati  imprudent  degree  of  general  exertion,  are  frequent 
causes  of  erysipelas  after  operations  and  wounds, 
and  in  the  course  of  ulcers  and  other  local  affections. 
When  these  several  points  arc  properly  attended  to, 
we  shall  not  be  much  troubled  with  traumatic  and  hos- 
pital erysipelas.  Irritating  plasters,  a heating  load  of 
dressings,  and  tight  bandaging,  are  common  causes  of 
erysipelas,  whether  in  the  case  of  wounds  or  opera- 
tions. Idght  applications,  and  keeping  the  parts  cool, 
are  simple  but  effectual  preventives.  The  most  fre- 
quent source,  however,  of  this  affection,  after  accidents 
or  operations,  is  improjier  diet,  that  is,  indulgence  in 
animal  food  or  fermented  yu\noTii."—( Lav'rence,  vol.  cit. 
p.  3.‘"i.)  As  far  as  I have  seen,  another  very  common 
.source  of  erysipelas  after  wounds,  is  the  indiscriminate 
use  of  sutures. 

According  to  Mr.  Lawrence,  sinijilc  erysipelas,  and 


554 


ERYSIPELAS 


the  cases  termed  exanthematous,  are  mostly  sympa- 
thetic, particularly  from  disorder  of  the  primae  vise  or 
liver;  and  hence  the  epithets  bilious  and  gastric. 
Phlegmonous  erysipelas  is  most  commonly  produced 
by  the  wound  of  venesection,  injuries  of  the  superficial 
bursae,  as  those  of  the  patella  and  olecranon,  incised 
and  lacerated  wounds,  and  compound  fractures ; in- 
flamed ulcers  of  the  legs,  and  a full  diet  to  persons  who 
have  large  wounds  or  ulcers  rapidly  healing;  the 
wounds  received  in  dissection,  &c. 

In  most  cases,  erj’sipelas  would  seernto  be  intimately 
dependent  on  the  state  of  the  censtitution.  Thus,  per- 
sons in  the  habit  of  drunkenness  and  other  kinds  of 
intemperance,  and  who  in  a state  of  intoxication  meet 
with  local  injuries,  often  have  erysipelatous  inflam- 
mation in  consequence  of  them.  Other  subjects,  who 
lead  more  regular  lives,  experience,  when  they  meet 
with  similar  injuries,  healthy  phlegmonous  inflam- 
mation. 

The  opinion  of  Hippocrates  and  Galen,  with  respect 
to  the  origin  of  this  disorder  from  a congestion  of  the 
bile,  is  universally  known  to  all  initiated  in  the  pro- 
fession of  surgery.  This  old  doctrine  has  been  in 
some  measure  revived  by  Tissot  and  other  believers  in 
the  humoral  pathology,  who  attribute  the  cause  of 
erysipelas  to  an  acrid  humour,  commonly  a bilious  one, 
diffused  through  the  mass  of  the  blood.  But  while  I 
cannot  discern  any  evidence  of  the  truth  of  this  theory, 
observation  obliges  me  to  confess,  that  the  complaint 
seems  frequently  to  be  connected  with  a disorder  of  the 
chylopoietic  viscera,  and  especially  of  the  liver. 

A farther  proof  that  erysipelas  is  mostly  dependent 
on  constitutional  cau.ses  is,  that  the  affection  is  particu- 
larly frequent  in  autumn,  or  in  any  season  when  hot 
Weather  is  succeeded  by  cold  and  wet. 

Erysipelas  attacks  both  sexes;  but  women  are 
thought  to  be  rather  more  subject  to  it  than  men,  and 
the  reason  for  this  circumstance  generally' mentioned 
is,  the  greater  delicacy  and  tenderness  of  the  skin  in 
females.  But  it  would  be  quite  as  rational  to  susi)ect 
their  weaker  and  more  irritable  constitutions,  and  their 
sedentary  mode  of  life.  In  lying-in  hospitals  and  other 
charities  for  the  reception  of  children,  new-born  in- 
fants are  often  afflicted  with  a species  of  erj'sipelas, 
which  begins  in  the  umbilical  region,  and  thence  extends 
to  the  pudenda.  This  case,  which  sometimes  termi- 
nates in  gangrene  and  proves  fatal,  has  been  ascribed 
by  some  writers  to  injury  done  to  the  navel-string 
during  labour,  and  by  others  to  the  bad  air  frequently 
allowed  to  accumulate  in  establishments  of  the  above 
description;  a cause  which  too  often  renders  complaints, 
which  are  at  first  trivial,  ultimately  fatal. 

Sometimes  the  complaint  is  scarcely  cured  in  one 
place  when  it  makes  its  appearance  in  another ; and 
when  this  tendency  is  evinced  in  a great  degree,  the 
case  is  termed  erysipelas  ambulans,  vel  erraticum.  La 
Motte  has  published  a striking  instance  of  this  form  of 
the  disease.  A child  between  nine  and  ten  years  of 
age  was  attacked  with  erysipelas  of  the  scalp,  fore- 
head, and  ears,  which  afterward  extended  to  the  neck 
and  then  to  the  shoulders,  while  the  scalp  and  face  be- 
came free  from  it : in  proi)ortion  as  the  disease  spread 
downwards,  all  the  upper  parts  got  well,  so  that  in  the 
end  there  was  no  portion  of  the  surface  of  the  body 
which  had  escaped,  even  down  to  the  fingers  and  toes, 
the  parts  last  of  all  affected.— (O65.  Chir.) 

A very  uncommon  variety  of  disease  is  a universal 
erysipelas.  No  disorder  is  more  subject  than  the  pre- 
sent to  relapses ; but  a remarkable  thing,  sometimes 
attending  the  return  of  the  complaint,  is  its  being 
sometimes  strictly  periodical.  In  chlorotic  women,  the 
erysipelatous  attack  is  occasionally  made  every  month 
just  at  the  period  when  the  menses  should  take  place. 
— (Hoffvnan.)  This  periodical  nature  of  erysipelas  has 
been  observed  in  men  : Larrey  knew  two. male  patients, 
one  of  whom  used  to  be  attacked  with  erysipelas  twice 
a year  at  the  time  of  the  equinox ; the  other  had  only 
one  attack  annually,  which  was  wont  to  happen  in  the 
beginning  of  the  spring.  My  friend  Mr.  Maul,  of 
Southampton,  once  informed  me  of  an  erysipelas  which 
was  both  periodical  and  universal,  affecting  a lady  se- 
veral times  at  intervals  of  two  years. 

A doctrine  has  been  started,  that  erysipelas  is  some- 
times propagated  by  contagion. — {Weils,  in  Trans,  for 
the  Improvement  of  Med.  and  Surg.  Knowledge,  vol.  2, 
art.  17,  ISOO.  A.  Riberi,  Sullu  Gangrena  Contagiosa, 
o Nosocomiale ; coH  alcuni  Cenni  sopra  una  Re.sipela 


Contagiosa.  8vo.  Torino,  1821.  Amott,  in  Med.  Phyr 
Joum.  vol.  17.)  But,  as  Dr.  Bateman  has  truly  re- 
marked, such  cases  are  at  all  events  extremely  rare, 
and  perhaps  never  happen  in  well-ventilated  and  cleanly 
houses. — {Synopsis,  iS  c.  p.  131.)  In  places  of  an  oppo- 
site description,  the  infection  of  many  individuals  to- 
gether might  be  explained  by  the  operation  of  the  same 
exciting  causes  upon  them  all,  without  any  supposition 
of  contagion.  This  part  of  the  subject,  however,  is 
yet  unsettled : Mr.  Lawrence  believes  that  erysipelas 
of  the  face  may  be  traced  in  some  instances  to  conta- 
gion.— (See  Afed.  Chir.  Trans,  vol.  14,  p.  39.) 

I think  we  must  agree  with  Mr.  I.awrence,  that  “ a 
consideration  of  the  origin,  developement,  and  effects  of 
erysipelas,  wfliether  local  or  general,  leads  us  irresisti- 
bly to  the  conclusion  that  the  nature  of  the  affection  is 
inflammatory.  In  its  four  leading  characters  of  redness, 
swelling,  heat,  and  pain,  and  in  its  effects  of  effusion, 
suppuration,  and  sloughing,  it  agrees  with  what  is 
called  common  or  phlegmonous  inflammation ; while 
the  general  disturbance  preceding  and  accompanying 
the  local  affection  is  often  exactly  alike  in  the  two 
cases.  Erysipelas,  then,  is  merely  a particular  modi- 
fication of  cutaneous,  or  cutaneous  and  cellular  inflam- 
mation. If  we  were  to  class  these  according  to  their 
natural  affinities,  we  should  place  erysipelas  between 
the  exanthemata  and  phlegmon.  It  is  less  diffused  than 
the  former — not  so  circumscribed  as  the  latter.  The 
exanthemata  are  confined  to  the  skin;  erysipelas  af- 
fects both  skin  and  cellular  structure ; while  phlegmon 
has  its  original  seat  in  the  latter,  the  skin  being  se- 
condarily involved. 

The  difference  between  erysipelas  and  phlegmon, 
however,  is  not  merely  in  the  original  seat  or  degree 
of  the  disturbance  ; there  is  also  a difference  in  kind. 
We  may  indeed  say,  generally,  that  plflegmon  is  a more 
violent  inflammation  than  erysipelas,  but  sloughing  of 
the  cellular  substance  is  more  frequent  in  the  latter 
than  the  former.  The  most  striking  and  important 
distinction  between  the  two  affections  is,  that  inflam- 
mation is  confined  to  one  spot  in  phlegmon,  and  is  dis- 
tinctly circumscribed  in  its  seat,  while  it  is  diffused  in 
erysipelas,  and  spreads  without  limit.  This  difference 
seems  to  depend  on  the  adhesive  character  of  the  in- 
flammatory process  in  the  former;  the  substance  called 
coagulating,  coagulable,  or  organizable  lymph,  effused 
around  the  inflamed  part,  forms  a boundary  between  it 
and  the  sound  portion,  which  is  altogether"  wanting  in 
erysipelas.  In  the  latter,  the  eff  usion  is  serous ; hence, 
when  matter  is  formed  it  is  not  confined  to  one  spot, 
but  becomes  extensively  diffused  in  the  cellular  tissue.” 
—{Med.  Chir.  Trans,  vol.  14,  p.  17,  A c.)  These  views 
correspond  to  those  given  by  Mr.  Hunter,  whose  origi- 
nal remarks  on  erysipelas  are  particularly  valuable 
both  to  the  pathologist  and  the  practical  surgeon. 

Like  phlegmonous  inflammation,  erysipelas  may  be 
excited  by  any  local  irritation.  Like  other  inflamma- 
tions it  may  end  in  suppuration,  though  of  a less  per- 
fect sort  than  that  in  which  phlegmon  ends,  the  pus  be- 
ing rarely  contained  in  a circumscribed  cavity.  The 
pulse,  in  phlegmonous  erysipelas,  is  frequent,  hard, 
sometimes  full ; and  when  the  patients  are  bled,  their 
blood  has  the  same  appearance,  and  is  covered  with  the 
same  kind  of  inflammatory  crust,  as  blood  taken  away 
in  other  kinds  of  inflammation. 

Mr.  Lawrence  does  not  agree  with  some  medical  au- 
thors, among  whom  may  be  placed  3Ir.  Hunter,  who 
regard  erysipelas  as  a distinct  species  of  inflammation, 
and  capable  of  affecting  various  parts  of  the  body  as 
well  as  the  skin.  Some  writers  (he  says)  have  referred 
to  erysipelas  certain  inflammations  of  the  conjunctiva, 
mouth,  and  fauces ; of  the  respiratory  and  alimentary 
mucous  surfaces;  of  the  serous  membranes  in  the 
head,  chest,  and  abdomen,  and  of  the  brain,  abdominal 
and  thoracic  viscera.  The  distinguishing  characters  of 
erysipelas  Mr.  Lawrence  refers  to  the  peculiarities  of 
the  cutaneous  and  cellular  structures  in  which  it  oc- 
curs, and  he  therefore  infers  that  such  an  affection  can- 
not exist  in  parts  so  differently  organized  as  serous 
membranes  and  the  viscera.  When  the  remarks  of 
some  of  the  WTiters  in  question  are  carefully  consi- 
dered, it  seems  as  if  their  meaning  were  only  that  ery- 
sipelas is  connected  with  a particular  state  of  consli 
tution,  in  which  the  inflammation,  wheresoever  situ- 
ated would  have  a tendency  to  spread  rapidly  and  ex- 
tensively; but  whether  the  doctrine,  even  thus  modi- 
fied, is  correct,  requires  farther  investig.ation. 


ERYSIPELAS. 


355 


Treatment  of  Erysipelas. 

Simple  erysipelas,  not  exceeding  a certain  degree  of 
Severity,  yields  to  nuld  purgatives,  and  a light  vegetable 
diet,  with  which  remedies  practitioners  usually  con- 
join diaphoretics  and  the  saline  mixture.  Whether 
bleeding  is  right  or  not,  in  this  species  of  erysipelas,  is 
a point  on  which  different  sentiments  prevail.  I be- 
lieve, however,  that  venesection,  in  the  milder  forms 
of  the  complaint,  is  now  pretty  generally  allowed  to  be 
as  unnecessary  as  it  is  urgently  required  in  more  se- 
vere examples.  It  is  rather  a prevalent  notion,  that  it 
is  unnecessary  to  repeat  bleeding  in  any  case  of  erysi- 
pelas so  frequently  as  is  done  in  other  inflammatory 
diseases.  We  ought  to  be  guided,  however,  in  this  re- 
spect, by  the  violence  and  extent  of  the  inflammation, 
the  state  of  the  pulse,  and  other  symptoms,  never  for- 
getting the  patient’s  age,  strength,  and  other  important 
considerations.  Another  common  belief  is,  that  the 
patient  will  bear  bleeding  better  in  the  country,  and  in 
an  open,  pure  air,  than  in  a large  city,  and  especially 
in  an  hospital.  And  it  is  remarked,  that  unless  there 
be  a considerable  tendency  to  delirium  or  coma,  blood- 
letting can  seldom  be  repeated  with  advantage,  at  least 
in  large  towns. — (Pearson's  Principles  of  Surgery. 
Bateman's  Synopsis,  p.  132,  ed.  3.)  Instead  of  this 
practice,  the  latter  author  recommends  local  bleeding 
and  blistering,  but  not  upon  or  very  near  the  diseased 
surface,  whereby  he  avoids  producing  the  troublesome 
sores,  the  frequency  of  which,  in  former  times,  after 
taking  blood  from  erysiitelatous  parts,  led  Mr.  B.  Bell 
to  pronounce  a general  condemnation  of  the  method. 
I ought  to  observe,  in  relation  to  the  above-mentioned 
fear  of  bleeding  patients  freely  in  large  cities,  that  it  is 
an  hypothesis  which  seems  to  be  declining,  many  ex- 
perienced and  judicious  surgeons  having  actually  re- 
jected it  as  unfounded ; and,  as  far  as  my  observations 
extend,  I have  no  hesitation  in  stating  my  opinion,  that 
the  abstract  consideration,  whether  a person  living  in 
town  or  country,  should  not  regulate  the  use  of  the 
lancet,  which  ought  to  be  decided  by  other  more  import- 
ant circumstances  in  the  case.  Alexander  of  Tralles, 
and  Par4,  had  a high  opinion  of  the  beneficial  effects  of 
plenty  of  fresh,  cool  air  in  cases  of  erysipelas ; but 
good  air  is  generally  beneficial  in  all  diseases,  and,  per 
haps,  not  more  so  in  erysipelas  than  other  disorders. 

Mr.  Lawrence  thinks,  that  as  erysipelas  resembles 
other  inflammations  in  its  causes,  symptoms,  and  ef- 
fects, it  should  be  treated  on  the  same  ])rinciples ; that 
is,  on  the  antiphlogistic  plan.  Venesection,  local  bleed- 
ing, purging,  and  low  diet  are  the  first  measures,  to 
which  saline  and  diaphoretic  medicines  may  be  after- 
ward added.  He  says,  the  earlier  these  means  are 
employed  the  better;  vigorous  treatment  in  the  begin- 
ning seems  to  him  most  calculated  to  shorten  the  at- 
tack, and  prevent  the  disease  from  spreading  beyond 
its  original  seat.  At  the  same  time  he  admits,  that  as 
the  skin  and  cellular  membrane  are  of  secondary  im- 
portance, it  is  not  so  urgently  necessary  to  arrest  in- 
flammation in  them  as  in  the  vital  organs ; neither  does 
the  same  reason  for  very  active  treatment  exist  as  in 
affections  of  the  eye,  where  a slight  change  of  structure 
may  seriously  impair  the  utility  of  the  organ  essential 
to  our  comfort  and  pleasure;  but  the  extensive  suppu- 
ration and  mortification  which  erysipelas  sometimes 
produces  may  render  a limb,  in  a great  measure,  to- 
tally useless,  or  may  even  destroy  life.  “ The  disposi- 
tion of  erysipelas  to  terminate  by  resolution,  is  another 
reason  against  resorting  indiscriminately  to  active  de- 
pletion. In  many  cases  the  disease  passes  through  a 
certain  course,  and  ends  spontaneously : it  is  sufficient 
to  put  the  patient  on  low  diet,  to  clear  the  alimentary 
canal,  and  then  to  use  mild  aperients  and  diaphoretics. 
When  it  proceeds,  as  it  often  does,  from  an  unhealthy 
condition  of  the  alimentary  canal,  the  removal  of  the 
internal  disorder  leads  to  the  cessation  of  the  local  com- 
plaint. It  must,  however,  be  observed,  that  venesec- 
tion is  sometimes  useful  both  in  curing  the  internal 
cause  and  in  promoting  the  termination  by  resolution.” 
Mr.  Lawrence  afterward  ob.serves,  that  he  does  not 
mean  to  recommend  that  measures  equally  active,  and 
in  particular,  that  bleeding,  whether  general  or  local, 
are  to  be  employed  in  all  cases.  In  young  persons,  in 
the  robust,  and  those  of  full  habit;  in  instances  where 
the  pulse  is  full  and  strong,  or  where  there  is  headache 
and  white  tongue;  in  erysipelas  of  the  head,  attended 
with  symptoms  denoting  affection  of  the  sensorium, 
and  more  especially  in  the  very  beginning  of  the  afl'ec 

Z 2 


tion,  venesection  will  be  proper ; and  it  may  be  neces* 
sary  to  bleed  largely,  to  repeat  the  evacuation,  or  to  fol- 
low venesection  by  local  abstraction  of  blood.  Under 
such  circumstances,  the  other  parts  of  the.  antiphlogistic 
plan  must  also  bejemployed  ; that  is,  the  alimentary  ca- 
nal should  be  cleared  by  an  active  purgative,  v/hich  may 
be  followed  by  salines  and  antimoinals,  with  the  occa- 
sional use  of  milder  aperients,  and  low  diet  should  be 
enjoined.  As  Mr.  Lawrence  adds,  nothing  can  be  more 
different  from  such  a case,  than  that  of  an  elderly  per- 
son, with  a small  and  feeble  pulse,  in  the  advanced 
stage  of  the  disease.  The  interval  between  these  ex- 
tremes is  filled  by  numerous  gradations,  requiring  cor- 
responding modifications  of  treatment.  The  antiphlo- 
gistic plan  itself  embraces  a wider  range  in  point  of 
degree;  from  blood-letting,  local  and  general,  with 
purging,  vomiting,  the  free  use  of  m.ercury  and  antimo- 
ny, and  low  diet,  to  the  exhibition  of  a mild  aperient, 
with  some  saline  medicine.  Mr.  Lawrence  believes, 
that  the  treatment  of  erysipelas,  like  that  of  any  other 
inflammation,  should  be  modified  according  to  the  age, 
constitution,  previous  health,  and  habits  of  the  patient, 
and  the  period  of  the  complaint.  “In  asserting  gene- 
rally that  the  antiphlogistic  treatment  is  proper,  1 speak 
(says  he)  of  the  beginning  of  the  disease,  whern  the 
original  and  proper  character  of  the  affection  is  appa- 
rent ; and  I am  decidedly  of  opinion  that,  in  some  shape 
or  degree,  such  treatment  will  always  be  beneficial  in 
that  stage.  In  many  instances,  active  antiphlogistic 
measures  are  of  the  greatest  service  in  lessening  the 
severity  both  of  the  local  and  general  symptoms.  In 
others,  the  administration  of  calomel  with  aperients,  and 
of  diaphoretics  with  low  diet,  will  be  sufficient.  When 
the  affection  occurs  in  old  and  debilitated  subjects,  the 
powers  of  life  are  soon  seriously  impaired,  and  our  efforts 
must  be  directed  rather  towards  supporting  them,  than 
combating  the  local  affection.  I have  often  seen  such 
subjects  labouring  under  erysipelas  of  the  face  in  its  ad- 
vanced stage,  with  rapid  and  feeble  pulse,  dry  and  browm 
tongue,  recovered,  under  circumstances  apparently  des- 
perate, by  the  free  use  of  bark  and  wine.”  The  same 
writer  deems  local  bleeding  sufficient  in  the  milder 
cases  of  erj'sijielas,  and  often  necessary  in  the  more  se- 
vere ones,  as  an  auxiliary  measure.  Cupping,  when 
practicable,  he  sets  down  as  more  efficacious  than 
leeches,  though  objectionable  on  account  of  the  pain- 
ful state  of  the  skin.  Leeches,  he  remarks,  when  ap- 
plied to  the  sound  skin  of  some  individuals,  produce  an 
effect  analogous  to  erysipelas,  but  they  exert  no  such 
influence  over  the  inflamed  skin,  to  which  they  maybe 
applied  freely  and  safely.  In  order  to  produce  any  de- 
cided benefit,  he  thinks  that  they  should  be  apiilied  in 
large  numbers. 

The  authorities  which  may  be  cited  in  favour  of  the 
treatment  of  erysipelas  on  antiphlogistic  principles,  are 
Sydenham  (Obs.  circa  Morborum  Acut.  Hist.  ^-c.  sect. 
6,  c.  6);  Cullen  (Works  by  Thomson,  vol.  2,  p.  188); 
Richter  (Anfangsgr.  der  Wundarzn.  vol.  1,  ^ 188); 
Vogel  (Handb.  vol.  3,  p.  348) ; J.  R.  Frank  (De  Cur. 
Hominum  Morbis,  lib.  3,  p.  54);  Dr.  Duncan,  junior 
(Edin.  Med.  Journ.  vol.  19).  Several  of  these  writers 
consider  bleeding  more  particularly  proper  when  ery- 
sipelas is  seated  on  the  head  and  face. 

As  Mr.  I.awrence  has  noticed,  high  authorities  may 
be  brought  forward  against  the  use  of  the  lancet  in  ery- 
sipelas, and  most  of  them  are  comparatively  of  modern 
date.  Some  of  them  not  only  object  to  evacuations  of 
all  kinds,  but  recommend  tonics  and  stimuli,  such  as 
bark,  ammonia,  and  wine.  Dr.  Fordyce  declares  that 
he  always  found  bleeding  and  evacuations  hurtful,  and 
Peruvian  bark  the  be.st  remedy.  “It  should  be  exhi- 
bited (he  says)  in  substance  if  the  patient’s  stomach 
will  bear  it,  and  in  this  disease  it  will  almost  always 
bear  it;  and  in  as  great  a quantity  as  the  patient’s  sto- 
mach will  bear,  which  is  commonly  to  the  quantity  of  a 
drachm  every  hour  [’’—(TmTis.  of  a Society  for  the  im- 
provement of  Chir.  Knowledge,  vol.  1,  p.  293.)  Some 
animadversions  on  the  practice  of  giving  bark  in  this 
manner  will  be  found  in  our  preceding  columns. — 
(See  Cinchona.)  Dr.  Wells  is  also  an  advocate  for  the 
treatment  recommended  by  Fordyce.  With  regard  to 
Cullen,  he  only  sanctioned  it  when  the  case  was  at- 
tended with  lyjdioid  symptoms. 

After  the  inflainmalion  has  been  checked  by  anti- 
phlogistic means,  the  surgeon  should  not  be  in  too  great 
a hurry  to  prescribe  tonics,  stimulr<«its,  and  a full  diet, 
“ Medical  jiractitioners  in  general  (says  Mr.  Lawrence) 


356 


ERYSIPELAS. 


are  anxious  to  begin  the  strengthening  plan  ; they  seem 
to  have  the  fear  of  debility  constantly  before  their  eyes 
and  lose  no  time  in  directing  the  employment  of  bark, 
and  recommending  animal  food  with  beer  or  wine.  In 
this  way  relapses  are  frequently  produced;  the  inflam- 
mation and  fever  are  renewed ; farther  local  miscliief 
is  caused,  and  recovery  is  retarded.” — {Med.  Chir. 
Trails,  vpl.  14,  p.  59.)  When  it  is  doubtful  whether 
stimuli  should  be  employed  or  not,  he  deems  subcar- 
bonate of  ammonia  the  best  medicine.  Bark  comes 
next  in  order  to  it,  and  the  sulphate  of  quinine  is  the 
most  eligible  preparation.  Wine  is  sometimes  neces- 
sary; but  Mr.  Lawrence  thinks  it  should  be  given 
very  sparingly. — (See  Med.  Chir.  Trans: vol.  14.) 

The  proposal  to  treat  ery.sipelas  by  compression  with 
bandages,  as  adopted  by  Bretontieau  and  Velpeau, 
seems  to  require  here  no  farther  notice  than  that  it  has 
proved  in  this  country'  very  unsuccessful,  and  even 
fatally  hurtful. — (See  Duncan.,  in  Med.  Chir.  Trans, 
x'ol.  1,  p.  543  ; Lawrence,  in  Med.  Chir.  Trans,  vol.  14, 
p.  65.)  The  application  of  blisters  to  erysipelatous 
parts,  as  sometimes  practised  by  Dupuytren,  can  only 
be  entitled  to  the  briefest  mention,  even  when  viewed 
as  represented  by  the  French  surgeons  themselves.— 
(See  Roche  and  Sanson,  Nouveaux  El  m.  de  Pathol. 
Med.  Chir.  t.  \,p.  352.) 

In  the  bilious  erysipelas,  or  that  originating  with 
strongly  marked  gastric  disorder,  whatever  degree  of 
heat  or  fever  might  exist,  Desault  gave  in  the  first  in- 
stance a grain  of  tartarized  antimony  dissolved  in  a 
considerable  quantity  of  fluid ; and  the  symptoms  gene- 
rally diminished  as  soon  as  the  effects  of  the  medicine 
had  ceased.  lie  had  seen  them  entirely  subside,  al- 
though the  medicine  produced  no  other  sensible  altera- 
tion in  the  animal  economy  than  an  increase  of  the 
insensible  perspiration  and  urine  ; sometimes  the  symp- 
toms resisted  these  evacuations,  and  he  was  obliged  to 
have  recourse  once  or  twice,  or  even  more  frequently, 
to  the  use  of  the  emetic  drink.  When  the  erysipelas 
w'as  cured,  and  the  bitterness  in  the  mouth  and  fever  , 
had  subsided,  two  or  three  purges  of  cassia  and  manna, 
with  a grain  of  emetic  tartar,  were  exhibited;  during 
the  cure,  the  patient  w'as  ordered  to  drink  freely  of  a I 
diluting  ptisan  acidulated  with  oxymel : and  as  soon  as 
the  symptoms  were  mitigated,  the  diet  of  the  patient 
was  allowed  to  be  more  nourishing  and  generous ; for 
when  it  was  too  spare,  the  case  was  remarked  never 
to  proceed  so  favourably',  particularly  in  hospitals, 
w’here  the  air.  generally' speaking,  is  unhealthy.  In 
the  bilious  ery  sipelas,  Desault  observed  that  the  cases 
of  the  patients  who  had  been  bled  previously  to  their 
admission  into  the  hospital,  were  invariably  the  most 
serious  and  obstinate,  particularly  w'hen  the  bleeding 
had  been  frequently  repeated. 

In  ca.ses  of  bilious  erysipelas,  many  modern  prac- 
titioners would  be  bolder  with  antimonials  than  De- 
sault, first  by  imitating  Richter,  and  giving  an  emetic  at 
the  commencement  of  the  attack,  and  then  by  exhibit- 
ing more  freely  either  antimonial  powder  or  tartarized 
antimony,  with  a dose  or  two  of  calomel. 

In  phlegmonous  erysipelas,  Desault  was  an  advocate 
for  bleeding  in  the  beginning  of  the  disorder,  and  this 
practice  he  followed  up  by  the  administration  of  tartar- 
ized antimony  and  evacuants. 

Mr.  Lawrence  recommends,  in  the  early  stage,  vene- 
section and  the  application  of  leeches  in  large  numbers 
to  the  inflamed  part,  together  w'ith  the  antiphlogistic 
treatment  generally,  in  order  to  prevent  the  full  develope- 
ment  of  the  affection.  The  bleeding  of  the  leech-bites 
he  directs  to  be  encouraged  by  fomentations,  and  cold 
lotions  afterward  to  be  applied.  When,  however,  the 
inflammation  is  more  advanced  (he  says),  the  latter 
should  be  exchanged  for  fomentations  and  poultices. 
My  own  experience  in  these  cases  leads  me  to  refer 
very  great  efficacy  to  cold  applications,  w'hich  I find 
particularly  useful  in  retarding  the  effusion  in  the  cel- 
lular membrane,  averting  gangrene  of  this  tissue,  and 
stopping  altogether  the  progress  of  the  disorder.  In 
the  case  of  a [latient  in  Fleet-market,  whom  I attended 
with  Mr.  Lawrence  and  Mr.  Bullin,  and  whose  limb 
W’as  so  swelled  as  to  be  nearly  twice  its  natural  thick- 
ness from  one  end  to  the  other,  cold  lotions,  evacuations, 
leeches,  and  other  antiphlogistic  remedies  had  a decided 
c-ffect  in  giving  ease,  and  preventing  all  occa.sion  for 
the  practice  of  extensive  incisions.  The  abscesses 
w'ere  very  limited ; and  tw’o  small  incisions,  made  at 
different  periods  for  tho  discharge  of  the  matter,  an- 


swered every  purpose.  After  the  bowels  have  been 
emptied,  Mr.  Lawrence  pre.scribes  freely  calomel  and 
antimony,  w’ith  saline  medicines.  The  local  abstrac- 
tion of  blood  he  considers  more  serviceable  in  p. fleg- 
monous erysipelas  than  venesection.  The  latter,  t'lere- 
fore,  he  advises  to  be  reserved  for  instances  in  wliich 
the  patient  is  young  and  plethoric,  the  pulse  full  and 
strong,  or  the  head  much  affected. 

When  such  practice  is  unavailing,  Mr.  Lawrence 
finds  the  plan  of  making  incisions  through  the  inflamed 
skin  and  the  subjacent  adipous  and  cellular  textures, 
the  most  powerful  means  of  arresting  the  complaint. 
If  this  be  not  done  (he  says),  the  inflammation  will  now 
pursue  its  course,  both  in  the  cellular  membrane  and 
skin,  in  spite  of  bleeding,  whether  general  or  local  ; 
suppuration  and  sloughing  rapidly  supervene;  and 
these  destructive  processes  soon  extend  over  a large 
portion  of  a limb.  It  w’as  with  the  view  of  preventing 
such  consequences,  that  Mr.  Lawrence,  in  imitation 
of  Mr.  C.  Hutchison,  tried  the  practice  of  making 
free  and  even  very  extensive  incisions  in  the  inflamed 
parts,  as  will  be  presently  noticed. 

In  cases  of  idiopathic  erysipelas,  whether  phlegmo- 
nous or  bilious,  external  applications  have  been  deemed 
useless  or  hurtful  by  a large  proportion  of  practitioners, 
among  whom  is  Desault.  In  the  early  stage  of  the  dis- 
ea.se.  Dr.  Bateman  found  powdery  substances,  like  flour, 
starch,  chalk,  &c.,  increase  the  heat  and  irritation,  and 
afterward  when  the  fluid  of  the  vesications  oozes  out, 
such  substances  produce  additional  irritation  by  form- 
ing with  the  concreting  fluid  hard  crusts  upon  the  ten- 
der surface.  This  practice  is  also  condemned  by  Mr. 
Pearson.  The  only  plan,  perhaps,  which  is  unobjec- 
tionable as  a means  of  allaying  the  irritation  produced 
by  the  discharge  from  the  vesication,  is  that  advised 
by  Dr.  Willan,  and  which  consists  in  fomenting  or 
w’ashing  the  jiarts  from  time  to  time  xvith  milk,  bran 
and  water,  or  a decoction  of  elder-flowers  and  poppy- 
heads.  In  the  early  stage  of  the  inflammation.  Dr. 
Bateman  saw  great  relief  derived  from  moderate  tepid 
xvashing,  or  the  application  of  the  diluted  liquor  ammon. 
acet.—{Sijnopsis  of  Cutaneov.s  Diseases,  p.  133,  ed.3.) 

Though  Desault  forbids  local  remedies  in  cases  of 
idiopathic  erysipelas,  he  does  not  extend  the  prohibition 
to  examples  either  of  bilious  or  phlegmonous  erysipelas 
from  a contusion,  wound,  or  ulcer : regimen  and  inter- 
nal medicines,  according  to  Desault,  here  being  insuffi- 
cient unless  topical  applications  are  employed  to  abate 
the  local  irritation,  and  excite  suppuration.  With  this 
view  he  commends  cataplasms,  but  he  deems  one  can 
tion  essential,  viz.  that  the  application  of  the  poultice 
should  not  extend  much  below  the  contused  surface  or 
the  edges  of  the  wound.  If  any  application  be  per 
mitted  on  the  rest  of  the  erysipelatous  surface,  he 
thinks  that  it  should  be  the  liquor  plumbi  acetatis  dilu- 
tus  made  weak.— {Parisian  Chir.  Joum.  vol.  2.) 

Mr.  Pearson  prefers  cataplasms  composed  of  the  pow- 
ders of  aniseed,  fennel,  chamomile-flowers,  &c.,  mixed 
with  a fourth  part,  or  an  equal  quantity  of  bread,  and  a 
proper  quantity  of  milk.  Linseed  powder,  he  says,  may 
sometimes  prove  a convenient  addition. 

As  for  w'hat  is  termed  accidental  erysipelas,  or  that 
caused  by  casual  local  irritation  applied  directly  to  the 
skin,  as  from  acrid  substances,  heat,  friction,  the  sting 
of  insects,  &c.,  the  removal  of  the  cause,  the  employ- 
ment of  cold,  or  even  ice-cold  lotions,  and  other  anti- 
phlogistic means,  are  the  only  measures  essentially  ne- 
cessary. 

In  cases  of  phlegmonous  erx’.sipelas,  if  the  inflamma- 
tion continue  in  an  unabated  form  beyond  the  seventh 
or  eight  day,  suppuration  is  to  be  apprehended.  Here 
Boyer  recommends  the  employment  of  emollient  appli- 
cations, and  as  soon  as  a fluctuation  is  distinguishable 
(or  even  what  he  terms  “ un  empdtement  purulent”) 
he  advises  the  surgeon  to  make  such  incisions  as  may 
be  necessary  for  the  discharge  of  the  matter.  He  also 
states  that  the  incisions  should  be  made  at  several  de- 
pending points. — {See  Boyer,  TraiU  des  Mai  Chir.  t.  2, 
p.  22.)  It  appears  from  the  observations  of  Mr.  A.  C. 
Hutchison,  formerly  surgeon  to  the  Naval  Hospital  at 
Deal,  that  seafaring  men  are  very  liable  to  phlcgmonoua 
erj-sipelas  of  the  extremities,  particularly  of  the  legs 
The  cause  is  ascribed  to  the  irritation  of  the  salt  water 
and  the  friction  of  their  loose  coarse  trousers.  In  this 
description  of  iiatieiits  the  disease  frequently  proceeds 
rapidly  to  the  gangrenous  state,  and  the  consequence 
is  the  loss  of  many  lives  and  limbs.  Even  when  the 


ERYSIPELAS. 


357 


danger  of  mortification  is  avoided,  abscesses  often 
occur,  wliich  spread  between  the  muscles  and  under 
the  integuments  to  a surprising  extent : “ from  the 
ankle  to  the  trochanter  and  over  the  gluttei  muscles.” 
In  the  first  few  cases  which  came  under  the  care  of 
Mr.  Hutchison,  this  gentleman’s  plan  of  treatment,  in 
addition  to  the  usual  medical  means,  consisted  of  local 
bleeding  by  means  of  cupping  glasses,  followed  bj-  fo- 
mentations. Subsequently,  however,  he  has  adoj)ted 
the  method  of  making  several  free  incisions  with  a 
scalpel  on  the  inflamed  surface  in  a longitudinal  direc- 
tion through  the  integuments,  and  down  to  the  mus- 
cles as  early  in  the  disease  as  possible,  and  before  any 
secretions  have  takeii  place.  These  incision.s  may  be 
about  an  inch  and  a half  in  length,  two  or  three  inches 
apart,  and  vary  in  number from  six  to  eighteen,  accord- 
ing to  the  extent  of  surface  w'hich  the  disease  is  found 
to  occupy.  Mr.  Hutchison  states,  that  these  incisions 
will  yield  between  fifteen  and  twenty  ounces  of  blood, 
and  give  relief  to  the  tense  skin,  at  the  same  time  that 
they  form  channels  for  the  escape  of  fluid,  and  the  pre- 
vention of  bags  of  matter.  After  the  operation,  fomen- 
tations or  saturnine  lotions  are  employed. 

By  the  preceding  kind  of  treatment,  Mr.  Hutchison 
thinks  the  fatal  termination  of  the  disease  may  be 
rendered  less  frequent,  and  gangrenous  mischief 
wholly  prevented.  He  supiiorts  this  assertion  by  ob- 
serving, that  he  never  lost  a case  in  the  Deal  Hospital 
for  the  last  five  years,  during  which  the  practice  was 
followed. — (See  Med.  Chir.  Trans,  vol.  5,  p.  278,  <^  c.) 

Mr.  Law'rence  thinks  the  most  powerful  means  of 
arresting  the  complaint  is  by  making  one  or  more  long 
incisions  through  the  inflamed  skin  and  the  subjacent 
adipous  and  cellular  textures,  which  are  the  seat  of  the 
disease.  These  incisions,  he  asserts,  are  followed  very 
quickly  and  almost  instantaneously  by  relief  and  cessa- 
tion of  the  pain  and  tension;  and  this  alleviation  of  the 
local  suffering,  he  assures  us,  is  accompanied  by  a cor- 
responding interruption  of  the  inflammation,  whether 
it  be  in  the  stage  of  effusion,  or  in  the  more  advanced 
period  of  suppuration  and  sloughing.  Mr.  Lawrence 
farther  maintains  that  this  treatment  is  employed  to 
the  greatest  advantage  at  the  beginning,  since  it  pre- 
vents the  farther  extension  of  inflammation  and  the 
occurrence  of  suppuration  and  sloughing.  At  a more 
advanced  stage  the  incisions  limit  the  extent  of  suppu- 
ration and  gangrene ; and  at  a still  later  time  they 
afford  the  readiest  outlet  for  matter  and  sloughs,  and 
facilitate  the  commencement  and  progress  of  granula- 
tion and  cicatrization. — {Med.  Chir.  Trans,  vol.  14,  p. 
67,  <S'C.)  The  great  points  on  which  a diversity  of  opi- 
nion exists  respecting  the  treatment  by  incisions  are 
the  period  when  they  are  really  necessary,  and  their 
number  and  extent.  Believing  from  extensive  observa- 
tion that  phlegmonous  erysipelas,  when  properly  treated, 
does  not  lead  so  invariably  to  extensive  gangrenous  mis- 
chief and  suppuration  under  the  skin  as  Mr.  Lawrence's 
account  would  make  us  suppose,  but,  on  the  contrary,  that 
it  frequently  admits  of  resolution,  and  often  occasions 
only  abscesses  which  may  be  effectually  opened  as  soon 
as  formed,  I cannot  acknowledge  the  wisdom  or  utility 
of  making  incisions  for  the  prevention  of  evils,  the  oc- 
currence of  which  at  all  is  quite  a matter  of  uncertainty. 
Thus,  though  Mr.  Lawrence  has  inferred  from  several 
of  the  cases  in  which  he  practised  early  and  free  inci- 
sions, that  these  had  the  effect  of  preventing  extensive 
sloughing  and  sujipuration,  the  conclu.sion  is  certainly 
without  satisfactory  proof;  and  a cure  might  have 
taken  place  very  well  without  them.  To  the  practice, 
therefore,  in  the  early  stage  of  the  disease  I should  ob- 
ject as  unnecessary.  At  a more  advanced  period,  how- 
ever, when  matter  is  formed,  I am  decidedly  an  advo- 
cate for  making  a free  opening  for  its  discharge,  but 
not  for  inflicting  ten  or  sixteen  different  wounds  for 
this  or  any  other  purpose,  nor  for  using  the  scalpel  v;ith 
such  perfect  reliance  on  the  innocence  and  sweetness 
of  its  edge  as  to  make  with  it  a gash  requiring  a foot  or 
yard  ruler  for  its  measurement.  Whoever  looks  over 
the  reiioris  of  this  treatment,  as  detailed  in  the  Lancet 
and  other  works,  cannot  fail  to  be  struck  with  the  fol- 
lowing facts.  Several  patients,  treated  in  this  way, 
have  not  been  saved,  and  some  have  certainly  gone  out 
of  the  world  in  a very  sudden  manner.  Whether  this 
arose  from  the  shock  of  an  enormous  wound  on  the 
constitution  m its  very  disturbed  state,  or  from  profuse 
hemorrhage,  or  other  causes,  it  is  needless  to  inquire. 
In  one  or  .wo  msianc.-s,  the  cutaneous  nerves  as  well  ' 


as  large  veins  and  arteries,  were  not  spared,  and  a par- 
tial paralysis  ensued.  Against  the  proposed  treatment 
by  numerous  or  long  incisions  I must  therefore  conti- 
nue to  protest ; in-  the  early  stage  the  practice  of  inci- 
sions in  any  way  is  not  truly  indicated  for  the  reason 
above  explained ; and  at  a more  advanced  period  if 
subcutaneous  suppuration  or  gangrene  commence,  a 
prompt  and  free  opening  is  undoubtedly  required  accord- 
ing to  all  the  established  principles  of  surgery,  but  not 
a wound  of  preposterous  extent.  Ur.  Dobson,  of  Green- 
wich Hospital,  makes  in  all  kinds  of  erysipelas  nume- 
rous small  punctures  in  the  part,  and  repeats  them  to  the 
number  and  extent  required  mostly  twice  a day ; and 
often  in  bad  cases  three  or  four  times  in  the  twenty-four 
hours.  The  quantity  of  fluid  (for  it  is  not  blood  alone, 
but  blood  and  effused  serum)  which  these  jiunctures  dis- 
charge, although  sometimes  considerable,  he  says,  need 
never  create  any  alarm.  With  this  practice  he  joins  the 
exhibition  of  the  camphor  mixture,  liquor  aminon.  acet. 
and  tincture  of  rhubarb.  He  also  employs  a lotion, 
composed  of  liq.  ammon.  acet.  camphorated  spirit,  and 
water.— (See  Med.  Chir.  Trans,  vol.  14,  p.  206.)  Of 
this  method  I shall  merely  observe  that  it  has  not  fallen 
to  my  lot  ever  to  see  it  tried ; but  that,  if  I were  the  pa- 
tient, I should  rather  submit  to  it  than  to  the  bold 
sweeping  incision  or  numerous  deep  cuts  which  have 
been  recommended  by  gentlemen  whose  opinions  on 
other  points  in  surgery  1 sincerely  respect. 

[In  this  country,  during  the  winter  months,  and  es- 
pecially in  variable  seasons,  phlegmonorts  erysipelas 
as  it  is  here  called,  is  a frequent  comsequence  of  local 
injury,  as  burns,  wounds,  &c.,  and  by  speedily  running 
into  suppuration,  this  disease  has  often  proved  fatal, 
although  the  original  mischief  was  circumscribed  and 
inconsiderable. 

I have  frequently  known  this  kind  of  ery.sipelas  to 
originate  from  a slight  wound  on  the  hand,  and  in  a 
few  days  involve  the  whole  arm  in  the  suppurative 
process.  And  although  the  wound  or  burn  scarcely 
penetrated  the  cutis,  yet  the  matter  would  diffuse  itself 
beneath  the  fascia  of  the  limb,  and  require  the  most 
prompt  and  efficient  remedies  to  jirevent  death  by  the 
pain  and  irritation  occasioned  by  distention. 

Mr.  Lawrence’s  plan  of  treatment  has  been  attended 
with  signal  success  under  my  own  observation,  the 
threatening  symptoms  subsiding  immediately  after 
long  and  free  incisions  were  made  through  the  skin 
and  subjacent  adipose  and  cellular  textures.  Professor 
Belafield  of  this  city  has  had  opportunities  of  testing 
this  practice  to  considerable  extent,  and  he  informs  me 
that  he  has  uniformly  obtained  the  most  satisfactory 
results.— JJee^e.] 

What  is  termed  cedematous  erysipelas  is  generally 
considered  to  be  an  unfit  case  for  bleeding  and  free 
evacuations,  and  almost  always  to  reiiuire  a tonic  plan 
of  treatment.  In  short,  the  right  practice,  in  every  ex- 
ample of  erysijielas,  is  to  let  the  remedies  be  regulated 
in  a great  measure  by  the  state  of  the  constitution,  the 
jiulse,  the  strong  or  reduced  condition  of  the  system, 
the  sort  of  fever  accompanying  the  disorder,  the  age. 
temperament  of  the  patient,  and  the  particular  stage  of 
the  conqilaint.  At  first,  though  antiphlogistic  treat- 
ment may  be  the  only  safe  plan,  circumstances  after- 
ward change  so  considerably  that  this  must  be  aban- 
doned, and  a method  quite  the  reverse  of  it  rigorously 
adopted. 

With  regard  to  the  treatment  of  gangrenous  erysi- 
pelas, nothing  more  need  be  said  than  what  is  con- 
tained in  the  article  on  Mortifleation. 

Consult  Desault’s  Parisian  Chirurgical  Jourjial,  vol. 
2.  Also,  (J.uvres  Chir.  de  Desault  par  Bichat,  t.  2,  p. 
581,  iS-c.  Encyclopedic  Mcthodique,  partie  Chir.  art. 
Erysipele.  Cullen's  First  Lines  of  tl^e  Practice  of 
Physic,  vol.  1.  Peart's  Pract.  Obs.  on  Erysipelas,  c. 
1802.  Pearson's  Principles  of  Surgery,  1808.  Some 
parts  of  Hunter's  Treatise  on  the  Blood,  Inflamrnntum, 

1. 'i-c.  Richer  and,  Nosogr.  Chir.  t.  I,  p.  118,  .?-c.  ed. 

2.  Lassus,  Pathologic  Chir.  t.  1,  p.  8,  i^c.  ed.  1809. 
Traite  des  Maladies  Chir.  par  le  Baron  Boyer,  t.  2, 
p.  6,  et  seq.  Will  an  on  Cutaneous  Diseases.  A.  C. 
Hutchison,  in  Med.  Chir.  Trans,  vol.  5,  p.  278,  &c.  and 
Practical  Obs.  in  Surgery,  ed.  2.  T.  Bateman,  H 
Practical  Synopsis  of  Cutaneous  Diseases,  p.  125, 
&-C.  ed.  .3.  Diet,  des  Sciences  Med.  vol.  13,  p.  253,  ij-c. 
Rayer,  Traite  des  Mai.  de  la  Peau,  t.  1.  Butter's  Re- 
marks on  Irritative  Fever.  Devonport,  1825.  Dr 
Duncan,  in  Edin.  Med.  Chir.  Tran  vol.  1.  Arnatt, 


358 


ERY 


EXF 


in  Med.  Phys.  Journ.  vol.  57.  James  mi  Injiamma- 
tion.  Wells,  in  TVans.  of  a Society,  for  the  Improve- 
ment of  Med.  and  Surgical  Knowledge,  vol.  1.  W.  H. 
Burrell,  in  Edin.  Med.  Journ.  vol.  24.  Lawrence,  in 
Med.  Ckir.  Trans,  vol.  14. 

ERYTHEMA.  (From  ipufipof,  red.)  A redness  of 
any  part.  A mere  rash  or  efflorescence,  not  accompa- 
nied by  any  swelling,  vesication,  or  fever ; circumstances 
which,  according  to  Dr.  Bateman,  distinguish  it  from 
erysipelas. — {Synopsis  of  Cutaneous  Diseases,  p.  119. 
ed.  3.)  Its  six  varieties  are  described  in  the  latter 
>vork.  For  the  erythema  mercuriale,  see  Mercury. 
The  tenh  is  often  wrongly  applied  to  eruptions  attended 
with  redness,  and  distinct  papular  and  vesicular  eleva- 
tion, as  we  see  in  the  instance  of  mercurial  erythema, 
which  Dr.  Bateman  says  should  be  named  eczema. 

[From  the  extraordinary  use  and  consequent  abuse 
of  mercurial  remedies,  which,  I regret  to  state,  too  much 
characterizes  the  practice  of  many  of  the  medical  pre- 
scribers  of  this  country,  I am  induced  to  add  a remark 
jor  two  on  this  very  interesting  disease.  The  erythi- 
mus  arising  from  mercury,  which  has  received  several 
different  names  by  different  authors,  as  the  hydrargj  ria 
of  Alley,  the  eczema  mercuriale  of  Pearson,  the  erythe- 
ma mercuriale  of  Spens,  the  mercurial  lepra  of  Mori- 
arty,  &c.,  is  sometimes  compounded  with  other  disor- 
ders of  an  eruptive  character,  supposed  to  arise  from 
a syphilitic  origin.  But  in  adverting  to  the  various 
causes  which  exert  their  influence  in  producing  affec- 
tions of  the  skin  resembling  that  under  notice,  we 
must  not  omit  to  remember  the  modifying  operation  of  a 
cachectic  condition  of  the  body,  and  that,  independently 
of  mercury,  occasionally  other  agents  are  capable  of 
producing  like  morbid  appearances.  These  disordered 
changes  are  often  difficult  to  discriminate,  and  can  per- 
haps only  be  known  by  the  history  of  the  case,  and  by 
a course  of  experimental  treatment.  Mr.  Carmichael 
has  well  pointed  out  that  diseases  likely  to  be  con- 
founded with  syphilis,  which  arise  spontaneously  from 
a disordered  state  of  the  constitution,  frequently  as- 
sume the  form  of  the  tubercular  eruption,  and  he  adds, 

“ before  ulceration  occurs  I have  seldom  been  able  to 
distinguish  this  spontaneous  disease  from  that  arising 
from  a venereal  infection.”  Hence,  while  in  the  mercu- 
rial erythema  mercury  will  often  aggravate  the  evil ; in 
that  species  of  affection  which  occurs  spontaneously 
we  may  derive  the  greatest  benefit  from  mercurials. 
Moreover,  in  that  which  has  taken  place  in  the  syphi- 
litic habit,  mercury  may  do  much  harm  from  the  pre- 
vious injudicious  use  of  this  remedy.  Hence,  too,  Bate- 
man has  given  us  an  excellent  history  of  a tubercular 
eruption  of  a syphilitic  appearance,  but  curable  with- 
out mercury, — (See  Medico-Chirurg.  Trans,  vol.  5.) 
The  history  of  the  mercurial  eczema  is  perhaps  best 
given  us  by  Pearson.  Examined  by  the  magnifying- 
glass,  the  eruption  appears  distinctly  vesicular,  though 
by  the  naked  eye  they  can  scarcely  be  distinguished. 
Notwithstanding  the  observation  of  Mr.  Pearson,  the 
disorder  sometimes  proves  fatal,  and  Alley  tells  us 
that  of  forty-three  cases  which  he  witnes.sed  within 
ten  years  eight  patients  died.  The  morbid  effects  of 
mercury  do  not  seem  to  depend  upon  the  quantity  gi- 
ven or  the  preparation  administered.  The  mercurial 
erj'thema  may  arise  from  calomel  or  corrosive  subli- 
mate, from  a few  grains  of  the  former  as  well  as  from 
a few  drops  of  a solution  of  the  latter.  Hence  every 
practitioner  is  aware  bow  serious  are  at  times  the  mis- 
chiefs of  the  mildest  mercurial  preparations,  even  in 
small  doses,  in  some  constitutions ; and  the  same  re- 
mark applies  to  the  mercurial  force  that  is  requisite  in 
inducing  salivation.  From  a careful  examination  of 
the  recorded  cases  of  the  mercurial  erythema.  Professor 
Francis  gives  it  as  his  result,  that  the  disease  is  of 
more  frequent  origin  from  the  external  application  of 
mercury  than  from  its  internal  administration,  and  in- 
asmuch as  unguents  are  most  frequently  applied  inside 
of  the  thighs,  so  we  find  the  disorder  very  commoidy 
to  commence  at  tho.se  parts.  Mr.  Carmichael  has  done 
great  public  service  by  the  facts  and  reasonings  with 
which  he  has  set  forth  the  advantage  of  antimonials 
in  the  mercurial  erythema,  and  accordingly  the  Plum- 
mer's pill  is  in  some  degree  restored  to  favour  again. 
Small  doses  of  the  antimonium  tartarizatum  are  also 
among  the  best  alteratives  for  the  mercurial  erythema, 
and  these  are  to  be  given  for  sometime  with  occasional  1 
intemitHsions.  We  are  to  keep  in  mind  the  singular  1 
occurrence  that  in  some  constitutions  antiinonir.l.';  will  , 


excite  the  salivary  discharge,  as  remarked  by  Dr.  Fran- 
cis ; yet  this  circumstance,  of  rare  occurrence  indeed, 
may  be  considered  as  the  occasional  cause  of  a more 
speedy  cure.  The  pulvis  ipecacuanha  in  doses  of  two  or 
three  grains  is  also  serviceable.  It  may  be  here  stated  that 
a decoction  of  parsley  (ap rim  petroeh/mrn)  has  some- 
times been  of  service  as  a lotion  for  the  erythema  mer- 
curiale; It  was  the  favourite  prescription  in  these  cases 
of  a distinguished  southern  practitioner,  who  was  re- 
markably successful  in  the  treatment  of  this  disease ; 
and  the  remedy  has  proved  efficient  in  other  hands.  A 
weak  solution  of  the  chloruret  of  lime  will  often  induce 
a most  salutary  change.—  Reese.] 

ESCHAR.  (From  iaxapow,  to  fonn  a scab  or  crust.) 
This  tenn  is  applied  to  a dry  crust,  Ibrined  by  a portion 
of  the  solids  deprived  of  life.  When  any  living  part 
has  been  burned  by  the  actual  or  potential  cautery,  all 
that  has  been  submitted  to  the  action  of  this  applica- 
tion loses  its  sensibility  and  vital  principle,  becomes 
hard,  rough  on  the  surface,  and  of  a black  or  gray  co- 
lour, forming  what  is  properly  named  an  eschar,  a 
slough,  produced  by  caustics  or  actual  fire. 

ESCHAROTICS.  (From  iaxapdio,  to  form  a crust 
over.)  Applications  which  form  an  eschar,  or  deaden 
the  surface  on  which  they  are  put.  By  escharotics, 
however,  surgeons  commonly  understand  the  milder 
kinds  of  caustics,  such  as  the  h ydrargyri  nitrico-oxy- 
dum,  subacetate  of  copper,  <S  c. 

EX^RESIS.  (From  elaipio,  to  remove.)  One  of 
the  divisions  of  surgery  adopted  by  the  old  surgeons; 
the  term  implies  the  removal  of  parts. 

EXCORIATION.  (From  excorio,  to  take  off  the 
skin.)  A separation  of  the  cuticle  ; a soreness,  merely 
affecting  the  surface  of  the  skin. 

EXFOI.IATION.  (From  exfolio,  to  cast  the  leaf.) 
The  separation  of  a dead  piece  of  bone  from  the  living 
is  termed  exfoliation. 

One  part  of  a bone  is  never  separated  from  another 
by  the  rotting  of  the  dead  jiart,  for  what  comes  away 
is  as  firm  as  it  ever  was.  Exfoliation  takes  place  with 
most  expedition  in  bones  which  have  the  fewest  cells, 
and  whose  texture  is  the  closest.  Before  any  part  of  a 
bone  can  be  thrown  off  by  exfoliation,  it  must  be  dead. 
But  even  then,  till  the  process  of  exfoliation  begins, 
the  bone  adheres  as  strongly  as  ever,  and  would  re- 
main for  years  before  it  could  be  separated  by  putrefac- 
tion alone.  The  human  bones  are  composed  of  two 
substances,  viz.  a true  animal  matter  and  an  earthy 
one,  the  phosphate  of  lime,  which  are  only  mixed  with 
each  other.  A dead  bone  acts  on  the  system  in  the 
same  manner  as  any  other  extraneous  body.  It  stimu- 
lates the  adjacent  living  parts,  in  consequence  of  which, 
such  a process  is  begun,  as  must  terminate  in  its  being 
thrown  off.  The  effects  of  this  stimulus  are,  first, 
that  the  living  adjacent  bone  becomes  more  vascular ; 
a circumstance  which  always  takes  place  when  a part 
has  more  to  do  than  is  just  sufficient  for  the  sujiport  of 
life.  Secondly,  that  the  earth  of  the  living  part,  when 
it  is  in  contact  with  the  dead  bone,  is  absorbed ; and 
there  the  bone  becomes  softer,  and  adheres  by  its  ani- 
mal m.atter  only.  As  Mr.  Wilson  has  stated,  “ before 
any  mark  of  separation  is  seen  on  the  surface,  the  livr 
ing  bone  surrounding  the  dead  for  the  extent  of  a mere 
line,  has  become  as  soft  as  if  it  had  been  steejied  in 
acid  ” — {On  the  Skeleton  and  Diseases  of  the  Bones,  p. 
281,  Svo.  lyynd.  1820.)  Thirdly,  that  the  living  animal 
part  is  at  last  absorbed  along  the  surface  of  contact ; 
this  part  of  the  process  commences,  however,  long  be- 
fore the  la.st  is  finished ; and  both  of  them  begin  at 
the  surface;  though  in  their  course,  t'uey  do  not  every 
where  take  place  in  an  equal  degree  at  the  same  time. 
Fourthly,  in  proportion  to  the  waste  made  by  the  last 
part  of  the  process,  granulations  arise  from  the  living 
sujpace,  and  fill  up  the  intermediate  space,  so  that  there 
is  no  vacuum.  These  different  stages  together  consti- 
tute ulceration.  When  any  part  of  a bone  is  once 
loose,  it  is  pushed  to  the  surface  in  the  same  manner 
as  most  other  inanimate  botlies  would  be,  and  this 
stage  is  partly  mechanical  and  partly  a continuation 
of  ulceration.  A proof  of  the  third  stage  above  men- 
tioned may  be  derived  from  cases  in  which  i)eoplc  die 
while  exfoliation  is  going  on.  A small  groove  or  worm- 
eaten  canal  can  then  be  discovered,  which  becoine.s 
gradually  deej^er,  and  follows  the  irregularities  of  the 
1 living  and  d<'ad  surfaces.  After  the  aj)plication  of  the 
1 trepan,  a cir'-n'ar  piece  of  bone  i.-;  frc.pn-nr’y  throwm 
. off  \,)ii-,’h  is  al\vu}s  less  than  the  sj'Qce  from  wnich  it 


EXF 


EXO 


359 


■came.  This,  as  Mr.  Hunter  observed,  would  never  be 
the  case  were  there  not  a loss  of  substance.  : 

“ Although  (says  Mr.  Wilson)  in  general  the  absorp- 
tion takes  place  in  the  living  bone,  it  still  appears,  that 
under  peculiar  circumstances,  the  absorbing  vessels 
have  the  power  of  acting  on  and  removing  the  sub- 
stance of  dead  bone.  This  happens  after  the  dead  part 
has  been  separated  from  the  living,  and  when,  from  its 
shape,  and  the  form  of  the  living  surrounding  bone,  it 
is  prevented  from  obtaining  a passage  to  the  surface 
of  the  body  ; as  in  exfoliations  of  the  cranium,  when 
the  inner  table  of  the  exfoliated  part  is  broader  and 
wider  than  the  outer  table.” — {On  the  Skeleton,  S c.  p. 
282.)  In  very  hard  bones,  the  colour  of  the  dead  exfo- 
liating portion  is  generally  white ; but  in  softer  bones, 
it  is  yellow,  dark,  and  sometimes  black. — {Wilson,  op. 
cit.) 

It  was  anciently  believed  that  whenever  a bone  was 
denuded,  the  exposed  surface  must  necessarily  exfoli- 
ate ; and  tliis  being  taken  for  granted,  the  old  surgeons 
used  to  put  immediately  in  practice  whatever  they 
thought  best  calculated  to  bring  on  an  exfoliation  as 
quickly  as  possible.  For  this  purpose,  the  actual  cau- 
tery was  usually  applied  to  the  part  of  the  bone  which 
was  uncovered  ; and  as,  under  such  treatment,  a por- 
tion of  the  bone  was  of  course  killed  and  then  exfo- 
liated, the  prejudiced  practitioner  believed,  that  he  had 
only  accelerated  a process  which  must  of  necessity 
have  followed  in  a more  slow  and  tedious  manner. 

According  to  Mr.  Hunter,  neither  caustics  nor  the  ac- 
tual cautery  hasten  exfoliation ; they  only  produce 
death  in  a part  of  the  bone,  which  is  the  first  step  to- 
wards exfoliation ; and  if  they  ever  hasten  exfoliation 
when  the  bone  is  already  dead,  it  must  be  by  producing 
inflammation  in  the  adjacent  living  bone ; a change 
that  makes  it  exert  a power  of  which  it  was  previously 
incapable. 

Exfoliation  is  not  a necessary  consequence  of  a bone 
being  laid  bare,  and  deprived  of  its  periosteum.  If  the 
bone  be  in  other  respects  uninjured , healthy,  and  enjoy 
a vigorous  circulation  of  blood  through  its  texture, 
granulations  will  be  generated  on  the  surface  of  such 
bone,  and  they  will  cover  and  firmly  adhere  to  it,  with- 
out the  smallest  exfoliation  being  thrown  off ; espe- 
cially in  young  subjects.  But  if  caustic,  stimulating, 
or  drying  applications  be  made  use  of,  or  the  bone  be 
left  for  a considerable  time  exposed,  the  circulation  in 
the  superficial  portion  of  it  will  necessarily  be  dis- 
turbed and  destroyed,  and  that  part  of  the  surface 
through  which  the  circulation  ceases  to  be  carried 
on,  will  be  separated  and  cast  off  by  the  process  of  ex- 
foliation. 

If  any  application  to  an  exfoliating  portion  of  bone 
be  at  all  efficacious,  it  must  be  one  which  will  stop  the 
mortification  in  the  affected  bone,  and  promote  the  ab- 
sorption of  those  particles  of  phosphate  of  lime  which 
form  the  connexion  between  that  which  is  living  and 
that  which  is  actually  dead.  And  as  the  bone  dies 
from  the  same  causes  as  the  soft  parts  mortify,  we 
should  at  least  follow  in  practice  the  same  principles 
which  we  adopt  in  the  latter  instance  ; and  though 
from  the  inferior  vascularity  and  vital  power  of  bones, 
we  cannot  expect  surgery  to  have  as  much  control 
over  their  affections  as  over  those  of  the  soft  parts,  yet 
every  good  will  thus  be  obtained  which  it  is  possible 
to  acquire.  Attention  to  such  principles  will  at  least 
teach  us  to  refrain  from  making  the  death  of  part  of  a 
bone  more  extensive  than  it  would  be,  if  the  cautery, 
caustics,  and  strong  astringents  were  not  employed. 

The  be.st  mode  of  attempting  to  prevent  an  exfolia- 
tion from  occurring  at  all  in  a bone  that  has  been  ex- 
posed by  a wound  is,  to  cover  the  part  again  as  soon 
as  possible  with  the  flesh  which  has  been  detached 
from  it.  This,  as  I shall  hereafter  notice  (see  Head, 
Injuries  of),  may  generally  be  practised  with  advan- 
tage, when  the  scalp  has  been  detached  from  the  cra- 
iiium,  provided  the  flap  still  retain  even  the  most  li- 
mited connexion  with  the  rest  of  the  integuments. 

When  the  exposed  bone  cannot  be  covered,  it  should 
be  dressed  with  the  mildest  and  simplest  applications, 
with  plain  lint,  or  lint  spread  with  the  unguentum  ce- 
taceum. 

The  dead  pieces  of  bone,  when  very  tedious  in  exfo- 
liating, when  wedged  in  the  sub.stance  of  the  surround- 
ing livipg  bone,  and  when  so  situated  as  to  admit  of 
tieing  safely  sawed  or  cut  away,  may  sometimes  be  ad- 
?/antageously  removed  in  this  manner.— (See  Caries 


and  Necrosis.)  In  such  operations,  Mr.  Hey’s  saws 
may  be  employed  with  great  convenience ; and  where 
these  are  not  applicable,  that  invented  by  Mr.  Machell, 
and  described  in  Sir  A.  Cooper’s  Surgical  Essays,  or 
another  devised  b^rGraefe,  and  explained  by  Schwalb 
{De  Serra  Orbiculari,  4to.  Berol,  1819),  deserve  to  be 
recollected. 

In  speaking  of  necrosis,  I shall  have  occasion  to 
notice  the  efficacy  of  blisters,  kept  open  with  the  savin 
cerate,  in  quickening  the  process  by  w'hich  dead  por- 
tions of  bone  are  loosened,  as  particularly  pointed  out 
by  the  late  Mr.  Crowther,  in  his  work  on  the  white- 
swelling. 

Tenon  published  three  Memoirs  on  the  Exfoliation, 
of  Bones.  The  frst  two  are  inserted  at  pages  372  and 
403,  Mtm.de  UAcad.  des  Sciences,  1758  ; the  third  at  p. 
223  of  the  same  work,  /or  1760.  P.  Poissonier,  An  re- 
centi  vulnere  nudatis  ossibus  exfoliatis?  conclusio 
negans,  Mo.  Parisii,  1760.  Journ.  de  Mid.  par  M. 
Roux,  t.M,p.  801 ; t.  32,  p.  181 ; t.  33,  p.  168 ; t.  36,  p. 
b37 ; t.  38,  p.  153 ; t.  39,  p.  432.  Theden,  Neue  Benier- 
kungen.  S c.  kap.  3,  %vo.  Berlin,  1782.  Trans,  for  the 
Improvement  of  Med.  and  Chir.  Knowledge,  vol.  2,  p.. 
277,  S'C.  Wiedmann,  in  his  excellent  book,  entitled,  De 
Necrosi  Ossium,  has  given  an  account  of  the  various 
opinions  of  several  distinguished  writers,  concerning 
the  way  in  which  a dead  portion  of  bone  is  separated 
from  the  living  part ; and  he  has  refuted  many  erro- 
neous doctrines  set  up  by  Hippocrates,  Van  Swieten, 
B.  Bell,  S-c.  Seep.  23,  et  seq.  op.  cit.  Diet,  des  Sciences 
Med.  art.  Exfoliation.  J.  Thompson's  Lectures  on 
Inflammation,  p.  394.  398.  P.  Boulay,  Sur  VExfolia- 
tion  des  Os,  Mo.  Paris,  1814.  J.  Wilson,  on  the  Struc- 
ture and  Physiology  of  the  Skeleton,  and  on  the  Dis- 
eases of  the  Bones,  tVc.  p.  230,  &-c.  8vo.  Land.  1820. 
Liston's  Essay  on  Caries,  Ac.  in  Edin.  Med.  Surg. 
Journ.  No.  78. 

EXOMPHALOS.  (From  f(,  out  of,  and  diJupa'Xoi, 
the  navel.)  A hernia  at  or  near  the  navel. 

EXOPHTHALMIA.  (From  i (,  out  of,  and  6^0a\pbs, 
the  eye.) 

In  the  case  to  which  the  most  judicious  surgical 
writers  apply  the  terms  exophthalmia,  ophthalmoptosis, 
ptosis  bulbi  oculi,  the  eyeball  is  of  its  natural  size,  and 
free  from  disease ; it  merely  changes  its  situation,  and 
partly  or  completely  protrudes  from  the  orbit.  It  is 
only  confusing  the  subject  to  consider,  as  specimens  of 
this  disease,  the  cases  in  which  the  globe  of  the  eye  is 
affected  with  enlargement,  and  on  that  account  projects 
from  the  orbit  in  a preternatural  degree,  as  happens  in 
hydrophthalmia,  staphyloma,  and  cancerous  diseases 
of  the  eye.  When  the  globe  of  the  eye  is  pushed  en- 
tirely out  of  the  orbit,  it  generally  lies  upon  the  temple 
or  cheek,  and  vision  is  totally  destroyed.  There  are 
instances,  however,  in  which  a considerable  degree  of 
sight  was  recovered,  notwithstanding  the  exophthalrnia 
was  complete,  and  had  lasted  several  years. — {Hope, 
in  Phil.  Trans,  for  1744.  Richter's  Bibl.  band.  4. 
p.  .343.) 

There  are  three  descriptions  of  causes  which  may 
occasion  exophthalmia. 

1 . Tlie  first  and  least  common  is  a violent  concussion 
of  the  head.  A man  fell  from  a height  of  about  fifteen 
or  sixteen  feet,  and  pitched  upon  his  head.  The  rigltt 
eye  was  forced  out  of  its  socket,  and  hung  over  the 
cheek.  The  patient  was  deprived  of  his  senses  imme- 
diately after  the  accident,  and  affected  W’ith  coma. 
There  was  a contusion  over  the  right  parietal  bone,  but 
no  fracture.  The  eye  spontaneously  resumed  its  na- 
tural position  a short  time  after  the  accident,  and  in  the 
course  of  a month,  with  the  assistance  of  low  diet  and 
repeated  bleeding,  the  cure  was  completed. — {Mhn.  de 
I'Acad.  de  Chirurgie,  t.  1,  p.  198,  Mo.)  It  is  alleged, 
that  the  eye  has  been  forced  out  of  the  orbit  in  a violent 
fit  of  sneezing.  But  such  cases,  says  Richter,  are  very 
uncommon,  and  always  imply  a considerable  relaxa- 
tion of  those  parts  which  serve  to  retain  the  eye  in  its 
socket,  or  some  other  predisposing  causes,  to  which 
attention  should  be  paid  in  the  treatment. — {Richter, 
Anfangsgr.  der  Wundarzu.  b.  3,  p.  407,  ed.  1795.) 

2.  A far  more  frequent  cause  of  exoplithalnha  is  a 
thrust  in  the  eye  with  an  instrument,  which  is  narrow 
enough  to  pass  between  the  orbit  and  the  eyeball,  so  as 
to  push  the  latter  out  of  its  place. 

A stick,  a tobacco-pipe  {White's  Cases  in  Surgery, 
p.  131),  a foil,  Ac.  may  caii.se  the  accident.  Repeated 
experience  proves,  sajs  Richter,  that  in  such  cases, 


360 


EXOPHTIIALMIA. 


though  the  optic  nerve  and  muscles  of  the  eye  may  be 
forcibly  stretched,  the  imerior  parts  of  the  organ  seri- 
ously injured,  and  the  dislocated  eye  generally  deprived 
of  the  faculty  of  seeing,  yet,  when  the  organ  is  replaced 
as  speedily  as  possible,  it  not  only  sometimes  recovers 
its  natural  motion,  but  also  its  original  power  ot  vision. 
— (See  ScuUet.  Appendix,  obs.  69.  Covillard,  obs.  27. 
BorelltLS,centur.  3,  o^s.  54.  Rhodius,  centur.  1,  obs. 
84.  White's  Cases,  p.  131.)  But  before  we  reduce  the 
eye,  Richter  advises  us  always  to  examine  th  instru- 
ment wliich  was  pushed  into  the  orbit ; as,  when  it  is 
brittle,  a fragment  of  it  may  remain  behind  in  the 
socket,  and  require  to  be  extracted  by  means  of  the 
finger  or  a probe.  When  the  weapon  is  pointed  or 
hard,  it  sometimes  pierces  the  bones  of  the  orbit,  and 
Sinters  the  brain,  nose,  or  antrum.  In  the  first  case, 
which  is  often  difficult  to  ascertain  immediately,  though 
alter  a time  it  is  generally  rendered  plain  enough  by 
the  symptoms  induced,  the  consequences  are  mostly 
fatal.  In  the  other  two  cases,  although  the  danger  is 
not  pressing,  yet  the  surgeon  should  be  very  attentive, 
in  the  event  of  suppuration,  to  procure  and  maintain  a 
re  dy  outlet  for  the  matter. 

There  is  generally  little  difficulty  in  replacing  the  eye. 
Frequently  it  returns  of  itself  into  its  natural  situation 
again,  as  soon  as  any  trivial  obstacles  to  its  reduction 
are  removed ; and  in  other  instances,  it  easily  admits 
of  being  put  into  its  proper  place  with  the  hand.  The 
indication,  says  Richter,  is  always  accomplished  with 
more  facility  the  sooner  it  is  attempted.  When  the 
protrusion  has  existed  several  days.,  and  the  eye  and 
other  parts  in  the  orbit  are  already  inflamed,  Richter  re- 
commends us  to  endeavour  to  diminish  the  inflammation 
by  general  antiphlogistic  means  and  external  emollient 
applications,  before  we  try  to  replace  the  eye ; and  the 
reduction  of  this  organ  is  afterward  to  be  effected  in  a 
gradual  manner.  When  the  optic  nerve,  and  one  or 
more  of  the  muscles  of  the  eye  are  torn,  no  hope  can 
be  entertained  that  the  eyesight  and  motion  of  the 
organ  w'ill  ever  be  regained.  But  this  degree  of  injury, 
as  Richter  observes,  cannot  always  be  immediately 
detected,  because  the  optic  nerve  and  muscles  are  con- 
cealed by  the  conjunctiva ; and  if  the  nature  of  thejiase 
were  known,  still  it  would  be  advisable  to  replace  the 
eyeball,  and  endeavour  to  prevent  the  disfigurement 
•which  its  loss  would  unavoidably  produce.  But,  says 
Richter,  it  is  necessary,  especially  if  the  parts  behind 
the  eyeball  have  suffered  severely,  to  use  such  means 
as  will  ensure  a ready  escape  for  the  matter  which  may 
possibly  form.  Though  Richter  offers  the  opinion,  it  is 
difficult  to  conceive  how  the  -violence  of  the  injury  of 
the  conjunctiva,  muscles,  and  nerve  can  ever  render  it 
most  prudent  not  to  reduce  the  part  until  after  suppu- 
ration has  taken  place.  Richter  thinks  that  a surgeon 
may  the  more  readily  make  up  his  mind  to  this  con- 
duct, as  many  cases  have  proved  that  the  eyeball,  even 
after  being  dislocated  from  the  orbit  a long  while,  lia.s 
been  easily  replaced.  In  other  instances,  the  parts 
which  connect  the  eye  with  the  orbit  may  be  so  torn 
and  injured,  that  it  will  be  most  advisable  to  extirpate 
the  organ. 

Richter  maintains,  however,  that  this  should  never 
be  done  when  there  is  the  least  chance  of  saving  the 
eye.  If  the  bones  in  the  orbit  be  fractured,  the  reduc- 
tion must  not  be  made  until  the  indications  which  this 
complication  presents  have  been  fulfilled. 

When,  says  Richter,  the  instrument  with  which  the 
eye  has  been  pushed  out  of  its  socket  is  blunt  and 
thick,  like  a finger,  a stick,  a foil,  &c.,  the  eyeball  itself 
always  sustains  a violent  contusion,  which  brings  on 
vehement  inflammation,  and  lessens  or  destroys  all 
hope  that  after  the  reduction  the  eyesight  will  be 
restored.  Sometimes,  in  these  cases,  an  extravasation 
of  blood  in  the  orbit  occurs,  the  iris  is  lacerated,  the 
cornea  burst,  and  i part  of  the  humours  of  the  eye  dis- 
charged. Although,  under  such  circumstances,  it  is 
scarcely  to  be  expected  that  the  eyesight  can  be  reco- 
vered, yet  it  is  proper  to  reduce  the  eye,  because,  should 
the  organ  be  destroyed  by  suppuration,  or  the  loss  of 
its  humours,  the  deformity  may  be  obviated  by  an  arti- 
ficial eye,  which  is  not  the  case  wlien  the  eye  has  been 
cut  away.  It  is  also  to  be  considered,  that  the  mischief 
olten  seems  to  be  worse  than  it  really  is,  and  the  eye- 
sight is  sometimes  regained,  contrary  to  all  expecta- 
tion. 

After  the  reduction  of  the  eye,  the  first  care  of  the 
surgeon  should  be  to  prevent  and  dimini.-b  inilamina-  1 


tion.  In  some  cases,  the  inflammation  i.s  slight ; 
while  in  others,  especially  when  the  eyeball  has  been 
severely  struck,  it  i.s  extremely  violent.  All  the  usual 
antiphlogistic  means,  both  general  and  topical,  are  to 
be  employed ; and  of  the  latter,  Richter  says,  astrin- 
gents are  the  best,  a^  the  inflammation  arises  from  the 
contusion  and  stretching  which  the  parts  have  suflered. 
The  possible  consequences  of  inflammation,  such  as 
suppuration,  opacity  of  the  cornea,  Ac.,  are  to  be  treated 
according  to  the  rules  laid  down  in  other  parts  of  this 
Dictionary. — (See  particularly  Cornea,  Opacity  of; 
Hypopium;  Ophthalmy.)  In  general,  the  sight  is  re- 
stored in  proportion  as  the  inflammation  is  diminished. 
Should  this  not  happen  after  the  ophthalmy  has  been 
entirely  removed,  the  surgeon  must  try  what  effect 
such  remedies  as  stimulate  the  nerves  will  have  upon 
the  optic  nerve.  An  account  of  the  most  eligible  me- 
dicines for  this  purpose  will  be  found  in  the  article 
Amaurosis. 

3.  The  third  cause  of  exophthalmia  is  a preternatural 
tumour  in  the  orbit  or  neighbouring  parts.  The  swell- 
ing, as  it  enlarges,  gradually  pushes  the  eyeball  out  of 
its  socket.  I'lie  tumours,  which  may  be  formed  in  the 
orbit,  are  of  several  kinds.  The  principal,  however, 
are  encysted  swellings,  which  contain  either  fat,  an 
aqueous  fluid,  a pappy  sub.stance,  or  a thick  matter. 
Sometimes  the  cellular  substance  in  the  orbit  is  affected 
with  induration  and  swelling,  so  as  to  force  the  eye 
partly  or  completely  out  of  this  cavity. 

According  to  Mr.  Travers,  adipous  swellings  occupy 
the  interspace  of  the  recti  muscles,  emerge  between 
the  globe  and  the  orbitar  circumference,  and  have  an 
oblong  figure.  When  the  conjunctiva  is  freely  divided, 
the  fatty  mass  is  easily  drawn  forwards  with  a hook, 
and  dissected  out. — (Synopsis  of  Diseases  of  the  Eye, 
p.  225.) 

An  abscess  in  the  orbit  may  cause  a protrusion  of 
the  eyeball.— (PeZ/ier.)  Exostoses  in  the  orbit  may 
have  the  sam.e  effect.  Sir  Astley  Cooper  has  related 
one  case  which  proved  fatal,  in  consequence  of  the 
exostosis  making  its  way  to  the  brain  through  the 
orbitar  process  of  the  os  frontis. — (Surgical  Essays, 
part  l,p.  157.)  Mr.  Guthrie  has  seen  two  instances: 
in  one,  the  disease  attained  the  size  of  a large  marble, 
and  then  became  stationary  ; in  the  other,  it  was  much 
larger,  and  a portion  of  it  had  been  ineffectually  reg 
moved  by  means  of  a hot  iron,  which  increased  the 
inconvenience  without  giving  any  relief.  Hence,  if  an 
operation  were  deemed  advisable,  Mr  Guthrie  would 
prefer  the  cautious  use  of  a small  chisel  or  saw. — (Ope- 
rative Surgery  of  the  Eye,  p.  154.)  This  author  is,  at 
the  same  time,  aware  of  the  case  in  which  Mr.  Bras- 
sant  brought  about  the  exfoliation  of  a considerable 
part  of  an  exostosis  of  the  os  jilanum  and  imernal 
angular  process  with  caustic,  -so  that  the  eye  returned 
into  its  place,  and  the  cure  was  completed.— (M  m.  de 
I' Acad,  de  Chir.  t.  5,  p.  171,  4Zo.)  In  the  records  of 
surgery  may  be  found  many  examples,  in  which  the 
displacement  of  the  eye  was  produced  by  a tumour  that 
grew  out  of  tlie  frontal  sinus. — (See  Langtvbeck's 
Neue  Bibl.  b.  2,p.  247.)  In  some  cases,  in  consequence 
of  suppuration  in  the  antrum,  the  lower  part  of  the 
orbk  is  raised,  and  the  eye  forced  out  of  its  place.  Fun- 
gous diseases  of  the  antrum  are  very  liable  to  occasion 
the  same  mischief. — (See  Parisian  ChirurgicaL  Journ. 
vol.  l,p.  104,  cVc.) 

Schmidt  records  two  cases  of  exophthalmia,  produc.ed 
by  a hydatid  of  the  lachrymal  gland.  One  had  a fatal 
tennnnation  ; but  in  the  other,  a puncture  gave  vent  to 
an  ounce  of  clear  fluid,  and  cured  the  I'rotrusion  of  the 
eye;  but  the  eyesight  was  lost.— (leier  die  Krank- 
heiten  des  Thrdnenorgans,  p.  54.)  Farther  particulars 
of  the  latter  case  may  be  seen  in  Mr.  Guthrie's  w ork, 
p.  157. 

Mot  long  ago,  Langenbeck  extracted  from  the  sinus 
frontalis  of  a girl  a large  hydatid,  which  had  forced 
the  outer  fable  considerably  Ibrwards,  and  depressed 
the  orbitar  process  of  the  os  frontis  so  far,  that  the  eye- 
ball was  jirojielled  as  low  as  the  extremity  of  the  nose. 
After  the  front  of  the  sinus  bad  been  poi  ibrated,  and 
the  hydatid  removed,  there  was  a cavity  left  two  inches 
and  a half  in  depth. — (Nnte  Uibl.  h.  2.  p.  247.  Hanm  er, 
1819.)  My  friend  Mr.  Lawrence  some  time  ago  men- 
tioned to  me  a remarkable  case,  which  ineser.tcd  itself 
at  the  London  Eye  Inlirtnnrv  : it  was  an  exoiilithalmia, 
which  arose  from  a col'ect'on  .-'f  hydatids  in  tt-e  rrhit. 
and  \»  as  cured  by  making  an  incision,  and  aacrwaid 


EXO 


EXO 


361 


promoting  their  discharge.  In  all  these  examples,  the 
eyeball  is  displaced  from  the  orbit  gradually,  and  vision 
is  at  length  impeded.  ^Instances,  however,  are  on  re- 
cord, where  the  sight  was  never  lost,  though  the  eye 
was  protruded  for  years. — (See  Richter's  Chirurg.  Bibli- 
othek,  band  4,  stuck  2,  p.  243.  White's  Cases  in  Sur- 
gery, p.  135.)  In  an  instanee  lately  reported,  the  sight 
was  not  at  all  lessened,  and  the  iris  retained  its  natural 
mobility. — {Langenbeck,  Neue  Eibl.  b.  2,  p.  245.) 

Experience  proves  also,  that  after  the  reduction,  the 
motion  of  the  eye  and  power  of  seeing  may  be  re- 
gained, in  cases  where  the  eye  has  been  gradually 
pushed  out  of  the  orbit,  and  been  displaced  a consider- 
able time,  even  as  long  as  several  years,  during  all 
which  period  vision  was  lost. — {Acrell.  Brocklesby,  in 
Med.  Obs.  and  Inquiries,  vol.  4,  p.  371.)  Langenbeck 
relates  a very  curious  case  of  exophthalmia  from  a 
steatoma  in  the  orbit,  wiiere,  though  vision  was  en- 
tirely prevented  during  the  displacement,  the  pupil 
was  of  its  regular  shape,  and  the  iris  capable  of  mo- 
tion : after  the  extirpation  of  the  tumour,  the  eyesight 
became  so  good,  that  the  patient  couid  discern  the 
smallest  objects.— (iNTtue  Bibl.  b.  2,  p.  240.)  In  order 
to  reduce  the  eye  into  its  natural  position,  it  is  neces- 
sary to  remove  the  cause  by  which  its  protiu.sion  is 
occa.sioned.  Suppuration  and  fungous  tumours  in  the 
antrum  mu.st  be  treated  according  to  directions  laid 
down  in  the  article  Antrum.  After  the  cure  of  such 
diseases,  the  antrum  is  often  reduced  to  its  natural  di- 
mensions, and  in  this  circumstance,  the  orbit  may  be- 
\;ome  so  wide,  that  the  eyeball  will  return  into  it  again. 
Should  this  not  happen,  the  extirpation  of  the  organ  will 
be  proper.  The  induration  and  swelling  of  the  cellu- 
lar substance  in  the  orbit  may  be  sometimes  dispersed 
by  means  of  mercury. — (Louis,  Sur  plusieurs  Maladies 
du  Globe  de  I'tEil,  in  M m.  de  I'Acad.  Royale  de  Chi- 
rurgie,  t.  13,  id.  12/no.)  When  such  treatment  fails, 
we  are  recommended  to  extirpate  the  eye.— (Kzc/iter, 
Anfangsgr.  der  Wundarzn.  b.  3,  p.  413.)  Exostoses 
situated  in  the  anterior  part  of  the  orbit  may  some- 
times be  removed.  The  continental  surgeons  generally 
advise  us  to  expose  the  tumour  by  an  incision,  and  to 
apply  caustic  or  the  actual  cautery  to  it,  in  order  to  kill 
the  protuberant  part  of  the  bone  and  make  it  exfoliate. 
In  this  country,  most  practitioners  would  prefer  the 
employment  of  cutting  instruments  for  removing  such 
exostoses.  When,  however,  the  tumour  lies  deeply  in 
the  orbit,  if  it  cannot  be  got  at,  and  it  should  resist  the 
effect  of  mercurial  medicines  and  mezereon,  we  are  di- 
rected to  e.xtirpate  the  eye.— (Richter,  op.  et  loco  cit.) 
Abscesses  in  the  orbit  ought  to  be  opened,  and  after 
this  has  been  done,  the  eye  generally  returns  into  its 
proper  position.— (PelZier.)  When  encysted  tumours 
in  the  orbit  admit  of  being  extirpated  in  the  customary 
manner,  the  plan  should  be  adopted ; but  when  this 
cannot  be  done,  Richter’s  advice  may  be  followed, 
which  is  to  open  them,  press  out  the  contained  matter, 
and  afterward  extract  the  cyst.  Considerable  diffi- 
culty, however,  frequently  attends  every  effort  to  re- 
move the  whole  cyst,  and  unless  this  be  done,  a perma- 
nent cicatrization  cannot  be  expected.— f See  Travers's 
Synopsis,  p.  225.  See  Tumours,  Encysted.) 

< In  account  of  the  vicinity  of  the  brain,  and  the  com- 
munication between  the  parts  within  the  orbit  and  the 
dura  mater,  the  extirpation  of  tumours  from  that  cavity 
is  not  exempt  from  risk  of  fatal  consequences,  as  two 
cases  recently  published  by  Langenbeck,  fully  prove.— 
(Neue  Bibl.  b.  2,  p.  241.  244.)  A young  lady  was  re- 
ferred to  Mr.  Lawrence  and  myself,  some  time  ago,  by 
Mr.  .Maul,  of  Southampton,  for  advice  respecting  a tu- 
mour occupying  the  inner  and  upper  portion  of  the 
orbit,  and  attended  with  a degree  of  exophthalmia,  con- 
stant exacerbation  at  the  period  of  the  menses,  and  oc- 
casionally double  vision.— (See  Diplopia.)  We  re- 
fr.ained  from  advLsing  any  immediate  attempt  at  extir- 
pation, the  swelling  being  so  firm  and  immoveable, 
that  the  disease  was  suspected  to  be  partly  of  a bony 
nature.  However,  on  seeing  this  case  about  a fortnight 
afterward,  I was  surpri.sed  to  find  the  tumour  not 
more  than  half  its  former  size,  and  all  the  firm  and 
(what  was  conceived  to  be)  bony  induration  below  the 
superciliary  ridge  of  the  os  frontis  gone,  as  well  as  the 
exophthalrnia  and  de.'-angement  of  vision.  Some  sharji 
bony  inegularities,  however,  could  now  be  most  plainly 
felt,  projecting  in  front  of  the  diminished  swelling. 

In  a late  publication,  a memorable  ca.se  of  exophthal- 
mia is  related  by  Mr.  Travers:  the  globe  of  the  eye 


appears  to  have  been  gradually  forced  upwards  and 
outwards,  and  to  have  had  its  motions  considerably 
impeded,  in  consequence  of  the  orbit  being  partly  occu- 
pied by  two  svvellings,  which  were  of  the  nature  of  the 
aneurism  by  anastomosis. — (See  Aneurism.)  The 
swellings  could  not  have  been  removed,  without  at  the 
same  time  extirpating  the  eye.  Mr.  Travers  was  there- 
fore induced  to  try  whetlier  applying  a ligature  to 
the  carotid  artery  would  have  the  effect  of  checking 
and  curing  the  disease;  an  expectation  which  was 
warranted  by  analogous  instances,  in  which  the  growth 
of  swellings  and  their  dispersion  are  brought  about 
by  lessening  the  quantity  of  blood  determined  to  them. 
The  experiment  completely  succeeded ; the  swellings 
in  the  vicinity  of  the  eye  subsided;  the  patient  was 
freed  from  several  grievous  complaints,  to  which  she 
had  been  previously  subject;  and,  among  other  bene- 
fits, a cure  of  the  exophthalmia  was  one  result,  which 
most  interests  us  in  the  present  place.  The  ca.se  is 
also  highly  important  on  other  accounts,  and  more  par- 
ticularly as  confirming  the  fact,  that  the  carotid  artery 
may  be  tied  without  any  dangerous  effects  on  the 
brain,  and  as  proving,  that  in  cases  of  aneurism,  the 
surgeon  should  not  be  afraid  of  proceeding  to  such  an 
operation. — (See  Med.  Chir.  Trans,  vol.  2,  art.  1.)  The 
judgment  and  decision  with  which  Mr.  Travers  acted 
in  this  case,  appear  to  me  highly  meritorious. 

The  carotid  artery  was  also  tied  by  Mr.  Dalrymple, 
surgeon  at  Norwich,  in  a case  very  similar  to  the  pre- 
ceding, and  with  equal  success.— (See ilfed.  Chir.  Trans, 
vol.  &,p.  Ill,  .1,  c.) 

Mr.  Guthrie  has  seen  an  exophthalmia  on  each  side, 
the  result  of  an  aneurism  of  each  ophthalmic  artery, 
and  other  disease  in  the  orbits.— (O^/tratiue  Surgery 
of  he  Eye,  p.  158.) 

When  the  causes  of  exophthalmia  have  been  removed, 
the  eye  must  be  put  into  its  natural  situation.  If  the 
organ  has  been  long  displaced,  the  surgeo.n  often  finds 
the  fulfilment  of  this  indication  attended  with  difficulty. 
Indeed,  he  is  frequently  obliged  to  employ  methodical 
bandages  for  the  purpose  of  promoting  the  gradual  re- 
turn of  the  eye  into  the  orbit.  Yet,  even  in  such  cases, 
the  eyesight  is  often  regained  ; but  if  this  should  not 
happen  spontaneously,  stimulants  and  tonics  are  to  be 
tried.— (See  Amaurosis.) 

Fab.  Hildan.  centur.  6,  obs.  1.  Vander  Wiel,  centvr. 
2,  obs.  9.  Paw.  Obs.  Anat.  23.  Tulpius,  lib.  1,  cap.  28. 
Hope,  in  Phil.  Trans,  for  1744.  Louis,  Sur  plusieurs 
Maladies  du  Globe  de  I' ii.il,  H-c.  in  Mem.  de  I'Acad.  de 
Chirurgie,  t.  13,  in  lUmo.  Brocklesby,  in  Medical  Obs. 
and  Inquiries,  vol.  4,  p.  371.  White's  Cases  in  Sur- 
gery,  p.  131 — \35,  <Src.  Warner's  Cases  in  Surgery, 
p.  108,  edit.  3.  Lassus,  Pathologie  Chir.  t.  2,  p. 
114,  edit.  2.  Richer  and,  Nosogr.  Chir.  t.  2,p.  117,  edit, 
2.  Med.  Chir.  Trans,  ml.  2’ art.  1 ; vol.  4,  p.  316  ; and 
vol.  6,  p.  Ill,  \ c.  Richter's  Anfangsgr.  der  Wun- 
darzn. b.  3,  p.  406,  a’  c.  Gdtt.  1795.  Langenbeck,  Neue 
Bibl.  b.  2.  B.  Travers,  Synopsis  of  the  Diseases  of  the 
Eye,  p.  225,  d c.  Land.  1820.  Dr.  Montcath,  in  Weller's 
Manual,  vol.  1,  p.  195.  Petitbeau,  inJoum.  de  Med. 
par  Corvisart,  t.  14.  G.  J.  Guthrie,  Operative  Surgery 
of  the  Eye,  p.  145,  .^c.  8vo.  Lond.  1823. 

EXOSTOSIS.  (From  out  of,  and  oareov,  a bone.) 
An  exostosis  is  a tumour  formed  by  an  exuberant  growth 
of  a bony  matter  on  the  surface  of  a bone,  or,  as  Boyer 
says,  it  is  formed  by  the  more  or  less  considerable  en- 
largement of  a part  or  the  whole  of  a hom.-  (TraiU 
des  Mol.  Chir.  t.  3,p.  541.) 

If  bones  resemble  the  soft  parts  of  the  body  in  their 
structure,  they  must  resemble  them  in  their  diseases, 
and  of  course  be  liable  to  various  kinds  of  tumours. 
Nay,  an  extraordinary  increase  of  the  size  and  density 
of  all  the  bones  of  an  individual  has  been  observed, 
which  affection  ought  probably  also  to  be  classed  with 
the  disease  to  which  surgeons  usually  apply  the  term 
exostosis. 

The  generality  of  writers,  even  the  most  modern, 
have  admitted  many  diseases  among  exostoses,  which 
ought  to  be  considered  in  a very  distinct  light ; I need 
only  instance  the  spina  ventosa. 

One  division  of  exostoses  is  into  true  and  false  ; the 
former  being  of  a truly  osseous  consistence,  the  others 
being  more  or  less  hollow,  spongy  expansions  of  the 
bones,  sometimes  containing  a ipiantity  of  fteshy,  fun- 
gous matter  within  the  shell  of  the  disease.  Perios- 
toses,  or  mere  thickenings  of  the  periosteum,  are  also 
classed  among  the yhl.ve  exosto.ses  — (Diet,  des  Sciinces 


362 


EXOSTOSIS. 


Med.  t.  14,  p.  218.)  According  to  Sir  Astley  Cooper, 
exostoses  have  two  different  seats : by  periosteal  ex- 
ostosis, he  means  an  osseous  deposition  seated  between 
the  external  surface  of  the  bone  and  the  internal  sur- 
face of  the  periosteum,  and  firmly  adherent  to  both;  by 
medullary  exostosis,  he  signifies  a similar  formation, 
originating  in  the  medullary  membrane  and  cancellated 
structure  of  the  bone.  The  same  experienced  surgeon 
makes  two  other  general  divisions  of  exostoses  into 
the  cartilaginous  and  fungoius,  the  first  being  pre- 
ceded by  the  formation  of  cartilage,  which  Ibrms  the 
nidus  for  the  ossifle  deposite,”  while  the  second  is  a tu- 
mour sorter  than  cartilage,  yet  firmer  than  fungus,  in 
other  parts  of  the  body,  containing  spicula  of  bone,  be- 
ing of  a malignant  nature,  and  depending  “ upon  a pe- 
culiar state  of  constitution  and  action  of  vessels.”  It  is 
a disease  similar  to  “ fungus  haematodes,  but  some- 
what modified  by  the  structure  of  the  part  in  which  it 
originates.” — {Surgical  Essays,  part  1,  p.  155.)  This 
last  form  of  exostosis  is  probably  the  disease  treated  of 
in  another  part  of  this  Dictionary  under  the  title  of  Os- 
teosarcoma. 

Exostoses  differ  very  much  in  respect  to  size.  Those 
of  the  cranium  are  generally  small  and  circumscribed. 
Exceptions  occur,  however;  for  we  learn,  that  Sir 
Everard  Home  removed  a very  large  tumour  which 
had  a bony  base  and  was  situated  on  the  head. — {A. 
Cooper,  Surgical  Essays,  part  1.  p.  156.)  The  largest 
■ true  exostoses  met  with  are  such  as  are  formed  upon 
the  long  bones.  In  the  history'  of  surgery  may  be  found 
numerous  cases  of  enormous  exostoses ; but  it  is  worthy 
of  notice,  that  these  were  nearly  all  of  them  of  the  spe- 
cies termed  false;  and  many  of  them  were  situated  in 
the  jaw,  the  clavicle,  or  the  extremities  of  the  long 
bones.  Observations  of  this  kind  are  abundant  in 
VHistoire  de  VAcad.  des  Sciences ; Its  Mem.  de  I’Acad. 
de  Chir.;  the  Sepulchretum  Anatomicum ; the  writings 
of  Morgagni,  &c.—{Dict.  des  Sciences  Med.  t.  14,  p. 
219.) 

The  bones  most  frequently  affected  with  exostosis, 
are  those  of  the  cranium,  the  lower  jaw,  sternum,  hu- 
merus, radius,  ulna,  bones  of  the  carpus,  and  particu- 
larly the  femur  and  tibia.  There  is,  however,  no  bone 
of  the  body  which  may  not  become  the  seat  of  this  dis- 
ease. It  is  not  uncommon  to  find  all  the  bones  of  the 
cranium  affected  with  exostosis,  and  the  ossa  parietalia 
sometimes  an  inch  thick. 

According  to  Sir  Astley  Cooper,  the  exostosis  which 
forms  between  the  outer  table  of  the  skull  and  the  peri- 
cranium, is  of  an  extremely  hard  consistence,  and  gene- 
rally attended  with  little  pain,  while  the  fungous 
exostosis,  springing  from  the  diploe  of  the  skull,  is 
less  firm  and  more  vascular.  It  is  described  as  being 
of  a malignant  nature,  making  its  way  through  the 
inner  table,  and  occasioning  disease  of  the  dura  mater 
and  fatal  effects  on  the  brain. — {Surgical  Essays,  part 
i,  p.  156.) 

Sometimes,  as  Boyer  remarks,  the  tumour  is  confined 
to  a small  part  of  the  affected  bone,  composing  a mass 
superadded  to  its  surface,  and  of  various  shapes. 
Sometimes  it  rises  insensibly,  having  no  very  distinct 
limits,  and  resembling  a more  or  less  regular  portion 
of  a sphere.  In  some  instances  its  figure  is  styloid, 
and  it  projects  in  a greater  or  less  degree.  On  other 
occasions,  its  base  is  rendered  distinct  by  a pedicle  or 
contraction,  which  varies  in  breadth  and  length  in  dif- 
ferent cases.  In  particular  instances,  the  exostosis, 
though  limited  to  the  surface  of  a bone,  occupies  the 
whole  extent  of  it.  Thus  the  whole  external  surface 
of  one  of  the  bones  of  the  skull  has  been  found  occupied 
by  an  exostosis,  while  the  cerebral  surface  of  the  same 
bone  was  in  the  natural  state.  The  whole  circumfe- 
rence of  the  femur  sometimes  acquires  an  enormous 
size,  at  the  same  time  that  its  medullary  surface  con- 
tinues entirely  unchanged.  These  are  the  periosteal 
exosto.ses  of  Sir  Astley  Cooper.  In  other  examples,  on 
the  contrary,  the  two  surfaces  and  the  whole  thickness 
of  the  bone  are  deformed  by  an  augmentation  of  bulk; 
and  when  this  happens  in  a cylindrical  bone,  the  me- 
dullary cavity  is  more  or  less  reduced,  or  even  totally 
obliterated.  Tliere  are  a few  extremely  uncommon 
cases,  in  which  the  substance  of  a bone  acquires  great 
solidity,  and  a hardness  compared  to  that  of  ivory, 
without  any  material  increase  of  bulk.  An  exostosis 
rarely  occupies  the  whole  extent  and  thickness  of  a 
bone;  but  when  this  happens  in  a cylindrical  bone,  the 
articular  surfaces  generally  remain  in  their  natural  state. 


The  structure  and  consistence  of  exostoses  present 
great  differences.  Sometimes,  especially  when  the  tu- 
mour is  not  very  large,  and  it  is  situated  on  the  sur- 
face of  a cylindrical  bone,  one  may  trace  with  the  eye 
the  diverging  of  the  osseous  fibres,  in  the  interspaces  of 
which  we  might  say  that  there  is  deposited  a new  bony 
substance,  the  orgaruzation  of  which  is  less  distinct. 
Sometimes  the  tumour  is  entirely  cellular,  and  formed 
of  a few  broad  laminae,  intercepting  extensive  spaces, 
which  are  filled  with  matter  different  from  the  medulla, 
and  of  various  quality.  This  case  is  denominated  the 
laminated  exostosis.  Sometimes  the  enlarged  portion 
of  bone  makes  a sort  of  hollow  sphere,  with  thick  hard 
walls,  and  the  cavity  of  which  is  filled  with  fungous 
granulations,  more  or  less  extensive  and  indolent. 
According  to  Boyer,  this  variety  of  the  disease  differs 
essentially  from  osteosarcoma,  notwithstanding  exter- 
nal appearances.  The  case  here  alluded  to  I conclude 
to  be  the  same  as  that  which  Sir  Astley  Cooper  has 
named  the  cartilaginous  exostosis  of  the  medullary 
membrane.  “In  this  case  the  shell  of  the  bone  be- 
comes extremely  expanded,  or  rather  the  original  shell 
is  absorbed,  and  a new  one  deposited  ; and  within  this 
ossified  cavity  thus  produced,  a ver>'  large  mass  of  car- 
tilage is  formed,  elastic,  firm,  and  fibrous.”  It  is  not 
malignant,  but  often  ends  in  a very  extensive  disease. — 
{Surgical.  Essays,  part  1,  p.  173.) 

In  other  instances  the  tumour  is  perfectly  solid,  ex- 
ceeding in  consistence  that  of  the  hardest  bones,  and 
equalling  that  of  ivory.  Here  the  surface  is  sometimes 
smooth,  and  like  that  of  the  bone  in  its  natural  state  ; 
sometimes  irregular,  full  of  little  projections,  and  in 
some  degree  stalactical.  It  is  very  uncommon  to  find  a 
large  portion  of  an  exostosis  converted  into  a pultace- 
ous  substance  ; but  it  is  not  at  all  unfrequent  to  see  this 
substance  composing  part  of  the  tumour.  Lastly,  it 
very  often  happens  that  the  same  exostosis  presents  an 
assemblage  of  the  ivory  substance,  and  of  the  cellular 
laminated  substance,  the  cavities  of  which  are  partly 
filled  vrith  a pultaceous  matter,  and  partly  with  a sort 
of  gelatinous  substance. 

When  an  exostosis  is  not  very  large,  it  hardly  affects 
the  surrounding  soft  parts  ; but  when  it  has  made  con- 
siderable progress,  the  muscles  become  stretched  and 
emaciated,  the  cellular  substance  is  thickened,  and  its 
layers  being  adherent  together,  a kind  of  confusion  is 
produced  among  all  the  adjacent  parts.  Exostoses  not 
of  considerable  size  may,  hov\’ever,  seriously  interrupt 
the  functions  of  certain  organs.  The  action  of  the  flexor 
muscles  of  the  leg  has  been  known  to  be  obstructed  by 
an  exo.stosis  in  the  vicinity  of  the  knee.  A similar  tu- 
mour arising  near  the  symphysis  pubis  need  not  be  very 
large  to  impede  considerably  the  functions  of  the  ure- 
thra. as  experience  has  proved.  An  exostosis  in  the 
orbit  has  been  known  to  displace  the  eye  and  to  destroy 
vision.  Lastly,  exostoses,  when  situated  near  certain 
important  organs,  and  of  large  size,  may  affect  with  dif- 
ferent degrees  of  gravity  the  functions  of  these  parts, 
as  the  brain,  the  lungs,  &c. — (See  Boyer,  Traite  des 
Mai.  Chir.  L3,  p.  541—544.) 

Sir  Astley  Cooper  has  related  a case  in  which  the 
eyes  were  pushed  out  of  their  sockets  by  two  exostoses, 
wliich  grew  from  the  antra,  and  one  of  which  destroyed 
the  patient  by  making  its  way  to  the  brain  through  the 
orbitar  process  of  the  os  frontis. — {Surgical  Essays, 
part  1,  p.  157.)  In  one  instance,  reported  by  the  same 
author,  an  exostosis  from  the  sixth  or  seventh  cervical 
vertebra  abolished  the  pulse  at  the  wrist,  by  pressing 
u]K)n  the  subclavian  artery.— (P.  159.)  In  another,  a 
cartilaginous  exostosis  of  the  medullary  membrane  of 
the  lower  jaw  extended  so  far  back  that  it  pressed  the 
epiglottis  down  upon  the  rima  glottidis,  and  caused 
such  difficulty  of  respiration,  and  so  much  irritation, 
that  the  patient  was  destroyed.— (P.  175.) 

Venereal  exostoses,  or  nodes,  are  observed  to  ari.se 
chiefly  on  compact  boties,  and  such  of  these  as  are  su- 
perficially covered  with  soft  parts,  as  for  instance  the 
bones  of  the  cranium,  and  the  front  surface  of  the  tibia. 

The  causes  of  exostosis  do  not  seem  to  be  at  all  under- 
stood. Most  writers  impute  the  list-ase  to  internal 
causes,  such  as  scrofula  and  lues  ' > h That  the 
latter  affection  is  the  cau.se  of  nodes,  w . e certainly 

a species  of  exostosis,  no  one  will  deu}  tl;  * scro- 
fula is  ever  concerned  in  producing  any  h-  'her 
kinds  of  exostosis  must  not  be  admitted,  at  1.  -it  bt  'ore 
some  evidence  is  adduced  in  support  of  the  doctrine. 
Boyer,  however,  and  all  the  surgeons  of  the  oontincui 


EXOSTOSIS.  363 


adopt  the  opinion  that  scrofula  is  sometimes  a cause 
of  the  disease. 

Hydatids  are  occasionally  found  within  exostoses,  in 
which  circumstance  the  former  are  supposed  to  be  the 
cause  of  the  enlargement  of  the  bone.  A remarkable 
specimen  of  such  a disease  in  the  tibia  is  mentioned  by 
Sir  Astley  Cooper. — {Surgical  Essays,  part  1,  p.  163.) 
He  refers  also  to  a humerus,  in  the  museum  of  St.  Tho- 
mas’s Hospital,  where  the  shell  of  the  bone  is  consider-, 
ably  expanded,  the  iteriosteum  over  it  thickened,  and  in 
the  seat  of  the  cancellated  structure,  several  hydatids, 
supposed  to  have  been  the  cause  of  the  enlargement  of 
the  e.xlerior  surface  of  the  bone,  as  well  as  of  the  increase 
of  its  cavity. — {VoL  cit.  p.  l&l.)  A most  interesting 
case  of  a bony  tumour  on  the  forehead,  containing  hyda- 
tids, has  likewise  been  published  by  Mr.  R.  Keate. — 
{Med.  Chir.  Trans,  vol.  10,  p.  278.) 

The  ease  with  which  bony  tumours  form  in  some 
persons,  is  a curious  and  remarkable  fact,  and  renders 
it  probable  that  constitutional  causes  here  have  great 
induence.  Thus  such  a blow  as  in  the  generality  of 
persons  would  hardly  excite  notice,  will  in  others  bring 
on  swellings  of  the  bone  which  is  struck.  Sir  Astley 
Cooper  adverts  to  a young  friend  of  his,  in  whom  an 
exostosis,  which  was  undoubtedly  caused  by  a blow, 
is  growing  on  the  metacarpal  bone  of  the  little  finger. — 
(Loc.  cit.)  Mr.  Abernethy  mentions  in  his  lectures  his 
having  seen  a boy  from  Cornwall,  who  was  so  exces- 
sively afflicted  with  an  apparent  predisposition  to  exos- 
tosis, or  an  exuberant  deposition  of  bony  matter,  that  a 
very  trifling  blow  would  occasion  a bony  swelling  on 
any  bone  of  his  body.  His  ligamentum  nuchae  was  os- 
sified, and  prevented  the  motion  of  his  neck  ; the  mar- 
gins of  his  axillae  were  also  ossified,  so  that  he  was,  as 
it  were,  completely  pinioned.  Besides  all  this,  the  sub- 
ject in  question  haa  numerous  other  exostoses  on  va- 
rious parts  of  his  body.  Mr.  Abernethy  gave,  in  this 
case,  muriatic  and  acetic  acids,  with  a view  of  dissolv- 
ing the  lime,  which  it  was  conceived  might  be  too 
abundant  in  the  system ; but  even  if  this  theory  had 
been  correct,  and  the  acids  capable  of  the  chemical  ac; 
tion  intended,  after  passing  into  the  circulation,  how 
could  they  be  expected  to  dissolve  only  the  redundant 
depositions  of  phosphate  of  lime,  and  at  the  same  time 
leave  the  skeleton  itself  undissolved  ? 

When  an  exostosis  depends  upon  lues  venerea,  it  is 
almost  always  preceded  by  an  acute  pain,  which  in  the 
beginning  extends  to  nearly  the  whole  of  the  affected 
bone;  but  afterward  becomes  fixed  to  the  point  where 
the  exostosis  forms,  and  it  is  most  severe  in  the  night- 
time. When  an  exostosis  is  caused  by  scrofula,  says 
Boyer,  the  pain  is  duller,  or  rather  it  is  quite  inconsider- 
able. It  is  the  same  with  the  exostosis  which  succeeds 
a blow  or  contusion,  without  any  manifest  general 
cause.  In  the  latter  example  the  pain  immediately  ex- 
cited by  the  accident  subsides  in  a few  days,  and  the 
swelling  occurs  so  slowly,  that  no  notice  is  taken  of  it 
till  It  has  attained  some  magnitude.— (Traffe  des.  Med. 
Chir.  t.  3,  p.  515.) 

An  exostosis  constantly  feels  hard ; but  its  size  is  va- 
rious, and  it  may  be  indolent  or  painful.  By  these  signs, 
and  its  firm  adhesion  to  the  bones,  it  may  be  always 
distinguished  from  other  tumours.  Some  exostoses 
cannot  be  ascertained  before  death.  Such  was  the  case 
in  which  the  parietal  bone  was  found,  after  death,  to  be 
throe  times  thicker  than  natural.  Such  also  was  the 
exarnble  related  in  the  memoirs  of  the  Academy  at  Di- 
jon, in  which  a person  died  from  an  exostosis  on  the 
internal  side  of  the  os  pubis,  the  tumour  having  pre- 
vented the  discharge  of  the  urine  and  the  introduction 
of  a catheter  by  its  pressure  on  the  neck  of  tlie  bladder. 

Exostoses  may  be  either  acute  or  chronic  in  their 
progress.  In  the  first  ca.se,  which,  according  to  Boyer, 
hapi)ens  most  commonly  in  the  cellular  exostosis,  de- 
scribed by  authors  under  the  name  of  laminated,  the 
appearance  and  formation  of  the  tumour  are  quick  ; tlie 
swelling  rapidly  acquires  a considerable  size,  and  it  is 
always  i)receded  by  and  accornparned  with  continual 
violent  i)ain,  which  the  external  and  internal  use  of 
opium  has  little  effect  upon,  and  the  intensity  of  which  is 
not  increased  by  pressure.  The  pain  is  sometimes  so 
severe  that  it  occasions  a good  deal  of  symptomatic  fe- 
ver. Boyer,  who  seems  not  be  aware  of  the  origin  of 
what  he  terms  the  cellular,  and  what  Sir  Astley  tloojier 
has  named  funy,ov.s  exostosis,  from  the  medullary 
membrane,  finds  difiiculty  in  accounting  for  the  rapid 
grounli  and  great  sensibility  of  the  tumour,  considering 


the  natural  density  of  the  bones,  and  the  little  energy 
of  their  vital  properties. 

In  the  hardest  kinds  of  exostosis,  says  Boyer,  the  tu- 
mour is  preceded  by  no  pain,  or,  if  any,  it  is  very  slight ; 
the  tumour  grows  slowly,  and  although  it  sometimes 
attains  a considerable  size,  its  increase  is  attended  with 
no  particular  sensibility,  and  no  disturbance  of  the  ani- 
mal economy.-  {Boyer,  op.  cit.  t.  3,  p.  546.) 

Our  ignorance  of  the  pathology  of  exostoses,  particu- 
larly their  causes,  accouiits  for  the  imperfection  of  our 
treatment  of  them.  With  the  exception  of  the  vene- 
real exostosis,  or  node,  there  is  no  species  of  this  affec- 
tion, for  which  it  can  be  said  that  we  have  any  one  me- 
dicinq  of  efficacy. 

* Boyer  and  other  writers  on  the  diseases  of  the  bones 
seem  to  regard  some  exostoses  as  a perfectly  inorganic 
mass  of  lime,  and  consequently  they  entertain  no  idea 
that  the  absorbent  vessels  can  possibly  take  away  the 
particles  of  the  tumour,  just  as  the  secerning  arteries 
have  laid  them  down.  Such  WTiters,  however,  are 
well  aware,  that  nodes  are  capable  of  being  fflmi- 
nished,  and  this  can  only  be  efiected  by  the  action  of  the 
absorbent  system. 

Boyer  does  acknowledge,  indeed,  that  he  has  seen  a 
venereal  exostosis  of  the  humerus,  as  well  as  a few 
other  bony  swellings,  subside ; but  he  represents  the 
event  as  extremely  rare ; and  he  advances  it  as  a prin- 
ciple, that  the  resolution  of  exostoses  hardly  ever  hap- 
pens, and  that  the  greater  part  of  the  examples  recorded 
in  proof  of  the  occurrence,  were  nothing  more  than  pe- 
riostoses.— (P.  547.) 

When  an  exostosis  is  hard,  chronic,  and  free  from 
pain  and  alteration  of  the  structure  of  the  bone,  it  is  a 
much  more  common  thing  for  it  to  cease  to  enlarge,  and 
remain  stationary  during  life,  without  producing  incon- 
venience, provided  it  be  so  situated  as  not  to  impede  the 
functions  of  any  vital  organ. 

But  in  the  cellular  exostosis  of  Boyer,  which  I take 
to  be  the  same  disease  as  the  fungous  exostosis  of  the 
medullary  membrane  of  Sir  Astley  Cooper,  the  acute 
and  rapid  progress  of  the  disease  indicates  a deeper  and 
more  serious  alteration  of  the  texture  of  the  bone.  A 
part  of  the  tumour  usually  consists  of  a pultaceous  or 
gelatinous  matter,  and  the  rest  still,  endued  with  its  na- 
tural organization,  though  altered  by  the  disease,  soon 
presents  one  or  several  cavities,  in  which  there  is  sup- 
puration. At  the  same  time,  the  external  soft  parts, 
being  excessively  and  rapidly  distended,  inflame,  ulcer- 
ate, and  leave  exposed  a more  or  less  extensive  portion 
of  the  tumour,  the  disease  of  which  has  in  many  cases 
been  very  wrongly  supposed  to  be  caries.  It  is  not,  ob- 
serves Boyer,  that  the  part  of  the  swelling  denuded  by 
ulceration  is  not  sometimes  affected  with  caries ; but 
then  it  exists  as  a complication  of  the  original  disease, 
and  as  a particularity  by  no  means  the  result  of  the  ul- 
ceration of  the  soft  parts,  and  of  the  exposure  of  the 
diseased  bone  to  the  contact  of  the  air.  When  the  soft 
parts  are  thus  ulcerated,  the  opening  contracts  to  a cer- 
tain point,  and  becomes  fistulous.  The  suppuration  is 
always  of  bad  quality,  and  in  a quantity  proportioned 
to  the  size  of  the  cavity  of  the  abscess  and  the  strength 
of  the  patient.  The  fever,  w'hich  commences  at  an 
early  period  of  the  disorder,  assumes  a slow  type,  and 
its  continuance,  together  with  the  copiousness  of  the 
ichorous  discharge,  the  irritation,  &c.,  may  bring  on  the 
patient’s  dissolution. 

The  following  are  the  symptoms  of  what  Sir  Astley 
Cooper  denominates  the  fungous  exostosis  of  the  me- 
dullary membrane.  The  disease  begins  v/ith  a general 
enlargement  of  the  affected  part  of  the  hmb,  extending 
a considerable  way  around  the  scat  of  the  exostosis  it- 
self. This  form  of  the  complaint  mostly  occurs  in 
young  persons,  though  Sir  Astley  Cooper  has  seen  it 
in  an  individual  fifty  years  old.  “ Its  increa.se  pro- 
ceeds very  gradually  ; and  even  when  it  has  acquired 
considerable  magnitude,  although  it  produces  some  di- 
minution of  motion  in  the  limb,  it  does  tiot  occasion 
pain,  nor  prevent  the  patient  from  using  it.  When  any 
pain  does  arise,  it  is  of  an  obtuse  kind,  only  being 
acute  in  the  event  of  a nerve  being  stretched  by  the 
tumour.  Thus  an  exostosis  of  the  thigh-bone  some- 
times causes  great  agony,  by  pressing  on  the  sciatic 
nerve.  Paleness,  debility,  and  irregularity  of  the 
bowels,  are  observed  to  attend  the  early  stage  of  the 
disease ; and  afterward  the  conqilexion  becomes  sal- 
low. In  the  mean  time  the  diseased  part  of  the  limb 
attains  an  enormous  size ; but  the  skin  retains  its  natu- 


364 


EXOSTOSIS, 


ral  colour.  At  many  points  the  swelling  feels  hard  ; 
at  others,  it  is  so  elastic  as  to  cause  the  presence  of 
fluid  to  be  suspected;  but  if  an  opening  be  made,  only 
blood  IS  discharged.  The  surface  of  the  tumour  next 
becomes  tuberculated,  and  the  prominences  tender,  and 
their  surface  is  often  slightly  inflamed.  The  rest  is 
now  broken,  the  appetite  impaired,  and  the  bowels  ex- 
tremely irregular.  At  length  the  tubercles  ulcerate ; 
the  skin  secretes  pus ; but  when  the  swelling  itself 
is  exposed,  it  discharges  a bloody-coloured  serum. 
A fungus  then  forms,  w'hicli  sometimes  bleeds  pro- 
fusely, and  after  it  has  risen  very  high,  sloughing  oc- 
curs, and  considerable  portions  of  the  swelling  are 
thrown  off.  But  although  the  swelhng  may  be  les- 
sened by  this  process.  Sir  A.  Cooper  has  never  known 
the  disea.se  cured  by  it ; and  in  the  end  the  patient  is 
destroyed  by  the  effects  of  the  repeated  bleeding,  im- 
mense discharge,  and  constitutional  irritation.”  In 
this  disease,  as  in  common  fungus  hacmatodes,  tu- 
mours of  a similar  nature  are  often  formed  in  other 
parts  of  the  body,  and  after  the  amputation  of  the  af- 
fected bone  frequently  make  their  appearance  in  organs 
of  the  greatest  importance  to  life.  The  swelling  is  de- 
scribed as  originating  from  the  medullary  membrane, 
and  as  removing  the  muscles  to  the  distance  of  three 
inches  or  more  from  the  bone,  so  that  they  represent  a 
thin  layer  spread  over  the  tumour.  The  blood-vessels 
and  large  nerves  are  also  similarly  displaced.  The  tu- 
berculated appearance  of  the  skm,  which  is  itself 
sound,  is  caused  by  projecting  small  masses  on  the 
surface  of  the  tumour.  Under  the  muscles  is  the  peri- 
osteum, pushed  to  a considerable  distance  from  the 
bone.  A part  of  the  swelling  itself  is  yellow,  like  fat ; 
another  portion  resembles  brain  ; and  a third  is  com- 
posed of  coagulated  blood  with  interstices  filled  with 
serum.  In  some  parts  the  white  substa;'!oe  is  found 
nearly  as  firm  as  cartilage  ; but  in  general  it  presents 
a more  spongy  appearance ; and  is  interspersed  with 
spiculae  of  bone.  The  shell  of  the  bone  itself  is  in  ps . i 
absorbed  ; in  some  places  it  is  only  thinner  than  usuai , 
while  in  others  it  is  immensely  expanded,  so  as  to  form 
a case,  like  wire-wmrk,  over  the  tumour.  The  fungous 
granulations,  proceeding  from  the  medullary  mem- 
brane itself,  are  exceedingly  vascular,  and  often  shoot 
from  the  cavity  of  the  bone  beyond  the  level  of  the  in- 
teguments.—(A.  Cooper,  Surgical  Essays,  part  1, 
p.  165-16S.) 

According  to  Boyer,  spherical  exostose.s,  with  an  in- 
ternal cavity,  and  hypersarcosis,  are  only  attended  with 
violent  pain  in  the  beginning,  and  when  they  have  at- 
tained a considerable  size  they  become  almost  indolent. 
But  the  successive  formation  of  the  fungosities,  con- 
tained in  their  ca\ity,  has  the  effect  of  distending  its 
parietes,  and  rendering  them  thin,  so  that  such  exosto- 
ses are  exposed  to  fractures  and  ulceration.  This  last 
effect  may,  indeed,  be  a consequence  of  the  progress  of 
the  disease,  and  give  rise  to  a series  of  consectuive 
symptoms,  which  may  be  compared  whth  those  which 
have  been  described  in  the  preceding  case.  The  spheri- 
cal exostosis,  however,  is  less  dangerous,  jierhaps,  be- 
cause the  disease  extends  less  deeply.  Such  tumours 
admit  of  being  directly  attacked  ; and  operations  for  the 
destruction  of  the  bony  shell,  and  of  the  fungous  growth 
which  it  includes,  may  be  successfully  practised ; an 
attempt  which  would  certainly  be  useless  atid  dan- 
gerous in  the  foregoing  instance. 

One  termination  of  exostosis,  not  spoken  of  by  wri- 
ters, but  which  has  been  observed,  especially  in  the 
hard  and  stalactical  exostosis,  is  that  by  necrosis.  Tu- 
mours of  this  description,  after  acquiring  a large  size, 
have  been  attacked  with  mortification,  separated  from 
the  bone,  which  served  them  as  a base,  and  been  sur- 
rounded with  a reproduction  in  every  respect  similar 
to  that  whth  which  nature  surrounds  sequestra  formed 
under  any  other  circumstances.  This  termination  is 
undoubtedly  the  most  favourable  of  all,  because  nature 
l)roceeds  in  it  slowly, without  any  violent  disturbance; 
but,  unfortunately,  it  is  the  least  common.  Art  can 
imitate  it ; but  her  means  are  very  inferior  to  those  of 
nature.  A most  interesting  case  oi  an  enormous  exo.s- 
tosis  of  the  upper  maxillary  bone,  which  followed  the 
preceding  course,  was  lately  under  my  notice. — {Boyer, 
Traite  des  Mai.  Cliir.  t.  3,  p.  547—  550.') 

The  hardest  exostosis,  w’hich  has  grown  slowdy,  and 
without  causing  severe  pain,  is  the  least  dangerous  of 
all,  especially  when  the  constitution  is  sound,' and  the 
patient  not  of  a bad  habit.  After  the  disease  has  at- 


tained a certain  size,  it  may  become  stationary,  and 
continue  in  this  state  without  inconvenience  during 
life.  This  is  most  frequently  observed  in  the  ivory  ex- 
ostosis. Without  having  precisely  this  extreme  hard- 
ness, however,  some  exostoses  which  are  tolerably 
solid,  and  in  v.  hich  the  natural  organization  of  bone  is 
still  distinguishable,  are  capable  of  undergoing  a slight 
reduction,  after  the  removal  of  their  cause  by  nature  or 
art.  Boyer  states,  that  this  sometimes  happens  in  a 
few  scrofulous  exostoses,  and  particularly  in  such  as 
are  venereal,  and  not  of  very  large  size. 

The  cellular  exostosis  of  Boyer,  the  fungous  exos- 
tosis of  Sir  A.  Cooper,  and  the  cases  which  are  named 
osteosarcomata,  are  the  most  serious  of  all,  especially 
w'hen  the  texture  of  the  bone  is  considerably  altered, 
and  the  disease  is  in  a state  of  ulceration.  The  rapid 
formation  of  the  disease,  the  violent  shock  which  it  im- 
parts to  the  constitution,  and  the  hectical  disturbance 
which  it  excites,  generally  bring  the  patient  into  immi- 
nent danger,  and  commonly  leave  no  other  resource 
but  that  of  amputating  the  limb. 

The  treatment  of  exostoses  is  to  be  considered  in  a 
medical  and  surgical  point  of  view.  When  any  gene- 
ral cause  of  the  disease  is  known  or  suspected,  such 
cause  is  to  be  removed  by  those  m.eans  which  expe- 
rience has  proved  to  be  most  efficacious.  Thus  Boyer 
recommends  mercurial  and  antiscrofulous  remedies, 
&c.,  according  to  the  nature  of  the  case. 

Whatever  may  be  the  species  of  exostosis,  or  the  na- 
ture of  its  cause,  relief,  says  Boyer,  may  be  derived 
from  thi^  outward  use  of  opium,  whenever  the  disease 
is  attenikid  with  severe  pain.  He  speaks  favourably  of 
the  apiilication  of  a linseed-meal  poultice,  made  with  a 
decoction  of  the  leaves  of  nightshade  and  henbane,  to 
which  a strong  solution  of  opium  has  been  added.  But 
he  thinks  that  an  antiphlogistic  plan,  with  bleeding,  is 
hardly  ever  admissible,  because  it  weakens  the  patient 
too  much  in  so  tedious  a disease,  and  can  only  be  a 
palliative,  incapable  of  curing  or  preventing  the  ravages 
of  the  disorder. 

When  there  is  no  pain,  or  it  has  been  appeased,  during 
or  after  any  general  method  of  treatment  which  may 
have  been  indicated,  the  surgeon  may  try  resolvent  ap- 
plications, particularly  soap  and  mercurial  plasters,  the 
tincture  or  ointment  of  iodine,  the  liniment  of  ammonia, 
bathing  in  water  containing  a small  quantity  of  soda, 
or  potassa,  hydro-sulphurated  washes,  &c.  Boyer  ac- 
knowledges, however,  that  the  progress  of  exostoses 
can  scarcely  ever  be  checked  by  any  general  methodi- 
cal treatment.  The  muriatic  and  ascetic  acids  have 
been  administered,  but  without  effect ; nor  am  I ac- 
quainted with  any  remedies  which  possess  efficacy, 
excepting  iodine  and  mercury,  which  last  we  know 
will  rarely  answer,  except  in  cases  of  nodes.  In  the 
commencement  of  any  deep-seated  disease  in  a bone, 
however.  Sir  A.  Cooper  thinks  that  the  best  medicine 
for  internal  exhibition,  is  the  oxymuriate  of  quicksilver 
in  small  doses,  together  with  the  compound  decoction 
of  sarsaparilla. — {Surgical  Essays,  part  1,  p.  169.) 
Boyer  is  firndy  of  opinion  that,  w ith  the  exception  of 
recent  small  exostoses,  the  nature  of  which  is  even 
doubtful,  the  resolution  of  such  tumours  is  almost  im- 
possible. A slight  diminution  of  the  sweliing,  and  its 
becoming  perfectly  indolent,  are  the  mo.st  favourable 
changes  which  can  be  hoped  for,  whether  thej  occur 
spontaneously,  or  are  the  fruit  of  surgical  assistance. — 
{Traite  des  Mai.  Chir.  t.  3,  p.  554—557.) 

Whether  any  exosto.ses  might  be  lessened  by  keeping 
open  a blister  over  them  for  a considerable  time,  is  a 
point,  perhaps,  worthy  of  farther  investigation.  It  is 
certain  that  such  applications  tend  to  diminish  venereal 
nodes,  after  they  have  been  lessetied  as  much  as  they 
can  be  by  mercury;  and  we  also  know  that  blisters 
kept  open  promote  the  absorption  of  the  dead  bone  in 
cases  of  necrosis.  In  the  local  treatment.  Sir  Astley 
Cooper  approves  of  the  use  both  of  leeches  and  blisters, 
a discharge  from  the  latter  being  kept  up  w ith  equal 
parts  of  the  mercurial  and  savin  ointments. — {Surgical 
Essays,  part  1,  p.  169.) 

When  exostoses  merely  occasion  a deformity,  and  no 
pain  nor  inccnvenience  from  the  pressure  which  ihe> 
produce  on  the  neighbouring  parts,  it  is  certainly  most 
advisable  not  to  undertake  any  operation  for  their  remo- 
val ; for,  as  Boyer  has  truly  observed,  in  by  far  the 
greater  number  of  instances,  the  local  atfection  is  muct 
less  to  be  dreaded  than  the  means  used  for  remov 
iug  it. 


EXO 


EYE 


365 


Caustics  and  the  cautery  have  occasionally  been  ap- 
plied to  exostoses  ; but  they  mostly  do  mischief.  Boyer 
mentions  an  unfortunate  woman,  in  whom  some  caustic 
was  applied  to  an  exostosis  at  the  inside  of  the  tibia ; 
but  which  instead  of  removing  the  tumour,  caused  a 
necrosis,  of  which  she  was  not  well  two  years  after- 
ward. In  a few  instances,  however,  after  the  removal 
of  fungotfs  or  cartilaginous  exostosis  of  the  interior  of 
a bone  with  cutting  instruments,  the  application  of  the 
cautery  has  prevented  a reproduction  of  the  diseased 
mass,  as  we  find  exemplified  in  a case  recorded  by  .Sir 
Astley  Cooper,  where  such  a disease  of  the  jaw  was 
thus  extirpated. — {Surgical  Essays,  part  1,  p.  15d.) 
The  bold  and  successful  manner,  also,  in  which  the 
hydatid  exostosis  of  the  head  was  attacked  with  the 
saw,  caustics,  and  the  actual  cautery,  by  Mr.  R.  Keate, 
IS  particularly  entitled  to  the  attention  of  the  surgical 
practitioner.— (died.  Chir.  Tran.s.  voL  10,  p.  28S,  a c.) 
As  far  as  my  information  extends,  no  attempt  to  stop 
the  progress,  or  efiecf  the  cure  of  a fungous  exostosis, 
by  tying  the  main  artery  of  the  limb,  has  ever  >ct  suc- 
ceeded. Two  cases,  proving  the  inellicacy  of  this  prac- 
tice, are  detailed  by  Sir  A.  Cooper. — {Vol.  cit.  p.  ITU.j 

As  the  fungous  exostosis  of  the  medullary  mem- 
brane is  evidently  connected  with  a state  of  the  consti- 
tution analogous  to  what  prevails  in  fungus  hiematodes 
(see  this  word),  the  permanent  success  of  amputation 
should  never  be  too  boldly  promised  ; but  as  no 
medicines  have  any  material  power  over  the  disease, 
and  the  operation  is  the  only  chance  of  relief,  it  ought 
to  be  advised. 

Cartilaginous  exostoses  of  the  medullary  membrane 
may  sometimes  be  extirpated  by  removing  their  outer 
bony  covering,  and  then  cutting  away  the  cartilaginous 
matter  closely  from  the  bony  surface  to  which  it  is  at- 
tached. Sometimes,  as  I have  noticed,  those  measures 
are  followed  by  the  use  of  the  actual  cautery. 

Periosteal  exostoses  are  also  either  cartilaginous  or 
fungous,  which  latter  are  attended  with  less  general 
swelling  of  the  limb,  and  are  more  prominent  than  fun- 
gous exostoses  of  the  medullary  membrane.  Ulcera- 
tion, bleeding,  sloughing,  and  great  discharge  ensue ; 
and  unless  some  operation  be  performed,  the  patient 
loses  his  life. — {A.  Cooper,  Surgical  Essays,  part  1, 
p.  180.) 

The  cartilaginous  exostosis,  between  the  periosteum 
and  bone,  arises  from  inflammation  of  the  periosteum 
and  subjacent  part  of  the  bone;  and  a de])osition  of 
firm  cartilage  adherent  to  both  these  surfaces  takes 
place.  In  this  substance  bony  matter  is  secreted,  which 
is  first  thrown  out  from  the  original  bone.  As  the  car- 
tilage increases  in  bulk,  the  quantity  of  phosphate  of  lime 
augments,  and  fresh  cartilage  is  constantly  deposited 
upon  the  outer  surface  of  the  tumour.  On  dissection  ; — 
1st, the  periosteum  is  found  thicker  than  natural;  2dly, 
immediately  below  the  periosteum  cartilage ; and  3dly, 
ossific  matter,  deposited  within  the  latter,  from  the  shell 
of  the  bone,  nearly  to  the  inner  surl'ace  of  the  perios- 
teum. When  the  growth  of  such  a swelling  ceases, 
and  the  disease  is  of  long  standing,  the  exterior  surface 
consists  of  a shell  of  osseous  matter,  similar  to  that  of 
the  original  bone,  and  communicating  with  its  cancelli, 
in  consequence  of  the  primitive  shell  having  been  ab- 
sorbed. {.i.  Cooper,  Surgical  Essays,  part  1,  p.  186.) 
The  periosteal  cartilaginous  exostoses  constitute  the 
indolent,  very  hard  forms  of  the  disease.  In  their  early 
stage  they  may  sometimes  be  checked  by  small  doses 
of  mercury,  the  decoction  of  sarsaparilla,  and  the  em- 
plastrum  ammoniaci  cum  hydrargyro.— (FoZ.  cit.  p. 
l'J6.)  When  large  or  troublesome  they  may  be  sawed 
away,  as  Sir  A.  Cooper  states,  without  danger,  if  the 
disease  be  well  discriminated  from  the  fungous  swell- 
ing. 

When  exostoses  are  productive  of  much  pain,  and 
injure  the  health,  and  their  situation  admits  of  their  be- 
ing safely  removed  with  the  aid  of  suitable  saws,  or 
even  with  that  of  a gouge  and  mallet,  the  operation 
may  be  undertaken.  Many  tumours  of  this  kind,  how- 
ever, have  bases  so  very  exten.sive  and  deep,  that  when 
situated  on  the  limbs,  amputation  becomes*  preferable, 
to  any  attempt  made  to  saw  or  cut  away  the  exostoses 
and  preserve  the  members  on  which  they  are  situated. 

In  removing  an  exostosis,  its  base  must  be  as  freely 
ex[K)Sfd  by  the  knife  as  circumstances  will  allow,  and 
to  this  part  a small  fine  saw  may  be  applied.  In  cut- 
ting away  some  exostoses,  the  flexible  saw,  described 
t)v  Dr.  Jeffray,  of  Glasgow  (see  Amputation),  will  be 


found  useful.  Mr.  Key’s  saws,  and  the  semicircular 
trephine,  are  now  so  well  known  to  the  profession,  that 
I scarcely  need  recommend  them  to  be  remembered  in  the 
present  cases.  Mr.  Machell,  a surgeon  in  London,  has 
invented  a saw,  well  palculated  for  cutting  a bone  at  a 
great  depth,  without  injuring  the  muscles.  It  is  a small, 
fine,  perpendicular  wheel-like  saw,  turned  by  means  of 
a handle  connected  with  machinery.  It  is  highly  com- 
mended by  Sir  A.  Cooper,  who  has  given  a drawing  of 
it  in  his  Surgical  Essays,  part  I.  An  orbicular  saw, 
invented  and  used  by  Professor  Graefe,  of  Berlin,  like- 
wise merits  particular  notice  on  account  of  its  inge- 
nuity.— iSee  C.  G.  E.  Schwcilb, . De  Serra  Orbiculari, 
ito.  Berol.  1819.)  I would  likewise  recommend  to  the 
notice  of  surgeons  the  ingenious  rotation  saw*,  contrived 
by  Professor  Thai,  of  Coiienhagen,  and  of  which  a de- 
scription and  engraving  may  be  found  in  the  Edin. 
Med.  and  Surgical  Journ.  No.  74.  A strong  pair  of 
bone-nippers,  and  especially  Mr.  Liston’s  forceps,  the 
edges  of  which  are  in  the  line  with  the  handles,  will 
also  be  useful. 

E.  Victoria,  De  Ossibus  tuberosis.  Upsal,  1717. 
Haller,  Disp.  Chir.  t.  4,  p.  561.  P.  H.  Mcehring,  De 
Exostosi  Steatomatode  Claviculae,  ejusdem  felici  Sec- 
tione,  Gedani,  1732.  J.  COspart,  De  Exostosi  Cranii 
rariore.  Argent.  1730.  J.  R.  Fayolle,  De  Exostosi, 
Monsp.  1774.  Abernethy,  in  Trans,  for  the  Improve- 
ment of  Med.  and  Chir.  Knowledge,  vol.  2,  p.  309. 
Bonn,  Descriptio  Thesauri  Ossium  Hoviani.  Dumont, 
Journ.  de  Mi  d.  1. 13.  Hist,  de  I'Acad.  des  Sciences,  1737, 
p.  28.  Houstet,  in  Mem.  de  VAcad.  de  Chir.t.  3.  Matani, 
De  Osseis  Tumoribus,  p.  20.  Petit,  Traits  des  Mai. 
des  Os,  t.  2,  Morgagni,  De  Sedibus,  dt  c.  ep.  50.  art.  56. 
Kulmus,  De  Exostosi  Claviculw.  Haller,  Collect.  Diss. 
Chir.  t.  4.  R.  Keate,  in  Med.  Chir.  TYans.  vol.  10. 
Sir  A.  Cooper,  Surgical  Essays,  part  1, 8vo.  Lond.  1818. 
J.  F.  Lobstein,  Compte  de  son  Mus.  e Anatomique,  p. 
24,  8vo.  Strasb.  1820.  # 

EXTRAVASATION.  (From  extra,  out  of,  and  vas 
a vessel.)  A term  applied  by  surgeons  to  the  passage 
of  fluids  out  of  their  proper  vessels  or  receptacles. 
Thus,  when  blood  is  effused  on  the  surface,  or  in  the 
ventricles  of  the  brain,  it  is  said  that  there  is  an  extra- 
vasation. 

When  blood  is  poured  from  the  vessels  into  the  ca- 
vity of  the  peritoneum,  in  wounds  of  the  abdomen,  or 
when  the  contents  of  any  of  the  intestines  are  effused 
in  the  same  way,  surgeons  call  this  accident  an  extra-, 
vasation.  The  urine  is  also  said  to  be  extravasatedj 
when,  in  consequence  of  a wound,  or  of  sloughing,  or 
ulceration,  it  makes  its  way  into  the  cellular  substance, 
or  among  the  abdominal  viscera.  When  the  bile 
spreads  among  the  convolutions  of  the  bowels  in 
wounds  of  the  gall-bladder,  this  is  a species  of  extra- 
vasation. 

In  wounds  of  the  thorax  an  extravasation  of  blood 
also  frequently  happens  in  the  cavity  of  the  pleura. 
Large  quantities  of  blood  are  often  extravasated  in 
consequence  of  vessels  being  rujitured  by  violent  blows ; 
in  the  scrotum,  on  the  shoulder,  and  under  the  scalp 
this  effect  is  observed  with  particular  frequency. 

In  the  articles  Head,  Injuries  of,  and  Wounds,  I have 
treated  of  extravasations  of  blood  in  the  cranium,  chest, 
and  abdomen. 

EYE,  Calcui.us  in  the  interior  of.  Scarpa 
dissected  an  eye  which  was  almost  entirely  transformed 
into  a stony  substance.  It  was  taken  from  the  body 
of  an  old  woman,  and  was  not  above  half  as  large  as- 
the  sound  one.  The  cornea  appeared  dusky,  and  be- 
hind it  the  iris,  of  a singular  shape,  concave,  and  with- 
out any  pupil  in  its  centre.  The  rest  of  the  eyeball, 
from  the  limits  of  the  cornea  backward,  was  unusually 
hard  to  the  touch.  The  particulars  of  the  dissection 
of  this  case  will  be  read  with  interest,  in  Scarpa’s 
Treatise  on  the  Diseases  of  the  Eye. 

Haller  met  with  a similar  case. — (See  Obs.  Pathol. 
Oper.  Min.  obs.  15.)  Fabricius  Ilildanus,  Lancisi, 
Morgagni,  Morand,  Zinn,  and  I’ellier  make  distinct 
mention  of  calculi  in  the  interior  of  the  eye.  08.sifica- 
tions  of  the  capsule  of  the  lens,  of  that  of  the  vitreous 
humour,  and  of  what  was  sujiposed  to  be  the  hyaloid 
membrane  are  noticed  by  Mr.  Wardro]). — (Morbid 
Anatomy  of  the  Human  Eye,  vol.  2,  p.  128,  bvo.  Lond. 
1818.) 

EVE,  Canckr  and  Extiri’ation  of.  One  of  the 
well-known  characters  of  carcinoma  in  general  is  lo 
attack  persons  advanced  in  age  rather  than  child  tu 


366 


EYE. 


and  young  subjects.  Hence,  an  observation  made  by 
the  experienced  Desault,  that  cancer  of  the  eye  is  most 
frequent  in  childhood,  could  not  but  appear  a position 
inconsistent  with  the  usual  nature  of  the  disease  in 
general.  Yet  how  was  this  statement  to  be  contra- 
dicted, while  it  was  confirmed  by  the  testimony  of  Bi- 
chat himself,  who  says,  that  more  than  one-third  of  the 
patients  on  whom  Desault  operated  in  the  Hdtel-Dieu 
for  cancer  of  the  eye  were  under  twelve  yetirs  of  age  ? 
Here  truth  and  accuracy  as  in  many  other  questions 
relative  to  disease  would  never  have  been  attained 
without  the  aid  of  morbid  anatomy,  whereby  distem- 
pers which  bear  a superficial  resemblance  to  each 
other,  while  they  are  in  reality  of  a totally  different  na- 
ture, are  prevented  from  being  confounded  together. 
Now,  when  Scarpa  even  goes  farther  than  Bichat,  and 
asserts,  that  in  twenty-four  individuals  affected  with 
what  is  called  carcinoma  of  the  eye,  twenty  of  those  at 
least  are  children  under  twelve  years  of  age,  this  decla- 
ration, con.sidered  with  the  acknowledged  propensity 
of  cancer  on  all  other  occasions  to  attack  old  rather  than 
young  subjects,  might  have  remained  a mysterious 
anomaly  in  the  history  of  disease,  had  not  the  valuable 
investigations  of  Mr  Wardrop  proved,  beyond  all  doubt, 
that  the  afflicting  disease  which  rendered  it  necessary 
for  so  many  young  subjects  to  undergo  a severe  opera- 
tion, was  not  true  cancer,  but  what  is  now  denominated 
by  modern  surgeons,  fungus  hcematodes. — {Gbs.  on 
Fungus  Hcematodes,  Svo.  Edin.  1809.)  As  Scarpa  ob- 
serves, this  author  has  afforded  a solution  of  the  ques- 
tion, by  .showing  from  carelul  observation,  founded  on 
pathological  anatomy,  that  the  morbid  change  of  struc- 
ture in  the  eyeball  of  a child,  commonly  c^led  carci- 
noma, is  not  in  reality  produced  by  cancer,  but  by  an- 
other species  of  malignant  fungus,  to  which  the  epithet 
haernatodes  is  applied  ; a disease,  indeed,  equally,  and, 
with  regard  to  the  eye,  more  formidable  and  fatal  than 
cancer,  but  distinguished  from  it  by  peculiar  characters, 
which,  not  being  confined  to  age,  sex,  or  part  of  the 
body,  attack  the  eyeball  both  of  the  infant  and  adult. — 
{Scarpa,  Transl.  by  Briggs,  p.  502,  ed.  2.) 

According  to  Scarpa,  and,  indeed,  the  sentiments  of 
several  other  surgeons  of  ihe  present  day,  cancer  is  al- 
ways preceded  by  scirrhus,  or  a morbid  induration  of 
the  part  affected.  As  the  disorganization  increases  in 
this  hard  scirrhous  substance,  an  ichorous  fluid  is 
formed  in  cells  within  it,  and  afterward  extends  towards 
the  external  surface  of  the  tumour,  causing  ulceration 
of  the  investing  parts.  The  compact  and  apparently 
fibrous  mass  is  tuen  converted  into  a malignant  fun- 
gous ulcer,  of  a livid  or  cineritious  colour,  with  edges 
everted  and  irregularly  excavated,  and  with  a discharge 
of  acrid,  offensive  sanies.  The  scirrhus  composing 
the  base  of  the  malignant  fungms,  instead  of  increasing 
in  size,  now"  rather  diminishes,  but  retains  all  its  ori- 
ginal hardness,  and,  after  rising  a certain  way  above 
the  ulcerated  surface,  is  destroyed  at  various  points  by 
the  same  ulcerated  process  from  which  it  originated. 
And  if  any  pan  of  the  livid  fungous  sore  seem  disposed 
to  heal,  it  is  a deceitful  appearance,  as,  in  a little  time, 
the  smooth  points  are  again  attacked  by  ulceration.  To 
relate  in  this  place  all  the  differences  between  cancer 
and  fungus  haernatodes  of  the  eye  would  be  superfluous, 
as  the  subject  is  considered  in  a future  article  (see 
Fungus  Haernatodes)]  but  I may  briefly  advert  to  a 
few  remarkable  points  of  diversity.  1st,  The  primary 
origin  of  fungus  haernatodes  is  generally  in  the  retina, 
especially  that  point  at  which  the  optic  nerve  enters  the 
cavity  of  the  eye.  2dly,  True  cancer  of  the  eyeball, 
when  it  begins  on  any  part  of  the  organ  itself,  instead 
of  commencing  as  fungus  haernatodes  at  the  deepest 
part  of  the  eye,  originates  on  its  surface  in  the  con- 
junctiva ; and,  as  far  as  present  evidence  extends,  if 
we  excent  the  lachrj-mal  gland,  this  membrane  is 
the  only  texture  connected  with  the  eye  ever  pnma- 
rily  affected  wnth  carcinoma. — {Scarpa,  On  Diseases 
of  the  Eye,  p.  526,  edit.  2 ; and  Tr  avers,  Synopsis  of 
the  Diseases  of  the  Eye,  p.  99.)  3dly,  Cancer  of  the 
eye,  as  Scarpa  truly  observes,  is  less  destructive  than 
fungus  haernatodes,  and  that  for  two  important  reasons. 
In  the  first  place,  because  carcinoma  begins  on  the  ex- 
terior parts  of  the  eye,  so  that  whatever  relates  to  the 
origin  and  formation  of  the  disease  is  open  to  observa- 
tion ; and,  secondly,  because  the  cancerous  fungus  of 
the  eye,  on  its  first  appearance,  is  not  actually  malig- 
nant, but  becomes  so  in  process  of  time,  or  from  im- 
proper treatment,  previously  to  which  p>criod  good  sur- 


gery may  be  employed  with  effect.  In  this  light  Scarpa 
views  many  excrescences  on  the  conjunctiva  and  ante-' 
rior  hemisphere  of  the  eye,  which  appear  in  consequence 
of  a staphyloma  of  the  cornea,  long  exposed  to  the  air 
and  ulceration ; those  which  arise  from  relaxation  and 
chronic  inflammation  of  the  conjunctiva ; from  ulcera- 
tion of  the  cornea,  neglected  or  improperly  treated ; 
from  violent  ophthalmy,  not  of  a contagious  nature, 
treated  in  the  acute  stage  with  astringent  and  irritating 
applications ; from  suppuration  of  the  eye,  rupture  of 
the  cornea,  and  w’asting  of  the  eyeball ; or  from  blows  or 
bums  on  the  part.  Nothing,  says  Scarpa, is  more  pro- 
bable, than  that  all  these  ulcerated  fungi  were,  on  their 
first  appearance,  not  of  malignant  character,  or  certainly 
not  cancerous,  and  that  many  of  them  w ere  not  actually 
so  at  the  time  of  a successful  operation  being  done. 

Now,  in  the  opinion  of  the  same  valuable  author, 
there  is  no  criterion  as  yet  known  of  the  precise  time 
when  a sarcoma  of  the  eye  changes  from  the  state  of  a 
common  ulcerated  fungus  to  that  of  carcinoma ; for  the 
exquisite  sensibility,  darting  pains,  rapidity  of  growth, 
colour,  and  ichorous  discharge  are  not  an  adequate 
proof  of  cancer.  The  symptom,  how'ever,  on  which 
he  is  inclined  to  place  the  greatest  dependence,  as  a 
mark  of  the  change  in  question,  is  the  almost  cartilagi- 
nous hardness  of  the  malignant  ulcerated  fungus, 
which  induration,  he  asserts,  is  not  met  w ith  in  the 
benign  fungus,  and  never  fails  to  precede  tlie  formation 
of  cancer. — (See  Scarpa,  On  the  Eye,  transl.  by  Briggs, 
edit.  2,  p.  511-513.) 

4thly.  The  last  difference  of  fungus  haernatodes  from 
cancer  of  the  eye  here  to  be  noticed,  is  the  pulpy  soft- 
ness of  the  whole  of  the  di.seased  mass  in  the  first  of 
these  diseases ; a character  completely  opposite  to  the 
firm  almost  cartilaginous  consistence  of  the  carcino- 
matous fungus. 

Before  describing  the  operation  of  removing  an  eye 
affected  with  malignant  disease,  the  following  corolla- 
ries, drawn  by  Scarpa,  should  be  recollected.  1.  The 
complete  extirpation  of  the  eye  for  the  cure  of  fungus 
haernatodes,  although  performed  on  the  first  appear- 
ance of  the  disease  under  the  form  of  a yellowish  spot 
deeply  seated  in  the  eye,  is  useless,  and  rather  acce- 
lerates the  death  of  the  patient. 

But  although  this  statement,  made  by  Scarpa,  may 
be  mostly  true,  I am  happy  to  say,  that  modem  expe- 
rience begins  to  raise  a hope  that  exceptions  to  the  fore- 
going melancholy  inference  are  possible.  Thus  Mr. 
Wishart  removed  from  a boy  nine  years  old  an  eye  that 
had  been  affected  wnth  fungus  haernatodes  about  four 
months,  and  no  relapse  had  taken  place  eighteen  months 
after  the  operation.-^See  Edin.  Med.  and  Surg.Journ. 
Xo.  :4,p.  51.) 

2.  The  exterior  fungous  excrescence  of  the  eye,  com- 
monly called  carcinoma,  beginning  on  the  conjunctiva 
and  anterior  hemisphere,  while  it  is  soft,  flexible,  and 
indpy,  although  accompanied  with  symptoms  similar 
to  those  of  carcinoma,  is  not  actually  this  disease,  nor 
does  it  become  malignant  and  strictly  cancerous  until 
it  is  rigid,  hard,  coriaceous,  warty,  and  in  every  re- 
spect scirrhous. 

3.  The  inveterate  fungous  excrescence,  hard  to  the 
touch  in  all  its  parts,  covered  with  ulcerated  warts, 
which  has  involved  the  whole  of  the  eyeball,  optic  nerve, 
and  surrounding  parts,  and  rendered  the  bones  of  the 
orbit  carious,  and  contaminated  the  lymphatic  glands 
behind  the  angle  of  the  jaw  andin  theneck,  isincurable. 

4.  On  the  contrary  the  partial  or  total  extirpation  of 
the  eye  will  succeed  when  attempted  before  the  exter- 
nal fungous  excrescence  has  changed  from  the  state  of 
softness  to  that  of  a scirrhous,  warty,  and  carcinoma- 
tous badness. — ( Vol.  cit.  p.  526.) 

The  operation  of  removing  the  eye  was  first  per- 
formed in  the  sixteenth  century  by  Bartisch,  a Ger- 
man, who  employed  a coarsely  constructed  instrument 
shaped  like  a spoon,  with  cutting  edges,  and  by  means 
of  which  the  eye  was  separated  from  the  surrounding 
parts,  and  taken  out  of  the  orbit.  This  instrument  was 
too  broad  to  admit  of  ready  introduction  to  the  deep 
contracted  part  of  the  orbit,  so  that  when  it  was  used 
either  a part  of  the  disease  was  likely  to  be  left  be- 
hind, or  the  thin  bones  of  the  orbit  to  be  fractured 
in  the  attempt  to  pass  it  more  deeply  into  tliat  ca- 
vity. FabricmsHildanus  learned  these  inconveniences 
from  experience,  and  in  order  to  avoid  them,  devised  a 
sort  of  probe-]X)inted  bistoury.  Bidloo  made  use  of 
scissors  and  a i<oialed  bistoury. 


EYE 


EYE 


367 


La  Vauguyon  is  the  first  French  surgeon  who  spoke 
of  this  operation ; and  all  his  countrymen  may  be  said 
to  have  regarded  the  operation  as  useless,  cruel,  and 
dangerous,  until  St.  Ives  performed  it  with  success. 
Heister  preferred  operating  with  the  bistoury  alone. 
Several  English  surgeons  used  a sort  of  curved  knife, 
an  engraving  of  which  is  given  in  B.  Bell’s  system  ; 
but  for  dissecting  out  the  tumour  this  instrument  was 
regarded  by  Louis  as  less  convenient  than  a straight 
bistoury. 

Thus  far  the  plans  of  operating  advised  by  authors 
were  not  guided  by  any  fixed  rules.  Louis  endea- 
voured to  lay  down  such  rules,  and  for  a long  while 
his  method  was  mostly  adopted  in  France.  It  consists 
in  dividing  the  attachments  of  the  eye  to  the  eyelids  ; 
then  those  of  the  small  oblique  muscle;  next  those 
of  the  great  oblique  muscle ; then  those  of  the  levator 
palpebrie  superioris,  varying,  according  to  their  inser- 
tions, the  manner  of  holding  the  knife.  The  eyeball 
is  afterward  detached,  and  the  four  straight  muscles 
and  optic  nerve  divided  with  a pair  of  scissors. 

This  way  of  operating,  founded  upon  anatomical 
principles,  seems  at  first  glimpse  to  offer  a method  in 
which,  as  Louis  remarks,  each  stroke  of  the  instru- 
ment is  guided  by  the  knowledge  of  the  parts.  But  it 
is  to  be  noticed,  that  these  parts,  being  altered  by  dis- 
ease, most  commonly  do  not  present  the  same  struc- 
ture and  relations  which  they  do  in  the  natural  state  ; 
and  that  the  flattened,  lacerated,  destroyed  muscles,  on 
their  being  confused  with  the  eye  itself,  cannot  serve, 
as  in  lithotomy,  for  the  foundation  of  any  precept  re- 
lative to  the  operation.  Desault  considered  the  scis- 
sors unnecessary,  because  the  inclination  of  the  outer 
side  of  the  orbit  will  always  allow  a bistoury  to  be 
carried  to  the  bottom  of  this  cavity,  so  as  to  divide, 
from  above  downwards,  the  optic  nerve  and  muscular 
attachments. 

Hence,  after  having  practised  and  taught  the  method 
of  Louis,  he  returned  to  Heister’s  advice,  who  directs 
only  a bistoury  to  be  employed.  To  have  an  exact 
idea  of  the  mode  of  operating,  which  is  always  easy 
and  simple  with  this  one  instrutnent,  we  must  sup- 
pose the  carcinoma  to  be  in  three  different  states.  1. 
When  the  tumour  hardly  projects  out  of  the  orbit,  so 
that  the  eyelids  are  free.  2.  When  it  is  much  larger, 
projects  considerably  forwards,  and  jiushes  in  this  di- 
rection the  healthy  eyelids,  which  are  in  contact  with 
it,  together  with  a portion  of  the  conjunctiva  which 
invests  them,  and  is  now  detached  from  them.  3. 
When,  at  a much  more  advanced  period,  the  eyelids 
particii)ate  in  the  cancerous  state.  In  the  first  case, 
the  eyelids  must  be  separated  from  the  eye,  by  cut- 
ting through  the  conjunctiva,  where  it  turns  to  be  re- 
flected over  the  globe  of  the  eye.  In  the  second  in- 
stance, the  eyelids  and  conjunctiva,  which  are  in  con- 
tact with  the  diseased  eye,  must  be  dissected  from  it. 
In  the  third,  these  parts  must  be  cut  away,  together 
with  the  eye. — ((Euvres  Chir.  de  Desault,  t.  2.) 

After  the  above  observations,  and  the  additional  in- 
formation on  the  subject,  contained  in  the  last  edition 
of  the  First  Lines  of  the  Practice  of  Surgery,  I shall 
conclude  this  article  with  a few  brief  directions. 

When  the  eyeball  is  exceedingly  enlarged,  it  is  ne- 
cessary to  divide  the  eyelids  at  the  external  angle,  in 
order  to  facilitate  the  operation.  The  surgeon  can  in 
general  operate  most  conveniently  when  he  employs 
a common  dissecting  knife,  and  when  his  patient  is  lying 
down  with  his  face  exposed  to  a good  light.  In  cutting 
out  a diseased  eye,  it  is  necessary  to  draw  the  part  for- 
wards regularly  as  its  surrounding  attachments  are 
divided,  in  order  that  its  connexions,  which  are  still 
more  deeply  situated,  may  be  reached  with  the  knife. 
This  object  cannot  be  very  well  accomiilished  with  the 
fingers  or  forceps,  and  therefore  most  surgical  writers 
recommend  us  either  to  introduce  a ligature  through 
the  front  of  the  tumour  (see  Travers,  Synopsis,  p.  308), 
or  to  employ  a hook  for  the  purpose  of  drawing  the  pan 
in  any  direction  during  the  operation,  which  the  ne- 
cessary proceedings  may  require.  When  the  eyelids 
are  diseased,  they  must  be  removed ; but  if  prudence 
sanctions  their  being  preserved,  this  is  an  immense 
advantage.  The  eye  must  not  be  drawn  out  too  forci- 
bly before  the  optic  nerve  is  divided,  and  care  must  be 
taken  not  to  penetrate  any  of  the  foramina,  or  thin  parts 


of  the  orbit  with  the  point  of  the  knife,  for  fear  of  in- 
juring the  brain.  Great  care  should  also  be  taken  to 
leave  no  diseased  parts  in  the  orbit  unremoved.  The 
hemorrhage  may  be  stopped  by  filling  the  orbit  with 
scraped  lint,  and”  applying  a compress  and  bandage.  It 
is  constantly  advisable  to  remove  the  lachrymal  gland, 
as  this  part  seems  to  be  particularly  apt  to  be  tho 
source  of  such  inveterate  fungotis  diseases  as  too  often 
follow  the  operation. 

Mr.  Travers,  with  a straight  double-edged  knife, 
freely  divides  the  conjunctiva  and  oblique  muscles,  so 
as  to  separate  the  eyeball  and  lachrymal  gland  from  the 
base  of  the  orbit.  Drawing  the  ej^e  then  gently  forwards 
wnth  the  ligature,  be  introduces  a double-edged  knife, 
“ curved  breadthwise,”  at  the  temporal  commissure 
of  the  lids,  for  the  purpose  of  dividing  the  muscles, 
vessels  and  nerves,  by  which  the  globe  remains  at- 
tached. The  hemorrhage  he  represses  with  a small 
bit  of  fine  sponge  put  into  the  orbit,  and  a light  com- 
press applied  over  the  eyelids,  and  supported  with  a 
bandage.  The  sponge,  he  says,  should  not  be  suffered 
to  remain  longer  than  the  following  day,  when  a soft 
poultice  in  a muslin  bag  may  be  substituted  for  the 
compress.  He  approves  of  giving  an  opiate  at  bed- 
time, and  joins  the  late  Mr.  Ware  in  condemning  the 
practice  of  cramming  the  orbit  with  lint,  or  charpie, 
and  leaving  it  to  be  discharged  by  suppuration. — {Sy- 
nopsis of  the  Diseases  of  the  Eye,p.  308.) 

For  a few  days  after  the  operation,  antiphlogistic 
treatment  is  proper.  The  patient  should  be  kept  in 
bed  until  all  risk  from  inflammation  is  past,  and  sup- 
puration has  been  freely  established.  In  one  case  ope- 
rated upon  by  Mr.  Guthrie,  the  symptoms  of  inflam- 
mation were  so  violent  that  it  was  necessary  to  take 
away  250  ounces  of  blood  in  the  course  of  the  first 
three  days— {Operative  Surgery  of  the  Eye,  p.  183.) 
Sometimes  fungous  granulations  continually  form  in 
the  orbit,  notwithstanding  they  are  repeatedly  destroyed; 
and  sometimes  the  disease  extends  even  to  the  brain, 
and  produces  fatal  consequences.  When  malignant 
fungous  excrescences  grow  from  the  cornea  alone,  it  is 
clearly  unnecessary  to  extirpate  the  whole  eyeball. 

P'or  information  relating  to  the  subjects  of  this  article, 
consult  particularly  M.  TOofre  sur  plusieurs  Maladies 
dv  Globe  de  V'F.il;  ou  Von  examine  particular ement 
les  cas  qui  exigent  Vexiirpation  de  cet  organe,  et  la 
mithode  d'y  proa  der ; parM.  Louis,  in  Mem.  de  VAcad, 
de  Chir.  1. 13,  p.  262,  edit,  in  \2mo.  C.F.  Kailtschmcid, 
Programma  de  oculo  ulcere  canceroso  laborante  fe- 
liciter  extirpato,  A c.  JencB,  1748.  J.  G.  G.  Voit, 
Oculi  Hitmani  Anatomia  et  Pathologia  ejusdemque  tn 
statu  morboso  Extirpatio,  Svo.  Norimb.  1810.  Ber~ 
trandi,  TraiU  des  Operations  de  Chirurgie,  p.  519,  ed, 
1784,  Paris.  Sabatier,  De  la  M decine  Op-ratoire,  t. 
3,  p.  54,  ed.  1.  Richter,  Aiifangsgr.  der  Wundarzn, 
b.  3,  p.  415,  Gott.  1795.  Mn'noire  sur  VExtirpation  de 
Vlhil  Carcinomateux,  in  thuvres  Chir.  de  Desault  par 
Bichat,  t.  2,  p.  102.  Richerand,  Nosographie  Chir.  t. 
2,  p.  103,  A c.  edit.  2.  Ware,  in  Trans,  of  the  Medical 
Society  of  London,  vol.  1,  part  1,  p.  140,  A c.  Lassusy 
Pathologic  Chir.  t.  1,  p.  450,  edit.  1809.  Wardrop  on 
Fungus  Hcematodes,  p.  93,  <^c.  Scarpa  on  the  Princi- 
pal Diseases  of  the  Eye,  chap.  21,  edit.  2,  transl.  by 
Briggs,  8vo.  Lond.  1818.  B.  Travers,  A Synopsis  of 
the  Diseases  of  the  Eye,  sec.  4,  8vo.  London,  1820. 

H.  Wishart,  in  Edin.  Med.  and  Surg.  Journ.  No.  74, 
G.  J.  Guthrie,  Operative  Surgery  of  the  Eye,  p.  178, 
A-c.  8vo.  Lond.  1823. 

EYE,  DISEASES  OF.  Amaurosis  ; Cataract, 
Cornea ; Encanthis ; Exophthalmia ; Fungus  Hae- 
matodes ; Gvtta  Serena;  Hemeralopia;  Hydroph- 
thalmia ; Hypopium  ; Iris ; Leucoma  ; Nyctalopia  ; 
0])hthalmy ; Pterygium ; Pupil,  Closure  of ; Staphylo- 
ma, A c.  iVc. 

EYELIDS,  DISEASES  OF.  See  Ectropium  ; Hor- 
deolum; Lagopht.halmus ; Ptosis;  Trichiasis;  and 
Tumours,  Encysted.  In  the  examination  of  the  inte- 
rior of  the  upper  eyelid,  a modern  and  very  convenient 
plan  is  now  pursued,  namely,  that  of  everting  the  part 
over  a probe  placed  just  across  the  ujtper  edge  of  the 
cartilage  of  the  tarsus,  which  is  then  to  be  suddenly 
inclined  outwards,  when  the  whole  inner  surface  of 
the  lid  will  be  exposed,  the  part  contiftuing  in  this) 
everted  state  until  replaced  by  the  surgeon. 


( 368  ) 


FEV 


F 


FEV 


f^EVERS,  SURGICAL.  Under  this  head  may  be 
^ comprehended  two  species  of  fever,  viz.  the  in- 
Jlammatory  and  the  hectic,  which  are  particularly  in- 
teresting to  surgeons,  because  frequently  attendant  on 
surgical  disorders. 

In  treating  of  inflammation,  I have  mentioned  that 
a febrile  disturbance  of  the  constitution  is  attendant 
on  every  considerable  inflammation.  In  the  present 
article,  some  account  will  be  offered  of  the  particulars 
of  this  disorder. 

The  fever  about  to  be  described  is  knowai  and  dis- 
tinguished by  several  names;  some  calling  it  inflam- 
matory, some  symptomatic,  and  others  sympathetic. 
It  is  supposed  by  certain  writers  to  be  sometimes  idio- 
pathic; that  is,  to  originate  at  the  same  time  with  the 
local  inflammation,  and  from  the  same  causes.— (/. 
Bams.)  In  other  instances,  and,  indeed,  we  may  say, 
in  all  ordinary  surgical  cases,  it  is  symptomatic ; or,  in 
other  words,  it  is  produced,  not  directly  by  the  causes 
which  originally  produced  the  inflammation,  but  in 
consequence  of  the  sympathy  of  the  whole  constitution 
with  the  disturbed  state  of  a part. 

Mr.  Travers’s  opinions  seem  partly  to  coincide  with 
those  of  Mr.  Burns,  though  differently  expressed.  He 
considers  constitutional  irritation  to  be  of  two  kinds, 
direct  and  reflected  ; by  which  he  implies.  “ that  the 
tirst  is  wholly  and  immediately  derived  from  the  part, 
commences  and  is  identified  with  the  local  mischief, 
and  the  constitution  has  no  share  in  its  production. 
The  second,  on  the  contrary,  originates  in  a peculiar 
morbid  state  of  the  constitution,  to  w'hich  the  injury  or 
inflammation  has  given  birth,  or  it  may  be  previously 
existing.  The  first  is  trul?’  symptomatic,  never  ori- 
ginating spontaneously,  and,  being  immediately  in- 
duced by  the  local  irritation,  is  capable  of  being  essen- 
tially mitigated  or  arrested  by  its  removal.  The  se- 
cond is  occasionally  purely  idiopathic,  and,  being 
oftener  the  cause  than  the  effect  of  the  local  action,  is 
seldom  influenced  by  the  local  treatment.  In  the  first, 
the  local  changes  are  dependent  on  local  causes ; in 
the  second  they  depend  on  constitutional  causes.” — 
(See  Travers  on  Constitutional  Irritation,  p.  47.)  As 
the  expression  reflected  irritation,  if  understood  in  its 
literal  sense,  involves  the  reader  in  an  hypothesis 
which  is  perhaps  not  correct,  I do  not  see  any  advan- 
tage in  the  employment  of  it.  Used  figuratively, how- 
ever, it  may  be  as  allowable  as  many  other  expres- 
sions in  medical  latiguage. 

Idiopathic  inflammatory  fever  is  said  to  be  alw'a)  s 
preceded  by  chilliness.  The  symptomatic  or  sympa- 
thetic inflammatory  fever  sometimes  takes  place  so 
quickly  in  consequence  of  the  violence  of  the  exciting 
cause  or  of  the  local  inflammation,  that  no  preceding 
coldness  is  observable.  If,  however,  the  local  inflam- 
mation be  more  slowly  induced,  and  consequently  ope- 
rate more  gradually  on  the  system,  then  the  coldness 
is  evidently  perceived.  The  symptomatic  fever,  in- 
duced by  scalding  or  burning  a part,  is  quickly  pro- 
duced, and  we  have  very  little  time  to  attend  to  the 
earliest  period  of  its  formation.  On  the  other  hand, 
the  symptomatic  fever  induced  by  wounds  is  excited 
more  slowly,  and  the  peried  of  its  formation  is  longer. 
This  fever  is  not  produced  when  the  inflammation  only 
a.ffects  parts  in  a slight  degree ; but  it  makes  its  ap- 
pearance if  the  local  inflammation  be  considerable,  or 
if  it  affect  very  sensible  parts. — yBums.) 

The  degree  in  which  the,  symptomatic  fever  is  ex- 
cited, does  not  altogether  depend  upon  the  absolute 
quantity  or  violence  of  the  inflammation  ; but,  in  a 
great  measure,  upon  the  degree  of  the  local  inflamma- 
tory action,  compared  with  the  ’natural  power  and  ac- 
tion of  the  part  affected.  Parts  in  which  the  action  is 
naturally  low,  are  extremely  painful  when  inflamed, 
and  the  system  sympathizes  greatly  wiih  them.  Hence 
the  constitution  is  very  much  affected  when  tendons, 
bones,  or  ligaments  are  the  parts  inflamed.  Severe 
inflammation  of  a large  joint,  every  one  knows,  is  apt 
to  excite  the  most  alarming  and  even  fatal  derange- 
ment of  the  system.  When  very  sensible  parts  are 
inflamed,  as,  ibr  instance,  the  eye,  the  symptomatic 
fever  is  generally  more  considerable  tiian  it  would  be, 


were  it  to  arise  from  an  equal  quantity  and  degree  of 
inflammation  in  a less  sensible  organ. 

In  common  parts,  as  muscles,  cellular  membrane, 
skin,  <fcc.,  the  symptoms  will  be  acute;  the  pulse 
strong  and  full,  and  the  more  so  if  the  inflammation 
be  near  the  heart ; but  perhaps  not  so  quick  as  w’hen 
the  part  is  far  from  it  : the  stomach,  will  sympathize 
less,  and  the  blood  will  be  pushed  farther  into  the  small 
vessels. 

If  the  inflammation  be  in  tendinous,  ligamentous, 
or  bony  parts,  the  symptoms  will  be  less  acute,  the  sto- 
mach will  sympathize  more,  the  pulse  will  not  be  so 
Bill,  but  perhaps  quicker;  there  will  be  more  irrita- 
bility, and  the  blood,  not  being  propelled  so  well  into 
small  vessels,  will  forsake  the  skin 

It  seems  to  be  a material  circumstance  whether  the 
inflammation  be  in  the  upper  or  lower  extremity;  that 

is,  far  from  or  near  the  heart ; for  the  s3  inptoms  are 
more  violent,  the  constitution  more  affected,  and  the 
power  of  resolution  less,  when  the  part  inflamed  is  far 
from  the  source  of  the  circulation,  than  w’hen  near 

it,  even  wiien  the  parts  are  similar,  both  in  texture 
and  use. 

If  the  heart  or  lungs  are  inflamed, either  immediately 
or  secondarily,  by  sympathy,  the  disease  has  more  vio- 
lent effects  upon  the  constitution  than  the  same  quan- 
tity of  inflammation  would  have  if  the  part  affected 
w ere  not  a vital  one,  or  one  with  which  the  vital  parts 
did  not  sympathize.  If  the  part  be  such  as  the  vital 
ones  readily  sympathize  with,  then  the  sympathetic 
action  of  the  latter  will  affect  the  constitution,  as  in  an 
inflammation  of  the  testicle.  In  such  cases  the  pulse 
is  much  quicker  and  smaller,  and  the  blood  is  more 
sizy  than  if  the  inflammation  were  in  a common  part, 
such  as  muscle,  cellular  membrane,  and  skin. 

VMien  the  stomach  is  inflamed,  the  patient  feels  an 
oppression  and  dejection  through  all  the  stages  of  the 
inflammation ; the  pulse  is  generally  low  and  quick, 
and  the  pain  obtuse,  strong,  and  oppressive ; such  as 
the  patient  can  hardly  bear.  If  the  intestines  are  much 
affected,  the  same  symptoms  take  place,  especially  if 
the  inflammation  be  in  the  upper  part  of  the  canal ; but 
if  only  the  colon  be  affected,  the  patient  is  more  roused, 
and  tlie  pulse  is  fuller  than  when  the  stomach  alone  is 
inflamed.  When  the  uterus  is  inflamed,  the  pulse  is 
extremely  quick  and  low.  When  the  inflammation  is 
either  in  the  intestines,  testicle,  or  uterus,  the  stomach 
generally  sympathizes.  In  inflammation  of  the  brain, 
the  pulse  varies  more  than  in  the  same  affection  of  any 
other  part;  and  perhaps  we  must,  m tliis  instance, 
form  a judgm.ent  of  the  complaint  more  from  other 
symptoms  than  the  pulse. 

When  inflammation  is  situated  in  apart  not  very  es- 
sential to  life,  and  occasions  the  gener^  affection  of  the 
system,  called  inflammatory  fever,  the  pulse  is  fuller 
and  stronger  than  common,' and  the  blood  is  pushed 
farther  into  the  e.xtreme  arteries  fhaii  when  the  inflam- 
mation is  in  a vital  part.  The  patient,  after  many  oc- 
casional rigours,  is  at  first  rather  roused.  The  pulse 
is  as  above  described,  when  the  constitution  is  strong 
and  not  irritable  ; but  if  this  be  extremely  irritable  and 
w’eak,  as  in  many  women  who  lead  -sedentary  lives, 
the  pulse  may  be  quick,  hard,  and  small,  at  the  com- 
mencement of  the  inflammation,  just  as  if  the  vital 
parts  were  concerned.  The  blood  may  also  be  sizy ; 
but  it  will  be  loose  and  flat  on  the  surface. — (Hunter.) 

The  kind  of  constitution  makes  a great  difference; 
and,  as  Mr.  Travers  has  justly  observed,  “it  is 
scarcely  necessary  to  illustrate  the  influence  of  an  ir- 
ritable temiterament  upon  the  consequences  of  casual 
injury  or  disease.  Practically,  we  all  know  it  well. 
\Ve  say,  such  a person  leould  be  a bad  subject  for  a 
compound  fracture;  and  whoever  has  had  opportuni- 
ties of  w’atching  several  subjects  of  compound  frac- 
ture under  treatment  at  one  and  the  same  time,  well 
knows  the  import  of  this  phrase,  and  that  the  greatest 
degree  of  mischief  is  ollen  accompanied  by  the  lea.st 
constitutional  disturbance,  and  for  this  reason  is 
sfjonest  and  most  perfectly  restored. . The  first  few 
hours  will  enable  an  experienced  observ  er  to  determine 
whether  the  subject  of  a senous  injur)  or  operation 


FEVERS. 


369 


■will  do  •well  or  otherwise.  How  vastly  different  in 
different  individuals  is  the  inconvenience  attending 
such  minor  derangements  as  a bile,  an  enlarged  gland, 
a whitlow,  or  a simple  ophthalmia ! In  some,  the  con- 
stitution seems  ignorant  of  the  affair,  and  the  indivi- 
dual pursues  his  ordinary  occupations.  In  others,  the 
whole  system  sympathizes;  the  spirits  are  ruffled; 
the  nights  are  restless,  the  appetite  fails;  the  pulse 
acquires  an  undue  bound  ; and  the  white  tongue,  the 
creeping  chilliness,  and  slight  erratic  pains  of  symp- 
tomatic fever  are  present.” — {Travers  on  Constitu- 
tional Irritation,  p.  15.) 

We  may  set  down  the  ordinary  symptoms  of  inflam- 
matory fever,  occurring  in  consequence  of  local  in- 
flammation in  common  parts  and  in  a healthy  habit, 
as  follows:  The  pulse  is  frequent,  full,  and  strong; 
all  the  secretions  are  diminished ; the  patient  is  vigi- 
lant and  restless ; the  perspiration  is  obstructed,  and 
the  skin  is  hot  and  dry ; the  urine  is  high-coloured  and 
in  small  quantity ; the  mouth  is  parched  and  the  tongue 
furred  ; an  oppressive  thirst  is  experienced  ; with  dis- 
turbance of  the  nervous  system ; loss  of  appetite  and 
sleep ; and,  in  some  cases,  delirium. 

TREATMENT  OF  INFLAMMATORY  FEVER. 

Upon  this  part  of  the  subject  very  little  is  to  be  said; 
fbr  as,  in  almost  every  instance,  the  febrile  disturbance 
of  the  system  is  produced  and  entirely  kept  up  by  the 
local  inflammation,  it  must  be  evident  that  the  means 
employed  for  diminishing  the  exciting  cause,  are  also 
the  best  for  abating  the  constitutional  effects.  Hence 
it  very  seldom  happens  that  any  particular  measures 
are.  adopted  expressly  for  the  fever  itself;  as  this  af- 
fection IS  sure  to  subside  in  proportion  as  the  local  in- 
flammation is  lessened  or  resolved.  But  when  the 
febrile  disturbance  is  considerable,  and  the  inflamma- 
tion itself  is  also  considerable,  the  agitated  stale  of  the 
system  may  have  in  its  turn  a share  in  keeping  up  and 
even  increasing  the  local  affection,  and  should  be 
quieted  as  much  as  possible.  However,  in  these 
very  instances,  in  all  probability,  we  should  be  led  to 
a more  rigorous  adoption  of  the  antiphlogistic  plan  of 
treatment,  by  an  abstract  consideration  of  the  state  of 
the  local  inflammation  itself,  without  any  reference  to 
that  of  the  constitution.  Indeed,  the  increased  action 
of  the  heart  and  arteries,  and  the  suppression  of  the 
secretions,  require  the  employment  of  antiphlogistic 
means  and  antimonials,  the  very  same  things  which 
are  indicated  for  the  resolution  of  the  local  inflamma- 
tion itself.  Bleeding,  purging,  cold  drinks,  low  diet ; 
the  exhibition  of  the  antimonmra  tartarizatum,  James’s 
powder,  or  the  common  antimonial  powder ; and  bath- 
ing the  feet  and  body  in  warm  water,  are  measures 
which  have  the  greatest  efficacy  in  tranquillizing  the 
constitutional  disturbance  implied  by  the  term  inflam- 
matory fever.  But  I think  it  right  to  repeat,  that  it  is 
hardly  ever  necessary  to  have  recourse  to  such  an  eva- 
cuation as  general^ bleeding  merely  on  account  of 
the  fever;  as  this  is  only  an  effect  which  invaria- 
bly subsides  in  proportion  as  the  local  cause  is  dimi- 
nished. 

As  Dr.  Thomson  has  remarked,  “ the  inflammatory 
fever,  succeeding  to  external  injuries  or  to  chirurgical 
operations,  undergoes  a kind  of  natural  crisis,  by  the 
appearance  of  suppuration.  In  these  instances,  there- 
fore, unless  when  the  patient  is  strong  andm  full  health, 
when  the  disease  is  seated  in  an  organ  of  much  im- 
portance to  life,  or  is  in  danger  of  spreading,  as  is  the 
case  in  all  inflammations  of  the  membranes  lining  the 
three  great  cavities  of  the  body,  the  lancet  ought  to  be 
used  with  caution.  For  we  may,  by  too  free  a detrac- 
tion of  blood,  produce  a sudden  sinking  of  the  powers 
of  life,  and  convert  the  existing  constitutional  symp- 
toms into  fever  of  a different  type  or  character.  But 
in  all  cases  of  inflammation  in  which  any  doubt  arises 
with  regard  to  the  farther  general  detraction  of  blood, 
it  may,  I believe,  he  laid  down  as  a general  rule,  that  it 
is  safer  to  employ  local  than  general  blood-letting.”— 
{Lectures  on  Inflammation,  p.  170.) 

HECTIC  FEVER. 

The  sympathetic  or  symptomatic  fever  already  de- 
scribed is  an  immediate  affection  of  the  constitution. 

In  consequence  of  some  local  disorder ; hectic  fever  is 
a remote  effect.  When  hectic  fever  is  a consequence 
of  local  disease,  it  has  commonly  been  preceded  by  in- 
flammation and  suppuration ; but  there  is  an  inability 
VoL.  L— A a 


to  produce  granulation  and  cicatrization  ; and  the  cure, 
of  course,  cannot  be  accomplished.  The  constitution 
may  now  be  said  to  be  oppressed  with  a local  disease 
or  irritation  from  which  it  cannot  deliver  itself, 

A distinction  should  be  made  between  hectic  fever 
arising  entirely  from' a local  complaint  in  a good  con- 
stitution, which  is  only  disturbed  by  too  great  an  irrita- 
tion, and  hectic  fever  arising  principally  from  the  bad- 
ness of  the  constitution,  which  does  not  dispose  the 
parts  to  heal.  In  the  first  species  it  is  only  necessary 
to  remove  the  part  (if  removable),  and  then  all  will  do 
well ; but  in  the  second,  nothing  is  gained  by  a removal 
of  the  part,  unless  the  wound  made  in  the  operation 
is  much  less,  and  more  easily  put  into  a local  method 
of  cure;  by  reason  of  which  the  constitution  sinks 
less  under  this  state  and  the  operation  together,  than 
under  the  former  disease.  Here  the  nicest  discrimina- 
tion is  requisite. — {Hunter.) 

Owing  to  a variety  of  circumstances,  hectic  fever 
comes  on  at  very  different  periods  after  the  inflammation, 
and  commencement  of  suppuration.  Some  constitu- 
tions, having  less  powers  of  resistance  than  others, 
must  more  easily  fall  into  this  state. 

Hectic  fever  takes  its  rise  from  a variety  of  causes, 
which  have  been  divided  into  two  species  with  regard 
to  diseased  parts ; viz.  parts  called  vital,  and  others  not 
of  this  nature.  Many  of  the  causes  of  hectic  fever, 
arising  from  diseases  of  the  vital  parts,  would  not 
produce  this  constitutional  affection  if  they  were  in 
any  other  part  of  the  body ; such,  for  instance,  is  the 
situation  of  tumours,  either  in,  or  so  situated  as  to 
press  upon  a vital  part,  or  one  whose  functions  are 
immediately  connected  with  life,  Scirrhi  in  the  sto- 
mach and  mesenteric  glands,  diseased  lungs,  liver,  &e. 
very  .soon  produce  hectic  fever. 

When  hectic  fever  arises  from  a disease  of  a part 
that  is  not  vital,  it  commences  sooner  or  later,  accord- 
ing as  it  is  in  the  pov.^er  of  the  part  to  heal  or  continue 
the  disease.  If  the  part  be  far  from  the  source  of  the 
circulation,  the  fever  will  come  on  sooner  v/ith  the 
same  quantity  of  disease.  When  the  disease  is  in  parts 
which  are  not  vital,  and  excites  hectic  fever,  it  is  gene- 
rally in  situations  where  so  much  mischief  happens  sm 
to  affect  the  constitution,  and  where  the  powers  of 
healing  are  little.  This  is  the  case  with  diseases  of 
many  of  the  joints.  We  must  also  include  parts  which 
have  a tendency  to  such  specific  diseases  as  are  not 
readily  cured  in  any  situation. 

Although  hectic  fever  commonly  arises  from  some 
incurable  local  disease  of  a vital  part,  or  from  an  ex- 
tensive disease  of  a common  part,  yet  it  is  possible  for 
it  to  be  an  original  disease  in  the  constitution,  without 
any  local  cause  whatever  that  can  be  specified. 

Hectic  is  a slow  mode  of  dissolution ; the  general 
symptoms  are  those  of  a low  or  slow  fever,  attended 
with  weakness.  But  there  is  rather  weak  action  than 
real  weakness ; for  upon  the  removal  of  the  hectic 
cause,  the  action  of  strength  is  immediately  produced, 
and  every  natural  function  is  re-established,  however 
much  it  may  have  been  previously  impaired. 

The  particular  symptoms  are  debility ; a small, 
quick,  and  sharp  pulse ; the  blood  forsakes  the  skin ; 
loss  of  appetite ; frequently  a rejection  of  all  aliment 
from  the  stomach ; wasting ; a great  readiness  to  be 
thrown  into  sweats  ; s}X)ntaneous  perspirations,  when 
the  patient  is  in  bed ; pale  coloured  and  very  copious 
urine;  and  often  a constitutional  purging. 

Hectic  fever  has  been  imputed  to  the  absorption  of 
pus  into  the  circulation ; but  no  doubt  much  exaggera- 
tion has  prevailed  in  the  doctrine  which  ascribes  to  this 
cause  many  of  the  bad  symptoms  frequently  attacking 
persons  who  have  sores.  When  suppuratum  takes 
place  in  particular  parts,  especially  vital  ones,  hectic 
fever  almost  constantly  arises.  It  akso  attends  many 
inflammations  before  suppuration  has  actually  hap- 
pened, as  in  cases  of  white  swelling  of  the  Large  joint's. 
The  same  quantity  and  species  of  inflammation  and 
suppuration  in  any  of  the  fleshy  parts,  especially  such 
as  are  near  the  source  of  the  circulation,  have  in  gene- 
ral no  such  effect.  Hence,  in  the  first  instances,  the 
fever  is  only  an  effect  on  the  system,  produced  by  a 
local  complaint  that  has  a peculiar  property 
The  constitution  sympathizes  more  readily  with  dis- 
eases of  vital  organs,  than  with  those  of  any  othei 
parts ; their  diseases  are  also  in  general  more  difficuU 
of  cure  than  the  same  affections  of  parts  which  are  nol 
vital.  All  diseases  of  bones,  ligaments,  and  tendon*. 


370 


FEV 


affect  the  constitution  more  readily  than  those  of  mus- 
cles, skin,  cellular  membrane,  &c. 

V/hen  the  disease  is  in  vital  parts,  and  is  such  as 
not  to  kill  by  its  first  constitutional  effects,  the  system 
tl'.en  becomes  teased  with  a complaint  which  is  dis- 
turbing the  necessary  actimis  of  health.  In  the  large 
joints,  a disease  continues  to  harass  the  constitution  by 
attacking  parts  which  have  no  power,  or  rather  no  dis- 
position^  to  produce  salutary  inflammation  and  suppu- 
ration. Thus,  the  system  is  also  irritated  by  the 
existence  of  an  incurable  disease.  Such  is  the  theory 
of  the  cause  of  hectic  fever. 

If  the  absorption  of  matter  always  produced  the 
symptoms  above  described,  how  could  any  patient  who 
has  a large  sore  possibly  escape  hectic  ? for  there  is 
no  reason  to  suppose  that  one  sore  can  absorb  more 
readily  than  another.  If  absorbed  matter  occasioned 
such  violent  effects  as  have  been  commonly  ascribed  to 
it,  why  does  not  venereal  matter  do  the  same?  We 
often  know  that  absorption  is  going  on  by  the  progress 
of  buboes.  A large  one,  just  on  the  point  of  bursting, 
has  been  known  to  be  absorb 'd,  in  consequence  of  a 
few  days’  sea-sickness.  The  person  continued  at  sea 
for  four-and-twenty  days  afterward,  yet  no  hectic 
symptoms  followed,  but  only  the  specific  constitutional 
effects,  which  were  of  a very  different  description. 

When  the  cavities  of  veins  are  inflamed,  matter  is 
sometimes  formed  within  these  vessels,  and  cannot  fail 
to  get  into  the  circulation  ; yet  hectic  symptoms  do  not 
arise.  Also  very  large  collections  of  matter,  produced 
without  visible  inflammation,  as  many  abscesses  of 
the  scrofulous  kind,  are  wfliolly  absorbed  in  a very- 
short  time,  but  no  bad  symptoms  are  the  consequence. 

We  may  conclude,  therefore,  that  the  absorption  of' 
pus  has  no  share  in  occasioning  hectic  fever.  Many 
arguments  might  be  adduced  to  expose  the  absurdity  of 
the  doctrine ; but  here  it  will  be  sufficient  to  refer  the 
reader  to  what  Mr.  Hunter  has  said  farther  on  the  sub- 
ject, in  his  work  on  inflammation 

It  is  much  more  probable  that  hectic  fever  arises 
from  the  effect,  which  the  irritation  of  a vital  organ,  or 
other  parts,  such  as  joints,  has  on  the  constitution, 
when  either  incurable  in  themselves,  or  are  so  for  a 
time  to  the  constitution. 

TREATMENT  OF  HECTIC  FEVER. 

There  is  no  method  of  curing  the  consequences  above 
related.  All  relief  must  depend  on  the  cure  of  the 
cause,  viz.  the  local  complaint,  or  on  its  removal. 

Tonic  medicines  have  been  recommended,  on  account 
of  the  evident  existence  of  great  debility.  Antiseptics 
have  also  been  given,  in  consequence  of  the  idea,  that 
when  pus  is  absorbed,  it  makes  the  blood  disposed  to 
putrefy.  For  these  reasons,  bark  and  wine  have  been 
exhibited.  In  most  cases,  bark  will  only  assist  in  sup- 
porting the  constitution.  Until  the  cause  is  removed, 
however,  there  seems  no  prospect  of  curing  a disorder 
of  the  constitution.  It  is  true,  tonic  medicines  may 
make  the  sj'stem  less  susceptible  of  the  disease,  and 
also  contribute  to  diminish  the  cause  itself,  by  dispos- 
ing the  local  complaints  to  heal.  When,  however, 
hectic  fever  arises  from  a specific  disease,  such  as  the 
venereal,  though  bark  may  en.ible  the  constitution  to 
bear  the  local  affection  better  than  it  other\vise  could 
do,  yet,  as  Mr.  Hunter  remarked,  it  can  have  little 
effect  upon  the  syphilitic  mischief. 

No  medicine,  not  even  bark  itself,  has  any  direct 
power  of  communicating  strength  to  the  human  con- 
stitution. All  that  can  be  done  in  the  treatment  of 
hectic  fever,  when  it  is  thought  inexpedient  or  imprac- 
ticable to  remove  the  morbid  part,  is  to  combat  particu- 
lar symptoms,  and  to  promote  digestion.  It  is  by 
bringing  about  the  latter  object  that  bark  in  these 
cases  is  useful.  The  infusion  of  cinchona,  and  the 
sulphate  of  quinine,  being  more  likely  to  agree  with 
the  stomach  than  the  decoction  or  powder,  should  ge- 
nerally be  preferred.  Nourishing  food,  easy  of  diges- 
tion, should  be  frequently  taken  in  .small  quantities 
at  a time.  Nothing  is  more  prejudicial  to  a weak  con- 
stitution than  overloading  the  stomach.  Wine  may 
also  be  given,  but  not  too  freely,  and  not  at  all  if  it 
should  create  heartburn,  as  it  sometimes  does  in  hectic 
patients.  Madeira  is  less  apt  than  port  to  have  this  dis- 
agreeable effect.  In  these  cases  it  is  likewise  often  found 
useful  to  administer  gentle  cordial  aromatic  draughts. 
But  of  all  m.edicines,  opium  is  perhaps  the  most  valu- 
able to  those  who  are  alflicted  with  hectic  ftAxr;  it 


FIIS 

Mleviates  pain,  procures  sleep,  and  checks  the  diarThreS/ 
which  so  frequently  contributes  to  hasten  the  patient’s 
dissolution. 

When  the  local  complaint  connected  with  this  fever 
is  totally  incurable,  it  must,  if  possible,  be  removed  by 
a manual  operation.  Thus,  when  a diseased  joint 
keeps  up  hectic  fever,  and  seems  to  present  no  hope  of 
cure,  amputation  must  be  performed.  But  when  the 
local  disease  is  attended  with  a chance  of  cure,  pro- 
vided the  state  of  the  constitution  were  improved,  the 
surgeon  is  to  endeavour  to  support  the  patient’s  strength. 
Great  discretion,  however,  must  be  exercised  in  de- 
ciding how  long  it  is  safe  to  oppose  the  influence  of  an 
obstinate  local  disease  over  the  system,  by  the  power 
of  medicine ; for,  although  some  patients  in  an  abject 
state  of  weakness  have  been  restored  to  health  by  a 
removal  of  the  morbid  part,  many  have  been  suffered 
to  sink  so  low,  that  no  future  treatment  could  save 
them  from  the  grave.  Clemency  in  the  practice  of  sur- 
gery does  not  consist  so  much  in  delaying  strong  and 
' vigorous  measures,  as  in  boldly  deciding  to  put  them 
in  execution  as  soon  as  they  are  indicated. 

When  hectic  fever  arises  from  local  diseases  in 
parts  which  the  constitution  can  bear  the  removal  of, 
such  parts  should  be  taken  away,  if  they  cannot  be 
cured  consistently  with  the  advice  already  given.  WTien 
the  disease  arises  from  some  incurable  disease  in  an 
extremity,  and  amputation  is  performed,  all  the  above- 
mentioned  symptoms  generally  cease  almost  immedi- 
ately after  the  removal  of  the  limb.  Thus,  as  Mr. 
Hunter  has  correctly  observed,  a hectic  pulse  at  one 
hundred  and  twenty  has  been  known  to  sink  to  ninety 
in  a few  hours  after  the  removal  of  the  hectic  cause. 
Persons  have  been  known  to  sleep  soundly  the  first 
night  afterward,  who  had  not  slept  tolerably  for  several 
preceding  weeks.  Cold  sweats  have  stopped  immedi- 
ately, as  well  as  those  called  colliquative.  A purging 
has  immediately  ceased,  and  the  urine  begun  to  drop  its 
sediment. 

FICATIO,  or  FICUS.  (A  fig.)  A tubercle  about 
the  anus  or  pudenda  resembling  a fig. 

FINGERS,  ABSCESSES  OF.  See  Whitlow. 

Fingers,  Amputation  of.  See  Amputation. 

Fingers,  Necrosis  of.  In  these  cases,  the  surgeon 
is  to  endeavour  to  extract  the  exfoliating  portions  of 
bone  iimnediately  they  become  loose.  For  this  pur- 
pose, he  is  justified  in  making  such  incisions  as  will 
enable  him  to  fulfil  the  object  in  view.  Until  the  pro- 
cess of  exfoliation  is  sulHciently  advanced,  he  can  do 
little  more  than  apply  simple  dressings,  and  keep  the 
part  in  a clean,  quiet  state. 

When  the  separation  of  the  dead  pieces  of  bone  will 
certainly  destroy  the  utility  of  the  finger,  and  convert 
the  part  into  an  inconvenient,  stiff  appendage  to  the 
hand ; or,  when  the  patient’s  health  is  severely  im- 
paired by  the  irritation  of  the  disease,  the  termination 
of  which  cannot  be  expected  within  a moderate  space 
of  time ; amputation  is  proper.  It  is  a truth,  however, 
that  many  fingers  are  amputated  t^'hich  might  be  pre- 
served ; and  surgeons  ought  to  consider  well  before 
presuming  to  remove  parts  winch,  when  curable,  may 
become  of  the  greatest  consequence  in  regard  to  the 
perfection  of  the  hand.  The  bread  of  many  persons,  it 
is  well  known,  depends  on  the  unmutilated  state  of 
certain  fingers.  These  remarks  are  offered,  because  I 
have  seen  several  surgeons,  fond  of  seizing  every  oppor- 
tunity of  cutting  their  fellow-creatures,  remove  fingers 
which  might  have  been  usefully  saved,  either  by  allot- 
ting a little  more  time  for  the  exfoliation,  or  by  making 
incisions,  and  cutting  out  the  dead  piece  of  bone. — [See 
note  on  article  Whitlow.] 

Fingers,  Dislocations  of.  See  Dislocation. 

Fingers,  Fractures  of.  See  Fracture. 

Fingers,  supernumerary.  The  instances  of  chil- 
dren born  with  a smaller  number  of  fingers  than  natural 
are  more  rare  than  cases  in  w'hich  the  number  is 
greater  than  usual.  Of  the  latter  malformation,  exam- 
ples w'ere  noticed  in  times  of  great  antiquity.  Thus, 
in  the  1st  book  of  Chronicles  is  the  following  notice  of 
such  an  occurrence : “ There  was  war  at  Gath,  where 
was  a man  of  great  stature,  whose  fingers  and  toes 
were  four-and-twenty,  six  on  each  hand,  and  six  on 
each  foot.” — (Chap.  xx.  ver.  6.)  Anne  Boleyn,  so  cele- 
brated for  her  beauty  and  her  misfortunes,  had  six 
fingers  on  her  right  hand.  Pliny,  the  naluralist,  speaks 
of  two  sisters,  who  had  six  fingers  on  each  of  their 
hands.  In  the  Memoirs  of  the  Royal  Academy  of  Sci- 


FIS 


fIS 


371 


ences  for  1743,  is  the  account  of  a child  which  was 
shown  at  one  of  the  meetings,  and  had  six  toes  on  each 
foot,  and  the  same  number  of  fingers  on  each  hand. 
In  each  foot  there  were  six  metatarsal  bones,  and  in 
the  left  hand  an  equal  number  of  metacarpal  bones  ; but 
in  the  right  hand  there  were  only  five,  the  outer  one  of 
which  had  two  articular  surfaces,  one  for  the  little,  and 
the  other  for  the  supernumerary  finger.  In  the  Copen- 
hagen Transactions,  T.  Bartholine  has  inserted  the 
de.scription  of  a very  cUrious  skeleton;  on  the  right 
hand  there  were  seven  fingers,  on  the  left  six ; and 
besides  these  circumstances,  the  thumb  was  double. 
On  the  right  foot  there  were  eight  toes,  on  the  left, 
nine ; the  right  metatarsus  consisting  of  six  bones,  the 
left  of  seven.  Saviard  speaks  of  a still  more  curious 
case : he  saw  a new-born  infant  at  the  Hotel-Dieu,  at 
Paris,  which  had  ten  fingers  on  each  hand,  and  ten 
toes  on  each  foot;  the  phalanges  seemed  as  if  they 
were  all  in  a broken,  imperfect  state,— (Ois.  de  Chir.) 
The  example  of  the  greatest  number  of  fingers  and 
toes  is  recorded  by  Voight : including  the  thumb,  there 
were  thirteen  fingers  on  each  hand,  and  twelve  toes  on 
each  foot.—  {Mag.  fur  das  neueste  der  Naturkunde,  b. 
3,  p.  174.)  Individuals  are  occasionally  born  with  two 
thumbs  on  the  same  hand— (Panarolus,  Oentec.  3, 
Obs.  4-8.) 

Since  allowing  the  redundant  number  of  fingers  to 
remain  would  keep  up  deformity,  and  create  future  in- 
convenience, the  surgeon  is  called  upon  to  amputate 
them.  The  redundant  fingers  are  sometimes  with, 
sometimes  without,  a nail ; seldom  more  numerous  than 
one  upon  each  hand  ; generally  situated  just  on  the  out- 
side of  the  little  fingers  ; and,  as  far  as  my  observation 
extends,  incapable  of  motion,  in  consequence  of  not 
being  furnished  like  the  re.st  of  the  fingers  with  muscles. 
For  the  most  part  the  phalanges  are  also  imperfectly 
formed  or  deficient.  The  best  plan  is  to  cut  off  supe- 
numerary  fingers  with  a scalpel  at  the  place  where  they 
are  united  to  the  other  part  of  the  hand.  The  operation 
should  be  performed  while  the  patient  is  in  the  infant 
state,  that  is  to  say,  before  the  superfluous  parts  have 
acquired  much  size,  and  while  the  object  can  be  accom- 
plished with  the  least  pain.  The  incisions  ought  to  be 
made  so  as  to  form  a wound  with  edges  which  will  ad- 
mit of  being  brought  together  with  strips  of  adhesive 
plaster.  As  soon  as  the  dressings  are  applied,  the  he- 
morrhage will  almost  always  cease  without  a ligature. 

FISSURE.  (From  Jindo,  to  cleave  asunder.)  A very 
fine  crack  in  a bone  is  so  called. 

FISTULA,  in  surgery,  strictly  means  a sore  which 
has  a narrow  orifice,  runs  very  deeply,  is  callous,  and 
has  no  disposition  to  heal.  The  name  is  evidently 
taken  from  the  similitude  which  the  long  cavity  of  such 
an  ulcer  has  to  that  of  a pipe  or  reed.  A fistula  com- 
monly leads  to  the  situation  of  some  disease  keeping 
up  suppuration  ; and  from  which  place  the  matter  can- 
not readily  escape.  No  technical  term  has  been  more 
misapplied  than  this ; and  no  misinterpretation  of  a 
word  has  had  worse  influence  in  practice  than  that  of 
the  present  one.  Many  simple,  healthy  abscesses  with 
small  openings  have  too  often  been  called  fistulous  ; 
and  being  considered  as  in  a callous  state,  the  treat- 
ment pursued  has  in  reality  at  last  rendered  them  so, 
and  been  the  only  reason  of  their  not  having  healed. 

FISTULA  IN  ANO.  See  Anus. 

FISTULA  LACHRYMALIS.  In  correct  language, 
this  term  can  be  applied  only  to  one  case,  viz.  that  in 
which  there  is  an  ulcerated  opening  in  the  lachrymal 
sac,  unattended  with  any  tendency  to  heal,  and  from 
which  opening  a quantity  of  puriform  fluid  is  from  time 
to  time  discharged,  especially  when  the  lachr3'mal  sac 
is  compressed.  Such  has  been  the  confusion,  however, 
respecting  the  nature  of  the  diseases  of  the  lachrymal 
passages,  and  so  great  has  been  the  force  of  ancient 
custom,  that  down  to  the  present  time  the  generality 
of  British,  as  well  as  foreign,  surgeons,  imply  by  the 
expression  fistula  lachrymalis  several  forms  of  dis- 
ease, totally  different  from  each  other,  and  to  only  one  of 
which  the  name  is  at  all  applicable.  In  order  not  to  assist 
in  perpetuating  this  absurd  and  erroneous  plan,  from 
which  nothing  but  mistakes  and  ignorance  can  resiilt, 
I shall  follow  the  example  pointed  out  by  Beer,  Schmidt, 
and  our  countryman  Mr.  M‘Kenzie,  and  consider  the 
various  forms  of  disease  to  which  the  lachrymal  pas- 
sages are  subject,  not  under  the  head  of  fistula  lachry- 
malis, but  under  the  more  sensible  title.  Lachrymal 
Organs,  Diseases  of  the. 


FISTULA  IN  PERINiEO.  As  Sir  Astley  Cooper 
has  justly  observed,  incisions  in  the  urethra  generally 
heal  with  great  facility;  a fact  amply  proved  by  the 
common  result  of  the  lateral  operation ; but  when 
apertures  are  formed  in  the  uretiira,  either  from  dis- 
eased states  of  the  constitution  and  the  part  together, 
or  of  the  latter  alone,  and  when  they  are  accompanied 
with  any  considerable  destruction  of  the  side.s  of  the 
urethra,  and  of  the  corpus  spongiosum,  they  are  mostly 
very  difficult  to  cure. — {Surg.  Essays,  pt.  2,  p.  211.) 

\^ien  the  methods  recommended  for  the  removal  of 
strictures  (see  Urethra,  Strictures  of')  have  not  been 
attempted,  or  not  succeeded,  nature  endeavours  to  re- 
lieve herself  by  making  a new  passage  for  the  urine, 
which,  although  it  often  prevents  immediate  death,  yet 
if  not  remedied  is  productive  of  much  inconvenience 
and  misery  to  the  patient  through  life.  The  mode  by 
which  nature  endeavours  to  procure  relief  is  by  ulcera- 
tion on  the  inside  of  that  part  of  the  urethra  which  is 
enlarged,  and  situated  between  the  stricture  and  the 
bladder.  Thus  the  urine  becomes  ai)plied  to  a new 
surface,  irritating  the  part,  and  occasioning  the  forma- 
tion of  an  abscess  into  which  the  urine  has  access ; 
and  when  the  matter  is  discharged,  be  it  by  nature  or 
by  art,  the  urine  passes  through  the  aperture,  and  ge- 
nerally continues  to  do  so  Avhile  the  stricture  remains. 
— (A.  Cooper,  Surgical  Essays,  part  2,  p.  212.) 

The  ulceration  commonly  begins  near  or  close  to  the 
stricture,  although  the  stricture  may  be  at  a consider- 
able distance  from  the  bladder.  The  stricture  is  often 
included  in  the  ulceration,  by  which  means  it  is  re- 
moved ; but  unluckily  this  does  not  constantly  happen. 
The  ulceration  is  always  on  the  side  of  the  urethra 
next  to  the  external  surface. 

The  internal  membrane  and  substance  of  the  urethra 
having  ulcerated,  the  urine  readily  gets  into  the  loose 
cellular  membrane  of  the  scrotum  and  penis,  and  dif- 
fuses itself  all  over  those  jiarts  ; and  as  this  fluid  is  very 
irritating  to  them,  they  inflame  and  swell.  I’he  pre- 
sence of  the  urine  prevents  the  adhesive  inflammation 
from  taking  place  ; it  becomes  the  cause  of  supimration 
wherever  it  is  diffused  ; and  the  irritation  is  often  so 
great  that  it  produces  mortification,  first  in  all  the  cellular 
membrane,  and  afterward  in  several  parts  of  the  skin  ; 
all  of  which,  if  the  patient  live,  slough  away,  making  a 
free  communication  between  the  urethra  and  external 
surface,  and  producing  what  are  termed  fistulm  in 
periruBo,  though  it  is  plain  enough  to  every  surgeon 
who  know’s  the  correct  meaning  of  tlie  word  fstula, 
that  a recent  opening,  produced  in  the  perinaeum  by 
ulceration  or  sloughing,  ought  not  to  be  called  a fistula 
immediately  it  is  formed,  and  at  least  not  until  it  has 
acquired  some  of  the  characters  specified  in  our  exi)la- 
nation  of  the  term  fistula. 

According  to  Mr.  Hunter,  when  ulceration  takes 
place  farther  back  than  the  portion  of  the  urethra  be- 
tween the  glans  penis  and  membranous  part  of  the 
canal,  the  abscess  is  generally  more  circumscribed. 

The  urine  sometimes  insinuaies  itself  into  the  cori)Us 
spongiosum  urethrae,  and  is  immediately  diffused 
through  the  whole,  even  to  the  glans  penis,  so  as  to 
produce  a mortification  of  all  those  parts.  A latal  in- 
stance of  this  kind  is  reported  by  Mr.  C.  Bell. — {Surgi- 
cal Obs.  vol.  1,  p.  98.) 

Although  the  ulceration  of  the  urethra  may  be  in  the 
perinaeurn,  yet  the  urine  generally  passes  easily  for- 
wards into  the  scrotum,  which  contains  the  loosest  cel- 
lular substance  in  the  body;  and  there  is  always  a 
hardness  extending  along  the  perinaeurn  to  the  swelled 
scrotum  in  the  track  of  the  pu‘s.— (Hunter.) 

Sir  Astley  Cooper  is  of  opinion,  that  as  soon  as  the 
abscesses,  which  are  the  forerunners  of  the  fistula,  can 
be  plainly  felt  to  contain  a fluid,  it  is  the  best  i)ractice 
to  open  them  with  a lancet.  The  exten.sive  destruction 
of  parts  by  ulceration  will  thus  be  prevented  ; the  place 
not  unfrequently  then  heals  up  expeditiously  without 
any  fistulous  orifice  being  left,  and  a tendency  to  those 
dangerous  extravasations  of  urine  is  also  prevented, 
which,  if  the  abscesses  are  not  uijened  early,  often  prove 
destructive  to  life. — (Vol.  cit.  p.  212.) 

Ulceration  can  only  be  prevented  by  destroying  the 
stricture  ; but  when  the  urine  is  diffused  in  the  cellular 
membrane,  the  removal  ol'  the  stricture  will  generally 
be  too  late  to  prevent  all  the  mischief,  although  it  will 
be  necessary  for  the  complete  cure.  Therefore,  an  at- 
tempt .should  be  made  to  pass  a bougie,  for  perhajHi  the 
stricture  may  have  been  destroyed  by  the  ulceration,  so 


Aa  2 


372 


FIS 


FLU 


as  to  alloAv  the  instrument  to  be  introduced.  When 
this  is  the  case,  bougies  must  be  almost  constantly 
used,  in  order  to  procure  as  free  a passage  as  possible. 
In  these  cases,  Sir  A.  Cooper  expresses  a preference  to 
metallic  bougies,  the  size  of  which  is  to  be  gradually 
increased  until  their  diameter  exceeds  the  natural  dia- 
meter of  the  passage-  In  some  instances,  however,  he 
says,  that  it  will  oe  nece'ssary  to  introduce  a pewter 
catheter,  of  large  size,  and  to  allow  it  to  remain  in  the 
bladder,  so  as  at  once  to  act  upon  the  stricture,  and 
hinder  the  urine  from  passing  through  the  preternatural 
opening.  In  this  manner  a permanent  cure  may  often 
be  effected.  Although  this  experienced  surgeon  agrees 
with  most  surgeons  of  the  present  day,  respecting  the 
general  inexpediency  of  employing  caustic  for  the  re- 
moval of  a stricture,  under  the  preceding  circumstances, 
yet  he  admits  that  instances  do  present  themselves,  in 
which,  from  long  neglect,  the  urethra  and  the  parts 
surrounding  the  stricture  are  so  altered  in  structure, 
that  no  instrument  can  be  passed  through  the  obstruction 
without  danger,  and  where  the  slower  action  of  caustic 
is  safer  than  the  use  of  a metallic  bougie. — {Surgical 
Essays,  part  2,  p.  213.)  The  experience  of  modern 
surgeons  tends  to  prove,  however,  that  there  are  some 
cases  which  form  exceptions  to  the  plan  of  employing 
bougies  or  catheters,  though  a fistulous  opening  may 
have  occurred  in  the  passage.  These  cases  are  the 
examples  in  which  the  apertures  in  the  urethra  are  the 
consequence  of  ulceration  and  abscess,  unaccompanied 
by  stricture,  and  taking  place  in  a bad  constitution,  and 
perhaps  only  preceded  by  a slight  discharge  from  the 
urethra.  Here  bougies  would  increase  the  tendency  to 
ulceration,  and  aggravate  the  local  and  constitutional 
irritation. — {A.  Cooper,  p.  216.) 

While  we  are  attempting  to  cure  the  stricture,  anti- 
phlogistic measures,  particularly  bleeding,  are  to  be 
adopted.  The  parts  should  be  exposed  to  the  steam  of 
hot  water ; the  warm  bath  made  use  of ; opium  and 
turpentine  medicines  given  by  the  mouth  and  in  glys- 
ters,  with  a view  of  diminishing  any  spasmodic  affec- 
tion. But,  as  Mr.  Hunter  observes,  all  these  proceed- 
ings are  often  insufficient ; and  therefore  an  immediate 
eflTort  must  be  made,  both  to  unload  the  bladder  and  to 
prevent  the  farther  efiTLision  of  urine,  by  making  an 
opening  in  the  urethra  somewhere  beyond  the  stricture, 
but  the  nearer  to  it  the  better. 

Introduce  a director,  or  some  such  instrument,  into  the 
urethra,  as  far  as  the  stricture,  and  make  the  end  of  it 
as  prominent  as  possible,  so  as  to  be  felt ; which,  in- 
deed, is  often  impossible.  If  it  can  be  felt,  it  must  be 
cut  upon,  and  the  incision  carried  on  a little  farther  to- 
wards the  bladder  or  anus,  so  as  to  open  the  urethra  be- 
yond the  stricture.  This  will  both  allow  the  urine  to 
escape,  and  destroy  the  stricture.  If  the  instrument  can- 
not be  felt  at  first  by  the  finger,  we  must  cut  down  to- 
wards it ; and  on  afterward  feeling  it,  proceed  as  above. 

When  the  stricture  is  opposite  the  scrotum,  as  the 
opening  cannot  be  made  in  this  situation,  it  must  be 
made  in  the  perinaeum  ; in  which  case,  there  can  be  no 
direction  given  by  an  instrument,  as  it  will  not  pass 
sufficiently  far,  and  the  only  guide  is  our  anatomical 
knowledge.  The  opening  being  made,  proceed  as  di- 
rected in  the  cure  of  a false  passage.— (See  Urethra, 
False  Passage  of,)  In  wheihsoever  way  the  operation 
is  done,  a bougie,  or  a catheter,  which  is  better,  must 
afterward  be  introduced,  and  the  wound  healed  oyer  it. 

When  the  inflammation  from  the  extravasation  of 
urine  is  attended  with  suppuration  and  mortijfication, 
the  parts  must  be  freely  scarified,  in  order  to  give  vent 
both  to  the  urine  and  pus.  When  there  is  sloughing, 
the  incisions  should  be  made  in  the  mortified  parts. 

Sometimes,  when  the  urethra  is  ulcerated,  and  the 
cellular  membrane  of  the  penis  and  prepuce  is  so  much 
distended  as  to  produce  a phymosis,  it  is  impossible  to 
find  the  orifice  of  the  urethra. 

Frequently  the  new  passages  for  the  urine  do  not 
heal,  on  account  of  the  stricture  not  being  removed  ; 
and  even  when  this  has  been  cured,  they  often  will  not 
heal,  but  become  truly  fistulous,  and  produce  fresh  in- 
flammation and  suppurations,  which  often  burst  by 
distinct  openings.  Such  new  abscesses  and  openings 
often  form  in  consequence  of  the  former  ones  having 
become  too  small  before  the  obstruction  in  the  urethra 
Is  removed. 

Such  diseases  sometimes  bring  on  intermittent  disor- 
ders, which  do  not  yield  to  bark,  but  cease  as  soon  as 
the  fistulas  and  disease  of  the  urethra  have  been  cured. 


In  order  to  cure  fistulae  in  perinaeo,  unattended  with 
the  above-described  urgent  symptoms,  the  urethra 
must  be  rendered  as  free  as  possible,  and  this  alone  is 
often  enough ; for  the  urine,  finding  a ready  passage 
forwards,  is  not  forced  into  the  internal  mouth  of  the 
fistulae,  which  therefore  heal  up.  The  cure  of  the 
strictures,  however,  is  not  always  sufficient,  and  the 
following  operation  becomes  indispensable. 

The  sinuses  are  to  be  laid  open  in  t^e  same  manner 
as  other  sinuses,  which  have  no  disposition  to  heal.  In 
doing  this,  as  little  as  possible  of  the  sound  part  of  the 
urethra  must  be  opened.  Hence  the  surgeon  must  di- 
rect himself  to  the  inner  orifice  of  the  fistulae,  by  means 
of  a staff,  introduced  (if  possible)  into  the  bladder,  and 
a probe  passed  into  one  of  the  fistulous  passages.  The 
probe  should  be  first  bent,  that  it  may  more  readily 
follow  the  turns  of  the  fistula.  When  it  can  be  made 
to  meet  the  staff,  so  much  the  better ; for  then  the  ope- 
rator can  just  cut  only  what  is  necessary. 

When  the  fistula  is  so  straight,  as  to  admit  of  a di- 
rector being  introduced,  this  instrument  is  the  best. 
When  neither  the  probe  nor  the  director  can  be  made 
to  pass  as  far  as  the  staff,  we  must  open  the  sinuses  as 
far  as  the  first  instrument  goes,  and  then  search  for  the 
continuation  of  the  passage,  for  the  purpose  of  laying 
it  open.  The  difficulties  of  this  dissection,  however,  in 
the  thickened,  diseased  state  of  the  parts  in  the  scrotum 
and  perinaeum,  are  such  as  can  only  be  duly  appreciated 
by  a man  who  has  either  made  the  attempt  himself,  or 
seen  it  made  by  others.  I have  myself  seen  one  of  the 
first  anatomists  in  London  fail  in  two  instances  to  trace 
the  continuation  of  the  urethra,  and  baffled  in  the  en- 
deavour, therefore,  to  pass  an  instrument  from  the 
orifice  of  that  passage  into  the  bladder.  The  difficulty 
and  confusion,  arising  from  the  hardened,  enlarged  state 
of  the  parts,  wliich  are  to  be  cut,  have  been  well  de- 
picted by  Mr.  C.  Bell. — {Surgical  Obs.  vol.  1,  p.  129.) 

Having  divided  the  fistulas  as  far  as  their  termination 
in  the  urethra,  a catheter  should  be  introduced  and 
worn,  at  first,  almost  constantly.  This  is  better  than  a 
bougie,  which  must  be  frequently  withdrawn  to  allow 
the  patient  to  make  water,  and  it  often  could  not  be  in- 
troduced again  without  being  entangled  in  the  wounds. 

In  many  cases  the  employment  of  the  catheter  should 
not  be  continued  after  a certain  period.  At  first,  it  often 
assists  the  cure  ; but,  in  the  end,  it  may  obstruct  the 
healing,  by  acting  at  the  bottom  of  the  Avound,  as  an 
extraneous  body. 

Hence,  when  the  sores  become  stationary,  let  the  ca- 
theter be  withdrawn,  and  introduced  only  occasionally. 
And  even  after  the  sores  are  well,  it  will  be  prudent  to 
use  the  bougie,  in  order  to  determine  whether  the  pas- 
sage is  free  from  disease. 

When  fistulae  in  ^)erinapo  have  been  laid  open,  the 
wounds  are  to  be  at  first  dressed  down  to  the  bottom 
as  much  as  possible,  which  will  prevent  the  reunion  of 
the  parts  first  dressed,  and  make  the  granulations 
shoot  from  the  bottom,  so  as  to  consolidate  the  whole 
by  one  bond  of  union. — {Hunter  on  the  Venereal  Disease, 
ed.  2.)  Additional  observations  upon  this  subject,  and, 
in  particular,  the  opinions  of  Desault,  will  be  found  in 
the  article  Urinary  Abscesses  and  Fistulas.  Sir  A. 
Cooper’s  practice,  in  cases  where  a considerable  portion 
of  the  urethra  has  been  destroyed,  will  be  hereafter  no- 
ticed. — (See  Urethra.) 

FISTULA,  SALIVARY.  See  Parotid  Duct. 

FLUCTUATION.  (From  Jiucto,  to  float.)  The  per- 
ceptible motion  communicated  to  any  collection  of  puru- 
lent matter,  or  other  kind  of  fluid,  by  applying  the  fin- 
gers to  the  surface  of  the  tumour,  and  pressing  with 
them  alternately,  in  such  a manner  that  the  fingers  of 
one  hand  are  to  be  employed  in  pressing,  or  rather  in 
briskly  tapping  upon  the  part,  while  those  of  the  other 
hand  remain  lightly  placed  on  another  side  of  the  swell- 
ing. When  the  ends  of  one  set  of  fingers  are  thus 
delicately  applied,  and  the  surgeon  taps,  or  makes  re- 
peated pressure  with  the  fingers  of  the  other  hand,  the 
impulse  given  to  the  fluid  is  immediately  perceptible  to 
him,  and  the  sensation  thus  received  is  one  of  the  prin- 
cipal symptoms  by  which  practitioners  are  enabled  to 
discover  the  presence  of  fluid  in  a great  variety  of  cases. 
Great  skill  in  ascertaining  by  the  touch  the  presence  of 
fluid  in  parts,  or  being  endued  with  the  tactvs  ernditus, 
as  it  is  termed,  distinguishes  the  man  of  experience  as 
remarkably,  perhaps,  as  any  quality  that  can  be  specified. 

When  the  collection  of  fluid  is  very  deeply  situated, 
the  fluctuation  is  frequently  exceedingly  obscure,  and 


FOR 


FRA 


373 


sometimes  not  at  all  distinguishable.  In  this  circum- 
stance, the  presence  of  the  fluid  is  to  be  ascertained  by 
the  consideration  of  other  symptoms.  For  example,  in 
eases  of  hydrops  pectoris  and  empyema,  surgeons  do 
not  expect  to  feel  the  undulation  of  the  fluid  in  the 
thorax  with  their  fingers ; they  consider  the  patient’s 
difliculty  of  breathing,  the  uneasiness  attending  his 
lying  upon  one  particular  side,  the  oedema  of  the  pa- 
rietes  of  the  chest,  the  dropsical  affection  of  other  parts, 
the  more  raised  and  arched  position  of  the  ribs  on  the 
affected  side,  the  preceding  rigors,  fever,  and  several 
other  circumstances,  from  which  a judgment  is  formed, 
both  with  regard  to  the  presence  and  the  peculiar  na- 
ture of  the  fluid. 

FOMENTATION.  By  a fomentation,  surgeons  com- 
monly mean  the  application  of  flannel  or  towels,  wet 
with  warm  water  or  some  medicinal  decoction.  In  the 
practice  of  surgery,  fomentations  are  chiefly  of  use  in 
relieving  pain  and  inflammation,  and  in  promoting  sup 
puration,  when  this  is  desirable.  Some  particular  de- 
coctions, however,  are  used  for  fomentations,  with  a 
view  of  affecting,  by  means  of  their  medicinal  qualities, 
scrofulous,  cancerous,  and  other  sores  of  a specific  na- 
ture. I shall  merely  subjoin  a few  of  the  most  useful 
fomentations  in  common  use. 

FOMENTUM  AMMONITE  MURIATiE.  : B^.  Fo- 
menti  communis  Ibij.  Ammon,  mur.  1'\.  Spirit, 
cdmph.  5ij- 

Just  before  using  the  hot  decoction,  add  to  it  the  am- 
monia muriata  and  spirit.  Said  to  be  of  service  to 
some  indolent  ulcers ; and,  perhaps,  it  might  be  of  use 
in  promoting  the  absorption  of  some  tumours,  and  sup- 
puration in  others. 

FOMENTUM  CHAM^MELI.  R.  Linicontusi  5j. 
Chamaemcli  ? ij.  Aq.  distillat.  ibvj.  Paulisper  coque, 
et  cola.  A fomentation  in  very  common  use. 

FOMENTUM  CONII  R.  Fol.  conii  recent,  Ibj.  vel 
fol.  cottii  exsiccat.  |iij.  Aq.  comm.  Ibiij.  Coque  usque 
reman.  Ibij.  et  cola.  Sometimes  applied  to  scrofulous, 
cancerous,  and  phagedenic  ulcers. 

FOMENTUM  GALL^E.  R.  Gallae  contusae  5ss. 
Aq.  ferventis  Ibij.  Macera  per  horam,  et  cola.  Used 
for  the  prolapsus  ani,  and  sometimes  employed  as  a 
cold  application,  in  cases  of  hemorrhoids. 

FOMENTUM  PAPAVERIS  ALBI.  R.  Papav.  alb. 
exsiccati,  5 iv.  Aq.  pur.  Ibvj.  Bruise  the  poppies,  put 
them  in  the  water  and  boil  the  liquor,  till  only  a quart 
remains,  which  is  to  be  strained.  This  fomentation  is 
an  excellent  one,  for  very  painful  inflammations  of  the 
eyes,  and  for  numerous  ulcers  and  other  diseases,  at- 
tended with  intolerable  pain. 

FORCEPS.  An  instrument  much  employed  in  surgery 
for  a variety  of  purposes,  and  having  accordingly  va- 
rious constructions.  The  general  design,  however,  of 
surgical  forceps  is  to  take  hold  of  substances  which 
cannot  be  conveniently  grasped  with  the  fingers ; and, 
of  course,  the  instrument  is  always  formed  on  the  prin- 
ciple of  a pair  of  pincers,  having  two  blades,  either 
with  or  without  handles,  according  lo  circumstances. 
The  smallest  forceps  is  that  which  is  employed  in  the 
operation  of  extracting  the  cataract,  and  which  is  useful 
for  removing  any  particles  of  opaque  matter  from  the 
pupil,  after  the  chief  part  of  the  crystalline  lens  has 
been  taken  away. 

Another  forceps,  of  larger  size,  is  that  used  for  taking 
up  the  mouths  of  the  arteries,  when  these  vessels  re- 
quire a ligature,  in  cases  of  hemorrhage.  This  instru- 
ment is  also  frequently  employed  for  taking  dressings 
off  sores,  removing  pieces  of  dead  bone,  foreign  bodies 
from  wounds,  and  particularly  for  raising  the  fibres, 
which  are  about  to  be  cut,  in  all  operations  where 
careful  dissection  is  required.  This  forceps  re.sembles 
that  which  is  contained  in  every  case  of  dissecting  in- 
.struments,  and  is  often  called  the  artery  or  dissecting 
forceps,  from  its  more  important  uses. 

Neither  of  the  foregoing  forceps  is  made  with  han- 
dles ; each  opens  by  its  own  elasticity ; and  the  ends 
of  the  blades  only  come  into  contact  when  pressed  to- 
gether by  the  surgeon. 

The  following  kinds  of  forceps  are  constructed  with 
handles,  by  means  of  which  they  tire  both  opened  and 
shut ; 

1.  The  common  forceps,  contained  in  every  pocket- 
case  of  surgical  instruments,  and  used  for  removing 
dressings  from  sores,  extracting  dead  pieces  of  bone, 
foreign  bodies^  &c. 

2.  Larger  forceps,  employed  for  extracting  polypi. 


3.  Forceps  of  different  sizes  and  constructions,  used 
in  the  operation  of  lithotomy,  for  taking  the  stone  out 
of  the  bladder,  or  for  breaking  the  calculus,  when  it  is 
too  large  to  be  extracted  in  an  entire  state. 

4.  Cutting  forceps,  as  the  common  bone-nippers,  and 
the  sharp  forceps,  made  with  the  edges  in  the  same  line 
with  the  handles,  used  by  Mr.  Liston  for  the  division 
of  bones. 

FRACTURE  is  a solution  of  continuity  of  one  or 
more  bones,  produced  in  general  by  external  force  ; but 
occasionally,  by  the  powerful  action  of  muscles,  as  is 
often  exemplified  in  the  broken  patella. 

The  subject  of  fractures  is  so  interesting  a branch  of 
surgery,  and  the  accidents  themselves  so  frequent  and 
important,  that  the  little  which  English  surgeons  have 
done  for  the  improvement  of  this  part  of  their  profession 
cannot  but  cause  equal  surprise  and  regret.  Mr.  Pott, 
it  is  true,  made  many  excellent  observations  on  the 
treatment  of  fractures  in  general,  and  his  remarks  on 
compound  fractures  in  particular  are  in  some  respects 
the  best  which  are  extant ; but  what  surgeon  will  now 
presume  to  defend  the  weak  arguments  upon  which  he 
lias  founded  the  doctrine  of  paying  unqualified  attention 
to  the  relaxation  of  the  muscles,  as  if  this  were  an  ob- 
ject which  should  constantly  supersede  every  other 
consideration,  and  invariably  regulate  the  posture  of 
the  limb  ? I have  no  hesitation  in  declaring  my  own 
belief,  that  the  doctrine  and  practice  recommended  by 
Mr.  Pott,  in  regard  to  fractured  thighs  has  done  consi- 
derable harm,  and  the  more  so,  as  coming  from  a man 
who  was  deservedly  looked  upon  as  one  of  the  best  and 
most  experienced  judges  of  surgical  practice.  Many 
a surgeon  in  this  country  implicitly  believed  every  thing 
which  was  asserted  by  so  able  a master,  and  the  very 
observations  which  some  years  ago  were  here  consi- 
dered to  be  the  glory  of  their  author  and  the  pride  of 
English  surgery,  are  now  exposed  by  the  surgeons  of 
neighbouring  countries,  as  specimens  of  wrong  pre- 
cepts and  bad  practice.  M.  Roux,  in  fact,  has  had  but 
too  much  room  for  animadversion  upon  this  subject. 
Down  to  the  period  of  his  visit  to  this  country,  if  we 
except  some  of  Mr.  Pott’s  observations  on  the  use  of  the 
eighteen-tailed  bandage,  the  necessity  of  quietude,  the 
principles  on  which  splints  ought  to  be  constructed,  and 
the  inestimable  remarks  on  compound  fractures  by  the 
same  distinguished  English  surgeon,  it  cannot  be  said 
that  we  had  made  a single  improvement  of  consequence 
in  the  treatment  of  any  particular  fracture,  while  the 
generality  of  our  surgical  writers  had  given  the  most 
faulty  and  imperfect  account  of  the  diagnosis,  and  every 
thing  else  relating  to  these  accidents.  What  is  w'orse, 
a view  of  our  practice  conveyed  no  better  opinion  of 
this  part  of  our  surgery.  Observe  the  care  and  neat- 
ness with  which  a French  surgeon  applies  the  bandages 
and  splints,  and  consider  how  well  every  indication  is 
accomplished  by  his  apparatus,  and  you  will  find  great 
cause  both  for  admiration  and  imitation.  On  the  other 
hand,  see  the  slovenly  way  in  which  an  English  sur- 
geon generally  puts  on  the  splints  and  roller,  and  the 
unscientific  method  in  which  he  usually  treats  a frac- 
tured thigh  or  clavicle,  and  you  cannot  fail  to  be 
ashamed  of  the  comparison.  This  was  a matchless 
opportunity  for  M.  Roux  to  draw  a parallel  in  favour  of 
French  surgery,  and  of  course  he  has  not  neglected  it, 
many  pages  of  his  work  being  devoted  to  an  explanation 
of  the  many  improvements  Desault  made  ; the  little,  or 
ratherthe  nothing,  which  we  had  done  ; and  the  errors, 
to  which  we  unfortunately  still  adhere.— (See  Voyage 
fait  a.  Londres  en  1814,  ou  ParalUle  de  la  Chirurgie 
Angloise  atiec  la  Chirurgie  Francoise,  p.  173,  A’  c.)  It 
is  to  be  hoped,  however,  that  the  period  has  now  ar- 
rived, when  we  shall  give  to  the  study  of  fractures  the 
time,  the  attention,  and  the  importance  which  it  claims  ; 
and  when  even  the  young  hospital  pupil  will  not  be 
convinced,  that  his  lecturer  by  one  or  two  cursory  dis- 
courses can  have  done  justice  to  the  subject.  The  ob- 
servations lately  published  by  Sir  Astley  Coojier,  on 
fractures  of  the  joints,  are  indeed  highly  creditable  to 
this  part  of  English  surgery,  and  afford  satisfactory 
evidence  of  the  increa.sed  attention  which  is  now  paid 
to  the  principles  which  ought  to  regulate  the  treatment 
of  each  individual  example  of  the  accident. 

In  this  article,  my  plan  is  to  follow  the  arrangement 
adopted  by  Boyer,  in  his  Traits  des  Maladies  Chirur~ 
gir.ales,  t.  3.  I shall  first  speak  of  fractures  in  gene- 
ral, and  allot  ceparato  sections  to  the  consideration  of, 
1 Their  diffl'ieaccs  ; 2.  J'aeir  l aiises  , .3.  Their  syiiqi- 


374 


FRACTURES. 


toms ; 4.  Their  prognosis ; 5.  Their  treatment ; 6.  The 
formation  of  callus. 

The  subject  will  then  conclude  with  a full  account 
of  the  symptoms,  causes,  and  treatment  of  the  frac- 
tures of  particular  bones. 

1.  Differences  of  Fractures. 

The  differences  of  fractures  depend  upon  what  bone  is 
broken;  what  portion  of  it  is  fractured;  the  direction  of 
the  fracture;  the  respective  position  of  the  fragments; 
and  lastly,  upon  circumstances  accompanying  the  in- 
jury, and  making  it  simple,  compound,  or  variously  com- 
plicated, 

1.  In  respect  to  the  hone  affected. — Sometimes  it  is 
one  of  the  broad  bones,  as  the  scapula,  the  sternum,  or 
the  os  ilium.  Sometimes  it  is  a short  bone,  like  the  os 
calcis ; but  far  more  commonly  it  is  one  of  the  long 
bones.  The  situation  and  functions  of  the  broad  bones 
render  their  fractures  unfrequent.  The  bones  of  the 
skull  are  the  only  exception  to  this  remark ; for  they 
are  often  broken  ; but  here  the  assistance  of  the  sur- 
geon is  required  less  for  he  solution  of  the  continuity 
itself,  than  for  the  affection  of  the  brain,  and  the  extra- 
vasation of  blood,  with  which  the  case  is  apt  to  be  com- 
bined. Fractiire.s  of  the  short  bones  are  still  more  un- 
usual, because  these  bones,  being  nearly  equal  in  their 
three  dimensions,  are  capable  of  greater  resistance, 
and  are  not  much  within  the  reach  of  external  vio- 
lence. Besides,  most  of  them  are  but  little  exposed  to 
the  operation  of  outward  force,  by  their  situation  or 
functions.  Hence,  except  when  limbs  are  crushed, 
fractures  of  short  bones  are  generally  caused  by  mus- 
cular action,  which  frequently  breaks  the  patella,  ole- 
cranon, and  os  calcis.  The  long  bones,  which  serve  as 
pillars,  or  arches  of  support,  or  levers,  are,  from  the  very 
nature  of  their  functions,  particularly  liable  to  fractures. 

2.  In  respect  to  the  part  of  the  bone  broken. — Bones 
may  be  fractured  at  different  points  of  their  length. 
Most  commonly,  their  middle  portion  is  broken,  and  in 
this  circumstance  they  usually  break  like  a stick,  which 
has  been  bent  beyond  its  extensibility  by  a force  ap- 
plied at  each  end  of  it.  Sometimes  the  fracture  occurs 
more  or  less  near  the  extremities  of  the  bone,  which 
is  always  an  unfavourable  event.  Lastly,  the  bone  is 
sometimes  broken  in  several  places,  and  the  injury  may 
be  produced  by  two  different  causes,  which  operate 
successively,  or  simultaneously,  upon  the  broken  parts 
of  the  bone ; or  it  may  be  occasioned  by  one  sii  gle 
cause,  which  acts  at  the  same  moment  upon  sev.jral 
points  of  it.  These  distinctions  of  fractures,  deduced 
from  their  particular  situation  (says  Boyer),  are  not 
mere  scholastic  refinements ; they  have  a truly  import- 
ant influence  over  the  prognosis  and  treatment. 

3.  In  respect  to  the  direction  in  which  the  bone  is 
broken. — A bone  may  be  fractured  in  various  ways, 
and  the  fracture  receives  different  names,  according  to 
its  direction  in  regard  to  the  axis  of  the  bone.  Thus, 
fractures  are  distinguished  into  transverse  and  oblique. 
The  obliquity  renders  the  surface  of  the  injury  larger, 
and  materially  increases  the  difficulty  of  maintaining 
the  ends  of  the  bone  in  contact,  after  the  fracture  has 
been  set.  Oblique  fractures  are  subject  to  considerable 
variety,  which  depends  upon  the  degree  of  their  obli- 
quity, and  whether  they  are  partly  oblique  and  partly 
transverse.  When  a bone  is  broken  in  different  places 
at  once,  and  divided  into  several  fragments,  or  splinters, 
the  fracture  is  termed  comminuted. 

Duvemey  admitted  another  class  of  fractures,  viz.  lon- 
gitudinal.—{See  Traite  des  Maladies  des  Os,  t.  \,p. 
167.)  But  such  cases  were  regarded  by  J.  L.  Petit  as 
only  imaginary,  because  he  conceived  that  any  blow, 
capable  of  breaking  a bone  longitudinally,  would  much 
more  readily  cause  a transverse  fracture.  For  the 
same  reason,  Louis  absolutely  rejected  the  possibility 
of  longitudinal  fractures,  and  this  sentiment  has  pre- 
vailed down  to  the  present  day. 

The  following  case,  however,  is  related  by  Leveillb, 
in  order  to  prove  the  possibility  of  longitudinal  frac- 
tures. He  amputated  the  thigh  of  an  Austrian  soldier 
who  was  put  under  his  care  in  the  year  1800,  in  conse- 
quence of  being  struck  by  a ball  in  the  lower  third  of 
the  leg  at  the  battle  of  Marengo.  The  soldier  had 
walked  several  miles,  after  receiving  the  injury,  before 
he  arrived  at  Pavia.  The  wound  appeared  simple  and 
likely  to  heal  as  soon  as  the  injured  portion  of  the  tibia 
had  exfoliated.  The  event  turned  out  otherwise,  and 
the  thigh  was  amputated. 


Leveill6  has  preserved  the  tibia,  upon  which  the  im- 
pression of  the  ball  may  be  distingmshed,  and  from  this 
point  run  several  longitudinal  and  oblique  lines,  which 
extend  from  the  lower  third  towards  the  upper  head  of 
tibia,  and  pass  through  the  whole  thickness  of  the  pa- 
rietes  of  the  medullary  canal.  They  were  acknow- 
ledged to  be  really  longitudinal  fractures,  by  Dubois, 
Chaufrier,  Dumeril,  Deschamps,  and  Roux,  who  were 
appointed  by  the  Ecole  de  Medecine  to  inquire  into  the 
fact.— {Leveille , Nouvelle  Doctrine  Chir.  t.  2,  p.  158.) 

In  several  cases  of  fractured  thigh-bones  from  gun- 
shot violence,  which  were  under  the  care  of  Dr.  Cole 
and  myself  in  Holland,  the  bone  was  split  longitudi- 
nally to  the  extent  of  seven  or  eight  inches.  The  fact, 
however,  that  bullets  and  other  balls  do  produce  lon- 
gitudinal fractures,  is  now  universally  admitted  ; and 
were  there  any  doubt  upon  the  subject,  a specimen  sent 
to  England  by  my  friend  Dr.  Cole,  would  soon  remove 
it.  Boyer,  who,  a few  years  ago,  denied  the  possibi- 
lity of  longitudinal  fractures,  in  his  late  work  remarks : 
“ On  trouve  manmoins,  a.  la  suite  des  plaies  d’armes 
d feu,  les  os  fendus  suivant  leur  longueur,  jusques 
dans  leurs  articulations," — but  he  is  correct  when  he 
adds,  that  such  instances  afford  no  proof  of  the  possi- 
bility of  a simple  longitudinal  fracture. — (See  Traiti 
des  Maladies  Chir.  t.  3,  p.  10.) 

4,  In  regard  to  the  respective  positiooi  of  the  frag- 
ments.— These  differences  are  highly  important  to  be 
understood,  because,  as  Boyer  remarks,  the  treatment 
of  fractures  consists  almost  entirely  in  remedying  or 
preventing  the  displacement  of  the  fragments.  It  is 
not  to  be  supposed,  however,  that  such  displacement  is 
an  absolutely  essential  symptom  of  all  fractures,  for  it 
seldom  exists  in  members  composed  of  two  bones, 
when  only  one  of  them  is  broken.  Neither  does  it  con- 
statitly  happen  in  every  fracture  of  the  neck  of  a bone, 
as  is  exemplified  in  certain  fractures  of  the  neck  of  the 
thigh-bone,  the  fragments  of  which  sometimes  change 
their  relative  situation  only  when  the  patient  tries  to 
walk,  or  the  limb  is  imprudently  moved  about.  Frac- 
tures of  the  leg  are  also  observed,  in  which  there  is 
neither  a displacement  of  the  fragments,  nor  an  altera- 
tion in  the  shape  of  the  limb,  especially  when  the  tibia 
alone  is  fractured  near  its  upper  part,  where  it  is  very 
thick.  When  the  ulna  alone  is  broken  at  its  upper 
part,  there  is  hardly  ever  any  displacement.  The  corres- 
ponding surfaces  of  the  fragments  having  a large  ex- 
tent cannot  be  separated,  or  can  only  be  so  with  diffi- 
culty. Fractures  of  the  fibula  are  also  frequently  un- 
attended with  displacement.  But  it  is  a symptom, 
that  almost  constantly  occurs  when  both  bones  of  the 
leg  or  forearm  are  fractured  together ; as,  also,  in  frac- 
tures of  limbs  which  contain  only  one  bone,  on  account 
of  the  little  extent  of  the  surfaces  of  the  fracture,  and 
the  great  number  of  muscles  which  tend  to  displace 
them. 

The  displacement  may  happen  in  respect  to  the  di- 
ameter, length,  direction,  or  circumference  of  the  bone. 

In  respect  to  the  diameter. — Transverse  fractures  are 
the  only  cases  in  which  this  kind  of  displacement  is 
observed.  The  two  fragments  may  either  be  in  con- 
tact at  a part  of  their  surfaces,  or  they  may  not  be  in 
contact  at  all.  In  the  latter  circumstance,  the  limb  is 
shortened  by  the  ends  of  the  fracture  slipping  over  each 
other. 

In  respect  to  length. — This  mode  of  displacement,  in 
which  the  ends  of  the  broken  bone  pass  more  or  less 
over  each  other,  constantly  occurs  in  oblique  fractures, 
and  sometimes  in  transverse  ones,  when  the  di.-place- 
ment  in  the  direction  of  the  diameter  of  the  bone  has 
been  such  that  the  surfaces  of  the  fracture  are  no 
longer  in  contact.  It  wall  be  hereafter  explained,  that 
w’henever  the  limb  is  shortened  in  fractures  of  the  e.x- 
tremities,  it  is  the  lower  fragment  that  is  displaced. 

We  may  refer  to  the  species  of  displacement  here 
spoken  of,  that  which  takes  place  in  fractures  of  the 
patella,  olecranon,  and  os  calcis ; but  with  this  diflTer- 
ence,  that  the  fragments,  instead  of  passing  over  each 
other  separate  from  each  other  in  the  direction  of  the 
length  of  the  bone,  and  continue  separated  by  an  inter- 
space more  or  less  considerable. 

In  respect  to  the  directioii  of  the  bone.— In  this  kind 
of  displacement,  the  two  fragments  form  an  angle  more 
or  less  prominent,  :md  the  bone  appears  arched.  It  is 
principally  observed  in  comminuted  fractures.  It  may 
also  happen  in  simple  fractures;  for  instance,  in  tlie 
leg,  when  the  limb  in  a straight  posture  docs  not 


FRACTURES. 


375 


lie  upon  a surface  exactly  horizontal,  and  the  heel  is 
lower  than  the  rest  of  the  limb.  The  angular  projec- 
tion is  then  anterior.  On  the  contrary,  it  would  be  pos- 
terior, if  the  heel  were  too  much  raised. 

In  respect  to  the  circumference  of  the  Tliis 

displacement  occurs  when  the  lower  fragment  performs 
a rotatory  movement,  while  the  upper  one  continues  mo- 
tionless. Thus,  in  fractures  of  the  neck  of  the  femur, 
if  the  foot  is  badly  supi)orted  by  the  apparatus,  its 
weight,  together  with  that  of  the  limb  and  the  action  of 
the  muscles,  inclines  it  outwards,  and  turns  the  lower 
fragment  in  the  same  direction. 

Besides  the  simple  displacements  above  described, 
there  are  others  of  a more  complicated  nature,  which 
happen  in  several  directions  at  once.  For  example, 
such  is  the  displacement  observed  in  a fracture  of  the 
thigh-bone,  when  the  lower  fragment  is  drawn  upwards 
and  inwards,  while  the  foot  is  turned  outwards. 

Let  us  next  consider  the  causes  of  the  displacement 
of  fractures. 

The  bones,  being  only  passive  instruments  of  loco- 
motion, possess  not,  in  their  own  organization,  any 
cause  of  the  change  of  situation  which  takes  place ; 
but  yield  to  the  impulse  of  external  bodies,  the  weight 
of  the  member,  and  the  action  of  the  muscles 

The  displacement  may  be  produced  by  an  external 
force,  either  at  the  moment  when  the  fracture  happens, 
and  by  the  very  action  of  the  fracturing  cause  itself : 
or  it  may  be  caused  by  the  weight  of  the  body  when 
the  fracture  precedes  the  fall;  or  lastly,  it  may  be 
brought  on  by  some  other  external  force,  acting  on  the 
fragments,  sooner  or  later,  after  the  occurrence  of  the 
injury. 

The  outward  violence,  which  is  productive  of  a frac- 
ture, operates  sometimes  directly  on  the  situation  of 
the  breach  of  continmty ; sometimes  on  parts  more  or 
less  distant  from  it.  In  both  cases,  the  action  of  the 
force  is  not  confined  to  the  production  of  the  fracture, 
but  is  partly  spent  in  causing  a displacement  of  the 
fragments. 

Fractures  are  generally  occasioned  by  falls.  Some- 
times, however,  the  fall  does  not  happen  till  after  the 
leg  or  thigh  is  actually  broken.  The  weight  of  the 
body  then  produces  the  displacement,  by  pushing  the 
upper  fragment  against  the  soft  parts,  wdiich  are  more 
or  less  lacerated.  This  is  what  happened  to  Ambrose 
Pard,  who,  being  kicked  by  a horse,  endeavoured  to  get 
out  of  the  way,  but  instantly  fell  down,  and  the  two 
bones  of  his  left  leg,  which  had  been  fractured,  being 
impelled  by  the  weight  of  the  body,  not  only  passed 
through  the  skin,  but  even  through  his  stocking  and 
boot.  Boyer  has  seen  a c^ise  nearly  similar  in  a young 
man  about  twenty  years  of  age,  wha  in  a standing 
posture,  was  struck  on  the  middle  of  the  thigh  with 
the  pole  of  a carriage,  which  fractured  the  femur.  The 
patient  fell  down,  and  in  the  fall  the  upper  fragment 
was  not  only  driven  through  the  muscles  and  integu- 
ments, but  also  through  his  breeches. 

'fhe  weight  of  the  limb  itself  may  produce  displace- 
ment according  to  the  direction  or  circumference  of  the 
bone,  as  already  detailed.  The  disturbanceof  the  limb, 
also,  in  lifting  the  patient  and  carrying  him  to  his  bed, 
may  sometimes  alter  the  relative  situation  of  the  frag- 
ments, and  cause  them  to  be  dksiilaced. 

But  of  all  the  causes  of  the  displacement  of  frac- 
tures, the  action  of  the  muscles  is  the  common  and 
most  powerful  one.  Among  the  muscles  surrounding 
a fractured  bone,  some  are  attached  to  it  throughout  its 
whole  length,  and  are  equally  connected  with  both  the 
fragments.  Some  arise  from  the  bone  above,  and  are 
inserted  either  into  that  which  is  articulated  with  the 
lower  fragment,  or  into  the  lower  fragment  itself. 
Lastly,  there  are  others  which  come  from  a point  more 
or  less  distant,  and  terminate  in  the  upper  fragment. 
The  muscles  round  the  thigh-bone  furnish  examples  of 
these  three  arrangements.  The  triceps  is  attached  to 
the  bone  its  whole  length.  The  biceps,  semi-mem- 
branosus,  and  semi-tendinosus,  come  from  the  pelvis, 
and  are  inserted  into  the  leg,  a part  with  which  the 
lower  fragment  is  articulated,  and  all  the  motions  of 
which  it  follows.  The  great  head  of  the  triceps  is  in- 
serted into  this  fragment  itself.  Lastly,  the  iliacus, 
psoa.s,  pectineus,  &c.,  come  from  the  loins  and  pelvis, 
and  are  attached  to  the  femur,  not  far  from  its  up- 
per end. 

The  muscles  attached  to  both  fragments  contribute 
very  little  to  their  di.splacemcnt.  They  may,  however, 


draw  them  to  the  side  on  which  they  are  situated,  and 
thus  change  the  direction  of  the  limb.  The  triceps, 
especially  its  middle  portion,  acts  in  this  manner  in 
fractures  of  the  femur,  and  renders  the  thigh  convex 
anteriorly.  The  coraco-brachialis  tends  to  produce 
the  same  effect  wheti  the  humerus  is  broken  below  its 
middle. 

The  displacement  is  principally  owing  to  such  mus- 
cles as  are  affixed  to  the  lower  fragment,  or  part  with 
which  this  fragment  is  articulated.  Suppose  the  hu- 
merus to  be  broken  between  its  upper  end  and  the  in- 
sertion of  the  great  pectoral.  This  muscle,  aided  by 
the  latissimus  dorsi  and  teres  major,  will  draw  the 
lower  fragment  inwards,  and  displace  it  by  drawing  it 
to  the  inner  side  of  the  upper  fragment,  which  re- 
mains motionless.  In  fractures  of  the  neck  of  the 
thigh-bone,  the  upper  fragment,  included  within  the 
capsular  ligament,  affords  attachment  to  no  muscle 
All  those  which  are  affixed  to  the  lower  fragment,  pull 
it  upwards  and  backwards,  in  which  direction  the  dis- 
placement is  inevitable.  In  all  fractures,  the  lower 
fragment  follows  every  movement  made  by  the  part  of 
the  limb  with  which  it  is  articulated,  and  consequent!; 
the  muscles  which  are  attached  to  the  bones  of  this 
last  part  of  the  limb,  become  a powerful  cause  of  dis- 
placement. Thus,  in  a fracture  of  the  thigh-bone,  the 
biceps,  semi-tendinosus,  and  semi-membranosus,  draw 
the  leg,  and  with  it  the  lower  fragment,  upwards,  in- 
wards, and  backwards,  so  as  to  make  the  lower  end 
of  the  fracture  ascend  at  the  inside  of,  and  rather  be- 
hind, the  upper  one,  the  extremity  of  which  then  pro- 
jects forwards  and  outwards.  In  a fracture  of  the  leg, 
the  gastrocnemius,  soleus,  and  peronei  muscles,  act- 
ing upon  the  foot,  pull  the  lower  fragments  of  the 
tibia  and  fibula,  and  draw  them  to  the  outer  and  poste- 
rior side  of  the  upper  fragments.  For  here,  as  well  as 
every  where  else,  the  strongest  muscles,  in  producing 
the  displacement,  draw  towards  their  own  side  the  end 
of  the  fracture  on  wliich  they  operate.  And  as  the 
posterior  muscles  of  the  leg  are  far  more  numerous 
and  powerful  than  those  on  the  front  of  the  limb,  while 
those  on  its  outside  are  not  antagonized  by  any  others, 
the  displacement  must  happen  in  the  direction  back- 
wards and  outwards.  Whenever,  therefore,  a bone  is 
fractured  at  a given  point,  a knowledge  of  the  muscles 
will  enable  one  to  determine  d priori  in  what  direction 
the  displacement  will  occur,  if  no  means  be  taken  to 
impede  it,  and  it  proceed  altogether  from  this  particu- 
lar cause. 

Lastly,  the  muscles  which  are  attached  only  to  the 
upper  fragment,  may  sometimes  displace  it.  In  a 
fracture  of  the  thigh  situated  immediately  below  the 
little  trochanter,  the  psoas  and  iliacus  muscles  to- 
gether carry  forwards  the  extremity  of  the  upjier  frag- 
ment, which  elevates  the  integuments  and  forms  a 
more  or  less  considerable  projection  near  the  fold  of 
the  groin.  But  it  is  to  be  observed,  that,  in  general, 
the  displacement  of  the  upper  fragment  is  not  com- 
mon, and  that  it  is  the  lower  one  which  is  drawn  out 
of  its  proper  position. 

The  manner  in  which  the  displacement  of  fractures 
is  effected  by  the  action  of  muscles  explains  one  cir- 
cumstance which  frequently  attends  these  cases,  espe- 
cially fractures  of  the  thigh,  clavicle,  and  leg.  This  is 
a rising,  a projection,  of  the  upper  fragment,  or  that 
which  is  nearest  the  trunk.  One  might  believe,  at  finst 
sight,  that  such  projectioit  is  formed  by  the  upper  frag- 
ment, which,  quitting  its  natural  situation,  rises  over 
the  lower  one.  But,  on  the  least  reflection,  it  becomes 
manifest  that  the  upper  end  of  the  fracture  ])rojects 
only  because  the  lower  one  is  displaced  and  drawn  to- 
w’ards  that  side  on  which  the  strongest  muscles  are 
situated.  Thus,  in  practice,  in  order  to  make  the  rising 
end  of  the  bone  (as  it  was  termed)  disappear,  it  is  only 
necessary  to  reduce  the  lower  fragment  into  its  na- 
tural place.  If,  instead  of  doing  this,  pressure  be 
made  on  the  projecting  part,  the  design  fails.;  and  if 
the  plan  be  still  more  forcibly  pursued  and  continued, 
inflammation  and  sloughing  of  the  integuments  and 
other  soft  parts,  and  the  conversion  of  the  case  into  a 
compound  fracture,  are  likely  to  be  the  unfortunate 
consequences. 

5.  In  respect  to  circumstances  mith  tvhich  fractures 
are  accompanied. — The  mo.st  Important  division  of 
fractures  is  into  simple  and  compound. 

By  a simple  fracture,  surgeons  moan  a breach  in  tbs 
continuity  of  one  or  more  bones,  without  any  external 


376 


FRACTURES. 


tvound,  communicatLiig  internally  with  the  fracture, 
and  caused  by  the  protrusion  of  the  ends  of  the  broken 
bone  or  bones.  By  a compound  fracture,  they  signify 
the  same  sort  of  injury  of  a bone  or  bones,  attended 
With  a laceration  of  the  integuments,  which  laceration 
is  produced  by  the  protrusion  of  one  or  both  ends  of 
the  fracture. 

The  dangerous  nature  of  compound  fractures  will 
be  fully  explained  in  the  sequel  of  this  article : the  sub- 
ject indeed  has  been  already  touched  upon  in  speaking 
of  Amputation. 

Fractures  are  said  to  be  complicated,  when  they  are 
attended  with  diseases  or  accidents,  which  render  the 
indications  in  the  treatment  more  numerous,  and  re- 
quire the  employment  of  different  remedies,  or  the 
practice  of  sundry  operations,  for  the  accomplishment 
of  the  cure. 

Thus,  fractures  may  be  complicated  with  severe  de- 
grees of  contusion,  wounds  of  the  soft  parts,  the  injury  of 
large  blood-vessels,  a dislocation,  or  diseases,  and  parti- 
cular states  of  the  constitution,  as  the  scurvy,  rickets, 
lues  venerea,  pregnancy,  &c.,  which  are  said  to  re- 
tard the  formation  of  callus,  and  render  the  cure  more 
backward. 

The  complication  of  fracture  with  dislocatiou  hap- 
pens but  seldom,  and  it  cannot  occur  unless  the  luxa- 
tion has  taken  place  first,  or  has  been  produced  at  the 
same  time  with  the  fracture,  and  by  the  same  cause. 
When  once  the  fracture  has  happened,  the  fragments 
are  not  sufficiently  within  the  grasp  of  external  force, 
and  are  too  moveable,  to  admit  of  the  bone  being  dislo- 
cated. 

A patient  with  fracture  may  be  attacked  by  an  acute 
disease,  which  may  render  the  treatment  more  trouble- 
some, and  the  cure  slower. 

[Under  the  head  of  differences  in  fractures  may  be 
fitly  introduced  that  injury  to  the  hones  of  children 
which  is  denominated  a bending  of  the  bones,  from 
falls,  blows,  and  external  violence,  since  this  injury 
requires  the  same  treatment  as  fractures,  although 
crepitus  and  displacement  of  fragments  are  absent.  In 
the  Amer.  Med.  Recorder  for  1821,  will  be  found  a valu- 
able paper  on  this  subject  from  Dr.  J.  R.  Barton,  of 
Philadelphia,  including  another  injury  to  the  bones  of 
children  which  is  not  unfrequent,  which  he  calls  a 
partial-  or  incomplete  fracture  of  a single  bone  or  both 
It  is  the  more  important  that  Dr.  B.’s  facts  and  obser- 
vations should  not  be  overloc.ked,  because  it  is  a sub- 
ject seldom  noticed  by  surgical  writers,  although 
highly  important.  Some  mention  is  made  of  it  by  Un- 
derwood and  Boyer,  and  perhaps  by  these  alone.  Dr. 
Barton  has  accompanied  his  paper  by  very  accurate 
drawings  of  the  deformity  occasioned  by  both  of  the 
accidents  to  which  he  refers. — Reese.] 

2.  Causes  of  Fractures. 

The  causes  of  fractures  are  divided  into  predisposing 
and  remote. 

In  the  first  class  are  comprehended  the  situation  and 
functions  of  the  bones,  the  age  of  the  patients,  and 
their  diseases.  Superficial  bones  are  more  easily  frac- 
tured than  those  which  are  covered  by  a considerable 
quantity  of  soft  parts.  The  functions  of  some  bones 
render  them  more  liable  tobe  fractured  than  others  ; thus 
the  radius,  which  supports  the  hand,  is  more  liable  to 
be  fractured  than  the  ulna.  The  clavicle,  which  serves 
to  keep  the  shoulder  in  its  proper  position  and  support 
on  its  arched  extremity  all  the  motions  of  the  upper 
extremity,  is  particularly  subject  to  be  broken.  The 
gradual  increase  of  the  quantity  of  the  phosphate  of 
lime,  in  the  structure  of  the  bones,  makes  them  brittle 
in  proportion  as  we  advance  in  years ; and,  in  old  age, 
the  proportion  of  the  inorganixed  to  the  organized  part  | 
is  so  great,  that  the  bones  are  fractured  by  the  slightest 
causes.  In  childhood,  the  fibrous  and  organized  pan  i 
bears  a greater  proportion  to  the  earth,  and  the  bones  i 
being  consequently  more  ela.stic  and  flexible,  are  not  so  , 
easily  broken  as  in  old  age.  I 

Lues  venerea,  arthritis,  cancer,  rachitis,  scurvy,  and  i 
scrofula,  says  Leveille,  predispose  to  fractures.  B.  Bell  j 
mentions  two  venerea'  patients,  of  whom  the  hardest  ] 
and  largest  bones  were  completely  broken  by  the  ordi- 
nary action  of  the  muscles  of  the  limb.  Fabricius 
Hildanus  quotes  from  Sarazin,  a physician  of  Lyons, 
the  case  of  a gouty  patient,  sixty  years  of  age,  who, 
in  putting  on  his  glove,  broke  his  arm  above  the  elbow. 
Desault  used  often  to  speak  of  a nun  of  Salpt>tri^re, 


whose  arm  tvas  broken  as  a person  was  handing  her 
out  of  a carriage.  Louis,  who  was  vexed  that  no 
union  took  place,  was  not  a little  surprised  to  find  her 
thigh-bone  experience  the  same  fate  one  day  as  she 
was  changing  her  posture  in  bed.  It  was  then  learned 
that  she  had  a cancer  in  her  right  breast.  Leveille  assures 
us,  that  he  has  observed  similar  cases  in  the  Hotel-Dieu, 
and  Sir  A.  Cooper  has  met  with  others .-^( See  Cancer.) 

According  to  Leveille,  the  history  of  two  girls  is  re- 
lated by  Buchner,  one  of  whom  died  rickety  at  the  age 
of  sixteen,  having  broken  the  femur  a short  time  be- 
fore her  death  ; and  the  other,  after  taking  the  breast 
very  well  for  two  years,  and  thriving  for  a time,  be- 
came affected  with  rachitis,  and  met  with  the  same 
accident  as  she  was  merely  running  along  the  street. — 
{Nouvelle  Doctrine  Chir.  t.  2,  p.  163.) 

Many  extraordinary  instances  of  fractures  from  the 
morbid  softness  and  fragility  of  the  bones  are  upon  re- 
cord. Suffice  it  here  to  refer  to  the  Philosophical  Trans- 
actions; Mem.  de  I’Acad.  Royale  des  Sciences;  Act, 
Hafnien’s. ; Ephem,  Nat,  Cur.  dec.  1,  ann.  3,  obs.  112  ; 
Gooch’s  Chirurgical  Works,  vol.  2;  Saviard,  Observa- 
tions Chir.  p.  274 ; Gibson’s  Institutes  of  Surgery,  voL 
1,  p.  370,  &c.— (See  also  Fragilitas  and  Mollities  Os- 
sium.) 

On  the  subject  of  fractures  produced  by  the  scurvy, 
Leveille  recommends  us  to  peruse  Marcellus  Donatus ; 
Saviard’s  Observations;  Heyne  de  Morbis  Ossium; 
Poupart’s  Works  inserted  in  the  Mem.  de  I’Acad.  des 
Sciences,  1699;  and  the  Treatise  published  at  Verona, 
in  1761,  by  Jean  de  Bona.  To  these  works  I would 
add  Lord  Anson’s  Voyage,  in  which  the  effect  of  the 
scurvy  in  producing  the  absorption  of  the  callus  of  old 
fractures,  and  a disjunction  of  the  fragments,  is  very 
curiously  exemplified. 

Pare,  Plainer,  Callisen,  and  several  other  winters, 
set  down  cold  as  a predispo.-ing  cause  of  fractures. 
This  doctrine  has  originated  from  these  injuries  being 
more  frequent  in  the  winter  time,  but  is  quite  erro- 
neous, since,  in  cold  countries,  the  greater  number  of 
falls  which  happen  in  winter  from  the  slippery  and 
very  hard  state  of  the  roads,  is  a circumstance  that 
fully  explains  why  fractures  are  then  more  common 
than  in  summer. 

The  remote  cause  of  fractures  is  external  force  va- 
riously applied  in  falls,  blows,  &c.  In  particular  in- 
stances the  bones  are  broken  by  the  violent  action  of 
the  muscles  attached  to  them ; this  is  almost  always 
the  case  with  the  fractured  patella.  The  olecranon 
and  os  calcis  have  likewise  been  broken  by  a violent 
contraction  of  the  muscles  inserted  into  them.  With 
respect  to  the  heel.  Petit  records  two  instances,  one  of 
which  was  communicated  to  him  by  Poncelet,  and  the 
other  seen  by  himself  in  Madame  La  Presidente  de 
Boissire,  who  met  with  the  accident  in  walking  a 
gentle  pace  in  the  court  of  the  Hotel  de  Soubise. 
When  the  injury  happens  in  leaping,  or  falls  from  a 
high  situation,  Leveili6  thinks  it  more  probable  that  a 
portion  of  the  os  calcis  is  tom  off  by  the  powerful  ac- 
tion of  the  muscles  of  the  calf,  than  that  it  is  broken 
by  any  blow'  immediately  on  the  part.  He  states  that 
Desault  used  frequently  to  cite  two  examples  of  this 
kind,  one  of  which  is  recorded  in  his  CEuvres  Chirur- 
gicales. 

Whether  the  long  bones  can  be  fractured  by  the 
mere  action  of  the  muscles  is  yet  an  unsettled  point. 
In  the  Philosoplucal  Transactions  a fracture  of  the 
humerus  is  ascribed  to  this  cause,  and  Botentuil  saw  the 
same  accident  produced  by  striking  a shuttlecock  with  a 
j battledore.  According  to  Debeaomarchef,  as  a man 
I w'as  descending  a ladder  at  a quick  nite,  his  heel  got 
i entangled  m an  opening,  and  he  made  a violent  exer- 
' tion  to  avoid  falling.  The  consequence  was  a fracture 
' of  the  lower  third  of  the  leg.  Curet  informs  us  that  a 
i cabin-boy,  aged  seventeen,  made  a considerable  cflbrt  to 
I keep  himself  from  being  thrown  down  by  the  rolling  of 
the  ship.  The  femur  was  fractured  by  the  powerful  ac- 
I tion  of  the  muscles  of  the  thigh.  The  lad  had  no  fall, 

I and,  with  some  difficulty,  supported  himself  on  the 
I other  limb  till  he  received  assistance. 

We  are  told,  says  l.eveillc,  by  Poupie  Desportes, 

! that  a negro,  about  tw’elve  or  thirteen  years  old,  was 
seized  with  such  violent  sjiasmodic  contractions  of  the 
muscles  of  the  lower  extremities,  that  the  feet  were 
turned  backw'ards.  and  the  neck  of  each  thigh-bone 
w'.'us  fractured,  the  ends  of  the  broken  bones  also 
' protruding  through  the  skin  uixai  the  outside  of  the 


FRACTURES. 


377 


thigh.  A cure  was  effected  after  an  exfbliation. 
read  also,  in  the  Miscellanea  Curiosa  Acad.  Ni 
Curiosorum,  that  during  a fit  of  epilepsy,  a child  ten 
years  old  had  its  left  humerus  and  tibia  broken,  and 
that,  upon  opening  the  body,  other  solutions  of  con- 
tinuity were  observed.  Chamseru  assisted  in  dressing 
a child,  eleven  or  twelve  years  old,  that  had  broken  the 
humerus  in  throwing  a stone  a considerable  distance. — 
{LeveilU,  Nouvelle  Doctrine  Chir.  t.  2,  p.  164.  166.) 

Richerand,  however,  positively  denies,  that  a long 
bone,  when  healthy,  can  ever  be  broken  by  the  mere 
contraction  of  the  muscles.— (iVoso^r.  Ckir.  t.  3,  p.  12, 
edit.  4.) 

For  my  own  part,  making  all  due  allowance  for  the 
inaccuracy  of  some  of  the  reports  made  by  writers,  I 
think  the  possibility  of  the  long  bones  being  broken  by 
the  violent  action  of  the  muscles  is  sufficiently  proved. 
I have  never  seen  but  one  example  ; but  it  was  a very 
unequivocal  one.  I once  attended,  for  the  late  Mr. 
Ramsden,  an  exceedingly  strong  man,  at  Pentonville, 
who  broke  his  os  brachii  in  making  a powerful  blow, 
although  he  missed  his  aim  and  struck  nothing  at  all. 
The  whole  limb  was  afterward  affected  with  vast 
swelling  and  inflammation.  This  man,  I remember, 
was  also  visited  by  Mr.  Wei  bank,  of  Chancery-lane. 
According  to  Nicod,  the  greater  number  of  fractures  of 
long  bones,  by  mere  muscular  action,  are  preceded  by 
pains  in  the  broken  limbs ; and  in  one  of  the  cases  pub- 
lished by  this  author,  not  only  was  this  circumstance 
remarked,  but  an  abscess  and  exfoliation  of  a portion 
of  the  fractujgd  humerus  ensued.  In  another  instance 
reported  by  tms  gentleman,  the  clavicle  in  a state  of 
preternatural  fragility  from  disease,  was  fractured  in 
an  effort  to  carry  the  arm  far  behind  the  back.  After 
the  reunion  of  the  fracture,  an  abscess  took  place,  and 
a piece  of  the  bone  exfoliated. — (Annuaire  MM.  Chir. 
des  Hopitaux  de  Paris,  p.  494 — 498,  ^c.  ito.  Paris 
1819.) 

3.  Symptoms  of  Fractures. 

Some  of  the  symptoms  of  fractures  are  equivocal ; 
the  pain  and  inability  to  move  the  limb,  commonly  enu- 
merated, may  arise  from  a mere  bruise,  a dislocation, 
or  other  cause.  The  crepitus ; the  separation  and  in- 
equalities of  the  ends  of  the  fracture,  when  the  bone 
is  superficial ; the  change  in  the  form  of  the  limb ; and 
the  shortening  of  it ; are  circumstances  communicating 
the  most  certain  information ; and  the  crepitus,  in  par- 
ticular, is  the  principal  symptom  to  be  depended  upon, 
though  occasionally  attendant  on  dislocations,  and  aris- 
ing, as  Sir  Astley  Cooper  has  explained,  from  a change 
in  the  quality  of  the  synovia.— Dislocations,  Src. 
p.  6.)  The  signs  of  fractures,  however,  are  so  exceed- 
ingly various,  according  to  the  bones  which  are  the 
subject  of  injury,  that  it  cannot  be  said,  that  there  is 
any  one  which  is  invariably  present  and  character- 
istically confined  to  them.  The  writers  of  systems  of 
surgery  usually  notice  loss  of  motion  in  the  injured 
limb,  deformity,  swelling,  tension,  pain,  &c.,  as  form- 
ing the  general  diagnosis  of  fractures.  However,  it  is 
ea.sily  comprehensible  by  any  one  acquainted  with 
anatomy,  that  numerous  fractures  cannot  prevent  the 
motion  of  the  part,  nor  occasion  outward  deformity  ; 
and  every  surgeon  must  know,  that  though  at  lirst 
there  may  be  pain  in  the  situation  of  a fracture,  no 
swelling  and  tension  take  place  till  after  a certain 
period. 

When,  therefore,  a limb  is  broken,  and  the  event  is 
not  manifest  from  the  distortion  of  the  part,  it  is  proper 
to  trace  with  the  fingers,  the  outlines  of  the  suspected 
bone : if  it  be  the  tibia,  let  the  surgeon  examine  with 
his  fingers,  whether  any  inequality  can  be  discovered 
along  the  anterior  surface,  and  along  the  sharp  front 
edge  of  that  bone.  If  it  be  the  clavicle,  let  him  trace 
the  superficial  course  of  the  bone,  in  the  same  attentive 
manner.  Wherever  any  unusual  pain  occurs,  or  any 
unnatural  irregularity  appears,  let  him  try  if  a grating 
or  crepitus,  cannot  be  felt,  on  endeavouring  to  make 
one  end  of  the  suspected  fracture  rub  against  the 
01  her.  When  the  humerus  or  the  os  femoris  is  the 
subject  of  inquiry,  a crepitus  is  felt  almost  as  soon  as 
the  limb  is  touched ; and,  in  the  case  of  the  broken 
thigh,  there  is  a considerable  shortening  of  the  extre- 
mity, except  in  a few  cases  of  fractures,  completely 
transverse.  But  when  there  are  two  bones,  as  in  the 
leg  and  the  forearm,  and  only  one  is  broken,  the 
otner  continues  to  prevent  the  limb  from  being  short- 


ened and  thrown  out  of  its  natural  shape,  so  that  a 
crepitus  can  only  be  felt  by  a very  careful  examination 
with  the  fingers.  The  difficulty  of  the  diagnosis  is  in- 
creased when  the  surgeon  is  consulted  late,  and  great 
swelling  has  come  on.  “ Where  is  the  surgeon,”  says 
Boyer,  “ that  has  not  sometimes  hesitated  to  deliver  an 
opinion  in  certain  cases  of  this  description?” — {Traite 
des  Malad.  Chir.  t.  3,  p.  27.) 

When  the  injured  limb  is  shortened,  the  surgeon 
before  pronouncing  that  such  change  proceeds  from  the 
passage  of  the  fragments  over  each  other,  must  be  sure 
that  the  bones  are  not  dislocated,  and  that  the  limb  is 
not  naturally  shorter  than  the  other,  or  in  consequence 
of  a previous  fracture  that  has  been  badly  set. 

In  comparing  the  length  of  the  lower  extremities,  one 
should  place  the  pelvis  in  a horizontal  position,  and 
put  the  two  anterior  superior  spines  of  the  ossa  ilium 
in  the  same  line ; for,  if  these  processes  are  not  on  a 
level,  the  limb  towards  which  the  pelvis  inclines,  will 
seem  longer  than  the  opposite  member. 

The  practitioner  who  is  well  acquainted  with  the 
anatomy  of  the  limbs,  and  particularly  with  the  mu- 
tual relations  of  the  eminences  of  the  bones  to  each 
other,  will  readily  perceive  the  alterations  produced 
by  a fracture.  Whenever,  in  consequence  of  a fall  or 
Now,  a limb  becomes  concave  at  a part  where  it  ought 
to  be  convex ; or  straight,  et  vice  versd ; the  change  of 
shape  and  direction  must  proceed  from  a fracture  with 
displacement.  The  inner  edge  of  the  great  toe,  when 
the  leg  rests  on  a horizontal  surface,  should  corres- 
pond with  the  inner  edge  of  the  knee-pan.  If  this  na- 
tural relation  be  altered ; if  the  inner  edge  of  the  great 
toe  correspond  with  the  outer  edge  of  the  knee-pan,  there 
can  be  no  doubt  of  the  existence  of  a fracture  of  both 
bones  of  the  leg. — {Boyer,  vol.  cit.  t.  3,  p.  25.) 

1 ani  aware,  that  considerable  harm  and  great  un- 
necessary pain  have  been  occasioned  in  the  practice  of 
surgery,  by  too  much  solicitude  to  feel  the  grating  of 
fractured  bones,  and  whenever  the  case  is  sufficiently 
evident  to  the  eyes,  the  practitioner  who  gives  way  to 
this  habit  at  the  expense  of  torture  to  the  unfortunate 
patient  ought  in  my  opinion  to  be  severely  censured. 
A fracture  is  an  injury  necessarily  attended  with  a 
great  deal  of  pain,  and  followed  by  more  or  less  swell- 
ing and  inflammation ; and  to  increase  these  evils  by 
roughly  or  unnecessarily  handling  the  part,  is  ignorant 
and  cruel,  and  (if  I may  use  the  expression)  unsur 
gical. 

In  some  kinds  of  fractures,  the  broken  bone  is  so 
surrounded  with  thick  fleshy  parts,  that  it  is  diffiult  to 
feel  a crepitus,  or  ascertain  the  existence  of  the  injury. 
Some  fractures  of  the  neck  of  the  thigh-bone,  unat- 
tended with  much  retraction  of  the  limb,  are  cases 
illustrative  of  this  observation.  Whether  Laennec’s 
stethoscope  will  become  practically  useful  as  a means 
of  elucidating  the  diagnosis,  farther  time  and  expe- 
rience must  determine ; Lisfranc  is  said  to  have  used 
it  with  success. — (See  Edinb.  Med.  and  Burg.  Joum. 
No.  78,  p.  237.) 

4.  Prognosis  of  Fractures. 

The  prognosis  of  fractures  varies,  according  to  the 
kind  of  bone  injured,  what  part  of  it  is  broken,  the  di- 
rection of  the  breach  of  continuity,  and  what  other 
mischief  complicates  the  case.  Fractures  of  bones 
which  have  many  strong  muscles  inserted  into  them, 
are  more  difficult  of  cure  than  those  of  other  bones 
which  have  not  so  many  powers  attached  to  them  ca- 
pable of  disturbing  the  fragments. 

A fracture  of  the  middle  part  of  a long  bone  is  less 
dangerous  than  a similar  injury  near  a joint.  Frac- 
tures near  joints  may  occasion  a false  anchylosis. 
Thus,  in  a fracture  of  the  thigh-bone  near  the  condyles, 
the  inflammation  and  swelling  extend  to  the  knee-joint, 
which  is  affected  with  a degree  of  stiffness  that  con- 
tinues for  a long  while,  and  sometimes  cannot  be  en- 
tirely cured  during  life.  Moreover,  the  inflammation 
of  the  joint  is  attended  with  more  severe  symptoms,  in 
consequence  of  the  contusion  having  been  more  violent. 
In  a fracture  near  an  articulation,  it  is  to  be  observed, 
also,  that  the  splints  have  little  command  over  the 
short  fragment,  so  that  it  is  often  diflicult  to  prevent 
disiilacernent ; and  with  respect  to  a transverse  frac- 
ture of  the  neck  of  the  thigh-bone  luitlun  the  capsular 
ligament,  whether  an  uiieciuivocal  siiecimen  of  the 
reunion  of  such  a case  by  means  of  bony  matter  is  to 
be  met  with  in  any  museum  in  this  country  is  yet  a 


378 


FRACTURES. 


disputed  point;  and  notwithstanding  the  statements 
in  the  publications  of  Messrs.  Earle,  Ameshury,  and 
Langstaff,  doubts  still  exist  in  the  mind  of  Sir  Astley 
Cooper  and  numerous  other  surgeons  of  vast  expe- 
rience, concerning  the  possibility  of  a bony  union  in 
the  particular  kind  of  accident  here  specified. 

V\hien  a bone  is  fractured  in  several  places,  the  case 
is  more  serious,  and  the  difficulty  of  cure  much  aug- 
mented. But  the  accident  is  still  worse  when  a limb 
is  fractured  in  two  different  places  at  once ; as,  for  in- 
stance, in  the  thigh  and  leg.  Here  it  is  almost  impos- 
sible to  reduce  the  fracture  of  the  thigh  and  maintain 
the  reduction  well,  so  as  to  preserve  the  natural  length 
of  the  limb.— (Boj/er,  Traited.es  Mai.  Chir.  t.  3,p.  29.) 

Oblique  fractures  are  more  troublesome  and  difficult 
of  cure  than  transverse  ones,  because  an  oblique  sur- 
face does  not  resist  the  retraction  of  the  lower  portion 
of  the  broken  bone,  and  consequently  it  is  very  difficult 
to  keep  the  ends  of  the  fracture  duly  applied  to  each 
other. 

Fractures  complicated  with  violent  contusion  of  the 
soft  parts,  or  with  a wound,  rendering  them  compound, 
are  much  more  dangerous  than  others  free  from  such 
accidents.  The  bad  symptoms  which  render  com- 
pound fractures  so  dangerous  are  of  many  kinds  : he- 
morrhage ; violent  and  extensive  inflammation  of  the 
limb,  with  extreme  pain,  delirium,  and  fever ; large  ab- 
scesses, gangrene,  &.c.  Fractures  of  the  leg  are  gene- 
rally more  serious  than  similar  injuries  of  the  upper 
extremity.  The  wound  of  a large  artery  may  add  con- 
siderably to  the  danger  of  a fracture. 

In  a debilitated  old  man,  a fracture  is  less  likely  to 
end  well  than  in  a healthy  child,  or  strong  young  sub- 
ject. In  extreme  old  age,  the  cure  of  a fracture  is 
always  more  difficult  and  sometimes  impossible.— (Bo- 
yer, t.  Z,p.  32.)  The  scurvy  certainly  retards  the  form- 
ation of  callus,  and,  as  I have  already  noticed,  even 
produces  its  absorption  again ; but  it  is  not  true,  that 
pregnancy  always  prevents  the  imion  of  fractures. 
Some  years  ago,  I attended,  for  Mr.  Ramsden,  a wo- 
man in  a court  leading  out  of  St.  Paul’s  churchyard, 
who  broke  both  bones  of  her  leg  when  she  was  several 
months  gone  with  child.  Her  pregnancy,  however,  did 
not  appear  to  be  at  all  unfavourable  to  the  cure,  as  she 
got  quite  well  in  the  usual  time.  “ It  is  not  generally 
settled,”  says  a modern  writer,  “ whether  pregnancy 
should  be  accounted  a complication.  I have,  as  well 
as  some  other  practitioners,  seen  a pregnant  woman 
get  well  of  a simple  fracture  in  the  ordinary  time.” — 
(Leueille,  Nouvelle  Doctrine  Chir.  t.  2,  p.  159.'  And 
in  another  place  he  says,  “ Contre  Vopinion  de  Fabrice 
de  Hildan.  Vexpiriencem'aprouve  que,  chezles femmes 
grosses,  le  cal  etait  aussi  prompt  d se former,  que  chez 
toute  autre  personne.”-^(Op.  cit.  t.  2,  p.  172.)  The 
experience  of  Boyer  also  tends  to  prove,  that  pregnancy 
IS  not  unfavourable  to  the  union  of  fractures. — (See 
Traife  des  Mai.  Chir.  t.  3,  p.  32.) 

The  cases  in  which  fractures  remain  disunited,  will 
be  considered  in  a future  section  of  the  present  article. 

5.  Treatment  of  Fractures  in  general. 

The  general  treatment  of  fractures  embraces  three 
principal  indications.  The  first  is  to  reduce  the  pieces 
of  bone  into  their  natural  situation.  The  second  is  to 
secure  and  keep  them  in  this  state.  And  the  third  is 
to  prevent  any  unpleasant  symptoms  likely  to  arise, 
and  relieve  them  when  they  have  come  on. 

Thefirst  indication  is  only  applicable  to  cases  attended 
with  displacement ; for  when  the  fragments  are  not  out 
of  their  relative  position,  the  surgeon  mtist  strictly  re- 
frain from  all  avoidable  disturbance  of  the  limb.  His 
interference  should  then  be  limited  to  putting  up  the 
fracture,  resisting  the  accession  of  all  unfiivourable 
symptoms,  and  removing  them,  if  possible,  after  they 
have  taken  place. 

6.  Of  the  Reduction  of  Fractures. 

The  means  employed  for  the  reduction  of  frac- 
tures in  general  are  chiefly  three,  viz.  extension,  coun- 
ter-extension, and  coaptation,  or  setting.  But,  as 
Boyer  remarks,  these  means  should  vary  according  to 
the  species  of  displacement;  and  surgical  writers  have 
(Tcneralized  too  much  in  representing  them  all  three  as 
necessary,  for  the  reduction  of  every  kind  of  fracture. 
In  fact,  there  are  several  cases  in  which  extension  and 
r'ounter-cxtension  are  positively  useless  ; of  this  nature 
are  fractures  of  the  patella  and  olecranon,  where  the 


displacement  consists  of  a separation  of  the  fragments. 
Here  the  reduction  njay  be  accomplished  by  putting  the 
limb  in  a position  in  which  the  muscles  attached  to  the 
upper  part  of  the  bone  are  relaxed,  and  then  pushing 
the  upper  fragment  into  contact  with  the  lower. 

Extension  signifies  the  act  of  pulling  the  broken  part 
in  a direction  from  the  trunk,  with  the  view  of  bringing 
the  ends  of  the  fracture  into  their  natural  situation. 
By  counter-extension,  surgeons  imply  the  act  of  mak- 
ing extension  in  the  opposite  direction,  in  order  to  hin- 
der the  limb,  or  even  the  whole  body,  from  being  drawn 
along  by  the  extending  power,  which  would  then  be 
unavailing. 

It  was  formerly  recommended  to  apply  the  extending 
force  to  the  lower  fragment,  and  the  counter-extension 
to  the  upper  one.  Such  practice,  indeed,  was  advised  by 
Mr.  Pott,  and  is  still  generally  preferred  in  this  country  ; 
but  upon  the  continent  it  has  been  abandoned.  The 
objections  made  to  it  by  Boyer  are,  first,  that  it  is  fre- 
quently difficult,  and  sometimes  impossible,  to  take  hold 
of  the;  t'Jvo  fragments,  as,  for  example,  when  the  neck 
of  the' thigh-bone  is  broken.  Secondly,  that  by  apply- 
ing the  extension  and  counter-extension  to  the  broken 
bone  itself,  most  of  the  muscles  which  surround  it  are 
compressed,  and  such  compression  produces  in  these 
organs  a spasmodic  contraction,  which  often  renders 
the  extension  and  counter-extension  useless,  and  some- 
times even  hurtful. — (fTraite  des  Mai.  Chir.  t.  3,  p.  34.) 
The  French  surgeons,  therefore,  apply  the  extending 
force  to  that  part  of  the  limb  which  is  articulated  with 
the  lower  fragment,  and  the  counter-ejapnsion  to  that 
which  is  articulated  with  the  upper.  :^r  instance,  in 
a fracture  of  the  leg,  the  extending  means  act  upon 
the  foot,  and  the  counter-extending  upon  the  thigh; 
and  in  a fracture  of  the  thigh,  the  extension  is  applied 
to  the  leg,  while  the  counter-extending  power  fixes  the 
pelvis. 

One  circumstance  must  here  occur  to  the  mind  of  the 
surgical  reader.  In  this  country,  it  is  properly  incul- 
cated that  one  of  the  first  principles  to  be  attended  to 
in  the  reduction  of  fractures,  is  to  put  the  limb  in  such 
a position  as  will  relax  the  most  powerful  muscles 
connected  with  the  broken  bone  ; because  these  mus- 
cles principally  impede  the  reduction  and  disturb  the 
ends  of  the  fracture.  But,  in  the  French  mode  of  mak- 
ing the  extension  and  counter-extension,  how  can  this 
grand  principle  be  observed?  If  the  extending  and 
counter-extending  means  are  not  to  be  applied  to  the 
broken  bone  itself,  but  to  others  which  are  articulated 
with  it,  the  limb  must  of  necessity  be  kept  in  a straight 
posture  at  the  time  of  reducing  the  fracture ; for  were 
the  limb  placed  in  a half-bent  state,  the  extension  and 
counter-extension,  as  practised  by  the  continental  sur- 
geons, would  not  be  in  the  same  line.  If,  therefore,  it 
be  advantageous  to  bend  the  limb  at  the  time  of  re- 
ducing a fracture,  the  French  mode  of  practising  exten- 
sion and  counter-extfnsion  must  be  relinquished.  I am 
not,  however,  one  of  those  surgeons  who  are  entirely 
blinded  with  the  idea  of  the  possibility  of  relaxing  the 
whole  of  the  muscles  connected  with  the  broken  bone, 
by  merely  bending  the  limb.  On  the  contrary,  I am 
perfectly  convinced,  with  Desault,  that,  in  general, 
what  is  gained  by  the  relaxation  of  some  muscles,  is 
lost  by  the  tension  of  others.  But  where  it  is  possible 
to  relax,  by  a certain  posture,  the  set  of  muscles  most 
capable  of  preventing  the  reduction  and  disturbing  the 
coaptation  of  a fracture,  that  posture  I would  select. 
Thus,  in  a fracture  of  the  leg,  the  strong  muscles  of 
the  calf  undeniably'possess  this  powder,  and  the  bent 
position,  which  relaxes  them,  appears  to  me,  therefore, 
the  most  judicious  and  advantageous,  not  only  during 
the  reduction,  but  during  the  whole  treatment  of  the 
case.  A few'  years  ago  I had  under  my  care,  in  the 
military  hospital  at  Cambray,  a fracture  of  the  tibia 
and  fibula,  which  was  at  first  treated  in  the  straight 
posture.  The  gentleman  who  assisted  me  reduced  the 
tragments,  and  made  them  lie  tolerably  well.  But 
every  time  the  bandage  w-as  opened,  the  bones  were 
ahvays  found  displaced  again.  Finding  that  this  incon- 
venience went  on  for  two  or  three  weeks,  we  resolved 
to  lay  the  limb  on  its  outside,  in  the  bent  position.  Not 
the  least  trouble  was  afterward  experienced  in  keeping 
the  fragments  reduced.  Unless,  therefore,  the  situa- 
tion of  a wound,  abscess,  or  some  particular  rea- 
son, indicate  an  advantage  or  convenience  from  the 
straight  posture,  I always  reduce  a fractured  leg  in 
the  bent  jrosition,  wliich  wll  be  hereafter  described 


FRACTURES. 


379 


Here,  therefore,  I consider  the  French  mode  of  making 
the  extension  and  counter-extension  as  generally  inad- 
missible. 

I was  also  formerly  of  opinion,  that  the  bent  position 
of  the  limb  on  its  side,  as  advised  by  Mr.  Pott,  was  the 
best  for  fractured  thighs ; but  this  sentiment  has  sub- 
sequently appeared  to  me  erroneous,  and  it  gives  me 
pleasure  to  have  this  opportunity  of  declaring  my  en- 
tire conversion  to  the  principles  and  practice  adopted 
in  these  cases  by  Desault  and  others,  who  urge  the  neces- 
sity of  endeavouring  to  render  the  apparatus  more  effi- 
cient. The  considerations  which  have  led  me  to  tliis 
change  will  be  related  in  speaking  of  fractured  thighs. 
If,  then,  the  straight  posture  be  advantageous  in  cases  of 
broken  thighs,  I think  it  will  be  universally  allowed,  that 
the  parts  of  the  limb  recommended  by  the  French  sur- 
geons for  the  application  of  the  extension  and  counter- 
extension are  the  most  proper. 

The  evils  and  difficulties  formerly  encountered  in 
setting  fractured  limbs,  undoubtedly  proceeded,  in  a 
great  measure,  from  the  violent  extension  and  counter- 
extension practised  by  our  ancestors.  As  they  were 
ignorant  of  the  utility  of  relaxing  the  muscles  which 
displaced  the  ends  of  the  broken  bone,  they  had  no 
means  but  the  emplojunent  of  actual  force  to  effect  the 
reduction.  Since,  however,  the  excellent  instructions 
contained  in  Mr.  Pott’s  remarks  on  fractures  have  re- 
ceived all  the  attention  due  to  them,  practitioners  have 
generally  been  careful,  in  the  reduction  of  fractures,  to 
incapacitate  the  muscles  as  much  as  possible  by  relax- 
ing them,  and  thus  the  necessity  for  the  employment 
of  violent  extension  and  counter-extension  is  effectually 
removed. 

It  is  difficult  to  lay  down  rules  respecting  the 
precise  degree  of  force  which  should  be  used  in  mak- 
ing extension ; for  it  must  vary  in  different  cases, 
according  to  the  species  of  displacement  and  the  num- 
ber and  power  of  the  muscles  concerned  in  pro- 
ducing it.  In  transverse  fractures  displaced  only  ac- 
cording to  the  diameter  of  the  bone,  a very  moderate 
extension  suffices,  as  it  is  merely  practised  with  a view 
of  lessening  the  friction  of  the  surfaces  of  the  fracture, 
which  are  always  more  or  less  rough.  But  whatever 
be  the  direction  of  the  fracture  when  the  fragments  pass 
over  each  other,  the  extension  and  counter-extension 
must  constantly  be  such  as  to  remove  the  shortening 
of  the  limb,  and  overcome  the  force  of  those  muscles 
which,  after  all  attention  has  been  paid  to  their  relax- 
ation, still  oppose  the  reduction.  Extension,  however, 
ought  never  to  be  practised  in  a violent  and  sudden 
way  ; but  in  as  gradual  a manner  as  possible,  the  ut- 
most care  being  taken  not  to  shake,  nor  even  move, 
the  limb  any  more  than  can  be  avoided.  When  the 
practitioner  extends  a broken  member  all  at  once  vio- 
lently, he  excites  the  muscles  to  strong  spasmodic 
action,  and  there  is  some  danger  of  lacerating  them, 
because  their  fibres  are  not  allowed  the  requisite  time 
to  yield  to  the  force  which  elongates  them.  The  exten- 
sion is  to  begin  in  the  direction  of  the  lower  fragment, 
and  be  continued  in  that  which  is  natural  to  the  body 
of  the  bone. 

In  every  case  of  fracture  with  displacement,  as  soon 
as  the  necessary  extension  has  been  made,  the  surgeon 
is  to  endeavour  to  place  the  ends  of  the  broken  bone  in 
their  natural  situation : this  is  termed  coaptation,  or 
setting.  This  operation  is  to  be  undertaken  in  differ- 
ent ways,  according  to  the  species  of  displacement,  and 
the  practitioner  can  almost  always  execute  it  by  acting 
upon  the  lower  fragment,  without  applying  his  fingers 
directly  to  the  fracture  itself,  in  order  to  regulate  the 
contact  of  the  extremities  of  the  bone.  When,  however, 
it  is  judged  necessary  for  this  purpose  to  touch  the 
broken  part  itself,  it  should  be  done  with  the  utmost 
gentleness,  so  as  to  avoid  jiressing  the  soft  parts  against 
the  jioints  and  splinters  of  bone. 

Although  the  reduction  of  fractures  may  in  general  be 
accomplished  with  tolerable  facility,  it  sometimes  hap- 
pens that  the  first  attempts  fail.  This  is  occasionally 
ascribable  to  the  employment  of  too  much  force,  and 
too  little  management,  in  making  the  extension  ; 
whereby  the  muscles  are  irritated,  and  act  so  power- 
fully, that  the  design  of  the  surgeon  is  completely  frus- 
traletl.  Here  the  grand  means  of  success  is  putting 
the  liiiib  into  such  a position  as  will  relax  the  most 
powerful  muscles  which  oppose  the  reduction.  Sorne- 
wn.es,  however,  the  irritable  and  convulsive  state  of 
the  muscles  is  not  the  effect  of  any  wrong  mode  of  pro- , 


cecding  on  the  part  of  the  surgeon,  but  arises  from  the 
alarm,  pain,  and  injury,  caused  by  the  accident  itself. 
Here  relaxing  the  muscles  as  much  as  possible  is  also 
the  most  likely  method  of  removing  the  difficulty.  In 
short,  now  that  the  titility  of  paying  attention  to  this 
principle  is  universally  known  in  the  profession,  a frac- 
ture is  hardly  ever  met  with  which  cannot  be  immedi- 
ately reduced;  particularly  if  a copious  bleeding  be 
premised  when  the  patient  is  a strong  muscular  sub- 
ject. This  evacuation,  indeed,  will  also  prove,  for 
other  reasons,  highly  beneficial,  where  the  limb  is  much 
contused  and  swollen,  and  the  tendency  to  inflamma- 
tion is  great. 

7.  Of  the  Means  for  keeping  Fractures  reduced. 

After  the  bones  have  been  put  into  their  natural  situ- 
ation, time  alone  would  complete  their  cure,  were  there 
not  in  the  muscles  a continual  propensity  to  displace 
the  ends  of  the  fracture  again.  In  cases  of  fracture  the 
muscles  are  often  affected  with  involuntary  spasmodic 
action,  by  which  the  broken  part  would  certainly  be 
displaced,  were  no  measures  taken  to  maintain  the  ex- 
tremities of  the  broken  bone  in  contact.  Besides,  the 
patient,  in  easing  himself,  coughing,  sneezing,  <fec.,must 
unavoidably  subject  the  limb  to  a degree  of  motion  by 
which  the  coaptation  would  be  altogether  destroyed. 
Hence  the  necessity  of  employing  means  for  fixing  the 
broken  limb  so  effectually  that  it  may  continue  perfectly 
motionless  during  the  whole  time  requisite  for  the  union 
of  the  fracture.  This  second  indication  is  sometimes 
troublesome  and  difficult,  and,  as  Boyer  observes,  it  is  in 
this  part  of  the  treatment  that  the  surgeon  has  an  op- 
portunity of  evincing  his  skill.  The  means  employed 
for  the  fulfilment  of  this  indication  are,  an  advantage- 
ous position,  quietude,  bandages,  splints,  and  various 
kinds  of  apparatus. 

In  the  treatment  of  all  fractures,  the  position  of  the 
part,  and  indeed  of  the  whole  body,  is  a thing  of  mate- 
rial importance.  Whenever  the  ca.se  is  a fracture  of  the 
lower  extremities,  the  patient  should  lie  strictly  in  bed 
until  the  callus  is  completely  formed.  It  is  likewise  an 
advantage  not  to  have  the  bed  much  more  than  a yard 
wide,  because  the  surgeon  and  assistants  can  then  more 
conveniently  get  at  any  part  of  the  limb.  Feather-beds 
are  a great  deal  too  soft  and  yielding:  a horse-hair 
mattress  is  far  preferable.  Boyer,  indeed,  is  so  im- 
pressed wth  the  utility  of  letting  the  patient  lie  upon  a 
surface  which  will  not  sink,  that  he  recommends  two 
mattresses  to  be  used,  and  a board  to  be  laid  under  the 
upper  one  from  the  hip  to  beyond  the  patient’s  foot.— 
{Traite  des  Mai.  Chir.  p.  39,  vol.  3.) 

The  most  favourable  position  for  a fractured  limb  is 
that  in  which  ail  the  muscles  passing  over  the  fracture, 
and  extending  either  to  the  lower  fragment  or  to  that 
part  of  the  limb  which  is  articulated  with  it,  are  equally 
relaxed.  The  injured  limb  should  also  have  firm  sup- 
port at  every  point,  and  its  position  ought  to  be  regu- 
lated so  that  not  only  this  object  be  carefully  fulfilled, 
but  at  the  same  time  the  chance  of  displacement  from 
the  action  of  the  muscles,  or  the  weight  of  the  body,  or 
part  itself,  may  be  diminished  as  much  as  possible. 

The  natural  or  rather  the  most  easy  position  of  the 
limb  is  that  which  is  usually  chosen  by  a person  who 
reposes  himself  or  who  is  sleeping ; for  then  all  mo- 
tion is  suspended,  and  every  part  assumes  that  posture 
which  is  most  congenial  to  it.  In  this  condition,  the 
limbs  are  not  extended,  nor  yet  entirely  bent ; but  only 
in  a moderate  state  of  flexion.  Hence,  Boyer  remarks, 
that  a half-bent  position  of  the  limbs  is  that  which  is 
most  natural,  and  that  in  which  all  the  muscles  enjoy 
an  equal  degree  of  relaxation,  and,  conseiiuently,  that 
it  is,  generally  speaking,  the  best  for  fractures.  This 
posture  which  was  recommended  by  Hippocrates  and 
Galen,  has  been  highly  extolled  by  Pott,  who  aiipears 
to  have  exaggerated  its  advantages.  Considered  in  a 
general  way,  it  is  without  contradiction  preferable  to 
every  other  position  of  the  limb  ; but  its  employment 
should  be  liable  to  exceptions,  as  will  be  noticed  in 
treating  of  particular  fractures.— (See  Boyer,  Traite 
des  Mai.  Chir.  t.  8,  p.  40.) 

In  whatever  position  a broken  limb  is  placed  (says 
this  writer),  it  should  bear  throughout  its  whole  length 
equally  and  perpendicularly  upon  the  surface  on  which 
it  lies,  and  not  be  only  partially  supported.  When, 
for  example,  only  the  extremities  of  a fractured  limb 
rest  upon  the  bed,  the  weight  of  the  limb  itself  will 
make  it  bend  in  the  situation  of  the  fracture.  Tlio 


380 


FRACTURES. 


limb  will  also  be  rendered  crooked,  if  the  broken  part 
be  supported,  while  the  extremities  of  the  limb  (espe- 
cially the  inferior)  sink  lower  by  their  own  weight. 
The  displacement  of  the  fracture  is  not  the  only  incon- 
venience arising  from  the  limb  being  laid  upon  a surface 
where  it  is  not  every  where  equally  supported.  The 
parts  which  do  bear  on  this  surface  experience  a pain- 
ful degree  of  pressure,  which,  if  long  continued,  is  apt 
to  produce  inflammation,  and  even  sloughing,  of  the 
integuments.  Thus,  in  fractures  of  the  leg,  gangrene 
of  the  heel  has  sometimes  arisen  entirely  from  this 
cause.  Such  inconveniences  may  be  prevented  by  lay- 
ing a fractured  limb  on  a surface  of  corresponding 
form ; that  is  to  say,  on  a surface  which  is  depressed 
where  the  limb  has  projections,  and  rises  where  it  pre- 
sents depressions.  The  surface  should  not  be  so  hard 
as  to  annoy  the  patient ; yet  it  ought  to  be  sufficiently 
firm  not  to  yield  to  the  weight  of  the  limb  and  appa- 
ratus. According  to  Boyer,  the  best  pillows  for  the 
support  of  broken  limbs  are  stuffed  with  chaff  of  oats, 
a substance  which  he  describes  as  far  preferable  to 
feathers,  because  it  more  readily  admits  of  being 
pushed  from  the  place  where  the  limb  is  prominent  to 
another  situation  where  the  member  presents  a depres- 
sion or  hollow;  and  it  has  the  advantages  of  being  less 
heating  than  feathers  and  less  apt  to  spoil. 

In  whatever  position  fractured  limbs  are  placed, 
they  ought  to  be  kept  perfectly  quiet  during  the  whole 
time  requisite  for  the  union.  If  the  broken  bone  be 
moved  while  the  callus  is  forming,  the  surfaces  of  the 
fracture  rub  against  each  other,  and  the  process  is  dis- 
turbed ; and,  indeed,  sometimes  by  repeatedly  moving 
the  limb,  the  consolidation  of  fractures  is  entirely  pre- 
vented, or,  at  least,  rendered  very  slow  and  difficult. 

In  order  to  mairuain  the  limb  in  the  right  position, 
and  in  a state  of  quietude,  and  to  preserve  the  frag- 
ments in  pro])er  contact  with  respect  to  each  other, 
the  surgeon  is  to  caution  the  patient  to  avoid  moving 
at  all  more  than  can  be  helped,  and  every  cause  likely 
to  subject  the  limb  to  any  kind  of  shock  or  concussion 
is  to  be  removed.  But  in  particular,  it  will  be  neces- 
sary to  apply  a retentive  apparatus,  usually  consisting 
of  some  application  to  the  skin  itself,  bandages,  splints, 
tapes,  straps,  and  buckles,  soft  pads,  &c.— (See  Boyer, 
Traits  des  Mai.  Chir.  t.  3,  p.  42.) 

Upon  the  subject  of  the  dressings,  bandages,  &c.  which 
ought  to  be  applied  to  fractures,  no  surgeon  has  writ- 
ten better  than  Mr.  Pott. 

“ The  intention  (says  he)  in  applying  any  kind  of  ex- 
ternal medicine  to  a broken  limb  is,  or  ought  to  be,  to 
repress  inflammation,  to  disperse  extravasated  blood, 
to  keep  the  skin  lax,  moist,  and  perspirable,  and  at  the 
same  time  to  afford  some,  though  a very  small  degree 
of  restraint  or  confinement  to  the  fracture,  but  not  to 
bind  or  press ; and  it  should  also  be  calculated  as  much 
as  possible  to  prevent  itching,  an  herpetic  eruption,  or 
an  ery.sipelatous  efflorescence.  At  St.  Bartholomew’s 
Hospital,  we  use  a cerate  made  by  a solution  of  li- 
tharge in  vinegar,  which,  with  soap,  oil,  and  wax,  is  af- 
terward formed  into  such  consistence  as  just  to  admit 
being  spread  without  warming. 

This  lies  very  easy,  repels  inflammation,  is  not  ad- 
herent. comes  off  clean,  and  very  seldom,  if  ever,  irri- 
tates, or  causes  either  herpes  or  erysipelas.  But  let 
the  form  and  composition  of  the  application  made  to 
the  limb  be  what  it  may,  one  thing  is  clear,  viz.,  that 
it  should  be  put  on  in  such  manner,  as  that  it  may  be 
renewed  and  shifted  as  often  as  may  be  necessary, 
without  moving  the  limb  in  any  manner : it  being  cer- 
tain, that  when  once  a broken  thigh  or  leg  has  been 
properly  put  to  rights,  and  has  been  deposited  properly 
on  the  pillow,  it  ought  not  ever  to  be  lifted  up  or  moved 
from  it  again  without  nece.ssity,  until  the  fracture  is 
perfectly  united  ; and  it  is  true  that  such  necessity  will 
not  very  often  occur.” 

Such  application  having  been  made  as  the  surgeon 
thinks  right , the  next  thing  to  be  done  is  to  put  on  a proper 
bandage.  That  formerly  used  was  what  is  commonly 
called  a roller.  This  was  of  different  lengths,  accord- 
ing to  the  surgeon’s  choice,  or  as  it  was  used  in  the 
form  of  one,  two  or  more  pieces. 

“ By  such  kind  of  bandage  three  intentions  are 
aimed  at,  and  said  to  be  accomplished,  viz.  to  con- 
fine the  fracture,  to  repress  or  prevent  a flux  of 
humours,  and  to  regulate  the  callus  (see  Duverney) ; 
but  whoever  will  reflect  seriously  on  this  matter, 
will  soon  be  convinced,  that  although  some  .soil  o; 


bandage  is  necessary  in  every  simple  fracture,  as  well 
for  preserving  some  degree  of  steadiness  to  the  limb, 
as  for  the  retention  of  the  applications,  yet  none  nor 
either  of  these  three  ends  can  be  answered  merely,  or 
even  principally,  by  bandage  of  any  kind  whatever.: 
and,  therefore,  if  this  should  be  found  to  be  true,  that 
is,  if  it  should  appear,  that  whatever  kind  of  deliga- 
tion be  made  use  of,  it  cannot  be  a principal,  but  only 
an  accessory  kind  of  assistance,  and  that  in  a small 
degree,  and  very  little  to  be  depended  upon,  it  will  fol- 
low that  such  kind  of  bandage  as  is  most  ditficult  to  be 
applied  with  justness  and  exactitude,  such  as  is  soonest 
relaxed  and  out  of  order,  such  as  stands  most  fre- 
quently in  need  of  renewal,  and  in  such  renewal  is 
most  likely  to  give  pain  and  trouble,  must  be  more  im- 
proper and  less  eligible  than  one  which  is  more  easily 
applied,  less  liable  to  be  out  of  order,  and  which  can 
be  adjusted  without  moving  the  limb,  &c. 

The  best  and  most  useful  bandage  for  a simple 
fracture  of  the  leg  or  thigh  is  what  is  commonly 
known  by  the  name  of  the  eighteen-tailed  bandage,  or 
rather,  one  made  on  the  same  principle,  but  with  a little 
difference  in  the  disposition  of  the  pieces.  The  com- 
mon method  is  to  make  it  so  that  the  parts  which  are 
to  surround  the  limb  make  a right  angle  with  that 
which  runs  lengthwise  under  it ; instead  of  which,  if 
they  are  tacked  on  so  as  to  make  an  acute  angle,  they 
will  fold  over  each  other  in  an  oblique  direction,  and 
thereby  sit  more  neatly  and  more  securely,  as  the  parts 
will  thereby  have  more  connexion  with,  and  more  de- 
pendence on,  each  other.  In  compound  fractures,  as 
they  are  called,  every  body  sees  and  acknowledges  the 
utility  of  this  kind  of  bandage  preferably  to  the  roller, 
and  for  very  obvious  and  convincing  reasons,  but  parti- 
cularly because  it  does  not  become  necessary  to  lift  up 
and  disturb  the  limb  every  time  it  is  dressed,  or  every 
time  the  bandage  loosens. 

The  pain  attending  motion  in  a compound  fracture, 
the  circumstance  of  the  wound,  and  the  greater  de- 
gree of  instability  of  parts  thereby  produced,  are  cer- 
tainly very  good  reasons  for  dressing  such  wound 
with  a bandage  which  does  not  render  motion  neces- 
sary ; but  I should  be  glad  to.  know  what  can  make  it 
necessary,  or  right,  or  eligible,  to  move  a limb  in  the 
case  of  simple  fracture  1 what  benefit  can  be  proposed 
by  it  ? what  utility  can  be  drawn  from  it  ? When  a 
broken  bone  has  been  well  set,  and  the  limb  well 
placed,  what  possible  advantage  can  arise  from  moving 
it  ? Surely  none ; but,  on  the  contrary,  pain  and  pro- 
bable mischief.  Is  it  not  the  one  great  intention  to  pro- 
cure unition?  Can  moving  the  limb  every  two  or 
three  days  contribute  to  such  intention  1 must  it  not, 
on  the  contrary,  obstruct  and  retard  it?  Is  not  perfect 
quietude  as  necessary  towards  the  union  of  the  bone 
in  a simple  as  in  a compound  fracture  ? It  is  true,  that 
in  the  one  there  is  a wound  which  requires  to  be 
dressed,  and  the  motion  of  the  limb  may  in  general  be 
attended  with  rather  more  pain  than  in  the  other ; but 
does  motion  in  the  simple  fracture  give  ease  or  procure 
more  expeditious  union  ? 

Every  benefit  then  which  can  be  supposed  to  be  ob- 
tained from  the  use  of  the  common  bandage  or  roller,  is 
equally  attainable  from  the  use  of  that  which  I have  just 
mentioned,  with  one  additional,  and  to  the  patient  most 
invaluable  advantage,  viz.  that  of  never  finding  it  ne- 
cessary to  have  his  leg  or  thigh  once,  during  the  cure, 
removed  from  the  pillow  on  which  it  has  been  properly 
deposited.” — {Pott's  Remarks  on  Fractures,  &c.) 

In  France  a universal  preference  is  given  to  Scul- 
tetus’s  bandage  in  every  instance  where  we  employ 
the  eighteen-tailed  one,  from  which  it  chiefly  differs  in 
being  composed  of  separate  pieces  admitting  of  remo- 
val, so  that  when  a part  of  the  bandage  is  soiled  it  can 
be  taken  away  without  disturbing  the  whole  of  the 
dressings.  The  clean  pieces  are  first  stitched  to  those 
which  are  about  to  be  removed,  and  then  they  are 
drawn  under  the  part.  In  cases  of  compound  fracture 
where  the  bandage  is  soiled  with  the  discharge  in  a 
very  short  time,  and  must  be  often  removed,  certainly 
Scultetus’s  bandage  is  the  best,  panicularly  as  it  pos- 
sesses all  the  recommendations  peculiar  to  that  of  the 
eighteen-tailed  kind. — {Boyer,  Traiti  des  Mai.  Chir.  t. 
3,p.  46.) 

With  respect  to  the  general  objects  and  uses  of  band- 
ages in  cases  of  fracture,  I ought  to  notice  one  design 
of  them,  which  is  strongly  inculcated  in  the  modern 
French  schools;  namely, that  ol’  “ beuiimbii.g  .he  .r. .- 


FRACTURES. 


381 


lability  of  the  muscles”  by  the  compression  resulting 
from  their  regular  and  even  application  to  the  whole 
of  the  member.  In  describing  the  treatment  of  parti- 
cular fractures,  I shall  have  occasion  to  advert  to  the 
examples  in  which  a moderate  general  compression 
of  the  muscles  may  be  attended  with  utility. 

“ The  parts  of  the  general  apparatus  for  a simple  frac- 
ture, which  come  next  in  order  (observes  Mr.  Pott),  are 
the  splints  which  are  unquestionably  the  most  efficient 
of  all  the  applications  made  to  a broken  limb  with  a 
view  of  keeping  the  ends  of  the  fracture  steady  and 
in  a proper  state  of  contact.  Without  them  the  surgeon 
would  in  vain  endeavour  to  maintain  the  reduction. 

“ Splints,”  says  Pott,  “ are  generally  made  of  paste- 
board, wood,  or  some  resisting  kind  of  stuff,  and  are 
ordered  to  be  applied  lengthwise  on  the  broken  limb  ; 
in  some  cases  three,  in  others  four ; for  the  more  steady 
and  quiet  detention  of  the  fracture. 

That  splints  properly  made  and  judiciously  applied 
are  very  serviceable  is  beyond  all  doubt ; but  their  uti- 
lity depends  much  on  their  size  and  the  manner  in 
which  they  are  applied. 

The  true  and  proper  use  of  splints  is  to  preserve 
steadiness  in  the  whole  limb  without  compressing  the 
fracture  at  all.  By  the  former  they  become  very  assist- 
ant to  the  curative  intention ; by  the  latter  they  are 
very  capable  of  causing  pain  and  other  inconveniences  ; 
at  the  same  time  that  they  cannot,  in  the  nature  of 
things,  contribute  to  the  steadiness  of  the  limb. 

In  order  to  be  of  any  real  use  at  all,  splints  should,  in 
the  case  of  a broken  leg,  reach  above  the  knee  and  below 
the  ankle  ; should  be  only  two  in  number,  and  should  be 
so  guarded  with  tow,  rag,  or  cotton,  that  they  should 
press  only  on  the  Joints,  and  not  at  all  on  the  fracture. 

By  this  they  become  really  serviceable  ; but  a short 
splint  which  extends  only  a little  above  and  a little  below 
the  fracture,  and  does  not  take  in  the  two  Joints,  is  an  ab- 
surdity, and,  what  is  worse,  it  is  a mischievous  absurdity. 

By  pressing  on  both  Joints,  they  keep  not  only  them 
but  the  foot  steady ; by  pressing  on  the  fracture  only,  they 
cannot  retain  it  in  its  place,  if  the  foot  be  in  he  smallest 
degree  displaced  ; but  they  may,  and  frequently  do,  oc- 
casion mischief,  by  rudely  pressing  the  parts  covering 
the  fracture  against  the  edges  and  inequalities  of  it. 

In  the  case  of  a fractured  os  femoris,  if  the  limb 
be  laid  in  an  extended  posture,  one  splint  should  cer- 
tainly reach  from  the  hip  to  the  outer  ankle,  and  an- 
other (somewhat  shorter)  should  extend  from  the  groin 
to  the  inner  ankle.  In  the  case  of  a broken  tibia  and 
fibula,  there  never  can  be  occasion  for  more  than  two 
splints,  one  of  which  should  extend  from  above  the 
knee  to  below  the  ankle  on  one  side,  and  the  other 
splint  should  do  the  same  on  the  other  side.”— (See 
Remarks  on  Fractures  and  Dislocations,  in  PotVs 
Chirurgical  Works,  x'ol.  1,  p.  298,  See.  edit.  1808.) 

Assalini  strongly  disapproves  of  the  employment  of 
all  tight  bandages,  and  of  covering  the  whole  of  a 
broken  limb  with  splints.  He  was  called  to  a gentle- 
man of  rank  at  Paris,  who  had  broken  the  knee-pan 
transversely.  He  laid  the  limb  upon  a concave  splint, 
the  shape  of  which  was  adapted  to  the  under  surface 
of  a part  of  the  leg  and  thign.  No  bandage  was  used ; 
merely  two  leather  straps,  which  cro.ssed  upon  the 
knee,  and  included  the  fractured  bone.  A perfect  bony 
union  was  thus  easily  effected.  Assalini  afterward 
extended  the  use  of  a concave  splint,  applied  under  the 
limb,  to  fractures  of  the  leg  and  thigh.  In  the  first  of 
these  cases,  however,  only  the  thigh  is  received  in  the 
hollow  splint,  and  from  this  two  branches,  or  lateral 
splints,  go  along  the  leg.  The  apparatus  has  also  a 
kind  of  sole  for  the  support  of  the  foot.  As  this  simple 
contrivance  is  fastened  with  a very  few  straps,  and  no 
plasters  or  bandages  are  used,  the  surgeon  has  con- 
stantly a view  of  the  whole  front  of  the  limb,  and  of 
the  fractured  part  of  it,  which  Assalini  thinks  a great 
advantage.  In  compound  fractures,  he  puts  no  other 
dressings  on  the  wound  but  linen  compresses,  which 
are  kept  continually  wet  with  cold  water.— (Manwa/e 
di  Chirurgia,  parte  prima,  1812.)  For  farther  obser- 
vations on  the  subject,  see  Splint. 

In  oblique  fractures  of  the  thigh,  and  sometimes  even 
in  those  of  the  leg,  the  difficulty  of  accomplishing  by 
the  ordinary  means  a cure  free  from  deformity,  and  es- 
pecially without  a shortening  of  the  limb,  has  led  to 
the  idea  of  employing  continual  extension.  This  ex- 
pression implies  the  operation  of  a bandage,  or  ma- 
chine, which  continually  draws  the  fragments  of  the 


broken  bone  in  contrary  directions,  at  the  same  time 
that  it  restrains  them  from  gliding  over  each  other,  and 
maintains  them  in  contact  during  the  whole  time  ne- 
cessary for  their  union.  In  England  this  practice  has 
long  been  relinquished.  It  appears  to  have  been  chased 
away  by  the  dazzling  theory  of  relaxing  every  muscle 
in  such  manner  as  to  render  it  incapable  of  displacing 
an  oblique  fracture ; a theory  with  which  the  surgeons 
of  this  country  were  but  too  much  blinded  by  the  per- 
suasive eloquence  of  the  late  Mr.  Pott.  Desault  saw 
at  once,  however,  every  inconsistency  in  the  doctrine 
of  the  possibility  of  relaxing  the  muscles,  so  as  to  in- 
capacitate entirely  the  whole  set  connected  with  a 
broken  thigh ; and  he  never  ceased  to  inculcate  in  his 
school,  that  in  such  a case  the  assistance  of  a me- 
chanical apparatus  applied  to  the  limb  was  the  main 
thing  by  which  the  shortening  of  the  limb  was  to  be 
prevented.  When  we  consider  the  treatment  of  frac- 
tured thighs,  we  shall  find  that  the  principle  of  con- 
tintial  but  moderate  extension  has  had  in  France  ad- 
vocates of  great  talent  and  eminence,  though  it  is  a 
method  to  which  many  surgeons  in  this  country  ap^pear 
to  entertain  strong  but  highly  exaggerated  objections. 

By  means  of  continual  extension  (observes  Boyer), 
we  not  only  succeed  in  uniting  the  fracture,  while  the 
limb  preserves  its  natural  length ; but  we  afford  the 
part  a steadiness,  which  is  singularly  favourable  to  the 
formation  of  the  callus. 

In  order  to  derive  from  continual  extension  the  ut- 
most benefit,  and  render  the  method  as  little  painful  as 
possible,  and  supportable  during  the  whole  time  of 
treatment,  the  machines  and  bandages,  according  to 
Boyer,  should  be  constructed  and  applied  conformably 
to  the  following  rules. 

We  should  avoid  compressing  the  muscles  which 
pass  over  the  situation  of  the fracture,  and  the  elonga- 
tion of  which  organs  is  necessary  to  restore  to  the  limb 
the  length  which  it  has  lost  by  the  gliding  of  the  frag- 
ments over  each  other. 

With  this  view,  the  extending  power  ought  to  be  ap- 
plied to  that  part  of  the  limb  which  is  articulated  with 
the  lower  head  of  the  fractured  bone  ; and  the  counter- 
extending force  to  that  which  is  articulated  with  the 
upper  head.  If  these  powers  were  applied  to  the  broken 
bone  itself,  the  muscles  passing  over  the  fracture  would 
suffer  such  compression  as  would  excite  spasm,  and  ren- 
der the  continual  extension  ineffectual  and  even  hurtful. 

The  extending  and  counter-extending  force  ought  to 
be  divided  upon  as  large  surfaces  as  possible. 

The  reason  of  this  rule  is  obvious.  The  pressure  of 
externeil  bodies  on  parts  is  less  painful,  in  proportion 
as  the  surface  pressed  upon  is  extensive  and  the  ope- 
ration supported  at  once  by  numerous  points.  On  this 
principle  a narrow  band  creates  stronger  and  more 
painful  pressure  than  a broad  one  ; and  hence,  the 
rollers  and  other  pieces  of  the  apparatus  for  making 
the  extension  and  counter-extension  should  be  as  wide 
as  possible. 

The  powers  making  continual  extension  should  act 
according  to  the  direction  of  the  axis  of  the  broken  bone.. 

The  continual  extension  should  be  practised  in  as 
slow,  gradual,  and  insensible  a manner  as  possible. 

The  muscles  easily  yield  to  a force  which  stretches 
them,when  such  force  acts  slowly,  and  is  very  gradually 
increased,  according  to  the  shortness  of  the  limb,  and 
the  power  of  the  muscles  pioducing  the  displacement. 
But  if  one  were  all  on  a sudden  to  begin  with  making 
violent  extension,  the  rough  forcible  elongation  of  the 
nmscles  would  excite  such  a spasmodic  action  of  them 
as  would  frustrate  every  attempt  to  re.store  the  natural 
length  of  the  limb.  And  if,  in  order  to  fulfil  this  pur- 
pose, the  extending  force  were  increased  in  a ratio  to 
the  resistance  of  the  muscles,  there  would  be  danger 
of  lacerating  these  organs,  because  their  fibres  would 
not  have  time  enough  to  yield. 

Lastly,  the  parts  upon  which  the  extending  and 
counter-extending  force  acts  should  be  defended ; and 
the  compression  made  by  the  tapes,  or  other  pieces  of 
the  bandage  and  apparatus,  ought  to  be  equalized. 

These  indications  may  be  fulfilled  by  covering  the 
parts  on  which  the  tapes  and  bandages  press  with  tow 
or  wool  pads ; and  by  filling  up  all  the  depressions  of 
the  limb  with  the  same  .soft  substances,  so  as  to  give  it 
a circular  Ibrm.  The  bandages  will  then  not  hurt  the 
most  projecting  parts,  on  which  they  would  make  a 
strong  and  injurious  degree  of  pressure,  if  the  depres- 
sions were  not  artificially  filled  up. 


382 


FRACTURES. 


By  observing  these  rules,  says  Boyer,  continual  ex- 
tension may  always  be  borne,  even  by  the  most  deli- 
cate and  irritable  patients;  and  the  important  advan- 
tage will  be  obtained  of  curing  the  fracture  with  the 
proper  length  of  the  limb  preserved. — iTraite  des  Mai. 
Chir.  t.  3,  p.  56.  59.) 

8 Means  for  preventing  and  removing  the  unfavour- 
able Symptoms  liable  to  arise  from  Fractures. 

After  having  reduced  the  fracture,  applied  a suitable 
apparatus  for  maintaining  the  reduction,  and  put  the 
part  in  an  advantageous  position,  the  practitioner  is  to 
attend  to  the  third  indication  in  the  treatment,  viz.  the 
prevention  and  removal  of  any  unfavourable  symptoms. 

With  the  exception  of  a few  simple  fractures  of  the 
upper  extremity,  it  is  proper  in  all  cases  to  allow  for 
the  first  few  days  only  very  low  diet,  broths,  tea,  &c. 
When  the  patient  is  young  and  strong,  and  the  swell- 
ing and  inflammatioii  are  likely  to  be  considerable,  ve- 
nesection should  be  practised.  In  other  circumstances 
it  may  in  general  be  dispensed  with,  because  it  is  well 
known,  that  for  the  quick  formation  of  callus,  by  which 
the  fracture  is  to  be  united,  strength  and  a vigorous 
circulation  are  highly  favourable.  The  patient  may  be 
permitted  to  drink  as  often  and  as  much  as  he  likes, 
of  any  cooling  acid  beverage.  A very  low  diet  is  only 
to  be  continued  the  first  few  days,  unless  great  inflam- 
mation arise ; for  experience  proves  that  the  method, 
when  too  much  prolonged,  has  bad  effects,  and  tends, 
on  the  same  principle  as  bleeding,  to  retard  the  union 
of  the  fracture. 

Costiveness  is  to  be  averted  by  the  use  of  clysters  and 
mild  aperient  medicines.  It  must  be  confessed,  that  in 
fractures  of  the  lower  extremity,  the  disturbance  of  the 
limb  caused  by  the  patient’s  being  obliged  to  move 
himself,  after  taking  a purgative,  is  seriously  objection- 
able ; but  perhaps  in  all,  and  certainly  in  some  habits, 
a neglect  to  open  the  bowels  soon  after  the  accident 
would  have  still  more  pernicious  consequences.  In 
order,  however,  to  lessen  the  disturbance,  a bed-pan 
should  be  carefully  introduced  under  the  patient.  Here, 
also,  I feel  it  my  duty  to  recommend  to  the  notice  of  the 
profession  a very  complete  fracture-bed,  invented  by  my 
friend  Mr.  Earle.  One  great  convenience  of  this  bed, 
the  cost  of  which  is  moderate,  is  to  enable  the  patient 
to  void  his  feces,  without  the  slightest  change  of  posi- 
tion or  disturbance ; an  object  effected  by  the  simple 
contrivance  of  a little  kind  of  trap,  opening  under  the 
bed,  out  of  which  a small  portion  of  the  mattress  ad- 
mits of  being  withdrawn,  and  a tin  receptacle  is  placed 
for  the  reception  of  what  is  voided  from  the  bowels  and 
bladder.  Some  other  advantages  of  this  apparatus  will 
be  hereafter  briefly  mentioned. 

With  respect  to  external  applications,  we  should 
carefully  avoid  using  all  such  plasters  and  ointments 
as  irritate  the  skin,  or  create  a disagreeable  itching ; 
for  they  sometimes  bring  on  erysipelas.  The  emplas- 
trum  saponis  in  common  use  is  the  best  for  all  simple 
fractures ; and  it  is  the  best  rather  because  it  does  no 
harm,  than  because  it  does  any  essential  good.  It  is, 
generally  speaking,  a good  plan  for  the  first  few  days 
to  wet  the  bandages  with  cold  water ; for  in  this  way, 
the  tendency  to  inflammation  and  swelling  may  be  con- 
siderably lessened.  The  surgeon,  however,  should  re- 
collect that  the  bandage  shrinks  when  wet,  and  may 
become  so  tight  as  to  do  harm  if  not  attended  to.  So- 
lutions of  the  acetate  of  lead  and  other  salts,  make  band- 
ages stiff  and  hard  ; and  as  they  are  perhaps  not  more 
efficacious  than  cold  water  alone,  the  latter  is  some- 
times preferred. 

When  a fracture  is  well  set,  the  position  of  the  part 
right,  and  the  bandage  and  splints  neither  too  tight  nor 
too  slack,  the  less  the  broken  bone  is  moved,  and  the 
less  the  apparatus  and  dressings  are  disturbed  the  bet- 
ter. Sometimes,  however,  the  practitioner  is  obliged 
to  take  off  the  splints,  and  undo  the  bandage,  in  order 
to  ascertain  that  the  ends  of  the  fracture  lie  in  even 
contact.  Were  he  to  leave  the  splints  on  the  part  ten 
days,  or  a fortnight,  without  ever  being  sure  of  this  im- 
pjortant  ix)int,  he  might  find,  when  too  late  for  altera- 
tion, that  the  fracture  was  in  a state  of  displacement, 
and  the  limb  seriously  deformed.  Hence,  a strong  rea- 
son for  employing  the  eighteen-tailed  bandage,  which 
admits  of  being  opened  without  disturbing  the  limb,  or 
even  without  lifting  it  from  the  surface  upon  wliich  it  j 
has  been  deposited. 

In  fractures  of  the  lower  extremities,  particularly  of  [ 


the  legs,  it  sometimes  happens  the  first  two  or  three 
nights  after  the  reduction,  that  the  limb  is  affected  with 
convulsive  spasms  and  cramps,  which  make  the  pa- 
tient start  in  his  sleep,  and  displace  the  ends  of  the 
bone,  which  must  be  again  reduced. 

When  the  callus  has  acquired  some  firmness,  the 
patient  should  still  keep  the  part  or  limb  quiet,  until 
fhe  union  is  perfectly  consolidated.  And  in  fractures 
of  the  lower  extremity,  even  after  the  union  has  i)ro 
ceeded  so  far  that  the  splints  admit  of  being  left  off,  the 
patient  ought  not  to  venture  to  get  out  of  bed,  or  bear 
upon  the  limb,  till  several  more  daj's  have  elapsed. 

All  fractures,  however  simple  and  well  treated  they 
may  be,  are  constantly  followed  by  weakness  and  stiff- 
ness of  the  limb.  These  unpleasant  consequences  are 
the  greater,  the  more  violently  the  limb  has  been  con- 
tused, the  nearer  the  fracture  is  to  a joint,  and  the 
longer  the  part  has  remained  motionless  and  without 
exercise.  The  stiffness  always  affects  the  inferior 
joint  of  the  broken  bone  much  more  than  the  supe- 
rior. For  the  relief  of  these  effects  of  fractures,  it  is 
customary  to  employ  friction,  liniments,  emollient  re- 
laxing applications,  cold  washes,  and  bathing  ; but 
sometimes,  notwithstanding  such  remedies,  the  mem- 
brane does  not  quickly  recover  its  strength,  but  con- 
tinues stiff  and  weak  for  a year,  or  even  a longer 
time.  The  most  effectual  plans  for  the  prevention  of 
this  state  should  therefore  be  resorted  to  early.  These 
consist  in  making  the  joints  nearest  the  fracture  exe- 
cute slight  motions,  as  soon  as  the  union  is  suffi- 
ciently advanced  not  to  be  in  danger  of  interruptiort 
from  this  practice.  A great  deal  of  caution,  however, 
is  necessary  in  moving  the  part,  and  it  is  safer  for  the 
surgeon  to  superintend  the  business  himself,  than  leave 
it  to  the  patient  or  others.  One  of  the  best  proceedings 
also  for  the  hindrance  of  much  weakness  and  stiffness 
in  the  limb  after  a fracture  is,  to  discontinue  the  splints 
and  tight  bandages  immediately  the  state  of  the  callus 
will  allow.  The  manner  in  which  their  pressure  re- 
tards the  circulation,  and  prevents  the  action  of  the 
muscles,  i.s  one  of  the  principal  causes  of  the  stiffness 
of  the  limb ; and,  consequently,  the  sooner  they  can  be 
safely  left  off  the  sooner  will  the  patient  regain  the 
free  use  of  the  limb. 

In  France,  the  chief  division  of  fractures  is  into 
simple  and  complicated  ; which  last  includes,  among 
many  varieties,  the  cases  which  we  name  compound. 
We  shall  here  briefly  notice  a few  of  the  complications, 
and  the  particular  treatment  which  they  require. 

Fractures  (says  Boyer)  are  always  attended  with  a 
certain  degree  of  contusion,  which  is  constantly  more 
severe  in  cases  where  the  violence  has  acted  directly 
on  the  sittiation  of  the  fracture.  But  such  contusion 
can  only  be  regarded  as  a complication  of  the  accident, 
when  it  exists  in  so  violent  a degree  as  to  demand  a 
different  treatment  from  that  which  is  employed  in 
simple  fractures. 

In  this  circumstance,  the  splints  and  bandage  should 
be  applied  rather  slackly,  and  the  latter  ought  to  be  wet 
with  cold  water,  or  some  resolvent  lotion.  The  patient 
is  to  be  bled  more  or  less  freely,  according  to  his  age, 
the  state  of  his  constitution,  and  violence  of  the  contu- 
sion. The  next  day,  the  splints  and  bandage  should  be 
opened ; a thing  highly  necessary  to  be  observed,  for 
where  it  has  been  neglected,  the  limb  lias  been  known 
to  mortify,  in  consequence  of  the  swelling  having  ren- 
dered the  bandage  too  tight. — (Boyer,  Traite  des  Mai. 
Chir.  t.  3,  p.  63, 64.) 

In  cases  where  the  contusion  is  severe,  but  unat- 
tended with  a wound  of  the  integuments,  the  tension 
and  swelling  may  be  so  intense,  that  the  cuticle  is  de- 
tached, forming  vesicles  filled  with  yellowish  serum. 
These  vesicles  may  deceive  an  inexperienced  surgeon, 
and  lead  him  to  imagine  that  the  limb  is  threatened,  or 
acturally  affected,  with  gangrene.  They  ought  to  be 
punctured,  and  covered  wdth  pledgets  of  simple  oint- 
ment. Here  some  practitioners  apply  emollient  poul- 
tices under  the  apparatus;  but  there  is  inconveni- 
ence in  their  use,  and  perhaps  cold  lotions  are  generally 
better. 

In  simple  fractures,  it  does  not  often  happen  that  a 
large  artery  is  wounded ; but  when  the  injury  does 
occur,  and  a diffused  aneurism  takes  place,  the  surgeon 
is  to  expo.se  the  vessel  by  an  incision,  and  apply  a 
j ligature  above  and  below  the  opening.  We  are  to  be 
careful,  however,  before  resorting  to  the  operation,  that 
[ the  tumour  is  not  a venous  extravasation,  which  may 


FRACTURES. 


383 


almost  always  be  dissipated  by  resolvent  applica- 
tions. 

Fractures  are  sometimes  complicated  with  a disloca- 
tion. Here,  if  possible,  the  luxation  should  invariably 
be  reduced  before  the  fracture  is  set.  The  possibility 
of  reducing  the  dislocation  (says  Boyer)  depends  upon 
the  species  of  articulation,  the  situation  of  the  fracture, 
and  other  circumstances  of  the  case.  When  it  is  a 
ginglymoid  joint,  when  the  ligaments  are  lacerated, 
and  the  swelling  is  not  considerable,  the  luxation  may 
be  reduced  easily  enough : but  when  it  is  an  orbicular 
joint,  surrounded  by  numerous  muscles ; and  when  the 
fracture  is  near  the  articulation,  and  situated  below  the 
dislocation,  the  reduction  of  the  latter  is  impossible. 
The  attempt,  indeed,  would  be  injurious,  because  the 
necessary  extension  could  not  act  upon  the  upper  frag- 
ment ; and  were  it  to  operate  upon  the  lower,  it  could 
only  have  the  effect  of  painfully  stretching  the  muscles, 
and  perhaps  lacerating  them.  The  fracture,  therefore, 
should  be  at  first  attended  to,  and  after  its  firm  union, 
tm  endeavour  may  be  made  to  rectify  the  dislocation. 
Boyer  conceives  that  there  wall  be  more  probability  of 
success,  when  care  is  taken  to  move  the  limb  gently, 
as  soon  as  the  state  of  the  callus  will  permit  it.  He 
also  recommends  the  employment  of  emollient  relax- 
ing applications.  He  confesses,  however,  that  the  at- 
tempt rarely  succeeds  after  the  perfect  union  of  the 
fracture.  There  are,  it  is  true,  examples  in  which  old 
dislocations  may  be  reduced ; but  these  are  cases 
which  are  not  complicated  with  a fracture ; an  accident 
which  always  renders  the  muscles  and  ligaments  so 
stiff,  that  they  cannot  yield  to  the  extension  requisite 
for  the  reduction.  “ I do  not  know  (says  Boyer)  that  a 
luxation  complicated  with  fracture  has  ever  been  re- 
duced, when  the  nature  of  the  joint  and  the  circum- 
stances of  the  case  prevented  the  treatment  from  begin- 
ning with  the  reduction  of  dislocation. — {Traitd  des  Mai. 
Chir.  t.  3,  p.  79.) 

COMPOUND  fractures. 

What  Mr.  Pott  has  said  upon  these  cases  is,  with 
one  or  two  exceptions  to  which  I shall  advert,  the  es- 
sence of  good  surgery,  not  in  the  least  deteriorated,  as 
a ffew  other  parts  of  his  precepts  have  been,  by  the 
more  mature  instructions  of  time  and  experience,  or  by 
that  growing  state  of  surgical  science,  which,  fostered 
by  genius  and  observation,  is  continually  bringing  to 
light  new  facts. 

In  a compound  fracture,  says  Mr.  Pott,  the  first  object 
of  consideration  is,  whether  the  preservation  of  the 
fractured  limb  can,  with  safety  to  the  patient’s  life,  be 
attempted;  or,  in  other  words,  whether  the  probable 
chance  of  destruction,  from  the  nature  and  circum- 
stances of  the  accident,  is  not  greater  than  it  would  be 
from  the  operation  of  amputation*!  Many  things  may 
occur  to  make  this  the  case.  The  bone  or  bones  being 
broken  into  many  different  pieces,  and  that  for  a consi- 
derable extent,  as  happens  from  broad  wheels,  or  other 
heavy  bodies  of  large  surface,  passing  over  or  falling  on 
such  limbs ; the  skin,  muscles,  tendons,  »fcc.  being  so 
torn,  lacerated,  and  destroyed,  as  to  render  gangrene 
and  mortification  the  most  probable  and  most  imme- 
diate consequence ; the  extremities  of  the  bones  form- 
ing a joint  being  crushed,  or,  as  it  were,  comminuted, 
and  the  ligaments  connecting  such  bones  being  torn 
and  spoiled,  are,  among  others,  sufficient  reasons  for 
proposing  and  fbr  performing  immediate  amputation. 

Mr.  Pott  admits  that  apparently  desperate  cases  are 
sometimes  cured,  and  that  limbs  so  shattered  and 
wounded  as  to  render  amputation  the  only  probable 
means  for  the  preservation  of  life,  are  now  and  then 
saved.  This  is  an  uncontroverted  fact,  but  a fact  which 
proves  very  little  against  the  common  opinion ; because 
every  man  of  experience  also  knows  that  such  escapes 
are  very  rare,  much  too  rare  to  admit  of  being  made 
precedents. 

This  consideration  relative  to  amputation  is  of  the 
more  imjwrtance,  because  it  most  frequently  requi  res 
immediate  detennination  ; every  minute  of  delay  is,  in 
many  instances,  to  the  patient’s  disadvantage;  and  a 
very  short  space  of  time,  indeed,  frequently  makes  all 
the  difference  between  probable  safety  and  fatality.  If 
these  cases  in  general  would  admit  of  deliberation  for 
two  or  three  days,  and  during  that  time  such  circum- 
stances might  be  expected  to  arise  as  ought  necessarily 
to  detennine  the  surgeon  in  his  conduct,  without  add- 
ing to  the  patient’s  hazc.rd,  the  difference  w ould  be 


considerable ; the  former  would  not  seem  to  be  so  pre- 
cipitate in  his  determination  as  he  is  frequently  thought 
to  be ; and  the  latter,  being  more  convinced  of  the  ne- 
cessity, would  submit  to  it  with  less  reluctance.  But, 
unhappily  for  both  parties,  this  is  seldom  the  case ; and 
the  first^opportunity  having  been  neglected,  or  not  em- 
braced, we  are  frequently  denied  another.  Here,  there- 
fore, the  whole  exertion  of  a man’s  judgment  is  re- 
quired, that  he  may  neither  rashly  and  unnecessarily 
deprive  his  patient  of  a limb,  nor  through  a false  ten- 
derness and  timidity  suffer  him  to  perish  by  endeavour- 
ing to  preserve  such  limb.” 

The  limb  being  thought  capable  of  preservation,  the 
next  consideration  is  the  reduction  of  the  fracture. 

“ If  the  bone  be  not  protruded  forth,  the  trouble  of 
reducing  and  of  placing  the  fracture  in  a good  position, 
will  be  much  less  than  if  the  case  be  otherwise  ; and 
in  the  case  of  protrusion,  or  thrusting  forth  of  the  bone 
or  bones,  the  difficulty  is  always  m proportion  to  the 
comparative  size  of  the  wound  through  which  such 
bone  has  passed.  In  a compound  fracture  of  the  leg 
or  thigh,  it  is  always  the  upper  part  of  the  broken  bone 
which  is  thrust  forth.  If  the  fracture  be  of  the  trans- 
verse kind,  and  the  wound  large,  a moderate  degree  of 
extension  will  in  general  easily  reduce  it ; but  if  the 
fracture  be  oblique,  and  terminates,  as  it  often  does,  in 
a long,  sharp  point,  this  point  very  often  makes  its  way 
through  a wound  no  longer  than  just  to  permit  such 
extension.  In  this  case,  the  very  placing  the  leg  in  a 
straight  position,  in  order  to  make  extension,  obliges 
the  wound  or  orifice  to  gird  the  bone  tight,  and  makes 
all  that  part  of  it  which  is  out  of  such  wound  press 
hard  on  the  skin  of  the  leg  underneath  it.  In  these 
circum.stances,  all  attempts  for  reduction  in  this  manner 
will  be  found  to  be  impracticable ; the  more  the  leg  is 
stretched  out,  the  tighter  the  bone  will  be  begirt  by 
the  wound,  and  the  more  it  will  press  on  the  skin  un- 
derneath. 

Upon  this  occasion,  it  is  not  very  unusual  to  have 
recourse  to  the  saw,  and  by  that  means  to  remove  a 
portion  of  the  protruded  bone. 

I will  not  say  that  this  is  always  or  absolutely  unne- 
cessary or  wrong,  but  it  most  certainly  is  frequently 
so.  In  some  few  instances,  and  in  the  case  of  extreme 
sharp-pointedness  of  the  extremity  of  the  bone,  it  may 
be,  and  undoubtedly  is  right. — (See  Dunn’s  Obs.  in 
Med.  Chir.  Trans,  vol.  12.)  But  in  many  instances  it 
is  totally  unnecessary. 

The  two  most  proper  means  of  overcoming  this 
difficulty  are,  change  of  posture  of  the  limb,  and  en- 
largement of  the  wound.  In  many  cases,  the  former  of 
these,  under  proper  conduct,  will  be  found  fully  suffi- 
cient ; and  where  it  f^ils,  the  latter  should  always  be 
made  use  of.  Whoever  will  attend  to  the  effect  which 
putting  the  leg  or  thigh  (having  a compound  fracture 
and  protruded  bone)  into  a straight  position  always 
produces,  that  is,  to  the  manner  in  which  the  wound  in 
such  position  girds  the  bone,  and  to  the  increased  diffi- 
culty of  reduction  thereby  induced ; and  will  then,  by 
changing  the  po.sture  of  such  limb  from  an  extended 
one  to  one  moderately  bent,  observe  the  alteration 
thereby  made  in  both  the  just-mentioned  circumstances, 
will  be  satisfied  of  the  truth  of  what  I have  said,  and  of 
the  much  greater  degree  of  ease  and  practicability  of 
reduction  in  the  bent  than  in  the  extended  position,  that 
is,  in  the  relaxed  than  in  the  stretched  state  of  the  mus- 
cles.” Reduction  being  found  impracticable,  either  by 
extension  or  change  of  posture,  Mr.  Pott  recommends 
an  enlargement  of  the  wound. 

“ If  the  bone  be  broken  into  several  pieces,  and  any 
of  them  be  either  totally  separated  so  as  to  lie  loose 
in  the  wound,  or  if  they  be  so  loosened  and  detached 
as  to  render  their  union  highly  improbable,  all  such 
jiieces  ought  to  be  taken  away;  but  they  should  be 
removed  with  all  possible  gentleness,  without  pain, 
violence,  or  laceration,  without  the  risk  of  hemorrhage, 
and  with  as  little  poking  into  the  wound  as  possible. 
If  the  extremities  of  the  bone  be  broken  into  sharp 
points,  which  points  wound  and  irritate  the  surround- 
ing parts,  they  must  be  removed  also. — (See  Dunn,  vol. 
cit.)  But  the  whole  of  this  part  of  the  treatment  of  a 
compound  fracture  .should  be  executed  with  great  cau- 
tion ; and  the  practitioner  should  remember,  that  if  the 
parts  surrounding  the  fracture  be  violated,  that  is,  be 
torn,  irritated,  and  so  disturbed  as  to  excite  great  pain, 
high  inllammation,  Ace.,  it  is  exactly  the  same  thing  to 
the  patient,  and  to  the  event  of  the  case,  whether  such 


384 


FRACTURES. 


violence  be  the  necessary  consequence  of  the  fracture  I 
or  of  the  unnecessary  and  awkward  manner  of  poking  | 
into  and  disturbing  the  wound.  The  great  objects  of 
fear  and  apprehension  in  a compound  fracture  (that  is, 
in  the  first  or  early  state  of  it)  are,  pain,  irritation,  and 
inflammation  ; these  are  to  be  avoided,  prevented,  and 
appeased  by  all  possible  means,  let  every  thing  else  be 
as  it  may;  and  although  certain  things  are  always 
recited  as  necessary  to  be  done,  such  as  removal  of 
fragments  of  bone,  of  foreign  bodies,  &c.  <kc.  &c. , yet  it 
is  always  to  be  understood  that  such  acts  may  be  per- 
formed without  prejudicial  or  great  violence,  and  with- 
out adding  at  all  to  the  risk  or  hazard  necessarily  in- 
curred by  the  disease. 

Reduction  of  or  setting  a compound  fracture  is  the 
same  as  in  the  simple ; that  is,  the  intention  in  both  is 
the  same,  viz.  by  means  of  a proper  degree  of  extension 
to  obtain  as  apt  a position  of  the  ends  of  the  fracture 
with  regard  to  each  other,  as  the  nature  of  the  case 
will  admit,  and  thereby  to  produce  as  perfect  and  as 
speedy  nnion  as  possible. 

To  repeat  in  this  place  what  has  already  been  said  under 
the  head  of  Extension  would  be  tedious  and  unneces- 
sary. If  the  arguments  there  used  for  making  exten- 
sion, with  the  linjb  so  moderately  bent  as  to  relax  the 
muscles  and  take  off  their  power  of  resistance,  have  any 
force  at  all,  they  must  have  much  more  when  applied 
to  the  present  case ; if  it  be  allowed  to  be  found  very 
painful  to  extend,  or  to  put  or  to  keep  on  the  stretch 
muscles  which  are  not  at  all  or  but  slightly  wounded, 
and  only  liable  in  such  extension  to  be  pricked  and 
irritated,  it  is  self-evident  that  it  must  be  much  more  so 
when  the  same  parts  are  torn  and  wounded.”  After  a 
few  additional  observations  in  praise  of  the  good  effects 
of  relaxing  the  muscles,  Mr.  Pott  proceeds  ; — 

“ The  wound  dilated  (if  necessary),  loose  pieces  re- 
moved (if  there  were  any),  and  the  fracture  reduced  in 
the  best  possible  position,  the  next  thing  to  be  done  is 
to  apply  a dressing.  ” 

When  Mr.  Pott  wrote  on  this  subject,  the  plan  of 
bringing  the  edges  of  the  wound  together  with  adhesive 
plaster,  in  cases  of  compound  fracture,  had  not  been 
established  ; and  the  advantage  of  this  mode  of  dress- 
ing in  the  first  instance  was  not  duly  knowm.  I do  not 
mean  the  practice  of  drawing  the  edges  of  the  wound 
forcibly  together  with  strips  of  plaster,  nor  of  encir- 
cling and  compressing  the  part  with  the  same ; but 
only  the  method  of  applying  two  or  three  short  pieces 
of  plaster,  so  as  lightly  and  gently  to  retain  the  oppo- 
site sides  of  the  wound  in  contact,  and  afford  them  an 
opportunity  of  uniting  by  the  first  intention.  Now,  al- 
though such  attempts  will  frequently  fail,  on  account 
of  the  wound  being  generally  in  i contused,  irregular, 
and  lacerated  state,  the  chance  of  success  should  be 
taken,  because  the  experiment  at  all  events  will  occa- 
sion no  harm,  and  if  it  answer,  it  will  change  the  case 
at  once  from  a fracture  with  an  open  wound  to  one 
which  has  no  external  communication,  or  as  might  al- 
most be  said,  from  a compound  into  a simple  fracture. 
►Some  of  the  following  directions,  therefore,  given  by 
Mr.  Pott,  I consider  in  the  present  state  of  surgery  as 
only  applicable  when  the  wound  has  suppurated. 

The  dressing  necessary  in  a compound  fracture  is 
of  two  kinds,  viz.  that  for  the  wmund,  and  that  for  the 
limb.  By  the  former,  we  mean  to  maintain  a proper 
opening  for  the  easy  and  IVee  discharge  of  gleet,  sloughs, 
matter,  extraneous  bodies,  or  fragments  of  bone,  and 
this  in  such  manner,  and  by  such  means,  as  shall  give 
the  least  possible  pain  or  fatigue,  shall  neither  irritate 
by  its  qualities,  nor  oppress  by  its  quantity,  nor  by  any 
means  contribute  to  the  detention  or  lodgement  of  what 
ought  to  be  discharged.  By  the  latter  our  aim  should 
be  the  prevention  or  removal  of  inflammation,  in  order, 
if  the  habit  be  good  and  all  other  circumstances  fortu- 
nate, that  the  wound  may  be  healed  by  what  surgeons 
call  the  first  intention,  that  is  without  suppuration  or 
abscess ; or,  that  not  being  practicable,  that  gangrene 
and  mortification,  or  even  very  large  suppuration  may 
be  prevented,  and  such  a moderate  and  kindly  degree 
of  it  established  as  may  best  serve  the  purpose  of  a 
cure.  The  first,  therefore,  or  the  dressing  for  the 
wound,  can  consist  of  nothing  better,  or  indeed  so 
good,  as  soft  dry  lint,  laid  on  so  lightly  as  just  to  ab- 
sorb the  sanies,  but  neither  to  distend  the  wound,  nor  be 
the  smallest  impediment  or  obstruction  to  the  discharge 
of  matter.  This  lint  should  be  kept  clear  of  the  edges, 
and  the  whole  of  it  should  be  covered  with  a pledget 


I spread  with  a soft  easy  digestive.  The  times  of  dressing 
I must  be  determined  by  the  nature  of  the  case  ; if  the 
discharge  be  small  or  moderate,  once  in  twenty-four 
hours  will  be  sufficient ; but  if  it  be  large,  more  fre- 
quent dressing  will  be  necessary,  as  well  to  prevent 
offence  as  to  remedy  the  inconveniences  arising  from 
a great  discharge  of  an  irritating  sharp  sanies. 

When,  from  neglect,  from  length  of  time  passed  with 
out  assistance,  from  misconduct  or  drunkenness  in  the 
patient,  from  awkwardness  and  unhamliness  in  the  as- 
sistants, or  from  any  other  cause,  a tension  has  taken 
possession  of  the  limb,  and  it  is  become  tumid,  swol- 
len, and  painful,  Mr.  Pott  admits,  that  a warm  cata- 
plasm is  the  most  proper  application  that  can  be  made; 
immediate  union  is  impossible,  and  every  thing  which 
can  tend  towards  relaxing  the  tense,  swollen,  and  irri- 
table state  of  the  parts  concerned,  must  necessarily  be 
right.  But  when  the  parts  are  not  in  this  state,  the  in- 
tention seems  to  be  very  different.  To  relax  swollen 
parts,  and  to  appease  pain  and  irritation  by  such  relax- 
ation, is  one  thing;  to  prevent  inflammatorj'  deflux- 
ion and  tumefaction  is  certainly  another;  and  they 
ought  to  be  aimed  at  by  verj'  different  means.  In  the 
former,  a large  suppuration  is  a necessary  circumstance 
of  relief,  and  the  great  means  of  cure  ; in  the  latter  it 
is  not,  and  a very  moderate  degree  of  it  is  all  that  is 
required.  The  warm  cataplasm,  therelbre,  although  it 
be  the  best  application  that  can  be  made  use  of  in  the 
one  case,  is  certainly  not  so  proper  in  the  other,  as  ap- 
plications of  a more  discutient  kind,  such  as  mixtures 
of  spirit,  vini,  vinegar  and  water,  with  the  muriate  of 
ammonia,  liquor  ammoniae  acetatis,  liquor  plumbi  ace- 
tatis,  and  medicines  of  this  class,  in  whatever  form  the 
surgeon  may  choose.  By  these,  in  good  habits,  in  for 
tunately  circumstanced  cases,  and  with  the  assistance 
of  what  should  never  be  neglected  (I  mean  phlebotomy* 
and  the  general  antiphlogistic  regimen),  infliomnation 
may  sometimes  be  kept  off,  and  a cure  accomplished, 
without  large  collections  or  discharges  of  matter.” 

“ Compound  fractures  in  general  require  to  be  dressed 
every  day  ; and  the  wounded  parts  not  admitting  the 
smallest  degree  of  motion  without  great  pain,  perfect 
quietude  becomes  as  necessary  as  frequent  dressing. 

The  common  bandage,  therefore  (the  roller),  has  al- 
ways in  this  case  been  laid  aside,  and  what  is  called 
the  eighteen-tafled  bandage  substituted  very  judiciously 
in  its  place. 

Splints  of  proper  length,  which  reach  from  joint  to 
joint,  comjirehend  them  both,  and  are  applied  on  each 
side  of  the  leg  only,  are  very  useful  both  in  the  simple 
and  in  the  compound  fracture,  as  they  may,  thus  ap- 
plied, be  made  to  keep  the  limb  more  constantly  steady 
and  quiet  than  it  can  be  kept  without  them.” 

Mr.  Pott  then  enters  into  the  consideration  of  the  pos- 
ture of  the  limb,  which  “is  so  principal  a circumstance, 
that  without  its  concurrence  ever>-  other  will  be  fruit- 
less. The  points  to  be  aimed  at  are,  the  even  position 
of  the  broken  parts  of  the  bone,  and  such  disposition 
of  the  muscles  surrounding  them,  as  is  most  suitable 
to  their  wounded,  lacerated  state,  as  shall  be  least  likely 
to  irritate  them,  by  keeping  them  on  the  stretch,  or  to 
produce  high  inflammation,  and  at  best  large  suppu- 
ration.” 

According  to  Mr.  Pott,  these  cases,  of  all  others,  re- 
quire at  first  the  most  rigid  observance  of  the  antiphlo- 
gistic regimen ; pain  is  to  be  appeased,  and  rest  ob- 
tained, by  anodynes  ; inflammation  is  to  be  prevented 
or  removed  by  bleeding  and  aperient  medicines.  And 
during  the  first  state  or  stage,  the  treatment  of  the 
limb  must  be  calculated  either  for  the  prevention  ol 
inflammatory  tumefaction  by  discutients,  or,  such  tu- 
mour and  tension  having  already  taken  possession  of 
the  limb,  warm  fomentation,  and  relaxing  and  emollient 
medicines  are  required. 

“ If  these,  according  to  the  particular  exigence  of  the 
case,  prove  successful,  the  consequence  is,  either  a 
quiet  easy  wound,  which  either  heals  by  the  first  in- 
tention or  suppurates  very  moderately,  and  gives  little 
or  no  trouble,  or  a w'ound  attended  at  first  with  con- 
siderable inflammation,  and  that  producing  large  sup- 
puration, wth  great  discharge  and  troublesome  fonna- 
tion  and  lodgement  of  matter.  If,  on  the  other  hand,  our 


* The  propriety  of  having  recourse  to  venesection 
will  depend  ujxtn  the  age,  strength,  and  general  habit  of 
the  patient.  In  the  young,  robust,  and  plethoric,  the 
practice  is,  on  every  account,  judicious. 


FRACTURES. 


386 


attempts  do  not  succeed,  the  consequence  is  gangrene 
and  mortification. 

These  are  the  three  general  events  or  terminations  of 
a compound  fracture,  and  according  to  these  must  the 
surgeon’s  conduct  be  regulated. 

In  the  first  instance,  he  has  indeed  nothing  to  do  but 
to  avoid  doing  mischief,  either  by  his  manner  of  dress- 
ing or  by  disturbing  the  limb.  Nature,  let  alone,  will 
accomplish  her  own  purpose ; and  art  has  little  more 
to  do  than  to  preserve  the  due  position  of  the  limb,  and 
to  take  care  that  the  dressing  applied  to  the  wound 
proves  no  impediment. 

In  the  second  stage,  that  of  formation  and  lodgement 
of  matter,  in  consequence  of  large  suppuration,  all  a 
surgeon’s  judgment  will  sometimes  be  required  in  the 
treatment  both  of  the  patient  and  his  injured  limb. 
Enlargement  of  the  present  wound,  for  the  more  con- 
venient discharge  of  matter  ;*  new  or  counter-openings 
for  the  same  purpose,  or  for  the  extraction  of  fragments 
of  broken  or  exfoliated  bone,  will  very  frequently  be 
found  necessary,  and  must  be  executed.  In  the  doing 
this,  care  must  be  taken  that  what  is  requisite  be  done, 
and  no  more;  and  that  such  requisite  operatiens  be 
performed  with  as  little  disturbance  and  pain  as  pos- 
sible.” 

Previous  to  large  suppuration,  or  considerable  col- 
lections and  lodgements  of  matter,  evacuation  by  phle- 
botomy, an  open  belly,  and  antiphlogistic  remedies,  as 
well  as  the  free  use  of  anodynes,  and  such  applications 
to  the  limb  as  may  most  serve  the  purpose  of  relaxa- 
tion, are  the  remedies  which  Mr.  Pott  advises  for  the 
relief  of  the  swelling,  induration,  and  high  inflamma- 
tion, attended  with  pain,  irritation,  and  fever.  “ But 
the  matter  having  been  formed  and  let  out,  and  the  pain, 
fever,  &c.,  which  were  symptomatic  thereof,  having 
disappeared  or  ceased,  the  use  and  purpose  of  such  me- 
dicines and  such  applications  cease  also,  and  they 
ought  therefore  to  be  discontinued.  By  evacuation,  &c. 
the  patient’s  strength  has  necessarily  (and  indeed  pro- 
perly) been  reduced ; by  cataplasm,  &c.  the  parts  have 
been  so  relaxed  as  to  procure  an  abatement  or  cessation 
of  inflammation,  a subsidence  of  tumefaction,  and  the 
establishment  of  a free  suppuration ; but  these  ends 
once  fairly  and  fully  answered,  another  intention  arises, 
which  regards  the  safety  and  well-doing  of  the  patient 
nearly,  if  not  fully,  as  much  as  the  former;  which  in- 
tention will  be  necessarily  frustrated  by  pursuing  the 
method  hitherto  followed.  The  patient  now  will  re- 
quire refection  and  support  as  much  as  he  before  stood 
in  need  of  reduction ; and  the  limb,  whose  indurated 
atid  inflamed  state  hitherto  required  the  emollient  and 
relaxing  poultice,  will  now  be  hurt  by  such  kind  of  ap- 
plication, and  stand  in  need  of  such  as  are  endued  with 
contrary  qualities,  or  at  least,  such  as  shall  not  conti- 
nue to  relax.  Good,  light,  easily  digested  nutriment, 
and  the  Peruvian  bark,  will  best  answer  the  pur- 
pose of  internals ; the  discontinuation  of  the  cata- 
plasms, and  the  application  of  medicines  of  the  cor- 
roborating kind,  are  as  necessary  with  regard  to  exter- 
iials.”! 

“ Every  body  who  is  acquainted  with  surgery  knows 
^says  Mr.  Pott)  that,  in  the  case  of  bad  compound  frac- 
ture, attended  with  large  suppuration,  it  sometimes 
hajipeas,  evert  under  the  best  and  most  judicious  treat- 
ment, that  the  discharge  becomes  too  great  for  the  pa- 
tient to  sustain ; and  that,  after  all  the  fatigue,  pain  and 
discipline  which  he  has  undergone,  it  becomes  neces- 


* “ It  is  a practice  with  .some,  from  a timidity  in  using 
a knife,  to  make  use  of  bolsters  and  plaster  compresses 
for  tlie  discharge  of  lodging  matter.  Where  another 
or  a counter-opening  can  conveniently  and  safely  be 
made,  it  is  always  preferable,  the  compress  some- 
times acting  diametrically  opposite  to  the  intention  with 
which  it  is  applied,  and  contributing  to  the  lodgement 
by  confining  the  matter;  besides  which,  it  requires  a 
gn-ater  degree  of  pressure  to  make  it  efficacious  than  a 
limb  in  such  circumstances  generally  can  bear.” 

T “ It  is  surprising  how  large  and  how  disagreeable 
a discharge  will  be  made  for  a considerable  length  of 
time,  in  some  instances,  from  the  detention  and  irrita- 
tion of  a splinter  of  bone.  If  therefore  such  discharge 
be  made,  and  there  be  neither  sinus  nor  lodgement  to 
account  for  it,  and  all  other  circumstances  are  favour- 
able, examination  should  always  be  made,  in  order  to 
know  whether  such  cau.se  does  not  exi.st,  and  if  it  does 
it  must  be  gently  and  carefully  removed.” 

V'uL,  L"  B b 


sary  to  compound  for  life  by  the  loss  of  the  limb.* 
This,  I say,  does  sometimes  happen  under  the  best  and 
most  rational  treatment;  but  I am  convinced  that  it 
also  is  now  and  then  the  consequence  of  pursuing  the 
reducing,  the  antiphlpgistic,  and  the  relaxing  plan  too 
far.  I would  therefore  lake  the  liberty  seriously  to  ad- 
vise the  young  practitioner  to  attend  diligently  to  his 
patient’s  pulse  and  general  state,  as  well  as  to  that  of 
his  fractured  limb  and  wound ; and  when  he  finds  all 
febrile  comi)laint  at  an  end,  and  all  inflammatory  tu- 
mour and  hardness  gone,  and  his  patient  rather  lan- 
guid than  feverish,  that  his  pulse  is  rather  weak  and 
low  than  hard  and  full,  that  his  appetite  begins  to  fail, 
and  that  he  is  inclined  to  sweat  or  purge  without  as- 
signable cause,  and  this  in  consequence  of  a large  dis- 
charge of  matter  from  a limb  which  has  suffered  great 
inflammation,  but  which  is  now  become  rather  soft  and 
flabby  than  hard  and  tumid  ; that  he  will  in  suuh  cir- 
cumstances set  about  the  support  of  his  patient,  and 
the  strengthening  of  the  diseased  limb,  totis  viribus ; 
in  which  I am  from  experience  satisfied  he  may  often 
be  successful,  where  it  may  not  be  generally  expected 
that  he  would.  At  least  he  will  have  the  satisfaction 
of  having  made  a rational  attempt;  and  if  he  is  obliged 
at  last  to  h#ve  recourse  to  amputation,  he  will  perform 
it,  and  his  patient  will  submit  to  it,  with  less  reluctance 
than  if  no  such  trial  had  been  made.” 

According  to  Mr.  Pott,  gangrene  and  mortification 
are  sometimes  the  inevitable  consequences  of  the  mis- 
chief done  to  the  limb  at  the  time  that  the  bone  is 
broken ; or  they  are  the  consequences  of  the  laceration 
of  parts,  made  by  the  mere  protrusion  of  the  said  bone. 
They  are  also  sometimes  the  effect  of  improper  or  ne- 
gligent treatment ; of  great  violence  used  in  making  ex- 
tension; of  irritation  of  the  wounded  parts,  by  poking 
after,  or  in  removing  fragments  or  splinters  of  bone ; of 
painful  dressings ; of  improper  disposition  of  the  limb, 
and  of  the  neglect  of  phlebotomy,  anodynes,  evacua- 
tion, &c. 

“ When  such  accident  or  such  disease  is  the  mere 
consequence  of  the  injury  done  to  the  limb,  either  at 
the  time  of  or  by  the  fracture,  it  generally  makes  its 
appearance  very  early ; in  which  case  also  its  progress 
is  generally  too  rapid  for  art  to  check.  For  these  rea- 
sons, when  the  mischief  seems  to  be  of  such  nature 
that  gangrene  and  mortification  are  most  likely  to  en- 
sue,r  no  time  can  be  spared,  and  the  impending  mis- 
chief must  either  be  submitted  to,  or  prevented  by  early 
amputation.  I have  already  said,  that  a very  few  hours 
make  all  the  difference  between  probable  safety  and 
destruction.  If  we  wait  till  the  disease  has  taken  pos- 
session of  the  limb,  even  in  the  smallest  degree,  the 
operation  will  serve  no  purpose,  but  that  of  accelerat- 
ing the  patients  death.  If  we  wait  for  an  apparent 
alteration  in  the  part,  we  shall  have  waited  until  all 
opportunity  of  being  really  serviceable  is  past.  The 
disease  takes  possession  of  the  cellular  membrane  sur- 
rounding the  large  blood-vessels  and  nferves  some  time 
before  it  makes  any  appearance  in  the  integuments; 
and  will  always  be  found  to  extend  much  higher  in  the 
former  part  than  its  apjiearance  in  the  latter  seems  to 
indicate.  I have  more  than  once  seen  the  experiment 
made  of  amputating,  after  a gangreme  has  been  be 
gun,  but  I never  saw  it  succeed ; it  has  always  has 
tened  the  patient's  de.ttruction.] 

As  far,  therefore,  as  my  experience  will  enable  me 
to  judge,  or  as  I may  from  thence  be  permitted  to  dic- 
tate, I would  advise  that  such  attempt  should  never 
be  made ; but  the  first  opportunity  having  been  ne- 
glected, or  not  embraced,  all  the  power  of  the  chirurgic 


* After  the  bones  had  united,  Mr.  Pott  never  found  it 
necessary  to  ain})utate  a limb  for  a compound  fracture, 
on  account  of  the  too  great  discharge. 

t In  the  article  Gun-shot  Wounds,  however,  the 
reader  will  find  that  there  is  a species  of  gangrene, 
arising  from  external  violence,  and  totally  unconnectc'd 
with  constitutional  causes,  where  the  surgeon  should 
deviate  from  the  common  rule  of  deferring  amputation 
until  the  mortification  has  ceased  to  spread.  A memoir 
“ Sur  la  Gangrene  Traumatiqve,"  which  was  published 
a few  years  ago  by  Baron  Larrey,  contains  the  most 
decisive  facts  in  regard  to  the  projjriety  of  such  i)ractice. 
—(See  hisMtJm.  de  Chir.  Miiitaire.  1. 2.)  The  experience 
of  Mr.  Lawrence  tends  also  to  confirm  the  truth  of  Lar- 
rey’s  observations.— (See  Med.  Ghir.  Trans,  vol.  f),  p 
184,  i c.) 


386 


FRACTURES. 


art  is  to  be  employed  in  assisting  nature  to  separate  the 
diseased  part  from  the  sound ; an  attempt  which  now 
and  then,  under  particular  circumstances,  has  proved 
successful,  but  which  is  so  rarely  so,  as  not  to  be  much 
depended  upon. 

If  the  parts  are  so  bruised  and  torn,  that  the  circu- 
lation through  them  is  rendered  impracticable,  or  if  the 
gangrene  is  the  immediate  effect  of  such  mischief,  the 
consequence  of  omitting  amputation,  and  of  attempting 
to  save  the  limb  is,  as  I have  already  observed,  most  fre- 
quently very  early  destruction ; but  if  the  gangrenous 
mischief  be  not  merely  and  iimnediately  the  effect  of 
the  wounded  state  of  the  parts,  but  of  high  inflamma- 
tion, badness  of  general  habit,  improper  disposition  of 
the  limb,  &c.,  it  is  sometimes  in  our  power  so  to  alle- 
viate, correct,  and  alter  these  causes,  as  to  obtain  a truce 
with  the  disease,  and  a separation  of  the  unsound  parts 
from  the  sound.  The  means  whereby  to  accomplish 
this  erid  must,  in  the  nature  of  things,  be  varied  accord- 
ing to  the  producing  causes  or  circumstances : the  san- 
guine and  bilious  must  be  lowered  and  emptied;  the 
weak  and  debilitated  must  be  assisted  by  such  medicines 
as  will  add  force  to  the  ins  vitae ; and  errors  in  the  treat- 
ment of  the  wound  or  fracture  must  be  corrected ; but 
it  is  evident  to  common  sense,  that  for  thes^here  is  no 
possibility  of  prescribing  any  other  than  very  general 
rules  indeed.  The  nature  and  circumstances  of  each  in- 
dividual case  must  determine  the  practitioner’s  conduct. 

In  general,  inflammation  will  require  phlebotomy  and 
an  open  belly,  together  with  the  neutral  antiphlogistic 
medicines;  pain  and  irritation  will  stand  in  need  of 
anodynes;  and  the  Peruvian  bark,  joined,  in  some 
cases,  and  at  some  times,  with  those  of  the  cooling 
kind,  at  others  with  the  cordial,  will  be  found  necessary 
and  useful.  So  also  tension  and  induration  will  point 
out  the  use  of  fomentation  and  warm  relaxing  cata- 
plasms, and  the  most  soft  and  lenient  treatment  and 
dressing.” 

Mr.  Pott  then  offers  many  just  observations  against 
stimulating  antiseptic  applications  to  the  wound  and 
scarification  of  the  limb,  as  practised  while  the  gan- 
grene is  forming.  The  custom  of  using  stimulating 
dressings  to  bad  compound  fractures  first  began  in 
cases  produced  by  gun-shot,  and  had  its  foundation  in 
the  opinion  that  gun-shot  wounds  were  poisonous, 
and  that  the  mortification  in  them  was  the  effect  of 
fire ; a doctrine  and  practice  now  completely  exploded. 
“ A gun-shot  wound  (says  Pott),  whether  with  or 
without  fracture,  is  a wound  accompanied  with  the 
highest  degree  of  contusion,  and  with  some  degree  of 
laceration;  and  every  greatly  contused  and  lacerated 
wound  requires  the  same  kind  of  treatment  which  a 
gun-shot  wound  does,  as  far  as  regards  the  soft  parts. 
The  intention  in  both  ought  to  be  to  appease  pain,  irri- 
tation, and  inflammation. 

Scarification,  in  the  manner  and  at  the  time  in 
which  it  is  generally  ordered  and  performed,  has  never 
appeared  to  me  to  have  served  any  one  good  purpose. 
When  the  parts  are  really  mortified,  incisions  made  of 
sufficient  depth  will  give  discharge  to  a quantity  of 
acrid  and  offensive  ichor,  wll  let  out  the  confined  air, 
which  is  the  effect  of  putrefaction,  and  thereby  will 
contribute  to  unloading  the  whole  limb ; and  they  will 
also  make  way  for  the  application  of  proper  dressings. 
But  while  a gangrene  is  impending,  that  is,  while  the 
parts  are  in  the  Ifighest  state  of  inflammation,  what  the 
benefit  can  be  which  is  supposed  or  expected  to  proceed 
from  scratching  the  surface  of  the  skin  with  a lancet, 

I never  could  imagine ; nor,  though  I have  often  seen  it 
practised,  do  I remember  ever  to  have  seen  any  real 
benefit  from  it.  If  the  skin  be  still  sound,  and  of  quick 
sensation,  the  scratching  it  in  this  superficial  manner 
is  painful,  and  adds  to  the  inflamed  state  of  it ; if  it  be 
not  sound,  but  quite  altered,  such  superficial  incision 
can  do  no  possible  service ; both  the  sanies  and  the  im- 
prisoned air  are  beneath  the  membrana  adiposa ; and 
merely  scratching  the  skin  in  the  superficial  manner  in 
w’liich  it  is  generally  done  will  not  reach  to  or  dis- 
charge either. 

From  what  has  been  said  it  will  appear,  that  there 
are  three  points  of  time,  or  three  stages,  of  a bad  com- 
pound fracture,  in  which  amputation  of  the  limb  may 
be  necessary  and  right ; and  these  three  points  of  time 
are  so  limited,  that  a good  deal  of  the  hazard  or  safety 
of  the  operation  depends  on  the  observance  or  non- 
(/bservance  of  them. 

“ The  first  is  immediately  after  the  accident,  before 


inflanrunation  has  taken  possession  of  the  parts.  If  tliis 
opportunity  be  neglected  or  not  embraced,  the  conse- 
quence is  either  a gangrene  or  a large  suppuration,  with 
formation  and  lodgement  of  matter.  If  the  former  of 
these  be  the  case,  the  operation  ought  never  to  be 
thought  of,  till  there  is  a perfect  and  absolute  separa- 
tion of  the  mortified  parts.*  If  the  latter,  no  man  can 
possibly  propose  the  removal  of  a limb  until  it  be  found 
by  suflicient  trial  that  there  is  no  prospect  of  obtaining  a 
cure  without ; and  that,  oy  not  performing  the  operation, 
the  patient’s  strength  and  life  will  be  exhausted  by  the 
discharge.  When  this  becomes  the  hazard,  the  sooner 
amputation  is  performed  the  better.  In  the  first  in- 
stance, the  operation  ought  to  take  place  before  inflam- 
matory mischief  is  incurred ; in  the  second,  we  are  to  wait 
for  a kind  of  crisis  of  such  inflammation ; in  the  third,  the 
proportional  strength  and  state  of  the  patient,  compared 
with  the  discharge  and  state  of  the  fracture,  must  form 
our  determination.”— (Pott’s  itemartsoTi  Fractures.) 

9.  Of  the  Formatipn  of  Callus,  the  Consolidation  of 
Fractures,  and  of  the  Cases  in  which  they  remain 
without  Union. 

In  tile  treatment  of  fractures,  the  whole  business  of 
the  surgeon  consists  in  putting  the  displaced  extremi- 
ties of  the  bone  into  their  natural  situation  again ; in 
keeping  thein  in  this  situation  by  means  of  a suitable 
apparatus ; in  endeavouring  to  avert  unfavourable 
symptoms,  and  in  adopting  measures  for  their  removal 
when  they  have  actually  occurred.  The  consolidation 
of  a broken  bone  is  (strictly  speaking)  the  work  of  na- 
ture, and  is  effected  by  a process  to  which  a state  of 
perfect  health  is  above  all  things  propitious. 

This  consolidation  of  a broken  bone,  which  is  ana- 
logous to  the  union  of  wounds  of  the  soft  parts,  is 
termed  the  formation  of  the  callus,  and  the  new 
uniting  bony  substance  itself  is  named  callus. 

\.  Of  the  Time  requisite  for  the  Formation  of  the  Cal- 
lus, and  of  general  Circumstances  which  favour,  re- 
tard, or  even  completely  prevent  it. 

Surgical  writers  have  been  absurdly  anxious  to  spe- 
cify a determinate  space  of  time  which  should  be  al- 
lowed for  the  formation  of  the  callus,  as  if  this  process 
always  went  on  in  different  cases  with  the  same  unin- 
terrupted regularity.  Forty  days  were  often  fixed  upon 
as  necessary  for  the  purpose.  This  prejudice  is  not 
only  false,  but  dangerous,  ina.smuch  as  patients  have 
been  thereby  induced  to  suppose  themselves  cured 
before  they  were  so  in  reality,  and  have,  consequently, 
moved  about  too  boldly,  and  thus  run  the  risk  of  occa- 
sioning deformity  or  a new  fracture.  As  Boyer  ob- 
serves, it  is  impossible  to  determine  precisely,  and  in  a 
general  way,  the  period  requisite  for  the  cure,  because 
it  differs  according  to  a variety  of  circumstances.  All 
we  know  is,  that  the  callus  is  usually  formed  between 
the  twentieth  and  seventieth  day,  sooner  or  later,  ac- 
cording to  the  age  and  constitution  of  the  patient,  the 
thickness  of  the  bone,  the  weight  which  it  has  to  sup- 
port, the  state  of  the  patient’s  health,  &c. 

1.  Age.  Fractures  are  consolidated,  ccE^en^  parz&7ts, 
with  more  ease  and  quickness  in  young  subjects  than 
in  adults  or  old  persons.  In  general  also  the  callus 
forms  more  speedily  in  proportion  as  the  individual 
approaches  to  infancy.  In  two  children,  whose  arnjs 
had  been  broken  in  difficult  labours,  De  la  Motte  saw 
the  humerus  united  in  twelve  days,  by  a very  simple 
apparatus.  In  fact,  at  this  period  of  life,  ever}-  part 
has  a tendency  to  grow  and  develope  itself,  and  the 


* Compound  fractures  are  cases  of  external  violence. 
Now,  as  the  mortification  proceeds  from  the  injury,  and 
may  not  be  connected  with  any  internal  cause,  it  is  an 
example  of  what  Larrey  calls  the  Gangrene  Trauma- 
tique ; and  the  question  whether  the  surgeon  ought  to 
be  governed  by  the  old  maxim  of  delaying  amputation 
until  the  spreading  of  the  mortification  has  ceased,  yet 
remains  UTisettled.  Were  the  patient  of  a sound  con- 
stitution, and  not  too  far  gone,  I should  not  fear  to  imi- 
tate Larrey,  and  amputate,  though  the  mortification 
were  actually  in  a spreading  state.  A few  years  ago 
I assisted  at  an  amputation  of  tne  shoulder  in  a case  of 
spreading  mortification  of  the  arm  from  a compound 
dislocation  of  the  elbow ; and  though  the  patient  ulti- 
mately died  of  a large  abscess  over  the  scapula,  tli# 
stump  went  on  favourably,  and  at  one  jieriod  strong 
hopes  of  recovery  were  entertained. 


FRACTURES.  387 


vitality  of  the  bones  is  more  active,  their  vascularity 
greater,  their  gelatinous  substance  more  abundant. 
On  the  contrary,  in  advanced  age,  the  parts  have  lost 
all  disposition  to  developement,  the  vascularity  of  the 
bones  is  in  a great  measure  obliterated,  and  (to  use  the 
expression  of  Boyer)  their  vitality  is  annihilated  under 
tlie  mass  of  phosphate  of  lime  which  accumulates  in 
them. 

It  has  been  asserted,  that  in  early  infancy  the  cal- 
lus is  generally  produced  in  excess,  and  may  cause 
deformity  by  its  redundance.  But  experience  does  not 
confirm  the  truth  of  this  statement.  The  real  cause 
of  deformity  always  proceeds  from  the  fracture  either 
being  badly  set,  or  not  kept  properly  reduced,  or  else 
from  the  part  being  moved  about  before  the  callus  has 
acquired  a due  degree  of  firmness. 

2.  Constitution.  A fracture  is  united  much  sooner 
in  a strong  healthy  person,  than  a weak  unhealthy 
subject.  Sometimes,  the  consolidation  is  prevented  by 
some  inexplicable  unknown  cause,  notlung  wrong  being 
remarkable  either  in  the  constitution  or  the  part. 
Ruysch  and  Van  Swieten  met  with  several  cases  of 
this  kind,  in  which  the  patients  were  apparently  quite 
healthy  and  judiciously  treated ; and  there  are  few 
surgeons  of  much  experience  who  are  not  acquainted 
with  similar  examples. 

3.  Thickness  of  the  Bone,  and  Weight  which  it  has 
to  support.  The  bones  are  thicker  and  larger,  in  pro- 
portion as  they  have  a greater  weight  to  bear,  and  as 
the  muscles  inserted  into  them  are  more  powerful.  It 
is  observed,  coiteris  paribits,  that  the  larger  the  bones 
are  the  longer  is  the  time  requisite  for  their  union. 
Thus  a broken  thigh-bone  is  longer  in  growing  to- 
gether again  than  a fractured  tibia;  the  tibia  longer 
than  the  humerus,  the  bones  of  the  forearm,  clavicle, 
ribs,  &c. 

As  the  callus  remains  a good  while  softer  than  the 
rest  of  the  bone,  it  follows,  that  if  the  newly  united 
bone  has  to  bear  all  the  weight  of  the  body  in  walk- 
ing, the  patient  should  defer  this  exercise  longer. 
Hence  one  reason  why  fractures  of  the  arm  are  sooner 
cured  than  those  of  the  tibia,  and  why  six  or  seven 
weeks  at  least  are  necessary  in  the  treatment  of  a bro- 
ken thigh-bone,  which  of  itself  has  to  support  in  pro- 
gression all  the  weight  of  the  trunk. 

4.  State  of  Health.  Fractures  unite  with  more  quick- 
ness and  facility  when  the  patient  enjoys  good  health. 
The  scurvy  has  a manifest  and  powerful  etfect  in  re- 
tarding the  consolidation  of  fractures,  and  even  in  caus- 
ing the  absorption  of  the  callus  several  years  after  its 
formation,  so  that  a bone  becomes  flexible  again  at  the 
point  where  it  was  formerly  broken.  In  Lord  Anson’s 
voyage  this  phenomenon  is  particularly  recorded. — (See 
p.  142,  edit.  15,  in  8uo.)  Langenbeck  is  acquainted 
with  several  cases,  in  which  the  callus  at  the  end  of 
eight  weeks  became  again  soft  and  the  bone  flexible, 
in  consequence  of  the  patient’s  being  attacked  with 
fevers  or  erysipelas. — (Neue  Bibl.  b.  1,  p.  90.)  Cancer, 
lues  venerea,  and  rickets  are  also  stated  by  surgical 
writers  to  obstruct,  and  sometimes  hinder  altogether, 
the  formation  of  callus. 

Fabricius  Hildanus  has  cited  two  cases,  which  tend 
to  prove  that  the  union  of  fractures  is  retarded  by  preg- 
nancy.—(CVnt  5,  obs.  87.  Cent.  6,  obs.  68.)  Alanson 
has  also  related  a ca.se  in  which  the  union,  which  had 
been  delayed  during  pregnancy,  took  place  after  deli- 
very {Med.  Obs.  and  Inq.  vol.  4,  No.  37);  and  Werner 
has  published  an  account  of  a firaeture  of  the  radius 
in  a pregnant  w'oman,  where  the  cure  was  apparently 
retarded  for  a long  time  by  this  circumstance,  and 
though  the  union  took  place  previously  to  delivery, 
the  callus  was  not  very  firm  till  after  that  event. — 
(Richter,  Bibl.  b.  11,  p.  591.)  From  the  facts,  however, 
mentioned  in  a preceding  page  of  this  article,  there  can 
now  be  no  doubt  that  pregnancy  frequently  does  not 
prevent  the  formation  of  callus  in  the  ordinary  time, 
though  the  observation  of  Mr.  Wardrop  is  true,  that 
many  instances  have  been  observed  of  bones  being 
fractured  during  pregnancy,  and  never  showing  any 
disposition  to  unite  till  after  delivery. — (Med.  Chir. 
Trans,  vol.  5,  p.  359.) 

Besides  the  remarks  made  here  and  in  a foregoing 
page,  on  the  causes  preventing  the  union  of  fractures, 
a few  additional  observations  on  the  same  subject  will 
be  intro<luced  in  the  sequel  of  this  article,  when  we 
speak  of  the  modes  of  attempting  the  cure  of  old  dis- 
united fractures. 


2.  Of  some  local  Circumstances  necessary  for  the  Con- 
solidation of  Fractures. 

As  Boyer  has  well  explained,  three  local  circum- 
stances are  necessary  to  obtain  a firm  callus  without 
deformity.  1.  The -two  fragments  must  be  possessed 
of  sufiicient  vascularity.  2,  The  surfaces  of  the  frac- 
ture must  correspond.  3.  They  must  be  kept  in  a 
completely  motionless  state. 

The  two  fragments  must  be  sufficiently  vascular. 
If  one  of  them  should  be  too  scantily  supplied  with 
blood,  the  fracture  would  be  incapable  of  union.  This, 
as  is  asserted  by  Boyer,  though  denied  by  Amesbury 
and  others.,  is  what  happens  in  certain  fractures  of  the 
neck  of  the  femur,  where  the  head  of  this  bone  is  en- 
tirely detached,  and  the  ligamentous  substance  which 
is  reflected  over  its  neck,  and  serves  as  its  periosteum, 
is  totally  lacerated,  as  well  as  the  vessels  which  ra- 
mify upon  it.  Hence,  the  upper  fragment  lodged  in  the 
cotyloid  cavity  no  longer  receives  from  the  vessels  sent 
to  it  through  the  ligamcntum  teres  a sufficiency  of 
blood  for  the  process  of  the  formation  of  callus.  This 
is  especially  likely  to  be  the  case  when  the  patient  is 
far  advanced  in  years,  and  the  vessels  considerably 
lessened  in  diameter.  An  adequate  circulation  must 
therefore  exist  in  both  portions  of  bone ; for  without 
it  the  attempt  at  union  will  fail. 

The  surfaces  of  the  fracture  must  correspond  ex- 
actly. This  circumstance  is  not  absolutely  necessary 
for  the  consolidation  of  the  fracture;  but  without  it 
the  formation  of  the  callus  is  always  slow  and  difficult. 
For  instance,  in  a transverse  fracture  of  the  thigh-bone, 
the  fragments,  after  being  displaced  according  to  the 
tliickness  of  the  bone,  may  undergo  a second  displace- 
ment according  to  its  length,  by  passing  beyond  each 
other.  The  surfaces  of  the  fracture  are  then  not  at 
all  in  contact,  and  the  portions  of  bone  only  touch  each 
other  by  their  sides,  which,  being  covered  by  the  peri- 
osteum, can  unite  with  difficulty.  Here,  at  the  end  of 
the  second  month,  the  union  will  frequently  have  made 
but  little  progress ; nor  can  the  cure  be  accomplished 
without  deformity  and  shortening  of  the  limb. 

The  fragments  must  be  retained  in  a completely 
motionless  state.  This  condition  is  so  essential  to  the 
formation  of  callus,  that  if  the  ends  of  a fracture  were 
daily  moved,  they  could  not  unite.  The  two  extremi- 
ties of  the  Done  would  then  heal  separately,  just  like 
the  sides  of  a wound  which  have  not  been  put  in  con- 
tact. The  ends  of  a fracture,  however,  which  cica- 
trize separately  do  not  (according  to  Boyer)  always  be 
come  smooth,  nor  is  there  ordinarily  any  capsulai 
ligament  formed. — (Traite  des  Mai  Chir.  t.  3,  p.  86  * 
3.  Different  Opinions  on  the  Formation  o/  callus 

As  Boyer  remarks,  perhaps  no  subject  nas  excited 
more  discussion  than  the  formation  of  callus.  The 
ancients  ascribed  it  to  the  extravasation  of  a gelatinous 
fluid  which  was  called  the  osseous  juice,  and  which, 
becoming  hard,  served  to  unite  the  ends  of  the  broken 
bone,  just  as  glue  serves  to  unite  two  pieces  of  woo<l. 
Hence,  in  order  to  favour  the  production  of  callus,  they 
were  in  the  habit  of  recommending  their  patients  to 
eat  abundantly  of  every  sort  of  viscid  farinaceous  ali- 
ment, theglu  inous  parts  of  animals,  and  especially  os- 
teocolla,  of  which  Fabricius  Hildanus  relates  miracles. 

But  if  these  accounts  were  true,  callus  must  be 
inorganic,  or  else  one  would  be  compelled  to  admit,  that 
the  inspissation  of  an  inorganic  fluid  was  capable  of 
producing  an  organized  substance;  which  is  an  ab- 
surditj^.  Besides,  observation  demonstrates  that  callus 
is  an  organized  matter,  like  the  substance  of  the  bene 
itself,  which  it  resembles,  and  that  when  subjected  to 
anatomical  and  chemical  experiments,  it  exhit..s  an 
the  appearances  of  the  projier  substance  of  bones. 

According  to  Duhamel,  callus  is  formed  by  the  peri- 
osteum, which  he  regards  as  the  organ  of  ossification. 
When  a bone  is  fractured  (says  this  naturalist),  the  pe- 
riosteum of  the  two  fragments  first  grows  together, 
and  then  swells,  and  forms  a circular  rising  round  the 
fracture.  The  thickened  membrane  is  converted  into  a 
gelatinous  substance,  which  soon  becomes  a c.artilagi- 
nous  matter.  In  this  ve.ssels  deveiope  themselves,  and 
different  points  of  ossification  commence,  which  mul- 
tiply and  unite.  Thus,  when  every  part  of  the  {Kirios- 
teum  near  th  - fracture  is  hardened  and  ossified,  this 
membrane  is  changed,  as  it  were,  into  a sort  of  clasp, 
which  exteiids  over  the  two  fiagt'<'»nts,  and  holds  them 
together. 


Bb2 


388 


FRACTURES. 


It  was  objected  to  Duliarrtel’s  theory^  that  if  a bone 
be  slit  longitudinally  in  the  situation  of  a former  frac- 
ture, the  fragments  are  observed  to  have  their  sub- 
stances blended  completely  together,  and  not  simply  to 
lie  in  contact  in  the  manner  of  two  pieces  of  wood 
placed  end  to  end,  and  kept  in  contact  by  means  of  a 
clasp.  Duhamel,  with  a view  of  obviating  this  diiR- 
culty,  supposed  that  the  periosteum  elongated  itself 
Irom  the  circumference  towards  the  centre  of  the  bone, 
and  that  such  continuation  of  this  membrane  under- 
went the  same  changes  as  that  portion  which  was  con- 
tiguous to  the  fracture,  and  thus  served  to  unite  the 
ends  of  the  fragments  between  which  it  was  inter- 
posed. He  admits,  also,  in  some  cases  that  the  inter- 
nal periosteum  or  medullary  membrane  may  furnish 
productions  extending  between  the  ends  of  the  frac- 
ture, like  the  continuation  of  the  external  periosteum 
with  which  they  become  connected.  Lastly,  he  sup- 
posed that  in  young  subjects,  whose  bones  had  ngt  ac- 
quired their  full  degree  of  hardness,  the  cartilaginous 
part  was  capable  of  extension,  and  that,  in  cases  of 
fracture,  it  contributed  to  the  more  perfect  union  of  the 
fragments. 

The  system  of  Duhamel  was  opposed  by  Haller  and 
Dethleef,  who,  after  a long  series  of  well-performed 
experiments,  came  to  the  conclusion,  that  the  callus 
was  formed  by  a gelatinous  juice,  which  exudes  from 
the  extremity  of  the  fractured  bone,  particularly  frpm 
the  medullary  texture,  and  is  effused  all  about  the  frac- 
ture ; that  such  juice  is  organized,  forms  a cartilage, 
and  at  length  ossifies. 

But  as  Boyer  justly  remarks,  whatever  difference 
there  may  seem  to  be  between  this  doctrine  and  that 
of  Duhamel,  it  is  merely  in  the  mode  of  explaining 
the  facts.  All  these  observers  noticed  the  same  pheno- 
mena ; and  all  the  experiments  of  Dethleef  accorded 
perfectly  well  with  those  of  Duhamel.  Both  found, 
during  the  first  days,  immediately  after  the  fracture, 
a lymph  extravasated  between  the  fragments,  and  a 
small  tumour  in  the  situation  of  the  fracture.  Both 
also  remarked,  that  this  tumour  became  softer,  and 
that  it  afterward  formed  a gelatinous,  then  a cartila- 
ginous, and  lastly  a bony  substance,  which  composed 
the  uniting  medium.  But  Duhamel  contends,  that  the 
cartilage  is  produced  by  the  periosteum,  while  Haller 
and  Dethleef  argue  that  it  is  the  production  of  the 
extravasated  lymph. 

Professor  Boyer  thinks,  that  Duhamel  imputes  too 
much  to  the  periosteum ; but  that  Haller  and  Dethleef 
were  also  wrong  if  they  supposed,  as  Fougeroux  al- 
leges, that  an  unorganized  lymph  could  produce  an 
organized  substance  by  inspissation.— (See  Le  second 
Mejnoire  sur  les  Os,  par  M.  Borden  ave,  recueilli  et  jnib- 
Ue  par  M.  Fovgeronx,  p.  124.)  It  appears  to  Boyer 
much  more  natural  to  believe  that  the  gelatinous  Ij  mph 
already  contains  the  rudiments  of  organization,  wliich 
become  visible  as  they  are  developed;  just  as  it  is 
usually  believed,  that  the  rudiments  of  all  our  organs 
are  contained  in  the  transparent  mucilage,  of  which 
the  embryo  seems  to  consist. 

The  experiments  of  Duhamel  and  Dethleef  were 
carefully  repeated  by  Bordenave,  w'ho  ascertained  se- 
veral new  and  interesting  facts.  The  result  was  the 
same  in  regard  to  the  phenomena  observed ; but  the 
explanation  of  them  was  different. 

Instead  of  attributing  the  formation  of  callus  to  the 
periosteum,  like  Duhamel,  or  to  the  extravasation  of 
lymph,  like  Dethleef,  Bordenave  conceived  that  broken 
bones  unite  again  by  a process  analogous  to  that^vhich 
nature  employs  for  the  union  of  the  divided  soft  parts. 
His  inference  is  principally  founded  on  two  facts  gene- 
rally admitted.  1st,  That  there  is  in  the  bones  a vas- 
cular texture  designed  to  maintain  the  circulation  in 
them.  2dly,  That  such  texture  dilates  when  Iractures 
are  uniting,  as  appears  from  the  swelling  in  the  situ- 
ation of  the  fracture,  without  which  swelling  there 
could  be  no  union.  Bordenave  farther  remarks,  with 
Haller  and  Dethleef,  1st,  That  callus,  at  the  commence- 
ment of  its  formation,  appears  to  consist  of  a gluti- 
nous fluid  effused  from  the  ruptured  vessels.  2dly, 
That  this  substance  afterward  assumes  the  form  of 
cartilage,  to  which  certain  vessels  are  distributed,  which 
deposite  the  bony  matter,  and  thus  begin  the  genera- 
tion of  callus.  3dly,  That  the  particles  of  bone,  being 
all  joined  together,  the  callus  changes  into  a porous 
substance,  which  in  time  becomes  solid  and  com.  act, 
like  the  sub.stance  of  bones 


Doubtless  (says  Boyer)  we  shall  always  remain  ig- 
norant of  the  process  which  nature  employs  for  the 
union  of  the  bones,  as  well  as  for  that  of  the  soft  parts. 
Every  theory  which  can  be  invented  on  this  point  will 
only  be  conjectures  more  or  less  probable.  However, 
if  this  author  were  to  adopt  any  system  exclusively, 
he  expresses  that  he  should  prefer  that  of  Bordenave, 

The  mechanism  of  nature  in  the  formation  of  callus, 
must  be  analogous  to  that  which  she  adopts  in  the 
union  of  wounds.  The  principal  difference  seems  to 
be,  that  in  the  union  of  a fracture  the  vessels  after  a 
time  deposite  the  phosphate  of  lime.  The  vessels  of  the 
periosteum,  medullary  membrane,  and  probably  also 
those  of  the  soft  jiarts  in  the  immediate  vicinity  of  the 
fracture,  first  effuse  coagulating  lymph.  This  gradu- 
ally becomes  vascular,  and  in  proportion  as  the  vessels 
acquire  the  power  of  secreting  earthy  matter,  it  is  by 
degrees  converted  into  new  bone,  termed  calltis,  which 
from  being  at  first  soft  and  fiexible,  at  length  becomes 
firm  and  unyielding,  and  fit  for  constituting  the  future 
bond  of  union  between  the  two  extremities  of  the  frac  t ure. 

The  observations  made  by  Baron  Larrey  lead  him  to 
reject  as  entirely  erroneous  the  doctrine  which  refers 
the  production  of  callus  to  the  periosteum,  and  he 
adopts  the  opinion,  that  the  union  and  reparation  of 
bones  are  the  work  of  their  own  vessels.  He  adverts 
to  examples  in  which,  after  the  use  of  the  trephine 
in  young  subjects,  the  perforation  becomes  more  or  less 
closed  by  new  bone,  thrown  out  from  the  circumfe- 
rence towards  the  centre.  Here,  says  he,  the  ossifica- 
tion assuredly  can  neither  be  referred  to  the  pericra- 
nium nor  the  dura  mater.  The  first  of  these  mem- 
branes has  been  extensively  destroyed,  and  if  the  se- 
cond were  concerned,  a vertical  substance,  shutting  up 
the  opening,  would  be  apparent.  In  farther  support  of 
his  opinions,  Baron  Larrey  cites  the  well-known  cele- 
rity with  which  fractures  of  the  lower  jaw  unite,  on 
account  of  the  great  vascularity  of  that  bone ; and  he 
believes,  with  Sir  Astley  Cooper,  that  if  the  ends  of  a 
fracture  do  not  touch  in  consequence  of  a loss  of  sub- 
stance, the  intervening  space  remains  unfilled  up  by  a 
new  bone ; a position  which  seems  rather  repugnant 
to  what  has  been  said  concerning  the  mode  of  repara- 
tion after  the  use  of  the  trephine. 

Larrey  has  often  seen  the  superficial  layers  of  the 
tibia  exfoliate,  after  a necrosis  produced  by  a cause 
which  had  destroyed  the  whole  of  the  periosteum  on 
the  front  surface  of  that  bone,  as  is  sometimes  the  case 
in  hospital  gangrene.  He  has  seen  these  layers  re- 
placed by  red  vascular  granulations  disposed  in  parallel 
lines,  which  granulations  soon  ossified,  that  is  to  say, 
phosphate  of  lime  was  substituted  for  the  Vermillion  co- 
lour of  the  vessels,  and  gave  the  new-formed  substance 
the  appearance  and  consistence  of  bone.  Lastly,  this 
substance  was  covered  with  a new  cellular  membrane, 
derived  from  the  adjacent  textures ; but  in  the  place  of 
the  cicatrix,  a depression  always  remained,  propor- 
tioned to  the  loss  of  substance.  If  the  formation  of 
callus  depended  on  the  periosteum,  Larrey  argues,  that 
the  broken  patella  could  never  unite  by  bone,  as  it  is 
often  found  to  do,  when  the  fragments  are  kept  closely 
in  contact.  Here  he  contends  that  the  union  is  brought 
about  by  the  action  and  inosculation  of  the  vessels  be- 
longing to  the  substance  of  the  fragments  themselves. 
Lastly,  he  adverts  to  preparations  in  wdiich  the  vessels 
of  callus  have  been  actually  injected  by  the  celebrated 
Soemmering. — {See  Journ.  ComplSm.  du  Dict.des  Sci- 
ences M d.  t.  8,  p.  107,  8?;o.  Paris,  1820.) 

Mr.  Liston,  of  Edinburgh,  coincides  very  much  with 
Baron  Larrey.  “ To  the  surrounding  soft  parts  (says 
he)  has  been  attributed  a great  share  of  the  work  in 
the  union  of  broken  bones;  and  when  bones  have 
been  fractured  in  circumstances  not  admitting  of  this 
assistance,  the  process  of  separation,  it  is  said,  caniot  be 
accoin])lished.  In  dissecting  a fractured  limb,  which 
has  been  removed  during  the  process  of  union  by  cal 
lus,  it  will  be  found  that  the  rtewbone  is  uniformly  at- 
tached to  the  sound  part  of  the  old,  the  vessels  of  the 
part  employed  in  this  process  being  much  increased  in 
size  ; the  newly  deposited  bone,  u^ich  in  its  turn  car- 
ries on  the  process,  being  perforated  by  numerous  and 
large  foramina,  for  the  entrance  of  corresponding 
ram  f cations  of  arteries.  The  new  formation  will  be 
perceived  shooting  from  the  opposed  ends  till  these  are 
united  ; and  the  masses  in  which  they  .are  dei)ositc<l 
will  be  direct,  and  but  slightly  prominent,  or,  on  the 
other  hand,  irregular  and  unshapely,  according  as  the 


FRACTURES. 


389 


separated  ends  are  favourably  or  unfavourably  placed. 
I can  conceive  it  possible  (says  Mr.  Liston),  and,  in 
fact,  have  frequently  found  newbone  connected  with  the 
8oft  parts;  but  this  was  the  produce  of  a splinter 
which  had  still  retained  its  vitality,  and  whose  vessels 
had  formed  a contribution  to  the  general  action.  Great 
powers,  not  only  in  the  production,  but  also  in  the  re- 
moval of  bone,  have  been  long  allowed  to  the  perios- 
teum. No  one,  I will  venture  to  say,  has  as  yet  de- 
tected this  membrane  in  either  of  these  acts.  New 
bone  has  not  been  found  adhering  to  the  periosteum, 
either  in  fractures  or  necrosis ; far  less  has  a complete 
substitute  composed  of  the  ossified  periosteum  been 
ever  discovered  enclosing  a sequestrum.  In  every  in- 
stance the  new  formation  is  deposited  in  nodules  ad- 
hering firmly  to  the  old  bone,  and,  as  remarked  above, 
freely  perforated  by  nutritious  arteries.  The  vessels 
of  the  bone,  no  doubt,  are  ramified  on  the  external  and 
internal  periosteum ; but  it  is  only  after  their  entrance 
into  the  perforations,  that  they  become  disposed  to  i)Our 
out  ossific  matter.” — (Edin.  Med.  and  Eurg.  Journ. 
No.  78,  p.  47.) 

From  experiments  instituted  by  Breschet  and  Vil- 
lermd,  it  would  appear  that  the  union  of  broken  bones 
is  not  exclusively  owing  to  the  effusion  of  a particular 
fluid  which  concretes  and  gradually  changes  into  an 
osseous  substance ; nor  to  the  ossification  of  the  swol- 
len and  elongated  periosteum  ; nor,  in  the  majority  of 
instances,  to  granulations  produced  from  the  surfaces 
of  the  fracture  ; but  it  is  frequently  dependent  upon  all 
these  circumstances  together,  or  at  least  several  of 
them ; and,  in  every  case,  it  is  the  result  of  a series  of 
changes,  observable  in  the  soft  parts  immediately  ad- 
joining the  fVacture,  in  the  periosteum,  in  the  medul- 
lary structure,  in  the  cavities  and  very  texture  of  the 
bones  themselves,  and  in  the  substance  intervening  be- 
tween the  two  fragments.  In  simple  fractures,  the 
following  are  stated  to  be  the  principal  circumstances 
remarked  during  the  process. 

1.  Extravasation  and  coagulation  of  a small  quantity 
of  blood  between  the  ends  of  the  fracture,  which  blood 
escapes  from  torn  or  ruptured  vessels. 

2.  A fluid,  at  first  of  a viscid  quality,  effused  and  se- 
creted, as  it  were,  between  the  periosteum  and  the 
bone,  and  likewise  exuding  from  the  surfaces  of  the 
flracture  and  the  soft  parts. 

3.  A gradual  increase  in  the  quantity  and  consist- 
ence of  the  preceding  substances  blended  together, 
forming  every  day  a stronger  and  stronger  connexion 
between  the  parts ; then  their  change  to  a red  interme- 
diate substance  between  the  fragments,  and  between 
the  bone  and  the  periosteum  to  a substance  which  is  at 
first  soft,  but  in  the  end  acquires  the  characters  of  bone. 

4.  At  the  fractured  part,  a reunion  of  the  periosteum 
and  soft  parts,  which  are  equally  indurated  and  con- 
fused together,  with  the  intermediate  substance  between 
the  fragments. 

5.  A diminution,  and  then  an  obliteration  of  the  me- 
dullary cavity,  at  first  by  a cartilaginous,  and  then  a 
bony  deposition. 

6.  Successive  ossification  of  the  whole  of  the  swell- 
ing composing  the  callus,  and  of  the  substance  be- 
tween the  fragments,  preceded  by  a fibrous  and  cartila- 
ginous state. 

7.  The  return  of  the  soft  parts  around  the  fracture, 
and  then  of  the  periosteum,  to  their  natural  state. 

8.  After  the  union  of  the  surfaces  of  the  fracture, 
the  medullary  cavity  and  texture  are  gradually  re-esta- 
blished, and  the  swelling  formed  by  the  callus  always 
diminishes. 

But  in  compound  fractures,  besides  these  circum- 
stances, the  production  of  granulations  from  the  sur- 
faces of  the  bone  is  also  to  be  taken  into  the  account. 
—(See  Diet,  des  Sciences  Mid.  t.  38,  p.  436.)  This 
difference  from  what  happens  in  the  process  of  union 
of  simple  fractures  is  also  particularly  noticed  by  Mr. 
Wilson : “ From  the  parts  being  exposed  (in  a com- 
pound fracture),  the  first  bond  of  union,  viz.  the  coagu- 
lable  lymph  of  the  blood,  is  removed  or  destroyed  be- 
fore it  can  become  vascular.  Inflammation  in  conse- 
quence of  the  injury  comes  on,  suppuration  takes  place, 
and  when  the  parts  are  healthy,  granulations  arise. 
These  granulations  from  the  broken  extremities  of  the 
bone  soon  ^sume  the  ossifying  disposition,  and  when 
they  come  in  contact  with  each  other,  unite.” — {On  the 
Skeleton,  Diseases  of  the  Bones,  d,-c.  p.  233, 8i;«  Land. 
1820.)  It  is  a curious  fact,  that  broken  cartilages  are 


united  by  means  of  bone ; a circumstance  which  has 
often  been  noticed  in  respect  to  the  cartilages  of  the  ribs. 

Whatever  may  be  the  process  by  which  callus  is 
formed,  it  is  during  the  first  two  or  three  weeks  after 
the  fracture  that  the  fragments  undergo  the  changes 
which  promote  their  reunion.  But  it  is  between  the 
twentieth  and  thirtieth,  and  especially  between  the  thir- 
tieth and  fiftieth  days,  that  nature  labours  effectually 
in  consolidating  the  callus.  Hence,  at  this  period,  our 
care  to  retain  the  ends  of  the  fracture  in  exact  contact 
and  perfectly  at  rest,  should  be  redoubled ; for  though 
there  are  a few  instances  in  which  deformity  really 
proceeds  from  irregular  ossifications,  it  is  a fact,  that 
the  deformity  almost  always  originates  from  the  frac- 
ture being  disturbed  and  not  kept  properly  reduced.— 
{Boyer,  '^aiti  des  Mai.  Chir.  t.  3,  p.  86,  ifc.) 

4.  Of  the  Conduct  to  be  adopted  at  the  ordinary  Period 

of  the  Consolidation  of  Fractures,  and  of  the  Treat- 
ment of  False  Joints. 

When  the  requisite  time  for  a broken  bone  to  be- 
come firmly  united  has  elapsed,  it  is  proper  to  examine 
carefully  and  cautiously  the  place  of  the  fracture,  in  or- 
der to  learn  whether  the  callus  has  acquired  a suitable 
degree  of  strength.  ' If  the  bone  should  be  found  to 
bend  in  the  least  at  the  injured  pari,  the  callus  is  not 
sufficiently  strong,  and  the  limb  should  be  immediately 
put  up  in  the  apparatus  again,  with  a view  of  prevent- 
ing a new  fracture,  or,  at  all  events,  deformity. 

For  the  same  reason,  the  patient  should  not  be  al- 
lowed to  make  use  of  his  limb,  as  soon  as  the  fracture 
has  united.  In  fractures  of  the  lower  extremity,  he 
ought  to  use  crutches,  and  only  let  the  weight  of  the 
trunk  by  degrees  bear  upon  the  injured  limb.  From 
neglect  of  this  precaution  the  callus  has  been  known 
to  be  absorbed,  the  limb  to  be  shortened,  and  the  pa- 
tient become  a cripple.  An  accidental  slip  may  also 
produce  the  fracture  again  ; for,  notwithstanding  the 
assertion  of  writers,  the  callus,  so  far  from  being  firmer 
than  the  rest  of  the  bone,  is  at  first  considerably 
weaker. — {Boyer,  t.  3,  p.  93.) 

If,  when  the  necessary  time  for  the  completion  of  the 
union  has  expired,  the  callus  is  not  yet  firm,  we  must 
examine,  1st,  The  relative  position  of  the  fragments 
and  the  consistence  of  the  callus  : 2dly,  The  causes 
which  may  have  retarded  its  consolidation. 

That  the  state  of  the  constitution  has  considerable 
influence  over  the  process  by  which  broken  bones  are 
reunited,  is  unquestionable.  Schmucker  found  the 
formation  of  callus,  even  in  the  most  simple  fractures, 
sometimes  delayed  eight  months,  and  in  one  example 
more  than  a year ; but  the  patients  were  all  of  them 
unhealthy  subjects. — {Vermischte  Chir.  Schriften,  b.  1, 

p.  26.) 

There  are  certain  indescribable  constitutions,  in 
which  bones,  more  particularly,  however,  the  os  bra- 
chii,  Avill  not  unite  again  after  being  broken.  These 
temperaments  are  also  very  various ; at  least,  I infer 
so  from  tw'o  subjects  to  whom  I paid  particular  atten- 
tion. One  was  a strong,  robust  man,  whose  chief  pe- 
culiarity seemed  to  be  his  indifference  to  pain : the 
ends  of  his  broken  humerus  were  cut  down  too,  turned 
out,  and  sawed  off,  by  Mr.  Long,  in  St.  Bartholomew’s 
Hospital,  and  the  limb  was  afterward  put  in  splints 
and  taken  the  greatest  care  of ; but  no  union  followed. 
The  other  case  was  a broken  tibia  and  fibula,  which 
remained  disunited  for  about  four  months  ; but  after- 
ward grew  together.  The  latter  subject  was  a com- 
plete instance  of  hypochondriasis.  I afterward  saw  a 
woman,  under  Sir  .lames  Earle,  in  the  above  hospital, 
whose  os  brachii  did  not  unite  in  the  least,  though  it 
had  been  broken  seve^il  months.  Every  attempt  to 
move  the  bone  occasioned  excruciating  torture.  The 
woman  died  of  some  illness  in  the  hospital,  and  on 
dissecting  the  arm,  the  cause  of  the  fracture  not  having 
united  was  found  to  arise  from  the  upper,  sharp, 
pointed  extremity  of  the  lower  portion  of  the  broken 
bone  having  been  forcibly  drawn  up  by  the  muscles, 
and  penetrated  the  substance  of  the  biceps,  in  which 
it  still  remained.  I am  indebted  to  Mr.  Earle  for  the 
description  of  the  appearance  in  the  dissection,  and  I 
do  not  know  that  this  kind  of  impediment  to  the  union 
of  a fracture  has  been  noticed  by  any  earlier  writer 
than  Mr.  Charles  White,  who  appears  to  have  con- 
ceived the  possibility  of  the  occurrence.— (Coat-.-?  in 
Svrgery,  p.  70,  edit.  1770.) 

The  causes  i»f  fractures  remoining  disunited  will 


390 


FRACTURES. 


according  to  Richerand,  be  found  to  depend  either  upon 
the  broken  ends  of  the  bone  not  being  properly  in  con- 
tact ; the  limb  having  been  moved  too  much ; the  ad- 
vanced age  of  the  patient ; or  upon  a general  inertia 
and  languor  of  the  constitution. — {Nosographie  Chir. 
tom,  3,  p.  37,  edit.  2.) 

It  is  observed  by  Larrey,  that  the  gun-shot  vcounds 
of  the  extremities,  complicated  with  fracture,  especially 
with  that  of  the  humerus,  received  by  the  soldiers  of 
the  French  army  m Syria,  were  almost  all  followed 
by  the  formation  of  accidental  joints.  The  two  frag- 
ments of  the  broken  bone  continued  moveable,  their 
asperities  and  projecting  angles  having  been  destroyed 
by  friction,  and  their  ends  being  rounded  and  covered 
with  a cartilaginous  substance,  so  as  to  facilitate  the 
motions  which  the  patients  executed  in  various  direc- 
tions, in  an  imperfect  manner  and  without  pain.  Lar- 
rey acquaints  us  that  many  invalids  were  sent  back 
to  France  with  such  infirmity. 

“ I ascribe,”  he  says,  “ the  causes  of  these  accidental 
articulations : 

1.  To  the  continual  motion  to  which  the  wounded 
soldiers  were  exposed,  after  their  departure  from  Sy- 
ria till  their  arrival  in  Egypt,  in  consequence  of  their 
haying  been  obliged  either  to  walk  this  journey  on  foot, 
or  to  be  carried  it  on  beasts. 

2.  To  the  bad  quality  of  the  food  and  the  brackish 
water  which  the  men  were  under  the  necessity  of 
drinking  in  this  painful  journey. 

3.  To  the  state  of  the  atmosphere  in  Sjria,  almost 
entirely  destitute  of  vital  air,  and  impregnated  with 
pernicious  gases,  issuing  from  the  numerous  marshes 
near  which  we  were  a long  while  stationed. 

All  these  causes  may  have  prevented  the  formation 
of  callus,  either  by  diminishing  the  quantity  of  the  phos- 
phate of  lime,  or  moving  the  bones  out  of  that  state  of 
coaptation  in  which  they  should  constantly  lie,  in  order 
to  unite. 

Bandages,  embrocations,  rest,  and  regimen  proved 
quite  ineflTectual. ’’-.-(Larrey,  Mem.  de  Chir.  Mil.  t.  2,  p. 
131,  132.  Langenbeck,  Neue  Bibl.  b.  1,  p.  81.) 

The  presence  of  an  ulcer,  a sinus,  loose  splinters  of 
bone,  a necrosis,  or  other  suppurating  disease  near  a 
fracture,  is  a circumstance  that  often  appears  seriously 
to  retard  or  completely  to  prevent  the  formation  of 
callus.  How  frequently  have  I noticed,  in  cases  of 
compound  fracture,  that  while  the  wound  suppurates 
largely,  and  while  there  are  spiculae  and  dead  portions 
of  bone  unextracted,  no  solid  union  takes  place ; but 
that,  as  soon  as  the  wound,  ulcer,  or  sinus  admits  of 
being  healed,  and  the  suppuration  ceases,  the  callus 
begins  to  form  in  the  most  favourable  manner.  Schmuc- 
ker  relates  a case  illustrating  the  truth  of  these  obser- 
vations, where  the  tibia  and  fibula  were  broken  so  ob- 
liquely, that  the  ends  of  the  fracture  could  not  be  made 
to  lie  well,  a necrosis  of  a portion  of  the  tibia  followed, 
and  no  callus  was  formed  at  the  end  of  eight  months, 
when  a sinus  on  each  aide  of  the  leg  still  continued. 
This  eminent  surgeon  now  laid  the  sinuses  open,  and 
extracted  the  dead  pieces  of  bone,  by  which  means  the 
impediment  to  the  formation  of  callus  was  removed, 
and  the  fracture,  wliich  had  till  then  remained  loose 
and  moveable,  became  firmly  united  in.two  months, — 
{Vermischte  Chir.  Schri/ten,  b.  1,  p.  25,  26.) 

False  or  preternatural  articulations,  which  occur  in 
oases  of  fracture  without  union,  have  been  generally 
supposed  to  resemble  common  joints.  According  to 
Boyer,  this  opinion  is  incorrect.  The  ends  of  the  frac- 
ture, which  are  sometimes  rounded  and  sometimes 
pointed,  are  connected  together  by  a cellular  and  liga- 
mentous substance.  But  their  surfaces  are  not  co- 
vered by  a smooth  cartilaginous  matter,  nor  is  there 
constantly  a capsular  ligament.  “ I am  convinced  of 
this  fact,  by  the  dissection  of  several  ununited  fractures, 
the  fragments  of  which  are  preserved  in  my  museum.” 
— {Boyer,  t.  3,  p.  94.)  And,  in  another  place,  the  same 
professor,  speaking  of  these  false  joints,  remarks : “ I 
repeat,  that  I have  never  found  in  their  structure  any 
thing  which  could  be  compared  with  an  articulation ; 
neither  capsular  ligament  nor  smooth  cartilaginous 
surfaces.  On  the  contrary,  I have  invariably  found  in 
the  false  joints  of  the  thigh-bone  and  humerus,  which  I 
have  had  opportunities  of  dissecting,  a fibrous  liga- 
mentous substance,  extending  from  one  fragment  to 
the  other,  and  it  is  very  probable  that,  with  some  mo- 
difications, it  is  the  same  wth  all  the  other  cases  which 
I have  not  seen. 


But,  in  the  forearm,  the  ends  of  the  fracture  may 
assume  a structure  which  bears  a greater  resemblance 
to  an  articulation.  This  is  what  happened  in  an  ex- 
ample which  was  communicated  toBayle  by  Sylvestre, 
in  the  Republique  des  Lettres,  Juillet,  1685,  p.  718,  it  c, 
A similar  case  is  recorded  by  Fabricius  Hildanus,  obs. 
91,  centur.  3.” — {Boyer,  TraiU  des  Mol.  Chir.  t.  3,p. 
101—103.) 

On  this  subject  Langenbeck  observes,  that  the  edges 
of  the  fragments  heal  and  resemble  those  of  a hare-lip. 
“ When  the  parts  are  incessantly  moved,  the  end  of 
one  fragment  becomes  excavated  in  the  form  of  an  arti- 
cular cavity.  I have  in  my  possession  (says  he)  a lower 
jaw  and  an  olecranon,  the  fractures  of  which  are  not 
united.  For  the  connecting  medium,  nature  hjis  pro- 
vided a white  substance  resembling  ligament.  In  a 
male  patient  I have  also  seen  an  articular  connexion  es- 
tablished in  the  body  of  the  thigh-bone  subsequently  to 
a fracture.” — {Neue  Bibl.  b.  1,  p.  93.)  When  a capsule 
is  formed,  it  is  alleged  not  to  be  of  a ligamentous  na- 
ture.—(Ric/io/,  Anatomic  Generate,  t.  3,p.  191.) 

In  the  Hunterian  collection  may  be  seen  a false  joint 
in  the  bones  of  the  forearm,  where  the  resemblance  to 
a natural  articulation  was  greater  than  what  Boyer  has 
seen  in  other  situations. 

A valuable  dissertation  on  false  joints  has  been  pub- 
lished by  Reisseisen,  entitled  “ De  Articulationibuj 
analogis,  qiuB  fracturis  ossium  superveniurU but  I 
am  sorry  that  it  has  not  been  in  my  power  to  meet  with 
a copy  of  it. 

A false  joint  in  the  arm  or  forearm  does  not  abso- 
lutely prevent  the  motion  of  the  limb,  which  may  yet 
be  of  considerable  use ; but  when  the  disease  is  in  tlie 
thigh  or  leg,  the  member  cannot  support  the  weight  of 
the  body,  and  the  patient  is  unable  to  walk  without 
crutches. 

The  diversity  of  causes  which  may  be  concerned  in 
preventing  the  union  of  fractures,  plainly  shows,  that 
the  treatment  should  be  different  in  different  cases. 

When  the  want  of  union  is  tiscribable  to  the 
ends  of  the  fracture  not  being  in  a state  of  coapta 
tion,  and  to  their  having  been  moved  about  too  fre- 
quently, the  obvious  indications  are,  to  set  the  fracture 
better,  and  to  take  adequate  measures  for  keeping  its 
extremities  in  contact  and  perfectly  motionless. 

If  the  union  has  been  prevented  by  a portion  of  mus- 
cle Of  other  soft  part  getting  between  the  ends  of  the 
bone,  the  only  means  of  affording  a chance  of  union 
would  be  cutting  through  the  integuments,  removing 
the  displaced  soft  parts,  and  placing  the  ends  of  the 
bone  in  contact. — {Wardrop,in  Med,  Chir.  Trans,  vol, 
5,  p.  363.) 

When  the  advanced  age  of  the  patient  seems  to  be 
the  cause  of  the  union  not  taking  place,  the  application 
of  the  proper  apparatus  is  to  be  continued  a consider- 
able time,  since  experience  proves,  that  in  old  subjects, 
the  cure  of  fractures  often  requires  many  months.  In 
such  examples,  also,  tonic  and  cordial  medicines,  with  a 
nutritive  diet,  are  highly  proper. 

When  several  months  have  elapsed  since  the  acci- 
dent, and  there  is  reason  to  apprehend  that  a preterna- 
tural joint  is  formed,  a variety  of  plans  have  been  pro- 
posed and  practised. 

The  most  ancient  method  of  treatment  is  that  of  for- 
cibly rubbing  the  ends  of  the  fracture  against  each 
other,  so  as  to  make  them  inflame  and  take  on  a dispo- 
sition to  form  callus.  This  plan  was  recommended  by 
the  late  Mr.  John  Hunter,  and  has  had  the  approbation 
of  many  other  distinguished  modem  practitioners.  Mr. 
Hunter  used  even  to  advise  us,  in  the  case  of  a dis- 
united fracture  of  the  leg  or  thigh,  to  let  the  patient  get 
up  and  attempt  to  walk  with  the  splints  on  the  limb, 
so  that  the  requisite  irritation  might  be  produced.  The 
idea  of  exciting  a degree  of  inflammation  in  the  situation 
of  the  fracture,  certainly  appears  rational,  and  I be- 
lieve the  practice  has  been  attended  with  a limited  de- 
gree of  success.  Mr.  White  records  an  example,  in 
which  he  cured  a broken  thigh  on  this  principle,  a 
strong  leather  case  having  been  made  tor  the  limb. — 
{Cases  in  Surgery,  p,  75.)  A broken  tibia,  treated  on 
similar  principles,  is  mentioned  by  Mr.  Amesbury. — 
(On  Fractures,  p.  211,  ed.  2.)  The  method  is  spoken 
of  in  Celsus  : si  vetustas  occupavit,  membrum  exten- 
dendumest  ut  aliquid  Icedatur : ossa  inter  se  manu 
dimovenda,  ut  concurrendo  exasperentur,  et  ut  .at 
quid  pingue  cst,  cradatur,  totumque  id  quasi  recent 
Jittt,  c. 


FRACTURES. 


391 


The  foregoing  treatment,  however,  is  only  likely  to 
answer  before  a new  joint,  or  at  all  events,  a ligament- 
ous fibrous  connexion  is  completely  formed,  and  when 
the  limb  has  hitherto  been  kept  entirely  motionless. 

When  the  case  is  old,  and  there  are  grounds  for  be- 
lieving that  a preternatural  articulation  or  fibrous  liga- 
mentous connexion  has  taken  place,  we  are  advised  to 
cut  down  to  the  ends  of  the  bone,  rasp  or  saw  them  off, 
and  then  treat  the  limb  just  as  if  the  case  were  a recent 
compound  fracture. 

This  bold  practice  was  first  suggested  by  Mr.  C. 
White.  “ Robert  Elliot,  of  Eyham,  in  Derbyshire,  a 
very  healthful  boy,  nine  years  old,  had  the  misfortune, 
about  midsummer  in  the  year  1759,  by  a fall  to  fracture 
the  humerus,  near  the  middle  of  the  bone.  He  was 
immediately  taken  to  a bone-setter  in  that  neighbour- 
hood, who  applied  a bandage  ^nd  splints  to  his  arm, 
and  treated  him  as  properly,”  says  Mr.  White,  “ as  I 
suppose  he  was  capable  of,  for  two  or  three  months. 
His  endeavours,  however,  were  by  no  means  produc- 
tive of  the  desired  effect,  the  bones  not  being  at  all 
united.  A surgeon  of  eminence  in  Bakewell  was  af- 
terward called  in ; but  as  he  soon  found  he  could  be 
of  no  service  to  him,  and  as  the  case  was  very  curious, 
he  advised  the  lad’s  friends  to  send  him  to  the  Infirmary 
at  Manchester.  He  was  accordingly  brought  thither 
the  Christmas  following,  and  admitted  an  in-patient. 
Upon  examination,  we  found  nt  to  be  a simple  oblique 
fracture,  and  that  the  ends  of  the  bone  rode  over  each 
other : his  arm  was  become  not  only  entirely  useless, 
but  even  a burden  to  him,  and  not  likely  to  be  otherwise 
as  there  was  little  probability  that  it  could  ever  unite, 
it  being  now  six  months  since  the  accident  happened. 

Amputation  was  therefore  proposed  as  the  only  me- 
thod of  relief : but  I could  not  give  my  consent  to  it, 
for  as  the  boy  was  young  and  had  a good  constitution, 
it  was  hardly  possible  that  it  could  be  owing  to  any 
fault  in  the  solids  or  fluids,  but  that  either  nature  was 
disappointed  in  her  work  by  frequent  friction  while 
the  callus  was  forming,  or  rather,  that  the  oblique  ends 
of  the  bone,  being  sharp,  had  divided  a part  of  a mus- 
cle, and  some  portion  of  it  had  probably  insinuated 
itself  between  the  two  ends  of  the  bone,  preventing  their 
union.  Whichever  of  these  might  be  the  case,  I was  of 
opinion,”  continues  Mr.  White,  “ that  he  might  be  re- 
lieved by  the  following  operation,  viz.  by  making  a 
longitudinal  incision  down  to  the  bone,  by  bringing  out 
one  of  the  ends  of  it,  which  might  be  done  with  great 
ease,  as  the  arm  was  flexible,  and  cutting  it  off  either  by 
the  saw  or  cutting  pincers ; then  by  bringing  out  the 
other,  and  cutting  off  that  likewise,  and  afterward  by 
replacing  them  end  to  end,  and  treating  the  whole  as  a 
compound  fracture. 

The  objections  made  by  the  other  gentlemen  con- 
cerned to  this  proposal  were,  first,  the  danger  of  wound- 
ing the  humeral  artery  by  the  knife.  Secondly,  the  la- 
ceration of  the  artery  by  bringing  out  the  ends  of  the 
bones.  And,  thirdly,  that  we  had  no  authority  for  such 
an  operation.  As  to  the  first,  that  was  easily  obviated, 
by  making  the  incision  on  the  side  of  the  arm  opposite 
to  the  humeral  artery.  The  place  of  election  appeared 
to  me  to  be  at  the  external  and  lower  edge  of  the  del- 
toid muscle,  as  the  fracture  was  very  near  to  the  inser- 
tion of  that  muscle  into  the  humerus ; the  danger  of 
wounding  the  vessel  not  only  being  by  that  means 
avoided,  but  after  the  operation,  while  the  patient  was 
confined  to  his  bed,  the  matter  would  be  prevented  from 
lodging,  and  the  wound  be  easily  come  at,  to  renew  the 
dressings.  The  second  objection  will  not  appear  to 
be  very  great,  when  we  consider  that  in  compound 
fractures  the  bone  is  frequently  thrust  with  great  vio- 
lence through  the  integuments,  and  seldom  attended 
with  laceration  of  any  considerable  artery ; and  as 
this  would  be  done  with  great  caution,  that  danger 
would  appear  very  trifling.  The  third  and  last  objec- 
tion is  no  more  than  a general  one  to  all  improvements. 

This  method  which  I have  been  proposing,”  says 
Mr.  White,  “ was  at  last  resolved  upon,  and  I assisted 
in  the  operation,  which  was  performed  by  a gentleman 
of  great  abilities  in  his  profession,  on  January  3d,  in  the 
present  year  (1760).  The  patient  did  not  lose  above  a 
spoonful  of  blood  in  the  operation,  though  the  tourni- 
quet was  not  made  u.se  of.  When  the  operation  and 
dressings  were  finished,  the  limb  was  placed  in  a frac- 
ture-box, contrived  on  purpose,  the  lad  confined  to  his 
bed,  and  the  re.st  of  the  treatment  was  nothing  different 
from  that  of  a compound  fracture. 


The  wound  was  nearly  healed  in  a fortnight’s  time, 
when  an  erysipelas  came  on,  and  spread  itself  all  over 
the  arm,  attended  with  some  degree  of  swelling;  this,  by 
fomentations  and  the  antiphlogistic  method,  soon  went 
off,  and  the  cure,  proceeded  happily,  without  any 
other  interruption.  In  about  six  weeks  after  the  opera- 
tion the  callus  began  to  form,  and  is  now  quite  firm. 
The  arm  is  as  long  as  the  other,  but  somewhat  smaller, 
in  consequence  of  such  long-continued  bandages : he 
daily  acquires  strength  in  it,  and  will  soon  be  fit  to  be 
discharged.” — (Cases  in  Surgery,  p.  69,  (5-c.) 

In  another  instance  of  a broken  tibia,  which  con- 
tinued disunited  an  extraordinary  length  of  time,  Mr 
White^practised  an  operation  somewhat  similar  to  the 
foregoing  one,  with  complete  success.  He  made  a lon- 
gitudinal incision,  about  four  inches  in  length,  through 
the  integuments  which  covered  the  fracture.  By  the 
application  of  a trephine,  he  cut  off  the  upper  end  of  the 
bone,  and  as  the  lower  end  could  not  be  easily  sawed 
off,  he  contented  himself  with  scraping  it.  In  the 
course  of  the  subsequent  treatment  he  had  occasion  to 
take  off,  with  the  cutting  pincers,  a small  angle  of  tibia, 
and  to  touch  the  lower  part  of  the  bone  with  the  butter 
of  antimony,  as  well  as  to  introduce  the  same  caustic 
between  the  extremities  of  the  fracture,  in  order  to  de- 
stroy a substance  which  intervened.  • A trifling  exfo- 
liation followed.  In  twelve  weeks  the  bone  was  firmly 
united.— (Op.  cit.  p.  81, 82.) 

Besides  Mr.  White’^  cases,  there  are  now  some  other 
instances  upon  record  where  the  operation  which  he 
first  proposed  has  succeeded.  In  the  year  1813  Lan- 
genbeck  operated  upon  a humerus  in  the  foregoing  man- 
ner, and  the  result  was  perfectly  successful.  The  un- 
united fracture  was  situated  at  the  insertion  of  the 
deltoid. — (Neue  Bibl.  b.  1,  p.  95.)  Mr.  Rowlands,  of 
Chester,  by  a similar  operation,  cured  a fractured  thigh, 
which  had  lost  all  disposition  to  unite. — (See  Med. 
Chir.  Trans,  vol.  2,  p.  47.)  Viguerie,  surgeon  to  the 
Hotel-Dieu,  at  Toulouse,  has  also  practised  Mr.  White’s 
operation  with  success. — (See  Larrey,  M^m.  de  Chir. 
Militaire,t.2,p.  132.) 

On  the  other  hand,  the  operation  has  frequently 
failed.  In  the  instance  in  which  I saw  it  executed  on 
the  humerus  by  Mr.  Long,  in  St.  Bartholomew’s  Hos- 
pital, it  did  not  answer,  though  the  ends  of  the  bone 
were  most  fairly  sawed  off,  and  the  case  treated  with 
particular  care  and  skill.  Boyer  states  that  he  once 
performed  the  same  operation  in  a similar  case  ; but 
that  it  had  not  the  desired  effect. — (TraiU  des  Mai. 
Chir.  t.  3,  p.  110.)  Dr.  Physick,  of  New-York,  when  he 
was  a student  in  1785,  saw  this  proceeding  unsuccess- 
fully adopted  in  a case  where  the  humerus  remained 
disunited.— <See  Medical  Repository,  vol.  1,  New-York, 
1804.)  Besides  these  examples,  I have  heard  of  others, 
in  which  Mr.  Cline,  Mr.  Green  (Med.  Chir.  Review,  Feb 
1828 ; and  Lond.  Med.  Gazette  p.  357),  and  other  prac- 
titioners, have  tried  the  experiment  with  no  better  suc- 
cess. What  is  still  more  discouraging,  the  operation 
has  sometimes  proved  fatal.— (RtcAerand,  Nosogr.  Chir. 
t.  3,  p.  39,  ed.  2.  Larrey,  Mem.  de  Chirurgie  Mili- 
taire,  t.  2,  p.  132.) 

The  difficulties,  the  danger,  and  the  frequent  ill  suc- 
cess of  the  foregoing  operation,  rendered  another  mode 
of  treatment  extremely  desirable,  when  Dr.  Physick,  of 
New-York,  suggested  the  plan  of  introducing  a seton 
through  the  preternatural  joint,  with  a view  of  exciting 
inflammation,  and  bringing  about  a union  of  the  bone. 
This  suggestion  promises  to  be  a considerable  improve- 
ment in  modern  surgery.  Dr.  Physick  had  an  oppor- 
tunity of  performing  the  new  operation  on  the  18th  De- 
cember, 1802,  in  an  example  of  disunited  humerus, 
twenty  months  after  the  occurrence  of  the  accident. 
“Before  passing  the  needle  (says  Dr.  Physick),  I de- 
sired the  assistants  to  make  some  extension  of  the  arm, 
in  order  that  the  seton  might  be  introduced,  as  much  as 
possible,  between  the  ends  of  the  bone.  Some  lint  and 
a pledget  were  applied  to  the  orifices  made  by  theseton- 
needle,  and  secured  by  a roller.  The  patient  suffered 
very  little  pain  from  the  operation.  After  a few  days 
the  inflammation  (which  was  not  greater  than  what  is 
commonly  excited  by  a similar  operation  through  the 
flesh  of  any  other  part)  was  succeeded  by  a moderate 
suppuration.  The  arm  was  now  again  extended,  and 
splints  applied.  The  dressings  were  renewed  daily  for 
twelve  wrecks,  during  which  time  no  amendment  was 
perceived  ; but  soon  afterward  the  bending  of  the  arm 
at  the  fracture  was  observed  not  to  be  so  easy  as  it  hud 


392 


FRACTURES. 


been,  and  the  patient  complained  of  mncli  more  pain 
than  usual,  whenever  an  attempt  was  made  to  bend  it 
at  that  place.  From  this  time  the  formation  of  the  new 
bony  union  went  on  rapidly,  and  on  the  4th  of  May, 
1803,  was  so  perfectly  completed,  that  the  patient  could 
move  his  arm  jn  all  directions  as  well  as  before  the  ac- 
cident happened.  The  seton  was  now  removed,  and  the 
small  sores  occasioned  by  it  healed  up  entirely  in  a few 
days.  On  the  28th  of  May,  1803,  he  was  discharged 
from  the  hospital  perfectly  well,  and  he  has  since  re- 
peatedly told  me  his  arm  is  as  strong  as  ever  it  was.”— 
(Physick,  in  Medical  Repository,  vol.  1,  New-  York.)  In 
the  London  Medical  Repository  for  Aug.  1823,  a case  is 
also  noticed,  in  which  Dr.  Physick  cured  an  ununited 
IVacture  of  the  lower  jaw  by  means  of  a seton. 

On  this  subject  an  interesting  memoir  was  read  by 
Laroche  to  the  Ecole  de  M^decine  at  Paris  {Germinal, 
an  13).  It  was  entitled  “ Dissertation  sur  la  non-re- 
union de  quelques  fractures,  et  en  particulier  de  celles 
du  bras,  et  sur  un  moyen  nouveau  de  guerir  les  fau- 
ses  articulations  qui  en  resultent."  The  author  of  this 
production  affirms,  that  when  he  was  at  Augsburg,  he 
saw  Baron  Percy,  then  with  the  army  of  the  Rhine, 
pass  a seton  through  the  imperfectly  healed  cicatrix 
of  a compound  fracture  of  the  thigh,  which  fracture 
seemed  to  have ‘lost  all  disposition  to  unite.  The  me- 
thod answered  so  well,  that  in  two  months  the  patient 
was  able  to  walk  without  crutches. 

Mr.  Brodie  has  also  successfully  employed  the  seton 
in  a case  of  ununited  broken  thigh.  The  patient  was  a 
boy  about  13.— (See  Med.  Chir.  Trans,  vol.  5,p.  387,  dS  c.) 
In  this  country  the  same  operation  has  been  practised 
for  the  cure  of  a disunited  humerus  by  Mr.  Stansfield, 
of  Leeds. — (See  op.  cit.  vol.  1,  p.  103,  &-c.)  It  appears, 
also,  that  Mr.  Charles  Bell  applied  the  method  to  a 
fracture  of  the  leg,  at  the  time  when  Roux  w^as  in 
England.  The  patient  was  a child  six  years  old,  and 
the  broken  bones  had  continued  without  union  three 
years.  The  case  had  been  originally  mistaken  by  some 
unskilful  surgeon  for  a mere  contusion.  Roux  knew 
not  whether  the  operation  succeeded  or  not.— (ParaZ- 
lile  de  la  Chir.  Angloise,  cS  c.  p.  195.) 

We  are  not  to  expect,  however,  that  Dr.  Physick’s  new 
operation  will  succeed  in  every  instance.  Like  most  other 
surgical  means,  it  is  liable  to  occasional  failures,  among 
which,  I believe,  we  must  include  the  attempt  made  on  a 
disunited  thigh  by  Mr.  Wardrop  (see  Med.  Chir.  Trans, 
voi.  5,  p.'365),  though  a partial  amendment  is  men- 
tioned. In  a case  recorded  by  Mr.  Amesbury,  the  seton 
did  not  answer.  Mr.  Hutchison  was  also  obliged  to  take 
out  the  seton  in  a case  of  ununited  humerus,  and  no  cure 
was  effected.— (See  Practical  Obs.p.  162.)  Three  in- 
stances of  failure  were  seen  by  Mr.  Amesbury  {On  Frac- 
tures, p.  224),  and  an  additional  one  has  been  recorded 
by  Mr.  Earle.— (See  Med.  Chir.  Trans,  vol.  12,  p.  195.) 

In  the  same  case,  and  also  in  another  which  I saw 
under  this  gentleman’s  care,  the  plan  of  cutting  down 
to  the  ends  of  the  fracture,  and  rubbing  them  with  caus- 
tic potassa  was  tried,  but  without  success. 

Instead  of  several  of  the  foregoing  severe  and  often 
unsuccessful  plans,  Mr.  Amesbury  has  tried,  with 
much  encouragement,  the  influence  of  local  pressure 
and  rest.  He  maintains  the  ends  of  the  fracture  closely 
pressed  together,  the  pressure,  when  the  fracture  is 
transverse,  operating  longitudinally,  and  when  oblique, 
transversely.  A short  sling,  pads,  and  a particular  ap- 
paratus are  used  accordingly. — {On  Fractures,  p.  236.) 
Mr.  Buchanan,  of  Hull,  has  related  two  cases,  in  which 
a union  of  the  fractures  followed  a perseverance  in 
the  application  of  tincture  of.  iodine.— (Cbi  Diseased 
Joints,  p.  75.) 

[This  tribute  to  the  ingenuity  and  skill  of  our  coun- 
tryman, Dr.  Physick,  is  without  doubt  well  merited ; 
for  the  use  of  the  seton  in  cases  of  artificial  joint  has 
found  advocates  in  almost  every  country,  and  been  at- 
tended with  great  utility  and  success.  Its  occasional  fail- 
ure, however,  has  led  to  the  trial  of  local  pressure  by  Mr. 
Amesbury  ; and  in  the  London  Med.  and  Phys.  Journal 
for  J827,  Mr.  Brodie  has  recorded  an  instance  of  the  suc- 
cess of  this  practice,  after  the  failure  of  the  seton.  Dr. 
Thos.  H.  Wright,  of  Baltimore,  and  Dr.  Webster,  of 
Philadelphia,  have  each  reported  successful  cases  of 
Mr.  Amesbury’s  treatment  of  ununited  fracture,  and 
pressure  seems  to  promise  to  take  the  place  of  the  seton 
in  this  country  among  surgeons  generally.  Dr.  Wright’s 
ca.scs  may  be  found  in  the  Am.  Journal  of  the  Med. 
Scimcesfor  1828.— ivee.ve.] 


fractures  of  the  ossa  NA.S1. 

These  bones,  from  their  situation,  are  much  exposed 
to  fractures.  The  fragments  are  sometimes  not  de- 
ranged ; but  most  frequently  they  are  depressed.  In 
order  to  replace  them  the  surgeon  must  pass  a fe- 
male catheter,  a ring-handled  forceps,  or  any  such  in- 
strument into  the  nostrils,  and  using  it  as  a lever,  push 
the  fragments  outwards  ; while,  with  the  index  finger 
of  the  left  hand,  he  prevents  them  from  being  pushed  out 
too  far.  When  the  fragments  are  disposed  to  fall  in- 
wards apin,  some  authors  ddvise  supporting  them  with 
an  elastic  gum  cannula,  or  lint,  introduced  into  the  nos- 
tril ; but  I am  inclined  to  believe,  with  Mr.  C.  Bell,  that 
no  tubes  can  be  employed  so  as  to  support  the  broken 
bones;  and  when  these  have  been  replaced,  they  w'ill 
not  readily  change  their  position,  as  they  are  acted 
upon  by  no  muscles. — (See  Operative  Surgery,  t.  2,  p. 
222.) 

Besides,  as  Delpech  remarks,  since  the  tubes  cannot 
reach  the  fragments,  they  cannot  support  them,  and 
they  must  be  attended  with  all  the  inconvenience  of  th- 
reign  bodies  placed  in  contact  with  parts  already  in- 
flamed, or  about  to  become  so. — {Precis  des  Mai.  Chir. 
t.\,p.  222.) 

As  fractures  of  the  ossa  nasi  are  the  result  of  falls, 
and  direct  blows  on  the  face,  the  soft  parte  are  always 
either  very  much  contused  or  wounded. 

Fractures  of  the  ossa'  nasi  are  sometimes  attended 
with  very  dangerous  symptoms  ; depending  either  upon 
the  concussion  of  the  brain,  produced  by  the  same  blow 
which  causes  the  fracture,  or  on  the  cribriform  lamella 
and  the  crista  galli  of  the  os  ethmoides  being  driven  in- 
wards, so  as  to  injure  and  compress  the  brain.  This 
last  danger,  however,  some  modern  surgeons  consider 
as  void  of  foundation ; and  whenever  the  symptoms  in- 
dicate an  affection  of  the  brain,  the  nature  of  the  case  is 
referred  to  the  intimate  connexion  between  the  bones 
of  the  nose  and  the  os  frontis. — {Delpech,  Precis  des 
Mai.  Chir.  t.  l,p.  221, 8vo.  Paris,  1816.) 

When  there  are  syn^ptoms  of  pressure  on  the  brain 
(see  Head,  Injuries  of),  and  the  ossa  nasi  are  much  de 
pressed,  the  surgeon  must  immediately  raise  them,  and 
endeavour  to  draw  gently  forwards  the  perpendicular 
process  of  the  os  ethmoides,  which  is  connected  with 
the  cribriform  lamella  and  crista  galli.  Perhaps  a pair 
of  closed  common  forceps,  introduced  into  each  nostril, 
might  best  enable  the  surgeon  to  do  what  is  necessary. 
Bleeding  and  the  antiphlogistic  treatment  are  always 
proper : for  the  vicinity  of  the  eye  renders  it  liable  to 
become  inflamed  ; and  when  there  are  symptoms  of  in- 
jury of  the  brain,  extravasation,  &c.,  the  necessity  of 
such  practice  is  still  more  strongly  indicated. 

FRACTURES  OF  THE  LOWER  JAW^ 

This  bone  is  sometimes  fractured  near  the  cliin  ; but 
seldom  so  as  to  produce  a division  of  the  symphysis,  the 
solution  of  continuity  generally  happening  between  this 
part  and  the  insertion  of  the  masseter.  In  other  in- 
stances the  fracture  occurs  near  the  angles  of  the  jaw, 
that  is  to  say,  between  the  insertion  of  the  masseter  and 
the  root  of  the  coronoid  process.  The  bone  may  also 
be  broken  in  two  places  at  the  same  time ; in  which 
event  the  middle  portion  is  extremely  difficult  to  keep 
right,  because  many  of  the  muscles  which  draw  the 
lower  jaw  downwards  are  attached  to  that  part. 

The  condyles  and  coronoid  j/roeesses  are  also  some- 
times broken  ; the  former  the  most  frequently. 

Fractures  of  the  lower  jaw  may  be  either  perj)endi- 
cular  to  its  basis,  oblique,  or  longitudinal:  of  the  latter, 
examples  have  been  known  in  which  a portion  of  the  al- 
veolar process,  with  the  teeth  in  it,  was  detached  from 
the  rest  of  the  bone. 

The  soft  parts  are  generally  contused  and  wounded. 
J.  L.  Petit  mentions  one  case  in  which  the  bone  was 
broken,  and  the  coronoid  process  quite  denuded,  by  the 
kick  of  a horse. 

Fractures  of  the  lower  jaw  are  subject  to  displace- 
ment in  the  following  way.  When  the  fracture  is  near 
the  symphysis,  the  side  on  which  the  processus  inno- 
minatus  is  situated  is  drawn  downwards  and  back- 
wards by  the  sub-maxillary  muscles,  while  the  other 
fragment  is  siijtported  by  the  muscles  which  close  the 
jaw.  When  the  fracture  is  more  backwards,  the 
displacement  occurs  in  the  same  way,  but  not  so  easily 
When  the  bone  is  fractured  in  two  places,  the  middle 
portion  is  always  pulled  downwards  and  backwards 
by  the  muscles  attached  to  the  chin,  while  the  two 


FRACTURES. 


393 


lateral  pieces  are  kept  up  by  the  levator  muscles. 
When  the  ramus  of  the  jaw  is  broken,  the  masseter, 
being  attached  to  both  pieces,  prevents  any  considera- 
ble degree  of  displacement.  When  the  neck  of  the 
condyle  is  fractured,  the  pterygoideus  externus  may 
pull  the  condyle  forwards. 

When  a blow  is  received  on  the  lower  jaw,  or  the 
bone  is  injured  by  a fall,  or  by  the  pressure  of  some 
heavy  body  ; when  an  acute  pain  is  experienced  in  the 
part,  and  an  inequality  can  be  felt  at  the  basis  of  the 
bone ; when  some  of  the  teeth,  corre.sponding  to  that 
inequality,  are  lower  than  the  others ; and  when  a cre- 
pitus is  perceptible  on  moving  the  two  pieces  of  the 
jaw  on  each  other ; there  can  be  no  doubt  of  a fracture. 
When  the  gums  are  lacerated,  or  the  bone  denuded  by 
a wound,  the  case  is  (if  possible)  still  more  manifest. 

Fractures  of  the  rami  and  condyles  produce  great 
pain  near  the  ear,  particularly  when  the  jaw  is  moved; 
and  a crepitus  may  also  be  felt. 

Fractures  of  the  lower  jaw,  whether  simple  or  dou- 
ble, are  easily  set  by  pushing  the  displaced  part  up- 
wards and  a little  forwards,  and  then  pressing  on  the 
basis  of  the  bone,  so  as  to  bring  it  exactly  on  a level 
with  the  portion  which  has  preserved  its  natural  posi- 
tion. Indeed,  the  correctness  of  the  reduction  can  al- 
ways be  rightly  judged  of  by  attending  to  the  line  which 
the  base  of  the  jaw  ought  to  form,  and  observing  that 
the  arch  of  the  teeth  is  as  regular  as  nature  will  allow. 
The  maintenance  of  the  reduction,  however,  is  diihcult ; 
and  can  only  be  well  executed  by  supporting  the  lower 
jaw,  and  keeping  it  applied  to  the  upper  one.  As  the 
latter  indication  cannot  be  properly  fulfilled  in  persons 
whose  teeth  are  very  irregular,  it  is  sometimes  neces- 
sary to  interpose  an  even  piece  of  cork  between  the 
teeth  on  each  side  of  the  mouth,  and  against  this  cork 
the  lower  jaw  is  to  be  kept  up  with  the  bandage  pre- 
sently noticed,  while  the  aperture  left  between  the  in- 
cisores  in  the  situation  where  no  cork  is  placed,  allows 
food  and  medicines  to  be  introduced  with  a small  spoon. 

As  soon  as  the  fracture  is  set,  the  surgeon  should 
adapt  some  thick  pasteboard,  previously  wet  and  soft- 
ened with  vinegar,  to  the  outside  of  the  jaw,  both  along 
its  side  and  under  its  basis.  Over  this  moistened  paste- 
board, a bandage  with  four  tails  is  to  be  applied,  the 
centre  being  placed  on  the  patient’s  chin,  while  the  two 
posterior  tails  are  to  be  pinned  to  the  front  part  of  a 
nightcap,  and  the  two  anterior  ones  fastened  to  a part 
of  the  same  cap  more  backwards.*  When  the  paste- 
board becomes  dry,  it  forms  the  most  convenient  appa- 
ratus imaginable  for  surrounding  and  supporting  the 
fracture.  A piece  of  soap-plaster  may  now  be  applied 
to  the  skin  underneath,  which  will  prevent  any  ill  effects 
of  the  hardness  and  pressure  of  the  jjasteboard. 

Until  the  bone  is  firmly  united,  the  patient  should  be 
allowed  only  such  food  as  does  not  require  mastication, 
and  it  may  be  given  by  means  of  a small  spoon  intro- 
duced between  the  teeth.  Broths,  soups,  jellies,  tea, 
and  other  slops  appear  most  eligible. 

In  order  to  keep  the  middle  portion  of  the  bone  from 
being  drawn  downwards  and  backwards  towards  the 
larynx,  it  is  frequently  necessary  to  apply  tolerably 
thick  compresses  ju.st  under  and  behind  the  chin ; 
which  are  to  be  well  supported  by  the  bandage  already 
described. 

I need  hardly  state  the  necessity  of  enjoining  the  pa- 
tient to  avoid  talking,  or  moving  the  jaw  more  than  can 
possibly  be  avoided. 

When  the  condyle  is  fractured,  as  it  is  incessantly 


* [Dr.  J.  Rhea  Barton,  of  Philadelphia,  to  whose 
science  and  skill  I have  had  frequent  occasion  to  allude, 
has  devised  a bandage  for  fractures  of  the  jaw,  tb  which 
a preference  is  now  generally  given  in  this  country,  as 
well  for  its  superiority  in  retaining  the  fragments  in  a 
state  of  coaptation,as  for  the  facility  it  affords  in  securing 
the  dressings  occasionally  applied  to  wounds  of  the  face 
and  chin.  He  commences  with  “ a roller  an  inch  and 
a half  wide  just  below  the  prominence  in  the  occipitis, 
and  continues  it  obliquely  over  the  centre  of  the  parie- 
tal bone  across  the  juncture  of  the  coronal  and  sagittal 
sutures,  over  the  zygomatic  arch,  under  the  chin,  and 
pursuing  the  same  direction  on  the  opposite  side,  until 
he  arrives  at  the  back  of  the  head  ; he  then  pas.ses  it 
obliiiuely  around  and  parallel  to  the  base  of  the  lower 
jaw  over  the  chin  ; and  continues  the  same  course  on 
tiie  other  side  until  it  etuis  where  he  commenced,  and 
repeats.”— Reese.] 


drawn  forwards  by  the  action  of  the  pterygoideus  ex- 
ternns,  and  on  account  of  its  deep  situation  cannot  be 
pressed  back,  the  lower  portion  must,  if  possible,  be 
pushed  into  contact  with  it.  For  this  purpose  the 
bandage  n»ust  be  nrade  to  operate  particularly  on  the 
angle  of  the  jaw,  where  a tliick  compress  should  be 
placed. 

Compound  fractures  of  the  lower  jaw  are  to  be  treated 
on  the  same  principles  as  similar  injuries  of  other  bones. 
If  possible,  the  external  wound  should  be  healed  by  the 
first  intention  ; and  when  this  attempt  fails,  care  must 
be  taken  to  keep  the  wound  clean  by  changing  the 
dressings  about  once  in  three  days ; but  not  oftener, 
lest  the  fracture  suffer  too  much  disturbance.  It  is  ob- 
served that  compound  fractures  of  the  jaw,  and  even 
simple  ones,  which  are  followed  by  abscesses,  are  par- 
ticularly liable  to  be  succeeded  by  troublesome  and 
tedious  exfoliations. 

In  very  bad  fractures,  in  w'hich  all  motion  of  the 
jaw  must  have  the  most  pernicious  effect,  I consider  it 
prudent  to  administer  every  kind  of  nourishment  in  a 
fluid  form  through  an  elastic  gum  catheter,  introduced 
through  one  of  the  nostrils  down  the  oesophagus. 

It  now  and  then  happens  that  fractures  of  the  lower 
jaw  continue  ununited  ; Dr.  Physick’s  successful  treat- 
ment of  one  such  case  with  a seton  I have  8)read> 
noticed. 

FRACTURES  OF  THE  VERTEBRA. 

On  account  of  the  shortness  and  thickness  of  these 
bones,  they  cannot  be  broken  without  considerable  vio- 
lence. The  spinous  processes  which  project  back- 
wards are  the  most  exposed  to  such  injury  ; for  they 
are  the  ;6veakest  parts  of  the  vertebrje,  and  most  super- 
ficially situated.  On  this  account  it  is  possible  for 
them  to  be  broken  without  any  mischief  being  done  to 
the  spinal  marrow.  The  violence,  which  is  great  enough 
to  break  the  bodies  of  the  vertebrae,  must  produce  a 
gre.ater  or  less  concussion  or  other  mischief  of  the  spi- 
ral marrow  ; from  which  accident  much  more  perilous 
consequences  are  to  he  apprehended  than  from  the  in- 
jury of  the  bones  abstractedly  considered.  The  dis- 
placed pieces  of  bone  may  press  on  the  spinal  marrow, 
or  even  wound  it,  so  as  to  occasion  a paralytic  affection 
of  all  the  parts  which  derive  their  nerves  from  the  con- 
tinuation of  this  substance  below  the  fracture. 

Sir  Astley  Cooper  divides  fractures  of  the  bodies  of 
the  vertebrae  with  displacement  into  two  classes ; first, 
those  which  occur  above  the  third  cervical  vertebra ; 
and,  secondly,  others  which  happen  below  that  bone. 
The  first  cases,  he  says,  are  almost  always  imme- 
diately fatal,  if  the  displacement  be  to  the  usual  extent. 
In  the  second  description  of  cases,  death  takes  place  at 
various  periods  after  the  injury.  The  reason  of  this 
difference  is  ascribed  to  the  circumstance  of  the  phrenic 
nerve  originating  from  the  third  and  fourth  cervical 
pairs,  whence  in  the  first  class  of  cases  death  is  imme- 
diately produced  by  paralysis  of  the  diaphragm,  and  the 
stoppage  of  respiration.— (On  Dislocations, 552.) 

As  the  mere  concussion  of  the  spine  may  occasion 
symptoms  v/hich  very  much  resemble  those  usually 
occurring  when  the  vertebrae  are  fractured,  the  diagno- 
sis is  generally  obscure.  An  inequality  in  the  line  of 
the  spinous  processes  and  a crepitus  may  sometimes 
be  distinctly  felt.  The  lower  extremities,  the  rectum, 
and  bladder  are  generally  paralytic ; the  patient  is  af- 
flicted with  retention  of  urine  and  feces,  or  with  an  in- 
voluntary discharge  of  the  latter.— (Boj/er.) 

If  the  lumbar  vertebrae  be  di.splaced,  the  lower  ex- 
tremities are  rendered  so  completely  insensible,  that 
they  may  be  pinched,  burnt,  or  blistered  without  the 
patient  suffering  any  pain.  The  penis  in  such  cases 
is  generally  erect.  In  general,  also,  according  to  Sir 
Astley  Cooper’s  observations,  patients  with  fractured 
lumbar  vertebrae  die  within  a month  or  six  weeks ; 
but  he  knew  of  one  patient  that  lived  two  years,  and 
then  died  of  gangrene  of  the  nates.  In  fractures  and 
displacement  of  the  dorsal  vertebrae,  the  symptoms  are 
very  similar ; but  the  paralysis  extends  higher,  and  the 
abdomen  becomes  excessively  inflated.  Death  com- 
monly follows  in  two  or  three  weeks  ; but  Sir  Astley 
Cooper  remembers  one  case,  in  which  a gentleman  sur- 
vived the  accident  nine  months.  Fractures  of  the  cer- 
vical vertebrae,  below  the  origin  of  the  j)hrenic  nerve, 
occasion  paralysis  of  the  arms,  tliough  it  is  seldom 
com})lete.  Soirietiirics,  when  the  fracture  is  oblique, 
one  arm  is  more  affected  than  the  other.  As  the  inter- 


394 


FRACTURES. 


costal  muscles  are  paraljtic,  great  difficulty  of  respira- 
tion prevails.  The  abdomen  is  also  considerably  in- 
flated. Death  generally  follows  in  from  three  to  seven 
days. 

Sir  Astley  Cooper  notices  the  following  as  the  ap- 
pearances found  in  the  dissection  of  such  cases.  The 
spinous  process  of  the  displaced  vertebra  is  depressed ; 
the  articular  processes  are  fractured ; the  body  of  the 
vertebra  is  broken  through,  the  separation  rarely  hap- 
pening in  the  intervertebral  substance.  The  body  of 
the  vertebra  usually  projects  forwards  half  an  inch  or 
an  inch.  Between  the  vertebra  and  the  sheath  of  the 
spinal  marrow  blood  is  extravasated,  and  frequently  on 
the  lower  part  itself.  When  the  displacement  is  slight, 
the  spinal  marrow  is  compressed  and  bruised.  When 
greater,  it  is  torn  by  the  bony  arch  of  the  spinous  pro- 
cesses, and  a bulb  is  formed  at  each  end,  but  the  dura 
mater  continues  whole. — (See  A.  Cooper  on  Disloca- 
tionsy^  c.  p.  554,  i-c.) 

Fractures  of  the  spinous  processes  without  other  se- 
rious mischief  are  not  dangerous,  and  are  the  only 
instances  of  fractures  of  the  vertebrae  which  admit  of 
being  detected  with  certainty. 

Any  attempt  to  set  fractures  of  the  bodies  of  the  ver- 
tebrae, even  were  they  known  to  exist,  would  be  both 
useless  and  dangerous.  General  treatment  can  alone 
be  employed.  Cupping  will  tend  to  prevent  inflamma- 
tion in  the  situation  of  the  injury.  When  the  patient 
is  affected  with  a flatulent  distention  of  the  abdomen, 
vomiting,  liiccough,  &,e.,  the  belly  may  be  rubbed  with 
camphorated  liniment,  and  purgative  clysters  and  anti- 
spasraodics  given.  If  requisite,  the  urine  must  be 
drawn  off  with  a catheter.  When  the  bladder,  rectum, 
and  lower  extremities  are  paralytic,  it  is  conunon  to  rub 
the  back,  loins,  sacrum,  and  limbs  with  liniments  con- 
taining the  tinctura  lytts. — {Boyer.)  With  respect  to 
the  external  and  internal  use  of  stimulants,  however, 
it  can  never  be  judicious,  when  there  is  reason  to  appre- 
hend much  inflammation  of  the  injured  parts ; and  as 
for  the  idea  of  thus  restoring  the  nervous  influence, 
there  can  be  little  chance  of  success,  the  cause  of  its 
interruption  being  here  of  a mechanical  nature. — {Del- 
pech,  Mai.  Chir.  t.  1,  p.  222.) 

Some  authors  recommend  trepanning,  or  cutting  out 
a portion  of  the  fractured  bone,  when  the  compression 
of  the  spinal  marrow  or  its  injury  by  a splinter  is  sus- 
pected ; but,  according  to  my  judgment,  the  indication 
can  never  be  sufficiently  clear  to  authorize  the  opera- 
tion, which,  on  account  of  the  great  depth  of  the  inter- 
vening soft  parts,  must  be  very  tedious,  and  even  diffi-  , 
cult  to  effect  without  a great  risk  of  increasing  the 
injury  which  the  spinal  marrow  may  already  have 
received.  An  unsuccessful  operation  of  this  kind  was 
once  performed  by  Mr.  H.  Cline,  and  another  by  Mr. 
TyrreU. 

Some  cases,  published  by  Mr.  C.  Bell,  tend  to  prove 
that  the  danger  to  be  apprehended  from  injuries  of  the 
vertebrae  is  the  same  as  that  which  accompanies  inju- 
ries of  the  brain.  Hence,  he  joins  the  generality  of 
practitioners  in  recommending  general  and  local  bleed- 
ing, and  keeping  the  patient  perfectly  quiet.  And,  with 
respect  to  operations  for  the  removal  of  fragments  of 
bone,  it  is  his  decided  belief  that  an  incision  through 
the  skin  and  muscles  covering  the  spine,  and  the  with- 
drawing of  a portion  of  the  circle  of  bone  which  sur- 
rounds the  marrow  would  be  inevitably  fatal,  the  mem- 
branes of  that  part  being  particularly  susceptible  of 
inflammation  and  suppuration.  And  even  if  a sharp 
spi'-ula  of  fracturgd  bone  had  run  into  the  spinal  mar- 
row, and  caused  palsy  of  the  lower  parts  of  the  body, 
Mr.  C.  Bell  thinks  that  exposing  the  medulla  to  extract 
the  fragment  would  so  aggravate  the  mischief,  that  in- 
flammation, suppuration,  and  death  would  be  the  in- 
evitable consequences. — {Surgical  Obs.  vol.  1,  p.  157.) 
The  same  author  describes  inflammation  of  the  spinal 
marrow  as  “ attended  with  an  almost  universal  nervous 
irritation,  which  is  presently  followed  by  excitement 
of  the  brain;  in  the  mean  time,  matter  is  poured  into 
the  sheath  of  the  spinal  marrow,  and  either  by  its  pres- 
sure causing  palsy,  or  by  its  irritation  disturbing  the 
functions  of  the  part,  so  as  to  be  attended  with  the 
same  consequences.  The  excitement  of  the  brain  being 
followed  by  effusion,  death  ensues.” — (P.  1.59.)  Cases 
are  also  referred  to,  where  palsy  of  the  lower  extremi- 
ties comes  on  se-veral  moiuhs  after  an  injury  of  the 
spine,  owing  to  thickening  of  the  membrane  of  the 
medulla,  or  disease  of  the  latter  part  itself.  Here  Mr 


C.  Bell  recommends  perseverance  in  local  bleeding  and 
deep  issues. — (P.  160.) 

A fracture  of  the  processus  deniatus  proves  instantly 
fatal,  as  happened  in  the  example  mentioned  by  Sir  A. 
Cooper.— (On,  Dislocations,  <S-c.  p.  548.)  In  the  prac- 
tice of  Mr.  Cline,  a case  occurred,  in  which  a boy  with 
a fracture  of  the  atlas  lived  a year  after  the  accident.— 
{A.  Cooper,  op.  cit.  p.549.  See  also  L.  T.  Soemmering, 
Bemerkungen  uber  Verrenkung  und  Bruch  des  Ruck- 
graths,  8vo.  Berlin,  1793.  F.  A.  F.  Cuenotte,  Dis.  Med. 
Chir.  sistens  Casum  Subluxationis  Vertebrae  Dorsi 
cum  Fractura  complicatae,  postfactam  Repositionem  et 
varia  dira  Symptomata  duodecima  demum  Septimana 
funestcB.  Argent.  1761.  Case  of  Fractured  Spine,  Lan- 
cet, vol.  2,  p.  97.) 

■ FRACTURES  OF  THE  STERNUM. 

The  sternum  is  not  frequently  broken,  and  the  rea 
son  of  this  fact  is  imputed  to  the  positioii  of  this  bone, 
resting,  as  it  were,  upon  the  cartilages  of  the  ribs,  and 
also  in  some  measure  to  its  spongy  texture.  When  the 
accident  does  occur,  it  is  from  the  direct  application  of 
external  violence  to  the  injured  part ; and  hence  the 
fracture  is  always  accompanied  with  great  contusion, 
or  even  a wound  of  the  integuments,  and  more  or  less 
injury  of  the  thoracic  viscera.  As  Boyer  remarks,  the 
sternum,  in  consequence  of  the  elasticity  of  the  carti- 
lages of  the  ribs,  may  be  readily  propelled  backwards 
by  pressure  in  this  direction  ; and  the  result  is  an  ac- 
tual change  in  the  form,  and  a real  diminution  of  the 
chest.  Now,  since  this  cavity  is  always  accurately 
fllled  by  its  contents,  these  alterations  cannot  happen 
in  a considerable  and  sudden  manner,  without  a risk 
of  the  thoracic  viscera  being  contused  and  even  rup- 
tured. Thus,  when  the  sternum  has  been  fractured  by 
violent  blows  on  the  chest,  the  heart  and  lungs  have 
been  found  severely  contused,  and  sometimes  lacerated ; 
and  there  will  always  be  greater  danger  of  such  mis- 
chief, when  the  fracture  is  attended  with  depression  of 
one  or  more  of  the  fragments.  In  some  cases,  a large 
quantity  of  blood  is  effused  in  the  cellular  membrane 
of  the  anterior  mediastinum ; and,  in  others,  the  acci- 
dent is  followed  by  inflammation  and  suppuration  in 
the  same  situation,  and  necrosis  of  the  broken  part  of 
the  bone.  Since  the  lungs  are  also  liable  to  be  rup- 
tured by  the  same  force  which  causes  the  fracture,  or 
wounded  by  the  depressed  pieces  of  bone,  emphysema 
may  become  another  complication,  as  we  see  exempli- 
fied in  a case  related  by  Flajani.—^ CoZZezione  d’Osser- 
vaz.  di  Chir.  t.  3,  p.  214,  8vo.  Roma,  1802.) 

A fracture  of  the  sternum  is  rendered  obvious  by  the 
inequalities  perceptible  when  the  surface  of  the  bone  is 
examined  with  the  fingers  ; by  a depression  or  eleva- 
tion of  the  broken  pieces ; a crepitus,  and  an  unusual 
moveableness  of  the  injured  part  in  respiration.  In 
many  cases,  the  fracture  may  be  seen,  the  soft  parts 
being  torn  or  otherwise  wounded-  The  breathing  is 
difficult,  and  mostly  accompanied  with  cough,  spitting 
of  blood,  palpitations,  and  inability  to  lie  on  the  back. 
According  to  the  observations  of  Petit  and  Baldinger, 
several  of  these  latter  symptoms  may  continue,  with 
less  intensity,  a long  while  after  the  fracture  is  cured. 
—{Leveill^,  Nouvelle  Doctrine  Chir.  t.  2,  p.  243.) 

Fractures  of  the  sternum,  when  mere  solutions  cf 
continuity,  only  require  common  treatment ; viz.  a piece 
of  soap-plaster  to  the  situation  of  the  injury,  a roller 
round  the  chest,  quietude,  bleeding,  and  a low  regimen, 
with  a view  of  preventing  what  may  be  considered  as 
the  most  dangerous  consequence,  inflammation  of  the 
parts  within  the  chest. 

In  cases  attended  with  great  depression  of  the  frac- 
tured bone,  the  necessary  incisions  should  be  made,  m 
order  to  raise  with  an  elevator  the  portions  of  the  bone 
driven  inwards,  or  to  extract  with  forceps  any  loose 
splinters,  which  seem  to  be  similarly  circumstanced. 
However,  it  is  not  often  necessary  to  trephine  the  ster- 
num, either  to  raise  a depressed  jiortion  of  the  bone,  or 
to  give  vent  to  extravasated  fluid.  In  the  first  of  these 
circumstances,  I believe,  with  Mr.  C.  Bell,  that  the 
formal  application  of  the  trephine  can  never  be  right  or 
necessary,  though  the  surgeon  may  be  called  upon  to 
extract  loose  sjilinters.-^See  Operative  Surgery,  vol.  2, 
p.  218.)  Such  an  operation,  however,  may  occasionally 
be  proper  when  abscesses  form  under  the  sternum,  or 
the  bone  is  affected  with  necrosis,  and  the  natural 
separation  of  the  diseased  parts  is  likely  to  occupy  a 
considerable  time. 


FRACTURES. 


395 


Fractures  of  the  sternum  are  more  frequently  pro- 
duced by  gun-shot  violence  than  any  other  cause ; and 
in  these  cases,  there  are  generally  many  splinters  re- 
quiring extraction.  At  the  battle  of  Marengo,  the  French 
general  Champeux  received  such  a wound,  with  which 
he  lived  nearly  a month  : the  injury  was  attended  with 
so  many  splinters,  that  when  they  were  removed,  the 
pulsations  of  the  heart  were  visible  to  a considerable 
extmi—{LeveilU,  vol.  cit.  p.  244.) 

The  ensiform  cartilage,  when  ossified  in  old  subjects, 
is  liable  to  fracture.  Little  more,  however,  can  be  done 
in  such  a case,  than  relaxing  the  abdominal  muscles 
by  raising  the  thorax  and  pelvis,  and  then  applying  a 
piece  of  soap-plaster  and  a roller  over  the  part,  for  the 
purpose  of  keeping  it  steady.  When  the  blow  has  been 
violent,  the  patient  should  always  be  bled. 

FRACTURES  OF  THE  RIBS. 

These  generally  happen  near  the  greatest  convexity 
of  the  bones,  several  of  which  are  often  broken  together. 
The  first  rib  being  protected  by  the  clavicle,  and  the 
lower  ribs  being  very  flexible,  are  less  liable  to  be  frac- 
tured than  the  middle  ones. 

When  the  spicnla  of  a fractured  rib  is  beaten  in- 
wards, it  may  lacerate  the  pleura,  wound  the  lungs, 
and  cause  the  dangerous  train  of  symptoms  attendant 
on  emphysema. — (See  Emphysema.) 

A pointed  extremity  of  the  rib,  projecting  inwards, 
may  also  cause  an  extravasation  of  blood ; or  by  its 
irritation  produce  inflammation  in  the  chest.  A frac- 
ture whichv.’s  not  at  all  displaced  is  very  difficult  to 
detect,  particularly  in  fat  subjects ; and,  no  doubt,  is 
very  frequently  never  discovered.  The  surgeon  should 
place  his  hand  on  the  part  where  the  patient  seems  to 
experience  a pricking  pain  in  the  motions  of  respiration, 
or  where  the  violence  has  been  applied.  The  patient 
should  then  be  requested  to  cough,  in  which  action  the 
ribs  must  necessarily  undergo  a sudden  motion,  by 
which  a erepitus  will  often  be  rendered  perceptible. 
All  the  best  practitioners,  however,  are  in  the  habit  of 
adopting  the  same  treatment,  when  there  is  reason  to 
suspect  a rib  to  be  fractured,  as  if  this  were  actually 
known  to  be  the  case  by  the  occurrence  of  a crepitus, 
or  the  projection  of  one  end  of  the  fracture;  which, 
indeed,  in  the  instances  which  are  displaced,  makes 
the  nature  of  the  accident  sufficiently  plain. 

A broken  rib  cannot  be  displaced  either  in  the  di- 
rection of  the  diameler  of  the  bone,  or  in  that  of  its 
length.  The  ribs,  being  fixed  posteriorly  to  the  spine, 
and  anteriorly  to  the  sternum,  cannot  become  short- 
ened. Nor  can  one  of  the  broken  pieces  become  higher 
or  lower  than  the  other,  because  the  same  muscles  are 
attached  to  both  fragments,  and  keep  them  at  an  equal 
distance  from  the  neighbouring  ribs.  The  only  possible 
displacement  is  either  outwards  or  inwards. — {Boyer.) 

Simple  fractures  of  the  ribs,  free  from  urgent  symp- 
toms, require  very  simple  treatment.  The  grand  ob- 
ject is  to  keep  the  broken  bones  as  motionless  as  pos- 
sible. For  this  purpose,  after  a piece  of  soap-plaster 
has  been  applied  to  the  side,  and  over  it  proper  com- 
presses, u broad  linen  roller  is  to  be  firmly  put  round 
Ihe  chest,  so  as  to  impede  the  motion  of  the  ribs,  and 
compel  the  patient  to  perform  respiration  chiefly  by  the 
descent  and  elevation  of  the  diaphragm.  A scapulary 
v/ill  prevent  the  bandage  from  slipping  downwards. 
When  the  fractured  part  is  depressed  inwards,  the  com- 
presses should  be  placed  on  the  anterior  and  posterior 
part  of  the  bone.  As  a roller  is  apt  to  become  slack, 
many  surgeons,  with  good  reason,  prefer  a piece  of 
strong  linen,  large  enough  to  surround  the  chest,  and 
laced  with  pack-thread,  so  as  to  compress  the  ribs  in 
the  due  degree. 

When  there  is  reason,  from  the  symptoms,  to  think 
the  lungs  injured,  or  disposed  to  inflame,  copious  and 
repeated  bleedings  should  be  practised.  Indeed,  as 
perii)neumony  is  always  liable  to  succeed  the  accident, 
and  is  a most  dangerous  occurrence,  every  person  free 
from  debility,  either  having  a broken  rib,  or  supposed 
to  have  such,  should  alwa;^  be  bled  in  the  first  in- 
stance. The  spermaceti  mixture,  with  opium,  is  an 
excellent  medicine  for  appeasing  any  cough,  which 
may  disturb  the  fracture,  and  give  the  patient  infinite 
pain. 

FRACTURES  OF  THE  SACRUM. 

Although  more  superficial  than  the  other  bones  of 
the  pelvis,  the  sacrum  is  less  frequently  fractured ; a 
/act,  explicable,  as  Boyer  has  remarked,  by  its  thick- 


ness, its  spongy  texture,  and  the  advantageous  way  in 
which  it  supports  the  weight  and  efforts  of  the  whole 
trunk.  For  the  sacrum  to  be  broken,  the  violence  must 
be  very  great,  like  that  resulting  tiorn  the  fall  of  a very 
heavy  body,  or  the  passage  of  a carriage-wheel  on  the 
convex  side  of  the  bone,  or  a fall  from  a great  height 
on  that  part.  On  the  other  hand,  fractures  of  the  sa- 
crum, when  they  do  happen,  are  more  serious  than 
those  of  the  ossa  innominata,  because,  in  addition  to  the 
great  degree  of  contusion  and  laceration,  with  which 
they  in  common  with  the  latter  cases  are  complicated, 
there  is  almost  always  great  damage  done  to  the  sacral 
nerves ; a kind  of  injury  which  may  have  fatal  conse 
quences.  Hence  retention  of  urine,  inability  to  retain 
this  fluid,  involuntary  discharge  of  the  feces,  paralysis 
of  the  lower  extremities,  &;c.  Another  principal  danger 
also  depends  upon  the  injury  which  the  pelvic  viscera 
may  have  suffered  from  the  same  violence  which  broke 
the  bone. 

When  the  fracture  is  situated  at  the  upper  part  of 
the  sacrum,  which  seldom  happens  on  account  of  the 
thickness  of  the  bone  in  that  situation,  there  is  no  dis- 
placement, unless  the  bone  is  smashed,  and  the  frag- 
ments are  driven  inwards  by  the  same  force  which 
produced  the  fracture ; a case  which  always  implies 
severe  injury  of  the  external  and  internal  soft  parts. 
But  when  the  fracture  occupies  the  lower  portion  of  the 
bone,  where  it  is  less  thick,  the  inferior  fragment  may 
be  displaced  inwards,  towards  the  rectum.  And,  as 
Boyer  observes,  fractures  of  the  higher  part  of  the  bone 
are  not  in  general  easily  detected. — ( Traitc  des  Mai. 
Chir.  t.  3,  p.  152.) 

When  the  violence  has  been  such  as  to  make  it  pro- 
bable that  it  has  extended  its  effects  to  the  pelvic  vis- 
cera, every  means  in  the  power  of  art  must  be  adopted 
for  the  prevention  of  inflammation.  In  particular,  co- 
pious bleeding  should  be  practised,  and,  if  necessary, 
repeated.  Leeches  should  also  be  applied  to  the  vi- 
cinity of  the  sacrum,  and  the  parts  kept  cool  with  the 
lotio  plumbi  acetatis.  Any  difficulty,  either  in  the  ex- 
pulsion or  retention  of  the  urine  and  feces,  will  like- 
wise claim  immediate  and  constant  attention. — (See 
Urine,  Retention  of;  Incontinence  of,  Src.)  With  re 
gard  to  the  particular  means  for  promoting  the  union 
of  the  fVactured  sacrum,  quietude  is  the  most  import 
ant,  and  after  the  risk  of  inflammation  is  over,  all  that 
can  be  done  is  to  apply  a piece  of  the  emplastrum  sa- 
ponis  to  the  part,  and  put  a roller  round  the  pelvis,  or 
a T bandage. 

FRACTURES  OF  THE  OS  COCCYGIS. 

Though  much  slighter  than  the  sacrum,  it  is  less  fre- 
quently broken,  because  less  exposed  to  external  force, 
and  capable  of  a degree  of  motion,  by  which  it  eludes 
the  effect  of  violence.  But  in  elderly  persons,  in  whom 
the  different  pieces  of  the  os  coccygis  are  connected  by 
anchylosis,  a fall  on  the  buttock  may  fracture  this  bone. 
The  accident  is  known  by  the  moveableness  of  the 
fragments,  and  the  acute  pain  produced  when  the  thighs 
are  moved,  the  fragments  being  then  disturbed  by  the 
action  of  the  glutei  muscles,  some  of  whose  fibres  are 
attached  to  them. — {Boyer,  t.  3,  p.  160.) 

The  treatment  of  fractures  of  the  os  coccygis  consists 
in  enjoining  quietude,  employing  discutient  or  emollient 
applications,  according  to  the  particular  state  of  the 
soft  parts,  and  taking  blood  away  from  the  patient  ; 
adopting  the  antiphlogistic  regimen,  and  enjoining  the 
patient  to  avoid  lying  on  his  back  or  sitting  down.  He 
should  also  avoid  walking,  so  as  to  put  the  glutei  mus- 
cles into  action,  which  would  disturb  the  broken  bone 
All  formal  attempts  at  reduction  are  not  only  useless 
in  respect  to  the  fracture,  but  highly  injurious  to  the 
soft  parts,  which  are  not  in  a state  to  bear  handling 
without  ill  effects. 

FRACTURES  OF  THE  OSSA  INNOMINATA. 

The  situation  and  shape  of  the  ossa  innominata,  and 
the  thickness  of  the  soft  parts  by  which  they  are  co- 
vered, explain  why  they  are  but  seldom  fractured. 
When  such  accidents  happen,  they  are  generally  pro- 
duced by  the  passage  of  lieavy  carriage-wheels  over 
the  pelvis,  falls  from  great  heights,  the  kick  of  a horse, 
<fcc.,  and  are  always  attended  with  considerable  contu- 
sion of  the  external  soft  parts,  and  sometimes  with 
great  injury  of  the  ])elvic  viscera.  The  anterior  supe- 
rior spinous  process  of  the  ileurn  is  sometimes  broken 
oir  by  the  kick  of  a horse.— (Bci/er.) 


396 


FRACTURES. 


The  two  ossa  innominata  may  be  broken  together ; 
but  commonly  only  one  of  them  is  thus  injured. 
Most  Q-equently  the  fracture  takes  place  in  the  upper 
expanded  portion  of  the  bone,  known  under  the  name 
of  the  ileum,  though  sometimes  it  happens  either  in. 
the  ischium  or  the  os  pubis.  The  solution  of  conti- 
nuity may  be  limited  to  one  part  of  the  bone,  or  extend 
to  several  parts  of  it ; and  there  may  be  a greater  or 
less  number  of  fragments,  and  these  attended  or  not 
with  displacement.  In  many  instances,  in  which  the 
pelvis  has  been  violently  jambed  between  two  bodies, 
or  run  over  by  a heavy  carriage,  the  bones  of  the  pel- 
vis, besides  being  fractured,  are  dislocated,  some  inte- 
resting examples  of  which  accident  have  been  recently 
published. — (A.  Cooper’s  Surgical  Essays,  part  1,  p. 
49,  iS-c.) 

During  my  apprenticeship  at  St.  Bartholomew’s 
Hospital,  several  cases  occurred  in  which  the  os  ileum, 
os  ischium,  and  os  pubis,  were  found  fractured  on 
opening  the  bodies  after  death ; and  when  the  great 
violence  necessary  to  produce  the  accident  is  con- 
sidered, we  cannot  wonder  that  the  injured  state  of  the 
pelvic  viscera  should  frequently  prove  fatal.  Frac- 
tures of  the  ossa  innominata  are  unavoidably  attended 
with  more  or  less  contusion  of  the  soft  parts  on  the 
outside  of  the  pelvis ; and  when  the  violence  has  been 
very  great,  the  pelvic  viscera  may  be  seriously  bruised, 
crushed,  or  lacerated,  and  the  large  nerves  contained 
in  the  pelvis,  or  the  spinal  marrow  itself,  injured  : 
hence,  extravasation  of  blood  or  urine  in  the  cellular 
membrane  of  the  pelvis  ; ecchymoses  deeply  situated 
even  in  the  substance  of  the  muscles  or  other  organs  ; 
injury  of  the  kidneys  ; complete  loss  of  motion ; a pa- 
ralysis of  the  lower  extremities ; discharge  of  blood  or 
a black  bilious  matter  by  vomiting  or  stool,  either  im- 
mediately or  at  more  or  less-  distant  periods  from  that 
of  the  accident ; retention  of  urine ; fever ; painful 
tension  of  the  abdomen,  from  inflammation  of  the  pe- 
ritoneum and  bowels;  the  formation  of  abscesses, 
which  are  sometimes  of  great  extent;  sloughing; 
and  death.— {Boj/er,  Traite  des  Mai.  Chir.  t.  3,  p. 
134.) 

As  the  same  author  has  observed,  the  violence  occa- 
sioning a fracture  of  the  ossa  innominata  may  produce 
a displacement  of  the  fragments,  and,  carry  them  more 
or  less  away  from  their  natural  situation.  When  the 
pubes  or  ischium  is  broken,  the  splinters  may  be  pro- 
pelled into  the  canal  of  the  urethra,  or  even  through 
the  bladder,  and  give  rise  to  extravasation  of  the  urine ; 
or  by  merely  compressing  these  organs,  they  may 
cause  more  or  less  interruption  .of  their  functions. 
But  unless  the  fragments  be  displaced  by  the  same 
force  which  caused  the  fracture,  they  can  hardly  be 
drawn  out  of  their  place  by  any  other  circumstance, 
since  they  are  retained  by  the  muscles  attached  to  both 
Iragments,  and  by  surrounding  ligamentous  expan- 
sions. 

Owing  to  the  deep  situation  of  fractures  of  the  pel- 
vis, and  to  there  being  no  displacement  nor  mobility 
of  the  fragments,  the  diagnosis  is  sometimes  attended 
with  great  difficulty.  A suspicion  of  the  accident  may 
be  entertained,  when  the  pelvis  has  suffered  great  vio- 
lence, the  patient  experiences  great  agony,  and  all  mo- 
tion of  the  trunk  and  lower  extremities  is  difficult  and 
painful.  Under  these  circumstances,  if  the  fracture 
should  be  in  the  ileum,  especially  its  upper  and  front 
portion,  or  in  the  os  pubis,  the  mobility  of  the  frag- 
ments or  even  a crepitus  may  be  distinguished  in  a 
thin  subject,  if,  when  he  is  lying  horizontally,  with 
his  thighs  and  legs  bent,  and  his  head  and  chest  ele- 
vated, the  projecting  part  of  the  os  innominatum  be 
taken  hold  of,  and  an  attempt  be  made  to  move  the 
fragments  in  opposite  directions.  In  this  business, 
however,  ene  caution  is  given  by  Boyer,  viz.  not  to 
mistake  the  crepitation  of  an  emphysema,  often  attend- 
ing large  extravasations  of  blood,  for  the  grating  of  the 
fractured  bone. 

In  cases  in  which  the  fracture  affects  a part  of  the 
os  innondnaturn  very  deeply  pjaced,  and  it  is  limited  to 
a single  point  of  the  os  pubis  or  the  ischium,  so  that  no 
detached  moveable  fragment  has  been  produced,  the 
exact  nature  of  the  case  is  rarely  made  out  with  cer- 
tainty before  the  patient’s  death,  and  the  dissection  of 
the  parts. 

Fractures  of  the  ossa  innominata  are  cases  accom- 
panied with  serious  danger.  When  the  fragments  are 
displaced,  and  do  not  admit  of  being  rectified  again. 


the  disorder  arising  from  this  cause  may  have  fatal 
consequences.  And,  as  Boyer  observes,  even  when 
such  displacement  does  not  exist,  these  fractures  are 
not  the  less  to  be  apprehended  on  account  of  the  injury 
which  the  spinal  marrow  and  the  nerves,  vessels,  mus- 
cles, and  viscera  within  the  pelvis  are  likely  to  have 
sustained.  These  complications,  which  are  almost  in- 
separable from  the  fracture,  may  prove  indeed  directly 
fatal,  or  destroy  the  patient  at  a period  more  or  less 
remote  from  the  time  of  the  accident.  One  terrible 
accident  of  this  kind,  which  I saw  about  two  years 
ago,  wdth  Mr.  Ives,  of  Cobham,  proved  fatal  in  about 
half  an  hour.  Sometimes,  however,  the  fracture  is  not 
extensive,  and  the  violence  w'hich  i)roduced  it  has  not 
caused  any  very  serious  injury  of  the  viscera  and  soft 
parts  : but  examples  of  this  kind  are  uncommon. 

In  these  last  cases,  wliich  are  the  most  simple,  a 
cure  of  the  fracture  may  be  easily  effected  by  means 
of  rest  ; a position  in  which  all  the  chief  muscles  at- 
tached to  the  pelvis  are  relaxed;  discutient  applica- 
tions; and  a roller,  or  T bandage. — {Boyer,  TraiU  des 
Mai.  Chir.  t.  3,  p.  156.)  The  grand  indication  is  to  ob- 
viate the  consequences  of  inflammation  of  the  parts 
within  the  pelvis,  and  even  of  the  peritoneum  and  ab- 
dominal viscera,  by  copious  and  repeated  blood-letting. 
Any  complaints  respecting  the  evacuation  of  the  urine 
and  feces  must  also  receive  immediate  attention. 
When  there  is  great  contusion,  and  the  bones  are  very 
badly  broken,  the  patient  cannot  move  nor  go  to  stool 
without  suffering  the  most  excruciating  pain.  To  af- 
ford some  assistance  in  such  circumstances,  Boyer,  in 
a particular  case,  passed  a piece  of  strong  girth  web 
under  the  pelvis,  and,  collecting  the  corners  Into  one, 
fastened  them  to  a pulley  suspended  from  the  top  of 
the  bed.  This  enabled  the  patient  to  raise  himself 
with  very  little  efforts,  so  that  a flat  vessel  could  be 
placed  under  him.  It  appears  to  me  that  a bed  con- 
structed on  the  principles  recommended  by  the  late 
Sir  James  Earle,  might  be  of  infinite  service  in  these 
cases  as  well  as  in  many  others,  particularly  com- 
pound fractures  and  paraljdic  affections  from  diseased 
vertebrae. — (See  Observations  on  Fractures  of  the 
Lower  Limbs ; to  which  is  added  an  account  of  a con~ 
trivance  to  administer  cleajiliness  and  comfort  to  the 
bed-ridden;  by  Sir  J.  Earle,  1807.)  Mr.  Earle  has 
also  exerted  his  mechanical  ingenuity  with  great  suc- 
cess in  the  invention  of  a bed,  admirably  well  calcu- 
lated for  the  treatment  of  fractures,  and  other  cases, 
in  which  it  is  an  object  of  high  importance  to  en- 
able the  patient  to  empty  the  bowels  without  changing 
his  position. 

Sometimes,  notwithstanding  the  rigorous  adoption  of 
antiphlogistic  measures,  abscesses  cannot  be  prevented 
from  fomiing  in  the  pelvis ; particularly  when  there 
are  detached  splinters  driven  inwards.  These  collec- 
tions of  matter  should  be  opened  as  soon  as  a distinct 
fluctuation  can  be  felt.  The  splinters  may  wound  the 
urethra  or  bladder,  and  cause  an  extravasation  of 
urine.  Desault  extracted  a splinter  which  had  had  this 
effect  from  the  bottom  of  a wound  made  for  the  dis- 
charge of  the  effused  urine.  In  these  cases,  a catheter 
should  be  kept  introduced,  in  order  to  prevent  the  urine 
from  collecting  in  the  bladder,  and  afterward  insinuat- 
ing itself  into  the  cavity  of  the  abdomen.— (CAqpart.) 
A very  interesting  case  of  fracture  of  the  ossa  inno- 
minata, attended  with  rupture  of  the  bladder,  and  fol- 
lowed by  a fatal  peritonitis,  has  been  recorded  by  Clo- 
quet.— {Nouveau  Joum.  de  Medccine,  Mars,  1820.) 
The  ossa  pubis  were  forced  half  an  inch  from  each 
other.  The  horizontal  branch  of  the  pubes,  and  the 
ascending  ramus  of  the  ischium,  were  broken ; the 
sacrum  dislocated  from  the  ossa  ileum,  and  driven  for- 
wards within  the  cavity  of  the  pelvis.  The  right  sa- 
cro-iliac  symphysis  was  broken  only  at  its  fore  part, 
and  its  bones  still  retained  their  connexion.  Vast 
quantities  of  blood  were  found  extravasated  in  the  lum- 
bar region  and  about  the  pudenda.  As  soon  as  the 
abdomen  was  opened,  three  pints  of  a yellowish  fluid, 
having  a urinary  smell,  fmmediately  gushed  out.  In 
this  case,  catheters  of  various  sizes  were  introduced, 
even  a syringe  adapted  to  them  was  used,  but 
nothing  could  be  thus  drawn  off  but  a few  drops  of 
blood.  The  possibility  of  mistaking  a fracture  of  the 
acetabulum  for  a dislocation  of  the  thigh-bone,  and 
the  differences  of  these  cases  as  explained  by  Sir 
A.  Cooper,  have  been  mentioned  in  the  article  Dis- 
location. 


FRACTURES. 


397 


FRACTHRES  OF  THE  THIGH. 

The  03  fernoris  is  liable  to  be  broken  at  every  point, 
fVom  its  condyies  to  its  very  head ; but  it  is  at  the  mid- 
dle third  of  this  extent  that  fractures  mostly  occur. 
The  fracture  is  sometimes  transverse,  but  more  fre- 
quently oblique.  The  latter  direction  of  the  injury 
makes  a serious  difference  in  the  difficulty  of  curing 
the  case  without  future  deformity  or  lameness.  Some- 
times the  fracture  is  comminuted,  the  bone  being 
broken  in  more  places  than  one ; and  sometimes  the 
case  is  attended  with  a wound,  communicating  with 
the  fracture,  and  making  it  what  is  termed  compound. 
As  Petit  remarks,  however,  tlie  thigh-bone  is  less  sel- 
dom broken  into  several  pieces  than  other  bones  more 
superficially  situated. 

A fractured  thigh  is  attended  with  the  following 
symptoms  ; a local  acute  pain  at  the  instant  of  the  ac- 
cident ; a sudden  inability  to  move  the  limb ; a pre- 
ternatural mobility  of  one  portion  of  the  bone  ; some- 
times a very  distinct  crepitus,  when  the  two  ends  of 
the  fracture  are  pressed  against  each  other ; deformity 
in  regard  to  the  length,  thickness,  and  direction  of  the 
limb.  The  latter  change,  viz.  the  deformity,  ought  to 
be  accurately  understood ; for,  having  a continual 
tendency  to  recur,  especially  in  oblique  fractures,  our 
chief  trouble  in  the  treatment  is  to  prevent  it.— (De- 
sault,  par  Bichat,  t.  1,  p.  181.) 

Almost  all  fractures  of  the  thigh  are  attended  with 
deformity.  When  this  is  considered  in  relation  to 
length,  it  appears  that,  in  oblique  fractures,  the  broken 
limb  is  always  shorter  than  the  opposite  one  ; a cir- 
cumstance denoting  that  the  ends  of  the  fracture  ride 
over  each  other.  We  may  also  easily  convince  our- 
selves, by  examination,  that  the  deformity  is  owing  to 
the  lower  end  of  the  fracture  having  ascended  above 
the  upper  one,  which  remains  stationary.  What 
power,  except  the  muscles,  can  communicate  to  the 
lower  portion  of  the  fractured  bone,  a motion  from  be- 
low upw^ards  ? At  one  end  attached  to  the  pelvis,  and  at 
the  other  to  this  part  of  the  bone,  the  patella,  the  tibia, 
and  fibula,  they  make  the  former  insertion  their  fixed 
point,  and,  drawing  upwards  the  leg,  the  knee,  and  the 
lower  portion  of  the  thigh,  they  cause  directly  or  indi- 
rectly the  displacement  in  question.  In  producing  this 
effect,  the  triceps,  semi-tendinosus,  semi-membrano- 
sus,  rectus,  gracilis,  sartorius,  «fec.,  are  the  chief  agents. 

For  the  purpose  of  exemplifying  the  power  of  the 
muscles  to  displace  the  ends  of  the  fracture,  mention 
is  made,  in  DesauU’.s  works,  by  Bichat,  of  a carpenter 
who  fell  from  a scaffold  and  broke  his  thigh.  The 
limb,  the  next  day,  was  as  long  as  the  other  ; but  the 
man  had  a complete  palsy  of  his  lower  extremities, 
and  could  not  discharge  his  urine.  The  moxa  was  ap- 
plied, the  muscles  soon  regained  their  jjower,  and  then 
the  shortening  of  the  limb  began  to  make  its  appear- 
ance. 

Besides  the  action  of  muscles,  there  is  another  cause 
of  displacement.  However  firm  the  bed  may  be  on 
which  the  patient  is  laid,  the  buttocks,  more  prominent 
than  the  rest  of  the  body,  soon  form  a depression  in 
the  bedding,  and  thence  follows  an  inclination  in  the 
plane  on  which  the  trunk  lies,  which,  gliding  from 
above  downwards,  pushes  before  it  the  ujiper  end  of 
the  fracture,  and  makes  it  ride  over  the  lowmr  one. 
The  muscles,  irritated  by  the  points  of  bone,  increase 
their  contraction,  and  draw  upwards  the  lower  part  of 
the  bone : and  from  this  double  motion  of  the  two  ends 
of  the  fracture  in  opposite  directions,  their  riding  over 
each  other  results. 

Transverse  fractures  are  less  liable  to  be  displaced 
in  the  longitudinal  direction  of  the  bone,  because,  when 
once  in  contact,  the  ends  of  the  fracture  form  a mutual 
resistance  to  each  other ; the  lower  ends,  drawn  up- 
wards by  the  muscles,  meets  with  resistance  from  the 
upper  one,  which  being  itself  inclined  downwards  by 
the  weight  of  the  trunk,  pushes  the  former  before  it, 
and  thus  both  retain  their  position  in  relation  to  each 
other. 

The  deformity  of  a fractured  thigh,  in  the  transverse 
direction,  always  accompanies  that  which  is  longitu- 
dinal ; but  sometimes  it  exists  alone.  This  is  the  case, 
when,  in  a transverse  fracture,  the  two  ends  of  the 
bone  lose  their  contact ; one  being  carried  outwards,  the 
other  inwanls ; or  one  remaining  in  its  jilace,  while  the 
other  is  separated.  The  upper  end  of  the  fracture  is 
not  now,  as  in  the  foregoing  instance,  motionless  in  re- 
gard to  the  muscular  action ; the  contraction  of  the 


pectineus,  psoas,  iliacus  internus,  and  upper  part  of  the 
triceps,  draws  it  from  its  natural  direction,  and  con- 
tributes to  displace  it. 

The  deformity  of  the  limb  in  regard  to  its  direction, 
is  either  the  consequence  of  the  blow,  which  produced 
the  fracture,  or,  what  is  more  common,  of  the  ill-di- 
rected exertions  of  persons  who  carry  the  patient. 
Thus  we  see  that  an  injudicious  posture  bends  the  two 
portions,  so  as  to  make  an  angle. 

Whatever  may  be  the  kind  of  deformity,  the  lower 
end  of  the  fracture  may  retain  the  natural  position  in 
which  it  is  placed,  or  else  undergo  a rotatory  motion  on 
its  axis  outwards,  which  is  very  common,  or  inwards, 
which  is  more  unusual.  This  rotation  always  aggra- 
vates the  displaced  state  of  the  fracture,  and  should  be 
attended  to  in  the  reduction.— (DesatiZi,  par  Bichat,  1. 1, 
p.  180.  185.) 

Every  one,  at  al!  initiqjed  in  the  surgical  profession, 
knows  that  there  are  two  very  different  methods  of 
treating  fractured  thighs.  In  one,  which  was  recom- 
mended and  practised  by  Desault,  and  is  still  univer- 
sally preferred  in  France,  the  limb  is  kept  in  the 
straight  or  extended  position.  In  the  other,  the  limb  is 
laid  upon  its  side,  with  the  knee  bent ; a mode  which 
was  extolled  by  the  celebrated  Mr.  Pott,  and  since  his 
time  has  found  many  partisans  in  this  country.  To 
these  two  positions  for  fractured  thighs  may  now  be 
added  that  in  which  the  patient  lies  upon  his  back, 
with  his  thigh  and  leg  in  the  bent  position,  supported 
on  two  oblique  planes,  or  surfaces,  the  apex  or  angle  of 
which  is  beneath  the  ham.  This  last  position, however, 
has  been  more  particularly  recommended  for  fractures 
of  the  neck  of  the  femur,  though,  if  it  be  advantageous 
for  them,  I see  no  reason  for  not  giving  it  a fair  trial  in 
other  fractures  of  tliat  bone. 

That  Mr.  Pott  lost  sight  of  certain  advantages  of  the 
straight  position  ; that  he  was  blind  to  the  imperfec- 
tions of  the  bent  posture ; and  that  he  exaggerated  the 
power,  which  we  have,  of  relaxing  all  the  muscles  of 
a limb  by  position ; few  reflecting  surgeons  of  the  pre- 
sent day  will  be  inclined  to  deny. 

Were  we  to  resign  the  privilege  of  thinking  for  our- 
selves, and  implicitly  to  mould  our  opinions  according 
to  any  authority,  however  high,  we  should  often  fall 
into  very  avoidable  errors.  Were  we  to  believe  the  literal 
sense  of  several  jjassages  in  Mr.  Pott’s  Remarks  upon 
Fractures,  w'e  should  suppose  it  possible  and  practicable 
to  relax  at  once,  by  a certain  posture  of  the  limb,  every 
muscle  connected  with  a fractured  bone.  In  the  first 
vol.  of  his  works,  page  389,  edit.  1783,  he  observes,  in 
speaking  of  what  must  best  answer  the  purpose  of  in- 
capacitating the  muscles  from  displacing  the  fracture 
“Is  it  not  obvious,  that  putting  the  limb  into  sue.h  posi- 
tion as  shall  relax  the  whole  set  of  muscles  belonging 
to,  or  in  connexion  v/ith,  the  broken  bone,  must  best 
answer  such  purpose  V’  and  in  the  next  page,  “ What 
is  the  reason  wffiy  no  man,  however  superficially  ac- 
quainted with  his  art,  ever  finds  much  trouble  in  set- 
ting a fractured  os  humeri?  is  it  not  because  both  pa- 
tient and  surgeon  concur  in  putting  the  arm  into  a state 
of  flexion,  that  is,  into  such  a state  as  relaxes  all  the 
muscles  surrounding  the  broken  bone  ?”  Also,  in  page 
393,  he  continues,  “ Change  of  posture  must  be  the 
remedy,  or  rather,  the  placing  the  limb  in  such  manner 
as  to  relax  all  its  muscles.”  That  to  have  all  the  mus- 
cles relaxed  in  cases  of  fracture  would  be  desirable, 
were  it  also  practicable,  every  one  will  admit ; but  the 
possibility  of  accomplishing  it,  so  long  as  different 
muscles  have  different  uses,  different  situations,  and 
different  attachments  to  the  bones,  every  one  must 
grant  to  be  only  a visionary  project.  For  instance,  do 
not  the  patient  and  surgeon,  in  the  case  of  fractured  os 
humeri  adverted  to  above,  rather  concur  in  putting  the 
fibres  of  the  triceps  and  anconeus  into  a stafte  of  ten- 
sion, at  the  same  moment  that  they  relax  the  biceps  and 
brachialis  internus  ? 

The  position  of  the  fractured  os  fernoris,  says  Mr. 
Pott,  should  be  on  its  outside,  resting  on  the  great  tro- 
chanter; the  patient’s  whole  body  should  be  inclined 
to  the  same  side  ; the  knee  should  be  in  a middle  state 
between  perfect  flexion  or  extension,  or  half-bent ; the 
leg  and  foot,  lying  on  their  outside  also,  should  be.  well 
supported  by  smooth  pillows,  and  should  bo  rather 
higher  in  their  level  than  the  thigh ; one  very  broad 
splint  of  deal,  hollowed  out  and  well  covered  with 
wool,  rag,  or  tow',  should  be  jilaced  under  the  thigh, 
from  above  the  troc  hauler  quite  below  the  knee  ; and 


398 


FRACTURES. 


another,  somewhat  shorter,  should  extend  from  the 
groin  below  the  knee  on  the  inside,  or  rather  in  this 
posture  on  the  upper  side.  The  bandage  should  be  of 
the  eighteen-tail  kind,  and  when  the  bone  has  been  set, 
and  the  thigh  well  placed  on  the  pillow,  it  should  not, 
without  necessity  (which  necessity  in  this  method  will 
seldom  occur),  be  ever  moved  from  it  again,  until  the 
fracture  is  united ; and  this  union  will  always  be  ac- 
complished in  more  or  less  time,  in  proportion  as  the 
limb  shall  have  been  more  or  less  disturbed. — (Pott.) 

Here  only  two  splints  are  mentioned;  the  surgeons 
of  the  present  day  usually  employ  four.  After  placing 
the  patient  in  a proper  position,  the  necessary  extension 
is  to  be  made.  Then  the  under  splint,  having  upon  it  a 
broad  soft  pad,  and  an  eighteen-tailed  bandage,  is  to  be 
laid  under  the  thigh,  from  the  great  trochanter  to  the 
outer  condyle.  The  surgeon,  before  applying  the  soap 
plaster,  laying  down  the  tails^f  the  bandage,  and  put- 
ting on  the  other  three  splints,  is  to  take  care  that  the 
fracture  lies  as  evenly  as  possible. 

In  the  position  for  a fractured  thigh,  Mr.  Pott,  we 
find,  directs  the  leg  and  foot  to  be  rather  higher  in  their 
level  than  the  thigh;  with  what  particular  design,  I 
have  not  myself  been  able  to  make  out.  Whoever  me- 
ditates upon  the  consequence  of  elevating  the  leg  and 
foot  above  the  level  of  the  thigh,  in  the  bent  position, 
will  know  that  it  is  to  twist  the  condyles  of  the  os  fe- 
moris  more  outward  than  is  natural.  When  a patient 
is  placed  according  to  Mr.  Pott’s  direction,  upon  a com- 
mon bed,  the  middle  soon  sinks  so  much  that  the  leg 
becomes  situated  very  considerably  higher  than  the 
thigh,  and  I am  disposed  to  think  that  tliis  is  one  cause 
why  so  many  broken  thighs  are  united  in  so  deformed 
a manner,  that  the  foot  remains  permanently  distorted 
outwards.  The  great  propensity  of  the  triceps  and 
other  muscles  to  produce  this  effect,  may  also  serve  to 
explain  the  frequency  of  the  deformity.  It  is  not 
merely  the  depression  of  the  middle  of  the  bed  which 
is  disadvantageous  : as  the  weight  of  the  patient’s  body 
falls  more  upon  one  side  of  the  bed  than  the  other,  in 
the  bent  position  of  the  limb,  unless  the  sacking  be  tight 
and  the  mattress  very  firm,  it  happens  that  such  a de- 
clivity is  formed  as  to  render  it  exceedingly  difficult,  if 
not  impracticable,  to  make  the  patient  continue  duly 
upon  his  side.  It  cannot  be  enjoined  too  forcibly,  that 
fractured  thighs  should  always  be  laid  upon  beds  not 
likely  to  sink  much.  .When  this  happens,  no  rational 
dependence  can  be  put  in  the  efficacy  of  the  bent  posi- 
tion, and,  as  Desault  has  explained,  the  same  thing  is 
hurtful  also  in  the  straight  posture. 

The  most  enthusiastic  advocates  for  the  bent  position 
must  allow,  that  it  leaves  the  leg  and  foot  too  moveable 
and  unsupported,  and  that,  though  it  may  relax  the 
muscles,  wliich  have  the  most  power  to  disturb  the  co- 
aptation of  a fractured  thigh,  it  yet  leaves  a mass  of 
muscle  unrelaxed,  quite  sufficient  to  displace  the  ends 
of  the  bone.  Hence,  practitioners  should  endeavour  to 
improve  the  apparatus  employed,  so  that  it  may  make 
a permanent  resistance  to  the  action  of  the  muscles, 
and  in  the  straight  position  such  resistance  may  cer- 
tainly be  practised  with  most  effect  and  convenience. 

The  whole  tenor  of  Mr.  Pott’s  observations  on  frac- 
tures w'ould  lead  one  to  suppose,  that  from  the  moment 
a muscle  is  partially  relaxed,  it  becomes  incapable  of 
acting  on  or  displacing  a fracture.  But  if  this  were 
correct  (which  it  cannot  he),  we  should  not  have  the 
power  of  completely  bending  or  extending  our  limbs  ; 
for  as  soon  as  the  set  of  muscles  designed  for  this  pur- 
pose were  partly  relaxed  by  the  half-flexion  or  half- 
extension of  the  joint,  they  would  be  deprived  of  all 
farther  power.  Therefore,  in  addition  to  the  arguments 
to  be  brought  against  the  bent  posture,  arising  from  its 
not  actually  relaxing  all  the  muscles  connected  with 
the  broken  bone,  we  are  also  to  take  into  the  account 
the  fact,  that  the  partial  relaxation  of  any  muscle  by 
no  means  incapacitates  it  from  acting. 

In  the  earlier  editions  of  this  Dictionary,  I expressed 
a preference  to  Mr.  Pott’s  method  of' treating  broken 
thighs.  More  mature  reflection,  however,  and  subse- 
quent experience  have  made  me  a convert  to  the  senti- 
ments of  Desault  on  this  subject.  The  terrible  com- 
pound fractured  thighs,  which  I had  under  my  care  in 
the  campaign  in  Holland  in  the  year  1814,  could  not 
have  been  at  all  retained  by  any  apparatus  put  merely 
upon  the  thigh  itself.  The  superiority  of  long  splints, 
extending  the  whole  length  of  the  limb,  was  in  these 
eases  particularly  manifest  With  such  splints,  which  1 


maintain  steady  the  fracture  itself,  the  knee,  leg,  ankle, 
and  foot,  your  patient  may,  in  fact,  even  be  removed 
upon  an  emergency  from  one  place  to  another,  without 
any  considerable  disturbance  of  the  broken  part.  But 
how  could  this  be  done  in  the  bent  position,  with  short 
splints,  merely  applied  to  the  thigh,  affording  no  support 
to  the  leg,  and  not  confining  the  motions  of  the  knee 
and  foot  1 

There  are  some  excellent  remarks  on  the  treatment 
of  fractured  thighs  in  the  writings  of  Desault.  It  is 
observed,  that,  if  we  compare  the  natural  powers  of 
displacement  with  the  artificial  resistaitce  of  almost 
every  apparatus,  we  shall  find  that  the  disproportion 
between  such  forces  is  too  great  to  let  the  former  yield 
to  the  latter.  The  action  of  the  muscles,  however, 
which  is  always  at  first  very  strong,  may  afterward  be 
gradually  diminished  by  the  extension  exercised  on 
them.  A power  incessantly  operating  can  effect,  what 
another  greater  power,  temporarily  applied,  cannot  at 
once  accomplish,  and  the  compression  of  circular 
bandages  tends  also  to  lessen  the  force  of  the  muscles, 

Desault  cured  in  the  Hdtel-Dieu  an  immense  number 
of  fractured  thighs,  without  any  kind  of  deformity. 
This  success,  it  is  said,  was  owing  particularly  to  the 
well-combined  employ  ment  of  extension  and  compres- 
sion of  the  muscles.  The  advantage  of  keeping  the 
muscles  a long  while  extended,  in  order  to  diminish 
their  power,  is  especially  evident  in  the  reduction  of 
certain  dislocations,  as  those  of  the  shoulder,  in  which 
we  often  cannot  succeed  till  the  muscles  have  been 
kept  on  the  stretch  for  a greater  or  less  time.  The 
fracture  of  the  patella  and  olecranon  equally  demon- 
strates the  utility  of  compression  for  the  same  purpose  ; 
tis  when  the  muscles  are  not  steadily  compressed  by 
the  bandage,  they  draw  upwards  the  fragment  of  bone 
with  double  or  triple  force. 

To  the  reduction  of  fractured  thighs  in  the  bent  pos 
ture,  Desault  entertained  the  following  objections  : the 
difficulty  of  making  the  extension  and  counter-extension, 
when  the  limb  is  so  placed ; the  necessity  of  then  ap 
plying  them  to  the  fractured  bone  itself,  instead  of  a 
situation  remote  from  the  fracture,  as,  for  example,  the 
lower  part  of  the  leg  ; the  impossibility  of  comparing 
with  precision  the  broken  thigh  with  the  sound  one,  in 
order  to  judge  of  the  regularity  of  its  shape  ; the  irk- 
someness of  this  position  long  continued,  though  it  may 
at  first  seem  most  natural ; the  inconvenient  and  painful 
pressure  of  a part  of  the  trunk  on  the  great  trochanter 
of  the  affected  side ; the  derangement  to  which  the 
limb  is  exposed  when  the  patient  has  a motion ; the 
difficulty  of  fixing  the  leg  firmly  enough  to  prevent  the 
effect  of  its  motion  on  the  thigh-bone ; the  manifest 
impossibility  of  adopting  this  method,  when  both  thighs 
are  fractured ; lastly,  experience  in  France  having 
been  iittle  in  favour  of  such  posture. 

Also,  what  is  gained  by  the  relaxation  of  some  mus- 
cles, is  lost  by  the  tension  of  others.  For  such  rea- 
sons (certainly  strong  ones),  Desault  abandoned  the 
bent  position,  and  always  employed  the  straight  one, 
which  was  advised  by  Hippocrates. 

Petit,  Heister,  and  Duverney  recommend  the  extend- 
ing means  to  be  applied  just  above  the  condyles  of  the 
os  femoris.  Dupouy  remarked  that  this  practice  ren- 
dered it  necessary  to  employ  very  great  force,  and  he 
preferred  extension  from  the  foot.  Fabre  took  also  into 
consideration  the  inconvenience  of  the  partial  pressure 
made  on  the  muscles,  which,  irritating  and  stimulating 
them  to  action,  multiplies  the  obstacles  to  the  setting 
of  the  fracture.  For  nearly  similar  motives  Desaull 
esjioused  their  doctrine,  introduced  it  at  the  Hotel- 
Dieu,  and  the  success  which  he  experienced  from  the 
practice  contributed  materially  to  its  more  extensive 
adoption. 

Desault,  as  we  have  stated,  preferred  the  straight 
posture,  and  laid  his  patients  on  surfaces  not  likely  to 
sink  with  the  weight  of  the  body.  The  feather-beds, 
formerly  in  common  use  at  the  Hdtel-Dieu,  had  this  in- 
convenience. For  these,  in  cases  of  fractures,  Desault 
substituted  a finn,  tolerably  hard  mattress,  which  did 
not  allow  the  continual  change  of  posture  to  occur 
which  a soft  bed  does.  I'he  object  of  every  apparatus 
being  to  keep  the  ends  of  the  fracture  from  being  dis- 
placed, the  mechanism  of  every  contrivance  for  this 
purpose  should  be  directed  against  the  causes  of  the 
displacement.  These  are,  1,  the  action  of  the  muscles 
draw’ing  upwards  Uie  lower  end  of  the  fracture;  2.  the 
weight  of  the  trunk  propelling  downw  ards  the  ujiiicr 


FRACTURES. 


399 


«nd.  Hence,  every  apparatus  intended  to  prevent  dis- 
placement of  a thigh  fractured  obliquely,  should,  1, 
draw  and  keep  downwards  the  lower  end  of  the  fracture ; 
2,  carry  and  maintain  upwards  the  upper  end  of  the 
fracture,  and  the  trunk  which  is  above  it.  This  prin- 
ciple is  of  general  application,  and  only  subject  to  a 
few  exceptions  in  transverse  fractures,  attended  merely 
with  displacement  in  the  direction  of  the  diameter  of 
the  limb,  or  else  none  at  all.  3,  There  must  also  be  in 
the  apparatus  a resistance  to  the  rotation  of  the  lower 
portion  of  the  broken  bone,  so  as  to  keep  the  limb 
steady,  even  in  case  of  any  sudden  motion. 

If  we  compare  the  operation  of  the  different  pieces 
of  our  apparatus  with  the  above  indications,  Desault 
says,  we  shall  find,  that  without  permanent  extension 
they  are  not  very  effectual.  With  regard  to  bandages, 
whether  a roller  or  eighteen-tailed  bandage  be  used, 
they  all  have  one  common  mode  of  operating;  they 
press  the  muscles  towards  the  ends  of  the  fracture,  so 
as  to  make  them  form  a kind  of  natural  case  for  the 
fracture,  and  thus  they  make  lateral  resistance  against 
the  parts.  In  this  manner  bandages  materially  aid  in 
preventing  displacement  sidewise,  and  are  particularly 
useful  in  transverse  fractures.  But  what  is  there  to 
hinder  the  two  inclined  surfaces  of  an  oblique  fracture 
from  slipping  one  over  the  other?  What  power  is 
there  to  keep  the  limb  from  receiving  the  effects  of  ac- 
cidental shocks  ? Is  the  pelvis  kept  back  ? Is  the  ac- 
tion of  the  muscles  resisted?  The  latter  is  indeed 
somewhat  diminished  by  the  pressure,  and  this  is  the 
chief  use  of  the  bandage ; but  will  such  compression 
be  enough  to  prevent  the  longitudinal  displacement  of 
the  broken  bone,  especially  if  the  bandage  be  applied 
slackly  as  some  advise? 

These  remarks  apply  also  to  compresses : 'petit  moyen 
contre  une  grande  cause. 

Splints  are  useful  in  firmly  fixing  the  limb,  and 
guarding  it  from  the  effects  of  accidental  shocks,  or  of 
contractions  of  the  muscles.  They  operate  more 
powerfully  than  bandages,  in  preventing  lateral  dis- 
placement ; and  hence  they  suffice  for  transverse  frac- 
tures, without  permanent  extension.  They  also  resist 
the  rotation  of  the  thigh  outwards  or  inwards.  But  when 
the  breach  of  continuity  is  oblique,  will  they  hinder  the 
ends  of  the  bone  from  gliding  over  each  other,  and  the 
consequent  shortening  of  the  limb  ? They  obviously 
could  only  do  so  by  the  friction  of  the  different  pieces 
of  the  apparatus,  especially  the  tapes,  which  fasten  it ; 
and  then,  to  make  the  resistance  effectual,  they  must  be 
tied  so  tightly  as  to  create  danger  of  mortification. 
Will  the  splints  prevent  the  trunk  from  descending, 
and  propelling  before  it  the  upper  end  of  the  fracture  ? 
Will  they  hinder  the  action  of  the  muscles  on  the  lower 
end?  Will  they,  in  short,  fulfil  all  the  above  indica- 
tions ? Their  chief  use  is  to  prevent  lateral  displace- 
ment, and  keep  the  limb  steady.  Hence,  they  should 
extend  along  the  leg  as  well  tis  the  thigh,  which  cannot 
fail  to  be  disturbed  whenever  the  lower  part  of  the  limb 
is  allowed  to  move. 

The  pads  serve  principally  to  keep  the  limb  from  be- 
ing galled  by  the  splints,  and  their  action  in  preventing 
displacement  of  the  fracture  must  be  but  trivial. 

According  to  Desault,  the  ordinary  pieces  of  appara- 
tus, which  do  not  execute  any  permanent  extension, 
may  suffice  for  transverse  fractures ; but  they  are  al- 
ways ineffectual  when  the  division  is  oblique,  because 
they  do  not  fhlfil  the  twofold  indication  of  drawing 
downwards  the  lower  end  of  the  fracture,  and  keeping 
the  other  one  upwards. 

He  inculcated  that  the  object  particularly  to  be  aimed 
at  was  such  a disposition,  that  the  foot,  leg,  thigh,  and 
pelvis  should  constitute  but  one  whole ; so  that,  though 
the  different  parts  thereof  might  be  drawn  in  different 
directions,  yet  they  would  still,  with  respect  to  one 
another,  preserve  the  same  mutual  relation.  He  in- 
vented the  following  apparatus  to  answer  these  pur- 
poses. 

A strong  splint,  long  enough  to  extend  from  the  crista 
of  the  os  ileum  to  a certain  length  beyond  the  sole  of 
the  foot,  and  rather  more  than  two  inches  and  a half 
broad,  with  each  of  its  extremities  pierced  in  the  fonn 
of  a mortise,  and  terminating  in  a semicircular  niche, 
is  a principal  part  of  Desault’s  apparatus.  It  is  ap- 
plied to  the  exterior  side  of  the  thigh,  by  means  of  two 
strong  linen  rollers,  each  more  than  a yard  long. 

The  middle  part  of  one  roller  is  to  be  apjilied  to  the 
uislde  of  the  thigh,  at  its  upiier  part;  its  cuds  are 


brought  to  the  exteriof  side  Of  the  thigh,  passed  through 
the  mortise,  and  knotted  on  the  semicircular  niche. 
Pads  are  to  be  previously  placed  under  its  middle  part, 
in  order  to  prevent  any  disagreeable  pressure ; as  well 
as  on  the  tuberosity,  of  the  ischium,  which  Desault 
considered  as  the  principal  point  of  action  of  this  band. 
The  inferior  part  of  the  leg  is  next  covered  with  pads, 
on  which  the  middle  part  of  the  second  roller  is  placed, 
the  extremities  of  which  cross  on  the  instep  and  upper 
part  of  the  foot,  then  on  the  sole,  after  which  they 
are  conveyed  outwards',  and  one  end  passed  through 
the  mortise,  and  knotted  with  the  other  on  the  niche, 
with  such  a degree  of  force  as  to  pull  the  inferior  por- 
tion of  the  femur  downwards,  and  push  the  splint  up- 
wards, and,  by  this  means,  the  pelvis  and  superior 
portion  of  the  fractured  bone.  On  the  internal  side  of 
the  limb  is  placed  a second  splint,  which  extends  from 
the  superior  part  of  the  thigh  to  a certain  distance  be- 
yond the  foot.  A third  is  placed  on  the  anterior  part  of 
the  limb  from  the  abdomen  to  the  knee.  The  superior 
extremities  of  the  anterior  and  exterior  splints  are  fixed 
by  means  of  a bandage  passed  round  the  pelvis.  A 
roller,  the  middle  part  of  which  is  placed  under  the 
sole  of  the  foot,  and  the  extremities  crossed  on  its  su- 
perior surface,  and  fastened  to  the  splints,  operates  with 
them  in  preventing  the  foot  from  moving. 

Before  applying  the  apparatus,  Desault  covered  the 
whole  limb  with  compresses,  wet  with  a solution  of  the 
acetate  of  lead.  Over  these  Scultetus’s  bandage  was 
put,  and  a roller  round  the  foot,  all  wet  with  the  same 
lotion.  For  more  particulars  the  reader  is  referred  to 
the  Parisian  Chiriirgical  Journal,  vol.  1.  CB'.uvres 
Chir.  de  Desault,  par  Bichat,  t.  1.  Rosalino  Giardina, 
Memoria  sulla  Fratture,  con  alcune  Modijicazipne  alV 
Apparato  di  Desault,  8vo.  Palermo,  1814.  ' Boyer, 
Traiti  des  Maladies  Chir.  t.  3.  Richerand,  Nosogr. 
Chir.  t.  3,  edit  4.  Boyer’s  apparatus  for  fractured  thighs 
is  described  in  the  last  edition  of  the  First  Lines  of 
the  Practice  of  Surgery. 

Instead  of  the  position  advised  by  Pott,  or  that  re- 
commended by  Desault  and  Boyer,  Mr.  C.  Bell  prefers 
the  posture  in  which  the  patient  lies  upon  his  back, 
with  the  limb  supported  in  the  bent  attitude  by  means 
of  a wooden  frame.  This  machine  is  simple  enough, 
consisting  of  boards  ten  or  eleven  inches  in  breadth, 
one  reaching  from  the  heel  to  the  ham,  the  other  from 
the  ham  to  the  tuberosity  of  the  ischium.  Under  the 
knee-joint  they  are  united  at  an  angle,  while  a horizon- 
tal board  connects  their  lower  ends  together.  Tims 
they  form  two  sloping  surfaces,  to  which  cushions  are 
adapted,  and  over  which  the  limb  can  be  placed  in  an 
easy  bent  position.  Near  the  edge  of  the  inclined 
boards,  holes  are  made  furnished  with  pegs.  After  the 
bone  has  been  set,  a long  splint  is  applied  f rom  the  hip 
to  the  side  of  the  knee,  and  another  along  the  inside  of 
the  thigh.— (See  Operative  Surgery,  vol.  2,  p.  189.)  1 
entertain  a very  favourable  opinion  of  th^s  mode  of 
placing  fractured  thighs.  However,  the  foregoing  ap- 
paratus does  not  sufficiently  secure  the  leg  and  foot 
from  motion,  though,  with  the  aid  of  a roller  and  a 
foot-board,  this  advantage  might  easily  be  obtained. 
The  fracture-apparatus,  devised  by  my  friend  Mr.  Earle, 
is  excellently  calculated  for  this  mode  of  treatment^ 
with  these  additional  recommendations,  that  the  obli- 
quity of  the  two  surfaces  on  which  the  limb  reposes 
can  be  altered  as  occasion  may  require : there  is  a foot- 
board for  the  support  of  the  foot,  and  a contrivance  by 
which  the  patient  is  enabled  to  have  stools  without 
moving  himself  or  changing  his  posture  in  the  slightest 
degree. — (See  his  Practical  Observations  in  Surgery, 
p.  125,  Se-c.  8vo.  Land.  1823.) 

Fractures  of  the  Neck  of  the  Thigh-Bone. 

As  this  is  a subject  which  has  of  late  years  excited 
considerable  discussion,  the  reader  cannot  be  too  parti- 
cular in  noticing,  that  three  distinct  kinds  of  fracture, 
very  different  in  their  nature,  treatment,  and  result 
have  been  generally  confounded  together  under  the 
name  of  “ fractures  of  the  neck  of  the  thigh-bone 
for  much  of  the  dispute  that  has  prevailed,  whether 
these  fractures  will  ^ite  like  those  of  other  bones, 
seems  to  have  proceeded  from  the  three  species  of 
fracture  not  having  been  properly  discriminated.  Two 
of  the  cases  unite  by  means  of  callus,  like  other  fVac- 
tures ; hut  the  other,  as  it  usually  occurs,  is  conceived 
by  some  surgeons  not  to  admit  of  a similar  mode  of 
union ; or,  at  all  events,  they  declare  that  the  fact  hoM 


400 


FRACTURES. 


not  yet  been  demonstrated.  Sir  Astley  Cooper  has 
therefore  divided  these  cases,  first,  into  fractures  which 
happen  through  the  neck  of  the  bone,  entirely  within 
the  capsular  ligament ; being  the  examples  in  which 
he  thinks  a union  by  bone  has  not  yet  been  proved ; 
secondly,  into  fractures  through  the  neck  of  the  bone 
at  its  junction  with  the  trochanter  major,  which  frac- 
tures are  of  course  external  to  the  capsular  ligament : 
thirdly,  'n\to  fractiores  through  the  trochanter  major, 
beyond  its  junction  with  the  neck  of  the  bone. — {On 
Dislocations,  <i-c.  p.  114 — 116.) 

Fractures  of  the  neck  of  the  thigh-bone  are  infinitely 
more  frequent  than  dislocations  at  the  hip,  and  may 
arise  from  a fall,  either  upon  the  great  trochanter,  the 
sole  of  the  foot,  or  the  knee.  According  to  Desault,  the 
first  accident  produces  the  injury  much  more  frequently 
than  the  two  latter.  Of  thirty  cases  which  were  seen 
by  Desault,  four-and-twenty  arose  from  falls  on  the 
side.  All  those  inserted  by  Sabatier  in  liis  interesting 
Memoir  were  the  result  of  a similar  accident.  These 
authors,  it  is  to  be  remarked,  are  not  speaking  particu- 
larly of  the  fracture  'within  the  capsular  ligament ; 
and  hence,  perhaps,  the  rea.son  of  their  sentiments 
dififering  from  those  of  Sir  Astley  Cooper,  who  observes, 
that  in  London  the  fracture  within  the  capsule  is  most 
commonly  produced  by  a person  slipping  off  the  edge 
of  the  foot-pavement.  According  to  this  eminent  sur- 
geon, a fracture  of  the  neck  of  the  thigh-bone,  within 
the  capsular  ligament',  seldom  happens  but  at  an  ad- 
vanced period  of  life;  and  the  reason  of  the  facility 
with  which  the  injury  takes  place  in  old  persons,  he 
ascribes  to  the  interstitial  absorption  which  that  part 
of  the  femur  undergoes  in  individuals  past  a certain 
age,  whereby  it  becomes  shortened,  and  altered  in  its 
angle  with  the  shaft  of  the  bone.  He  adiruts,  however, 
that  the  accident  is  frequently  caused  by  a fall  upon  the 
trochanter  major. — {Surgical  Essays,  part  2,  p.  35,  36. 
Also,  Larrey,  Journ.  Complem.  t.  8,  p.  98,  8vo.  Paris, 
1820.)  Fractures  of  the  neck  of  the  thigh-bone  within 
the  capsule  are  more  common  in  women  than  men. — 
(/.  Wilson,  On  the  Skeleton,  <S-c.  p.  245.  A.  Cooper,  On 
Dislocations,  S,-c.  p.  122.) 

The  division  is  more  frequently  tr^insverse  than 
oblique ; the  neck  being  sometimes,  in  the  former  case, 
wedged  in  the  body  of  the  bone,  as  Desault  found  in 
several  instances ; a model  of  one  of  which,  in  wax,  is 
preserved  in  the  collection  of  L’Ecole  de  Sante,  and  the 
natural  specimen  of  which  was  in  the  possession  of 
Bichat.  A fracture  of  the  neck  of  the  thigh-bone  is 
sometimes  complicated  with  one  of  the  trochanter  ma- 
jor. 

With  respect  to  the  diagnosis  of  a fracture  wthin  the 
capsular  ligament,  an  acute  pain  is  felt,  a sudden  in-' 
ability  to  walk  occurs,  and  the  patient  cannot  raise 
himself  from  the  ground.  The  latter  circumstance, 
however,  is  not  invariable.  In  the  fourth  vol.  of  the 
Mem.  de  VAcad.  de  Chirurgie,  a case  is  related,  in 
which  the*  patient  walked  home  after  the  accident, 
and  even  got  up  the  next  day.  Desault  published 
a similar  example.  The  locking  of  one  end  of  the  frac- 
ture in  the  other  may  offer  an  explanation  of  this  cir- 
cumstance. The  dissections  m.ade  by  Dr.  Colies  have 
recently  led  to  another  discovery,  viz.  that  sometimes 
the  solution  of  continuity  does  not  extend  completely 
through  the  neck  of  the  femur. — (See  Dublin  Hospital 
Reports,  vol.  2.)  Three  cases  proving  this  fact  are 
there  adduced ; a fact  which  at  once  explains  the  abi- 
lity of  some  i)atients  to  walk  directly  after  the  injury, 
and  the  absence  of  all  retraction  of  the  limb.  Accord- 
ing to  Mr.  Amesbury,  incomplete  oblique  fractures  of 
the  neck  of  the  femur  are  easily  produced  in  the  recently 
dead  subject. — {On  Fractures  of  the  Upper  Third  of  the 
Thigh-Bone,  p.  3.) 

A shortening  of  the  limb  almost  always  takes  place : 
the  “ leg  becomes  from  one  to  two  inches  shorter  than 
the  other ; for  the  connexion  of  the  trochanter  major 
with  the  head  of  the  bone,  by  means  of  the  cervix,  being 
destroyed  by  the  fracture,  the  trochanter  is  drawn  up 
by  the  muscles  as  high  as  the  ligament  will  permit, 
and  consequently  rests  upon  the  edge  of  the  acetabu- 
lum, and  upon  the  ileum  above  ifai’ — {Sir  A.  Cooper  on 
Dislocations,  k\  c.  p.  117.)  The  *tion  of  the  muscles 
drawing  upwards  the  lower  end  of  the  fracture,  the 
weight  of  the  trunk  in  propelling  downwards  the  pel- 
vis and  upper  end  of  the  fracture,  are  the  two  causes  of 
the  shortening  of  the  limb.  In  general,  a slight  effort 
suftices  for  the  restoration  of  ihtrnatural  length  of  the 


limb ; but  the  shortness  recurs  almost  as  soon  as  tha 
extension  ceases.  “ This  evidence  of  the  nature  of  the 
accident  continues,”  as  Sir  A.  Cooper  correctly  remarks, 
“ until  the  muscles  acquire  a fixed  contraction,  which 
enables  them  to  resist  any  extension  which  is  not  of  the 
most  powerful  liind.”— {Surgical  Essays,  part  2,p.  31.) 
Goursault  and  Sabatier  remark,  that  sometimes  the 
shortening  of  the  member  does  not  take  place  till  a 
long  while  after  the  accident.  In  opposition  to  the 
common  belief  that  the  limb  is  shortened,  Baron  Lar- 
rey asserts,  that  the  member  is  at  first  actually  length- 
ened.— {Joum.  Complem.  t.  8,  p.  99.)  This  slaic- 
rnent  I have  never  seen  confirmed,  and  it  is  contra- 
dicted by  daily  experience.  And  to  prove  how  -widely 
Larrey  differs  from  Sir  A.  Cooper,  the  following  passage 
will  suffice.  “ In  order  to  form  a still  more  decided 
judgment  of  this  accident  (says  the  latter  writer)  after 
the  patient  has  been  examined  in  the  recumbent  pos- 
ture, let  him  be  directed  to  stand  by  his  bedside  sup- 
ported by  an  assistant,  so  as  to  bear  his  weight  upon 
the  sound  limb.  Immediately  he  does  this,  the  surgeon 
observes  most  distinctly  the  shortened  state  of  the  in- 
jured leg,  the  toes  resting  on  the  ground,  but  the  heel 
not  reaching  it,  the  everted  foot  and  knee,  and  the  di- 
minished prominence  of  the  hip.” — {Surgical  Essays, 
part  2,  p.  34.)  The  lessened  projection  of  the  trochan- 
ter major  arises  from  its  not  being  supported  by  the 
neck  of  the  bone,  as  it  always  is  in  the  natural  state 
of  the  parts.  A swelhng  is  observable  at  the  upper 
and  front  part  of  the  thigh,  always  proportioned  to  the 
retraction  of  which  it  appears  to  be  an  effect. 

The  projection  of  the  great  trochanter  is  almost  en- 
tirely efeced.  Directed  upwards  and  backwards,  this 
eminence  becomes  approximated  to  the  crista  of  the  os 
ileum  ; but,  if  pushed  in  the  opi)Osite  direction,  it  rea- 
dily yields ; and,  when  it  has  arrived  at  its  natural 
level,  the  patient  becomes  capable  of  moving  his 
thigh. 

The  knee  is  a little  bent.  Abduction  of  the  limb  al- 
ways occasions  acute  pain,  and  it  is  noticed  by  Sir  A. 
Cooper,  that  the  rotation  inwards  is  particularly  pain- 
ful, because  the  broken  extremity  of  the  bone  then  rubs 
against  the  capsular  ligament. — {Vol.  cit.  p.  33.)  If, 
while  the  hand  is  placed  on  the  great  trochanter,  the 
limb  is  rotated  on  its  axis,  this  bony  projection  may  be 
felt  revolving  on  itself,  as  on  a pivot,  instead  of  de- 
scribing, as  in  the  natural  state,  the  segment  of  a cir- 
cle, of  which  the  neck  of  the  feinur  is  the  radius.  This 
symptom,  wliich  was  particula'rly  noticed  by  Desault, 
is  very  manifest  when  the  fracture  is  situated  at  the 
base  of  the  neck,  less  so  when  at  its  middle  ; and  it  is 
not  very  perceptible  -when  the  breach  is  near  the  head 
of  the  bone.  In  the  rotatory  motions,  the  iower  frag- 
ment rubbing  against  the  upper  one  produces  a dis- 
tinct crepitus,  which,  however,  is  not  an  invariable 
symptom,  as  I.arrey  would  lead  one  to  suppose.  In 
fact,  as  Sir  A.  Cooper  has  explained,  it  is  not  discover- 
able while  the  patient  is  lying  upon  his  back  with  the 
limb  shortened ; but  if  the  leg  be  drawn  down,  so  as  to 
bring  the  limbs  to  the  same  length,  and  rotation  be 
then  performed,  especially  inwards,  the  crepitus  is 
sometimes  observed,  in  consequence  of  the  broken  ends 
of  the  bone  being  thus  brought  into  contact. — {On  Dis 
locations,  d-c.  p.  121.) 

It  appears  'm  Mr.  Amesbury,  that  the  head  of  the 
bone  moves  so  readily  in  the  acetabulum,  “ that  the 
least  impetus,  even  through  the  jKjriosteum  and  re- 
flected membrane  (supposing  them  to  be  entire),  will 
cause  it  to  move  simultaneously  with  the  shaft;  and 
if  it  should  do  so  in  the  same  relative  proportion,  cre- 
pitus cannot  be  felt.  If  crepitus  oe  not  elicited  by 
bending  the  limb  upon  the  pelvis,  the  surgeon  may 
try  to  produce  it  by  causing  the  limb  to  be  gently  ro- 
tated, while  he  endeavour.s  to  fix  the  head  of  the  bone 
by  pre.ssing  it  with  his  fingers  back  against  the  aceta- 
bulum.”— {On  Fractures  of  the  Upper  Third  of  the 
Thigh-Bone, p.  I.*).) 

The  toes  are  usually  turned  outwards;  a position 
which  Sabatier  considers  as  the  inevitable  effect  of  the 
fracture,  tiiough  Parc  and  Petit  noticed  that  it  did  not 
constantly  occur.  Two  cases,  adduced  by  these  illus- 
trious surgeons,  were  not  credited  by  M.  Louis;  hut 
the  exj'cvience  of  Desault  fully  confirmed  the  pos.si- 
bility  of  the  limb  not  being  always  rotated  outward.s  : 
and,  as  Sir  A.  Coo])er  has  remarked,  three  or  four 
hours  srenerally  olap.se  before  the  turning  of  the  liiiib 
()Ui\Naras  i.s  reedt  i'vi.  most  by  the  fixed  con- 


FRACTURES. 


401 


traction  of  the  muscles.  -(S«rg-icai  Ensays,  part  2, 
p.  32.) 

Mr.  Langstaff  dissected  one  case,  in  which  the  great 
toe  was  in  the  first  instance  everted,  but  subsequently 
t»irned  inwards  when  the  patient  began  to  use  the  limb. 
“ The  preparation  shows  the  fracture  to  have  been 
within  the  capsular  ligament,  close  to  the  head  of  the 
bone,  and  gives  a decided  refutation  to  the  opinion  of 
the  length  of  the  broken  portion  attached  to  the  tro- 
chanter being  the  cause  of  the  inversion,  inasmuch  as 
this  part  has  been  removed  by  absorption.  The  point 
of  the  foot  was  everted,  while  it  retained  its  proper 
length,  and  only  became  inverted  by  a wise  provision 
of  nature  to  assist  progression  after  it  had  begun  to  be 
shortened.  This  circumstance  received  great  illustra- 
tion in  the  person  of  Henry  West,  a boy  from  whom 
Mr.  White,  of  the  Westminster  Hospital,  removed  the 
head,  neck,  and  part  of  the  trochanter  of  the  left  thigh- 
bone, in  consequence  of  scrofulous  disease  of  the  hip- 
joint,  attended  by  abscess.  He  recovered  after  the  re- 
moval of  the  bone.  The  thigh  is  three  inches  and  a 
half  shorter  than  the  other,  and  the  toes  turn  inwards, 
not  only  in  walking,  but  when  he  lies  on  his  back  in  a 
quiescent  posture,  or  prepared  for  sleep.” — {Guthrie,  in 
Med.  Chir,  Trans,  vol.  13,  p.  109.)  The  possibility  of 
the  foot  being  turned  inwards  directly  after  the  acci- 
dent, is  the  subject  that  now  more  immediately  inte- 
rests us.  Of  this  occurrence  an  example  is  reported  by- 
Mr.  Stanley.  “ A middle-aged  man  fell  in  the  street, 
and  his  hip  struck  the  curb-stone.  The  immediate  con- 
quences  were,  that  the  limb  was  inverted  and  short- 
ened to  the  extent  of  an  inch,  and  no  crepitus  could  be 
discovered.  It  was  presumed  that  a dislocation  had 
occurred,  and  accordingly  an  extension  of  the  limb  was 
made,  and  so  great  was  the  constitutional  irritation  oc- 
casioned by  the  repeated  trials  to  reduce  the  supposed 
dislocation,  that  the  man  died  about  five  months  from 
the  time  of  the  accident.  In  the  dissection  of  the  hip, 
a fracture  was  found,  extending  obliquely  through  the 
middle  of  the  neck  of  the  femur,  but  entirely  within  the 
capsule.  A portion  of  fibrous  and  synovial  membrane 
on  the  anterior  side  of  the  neck  of  the  bone  had  es- 
caped laceration.”  “ In  a male  subject  that  had  been 
brought  for  dissection,  it  was  observed,  that  the  left 
lower  extremity  was  turned  inwards  and  considerably 
shortened.  On  examining  the  hip,  a fracture  was 
found,  extending  through  the  neck  and  shaft  of  the  fe- 
mur. The  neck  had  been  broken  at  its  junction  with 
the  shaft,  and  a fracture  had  extended  from  the  upper 
part  of  the  trochanter  major  downwards  at  the  poste- 
rior side  of  the  femur,  a little  below  the  trochanter 
minor.  The  upper  part  of  the  shaft  was  thus  split  into 
two  portions,  one  of  which  was  of  sufficient  magnitude 
to  include  the  trochanter  minor  and  nearly  the  whole 
of  the  trochanter  major. 

In  the  last  two  cases,  it  may  be  asked,  to  what  cause 
the  inversion  of  the  limb  should  be  attributed  ? Whether 
to  the  direct  ion  of  the  fracture  ? If  not,  whether  there 
be  any  other  circumstance  adequate  to  its  explanation  ? 
In  the  instance  of  fracture  within  the  capsule,  the  por- 
tion of  the  synovial  and  fibrous  membrane  which  had 
escaped  laceration  on  the  anterior  side  of  the  neck  of 
the  bone  might  probably  prevent  the  limb  from  being 
turned  outwards  ; but  (says  Mr.  Stanley)  why  it  should 
have  been  turned  inwards,  I confess  myself  unable  to 
explain.  In  the  instance  of  fracture  without  the  cap- 
sule, by  considering  the  direction  of  the  fracture,  in  re- 
ference to  the  attachments  of  the  muscles,  we  obtain 
an  explanation  of  both  points.  For,  as  Yiearly  the 
whole  of  the  muscles  that  rotate  the  thigh  outwards 
were  connected  with  the  separated  portion  of  bone, 
they  must  have  ceased  to  infiuence  the  limb  in  one 
direction,  and  of  course  have  left  their  antagonists  at 
liberty  to  turn  it  in  the  other;  and  the  fractured  sur- 
faces being  permitted  to  unite  without  any  change  in 
the  position  of  the  limb,  the  inversion  would  become 
permanent.”— (Med.  Chir.  Trans,  vol.  13,  p.  508.)  The 
merit  of  having  first  explained  the  cause  of  the  inver- 
sion of  the  foot  in  certain  fractures  on  the  outside  of 
the  capsular  ligament  is  due,  I believe,  to  Mr.  Guthrie. 

“ When  (says  he)  the  fracture  has  taken  place  in  such 
a manner  as  to  be  external  to  the  insertion  of  these  ro- 
tators outwards,  yet  sufficiently  within  the  insertion  of 
the  glutaius  medius  and  minimus,  so  as  not  to  deprive 
them  of  their  due  action,  the  toe  will  be  turned  in- 
wards and  mu.st  idways  be  so;  or  remain  without  any 
alteration  of  position,  according  to  certain  variations  in 

Vol.  I.— C c 


I the  inclination  of  the  fracture  affecting  the  power  of 
these  muscles.”  In  the  instance  recorded  by  Mr.  Guth- 
rie, the  little  trochanter  was  broken  off ; but  whether 
it  be  an  essential  complication,  he  conceives  must  be 
determined  by  future'  observation. — (Vol.  cit.  p.  112.) 
The  principles  on  which  this  gentleman  founds  his  ex- 
planation have  since  been  corroborated  by  the  parti- 
culars of  a case  that  was  examined  by  Mr.  Syme. — (See 
Edin.  Med.  Journ.  April,  1826.)  The  reason  of  the 
foot  being  occasionally  inverted,  even  when  the  frac- 
ture is  quite  within  the  capsular  ligament,  still  remains, 
however,  a point  in  surgery  requiring  explanation. 

The  ordinary  position  of  the  toes  outwards  is  com- 
monly, and  I believe  correctly,  imputed  to  the  rotator 
muscles.  Bichat  conceived,  however,  that  if  this  doc- 
trine were  true,  such  position  ought  always  to  exist ; 
and  he  reminds  us,  that  all  the  muscles  which  proceed 
from  the  pelvis  to  the  trochanter  are,  with  the  excep- 
tion of  the  quadratus,  in  a state  of  relaxation,  by  the 
approximation  of  the  femur  to  their  point  of  insertion ; 
and  tliat  the  contracted  muscles  would  not  allow  the 
foot  to  be  so  easily  turned  inwards  again.  Hence  Bi- 
chat thought  it  probable,  that  the  weight  of  the  foot 
itself  might  pull  the  limb  into  the  position  in  which  it 
is  commonly  found.  On  the  other  hand,  it  is  remarked 
by  Sir  A.  Cooper,  that  any  one  may  satisfy  himself  that 
the  rotation  of  the  limb  outwards  is  in  part  owing  to 
the  muscles,  by  feeling  the  resistance  which  is  made 
to  rotation  inwards,  which  resistance,  however,  he 
thinks,  may  in  some  measure  depend  upon  the  length 
of  the  portion  of  the  neck  of  the  femur,  which  remains 
attached  to  the  trochanter  major,  and  rests  against  the 
ileum. — {Surgical  Essays,  part  2,  p.  32.) 

In  addition  to  the  foregoing  observations  respecting 
the  diagnosis,  it  is  to  be  remembered,  that  a fracture 
within  the  capsular  ligament  seldom  happens  but  at 
an  advanced  period  of  life,  and  is  much  more  frequent 
in  women  than  men. — {Sir  A.  Cooper  on  Dislocations, 
Ac.  p.  123.) 

A fracture  of  the  neck  of  tlie  thigh-bone,  on  the  out- 
side of  the  capsular  ligament,  is  attended  with  but  little 
shortening  of  the  limb,  and  is  frequently  met  with  in 
persons  under  fifty,  though  it  may  and  does  occur  in 
older  subjects.  Also,  while  the  fracture  within  the 
capsule  takes  place  from  very  slight  causes,  this  is 
generally  the  result  of  great  violence,  severe  blows, 
falls,  and  the  passage  of  heavy  carriages  over  the 
pelvis.  The  crepitus  can  be  easily  felt  without  previ- 
ously drawing  down  the  limb,  and  the  case  is  charac- 
terized by  greater  suffering  than  what  is  usually 
noticed  when  the  Iracture  is  within  the  capsule.  But 
the  most  important  circumstance  in  wliich  a fracture  on 
the  outside  of  the  capsule  differs  from  one  within  it  is, 
in  its  readily  admitting  of  bony  union,  which  it  is  much 
more  difficult  to  accomplish  in  the  latter  case,  and  so 
rare  as  to  be  doubted  by  a surgeon  of  the  highest  reputa- 
tion and  greatest  experience. — (See  Sir  A.  Cooper  on 
Dislocations,  Ac.  p.  185,  &c.) 

In  an  oblicjue  fracture  through  the  trochanter  major, 
without  injury  of  the  neck  of  the  bone,  the  leg  is 
very  little,  and  sometimes  not  at  all,  shortened ; the  foot 
is  benumbed ; the  patient  cannot  turn  in  bed  without 
great  difficulty  and  pain;  in  some  cases  the  detached 
portion  of  the  trochanter  is  drawn  forwards  towards 
the  ileum ; in  others  it  falls  towards  the  tuberosity  of 
the  ischium ; but  in  general  it  is  widely  separated  from 
that  portion  which  remains  connected  with  the  neck  of 
the  bone.  The  foot  is  considerably  turned  outwards, 
and  a crepitus  not  readily  detected.  This  accident 
may  happen  at  any  period  of  life.  It  unites  readily, 
and  the  patient  recovers  with  a very  good  use  of  the 
limb.— (VoZ.  cit.  p.  158.) 

Many  years  ago,  it  tvas  supposed  that  fractures  of 
the  neck  of  the  thigh-bone  could  not  be  cured,  without 
some  shortening  of  the  limb  and  lameness.  Ludwig, 
Sabatier,  and  Louis  broached  this  doctrine,  and  imputed 
the  circumstance  to  the  destruction  of  the  neck  of  the 
bone.  That  this  sometimes  happens  has  been  well 
ascertained.  A late  surgical  visiter  to  Paris  informs  us, 
that  in  several  specimens  which  he  examined  in  different 
museums,  whether  imperfect  union  or  no  union  at  all 
had  followed  the  fracture,  this  absorption  of  the  neck 
of  the  bone  had  taken  i)lace  to  a great  extent,  and  in 
some  to  so  great  an  extent  that  the  articulating  surface 
of  the  bone  which  plays  in  the  acetabulum  rested 
between  the  trochanters,  consolidated  to  the  body  of 
the  bone  by  ligamentous  union,  and  the  thickening  of 


402 


FRACTURES. 


the  surrounding  parts,  Avhile  all  the  intervening  neck  i 
of  the  bone  was  absorbed.— (See  Sketches  of  the  Medical 
Schools  of  Pans,  by  J.  Cross,  p.  90.)  M.  Roux  has  also  | 
nearly  always  found  the  neck  of  the  femur  shortened  | 
and  deformed  after  its  reunion.— (ParaZ/e/e  de  la  Chir. 
Angloise  avec  la  Chir.  Francoise,  p.  178.)  Desault, 
however,  in  his  practice,  is  said  to  have  rarely  met  with 
instances  of  lameness  from  such  a cause. 

A question  that  has  lately  been  much  agitated  (see 
Earle's  Practical  Obs.  in  Surgery,  Lond.  1823 ; and 
Amesbury's  Obs,  on  the  Nature  and  Treatment  of 
Fractures  of  the  Upper  Third  of  the  Thigh-bone,  i,-c. 
Lond.  1829,  ed.  2)  is,  whether  reunion  by  bene  ever 
follows  cases  in  which  the  fracture  is  entirely  within 
the  capsule,  and  the  head  of  the  bone  insulated,  except 
at  its  attachment  to  the  acetabulum  by  the  round  liga- 
ment ? A few  years  ago,  the  decision  of  the  French 
surgeons  used  to  be  in  the  affirmative,  and  they  pre- 
tended actually  to  demonstrate  the  fact  by  preparations 
in  their  museums.  M.  Iloux,  indeed,  sent  over  a spe- 
cimen to  Sir  A.  Cooper,  with  the  hope  of  producing 
conviction ; but  this  eminent  surgeon  was  not  satisfied 
with  the  evidence,  because  the  traces  of  reunion  in  the 
preparation  appear  to  him  to  indicate  a sort  of  fracture, 
where  the  internal  fragment  still  retained  some  con- 
nexionwith  the  capsular  ligament. — (Roux,  Par  allele  de 
la  Chirurgie  Angloise,  A-c.  p.  179, 180.)  In  fact,  it  was 
a case  in  which  the  fracture  happened  at  the  junction 
of  the  cervix  with  the  trochanter.  And  Sir  A.  Cooper 
distinctly  states,  that  in  all  the  examinations  which  he 
has  made  of  transverse  fractures  of  the  cervix  femoris, 
within  the  capsular  ligament,  he  has  never  met  with  a 
bony  union,  or  with  any  which  did  not  admit  of  motion 
of  one  bone  upon  the  other. — {Surgical  Essays,  part  2, 
p.  39.)  He  imputes  the  want  of  bony  union  to  the 
fragments  not  being  in  contact  and  duly  pressed  against 
each  other,  and  to  the  little  action  in  the  head  of  the 
bone  separated  from  the  cervix,  “its  life  being  supported 
solely  by  the  ligamentum  teres,  which  has  some  few 
vessels  ramifying  from  it  to  the  head  of  the  bone.”  For 
the  particular  appearances  found  in  the  dissection  of 
these  cases,  I must  refer  to  the  statements  of  Dr. 
Codes  {Dublin  Hospital  Reports,  vol.  2),  and  to  Sir 
Astley  Cooper’s  own  account,  from  which  it  seems  that 
“ no  ossific  union  is  produced ; that  nature  makes 
slight  attempts  for  its  production  upon  the  neck  of  the 
bone  and  upon  the  trochanter  major,  but  scarcely  any 
upon  the  head  of  the  bone ; and  that  if  any  union  is 
produced,  it  is  by  ligament  only.”— (FoZ.  cit.  p.  46.) 
Mr.  Wilson’s  observations  are  all  in  confirmation  of  the 
same  explanation  {On  the  Skeleton,  p.  247) ; and  he 
adverts  to  two  preparations  in  the  museum  of  the  Col- 
lege of  Surgeons,  which  have  been  supposed  to  be 
proofs  of  a bony  reunion  of  the  neck  of  the  femur,  sub- 
sequently to  a fracture  within  the  capsular  ligament ; 
but  (says  Mr.  Wilson)  “ I have  very  attentively  ex- 
amined these  two  preparations,  and  cannot  perceive  one 
decisive  proof  in  either  of  the  bone  having  been  actu- 
ally fractured.”  One  of  these  cases  is  that  which  was. 
published  by  Mr.  Liston  in  the  Edin.  Med.  and  Surg. 
Journ.  Lastly,  Dr.  Codes,  of  Dublin,  dissected  several 
cases,  in  which  the  neck  of  the  femur  had  been  broken. 
In  one,  where  the  injury  was  within  the  capsular  liga- 
ment, “ no  effort  of  nature  had  been  made  to  create  a 
reunion  between  the  two  pieces  of  the  fracture,  and 
the  stability  of  the.  limb  had  deperided  upon  the  strength 
of  those  ligamentous  bands,  by  which  each  piece  was 
connected  with  the  capsular  ligamen.t  of  the  joint, 
aided,  no  doubt,  by  the  extraordinary  thickness  which 
the  capsular  ligament  had  acquired.”~{DubIin  Hospi- 
tal Reports,  vol.  2,  p.  336.)  In  the  first  two  instances 
reported  by  this  author,  “ the  broken  surfaces  moved 
on  each  other,  and  were  converted  into  a state  approach- 
ing to  ivory.  No  attempt  had  been  made  to  reunite  the 
fracture,  and  the  pieces  of  bone  were  held  in  apposition 
only  by  new  ligamentous  productions  from  the  capsular 
ligament,  which  were  inserted  into  the  externtd  sur- 
faces of  each  piece.  In  No.  3 there  had  been  a slight 
attempt  made  at  reunion.  In  Nos.  7,  8,  and  9,  we  ob- 
served a phenomenon,  which,  I believe,  is  now  for  the 
first  time  mentioned,  a fracture  of  only  part  of  the 
bone.  No.  6 presented  us  with  that  mode  of  reunion 
which  some  have  supposed  the  most  perfect  of  which 
this  fracture  is  susceptible.  While  Nos.  10  and  11 
exhibit  a mode  of  reunion  very  little  inferior  to  callus 
in  point  of  firmness,  but  very  different  in  its  nature, 
and  which  : conceive  is  peculiar  to  the  fracture  of  the 


neck  of  the  femur.”  Dr.  Colies  also  found  that,  in  all 
these  cases  (except,  perhaps.  No.  5),  the  capsular  liga- 
ment was  not  lacerated.  In  every  instance,  however, 
there  was  an  increased  thickness  of  the  capsule,  and  a 
removal  of  all  or  the  greater  part  of  the  neck  of  the  bone. 
“ Although  the  ligamentous  bands  seem,  in  a majority 
of  instances,  to  have  proceeded  from  the  capsular  liga- 
ment, yet  it  is  evident  from  No.  6,  that  these  may  arise 
merely  from  the  broken  surfaces  of  the  bone  ; for  in  this 
case,  not  a single  fibre  was  attached  to  the  capsular 
ligament,  the  new  bond  of  union  being  covered  by  the 
refiected  portion  of  the  synovial  membrane  or  periosteum 
of  the  neck.  We  have  an  illustration  of  this  in  Ruysch, 
tab.  1,  thes.  9.”  In  Nos.  10  and  11,  the  fragments  were 
united  by  a cartilaginous  substance.  In  Nos.  7,  8,  and 
9,  the  unbroken  portion  of  the  neck  was  so  softened, 
that  it  more  resembled  cartilage  than  bone,  and,  in  this 
state,  “ it  was  laid  down  upon  the  fractured  surface, 
and  united  to  it.” — {Dr.  Colles,  in  Dublin  Hospital  Re- 
ports, vol.  2,  p.  353 — 355.)  In  the  Museum  of  the 
Ecole  de  M6decine  at  Paris,  there  are  some  preparations 
which  the  professors  exhibit  at  their  lectures,  in  order 
to  prove  that  bony  union  may  succeed  a fracture  of  the 
femur.  These  specimens  were  carefully  examined  by 
Mr.  Cross ; but  none  of  them  proved  to  him  that  bony 
union  ever  follows  where  the  head  of  the  bone  becomee 
insulated,  excepting  its  attachment  to  the  pelvis  by  the 
ligamentum  teres.-^Sketches  of  the  Medical  Schools  ai 
Paris,  p.  93.)  On  the  other  hand,  Boyer  observes,  tha> 
experience  fully  proves  the  possibihty  of  uniting  such 
fractures  of  the  neck  of  the  thigh-bone  as  are  situatet^ 
within  the  capsular  ligament ; but  he  acknowledges  tha^ 
there  are  certain  circumstances  which  may  prevent  this 
desirable  event.  “ From  all  that  has  been  hitherto  said 
on  the  prognosis  of  a fracture  of  the  neck  of  the  femur, 
we  may  conclude  (says  Boyer)  that  this  fracture  is 
more  serious  than  that  of  any  other  part  of  the  same 
bone,  because  the  difficulty  of  keeping  it  reduced  is 
greater.  That  it  may  in  general  be  reunited,  especially 
in  young,  healthy  subjects  (in  whom,  however,  be  it 
observed,  the  accident  hardly  ever  occurs)  ; but  more 
easily  when  it  is  situated  near  the  base  of  the  neck  than 
near  the  head  of  the  bone.  That  the  languid  vitality 
of  one  of  the  fragments,  and  the  impossibility  of  ascer- 
taining whether  the  coaptation  be  exact,  make  the  cure 
slow,  and  the  time  necessary  for  their  consolidation 
uncertain.  That  the  neglect  of  means  adapted  to  main- 
taining the  limb  in  its  proper  length  and  natural 
straightness,  and  the  fragments  sufficiently  motionless, 
may  cause  them  to  unite  by  an  intermediate  substance. 
Lastly,  that  the  situation  of  the  fracture  near  the  head 
of  the  femur  ; the  complete  laceration  of  the  elongation 
of  the  capsule  investing  the  neck  of  the  beme;  the  great 
age  of  the  patient ; and  particularly  the  constitution 
labouring  under  some  diathesis,  which  affects  the  os- 
seous system,  may  render  the  cure  absolutely  impos- 
sible ; iliat,  in  this  circumstance,  one  of  the  fragments 
is  more  or  less  destroyed  by  the  friction  of  the  other 
against  it,  and  in  the  joint  a disease  is  formed,  which 
tends  to  carry  off  the  patient.” — {Traite  des  Mai.  Chir. 
t.  3,  p.  284.)  This  professor  lays  much  stress  on  the 
complete  laceration  of  the  continuation  of  the  capsule 
over  the  neck  of  the  bone,  as  an  occurrence  preventive 
pf  union.  But  he  thinks  it  does  not  frequently  happen, 
because  the  capsular  ligament  hinders  much  displace- 
ment of  the  fragment  {op.  cit.  p.  278)  ; a remark  rather 
at  variance  with  the  shortened  state  of  the  limb.  As 
for  Baron  Larrey,  he  appears  to  entertain  no  doubt  of 
the  possibility  of  uniting  fractures  of  the  neck  of  the 
femur  within  the  capsular  ligament,  and  concludes  his 
tract  on  this  subject  with  the  case  of  General  Fririon, 
who  w'as  perfectly  cured  after  a supposed  injurj-  of  this 
description.— (See  Journ.  Complem.t.  8,p.  118!)  That 
some  French  surgeons,  however,  are  now  beginning  to 
be  less  positive  in  their  belief,  is  sufficiently  manifest 
from  the  circumstance  of  a rew  ard  having  been  offered 
in  France  for  the  best  explanation  of  the  cause  of  such 
fractures  not  uniting  by  bone.— (;?/>  A.  Cooper,  Appen- 
dix, p.  43.) 

How  is  this  discordance  to  be  reconciled  and  accounted 
for  ? After  the  very  numerous  and  careful  dissectiona 
w'hich  have  been  j)erformed  by  Sir.  A.  Cooper  and  Dr. 
Colies,  with  the  view  of  ascertaining  the  state  of  the 
joint,  after  fractures  of  the  neck  of  the  thigh-bone,  htlle 
doubt  can  be  entertained  that,  where  the  fracture  is 
transverse,  and  ivithin  the  capsular  ligament,  a bony 
reunion,  if  not  absolutely  impossible,  is  at  least  so 


FRACTURES. 


403 


fate  an  occurrence  as  not  to  be  calculated  upon.  The 
difference  of  the  French  surge«ns  upon  this  question  is 
to  be  ascribed  to  their  not  having  duly  rliscriininaied 
from  the  foregoing  kind  of  case  either  fractures  extend- 
ing more  or  less  in  the  direction  of  the  axis  of  the  neck 
of  the  bone,  or  other  fractures  external  to  the  capsular 
ligament.  How  much,  however,  the  safety  of  a prac- 
titioner’s reputation  will  depend  upon  the  progno.sis 
which  is  given  must  be  quite  evident ; for  in  the  trans- 
verse fracture  within  the  capsule,  lameness  is  almost 
sure  to  follow,  though  its  degree  cannot  at  first  be 
exactly  estimated. — {Sir  A.  Cooper,  Surgical  Essays, 
parti,  p.  51.) 

As  far  as  I am  able  to  judge  of  this  subject.  Sir  Astley 
Cooper  has  been  the  means  of  introducing  clear  and 
discriminate  views  of  it,  and,  without  his  able  exer- 
tions, the  important  differences  in  the  nature,  symp- 
toms, and  curableness  of  the  various  kinds  of  fractures 
of  the  neck  and  upper  part  of  the  thigh-bone,  depending 
upon  their  exact  situation  and  direction,  might  yet  have 
continued  very  imperfectly  comprehended.  This  re- 
mark is  made  without  any  intention  of  deducting  from 
the  merits  of  Desault,  Platner,  and  Mr.  John  Bell ; ail 
of  whom  seem  to  have  expressed  their  belief,  that  a 
fracture  within  the  capsular  ligament  will  not  admit  of 
union  by  callus.— (C.  Bell  on  Injuries  of  the  Spine  and 
Thigh-bone,  Ato.  Lond.  1824,  p.  62,  iS-c.) 

Mr.  Amesbury,  in  his  late  treatise,  attem])ts  to  prove, 
that  all  fractures  of  the  neck  of  the  thigh-bone  admit 
of  union,  whether  they  be  situated  quite  within  the 
capsular  ligament  or  not,  and  whether  the  reflected 
portion  of  that  ligament  be  ruptured  or  not ; and  he 
ascribes  the  usual  want  of  success,  not  to  the  nature 
of  the  injury,  not  to  the  insufficient  circulation  in  the 
pelvic  portion  of  the  bone,  but  to  the  imperfection  of 
the  mechanical  means  employed  in  the  treatment.  As, 
however,  the  important  point  under  consideration, 
namely,  whether  transverse  fractures  of  the  neck  of 
the  femur,  situated  entirely  within  the  capsular  liga- 
ment, admit  of  bony  union,  is  one  that  can  only  be  de- 
termined by  experience,  Mr.  Amesbury  follows  up  his 
arguments  by  a reference  to  cases.  “ Though,”  says 
he,  “ Sir  Astley  has  not,  I believe,  yet  seen  a specimen 
sufficient  to  convince  him  that  this  variety  of  fracture 
has  ever  united  by  bone,  there  are  now  fbur  prepara- 
tions, which  satisfy  the  minds  of  many  other  surgeons 
that  osseous  union  is  occasionally  produced.”  The  first 
case  adduced  is  one  that  was  under  the  care  of  Mr. 
Cribbe,  of  Holburn,  and  is  described  by  Mr.  Lang- 
staff,  who  has  the  prepartion : “ The  woman  was  about 
50  years  of  age  when  the  accident  occurred.  The  foot 
was  everted,  and  there  was  shortening  of  the  limb  at 
this  time ; and,  after  death  it  was  shorter  than  the 
other  full  two  inches  and  a half.  She  was  confined  to 
bed  nearly  twelve  months:  during  the  remainder  of 
her  life,  which  was  ten  years,  she  walked  with  crutches. 
This  (says  Mr.  Langstaff,  alluding  to  the  preparation) 
is  a specimen  of  fracture  of  the  neck  of  the  thigh-bone 
within  file  capsular  ligament ; the  principal  part  of  the 
neck  is  absorbed ; the  head  and  remaining  portion  of 
the  neck  were  united  principally  by  bone,  and  partly 
by  a cartilaginous  substance.  The  capsular  ligament 
was  immensely  thickened,  and  embraced  the  joint 
very  closely.  The  cartilaginous  covering  of  the  head 
of  the  bone  and  acetabulum  had  suffered  partial  ab- 
sorption ; the  internal  surface  of  the  capsular  ligament 
was  coated  with  lymph.  On  making  a section  of 
the  bone,  it  was  evident,  that  there  had  been  a frac- 
ture of  the  neck  vnthin  the  capsular  ligament,  and 
that  union  had  taken  place  by  osseous  and  cartilagi- 
nous media.” — (See  Med.  Chir.  Trans,  vol.  13.)  Mr. 
Amesbury  then  adverts  to  Dr.  Brulatour’s  case  re- 
ported in  the  same  volume  of  the  latter  work.  This 
gentleman  died  about  nine  months  after  the  injury. 
Tlie  following  appearances  presented  themselves.  1. 
Th-  capsule  a little  thickened.  2.  The  cotyloid  cavity 
sound.  3.  The  interarticular  ligament  in  a natural 
Slate.  4.  The  neck  of  the  femur  shortened : from  the 
bottom  of  the  head  to  the  top  of  the  great  trochanter 
was  only  four  lines,  and  from  the  same  point  to  the 
top  of  the  small  trochanter  six  lines.  5.  An  unequal 
line  surrounded  the  neck,  denoting  the  direction  of  the 
fracture.  6.  At  the  bottom  of  the  head  of  the  femur, 
and  at  the  extenial  and  po.sterior  part,  a considerable  | 
bony  deposite  had  taken  place.  A section  of  the  bone  | 
was  made  in  a line  drawn  from  the  centre  of  the  head 
of  the  femur  to  the  bottom  of  the  great  trochanter,  so  [ 


as  perfectly  to  expose  the  callus.  Tlie  line  of  bone  in- 
dicated by  the  callus  was  smooth  and  polished  as  ivory. 
The  line  of  callus  denoted  also  that  the  bottom  of  the 
head  of  the  femur  had  been  broken  at  its  superior  and 
posterior  parts. 

In  another  example  communicated  to  Mr.  Amesbury 
by  Mr.  Chorley,  of  Leeds,  a gentleman. died  twelve 
months  after  the  accident,  and  on  examming  the  hip, 
the  synovial  covering  was  found  united  with  the  short- 
ened neck  of  the  bone  nearly  at  the  head.  Here  nature 
had  also  thrown  out  broad  ligamentous  bands,  one  on 
each  side  of  the  joint.  They  were  firmly  united  to  the 
head  of  the  bone.  When  the  soft  parts  had  been  re 
moved,  the  head  of  the  bone  was  seen  depressed  in  a 
line  with  the  shaft.  The  fracture  was  slightly  oblique, 
commencing  at  the  upper  part  close  against  the  carti 
laginous  covering  of  the  head  of  the  bone,  and  extend- 
ing downwards  and  outwards,  so  as  to  terminate  in  a 
point  at  the  lower  surface  of  the  neck,  one  inch  from 
the  cartilaginous  covering  of  the  head.  The  jiosterior 
surface  of  the  shed  of  the  neck  had  the  appearance 
of  having  been  splintered,  so  as  to  make  a part  of  the 
fractured  end  of  the  pelvic  portion  extend  in  one  situa- 
tion a little  on  the  outside  of  the  capsular  ligament, 
and  where  no  union  had  taken  place. 

In  a fourth  instance,  where  the  necks  of  both  thigh- 
bones had  been  broken  at  different  periods,  the  parts 
were  examined  after  the  patient's  decease.  On  the 
right  side,  the  fracture  extended  througli  the  neck  of  the 
bone,  in  a direction  downwards  and  outwards.  In  one 
part  a portion  of  the  reflected  membrane  remained  entire ; 
but  was  separated  from  the  neck  of  the  bone  in  such  a 
manner  as  not  to  prevent  the  retraction  of  the  limb. 
The  head  of  the  bone  was  somewhat  excavated  ; and 
that  portion  of  the  neck  attached  to  the  trochanter  was 
partially  absorbed.  There  was  no  soft  substance  be- 
tween the  surfaces  of  the  fracture.  A bond  of  union, 
however,  consisting  of  fibrinous  matter,  adhered  to  the 
sides  of  the  ends  of  the  fracture,  and  in  one  part  it  was 
strong.  No  surgical  attempt  had  been  made  to  unite 
the  fracture  on  the  right  side.  On  the  left,  the  neck  of 
the  bone  had  been  broken  within  the  capsule,  and  was 
firmly  united.  The  cervix  was  nearly  absorbed ; and 
the  head  was  depressed,  so  as  to  come  within  about 
two  lines  of  the  trochanter  minor,  to  which  it  was 
united  at  its  base  by  a small  short  process  of  bone. 
Strong  bands  of  ligament  were  seen  connecting  the 
pelvic  portion  of  bone  to  the  capsule,  which  had  be- 
come thickened  and  much  smaller  than  natural.  There 
had  been  a longitudinal  fracture  of  the  trochanter  ma- 
jor, but  quite  independent  of  the  injury  of  the  cervix. 
The  fracture  of  the  latter  part  w^as  united  with  the 
head,  about  two  inches  and  a half  below  its  natural  si- 
tuation ; which  leads  Mr.  Amesbury  to  believe,  that 
what  he  terms  the  close  coverings  of  the  neck  of  the 
bone  had  been  nearly  or  quite  divided.  A longitudinal 
section  of  the  head  and  neck  of  the  bone  showed,  ac- 
cording to  Mr.  Amesbury,  that  the  fracture  had  taken 
place  close  to  the  head.  The  uniting  callus  had  be- 
come cancellated ; but  he  says  that  the  direction  of  the 
fracture  could  be  seen  “ by  the  situation  of  the  tro- 
chanteral  portion  of  the  neck,  when  examined  in  dif- 
ferent parts  of  Its  circumference.”— (See  Amesbury  on 
Fractures,  (S-c  p.  43,  <J-c.) 

With  respect  to  some  of  these  cases  and  dissections, 
if  they  are  correctly  described,  they  sufficiently  esta- 
blish the  possibility  of  bony  union  in  fractures  entirely 
within  the  capsular  ligament;  but  in  order  that  the 
point  may  be  completely  settled,  I should  recommend 
Mr.  Amesbury  to  submit  the  preparations  to  which  he 
refers  to  a committee  of  the  profes.sion,  including  those 
gentlemen  who  have  not  hitherto  been  satisfied  with 
any  specimens  yet  presented  to  them.  The  rapidity 
with  which  absorption  proceeds  in  the  head  and  neck 
of  the  thigh-bone  after  fractures,  brings  about  such 
changes  as  must  soon  greatly  obscure  the  exact  origi- 
nal situation  and  direction  of  the  injury,  and  particu- 
larly the  question  whether  the  injury  reached  also  on 
the  outside  of  the  capsular  ligament.  That  fractures 
extending  beyond  the  capsular  ligament  may  be  united 
by  bone,  is  admitted  by  all  parties,  as  well  as  the  fact, 
that  those  entirely  within  the  capsule  are  often  united 
with  the  intervention  of  fibrous  or  ligamentous  bands. 

I In  confirmation  of  this  circumstance,  I have  already 
j cited  the  dissections  performed  by  Dr.  C'olles,  of  Dublin"’ 
and,  in  farther  proof  of  it,  1 refer  to  the  preparations 
1 in  the  musetim  of  the  College  of  .Surgeons  at  Ediix- 


FRACTURES. 


burgh,  as  specified  by  Mr.  B.  Bell  of  that  city.— (See 
Treatise  on  the  Diseases  of  the  Bones,  p.  205,  >i'  c.  1828.) 

Having  spoken  of  the  nature  of  fractures  of  the  neck 
of  the  thigh-bone,  within  and  without  the  capsular  liga- 
ment, I come  next  to  the  consideration  of  the  proper 
practice  to  be  adopted.  In  the  first  description  of  the 
injury,  as  osseous  union  is  rare,  perhaps  even  not  at- 
tainable, ought  we  to  endeavour  to  keep  the  fragments 
as  nearly  in  a state  of  apposition  as  possible,  and  sub- 
ject the  patient  to  rest  and  confinement,  with  the  view 
of  promoting  the  other  modes  of  union  so  well  pointed 
out  in  Dr.  Colles’  paper?  Or  should  we,  as  Sir  A. 
Cooper  does,  avoid  confining  the  patient  to  any  long  or 
continued  extension,  “ as  being  likely  to  be  productive 
of  ill-health,  without  the  possibility  of  producing 
union?”  Yet  it  appears  both  from  this  gentleman’s 
own  statements,  and  from  those  of  Dr.  Colles,  Mr. 
Langstaff,  Mr.  B.  Bell,  and  others,  that  though  a bony 
union  cannot  always  be  effected,  other  connecting 
means  may  be  established,  and  the  more  perfect  these 
are,  the  less  will  be  the  subsequent  lameness.  As  long, 
therefore,  as  these  facts  are  incontrovertible,  I should 
be  disposed  to  recommend  surgeons  to  do  every  thing 
in  their  power  to  keep  the  limb  quiet,  and  in  a desirable 
posture  for  a due  length  of  time.  On  this  point  all 
surgeons  must,  on  reflection,  be  unanimous.  It  is  one 
that  I have  always  insisted  upon  in  my  surgical  wri- 
tings, and  it  is  one  that  is  very  properly  defended  by 
Mr.  Amesbury  in  his  recent  publication.  Whether, 
for  this  purpose,  Boyer’s  apparatus,  with  the  limb  in 
the  straight  posture;  or  the  apparatus  with  two  in- 
clined surfaces,  with  the  limb  in  the  bent  position,  and 
the  patient  on  his  back  ; or,  lasUy,  Hagedorn’s  ingeni- 
ous and  scientific  treatment,  as  explained  in  the  last 
edition  of  the  First  Lines  of  Surgery,  should  be  pre- 
ferred, time  and  experience  must  determine.  Sir  A. 
Cooper  merely  places  one  jiillow  under  the  whole 
length  of  the  limb,  and  puts  another  transversely  under 
the  patient’s  knee,  so  as  to  keep  the  limb  in  an  easy 
bent  position.  In  a fortnight  or  three  weeks  the  pa- 
tient is  allowed  to  sit  upon  a high  chair,  and  in  a few 
more  days  he  begins  to  take  exercise  upon  crutches. 
After  a time,  these  are  laid  aside,  a stick  substituted 
for  them,  and  in  a fe,w  months  this  assistance  may  be 
dispensed  with.  At  the  end  of  the  treatment,  a shoe 
must  be  worn  with  a sole  of  equal  thickness  to  the 
diminished  length  of  the  \imh.—{S7irgical  Essays, 
part  2,  p.  50.)  For  the  management  of  fractures  of  the 
neck  of  tlie  thigh-bone,  Messrs.  Amesbury  and  Earle  em- 
ploy fracture-beds,  constructed  with  the  view  of  fulfil- 
ling all  the  main  indications,  and  in  particular  of  keep- 
ing the  ends  of  the  fracture  at  rest  in  the  best  posi- 
tion. Their  contrivances  display  great  ingenuity,  and 
well  deserve  the  attention  of  the  profession. 

In  the  treatment  of  such  fractures  of  the  neck  of 
the  femur  as  are  situated  on  the  outside  of  the  capsu- 
lar ligament.  Sir  A.  Cooper  prefers  the  position  in 
which  the  patient  lies  on  his  back,  with  the  injured 
limb  in  a bent  posture,  supported  on  what  is  termed 
the  double-inclined  plane,  the  kind  of  instrument  al- 
ready spoken  of,  as  being  sometimes  employed  by  Mr. 
C.  Bell.  When  the  limb  has  been  placed  over  this 
machine  in  an  easy  bent  position,  a long  splint,  reach- 
ing above  the  trochanter  major,  is  applied  to  the  outer 
side  of  the  thigh,  and  fastened  to  the  pelvis  with  a 
strong  leather  strap,  so  as  to  press  one  portion  of  bone 
towards  the  other.  The  lower  part  of  the  splint  is 
also  fastened  to  the  outside  of  the  knee  with  a strap. 
The  limb  is  to  be  kept  as  quiet  as  possible  for  eight  weeks, 
at  the  end  of  which  time  the  patient  may  leave  his 
bed,  if  the  attempt  should  not  cause  too  much  pain ; 
but  the  splint  is  to  be  continued  another  fortnight.— 
(Surgical  Essays,  part  2,  p.  59.)  Desault’s  apparatus 
has  been  described  in  the  foregoing  columns,  and  those 
of  Boyer  and  Hagedoni  are  explained  and  represented 
in  the  First  Lines  of  Surgery. 

Larrey,  who  disapproves  of  the  plan  of  continued 
extension,  has  lately  proposed  a particular  apparatus 
for  fractures  of  the  neck  of  the  femur ; but  as  it  ap- 
pears to  me  very  inferior  to  other  methods  already 
mentioned,  I shall  here  merely  refer  to  the  .Joum. 
Compl.  t.  8,  p.  115,  where  a description  of  it  may  be 

I am  glad  to  find  the  number  of  advocates  for  Pott  s 
method  of  treatment  annually  diminishing.  Indeed, 
the  bad  eflects  and  painful  consequences  of  having  the 
whole  weight  of  the  trunk  operating  upon  the  frac- 


tured ends  of  the  bone,  which  are  often  not  properly 
in  contact,  are  too  obvious  to  need  any  comment.  Yet 
this  injudicious  pressure  is  made  in  the  bent  position, 
which  also  forbids  the  use  of  long  effective  splints,  and 
all  assistance  from  moderate  continued  extension. 

A fracture  of  the  neck  of  the  thigh-bone  may  be  com- 
plicated with  a dislocation  of  the  head  of  the  bone. — 
(See  J.  G.  Haase,  De  Fracturd  Colli  Ossis  Femoris,  cum 
Luxatione  Capitis  ejusdem  Ossis  conjuncta,  Lips. 
1798.)  For  farther  information  relative  to  fractures  of 
the  neck  of  the  femur,  the  following  authors  may  be 
consulted.  C.  G.  Ludwig  de  Collo  Femoris  ejusque 
Fractura  Programma,  Lips.  1755.  Bellocq,  in  Mem.  de 
VAcad.  de  Chir.  t.  3.  Aitken's  and  GoocKs  machines 
are  described  in  B.  Bell's  Surgery,  vol.  4.  Sabatier,  in 
Mem.  de  VAcad.  de  Chir.  t.  4.  Duvemey,  Traite  des 
Mai.  des  Os,  t.  1 . Unger,  in  Richter's  Bibl.  b.  6,  p. 
520.  Theden,  Neue  Bemerkungen,  Src.  th.  2.  Brun- 
ninghausen  uber  den  Bruch  des  Schenkelbeinhalses, 
iS  c.  Wurzb.  1789.  Van  Gescher  iiber  die  Entstellun- 
gen  des  Ruckgrats,  und  iiber  der  Verrenkungen  und 
Bruch  dez  Schenkelbeins,  aus  d.  Holland.  Hedenus, 
in  Bernstein's  Darstellung  des  Chir.  Verbandes,  tab. 
42,  fig.  82  and  83.  M.  Hagedom  iiber  der  Bruch  des 
Schenkelbeinhalses,  frc.  Leipz.  1808.  J.  N.  Sauter, 
Anweisung  die  Beinbriiche  der  Gleidmassen  vorz'i- 
glich  die  complicierten  und  den  Schenkelbeinhalsbruch 
nach  einer  neuen,  Arc.  Methods,  ojme  Schienen,  si- 
cker zu  heilen,  6vo.  Konstanz.  1812.  J.  Wilson  on 
the  Structure  and  Physiology  of  the  Skeleton,  &-c.  p. 
243,  Src.  Svo.  Land.  1820.  Dr.  Colles,  in  Dublin  Hos- 
pital Reports,  vol.  2.  Sir  A.  Cooper,  Surgical  Essays, 
part  2 ; and  Treatise  on  Dislocations,  A c.  4to.  1822, 
tvith  Appendix,  1823.  H.  Eai  le.  Practical  Obs.  on  Sur- 
gery, 1823.  Lancet,  Nos.  5 and  8,  vol.  1,  p.  302.  Boyer, 
TraiU  des  Mai.  Chir.  t.  3.  John  Bell,  Principles  of 
Surgery,  Mo.  1801,  p.  549,  (S  c.  C.  Bell,  on  Injuries  of 
the  Spine  and  Thigh-Bone,  Mo.  1824.  G.  hangstajf, 
Cases  of  Fractured  Neck  of  the  Thigh-Bone,  within  the 
Capsular  Ligament,  with  the  Dissections  and  Obs.  in 
Med.  Chir.  Trans,  vol.  13.  E.  Stanley,  Cases  of  In- 
juries of  the  Hip-Joint,  vol.  cit.  G.  J.  Guthrie  on  the 
Diagnosis,  and  on  the  Inversion  of  the  Foot  in  Frac- 
ture of  the  Neck,  Srv.  of  the  Thigh-Bone,  vol.  cit.  p. 
103.  Syme,  in  Edin.  Med.  Jou.in.  April,  1826.  B 
Bell,  on  Diseases  of  the  Bone,  1828.  J.  Amesbury, 
Obs.  on  Fractures  of  the  Upper  Third  of  the  Thigh- 
Bone,  (S-c.  2d  ed.  1829. 

OBLIQUE  FRACTURES  OF  THE  EXTERNAL  OR  INTERNAL 
CO.NDYLE  OF  THE  FEMUR  INTO  THE  JOINT. 

In  these  cases.  Sir  A.  Cooper  prefers  the  straight  po- 
sition, because  the  tibia  presses  the  extremity  of  the 
broken  condyle  into  a line  with  that  which  is  not  in- 
jured. The  limb  is  to  be  put  in  the  extended  posture 
upon  a pillow,  and  evaporating  lotions  and  leeches  are 
to  be  used  for  the  removal  of  the  swelling  and  inflam- 
mation. “ When  this  object  has  been  effected,  a roller 
is  to  be  applied  around  the  knee,  and  a piece  of  stiff 
pasteboard,  about  sixteen  inches  long,  and  sufficiently 
wide  to  extend  entirely  under  the  joint,  and  to  pass  on 
each  side  of  it,  so  as  to  reach  to  the  edge  of  the  pa- 
tella, is  to  be  dipped  in  warm  water,  and  applied  under 
the  knee,  and  confined  by  a roller.  When  this  is  dry, 
it  has  exactly  adapted  itself  to  the  form  of  the  joint, 
and  this  form  it  afterward  retains,  so  as  best  to  confine 
the  bones.  Splints  of  wood  or  tin  may  be  used  on 
each  side  of  the  joint ; but  they  are  apt  to  make  un- 
easy pressure.  In  five  weeks,  passive  motion  of  the 
limb  may  be  gently  begun,  to  prevent  anchylosis.”— 
{Surgical  Essays,  part  % p.  101 ; also.  Treatise,  p.  221.) 
This  author  afterward  describes  a compound  fracture 
of  the  external  condyle,  a portion  of  which  was  after 
a lime  extracted,  and  the  case  ended  so  favourably, 
that  the  patient,  who  was  a boy,  was  able  to  bend  and 
extend  the  leg  without  pain. 

For  fractures  just  above  the  condyles.  Sir  A.  Cooper 
recommends  the  bent  position,  without  which,  he  says, 
deformity  is  sure  to  follow.  He  advises  the  limb  to  be 
placed  over  the  double  inclined  plane,  and  a roller  ap- 
plied round  the  lower  portion  of  the  femur. — (P.  103.) 

FRACTURES  OF  THE  PATELLA. 

This  bone  is  most  frequently  broken  transversely, 
and  the  accident  may  be  produced  either  by  the  action 
of  external  bodies,  or  by  that  of  the  exten.sor  muscles. 
In  the  latter  case,  the  fall  is  subsequent  to  the  fracture. 


FRACTURES. 


405 


and,  as  Camper  has  remarked,  it  is  mostly  only  an  ef- 
fect of  it.  For  instance,  the  line  of  gravity  of  the 
body  is,  by  some  cause  or  another,  inclined  backwards  ; 
the  muscles  in  front  contract  to  bring  it  forwards 
again ; the  extensors  act  on  the  patella ; this  breaks, 
and  the  fall  ensues.  That  it  is  the  action  of  the  mus- 
cles and  not  the  fall  which  usually  breaks  the  knee- 
pan,  is  well  ascertained.  Sometimes  the  fracture  oc- 
curs, though  the  patient  completely  succeeds  in  pre- 
venting himself  from  falling  backwards,  as  we  find 
exemplified  in  two  cases  reported  by  Sir  A.  Cooper. — 
(Surgical  Essays,  part  2,  p.  85.)  A soldier  broke  his 
patella  in  endeavounng  to  kick  his  sergeant:  the  ole- 
cranon has  been  broken  in  throwing  a stone.  In  the 
operating  theatre  of  the  Hdtel-Dieu,  both  the  knee-pans 
of  a patient  were  broken  by  the  violent  spasms  of  the 
muscles,  which  followed  an  operation  for  the  stone. 
The  force  of  the  muscles  occasionally  ruptures  the 
common  tendon  of  the  extensor  muscles,  or,  what  is 
more  frequent,  the  ligament  of  the  patella.  Of  these 
cases.  Petit,  Desault,  and  Sabatier  met  with  examples. 
When  the  patella  is  broken  longitudinally,  the  cause  is 
always  outward  violence. — (CEuvres  Chir.  de  Desault, 
t.  1,  p.  252.) 

A transverse  fracture  of  the  patella  may  also  origi- 
nate from  a blow  or  fall  on  the  part ; but  in  common 
cases  it  is  produced  by  the  violent  action  of  the  ex- 
tensor muscles  of  the  leg.  It  is  only  of  late  years, 
however,  that  the  true  mode  in  which  the  bone  is  usu- 
ally broken  has  been  understood.  As  Boyer  observes, 
for  the  production  of  a transverse  fracture  of  the  knee- 
pan,  the  extensor  muscles  of  the  leg  need  not  act  with 
a convulsive  force,  their  ordinary  action  being  strong 
enough  to  produce  the  effect  in  question  when  the 
body  is  inclined  backwards,  and  the  patient  is  in  dan- 
ger of  falling  upon  his  occiput.  In  this  stale,  the 
thigh  being  bent,  the  extensor  muscles  of  the  leg  con- 
tract powerfully,  in  order  to  bring  the  body  forwards 
and  prevent  the  fall  backwards;  and  the  patella, 
whose  posterior  surface  then  rests  only  by  a point 
against  the  fore  part  of  the  condyles  of  the  femur,  is 
placed  between  the  resistance  of  the  ligament  binding 
it  to  the  tibia,  and  the  action  of  the  extensor  muscles. 
A fracture  now  happens  the  more  easily,  because,  by 
the  flexion  of  the  knee,  the  line  of  the  extensor  mus- 
cles and  that  of  the  ligament  of  the  patella  are  ren- 
dered oblique,  with  respect  to  the  vertical  axis  of  this 
bone,  which  is  bent  backwards  at  the  point,  where  it 
rests  upon  the  condyles.— (Traif^  des  Mai.  Chir.  t.  3, 
p.  322.  C.  Bell’s  Operative  Surgery,  vol.  2,  p.  201,  8uo. 
Land.  1809.  A.  Cooper’s  Surgical  Essays,  part  2,  p. 
86.)  By  violent  spasmodic  action  of  the  extensor 
muscles,  however,  the  patella  may  be  broken  trans- 
versely, while  the  limb  is  perfectly  straight.  A very 
singular  case  is  mentioned  by  Sir  A.  Cooper,  where  a 
patella,  which  had  been  formerly  broken  and  united 
by  ligament,  was  again  divided  into  two  portions,  in 
consequence  of  the  destruction  of  the  uniting  medium 
by  ulceration. — (Vol.  cit.  p.  100.)  A case  is  also  on 
record,  where  the  ligamentous  uniting  substance  was 
so  incorporated  with  the  skin,  that  when  the  latter 
happened  to  be  lacerated,  the  knee-joint  was  laid  open, 
and  amputation  became  necessary.— (C.  Bell,  Op.  Sur- 
gery, vol.  2,  p.  204.) 

In  transverse  fractures,  there  is  a considerable  sepa- 
ration between  the  two  fragments  of  the  bone,  very 
perceptible  to  the  finger  when  the  hand  is  placed  on 
the  knee.  This  separation  is  not  occasioned  equally 
by  both  portions  ; the  upper  one,  embraced  by  the  ex- 
tensor muscles,  is  drawn  upwards  very  forcibly  by 
these  powers,  which  the  patella  no  longer  resists ; 
while  the  inferior  portion,  being  merely  connected  with 
the  ligament  below,  is  not  moved  by  any  muscle,  and 
can  only  be  displaced  by  the  motions  of  the  leg  to 
which  it  is  attached.  Hence  the  separation  is  least 
when  the  limb  is  extended,  being  then  only  produced 
by  the  upper  fragment;  greatest  when  the  limb  is 
bent,  because  both  pieces  contribute  to  it ; and  it  may 
be  increa.sed  or  diminished  by  bending  the  knee  more 
or  less. 

As  Boyer  has  particularly  noticed,  the  laceration  or  not 
of  the  tendinous  expansion  upon  the  front  of  the  patella, 
makes  a material  difference  in  these  cases,  because  it 
is  a part  of  great  importance  in  the  cure.  According 
to  this  author,  a portion  of  it  in  simple  fractures  of  the 
patella  generally  escapes  laceration,  and  the  separation 
of  the  fragments  is  then  not  very  considerable  ; but 


violent  action  of  the  extensor  muscles,  the  fall  subse- 
quent to  the  fracture  or  bending  of  the  knee  too  much, 
may  separate  the  pieces  of  bone  far  from  each  other, 
and  rupture  the  tendinous  expansion. — (Traiti  des 
Mai.  Chir.  t.  3,  p.,  328.)  According  to  Sir  A.  Cooper, 
“ when  the  ligament  is  but  little  torn,  the  separation 
will  be  but  half  an  inch ; but  under  great  extent  of  in- 
jury, the  bone  is  drawn  five  inches  upwards,  the  cap- 
sular ligament  and  tendinous  aponeurosis  covering  it 
being  then  greatly  lacerated.” — (Surgical  Essays,  part 
2,  p.  84.) 

The  upper  portion  of  bone  may  be  moved  trans- 
versely, and  pain  is  thus  excited,  but  no  crepitus 
can  be  felt,  as  the  two  pieces  of  bone  are  not  suffi- 
ciently near  each  other.  When  the  swelling  of  the 
knee,  consequent  to  fractures  of  the  patella,  is  very 
great,  the  symptoms  of  the  injury  may  be  more  or  less 
obscure.  However,  in  consequence  of  the  inability  of 
the  extensor  muscles  to  move  the  leg,  except  in  a few 
cases  where  the  fracture  is  very  low,  the  patient  can- 
not stand  without  difficulty,  and  is  unable  to  walk. 

In  the  treatment,  the  chief  indications  are  to  over- 
come the  action  of  the  extensor  muscles  of  the  leg, 
and  to  keep  the  fragments  as  near  each  other  as  pos- 
sible, partly  by  a judicious  position  of  the  limb,  and 
partly  by  mechanical  means.  The  first  indication  is 
fulfilled  by  relaxing  the  above-mentioned  muscles  ; 1st, 
by  extending  the  leg ; 2dly,  by  bending  the  thigh  on 
the  pelvis,  or,  in  other  w'ords,  raising  the  femur,  so 
that  the  distance  between  the  knee  and  anterior  su- 
perior spinous  process  of  the  ileum  may  be  as  little  as 
possible  ; which  object,  however,  will  also  require  the 
body  to  be  raised,  and  the  pelvis  somewhat  inclined 
forwards.  In  short,  as  Richter  long  ago  advised,  the 
patient  should  be  almost  in  a sitting  posture,  the  trunk 
forming  a right  angle  with  the  thigh. — (Bill.  Chir.  b. 
6,  p.  611,  Gottingen,  1782.)  3dly,  The  muscles  are 
to  be  compressed  with  a roller.  The  second  indica- 
tion, or  that  of  placing  and  maintaining  the  fragments 
in  contact,  or  as  nearly  so  as  circumstances  will  al- 
low, is  in  a great  measure  already  answered  by  the 
above-recommended  position  of  the  limb  and  trunk ; 
but  it  is  not  perfectly  fulfilled  unless  the  upper  portion 
of  the  bone  be  also  pressed  towards  the  lower  frag- 
ment, and  mechanically  held  in  this  situation  by  the 
pressure  of  an  apjjaratus  or  bandage.  And,  in  push- 
ing the  upper  fragment  towards  the  lower  one,  the 
surgeon  should  always  be  careful  that  the  skin  be  not 
depressed  and  pinched  between  them. 

Having  described  the  principles  which  ought  to  be 
observed,  I do  not  know  that  any  great  utility  would 
result  from  a detail  of  the  various  methods  of  treating 
a broken  patella,  preferred  by  different  surgeons.  In 
the  last  edition  of  the  First  Lines  of  Surgery  may  be 
found  a description  of  the  plan  and  apparatus  employed 
by  Baron  Boyer.  Desault’s  practice,  which  was  re- 
lated in  the  third  edition  of  this  Dictionary,  I now 
omit  as  not  being  exactly  such  as  modern  surgeons 
would  adopt ; not  from  any  of  his  principles  being 
erroneous,  but  because  his  apparatus  is  more  compli- 
cated than  necessary. 

After  putting  the  patient  to  bed  upon  a mattress,  and 
in  the  desirable  posture,  with  the  limb  confined,  sup- 
ported, and  raised,  as  above  directed,  upon  a well 
padded  hollow  splint.  Sir  A.  Cooper  applies  at  first  no 
bandage  to  the  knee,  but  covers  it  with  linen  wet  with 
a lotion  composed  of  liq.  plunibi  acet.  dilut.  1 v.  and 
spir.  vin.  5 j-  if)  on  the  succeeding  day  or  two,  there 
be  much  tension  or  ecchyrnosis,  leeches  should  be  ap- 
plied, and  the  lotion  continued;  but  the  employment 
of  a bandage  is  not  to  commence  until  the  tension  has 
subsided  ; for  Sir  A.  Cooper  assures  us  that  he  has 
seen  the  greatest  sufi'ering,  and  such  swelling  as 
threatened  gangrene,  produced  in  these  cases  by  the 
too  early  use  of  a roller.  Instead  of  a circular  band- 
age, placed  above  and  below  the  broken  bone,  and 
drawn  together  with  tape,  &c.,  so  as  to  bring  the  upper 
fragment  towards  the  lower  one,  this  experienced  sur- 
geon prefers  the  following  method.  A leather  strap  is 
buckled  round  the  thigh,  above  the  broken  and  elevated 
portion  of  bone,  and  from  this  circular  piece  of  leather 
another  strap  passes  under  the  middle  of  the  toot,  the 
leg  being  extended,  and  the  foot  considerably  raised. 
This  strap  is  brought  up  to  each  side  of  the  patella, 
and  buckled  to  the  leather  band  already  applied  to  the 
lower  part  of  the  thigh.  It  may  al.so  be  lastened  to  the 
foot  or  any  part  of  the  leg  with  tapes.  The  limb  is 


406 


FRACTURES. 


to  be  confined  iu  this  position  five  weeks  if  the  patient 
be  an  adult,  and  six  if  advanced  in  years.  Then  a 
slight  passive  motion  is  to  be  begun,  and  to  be  gently  in- 
creased from  day  to  day,  until  the  flexion  of  the  knee  is 
complete. — {Surgical  Essays,  part  2,  p.  91.)  But,  al- 
though the  impropriety  of  making  any  constriction  of 
the  knee  with  a bandage,  while  the  skin  is  swelled  and 
inflamed,  must  be  obvious,  the  surgeon  ought  to  be 
apprized  that  such  swelling  and  inflammation  ought 
not  to  occa.sion  the  least  delay  in  placing  the  limb  in 
the  right  posture,  and  pressing  the  upper  fragment  to- 
wards the  lower  one.  Mohrenheim  ascribes  the  lame- 
ness formerly  so  frequent  after  this  fracture,  partly  to 
the  custom  of  not  thinking  of  bringing  the  jneces  of 
bone  together  until  the  swelling  had  subsided,  and 
partly  to  the  fashion  of  bending  the  joint  too  soon, 
with  a view  of  preserving  its  motion.  But,  says  he, 
nothing  can  be  clearer  than  that  It  is  most  advanta- 
geous to  attend  to  the  union  of  the  fracture  first, 
and  to  the  flexibility  of  the  joint  afterward. — {Beohach- 
tungen,  b.  2,  8vo.  1783.)  Boyer  has  likewise  re- 
marked, that  the  uniting  substance  is  apt  to  yield,  and 
become  lengthened,  by  bending  the  knee  too  early,  and 
he  therefore  never  allows  this  motion  to  be  performed 
before  the  end  of  two  months.  When  the  ligamentous 
substance  is  long,  and  the  patient  very  slow  in  regain- 
ing the  use  of  the  extensor  muscles,  he  should  sit 
every  day  on  a table,  and  endeavour  to  bring  them  into 
action,  and  as  this  increases,  a weight  may  be  affixed 
to  the  foot,  as  Hunter,  Sheldon,  «&c.  recommend. 

Nothing  keeps  the  leg  more  surely  extended  than  a 
long,  broad,  excavated  splint,  with  a suitable  pad,  ap- 
plied to  the  posterior  part  of  the  thigh  and  leg,  and 
fixed  there  with  a roller,  while  the  thigh  itself  is  to  be 
bent  by  raising  the  whole  limb,  from  the  heel  to  the  top 
of  the  thigh,  with  pillows,  which,  of  course,  must  form 
a gradual  ascent  from  the  tuberosity  of  the  ischium  to 
the  foot. 

The  broken  patella  is  almost  always  united  by  means 
of  a ligamentous  substance,  instead  of  bone. 

However,  that  an  osseous  union  may  follow  a trans- 
verse fracture  of  the  patella,  and  still  more  frequently 
a perpendicular  one,  is  a fact  of  which  there  is  not  noAV 
the  slightest  doubt.  Thus,  Lallement  has  published 
an  unequivocal  specimen  of  a transverse  fracture 
united  by  bone,  with  the  history  of  the  case,  and  the 
appearances  after  the  death  of  the  patient  from  some 
other  affection. — {Boyer,  Traite  des  Mai.  Chir.  t.  3,  p. 
355,  &c.)  In  the  collection  of  Dr.  William  Hunter, 
there  is  one  well-marked  instance  of  the  bony  union  of 
a transverse  fracture  of  the  patella,  and  other  exam- 
ples have  been  seen  in  the  dead  subject  by  Mr.  Wilson. 
— {On  the  Structure,  Physiology,  ^c.  of  the  Skeleton, 
p.  240.)  In  Mr.  Charles  Bell’s  museum  may  also  be 
seen  similar  specimens. — {On  Injuries  of  the  Spine 
and  Thigh-bone,  p.  57,  58.)  The  reason  why  trans- 
verse fractures  of  the  patella  do  not  commonly  unite  by 
callus,  is  not  owing  to  the  want  of  power  in  this  bone 
to  produce  an  osseous  connecting  substance  ; for,  as 
Larrey  has  several  times  noticed,  if  the  fragments  are 
kept  in  perfect  contact  by  means  of  a suitable  appara- 
tus, their  bony  reunion  becomes  so  complete,  that 
scarcely  any  vestige  of  the  injury  can  afterward  be 
traced. — {Journ.  Complrm.  t.  8,  p.  114.)  Indeed,  it  is 
a fact,  on  which  Larrey  dwells,  as  affording  a proof 
that  callus  is  produced  not  by  the  periosteum,  but  by 
the  vessels  of  the  bones  themselves.  And  what  must 
add  strength  to  the  purport  of  the  foregoing  remarks  is 
the  consideration,  that  perpendicular  or  longitudinal  frac- 
tures of  the  patella,  which  are  not  liable  to  any  displace- 
ment from  the  action  of  the  extensor  muscles  of  the  leg, 
readily  admit  of  bony  union.— (WiZvon  on  the  Structure 
and  Physiology,  <fi  c.  of  the  Skeleton,  p.  239.)  This  is 
a statement  which,  I think,  could  not  be  rendered  doubt- 
ful by  any  experiments  made  on  animals,  without  the 
advantages  of  quietude  and  proper  treatment.  Yet, 
there  are  other  facts  related,  which  prove  that,  both  in 
longitudinal  and  transverse  fractures,  a ligamentous 
union  is  generally  produced,  when  the  fragments  are 
separated ; but,  if  these  are  not  drawn  asunder,  an  os- 
seous union  takes  place.  Thus,  in  one  case  reported 
by  Sir  A.  Cooper,  one-third  of  the  patella  was  sepa- 
rated from  the  rest  of  this  bone,  and  had  united  by  liga- 
ment, a free  motion  being  left  between  the  fragments. 
—{Surgical  Essays,  part  2,  p.  94.)  The  same  gentle- 
man divided  the  patella  longitudinally  in  a dog,  with- 
out extending  the  division  into  the  tendon  above,  or  the 


ligament  below,  so  that  tlie  fragments  could  not  be  se- 
parated. In  three  weeks  a close  bony  union  was  tha 
result.— (P.  95.)  A case  is  also  related,  in  which  a 
gentleman  fractured  the  patella  transversely,  and  the 
lower  portion  likewise  perpendicularly.  The  trans- 
verse fracture  united  as  usual  by  ligament ; the  perpen- 
dicular one  by  bone. — (P.  96.)  Mr.  Charles  Bell  gives 
another  explanation  of  the  cause  of  union  being  by 
bone  or  ligament.  In  the  common  case,  says  he,  of 
fracture  of  the  patella  by  the  sudden  action  of  the  quad- 
riceps extensor,  the  pieces  are  separated  without  that 
degree  of  violence  which  is  necessary  to  produce  re- 
union by  bone.  But  when  the  patella  is  broken  by  a 
blow  or  kick,  there  is  not  only  less  retraction,  but  “ the 
injury,  bloody  effusion,  tumefaction,  and  rigidity  of  the 
parts,  resemble  that  which  attends  the  fracture  of  any 
other  bone,  and  the  fragments  unite  by  bone.”— (On  In- 
juries of  the  Spine  drc.  p.  58.) 

The  incorrect  notions  formerly  entertained  respect- 
ing the  inconveniences  of  an  exudation  and  projection 
of  the  callus  into  the  joint  after  a fracture  of  the  pa- 
tella, and  especially  when  the  fragments  are  kept  in 
contact,  were  long  ago  refuted  by  Pott  and  Sheldon. — 
{Pott's  Chir.  Works,  vol.  1,  p.  332,  ed.  of  1808.  Shel- 
don's Essay  on  the  Fracture  of  the  Patella,  Sec.  8vo. 
Land.  1789.)  On  the  contrary,  as  Sir  A.  Cooper  par- 
ticularly remarks,  “the  internal  articular  surface  of 
the  bone  preserves  its  natural  smoothness.” — {Essays, 
part2,p.  86.)  How  such  doctrine  of  a superabnndant  cal- 
lus could  be  reconciled  with  the  doubts  about  abony  union 
being  ever  possible,  appears  difficult  of  explanation. 

Pott,  and  some  others,  thought  that  there  being  com- 
monly an  interspace  afterward,  between  the  two  pieces 
of  the  patella,  with  a certain  length  of  the  connecting 
substance,  might  be  advantageous  in  the  motion  of  the 
joint ; but  Desault,  Boyer,  Sir  A.  Cooper,  Sir  J.  Earle, 
and  others,  have  always  fbund  that  the  greater  the  dis- 
tance between  the  two  pieces  of  the  bone,  the  greater  is 
the  difficulty  afterward  in  walking  up  a rising  or  over 
an  unequal  ground. 

In  the  treatment  of  a longitudinal  or  perpendicular 
fracture  of  the  patella,  the  leg  should  be  kept  extended, 
leeches  used,  and  a cold  lotion  applied.  After  a few 
days  a roller  is  to  be  put  round  the  limb,  and  then  a laced 
knee-cap  with  straps  buckled  round  the  limb  above  and 
below  the  patella.— (A.  Cooper,  vol.  cit.  p.  96.)  The  ex- 
perience of  Dupuytren  confirms  the  fact,  that  a longi- 
tudinal fracture  of  the  patella  is  soon  firmly  consoli- 
dated.— {Annuaire  M:  d.  Chir.  de  Paris,  p.  94, 4fo.  Pa- 
ris, 1819.)  Compound  fractures  of  the  patella  fre- 
quently tenninate  in  the  death  of  the  patient,  unless 
amputation  be  done  early.  The  injury,  however,  does 
not  invariably  lead  either  to  the  loss  of  life  or  limb.  I 
saw  a case  in  St.  Bartholomew’s  Hospital,  in  the  year 
1820,  under  Mr.  Vincent,  where  the  patella  was  broken 
to  pieces,  and  the  opening  so  extensive  that  the  fingers 
readily  passed  into  the  joint ; yet,  after  a tedious  con- 
finement, the  formation  of  abscesses,  and  the  separa- 
tion of  several  fragments  of  bone,  the  patient  reco- 
vered with  astiff  joint.  In  general,  however,  I believe, 
with  Sir  A.  Cooper,  that  in  compound  fractures  of  the 
patella,  if  the  laceration  be  extensive,  or  the  contusion 
very  considerable,  amputation  will  be  required  ; but  if 
the  wound  be  small,  the  patient  not  irritable,  and  no 
sloughing  of  the  integuments  or  ligament  likely  to  oc- 
cur, it  will  be  best  to  try  to  save  the  limb. — ( Vol.  cit. 
p.  99.)  The  wound  should  be  reunited  as  speedily  as 
possible,  and  advantage  taken  of  evaporating  lotions, 
perfect  rest  in  a desirable  posture,  a very  low  regimen, 
leeches,  venesection,  and  saline  opening  medicines. 
Since  writing  the  above  remarks  I have  seen  another 
case  of  bad  compound  fracture  of  the  patella  in  St. 
Bartholomew’s  Hospital,  where  it  has  been  about  a 
month.  No  fragments  of  bone  have  yet  been  removed, 
but  a good  deal  of  matter  issues  daily  from  the  wound. 
The  case  must  be  regarded  as  in  a very  precarious  state, 
though,  if  hectic  symptoms  should  not  lower  the  patient 
too  much,  the  limb  will  probably  be  saved. 

In  addition  to  the  works  already  cited,  consult  D.  H. 
Meibomius  de  Patellae  Osse,  ejusque  Laesionibus  et 
Curotione,  FraTick.  1697,  P.  Camper,  Diss.  de  Frac- 
turd  Patellae  et  Olecrani,  4Zo.  Hagae  Comit.  1789, 
Buirer  in  v.  Siebold,  Chiron,  t.  1,  p.  64.  T.  Alcock, 
in  Trans,  of  the  Associated  Apothecaries,  iW.  vol  1. 

FR.VCTURK9  OF  THK  LEO 

May  be  transverse  or  obliiiue.  The  first  case  is  al* 


FRACTURES. 


407 


leged  to  be  most  common  in  children.  Experience 
proves  that  the  two  bones  of  the  leg  are  much  more 
frequently  broken  together  than  singly ; a fact  ascribed 
by  Boyer  to  the  strength  of  the  knee  and  ankle-joints. 
—{TraiU  des  Mai.  Chir.  t.  3,  p.  360.)  The  direction  of 
an  oblique  fracture  of  the  tibia  is  found  to  be  pretty 
constantly  from  below  upwards,  and  from  within  out- 
wards, the  end  of  the  upper  fragment  mostly  present- 
ing itself  under  the  skin  at  the  front  and  inner  part  of 
the  leg.  In  these  cases,  the  longitudinal  displacement  of 
the  fracture  is  less  constant  than  the  horizontal  and  angu- 
lar. However,  when  it  does  happen,  the  inferior  frag- 
ments are  drawn  outwards  and  backwards,  while  the  su- 
perior project  internally  and  forwards.  The  angular  dis- 
placement may  be  produced  either  by  the  action  of  the  ik)s- 
terior  muscles  of  the  leg,  or  the  weight  of  the  foot,  and 
in  both  cases  the  angle  projects  forwards.  But  it  may 
be  directed  posteriorly,  if  the  heel  be  too  much  raised. 
A rotatory  displacement,  most  commonly  happening  in 
the  direction  outwards,  is  produced  by  the  inclination 
of  the  foot,  and  if  this  be  turned  too  much  inwards,  the 
rotatory  displacement  will  be  in  that  direction.  A lon- 
gitudinal displacement  cannot  take  place  in  transverse 
fractures,  on  account  of  the  considerable  extent  of  the 
surfaces  of  bone ; but  in  oblique  fractures,  the  inferior 
fragments  are  almost  always  drawn  upwards  by  the 
action  of  the  posterior  muscles  of  the  leg,  in  which  po- 
sition of  the  parts  the  lower  ends  of  the  superior  frag- 
ments project  forwards,  and  may  be  felt  by  the  hand. 
Sometimes,  however,  when  the  solution  of  continuity 
is  obliquely  downwards  and  outwards,  the  anterior  pro- 
jection will  be  produced  by  the  lower  pieces.  In  both 
kinds  of  displacement,  the  pointed  ends  of  the  bones 
may  tear  and  penetrate  the  integuments,  and  cause  a 
compound  fracture. 

The  usual  symptoms  denoting  a fracture  of  both 
bones  of  the  leg  are,  a change  in  the  direction  and  shape 
of  the  limb,  pain,  and  incapability  of  walking,  or  bear- 
ing upon  the  limb,  mobility  of  the  fractured  pieces,  and 
a distinct  crepitus. 

Fractures  near  the  knee  are  not  very  subject  to  dis- 
placement, on  account  of  the  thickness  of  the  tibia  at 
that  part ; but  they  are  more  dangerous  than  those  of 
the  middle  of  the  bone,  because  often  followed  by  in- 
flammation of  the  knee-joint.  Fractures  close  to  the 
ankle  are  still  more  dangerous.  Oblique  fractures  are 
very  difficult  of  management,  and  when  their  displace- 
ment is  upwards  and  outwards,  the  integuments  are  in 
danger  of  being  torn  by  the  projecting  points  of  the  su- 
perior portion  of  the  tibia. — (Boyer.)  To  bad  com- 
pound fractures  of  the  leg  most  of  the  observations  are 
applicable  already  delivered  on  compound  fractures  in 
general. 

When  the  size  of  the  tibia  is  compared  with  that  of 
the  fibula,  and  the  close  connexion  of  these  bones  to 
each  other  is  remembered,  an  opinion  might  be  formed, 
that  the  first  could  never  be  broken  without  the  second. 
Experience,  however,  proves  the  contrary.  And  rea- 
sons for  this  fact,  as  Boyer  remarks,  may  be  deduced 
fl-em  the  consideration  that  the  tibia  is  the  bone  which 
suj.ports  the  weight  of  the  body,  and  that  it  is  situated 
at  the  fore  part  of  the  limb,  simply  covered  by  the  skin 
and  much  exposed  to  the  effects  of  violence.— (TV/zite 
des  Mai.  Chir.  t.  3,  p.  373.)  When  the  tibia  alone  is 
broken,  the  fracture  is  said  to  be  generally  transverse. 

If  the  injury  happens  near  the  knee,  the  great  extent 
of  the  fractured  surfaces  prevents  any  considerable  dis- 
placement of  the  fragments  ; and  the  fibula,  acting  as 
a support  on  fhe  external  side,  contributes  also  to  this 
effect.  Boyer,  however,  has  seen  one  instance  in  which 
the  tibia  was  broken  by  the  kick  of  a horse,  and  the 
fragments  displaced  in  the  direction  of  the  axis  of  the 
bone,  which  displacement  could  not  be  rectified,  so  that 
the  bone  remained  permanently  arched  at  the  part. 

The  absence  of  displacement  often  renders  the  diag- 
nosis of  fractures  of  the  tibia  very  difficult,  and  the  dif- 
ficulty is  farther  increased  by  the  little  pain  and  incon- 
venience produced  by  such  a fracture,  with  which  per- 
sons have  been  known  even  to  walk. 

Whenever  there  is  reason  to  suspect  the  accident,  in 
consequence  of  a blow  or  a fall  on  the  leg,  the  part 
should  be  minutely  examined.  The  fingers  are  to  be 
nioved  along  the  anterior  side  of  the  tibia,  the  slightest 
inequality  in  which  may  be  easily  perceived,  on  ac- 
< (nint  of  its  being  covered  only  by  the  skin ; and  the 
motion  of  the  pieces  may  be  di.stinguished  by  grasping 
the  opj)o,site  ends  of  the  bone,  and  pushing  them  in  con- 


trary directions.  However,  this  motion  and  the  crepi- 
tus are  not  always  very  plain,  on  account  of  the  fibula 
not  allowing  the  fractured  portions  to  be  sufficiently 
moved  on  one  another. 

In  a review  of  the  position  and  strength  of  the  two 
bones  of  the  leg,  if  will  appear  that  the  tibia  supports 
alone  the  whole  weight  of  the  body,  every  shock  di- 
rected in  the  axis  of  the  limb,  and  many  kinds  of  force 
applied  also  in  the  transverse  direction,  without  ope- 
rating upon  any  particular  point.  Hence  the  frequency 
of  fractures  of  the  tibia  ; and  if  the  fibula  is  generally 
broken  at  the  same  time,  the  latter  injury  is  but  subse- 
quent to  the  other,  and  takes  place  because  this  slen- 
der bone  is  not  capable  of  bearing  the  weight  of  the 
body,  the  impulse  of  external  violence,  and  even  the  ac- 
tion of  the  muscles,  after  the  tibia  has  given  way. — 
(Dupuytren,  Annuaire  M^d.  Chir.  des  Hdpitaux  de  Pa- 
ris, p.  15,  4to.  Paris,  1819.)  On  the  other  hand,  as  the 
same  distinguished  surgeon  remarks,  the  fibula  being 
principally  designed  as  a support  for  the  outside  of  the 
foot,  it  is  imrticulurly  when  this  function  is  to  be  exe- 
cuted, and  its  lower  end  has  to  make  resistance  to  ef- 
forts made  in  that  direction,  that  it  is  fractured;  and  if 
the  lower  part  of  the  tibia  be  also  sometimes  broken  by 
the  same  force,  it  is  almost  always  con.secutively,  and 
hot  by  the  effect  of  a diiect  and  simultaneous  action 
upon  the  two  bones. — (P.  17.)  All  fractures  of  the 
fibula,  however,  are  not  caused  in  the  preceding  man- 
ner; and  Dupuytren  concurs  with  i:oyer,  Mr.  C.  Bell, 
and  all  the  best  writers  on  this  subject,  in  dividing 
these  cases  into  two  kinds ; first,  those  in  which  the 
force  is  applied  directly  to  the  bone  itself;  secondly, 
the  more  important  and  serious  cases,  in  which  the 
force  operates  upon  the  fibula,  through  the  medium  of 
the  foot.  With  respect  to  the  first  class  of  cases,  the 
situation  of  the  fibula  on  the  outer  side  of  the  leg,  a 
situation  which  would  seem  to  expose  it  much  to  ex- 
ternal violence ; its  slenderness ; the  interspace  left  be- 
tween it  and  the  tibia  at  the  middle  part  of  the  leg; 
and  the  way  in  which  each  end  of  it  rests  upon  the 
latter  bone ; would  lead  one  to  expect  that  its  middle 
portion  must  often  be  broken ; yet  the  case  is  less  fre- 
quent than  might  be  apprehended.  And,  as  Dupuytren 
observes,  there  are  two  reasons  for  this  fact;  viz.  the 
protection  which  the  fibula  receives  from  the  peronsei 
muscles,  and  the  rarity  of  circumstances  capable  of 
producing  a fracture  by  a direct  cause.  These  frac- 
tures, which  are  not  usually  attended  with  deformity, 
and  in  some  cases  even  do  not  hinder  the  patient  from 
bearing  upon  the  foot,  cannot  for  the  most  part  be  ascer- 
tained, unless  attention  be  paid  to  the  manner  in  which 
the  accident  was  produced,  and  to  the  presence  of  ee- 
chymosis,  and  of  more  or  less  pain  in  the  part  which 
has  been  struck,  or  pressed  upon  ; together  with  a de- 
gree of  irregularity  of  the  fibula,  perceptible  by  the 
fingers,  and  a more  or  less  distinct  moveableness  and 
crepitus  of  the  ends  of  the  fracture. 

The  usual  cau.ses  of  this  sort  of  fracture  are  blows 
on  the  fibula,  gun-shot  wounds,  the  fall  of  heavy  bodies 
on  the  outside  of  the  leg,  or  the  passage  of  them  over 
the  sam^part.  The  toot  is  generally  twisted,  either 
inwards  or  outwards ; and  in  most  instances  the  acci- 
dent is  easily  cured  by  means  of  rest,  without  being 
accompanied  by  any  of  the  symptoms  so  often  compli- 
cating other  fractures  of  the  fibula,  produced  by  distor- 
tion of  the  foot. ^(Dupuytren,  vol.  cit.  p.  40.)  A striking 
analogy  may  be  remarked  between  fractures  of  the 
central  part  of  the  fibula  and  those  of  the  correspond- 
ing portion  of  the  ulna,  and  this  in  respect  to  causes, 
symptoms,  treatment,  and  consequences.  Fractures  of 
the  middle  of  the  ulna,  like  those  of  the  body  of  the 
fibula,  are  always  occasioned  by  blows  or  falls  on  the 
fractured  iiart,  or  by  violence  applied  directly  to  the 
bone.  Such  fractures  are  scarcely  ever  attended  with 
any  deformity  in  the  limb,  incapacity  of  moving  it,  or 
displacement  of  the  fragments ; and  just  as  some  indi- 
viduals are  able  to  walk  with  a broken  fibula,  others, 
notwithstanding  a fracture  of  the  ulna,  are  found  capa- 
ble of  using  their  forearm  nearly  as  well  as  if  it  were 
free  from  injury.  The  latter  case,  like  that  of  a frac- 
ture of  the  fibula,  can  only  be  known  by  the  recollec- 
tion of  the  way  in  which  the  hurt  was  received,  the 
pain,  ecchymosis,  irregularities,  motion,  and  crepitus, 
which  last  effects  are  also  not  very  obvious  so  high  up 
the  bone.  I.ike  fractures  of  the  body  of  the  fibula,  those 
of  the  body  of  the  ulna  only  require  rest  and  discutient 
applications,  and  very  seldom  llie  bandages,  &c.  ueces- 


408 


FRACTURES. 


sary  in  the  treatment  of  fractures  of  both  bones  of  the 
forearm,  or  of  those  of  the  radius  alone. — (FoZ.  cit. 
p.  50.) 

Fractures  of  the  fibula  from  an  i-ndirect  cause  may 
happen  from  the  foot  being  violently  twisted  either  in- 
wards or  outwards.  In  both  instances  the  cause  of  the 
fracture  is  a change  in  the  direction  of  the  line  in 
which  the  weight  of  the  body  is  transmitted.  In  the 
first  case,  the  said  line,  instead  of  following,  as  it  com- 
monly does,  the  axis  of  the  tibia,  and  falling  upon  the 
astragalus,  crosses  the  lower  end  of  the  tibia  and  the 
ankle-joint,  obliquely  from  within  outwards,  and  after 
passing  across  the  malleolus  externus,  extends  to  the 
outside  of  the  member.  The  parts  then  supporting  the 
weight  of  the  body  are  the  malleolus  externus  and  the 
lower  end  of  the  tibia ; besides  which  state  of  parts, 
the  same  malleolus  is  subjected  to  the  fraction  of  the 
external  lateral  ligaments,  which  operate  with  great 
force,  in  consequence  of  those  ligaments  being  now 
nearly  at  a right  angle  with  the  lower  end  of  the  fibula, 
while  this  process  itself  is  in  contact  with  the  astraga- 
lus, wliich  is  propelled  from  witliin  outwards  by  the 
tibia.  The  latter  bone,  being  thicker  and  stronger 
than  the  fibula,  generally  resists;  and  if  the  mal- 
leolus internus  sometimes  happens  to  break,  it  is  se- 
condarily, as  an  effect  of  the  displacement  of  the  foot 
outwards. 

In  the  other  example,  where  the  foot  is  twisted  out- 
wards, the  centre  of  gravity  of  the  body,  instead  of  fol- 
lowing its  usual  course,  obliquely  crosses  the  lower 
end  of  the  fibula,  the  ankle-joint,  and  the  malleolus  in- 
temus,  and  falls  on  the  ground  at  a greater  or  less 
distance  from  the  inner  edge  of  the  foot.  On  the  one 
side,  the  internal  lateral  ligaments  and  malleolus,  and 
on  the  other,  the  lower  end  of  the  fibula,  are  then  the 
parts  which  have  to  bear  the  weight  of  the  whole  body 
and  the  force  of  the  muscles ; and  they  are  also  the 
parts  which  are  torn  and  fractured ; first,  the  internal 
lateral  ligaments,  or  the  malleolus ; and,  secondly,  the 
lower  portion  of  the  fibula.— Med.  Chir.  de 
Paris,  1819,  p.  66,  67.)  Some  of  the  symptoms  of  a 
fracture  of  the  fibula,  from  an  indirect  cause,  depend 
upon  the  fracture  of  that  bone,  and  others  upon  the  dis- 
location of  the  foot.  They  are  divided  by  Dupuytren 
into  two  kinds ; viz.  presumptive  and  characteristic. 
The  first  are,  the  way  in  which  the  patient  received  his 
hurt : a noise  or  sort  of  crack  heard  by  him  at  the  instant 
of  the  injury ; a fixed  pain  at  the  lower  part  of  the  fibula ; 
a difficulty  or  inability  of  walking  ; more  or  less  swell- 
ing round  the  ankle,  especially  about  the  malleolus  ex- 
ternus and  lower  portion  of  the  fibula.  The  charac- 
teristic symptoms  are,  an  irregularity  and  unnatural 
moveableness  of  some  point  of  the  lower  end  of  the 
fibula ; a crepitus,  which  can  be  more  or  less  distinctly 
felt  by  pressing  upon  and  moving  the  part ; mobility  of 
the  whole  foot  transversely  or  horizontally ; a facility 
of  bringing  the  lower  end  of  the  fibula  towards  the  tibia 
by  pressure ; a change  in  the  point  of  incidence  of  the 
axis  of  the  limb  upon  the  foot ; distortion  of  the  foot 
outwards,  and  sometimes  backwards ; rotation  of  the 
same  part  upon  its  axis  from  within  outw^ards ; an  an- 
gular depression,  more  or  less  manifest,  at  the  outer 
and  lower  part  of  the  leg ; projection  of  the  internal 
malleolus  ; disappearance  of  almost  all  these  symp- 
toms, as  soon  as  reduction  is  effected  by  a force  ap- 
plied to  the  foot ; and  their  immediate  recurrence  when 
such  force  is  discontinued,  particularly  if  the  hmb  be  in 
the  extended  posture.— (To/,  cit.  p.  68.) 

In  considering  the  varieties  of  simple  fracture  of  the 
fibula,  the  first  to  wffiich  Dupuytren  adverts  is  that  in 
which  the  bone  is  broken  more  than  three  inches  above 
the  extremity  of  the  malleolus  externus ; a case  nei- 
ther accompanied  nor  followed  by  any  displacement  of 
the  foot,  and  almost  always  produced  by  the  direct 
application  of  violence  to  the  broken  part  of  the 
bone. 

A second  variety  of  simple  fractures  of  the  fibula  is 
when  the  bone  has  been  broken,  either  by  direct  or 
indirect  force,  within  three  inches  from  the  end  of  the 
malleolus  externus,  and  when  the  foot  is  not  displaced, 
though  much  displacement  is  possible,  and,  indeed, 
often  arises  from  the  slightest  effort  or  movement 
made  by  the  patient.,  The  most  frequent  point  of  in- 
jury is  about  two  inches  and  a half  above  the  extremity 
of  the  outer  malleolus.  This  is  generally  the  place  of 
a fracture  caused  by  a twist  of  the  foot  outwards  ; but 
the  accident  may  happen  lower  down,  as  is  commonly 


seen,  when  the  fracture  is  occasioned  by  a twist  ol  the 
foot  inwards. 

These  fractures  of  the  fibula,  abstractedly  viewed,  are 
not  of  much  importance  in  themselves ; but  with  refer- 
ence to  the  manner  in  which  they  facilitate  the  dislo- 
cation of  the  foot,  they  are  verj'  serious. 

Among  the  most  frequent  complications  of  fractures 
of  the  fibula,  are  the  rupture  of  the  internal  lateral  liga- 
ments, the  detachment  of  the  point  of  the  inner  mal- 
leolus, and  fracture  of  the  lower  part  of  the  tibia.  When 
these  injuries  originate  from  a violent  twist  of  the  foot 
outwards,  they  precede  the  fracture  of  the  fibula  ; but 
when  they  are  caused  by  a twist  inwards,  they  follow 
the  breaking  of  that  bone. — {Dripuytren,  vol.  cit.  p.  96.) 

Besides  distortion  of  the  foot  outwards  or  inwards, 
as  attending  certain  fractures  of  the  fibula,  another 
complication  may  be  dislocation  of  the  foot  backwards, 
produced  by  the  action  of  the  muscles  of  the  calf,  and 
not  by  the  same  causes  which  broke  the  bone.  How'- 
ever,  whenever  the  malleolus  internus  has  not  ^ven 
way,  the  dislocation  is  incomplete,  and  the  foot  is  in- 
clined outwards  as  well  as  backwards.  In  the  com- 
plete luxation,  as  Dupuytren  remarks,  the  bent  posture 
is  found  exceedingly  advantageous,  though  he  admits 
that  it  will  not  always  answer  in  maintaining  the  re- 
duction. 

TREATME.NT  OF  FRArTURES  OF  THE  LEG. 

As  in  cases  of  fractured  thighs,  the  practitioner  may 
adopt  either  a bent  or  a straight  position  of  the  limb  ; 
in  this  country,  surgeons  mostly  follow  Mr.  Pott’s  ad- 
vice, and  select  the  first  one,  of  w hich  alone  I shall 
treat.  That  the  bent  position  is,  generally  speaking, 
the  most  advantageous  for  a broken  leg,  I am  well  #011- 
vinced.  The  strong  muscles  of  the  calf  of  the  leg  are 
the  powers  which  tend  to  displace  the  ends  of  the  Irac- 
ture,  and  their  relaxation  is  a thing  of  the  first-rate  im- 
portance. It  is  quite  different  in  the  thigh,  where  the 
muscles  are  so  numerous,  that  the  attempt  to  relax,  by 
any  position  of  the  limb,  all  such  as  have  the  power  of 
displacing  the  fragments,  would  be  in  vain.  I am 
ready  to  acknowledge,  however,  that  in  the  bent  pos- 
ture the  apparatus  is  defective,  inasmuch  as  it  does 
not  keep  the  knee-joint  from  moving  ; but  yet  it  is  cer- 
tain that  such  motion  has  not  so  injurious  an  effect 
uiwn  fractures  of  the  leg  as  it  has  upon  those  of  the 
thigh.  WTien  the  case  is  complicated  with  a wound, 
whkh  cannot  be  dressed  in  the  bent  posture  of  the 
limb,  without  great  disturbance  of  the  fractiire,  the 
straight  position  ought  unquestionably  to  be  preferred. 
With  respect  to  one  of  Mr.  Pott’s  objections  to  this  po- 
sition, viz.  that  it  makes  the  knee  stiff  for  a long  w hile 
afterward,  I suspect  that  we  should  not  lay  much 
stress  upon  the  circumstance ; because,  as  Boyer  has 
correctly  observed,  it  is  always  the  joint  situated  below 
the  fracture  that  is  thus  affected. 

“ In  the  fracture  of  the  fibula  only  (says  Pott),  the 
position  is  not  of  much  consequence  ; because,  by  the 
tibia  remaining  entire,  the  figure  of  the  leg  is  preserved, 
and  extension  quite  unnecessary  ; but  still,  even  here, 
the  laying  the  leg  on  its  side  instead  of  on  the  calf  is 
attended  with  one  very  good  consequence,  viz.  that  the 
confinement  of  the  knee,  in  a moderately  bent  position, 
does  not  render  it  so  incapable  of  flexion  and  use  after- 
ward as  the  straight  or  extended  position  of  it  does ; 
and  consequently,  that  the  patient  will  be  much  sooner 
able  to  walk  whose  leg  has  been  kept  in  the  former 
posture,  than  he  whose  leg  has  been  confined  in  the 
latter. 

In  the  fracture  of  both  tibia  and  fibula,  the  knee 
should  be  moderately  bent,  the  thigh,  body,  and  leg  be- 
ing in  the  same  position  as  in  the  broken  thigh.  If 
common  splints  be  u-sed,  one  should  be  placed  under- 
neath the  leg,  extending  from  above  the  knee  to  below 
the  ankle,  the  foot  being  properly  supported  by  pillows, 
bolsters,  sfec.,  and  another  splint  of  the  same  length 
should  be  placed  on  the  upper  side,  comprehending 
both  joints  in  the  same  manner ; which  disposition  of 
splints  ought  always  to  be  observed,  as  to  their  length, 
if  the  leg  be  laid  extended  in  the  common  way,  only 
changing  the  nominal  position  of  them,  as  tiie  jxjsture 
of  the  leg  is  changed,  and  calling  what  is  inferior  in 
one  case  exterior  in  the  other ; and  w hat  is  suiterior  in 
one,  in  the  other  inferior. 

If  Mr.  Sharp’s  splints  be  made  use  of,  there  is  in 
one  of  them  a provision  for  the  more  easy  suj)port  of 
the  foot  and  ankle,  by  an  excavation  in,  and  a prulonga- 


FRACTURES. 


409 


tion  of,  the  lower  or  fibular  splint,  for  the  purpose  of 
keeping  the  foot  steady.” — (Pott.) 

The  strong  muscles  of  the  leg  being  relaxed  by  plac- 
ing the  limb  in  the  bent  position,  as  advised  by  I^tt, 
the  surgeon  is  to  make  such  extension  as  seems  re- 
quisite for  bringing  the  ends  of  the  fracture  into  even 
apposition.  Then  he  is  carefully  to  raise  the  leg  a 
little  way  from  the  surface  of  the  bed,  by  taking  firmly 
hold  of  the  limb  above  and  below  the  fracture,  and  ele- 
vating the  broken  bones  together  in  such  a way  as 
shall  keep  both  the  upper  and  lower  portions  as  nearly 
as  possible  on  the  same  level.  At  this  moment  an  as- 
sistant should  put  exactly  beneath  the  leg  the  under 
splint,  which  has  been  previously  made  ready  by  co- 
vering it  with  a soft  pad,  and  laying  over  this  an  eigh- 
teen-tailed bandage.  The  limb  is  now  to  be  gently  de- 
pressed till  it  rests  on  the  apparatus.  The  surgeon, 
before  proceeding  farther,  must  once  more  observe  that 
the  ends  of  the  bones  are  evenly  in  contact.  Being 
assured  of  this  Important  point,  he  is  to  apply  a jiiece  of 
soap-plaster,  and  lay  down  the  tails  of  the  bandage. 
Another  soft  pad  well  filled  with  tow,  is  next  to  be  put 
over  the  upper  surface  of  the  leg,  and  over  that  the 
other  splint,  when  the  straps  are  to  be  tightened. 

Mr.  Pott’s  method  of  treating  fractures  of  the  fibula 
complicated  with  luxation  of  the  tibia,  is  described  in 
the  article  Dislocation ; and  Dupuytren’s  practice  in  the 
last  edition  of  the  First  Lines  of  the  Practice  of  Sur- 
gery. 

In  an  oblique  fracture  of  the  head  of  the  tibia,  ex- 
tending into  the  knee-joint.  Sir  A.  Cooper  recommends 
the  straight  position,  in  which  the  femur  has  the  good 
eflfect  of  keeping  the  articular  surfaces  of  the  tibia 
even.  A roller  is  to  be  used  for  pressing  one  fragment 
towards  the  other ; a pasteboard  splint  is  also  to  be  ap- 
plied with  the  same  view ; and  early  passive  motion 
of  the  joint  is  to  be  practised  in  order  to  prevent  an- 
chylosis. 

When  the  fracture  is  oblique,  but  does  not  reach 
into  the  joint,  the  same  author  prefers  placing  the  limb 
on  the  double-inclined  plane.— (6’Mrg-icaZ  Essays,  part 
1,  p.  103 ; and  on  Dislocations,  vj-c.  p.  235.) 

FRACTURES  OF  THE  SCAPUL.V. 

As  Boyer  correctly  observes,  fractures  of  the  scapula 
are  not  very  common ; a circumstance  explicable  by 
the  deep  and  covered  position  of  the  greater  part  of 
this  bone,  and  its  great  mobility.  Nor  can  these  acci- 
dents ari.se  without  considerable  direct  violence.  How- 
ever, there  are  some  parts  of  the  scapula,  which,  be- 
ing more  superficial,  and  of  a form  more  likely  to  be 
acted  upon  by  external  bodies,  are  more  frequently 
fractured ; such  are  the  acromion  and  inferior  angle  of 
the  bone.  Fractures  of  the  coracoid  process,  and  even 
of  the  neck  of  the  scapula,  are  also  mentioned ; but  the 
instances’  of  such  accidents  are  not  common ; and 
though  these  parts  of  the  bone  may  appear  in  the  ske- 
leton likely  to  be  often  broken,  their  deep  situation  in 
the  living  subject  generally  saves  them.  Indeed,  as 
Boyer  says,  they  generally  require  great  violence  to 
break  them,  and  then  the  contusion  of  the  soft  parts  is 
a worse  injury  than  the  fracture  itself ; thus,  this  au- 
thor has  seen  the  coracoid  process  broken  by  the  blow 
of  the  pole  of  a carriage,  and  the  patient  lost  his  life 
from  the  violence  at  the  same  time  inflicted  upon  all 
the  soft  parts  about  the  shoulder.— (TVaite  des  Mai. 
Ckir.  t.  3,  p.  161.) 

When  the  acromion  is  broken,  the  weight  of  the  arm, 
and  the  contraction  of  the  deltoid  muscle,  draw  it 
downwards,  while  the  trapezius  and  levator  scapulae 
draw  the  rest  of  the  bone  upwards  and  backwards.  The 
roundness  of  the  injured  shoulder  is  lost,  and  part  of 
the  attachment  of  the  deltoid  being  broken  off,  the  head 
of  the  os  humeri  sinks  towards  the  axilla,  as  far  as 
the  capsular  ligament  will  permit.  On  tracing  the 
acromion  from  the  spine  of  the  scapula  to  the  clavicle, 
the  surgeon  will  feel  a depression  just  at  their  junction. 
The  distanc#  from  the  sternal  end  of  the  clavicle  to  the 
extremity  of  the  shoulder  is  lessened.  The  natural 
form  of  the  shoulder  may  be  restored  by  raising  the 
arm  by  the  elbow  ; but  the  deformity  returns  immedi- 
ately the  arm  is  suffered  to  fall  again.  The  accident 
may  be  distinguished  from  a dislocation,  if  the  surgeon 
raise  the  shoulder  by  pushing  the  humerus  upwards, 
when  a crepitus  will  be  perceptible  to  the  surgeon’s 
hand  applied  over  the  acromion,  on  the  limb  being  ro- 
tated.— (A.  Cooper  on  Dislocations,  Src.  p.  455.) 


When  the  lower  angle  is  broken,  the  serratus  major 
anticus  draws  it  forwards,  while  the  rest  of  the  scapula 
remains  in  its  natural  situation ; or  if  the  angular  por- 
tion be  considerable,  the  teres  major,  and  some  fibres 
of  the  latissimus  dorsi,  contribute  to  its  displacement 
forwards  and  upwards. 

When  the  coracoid  process  is  fractured,  the  pecto- 
ralis  minor,  coraco-brachialis,  and  short  head  of  the 
biceps  concur  in  drawing  it  forwards  and  downwards. 

When  the  neck  of  the  scapula  is  fractured,  the 
weight  of  the  arm  makes  it  drop  down  so  considera- 
bly as  to  give  the  appearance  of  a dislocation  ; but  the 
facility  of  lifting  the  os  brachii  upwards,  the  crepitus, 
and  the  falling  of  the  limb  downwards  again,  immedi- 
ately it  is  unsupported,  are  circumstances  clearly  mark- 
ing that  the  case  is  not  a dislocation.  According  to 
Sir  Astley  Cooper,  the  crepitus  is  best  perceived  through 
the  medium  of  the  coracoid  process.  The  degree  in 
which  the  glenoid  cavity  and  the  head  of  the  humerus 
descend,  he  observes,  depends  very  much  upon  whe- 
ther the  ligament  between  the  under  part  of  the  spine 
of  the  scapula  and  the  glenoid  cavity  is  lacerated  or 
not. — (Un  Dislocations,  c.  p.  459.) 

Sometimes  great  pains  and  a crepitus  are  experi- 
enced on  moving  the  shoulder-joint  after  an  accident ; 
and  yet  the  spine,  the  neck  of  the  scapula,  and  all  the 
above  parts,  are  not  broken.  In  this  circumstance,  it  is 
to  be  suspected  either  that  a small  portion  of  the  head 
of  the  os  brachii,  or  a little  piece  of  the  glenoid  cavity 
of  the  scapula,  is  broken  off ; which  latter  occurrence, 
I think,  is  not  very  uncommon. 

When  the  inferior  angle  is  broken  the  part  remains 
motionless,  while  the  rest  of  the  scapula  is  moved  ; 
and  it  is  so  separated,  that  no  mistake  can  be  made. — 
(Boyer.) 

Fractures  of  the  spine  and  body  of  the  bone  are  all 
attended  with  a crepitus ; and  in  the  first  cases,  an 
irregularity  of  the  injured  part  may  generally  be  felt. 

The  prognosis  of  fractures  of  the  scapula  varies  ac- 
cording to  the  situation  of  the  injury,  and  the  attendant 
circumstances.  Fractures  of  the  body  of  the  bone, 
whatever  may  be  their  direction,  are  generally  very 
simple  and  readily  cured.  Those  of  the  acromion  and 
lower  angle  are  more  troublesome  to  keep  right ; but 
the  most  serious  cases  are  fractures  of  the  coracoid 
process  and  neck  of  the  bone,  which  cannot  be  kept 
right  without  great  difficulty,  and  are  said  to  be  fre- 
quently followed  by  a considerable  stiffness  of  the  arm, 
inability  to  raise  it,  its  atrophy,  and  even  paralysis. 
In  other  respects,  the  danger  of  fractures  of  the  sca- 
pula depends  less  upon  the  solution  of  continuity  in 
the  bone,  than  the  contusion  of  the  soft  parts  or  injury 
of  the  thoracic  viscera.  However,  when  the  fracture 
is  comminuted  and  the  splinters  are  forced  into  the 
subscapularis  muscle,  abscesses  may  form  under  the 
bone,  and,  according  to  Boyer,  require  a perforation  to 
be  made  in  it  (Mai.  Chir.  t.  3,  165) ; a proceeding 

which  I cannot  bring  myself  to  think  would  ever  be 
judicious,  as  making  a depending  opening  in  the  soft 
parts  must  be  far  better  practice.  In  military  surgery 
the  scapula  is  often  injured  by  sabre-cuts  ; but  as  Dr. 
Hennen  remarks,  this  bone,  when  preserved  from  mo- 
tion, is  found  in  these  cases  to  unite  with  great  readi 
ness  and  without  future  inconvenience. — (Principles 
of  Military  Surgery,  p.  48,  ed.  2.) 

According  to  Boyer,  when  the  scapula  is  fractured 
longitudinally  or  transversely,  it  is  merely  necessary 
to  fix  the  arm  to  the  side  by  means  of  a bandage  which 
includes  the  arm  and  trunk  from  the  shoulder  to  the 
elbow.  Thus  the  motions  of  the  shoulder,  which  are 
only  concomitant  with  those  of  the  arm,  are  prevented 

When  the  inferior  angle  is  broken  and  drawn  down- 
wards and  forwards  by  the  serratus  major  anticus,  the 
scapula  must  be  pushed  towards  the  fragment  by  inclin 
ing  the  arm  itself  inwards,  downwards,  and  forwards, 
where  it  is  to  be  kept  with  a roller.  The  fragment  ia 
also  to  be  kept  backwards  as  much  as  possible  with 
compresses  and  a roller,  and  the  arm  is  to  be  sup- 
l)ortcd  in  a sling. 

The  fractured  acromion  requires  the  arm  to  be  .so 
raised  that  the  head  of  the  os  brachii  will  j)ush  up  the 
acromion,  while  an  assistant  pushes  the  scapula  for 
wards  and  downwards  in  a contrary  direction  to  that 
of  the  arm.  To  maintain  this  position,  a circular  band 
age  is  to  be  applied  round  the  arm  and  body. 

Desault  used  to  apjdy  also  a small  pillow  under  the 
axilla  before  i)utting  on  the  bandage,  in  order  to  make 


410 


FRACTURES. 


the  head  of  the  os  brachii  project  more  upwards  on 
bringing  the  arm  near  the  side ; but  Sir  Astley  Cooper 
finds  that  a pillow  so  placed  does  harm  by  throwing 
the  head  of  the  os  humeri  outwards,  and  widely  sepa- 
rating the  acromion  from  the  spine  of  the  scapula.  He 
approves  of  raising  the  elbow  and  keeping  the  arm 
fixed.  He  also  relaxes  the  deltoid  muscle  by  means 
of  a cushion  put  between  the  elbow  and  the  side,  the 
elbow  inclining  a little  backwards  ; the  limb  is  to  be 
bound  to  the  chest  in  this  position  with  a roller.  The 
union  may  take  place  by  bone,  but  owing  to  the  diffi- 
culty of  maintaining  the  coaptation,  the  uniting  sub- 
stance is  generally  ligamentous. — {A.  Cooper  on  Dis- 
locations, p.  455.) 

When  the  coracoid  process  is  fractured,  the  muscles 
attached  to  it  are  to  be  relaxed  by  bringing  the  arm  for- 
wards towards  the  breast  and  confining  it  there  in  a 
sling;  while  the  shoulder  is  kept  downwards  and  for- 
wards, and  a compress  confined  just  under  the  broken 
part  with  a roller. 

The  treatment  of  a fracture  of  the  neck  of  the  sca- 
pula consists  in  keeping  the  head  of  the  os  humeri  out- 
wards by  means  of  a thick  cushion  in  the  axilla ; in 
keeping  the  glenoid  cavity  and  arm  raised  with  a sling ; 
and  in  preventing  all  motion  of  the  arm  by  binding  it 
to  the  trunk  with  a roller.  In  some  of  these  cases, 
the  apparatus  proposed  by  Mr.  Earle  might  be  very 
useful.— (Pract.  Obs.  in  Surg.  1823.) 

FR.iCTURES  OF  THE  CL.VVICLE. 

This  bone,  being  long  and  slender,  unsupported  at  its 
middle,  and  protected  externally  only  by  the  integu- 
ments, is  very  often  broken.  Its  serving  to  keep  the 
scapula  at  a proper  distance  from  the  sternum,  and  as 
a pomt  d'appui  for  the  os  brachii,  every  impulse  of 
which  it  receives  makes  its  fractures  still  more  com- 
mon. 

It  may  be  broken  at  any  part ; but  its  middle,  where 
the  curvature  is  greatest,  is  most  frequently  the  situa- 
tion of  the  injury.  It  is  not  very  often  fractured  at  its 
scapulary  extremity.  However,  a direct  force  falling 
on  the  shoulder  may  break  any  part  of  the  clavicle  on 
which  it  immediately  acts.  The  soft  parts  in  this  kind 
of  case  will  also  be  contused  or  even  lacerated. 

A comminuted  fracture  may  be  thus  occasioned,  and 
if  the  violence  be  very  great,  the  subclavian  vessels 
and  nerves  may  be  torn.  The  fall  of  a heavy  body  on 
the  shoulder  often  gives  rise  to  a paralysis  of  the  arm. 

When  the  fracturing  force  is  applied  to  the  ends  of 
the  bone,  as  in  a fall  on  the  point  of  the  shoulder  or  on 
the  hands  while  the  arms  are  extendeil,  the  clavicle 
may  be  very  much  bent,  and  fractured  so  obliquely,  that 
the  broken  portions  protrude  through  the  skin. 

Fractures  of  this  bone  are  usually  attended  with  dis- 
placement, except  when  the  injury  takes  place  at  the 
scapulary  extremity  and  within  the  ligament,  lying  the 
clavicle  and  coracoid  process  together. 

The  external  portion  of  the  clavicle  is  always  that 
which  is  displaced.  The  internal  part  cannot  be  moved 
out  of  its  natural  situation,  by  reason  of  the  costo-cla- 
vicular  ligaments,  and  of  its  being  drawn  in  opposite 
directions  by  the  sterno-cleido-mastoideus  and  pectora- 
lis  major  muscles.  The  external  portion,  drawn  down 
both  by  the  weight  of  the  arm  and  the  action  of  the 
deltoid  muscle,  and  forwards  and  inwards  by  the  pecto- 
ralis  major,  is  carried  under  the  internal  portion,  which 
projects  over  it.  The  broken  clavicle  no  longer  keep- 
ing the  shoulder  at  a due  distance  from  the  sternum, 
the  arm  falls  forwards  towards  the  breast.  The  pa- 
tient finds  it  impossible  to  put  his  hand  to  his  forehead, 
because  this  act  makes  a semicircular  motion  of  the 
humerus  necessary,  which  cannot  be  done  while  that 
bone  has  not  a firm  point  d’appui.  The  shoulder  and 
upper  extremity  may  be  observed  to  be  nearer  the 
breast  than  those  of  the  opposite  side.  The  motion  of 
the  pieces  of  bone  on  one  another  may  be  felt,  as  well 
as  the  projection  of  the  end  of  the  internal  portion. 
When  the  shoulder  is  moved  a crepitus  may  also  be 
perceived ; but  this  is  productive  of  great  pain,  and 
the  diagnosis  is  so  obvious  that  it  is  quite  unnecessary. 

The  ancients,  and  many  moderns,  have  supposed, 
that,  in  order  to  set  a fracture  of  the  clavicle,  the  shoul- 
der must  be  drawn  back,  and  fixed  m that  position. 
The  patient  was  placed  on  a low  stool,  so  that  an  as- 
sistant might  put  his  knee  between  the  shoulders,  which 
he  drew  back  at  the  same  time  with  both  hands,  while 
the  surgeon  aiiplied  the  bandage  which  was  to  keep  the 


parts  in  tliis  position.  But  when  the  shoulders  are 
thus  drawn  towards  one  another,  the  scapula  is  obvi- 
ously pushed  lovvards  the  sternum,  and  with  it  the  ex- 
ternal portion  of  the  clavicle,  which  passes  under  the 
internal  fragment. 

The  figure  of  8 bandage  has  commonly  been  used  for 
maintaining  the  parts  in  this  position.  While  the  as- 
sistant keeps  back  the  shoulders,  as  above  described, 
the  sui  geonis  to  apply  one  end  of  a roller  to  the  armpit 
on  the  side  affected,  and  then  make  it  cross  obliquely 
to  the  opposite  shoulder,  round  which  it  is  to  pass,  and 
from  this  to  the  other  shoulder,  about  which  it  is  to  be 
applied  in  the  same  manner,  and  afterward  repeatedly 
crossed  before  and  behind.  The  tightness  with  which 
it  is  necessary  to  apjily  this  bandage  produces  a great 
deal  of  excoriation  about  the  armpits,  and  the  effect  is 
to  make  the  ends  of  the  fracture  overlap  each  other, 
the  very  thing  which  it  is  wished  to  avoid.  Boyer  re- 
marks, that  the  iron  cross  proposed  by  Heister,  the 
corslet  described  by  Brasdor  in  the  MXm.  de  I' Acad,  de 
Ckir.,  and  the  leather  strap  recommended  by  Brunning- 
hausen,  are  only  modifications  of  the  figure  of  8 band- 
age, and  are  not  at  all  better. 

Desault  advised  extension  to  be  made  by  means  of 
the  limb,  which  is  articulated  with  the  fractured  bone. 
This  is  done  by  converting  the  humerus  into  a lever, 
by  carrying  its  lower  end  forwards,  inwards,  and  up- 
wards, pushing  the  shoulder  backwards,  upwards,  and 
outwards,  and  putting  a cushion  in  the  armpit  to  serve 
as  a fulcrum. 

Desault  used  to  put  in  the  armpit  a hair  or  flock 
cushion,  five  or  six  Inches  long,  and  three  inches  and  a 
quarter  thick  at  its  base.  Two  strings  are  attached  to 
the  corners  of  the  base,  which  is  placed  upwards : they 
cross  the  back  and  breast,  and  are  tied  on  the  shoulder 
of  the  other  arm.  The  cushion  being  thus  placed  in  the 
armpit,  and  the  forearm  bent,  Desault  used  to  take 
hold  of  the  patient’s  elbow,  and  carry  it  forwards,  up- 
wards, and  inwards,  pressing  it  forcibly  against  the 
breast.  By  this  manoeuvre,  the  humerus  carries  the 
shoulder  outwards,  the  ends  of  the  fracture  become 
situated  opposite  each  other,  and  all  deformity  is  re- 
moved. 

An  assistant  is  to  support  the  arm  in  this  position, 
while  the  surgeon,  having  a single-headed  roller  nine 
yards  long,  is  to  place  one  end  of  it  in  the  armpit  of  the 
opposite  side,  and  then  apply  the  bandage  over  the 
upper  part  of  the  arm,  and  across  the  back  to  the  same 
situation.  The  arm  and  trunk  are  to  be  covered  with 
such  circles  of  the  roller,  as  far  down  as  the  elbow, 
drawing  the  bandage  more  tightly  the  lower  it  descends. 

Compresses,  dipped  in  camphorated  spirit,  are  next 
to  be  placed  along  the  fractured  bone.  Desault  then 
took  a second  roller,  of  the  same  length  as  the  first,  and 
put  one  end  of  it  under  the  opposite  armpit,  whence  it 
was  carried  across  the  breast  over  the  compress  and 
fracture,  then  down  behind  the  shoulder  and  arm, 
and  after  having  passed  under  the  elbow,  upwards  on 
the  breast.  Desault  next  brought  it  across  to  the 
sound  shoulder,  under  and  round  which  he'  passed  it, 
for  the  purpose  of  fixing  the  first  turn.  He  then  con- 
veyed the  roller  across  the  back,  brought  it  over  the 
compresses,  carried  it  down  in  front  of  the  shoulder 
and  arm,  under  the  elbow,  and  obliquely  behind  the 
back  to  the  armpit,  where  the  application  began.  The 
same  plan  was  repeated,  until  all  the  roller  was  spent. 
The  apparatus  was  secured  by  pins,  wherever  they 
l)romised  to  be  useful,  and  the  patient’s  hand  was  kept 
in  a sling. 

Boyer  has  invented  an  apparatus  for  fractured  clavi- 
cles, which  is  more  simple  than  that  employed  by 
Desault. 

The  cushion  is  toie  applied  under  the  arm.  The 
apparatus  consists  of  a girdle  of  linen  cloth,  which 
passes  round  the  trunk  on  a level  with  the  elbow.  It  is 
fixed  on  by  means  of  three  straps  and  as  many  buckles. 
At  an  equal  distance  from  its  extremities  are  i)laced 
externally  on  each  side  two  buckles,  two  before  and  two 
behind  the  arm.  On  the  lower  part  of  the  arm  is  to  be 
laced  a piece  of  quilted  cloth,  five  or  six  fingers  broad. 
Four  straps  are  attached  to  it,  which  correspond  to  the 
buckles  on  the  outside  of  the  girdle,  and  serve  both  to 
keep  the  arm  close  to  the  trunk,  and  from  moving  either 
backwards  or  forwards. 

Certainly,  the  methods  recommended  by  Desault  and 
Boyer  are  very  judicious  and  scientific.  They  are  not, 
however,  much  adopted  in  this  countrj-,  perhaus  in  con- 


FRACTURES. 


411 


sequence  of  the  general  aversion  among  English  sur- 
geons to  every  apparatus  which  is  not  exceedingly  sim- 
ple. It  is  to  be  hoped,  at  the  same  time,  that  in  the 
treatment  of  fractured  clavicles,  they  will  always  attend 
to  the  principles  which  Desault  and  Boyer  have  incul- 
cated. If  they  understand  why  the  position  of  the  arm 
should  be  such  as  these  eminent  surgeons  point  out, 
they  will  have  no  difficulty  in  doing  what  is  proper,  and 
with  a cushion,  sling,  and  a couple  of  rollers,  they  will 
easily  maintain  the  proper  posture.  A simple  and  good  ap- 
paratus for  fractures  of  the  clavicle, and  those  of  the  neck 
of  the  scapula,  has  been  recently  proposed  by  Mr.  Earle. 
— (See  his  Practical  Observations  on  Surgery,  p.  187, 
i?-c.)  It  is  also  calculated  for  cases  of  dislocated  cla- 
Nicle,  and  other  injuries  of  the  shoulder. 

I cannot  quit  this  subject  without  cautioning  surgeons 
never  to  fall  into  the  error  of  supposing  the  rising  end 
of  a broken  clavicle  to  be  the  end  which  is  displaced. 
This  is  the  one  wliich  is  truly  in  its  right  situation,  and 
■which  has  often  been  made,  by  injudicious  pressure,  to 
protrude  through  the  integuments,  one  or  two  instances 
of  which  have  fallen  under  my  own  observation. 

[Until  within  a few  years,  fractured  clavicle  was  al- 
most imiversally  treated  in  this  country  by  Desault’s 
bandage.  The  objections  to  it  have  been  apparent  for  a 
long  time,  for  although,  properly  applied,  it  is  adequate  to 
fulfil  all  the  indications  necessary  in  this  kind  of  injury, 
yet  its  complexity,  its  liability  to  be  deranged,  and  the 
pressure  it  makes  upon  the  mammae  in  female  patients, 
rendered  a substitute  for  it  in  many  cases  very  desirable. 
Dr.  Skipwith  H.  Coale,  of  Baltimore,  constructed  an 
apparatus,  in  1816,  for  this  purpose,  which  in  his  hands 
was  entirely  successful  in  bad  cases  of  oblique  fracture 
of  the  clavicle,  and  was  highly  recommended  by  Pro- 
fessors Davidge  and  Gibson,  of  the  University  of  Ma- 
ryland. It  was  made  of  leather  straps  and,  buckles, 
performing  the  triple  purposes  for  which  Desault’s 
bandage  was  adapted,  and  its  simplicity  as  well  as  its 
permanence,  together  with  its  adaptation  to  ffemale  pa- 
tients, has  brought  it  into  general  favour  in  the  south. 
Dr.  Stephen  Brown,  of  New-York,  has  introduced  to 
the  profession  an  improvement  or  modification  of  De- 
sault’s bandage,  which  is  now  in  general  use  in  many 
parts  of  the  United  States.  It  consists  of  a single 
headed  roller,  eleven  yards  long,  and  three  and  a half 
inches  wide,  the  convolutions  of  which  are  so  perfectly 
simple,  that  a description  of  his  method  will  be  found 
sufficient  to  enable  any  practitioner  to  apply  it  with 
neatness  and  facility. 

A full  description  of  this  apparatus  may  be  found  in 
the  4th  vol.  of  the  Am.  Med.  Recorder.  And  as  it  fulfils 
every  necessary  indication,  without  being  liable  to  the 
objections  acknowledged  to  exist  against  that  of  Desault, 
it  is  well  worthy  of  the  confidence  of  surgeons  gene- 
rally, and,  indeed,  it  promises  in  this  country  altogether 
to  supersede  it. — Reese.'] 

FRACTURES  OF  THE  OS  BRACHII  OR  HUMERUS. 

This  bone  may  be  fractured  at  any  point  of  its  length  : 
at  its  middle,  either  of  its  extremities,  or  above  the  in- 
sertion of  the  pectoralis  major,  latissimus  dorsi,  and 
teres  major.  The  last  case  is  termed  fracture  of  the 
neck  of  the  humerus ; but  that  denomination  has  not 
the  merit  of  being  strictly  anatomical.  It  is  possible, 
however,  that  what  is  strictly  called  the  neck  of  the 
humerus  may  be  fractured,  particularly  by  a gun-shot 
wound.  By  neck  of  the  humerus,  we  understand  that 
circular  narrowing  which  separates  the  tuberosities 
from  the  head. 

The  fractures  of  this  bone  may  be  transverse  or 
oblique,  simple  or  compound.  Transverse  fractures  ol 
its  middle  part,  below  the  insertion  of  the  deltoid  mus- 
cle, are  attended  with  but  little  displacement,  for  the 
brachialis  intemus  and  the  triceps,  being  attached  pos- 
teriorly and  anteriorly  to  both  fragments,  counteract 
one  another,  and  admit  only  a slight  angular  displace- 
ment. When  the  fracture  takes  place  above  the  inser- 
tion of  the  deltoid  muscle,  the  inferior  portion  is  first 
drawn  outwards  and  then  upwards  on  the  external  side 
of  the  superior.  Fractures  of  the  humerus,  near  its 
lower  end,  such  particularly  as  are  transverse,  are  not 
subject  to  much  displacement : a circumstance  to  be 
attributed  to  the  breadth  of  the  fractured  surfaces  ; to 
their  being  covered  posteriorly  by  the  triceps  muscle, 
and  anteriorly  by  the  brachialis  internus,  which  admit 
only  a slight  angular  displacement,  by  the  inferior 
portion  being  drawn  a little  forwards. 


Oblique  fractures  are  always  attended  with  displace- 
ment, whatever  be  the  part  of  the  bone  broken.  The 
inferior  portion  being  drawn  upwards  by  the  action  of 
the  deltoides,  biceps,  coraco-bracliialis,  and  long  portion 
of  the  triceps,  glides  easily  on  'he  superior,  and  passes 
above  its  lower  extremity.  Finally,  fractures  of  the 
neck  of  the  humerus  are  always  attended  with  dis- 
placement, produced  by  the  action  of  the  pectoralis 
major,  latissimus  dorsi,  and  teres  major,  which,  being 
attached  to  the  lower  portion  near  its  superior  extremity, 
draw  it  first  inwards  and  then  upwards,  in  which  last 
direction  it  is  powerfully  urged  by  the  biceps,  coraco- 
brachialis,  and  long  portion  of  the  triceps.  In  this  case, 
the  superior  portion  itself  is  directed  a little  outwards 
by  the  action  of  the  infra.spinatus,  supraspinatus  and 
teres  minor,  which  make  the  head  of  the  humerus  per- 
form a rotatory  motion  in  the  glenoid  cavity. 

The  shortening  and  change  in  the  direction  of  the 
limb,  the  crepitus,  which  may  be  very  distinctly  per- 
ceived by  moving  the  broken  pieces  in  opposite  direc- 
tions, the  pain  and  impossibility  of  moving  the  arm, 
tfec.,  joined  to  the  history  of  the  case,  render  the  diag- 
nosis sufficiently  plain. 

Fractures  of  the  neck  of  the  humerus,  however,  are 
not  so  easily  ascertained,  and,  from  want  of  attention, 
have  been  frequently  confounded  with  luxations  of  that 
bone.  Yet  the  diagnostic  symptoms  of  these  two  af- 
fections are  very  different. 

When  the  neck  of  the  humerus  is  fractured,  a de- 
pression is  observed  at  the  upper  part  and  external 
side  of  the  arm,  very  different  from  what  accompanies 
the  luxation  of  that  bone  downwards  and  inwards.  In 
the  latter  case,  a deep  depression  is  found,  just  below 
the  projection  of  the  acromion,  in  the  natural  situation 
of  the  head  of  the  humerus ; whereas,  in  fracture  of  the 
neck  of  that  bone,  the  shoulder  retains  its  natural 
form,  the  acromion  does  not  project,  and  the  depression 
is  found  below  the  point  of  the  shoulder.  Besides,  on 
examining  the  armpit,  instead  of  finding  there  a round 
tumour,  formed  by  the  head  of  the  humerus,  the  frac- 
tured and  unequal  extremity  of  that  bone  v/ill  be  easily 
distinguished.  The  motion  of  the  broken  portions, 
and  the  crepitus  thus  produced,  serve  still  farther  to 
establish  the  diagnosis.— (Boyer.) 

In  a simple  fracture  of  the  body  of  the  humerus, 
the  prognosis  is  generally  favourable ; but  fractures 
near  the  elbow  are  liable  to  be  followed  by  more 
or  less  stiffness  of  the  joint,  often  very  difficult  of  re- 
moval. 

In  ordinary  fractures  of  the  os  brachii,  it  is  usual  to 
apply  two  pieces  of  soap-plaster,  which  together  sur- 
round the  limb,  at  the  situation  where  the  accident  has 
happened.  Extension,  if  necessary,  being  now  made 
by  an  assistant,  who  at  once  draws  the  lower  portion 
of  the  bone  downwards  and  bends  the  elbow,  the  sur- 
geon is  to  apply  a roller  round  the  limb.  The  external 
splint  is  to  extend  from  the  acromion  to  the  outer  con- 
dyle, and  being  lined  with  a soft  pad,  the  wood  cannot 
hurt  the  limb  by  pressure.  The  internal  splint  is  to 
reach  from  tlie  margins  of  the  axilla  to  a little  below 
the  inner  condyle,  and  is  to  be  well  guarded  with  a pad, 
filled  with  tow,  or  any  other  soft  materials. 

Some  surgeons  are  content  with  the  application  of 
two  splints  ; but  though  the  two  above  described  are 
those  on  which  we  are  to  place  the  greatest  reliance, 
yet  as  the  cylindrical  form  of  the  arm  conveniently 
allows  us  completely  to  incase  this  part  of  the  limb  in 
splints,  I consider  the  employment  of  four  better ; one 
on  the  outside,  one  on  the  inside,  one  on  the  front,  and 
another  on  the  back  of  the  arm.  These  are  to  be  care- 
fully fixed  in  their  respective  situations  by  means  of 
ta])e. 

Throughout  the  treatment,  the  elbow  and  whole  of 
the  forearm  are  to  be  quietly  and  effectually  supported 
in  a sling. 

FRACTURE  OF  THE  HKAU  OR  NECK  OF  THE  OS  BRACHir. 

Chirurgical  language  here  differs  from  that  adopted 
by  anatomists,  and,  under  the  name  of  fracture  of  the 
neck  of  the  humerus,  is  not  meant  that  of  the  circular, 
hardly  perceptible  depression,  which  separates  the  head 
from  the  tuberosities  of  this  bone.  By  this  expression, 
surgeons  imply  the  fracture  of  that  contracted  part  of 
the  humerus,  which  is  bounded  above  by  these  tubero- 
sities ; which  below  is  continuous  with  the  body  of  the 
bone  ; which  has  the  tendons  of  the  pectoralis  major, 
latissimu.s  dorsi,  and  teres  major  inserted  below  it , and 


412 


FRACTURES. 


which  many  practitioners  extend  even  as  low  as  the 
insertion  of  the  deltoid  muscle. 

Indisputable  facts,  however,  prove  the  possibility  of 
the  anatomical  neck  of  the  bone  being  fractured,  and 
C.  Larbaud  showed  Bichat  the  humerus  of  a young 
man,  aged  17,  the  head  of  which  bone  was  accurately 
detached  from  its  body,  by  a division  which  had  passed 
obliquely  through  the  upper  part  of  the  tuberosities. 
Another  example  proved  by  dissection,  has  been  very 
lately  recorded  by  Delpech. — {Chirurgie  Clinique.)  An 
instance  of  this  kind,  I think,  was  pointed  out  to  me  in 
the  spring  of  1821,  in  St.  Bartholomew’s  Hospital. 
The  patient  was  a boy,  whose  elbow  had  been  strongly 
kept  up,  on  the  supposition  that  the  case  was  a fracture 
of  the  neck  of  the  scapula,  and,  consequently,  the  irre- 
gular end  of  the  humerus  formed  a remarkable  pro- 
jection in  front  of  the  acromion,  yet  capable  of  being 
pushed  back,  where,  however,  it  would  not  remain. 
When  the  accident  is  produced  by  a direct  blow  or  fall 
on  the  lleshy  part  of  the  shoulder,  the  deltoid  is  some- 
times contused  and  affected  with  ecchymosis.  Even 
blood  may  be  effused  from  some  of  the  ruptured  arti- 
cular veins  or  arteries,  and  form  a collection  which 
Desault  recommended  to  be  speedily  opened,  though 
the  reason  of  such  practice,  as  a general  thing,  must  be 
questionable,  because  large  extravasations  of  blood 
about  the  shoulder  are  usually  very  soon  absorbed. 

Sir  Astley  Cooper  has  seen  this  accident  both  in  old 
and  in  young  persons  ; but,  according  to  his  observa- 
tion, it  rarely  occurs  in  middle  age.  In  the  young, 
he  says,  it  happens  at  the  junction  of  the  epiphysis, 
where  the  cartilage  is  situated  ; and  in  the  old  it  arises 
from  the  greater  softness  of  this  part  of  the  bone.— 
{On  Dislocations,  i-c.  p.  459.) 

An  acute  pain  is  experienced  at  the  moment  of  the 
fall;  sometimes  the  noise  of  something  breaking  is 
heard.  There  is  always  a sudden  inability  to  move  the 
limb,  which,  left  to  itself,  remains  motionless.  But, 
on  external  force  being  applied,  it  readily  yields,  and 
admits  of  being  moved  with  the  greatest  ease  in  every 
direction.  Such  motion  is  attended  with  severe  pain, 
and,  if  carried  too  far,  may  cause  ill  consequences,  as 
has  been  observed  in  patients  in  whom  the  fracture  has 
been  mistaken  for  dislocation. 

Below  the  acromion  a depression  is  remarkable,  al- 
ways situated  lower  down  than  that  which  attends  a 
dislocation.  If  we  place  one  hand  on  the  head,  while 
the  lower  part  of  the  bone  is  moved  in  various  direc- 
tions with  the  other  hand  ; or  if,  while  extension  is 
made,  an  assistant  communicates  to  the  bone  a rotatory 
motion,  the  following  circumstances  are  perceived.  1. 
The  head  of  the  humerus  remains  motionless.  2.  A 
more  or  less  distinct  crepitus  is  felt,  arising  from  the 
two  ends  of  the  fracture  rubbing  against  each  other. 
These  two  symptoms  are  characteristic  of  the  accident ; 
but  the  swelling  of  the  joint  may  prevent  us  from  de- 
.tecting  them. 

Sometimes  there  is  no  displacement  of  the  ends  of 
the  fracture,  and  then,  as  most  of  the  symptoms  are  ab- 
sent, the  diagnosis  is  still  more  difficult.  In  general, 
however,  the  ends  of  the  fracture  are  displaced,  and  in 
this  circumstance  it  is  the  lower  one  which  is  out  of  its 
proper  position,  and  not  the  upper  one,  which  is  of  lit- 
tle extent,  and  is  not  acted  upon  by  many  muscles. 

The  displacement  is  generally  not  very  perceptible 
in  regard  to  length  unless  the  fracture  be  very  oblique, 
and  its  pointed  spiculae  irritate  the  muscles,  and  make 
them  contract  with  increased  power;  or  unless  the 
blow,  which  was  very  violent,  continued  to  operate 
after  the  bone  had  been  broken,  and  forced  the  ends  of- 
the  fracture  from  their  state  of  apposition.  In  this 
way  the  body  of  the  humerus  has  deen  drawn  or  driven 
upwards,  so  as  to  protrude  through  the  deltoid  muscle 
and  integuments  far  above  the  height  of  the  head  of  the 
bone. 

But  commonly,  as  Petit  observes,  the  weight  of  the 
limb  powerfully  resists  the  action  of  the  muscles,  and 
the  displacement  of  the  fracture  is  more  liable  to  be 
transverse.  In  this  circumstance  the  lower  end  of  the 
fracture  is  displaced  outwards  or  inwards,  and  rarely 
in  any  other  direction.  In  the  most  frequent  case,  the 
elbow  is  separated  from  the  trunk,  and  cannot  be 
brought  near  it  without  pain ; and  in  the  instance  of 
the  bone  being  displaced  outwards,  the  limb  has  a ten- 
dency to  the  opposite  direction.  According  to  Sir  Ast- 
ley Cooper,  the  upper  end  of  the  main  portion  of  the  hu- 
. merus  sinks  into  the  axilla,  where  it  can  be  felt,  and  the 


deltoid  is  drawn  down  by  it,  so  that  the  roundness  of  the 
shoulder  is  diminished.-^ On  Dislocations,  Src.  p.  459.) 

The  reduction  takes  place  of  itself  on  employing  a 
very  little  force  methodically  directed,  according  as 
the  fracture  is  displaced  inwards  or  outwards.  If  the 
surgeon  put  his  hands  on  the  situation  of  the  fracture, 
it  is  rather  to  examine  the  state  of  the  ends  of  the  broken 
bone  than  to  accomplish  a thing  seldom  required, 
namely,  what  is  implied  by  the  term  coaptation. 

Every  apparatus  for  the  cure  of  fractures  being  only 
resistances  made  by  art  to  the  powers  causing  the  dis- 
placement of  the  broken  part,  it  follows  that  the  whole 
should  act  in  an  inverse  ratio  to  such  powers.  These 
consist,  1.  Of  the  action  of  external  bodies,  favoured 
by  the  extreme  mobility  of  the  arm  and  shoulder : 2.  Of 
the  action  of  the  latissimus  dorsi,  pectoralis  major,  and 
teres  major,  which  draw  inwards  the  lower  end  of  the 
fracture,  or  of  the  deltoid,  which  pulls  it  outwards ; 3.  Of 
the  contractions  of  the  muscles  of  the  arm,  which  tend 
to  draw  the  end  of  the  fracture  a little  upwards. 

Hence,  in  the  treatment,  the  three  indications  are,  1. 
To  render  the  arm  and  shoulder  immoveable ; 2.  To 
bring  either  outwards  or  inwards  the  lower  end  of  the 
fracture  ; 3.  To  draw  downwards  the  same.  The  last 
object  merits  less  attention  than  the  two  others,  because 
the  weight  of  the  arm  is  alone  almost  sufficient  for  the 
purpose.  Desault  used  to  employ  the  following  appa- 
ratus : 

1.  Two  long  rollers.  2.  Three  strong  splints,  of  dif- 
ferent lengths,  and  between  two  and  three  inches  broad. 
3.  A cushion  or  pillow,  three  or  four  inches  thick  at 
one  of  its  ends,  terminating  at  the  other  in  a narrow 
point,  and  long  enough  to  reach  from  the  axilla  to  the 
elbow.  4.  A sling  to  support  the  forearm.  5.  A towel 
to  cover  the  whole  of  the  apparatus. 

The  reduction  having  been  effected,  the  assistants 
are  to  continue  the  extension.  Then  the  surgeon  is  to 
take  the  first  roller,  which  is  to  be  wet  -with  the  liq. 
plumbi  acet.  dil.,  and  he  is  to  fix  one  of  its  heads  by 
applying  two  circular  turns  to  the  upper  part  of  the 
forearm.  The  bandage  is  now  to  be  rolled  moderately 
tight  round  the  arm  upwards,  making  each  turn  over- 
lap two-thirds  of  that  which  is  immediately  below  it. 
When  the  roller  has  reached  the  upper  part  of  the  limb, 
it  must  be  doubled  back  a few  times  to  prevent 
the  folds  which  the  inequality  of  the  part  would  create. 
The  bandage  is  afterward  to  be  carried  twice  under 
the  opposite  axilla,  and  the  rest  of  it,  rolled  up,  is  to  be 
brought  up  to  the  top  of  the  shoulder,  and  conunitted 
to  the  care  of  an  assistant. 

The  first  splint  is  to  be  placed  in  front,  reaching 
from  the  bend  of  the  arm  as  high  as  the  acromion.  The 
second,  on  the  outside,  from  the  external  condyle  to 
the  same  height.  The  third,  behind,  from  the  olecranon 
to  the  margin  of  the  axilla.  The  pillow,  interposed  be- 
tween the  arm  and  thorax,  serves  as  a fourth  splint, 
which  becomes  useless.  An  assistant  applies  these 
parts  of  the  apparatus,  and  holds  them  on  by  applying 
his  hands  near  the  bend  of  the  arm,  in  order  not  to  ob- 
struct the  application  of  the  remainder  of  the  bandage. 

The  surgeon  takes  hold  of  the  bandage  again,  and 
applies  it  over  the  splints  with  moderate  tightness,  and 
the  bandage  ends  a»  the  upper  part  of  the  forearm  where 
it  began. 

While  the  assistants  still  keep  up  the  extension,  the 
surgeon  is  to  place  the  pillow  between  the  arm  and 
trunk,  taking  care  to  put  the  thick  end  upwards,  if  the 
fracture  be  displaced  inwards  ; but  downwards  if  this 
should  be  displaced  outwards,  which  Desault  found 
most  common.  Then  the  pillow  is  to  be  fastened  with 
two  pins  to  the  upper  part  of  the  roller. 

The  arm  is  to  be  brought  near  the  trunk,  and  fixed 
upon  the  pillow  by  means  of  the  second  roller  applied 
round  the  arm  and  thorax.  The  turns  of  this  bandage 
should  be  rather  tight  below  and  slack  above,  if  the 
fracture  be  displaced  inwards ; but  if  outwards,  they 
should  be  slack  below  and  tight  above. 

The  forearm  is  to  be  sui)ported  in  a sling,  and  the 
whole  of  the  apparatus  is  to  be  enveloped  in  a napkin, 
which  will  prevent  the  bandages  from  being  pushed 
out  of  their  places. 

If  the  effect  of  the  above  apparatus  in  fulfilling  the 
indications  above  specified  is  considered,  we  shall  easily 
see  that  they  are  very  well  accomplished.  ITie  ann, 
firmly  fixed  against  the  trunk,  can  only  move  with  it, 
and  then  nothing  displaces  the  lower  end  of  the  firac- 
ture,  which  is  equally  motionless.  The  shoulder  can 


FRACTURES. 


413 


not  communicate  any  motion  to  the  upper  end  of  the 
fracture.  The  pillow,  differently  disposed,  according 
to  the  direction  in  which  the  lower  extremity  of  the 
fracture  is  displaced,  serves  to  keep  this  part  in  the  op- 
posite position. 

Should  this  part  of  the  bone  project  inwards,  the 
thick  end  of  the  pillow  will  remove  it  farther  from  the 
chest.  The  bone  will  be  kept  at  this  distance  from  the 
side  by  the  turns  of  the  bandage,  which,  being  very 
tight  dovtmwards,  will  act  upon  the  limb  as  a lever, 
the  fulcrum  for  which  will  be  the  pillow,  and  the  re- 
sistance the  action  of  the  pectoralis  major,  latissimus 
dorsi,  and  teres  major.  Thus  the  bandage  will  have 
the  effect  of  bringing  the  elbow  nearer  the  trunk,  and 
move  the  lower  end  of  the  fracture  in  the  opposite  di- 
rection, so  that  it  may  here  be  considered  as  an  artificial 
muscle  directly  opposing  the  natural  ones. 

When  the  lower  end  of  the  fracture  is  drawn  out- 
wards, the  contrary  effect  will  be  produced,  both  from 
the  pressure  exercised  by  the  bandage  on  the  upper  end 
of  the  displaced  portion  of  the  bone,  and  from  the  situa- 
tion of  the  elbow ; which  is  kept  outwards  by  the  thick 
part  of  the  pillow.  The  outer  splint  will  also  prevent 
the  lower  end  of  the  fracture  from  being  displaced  out- 
wards, both  by  its  mechanical  resistance  to  the  bone, 
and  by  compressing  the  deltoid  muscle,  which  is  the 
chief  cause  of  such  displacement.  All  displacement 
of  the  lower  end  of  the  fracture  forwards  or  back- 
wards is  prevented  by  the  back  splint ; and  as  for  the 
longitudinal  displacement,  which  is  already  prevented 
by  the  weight  of  the  limb,  it  is  still  more  effectually 
hindered  by  the  compression  of  the  muscles  of  the  arm 
both  by  the  splints  and  roller. — (See  (Euvres  Chir.  de 
Desault,  par  Bichat,  f.  1.) 

Sir  Astley  Cooper  recommends  a roller  to  be  applied 
from  the  elbow  to  the  shoulder-joint ; two  splints  to  be 
bound  on  the  inner  and  outer  sides  of  the  arm  with  a 
roller ; a cushion  to  be  placed  in  the  axilla  in  order 
to  throw  out  the  head  of  the  bone ; and  gently  support- 
ing the  arm  in  a sling  ; for  if  the  elbow  is  much  raised, 
he  says,  the  bones  will  overlap,  and  the  union  be  at- 
tended with  deformity. — {On  Dislocations,  Src.p.  461.) 

FRACTURES  OF  THE  LOWER  ENDS  OF  THE  OS  BRACHII, 
WITH  SEPARATION  OF  THE  CONDYLES. 

Fractures  of  the  os  brachii,  with  detachment  of  its 
condyles,  seem  to  have  escaped  the  notice  of  most 
authors  who  have  written  on  the  diseases  of  the  bones. 
The  accident,  however,  is  not  uncommon,  and  Desault 
in  particular  had  frequent  occasion  to  meet  with  it. 

Whatever  its  causes  may  be,  the  two  condyles  are 
usually  separated  from  each  other  by  a longitudinal 
division,  which,  extending  more  or  less  upwards,  is 
bounded  by  another  transverse  or  oblique  division, 
which  occupies  the  whole  thickness  of  the  bone.  Hence, 
there  are  three  different  pieces  of  bone  and  two  frac- 
tures. 

Sometimes,  the  division  is  more  simple ; as  when, 
taking  a direction  outwards  or  inwards,  it  crosses  ob- 
liquely down  the  lower  end  of  the  os  brachii,  terminates 
in  th(.  joint,  and  only  detaches  one  of  the  condyles  from 
the  body  of  the  bone. 

In  the  first  case  the  deformity  is  greater,  and  the 
fractured  part  is  more  moveable.  When  pressure  is 
made  either  before  or  behind,  on  the  track  of  the  longi- 
tudinal fracture,  the  two  condyles,  becoming  farther 
separated  from  each  other,  leave  a fissure  between 
them,  and  the  fractured  part  is  widened.  The  forearm 
is  almost  always  in  a state  of  pronation.  On  taking 
hold  of  the  condyles  and  moving  them  in  different  di- 
rections, a distinct  crepitus  is  perceived. 

In  the  second  case,  the  separation  of  the  condyles 
from  each  other  is  not  so  easy  ; but  a crepitus  can  al- 
ways be  distinguished  on  moving  the  detached  con- 
dyle. In  one  case,  in  which  only  the  external  condyle 
was  broken,  Desault  found  the  limb  always  supine ; a 
position  which  the  muscles  inserted  into  this  part  were, 
doubtless,  concerned  in  producing. 

In  both  cases,  an  acute  pain,  the  almost  inevitable 
effect  of  bending  or  extending  the  forearm ; an  habitual 
half-bent  state  of  this  part  of  the  limb,  and  sometimes 
a subsequent  swelling  of  it,  together  with  more  or  le.ss 
tumefaction  round  the  joint,  are  observable.  When 
the  blow  has  been  very  violent,  or  a pointed  piece  of 
the  bone  protrudes  through  the  flesh,  the  accident  may 
be  complicated  writh  a wound,  splinters  of  bone,  &c. 

When  the  condyles  of  the  humerus  are  obliquely 


broken  off  just  above  the  joint,  the  appearances,  as  de- 
scribed by  Sir  Astley  Cooper,  are  those  of  a dislocation 
of  the  radius  and  ufna  backwards  ; but  the  nature  of 
the  case  is  evinced  by  the  circumstance  of  the  displace- 
ment recurring  as  soon  as  the  extension  is  stopped, 
and  also  by  the  crepitus,  generally  perceptible  when 
the  forearm' is  rotated  upon  the  humerus. — {On  Dislo- 
cations, Ac.  p.  481.) 

The  old  w riters  consider  the  communication  of  a 
fracture  with  a joint  a fatal  kind  of  complication. 
Swelling  and  inflammation  of  the  adjacent  parts  ; con- 
tinuance of  pain  after  the  reduction  ; large  abscesses ; 
even  mortification  of  the  soft  parts,  and  caries  of  the 
bones,  are,  according  to  such  authors,  the  almost  inevi- 
table consequences  of  these  fractures,  and  anchylosis 
the  most  favourable  termination.  Pare,  Petit,  Heister, 
Duverney,  all  give  this  exaggerated  picture.  However, 
analogous  fractures  of  the  olecranon  and  patella  prove 
that  this  representation  is  magnified  beyond  truth. 
Modern  observation  has  dispelled  the  ancient  doctrine 
of  the  effusion  of  callus  into  the  joint,  and  with  it  one 
of  the  principal  causes  assigned  by  authors  for  the 
symptoms  so  much  dreaded. 

The  detached  condyles  being  drawn  in  opposite  di- 
rections by  the  muscles  of  the  arm  and  forearm,  com- 
monly remain  unmoved  between  these  two  powers, 
and  are  but  little  displaced.  External  force  may,  how- 
ever, put  them  out  of  their  proper  situation,  and  they 
may  then  be  displaced  forwards  or  backwards,  or  they 
may  separate  from  each  other  sidewise,  leaving  an 
interspace  between  them.  Hence,  the  apparatus  should 
resist  them  in  these  four  directions,  and  this  object  is 
easily  accomplished  by  means  of  lour  splints  kept  on 
with  a roller.  The  two  lateral  splints  are  particularly 
necessary  when  the  condyles  are  separated  from  the 
body  of  the  bone  with  an  interspace  between  them. 
If  one  of  them  be  still  continuous  with  the  humerus, 
no  splint  on  this  side  will  be  requisite. 

The  apparatus  need  not  extend  as  high  as  when 
the  arm  is  fractured  higher  up ; but  the  roller  should 
be  continued  over  the  forearm,  in  order  that  the  joint 
may  correspond  to  the  middle  of  the  bandage,  which 
should  here  be  firmer  than  any  where  else.  This  me- 
thod is  also  of  use  in  producing  a gentle  compression 
of  the  muscles  implanted  into  the  condyles. 

Desault  recommends  the  front  and  back  splints  to 
be  flexible  at  their  middle  part,  which  should  be  ap- 
plied to  the  bend  of  the  arm  and  elbow. — {CEuvres 
Chir.  de  Desault,  par  Bichat,  t.  1.) 

The  treatment  advised  by  Sir  Astley  Cooper  consists 
in  bending  the  arm,  drawing  it  forwards  so  as  to  re- 
duce the  parts,  and  then  applying  a roller.  The  best 
si)lint  for  this  case,  he  says,  is  one  formed  at  right  an- 
gles, the  upper  portion  of  it  being  placed  behind  the 
upper  arm,  and  the  lower  under  the  forearm.  He 
also  directs  the  application  of  a splint  to  the  fore  part 
of  the  upper  arm.  The  splints  are  to  be  fixed  with 
straps ; evaporating  lotions  used ; and  the  arm  kept  in 
a bent  position  in  a sling.  In  a fortnight,  if  the  pa- 
tient be  young,  and  in  three  weeks  if  he  be  an  adult, 
passive  motion  ma^  be  gently  employed  for  the  pur- 
pose of  hindering  an  anchylosis. — {On  Dislocations,  d-c. 
p.  482.)  According  to  the  same  author,  when  the  in- 
ternal condyle  is  broken  off  obliquely  the  ulna  loses 
its  natural  support  and  projects  backwards. 

FRACTURE  OF  THE  FOREARM. 

The  forearm  is  more  frequently  broken  than  the 
arm,  because  external  force  operates  more  directly 
upon  it  than  the  latter  part,  especially  in  falls  on  the 
hands,  which  are  frequent  accidents.  Bichat  in  his 
account  of  Desault’s  practice,  mentions,  that  fractures 
of  the  forearm  often  held  the  first  place  in  the  com- 
parative table  of  such  cases  kept  at  the  Hotel- Dieu. 

We  know  that  the  forearm  is  composed  of  two 
bones,  the  ulna  and  radius.  The  last  is  much  more 
liable  to  fractures  than  the  first,  because  it  is  articu- 
lated with  the  hand  by  a large  surface,  and  all  the 
shocks  received  by  the  latter  part  are  communicated  to 
it.  The  situation  of  it  also  more  immediately  exposes 
it  to  such  causes  as  may  break  it.  However,  both  the 
bones  are  frequently  broken  together. 

FRACTURES  OF  LOTH  BONKS 

May  occur  at  the  extremities  or  middle  of  the  fore 
arm.  They  are  frequent  at  the  middle,  very  common 
below,  but  seldom  happen  at  the  upper  part  of  the 


414 


FRACTURES. 


forearm,  where  the  numerous  muscles,  and  the  con- 
siderable thickness  of  the  ulna,  resist  causes  which 
would  otherwise  occasion  the  accident.  The  bones  are 
usually  broken  in  the  same  line,  but  sometimes  in  two 
different  directions.  The  fracture  is  almost  always 
single,  but  in  a few  instances  it  is  double ; and  De- 
sault, in  particular,  was  one  day  called  to  a patient, 
over  whose  forearm  the  wheels  of  a cart  had  passed, 
so  as  to  break  the  bones  at  their  middle  and  lower  part, 
into  six  distinct  portions.  The  middle  ones,  notwith- 
standing they  were  quite  detached,  united  very  well 
w)th  hardly  any  deformity. 

These  accidents  are  most  commonly  occasioned  by 
direct  external  violence ; but  sometimes  they  are  pro- 
duced by  a counter-stroke,  which  is  generally  the  case 
when  the  patient  falls  on  his  hand.  But  in  this  in- 
stance, as  the  hand  is  principally  connected  wth  the 
lower  broad  articular  surface  of  the  radius,  this  bone 
alone  has  to  sustain  almost  the  whole  shock  of  the 
blow,  and  hence  is  usually  the  only  one  broken. 

The  symptoms  indicating  fractures  of  the  forearm 
are  not  likely  to  lead  the  surgeon  into  any  mistake : 
motion  at  a part  of  the  limb  where  it  was  previously 
inflexible ; a crepitus,  almost  always  easily  felt ; some- 
times a distinct  depression  in  the  situation  of  the  frac- 
ture ; occasionally  a projection  of  the  ends  of  the  frac- 
ture beneath  the  skin ; pain  on  moving  the  part ; a 
noise  sometimes  audible  to  the  patient  at  the  moment 
of  the  accident ; an  inability  to  perform  the  motion  of 
pronation  and  supination ; and  an  almost  constant 
half-bent  state  of  the  forearm. 

There  is  one  case,  however,  in  which  the  fracture 
being  very  near  the  wrist-joint,  similar  appearances  to 
those  of  a dislocation  of  this  part  may  arise.  But  at- 
tention to  whether  the  styloid  processes  are  above  or 
below  the  deformity  will  discover  whether  the  case  be 
a fracture  or  dislocation.  In  a fracture,  the  part  is 
also  more  moveable,  and  there  is  a crepitus. — {(Euvres 
Chir.  de  Desault,  -par  Bichat,  t.  1.)  According  to  Boyer, 
the  two  cases  may  be  distinguished  by  simply  moving 
the  hand;  by  which  motion,  if  there  be  a luxation 
without  fracture,  the  styloid  processes  of  the  radius 
and  ulna  will  not  change  their  situation  ; but  if  a frac- 
ture exist,  they  will  follow  the  motion  of  the  hand. 

The  conne.xion  of  the  t^^'o  bones  of  the  forearm  by 
the  interosseous  ligament,  which  occupies  the  inter- 
space by  which  they  are  separated,  and  the  manner  in 
which  the  muscles  attached  to  both  are  inserted  into 
them,  render  any  displacement  of  the  broken  pieces 
in  the  longitudinal  direction  very  difficult ; and  in  real- 
ity, such  displacement  is  seldom  observed,  and  never 
in  any  considerable  degree.  When  it  does  take  place, 
it  is  to  be  ascribed  to  the  cause  of  the  fracture,  rather 
than  to  muscular  contraction.  On  the  contrary,  in  the 
transverse  displacement,  the  four  pieces  approach  one 
another,  and  the  interosseous  space  is  diminished  or  en- 
tirely obliterated  near  the  seat  of  the  fracture ; attended 
with  evident  deformity  of  the  part.  There  is  an  an- 
gular displacement  which  the  fracturing  cause  always 
produces,  either  forwards  or  backwards,  according  to 
its  direction. 

Boyer  gives  the  follov.ing  account  of  the  treatment 
of  the  fracture  of  both  bones  of  the  forearm. 

The  forearm  is  to  be  bent  to  a right  angle  with  the 
arm,  and  the  hand  placed  in  a position  between  the  pro- 
nation and  supination.  The  forearm  and  hand  being 
thus  placed,  an  assistant  takes  hold  of  the  four  fingers 
of  the  patient,  and  extends  the  fractured  parts,  while 
another  assistant  makes  counter -extension  by  fixing 
the  humerus  %vith  both  his  hands.  By  these  means 
the  operator  is  enabled  to  restore  the  bones  to  their 
natural  situation,  and  to  push  the  sotY  parts  into  the 
interosseous  space,  by  a gentle  and  graduated  pressure 
on  the  anterior  and  posterior  sides  of  the  arm. 

The  bones  are  kept  in  their  place  by  applying  first 
on  the  anterior  and  posterior  sides  of  the  forearm  two 
longitudinal  and  graduated  compresses,  the  base  of 
which  is  to  be  in  contact  with  the  arm.  The  depth  of 
these  compresses  should  be  proportioned  to  the  thick- 
ness of  the  arm,  increasing  as  the  diameter  of  the  arm 
diminishes.  In  the  next  place,  the  surgeon  takes  a 
single-headed  roller,  about  six  yards  long,  and  makes 
three  turns  of  it  on  the  fractured  part;  he  then  de- 
scends to  the  hand  by  circles  partially  placed  over  one 
another,  and  envelopes  the  hand  by  passing  the  band- 
age between  the  thumb  and  index  finger  ; the  bandage 
Is  next  carried  upwards  in  the  same  manner,  and  re- 


flected wherever  the  inequality  of  the  arm  may  render 
it  necessary.  The  compresses  and  bandage  being  thus 
far  applied,  the  surgeon  lays  on  two  splints,  one  ante- 
riorly, the  other  posteriorly,  and  applies  the  remainder 
of  the  bandage  over  them.  The  compresses  and  splints 
should  be  of  the  same  length  as  the  forearm.  It  would 
be  useless  to  employ  lateral  splints  in  this  case,  unless 
(what  is  scarcely  ever  to  be  expected  or  met  with)  a 
displacement  should  have  taken  place  in  that  direction. 
Lateral  splints  would  counteract  the  compresses  aiid 
two  other  splints,  by  lessening  the  radio-cubital  diame- 
ter of  the  arm,  and  with  the  action  of  the  pronators, 
tend  to  push  the  ends  of  the  fracture  into  the  inter- 
osseous space.  The  surgeon’s  attention  should  be  par- 
ticularly directed  to  preserve  the  interosseous  space  j 
for,  if  this  be  obliterated,  the  radius  cannot  rotate  on 
the  ulna,  nor  the  motion  of  pronation  or  supination  be 
executed ; and  this  object  may  be  obtained  with  cer- 
tainty by  applying  the  compresses  and  splints  in  such  a 
manner,  that  the  fleshy  parts  may  be  forced  into  and 
confined  in  the  interosseous  space,  and  by  renewing  the 
bandage  every  seven  or  eight  days. 

If  the  fracture  be^^imple,  and  the  contusion  inconsi- 
derable, the  patient  need  not  be  confined  to  bed,  but 
may  walk  about  with  his  arm  in  a sling. 

FRACTURES  OF  THE  RADIUS 

Are  the  most  frequent  of  those  of  the  forearm.  The 
radius  being  almost  the  sole  support  of  the  hand,  and 
placed  in  the  same  line  with  the  humerus,  is  for  both 
these  reasons  more  exposed  to  fractures  than  the  ulna. 

Fractures  of  the  radius,  whether  transverse  or  ob- 
lique, near  its  middle  part  or  extremities,  may  be 
caused  by  a fall  or  blow  on  the  forearm,  or  as  hap- 
pens in  most  cases,  by  a fall  on  the  palm  of  the  hand. 
When  likely  to  fall  we  extend  our  arms,  and  let  the 
hands  come  first  to  the  ground ; in  which  case,  the  ra- 
dius pressed  between  the  hand  on  the  ground  and  the 
humerus,  from  which  it  receives  the  whole  momentum 
of  the  body,  is  bent,  and  if  the  fall  be  sufficiently  vio- 
lent, broken  more  or  less  near  its  middle  part.  When 
after  an  accident  of  this  kind,  pain  and  difficulty  of  per- 
forming the  motions  of  pronation  and  supination  su- 
pervene, the  probability  of  a fracture  of  the  radius  is 
very  strong.  The  truth  is  fully  ascertained  by  pressing 
with  the  fingers  along  the  external  side  of  the  forearm. 
Also,  in  endeavouring  to  perform  supination  or  prona- 
tion of  the  hand,  a crepitus  and  a motion  of  the  broken 
portions  will  be  perceived.  When  the  fracture  takes 
place  near  the  head  of  the  radius,  the  diagnosis  is  more 
difficult,  on  account  of  the  depth  of  soft  parts  over  that 
part  of  the  bone.  In  this  case,  the  thumb  is  to  be 
placed  under  the  external  condyle  of  the  os  humeri, 
and  on  the  superior  extremity  of  the  radius,  and  at  the 
same  time  the  hand  is  to  be  brought  into  the  prone 
and  supine  positions.  If  in  these  trials,  which  are 
always  painful,  the  head  of  the  radius  rests  motionless, 
there  can  be  no  doubt  of  the  bone  being  fractured. 
Here  the  causes  of  displacement  are  the  same  as  in 
fractures  of  the  forearm ; it  can  never  take  place,  ex- 
cept in  the  direction  of  the  diameter  of  the  bone,  and  is 
effected  principally  by  the  action  of  the  pronating  mus- 
cles. The  ulna  serves  as  a splint  in  fractures  of  the  ra- 
dius ; and  the  more  effectually,  as  these  two  bones  are  con- 
nected %\ith  one  another  throughout  their  whole  length. 

In  general,  when  only  the  radius  is  fractured,  no  ex- 
tension is  requisite.  During  the  treatment,  the  elbow 
is  to  be  bent,  and  the  hand  put  in  the  mid-state  between 
pronation  and  supination ; that  is  to  say,  the  palm  of 
the  hand  is  to  face  the  patient’s  breast.  Having  re- 
duced the  ends  of  the  fracture  when  they  appear  m be 
displaced,  the  soap  plaster  is  to  be  ai  plied,  and  over 
this  a slack  roller.  This  bandage  is,  indeed,  of  no 
utility;  but  it  makes  the  limb  seem,  to  the  unknowing 
bystanders,  more  comfortable  than  if  it  were  omitted, 
and  as  it  does  no  harm,  the  surgeon  may  honestly  ap- 
ply it.  However,  no  one  can  doubt,  that  ti|ht  bandage.s 
may  act  very  perniciously,  by  pressing  the  radius  and 
ulna  together,  causing  them  to  grow  to  each  other,  or 
at  all  events,  making  the  fracture  unite  in  an  uneven 
manner.  Only  two  splints  are  necessarj’;  one  is  to 
be  placed  along  the  inside,  the  other  along  the  outside, 
of  the  forearm.  Soft  pads  must  always  be  placed  be- 
tween the  skin  and  the  splints,  in  order  to  obviate  the 
pressure  of  the  hard  materials  of  which  the  latter  are 
formed.  The  inner  splint  should  extend  to  about  the 
last  joint  of  the  fingers;  but  not  completely  to  the  end 


FRACTURES. 


415 


of  the  nails , for  many  patients,  after  having  had  their 
fingers  kept  for  several  weeks  in  a state  of  perfect  ex- 
tension, have  been  a very  long  time  in  becoming  able 
to  bend  them  again. 

Sometimes  it  may  be  proiier  to  apply  a compress 
just  under  the  ends  of  the  fracture,  to  prevent  their 
being  depressed  towards  the  ulna  too  much,  the  conse- 
quence of  which  has  occasionally  been  the  loss  of  the 
prone  and  supine  motions  of  the  hand. 

In  setting  a fractured  radius,  the  hand  should  be  in- 
clined to  the  ulnar  side  of  the  forearm. 

FRACTURES  OF  THE  ULNA. 

Fractures  of  this  bone  are  less  frequent  than  those 
of  the  radius,  and  take  place  generally  at  its  lower  ex- 
tremity, whiih  is  most  slender  and  least  covered.  A 
fracture  of  this  bone  is  almost  always  the  result  of  a 
force  acting  immediately  on  the  part  fractured ; as,  for 
instance,  when  in  a fall  the  internal  side  of  the  fore- 
arm strikes  against  a hard  resisting  body.  On  apply- 
ing the  hand  judiciously  to  the  inside  of  the  forearm, 
this  fracture  is  easily  ascertained  by  the  depression  at 
that  part,  in  consequence  of  the  inferior  portion  being 
drawn  towards  the  radius  by  the  action  of  the  prona- 
tor radii  quadratus.  This  displacement,  however,  is 
less  considerable  than  what  takes  place  in  fractures  of 
the  radius.  The  superior  portion  of  the  ulna  remains 
unmoved.— (/.  L.  Petit.) 

In  this  case,  the  assistant,  who  makes  whatever 
little  extension  may  be  necessary,  should  incline  the 
hand  to  the  radial  side  of  the  forearm,  while  the  sur- 
geon pushes  the  flesh  between  the  two  bones,  and  ap- 
plies the  apparatus  as  in  the  preceding  case.  In  all 
fractures  of  the  bones  of  the  forearm,  and  particularly 
in  those  which  are  near  the  head  of  the  radius,  a false 
anchylosis  is  to  be  apprehended,  and  should  be  guarded 
against  by  moving  the  elbow  gently  and  frequently, 
when  the  consolidation  is  in  a certain  degree  advanced. 

Fractures  of  the  forearm  always  require  the  part  to 
be  kept  quietly  in  a sling. 

FRACTURES  OF  THE  OLECRANON. 

The  olecranon  may  be  fractured  either  at  its  base, 
its  centre,  or  its  extremity ; but  the  second  case  is  the 
most  frequent.  The  division  is  almost  always  trans- 
verse, though  occasiona'ly  oblique.  The  accident  is 
very  rarely  produced  by  tho  action  of  the  muscles,  but 
almost  always  by  external  violence,  directly  applied  to 
the  part  in  a blow  or  fall  upon  the  elbow. 

With  regard  to  symptoms,  the  contraction  of  the  tri- 
ceps, being  no  longer  resisted  by  any  connexion  with 
the  ulna,  draws  upwards  the  short  fragment  to  which 
it  adheres,  so  as  to  produce,  between  it  and  the  lower 
one,  a more  or  less  evident  interspace.  This  inter- 
space is  situated  at  the  back  part  of  the  joint,  and  may 
be  increased  or  diminished  at  will,  by  augmenting  the 
flexion  of  the  forearm,  and  putting  the  triceps  into  ac- 
tion, or  extending  the  limb.  Another  symptom  is  the 
impossibility  of  spontaneously  extending  the  forearm, 
the  neccssarj"  effect  of  the  detachment  of  the  triceps 
from  the  ulna.  It  appears  from  the  dissections  made 
by  Sir  Astley  Cooper,  that  the  extent  of  the  separation 
depends  upon  the  degree  of  laceration  of  the  capsular 
ligament,  and  of  that  portion  of  ligament  which  pro- 
ceeds from  the  side  of  the  coronoid  process  to  that  of 
the  olecranon. — (On  Dislocations.,  vCc.  p.  487.)  It  must 
be  owing  to  the  untorn  state  either  of  the  latter  part, 
or  of  the  aponeurosis  covering  the  olecranon,  that  pa- 
tients occasionally  retain  the  power  of  extending  the 
forearm,  as  is  exemplified  in  the  case  reported  by  Mr. 
Earle,  where,  on  the  sixth  day  after  the  accident  (and  not 
before)  this  power  was  destroyed  by  a sudden  flexion  of 
the  forearm. — {Practical  Ohs.  p.  147.)  The  forearm  is 
constantly  half-bent,  the  biceps  and  brachialis  having  no 
antagonists.  The  olecranon  is  more  or  less  drawn  up 
higher  than  the  condyles  of  the  os  brachii,  which  lat- 
ter parts,  on  the  contrary,  are  naturally  situated  higher 
than  the  olecranon,  when  the  forearm  is  half-bent. 
The  upper  piece  of  bone  may  be  moved  in  every  di- 
rection without  the  ulna  participating  in  the  motion. 
Besides  these  symptoms,  we  must  take  into  the  ac- 
count the  considerable  pain  experienced,  and  the  cre- 
pitus perceptible,  when  the  fragment  is  approximated 
to  the  surface  from  which  it  is  detached. 

The  indications  are,  to  push  the  retracted  portion  of 
the  olecranon  downwards,  and  to  keep  it  in  this  posi- 
tion at  the  same  time  that  the  ulna  is  made  to  meet  it. 


as  it  were,  by  extending  the  tbrearm.  According  to 
Desault,  however,  the  forearm  should  not  be  com- 
pletely extended,  as  when  the  pieces  of  bone  touch  at 
their  back  part,  they  leave  a vacancy  in  front,  which  is 
apt  to  be  followed  by  an  irregular  callus,  prejudicial  to 
the  free  motion  of  the  elbow.  Hence,  it  was  his  prac- 
tice to  put  the  arm  between  the  half-bent  and  the  com- 
pletely extended  state,  and  to  maintain  this  posture  by 
means  of  a splint  along  the  fore  part  of  the  arm.  But 
as  position  operates  only  on  the  lower  part  of  the  ole- 
cranon, the  upper  one  requires  to  be  brought  near  the 
former  and  fixed  there,  which  is,  doubtless,  the  most 
difficult  object  to  effect,  because  the  triceps  is  continu- 
ally resisting. 

Desault  used  to  adopt  the  following  method  : the 
forearm  being  held  in  the  above  position,  the  surgeon 
is  to  begin  applying  a roller  round  the  wrist,  and  to 
continue  it  as  high  as  the  elbow.  The  skin  covering 
this  part,  being  wrinkled  in  consequence  of  the  exten- 
sion of  the  limb,  might  insinuate  itself  between  the 
ends  of  the  fracture,  and  consequently  it  must  now  be 
pulled  upwards  by  an  assistant.  The  surgeon  is  then 
to  push  the  olecranon  towards  the  ulna,  and  confine  it  in 
this  situation  with  a turn  of  the  roller,  with  which  the 
joint  is  then  to  be  covered,  by  applying  it  in  the  form 
of  a figure  of  8. 

A strong  splint  a little  bent,  just  before  the  elbow, 
is  next  laid  along  the  arm  and  forearm,  and  fixed  by 
means  of  a roller.  The  limb  is  then  to  be  evenly  sup- 
ported on  a pillow. 

The  cure  of  the  fractured  olecranon  is  seldom  ef- 
fected by  the  immediate  reunion  of  its  fragments  : 
there  generally  remains  a greater  or  less  interspace 
between  them,  which  is  filled  up  by  a substance  not  of 
a bony  consistence.  Indeed,  the  tenor  of  the  remarks 
and  experiments  lately  published  by  Sir  Astley  Cooper 
on  this  subject  is  to  represent  the  broken  olecranon  as 
similarly  circumstanced  with  respect  to  bony  union,  as 
the  fractured  neck  of  the  femur.  He  has  seen  union 
by  bone  effected  in  the  living  subject ; but  this  was 
when  the  fracture  had  taken  place  very  near  the  shaft 
of  the  ulna.  The  ligamentous  substance,  he  says, 
which  generally  forms  the  bond  of  union,  often  has 
one  or  even  several  apertures  in  it,  when  it  is  of  con 
siderable  length.  The  arm  is  observed  to  be  weakened 
in  proportion  to  the  length  of  the  ligament.— (On  Dis- 
locations, <S-c.  p.  489.) 

Camper  laid  great  stress  upon  the  inutility  of  keep- 
ing the  arm  perfectly  extended : he  found  patients  re- 
cover sooner  and  better  when  the  elbow  was  kept  half- 
bent, and  the  joint  gently  exercised  at  as  early  a pe- 
riod as  possible.  “ Agglutinationem  scilicet  motiri 
non  debet  chirurgus,  sed  sublatis  tumore  ac  inflamma- 
tione  quiete  et  remediis  aptis,  cubitum  quotidie  pru- 
denter  movere,  ut  unio  per  tricipilis  tendinem,  seu  per 
concretionem  membranosam  fometur,  et  os  ossi  non 
admoveatur.  Verbo  quernadmodum  C.  Celsus  in  Med. 
lib.  8,  c.  10,  ^ 4,  p.  537,  de  cubito  fracto  praecepit. 
Quod  si  ex  suinmo  cubito  quid  fractum  sit,  glutiiiare  id 
vinciendo  alienum  est,  fit  enim  brachium  immobile,  ac, 
si  nihil  aliud  quam  dolore  occurrendum  est,  idem  qui 
fuit  ejus  usus  est.”— (Camper  de  Fracturd  Patellae,  p. 
66,  Hag(B,  1789.)  Mr.  Earle  is  also  an  advocate  for 
placing  the  limb  in  a slightly  bent  position. — (Pract. 
Ohs.  p.  165.)  The  late  Mr.  Sheldon,  however,  does  not 
concur  with  Desault  and  Camper,  respecting  the  posi- 
tion of  the  limb  during  the  treatment,  but  insists  ujxtn 
the  utility  of  keeping  the  forearm  perfectly  extended. 

When  there  is  much  swelling.  Sir  A.  Cooper  em- 
ploys leeches  and  evaporating  lotions  for  two  or  three 
days ; but  when  not  much  violence  has  been  done  to 
the  limb,  he  applies  the  bandage  at  once.  He  places 
the  arm  in  a straight  position,  pres.ses  down  the  frag- 
ment until  it  touches  the  ulna,  and,  after  putting  a slip 
of  linen  along  each  side  of  the  joint,  puts  a roller  round 
the  limb  above  and  below  the  olecranon.  By  tying  the 
slijis  of  linen  which  pass  under  the  rollers,  these  are 
drawn  nearer  together,  and  the  fragment  of  the  ole- 
cranon is  thus  kept  as  near  as  possible  to  the  ulna.. 
Lastly,  a splint  well  padded  is  aj»plied  along  the  front 
of  the  arm,  and  secured  with  a bandage,  which  is  fre- 
qently  wetted  with  sihrit  of  wine  and  water. — {On 
Dislocations,  S,  c.  p.  490.) 

On  an  average,  the  olecranon  becomes  firmly  united 
about  the  twenty-sixth  day. — {Desault.)  In  a month 
the  splint  is  to  be  removed  and  passive  motion  beguit 
— (A.  Cooper.) 


416 


FRA 


FR^ 


FKA.CTURS  OF  THE  CORONOID  PROCESS. 

Two  examples  of  this  accident  are  noticed  by  Sir 
Astley  Cooper : in  one  case,  seen  by  him  several 
months  after  its  occurrence,  the  same  appearances  pre- 
sented themselves  as  were  remarked  by  the  surgeon 
who  first  attended  the  patient ; namely,  the  ulna  pro- 
jected backwards  while  the  arm  was  extended,  but  it 
oould  be  drawn  forwards  and  the  elbow  bent  without 
much  difficulty,  when  the  deformity  disappeared.  In 
the  other  instance,  which  presented  itself  in  the  dis- 
section-room, the  coronoid  process,  which  had  been 
broken  off,  v^as  united  by  ligament,  and  so  moveable 
that  when  the  forearm  was  extended,  the  ulna  glided 
backwards  upon  the  condyles  of  the  humerus.  Sir 
Astley  Cooper  is  of  opinion  that  the  case  admits  of  no 
other  mode  of  union ; he  recommends  keeping  the  arm 
steadily  in  the  bent  position  for  three  weeks. — {On  Dis- 
locations, 4-c.  p.  434.) 

FRACTURES  OF  THE  CARPAL  AND  METACARPAL  BONES, 
AND  PHALANGES  OF  THE  FINGERS. 

The  bones  of  the  carpus,  when  broken,  are  usually 
crushed,  as  it  were,  between  very  beavj-  bodies,  or  the 
limb  has  been  entangled  in  powerful  machinery,  or 
suffered  gun-shot  violence.  It  must  be  obvious,  there- 
fore, that  as  the  soft  parts  are  also  seriously  injured, 
these  cases  are  generally  followed  by  severe  and 
troublesome  sjTnptoms,  and  sometimes  require  the  per- 
formance of  amputation,  either  immediately  or  subse- 
quently. When  an  attempt  is  to  be  made  to  save  the  part, 
the  chief  indications  are  to  extract  splinters  of  bone, 
and  prevent  inflammation,  abscesses,  and  mortifica- 
tion. The  parts  may  at  first  be  kept  wet  with  a cold 
evaporating  lotion,  any  wound  present  being  lightly 
and  superficially  dressed ; but  afterward,  as  soon  as 
all  tendency  to  bleeding  is  over,  emollient  poultices 
may  be  applied  over  the  dressings  instead  of  the  lo- 
tion. The  dressings  themselves,  however,  should  not 
be  remaved  for  the  first  three  or  four  days,  all  unne- 
cessary disturbance  of  the  crushed  parts  being  highly 
injurious.  Should  abscesses  form,  early  openings 
should  be  practised,  so  as  to  prevent  the  matter  from 
extending  up  the  forearm.  Duly  supporting  the  hand 
and  forearm  in  a sling  is  of  the  greatest  importance. 
The  metacarpal  bones  of  the  little  finger  and  thumb  are 
more  frequently  broken  than  the  other  three.  A fracture 
of  a metacarpal  bone  is  generally  produced  by  violence 
applied  directly  to  the  part,  as  no  force  capable  of  causing 
the  accident  can  well  act  upon  the  tw'o  ends  of  the  bone 
so  as  to  break  it.  The  fracture  may  be  simple,  but  more 
commonly  it  is  compound,  the  soft  parts  being  w'ounded 
and  lacerated  by  the  same  violence  which  has  injured 
the  bone.  In  most  cases,  also,  unless  the  force  has 
operated  by  a very  limited  surface,  more  than  one  me- 
tacarpal bone  is  fractured.  At  first,  the  same  kind  of 
treatment  is  requisite  tus  in  the  preceding  cases,  and, 
after  the  inflammation  has  subsided,  a hand-board  or 
splint  may  be  employed.  When  the  hand  is  very  badly 
crushed,  amputation  is  indicated. 

In  fractures  of  the  finger-bones,  the  treatment  con- 
sists in  applying  a piece  of  soap-plaster,  rolling  the 
part  with  tape,  covering  it  in  paste-board,  sometimes 
placing  the  hand  on  a flat  splint  or  finger-board,  and  al- 
ways keeping  the  hand,  forearm,  and  elbow  well  sup- 
jwrted  in  a sling. 

For  Fractures  of  the  Cranium,  see  Head,  Inju- 
ries of. 

For  information  on  fractures,  consult  particularly  J. 
L.  Petit,  TVaite  des  Maladies  des  Os.  Duvemey,  Traite 
des  Maladies  des  Os.  Jonathan  Wathen,  The  Con- 
ductor and  Containing  Splints ; or,  a Description  of 
two  new-invented  Instruments,  for  the  more  scfe  Con- 
veyance, as  well  as  the  more  easy  and  perfect  Cure, 
of  Fractures  of  the  Leg,  2d  ed.  8vo.  Lond.  1767.  IF. 
Sharp,  in  vol.  57  of  the  Philosophical  Trans,  part  2, 
1767.  An  Account  of  a New  Method  of  treating  Frac- 
tured Legs.  Pott's  Remarks  on  Fractures  and  Dislo- 
cations. T.  Kirkland,  Obs.  upon  Mr.  Pott's  General 
Remarks  on  Fractures,  <S-c.  8vo.  Lond.  1770  ; also.  Ap- 
pendix to  the  same,  8vo.  Land.  1771.  Cases  in  Sur- 
gery, by  C.  White,  edit.  1770.  J.  Aitken,  Essays  on 
several  Important  Subjects  in  Surgery,  chief  y on  the 
Nature  of  Fractures  of  the  Long  Banes  of  the  Extre- 
mities, particularly  those  of  the  Thigh  and  Leg,  Svo. 
1771.  Boyer,  TVaite  des  Mol.  Chir.  t.  3,  Encyclo- 
pidie  M'  thodique,  partie  Chir.  art.  Fracture,  Ctiisse, 
Omoplate,  Ileum,  Src.  (Euvres  Chir.  de  Desault, 


par  Bichat,  t.  1.  Parts  of  the  Parisian  Chirurgical 
Journal.  Sir  J.  Earle,  A Letter,  containing  some 
Observations  on  the  Fractures  of  the  Lower  Limbs ; 
to  which  is  added  an  Account  of  a Contrivance  to  ad- 
minister Cleanliness  and  Comfort  to  the  Bed-ridden, 
or  Persons  confined  to  Bed  by  Age,  Accident,  Sickness, 
or  other  Infirmity,  8uo.  Lond.  1807.  Leveille,  Nouvelle 
Doctrine  Chir.  t.  2,  1812.  Assalini,  Manuale  di  Chi- 
rurgia,  parte  prima,  Milano,  1812.  Dupuytren,  Des 
FVuctures  ou  Courbures  des  Os  des  Eiifans,  in  Bul- 
letin de  la  Faculty  de  Med.  Paris,  1811.  Idem,  Sur  la 
Fracture  de  VExtremite  inferieure  du  Perone,  Ics  Lux- 
ations et  les  Accidens  qui  en  sant  la  suite,  in  An- 
nuaire  Med.  Chir.  de  Paris,  Mo.  Paris,  1819.  Roux, 
Relation  d'un  Voyage  fait  d Londres  en  1814,  au  Pa- 
rallele  de  la  Chirurgie  Angloise  avec  la  Chirurgie 
Francoise,  p.  173,  <^c.  Paris,  1815.  Med.  Chir. 
Trans,  vol.  2,  p.  47,  Src. ; vol.  5,  p.  358,  (S-c.;  vol.  7,  p. 
103.  Sketches  of  the  Medical  Schools  of  Paris,  by  J. 
Cross,  p.  87,  d'C.  Sir  A.  Cooper,  A Treatise  on  Dislo- 
cations and  Fractures  of  the  Joints,  Mo.  Lond.  1822 ; 
and  Obs.  on  Fractures  of  the  Neck  of  the  Thigh-Bone, 
1823.  H.  Earle,  Practical  Observations  in  Surgery, 
Svo.  1823.  IF.  Gibson's  Institutes  and  Practice  of 
Surgery,  8uo.  vol.  1,  Philadelphia,  1824.  B.  Bell,  on 
the  Diseases  of  the  Banes,  \2mo.  Edin.  1828.  J. 
Amesbury  on  Fractures  of  the  Upper  Third  of  the 
Thigh-Bone,  and  Fractures  of  Icrng  standing,  ed.  2, 
8i;o.  Lond.  1829. 

FR.3ENUM  LINGU.®.  In  infants,  the  tongue  is 
sometimes  too  closely  tied  do\vn,  by  reason  of  the  frse- 
num  being  extremely  short,  or  continued  too  far  for- 
wards. In  the  latter  case,  the  child  will  not  be  able  to 
use  its  tongue  with  sufficient  ease  in  the  actions  of 
sucking,  swallowing,  &c.,  in  consequence  of  its  point 
being  confined  at  the  bottom  of  the  mouth.  Though 
this  affection  is  not  unfrequent,  it  is  less  common  than 
is  generally  supposed  by  parents  and  nurses.  When 
the  child  is  smtdl  and  the  nurse’s  nipple  large,  it  is 
common  for  her  to  suppose  the  child  to  be  tongue-tied, 
when,  in  fact,  it  is  only  the  smallness  of  the  child’s 
tongue  that  prevents  it  from  surrounding  the  nipple,  so 
as  to  enable  it  to  suck  with  facility.  Mothers  also 
commonly  suspect  the  existence  of  such  an  erroneous 
formation,  whenever  the  child  is  long  in  beginning  to 
talk. 

The  reality  of  the  case  may  alw^ays  be  easily  ascer- 
tained by  examining  the  child’s  mouth.  In  the  natural 
state,  the  point  of  the  tongue  is  always  capable  of  being 
tum^  upwards  towards  the  palate,  as  the  fraenum  does 
not  reach  along  above  a quarter  of  an  inch  of  the  lower 
part  of  the  tongue  from  the  apex.  But  in  tongue-tied 
children,  by  looking  upon  one  side,  we  may  see  the 
fraenum  extending  from  the  back  part  to  the  very  point, 
so  that  the  whole  length  of  the  tongue  is  tied  down  and 
unnaturally  confined. 

The  plan  of  cure  is  to  divide  as  much  of  the  fraenum 
as  seems  proper  for  setting  the  tongue  at  liberty.  The 
incision,  however,  should  not  be  carried  more  exten- 
sively backwards  than  is  necessary,  lest  the  raninal 
arteries  be  cut ; an  accident  that  has  been  known  to 
prove  fatal.  For  thq.  same  reason,  the  scissors  used  for 
this  operation  should  have  no  points.  I think  the  fol- 
lowing piece  of  advice  offered  by  a modem  author  may 
be  of  service  to  practitioners,  who  ever  find  it  necessary 
to  divide  the  frasnum  linguae : “ It  is  not  the  relations 
of  the  trunk  of  the  lingual  artery  alone  which  the  stu- 
dent ought  to  make  himself  acquainted  with.  He  will 
do  well  to  study  the  position  of  the  arteria  ranina  in 
respect  to  the  fraenum  linguae.  This  information  will 
teach  him  the  impropriety  of  pointing  the  scissors  up- 
wards and  backwards,  when  snipping  the  fraenum ; an 
operation,  by-the-by,  oftener  perfonned  than  needed. 
He  will  learn  that  the  ranular  artery  lies  just  above  the 
attachment  of  the  fraenum  ; so  that,  if  he  would  avoid 
it,  he  must  turn  the  iioints  of  the  scissors  rather  down- 
wards ; if  he  do  not,  the  artery  will  probably  suffer.” 
— (A.  Bums,  Surgical  Anatomy  of  the  Head  and 
Neck,  p.  239.) 

When  an  inftint  has  the  power  of  sucking,  this  pro- 
ceeding should  never  be  resorted  to,  even  though  the 
fraenum  may  have  the  appearamce  of  being  too  short,  or 
extending  too  far  forwards. — {Fab.  Hitdanus,  centur.  3, 
obs.  28.  Petit,  Traite  des  Mol.  Chir.  t.  3,  p.  265,  edit 
1774.) 

Although  the  operation  of  dividing  the  fraenum  linguae 
is  for  the  most  part  done  without  any  bad  consequencee, 


FRA 


FRA 


417 


s«rgeoi»8  should  remember  well  that  it  is  liable  to 
dangers,  especially  when  performed  either  unnecessa- 
rily or  unskilfully. 

Besides  the  fatal  events  which  have  occasionally 
resulted  from  wounding  the  raninal  arteries,  the  records 
of  surgery  Aimish  us  with  proofs  that  the  mere  bleed- 
ing from  the  raninal  Veins,  and  the  small  vessels  of  the 
fraenum,  may  continue  so  long,  in  consequence  of  the 
infant’s  incessantly  sucking,  as  to  produce  death.  In 
such  cases,  the  child  swallows  the  blood  as  fast  as  it 
issues  from  the  vessels,  so  that  the  cause  of  death  may 
eve-.i  escape  observation.  But  if  the  body  be  opened, 
the  stomach  and  intestines  will  be  found  to  contain 
large  quantities  of  blood. — (See  Dionis,  Cours  (VOpdra- 
t/ans  de  Chirurgie,  7e  DenumstratioTi,  Petit,  Traite 
dvs  Maladies  Chir.  t.  3,p.  282, 

Another  accident,  sometimes  following  an  unneces- 
sary or  loo  extensive  a division  of  the  fr®num,  consists 
in  the  tong^ie  becoming  thrown  backwards  over  the 
glottis  into  the  pharynx^  wliere  it  lies  fixed,  and  causes 
suffocation.  The  observations  of  Petit  on  this  subject 
are  highly  interesting. — (See  Op.  cit.  t.  3,  p.  267,  <^c.) 

Lastly,  it  should  be  known,  that  an  infant’s  inability 
to  move  its  tongue,  or  suck,  is  not  always  owing  to  a 
malformation  of  the  fraenum.  Sometimes  the  tongue  is 
applied  and  glued,  as  it  were,  to  the  roof  of  the  mouth, 
by  a kind  of  mucous  substance ; and  in  this  case,  it 
shoul-i  be  separated  with  the  handle  of  a spatula.  By 
this  means,  infants  have  been  saved  who  were  unable 
to  suck  during  several  days,  and  were  in  imminent 
danger  of  perishing  from  want  of  nourishment.— (See 
M^nioires  de  VAcad.  de  Chir.  t.  3,  p.  16,  ^d.  Mo.) 

See  particularly  Petit,  Traite  des  Maladies  Chir.  L 3, 
p.  260,  &-C.  Dionis,  Cours  dlOpdrations,  le  Demonstr. 
Sabatier,  Mifdecine  Operatoire,  t.  3,  p.  132,  &c.  Lassus, 
Pathologie  Chir.  t.  2,  p.  454.  Richerand,  Nosogr.  Chir. 
t.  3,  p.  284,  ed.  2.  Richter,  Anfangsgr.  der  Wundarzn. 
b.  4t,kap.2,p.  11,  ed.  1800. 

FRAGILITAS  OSSIUM,  A morbid  brittleness  of 
the  bones.  Although  it  may  take  place  at  different 
periods  of  life,  it  is  remarked  to  be  more  common  in 
childhood  and  in  persons  of  advanced  age. — (See  B. 
Bell  on  Diseases  of  the  Bones,  p.  74.) 

Boyer  imputes  mollities  ossium  to  a deficiency  of  lime 
in  their  structure;  fragilitas  ossium  to  a deficiency  of 
the  soft  matter  naturally  entering  into  their  texture. 
He  states,  that  a certain  degree  of  fragilitas  ossium 
necessarily  occurs  in  old  age,  because  the  proportion  of 
lime  in  the  bones  naturally  increases  as  we  grow  old, 
while  that  of  the  organized  part  diminishes.  Hence, 
the  bones  of  old  persons  more  easily  break  than  those 
of  young  subjects,  and  are  longer  in  uniting  again  As 
Mr.  Wilson  observes,  however,  they  never  are  found  so 
friable  and  fragile,  as  to  crumble  like  a calcined  bone, 
but,  on  the  contrary,  they  contain  a large  quantity  of 
oil ; a fact  particularly  noticed  by  Saillant  (see  Hist,  de 
la  Societi  de  MH.  1776,  p.  316),  and  when  dried  after 
death,  they  are  so  greasy  as  to  be  unfit  to  be  preserved 
as  preparations.  Their  organized  vascular  part  is  di- 
ininished,  but  their  oily  animal  matter  is  increased. — 
{On  the  Skeleton  and  Diseases  of  Bones,  p.  258.) 

In  persons  who  have  been  long  afflicted  with  can- 
cerous diseases,  the  bones  become  sometimes  as  brittle 
as  if  they  had  been  calcined.  Saviard  and  Louis  relate 
cases  of  this  description. — (Obs.  Chir.  et  Joum.  des 
Savans,  1691.  Obs.  et  Remarques  sur  les  Effets  du 
Vines  Cancereux,  Paris,  1750.  Pouteau,  lEuvres 
Posthumes,  t.  1 .)  Two  remarkable  instances  of  this 
kind  have  been  published  by  Mr.  Salter,  of  Poole.  In  the 
first,  the  patient,  a female,  aged  82,  felt  the  right  thigh 
suddenly  break  as  she  was  standing  at  her  drawers. 
For  several  months  previous  to  the  accident,  she  had  had 
constant  and  very  severe  pain  in  the  part  of  the  bone 
Which  was  broken,  and  she  had  been  long  afflicted  with 
a cancerous  ulceration  of  the  mamma.  After  death, 
tlie  bone  was  so  fle.xible,  that  no  bony  union  could  have 
l iken  place  A regular  dissection  of  the  limb  was  not 
allowed.  In  Mr.  Salter’s  second  case,  the  patient  was 
al.so  a female,  56  years  of  age,  and  for  five  months  pre- 
ceding the  accident  had  laboured  tmder  violent  pain  of 
the  right  thigh,  and  a thickening  of  the  periosteum  a 
little  above  the  patella.  As  her  friends  were  putting 
her  Into  a cart,  the  bone  snapped  about  three  inches 
below  the  trochanter.  For  several  years  she  had  a 
scirrhus  of  the  left  breast.  This  had  been  removed, 
and  the  wound  healed,  but  afterward  broke  out  in  the 
form  of  cancerous  ulceration.  In  this  stage  the  firac- 

VoL.  I.— B d 


ture  took  place,  and  was  followed  in  about  three  month* 
by  her  death.  Mr.  Salter  removed  the  thigh-bone,  and 
brought  it  home  for  examination ; but,  previously  to  its 
removal,  the  aflected  limb  was  observed  to  be  consider- 
ably shorter  than  tfie  other,  and  flexible  at  its  middle, 
and  a good  deal  deformed  by  a projection  just  below  the 
trochanter  major.  The  muscles  of  tne  thigh  were  pale 
and  shrunk ; a bloody  fluid  escaped  from  the  capsular 
ligament  of  the  knee-joint,  and  two  or  three  clots  of 
pure  blood  were  in  the  articular  cavity.  On  removing 
the  patella,  a small  ulcer  was  discovered  in  the  upper 
and  external  part  of  the  articular  surface  of  the  bone. 
Among  other  particulars,  it  is  stated  that  the  thigh-bone 
was  remarkably  soft  throughout  its  whole  length,  and 
the  knife  could  be  pushed  through  it  at  any  part ; but 
at  its  middle  it  was  most  conspicuously  deficient  in 
earthy  matter.  At  about  three  inches  from  either  ex- 
tremity, it  could  be  bent  in  any  direction ; and  it  was 
on  the  upper  part  of  this  portion  that  the  fracture  had 
taken  place,  but  the  precise  situation  of  it  was  not  dis- 
tinctly visible  ; and  Mr.  Salter  conceives,  that  there  had 
been  no  complete  separation  like  what  occurs  in  common 
fractures.  The  distortion  did  not  arise  from  any  over- 
lapping, but  from  a bending  of  the  bone.  The  muscles 
about  the  upper  part  of  the  limb  were  confounded  toge- 
ther into  a uniform  mass  of  a pale  red  colour,  firm  and 
cartilaginous,  with  bony  spiculae  thickly  dispersed 
through  them,  and  puriform  matter  slightly  tinged  with 
blood  issuing  from  the  cut  surfaces.  The  integuments 
had  suffered  no  change.  In  the  situation  of  the  swell- 
ing noticed  above  the  patella,  the  tendon  of  the  cruralis 
was  much  thickened  and  altered  in  texture,  and  a con- 
siderable quantity  of  pus  came  from  under  it ; the  sub- 
jacent periosteum  was  also  much  thickened,  and  readily 
detached.  The  parietes  of  the  bone  were  here  nearly 
absorbed,  and  the  medullary  cavity  was  filled  with  a 
bloody  pultaceous  substance.— (See  Med.  Chir.  Trans, 
vol.  15,  p.  186.)  It  is  justly  inferred  by  Mr.  Salter,  that 
as  these  cases  corresponded  in  so  many  points,  the 
predisposing  cause  of  fracture  was  probably  the  same 
in  both.  Both  the  patients  laboured  under  cancer  of 
the  breast,  and  both  suffered  much  from  previous  pain 
and  lameness.  These  cases,  it  is  to  be  remarked,  were 
rather  specimens  of  mollities  ossium,  or  preternatural 
flexibility  of  the  bones  affected,  and  seem  to  have  dif- 
fered from  some  examples  of  fragility  on  record,  not 
only  in  their  cause,  but  in  the  circumstance  of  no  at- 
tempt at  ossification  having  taken  place  in  the  broken 
or  flexible  parts.  They  resemble,  in  some  respects,  Mr. 
Howship’s  case ; yet  differ  in  the  affection  being  re- 
stricted to  one  bone,  and  being  the  sequel  of  a cancerous 
disease  of  the  breast. 

Louis  mentions  a nun  who  broke  her  arm  by  merely 
leaning  on  a servant ; and  in  the  London  Medical 
Journal  an  account  is  given  of  a person  who  con  Id 
not  even  turn  in  bed  without  breaking  some  of  his 
bones.  One  of  Professor  Gibson’s  patients,  residing 
near  Trenton,  in  the  United  States,  has  a son  19  years 
of  age,  who  from  infancy  has  been  subject  to  fractures 
from  the  slightest  causes,  owing  to  an  extraordinary 
brittleness  of  the  bones.  “ The  bones  of  the  arm,  fore- 
arm, thigh,  and  leg  have  all  been  broken  repeatedly, 
even  from  so  trivial  an  accident  as  catching  the  foot  in 
a fold  of  carpet  while  walking  across  the  room.  ’ The 
clavicles  have  suffered  more  than  any  other  bone, 
having  been  fractured  eight  times.  What  is  remark- 
able, the  boy  has  always  enjoyed  excellent  health,  and 
the  bones  have  united  without  difficulty  or  much 
deiiQrmiiy.— {Institutes,  S,-c.  of  Surgery,  vol.  1,  p.  370.) 

Similar  cases  are  mentioned  by  Mr.  B.  Bell.  A child, 
he  observes,  fractures  a limb.  The  fracture  unites, 
and  is  consolidated  perhajis  in  less  than  the  usual  jie- 
riod.  Some  time  afterward,  on  lifting  a moderate 
weight,  or  on  giving  the  limb  a slight  twist,  it  is  again 
broken,  and  again  unites.  Mr.  Bell  saw  this  occur 
three  times  in  different  parts  of  the  right  humerus  of 
a child  five  years  of  age,  within  the  short  jieriod  of 
eighteen  months.  “ Several  similar  cases,”  he  says, 
“ have  been  under  my  care ; in  all  of  them,  the  patients 
seemed  to  enjoy  robust  health,  were  apparently  un- 
tainted by  scrofula,  and  their  fragile  bones  united  in  a 
shorter  space  of  time  than  I have  generally  observed 
to  be  the  casein  individuals  whose  bones  were  tougher.” 
—{On  Diseases  of  Bones,  p.  71 .)  'J'he  same  author  has 
been  able  to  discern  in  only  two  cases  of  fragility  a pal- 
pable deviation  from  the  healthy  structure  of  the  bones 
affected.  The  subject  of  one  case  was  a gentleman  9t 


418 


FUN 


FUN 


the  middle  period  of  life,  who  fractured  his  humerus  in 
unscrewing  a music-stool.  The  fracture  was  commi- 
nuted and  did  not  unite.  The  arm  was  at  length  am- 
putated, by  Mr.  George  Bell,  at  the  shoulder  On  ex- 
amining the  limb,  the  muscles  around  the  fractured 
bone  were  found  in  a pulpy  state  The  bone  sur- 
rounded with  blood  partly  fluid  and  partly  coagulated, 
was  almost  friable,  and  its  whole  surface  perforated  by 
innumerable  small,  irregularly  shaped  holes,  giving  it 
a reticulated  appearance. — {Op.  cit.  p.  72.) 

In  the  latter  stages  ol‘ syphilis,  the  bones  are  alleged 
to  be  sometimes  remarkably  brittle.— (£pAem.  Nat. 
Cur.  dec.  1,  aim.  3,  obs.  112.  Walther,  Museum  Anat. 
t.  2,  p.  29.) 

In  bad  cases  of  scurvy,  the  bones  occasionally  become 
so  brittle,  that  they  are  broken  by  the  slightest  cause, 
and  do  not  grow  together  again. — {Boettcher  von  den 
Krankh.  der  Knochen,  p.  68.) 

Dr.  Good  was  once  present  at  a church,  in  which  a 
lady,  nearly  seventy  years  old,  broke  both  the  tliigh- 
bones  in  merely  kneeling  down  ; and  on  being  taken 
hold  of  to  be  carried  away,  had  an  os  humeri  also 
broken,  without  any  violence,  and  with  little  pain. 
Hardly  any  constitutional  disturbance  ensued,  and  in  a 
few  weeks  the  bones  united. — {Study  of  Medicine,  vol. 
a,  p.  332,  ed.  3.) 

The  fragilitas  ossium  of  old  age  is  incurable ; but  in 
children  the  tendency  depends  on  some  other  constitu- 
tional disease,  and  can  only  be  cured  by  a removal  of 
the  latter. — (See  Boyer  on  Diseases  of  the  Bones, 
vol.  2.) 

This  author,  in  one  of  his  last  works,  expresses  his 
opinion  that  the  doctrine  of  mollities  and  fragilitas  os- 
sium being  distinct  and  different  disfeases,  is  by  no 
means  sufficiently  proved  by  a due  number  of  accurate 
observations.— (Traife  des  Mai.  Chir.  t.  3,  p.  607,  608.) 
Consult  Waldschmidt,  Dis.  de  Fracturd  Ossium  sine 
Causa  violentd  extemd,  Kilon.  1721.  Acrel,  Chir. 
Vorfdlle,  b.  2,  p.  136.  Courtial,  Nouvelles  Obs.  Jlnat. 
sur  les  Os,  p.  64,  12nio.  Paris,  1705.  Marcellas  Dona- 
tus,  lib.  5,  c.  1,  p.  528.  Walther,  Museum  Anat.  vol. 
2,  p.  29.  Schmucker,  Vermischte  Schriften,  b.\,  p. 
385.  Kentish,  in  Edin.  Med.  Comment,  vol.  1.  Hist, 
de  I' Acad,  des  Sciences,  1765,  p.  65.  Hist,  de  la  Soc. 
Royale  de  M decine,  1777  and  1778,  p.  224.  Joum.  de 
Mid.  t.  77,  p.  267;  t.  84,  p.  216.  Isenfiamm,  Pract. 
Bemerk.  iiber  Knochen,  p.  368.  415.  466.  Fabricius 
Hildarms,  cent.  2,  obs.  66,  67,  68 ; cent.  5,  obs.  89. 
D’AuJienton,  Description  du  Cabinet  du  Roi,  t.  3.  Ossa 
Venere  sponte  fracta.  Meckren,  Obs,  Med.  Chir.  p. 
341.  Amst.  1682.  Weidmann  da  Necrosi  Ossium,  p.  2. 
Francofurti,  1793;  and  the  writings  of  Duverney, 
Petit,  and  Pringle.  Gooch’s  Obs.  Apvendix.  J.  Wil- 
son on  the  Skeleton,  frc.  p.  258, 8vo.  Lond.  1820.  Gib- 
son's Institutes  of  Surgery,  vol.  1,  p.  370;  and  vol.  2, 
p.  70,  Philadelphia,  1825.  B.  Bell  on  Diseases  of  the 
Bones,  p.  71,  Edin.  1828.  Salter,  in  Med.  Chir.  TYans. 
vol.  15.  Howship,  in  Edin.  Med.  Chir.  Trans,  vol.  2. 

FUNGUS.  Any  sponge-like  excrescence.  Granula- 
tions are  often  called  fungous  when  they  are  too  high, 
large,  flabby,  and  unhealthy. 

FUNGUS  H.EMATODES.  (From  fungus,  and 
oipo,  blood.)  The  Bleeding  Fungus.  Spongoid  In- 
flammation. Soft  Cancer.  Carcinome  Sanglante. 
Medullary  Sarcoma. 

This  disease,  which  has  been  accurately  described 
only  of  late  years,  was  formerly  generally  confounded 
with  cancer.  The  public  are  indebted  to  Mr.  J.  Burns, 
of  Glasgow,  for  the  first  good  account  of  it ; and  the  sub- 
aequent  writings  of  Mr.  Hey,  of  Leeds,  Mr.  Freer,  of 
Birmingham,  Mr.  J.  Wardrop,  Mr.  Langstaff,  and 
others,  have  made  us  still  better  acquainted  with -the 
subject. 

It  is  unquestionably  one  of  the  most  alarming  dis- 
eases incidental  to  the  human  body,  because  we  know 
of  no  specific  remedy  for  it ; and  an  operation  can  only 
be  useful  at  a time  when  it  is  very  difficult  to  persuade 
a patient  to  submit  to  it. 

Indeed,  when  the  diseased  part  is  extirpated  at  an 
early  period,  a recovery  hardly  ever  follows ; for  ex- 
perience proves  that  it  isnotadisea.se  of  a local  nature, 
but  almost  always  extends  to  a variety  of  organs  and 
structures  at  the  same  time,  either  to  the  brain,  the  liver, 
or  lungs,  &c.  It  is  of  the  utmost  consequence  to  be 
aware  of  this  fact,  since  we  should  otherwise  be  in- 
duced to  attempt  many  hopele.ss  operations,  and  deliver 
a prognosis  that  niiglit  cause  disappointment  and  cen- 


sure. In  a large  proportion  of  patients,  afflicted  with 
fungus  hsematodes,  the  general  disorder  of  the  system 
is  indicated  by  a peculiarly  unhealthy  aspect ; a sallow, 
greenish-yellow  colour  of  the  skin,  which  is  frequently 
covered  with  clammy  perspiration;  constant  trouble- 
some cough  ; difficulty  of  breathing,  &c. 

Fungus  Hmmatodes  is  the  name  used  by  Mr.  Hey. 
Mr.  J.  Bums  has  called  the  disease  spongoid  inflam- 
mation, from  the  spongy  elastic  feet  which  peculiarly 
characterizes  it,  and  which  continues  even  after  ulcera- 
tion takes  place.  Fungus  haematodes  has  most  frequently 
been  seen  to  attack  the  eyeball,  the  upper  and  lower  ex- 
tremities, the  testicle,  and  the  mamma.  But  the  uterus, 
ovary,  fiver,  spleen,  brain,  lungs,  thyroid  gland,  hip, 
and  shoulder-joints,  have  also  been  the  seat  of  the  dis- 
ease. A distemper  which  presents  itself  in  so  many 
parts  must  be  subject  to  variety  in  its  appearances. 

FUNGUS  HiEMATODES  OF  THE  EYE. 

I.  When  it  attacks  the  eye,  the  first  symptoms  are 
observable  in  the  posterior  chamber,  an  appearan<-e 
like  that  of  polished  iron  presenting  itself  at  the  bottom 
of  the  eye. — {Scarpa,  on  Diseases  of  the  Eye,  p.  505, 
ed.  2.)  The  pupil  becomes  dilated  and  immoveable, 
and  instead  of  having  its  natural  deep  black  colour,  it 
is  of  a dark  amber,  and  sometimes  of  a greenish  hue. 
The  change  of  colour  becomes  gradually  more  and 
more  remarkable,  and  at  length  is  discovered  to  be  oc- 
casioned by  a solid  substance,  which  proceeds  from 
the  bottom  of  the  eye  towurds  the  cornea.  The  surface 
of  this  substance  is  generally  rugged  and  unequal,  and 
ramifications  of  the  central  artery  of  the  retina  may 
.sometimes  be  seen  running  across  it.  The  front  sur- 
face of  the  new  mass  at  length  advances  as  far  for 
wards  as  the  iris,  and  the  amber  or  brown  appearance 
of  the  pupil,  has,  in  this  stage,  been  known  to  mislead 
surgeons  into  the  supposition  of  there  being  a cataract, 
and  makes  them  actually  attempt  coucliing.  The  dis- 
ease continuing  to  increase,  the  eyeball  loses  its  natu- 
ral figure,  and  assumes  an  irregular  knobby  appearance. 
The  sclerotica  also  loses  its  white  colour,  and  becomes 
of  a dark  blue  or  livid  hue.  Sometimes  matter  now 
collects  between  the  tumour  and  the  cornea.  The  latter 
membrane  in  time  ulcerates,  and  the  fungusshootsout. 
In  a few  instances,  it  makes  its  way  through  the  scle- 
rotica, and  is  then  covered  by  the  conjunctiva.  The 
surface  of  the  excrescence  is  irregular,  often  covered 
with  coagulated  blood,  and  bleeds  profusely  from  slight 
causes.  When  the  fungus  is  very  large,  the  most  pro- 
minent parts  slough  away,  attended  with  a fetid  sani- 
ous  discharge.  In  the  course  of  the  disease,  the  absorb- 
ent glands,  under  the  jaw,  and  about  the  parotid  gland 
become  contaminated.  On  dissection,  a diseased  mass 
is  found  extending  forwards  from  the  entrance  of  the 
optic  nerve,  the  vitreous,  crystalline,  and  aqueous  hu- 
mours being  absorbed.  The  retina  is  annihilated, 
and  the  choroid  coat  propelled  forwards,  or  quite  de- 
stroyed. The  tumour  seems  to  consist  of  a sort  of 
medullary  matter,  resembling  brain.  The  optic  nerve 
is  thicker  and  harder  than  natural,  of  a brownish  ash- 
colour,  and  destitute  of  its  usual  tubular  appear 
ance.  In  other  cases,  the  nerve  is  split  into  two  or 
more  pieces,  the  interspaces  being  filled  up  with  the 
morbid  growth. — ( Wardrop.)  Nay,  as  Mr.  Travers  has 
stated,  the  optic  ganglion,  tractus  opticus,  and  thalamus 
have  been  repeatedly  found  diseas^,  and  the  surround- 
ing adipose  substance  in  the  orbit  affected  to  a consi- 
derable extent  in  places  also  where  there  was  no  direct 
communication  with  the  diseased  contents  of  the  globe. 
— {Syni^sis  of  the  Diseases  of  the  Eye,  p.  221.)  Even 
the  brain  has  been  observed  to  share  in  the  disease, 
sometimes  dark  red  spots  appearing  on  the  dura  mater ; 
sometimes  small  spots,  containing  a fluid  like  creairv, 
being  found  between  the  pia  mater  and  tunica  arach- 
noides.  Mr.  Travers  has  a preparation,  exhibiting  a 
genuine  example  of  the  disea.se  affccring  the  anterior 
right  lobe  of  the  cerebrum,  and  protruding  the  eye  from 
its  socket,  while  the  eye  itself  was  perfectly  free  from 
disease. — {Op.  cit.  p.  223.)  \Mien  the  lymphatic  glands 
at  the  angle  of  the  jaw  are  enlarged,  as  they  frefiuentlj 
are,  they  are  also  found  convened  into  a kind  of  medul- 
lary matter,  similar  to  that  which  cojnposes  the  dis- 
eased mass  in  the  eyeball.  When  the  skin  bursts  over 
a diseased  absorbent  gland,  a sloughy  ulcer  is  produced ; 
but  no  ftingus  is  emitted,  unless  the  affection  of  the 
gland  with  fungus  lupinaiodes  be  primary.  Fungus 
haenwtodcs  of  tlie  eye  hat  been  erroneously  regarded 


FUNGUS. 


419 


cart&cr  by  the  best  writers.  We  learn  from  Bichat, 
that  more  than  one-third  of  the  patients  on  whom  De- 
sault operated  for  supposed  carcinoma  of  the  eye  were 
tinder  twelve  years  of  age.  Twenty  out  of  twenty-four 
cases  of  fungus  haematodes  of  the  eye,  with  which  Mr, 
Wardrop  has  been  acquainted,  happened  to  children 
under  twelve  years  of  age.  Now,  as  cancer  is  rather  a 
disease  of  aged  than  young  persons,  and  we  find  from 
Mr.  Wardrop,  thatthngus  haematodes  of  the  eye  mostly 
atfects  persons  under  twelve  years  of  age,  it  is  tolerably 
certain  that  most  of  Desault’s  cases,  reported  to  be  can- 
cers of  the  eye,  werein  fact  the  equally  terrible  disease 
now  engaging  our  consideration.  According  to  Mr. 
Travers,  the  only  parts  of  the  eye  and  its  appendages 
subject  to  be  primarily  attacked  by  cancer  are  the  la- 
chrymal gland,  conjunctiva,  and  eyelids ; wliile  the  evi- 
dence of  many  cases  has  assured  him,  that  fungus 
hiernatodes  may  originate  in  any  texture  of  the  eye, 
with  the  exception  of  the  lens  and  cornea. — (St/no})sis 
of  the.  Diseases  of  the  Eye,p.  216.  222.  and  421.)  This 
account,  however,  differs  from  that  delivered  by  Mr. 
Wardrop  and  Professor  Scarpa,  who  describe  the  dis- 
ease as  first  commencing  in  the  retina,  and  particularly 
at  the  point  where  the  optic  nerve  enters  the  eye.  “ For 
(says  the  latter  author),  on  the  first  appearance  of  the 
yellowish  or  greenish  spot,  the  retina,  on  examination, 
is  found  to  be  entirely  deficient,  or,  in  other  words,  to 
have  degenerated  into  the  malignant  fungus.  It  is  also 
found,  that  the  choroid  membrane,  while  the  fungus 
hsematodes  is  in  its  incipient  state,  does  not  appear  to 
have  suffered  any  remarkable  alteration  in  its  texture, 
and  that  it  is  only  at  a more  advanced  period  of  the  dis- 
ease that  this  membrane  becomes  thickened  and  se- 
parated from  its  connexion  with  the  sclerotica.  The 
choroid  membrane,  even  in  the  most  advanced  stage  of 
the  disorder,  preserves,  more  than  all  others,  its  natu- 
ral texture.”-^ O/i  the  Principal  Diseases  of  the  Eye., 
p.  507,  ed.  2.)  In  cases  of  fungus  haematodes,  the 
sight  of  young  subjects  is  generally  destroyed  before 
the  attention  of  parents  is  excited  to  the  distemper. 
Freqivntly,  however,  a blow,  followed  by  ophthalmy, 
precedes  the  growth  of  the  diseased  mass.  When  no 
external  violence  has  occurred,  the  first  symptom  is  a 
trivial  fulness  of  the  vessels  of  the  conjunctiva,  the  iris 
becoming,  at  the  same  time,  extremeiy  vascular,  and 
altered  in  colour,  aud  the  pupil  dilated  and  immoveable. 
There  is  seldom  much  complaint  made  of  pain ; but 
the  child  is  sometimes  observed  to  be  languid  and  fe- 
verish. In  adults,  fungus  haematodes  of  the  eye  ge- 
nerally comes  on  without  any  apparent  cause,  though 
sometimes  in  consequence  of  a blow.  At  first,  the  tu- 
nica conjunctiva  is  slightly  reddened,  and  vision  indis- 
tinct. The  redness  and  obscurity  of  sight  increases 
slowly,  and  an  agonizing  nocturnal  headache  is  ex- 
perienced ; the  eye  bursts,  and  the  humours  are  dis- 
charged. 

With  regard  to  the  cure  of  the  fungus  haematodes  of 
the  eye,  the  only  chance  of  effecting  this  desirable  ob- 
ject depends  upon  the  early  extirpation  of  the  diseased 
organ.  It  must  be  acknowledged,  however,  that  most 
of  the  operations,  in  which  the  morbid  eye  has  been  re- 
moved, have  hitherto  proved  unsuccessful,  owing  to  a 
recurrence  of  the  disease.  The  reason  of  such  ill  suc- 
cess may  be  imputed  to  the  optic  nerve  and  other  parts 
being  almost  always  in  a morbid  state,  before  an  at- 
tempt is  made  to  remove  the  eye.  One  case,  however, 
described  by  Mr.  Travers,  as  having  its  seat  in  the  cel- 
lular texture  connecting  the  conjunctiva  to  the  cornea, 
was  operated  upon,  and  no  recurrence  of  the  disease 
had  occurred  a twelvemonth  afterward.  No  other  tex- 
ture was  affected  more  than  the  contiguity  and  extent 
of  the  disease  explained. — (Synopsis  of  the  Diseases  of 
the  Eye,  p.  413.)  The  most  successful  extirpation  of  an 
eye  in  an  advanced  stage  of  this  di.sease,  and,  perhaps, 
die  only  satisfactory  one  at  present  on  record,  is  that 
which  was  performed  by  Mr.  Wishart,  the  cure  conti- 
nuing complete  eighteen  months  after  the  operation.— 
(See  Edin.  Med.  Journ.  vol.  19,  p.  51.)  The  operation 
has  nearly  always  been  found  to  fail  when  the  disease 
8 advanced  so  far  that  the  posterior  chamber  is  filled 
jy  the  fungous  mass.  With  the  very  few  exceptions 
which  there  are  to  this  statement,  it  may  be  correctly 
said,  that,  as  no  internal  medicines  nor  external  appli- 
calion.s  alford  the  least  hope  of  checking  any  form  of 
the  fungus  hteinatodes,  it  is  manifest,  that  when  the 
di.stenqM:r  of  the  eye  exceeds  certain  bounds,  the  mise- 
rable patient  is  placed  beyond  the  reach  of  any  efiectual 

Dd2 


aid  from  surgery.  In  a case  which  I saw  in  April, 
1821,  in  the  London  Eye  Infirmary,  the  disease  formed 
a diseased  mass  as  large  as  an  orange,  accompanied 
with  enlarged  lymphatic  glands  over  the  parotid.  The 
patient  was  an  infhut.  In  this  instance,  Mr.  Lawrence 
used,  as  a local  application,  the  liquor  opii  sedativus, 
prepared  by  Mr.  Battlcy,  which  was  found  to  lessen 
considerably  the  child’s  sufferings. — (See  particularly 
Wardrop's  Obs.  on  Fungus  Haematodes.  Scarpa,  On 
the  Principal  Diseases  of  the  Eye,  chap.  21.  Some 
Cases  in  Saunders's  Treatise  on  Diseases  of  the  Eye; 
and  B.  Travers's  Synopsis  of  the  Diseases  of  the  Eye, 
Sao.  Lcnid.  1820.) 

FUNGtTS  HVEMATODES  OF  THE  LIMBS. 

2.  In  the  extremities,  the  disease  begins  wdth  a small 
colourless  tumour,  which  is  soft  and  elastic,  if  there  be 
no  thick  covering  over  it,  such  as  a fascia ; but  other- 
wise it  is  tense.  At  first,  it  is  free  from  uneasiness; 
but  by  degrees  a severe  acute  pain  darts  occasionally 
through  it  more  and  more  frequently^  and  at  length  be- 
comes incessant.  For  a considerable  the  tumour  is 
smooth  and  even  ; but  afterward  it  projects  irregularly 
at  one  or  more  points ; and  the  skin  at  these  places  be* 
comes  of  a livid  red  colour,  and  feels  thinner.  In  this 
situation  it  easily  yields  to  pressure,  but  instantly 
bounds  up  again.  Small  openings  now  form  in  these 
projections,  through  which  is  discharged  a thin  bloody 
matter.  Almost  immediately  after  these  tumohrs 
burst,  a small  fungus  protrudes  like  a papilla,  and  this 
rapidly  increases  both  in  breadth  and  height,  and  has 
exactly  the  appearance  of  a carcinomatous  fungus,  and 
frequently  bleeds  i)rofusely.  The  matter  is  thin,  and 
exceedingly  fetid,  and  the  pain  becomes  of  the  smarting 
kind.  The  integuments,  for  a little  way  round  these 
ulcers,  are  red  and  tender.  After  ulceration  takes  place, 
the  neigbouring  glands  swell,  and  assume  exactly  the 
spongy  qualities  of  the  primary  tumour.  If  the  patient 
still  survive  the  disease  in  its  present  advanced  pro- 
gress, similar  tumours  form  in  other  parts  of  the  body, 
and  the  patient  dies  hectic. 

After  death  or  amputation  the  tumour  is  found  to 
consist  of  a soft  substance,  somewhat  like  the  brain,  of 
a grayish  colour,  and  greasy  appearance,  with  thin 
membrane-like  divisions  running  through  it,  and  cells 
or  abscesses  in  different  places,  containing  a thin 
bloody  matter,  occasionally  in  very  considerable  quan- 
tity. There  does  not  seem  uniformly  to  be  any  entire 
cyst  surrounding  the  tumour;  for  it  very  frequently 
dives  down  between  the  muscles,  or  down  to  the  bone, 
to  which  it  often  appears  to  adhere.  The  neighbouring 
muscles  are  of  a pale  colour,  and  lose  their  fibrous  ap- 
pearance, becoming  more  like  liver  than  muscle.  The 
bones  are  always  carious  in  the  vicinity  of  the  disease. 

The  distemper  is  sometimes  caused  by  external  vio- 
lence, though  in  general  there  is  no  evident  cause 
whatever. — (Dissertations  on  Inflammation,  by  J, 
Burns,  vol.  2.) 

Mr.  Hey  has  given  several  cases  of  the  fungus  has* 
matodes.  If  I notice  the  most  particular  circumstances 
relative  to  one  of  these,  it  will  suffice  to  inform  the 
reader  of  the  form  in  which  this  terrible  affliction  has 
presented  itself  in  this  gentleman’s  practice. 

A young  man,  aged  twenty-one,  two  years  before  ap- 
plying to  Mr.  Hey,  perceived  a small  swelling  on  the 
inside  of  the  right  knee,  not  far  from  the  patella.  This 
tumour  was  moveable,  and  did  not  impede  the  motion 
of  the  joint : it  was  not  discoloured,  but  was  painful 
when  moved  or  pressed  upon.  It  continued  in  this 
state  half  a year,  and  then,  the  man  having  hurt  his 
knee  against  a stone,  it  gradually  increa.sed  in  bulk, 
but  did  not  exceed  the  size  of  an  egg.  The  skin  was 
now  discoloured  with  blue  specks,  which  were  taken 
to  be  veins.  He  could  still  walk  xvith  ease,  and  follow 
his  business. 

Two  months  before  his  admission  into  the  Leeds  In- 
firmary he  met  with  a fall,  and  violently  bent  his  knee, 
but  did  not  strike  it  against  any  thing.  The  tumour 
began  immediately  to  enlarge  ; and,  within  a few  hours, 
it  extended  halfway  up  the  inside  of  the  thigh.  About 
a fortnight  after  this  accident  the  skin  bur.st  at  the 
lowest  part  of  the  tumour,  and  discharged  some  blood. 
A dark-coloured  fungus,  about  the  size  of  a pigeon’s 
egg,  here  made  its  appearance,  and  a few  weeks  after- 
ward the  skin  burst  at  another  part  of  the  large  tumour, 
and  some  blood  was  again  di.scharged.  From  the  fis- 
sure arose  another  fungus,  which  had  increased  in  the 


420 


FUNGUS. 


course  of  the  last  week  to  the  size  of  a small  melon,  and 
now  measured  eight  inches  from  one  side  of  its  base 
to  the  other.  The  base  of  the  fungus  frequently  bled, 
especially  when  the  man  allowed  his  limb  to  hang  down. 

The  whole  tumour  was  now  of  an  enormous  size, 
being  nineteen  inches  across,  when  the  measure  was 
carried  over  the  last-mentioned  fungus.  From  its  high- 
est part  in  the  thigh  to  the  lowest  part,  just  below  the 
knee,  it  measured  seventeen  inches,  without  including 
the  fungus.  The  base  of  the  tumour  at  the  knee,  ex- 
clusive of  that  part  which  ran  up  the  thigh,  measured 
twenty-four  inches  in  circumference.  The  tumour  was 
situated  on  the  inner  side  of  the  limb,  and  was  dis- 
tinctly defined.  The  skin  covering  the  disease  was  in 
some  places  livid,  and  had  several  fissures  and  small 
ulcerations  upon  it ; but  had  not  burst  asunder,  except  in 
the  two  places  above  described.  The  tumour  was  soft, 
and  gave  a sensation  of  some  contained  fluid,  when 
gently  pressed  with  the  hands  alternately  in  opposite 
directions.  The  patient  said  he  had  walked  without 
pain  in  his  knee  a week  before  his  admission  into 
the  Infirmary;  and  he  had  lost  very  little  blood  in 
his  journey  to  Leeds.  He  complained  of  the  greatest 
uneasiness  in  the  highest  part  of  the  tumour.  It  had 
become  hot  and  painful  in  the  night-time  for  some  days 
past.  His  pulse  was  114  in  a minute,  his  tongue  was 
clean,  and  his  appetite  had  been  good  till  the  last  few 
days.  He  h.ad  never  felt  any  pulsation  in  the  turnout'. 

In  a consultation  it  was  determined,  that  the  tumour 
should  be  laid  open,  by  cutting  off  a portion  of  the  dis- 
tended integuments ; and  that,  after  removing  the  con- 
tents, if  the  sac  should  be  found  in  a sound  state,  the 
disease  should  be  treated  as  a sim])le  wound ; but  if  in 
a morbid  state,  amputation  of  the  limb  should  be  imme- 
diately performed. 

A large  oval  piece  of  the  integuments  being  removed, 
the  |tumour  was  found  to  contain  a very  large  quantity 
of  a substance  not  much  unlike  coagulated  blood ; but 
more  nearly  resembling  the  qaedullary  part  of  the  brain 
in  its  consistence  and  oily  nature.  It  was  of  a varie- 
gated reddish  colour,  in  some  parts  approaching  to 
white,  and,  as  blood  issued  from  it,  Mr.  Hey  conceived 
it  was  organized.  This  mass  was  partly  diffused 
through  the  circumjacent  parts  in  innumerable  pouches, 
to  which  it  adhered,  and  was  partly  contained  in  a large 
sac  of  an  aponeurotic  texture,  which  was  connected  [ 
•tvith  the  capsule  of  the  knee-joint.  There  was  a great 
and  universal  effusion  of  blood  from  the  internal  sur- 
ftice  of  the  sac,  and  from  the  pouches  containing  this 
morbid  mass. 

Amputation  of  the  limb  was  immediately  performed, 
on  finding  such  to  be  the  nature  of  the  case.  Mr.  Hey 
unfortunately,  however,  left  a portion  of  the  diseased 
surface  behind  on  the  inner  part  of  the  tliigh,  and  hoping 
that  a small  narrow  portion  of  the  upper  part  of  the 
sac  would  soon  become  a clean  sore,  and  not  impede 
the  cure,  he  made  the  circular  incision  two  inches  be- 
low its  higher  part. 

On  examining  the  amputated  limb,  the  vastus  inter- 
Bus  was  found  to  be  brown,  and  much  softer  than  the 
other  muscles,  which  were  healthy.  There  were  many 
small  portions  of  blood  extravasated  in  the  substance 
of  this  muscle.  The  sac  was  formed  on  the  aponeu- 
rotic covering  of  the  muscle,  and  ended  below  where 
this  aponeurosis  begins  to  cover  the  capsular  ligament 
of  the  knee.  The  two  fungous  substances  above  de- 
scribed appeared  to  have  been  only  extensions  of  the 
morbid  mass,  where  this  had  made  its  way  through 
the  sac  and  the  integuments.  The  joint  of  the  knee 
and  muscles  of  the  leg  were  perfectly  sound. 

I need  not  detail  all  the  particulars  after  the  opera- 
tion. Suffice  it  to  say,  the  man  suffered  a good  deal  of 
constitutional  disorder.  After  a few  weeks,  the  granu- 
lations upon  the  stump  became  good,  and  the  cicatriza- 
tion was  nearly  completed  at  the  end  of  the  sixth  week 
after  the  amputation.  At  this  period,  the  small  and  su- 
perficial portion  of  the  upper  part  of  the  great  sac, 
which  Mr.  Hey  had  unfortunately  left,  was  now  healed; 
bat  a tumour  now  about  four  inches  in  length,  and  be- 
fwei  I)  two  and  three  in  breadth,  had  gradually  ri.sen  at 
the  lower  and  under  part  of  the  thigh  beneath  the  cica- 
trix. 'rhus  contained  a soft  substance,  exactly  similar, 
far  as  the  touch  could  discover,  to  that  which  had 
fillc.l  the  large  sac.  This  tumour  became  painful,  and 
sometimes  discharged  a bloody  serum,  sometimes  dark- 
en’) ured  blood,  through  four  or  five  small  openings  in 
the  eicatiix. 


Mr.  Hey  laid  open  the  tumour,  and  removed  its  con- 
tents; but  no  advantage  was  gained  by  this  proceeding. 
The  interior  surface  was  found  to  be  too  much  diseased 
to  produce  good  granulations.  Blood  continued  to  ooze 
out  of  the  wound  for  a few  days.  Then  the  inner  sur- 
face became  covered  with  a blackish  substance,  which 
gradually  extended  itself,  and  formed  a new  fungus.  A 
variety  of  escharotics  were  applied  to  destroy  the  fun- 
gous and  morbid  surface  of  the  wound,  but  to  no  pur- 
pose; the  growth  of  the  fungus  always  exceeded  the 
quantity  destroyed.  Undiluted  oil  of  vitriol  apphed 
freely  had  very  little  effect. 

An  attempt  was  once  more  made  to  cut  away  the  dis- 
ease ; but  on  examining  the  wound  carefully,  after  the 
contained  substance  was  removed,  the  muscular  sub- 
stance was  found  degenerated  into  a hard  mass,  which 
felt  somewhat  like  cartilage.  The  adipose  membrane 
was  also  diseased,  and  formed  into  large  cells,  which 
had  contained  the  fungous  substance.  Hence,  another 
amputation  seemed  the  only  resource. 

After  this  operation,  the  whole  surface  of  the  stump 
seemed  sound,  except  the  principal  artery,  which  was 
filled  with  a somew'hat  stiff  matter,  resembling  coagu- 
lated blood,  Avhich  prevented  its  bleeding.  The  inside 
of  the  vessel,  on  being  touched  with  the  scalpel,  felt 
hard,  and  communicated  a sensation  like  that  of  scrap- 
ing bone. 

'fhe  man  was  sent  home  as  soon  as  his  state  would 
admit  of  it ; but  he  died  consumptive  about  six  months 
afterward.  Besides  this  instance  in  the  thigh,  Mr.  Hey 
relates  cases  of  fungus  haematodes  situated  in  the  fe- 
male breast,  in  the  leg,  in  the  neck  (extending  from  the 
jaw  to  the  clavicle,  and  producing  suffocation),  on  the 
back  part  of  the  neck,  on  the  back  part  of  the  shoulder, 
and  at  the  extremity  of  the  forearm,  near  the  wrist. 

“ If  I do  not  mistake  (says  Mr.  Hey),  this  disease 
not  unfrequently  affects  the  globe  of  the  eye,  causing 
an  enlargement  of  it,  with  the  destruction  of  its  inter- 
nal organization.  If  the  eye  is  not  extirpated,  the  scle- 
rotis  bursts  at  the  last,  a bloody  sanious  matter  is  dis- 
charged, and  the  patient  sinks  under  the  complpsit.” — 
(P.  283.) 

Besides  some  cases  in  similar  situations  to  those 
mentioned  by  Mr.  Hey,  one  is  related  by  Mr.  Burns,  in 
which  the  liip-joint  was  the  seat  of  this  terrible  affec- 
[ tion.  After  detailing  the  progress  of  the  case  to  the 
poor  man’s  death,  this  author  states,  that  he  found,  on 
dissection,  the  hip-joint  completely  surrounded  with 
a soft  matter,  resembling  the  brain,  enclosed  in  thin 
cells,  and  here  and  there  cells  full  of  thin  bloody  wa- 
ter ; the  head  of  the  thigh-bone  was  quite  carious,  as 
was  also  the  acetabulum.  The  muscles  were  very 
pale,  and  almost  like  boiled  liver,  having  completely 
lost  their  fibrous  appearance  and  muscular  properties. 
The  same  sort  of  morbid  mischief  was  also  found 
within  the  pelvis,  most  of  the  inside  of  the  bones  on 
the  affected  side  being  carious.  An  attempt  had  been 
made,  before  the  patient  died,  to  tap  the  bladder ; but 
the  trocar  had  only  entered  a cell  filled  with  bloody  w'a- 
ter,  and  situated  in  a mass  of  the  soft  brain-like  sub- 
stance. 

I have  already  said  enough  to  render  the  description 
of  the  dreadful  nature  of  the  fun^s  hsematodes  tole- 
rably complete.  Little  can  be  said  of  the  treatment ; 
for  we  know  not  of  one  medicine  that  seems  to  have 
the  least  powder  of  putting  a stop  to  the  disease,  and, 
with  the  exception  of  a case  under  Mr.  Cline,  where 
the  breast  healed  up  after  the  diseased  mass  had  been 
thrown  off  by  sloughing  {Lancet,  vol.  2,  p.  401),  we 
have  no  reason  to  believe  that  there  is  ever  the  small- 
est chance  of  any  spontaneous  amendment,  much  less 
of  such  a cure.  Also,  in  the  case  just  now  cited,  it  is 
not  known  whether  any  relapse  followed. 

We  have  seen  that  w'hen  the  chief  part  of  a fungus 
haematodes  is  cut  away,  and  only  a small  portion  of  its 
cyst  left  behind,  the  fungus  is  reproduced  from  this 
part,  and  soon  becomes  as  formidable,  nay,  more  for- 
midable than  it  was  before,  and  this  notwithstanding 
the  application  of  the  most  powerful  escharotics.  Nei- 
ther the  hydrargyrus  nitratus  ruber,  the  hydrargyrua 
muriatus,  the  antimonium  muriatum,  nor  the  undi- 
luted vitriolic  acid,  has  always  been  able  to  repress  the 
growth  of  such  fungus. — (Hey.) 

No  known  remedy  has  the  power  of  checking  or  re- 
moving the  complaint.  Friction,  with  anodyne  bal- 
sams, sometimes  gives  relief  in  the  early  stages ; but 
it  does  not  retard  the  progress  of  the  disease. 


FUNGUS. 


421 


In  short,  the  only  chance  of  cure  consists  in  extirpa- 
ting the  whole  of  the  distempered  parts,  removing  not 
only  the  soft,  brain-like,  fungous  substance,  but  every 
part  of  the  cysts,  sacs,  or  pouches  in  which  it  may  be 
contained.  An  operation  of  this  kind,  however,  is  only 
advisable  in  the  early  stages,  while  the  disease  is  en- 
tirely local,  if  it  ever  be  so,  a circumstance  much  to  be 
doubted ; for,  after  the  neighbounng  glands  have  be- 
come affected,  the  chance  of  recovery  is  almost  de- 
stroyed. It  is  sometimes  difficult,  however,  to  per- 
suade patients  at  an  early  period  to  submit  to  amputa- 
tion or  extirpation,  because  the  pain  and  inconveni- 
ences are  inconsiderable ; but  the  operation  should  be 
urged  with  all  the  force  which  a conviction  of  its  ab- 
solute necessity  and  the  fatal  peril  of  delay  ought  to 
inspire. 

The  attempts  to  cure  the  disease  by  cutting  it  away, 
have  been  attended  with  such  ill  success  that  some  sur- 
geons deem  it  advisable  not  to  follow  this  method,  but 
amputate  the  limb  at  once.  The  annexed  views  of  the 
matter  appear  to  me  to  be  most  judicious  and  rational. 
First,  that  if  an  attempt  be  made  to  cut  away  the  tu- 
mour and  save  the  limb,  the  surgeon  must  be  careful 
to  remove  at  the  same  time  a considerable  quantity  of 
the  soft  parts  in  the  circumference  of  'the  swelling. 
Secondly,  that  the  earlier  this  is  done  the  more  likely 
is  it  to  succeed.  Thirdly,  that  after  the  tumour  is  taken 
out,  an  attentive  examination  of  the  surface  of  the 
wound  should  be  made,  and  every  suspicious  part  or 
fibre  be  cut  away.  Fourthly,  that  should  the  disease 
still  recur,  amputation  ought  to  be  instantly  performed. 
Fifthly,  that  caustics  should  never  be  applied  to  this 
disease.  Sixthly,  that  even  when  one  of  these  opera- 
tions effectually  extirpates  the  distemper  of  the  limb, 
the  patient’s  entire  recovery  is  always  rendered  exceed- 
ingly uncertain  by  reason  of  the  viscera  and  other  in- 
visible parts  being  frequently  affected,  at  the  time  of 
the  operation,  with  the  same  sort  of  disease. 

FUNGUS  HJEMATODKS  OF  THE  TESTICLE. 

3.  Fungus  haematodes  of.the  testicle  sometimes  be- 
gins in  its  glandular  part,  sometimes  in  the  epididymis. 
Its  progress  is  slow,  and  the  pain  generally  not  se- 
vere. Nor  is  there  at  first  any  inequality  or  hardness 
of  the  diseased  part,  nor  change  in  the  scrotum.  When 
the  testicle  has  become  exceedingly  large,  it  feels  re- 
markably soft  and  elastic,  as  if  it  contained  a fluid. 
Hence,  the  case  has  often  been  mistaken  for  a hydro- 
cele, and  punctured  with  a trocar.— ( Wardrop  ; Earle, 
in  Med.  Chir.  Trans,  vol.  3,  p.  60.)  Occasionally, 
when  the  tumour  is  large,  it  is  in  some  places  hard,  in 
others  soft.  The  hydrocele  may  be  known  by  the  wa- 
ter beginning  to  collect  at  the  bottom  of  the  scrotum, 
and  then  ascending  towards  the  spermatic  cord,  and 
by  the  swelling  being  circumscribed  towards  the  abdo- 
minal ring;  whereas,  the  fungus  haematodes  begins 
with  a gradual  enlargement  of  the  testicle  itself,  fol- 
lowed by  a fulness  which  extends  up  the  spermatic 
cord.  It  is  not  in  the  slightest  degree  diaphanous,  and 
is  much  heavier  than  a similar  bulk  of  water. — {Earle, 
op  cit.)  As  the  disease  advances,  abscesses  form,  and 
the  scrotum  ulcerates,  but  no  fungus  shoots  out.  When 
the  inguinal  glands  become  contaminated,  they  often  ac- 
quire an  immense  size ; and  as  soon  as  the  skin  over 
them  bursts,  large  portions  of  them  slough  away. 
Fungus  haematodes  of  the  testicle  is  said  to  afllict  young 
more  frequently  than  old  subjects.  On  dissection,  the 
substance  of  the  diseased  testicle  is  found  to  present  a 
medullary  or  pulpy  api)earance,  generally  of  a pale 
brownish  colour,  though  sometimes  red.  In  most 
cases  the  tunica  vaginalis  and  tunica  albuginea  are 
adherent  together ; occasionally  there  is  fluid  between 
them. 

In  an  example  dissected  by  Mr.  Lawrence,  the  swell- 
ing of  the  testicle  consisted  of  cellular  septa  fllled  with 
pulpy  matter.  Numerous  tubercles  of  the  disease 
were  found  in  the  omentum,  and  about  the  pelvis,  in- 
termixed with  recently  effused  coagula.  A mass  of 
soft  matter,  equal  in  size  to  a man’s  head,  lay  on  the 
spine  behind  the  aorta  and  vena  cava,  which  last  ves- 
sel was,  closed  for  some  extent.  The  spermatic  vessels 
could  not  be  found.— (See  Med.  Chir.  Trans,  vol.  P, 
part  1,  art.  13.) 

The  only  chance  of  a cure  must  be  derived  from  a 
very  early  performance  of  castration,  before  the  dis- 
ease has  extended  to  the  inguinal  glands,  or  far  up  the 
spermatic  cord  Indeed,  very  little  hope  should  be 


placed  in  the  removal  of  the  testicle ; for  fungus  haema- 
todes appears  to  be  rather  a constitutional  than  a local 
disease.  Nearly  every  case  on  record  has  terminated 
fatally,  and  upon  dissection  either  the  liver,  the  lungs, 
the  brain,  the  mesenteric  glands,  or  other  internal 
parts,  have  been  found  affected  with  the  same  disease. 
In  one  case  dissected  by  Mr.  Lawrence,  tubercles  of  a 
similar  structure  to  the  disease  in  the  axilla  were  found 
in  the  lungs,  heart,  and,  in  short,  in  nearly  all  the  tho- 
racic and  abdominal  viscera,  though  the  contents  of  the 
skull  were  free  from  disease. — (See  Cases  recorded  by 
Wardrop,  Earle,  Lawrence,  and  Langstaff,  in  Med. 
Chir.  Trans,  vol.  3 and  8.) 

Whe  shtill  quit  this  subject  with  stating  some  of  the 
principal  differences  between  two  diseases  which  have 
been  commonly  confounded.  A scirrhous  tumour  is, 
from  its  commencement,  hard,  firm,  and  incompressi- 
ble, and  is  composed  of  two  substances ; one  hard- 
ened and  fibrous,  the  other  soft  and  inorganic.  The 
fibrous  matter  is  the  most  abundant,  consisting  of 
septa,  which  are  paler  than  the  soft  substance  between 
them.  A scirrhous  tumour,  situated  in  the  gland  is  not 
capable  of  being  separated  from  the  latter  part,  so  much 
are  the  two  structures  blended.  A scirrhus  in  another 
situation  sometimes  condenses  the  surrounding  cellu- 
lar substance,  so  as  to  form  a kind  of  capsule,  and  as- 
sume a circumscribed  appearance.  When  a scirrhous 
swelling  ulcerates,  a thin  ichor  is  discharged,  and  a 
good  deal  of  the  hard  fibrous  substance  is  destroyed 
by  the  ulceration ; other  parts  become  affected,  and  the 
patient  dies  from  the  increased  ravages  of  the  disease, 
and  its  irritation  on  the  constitution.  Sometimes, 
though  not  always,  after  a scirrhus  has  ulcerated,  it 
emits  a fungus  of  a very  hard  texture.  Such  excres- 
cence, however,  is  at  last  destroyed  by  the  ulceration. 
Cancerous  sores,  also,  frequently  put  on  for  a short 
time,  in  some  places,  an  appearance  of  cicatrization. 
On  the  other  hand,  the  fungus  haematodes,  while  of 
moderate  size,  is  a soft  elastic  swelling,  with  an  equal 
surface,  and  a deceitful  feel  of  fluctuation.  It  is  in  ge- 
neral quite  circumscribed,  being  included  within  a 
capsule.  The  substance  of  the  tumour,  instead  of  be- 
ing for  the  most  part  hard,  consists  of  a soft,  pulpy, 
medullary  matter,  which  readily  mixes  with  water. 
When  ulceration  occurs,  the  tumour  is  not  lessened 
by  this  process,  as  in  scirrhus ; but  a fungus  is  emit- 
ted, and  the  wljole  swelling  grows  with  increased  ra- 
pidity. Cancerous  diseases  are  mostly  met  with  in 
persons  of  advanced  age,  while  fungus  haematodes 
generally  afflicts  young  subjects.— (Wardrop.)  Many 
dissections  have  now  proved,  that  the  substance  of 
fungus  haematodes  may  contain  cellular  septa,  which 
include  the  pulpy  medullary  matter. 

Fungus  haematodes,  in  its  early  stage,  is  generally 
attended  with  less  acute  pain  than  what  is  experienced 
in  cases  of  scirrhus.  The  tumour  also  has  a less  de- 
finite boundary  than  a scirrhus,  and  it  is  more  diffi- 
cult to  say  where  the  diseased  structure  terminates, 
and  where  the  healthy  commences.  When  the  disease 
is  in  the  breast,  there  is  less  tendency  than  in  scirrhous 
cases  to  disease  in  the  axillary  glands,  which  may  re- 
main sound  though  the  disorder  in  the  breast  may  have 
advanced  to  suppuration  and  ulceration.  In  the  breast 
the  disease  is  also  much  quicker  in  its  progress  than 
scirrhus. — (A.  Cooper,  Lancet,  vol.  2,p.  399.) 

In  cases  of  external  cancer,  the  viscera  are  not  in  ge- 
neral affected  at  the  same  time  with  cancerous  disease  j 
but  in  the  majority  of  examples  of  fungus  haematodes, 
this  distemper  is  found  affecting  in  the  same  subject  a 
variety  of  parts.  In  addition  to  the  outward  tumour, 
we  find  swellings  of  a similar  nature,  perhaps,  in  the 
liver,  the  lungs,  the  mesenteric  glands,  or  even  in  the 
brain.  Yet  M.  Roux  will  have  it,  that  cancer  and  ftm- 
gus  haematodes  are  the  same  disease ; or  at  least  that 
the  latter  is  only  a species  of  the  former,  and  that  in 
both  cases  the  same  peculiar  diathesis  prevails. — {Rovx, 
Parallile  de  la  Chirurgie  Angloise  avec  la  Chirurgie 
Francoise,  p.  216,  217.) 

See  Dissertations  on  Inflammation,  by  J.  Burns,  vol. 
2.  Hey^s  Practical  Observations  in  Surgery,  ed.  3. 
Freer  on  Aneurism.  Observations  on  Fungus  Hcema- 
todes,  or  Soft  Cancer,  by  James  Wardrop,  8uo.  Ediia. 
1809.  This  last  publication  is  highly  deserving  of  the 
attention  of  the  surgical  practitioner,  the  disease  in 
different  organs  being  well  described,  and  its  character 
discriminated  from  that  of  cancer. 

A case  of  this  disease  is  related  in  vol.  5 of  the  Lon- 


422 


GAN 


GAN 


don  Medical  Journal.  It  xfas  the  con.’^Pijncncc  of  an 
attempt  to  cure  a ganglion  by  means  of  a .seUm,  and  it 
proved  fatal.  A case  is  also  related  by  Mr.  Abemethy, 
in  Surgical  Observations,  ] 804,  p.  99.  See  also  a Case 
of  Diseased  Testicle,  accompanied  with  Disease  of  the 
Lungs  and  Brain,  by  H.  Earle,  in  Medico-Chirurg. 
Trans,  vol.  3,  p.  59,  Src.  in  which  vol.  four  other  cases 
are  recorded  by  Mr.  Lawrence,  p.  71,  et  seq.,  and  one  by 
Mr.  Langstqff,  p.  277 ; which  last  I remember  to  have 
visited  in  company  with  this  gentleman  and  Mr. 
Lawrence,  a short  time  before  the  patient  died.  See 
also  Langstaff's  Cases  and  Observations  in  the  Sth 
and  9th  vols.  of  the  same  work.  Voyage  fait  d Lon- 
dres  en  1814 ; ou  Parallele  de  la  Chirurgie  Angloise 
avec  la  Chirurgie  Francoise,  p.2\\,  &rc.  On  Fungus 
Hcematodes  of  the  Eye  there  are  some  valuable  obser- 
vations in  the  last  edition  of  Scarpa's  Treatise  on  the 
Diseases  of  that  organ.  See  also  Saunders  on  Dis- 
eases of  the  Eye,  and  B.  Travers's  Synopsis  of  Dis- 
eases of  the  Eye,  Svo.  Lond.  1820.  G.  Frick  on  Dis- 
eases of  the  Eye,  p.  287,  ed.  by  Welbank,  8vo.  Lond. 
1826, 

Respecting  medullary,  sarcoma,  which  is  generally 
considered  as  the  same  affection  as  fungus  haematodes, 
some  farther  observations  will  be  delivered  in  the  arti- 
cle Tumours. 

FURUNCULUS.  (From  furo,  to  rage.)  A bile,  so 
named  from  the  violence  of  the  heat  and  inflammation 
attending  it. 

A bile  is  a circumscribed,  very  prominent,  hard,  deep- 
red,  inflammatory  swelling,  which  is  exceedingly  pain- 
ful, and  commonly  terminates  in  a slow  and  imperfect 
suppuration.  The  figure  of  the  tumour  is  generally 
that  of  a cone,  the  base  of  which  is  considerably  below 
the  surface.  Upon  the  most  elevated  point  of  the  bile 
there  is  usually  a whitish  or  livid  pustule,  which  is 
exquisitely  sensible,  and  immediately  beneath  this  is 
the  seat  of  the  abscess.  The  matter  is  mostly  slow  in 
forming,  is  seldom  very  abundant,  and  never  healthy 
at  first,  being  always  blended  vvith  blood.  The  com- 
plaint is  seldom  attended  with  fever,  except  when  the 
tumour  is  very  large,  situated  on  a sensible  part,  or 
>vhen  several  of  these  swellings  occur  at  the  same 
lime  in  different  places.  In  the  last  circumstance  they 
often  occasion  in  children,  and  even  in  irritable  adults, 
restlessness,  loss  of  appetite,  spasms,  &c.  They  rarely 
exceed  a pigeon’s  egg  in  size,  and  they  may  originate  on 
any  part  of  the  body.  '• 

Biles  commonly  arise  from  constitutional  causes. 
Young  persons,  and  especially  subjects  of  Ihll  plethoric 
habits,  are  most  subject  to  them.  The  disease  is  also 
observed  to  occitr  with  most  frequency  in  the  spring. — 
(Lassus,  Pathologie  Chir.  t.  1,  p.  16.)  According  to 
Richerand,  the  origin  of  biles  depends  upon  a disordered 
state  of  the  gastric  organs. — (Nosographie  Chir.  t.  1, 
p.  124,  Hit,  2,)  Frequently  they  arise  without  any 
evident  capse,  and  apparently  in  healthy  constitutions. 
At  other  times  they  follow  emptive  diseases  and  typhus. 
—(IF.  Gibson,  Institutes,  <S  c.  of  Surgery,  p.  48,  vol.  1.) 

The  suppuration  attending  a bile  is  never  perfect, 
and  the  matter  which  forms  is  not  only  tinged  with 
blood,  but  surrounded  with  a sloughy  substance,  w'hich 
imust  generally  be  discharged  before  the  part  affected 
xvill  suppurate  kindly,  and  the  disease  end.  Richter 
compares  the  slough  to  a kind  of  bag  or  cyst,  and  the 
\vhole  bile  to  an  inflamed  encysted  tumour. 

The  best  plan  is  mostly  to  endeavour  to  make  biles 
suppurate  as  freely  as  possible  by  applying  external 
emollient  remedies.  This  seems  to  be  the  natural 
course  of  the  disease  in  its  progress  to  a cure,  and,  in- 
deed, all  endeavours  to  disperse  Ajrunculous  tumours 


commonly  fail,  or  succeed  very  imperfectly ; only  re- 
moving the  inflammation,  and  leaving  behind  an  indo- 
lent hardness ; wlrich  occasions  various  inconveniences, 
according  to  its  situation,  every  now  and  then  inflames^ 
anew,  and  never  entirely  disappears  until  a free  suppu-' 
ration  has  been  established. 

In  a verj"  few  cases,  j)erhaps,  it  may  be  proper  to 
try  to  resolve  biles.  For  this  purpose,  besides  bleeding, 
gentle  evacuations,  and  a low  diet,  which  are  requisite 
in  this  as  well  as  other  local  inflammations,  some 
prescribe  as  external  applications  honey  .strongly  aci- 
dulated with  sulphuric  acid,  alcohol,  or  camphorated 
oil. 

But  in  the  generality  of  instances  suppuration  mu.st 
be  promoted  by  the  use  of  emollient  poultices.  The 
tumour,  when  allowed  to  burst,  generally  does  so  at 
its  apex.  However,  as  the  opening  is  generally  long 
in  forming,  and  too  small  to  allow  the  sloughy  cellular 
substance  to  be  discharged,  it  is  always  best,  as  soon 
as  matter  is  known  to  exist  in  the  tumour,  to  make  a 
free  opening  with  a lancet,  and  immediately  afterward 
to  press  out  as  much  of  the  matter  and  sloughs  as  can 
be  prudently  done.  This  having  been  accomplished, 
and  the  rest  of  the  sloughs  pressed  out  as  soon  as  it  is 
practicable,  healthy  pus  will  be  secreted,  and  the  part 
will  granulate  and  heal.  Until  the  suppuration  becomes 
of  the  healthy  kind,  and  the  sloughy  substances  are  en- 
tirely discharged,  an  emollient  linseed  poultice  is  the 
best  application ; and  w'hen  granulations  begin  to  fill 
up  the  cavity,  plain  lint  and  a simple  pledget  are  the 
only  dressings  necessary. 

For  the  purpose  of  stimulating  the  cavity,  and  caus- 
ing it  to  fill  up.  Professor  Gibson,  of  Philadelphia,  has 
sofrretimes  employed  with  success  an  injection  of  the 
nitrate  of  silver. 

Where  there  is  reason  to  suppose  the  gastric  organs 
to  be  in  a disordered  state,  an  emetic  should  be  given 
in  the  early  part  of  the  treatment,  and  afterward  small 
repeated  doses  of  any  of  the  mild  purging  salts. 

When  an  indolent  hardness  continues  after  the  in- 
flammatory and  suppurative  state  of  biles  has  been  re- 
moved, the  part  should  be  rubbed  with  camphorated 
mercurial  ointment. 

Besides  the  above  acute  bile,  authors  describe  a chro- 
nic one,  which  is  said  frequently  to  occur  in  subjects 
who  have  suffered  severely  from  the  small-pox,  measles, 
lues  venerea,  scrofula,  and  in  constitutions  which  have 
been  injured  by  the  use  of  mercury. 

The  chronic  bile  is  commonly  situated  upon  the  ex- 
tremities, is  of  the  same  size  as  the  acute  one,  has  a 
hard  base,  is  not  attended  with  much  pain,  nor  any  con- 
siderable discoloration  of  the  skin,  until  suppuration  is 
far  advanced,  and  the  matter  is  seldom  quite  formed 
before  the  end  of  three  or  four  w'eeks.  This,  like  tlte 
former,  sometimes  appears  in  a considerable  number  at 
a time.  The  discharge  is  alw'ays  thinner  than  good 
pus,  and  when  the  bile  is  large,  and  has  been  long  in 
suppurating,  a great  deal  of  sloughy  cellular  membrane 
must  be  cast  off  before  the  sore  will  heal. 

The  principal  thing  requisite  in  the  local  treatment  of 
all  furunculous  and  carbuncular  tumours  is  to  make  an 
early  free  opening  into  them,  and  to  press  out  the  matter 
and  sloughs,  emplojdng  emollient  poultices  till  all  the 
mortified  parts  are  detached  and  removed,  and  afterward 
simple  dres.sings.— (See  Pearson's  Principles  of  Sur- 
gery. Richter,  Anfangsgriinde  der  Wundarzn.  b.  1. 
Lassus,  Pathologie  Chir.  t.  \,p.  15.  Richerand,  Noso- 
graphie Chir.  t.  l,p.  123,  idit.  2.  W.  Gibson's  Insti- 
tutes of  Surgery,  vol.  1,  Philadelphia,  1824.  C.  J.  M. 
Langenbeck,  Nosologie,  & c.  b.  I,  p.  357,  Gott.  1822. 
M.J.  Chelius,  Handb.  der  Chir.  b.  l,p.74,  Heidelb.  1826.) 


Q 


Ganglion.  (FayyXlov.)  in  surgery,  a tumour  on 
a tendon  or  aponeurosis. 

A ganglion  is  an  encysted,  circumscribed,  moveable 
Dwelling,  commonly  tree  from  pain,  causing  no  altera- 
tion in  the  colour  of  the  skin,  and  formed  upon  tendons 
in  different  parts  of  the  body,  but  most  frequently  upon 
the  back  of  the  hand  and  over  the  wrist.  A French 
gentleman  consulted  me,  who  had  one  upon  the  upper 
part  of  his  foot,  which  created  a great  sensation  of 


weakness  in  the  motion  of  the  foot ; and  I have  taken 
notice  that  ganglions  occur  particularly  often  just  be- 
low the  knee-pan  in  housemaids  who  are  in  the  habit  of 
kneeling  a great  deal  in  order  to  scour  rooms.  A cu- 
rious example  is  recorded,  in  which  a ganglion,  situated 
exactly  over  the  arteria  radialis  and  the  arteria  super 
ficialis  volte,  was  at  first  supposed  to  be  an  aneurism 
—(See  Edin.  Med.  and  Surg.  Joum.  for  April,  1821.) 

These  tumours,  w hen  compn  .sscd,  seem  to  posses# 


GAN 


GAS 


423 


considerable  elasticity.  They  oflen  occur  unjjreceded 
by  any  accident ; frequently,  they  are  the  ccrasequence 
of  bruises  and  violent  sprains.  They  seldom  attain  a 
considerable  size,  and  ordinarily  are  not  painfUl,  though 
every  now  and  then  there  ai-e  instances  to  the  contra^-. 
When  opened,  they  are  found  to  be  ^ed  with  a viscid, 
transparent  fluid,  resembling  white  w egg.  If  they  do 
not  disappear  of  themselves,  or  are  not  cured  while  re- 
cent by  surgical  means,  they,  in  some  cases,  become 
so  large  that  they  cause  great  inconvenience,  by  ob- 
structing the  motion  of  the  part  and  rendering  it  painful. 

Discutient  applications  sometimes  succeed  in  curing 
ganglions,  and  in  this  country  friction  with  the  oleum 
crigani  is  a very  common  method.  I have  often  seen 
such  tumours  very  much  lessened  by  this  plan  of  treat- 
ment, but  seldom  cured  ; for  no  sooner  has  the  friction 
discontinued  than  the  fluid  in  the  cyst  in  general  accu- 
mulates again. 

Compression  is  usually  more  effectual  than  discutient 
liniments.  Persons  with  ganglions  have  been  recom- 
mended to  rub  them  strongly  with  their  thumb  several 
times  a day.  After  this  has  been  repeated  very  often 
the  tumour  has  sometimes  disappeared.  But  the  best 
method  is  to  make  continual  pressure  on  ganglions  by 
means  of  a piece  of  sheet-lead  bound  upon  the  part 
with  a bandage.  There  is  no  objection,  however,  to 
using  once  or  twice  a day,  in  conjunction  with  this 
treatment,  frictions  with  the  oleum  origani  or  campho- 
rated mercurial  ointment,  provided  these  measures  to- 
gether do  not  seem  likely  to  make  the  tumour  inflame, 
an  event  which  should  always  be  carefully  avoided. 
Ganglions,  when  irritated  too  much,  have  been  known 
to  become  most  malignant  fungous  diseases. 

Setons  have  been  recommended  to  be  introduced 
through  ganglions  with  a view  of  curing  them.  This 
method,  however,  is  not  an  eligible  one ; for  it  is  by  no 
means  free  from  danger,  as  the  records  of  surgery  fully 
prove.  Cancerous  diseases,  and  even  a malignant  fatal 
fungus  {Med.  Joum.  vol.  5),*iiave  arisen  from  the  irri- 
tation of  a seton  passed  through  a ganglion. 

Fre»iuently,  when  a ganglion  inflames  and  ulcerates, 
the  c)  st  throws  out  a fungus  which  is  of  a very  ma- 
lignant nature.  Hence,  the  practitioner  should  avoid 
making  an  opening  into  the  swelling,  or  doing  any 
thing  which  is  likely  to  occasion  sloughing  or  ulcera- 
tion of  the  disease.  Ganglions  may  be  cured  by  pres- 
sure sufliciant  to  rupture  the  cyst,  and  some  authors 
have  recommended  putting  the  hand  affected  upon  a 
table,  and  then  striking  the  ganglion  several  times  with 
the  fist  or  a mallet.  The  cyst  of  a recent  ganglion  may 
also  be  burst  by  compressing  it  strongly  with  the  thumbs 
with  or  without  the  intervention  of  a piece  of  money  ; 
the  fluid  is  effused  into  the  adjacent  cellular  membrane ; 
and  pressure  being  now  employed,  the  opposite  sides 
of  the  cavity  become  united  by  the  adhesive  inflamma- 
tion, and  the  recurrence  of  the  disease  is  prevented. 
On  this  principle  Sir  Astley  Cooper  cures  the  disease. 
— (See  U Encyclopidie  Mithodique,  partie  Chir.  art. 
Ganglion ; Lassus,  Pathologie  Chir.  t.  p.  400,  <irc. ; 
LeveilU,  Nouvelle  Doctrine  Chir.  t.  3,  p.  7.) 

In  almost  every  instance,  a ganglion  may  be  cured 
by  pressure  and  friction ; and  if  not  actually  cured,  the 
disease  may  be  rendered  so  bearable  by  these  means, 
that  few  patients  would  choose  to  have  the  tumour  cut 
out.  Under  this  plan,  the  swelling  becomes  very  much 
diminished,  and  should  it  enlarge  again,  the  mode  of 
relief  is  so  simple,  and  the  case  so  little  troublesome, 
that  patients  generally  content  themselves  with  occa- 
sionally wearing  a piece  of  lead  on  the  part. 

But  when  ganglions  resist  all  attempts  to  disperse  or 
palliate  them ; when  they  become  extremely  inconve- 
nient, either  by  obstructing  the  functions  of  the  joint 
or  causing  pain,  they  should  be  carefully  dissected  out 
by  first  making  a longitudinal  incision  in  the  skin  cover- 
ing them,  then  sei)arating  the  cyst  on  every  side  from 
the  rx)ntiguous  parts,  and  lastly  cutting  every  particle 
of  it  off  the  subjacent  tendon  or  fascia.  The  greatest 
cure  must  be  taken  not  to  make  any  opening  in  the  cyst, 
80  as  to  let  out  its  contents,  and  make  it  collapse ; a 
circumstance  which  would  render  the  dissection  of  it 
entirely  out  much  more  difficult. 

The  operation  being  accomplished,  the  skin  is  to  be 
brought  together  with  sticking  plaster,  and  a compress 
placed  over  the  situation  of  the  tumour,  with  a view 
-of  healing  the  wound  and  the  cavity  by  adhesion. 

When  the  ganglion  has  burst,  or  is  ulcerated,  it  is 
best  to  remove  the  diseased  skin  together  vvith.tho  cyst, 


and  of  cour.se  the  incision  must  be  oval  or  circular,  as 
may  seem  most  convenient.  The  grand  object  is,  not 
to  allow  any  particle  of  the  cyst  to  remain  beliind,  as  it 
would  be  very  likely  to  throw  out  a fungus,  and  prevent 
a cure.  In  Warner’s  Cases  of  Surgery  is  an  account 
of  two  considerable  ganglions  which  this  gentleman,  in 
imitation  of  Celsus  and  Paulus  .®gineta,  thought  it 
right  to  extirpate.  These  had  become  adherent  to  the 
tendons  of  the  fingers.  In  the  operation  he  was  ob- 
liged to  cuf  the  transverse  ligament  of  the  w'rist ; and 
the  patients,  who  before  could  not  shut  their  hands,  nor 
close  their  fingers,  perfectly  regained  the  use  of  these 
parts.  Mr.  Gooch  relates  a case  of  the  same  kind, 
which  had  been  occasioned  by  a violent  bruise  throe  or 
four  years  before.  The  tumour  reached  from  the  wrist 
to  the  middle  of  the  hand,  and  created  a great  deal  of 
pain.  Mr.  Gooch  extirpated  it,  and  then  restored  the 
position  of  the  hand  and  free  motion  of  the  joint  by  the 
use  of  emollient  applications  and  suitable  pressure, 
made  wdth  a machine  constructed  for  the  purpose. 
Other  cases,  confirming  the  safety  of  cutting  out  gan 
glions,  are  recorded  in  the  London  Medical  Jourrud 
for  1787,  p.  154;  by  Eller,  in  Mem.  de  VAead.  des 
Sciences  de  Berlin,  t.  2,  ann.  1746 ; Schmucker,  in 
Chir.  Wahmehmungen,  b.  1,  p.  332;  Girard,  Lupio- 
logic. 

The  ganglions  which  occur  just  below  the  knee  1 
have  seen  cured  by  a little  blister  applied  over  them, 
and  kept  open  by  the  savin  cerate.  Camphorated  blisters, 
indeed,  have  been  proposed  as  a means  of  dispersing 
other  ganglions. — {Jaeger,  Chir.  Cautelen,  b.  2.) 

For  information  relative  to  ganglions,  consult  War- 
neT's  Cases  in  Surgery.  Chirurgical  Works  of  B. 
Gooch,  vol.  2,  p.  376.  Heister's  Surgery.  B.  BelJs 
Surgery.  Lana’s  System  of  Surgery.  L’Encylophlie 
Methodique,  partie  Chir.  art.  Ganglion.  Richter,  An 
fangsgr.  der  Wnndarzn.  h.  1.  Lassus,  Pathologie 
Chir.  t.  \,p.  399.  Diet,  des  Sciences  MM.  t.  17, p.  311. 

GANGRENE.  tFrom  ypatvw,  to  feed  ujwn.)  An  in- 
cipient mortification,  so  named  from  its  eating  away  the 
flesh. 

Authors  have  generally  distinguished  mortification 
into  two  stages  ; the  first,  or  incipient  one,  they  name 
gangrene,  which  is  attended  with  a sudden  diminution 
of  pain  in  the  place  affected;  a livid  discoloration  of  the 
part,  which,  after  being  yellowish,  becomes  of  a green- 
ish hue ; a detachment  of  the  cuticle,  under  which  a 
turbid  fluid  is  effused ; lastly,  the  swelling,  tension,  and 
hardness  of  the  previous  inflammation  subside,  and  on 
touching  the  part  a crepitus  is  perceptible,  owing  to 
the  generation  of  air  in  the  gangrenous  parts. 

When  the  part  has  become  quite  cold,  black,  fibrous, 
incapable  of  moving,  and  destitute  of  all  feeling,  circu- 
lation, and  life,  this  is  the  second  stage  of  mortification, 
termed  sphacelus.  Gangrene,  however,  is  frequently 
used  synonymously  with  the  word  mortification. — (See 
Mortijicatioyi.) 

GASTROCELE.  (From  yaorop,  the  stomach,  and 
Kq}^T},  a tumour.)  A hernia  of  the  stomach. 

GaSTRORAPHIA,  or  gastroraphe.  (From  yaa- 
rrip,  the  belly,  and  pn^ij,  a suture.)  A suture  of  the 
belly,  and  some  of  its  contents. 

Although  the  term  gastroraphe,  in  strictness  of  ety 
mology,  signifies  the  sewing  up  of  any  wound  of  the 
belly,  yet  Mr.  S.  Sharp  informs  us  that  in  his  tirnp  the 
word  implied,  that  the  wound  of  the  abdomen  was  com- 
plicated with  another  of  the  bowels. 

The  moderns,  I think,  seem  to  limit  the  meaning  of  the 
word  to  the  operation  of  sewing  up  a wound  in  the  pa- 
rietes  of  the  abdomen. 

What  was  formerly  meant  by  gastroraphe  could 
scarcely  ever  be  practised,  because  the  symptoms  laid 
down  for  distinguishing  when  an  intestine  is  wounded 
do  not  with  any  certainty  determine  in  what  particular 
part  it  is  w'ounded  ; which  want  of  information  makes 
it  absuid  to  open  the  abdomen  in  order  to  get  at  it. 
Hence  the  operation  of  stitching  the  bowels  can  only 
take  place  when  they  fall  out  of  the  abdomen,  and  when 
we  can  see  where  the  wound  is  situated.  And,  indeed, 
even  in  these  circumstances,  the  employment  of  sutures 
is  a practice  the  propriety  of  which  is  questionable,  as 
will  be  farther  considered  in  the  article  Wouiids. 

The  circumstances  making  the  practice  of  sewing  up 
a wounded  intestine  proper  are  so  rare,  that  Duverney 
who  was  the  most  eminent  surgeon  in  the  French  aimy 
a great  many  years,  and  at  a period  when  duels  were 
particularly  frequent,  and  his  country  at  war,  declared 


424 


GLA 


GLA 


that  he  had  never  had  a single  opportunity  of  practising 
gastroraphe,  according  to  the  former  acceptation  of  that 
word. 

Gastroraphe,  or  merely  sewing  up  a wound  of  the  pa- 
rietes  of  the  abdomen,  may  be  done,  as  Mr.  Sharp  ex- 
plains, with  common  interrupted  suture  (see  Suture), 
or  with  the  quilled  one,  which  is  better,  as  follows  : 

A ligature,  capable  of  splitting  into  two,  has  a needle 
attached  to  each  end  of  it.  The  lip  of  the  wound  is  to 
be  pierced,  from  within  outwards,  about  an  inch  from  its 
edge.  The  other  needle  is  to  be  passed  in  the  same  way 
through  the  opposite  lip.  Then  the  two  needles  are  to 
be  cut  off.  As  many  such  sutures  must  be  made  as  the 
extent  of  the  wound  may  require. 

The  sides  of  the  wound  are  next  to  be  brought  toge- 
ther, and  the  ligatures  tied,  not  in  a bow,  in  the  way  of 
Uie  interrupted  suture,  becau.se  the  continual  action  of 
the  abdominal  muscles  might  make  the  ligatures  cut 
their  way  through  the  parts.  On  the  contrary,  it  is  bet- 
ter to  divide  each  end  of  the  ligatures  into  two  portions, 
and  to  tie  these  over  a piece  of  bougie  laid  along  the 
line  at  which  the  ligatures  emerge  from  the  flesh.  This 
is  to  be  done  to  all  the  ligatures  on  one  side  first.  Then 
the  wound  being  closed,  another  piece  of  bougie  is  to  be 
placed  along  the  other  lip  of  the  wound,  and  the  oppo- 
site ligatures  tied  over  it  with  sufficient  tightness  to 
keep  the  sides  of  the  wound  in  contact.  This  suture  is 
certainly  preferable  to  the  interrupted  one,  because  a 
great  deal  of  its  pressure  is  made  on  the  two  pieces  of 
bougie,  and  of  course  it  is  less  likely  to  cut  its  way  out. 
Its  operation  is  to  be  assisted  with  compresses  laid  over 
each  side  of  the  wound,  and  the  uniting  bandage. 

In  four  or  five  days  the  sutures  may  generally  be  re- 
moved, and  sticking  plaster  alone  emiiloyed.— -(See 
Woioids  of  the  Abdomen.) 

It  is  generally  allowed  that  sutures  are  violent  means, 
to  which  we  should  only  resort  when  it  is  impossible 
to  keep  the  lips  of  a wound  in  contact  by  the  observance 
of  a proper  posture  and  the  aid  of  a methodical  bandage. 
M.  Pibrac  believes  such  circumstances  exceedingly 
nucommon,  and  in  his  excellent  production  in  the  third 
volume  of  the  Memoirs  of  the  Royal  Academy  of  Sur- 
gery, relative  to  the  abuse  of  sutures,  cases  are  related 
which  fully  prove  that  wounds  of  the  belly  readily  unite 
by  means  of  a suitable  posture  and  a proper  bandage, 
without  the  practice  of  gastroraphe.  These  cases,  how- 
ever, are  less  decisive  and  convincing  (if  possible  to  be 
so)  than  the  relations  of  the  Caesarean  operation,  the  ex- 
tensive wound  of  which  has  often  been  healed  by  sim- 
ple means,  after  the  failure  of  sutures.  In  fact,  it  is 
not  only  possible  to  dispense  with  gastroraphe,  it  is 
even  mostly  advisable  to  do  so;  for  experience  has 
proved  that  this  operation  hats  sotnetimes  occaisioned 
very  bad  symptoms. 

Under  certain  circumstances,  however,  it  may  be  es- 
sentially necessary  to  practise  gastroraphe.  For  in- 
stance, were  a large  wound  to  be  made  across  the  parie- 
tes  of  the  abdomen,  asuture  might  become  indispensably 
requisite  to  prevent  the  protrusion  of  the  bowels.  Yet 
even  in  this  case  the  sutures  should  be  as  few  in  num- 
ber as  possible.  In  a longitudinal  wotind  of  the  abdo- 
men, a bandage  of  the  eighteen-tailed  kind  might  prove 
very  useful,  and  do  away  all  occasion  for  gastroraphe. 
— (See  Sutures.) 

I shall  conclude  this  article  with  a fact,  perhaps  more 
curious  than  instructive,  related  by  M.  Bordier,  of  Pon- 
dicherry, in  the  Journal  de  Medecine,  vol.  26,  p.  538. 
An  Indian  soldier,  an^y  with  his  wife,  killed  her,  and 
attempted  to  destroy  himself  by  giving  himself  a wound 
with  a broad  kind  of  dagger  in  the  abdomen,  so  as  to 
cause  a protrusion  of  the  bowels.  A doctor  of  the 
country  being  sent  for,  dissected  between  the  muscles 
and  skin,  and  introduced  a thin  piece  of  lead,  which 
kept  up  the  bowels.  The  wound  soon  healed  up,  the 
lead  having  produced  no  inconvenience.  The  man  was 
afterward  hanged,  and  M.  Bordier,  when  the  body  was 
opened,  assured  himself  more  particularly  of  the  fact. 
Indeed,  numerous  cases  prove  that  lead  may  lodge  in  the 
living  body  without  occasioning  the  inconvenience 
which  results  from  the  presence  of  many  other  kinds  of 
extraneous  bodies. 

See  he  Dran,  Opcrationes  de  Chirurgie.  Sharp's 
Treatise  on  the  Operations  of  Surgery.  L'Encyclope- 
die  Methodique,  partie  Chirurgicale,  art.  Gastroraphe. 
Sabatier,  Medicine  Operatoire,  t.  1. 

GLAUCOMA  (from  yAai')c6j,  bluish  green)  is  now  de- 
fined by  modern  surgeons  to  be  a greenish  or  gray  opa- 


city of  the  vitreous  humour,  atlethled  with  tite  loss  oi  a 
considerable  impairment  of  sight. — {Weller  on  Diseases 
of  the  Eye,  transl.  by  Monteith,  vol.  2,  p.  27.)  In  the 
words  of  Mr.  Guthrie,  the  disease  essentially  consists  in 
an  alteration  of  the  component  parts  of  the  vitreous  hu- 
mour, accompanied  with  derangement  of  the  structure 
of  the  hyaloid  membrane,  retina,  and  tunica  choroidea, 
the  vessels  of  which  are  always  more  or  less  varicose. 
— {Operative  Surgery  of  the  Eye,  p.  214.)  Professor 
Beer  considers  the  subjects  of  glaucoma  and  the  cata- 
racta  viridis  or  glaucomatosa  together  in  the  same 
chapter.  He  observes  that  these  diseases  occur  rather 
frequently,  not  only  as  true  effects  of  inflamma- 
tion of  the  eye,  but  sometimes  quite  unpreceded  by 
this  affection.  Although  glaucoma  may  continue  for  a 
long  time  as  the  only  disorder,  without  the  crystalline 
lens  being  changed  in  the  slightest  degree,  yet  Beer  has 
never  seen  the  case  reversed,  and  the  lens  become  al- 
tered as  it  does  in  glaucoma  first,  and  the  vitreous  hu- 
mour afterward.  In  what  this  author  describes  as 
gouty  ophthalmy,  glaucoma  is  said  to  come  on  with  the 
following  symptoms.  The  iris  is  not  t*served  to  ex- 
pand, but  rather  to  become  contracted  ; the  pupil  is  not 
eqtially  dilated,  but  extends  more  towards  the  cantlii, 
the  iris  at  length  becoming  scarcely  perceptible  towards 
each  angle  of  the  eye,  especially  the  outer  one,  aitd  the 
pupil  of  course  assuming  something  of  the  appearance 
which  is  seen  in  the  eye  of  a ruminating  animal.  In  a 
case,  however,  which  I once  saw  in  the  London  Eye 
Infirmary  under  Mr.  Lawrence,  it  was  particularly  re- 
marked, that  the  diameter  of  the  pupil  was  not  greatest 
in  the  transverse  direction  ; a circumstance  which  Beer’s 
account  would  lead  us  to  expect  wa.s  constant.  And  it 
particularly  merits  notice,  that  as  the  iris  shrinks  to- 
wards the  margin  of  the  cornea,  its  papillary  edge  is  itt- 
verted  towards  the  lens,  so  that  its  smaller  circle  com- 
pletely disappears.  In  this  very  dilated  state  of  the  pu- 
pil, a gray,  greenish  opacity  is  perceived,  seeming  to  be 
very  deep,  and  arising  from  a real  loss  of  transparency 
in  the  vitreous  humour.  At  this  period  the  lens  evidently 
becomes  opaque,  acquiring  a sea-green  hue,  and  the  ca- 
taracla  viridis,  or  glaucomatosa,  now  swells  and  ap- 
pears to  project  forwards  into  the  anterior  chamber. 
The  pain  then  becomes  more  incessant  and  violent; 
the  varicose  affection  of  the  eyeball  seriously  increases; 
and  the  eyesight,  which  began  hourly  to  diminish  from 
the  moment  when  the  pupil  was  first  observ'ed  to  be  in 
any  degree  expanded  and  opaque,  and  the  iris  motion- 
less, is  now  so  entirely  destroyed,  that  not  the  slightest 
perception  of  external  light  remains,  though  the  patient 
may  vainly  congratulate  himself  on  discerning  lumi- 
nous appearances  produced  within  the  eye  itself,  in  the 
form  of  a fiery,  shining  circle,  especially  when  the  or- 
gan is  gently  pres.sed  upon.  An  eye  in  this  condition 
(says  Beer)  has  really  a look  as  if  it  were  dead,  the 
cornea  being  as  flaccid  and  void  of  lustre  as  iti  a 
corpse.  Finally,  w'hen  these  symptoms  have  attained 
their  utmost  pitch,  an  atrophy  of  the  eyeball  follows, 
and  the  painful  sensations  about  the  organ  cease.  In 
corpulent  individuals,  however,  they  still  continue  with 
greater  violence.  Sooner  or  later  the  other  eye  is  also 
either  attacked  with  arthritic  iritis,  or  ophthalmy,  or 
becomes  affected  with  glaucoma,  which  is  ushered  in  by 
violent  and  incessant  headache. — {Beer,  Lehre  von  den 
Augenkrankheiten,  b.  1,  p.  581,  d^c.  Svo.  Wien,  1813.) 
According  to  this  author,  glaucoma  and  tho  green  cata- 
ract are  never  the  consequences  of  any  description  of 
ophthalmy,  but  what  he  terms  arthritic. — {B.  %p.  255. 
Wien,  1817.)  I believe,  however,  with  Mr.  Guthrie, 
that  the  inflammation  is  really  an  unhealthy  disorgan 
ixing  inflammation,  not  necessarily  dependent  upon  nor 
connected  with  gout  {Operative  Surgery  of  the  Eye,  p 
216),  of  the  effects  of  which  disorder  the  German  prac- 
titioners entertain  the  most  vague  notions.  Both  these 
affections,  after  they  are  conjoined  with  a general  vari- 
cose disease  of  the  eyeball,  are  set  down  bv  Beer  as  ge- 
nerally incurable.  According  to  Weller,  when  the  vi- 
treous humour  first  begins  to  be  muddy,  the  disease 
may  sometimes  be  checked. — {On  Diseases  of  the  Eye, 
vol.  2,  p.  29.)  The  means  of  relief  depended  ujion  in 
Germany  are,  frictions  on  the  eyebrow  with  tinct.  opii 
croc.,  or  liniment,  ammon. ; the  avoi  ’ance  of  cold ; 
camphorated  bags  of  aromatic  herbs  applied  over  the 

I eye,  but  the  effect  ot  which  must  be  rather  insignifi- 
cant; issues;  setons;  rubbing  the  antimonial  ointment 
over  the  spine,  or  behind  the  ears,  dtc.— (V’o/.  cit.  p.  228.) 

1 Other . authors  recommend  applying  blisters,  and 


GLE 


GON 


425 


giving  internally  the  extract  of  cicnta,  calomel,  and  noap. 
—[Eacyclopedie  Methodique,  partie  Chir.)  The  to- 
pical use  of  ether  might  be  tried  ; but  from  the  history 
of  the  disease,  the  chances  of  cure  must  evidently  be 
nearly  hopeless. — (See  also  TV.  G.  Benedict  de  Morbis 
Humoris  Vitrei^  uo.  Lips.  1809.) 

GLEET.  By  the  term  gleet  is  commonly  understood 
a continued  running  or  discharge,  after  the  inflamma- 
tory symptoms  of  a clap  have  for  some  time  ceased,  un- 
attended with  pain,  scalding  in  making  water,  &c.  Mr. 
Hunter  remarks,  that  it  differs  from  a gonorrhoea  in  be- 
ing uninfectious,  and  in  the  discharge  consisting  of  glo- 
bular bodies,  contained  in  a slimy  mucus  instead  of  se- 
rum. He  says,  that  a gleet  seems  to  take  its  rise  from 
a habit  of  action  which  the  parts  have  contracted.  The 
disease,  however,  sometimes  stops  of  itself,  even  after 
every  method  has  been  ineffectually  tried.  This  proba- 
bly depends  upon  accidental  changes  in  the  constitution, 
and  not  at  all  upon  the  nature  of  the  disease  itself.  Mr. 
Hunter  had  a suspicion  that  some  gleets  were  connected 
with  scrofula.  Certain  it  is,  the  sea-bath  cures  more 
gleets  than  the  common  cold  bath,  or  any  other  mode 
of  bathing;  and  a cure  may  sometimes,  but  not  always 
be  accomplished  by  an  injection  of  diluted  sea-water. 

Gleets  are  often  attended  with  a relaxed  constitution. 
They  also  sometimes  arise  from  other  affections  of  the 
urethra,  besides  gonorrhoea.  A stricture  is  almost  al- 
ways accompanied  with  a gleet ; and  so  sometimes  is 
disease  of  the  prostate  gland. 

It  is  remarked  by  Mr.  Hunter,  that  if  a gleet  does 
not  arise  from  any  evident  cause,  and  cannot  be  sup- 
posed to  be  a return  of  a former  gleet,  in  consequence 
of  a gonorrhoea,  either  a stricture  or  diseased  prostate 
gland  iji  to  be  suspected  : an  inquiry  should  be  made 
whether  the  stream  of  urine  is  smaller  than  common, 
whether  there  is  any  difficulty  in  voiding  it,  and  whe- 
ther the  calls  to  make  it  are  frequent.  If  there  should 
be  such  symptom,  a bougie,  rather  under  the  common 
size,  should  be  introduced ; and  if  it  passes  into  the 
bladder  with  tolerable  ease,  the  disease  is  probably  in 
the  prostate  gland,  which  should  next  be  examined. — 
(See  Urethra,  Strictures  of;  and  Prostate  Gland.) 

Balsams,  iuri)entines,  and  the  tinctura  canth.,  given 
internally,  are  of  service,  especially  in  slight  cases ; 
and  when  they  are  useful  they  prove  so  almost  imme- 
diately. Hence,  if  they  had  neither  lessened  nor  re- 
moved the  gleet  in  five  or  six  days,  Mr.  Hunter  never 
continued  them  longer.  The  same  observation  applies 
to  cubebs,  so  celebrated  of  late  as  a remedy  for  gonor- 
rhoea anjd  gleet,  and  the  common  dose  of  which  is  3 ij. 
in  any  convenient  fluid  three  times  a day.  As  the  dis- 
charge when  removed  is  also  apt  to  recur,  such  medi- 
cines should  be  continued  for  some  time  after  the  symp- 
toms have  disappeared. 

When  the  whole  constitution  is  weak,  the  cold  bath, 
sea-bath,  bark,  and  steel  may  be  given.  The  astrin- 
gent gums  and  salt  of  steel,  given  as  internal  astrin- 
gents, have  little  power. 

With  regard  to  local  applications,  the  astringents 
commonly  used  are,  the  decoction  of  bark,  sulphate  of 
zinc,  alum,  and  preparations  of  lead.  The  aqua  vitrio- 
lica  caerulea,  of  the  old  London  Dispensator^,  diluted 
with  eight  times  its  quantity  of  water,  makes  a very 
good  injection. 

Irritating  applications  consist  either  of  injections  or 
bougies,  simple  or  medicated  with  irritating  medicines. 
V'iolent  exercise  maybe  considered  as  having  the  same 
effect.  Such  applications  should  never  be  used  till  the 
other  methods  have  been  fully  tried  and  found  unsuc- 
cessful. They  at  first  increase  the  discharge,  and  on 
this  account  are  sometimes  abandoned  too  early.  Two 
grains  of  the  oxymuriate  of  mercury,  dissolved  in  eight 
ounces  of  distilled  water,  make  a very  good  irritating 
injection.  In  irritable  habits  such  an  application  may 
do  great  harm,  and  therefore,  if  possible,  the  capability 
of  the  parts  to  bear  its  employment  should  first  be 
made  out. 

Bougies  sometimes  act  violently,  but  Mr.  Hunter 
thought  them  more  efficacious  than  injections.  A sim- 
ple unmedicated  one  is  generally  suflicient,  and  must 
be  used  a month  or  six  weeks  before  the  cure  can  be 
depended  upon.  Bougies  medicated  with  camphor  or 
turpentine  were  formerly  employed  for  the  cure  of 
gleet : they  did  not  require  so  long  a trial  as  common 
bougies  : at  present,  I believe,  they  are  not  used  at  all 
by  any  surgeon  of  eminence.  Whatever  bougies  are 
employed  should  be  under  the  common  size. 


Mr.  Hunter  knew  a gleet  disappear  on  the  breaking 
out  of  two  chancres  on  the  glans.  Gleets  have  also 
been  cured  by  a blister  on  the  under  side  of  the  ure- 
thra, and  by  electricity. 

In  every  plan  of  treatment,  rest  or  quietness  is  gene- 
rally of  great  consequence  ; but,  after  the  failure  of  the 
usual  modes,  riding  on  horseback  will  sometimes  im- 
mediately eftect  a cure. 

Regularity  and  moderation  in  diet  are  to  be  observed. 

Intercourse  with  women  often  causes  a return  or  in- 
crease of  gleet ; and  in  such  cases,  it  gives  suspicion 
of  a fresh  infection ; but  the  difference  between  this 
and  a fresh  infection  is,  that  here  the  return  is  almost 
immediately  after  the  connexion. 

Gleets  in  women  are  cured  nearly  in  the  same  man- 
ner as  those  of  men.  Turpentines,  however,  have  no 
specific  effect  on  the  vagina ; and  the  astringent  injec- 
tions used  may  also  be  stronger  than  those  intended 
for  male  patients. 

[The  tincture  of  cantharides,  pretty  freely  adminis- 
tered, and  for  some  time,  is  a powerful  means  of  re- 
storing the  tone  of  the  genital  organs,  and  of  curing 
gleet.  Its  use,  however,  must  be  persisted  in  for  some 
time.  In  that  condition  of  the  system  in  which  a 
gleety  discharge  depends  upon  a diseased  state  of  the 
prostate  gland.  Dr.  Francis,  of  New-York,  has  given 
the  muriated  tincture  of  gold  with  relief,  in  cases 
where  the  muriated  tincture  of  iron  proved  irritating, 
and  seemed  to  augment  existing  evils.  Our  Ameri- 
can remedy,  the  pyrola,  ought  not  in  instances  of  this 
sort  to  be  overlooked.  Wltile  it  invigorates  the  tone 
of  the  digestive  organs,  it  is  valuable  in  various  affec- 
tions of  the  urinary  organs. — Reese.] 

See  A Treatise  on  the  Venereal  Disease,  by  John 
Hunter,  ed.  2.  Also,  SwediauPs  Practical  Observa- 
tions on  Venereal  Complaints. 

GLOSSOCATOCHUS.  (From  yfdaaa,  the  tongue, 
and  xarfxw,  to  depress.)  The  ancient  glossocatochus 
was  a sort  of  forceps,  one  of  the  blades  of  which 
served  to  depress  the  tongue,  while  the  other  was  ap- 
plied under  the  chin. 

GOITRE.  See  Bronchocele. 

GONORRHCEA.  (From  yovrj,  the  semen,  and  p/w, 
to  flow.)  Etymologically,  an  involuntary  discharge  of 
the  semen  • out  always,  according  to  modem  surgery, 
a disenarge  of  purulent  infectious  matter,  from  the  ure- 
thra in  the  male,  and  from  the  vagina  and  surfaces  of 
the  labia,  nymphse,  clitoris,  &c.,  in  the  female  subject. 

Dr.  Swediaur,  after  censuring  the  etymological  im- 
port as  conveying  an  erroneous  idea,  says,  if  a Greek 
name  is  to  be  retained,  he  would  call  it  blennorrhagia, 
from  (SXevva,  mucus,  and  pew,  to  flow.  However,  as 
most  of  the  moderns  consider  the  discharge  as  pus,  not 
mucus,  the  etymological  import  of  blenorrhcea  is  as 
objectionable  as  that  of  gonorrhoea.  Mr.  Howship  has 
repeatedly  examined  the  discharge  with  a microscope^ 
but  without  perceiving  any  essential  difference  between 
such  discharge  and  the  pus  effused  from  an  ulcer.— 
(On  Complaints  ejecting  the  Secretion  and  Eoocretion  of 
the  Urine,  p.  260.)  In  English,  the  disease  is  commonly 
called  a clap,  from  the  old  French  word  clapises,  whiclt 
were  public  shops,  kept  and  inhabited  by  single  prosti^ 
tutes,  and  generally  confined  to  a particular  quarter  of 
the  town,  as  is  even  now  the  case  in  several  of  thp 
great  towns  in  Italy.  In  German,  the  disorder  is  napie4 
a tripper,  from  dripping  ; and  in  French,  a chaudepisse, 
frorntheheat  andscaldingin  making  MVdXer. -(Swediaur.) 

We  shall  first  present  the  reader  with  some  of  Mr, 
Hunter’s  opinions  concerning  the  nature  of  gonorrhoea, 
its  symptoms,  and  treatment ; and,  lastly,  take  notice 
of  the  observations  c-f  some  other  writers. 

When  an  irritating  matter  of  any  kind  is  applied  to 
a secreting  surface  it  increases  that  secretion,  and 
changes  it  from  its  natural  state  to  some  other.  In 
the  present  instance,  it  is  changed  from  mucus  to  pus. 

Till  about  the  year  1753,  it  was  generally  supposed, 
that  the  matter  from  the  urethra  in  cases  of  gonorrhcea 
arose  from  ulcers  in  the  passage ; but  about  that  time 
it  was  ascertained  that  pus  might  be  secreted  without 
a breach  of  substance.  It  was  first  accidentally  proved 
by  dissection,  that  pus  might  be  formed  in  the  bag  of 
the  pleura  without  ulceration  ; and  Mr.  Hunter  after- 
ward examined  the  urethra  of  malefactors  and  others, 
who  were  executed  or  died  while  known  to  be  affected 
with  gonorrhoea,  and  demonstrated  that  the  canal  was 
entirely  free  from  every  appearance  of  ulcer. 

The  time  when  a gonorrhoea  first  appear#  after  infec- 


426 


GONORRHCEA. 


tion,  is  extremely  various.  It  generally  comes  on 
sooner  than  a chancre.  Mr.  Hunter  had  rea.son  to  be- 
lieve that  in  some  instances  the  disease  began  in  a few 
hours  ; while  in  others,  six  weeks  previously  elapsed ; 
but  he  had  known  it  begin  at  all  the  intermediate  pe- 
riods. However,  it  was  his  opinion,  that  about  six, 
eight,  ten,  or  twelve  days  after  infection  is  the  most 
common  period. 

The  surface  of  the  urethra  is  subject  to  inflamma- 
tion and  suppuration  from  various  other  causes  besides 
the  venereal  poison ; and  sometimes  discharges  hap- 
pen spontaneously,  when  no  immediate  cause  can  be 
assigned.  Such  may  be  called  simple  gonorrhoea,  hav- 
ing nothing  of  the  venereal  infection  in  them. 

Mr.  Hunter  knew  of  cases  in  which  the  urethra 
sympathized  with  the  cutting  of  a tooth,  and  all  the 
symptoms  of  a gonorrhoea  were  produced.  This  hap- 
pened several  times  to  the  same  patient.  The  urethra 
is  known  to  be  sometimes  the  seat  of  the  gout ; and 
Mr.  Hunter  was  acquainted  with  instances  of  its  being 
the  seat  of  rheumatism. 

When  a secreting  surface  has  once  received  the  inflam- 
matory action,  its  secretions  are  increased  and  visibly 
altered.  Also,  when  irritation  has  produced  inflamma- 
tion and  an  ulcer  in  the  solid  parts,  a secretion  of  mat- 
ter takes  place,  the  intention  of  which,  in  both,  seems 
to  be  to  wash  away  the  irritating  matter.  But  in  in- 
flammations arising  from  specific  or  morbid  poisons, 
the  irritation  cannot  be  thus  got  rid  of ; for  although 
the  first  irritating  matter  be  washed  away,  yet  the 
new  matter  has  the  same  quality  as  the  original  had; 
and  therefore,  upon  the  same  principle,  it  would  pro- 
duce a perpetual  source  of  irritations,  even  if  the  ve- 
nereal inflammation,  like  many  other  specific  diseases, 
were  not,  what  it  really  is,  kept  up  by  the  specific 
quality  of  the  inflammation  itself.  Tliis  inflammation 
seems,  however,  to  be  only  capable  of  lasting  a limited 
time,  the  symptoms  peculiar  to  it  vanishing  of  them- 
selves, by  the  parts  becoming  less  and  less  susceptible 
of  irritation  ; and  the  subsequent  venereal  matter  can 
have  no  power  of  continuing  the  original  irritation,  for 
otherwise  there  would  be  no  end  to  the  disease.  The 
time  which  the  susceptibility  of  the  irritation  lasts 
must  depend  upon  the  difference  in  the  constitution, 
and  not  upon  any  difference  in  the  poison  itself. 

Mr.  Hunter  believed  that  the  venereal  disease  only 
ceased  spontaneously  when  it  attacked  a secreting  sur- 
face, and  produced  a mere  secretion  of  pus  without  ul- 
ceration. Such  were  some  of  the  sentiments  of  this 
great  man,  who  was  a firm  believer  in  the  identity  of 
the  poisons  of  syphilis  and  gonorrhoea , but  this  idea, 
and  the  hypothesis  about  the  impossibility  of  any  spon- 
taneous cure  of  venereal  sores,  are  now  very  generally 
relinquished. 

The  first  symptom  of  gonorrhoea  is  generally  an 
itching  at  the  orifice  of  the  urethra,  sometimes  extend- 
ing over  the  whole  glans.  A little  fulness  of  the  lips 
of  the  urethra,  the  effect  of  inflammation,  is  next  ob- 
servable, and  soon  afterward  a running  appears. 

The  itclmig  changes  into  pain,  more  particularly  at 
the  time  of  voiding  the  urine.  There  is  often  no  pain 
till  some  time  after  the  appearance  of  the  discharge 
and  other  symptoms ; and  in  many  gonorrhoeas  there 
is  hardly  any  pain  at  all  even  wdien  the  discharge  is 
very  considerable.  At  other  times,  a great  degree  of 
soreness  occurs  long  before  any  discharge  appears. 
There  is  generally  a particular  fulness  in  the  penis, 
and  more  especially  in  the  glans.  The  glans  has  also 
a kind  of  transparency,  especially  near  the  beginning 
of  the  urethra,  where  the  skin,  being  distended,  smooth, 
and  red,  resembles  a ripe  cherry.  The  mouth  of  the 
urethra  is,  in  many  instances,  evidently  excoriated. 
The  surface  of  the  glans  itself  is  often  in  a half-exco- 
riated  state,  consequently  very  tender ; and  it  secretes 
a sort  of  discharge.  The  canal  of  the  urethra  becomes 
narrower,  which  is  known  by  the  stream  of  urine  be- 
ing smaller  than  common.  This  proceeds  from  the 
fulness  of  the  penis  in  general,  and  either  from  the 
lining  of  the  urethra  being  swollen  or  in  a spasmodic 
state.  The  fear  of  the  patient  while  voiding  his  urine, 
also  disposes  the  urethra  to  contract ; and  the  stream 
of  urine  is  generally  much  scattered  and  broken  as 
soon  as  it  leaves  the  passage.  There  is  freciuently 
some  degree  of  hemorrhage  from  the  urethra,  perhaps 
lYom  the  distention  of  the  vessels,  more  especially  when 
there  is  a chordee,  or  a tendency  to  it.  Small  swell- 
ings often  occur  along  the  lower  surface  ol'  the  penis, 


in  the  course  of  the  urethra.  These  Mr.  Hunter  sus- 
pected to  be  enlarged  glands  of  the  passage.  They  oc- 
casionally suppurate  and  burst  outwardly,  but  now 
and  then  in  the  urethra  itself.  Mr.  Hunter  has  also 
suspected  such  tumours  to  be  ducts,  or  lacunte  of  the 
glands  of  the  urethra  distended  witn  mucus,  in  conse- 
quence of  the  mouth  of  the  duct  being  closed,  in  a 
manner  similar  to  what  happens  to  the  duct  leading 
from  the  lachrymal  sac  to  the  nose,  and  so  as  to  induce 
inflammation,  suppuration,  and  ulceration.  Hardness 
and  swelling  may  also  occur  in  the  situation  of  Cow- 
per’s  glands,  and  end  in  considerable  abscesses  in  the 
perinaeum.  The  latter  tumours  break  either  internally 
or  externally,  and  sometimes  in  both  ways,  so  as  to 
produce  fistulae  in  perinaeo. 

A soreness  is  often  felt  all  along  the  under  side  of  the 
penis,  frequently  extending  as  far  as  the  anus.  The 
pain  is  particularly  great  in  erections;  but  the  case 
differs  from  chordee  by  the  penis  remaining  straight. 
In  most  cases  of  gonorrhoea,  erections  are  frequent,  and 
even  sometimes  threaten  to  bring  on  mortification  ; as 
opium  is  of  great  service,  Mr.  Hunter  thought  that  there 
was  reason  to  suppose  them  of  a spasmodic  nature. 

The  natural  slimy  discharge  from  the  glands  of  the 
urethra  is  first  changed  from  a fine,  transparent,  ropy 
secretion  to  a watery,  whitish  fluid  ; and  the  lubricating 
fluid  which  the  passage  naturally  exhales  becomes 
less  transparent ; both  these  secretions  becoming  gra- 
dually thicker,  assume  more  and  more  the  qualities  of 
common  pus. 

The  matter  of  gonorrhoea  often  changes  its  colour  and 
consistence,  sometimes  from  a white  to  a yellow,  and 
often  to  a greenish  colour.  These  changes  depend  on 
the  increase  and  decrease  of  the  inflammation,  jind  not 
on  the  poisonous  quality  of  the  matter  itself ; for  an 
irritation  of  these  parts,  equal  to  that  produced  in  a 
gonorrhoea,  will  produce  the  same  appearances. 

The  discharge  is  produced  from  the  membrane  lining 
the  urethra,  and  from  the  lacunae,  but  in  general  only 
for  about  two  or  three  inches  from  the  external  orifice. 
Mr.  Hunter  says,  seldom  farther  than  an  inch  and  a 
half,  or  two  inches  at  most.  This  he  terms  the  specific 
extent  of  the  inflammation.  Whenever  he  had  an  op- 
portunity of  examining  the  urethra  affected  with  gonor- 
rhoea, he  always  found  the  lacunae  loaded  with  matter, 
and  more  visible  than  in  the  natural  state.  Before  the 
time  of  this  celebrated  man,  it  was  commonly  supposed 
that  the  discharge  arose  from  the  whole.surface  of  the 
urethra,  and  even  from  Cowper’s  glands,  the  prostate 
and  vesiculae  seminales. 

But  if  the  matter  were  secreted  from  all  these  parts, 
the  pus  would  collect  in  the  bulb,  as  the  semen  does, 
and  thence  be  emitted  in  jerks  ; for  nothing  can  be  in 
the  bulbous  part  of  the  urethra  without  stimulating  it 
to  action,  especially  when  in  a state  of  irritation  and 
inflammation. 

When  the  inflammation  is  violent,  some  of  the  ves- 
sels of  the  tirethra  often  burst,  and  a discharge  of  blood 
ensues.  Sometimes  such  blood  is  only  just  enough  to 
give  the  matter  a tinge.  In  other  instances,  erections 
cause  ai^extravasation  by  stretching  the  part. 

When  the  inflammation  goes  more  deeply  than  the 
membranous  lining,  and  affects  the  reticular  membrane 
of  the  urethra,  it  produces  in  it  an  extravasation  of 
coagulable  lymph,  the  consequence  of  which  is  a 
chordee. — (See  Chordee.) 

Mr.  Hunter  suspected  that  the  disease  is  communi- 
cated or  creeps  along  from  the  glans  to  the  urethra,  or, 
at  least,  from  the  lips  of  the  urethra  to  its  inner  surface, 
as  it  is  impossible  that  the  infectious  matter  can,  during 
coition,  get  as  far  as  the  disease  extends.  He  mentions 
an  instance,  in  which  a gentleman,  who  had  not  co- 
habited with  any  woman  for  many  weeks,  to  all  ap- 
pearance caught  a gonorrhoea  from  a piece  of  plaster, 
which  had  adhered  to  his  glans  penis  in  a necessary 
abroad.  The  infection  is  accounted  for,  by  sujjposing 
that  some  person  with  a clap  had  previously  been  to  this 
place,  and  had  left  behind  some  of  the  discharge,  and  that 
the  above  gentleman  had  allowed  his  penis  to  remain 
in  contact  with  the  matter  till  it  had  dried. 

Many  symptoms  depending  on  the  sympathy  of  other 
parts  with  the  urethra  sometimes  accompany  a gonor- 
rhoea. An  uneasiness,  partaking  of  soreness  and  itain, 
and  a kind  of  weariness,  are  ftelt  about  every  part  of  the 
pelvis.  The  scrotum,  testicles,  perinaeum,  anus,  and 
hips  become  disagreeably  sensible,  and  the  testicles 
often  require  to  bo  suspended.  So  irritable,  indeed,  are 


GONORRHOEA. 


427 


they  in  such  cases,  that  the  least  accident,  or  even  ex- 
ercise, which  would  have  no  effect  of  this  kind  at  an- 
- other  time,  will  make  them  swell.  The  glands  of  the 
groin  are  often  affected  sympathetically,  and  even  swell 
a little,  but  they  do  not  suppurate,  as  they  generally  do 
when  they  inflame  from  the  absorption  of  matter.  Mr. 
Hunter  has  seen  the  irritation  of  a gonorrhcea  so  exten- 
sive as  to  affect  with  real  pain  the  thighs,  buttocks,  and 
abdominal  muscles.  He  knew  one  gentleman  who 
never  had  a gonorrhoea  without  being  immediately 
seized  with  universal  rheumatic  pains. 

When  the  disorder,  exclusive  of  the  affections  from 
sympathy,  is  not  more  violent  than  has  been  described, 
Mr.  Hunter  termed  it  a common  or  simple  venereal 
gonorrhoea ; but  if  the  patient  is  very  susceptible  of 
such  irritation,  or  of  any  other  mode  of  action  which 
may  accompany  the  venereal,  then  the  symptoms  are 
in  proportion  more  violent.  In  such  circumstances,  we 
sometimes  find  the  irritation  and  inflammation  exceed 
the  specific  distance,  and  extend  through  the  whole 
urethra.  There  is  often  a considerable  degree  of  pain 
in  the  perinaeum ; and  a frequent,  though  not  a constant, 
symptom  is  a spasmodic  contraction  of  the  accelera- 
tores  urin*  and  erectores  muscles.  In  these  cases,  the 
inflammation  is  sometimes  considerable,  and  goes 
deeply  into  the  cellular  membrane,  but  without  pro- 
ducing any  effect  except  swelling.  In  other  instances, 
it  goes  on  to  suppuration,  often  becoming  one  of  the 
causes  of  fistulae  in  perinaeo.  Thus,  Cowper’s  glands 
may  suppurate,  and  the  irritation  often  extends  even  to 
the  bladder  itself. 

^Vhen  the  bladder  is  affected,  it  becomes  more  sus- 
ceptible of  every  kind  of  irritation.  It  will  not  bear  the 
usual  distention,  and  therefore  the  patient  cannot  retain 
his  water  the  ordinary  time  ; and  the  moment  the  desire 
of  making  water  takes  place,  he  is  obliged  instantly  to 
make  it,  with  violent  pain  in  the  bladder,  and  still  more 
in  the  glans  penis,  exactly  similar  to  what  happens  in 
a fit  of  the  stone.  If  the  bladder  be  not  allowed  to  dis- 
charge its  contents  immediately,  the  pain  becomes 
almost  intolerable ; and  even  when  the  water  is  evacu- 
ated, there  remains  for  some  time  a considerable  pain 
both  in  the  bladder  and  glans. 

Sometimes,  though  rarely,  when  the  bladder  is  much 
affected,  the  ureters,  and  even  the  kidne\"s  sympathize ; 
and  Mr.  Hunter  had  reason  to  suspect  that  the  irrita- 
tion might  be  communicated  to  the  peritoneum  by 
means  of  the  vas  deferens. 

Mr.  Hunter  mentions  a case,  in  which,  while  the  in- 
flammatory symptoms  of  a gonorrhoea  were  abating, 
an  incontinence  of  urine  came  on  ; but  in  time  got  spon- 
taneously welt. 

A very  common  symptom  attending  a gonorrhoea  is  a 
swelling  of  the  testicle. — (See  Hernia  Humor alis.) 

Another  occasional  consequence  is  a sympathetic 
swelling  of  the  inguinal  glands. — (See  Bubo.) 

A hard  cord  is  sometimes  observed,  leading  from 
the  prepuce  along  the  back  of  the  penis,  and  often  di- 
recting its  course  to  one  of  the  groins,  and  affecting  the 
glands.  At  the  part  of  the  prepuce  where  the  cord 
takes  its  rise,  there  is  most  commonly  a swelling. 
This  sometimes  happens  when  an  excoriation  and  a 
discharge  from  the  prepuce  or  glans  penis  exist.  In 
one  case,  Mr.  Howship  thought  the  large  vein  on  the 
dorsum  of  the  penis  was  inflamed  and  thickened. — (On 
Complaints  affecting  the  Secretion  and  Excretion  of  the 
Urine,  &rc.  p.  266.) 

From  the  above  account,  the  symptoms  of  gonorrhcea 
in  different  cases  seem  to  be  subject  to  infinite  variety. 
The  discharge  often  appears  without  any  pain,  and  the 
coming  on  of  the  pain  is  not  at  any  stated  time  after 
the  appearance  of  the  discharge.  There  is  often  no  pain 
at  all,  although  the  discharge  is  in  considerable  quan- 
tity, and  of  a bad  apjiearance.  The  pain  often  goes  off 
white  the  discharge  continues,  and  will  return  again. 
In  some  cases,  an  itching  is  felt  fora  considerable  time, 
which  is  sometimes  succeeded  by  pain;  though  in 
many  cases  it  continues  till  the  end  of  the  d.6ease.  On 
the  other  hand,  the  pain  is  often  troublesome  and  con- 
siderable, even  when  there  is  little  or  no  discharge. 
The  neighbouring  parts  sympathize,  as  the  glands  of 
the  groin,  the  testicle,  the  loins  and  pubes,  the  upper 
parts  of  the  thighs,  and  the  abdominal  muscles.  Some- 
times the  disease  appears  a few  hours  after  the  applica- 
tion of  the  poison  ; sometimes  not  till  six  weeks  have 
elapsed.  Lastly,  it  is  often  impossible  to  determine 
whether  th/^  case  is  a venereal  discharge,  or  rather  one 


produced  by  the  application  of  infectious  matter,  or 
only  an  accidental  discharge,  arising  from  some  un- 
known cause. 

GONORRHCEA  IN  W'OMEN. 

The  disorder  is  not  so  easily  ascertained  in  them  as 
in  men,  because  they  are  subject  to  a disorder  called 
jlxtor  albus,  which  resembles  gonorrhoea.  A mere  dis- 
charge in  women  is  less  a proof  of  the  existence  of  a 
gonorrhcea  than  even  a discharge  without  pain  in  men. 
The  kind  of  matter  does  not  enable  us  to  distinguish  a 
gonorrhcea  from  a fluor  albus  ; for  in  the  latter  affec- 
tion, the  discharge  often  puts  on  all  the  appearance  of 
venereal  matter.  Pain  is  not  necessarily  present,  and 
therefore  forms  no  line  of  distinction.  The  appearance 
of  the  parts  often  gives  us  but  little  information ; “ for 
(says  Mr.  Hunter)  I have  frequently  examined  the  parts 
of  those  who  confessed  all  the  symptoms,  such  as  in- 
crease of  discharge,  pain  in  making  water,  soreness  in 
walking,  or  when  the  parts  were  touched,  yet  I could 
see  no  difference  between  these  and  sound  parts.  I 
know  of  no  other  way  of  judging,  in  cases  where  there 
arc  no  symptoms  sensible  to  the  person  herself,  or  where 
the  patient  has  a mind  to  deny  any  uncommon  symp- 
toms, but  from  the  circumstances  preceding  the  dis- 
charge ; such  as  her  having  been  connected  with  men 
supposed  to  be  unsound,  or  her  being  able  to  give  the 
disorder  to  others ; which  last  circumstance,  being  de- 
rived from  the  testimony  of  another  person,  is  not 
always  to  be  trusted  to,  for  obvious  reasons.”  But 
though  there  may  sometimes  be  great  difficulty  in  form- 
ing a judgment  of  some  of  these  cases,  the  surgeon 
may  frequently  come  to  a right  conclusion,  by  recol- 
lecting, as  Mr.  Dunn  has  reminded  me,  that,  besides 
the  difference  depending  on  the  suddenly  severe  symp- 
toms of  gonorrhcea,  fluor  albus  may  be  known  by  the 
great  debility ; the  sinking  of  the  stomach ; the  weari- 
ness of  the  limbs ; the  pain  of  the  back,  always  in- 
creased by  the  erect  posture;  the  severe  headaches ; the 
painful  menstruation,  together  with  the  very  gradual 
increase  of  the  disease. 

From  the  manner  in  which  the  disease  is  contracted, 
it  must  principally  attack  the  vagina,  a part  not  en- 
dowed with  much  sensation.  In  many  cases,  however, 
it  produces  a considerable  soreness  on  the  inside  of  the 
labia,  nymphae,  clitoris,  carunculae  myrtiformes,  and 
meatus  urinarius.  In  certain  cases,  these  parts  are  so 
sore,  that  they  will  not  bear  to  be  touched ; the  person 
can  hardly  walk ; the  urine  gives  pain  in  its  passage 
through  the  urethra,  and  when  it  comes  into  contact  with 
the  above-mentioned  parts. 

The  bladder,  and  even  the  kidneys,  occasionally 
sympathize.  The  mucous  glands  on  the  inside  of  the 
labia  often  swell,  and  sometimes  suppurate,  forming 
small  abscesses,  which  open  near  the  orifice  of  the 
vagina. 

According  to  Mr.  Hunter,  the  venereal  matter  from 
the  vagina  sometimes  runs  down  the  perinaeum  to  the 
anus,  and  produces  a gonorrhcea  or  chancre  in  that 
situation.  The  disease  in  women  may  probably  wear 
itself  out,  as  in  men ; but  it  may  exist  in  the  vagina  for 
years,  if  the  testimony  of  patients  can  be  rehed  on. 

TREATMENT  OF  GONORRHCEA. 

As  every  form  of  the  venereal  disease  is  suppo.sed  to 
arise  from  the  same  cause,  and  as  we  have  a specific 
for  some  forms,  we  might  expect  that  this  would  be  a 
certain  cure  for  every  one ; and  therefore,  that  it  must 
be  no  difficult  task  to  cure  the  disease,  when  in  the 
form  of  inflammation  and  suppuration  in  the  urethra. 
Experience  teaches  us,  however,  that  the  gonorrhcea 
is  the  most  variable  in  its  symptoms,  while  under  a 
cure ; and  the  most  uncertain,  with  respect  to  its  cure, 
of  any  forms  of  the  venereal  disease  (if  it  ever  be  a 
form  of  this  disease  at  all),  many  cases  terminating  in 
a week,  while  others  continue  for  months  under  the 
same  treatment. 

The  only  curative  object  is,  to  destroy  the  disposition 
and  specific  mode  of  action  in  the  solids  of  the  parts, 
and  as  they  become  changed,  the  poisonous  quality  of 
the  matter  produced  will  also  be  destroyed.  This  effects 
the  cure  of  the  disease,  but  does  not  aiwaj  s remove  the 
con.sequence. 

Gonorrhcea  is  incapable  of  being  continued  beyond  a 
certain  time  in  any  constitution ; and  when  it  is  vio- 
lent, or  of  long  duration,  it  is  owing  to  the  part  being 
very  susceptible  of  such  irritation,  and  readily  retain- 


428 


GONORRHOEA. 


ing  it.  As  no  specific  remedy  for  gononhffia  is  known, 
it  is  fortunate  that  time  alone  will  effect  a cure.  It  is 
worthy  of  consideration,  however,  whether  medicine 
can  be  of  any  service.  Mr.  Hunter  is  inclined  to  think 
it  not  of  the  least  use  in  nine  cases  out  of  ten.  But 
even  this  would  be  of  some  consequence,  if  the  cases 
capable  of  being  benefited  could  be  distinguished. 

The  means  of  cure  generally  adopted  are  of  two 
kinds,  interna]  remedies  and  local  applications;  but 
whatever  plan  is  pursued,  we  are  always  to  attend 
more  to  the  nature  of  the  constitution,  or  to  any  accom- 
panying disease  in  the  parts  themselves,  or  parts  con- 
nected with  them,  than  to  the  gonorrhoea  itself. 

When  the  symptoms  are  violent,  but  of  the  common 
inflammatory  kind,  known  by  the  extent  of  the  inflam- 
mation not  exceeding  the  specific  distance,  the  local 
treatment  may  be  either  irritating  or  soothing. 

According  to  Mr.  Hunter,  irritating  applications  are 
less  dangerous  in  these  cases,  than  when  irritable  in- 
flammation is  present,  and  they  may  alter  the  specific 
action ; but  to  produce  this  effect  their  irritation  must 
be  greater  than  that  of  the  original  injury.  The  parts 
will  afterward  recover  of  themselves,  as  from  any 
other  common  inflammation. 

Mr.  Hunter  believes,  however,  that  in  the  beginning 
the  soothing  plan  is  the  best.  If  the  inflammation  be 
great,  and  of  the  irritable  kind,  no  violence  is  to  be 
used,  for  it  would  only  increase  the  symptoms ; and 
nothing  should  be  done  that  can  tend  to  stop  the  dis- 
charge, as  it  would  not  put  a stop  to  the  inflammation. 
The  constitution  is  to  be  altered,  if  possible,  by  reme- 
dies adapted  to  each  disposition,  and  reducing  the  dis- 
ease to  its  simple  form.  If  the  constitution  cannot  be 
altered,  nothing  is  to  be  done,  and  the  action  is  to  be 
allowed  to  wear  itself  out. 

When  the  inflammation  has  abated,  the  cure  may  be 
attempted  by  internal  remedies  or  local  applications 
which  do  not  operate  violently,  whereby  the  irritation 
might  be  reproduced.  Gentle  astringents  may  be  ap- 
plied. 

But  if  the  disease  has  begun  mildly,  an  irritating  in- 
jection may  be  used,  in  order  quickly  to  get  rid  of  the 
specific  mode  of  action.  This  application  will  increase 
the  symptoms  for  a time  ; but  when  it  is  left  off  they 
will  often  abate  or  wholly  disappear ; and  after  such 
abatement  astringents  may  be  used,  the  discharge  be- 
ing the  only  thing  to  be  removed. 

When  itching,  pain,  and  other  uncommon  sensations 
are  felt  for  some  time  before  the  discharge  appears,  Mr. 
Hunter  diffidently  expresses  his  inclination  to  recom- 
mend the  soothing  plan,  instead  of  the  irritating  one,  in 
order  to  bring  on  the  discharge,  which  is  a step  to- 
wards the  resolution  of  the  irritation  ; and  he  adds,  that 
to  use  astringents  would  be  bad  practice,  as  by  retard- 
ing the  discharge  they  would  only  protract  the  cure. 
When  there  are  strictures  or  swelled  testicles,  astrin- 
gents should  not  be  used;  for  while  there  is  a dis- 
charge such  complaints  are  relieved. 

Mr.  Hunter  thus  expresses  himself  in  regard  to  the 
effect  of  mercury  in  gonorrhoea  : “ I doubt  very  much 
of  mercury  having  any  specific  virtue  in  this  species  of 
the  disease ; for  I find  that  it  is  as  soon  cured  without 
mercury  as  with  it,  &c.  So  little  effect,  indeed,  has  this 
medicine  upon  a gonorrhoea,  that  I have  known  a gonor- 
rhoea take  place  [while  the  patient  was]  under  a course 
,of  mercury  sufficient  for  the  cure  of  a chancre.  Men 
•Jiave  also  been  known  to  contract  a gonorrhoea  when 
•loaded  with  mercury  for  the  cure  of  a lues  venerea : 
•the  gonorrhoea,  nevertheless,  has  been  as  difficult  of 
cure  as  in  ordinary  cases.” 

Mr.  Hunter  does  not  say  much  in  favour  of  evacu- 
ants,  diuretics,  and  astringents  given  internally.  He 
allows,  however,  that  astringents,  which  act  specifi- 
cally on  the  parts,  as  the  balsams  conjoined  with  any 
other  medicine  which  may  be  thought  right,  may  help 
to  lessen  the  discharge,  in  proportion  as  the  inflamma- 
tion abates. 

Local  applications  may  be  either  internal  to  the  ure- 
thra, external  to  the  penis,  or  both.  Those  which  are 
applied  to  the  urethra  seem  to  promise  most  efficacy, 
because  they  come  into  immediate  contact  with  the 
diseased  parts.  They  may  be  either  in  a solid  or  fluid 
form.  A fluid  is  only  a very  temporary  application. 
The  solid  ones,  or  bougies,  may  remain  a long  while  ; 
but  in  general  irritate  immediately,  from  their  solidity 
alone  ; and  Mr.  Hunter  says,  the  less  bougies  are  used 
when  the  parts  are  in  an  inflamed  state  th  ^ter, 


though  he  never  sav/  any  bad  effects  from  them  when 
applied  with  caution. 

At  present  bougies  are  rarely  used  in  cases  of  gonor- 
rhoea, in  consequence  of  the  irritation  which  they  pro- 
duce, and  their  tendency  to  bring  on  swelling  of  the 
testes. 

The  fluid  applications  or  injections  in  use  are  innu- 
merable ; and  as  gonorrhoea  frequently  gets  well  with 
so  many  of  various  kinds,  we  may  infer,  that  the  com- 
plaint would,  in  time,  get  well  of  itself.  However, 
there  cannot  be  a doubt  that  injections  often  have  an 
immediate  effect  on  the  symptoms,  and  hence  must 
have  power ; though  the  injection  which  possesses  the 
greatest  power  is  unknown.  As  injections  are  only- 
temporary  applications,  they  must  be  used  often,  espe- 
cially when  found  useful,  and  not  of  an  irritating  kind. 

Mr.  Hunter  divides  injections  into  four  kinds,  the 
irritating,  sedative,  emollmit,  and  astringent.  Ac- 
cording to  his  doctrines,  irritating  injections  of  every 
kind  act  in  this  disease  upon  the  same  principle ; that 
is,  by  producing  an  irritation  of  another  kind,  which 
ought  to  be  greater  than  the  venereal ; by  which  means 
the  venereal  is  destroyed  and  lost,  and  the  disease 
cured,  although  the  pain  and  discharge  may  still  be 
kept  up  by  the  injection  ; effects,  however,  which  tvill 
soon  go  off  when  the  injection  is  laid  aside.  In  this 
way  bougies  also  perform  a cure.  Most  of  the  irri- 
tating injections  have  an  astringent  effect,  and  prove 
simply  astringent  when  mild. 

Irritating  injections  should  never  be  used  when  there 
Is  already  much  inflammation ; especially  in  constitu- 
tions which  are  known  to  be  incapable  of  bearing  much 
irritation  : nor  should  they  be  used  when  the  inflam- 
mation has  spread  beyond  the  specific  distance;  nor 
when  the  testicles  are  tender ; nor  when,  upon  the  dis- 
charge ceasing  quickly,  these  parts  have  become  sore ; 
nor  when  the  perinaeum  is  vei7  susceptible  of  inflam- 
mation, and  especially  if  it  formerly  should  have  sup- 
purated ; nor  when  there  is  a tendency  in  the  blad- 
der to  irritation,  known  by  the  frequency  of  making 
water. 

In  mild  cases,  and  in  constitutions  which  are  not 
irritable,  such  injections  often  succeed,  and  remvoe  the 
disease  almost  immediately.  The  practice,  however, 
ought  to  be  attempted  with  caution,  and  not,  perhaps, 
till  milder  methods  have  failed.  Two  grains  of  the 
hydrargyrus  muriatus,  dissolved  in  eight  ounces  of  dis- 
tilled water,  form  a very  good  irritating  injection  ; but 
an  injection  of  only  half  this  strength  may  be  used, 
when  it  is  not  intended  to  attempt  a cure  so  quickly. 
If,  however,  the  injection,  even  in  that  proportion,  gives 
considerable  pain  in  its  application,  or  occasions  a great 
increase  of  pain  in  making  water,  it  should  be  farther 
diluted. 

Sedative  injections  will  always  be  of  service  when 
the  inflammation  is  considerable,  and  they  are  very 
useful  in  relieving  the  pain.  Perhaps  the  best  sedative 
is  opium,  as  well  when  given  by  the  mouth  or  anus, 
as  when  applied  to  the  part  affected  in  the  form  of  an 
injection.  But  even  opium  will  not  act  as  a sedative 
in  all  constitutions  and  parts;  but,  on  the  contrary, 
often  has  opposite  effects,  producing  great  irritability. 
Lead  may  be  reckoned  a .sedative,  so  far  as  it  abates  in- 
flammation, while  at  the  same  time  it  may  act  as  a 
gentle  astringent.  Fourteen  grains  of  acetate  of  lead, 
in  Iviij.  of  distilled  water,  make  a good  sedative  as- 
tringent injection. 

Drinking  freely  of  diluting  liquors  may,  perhaps,  have 
a sedative  efffect,  as  it  in  part  removes  some  of  tlie 
causes  of  irritation,  by  rendering  the  urine  less  stimu- 
lating to  the  bladder  when  the  irritation  is  there,  and 
to  the  urethra  in  its  passage  through  it.  Diluting 
drinks  may  possibly  lessen  the  susceptibility  of  irrita- 
tion. The  vegetable  mucilages  of  certain  seeds  and 
plants,  and  the  emollient  gums,  are  recommended.  Mr. 
Hunter  does  not  entertain  much  opinion  of  their  effi- 
cacy, though  some  of  his  patients  told  him  that  they 
experienced  less  uneasiness  in  making  water,  when 
their  drink  was  impregnated  with  mucilaginous  sub- 
stances. 

Emollient  injections  are  the  most  proper  when  the 
inflammation  is  very  great ; and  they  probably  act  by 
first  simply  washing  away  the  matter,  and  then  leaving 
a soft  application  to  the  part,  so  as  to  be  singularly  ser- 
viceable by  lessening  the  irritating  effects  of  the  urine 
Indeed,  practice  proves  this  ; for  a solution  of  gum  ara- 
ble, milk  and  water,  or  sweet  oil,  will  often  lessen  the 


GONORRHCEA.  429 


pain  and  othclr  symptoms,  when  the  more  active  injec- 
lions  have  done  nothing,  or  seemed  to  do  harm. 

The  irritation  at  the  orifice  of  the  urethra  is  fre- 
quently so  great  that  the  point  of  the  syringe  cannot  be 
sutfered  to  enter.  In  this  case,  no  injection  should  be 
used  till  the  inflammation  has  abated  ; but,  in  the 
mean  while,  fomentations  may  be  employed. 

Astringent  injections  act  by  lessening  the  discharge. 
They  should  only  be  used  towards  the  latte%end  of  the 
disease,  when  it  has  become  mild.  But  if  the  disease 
should  begin  mildly,  they  may  be  used  at  the  very  be- 
ginning; for  by  gradually  lessening  the  discharge,  with- 
out increasing  the  inflammation,  we  complete  the  cure, 
and  prevent  a continuance  of  the  discharge  called 
gleet.  They  will  have  an  irritating  quality  if  used 
strong,  and  hence  increase  the  discharge,  instead  of 
lessening  it.  Mr.  Hunter’s  experience  did  not  teach 
him  that  one  astringent  was  much  better  than  another. 
The  astringent  gums,  as  dragon’s  blood,  the  balsams, 
and  the  turpentines,  dissolved  in  water ; the  juices  of 
many  vegetables,  as  oak  bark,  Peruvian  bark,  tormentil 
root,  and  perhaps  all  the  metallic  salts,  as  green,  blue, 
and  white  vitriols  ; the  salts  of  mercury,  and  also 
alum ; probably  all  act  much  in  the  same  way  ; though 
the  mere  changing  of  an  injection  is  often  efficacious. 
The  local  use  of  the  nitric  acid,  properly  diluted,  has 
been  commended  by  Vigaroux,  Toepelmann,  and  others, 
as  a safe  remedy  for  the  stoppage  of  gonorrhoea. — (See 
Pearson  on  the  Effects  of  various  Articles  in  the  Cure 
of  Lues  Venerea,  p.  205,  ed.  2 ; and  Neuere  Erfahr. 
uber  zweckm.  Behdl.  venerisch.  Schleimensjlusse,  4-c. 
Leipz.  1809.) 

The  external  applications  are  poultices  and  fomen- 
tations, which  can  only  be  useful  when  the  prepuce, 
glans,  and  orifice  of  the  urethra  are  inflamed. 

Since  Mr.  Hunter’s  time,  many  surgeons  have  been 
in  the  habit  of  keeping  the  penis,  in  the  incipient  in- 
flammatory stage  of  gonorrhoea,  covered  with  linen, 
continually  wet  with  the  liquor  plumbi  acetatis  diluius ; 
a practice  which  is  certainly  both  rational  and  benefi- 
cial. INlr.  Abernethy,  in  his  Lectures  on  Surgery, 
speaks  in  favour  of  this  method.  And  some  surgeons, 
among  whom  is  my  intelligent  correspondent  Mr. 
Dunn,  of  Scarborough,  have  seen  great  relief  derived 
from  the  u.se  of  a suspensor  scroti,  or  double  handker- 
chief, which,  combined  with  rest  and  the  elevation  of 
the  penis,  the  last-mentioned  practitioner  has  frequently 
found,  indeed,  of  more  service  than  any  thing  else. 

In  the  treatment  of  gonorrhoea,  the  liquor  potassae  is 
a favourite  internal  medicine  with  many  practitioners, 
who  begin  with  prescribing  it,  and  continue  its  use 
until  the  inflammatory  stage  has  subsided.  However, 
according  to  Mr.  Howship,  its  effects  are  very  uncer- 
tain, and  sometimes  it  excites  uneasiness  and  irritation 
about  the  neck  of  the  bladder,  and  difficulty  of  voiding 
the  urine.  Hence,  whenever  he  now  directs  this  medi- 
cine, it  is  in  combination  with  some  aperient,  so  that  it 
may  not  remain  long  in  the  bowels.— (0«.  Complaints 
affecting  the  Secretion  and  Excretion  of  the  Urine, 
p.  2()9.) 

The  latter  gentleman,  and  a great  many  other  modem 
surgeons,  have  relinquished  the  use  of  all  injections  in 
the  treatment  of  gonorrhma,  and  manage  the  disease 
on  common  antiphlogistic  principles.  Mr.  Howship 
states,  that  when  injections  are  used,  they  are  not  un- 
frequently  followed  by  a most  distressing  and  perma- 
nent irritability  of  the  bladder.— (On.  Complaints  af- 
fecting the  Secretion  and  Excretion  of  the  Urine, 
p.  268.)  But  the  common  objection  to  them  is  founded 
ujwn  the  suspicion  that  they  increase  the  frequency  of 
hernia  humoralis  and  strictures. 

When  the  glands  of  the  urethra  are  enlarged,  mer- 
curial ointment  may  be  rubbed  on  the  part ; but  this 
will  probably  be  of  most  service  after  the  inflammation 
has  subsided. 

treatment  or  gonorrikea  in  women. 

Thus  is  nearly  the  same  as  that  of  the  disease  in 
men,  but  is  more  simple.  When  the  disorder  is  in  the 
vagina,  injections  are  best ; and  after  their  use  the  ex- 
ternal parts  should  be  well  washed.  It  is  almost  im- 
possible for  the  patient  to  throw  an  injection  into  the 
urethra,  when  it  is  affected.  The  same  injections  are 
proper  as  for  men;  but  they  may  be  made  doubly 
strong.  When  the  glands  of  the  vagina  suppurate  and 
form  abscesses,  these  should  be  opened  and  dressed  ; 
but  the  practice  of  smearing  the  parts  with  mercurial 


ointiflent,  as  advised  by  Mr.  Hunter,  is  now  entirely 
abandoned. 

CONSTITUTIONAL  TREATMENT  OF  GONORRHCEA. 

In  many  strong  phlethoric  constitutions,  the  symp- 
toms are  violent,  and  there  is  a great  tendency  to  in- 
flammatory fever.  In  such  instances,  opiate  clysters, 
though  at  first  productive  of  relief,  sometimes  occasion 
in  the  end  fever,  and  consequently  aggravate  all  tho 
symptoms.  In  these  cases  the  balsam  of  copaiba  also’ 
sometimes  increases  the  inflammatory  symptoms.  In 
a constitution  of  this  kind,  the  treatment  consists  chiefly 
in  evacuations,  the  best  of  which  are  bleeding  and 
gentle  purging.  The  patient  must  live  sparingly,  andy 
above  all,  use  little  exercise. 

In  a weak  and  irritable  constitution,  the  symptoms 
are  frequently  violent,  the  inflammation  extending  be- 
yond the  specific  distance,  running  along  the  urethra, 
and  even  affecting  the  bladder.  Here  the  indication  is 
to  strengthen  ; and,  according  to  Mr.  Hunter,  bark 
alone  has  been  known  to  effect  a cure.  All  evacua- 
tions are  hurtful. 

A fever  has  been  known  to  stop  the  discharge,  re- 
lieve the  pain  in  making  water,  and  finally  cure  the 
disease.  On  other  occasions,  Mr.  Hunter  has  seen  all' 
the  symptoms  of  gonorrhoea  cease  on  the  accession  of 
a fever  and  return  when  the  fever  was  subdued.  In 
other  examples,  a gonorrhoea,  mild  at  first,  has  been 
rendered  severe  by  the  coming  on  of  a fever,  and  upon 
its  subsidence,  the  gonorrhoea  has  ceased.  Although  a 
fever  does  not  always  cure  a gonorrhoea,  yet,  as  it  may 
do  so,  nothing  should  be  done  while  it  lasts.  If  the 
local  complaint  should  continue  after  the  fever  has 
gone,  it  is  to  be  treated  according  to  symptoms. 

A gonorrhoea  may  be  considerably  affected  by  the 
patient’s  manner  of  living,  and  by  other  diseases  attack- 
ing the  constitution.  Most  things  which  hurry  or  in- 
crease the  circulation  aggravate  the  symptoms  ; such 
as  violent  exercise,  drinking  strong^  liquors,  eating 
strong,  indigestible  food,  some  kinds  of  which  act  speci- 
fically on  the  urethra,  so  as  to  increase  the  symptoms 
more  than  simply  heating  the  body  do ; such  as  pep- 
per, spices  in  general,  and  spirits. 

In  cases  which  have  begun  mildly,  in  which  the  in- 
flammation is  only  slight,  or  in  others,  in  which  the 
violent  symptoms  have  subsided,  such  medicines  as 
have  a tendency  to  lessen  the  discharge  may  be  given, 
together  with  the  local  remedies  before  mentioned. 
Turpentines  are  the  most  efficacious,  particularly  the 
balsam  of  copaiba  and  cubebs. — (See  Edin.  Med.  and 
Surgical  Journ.for  January,  1818,  and  for  the  same 
month,  1819 ; also  H.  Jeffrey's  Pract.  Obs.  on  Cubebs, 
Svo.  Lond.  1821.)  Of  the  latter  medicine  3 ij.  may  be 
given  thrice  in  the  24  hours ; but  with  respect  to  these 
and  all  other  medicines  which  act  upon  the  disease 
through  the  medium  of  the  urine,  if  they  succeed  at  ally 
it  is  always  within  a week  or  ten  daj  s from  the  be- 
ginning of  their  use;  and,  therefore,  if  no  amendment 
take  place  in  this  time,  they  should  not  be  continued, 
Cantharides,  the  salts  of  lead  and  copper,  and  alumy 
have  also  beisn  recommended. 

The  opinions  entertained  by  Mr.  Hunter,  respecting 
the  identity  of  the  infection  of  gonorrhoea,  and  that  of 
the  venereal  disease,  led  him  to  prescribe  small  doses 
of  mercury,  in  consequence  of  the  possibility  of  absorp- 
tion, and  with  the  view  of  preventing  lues  venerea. 

TREATMENT  OF  SOME  OCCASIONAL  EFFECTS  OF 
GONORRHOEA. 

Bleeding  from  the  Urethra  is  sometimes  relieved  by 
the  balsam  copaiba.  Mr.  Hunter  did  not  find  astrin- 
gent injections  of  use. 

Pairiful  Erections  are  greatly  iirevented  by  taking 
twenty  drops  of  tinctura  opii  at  bedtime.  Cicuta  has 
also  .some  power  in  this  way ; and  many  surgeons, 
among  whom  is  Mr.  Dunn,  of  Scarborough,  have  a fa 
vourable  opinion  of  camphorated  poultices,  and  of  the 
internal  exhibition  of  camphor ; a medicine  which  I 
ought  to  have  mentioned  in  former  editions,  as  a 
common  means  of  lessening  the  pain  and  inconvenience 
of  erections  in  the  inflammatory  stage  of  gonorrhoea 

Chordee.  See  this  word. 

Bladder  affected.  Opiate  clysters,  the  warm  bath, 
and  bleeding,  if  the  patient  is  of  full  habit,  are  proper. 
Leeches  may  be  applied  to  the  perinteum.  When  thi» 
affection  lasts  a considerable  time,  and  is  not  mitigated 
by  common  methods,  Mr.  Hunter  advises  trying  ai> 


430 


GONORRHCEA. 


opiate  plaster  on  the  pubes,  or  the  loins,  wher«»the 
nerves  of  the  bladder  originate  ; or  a small  blister  on 
the  perinaeum.  In  another  place  he  mentions  bark,  ci- 
cuta,  sea-air,  and  sea-bathing,  among  the  proper 
means. 

Swelled  Testicles.  See  Hernia  Humor alis. 

For  a more  full  account  of  gonorrhcea,  according  to 
the  above  doctrines,  see  A Treatise  on  the  Venereal 
Disease,  by  John  Hunter,  from  page  29  to  90. 

ON  THE  QUESTION  WHETHER  GONORRHCEA  IS  REALLY 
A FORM  OF  THE  VENEREAL  DISEASE. 

The  foregoing  remarks,  and  others  in  Mr.  Hunter’s 
Work,  would  lead-  one  to  believe,  that  the  poison  of 
gonorrhcea  and  the  venereal  virus  are  the  same.  Here 
it  is  my  duty  impartially  to  state  the  arguments  which 
have  been  urged  for  and  against  this  important  doc- 
trine. 

Mr.  Hunter  assures  us,  that  he  has  seen  all  the 
symptoms  of  lues  venerea  originating  from  gonorrhcea 
only ; that  he  had  even  produced  venereal  chancres  by 
inoculating  with  the  matter  of  gonorrhoea ; and  that  he 
afterward  repeated  these  experiments  in  a manner  in 
which  he  could  not  be  deceived.— (P.  293,  et  seq.) 

Mr.  Hunter’s  experiments,  it  is  true,  have  been  re- 
peated with  a different  result ; but,  a.s  a late  writer  has 
remarked,  can  we  wonder  at  this,  when  we  consider 
from  how  many  causes  gonorrhoea  may  arise,  and  how 
impossible  it  is  to  distinguish  the  venereal  from  any 
other?— (Oft^.  on  Morbid  Poisons,  by  J.  Adams,  M.D. 
p.  91,  ed.  2.) 

Another  argument  adduced  by  Hunter,  in  favour  of 
the  poisons  of  gonorrhoea  and  chancre  being  the  same, 
is  the  probability  that  the  Otaheitans  had  the  venereal 
disease  propagated  to  them  by  European  sailors,  who 
were  affected  with  gonorrhcea ; for  these  can  hardly  be 
supposed  to  have  had  a chancre  during  a voyage  of  five 
months,  without  the  penis  being  destroyed. 

It  is  impossible,  however,  to  say  what  time  may 
elapse  between  the  application  of  (he  venereal  poison  to 
the  penis  and  the  commencement  of  the  ulceration. 
Therefore,  Bougainville’s  sailors,  alluded  to  by  Mr. 
Hunter,  might  have  contracted  the  infection  at  Rio  de 
la  Plata;  but  actual  ulcers  on  the  penis  might  not 
have  formed  till  about  five  months  afterward,  when  the 
ship  arrived  at  Otaheite. 

In  attempting  to  explain  why  a gonorrhcea  and  a 
chancre  do  not  equally  produce  lues  venerea,  and  why 
the  medicine  which  almost  universally  cures  chancre 
has  less  effect  on  gonorrhcea,  a modern  advocate  for 
Mr.  Hunter’s  doctrine  says,  that  we  must  take  into 
consideration,  that  the  seat  of  the  two  diseases  is  dif- 
ferent ; that  the  same  cause  may  produce  different  ef- 
fects upon  different  parts;  that  the  same  poison,  when 
mixed  with  different  fluids,  may  be  more  or  less  vio- 
lent in  its  operation ; and  that  there  may  be  greater  or 
less  attraction  of  certain  fluids  to  a part,  according  to 
its  nature  and  composition. — ( Inquiry  mto  some  Effects 
of  the  Venereal  Poison,  by  S.  Saivrey,  1802,  p,  4.)  Mr. 
Sawrey  very  truly  remarks,  p.  6,  that  if  the  gonor- 
rhceal  matter  has  clearly  and  decidedly  produced  chan- 
cre, or  contaminated  the  system  in  any  one  instance, 
the  question  is  determined.  It  could  in  no  instance 
produce  these  effects,  unless  it  had  the  power  of  doing 
so.  This  writer  brings  forward  some  cases  to  prove, 
that  the  poison  of  gonorrhcea  may  ])roduce  gonorrhcea 
or  chancre ; but  the  limits  of  this  work  only  aflbrd  room 
to  observe  that  these  instances  are  by  no  means  deci- 
sive of  the  point,  because  some  objections  may  be  urged 
against  them,  as  indeed  Mr.  Sawrey  himself  allows. 
1’hat  Mr.  Hunter’s  cases  are  inconclusive,  I have  par- 
ticularly endeavoured  to  explain  in  the  last  edition  of 
the  First  Lines  of  the.  Practice  of  Surgery. 

Why  does  not  gonorrhcea  commonly  produce  ulcer- 
ation in  the  urethra?  Mr.  Sawrey  tries  to  solve  this 
question,  by  saying,  that  the  product  of  the  venereal  in- 
flammation, the  diseased  contents  of  the  small  arteries 
of  the  urethra,  are  thrown  out  of  these  open-mouthed 
vessels  mto  this  canal,  without  any  breach  of  their  tex- 
ture, which  otherwise  would  be  a necessary  conse- 
sequence. 

Why  does  not  gonorrhena  equally  contaminate  the 
system  as  chancre  ? In  gonorrhcea,  says  Mr.  Sawrey, 
the  discharge  is  very  plentiful ; it  is  not,  in  general, 
attended  with  ulceration ; the  poison  is  much  more 
diluted  and  mixed  with  a mucous  and  puriform  fluid. 
It  is  deposited  in  the  urethra  and  its  lacunae,  where 


little  or  no  pressure  is  applied,  and  it  finds  easy  rgfosS' 
out  of  the  canal.  In  chancre,  there  is  breach  of  sub- 
stance, the  poison  is  not  much  diluted,  &c. 

Why  does  not  chancre  generally  in  the  same  person 
produce  gonorrhcea  and  gonorrhcea  chancre?  Mr. 
Sawrey,  in  answer,  expresses  his  belief,  that  these  in- 
cidents are  not  very  unfrequent.  He  says,  he  has 
known  persons  having  a chancre,  which  continued  for 
months,  b^ome  affected  after  that  time  with  a claj), 
without  any  farther  exposure.  His  opinion  is,  that  the 
matter  of  the  chancre  had  insinuated  itself  into  the 
urethra  and  produced  the  disease ; though  he  confesses, 
many  would  explain  the  circumstance  by  supposing 
that  the  chancre  and  gonorrhcea  were  both  communi- 
cated at  the  same  time  by  two  different  poisons. 

Mr.  Hunter  remarks,  that  the  presence  of  one  dis- 
ease renders  the  adjacent  parts  less  susceptible  of  the 
influence  of  the  other. 

Mr.  Sawrey  concludes  his  second  chapter  with  in- 
clining to  the  idea,  that  the  matter  of  gonorrhoea  is  not 
strictly  pus,  but  of  a more  mucous  nature  than  that  of 
a chancre.  However,  when  he  mentions  chemical  at- 
tractions, as  drawing  the  poison  from  mucus  to  the 
urethra,  and  from  pus  to  the  dry  parts,  in  order  to  ex- 
plain thelastofthe  above  questions,  every  sober  reader 
must  feel  sorry  that  a work  which  contains  some  really 
sensible  observations  should  comprehend  this  most 
unfortunate  one. 

Mr.  Whately  also  supported  the  opinion,  that  the 
matter  of  gonorrhcea  and  that  of  chancre  are  the  same. 
— (On  Gonorrhcea  Vimlenta.) 

Another  defender  of  this  side  of  the  question  is  Dr. 
Swediaur,  who  endeavours  to  prove  the  fallacy  of 
the  following  positions:  1.  That  the  poison  which 
produces  the  clap  does  never,  tike  that  of  chancres, 
produce  any  venereal  symptoms  in  the  mass,  or 
lues  itself.  2.  That  the  poison  of  the  clap  never  pro-- 
duces  chancres,  and  that  the  poison  of  chancres  never 
produces  a clap.  3.  That  mercury  never  co7itributes 
to,  nor  accelerates,  the  cure  of  a clap;  but  that,  on  the 
contrary,  every  ble^iorrhagia  may  be  certainly  cured 
without  mercury,  and  without  any  danger  of  leaving  a 
lues  behind. 

His  arguments  run  thus  : — the  reason  why  claps  do 
not,  like  chancres,  constantly  produce  the  lues  is,  that 
most  of  them  excite  only  a superficial  inflammation  in 
the  membrane  of  the  urethra,  without  any  ulceration. 
Hence,  absorption  cannot  easily  take  place,  the  poison 
being  out  of  the  course  of  the  circulation.  But  he  has 
seen  claps  with  an  ulcer  in  the  urethra,  followed  by 
the  most  unequivocal  symptoms  of  lues  itself.  He 
mentions  the  urethra  being  defended  with  a large  quan- 
tity of  mucus,  as  the  thing  impeding  the  common  form- 
ation of  ulcers,  which  do  occasionally  occur  when 
the  mucus  is  not  secreted  as  usual,  or  is  washed  away. 
He  asserts,  that  in  many  cases,  where  he  had  occasion 
to  examine  both  parties,  he  was  convinced  that  the 
chancres  were  communicated  by  a person  affected  with 
a simple  gonorrhoea;  and  vice  versd,  that  a virulent 
clap  had  been  the  consequence  of  an  infection  from  a 
person  having  merely  chancres.  He  says,  that  if  a 
patient  with  a venereal  running  does  not  take  care  to 
keep  the  prejjuce  and  glans  perfectly  clean,  chancres 
will  very  often  be  produced.  He  ov.tis  a great  many 
claps  are  cured  without  mercury ; j et,  repeated  expe- 
rience has  shown  him  a cure  cannot  be  always  thus 
accomplished.  Mild  cases,  without  ulcer  or  excoriation 
in  the  urethra,  may  certainly  be  radically  cured  witl>- 
out  a grain  of  mercury ; and  though  mercury  should 
be  given,  it  would  not  have  the  least  effect ; not  be- 
cause the  disease  does  not  proceed  from  the  venereal 
poison,  but  becau.se  it  is  out  of  the  course  of  the  circu- 
lation. He  contends,  that  the  topical  use  of  mercury 
in  injections  acts  usefully  even  in  these  cases.  But 
when  a clap  is  joined  with  ulceration  in  the  urethra,  it 
is  always  cured  more  safely  and  expeditiously  with 
mercury,  and  is  frequently  incurable  without  it.  A 
lues  also  follows  ca.ses  attended  with  ulcers  in  the  ure- 
thra. He  allows,  that  all  claps  are  not  venereal. — (See 
Tract.  Ohs.  on  Venereal  Complaints,  by  J.  Swidianr.) 

One  argument  urged  against  the  identity  of  gonorrhmal 
ami  chancrous  virus  is,  that  gonorrhoea  was  described 
as  a symptom  till  nearly  half  a century  after  the  other 
symittoins  of  the  venereal  disease  were  known.  Fal- 
lopius is  among  the  first  who  observed  gonorrhoea  a.s 
a symptom  of  the  venereal  disease.  “ If.  however,  ’ 
says  Dr.  Adams,  “ venereal  gonorrhcea  was  unnoticed 


GON 


GRA 


till  about  fifty  years  after  the  other  forms  of  the  dis- 
ease were  described,  what  does  this  prove,  but  that 
contagious  gonorrhoea  was  so  common  as  to  be  disre- 
garded as  a symptom  of  the  new  complaint?  Can 
there  be  a doubt,  from  the  caution  given  by  Moses,  that 
gonorrhma  was  considered  as  contagious  in  his  days  ? 
During  the  classical  age,  we  find  inconveniences  of 
the  urinary  passages  were  imputed  to  incontinence ; 
and  the  police  of  several  states,  before  the  siege  of  Na- 
ples, made  laws  for  preserving  the  health  of  such  as 
would  content  themselves  with  public  stews  instead 
of  disturbing  the  peace  of  families. 

This  is  enough  to  lessen  our  surprise  that  gonorrhoea 
should  be  unnoticed  for  some  time  after  the  appearance 
of  the  venereal  disease.  But  so  far  is  it  from  proving 
that  the  two  contagions  are  different,  that  the  fairest 
inference  we  can  draw  is  in  favour  of  their  identity. 
For  if  by  this  time  the  venereal  disease  began  to  be  so 
far  understood,  that  secondary  symptoms  were  found 
the  consequence  of  primary  ones  in  the  genitals,  it  is 
most  probable,  that  the  first  suspicion  of  venereal  go- 
norrhcea  arose  from  the  occurrence  of  such  secondary 
appearances,  where  no  other  primary  symptoms  could 
be  -{Adams,  on  Morbid  Poisons,  p.  95, 

ed.  2.) 

In  relating  the  arguments  maintained  by  the  best 
modern  writers  to  repel  the  attacks  made  on  the  doc- 
trine that  gonorrhoea  and  chancre  arise  from  the  same 
poison,  we  have  been  compelled  to  disclose  the  chief 
grounds  on  which  the  assailants  venture  to  entertain  a 
contrary  theory. 

The  sentiments  of  Mr.  B.  Bell  are  quite  at  variance 
■with  those  of  Hunter,  Sawrey,  Swediaur,  Adams,  How- 
ship,  &c. ; but  my  limits  •will  only  allow  me  just  to 
enumerate  a few  of  his  leading  arguments. 

If  the  matter  of  gonorrhoea  and  that  of  chancre 
were  of  the  same  nature,  we  must  admit  that  a person 
with  a chancre  only  can  communicate  to  another,  not 
only  every  symptom  of  pox,  but  of  gonorrhoea;  and 
that  another,  with  gonorrhoea  only,  can  give  to  all 
with  whom  he  may  have  connexion,  chancres,  with 
their  various  consequences.  This  ought  indeed  to  be 
a very  frequent  occurrence ; whereas  all  allow  that  it 
is  even  in  appearance  very  rare. 

On  the  supposition  that  the  matter  of  gonorrhoea 
and  lues  venerea  being  the  same,  the  latter  ought  to  be 
a much  more  frequent  occurrence  than  the  former, 
from  the  greater  ease  with  which  the  matter  of  infec- 
tion must,  in  every  instance,  be  applied  to  those  parts 
on  which  it  can  produce  chancres,  than  that  of  the 
urethra,  where,  instead  of  chancre  of  ulceration,  it  al- 
most always  excites  gonorrhoea.  It  is  difficult  to  con- 
ceive how  the  matter,  by  which  the  disease  is  commu- 
nicated, should  find  access  to  the  urethra ; while  all 
the  external  parts  of  the  penis,  particularly  the  glans, 
must  be  easily  and  universally  exposed  to  it ; and  yet 
gonorrhoea  is  a much  more  frequent  disease  than  pox. 
Cases  of  gonorrhoea  are  in  proportion  to  those  of 
chancre,  according  to  Mr.  B.  Bell’s  experience,  as  three 
to  one.  It  is  obvious  that  the  very  reverse  should  hap- 
pen, if  the  two  diseases  were  produced  by  the  same 
kind  of  matter. 

I need  not  adduce  other  arguments,  as  the  reader 
must  be  already  acquainted  with  any  w'orth  knowing, 
from  what  is  said  in  the  previous  part  of  this  article. 

The  grand  practical  consideration  depending  on  the 
possibility  of  the  venereal  disease  arising  from  gonor- 
rhfea  is,  whether  mercurials  should  not  be  exhibited, 
in  all  cases,  with  the  view  of  preventing  such  a conse- 
quence. 

Waving,  on  my  own  jiart,  all  attempts  to  decide  the 
point,  whether  the  matter  of  a chancre  and  that  of  one 
species  of  gonorrhoea  are  of  the  same  nature,  I shall 
merely  content  myself  with  stating,  that,  as  far  as  my 
observation  and  inquiries  extend,  the  majority  of  the  j 
best  practitioners  of  the  present  day  consider  the  exhi- 
bition of  mercury  unnecessary,  and  consequently  im- 
proper, in  all  cases  of  gonorrhtca.  This  fact  almost 
amounts  to  a proof  that,  if  venereal  symptoms  do  ever 
follow  a clap,  they  are  so  rare,  and,  I may  add,  always 
so  imputable  to  other  causes,  that  the  employment  of  | 
mercury,  as  a preventive,  would,  upon  the  whole,  do 
more  injury  than  benefit  to  mankind ; and  this  even 
ailmittiiig  (what  to  my  mind  has  never  been  unequivo- 
cally proved)  that  the  matter  of  gonorrlicea  is  really 
capable,  in  a very  few  instances,  of  giving  ri.se  to  the 
venereal  disease. 


431 

The  reader  must  weigh  the  different  arguments  him- 
self. Some  of  Mr.  B.  Bell’s  reasoning  is  certainly  un- 
tenable, as  Mr.  Sawrey  has  clearly  shown ; but  the 
latter,  also,  is  not  invulnerable  in  many  points,  which 
he  strives  to  defend.  . 

/.  Andrie,  An  Essay  on  the  Theory  and  Cure  of  the 
Venereal  Gonorrhoea,  and  the  Diseases  which  happen 
in  consequence  of  that  Disorder,  8vo.  Land.  1777.  J. 
Nevill,  A Description  of  the  Venereal  Gonorrhoea,  8ro. 
Lond.  1754.  /.  Norman,  Method  of  Curing  the  Viru-‘ 
lent  Stillicidium,  or  Gonorrhoea,  with  an  Account  of 
the  Efficacy  of  Plummer's  Al  terative  Pills,  Svo.  J. 
Clubbe,  An  Essay  on  the  Gonorrhoea  Virulenta,  in 
which  the  different  Opinions  respecting  the  Treatment 
of  the  Disease  are  carefully  examined,  d,  c.  8vo.,  Lond. 
1786.  W.  Thomas,  An  Essay  on  Gonorrhoea,  with 
some  Obs.  on  the  Use  of  Opium  in  the  Cure  of  that 
Disease,  8vo.  Lond.  1780.  A Treatise  on  the  Venereal 
Disease,  by  J.  Hunter,  1788.  W.  Rowley,  The  most  co- 
gent Reasons  why  astringent  Injections,  Src.  should  be 
banished,  £rc.  8vo.  Lond.  1800.  J.  H.  G.  Schlegelf 
Versuch  einer  Geschichte  des  Streites  ilber  die  Iden- 
titdt  des  Venus  und  Tripper  gif tes,  12mo.  Jenoe,  1796. 
Whately  on  the  Gonorrhoea  Virulenta,  8vo.  Lond. 
1801.  Pract.  Obs.  on  Venereal  Complaints,  by  F, 
Swediaur,  M.D.  edit.  3.  An  Inquiry  into  som  e of  the 
Effects  of  the  Venereal  Poison,  by  S.  Sawrey,  1862. 
Obs  on  Morbid  Poisons,  by  J.  Adams,  M.D.  edit.  2, 
1807.  J.  C.  Jacobs,  Demonstration  de  VIdentiU  des 
Virus  de  la  V&ole  et  de  la  Gonorrhee,  8vo.  Bruxelles,- 
1811.  J.  F.  Hernandez,  Essai  Analytique  sur  la 
Non-identite  des  Virus  Gonorrhoique  et  Syphilitique, 
8vn.  Toulon,  1812.  R.  Carmichael,  Essays  on  the  Ve- 
nereal Diseases  which  have  been  confounded  with  Sy- 
philis, «S-c.  4to.  Lond.  1814  ; and  his  Obs,  on  the  Symp- 
toms and  Specific  Distinctions  of  Venereal  Diseases, 
Svv.  Lond.  1818.  John  Howship,  on  Complaints  af- 
fecting the  Secretion  und  Excretion  of  the  Urine,  Svo. 
Lond.  1823. 

GOKGET.  An  instrument  used  in  the  operation  of 
lithotomy,  for  the  purpose  of  cutting  the  prostate  gland 
and  neck  of  the  bladder,  so  as  to  enable  the  operator 
to  introduce  the  forceps  and  extract  the  stone.  It  is, 
in  fact,  a sort  of  knife,  at  the  end  of  w'hich  is  a beak 
that  fits  the  groove  of  the  staff,  and  admits  of  being 
pushed  along  it  into  the  bladder. 

Besides  cutting  gorgets,  constructed  for  the  preced- 
ing design,  there  are  also  blunt  ones,  intended  to  be  in- 
troduced into  the  wound,  where  their  concavity  serves 
as  a guide  for  the  forceps  into  the  bladder. 

GRANULATIONS.  The  little,  grain-like,  fleshy 
bodies,  which  form  on  the  surfaces  of  ulcers  and  sup- 
purating wounds,  and  serve  both  for  filling  up  the  ca- 
vities and  bringing  nearer  together  and  uniting  their 
sides. 

We  must  here  consider  the  operations  of  nature,  in 
bringing  parts  as  nearly  as  possible  to  their  original 
state,  whose  disposition,  action,  and  structure  have 
been  altered  by  accident  or  disease.  Having  formed 
pus,  she  immediately  begins  to  form  new  matter  upon 
surfaces  in  which  there  has  been  a breach  of  conti- 
nuity. This  process  is  called  granulating  or  incar- 
nation; and  the  substance  formed  is  called  granula- 
tions. 

Granulations  are  an  accretion  of  animal  matter  upon 
the  wounded  or  exposed  surface ; they  are  formed  by 
an  exudation  of  the  coagulating  lymph  from  the  vessels  ; 
into  which  new  substance  the  old  vessels  very  pro- 
bably extend,  and  in  ■w'hich  new  ones  are  formed. 
Hence,  granulations  are  extremely  vascular ; indeed,, 
more  so  than  almost  any  other  animal  substance, 
‘‘That  this  is  the  case  (says  Mr.  Hunter)  is  seen  in 
sores  every^  day.  I have  often  been  able  to  trace  the 
growth  and  vascularity  of  this  new  substance.  I have 
j seen  upon  a sore  a white  substance  exactly  similar,  in 
every  visible  respect,  to  coagulating  lymph.  I have 
not  attempted  to  wipe  it  off,  and  the  next  day  of  dress- 
ing I have  found  this  very  substance  vascular ; for,  by 
wiping  or  touching  it  with  a probe,  it  has  bled  freely, 

I have  observed  the  same  appearance  on  the  surface  of 
j a bone  that  has  been  laid  bare.  I once  scraped  off 
some  of  the  external  surface  of  a bone  of  the  foot,  to 
see  if  the  surface  would  granulate.  I remarked,  the 
following  day,  that  the  surfatai  of  the  bone  was  co- 
vered with  a whitish  substance,  having  a tinge  of  blue. 
When  I passed  my  probe  into  it,  I did  not  feel  the 
bone  bare,  but  only  its  resistance.  I conceived  this 


43^ 


GRA 


GUA 


substance  to  be  coagulable  lymph  thrown  out  from  in- 
flammation, and  that  it  would  be  forced  off  when  sup- 
puration came  on  ; but  on  the  succeeding  day  I found 
it  vascular,  and  appearing  like  healthy  granulations.” 
The  vessels  in  granulations  pass  from  the  original 
parts  to  their  basis,  and  thence  towards  their  external 
surface,  in  tolerably  regular  parallel  lines.  The  sur- 
face of  this  new  substance  has  the  same  disposition  to 
secrete  pus  as  the  parts  which  produced  it.  The  sur- 
faces of  granulations  are  very  convex,  the  reverse  of 
ulceration,  having  a great  many  small  points  or  emi- 
nences, so  as  to  appear  rough.  The  smaller  such 
points  are,  the  more  healthy  are  the  granulations.  The 
colour  of  healthy  granulations  is  a deep  florid  red. 
When  livid,  they  are  unhealthy,  and  have  only  a lan- 
guid circulation.  Healthy  granulations,  on  an  exposed 
or  flat  surface,  rise  nearly  even  with  the  surface  of  the 
surrounding  skin,  and  often  a little  higher ; but  when 
they  exceed  this,  and  take  on  a growing  disposition, 
they  are  unhealthy,  become  soft,  spongy,  and  without 
any  disposition  to  form  skin.  Healthy  granulations 
are  always  prone  to  unite  to  each  other,  so  as  to  be  the 
metins  of  uniting  parts. 

Granulations  are  not  easily  formed  on  the  side  of  an 
abscess  nearest  the  surface  of  the  body. 

They  are  not  endowed  with  the  same  powers  as 
parts  originally  formed.  Hence  they  more  readily  ul- 
cerate and  mortify.  The  curious  mode  in  which  gra- 
nulations contract  when  sores  are  healing,  and  even 
for  some  time  after  they  are  healed,  has  been  explained  in 
the  article  Cicatrization. — (See  A Treatise  on  the  Blood, 
Inflammation,  ^c.  by  John  Hunter, y.  473,  etseq.  1794.) 

It  is  a question  whether  granulations  can  ever  be 
formed  without  suppuration  I Mr.  Hunter  seems  in- 
clined to  think  that  they  may  occasionally  be  produced 
without  it,  and  he  supports  his  opinion  by  the  relation 
of  the  dissection  of  a fractured  limb,  in  which  he  ob- 
served a substance  resembling  granulations.  Dr. 
John  Thomson,  on  the  other  hand,  declares  that  he  has 
never  seen  any  thing  which  he  could  regard  as  an.  ex- 
ample of  a granulation,  and  still  less  of  a granulating 
surface,  where  pus  was  not  formed. — (See  Lectures  on 
Inflammation,  p.  408.) 

The  exact  process  by  which  the  blood-vessels,  nerves, 
and  absorbents  of  granulations  are  formed,  is  still 
among  the  secrets  of  nature.  The  observations  of  Mr. 
Hunter  on  the  subject  amount  only  to  conjecture. 
“The  growth  of  nerves  and  their  developement  in 
new-formed  flesh  or  granulations  (says  Dr.  J.  Thom- 
son), is  a subject  of  equal  curiosity  with  the  growth 
of  blood-vessels  in  the  same  structure.  Their  exist- 
ence in  granulations  is  proved  by  the  pain  which  is  felt 
on  our  pinching,  rubbing,  or  wiping,  the  surface  of  a 
sore.  Even  the  granulations  which  arise  from  the 
surface  of  bone  are  sensible  (a  statement  not  admit- 
ted by  Sir  Astley  Cooper),  though  we  are  not  very 
well  able  to  prove  the  sensibility  of  the  larger  branches 
of  nerves,  from  which  the  newly  formed  and  sensible 
nerves  and  filaments  in  the  granulation  are  imme- 
diately derived.  All  the  difficulties  which  I formerly 
mentioned  to  you,  as  occurring  in  the  explanation  of 
the  manner  in  which  coagulable  Ijunph  or  granulations 
are  penetrated  with  blood-vessels,  present  themselves 
the  moment  w^e  begin  to  reflect  on  the  manner  in 
which  the  same  granulations  are  provided  wth  nerves ; 
and  these  difficulties  are  still  increased,  when  we  re- 
flect that  the  same  granulations  are  in  the  course  of  a 
few  hours  provided,  not  only  with  blood-vessels  and 
nerves,  but  also  with  a system  of  absorbents.  The 
existence  of  absorbents  in  granulations  is  proved  not 
only  by  the  changes  of  hulk  which  we  see  them  daily 
undergo,  becoming  gradually,  in  the  healthy  state, 
smaller,  firmer,  and  more  compact,  but  also,  by  the 
frequent  disappearance  in  whole  or  in  part  of  a granu- 
lating surface  by  the  process  of  ulcerative  absorption.” 
— (See  Thomson’s  Lectures  on  Inflammation,  p.  419.) 
According  to  Sir  Astley  Cooper,  granulations  which 
spring  from  parts  endued  with  great  sensibility,  like 
muscles,  are  extremely  sensitive;  but  granulations 
which  arise  from  bones,  he  says,  have  no  sensibility 
whatever.  These  observations  are  qualified  with  the 
condition  that  the  bone  be  uninflamcd,  and  it  is  ac- 
knowledged, that  granulations  arising  from  the  cancel- 
lated structure  of  bones  are  sometimes  extremely  sen- 
sitive. He  describes  granulations  from  tendons  as 
quite  insensible,  and  those  ffom  aponeuro.ses  and  fascia; 
as  jwssessing  very  little  sensibility. — (,See  Lancet,  vol 


1,  p.  22.3.)  Every  young  dresser  of  sores  at  an  hospital 
who  has  been  too  lavish  of  the  red  precipitate  oint- 
ment, must  have  learned  from  experience,  that  granula- 
tions are  furnished  with  absorbent  vessels,  and  that 
mercu^  may  be  absorbed  from  the  surface  of  ulcers, 
and  bring  on  an  unwished-for  salivation  of  the  patient. 
It  is  observed  by  Sir  Astley  C(»oper,  that  in  recently 
formed  ulcers,  the  granulations  are  not  good  absorbent 
surfaces;  but  that  when  the  sores  have  existed  a good 
■while,  they  readily  take  into  the  system  any  substance 
which  may  be  applied  to  them.  Thus,  when  old  si- 
nuses are  injected  with  a solution  of  the  oxymuriate 
of  mercury,  with  the  view  of  stimulating  them  to  heal, 
the  patients  are  sometimes  salivated  by  the  mercury 
being  absorbed  into  the  system.  Sir  Astley  has  seen 
the  same  effect  produced  by  the  ajjplication  of  the  lo- 
tion of  lime-water  and  the  submuriate  of  mercury  to 
the  surface  of  ulcers.  Indeed,  the  absorbent  power  of 
granulations  is  frequently  the  means  of  producing 
baneful  effects  upon  the  constitution,  by  the  introduc- 
tion of  deleterious  substances  into  the  circulation. 
Thus  arsenic,  applied  to  sores,  is  often  conveyed  into 
the  system,  and,  on  this  account,  is  to  be  regarded  as  a 
dangerous  external  remedy.  Sir  Astley  Cooper  quotes 
one  instance,  in  which  the  patient  seems  to  have  been 
poisoned  by  the  indiscriminate  application  of  arsenic 
to  a fungus  of  the  eye.  Opium,  also,  when  applied  to 
the  surfaces  of  sores,  is  very  readily  absorbed,  produc- 
ing similar  effects  to  those  which  arise  from  its  intro- 
duction into  the  stomach.  Thus,  when  the  quantity 
absorbed  is  too  great,  excessive  costiveness,  extreme 
pain  in  the  head,  and  torpor  of  the  system,  are  the  con- 
sequences, which  require  the  frequent  administration 
of  active  purgatives  for  their  removal. — (See  Lancet, 
vol.  1,  p.  219,  £,-c.)  A temporary  amaurosis  has  been 
known  to  be  produced  by  the  absorption  of  the  extract 
of  belladonna  from  the  surface  of  irritable  malignant  ul- 
cers.—(F.  Tt/rrelZ;  A.  Cooper's  Lectures,  vol.  l,p.  169.) 

GUAIACUM.  Many  writers  of  the  sixteenth  cen- 
tury contended  that  guaiacum  was  a true  specific  for 
the  venereal  disease ; and  the  celebrated  Boerhaave, 
in  the  eighteenth,  maintained  the  same  opinion.  Mr. 
Pearson  mentions,  that  when  he  tvas  first  intrusted 
with  the  care  of  the  /.ock  Hospital,  in  1781,  Mr  Brom- 
field  and  Mr.  Williams  were  in  the  habit  of  reposing 
great  confidence  in  the  efficacy  of  a decoction  of  guaia- 
cum wood.  This  was  administered  to  such  patients  as 
had  already  employed  the  usual  quantity  of  mercury  ; 
but  w'ho  complained  of  nocturnal  pains,  or  had  gum- 
mata,  nodes,  ozaena,  and  such  other  effects  of  the  vene- 
real virus,  connected  with  secondary  symptoms,  as  did 
not  yield  to  a course  of  mercurial  frictions.  The  diet 
consisted  of  raisins  and  hard  biscuit ; from  two  to  four 
pints  of  the  decoction  were  taken  every  day ; the  hot 
bath  was  used  twice  a week ; and  a dose  of  antimonial 
wine  and  laudanum,  or  Dover’s  powder,  was  com- 
monly taken  every  evening.  Constant  confinement  to 
bed  was  not  deemed  necessary  ; neither  was  exposure 
to  the  vapour  of  burning  spirit,  with  a view  of  exciting 
perspiration,  often  practised ; as  only  a moist  state  of 
the  skin  wa.s  desired.  This  treatment  was,  sometimes, 
of  singular  advantage  to  those  whose  health  had  sus- 
tained injury  from  the  disease,  long  confinement,  and 
mercury.  The  strength  increased;  bad  ulcers  healed ; 
exfoliations  were  completed ; and  these  anomalous 
symptoms,  which  would  have  been  exasperated  by 
mercury,  soon  yielded  to  guaiacum. 

Besides  such  cases,  in  which  the  good  effects  of  guai- 
acum caused  it  to  be  erroneously  regarded  as  a specific 
Ibr  the  lues  venerea,  the  medicine  was  also  formerly 
given  by  some,  on  the  first  attack  of  the  venereM 
disease.  The  disorder  being  thus  benefited,  a radical 
cure  was  considered  to  be  accomplished  ; and,  though 
frequent  relapses  followed,  yet,  as  these  partly  yielded 
to  the  same  remedy,  its  reputation  was  still  kept  up. 
Many  diseases  also,  w'hich  got  well,  were  probably  not 
really  venereal  cases.  Mr.  Pearson  seems  to  allow, 
that,  in  syphilitic  affections,  it  may,  indeed,  operate 
like  a true  antidote,  suspending,  for  a time,  the  progress 
of  certain  venereal  symi)toms,  and  removing  other  ap- 
pearances altogether ; but  he  observes,  that  experience 
lias  evinced  that  the  unsubdued  virus  yet  remains  active 
in  the  constitution. 

Mr.  Pearson  found  guaiacum  of  little  use  in  pains  of 
the  bones,  except  when  it  proved  sudorific  ; but  that  it 
was  then  inferior  to  antimonv  or  ammonia.  When 
the  constitution  has  been  impaired  by  mercurv-and  long 


SUH 


GUN 


433 


confinement,  a thickened  state  of  the  ligaments,  or  pe- 
riosteum, or  foul  ulcers,  still  remaining,  Mr.  Pearson 
says,  these  effects  will  often  subside  during  the  e.xhi- 
bition  of  the  decoction.  lie  says  it  will  often  suspend, 
for  a short  time,  the  progress  of  certain  secondary 
symptoms  of  the  lues  venerea  ; for  instance,  ulcers  of 
■(’ie  tonsils,  venereal  eruptions,  and  even  nodes.  Mr. 
P''arson,  however,  never  knew  one  instance,  in  which 
guaiacum  eradicated  the  virus ; and  he  contends,  that 
its  being  conjoined  with  mercury  neither  increases  the 
virtue  of  this  mineral,  lessens  its  bad  effects,-  nor  dimi- 
nishes the  necessity  of  giving  a certain  quantity  of  it. 
He  has  seen  guaiacum  produce  good  effects  in  cutaneous 
diseases,  the  ozsua,  and  scrofulous  affections  of  the 
membranes  and  ligaments. — (See  Pearson  on  the  Effects 
of  Various  Articles  in  the  Cure  of  Lues  Venerea,  edit. 
2,  1S07.)  Many  of  the  foregoing  observations  on  the 
virtues  of  guaiacum  in  syphilis  are  considerably  af- 
fected by  the  fact,  now  so  completely  established,  that 
this  disease  is  generally  capable,  in  the  end,  of  a spon- 
taneous and  lasting  cure.— ^See  Vejiereal  Disease.) 

GUMMA.  A soft  tumour,  so  named  from  the  resem- 
blance of  its  contents  to  gum. 

GUN-SHOT  WOUNDS  receive  their  name  from  the 
manner  in  which  they  are  produced,  being  generally 
caused  by  hard,  obtuse,  metallic  bodies,  projected  from 
cannons,  muskets,  or  some  other  species  of  firearm. 
With  such  injuries,  it  is  also  usual  to  comprehend  a 
variety  of  dreadful  accidents  arising  from  the  explosion 
of  shells,  or  the  violence  with  which  pieces  of  stones 
from  ramparts,  or  splinters  of  wood  on  board  of  ship, 
are  driven  about.  Gun-shot  wounds  are  the  most  con- 
siderable of  the  contused  kind ; and  what  is  to  be  said 
of  them  will  apply,  more  or  less,  to  all  contused 
wounds,  according  to  the  degree  of  contusion.  They 
are  particularly  characterized  by  what  the  French  sur- 
geons are  fond  of  calling  a disorganization,  of  their 
surface.  The  excessive  contusion  and  violence  ob- 
servable in  gun-shot  wounds  depend  upon  the  rapidity 
with  which  the  bodies  occasioning  them  are  propelled. 
The  parts  touched  by  the  ball  are  frequently  converted 
into  a blackish  slougli,  the  colour  of  which  made  our 
ancestors  suppose,  that  bodies  projected  by  gunpowder 
became  heated,  and  actually  bunted  the  flesh  with  which 
they  came  into  contact.  But  reason  and  experience 
have  now  proved,  that  whatever  may  be  the  rapidity 
of  a projectile,  it  never  acquires  in  its  jiassage  any  per- 
ceptible heat.  Indeed,  a modern  wTiter  asserts,  that 
such  a degree  of  heat  as  would  be  requisite  to  make  a 
ball  burn  parts  in  its  passage,  would  really  melt  it. 
—(Rickerand,  Nosographie  Chir.  t.  1,  p.  217,  edit.  2.) 
In  general,  gun-shot  wounds  do  not  bleed  much,  unless 
large  blood-vessels  be  injured ; their  circumference  is 
often  livid  ; and  the  shock  that  attends  their  infliction, 
or  the  injury  done  to  the  nerves,  may  occasion  in  the 
limb  or  part  a kind  of  toqtor,  sometimes  extending 
itself  to  the  whole  system. 

How^ever,  as  Dr.  Hennen  most  truly  observes,  “ the 
effects  of  a gun-shot  w'ound  differ  so  materially  in  dif- 
ferent men,  and  the  appearances  are  so  various,  ac- 
cord'ug  to  the  nature  of  the  part  wounded,  and  the 
greater  or  less  force  with  which  it  has  been  struck, 
that  no  invariable  train  of  symptoms  can  be  laid  down 
as  its  necessary  concomitants.  If  a musket  or  pistol- 
ball  has  struck  a fleshy  part,  without  injuring  any  ma- 
terial blood-vessel,  we  see  a hole  about  the  size  of,  or 
smaller  than,  the  bullet  itself,  with  a more  or  less  dis- 
coloured lip,  forced  inwards ; and  if  it  has  passed 
through  the  parts,  we  find  an  everted  edge,  and  a more 
ragged  and  larger  orifice  at  the  point  of  its  exit.  The 
hemorrhage  is  in  this  ca.se  very  slight,  and  the  pain  in- 
considerable, insomuch  that,  in  many  instances,  the 
wounded  man  is  not  aware  of  his  having  received  any 
injury.  If,  however,  the  ball  has  torn  a large  vessel,  or 
nerve,  the  hemorrhage  will  generally  be  profuse,  or  the 
jiain  of  the  wound  severe,  and  the  power  of  the  part 
lost.  Some  men  will  have  a limb  carried  off  or  shat- 
tered to  pieces  by  a cannon-ball,  without  exhibiting  the 
sliglite.st  symptoms  of -mental  or  corporeal  agitation; 
tiay,  even  without  being  conscious  of  the  occurrence  ; 
and  when  they  are,  they  will  coolly  argue  on  the  pro- 
bable result  of  the  injury ; while  a deadly  paleness, 
instant  vomiting,  profuse  per.«piration,  and  universal 
tremor  will  seize  another  on  the  receipt  of  a slight 
fh'.sh  wound.  This  tremor,  which  has  been  so  much 
talked  of,  and  wdiit  h tp  an  inexperienced  eye  is  really 
terrifying,  is  soon  relieved  bv  a mouthful  of  wine  or 
Vox-  I.-E  e 


spirits,  or  by  an  opiate ; but  above  all  by  the  tenderness 
and  sympathizing  manner  of  the  surgeon,  and  his  as- 
surance of  the  patient’s  safety.”— (Principles  of  Mil. 
Surgery,  p.  33,  ed.  2.) 

On  the  other  hand,  it  is  correctly  noticed-  by  Mr. 
Guthrie,  tliat  the  'continuance  of  the  constitutional 
alarm  or  shock'  ought  to  excite  great  suspicion  of  .se- 
rious injury  ; and  when  wounds  have  been  received  in 
such  situal'ions,  or  bear  such  appearances,  as  render  it 
doubtful  whether  any  parts  of  vital  importance  have 
been  injured  or  not,  the  manner  in  which  the  constitu- 
tional perturbation  lasts  may  be  as.sumed  as  evidence 
of  the  fact,  when  other  symptoms  more  indicative  of 
the  injury  are  wanting ; and  under  all  such  circum- 
stances, a very  cautious  prognosis  should  be  delivered. 
— (On  Gun-shot  Wounds,  p.  11,  ed.  2.) 

Respecting  the  general  character  of  gun-shot  wounds 
not  to  bleed  much  unless  large  vessels  be  injured,  it  is 
a fact  which  necessarily  depends  upon  the  degree  of 
contusion  usually  attending  these  injuries.  But  it  is 
also  true,  as  the  preceding  author  has  stated,  that  al- 
though some  gun-shot  wounds  bleed  but  little  at  first, 
there  is  in  the  greater  number  of  cases  more  or  less  of 
blood ; and  in  wounds  of  vascular  parts,  like  the  face 
and  neck,  the  quantity  lost  is  often  considerable,  though 
the  main  arterial  branches  may  not  be  injured. — (Op. 
cit.p.  6,  ed.  2.) 

In  gun-shot  wmunds,  another  circumstance  is  ob- 
served, which  is  often  remarked  in  other  cases,  viz. 
when  a large  artery  is  partially  divided,  the  bleeding  is 
more  profuse  and  dangerous  than  when  the  vessel  is 
completely  severed,  and  the  hemorrhage,  if  not  re- 
pressed by  a tourniquet,  or  other  means,  wdll  often 
continue  until  the  patient  dies.  Thus,  Mr.  Guthrie 
speaks  of  three  cases  in  which  life  was  lost  from  wounds 
of  the  femoral,  humeral,  and  c.arotid  arteries,  no  e(- 
fectual  means  of  stopping  the  hemorrhage  having  been 
adopted.-^(P.  8.)  • 

Until  Ambrose  Pare  introduced  more  correct  theories 
upon  the  subject  of  gun-shot  wounds,  ideas  the  most 
false,  and  errors  highly  prejudicial,  prevailed  both  in 
their  history  and  treatment,  and  particularly  respecting 
what  have  been  falsely  named  wind-contusions.  Can- 
non-balls and  bullets  Sometimes  produce  dreadful  de- 
grees-of  injury,  without  occasioning  any  breach  of  conti- 
nuity in  the  integuments.  This  observation  is  so  strictly 
true,  that  the  muscles  and  bones  may  actually  be  crushed 
and  broken  to  atoms,  without  the  skin  being  at  all  wound 
ed.  Such  cases  were  for  a long  while  imputed  to  the  vio- 
lent motion  supposed  to  be  communicated  to  the  air  by 
the  ball  itself.  It  was  imagined,  that  this  elastic  fluid, 
being  rapidly  displaced  by  the  shock  of  the  projectile, 
was  capable  of  making  such  pressure  on  surrounding 
bodies,  as  to  destroy  their  texture.  But  how  could  this 
violent  pressure  originate  in  the  midst  of  the  open  and 
unbounded  air  ? If  this  theory  were  true,  the  effect  in 
question  would  constantly  happen,  whenever  a ball 
passes  near  any  part  of  the  body.  The  contrary,  how 
ever,  is  so  much  the  case,  that  pieces  of  soldiers’  and 
seamen’s  hats,  of  their  feathers,  clothes,  and  even  hair, 
are  shot  away  in  everj"  battle,  without  any  other  mis- 
chief being  done. 

In  consequence  of  the  manner  in  which  such  inju- 
ries of  the  soft  parts,  and  even  of  the  bones,  unatteuded 
with  any  breach  in  the  skin,  have  been  supposed  to  be 
produced,  they  have  been  erroneously  termed  wind- 
contusions.  In  fact,  these  cases  are  now  universally 
acknowledged  by  all  the  most  accurate  observers  never 
to  proceed  from  the  cause  to  which  formerly  they  were 
■always  ascribed. 

The  air  does  not  move  with  the  same  rapidity  as  tlie 
ball ; but  its  motion  is  less  in  proportion  as  it  is  a more 
subtile  matter,  and  must  be  too  feeble  to  ai'count  for 
such  a violent  degree  of  injury.  The  air  to  which  the 
ball  must  really  communicate  the  greatest  motion  is 
what  is  directly  before  it;  and  this  never  bruises  the 
part  untouched  by  the  ball  itself.  It  is  only  the  air  si- 
tuated laterally  to  the  shot  that  is  imaginiMl  to  do  in- 
jury, and  it  cannot  be  greatly  agitated.  The  violent 
consequences  of  sudden  exi)losions,  and  the  effects  pro- 
duced on  the  organ  of  hearing  by  strong  commotions 
of  the  air,  prove  nothing  relative  to  the  point  in  ques- 
tion. I-.astly,  experience  does  not  confirm  the  reality 
of  such  wind-contusions;  for  cannon-bails  often  tear 
off  whole  members,  without  the  adjacent  parts  being 
in. the  least  injured. — (Sec  Lc  Vucher,  in  Mmioires  de 
VAcad.  dc  Chir.  t.  4,  p.  22.) 


434 


GUX-SHOT  VVOUxNDS. 


All  eminent  professor,  who  visited  the  continent  for 
the  purpose  of  seeing  tiie  wounded  after  the  battle  of 
Waterloo,  fully  coincides  with  M.  le  Vacher  and  all  the 
moderns  upon  this  subject.  “We  saw,  and  were  in- 
formed of  many  instances  in  which  cannon-balls  had 
ptissed  quite  close  to  all  the  parts  of  the  body,  and  had  re- 
moved portions  of  the  clothes  and  accoutrements,  with- 
out producing  the  slightest  injury  of  any  kind.  In 
other  instances,  portions  of  the  body  itself  were  re- 
moved by  cannon-balls,  without  the  contiguous  parts 
having  been  much  injured.  In  one  case,  the  point  of 
the  nose  w£is  carried  off  by  a cannon-ball  without  re- 
spiration being  at  all  affected ; and  in  another  very  re- 
markable case,  the  e.xternal  part  of  the  ear  was  shot 
away,  without  even  the  power  of  hearing  being  sensi- 
bly irnpaired.”— (See  Report  of  ObservatioTis  made  in 
the  British  Military  Hospitals  in  Belgium,  ij-c.  by  J. 
Thomson,  p.  33,  Edin.  1816.) 

I could  cite  many  ca.ses,  which  I have  seen  myself, 
in  proof  of  the  truth  of  Le  Vacher’s  opinions ; but  the 
point  is  now  so  universally  admitted,  that  I shall  merely 
add  one  observation  that  occurred  to  the  notice  of  many 
as  well  as  myself.  At  the  bombardment  of  the  French 
fleet  in  the  basin  of  Antwerp  early  in  1814,  a cannon- 
shot  shattered  the  legs  of  two  officers  so  badly,  that 
the  limbs  were  amputated.  These  gentlemen  were 
walking  at  the  moment  of  the  accident  in  the  \111age 
of  Merksam,  taking  hold  of  the  arm  of  my  friend  As- 
sistant-surgeon Stobo,  of  the  37th  regiment,  who  was 
in  the  middle.  Now  the  ball  which  produced  the  injury 
did  not  the  slightest  harm  to  the  latter  gentleman,  al- 
though it  must  have  passed  as  close  as  possible  to 
his  lower  extremities,  and  most  probably  between 
them. 

Neither  can  what  have  been  improperly  called  u-ind- 
contusions  be  attributed  to  an  electrical  shock  on  the 
parts,  in  consequence  of  the  ball  being  rendered  electrical 
by  friction  in  the  caliber  of  the  gun,  and  giving  off  the 
electricity  as  it  passes  by  (Vide  Plenck's  Sammlun- 
gen,  1 theii,  p.  99);  for  metals  never  aciiuire  this  pro- 
perty from  friction. 

The  mischief  imputed  to  the  air  is  occasioned  by  the 
ball  itself.  Its  producing  a violent  contusion,  without 
tearing  the  skin  and  entering  the  limb,  is  to  be  ascribed 
to  the  oblique  direction  in  which  it  strikes  the  part,  or, 
in  other  instances,  to  the  feebleness  with  which  the 
ball  strikes  the  surface  of  the  body,  in  consequence  of 
its  having  lost  the  greater  part  of  its  momentum,  and 
acting  principally  by  its  weight,  being,  in  short,  what 
is  called  a spent  ball.  Daily  observation  evinces  tha» 
balls,  wliich  strike  a surface  obliquely,  do  not  penetrate, 
but  are  reflected ; though  they  may  be  impelled  with 
the  greatest  force,  and  the  body  struck  may  be  as  soft 
and  yielding  as  water.  This  alteration  in  the  course 
of  the  ball,  not  only  happens  on  the  surface  of  the  hu- 
man body,  but  also  in  the  substance  of  a limb  which 
it  has  entered.  Thus,  a bone,  a tendon,  &c.  may 
change  the  direction  of  a ball  w hich  touches  them  at 
all  obliquely.  Hence,  it  is  manifest,  how  it  happens 
that  the  track  of  a gun-shot  wound  is  not  ahvays 
straight,  and  how  balls  sometimes  run  under  the  inte- 
guments nearly  all  round  the  body  or  limb. 

The  causes  of  several  of  the  peculiarities,  attending 
gun-shot  wounds,  are  to  be  sought  among  the  laws  by 
wldch  moving  bodies  are  governed,  and  by  which  the 
mechanical  effect  of  a ball,  projielled  against  any  part 
of  the  body,  must  therefore  be  determined.  The  form, 
the  momentum,  and  the  direction  of  the  shot  that  is  re- 
ceived; the  position,  and  the  variety  of  structure,  or, 
in  other  words,  the  variety  of  density  and  powers  of 
resistance,  in  the  part  receiving  it,  must  always  be  con- 
sidered, in  order  to  account  satisfactorily  for  the  effects 
which  it  produces.  And  though,  says  Mr.  Chevalier, 
in  many  cases,  a mathematical  explication  of  the  course 
of  the  ball  cannot  be  given,  this  arises  entirety  from 
the  want  of  data,  the  laws  of  matter  being  fi.xed  and 
immutable.  But  wffien  the  data  are  known,  as,  for  in- 
stance, the  velocity  and  direction  of  the  shot,  the  posi- 
tion of  the  patient,  or  of  the  wounded  part  at  the  time 
of  the  accident,  and  the  structure  of  the  parts  pene- 
trated, a much  more  probable  conjecture  of  the  course 
of  the  ball  may  generally  be  formed,  than  if  these  cir- 
cumstances had  not  been  regarded. 

On  the  principle  of  the  density  and  resistance  of 
parts,  attempts  have  been  made  to  exjilain  the  reason 
of  the  concussion  or  shock  wffiich  is  givfn,  in  many  i 
instances,  to  the  whole  system  by  giui-shol  wounds,  j 


and  which  is  represented,  by  writers  on  this  subject, 
to  be  often  attended  with  grave  and  even  alarming  ef- 
fects, extending,  not  only  over  the  injured  part,  but  af- 
fectmg  the  system  at  large.  Thus,  a shot  striking 
against  a tendon  or  a bone,  in  one  of  the  extremities, 
will  produce  a greater  concussion  than  if  it  struck  only 
against  softer  parts.  A shot  striking  a muscle  in  action 
will  produce  more  concussion  than  if  it  struck  against 
the  same  part  of  the  same  muscle  at  rest ; and  a shot 
striking  the  head  or  wounding  the  liver,  lungs,  or  in- 
testinal canal,  will  generally  bring  on  instantaneous 
derangement  of  the  whole  system,  with  which  the 
fmictions  of  these  parts  are  so  closely  connected. — (T. 
Chevalier  on  Gun-shot  Wounds,  part  1,  sect.  7.) 

Respecting  the  mechanical  effects  of  the  concussion, 
I am  disposed  to  think,  with  Mr.  Guthrie,  that  they  have 
been  rather  exaggerated,  and  that  in  reality  a more  ac- 
curate explanation  of  the  disorder  of  the  system  might 
be  derived  from  other  considerations ; “ A shot  through 
the  lungs  (says  he)  will  cause  an  instantaneous  de- 
rangement of  the  whole  system,  but  the  resistance 
afforded  by  the  part  has  little  to  do  with  it ; it  is  the 
lesion  of  the  organic  functions,  intimately  connected 
with  life,  that  is  the  cause  of  the  derangement.  In  the 
same  manner,  I do  not  conceive,  that  the  general  affec- 
tion of  the  system  depends  alone  on  the  shock  received, 
but  on  the  effect  the  injury  committed  has  on  the  ner- 
vous system.” — (On  Gun-shot  Wounds,  p.  26,  ed.  2.) 

A ball,  when  it  strikes  a part  of  the  body,  may  cause 
four  kinds  of  injurj".  1.  It  may  only  occasion  a contu- 
sion, without  penetrating  the  part,  on  account  of  its 
being  too  much  spent,  or  of  the  oblique  way  in  which  it 
strikes  the  surface  of  the  body.  2.  It  may  enter  and 
lodge  in  the  substance  of  a part ; in  which  case  the 
wound  has  only  one  aperture.  3.  It  may  pierce  through 
and  through;  and  then  there  are  tw'o  openings,  one  at 
the  entrance,  the  other  at  the  exit  of  the  ball.  The  cir- 
cumference of  the  aperture,  where  the  shot  entered,  is 
usually  depressed  ; that  of  the  opening,  from  which  it 
came  out,  elevated.  At  the  entrance,  there  is  com- 
monly more  contusion,  than  at  the  exit  of  the  ball. 
The  former  opening  is  generally  narrower ; the  latter 
wider  and  more  irregular,  especially  when  the  round 
smooth  figure  of  the  ball  has  been  changed  by  its  having 
struck  a bone.  4.  A cannon-ball  may  tear  off  a whole 
limb. — (Richter,  Anfangsgr.  der  Wundarzn.  b.  I.) 

Gun-shot  wounds  differ  very  much,  according  to  the 
kind  of  body  projected,  its  velocity,  and  the  nature  and 
peculiarities  of  the  parts  injured.  The  projected  bodies 
are  mostly  bullets,  sometimes  cannon-balls,  sometimes 
pieces  of  broken  shells,  and  very  often,  on  board  of 
ship,  splinters  of  wood.  On  account  of  the  contusion 
w hich  the  parts  suffer,  from  the  violent  passage  of  the 
nail  through  them,  there  is  most  commonly  a part  of 
the  solids  surrounding  the  wound  deadened,  which  is 
afterward  thrown  Off  in  the  form  of  a slough,  gene- 
rally preventing  such  wounds  fronri  healing  by  the  first 
intention,  and  making  most  of  them  necessarily  sup- 
purate. This  does  not  take  place  equally  in  every 
gun-shot  wound,  not  in  every  part  of  the  same  wound ; 
and  the  difference  commonly  arises  from  the  variety 
in  the  velocity  of  the  body  projected  ; for  where  the  ball 
has  passed  with  little  velocity,  which  is  sometimes  the 
case  at  its  entrance,  but  still  more  frequently  at  the  part 
last  wounded,  the  injury  may  often  be  healed  by  the 
first  intention.— <7.  Hunter,  p.  523.) 

Until  I had  the  pleasure  of  reading  the  last  edition 
of  a valuable  book  on  gun-shot  wounds,  I did  not  know 
that,  at  the  present  day,  any  surgeons  entertained  the 
idea,  that  the  whole  track  of  every  gun-shot  wound 
must  unavoidably  suppurate  and  slough  (Guthrie  on 
Gun-shot  Wourids,  p.  62,  ed.  2);  but  if  this  sentiment 
prevail,  it  is  plain  from  the  preceding  statement,  that 
the  authority  of  Mr.  Hunter  cannot  be  adduced  in  its 
support.  At  the  same  time,  I believe,  that  few'  army 
surgeons  will  be  inclined  to  question  the  correctness 
of  Mr.  Hunter’s  account  of  the  general  occurrence  of 
a degree  of  sloughing,  or  of  the  deadened  state  of  a 
part  of  the  surface  of  a wound,  particularly  in  the 
vicinity  of  the  entrance  of  the  ball  or  the  truth  of  hie 
observations  about  tha  common  necessity  of  the  se- 
paration of  such  slough  before  the  parts  w ill  heal ; 
and  whether  the  dead  parts  be  thrown  oft'  in  small 
fragments  with  the  matter,  or  larger  jiortions,  the  fact 
is  still  correct. 

I Foreign  bodies  more  frequently  lodge  in  gun-shot 

j wounds  than  aiiy  others,  and  are  commonl}  of  three 


GlJiN-SHOT  WOUNDS. 


435 


kinds.  1.  Pieces  of  clothing  or  other  things  which 
the  ball  forced  before  it  into  the  limb.  2.  The  ball  it- 
self. 3.  Loose  splinters  of  bone.  It  is  only  when  the 
ball  strikes  the  naked  flesh,  touches  no  bone,  and  goes 
quite  through  the  part,  that  the  wound  can  be  free 
from  e.xtraneous  matter.  Foreign  bodies  are  the  cause 
of  numerous  unfavourable  symptoms,  by  irritating 
sensible  parts,  and  exciting  pain,  inflammation,  con- 
vulsions, hemorrhage,  long  suppurations,  &c. ; and 
the  more  uneven,  pointed,  and  hard  they  are,  the  more 
likely  they  are  to  produce  these  evils.  Hence  spiculte 
of  bone  are  always  the  most  to  be  dreaded. — (Richter.) 

The  great  obliquity  and  length  of  the  fissures  pro- 
duced in  the  cylindrical  bones  by  musket-balls,  are 
such  as  are  not  remarked  in  any  common  cases  of  frac- 
ture. When  I was  with  the  army  in  Holland,  in  the 
year  1814,  I had  in  my  hospital  at  Oudenbosch  several 
fatal  compound  fractures  of  the  thigh,  caused  by  gun- 
shot violence.  The  fissures  in  some  of  these  exam- 
ples were  found  to  extend  two-thirds  of  the  length  of 
the  bone.  This  fact  is  noticed  by  Mr.  Guthrie  ; “ The 
fractures  extend  far  above  and  below  the  immediate 
part  struck  by  the  ball,  and,  as  far  as  depends  upon 
my  information  from  the  examination  of  limbs  that 
were  amputated,  farther  downwards  than  upwards ; 
so  that,  from  a fracture  in  the  middle  of  the  thigh,  I 
have  often  seen  fissures  extend  into  the  condyles,  and 
cause  ulceration  of  the  cartilages  of  the  knee-joint,” 
&,c.—(On  Gun-shot  Wounds,  p.  190.) 

When  the  ball  strikes  a bone,  the  concussion  produced 
is  another  occasion  of  bad  symptoms,  to  be  added  to 
those  already  mentioned.  When  slight,  its  effects  are 
confined  to  the  injured  limb  ; but  sometimes  they  ex- 
tend to  the  neighbouring  joints,  in  which  they  produce 
inflammation  and  abscesses. 

It  is  commonly  stated  in  surgical  books,  that  when  a 
cannon-ball  tears  off  a limb,  it  produces  a violent  con- 
cussion of  the  whole  body,  and  a general  derangement 
of  all  its  functions.  This,  however,  is  by  no  means 
always  true.  I saw,  some  years  ago  in  London,  a 
young  sailor,  whose  ann  had  been  completely  torn  off 
at  the  shoulder,  by  a cannon-ball  from  one  of  the  for  s 
at  Guadaloupe,  in  March,  1808 ; he  suffered  no  dread- 
ful concussion  of  his  body,  nor  were  his  senses  at  all 
impaired.  This  case  was  very  remarkable,  as  the  sca- 
pula was  so  shattered  that  Mr.  Cummings,  of  Antigua,  | 
was  under  the  necessity  of  removVig  the  whole  of  it. 
The  patient  recovered  in  two  months.  From  the  ac- 
counts which  I heard,  I do  not  believe  that  the  axillary 
artery  bled  immediately  after  the  accident.  The  young 
man  was  shown  to  the  gentlemen  of  St.  Bartholomew’s 
Hospital,  quite  well. 

One  curious  effect  occasionally  follows  gun-shot 
wounds ; but  I do  not  pretend  to  understand  the  ra- 
tionale of  it:  viz.  inflammation  and  suppuration  of 
some  internal  viscus,  especially  of  the  liver.  Mr.  Rose 
classes  these  occurrences  among  the  effects  of  con- 
stitutional irritation  arising  from  local  injury,  and  consi- 
ders them  as  striking  illustrations  of  the  irregular  ac- 
tion in  the  vascular  system  to  which  that  irritation  may 
give  rise.  He  is  also  of  opinion  that  an  explanation 
of  the  subject  may  be  deduced  from  the  principles  laid 
down  by  Mr.  Travers. — (See  Med.  Chir.  Trans,  vol.  14, 
p.  263  ; and  Travers's  Inquiry  concerning  Constitu- 
tional Irritation,  8vo.  Load.  1826.)  Several  cases  of 
the  above  nature  are  related  in  the  M m.  de  I'Acad.  de 
Chirurgie,  and  according  to  Mr.  Guthrie  many  patients 
in  the  Peninsula  who  had  undergone  secondary  am- 
putations for  gun-shot  injuries  were  destroyed  by  affec- 
tions of  their  lungs,  liver,  <fec. — (On  Gun-shot  Wounds 
of  the  Extremities,  p.  74,  et  seq.) 

From  the  circumstance  of  the  inner  surface  of  gun- 
shot wounds  being  often  more  or  less  deadened,  they 
are  late  in  inflaming.  But  when  a ball  has  fractured  a 
bone,  which  fracture  has  occasioned  great  injury  of  the 
soft  parts,  independently  of  that  caused  immediately 
by  the  ball  itself,  the  inflammation  will  come  on  as 
(juickly  as  in  casc.s  of  compound  fracture  ; because 
the  deadened  part  bears  no  proportion  to  the  laceration 
or  wound  in  general. — (J:  Hunter,  p.  524.) 

From  the  same  circumstance  of  a part  being  often  dead- 
ened, gun-shot  wounds  frequently  cannot  be  completely 
understood  in  the  first  instance,  for  in  many  cases  it  is 
at  first  impossible  to  know  what  parts  are  killed,  whe- 
ther bone,  tendon,  or  soft  part.  Is'or  can  this  be  ascer- 
tained till  the  slough  separates,  which  often  makes  the 
wound  much  more  comnlicatcd  than  was  previously 

• E 2 


imagined.  For  very  often  some  viscus,  or  g part  of 
some  viscus,  or  a part  of  some  large  artery,  or  even  a 
bone  has  been  killed  by  the  violence.  If  a piece  of 
intestine  has  been  killed,  the  contents  of  the  bowel 
will  begin  to  come  through  the  wound  when  the  slough 
separates.  If  a portion  of  a large  blood-vessel  be 
killed,  a profuse  and  even  fatal  hemorrhage  may  come 
on,  when  the  slough  is  detached,  although  no  ma- 
terial quantity  of  blood  may  have  been  previously 
lost. — (See  Hunter,  p.  525.)  Thus,  several  days  after 
the  receipt  of  the  wound,  and  when  all  danger  from 
inflammation  is  over,  a bleeding  per  anum,  occasioned 
by  the  separation  of  a slough  from  some  internal  ves- 
sel, may  destroy  the  patient,  as  happened  in  a very 
interesting  case  reported  by  Mr.  Guthrie. — (P.  13,  ed. 
2.)  A soldier  of  the  2d  battalion  of  the  44th  regi- 
ment was  shot  in  the  ham  at  the  assault  of  Bergen- 
op-zoom  in  1814.  There  was  no  hemorrhage  tor  ten 
days;  but  at  the  end  of  this  period  the  popliteal  ar- 
tery gave  way,  and  1 was  obliged  to  take  up  the  fe- 
moral artery,  by  which  means  the  bleeding  was  effect- 
ually stopped,  and  the  man  recovered.  This  fact,  and 
another  related  by  Baron  Boyer  (Amiuaire  Med.  Chir. 
de  Paris,  p.  364,  Ato.  Paris,  1819),  prove  that  a ligature 
on  the  femoral  artery  may  sufficiently  check  the  cur- 
rent of  blood  tliroiigh  the  popliteal  artery  to  put  a stop 
to  hemorrhage  from  a wound  in  it ; and  though  such 
practice  in  some  other  cases  of  wounded  arteries  is  inef- 
cient  on  account  of  the  facility  with  which  tfie  blo<Kl 
passes  through  the  anastomoses  into  the  part  of  those 
vessels  below  the  ligature  (see  Arteries),  its  general 
success  in  gun-shot  wounds  of  the  ham,  would  be  of 
infinite  advantage,  not  only  on  account  of  the  difficul- 
ties of  taking  up  the  popliteal  artery  itself  (difficulties 
. ably  depicted  by  Scarpa),  but  because  laying  open  the  in- 
flamed and  diseased  parts  would  frequently  have  a fatal 
termination.  At  the  same  time  1 would  have  surgeon.s 
always  recollect  the  important  difference  between  an 
aneurismal  and  a wounded  artery  ; for,  as  in  the  first 
case  there  is  no  outlet  for  the  blood,  the  transmission 
of  this  fluid  into  the  part  of  the  vessel  below  the  liga- 
ture may  keep  up  a pulsation  in  the  tumour,  and  re- 
tard the  cure  of  the  disease,  but  is  attended  with  no 
risk  of  hemorrhage  : while  the  same  free  passage  of 
the  blood  into  the  wounded  portion  of  a large  artery 
I would  give  rise  to  dangerous  bleeding ; and  hence 
the  general  necessity  of  applying  two  ligatures,  one 
immediately  above,  the  other  below,  the  aperture  in 
such  a vessel.  A single  ligature  on  the  brachial  ar- 
tery fails,  as  I had  an  opportunity  of  seeing  in  Holland 
in  a case  of  gun-shot  wound,  where  either  that  vessel 
or  the  commencement  of  the  radial  or  ulnar  gave  w'ay, 
on  the  loosening  of  the  sloughs,  and,  as  there  was  con- 
siderable swelling,  oedema,  and  inflammation  of  the  limb, 
threatening  gangrene,  the  surgeon  under  whose  care 
the  patient  was  deemed  it  right  to  perform  amputation. 

I should  be  sorry  if  these  observations  were  to  hold 
out  any  general  encouragement  of  the  wrong  and  dan- 
gerous practice  of  applying  only  one  ligature  above  a 
wound  in  a large  artery,  or  in  any  recent  case  of  false 
difustd  aneurism.  The  remarks  delivered  above  were 
chiefly  intended  to  refer  to  gun-shot  wounds  of  the 
ham,  with  injury  of  the  popliteal  artery,  and  hemor- 
rhage first  breaking  out  several  days  after  the  receipt 
of  the  wound,  when  all  the  parts  behind  the  knee  are 
enormously  swelled,  and  in  a state  of  inflammation 
and  suppuration.  Here  the  hope  of  avoiding  any  ad- 
ditional violence  or  injury  of  the  diseased  parts  behind 
the  knee  may  be  a good  reason  for  taking  the  chance 
of  stopping  the  bleeding  by  a ligature  applied  to  the 
femoral  artery  ; a reason,  however,  which  would  not 
exist  in  the  case  of  a recent  wound  of  the  jiopliteal 
artery  with  a knife.  At  the  same  time  1 believe  this 
means  of  checking  the  current  of  blood  will  not  always 
suffice,  and  that  occasionally  either  the  dangerous  ex- 
pedient of  cutting  open  the  swelling  in  this  diseased 
state  of  the  ham,  and  of  applying  a ligature  above  and 
below  the  aperture  in  the  popliteal  artery,  must  un- 
avoidably be  encountered,  or  amputation  performed. 
Why  the  first  plan  has  answered  in  some  cases  and 
not  in  others,  may  depend  upon  Che  size  and  condition 
of  the  wound  or  opening  in  the  artery,  and,  in  exam- 
ples of  sloughing,  upon  the  degree  in  whicli  the  tube 
of  the  vessel  may  have  been  clo.sed  by  the  adhesive 
inflammation.  Some  wrong  coticlusiotis  may  also  have 
been  made  respecting  the  trunk  of  the  vessel  being 
wounded  or  opened,  while  in  fact  only  a branch  of  it 


436 


GUN-SHOT  WOUNDS. 


was  concerned.  As  a qualification,  therefore,  of  any 
inferences  which  might  be  drawn  from  the  partial 
success  of  applying  one  ligature  only  in  cases  of  large 
wounded  arteries,  T annex  the  following  remarks,  pub- 
lished some  little  time  ago  in  an  ably-conducted  peri- 
odical work.  “ It  appears  to  us  that  some  of  the  cases 
which  M.  Roux  has  given,  as  the  most  favourable  for 
the  operation  of  Hunter,  are  the  least  so ; for  example, 
he  performs  it  in  the  cases  where  aneurism  has  formed 
in  consequence  of  the  wound  of  the  artery.  In  sup- 
port of  this  he  gives  two  cases,  where,  upon  the  au- 
thority of  M.  Mirault,  of  Angers,  the  ligature  of  the 
artery  above  the  wound  was  sufficient.  In  one  case, 
the  humeral  was  the  artery  said  to  be  wounded  ; in  the 
other  the  femoral.  We  doubt  if  the  femoral  were 
really  wounded  in  this  case ; for,  on  referring  to  the 
rejiort,  we  do  not  find  sufficient  evidence  of  that  fact ; 
it  appears  more  probable  that  a branch  only  was 
wounded.  We  have  seen  the  operation  of  Hunter  per- 
formed unsuccessfully  in  two  cases  of  aneurism  con- 
sequent upon  a wound  of  the  artery ; and  we  have 
seen  the  preparation  of  a third  case,  where  the  same 
operation  was  performed  and  failed ; that  is  to  say,  the 
inosculations  were  so  free  that  hemorrhage  returned 
by  the  lower  orifice.  In  the  first  case,  the  popliteal 
artery  was  ruptured  by  a spicula  of  bone.  The  second 
was  a wound  of  the  femoral  artery  by  an  iron  spike; 
and  the  third  was  a stab  of  the  femoral  artery  by  a 
knife.  In  each  of  these  cases  the  hemorrhage  returned 
by  the  lower  part  of  the  artery.  There  is  in  the  Kul- 
letins  de  la  Faculte  de  Medecine  for  1813,  a case  by 
the  same  Mirault,  of  an  aneurism  of  the  femoral  ar- 
tery, in  consequence  of  a wound  some  considerable 
time  before.  Mirault  operated  according  to  the  method 
of  Hunter,  that  is.  he  tied  the  artery  above  the  aneu- 
rism. The  sac  burst,  two  hemorrhages  ensued,  and 
the  second  carried  off  the  patient  on  the  fifteenth  day 
after  the  operation.  (N.B.  Here,  however,  it  is  pro- 
per to  remark,  that  if  the  case  had  been  a true  aneu- 
rism, and  the  sac  had  burst,  while  a stream  of  blood 
was  yet  passing  through  it,  as  always  happens  for 
some  days  after  the  ligature  of  the  artery  above  the 
tumour,  hemorrhage  would  have  occurred,  just  as  it 
did  in  the  present  case  of  false  aneurism.  The  pr^ 
mature  bursting  of  the  tumour,  in  fact,  converted  the 
case  directly  into  one  analogous  to  a wounded  artery, 
the  blood  having  a passage  outwards.)  It  is  rather 
curious,  that  the  first  case  which  occurred  to  M.  Roux 
after  his  return  from  England,  should  be  one  which 
forms  a strong  argument  against  performing  the  ope- 
ration of  Hunter  for  a wounded  artery.  The  case  here 
alluded  to  was  that  of  a wound  of  the  femoral  artery 
with  a knife  a little  below  the  middle  of  the  thigh, 
where  M.  Roux  immediately  cut  down  to  the  vessel 
some  way  above  the  injury,  and  there  applied  two  liga- 
tures, besides  a reserve  ligature.  On  the  tenth  day 
hemorrhage  came  on,  when  the  tightening  of  the  latter 
ligature  having  no  effect,  M.  Roux  exposed  the  artery 
higher  up,  and  applied  fresh  ligatures  immediately  be- 
low the  profunda.  This  stopped  the  hemorrhage  from 
the  upper  end  of  the  vessel ; but  on  the  following  morn- 
ing fresh  bleeding  took  place  from  the  lower  end  of 
the  artery,  and  it  became  necessary  to  lay  open  the  ar- 
tery below  the  wound,  and  also  apply  ligatures  there. 
No  farther  bleeding  took  jilace.” — (See  Quarterly 
Journ.  of  Foreign  Medicine,  voL.  1,  p.  14,  8vo.  Lenid. 
1819.)  The  tenor  of  the  preceding  observations  is  un- 
questionably correct,  inasmuch  as  wounded  arteries 
and  recent  false  diffused  aneurisms  are  concerned  ; but 
with  respect  to  cases  of  false  circumscribed  aneurisms 
of  some  standing,  without  any  external  opening  in  the 
skin,  they  are  examples  to  which  the  same  principles 
should  not  always  be  applied,  which  are  so  properly 
recommended  to  be  observed  with  regard  to  the  other 
instances.  In  these  latter  the  blood  may  either  escape 
from  the  lower  end  of  the  vessel  out  of  the  external 
wound,  or  into  the  cellular  membrane  after  the  ligature 
is  applied  above  the  aperture  in  the  artery;  but  no 
sooner  is  a false  aneurism  encysted,  than  these  dan- 
ger.s  are  prevented. 

When  the  ball  moves  with  little  velocity,  the  mis- 
chief is  generally  less ; the  bones  are  not  so  likely  to  be 
fractured  ; the  parts  are  less  deadehed,  ifcc.  However, 
when  the  velocity  is  just  great  enough  to  splinter  a 
bone  which  is  touched,  the  splintering  is  generally 
more  extensive  than  if  the  impetus  of  the  ball  had  been 
mueh  greater,  in  which  case  a piece  is  more  likely  to 


be  taken  out.  When  the  ball  moves  slowly,  it  is  more 
hkely  to  be  turned  by  any  resistance  it  may  encounter 
in  its  passage  through  parts,  and  hence  the  wound  is 
more  apt  to  take  a winding  course. 

When  a ball  enters  a part  with  great  velocity,  but  is 
almost  spent  before  it  comes  out  again,  in  consequence 
of  the  resistance  it  has  met  with,  there  may  be  a good 
deal  of  sloughing  about  the  entrance,  and  little  or  none 
about  the  exit,  owing  to  the  different  degrees  of  cele 
rity  with  which  the  ball  traversed  the  parts.— (Seo 
Hunter.) 

Gun-shot  wounds  may  have  either  one  or  two  aper 
tures,  according  as  the  ball  has  lodged  or  passed  quite 
through  the  part.  In  some  cases,  the  openings  are  dia- 
metrically opposite  each  other;  in  others  they  arc  not 
so,  the  direction  of  the  ball  having  been  changed  by 
the  resistance  which  it  met  with  from  a bone,  cartilage, 
tendon,  &c.  Thus  a ball  has  been  known  to  enter 
just  on  the  inside  of  the  ankle,  and  come  out  near  the 
knee ; to  enter  the  forehead  and  come  out  at  the  tem- 
ple, <fec. — {Richerand,  Nosegraphie  Chir,  t.  1,  p.  219, 
edit.  2.)  Hr.  Hennen  mentions  an  instance  in  which  a 
ball  entered  near  the  pomum.  adami,  and  after  running 
completely  round  the  neck,  was  found  in  the  very  ori- 
fice in  w'hich  it  had  entered.  “ This  circuitous  route  is  a 
very  frequent  occurrence,  particularly  when  balls  strike 
the  ribs  or  abdominal  muscles ; for  they  are  turned 
from  the  direct  line  by  a very  slight  resistance  indeed, 
although  they  will  at  times  run  along  a continued  sur- 
face, as  the  length  of  a bone  along  a muscle  or  a fascia, 
to  a very  extraordinarj'  distance.”  Dr.  Hennen  reters 
to  cases  in  which  the  ball  traversed  almost  the  w’hole 
extent  of  the  body  and  extremities.  “ In  one  instance 
which  occurred  in  a soldier,  with  his  arm  extended  in 
the  act  of  endeavouring  to  climb  up  a scaling  ladder,  a 
ball,  which  entered  about  the  centre  of  the  humerus, 
passed  along  the  limb  and  over  the  posterior  jiart  of 
the  thorax,  coursed  among  the  abdominal  muscles, 
dipped  deep  through  the  glutaei,  and  presented  on  tha 
fore  part  of  the  opposite  thigh,  about  midway  down. 
In  another  case,  a ball  which  struck  the  breast  of  a 
man  standing  erect  in  the  ranks,  lodged  in  the  scro- 
tum.”— {Principles  of  Military  Surgery,  p.  34,  ed.  2.) 
The  opening  where  the  ball  enters  is  always  smaller 
than  that  from  which  it  escapes,  and  its  ma^rgin  is 
forced  inwards,  while  the  circumference  of  the  other 
apenure  is  quite  prominent.  The  contusion  and  in- 
jury which  the  parts  suffer  are  also  greatest  about  the 
entrance  of  the  ball,  owing  to  the  more  considerable 
impetus  with  which  it  moves.  The  yellowish  livid 
hue  around  gun-shot  wounds  is  a sort  of  ecchymosis, 
or  extravasation  of  blood.  The  injured  member  is 
often  benumbed  and  stupified,  and  when  mortification 
occurs,  it  spreads  with  extraordinary  rapidity.  When 
the  whole  constitution  is  thrown  into  this  kind  of  tor- 
por, the  most  fatal  consequences  are  to  be  apprehended. 
“ C’est  dans  cet  etat  (says  Richerand),  que  mourut  le 
chevauleger,  dont  parle  Quesnay ; I’etat  d’hfebetude 
6tait  tel,  que  cet  individu,  k qui  I’on  proposa  I’amputa- 
tion  de  la  jambe,  r^pondit,  que  ce  n’6tait  pas  son  af- 
faire.”— {HosographieChirurg.  torn.  l,p.  221,  edit.  2.) 
In  cases  of  gun-shot  wounds,  sudden  shiveriiigs,  syn- 
cope, and  nervous  symptoms  are  not  unfrequent.  Such 
occurrences,  with  other  bad  effects,  made  the  ancients 
suspect  that  something  poisonous  was  carried  into  the 
wound ; an  opinion  which  is  now  well  known  to  be 
. erroneous. 

When  there  is  only  one  opening,  we  niay  infer  that 
the  wound  contains  a foreign  body.  An  exception  to 
this  observation  occurs,  however,  when  a ball,  instead 
of  tearing  the  clothes  or  linen,  carrie.s  a p>ortion  of  them, 
in  the  form  of  a sac,  into  the  wound,  and  when  such 
{vortiou  of  the  clothes  is  withdrawn  the  ball  falls  out ; 
and  if  thi.s  circumstance  be  not  noticed,  the  jire.'  ence 
of  a single  opening  may  lead  to  the  idea,  that  the  bullet 
is  lodged  in  the  part.  An  instance  of  this  kin^  is  cited 
by  Pare  for  the  purpose  of  refuting  the  former  notion, 
that  the  ball  burned  the  part.s.  A case  in  w Inch  a piece 
of  a shirt  was  carried  in  this  manner  four  inches  into 
the  flesh,  is  mentioned  by  Mr.  Guthrie.— (P.  20,  td.  2.) 
It  is  possible  also  for  a ball  to  be  stopped  immediately 
it  has  entered  the  body,  and  then  to  be  ejected  by  the 
elasticity  of  the  parts  against  which  it  strikes,  as  the 
cartil.ages  of  the  riba.— {Guthrie,  19,  (d.  2.)  When 
there  are  two  apertures  made  by  one  shot,  the  ball  has 
escaped;  but  jiicces  of  the  clothes,  Ac.  n ay  .stdl  he 
lodged  in  the  part.  Care  must  be  taken,  however,  not 


GUN-SHOT  WOUNDS. 


437 


to  confound  with  these  cases  others,  in  which  the  plu- 
rality of  openings  has  been  made  by  ditr.rent  balls. 

As  a modern  writer  has  accurately  e.Kplained,  “It 
is  no  uncommon  thing  for  a ball,  in  striking  against 
the  sharp  edge  of  a bone,  to  be  split  into  two  pieces, 
each  of  which  takes  a different  direction.  Sometimes 
it  happens  that  one  of  the  pieces  remains  in  the  place 
wliich  it  struck,  while  the  other  continues  its  course 
through  the  body.  Of  a ball  split  by  the  edge  of  the 
patella,  I have  known  one  half  pass  through  at  the  mo- 
ment of  the  injury,  and  the  other  remain  in  the  joint. for 
months,  without  its  prcsetice  there  being  suspected. 
In  the  same  manner  I have  known  a ball  divided  by 
striking  against  the  spine  of  the  scapula,  and  one  por- 
tion of  it  pass  directly  thrpugh  the  chest,  from  the  point 
of  impulse,  while  the  other  moved  along  the  integu- 
ments, till  it  reached  the  elbow-joint.  But  the  most 
frequent  examples  of  the  division  of  bullets  which  we 
had  occasion  to  see,  were  those  which  Avere  prbduced  by 
balls  St  nking  againstthe  spherical  surface  of  the  cranium. 
It  sometimes  happens,  that  one  portion  of  the  ball  enters 
the  cranium,  while  the  other  either  remains  without, 
or  passes  over  its  external  surface.  Not  unfrequently, 
in  injuries  of  the  cranium,  the  balls  are  lodged  between 
its  two  tables,  in  some  instances  much  flattened  and 
altered  in  their  shape,  and  in  other  instances  without 
their  form  being  changed.’’  From  these  facts  it  must  be 
evident,  that  even  when  a gun-shot  wound  has  two  ori- 
fices, the  surgeon  cannot  be  certain  that  the  bullet  has 
not  been  divided,  and  that  no  portion  is  lodged,  unless 
the  entire  ball  itself  happen  to  be  found. — (See  Thovi- 
son's  Obs.  in  Military  Hospitals  in  Belgium^  p.  37,  <:5-c.) 

As  the  ends  of  the  torn  vessels  are  contused  and 
compressed,  gun-shot  wounds  have  at  first  less  pro- 
pensity to  kleed  seriously  than  most  other  wounds,  un- 
less vessels  of  importance  happen  to  be  injured,  in  the 
beginning  there  may  even  be  little  hemorrhage,  though 
a considerable  arterj-  be  so  hurt,  that  it  af.erward 
sloughs,  and  a dangerous  or  fatal  bleeding  arises.  Thus 
(as  I have  already  mentioned),  in  one  of  my  own  patients 
Avho  had  received  a musket-ball  through  the  ham,  the 
popliteal  artery  gave  way  about  ten  days  after  the  in- 
jury, and  compelled  me  to  take  up  the  femoral  artery  ; 
and  in  the  Elizabeth  Hospital  at  Brussels,  among  the 
patients  under  the  care  of  my  friend  Mr.  Collier  and 
myself,  about  a week  after  the  battle  of  Waterloo,  the 
cases  of  heihorrhage,  on  the  loosening  of  the  sloughs, 
were  tolerably  numerous,  not  at  all  coinciding  with  a 
recent  calculation,  that  the  proportion  of  such  exam- 
l)les,  requiring  the  ligature  of  arteries,  is  only  three  or 
four  in  1000. — {Guthrie  Gun-shot  Wounds,  p.  8, 

ed.  2.)  In  Holland,  the  truth  of  Mr.  Hunter’s  observa- 
tion upon  this  point  appeared  to  me  to  bo  completely 
confirmed. 

It  has  long  been  known,  that  a limb  may  be  torn  or 
shot  off,  even  near  to  the  trunk  of  the  body,  and  hardly 
any  hemorrhage  arise.  We  had  numerous  proofs  of 
this  fact  after  the  battle  of  Waterloo.  I had  under  my 
care  a man  of  the  rifle  brigade,  whose  arm  was  shat- 
tercl  to  pieces  as  high  as  the  shoulder,  yet  there  was 
no  hemorrhage.  I amputated  the  thigh  of  a Dutch  sol- 
dier whose  leg  had  been  completely  shot  off  by  a can- 
non-ball ; but  there  was  no  hemorrhage  before  the  ope- 
ration. At  Merksam,  in  1814,  I saw  a case  in  which 
the  greater  part  of  the  clavicle,  scapula,  and  many  ad- 
jacent parts  had  been  carried  away  by  a cannon-ball ; 
and  yet  no  bleeding  of  consequence  occnirred. 

Sometimes,  after  these  violent  injuries,  the  large  ar- 
teries do  not  bleed  in  amputation.  “ We  saw  a man 
(says  Dr.  Thomson),  whose  leg  had  been  shot  off  by 
a cannon-ball ; in  amputating  his  limb  above  tlie  knee, 
the  arteries  of  the  thigh  were  not  perceived  to  bleed  ; 
nor  did  any  of  them  afterward  require  to  be  tied.  A 
case  similar  to  this  also  presented  itself,  in  which  the 
arm  had  been  shot  away  close  to  the  shoulder-joint.” 

Sometimes  the  contusion  produced  by  a cannon-ball, 
or  the  passage  of  a bullet  in  the  vicinity  of  a large  ar- 
tery, seems  to  cause  a laceration  of  the  inner  coat  of 
the  vessel,  and  a subsequent  obliteration  of  its  cavity 
by  the  effusion  of  coagulable  lymph.  Facts  in  proof 
of  ihi.s  statement  are  recorded  by  Dr.  Thomson. — (See 
Ohs.  in  the  Military  Hospitals  in  Belgiwn,  p.  31,  35.) 

Angular,  uneven  bodies,  such  as  pieces  of  iron,  cut 
lead,  Ac.,  produce  far  more  dangerous  wounds  than 
round  even  bodies,  like  leaden  btillets.  Wounds  occa- 
sioned by  a small  shot  are  frequently  more  perilous 
than  others  produced  by  larger  balls;  because  their 


track  is  so  narrow  that  it  cannot  be  traced,  nor  con- 
sequently the  extraneous  body  itself  extracted.  Such 
a .shot  often  injures  a viscus,  when  there  is  not  the 
smallest  external  symptom  of  the  occurrence.  Some- 
times a great  part ' of  the  danger  also  arises  from  the 
number  of  the  shots  wliich  have  entered. 

TKKATMENT  OF  GU.N-SHOT  WOUNDS. 

The  first  thing  in  the  treatment  of  a gun-shot  wound 
in  one  of  the  extremities  is,  to  determine  whether  it 
be  most  advisable  to  amputate  the  limb  immediately, 
or  to  undertake  the  cure  of  the  wound.  When  a bone, 
especially  at  a joint,  is  very  much  shattered  ; when  the 
fleshy  parts;  particularly  the  great  blood-vessels  and 
nerves,  are  lacerated ; when  the  whole  limb  has  suf- 
fered a violent  concussion,  and  is  cold  and  senscle.ss  ; 
there  is  no  hope  of  preserving  it.  In  this  case,  it  is 
the  surgeon’s  duty  to  amputate  at  once,  and  not  to  de- 
lay till  inflammation,  fever,  and  a tendency  to  morrili- 
cation  come  on.  But  besides  this  violent  degree  of 
injury  in  which  the  propriety  of  amputation  is  obvious, 
there  are  several  lower  degrees,  in  which  it  is  often  a 
difficult  thing  to  decide  whether  the  operation  be  ne- 
cessary or  not.  Here  the  surgeon  must  look  not  only 
to  the  injury,  but  also  to  the  patient’s  constitution,  and 
even  to  external  circumstances,  such  as  the  possibility 
or  impossibility  of  procuring  good  accommodation,  rest, 
attendance,  and  pure  air.  But  it  is  impossible  to  de- 
termine the  necessity,  of  amputation  by  general  rules. 
In  every  individual  case,  the  surgeon  must  consider 
maturely  the  particular  circumstances,  before  he  ven- 
tures to  decide.  The  grounds  against  the  operation 
are,  the  pain  which  it  causes  at  the  period  when  the 
whole  system  is  disordered  by  a terrible  injury ; the 
privation  of  a limb  ; and  frequent  examples,  in  which 
nature,  aided  by  judicious  surgery,  repairs  the  most 
horrible  wounds.  The  follow'ing  are  the  reasons  in 
favour  of  the  operation.  By  it  the  patient  gets  rid  of 
a dreadful  contused  wound,  which  threatens  the  great- 
est peril,  and  which  is  exchanged,  as  it  were,  for  a 
simple  incised  one.  The  pain  of  amputation  is  not  of 
more  moment  than  the  pain  which  the  requisite  inci- 
sions, and  the  extraction  of  foreign  bodies  would  cause 
in  case  the  operation  were  abandoned.  In  cases  of . 
gun-shot  wounds,  the  loss  of  the  limb  cannot  be  taken 
into  the  account ; for  the  surgeon  only  undertakes  the 
operation  where  he  designs  to  save  the  patient’s  life 
by  that  privation,  and  anticipates  that  the  part  itself 
cannot  be  preserved.  Even  if  he  should  deprive  the 
patient  of  a limb  that  perhaps  might  have  been  pre- 
served, there  is  this  atonement,  that  he  can  furnish 
him  with  an  artificial  leg,  which  often  proves  far  more 
serviceable  than  the  lost  limb  would  have  proved,  had 
it  been  preserved.  Should  the  operation  be  fixed  on, 
it  is  to  be  immediately  performed  above  the  wound. — 
{Richter,  Avfangsgr.  der  Wundarzn.  b.  1.) 

When  amputation  is  deemed  unnecessary,  the  sur- 
geon, according  to  precepts  fonuerly  in  vogue,  is  to 
dilate  the  w’ound  by  one  or  more  incisions.  Many  of 
the  missile  weapons  employed  by  the  ancients,  when 
received  into  the  body,  required  incisions  before  they 
could  be  extracted;  and  this  was  the  case,  not  only 
with  regard  to  darts  and  arrows,  but  also  whh  regard 
to  bits  of  stone,  pieces  of  iron,  and  leaden  bullets,  which 
were  thrown  by  means  of  slings.  Celsus  mentions 
the  necessity  of  enlarging  the  orifices,  through  w'hich 
these  bodies  had  entered,  and  may  therefore  be  justly- 
regarded  as  the  first  who  recommended  the  practice  of 
dilatation  in  the  treatment  of  wounds  made  by  leaden 
bullets. — {Thomson's  Obs.  in  the  Military  Hospitals  of 
Belgium,  p.  39.) 

Such  dilatation  has  been  said  to  have  numerous  ad- 
vantages : to  facilitate  the  extraction  of  foreign  bodies; 
to  occasion  a topical  bleeding,  and  afford  an  outlet  lor 
the  extravasated  fluid  in  the  circumference  of  the 
wound ; to  convert  the  fistulous  form  of  the  track  of 
the  ball  into  an  open  wound  ; and,  lastly,  to  divide 
ligamentous  aj)oneuroses,  which  otherwise  might  give 
ri.se  to  spasmodic  and  other  untoward  symiitoms. 

More  m.odern  experience  proves,  however  {HvnUr, 
p.  529),  that  the  utility  of  such  incisions  has  been  over- 
ratefl  ; that  they  generally  increase  the  inflammation, 
which  in  these  cases  is  so  much  to  be  appn.-hended ; 
that  wounds  which  are  not  dilated  commonly  heal 
more  speedily  than  others  which  are;  and  that  there 
are  only  a few  cases  in  w Inch  incisions  are  beneficial. 
In  fact,  as  Dr.  Hennen  has  correctly  stated,  the  kuifa 


438 


GUN-SHOT  WOUNDS. 


is  now  rarely,  if  ever,  employed  in  the  first  instance 
by  English  surgeons,  except  for  the  purpose  of  ex- 
tracting balls,  splinters  of  bone,  and  other  extraneous 
bodies,  or  for  facilitating  the  application  of  ligatures 
to  bleeding  vessels. — (See  Principles  of  Military  Sur- 
gery, p.  49,  ed.  2.) 

The  injuries  arising  from  the  practice  of  indiscrimi- 
nate dilatation  (says  Dr.  Thomson),  were  very  early 
pointed  out  by  Botallus  ; and  it  is  singular  how  much 
the  opinions  of  this  author,  with  regard  to  this  point 
in  military  surgery,  coincide  with  those  of  Mr.  Hun- 
ter.—(Op.  cit.  p.  40.) 

The  cases  of  gun-shot  wounds  are  various.  Some- 
times the  track  of  the  ball  lies  superficially  under  the 
skin,  and  only  has  one  opening.  When  it  lies  in  soft 
parts,  and  the  ball  has  neither  touched  a bone,  nor  a 
considerable  blood-vessel,  all  incisions  are  useless,  let 
the  wound  have  one  or  two  apertures.  Though  di- 
lating the  wound  has  been  practised  with  a view'  of 
giving  vent  to  matter,  eschars,  and  foreign  bodies,  and 
even  its  whole  track  has  been  laid  open  when  super- 
ficial ; yet  experience  proves  the  inutility  of  such  steps. 
As  when  a ball  has  passed  with  great  force  there  is 
often  a real  loss  of  substance  in  the  skin,  a portion 
of  which  is  driven  inwards  before  the  ball,  it  follows 
that  the  opening  of  a gun-shot  w'ound  must  be  more 
capacious  than  that  of  a punctured  one.  By  the  sepa- 
ration of  sloughs,  the  wound  becomes  still  more  di- 
lated, so  that  not  only  matter,  but  foreign  bodies  which 
approach  the  skin,  easily  find  an  exit.  Besides,  inci- 
eions  commonly  close  again  very  soon,  and  in  a few 
days  the  wound  falls  into  the  same  state  as  if  no  di- 
latation at  all  had  been  made. — {Hunter,  p.  532,) 

Ligamentous  fibres  and  fasciae  are  often  situated 
abom  the  orifice  of  a gun-shot  wound,  and  some  sur- 
geons have  made  it  a rule  always  to  divide  them  com- 
pletely, lest,  when  the  wound  inflames,  the  tension  and 
confinement  of  parts  should  cause  violent  spasms  and 
nervous  symptoms,  and  afterward  impede  the  di.scharge 
of  matter  and  foreign  bodies.  When  they  obviously 
have  the  first  effects,  the  propriety  of  dividing  them 
cannot  be  doubted ; but  with  a mere  expectation  of  the 
other  evils  I consider  the  practice  injudicious.  Here, 
as  Mr.  Hunter  wisely  remarks,  the  method  would  be 
very  good  if  tension  and  inflammation  were  not  a con- 
sequence of  wounds,  or  if  it  could  be  proved  that  the 
effects  of  dilating  a part  that  is  already  wounded  w'ere 
different  from  those  of  the  first  wound ; but  the  em- 
plojTnent  of  the  knife,  being  only  an  extension  of  the 
first  mischief,  must  be  contradictory  to  common  sense 
and  common  obsert'ation.-.--(On.  Gun-shot  Wounds,  p. 
534, 4<o,) 

The  extraction  of  foreign  bodies  ranks  as  one  of  the 
roost  urgent  motives  for  the  dilatation  of  the  wound, 
and  no  doubt  it  is  right  to  remove  at  first  as  many  of 
them  as  possible.  Their  lodgement  irritates  the  wound, 
causes  violent  nervous  and  inflammatory  symptoms, 
and  copious  suppuration ; circumstances  which  the 
timely  extraction  of  them  may  prevent.  Yet  let  it  be 
remembered  that  the  extraction  of  foreign  bodies  is  fre- 
quently attended  with  immense  irritation,  and  that, 
while  they  lie  too  firmly  fixed  in  parts,  it  is  often  a 
matter  of  impossibility.  After  the  sloughs  have  sepa- 
rated, and  the  wound  has  become  widened,  suppuration 
frequently  does  not  prevail  long  before  the  extraneous 
substances  become  loose,  spontaneously  approach  the 
skin,  and  easily  admit  of  removal  without  any  dilatation. 

Hence,  it  is  generally  prudent  to  extract  at  first  only 
such  foreign  bodies  as  are  near  the  external  opening, 
quite  loose,  and  removeable  without  much  irritation  ; or 
such  as  press  on  parts  of  importance,  and  thereby  ex- 
cite dangerous  symptoms.  The  surgeon  should  avoid 
interfering  with  those  w'hich  are  deeply  and  firmly 
lodged  in  the  wound.  He  should  await  suppuration 
and  the  detachment  of  sloughs,  and  when  the  foreign 
bodies  become  moveable  and  ajjparent,  he  should  ex- 
tract them  with  or  without  an  incision,  as  circum- 
stances may  demand.  The  examination  of  the  wound 
ought  to  be  made  as  much  as  possible  with  the  finger, 
which  irritates  le.ss,  and  feels  more  distinctly,  than  a 
probe.  A great  variety  of  instruments  have  been  de- 
vised, either  for  ascertaining  the  position  of  balls  and 
other  foreign  bodies  in  gun-shot  wounds,  or  for  extract- 
ing them.  But  however  numerous  and  diversified  bul- 
let-drawers may  be,  they  all  admit  of  being  divided  into 
three  kinds.  The  first  are  constructed  on  the  principle 
of  a pair  of  forceps ; others  are  shaped  more  or  less 


like  spoons  ; and  a third  description  are  made  on  the 
plan  of  a cork-screw  or  worm.  These  last  are  only 
designed  for  cases  in  which  the  ball  is  fi^ed  in  the  sub- 
stance of  a bone,  and  is  quite  immoveable ; for  if  it 
were  lodged  in  the  .soft  parts,  the  pressure  requisite  for 
introducing  the  screw  into  it  would  injure  and  lacerate 
the  parts  at  the  bottom  of  the  wound.  Bullet-drawers, 
constructed  on  the  plan  of  forceps,  have  the  inconve- 
nience of  not  being  adapted  for  seizing  the  ball  unless 
their  blades  are  expanded,  which  always  stretches  the 
wound,  and  creates  a great  deal  of  irritation.  Forceps 
have  been  contrived  with  blades  which  may  be  intro- 
duced separateiy,  and  then  joined  together  with  a screw. 
When  a ball  lies  superficially,  the  fingers  or  a small 
pair  of  forceps  will  extract  it  most  conveniently.  And 
with  respect  to  bullet-extractors,  as  Dr.  Hennen  has 
justly  observed,  they  are  completely  superseded  by  the 
common  forceps,  or  that  of  Baron  Percy,  though  un- 
fortunately the  aid  of  instruments  is  most  required  in 
tortuous,  deep  passages  where  we  can  least  make  use 
of  them. — {Principles  of  Military  Surgery,  p.  76,  ed.  2.) 

The  event  of  the  treatment  above  recommended  is 
various.  Extraneous  substances  remaining  in  the 
wound  either  loosen  gradually,  or  come  into  view  so  as 
to  be  easily  removeable ; or  they  continue  concealed, 
prevent  the  cure,  and  give  birth  to  a fistulous  ulcer.  In 
some  instances,  the  wound  closes,  and  the  foreign 
bodies  remain  in  the  limb  during  life  without  incon- 
venience ; and  in  other  cases  after  a time  they  bring  on 
a renewal  of  inflammation  and  suppuration.  Some- 
times a foreign  body  varies  its  situation,  sinking  down, 
and  afterward  making  its  appearance  at  a difierent  part, 
where  it  may  excite  inflammation  and  suppuration. 

When  the  bali  lodges  in  the  wound,  it  is  usually  dif- 
ficult to  trace  it,  as  the  parts  collapse  after  its  passage, 
and  leave  an  opening  in  the  skin  much  smaller  than 
the  ball  itself.  The  ball  does  not  regularly  take  a 
straight  direction  through  the  injured  part,  but  often  a 
very  tortuous  one,  particularly  when  the  ball  is  nearly 
spent.  In  every  case  in  w'hich  it  is  not  easily  disco- 
verable all  painful  examinations  should  be  abandoned, 
and  the  foreign  body  left  in  its  situation  until  its  place 
is  better  known,  and  the  first  inflammation  is  over. 

Sometimes  the  ball  may  be  both  easily  found  and  ex- 
tracted. At  other  times  it  lodges  on  the  opposite  side 
of  the  limb,  closely  under  the  skin.  According  to  Mr. 
Hunter,  if  the  integuments  under  which  the  ball  is 
lodged  should  be  so  contused  that  they  will  probably 
slough,  they  are  to  be  considered  as  already  dead,  and 
an  opening  is  to  be  made  in  them  for  the  extraction  of 
the  ball.  But  when  the  ball  lies  so  remotely  from  the 
skin  that  it  can  only  just  be  felt,  and  the  skin  itself  is 
quite  uninjured,  ru)  counter-opening  ought  to  be  made. 
The  wound  heals  better  when  the  ball  is  left  in,  and 
far  less  inflammation  takes  place  in  the  vicinity  of  this 
extraneous  body  than  about  the  orifice  of  the  wound. 
A counter-opening  always  renders  the  inflammation  at 
the  bottom  of  the  wound  as  great  as  at  its  orifice.  It 
is  better  to  let  the  wound  heal  up,  and  extract  the  balls 
afterward. — (See  Hunter,  p.  541.) 

To  the  justness  of  this  advice  Mr.  Guthrie  does  not 
assent,  who  assures  us  that  he  has  cut  out  a great 
number  of  balls  which  were  not  more  than  an  inch 
from  the  surface,  and  never  found  any  inconvenience 
ensue.  But  when  the  ball  lies  three  or  four  inches 
from  the  surface,  and  cannot  be  distinctly  felt,  he  thinks 
that  no  incision  should  at  first  be  niade  with  the  view  of 
extracting  it. — {On  Gun-shot  Wounds,  p.  94,  95,  ed.  2.) 

Sometuncs  the  ball  penetrates  the  spongy  part  of  a 
bone,  and  lodges  firndy  in  it.  When  it  has  only  en- 
tered superficially,  it  may  sometimes  be  loosened  and 
extracted  by  means  of  an  elevator  with  a thin  and  some- 
what curved  extremity,  and  when  it  is  more  firmlj 
fixed  a screw  bullet-drawer  will  sometimes  serve  for 
its  removal.  Should  the  attempt  fail,  the  employment 
of  a trepan  for  the  removal  of  the  ball  is  recomi/tended 
by  .some  writers ; while  others,  fearful  of  the  irritation, 
difliculty,  and  cflfects  of  such  an  operation,  and  recol- 
lecting that  balls  have  sometimes  remained  fixed  in 
bones  for  many  years  without  any  serious  inconve- 
nience, condemn  that  practice.  On  the  contrary,  Mr. 
Guthrie  lays  it  down  as  a general  rule,  subject  to  a few 
exceptions,  that  a ball  shall  never  be  allowed  to  remain 
in  a bone  ; for,  says  he,  ■*  if  a hall  lodge  in  the  head  of 
a bone,  and  is  not  removed,  it  generaliy  causes  caries 
of  the  bone,  disease  of  the  joint,  amputation,  or  death. 
If  in  the  shaft  of  a long  bone,  necrosis  for  the  most  part 


GUN-SHOT  WOUNDS. 


439 


follows,  witli  months  and  j’ears  of  misery.  On  a flat 
bone  caries  is  equally  the  result,  and  if  it  be  .surrounded 
by  large  musdes,  sinuses  form  in  various  directions, 
contractions  of  the  limb  take  place,  and  the  patient 
drags  on  for  years,  careless  of  life,  and  ready  to  submit 
to  any  thing  to  obtain  relief.” — {On,  Gun-shot  Wounds, 
p.  91.  93,  ed.  2.)  In  many  of  these  cases  one  thing  de- 
serves to  be  recollected,  however,  that  the  necrosis, 
abscesses,  and  sinuses  are  less  the  effect  of  the  lodge- 
ment of  the  ball,  than  of  the  violence  originally  com- 
mitted on  the  parts  against  which  it  has  struck.  Al- 
though Baron  Larrey  only  sanctions  the  attempt  to 
remove  balls  with  a trephine  when  they  actually  pro- 
duce dangerous  effects  (3/'’ /n.  de  Chir.  Mil.  t.  4,p.  185), 
I am  disposed  to  believe  that  whenever  the  situation 
of  the  ball  is  such  that  it  can  be  removed  at  once  from 
a bone  with  tolerable  certainty,  and  without  too  much 
irritation,  the  practice  is  commendable.  This  branch  of 
the  treatment  of  gun-shot  wouhds  appears  to  me  still 
to  require  farther  elucidation,  for  though  experience 
has  been  abundant,  the  right  rules  and  principles  of 
practice  are  not  yet  laid  down  in  the  best  modern  works. 

As  soon  as  the  requisite  incisions  are  made,  and 
foreign  bodies  extracted,  the  prime  objects  in  the. treat- 
ment of  gun-shot  wounds  are  accomplished,  and  the 
rest  is,  in  reality,  not  different  from  the  surgery  of 
other  wounds. 

With  regard  to  probing  gun-shot  wounds ; when  it 
is  evident  that  the  shot  has  passed  out,  and  no  particu- 
lar object  can  be  fulfilled  with  the  probe,  it  is  often 
better  to  dispense  with  such  examination,  at  least  till 
suppuration  has  come  on.  Introducing  any  instrument 
is  generally  productive  both  of  pain  and  irritation.  But 
when  the  ball  or  any  other  extraneous  substance  has 
lodged  in  the  w’ound,  and  its  situation  is  not  imme- 
diately evident,  it  will  often  be  advisable  to  search  for 
it  at  once,  in  order  that  it  may  be  extracted,  if  its  situa- 
tion will  allow,  before  inflammation  begins.  The  sur- 
geon, therefore,  considering  all  the  circumstances  which 
can  assist  him  in  forming  a reasonable  conjecture  of 
the  course  of  the  wound,  must  give  to  a probe  that 
curvature  or  form  which  he  thinks  most  likely  to  pass 
readily  along  it,  and  must  then  proceed  to  make  the 
examination.  But  when  this  is  verj"  painful,  and  the 
course  of  the  wound  obscure,  it  will  often  bo  better  to 
desist,  and  renew  the  search  when  suppuration  has 
taken  place,  in  which  stage  it  can  be  undertaken  with 
more  ease  and  a greater  prospect  of  success.  When 
gun-shot  wounds  are  inflamed,  the  tenderness  and 
swelling  of  the  parts  are  peculiarly  strong  reasons 
against  painful  probings,  or  efforts  to  extract  foreign 
bodies  as  long  as  this  state  lasts. — (See  Chevalier  on 
Gun-shot  Wo-unds,  p.  67,  68,  edit.  3.) 

There  is  no  fact  in  the  practice  of  surgery  better 
established  than  that  the  cramming  of  narrow  stabs 
and  gun-shot  wounds  with  lint  is  particularly  hurtful. 
The  only  possible  rea.son  for  doing  so  in  the  latter  cases 
must  be  to  keep  the  orifice  of  the  wound  from  healing 
up,  and  confining  extraneous  bodies,  matter,  &c.  The 
apprehension  of  this  happening  at  first  is  quite  un- 
founded ; for  the.  inside  of  the  mouth  of  the  injured 
part  is  often  lined  with  a slough  or  eschar,  which 
must  necessarily  be  detached  before  the  parts  can  heal. 
The  first  dressings,  therefore,  should  be  quite  superfi- 
cial, and  of  a mild,  unirritating  nature.  On  the  field 
of  battle,  indeed,  it  would  be  well  for  many  of  the 
wounded,  if  the  surgeon  were  to  content  himself  with 
applying  simple  pledgets,  and  covering  the  part  with 
linen  wet  with  cold  water.  This  method  would  prove 
much  more  beneficial  than  the  hasty  and  indiscriminate 
use  of  adhesive  plasters,  sutures,  and  tight  bandages, 
from  the  bad  effects  of  which  thousands  of  soldiers 
have  lost  limbs  or  lives,  which,  under  more  judicious 
treatment,  might  have  been  saved.  Hunter  used  to 
employ  fomentations,  pledgets  of  simple  ointments, 
and  frequently  over  the  latter  an  emollient  poultice. 
In  the  suppurative  stage  of  gun-shot  wounds  poultices 
are  generally  allowed  to  be  the  best  applications. 

Possessing  these  ideas,  I cannot  altogether  approve 
the  following  directions,  though  they  are  certainly  bet- 
ter than  are  given  in  many  surgical  books.  “ A small 
bit  of  soft  lint  may  be  placed  lightly  between  the  lips 
of  the  wound,  in  order  to  keep  it  from  closing.  In 
some  instances,  it  should  be  introduced  a little  beyond 
the  lips,  in  order  to  conduct  off  the  fluids  effiLsed,  and 
to  prevent,  irregular  adhesions  from  forming  near  the, 
surface  during  the  inflammatory  stage;  as  these 


would  impede  the  direct  exit  of  the  discharge.  But 
the  wound  is  not  to  be  filled  with  lint,  much  lesq 
crammed  with  it.  A pledget  of  some  simple  ointment 
being  then  laid  on  with  tow  or  cloths  to  receive  the 
discharge,  and  these  prevented  from  coming  off  by  a 
bandage  loosely  ajjplied,  the  patient  may  be  put  to  bed, 
and  so  placed,  if  possible,  as  to  keep  the  orifice  of  the 
wound  dependent.”— (C/ieoaZjer,p.  125, 126.)  The  rea- 
sons for  what  I consider  objectionable,  namely,  intro- 
ducing lint  on  first  dressing  the  wound,  are  too  frivolous 
to  need  comment. 

In  considering  the  effects  of  poultices  and  cold  appli- 
cations upon  gun-shot  wounds,  Mr.  Guthrie  expresses 
his  decided  preference  to  the  use  of  cold  water : — “ The 
inflammation  is,  in  some  instances,  materially  pre- 
vented, in  many  greatly  controlled,  and,  in  almost  all, 
very  much  subdued  by  it,  while  the  suppurative  pro- 
cess is  not  impeded,  m the  generality  of  cases,  in  a 
degree  sufficient  to  interrupt  the  subsequent  one  of 
granulation.  In  all  simple  cases  of  gun-shot  wounds, 
that  is  to  say,  flesh  wounds,  in  persons  of  a healthy 
constitution,  a piece  of  lint  which  has  been  dipped  in 
oil,  or  bn  which  some  ointment  has  been  spread,  is  the 
best  application  at  first  to  prevent  irritation,  with  two 
slips  of  adhesive  plaster  placed  across  to  retain  it  in 
its  situation.  A compress,  or  some  folds  of  linen 
wetted  with  cold  water,  are  then  to  be  applied  over -it, 
and  kept  constantly  wet  and  cold,  even  by  the  use  of 
ice,  if  it  can  be  obtained, .and  be  found  comfortable  to 
the  feelings  of  the  patient.  A roller  is  of  no  use,  ex- 
cept to  prevent  the  compress  from  changing  its  position 
during  sleep,  and  is,  therefore,  at  that  period  useful ; 
but  as  a surgical  application  it  is  useless,  if  not  posi- 
tively injurious,  because  it  binds  a part  which  ought, 
to  a certain  extent,  to  swell,  and  by  pressure  causes 
irritation.  Rollers  ought  not  to  be  applied  surgically 
until  after  some  days  have  elapsed,  and  it  is  inexpe- 
dient to  employ  them  in  the  field  of  battle,  even  if  they 
were  useful,  except  where  some  parts  are  to  be  kept  in 
position  ; because,  when  they  are  applied  in  the  first 
instance,  they  soon  become  stiff  and  bloody,  are  for 
the  most  part  cut,  and  are  seldom  preserved  after  the  first 
dressing  so  as  to  become  useful  at  the  period  when  the  sur- 
gical application  of  a roller  is  indispensable.”  To  this 
just  censure  of  the  wrong  employment  of  rollers,  Mr. 
Guthrie  annexes  some  remarks,  in  which  he  enters 
into  a general  condemnation  of  poultices,  as  applica- 
tions to  gun-shot  wounds,  believing  that,  in  many  in- 
stances, cold  water  may  be  employed  with  the  best 
effect  during  the  whole  progress  of  the  cure.  These 
remarks  are  tempered  with  the  following  admission : 
— “ Cold  water  is  not,  however,  an  infallible  or  even 
always  an  advantageous  remedy : there  are  many  per- 
sons with  whom  cold  applications  do  not  agree ; there 
are  more  with  whom  they  disagree  after  a certain  pe 
riod;  and,  in  either  case,  they  should  not  be  persisted 
in.  Cold  does  no  good  in  any  stage  of  inflammation, 
when  the  sensation  accruing  from  the  first  application 
of  it  is  not  agreeable  to  the  feelings  of  the  patient ; 
when,  in  fact,  it  does  not  give  relief;  for  if  it  produces 
a sensation  of  shivering,  or  an  uncomfortable  feeling 
of  any  kind,  with  stiffness  of  the  part,  it  is  doing 
harm,  and  a change  to  the  genial  sensation  of  warmth 
will  not  only  prove  more  agreeable  but  more  advan- 
tageous. This  occurs  in  general  about  the  period 
when  suppuration  has  taken  place;  and  cold,  in  such 
cases,  is  preventing  the  full  effect  of  the  action  which 
warmth  encourages.  Fomentations  are  then  proper; 
and  if  a poultice  be  preferred  for  convenience  by  day 
or  by  night,  an  evaporating  one  of  bread  will  be  found 
sufficient.  In  the  spring  of  the  j'ear,  the  marsh  mal- 
low makes  an  excellent  poultice,  and  so  do  turnij)s, 
gourds,  carrots,  &c.,  independently  of  oatmeal,  linseed 
meal,  Indian  meal,  and  other  farinaceous  substances. 

In  all  those  cases  where  a poultice  is  resorted  to,  as 
much  attention  is  to  he  paid  to  the  period  of  removing 
as  of  applying  it.  It  is  used  to  alleviate  pain,  stiff- 
ness, swelling,  the  uneasiness  arising  from  cold,  and 
to  emrourage  the  commencing  or  interrupted  action  of 
the  vessels  towards  the  formation  of  matter ; and  as 
soon  as  the  effect  intended  has  been  gained,  the  poul- 
tice .should  be  abandoned,  and  recourse  again  had  to 
cold  water  with  comi)re.ss  and  bandage.”— (.^.  62 — 67, 
ed.  2.)  Although  I fully  coincide  with  Mr.  Guth- 
rie, respecting  the  general  advantage  of  cold  water, 
the  dangers  of  tight  bandages,  and  the  bad  effects  of 
continuing  poultices  too  long,  I do  not  ioin  him  in 


440 


GUX-SnOT  WOUXDS. 


many  of  the  sentiments  which  he  has  exitrcssed  about  ' 
these  last  invaluable  applications.  On  the  contrary,  T 
appreciate  them  as  the  best  means,  wherever  a slough 
is  to  be  thrown  off  or  matter  is  decidedly  forming,  and 
as  these  elfects  are  very  frequent  in  cases  of  gun-shot 
wounds,  my  own  opinion  of  the  utility  of  cold  appli-  | 
cations  is  limited  to  the  first  three  or  four  days  after  | 
the  receipt  of  the  injury.  Nor  ought  cold  applications  j 
ever  to  be  continued  where  the  torpor,  low  tempera-  | 
ture,  and  languid  circulation  in  the  limb  indicate  a 
risk  of  gangrene.  Hence,  when  a principal  artery  is  ; 
tied,  their  employment  is  always  wTong  and  hazardous,  i 
At  the  same  time  I have  no  hesitation  in  declaring  my  ; 
firm  belief,  that  fifty  times  more  mischief  has  been  | 
done  by  tight  rollers  applied  to  recent  gun-shot  wounds,  : 
than  by  either  poultices  or  cold  applications.  I 

Formerly,  w'hen  the  track  of  the  ball  had  two  aper-  | 
tnres,  a seton  was  sometimes  drawn  through  it,  with  ! 
the  view  of  preventing  a premature  closure  of  the  j 
wound,  and  introducing  proper  applications.  The  I 
seton  was  also  imagined  to  give  free  vent  to  pus,  and  | 
to  promote  the  evacuation  of  foreign  bodies.  But  a i 
gun-shot  wound  is  little  inclined  to  close  prematurely,  1 
and  while  a seton  rather  obstructs  the  exit  of  pus,  it  ' 
may  as  easily  push  foreign  bodies  more  deeply  into  the 
limb,  as  out  of  it.  There  are  preferable  modes  of  ap- 
plying the  necessary  remedies,  and  as  a seton  is  an 
extraneous  substance  itself,  its  employment  cannot  fail 
to  be  highly  pernicious. 

Gun-shot  wounds  generally  demand  the  employment 
of  antiphlogistic  means,  just  as  other  cases,,  attended 
with  equal  inflammation.  When  they  are  in  the  in- 
flamed state,  the  application  of  leeches  is  highly  pro- 
per. In  these  cases  bleeding  Ls  recommended,  and  in 
such  a manner  as  if  it  w'ere  of  more  service  in  them 
than  wounds  in  general.  But  the  necessity  for  the 
practice  is  really  not  greater  than  in  other  wounds, 
which  have  done  the  same  degree  of  mischief,  and 
from  which  the  same  quantity  of  inflammation  and 
other  consequences  are  expected.  Bleeding  is  cer- 
tainly proper  here,  just  as  it  is  in  all  considerable 
wounds  attended  with  a strong,  full  habit,  and  great 
chance  of  extensive  inflammation,  and  much  symp- 
tomatic fever.  In  every  instance,  however,  the  prac- 
titioner must  take  particular  care  not  to  be  too  bold  in 
the  practice  of  bleeding ; for  when  the  patient  is  re- 
duced below  a certain  degree,  his  .strength  is  inade- 
quate.to  support  the  large  and  long-continued  suppura- 
tions which  often  cannot  be  avoided. — (See  Hunter,  p. 
503,  564.) 

As  the  orifices  of  the  vessels  torn  by  the  ball  are  com- 
pressed, and,  as  it  were,  obliterated,  sometimes  no  hemor- 
rhage of  importance  is  remarked  at  first.  But  as  I have 
already  stated,  after  some  days,  and  frequently  at  a very 
late  period,  when  the  sloughs  separate,  copious  he- 
morrhages may  occur,  which  are  the  more  dangerous  as 
they  come  on  unexi)ected!y,  and  often  when  the  sup- 
puration has  already  induced  great  debility.  The  sur- 
geon himself  may  occasion  the  bleeding,  by  removing 
the  dressings  carelessly.  Hence,  in  every  case  where, 
from  the  situation  of  the  w^ound,  there  is  reason  to  ap- 
prehend injury  of  some  considerable  vessel,  the  patient 
must  be  constantly  and  attentively  w^atched,  and  every 
thing  necessary  for  the  immediate  stoppage  of  hemor- 
rhage provided. 

Another  kind  of  hemorrhage,  still  more  dangerous 
than  the  former,  particularly  occurs  in  such  gun-shot 
wounds  as  have  long  been  in  a state  of  copious  suppu- 
ration. The  blood  does  not  issue  from  one  individual 
vessel,  but  from  the  w-hole  surface  of  the  wound,  as 
from  a sponge,  and  is  so  thin  as  to  resemble  blood  and 
water.  This  hemorrhage  is  very  dangerous,  because 
it  is  particularly  apt  to  exhaust  the  patient,  who  is  al- 
ready debilitated,  and  its  causes  are  difficult  of  removal. 
The  ca.se  demands  the  exhibition  of  bark  and  diluted 
sul  phuric  acid ; the  decoction  of  bark  with  a propor- 
tion of  muriatic  acid  being  applied  to  the  wound.— 
(Richter.) 

Gun-shot  wounds  in  crowded  military  hospitals,  es- 
pecially when  they  are  established  in  unhealthy,  low 
situations,  and  due  attention  is  not  paid  to  ventilation, 
cleanliness,  and  fumigations  with  nitric  acid  gas,  are 
often  attacked  with  hospital  gangrene,  a very  serious 
and  dangerous  complication,  of  which  I sh^l  speak 
under  the  head  of  Hnftpital  Gangrene. 

Ihe  plan  of  removing  the  first  dressings  too  soon  is 
aa  injurious  in  gun-shot  wounds  as  other  cases,  by 


cre.ating  a premature  disturbance  of  the  parts.  This 
observation  is  particularly  true  where  dry  lint  has  lieen 
used,  and  it  is  adherent  to  the  wound.  Unle.ss  the  oc- 
currence of  bleeding,  severe  pain,  or  other  untoward 
symptoms  were  to  render  a different  line  of  conduct 
necessary,  I think  such  dressings  should  rarely  be  re- 
moved before  the  end  of  the  fourth  day.  And  if  cold 
water  has  not  been  continually  applied  over  the  lint, 
so  as  to  keep  it  moist,  or  if  such  lint  has  not  been 
spread  wnth  some  mild  salve  or  dipped  in  oil,  I deem  it 
a good  rule  to  apply  an  emollient  poultice  over  it  the 
evening  preceding  the  morning  on  which  the  dressings 
are  to  be  first  changed.  By  this  means  they  will  be 
loosened,  and  admit  of  being  taken  away  without  pain 
or  irritation.  With  the  same  view,  plenty  of  warm 
water  should  be  squeezed  from  a sponge,  and  allow'cd 
to  fall  upon  the  dressings.  Pledgets  of  oil  or  ointment 
should  generally  be  taken  off  earlier  than  dry  lint,  tor 
they  are  less  adherent,  and,  in  warm  weather,  soon  be- 
come rancid  and  irritating. 

For  a few  days  the  matter  seldom  assumes  a healthy 
appearance;  but  as  soon  as  the  sloughs  separate,  it 
then  becomes  of  a proper  quality,  and  the  wound  is  to 
be  treated  as  a simple  abscess. 

Sometimes  the  healing  process  does  not  commence, 
though  suppuration  has  prevailed  a considerable  time. 
On  the  contrary,  notwithstanding  the  exhibition  of  to- 
nics and  a generous  diet,  the  suppuration  ceases  to 
proceed  favourably,  and  the  wound  becomes  unhealthy, 
and  the  matter  thin.  The  bones  show  no  disposition 
to  unite,  and  the  patient,  reduced  by  hectic  symptoms, 
is  rapidly  approaching  dissolution.*  In  this  state,  life 
may  sometimes  be  preserved  by  amputation  ; the  anccp.s, 
but  unicum  rtmedium.  We  ought  never  to  be  de- 
terred from  undertaking  the  operation  by  the  fever  and 
weakness,  which  frequently  soon  disappear  when  the 
local  cause  is  removed. 

or  A.MPI.'TATION  IN  CASKS  OF  GUN-SHOT  W Ol  Kp.v. 

The  2d  edition  of  this  Dictionary',  publi.shed  in  1813, 
contained  all  the  valuable  observations  of  Baron  Lar- 
rey  in  favour  of  immediate  amputation  in  every'  in- 
stance in  which  the  operation  is  considered  indispen- 
saole.  Since  then,  the  public  have  been  favoured  w ith 
several  good  practical  books,  in  which  the  propriety 
and  necessity  of  early  or  immediate  amputation  in 
such  cases  are  urgently  inculcated,  and  the  truth  of 
the  doctrine  is  illustrated  by  additional  facts.  It  is  to 
be  observed,  however,  tha't  for  nearly  two  hundred 
y'ears  past,  there  have  always  been  some  advocates  for 
this  judicious  practice.  “ Du  Chesne  (says  Dr.  .1. 
Thomson)  is  the  first  writer  on  military  surgery,  in  who.se 
works  I have  found  the  recommendation  to  amputate 
in  the  severe  injuries  of  the  extremities;  and  it  is 
worthy  of  remark,  that  he  directs  the  operation  to 
be  performed  before  infiommation  and  other  constitu- 
tional symptoms  shall  have  supervened.” — (See  Trait e 
de  la  Cure  gendrale  ct  particuliere  des  Arebusades,  par 
Jos.  Du  Chesne,  Paris,  1625,  p.  143;  and  Thomson's 
Report,  i c.  p.  160.)  Wiseman  not  only  recomm.ended 
and  practised  immediate  amputation,  but  the  same 
thing  w'as  not  unfrequently  done  by  the  military  sur- 
geons of  his  time. — (Chimrgical  Treatises,  by  R.  Wise- 
man, 3d  edit.  Land.  1696,  p.  410.)  3'he  celebrated  I.o 
Dran,  in  his  excellent  little  manual  of  military' surgery, 
declared  himself  an  advocate  for  immediate  amputa- 
tion in  all  cases  in  which  that  operation  from  the  first 
appears  to  be  indispensable.  Le  Dran  has  at  the  same 
time  stated  briefly,  but  most  distinctly,  the  compara- 
tive advantages  of  that  practice,  with  those  which  may 
be  expected  by  delay. — (See  Traite  ou  Reflexions  tir  e.s 
de  la  Pratique  sur  les  Plaies  d' Amies  d feu,  par  H.  F. 
Le  Dran,  d Paris,  1737.)  Ranby,  who  was  sergeant- 
surgeon  to  king  George  II.,  entertained  similar  opi- 
nions to  those  of  Le  Dran,  with  regard  to  the  utility  of 
immediate  amputation.  In  order  to  give  immediate 
relief  to  the  wounded,  and  to  facilitate  the  performance 
of  the  necessary  ojierations,  Ranby  proposed  that  the 
surgeons,  during  battle,  .should  be  collected  into  small 
bodies,  and  stationed  in  the  rear  of  the  army. — (See 
The  Method  of  Treating  Gun-shot  Wounds,  by  John 
Ranby,  edit.  3,  p.  29,  Londm,  1781.) 

After  the  battle  of  Fontenoy,  in  the  year  1756,  the 
Royal  Academy  of  Surgery  in  France  offered  a prize 
for  the  best  dissertation  on  the  gun-shot  injuries  re- 
quiring immediate  amiiutation.  and  on  other  c.n  -os  of  the 
same  nature,  where  the  operation,  though  deemed  i 


GUN-SIIOT  WOUNDS. 


441 


evitable,  might  be  dclaj'ed.  “ IJcanputatim.  Hant  ab- 
solument  nScessaire  dans  les  plaies  compliquees  de 
fracas  des  os,  et  principalement  celles  qui  sont  faites 
par  armis  d feu,  determiner  les  cas  ou  il  faut  faire 
I'opcration  sur  le-  champ,  et  ceux  ou  il  convimt  de  la 
diferer,  et  en  donner  les  raisonsy  The  prize  ^vas  ad- 
judged to  the  dissertation  of  M.  Faure,  the  main  object 
of  whose  paper  was  to  recommend  delaying  the  opera- 
tion. The  side  of  the  question  espoused  by  M.  Faure 
has  found  some  modern  advocates  of  distinguished 
talents  and  celebrity.  Suffice  it  to  mention  the  names 
of  Hunter,  Baron  Percy,  and  Lombard.  It  is,  how- 
ever, only  justice  to  M.  Faure  to  state  in  this  place, 
that  though  he  regarded  immediate  amputation  as  full 
of  danger,  he  adrnitted  that  there  were  several  kinds  of 
injuries  of  the  extremities  in  which  it  Avas  indispen- 
sably and  immediately  required.  “ The  enumeration 
(says  Dr.  Thomson)  which  this  author  has  gi\'eo  of 
these  injuries  is  more  full  and  distinct  than  any  which 
had  been  published  before  his  time;  and,  what  may  ap- 
pear singular,  it  does  not  differ,  in  any  essential  re- 
spect, from  the  enumerations  given  by  later  uriters, 
Avho,  in  combating  his  opinions,  have  represented  him 
as  an  enemy  to  amputation  in  almost  all  injuries  of  the 
extremities. — (See  Report  of  Observations  made  in  the 
Military  Hospitals  in  Belgiun,  p.  169.) 

In  1792,  Baron  Percy,  who  was  a few  years  ago  at  the 
head  of  the  medical  department  of  the  r reach  army, 
published  a book,  in  which  he  gives  a preference  to  de- 
laying amputation  at  first,  even  in  cases  where  it  is  cer- 
tain that  the  operation  cannot  ultimately  be  dispensed 
AAdth.— (See  Manuel  de  Chirurgien  d'Armee.)  Even  as 
late  as  1804,  Lombard,  professor  in  the  Military  Aca- 
demy of  Strasburg,  defended  the  doctrines  of  M.  Faure. 
—(See  Clinique  Chirurgicale  des  Plaies  faites  par  Ar- 
mes  d feu.) 

Although  in  France  the  Academy  of  Surgery  thought 
proper  to  decree  the  prize  to  M.  Faure,  whose  doctrine 
thus  received  the  highest  approbation,  yet  in  that  coun- 
try very  opposite  tenets  were  set  up  by  some  men  of 
distinguished  talents  and  extensive  military  practice. 
Thus,  Le  Dran,  consulting-surgeon  to  the  French  army, 
in  his  work  on  gun-shot  wounds,  publi.shed  in  1737,  ex- 
pressly states,  “ that  when  the  amputation  of  a limb  is 
indispensably  necessary  in  the  case  of  a gun-shot  wound, 
it  ought  to  be  done  without  delay.” — (Aphorism  9.)  De 
la  Martinidre  in  particular  also  wrote  some  excellent  ar- 
guments in  rejtly  to  Bilguer ; arguments  which,!  think, 
would  do  honour  to  the  most  accomplished  surgeon  of 
the  age  in  wliich  aa'b  live. — (See  M moire  sur  le  Traite- 
ment  des  Plaies  d'Armes  d feu,  in  M m.  de  VAcad.  de  Chi- 
rurgie,  t.  ll,p.  1.  edit,  in  12/rto.)  M.  Boucher,  of  Lisle, 
was  an  advocate  for  the  same  side  of  the  question. — (See 
Obs.  sur  des  Plaies  d'Armes  d feu,  i,c.  inMem.de  VAcad. 
de  Chir.  t.  5,  p.  279,  li-c.  edit,  in  12/no.)  Schmucker,  who 
Avas  many  years  surgeon-general  to  the  Prussian  armies, 
published  in  1776  an  essay  on  amputation,  in  which  he 
particularly  mentions,  that  during  his  stay  at  Paris,  in 
1738,  the  surgeons  of  the  Hdtel  Dieu  had  been  in  the 
habit  of  performing  immediate -amputation  in  severe  in- 
juries of  the  extremities.  He  also  declares  himself  an 
advocate  for  operating  immediately  in  all  cases,  in 
which  amputation  from  the  first  appears  to  be  necessary, 
and  insists,  in  a particular  manner,  on  the  increased 
danger  which  he  had  seen  arise  from  the  ojieration 
during  the  second  period.  He  gives  (as  Dr.  J.  Thomson 
has  observed)  a-minute  and  circumstantial  enumeration 
of  those  injuries,  both  of  the  up])er  aiKi  lower  e.xtremi- 
ties,  in  which  he  conceived  amputation  to  be  necessary, 
and  in  many  of  which  he  had  actually  performed  it  with 
great  success.  Schrnuc-ker  appears  to  Dr.  Thomson  to 
have  given  a better  account  than  any  preceding  military 
surgeon  of  the  injuries  of  the  thigh;  and  from  the  re- 
sults of  his  experience,  he  was  led  to  belie\'e,  that 
tlunjgh  compound  fractures  of  the  lower  part  of  the 
thigh-bone  might,  in  favourable  circumstances,  be 
cured  vhthout  amputation,  yet  that  this  operation  is 
peculiarly  necessary  in  all  cases  in  which  the  fracture  is 
situated  hi,  or  above,  the  middle  of  that  bone. — (J.  L. 
Srh.nucker,  Vermi.schte  Chirurgische  Schriften,  l>.  1, 
li.  rlin,  1785).  With  the  foregoing  high  autiiority  we 
have  to  join  one  of  not  less  celebrity,  namely,  that  of 
Baron  Larrey,  who  has  proved  most  convincingly,  that 
when  amputation  is  to  be  done  in  cases  of  gun-shot 
wound.s,  nothing  is  so  pernicious  as  delay. — (See  Me- 
rnoires  de  (thirurgie  Militaire,  tom.  2,  p.  451,  it  c.) 

it  becomes  me  here  to  state  also,  that  the  principles 


inculcated  by  Baron  Larrey  are,  in  point  of  fact,  the 
same  as  those  which  were  so  strennou.sly  insisted 
u;)on  by  Mr.  Pott,  whose  principal  remarks  on  the  ne- 
cessity of  amputation  in  certain  cases  are  detailed  in 
another  part  of  this  publication. — (See  Amputation.) 
Mr.  Pott,  indeed,  Avas  not  an  army-surgeon,  and  Avhat  he 
says  was  not  particularly  designed  to  apply  to  military 
jiractice  ; but  he  has  represented,  as  well  as  any  body 
can  do,  the  propriety  of  immediate  amputation  for  inju- 
ries AA'hich  leave  no  doubt  that  such  operation  cannot  be 
dispensed  Avith. 

Mr.  .lohn  Bell,  among  the  moderns,  appears  to  me 
likeAvise  to  have  much  merit  for  the  able  manner  in 
which  he  defended  the  propriety  of  early  affiputation, 
long  before  the  sentiments  of  later  AA'riters  were  ever 
heard  of.  He  distinctly  states,  that  “ amputation  should, 
in  those  cases  where  the  1 imb  is  plainly  and  i rrecoverably 
disordered,  be  performed  upon  the  spot.” — (See  Dis- 
courses on  the  Nature,  S,c.  of  Wounds,  p.  488,  edit.  3.) 
In  short,  notAAdthstandmg  all  the  modern  pretensions  to 
novelty  upon  this  interesting  topic,  we  must  acknow- 
ledge, with  Dr.  Thomson,  that  the  evidence  in  favour 
of  the  advantages  of  immediate  amputation,  has  always 
preponderated  over  that  for  delay. — (See  Report  ef  Obs. 
made  in  the  Military  Hospitals  in  Belgium,  p.  225.) 

The  strongest  body  of  evidence  upon  this  matter  is 
undoubtedly  adduced  by  Baron  Larrey,  whose  situation 
at  the  head  of  the  medical  department  of  the  French  ar- 
mies aflbrded  him  most  numerous  oiiportunities  of  judg- 
ing from  actual  experieneg.  “ Upon  this  subject  (says 
he),  now  that  twenty  years  of  continual  war  have  car- 
ried our  art  to  the  highest  pitch  of  perfection,  there  can 
only  be  or,e  opinion.  It  is  after  having  incessantly  di- 
rected the  medical  service,  all  this  time,  in  quality  of 
head-surgeon  and  inspector-general  of  the  armies,  that 
1 proceed  to  discuss  the  different  opinions  delivered  in 
the  Academy,  and  to  settle  definitively  this  great 
question,  AA  hich  I regard  as  the  most  important  in  mi- 
litary surgery. 

If  we  are  to  be  told  that  the  amputation  of  a limb  is  a 
cruel  operation,  dangerous  in  its  consequences,  and  al- 
ways grievous  to  the  ])atient  who  is  thereby  mutilated  ; 
that,  consequently,  there  is  more  honour  in  saving  a 
limb,  than  in  cutting  it  off  w'ith  dexterity  and  success ; 
these  arguments  may  be  refuted  by  ansAvering,  that 
amputation  is  an  operation  of  necessity,  which  offers  a 
chance  of  preservaxon  to  the  unfortunate,  whose  death 
appears  certain  under  any  other  treatment ; and  that  if 
any  doubt  should  exist  of  amputation  being  absolutely 
indispensable  to  the  patient’s  safety,  the  operation  is  to 
be  deferred,  till  nature  has  declared  herself,  and  given 
a positive  indication  for  it.  We  are  also  justified  in 
adding,  that  this  chance  of  preservation  is  at  the  pre- 
sent day  much  greater  than  at  the  epoch  of  the  Aca- 
demy of  Surgery.  We  learn  from  M.  Faure,  that  of 
about  three  hundred  amputations,  performed  after  the 
battle  of  Fontenoy,  only  thirty  were  followed  by  suc- 
cess, while,  on  the  contrary  (says  Baron  Larrey),  Ave 
haA'e  saved  more  than  three-fourths  of  the  patients  on 
whom  amputation  has  been  done,  and  some  of  whom  also 
had  two  limbs  removed.”  This  improvement  is  ascribed 
by  Larrey,  1.  To  our  now  knowing  better  how  to  take 
advantage  of  the  indication  and  favourable  time  for 
amputating.  2.  To  the  bettor  method  of  dn  .ssing.  3.  To 
the  mode  of  operating  being  more  simple,  less  painful, 
and  more  expeditious  than  that  formerly  in  vogue. 

To  the  preceding  authorities  against  delaying  ampu- 
tation, in  cases  of  gun-shot  wounds  requiring  .such  oj)e- 
ration,  I have  to  add  Mr.  Guthrie,  deputy-insiiector  of 
military  hospitals,  whose  opportunities  of  observation, 
during  the  late  war  in  S}tain,  were  particularly  exten- 
sive. In  his  work  he  has  detailed  the  opinions  of  many 
eminent  foreign  and  British  surgeons,  respecting  the 
propriety  or  impropriety  of  the  doctrine  of  immediate 
ami)Utation ; and  he  has  introduced  some  good  criti- 
cisms, particularly  on  Bilguer’s  statement  of  the  suc- 
cess which  was  experienced  in  the  Prussian  hospitals 
from  not  performing  the  operation.  Mr.  Guthrie,  how- 
ever, does  not  recommend  amputation  to  be  done  immer 
diately,  if  the  patient  be  particularly  depressed  by*  the 
shock  of  the  injury  directly  after  its  roceij)t;  a [decc  of 
advice,  which,  1 believe,  has  in  reality  been  at  ail  times 
followed,  not  only  in  respect  to  amputations  in  cases  of 
gun-shot  wounds,  but  all  other  severe  loi-al  injuries.  “ I 
believe  it  to  be  (says  Mr.  Guthrie)  a stretch  of  fancy  in 
those  surgeons  aa'Iio  conceive  that  if  the  knife  folloAA'ed 
the  shot  in  all  cases,  the  patient  would  have  the  best 


442 


GUN-SHOT  WOUNDS 


chance  of  sticcess.  No  one  will  deny  that  if  the  shot 
performed  a regular  amputation,  it  would  not  be  better 
than  to  have  it  to  do  afterward : but  if  they  mean  to 
say  the  operation  should  in  general  be  performed  im- 
mediately after  the  injury,  I can  only  oppose  to  them  the 
facts  above  stated,  and  the  general  result  of  my  experi- 
ence, which  is  decideuiy  in  favour  of  allowing  the  first 
moments  of  agitation  to  pass  over  before  any  tiling  be 
done  ; a period  extending  from  that  to  one,  six,  or  eight 
hours,  according  to  the  difference  of  constitution  and 
the  different  injuries  that  have  been  sustained.  But 
/rom  one  to  three  hours  will  in  most  cases  be  found 
sufficient. — (On  Gun-shot  Wounds,  p.  226,  edit.  2,  Lond. 
1820.)  In  the  first  edition  of  tins  gentleman’s  book, 
some  little  want  of  precision  rather  concealed  his  exact 
meaning  with  re.specttothe  period  of  time  which  should 
generally  be  allowed  to  transpire  between  the  receipt 
of  the  injury  and  the  performance  of  amputation;  but 
after  alt  the  disposition  to  controversy  upon  this  point, 
it  appears  there  is  little  to  fight  about,  as  there  is  rather 
a misunderstanding  than  a difference  of  opinion.  All 
acknowledge  the  advantage  of  doing  the  operation  im- 
mediately, when  the  patient  is  not  faint  and  depressed 
by  the  shock  of  the  accident ; all  admit  the  prudence 
of  deferring  the  use  of  the  knife  in  other  cases  until  the 
constitution  has  revived  sufficiently  to  be  capable  of 
bearing  the  removal  of  the  limb.— <See  A.  C.  Hutchi- 
son, Pract.  Obs.  in  Surgery,  8vo.  Lond.  edit.  2 ; and 
his  farther  Observations  an  the  proper  Period  for  am- 
putating in  Gun-shot  Wounds,  1817.  Quarrier,  in 
Med.  Chir.  Trans,  vol.  8 ; and  Dewar,  in  Med.  Chir. 
Journ.  April,  1819.) 

As  far  as  my  experience  goes,  when  the  necessity  of 
amjiutation  is  undoubted,  all  delay  is  improper  beyond 
the  short  period  during  which  the  faintness  immediately 
arising  from  the  injury  usually  lasts.  In  the  cam- 
paign in  Holland,  1814,  the  most  successful  amputations 
were  those  done  in  the  field-hospitals  directly  after  the 
arrival  of  the  patients,  or  rather,  as  Dr.  Hennen  has 
expressed  it,  with  as  little  delay  as  possible.  “While 
hundreds  are  waiting  for  the  decision  of  the  surgeon,  he 
will  never  be  at  a loss  to  select  individuals  who  can 
safely  and  advantageously  bear  to  be  operated  upon,  as 
quickly  as  himself,  or  assistants,  can  offer  their  aid ; 
but  he  will  betray  a miserable  want  of  science,  indeed, 
if,  in  this  crowd  of  sufferers,  he  indiscriminately  ampu- 
tates the  weak,  the  terrified,  the  sinking,  and  the  deter- 
mined. While  he  is  giving  his  aid  to  a few  of  the  latter 
class,  encouragement  and  a cordial  will  soon  make  a 
change  in  the  state  of  the  weakly  or  the  terrified ; and 
a iongcr  period  and  more  active  measures  will  render 
even  the  sinking  proper  subjects  for  operation. — (On 
Military  Surgery,  p.  45,  ed.  2.)  It  appears  from  some 
returns  collected  by  Mr.  Guthrie,  that  in  the  Peninsula, 
the  comparative  loss,  in  secondary  or  delayed  opera- 
tions, and  in  primary  or  immediate  amputations,  was  as 
follows : — 

Secondary.  Primary. 

Upper  extremities  ....  12  . to  . 1 

Lower  extremities  ....  3 . to  . 1 

The  great  success  attending  amputation  on  the  field 
of  battle  was  also  convincingly  proved  after  the  battle 
of  Toulouse.  Here,  of  47  immediate  amputations,  38 
were  cured,  while  of  the  51  delayed  operations,  on  that 
occasion,  21  had  fatal  terminations. — (P.  42 — 44,  ed.  1.) 
After  the  j^ttack  on  New-Orleans,  out  of  45  primary  am- 
putations, 38  patients  recovered,  while  only  2 of  7 se- 
condary amputations  terminated  in  the  preservation  of 
the  patients. — (Op.  cit.  p.  294,  edit.  2.) 

OF  IMMEDIATE  AMPUTATION. 

When  a limb  that  has  received  a gun-shot  wound 
cannot  be  saved,  amputation  should  be  immediately 
practised.  The  first  four-and-twenty  hours,  Baron 
Larrey  observes,  are  the  only  time  that  nature  remains 
tranquil  (I  should  say,  she  does  not  remain  quiet  so 
long),  and  we  must  hasten  to  take  advantage  of  this 
period  in  order  to  administer  the  necessary  remedy. 

In  the  army  a variety  of  circumstances  make  the 
urgency /or  amputation  still  greater.  1.  The  inconve- 
nience attending  the  transport  of  the  wounded  from  the 
field  of  battle  to  the  military  hospitals,  in  carriages 
badly  suspended,  the  jolting  of  which  would  produce 
such  disorder  in  the  wound,  . and  in  the  vvhole  body, 
that  most  patients  would  die  in  the  journey,  especially 
if  it  were  long,  and  the  weather  either  extremely  hot 
or  cold,  » 


2.  The  danger  of  a long  continuance  in  the  hospitals ' 
a danger  which  amputation  materially  diminishes,  by 
changing  a gun-shot  injury  into  a wound  that  may  be 
speedily  healed,  and  reducing  the  causes  of  fever,  and 
the  hospital  gangrene. 

3.  The  cases  in  which  there  is  a necessity  for  aban 
doning  the  wounded.  In  this  circumstance,  it  is  of 
importance  to  have  amputated,  for  after  the  operation 
the  patients  may  remain  some  days  without  being 
dressed,  and  the  dressings  are  afterward  more  easy. 
Besides,  it  might  often  happen,  that  these  unfortunate 
objects  would  not  meet  with  surgeons  of  sufficient  skill 
to  do  the  operation ; a circumstance,  says  Larrey,  that  we 
have  seen  happen  among  certain  nations,  whose  cara- 
vans for  the  medical  service  of  the  army  (ambulances), 
are  not  constructed  like  those  in  use  with  the  French. 

OF  CASES  IN  WHICH  AMPUTATION  SHOULD  BE  DONE 
IMMEDIATELY. 

First  ca.se.  A limb  carried  away  by  a cannon-ball, 
or  the  explosion  of  a howitzer  or  bomb,  requires  ampu- 
tation without  any  loss  of  time ; the  least  delay  puts 
the  patient’s  life  in  danger. 

in  this  case,  the  necessity  of  the  practice  is  inculcated 
by  M.  Faure  himself,  as  w^ll  as  by  Schmucker,  Rich- 
ter, Larrey,  Dr.  Thomson,  and  every  modern  writer 
upon  gun-shot  wounds. 

When  a cannon-ball  has  torn  off  a limb,  amputation 
of  the  stump  should  be  performed,  in  order  to  procure 
the  patient  an  even,  smooth  incision,  instead  of  an  irre- 
gular, jagged,  and  -highly  dangerous  wound.  As  the 
limb  has  commonly  suffered  a violent  concussion,  is  al- 
most bereft  of  sense  and  power  of  motion,  and  the 
bone  frequently  has  a fissure  extending  some  way  up- 
wards, the  amputation  is  sometimes  recommended  to 
be  done,  if  possible,  above  the  nearest  joint.  W’ere  the 
operation  not  done,  this  kind  of  injuby  would  require 
large  and  free  incisions  for  the  extraction  of  foreign 
bodies,  the  shortening  of  projecting  muscles  and  ten- 
dons, and  the  discharge  of  abscesses;  and,  as  these  in- 
cisions are  likely  to  occasion  at  least  as  much  irritation 
as  amputation  itself,  without  being  productive  of  equal 
good,  the  avoidance  even  of  pain  cannot  be  urged  as  a 
reason  against  the  practice.  The  occasional  healing  of 
such  wounds  only  proves,  that  it  is  not  altogether  impos- 
sible, in  certain  instances,  to  effect  a cure  without  ampu- 
tation. The  surgeon  can  the  more  readily  make  up  his 
mind  to  amputate,  as  in  this  case  the  operation  does  not 
occasion  the  loss  of  a limb.  As  for  the  place  of  the 
incision,  no  one  would  be  justified  in  amputating  above 
the  knee,  when  the  limb  is  injured  at  the  foot  or  ankle. 

The  skin  has  been  violently  stretched  and  lacerated; 
the  muscles  have  been  ruptured  and  irregularly  tom 
away;  the  tendons  and  aponeuroses  lacerated;  the 
nerves  and  vessels  divided  and  forcibly  dragged ; lastly, 
the  bones  broken  and  smashed  to  a greater  or  less  ex- 
tent. These  first  effects  are  followed  by  a general  or 
partial  commotion ; by  a kind  of  torpor  in  the  injured 
part,  and  a good  w'ay  above  the  wound;  by  a painful 
trembling  in  the  remains  of  the  member,  an  event  that 
is  singularly  afflicting  to  the  patient ; and  by  a local 
swelling  preceding  the  erethismus,  which  quickly 
shows  itself.  The  hemorrhage,  says  Baron  Larrey,  an 
accident  much  more  to  be  apprehended  than  has  been 
supposed,  often  comes  on  a few  moments  after  the  in- 
jury, and,  if  prompt  succour  were  not  afforded,  would 
put  a period  to  the  patient’s  existence.  “ I can  even 
declare,  that  had  it  not  been  for  the  activity  of  the  train 
of  flying  surgical  carriages  (ambulances  i-olantes),  by 
means  of  which  the  wounded  have  always  been  dressed 
upon  the  field  of  battle,  many  soldiers  wmuld  have 
perished  from  this  accident  alone.” 

If  the  operation  is  not  speedily  done,  pain  commences, 
fever  occurs,  and  the  functions  of  the  system  become 
disordered  ; the  irritation  then  increases,  and  convulsive 
motions  take  place.  If  the  patient  should  not  be  a vic- 
tim to  these  first  symptoms,  gangrene  of  the  stump 
follows,  the  fatal  consequences  of  which  it  is  extremely 
difficult  to  prevent. 

After  this  short  exposition,  it  is  easy  to  see  that,  in 
this  case,  amputation  ought  to  be  practised  im.mediately, 
and  to  delay  the  operation,  and  merely  apply  simple 
dressings,  would  be  affording  time  for  the  preceding 
accidents  to  arise.- 

At  Strasburg,  during  the  bombardment  of  the  fort  of 
Kell,  in  1792,  three  volunteers,  says  Baron  Larrey,  had 
limbs  shot  off  by  the  explosion  of  shells : one,  an  arm ; 


GUN-SHOT  WOUNDS. 


443 


aiwlher,  a forearm ; and  the  third,  a leg.  They  were 
conveyed  to  the  hospital  for  the  wounded  in  that  town, 
which  was  superintended  by  M.  Boy.  Several  days 
were  suffered  to  elapse  before  amputation  was  per- 
fornoed  ; not  one  of  the  patients  escaped. 

At  Mentz,  after  the  retreat  from  Frankfort,  several  of 
the  wounded,  who  had  had  limbs  shot  off,  did  not  have 
amputation  don?  till  some  time  afterward,  and  not  one 
of  them  recovered. 

At  Nice,  after  the  taking  of  Saourgio,  two  amputa- 
tions were  practised  at  the  hospital  No.  2,  one  of  the 
forearm,  the  other  of  the  arm,  nine  or  ten  days  after 
the  receipt  of  the  injuries : both  the  patients  died. 

At  Perpignan,  Baron  I.arrey  visited  two  soldiers,  on 
whom  amputation  had  been  done,  seven  or  eight  days 
after  the  receipt  of  gun-shot  injuries  in  the  action  of  the 
14th  of  July,  1794.  One  had  had  a leg  shot  off,  and  the 
other  his  right  arm.  Notwithstanding  Larrey’s  utmost 
care,  he  could  not  save  their  lives : one  died  of  tetanus ; 
the  other  of  gangrene. 

In  the  month  of  August,  1805,  two  cannoniers  of  the 
guards,  in  discharging  the  artillery,  had  each  a hand 
shot  away,  and  all  the  fore  part  of  their  bodies  burnt. 
These  were  the  two  men  whose  office  it  was  to  charge 
the  gun.  At  the  moment  when  they  had  just  rarrimed 
down  the  wadding  on  the  cartridge,  a spark  that  had 
been  left  unextinguished,  from  the  neglect  to  keep  the 
touch-hole  closed,  set  fire  to  the  powder:  the  ramrod 
was  violently  repelled  by  the  explosion,  together  with 
every  thing  that  was  situated  in  front  of  the  charge. 
The  right  hand  of  one  of  the  cannoniers  was  com- 
pletely torn  off,  between  the  two  phalanges  of  the  car- 
pus, and  thrown  more  than  two  hundred  paces.  The 
counter-shock  even  threw  the  man  down  into  the  ditch, 
of  the  .square  of  the  H6tel  des  Invalide.s.  The  left, 
hand  of  the  other  cannonier  was  torn  away,  together 
with  the  forearm  at  the  elbow-joint,  and  also  forced  to 
a considerable  distance.  The  tendons  and  muscles 
sustained  vast  injury,  and  the  worst  symptoms  would 
have  occurred,  if  amputation  had  not  been  instantly 
performed.  In  one  case  amputation  was  done  at  the 
wrist ; and  in  the  other  at  the  lower  third  of  the  arm. 
The  two  operations  were  followed  by  complete  suc- 
ce.ss,  although  the  burns  upon  the  face  and  chest,  in 
both  the  patients,  were  serious  and  extensive. 

Second  case.  When  a body,  propelled  by  gun- 
powder, strikes  a limb  in  such  a manner  as  to  smash 
the  bones,  violently  contuse,  lacerate,  and  deeply  tear 
away  the  soft  parts,  amputation  ought  to  be  irnmediately 
performed.  If  this  measure  be  neglected,  all  the  injured 
parts  will  soon  be  seized  with  gangrene ; and  besides, 
as  Larrey  has  explained,  the  accidents  which  the  gra- 
vity of  the  first  case  produces  will  also  here  be  excited; 

It  is  only  doing  justice  to  the  memory  of  M.  Faure  to 
state,  that  this  second  ca.se  was  one  which  he  akso  par- 
ticularly instanced  as  demanding  the  immediate  per- 
formance of  amputation. — (See  Prix  de  VAcad.  Royale 
de  Chirurgie,  t.  8,  p.  23,  ed.  12too.) 

Third  case.  If  a similar  body  were  to  carry  away  a 
great  mass  of  the  soft  parts,  and  the  principal  vessels 
of  a limb  (of  the  thigh,  for  instance),  without  frac- 
turing the  bone,  the  patient  would  be  in  a .state  demand- 
ing immediate  amputation ; for,  independently  of  the 
accidents  which  wouid  originate  from  a considerable 
lo.ss  of  substance,  the  limb  must  inevitably  mortify. 
Mr.  Guthrie  also  says,  “ -A  cannon-shot  destroying  the 
anery  and  vein  on  the. inside  (of  the  thigh),  without 
injuring  the  bone,  requires  amputation.” — (P.  185.) 
When,  however,  the  femoral  artery  or  vein  is  injured  by 
a rnusket-ball,  or  small  canister-shot,  this  gentleman  re- 
commends tying  the  vessel  above  and  below  the  wohyd 
in  it,  if  the  nature  of  the  case  be  evinced  by  hemorrhage. 
But  he  believes,  that  when  both  vein  and  artery  are 
injured,  amputation  is  necessary. — (P.  18fi,)  With  re- 
spect to  bleeding  ftom  the  femoral  vein,  as  it  may  easily 
be  stopped  by  moderate  pressure,  the  propriety  of  using 
any  ligature  at  all  is  questionable. 

‘‘  An  injury  of  the  femoral  artery  (observes  Mr. 
Guthrie)  requiring  an  operation,  accompanied  with 
fracture  of  the  bone  of  the  most  simple  kind,  is  a proper 
ease  for  immediate  amputation ; for,  although  many 
p.itients  would  recover  from  either  accident  alone,  none 
would,  I believe,  surmount  the  two  united ; and  the 
higher  the  accident  is  in  the  thigh,  the  more  imperious 
is  the  necessity  for  amputation.”— (GnPrr/c,  On  Gun- 
shot. Wounds,  p.  187.) 

F'/irrth  cfuir.  grape-shot  strikes  the  thick  part  of 


a member,  breaks  the  bone,  divides  and  tears  the  mus- 
cles, and  destroj^s  the  large  nerves,  without,  however, 
touching  the  main  artery.  According  to  Larrey,  this 
is  a fourth  case  requiring  immediate  amputation. 

Mr.  Guthrie  scemS  to  coincide  on  this  point  with 
Larrey  : “ If  a cannon-shot  strike  the  back  part  of  the 
thigh,  and  carry  away  the  muscular  part  behind,  and 
with  it  the  great  sciatic  nerve,  amputation  is  necessary, 
even  if  the  bone  be  untouched,  «fec.  In  this  case,  I 
would  not  perform  the  operation  by  the  circular  inci- 
sion, but  would  preserve  a flap  from  the  fore  part  or 
sides,  as  I could  get  it,  to  cover  the  bone,  which  should 
he  short.” — {Guthrie,  On  Gun-shot  Wounds  of  the  Ex- 
tremities, p.  184.) 

Fifth  case.  If  a spent  cannon-shot,  or  one  that  ha.s 
been  reflected,  should  strike  a member  obliquely,  without 
producing  a solution  of  continuity  in  the  skin,  as  often 
happens,  the  parts  which  resist  its  action,  such  as  the 
bones,  muscles,  tendons,  aponeuroses,  and  vessels,  may 
be  ruptured  and  lacerated.  The  extent  of  the  internal 
disorder  is  to  be  examined ; and  if  the  bones  should  feel, 
through  the  soft  parts,  as  if  they  were  smashed,  and  if 
there  should  be  reason  to  suspect,  from  the  swelling, 
and  a sort  of  fluctuation,  that  the  ves.sels  are  lacerated, 
amputation  ought  to  be  immediately  practised.  We 
learn  from  Larrey,  that  this  is  also  the  advice  of  Baron 
Percy.  Sometimes,  however,  the  ves.sels  and  bones 
escape  injury,  and  the  muscles  are  almost  the  only 
parts  disordered..  In  this  circumstance  we  are  enjoined 
to  follow  the  counsel  of  De  la  Marfinicre,  who  recom- 
mended making  an  incision  through  the  skin.  By  this 
means,  a quantity  of  thick  blackish  blood  will  be  dis- 
charged, and  the  practitioner  must  await  events.  Ac- 
cording to  Larrey,  such  incision  is  equally  necessary  in 
the  preceding  case'  before  amputation,  in  order  to  as- 
certain the  extent  of  the  mischief  which  the  parts  have 
sustained. 

It  is  to  such  injury  done  to  internal  organs,  that  we 
must  ascribe  the  death  of  many  individuals,  which  wa.s 
for  a long  while  attributed  to  the  commotion  produced  in 
the  air. — (See  Ravaton,  TraiU.  desPlaiesd’Armes  d feu.) 

Although,  says  Larrey,  this  opinion  has  been  sanc- 
tioned by  surgeons  of  high  repute,  we  may  easily  con- 
vince ourselves  of  its  falsity,  if  we  carefully  consider, 
1st,  the  direction  and  course  of  solid  hard  bodies,  and 
their  relation  to  the  air  through  which  they  have  to 
pass;  2dly,  the  internal  disorder  observable  in  the  dead 
bodies  of  persons  whose  death  is  imputed  to  the  mere 
impression  of  he  air  agitated  by  the  ball ; 3dly,  the 
properties  of  the  elastic  substances,  such  as  the  integu- 
ments, cellular  substance,  &c.,  struck  by  the  shot. 

It  is  universally  agreed  among  philosophers,  that  a 
.solid  body,  moving  in  a fluid,  only  acts  upon  a column 
of  this  fluid,  the  base  of  which  column  is  nearly  equal 
to  the  surface  which  the  solid  body  presents. — (See  Le 
Vacher  sur  quelques  Particularit^s  concernant  les 
Plaies  faites  par  Armes  d fev.,  in  Mim.  de  VAcad.  de 
Chirurgie,  t.  11,  p.  34,  ed.  Hmo.) 

Thus,  a cannon-ball,  in  traversing  a space  equal  to 
its  diameter,  can  only  displace  a portion  of  air,  in  the 
relation  of  three  to  two,  compared  with  the  .size  of  the 
shot.  This  fluid,  in  consequence  of  its  divisibility  and 
homogenealness  with  the  ambient  air,  is  dispersed  in 
all  directions,  and  confounded  with  the  total  mass  of 
the  atmosphere.  The  effects  of  this  aeriform  substance 
amount  to  nothing,  and  not  a doubt  can  be  entertained, 
that  if  there  is  the  slightest  solution  of  continuity  of 
any  part  of  the  body,  it  must  depend  upon  the  direct 
action  of  the  ball  Itself. 

Besides,  if  the  quickness  of  the  motion  of  a ball  be 
considered,  which  quickness  is  known  to  diminish  in 
an  inverse  ratio  to  the  squares  of  the  distance,  it  will 
be  seen  that  the  space  through  which  the  shot  has  passed 
before  striking  the  object  against  which  it  wa.s  di- 
rected, will  already  have  materially  lessened  the  cele- 
rity of  the  projectile,  while  the  motion  of  the  column 
of  air  mu.st  be  totally  lost. 

The  different  movements  which  the  ball  describes  in 
its  course,  and  the  elasticity  of  the  skin,  enable  us  to  ex- 
plain how  internal  injuries  are  produced,  without  any 
external  solution  of  continuity,  and  often  even  without 
ecchy?rioses.  The  motion  communicated  to  the  ball  by 
the  power  which  projects  it  is,  for  a given  space,  recti- 
linear. If,  at  this  distance,  it  strikes  against  the  body, 
it  carrie.s  the  part  away  to  an  extent  proportioned  to 
the  mass  wdth  which  it  touches  the  part.  But  the  ball, 

• ifter  having  traversed  a certain  distance,  undergoos| 


444 


GUN-SHOT  WOUNDS. 


in  consccinence  of  the  resistance  of  the  air,  and  the  at- 
traction of  gravity,  a change  of  motioii,  and  now  turns 
on  its  own  axis  in  the  diagonal  direction. 

If  the  shot  should  strike  any  rounded  part  of  the 
body,  towards  the  end  of  its  course,  it  will  run  round 
a great  portion  of  the  circumference  of  the  part,  by  the 
effect  of  its  curvilinear  movement.  It  is  also  in  this 
maimer,  observes  I.arrey,  that  the  wheel  of  a carriage 
acts  in  passing  obliquely  over  the  thigh  or  leg  of  an 
individual  stretched  upon  the  ground.  In  this  case, 
the  results  are  the  same  as  those  of  which  we  have 
been  speaking.  The  most  elastic  parts  yield  to  the  im- 
pulse of  the  contusing  body ; while  such  as  offer  re- 
sistance, as,  for  instance,  the  bones,  tendons,  muscles, 
and  aponeuroses,  are  fractured,  ruptured,  and  lacerated. 
For  the  same  reason,  it  sometimes  happens  that  the 
xuscera  are  similarly  injured. 

At  first  sight,  all  the  p^arts  appear  to  be  entire ; but 
a careful  examination  will  not  let  us  remain  long  in 
doubt  about  the  internal  mischief.  In  this  case,  an  ec- 
chymosis  cannot  manifest  itself  outwardly,  because 
the  extravasation  of  blood  naturally  takes  place  in  the 
deep  excavations  occasioned  by  the  rupture  of  the 
muscles  and  other  parts,  and  because  this  fluid  cannot 
make  its  way  through  the  texture  of  the  skin.  Such  { 
extravasations  can  only  be  detected  by  the  touch. 

The  foregoing  reasoning  is  supported  by  experience. 
How  often,  says  Larrey,  have  we  not  seen  the  ball 
carry  away  pieces  of  helmets,  hats,  cartridge-boxes, 
knapsacks,  or  other  parts  of  the  soldfer’s  dress,  with- 
out doing  any  other  injury  1 The  same  ball,  perhaps, 
takes  off  his  arm,  often  at  a time  when  it  is  closely  ap- 
plied to  the  body  of  his  comrade,  and  yet  the  latter 
does  not  receive  the  slightest  harm.  The  shot  may 
pass  between  the  thighs,  and  these  members  hardly 
exhibit  an  ecchymosis  at  the  points  which  are  gently 
grazed ; the  only  example  in  which  ecch>TTiosis  does 
occur.  In  other  instances,  the  ball  severs  the  arm 
from  the  trunk,  and  the  functions  of  the  thoracic  vis- 
cera are  not  at  all  injured. 

Baron  Larrey  then  relates  the  following  case,  which  is 
analogous  to  one  which  I saw  near  Antwerp,  and  have 
already  mentioned  in  the  foregoing  columns.  M.  Meget, 
a captain,  marching  in  the  front  of  a square  of  men,  in  i 
the  heat  of  the  battle  of  Altzey,  30th  March,  1793,  had 
his  right  leg  almost  entirely  carried  away  by  a large 
cannon-shot,  without  the  contiguous  limb  of  his  lieute-  | 
nant,  who  was  as  clase  as  possibie  to  him,  receiving 
the  least  injury.  The  violent  general  commotion  ex- 
cited, and  the  extreme  severity  of  the  weather,  made 
this  officer’s  condition  imminently  perilous.  The  pro- ' 
gress  of  the  symptoms,  however,  was  checked  by  am- 
jmtation,  which  was  instantly  performed.  M.  Meget  j 
WAS  then  conveyed  to  the  hospital  at  Landau,  fifteen 
leagues  from  the  field  of  battle,  where  he  got  quite 
well. 


Larrey  declines  relating  numerous  other  analogous 
amputations,  which  he  has  been  called  upon  to  practise 
under  the  same  circumstances.  M.  Buffy,  a captain  of 
the  artillery  of  the  army  of  the  Rhine,  was  struck  by 
a howitzer  ; his  left  arm  being  injured,  and  his  head  so 
nearly  grazed  that  the  corner  of  his  hat,  w'hich  w^as 
jilaced  forwards  over  his  ■face,  was  shot  away  as  far  as 
the  crown.  This  officer,  the  skin  of  whose  nose  was 
even  torn  off,  was  not  deprived  of  his  senses,  and  he 
was  actually  courageous  enough  to  continue  for  some 
minutes  commanding  his  company.  At  length,  he  was 
conveyed  to  Larrey’s  ambulance,  who  amputated  his 
arm : in  about  a month  the  patient  was  well. 

Larrey  expresses  his  belief,  that  what  have  been  er- 
roneously termed  wind  c(mtusions,  if  attended  with 
the  mischief  above  specified,  require  immediate  ampu- 
tation. The  least  delay  makes  the  patient’s  preserva- 
tion extremely  doubtful.  The  internal  injury  of  the 
member  may  be  ascertained  by  the  touch,  by  the  loss 
of  motion,  by  the  little  sensibility  retained  by  the  parts, 
which  have  been  struck  : and,  lastly,  by  practising  an 
incision,  as  already  recommended. 

In  order  to  confirm  the  principle  which  he  endeavours 
to  establish  in  opposition  to  many  writers,  Larrey  in- 
dulges himself  with  the  following  digression. 

At  the  siege  of  Roses,  two  cannoniers,  having  nearly 
similar  wounds,  were  brought  from  the  trenches  to  the 
ambulance,  which  Baron  Larrey  had  posted  at  the  vil- 
lage of  Palau.  They  had  been  struck  by  a large  shot, 
winch,  towards  the  termination  of  its  course,  had 
grazed  posteriorly  both  shoulders.  In  one,  Larrey  per- 


ceived a slight  ecchymosis  over  all  the  back  part  of  the 
trunk  without  any  apparent  solution  of  continuity. 
Respiration  hardly  went  on,  and  the  man  spit  up  a 
large  quantity  of* frothy  vermilion  blood.  The  pulse 
was  small  and  intermitting,  and  the  extremities  were 
cold.  He  died  an  hour  after  the  accident,  as  I.arrey 
had  prognosticated.  This  gentleman  opened  the  body 
in  the  presence  of  M.  Dubois,  inspector  of  the  military 
hospitals  of  the  army  of  the  eastern  Pyrenees.  1'h’e 
skin  was  entire;  the  muscles,  aponeuroses,  nerves, 
and  vessels  of  the  shoulders  were  ruptured  and  lace- 
rated, the  scapula  broken  in  pieces,  the  spinous  pro- 
cesses of  the  corresponding  dorsal  vertebrae,  and  the 
posterior  extremity  of  the  adjacent  ribs,  fractured. 
The  spinal  marrow  had  suffered  injury ; the  neighbour- 
ing part  of  the  lungs  was  lacerated,  and  a considerable 
extravasation  had  taken  place  in  each  cavity  of  the 
chest. 

The  second  cannonier  died  of  similar  symptoms, 
three-quarters  of  an  hour  after  his  arrival  at  the  ho.s- 
pital.  On  opening  the  body,  the  same  sort  of  mischief 
was  discovered,  as  in  the  preceding  example. 

In  the  German  campaigns  of  the  French  armies, 
Larrey  met  with  several  similar  cases,  and  accurate 
examination  has  invariably  convinced  him  of  the  di- 
rect action  of  a spherical  body,  propelled  by  means  of 
gunpowder. 

Sia;th  case.  According  to  Baron  Larrey,  when  the 
articular  heads  are  much  broken,  especially  those 
which  form  the  joints  of  the  foot  or  knee,  and  the  liga- 
ments which  strengthen  these  articulations  are  bro- 
ken and  lacerated  by  the  fire  of  a howitzer  or  a grape- 
shot,  or  other  kind  of  ball,  immediate  amputation  is  in- 
dispensable. The  same  indication  would  occur,  were 
the  ball  lodged  in  the  thickness  of  the  articular  head 
of  a bone,  or  were  it  so  engaged  in  the  joint  as  not 
to  admit  of  being  extracted  by  simple  and  ordinary 
means. — (See  also  Guthrie  on  Gun-shot  Wounds,  p. 
197.) 

Fractures  extending  into  the  joints,  and  accompanied 
with  great  laceration  of  the  ligaments,  were  cases  of 
gun-shot  injuries  pointed  out  by  M.  Faure  as  indispen- 
sably requiring  immediate  amputation. — (See  Prix  de 
I’Acad.  de  Chir.  t.  8.)  Thus  we  see,  that  this  author 
was  not  so  averse  to  early  amputation  as  several  mo- 
dern WTiters  have  represented. 

It  is  only  in  this  manner  that  the  patients  can  be 
rescued  from  the  dreadful  pain,  the  spasmodic  affec- 
tions, the  violent  convulsions,  the  acute  fever,  the  con- 
siderable tension,  and  the  general  inflammation  of  the 
limb,  which,  Larrey  observes,  are  the  invariable  con- 
sequences of  bad  fractures  of  the  large  joints.  But, 
adds  this  author,  if  the  voice  of  experience  be  not  lis- 
tened to,  and  amputation  be  deferred,  the  parts  become 
disorganized,  and  the  patient’s  Ufe  is  put  into  imminent 
peril. 

It  is  evident,  says  he,  that  in  this  case  if  we  wish  to 
prevent  the  patient  from  dying  of  the  subsequent  symp- 
toms, amputation  shoffid  be  performed  before  tw'elve 
or  at  most  tw'enty-four  hours  have  elapsed : even  M 
Faure  himself  professed  this  opinion  in  regard  to  cer- 
tain descriptions  of  injury. — {Mem.  de  Chir.  Militaive, 
t.  2.) 

With  respect  to  wounds  of  the  knee,  the  sentiments 
of  Mr.  Guthrie  nearly  coincide  with  those  of  Larrey. 
“ I most  solemnly,  protest  (says  Mr.  G.),  I do  not  r^ 
member  a case  do  well,  in  xvhich  1 knew  the  articulat- 
ing end  of  the  femur  or  tibia  to  be  fractured  by  a ball 
that  passed  through  the  joint,  although  1 have  tried 
great  numbers,  even  to  the  last  battle  of  Toulouse.  I 
know  that  persons  w'ounded  in  this  way  have  lived ; 
for  a recovery  it  cannot  be  called,  where  the  limb  is 
useless,  bent  backwards,  and  a constant  source  of  irri 
tation  and  distress,  after  several  months  of  acute  suf- 
fering, to  obtain  even  this  jiartial  security  from  im- 
pending death ; but  if  one  case  of  recovery  should 
take  place  in  fifty,  is  it  any  sort  of  equivalent  for  ibe 
sacrifice  of  the  other  forty-nine?  Or  is  the  preserving 
of  a limb  of  this  kind  an  equivalent  for  the  loss  of  one 
man  ?”— (On  Gun-shot  Wounds,  p.  196.) 

In  the  attack  of  the  village  of  Merksam,  near  Ant- 
werp, early  in  1814,  a soldier  of  the  95th  regiment  w as 
brought  to  our  field-hospital,  having  received  a musket- 
ball  through  the  knee-joint.  The  stafi-surgeons  on 
duty,  and  Mr.  Curtis,  surgeon  of  the  1st  guards,  were 
preparing  to  amputate  the  limb,  when  a surgeon  at- 
tached to  the  95fh,  urgently  recommended  deferring 


GUN-SHOT  WOUNDS. 


145 


the  operation.  Superficial  dressing;?  ’vere  applied,  and  , 
the  patient  sent  tu  the  rear.  He  lived  several  months 
after  the  accident,  at  times  affording  ho})es  of  a perfect 
recovery  ; but  in  the  end,  he  fell  a victim  to  hectic 
symptoms. 

Indeed,  such  is  the  general  unfortunate  result  of 
these  c.ases,  that  Dr.  Hcnnen  lays  it  down  as  a law  of 
military  surgery,  that  no  lacerated  joint,  particularly 
the  knee,  ankle,  or  elbow,  should  ever  leave  the  field 
uiiamputated  where  the  patient  is  not  obviously  sink- 
\r\g.—{On  Military  Surgery,  p.  41,  ed.  2.) 

-Vccording  to  Mr.  Guthrie,  fractures  of  the  patella, 
without  injury  of  the  other  bones,  admit  of  delay,  pro- 
vided the  bone  is  not  much  splintered. 

Seventh  case.  Larrey  observes,  that  if  a large  bis- 
cayen,  asmall  cannon-shot,  or  a piece  of  a bomb-shell, 
in  passing  through  the  substance  of  a member,  should 
have  extensively  denuded  the  bone  without  breaking 
it,  amputation  is  equally  indiqated,  although  the  soft 
|):irts  may  not  appear  to  have  particularly  suffered. 
Indeed,  the  violent  concussion  produced  by  the  acci- 
dent has  shaken  and  disorganized  alt  the  parts ; the 
medullary  substance  is  injured,  the  vessels  are  lace- 
rated, the  nerves  immoderately  stretched,  and  thrown 
into  a state  of  stupor;  the  muscles  are  deprived  of 
their  tone ; and  the  circulation  and  sensibility  in  the 
iimb  are  obstructed.  Before  we  decide,  however,  Ba- 
ron Larrey  cautions  us  to  observe  attentively  the  symp- 
toms which  characterize  this  kind  of  disorder.  The 
case  can  be  supposed  to  happen  only  in  the  leg  v/heie 
the  bone  is  very  superficial,  and  merely  covered  at  its 
anterior  part  with  the  skin. 

The  following  are  described  as  the  symptoms : the 
limb  is  insensible,  the  foot  cold  as  ice,  the  bone  partly 
e.\ posed,  and,  on  careful  examination,  it  will  be  found 
that  the  integuments,  and  even  the  periosteum,  are  ex- 
tensively detached  from  it.  The  commotion  extends  to 
a considerable  distance  ; the  functions  of  the  body  are 
disordered ; and  all  the  secretions  experience  a more  or 
less  palpable  disturbance.  The  intellectual  faculties 
are  suspended,  and  the  circulation  is  retarded.  The 
pulse  is  small  and  concentrated ; the  countenance  pale ; 
and  the  eyes  have  a dull,  moist  appearance.  The  pa- 
tient feels  such  anxiety,  that  he  cannot  long  remain 
in  one  posture,  and  requests  that  his  leg  may  be  quickly- 
taken  off,  as  it  incommodes  him  severely,  and  he  expe- 
riences very  acute  pain  in  the  knee.  When  all  these 
characteristic  symptoms  are  conjoined,  says  Larrey, 
we  should  not  hesitate  to  amputate  immediately : for 
otherwise  the  leg  will  be  attacked  with  sphacelus,  and 
the  patient  certainly  perish. 

Larrey  adduc.es  several  interesting  cases  in  support 
of  the  preceding  observations. 

Eighth  case.  When  a large  ginglymoid  articulation, 
such  as  the  elbow,  or  especally  the  knee,  has  been  ex- 
tea.sively  opened  with  a cutting  instrument,  and  blood 
is  extravasated  in  the  joint,  Larrey  deems  immediate 
amputation  necessary.  In  these  cases,  the  synovial 
membranes,  the  ligaments,  and  aponeuroses  inflame, 
the  part  swells,  and  erethismus  rajiidly  takes  place; 
and  acvite  pains,  abscesses,  deep  sinuses,  caries,  febrile 
svrnpt.ims,  and  death  are  the  speedy  consequences. 
Larrey  has  seen  numerous  subjects  die  of  such  injuries, 
Oil  account  of  the  operation  having  been  post])oned 
through  a hope  of  saving  the  limb.  In  his  M moires 
do  Chifurgie  Militaire,  tom.  2,  some  of  these  are  de- 
tailed. 

Although  a wmund  may  penetrate  a joint,  yet  if  it  be 
small,  and  unattended  with  extravasation  of  blood,  M. 
Larrey  informs  us,  it  xyill  generally  heal,  provided  too 
much  compression  be  not  employed.  This  gentleman 
believes  in  the  common  doctrine  of  the  pernicious  effect 
of  the  air  on  the  cavities  of  the  body;  yet  in  this  place 
a doubt  seems  to  affect  him;  speaking  of  the  less  dan- 
ger of  small  wounds  of  joints,  he  says,  “ a qnoi  tient 
relte  diffirence,  pnisque  U air  penitre  dans  V articula- 
tion dans  run  cmime  daius  I autre  casV' 

When  tw'o  limbs  have  been  at  the  same  time  so  in- 
jured as  to  re<iuire  amputation,  we  should  not  be  afraid 
of  amputating  them  both  immediately,  without  any  in- 
terval. We  have,  says  Larrey,  several  times  performed 
this  double  amputation  with  almost  as  much  success 
as  the  amputation  of  a single  member.  He  has  re- 
corded an  excellent  case  in  confirmation  of  this  state- 
ment.— {Mem.  de  Chir.  MHHaire.  t.  2,  p.  478.) 

When  a limb  is  differently  injured  at  the  same  time 
in  two  places,  and  one  ol‘  the  wounds  requires  ampu- 


I tation  (suppose  a wound  of  the  leg  with  a splintered 
fracture  of  the  bone,  and  a second  of  the  thigh,  done 
with  a ball,  but  without  any  fracture  of  the  os  femoris, 
or  other  bad  accident),  Larrey  recommends  us  first  to 
dress  the  simple  wound  of  the  thigh  and  amjiutate  the 
leg  immediately  afterward,  if  the  knee  be  free  from 
injury.  When  it  is  necessary  to  amputate  above  this 
joint,  the  less  important  wound  need  not  be  dressed 
till  after  the  operation,  provided  it  can  be  comprehended 
in  the  section  of  the  member,  or  be  .so  near  the  place 
of  the  incision  as  to  alter  the  indication.  When  the 
wound  demanding  amputation  is  the  upper  one,  the 
operation  of  course  is  to  be  done  above  it,  without 
paying  any  regard  to  the  injury  situated  lower  down. 

Ninth  case.  I'o  the  foregoing  species  of  gun-shot 
wounds,  pointed  out  by  Baron  Larrey  as  urgently  re- 
quiring immediate  amputation,  my  own  experience  and 
the  observations  of  Dr.  Thomson  justify  me  in  adding 
compound  fractures  of  the  thigh  from  gun-shot  violence. 
I am  iiarticularly  glad  that  the  latter  gentleman  has 
devoted  a proper  degree  of  attention  to  these  cases ; for 
the  opportunities  which  1 had  of  judging  when  abroad, 
incline  me  to  believe,  that  military  surgeons  are  hardly 
yet  .sufficiently  impressed  with  the  propriety  of  imme- 
diate amputation  in  gun-shot  fractures  of  the  thigh. 
There  were  brought  into  my  hospital  at  Oudenbosch, 
in  1814,  about  eight  of  such  cases,  all  in  the  worst  state 
for  an  ojieration,  because  several  days  had  elapsed  after 
the  receipt  of  the  injuries.  All  these  patients  died,  ex- 
cepting one,  whose  fracture  was  not  far  above  the  con- 
dyles, and  I do  not  know',  that  he  ever  regained  a very 
useful  limb.  Another  had  indeed  been  rescued  by  am- 
putation from  the  dangers  of  the  injury;  but  was  un- 
fortunately lost  by  secondary  hemorrhage  about  three 
days  after  the  operation.  The  bleeding  was  almost 
instantly  suppressed;  yet  .such  was  the  weakness  of 
the  patient,  that  the  irritation  of  securing  the  vessel, 
and  the  loss  of  blood  together,  destroyed  at  once  every 
hope  of  recovei'y.  Were  I to  judge,  then,  from  my 
own  personal  observations  in  the  army,  and  from  some 
other  cases  which  I saw  under  my  colleagues,  I should 
without  hesitation  recommend  immediate  amputation 
in  all  cases  of  compound  fractures  of  the  thigh,  caused 
by  grape-shot,  musket-balls,  <fcc.  If  there  are  any  ex- 
ceptions to  this  advice,  they  are  such  as  are  specified 
in  the  article  Amputation. 

“ Gun-shot  fractures  of  the  thigh  (says  Dr.  J.  Thom- 
son) have  been  universally  allowed  to  be  attended  with 
a high  degree  of  danger ; indeed,  till  of  late  years,  very 
few  instances  have  been  recorded  of  recovery  from 
these  injuries.  Kavaton  acknowledges,  that  in  his 
long  and  extensive  experience,  he  had  never  seen  an 
example  of  recovery  tVorn  a gun-shot  fracture  of  the 
thigh ; and  Bilguer,  in  his  calculations  with  regard  to 
those  who  recover-from  gun-shot  fractures,  sets  aside 
those  of  the  thigh-bone  as  being  of  a nature  altogether 
hopeless.  In  the  jirescnt  improved  state  of  military 
surgery,  instances  not  unfrequently  occur  of  recovery 
from  this  fracture ; but  of  these  the  number  will  be 
found,  I believe,  to  be  exceedingly  small  in  compari- 
son with  those  who  die,  particularly  when  the  fracture 
has  had  its  seat  above  the  middle  of  the  bone,  &c. 

According  to  the  observations  of  Percy,  scarcely  two 
of  ten  recover  of  those  who  have  suffered  gun-shot  frac- 
tures of  the  thigh-bone.  Mr.  Guthrie,  who  seems  to 
have  paid  greater  attention  to  this  subject  than  any  pre- 
ceding author,  says,. that  “ upon  a review  of  the  many 
cases  which  I have  seen,  I do  not  believe  that  more 
than  one-sixth  recovered  so  as  to  have  useful  limbs ; 
two-thirds  of  the  whole  died  either  with  or  without 
amputation;  and  the  limbs  of  the  remaining  sixth  were 
not  only  nearly  useless,  but  a cause  of  much  uneasi- 
Jiess  to  them  for  the  remainder  of  their  lives.’’ — (.See 
Guthrie  on  Gun-shot  Wounds,  p.  101.) 

“ In  fractures  by  musket-bullets  of  the  lower  part  of 
the  thigh-bone  (says  Dr.  Thomson)  recovery  not  uti- 
freiiuently  takes  place,  and  both  Schmucker  and  Mr. 
Guthrie  conceive,  that  they  are  injuries  in  which  am- 
putation may  be  delayed  with  safety.  It  would  be 
very  agreeable,  that  this  opinion  should  be  confirmed 
by  future  ex])erience  ; but  it  appears  to  me,  that  before 
it  can  be  received  as  a ma.vini  in  military  surgery, 
much  more  extensive  and  accurate  observation  than 
we  yet  possess,  will  be  reipiired  with  regard  to  the 
proportion  of  those  who  recover  without  amputation, 
or  afier  secondary  o[)erations,  and  of  those  who  recover 
after  primary  ami»utation.  Of  those  who  had  sutl'cred 


446 


GUN-SHOT  WOUNDS.  . 


this  injury,  we  saw  eoinpuratively  but  a small  number 
recovering  in  IJelgiurn,  and  they  bad  been  attended 
with  severe  local  and  constitutional  symptoms,”-  (See 
Obs.  made  in  the  Military  Hospitals  m Belgium, p.  247, 
et  seq.) 

In  the  article  Amputation  I have  described  the  man- 
ner in  which  balls  produce  fissures  of  several  inches 
in  length  in  the  thigh-bone.  This  state  of  the  bone, 
observes  Dr.  Thomson,  must  be  very  unfavourable  to 
recovery,  and  his  conclusion  is,  that  in  general,  even 
in  fractures  of  the  lower  part  of  the  thigh-bone,  a 
greater  number  of  lives  will  be  preserved  in  military 
practice  by  immediate  amputation,  than  by  attempting 
the  cure  without  that  operation.  “ When  the  bone  ap- 
pears, on  a careful  examination,  to  be  broken  without 
being  much  splintered,  and  when  the  patient  can  be  re- 
moved easily  to  a place  of  rest  and  safety,  it  may  be 
right  to  attempt  to  preserve  the  limb  ; but  if  the  bone 
be  much  splintered,  or  if  the  conveyance  is  to  be  long 
or  uncertain,  it  will,  in  most  instances,  I am  convinced, 
be  a much  safer  practice,  even  in  fractures  of  tliis  part 
of  the  thigh-bone,  to  amputate  without  delay. 

Musket-bullets,  in  passing  through  the  femur  near  to 
the  knee-joint,  produce  fissures  of  the  condyles,  which 
generally  communicate  with  the  joint.  These  cases, 
like  those  in  which  the  bullets  have  passed  directly 
through  the  joint,  require  immediate  amputation. 

The  writings  of  military  surgeons  contain  but  few 
histories  of  cases  in  which  the  thigh-bone  had  been 
fractured  above  its  middle  by  the  passage  of  musket- 
bullets.  These  are  cases,  I believe,  which  have  gene- 
rally had  a fatal  termination  ; and  the  danger  attendant 
upon  the  amputation  which  they  require  seems  long 
to  have  deterred  surgeons  from  attempting- to  ascertain 
what  advantages  might  be  derived  from  the  employ- 
ment of  that  operation.  Schmucker  recommends,  and 
states  that  he  had  practised  with  success,  immediate 
amputation  in  those  cases  in  which  a sufficient  space 
was  left  below  the  groin  for  the  application  of  the 
tourniquet.  It  is  curioas  to  remark,  in  the  history  of 
amputation,  how  long  surgeons  were  in  discovering 
the  ease  and  safety  with  which  the  femoral  artery  may 
be  compressed  by  the  fingers,  or  pads,  in  its  passage 
over  the  brim  of  the  pelvis.  Boy,  from  the  immediate 
danger,  protracted  suffering,  and  ultimate  want  of  suc- 
cess which  he  had  observed  to  follow  this  kind  of  -in- 
jury, urges  strenuously  the  propriety  of  immediate  am- 
putation. Mr.  Guthrie’s  opinion,  with  regard  to  the 
dangerous  nature  of  these  injuries,  and  the  advantages 
to  be  derived  in  them  from  immediate  amputation,  coin- 
cides in  every  respect  with  those  of  Schmucker  and 
Boy.  He  observes,  that  those  whose  thigh-bone  has 
been  fractured  in  its  upper  part  by  a musket-bullet  ge- 
nerally die  with  great  suffering,  before  the  end  of  the 
sixth  or  eighth  week  ; and  that  few  even  of  those  es- 
cape, in  whom  that  bone  has  been  fractured  in  its  mid- 
dle part.  Of  the  few  whom  we  saw,  who  had  survived 
gun-shot  fractures  in  the  upper  part  of  the  thigh-bone 
in  Belgium,  scarcely  any  one  could  be  said  to  be  in  a 
favourable  condition.  In  all,  the  limbs  were  much 
contracted,  distorted,  and  swollen,  and  abscesses  had 
formed  round  and  in  the  neighbourhood  of  the  fractured 
extremities  of  the  bones.  In  some  instances,  these  ab- 
scesses had  extended  down  the  thigh;  but  more  fre- 
quently they  pa.s.sed  upwards  and  occupied  the  region 
of  the  hip-joint  and  buttocks.  In  several  instances,  in 
which  incisions  had  been  made  for  the  evacuation  of 
matter,  the  fractured  and  exfoliating  extremities  of  the 
bones,  sometimes  comminuted,  and  sometimes  form- 
ing the  whole  cylinder,  could  be  felt  bare,  rough,  and 
extensively  separated  from  the  soft  jiarts  w'hich  sur- 
rounded them.  In  other  instances,  these  extremities 
were  partially  enclosed  in  depositions  of  new  bone, 
which,  from  the  (juantity  thrown  out,  seemed  to  be  pre- 
sent in  a morbid  degree.  It  was  obvious,  that  in  all  of 
these  cases,  several  months  would  be  required  for  the 
reunion  of  the  fractured  extremities ; that  in  some 
much  pain  and  misery  were  still  to  be  endured  from 
the  processes  of  suppuration,  ulceration,  exfoliation, 
and  ejection  of  dead  bone ; that  in  some  cases,  the  pa- 
tients were  incurring  great  danger  from  hectic  fever" 
and  from  diarrhoea;  that  the  ultimate  lecovery  in  most 
of  them  was  doubtful,  ahd  that  of  those  in  whom  this 
might  take  place,  there  was  but  little  probability  that 
any  would  be  able  to  use  their  limbs ! The  sight  of 
these  cases  (says  Dr.  Thomson)  made  a deep  impres- 
sion upon  my  mind,  and  has  tended  to  increasemy  con- 


viction that  this  is,  of  all  others,  the  class  of  injuries 
in  which  immediate  amputation  is  most  indispensably 
required.” — (See  Obs.  made  in  the  Military  Hospitals 
in  Belgium,  p.  254—258.) 

Dr.  Thomson  adds,  that  wliaf  has  been  said  of  the 
danger  of  fractures  produced  by  musket-bullets  in  the 
upper  part  of  the  femur,  is  trfle  in  a still  greater  degree 
of  those  which  have  their  seat  in  the  neck  or  head 
of  that  bone.  In  such  instances.  Dr.  Thomson  joins 
the  generality  of  modern  army  surgeons  in  strongly 
recommending  amputation  at  the  hip-joint;  a subject 
of  which  I have  already  spoken. — (See  Amputation.) 

ON  CiUN-SHOT  WOUNDS  IN  WHICH  AMPITATION  MAY 
BE  DEFERRED. 

If,  says  Baron  Larrey,  it  be  possible  to  specify  the 
cases  in  which  amputation  ought  to  be  immediately 
performed,  it  is  impossible  to  determine,  d priori,  those 
which  will  require  the  operation  subsequently.  One 
gun-shot  wound,  for  example,  will  be  cured  by  ordinary 
treatment,  while  another  that  is  at  first  less  severe, 
will  afterward  render  amputation  indispensable,  whe- 
ther this  be  owing  to  the  patient’s  bad  constitution,  or 
the  febrile  complaints  which  are  induced.  However 
this  may  be,  the  safe  rule  for  fulfilling  the  indication 
that  presents  itself  is,  to  amputate  consecutively  only 
in  circumstances  in  which  every  endeavour  to  save 
the  limb  is  manifestly  in  vain.  Upon  this  point  Larrey’s 
doctrine  differs  from  that  of  Faure. 

The  latter  practitioner  admits  cases,  which  he  terms 
cases  of  the  second  kind,  in  which  he  delays  ampu- 
tation, not  with  any  hope  of  saving  the  limb,  but  in 
order  to  let  the  first  symptoms  subside.  The  operation 
done  between  the  fifteenth  and  twentieth  day  appears 
to  him  less  dangerous  than  when  performed  imme- 
diately after  the  receipt  of  the  injury.  At  the  above 
period,  according  to  M.  Faure,  the  commotion  occa- 
sioned by  the  gun-shot  injury  is  dispelled ; the  jiatient 
can  reconcile  himself  to  amputation,  the  mere  mention 
of  which  fills  the  pusillanimous  with  terror  in  a greater 
or  less  degree;  the  debility  of  the  individual  is  no 
objection ; and  it  is  laid  down  as  an  axiom,  “ that  the 
consequences  of  every  amputation,  done  in  the  first  in- 
stance, are  in  general  extremely  dangerous.”  In  sup- 
port of  this  theory,  M.  Faure  adduces  ten  cases  of  gun- 
shot injuries,  in  which,  after  the  battle  of  Fontenoy, 
the  operation  was  delayed,  in  order  that  it  might  after- 
ward be  performed  with  more  success ; a plan  which, 
according  to  the  author,  proved  completely  successful. 
— (See  Prix  de  I’ Acad,  de  Chirurgie,  tom.  8,  edit,  in 
127710.) 

This  division  of  the  cases  for  amputation  into  two 
classes,  not  consistent  with  nature,  Larrey  conceives, 
has  been  the  cause  of  a great  deal  of  harm.  Verj'  often 
the  partisans  of  M.  Faure  have  not  dared  to  resort  in 
the  first  instance  to  amputation,  the  dangers  of  which 
they  exaggerate  ; while  on  other  occasions  they  ampu- 
tate consecutively  without  any  success. 

Larrey,  after  arguing  that  the  elTects  of  commotion, 
instead  of  incre.asing,  gradually  diminish  and  disapjiear 
after  the  operation,  ventures  into  some  hypothesis  about 
the  proximate  cause  of  the  ill  effects  of  commotion, 
which,  as  being  wild  and  unsatisfactory,  I shall  not 
here  repeat. 

Baron  Larrey  will  not  even  admit  that  the  patient’s 
alarm  ought  to  be  a reason  for  posljxtning  the  ope- 
ration : because  the  patient,  just  after  the  accident,  will 
be  much  less  afraid  of  the  riskwhicli  he  has  to  encoun- 
ter, than  at  the  expiration  of  the  first  four-and-twenty 
hours,  when  he  has  had  time  to  rellect  upon  the  con- 
sequences of  the  injury  or  of  amputation;  a remark 
made  by  fhe  illustrious  Parfi. 

“ Experience  agreeing  with  my  theory  (says  Baron 
Larrey),  has  proved,  both  to  the  army  and  navy  surgeons, 
that  the  bad  symptoms  which  soon  follow  such  gun-shot 
injuries,  as  must  occasion  the  loss  of  a limb,  are  much 
more  to  be  dreaded  than  those  of  immediate  amputa- 
tion. Out  of  a vast  number  of  the  wounded  who  suf- 
fered amputation  in  the  course  of  the  first  four-and- 
twenty  hours  after  the  memorable  naval  battle  of  the 
1st  of  .lune,  1794,  a very  few  lost  liieir  lives.  This  fact 
has  been  attested  by  several  of  our  colleagues,  andespe- 
cially  by  Fercoc,  surgeon  of  the  ship  Le  Jemaiqie.” 

The  following  is  said  to  be  an  extract  from  one  of  his 
letters. 

“ After  the  naval  engagement  on  the  1st  of  .lune,  1794, 
a great  number  of  amputations  were  done  iimnediately 


GUN-SHOT  WOUNDS. 


447 


after  the  receipt  of  the  injuries.  Sixty  of  the  patients 
whose  limbs  had  been  thus  cut  off  were  taken  to  the 
naval  hospital  at  Brest,  and  put  under  the  care  of  M. 
Duret.  With  the  exception  of  two,  who  died  of  teta- 
nus, all  the  rest  were  cured ; and  there  was  one  who 
had  both  his  arms  amputated.  The  surgeon  of  the 
Tim  r air which  ship  was  captured  by  the  English, 
was  desirous,  in  compliance  with  the  advice  of  their 
medical  men,  to  defer  the  operation  which  many  of  the 
wounded  stood  in  need  of,  till  his  arrival  in  port ; but 
he  had  the  mortification  to  see  them  all  die  during  the 
passage,”  &c. 

Larrey  next  acquaints  us,  that  when  he  was  sent  to  the 
army  of  Italy,  in  1796,  he  had  also  the  pain  of  seeing  in  the 
hospitals  great  numbers  of  the  wounded  fall  victims  to 
the  confidence  which  many  of  the  surgeons  of  that  army 
placed  in  the  principles  of  M.  Faure.  General  Buona- 
parte saw  that  the  ambulance  volante  was  the  only 
thing  that,  in  the  event  of  fresh  hostilities,  could  pre- 
vent such  accidents  : and  in  consequence  of  his  orders, 
Larrey  formed  the  three  divisions  d'ambulance  which 
are  described  in  his  Memoires  de  Chmtrgie  Militaire. 

Since  this  period  it  has  always  been  customary  in  the 
French  armies,  on  the  day  of  battle,  to  make  every  pre- 
paration for  performing  amputations  as  speedily  as  pos- 
sible. The  mere  sight  of  these  ambulances  (always  at- 
tached to  the  advanced-guard),  says  M.  Larey,  encou- 
rages the  soldiers,  and  inspires  them  with  the  greatest 
courage.  On  this  occasion,  the  following  anecdote  is 
cited  from  Ambrose  Pare. 

This  famous  surgeon  having  been  urgently  sent  for 
by  the  Duke  de  Guise,  besieged  in  Metz,  to  attend  the 
wounded  of  his  army,  who  were  in  want  of  assistance, 
Ambrose  Par6  was  shown  to  the  frightened  soldiers  at 
the  breach.  Upon  this,  they  immediately  filled  the  air 
with  shouts  of  the  most  lively  joy,  and  cried  out : 
“ Nous  Tie  pouvons  plus  mourir,  s^il  arrive  que  nous 
soyons  bless'  S,  puisque  Pare  est  parmi  nous."  Their 
courage  revived,  and  their  confidence  in  this  skilful 
surgeon  contributed  to  the  pre.servation  of  a place,  be- 
fore which  a formidable  army  was  destroyed. 

Larrey  desires  us  to  interrogate  the  invalids  who 
have  lost  one  or  two  of  their  limbs,  and  nearly  all  will 
tell  us  that  they  suffered  amputation  a few  minutes 
after  the  accident,  or  in  the  first  four-and-tw'enty  hours. 

“ If  Faure  now  retains  any  partisans,”  says  Larrey, 
“ I recommend  them  to  repair  to  the  field  of  battle  the 
day  after  an  action  ; they  would  then  soon  be  convinced, 
that  without  the  prompt  performance  of  amputation, 
great  numbers  of  soldiers  must  inevitably  lose  their 
lives.  In  Egypt  this  truth  was  particularly  manifested.” 

The  following  communication  upon  this  point  was 
made  to  Baron  Larrey  by  M.  Masclet,  a French  sur 
geon  on  duty  at  Alexandria. 

“ In  the  naval  hospital  of  this  port  I have  seen  ele 
ven  soldiers  or  sailors,  who  were  wounded  in  the  na 
val  action  off  Aboukir,  and  who  had  suffered  amputa- 
tion in  the  first  four-and-twenty  hours.  In  five  of 
these  cases  the  operation  had  been  done  on  the  arm ; in 
two  on  the  thigh  ; and  iu  three  others  on  the  leg.  All 
these  men  are  recovering.  In  the  army  hospital  there 
have  been  only  three  thigh-amputations,  which  we  per- 
formed seven  or  eight  days  after  the  battle,  and  these 
three  patients  died  a few  days  after  the  operation,  al- 
though the  operation  was  done  methodically,  and  no 
grave  symptoms  prevailed  at  the  time  of  its  perform- 
ance. You  see,  sir,  experience  has  in  this  instance 
quite  confirmed  your  principles.” 

In  1780,  during  the  American  war,  we  are  informed  • 
by  Larrey,  that  the  surgeons  of  the  French  army  per- 
formeil  a great  number  of  amputations,  according  to 
the  opinion  then  generally  adojited  in  France,  that  the 
operation  should  not  be  undertaken  till  after  the  subsi- 
dence of  the  first  symptoms.  Almost  all  the  patients 
thus  treated  died  after  the  operation.  On  the  contrary, 
the  Americans,  who  had  the  boldness  to  amputate  im- 
mediately (or  in  the  first  twenty-four  hours)  upon 
many  of  their  wounded  countrymen,  lost  only  a very 
few.  Yet  M.  Dubor,  at  that  time  surgeon  to  the  Ar- 
tois dragoons,  and  from  whom  Larrey  has  collected 
this  fact,  relates,  that  the  situation  of  the  hospital  for 
the  French  wounded  was,  gn  many  accounts,  the  mo.st 
advantageous.— (/hiftor,  Thi.'se  Inaugurale,  soutenue 
16  Sept.  1803,  d VEcole  de  Stra.ib'urg.) 

Admitting  that,  by  a concurrence  of  fortunate  cir- 
cumstances, which  are  net  always  to  be  calculated 
ui)on,  some  patients  escape  the  danger  of  the  first 


symptoms,  as  Larrey  remarks,  this  proves  nothing  in 
favour  of  doing  the  operation  afterward : it  must  be 
seen  what  nature  will  do  towards  the  event  of  the  case. 

If,  at  the  end  of  twenty  or  thirty  days,  the  prognosis 
is  as  bad  as  it  was  previously,  amputation  cannot  be 
avoided.  Thus  all  the  sufferings  which  the  patient  has 
endured  have  been  undergone  tor  nothing,  and  the  ope- 
ration wall  now  be  attended  with  considerable  risk, 
inasmuch  as  the  patient  may  lie  in  a dangerously 
weakened  state. 

If  nature  revives  at  all,  no  doubt  the  success  of  the 
operation  becomes  more  probable ; but  in  this  case  the 
surgeon,  instead  of  having  recourse  to  amputation, 
should  redouble  his  efforts  to  preserve  the  limb. 

[Dr.  Brown,  of  the  U.  S.  navy,  during  the  late  war, 
dissected  out  the  head  of  the  humerus  after  a gun-shot 
wound  received  at  the  battle  on  Lake  Champlain  ; and 
soon  after.  Dr.  Henry  Hunt,  of  Washington,  D.  C.,  re- 
moved the  coracoid  and  acromion  apophyses  of  the 
scapula,  the  humeral  end  of  the  clavicle,  together  with 
a superior  projecting  portion  of  the  os  humeri,  from  the 
same  patient. — (See  Am.  Med.  Recorder  for  1828.) 

• In  this  case  the  limb  was  preserved  by  these  bold 
operations ; whereas,  if  amputation  even  at  the  joint 
had  been  attempted,  the  patient’s  life  might  have  been 
the  forfeit. — Reese..] 

exSES  DEMANDING  AMPUTATION  CONSECUTIVELY. 

Upon  this  subject  Larrey  gives  us  the  annexed  in 
formation. 

First  Case.  A spreading  Mortification.  If  the  dis- 
order be  owing  to  an  internal  and  general  cause,  it 
would  then  be  rashness  in  the  surgeon  to  amputate 
before  nature  had  put  limits  to  the  disease.  Larrey 
describes  this  kind  of  gangrene  as  being  listinguished 
from  that  which  is  named  traumatic,  by  the  symptoms 
which  precede  and  accompany  it.  . These  symptoms 
are  similar  to  tho.se  which  are  observed  in  nervous 
ataxia  or  adynamia.  Here  the  operation  ought  to  be 
deferred,  and  endeavours  made  to  combat  the  general 
causes  with  regimen  and  internal  medicines. 

But  when  the  gangrene  is  traumatic,  Larrey  advises 
the  limb  to  be  immediately  cut  off  above  the  disorgan- 
ized part.  Several  facts  in  support  of  this  doctrine 
are  related  by  this  experienced  surgeon  in  his  Mimoire 
sur  la  Gangrene  Traumatique. — (See  Mortification.) 

In  that  part  of  the  Dictionary  will  be  found  additional 
observations  in  favour  of  the  practice  adopted  and  re- 
commended by  Larrey,  which  is  so  oppo.site  to  that  in- 
culcated by  Sharp,  Pott,  and  the  generality  of  writers. 

In  the  article  AmputatinnlYraxe  noticed  a jiarticular 
case  of  gangrene,  which  has  been  pointed  out  by  Mr. 
Guthrie,  as  demanding  the  early  jierfbnnance  of  ampu- 
tation and  a deviation  from  the  old  rule  of  waiting  till 
the  mortification  has  ceased  to  spread. — (See  Guthrie 
on  Gun-shot  Wounds  of  the  Extremities,  p.  63,  xSre.) 

Second  Case.  Convulsions  of  the  wounded  Limb. 
It  is  one  of  Larrey’s  doctrines  (though  of  a very  ques- 
tionable description),  that  amputation  of  the  member, 
performed  immediately  the  first  syrrtptoms  of  tetanus 
manifest  themselves,  interrupts  all  communication 
between  the  source  of  the  disorder  and  the  rest  of  the 
body.  He  states,  that  the  operation  unloads  the  ves- 
sels, and  thus  puts  a stop  to  the  tension  of  the  nerves 
and  to  the  convulsions  of  the  muscles.  The.se  first 
effects,  he  says,  are  followed  by  a general  collapsus, 
which  promotes  the  excretions,  sleep,  and  the  equili- 
brium of  every  part  of  the  system.  He  argues,  that  the 
whole  of  the  momentary  pain  caused  by  the  operation 
cannot  increase  the  existing  irritation  : besides  the  suf- 
ferings of  tetanus  render  those  of  amputation  more 
bearable,  and  lessen  their  intensity,*  especially  when 
the  principal  nerves  of  the  limb  are  strongly  com- 
pressed. Some  observations  will  be  made  on  this  sub- 
ject in  the  article  Tetanus. 

Third  Case.  Bad  state  of  the  Discharge.  It  often 
hajipens,  that  in  gun-shot  wounds  complicated  with  frac- 
tures, notwithstanding  the  most  skilful  treatment,  the 
discharge  becomes  of»a  bad  quality ; the  fragments  of 
bone  lie  surrounded  with  the  matter,  and  have  not  the 
least  tendency  to  unite : the  patient  is  attacked  with 
hectic  fever,  and  a colliijuative  diarrheea.  IJufier  these 
circumstances,  life  may  sometimes  be  preserved  by 
amputation. 

Fourth  Case.  Bad  state  of  the  Stump.  In  hospitals, 
as  Baron  Larrey  observes,  the  cure  of  amputations  is 
sometimes  prevented  by  a fever  of  a bad  character 


443 


GUN-SHOT  WOUNDS. 


The  stump  swells,  the  integuments  become  at  first  re- 
tracted, and  then  everted  and  diseased  a good  way  up- 
wards. The  wound  changes  into  a fungous  ulcer,  the 
cicatrization  of  which  is  hindered  by  the  deep  disor- 
der of  the  bone  and  the  ulceration  of  the  soft  parts. 
The  extremity  of  the  bone  projects.  In  order  to  remedy 
this  last  evil,  it  has  been  proposed  to  saw  off  the  pro- 
jecting part  of  the  bone,  and  with  this  even  to  ampu- 
tate all  the  flesh  beyond  the  level  of  the  skin.  Larrey 
condemns  such  practice  as  unnecessary  and  dangerous, 
and  he  recommends  giving  nature  time  to  bring  about  the 
exfoliation  of  the  diseased  projecting  part  of  the  bone,  and 
heal  the  wound. — (Bee'Memoires  de  Chir.  Militaire,  t.  2.) 

GUN-SHOT  WOUNDS  OF  THE  -XBDOMEN. 

These  cases  may  be  divided  into  two  kinds ; one  only 
penetrates  the  parietes  of  the  belly,  without  hurting 
the  contained  parts ; the  other  does  mischief  also  to 
the  viscera.  The  event  of  these  two  kinds  of  wounds 
is  very  different.  In  the  first,  little  danger  is  to  be  ex- 
pected, if  properly  treated  ; but  in  the  second  the  suc- 
cess will  be  extremely  uncertain,  for  in  many  instances 
nothing  can  be  done  for  the  patient,  and  on  other  occa- 
sions a good  deal. 

It  is  observed  by  Mr.  Hunter,  that  such  wounds  of 
the  abdomen  as  do  not  injure  parts  like  the  stomach, 
intestines,  bladder,  ureters,  gall-badder,  large  blood- 
vessels, &c.,  all  which  contain  particular  fluids,  will 
generally  end  well.  But  he  adds  that  there  will  be  a 
great  'difference  when  the  ball  has  passed  with  im- 
mense velocity,  as  a slough  will  be  produced ; whereas, 
when  the  ball  has  moved  with  less  impetus,  there  will 
not  be  so  much  sloughing,  and  the  parts  will,  in  some 
degree,  heal  by  the  first  intention.  Even  when  the 
ball  occasions  a slough,  the  wound  frequently  termi- 
nates well,  the  adhesive  inflammation  t2iking  place  in 
the  peritoneum  all  round  the  wound,  so  as  to  exclude 
the  general  cavity  of  the  abdomen  from  taking  part  in 
the  inflammation.  Such  is  often  the  favourable  event 
when  the  ball,  besides  entering  the  abdomen,  has 
wounded  parts  like  the  omentum,  mesentery,  <fec.,  and 
gone  quite  through  the  body. — {Hunter  on  Iriflamma- 
tion,  Gun-shoi  Wounds,  <t-c.  p.  543.) 

In  gun-shot  w'tunds  of  the  belly,  an  extravasation  is 
apt  to  take  place  on  the  sloughs  becoming  loose,  about 
eight,  ten,  twelve,  or  fourteen  days  after  the  accident ; 
but,  says  Mr.  Hunter,  although  this  new  symptom  is  in 
general  very  disagreeable,  most  of  the  danger  is  usually 
over  before  it  can  appear. 

In  the  article  Wounds  \ have  detailed  at  large  the 
general  principles  which  should  be  observed  in  the 
treatment  of  wou'ids  of  the  belly ; consequently,  it 
would  be  superfluous  here  m go  over  the  w'hole  of  this 
extensive  subject  again.  As  a modern  writer  observes, 
“ In  their  treatment,  the  violence  of  symptoms  is  to  be 
combated  more  by  general  means  than  by  any  of  the 
mechanical  aids  of  surgery.  Tne  search  for  extraneous 
bodies,  unless  superficially  situa  ed,  is  altogether  out 
of  the  question,  except  they  can  b„  tbit  with  the  probe, 
as  in  Ravaton’s  case  {Chir.  d'.drm^t,  p.  211),  or  in  other 
cases  of  lodgement  in  the  bladder,  wh'Te  they  may  be- 
come the  object  of  secondary  operations  Enlargement 
or  contraction  of  the  original  wounu,  .*s  the  case  may 
require,  for  returning  the  protruded  intestine,  securing 
the  intestine  itself,  and  promoting  the  adhesion  of  the 
parts,  are  all  that  the  surgeon  has  to  do  in  the  way  of*' 
operation  ; and  even  in  this  the  less  he  interferes  the 
better.  Nature  makes  wonderlul  exertions  to  relieve 
every  injury  inflicted  upon  her,  and  they  are  often 
surprisingly  successful,  if  not  injudiciously  inter- 
fered with.  In  a penetrating  wound  of  the  abdomen, 
whether  by  gun-shot  or  by  a cutting  instrument,  if  no 
protru.sion  of  intestine  take  jdace  (and  this,  it  must  be 
observed,  in  musket  or  pistol  wounds  rarely  occurs), 
the  lancet,  with  its  powerful  concomitants,  abstinence 
and  rest,  particularly  in  the  supine  ])osture,  are  our 
chief  dependence.  (Ireat  pain  and  tension,  which 
usually  accompany  these'wounds,  must  be  relieved  by 
leeches  to  the  abdomen  (if  they  can  be  procured),  by 
topical  applications  of  fomentations,  and  the  warm 
bath  ; and  if  any  internal  medicine  is  given  as  a purga- 
tive, it  must,  for  obvious  reasons,  be  of  the  mildest 
nature.  The  removal  of  the  ingesta,  as  a source  of  irri- 
tation, is  best  effected  by  frequently  repealed  oleaginous 
clysters”  (see  Hennen's  Principles  of  Military  Sur- 
gery, p.  431,  ed.  2) ; ami  with  re.spect'  to  dressings,  as 
the  same  author  has  observed  concerning  cases  in 


which  a ball  has  passed  directly  through  the  abdomen, 
the  mildest  application  should  be  employed,  and  no 
plugging  whth  tents,  nor  introduction  of  medicated 
dres.sings,  thought  of. — (P.  406.)  In  this  publication  may 
be  found  cases,  in  which  mu.sket-balls  were  passed  by 
stool  tp.  404);  in  which  an  artificial  anus  w- as  formed 
{p.  407,  <S-c.) ; or  the  kidneys,  liver  {p.  430 — 432),  dia- 
phragm {p.  437),  and  other  viscera,  injured. 

The  following  case,  exhibiting  the  possibility  of  re- 
covery, though  the  small  intestine  be  completely 
severed  with  a ball,  is  interesting,  partictdarly  as  cases 
of  this  kind  have  been  regarded  as  positively  fatal. 
The  success  was  also  obtained,  notwithstanding  the 
treatment  appears  to  have  been  rather  too  ofliciou.s,  es- 
pecially in  regard  to  four  incisions  made  in  the  end  of 
the  bowel,  when  one  would  have  removed  the  constric- 
tion spoken  of. 

At  the  assault  of  Cairo,  1799,  M.  N.  was  shot  in  the 
abdomen  with  a ball,  which  divided  the  muscular  pa- 
rietes of  this  cavity  on  the  right  side,  and  a portion  of 
the  deum.  Larrey,  being  upon  the  field  of  battle,  gave 
him  the  first  assistance.  The-  two  ends  of  the  intestine 
protruded  in  a separated  and  inflated  state.  The  upper 
end  was  everted  in  such  a way,  that  its  contracted 
edge,  like  the  prepuce  in  a case  of  paraphymosis,  slran* 
gulated  the  intestinal  tube.  The  course  of  the  feces 
was  thus  obstructed,  and  the  contents  of  the  bowel  ac- 
cumulated above  the  constriction. 

Although  the  patient’s  recovery  was  nearly  hopeless, 
both  from  the  nature  of  the  wound  and  from  the  de- 
bility and  cholera  morbus,  which  had  already  seized  him 
•in  the  short  period  that  he  remained  without  succour  in 
one  of  the  intrenchments,  Larrey  was  desirous  of  trying 
what  could  be  done  for  so  singular  a case.  He  first 
made  four  small  cuts  through  the  constricted  part  of 
the  intestine,  with  a pair  of  curved  scissors,  and  put 
the  bowel  into  its  ordinary  state.  H.e  passed  a ligature 
through  the  piece  of  the  tn.esentery,  corresponding  to 
the  two  extremities  of  the  bowel.  These  he  reduced  as 
far  as  the  margin  of  the  opehing,  which  he  had  taken 
care  to  dilate ; and  the  dressings  having  been  applied, 
he  awaited  events.  The  first  days  were  attended  with 
alarming  sjTnptoms,  which,  however,  afterward  sub- 
sided. Tliose  which  depended  upon  the  lo.ss  of  the  ali- 
mentary matter,  successively  abated;  and  after  two 
months,  the  ends  of  the  ileum  were  opposite  each  other, 
and  dis))osed  to  become  connected  together.  Larrey 
seconded  the  efforts  of  nature,  and  dressed  the  patient 
with  a tampon  or  sort  of  tent,  that  was  occa.sionally 
employed,  for  two  months.  The  patient  was  then  dis- 
charged from  the  hospital  quite  cured. 

In  several  instances,  says  Lafrey,  the  sigmoid  flexure 
of  the  colon  was  injured,  and  yet  the  wounds  were  cured 
witliout  any  fecal  fistula;.  At  the  siege  of  Acre,  three 
examples  occurred  ; and  at  that  of  Cairo  two.  Larrey 
dilated  the  entrance  and  exit  of  the  ball.  Clysters, 
made  of  the  decoction  of  linseed,  and  emollient  beve- 
rages, were  frequently  exhibited ; and  the  patients  were 
kept  on  low  diet,  and  in  the  most  quiet  state. 

Sword- W'ounds,  and  those  made  with  the  bayonet  or 
lance,  may  injure  some  part  of  the  bladder,  or  even  pass 
through  both  sides  of  this  organ.  In  the  latter  ease, 
the  injury  is  usually  fatal,  as  the  urine  escapes  from  the 
inner  wound  into  the  abdomen,  and  immediately  excites 
mortal  inflammation.  Baron  Larrey  dressed  on  the 
field  of  battle  several  soldiers,  who.se  bladders  were 
thus  completely  transfixed,  and  who  all  perished  of  in- 
flammation and  gangrene,  within  tlie  first  forty-eight 
hours.  However,  he  observes,  that  it  the  weapon  enter 
the  bladder  at  that  part  of  its  ftindus  which  is  not  co- 
vered by  the  peritoneum,  the  case  is  curable,  unless 
complicated  with  too  much  internal  hemorrhage. 

The  surest  criterion  of  these  cases  is  the  escape  of 
the  urine  from  the  external  wound  ; and  its  discharge 
may  either  be  momentary,  occa.sional,  or  continual ; 
diflferences  to  be  accounted  for  by  the  situation  of  the 
wound,  and  the  changes  which  happen  in  the  bladder. 
When  the  bladder  is  full,  and  its  upper  part  is  pierced, 
the  urine  will  issue  only  just  at  the  moment  of  the  ac- 
cident, and  as  soon  as  it  is  discharged,  the  edges  of  the 
wound  will  come  together,  and  permanently  close,  es- 
pecially if  the  urine  can  pass  freely  through  the  natural 
channel.  But  when  this  favourable  condition  is  absent, 
the  bladder  becomes  enormously  distended  again,  the 
wound  is  opened  anew,  and  the  urine  discharged  once 
more  from  the  external  opening.  The  same  things 
might  hapi«;n,  if  one  were  to  withdraw  too  soon  tho 


GUN-SHOT  WOUNDS. 


449 


elastic  gum  catheter,  which  has  been  introduced  : and 
by  introducing  the  instrument  again,  the  urine  might 
be  diverted  from  the  wound,  and  its  natural  course  re- 
established. Lastly,  Larrey  observes,  that  when  the 
Wound  is  situated  at  one  of  the  lowest  points  of  the 
bladder,  the  discharge  of  urine  may  be  incessant,  and 
be  of  more  or  less  duration. 

When  the  track  of  these  punctured  wounds  is  ex- 
tensive, and  not  direct,  abscesses  form  at  different 
points  where  the  urine  passes.  These  abscesses 
Larrey  directs  to  be  immediately  opened,  and  their  re- 
currence prevented  by  the  introduction  of  an  elastic 
gum  catheter  through  the  urethra;  one  of  the  chief 
means  of  relief  in  all  wounds  of  the  bladder.  To- 
gether with  this  treatment,  he  recommends  the  warm 
bath,  the  application  of  camphorated  oily  liniments  to 
the  belly,  antispasmodic  cooling  medicines,  frequent 
clysters,  and  sometimes  cupping  in  the  vicinity  of  the 
wound,  or  bleeding. — (See  Mem.  de  Chir.  Mil.  t.  4,  p. 
886, 287.)  On  the  last  two  means  of  relief,  it  would  have 
been  better  if  Larrey  had  laid  more  stress;  for,  next  to 
the  catheter,  they  are  unquestionably  the  most  essential. 

Baron  Larrey  informs  us,  that  the  gun-shot  wounds 
of  the  bladder  which  occurred  in  Egypt  had  for  the 
most  part  a favourable  termination.  The  most  re- 
markable case  was  that  of  F.  Chaumette,  a light-horse- 
man, who  was  wounded  at  the  battle  of  Tabor.  The 
ball  passed  across  the  hypogastrium,  about  one  finger- 
breadth  above  thepubes,  tothepointof  the  left  buttock, 
which  corresponds  to  the  ischiatic  notch.  The  direction 
of  the  wound,  and  the  issue  of  feces  and  urine  from  the 
two  orifices,  left  no  doubt  that  the  bladder  and  rectum 
were  injured.  M.  Milioz,  who  directed  the  surgical 
affairs  of  the  division  of 'the  army  under  Kleber,  dili- 
gently pursued  the  same  kind  of..treatment  which  he 
had  seen  Larrey  adopt  at  the  siege  of  Acre.  During 
the  suppurative  stage,  the  patient  was  affected  with 
fever;  and  after  trf6  sloughs  were  detached,  the  dis- 
charge was  very  copious.  A catheter  that  was  passed 
into  the  bladder  prevented  an  extravasation  of  the 
urine,  and  at  the  same  time  promoted  the  union  of  the 
wound  of  that  viscus.  This  was  healed  the  first,  and 
the  patient  upon  his  return  to  Cairo  was  quite  cured. 

Larrey  has  recorded  several  other  interesting  cases 
of  wounds,  either  of  the  bladder  alone,  or  of  it  and  the 
rectum  together,  to  which  1 must  content  myself  with 
referring. — (See  M^m.  de  Chir.  Mihtaire,  t.  2,  p.  160. 
165 ; UZ,p.  340,  <J-c. ; t.  4,  p.  296,  <S'C.) 

A ball  may  go  through  both  sides  of  the  bladder,  and 
then  either  perforate  the  neighbouring  parts  and  escape 
externally,  or  bury  itself  deeply  in  the  flesh.  When  it 
has  gone  quite  through  the  bladder,  and  afterward 
passed  out  of  the  body  again,  urine  blended  with  blood 
immediately  issues  from  one  or  both  apertures,  accord- 
ing to  their  situation.  The  flow  of  urine  through  the 
urethra  is  either  lessened,  or  completely  suppressed ; 
but  through  this  passage  the  patient  generally  voids 
more  or  less  blood.  Acute  and  incessant  pain  is  felt  in 
the  course  of  the  wound,  together  with  a frequent 
painful  desire  to  make  water,  nausea,  sometimes  actual 
vomiting,  and  extreme  anxiety  and  restlessness.  Either 
in  its  passage  inwards,  or  its  course  outwards,  the  ball 
may  have  injured  or  perforated  the  rectum  ; in  which 
case,  the  urine  passes  into  this  bowel,  and,  mixing  with 
the  feces,  is  discharged  from  the  anus. 

When  a part  of  the  bladder  towards  the  cavity  of  the 
abdomen  is  injured,  a.s,  for  instance,  its  posterior  sur- 
face, w'hich  is  covered  by  the  peritoneum,  the  urine  is 
generally  extravasated  within  the  belly,  and  inflamma- 
tion of.  the  preceding  membrane  is  the  immediate  con- 
sequence. This  inflammation  spreads  with  rapidity, 
and  attacks  all  the  viscera,  producing  vast  distention 
of  the  abdomen,  fever,  coma,  and  other  bad  symptoms, 
soon  terminating  in  gangrene  and  death.— (Larrey, 
Mem.  de  Chir.  Mil.  t,  4,  p.  292,  293.) 

During  the  first  fbur-and- twenty  hours,  very  little 
urine  escapes  from  gun-shot  wounds  of  the  bladder,  in 
consequence  of  the  swelling,  which  almost  instantly 
affects  the  lips  of  the  wound.  When  the  bladder  is  fUll, 
this  fluid  is  discharged  only  at  the  moment  of  the  acci- 
dent, and  mostly  only  from  the  wound,  by  which  the 
»all  has  made  its  exit.  An  extravasation  is  prevented 
by  the  thick  slough  which  fills  all  the  track  of  the  injury, 
and  it  is  not  till  the  deadened  parts  become  loose,  that 
any  effusion  can  happen.  Hence,  it  is  of  the  highest 
importance  to  introduce  an  elastic  gum  catheter  into 
the  urethra,  v'here  it  should  be  kept,  and  the  instrument 

Vo  I..  l.-F  f 


should  be  large  enough  to  fill  exactly  this  canal ; for, 
acco.-ding  to  Baron  I>arrey’s  observations,  if,  at  the  pe- 
riod when  the  sloughs  are  detached,  the  urine  has  not 
a ready  passage  outwards,  it  passes  through  the  wound, 
and  is  extravasated  the  more  readily,  inasmuch  as  the 
separation  of  the  sloughs  has  occasioned  many  openings, 
by  which  the  fluid  may  insinuate  itself  into  the  cellu- 
lar membrane.  Hence  gangrenous  mischief  and  death 

On  two  points,  my  own  experience  would  not  lead 
me  to  join  in  the  sentiments  of  Larrey  : first,  in  oppo- 
sition to  his  statement,  I am  sure  that  there  is  risk  of 
extravasation  of  urine  earlier  than  the  period  which  he 
specifies,  having  known  this  accident  commence,  as  it 
were,  within  a few  hours  after  the  receipt  of  the  wound ; 
and,  therefore,  I should  not  depend  upon  the  sloughs 
being  always  at  first  a complete  barrier  to  extravasation 
of  urin’e  (indeed,  their  formation  throughout  the  whole 
track  of  a gun-shot  wound  is  by  no  means  a regular 
occurrence),  but  invariably  pass  a catheter  as  soon  aa 
possible,  for  the  more  certain  prevention  of  this  dan- 
gerous consequence.  Secondly,  the  period  of  the  sepa- 
ration of  sloughs  may,  indeed,  often  be  contemporary 
with  the  first  appearance  or  symptoms  of  extravasation, 
particularly  in  cases  where  the  employment  of  the  ca- 
theter is  tbr  some  time  deferred,  as  in  Baron  I.arrey’s 
practice,  because  then  a partial  extravasation  of  the 
urine,  soon  after  the  injury,  and  previous  to  the  intro- 
duction of  the  catheter,  will  cause  rapid  sloughing,  and 
actually  prevent  the  adhesive  inflammation  from  closing 
up  the  cavities  of  the  cellular  membrane  in  time  to 
prevent  a fatal  extension  of  that  irritating  fluid  among 
the  surrounding  parts.  Were  it  not  for  the  partial  early 
effusion  of  urine,  no  doubt,  the  adhesive  inflammation 
would,  inthese  cases,  soon  have  the  same  effect,  in  obvia- 
ting the  danger  of  urinary  extravasation,which  it  has  after 
lithotomy,  or  paracentesis  of  the  bladder.— (SeeLtod<ier.) 

It  is  the  practice  of  Baron  Larrey  to  dilate  the  wound^ 
in  order  to  facilitate  the  escape  of  the  urine,  which 
might  otherwise  lodge  in  the  track  of  the  ball ; and 
perhaps  here  the  method  may  frequently  be  right,  though 
I should  conceive  its  propriety  must  usually  depend 
upon  whether  the  urine  has  a tendency  to  continue  to 
flow  out  through  the  wounds  or  not,  and  upon  the  pre- 
sence of  obstruction  or  not.  And  in  confirmation  of 
this  opinion,  I may  cite  Dr.  Hennen’s  declaration,  that 
in  these  cases,  he  has  very  rarely  found  it  necessary 
to  enlarge  the  wound  when  the  catheter  and  proper 
dressings  have  been  employeA.— (On  Military  Surgery, 
p.  421,  ed.  2.)  And  as  soon  as  possible  a large  elastic 
gum  catheter  should  be  introduced,  and  left  in  the  ure- 
thra, taking  care  to  withdraw  it,  and  pass  in  a clean 
one  every  two  or  three  days,  so  that  no  incrustations 
may  occur.  Sometimes,  however,  the  passage  of  a ca- 
theter is  very  difficult,  as  is  the  case  when  there  are 
splinters  of  bone  in  the  urethra,  or  the  parts  about  the 
neck  of  the  bladder  are  inflamed. — (Mem.  de  Chir.  Mi- 
litaire,  t.  4,  p.  294.)  Emollient  clysters  and  acidulated 
demulcent  drinks  are  to  be  prescribed,  and  the  patient 
is  to  be  kept  upon  a very  low  regimen,  and  in  the  most 
quiet  state.  The  dressings  are  to  be  light  and  simple, 
and  cleanliness  observed. — (Op.  cit.  t.  2,  p.  165—170.) 
Instead  of  camphorated  embrocations  to  the  abdomen, 
another  means  commended  by  Larrey,  it  appears  to 
me,  that  this  author’s  directions  would  have  been  more 
complete  and  judicious,  had  be  advieed  in  these  cases 
bleeding,  both  topical  and  general. 

From  the  injury  of  arterial  ramifications,  nr  varicose 
vessels,  blood  is  sometimes  extravasated  within  the 
wounded  bladder,  and  causes  deep-seated  irritation. 
According  to  Baron  Larrey,  the  case  is  indicated  by  the 
symptoms  of  retention  of  urine,  and  those  of  inflamma- 
tion, with  a small  pulse,  pallor  of  the  countenance,  and 
dryness  of  the  wounds.— ( T.  4,  p.  295.)  A more  decided 
criterion,  I should  think,  would  be  the  partial  escape  of 
urine  mixed  with  blood,  a symptom  which  could  deceive 
only  where  the  urethra  itself  h.ad  been  injured.  Larrey 
states,  that  blood  extravasated  in  the  bladder  rarely  co 
agulates,  because  blended  with  urine ; and  hence,  he  ad 
vises  its  discharge  to  be  facilitated  bymeansofa  catheter, 
and  tepid,  emollient,  anodyne  injections.— (T.  4,  p.  295.) 

Sometimes  balls  carry  before  them  into  the  bladder 
fragments  of  bone,  small  coins,  pieces  of  buttons,  &c. ; 
or  bits  of  bullets  break  off,  and  lodge  in  that  viscus. 
When  these  extraneous  bodies  are  not  above  a certain 
size,  they  are  frequently  voided  through  the  urethra 
(see  Cases  in  Dr.  Hennen’s  work,  p.  419.  422.  424,  <J-c 
ed.  2) ; and  their  evacuation  may  be  materially  facil: 


450 


GUN-SHOT  WOUNDS. 


tated  by  the  introduction  of  an  elastic  gum  catheter, 
the  size  of  which  is  to  be  increased  gradually,  nntil 
the  largest  can  be  passed,  when  the  foreign  substances 
will  readily  enter  the  tube,  or  pass  out  through  the 
dilated  urethra.  In  this  way  Baron  Larrey  has  saved 
gravel  patients  from  a vast  deal  of  suffering.— 
de  Chir.  Mil.  t.  4,  p.  302.)  In  such  cases,  the  urethral 
forceps  made  by  Mr.  Weiss  might  often  be  used  with 
advantage. — (See  Lithotomy.)  When  the  ball  is  too 
large  to  be  taken  out  in  this  manner,  the  lateral  opera- 
tion is  to  be  performed,  and  it  ought  to  be  done  before 
the  bladder  falls  into  an  ulcerated  or  gangrenous  state, 
from  the  pressure  and  irritation  of  the  foreign  body. 
However,  as  wounds  of  this  organ  frequently  give  rise 
to  dangerous  inflammation,  Larrey  recommends  this 
operation  to  be  done  either  before  its  attack  or  not  till 
after  its  subsidence. — (LoZ.  cit.  p.  309.)  In  fact,  almost 
all  the  operations  of  this  kind  on  record  have  been 
done  some  considerable  time  after  the  receipt  of  the 
wound,  and  to  this  practice  my  own  judgment  would 
lead  me  to  give  a general  preference.  In  one  case, 
however,  Larrey  operated  on  the  fourth  day  after  the 
receipt  of  the  wound,  and  with  success. 

After  the  battle  of  Waterloo,  I was  not  a little  sur- 
prised to  find,  in  the  St.  Elizabeth  Hospital  at  Brussels, 
a considerable  number  of  cases,  in  which  either  the 
intestines,  the  stomach,  the  omentum,  or  the  bladder 
protruded.  I think  we  had  in  the  division  under  Mr. 
Collier  and  myself  not  less  than  three  protrusions  of 
the  bladder.  An  order  w'hich  I received  to  join  the 
army  in  the  field  on  the  27th  of  June,  deprived  me  of 
the  opportunity  of  witnessing  the  progress  and  termi- 
nation of  these  interesting  cases.  However,  many  had 
ended  fatally  before  my  departure  from  Brussels. 

GUN-SHOT  WOUNHS  OF  T3IE  THORAX. 

W ounds  of  the  lungs,  abstracted  from  other  mischief, 
are  now  well  knowm  not  to  be  always  fatal.  Balls 
have  been  found  in  the  substance  of  the  lungs  after 
having  lodged  there  twenty  years,  during  all  which 
time  the  patients  were  healthy,  and  free  from  symp- 
toms indicative  of  the  case. — {Percy,  Manuel,  A c.  p.  25.) 
Mr.  Hunter  had  some  reason  to  believe,  that  wmunds 
of  the  lungs  made  with  balls  were  generally  less  dan- 
gerous than  such  as  were  made  with  sharp-pointed  in- 
struments ; for  he  had  seen  .several  patients  recover  af- 
ter they  had  been  shot  through  the  lungs,  while  other 
persons  died  of  very  small  wounds  of  those  organs, 
done  with.swords  and  bayonets.  Perhaps  one  cause 
of  this  fact  may  be  owing  to  the  circumstance  of  gun- 
shot wounds  generally  bleeding  less  than  other  wounds, 
so  that  there  is  not  so  much  danger  of  blood  being  ef- 
fused in  the  cavity  of  the  chest  or  the  cells  of  the  lungs. 
The  indisposition  of  the  orifice  of  a gun-shot  wound  to 
heal  up  too  soon,  is  also  another  circumstance  that  must 
lessen  the  hazard,  as  w-hatever  matter  happens  to  be 
exlravasated  has  thereby  an  opportunity  of  escaping. 

But  from  w'hat  has  been  stated,  it  must  not  be  in- 
ferred that  gun-shot  wounds  of  the  lungs  are  not  ac- 
companied with  a serious  degree  of  danger.  Frequently 
the  patient  expires  instantly,  being  suffocated  in  conse- 
quence of  profuse  hemorrhage  from  those  organs  ; for 
though  it  be  true  that  gun-shot  w'ounds  generally  do 
not  bleed  much  when  the  injured  vessels  are  under 
a certain  size,  yet  the  contrary  is  the  case  when  the 
wounded  vessels  are  like  those  situated  tow^ards  the 
root  of  the  lungs.  Gun-shot  w ounds  of  the  chest  also 
often  prove  fatal  by  the  inflammation  that  is  excited 
within  this  cavity. 

Appearances  sometimes  create  a belief,  that  a ball 
has  passed  completely  through  the  chest  and  lungs, 
when  the  fact  is  otherwise.  “Thus  (as  L)r.  Ilennen 
observes),  I have  traced  a ball  by  dissection,  passing 
into  the  cavity  of  the  thorax,  making  the  circuit  of  the 
lungs,  penetrating  nearly  opposite  the  point  of  entrance, 
and  giving  the  appearance  of  the  man  having  been  shot 
fairly  across,  while  bloody  sputa  seemed  to  prove  the 
fact,  and  in  reality  rendered  the  same  measuies,  to  a 
Certain  extent,  as  necessary  as  if  the  case  had  been 
what  was  suspected.  The  bloody  sputa,  however,  were 
only  secondary,  and  neither  so  active  and  alarming  as 
those  which  pour  out  at  once  from  the  lungs  when 
wounded.” — {Military  Sunrery,  p.  368,  ed.  2.)  A se- 
cond cause  of  deception  i.s  the  frequent  long  course  of 
a ball,  round  the  chest  under  the  skin  and  muscles, 
previously  to  its  exit,  whereby  an  appearance  is  pre- 
sented, a.s  if  the  patient  had  been  shot  through  the 


thorax.  And  another  source  of  deception,  as  to  tho 
actual  penetration  of  balls,  is,  “where  they  strike  against 
a handkerchief,  linen,  cloth,  &c.,  and  are  drawm  out 
unperceived  m their  folds,  a peculiarity  which  has  not 
escaped  M.  Larrey,  who  gives  an  interesting  notice  on 
it  in  the  Bulletins  de  la  Faculte  de  Med.  Paris,  1815, 
iVo.  2.  I have  also  given  an  instance  in  the  preceding 
pages.” — {Hennen,  loco  cit.)  In  these  cases,  the  ab- 
sence of  bloody  expectoration  directly  after  the  injury, 
the  undisturbed  state  of  respiration,  and  the  greater 
■fi-eedom  from  oppression,  anxiety,  syncope,  and  other 
bad  symptoms,  than  in  cases  where  the  lungs  are  hurt, 
form  grounds  for  a correct  opinion  on  the  true  na- 
ture of  the  accident. 

It  cannot  be  supposed  that  adhesions  always  take 
place  round  the  opening  of  a gun-shot  wound  in  the 
chest,  because  the  lungs  must  sometimes  collapse,  and 
become  considerably  distant  from  the  pleura,  especially 
when  the  communication  established  between  the  at- 
mospheric air  and  the  cavity  of  the  thorax  is  very  free 
and  direct.  However,  as  adhesions  are  extremely  com- 
mon between  the  outer  surface  of  the  lungs,  and  the 
inner  surface  of  the  pleura  cOstalis,  they  must  in  many 
'instances  exist  before  the  receipt  of  a wound,  and,  of 
course,  prevent  the  usual  collapse  of  the  lungs. 

As  the  general  symptoms  and  treatment  of  wounds 
of  the  chest  are  detailed  in  the  article  Wounds,  I shall 
not  here  detain  the  reader  long  upon  the  subject.  When 
a patient  has  been  shot  in  the  chest,  the  most  impor- 
tant indication  is  to  prevent  and  subdue  inflammation 
of  the  lungs  and  pleura.  In  few  other  eases  can  re- 
peated and  large  bleedings  be  so  advantageously  prac- 
tised. Here  there  will  not  be  so  much  danger  of  an 
extravasation  of  blood  as  in  stabs ; and  even  if  an  effu- 
sion of  that  fluid  w ere  .to  happen  within  the  cavity  of 
the  pleura,  the  opening  w ould  generally  be  sufficient 
for  its  escape,  and  it  would  not  be  so  frequently  found 
necessary  to  dilate  the  wound,  or  ntake  a new  opening, 
as  when  the  injury  has  been  inflicted  with  a sharp- 
pointed  weapon. 

Ill  this  last  kind  of  case,  when  attended  in  the  begin- 
ning with  bleeffing,  Baron  Larrey  particularly  insists 
upon  the  advantage  of  immediately  bringing  the  edges 
of  the  wmund  together  with  adhesive  plaster,  instead  of 
leaving  it  open,  as  advised  by  the  generality  of  writers; 
and  he  endeavours  to  prove,  that  this  immediate  clo- 
sure of  the  wound  has  great  effect  in  stopping  the  he- 
morrhage from  the  pulmonarj-  vessels  Supposing  an 
extravasation  of  blood  in  the  chest  were  to  follow,  he 
argues  that  it  would  be  better  to  let  it  out  afterward  by 
a suitable  incision,  than  to  suffer  the  patient  to  perish 
of  hemorrhage  at  once  by  not  closing  the  wound. — 
Qlem  de  Chir.  Mil.  t.  4,  p.  151,  &c.)  Dr.  Hennen  is 
in  favour  of  the  same  practice. — (Ora  Military  Surgery, 
p.  373,  ed.  2.)  In  a penetrating  gun-shot  wound  of  the 
chest,  after  taking  aw-ay  from  thirty  to  forty  ounces  of 
blood,  the  surgeon  should  extract  all  extraneous  sub- 
stances and  splinters  of  bone  within  reach,  and  even 
dilate  the  external  wound  for  this  purpose,  if  necessary. 
Light,  unirritating  dressings  are  then  to  be  applied. 
The  jialient  may  now’  be  (comparatively  speaking)  easy, 
until  the  spitting  of  blood,  and  danger  of  sufibcation 
from  inward  hemorrhage  come  on  again,  when  the 
lancet  must  be  again  employed  ; “ and  if  by  this  ma- 
nagement, repeated  as  often  as  ciicumstances  demand, 
the  patient  survives  the  first  twelve  hours,  hopes  may 
begin  to  be  entertained  of  his  recovering  from  the  im 
mediate  effects  of  hemorrhage  and  until  this  dangei 
is  over,  as  Dr.  Hennen  truly  observes,  the  lancet  is  the 
only  tiling  which  can  save  life.  Afterward,  when  the 
paroxysms  of  pain,  the  sense  of  suffocation,  and  the 
return  of  hem,orrhage  have  become  more  moderate,  di- 
gitalis may  be  prescribed  with  the  most  beneficial  ef- 
fect ; and  if  the  cough  be  very  troublesome,  no  medi- 
cine is  more  useful  than  the  spermaceti  mixture  with 
opium.  With  this  treatment  must  be  combined  the 
exhibition  of  saline  purgatives,  mild  laxative  clysters, 
and  a strictly  low’  diet,  the  patient  being  allowed  only 
slops.— (See  Hennen's  Military  Surgery,  p.  373,  ed.  2.) 

When  matter  forms  in  the  thorax,  in  consequence  of 
gun-shot  wounds,  the  opening  will  generally  suffice  for 
its  escape;  but  should  the  collection  of  pus  be  con- 
fined, and  occasion  dangerous  symptnuis,  the  external 
wound  must  either  be  enlarged,  or  a new  incision  prac- 
tised. as  circumstances  may  indicate.  Tlie  mode  of 
making  an  opening  into  the  chest  is  considered  in  the 
aiiicle  Paracentesis. 


GVN 


GUT 


451 


When  a ball  lodges,  without  falling  ii\to  the  chest,  it 
may  lie  either  in  the  substance  of  the  parietes  of  this 
cavity  between  the  muscles,  or  in  one  of  the  intercostal 
spaces,  and  continue  there  a very  long  time  without 
causing  much  inconvenience,  or  Inaking  its  way  out- 
wards. Hut  when  it  is  lodged  in  the  thoracic  cavity 
itself,  it  descends  by  its  weight,  and  sometimes  excites 
considerable  irritation,  suppuration,  sinuses,  and  hectic 
symptoms;  in  this  case,  if  its  situation  can  be  ascer- 
tained, Baron  Larrey  recommends  an  attempt  to  ex- 
tract it.  In  an  early  stage  of  the  case,  he  says  that 
the  intercostal  space  will  often  be  wide  enough  to  let 
the  ball  pass  through  it ; but  that,  at  a later  period, 
this  space  becomes  too  narrow,  and  it  will  be  neces- 
sary to  cut  away  a portion  of  the  upper  edge  of  the  rib 
with  a lenticular  ktiife,  which  is  to  be  preferred  to  a 
trephine  or  saw.  This  advice  is  supported  by  some 
very  interesting  cases. — (See  Mem.  de  Ckir.  Mil.  t.  4, 
p.  253.)  Frequently  the  ball  fractures  the  rib,  and, 
with  the  aid  of  dilatation,  sufficient  room  for  its  ex- 
traction maybe  made:  but  the  possibility  and  propriety 
of  removing  it  through  the  original  opening  will,  of 
course,  depend  upon  the  situation  of  the  foreign  body, 
and  the  urgency  of  the  symptoms.  A case  is  recorded 
in  which  a ball,  weighing  three  ounces  and  a half,  was 
thus  removed. — (Med.  and  Surg.  Joum.  vol.  3,  p.  353.) 

Alphons.  Ferrius  de  Sclopetorum,  sive  Archibuso- 
rum  Vulneribus,  &c.  8vo,  Romce,  1552.  /.  F.  Rota  de 
Bellicorum  Tormentariorum  Vulneribus  et  Curatione, 
Ato.  Bonon.  1555.  Botallusde  Curat.  Vulner.  1565.  Wm. 
Clowe's  Approved  Treatise  for  all  young  Chirurgeons 
concerning  Burnings  with  Gunpowder,  and  Wounds 
ytiade  with  Gun-shot,  t^-c.  Ato.  1591.  J.  Quercetanus, 
Sclnpetarius,  sive  de  curandis  Vulneribus  qucB  Sclo- 
petorurn  et  simUium  Tormentorum  Ictibus  accidm-unt, 
Svo.  1591, 12mo.  Leipz.  1614.  Fr.  Plazzonus,  de  Vulne- 
ribus Sclopetorum,  ^-c.  Ato.  Venet.  1618.  J.  Woodal, 
Viaticum,  fol.  Load.  1639.  H.  F.  Le  Bran,  Traite,  ou 
Rf  exions  tiries  de  la  Pratique  sur  les  Plaies  d'Armes 
d feu,  2de  id.  12mo.  Paris,  1740.  Desport,  Traite  des 
Plaies  d'Armes  d feu,  \2mo.  Paris,  1749.  Ran- 
by's  Method  of  treating  Gun-shot  Wounds,  \2mo.  Lon- 
don, 1781.  dbsenmtions  sur  les  Plaies  d'Armes  A feu, 
compliquies  de  Fracture  aux  Articulations  des  Extre- 
mitis,  ou  au  Voisinage  de  ces  Articulations,  par  M. 
Boucher,  in  Mim.  de  I'Acad.  de  Chirurgie,  t.  5,  p.  279, 
idit.  in  l2mo.  Observations  sur  des  Plaies  d'Armes 
<i  feu,  compliquies  sur  tout  de  Fracas  des  Os,  par  M. 
Boucher,  in  opere  cit.  t.  6,  p.  109,  &c.  idit.  in  Vi,mo. 
Observations  sur  les  Plaies  d'Armes  A feu : 1.  Sur  un 
Coup  de  Fusil,  avec  Fracas  des  deux  Machoires ; par 
M.  Cannae : 2.  Sur  une  Plaie  d'Arme  A feu  traversant 
la  Poitrine  d'un  c6ti  A I' autre ; par  M.  Gerard : 3. 
Sur  une  Plaie  d'Arme  A feu,  p-n^trante  depuis  la  Par- 
tie  ant  rieure  du  Pubis  jusqu'A  I'Os  Sacnem ; par  M. 
Andouilli : 4.  Sur  une  Jambe  icrasee  par  tin  Obus,  ou 
petit.e_  Bombe ; par  M.  Cannae : 5.  Sur  une  Plaie  A la 
Partie  infirieure  et  interne  de  la  Jambe,  faite  par  un 
Eclat  de  Gr anode,  sans  Fracas  (TOs ; par  M.  Cavnac : 
6.  Precis  de  plusieurs  Observations  sur  les  Plaies 
d'Armes  d feu  en  difirentes  Parties,  par  M.  Bordenave : 
— all  these  papers  are  inserted  in  Mim.  de  I'Acad.  de 
Chirurgie,  t.  6,  in  12mo. ; and  in  t.  \ l of  the  same  edi- 
tion are  inserted  Memoires  sur  le  Traitement  des  Plaies 
d'Armes  A feu,  par  M.  de  la  Martiniire,  et  Memoires 
sur  quelques  Particularit‘S  concemant  les  Plaiesfaites 
par  Armes  A feu,  par  M.  Vacher.  M.  Faure's  memoirs 
relative  to  amputation  in  cases  of  gun-shot  wounds 
may  be  seen  in  t.  8 of  the  Recueil  des  Piices  qui  ont 
concouru  pour  le  Prix  de  I'Acad.  de  Chirurgie,  edit,  in 
12/ho.  John  Hunter's  Treatise  on  the  Blood,  Inflam- 
mation, and  Gun-shot  Wounds,  1794.  Richter,  An- 
fangsgrunde  der  Wundarzneykunst,  b.  1.  Schmucker, 
Vermischte  Chir.  Schriften,  3 vols.  8vo.  Berlin,  1776. 
1782.  Chirurgische  Wahrnehmungen,  Berlin,  2 vols. 
8vo.  \7AA.  1789  : works  (f  high  value.  Discourses  on 
the  Nature  and  Cure  of  Wounds  by  John  Bell,  p.  169, 
irc.  edit.  3.  Richerand,  Nosographie  Chir.  t.  1 , Hit.  A. 
Chevalier's  Treatise  on  Gun-shot  Wounds,  edit.  3.  Le- 
veilU,  Nouvelle  Doctrine  Chirurgicale,  t.  1,  chap.  8, 
p.  436,  <^c.  Encyclopidie  Methodique,  partie  Chir.  art. 
Plaies  d' Armes  A feu.  Larrey,  M/moires  de  Chirurgie 
Militaire,  A tonies,  8vo.  Paris,  1812.  1817;  on  the 
whole  the  most  instructive  book  for  army  surgeons 
ever  published.  M moire  par  M.  De  Conte,  Prix  de 
I'Acad.  1.  8.  Examen  des  plusieurs  Parties  de  la  Chi- 
r urgie,  par  M.  Bagieu,  A Paris,  1756.  Bilguer,  Dissert. 


deMembrorum  Amputatione  rarissime  administranddf 
axit  quasi  ahrogandd  ; Hallo:,  1761 : this  work  is  cele 
brated  as  having  attracted  most  deservedly  the  just 
and  severe  criticlsjrtK  of  Pott,  La  Martiniire,  Morand, 
ifc.  Morand' s Opuscules  de  Chirurgie,  1768.  Van 
Gesscher,  Abhandlung  von  der  Nothwendigkeit  der 
Amputation  ; Freyburgh,  1775.  M.  G.  Daignan,  Ri- 
flexions  Importantes  sur  le  Service  des  Hopitaux 
Militaires,  8vo.  Par.  1785.  Mursinna,  Neue  Medici- 
nisch-Chirurgische  Beobachtungen,  zweiter  theil,  s. 
138,  Berlin,  1796.  Wedekind's  Nachrichten  uher  das 
Franzos  '-^che,  Kriegspitalwesen,  erstei-  b.  Leipzig,  1797 
Baron  Percy,  Manuel  du  Chirurgicn  d’Armee,  8vo, 
Paris,  1792.  Paroisse,  Opuscules  de  Chir.  8vo.  Paris, 
1806.  Graefe,  Normen  fur  die  Ablosung  Grosserer 
Gliedmassen,  Ato.  Bei-lin,  1812.  Assalini,  Manvale  di 
Chirurgia,  8vo.  Milano,  1812.  Guthrie  on  Gun-shot 
Wounds  of  the  Extremities,  London,  1815;  or  the  2d 
ed.  entitled  a Treatise  on  Gun-shot  Wounds,  S,-c.  8vo. 
London,  1820 : a work  detailing  the  practice  of  our 
military  surgeov.s  during  the  late  war  in  Spain,  and 
replete  with  valuable  information.  Thomson's  Report 
of  Observations  made  in  the  Military  Hospitals  in 
Belgium,  Edinburgh,  1816.  A.  C.  Hutchison's  Prac- 
tical Observations  in  Surgery,  1816 ; and  Farther  Obs. 
on  the  Period  for  ampirtating  in  Gun-shot  Wounds, 
Lond.  1817.  Millingen's  Manuel,  8vo.  Lond^l8l9.  J. 
Hennen's  Principles  of  Military  Surgery,  2d  edit.  8uo. 
Edinb.  1820 ; a publication  which  I cannot  too  strongly 
recommend,not  only  to  army  and  navy  surgeons,  hut  to 
practitioners  in  general.  James  Mann,  Med.  Sketches 
of  the  Campaigns  of  \8\2, 13, 14;  fo  which  are  added  Sur- 
gical Cases,  Obs.  on  Military  Hospitals  and  Flying  Hos- 
pitals attachedto  amoving  Jtrmy,  Sri..  8vo.Dedham,\8\8. 

GUTTA  SERENA.  A term  said  to  have  been  first 
applied  by  Actuarius  to  amaurosis,  or  the  species  of 
blindness  arising  from  a morbid  state  of  the  retina  or 
optic  nerve.— (See  Amaurosis.) 

In  the  present  place  I mean  first  briefly  to  advert  to 
a case  which  the  late  Mr.  Ware  has  describetl  as  com- 
bined with  a particular  kind  of  oiditlialmy,  that  occa- 
sions excruciating  pain,  and  requires  peculiar  treat- 
ment. One  example  of  this  kind  was  greatly  relieved 
by  a puncture  made  through  the  tunica  sclerotica  into 
the  ball  of  the  eye  with  a grooved  needle,  somewhat 
larger  than  a common-sized  couching  needle,  nearly 
in  the  part  where  this  instrument  is  introduced  in  the 
operation  of  depressing  the  cataract.  Through  the 
groove  of  the  instrument  a watery  fluid  immediately 
issued,  which  was  not  unlike  that  which  Mr.  Ware 
several  times  found  after  death  effused  between  the 
choroid  coat  and  retina  in  cases  of  gutta  serena.  After 
the  pain  of  the  operation  had  ceased,  the  patient  be- 
came quite  easy,  and  the  inflammation  soon  subsided. 
Mr.  Ware  afterward  performed  a similar  operation  in  a 
considerable  number  of  resembling  instances,  and  in 
several  of  them  the  proceeding  was  attended  v.dth  al- 
most immediate  good  effect. — (See  Ware  on  the  Opera- 
tion of  largely  puncturing  the  Capsule  of  the  Crystal- 
line ilvmour,  (Src.  and  on  the  Gutta  Serena,  accompa- 
nied with  Pain  and  Inflammation,  1812.) 

Under  the  head  of  gutta  serena  I ])romised  to  notice 
Beer’s  opinions  concerning  amaurotic  remedies,  which 
he  divides  into  two  classes,  viz.  general  or  internal 
means,  and  local  or  external.  Sometimes  only  the  first 
are  requisite;  more  rarely  only  the  second;  but  fre- 
quently both  together. 

Among  the  internal  remedies  are  emetics,  which  may 
be  useful  in  two  ways,  either  as  real  evacuants,  or  as 
nauseating  means.  It  was  Beer’s  opinion  that  for  the 
purpose  of  exciting  actual  vomiting  they  .should  be  ex- 
hibited only  when  the  stomach  is  foul,  and  no  consi- 
derable plethora  exists  ; and  he  deems  them  improper 
whenever  any  great  determination  of  blood  to  the  head 
and  eyes  prevails,  or  any  increased  velocity  of  the  cir- 
culation. Should  the  surseo:i  find  it  neces.sary  to  em- 
ploy emetic  medicines,  simply  as  alteratives,  he  must 
consider  well  whether  the  digestive  organs  will  bear 
their  great  and  long-continued  oiieration.— (LeArc  i;oh 
den  Augenkr.  b.  2,  p.  463.)  Notwithstanding  the  fa- 
vourable accounts  given  by  Schmucker,  Richter,  and 
Scarpa  of  the  good  effects  of  emetics  in  many  ca.ses 
of  amaurosis  abroad,  this  treatment  has  bad  but  little 
success  in  England.  Mr.  Travers  even  declares  that 
he  does  not  recollect  an  instance  of  decided  benefit  from 
the  emetic  practice,  although  he  has  fairly  tried  it.  “ The 
cases  of  gastric  disorder,  to  which  it  is  esjiecially  appli 


452 


GUTTA  SERENA. 


cable  are  most  benefited  by  a long-continued  course 
of  the  blue  pill,  with  gentle  saline  purgatives  and  tonic 
bitters.” — {Synopsis  of  Diseases  of  the  Eye,  p.  304.) 
Mr.  Lawrence  also  states  in  his  lectures,  that  in  this 
country  the  treatment  of  amaurosis  by  emetics  is  not  at- 
tended with  the  success  that  has  resulted  from  it  abroad. 

When  the  bowels  are  loaded,  and  there  is  frequent 
determination  of  blood  to  the  head  and  eyes,  and  an 
accelerated  circulation,  and,  particularly,  if  after  these 
effects  the  sight  is  always  manifestly  worse,  brisk  pur- 
gatives may  be  prescribed.  When,  however,  constipa- 
tion has  prevailed  for  a long  time,  drastic  purgatives 
should  not  be  exhibited  before  one  or  two  loose  motions 
have  been  procured  with  laxative  clysters.  Gentle 
aperients  are  more  particularly  indicated  when  the  pa- 
tient does  not  have  a stool  daily,  and  the  evacuation  is 
never  made  with  ease  nor  without  considerable  strain- 
ing ; when  he  often  passes  two  or  three  days  without 
any  evacuation  at  all,  circumstances  sure  to  be  fol- 
lowed by  repeated  determination  of  blood  to  the  head 
and  eyes,  and  other  ill  consequences,  which,  according 
to  Beer,  have  a very  prejudicial  effect  on  amaurosis. 

Beer  is  of  opinion  that  diaphoretics  should  be  em- 
ployed with  great  caution,  because  they  are  apt  to 
bring  on  violent  determinations  of  blood  and  an  accele- 
rated state^f  the  circulation ; and  they  can  only  be 
employed  with  judgment  and  a hope  of  benefit  when 
there  are  good  grounds  for  believing  that  a previous 
stoppage  of  the  cutaneous  functions  has  had  a real 
share  in  producing  or  keeping  up  the  blindness.  They 
are  still  more  strongly  indicated  when  the  cessation  of 
those  functions  is,  in  some  measure,  evinced  by  the 
dry  state  of  the  integuments,  wandering  pains  between 
the  skin  and  muscles,  and  considerable  melioration  of 
the  eyesight  after  the  breaking  out  of  any  accidental 
perspiration. — (B.  2,  p.  465.) 

Professor  Beer  thinks  that  in  amaurosis  medicines 
for  promoting  the  menstrual  discharge  are  too  often 
employed  on  empirical  principle.s,  to  the  serious  detri- 
ment of  the  patient,  the  cessation  of  this  discharge 
being  mostly  regarded  as  the  cause  of  the  amaurosis, 
while,  in  reality,  it  is  very  seldom  really  so,  both  affec- 
tions being  dependent  upon  one  and  the  same  cause. 
Hence  much  circumspection  and  the  closest  investiga- 
tion are  necessary  to  trace  the  connexion  between  these 
morbid  effects,  and  to  ascertain  when  such  medicines 
can  be  given  without  risk. 

Still  greater  mischief  results  from  the  treatment  of 
amaurotic  children  with  anthelmintics  ; nay,  Beer  as- 
sures us,  that  he  has  seen  numerous  amaurotic  boys 
and  girls  thus  wrongly  treated,  who  had  not  the  slight- 
est symptoms  of  worms.  However,  when  amaurosis  is 
unattended  with  any  leading  indications,  anthelmintics 
may  be  tried,  for  they  are  less  injurious  to  the  eyes  than 
many  other  medicines,  though,  as  they  consist  of  drastic 
purgative  means,  they  must  soon  occasion  great  debility. 

According  to  Beer,  when  there  is  good  ground  for 
suspecting  the  patient  to  be  suffering  from  the  effects 
of  syphilis,  mercurials  may  be  given  with  great  pros- 
pect of  benefit.  Also,  when  no  suspicion  of  this  kind 
can  be  entertained,  but  amaurosis  is  accomparnied  with 
infarction  of  the  abdominal  viscera,  especially  chronic 
disease  of  the  liver,  or  serious  chronic  swellings  and 
indurations  of  the  glands,  a periodical  headache  of  no 
determinate  character  in  other  respects,  and  aggrava- 
tion of  the  blindness  after  every  such  attack,  mercurial 
preparations,  as  Beer  can  assert  from  manifold  obser- 
vation, are  productive  of  the  best  effects  upon  the  dis- 
ease of  the  eyes.  Yet,  says  he,  under  these  circum- 
stances mercury  should  never  be  exhibited  where  the 
individuals  are  of  a debilitated  scorbutic  diathesis  or 
subject  to  bleedings,  and  more  particularly  where  there 
is  the  least  mark  of  a dissolution  of  the  vitreous 
humour. — {Lehre  von  den  Augenkr.  b.  2,  p.  466.)  Upon 
the  whole,  from  what  I am  able  to  learn  of  the  prac- 
tice in  London,  mercury,  preceded  by  antiphlogistic 
remedies,  is  more  extensively  and  successfully  used 
as  a remedy  for  amaurosis  than  any  other  medicine  in 
the  whole  pharmacopoeia.  “ When  the  amaurosis  is 
recent  and  sudden  (says  Mr.  Travers),  and  either  the 
signs  of  an  obscure  inflammation  are  present,  or  only 
the  amplitude  and  inactivity  of  the  pupil  correspond  to 
the  patient’s  history— mercury  should  be  introduced 
with  ail  convenient  rapidity  into  the  system,  I mean, 
so  as  to  ruffle  it  in  the  least  possible  degree.  No  ad- 
vantage is  obtained  by  salivation  ; on  the  contrary,  1 
tliink  it  hurtful';  when  mercury  i.s  beneficial,  its  efficacy 


is  perceived  as  soon  as  the  mouth  is  BoreJ'— {Synopsis 
of  the  Diseases  of  the  Eye,  p.  305.) 

Antinervous  medicines  have  at  all  times  ranked  very 
high  on  empirical  principles,  as  means  for  the  cure  of 
amaurosis ; but  how  often  is  this  disease  not  simply  a 
nervous  affection  1 Beer  divides  the  medicines  of  this 
sort,  employed  in  cases  of  amaurosis,  into  three  classes, 
namely,  antiparalytic,  antispasmodic,  and  tonic.  To 
the  frst  class  belong  arnica,  naphtha,  camphor,  mille- 
pedes, sulphur  auratum,  antimonii,  liquor  ammonite  la- 
vendulatus,  pulsatilla,  black  hellebore,  and  phosphorus. 
These  medicines  can  be  safely  given  to  amaurotic  pa- 
tients when  an  evident  general  nervous  debility  and 
morbid  irritability  prevail,  without  any  other  particular 
appearances  of  disease,  and  especially  when,  at  the 
same  time,  there  are  genuine  paralytic  appearances  in 
the  eye  itself,  or  in  the  parts  immediately  surrounding 
it,  or  not  very  far  from  it.  Among  the  antispasmodic 
remedies,  particularly  when  used  on  empirical  princi- 
ples, Beer  has  found  the  most  efficacious  to  be  valerian, 
liquor  ammoniae  carbonatis,  asafeetida,  opium,  hyosci- 
amus,  castoreum,  musk,  flores  zinci,  and  extract  of 
chamomile.  Tonic  nervous  remedies  (says  Beer)  are 
to  be  used  with  more  caution  ; for  bitter  medicines, 
when  injudiciously  prescribed  for  nervous,  debilitated 
individuals,  rather  promote  the  formation  of  amaurosis. 
When  calamus  aromaticus  is  in  question,  care  must  be 
taken  that  there  be  no  tendency  to  pectoral  complaints, 
which  this  medicine  is  too  apt  to  bring  on  in  weak  sub- 
jects, in  which  event  the  sight  is  always  very  much  im- 
paired by  it.  In  costive  habits,  bark  is  likewise  apt  to 
render  the  blindness  worse.  And  according  to  the  same 
experienced  oculist,  it  is  necessary  to  be  very  circumspect 
with  steel  medicines,  empirically  prescribed,  as  they 
frequently  occasion  determinations  of  blood  to  the  head 
and  eyes,  and  quicken  the  circulation,  whereby  every 
remnant  of  vision  may  be  abolished.  Steel  medicines 
do  the  greatest  and  quickest  injury  to  amaurotic  eyes, 
when  combined  with  narcotics.  Above  all  things,  it  is 
generally  prudent,  in  cases  of  amaurosis,  careftilly  to 
abstain  from  all  the  stronger  and  long-operating  ner- 
vous medicines,  whenever  plethora,  determinations  of 
blood,  and  tendency  to  inflammation  exist. — {Lehre  von 
den  Augenkr.  b.  2,  p.  467.)  In  this  country,  I do  not 
believe  that  antinervous  and  antispasmodic  medicines 
have  obtained  credit  for  their  efficacy  in  this  disease. 
Thus,  Mr.  Travers  states,  that  he  has  never  known  any 
real  benefit  derived  from  camphor,  asafeetida,  valerian, 
<fec.,  though  he  has  seen  much  good  derived  from  tonics, 
the  mineral  acids,  bark,  steel,  and  arsenic,  after  a due 
regulation  of  the  digestive  functions. — {Synopsis,  &-c.  p. 
304.)  In  arnica  montana,  aconite,  euphrasia,  and  sti- 
mulants in  general,  he  has  no  confidence. 

Local  or  external  medicines  for  amaurosis  are  divided 
by  Beer  into  two  classes,  namely,  into  those  which  are 
applied  to  parts  more  or  less  distant  from  the  eyes,  and 
having  some  sympathetic  connexion  with  these  organs, 
and  into  others  which  are  usually  put  upon  the  eye  itself. 

In  the  first  class,  bleeding  has  obtained  high  repute, 
either  by  venesection  in  the  common  way,  the  applica- 
tion of  leeches  to  the  pudenda,  the  arms,  behind  the 
ears,  or  upon  the  temple ; cupping  the  back,  or  by  open- 
ing the  temporal  artery  or  jugular  vein.  Bleeding  is 
indicated  when  manifest  plethora,  a determination  of 
blood  to  the  head  and  eyes,  or  an  accelerated  circulation 
is  combined  with  a considerable  decrease  of  vision ; 
when  the  menses  are  nearly  or  quite  suppressed  in  ple- 
thoric subjects,  a manifest  determination  of  blood  to  the 
parts  of  generation  prevails ; or  the  same  thing  occurs 
in  hemorrhoidal  patients. — {Beer,  Lehre,  iS,  c.  p.  469.) 

According  to  Mr.  Travers,  all  the  cases  of  direct  de- 
bility and  proper  paralysis  of  the  optic  nerve  are  aggra- 
vated by  loss  of  blood.-^Syn.op5ts,  Ac.  p.  303.) 

Professor  Beer  gives  his  testimony  also  in  favour  of 
the  efficacy  of  such  applications  as  produce  a counter- 
irritation, not  merely  as  rubefacients,  but  as  means 
occasioning  an  evacuation  of  lymph  ; such  are  blisters, 
sinapisms  laid  on  the  back  or  calves  of  the  legs,  vesica- 
tion by  means  of  the  bark  of  mezereon,  issues,  and 
setons.  These  means  are  proper  when  the  blindness  is 
attended  with  continual  but  wandering  pains  in  the 
aponeurotic  covering  of  the  head,  or  in  the  vicinity  of  the 
eye,  with  a whizzing  noise  and  irritating  pain  in  the 
ear,  or  with  the  suppression  of  a purulent  discharge 
from  the  meatus  auditorius  In  such  cases,  however, 
there  must  be  no  particular  plethora,  still  le.s.s  any 
determination  of  blood  to  the  head  and  eyes.  Here 


GUTTA  SERENA. 


453 


should  also  be  mentioned  friction  with  antimonial  oint- 
munt,  which  is  especially  indicated  where  there  is  rea- 
son to  believe  that  the  amaurosis  has  been  preceded, 
and  partly  produced,  by  a long  interruption  of  the  cuta- 
neous secretion. 

Beer  says,  that  aperient  clysters  are  attended  with  the 
most  decided  good  effects  in  that  amaurotic  weakness  of 
sight  which  sometimes  occurs  towards  the  end  of  preg- 
nancy, and  is  combined  with  obstinate  constipation, 
continual  headache,  evident  determination  of  blood  to  the 
head  and  eyes,  and  such  an  inflammatory  diathesis  as 
cannot  be  mistaken.  On  the  other  hand,  the  employ- 
ment of  clysters  as  anodyne  remedies,  not  as  evacuants, 
is  principally  useful  in  hypochondriacal  and  hysterical 
amaurotic  patients,  when  they  are  troubled  with  much 
general  cramp  and  spasms  in  the  abdomen. — {Vol.  cit. 
p.  470.) 

According  to  the  statements  of  the  same  writer, 
baths,  whether  warm  or  cold,  adapted  for  the  whole 
body  or  in  the  form  of  a slipper-bath,  a pediluvium  or 
affusion,  have  hitherto  not  proved  very  efficacious  re- 
medies for  amaurosis ; and  this,  whether  they  consist 
of  simple  water,  or  aromatic  decoctions,  or  of  waters 
impregnated  with  sulphur  or  iron.  The  reason  why 
baths  in  general  are  less  frequently  employed  as  empi- 
rical remedies  in  cases  of  amaurosis,  and  why  they  are 
still  more  rarely  successful,  may  be  because  in  the  very 
cases  of  amaurosis  in  which  baths  of  various  kinds  are 
clearly  indicated,  the  greatest  attention  must  be  paid  to 
the  patient’s  constitution,  to  the  state  of  the  skin  espe- 
cially, and  to  the  temperature  of  the  fluid  employed; 
for,  in  a healthy  subject,  too  warm  a bath  may,  under 
certain  circumstances  (as,  for  instance,  when  there  is 
plethora),  of  itself  occasion  a serious  amaurotic  ambly- 
opia ; and  therefore,  under  similar  circumstances,  must 
be  likely  to  increase  any  present  amaurotic  weakness 
of  sight  into  comjjlete  blindness.  In  general,  warm  or 
slipper-baths  must  be  employed  as  empirical  remedies 
in  amaurosis  only  when  the  regular  action  of  the  skin 
is  disturbed,  without  febrile  symptoms,  when  the  affec- 
tion of  the  eyes  has  been  preceded  by  the  sudden  stop- 
page of  a profuse  perspiration,  or  some  cutaneous  efflo- 
rescence is  coexistent  with  the  amaurosis.  On  the  con- 
trary, pediluvia  with  salt,  mustard,  &c.  are  chiefly 
proper  when  amaurosis  is  accompanied  with  a deter- 
mination of  blood  to  the  head  and  eyes,  or  any  local 
inflammations,  after  which  the  eyesight  is  always 
found  to  be  worse.  In  cases  of  amaurosis,  affusion 
can  be  seldom  used  empirically,  and  only  under  those 
circumstances  where  modem  experience  has  proved  the 
shower-bath  to  be  allowable.  Cold  bathing  generally 
agrees  badly  with  an  amaurotic  patient,  and  when  his 
skin  is  extremely  sensible,  when  wandering  pains  are 
felt  between  the  integuments  and  muscles,  or  there  is 
a tendency  to  erysipelatous  inflammation,  the  power  of 
vision  evidently  declines  after  every  trial  of  the  plan. 
But,  according  to  Beer,  mineral  waters  impregnated 
with  iron,  in  the  form  either  of  a hath  for  one  half  or 
for  the  whole  of  the  body,  generally  produce,  under 
these  circumstances,  the  most  favourable  effects  upon 
the  skin,  and,  through  the  medium  of  it,  upon  the  dis- 
eased eye.  The  case,  however,  is  to  be  excepted  where 
flying  rheumatic,  and  perhaps  gouty,  pains  constantly 
tease  the  patient,  unaccompanied  with  fever,  and  where 
bathing  of  the  whole  body  in  sulphurous  mineral  water 
should  be  preferred. — (Lehre  von  den  Augenkr.  b.  2,  p. 
471,  472.) 

If  we  are  to  believe  Beer,  the  empirical  employment 
of  applications  which  have  the  effect  of  increasing  the 
secretion  of  mucus  is  very  seldom  proper,  such  as  irri- 
tating gargles,  the  smoking  of  tobacco,  and  sternutatory 
powders  ; for  these  means  can  only  be  adopted  with  any 
prospect  of  benefit  when  amaurosis  is  accompanied 
with  plethora,  a sense  of  spasm  and  weight  about  the 
frontal  sinuses,  an  incessant,  obtuse  heaviness  at  the 
bridge  of  the  nose,  and  unusual  dryness  of  the  nostril, 
in  an  individual  who  has  frequently  suffered  catarrhal 
complaints,  but  some  time  previously  to  the  origin  of 
the  amaurotic  symptoms  has  continued  nearly  or  quite 
free  from  colds  ; and  when  the  patient  has  no  tendency 
to  plethora,  determination  of  blood  to  the  head  and  eyes, 
and  acceleration  of  the  circulation.— (ToZ.  cit.  p.  473.) 

The  application  of  sternutative  powders  to  the  nos- 
trils is,  perhaps,  to  be  regarded  as  a mode  of  treatment 
established  on  empirical  principles,  unless  we  can  place 
confidence  in  the  statement  of  Schrnucker,  Richter,  and 
Beer,  that  an  unusual  dryness  of  the  mucous  tnenibrane 


of  the  nose,  following  tedious  and  severe  catarrhs,  may 
have  the  effect  of  inducing  amaurosis.  The  snuff  em- 
ployed by  Schrnucker  is  thus  composed : R.  Mercur.  viv. 
3 i.  Sacchar.  alb.  3 iij.  Lill.  alb.  rad.  valerian  a a 3 j. 
Misce. 

The  late  Mr.  Ware  imputed  considerable  efficacy  to 
electricity  and  a mercurial  snuff  in  cases  of  gutta  sere- 
na.  The  snuff  was  compounded  of  ten  grains  of  turbith 
mineral  (hydrargyrus  sulphuratus),  well  mixed  v/ith 
about  a drachm  ofthepulvis  sternutatorius,  glycirrhiza, 
or  common  sugar.  A small  pinch  of  this  snuff  taken 
up  the  nose  is  found  to  stimulate  it  very  considerably  ; 
sometimes  exciting  sneezing,  but  in  general  producing 
a very  large  discharge  of  mucus.— (See  Chir.  Obs.  rela- 
tive to  the  Eye,  vol.  1.) 

Among  the  remedies  which  are  intended  to  be  applied 
directly  to  the  eye  and  its  surrounding  parts,  local 
bleeding  merits  the  first  rank.  The  extraction  of  blood 
by  means  of  leeches,  or  by  cupping  the  temples,  is  the 
only  mode  in  which  the  practice  can  here  be  executed. 
The  method,  however,  is  only  proper  when  manifest 
turgescence  of  the  vessels  of  the  conjunctiva  and  scle- 
rotica is  combined  with  a feeling  of  constant  pressure 
about  the  eye,  a sense  of  fulness  and  tension  in  the 
ball,  and  evident  plethora,  without  any  local  inflamma- 
tion or  increase  in  the  velocity  of  the  circulation. 

Experience  proves  also,  says  Beer,  that  the  empirical 
application  of  rubefacients,  or  drawing-plasters,  to  the 
temples  or  eyebrows  is  fraught  with  not  less  efficacy 
when  all  sensibility  in  the  retina  appears  to  be  extin- 
guished, without  any  defect  in  the  texture  of  the  eye, 
any  varicose  dilatation  of  its  blood-vessels,  or  any  parti- 
cular determination  of  blood  to  it.  Applications  pro- 
ducing an  evacuation  of  lymph,  including  both  blisters 
and  antimonial  ointment,  may  be  alternately  employed 
upon  the  eyelids  and  temples,  when  there  are  grounds 
for  believing  that  the  functions  of  the  skin  have  already 
been  long  suspended  by  porrigo,  or  the  stoppage  of  per- 
spiration on  the  forehead. — {Beer,  Lehre  von  den  Au- 
genkr. b.  2,  p.  474.) 

As  iu  the  rational  plan  of  treatment,  the  rubbing  of 
fluid,  pungent  or  irritating  medicines  upon  the  eye- 
brows, in  certain  kinds  of  amaurotic  blindness,  is  often 
attended  with  considerable  efficacy;  so,  in  Beer’s 
opinion,  it  should  not  be  neglected  in  cases  where  the 
surgeon  is  compelled  to  have  recourse  to  empirical 
methods  of  cure  ; for  instance,  where  it  is  observable 
that  generally  in  the  evening,  or  the  shade,  the  eye- 
sight immediately  grows  weaker ; that  on  the  patient’s 
first  awaking  in  the  morning,  it  is  weaker  than  in  the 
middle  of  the  day  ; and,  what  partiuclarly  merits  notice, 
while  the  case  is  unattended  with  any  sensations  of 
imaginary  flashes  of  light;  a very  feeble  or  entirely 
abolished  motion  of  the  iris ; not  the  least  vestige  of  any 
defect  in  the  structure  of  the  eye;  and  no  symptoms  of 
determination  of  blood  to  the  head  and  eyes,  or  of  a ge- 
neral tendency  to  inflammation.  Beer  recommends  pun- 
gent applications  to  be  first  tried,  such  as  the  spiritus 
aromaticus,  or  Cologne  water.  These  may  be  followed 
by  aqueous  substances,  naphtha,  «fcc. ; then  by  narcotics, 
like  the  tincture  of  opium ; and  lastly,  by  irritating  re- 
medies, like  the  tinctura  lyttie.'  The  tincture  of  iodine 
I should  also  consider  an  application  well  deserving  of 
trial.  Fluid  applications  which  are  applied  in  the  form 
of  vapour  to  the  eye  demand  greater  circumspection, 
like  naphtha,  the  liquor  ammonias,  &c.  These  may  be 
best  applied  by  putting  a small  quantity  of  them  into 
the  hand,  oyer  which  the  eye  must  be  held  in  such  a 
manner  that  none  of  the  fluid  will  come  into  contact 
with  it.  But  as  soon  as  the  eye  begins  to  be  irritated 
by  the  vaponr,  the  tears  to  run,  or  actual  pain  is  felt, 
the  hand  is  to  be  removed,  lest  too  much  irritation  be 
produced. — {Beer,  vol.  cit.p.  475.) 

Not  only  in  the  empirical,  but  also  in  every  scienti- 
fic mode  of  treating  amaurosis,  says  this  author,  such 
remedies  as  are  intended  to  produce  a shock  upon  the 
nerves  and  vessels  require  the  utmost  caution,  because, 
of  all  the  various  classes  of  remedies,  they  are  the 
most  powerful ; and  consequently;  if  misapplied,  are 
likely  to  convert  an  amaurotic  weakness  of  sight  into 
complete  blindness.  This  mournful  event  is  most  ra- 
pidly produced  when  applications  of  this  description 
are  employed  in  plethoric  subjects  affected  with  partial 
determinations  of  blood  and  local  inflammations,  a va- 
ricose state  of  the  blood-vessels  of  the  eye,  defects  in 
the  traiifjDarent  media  of  that  organ,  or  frequent  head- 
ache. 'i  o this  class  of  remedies  belong  especially  the 


454 


H^M 


H^M 


shower  bath,  electricitj',  galvanism,  &c.  On  the  em- 
pirical plan,  they  can  only  be  used  with  safety  or  ad- 
vantage when  decided  marks  of  paralysis,  either  in  the 
amaurotic  eye  or  its  appendages,  are  present. — {Lehre 
von  den  Augenkr.  b.  2,p.  477.) 

Mr.  W are  has  observed  that  the  pupil  has  been  ge- 
nerally dilated  in  the  cases  benefited  by  electricity. 
He  notices,  however,  that  there  are  many  instances  in 
which  a contraction  of  the  pupil  is  the  only  change 
which  takes  place  in  the  appearance  of  the  eye.  In 
this  sort  of  case,  the  impairment  of  sight  is  usually 
preceded  by  severe  pain,  and  the  original  cause  may 
be  an  internal  ophthalmy  of  long  continuance.  The 
crystalline  is  sometimes  visibly  opaque.  Here  electri- 
city has  been  found  useful;  but  Mr.  Ware  states,  that 
in  these  instances  the  sublimate  has  proved  sujieriorly 
and  more  certainly  efficacious,  and  consequently  he 
prefers  it  to  all  external  applications  whatever.  He  re- 
commends one-fourth  of  a grain  as  a quantity  proper 
for  a common  dose,  and  says  that  it  agrees  best  with 
the  stomach  when  first  dissolved,  as  Van  Swieten  di- 
rects, in  half  an  ounce  of  brandy,, and  taken  in  a basin' 
of  sago  or  gruel.  For  young  patients  the  dose  mnst  be 
diminished  in  proportion  to  their  youth.  The  medicine 
is  to  be  continued  as  uninterruptedly  as  the  constitutior. 
will  allow,  for  a month,  six  weeks,  or  even  longer. 

Electricity  is  said  to  have  proved  more  strikingly 
useful  in  cases  of  amaurosis  originating  from  light- 
ning, than  when  the  disease  has  arisen  from  any  other 
cause.  Mr.  Ware  relates  a most  interesting  instance 
of  the  success  of  electricity  in  a case  which  came  on 
very  suddenly  after  great  pain  in  the  teeth  and  a swell- 
ing of  the  face  had  gone  oflT.  The  disorder  came  on 
more  suddenly,  the  temporary  blindness  was  more 
entire,  the  eyelids  were  more  affected,  and  the  cure 
more  speedy,  than  in  the  instances  related  by  Mr. 
Hey,  in  the  5th  vol.  of  the  Med.  Obs.  and  Inq.—{Chir. 
Observ.  relative  to  the  Eye.,  by  J.  Ware,  vol.  1.)  How- 
ever, the  amaurosis  produced  by  lightning  may  also  be 
sometimes  cured  in  other  ways.  Mr.  Wardrop  men- 
tions that  he  has  only  seen  one  case  of  this  kind,  and 
the  sight  was  restored  by  the  repeated  application  of 
small  blisters  over  the  frontal  nerve.— {Essays  on 
the  Morbid  Anatomy  of  the  Human  Eye,  vol.  2,  p. 
173.) 

With  the  exceprtion  of  one  case  related  by  Valsalva, 
Scarpa  was  unacquainted  with  any  instance  of  amau- 
rosis, arising  from  a wound  of  the  eyebrow,  that  was 


relieved,  and  he  has,  therefore,  set  down  this  species 
as  incurable.  The  opinion,  however,  is  not  perhaps 
correct;  for  the  first  case  related  by  Mr.  Hey  arose 
from  this  cause,  and  was  cured  by  giving  every  night 
the  following  dose:  IjL.  Calomel,  camphor,  a a gr.  iij. 
Conserv.  cynosb.  q.  s.  pj-obe  misceant  et  f.  bolus,  m 
conjunction  with  electricity.  The  lady,  however,  had 
been  previously  bled  tw'ic«,  had  taken  some  nervous 
medicines,  and  had  had  a blister  between  the  shoulders. 
The  patient  was  first  set  upon  a stool  with  glass  feet, 
and  had  siiarks  drawn  from  the  eyes  and  parts  sur- 
rounding the  orbits,  especially  where  the  superciliary 
and  infra-orbitary  branches  of  the  fifth  pair  of  nerves 
spread  themselves.  After  this  operation  had  been  con- 
tinued half  an  hour,  she  was  made  to  receive,  for  an 
equal  time,  slight  shocks  through  the  affected  parts. 
In  a few  days,  sight  began  to  return,  and  in  less  than 
three  months  it  was  quite  restored.  In  another  case, 
one  grain  of  calomel  and  two  of  camphor  given  every 
night,  and  the  employment  of  electricity,  effected  a 
cure.  The  disease  had  come  on  gradually,  without  any 
previous  accident  or  pains  in  the  head.  The  patient 
w',as  a boy  nine  years  old. 

There  are  several  other  very  interesting  cases  of 
amaurosis  related  by  Mr.  Hey,  all  of  which  make  elec- 
tricity appear  an  efficacious  remedy,  though  it  is  true, 
as  Scarpa  observes,  that  in  most  of  these  instances 
internal  medicines  were  also  given,  and  bleeding  occa- 
sionally practised.  Mr.  Hey  attributes  the  benefit 
chiefly  to  the  electricity,  because,  in  two  of  his  cases,  no 
medicines  were  used,  yet  the  progress  of  tile  amendment 
seemed  to  be  as  speedy  in  them  as  in  the  rest ; and  in 
two  instances  a degree  of  sight  was  obtained  by  the 
first  application  of  electricity.  At  present,  1 think 
electricity  and  galvanism,  as  means  of  benefitiug^amau- 
rosis,  are  less  valued  in  England  than  on  the  continent 
Mr.  Travers  states,  that  he  has  had  recourse  to  them 
in  many  cases,  some  of  which  were  of  a very  favour- 
able description,  but  he  never  saw  any  good  produced 
by  them. — (Synopsis  of  the  Diseases  of  the  Eye,  p.  303. 

How  far,  however,  the  statements  of  Beer,  Ware 
&c.,  about  the  efficacy  of  local  applications,  can  be 
trusted,  is  yet  a question ; for  they  disagree  with  re- 
ports made  by  other  writers.  Thus,  with  the  exception 
of  cupping,  issues,  setons,  and  particularly  blisters, 
Mr.  Travers  declares,  that  his  experience  leads  him  to 
attach  no  value  to  the  various  forms  of  external  reme- 
dies.— (Synopsis,  Ac.  p.  30,  8vo.  Land.  1820.) 


H 


HiEMATOCELE.  (From  aipa,  blood,  and  Ky\r),  a 
tumour.)  A swelling  of  the  scrotum,  or  spermatic 
cord,  proceeding  from,  or  caused  by,  blood. 

According  to  Mr.  Pott,  when  the  tunica  vaginalis  has 
been  long  or  much  di-stenfied,  “ it  becomes  thick  and 
tough ; and  the  vessels  (especially  those  of  its  inner 
surface)  are  sometimes  so  large  as  to  be  very  visible, 
and  even  varicose.  If  one  of  these  lies  in  the  way  of 
the  instrument  wherewith  the  palliative  cure  is  per- 
formed, it  is  sometimes  wounded  ; in  which  case  the 
first  part  of  the  serum  which  is  discharged  is  pretty 
deeply  tinged  with  blood. 

Upon  the  collapsion  of  the  membranes,  and  of  the 
empty  bag,  this  kind  of  hemorrhage  generally  ceases, 
and  nothing  more  comes  of  it.  But  it  sometimes  hap- 
pens, either  from  the  toughness  of  the  tunic,  or  from 
the  varicose  state  of  the  vessel,  that  the  wound  (espe- 
cially if  made  by  a lancet)  does  not  immediately  unite; 
but  continues  to  discharge  blood  into  the  cavity  of  the 
said  tunic,  thereby  producing  a new  tumour,  and  a 
fresh  necessity  of  operation.” 

This  is  what  Mr.  Pott  calls  the  first  species  of  haema- 
tocele,  tvhich  evidently  proceeds  from  a w'eund  of  a 
vessel  of  the  vaginal  tunic.  i 

“Upon  the  sudden  discharge  of  the  fluid  from  the 
bag  of  an  over-stretched  hydrocele,  and  thereby  re- 
moving all  counter-pressure  against  the  sides  of  the 
vessels,  some  of  which  are  become  varicose,  one  of 
theru  will  sometimes,  without  having  been  wounded, 
burst;  hence  the  last  running  of  water  from  a hydro- 
cele is  often  bloody.  If  the  quantity  of  blood  shed 


from  the  vessel  so  burst  be  small,  it  is  soon  absorbed 
again  ; and  creating  no  trouble,  the  thing  is  not  known. 
But  if  the  quantity  be  considerable,  it,  like  the  pre- 
ceding, occasions  a new  tumour,  and, calls  for  a repeti- 
tion of  the  operation.”  This  Mr.  Pott  calls  the  second 
species,  “which,  like  the  first,  belongs  entirely  to  the 
vaginal  coat,  and  has  no  concern  either  with  the  testi- 
cle or  with  the  spermatic  vessels.  In  both,  the  bag, 
which  was  full  of  water,  becomes  in  a short  space  of 
time  distended  with  blood  ; which  blood,  if  not  carried 
off  by  absorption,  must  be  discharged  by  opening  the 
containing  cyst ; but  in  neither  of  these  can  castration 
(though  said  to  be  the  only  remedy)  be  ever  necessary; 
the  mere  division  of  the  sacculus,  and  the  application 
of  dry  lint  to  its  inside,  will  in  general,  if  not  always, 
restrain  the  hemorrhage,  and  answer  every  purpose  for 
which  so  severe  a remedy  has  been  prescribed.”  With 
respect  to  filling  the  cavity  of  thetunica  vaginalis  with 
lint,  1 believe  few  good  surgeons  of  the  presetit  day 
would  consider  the  measure  at  all  necessary  or  proper, 
I have  seen  three  or  lour  cases  of  hiemaiocele  of  the 
above  kind  laid  open,  but  never  knew  the  surgeon  com- 
pelled by  the  bleeding  to  cram  tl^e  tunica  vagitialis  with 
lint,  to  the  great  irritation  and  injury  of  the  tesiule 
itself.  On  the  con*rar5^  after  taking  out  the  blood,  let- 
ting the  parts  coUajise,  and  applying  the  cold  lotio 
plumbi  acetatis  for  a few  hours  to  the  scrotum,  by- 
means  of  linen  wet  with  the  ajiplication,  the  surg»*on 
substituted  for  the  lotion  an  emollient  poultice,  and  had 
recourse  to  fomentations,  saline  purgatives,  leeches, 
and  even  venesection,  according  to  circumstances. 


H/EM 


HAR 


455 


The  next  example  regarded  by  Pott  and  Richter  as  a 
form  of  hajmatocele,  is  not  admitted  by  Richerand, 
Jourdan  (see  Diet,  des  Sciences  MM.  t.  20,  p.  120),  and 
other  modern  surgeons. 

“ If,”  says  Mr.  Pott,  “ blood  be  extravasated  within 
the  tunica  albuginea,  or  proper  coal  of  the  testicle,  in 
consequence  of  a great  relaxation  and  (as  it  were)  dis- 
solution of  part  of  the  vascular  compages  of  that  gland, 
and  the  quantity  be  considerable,  it  will  afford  or  pro- 
duce a fluctuation  to  the  hand  of  an  examiner  very  like 
to  that  of  a hydrocele  of  the  tunica  vaginalis  ; allowing 
something  for  the  different  density  of  the  different 
fluids,  and  the  greater  depth  of  tiie  former  from  the 
surface. 

If  this  be  niistaken  for  a simple  hydrocele,  and  an 
opening  be  made,  the  discharge  will  be  blood ; not  fluid 
or  very  thin ; not  like  to  blood  circulating  through  its 
proper  vessels ; but  dark  and  dusky  in  colour,  and 
nearly  of  the  consistence  of  thin  chocolate  (like  to  what 
is  most  frequently  found  in  the  imperforate  vagina). 
The  quantity  discharged  will  be  much  smaller  than 
was  expected  from  the  size  of  the  tumour ; which  size 
wll  not  be  considerably  diminished.  When  this  small 
quantity  of  blood  has  been  so  drawn  off,  the  testicle 
wall,  upon  examination,  be  found  to  be  much  larger 
than  it  ought  to  be,  as  well  as  much  more  loose  and 
flabby : instead  of  that  roundness  and  resistance  aris- 
ing from  a healthy  state  of  the  gland,  within  its  firm 
strong  coat,  it  is  soft,  and  capable  of  being  compressed 
almost  flat,  and  that  generally  without  any  of  that  pain 
and  uneasiness  which  always  attend  the  compression 
of  a sound  testicle.  If  the  bleeding  ceases  upon  the 
withdrawing  the  cannula  (supposing  a trocar  to  have 
been  used),  and  the  puncture  closes,  a fresh  accumu- 
lation of  the  same  kind  of  fluid  is  soon  made,  and  the 
same  degree  of  tumefaction  is  produced  as  before  the 
operation ; if  the  orifice  does  not  close,  the  hemorrhage 
continues,  and  very  soon  becomes  alarming.” 

In  the  fir-st  two  species,  “the blood  comes  from  the 
tunica  vaginalis,  the  testis  itself  being  safe  and  uncon- 
cerned, and  the  remedy  is  found  by  opening  the  cavity 
of  the  said  tunic ; but  in  this  the  hemorrhage  comes 
from  the  substance  of  the  testicle;  from  the  convolu- 
tions of  the  spermatic  artery  witliin  the  tunica  albugi- 
nea : the  division  of  the  vaginal  coat  can  here  do  no 
good ; and  an  incision  made  into  the  albuginea  can 
only  increase  the  mischief ; the  testicle  is  spoiled,  or 
rendered  useless,  by  that  kind  of  alteration  made  in  it 
previous  to  the  extravasation  ; and  castration  is  the 
only  cure  which  a patient  in  such  circumstances  can 
depend  upon.” 

I confess  that  no  good  reason  appears  for  arranging 
cases  of  the  preceding  kind  with  hfematocele ; for  what 
are  they  but  diseased  testicles  which  have  been  punc- 
tured, either  on  account  of  their  seeming  to  contain  a 
fluid,  or  really  having  within  them  cysts  filled  \^^th  a 
chocolate-coloured  or  other  fluid,  as  I have  seen  in  hun- 
dreds of  instances  of  sarcocele,  and  whatever  blood  is 
discharged  is  not  extravasated  in  the  substance  of  the 
testis  previously  to  the  puncture,  but  issues  as  a neces- 
sary consequence  of  that  proceeding : however,  of  the 
propriety  of  the  practice  advised  by  Mr.  Pott,  no  doubt 
can  be  entertained. 

The  last  species  of  this  disease  noticed  by  Mr.  Pott 
“ arises  from  a bursting  of  a branch  of  the  spermatic 
vein,  between  the  groin  and  scrotum,  in  what  is  gene- 
rally known  by  the  name  of  the  spermatic  process. 
This,  which  is  generally  produced  by  great  or  sudden 
exertions  of  strength,  feats  of  agility,  <fcc.,  may  happen 
to  persons  in  the  best  health,  whose  blood  and  juices 
are  in  the  best  order,  and  whose  genital  parts  are  free 
from  b!>mish  or  disease. 

The  effusion  or  extravasation  is  made  into  the  cellu- 
lar membrane,  which  invests  and  envelopes  the  sjier- 
maiic  vessels,  and  has  something  the  appearance  of  a 
true  hernia.  When  the  case  is  clear,  and  the  extrava- 
sated blood  does  not  give  way  to  discutient  applications, 
the  only  remedy  is  to  lay  the  tumour  fairly  ojien  through 
Us  whole  length.  If  the  vessel  or  breach  be  small,  the 
hemorrhage  may  be  restrained  by  mere  compression 
with  dry  lint,  or  by  the  use  of  styptics;  but  if  it  be 
large,  and  these  means  do  not  succeed,  the  ligature 
must  be  made  use  of.” 

1 cannot  conceive,  that  in  any  case  of  a mere  rupture 
of  one  of  the  spermatic  veins,  it  can  ever  be  justifiable 
to  tie  the  whole  spermatic  cord,  and  then  perform  cas- 
tration ; though  Mr.  Pott  advises  this  plan,  in  case  the 


, bleeding  branch  cannot  be  tied  singly.  Discutient  ap- 
plications, and  an  occasional  purge,  wdll  almost  always 
disperse  the  swelling;  and  if  not,  opening  it,  taking 
out  the  blood,  applying  cold,  or,  if  necessary,  filling  the 
cavity  with  lint,  and-using  compression,  would  be,  ac- 
cording to  my  humble  judgment,  the  most  judicious 
treatment. 

A case  precisely  of  the  latter  kind  is  not  verj'  com- 
mon, yet  Mr.  Pott  has  not  omitted  it  as  one  of  the  forms 
of  haeinatocele  : but  why  he  has  not  taken  notice  of  the 
most  frequent  of  all  the  varieties  of  the  disease,  I am 
at  a loss  to  conjecture;  I mean  the  extravasation  of 
blood  in  the  loose  cellular  membrane  of  the  scrotum 
from  blows  on  the  part,  and  sometimes  from  lithotomy, 
castration,  &c.,  quite  unconnected  v.dth  any  rupture 
of  the  spermatic  veins.  These  are  the  cases  which 
are  mostly  met  with  in  practice.  I have  seen  them  fol- 
lowed bj’  suppuration ; but  in  general  the  effused  blood 
is  gradually  absorbed,  with  the  aid  of  discutient  appli- 
cationsj  leeches,  fomentations,  poultices,  and  saline 
purges.  A surgeon  should  generally  be  reluctant  to 
lay  open  the  tumour,  as,  in  many  instances,  sloughing 
and  very  severe  symptoms  have  been  the  result. 

Celsus  and  Paulus  JEgineta  are  the  best  of  the  old 
writers  on  hcematocele.  For  modem  information,  con- 
sult Pott’s  Chir.  Works,  vol.  2.  B.  Bell,  On  Hydrocele. 
Flajani,  Collezione  d’Osservazioni,  I'i  c.,  t.  2.  Richter, 
Anfangsgr.  der  Wundarzn.  b.  6.  Richerand,  Noso- 
graphie  Chir.  t.  4.  Ossiander,  in  Arnemann’s  Maga- 
zin fur  die  Wundarzn.  b.  1,  p.  355  ; the  patient  died 
af  ter  an  openmg  had  been  made  in  the  swellmg.  Fol- 
Let,  in  Joum,.  de  M d.  continu/  , vol.  13,  p.  422 : a case 
from  contusion,  cured  by  an  incision..  Harris,  in 
Me?n.  of  Land.  Med.  Society,  vol.  5. 

HARE-LIP.  {Labia  Leporina.)  A fissure  or  per- 
pendicular division  of  otie  of  both  lips.  The  term  has 
arisen  from  the  fancied  resemblance  of  the  part  to  the 
upper  lip  of  a hare.  Occasionally  the  fissure  is  more 
or  less  oblique.  In  general,  it  is  directly  below  the 
septum  of  the  nose ; but  sometimes  it  corre.sponds  to 
one  of  the  nostrils.  The  two  portions  of  the  lip  are 
generally  moveable,  and  not  adherent  to  the  alveolary 
process;  in  less  common  cases  they  are  closely  at- 
tached to  the  fore  part  of  the  jaw. 

Children  are  fre4uently  born  with  this  kind  of  mal- 
formation, which  is  called  a natural  hare-lip,  while 
that  which  is  produced  by  a wound  is  named  acciden- 
tal. Sometimes  the  portions  of  the  lip,  which  ought  to 
be  united,  have  a considerable  interspace  between 
them  ; while  in  other  instances  they  are  not  much 
apart.  The  cleft  is  occasionally  double,  a little  lobe  or 
small  portion  of  the  lip  being  situated  between  the  two 
fissures. 

The  fissure  commonly  affects  only  the  lip  itself,  and 
usually  the  upper  one.  In  many  cases,  however,  it  ex- 
tends along  the  bones  and  soft  parts  forming  the  pa- 
late, even  as  far  as  the  uvula;  and  sometimes  those 
bones  are  entirely  wanting.  In  a few  instances,  the 
jaw  not  only  is  imperfectly  ossified  in  front,  so  that  a 
cleft  presents  itself  there,  but  one  side  of  it  projects 
forwards,  and  is  at  the  same  time  inclined  too  much 
outwards,  drawing  with  it  the  corresponding  part  of  the 
palate,  and  the  septum  nasi,  so  that  a very  unsightly 
distortion  of  the  nostril  and  nose  is  produced.  The 
case,  I believe,  has  not  been  described  in  surgical  books. 

A hare-lip,  in  its  least  degree,  occasions  considerable 
deformity;  and  when  more  marked,  it  frequently  hin- 
ders infants  from  sucking,  and  makes  it  indispensable 
to  nourish  them  by  other  means.  When  the  lower  lip 
alone  is  affected,  which  is  rare  as  a malformation,  the 
child  can  neither  retain  its  saliva,  nor  learn  to  speak, 
except  with  the  greatest  imj)ediment.  The  constant  es- 
cape ol'the  saliva,  besides  being  an  annoyance,  is  found 
to  be  detrimental  to  the  health;  for  its  loss  impairs  the 
digestive  functions,  the  patient  becomes  emaciated,  and 
even  death  would  sometimes  ensue,  if  the  incessant 
discharge  of  so  necessary  a fluid  in  the  animal  economy 
were  not  prevented.  'I'hus,  a lady,  who  was  in  this 
state,  consulted  Tronchin,  who  immediately  saw  the 
cause  of  her  indis})osition,  and  recommended  the  fissure 
in  the  lip  to  be  united ; the  operation  was  done,  and  the 
dyspeptic  symptoms  then  ceased.  And  wlien  the  fis- 
sure pervades  the  palate,  the  jiatient  not  only  articulates 
very  imperfectly,  but  cannot  masticate  nor  swallow, 
except  with  great  difficulty,  on  account  of  the  food 
readily  getting  up  into  the  nose. 

An  early  removal  of  the  deformity  must  obviously  be 


456 


HARE-LIP. 


very  desirable ; but,  as  it  cannot  be  accwnplished  with- 
out an  operation  attended  with  some  degree  of  pain, 
Dionis,  Garengeot,  and  others  advise  waiting  till  the 
child  is  four  or  five  years  old,  on  the  supposuion  that, 
at  an  earlier  age,  the  child’s  agitations  and  cries  would 
ren^r  the  operation  impracticable,  or  derange  all  the 
proceedings  taken  to  ensure  its  success.  It  is  plain, 
however,  that  such  reasons  are  not  of  great  weight. 
A child,  four  or  five  years  old,  and  very  often  even  one 
eight  or  ten  years  of  age,  is  more  difficult  to  manage 
than  an  infant  only  a few  months  old.  Every  child  of 
the  above  age  has  a thousand  times  more  dread  of  the 
pain,  than  of  the  deformity  or  of  the  inconveniences  of 
the  complaint,  to  which  he  is  habituated  ; while  an  in- 
fant of  tender  years  fears  nothing,  and  only  feels  the 
pain  of  the  moment. 

A more  rational  objection  is  the  liability  of  infants  to 
convulsions  after  operations,  and  this  has  induced  many 
excellent  surgeons  to  postpone  the  cure  of  the  hare-lip 
till  the  child  is  about  two  years  old.  This  custom  is 
also  sanctioned  by  Sir  Astley  Cooper,  who  mentions  in 
his  lectures  several  instances,  which  have  either  been 
communicated  to  him  by  others,  or  have  occurred  in 
his  own  practice,  where  operations  for  the  cure  of  hare- 
lips ju  very  young  infants  have  had  a fatal  termination, 
in  consequence  of  an  attack  of  convulsions  or  diarrhcea. 
The  period  when  dentition  is  completed,  or  the  age  of 
two  years,  he  therefore  sets  down  as  the  most  advan- 
tageous for  the  operation,  and  if  parents  urge  its  being 
done  earlier,  he  very  properly  advises  the  surgeon  to 
let  them  be  duly  apprized  of  the  risk,  so  that  in  the 
event  of  the  child  being  cut  off,  he  may  not  incur 
blame  for  having  operated  at  a disadvantageous  period 
of  life.— (See  Lancet,  vol.  3,  p.  108.)  The  latter  end  of 
1823, 1 met  Sir  Astley  Cooper  in  consultation  in  a case 
where  this  very  question  occurred.  The  deformity  was 
particularly  unsightly,  in  consequence  of  the  upper 
jaw-bone  being  imperfectly  ossified  in  front,  and  one 
side  of  it  forming  a considerable  projection  forwards 
through  the  fissure  which  extended  into  the  nostril,  at 
the  same  time  that  the  nose  was  seriously  distorted 
to  one  side  of  the  face.  The  parents,  persons  of  the 
first  respectability,  were  therefore  uncommonly  solicit- 
ous for  an  early  operation,  some  instances  of  the  suc- 
cess of  which  in  very  young  infants  had  already  been 
communicated  to  them  by  their  friends.  The  projection 
of  bone,  they  had  also  learned,  might  be  cut  away,  so 
,as  to  permit  the  soft  parts  to  meet,  which  they  now 
would  not  do.  The  risk  of  an  operation  on  the  infant 
in  question,  then  scarcely  two  months  old,  was  fairly 
explained  to  the  parents ; but  I doubt  whether  they  could 
have  been  prevailed  upon  to  wait  three  months  longer, 
had  not  Sir  Astley  Cooper  represented  to  them  the  dis- 
advantages of  cutting  away  the  bony  projection,  and 
urged  the  allowance  of  a little  time  to  reduce  the  pro- 
tuberance by  means  of  pressure.  As  I had  not  had 
any  previous  conference  with  Sir  Astley  on  the  subject, 
I was  particularly  gratified  in  finding  his  advice  agree 
precisely  with  what  I had  already  given,  when  the  case 
was  first  shown  to  me.  Exactly  when  the  infant  was 
five  months  old,  a period  selected  on  account  of  its  be- 
ing the  latest  previously  to  the  usual  time  of  the  com- 
mencement of  the  ailments  of  dentition,  I performed 
the  operation  in  the  presence  of  Messrs.  Ives,  of  Chert- 
sey,  and  Mr.  Ives,  jun.,  of  Chobham.  By  this  time  the 
bone  had  been  so  effectually  depressed,  by  means  of  a 
kind  of  spring-truss,  constructed  by  Messrs.  Salmon 
and  Ody  for  the  purpose,  and  worn  several  hours  daily, 
thnt  the  soft  parts  admitted  of  being  brought  over  it 
with  tolerable  facility.  Union  followed  very  well,  and, 
though  it  was  one  of  the  worst  hare-lips  ever  seen  by 
Mr.  Ives,  senior,  or  myself,  without  an  extensive  divi- 
sion of  the  palate,  the  disfigurement  is  now  very  trivial, 
and  the  wrong  direction  of  the  nose  constantly  under- 
going farther  diminution,  in  proportion  as  the  jaw  re- 
cedes under  the  pressure  of  the  apparatus,  which  is  still 
employed. 

This  IS  the  youngest  infant  on  which  I have  operated ; 
but,  in  October,  1824,  I performed  the  operation  on  an 
infant  twelve  months  old,  at  Walton  on  Thames,  where 
I was  kindly  assisted  by  Mr.  Stillwell,  surgeon  in  that 
town.  Union  took  place  very  favourably,  without  any 
indisposition  whatever.  Only  one  pin  wtis  Uvsed  at  the 
lower  part  of  the  lip,  as  I found  that  the  upper  part  of 
the  division  could  be  perfectly  and  readily  closed  with  a 
strip  of  adhesive  plaster. 

Mr,  Sharp  observes,  “ there  are  many  lips  where  the 


loss  of  substance  is  so  great,  that  the  edges  of  the  fissure 
cannot  be  brought  together,  or  at  best  where  they  can 
but  just  touch;  in  which  case  it  need  not  be  advised  to 
forbear  the  attempt ; it  is  likewise  forbid  in  young  chil- 
dren, and  with  reason,  if  they  suck;  but  otherwise  it 
may  be  undertaken  with  great  safety,  and  even  with 
more  probability  of  success  than  in  others  that  are 
older.” — {Operations  in  Surgery,  chap.  -34.) 

Le  Dran  performed  the  operation  on  children  of  all 
ages,  even  on  those  at  the  breast.  B.  Bell  did  it  with 
success  on  an  infant  only  three  months  old.  Muys  ad- 
vises it  to  be  undertaken  as  soon  as  the  child  is  six 
months  old.  Roonhuysen  operated  on  children  ten 
weeks  after  their  birth,  and  all  his  contemporaries  Imve 
praised  his  singular  dexterity  and  success.  As  an  es- 
sential step  to  the  success  of  the  operation,  he  recom- 
mended hindering  the  children  from  sleeping  a certain 
length  of  time  before  it  was  undertaken,  in  order  that 
they  might  fall  asleep  immediately  afterward;  and 
with  the  same  view  opiates  have  been  prescribed. 

Putting  out  of  consideration  the  partial  success  which 
has  attended  the  use  of  blistering  plaster  for  making 
the  edges  of  the  fissure  raw  and  capable  of  union,  all 
practitioners  entertain  the  same  sentiment  with  regard 
to  the  object  of  this  operation,  which  consists  in  reduc- 
ing the  preternatural  solution  of  continuity  to  the  state 
of  a simple  wound,  by  cutting  off  the  edges  of  the  se- 
parated parts  throughout  their  length,  and  then  keep- 
ing these  parts  in  contact  until  they  have  completely 
grown  together.  But  altliough  such  principles  have 
been  generally  admitted,  there  was  formerly  some 
difference  of  opinion  with  respect  to  the  best  method  to 
be  followed  in  practice;  some  operators  having  pre- 
ferred sutures  for  keeping  the  edges  of  the  wound  in 
contact ; while  others  disapproved  of  them,  believing 
that  a perfect  cure  might  always  be  accomplished  by 
means  of  adhesive  plaster  and  a uniting  bandage,  so 
as  to  save  the  patient  from  all  the  pain  and  annoyance 
of  sutures. 

M.  Louis  thought  that  the  use  of  sutures  in  the  ope- 
ration for  the  hare-lip  proceeded  from  a false  idea  re- 
specting the  nature  of  the  disease ; for,  the  fissure  in 
the  lip  being  wrongly  imputed  to  loss  of  substance,  it 
was  deemed  impossible  to  keep  the  parts  in  contact, 
except  by  a suture. 

“ The  separation  of  the  edges  of  the  fissure  in  the 
lip,”  says  M.  Lonis,  “ is  only  the  effect  of  the  retraction 
of  the  muscles,  and  is  always  proportioned  to  the  ex- 
tent of  the  cleft.  Persons  with  hare-lips  are  capable 
of  bringing  the  edges  of  the  fissure  together  by  muscu- 
lar action,  by  puckering  up  their  mouths.  On  the  other 
hand,  the  separation  is  considerably  increased  when 
they  laugh,  and  the  breach  appears  excessively  large 
after  superficially  paring  off  its  edges  on  both  sides. 
The  interspace  in  the  hare-lip  must  not,  therefore,  be 
mistaken  for  a loss  of  substance.  This  truth  is  con- 
firmed by  the  effects  of  sticking-plaster,  which  has 
sometimes  been  applied  to  the  hare-lip,  as  a preparatory 
measure  before  the  operation,  and  which  materially 
lessens  the  separation  of  the  parts. 

According  to  the  confession  of  all  who  have  WTit- 
ten  in  favour  of  the  twisted  suture,  it  seems  advisable 
only  on  the  false  idea,  that  the  hare-lip  is  the  effect  of 
a greater  or  less  loss  of  substance : and  they  say,  posi- 
tively, that  we  must  not  have  recourse  to  it  when  there 
is  only  a simple  division  to  be  united.  The  twisted 
suture  must  then  be  proscribed  from  the  operation  for 
the  natural  hare-lip,  since  it  is  proved  that  this  mal- 
formation is  unattended  with  loss  of  substance.  At 
the  same  time,  a loss  of  substance  is  but  too  real,  after 
the  extirpation  of  scirrhous  and  cancerous  tumours,  to 
which  the  lips  are  very  subject.  Yet,  even  in  these 
cases,  the  extensibility  of  the  lips  allows  an  attempt 
to  be  made  to  reunite  the  double  incision,  by  which  the 
tumour  has  been  removed,  and  it  succeeds  without  the 
smallest  deformity,  w'hen  care  is  taken  to  direct  each 
incision  obliquely,  so  that  both  of  them  form,  where 
they  meet,  an  acute  angle,  in  the  base  of  which  the  tu- 
mour is  comprised.  Here  the  means  of  union  ought  to 
be  the  more  efficacious,  because  the  difficulty  of  keeping 
the  edges  of  the  wound  approximated  is  greater.  M. 
Pibrac,  in  his  memoir  on  the  abuse  of  sutuics,  when 
speaking  of  the  hare-lijt,  has  already  explained,  that 
they  are  badly-conceived  means,  and  more  hurtftil  in 
proportion  as  there  is  a greater  loss  of  substance,  be- 
cause the  greater  the  interspace  is  between  the  two 
parts,  the  more  fear  is  there  of  their  efforts  on  the 


HARE-LIP. 


457 


needles  or  pins  left  in  the  wound.  Hence,  care  has  al- 
ways been  taken  to  make  the  dressings  aid  the  opera- 
tion of  the  suture.  After  this  consideration,  judici- 
ously made  by  the  partisans  of  this  plan,  there  was 
only  one  more  step  to  be  taken,  according  to  M.  Pibrac, 
in  order  to  evince  the  necessity  of  proscribing  it.  The 
cap  or  copper  headpiece  described  by  Verduc  and  Nuck, 
for  compressing  the  cheeks ; the  clasps  of  Ileister ; 
and  strips  of  adhesive  plaster ; are  all  only  inventions 
for  the  support  of  the  parts,  and  keeping  them  from  be- 
ing disunited.  When  the  suture  failed,  it  was  by  these 
means  that  the  original  deformity  was  corrected,  to- 
gether with  that  produced  by  the  laceration,  which 
would  not  have  occurred  without  the  suture.  As  then, 
the  dressings,  when  methodically  applied,  are  capable 
of  effectually  rectifying  the  mischief  of  the  suture,  M. 
Louis  inquires,  why  should  they  be  considered  only  as 
a resource  in  a mere  accidental  case"?  Why  should 
they  not  be  made  the  chief  and  primary  means  of  reu- 
niting the  lip,  even  when  there  is  a loss  of  substance? 

Nothing  can  be  opposed  to  the  proofs  adduced  upon 
this  point.  They  are  even  drawn  from  the  practice 
of  those  who  have  employed  sutures  without  success. 
Such  persons  have  themselves  furnished  the  proofs  of 
the  bandage  being  capable  of  repairing  the  mischief 
resulting  from  the  twisted  suture.” 

M.  Louis,  with  a view  of  perfecting  our  notions  on 
this  matter,  lays  it  down  as  a fact,  that  the  retraction 
of  the  muscles  being  the  cause  of  the  separation  of  the 
edges  of  the  fissure,  it  is  not  to  these  edges  we  are  to 
apply  the  force  which  is  to  unite  them ; but  that  it 
should  be  applied  farthec  to  the  very  parts,  whose  ac- 
tion (the  cause  of  the  separation)  is  to  be  impeded,  and 
whose  contraction  is  thus  to  be  prevented.  A great 
many  means  for  supporting  the  wound,  only  irritate 
the  muscles  and  excite  them  to  action,  and  it  is  this  ac- 
tion which  we  should  endeavour  to  overcome.  The 
means  for  promoting  union  can  only  be  methodical, 
when  directly  employed  to  prevent  such  action,  by  an 
immediate  application  on  the  point  where  it  is  to  be  re- 
sisted. The  facility  with  which  the  parts  may  be 
brought  forwards,  so  as  to  bring  the  two  commissures 
of  the  lips  into  contact  by  the  mere  pressure  of  the 
hands,  shows  what  may  be  expected  from  a very  sim- 
ple apparatus,  which  will  execute  the  same  office  with- 
out any  effort,  in  a firm  and  permanent  manner,  and 
which  will  render  sutures  unnecessary,  the  inconve- 
niences of  which  are  too  well  known. 

M.  Louis,  after  having  explained  the  reasons  of  the 
theory  on  which  he  founded  his  method,  relates  seve- 
ral cases,  taken  either  from  his  own  practice  or  that  of 
others,  to  illustrate  its  advantages.  He  details  the  his- 
tory of  twenty  cases  in  which  his  plan  perfectly  suc- 
ceeded, both  in  accidental  hare-lips,  with  considerable 
loss  of  substance,  and  in  natural  ones.  In  most  of 
these  instances,  however,  it  was  thought  proper  to  as- 
sist the  bandage  with  one  stitch  at  the  extremity  of  the 
fissure,  close  to  the  vermilion  border  of  the  lip,  for  the 
purpose  of  keeping  the  parts  securely  on  a level. 

Notwithstanding  the  operation  as  performed  with 
the  twisted  suture  is  opposed  by  an  authority  of  such 
weight  as  that  of  M.  Louis,  still  it  is  the  method  most 
commonly  practised.  No  modem  surgeons  doubt  that 
a hare-lip  may  be  cured  by  means  of  adhesive  plaster 
and  uniting  bandages,  quite  as  perfectly  as  with  a su- 
ture ; and  all  readily  allow,  that  the  first  of  these  me- 
thods, as  being  more  simple  and  less  painful,  would  be 
preferable  to  the  latter  one,  if  it  were  equally  sure  of 
succeeding.  But  it  is  considered  far  more  uncertain  in 
its  effect.  To  accomplish  a complete  cure,  the  parts  to 
be  united  must  be  maintained  in  perfect  contact,  until 
they  have  contracted  the  necessary  adhesion  ; and  how 
can  we  always  depend  upon  a bandage  for  keeping 
them  from  being  displaced?  What  other  means,  be- 
sides a suture,  affords  in  this  respect  perfect  security  ? 

I shall  first  describe  the  operation  as  usually  done 
by  surgeons  of  the  present  day  with  the  twisted  suture. 
The  first  thing  is  to  examine  whether  there  is  any  ad- 
hesion of  the  lip  to  the  gum  ; and  if  there  be,  to  divide 
it  with  a knife.  Some  authors  (Sharp)  recommend 
the  frsnulum,  which  attaches  the  lip  to  the  gum,  al- 
ways to  be  divided : but  when  the  hare-lip  is  at  some 
distance  from  this  part,  it  will  not  be  in  the  way  of  the 
operation,  and  need  not  be  cut.  On  the  other  hand, 
when  the  frsenulurn  is  situated  in  the  centre  of  the  di- 
.vi.sion,  it  is  clear  that  in  operating,  we  must  necessa- 
jrUv  include  it  in  the  incision,  and  it  should  therefore 


be  divided  beforehand,  taking  care  not  to  encroach  too 
much  upon  the  gum,  lest  the  alveolary  process  be  laid 
bare ; nor  too  much  upon  the  lip,  because  making  it 
thinner  would-  be  unfavourable  to  its  union. 

When  one  of  the  incisor  teeth  opposite  the  fissure  pro- 
jects forwards,  it  must  be  drawn,  lest  it  distend  and  irri- 
tate the  pans  after  they  have  been  brought  into  con- 
tact. 

Sometimes,  but  particularly  in  cases  in  which  there 
is  a cleft  in  the  bony  part  of  the  palate,  a portion  of  the 
os  maxillare  superius  forms  such  a projection  just  in  the 
situation  of  the  fissure  in  the  lip,  that  it  would  render 
the  union  very  difficult,  if  not  impracticable.  In  this 
circumstance,  the  common  plan  has  been  to  cut  off  the 
projecting  angles  of  bone  with  a strong  pair  of  bone- 
nippers.  The  part  was  then  healed,  and  the  operation 
for  the  hare-lip  performed.  Instead  of  cutting  off  the 
projection  of  bone,  which  is  always  a painful  measure, 
Desault  used  to  employ  simple  compression,  by  which 
means  the  prominence  was  usually  reduced  in  a few 
weeks,  and  the  opportunity  afforded  of  operating  for 
the  cure  of  the  hare-lip. — (dluvres  Chir.  par  Bichat,  t. 
2,  p.  207.)  Of  course,  the  actual  necessity  of  using 
bone-nippers,  or  even  of  having  recourse  to  compres- 
sion of  the  bony  projection,  will  depend  upon  circum- 
stances ; for  if  the  prominence  of  bone  be  sharp  and 
irregular,  no  surgeon,  I conceive,  would  hesitate  about 
the  removal  of  such  inequalities  in  preference  to  the 
trial  of  pressure.  Mr.  Dunn,  of  Scarborough,  has  ex- 
pressed to  me  his  doubts  whether  cutting  off  the  pro- 
jections of  the  alveolary  process  be  ever  necessary,  as 
the  pressure  of  the  entire  lip  gradually  diminishes  the 
deformity.  “ I had  (says  he)  two  very  unseemly  cases, 
with  an  immense  division  of  the  palate,  together  with 
a projection  of  the  alveolary  process,  which,  with  the 
incisor  teeth,  resembled  the  talons  of  a bird.  A tuber- 
cular appendage  of  skin  hung  upon  the  base  of  the 
nose.  By  drawing  the  teeth  in  the  first  case  very  deli- 
cately, I avoided  fracturing  the  bony  projection.  I then 
cut  off  one  edge  of  the  nasal  appendage,  and  of  the 
lip  on  the  same  side,  and  attached  them  together  with 
two  needles.  The  wound  was  sufficiently  united  in  a 
week  or  ten  days  to  allow  the  same  operation  on  the 
other  side.  In  less  than  three  weeks  the  boy  was 
sent  home  quite  well,  to  the  astonishment  of  the  neigh- 
bourhood, where  his  frightful  appearance  had  made  him 
an  object  of  disgust  and  ridicule.  I succeeded  in  the 
other  case  even  without  the  extraction  of  the  teeth. 
Both  the  patients  can  now  articulate  labial  sounds,  re- 
tain their  saliva,  and  are  gradually  losing  the  inconve- 
nience of  the  passage  of  the  mucus  from  the  nose  into 
the  mouth,  as  the  fissure  is  more  contracted,  and  the 
projection  by  no  means  so  disagreeable.”  These  facts 
should  lessen  the  haste  with  which  certain  operators 
proceed  to  cut  off  every  projection  of  the  alveolary 
process ; for  a moderate  prominence  of  bone  without 
any  sharp,  irritating  edges  or  angles,  will  not  hinder 
the  success  of  the  operation  ; and  even  the  propriety 
of  removing  teeth  must  entirely  depend  upon  their  ber 
ing  likely,  by  their  direction,  to  irritate  the  lip,  and  dis- 
turb the  union  of  the  fissure. 

One  serious  objection  to  cutting  away  the  projection 
of  the  jaw  is  the  deformity  afterward  likely  to  contir 
nue  during  life  from  the  deficiency  of  the  incisores 
teeth ; and  another  is,  the  subsequent  overlapping  of 
the  lower  jaw,  and  its  projection  beyond  the  upper  one ; 
communicating  to  the  mouth  an  appearance  seen  in 
very  old  subjects.  These  were  the  considerations 
which  induced  me,  in  the  case  above  mentioned,  to  emr 
ploy  pressure,  which  is  much  more  conveniently  ap- 
plied by  means  of  a kind  of  spring-truss,  adapted  to 
the  child’s  head,  than  with  bandages,  which  would  be 
seriously  annoying,  and  the  right  action  of  which  could 
not  be  regulated  without  the  utmost  difficulty.  When 
also  some  of  the  bone  must  be  cut  away  on  account 
of  its  roughness  and  angular  prominences,  I advise  the 
practitioner  to  remove  only  the  irritating  points,  and 
afterward  have  recourse  to  pressure. 

In  the  operation,  the  grand  object  is  to  make  as 
smooth  and  even  a cut  as  possible,  in  order  that  it 
may  more  certainly  unite  by  the  first  intention,  and  of 
such  a shape  that  the  cicatrix  may  form  only  one  nar- 
row line.  The  edges  of  the  fissure  should,  therefore, 
never  be  cut  off  with  scissors,  which  constantly  bruise 
the  fibres  which  they  divide,  and  a sharp  knife  is  al- 
ways to  be  preferred.  The  best  plan  is,  either  to  place 
any  flat  instrument,  such  as  a piece  of  horn,  wood,  or 


458 


HARE-LIP. 


pasteboard,  underneath  one  portion  of  the  lip,  and  then 
holding  the  part  stretched  and  supported  on  it,  to  cut 
away  the  whole  of  the  callous  edge ; or  else  to  hold 
the  part  with  a pair  of  forceps,  the  under  blade  of 
which  is  much  broader  than  the  upper  one : the  first 
serves  to  support  the  lip,  the  other  contributes  also  to 
this  effect,  and,  at  the  same  time,  serves  as  a sort  of 
ruler  for  guiding  the  knife  in  an  accurately  straight 
line.  VV'hen  tlie  forceps  are  preferred,  the  surgeon 
must  of  course  leave  on  the  side  of  the  upper  blade 
just  as  much  of  the  edge  of  the  fissure  as  is  to  be  re- 
moved, so  that  it  can  be  cut  off  with  one  sweep  of 
the  knife.  This  is  to  be  done  on  each  side  of  the  cleft, 
observing  the  rule,  to  make  the  new 

A wound  in  straight  lines,  because  the  sides 
of  it  can  never  be  made  to  correspond 
without  this  caution.  For  instance,  if 
the  hare-lip  had  this  shape,  the  incision 
of  the  edges  must  be  continued  in  straight 
lines  till  they  meet  in  the  manner  here  represented. 

Ain  short,  the  two  incisions  are  to  be  per- 
fectly straight,  and  are  to  meet  at  an 
angle  above,  in  order  that  the  whole  track 
of  the  wound  may  be  brought  together, 
and  united  by  the  first  intention. 

Two  silver  pins,  made  with  steel  points,  are  next  to 
be  introduced  through  the  edges  of  the  wound,  so  as  to 
keep  them  accurately-  in  contact ; the  lowest  pir.  being 
introduced  first,  near  the  inferior  termination  of  the 
wound,  and  the  upper  pin  afterward,  about  a quarter 
of  an  inch  higher  up.  A piece  of  thread  is  then  to  be 
repeatedly  wound  round  the  ends  of  the  pins,  from  one 
side  of  the  division  to  the  other,  first  transversely,  then 
obliquely,  from  the  right  or  left  end  of  one  pin  above, 
to  the  opposite  end  of  the  lower  one,  <fec.  Thus  the 
thread  is  made  to  cross  as  many  points  of  the  wound 
as  possible,  which  greatly  contributes  to  maintaining 
its  edges  in  even  apposition.  Any  portion  of  the  wound 
above  the  pins  not  closed  by  the  preceding  means  may 
now  have  its  edges  brought  together  with  a strip  of  ad- 
hesive plaster.  Lastly,  the  ends  of  the  pins  are  to  be 
supported  by  small  dossils  of  lint,  placed  between  them 
and  the  flesh ; a minute  but  essential  circumstance, 
which,  as  my  friend  Mr.  Dunn,  of  Scarborough,  re- 
minds me,  I forgot  to  mention  in  a former  edition  of 
this  work.  It  is  obvious  that  a great  deal  of  exactness 
is  requisite  in  introducing  the  pins,  in  order  that  the 
edges  of  the  incision  may  afterward  be  precisely  ap- 
plied to  each  other.  For  this  purpose,  some  surgeons 
previously  place  the  sides  of  the  wound  in  the  best  po- 
sition, and  mark  with  a pen  the  points  at  which  the 
pins  should  enter  and  come  out  again ; a method 
which,  as  far  as  my  observations  extend,  merits  imita- 
tion. The  pins  ought  never  to  extend  more  deeply  than 
about  two-thirds  through  the  substance  of  the  lip,  and 
it  would  be  a great  improvement  always  to  have  them 
of  a flat,  instead  of  a round  shape,  and  a little  curved, 
as  this  is  the  course  which  they  naturally  ought  to  take 
when  introduced.  The  steel  points  should  also  admit  of 
being  easily  taken  off,  whenthepins  have  been  applied ; 
and,  perhaps,  having  them  to  screw  off  and  on  is  the 
best  mode,  as  removing  them  in  this  way  is  not  so 
likely  to  be  attended  %vith  any  sudden  jerk  which  might 
be  injurious  to  the  wmund,  as  if  they  were  made  to  pull 
off.  In  general,  the  pins  may  be  safely  removed  in 
about  four  days,  when  the  support  of  sticking  plaster 
will  be  quite  sufficient. 

After  the  operation,  the  surgeon  should  never  omit 
the  use  of  compresses  and  a bandage  for  keeping  for- 
ward the  cheeks,  so  that  the  risk  of  the  pins  making 
their  wav  out  by  ulceration,  arising  from  the  dragging 
of  the  soil  parts  on  them,  may  be  prevented.  With  this 
view,  a close,  strong  nightcap,  with  a piece  of  broad 
tape  attached  to  the  back  part  of  it,  and  with  tw'o  ends 
of  sufficient  and  eciual  length,  is  to  be  put  on;  a com- 
press is  then  to  be  laid  over  one  cheek,' and  fixed  by 
bringingorie  portion  of  the  tape  forwards  over  it,  which 
is  to  be  fastened  to  the  capon  the  oppc.site  side  of  the 
head.  The  other  compress  is  then  to  be  applied,  and 
fixed  in  a similar  manner.  Lastly,  a bandage  is  to  be 
put  under  the  chin,  and  brought  over  each  compress  up 
to  the  top  of  the  head,  w’here  the  ends  of  it  are  to  be 
fastened  to  the  cap.  During  all  these  proceedings,  until 
the  compresses  are  well  secured,  the  assistant  must 
support  them . steadily  with  his  hands.  Lastly,  the 
bandage,  compresses,  and  cap  should  all  be  securely 
atitched  together. 


The  process  just  described  is  xvhat  is  well  knoxvn  by 
the  name  of  the  twisted  suture,  w'hich  is  applicable  to 
other  surgical  ca.ses,  in  which  the  grand  object  is  to  heal 
some  fistula  or  opening  by  the  first  intention.  Mr. 
Sharp  says,  it  is  of  great  service  in  fistulae  of  the  ure- 
thra, remaining  after  the  operation  for  the  stone,  in 
which  case  the  callous  edges  may  be  cut  off,  and  the 
lips  of  the  wound  held  together  by  the  above  method. 

Although  the  generality  of  surgeons  used  the  twisted 
suture,  I ought  to  notice  that  Sir  A.  Cooper  gives  the 
preference  to  the  common  interrupted  suture,  on  account 
of  the  difficulty  sometimes  experienced  in  withdrawing 
the  pins,  and  the  liability  of  the  new-  adhesions  to  be 
broken  on  the  occasion ; whereas  the  threads  of  a com- 
mon suture  may  be  cut  and  taken  out  xvith  the  greatest 
facility. — (See  Lancet,  vol.  3,  p.  107.)  However,  as 
most  children  cry  on  the  removal  of  the  suture,  w hether 
one  kind  or  the  other  be  employed,  the  only  safe  plan  is 
not  to  withdraw  the  pins  or  ligatures  till  four  complete 
days  have  elapsed  from  the  time  of  the  operation,  when 
the  adhesions  will  be  tolerably  strong ; and  the  cheeks 
should  ahvays  be  held  forwards  by  a skilful  assistant 
during  the  period  of  changing  the  dressings,  and  until 
the  compresses  on  the  cheeks  have  been  again  duly  se- 
cured with  a bandage. 

[When  pins  are  used  in  this  operation,  they  ought 
to  be  made  of  gold,  which  is  not  liable  to  become  oxi- 
dized. Instead,  however,  of  these  pins,  which  are  ordi- 
narily made  with  steel  points.  Dr.  Barton,  of  Philadel- 
phia. prefers  to  use  a piece  of  iron  wire,  with  a point 
made  by  simply  cutting  it  with  a pair  of  scissors ; thus 
avoiding  the  risk  of  the  steel  point  slipping  off  the  pin, 
an  accident  which  has  often  happened,  and  left  the  point 
within  the  lip. 

■ So  many  failures  have  occurred  from  the  pins  being 
torn  out  by  the  child,  or  catching  in  the  nurse’s  clothes, 
that  if  there  were  no  other  objection  to  the  use  of  pins, 
they  ought  to  be  abandoned.  Many  surgeons  in  this 
country  (and  among  these  Dr.  Mott)  have  adopted  the 
interrupted  suture  in  cases  of  hare-lip,  and  with  the 
most  satisfactory  results  ; and  it  is  confidently  believed 
that  the  twisted  suture  ought  to  be  abandoned,  on  ac- 
count of  the  obvious  objections  which  attach  to  every 
modification  of  the  shape,  configuration,  and  materials 
of  the  pins.  It  will  be  seen  that  Sir  A.  Cooper  has  laid 
it  aside  altogether. — Reese.] 

What  has  hitherto  been  stated  refers  to  the  most 
simple  form  of  the  hare-lip,  viz.  to  that  which  presents 
only  one  fissure.  When  there  are  two  clefts,  the  cure 
is  accomplished  on  the  same  principle,  but  it  is  rather 
more  difficult  of  execution ; so  that  the  old  surgeons, 
until  the  time  of  Heister,  almost  all  regarded  the  opera- 
tion for  the  double  hare-lip  as  impracticable.  Only  a 
few  described  it.  with  the  direction  to  operate  on  each 
fissure,  just  as  if  it  were  single.  M.  de  la  Faye  even 
operated  in  this  way  with  success. — (Man.  de  PAcad. 
de  Chir.  t.  4,  4<o.)  M.  Louis  was  of  opinion,  that  all 
difficulties  would  be  obviated  by  doing  the  operation  at 
two  different  times,  and  awaiting  the  perfect  cure  of 
one  of  the  fissures  before  that  of  the  other  was  under- 
taken. Heitster  had  similar  ideas,  but  he  never  put  the 
scheme  in  practice,  nor  did  he  even  positively  ad- 
vise it. 

After  all,  however,  experience  proves  that  it  is  not 
essential  to  perform  two  operations  for  the  cure  of  the 
double  hare-lip.  Desault  found  that  when  the  edges  of 
the  two  fissures  were  pared  off,  and  care  taken  to  let 
one  of  the  pins  pass  across  the  central  piece  of  the  lip, 
the  practice  answered  extremely  well. — (See  (F.uvres 
Chir.  t.  2,  p.  201.) 

In  cutting  off  the  edges  of  the  fissure,  the  incision 
must  be  carried  to  the  upper  part  of  the  lip ; and  ex’en 
when  the  fissure  does  not  reach  wholly  up  the  lip,  the 
same  thing  should  be  done;  for  in  this  manner  the 
sides  of  the  wound  will  admit  of  being  applied  together 
more  uniformly,  and  the  cicatrix  will  have  a better  ap- 
pearance. We  should  also  not  be  too  sparing  of  the 
edges,  W'hich  are  to  be  cut  off.  ’ Practitioners,  says  M. 
Louis,  persuaded  that  the  hare-lip  was  a division*  with 
loss  of  substance,  have  invariably  advised  the  removal 
of  the  callous  edges.  But  in  the  natural  hare-lip,  there 
is  no  callosity ; tiie  margins  of  the  fissure  are  composed, 
like  those  of  the  lip  itself,  of  a pulpy,  fresh-coloured, 
vermilion  flesh,  covered  with  an  exceedingly  delicate 
cuticle.  The  whole  of  the  part  having  this  appearance 
must  be  taken  away,  together  with  a little  of  the  true 
skin.  At  the  lower  part  of  the  fissure,  towards  the 


HARE-LIP. 


459 


nearest  commissure,  a rounded  red  substance  is  com- 
monly situated,  which  it  is  absolutely  necessary  to 
include  in  the  incision.  Were  this  neglected,  the  union 
below  Would  be  unequal,  and,  through  an  injudicious 
economy,  a degree. of  deformity  would  remain.  The 
grand  object,  however,  is  to  make  the  two  incisions 
diverge  at  an  acute  angle,  so  that  the  edges  may  be  put 
into  reciprocal  contact  their  whole  length,  without  the 
least  inequality. 

M.  Louis  used  to  operate  as  follows ; the  patient  being 
seated  in  a good  light,  his  head  is  to  be  supported  on  an 
assistant’s  breast,  who  with  the  fingers  of  both  hands 
pushes  the  cheeks  forwards,  in  order  to  bring  the  edges 
of  the  fissure  near  to  each  other.  These  are  to  be  laid 
on  a piece  of  pasteboard,  which  is  to  be  put  between  the 
jaw  and  lip,  and  be  an  inch  and  a half  long,  Irom  twelve 
to  fifteen  lines  broad,  and  at  most  one  line  thick.  The 
upper  end  should  be  rounded  by  flattening  the  corners. 
In  order  to  facilitate  the  incision,  the  lip  is  to  be 
stretched  over  the  pasteboard,  the  operator  holding  one 
portion  over  the  right  with  the  thumb  and  index  finger  of 
the  left  hand,  while  the  assistant  does  the  same  thing  on 
the  left  side.  Things  being  thus  disposed,  the  edges  of 
the  hare-lip  are  to  be  cut  otf  with  two  sweeps  of  the 
bistoury,  in  two  oblique  lines,  forming  an  acute  angle 
above  the  fissure. 

For  the  removal  of  the  edges  of  the  hare-lip.  scissors 
have  sometimes  been  preferred  to  a knife  ; but  notwith- 
standing Desault’s  partiality  to  them,  as  most  conve- 
nient (see  (F.uvres  C/iir.  t.  2,  p.  179),  they  are  now 
very  generally  disused.  The  pinching  and  bruising 
which  result  from  the  action  of  the  two  blades  are  cir- 
cumstances which  cannot  be  favourable  to  the  union  of 
the  wound ; and  though  they  may  not  commonly  be 
serious  enough  to  pbevent  union  by  the  first  intention, 
they  might  occasionally  tend,  with  any  other  untoward 
occurrence,  to  hinder  this  desirable  event.  Let  not 
practitioners  here  be  led  by  Mr.  'B.  Bell’s  statement, 
that  in  one  instance  he  cut  off  one  side  of  the  fissure 
with  a knife,  and  the  other  with  scissors ; that  the  latter 
cut  produced  least  pain,  and  that  on  this  side  there  was 
no  more  swelling  nor  inflammation  than  on  the  opposite 
one. 

The  pins  should  be  introduced  at  least  two-thirds  of 
the  way  through  the  substance  of  the  lip,  lest  a furrow 
should  remain'  on  the  inside  of  the  part,  which  might 
prove  troublesome  by  allowing  pieces  of  food  to  lodge 
in  it.  There  is,  however,  a stronger  reason  for  attend- 
ing to  this  circumstance,  viz.  the  hemorrhage  which 
may  take  place  when  it  is  neglected.  As  soon  as  the 
edges  of  the  wound  have  been  brought  together  by 
means  of  the  suture,  and  the  pins  are  properly  placed, 
the  bleeding  almost  ahvays  ceases ; but  when  the  pins 
have  not  been  introduced  deeply  enough,  and  the  poste- 
rior surfaces  of  the  incisions  are  not  applied  to  each 
other,  the  blood  may  continue  to  run  into  the  mouth, 
and  give  the  surgeon  an  immen.se  deal  of  trouble.  In 
the  memoir  written  by  Louis,  there  is  a case  in  which 
the  patient  died  in  consequence  of  such  an  accident. 
Persons  who  had  undergone  the  operation  were  always 
advised  to  swallow  their  spittle,  even  though  mixed 
with  blood,  in  order  to  avoid  disturbing  the  wound  by 
getting  rid  of  it  otherwise.  In  the  case  alluded  to,  the 
patient,  who  had  been  operated  upon  for  a cancerous 
affection  of  the  lip,  swallowed  the  blood  as  he  had  been 
directed  to  do,  and  he  bled  so  profusely  that  he  died. 
On  the  examination  of  the  body,  the  stomach  and  small 
intestines  were  found  full  of  blood.  “ This  deplorable 
case,”  says  the  illustrious  author  who  relates  it,  “de- 
serves to  be  recorded  for  public  instruction,  for  the 
purpose  of  keeping  alive  the  attention  of  surgeons  on 
all  occasions,  where,  in  consequende  of  any  operation 
whatsoever,  there  is  reason  to  apprehend  bleeding  in  the 
cavity  of  the  mouth.  Platner  is  the  only  writer  who,  as 
far  as  I know,  foresaw  this  kind  of  danger.  The  bleed- 
ing from  the  edges  of  the  wound  stops  of  itself  (says  he) 
as  soon  as  they  have  been  brought  into  con'act  and 
siitclled  together ; but  care  must  be  taken  that  the  pa- 
tient does  not  swallow  thg  blood,  which  might  make 
him  vomit*  or  else  suffocate  him.  Hence,  his  head 
should  be  elevated  that  the  blood  may  escape  externally, 
a precaution  more  particularly  necessary  in  young  chil- 
dren ” 

Having  described  the  mode  of  operating  for  the  liare- 
‘.ip  as  ayiproved  of  by  the  generality  of  practitioners,  and 
detailed  every  thing  which  seemed  material,  I have  now 
only  to  explain  the  method  adopted  by  M.  Mis 


sentiments  respecting  several  particular  points  of  the 
operation  have  been  already  stated ; and  an  account  of 
the  means  which  he  employed  in  lieu  of  the  twisted 
suture,  for  uniting  the  edges  of  the  wound,  is  all  that 
remains  to  be  noticed. 

Several  bandages  for  supporting  the  two  portions  of 
the  divided  lip,  and  lessening  the  pressure  which  they 
make  against  the  pins,  have  been  mentioned  by  authors. 
Franco  and  Quesnay,  in  particular,  de.scribe  two  kinds. 
These  means  were  not  only  employed  as  auxiliary,  but 
even  sometimes  as  curative  ones,  when  it  was  impossible 
to  use  needles.  To  such  bandages,  too  complicated  and 
too  uncertain  in  their  effect,  M.  Louis  prefers  a simple 
linen  roller,  one  inch  wide,  three  ells  long,  and  rolled 
up  into  two  unequal  heads.  He  begins  with  applying 
the  body  of  this  bandage  to  the  middle  of  the  forehead; 
he  unrolls  the  two  heads  from  before  backw'ards,  above 
the  ears,  betw'een  the  upper  part  of  the  cartilage  and 
the  cranium,  in  order  to  let  them  cross  on  the  nape  of 
the  neck,  and  i.hen  pass  forwards  again.  The  assistant 
who  supports  the  head,  and  pushes  forwards  the  cheeks, 
must  lift  up  the  ends  of  his  fingers,  in  the  place  of 
which,  on  each  side,  a thick  compress  is  to  be  put.  This 
being  covered,  and  pushed  from  behind  forwards  by  the 
roller,  will  constantly  perform  the  office  of  the  assist- 
ant’s fingers,  who  is  to  continue  to  support  the  appara- 
tus, until  it  is  all  completely  applied.  The  longest  of 
the  two  heads  of  the  roller  being  slit  in  two  places  near 
the  lip,  presents  two  parallel  openings;  the  remnant  of 
the  shortest  one  is  divided  into  two  parts,  as  far  as  its 
end.  The  two  little  narrow  bands  in  which  it  termi- 
iiates  must  then  pass  through  the  openings  of  the  former, 
and  cross  upon  the  middle  of  the  lip.  The  ends  of  the 
roller  being  carried  from  before  backwards,  are  then  to 
be  made  to  cross  again  on  the  nape  of  the  neck,  where 
the  shortest  is  to  end.  The  remainder  of  the  long  one 
is  to  be  employed  in  making  turns  round  the  head. 
'I'his  bandage  may  be  still  more  securely  fixed  by  means 
of  a piece  of  tape,  which  is  to  pass  the  forehead  over 
the  sagittal  suture,  and  be  pinned  at  each  end  to  the 
circumvolutions  of  the  roller;  while  ^-second  piece  of 
tape  is  to  cross  the  first  one  at  the  top  of'  the  head,  and 
also  to  be  attached  at  its  extremities  to  the  uniting 
bandage,  and  the  compresses  placed  under  the  zygo- 
matic arches,  for  the  purpose  of  pushing  forwards  the 
cheeks. 

This  bandage  is  extremely  simple,  and  would  answer 
well  as  an  auxiliary  to  the  twisted  suture.  I think 
this  last  means  will  always  be  the  favourite  of  the 
practical  surgeon,  because  the  desired  effect  can  be 
produced  by  it  with  much  less  trouble  than  must  be 
taken  with  the  bandage,  in  order  to  render  the  operation 
of  the  latter  sufficiently  certain.  Besides,  as  I have 
noticed,  M.  Louis  himself  mostly  made  one  stitch  near 
the  red  part  of  the  lip,  so  that  he  cannot  be  said  to  have 
trusted  altogether  to  the  bandage. 

What  has  been  said  concerning  the  operation  for  the 
hare-lip,  is  equally  applicable,  not  only  to  the  treat- 
ment of  cancer  of  the  lip,  but  also  to  that  of  accidental 
cuts  or  lacerations  of  this  part,  from  any  cause  what- 
soever. We  shall  only  remark,  that  in  a recent  wound, 
all  the  surgeon  has  to  do,  is  to  apply  the  twisted  suture 
and  adhesive  plaster  without  delay. 

When  there  is  a fissure  in  the  bones  forming  the 
roof  of  the  mouth,  it  usually  diminishes,  and  gradually 
closes,  after  the  hare-lip  is  cured.  But  this  does  not 
always  happen,  and  when  the  parts  remain  so  consi- 
derably separated  as  to  ob.struct  speech  and  deglutition, 
or  cause  any  other  inconvenience,  a plate  of  gold  or 
silver,  exactly  adapted  to  the  arch  of  the  palate,  and 
steadied  by  means  of  a piece  of  sponge  fixed  to  its  con- 
vex side  and  introduced  into  the  cleft,  may  sometimes 
be  usefully  employed.  When  the  sponge  is  of  suita- 
ble size  and  very  dry  before  being  used,  the  moisture 
of  the  adjacenl  parts  will  make  it  swell,  and  in  many 
cases  be  sufficient  to  keep  it  in  its  situation,  so  as 
greatly  to  facilitate  speaking  and  swallowing.  Some- 
times, however,  the  fissure  is  se  shajied  that  the  sponge 
cannot  be  fixed  in  it:  this  principally  happens  when 
the  opening  widens  very  much  towards  the  front  of 
the  jaw.  In  such  cases,  it  has  been  proposed  to  fix  a 
plate  of  gold  by  means  of  springs  covered  with  the 
same  metal.  Piatina,  which  is  cheaper,  might  be  used 
for  the  same  purpose.  The  subject,  however,  of  arti- 
ficial palates  is  one  on  which  much  mechanical  inge- 
nuity may  yet  be  usefully  exerted,  and  it  can  hardly  be 
expected  that  I should  here  do  more  than  give  refer- 


460 


HEA 


HEA 


ences  to  works  in  which  the  reader  may  find  informa- 
tion upon  it. — (See  Fauchard,  Le  Chirurg^im-Dentiste, 
3 tom.  12mo.  Paris,  1728.  Camper,  Vermischte  Schrif- 
ten.  No.  13.  Loder's  Joum.  b.  2,  p.  25,  p.  185,  <i-c. 
Von  Steveling  iiber  eine  merkwurdige  kunstliche  Er- 
setzung  mehrerer,  sowohl  zur  Sprache,  als  zum 
Schlucken  nothwendiger,  zerstorter  Werkzeuge ; 8vo. 
Heidelb.  1793.  Siebold,  Chir.  Tagebuch,  No.  20.  J. 

H.  F.  Autenrieth,  Supplementa  ad  Hist.  Embryonis 
Hiimani,  quibus  accedunt  Observata  qucedam  circa  Pa- 
latum Jissum,  verosimiUimamque  illi  medendi  Metho- 
dum,  ito.  Tubing.  1797.  Cullerion,  in  Journ.  Gin. 
<t  c.  t.  19.  Recueil  Period,  ^c.  t.  11,  p.  22.  Diet,  des 
Sciences  Mtd.  t.  37,  art.  Obturateur.  C.  Grae/e  et  Ph. 
von  Walther,  Joum.  der  Chir.  b.  1,  p.  1,  6vo.  Berlin, 
1820 ; in  this  work  Graefe  has  described  a method  of 
curing  fissures  in  the  soft  palate  by  means  of  a parti- 
cular kind  of  suture,  with  the  various  instruments 
necessary  in  the  operation.) 

[The  operation  of  staphyloraphy,  or  palate  suture 
was  first  performed  in  1816,  by  Professor  Graefe,  of 
Berlin,  and  soon  afterward  repeated  in  Paris  by  M. 
Roux. 

Professor  Warren,  of  Harvard  University,  was  the 
first  to  perform  it  in  this  country,  and  Professor  Ste- 
vens, of  New-York,  has  since  repeated  it  on  a young 
man,  set.  25,  for  a frightful  congenital  division  of  the  pa- 
late, with  very  satisfactory  success.  This  latter  case 
is  reported  at  length  in  the  New-York  Medical  and 
Surgical  Journal,  for  April,  1827. — Reese.] 

For  information,  relative  to  the  hare-lip,  see  B.  Bell's 
Surgery,  vol.  4.  Heister's  Surgery.  Le  Dran's  Opera- 
tions. Sharp's  Operations.  F.  D.  Herissant,  Mim.  de 
I'Acad.  des  Sciences,  annee  1743,  p.  86:  a very  curious 
case,  complicatedwith  a fissure  in  the  palate,  and  two  ob- 
long apertures  at  the  sides  of  this  cleft.  In  play,  the 
child  would  sometimes  fill  his  mouth  with  water,  and 
through  those  apertures  let  it  .spout  out  at  the  nostrils, 
in  imitation  of  what  takes  place  in  whales.  G.  D.  La 
Faye,  Mem.  de  I'Acad.  Roy  ale  de  Chir.  t.\,p.  605,  annie 
1743.  E.  Sandifort,  Obs.  Anat.  Pathol.  Mo.  et  Mu- 
seum Anat.  p.  110.  164,  Inigd.  Bat.  1777.  Flajani, 
Collezione  d'Oss.,  ^'C.  t.  8,  8vo.  Roma.  Latta's  Sur- 
gery, vol.  2.  Louis,  in  Mim.  de  I’Acad.  de  Chir.  t.  4, 
p.  385,  Mo.  annee  1768,  t.  5,  p.  292,  annee  1774.  De  la 
Medecine  Operatoire,  par  Sabatier,  t.  3,  p.  272,  8vo.  Pa- 
ris, 1810.  CEuvres  Chir.  de  Desault,  par  Bichat,  t.  2, 
p.  173.  Traite  des  Operations  de  Chirurgie,  par  A. 
Bertrandi,  chap.  19.  P.  N.  Haguette,  Sur  le  Bec-de- 
liivre  naturel.  Mo.  Paris,  1804.  J.  Kirby,  Cases,  f,  c. 
Svo.  Land.  1819  : forceps  recommended  for  holding  the 
lip  in  the  operation.  Richter,  Anfangsgr.  der  Wun- 
darzn.b.  2,kap.  7.  Locherde  Operationelabiileporini, 
fence,  1792.  Fretur  de  Labio  leporino,  Halce,  1793. 
Rieg.  von.  der  Hasencharte,  Frankf.  1803.  M.  J.  Che- 
lius,  Handb.  der  Chir.  b.  1,  p.  425,  Heidelb.  1826. 
Sprengel,  Geschichte  der  Chir.  Operationen,b.  1,  p.  155. 
Graefe,  Angiectasie,  v.  Langenbeck  Bibl.  b.  2,  p.  359. 
Pckoldt,  Ueber  eine  sehr  complicirte  Hasenscharte ; 
Leipz.  1804,  fol. 

HEAD,  INJURIES  OF  THE.  From  the  variety  of  parts 
of  which  the  .scalp  is  composed,  from  their  structure, 
connexions,  and  uses,  injuries  done  to  it  by  external 
violence  become  of  much  more  consequence  than  the 
same  kind  of  ills  can  prove,  when  inflicted  on  the  com- 
mon integuments  of  the  rest  of  the  body.  One  princi- 
pal reason  of  the  danger  in  these  cases  depends  upon 
the  free  communication  between  the  vessels  of  the  pe- 
ricranium and  those  of  the  dura  mater,  through  the 
diploe  of  the  skull ; for  when  inflammation  is  kindled 
in  the  former  membrane,  it  may  extend  itself  to  the 
latter.  According  to  Sir  Astley  Cooper,  there  are 
three  modes  in  which  wounds  of  the  scalp  may  induce 
fatal  consequences.  1st,  by  producing  what  is  called 
an  erysipelatous  inflammation  on  the  head  ; 2dly,  by- 
producing  extensive  suppuration  under  the  tendon  of 
the  occipito-frontalis  muscle;  3dly,  by  rendering  a 
simple  fracture  compound,  so  as  to  cause  more  exten- 
sive inflammation  of  the  dura  mater. — {Lectures,  vol. 

I,  p.  350.)  The  latter  observation,  as  far  as  my  inform- 
ation reaches,  is  new,  and  deserves  the  serious  con- 
sideration of  the  practitioner ; for  in  the  great  hospital 
where  I was  educated,  and  in  all  the  practice  which  I 
have  seen  in  the  army  and  elsewhere,  no  analogy  of 
this  kind  was  ever  suspected  between  ordinary  com- 
pound fractures  and  those  of  the  cranium.  If  the  doc- 
trine be  correct,  it  forms  another  weighty  argument 


against  the  method  of  cutting  down  to  a fracture  of 
the  skull  without  urgent  motives. 

Incised  wounds  of  the  scalp  are,  indeed,  less  liable 
than  contused  or  lacerated  ones  to  produce  bad  conse- 
quences ; but  they  are  not  entirely  devoid  of  danger ; 
in  proof  of  which.  Sir  Astley  Cooper  mentions  the  case 
of  a lady  of  rank  in  the  country  who  died  from  the  re- 
moval of  an  encysted  tumour  of  the  sca\p.— (Lectures, 
vol.  1,  p.  349.)  Passing  over  these  cases,  however,  which 
generally  heal  as  well  the  generality  of  cuts  in  the 
skin  of  other  parts  of  the  body,  and  require  no  particu- 
larity of  treatment,  Mr.  Pott  proceeds  immediately  to 
lacerated  and  punctured  wounds.  “ The  former  may 
be  reduced  to  two  kinds ; viz.  those  in  which  the  scalp, 
though  tom  or  unequally  divided,  still  keeps  its  natu- 
ral situation,  and  is  not  stripped  nor  separated  from 
the  cranium  to  any  considerable  distance  beyond  the 
breadth  of  the  wound  ; and  those  in  w-hich  it  is  consi- 
derably detached  from  the  parts  it  ought  to  cover.  The 
first  of  these,  if  simple,  and  not  combined  with  the 
symptoms  or  appearances  of  any  other  mischief,  does 
not  require  any  particular  or  different  treatment  from 
what  the  same  kind  of  wounds  require  on  all  other 
parts but  with  respect  to  those  in  which  the  scalp 
is  separated  and  detached  from  the  parts  it  ought  to  co- 
ver, Mr.  Pott  makes  no  scruple  of  declaring  it  as  his 
opinion,  that  its  preservation  ought  always  to  be  at- 
tempted, unless  it  be  so  tom  as  to  be  absolutely  spoiled, 
or  there  are  manifest  present  symptoms  of  other  mis- 
chief. In  former  days,  the  excision  of  the  lacerated 
and  detached  scalp  was  the  general  practice  ; but  Mr. 
Pott  had  so  often  made  the  experiment  of  endeavour- 
ing to  preserve  the  torn  piece,  and  so  often  succeeded, 
that  he  recommended  it  as  a thing  always  to  be  at- 
tempted, even  though  a part  of  the  cranium  were  per- 
fectly bare. 

Here  I may  remark  that  all  practitioners  now  inva- 
riably avoid  cutting  away  the  scalp,  even  in  the  cir- 
cumstances in  which  such  practice  was  allowed  by 
Pott.  By  spoiled,  this  eminent  writer  must  mean  so 
injured  as  necessarily  to  slough  afterward.  However, 
as  no  harm  results  from  taking  the  chance  of  its  not 
sloughing,  which  never  can  be  with  certainty  foretold ; 
and  as  the  excision  of  the  part  is  painftil  and  pro- 
ductive of  no  benefit,  even  if  sloughing  must  follow ; 
such  operation  is,  in  every  point  of  view,  hurtful  and 
wrong.  With  respect  to  other  mischief,  as  a reason, 
the  examination  of  the  cranium,  and  even  the  applica- 
tion of  the  trephine,  never  require  any  of  the  scalp  to 
be  cut  away.— (See  Trephine.) 

Let  the  surgeon,  therefore,  free  the  tom  piece  from 
all  dirt  or  foreign  bodies,  and  restore  it  as  quickly  and 
as  perfectly  as  he  can  to  its  natural  situation. 

Notwithstanding  Mr.  Pott  assents  to  the  employment 
of  sutures  for  uniting  certain  lacerated  wounds  of  the 
scalp,  the  best  practitioners  of  the  present  day  gene- 
rally employ  only  sticking  plaster.  Sometimes  the 
loosened  scalp  will  unite  with  the  parts  from  which  it 
is  torn  and  separated,  and  there  will  be  no  other  sore 
than  what  arises  from  the  impracticability  of  bringing 
the  lips  of  the  wound  into  smooth  and  immediate  con- 
tact, the  scar  of  which  sore  must  be  small  in  propor- 
tion. Sometimes  such  perfect  reunion  is  not  to  be  ob- 
tained ; in  which  case,  matter  will  be  fonned  and  col- 
lected in  those  places  where  the  parts  do  not  coalesce : 
but  this  does  not  necessarily  make  any  difference  ei- 
ther in  the  general  intention  or  in  the  event ; this  mat- 
ter may  easily  be  discharged  by  one  or  two  small  open- 
ings ^de  with  a lancet ; the  head  will  still  preserve 
its  natural  covering  ; and  the  cure  will  be  very  little 
retarded  by  a few  small  abscesses. 

In  some  cases' (as  Pott  proceeds  to  describe),  the 
whole  separated  piece  will  unite  perfectly,  and  give 
little  or  no  trouble,  especially  in  young  and  healthy  per- 
sons. In  some,  the  union  will  take  place  in  certain 
parts  and  not  in  others  (also  Brodie,  in  Med.  Chir. 
Trans,  vol.  14,  p.  408) ; and  consequently  matter  will 
be  formed,  and  require  to  be  discharged,  perhaps  at  se- 
veral different  points  ; and  in  some  particular  cases, 
circumstances,  and  habits,  there  wnll  be  no  union  at  all, 
the  torn  cellular  membrane  or  the  naked  aponeurosis 
will  inflame  and  become  sloughy,  a considerable  quan- 
tity of  matter  will  be  collected,  and,  perhaps,  the  cra- 
nium will  be  denuded.  But  even  in  this  state  of  things, 
which  does  not  very  often  happen,  where  care  has 
been  taken,  and  is  almost  the  worst  which  can  happen 
in  the  case  of  mere  simple  laceration  and  detachment, 


HEAD.  461 


If  the  surgeon  will  not  be  too  soon  or  too  much  alarmed, 
nor  in  a hurry  to  cut,  he  will  often  find  the  cure  much 
more  feasible  than  he  may  at  first  imagine  : let  him 
take  care  to  keep  the  inflammation  under  by  proper 
means,  let  him  have  patience  till  the  matter  is  fairly 
and  fully  formed,  and  the  sloughs  perfectly  separated, 
and  when  this  is  accomplished,  let  him  make  a proper 
number  of  dependent  openings  for  the  discharge  of 
them,  and  let  him  by  bandage  and  other  proper  ma- 
nagement keep  the  parts  in  constant  contact  with  each 
other,  and  he  will  often  find,  that  although  he  was 
foiled  in  his  first  intention  of  procuring  immediate 
union,  yet  he  will  frequently  succeed  in  this  his  se- 
cond ; he  will  yet  save  the  scalp,  shorten  the  cure,  and 
prevent  the  great  deformity  arising  (particularly  to  wo- 
men) not  only  from  the  scar,  but  from  the  total  loss  of 
hair. 

This  union  may  often  be  procured,  even  though  the 
cranium  should  have  been  perfectly  denuded  by  the 
accident ; and  it  is  true,  not  only  though  it  should  have 
been  stripped  of  its  pericranium  at  first  (see  Abeme- 
thy  on  the  Injuries  of  the  Head,  case  6),  but  even  if 
that  pericranium  should  have  become  sloughy  and  cast 
off,  as  Mr.  Pott  has  often  seen. 

“ Exfoliation  from  a cranium  laid  bare  by  external 
violence,  and  to  which  no  other  injury  has  been  done 
than  merely  stripping  it  of  its  covering,  is  a circum- 
stance (says  Pott)  which  would  not  so  often  happen  if 
it  was  not  taken  for  granted  that  it  must  be,  and  the 
bone  treated  according  to  such  expectation.  The  soft 
open  texture  of  the  bones  of  children  and  young  people 
will  frequently  furnish  an  incarnation,  which  will  cover 
their  surface,  and  render  exfoliation  quite  unnecessary 
(see  also  Brodie,  in  Med.  Chir.  Trans.  uoZ.  14,  p.  409) : 
and  even  in  those  of  mature  age,  and  in  whom  the 
bones  are  still  harder,  exfoliation  is  full  as  often  the 
effect  of  art  as  the  intention  of  nature,  and  produced 
by  a method  of  dressing  calculated  to  accomplish  such 
end,  under  a supposition  of  its  being  necessary.  Some- 
times, indeed,  it  happens  that  a small  scale  will  neces- 
sarily separate,  and  the  sore  cannot  be  perfectly  healed 
till  such  separation  has  been  made ; but  this  kind  of 
exfoliation  will  be  very  small  and  thin  in  proportion  to 
that  produced  by  art,  that  is,  that  produced  by  dressing 
the  surface  of  the  bare  bone  with  spirituous  tinc- 
tures, &c. 

Small  wounds,  that  is,  such  as  are  made  by  instru- 
ments or  bodies  which  pierce  or  puncture  rather  than 
cut,  are  in  general  more  apt  to  become  inflamed  and  to 
give  trouble  than  those  which  are  larger ; and,  in  this 
part  particularly,  are  sometimes  attended  with  so  high 
inflammation,  and  with  such  symptoms,  as  alarm  both 
patient  and  surgeon. 

If  the  wound  affects  the  cellular  membrane  only, 
and  has  not  reached  the  aponeurosis  or  pericranium, 
the  inflammation  and  tumour  affect  the  whole  head 
and  face,  the  skin  of  which  wears  a yellowish  cast, 
and  is  sometimes  thick  set  with  small  blisters,  contain- 
ing the  same  coloured  serum : it  receives  the  impres- 
sion of  the  fingers,  and  becomes  pale  for  a moment,  but 
returns  immediately  to  its  inflamed  colour ; it  is  not 
very  painful  to  the  touch,  and  the  eyelids  and  ears  are 
always  comprehended  in  the  tumefhetion,  the  former 
of  which  are  sometimes  so  distended  as  to  be  closed  ; 
a feverish  heat  and  thirst  generally  accompany  it ; the 
patient  is  restless,  has  a quick  pulse,  and  most  com- 
monly a nausea  and  inclination  to  vomit. 

I'his  accident  generally  happens  to  persons  of  bilious 
habit,  and  is  indeed  an  inflammation  of  the  erysipela- 
tous kind  : it  is  somewhat  alarming  to  look  at,  but  is 
not  often  attended  with  danger.  The  wound  does  in- 
deed neither  look  well,  nor  yield  a kindly  discharge, 
while  the  fever  continues,  but  still  it  has  nothing 
threatening  in  its  appearance,  none  of  that  look  which 
bespeaks  internal  mischief ; the  scalp  continues  to  ad- 
here firmly  to  the  skull,  and  the  patient  does  not  com- 
plain of  that  tensive  pain,  nor  is  he  afflicted  with  that 
fatiguing  restlessness  which  generally  attends  mis- 
chief underneath  the  cranium. 

Phlebotomy,  lenient  purges,  and  the  use  of  the 
common  febrifuge  medicines,  particularly  those  of  the 
neutral  kind,  generally  remove  it  in  a short  time. 
When  the  inflammation  is  gone  off,  it  leaves  on  the 
skin  for  a little  while  a yellowish  tint  and  a dry  scurf, 
and,  upon  the  disappearance  of  the  disease,  the  wound 
immediately  recovers  a healthy  aspect,  and  soon  heals 
wmiout  any  farther  trouble.  I do  not  believe  that  the 


exhibition  of  bark,  in  this  form  of  erysipelas,  is  ever 
productive  of  any  decided  benefit. 

Wounds  and  contusions  of  the  head,  which  affect 
the  brain  and  its  membranes,  are  also  subject  to  an 
erysipelatous  kind  of, swelling  and  inflammation ; but 
it  is  very  different  both  in  its  character  and  conse- 
quences from  the  preceding. 

In  this  (which  is  one  of  the  effects  of  inflammation 
of  the  meninges),  the  febrile  symptoms  are  much 
higher,  the  pulse  harder  and  more  frequent,  the  anxiety 
and  restlessness  extremely  fatiguing,  the  pain  in  the 
head  intense ; and  as  this  kind  of  appearance  is,  in 
these  circumstances,  most  frequently  the  immediate 
precursor  of  matter  forming  between  the  skull  and 
dura  mater,  it  is  generally  attended  with  irregular  shi- 
verings,  which  are  not  followed  by  a critical  sweat,  nor 
afford  any  relief  to  the  patient.  To  which  it  may  be 
added,  that  in  the  former  case  the  erysipelas  generally 
appears  within  the  first  three  or  four  days  ; whereas, 
in  the  latter,  it  seldom  comes  on  till  several  days  after 
the  accident,  when  the  symptomatic  fever  is  got  to 
some  height.  In  the  simple  erysipelas,  although  the 
wound  be  crude  and  undigested,  yet  it  has  no  other 
mark  of  mischief;  the  pericranium  adheres  firmly  to 
the  skull,  and  upon  the  cessation  of  the  fever,  all  ap- 
pearances become  immediately  favourable.  In  that 
which  accompanies  injury  done  to  the  parts  under- 
neath, the  wound  not  only  has  a spongy,  glassy,  un- 
healthy aspect,  but  the  pericranium  in  its  neighbour- 
hood separates  spontaneously  from  the  bone,  and  quits 
all  cohesion  with  it.  In  .short,  one  is  an  accident  pro- 
ceeding from  a bilious  habit,  and  not  indicating  any 
mischief  beyond  itself ; the  other  is  a symptom  or  a 
part  of  a disease,  which  is  occasioned  by  injury  done 
to  the  membranes  of  the  brain  : one  portends  little  or 
no  ill  to  the  patient,  and  almost  always  ends  well ; the 
other  implies  great  hazard,  and  most  commonly  ends 
fatally.  It  is  therefore  hardly  necessary  to  say,  that  it 
behooves  every  practitioner  to  be  careful  in  distinguish- 
ing them  from  each  other. 

If  the  wound  be  a small  one,  and  has  passed  through 
the  cellular  membrane  to  the  aponeurosis  and  pericra- 
nium, it  is  sometimes  attended  with  very  disapeeable, 
and  even  very  alarming  symptoms,  but  which  arise 
from  a different  cause,  and  are  very  distinguishable 
from  what  has  been  yet  mentioned. 

In  this,  the  inflamed  scalp  does  not  rise  into  that  de- 
gree of  tumefaction  as  in  the  erysipelas,  neither  does  it 
pit,  or  retain  the  impression  of  the  fingers  of  an  ex- 
aminer. It  is  of  a deep  red  colour,  unmixed  with  the 
yellow  tint  of  the  erysipelas ; it  appears  tense,  and  is 
extremely  painful  to  the  touch ; as  it  is  not  an  affec- 
tion of  the  cellular  membrane,  and  as  the  ears  and  the 
eyelids  are  not  covered  by  the  parts  in  which  the 
wound  is  inflicted,  they  are  seldom  if  ever  compre- 
hended in  the  tumour,  though  they  may  partake  of  the 
general  inflammation  of  the  skin ; it  is  generally  at- 
tended with  acute  pain  in  the  head,  and  such  a degree 
of  fever  as  prevents  sleep,  and  sometimes  brings  on  a 
delirium. 

A patient  in  these  circumstances  will  admit  more 
free  evacuations  by  phlebotomy  than  one  labouringr 
under  an  erysipelas  : the  use  of  warm  fomentation  is 
required  in  both,  in  order  to  keep  the  skin  clean  and 
perspirable,  but  an  emollient  cataplasm,  which  is  gene- 
rally forbid  in  the  former,  may  in  this  latter  case  be 
used  with  great  advantage. 

When  the  s>Tnptoms  are  not  very  pressing,  nor  the 
habit  very  inflammable,  this  method  will  prove  suffi- 
cient; but  it  sometimes  happens  that  the  scalp  is  so 
tense,  the  pain  so  great,  and  the  symptomatic  fever  so 
high,  that  by  waiting  for  the  slow  effect  of  such  means,- 
the  patient  runs  a risk  from  the  continuance  of  the 
fever,  or  else  the  injured  aponeurosis  and  pericranium, 
becoming  sloughy,  produce  an  abscess,  and  render  the 
case  both  tedious  and  troublesome.  A division  of  the 
wounded  part  by  a simple  incision  down  to  the  bone, 
about  half  an  inch  or  an  inch  in  length,  will  most 
commonly  remove  all  the  bad  symptoms,  and,  if  it  be 
done  in  time,  will  render  every  thing  else  unneces- 
sary.” We  here  perceive  that,  in  this  form  of  inflam- 
mation, the  practice  of  making  an  incision  had  the 
sanction  of  Pott ; but  the  extent  of  the  wound  recom- 
mended is  moderate,  and  very  different  from  what  has 
been  recently  juoposed  for  phlegmonous  erysipelas  of 
the  limbs.  With  respect  to  the  good  effects  of  such 
, an  incision  Desault  considers  them  greatly  exag- 


462 


HEAD. 


gerated  by  authors  ; and  'while  he  admits  that  they  are 
useful  when  the  inflammation  extends  under  the  apo- 
neurosis, he  is  not  inclined  to  sanction  it  as  a right 
proceeding  in  other  instances. — (See  cEuvres  Chir.  par 
Bichat,  t.  2,  p.  8.) 

Thus  Mr.  Pott  was  of  opinion,  that  the  ditferences 
of  the  symptoms  in  the  foregoing  cases  depended  upon 
whether  the  w'ound  only  affected  the  skin  and  cellular 
membrane  or  reached  more  deeply  to  the  aponeurosis 
and  pericranium  ; a doctrine  which  has  been  justly  re- 
garded as  questionable.  With  respect  to  the  observa- 
tion that  in  a puncture  of  the  aponeurosis  the  swell- 
ing is  confined  within  the  limits  of  this  fascia,  and 
does  not  extend  to  the  ears  and  eyelids,  it  is  a senti- 
ment which  Desault  thought  arose  rather  from  ana- 
tomical speculations  than  the  observation  of  nature. 
The  doctrine,  indeed,  must  ajipear  doubtful,  when  it  is 
recollected,  1st,  That  the  aponeurosis  and  pericranium 
are  parts  of  scarcely  any  sensibility.  2dly,  That  the 
opinion  had  its  origin  at  a period  when  these  parts 
were  imagined  to  be  highly  sensible.  3dly,  That  in 
other  parts  of  the  body,  a wound  in  which  a fascia  or 
the  periosteum  is  concerned  is  rarely  attended  with 
the  above-described  severe  sjmptorns.  4tlily,  That 
here  the  wounds  often  affect  only  the  sltin  and  cellular 
membrane,  and  yet  these  symptoms  occur  even  with  a 
phlegmonous  character,  otly.  On  the  contrary,  in 
other  instances,  in  which  the  aponeurosis  and  pericra- 
nium are  undoubtedly  wounded,  no  bad  symptoms  at 
all  lake  place.  6thly,  These  symptoms  may  almost 
always  be  removed  by  the  exhibition  of  tartarized  an- 
timony.— (CKuvres  Chir.  de  Desault,  t.  2,  p.  8.)  In  the 
case  often  named  inflammation  of  the  fascia,  after 
bleeding,  it  is  not  the  fascia  itself,  wliich  is  the  real  and 
chief  seat  of  the  pain,  inflammation,  <fcc.,  but  the  sub- 
jacent cellular  membrane  and  muscles.  The  theory  of 
Desault  is,  that  the  erysipelatous  affections  of  the 
scalp,  so  frequent  after  injuries  of  the  head,  are  con- 
nected with  disorder  of  the  functions  of  the  liver,  pro- 
duced by  such  .accidents.  Yet  it  is  difficult  to  under- 
stand why  a mere  puncture  of  the  scalp  should  cause 
this  disorder  of  the  liver  more  commonly  than  the  same 
kind  of  wound  of  any  other  superficial  part  of  the  body. 

The  injuries  to  which  the  scalp  is  liable  from  contu- 
sion, or  appearances  proiluced  in  it  by  such  general 
cause,  may  be  divided  into  those  in  which  the  mischief 
is  confined  merely  to  the  scalp,  and  those  in  which 
other  parts  are  interested. 

The  former,  which  only  come  under  our  present  con- 
sideration, are  not  indeed  of  importance,  considered 
abstractedly.  The  tumour  is  either  very  readily  dissi- 
pated, or  the  extravasated  blood  causing  it  is  easily  got 
rid  of  by  a small  openhig.  J.  L.  Petit  first,  and  after- 
ward Pott,  particularly  noticed  this  case,  on  account 
of  an  accidental  circumstance  which  sometimes  at- 
tends it,  and  renders  it  liable  to  be  very  much  mis- 
taken. 

“ When  the  scalp  receives  a very  smart  blow,  it 
often  happens  that  a quantity  of  extravasated  blood 
immediately  forms  a tumour,  easily  distinguishable 
from  all  others,  and  generally  very  easily  cured.  But 
it  also  sometimes  happens,  that  this  kind  of  tumour 
produces  to  the  fingers  of  an  unadvised  or  inattentive 
examiner  a sensation  so  like  to  that  of  a fracture, 
with  depression  of  the  cranium,  as  may  be  easily  mis- 
taken.” Now  if,  upon  such  supposition,  a surgeon 
immediately  makes  an  incision  into  the  tumid  scalp, 
he  may  give  liis  patient  a great  deal  of  unnecessary 
pain,  and  for  that  reason  run  some  risk  of  his  own 
character. 

“ The  touch  is  in  this  case  so  liable  to  deception,  that 
recourse  should  always  be  had  to  other  circumstances 
and  symptoms,  before  an  opinion  be  given. 

If  a person  with  such  tumour,  occasioned  by  a blow, 
and  attended  with  such  apjwtarances  and  feel,  has  any 
complaint  which  seems  to  be  the  effect  of  pressure 
made  on  the  brain  and  nerves,  or  of  any  mischief  done 
to  the  parts  within  the  cranium,  the  division  of  the 
scalp,  in  order  to  inquire  into  the  state  of  the  skull,  is 
right  and  necessary ; but  if  there  are  no  such  general 
symptoms,  and  the  patient  is  in  every  respect  perfectly 
well,  the  mere  feel  of  something  like  a fracture  wall 
not  authorize  or  vindicate  such  oiieration,  since  it  will 
often  be  found  that  such  .sensation  is  a deception,  and 
that,  when  the  extravasated  fluid  is  removed,  or  di.s- 
sipated,the  cranium  is  perfectly  sound  and  uninjured.” 
-{Pott.) 


With  the  exception  of  instances  in  which  the  dura 
mater  suppurates  from  a blow  on  the  head,  and  the 
symptoms  are  such  as  to  require  the  trephine,  or  other 
examples  in  which  an  abscess  forms  under  the  scalp, 
or  a large  quantity  of  blood  is  effused  in  the  same  situ- 
ation, none  of  the  cases  which  have  here  been  con- 
sidered can  justify  making  incisions  in  the  scalp. 
When  blood  is  extravasated  under  the  scalp,  the  siu- 
geon  need  not  be  too  officious  with  his  knife,  merely 
because  there  is  a tumour  containing  blood.  The  fa- 
cility with  which  an  effusion  of  blood  under  the  scalp 
is  dispersed  is  well  illustrated  in  a case  mentioned  by 
Mr.  Brodie.  He  was  consulted  about  a young  gentle- 
man, under  whose  scalp  an  effusion  of  blood  extended 
from  the  superciliary  ridges  to  the  nape  of  the  neck, 
and  from  ear  to  ear.  'Tlie  blood  appeared  to  be  in  a 
fluid  state,  and  was  so  copious,  that  no  part  of  the 
cranium  could  be  felt.  In  a few  w eeks,  and  with  the 
aid  of  a cold  lotion,  the  whole  tumour  was  dispersed. 
Mr.  Brodie  observes,  that  whatever  might  be  the  ves- 
sel ruptured,  it  must  have  continued  to  bleed  a con- 
siderable time,  in  order  to  produce  so  large  an  extravasa- 
tion. I have  seen  three  or  four  cases  nearly  as  remark- 
able as  the  preceding,  and  having  a similar  favourable 
termination  under  the  use  of  simple  discutient  lotions 
and  occasional  purgatives.  In  one  instance,  attended 
by  Mr.  Brodie,  he  succeeded  in  preventing  the  effusion 
from  attaining  the  extent  described  in  his  other  ca.se, 
by  means  of  pressure  applied  to  the  point  w'here  the 
blow  had  been  received,  and  a vessel  ruptured. — (See 
Med.  Chir.  Trcms.  vol.  15,  p.  40<i.) 

The  utility  of  an  incision  in  what  was  supposed  by 
Pott  to  be  an  inflammation  of  the  aponeurosis  is  at 
least  questionable,  as  far  as  it  is  done  under  the  idea 
of  merely  obviating  tension,  without  there  being  any 
matter  to  be  discharged.  Incisions,  expressly  for  the 
purpo.se  of  exposing  the  bone,  are  only  right  as  a pre- 
paratory step  to  trephining,  when  the  necessity  for  this 
operation  is  indicated  by  decided  and  urgent  symptoms 
of  pressure  on  the  brain.  Now  such  pressure,  in  any 
of  the  examples  above  treated  of,  can  only  arise  from 
a suppuration  under  the  skull,  a subject  which  will 
presently  be  considered. 

Dr.  Hennen,  in  his  truly  practical  work,  has  very 
properly  advised  surgeons  not  to  be  content  with  clip- 
ping away  a little  of  the  hair  around  the  injury,  but  al- 
ways to  have  the  head  shaved  to  a proper  extent.  This  pro- 
ceeding, which  is  perfectly  harmless  in  itself,  is  more  ge- 
nerally right  than  the  custom  of  cutting  the  scalp,  which 
has  been  too  frequently  employed  without  any  rational 
aim.  The  free  removal  of  the  hair  directly  aftert  he  acci- 
dent often  brings  into  view  marks  indicative  of  other 
parts  of  the  head  having  been  struck  besides  that  which 
is  at  first  noticed,  and  thus  the  practitioner  will  have  a 
more  correct  notion  of  the  serious  nature  ol'  the  acci- 
dent than  he  might  otherwise  have  conceived,  and  be 
more  strict  in  bis  mode  of  treatment.  Nay,  fractures 
and  depression  of  the  skull,  sometimes  not  denoted  by 
any  disturbance  of  the  functions  of  the  brain,  and  liable 
to  escape  obsen'ation  while  concealed  under  the  hair, 
are  frequently  detected  after  its  removal,  and  the  sur- 
geon being  now  aware  of  the  extent  and  situation  of 
the  mischief,  must  of  course  be  better  qualified  to  con- 
duct the  treatment.  In  short,  as  Dr,  Hennen  lias  ob- 
served, “ independent  of  the  more  accurate  view  (thus 
procured), -we  facilitate  the  application  of  leeches,  if 
they  may  be  found  necessary,  and  of  a most  excellent 
adjuvant  on  all  occasions,  viz.,  cold  applications.” 

It  affords  me  particular  pleasure  to  be  able  to  num- 
ber so  good  a surgeon  as  Dr.  Hennen  among  the  ad- 
vocates of  Schmucker’s  plan  of  having  the  head  well 
shaved  and  covered  with  cloths  wet  with  a very  cold 
lotion  ; a practice  which  the  latter  eminent  surgeon  al- 
ways adopted,  whether  a sabre-cut  or  gun-shot  injury 
of  this  part  had  the  appearance  of  being  serious  or  not. 
“ As  soon  as  the  patient  was  brought  to  the  hospital 
with  a wound  of  the  head,  whether  the  injury  looked 
important  or  not  (says  Schmiicker),  1 directed  the  hair 
to  be  immediately  removed,  and  after  the  necessary  di- 
latation applied  dressings.  Sixteen  ounces  of  blood 
were  next  taken  away,  and  the  evacuation,  in  less  quan- 
tity, repeated,  according  to  circumstances,  three  or  four 
times  within  the  space  of  twenty-four  hours.  The 
pulse  now  generally  became  softer,  and  the  determina- 
tion of  blood  to  the  head  lessened.  Over  the  dressing.^ 
and  the  whole  of  the  head,  thick  cloths,  dipped  in  the 
cold  mLxture  hereafter  specified,  were  laid,  and  renewed 


HEAD. 


463 


every  hour.  These  cloths  were  kept  in  their  place  with 
the  bandage  called  the  grand  couvre-chef. — (See  Band- 
age.) As  internal  medicines,  the  nitrate  ot'  potassa, 
neutial  salts,  and  emollient  and  stimulating  clyster.s, 
and  gentle  aperients  were  given.  These  means  were 
employed,  both  in  slight  injuries  and  in  those  where  the 
bones  were  depressed,  and  the  fissures  and  fractures 
were  accompanied  with  violent  convulsive  twitchings, 
coma,  paralysis,  and  other  bad  symptoms  ; and  even  in 
cases  where  the  use  of  the  trephine  was  indispensable, 
the  practice  was  continued  until  the  r:ure  was  complete.” 
Schmucker  assures  us,  that  under  such  treatment, 
fewer  patients  with  wounds  of  the  head  were  lost  than 
used  previously  to  happen,  especially  of  those  whose 
injuries  at  first  had  the  appearance  of  being  but  slight. 
—{See  Chir.  Wahrnehmungen,  b.  1,  p.  154.) 

Schmucker  was  led  to  try  this  practice  by  the  great 
benefit  which  he  had  seen  afforded  by  the  application 
of  cold  water  to  the  head  in  cases  of  mania,  attended 
with  great  determination  of  blood  to  the  brain.  And 
in  order  to  increase  the  efficacy  of  the  water,  he  added 
to  every  five  gallons  of  it  two  quarts  of  vinegar,  six- 
teen ounces  of  nitre,  and  eight  of  the  muriate  of  am- 
monia. This  mixture  was  then  preserved  for  use  in  a 
cold  place. — {Vol.  cit.  p.  153.)  Or,  in  order  to  avail 
ourselves  fully  of  the  frigorific  effects  of  this  mixture, 
it  should  be  prepared,  as  L)r,  Hennen  observes,  in  small 
quantities,  and  used  immediately  before  its  tempera- 
ture has  risen  ; or  “snow,  or  pounded  ice,  or  ice-water 
applied  to  the  parts  in  a half  filled  bladder,  or  cloths 
simply  dipped  in  cold  water,  will  often  answer  every 
purpose.-^ O/i  Military  Surgery,  p.  279,  ed.  2.)  Dr. 
Hennen  mentions  one  important  fact,  in  recommenda- 
tion of  cold  applications,  antimonials,  and  saline  pur- 
gatives, preceded  by  the  common  blue  pill,  and  assisted 
v;ith  quiet  and  abstinence,  viz.  by  such  means,  “ those 
troublesome  puffy  enlargements  and  erysipelatous  af- 
fections of  the  scalp,  which  so  often  succeed  to  bruises, 
are  prevented,  and  where  the  evacuant  plan  is  duly  ob- 
served, the  extensive  and  formidable  erysipelatous  af- 
fections, so  common  formerly,  are  rare  and  mild  at  pre- 
sent in  military'  hospitals.” 

2.  Effects  of  Contusion  on  the  Dura  Mater  and  Parts 
within  the  Skull. 

In  consequence  of  blows,  falls,  and  other  shocks, 
either  blood  may  be  effused  under  the  cranium,  or  in- 
flammation and  suppuration  of  the  dura  mater  may 
arise.  The  best  description  of  the  latter  case  is  that 
delivered  by  Mr.  Pott. 

Srnart  and  severe  strokes  on  the  middle  part  of  the 
bones,  at  a distance  from  the  sutures,  he  says,  are  most 
frequently  followed  by  this  kind  of  mischief : the  coats 
of  the  small  vessels,  which  sustain  the  injury,  inflame 
and  become  sloughy,  and  in  consequence  of  such  alter- 
ation in  them,  the  pericranium  separates  from  the  out- 
side of  that  part  of  the  bone  which  received  the  blow, 
and  the  dura  mater  from  the  inside,  the  latter  of  which 
membranes,  soon  after  such  inflammation,  becomes 
sloughy  also,  and  furnishes  matter,  which  matter  being 
collected  between  the  said  membrane  and  the  cranium, 
and  having  no  natural  outlet,  whereby  to  escape  or  be 
discharged,  brings  on  a train  of  very  terrible  symptoms, 
and  is  a very  frequent  cause  of  destruction.  The  efifect 
of  this  kind  of  violence  is  frequently  confined  to  the 
vessels  connecting  the  dura  mater  to  the  cranium,  in 
which  case  the  matter  is  external  to  the  said  membrane; 
but  sometimes  the  matter  fonned  in  consequence  of  > 
such  violence  is  found  on  the  surface  of  the  brain,  or 
between  the  pia  and  dura  mater,  as  well  as  on  the  sur- 
face of  the  latter ; or,  perhaps,  in  all  these  three  situa- 
tions at  the  same  time. 

I’he  difference  of  this  kind  of  disease  from  either  an 
extravasation  of  blood  or  a concussion  of  the  brain  is 
great  and  obvious.  “All  the  complaints  produced  by 
extravasation  are  such  as  proceed  from  pressure  made 
on  the  brain  and  nerves,  and  obstruction  to  the  circula- 
tion of  the  blood  through  the  former;  stupidity,  loss  of 
sense  and  voluntary  motioii,  laborious  and  obstructed 
pulse  and  respiration,  &c.,  and  (which  is  of  importance 
to  remark),  if  the  ffusion  be  at  all  considerable,  these 
.symptoms  appear  immediately  or  very  soon  after  the 
acc.  dent. 

The  symptoms  attending  an  inflamed  or  sloughy 
state  of  the  membranes,  in  conse(}uence  of  external  vio- 
lence, are  very  different;  they  are  all  of  the  febrile  kind, 
atid  never  at  first  unply  any  unnatural  pressure  : such 


are  pain  in  the  head,  restlessness,  w'anf  of  sleep,  fre- 
quent and  hard  pulse,  hot  and  dry  skin,  flushed  counte- 
nance, inflamed  eyes,  nausea,  vomiting,  rigor ; and,  to- 
wards the  end,  convulsion  and  delirium.  And  none  of 
these  appear  at  first,  that  is,  immediately  after  the  ac- 
cidend  ; seldom  until  some  days  are  passed.” 

This  last  observation,  made  by  Pott,  is  one  that  is 
well  worthy  of  the  practitioner’s  constant  recollection, 
lest  he  wrongly  fancy  his  patient  secure  too  soon,  and 
neglect  the  early  use  of  the  only  means  by  which  a re- 
covery can  be  effected.  Thus,  as  Sir  Astley  Cooper 
notices,  the  time  when  inflammation  of  the  brain  (and, 
it  may  be  added,  of  its  membranes)  follows  the  violence 
is  generally  about  a week  ; rarely  sooner.  Frequently 
it  does  not  come  on  till  a fortnight  or  three  weeks  after 
the  injury  ; and  even  more  time  mu.st  elapse  before  the 
patient  is  quite  safe,  or  ought  to  deviate  from  a strict 
and  temperate  regimen.  In  confirmation  of  this  re- 
mark, a case  is  mentioned,  where  the  neglect  to  keep 
the  boxvels  regular  brought  on  a fatal  attack  of  inflam- 
mation of  the  brain,  as  late  as  four  months  after  the 
receipt  of  a blow  on  the  head. — {Lectures,  ire.  p.  339-) 

One  set  or  class  of  sy^mptoms  is  produced  By  an  ex- 
iravasated  fluid  making  pressure  on  the  brain  and  ori- 
gin of  the  nerves,  so  as  to  impair  or  abolish  voluntary 
motion  and  the  senses ; the  other  is  caused  by  the  in- 
flamed or  putrid  state  of  the  membranes  covering  the 
brain,  and  seldom  affects  the  organs  of  sense,  until  the 
lattpr  end  of  the  disease,  that  is,  until  a considerable 
quantity  of  matter  is  formed,  which  matter  must  press 
like  any  other  fluid. 

“If  there  be  neither  fissure  nor  fracture  of  the  skull, 
nor  extravasation  nor  commotion  underneath  it,  and 
the  scalp  be  neither  considerably  bruised  nor  wounded, 
the  mischief  is  seldom  discovered  or  attended  to  tor 
some  few  days.  The  first  attack  is  generally  by  pain 
in  the  part  which  received  the  blow.  This  pain,  though 
beginning  in  that  point,  is  soon  extended  all  over  the 
head,  and  is  attended  with  a languor,  or  dejection  of 
strength  and  spirits,  which  are  soon  followed  by  a nau- 
sea and  inclination  to  vomit,  a vertigo  or  giddiness,  a 
quick  and  hard  pulse,  and  an  incapacity  of  sleeping,  at 
least  quietly.  A day  or  two  after  this  attack,  if  no 
means  preventive  of  inflammation  are  used,  the  part 
stricken  generally  swells,  and  becomes  puffy  and  ten- 
der, but  not  painful ; neither  does  the  tumour  arise  to 
any  considerable  height,  nor  spread  to  any  great  ex- 
tent : if  this  tumid  part  of  the  scalp  be  now  divided, 
the  pericranium  will  be  found  of  a darkish  hue ; an<J 
either  quite  detached  or  very  easily  separable  from  the 
skull,  between  which  and  it  will  be  found  a small  quan- 
tity of  dark-coloured  ichor.  * 

If  the  disorder  has  made  such  progress  that  the  peri- 
cranium is  quite  separated  and  detached  from  the  skull, 
the  latter  xvill  even  now  be  found  to  be  somewhat  al- 
tered in  colour  from  a sound,  healthy  bone. 

From  this  time  the  symptoms  generally  advance  more 
hastily  and  more  aj)parently ; the  fever  increases,  the 
skin  becomes  hotter,  the  pulse  quicker  and  harder,  the 
sleep  more  disturbed,  the  anxiety  and  re.stlessness  more 
fatiguing ; and  to  these  are  generally  added  irregular 
rigors,  which  are  not  followed  by  any  critical  sweat, 
and  w'hich,  instead  of  relieving  the  patient,  add  consi- 
derably to  his  sufferings.  If  the  scalp  has  not  been  di- 
vided or  removed,  until  the  symptoms  are  thus  far  ad- 
vanced, the  alteration  of  the  colour  of  the  bone  will  be 
found  to  be  more  remarkable ; it  will  be  found  to  be 
whiter  and  more  dry  than  a healthy  one;  or,  as  Fallo- 
pius has  very  justly  observed,  it  will  be  found  to  be 
more  like  a dead  bone  : the  sanies  or  fluid  between  it 
and  tlie  pericranium  will  also,  in  this  state,  be  found  to 
be  more  in  quantity,  and  the  said  membrane  will  have 
a more  livid,  diseased  aspect. 

In  this  state  of  matters,  if  the  dura  mater  be  denuded 
it  will  be  found  to  be  detached  from  the  inside  of  the 
cranium,  to  have  lost  its  bright  silver  hue,  and  to  be,  as 
it  were,  smeared  over  with  a kind  of  mucus,  or  with 
matter,  but  not  with  blood.  Every  hour  after  this  pe- 
riod, all  the  symptoms  are  exasperated,  and  advance 
with  hasty  strides:  the  headache  and  thirst  become 
more  intense,  the  strength  decreases,  the  rigors  are 
more  frequent,  and  at  last  convulsive  motions,  attended 
in  some  with  delirium,  in  others  with  paralysis  or  co- 
matose stujiidity,  finish  the  tragedy. 

If  the  scalp  has  not  been  divided  till  this  point  of 
time,  and  it  be  done  now,  a very  offensive  discoloured 
kind  of  fluid  will  be  found  lying  oti  the  bare  cranium, 


464 


HEAD. 


whose  appearance  will  be  st  ill  more  unlike  to  the  healthy  j 
natural  one ; if  the  bone  be  now  perforated,  matter  will 
be  found  between  it  and  the  dura  mater,  generally  in 
considerable  quantity,  but  different  in  different  cases 
and  circumstances.  Sometimes  it  will  be  in  great 
abundance,  and  diffused  over  a very  large  part  of  the 
membrane ; and  sometimes  the  quantity  will  be  less, 
and  consequently  the  space  which  it  occupies  smaller. 
Sometimes  it  lies  only  on  the  exterior  surface  of  the 
dura  mater ; and  sometimes  it  is  between  it  and  the  pia 
mater,  or  also  even  on  the  surface  of  the  brain,  or 
within  the  substance  of  it,  «fcc. 

As  the  inflammation  and  separation  of  the  dura  ma- 
ter is  not  an  immediate  consequence  of  the  violence,  so 
neither  are  the  symptoms  immediate,  seldom  until  some 
days  have  passed ; the  fever  at  first  is  slight,  but  in- 
creases gradually ; as  the  membrane  becomes  more  and 
more  diseased,  all  the  febrile  symptoms  are  heightened ; 
the  formation  of  matter  occasions  rigors,  frequent  and 
irregular,  until  such  a quantity  is  collected  as  brings 
on  delirium,  spasm,  and  death.” 

When  the  scalp  has  been  wounded,  Mr.  Pott  ob- 
serves, the  wound  will  for  some  little  time  have  the 
same  appearance  as  a mere  simple  wound  of  this  part, 
unattended  with  other  mischief,  would  have  ; it  will, 
like  that,  at  first  discharge  a thin  sanies  or  gleet,  and 
then  begin  to  suppurate  ; it  will  dige.st,  begin  to  incarn, 
and  look  perfectly  well ; but  after  a few  days,  all  these 
favourable  appearances  will  vanish ; the  sore  will  lose 
its  florid  complexion  and  granulated  surface ; will  be- 
come pale,  glassy,  and  flabby ; instead  of  good  matter, 
it  will  discharge  only  a thin  discoloured  sanies ; the 
lint  with  which  it  is  dressed,  instead  of  coming  off  ea- 
sily (as  in  a kindly  suppurating  sore),  will  stick  to  all 
parts  of  it ; and  the  pericranium,  instead  of  adhering 
firmly  to  the  bone,  will  separate  from  it  all  round  to 
some  distance  from  the  edges. 

“ This  alteration  in  the  face  and  circumstances  of  the 
sore  is  produced  merely  by  the  diseased  state  of  the 
parts  underneath  the  skull ; which  is  a circumstance 
of  great  importance  in  support  of  the  doctrine  advanced ; 
and  is  demonstrably  proved,  by  observing  that  this 
diseased  aspect  of  the  sore  and  this  spontaneous  sepa- 
ration of  the  pericranium  are  always  confined  to  that 
part  which  covers  the  altered  or  injured  portion  of  the 
dura  mater,  and  do  not  at  all  affect  the  rest  of  the  scalp : 
nay,  if  it  has  by  accident  been  wounded  in  any  other 
part,  or  a portion  has  been  removed  from  any  part  where 
no  injury  has  been  done  to  the  dura  mater,  no  such  sepa- 
ration will  happen,  the  detachment  above  will  always 
correspond  to  that  below,  and  be  found  no  where  else. 

The  first  appearance  of  alteration  in  the  wound  im- 
mediately succeeds  the  febrile  attack ; and  as  the  febrile 
symptoms  increase,  the  sore  becomes  worse  and  worse ; 
that  is,  degenerates  more  and  more  from  a healthy, 
kindly  aspect. 

Through  the  whole  time  from  the  first  attack  of  the 
fever  to  the  last  and  fatal  period,  an  attentive  observer 
will  remark  the  gradual  alteration  of  the  colour  of  the 
bone,  if  it  be  bare.  At  first,  it  will  be  found  to  be 
whiter  and  more  dry  than  the  natural  one ; and  as  the 
symptoms  increase,  and  either  matter  is  collected  or 
the  dura  mater  becomes  sloughy,  the  bone  inclines 
more  and  more  to  a kind  of  purulent  hue  or  whitish 
yellow : and  it  may  also  be  worth  while  in  this  jflace 
to  remark,  that  if  the  blow  was  on  or  very  near  to  a 
suture,  and  the  subject  young,  the  said  suture  will 
often  separate  in  such  a manner  as  to  let  through  it  a 
loose,  painful,  ill-natured  fungus  ; at  which  time,  also, 
it  is  not  uncommon  for  the  patient’s  head  and  face  to 
be  attacked  with  an  erysipelas. 

In  those  cases  in  which  the  scalp  is  ver>'  little  in- 
jured by  the  bruise,  and  in  which  there  is  no  wound 
nor  any  immediate  alarming  symptoms  or  appearances, 
the  patient  feels  little  or  no  inconvenience,  and  seldom 
makes  any  complaint,  until  some  few  days  are  past. 
At  the  end  of  this  uncertain  time,  he  is  generally  at- 
tacked by  the  symptoms  already  recited ; these  are  not 
pressing  at  first,  but  they  soon  increase  to  such  a de- 
gree, as  to  baffle  all  our  art : from  whence  it  w'ill  ap- 
pear, that  when  this  is  the  case,  the  patient  frequently 
suffers  f rom  what  seems  at  first  to  indicate  his  safety,  and 
prevents  such  attempts  being  made,  and  such  care  from 
being  taken  of  him,  as  might  prove  preventive  of  mischief. 

But  if  the  integuments  are  so  injured  as  to  excite  or 
claim  our  early  regard,  very  useful  information  may 
iroin  thence  be  collected;  for  whether  the  scalp  be  con- 


j siderably  bruised,  or  whether  it  be  found  neccssar  to 
divide  it  for  the  discharge  of  extravasated  blood,  or  on 
account  of  worse  appearances  or  more  urgent  symj)- 
toms,  the  state  of  the  pericranium  may  be  thereby 
sooner  and  more  certainly  known : if  in  the  place  of  such 
bruise,  the  pericranium  be  found  spontaneously  de- 
tached from  the  skull,  having  a quantity  of  discoloured 
sanies  between  them  under  the  tumid  part,  in  the  man- 
ner already  mentioned,  it  may  be  regarded  as  a pretty 
certain  indication,  either  that  the  dura  mater  is  begin- 
ning to  separate  in  the  same  manner,  or  that,  if  some 
preventive  means  be  not  immediately  used,  it  will  soon 
suffer ; that  is,  it  will  inflame,  separate  from  the  skull, 
and  give  room  for  a collection  of  matter  between  them. 
And  with  regard  to  the  wound  itself,  whether  it  was 
made  at  the  time  of  the  accident,  or  afterward  artifi- 
cially, it  is  the  same  thing ; if  the  alteration  of  its  ap- 
l)earance  be  as  related,  if  the  edges  of  it  spontaneously 
quit  their  adhesion  to  the  bone,  and  the  febrile  symp- 
toms are  at  the  same  time  making  their  attack,  these 
circumstances  will  serve  to  convey  the  same  inform- 
ation, and  to  prove  the  same  thing. 

The  particular  effect  of  contusion  is  frequently  found 
to  attend  on  fissures,  and  undepressed  fractures  of  the 
cranium,  as  well  as  on  extravasations  of  fluid,  in  cases 
where  the  bone  is  entire ; and,  on  the  other  hand,  all 
these  do  often  happen  without  the  concurrence  of  this 
individual  mischief.  All  this  is  matter  of  accident ; but 
let  the  other  circumstances  be  what  they  may,  the 
spontaneous  separation  of  the  altered  pericranium,  in 
consequence  of  a severe  blow,  is  almost  always  fol- 
lowed by  a suppuration  between  the  cranium  and  dura 
mater ; a circumstance  extremely  well  wonh  attending 
to  in  fissures  and  undepressed  fractures  of  the  skull, 
because  it  is  from  this  circumstance  principally  that 
the  bad  symptoms  and  the  hazard  in  such  cases  arise. 

It  is  no  very  uncommon  thing  for  a smart  blow  on 
the  head  to  produce  some  immediate  bad  symptoms, 
w hich  after  a short  space  of  time  disappear  and  leave 
the  patient  pe»fectly  well.  A slight  pain  in  the  head, 
a little  acceleration  of  pulse,  a vertigo  and  sickness, 
sometimes  immediately  follow  such  accident,  but  do 
not  continue  many  hours,  especially  if  any  evacuation 
has  been  used.  These  are  not  improbably  owing  to 
a light  commotion  of  the  brain,  which  having  suffered 
no  material  injury  thereby,  soon  cease.  But  if,  after 
an  interval  of  some  time,  the  same  symptoms  are  re- 
newed; if  the  patient,  having  been  well,  becomes 
again  feverish  and  restless,  and  that  without  any  new 
cause ; if  he  complains  of  being  languid  and  uneasy, 
sleeps  disturbedly,  loses  his  appetite,  has  a hot  skin,  a 
hard,  quick  pulse,  and  a flushed,  heated  countenance ; 
and  neither  irregularity  of  diet  nor  accidental  cold  has 
been  productive  of  these ; the  mischief  is  most  certainly 
impending,  and  that  most  probably  under  the  skull. 

If  the  symptoms  of  pressure,  such  as  stupidity,  loss 
of  sense,  voluntary  motion,  &c.,  appear  some  few  days 
after  the  head  has  suffered  injury  from  external  mis 
chief,  they  dp  most  probably  imply  an  efl'usion  of  a 
fluid  somew’here;  this  effusion  may  be  in  the  sub- 
stance of  the  brain,  in  its  ventricles,  between  its  mem- 
branes, or  on  the  surface  of  the  dura  mater ; and  which 
of  these  is  the  real  situation  of  such  extravasation  is  a 
matter  of  great  uncertainty,  none  of  them  being  at- 
tended with  any  peculiar  mark  or  sig?i  that  can  be  de- 
pended upon  as  pointing  it  out  precisely ; but  the  in- 
flammation of  the  dura  mater,  and  the  formation  of 
matter  betw'een  it  and  the  skull,  in  consequence  of 
contusion,  is  generally  indicated  and  preceded  by  one 
which  Mr.  Pott  has  hardly  ever  known  to  fail ; a 
pvffy,  circumscribed,  indolent  tumoitr  of  the  scalp,  and 
a spontaneous  separation  of  the  pericranium  froni  tine 
skull  under  such  tumour. 

These  appearances,  therefore,  following  a smart 
blow  on  the  head,  and  attended  with  languor,  pain, 
restlessness,  w'atching,  quick  pulse,  headache,  and 
slight,  irregular  shivenngs,  do  almost  infallibly  indi- 
cate an  inflamed  dura  mater,  and  pus  either  forming  or 
formed  between  it  and  the  cranium.” 

By  detachment  of  the  pericranium  is  not  meant 
every  separation  of  it  from  the  bone  which  it  should 
cover.  It  may  be,  and  often  is,  cut,  torn,  or  scraped 
off,  without  any  such  consequence;  but  these  sepa- 
rations are  violent ; whereas  that  which  Mr.  Pott  means 
is  sj>ontaneous,  and  is  produced  by  the  de.struction  of 
those  vessels  by  which  it  was  connected  with  the 
skull,  and  by  which  the  communication  between  it  and 


HEAD.  465 


the  internal  parts  was  carried  on ; and  therefore  it  is 
to  be  observed,  that  it  is  not  the  mere  removal  of  that 
membrane  which  causes  the  bad  symptoms,  but  it  is 
the  inflammation  of  the  dura  mater ; of  which  inflam- 
mation this  spontaneous  secession  of  the  pericranium 
is  an  almost  certain  indication. 

Sometimes  the  scalp  is  so  wounded  at  the  time  of 
the  accident,  or  so  torn  away,  as  to  leave  the  bone  per- 
fectly bare ; and  yet  the  violence  has  not  been  such  as 
to  produce  the  evil  just  now  spoken  of.  In  this  case, 
if  the  pericranium  be  only  turned  back  along  with  the 
d.o.tached  portion  of  scalp,  there  may  be  probability  of 
its  reunion;  and  it  should  therefore  be  immediately 
made  clean  and  replaced,  for  the  purpose  of  such  expe- 
riment ; which,  if  it  succeeds,  will  save  time  and  pre- 
vent considerable  deformity.  Should  the  attempt  fail, 
it  can  only  be  in  consequence  of  the  detached  part 
sloughing.  Hence,  removing  it  with  a knife,  though 
allowed  by  Pott,  is  now  never  practised.  Frequently, 
when  the  scalp  does  not  adhere  at  once,  it  becomes  at- 
tached to  the  cranium  afterward  by  a granulating 
process.  When  the  detached  piece  sloughs,  the  worst 
that  can  happen  is  an  exfoliation  from  the  bare  skull. 

Sometimes  the  force  which  detaches  or  removes  the 
scalp  also  occasions  the  mischief  in  question ; but,  the 
integuments  being  wounded  or  removed,  we  cannot 
have  the  criterion  of  the  tumour  of  the  scalp  for  the  di- 
rection of  our  judgment.  Our  whole  attention  must  be 
directed  to  the  wound  and  general  symptoms.  The 
edges  of  the  former  will  digest  as  well,  and  look  as 
kindly  for  a few  days,  as  if  no  mischief  was. done  un- 
derneath. But  after  some  little  space  of  time,  when 
the  patient  begins  to  be  restless  and  hot,  and  to  com- 
plain of  pain  in  the  head,  these  edges  will  lose  their 
vermilion  hue,  and  become  pale  and  flabby.  Instead 
of  matter,  they  will  discharge  a thin  gleet,  and  the  pe- 
ricranium will  loosen  from  the  skull  to  some  distance 
from  the  said  edges.  Immediately  after  this,  all  the 
general  symptoms  are  increased  and  exasperated ; and 
as  the  inflammation  of  the  membrane  is  heightened  or 
extended,  they  become  daily  worse  and  worse,  until  a 
quantity  of  matter  is  formed  and  collected,  and  brings 
on  that  fatal  period,  which,  though  uncertain  as  to  date, 
very  seldom  fails  to  arrive. 

“ The  method  of  attempting  the  relief  of  this  kind  of 
injury  consists  in  two  points : vir,.  to  endeavour  to  pre- 
vent the  injlammation  of  the  dura  mater ; or,  that  being 
neglected  or  found  impracticable,  to  give  discharge  to 
the  fluid  collected  within  the  cranium,  in  consequence 
of  such  inflammation. 

Of  all  the  remedies  in  the  power  of  art,  for  inflam- 
mations of  membranous  parts,  there  is  none  equal  to 
phlebotomy.  To  this  truth  many  diseases  bear  testi- 
mony ; pleurisies,  ophthalmies,  strangulated  hernias, 
&e.;  and  if  any  thing  can  particularly  contribute  to 
the  prevention  of  the  ills  likely  to  follow  severe  con- 
tusions of  the  head,  it  is  this  kind  of  evacuation  ; but 
then  it  must  be  made  use  of  in  such  a manner  as  to  be- 
come truly  a preventive  ; that  is,  it  must  be  made  use 
of  immediately  and  freely.” 

Acceleration  or  hardness  of  pulse,  restlessness,  anx- 
iety, and  any  degree  of  fever,  after  a smart  blow  on  the 
head,  are  always  to  be  suspected  and  attended  to.  Im- 
mediate, plentiful,  and  repeated  evacuations  by  bleed- 
ing have  in  many  instances  removed  these  in  per- 
sons to  whom  Mr.  Pott  firmly  believes  very  terrible 
mischief  would  have  happened,  had  not  such  precau- 
tion been  used.  In  this,  as  well  as  some  other  parts 
of  practice,  we  neither  have  nor  can  have ' any  other 
method  of  judging,  than  by  comparing  together  cases 
apparently  similar.  Mr.  Pott  had  more  than  once  or 
twice  seen  that  increased  velocity  and  hardness  of 
puKse,  and  that  oppressive  languor,  which  most  fre- 
quently precede  mischief  under  the  bone,  removed  by 
free  and  rejieated  bloodletting;  and  had  often,  much 
too  often,  seen  cases  end  fatally,  whose  becinnings 
were  fully  as  slight,  but  in  which  such  evacuation  had 
been  either  neglected  or  not  complied  with.  This  ju- 
dicious writer,  “ would  by  no  means  be  thought  to  in- 
fer from  hence,  that  early  bleeding  will  always  prove 
a certain  preservative ; and  that  they  only  die  to 
whom  it  has  not  been  applied ; this,  like  all  other  hu- 
man means,  is  fallible;  and  perhajts  there  are  more 
cases  out  of  its  reach  than  within  it,  but  where  pre- 
ventive means  can  take  place,  thi.s  is  certainly  the  best 
and  the  most  frequently  su.rcessful. 

ITie  second  intention,  viz.  the  discharge  of  matter 

VoL.  I.— G g 


collected  under  the  cranium,  can  be  answered  only  by 
the  perforation  of  it. 

When  from  the  symptoms  and  appearances  already 
described,  there  is  just  reason  for  supposing  matter  to 
be  formed  under  the  skull,  the  operation  of  perforation 
cannot  be  performed  too  soon  : it  seldom  happens  that 
it  is  done  soon  enough.” 

In  short,  whenever  the  dura  mater,  after  the  head 
has  received  external  violence,  separates  or  is  detached 
spontaneously  from  the  bone  underneath  it,  and  such 
separation  is  attended  with  the  collection  of  a small 
quantity  of  thin  brown  ichor,  an  alteration  of  colour 
in  the  separated  pericranium,  unnatural  dryness  of  the 
bone,  chilliness,  horripilatio,  languor,  and  some  degree 
of  fever,  Mr.  Pott  considers  the  operation  indispensably 
necessary  to  save  the  patient’s  life. 

When  the  skull  has  been  once  perforated,  and  the 
dura  mater  thereby  laid  bare,  the  state  of  the  matter 
must  principally  determine  the  .surgeon’s  future  conduct. 
In  some  ca-ses,  one  opening  will  prove  sufficient  for  all 
necessary  purposes ; in  others,  several  may  be  necessar}^ 

Notwithstanding  the  operation  of  perforation  be  abso- 
lutely and  unavoidably  necessary,  as  Mr.  Pott  remarks, 
“ the  repetition  of  bloodletting  or  cooling  laxative  me- 
dicines, the  use  of  antiphlogistic  remedies,  and  a most 
strict  observance  of  a low  diet  and  regimen,  are  as  in- 
dispensably requisite  after  such  operation  as  before; 
the  perforation  sets  the  membrane  free  from  pressure, 
and  gives  vent  to  collected  matter,  but  nothing  more; 
the  inflamed  state  of  the  parts  under  the  skull,  and  all 
the  necessary  consequences  of  such  inflammation,  ca’J 
for  all  our  attention,  full  as  much  afterward  as  before; 
and  although  the  patient  must  have  perished  without 
the  use  of  the  trephine,  yet  the  m.erely  having  used  it 
will  not  preserve  him  without  every  other  caution  and 
cave.'’--{Pott.) 

In  relation  to  this  subject,  a remark  made  by  Sir  Ast- 
ley  Cooper  merits  notice  : when  pus  lies  between  the 
dura  n)ater  and  skull,  the  application  of  the  trephine, 
he  acknowledges,  is  a successful  practice ; but,  accord- 
ing to  his  experience,  this  situation  of  the  purulent 
matter  is  comparatively  rare,  as  it  generally  collects 
between  the  pia  mater  and  surface  of  the  brain,  frr 
which  case  an  operation  will  he  useless. — {Lectures, 
.?-c.  vol.  1,  p.  325.)  It  is  stated  by  Mr.  Brodie,  that  in 
ho.spital  practice,  suppuration  between  the  dura  mater 
and  the  bone,  in  consequence  of  fracture,  is  also  less 
common  at  the  present  period  than  when  Mr.  Pott 
wrote ; a change  which  he  refers  to  the  stricter  anti- 
phlogistic plan  adopted  by  modern  surgeons,  whether 
the  early  symptoms  be  or  be  not  of  a dangerous  de- 
scription.— (See  Med.  Chir.  Trans,  vol.  14,  p.  411.) 

I think  it  not  improper  to  recommend  again  the  prac- 
tice of  applying  cold  wet  cloths  to  the  head  for  the  pre- 
vention and  relief  of  inflammation  of  the  dura  mater; 
a plan  to  which,  as  already  explained,  Schmucker  as- 
cribed a good  deal  of  the  success  with  which  he  treated 
injuries  of  the  head.  It  is  favourably  mentioned  by  Dr. 
Hennen,  and  has  received  the  recommendation  of  an- 
other modern  writer,  whose  opinion  must  have  great 
weight : “ In  the  inflammation  which  succeeds  slowly 
to  injuries  of  the  head,  a species  of  inflammation  not 
more  insidious  in  its  approach  than  dangerous  in  its 
consequences,  cold  is  by  far  the  most  efficacious  re- 
medy that  has  yet  been  discovered.”— (See  Thomson's 
Lectures  on  Inflammation,  p.  181.) 

Both  tables  of  the  skull  sometimes  exfoliate  in  con- 
sequence of  external  violence.  The  dead  bone  must  be 
removed,  as  soon  as  loose ; and,  if  necessary,  the  scalp 
divided  for  the  purpose. 

3.  Fissures  and  Fractures  of  the  Cranium,  without 
Depression . 

Fractures  of  the  cranium  are  divisible  into  “ those  in 
which  the  broken  parts  keep  their  proper  level  or 
equality  of  surface  with  the  rest  of  the  skull,  and  those 
in  which  they  do  not ; or  in  other  words,  fractures 
without  depression  and  fractures  with. 

These  two  distinctions  are  all  which  are  really  ne- 
cessary to  be  made,  and  will  be  found  to  comprehend 
every  violent  division  of  the  parts  of  the  skull  (not 
made  by  a cutting  instrument),  from  the  finest  capil- 
lary fissure,  up  to  the  most  complicated  fracture.” — 
{Pott.)  In  most  instances,  the  fracture  takes  place  in 
the  upper  part  of  the  cranium ; and  it  is  also  correctly 
noticed  by  Mr.  Brodie,  that  fractures  of  its  basis  arc 
always  the  consequence  of  very  great  violence,  and  re- 


466 


MEAD. 


coveries  from  them  comparatively  rare. — {Med.  Chir. 
Trans,  vol.  14,  p.  328.)  Sometimes  the  fracture  does 
not  occur  at  the  point  to  which  the  violence  has  been 
directly  applied,  but  elsewhere,  as  the  effect  of  what 
the  French  term  a contre-coup.  Various  explanations 
of  the  fact  have  been  offered.  Mr.  Earle  has  never 
known  it  happen,  except  when  the  occiput  seemed  to 
have  been  forcibly  impelled  against  the  atlas.— {Brodie, 
in  Med.  Chir.  Trans,  vol.  14,  p.  329.)  An  ingenious  at- 
tempt to  account  for  the  circumstance  may  be  found  in 
the  writings  of  Mr.  C.  Bell ; though  certain  cases  on  re- 
cord will  not  conform  to  any  princii)les  yet  offered  in  ex- 
planation of  them.  The  disjunction  ol  the  sut  ures  is  much 
more  rare  than  fractures  of  the  cranium,  and  can  only 
happen  in  young  subject.s,  in  whom  the  sutures  are  not 
yet  consolidated.  They  are  accidents  implying  the  one- 
ration  of  great  violence,  and  in  this  point  of  view  may  be 
viewed  as  dangerous.--(See  Brodie,  in  Med.Chir.l'rans. 
vol.  14,  p.  332.) 

No  truth  in  surgery  is  now  better  understood  and 
established,  than  that  the  bad  symptoms  very  fre- 
quently accompanying  a broken  skull  are  not  produced 
by  the  breach  made  in  the  bone,  nor  indicate  such 
breach  to  have  been  made.  As  Sir  Astley  Cooper  re- 
marks, the  danger  of  fractures  of  the  skull  depends 
upon  their  being  united  with  concussion  or  extravasa- 
tion ; there  is  also  a remote  danger  from  inflammation. 
— {Lectures,  Ac.  p.  289.)  This  was  the  doctrine  so 
well  explained  by  Pott,  who  observes  “ the  sickness, 
giddiness,  vomiting,  and  loss  of  .sense  and  motion  can 
only  be  the  consequence  of  an  affection  of  the  brain,  as 
the  common  sensorium.  They  may  be  produced  by  its 
having  been  violently  shaken,  by  a derangement  of  its 
medullary  structure,  or  by  unnatural  pressure  made 
by  a fluid  extravasated  on  its  surface,  or  within  its 
ventricles  ; but  never  can  be  caused  by  the  mere  divi- 
sion of  the  bone  (considered  abstractedly) ; which  di- 
vision, in  a simple  fracture,  can  neither  press  on  nor 
derange  the  structure  of  the  parts  within  the  cranium. 

If  the  solution  of  continuity  in  the  bone  be  either 
produced  by  such  a,  degree  of  violence  as  hath  caused 
8 considerable  disturbance  in  the  medullary  parts  of 
ihe  brain,  or  has  disturbed  any  of  the  functions  of  the 
nerves  going  off  from  it ; or  has  occasioned  a breach  of 
any  vessel  or  vessels,  whether  •sanguine  or  lymphatic, 
and  that  hath  been  followed  by  an  extravasation  or 
lodgement  of  fluid  ; the  syrnihoms  necessarily  conse- 
quent upon  such  derangement,  or  such  pressure,  will 
follow:  but  they  do  not  follow  because  the  bone  is 
broken  ; their  causes  are  superadded  to  the  fracture,  and 
although  produced  by  the  same  external  violence,  are 
yet  perfectly  and  absolutely  independent  of  it ; so  much 
so  that  they  are  freijuently  found  where  no  fracture  is. 

The  operation  of  the  trepan  is  frequently  performed 
in  the  case  of  simple  fractures,  and  that  very  judi- 
ciously and  properly  ; but  it  is  not  performed  because 
the  bone  is  broken  or  cracked.  A mere  fracture  or 
fissure  of  the  skull  can  never  require  perforation,  or 
that  the  dura  mater  under  it  be  laid  bare  ; the  reason 
for  doing  this  springs  from  other  causes  than  the  frac- 
ture, and  those  really  independent  of  it : they  spring 
from  the  nature  of  the  mischief  which  the  parts  within 
the  cranium  have  sustained,  and  not  from  the  acciden- 
tal division  of  the  bone.  From  these  arise  the  threat- 
ening symptoms ; from  these  all  the  hazard  ; and  from 
these  the  necessity  and  vindication  of  performing  the 
operation  of  the  trepan. 

If  a simple  fracture  of  the  cranium  was  unattended 
in  present  with  any  of  the  before-mentioned  symptoms, 
and  there  was  no  reason  for  apprehending  any  other 
'Wil  in  future,  that  is,  if  the  solution  of  continuity  in 
the  bone  was  the  whole  disease,  it  could  not  possibly 
indicate  any  other  curative  intention  but  the  general 
one  in  all  fractures,  viz.  the  union  of  the  divided  parts." 
Even  fractures  of  the  basis  of  the  skull,  which  are 
most  frequently  fatal,  prove  so,  not  because  this  part 
of  the  cranium  is  broken  (the  fracture  itself  being  here 
not  more  dangerous  than  elsewhere),  but  “ because  it 
is  almost  invariably  complicated  with  extensive  injury 
of  other  and  more  important  parts." — {Brodie,  in  Med. 
Chir.  Trans,  vol.  14,  p.  328.)  The  post  mortem  ex- 
aminations which  I have  attended,  lead  me  to  believe  that 
most  of  these  cases  are  complicated  with  extravasation. 

I could  relate  numerous  examj)lcs  to  the  point,  if  it 
were  any  longer  necessary,  in  the  present  state  of  sur- 
gical knowledge,  to  cite  facts  in  proof  of  the  important 
truth,  that  the  mere  undepressed  fissure  or  fracture  of 


the  skull  itself  cannot  be  the  source  of  the  immediate 
bad  symptoms,  but  that  in  these  cases  the  whole  of  the 
sudden  peril  arises  from  the  manner  in  which  the  brain 
and  its  membranes  have  been  hurt  by  the  same  vio- 
lence which  caused  the  injury  of  the  bone.  Professor 
Thomson  had  opportunities  of  witnessing  in  the  Nfether- 
lands  several  instances,  which  can  leave  no  doubt  upon 
this  subject.  “ In  some  of  the  wounds  (says  he)  in 
which  the  head  had  been  struck  obliquely  by  the  sabre, 
portions  of  the  cranium  had  been  removed,  without  the 
brain  appearing  to  have  sustained  much  injury.  In  ono 
case  of  this  kind,  where  a considerable  portion  of  the 
upper  part  of  the  occipital  bone,  along  with  the  dura 
mater,  had  been  removed,  a tendency  to  protrusion  of 
the  brain  took  place  during  an  attack  of  inflammation  j 
a slight  degree  of  stupor  with  loss  of  memory  occurred; 
but  on  the  inflammatory  state  having  been  subdued, 
the  brain  sunk  to  its  former  level,  the  stupor  went  off, 
and  the  memory  returned  and  in  another  remarka- 
ble sabre-cut,  more  than  an  inch  in  breadth  of  the  left 
lobe  of  the  cerebellum  was  exposed,  and  was  seen  pul- 
sating for  a period  of  eight  weeks,  yet  the  injury  was 
unaccompanied  with  any  particular  constitutional 
symptoms. — (See  Obs.  made  in  the  Military  Hospitals 
of  Belgium,  p.  50,  51.) 

In  many  cases  of  simple  undepressed  fractures  of  the 
cranium,  it  is  true  that  trephining  is  necessary ; but 
the  reasons  for  the  operation  in  these  instances  are,  first, 
the  immediate  relief  of  present  symptoms,  arising  from 
the  pressure  of  extravasated  fluid  ; and,  secondly,  the 
discharge  of  matter,  formed  between  the  skull  and  dura 
mater,  in  consequence  of  inflammation.  The  operation 
of  trephining  was  also  recommended  by  Pott,  as  a pre- 
ventive of  ill  consequences  ; a practice,  however,  which 
is  now  never  adopted  ; and  many  w riters  of  the  highest 
reputation,  especially  Desault,  Dease,  Mr.  John  Bell,  and 
Mr.  Abernethy,  have  strongly  remonstrated  against  it. 

The  latter  remarks,  “ In  the  accounts  which  we 
have  of  the  former  practice  in  France,  it  is  related,  that 
surgeons  made  numerous  perforations  along  the  whole 
track  of  a fracture  of  the  cranium  ; and,  as  far  as  1 am 
able  to  judge,  without  any  clear  design.  Mr.  Pott  also 
advises  such  an  operation,  with  a'  view  to  prevent  the 
inflammation  and  suppuration  of  the  dura  mater,  which 
he  so  much  apprehended.  But  many  cases  have  oc- 
curred of  late,  where,  even  in  fractures  with  depres- 
sion, the  patients  have  done  well  without  an  operation,” 

Mr.  Abernethy  next  relates  several  cases  of  fracture 
of  the  cranium  with  depression,  which  terminated  fa- 
vourably, although  no  operation  was  performed.  This 
judicious  surgeon  thinks  that  these  cases,  as  well  as  a 
great  many  others  on  record,  prove  that  at  all  events  a 
slight  degree  of  pressure  may  not  derange  the  functions 
of  the  brain,  for  a limited  time  after  its  application,  and 
in  this  circumstance  probably  never;  for  all  those  pa- 
tients whom  he  had  an  opportunity  of  knowing  for  any 
length  of  time  after  the  accident,  continued  as  well  as 
if  nothing  of  the  kind  had  happened  to  them.  In  Mr. 
Hill’s  Cases  in  Surgery,  two  instances  of  this  sort  are 
related,  and  Mr.  Hill  knew  both  the  patients  for  many 
years  afterward  : yet  no  inconvenience  arose.  Indeed, 
it  is  not  easy  to  conceive  that  the  pressure,  which 
caused  no  ill  effects  at  a time  when  the  contents  of  the 
cranium  filled  its  cavity  completely,  should  afterward 
prove  injurious,  when  they  have  adapted  themselves  to 
its  altered  size  and  shape.  Severe  illness,  it  is  true,  of- 
ten intervenes  between  the  receipt  of  the  injury,  and  the 
time  of  its  recovery ; and  many  surgeons  might  be  in- 
clined to  attribute  this  to  pressure  ; but  it  eijually  oc- 
curs when  the  depressed  portion  is  elevated.  If  a sur- 
geon, prepossessed  with  the  opinion  that  elevation  of 
the  bone  is  necessary  in  every  instance  of  depressed 
cranium,  should  have  acted  upon  this  opinion  in  seve- 
ral of  the  cases  which  Mr.  Abernethy  has  related,  and 
afterward  have  employed  proper  evacuations,  his  pa- 
tients would  probably  have  had  no  bad  symptoms,  and 
he  would  naturally  have  attributed  their  well-doing  to 
the  mode  of  treatment  which  he  had  pursued  : yet  these 
cases  did  equally  well  without  an  operation. — (See  Aber- 
nethy's  Surgical  Works,  vol.2,p.  A,  S,c.%vo.  bond.  1611.) 

Depressed  fractures  of  the  skull  not  being  our  imme- 
diate consideration,  we  need  not  exi)!itiate  upon  them  ; 
but  it  seemed  right  to  make  the  preceding  remarks,  in 
order  to  show  how  unnecessary  it  must  be  to  trephine 
a patient,  merely  because  there  is  a fracture  in  the  cra- 
nium, and  with  a view  o{ pre^  entinshad.  consctiuences, 
Eveji  when  the  fracture  is  depressed,  it  is  not  iieces- 


HEAD. 


467 


sary,  unless  there  are  evident  signs  that  the  degree  of 
pressure  thus  produced  on  the  brain  is  the  cause  of 
existing  bad  symptoms. 

The  inflammation  and  suppuration  of  the  parts  be- 
neath the  skull,  which  Mr;  Pott  v/ished  so  much  to 
prevent  by  trephining  early,  do  not  arise  from  the  oc- 
currence of  a breach  in  the  cranium,  but  are  the  conse- 
quences of  the  same  violence  which  was  the  occasion 
of  the  fracture.  Hence  it  is  obvious,  that  removing  a 
portion  of  the  bone  cannot  in  the  least  prevent  the  in- 
flammation and  suppuration,  which  must  result  from 
the  external  violence  which  was  first  applied  to  the 
head ; but,  on  the  contrary,  such  a removal,  being  an 
additional  violence,  must  have  a tendency  to  increase 
the  inevitable  inflammatory  mischief. 

From  what  has  been  said,  it  is  not  to  be  inferred,  how- 
ever, that  trephining  is  never  proper,  when  there  is  a 
simple  undepressed  fracture  of  the  skull.  Such  injury 
may  be  joined  with  an  extravasation  of  blood  on  the 
dura  mater ; or  it  may  be  followed  by  the  formation  of 
matter  between  this  membrane  and  the  cranium ; in 
both  which  circumstances,  the  operation  is  essential  to 
the  preservation  of  the  patient,  immediately,  but  not 
before  the  symptoms  indicative  of  the  existence  of  dan- 
gerous pressure  on  the  brain  begin  to  show  themselves. 
— (See  Trephine.) 

A fracture  of  the  skull,  unattended  with  urgent  symp- 
toms, and  not  brought  into  the  surgeon’s  view  by  any 
accidental  wound  of  the  integuments,  often  remains  for 
ever  undiscovered ; and  as  no  benefit  could  arise  from 
laying  it  bare  by  an  incision,  such  practice  should  never 
be  adoi)ted.  The  surgeon  ought  only  to  be  officious  in 
this  way,  wffien  he  can  accomplish  by  it  some  better 
object  than  the  mere  gratification  of  his  own  curiosity. 
And  as  we  shall  find  from  the  perusal  of  this  article, 
and  the  one  entitled  Trephine,  that  in  these  cases,  the 
removal  of  pressure  otf  the  surface  of  the  brain  is  the 
onfy  possible  reason  for  ever  perforating  the  cranium 
with  this  instrument ; and  as  dividing  the  scalp  is  only 
a useful  measure  when  it  is  preparatory  to  such  ope- 
ration ; neither  the  one  nor  the  other  should  ever  be 
practised,  unless  there  exist  unequivocal  symptoms 
that  there  is  a dangerous  degree  of  pressure  operating 
on  the  brain,  and  caused  either  by  matter,  extravasated 
blood,  or  a depressed  portion  of  the  skull.  If  any  ex- 
ceptions can  be  made  to  this  observation,  these  are 
cases  in  which  it  is  advisable  to  remove  loose  splinters 
and  fragments  of  bone,  or  balls,  plainly  felt  under  the 
scalp. 

The  true  mode  of  preventing  the  bad  effects,  fre- 
quently following,  but  not  arising  from,  simple  fractures 
of  the  skull,  is  not  to  trephine,  but  to  put  in  practice  all 
kinds  of  antiphlogistic  means.  For  this  purpose,  let 
the  patient  be  repeatedly  and  copiously  bled,  both  from 
the  arm  and  temporal  arteries ; let  him  be  properly 
purged  ; give  him  antimonials  ; keep  him  on  the  lowest 
diet ; let  him  remain  in  the  most  quiet  situation  possible ; 
and  if,  notwithstanding  such  steps,  the  symptoms  of 
inflammation  of  the  brain  continue  to  increase,  let  a 
large  blister  be  applied  to  the  scalp.  If  the  scalp  be 
wounded,  it  is  to  be  healed  as  speedily  as  possible. 
Bloodletting  and  purgatives  (as  Sir  Astley  Cooper  re- 
marks) wilT  sometimes  remove  the  symptoms  of  con- 
cussion and  extravasation,  when  they  accompany  the 
fracture,  and  a few  hours  will  often  show  that  the  tre- 
phine, which  was  at  first  thought  indispensable,  is  un- 
necessary. Irreparable  mischief  might  arise  from  your 
making  an  incision,  and  converting  a simple  into  a 
compound  fracture.  “ If  you  act  prudently  (he  adds), 
you  will  try  bleeding  and  purgatives  before  you  operate ; 
and  the  depletion  will  prove  of  the  greatest  possible 
advantagein  preventinginflammation.”— (Lecfitrci',  vol. 
\,p.  299.)  These  are  the  cases,  al.so, in  which  the  topical 
application  of  cold  water  to  the  shaved  and  naked  head, 
by  means  of  cloths  kept  constantly  wet,  is  an  eligible, 
though  in  this  country  a much-neglected  practice.  Nume- 
rous instances,  however,  in  favour  of  the  method  are  re- 
corded by  the  experienced  Schmucker  {Chir.  Wahrneh- 
mungen,b.  1,  Berlin,  1774),  and  the  trials  which  I have 
seen  made  of  it,  give  me  a high  opinion  of  its  superior 
efficacy.  When,  in  spite  of  all  these  measures,  matter 
forms  under  the  cranium,  attended  with  symptoms  of 
pressure,  a puffy  tumour  of  the  injured  part  of  the 
scalp,  or  those  changes  of  the  wound,  if  there  is  one, 
which  Mr.  Pott  has  so  excellently  described  ; not  a mo- 
ment should  be  lost  in  delaying  to  perforate  the  bone 
with  the  trephine,  and  giving  vent  to  the  confined  matter. 

G g2 


Experience  teaches  that  fractures  at  the  basis  of  the 
skull  are  extremely  dangerous,  because  they  are  gene- 
rally attended  with  extravasation,  or  followed  by  in- 
flammation of  the  brain,  in  consequence  of  the  violence 
of  the  injury.  According  to  Sir  Astley  Cooper,  they  are 
produced  by  falls  from  a great  height  on  the  summit  of 
the  head.  The  whole  weight  of  the  body  is  received 
on  the  foramen  magnUm,  and  cuneiform  process  of  the 
os  occipitis,  and,  in  many  instances,  the  consequence  is 
a transverse  fracture  through  the  foramen  magnum,  the 
cuneiform  process,  and  part  of  the  temporal  bone.  A 
discharge  of  blood  into  each  meatus  auditorius  accom- 
panies the  accident.  It  is  supposed,  also,  that  the  deaf- 
ness, which  sometimes  remains  during  life,  in  rare  in- 
stances of  recovery,  is  the  result  of  this  kind  of  injury. 
-^{Lectures,  &-c.  vol.  l,p.  289.) 

A fracture  within  the  orbit  is  sometimes  occasioned 
by  the  forcible  introduction  of  a stick,  weapon,  or 
pointed  instrument,  and  is  generally  a fatal  case,  from 
the  pressure  and  irritation  of  the  depressed  splinters 
of  bone,  and  the  simultaneous  wound  of  the  brain. 
The  symptoms  in  the  beginning,  however,  are  fre- 
quently mild  and  deceitful,  and  it  is  not  till  inflamma- 
tion and  suppuration  ensue,  that  the  patient’s  condition 
is  always  such  as  to  create  immediate  alarm.  A case, 
exemplifying  this  fact,  is  reiwrted  by  Sir  A.  Cooper. 
— (FoZ.  cit.  p.  295.)  The  same  eminent  surgeon  men- 
tions the  occasional  production  of  a circular  fracture  of 
the  entire  cranium,  by  a blow  on  the  vertex ; also  the 
emphysema  of  the  forehead,  or  the  escape  of  the  air,  if 
there  be  a wound,  caused  when  the  nose  is  blown,  in 
the  case  of  a fracture  extending  into  the  frontal  sinuses ; 
the  complete  detachment,  sometimes  met  with,  of  the 
fragments,  instead  of  their  depression.  His  observa- 
tions confirm  the  fact,  that  fractures  of  the  skull,  if  un- 
accompanied with  concussion  or  compression,  become 
united  like  those  of  other  bones  ; but,  he  adds,  that  it  is 
more  slowly,  and  that  where  the  interspace  is  wide,  it 
will  not  be  filled  up  with  bony  matter.— (P.  297, 298.) 

4.  Fractures  of  the  Cranium  ivith  Depression. 

In  simple  fractures  of  the  skull,  or  those  in  which 
the  parts  of  the  broken  bone  are  not  depressed  from 
their  situation,  Mr.  Pott  remarks,  that  “ the  chirurgical 
intention  and  requisite  treatment  are  the  same  in  each, 
viz.  to  procure  a discharge  for  any  fluid  which  may  be 
extravasated  in  present  {provided  the  pressure  of  such 
extravasation  produces  urgent  symptoms,  a condition 
which  should  here  be  added),  and  to  guard  against  the 
formation  or  confinement  of  matter.”  The  prevention 
of  suppuration  will,  as  we  have  already  remarked,  be 
best  accomplished,  not  by  perforating  the  cranium,  as 
Mr.  Pott  advised,  but  by  copious  bleeding,  evacuations, 
cold  washes  to  the  head,  blisters,  and  a rigorous  an- 
tiphlogistic regimen.  How'ever,  the  confinement  of 
matter,  producing  sjanptoms  of  pressure  on  the  brain, 
certainly  indicates  the  immediate  use  of  the  trephine. 

“ But  (says  the  author)  in  fractures  attended  with 
depre.ssion  there  are  other  intentions.  In  these  the 
depressed  parts  are  to  be  elevated,  and  such  as  are  so 
separated  as  to  be  incapable  of  reunion,  or  of  being 
brought  to  lie  properly,  and  without  pressing  on  the 
brain,  are  to  be  totally  removed.  These  circumstances 
are  jieculiar  to  a depressed  fracture ; but  although  they 
are  peculiar,  they  must  not  be  considered  as  sole,  but 
as  additional  to  those  which  have  been  mentioned  at 
large  under  the  head  of  simple  fracture  ; commotion, 
extravasation,  inflammation,  suppuration,  and  every  ill 
which  can  attend  on  or  be  found  in  the  latter,  are  to  be 
met  with  in  the  former,  and  will  require  the  same 
method  of  treatment.”  That  loose  splintered  pieces  of 
the  cranium,  when  quite  detached,  and  already  in  view', 
in  consequence  of  the  scalp  being  wounded,  ought  to  be 
taken  away,  no  one  will  be  inclined  to  question.  That 
they  ought  also  to  be  exposed  by  an  incision,  even  when 
the  scalp  is  unwounded,  and  then  taken  away  whenever 
they  cause  symptoms  of  irritation  or  pre.ssure,  I be- 
lieve will  be  universally  allowed.  But  the  reader  will 
already  understand,  from  what  has  been  said  in  the 
preceding  section,  that  several  excellent  surgeons  do 
not  coincide  with  Pott  in  believing  that  every  depressed 
fracture  of  the  skull  necessarily  demands  the  applica- 
tion of  the  trephine. 

“ There  certainly  are  (says  Mr.  Abernethy)  degrees 
of  this  injury,  which  it  would  be  highly  imprudent  to 
treat  in  this  manner.  Whenever  the  patient  retains  his 
senses  perfectly,  I should  think  it  improper  to  trephine 


463 


HEAD. 


him,  unless  svmptoms  arose  that  indicated  the  necessity 
of  it.”— (P.  21.) 

It  is  extraordinary  and  unaccountable,  but  it  is  not 
less  true,  that  no  calculation  of  the  bad  etfects  Qan  be 
made  by  the  degree  in  which  a part  of  the  skull  is  de- 
pressed. This  is  a fact  which  has  been  long  known. 
It  has  also  been  particularly  adverted  to  by  an  eminent 
modern  writer.  “Various  instances  also  presented 
themselves,  in  which,  though  a considerable  degree  of 
compression  must  have  been  occasioned,  sometimes  by 
the  depression  of  both  tables,  and  at  other  times  by  the 
depression  of  the  inner  table  only  of  the  skull,  yet  neither 
stupor,  paralysis,  nor  loss  of  memory  was  produced. 
In  one  of  these  cases  the  middle  of  the  right  parietal 
bone  was  fractured,  and  considerably  depressed  by  a 
ball,  which  was  extracted  on  the  2flth  day.  In  this  case, 
neither  stupor  nor  paraly.sis  appeared.  In  another,  a 
musket-ball  had  struck  the  right  parietal  bone,  fractured 
it,  and  was  flattened  and  lodged  between  the  tables  of 
the  skull.  The  inner  table  was  much  depressed,  yet 
no  bad  symptoms  supervened.” — (See  Thmison's  Ob- 
servations made  in  the  Military  Hospitals  in  Belgium, 
p.  59,  60.)  The  same  author  also  saw  a singular  case, 
in  which  a ball,  entering  behind  the  right  temple,  and 
passing  backwards  and  downwards,  had  fractured  the 
bones  in  its  passage,  and  lodged  in  the  surface  of  the 
brain,  over  the  tentorium,  froni  which  place  it  was  ex- 
tracted on  the  seventeenth  day  after  the  injury.  No 
bad  symptom  had  manifested  itself  previously  to  the 
operation,  and  the  man  recovered,  under  the  strictest 
antiphlogistic  regimen,  with  little  or  no  constitutional 
derangement.  Dr.  Hennen  has  recorded  two  cases, 
fully  proving  the  correctness  of  Mr.  Abernethy’s  opi- 
nions about  the  impropriety  of  using  the  trephine  in 
cases  of  depression  unattended  with  urgent  symptoms : 
in  one  of  these  instances,  the  upper  and  pasterior  angle 
of  the  parietal,  which  had  been  struck  by  a musket- 
ball,  was  depressed  exactly  an  inch  and  a quarter  from 
the  surface  of  the  scal.p,  yet  no  bad  symptcrnis foliotoed, 
and  with  the  aid  of  bleeding  and  other  antiphlogistic 
remedies,  the  soldier  recovered  perfectly  in  a few  weeks. 
“ In  a similar  case,  where  the  man  survived  thirteen 
years,  with  no  other  inconvenience  than  occasional  de- 
termination of  blood  to  the  head  on  hard  drinking,  a 
fnnnel-like  depression  to  the  depth  of  an  inch  and  a 
half  was  formed  in  the  vertex.” — (See  Henneids  Mili- 
tary Surgery,  p.  287,  ed.  2.) 

If  then  the  violence  of  the  symptoms  is  not  always 
in  proportion  to  the  compression,  but  is  sometimes  con- 
siderable when  the  pressure  is  slight,  every  surgeon 
cannot  be  loo  fully  impressed  with  the  following  truth, 
that  existing  symptoms  of  dangerous  pressure  on  the 
brain,  which  symptoms  will  be  presently  related,  can 
alone  form  a true  reason  for  perforating  the  cranium. 

Although  the  doctrines  of  Sir  Astley  Cooper,  gene- 
rally speaking,  coincide  very  much  with  the  preceding 
maxim,  which  I regard  as  a very  important  one  ; there 
is  an  exception  to  it  in  his  advice,  in  relation  to  com- 
pound fractures  of  the  skull,  as  will  be  understood  from 
the  Ibllowing  passage.  “ The  old  practice  used  to  be, 
the  moment  an  injury  of  the  brain  was  suspected,  and 
the  least  depression  of  the  bone  appeared,  to  make  an 
incision  into  the  scalp.  This  is  putting  the  jiatient  to 
considerable  hazard ; for  the  simple  fracture  would  by 
the  incision  be  rendered  compound.  In  simple  fracture, 
then,  when  it  is  aitended  with  symptoms  of  injury  of 
th^  brain,  deplete  before  you  trephine  ; and  when  it  is 
unattended  with  such  s3'mptoms,  deplete  merely,  and 
do  not  divide  the  scalp,  <fec.  If  the  fracture  be  com- 
pound, the  treatment  must  be  very  different ; because  a 
compound  fracture  is  very  generally  followed  by  inflam- 
mation of  the  brain  ; and  it  will  be  of  little  use  to  tre- 
phine, when  inflammation  is  once  produced.  If  the 
inflammation  come  on,  the  patient  will  generally  die, 
whether  you  trephine  or  not,”  and  it  is  added,  that  the 
operation  will  even  be  likely  to  increase  the  inflamma- 
tion, which  has  been  excited  by  a depressed  portion  of 
the  skull.  “ The  rule  (saj's  Sir  Astley)  which  I always 
follow,  is  this;  when  I am  called  to  a compound  frac- 
ture with  depression,  which  is  exposed  to  view,  whe- 
ther symptoms  of  injured  brain  exist  or  not,  I generally 
use  an  elevator,  and  very  rarely  the  trephine.  1 put  the 
elevator  under  the  bone,  raise  it,  and  if  it  has  been  com- 
minuted, remove  the  small  portions  of  bone.”— <Lec- 
tures,  Ac.  vol.  1,  p.  3U4.  306.)  Of  the  propriety  of 
using  the  elevator  in  such  cases,  and  also  of  taking 
away  loos?  fragments,  there  rann-.r  be  a doubt ; but 


many  surgeons  object  (and  I confess  mvself  one  of  lh« 
number)  to  saw'  out  a portion  of  the  skull  while  the 
patient  is  free  from  urgent  symptoms.  I believe,  also, 
that  the  inflammation,  when  it  does  arise,  is  mostly  the 
effect  of  the  violence  itself,  not  of  the  depression  of  the 
bone,  and,  therefore,  more  likely  to  be  increased  than 
prevented  by  the  application  of  the  trephine.  I think 
a better  reason  for  elevating  the  bone,  when  it  is  ex- 
posed, and  there  are  no  bad  symptoms,  is  the  fact  that 
many  patients,  after  their  recovery  from  the  imminent 
danger  of  the  accident,  become  subject,  whenever  the 
circulation  is  hurried,  to  insanity,  epilepsy,  <fcc.  Yet, 
here  it  is  to  be  considered,  that  it  may  be  quite  time 
enough  to  trephine,  when  such  ills  follow  the  continu- 
ance of  the  depression,  and  that,  perhaps,  the  operation 
w’ould  then  be  in  itself  less  dangerous,  inasmuch  as  the 
tendency  to  inflammation,  arising  from  the  first  vio- 
lence, must  now  have  subsided. 

In  children  a portion  of  the  skull  is  sometimes  de- 
pressed or  indented  by  a blow,  but  in  a few’  days  regains 
its  natural  level  without  the  aid  of  the  surgeon.  In 
such  examples,  it  is  conceived  by  Mr.  Brodie,  that  the 
earthy  part  of  the  bone  gives  way,  while  the  animal 
part  remains  entire,  so  that  there  is  not  an  actual  solu- 
tion of  continuity,  and  he  supposes  that  the  restoration 
of  the  bone  to  its  proper  level  is  brought  about  by  the 
constant  pulsations  of  the  brain  against  its  inner  sur- 
face.— (See  Med.  Chir.  Trans,  vol.  14,  p.  332.) 

Sometimes  a considerable  depression  of  the  bone 
arises  from  the  external  table  being  driven  into  the  di- 
ploe,  w’hile  the  inner  table  is  entire.  To  trephine,  there- 
fore, merely  because  there  is  a depression  of  the  bone, 
would  be  completely  erroneous,  and  the  only  safe  prin- 
ciple is  that  which  I have  just  now  specified.  The  de- 
pression of  the  outer  table  in  the  foregoing  manner  1 
have  never  seen  myself ; Sir  Astley  Cooper,  however, 
mentions  it  as  a frequent  occurrence ; but  that  it  is 
confined  to  persons  of  middle  age,  as  in  very  young 
and  very  old  persons  the  skull  is  thin  and  without  di- 
p\oe.— {Lectures,  vol.  ] , p.  302.)  Another  sort  of  de- 
pression, I believe,  is  more  frequent ; at  least,  I have 
seen  several  examples  of  the  case ; it  consists  in  a 
fracture  and- depression  of  the  internal  table,  while  the 
external  one  continues  unbroken.  A case  of  this  kind, 
attended  with  urgent  symptoms  of  compression,  I tre- 
phined at  Brussels ; a large  .splinter  of  the  inner  table 
was  driven  more  than  an  inch  into  the  brain,  and  on  its 
extraction  the  patient’s  senses  and  power  of  voluntary 
motion  instantly  returned.  Part  of  the  skull  to  which 
the  trephine  w’as  applied,  of  course,  did  not  indicate  ex- 
ternally any  depression,  and  it  w'as  selected  because 
the  appearance  of  the  scalp  show’ed,  that  there  the  ex- 
ternal violence  had  operated.  I rather  expected  to  find 
extravasated  blood,  than  a depression  of  the  inner  table 
of  the  skull.— (See  also  Saucerotte,  in  M&m.  pour  It 
Prix  de  VAcad.  de  Chir.  t.  4,  ed.  1819,  p.  322.  HennaVs 
Military  Surgery,  p.  323,  ed.  2 ; and  B.  C.  Brodie,  in 
Med.  Chir.  TVa7i.s.  vol.  14,  p.  331.) 

In  militaiy  surgery’  particular  cases  present  them- 
selves, w’hich  scarcely,  admit  of  being  comprehended 
within  the  tenor  of  any  general  rules  and  principles. 
Thus,  it  sometimes  happens,  that  a ball  breaks  the  os 
frontis,  and  the  whole  or  a part  of  it  lodges  in  the 
frontal  sinus,  with  or  without  fracture  of  the  inner 
boundary  of  this  cavity.  In  cases  of  this  description, 
Baron  Larrey  recommends  exposing  the  course  of  the 
fracture  by  a free  incision,  and  the  use  of  the  trephine 
for  the  removal  of  the  extraneous  body.  When  the  in- 
ner side  of  the  sinus  was  found  broken  and  depressed, 
he  next  perforated  that  part  of  the  cavity  with  a small 
conical  trephine,  took  away  such  pieces  of  bone  as  re- 
quired removal,  and  let  out  any  extravasated  blood. 
Sometimes,  however,  the  front  of  the  sinus  i.s  so  .splin- 
tered, that  the  fragments,  when  taken  away  w ith  the 
forceps,  leave  the  cavity  sutficiently  opened,  not  only 
for  the  extraction  of  the  ball,  but  for  the  application  of 
the  trephine  to  the  ins'de  of  the  sinus  as  we  find  cx- 
empUfied  in  one  of  the  two  cases  of  this  nature  which 
Larrey  met  with  in  the  Egyptian  campaign. — {Mem  de 
Chir.  Militairc,  t.  2,  p.  1,18.)  After  the  battle  of  Wi- 
tepsk,  in  1812,  he  was  called  to  two  Russian  soldiers, 
whose  cases  were  remarkable ; one  of  them  had  been 
struck  above  the  right  eyebrow  with  a grape-.shot, 
which,  after  breaking  and  penetrating  the  frontal  bone, 
entered  the  cavity  of  the  cranium,  so  as  to  lodge  ujion 
the  anterior  right  lobe  of  the  brain,  and  the  orb  tar  pro 
cess  an.d  in’emal  crista  of  the  os  frotitjs.  No.v.  ith- 


HEAD. 


469 


standing  the  large  size  of  the  ball,  little  of  it  could  be 
seen  externally,  and  the  aperture  through  which  it  had 
passed  was  not  more  than  three  or  four  lines  broad ; 
every  attempt  to  extract  it,  therefore,  was  in  vain. 
The  patient  exiierienced  a painful  sense  of  oppression 
and  weight  in  the  head,  and,  whenever  he  inclined  it 
backwards,  was  seized  with  syncope.  He  kept  him- 
self constantly  in  a sitting  posture  with  his  head  on 
his  knees.  Larrey  adds,  that  every  symptom  of  com- 
pression of  the  brain  also  prevailed,  though  this  ac- 
count is  rather  dithcult  to  comprehend,  considering  that 
the  patient  could  sit  up,  and  choose  his  posture.  As 
for  any  description  given  by  himself  of  his  sufferings, 
that  is  another  circumstance  on  which  I should  not  be 
inclined  to  dwell,  because  in  all  probability  the  baron 
was  not  able  to  converse  in  the  Russian  language,  and 
the  inferences  respecting  the  man’s  feelings  were  made 
in  some  other  way.  But  whatever  might  be  the  real 
state  of  the  symptoms  (and  m a case  of  this  kind  a 
correct  account  of  them  would  have  been  interesting), 
the  ball  wa.«  plainly  ascertained,  by  means  of  a probe, 
to  be  of  iron,  and  of  much  larger  diameter  than  the 
opening  through  which  it  had  entered  ; and  that  for  the 
purpose  of  extracting  it  the  application  of  the  trepan 
was  urgently  necessary.  The  fracture  was  fairly 
brought  into  view  by  suitable  incisions ; three  perfora- 
tions were  made  with  a small  trephine  at  its  upper 
part,  and  after  the  removal  of  the  angles  of  the  bone 
between  these  perforations,  the  ball,  which  weighed 
seven  French  ounces,  was  readily  extracted  with  the 
aid  of  a strong  pair  of  forceps  and  an  elevator.  A 
considerable  quantity  of  coagulated  blood  was  also  re- 
moved, under  which  the  brain  was  found  with  a de- 
pression of  three  or  four  lines  deep.  As  soon  as  some 
splinters  of  the  bone  had  been  taken  away,  the  part 
was  dressed  with  a bit  of  fine  linen  dipped  in  warm 
wine,  sweetened  with  sugar,  over  which  were  placed 
charpie,  several  compresses,  and  a bandage.  With  re- 
spect to  the  application  of  warm  wine  and  other  sti- 
mulants to  the  surface  of  the  brain,  in  wounds  exposing 
or  interesting  that  organ,  it  seems  to  be  an  invariable 
practice  with  Larrey,  as  well  as  Schmucker,  and  the 
older  surgeons.  On  what  principle  the  custom  is  still 
kept  up,  and  whether  it  is  truly  right  and  useful,  are 
questions  which  may  be  rationally  put.  In  whatever 
way  experience  may  hereafter  decide  these  matters, 
suffice  it  to  add,  that  the  patient  was  relieved  by  the 
treatment,  and  fell  into  a quiet  sleep  for  two  hours ; 
but  in  the  evening  he  became  feverish,  and  the  wound 
acutely  painful.  A considerable  quantity  of  blood  was 
taken  from  the  vena  saphena  (and  why  bleeding  was 
not  practised  at  first,  seems  extraordinary).  The 
dressings,  which,  according  to  my  ideas,  were  highly 
objectionable,  were  removed,  and  a large  emollient 
poultice  applied.  Cooling  beverages,  containing  a 
small  quantity  of  tarlarized  antimony,  and  antispas- 
modic  anodyne  medicines  were  prescribed.  The  fol- 
lowing day  the  patient’s  state  appeared  satisfactory, 
without  the  slightest  disturbance  of  the  senses,  and  in 
due  time  he  perfectly  recovered. 

The  other  soldier  had  been  wounded  in  the  left  tem- 
ple with  a leaden  ball,  five  days  before  Larrey  saw  him. 
One  half  of  the  ball  had  gone  into  the  cranium,  through 
a very  narrow  breach ; the  other  had  burrowed  under 
the  temporal  muscle,  and  lodged  near  the  mastoid  pro- 
cess. The  right  side  of  the  body  was  paralytic,  the 
senses  were  annihilated,  and  the  man  was  in  a state  of 
incessant  agitation.  After  dilating  the  wound  in  the 
temple,  and  exposing  the  fracture,  Larrey  discovered 
the  track  of  the  piece  of  lead,  which  had  gone  towards 
the  mastoid  process,  and  which  he  immediately  ex- 
tracted by  a counter-opening.  At  the  lower  part  of  the 
lemjwral  wound,  he  applied  a trepan  very  near  the 
spot  where  the  other  portion  of  the  ball  was  lodged. 
This,  with  some  fragments  of  the  bone,  and  a quan- 
tity of  extravasated  blood,  was  easily  extracted.  The 
patient,  however,  was  not  saved ; a circumstance 
a.scribed  by  Larrey  to  the  operation  having  been  done 
too  late. 

In  another  case,  one  of  the  imperial  guards,  wounded 
at  the  battle  of  the  Moskowa,  died  with  symptoms  of 
compression,  and,  after  death,  a quarter  of  a bullet, 
and  H fragment  of  bone  were  found  under  the  skull, 
attended  with  an  ulcerated  or  wounded  state  of  the 
adjacent  portion  of  the  brain.  Larrey  very  properly 
expresses  his  opinion,  that  this  soldier  would  have  hail 
a chance  of  being  saved,  had  me  trepan  been  used. — 


(See  M'Vt.  de  Chir.  MU.  t.  4,  p.  183,  <S-c.)  The  practice 
of  trejihining  for  the  removal  of  balls,  situated  near  a 
fracture  of  the  skull,  within  this  bony  cavity,  or  lodged 
among  the  fragments,  or  between  the  two  tables  forced 
asunder  (see  Engel’s  case,  in  Vermischte  Chir.  Schrif- 
ten  von  J.  L.  Schmucker,  b.  1,  p.  242),  is  not  peculiar  to 
Larrey,  for  it  has  been  done  by  many  other  surgeons 
(see  Schmucker's  Wahmekmungen,  b.  1,  p.  298) ; but  I 
do  not  know  that  he  has  been  anticipated  in  his  bold  prac- 
tice of  making  a counter-opening  in  the  skull,  when 
the  ball  is  lodged  at  such  a distance  from  the  fracture, 
that  it  cannot  be  extracted  through  any  perforation 
made  in  the  vicinity  of  the  original  injury ; for  it  is  a 
principle  which  he  ventures  to  lay  down,  that  when  a 
ball  has  entered  the  cranium ^ without  quitting  the  rooj 
of  this  cavity,  the  case  is  one  requiring  the  application 
of  the  trepan. — {Mem.  de  Chir.  Mil.  t.  4,  p.  180.)  In 
the  2d  vol.  of  this  work  (p.  139),  the  reader  will  find 
the  account  of  a soldier,  who  was  struck  on  the  mid- 
dle of  the  forehead  with  a ball  which  penetrated  the 
os  frontis,  and  then  passed  obliquely  backwards,  be- 
tween the  skull  and  the  dura  mater,  in  the  course  of  the 
longitudinal  sinus,  as  far  as  the  lambdoidal  suture, 
where  it  stopped.  I^arrey  traced  the  situation  of  the 
ball,  by  the  introduction  of  an  elastic  gnm  catheter  into 
the  opening;  and  measuring  the  distance  between  the 
fracture  and  the  place  where  he  felt  the  ball,  he  cut 
down  upon  that  part  of  the  skull,  beneath  which  he 
concluded  that  the  ball  was  lodged.  The  bone  was 
then  perforated  with  a large  trepan;  a good  deal  of 
pus  was  discharged ; the  ball  was  extracted,  and  the 
patient  recovered.  One  thing  here  merits  the  attention 
of  surgeons;  Larrey  tells  us,  that  a good  deal  of  pus 
issued  as  soon  as  an  opening  was  made  in  the  skull; 
there  must  then  have  been  suppuration  under  the  bone, 
and  inflammation  and  detachment  of  the  dura  mater ; 
circumstances  alw  ays  indicated,  according  to  Pott,  by 
a corresiionding  separation  of  the  pericranium,  and  a 
puffy  tumour  of  the  scalp.  Did  these  symptoms  take 
place  in  the  foregoing  case,  so  as  to  be  of  any  assistance 
to  Larrey,  in  judging  of  the  place  where  the  ball  was 
lodged  ? and  has  the  mention  of  them  been  omitted  only 
by  accident?  or  are  we  to  infer  that  suppuration  may 
happen  between  the  cranium  and  dura  mater,  without 
any  detachment  of  the  pericranium  and  puffy  tumour 
of  the  scalp?  a thing  which  Bichat  asserts  is  proved 
by  daily  experience  in  the  Hoiel-Dieu,  at  Paris.— (See 
(E.uvres  Chir.  de  Desault,  t.  2,  p.  29.)  Larrey,  in  his 
3d  vol.  (p.  82),  gives  us  another  case,  in  which  a ball 
pierced  the  left  parietal  bone,  and  lodged  near  the  lamb- 
doidal suture.  Its  situation  was  detected  with  the  aid 
of  an  elastic  gum  catheter,  and  partly  in  consequence 
of  there  being  a slight  ecchymosis  over  the  part. 
Here  a crucial  incision  was  made  through  the  scalp, 
and  a small  fissure  discovered.  As  the  symptoms  of 
compression  increased,  the  trepan  was  applied,  so  as 
to  include  the  fissure.  A half  of  the  ball  flattened  was 
found  directly  under  the  perforation,  and  a good  deal  of 
blood  was  voided  from  the  two  openings  in  the  cranium. 
For  a fortnight  the  case  w^ent  on  favourably,  but  the 
patient  was  then  attacked  with  what  Larrey  terms 
hospital  fever,  but  which  in  all  probability  was  inflam- 
mation and  suppuration  of  the  membranes  of  the  brain, 
and  died. 

The  records  of  surgery  furnish  numerous  instances 
in  which  the  patients  lived  a considerable  time  with 
balls  lodged  in  the  cavity  of  the  cranium.  Thus,  one 
is  related  by  Paroisse,  where  the  patient  soon  reco- 
vered his  senses  after  the  injury,  and  at  the  end  of  six 
months  fell  no  inconvenience,  excejit  a difficulty  of 
opening  the  mouth.  - {Opuscules  de  Chir.  Obs.  1,  8vo. 
Paris,  1806.)  Ramdohr  has  published  another  case, 
where  a soldier  was  shot  through  the  frontal  sinus,  and 
the  ball  was  found  after  death  in  the  medullary  sub- 
stance of  the  left  hemisphere  of  the  brain,  half  an  inch 
above  the  ventricle ; yet  this  patient  lived  four  months 
after  the  injury,  find  soon  recovered  his  senses  after  its 
occurrence.  For  a considerable  part  of  this  time  he 
was  also  free  from  any  bad  symptoms.  At  last  he  was 
affected  with  a kind  of  stupor,  and  an  inability  to  open 
his  left  eye,  and  fell  into  a lethargic  and  convulsed 
state. — {Schmucker,  Vermischte  Chir.  Schriflen,  b.  1, 
p.  277.)  A French  soldier,  at  the  battle  of  Waterloo, 
was  wounded  with  a musket-ball,  which  entered  at 
the  anterior  portion  of  the  squamous  suture,  lodged  in 
the  substance  of  the  brain,  and  on  the  fifth  day  after 
an  enlargement  of  the  wound,  and  the  removal  of  seve- 


470 


HEAD. 


ral  fragments  of  bone,  was  extracted  from  the  poste- 
rior lobe  of  the  right  hemisphere  of  the  brain,  ■where  it 
was  found  resting  on  the  tentorium.  Yet,  during  the 
several  previous  days,  the  man,  with  the  exception  cf 
a slight  headache,  and  partial  deafness  of  the  right  ear, 
seemed  to  enjoy  perfect  health.  The  case  ended  well. 
—(See  Hennen's  Mil.  Siirg.  p.  289,  ed.  2.)  Still  more 
remarkable  instances  of  the  duration  of  life,  and  even 
of  the  absence  of  verj'  serious  sjmptoms,  alter  great 
and  serious  wounds  of  the  brain,  and  the  lodgement  of 
balls,  might  here  be  cited;  but  it  will  suffice  to  refer  to 
the  instructive  Essay  of  M.  Que.snay  on  the  subject,  in 
vol.  1,  of  the  Mem.  de  PAcad.  de  Chir.  ^to.,  and  to  the 
account  of  twenty-two  French  soldiers,  whose  vertices, 
with  more  or  less  of  the  brain,  were  cut  off  by  sabre- 
strokes.  All  these  men  ultimately  died ; but  at  first 
had  not  a single  bad  symptom,  and  performed  a journey 
of  thirty  leagues  after  being  wounded,  and  one-half  of 
this  distance  on  foot, — (See  Paroisse,  Opuscules  de 
Chir.  p.  41,  (S'C.) 

5.  Extravasation  under  the  Cranium,  Symptom.s  of 
Pressure  on  the  Brain,  Ac. 

Mr.  Pott  remarks,  “ the  shock  which  the  head  some- 
times receives  by  falls  from  on  liigh,  or  by  strokes  from 
jionderous  bodies,  does  not  unfrequently  cause  a breach 
m some  of  the  vessels  either  of  the  brain  or  its  menin- 
ges, and  thereby  occasions  extravasation  of  the  duid 
which  should  circulate  through  them.  This  extrava- 
sation may  be  the  only  complaint  produced  by  the  ac- 
cident; or  it  may  be  joined  with,  or  added  to,  a fracture 
of  the  skull.  But  this  is  not  all;  for  it  may  be  pro- 
duced not  only  when  the  cranium  is  unhurt  by  the 
blow,  but  even  when  no  violence  of  any  kind  has  been 
offered  to  or  received  by  the  head.” 

The  effused  blood  may  lie  between  the  cranium  and 
dura  mater;  between  the  latter  membrane  and  the 
arachnoides  ; on  the  surface  of  the  pia  mater,  or  under 
this  membrane,  on  the  surface,  in  the  substance,  or  ca- 
vities of  the  brain.  The  first  species  of  extravasation, 
w'hich  is  observed  to  be  always  more  or  less  circum- 
scribed, may  occur  at  any  part  of  the  skull,  but  when 
situated  at  its  base,  is  generally  fatal.  In  the  second, 
which  is  the  most  common  species  of  extravasation 
within  the  dura  mater  (see  Brodie,  in  Med.  Chir. 
Trans,  vol.  14,  p.  333),  the  blood  is  widely  scattered 
abotft  between  the  dura  mater  and  arachnoides,  and 
on  this  account,  unless  its  quantity  be  very  consider- 
able, it  does  not  cause  any  great  degree  of  pressure. 
In  the  third  example,  if  the  blood  be  situated  in  the 
convolutions,  it  is  also  ■widely  diffused,  but  if  it  be 
within  the  substance  or  ventricles  of  the  brain,  which 
is  rare  (Brodie,  vol.  cit.),  it  is  circumscribed. — (IF.uvres 
Chir.  de  Desault,  t.  2,  p.  23.)  Sometimes  in  cases  of 
great  ■violence,  as  Mr.  Pott  has  justly  observed,  the 
blood  is  found  at  the  same  time  in  all  these  different 
parts. 

According  to  Mr,  Brodie’s  experience,  which  confirms 
the  observations  of  Mr.  Abemethy,  there  is  never 
such  hemorrhage  from  a rupture  of  the  blood-vessels, 
by  which  the  dura  mater  is  connected  to  the  bone,  as 
will  produce  dangerous  pressure  on  the  brain,  except 
when  the  middle  meningeal  artep'  has  been  lacerated, 
from  which  vessel  the  bleeding  is  sometimes  very  co- 
pious. Mr.  Brodie  has  never  seen  this  artery  lace- 
rated, except  in  the  combination  with  a fracture  run- 
ning across  the  bony  canal  in  which  it  is  situated ; but 
he  adverts  to  other  cases,  recorded  by  Mr.  Latta  and 
Mr.  Abernelhy,  in  which  no  such  fracture  accompanied 
the  rupture  of  the  vessel.^See  MedL  Chir.  Trans,  vol. 
14,  p.  333.) 

Another  observation  made  by  Mr.  Brodie  is,  that 
large  extravasations  are  sometimes  found  upon  the  up- 
per surface  of  the  brain,  but  more  frequently  at  its 
basis,  where  they  are  usually  the  consequence  of  a 
rupture  of  the  substance  of  the  brain.  The  same  surgeon 
has  never  seen  an  instance,  in  wliich  the  blood  from  a 
wounded  sinus  collected  between  the  dura  mater  and 
the  skull,  or  between  that  membrane  and  the  brain,  in 
sufficient  quantity  to  interfere  with  the  functions  of  the 
latter  Oman. 

WTien'  the  blood  is  extravasated  beneath  the  skull, 
the  violence  which  produces  the  rupture  of  the  vessel 
usually  stuns  the  patient,  from  which  state,  provided 
the  quantity  and  pressure  of  the  blood  and  the  force  of 
the  concussion  be  not  too  great,  he  gradually  recovers 
ami  regains  h.s  senses.  If  the  first  extravasation  be 


trivial,  the  patient,  after  regaining  his  senses,  may  only 
feel  a little  drowsiness  and  go  to  bed.  The  bleeffing 
from  the  ruptured  vessel  continuing,  and  the  pressure 
on  the  brain  increasing,  he  becomes  more  and  more  in- 
sensible, and  begins  to  breathe  in  a slow,  interrupted, 
stertorous  manner.  In  cases  of  compression,  whether 
from  blood  or  a depressed  portion  of  the  skuli,  there  is 
a general  insensibility ; the  eyes  are  half  open ; the  pu- 
pils dilated  and  motionless,  even  before  the  vivid  light 
of  a candle;  the  retina  is  insensible;  the  limbs  relaxed; 
the  breathing  stertorous ; the  pulse  slow,  and,  according 
to  Mr.  Abemethy,  less  subject  to  intermission,  than  in 
cases  of  concussion.  The  absence  ofstertor,  however, 
as  this  gentleman  admits,  niust  not  be  relied  upon  as  a 
proof  of  their  being  no  compression ; for  Morgagni  re- 
lates dissections  of  apoplectic  persons,  in  whom  the  effu- 
sion w as  considerable,  yet  no  stertor  had  occurred. 

In  a case  of  wound  of  the  posterior  part  of  the  skull, 
with  depression,  seen  by  Dr.  J.  Thomson,  the  pulse  a- 
one  time  sunk  as  low  as  36  strokes  in  a minute. 
This  eminent  professor,  however,  is  at  variance  with 
Mr.  Abemethy  upon  one  point,  by  stating  that  irregu- 
larity of  the  pulse  is  a frequent  attendant  upon  com- 
pressed brain.— (ileporf  of  Obs.  Ac,  p.  54,  55.) 

Mr.  Brodie  does  not  give  any  positive  opinion  on  the 
statement  made  by  Mr.  Abemethy,  that  intermission  of 
the  pulse  is  less  frequent  in  compression  than  concus- 
sion ; but  he  expresses  his  belief,  that  pressure  on  the 
brain  for  the  most  part  Eiffects  the  action  of  the  heart ; 
not  by  producing  actual  interruptio-n,  trut  by  causing 
its  contractions  to  be  either  less frequent,  or  less  forci^ 
ble  than  natural.— (Med.  Chir.  Trans,  vol.  14, p.  355.) 
In  the  cases  referred  to  in  Dr.  Thomson’s  report,  con- 
vulsions sometimes  arose  from  the  pressure  of  por- 
tions of  the  skull,  forced  intvards  upon  the  brain.  This 
is  a very  dangerous  symptom ; but  Dr.  Thomson  saw 
it  cease  in  a few'  examples,  after  the  depressed  piece  of 
bone  had  been  elevated,  and  the  antiphlogistic  regimen 
adopted. — (P.  60.)  Convulsions  1 am  disposed  to  re- 
gard, with  Bichat,  rather  as  a symptom  of  injury  of  the 
brain,  than  of  compression. — (Oeuvres  Chir.  de  Desault, 
t.  2,  p.  27.) 

Mr.  Brodie,  seemingly  unaware  of  the  corresponding 
remark  published  in  the  foregoing  work,  considers  it 
questionable,  whether  convulsive  twitches  of  the  mus- 
cles ought  to  be  regarded  as  the  consequence  of  sim- 
ple pressure  on  the  brain  ? We  find  them  occur,  says 
he,  in  cases  of  punctured  and  wounded  brain,  where 
there  is  no  pressure;  and  whenever  he  has  noticed 
them  as  attendant  on  depression  of  the  skull  or  ex- 
travasated blood,  and  has  afterward  had  the  oppor- 
tunity of  ascertaining  the  exact  nature  of  the  injury, 
the  pressure  has  always  been  found  to  be  complicated 
with  wound  or  laceration  of  the  substance  of  the  brain. 
The  convulsive  twitches  to  which  Mr.  Brodie  alludes, 
he  particularly  describes  as  slight  and  partial,  and 
different  from  the  more  violent  and  general  convulsions, 
—(See  Med.  Chir.  Trans,  vol.  14,  p.  352.) 

Indeed,  the  difficulty  of  the  diagnosis  of  many  cases 
may  be  well  conceived  by  what  Dr.  Hennen  remarked 
in  his  practice;  viz.  that  in  some  instances  the  pupils 
were  contracted,  in  others  dilated,  where  the  injury 
was  nearly  of  a similar  nature  and  degree ; while 
sometimes,  in  the  same  patient,  one  pupil  was  dilated 
and  the  other  much  contracted.  He  saw,  also,  paraly- 
sis occur  on  one  side,  and  convulsions  on  the  other, 
when  the  blow  had  been  on  the  forehead,  and  the  same 
when  it  had  been  on  the  occiput.— (Op.  cit.  p.  3C0, 
301.) 

Mr.  Brodie  has  seen  the  pupils  dilate  with  the  ab- 
sence, and  contract  with  the  presence  of  light,  although 
the  patient  lay  in  a state  of  complete  insensibility,  and 
did  not  seem  to  be  at  all  conscious  of  the  impressions 
made  on  the  retina  He  admits,  however,  that  this  is 
a rare  occurrence,  and  that,  when  the  other  symptoms 
of  pressure  are  present,  the  pupils  are  generally  insnu 
sible  and  motionless,  and  mostly  dilated,  though  some- 
times contracted.  Every  surgeon  of  experience  must 
be  aware  of  another  circumstance  mentioned  by  the 
same  surgeon ; namely,  that  it  is  not  uncommon  for 
the  pupils  to  remain  for  a time  in  a state  of  dilatation, 
then  to  become  suddenly  contracted,  and  after  remain- 
ing so  for  a longer  or  shorter  time,  to  become  again  di- 
lated ; these  changes  taking  place  independently  of  light 
and  darkness.  When  the  pupils  have  been  dilated, 
Mr.  Brodie  has  frequently  known  them  to  become  ern- 
tracte.d  after  the  abstroction  ot  hlood;  the  dilatatioq 


HEAD. 


471 


returning  as  soon  as  the  immediate  effect  of  the  blood- 
letting had  ceased.  He  adverts  to  a curious  case,  re- 
ported by  Dr.  Hennen,  in  which  blood  was  extravasated 
between  the  membranes  of  the  brain,  and  the  pupils 
sometimes  dilated  in  an  increased  tight,  and  contracted 
in  a diminution  of  it.— (See  iUed.  Ckir.  Trans,  vol.  14, 
p.  352.)  Another  observation  made  by  Mr.  Brodie  is, 
an  occasional  insensibility  of  one  iris,  dilatation  ol'the 
pupil,  and  aptosis,  continuing  after  the  subsidence  of 
the  general  insensibility  of  the  body,  and  even  unat- 
tended with  loss  of  vision. — {Vol.  cit.  p.  354.) 

The  patient  is  hardly  ever  sick  when  the  pressure 
on  the  brain  and  the  general  insensibility  are  consider- 
able ; for  the  very  action  of  vomiting  betrays  sensibility 
in  the  stomach  and  oesophagus.  The  truth  of  this 
statement,  which  agrees  with  Mr.  Aberneihy’s  expe- 
rience, is  strikingly  confirmed  by  an  observation  made 
by  Mr.  Brodie ; namely,  that  when  he  has  had  occasion 
to  apply  the  trephine  on  account  of  a fracture  and  de- 
pres.sian,  and  no  sickness  existed  previously,  he  has 
sometimes  known  the  patient  become  sick  and  vomit 
immediately  the  depressed  bone  was  elevated.— (See 
Med.  Chir.  Trans,  vol.  14,  p.  356.)  These  symptoms 
are  not  peculiar  to  pressure  from  blood,  but  arise  also 
from  that  of  many  depressed  fractures  of  the-  skull  and 
of  suppuration  under  this  part.  They  are  all  attribu- 
table to  the  unnatural  pressure  made  on  the  brain  and 
nerves,  and  have  too  dnen  been  mistaken  as  indications 
of  an  injury,  which,  considered  abstractedly,  can  never 
cause  them ; I allude  to  a simple  undepressed  fracture 
of  the  cranium,  which  may  be  accompanied  with  them 
but  cannot  cause  them.  They  differ  in  degree,  according 
to  the  quantity,  kind,  and  situation  of  the  pressing  fluid. 
The  hemorrhage  from  the  nose  and  ears,  which  often  fol- 
lows violence  applied  to  the  head,  is  generally  conceived 
to  lead  to  no  particular  or  useful  inference:  we  cannot 
even  calculate,  by  this  sign,  that  the  force  has  exceeded 
a certain  degree;  for  such  bleedings  take  place  from 
much  slighter  causes  in  some  persons  than  others. 

Mr.  Brodie’s  observations  on  this  point  merit  atten- 
tion : “ There  is  often  a considerable  effusion  of  blood 
from  the  ear,  especially  in  cases  of  fracture  of  the 
basis  of  the  cranium.  This  may,  as  far  as  I know, 
sometimes  arise  from  other  sources ; but  it  seems  pro- 
bable that  it  must  in  most  instances  arise  from  the 
laceration  of  the  lateral  sinus,  where  it  extends  down- 
wards behind  the  petrous  process  of  the  temporal  bone 
and  the  external  meatus;  and  in  one  instance  I ascer- 
tained it  to  have  been  so  by  the  examination  of  the 
body  after  death.  In  another  case  which  fell  under  my 
observation,  there  was  hemorrhage  both  from  the  ear 
and  the  nostrils.  The  patient,  a boy,  died  shortly  af- 
ter the  accident ; and  it  was  found,  on  dissection,  that 
there  was  a fracture  of  the  base  of  the  cranium,  with 
laceration  of  the  cavernous  sinus,  and  that  the  hemor- 
rhage had  taken  place  from  this  sinus.”— (See  Med. 
Ckir.  Trans,  vol.  14,  p.  334.)  According  to  my  expe- 
rience, bleedings  from  the  ear  and  nose  from  injuries 
of  the  head  are  particularly  frequent  in  children,  and 
often  manifestly  consist  of  arterial  blood. 

Paralysis  is  a symptom  which  generally  attends 
hurtful  pressure  on  the  brain.  The  particular  circum- 
stances, however,  which  determine  its  degree,  extent, 
and  situation,  are  not  well  understood.  “ In  some  in- 
stances of  paralysis  from  sabre-wounds,  as  well  as  in 
those  made  by  gun-shot  (says  Dr.  J.  Thomson),  para- 
lysis was  confined  to  the  upper,  and  in  others  to  the 
lower  extremity.  In  every  instance  in  which  it  di.s- 
tinctly  appeared  that  the  injury  existed  on  one  side  of 
the  head,  the  paralysis  uniformly  manifested  itself 
upon  the  other;  but  we  were  unable  to  perceive  any 
other  fixed  relation  betw-een  the  part  of  the  brain  which 
had  been  injured  and  the  part  of  the  body  affected  with  | 
palsy.  A wound  of  the  right  parietal  bone  by  a mus-  I 
ket-ball  was  followed  by  palsy  of  the  left  arm  and  leg.  i 
In  another  ca.se,  a wound  penetrating  the  upper  part  j 
of  the  right  parietal  bone  was  accompanied  with  a ' 
slight  paralytic  affeclion  of  the  left  side  of  the  mouth,  ! 
and  complete  palsy  of  the  left  leg.  In  a third  case,  a | 
sabre-wound  of  the  same  bone,  followed  by  extensive 
exfoliatioiis,  gave  rise  to  a complete  palsy  of  the  left 
side.” — {Ohs.  made  in  the  Military  Hospitals  in  Bel- 
gium,  p.  52,  53.)  ! 

When  the  destruction  of  sensibility  is  complete,  the  ^ 
voluntary  muscles  are  entirely  paralyzed.  The  patient 
lies  motionless  in  any  position  in  which  he  happens  to 
be  placed.  The  bladder,  incapable  of  contraction,  be- 


comes preternaturally  distended  with  urine ; and  the 
relaxation  of  the  sphincter  ani  allows  the  involuntary 
discharge  of  feces  from  the  rectum.  Afterward  the 
muscles  of  respiration  become  affected  also;  the  pa- 
tient breathes  with  stertor,  as  in  a most  profound  sleep  ; 
and  the  diaphragtn  contracts  at  longer  and  longer  in- 
tervals, until  respiration  altogether  ceases.  It  is  this 
paralysis  of  the  muscles  of  respiration  which  in  ordi- 
nary cqses  of  pressure  on  the  brain  is  the  immediate 
cause  of  death.  When  the  loss  of  sense  is  imperfect, 
there  are  often  no  marks  of  paralysis  whatever.  At 
other  times,  there  is  hemiplegia,  which,  however,  is 
much  more  rarely  the  consequence  of  accidental  vio- 
lence than  of  apoplexy.  Mr.  Brodie  conceives  that  this 
difference  is  referrible  to  the  different  situation  of  the 
pressure.  In  apoplexy,  the  extravasation  is  mostly 
situated  in  one  of  the  ventricles,  or  in  the  substance 
of  the  brain  ; but  after  a blow  on  the  head,  the  cause 
of  pressure  coninionly  operates  upon  the  surface. — 
{Med.  Chir.  Ti'ans.  vol.  14,  p.  349,  350.) 

With  respect  to  paralysis,  it  is  unquestionably  one 
of  the  common  symptoin.s  of  pressure  on  the  brain  ; 
but,  according  to  Bichat,  it  may  also  be  caused  by  con- 
cussion ; and  we  know  that  it  may  arise  in  cases  of 
inflammation  and  suppuration  within  the  skull.  The 
above  statement  respecting  the  paralysis  being  always 
on  the  side  of  the  body  opposite  that  on  which  the 
brain  is  compressed,  agrees  with  what  is  generally  re- 
marked by  other  surgical  writers. — (See  Larrey's  Mem. 
de  Chir.  Mil.  t.  4,  p.  180 ; Hennen's  Princijiles,  p.  301, 
ed.  2,  4 c.)  Yet,  at  the  H6tel-Dieu,  at  Paris,  extrava-^ 
sation  has  very  often  been  noticed  both  on  the  side 
affected  with  paralysis  and  on  the  opposite  one ; or 
else  the  blood  was  generally  diffused,  while  the  paraly- 
sis was  local. — {(Luvres  Chir.  de  Desault,  t.  2,  p.  27.) 

The  preceding  class  of  symptoms  only  informs  us, 
that  the  brain  is  suffering  compression  ; and  leaves  us 
quite  in  the  dark  respecting  several  other  very  import- 
ant circumstances.  “We  not  only  have  no  certain 
infallible  rule,  whereby  to  distinguish  what  the  press- 
ing fluid  is,  or  where  it  is  situated,  but  we  are,  in  many 
instances,  absolutdy  incapable  of  knowing  whether 
the  symptoms  be  occasioned  by  any  fluid  at  all ; for 
a fragment  of  bone  broken  off from  the  internal  table 
of  the  cranium,  and  making  an  equal  degree  of  pres- 
sure, will  produce  exactly  the  same  complaints." — 
{Pott.)  In  detailing  the  symptoms  of  pressure  from 
blood,  I took  particular  notice  of  the  patient  being  at 
first  generally  stunned  by  the  blow,  of  his  gradually 
regaining  his  senses,  and  of  his  afterward  relapsing 
into  a state  of  insensibility  again.  The  interval  of 
sense  which  thus  occurs,  was  pointed  out  by  Petit  as  a 
circumstance  of  the  greatest  consequence  in  elucida- 
tion of  the  nature  of  the  case. 

“A  concussion  and  an  extravasation  (as  Mr.  Pott  ob- 
serves) are  very  dist.-nct  causes  of  mischief,  though 
not  always  very  distinguishable. 

M.  Le  Dran,  and  others  of  the  modern  French  wri- 
ters. have  made  a very  sensible  and  just  distinction 
between  that  kind  and  degree  of  loss  of  sense  which 
arises  from  a mere  commotion  of  the  brain,  and  that 
which  is  caused  by  a mere  extravasation,  in  those  in- 
stances in  which  the  time  of  the  attack  or  appearance 
of  such  symptoms  are  different  or  distinct.  The  loss 
of  sense  which  immediately  follows  the  violence,  say 
they,  is  most  probably  owing  to  a commotion ; but 
that  which  comes  on  after  an  interval  of  time  has  passed 
is  most  probably  caused  by  extravasation. 

This  distinction  is  certainly  just  and  good  as  far  as 
it  will  go.  That  degree  of  abolition  or  diminution  of 
sense  which  immediately  attends  or  follows  the  blow 
or  fall,  and  goes  off  again  without  the  assistance  of 
art,  is  in  all  probability  occasioned  by  the  sudden  shake 
or  temporary  derangement  of  the  contents  of  the  head  : 
and  the  same  kind  of  symptoms  recurring  again  some 
time  after  they  had  ceased,  or  not  coming  on  until  some 
time  has  jiassed  from  the  receipt  of  the  violence,  do 
most  probably  proceed  from  the  breach  of  a vessel 
within  or  upon  the  brain.  But,  unluckily,  we  have  it 
not  very  often  in  our  power  to  make  this  exact  distinc- 
tion, An  extravasation  is  often  made  so  immediately, 
and'so  largely,  at  the  instant  of  the  accident,  that  all 
sense  and  motion  are  instantaneously  lost,  and  never 
again  return.  And  it  also  sometimes  hapjiens,  that  al- 
though an  extravasation  may  possibly  not  have  been 
made  at  the  moment  of  the  accident,  and  the  first  corn- 
jilaiuts  may  have  been  owing  to  commotion  merely,  yet 


472 


HEAD. 


a quantity  of  fluid  having  been  shed  from  its  proper 
vessels  very  soon  after  the  accident,  and  producing  its 
proper  symptoms,  before  those  caused  by  the  commo- 
tion have  had  time  to  go  OB',  the  similarity  of  the  effects 
of  each  of  these  different  causes  is  such,  as  to  deprive 
us  of  all  power  of  distinguishing  between  the  one  and 
the  other,  or  of  determining,  with  any  tolerable  preci- 
sion, to  which  of  them  such  symptoms  as  remain  are 
really  owing.” 

A man  meets  with  a fall ; a slight  concus-sion  of  the 
brain  is  the  consequence,  and  the  patient  is  instantly 
stunned.  The  effects  of  concussion  gradually  subside, 
but  an  e.xtravasation  takes  place,  and  the  loss  of  the 
senses  continues,  though  from  a different  cause.  Here, 
according  to  the  principles  of  Petit,  the  case  would  be 
set  down  as  concussion  ; yet,  things  are  quite  the  con- 
trary, the  extravasation  now  keeping  up  the  symptom 
which  was  only  temporarily  produced  by  concussion. 
In  many  instances,  also,  the  effects  of  concussion  and 
extravasation  e.xist  together,  and  then  how  is  a sur- 
geon to  judge  of  the  nature  of  the  case  7— (See  (Euvres 
Chir.  de  Desault.,  t.  2,  p.  25.) 

“ When  an  extravasation  of  any  kind  is  made  either 
upon  or  within  the  brain,  if  it  be  in  such  quantity,  or 
so  situated,  as  to  disorder  the  economy  of  the  animal, 
St  always  produces  such  disorder  by  making  an  unna- 
tural pressure  on  the  parts  where  it  lies.  The  nature 
and  degree  of  the  symptoms  hereby  produced  are  va- 
rious and  different  in  different  persons,  according  to 
the  kind,  quantity;  and  situation  of  the  pressing  fluid. 
Sometimes  it  is  merely  fluid  blood,  sometimes  blood  in 
a state  of  coagulation ; sometimes  it  is  a clear  lymph, 
and  at  others  blood  and  water  are  found  mixed  to- 
gether : each  of  these  is  found  either  simple  or  mixed 
in  different  situations,  that  is,  between  the  skull  and 
dura  mater,  between  the  dura  and  pia  mater,  or  in  the 
natural  cavities  of  the  brain  called  its  ventricles,  and 
sometimes,  in  cases  of  great  violence,  they  are  found 
at  the  same  time  in  all  these  different  parts.  Some- 
times a considerable  quantity  is  shed  instantly  at  the 
time  of  the  accident ; and  sometimes  the  breach  by 
which  the  effusion  is  made  is  so  circumstanced,  both  as 
to  nature  and  situation,  that  it^s  at  first  very  small, 
and  increases  by  faster  or  slower  degrees.  In  the  for- 
mer, the  symptoms  are  generally  immediate  and  ur- 
gent, and  the  extravasation  is  of  the  bloody  kind ; in 
the  latter,  they  are  frequently  slight  at  first,  appear 
after  some  little  interval  of  time,  increase  gradually  till 
they  become  urgent  or  fatal,  and  are  in  such  case  ge- 
nerally occasioned  by  extravasated  lymph.  So  that  al- 
though the  immediate  appearance  of  bad  symptoms 
does  ijiost  certainly  imply  mischief  of  some  kind  or 
other,  yet,  on  the  other  hand,  no  man  ought  to  suppose 
his  patient  free  from  hazard,  either  because  such  symp- 
toms do  not  show  themselves  at  first,  or  because  they 
appear  to  be  but  slight ; those  which  come  on  late,  or, 
appearing  slight  at  first,  increase  gradually,  being  full 
as  much  to  be  dreaded,  as  to  consequence,  as  the  more 
immediately  alarming  ones;  with  this  material  differ- 
ence between  them,  that  the  one  may  be  the  conse- 
quence of  a mere  concussion  of  the  brain,  and  may  by 
means  of  quietude  and  evacuation  go  quite  off;  whereas, 
the  other  being  most  frequently  owing  to  an  extravasa- 
tion of  Jymph  (though  sometimes  of  blood  also)  within 
the  substance  of  the  brain,  are  very  seldom  removed 
by  art.” — {Pott.) 

The  case  of  extravasation  between  the  cranium  and 
dura  mater  is  almost  the  only  one  which  admits  of 
relief  from  trephining.  Mr.  Abernethy  informs  us, 
that  in  the  cases  which  he  has  seen  of  blood  extrava- 
sated between  the  dura  and  pia  mater,  on  a division  of 
the  former  membrane  being  made  for  its  discharge, 
only  the  serous  part  of  it  could  be  evacuated;  for  the 
coagulum  was  spread  over  the  hemisphere  of  the 
brain,  and  had  descended  as  low  as  possible  towards 
its  inferior  part,  so  that  very  little  relief  was  obtained 
by  the  operation. — {Surgical  Works,  vol.  2,  p.  46.) 
I'his  statement  is  confirmed  by  that  of  Bichat,  and  the 
practice  inculcated  agrees  with  what  Sir  Astley  Cooper 
also  directs,  as  will  be  presently  noticed. 

Fractures  of  the  cranium  which  take  place  across 
the  lower  and  front  angle  of  the  parietal  bone,  and  the 
rest  of  the  track  of  the  trunk,  and  large  branches  of 
the  spinous  artery  of  the  dura  mater,  are  cases  very 
apt  to  be  attended  with  a copious  extravasation.  This 
vessel,  aiid  others  more  deeply  seated,  however,  may 
be  ruptured,  pour  out  a considerable  quantity  of  blood. 


and  induce  urgent  sjTnptoms  of  pressure  on  the  brain, 
not  only  without  the  co-e.xistence  of  a fracture,  but 
even  of  any  external  mark  of  violence  on  the  scalp. 

The  effused  blood  is  frequently  situated  below  tho 
part  on  which  the  violence  has  operated,  and  hence, 
when  such  part  is  pointed  out  by  a wound  or  discolor- 
ation of  the  scalp,  or  a fracture,  and  the  symptoms  of 
pressure  are  considerable,  I should  have  no  he.sitaiion 
about  immediately  trephining  in  the  situation  of  the 
external  injury.  I have  seen  many  cases  in  which 
such  practice  was  justified  by  the  result,  and  even 
when  no  extravasation  exists,  this  plan  will  sometimes 
detect  a depression  of  the  inner  table  of  the  skull,  and 
be  the  means  of  saving  life,  as  happened  in  one  very 
remarkable  case,  which  1 trephined  at  Brussels  after 
the  battle  of  Waterloo.  At  the  same  time,  it  would  be 
wrong  to  hold  out  the  expectation,  that  by  acting  on 
this  principle,  the  surgeon  will  always  find  blood  im- 
mediately under  the  part  of  the  cranium  which  he 
perlbrates.  With  respect  to  a fracture  also,  as  a guide 
to  the  place  for  the  application  of  the  trephine  in  cases 
of  extravasation,  Desault  regards  it  as  very  fallacious, 
dissections  proving  that  numerous  fractures  of  the 
skuli  are  unattended  with  any  effusion  of  blood  imme- 
diately under  them ; and  his  experience  taught  him 
that  the  most  frequent  cases  were  those  in  which  there 
was  either  extravasation  without  fracture,  or  a fracture 
with  blood  effused  in  a part  of  the  head  remote  from 
the  injury  of  the  bone. — {(Pluvres  Chir.  t.  2,  p.  130.) 
Even  when  blood  is  seen  issuing  from  the  fissure,  he 
regards  it  as  no  proof  of  the  dura  mater  being  de- 
tached, as  such  blood  may  proceed  from  the  vessels  of 
the  diploe. — (P.  31.)  But  w hat  is  to  be  done  when  dan- 
gerous symptoms  of  pressure  prevail,  without  any  ex- 
ternal mark  to  denote  what  part  of  the  head  has  re- 
ceived the  blow,  or  whether  any  at  all  7 for  a general 
concussion  of  the  head  may  produce  an  effusion  of 
blood  within  the  cranium.  Under  these  circumstances, 
Mr.  Pott  was  against  the  operation,  and  says,  that  “ the 
only  chance  of  relief  is  from  phlebotomy  and  an  oj)en 
belly ; by  which  we  may  hope  so  to  lessen  the  quantity 
of  the  circulating  fluids  as  to  a.ssist  nature  in  the  dissi- 
pation or  absorption  of  what  has  been  extravasated. 
This  is  an  effect  which,  although  not  highly  improba- 
ble in  itself,  yet  is  not  to  be  expected  from  a slight  or 
trifling  application  of  the  means  proposed.  The  use 
of  them  must  be  proportioned  to  the  hazard  of  the  case. 
Blood  must  be  drawn  off  freely  and  repeatedly,  and 
from  different  veins  ; the  belly  must  be  kept  constantly 
open,  the  body  quiet,  and  the  strictest  regularity  of  ge- 
neral regimen  must  be  rigidly  observed.  By  these 
means,  very  alanning  symptoms  have  now  and  then 
been  removed,  and  people  in  seemingly  very  hazardous 
circumstances  have  been  recovered.”  Desault  also 
promulgated  the  same  advice,  and  blamed  the  doctrine 
formerly  in  vogue,  that  it  was  better  to  apply  the  tre- 
phine many  times  uselessly  than  to  let  a single  extra- 
vasation remain  undetected ; for  he  was  firmly  con 
vinced  that  the  trephine,  when  used  on  this  principle, 
was  a source  of  greater  mischief  than  the  effused  blood 
itself. — {(Euvres  Chir.  t.  2,  p.  34.)  The  same  doctrine 
is  espoused  by  Sir  Astley  Cooper  {Lectures,  ire.  vol.  l,p, 
288),  and,  I believe,  by  all  the  best  modern  surgeons. 

But  should  the  mode  of  judging  whether  blood  lies 
immediately  under  the  skull,  suggested  by  Mr.  Aber- 
nethy, prove  invariably  correct,  the  question  w'hether 
the  trephine  should  be  applied  or  not,  may  in  future  be 
more  easily  determined.  Even  when  the  injured  scalp 
shows  where  the  violence  has  operated,  the  criterion 
about  to  be  noticed  may  inform  us  whether  we  should 
perforate  the  bone  or  not ; for  though  the  extravasa- 
tion is  sometimes  found  immediately  under  the  external 
mark,  yet  it  often  is  not  so,  but  is  in  a part  distant  from 
that  mark,  to  which  situation  w-e  have  nothing  to  lead 
us,  and  to  which,  indeed,  if  w'e  knew  it,  we  could  not 
reach.  Mr.  Abernethy  has  observed,  “ that  unless  one 
of  the  large  arteries  of  the  dura  mater  be  wounded, 
the  quantity  of  blood  poured  out  will  probably  be  in- 
considerable ; and  the  slight  compression  of  the  brain, 
which  this  occasions,  may  not  be  attended  with  any 
peculiar  symptoms,  or  perhaps  it  may  occasion  some 
stupor,  or  excite  an  irritation,  disposing  the  suojacent 
parts  to  become  inflamed.  It  is  iiideod  highiy  probable, 
that  in  many  cases  which  have  done  well  without  an 
ojieration,  such  an  exlrava.saiion  has  existed.  But  if 
there  be  so  much  blood  on  the  dura  mater  as  materially 
to  derange  the  Amotions  of  the  brain,  the  bone,  to  a 


HEAD. 


473 


certain  extent,  will  no  longer  receive  blood  from 
within,  and  by  the  operation  performed  for  its  expo- 
sure, the  pericranium  must  have  been  separated  from 
its  outside.  I believe  that  a bone  so  circumstanced 
will  not  he  found  to  bleed ; and  I am  at  least  certain  it 
cannot  with  the  same  freedom  and  celerity  as  it  does 
when  the  dura  mater  remains  connected  with  it  inter- 
nally.”— (See  Aberncthifs  Surgical  Works,  vol.  2,  p. 
47.)  In  some  cases  related  by  this  gentleman,  there 
was  no  hemorrhage ; twice  he  was  able,  by  attending 
to  this  circumstance,  to  tell  how  far  the  detachment  of 
the  dura  mater  extended  ; and  often,  w hen  symptoms 
seemed  to  demand  a perforation  of  the  skull,  he  has 
seen  the  ojieration  contra-indicated  by  the  hemorrhage 
from  the  bone,  and,  as  the  event  showed,  with  accu- 
racy. Mr.  Abernethy  admits,  however,  that  in  aged 
persons,  and  in  those  in  whom  the  circulation  has 
been  rendered  languid  by  the  accident,  the  mode  of 
distinction  which  he  has  pointed  out  will  be  less  con- 
clusive. 

Pott  remarks,  that  “if  the  extravasation  be  of  blood, 
and  that  blood  be  in  a fluid  state,  small  in  quantity,  and 
lying  between  the  skull  and  dura  mater,  immediately 
under  or  near  to  the  place  perforated,  it  may  happily  be 
all  discharged  by  such  perforation,  and  the  patient’s 
life  may  thereby  be  saved  ; of  which  many  instances 
are  producible.  But  if  the  event  does  not  prove  so 
fortunate,  if  the  extravasation  be  so  large  or  so  situ- 
ated that  the  operation  proves  insufficient,  yet  the 
symptoms  having  been  urgent,  general  evacuation  hav- 
ing been  used  ineffectually,  and  a wound  or  bruise  of 
tile  scalp  having  pointed  out  the  part  which  most  pro- 
bably received  the  blow,  although  the  removal  of  that 
part  of  the  scalp  (a  simple  incision  ought  to  have  been 
said)  should  not  detect  any  injury  done  to  the  bone, 
yet  the  symptoms  still  subsisting,  I cannot  help  think- 
ing that  perforation  of  the  cranium  is  in  these  circum- 
stances so  fully  warranted,  that  the  omission  of  it  may 
truly  be  called  a neglect  of  having  done  that  which 
might  have  proved  serviceable,  and,  rebus  sic  stantibus, 
can  do  no  harm.  It  is  very  true,  that  no  man  can  be- 
forehand tell  whether  such  operation  will  prove  bene- 
ficial or  not,  because  he  cannot  know  the  precise  na- 
ture, degree,  or  situation  of  the,  mischief ; but  this 
uncertainty,  properly  considered,  is  so  far  from  being;, 
a dissuasive  from  the  attempt,  that  it  is  really  a strong 
incitement  to  make  it ; it  being  fully  as  impossible  to 
know  that  the  extravasated  fluid  does  not  lie  between 
the  skull  and  dura  mater,  and  that  under  the  part 
stricken,  as  that  it  does ; and  if  the  latter  should  be 
the  case,  and  the  operation  be  not  performed,  one,  and 
most  probably  the  only,  means  of  relief  will  have  been 
omitted.” 

On  some  of  the  foregoing  points,  Mr.  Brodie’s  ad- 
vice coincides  very  much  with  the  precepts  of  Mr. 
Abernethy,  and  with  the  doctrines  which  have  been 
for  many  years  inculcated  in  this  work.  Blood,  he  ob- 
serves, is  seldom  poured  out  in  any  considerable  quan- 
tity between  the  dura  mater  and  the  bone,  except  in 
consequence  of  a laceration  of  the  middle  meningeal 
arterv , or  one  of  its  principal  branches.  If,  therefore, 
we  find  the  patient  lying  in  a state  of  stupor,  and  dis- 
cover a fracture  with  or  without  depression,  extending 
in  the  direction  of  the  middle  meningeal  artery,  Mr. 
Brodie  is  an  advocate  for  the  trephine.  When  no  frac- 
ture is  discoverable,  but  there  is  other  evidence  of  the 
injury  having  fallen  on  that  part  of  the  cranium  under 
which  the  middle  meningeal  artery  is  situated,  the  tre- 
phine, he  says,  may  be  employed  on  speculation,  rather 
than  that  the  patient  should  be  left  to  .die  without  any 
attempt  being  made  for  his  preservation.— (See  J\led, 
Chir.  Trans,  vol.  14,  p.  385.) 

When  there  is  no  interval  of  sense  between  the 
blow  and  the  coming  on  of  perilous  symptoms,  it  is 
frequently  impossible  to  determine  whether  the  mis- 
chief be  owing  to  the  largeness  and  suddenness  of  the 
extravasation,  to  the  violence  of  the  shock  which  the 
brain  has  received,  or  to  both  these  causes  at  once, 
which,  unfortunately,  is  too  often  the  case.  In  this 
latter  complication,  indeed,  trephining  will  frequently 
be  of  no  avail,  even  though  it  serve  for  the  entire  re- 
moval of  all  pressure  off  the  brain ; for  the  patient 
cannot  recover  from  the  violence  of  the  concussion, 
and  never  regains  his  senses.  This  is  norea.son,  how- 
ever. why  tlie  chance  of  the  operation  doing  good 
slioufd  not  be  taken  when  there  are  evident  symptoms 
ot’ pri -sum.  l.ci  us,  m these  darkened  cases,  call  to 


mind  the  sentiments  of  Pott,  who  says,  “No  man 
who  is  at  all  acquainted  w'ith  this  subject  will  ever 
venture  to  pronounce  or  promise  success  from  the  use 
of  the  trephine,  even  in  the  most  apparently  slight 
cases : he  knows  that  honestly  he  cannot : it  is  enough 
that  it  has  often  been  successful  where  and  when 
every  other  means  has  failed.  The  true  and  just  con- 
sideration is  this : does  the  operation  of  perforating 
the  cranium  in  such  case  add  at  all  to  that  degree  of 
hazard  which  the  patient  is  in  before  it  is  performed  ? 
or  can  he  in  many  instances  do  well  without  it?  If  it 
does  add  to  the  patient’s  hazard,  that  is  certainly  a very 
good  reason  for  laying  it  aside,  or  for  using  it  very 
cautiously;  but  if  it  does  not,  and  the  only  objection 
made  to  it  is,  that  it  frequently  fails  of  being  success- 
ful, surely  it  cannot  be  right  to  disuse  that  which  has 
often  been,  not  only  salutary,  but  the  causa  sine  qud 
non  of  preservation,  merely  becau.se  it  is  also  often 
unsuccessful,  that  is,  because  it  is  not  infallible.” 

Giving  vent  to  the  confined  blood  “may  produce  a 
cure,  or  it  may  prove  only  a temporary  relief,  accord- 
ing to  the  different  circumstances  of  different  cases. 
The  disappearance  and  even  the  alleviation  of  ihe  most 
pressing  symptoms,  is  undoubtedly  a favourable  cir- 
cumstance, but  is  not  to  be  depended  upon  as  abso- 
lutely portending  a good  event.  Either  a bloody  or 
limpid  extravasation  may  be  formed  or  forming  be- 
tween the  meninges,  or  Kpon  or  within  the  brain,  and 
may  prove  as  certainly  jiernicious  in  future,  as  the 
more  external  efftision  would  have  done  had  it  not 
been  discharged  ; or  the  dura  mater  may  have  been  so 
damaged  by  the  violence  of  the  blow  as  to  inflame  and 
suppurate,  and  thereby  destroy  the  patient. 

If  the  disease  lies  between  the  dura  and  pia  mater, 
mere  perforation  of  the  skull  can  do  nothing ; and, 
therefore,  if  the  symptoms  are  pressing,  there  is  no  re- 
medy but  division  of  the  outer  of  these  membranes. 
The  division  of  the  dura  mater  is  an  operation  which  I 
have  several  times  seen  done  by  others,  and  have  often 
done  myself ; I have  seen  it,  and  found  it  now  and 
then  successful ; and,  from  those  instances  of  suc- 
cess, am  satisfied  of  the  propriety  and  necessity  of  its 
being  sometimes  done.”  He  next  states,  however,  his 
sentiment,  that  wounding  the  dura  mater  is  itself  at- 
tended with  dangerous  consequences.  Mr.  Aberne- 
thy’s  opinion  of  such  operation  has  already  been  given. 
It  is  also  disapproved  of  by  Sir  Astley  Cooper,  who  says, 
that  if  blood  be  not  found  between  the  dura  mater  and 
skull,  do  not  puncture  the  dura  mater  to  seek  for  it ; 
which  would  be  of  no  use,  as  the  blood  is  coagulated, 
and  could  not  escape,  being  seated  under  the  pia  mater, 
or  in  the  brain  itself. — {Lectures,  ^c.  p.  289.) 

If,  after  the  removal  of  a portion  of  bone,  the  dura 
mater  should  present  itself  of  a blue  colour,  be  lifted 
up  by  blood  underneath  it,  and  bulge,  as  it  were,  into 
the  aperture,  Mr.  Brodie  approves  of  a puncture  being 
made  in  that  membrane;  and,  though  he  joins  Pott  in 
regarding  a wound  of  the  dura  mater  as  a dangerous 
measure  itself,  he  considers  it  here  justified  by  circum- 
stances, and  supports  his  advice  by  a reference  to  a 
case  in  which  Mr.  Chevalier  thus  discharged  a con- 
siderable quantity  of  blood,  and  the  j'atient  recovered. 
— (See  Med.  and  Physical  Journ.  vol.  8,  p.  505.)  He 
has  also  adduced  another  instance  of  the  success  of  tho 
practice,  in  the  hands  of  my  friend  and  neighbour  Mr. 
Ogle. 

Upon  the  removal  of  a piece  of  bone  by  means  of 
the  trephine ; if  the  operation  has  been  performed  over 
the  part  where  the  disease  is  situated,  and  thb  extra- 
vasation be  of  the  fluid  kind,  and  between  the  cranium 
and  dura  mater ; such  fluid,  whether  it  be  blood,  water, 
or  both,  is  immediately  seen,  and  is  partly  discharged 
by  such  opening ; if,  on  the  other  hand,  the  extravasa- 
tion be  of  blood  in  a coagulated  or  gmmous  state,  it  is 
either  loose  or  in  some  degree  adherent  to  the  dura 
mater ; if  the  former  of  these  be  the  case,  it  is  either 
totally  or  partially  discharged  at  the  time  of,  or  soon 
after,  the  operation,  according  to  the  quantity  or  extent 
of  the  mischief ; if  the  latter,  the  perforation  disco- 
vers, but  does  not  immediately  discharge  it.”  Mr. 
Pott  then  lays  it  down  as  a rule,  that  a large  extrava- 
sation must  necessarily  require  a more  free  removal  of 
bone  than  a small  one ; and  a grumous  or  coagulated 
extravasation  a still  more  free  use  of  the  instrument. 

In  applying  the  trephine,  on  account  of  a fracture 
with  depression,  Mr.  Brodie  deems  the  removal  of  a 
small  portion  of  bone  generally  sufficient;  but  wlicn 


474 


HEAD. 


'blood  is  extrsvssated  on  the  surface  of  the  dura  mater, 
he  recommends  the  bone  to  be  more  freely  taken  away. 
He  founds  this  advice  on  the  circumstances  of  a case 
which  he  has  recorded,  where  a more  limited  opening 
^id  not  give  a sufficiently  ready  outlet  to  the  suppura- 
.tion  that  ensued,  and  the  patient  died. — (See  Med.  Chir. 
Trans,  vol.  14,  p.  386.) 

In  the  treatment  of  pressure  from  extravasation.  Sir 
Astley  Cooper  joins  the  generality  of  surgeons  in  re- 
commending free  depletion,  in  order  to  prevent  intlam- 
.mation  ; the  bowels,  he  says,  are  to  be  ojiened,  and  the 
patient  kept  very  <iuiet.  “ If  there  be  a bruise,  indi- 
cating the  spot  at  which  the  injury  has  been  sustained, 
you  may  trephine  after  every  other  means  has  been 
■tried  ineffectually.  If  a fracture  exists,  and  the  symp- 
toms do  not  yield  to  depletion,  you  will  trephine  to  seek 
the  extravasation.” — {Lectures,  p.  288.) 

All  cases  of  pressure  on  the  brain  are  attended  with 
hazard  of  inflammation  of  this  organ  and  its  mem- 
branes. The  danger  must  be  averted  as  much  as  pos- 
sible, by  applying  cold  washes  to  the  head,  and  em- 
ploying free  and  repeated  bleeding,  leeches,  antimo- 
nials,  saline  purgatives,  and  other  antiphlogistic 
means.  After  the  depleting  method  has  been  con- 
tinued some  time,  blisters  may  be  applied  to  the  head, 
and  the  cold  wash  omitted. 

CONCUSSION  OR  COMMOTION  OF  THE  BRAIN. 

It  is  observed  by  Mr.  Pott,  that  “very  alarming 
symptoms,  followed  sometimes  by  the  most  fatal  con- 
sequences, are  found  to  attend  great  violence  offered  to 
the  head ; and,  upon  the  strictest  examination  both  of 
the  living  and  the  dead,  neither  fissure,  fracture,  nor 
extravasation  of  any  kind  can  be  discovered.  The 
.same  symptoms,  and  the  same  event,  are  met  with, 
when  the  head  has  received  no  injury  at  all  ab  externo, 
but  has  only  been  violently  shaken  ; nay,  when  only 
the  body  or  general  frame  has  seemed  to  have  sus- 
tained the  whole  violence.”  And  he  afterward  re- 
marks, that  “ the  symptoms  attending  a concussion  are 
generally  in  proportion  to  the  degree  of  violence  which 
the  brain  itself  has  sustained,  and  which,  indeed,  is 
cognizable  only  by  the  symptoms.  If  the  concussion 
be  very  great,  all  sense  and  power  of  motion  are  imme- 
diately abolished,  and  death  follows  soon;  but  be- 
tween this  degree  and  that  slight  confusion  (or  stun- 
ning as  it  is  called)  which  attends  most  violences  done 
to  the  head,  there  are  many  stages.”  But  besides  the 
foregoing  description  of  concussion,  which  seems  ra- 
ther to  consist  in  a lesion  of  function  than  in  any 
visible  disorganization.  Sir  Astley  Cooper  has  found 
the  more  violent  degrees  of  it  attended  with  laceration 
of  the  brain,  and  slight  extravasation. — {Lectures,  (S'-c. 
p.  262.)  The  latter,  however,  are  rather  to  be  con- 
sidered as  compound  cases  than  as  instances  of  pure 
concussion.  Mr.  Brodie  has  observed,  that  the  symp- 
toms of  concussion  do  not  depend  upon  any  such  de- 
rangement of  the  organization  of  the  brain  as  admits 
of  being  disclosed  to  us  by  dissection ; yet  he  thinks 
the  inference  not  justified,  that  there  is  really  no  or- 
ganic change.  It  is  difficult,  he  says,  to  conceive  in 
what  other  manner  concussion  of  the  brain  can  ope- 
rate so  as  to  produce  the  effects  which  it  is  known  to 
produce ; and  if  we  consider  that  the  ultimate  struc- 
ture of  the  brain  is  on  so  minute  a scale  that  our  senses 
are  incapable  of  detecting  it.  it  is  evident  that  there 
may  be  changes  and  alterations  of  structure  which  our 
senses  are  also  incapable  of  detecting. — {Brodie  in 
Med.  Chir.  Trans,  vol.  14,  p.  337.) 

Mr.  Abernethy,  I think,  has  removed  a good  deal  of 
the  perplexity  of  this  subject  by  dividing  concussion 
into  three  stages.  In  fact,  without  discriminating  them, 
the  various  descriptions  of  the  symptoms,  as  given  by 
different  writers,  cannot  be  at  all  reconciled. 

“The  first  is,  that  state  of  insensibility  and  de- 
rangement of  the  bodily  powers  which  immediately 
succeeds  the  accident.  While  it  lasts,  the  patient 
scarcely  feels  any  injury  that  may  be  inflicted  on  him. 
His  breathing  is  difficult,  but  in  general  without  ster- 
tor  ; his  pulse  intermits,  and  his  extremities  are  cold. 
But  such  a state  cannot  last  long ; it  goes  off  gradually, 
and  is  succeeded  by  another,  which  I consider  as  the 
second  stage  of  concussion.  In  this,  the  pulse  and  res- 
piration become  better,  and  though  not  regularly  jier- 
formed,  are  sufficient  to  maintain  life,  and  to  diffuse 
warmth  over  the  extreme  parts  of  the  body.  The  feel- 
ing of  the  patient  is  now  so  far  restored,  that  he  is  sen- 


sible if  his  skin  be  pinched ; but  he  lies  stupid  and  in- 
attentive to  slight  external  impressions.  As  the  effects 
of  concussion  diminish,  he  becomes  capable  of  replying 
to  questions  put  to  him  in  a loud  tone  of  voice,  espe- 
cially when  they  refer  to  his  chief  suffering  at  the  time, 
as  pain  in  the  head,  &c. ; otherwise  he  answers  inco- 
herently, and  as  if  h'.s  attention  was  occupied  by  some- 
thing else.  As  long  as  the  stupor  remains,  the  inflam- 
mation of  the  brain  seems  to  be  moderate;  but  as  the 
former  abates,  the  latter  seldom  fails  to  increase;  and 
this  constitutes  the  third  stage,  which  is  the  most  im- 
portant of  the  series  of  effects  proceeding  from  con- 
cussion. 

, These  several  stages  vary  considerably  in  their  de- 
gree and  duration ; but  more  or  less  of  each  will  be 
found  to  take  place  in  every  instance  where  the  brain 
has  been  violently  shaken.  Whether  they  bear  any 
certain  proportion  to  each  other  or  not,  I do  not  know. 
Indeed,  this  will  depend  upon  such  a variety  of  circum- 
stances in  the  constitution,  the  injury,  and  the  after- 
treatment,  that  it  must  be  difficult  to  determine. 

With  regard  to  the  treatment  of  concussion,  it  would 
appear  that  in  the  first  stage  very  little  can  be  done ; 
and,  perhaps,  what  little  is  done  had  better  be  omitted, 
as  the  brain  and  nerves  are  probably  insensible  to  any 
stimulants  that  can  be  employed.  From  a loose  and, 
I think,  fallacious  analogy  between  the  insensibility  in 
fainting  and  that  which  occurs  in  concussion,  the  more 
powerful  stimulants,  such  as  wine,  brandy,  and  vola- 
tile alkali,  are  commonly  had  recourse  to,  as  soon 
as  the  patient  can  be  got  to  swallow.  The  same  rea- 
soning which  led  to  the  employment  of  these  reme- 
dies in  x\\e  first  stage,  in  order  to  recall  sensibility,  has 
given  a kind  of  sanction  to  their  repetition  in  the  second 
with  a view  to  continue  and  increase  it. 

But  here  the  practice  becomes  more  pernicious  and 
less  defensible.  The  circumstance  of  the  brain  having 
so  far  recovered  its  powers  as  to  carry  on  the  animal 
functions  in  a degree  sufficient  to  maintain  life,  is  surely 
a strong  argument  that  it  will  continue  to  do  so,  with- 
out the  aid  of  means  which  probably  tend  to  exhaust 
parts  already  weakened  by  the  violent  action  they  in- 
duce. 

And  it  seems  probable  that  these  stimulating  liquors 
will  aggravate  that  inflammation  which  must  sooner 
orlater  ensue.”— (£.ys£(j/ 071  Injuries  of  the  Head,  p.  59.) 

In  most  cases  of  concussion,  the  patient  vomits  after 
the  accident.  According  to  Mr.  Brodie,  sickness  and 
vomiting  are  generally  early  sympioins,  and  seldom 
continue  after  the  patient  has  recovered  from  the  first 
shock  of  the  accident .—( Med.  Chir.  Trans,  vol.  14,;?. 
S39.)  In  the  beginning,  a torpor  exists  in  the  intesti- 
nal canal,  and  considerable  difficulty  in  procuring  an 
evacuation  ; but  afterward  the  feces  are  sometimes 
involuntarily  discharged ; and  the  bladder  becomes  dis- 
tended, so  as  to  require  the  catheter  ; but  after  a time, 
the  urine  also  comes  away  involuntarily.  There  is 
sometimes  bleeding  at  the  nose,  and  a part  of  the  blood 
which  drops  into  the  throat  is  vomited  up.  The  pupils 
of  the  eyes  are  generally  natural ; but  if  changed,  both 
are  a little  dilated,  or  sometimes  only  one.  The  state 
of  the  pupils,  however,  is  differently  represented  by 
different  writers,  and  my  experience  has  taught  me  that 
it  is  subject  to  much  variety.  In  that  stage  in  which 
the  sensibility  of  the  patient  is  impaired,  but  not  annihi- 
lated, “the  pupils  contract  on  exposure  to  light,  and 
are  sometimes  more  contracted  than  under  ordinary 
circumstances.” — {Brodie,  vol.  cit.  p.  338.)  According 
to  Sir  Astley  Coojier,  the  pulse,  although  natural  when 
the  patient  is  undisturbed,  scarcely  ever  fails  to  be 
quickened  by  any  exertion  made  by  the  patient ; and 
the  carotids  sometimes  pulsate  with  great  force ; but 
the  latter  symptom  is  generally  not  noticed  till  after  a 
few  hours.  The  state  of  the  pulse  is  very  different,  ac- 
cording to  the  stage  of  the  disorder.  In  severe  cases, 
the  pulse  is  at  first  intermitting,  irregular,  feeble,  j>er- 
haps  scarcely  perceptible,  and  the  patient  in  a condi- 
tion approaching  that  of  syncope.  Such  may  be  his  si- 
tuation for  several  hours  after  the  accident.  V^■hen 
concussion  proves  fatal,  the  cause  of  death  is  imputed 
by  Mr.  Brodie  to  this  disturbance  of  the  action  ot  the 
heart.  “ In  general,  when  the  patient  has  lam  for  some 
time  in  the  state  w hich  has  been  described,  a reaciiou 
of  the  circulating  system  takes  place,  and  the  pulse 
beats  with  greater  strength  in  proportion  as  the  failure 
of  it  was  greater  in  the  first  instance.  But  where  the 
shock  has  been  unusually  severe,  there  is  no  such 


HEAD. 


476 


reaction.  The  pulse  becomes  more  and  more  feeble, 
more  irregular  and  intermittent ; the  extremities  grow 
cold,  and  at  last  the  action  of  the  heart  being  altoge- 
ther suspended,  the  patient  expires.  In  some  cases, 
even  after  reaction  has  begun  to  take  place,  it  seems  as 
if  the  constitution  were  unequal  to  the  effort : there  is 
another  failure  of  the  circulation,  the  result  of  which  is 
the  same  as  if  the  patient  had  never  rallied  from  the 
beginning.” — {Brodie,  in  Med.  Chir.  Trans,  vol.  14,  p. 
341.)  The  mind,  as  Sir  Astley  Cooper  remarks,  is  va- 
riously affected,  according  to  the  degree  of  injury  which 
the  patient  has  sustained.  In  some  cases,  there  is  a 
total  loss  of  mental  power ; in  others,  the  patient  is 
capable,  though  with  difficulty,  of  being  roused  to  make 
a rational  answer,  but  immediately  sinks  again  into 
coma.  Sometimes  the  memory  is  lost ; while  in  other 
instances,  it  is  only  partially  impaired.  A total  forget- 
fulness of  any  foreign  language  is  a common  effect  of 
concussion.  It  frequently  happens  that  the  patient, 
when  roused,  will  be  perfectly  sensible  and  answer 
questions  rationally  ; but  if  left  undisturbed,  the  mind 
appears  to  be  occupied  by  some  particular  circumstance 
(often  an  incoherent  one),  of  which  he  is  constantly 
talking.  Patients  recollect  nothing  about  the  mode  in 
which  their  accidents  took  place.  If  the  injury  has  been 
occasioned  by  a fall  from  a horse,  they  can  only  remem- 
ber mounting  and  riding  to  some  distance,  but  not  that 
the  animal  ran  away  or  threw  them ; nor,  however 
perfectly  they  may  recover  in  other  respects,  do  they 
ever  have  any  recollection  of  the  kind  of  accident. 
The  change  produced  by  injuries  of  the  brain  is  re- 
marked to  be  somewhat  similar  to  the  effects  of  age  ; 
the  patient  loses  impressions  of  a recent  date,  and  is 
sensible  of  those  which  he  received  in  his  earlier  years- 
But,  as  Sir  Astley  correctly  explains,  I he  degree  of  in- 
jury sustained  by  the  brain  varies  considerably  in  dif- 
ferent cases.  Some  patients  are  only  stunned,  or  de- 
jtrived  of  sense  for  a moment ; others  recover  in  a 
few  hours  ; some  remain  in  a great  degree  insensible 
for  fifteen  or  twenty  days.  Some  recover  entirely ; 
others  have  afterward  an  imperfect  memory.  A par- 
tial loss  of  sense  will  be  produced  in  the  function  of 
one  eye,  or  deafness  in  one  ear ; and  so  of  volition, 
the  squinting  caused  by  an  injury  of  the  brain  being 
>sometimes  permanent.  In  some  cases  a degree  of  fa- 
tuity ; in  some,  great  irritability ; in  others,  vertigo, 
and  tendency  to  severe  headache  from  the  slightest  e.x- 
citement,  will  remain.  In  one  example  seen  by  Sir 
Astley  Cooper,  a remarkable  irritability  of  the  stomach 
and  disposition  to  vomit  were  the  permanent  conse- 
quences of  a concussion  of  the  brain.  In  particular 
Instances,  the  faculty  of  readily  uttering  the  pro])er 
words  for  expressing  ideas  is  lost  and  never  regained, 
and  wrong  terms  are  used.  Often  the  judgment  re- 
mains enfeebled. — {Le:  tures,vol.  1,  p.  254,  a c.)  Many 
of  the  observations  in  the  foregoing  statement  coincide 
with  the  accounts  given  of  the  subject  in  the  writings 
of  Bichat  and  Desault. 

The  following  passage,  extracted  from  a writer  who 
has  already  been  of  material  assistance  in  this  article, 
cannot  be  too  deeply  impressed  on  the  memory  of  every 
surgical  practitioner. 

“To  distinguish  between  an  extravasation  am!  com- 
jfiotion  by  the  symptoms  only,  is  frequently  a vf  ry  dif- 
ficult matter,  sometimes  an  impossible  one.  The  si- 
milarity of  the  effects  in  some  cases,  and  the  very  small 
space  of  time  which  may  intervene  between  the  going 
off  of  the  one  and  accession  of  the  other,  render  this  a 
very  nice  exercise  of  the  judgment.  The  first  stun- 
ning or  deprivation  of  sense,  whether  total  or  partial, 
may  be  from  either,  and  no  man  can  tell  from  which  ; 
but  when  these  first  symptoms  have  been  removed,  or 
have  spontaneously  disappeared,  if  such  patient  is  again 
oppre.ssed  with  drowsiness  or  stupidity,  or  a totai  or 
partial  loss  of  sense,  it  then  becomes  most  probable, 
that  the  first  complaints  were  from  commotion,  and  that 
the  latter  arc  from  extravasation  ; and  the  greater  the 
distance  of  time  between  the  two,  the  greater  is  the  pro- 
bability not  only  that  an  extravasation  is  the  cause,  but 
that  the  extravasation  is  of  the  limpid  kind,  made  gra- 
datiin,  and  within  the  brain. 

When  there  is  no  reason  to  apprehend  any  other  in- 
jury, and  commotion  seems  to  be  the  sole  disease, 
plentiful  evacuation  by  phlebotomy  and  lenient  cathar- 
tics, a dark  room,  the  most  perfect  quietude,  and  a very 
low  regimen,  are  the  only  means  in  our  power;  and 
are  sometimes  successful.” — (Pott.)  When  the  patient 


is  at  all  sensible,  every  thing  likely  to  irritate  the 
mind  is  to  be  avoided. — (A.  Cooper,  Lectures,  ^c.  p. 
21^,  vol.  1.) 

With  these  means  should  also  be  associated  the 
constant  application  to  the  head  of  cloths  dipped  in 
very  cold  water,  or  'Schmucker’s  frigorific  lotion. 
When  the  effects  of  the  violence  are  not  necessarily 
fatal  in  a very  short  time  after  the  accident,  the  great 
danger  which  is  to  be  guarded  against  is  certainly  in- 
flammation of  the  brain.  Hence  the  necessity  of  freely 
employing  the  lancet  and  antiphlogistic  means.  The 
discrimination  which  Mr.  Abernethy  introduced  into 
the  views  of  the  present  subject,  by  his  division  of 
concussion  into  three  stages,  has  led  also  to  more  ra- 
tional and  successful  practice.  For,  though  bleeding 
is  now  generally  allowed  to  be  the  great  means  of  re- 
lief in  concn.ssion,  it  is  not  rashly  practised  at  the 
beginning  of  many  cases,  when  the  pulse  can  hardly 
be  felt,  w’hen  the  circulation  scarcely  goes  on,  and 
every  action  in  the  system  is  nearly  annihilated.  But 
the  state  of  the  pulse  and  circulation  is  closely 
watched,  and  the  surgeon  bleeds  in  sufficient  time  and 
quantity,  to  prevent  in  many  instances  that  immoderate 
frequency  and  hardness  which  the  pulse  always  has 
a tendency  in  these  cases  to  assume,  immediately  the 
first  shock  of  the  accident  begins  to  abate.  “ Bleed- 
ing,” as  Sir  Astley  Cooper  correctly  notices,  “ may  be 
carried  to  excess.  You  must,  in  the  repetition  of  bleed- 
ing, regulate  your  conduct  by  the  symptoms;  observe 
whether  there  be  any  hardness  in  your  patient’s  pulse, 
and  whether  he  complains  of  pain  in  the  head,  if  he 
have  still  the  power  of  complaining.  Watch  your  pa- 
tient with  the  greatest  possible  anxiety ; visit  him  at 
least  three  times  a day  ; and  if  you  find  any  hardness 
of  the  pulse  supervening  after  the  first  copious  bleed- 
ing, take  away  a tea-cupful  of  blood ; but  do  not  go 
on  bleeding  him  largely;  for  you  would,  by  this 
means,  reduce  the  strength  too  much,  and  prevent  the 
reparative  process  of  nature.”  Sir  Astley  admits,  how- 
ever, that  it  is  frequently  necessary  to  take  away 
blood  after  the  first  bleeding  ; but  he  directs  this  to  be 
generally  done  in  small  quantities.  He  acknowledges, 
also,  that  it  is  sometimes  necessary  to  take  away  large 
quantities  by  repeated  bleedings. — (P.  271.)  The  re- 
covery of  many  cases  which  have  fallen  under  my 
own  observation,  I have  imputed  to  the  frequent  and 
even  copious  abstraction  of  blood,  by  means  of  the 
lancet,  leeches,  and  cupping ; at  the  same  time,  1 know 
that  this  practice  is  often  carried  beyond  all  modera- 
tion, without  due  attention  to  those  circumstances 
which  I have  pientioned  as  the  proper  guide. 

I believe,  with  Mr.  Abernethy  and  Mr.  Brodie,  that 
in  the  very  first  stage  of  concussion,  when  all  the 
powers  of  life  are  depressed,  cordials  and  stimulants 
can  rarely  be  employed  with  advantage.  The  latter 
gentleman  has  lately  offered  some  considerations 
against  the  method  which  merit  attention.  There  are, 
he  observes,  sufficient  reasons  why  we  should  regard 
that  condition  of  the  system  which  approaches  to  syn- 
cope, as  being  mostly  conducive  to  the  patient’s  wel- 
fare, and  why  we  should  wish  to  prolong  rather  than 
abridge  the  period  of  its  duration.  The  same  blow 
which  gives  rise  to  symptoms  of  concussion,  he  re- 
marks, frequently  occasions  the  rupture  of  some  small 
vessels  within  the  cranium.  The  same  state  of  the 
system  which  produces  an  enfeebled  action  of  the 
heart,  is  calculated  to  prevent  the  ruptured  vessels 
from  pouring  out  their  contents;  and  the  longer  it  con- 
tinues,  the  less  is  the  danger  of  internal  hemorrhage. 
If  we  excite  the  action  of  the  heart  with  wine  and  am- 
monia, we  may  bring  on  symptoms  of  pressure  on  the 
brain.  If,  on  the  contrary,  we  watch  the  gradual  re- 
storation of  the  pulse,  and  bleed  at  the  proper  moment 
in  quantity  sufficient  to  keej)  down  the  action  of  the 
heart,  we  may  often  check  extravasation.  Mr.  Brodie 
also  argues,  that  as  the  state  of  depression  is  followed 
by  one  of  excitement,  it  is  another  strong  consideration 
in  favour  of  avoiding  stimuli,  and  having  recourse  to 
bleeding  in  time  to  prevent  the  action  of  the  heart  from 
becoming  too  vehement. — (See  Med.  Chir.  Trans,  vol, 
14,  p.  377.) 

With  respect  to  emetics,  I have  no  confidence  my- 
self in  their  usefulness  in  cases  of  concussion,  and 
much  doubt  even  their  safety,  especially  when  the  dis- 
order is  complicated  with  extravasation  (A.  Cooper, 
Lectures,  i^c.  vol.  1,  p.  276),  a point  often  incapable 
of  positive  decision. 


476 


HE  A 


HEM 


Purgative  an  antimoriial  medicines  siiou’.d  be  pre- 
scribed, and  a low  regimen  enjoined.  After  bleeding 
has  been  freely  practised  and  the  bowels  emptied,  blis- 
ters on  the  scalp  and  nape  of  the  neck  are  frequently 
very  useful  in  preventing  or  les.sening  the  tendency  to 
Inflammation  of  the  brain  and  its  membranes. 

As  bleeding  from  the  arm  cannot  be  employed  in 
young  children,  Sir  A.  Cooper  recommends  the  exhibi- 
tion of  calomel,  with  acescent  drinks,  so  as  to  purge 
them  ; and  leeches,  or  opening  the  jugular  vein. 

For  the  relief  of  certain  symptoms,  frequently  re- 
maining after  concussion,  as  pain  in  the  head,  giddi- 
ness, diminution  of  sight,  and  deafness.  Sir  A.  Cooper 
directs  the  head  to  be  washed  with  spirit  of  wine  and 
water,  or  the  use  of  the  shower-bath.  Sometimes  he 
orders  the  ung.  canlhar.  to  be  rubbed  on  the  head,  and 
pil.  hydrarg.  and  exir.  eolocynth.  to  be  given.  In  cases 
of  nervous  debility  of  an  organ,  electricity  is  sometimes 
useful;  and  occasionally,  in  long-continued  pains  of  the 
head,  he  forms  an  issue  in  the  scalp,  benefit  sometimes 
resulting  even  from  slight  exfoliations. — {Lectures, 
vol.  1,  p.  280.)  These  measures  are  infinitely  more 
prudent  than  the  old  custom  of  trephining. 

I cannot  conclude  this  article  without  adverting  to 
the  great  propensity  to  relapse,  after  patients  have  long 
appeared  out  of  every  danger  from  wounds  of  the  head, 
the  bad  symptoms  sometimes  coming  on  again,  and 
proving  fatal  many  years  after  the  original  injury,  as 
is  stroiigly  exemplified  in  a case  related  in  a work  of 
high  character. — (See  Schmucker's  Vermisckte  Schrif- 
ten,  b.\,p.  247.) 

[In  the  third  number  of  the  Amer.  Jour,  of  the  Med. 
and  Pkys.  Sciences,  Professor  Sewall,  of  Washington 
city,  has  reported  two  cases  of  fracture  of  the  cranium, 
with  loss  of  a portion  of  the  substance  of  the  brain. 
The  wound  in  one  of  them  was  inflicted  with  a spade, 
which  penetrated  through  the  dura  mater  and  into  the 
medullary  portion  of  the  brain.  The  antiphlogistic  treat- 
ment was  relied  upon  from  the  commencement,  and 
during  the  suppuration  which  followed : the  brain  it- 
self protruded  and  sloughed  away,  and  subsequently 
portions  of  it  were  removed  by  the  spatula.  This  pa- 
tient, nevertheless,  recovered  entirely  in  six  weeks  after 
the  accident. 

Professor  Dudley  has  also  written  a valuable  paper 
on  injuries  of  the  head,  which  may  be  found  in  the  first 
number  of  the  Transylvania  Journal  of  Medicine.  He 
reports  a number  of  cases  of  epilejisy  occurring  after 
injuries  of  the  cranium,  which  he  has  cured  by  tre- 
phining. In  confirmation  of  his  views  I may  here  refer 
to  a case  published  in  the  5th  vol.  of  the  N.  Y.  Med. 
and  Phys.  Journal,  in  which  epilepsy,  originating  from 
depression  of  bone,  was  cured  by  trephining,  % Dr. 
David  L.  Rogers,  of  this  city. — Reese.] 

Hippocrates,  De  Capitis  Vulneribus,  l'2rno.  Lutetm, 
1578.  Jac.  Berengarius,  De  Fracturu  Cranii,  Bologna, 
1513.  James  Yonge,  Wounds  of  the  Brain  proved 
curable,  not  only  by  the  Opinion  and  Experience,  of 
many  of  the  best  Authors,  but  the  remarkable  History 
of  a Child  cured  of  two  very  large  Depressions,  with 
the  Loss  of  a great  Part  of  the  Skull ; a Portion  of 
the  Brain  also  issuing  through  a penetrating  Wound 
of  the  Dura  and  Pia  Mater,  \2mo.  Lond.  1682.  J.  J. 
Wepfer,  Observationes  Medico-practicae  de  Affectibus 
Capitis  internis  et  externi.s,  Scaphusii,  1727.  Murray, 
An  post  gravem  ab  ictu  vel  casu  capitis  percussionem, 
non  juvante  etiam  iterata  terebratione,  dura  meninx 
incisione  aperienda?  Lutet.  Paris,  1736.  (Haller,  Disp. 
Chir.  vol.  1,  p.  97.)  R.  C.  Wagner,  De  Contrufssura, 
Jen<B,  1708.  (Haller,  Disp.  Chir.  vol.  1,  p.  15.)  J.  C. 
Teubeler,  De  Vulneribus  Cerebri  non  semper  lethalibus, 
Halae,  1760.  J.  Chr.  Camerarius,  Diss.  Inaug.  exhi- 
bens  rarissimam  Sanationem  Cerebri  quassati  cum 
notabili  Substantice  Deperditione,  Tubing.  1719.  Alex. 
Camerarius,  et  Th.  Fr.  Faber,  De  Apostemate  Pias  Ma- 
tris.  Tubing.  1722.  J.  A.  Conradi,  De  Vulnere  Fronti 
injiictn,  Ltigd.  1722.  M.  E.  Boretius,  et  J.  G.  Arnoldt, 
De  Epilepsia  ex  Depresso  Cranio,  Regiomont.  1724. 
G.  A.  Langguth,  Prograrnma  de  Sinus  Frontalis  Vul- 
nere sine  Terebratione  curando,  Wittemb.  1748.  Cho- 
part,  Memoire  sur  les  Lesions  de  la  Tete  par  Cimtre- 
coup,  8no.  Paris,  1771.  J.  La  Fosse,  De  Cerebri  Affecti- 
bus  a Causis  extemis  evidentibus,  Monsp.  1763.  A.  J. 
Van  Hulst,  De  Cerebri  ejusqne  Membranarum  lufiarn- 
rnatione  et  Suppuratione  occulta,  Ghidlenop,  1784.  P. 
J.  Primelius,  De  Utilitate  Incisionis  integumentorum 
Capitis  in  Lassionibus  Capitis,  S,  c.  Aeltlire,  1788.  Bor-  | 


denave,  in  Mim.  de  VAcad.  de  Ckirurgie,  t.  2.  Le 
Dr  an,  TrniU  des  Operations  de  Chirurgie.  J.  L.  Petit, 
Trait  des  Mai.  Chir.  t.  I.  Dease,  Obs.  on  Wounds  of 
the  Head,  Svo.  Lond.  1776.  Pott  on  Injuries  of  the 
Head  from  External  Violence.  Hill's  Cases  in  Sur- 
gery. O'Halloran  on  the  different  Disorders  arising 
from  External  Injuries  of  the  Head,  8vo.  Dublin,  1793. 
Some  cases  in  Desault's  Parisian  Chirurgical  Journal. 
M moire  sur  les  Plaies  de  Tete,  in  (l.uvres  Chir.  de 
Desault,  par  Bichat,  t.  2.  Lassus,  Pathologic  Chirur- 
gicale,  t.  2,  p.  252,  A c.  edit.  1809.  Schmucker's  Wahr- 
nehmungen,  b.  1 ; and  Vermischte  Chir.  Schriften, 
b.  1 and  3,  Svo.  Berlin,  1785.  Richeraud,  Nosographie 
Chir.  t.  2,  p.  230,  et  seq.  <dit.  4.  J.  Abemethy  gn  In- 
juries of  the  Head,  in  his  Surgical  Works,  vol.  2,  ed. 
1811.  Larrey,  in  Mem.  de  Chir.  Militaire,  t.  2,  3,  et  4, 
8vo.  Paris,  1812 — 1817.  Dr.  Hennen,  Principles  of 
Military  Surgery,  ed.  2 8vo.  Edin.  1820.  The  three 
last  works,  and.  those  of  Le  Dran,  Petit,  Desault,  and 
Bichat,  Dense,  O'Halloran,  Pott,  and  Schmucker,  de- 
serve particular  attention.  Also,  Dr.  J.  Thomson's  Re- 
port of  Observations  made  in  the  Military  Hospitals 
in  Belgium,  Edinb.  1816.  Sir  Astley  Cooper,  Lectures 
on  the  Principles,  <S~c.  of  Surgery,  vol.  1,  1824,  B.  C. 
Brodie,inMed  Chir. Trans.vol.  14,1828.  See  TYephine. 

HEMERALOPIA.  According  to  M.  Dujardin,  this 
term  is  (ferived  from  fjpipa,  the  day,  dAods,  blind,  and 
uiip,  tlie  eye,  and  its  right  signification  is  therefore  in- 
ferred to  be  diuma  ccecitudo,  or  day-blindness. — (See 
Journal  de  Med.  t.  19,  p.  348.)  In  the  same  sense.  Dr. 
Hillary  (Obs.  on  the  Diseases  of  Barbadoes,  p.  298, 
edit.  2)  and  Dr.  Heberden  (Med.  Trans,  vol.  1,  art.  5) 
have  employed  the  term. 

Hemeralopia,  then,  which  is  of  very  rare  occurrence, 
stands  in  opposition  to  the  nyctalopia  of  the  ancients, 
or  night-blindness.  Numerous  modem  writers,  how- 
ever, have  used  these  terms  in  the  contrary  sense ; 
considering  the  hemeralopia  as  denoting  sight  during 
the  day,  and  blindness  in  the  night ; and  nyctalopia  as 
expressing  night-seeing,  owl-sight,  as  the  French  call 
it,  and  blindness  during  the  daytime. 

Hemeralopia,  in  the  meaning  of  day-blindness,  is  a 
very  uncommon  affection.  Dr.  Hillary  never  met  with 
but  two  examples.  He  mentions  a report,  however, 
that  there  are  a people  in  Siam,  in  the  East  Indies,  and 
also  in  Africa,  who  are  subject  to  the  disease  of  being 
blind  in  the  daytime,  and  seeing  well  by  night.— -(Mod. 
Univ.  Hist.  vol.  7.) 

According  to  Sauvages,  hemeralopia  (in  his  nomen- 
clature called  amblyopia  crepuscularis)  was  in  some 
degree  epidemic  in  the  neighbourhood  of  Montpellier, 
in  the  villages  in  damp  situations,  adjoining  rivers,  and 
it  particularly  affected  the  soldiers,  who  slept  in  the 
open  damp  air.  They  were  cured,  he  says,  by  blister- 
ing, together  with  emetics  and  cathartics,  and  other 
evacuaiits.— (iVosoZ.  Method,  class  6,  gen.  3,  spec.  1.) 

See  some  ingenious  observations  on  the  subject  in 
Dr.  Rees's  Cyclopaedia,  art.  Hemeralopia,  and  by  Mr. 
Bampfield,  in  Med.  Chir.  Trans,  vol.  5,  p.  34,  Scc. 

Scarpa,  with  the  generality  of  modern  writers,  has 
considered  hemeralopia  as  an  affection,  in  which  the 
patient  sees  very  well  in  the  day,  but  not  in  the  night- 
time. 

The  abolition  of  eyesight  by  night  (observes  Mr. 
Bampfield)  has  occurred  in  all  ages,  and  is  a common 
disease  of  seamen  in  the  East  and  West  Indies,  Medi- 
terranean, and  in  all, hot  and  trojiical  countries  and 
latitudes,  and  affects  more  or  less  the  natives  likewise 
of  those  regions  of  the  globe.  It  also  occurs  frequently 
among  soldiers  in  the  East  and  West  Indies;  but  he 
has  been  informed  that  it  is  by  no  means  so  prevalent 
among  them  as  sailors.  It  is  not  an  uncommon  com- 
plaint of  the  Lascars  employed  in  the  East  India  Com- 
pany’s ships  trading  between  India  and  Europe.  It 
has  very  rarely  indeed  affected  the  officers  of  his  Ma- 
jesty’s or  of  the  East  India  Company’s  ships.  Celsus 
has  remarked,  that  women  and  virgins,  whose  men- 
strual returns  are  regular,  are  exempt  from  this  disease 
(lib.  6,  cap.  6) ; and  it  may  be  observed,  that  the  in- 
habitants of  cold  latitudes  are  less  subject  to  hemera- 
lopia in  their  own  climate,  than  the  natives  of  tropical 
countries  are  in  theirs;  but  more  so,  when  they  visit 
the  tropics. — (Med  Chir.  Trans,  vol.  5,  p.  38.) 

'•^Hemeralopia,  or  noctunial  blindness  (r.ays  Scarpa), 
is  properly  nothing  but  a kind  of  imperfect  periudK-al 
amaurosis,  most  commonly  sympathetic  with  the  sto- 
mach. Us  paroxysms  come  on  towards  the  evening,  and 


HEMERALOPIA.  477 


disappear  in  the  morning.  Tiie  disease  is  endemic  m 
some  countries,  and  epidemic  at  certain  seasons  of  the 
year  in  others. 

At  sunset,  objects  appear  to  persons  affected  with 
the  complaint,  as  if  covered  with  an  ash-coloured  veil, 
which  gradually  changes  into  a dense  cloud,  which  in- 
tervenes between  the  eyes  and  surrounding  objects. 
Patients  with  hemeralopia  have  the  pupil,  both  in  the 
day  and  night-time,  more  dilated  and  less  moveable 
than  it  usually  is  in  healthy  eyes.  The  majority  of 
them,  however,  have  the  pupil  more  or  less  moveable 
in  the  daytime,  and  always  expanded  and  motionless 
at  night.  When  brought  into  a room  faintly  lighted  by 
a candle,  where  all  the  bystanders  can  see  tolerably 
well,  they  cannot  discern  at  all.  or  in  a very  feeble 
manner,  scarcely  any  one  object : or  they  only  find 
themselves  able  to  distinguish  light  from  darkne.ss  : 
and  at  moonlight  their  sight  is  still  worse.  At  day- 
break they  recover  their  sight,  which  continues  perfect 
all  the  rest  of  the  day  till  sunset.”— (Cap.  ID,  p.  322, 
ed.  Svo.) 

According  to  Mr.  Bampfield,  the  disease  always  af- 
fects both  eyes  at  the  same  time.  “ In  general  (says 
this  gentleman),  the  nocturnal  blindness  is  at  first  par- 
tial, the  patient  is  enabled  to  see  objects  a short  time 
after  sunset,  and  perhaps  will  be  able  to  see  a little  by 
clear  moonlight.  At  this  period  of  the  complaint,  he  is 
capable  of  seeing  distinctly  by  bright  candlelight.  The 
nocturnal  sight,  however,  becomes  daily  more  impaired 
and  imperfect ; and,  after  a ffew  days,  the  patient  is 
unable  to  discriminate  the  largest  objects  after  sunset, 
or  by  moonlight,  &c. ; and  finally,  after  a longer  lapse 
of  time,  he  cannot  perceive  any  object  distinctly  by  the 
brightest  candlelight.  If  the  patient  is  permitted  to  re- 
main in  this  state  of  disease,  the  sight  will  become 
weak  by  daylight,  the  rays  of  the  sun  will  be  too  power- 
ful to  be  endured,  whether  they  are  direct  or  reflected ; 
lippitude  is  sometimes  induced ; myopism,  or  short- 
ness of  sight  succeeds ; and  in  progress  of  time  vision 
becomes  so  impaired  and  imperfect,  that  apprehensions 
of  a total  loss  of  sight  are  entertained  ; and  this  dread- 
ful consequence  has  been  known  to  ensue,  where  the 
complaint  has  been  totally  neglected,  or  left  to  nature, 
or  where  ineffectual  remedies  have  been  employed.”— 
{Bo7iti7is,  p.  73.) 

“It  has  been  remarked  by  some,  that  the  patients 
are  capable  of  seeing  distinctly,  at  all  periods  of  the 
complaint,  with  the  aid  of  a strong  artificial  light ; but 
in  bad  cases  of  hemeralopia,  in  my  practice,  the  pa- 
tients positively  denied  the  existence  of  the  sense  of 
distinct  sight  by  very  clear  candlelight.”— (Ham^eW, 
in  Medico-Chir.  Trans,  vol.  5,  p.  39,  40.) 

The  duration  of  the  disea.se,  when  left  to  itself,  is 
generally  from  two  weeks  to  three  or  six  months.  Ex- 
perience has  not  proved  that  the  disposition  to  the 
complaint  depends  Uj>on  any  particular  colour  of  the 
iris,  as  several  writers  have  conjectured  ; nor  upon  the 
largeness  of  the  eyes,  as  alleged  by  Hippocrates. — 
{Lib.  6,  sec.  7.) 

In  idiopathic  cases,  the  health  does  not  in  general 
suffer,  and,  except  in  the  worst  stage,  the  eye  is  not 
altered  .n  appearance.  But  in  cases  of  long  duration 
the  pupil,  according  to  Mr.  Bampfield,  “ is  often  con- 
tracted, and  the  eyes  and  actions  of  the  patient  evince 
marks  of  painful  irritation,  if  the  eyes  are  exposed  to 
a vivid  light,  or  if  he  looks  upw  ards.  But  if  they  meet 
the  direct  rays  of  the  sun,  which  in  the  tropics  are 
always  powei  Ail,  or  a strong  glaring  reflection  of  them, 
pain  and  temtiorary  blindness  are  induced,  from  which 
the  patient  recovers  by  closing  his  eyelids  for  a time  to 
exclude  the  rays  of  light,  and  retiring  to  the  shade.  The 
pupil  of  the  eye  is  considerably  dilated  both  by  day  and 
night,  in  the  proportion  of  about  one  case  in  tw-elve,  and 
at  night  the  pupil  is  often  dilated,  and  does  not  perform 
its  expansions  and  contractions  when  exposed  to  the 
moon  or  artificial  light.  The  cases  attended  with  di- 
lated pupil  were  generally  those  of  long  duration,  &c. 

“ Europeans,  who  have  been  once  affected  with  he- 
meralopia in  tropical  climates,  are  particularly  liable 
to  a recurrence  of  this  disea.se  as  long  as  they  remain 
in  them.” — {Bamjfield,  op.  dt.  p.  42,  43.) 

In  two  examples,  described  by  i)r.  Andrew  Smith, 
the  pupils  were  observed  to  contract  and  dilate  regu- 
larly in  the  daytime,  according  to  the  quantity  of  light ; 
but  after  sunset  they  seemed  a little  more  dilated  than 
natural,  and  contracted  but  sluggishly  upon  exposure 
to  light,  while  the  eyes  themselves  sjemed  devoid  of 


their  usual  energy  and  vivacity.— (See  Edinb.  Med. 
and  Surgical  Jrnim.  No.  74,  p.  22.) 

The  remote  causes  of  idiopathic  hemeralopia  are  not 
well  ascertained.  Sleeping  with  the  face  exposed  to  the 
brilliancy  of  daylight,  the  vivid  reflection  of  the  sun’s 
rays  from  the  sandy  shores  of  hot  countries,  and  bright 
moonlight,  have  been  enumerated  as  causes.  Dr.  Pye 
thinks  the  disorder  intermittent. — {Med.  Obs.  and  In- 
quiries, vol  1,  art.  13.)  But,  as  Mr.  Bampfield  properly 
observes,  though  the  complaint  is  certainly  periodical,- 
there  is  nothing  in  its  character  tending  to  prove  that 
it  is  influenced  by  the  same  causes  as  intermittent 
fever.  The  latter  gentleman  conjectures,  “ that  too 
much  light  suddenly  transmitted  to  the  retina,  or  for  a 
long  period  acting  on  it,  may  afterward  render  it  unsus- 
ceptible of  being  stimulated  to  action  by  the  weaker  or 
smaller  quantities  of  light  transmitted  to  it  by  night.”^ 
— (P.  44.)  The  same  sentiment  is  adopted  by  Dr. 
Smith. — {Edinb.  Med.  Journ.  No.  74,  p.  23.)  Among 
other  objections  to  this  explanation,  however,  it  might 
be  remarked,  that  the  patients  do  not  always  see, 
though  the  light  be  good ; and  Mr.  Bampfield’s  own 
“ patients  positively  denied  the  existence  of  distinct 
sight  by  very  clear  candlelight.”  Besides,  if  the  dis- 
ease were  entirely  caused  by  the  sudden  or  long  opera- 
tion of  vivid  light,  one  would  conclude  that  all  persons 
subjected  to  that  cause  ought  to  have  the  effect  pro- 
duced, which  is  far  from  being  the  case. 

When  the  tongue  is  white,  and  the  patient  has  head- 
ache and  bilious  complaints,  M.  Lassus  thinks  the 
cause  of  the  disease  is  in  the  stomach  and  primae  vise. 
The  same  author  likewise  states,  that  hemeralopia 
attacks  debilitated  persons  subject  to  catarrhal  affec- 
tions, residing  in  damp  situations,  and  living  on  indi- 
gestible food.  From  the  combination  of  such  causes 
(says  he)  the  disorder  was  epidemic  in  the  vicinity  of 
Montpellier  {Sauvage,  Nosolog.  M thod.  t.  2,  p.  732) ; 
at  Belle-Isle  sur  Mer.  {Recueil  d'Observ.  de  Medecine 
des  Hopita^ix  Militaires,  par  Richard,  t.  2,  p.  573) ; 
and  hence  it  is  endemic  in  watery  situations  where 
the  nights  are  cold  and  damp.  They  who  expose  them- 
selves to  this  humidity  (says  1)1.  Lassus),  or  who  navi- 
gate along  the  eastern  coasts  of  Africa,  who  traverse 
the  Mozambique  channel,  or  sail  along  the  coasts  of  Ma- 
labar and  Coromandel,  are  sometimes  attacked  by  it. 
— (See  Pathologie  Chir.  t.  2,  p.  542,  543.)  Hemeralopia 
sometimes  occurs  as  a symptom  of  the  scurvy.  This 
fact  was  noticed  by  Mr.  Telford,  in  Sir  G.  Blane’s  Trea- 
tise on  Diseases  of  Seamen,  and  it  is  likewise  con- 
firmed by  Mr.  Bampfield,  who  remarks  that  hemeralopia 
should  be  referred  to  the  same  causes  as  scurvy, 
“ when  the  subject  of  it  has  for  a long  period  .subsisted 
on  a salted  diet  at  sea,  &c.,  and  if  any  other  scorbutic 
symptom  be  present,  such  as  spongy  gums,  ecchy- 
moses,  saline  smell  of  the  secretions,  ulcers,  with  liver- 
like fungus,  &c.” — {Medico-Chir.  Trans,  vol.  5,  p.  45.) 

This  disease,  according  to  Scarpa,  may  commonly  be 
completely  cured,  and  oftentimes  in  a very  short  time, 
by  treating  it  on  the  same  plan  by  which  the  imperfect 
amaurosis  is  remedied  (see  Amaurosis) ; viz.  by  em- 
ploying emetics,  the  resolvent  powders  and  pills,  and  a 
blister  on  the  nape  of  the  neck ; and  topically,  the  va- 
pours of  ammonia  ; lastly,  by  prescribing  towards  the 
end  of  the  treatment  bark  conjoined  with  valerian.  In 
cases  in  which  the  disease  has  been  preceded  by  ple- 
thora and  suppressed  perspiration,  bleeding  and  su- 
dorifics  are  also  indicated. — {Cap.  19,  p.  322.  333.) 

Scarpa  supports  this  statement  by  the  relation  of 
three  cases  in  which  he  cured  the  disease  by  such 
treatment.  These  patients  were  all  unhealthy,  and 
evidently  labouring  under  disorder  of  the  gastric  organs. 

One  hundred  cases,  hoAvever,  of  idiopathic,  and  two 
hundred  of  synqitomatic  hemeralopia,  occurred  in  the 
practice  of  Mr.  Bampfield  in  different  parts  of  the  globe, 
but  chiefly  in  the  East  Indies.  All  these  cases  per- 
pectly  recovered  : and  hence  we  may  infer  that  under 
proper  treatment  a favourable  prognosis  may  always 
be  given. 

C’elsus  has  stated  that  persons  who  have  been  for 
some  time  affected  with  amaurosis,  have  regained  their 
sight  on  being  attacked  by  a diarrheea.  'I'liis  .seems  to 
Scarpa  to  be  corroborated  by  the  case  related  by  Dr. 
Pye. — {Med.  Obs.  and  Inq.  vol.  1.)  Scarpa  entertains 
no  doubt  that  many  similar  facts,  showing  the  influence 
of  what  he  terms  morbific  gastric  stimuli  over  the  or- 
gan of  sight,  might  he  found  in  the  records  of  medi- 
cine, ami  proving  the  great  utility  of  a siioiuaneous 


478  HEM  HEM 


looseness  of  the  bowels  in  the  cure  of  imperfect  amau- 
rosis. 

But,  says  Scarpa,  even  if  such  examples  of  incom- 
plete amaurosis  beitig  dissipated  in  consequence  of 
spontaneous  vomiting  or  copious  evacuations  from  the 
bowels,  produced  entirely  by  nature,  were  rare,  and 
noticed  by  few,  we  now  liave  many  cases  evincing  the 
Successful  cure  of  this  disease  by  means  of  such  eva- 
cuations artificially  produced  by  emetics  and  purgative 
medicines.  Of  this  the  accurate  observations  of 
Schmucker  and  Richter  furnish  us  with  numerous 
satisfactory  proofs,  and  it  is  added,  that  our  confidence 
in  the  above  method  of  curing  the  imperfect  and  pe- 
riodical amaurosis  mu.st  increase  when  we  take  notice 
that  the  most  respectable  practitioners  of  past  times 
have,  in  the  majority  of  cases,  cured  this  disease  only 
by  means  of  emetics  and  opening  medicines,  though 
in  their  writings  they  may  have  imputed  the  success  of* 
the  treatment  to  other  causes,  or  the  efficacy  of  other 
remedies  which  were  also  prescribed. 

Scarpa,  after  several  valuable  remarks  on  amaurosis 
in  general,  refers  to  the  Mercure  de  France,  for  Febru- 
ary, 1756,  where  there  is  an  account  of  the  cures  per- 
formed by  Fournier,  by  means  of  bleeding  and  emetics. 

Night-blindness  is  sometimes  congenital,  and  there- 
fore constitutional,  and  altogether  beyond  the  reach  of 
any  curative  measure.  It  is  said  sometimes  to  be  he- 
reditary, and  the  writer  of  the  article  Nyctalopia  in 
Dr.  Rees’s  Cyclopaedia  was  acquainted  with  an  instance 
in  which  it  occurred  to  two  children  of  the  same  family. 
A case  of  congenital  nyctalopia,  which  had  continued 
many  years  without  change,  and  independently  of  any 
disease,  is  related  by  Dr.  Parham. — (See  Med.  Obs.  and 
Inquiries,  vol.  1,  p.  122,  note.) 

Pellier  {Recueil  de  Mim.  et  Obs.  sur  I’iEil,  obs.  132) 
cured  hemeralopia  by  repeated  doses  of  tartar-emetic, 
a seton  in  the  nape  of  the  neck,  and  cooling,  aperient 
beverages. 

The  method  of  treatment  which  Mr.  Bampfield 
adopted  is  certainly  quite  simple.  “ A succession  of 
blisters  to  the  temples  (says  he),  of  the  size  of  a crown 
or  half-crown  piece,  applied  tolerably  close  to  the  ex- 
ternal canthus  of  the  eye,  has  succeeded  in  every  case 
of  idiopathic  hemeralopia  which  I have  seen,  &c.  The 
first  application  of  blisters  commonly  enables  the  patient 
to  see  dimly  by  candlelight,  or  perceive  objects  without 
the  power  of  discriminating  what  they  are.  In  some 
slight  cases  which  admitted  of  easy  cure,  the  first  appli- 
cation succeeded  perfectly.  The  second  application  of 
blisters  commonly  enables  the  patient  to  see  by  can- 
dlelight distinctly,  perhaps,  by  bright  moonlight,  and 
even  half  an  hour  after  sunset,  or  the  sight  is  restored 
for  short  periods  during  the  night,  arid  is  again  abolished. 
The  second  application  very  often  effects  a perfect  re- 
covery. The  third,  fourth,  or  fifth  applications  in  suc- 
cession generally  produce  a complete  recovery  where 
the  first  or  second  have  failed ; but  some  rare  instances 
of  very  obstinate  hemeralopia  have  required  even  ten 
successive  blisters  to  each  temple  ; or  instead  of  using 
them  in  succession,  a perpetual  vesicatory  has  been 
formed  on  each  temple,  and  maintained  until  a cure 
has  been  accomplished,  an  event  which  has  generally 
followed  in  a fortnight.” — {Bainpjield  in  Medico-Chir. 
Trans,  vol.  5,  p.  47,  48.)  In  some  cases,  shades  over 
the  eyes  were  worn  during  the  treatment,  and  a certain 
t'me  afier  the  cure.  The  patients  were  also  often 
directed  to  bathe  their  eyes  with  cold  water  two  or 
three  times  a day. 

Mr.  Bampfield  knew  of  some  instances  in  which 
electricity  was  successfully  employed  as  a topical  sti- 
mulus to  the  eye.  He  also  informs  us  that  a sponta- 
neous cure  sometimes  followed  the  eruption  of  biles  on 
the  head  or  face,  or  the  formation  of  abscesses  on  these 
parts,  or  in  the  ears. 

Although  blisters  will  generally  effect  a cure,  there 
were  particular  cases  in  w’hich  Mr.  Bampfield  adminis- 
tered cathartics,  such  as  calomel  and  the  neutral  salts. 
In  these  examples  the  patient  had  bilious  complaints,  in- 
dicated by  a yellow  state  of  the  tongue  and  .skin,  head- 
ache, and  pain  about  the  praecordia ; or  symptoms  of 
indigestion ; white  tongue,  loss  of  appetite,  pain  and 
flatulence  of  the  stomach,  Ac.  With  blisters  and  ape- 
rient medicines  Mr.  Lawrence  sometimes  combines 
Clipping  on  the  temples  or  nape  of  the  neck. 

The  ]iatients  treated  by  Dr.  Smith  w'ere  put  into  a 
ward  moderately  lighted,  and  their  bowels  emptied  by 
a gentle  cathartic.  A blister  was  then  applied  to  each  j 


temple,  and  kept  open  with  savin  cerate.  A little  of  a 
solution  of  the  oxymuriate  of  mercury,  in  the  proportion 
of  two  grains  to  an  ounce  of  water,  was  dropped  into 
the  eyes  twice  a day.  The  purgatives  were  repeated 
on  the  third  day,  and  the  quantity  of  light  to  wiiich  the 
patients  were  exposed  was  afterward  gradually  in- 
creased.—(See  Edinb.  Med.  Joum.  No.  74,  p.  24.) 

In  the  scorbutic  hemeralopia,  the  application  of  blis- 
ters is  to  be  deferred,  until  the  state  of  the  constitution 
is  amended  by  giving  lemon  and  lime-juice,  and  fresh 
animal  and  vegetable  food ; because  the  hemeralopia 
often  gradually  ceases  as  the  scurvy  is  cured ; and 
before  this  last  event  the  blister  might  produce  a scor- 
butic ulcer.  Mr.  Bampfield  estimates  that  about  one- 
third  of  the  cases  of  scorbutic  hemeralopia  resist  the 
efficacy  of  the  antiscorbutic  regimen  and  medicines  , 
and  consequently  must  ultimately  be  treated  as  idio- 
pathic cases. 

The  frequent  recurrence  of  this  disease,  during  the 
patient’s  continuance  in  a tropical  or  hot  climate,  natu- 
rally suggests  the  propriety  of  recommending  him  to 
return  to  his  native  climate,  by  which  change  the  ten- 
dency to  a relapse  is  in  genera]  completely  removed.—- 
{Bampfield,  in  Medico-Chir^  Trans,  vol.  5,  p.  53.) 

Consult  Celsus  de  Re  Medicd,  cap.  6,  lib.  6.  Galeni 
Op.  Lib.  de  Oculis,  pars  4,  cap.  II.  22.  ,Mi'.tii  Sermo 
Septimus,  cap.  48,  i^c,  Paul.  .MgincB,  lib.  3,  cap.  48/ 
Actuarius,  De  Method.  Med.  lib.  4,  cap.  II.  Rhases^ 
De  JEgritud.  Ocul.  cap.  4.  Avicenna,  lib.  3,  fen.  3, 
tractat.  4.  Frabricii  Hildani  centur.  I,  obs.  24 ; cen- 
tur.  5,  obs.  13,  Plainer,  Praxis  Med.  C.  A.  Bergen  et 
J.  C.  Weise,  De  Nyctalopia  seu  CeBcitate  Nocturna;- 
Haller,  Disp.  ad  JMorb.  f\  c.  359.  Journal  de  MMecine 
et  de  Chirurgie,  an  1756,  t.  4.  Medical  Observations 
and  Inquiries,  vol.  I.  Recueil  d' Observations  de  Mide^ 
cine  des  Hopitaux  Militaires,  par  Richard,  t.  2.  Du- 
port,  Mimoire  sur  la  Goutte  Sereine  Nocturne  ^pidd- 
mique,  au  Nyctalopie.  Observations  on  Tropical  Nyc‘ 
talopia,  by  Mr.  J.  Forbes,  in  Edinb.  Medical  and 
Surgical  Journal,  No.  28,  p.  417,  et  seq.  Richter's 
Anfangsgrunde  der  Wundarzneykunst,  b.  3,  p.  483,  et 
seq.  Schmucker's  Chirurgische  Schriften,  band  2. 
Saggio  di  Ossetvazioni  e d'Esperienze  sullc  Principali 
Malattie  degli  Occhi  di  Antonio  Scarpa,  p.  322,  et  seq, 
edit  8vo.  Venezia,  1802.  Lassus,  Pathologic  Chirur-- 
gicale,  t.  2,p.  539,  edit.  2.  Rees's  Cyclopaedia,  art.  Nyc- 
talopia. A Practical  Essay  on  Hemeralopia,  or  Night-^ 
blindness,  commonly  called  Nyctalopia,  by  R.  W. 
Bampfield,  in  Medico-Chirurgical  Trans,  vol.  5,  p.  32,- 
et  seq.  A.  Simpson  on  Hemeralopia,  8vo.  GlasgoiVf 
1819.  C.  H.  Weller,  A Manual  of  the  Diseases  of  the 
Eye,  transl.  by  D.  Monteath,  vol.  2,  p.  142,  8uo.  GZas- 
gow,  1821.  Good's  Study  of  Aledicine,  vol.  4,  p.  203, 
edit.  3, 1829.  Laurence's  Ixctures  on  the  Diseases  of 
the  Eye,  ptiblished  in  the  Lancet.  Dr.  A.  Smith,  in 
Edinb.  Med.  and  Surgical  Jonm.  No.  74. 

HEMIOPIA.  (From  ppiavi,  half,  and  dJi//,  the  eye.) 
A certain  disorder  of  the  eye,  in  which  the  patient 
cannot  see  the  whole  of  any  object  which  he  is  looking 
at,  but  only  a part  of  it.  Sometimes  he  sees  the  mid- 
dle, but  not  the  circumference  ; sometimes  the  circum- 
ference, but  not  the  centre ; while  on  other  occasions, 
it  is  only  the  upjier  or  Imver  half  which  is  discerned. 
Sometimes  objects  are  seen  thus  imperfectly,  w-hether 
distant  or  near;  sometimes  only  when  they  are  near, 
and  not  at  a great  distance. 

The  causes  of  hemiopia  are  divided  by  Richter  into 
four  kinds. 

To  the  first  belong  opacities  of  the  cornea  and  crys- 
talline lens,  especially  such  as  destroy  the  transparency 
of  only  a certain  portion  of  these  parts. 

The  cure  of  this  species  of  hemio[)ia  depends  upon 
the  removal  of  the  partial  opacity  from  w hich  it  origin- 
ates,— (See  Cataract,  and  Cornea,  Opacities  of.) 

Under  certain  circumstances,  persons  whose  upper 
eyelids  cannot  be  properly  raised,  are  affected  with 
hemiopia.  They  can  only  driscern  the  low  er  half  of  an 
object  which  is  near  and  of  large  size,  unless  they  go 
farther  from  it,  draw  their  heads  backwards,  or  turn 
their  eyes  dowmwards.  The  pupil,  in  particular  in- 
stances, becomes  drawn  away  from  the  middle  of  the 
iris.  This  may  al.so  be  a cau.se  of  hemiopia : it  is  a 
case  that  does  not  admit  of  a cure.  The  aflection  may 
likewise  proceed  from  a separation  of  the  iris  from  tli^ 
margin  of  the  cornea  by  external  violence  or  other 
caii.ses.  Here  the  cure  is  equally  impracticable. 

The  foregoing  species  of  hemiopia  are  merely  efl'c-na 


HEM 


HEM 


of  other  diseases.  The  fourth  and  last  kind  is  the  most 
important,  being  generally  regarded  as  an  independent 
disorder.  Sometimes  it  appears  rather  to  be  the  effect 
of  a sudden  and  transient  irritation,  producing  a mor- 
bid sensibility  in  the  optic  nerve. 

The  causes  of  this  sort  of  case,  if  we  can  credit 
Richter,  are  mostly  seated  in  the  abdominal  viscera. 
When  the  affection  is  more  durable,  forming  what  has 
been  termed  amaurosis  dimidiata,  the  same  treatment 
is  indicated  as  in  Amaurosis,  in  which,  indeed,  it  often 
terminates. — {Richter,  Anfangsgr.  derWundarzn.  b.  3, 
kap.  17.) 

HEMORRHAGE.  (From  a\pa,  blood,  and  pfiyvcpi, 
to  break  out.)  Bleeding. 

This  is  doubtless  one  of  the  most  important  subjects 
in  surgery.  The  fear  of  hemorrhage  retarded  the  im- 
provement of  our  professihn  for  a^es ; the  ancients,  ig- 
norant how  to  stop  bleeding,  were  afraid  to  cut  out  the 
most  trivial  tumour,  or  they  did  so  with  terror.  They 
generally  performed  slowly  and  imperfectly,  by  means 
of  burning  irons  or  ligatures,  the  same  operations  which 
the  moderns  execute  quickly  and  safely  with  a knife. 
If  the  old  surgeons  ventured  to  amputate  a limb,  they 
only  did  so  after  it  had  mortified,  by  dividing  the 
dead  parts;  and  so  great  was  their  apprehension  of 
hemorrhage,  that  they  only  dared  to  cut  parts  which 
could  no  longer  bleed. — {John  Bell’s  Principles  of  Sur- 
gery, vol.  \,p.  142.)  But  not  only  as  a consequence  o<^ 
surgery  is  hemorrhage  to  be  feared  ; it  is  also  one  of 
the  most  alarming  accidents  which  surgery  is  called 
upon  to  relieve.  “ Un  sentiment  naturel  attache  d 
VMe  deperdre  son  sang ; un  terreur  machinale,  dont 
V enfant  qui  commence  d parler,  et  I’homme  le  plus  de- 
cide, sont  igalement  susceptibles.  On  ne  pent  point 
dire,  que  cette  peur  soit  chim  rique.  Si  Von  comptoit 
ceux,  qui  perdent  la  vie  dans  une  bataille,  on  verroit, 
que  les  trois  quarts  ont  peri  par  quelque  hemorrhagie ; 
et  dans  les  grandes  op<  rations  de  chirurgie  cet  acci- 
dent est  presque  toujours  le  plus  formidable.” — {Mo- 
rand,  Mem.  de  I’Acad.  Roy  ale  de  Chirurgie,  vol.  5, 8vo.) 
'As  the  blood  circulates  in  the  arteries  with  much 
greater  impetus  and  rapidity  than  in  the  veins,  it  ne- 
cessarily follows,  that  their  wounds  are  generaily  at- 
tended with  much  more  hemorrhage  than  those  of  the 
latter  vessels,  and  that  such  hemorrhage  is  more  diffi- 
cult to  suppress.  However,  as  the  blood  also  flows 
through  veins  of  great  magnitude  with  much  velo- 
city. bleedings  from  them  are  frequently  highly  danger- 
ous, and  sometimes  unavoidably  fatal.  When  an  artery 
is  wounded  the  blood  is  of  a bright  scarlet  colour,  and 
gushes  from  the  vessel  per  saltum,  in  a very  rapid 
manner.  The  blood  issues  from  a vein  in  an  even,  un- 
broken streatn,  and  is  of  a dark  purple  red  colour.  It 
is  of  great  practical  use  to  remember  these  distinguish- 
ing differences  between  arterial  and  venous  hemor- 
rhage, because,  though  in  both  cases  the  oozing  of  biood 
may  be  equal  in  quantity,  yet,  in  the  latter  instance, 
the  surgeon  is  often  justified  in  bringing  the  sides  of  a 
wound  together,  without  taking  farther  means  to  sup- 
press the  bleeding,  while  it  would  not  be  proper  to 
adopt  the  same  conduct  were  there  an  equal  discharge 
of  arterial  blood. 

Dr.  Jones  has  favoured  the  world  \vith  a matchless 
woik  on  the  present  subject;  and  as  one  grand  object 
of  this  Dictionary  is  to  present  a careful  account  of 
the  principal  modern  improvements  in  surgical  science, 

I shall  first  endeavour  to  make  the  reader  acquainted 
with  the  more  accurate  doctrines  first  promulgated  by 
this  gentleman  relative  to  the  subject  of  hemorrhage. 
Afterward,  the  surgical  means  to  be  practised  in  dif- 
ferent cases  will  be  considered. 

The  sides  of  the  arteries  are  divisible  into  three 
cx)ats.  The  interned  one  is  extremely  thin  and  smooth. 
It  is  elastic  and  firm  (considering  its  delicate  structure) 
in  the  longitudinal  direction,  but  so  weak  in  the  cir- 
cular as  to  be  very  easily  torn  by  the  slightest  force 
fipplied  in  that  direction.  Its  diseases  show  that  it  is 
vascular,  and  it  is  also  probably  sensible. 

The  middle  coat  is  the  thickest  and  is  composed  of 
muscular  fibres  all  arranged  in  a circular  manner; 
they  differ,  however,  from  common  muscular  fibres  in 
being  more  elastic,  by  which  they  tend  to  keep  a dead 
artery  open,  and  of  a cylindrical  form.  As  this  middle 
coat  has  no  longitudinal  fibres,  the  circular  fibres  are 
held  together  by  a slender  connexion,  ivhich  yields 
readily  to  any  force  applied  in  the  circumference  of  the 
artery. 


Tlie  external  coat  is  remarkable  for  its  whiteness, 
density,  and  great  elasticity.  When  an  artery  is  sur- 
rounded with  a tight  ligature,  its  middle  and  internal 
coats  are  as  completely  divided  by  it  as  they  could  be 
by  a knife,  while  the  external  coat  remains  entire. 

Besides  these  proper  coats,  all  the  arteries  in  their 
natural  situations  are  connected  by  means  of  fine  cel- 
lular substance,  with  surrounding  membranous  sheaths. 
If  an  artery  be  divided,  the  divided  parts,  owing  to 
their  elasticity,  recede  from  each  other,  aruPthe  length/ 
of  the  cellular  substance  connecting  the  artery-with  the 
sheath  admits  of  its  retracting  a certain  way  within 
the  sheath. 

Another  important  fact  is ; that  when  an  artery  is 
divided,  its  truncated  extremities  contract  in  a greater 
or  less  degree,  and  the  contraction  is  generally,  if  not 
always,  permanent. 

Arteries  are  furnished  with  arteries,  veins,  absorb-- 
ents  and  nerves  ; a structure  which  makes  them  sus-- 
ceptible  of  every  change  to  which  living  parts  are  sub- 
jected in  common ; enables  them  to  inflame  when  in-- 
jured,  and  to  pour  out  coagulable  lymph,  by  which  the 
injury  is  repaired  or  the  tube  permanently  closed. — (See 
Jones  on  Hemorrhage.) 

Petit  the  surgeon,  in  1731,  first  endeavoured  to  ex- 
plain the  means  which  nature  employs  for  the  suppres 
sion  of  hemorrhage.  He  thought  that  bleeding  from  a di- 
vided artery  is  stopped  by  the  formation  of  acoagulum  of 
blood,  which  is  situated  partly  within  and  partly  with-- 
OTzi  the  vessel.  The  clot,  he  says,  afterward  adheres 
to  the  inside  of  the  artery,  to  its  orifice,  and  to  the  sur- 
rounding pans ; and  he  adds,  that  when  hemorrhage 
is  stopi)ed  by  a ligature,  a coaguium  is  formed  above 
the  ligature,  which  only  differs  in  shape  from  the  one 
which  takes  place  when  no  ligature  is  employed. 
His  theory  leads  him  to  recommend  compression  for 
the  support  of  the  coaguium. 

In  1736,  Morand  published  additional  interesting 
remarks.  He  allowed,  that  a coaguium  had  some  effect 
in  stopping  hemorrhage,  but  contended  that  a corruga- 
tion,  or  plaiting  of  the  circular  fibres  of  the  artery  which, 
diminish  its  canal,  and  a shortening  and  consequent 
thickening  of  its  longitudinal  ones,  which  nearly  ren- 
dered it  impervious,  had  some  share  in  the  process. 
He  thought  that  the  cavity  of  an  artery  might  be  ob- 
literated, by  the  puckering  or  corrugation,  when  circu- 
lar pressure  like  that  of  a ligature  was  made. 

Morand  erred  chiefly  in  his  mode  of  explanation, 
and  in  his  belief  in  the  existence  of  longitudinal  fibres, 
which  no  modern  anatomists  admit;  lov  Vae  contraction 
and  retraction  of  divided  arteries  are  indisputable  facts, 
and  as  Dr.  Jones  remarks,  this  does  not  affect  the  truth 
of  his  general  conclusion,  that  the  change  produced  on 
a divided  artery,  contributes  with  the  coaguium  to  stop 
the  flow  of  blood. 

Mr.  S.  Sharp  {2d  edit,  of  Operations  of  Surgery^ 
1739)  supported  the  same  doctrine.  “ The  blood-ves- 
sels, immediately  upon  their  division,  bleed  freely,  and 
continue  bleeding  till  they  are  either  stopped  by  art, 
or  at  length  contracting  and  withdrawing  themselves 
into  the  wound,  their  extremities  are  shut  up  by  co- 
agulated blood.” 

Pouteau  {Melanges  de  Chirurgie,  1760)  denied  that 
a coaguium  is  always  found  after  an  artery  is  divided; 
and  when  it  is,  he  thought  it  only  a feeble  subsidiary 
means  towards  the  suppression  of  hemorrhage.  He 
contended  that  the  retraction  of  the  artery  had  not 
been  demonstrated,  and  could  not  be  more  effectual 
than  a coaguium.  His  theory  was,  that  the  swelling 
of  the  cellular  membrane  at  the  circumference  of  the 
cut  extremity  of  the  artery  forms  the  principal  impe- 
diment to  the  flow  of  blood ; and  that  a ligature  is  use- 
ful in  promoting  a more  immediate  and  extensive  in- 
duration of  the  cellular  substance. 

Gooch,  White,  Aikin,  and  Kirkland,  all  oppose  Pe- 
tit's doctrine  of  coaguium.  The  first  blends  some  of 
Pouteau’s  theory  with  his  own,  by  observing,  that 
“ when  a small  artery  is  totally  divided,  its  retraction 
may  bring  it  under  the  surrounding  parts,  and  with  the' 
natural  contraction  ofthe  diameter  ofits  mouth,  assisted 
by  the  compressive  power  of  those  parts,  increased 
by  their  growing  tumid,  the  efflux  of  blood  may  bo 
stojiped.” 

White  was  convinced,  from  what  Gooch  had  sug- 
gested and  Kirkland  confirmed,  that  the  arteries,  by 
their  natural  contraction,  coalesce  as  far  as  their  first 
ramification. 


480 


HEMORRHAGE. 


Dr.  Jones  admits,  that  an  artery  contracts  after  it 
has  been  divided,  and  his  experiments  authorize  him  to 
say,  that  the  contraction  of  an  arterj-  is  an  important 
means,  but  certainly  not  the  oniy  nor  even  the  chief 
mer.ns,  by  wliich  hemorrhage  is  stopped.  When  the 
artery  is  above  a certain  size,  the  impetuous  flow  of 
blood  through  the  wound  of  the  artery  would  resist  the 
contraction  of  the  vessel  in  such  a degree,  that  the  con- 
sequences would  be  fatal  in  almost  every  instance, 
were  it  not  for  the  formation  of  coagulum. 

Mr.  J.  Bell  thinks,  that  when  hemorrhage  stops  of 
its  own  accord,  it  is  neither  from  the  retraction  of  an 
artery,  nor  the  constriction  of  its  fibres,  nor  the  form- 
ation of  clots,  but  by  the  cellular  substance  which 
surrounds  the  artery  being  injected  with  blood. 

We  must  refer  the  reader  to  Dr.  Jones’s  work  for  a 
complete  e-xposure  of  the  inconsistencies  and  absurdi- 
ties in  Mr.  Bell’s  account  of  his  own  theory. — ^See 
p.  *25,  A c.) 

Dr.  Jones  concludes  his  criticisms  on  Mr.  Bell  with 
ob.serving,  that  if  this  gentleman  really  mean  to  con- 
fine his  doctrine  of  the  natural  mean  of  suppressing 
he,niorrhage  to  the  injection  of  the  cellular  substance 
round  the  artery  with  blood,  he  dwells  improperly  on 
one  of  the  attendant  circumstances,  to  the  exclusion  of 
the  retraction  and  contraction  of  an  artery,  and  the  form- 
ation of  a distinct  clot,  all  primary  parts  of  the  process. 

The  blood,  besides  filling  the  cellular  substance 
round  the  artery,  also  fills  the  cellular  substance  at  the 
mouth  of  the  artery  in  a particular  manner;  for  the 
divided  vessel,  by  its  retraction  within  its  cellular 
sheath,  leaves  a space  of  a determinate  form,  which, 
when  all  the  circumstances  necessary  for  the  suppres- 
sion of  hemorrhage  operate,  is  gradually  filled  up  by 
a distinct  clot. — (Jones.) 

MEANS  OF  N.iTlTRE  IN  STOPPING  BLEKDINO  FROM 
niVIDED  ARTERIES. 

Dr.  Jones  has  given  a faithful  and  accurate  detail 
of  a series  of  experiments  on  animals,  which  demon- 
strate “that  the  blood,  the  action,  and  even  the 
structure  of  the  arteries,  their  sheath,  and  the  cellular 
substance  connecting  them  with  it,”  are  concerned  in 
stopping  bleeding  from  a divided  artery  of  moderate 
size  in  the  following  manner;  “An  impetuous  flow  of 
blood,  a sudden  and  forcible  retraction  of  the  artery 
within  its  sheath,  and  a slight  contraction  of  its  extre- 
mity, are  the  immediate  and  almo.st  simultaneous  ef- 
fects of  its  division.  The  natural  impulse,  however, 
with  which  the  blood  is  driven  on  in  some  measure 
counteracts  the  retraction,  and  resists  the  contraction 
of  the  artery.  The  blood  is  elfused  into  the  cellular 
substance,  between  the  artery  and  its  sheath,  and  pass- 
ing through  that  canal  of  the  sheath,  which  had  been 
formed  by  the  retraction  of  the  artery,  flows  freely  ex- 
ternally, or  is  extravasated  into  the  surrounding  cellu- 
lar membrane,  in  proportion  to  the  open  or  confined 
state  of  the  wound.  The  retracting  artery  leaves  the 
internal  surface  of  the  sheath  uneven,  by  lacerating  or 
stretching  the  cellular  fibres  that  connected  them.  These 
fibres  entangle  the  blood  as  it  flows,  and  thus  the  foun- 
dation is  laid  for  the  formation  of  a coagulum  at  the 
mouth  of  the  artery,  and  which  apjjears  to  be  com- 
pleted by  the  blood  as  it  passes  through  this  canal  of 
the  sheath,  gradually  adhering  and  coagulating  around 
its  internal  surface,  till  it  completely  fills  it  up  from  the 
circumference  to  the  centre.— (/o/ie.s-,  p.  53.) 

The  effusion  of  blood  into  the  surrounding  cellular 
membrane,  and  between  the  artery  and  its  sheath ; but 
in  particular  the  diminished  force  of  the  circulation 
from  loss  of  blood,  and  the  speedy  coagulation  of  this 
fluid  under  these  circumstances,  most  e.ssentialiy  con- 
tribute, says  Dr.  Jones,  to  the  desirable  effect. 

It  appears  then,  that  a coagulum,  which  Dr.  Jones 
calls  the  external  one,  situated  at  the  mouth  of  the  ar- 
tery and  within  its  sheath,  forms  the  first  complete  ob- 
stacle to  the  continuance  of  bleeding ; and  though  it 
seems  externally  like  a continuation  of  the  artery,  yit, 
on  slitting  open  this  vessel,  its  termination  can  be 
plainly  ob.served,  with  the  coagulum  shutting  up  its 
mouth,  and  contained  in  its  sheath. 

No  collateral  branch  being  very  near  the  impervious 
mouth  of  the  artery,  the  blood  just  within  it  is  at  rest, 
and  usually  forms  a slender  conical  coagulum,  which 
neither  fills  up  the  canal  of  the  artery  nor  adheres  to 
Its  sides,  except  by  a small  portion  of  the  circuinfc- 
ronce  of  its  bxse  near  the  extremity  of  the  ve.ssel.  Thi.s  ' 


coagulum  is  distinct  from  the  former,  and  what  Dr. 
Jones  calls  the  internal  one. 

The  cut  end  of  the  artery  next  inflames,  and  the 
vasa  vasorum  pour  out  lymph,  which  fills  up  the  ex- 
tremity of  the  artery,  is  situated  between  the  internal 
and  external  coagula,  and  is  somewhat  intermingled 
with  them,  or  adheres  to  them,  and  is  firmly  united  all 
round  to  the  internal  coat  of  the  vessel.  Dr.  Jones 
farther  states,  that  the  permanent  suppression  of  he- 
morrhage chiefly  depends  on  this  coagulum  of  lymph ; 
but  that  the  end  of 'the  artery  is  also  secured  by  a gra- 
dual contraction  which  it  undergoes,  and  by  an  effusion 
of  lymph  between  its  tunics,  and  into  the  surrounding 
cellular  substance ; whereby  these  parts  become  thick- 
ened, and  so  incorporated  with  each  other,  that  one 
cannot  be  discerned  from  the  other.  Should  the  wound 
in  the  integuments  n(jt  heal  by  the  first  intention,  the 
coagulating  lymph,  soon  effused,  attaches  the  artery 
firmly  to  the  subjacent  and  lateral  parts,  gives  it  a new 
covering,  and  entirely  excludes  it  from  the  outward 
wound. 

The  same  circumstances  are  also  remarkable  in  the 
portion  of  the  vessel  most  remote  from  the  heart.  Its 
orifice,  however,  is  usually  more  contracted,  and  its 
external  coagulum  smaller,  than  the  one  which  at- 
taches itself  to  the  other  cut  end  of  the  artery.— (Jonw 
on  Hemorrhage.,  p.  56.) 

The  impervious  extremity  of  the  artery  no  longer  al- 
lowing blood  to  circulate  through  it,  the  portion  which 
lies  between  it  and  the  first  lateral  branch  gradu- 
ally contracts,  till  its  cavity  is  completely  obliterated 
and  its  tunics  assume  a ligamentous  appearance.  In  a 
few  days  the  external  coagulum,  which  in  the  first  in- 
stance stopped  the  hemorrhage,  is  absorbed,  and  the 
coagulating  lymph  effused  around  it,  and  by  which  the 
parts  were  thickened,  is  gradually  removed,  so  that 
they  resume  again  their  cellular  texture. 

At  a still  later  period  the  ligamentous  portion  is  re- 
duced to  a filamentous  slate,  so  that  the  artery  is,  as 
it  were,  completely  annihilated  from  its  cut  end  to  the 
first  lateral  branch ; but  long  before  this  final  change  is" 
accomplished,  the  inosculating  branches  have  become 
considerably  enlarged,  so  as  to  establish  a free  commu- 
nication between  the  disunited  parts  of  the  main  artery. 

When  an  artery  has  been  divided  at  so7ne  distance 
from  a lateral  branch,  three  coagula  are  formed;  one 
of  blood  externally,  which  shuts  up  its  mouth ; one  of 
lymph,  just  within  the  extremity  of  its  canal ; and  one 
of  blood  within  its  cavity  and  contiguous  to  that  of 
lymph.  But  when  the  artery  has  been  divided  near  a 
lateral  branch,  no  interned  coagulum  of  blood  is  formed. 
— (Jones,  p.  63.) 

The  external  coagulum  is  alw'ays  formed  w'hen  the 
divided  artery  is  left  to  nature ; not  so,  however,  if  art 
interfere,  for  under  the  application  of  the  ligature  it 
can  never  form.  If  agaric,  lycoj.erdon,  or  sponge  be 
used,  its  formation  is  doubtful,  dejiending  entirely  upon 
the  degree  of  pressure  that  is  used  ; but  the  internal 
coagulum  of  blood  will  be  equally  formed,  whether  the 
treatment  be  left  to  art  or  nature,  if  no  collateral  branch 
be  near  the  truncated  extremity  of  the  artery  ; and  lastly, 
effu-sed  lymph,  which,  when  in  sufficient  quantity, 
forms  a distinct  coagulum  just  at  the  mouth  of  the 
artery,  will  be  always  found,  if  the  hemorrhage  be  per- 
manently suppressed. — (Jories,  p.  71.) 

means  which  nature  employs  for  suppressing 

THE  HEMORRHAGE  FROM  PI.M.TIKED  OR  PAK- 

tiali.y  divided  arteries. 

The  suppression  of  hemorrhage  by  the  natural  means 
is  sometimes  more  easily  accomplislied  when  an  artery 
is  completely  divided,  than  when  merely  punctured  or 
partially  divided.  Completely  dividin.g  a w’ounded  ar- 
tery was  one  means  practised  by  the  ancients  for  the 
stoppage  of  hemorrhage ; the  moderns  frequently  do 
the  same  thing  when  bleeding  from  the  temporal  artery 
proves  troublesome. 

Dr.  Jones  has  related  many  experiments  highly 
worthy  of  periLsal,  and  whh  h were  undertaken  to  in- 
vestigate the  present  part  of  the  subject  of  hemorrhage. 
He  candidly  acknowledges,  however,  that  in  regard  to 
the  temporary  means  by  which  the  bleeding  from  a 
(lunctured  artery  is  stopjied,  he  has  but  little  to  add  to 
what  I’etit  has  explained  in  his  third  publication  on 
hemorrliage. — (Mem  de  PAcad.  des  .Scnuce.v,  1735.) 
I'he  blood  is  etTuecd  into  the  cellular  substance,  be- 
tween the  artery  and  its  shenth,  for  some  dlsunce  both 


HEMUKRIIAGE. 


48) 


above  and  below  the  wounded  part;  and  when  the 
parts  are  examined  a short  time  alter  the  hemorrhage 
has  completely  stopped,  we  find  a stratum  of  coagula- 
ted blood  between  the  artery  and  its  sheath,  extending 
from  a few  inches  below  the  wounded  part  to  two  or 
three  inches  above  it,  and  somewhat  thicker  or  more 
prominent  over  the  wounded  part  than  elsewhere. 

Hence,  rather  than  say  that  the  hemorrhage  is  stopped 
by  a coagulum,  it  is  more  correct  to  say,  that  it  is 
Slopped  by  a thick  lamina  of  coagulated  blood,  which, 
though  somewhat  thicker  at  the  wounded  part,  is  per- 
fectly continuous  with  the  coagulated  blood  lying  be- 
tween the  artery  and  its  sheath. — {Jones,  p.  113.) 

When  an  artery  is  punctured,  the  immediate  hemor- 
rhage, by  filling  up  the  space  between  the  artery  and 
its  sheath  with  blood,  and  consequently  distending  the 
sheath,  alters  the  relative  situation  of  the  puncture  in 
the  sheath  to  that  in  the  artery,  so  that  they  are  not 
exactly  opposite  to  each  other ; and  by  this  means  a 
layer  of  blood  is  confined  by  the  sheath  over  the  punc- 
ture in  the  artery,  and  by  coagulating  there  prevents 
any  farther  eflhsion  of  blood. 

But  this  coagulated  blood,  like  the  external  coagulum 
of  a divided  artery,  affords  only  a temporary  barrier  to 
the  hemorrhage ; its  permanent  suppression  is  effected 
by  a process  of  reparation  or  of  obliteration. 

Dr.  Jones’s  experiments  prove,  that  an  artery,  if 
wounded  only  to  a moderate  extent,  is  capable  of  re- 
uniting and  healing  so  completely,  that  after  a certain 
time  the  cicatrization  cannot  be  discovered,  either  on 
its  internal  or  e.xternal  surface ; and  that  even  oblique 
and  transverse  wounds  (which  gape  most),  when  they 
flo  not  open  the  artery  to  a greater  extent  than  one- 
fourth  of  its  circumference,  are  also  filled  up  and  healed 
by  an  effusion  of  coagulating  lymph  from  their  inflamed 
lips,  so  as  to  occasion  but  little  or  no  obstruction  to  the 
canal  of  the  artery.  The  utmost  magnitude  of  a wound, 
which  will  still  allow  the  continuity  of  the  canal  to  be 
preserved,  is  difficult  to  be  learned ; for  when  the  wound 
is  large,  but  yet  capable  of  being  united,  such  a quan- 
tity of  coagulating  lymph  is  poured  out,  that  the  canal 
of  the  vessel  at  the  wounded  part  is  more  or  less  filled 
up  by  it.  And  when  the  wound  is  still  larger,  the  ves- 
sel soon  becomes  either  torn  or  ulcerated  completely 
across,  by  which  its  complete  division  is  accomplished. 

Bedard  made  a series  of  experiments  upon  dogs, 
whose  arteries  are  said  not  to  differ  much  from  th  ose 
of  man,  though  the  impulse  of  the  heart  is  not  so 
strong,  and  the  blood  is  more  coagulable  ; two  circum- 
stances which  should  be  duly  considered  in  applying 
any  of  the  inferences  drawn  from  such  experiments  to 
the  human  subject.  “ In  his  first  experiment  he 
pricked  the  femoral  artery  wth  a needle;  the  blood 
flowed,  but  soon  stopped.  On  removing  the  coagulum 
It  again  flowed,  but  in  a smaller  stream ; it  gradually 
ceased  to  bleed,  and  finally  stopped,  though  the  coagu- 
lum was  again  scraped  off.  On  examination  of  the 
artery  no  trace  of  the  cicatrix  was  found.  Several 
similar  experiments  had  the  same  result.  In  experi- 
ment 4,  he  denuded  the  femoral  artery,  and  made  a lon- 
gitudinal cut  in  it  from  two  to  three  lines.  The  lips 
of  the  wound  were  seen  in  contact  during  the  diastole 
of  the  ventricle,  and  to  be  separated  by  a jet  of  blood 
during  the  systole.  The  blood  was  stopped  by  a coagu- 
lum; this  was  removed  twice,  and  each  time  the  blood 
flowed  in  a diminished  stream,  but  the  animal  died. 
In  experiment  6,  he  made  the  same  inci.sion,  but  did  not 
detach  the  sheath  from  the  artery,  and  the  wound  was 
left  to  nature..  The  hemorrhage  was  not  great ; there 
w'as  an  infiltration  of  blood  into  the  sheath,  the  size  of 
an  almond,  which  at  the  end  of  some  days  began  to  dimi- 
ni.sh,  and  disappeared  in  two  or  three' weeks.  On  the 
limb  being  examined,  fifteen  days  afterward,  a little 
white  ridge  was  found  adhering  firmly  to  the  artery 
a!id  to  the  sheath,  and  completely  closing  the  wound. 
In  the  interior,  there  was  a depressed  longitudinal  cica- 
trix of  the  breadth  of  the  fifth  of  a line.  The  canal 
teas  regular  and  pervvms  through  its  whole  extent. 

I n experiments  7, 8,  9,  he  made  transverse  incisions 
of  i,  A,  and  \ of  the  circumference  of  the  femoral  ar- 
tery separated  from  its  sheath : all  the  animals  died. 
In  exj  rirnent  10,  he  made  a transverse  incision  through 
! of  the  circumference,  without  disturbing  the  sheath. 
The  bleeding  was  stopped  by  a co.agulunl,  but  on  the 
animal  moving  it  again  flowed,  and  the  dog  died.  But 
in  the  next  experiment  of  the  same  kind  the  blood  was 
stojiperl  t:y  a coagnlnm,  and  the  artery  was  closed  by 

Voi  . T,-  -II  h 


nearly  the  same  process  as  in  the  6th  experiment.  So 
completely  was  the  cure  at  the  end  of  six  weeks  that 
the  external  part  of  the  artery  did  not  show  any  mark 
of  a wound,  and  the  cicatrix  was  scarcely  observable 
on  the  interior  surface.  In  his  12th  experiment  he  cut 
one-half  of  the  circumference  : the  animal  died  ; and 
so  did  it  in  several  similar  experiments.  In  experiment 
13,  he  cut  of  the  circumference  : after  the  animal  was 
much  reduced  the  bleeding  ceased,  and  the  artery  was 
closed  in  the  same  manner  that  it  is  when  the  section 
is  complete. 

From  these  experiments  he  concludes  wounds  of  the 
arteries  of  dogs  are  cured  by  nature  when  they  are  only 
occasioned  by  a puncture,  or  a longitudinal  incision, 
whether  the  artery  be  denuded  or  not;  but  when 
arising  from  transverse  incisions  they  are  always  mor- 
tal if  the  artery  be  laid  bare.  If  the  artery  retain  its 
sheath,  arvd  the  wound  be  ^ or  5 of  the  circumference, 
it  may  be  cured  by  the  efforts  of  nature  ; but  it  is  al- 
ways fatal  if  ^ of  it  be  cut  through. — (^e  Quarterly 
Jov.rn.  of  Foreign  Medicine  and  Surgery,  vol.  1,  p. 
26.)  The  inferences  respecting  the  curability  of  a 
wound  extending  through  | of  the  circumference,  and 
the  incurability  of  one  that  affects  only  ^ of  the  cir- 
cumference of  the  vessel,  I should  presume  must  re- 
quire farther  examination,  notwithstanding  an  acci- 
dental laintness  produced  by  the  sudden  loss  of  blood 
in  the  first  instance  may  have  been  the  means  of  saving 
one  or  two  of  the  animals  on  which  Bedard  made  his 
experiments. 

This  author  thinks  it  probable  that  a puncture,  or 
longitudinal  incision,  in  the  artery  of  a man  may  be 
cured  by  nature ; but  that  a transverse  wound  never 
cicatrizes  properly,  as  the  clot  becomes  displaced,  or,  if 
a cicatrix  be  formed,  it  will  be  distended  and  torn. 

One  fact  made  out  by  the  same  professor  is,  that 
when  an  artery  is  deprived  of  its  sheath  for  an  extent 
greater  than  its  distance  of  retraction,  the  hemorrhage 
is  mortal.  I have  not  yet  had  time  to  look  over  the  ori- 
ginal paper;  but  it  appears  to  me,  that  it  would  be  de- 
sirable to  know  precisely  to  what  sized  arteries  the 
author  is  referring,  when  he  is  making  some  of  the 
above  inferences.  The  size  and  condition  of  each  ani- 
mal, the  subject  of  experiment,  should  also  be  particu- 
larly specific ; as  experiments  made  on  the  femoral 
artery  of  a lady’s  lapdog  would  surely  not  have  the 
same  results  as  those  performed  on  the  same  artery  of 
a large  terrier,  setter,  or  Newfoundland  dog. 

According  to  Dr.  Jones,  the  lymph  which  fills  up  the 
wound  of  an  artery  is  poured  out  very  freely  both  from 
the  vessel  and  the  surrounding  parts,  and  it  accumulates 
around  the  artery,  particularly  over  the  wound,  where 
it  Ibrms  a more  distinct  tumour.  The  exposed  sur- 
rounding parts  at  the  same  time  inflame,  and  pour  out 
coagulating  lymph,  with  which  the  whole  surface  of  the 
wound  becomes  covered,  and  which  completely  excludes 
the  artery  from  the  external  wound.  This  lymph  granu- 
lates, and  the  wound  is  filled  up  and  healed  in  the  usual 
manner. — (See  Jones  on  Hemorrhage,  p.  113,  ^-c.) 

St'RRICAL  MEANS  OF  SUrPRESSING  HKMORRHAOE. 

It  must  be  plain  to  every  one  who  understands  the 
course  of  the  circulation,  that  pressure,  made  on  that 
portion  of  a wounded  artery  which  adjoins  the  wound 
towards  the  heart,  must  check  the  effusion  of  blood. 
The  current  of  blood  in  the  veins,  running  in  the  oppo- 
site direction,  requires  the  pressure  to  be  applied  to  that 
side  of  the  wound  which  is  most  remote  from  the  heart. 
However,  on  account  of  the  freedom  and  facility  with 
which  the  blood  is  transmitted  through  the  anastomo.ses, 
from  the  portion  of  the  artery  above  the  point  of  pres- 
sure into  the  lower  continuation  of  the  artery,  such 
pressure  will  often  only  check,  and  not  effectually  stop 
the  bleeding,  unless  the  part  of  the  vessel  directly  below 
the  wound  be  also  compressed  or  secured.  As  pre^ssurc 
is  the  most  rational  means  of  impeding  hemorrhage,  so 
it  is  the  most  effectual ; and  almost  all  the  plans,  em- 
ployed for  this  purpose,  are  only  modifications  of  it. 
The  tourniquet,  the  ligature,  the  application  of  a roller 
atid  compresses,  even  agaric  itself,  only  become  useful 
in  the  supi)ression  of  hemorrhage,  on  the  principle  of 
pressure  ; the  cautery,  caustics,  and  stypics,  however, 
have  a different  mode  of  ojje ration. 

In  order  to  prevent  a wounded  person  from  dying  of 
hemorrhage,  Celsus  advised  the  wound  to  be  filled  with 
dry  lint,  over  which  was  laid  a sponge  dipped  in  cold 
water,  and  pressed  on  the  part  with  ihe  hand.  If,  not 


482 


HEMORRHAGE. 


withstanding  these  means,  the  hemorrhage  should  con- 
tinue, he  recommends  repeatedly  applying  fresh  lint, 
wet  with  vinegar ; but  he  is  against  the  use  of  corroding 
escharotic  applications,  on  account  of  the  inflammation 
which  they  produce ; or  only  sanctions  the  employment 
of  the  mildest  ones.  When  the  hemorrhage  resists 
these  methods,  he  advises  two  ligatures  to  be  applied 
to  the  wounded  part  of  the  vessel,  and  then  dividing 
the  portion  situated  between  them : “ Quod  si  ilia 
quoque  prqfluvio  vincuntur,  venae,  quxB  sanguinem 
fundunt,  apprehendendcB,  circaque  id,  quod  ictum  est, 
iuobus  locis  deligandae,  intercidendcsque  sunt,  ut  et  in 
se  ipscB  coeant,  et  K'ihilominus  ora  praeclusa  habeant.” 
—{Lib.  5,  cap.  26.)  When  the  ligature  was  imprac- 
ticable, the  wound  bled  dangerously,  and  no  large  nerves 
nor  muscles  were  situated  in  the  bleeding  part  Celsus 
proposed  the  actual  cautery. 

Galen  also  mentions  tying  the  vessels  for  the  purpose 
of  stopping  hemorrhage ; and  there  are  some  traces  of 
the  same  information  in  other  authors,  who  lived  before 
him,  as  Archigenes  and  Rufus.  Probably,  however, 
the  ligature  was  little  used  at  these  early  periods,  as 
may  be  inferred  from  the  multitude  of  astringents, 
caustics,  and  other  applications,  which  were  advised 
for  stopping  bleeding,  and  in  which  less  confidence 
would  have  been  put,  had  the  use  of  the  ligature  been 
familiarly  known.  No  one  can  doubt,  that  if  the  old 
surgeons  had  had  many  opportunities  of  seeing  the  ad- 
vantages of  the  ligature,  they  would  soon  have  used  it 
after  amputations;  but  so  far  were  they  from  adopting 
such  practice,  that  Albucasis,  a long  w^hile  afterward, 
refused  to  amputate  at  the  wrist,  lest  he  should  see  his 
patient  bleed  to  death. 

Pare  is  considered  as  the  first  who  regularly  employed 
the  ligature  after  amputation.  His  method  having  been 
attacked,  he  modestly  defends  it  in  the  part  of  his 
works  entitled  Apologie,  where  he  takes  great  care  to 
impute  the  origin  of  it  to  the  ancients,  and  cites  many 
of  them  who  have  made  mention  of  it.  However,  he 
thinks  its  utility  in  amputations  of  such  consequence, 
that  he  ascribes  his  first  adoption  of  this  practice  to  in- 
spiration of  the  Deity. 

The  method  in  which  the  ancients  placed  most  con- 
fidence for  stopping  hemorrhage  after  the  amputation 
of  a limb,  was  the  cauterization  of  the  cut  vessel,  and 
surrounding  flesh.  The  parts  thus  affected  by  the 
heat  formed  an  eschar,  of  greater  or  less  thickness, 
which  blocked  up  the  opening  of  the  vessel,  and  hin- 
dered the  blood  from  escaping.  The  separation  of  the 
eschar,  however,  which  frequently  took  place  too  soon, 
occasioned  a return  of  hemorrhage,  and  rendered  it 
the  more  dangerous,  as  its  suppression  was  now  more 
difficult  than  before  the  cautery  had  been  applied. 
Sometimes  the  instrument,  being  too  much  heated,  im- 
mediately brought  away  with  it  the  eschar.  At  the 
present  time,  the  cautery  is  never  employed  as  a means 
of  suppressing  hemorrhage,  or,  at  most,  only  in  a few 
very  unusual  cases,  in  which  neither  compression  nor 
the  ligature  can  be  made  use  of.  In  Great  Britain,  the 
cautery  may  be  said  to  be  entirely  exploded ; but  in 
France,  the  best  hospital  surgeons  now  and  then  employ 
it  to  stop  bleedings  from  the  antrum  and  the  mouth. 

The  old  surgeons  also  very  commonly  applied  to 
bleeiling  parts  pledgets,  dipped  in  boiling  turpentine— a 
practice  that  has  long  been  most  justly  abandoned. 

ASTRINGENTS,  STYPTICS,  &C. 

Le  Dran,  in  his  Treatise  on  the  Operations  of  Surgery, 
says  that  a button  of  vitriol,  or  alum,  applied  and  pro- 
perly confined  on  the  extremity  of  the  vessel,  is  suffi- 
cient JO  stop  the  hemorrhage  in  amputations.  Ileister 
recommends  the  application  of  vitriol,  in  preference  to 
the  ligature,  in  the  amputation  of  the  forearm.  Great 
praises  have  also  been  conferred  on  agaric,  and  sponge, 
for  their  styptic  properties.  Solutions  of  iron,  and  all 
the  mineral  acids  in  various  forms,  have  been  recom- 
mended to  the  public,  as  remedies  of  the  same  kind, 
and  possessing  great  efficacy.  The  ancients,  centuries 
ago,  left  no  application  of  this  nature  untried,  and  the 
pretended  discoveries  of  new  and  more  effectual  styp- 
tics in  later  times  may  almost  all  be  met  with  in  tlieir 
writings.  This  fact  merits  particular  notice,  because 
the  little  success  attending  their  practice,  especially 
when  bleeding  from  a considerable  artery  was  to  be 
suppressed,  clearly  proves  wbat  little  reliance  ought  to 
be  placed  on  means  of  this  description.— C£/tc7/c/optfdM; 
R.tioiijiie,  partie  Chir.)  Ine  most  w'hioh  styptics 


can  do  is  to  stop  hemorrhages  from  small  arteries ; btft 
they  ought  never  to  be  trusted  when  large  vessels  are 
concerned. 

There  is  no  doubt,  that  cold  air  has  a styqitic  property ; 
by  which  expression  I mean,  that  it  promotes  the  con- 
traction of  the  vessels  ; for  no  styptics  can  contribute 
to  make  the  blood  coagulate,  though  such  an  erroneous 
idea  is  not  uncommon.  We  frequently  tie,  on  the  sur- 
face of  a wound,  every  artery  that  betrays  the  least 
disposition  to  bleed,  as  long  as  the  wmund  continues 
exposed  to  the  air.  We  bring  the  opposite  sides  of  this 
wound  into  contact,  and  put  the  patient  to  bed.  Not  an 
hour  elapses  before  the  renewal  of  hemorrhage  compels 
us  to  remove  the  dressings.  The  wound  is  again  ex- 
posed to  the  air,  and  again  the  bleeding  ceases.  This 
often  happens  in  the  scrotum,  after  the  removal  of  a 
testicle,  and  on  the  chest,  after  the  removal  of  a breast. 
The  proper  conduct  in  such  cases,  is  not  to  open  the 
wound  unnecessarily,  but  to  apply  pressure,  or  else  w-et 
linen  to  the  jiart,  so  as  to  produce  such  an  evaporation 
from  its  surface,  as  shall  create  a sufficient  degree  of 
cold  to  stop  the  bleeding.  As  all  styptics  are  more  or 
iess  irritating,  no  judicious  prtuititioners  apply  them  to 
recent  wounds.  However,  for  the  suppression  of  he- 
morrhage from  diseased  surfaces,  where  the  vessels 
seem  to  have  lost  their  natural  disposition  to  contract, 
these  applications  are  sometimes  indicated. 

COMPRESSION. 

We  have  already  remarked  that  all  the  best  means  of 
checking  hemorrhage  operate  on  the  principle  of  pres- 
sure ; the  actual  and  potential  cautery,  and  some  styp- 
tics excepted : the  first  two  of  which  operate  by  forming 
a slough,  which  stops  up  the  mouths  of  the  vessels  ; 
while  the  latter  operate  by  promoting  their  contraction. 
Let  us  next  consider  the  various  modifications  of 
pressure. 

In  a dissertation  on  the  manner  of  stopping  hemor- 
rhage, printed  in  the  M^m.  de  VAcad.  des  Sciences,  annie 
1731,  Petit  endeavoured  to  prove,  that  different  articles, 
praised  as  infallible  specifics,  would  seldom  or  never 
have  succeeded  without  compression.  Even  when 
caustics  were  employed,  it  was  usual  to  bind  coi  ‘presses 
tightly  on  the  part,  so  as  to  resist  the  impulse  of  the 
blood  in  the  artery,  and  the  premature  separation  of  the 
eschar.  Had  this  precaution  not  been  taken.  Petit  be- 
lieves hemorrhage  would  almost  invariably  have  fol- 
lowed, and  indeed,  notwithstanding  the  pains  taken  to 
avert  it  by  suitable  compression,  it  did  too  frequently 
take  place  on  the  detachment  of  the  eschar.  Petit  has 
noticed  that  the  end  of  a finger,  gently  compressing  the 
mouth  of  a vessel,  is  a sufficient  means  of  stopping  he- 
morrhage from  it,  and  that  nothing  else  would  be 
necessary,  if  the  finger  and  stump  could  always  be 
kept  in  this  posture.  Hence  he  endeavoured  to  obviate 
these  difficulties  by  inventing  a machine  which  securely 
and  incessantly  executed  the  office  of  the  finger.  The 
instrument  was  a double  tourniquet,  which,  when  ap- 
plied, compressed  at  once  both  the  extremity  of  the  di- 
vided artery  and  its  trunk  above  the  wound.  The  com- 
pression on  the  end  of  the  vessel  was  permanent ; that 
on  the  trunk  was  made  only  at  the  time  of  dressing  the 
wonnd,  or  when  it  was  necessary  to  relax  the  other. 
An  engraving  and  particular  description  of  the  instru- 
ment are  to  be  found  in  Petit’s  memoir. 

Surgeons  formerly  filled  the  cavities  of  wounds  with 
lint  or  charpie,  and  then  made  pressure  on  the  bleeding 
vessels,  by  applying  compresses  and  a tight  roller  over 
the  part.  The  practitioners  of  the  present  day  are  too 
w'ell  acquainted  with  the  advantages  of  not  allowing 
any  extraneous  substance  to  intervene  between  the  oj>- 
posite  surfaces  of  a recent  wound,  to  persist  in  the 
above  plan.  They  know  that  the  sides  of  the  wound 
may  be  brought  into  contact,  and  that  compression 
may  yet  be  adopted,  so  as  both  to  restrain  particular 
hemorrhages,  and  rather  promote  than  retard  the  union 
of  the  w ound. 

When  the  blood  does  not  issue  from  any  particular 
vessel,  but  from  numerous  small  ones,  compre-ssion  is 
preferable  to  the  ligature.  In  the  employment  of  ihe 
latter,  it  would  be  necessary  to  tie  the  whole  surface 
of  the  wound.  The  sides  of  the  wound  are  to  be 
brought  accurately  together,  and  compresses  are  then 
to  be  placed  over  the  part,  and  a roller  to  be  applied 
w ith  sufficient  tightne.ss  tomakeeftectual  pre.s.sure,  but 
not  so  forcibly  as  to  produce  any  chance  of  trie  cir,  ula 
lion  in  the  limb  beiug  compleitiy  stciped 


HEMORRHAGE. 


483 


If,  in  bleedings  from  large  arteries,  compression  can 
ever  bo  prudently  tried,  it  is  when  these  vessels  lie  im- 
mediately over  a bone.  Bleedings  from  the  radial  and 
temporal  arteries  are  generally  cited  as  cases  of  this 
kind,  though  from  the  many  instances  of  failure  which 
I have  seen  happen  where  the  first  of  these  vessels  is 
concerned,  I should  be  reluctant  either  to  advise  or 
make  such  an  attempt.  Compression  is  sometimes 
tried,  when  the  brachial  artery  is  wounded  in  phlebo- 
tomy. Here  it  is  occasionally  tried,  in  preference  to 
the  ligature,  because  the  latter  cannot  be  employed 
without  an  operation  to  expose  the  artery. 

When  there  is  a small  wound  in  a large  artery,  the 
following  plan  may  be  tried ; a tourniquet  is  to  be  ap- 
plied, so  as  to  command  the  flow  of  blood  into  the 
vessel.  The  edges  of  the  external  wound  are  next  to 
be  brought  into  contact.  Then  a compress,  shaped 
like  a blunt  cone,  and  which  is  best  formed  of  a series 
of  compresses,  gradually  increasing  in  size,  is  to  be 
placed  with  its  apex  exactly  on  the  situation  of  the 
wound  in  the  artery.  This  graduated  compress,  as 
it  is  termed,  is  then  to  be  bound  on  the  part  with  a 
roller. 

In  this  manner,  I once  healed  a wound  of  the  super- 
ficial palmar  arch,  in  a young  lady  in  Great  Pulteney- 
street.  The  outward  wound  was  very  small,  and 
though  the  hemorrhage  was  profuse,  I conceived  that 
it  might  be  permanently  stopped,  if  compression  could 
be  so  made  as  to  keep  the  external  wound  incessantly 
and  firmly  covered  for  the  space  of  a day  or  two.  At 
first,  I tried  a compress  of  lint,  bound  on  the  part  with 
a roller;  but  this  proving  ineffectual,  I took  some 
pieces  of  money,  from  the  size  of  a farthing  to  that  of 
a half-crown,  and,  wrapping  them  up  in  linen,  put  the 
smalle.st  one  accurately  over  the  w'ound,  so  as  com- 
pletely to  cover  it.  Then  the  others  were  arranged, 
and  all  of  them  were  firmly  confined  with  a roller, 
and  the  arm  kept  as  quiet  as  possible  in  a sling.  They 
were  taken  off  after  three  days,  and  no  hemorrhage 
ensued. 

It  is  to  be  observed,  that  the  palmar  fascia,  in  this 
instance,  would  prevent  the  compression  from  operat- 
ing on  the  vessel ; but  the  case  shows  that  this  artery, 
when  wounded,  is  capable  of  healing,  if  the  blood  be 
completely  prevented  from  getting  out  of  the  external 
wound  by  the  proper  application  of  compression. 
Were  the  outer  wound  too  large  to  admit  of  this  plan, 
it  would  probably  be  the  safest  practice  to  cut  dowm, 
at  once,  to  the  ulnar  artery,  and  put  a ligature  round 
it,  though,  as  this  would  only  certainly  stop  the  bleed- 
ing from  one  end  of  the  vessel  in  the  hand,  pressure  on 
the  wound  would  yet  be  necessary.  I have  never  seen 
a surgeon  succeed  in  taking  up  the  artery  in  the  hand. 

Besides  compressing  the  wounded  part  of  the  artery, 
some  surgeons  also  apply  a longitudinal  compress  over 
the  track  of  the  vessel  above  the  wound,  with  a view 
of  weakening  the  flow  of  blood  into  it.  Whatever 
good  effect  it  may  have  in  this  way,  is  more  than  coun- 
terbalanced by  the  difficulty  which  it  must  create  to 
the  circulation  in  the  arm.  If  the  graduated  compress 
be  properly  arranged,  an  effusion  of  blood  cannot  pos- 
sibly happen,  and  pressure  along  the  course  of  the  ar- 
tery must  at  all  events  be  unnecessary.  After  relax- 
ing the  tourniquet,  if  no  blood  escape  front  the  artery, 
the  surgeon  (supposing  it  to  be  the  brachial  artery 
wounded)  should  feel  the  pulse  at  the  wrist,  in  order 
to  ascertain  that  the  compression  employed  is  not  so 
powerful  as  entirely  to  impede  the  circulation  in  the 
forearm  and  hand.  The  arm  is  to  be  kept  quietly  in  a 
sling,  and,  in  forty-eight  hours,  if  no  bleeding  take 
place,  there  will  be  great  reason  to  expect  that  the  case 
will  do  well.  In  another  work,  I have  given  an  engrav- 
ing and  description  of  an  instrument  invented  by 
Plenck,  for  making  pressure  on  the  wounded  brachial 
artery,  at  the  bend  of  the  arm,  without  pressing  upon 
the  whole  circumference  of  the  limb  and  consequently 
without  stopping  the  circulation.  No  one,  however, 
would  prefer  compression  when  large  arteries  are  in- 
jured, except  in  the  kind  of  cases  to  which  we  have 
just*  now  adverted,  or  in  those  in  which  the  wounded 
vc.ssel  can  be  firmly  compressed  against  a subjacent 
bone.  Sometimes  the  compresses  slip  off,  or  the  band- 
ages become  slack,  and  a fatal  hemorrhage  may  arise ; 
and  a still  greater  risk  is  that  of  mortification  from 
the  constricted  state  of  the  limb.  When  the  method  is 
tried,  the  tourniquet  should  always  be  left  loosely 
round  the  limb,  ready  to  be  tightened  in  an  instant 


Sometimes  the  external  wound  heals,  while  the  open- 
ing in  the  artery  remains  unclosed,  and  a false  aneu- 
rism is  the  consequence. 

tourntqiet. 

When  hemorrhage  takes  place  from  a large  artery  in 
one  of  the  limbs,  where  the  vessel  can  be  conveniently 
compressed  above  the  wound  in  it,  a tourniquet.  Judi- 
ciously applied,  never  fails  to  put  an  immediate  stop  to 
the  bleeding. 

Before  the  invention  of  this  instrument,  which  did  not 
take  place  till  the  latter  part  of  the  17th  century,  surgery 
was  really  a very  defective  art.  No  important  opera- 
tion could  be  undertaken  on  the  extremities,  without 
placing  the  patient  in  the  most  imminent  peril ; and 
many  wounds  w^ere  mortal,  which,  with  the  aid  of  this 
simple  contrivance,  would  not  have  been  attended  with 
the  least  danger. 

The  first  invention  of  the  tourniquet  has  been  claimed 
by  different  surgeons,  and  even  different  nations.  But, 
whoever  was  the  inventor,  it  was  first  presented  to  the 
public  in  a form  exceedingly  simple  ; so  much  so,  in- 
deed, that  it  seems  extraordinary  that  its  invention  did 
not  happen  sooner.  A small  pad  being  placed  on 
the  principal  artery  of  a limb,  a band  was  applied  over 
it,  so  as  to  encircle  the  limb  twice.  Then  a stick  was 
introduced  between  the  two  circles  of  the  band,  which 
was  twisted : thus  the  pad  was  made  completely  to 
stop  the  flow  of  blood  into  the  lower  jtart  of  the  vessel. 

Although  in  the  Armamentarium  Chirurgicum  of 
Scultetus  there  is  a plate  of  a machine  invented  by 
this  author  for  compressing  the  radial  artery  by  means 
of  a screw,  J.  L.  Petit  is  universally  allowed  to  be  the 
first  who  brought  the  tourniquet  to  perfection,  by  com- 
bining the  circular  band  with  a screw,  so  that  the 
greatest  pressure  may  operate  on  the  principal  artery. 

The  advantages  of  the  modern  tourniquet  are,  that 
its  pressure  can  be  regulated  with  the  utmost  exact- 
ness ; that  it  operates  chiefly  on  the  point  where  the 
pad  is  placed,  and  where  the  main  artery  lies ; that  it 
does  not  require  the  aid  of  an  assistant  to  keep  it 
tense ; that  it  completely  commands  the  flow  of  blood 
into  a limb ; that  it  can  be  relaxed  or  tightened  in  a 
moment ; and  that,  when  there  is  reason  to  fear  a sud- 
den renewal  of  hemorrhage,  it  can  be  left  slackly  round 
the  limb,  and,  in  case  of  need,  tightened  in  an  instant. 
Its  utility,  however,  is  confined  to  the  limbs,  and  as  the 
pressure  necessary  to  stop  the  flow  of  blood  through 
the  principal  artery  completely  prevents  the  return 
of  blood  through  the  veins,  its  application  cannot  be 
made  very  long  without  inducing  mortification.  It  is 
only  of  use  also  in  putting  a sudden  stop  to  profuse 
hemorrhages  for  a time,  that  is,  until  the  surgeon  has 
put  in  practice  some  means,  the  effect  of  which  is 
more  permanent. 

LIGATURE. 

The  ancients  were  quite  unacquainted  with  the  use 
of  the  tourniquet,  and  though  some  of  their  writers 
have  made  mention  of  the  ligature,  they  do  not  seem 
to  have  known  how  to  make  proper  use  of  it,  nor  to 
have  possessed  any  other  certain  means  of  suppress- 
ing hemorrhage  from  wounds.  In  modern  times,  it  is 
easily  comprehensible,  that  when  any  great  operation 
was  undertaken,  while  surgery  was  so  imperfect,  there 
was  more  likelihood  of  the  patient’s  life  being  short- 
ened than  lengthened,  by  what  was  attempted.  Under 
these  circumstances,  it  is  not  surprising  that  the  old 
practitioners  should  have  taken  immense  pains  to  in- 
vent a great  many  topical  astringents.  But  now  that 
the  ligature  is  known  to  be  a means  which  is  safer  and 
less  painful  than  former  methods,  no  longer  search  need 
be  made  for  specifics  against  hemorrhage. 

It  may,  indeed,  be  set  down  as  a rule  in  surgery, 
that  whenever  large  arteries  are  wounded,  no  styptic 
application  should  ever  be  employed,  but  immediate  re- 
course had  to  the  ligature,  as  being,  when  properly 
applied,  the  most  simple  and  safe  of  all  methods. 

In  order  to  quality  the  reader  to  judge  of  the  best 
mode  of  applying  ligatures  to  arteries,  I shall  first  ex- 
plain to  him  their  effect  on  these  vessels,  as  related  by 
Dr.  Jones. 

This  gentleman  learned  from  Dr.  J.  Thomson,  of 
Edinburgh,  that  in  every  instance  in  which  a ligature 
is  applied  around  an  artery,  without  including  the  sur- 
rounding parts,  the  interna!  coat  of  the  vessel  is  tom 
through  by  it ; and  that  this  fact  had  been  originally 


484 


HEMORRHAGE. 


noticed  by  Desault.  Dr.  Thomson  even  demonstrated 
10  Dr.  Jones,  on  a portion  of  artery  taken  from  the  hu- 
man subject,  that  the  internal  and  middle  coats  are 
divided  by  the  ligature. — {Jones,  p.  126.) 

This  led  Dr.  Jones  to  make  some  experiments  on  the 
arteries  of  dogs  and  ihorses,  tending  to  the  conclusion, 
that  ivken  several  ligatares  are  applied  round  an  ar- 
tery with  sufficient  tightness  to  cut  through  its  internal 
and  middle  coats,  although  the  cords  be  immediately 
afterward  removed,  the  ve.ssel  will  always  become  im- 
pervious at  the  part  which  was  tied,  as  far  as  the  first 
collateral  branches  above  and  below  the  obstructed 
part.  Dr.  Jones  thinks  it  reasonable  to  expect  that  the 
obstruction  produced  in  the  arteries  of  dogs  and  horses, 
in  the  manner  he  has  related,  “ might  be  effected  by 
the  same  treatment  in  the  arteries  of  the  human  sub- 
ject ; and,  if  it  should  prove  successful,  it  might  be 
employed  in  some  of  the  most  important  cases  in  sur- 
gery. The  success  of  the  late  important  improve- 
ments which  have  been  introduced  in  the  operation  for 
aneurism,  may  perhaps  appear  to  most  surgeons  to 
have  rendered  that  operation  sufficiently  simple  and 
safe ; but  if  it  be  possible  to  produce  obstruction  in  the 
eanal  of  an  artery  of  the  human  subject  in  the  above- 
mentioned  manner,  may  it  not  be  advantageously  em- 
ployed in  the  cure  of  aneurism ; inasmuch  as  nothing 
need  be  done  to  prevent  the  immediate  union  of  the  ex- 
ternal wound?”  Dr.  Jones  next  questions  whether 
this  mode  of  obstructing  the  passage  of  blood  through 
the  arteries  may  not  also  be  advantageously  practised 
in  cases  of  bronchocele  1 — (P.  136.) 

Subsequent  e.xperimenters  have  not  been  equally  suc- 
cessful with  Dr.  Jones  in  obtaining  the  obliteration  of 
the  cavity  of  the  vessel  after  this  operation.  Did  this 
difference  depend  upon  tiieir  having  tied  the  vessel 
only  in  one  place  ? Mr.  Hodgson  tried  the  experiment 
in  two  instances  upon  the  carotid  arterie»of  dogs  ; and 
in  neither  of  them  was  the  cavity  of  the  vessel  oblite- 
rated. The  same  experiment  has  been  repeated  by 
several  surgeons  upon  the  arteries  of  dogs  and  horses ; 
but  in  no  example,  as  far  as  Mr.  Hodgson  knows,  has 
the  complete  obliteration  of  the  cavity  of  the  vessel 
been  accomplished.  However,  as  an  effusion  of  lymph 
is  an  invariable  consequence  of  the  operation,  the  want 
of  union  is  owing  to  the  opposite  sides  of  the  vessel 
not  being  retained  in  a state  of  contact,  so  as  to  allow 
of  their  adhesion. — (See  Observations  07l  the  Applica- 
tion of  the  Ligature  to  Arteries,  iS-c.  by  B.  Travers, 
vol.  4,  Med.  Chir.  Trayis.)  The  presence  of  the  liga- 
ture, in  the  common  mode  of  its  application,  effects 
this  object ; and  for  the  success  of  Dr.  Jones’s  experi- 
ment, it  appeared  only  necessary  that  the  opposite  sides 
of  the  wounded  vessel  should  be  retained  in  contact 
until  their  adhesion  is  sufficiently  accomplished  to  re- 
sist the  passage  of  the  blood  through  the  tube.  This 
object  might  probably  be  effected  by  compression  ; but 
the  inconveniences  attending  such  a degree  of  pressure 
as  shall  retain  the  opposite  sides  of  an  artery  in  con- 
tact at  the  bottom  of  a recent  wound,  are  too  great  to 
permit  its  employment.  It  occurred  to  Mr.  Travers, 
that  if  a ligature  were  applied  to  an  artery,  and  suf- 
fered to  remain  only  a few  hours,  the  adhesion  of  the 
wounded  surfaces  would  be  sufficiently  accomplished 
to  ensure  the  obliteration  of  the  canal ; and  by  the  re- 
moval of  the  ligature  at  this  period,  the  inconveniences 
attending  its  stay  would  be  obviated.  The  danger  pro- 
duced by  the  continuance  of  a ligature  upon  an  artery 
arises  from  the  irritation  which,  as  a foreign  body,  it 
produces  in  its  coats.  Ulceration  has  never  been  ob- 
served to  commence  in  less  than  twenty-four  hours 
after  the  application  of  a ligature;  while  it  is  an  ascer- 
tained fact  that  lymph  is  in  a favourable  state  for  or- 
ganization in  less  than  six  hours,  in  a wound  the  sides 
of  which  are  preserved  in  contact. — {Jones,  chap.  4, 
exp.  1.)  If  it  be  sufficient,  therefore,  to  ensure  their 
adhesion,  that  the  wounded  coats  of  an  artery  be  kept 
in  contact  by  a ligature  only  three  or  four  hours,  ulcer- 
ation and  sloughing  may  in  a great  degree  be  obviated 
by  promoting  the  immediate  adhe.sion  of  the  wound. 
Justified  by  this  rea.soning,  Mr.  Travers  performed 
several  experiments,  by  which  he  ascertained,  that  if 
a ligature  be  kept  six,  two  hours,  or  even  one  hour 
upon  the  carotid  artery  of  a horse,  and  then  removed, 
the  adhesion  is  suificiently  advanced  to  secure  the  per- 
manent obliteration  of  the  canal.  It  apiwared  probable 
that  the  same  result  would  be  obtained  upon  the 
healthy  artary  of  a human  .subjert. — {Hodgson  on  the 


Diseases  of  Arteries,  ^c.  p.  22.9,  et  seq.)  Mr.  A.  C. 
Hutchison,  in  the  year  1800,  tied  the  brach  al  arteries 
of  two  dogs,  and  removed  the  ligatures  immediately 
after  their  application.  In  both  instances,  the  complete 
obliteration  of  the  canal  of  the  artery  was  the  conse- 
quence of  the  operation.— (See  Practical  Observations 
in  Surgery,  p.  103.)  He  has  also  tried  this  method,  as 
modified  by  Mr.  Travers,  in  an  operation  which  he 
performed  for  a popliteal  aneurism  in  a sailor,  in  Nov. 
1813.  A double  ligature  was  passed  under  the  femoral 
artery.  The  ligatures  were  tied  with  loops  or  slip- 
knots, about  a quarter  of  an  inch  of  the  vessel  being 
left  undivided  between  them.  All  that  now  remained 
of  the  pulsation  in  the  tumour  was  a slight  undula- 
tory  motion.  Nearly  six  hours  having  elapsed  from 
the  application  of  the  ligatures,  the  wound  was  care- 
fully opened,  and  the  ligatures  untied  and  removed, 
without  the  slightest  disturbance  of  the  vessel.  In 
less  than  half  a minute  afterward  the  artery  became 
distended  wth  blood,  and  the  pulsations  in  the  tumour 
were  as  strong  as  they  had  been  before  the  operation. 
Mr.  Hutchison  then  applied  two  fresh  ligatures;  he 
morrhage  afterward  came  on ; amputation  was  per- 
formed, and  the  patient  died. — (See  Practical  Observa- 
tioois  in  Surgery,  p.  102,  Src.)  Now,  as  Mr.  Hutchison 
chose  to  apply  other  ligatures,  on  finding  that  the  pul- 
sation returned,  the  above  case  only  proves  that  the 
artery  was  not  obliterated  in  about  six  hours,  and  we 
are  left  in  the  dark  respecting  the  grand  question, 
namely,  whether  the  vessel  w'ould  have  become  obli- 
terated by^  the  effusion  of  coagulating  lymph  and  the 
adhesive  inflammation,  notwithstanding  the  return  of 
circulation  through  it.  As  for  the  hemorrhage  which 
occurred,  I think  it  might  have  been  expected,  consider- 
ing the  disturbance  and  irritation  which  the  artery 
must  have  sustained  in  the  proceedings  absolutely  ne- 
oessary  for  the  application  of  not  less  than  four  liga- 
tures, and  the  removal  of  two  of  them.  According  to 
my  ideas,  only  one  ligature  ought  to  have  been  used, 
and  none  of  the  artery  detached.  We  also  have  no  de- 
scription of  the  sort  of  ligatures  which  were  employed ; 
an  essential  piece  of  information  m forming  a judg- 
ment of  the  merits  of  the  preceding  method.  The 
application,  removal,  and  reapplication  of  ligatures 
are  not  consistent  tvith  the  wise  principles  inculcated 
by  the  late  Dr.  Jones,  and  have,  in  more  instances  than 
that  recorded  by  my  friend  Mr.  Hutchison,  brought  on 
ulceration  of  the  artery  and  hemorrhage.  For  farther 
information  on  the  question  concerning  the  propriety 
of  withdrawing  the  ligature  previously  to  its  detach- 
ment, see  the  article  Aneurism. 

From  Dr.  Jones’s  experiments,  it  appears  that  the 
first  effects  of  a ligature  upon  an  artery  are,  a com- 
plete division  of  its  internal  and  middle  coats,  the 
bringing  of  its  wounded  surfaces  into  contact  with  each 
other,  and  an  obstruction  to  the  circulation  of  the  bloo<l 
through  its  canal.  There  must  be  a small  quantity  of 
stagnant  blood  just  within  the  extremity  of  the  artery ; 
but  this  does  not,  in  every  instance,  immediately  fonu 
a coagulum  capable  of  filling  up  the  canal  of  the  artery. 
In  most  cases,  only  a slender  coagulum  is  formed  at 
first,  which  gradually  becomes  larger  by  successive 
coagulations  of  the  blood  ; and  hence  the  coagulum  is 
always  at  first  of  a tapering  form,  with  its  base  at  the 
extremity  of  the  artery.  Jlut,  as  Dr.  Jones  remarks,  the 
formation  of  this  coagulum  is  not  material ; for  soon 
after  the  ligature  has  been  applied,  the  end  of  the  artery 
inflames,  and  the  wounded  internal  surface  of  its  canal 
being  kept  in  close  contact  by  the  ligature,  adheres  and 
converts  this  portion  of  the  artery  into  an  impervious 
and,  at  first,  slightly  conical  sac.  It  is  to  the  effttsed 
lymph  that  the  base  of  the  coagulum  adheres,  when 
found  to  be  adherent.  I.ymph  is  also  effused  between 
the  coats  of  the  artery,  and  among  the  parts  surround- 
ing its  extremity.  In  a little  time,  the  ligature  make.s 
the  part  on  which  it  is  directly  applied  ulcerate,  and, 
acting  as  a tent,  a small  aperture  is  formed  in  the  layer 
of  lymph  effused  over  the  artery.  Through  this  aper- 
ture a small  quantity  of'pus  is  discharged,  as  long  as 
the  ligature  remains ; and  finally,  the  ligature  itself  also 
escapes,  and  the  little  cavity  which  it  has  occasioned 
granulates  and  fills  up,  and  the  external  wound  heals, 
leaving  the  cellular  substance  a little  beyond  the  end 
of  the  artery  much  thickened  and  indurated. — {Jones, 
p.  159.  161.) 

In  short,  when  an  artery  is  properly  tied,  the  follow- 
. ing  are  the  effects,  as  enumerated  by  Dr.  Jones  : 


HEMORRHAGE. 


485 


1.  To  cut  through  the  internal  and  middle  coats  of 
the  artery,  and  to  bring  the  wounded  surfaces  into  per- 
fect apposition. 

2.  To  occasion  a determination  of  blood  to  the  colla- 
teral branches. 

3.  To  allow  the  formation  of  a coagulum  of  blood  just 
within  the  artery,  provided  a collateral  branch  be  not 
very  near  the  ligature.  It  merits  particular  notice, 
however,  that  though  the  nearness  of  a collateral  branch 
prevents  the  formation  of  the  coagulum,  it  cannot  always 
prevent  the  completion  of  the  adhesive  process.  In  the 
experiments  made  oti  the  arteries  ol'horses  and  dogs  by 
Mr.  Travers,  the  ligature  was  purposely  applied  close 
to  large  collateral  branches,  yet  the  vessels  were  safely 
obliterated.— (See  Med.  Chir.  Trans,  vol.  6,  'p.  658. 
€60.) 

4.  To  excite  inflammation  in  the  internal  and  middle 
coats  of  the  artery,  by  having  cut  them  through,  and, 
consequently,  to  give  rise  to  an  effusion  of  ly/nph,  by 
which  the  wounded  surfaces  are  united,  and  the  canal 
is  rendered  impervious;  to  produce  a simultaneous 
inflammation  on  the  corresponding  external  surface  of 
the  artery,  by  which  it  becomes  very  much  thickened 
with  effused  lymph;  and,  at  the  same  time,  from  the 
exposure  and  inevitable  wounding  of  the  surrounding 
parts,  to  occasion  inflammation  in  them,  and  an  effusion 
of  lymph,  which  covers  the  artery,  and  forms  the  sur- 
face of  the  wound. 

5.  To  produce  ulceration  in  the  part  of  the  artery 
around  which  the  ligature  is  immediately  applied,  viz. 
its  external  coat. 

6.  To  produce  indirectly  a complete  obliteration,  not 
only  of  the  canal  of  the  artery,  but  even  of  the  artery 
itself,  to  the  collateral  branches  on  both  sides  of  the 
part  which  has  been  tied. 

7.  To  give  rise  to  an  enlargement  of  the  collateral 
branches. — (Jones,  p.  163,  164.) 

Every  part  of  an  artery  is  organized  in  a similar 
manner  to  the  other  soft  parts,  and  its  coats  are  suscep- 
tible of  the  same  process  of  adhesion,  ulceration,  &c.  as 
the  other  parts  are.  Hence,  the  precautions  taken  to 
secure  the  adhesion  of  other  parts  should  be  observed 
for  the  same  purpose  with  regard  to  an  artery.  The 
vessel  is  put  in  a state  to  admit  of  adhesion  by  the  liga- 
ture, which,  when  properly  applied,  cuts  through  its 
internal  and  middle  coats,  keeps  their  cut  surfaces  in 
contact,  and  affords  them  an  opportunity  of  uniting  by 
the  adhesive  inflammation,  as  other  cut  surfaces  do. 
The  immediate  stoppage  of.  the  bleeding  is  merely  the 
incipient  and  temporary  part  of  what  the  ligature  has  to 
accomplish ; it  has  also  to  effect  the  adhesion  of  the 
internal  and  middle  coats  of  the  artery,  which,  being  the 
thing  on  which  tile  permanent  supjiression  of  hemor- 
rhage depends,  is  the  most  important.  The  size  and 
form  of  the  ligature,  whether  completely  flat  or  irregu- 
lar, have  not  been,  as  Dr.  .Tones  remarks,  sufficiently 
attended  to;  nor  is  the  degree  of  force  employed  in 
tying  the  artery  often  considered.  Some  surgeons, 
wishing  to  guard  against  the  ligature  slipping  off,  tie  it 
with  very  considerable  force ; while  others,  apprehen- 
sive of  cutting  through  the  artery,  or  of  occasioning  too 
early  a separation  of  the  ligature,  draw  it  only  suffi- 
ciently tight  just  to  prevent  the  escape  of  blood.  A 
broad,  flat  ligature  is  not  likely  to  make  such  a wound 
in  the  internal  and  middle  coats  of  the  artery  as  is  most 
favourable  to  adhesion,  because  it  is  scarcely  possible 
to  tie  it  smoothly  round  the  vessel,  which  is  very  likely 
to  be  thrown  into  folds  or  puckered  by  it,  and  conse- 
quently to  have  an  irregular  bruised  wound  made  in  its 
middle  and  internal  coats.  By  covering  also  a consi- 
derable space  of  the  external  coat,  it  may  destroy  the 
very  vessels  which  jtass  on  it  in  their  way  to  the  cut 
surfaces  of  the  inner  coats,  and  thus  render  them  inca- 
pable of  inflaming.  Even  supposing  the  wound  to  unite, 
still  such  a ligature  may  cover  that  part  of  the  external 
coat  which  is  directly  over  the  newly  united  part,  and, 
consequently,  as  soon  as  it  has  produced  ulceration 
through  the  external  coat,  it  will  cau.se  the  same  effect 
on  the  newly  united  parts,  and,  of  course,  secondary 
hemorrhage. — (Jones,  p.  168.) 

When  a ligature  is  of  an  iivegular  form,  it  is  apt  to 
out  through  the  internal  and  middle  coats  of  an  artery 
more  completely  at  some  parts  than  others;  but  these 
coats  must  be  perfectly  cut  through,  in  order  to  produce 
an  effusion  of  lymph  from  the  inside  of  the  ve.ssel, 
winch  sp'-.ms  to  adhere  mo.st  securely  at  its  cut  sur- 
fiC.;,. 


Also,  when  the  ligature  is  not  apiilied  with  sufficient 
tightness,  the  inner  coats  of  the  artery  will  not  be  pro- 
perly cut  through.  Dr.  Jones  thinks  that  the  ligature, 
being  sometimes  put  on  so  as  to  deviate  from  a circle, 
has  a tendency  to  produce  secondary  hemorrhage. 

Dr.  Jones  conceives  that  ligatures  are  best  when 
they  are  round  and  very  firm  ; and  he  adds,  that  though 
only  a slight  force  is  necessary  to  cut  through  the  inter- 
nal and  middle  coats  of  an  artery,  it  is  better  to  tie  the 
vessel  more  tightly  than  is  necessary  merely  to  cut 
through  its  inner  coats,  because  the  cut  surfaces  will 
thus  be  more  certainly  kept  in  contact;  the  separation 
of  the  ligature  expedited  ; and  the  danger  of  ulceration 
spreading  to  the  newly  cicatrized  part  diminished.  The 
external  part  will  never  ulcerate  through  before  the 
inner  ones  have  adhered.  Tlie  limb,  however,  should 
be  kept  in  a perfectly  quiet  state. 

I am  sincerely  glad  to  find  that  so  accurate  an  ob- 
server as  Dr.  Jones  has  refuted  the  idea  that  ligatures 
occasionally  slip  off  the  vessels,  in  consequence  of  the 
violent  impulse  of  the  blood.  In  fact,  the  blood  does  not 
continue  to  be  impelled  against  the  extremity  of  the 
artery,  with  the  same  impetuosity  with  which  it  circu- 
lated through  the  vessel  before  it  was  tied.  The  blood 
is  immediately  determined  into  the  collateral  branches, 
nor  is  there  any  pulsation  for  some  way  above  the 
ligature. 

Dr.  Jones  much  more  rationally  imputes  this  occa- 
sional accident  either  to  the  clumsiness  of  the  ligature, 
which  prevents  its  lying  compactly  and  securely  round 
the  artery,  or  to  its  not  having  been  applied  with  suffi- 
cient tightness ; or  to  its  having  that  very  insecure  hold 
of  the  vessel  which  the  deviation  from  the  circular 
application  must  occasion. — (P.  173.) 

Dr.  Jones  is  of  opinion,  that  in  cases  of  aneurism,  in 
which  the  artery  has  only  been  tied  with  one  ligature, 
and  left  undivided,  and  in  which  secondary  hemorrhage 
has  arisen,  that  this  has  most  probably  been  owing 
either  to  a diseased  state  of  the  artery  ; to  various  con- 
trivances for  compressing  a large  portion  of  the  vessel ; 
to  having  a loose  ligature  above  the  one  which  is  tied ; 
or,  lastly,  to  not  tying  the  artery  sufficiently  tight  to 
cut  through  the  internal  and  middle  coats,  so  as  to  fit 
them  for  adhesion.  The  latter  fault  can  hardly  fail  to 
produce  a gradual  ulceration  of  those  coats,  and  of 
course  bring  on  hemorrhage,  which  returns  with  greater 
violence  as  the  ulceration  advances. — (P.  176.) 

These  reflections  must  also  obviously  explain  why 
Scarpa’s  practice  of  using  a largish  ligature,  with  the 
intervention  of  a piece  of  cloth  between  the  cord  and 
the  vessel,  for  the  express  purpose  of  hindering  the 
inner  coats  of  the  vessel  from  being  divided,  must  be 
objectionable,  because  it  may  be  set  down  as  an  axiom 
in  all  operations  where  large  arteries  are  to  be  tied, 
that  the  quantity  of  extraneous  substances  in  the  wound, 
and  particularly  of  such  as  are  in  contact  with  the  ar- 
tery. should  be  diminished  as  much  as  possible.  And 
though  I may  be  disposed  to  go  so  far  with  Scarpa  as  to 
believe  that  the  interposition  of  a piece  of  cork  or  wood 
is  worse  than  that  of  a cylinder  of  linen,  I cannot  accede 
to  the  proposition  that  the  latter  is  free  from  objection^ 
because  it  rather  acts  as  a cushion  than  as  a body 
likely  to  bruise. — (See  Mem.  on  the  Ligature  of  Arte- 
ries, p.  44.) 

With  the  differences  in  the  constitutions  of  man  and 
animals,  1 know  that  the  results  of  experiments  on  the 
latter  can  never  be  looked  upon  as  a positive  proof  of 
what  would  happen  from  the  same  experiments  per- 
formed on  the  human  subject.  The  stronger  or  weaker 
impulse  of  the  heart,  the  more  or  less  coagulable  nature 
of  the  blood,  the  greater  or  less  degree  of  general  and 
local  irritability,  the  more  or  less  quick  tendency  to 
adhesive  inflammation  and  ulceration,  are  circumstances 
which  must  make  in  different  animals  the  same  experi- 
ments lead  to  opposite  results.  The  question  whether 
a small  round  ligature,  or  a larger  flat  one,  with  a 
piece  of  linen  between  it  and  the  vessel,  be  best,  mu-st 
therefore,  after  all,  be  decided,  not  by  Dr.  Jones’s  expe- 
riments, nor  those  of  Scarpa,  or  Mislel,  but  by  the  prac- 
tice of  surgery  on  the  human  body ; and  that  the  prin- 
ciples defended  in  this  Dictionary  are  on  the  whole  to 
be  preferred,  can  hardly  be  questioned  by  any  man  who 
knows  how  much  less  frequent  secondary  hemorrhage 
now  is  in  this  metropolis  than  it  was  formerly,  when 
those  principles  were  neither  observed  nor  compre- 
hended.— (See  Amputation,,  Anemrism,  Arteries,  aaj 
Ligature.) 


486 


HEMORRHAGE. 


Dr.  Jones  seems  to  consider,  that  the  advantage  of 
the  retraction  of  the  divided  artery  within  the  cellular 
membrane  is  compensated,  in  the  case  of  the  undivided 
artery,  by  the  speedy  and  profuse  effusion  of  lymph, 
which  takes  place  over  and  round  the  vessel  at  the  tied 
part,  and  even  covers  the  ligature  itself.  Another 
cause  of  secondary  hemorrhage  is,  the  including  of 
other  parts  in  the  ligature,  together  with  the  artery ; 
by  doing  which  the  division  of  the  inner  coats  of  the 
ve.ssel  may  be  prevented. 

In  the  valuable  imblication  of  Dr.  Jones  to  which  1 
have  so  freely  adverted,  some  secondary  hemorrhages 
are  also  imputed  to  the  hidden  separation  or  laceration 
of  the  recently  united  parts  of  an  artery,  by  premature 
and  extraordinary  exertions  of  the  patient.  Hence,  he 
strongly  insists  on  keeping  a limb  in  which  a large  ar- 
tery has  been  tied  perfectly  at  rest. 

I shall  conclude  these  remarks  on  the  ligature  with  a 
few  practical  rules. 

1.  Always  tie  a large  artery  as  separately  as  possible, 
but  still  let  the  ligature  be  aiiplied  to  a part  of  the  ves- 
sel which  is  close  to  its  natural  connexions. 

Besides  the  reasons  for  this  practice  already  speci- 
iied,  we  may  observe,  that  including  other  substances 
in  the  ligature  causes  immense  pain,  and  a larger  part 
of  a wound  to  remain  disunited.  The  ligature  is  also 
apt  to  become  loose,  as  soon  as  the  substance  between 
it  and  the  artery  sloughs  or  ulcerates.  Sometimes  'he 
ligature,  thus  applied,  forms  a circular  furrow  in  the 
flesh,  and  remains  a tedious  time  incapable  of  a sepa- 
ration. 

The  blood-vessels  being  organized  like  other  living 
parts,  the  healing  of  a wounded  artery  can  only  take 
place  favourably  when  that  part  of  the  vessel  which 
is  immediately  contiguous  to  the  ligature  continues  to 
receive  a due  supply  of  blood  through  its  vasa  vaso- 
rum,  which  are  ramifications  of  the  collateral  arteries. 
Hence  the  disadvantage  of  putting  a ligature  round 
the  middle  of  a portion  of  an  artery,  which  has  been  sepa- 
rated from  its  surrounding  connexions  ; and  hence  the 
utility  of  making  the  knot  as  closely  as  possible  to  that 
part  of  the  vessel  which  lies  undisturbed  among  the 
surrounding  flesh. 

Small  arteries  neither  allow  nor  require  these  minute 
attentions  to  the  mode  of  tying  them. 

2.  When  a divided  artery  is  large,  open-mouthed,  and 
quite  visible,  it  is  best  to  take  hold  of  it,  and  raise  its 
extremity  a little  way  above  the  surface  of  the  wound 
with  a pair  of  forceps.  When  the  vessel  is  smaller, 
the  tenaculum  is  the  most  convenient  instrumeht. 

3.  While  the  surgeon  holds  the  vessel  in  this  way, 
the  assistant  is  to  place  the  noose  of  the  ligature  round 
it,  and  tie  it  according  to  the  above  directions.  In 
order  that  the  noose  may  not  rise  too  high,  and  even 
above  the  mouth  of  the  artery,  when  it  is  tightened,  the 
ends  of  the  ligature  mu-st  be  drawn  as  horizontally  as 
possible,  which  is  best  done  with  the  thumbs.  A knot 
is  next  to  be  made. 

4.  As  ligatures  always  operate  in  wounds  as  extra- 
neous bodies,  and  one-half  of  each  is  sufficient  for  the 
removal  of  the  noose  when  detached,  the  other  should 
be  cut  off  close  to  the  knot,  and  taken  away. 

As  we  have  explained  in  the  article  Amputation,  and 
as  we  shall  notice  again  in  speaking  of  the  Ligature, 
trials  have  of  late  years  been  made  of  the  practice  of 
cutting  off  both  ends  of  the  ligature  close  to  the  knot, 
with  a view  of  diminishing,  as  far  as  possible,  the  quan- 
tity of  extraneous  substances  in  the  wound.  This 
plan  requires  the  use  of  very  small  silk  ligatures,  in 
order  to  be  duly  judged  of. — (See  Mr.  Laureiice's  Obs. 
in  Medico-Chir.  Trans,  vol.  6,  p.  156,  et  seq.) 

5.  When  a large  artery  is  completely  divided,  two 
ligatures,  one  to  the  upper,  the  other  to  the  lower  part 
of  the  vessel  are  commonly  necessary,  in  consequence 
of  the  anastomosing  branches  conveying  the  blood'very 
readily  into  the  part  of  the  artery  most  remote  from  the 
heart,  as  soon  as  the  first  ligature  has  been  applied. 

6.  When  a large  artery  is  only  punctured,  and  com- 
pression cannot  be  judiciously  tried,  the  vessel  must  be 
first  expo.sed  by  an  incision,  and  then  a double  ligature 
Introduced  under  it,  with  the  aid  of  an  eye-probe. 
One  ligature  is  to  be  tied  above,  the  other  below  the 
bleeding  orifice ; with  due  attention  to  the  principles 
explained  in  this  article,  and  that  on  Aneurism. 

7.  Ligatures  usually  come  away  from  the  largest  ar- 
tery ever  tied  in  about  a fortnight,  and  from  those  of 
moderate  size  in  six  or  seven  days.  When  they  con- 


tinue attached  much  beyond  the  usual  period,  it  is 
proper  to  draw  them  very  gently  every  time  the  wound 
is  dressed,  for  the  purpose  of  accelerating  their  detach- 
ment. Great  care,  however,  is  requisite  in  doing  this; 
for,  as  Dr.  Jones  remarks,  as  long  as  the  ligature  seems 
firmly  attached,  pulling  it  rather  strongly  must  act 
more  or  less  on  the  recently  cicatrized  extremity  of  the 
arterj',  which  is  not  only  contiguous  to  it,  but  is  still 
united  to  that  portion  of  the  artery  (the  external  coat) 
which  detains  the  ligature. — {Jones,  p.  162.) 

In  particular  individuals  there  appears  to  be  an  ex- 
traordinary tendency  to  profuse  hemorrhage  from  very 
slight  injuries.  An  instance  of  this  kind  has  been  re- 
corded by  Mr.  Blagden,  where  a fatal  hemorrhage  arose 
from  the  extraction  of  a tooth.  The  patient,  who  was 
tw'enty-seven  years  of  age,  had  had  a tootli  extracted 
when  a boy,  in  consequence  of  which  operation  the 
bleeding  continued  for  twenty-one  days  from  the  socket 
before  it  ceased.  A very  slight  cut  on  the  head  w as 
also  followed  by  an  alarming  bleeding,  w hich  could  not 
be  stopped  by  pressure,  styptics,  or  the  ligature,  so  that 
it  became  necessary  to  apply  the  kali  pururn,  which 
succeeded.  On  his  having  another  carious  tooth  taken 
out,  a profuse  bleeding  followed,  which  resisted  the 
effect  of  styptics,  caustic,  and  every  means  adopted  to 
stop  up  the  socket.  The  actual  cautery  was  tried  in 
vain.  The  dangerous  condition  of  the  patient  seemed 
to  leave  no  other  resource,  but  that  of  tying  the  carotid 
artery,  which  was  done  by  Mr.  Brodie.  But  even  thi.s 
proceeding  failed  to  suppress  the  hemorrhage,  which 
proved  fatal. — (See  Med.  Chir.  Trans,  vol.  H,  p.  224, 
Land.  1817.)  On  the  mode  of  stopping  hemorrhage 
from  the  sockets  of  the  teeth,  the  reader  may  find  some 
remarks  in  the  Edin.  Med.  and  Surg.  Journ.  JVo.  58, 
p.  157. 

The  hemorrhage  from  the  bites  of  leeches  sometimes 
proves  exceedingly  obstinate,  and  instances  of  death 
from  this  cause  have  occasionally  happened,  ptirticu- 
larly  in  children.  When  common  methods  fail,  the 
plan  has  been  recently  tried  of  passing  a fine  sewing 
needle  through  the  skin  on  one  side  of  the  w'ound,  and 
then  another  through  the  skin  on  the  opposite  side,  and 
then  twisting  some  thread  round  the  needles,  so  as  to 
draw  them  together,  and  close  the  bite.  The  experi- 
ment fully  answered. — (See  Lond.  Med.  Repository, 
Jan.  1819,  p.  23—26.) 

For  more  information  respecting  hemorrhage,  see 
Amputation,  Aneurism,  Arteries,  Ligature,  and 
Wounds. 

Cons'olt  also  Petit's  Memoirs,  among  those  of  V Acad, 
des  Sciences  for  the  years  1731,  1732 — 1735.  Morand, 
Sur  le  Changement  qui  arrive  aux  Arteres  coupfes, 
1736.  Pouteau,  Melanges  de  Chirurgie.  Gooch's  Chi- 
rurgical  Works,  vol.  1.  Kirkland's  Essay  on  the 
Method  of  suppressing  Hemorrhages  from  Divided 
Arteries,  Qvo.  Lond.  1763.  White’s  Cases  in  Surgery. 
J.  Bell's  Principles  of  Surgery,  vol.  1.  Partie  Chirur- 
gicale  de  I'Encycl.  Meth.  Larrey,  Memoires  de  Chirur- 
gie Militaire,  tom.  2,  p.  379.  Pelletan,  Clinique  Chir. 
t.  2,  p.  240,  4'C.  M moire  Elementaire  sur  les  Hemoi- 
rhagies.  Richerand,  Nosographie  Chir.  t.  4,  sect,  sur 
les  MKadies  des  Artires,  p.  23,  <i  c.  edit.  4.  Leveilli, 
Nouvelle  Doctrine  Chir.  t.  1,  chap.  3 ; and  particularly 
Jones,  On  the  Process  employed  by  Nature,  in  sup- 
pressing the  Hemorrhage  from  Divided  and  Punctured 
Arteries,  1805.  Many  u.seful  remarks  on  the  subject 
of  Hemorrhage  will  be  found  in  Hodgson's  Treatise 
on  the  Diseases  of  Arteries  and  Veins.  See  also,  Ob- 
servations  upon  the  Ligature  of  Arteries,  and  the 
Causes  of  Secondary  Hemorrhage,  Ac.,  by  B.  Travers, 
in  Med.  Chir.  Trans,  vol.  4,  p.  435,  et  seq.  Likewise, 
Farther  Obserintions  on  the  Ligature  of  Arteries,  by 
the  same,  in  Med.  Chir.  Tians.  vol.  6,  p.  632,  et  seq. 
Laivrence,  On  a New  Method  of  tying  the  Arteries  in 
Aneurism,  Amputation,  Ac.  in  vol.  6 of  the  Med.  Chir. 
Trans,  p.  156,  Ac.;  and  Crampton,  in  vol.  7 of  the 
same  work.  Langenbeck,  Bibl.  b.  1.  Dr.  J.  Thoms-on's 
Lectures  on  Inflammation,  p.  250,  »i-c.,  and  Observa- 
tions made  in  the  Military  Hospitals  in  Belgium,  p. 
42 — 44.  Scarpa,  On  Aneurism,  and  particularly  his 
Memoir  on  the  Ligature  of  Arteries . this  is  contained 
in  the  second  edit,  of  the  Transl.  by  Mr.  Wisharl. 
Bedard,  Experiences  sur  les  Blessures  des  Artires. 
Robt.  Harrison,  Surgical  Anatomy  of  the  Arteries,  2 
vols.  Dublin,  1824,  18J5.  T.  Turner,  On  the  Arterial 
System,  Ac.  and  the  Surgical  Treatment  of  Hemor- 
rhage 8uo.  Lull.  25.  tVf  Ancit.li,..  Our.  2 


HEM 


HEM 


487 


times,  Svo.  Paris,  1825.  John  Cross,  A Case  of  Am- 
putation., with  some  Experiments  and  Observations  on 
the  securing  of  Arteries  with  minute  silk  Ligatures, 
in  Land.  Med.  Repository,  vol.  1,  p.  353.  The  author 
relates  several  experiments  for  the  purpose  of  ascer- 
taining the  utility  of  tying  arteries  ivith  such  liga- 
tures, and  cutting  the  two  ends  off  close  to  the  knot. 
They  were  performed  on  the  carotids  of  dogs  and 
asses.  The  conclusions  are  unfavourable  to  the  prac- 
tice. After  one  case  of  amputation,  where  the  method 
was  tried,  the  stump  healed  slowly,  and  for  several 
months  small  abscesses  repeatedly  formed. 

HEMORRHOIDS.  (From  a\pa,  blood,  and  pem,  to 
flow.)  Piles,  divided  into  such  as  do  not  bleed,  and 
termed  blind,  and  into  others  subject  to  occasional  he- 
morrhage, and  distinguished  by  the  epithet  open.  The 
etymological  meaning  of  the  word  is  evidently  only  a 
discharge  of  blood.  Surgeons,  however,  sanctioned  by 
long  custom,  have  generally  implied  by  the  term  hemor- 
rhoids either  a simple  bleeding  from  the  veins  of  the 
lower  part  of  the  rectum,  recurring  more  or  less  fre- 
quently, yet  not  accompanied  with  any  distinguishable 
permanent  tumours  within,  or  on  the  outside  of  the 
anus;  or  else  swellings  formed  by  a varicose  disten- 
tion and  morbid  thickening  of  those  vessels,  either  with 
or  without  occasional  hemorrhage;  or  lastly,  tumour's 
originally  produced  by  effused  blood,  but  subsequently 
converted  into  an  organized  substance. — {Abernethy, 
Surgical.  Works,  vol.  2,  p.  234.) 

According  to  Richter,  blind  hemorrhoids  consist  of 
preternatural  cysts  or  sacs  at  the  lower  extremity  of  the 
rectum,  from  the  size  of  a pea  to  that  of  an  apple. 
Sometimes  they  are  distended  with  blood,  and  very 
much  swelled;  and  at  other  periods  entirely  subside; 
though,  when  they  have  been  often  considerably  swelled, 
they  never  quite  disappear,  but  are  alternately  in  a full 
enlarged  state  and  empty  and  flaccid.  Indeed,  the  more 
frequent  and  considerable  the  enlargement  has  been,  the 
greater  rs  their  size.  It  is  generally  supposed,  that  these 
tumours  or  cysts  are  varicose  expansions  of  the  veins  of 
the  rectum  ; and  probably,  says  Richter,  this  may  some- 
times really  be  the  case;  but  the  disease  is  not  always 
of  this  nature.  In  particular  instances,  and,  perhaps, 
in  most  cases,  they  arise  from  an  extravasation  of  blood 
under  the  inner  coat  of  the  rectum;  and  then  the  cyst 
is  altogether  formed  by  this  membrane,  and  not  by  the 
vein.  The  following  circumstances  furnish  proof  of 
what  h£is  been  here  observed.  Hemorrhoids  are  some- 
times as  large  as  a walnut  or  apple ; yet  it  is  scarcely 
credible,  that  a mere  varix  could  attain  such  a size. 
When  cut  away,  the  bleeding  is  often  very  slight,  even 
when  they  are  large.  .Surely,  if  the  tumours  were 
varices,  there  would  always  be  profuse  hemorrhage. 
Sometimes  the  cyst  is  found  quite  empty ; but  how  can 
a varix  be  supposed  to  be  in  this  state  ? The  shape  of 
hemorrhoids  is  also  remarked  to  be  subject  to  greater 
variety  than  can  hardly  attend  dilatations  of  veins  ; 
thus  they  are  sometimes  oblong,  sometimes  cylindrical, 
like  a finger,  «fec.  Ltistly,  when  cut  away,  the  sac  is 
plainly  seen  to  consist  only  of  a single  membrane. — 
(Anfang.sgr.  der  Wundarzn.  b.  6,  p.  395,  ed.  2,  Gbtt. 
mfi.) 

At  the  same  time,  it  should  be  recollected  that  “ the 
blood  sometimes  coagulates  in  the  dilated  vein,  and  tin 
swelling  becomes  hard,  inflamed,  and  very  painfhl. 
The  coagulum  is  subsequently  absorbed,  but  the  thick- 
ened coals  of  the  vein  and  the  surrounding  parts  form 
a tumour  which  is  liable  to  inflame  and  atford  great 
distress.” — {Hodgson  on  Diseases  of  Arteries,  <.{-c.  p. 
56(5.)  in  short,  all  surgeons  who  consider  the  dis- 
ease as  varices,  admit,  with  Sir  E.  Home,  that  in  cases 
of  long  standing,  the  contents  of  hemorrhoidal  tumours 
“ coaiiulate  and  become  solid  ; their  coats  increase  in 
thickness,  and  they  resemble  pendulous  excrescent  tu- 
mours in  other  situations  in  the  body. — {On  Ulcers,  Ac.) 
.\vading  himself  of  the  extensive  opportunity  afforded 
by  his  dissecting-room,  Mr.  Kirby  has  taken  some  pains 
to  ascertain  the  nature  of  these  tumours;  and  he  ob- 
wTves,  “ 1 cannot  say,  that  they  seemed  to  be  formed 
of  a varicxtse  distention  of  the  great  hemorrhoidal  vein, 
even  in  a single  instance.  In  every  case  of  external 
hemorrhoids,  the  tumour  appeared  to  be  composed  of  a 
jirolongation  of  the  cellular  substance  in  a state  of  un- 
usual firmness,  surrounded  by  some  veins,  and  covered 
by  the  integuments.  The  veins  were  branches  of  the 
iiiteinal  iliac.  In  every  case  of  internal  hemorrhoid, 
the  structure  was  pretty  similar ; the  veins,  ho.vever, 


seemed  enlarged,  and  were  branches  of  the  hemor- 
rhoidal.”—(On  certain  severe  Forms  of  Hemorrhoidal 
Excrescence,  p.  40.) 

The  opinion  that  piles  are  formed  of  cells  filled  with 
blood  13  also  adopted  by  Dr.  Ribes.  The  distention  of 
the  hemorrhoidal  veins  w'ith  blood,  he  observes,  gives 
rise  to  varices ; but  if  any  of  their  blood  is  extrava- 
sated  in  the  cellular  membrane,  at  the  inferior  and  in- 
ternal part  of  the  anus,  hemorrhoids  are  the  result.  If 
the  inferior  mesenteric  vein  be  dissected  in  hemor- 
rhoidal patients,  the  ramifications  of  the  vessel  are 
seen  terminating  in  these  cysts  of  blood,  and  on  com- 
pletely removing  the  whole,  the  hemorrhoids  appear 
suspended  from  the  branches  of  the  vein,  as  grapes 
from  the  vine.— (See  Revue  Mhl.  t.  1, 8vo.  1820.)  Mon- 
tegre,  well  known  as  the  author  of  a copious  treatise 
on  the  present  subject,  is  the  only  writer  who  defines  a 
hemorrhoid  to  be  a preternatural  determination  of  blood 
{fluxion  sanguine)  to  the  extremity  of  the  rectum,  be- 
cause he  conceives  that  hemorrhage,  swelling,  &c.  are 
accidental  circumstances,  not  constantly  attending  the 
disease. — (See  Diet,  des  Sciences  Med  t.  20,  p.  445.) 

Whether  the  account  of  some  piles  being  formed  of 
distinct  cysts  or  sacs  of  blood  be  correct  or  not,  there 
is  no  doubt,  that  the  tumours  sometimes  consist  of  a 
varicose  enlargement  of  the  branches  of  the  hemor- 
rhoidal veins.  Were  this  not  the  fact,  how  could  cases 
like  the  following  ever  take  place?  “ One  of  my  pa- 
tients (says  M.  Delatour)  had  several  of  these  tumours 
of  very  large  size,  and  at  every  contraction  of  the 
sphincter  ani,  the  blood  issued  from  them  per  saltum.'’ 
— (Hist.  Phil.  obs.  212.)  Montegre  has  likewise  seen 
two  instances  in  which  the  blood  spouted  out  of  the 
tumours  in  a continued  stream.— (D/ct.  des  Sciences 
M d.  t.  20,  p.  453.)  And  Richerand  mentions  a mer- 
chant who  lived  to  the  age  of  eighty-nine,  quite  free 
from  infirmity,  and  whose  good  health  was  ascribed  to 
periodical  bleedings  from  piles,  during  fifty  years  of 
his  life;  the  evacuation  being  very  regular,  and  so  pro- 
fuse, that  the  blood  was  thrown  some  distance,  as  from 
a vein  opened  in  phlebotomy. — (See  Nosogr.  Chir.)  If 
many  piles  were  not  either  varices,  or  cysts  in  direct 
communication  with  the  large  veins  of  the  rectum,  Pe- 
tit would  not  have  succeeded  in  taking  blood  from  them 
by  puncture,  as  he  often  did  in  lieu  of  the  ordinary 
mode  of  venesection. — {Mol..  Chir.  t.  2,  p.  134.) 

Hemorrhoids  vary  in  number,  size,  form,  and  situ- 
ation : some  being  external ; others  internal ; and  some 
hardly  larger  than  a pea,  while  others  exceed  a hen’s 
egg  in  size.  Sometimes  they  bring  on  very  serious 
complaints,  either  by  bursting  and  discharging  blood 
so  profusely  as  dangerously  to  reduce  the  patient ; or 
by  exciting  inflammation  of  the  adjacent  parts,  and 
causing  abscesses  and  fistulse;  or,  lastly,  by  becoming 
strangulated  by  the  contraction  of  the  sphincter  ani,  so 
as  to  occasion  severe  pain.  Piles  which  bleed  but 
little  are  not  of  much  consequence ; but  those  w^hich 
bleed  profusely  cause  violent  pain,  or  which  induce 
inflammation  and  all  its  effects,  demand  the  greatest 
attention.  Lieutaud  mentions  a person  who  lost  three 
quarts  of  blood  from  some  piles  in  the  course  of  a cou- 
ple of  days ; and  both  Arius  and  the  celebrated  philo- 
sopher Copernicus  are  said  to  have  bled  to  death  in 
this  manner. 

I do  not  know  what  credit  ought  to  be  given  to  the 
extraordinary  case  cited  by  Panaroli,  in  which  a Spanish 
nobleman  voided  every  day,  for  four  years,  a pint  of 
blood  from  some  hemorrhoids,  and  yet  enjoyed  perfect 
health !— (See  Obs.  Chir.  pentec.  2,  obs.  46.)  For  other 
curious  facts  of  this  nature,  see  Diet,  des  Sciences  Med. 
t.  20,;;.  458. 

As  Mr.  Howship  remarks,  hemorrhoidal  tumours, 
when  connected  with  inflammation,  are  very  painful. 

“ The  patient  can  then  neither  walk,  ride,  nor  sit ; the 
only  tolerable  state  being  that  of  rest  in  the  reclined 
position.  Should  he,  during  the  continuance  of  inflam- 
mation, be  obliged  to  pass  a motion,  the  distress  is  ex- 
treme. With  these  symptoms,  there  is  generally  more 
or  less  feverish  heat  and  restlessness,  now  and  then 
delirium.” — {On  Diseases  of  the  Loner  Intestines,  p 
208,  ed.  3.) 

In  general,  when  piles  are  situated  far  up  the  rec- 
tum, they  are  less  painful  than  when  low  down,  and 
sometimes  the  patient  is  not  conscious  of  having  them 
till  he  begins  to  void  blood  from  the  rectum.  In  the 
former  case,  the  veins  or  tumours  are  surrounded 
by  soft  and  yielding  bubstances,  which  do  act  make 


488 


HEMORRHOIDS. 


any  painful  pressure  on  them  ; but  when  they  are  si- 
tuated towards  the  anus,  they  often  suffer  painful  con- 
striction from  the  action  of  the  sphincter  muscle.  Mr. 
Heaviside  met  with  two  examples  where  hemorrhoidal 
swellings  were  attacked  with  inflammation,  and  so 
violently  strangulated  by  the  spasmodic  action  of  the 
sphincter  ani,  that  the  parts  underwent  a spontaneous 
mortiflcation,  and  a radical  cure  was  the  result. — {J. 
Howship  on  Diseases  of  the  Lower  Intestines,  6,  c. 
p.  210,  ed.  3.) 

With  regard  to  the  cause  of  hemorrhoids,  any  thing 
capable  of  retarding  the  return  of  blood  through  the 
hemorrhoidal  veins  may  occasion  the  disease.  The 
pressui  e ol  the  gravid  uterus,  costiveness,  and  the  fre- 
quent retention  of  hardened  feces  in  the  rectum,  are 
very  frequent  causes.  Persons  who  lead  sedentary 
lives  are  often  troubled  with  the  complaint.  Women 
are  more  subject  to  piles  than  men. 

The  pressure  of  an  enlarged  liver,  or  of  water  accu- 
mulated in  the  cavity  of  the  peritoneum,  may  occasion 
piles. 

I have  adverted  to  the  opinion  of  Montegre,  that  he- 
morrhoids depend  upon  a determination  of  blood  to  the 
lower  part  of  the  rectum ; which  sentiment  is  perhaps 
correct  in  cases  where  the  disease  arises  from  irritation 
in  that  bowel,  or  the  neighbouring  parts. 

When  these  tumours  are  produced  by  the  pressure  of 
the  gravid  uterus,  no  cure  can  be  expected  till  after  de- 
livery, when  one  generally  follows  spontaneously.  Also, 
when  piles  are  an  effect  of  dropsy,  they  cannot  get  well 
before  the  pressure  of  the  fluid  in  the  abdomen  has  been 
removed  by  tapping.  Gently  laxative  medicines  and 
a horizontal  position  of  the  body  commonly  alleviate 
the  uneasiness  resulting  from  hemorrhoids.  The  appli- 
cation of  an  ointment  composed  of  equal  parts  of  the 
powder  of  oak-galls  and  of  elder  ointment  or  hog’s  lard 
contributes  to  the  same  beneficial  effect.  The  applica- 
tion of  warm  water  by  means  of  a bidet,  or  semicupium, 
is  also  frequently  productive  of  great  ease.  When  jhles 
are  constricted  by  the  sphincter  ani  muscle,  the  pain 
may  often  be  at  once  removed  by  pushing  the  swellings 
up  the  rectum,  and  using  fomentations  or  even  the 
warm  bath.  Mr.  Howship,  in  cases  where  the  dispo- 
sition to  spa^im  in  the  sphincter  is  connected  with  high 
irritability  in  the  bowel,  recommends  the  introduction 
of  a metallic  bougie  for  a certain  length  of  time,  the 
size  of  the  instrument  and  frequency  of  repetition  of 
the  operation  being  duly  regulated. — {On  Diseases  of 
the  Lower  Intestines,  drc.  p.  214,  ed.  3.)  When  the  dis- 
ease is  in  a state  of  inflammation,  leeches  applied  to  the 
vicinity  of  the  anus,  and  puncturing  the  dilated  hemor- 
rhoidal ve.ssels  with  a lancet,  for  the  purpose  of  taking 
away  blood,  and  the  apjflication  of  cold  lotions,  are 
measures  occasionally  employed  to  procure  ease.  The 
usefulness  of  leeches  was  particularly  noticed  by 
Schrnucker. — (Vermischte  Chir.  Schriften,  b.  1,  p.  107.) 
Petit  preferred  the  lancet. 

According  to  Mr.  Howship,  when  there  is  “ frequent 
hemorrhage  from  the  veins  within  the  sphincter,  with 
perhaps  little  or  no  external  tumour,  one  of  the  best 
means  of  relief  is  the  metallic  bougie,  regulated  by  the 
patient’s  feelings,  and  also  by  the  promptitude  with 
which  inflammation  and  consolidation  take  place.” — 
{On  Diseases  of  the  Lower  Intestines,  if c.  p.  215,  ed.  3.) 

When  the  number  and  size  of  hemorrhoids  are  so 
considerable,  as  materially  to  obstruct  the  discharge  of 
the  feces  ; when  they  are  severely  painful,  and  subject 
to  profuse  bleedings;  when  the  patient  is  disabled 
from  following  his  usual  occupations ; and  when  the 
above  means  afford  insufficient  relief,  the  surgeon 
should  recommend  their  removal. 

The  extirpation  of  piles  with  the  actual  cautery  and 
cau.stics,  as  practised  by  the  old  surgeons,  is  now  alto- 
gether relinquished.  The  only  plan  ever  followed  in 
the  present  state  of  surgery  is,  either  to  cut  the  tumours 
off  with  a pair  of -scissors  or  knife,  or  to  apply  a tight 
ligature  round  their  base,  so  as  to  cause  them  to  slough 
away.  If  possible,  the  opportunity  of  doing  either  of 
these  operations  should  always  betaken  when  the  dis- 
ease is  in  a tolerably  quiet  state. 

When  piles  are  to  be  cut  off,  and  they  are  not  suffi- 
ciently visible,  the  patient  must  fir.st  stram,  as  at  stool, 
in  order  to  make  the  swellings  more  apparent.  With 
the  aid  of  a pair  of  directing  (breeps,  the  skin  covering 
the  hemorrhoids  is  then  to  be  separated  from  them 
with  the  knife,  but  not  cut  away,  and  the  tumours  be- 
ing taketf  hold  of  with  a tenaculum,  are  to  be  removed. 


Sabatier  states,  that  saving  the  skin  i.s  very  essential , 
for  any  hemorrhage  which  may  arise  can  then  be' 
more  easily  suppressed ; and  when  there  are  several 
hemorrhoids  to  be  extirpated,  the  loss  of  substance 
about  the  anus  will  be  less,  and,  of  course,  the  patient 
will  not  be  so  liable  to  a contraction  of  this  part,  which 
is  sometimes  a very  great  affliction. 

Previously  to  the  performance  of  any  operation,  Mr. 
Abernethy  endeavours  to  bring  the  bowels  into  a more 
regular  state,  and  takes  care  to  clear  them  with  any 
medicine  found  by  experience  to  answer  the  purpose 
without  inducing  a continuance  of  irritation  and  purg- 
ing. “ The  bowel  being  everted  to  the  utmost  by  the 
efforts  used  in  evacuating  the  feces,  and  the  parts 
cleansed  by  bathing  with  tepid  w'ater,  the  piles  should 
be  taken  hold  of  with  a double  hook  and  removed  with 
a pair  of  scissors.  A protruded  and  thickened  plait  of 
the  bowel  may  be  removed  in  the  same  way;  but  I 
think  it  is  best  to  use  the  bistoury  in  reraovitigit,  because 
the  depth  to  which  the  scissors  may  cut  is  uncertain. 
The  incision  made  by  the  knife  resembles  two  curved 
lines  joined  at  each  extremity.”  The  direction  of  the 
incision,  both  for  the  removal  of  piles,  and  that  of 
plaits,  he  says,  should  be  longitudinal  in  the  direction 
of  the  bowel.  When  there  is  a transverse  fold  of  the 
bowel  of  considerable  extent,  he  prefers  taking  away 
two  elliptical  portions  in  the  long  axis  of  the  rectum. — 
(See  Ahemethy's  Surgical  Works,  vol.  2,p.  239.) 

As  I have  explained  in  the  former  part  of  this  work 
(see  Anus,  Prolapsus  of),  the  late  Mr.  Hey  used  to  re- 
move these  extensive  diseased  folds  about  the  verge  of 
the  anus,  with  great  success.  J.  L.  Petit  followed  the 
same  practice  {Mai.  Chir.  t.  2,  p.  134),  and  more  re- 
cently Mr.  Kirby.— (O&s.  07i  the  Hemorrhoidal  Excres- 
cence, Lond.  1817.) 

The  late  Mr.  Ware  published  some  remarks,  the  te- 
nor of  which  is  to  prove,  that  when  there  are  several 
hemorrhoids,  the  removal  of  one  or  two  of  the  most 
painful  of  them,  with  a pair  of  scissors,  will  afford  ef- 
fectual relief. 

The  e.xcision  of  piles  is  occasionally  followed  by  dan- 
gerous bleeding,  as  is  exemplified  in  a case  related  by 
Petit.  A patient  had  some  hemorrhoids,  which  were 
supposed  to  be  external,  while  they  were  only  tempo- 
rarily protruded.  Almost  immediately  after  they  had 
been  cut  off,  the  skin  which  had  supported  them  was 
drawn  inwards.  An  internal  hemorrhage  ensued,  which 
could  not  he  suppressed,  and  proved  fatal  in  less  than 
five  hours.  The  rectum  and  colon  were  found  full  of 
black,  coagulated  blood.  Sir  E.  Home  speaks  also  of 
some  instances  within  his  knowledge,  where,  after  the 
removal  of  intenial  piles  with  the  knife,  the  bleeding 
endangered  life. — {On  Ulcers,  p.  365.) 

If  the  bleeding  should  be  troublesome,  and  proceed 
from  vessels  within  the  rectum,  the  best  plan  would  be  . 
to  distend  the  gut  with  a suitable  piece  of  sponge,  sc 
as  to  make  pressure  on  the  wound.  Cold  should  also 
be  applied  to  the  sacrum  and  nates. 

The  removal  of  hemorrhoids  with  a ligature  may  ge- 
nerally be  done  with  sufficient  safety  ; but  still  it  has  its 
inconveniences,  though  they  are  not  constant.  Petit 
frequently  practised  this  method  without  any  ill  effects. 
In  other  instances  he  had  reason  to  repent  of  having 
adopted  it.  A woman,  in  whom  he  had  tied  three  he- 
morrhoids with  narrow  pedicles,  which  were  favour- 
ably situated  for  this  operation,  did  not  at  first  experi- 
ence a great  deal  of  pain.  However,  five  hours  after- 
ward he  was  informed  that  she  suffered  violent  colic 
pains,  which  extended  along  the  colo.n.  She  was  bled 
four  times  without  material  relief.  At  la.st  Petit  cut 
the  ligatures,  which  could  not  be  loosened,  in  conse- 
quence of  their  being  concealed  so  deeply  in  the  sub- 
stance of  the  swollen  parts.  The  pain  very  soon  sub- 
sided. The  ligatures  had  only  been  applied  four-and- 
twenty  hours,  but  the  piles  had  become  black,  and  the 
skin  covering  their  bases  was  cut  through.  Petit  then 
removed  them  without  the  least  effusion  of  blood. 

Petit  also  relates  a ca.se  in  which  a patient,  after  hav- 
ing htKl  some  piles  tied,  died  of  symjttoms  resembling 
those  which  take  place  in  ca.ses  of  strangulated  hernia*, 
notwithstanding  the  ligatures  had  been  cut,  as  in  the 
foregoing  instance.  After  these  two  cases.  Petit  aban- 
doned the  practice  of  tving  hemorrhoids.  ?ilr.  Kirby 
has  mentioned  two  cases  proving  the  ill  effects  some- 
times arising  from  the  ligature  of  piles : in  one  of  these 
examples,  the  patient’s  life  was  saved  with  great  dif- 
ficulty ; and  in  the  other  the  operalioti  was  followed  by 


HEMORRHOIDS. 


489 


tetanus  and  death. — (Obs.  on  the  Treatment  of  certain 
gevere  Forms  of  Hemorrhoidal  Excrescence, p.  1 — 3,  Bvo. 
Land.  1817.) 

Mr.  Howship,  who  prefers  the  use  of  the  ligature, 
ohserves,  that  in  performing  the  operation,  it  is  not  ne- 
cessary to  take  up  all  the  tumours ; but  that,  if  there 
are  five  or  six,  the  tying  of  two  or  three  of  the  largest 
will  generally  produce  such  a change  in  the  texture  of 
the  rest,  as  will  secure  the  patient  from  any  return  of 
the  disease.  After  the  ligatures  are  detached,  he  dis- 
continues the  fomentations  and  applies  cold  lotions. — 
(On  Diseases  of  the  Lower  Intestines,  SfC.  p.  216, 
ed.  3.) 

I believe,  on  the  whole,  that  it  is  best  to  remove  he- 
morrhoids with  a knife,  except  when  they  are  situated 
high  up  the  rectum,  where  the  veins  are  of  large  size 
end  likely  to  bleed  profusely.  If  a tumour  so  situated 
should  absolutely  require  removal,  which  can  rarely 
happen,  a ligature  might  be  put  round  its  base  with  the 
aid  of  a double  cannula.  When  the  base  of  the  tumour, 
however,  is  large,  admits  of  being  brought  into  view, 
and  the  surgeon  prefers  tying  it,  he  should  pass  a nee- 
dle, armed  with  a strong  double  ligature,  through  the 
root  of  the  hemorrhoid,  and  tie  one  part  of  this  ligature 
firmly  over  one  side  of  the  swelling  and  the  other  over 
the  opposite  side.  When  the  base  of  the  tumour  is 
narrow,  and  the  ligature  is  preferred,  the  part  may  be 
tied  at  once,  without  passing  a double  ligature  through 
its  middle. 

Old  hemorrhoids,  which  have  been  repeatedly  in  a 
state  of  inflammation,  at  length  acquire  a considerable 
degree  of  hardness.  The  internal  membrane  of  the 
rectum  becomes  thickened,  loses  its  natural  softness, 
and  forms  a kind  of  cyst  which  prevents  the  tumour 
from  bursting  and  bleeding. — (See  Theden,  Progris  de 
la  Chinirgie,  sect.  4,  p.  73.)  In  the  end,  it  ulcerates 
and  pours  out  a fetid  discharge.  Its  size  cannot  now 
be  lessened  by  the  use  of  emollient  applications ; and 
its  excision  is  indispensably  necessary. — (See  Lassiis, 
Patholo^e  Chir.  t.  1,  p.  336.) 

An  opinion  has  commonly  prevailed,  that  the  bleed- 
ing from  piles  is  of  a salutary  or  critical  nature ; an 
evacuation,  by  which  some  peccant  or  morbid  matter 


is  thrown  off  from  the  body.  Hence,  many  patients 
have  been  advised  to  submit  to  all  the  pain  and  uneasi- 
ness which  the  disease  occasions,  rather  than  seek  a 
cure.  If  the  fact,  that  some  patients  lose  their  health 
after  their  piles  have  been  cured,  be  received  as  suffi- 
cient proof  of  the  disease  having  had  a salutary  effect, 
the  doctrine  must  remain  fully  established.  But  be- 
fore this  inference  should  be  drawn,  it  ought  to  be 
known  whether  the  frequency  of  the  fact  is  such  as  to 
warrant  the  conclusion ; for  it  is  not  to  be  supposed 
that  the  removal  of  piles  places  the  patient  altogether 
beyond  the  reach  of  disease  and  illness ; and  no  one 
will  deny,  that  such  operation  frequently  leads  to  im- 
provement of  the  health.  Were  a patient  to  appear  to 
suffer  from  the  cessation  of  an  habitual  bleeding  from 
piles,  leeches  and  even  cupping-glasses  might  be  ap- 
plied. 

Consult  Petit,  lEuvres  Posthumes,  t.  2.  Callisen, 
Systema  Chirurgiae  Hodiemoe,  t.  2,  p.  105,  ed.  1800 
Sabatier,  De  la  Medecine  Op^ratoire,  t.  2.  Latta’s  Sys- 
tem of  Surgery,  vol.  2.  Ware,  on  the  Treatment  of 
Hemorrhoids.  Truka  de  Krzowitz,  Historia  Hemor- 
rhoidum,  3 vols.  8vo.  Vindob.  1794,  1795.  Sir  J.  Earle, 
Obs.  on  Hemorrhoidal  Excrescences,  M ed.  8vo.  Lond. 
1807.  T.  Copeland,  Obs.  on  the  Principal  Diseases  of 
the  Rectum  and  Anus,  8vo.  Lond.  1814.  Schreger, 
Chirurgixche  Versiiche,  b.  1,  p.  253,  iS  c.  Ueber  tubu- 
culose  Exa-escenz  des  Afterdarms,  8t;o.  Niimberg, 
1811.  John  Kirby,  Obs.  on  the  TreatmevA  of  certain 
severe  Forms  of  Hemorrhoidal  Excrescence,  8vo.  Land. 
1817.  Abemethy  on  Hemorrhoidal  Diseases,  in  his 
Surgical  Works,  vol.  2,  p.  231,  drc.  Lasstis,  Patho- 
logic Chir.  t.  \,p.  331,  ed.  1809.  Richter  vonderBlin- 
den  Guldnen  Ader,  in  Anfangsgr.  der  Wundarzney- 
kunst,  b.  6,  p.  395,  ed.  1802.  W.  Hey,  Pract.  Obs.  in 
Surgery,  p.  439,  <^c.  ed.  2,  8vo.  Lond.  1810.  Diet,  des 
Sciences  Med.  t.  20,  p.  441,  <S-c.  8vo.  Paris,  1817.  Moti- 
tegre,  Des  Hemorrhoides,  otd  f Traits  Analytique  de 
toutes  les  Affections  Hemorrhoidales,  nouvelle  edit.  Pa- 
ris, 1819.  W.  Whyte,  Obs,  on  Strictures  of  the  Rec- 
tum, (S-c.  3d  ed.  Bath,  1820.  J.  Howship  on  Diseases 
of  the  Lower  Intestines  and  Anus,  ed.  3,  8vo.  Lond. 
1824.  G.  Calvert  on  Hemorrhoids,  Src.  8vo . London,  1824. 


END  or  VOL.  I. 


Harper's  Stereotype  Edition^  uniform  with  Hooper's  Medical  Dictionaryi 


A 

DICTIONARY 


OF 

PRACTICAL.  SURGERY: 

COMPREHENDING 


ALL  THE  MOST  INTERESTING  IMPROVEMENTS,  FROM  THE  EARLIEST  TIMES  DOWN 
TO  THE  PRESENT  PERIOD;  AN  ACCOUNT  OF  THE  INSTRUMENTS 
AND  REMEDIES  EMPLOYED  IN  SURGERY  ; THE  ETY- 


MOLOGY AND  SIGNIFICATION  OF 

THE  PRINCIPAL  TERMS? 


AND 

NUMEROUS  REFERENCES  TO  ANCIENT  AND  MODERN  WORKS  : FORMING  A 
“CATALOGUE  RAISONNe”  OF  SURGICAL  LITERATURE. 

BY  SAMUEL  COOPER,  \ 

SURGEON  TO  THE  KING’S  BEJjICH,  THE  BLOOMSBURY  DISPENSARY,  AND  HIS  MAJESTY’S  PRISON  OP  THE  FI 
MEMBER  OF  THE  COUNCIL  OF  THE  ROYAL  COLLEGE  OF  SURGEONS  IN  LONDON  ; SURGEON  TO 
THE  FORCES  ; HONORARY  MEMBER  OF  THE  ACADEMY  OF  NATURAL  SCIENCES 

AT  CATANIA  J THE  MEDICAL  SOCIETY  OF  MARSEILLES  ; &C.  ' 


FROM  THE  SIXTH  LONDON  EDITION. 

REVISED,  CORRECTED,  AND  ENLARGED. 


WITH  NUMEROUS  NOTES  AND  ADDITIONS, 

EMBRACING  ALL  THE  PRINCIPAL  IMPROVEMENTS  AND  GREATER  OPERATIONS 
INTRODUCED  AND  PERFORMED  BY  AMERICAN  SURGEONS. 


BY  DAVID  MEREDITH  REESE,  M.D. 


LICENTIATE  IN  SURGERY  AND  MIDWIFERY  ; HONORARY  MEMBER  OF  THE  MEDICAL  AND  CHIRURGICAL  FACl 
OF  MARYLAND,  AND  OF  THE  MEDICAL  SOCIETY  OP  MARYLAND  ; RESIDENT  FELLOW  OF  THE  I 
MEDICAL  AND  PHILOSOPHICAL  SOCIETY  OF  NEW-YORK  ; PRACTITIONER  j 

OF  PHYSIC  AND  SURGERY  IN  THE  CITY  OF  NEW-YORK,  &C  / 


IN  TWO  VOLUMES. 

VOL.  II. 


NEW-YORK: 


PUBLISHED  BY  HARPER  & BROTHERS, 

NO.  82  CLIFF-STREET. 


18  3 4. 


\ 


SOUTHERN  DISTRICT  OF  NEW-YORK,  ». 

Be  it  RE^IEMBERED,  That  on  the  ll;th  day  of  June,  A.  D.  lf!30,  jn  the  fifty-fourth  ye»r  of  the  independence  of  the  United  States 
of  Anierin.,  J.  & J.  HARPER,  of  the  said  district,  have  depositeil  in  this  office  the  title  of  a book,  the  right  whereof  they  claina 
as  Proprietors,  in  tlie  words  following,  to  wit , 

“ A Dictiomry  of  Practical  Surgery  . comprehending  all  the  most  interesting  Improvements,  from  the  earliest  times  down  to  the  present 
period;  an  Account  of  the  Instruments  and  Remedies  employed  in  Surgery;  the  Etymology  and  Si^ificaiion  of  the  principal  Terms;  and 
numenus  Rf.ferences  to  ancient  and  modern  Works ; forming  a ‘ Catalogue  Raisonne’  of  surgical  Literature.  By  Samuel  Cooper,  Surgeon 
to  the  King’s  Bench,  the  Bloomsbury  Dispensary,  and  his  Majesty’s  Prison  of  the  Fleet ; Member  of  the  Council  of  the  Royal  College  of 
SurgKins  in  London;  Surgeon  to  the  Forces  ; Honorary  Member  of  the  Academy  of  Natural  Sciences  at  Catania,  the  Medical  Society  of 
Maneilles;  &c.  From  the  Sixth  lajndon  Edition  ; revised,  corrected,  and  enlarged.  With  numerous  Notes  and  Additions,  embracing  all 
theprincipal  Improvements  and  ^eater  Operations  infroduc.ad  and  performed  by  American  Surgeons.  By  David  Meredith  Reese,  M.D. 
Liicntiate  in  Surgery  and  Midwifery  ; Honorary  Meu  ber  of  the  Medical  and  Chirurgjcal  Faculty  of  Maryland,  and  of  the  Medical  Society 
ofMaryland  ; Resident  Member  of  the  Medical  and  Philosophical  Society  of  New-York  ; Practitioner  of  Physic  and  Surgery  in  the  city 
«New.York,&c.”  v j , re/. 

In  conformity  to  the  Act  of  the  Congress  of  the  United  States,  entitled  “ An  Act  for  the  encouragement  of  Learning,  by  securing  the  copies 
0 maps,  charts,  and  books,  to  the  authors  and  proprietors  of  siich  copies,  during  the  times  therein  mentioned.”  And  also  to  an  Act,  entitled 
‘An  Act,  supplementary  to  an  Act,  eniitleil  an  Act.  for  the  encouragement  of  Learning,  by  securing  the  copies  of  maps,  charts,  anddiooks, 
t the  authors  and  proprietors  of  such  copies,  during  the  times  therein  mentioned,  and  extending  the  benefits  thereof  to  the  arts  of  designing, 
egraving,  and  etching  historical  and  other  print*  ” 

FREDERICK  J.  BETTS, 
Clerk  of  the  Southern  District  of  AVu*-PwA, 


SURGICALr  DICTIONARY, 


HE'RNIA.  (From  epi/o?,  a branch,  from  its  protru- 
ding forward.)  Surgeons  understand,  by  the  term 
hernia.,  a tumour,  formed  by  the  protrusion  of  some  of 
the  viscera  of  the  abdomen,  out  of  that  cavity,  into  a 
kind  of  sac,  composed  of  the  portion  of  peritoneum, 
which  is  pushed  before  them.  However,  there  are 
certainly  cases  which  will  not  be  comprehended  in 
this  definition ; either  because  the  parts  are  not  pro- 
truded at  all,  or  have  no  hernial  sac.  It  is  only  in  rare 
cases,  that  the  sac  is  wanting ; as,  for  example,  when 
the  hernia  has  been  produced  by  the  operation  of  great 
violence,  or  has  been  preceded  by  a wound  of  the  ab- 
dominal parietes,  or  an  attempt  at  a radical  cure  has 
been  made  with  caustic.  The  sac  is  also  sometimes 
rendered  imperfect  by  laceration  or  ulceration.  Some 
viscera,  which  occasionally  protrude,  are  not  included 
in  the  peritoneum,  as  the  bladder  and  coecum ; and 
when  they  are  considerably  displaced,  they  draw  after 
tlieni  the  portion  of  peritoneum  connected  with  them, 
which  forms  a sac  into  which  other  bowels  may  fall. 

“ The  brilliant  progress  which  surgery  has  made  in 
modern  times  (says  Scarpa)  is,  properly  speaking, 
only  the  result  of  pathological  anatomy  ; that  is  to  say, 
of  exact  comparisons  of  the  natural  state  of  our  organs 
with  their  different  diseases,  which  may  depend  upon 
an  alteration  of.  texture,  a derangement  of  functions,  a 
solution  of  continuity,  or  a change  of  situation.  It  is 
from  morbid  anatomy,  that  the  most  rational  curative 
methods,  with  which  modern  surgery  is  enriched,  are 
deduced  as  so  many  corollaries;  methods,  to  which 
we  are  also  indebted  for  the  perfection  of  operations. 

“ There  are  indeed  a certain  number  of  surgical 
operations,  for  the  prompt  and  safe  execution  of  which 
mere  anatomical  knowledge  will  suffice ; but,  in  many 
others,  the  surgeon  cannot  promise  himself  success, 
even  though  he  be  well  acquainted  with  anatomy, 
unless  he  has  particularly  studied  the  numerous  changes 
of  position,  and  alterations  of  texture,  of  which  the 
parts  upon  which  he  is  about  to  operate  are  suscep- 
tible. If  he  has  not  the  requisite  information  upon  all 
these  points,  false  appearances  may  deceive  his  judg- 
ment, and  make  him  commit  mistakes,  sometimes  of 
a very  serious  and  irreparable  kind. 

“ In  order  to  have  a convincing  proof  of  this  truth,  it 
will  be  sufficient  to  take  a view  of  the  different  species 
of  herniaj,  and  their  numerous  complications.  As- 
suredly, no  anatomist  would  believe,  that  the  intestine 
coecum,  naturally  fixed  in  the  right  ilium,  and  the 
urinary  bladder,  situated  at  the  bottom  of  the  pelvis, 
could  undergo  without  being  torn,  so  considerable  a 
displacement  as  to  protrude  through  the  abdominal 
ring,  and  descend  even  into  the  scrotum ; that  the  same 
intestine,  the  coecum,  could  pass  from  the  right  iliac 
region  to  the  umbilicus,  protrude  at  this  opening,  and 
form  an  umbilical  hernia ; that  the  right  colon  could 
have  been  found  protruded  from  the  abdomen  at  the 
left  abdominal  ring,  and  the  left  colon  through  the  right 
one;  that  the  liver,  spleen,  and  ovary  could  sometimes 
form  the  contents  of  umbilical,  inguinal,  and  femoral 
herniae;  that  the  coecum  could  engage  itself  within  the 
colon,  and  even  protrude  at  the  anus;  that  the  stomach 
could  be  forced  through  the  diaphragm,  and  form  a 
hernia  within  the  chest ; that  the  omentum,  or  intes- 
tine, or  both  these  parts  together,  could  sometimes 
escape  from  the  belly  through  the  foramen  ovale,  or 
sacro-ischiatic  notch  of  the  pelvis;  that  a noose  of 
small  Intestine,  after  being  engaged  in  the  abdominal 
ring,  or  under  the  femoral  arch,  could  suffer  the  most 
violent  strangulation,  without  the  course  of  the  intes- 


tinal matter  being  intercepted  ; lastly,  that  in  certain 
circumstances,  the  intestine  and  oixjentum  could  be  in 
immediate  contact  with  the  testicle,  within  the  tunica 
vaginalis,  without  the  least  laceration  of  tJris  latter 
membrane.  These  and  several  other  analogous  facts 
(says  Scarpa)  are  so  surprising,  that  they  would  yet  be 
regarded  as  incredible,  had  they  not  been  proved  by 
numerous  observations  on  individuals  affected  with 
hernia  : their  possibility  (repeats  this  experienced  pro- 
fessor) would  not  even  have  been  suspected,  either  by 
the  anatomist  or  physiologist.” — (See  Scarpa,  Traiti 
des  Hernies,  Pref.) 

The  parts  of  the  body,  where  hernisB  most  frequently 
make  their  appearance,  are  the  groin,  the  navel,  the 
labia  pudendi,  and  the  upper  and  forepart  of  the  thigh ; 
they  do  also  occur  at  every  point  of  the  anterior  part 
of  the  abdomen  ; and  there  are  several  less  common 
instances,  in  which  hernial  tumours  present  themselves 
at  the  foramen  ovale ; in  the  perineum  ; in  the  vagina ; 
at  the  ischiatic  notch,  &c. 

The  parts,  which,  by  being  thrust  forth  from  the 
cavity  in  which  they  ought  naturally  to  remain,  mostly 
produce  herniae,  are  either  a portion  of  the  omentum, 
or  a part  of  the  intestinal  canal,  or  both  together.  But 
the  stomach,  the  liver,  spleen,  uterus,  ovaries,  bladder, 
&c.  have  been  known  to  form  the  contents  of  some 
hernial  tumours.  The  small  intestine  is  more  frequently 
protruded  than  the  large,  and  the  iliunr  more  frequently 
tlian  the  jejunum,  in  consequence  of  its  greater  prox- 
imity to  the  ring  and  crural  arch.  A part  only  of  the 
diameter  of  the  tube  is  sometimes  included  in  a hernia ; 
any  larger  quantity  may  descend,  from  a.  single  fold 
to  the  whole  moveable  portion  of  the  canal.— (See 
Lawrence  on  Ruptures,  p.  5,  ed.  4.) 

From  these  two  circumstances  of  situation  and  con- 
tents, are  derived  all  the  different  appellations  by  which 
herniaj  are  distinguished.  If  a portion  of  intestine 
alone  form  the  contents  of  the  tumour,  the  case  is  called 
enter ocele;  if  a piece  of  omentum  only,  epiplocele ; 
and  if  both  intestine  and  omentum  contribute  to  the 
formation  of  the  tumour,  it  is  called  an  entero-epiploccle. 
When  the  contents  of  a hernia  protrude  at  the  abdo- 
minal ring,  but  only  pass  as  low  as  the  groin,  or  la- 
bium pudendi,  the  case  receives  the  name  of  bubo- 
nocele or  inguinal  hernia;  but  if  the  parts  descend 
into  the  scrotum,  it  is  called  an  oscheocele  or  scrotal 
hernia.  The  crural  or  femoral  hernia  is  the  name 
given  to  that  which  takes  place  below  Poupart’s  liga- 
ment. When  the  bowels  protrude  at  the  navel,  tiie 
case  is  named  an  exomphales  or  umbilical  hernia;  and 
ventral  is  the  epithet  given  to  the  swelling,  when  it 
occurs  at  any  other  promiscuous  part  of  the  front  of 
the  abdomen.  The  congenital  rupture  is  a very  par- 
ticular case,  in  which  the  protruded  viscera  are  not 
covered  with  a common  hernial  sac  of  peritoneum,  but 
are  lodged  in  the  cavity  of  the  tunica  vaginjilis,  in 
contact  with  the  testicle;  and,  as  must  be  obvious,  it 
is  not  named,  like  herniae  in  general,  from  its  situation, 
or  contents,  but  from  the  circumstance  of  its  existing 
from  the  time  of  birth. 

Wlien  the  protruded  bowels  lie  quietly  in  the  sac, 
and  admit  of  being  readily  put  back  into  the  abdomen, 
the  case  is  termed  a reducible  hernia;  and  when  they 
suffer  no  constriction,  yet  cannot  be  put  back,  owing 
to  adhesions,  or  their  large  size  in  relation  to  the  aper- 
ture through  which  they  have  to  pass,  the  hernia  is 
termed  irreducible.  An  incarcerated  or  strangulated 
hernia,  signifies  one,  which  not  only  cannot  be  re- 
duced, but  suffers  constriction ; so  that,  if  a piece  of 


4 


HERNIA. 


intestine  be  protruded,  the  pressure,  to  vvliich  it  is  sub- 
jected, stops  the  passage  of  its  contents  towards  the 
anus,  excites  inflammation  of  the  bow'el,  and  brings  on 
a train  of  alarming,  and  often  fatal,  consequences. 

The  causes  of  herni®  are  either  predisposing  or  ex- 
citing. Among  the  former,  writers  mention  a preter- 
naturally  large  size  of  the  openings,  at  which  the 
bowels  are  liable  to  protrude ; a weakness  and  relax- 
ation of  the  margins  of  these  apertures ; a preterna- 
tural laxity  of  the  peritoneum ; an  unusually  long 
mesentery,  or  omentum,  &c.  With  regard  to  the 
abdominal  ring,  the  transverse  tendinous  fibres, 
which  naturally  cross  and  strengthen  its  upper  and 
outer  part,  are  much  weaker  in  some  subjects  than 
others.  No  idea  seems  more  prevalent  in  books,  than 
that  taking  a good  deal  of  oil  with  our  food,  is  condu- 
cive to  the  formation  of  hernial  diseases.  Some  of  the 
alleged  predisposing  causes  may  justly  excite  skepti- 
cism ; but  several  circumstances  tend  to  prove,  that  a 
natural  deficiency  of  resistance,  in  any  part  of  the  pa- 
rietes  of  the  abdomen,  promotes  the  occurrence  of 
hernia.  Hence,  persons  who  have  had  the  peritoneum 
wounded  are  very  liable  to  the  present  disease  {Riche- 
rand,  J\rosogr.  Chir.  t.  3,  p.  317 ; Schmucker,  Vcr- 
mischte  Chir.  Schriften,  b.  1,  p.  197) ; and  men  are 
much  more  liable  than  women  to  inguinal  hernia,  evi- 
dently from  the  larger  size  of  the  abdominal  ring; 
while,  in  women,  as  there  is  a larger  space  for  the  pro- 
trusion of  the  viscera,  below  Poupart’s  ligament,  they 
are  more  exposed  than  men  to  femoral  herni®. 

With  regard  to  the  exciting  causes,  our  knowledge 
is  involved  in  loss  doubt.  The  grand  cause  of  this 
kind  is  the  powerful  action  of  the  abdominal  muscles 
and  diaphragm  on  the  viscera.  In  feats  of  agility, 
such  as  jumping,  &c.  the  pressure  which  the  contents 
of  the  abdomen  must  often  encounter,  sufficiently  ac- 
counts for  their  protruding  at  any  part,  where  the  ab- 
dominal parietes  donot  make  adequate  resistance.  The 
same  consideration  explains  why  herni®  very  often 
take  place  in  lifting  and  carrying  heav'y  weights,  run- 
ning, vomiting,  straining  at  stool,  parturition,  &c.  and 
in  people  who  inhabit  mountainous  countries. 

The  diminution  of  the  capacity  of  the  abdomen,  by 
the  action  of  the  abdominal  muscles  and  diaphragm, 
in  many  occasional  exertions,  must  take  place  in  every 
body,  by  reason  of  the  common  habits  and  necessities 
of  life.  But,  as  only  a certain  number  of  persons 
meet  with  the  disease,  it  is  fair  to  infer,  that  either  the 
exciting  causes  must  operate  with  greater  force  in 
them,  than  in  the  generality  of  people,  or  else  that  their 
abdominal  parietes  have  not  been  capable  of  the  ordi- 
nary degree  of  resistance.  Many  patients,  who  meet 
with  herni®  in  making  violent  efforts  and  exertions, 
may  be  in  the  former  circumstance;  while  others, 
whose  viscera  protrude  from  such  trivial  things  as 
coughing,  sneezing,  crying,  &c.  must  be  considered  as 
being  under  the  influence  of  some  predisposing  cause. 
A gentleman,  who  has  gained  great  honour  by  a most 
valuable  treatise  on  hernia,  remarks,  that  “herni®, 
which  originate  in  predisposition,  generally  come  on 
gradually,  and  almost  imperceptibly;  while  those 
which  are  produced  by  bodily  exertions,  are  formed 
suddenly,  and  by  the  immediate  action  of  the  exciting 
cause.  The  occurrence  of  the  complaint  is  often  indi- 
cated, in  the  first  instance,  by  a fulness,  combined 
with  a sense  of  weakness,  about  the  abdominal  ring. 
The  swelling  is  increased  by  any  action  of  the  respi- 
ratory muscles,  and  disappears  on  pressure,  and  in  the 
recumbent  position  of  the  body.  It  gradually  finds  its 
way  through  the  tendon  of  the  external  oblique  mus- 
cle, into  the  groin,  and  afterward  into  the  scrotum. 
When  a hernia  takes  place  suddenly,  it  is  generally 
attended  with  a sensation  of  something  giving  way  at 
the  part,  and  with  —{Lawrence  on  Ruptures, 

p.  42,  edit.  4.) 

Upon  the  subject  of  the  immediate  cause  of  herni®, 
it  is  ob.served  by  Scarpa,  that  several  distinguished 
modern  surgeons,  as,  for  instance,  Warton  {Jldeno- 
graph.  cap.  11),  Benevoii  {Dissertazioni  Chirvrgische, 
1),  Rossius  {Jicta  Kat.  Cur.  t.  2,  obs.  178),  Brendel 
{De  Herni  arum  J^atalibus),  and  xMorgagni  {De  Sed.et 
Caus.  Morb.  epist.42,  art.  13),  consider  a relaxation 
and  elongation  of  the  mesentery  as  the  principal  cause 
of  herni®  in  general,  and  of  the  bubonocele  in  parti- 
cular. Hence,  say  they,  the  whole  mass  of  intestines, 
or  only  a portion  of  an  intestine,  descends  against  the 
inner  orifice  of  the  inguinal  ring,  presses  against  this 


opening,  and  gradually  makes  its  way  out  of  the  abdo- 
men. In  examining  this  pathological  point  without 
prejudice,  it  is  incontestable,  says  Scarpa,  that  an  in- 
testine cannot  be  moved  beyond  its  natural  limits,  un- 
less that  part  of  the  mesentery,  which  retains  and  fixes 
the  bowel  in  its  proper  place,  be  at  the  same  time 
elongated.  But  it  does  not  follow  from  this,  tliat  a 
relaxation  of  the  mesentery  must  precede  the  displace- 
ment of  the  intestme.  It  appears  to  Scarpa  much 
more  probable,  that  these  two  events  are  simultaneous, 
and  depend  upon  one  and  the  same  cause. 

“ In  the  healthy  state,  the  abdomen,  considered  alto- 
gether, is  submitted  to  two  opposite  forces,  which  re- 
ciprocally balance  each  other.  One  is  the  pressure  of 
the  viscera  against  the  abdominal  parietes;  the  other 
is  the  reaction  of  these  same  parietes  upon  the  viscera, 
which  they  contain.  If  these  two  forces  were  in  per- 
fect equilibrium  in  all  individuals,  and  under  all  the 
circumstances  of  life,  we  should  not  be  in  the  least 
subject  to  herni®.  If,  w'hen  the  equilibrium  has  been 
broken,  every  point  of  the  parietes  of  the  belly  were  to 
yield  equally  to  the  impulse  of  the  viscera,  an  increase 
of  the  volume  of  the  whole  abdomen  would  be  the 
consequence;  but  a true  hernia  would  never  happen. 
The  cavity  of  the  abdomen  is  always  completely  full. 
The  containing  and  contained  parts  react  upon,  and 
reciprocally  compress,  one  another.  It  is  by  the  effect 
of  this  moderate,  but  equal  and  unremitting  pressure, 
that  all  the  viscera  mutually  support  each  other. 
Without  it,  the  ligaments  of  the  liver,  those  of  the 
spleen,  and  the  various  membranous  bands  of  the  in- 
testines in  general,  would  only  be  feeble  means  for 
fixing  such  parts  in  their  respective  situations.  But 
there  are  certain  points  of  the  abdominal  parietes 
which  naturally  present  much  less  resistance  than 
others,  and  which  react  with  much  less  power  against 
the  pressure  made  from  within  outwards  by  the  abdo- 
minal viscera.  Such  is  particularly  the  part  which 
extends  front  the  pubes  to  the  anterior  superior  spinous 
process  of  the  ilium.  This  relative  weakness  of  some 
points  of  the  abdominal  parietes  is  very  marked  in 
certain  individuals,  in  consequence  of  a defect  of  or- 
ganization. It  may  also  be  increased  by  internal  or 
external  causes,  which  are  as  various  as  they  are  nu- 
merous, When,  in  one  of  these  cases,  the  pressure 
made  by  the  viscera  is  unusually  increased,  as  iiappens 
in  a violent  effort,  a defect  in  the  equilibrium  between 
the  two  forces  above  mentioned  is  occasioned ; that  is 
to  say,  the  reaction  of  the  abdominal  parietes  is  no 
longer  proportioned,  at  least  at  certain  points,  to  the 
force  of  the  impulse  of  the  viscera.  The  conjoined 
powers  of  the  abdominal  muscles,  diaphragm,  and  le 
vator  ani,  are  then  directed  and  concentrated  against 
the  most  feeble  point  of  the  abdomen,  towards  which 
they  propel  the  nearest  viscus,  or  that  which,  from  its 
moveablencss,  is  the  most  liable  to  displacement.  If 
such  viscus  should  happen  to  be  the  noose  of  an  intes- 
tine, it  is  evident,  that  the  power,  which  tends  to  make 
it  protrude  from  the  belly,  must  at  the  same  time  act 
upon  the  corresponding  portion  of  the  mesentery ; and 
the  intestine,  in  passing  through  the  parietes  of  the 
abdomen,  drags  the  mesentery  after  it,  and  makes  this 
membrane  yield  and  become  elongated.  When  the 
displaced  viscera  meet  with  little  resistance  on  the  part 
of  the  parietes  of  the  abdomen,  the  hernia  is  quickly 
formed,  and  the  elongation  of  the  mesentery  occurs 
with  equal  celerity.  We  have  an  example  of  this  in 
the  inguinal  congenital  hernia:  in  this  case  the  intes- 
tine is,  in  some  measure,  precipitated  into  a sac  pre- 
viously prepared  for  its  reception.  On  the  contrary,  in 
the  ordinary  inguinal  hernia,  a totally  different  dispo- 
sition of  the  parts  renders  the  progress  of  the  disease 
much  slower.  In  most  instances,  the  hernia  is  not 
formed  immediately  the  equilibrium  between  the  im- 
pulse of  the  viscera  and  the  reaction  of  the  abdominal 
parietes  is  broken.  But  in  the  groin,  a slight  elevation 
is  first  observed,  in  the  direction  from  the  anterior  su- 
perior spinous  process  of  the  ilium  towards  the  inguinal 
ring.  Some  time  afterward,  when  the  intestine  has 
made  its  appearance  on  the  outside  of  the  ring,  the  en- 
largement of  the  hernia,  and  the  elongation  of  the 
mesentery,  make  mtich  more  rapid,  though  always 
simultaneous,  progress.” 

“ Numerous  practical  observations  (says  Scarpa) 
concur  in  proving,  that  we  must  not  search  for  the  im- 
mediate cause  of  herni®  in  the  relaxation  of  the  me- 
sentery, but  rather  in  a want  of  equilibrium  between 


HERNIA. 


5 


Uie  pressure  of  the  viscera  and  the  resistance  of  one  or 
several  points  of  the  abdominal  parietes.  Indeed, 
herniffi  are  seen  occurring  from  the  slightest  causes  in 
infants,  in  whom  the  neck  of  the  tunica  vaginalis  is 
not  speedily  obliterated,  and  in  individuals  who,  from 
being  fat,  have  all  on  a sudden  become  extremely  thin. 
Such  women  as  have  had  children  are  more  subject  to 
the  disease  than  others.  Persons  also  of  both  sexes, 
who  carry  considerable  burdens,  or  who  play  upon 
wind-instruments,  or  who  have  suffered  a forcible  con- 
tusion of  the  abdomen,  are  particularly  exposed  to  the 
disorder,  even  though  there  be  not  the  least  reason  for 
suspecting  in  them  a relaxation  of  the  mesentery.  Va- 
ginal herniai  which  arise  after  difficult  labours,  afford 
another  proof  of  the  same  truth:  their  cause  is  owing 
to  a laxity  and  weakness  of  the  parietes  of  the  vagina, 
which,  not  being  capable  of  making  any  farther  re- 
sistance to  the  pressure  of  the  viscera,  situated  in  the 
cavity  of  the  pelvis,  at  length  suffer  these  parts  to  pro- 
trude. 

“ With  respect  to  the  second  proposition,  that  during 
the  formation  of  a hernia,  the  combined  force  of  all 
the  abdominal  muscles  is,  as  it  were,  directed  and  con- 
centrated against  the  most  feeble  point  of  the  parietes, 
we  see  a proof  of  it  in  a fact  that  occurs  to  our  ob- 
servation every  day.  In  order  to  convince  ourselves 
of  this,  we  need  only  notice  what  happens  in  indivi- 
duals afflicted  with  herniae;  if  they  cough,  or  sneeze, 
or  make  the  slightest  effort,  they  instantly  find  the  size 
of  the  swelling  increased,  and  hasten  to  support  the 
part  with  their  hand.-  During  the  slightest  efforts, 
which  render  the  herniae  larger,  it  is  also  indisputable, 
that  the  mesentery  is  elongated  in  the  same  proportion 
as  the  intestine  protrudes.  All  the  viscera  have  such 
a tendency  to  be  displaced  and  carried  towards  the 
weakest  point  of  the  parietes  of  the  abdomen,  that 
even  those  which  are  naturally  the  most  distant  from 
it,  and  are  the  most  firmly  fixed  by  the  folds  of  the 
mesentery,  may  in  their  turn  descend  into  the  herniae. 
Anatomical  knowledge  alone  would  never  have  led  us 
to  entertain  a suspicion  of  the  possibility  of  these  oc- 
currences. Sandifort  and  Paletta  have  found,  in  an 
umbilical  hernia,  the  ccecum,  with  a portion  of  the 
ilium  and  colon. — ( Obs.  Pathol,  cap.  4 ; and  J^Tova  Ou- 
beniaculi  Testis  Descriptio.)  Mauciiart,  Camper,  and 
Bose  have  met  with  the  ccecum  in  an  inguinal  hernia 
of  the  left  side. — {De  Hern.  Incarc.  in  Halleri  Disput. 
Chirurg.  tom.  3 ; Demonstrat.  Jinat.  Palholog.  lib.  2, 
p.  18 ; et  ..Onimadvers.  de  Hern.  Ingum.  p.  5.)  Lassus 
has  seen  the  left  colon  protrude  at  the  right  inguinal 
ring. — {Mddecine  Opiratoire,  t.  1,  p.  173.)  If  it  be 
proved  by  all  these  facts,  that  such  viscera  as  are  the 
most  closely  united  to  the  great  sac  of  the  peritoneum 
and  neighbouring  parts,  are  nevertheless  liable  to  form 
hernia; ; and  if  such  displacements  cannot  happen 
without  a considerable  elongation  of  the  membranous 
bands  fixing  these  bowels  in  their  natural  situation; 
how  can  vve  refuse  to  admit,  that  a noose  of  intestine, 
pushed  by  degrees  through  the  inguinal  ring,  drags' 
along  with  it  the  corresponding  portion  of  the  mesen- 
tery 1 In  order  to  explain  this  event,  there  is  no  ne- , 
cessity  for  supposing  a partial  relaxation  of  the  mesen- 
tery.”— ( Traile  Pratique  des  Hernies,  par  j3.  Scarpa, 
trad,  de  I'ltalien,  p.37 — 43.) 

The  same  causes,  which  first  produced  the  com- 
plaint, or  others  of  an  analogous  nature,  as  Mr.  Law- 
rence has  noticed,  are  constantly  tending  to  promote 
its  increase.  The  tumour  becomes  larger,  in  proportion 
as  the  pressure  against  the  hernial  sac  is  stronger,  and 
more  frequent.  Hence,  the  great  size  which  it  often 
attains  in  persons  constantly  pursuing  laborious  occu- 
pations. Its  increase  will  also  be  in  proportion  to  the 
less  considerable  re.«istance  of  the  parts  in  which  it  is 
situated.  Hence,  the  magnitude  of  scrotal  ruptures, 
and  the  generally  small  size  of  a femoral  hernia.  The 
size  of  a hernia  is  likewise  in  part  dependent  upon  the 
largeness  and  weakness  of  the  opening,  through  which 
the  protrusion  happens.  Hence,  inguinal  ruptures  are 
usually  much  larger  than  those  called  femoral,  or 
crural.  The  looseness  of  the  cellular  connexion  of  the 
peritoneum  is  another  cause  of  the  disposition  of  a 
hernia  to  attain  a considerable  magnitude;  while  the 
shortness  and  closeness  of  the  same  uniting  medium 
operate,  in  particular  cases,  as  a check  to  the  enlarge 
inent  of  the  tumour,  as  is  exemplified  in  hernia;  of  the 
linea  alba,  which  are  generally  small.  When  the  sac, 
after  it  has  passed  the  parietes  of  the  abdomen,  is 


situated  among  cellular,  or  adipous  substance,  it  ex- 
pands  equally  in  all  directions,  and  forms  a nearly 
spherical  tumour,  being,  however,  generally  rather  flat 
tened,  as  in  umbilical  and  crural  herniae.  If  it  protrude 
through  a canal,  it  is  nearly  cylindrical,  as  in  incipient 
inguinal  herniae ; and  even  in  those  which  have  passed 
the  ring,  and  are  still  confined  by  the  sheath  of  the 
spermatic  cord.  The  fundus  of  the  sac  enlarges  as  it 
descends  into  the  scrotum,  and  thus,  in  almost  all 
scrotal  cases,  the  swelling  becomes  pyriform.  Irregu 
laritiesof  shape  often  take  place  from  the  extension  of 
the  membrane  in  directions  presenting  the  least  resist 
ance.  At  the  first  moment  of  the  occurrence  of  a 
hernia  of  sudden  formation,  the  protruded  peritoneum 
is  unconnected  to  the  parts  among  which  it  lies;  but 
adhesions  take  place  so  quickly,  that  the  sac  is  found 
universally  connected  to  the  contiguous  parts,  even  in 
a rupture  of  two  or  three  days’  standing.  These  ad- 
hesions prevent  the  return  of  the  sac  into  the  abdomen, 
when  the  contents  of  the  swelling  are  replaced.  The 
peritoneum,  which  immediately  surrounds  the  pro- 
truded viscera,  generally  retains  the  same  thin  and 
delicate  structure  which  characterizes  that  membrane 
in  its  natural  situation.  It  is  covered  by  other  invest- 
ments, varying  in  thickness  and  structure,  according  to 
the  part  in  which  the  swelling  is  formed,  and  the  size 
and  duration  of  the  tumour,  &c. — (See  Lawrence  on 
Ruptures,  p.  18,  Src.  edit.  4.) 

Many  interesting  circumstances,  in  relation  to  hernial 
sacs,  have  been  satisfactorily  explained  by  Cloquet; 
and  some  of  them  are  noticed  in  Mr.  Lawrence’s  work. 
“If  the  causes  which  have  produced  the  hernia  con- 
tinue to  operate,  and  further  descent  of  the  peritoneum 
be  prevented  by  its  strong  adhesion  to  the  tendinous 
opening,  the  sac  becomes  thin  by  distention.  It  may 
give  way  partially  by  a kind  of  laceration,  and  thus  be- 
come irregular  in  figure,  presenting  an  appearance  of 
small  cysts,  or  secondary  cavities.  On  the  contrary, 
when  the  neck  does  not  adhere  so  strongly,  and  the 
mouth  of  the  sac  forms  a thickened  ring,  the  renewed 
action  of  pressure  may  make  the  ring  descend,  and 
a fresh  one  will  form  at  the  new  mouth  of  the  sac. 
Tliis  process  may  be  again  repeated ; and  thus  the  sac 
presents  one  or  more  constrictions,  by  which  the  pro- 
truded parts  may  be  compressed,  and  even  strangulated. 
Inguinal  and  scrotal  ruptures  are  almost  the  only  cases 
in  which  this  occurrence  can  take  place.  When  a 
hernia  passes  through  a canal,  a thickened  ring  may  be 
formed  at  both  orifices  of  the  canal.  If  a hernial  sac 
has  been  formed,  and  its  mouth  become  thickened,  a 
new  protrusion  may  take  place  by  the  side  of  it : this 
may  occur  again : and  thus  we  may  liave  sacs  com- 
posed of  two  lateral  cavities,  or  consisting  of  two  or 
more  secondary  openings  into  one  principal  protrusion; 
or,  the  original  serous  cavity  may  be  contracted,  and 
form  a small  appendix  to  the  subsequent  protrusion.” 
— (See  Lawrence  on  Ruptures,  p.  26 ; and  Cloquet's 
Recherches  sur  les  Causes,  Src.  des  Hernies.) 

Herniae  are  more  frequent  on  the  right,  than  on  the 
left  side  of  the  body.  This  fact,  as  Mr.  Lawrence  has 
remarked,  does  not  depend  on  any  disparity  in  size,  be- 
tween the  apertures  of  the  two  sides,  but  must  be  re- 
ferred to  the  employment  of  the  right  side  in  those  of- 
fices of  life  which  require  the  most  powerful  exertion. 
— ( 071  Ruptures,  p.  33,  ed.  4.)  This  subject  has  been 
particularly  considered  by  Cloquet.— (See  Recherches 
sur  les  Causes  et  VJinaiomie  des  Hernies  Abdominales, 
p.  10,  (J-c.  4to.  Paris,  1819.) 

The  general  symptoms  of  a hernia,  which  is  reduci- 
ble, and  free  from  strangulation,  are,  an  indolent  tu- 
mour at  some  point  of  the  abdomen,  most  frequently 
descending  out  of  the  abdominal  ring,  or  from  just  be- 
low Poupart’s  ligament,  or  else  out  of  the  navel ; but, 
occasionally,  from  various  other  situations,  as  will  be 
presently  explained.  The  swelling  often  originates 
suddenly,  except  in  the  circumstances  above  related, 
and  it  is  subject  to  a change«of  size,  being  smaller 
when  the  patient  lies  down  on  his  back,  and  larger 
when  he  stands  up,  or  holds  his  breath.  It  frequently 
diminishes  when  pressed,  and  grows  large  again  when 
the  pressure  is  removed.  Its  size  and  tension  often  in- 
crease after  a meal,  or  when  the  patient  is  flatulent. 
In  consequence  of  the  unnatural  situation  of  the 
bow'els,  many  patients  with  hernia  are  occasionally 
troubled  with  colic,  constipation,  and  vomitirig. 
Sometimes,  however,  the  functions.of  the  viscera  seem 
to  suffer  little  or  no  interruption. 


6 


HERNIA. 


Sometimes  the  contained  parts  may  be  known  by  the 
symptoms.  But,  as  Mr.  Lawrence  justly  remarks,  this 
discrimination  is  often  difficult,  and  even  impossible, 
when  the  hernia  is  old,  large,  and  very  tense ; for,  in 
cases  of  this  description,  the  viscera  experience  consi- 
derable changes  in  their  figure  and  state,  while  the 
thickened  hernial  sac  prevents  an  accurate  examina- 
tion by  the  hand. — (Ore  Ruptures,  p.  46,  ed.  4.) 

If  the  case  be  an  enterocele,  and  the  portion  of  intes- 
tine be  small,  the  tumour  is  small  in  proportion ; but, 
though  small,  if  the  gut  be  distended  with  wind,  in- 
flamed, or  have  any  degree  of  stricture  made  on  it,  it 
will  be  tense,  resist  the  impression  of  the  finger,  and' 
give  pain  upon  being  handled.  On  the  contrary,  if 
there  be  no  stricture,  and  the  intestine  sufier  no  degree 
of  inflammation,  let  the  prolapsed  piece  be  of  what 
length  it  may,  and  the  tumour  of  whatever  size,  the  ten- 
sion will  be  little,  and  no  pain  w'ill  attend  the  handling 
of  it ; upon  the  patient’s  coughing,  it  will  feel  as  if  it 
were  blown  into ; and,  in  general,  it  will  be  found  very 
easily  returnable. — {Pott.)  A guggling  noise  is  often 
made  when  the  bowel  is  ascending.  An  enterocele  is 
also  generally  characterized  by  the  uniformity  of  its 
surface  and  its  elasticity. 

If  the  hernia  be  an  epiplocele,  or  one  of  the  omental 
kind,  the  tumour  has  a more  flabby,  and  a more  unequal 
feel ; it  is  in  general  perfectly  indolent,  is  more  com- 
pressible, and  (if  in  the  scrotum)  is  more  oblong,  and 
less  round,  than  the  swelling  occasioned  in  the  same 
situation  by  an  intestinal  hernia ; and,  if  the  quantity 
be  large,  and  the  patient  adult,  it  is,  in  some  mea- 
sure, distinguishable  by  its  greater  weight.  In  very 
young  subjects,  the  contents  of  a hernia  are  generally 
intestine,  and  but  seldom  omentum.— (j2.  Cooper,  Lec- 
tures, vol.  3,  p.  8.) 

If  the  case  be  an  entero-epiplocele,  that  is,  one  consist- 
ing of  both  intestine  and  omentum,  the  characteristic 
marks  will  be  less  clear  than  in  either  of  the  simple 
cases;  but  the  disease  may  easily  be  distinguished 
from  every  other  one,  by  any  body  in  the  habit  of 
making  the  examination. — {Pott,  p.'28.) 

As  the  smooth  slippery  surface  of  the  intestine  gene- 
rally makes  its  reduction  easier  than  that  of  the  omen- 
tum, we  may  infer,  with  Mr.  Lawrence,  “that  if  a 
portion  of  the  contents  slip  up  quickly  and  with  noise, 
leaving  behind  something  which  is  less  easily  reduced, 
the  case  is  probably  an  entero-epiplocele.” — {Op.  cit. 
ed.  4,  p.  47.) 

On  the  subject  of  prognosis,  Mr.  Pott  remarks,  that 
the  age  and  constitution  of  the  subject,  tiie  date  of  the 
disease,  its  being  free  or  not  free  from  stricture  or  in- 
flammation, the  symptoms  which  attend  it,  and  the 
probability  or  improbability  of  its  being  returnable, 
necessarily  produce  much  variety. 

If  the  subject  be  an  infant,  the  case  is  not  often  at- 
tended with  much  difficulty  or  hazard,  the  reduction 
being  easy  as  well  as  the  descent ; and  though  from  ne- 
glect, or  inattention,  the  bowel  may  fall  down  again,  yet 
it  is  as  easily  replaced,  and  mischief  seldom  produced : 
Mr.  Pott  says  seldom,  because  he  has  seen  an  infant, 
one  year  old,  die  of  a strangulated  hernia,  which  had 
not  been  down  two  days,  with  all  the  symptoms  of 
mortified  intestine.  For  other  examples  of  strangula- 
ted hernia  in  very  young  infants,  refer  to  Oooch's 
Chir.  Works,  vol.%  p.'i'i  \ Lawrence  on  Ruptures,  p. 
77,  edit.  4 ; Edin.  Med.  and  Surgical  Journal,  vol.  3, 
p.  470,  Src. 

“ If  the  patient  be  adult,  and  in  the  vigour  of  life, 
the  consequences  of  neglect,  or  of  mal-lreatment,  are 
more  to  be  feared  than  at  any  other  time,  for  reasons 
too  obvious  to  need  relating.  The  great  and  principal 
mischief  to  be  apprehended,  in  an  intestinal  hernia,  is 
an  inflammation  of  the  gut,  and  an  obstruction  to  the 
passage  of  the  aliment  and  fbces  through  it ; which  in- 
flammation and  obstruction  are  generally  produced  by 
a stricture  made  on  the  intestine.  In  very  old  people, 
the  symptoms  do  not  usually  make  such  rapid  pro- 
gress, both  on  accountT»f  the  laxity  of  their  frame,  and 
their  more  languid  circulation : and  also  because  their 
ruptures  are  most  frequently  of  ancient  date,  and  the 
passage  a good  deal  dilated : but  then,  on  the  other 
hand,  it  should  also  be  remembered,  that  they  are  by 
no  means  exempt  from  inflammatory  symptoms;  and 
that  if  such  should  come  on.  the  infirmity  of  old  age  is 
no  favourable  circumstance  in  the  treatment,  which 
niay  become  necessary.” — {Pott.) 

If  the  disease  be  recent,  and  the  patient  young,  im- 


mediate reduction,  and  constant  care  to  prevent  another 
protrusion,  are  the  only  means  whereby  it  is  possible 
to  obtain  a perfect  cure. 

“If  the  disease  be  of  long  standing,  has  been  neglected, 
or  suffered  to  be  frequently  down,  and  has  given  little  or 
no  trouble,  the  aperture  in  the  abdominal  muscle,  and 
the  neck  of  the  hernial  sac,  may  both  be  presumed  to 
be  large;  which  circumstances  in  general  render  im- 
mediate reduction  less  necessary  and  less  difficult,  and 
also  frustrate  all  rational  expectation  of  a perfect  cure. 
On  the  contrary,  if  the  rupture  be  recent,  or,  though 
old,  has  generally  been  kept  up,  its  immediate  reduc- 
tion is  more  absolutely  necessary,  as  the  risk  of  stric- 
ture is  greater  from  the  supposed  smallness  of  the 
aperture,  and  narrowness  of  the  sac.  If  the  rupture 
be  very  large  and  ancient,  the  patient  far  advanced  in 
life,  the  intestine  not  bound  by  any  degree  of  stricture, 
but  does  its  office  in  the  scrotum  regularly,  and  no 
other  inconvenience  be  found  to  attend  it,  but  what 
proceeds  from  its  weight,  it  will  in  general  be  better  not 
to  attempt  reduction,  as  it  will,  in  these  circumstances, 
most  probably  prove  fruitless,  and  the  handling  of  the 
parts,  in  the  attempt,  may  so  bruise  and  injure  them  as 
to  do  mischief.” 

With  respect  to  the  correctness  of  the  advice  here 
delivered,  some  doubt  may  be  entertained,  because, 
though  it  w ould  certainly  not  be  right  to  protract  the 
attempts  at  reduction,  so  as  to  do  mischief,  it  must  be 
equally  wrong  to  make  no  trial,  whether  the  hernia  is 
reducible  or  not;  and  if  reducible,  I should  say,  that 
it  ought  to  be  reduced  without  delay,  and  a truss  ap- 
plied. This  opinion,  however,  seems  to  agree  with  the 
injunctions  delivered  by  Pott  in  another  place,  as  will 
be  seen  in  the  next  section  of  this  article. 

With  regard  to  the  contents  of  a hernia,  Mr.  Pott 
observes,  that  “ if  it  be  a portion  of  omentum  only, 
and  has  been  gradually  formed,  it  seldom  occasions  any 
bad  ^mptoius,  though  its  weight  will  sometimes  ren- 
der it  very  troublesome.  But  if  it  be  produced  sud- 
denly, by  effort  or  violence,  that  is,  if  a considerable 
piece  of  tlie  caul  by  accident  slip  dowm  at  once,  it  will 
sometimes  prove  painful,  and  cause  very  disagreeable 
complaints;  the  connexion  between  the  omentum,  sto- 
mach, duodenum,  &c.  being  such  as  to  render  the  sud- 
den descent  of  a large  piece  of  the  first  sometimes  pro- 
ductive of  nausea,  vomiting,  colic,  and  all  the  dis- 
agreeable symptoms  arising  from  the  derangement  of 
these  viscera.  When  the  piece  of  caul  is  engaged  in 
such  a degree  of  stricture  as  to  prevent  the  circulation 
of  blood  through  it,  it  will  sometimes,  by  becoming 
gangrenous,  be  the  occasion  of  very  bad  symptoms, 
and  even  of  death,  as  I have  more  than  once  seen : and 
thus,  as  a mere  omental  hernia,  it  may  sometimes  be 
subject  to  great  hazard.  But  even  though  it  should 
never  be  liable  to  the  just-mentioned  evil,  that  is, 
though  the  portion  of  the  caul  should  remain  uninjured 
in  the  scrotum,  yet  it  renders  the  patient  constantly 
liable  to  hazard  from  another  quarter;  it  makes  it 
every  moment  possible  for  a piece  of  intestine  to  slip 
into  the  same  sac,  and  thereby  add  to  the  case  all  the 
trouble  and  all  the  danger  arising  from  an  intestinal 
rupture.  It  is  by  no  means  an  uncommon  thing  for  a 
piece  of  gut  to  be  added  to  a rupture,  which  had  for 
many  years  been  merely  omental,  and  for  that  piece  to 
be  strangulated,  and  require  immediate  help. 

“ An  old  omental  hernia  is  often  rendered  not  re- 
ducible, more  by  an  alteration  made  in  the  state  of  the 
prolapsed  piece  of  caul,  than  by  its  quantity.  It  is 
very  common  for  that  part  of  the  omentum  which 
passes  through  the  neck  of  the  sac  to  be  compressed 
into  a hard,  smooth  body,  and  all  appearance  of 
caul,  while  what  is  below  in  the  scrotum  is  loose  and 
expanded,  and  enjoys  its  natural  texture  : in  this  case, 
reduction  is  often  impossible,  from  the  mere  figure  of 
the  part:  and  I have  so  often  seen  this,  both  in  the  living 
and  the  dead,  that  I am  satisfied,  that  for  one  omental 
rupture,  rendered  irreducible  by  adhesions,  many  more 
become  so  from  the  cause  above  mentioned. 

“ In  the  sac  of  old  omental  ruptures  that  have  been 
long  down,  and  only  suspended  by  a bag-trnss,  it  is  no 
very  uncommon  thing  to  have  a pretty  considerable 
quantity  of  fluid  collected  ; this,  in  different  states  and 
circumstances  of  the  disease,  ife  of  difl'erent  colour  and 
consistence,  and  seldom  so  much  in  quantity  as  to 
occasion  any  particular  attention  to  it ; but,  on  the 
other  hand,  it  sometimes  is  so  much  in  quantity  as  to 
become  an  additional  disease  to  the  original  oue.  I 


HERNIA, 


7 


have  more  than  once  been  obliged  to  let  it  out,  in  order 
to  remove  the  inconvenience  arising  from  its  weight, 
and  the  distention  of  the  scrotum,  which  I have  also 
seen  become  gangrenous  by  the  negiectofthisoperation. 

“ If  the  hernia  be  of  the  intestinal  kind  merely,  and 
the  portion  of  gut  be  small,  the  risk  is  greater,  strangu- 
lation being  more  likely  to  happen  in  this  case,  and 
more  productive  of  mischief,  when  it  has  happened : 
for  the  smaller  the  portion  of  gut  is  which  is  engaged, 
the  tighter  the  tendon  binds,  and  the  more  hazardous 
is  the  consequence.  I have  seen  a fatal  gangrene,  in 
a bubonocele,  which  liad  not  been  formed  forty-eight 
hours,  and  in  which  the  piece  of  intestine  was  little 
more  than  half  an  inch.” 

Another  observation  made  by  Pott  is,  that  “ if  the 
hernia  be  caused  by  a portion  of  the  intestine  ilium 
pnly,  it  is  in  general  more  easily  reducible,  than  if  a 
part  of  the  colon  has  descended  with  it,  which  will  also 
require  more  address  and  more  patience  in  the  attempt. 
The  reduction  of  a mere  intestinal  hernia  too  (^cateris 
paribus)  will  always  remain  more  practicable  than 
that  of  a mere  omental  one,  after  it  has  attained  to  a 
certain  size  and  state,  as  the  part  contained  within  the 
former  is  liable  to  less  alteration  of  form  than  that 
within  the  latter;  which  alteration  has  already  been 
mentioned  as  no  unfrequent  hinderance  of  the  return 
of  an  old  caul-rupture. 

“ Not  that  the  parts  within  a mere  intestinal  hernia 
are  absolutely  exempt  from  such  an  alteration  as  may 
render  their  return  into  the  belly  impracticable,  even 
where  there  is  no  stricture ; for  (says  Pott)  I have  seen 
that  part  of  the  mesentery  which  has  lain  long  in  the 
neck  of  the  sac  of  an  old  rupture,  so  considerably 
hardened  and  thickened,  as  to  prove  an  insuperable 
obstacle  to  its  reduction.” 

Upon  the  whole,  this  author  infers,  that  an  intestinal 
rupture  is  subject  to  worse  symptoms,  and  a greater 
degree  of  hazard,  than  an  omental  one,  though  the 
latter  is,  by  no  means,  so  void  of  either  as  it  was  for- 
merly supposed  to  be;  that  bad  symptoms  are  more 
likely  to  attend  a recent  rupture,  than  one  of  ancient 
date";  that  the  descent  of  a very  small  piece  of  intestine 
is  more  hazardous  than  that  of  a larger ; and  that  the 
hernia,  which  consists  of  gut  only,  is  in  general  at- 
tended with  worse  circumstances,  than  that  which  is 
made  up  of  both  gut  and  caul. — (See  also  Lawrence  on 
Ruptures,  p.  75,  76,  ed.  4.) 

Mr.  Hey  coincides  with  Pott,  in  thinking  the  prog- 
nosis more  unfavourable  when  the  tumour  is  small. 
‘‘I  think  it  is  not  a bad  general  rule,  that  the  smaller 
the  hernia,  the  less  hope  there  is  of  reducing  it  by  the 
taxis.  Long-continued  efforts  to  reduce  a prolapsed 
Intestine,  are  most  likely  lo  succeed  in  old  and  large 
hernias,  when  no  adhesions  have  taken  place.”~(Pract. 
Observ.  in  Surgery,  p.  203.) 

It  is  correctly  remarked  by  Mr.  Lawrence,  that  “ the 
danger  is  greatest,  when  a rupture  is  incarcerated  at 
the  moment  of  its  formation.  Herniffi,  which  arise 
spontaneously,  and  merely  from  predisposing  weak- 
ness, seldom  become  strangulated:  the  stricture,  in 
such  cases,  is  never  close,  nor  are  the  symptoms  vio- 
lent, because  the  parts  concerned  are  weak  and  relaxed. 

“ The  opening  through  which  the  parts  protrude  is 
narrower  in  some  situations  than  in  others ; the  pro- 
gress of  the  case  will  therefore  be  more  rapid,  and  the 
danger  of  the  patient  more  urgent.  The  aperture  is 
generally  very  small  in  femoral  hernia : this  kind  of 
rupture  in  men,  and  the  bubonocele  in  women,  have  a 
particularly  narrow  entrance.  On  the  same  grounds, 
femoral,  inguinal,  and  umbilical  ruptures  are  more  ' 
dangerous  than  the  ventral,  perineal,  or  vaginal  kinds.” 
{Treatise  on  Ruptures,  p.  75,  ed.  4.) 

TREATMENT  OF  A HERNIA  CAPABLE  OF  EASY  AND  IM- 
MEDIATE REDUCTION,  AND  NOT  ATTENDED  WITH 

ANV  TROUBLESOME  OR  BAD  SY.MPTOMS. 

“ This  case,”  says  Pott,  “ is  very  frequently  met 
with  in  infants,  and  sometimes  in  adults,  and  is  too 
often  neglected  in  both.  In  the  former,  as  the  descent 
seldom  happens  but  when  the  infant  strains  to  cry, 
and  the  gut  is  either  easily  put  up,  or  returns  sud 
sponte,  as  soon  as  the  child  becomes  quiet,  it  often  is 
either  totally  unattended  to,  or  an  attenqit  made  to  re- 
•strain  it  only  by  a bandage  made  of  cloth  or  dimity, 
and  which,  being  ineffectual  for  such  purpose,  lays  the 
for  future  trouble  and  mischief. 

“ Tills  is,  in  great  measure,  owing  to  a common 


opinion,  that  a young  Infant  cannot  wear  a steel  truss  j 
a generally  prevailing  error,  and  which  ought  to  be 
corrected.  There  is  no  age  at  which  such  truss  may  not 
be  worn,  or  ought  not  to  be  applied;  it  is,  when  well 
made  and  properly  put  on,  not  only  perfectly  safe  and 
easy,  but  the  only  kind  of  bandage  that  can  be  depended 
upon  ; and  as  a radical  cure  depends  greatly  on  the 
thinness  of  the  hernial  sac,  and  its  being  capable  of 
being  so  compressed  as  possibly  to  unite,  and  thereby 
entirely  close  the  passage  from  the  belly,  it  must  there- 
fore appear  to  every  one  who  will  give  himself  the 
trouble  of  thinking  on  the  subject,  that  the  fewer  times 
the  parts  have  made  a descent,  and  the  smaller  and 
finer  the  elongation  of  the  peritoneum  is,  the  greater 
the  probability  of  such  cure  must  be. 

“ The  same  method  of  acting  must,  for  the  same 
reasons,  be  good  in  every  age,  in  which  a radical  cure 
may  reasonably  be  expected ; that  is,  the  prolapsed 
parts  cannot  be  too  soon  returned,  nor  too  carefully 
prevented  from  falling  down  again ; every  new  descent 
rendering  a cure  both  more  distant  and  more  uncertain. 

“ As  soon  as  the  parts  are  returned,  the  truss  should 
be  immediately  put  on,  and  worn  without  remission; 
care  being  taken,  especially  if  the  patient  be  an  infant, 
to  keep  the  parts  upon  which  it  presses  constantly 
washed,  to  prevent  galling. 

“ It  can  hardly  be  necessary  to  say,  that  the  surgeon 
should  be  careful  to  see  that  the  truss  fits,  as  his  suc- 
cess and  reputation  depend  on  such  care.  A truss 
which  does  not  press  enough  is  worse  than  none  at 
all,  as  it  occasions  loss  of  time,  and  deceives  the  pa- 
tient or  his  friends;  and  one  which  presses  too  much, 
or  on  an  improper  part,  gives  pain  and  trouble,  by  pro- 
ducing an  inflammation  and  swelling  of  the  spermatic 
cord,  and  sometimes  of  the  testicle. 

“ In  adults,  whose  ruptures  are  of  long  standing,  and 
accustomed  to  frequent  descent,  the  hernial  sac  is 
generally  firm  and  thick,  and  the  aperture  in  the  ten- 
don of  the  abdominal  muscle  large  ; the  freedom  and 
ease  with  which  the  parts  return  into  the  belly  when 
the  patient  is  in  a supine  posture,  and  the  little  pain 
which  attends  a rujiture  of  this  kind,  often  render  the 
persons  who  labour  under  It  careless : but  all  such 
should  be  informed,  that  they  are  in  constant  danger 
of  such  alteration  in  their  complaint,  as  may  pul  them 
into  great  hazard,  and  perhaps  destroy  them.  The 
passage  from  the  belly  being  open,  the  [quantity  of  in- 
testine in  the  hernial  sac  is  always  liable  to  be  in- 
creased, and,  when  down,  to  be  bound  by  a stricture. 
An  inflammation  of  that  portion  of  the  gut  which  is 
down,  or  such  obstruction  in  it  as  may  distend  and 
enlarge  it,  may  at  all  times  produce  such  complaints  as 
may  put  the  life  of  the  patient  in  imminent  danger; 
and  therefore,  notwithstanding  this  kind  of  hernia  may 
have  been  borne  for  a great  length  of  time,  without 
having  proved  either  troublesome  or  hazardous,  yet  as 
it  is  always  po.esible  to  become  so,  and  that  very  sud- 
denly, it  can  never  be  prudent  or  safe  to  neglect  it. 

“ Even  though  the  rupture  should  be  of  the  omental 
kind  (which  considered  abstractedly  is  not  subject  to 
that  degree  or  kind  of  danger  to  which  the  intestinal 
is  liable)  yet  it  may  be  secondarily,  or  by  accident,  the 
cause  of  all  the  same  mischief ; for  while  it  keeps  the 
mouth  of  the  hernial  sac  open,  it  renders  the  descent 
of  a piece  of  intestine  always  possible,  and  consequently 
always  likely  to  produce  the  mischief  which  may  pro- 
ceed from  thence. 

“ They  who  labour  under  a hernia  thus  circum- 
stanced, tliat  is,  whose  ruptures  have  been  generally 
down  while  they  have  been  in  an  erect  posture,  and 
which  have  either  gone  up  of  themselves,  or  have 
been  easily  put  up  in  a supine  one,  should  be  particu- 
larly careful  to  have  their  truss  well  made,  and  pro- 
perly fitted  for  the  mouth  of  the  sac;  and  the  opening 
in  the  tendon  being  both  large  and  lax,  arid  the  parts 
having  been  used  to  descend  through  it,  if  the  pad  of 
the  truss  be  not  placed  right,  and  there  be  not  a due 
degree  of  elasticity  in  the  spring,  a piece  of  intestine 
will,  in  some  posture,  slip  down  behind  it,  and  render 
the  truss  productive  of  that  very  kind  of  mischief 
which  it  ought  to  prevent.” — (See  Truss.) 

[This  accident,  so  justly  deprecated  by  Mr.  Pott,  is 
not  only  frequent,  but  unavoidably  so,  if  the  rupture 
pad  of  the  truss  be  “ fitted  for  the  mouth  of  the  sac,” 
as  he  directs  in  this  paragraph.  For  if  the  internal 
surface  of  the  pad  be  convex,  as  was  formerly  universal, 
and  thought  indispensable,  and  as  indeed  Mr.  Pott 


HERNIA. 


plainly  intimates ; it  is  no  mangel  that  a “ piece  of  in- 
testine should  slip  down  behind  it,”  because  the  pad  is 
“fitted /or  the  mouth  of  the  sac,”  and  the  “ opening  in 
the  tendon”  is  thereby  made  larger  and  more  lax  by 
the  instrument  itself,  and  the  liability  increased  to  a 
recurrence  of  the  accident. 

If  on  the  contrary  the  rupture  pad  be  concave  on  its 
internal  surface,  and  thus  by  its  raised  circular  margin 
fitted  to  close  the  mouth  of  the  sac,  instead  of  opening 
it  as  it  does  when  convex,  this  accident,  so  inconvenient 
and  so  often  fatal,  could  not  happen.  This  is  an  Ame- 
rican improvement;  but  this  is  not  a sufficient  reason 
for  its  being  passed  over  in  silence  by  Dr.  Cooper.  See 
note  on  the  article  Truss. — Reese-I 

Mr.  Pott  then  comments  upon  the  importance  of 
having  the  parts  completely  reduced  before  the  truss  is 
applied,  and  upon  the  danger  that  may  be  incurred 
by  laying  such  bandage  aside  after  it  has  been  worn 
some  time ; since  the  partial  closure  of  the  ring, 
whereby  the  descent  of  the  gut  is  rendered  less  easy, 
will  also  make  the  reduction  more  difficult,  if  a piece 
should  happen  to  slip  down : and  hence  he  insists,  that 
a truss  “ should  be  long  and  unremittingly  worn  by  all 
those  whose  time  of  life  makes  the  expectations  of  a 
perfect  cure  reasonable,  many  of  the  ruptures  of  adults* 
being  owing  to  the  negligent  manner  in  which  children 
at  school  are  suffered  to  w'ear  their  trusses.” 

Besides  the  danger  of  strangulation,  and  the  loss  of 
all  chances  of  a radical  cure,  when  a reducible  hernia 
is  neglected,  and  allowed  to  remain  dow’n,  there  are 
other  motives  for  keeping  up  the  tumour  with  a truss, 
and  preventing  its  increase  of  .-ize.  The  vast  size  to 
which  neglected  hernite  sometimes  increase,  not  only 
prohibits  all  active  exertion,  but,  by  involving,  in  the 
male,  the  integuments  of  the  penis,  incapacitates  the 
subject  from  the  act  of  copulation,  and  gives  rise  to 
excoriation  from  the  discharge  of  the  urine  over  the 
sw'^elling.  Probably,  too,  the  testis  may  be  aflfected  by 
the  pressure  of  a very  large  scrotal  hernia.— 
de  Cans,  et  Sed.  ep.33,  art.  12;  Schmucker,  Vermischte 
Chir.  Schriftcn,  b.  3,  p.  195.)  Disordeis  of  the  intes- 
tinal functions  invariably  attend  these  large  ruptures, 
and  increase  in  frequency  and  violence  in  proportion 
to  the  size  of  the  swelling,  and  age  of  the  patient.  All 
the  moveable  viscera  of  the  abdomen  gradually  find 
their  way  into  the  hernial  sac,  if  a rupture  be  entirely 
neglected. — {Lawrence  on  Ruptures^  p.  80,  edit.  4.) 

TREATMENT  OF  IRREDUCIBLE  HERNIA:,  FREE  FROM 

INFLAMMATION,  AND  UNATTENDED  WITH  TROUBLE- 
SOME OR  DANGEROUS  SYMPTOMS. 

Mr.  Pott,  and  all  the  best  writers  on  ruptures,  ascribe 
the  incapacity  of  reduction,  in  most  cases,  either  to  the 
largeness  of  the  quantity  of  the  contents,  an  alteration 
made  in  their  form  and  texture,  or  to  adhesions,  which 
they  have  contracted  with  each  other  or  their  contain- 
ing bag.  The  reduction  is  also  sometimes  prevented 
by  transverse  membranous  bands  within  the  sac. 

Mr.  Pott  was  also  aw’are  that  ruptures  are  sometimes 
rendered  difficult  to  be  reduced,  by  the  coecum  being 
contained  in  the  hernial  sac.  Of  this  fact  he  was  as 
much  convinced,  ns  the  nature  of  such  kind  of  things 
would  permit ; that  is,  by  observations  made  both  on 
the  living  and  the  dead.  This  statement,  made  by 
Pott  many  years  back,  deserves  particular  notice, 
because  its  truth  is  confirmed  by  the  modern  observa- 
tions of  Scarpa,  whose  very  important  explanations 
of  the  cause  of  the  difficulty  of  reduction,  may  be  seen 
in  the  last  edition  ol'the  First  Lines  of  Surgery. 

Mr.  Pott  has  adverted  to  the  kind  of  impediment  to 
reduction  produced  by  the  thickening  of  the  neck  of 
the  sac,  when  the  hernia  is  long  neglected,  and  suffered 
to  remain  in  the  scrotum  without  any  bandage  to  sup- 
port its  weight. 

The  same  author  ueckons  an  alteration  produced  by- 
time,  and  constant  tl  lougli  gentle  pressure,  in  the  form 
and  consistence,  or  texture  of  the  omentum,  as  no  in- 
frequent cause  why  nuglected  omental  ruptures  become 
irreducible. 

When  a portion  of  omentum  “has  been  suffered  to 
remain  for  a great  lengt  h of  time  in  the  scrotum,  with- 
out having  ever  beeir  returned  into  the  belly,  it  often 
happens,  that  althougti  that  part  of  it  which  is  in  the 
lower  part  of  the  herni  al  sac  preserves  its  natural,  soft, 
adipose,  expansile  stat'-*,  yet  all  that  part  which  passes 
through  what  is  called  the  neck  of  the  sac  is,  by  coii- 
siant  pressure,  formed  into  a hard,  fu  in,  inconqiressible. 


carnous  kind  of  body,  incapable  of  being  expanded,  and 
taking  the  form  of  the  passage  in  which  it  is  confined, 
exactly  filling  that  passage,  and  rendering  it  impossible 
to  push  up  the  loose  part  which  fills  the  scrotum. 

“ The  same  reason  for  incapacity  of  reduction  is  also 
sometimes  met  with  in  ruptures  of  the  intestinal  kind, 
from  an  alteration  produced  on  that  part  of  the  mesen- 
tery which  has  been  suffered  to  lie  quiet  for  a great 
length  of  time  in  the  neck  of  an  old  hernial  sac. 

“ The  other  impediment,  which  I mentioned,  to  the 
return  of  old  ruptures,  is  the  connexion  and  adhesion  of 
the  parts,  either  with  each  other,  or  with  tiie  bag  con- 
taining them.  This  is  common  to  both  the  intestinal 
and  omental  hernia,  and  is  produced  by  slight  inflam- 
mations of  the  parts,  which  have  been  pei-mitted  to  lie 
long  in  contact  with  each  other,  or  perhaps  in  many 
cases  from  the  mere  contact  only.  These  adhesions 
are  more  or  less  firm  in  different  cases,  but  even  the 
slightest  will  almost  always  be  found  an  invincible  ob- 
jection to  the  reduction  of  the  adherent  parts,  by  the 
hand  only. 

“Many,  or  perhaps  most,  of  these  irreducible  rup- 
tures, become  so  by  mere  time  and  neglect,  and  might 
at  first  have  been  returned  ; but  when  they  are  got  into 
this  state,  they  are  capable  of  no  relief  from  surgery  but 
the  application  of  a suspensory  bag,  to  take  off,  or  lessen 
the  inconvenience  arising  from  the  weight  of  the  scro- 
tum. 

“ People  in  tliis  situation  should  be  particularly  care- 
ful not  to  make  any  attempts  beyond  th«r  strength,  nor 
aim  at  feats  of  agility ; they  should  take  care  to  sus- 
pend the  loaded  scrotum,  and  to  keep  it  out  of  the  way 
of  all  harm  from  pressure,  bruise,  &c.  When  the  tumour 
is  very  large,  a soft  quilted  bolster  should  be  worn  at 
the  bottom  of  the  suspensory  to  prevent  excoriation, 
and  the  scrotum  should  be  frequently  w'ashed  for  the 
same  reason ; a loss  of  skin  in  this  part,  and  in  such 
circumstances,  being  sometimes  of  the  utmost  impor- 
tance. They  ought  also  to  be  particularly  attentive  to 
the  office  of  the  intestinal  canal,  to  see  that  they  do  not 
by  any  irregularity  of  diet  disorder  it,  and  keep  them- 
selves from  being  costive.”  Mr.  Pott  observes,  how- 
ever, that  the  quiet,  inoffensive  state  of  this  kind  of 
hernia  is  by  no  means  to  be  depended  upon  : many 
things  may  happen  to  it  by  which  it  may  be  so  altered, 
as  to  become  hazardous,  and  even  fatal : an  inflamma- 
tion of  that  part  of  the  gut  w hich  is  down,  any  ob- 
struction to  the  passage  of  the  aliment  or  feces  through 
it,  a stricture  made  by  the  abdominal  tendon,  either  on 
what  has  been  long  down,  or  on  a new  portion  which 
may  at  any  time  be  added  to  it,  are  always  capable  of 
so  altering  the  state  of  the  case,  as  to  put  the  life  of  the 
patient  into  danger. 

“ Indeed,  the  hazard  arising  from  a stricture  made 
on  a piece  of  intestine  contained  in  the  sac  of  an  old 
irreducible  hernia,  is  in  one  respect  greater,  than  that 
attending  one  that  has  been  found  at  limes  reducible  ; 
since  from  the  nature  of  the  case  it  will  hardly  admit 
of  any  attempt  tow-ards  relief,  but  the  operation,  which 
in  these  circumstances  must  necessarily  be  accompa- 
nied with  additional  difficulty. 

“ Among  the  ruptures  which  have  been  thought  not 
reducible,  and  treated  as  such,  there  have  been  some 
which,  u^n  more  judicious  and  more  patient  attempts, 
have  been  found  capable  of  reduction. 

“ When  this  is  suspected  to  be  the  case,  the  proper 
method  is  by  absolute  rest,  in  a supine  posture  for  a 
considerable  length  of  time,  by  great  abstinence,  and 
the  use  of  evacuants,  so  as  to  lessen  the  size  of  the 
parts  in  the  liernial  sac,  and  render  them  capable  of 
passing  back  again  into  the  belly.” — {Pott  on  Ruptures.) 

Fabricius  Hildanus  gives  an  account  of  a man,  w'ho 
was  radically  cured  of  a rupture,  of  twenty  years’  date, 
by  six  months’  confinement  to  bed. — {Cent.  5,  obs.  54.) 

Le  Dran  and  Arnaud  relate  instances  of  monstrous 
bubonoceles,  which  disappeared  entirely,  after  the  pa- 
tients had  been  long  confined  to  bed,  and  rendered  much 
emaciated  by  tedious  illnesses.  Some  of  the  mo- 
derns have  imitated  this  operation  of  nature,  and  by 
frequent  bleedings,  and  repeated  purges,  have  some- 
times so  far  reduced  the  size  of  the  hernia,  that  it  has 
been  returned  into  the  abdomen.  Mr.  Hey  has  several 
times  succeeded  in  this  way .—(P.  219.)  But,  the  prac- 
tice cannot  prove  successful,  w hen  the  viscera  adhere 
to  the  sac,  or  to  the  peritoneum,  just  within  the  abdo- 
men. The  greatest  objection  to  this  method  of  cure, 
is  the  w-ant  of  an  absolute  criterion  for  distinguishing. 


HERNIA. 


when  the  parts  do  or  do  not  adhere  to  the  hernial  sac ; 
and,  in  advanced  years,  though  one  were  sure  that  the 
viscera  were  free  from  the  sac,  the  possibility  of  hurting 
the  body,  by  the  necessary  evacuations,  is  also  another 
objection.— (SAa?77’s  Critical  Inquiry^  p.  15.) 

Were  the  plan  to  be  thought  worthy  of  trial,  keeping 
up  a constant  pressure  on  the  tumour,  by  means  of  a 
suspensory  bandage,  made  to  lace  in  front,  would  be 
proper  for  promoting  the  absorption  of  the  thickened 
parts  in  the  hernial  sac.  Sir  A.  Cooper  has  reduced 
such  hernia,  after  applying  ice  to  them ; the  good  ef- 
fects of  which  lie  imputes  to  its  producing  a contrac- 
tion of  the  scrotum,  and  thus  a strong  and  permanent 
compression  of  the  tumour.  Mr.  Earle  once  mentioned 
to  me  the  suggestion  of  keeping  up  a general  pressure 
on  the  swelling,  by  means  of  a bladder  containing 
quicksilver,  the  quantity  of  which  can  be  regulated 
according  to  circumstances. 

Whenever  any  attempts  of  this  kind  succeed,  a truss 
should  be  immediately  put  on,  and  worn  without  re- 
mission. 

However,  there  are  instances  on  record  where  the 
capacity  of  the  abdomen  had  become  so  adapted  to  the 
diminished  quantity  of  the  viscera,  that  when  the  con- 
tents of  the  hernia  were  reduced,  serious  complaints 
arose  from  their  introduction  into  the  belly.  Schmucker 
met  with  several  such  cases,  in  which  he  was  obliged 
to  take  off  the  truss  again.  Petit  has  known  the  re- 
duction of  a hernia  of  this  kind  prove  fatal,  the  parts 
not  descending  again  when  the  truss  was  removed,  the 
nausea  and  vomiting  continuing,  and  peritonitis  taking 
place. — {Chirurgische  Wahrnekmungen^  vol.  2,  p.  243. 
Maladies  Chir.  t.2,p.  392.) 

Mr.  Pott  remarks,  that  “ an  omental  rupture,  which 
has  been  so  long  in  the  scrotum  as  to  have  become  irre- 
ducible, is  very  seldom  attended  with  any  bad  symptoms, 
considered  abstractedly ; but  it  is  constantly  capable 
of  being  the  occasion  of  an  intestinal  hernia,  and  all 
its  consequences  ; neither  is  that  all ; for  the  omentum, 
either  so  altered  in  form  and  texture,  or  so  connected 
as  to  be  incapable  of  reduction,  may  by  accident  in- 
flame, and  either  become  gangrenous,  or  suppurate, 
and  the  occasion  of  a great  deal  of  trouble. In  a few 
instances,  epiploceles  produce  very  bad  symptoms  in- 
deed, cases  of  which  are  to  be  found  in  Gareligeot,  Di- 
onis,  &c. 

Sometimes,  in  old  cases  of  entero-epiplocele,  the  in- 
testine is  reducible,  but  the  omentum  is  not ; in  which 
case  some  writers  advise  keeping  up  the  piece  of  bowel 
with  a truss,  the  pad  of  which  must  be  so  contrived  as 
not  to  press  on  the  omentum.  Mr.  Pott,  however,  con- 
siders this  method  not  often  practicable,  and,  should 
such  a truss  be  used,  he  recommends  great  caution  in 
its  construction  and  application,  lest  a small  piece  of 
gut  slip  down,  and,  being  pressed  on  by  the  truss,  pro- 
duce fatal  mischief. 

“ Irreducible  herniae  must  of  course  be  exposed  to  all 
the  consequences  of  external  injury  and  violence ; 
hence,  various  cases  are  recorded  in  which  the  bowels 
have  been  burst  by  blows,  falls,  &c.” — {.Lawrence  on 
ruptures,  p.  131,  edit.  4.) 

For  examples  of  such  accidents,  Mr.  Lawrence  refers 
to  .^.  Cooper  on  Hernia,  part  2,  Pref.  p.  2 ; and  to 
Travers's  Inq.  into  the  Process  of  Mature,  &rc..p.  37. 
A case  is  also  quoted  from  Scarpa,  p.  310,  where  a vio- 
lent exertion  caused  a sudden  return  of  a hernia 
which  had  been  long  regarded  as  cured.  The  viscera 
lay  in  the  tunica  vaginalis,  which  was  burst  to  the  ex- 
tent of  an  inch. 

SYMPTOMS  AND  TREATMENT  OF  A STRANGULATED,  OR 

AN  INCARCERATED  HERNIA.— MEANS  TO  BE  TRIED 

BEFORE  AN  OPERATION. 

“ Difficulty  of  reduction  (says  Pott)  may  be  owing 
to  several  causes.  The  size  of  the  piece  of  omentum, 
or  the  inflamed  state  of  it;  the  quantity  of  intestine  and 
mesentery  ; an  inflammation  of  the  gut,  or  its  disten- 
tion by  feces  or  wind  ; or  the  smallness  of  the  aper- 
ture of  the  tendon  through  which  the  hernia  passes. 
But,  to  whatever  cause  it  be  owing,  if  the  prolapsed 
body  cannot  be  immediately  replaced,  and  the  patient 
suffers  pain,  or  is  prevented  thereby  from  going  to  stool, 
it  is  called  an  incarcerated  hernia,  a strangulated  her- 
nia, or  a hernia  with  stricture. 

“ The  symptoms  are  a swelling  in  the  groin  or  scro- 
tum, resisting  the  impression  of  the  fingers;  if  the 
hernia  be  of  the  intestinal  kind,  it  is  generally  painful 


to  the  touch,  and  the  pain  is  increased  by  coughing, 
sneezing,  or  standing  upright.  These  are  the  very  first 
symptoms,  and,  if  they  are  not  relieved,  are  soon  fol- 
lowed by  others,  viz.  a sickness  at  the  stomach,  a fre- 
quent retching  or  inclination  to  vomit,  a stoppage  of 
all  discharge  per  anum,  attended  with  a frequent  hard 
pulse  and  some  degree  of  fever.” 

A patient  thus  circumstanced  is  in  some  danger,  and 
demands  immediate  assistance.  A stricture  made  on 
the  prolapsed  part  of  the  gut  by  the  aperture  through 
which  it  passes,  is  the  immediate  cause  of  all  the  bad 
.symptoms,  and  of  course  the  removal  of  such  stricture 
is  the  only  thing  which  can  bring  relief.  This  object 
can  only  be  accomplished  by  returning  the  bowel  back 
into  the  abdomen,  or  dividing  the  parts  which  form  the 
stricture.  The  former  plan  is  always  the  most  desi- 
rable, when  practicable. 

We  next  proceed  to  notice  the  various  measures  lobe 
adopted  for  the  relief  of  a strangulated  hernia,  so  as 
to  obtain  the  best  chance  of  doing  away  the  necessity 
of  an  operation.  After  treating  of  the  merits  of  each 
plan,  a few  remarks  will  be  offered  on  the  order  in 
which  the  means  should  be  put  in  practice. 

Taxis. — This  is  the  term  applied  to  the  operation  of 
reducing  a hernia  with  the  hand.  It  is  much  pro- 
moted by  the  position  of  the  body ; which  Winslow 
thought  should  be  placed  on  an  inclined  plane  and  the 
thighs  bent  towards  the  trunk.  Sir  A.  Cooper  advises 
the  same  practice,  observing  that  this  posture  by  relaxing 
the  fascia  of  the  thigh,  relaxes  also  the  aperture  through 
which  the  hernia  passes.  Every  degree  of  tension  and 
relaxation  of  the  femoral  fascia,  must  undoubtedly  be 
attended  with  a corresponding  change  in  the  abdominal 
ring.  But  flexion  of  the  thigh,  besides  relaxing  this 
fascia,  also  relaxes  the  abdominal  internal  iliac,  and 
psoas  muscles.  In  cases  of  inguinal  hernia,  the  pres- 
sure made  on  the  tumour  by  the  hands  of  the  surgeon, 
should  always  be  directed  upwards  and  outwards, 
along  the  course  of  the  spermatic  cord ; and  Sir  A. 
Cooper  advises  it  to  be  continued  from  a quarter  to 
half  an  hour. — ( On  Inguinal  and  Congenital  hernia.) 

As  the  femoral  hernia  passes  downwards  and  then 
forwards,  the  pressure  must  be  directed  first  backwards 
and  then  upwards.  In  umbilical  and  ventral  herniie  it 
is  to  be  made  straight  backwards.  No  violence  should 
ever  be  used  ; for,  besides  being  unavailing,  it  greatly 
aggravates  the  inflamed  state  of  the  contents  of  the 
hernial  sac,  and  has  been  known  even  to  burst  the  in- 
testine.— (See  Cooper  on  Inguinal  Hernia,  p.23.) 

Besides  bending  the  thigh,  care  should  also  be  taken 
to  rotate  it  inwards,  which  will  have  great  effect  in 
relaxing  the  femoral  fascia  and  tendon  of  the  external 
oblique  muscle.  Suspension  of  the  patient  over  the 
shoulders  of  an  assistant  has  been  thought  to  facilitate 
reduction : “ I have  tried  it  often  (says  Mr.  Hey),  but 
have  not  found  it  to  be  of  such  superior  efficacy  as 
some  authors  have  represented.” — (P.  144.) 

The  manoeuvre  of  gently  pulling  the  intestine  down- 
wards, or  a little  way  further  out  of  the  ring,  previously 
to  the  attempt  to  reduce  the  hernia,  has  been  suggested. 
— {See  Balfour’s  Mew  Mode  of  the  Taxis,  in  Med.  and 
Phys.  Journ.  Mov.  1824.)  The  plan,  I believe,  is  not 
entirely  new,  and  it  is  noticed  by  Mr.  Lawrence ; who 
says,  that  it  will  sometimes  succeed,  when  the  difficulty 
of  reduction  is  owing  to  an  accumulation  of  fecal 
matter. 

The  return  of  a piece  of  intestine  is  generally  pre- 
ceded by  a peculiar  noise,  caused  by  the  passage  of  air 
through  the  stricture.  It  recedes  at  first  gradually,  and 
then  slips  up  suddenly.  The  omentum  goes  up  slowly 
to  the  very  last  portion,  which  must  be  actually  pushed 
through  the  opening.  If  the  taxis  should  not  succeed 
at  first,  it  will  often  do  so  after  the  warm  bath,  bleed- 
ing, or  cold  applications.  Small  herniae,  being  attended 
with  the  closest  stricture,  are  the  most  difficult  to  re- 
duce, and,  for  the  same  reason,  crural  ruptures  do  not 
so  often  yield  to  the  taxis,  as  inguinal  hernia.'  in  the 
male  subject.  The  taxisbecomes  less  likely  to  succeed, 
the  longer  the  inflamed  viscera  have  been  down,  be- 
cause adhesions  are  liable  to  form.  Mr.  Lawrence  ob- 
serves {p.  63,)  “ When  the  rupture  becomes  painf  ul,  we 
are  no  longer  justified  in  persevering  in  attempts  at 
reduction  by  the  hand.  A sufficient  pressuie  cannot 
now  be  endured ; and  the  force  which  is  employed 
only  tends  to  increase  the  inflamniation,  and  accelerate 
the  approach  of  gangrene.  J3l  this  period,  the  opera- 
tion is  required,  and  should  be  performed  without 


10 


HERNIA. 


delay."  Desault  even  proscribed  the  taxis  altogether  in 
the  inflammatory  strangulation,  until  the  previous  use 
of  other  means  had  produced  a change  in  the  state  of 
the  swelling. 

That  the  taxis  is  frequently  abused,  and  the  cause  of 
serious  mischief,  is  a truth  which  cannot  be  doubted. 
“Strangulated  herniae  (says  Scarpa)  very  frequently 
mortify  from  the  negligence  of  the  patients,  and  Uieir 
repugnance  to  submit  to  an  operation ; and,  perhaps,  still 
more  frequently  from  the  effect  of  the  taxis,  unskilfully 
exercised  by  uninformed  surgeons,  who  are  determined, 
at  any  price  whatsoever,  to  accomplish  the  speedy 
reduction  of  the  viscera.  The  majority  of  them  make 
no  distinction  between  the  acute  and  the  chronic  stran- 
gulation. In  both  cases,  no  sooner  are  the  symptoms 
of  strangulation  evinced,  than  they  begin  to  handle  the 
swelling  roughly,  and  to  push  the  viscera  with  all  their 
force,  in  order  to  make  them  return  into  the  abdomen ; 
while,  when  the  strangulation  is  acute,  and  the  patient 
young  and  strong,  thv*  taxis  ought  never  to  be  prac- 
tised, before  all  the  means  proper  for  diminishing  the 
strength,  calming  spasm,  and  relaxing  the  parts,  which 
are  to  be  reduced,  have  been  employed  for  a certain 
time.  These  means,  we  know,  are  bleedings,  foment- 
ations, emollient  clysters,  and  especially  the  warm 
bath,  which,  next  to  bleeding,  holds  the  first  rank.  At 
tins  school  of  surgery,  I have  frequently  had  opportu- 
nities of  observing  the  salutary  effect  of  this  treatment. 
My  pupils  have,  more  than  once,  seen  hernias,  which 
had  been  painfully  handled,  without  any  good,  reduced, 
as  it  were,  spontaneously,  after  a bleeding,  or  while 
the  patient  was  in  the  bath.  If  what  I have  said  upon 
the  subject  of  the  acute  strangulation,  and  the  treatment 
that  it  requires,  were  generally  known  by  surgeons,  I 
think  that  operations  for  strangulated  herniae  would  be 
less  frequent.” 

[The  distinction  here  made  by  Scarpa  is  one  of  the 
greatest  practical  importance,  and  one  which  no  surgeon 
should  lose  sight  of  in  his  attempts  at  the  taxis.  The 
terms  acute  and  chronic  applied  to  each  individual  case 
of  incarcerated  hernia,  will  be  intelligible  to  the  merest 
tyro,  although  the  ambiguity  in  the  application  of  these 
terms  to  other  subjects  is  too  obvious  and  perplexing  to 
be  denied.  To  recognise  this  distinction  will  result  as 
Mr.  Scarpa  predicts;  and  operations  for  strangulated 
hernia  will  be  less  frequent,  “and  the  taxis  will  very 
generally  be  successful.”  I speak  on  this  subject  from  a 
personal  knowledge  of  its  value ; and  for  several  years, 
although  sent  for  frequently  to  operate,  I have  been 
able  to  succeed  in  dispensing  with  the  use  of  the  knife 
very  generally,  by  a modification  of  the  practice  here 
recommended,  after  the  taxis  had  been  ineffectually 
attempted  for  hours,  and  in  one  instance  these  at- 
tempts had  been  continued  at  intervals  for  two  days. — 
Reese.] 

“Things  are  different  with  regard  to  the  chronic 
strangulation  of  old  large  hernia?,  in  feeble  or  aged 
persons;  for,  in  these  cases,  it  is  of  great  importance 
to  support  the  patient’s  strength.  Bleeding,  the  warm 
bath,  and  other  weakening  means  should  also  be 
avoided,  which,  in  producing  a general  atony,  might 
bring  on  gangrene  of  the  intestine,  either  during  the 
strangulation,  or  after  the  reduction  of  the  viscera.  It 
is  ascertained,  that  these  kinds  of  strangulation  are  al- 
most always  occasioned  by  an  accumulation  of  fecal 
matter,  or  an  extraordinary  quantity  of  air  in  the  her- 
nia. Nothing  is  more  efficacious  than  cold  applica- 
tions, for  promoting,  the  action  of  the  bowel  on  the 
matter,  which  distends  it,  or  for  lessening  the  volume 
of  the  air.  They  produce  a corrugation  of  all  the  scro- 
tum, and  contractions  of  the  cremaster,  which  alone 
sometimes  suffice  for  reducing  the  viscera,  in  a much 
better  manner  than  could  be  done  by  the  hands  of  the 
most  experienced  surgeon.”— (Scarpa,  Traiti  des  Her- 
Ties,  p.  244 — 247.) 

Bleeding.— The  inflammation  which  attacks  the 
protruded  viscera,  and  spreads  thence  over  the  whole 
abdomen,  and  the  temporary  weakness  and  often  faint- 
ing, which  the  sudden  loss  of  blood  induces,  and 
which  is  a peculiarly  favourable  opportunity  for  redu- 
cing the  herniae  by  the  hand,  are  the  reasons  in  favour 
of  bleeding.  Sharp,  Pott,  B.  Bell  Sabatier,  Richter, 
Callisen,  and  Scarpa,  names  which  can  never  be  sur- 
passed in  respectability,  are  all  in  favour  of  bleeding. 
Wilmer,  Alanson,  and  Sir  Astley  Cooper  have  pub- 
lished against  the  practice.  Mr.  Iley  has  related  two 
cases,  which  strongly  evince  the  manner  in  which 


bleeding  facilitates  the  return  of  a hernia;  the  pro- 
truded viscera,  in  one  instance,  went  up  spontaneously, 
on  blood  being  taken  away  ; in  the  other,  the  taxis  suc- 
ceeded immediately  afterwaid,  though  the  previous 
attempt  had  been  made  in  vain.— (P.  125,  126.)  Mr. 
Key’s  experience,  however,  leads  him  to  concur  so  far 
with  Wilmer  and  Alanson,  as  to  declare,  that  bleeding 
has  generally  failed  to  procure  a reduction  of  the  stran- 
gulated intestine,  though  he  is  persuaded  that,  in  many 
cases,  it  may  be  used  with  advantage.  But  he  cannot 
agree  with  Wilmer,  that  it  generally  renders  the  sub- 
sequent operation  more  dangerous. — (P.  126.)  The 
majority  of  candid  practitioners,  I believe,  will  allow, 
that  bleeding  is  always  proper,  when  the  hernia  is  small 
and  recent,  the  abdomen  tense  and  painful,  and  the 
patient  young,  strong,  and  plethoric. 

Purgative  Medicines. — My  experience  (says  Mr. 
Hey)  leads  me  to  condemn  almost  universally  the  use  of 
purgatives,  while  an  intestine  remains  firmly  strangu- 
lated. In  the  entero-epiplocele,  when  the  intestine  has 
retired,  and  the  omentum  remains  strangulated  ; or  in 
a simple  strangulation  of  the  omentum,  where  the  in- 
testine has  not  been  prolapsed ; purgatives  are  of  great 
utility.  So  likewise  in  very  large  and  old  hernias, 
where  there  is  reason  to  doubt,  whether  the  disease  is 
not  to  be  considered  as  a morbid  affection  of  the  intes- 
tinal canal,  rather  than  the  effect  of  strangulation,  pur- 
gatives may  be  as  useful  as  in  the  simple  ileus  without 
hernia.  While  the  intestine  remains  firmly  strangu- 
lated, they  usually  increase  the  vomiting,  and  add  to 
the  distress  of  the  patient.  If  they  are  to  be  tried  at 
any  time  with  hope  of  success,  the  trial  would  ap- 
pear to  have  the  greatest  advantage  when  the  vomit- 
ing has  been  removed  by  means  of  an  opiate;  yet  I 
have  repeatedly  given  them  in  vain  during  such  an  in- 
terval of  relief. — {Practical  Obs.  in  Surgery,  p.  128  ) 

Purgatives  are  supposed  to  operate  by  exciting  the  pe- 
ristaltic action  of  the  intestine,  and  thereby  extricating 
it  from  the  stricture.  Besides  the  above  eminent  sur- 
geon, Pott  and  Richter  have  joined  in  their  general  con- 
demnation, and,  to  all  appearances,  with  very  great  rea- 
son. Purgative  clysters  certainly  have  not  the  objection 
of  increasing  the  irritation ; but  their  efficacy  is  not  de- 
serving of  much  confidence.  Mr.  Hey  never  saw  one 
case,  in  which  either  purgative,  or  emollient  clysters 
produced  a return  of  a strangulated  hernia.  Such  in- 
jections will  empty  the  large  intestines ; but  they  do  no 
more.  It  is  common  also  for  a natural  evacuation  to 
be  the  immediate  consequence  of  strangulation. — (P. 
131.) 

Warm  Bath.—^^  Many  instances  (says  Hey)  are  upon 
record  of  the  good  effect  of  warm  bathing  iii  procuring 
the  reduction  of  a strangulated  hernia.  I have  often 
seen  it  useful ; but  I have  often  seen  it  fail.  When- 
ever it  is  used  in  this  disease,  the  patient  should  be 
placed,  if  possible,  in  a horizontal  position.  Gentle  ef- 
forts with  the  hand  to  reduce  the  prolapsed  part  are 
perhaps  attended  with  less  danger,  and  greater  prospect 
of  success,  while  the  patient  lies  in  the  bath,  than  in 
any  other  position.  The  free  use  of  opiates  coincides 
with  that  of  warm  bathing,  and,  under  some  circum- 
stances, these  means  deserve  to  be  tried  in  conjunction.” 
— (P.  132.) 

Cold  Bath,  and  Cold  .Applications. — The  cold  bath, 
and  dashing  of  cold  water  on  the  patient,  are  little  to  be 
depended  on,  though  success  has  sometimes  been  ob- 
tained in  this  manner. — {Petit,  Traiii  des  Chir.t.2,p. 
325 : Hey,  p.  136.) 

Wilmer  strongly  recommended  the  application  of 
cold  to  the  tumour  itself,  and  this  plan  has  acquired  the 
approbation  of  the  most  celebrated  modern  surgeons. 
It  is  generally  tried  in  conjunction  with  the  eflert 
of  tobacco  clysters,  which  will  be  presently  noticed. 
Cold  applications,  in  the  form  of  ice,  were  indeed  par- 
ticularly recommended  by  B.  Bell.  The  best  way  is  to 
pound  the  ic»,  tie  it  up  in  a bladder,  and  place  it  on  the 
rupture.  When  ice  cannot  be  procured.  Sir  A.  Cooper 
employs  a mixture  of  equal  parts  of  nitre  and  muriate 
of  ammonia.  To  one  pint  of  water,  in  a bladder,  ten 
ounces  of  the  nii.xed  salts  are  to  be  added.  “ If,  after  four 
hours,  (says  this  distinguished  surgeon)  the  symptoms 
become  mitigated,  and  the  tumour  lessens,  this  remedy 
may  be  peise  vered  in  for  .some  time  longer  ; but  if  they 
continue  with  unabated  violence,  and  the  tumour  resist 
every  attempt  at  reduction,  no  farther  trial  should  ba 
made  of  the  application.” — ( On  Inguinal  and  Congeni 
tal  Hernia.)  When  ice  is  not  at  hand,  tether  some 


HERNIA. 


11 


times  proves*  a good  substitute,  when  allowed  to' eva- 
porate from  the  surface  of  the  swelling. 

Care  mast  be  taken  that  the  cold  be  not  so  applied 
as  to  freeze  the  scrotum,  and  bring  on  sloughing. — (./3. 
Cooper,  p.  15.) 

[The  importance  of  cold  applications  to  the  hernial 
tumour  cannot  be  too  strongly  urged  upon  the  prac- 
titioner ; and  hence  this  caution  of  Sir  A.  Cooper  in 
the  use  of  ice,  lest  “ sloughing  be  produced  by  freezing 
the  scrotum,”  may  intimidate  some  younger  prac- 
titioners from  persevering  in  the  practice  sufficiently 
long.  That  the  long-continued  application  of  ice,  and 
some  frigorific  jnixtures  still  colder,  (or  to  speak  more 
“ secundum  artem,”  producing  a still  greater  absorp- 
tion of  caloric,)  may  do  mischief  in  this  way,  cannot  be 
questioned. 

But  the  substitute  for  ice,  proposed  by  Mr.  Cooper 
when  this  is  not  to  be  had,  will  be  found  preferable  to 
the  ice  itself,  particularly  as  its  stimulating  effects  upon 
the  surface  remove  all  liability  to  freezing  the  parts. 
If  the  “ iEther  Sulphuricus”  of  the  shops,  highly  con- 
centrated, be  poured  upon  the  tumour  at  short  intervals, 
and  its  evaporation  be  promoted  by  the  brisk  use  of 
the  bellows,  a more  speedy  effect  will  be  produced  than 
by  the  ice,  or  combination  of  salts. — Reese.] 

Opiates. — Mr.  Hey  met  with  several  cases,  in  which 
opiates,  given  freely  (in  athletic  persons  after  bleeding), 
procured  a reduction  of  strangulated  hernia. 

He  cannot  say,  however,  that  this  remedy  is  generally  * 
successful ; but  it  has  the  advantage  of  removing,  for  a 
time,  the  pain  and  vomiting  usually  attendant  on  stran- 
gulation, even  though  it  prove  ultimately  inefficacious. 
Opiates  should  be  given  in  large  doses,  when  it  is  wished 
to  try  their  effect  in  procuring  reduction ; and  when- 
ever the  symptoms  of  strangulation  return,  after  having 
been  removed  by  opiates,  the  operation  should  be  per- 
formed without  delay.— (P.  134,  135.) 

Tobacco  Clysters.~Fox  this  purpose,  some  surgeons 
prefer  a decoction  of  tobacco,  made  by  infusing,  or  boil- 
ing, one  drachm  of  the  plant,  for  ten  minutes,  in  a pint 
of  water;  others  employ  the  smoke,  which  is  prepared, 
and  introduced  into  the  rectum,  by  means  of  an  appa- 
ratus sold  at  almost  every  surgical  instrument-maker’s. 
Perhaps  both  methods  are  equally  efficacious ; but,  as 
one  requires  an  apparatus,  while  the  other  does  not, 
and  is  equally  proper,  the  decoction  may  be  entitled  to 
most  recommendation.  The  machine  for  the  smoke  il 
also  frequently  out  of  order.  Next  to  the  operation, 
tobacco  clysters  are  the  most  certain  means  of  bringing 
about  the  reduction  of  the  strangulated  parts.  Besides 
exciting  the  action  of  the  intestines,  they  exert  a pe- 
culiarly depressing  influence  on  the  whole  system,  re- 
ducing the  pulse,  and  causing  nausea  and  sickness, 
cold  sweats  and  fainting,  under  which  circumstances, 
the  parts  often  recede  spontaneously,  or  may  be  easily 
reduced.  Sir  A.  Cooper  prudently  advises  injecting 
half  the  above  quantity  at  first ; for  he  has  seen  two 
drachms,  and  even  one,  when  used  as  an  infusion,  and 
introduced  at  once,  prove  fatal. — (P.  24.)  The  rest 
should  be  injected  presently,  w'hen  it  appears  that  the 
tobacco  does  not  operate  with  the  extraordinary  vio- 
lence with  which  it  does  in  a few  particular  consti- 
tutions. 

A case,  published  by  Mr.  C.  Bell,  looks  to  me  very 
much  like  an  example  of  the  occasion.al  poisonous  ef- 
fects of  the  tobacco,  though  not  reported  as  such  by 
the  author.  At  least  no  particulars  of  any  fatal  mis- 
chief, either  in  the  tumour  or  abdomen,  are  detailed ; 
and  it  is  remarked  of  the  patient,  “His  strength  lield 
up  until  the  tobacco  clyster  was  administered  to  him, 
after  which,  he  very  suddenly  fell  low,  and  sunk.” — 
(Surgical  Obs.  part  2,  p.  189.)  The  smoke  proved 
fatal  in  an  instance  witnessed  by  Desault  (CEuvres  de 
Chir.  t.  2,  p.  344) ; and  an  infusion  of  3 ij.  to  | viij.  of 
water  seemed  to  produce  suddenly  mortal  effects  in  an- 
other example  on  record.— (£dm6.  Med.  and  Surgical 
Journ.  vol.  9,  p.  159.) 

[I  have  often  seen  the  most  threatening  symptoms 
produced  by  the  injection  of  the  tobacco ; and  lest  some 
ihould  shrink  from  the  use  of  this  violent  remedy 
where  it  would  be  expedient  to  employ  it,  I would  here 
state,  as  the  result  of  my  experience  and  observation, 
that  in  several  instances  where  the  most  alarming 
symptoms  supervened  after  the  use  of  tobacco,  I have 
found  an  injection  per  anum  of  an  ounce  of  oleum 
terebimhina  has  suddenly  removed  the  symptoms,  and 
roused  the  patient  from  the  syncope.  1 remember  one 


case  in  which  the  hernia  was  reduced  sud  sponte  by 
the  tobacco  clyster ; the  nausea,  cold  sweats,  and  fainting 
which  followed  threatened  instant  dissolution,  but  by 
the  prompt  enema  of  terebinthina,  which  was  in  rea- 
diness, a free  evacuation  of  the  bowels  was  produced, 
and  the  patient  very  speedily  recovered.  Whether 
there  is  any  antidotal  property,  by  the  incompatibility 
of  the  two  agents,  may  not  be  easily  deduced ; but  the 
effects  I have  often  seen  when  the  tobacco  has  been 
premised  in  the  treatment  of  obstipatio. — Reese.] 

Poultices  and  Fojnentations  have  not  the  confidence 
of  any  experienced  or  intelligent  surgeon.  Whoever, 
in  these  urgent  cases,  wastes  time,  in  trying  the  effects 
of  such  applications,  merits  censure  for  his  credulity, 
ignorance,  and  unfitness  to  undertake  the  treatment  of 
a rapid  disease,  in  which,  as  Pott  remarks,  if  we  do  not 
get  forward,  we  generally  go  backward;  and  whatever 
does  no  gooid,  if  it  be  at  all  depended  upon,  certainly 
does  harm,  by  occasioning  an  irretrievable  loss  of  time. 

OF  THE  ORDER  IN  WHICH  THE  PRECEDING  METHODS 

SHOULD  BE  TRIED,  AND  OF  THE  TIME  WHEN  THE 

OPERATION  SHOULD  NOT  BE  DELAVKD. 

In  the  treatment  of  a strangulated  hernia,  a surgeon 
cannot  be  too  deeply  impressed  with  the  danger  of 
spending  time  in  the  trial  of  methods  of  inferior  effi- 
cacy, or  of  such  as  are  evinced  to  be  ineffectual  in  the 
cases  before  them. 

The  rapidity  with  which  gangrenous  mischief  some- 
times arises,  and  the  patient  loses  his  life,  has  been 
proved  in  a multitude  of  unfortunate  examples,  and 
should  operate  as  a warning  to  all  practitioners  against 
the  danger  of  deferring  the  operation  too  long.  In  the 
course  of  my  reading,  however,  I have  not  met  with 
so  remarkable  an  instance  of  the  sudden  mortification 
and  rapidly  fatal  termination  of  a hernia,  as  the  fol- 
lowing case  recorded  by  Baron  Larrey,  in  speaking  of 
the  fatiguing  and  forced  marches  performed  by  the 
French  soldiers  in  Egypt.  These  marches,  he  says, 
brought  on,  in  one  case,  “ a hernia,  which  formed  sud- 
denly, and  became  at  the  same  time  strangulated.  The 
man  was  immediately  brought  to  my  ambulance;  but 
a spontaneous  gangrene,  which  had  all  on  a sudden 
attacked  the  intestine,  and  extended  to  the  other  ab- 
dominal viscera,  caused  the  patient’s  death  in  the  space 
of  two  hours,  and  made  it  impossible  for  me  to  do  the 
operation  for  him.  This  is  the  second  example,  that  I 
have  been  acquainted  with,  in  which  the  effects  were 
thus  rapid.”— (A/<^m.  de  Chir.  Militaire,  t.  l,p.  196.) 

The  taxis  is  generally  among  the  first  things  to  be 
tried,  and  Sir  A.  Cooper  thinks  the  attempts  should  be 
continued  for  a quarter,  or  half  an  hour.  When  these 
have  been  ineffectual,  the  patient,  if  the  circumstances 
do  not  forbid,  should  be  immediately  bled,  and  have  a 
large  opening  made  in  the  vein,  so  that  the  suddenness 
of  the  evacuation  may  be  most  likely  to  bring  on  faint- 
ing. The  taxis  should  then  be  tried  again. 

When  the  strangulation  is  very  acute,  and  the  pa- 
tient young  and  strong,  perhaps  it  may  be  most  advisa- 
ble to  follow  the  advice  delivered  by  Scarpa  and  De- 
sault, which  is  to  bleed  the  patient,  and  put  him  in  the 
warm  bath,  before  the  taxis  is  attempted  at  all. 

If  bleeding  alone  has  been  practised,  and  the  manual 
efforts  at  reduction  should  not  now  succeed,  the  warm 
bath  may  be  employed,  provided  it  can  be  got  ready  in 
a very  short  time,  but  none  should  ever  be  lost  in  wait 
ing  for  it  to  be  prepared.  When  the  bath  is  used,  the 
taxis  may  be  attempted,  as  the  patient  lies  in  the  water ; 
a situation  in  which  I have  succeeded  in  reducing 
several  herniai. 

Certainly  not  more  than  one  hour  should  ever  be 
allotted  for  putting  in  practice  the  first  attempts  at 
reduction,  bleeding,  and  the  warm  bath. 

The  plan  should  be,  while  the  trial  of  one  thing  is 
going  on,  another  should  be  preparing ; so  when  the 
preceding  measures  have  been  tried  in  vain,  the  appli- 
cation of  a bladder  filled  with  ice,  or  the  solution  of 
nitre  and  muriate  of  ammonia,  and  the  injection  of 
tobacco,  in  the  form  of  smoke,  or  decoction,  should 
never  be  delayed  for  want  of  due  previous  preparation 
of  all  the  requisites.  Both  these  measures  should  be 
practised  at  the  same  time,  immediately  after  the 
failure  of  the  taxis,  bleeding,  and  the  warm  batli.  Sir 
A.  Cooper  computes,  that  four  hours  are  enough  for  the 
trial  of  the  tobacco  clyster,  together  with  cold  appli- 
cations. 

In  omental  hernise,  the  necessity  for  operating  may 


12 


HERNIA. 


frequently  be  obviated,  by  the  good  effects  of  bleeding, 
purgative  medicines,  and  clysters,  and  leeches  applied 
to  the  tumour.  Mr.  Lawrence  has  justly  observed,  that 
“ when,  as  it  very  frequently  happens,  the  aid  of  the 
surgeon  is  not  required,  until  the  complaint  has  lasted 
for  some  time,  a trial  of  the  tobacco,  together  with  the 
topical  use  of  cold,  should  be  immediately  resorted  to, 
as  circumstances  will  not  admit  of  delay  in  the  pre- 
vious use  of  less  powerful  remedies.” — (P.  148,  edit.  3.) 

Every  man  who  has  seen  much  of  hernite,  will  im- 
mediately recognise  tlie  propriety  of  the  following  sen- 
timents of  the  experienced  Mr.  Hey. 

“ I can  scarcely  press  in  too  strong  terms  the  neces- 
sity of  an  early  recourse  to  the  operation,  as  the  most 
effectual  method  of  preserving  life  in  this  dangerous 
disease.  If  Mr.  Pott’s  opinion  be  true,  that  the  opera- 
tion, when  performed  in  a proper  manner,  and  in  due 
time,  does  not  prove  the  cause  of  death  oftener  than 
perhaps  once  in  fifty  times;  it  would  undoubtedly  pre- 
serve the  lives  of  many,  to  perform  it  almost  as  soon 
as  the  disease  commenced,  without  increasing  the  dan- 
ger by  spending  much  time  in  the  use  of  means  which 
cannot  be  depended  upon  for  a cure. 

“I  have  twice  seen  this  disease  prove  fatal  in  about 
twenty-four  hours.  In  such  cases,  it  is  evident  there  is 
little  time  for  delay.  A surgeon,  who  is  competent  to 
perform  the  operation,  is  not  perhaps  consulted  till  the 
intestine  is  on  the  point  of  being  mortified,  or  is  actu- 
ally in  a state  of  mortification.  The  dilemma  into 
which  he  is  then  cast,  is  painful  indeed.  But  when 
the  fullest  opportunity  is  afforded  him  of  using  the  best 
mode  of  treatment,  I am  satisfied  that  his  success  will 
be  the  greatest  when  the  operation  is  not  long  delayed. 
This,  at  least,  has  been  my  own  experience.  When  I 
first  entered  upon  the  profession  of  surgery  in  the  year 
1759,  the  operation  for  the  strangulated  hernia  had  not 
been  performed  by  any  of  the  surgeons  in  Leeds.  My 
seniors  in  the  profession  were  very  kind  in  affording 
me  their  assistance,  or  calling  me  into  consultation 
when  such  cases  occurred ; but  we  considered  the  ope- 
ration as  the  last  resource,  and  as  improper  until  the 
danger  appeared  imminent.  By  this  dilatory  mode  of 
practice,  I lost  three  patients  in  five,  upon  whom  the 
operation  was  performed.  Having  more  experience 
of  the  urgency  of  the  disease,  I made  it  my  custom, 
when  called  to  a patient  who  had  laboured  two  or 
three  days  under  the  disease,  to  wait  only  about  two 
hours,  that  I might  try  the  effect  of  bleeding  (if  this 
evacuation  was  not  forbidden  by  some  peculiar  cir- 
cumstances of  the  case)  and  the  tobacco  clyster.  In 
this  mode  of  practice,  I lost  about  two  patients  in  nine, 
upon  whom  I operated.  This  comparison  is  drawn 
from  cases  nearly  similar,  leaving  out  of  the  account 
those  cases  in  which  a gangrene  of  the  intestine  had 
taken  place. 

“ I have  now,  at  the  time  of  writing  this,  performed 
the  o{K*ration  thirty-five  times ; and  have  often  had  oc- 
casion to  lament,  that  I had  performed  it  too  late,  but 
never  that  I had  performed  it  too  soon.  There  are 
some  cases  so  urgent,  that  it  is  not  advisable  to  lose  any 
time  in  the  trial  of  means  to  produce  a reduction.  The 
delay  of  a few  hours  may  cut  off  all  hope  of  success, 
w'hen  a speedy  operation  might  have  saved  the  life  of 
the  patient.” — (P.  141,  Src.) 

To  determine  the  exact  moment,  when  to  give  up 
the  trial  of  the  preceding  measures,  and  to  have  im- 
mediate recourse  to  the  operation,  is  certainly  difficult ; 
but,  no  one  can  doubt,  that  it  is  generally  better  to 
operate  too  early,  than  too  late. 

All  directions  must  be  general  ones,  liable  to  many 
exceptions:  in  rapid  cases,  little  or  no  time  should  be 
allotted  to  the  trial  of  any  plan,  and  the  operation 
should  be  done  without  the  least  delay.  In  other  in- 
stances, we  have  full  time  to  try  the  effects  of  every 
thing  at  all  likely  to  succeed.  The  symptoms,  which 
ought  to  guide  us,  in  having  recourse  to  the  operation, 
arise  from  an  attack  of  inflammation  in  that  part  of 
the  intestine  contained  in  the  hernial  sac,  and  from  its 
spreading  into  the  abdominal  cavity.  It  is  in  propor- 
tion to  their  violence,  that  we  ought  to  urge  the  per- 
formance of  the  operation.  Sir  A.  Cooper  considers 
pain  on  pressing  the  belly,  and  tension,  as  the  symp- 
toms which  point  out  its  immediate  necessity.  He 
adds,  “indeed,  there  is  scarcely  any  period  of  the 
symptoms,  whicli  should  forbid  the  operation  ; for,  even 
if  mortification  has  actually  begun,  the  operation  may 
be  the  means  of  saving  life,  by  promoting  the  ready 


separation  of  gangrenous  parts”— (On  Inguinal  and' 
Congenital  Hernia,  p.  27.) 

Whenever  the  surgeon  has  succeeded  in  reducing 
the  parts,  without  having  recourse  to  the  knife,  if  the 
symptoms  of  pain,  inflammation,  &c.,  ran  high  before 
such  reduction,  tliey  will  not  always  cease  immediately 
afterward.  As  they  probably  depend  on  the  reduced 
bowel  having  been  inflamed  by  the  stricture,  the  body 
should  be  kept  open,  and  the  diet  and  regimen  should 
be  lovv  and  sparing,  while  the  least  degree  of  pain  and 
tension  remain ; in  short,  till  all  cfimplaint  is  absolutely 
removed  from  the  abdomen,  and  the  intestines  do  their 
office  freely,  and  without  trouble. — (Pott.) 

PROGRESS  OF  THE  SYMPTOMS  OF  A STRANGULATED 
HERNIA. 

The  earliest  symptoms  have  been  already  related, 
viz.  “ tumour  in  the  groin  or  scrotum,  attended  with 
pain,  not  only  in  the  part,  but  all  over  the  belly,  and 
creating  a sickness  and  inclination  to  vomit,  suppres- 
sion of  stools,  and  some  degree  of  fever.  These  are 
the  first  symptoms,  and,  if  they  are  not  appeased  by  the 
return  of  the  intestine;  that  is,  if  the  attempts  made 
for  this  purpose  do  not  succeed ; the  sickness  becomes 
more  troublesome,  the  vomiting  more  frequent,  the 
pain  more  intense,  the  tension  of  the  belly  greater,  the 
fever  higher,  and  a general  restlessness  comes  on, 
which  is  very  terrible  to  bear  When  this  is  the  state 
'of  the  patient,  no  time  is  to  be  lost;  a very  little  delay 
is  now  of  the  utmost  consequence;  and  if  the  one 
single  remedy  which  the  disease  is  now  capable  of,  be 
not  administered  immediately,  it  will  generally  baffle 
every  other  attempt.  This  remedy  is  the  operation, 
whereby  the  parts  engaged  in  the  stricture  may  be  set 
free.  If  this  be  not  now  performed,  the  vomiting  is 
soon  exchanged  for  a convulsive  hiccough,  and  a fre- 
quent gulping  up  of  bilious  matter : the  tension  of  the 
belly,  the  restlessness,  and  fevey  having  been  con- 
siderably increased  for  a few  hours,  the  patient  sud- 
denly becomes  perfectly  easy,  the  belly  subsides,  the 
pulse,  from  having  been  hard,  full,  and  frequent,  be- 
comes low,  languid,  and  generally  interrupted,  and  the 
skin,  especially  that  of  the  limbs,  cold  and  moist : the 
eyes  have  now  a languor  and  a glassiness,  a lack-lustre 
not  easily  to  be  described ; the  tumour  of  the  part  dis- 
appears, and  the  skin  covering  it  sometimes  changes 
Its  natural  colour  for  a livid  hue  ; but  whether  it  keeps 
or  loses  its  colour,  it  has  an  emphyseiratous  feel,  a cre- 
pitus to  the  touch,  which  will  easily  be  conceived  by 
all  who  have  attended  to  it,  but  is  not  so  easy  to  convey 
an  idea  of  by  words : this  crepitus  is  the  too  sure  in- 
dicator of  gangrenous  mischief  within.  In  this  state, 
the  gut  either  goes  up  spontaneously,  or  is  returned 
with  the  smallest  degree  of  pressure ; a discharge  is 
made  by  stool,  and  the  patient  is  generally  much  pleased 
at  the  ease  he  finds ; but  this  pleasure  is  of  short  dura- 
tion, for  the  hiccough  and  the  cold  sweats  continuing 
and  increasing,  with  the  addition  of  spasmodic  rigours 
and  subsultus  tendinum,  the  tragedy  soon  finishes.” 
—{Pott.) 

According  to  Sir  Astley  Cooper,  one  of  the  earliest 
symptoms  of  a strangulated  hernia  is  pain  about  the 
diaphragm,  followed  by  continual  eructation.  The 
patient  is.  next  troubled  with  vomiting  and  costiveness. 
He  feels  a great  inclination  to  have  stools,  but  cannot 
succeed  in  his  attempts  to  expel  the  feces.  There  is 
some  pain  in  the  swelling ; and  a groat  deal  at  the  part 
where  the  stricture  is  situated.  Afterward  the  abdo- 
men becomes  considerably  distended  with  air,  such 
distention  not  arising  at  first  from  inflammation,  but 
from  the  cattse  here  mentioned,  as  is  proved  by  {)res- 
sure  on  the  abdomen  not  giving  at  first  any  pain.  The 
vomiting  becomes  more  frequent,  and  feculent  matter 
is  ejected  from  the  stomach ; into  which  it  is  brought 
by  what  is  called  the  antiperistaltic  action  of  the 
bowels.  A clyster  will  sometimes  bring  away  a por- 
tion of  feculent  matter,  but  the  quantity  will  be  ex- 
tremely small.  While  the  abdomen  is  in  this  tense 
state,  but  unaccompanied  with  pain,  and  while  there  is 
frequent  vomiting  of  the  feces,  the  pulse  is  hard,  fre- 
quent, and  very  distinct:  but,  in  tlie  next  stage  of  the 
symptoms,  when  the  abdomen  is  not  only  tense,  but 
painful  on  being  touched,  the  pul.<e  is  extremely  small 
and  frequent.  The  vomiting  and  eructation  continue, 
and  tlie  patient  is  pale,  and  covered  with  a cold  per- 
spiration. The  tumour  becomes  very  tense,  hard,  and 
in  general  a little  inflamed  on  tlte  surface  of  tlie  skin. 


HERNIA. 


13 


With  respect  to  the  hiccough  wliich  now  succeeds, 
and  which  has  usually  been  considered  as  a sign  of  the 
presence  of  gangrene,  Sir  Astley  Cooper  declares,  that 
it  is  now  known  not  to  be  so,  patients  liaving  had  it  for 
many  hours,  and  yet  recovered  after  the  operation. 
Hiccough  sometimes  continues  several  days,  after  the 
latter  proceeding,  and,  in  this  case,  bleeding  does  more 
good  than  any  other  measure.— (See  Lancet^  vol.  2, 

p.  120.) 

ANATOMY  OF  INGUINAL  HERNIA. 

This  subject  must  necessarily  precede  the  account 
of  the  operation,  which  would  otherwise  be  unintelli- 
gible. It  is  chielly  in  the  anatomical  information  re- 
lative to  hernia,  and  in  the  mode  of  operating,  that 
modern  surgeons  have  a decided  superiority  over  their 
predecessors ; for,  before  Gimbernat,  Camper,  Hey, 
Lawrence,  Cooper,  Scarpa,  Hesselbach,  Langenbeck, 
and  Cloquet  published  their  several  works  on  hernia, 
the  anatomy  of  the  disease  was  but  imperfectly  under- 
stood. 

Tlie  tendinous  fibres  of  the  aponeurosis  of  the  exter- 
nal oblique  muscle,  as  they  run  downwards  and  for- 
wards towards  the  pubes,  separate  from  each  other  so 
as  to  leave  a triangular  opening,  called  the  abdominal 
ring,  which  is  usually  more  capacious  in  the  male  than 
the  female  subject.  The  upper  and  inner  pillar  (as  it 
is  termed)  of  this  aperture  is  inserted  into  the  sym- 
physis of  the  pubes,  and  is  the  weakest  of  the  two ; 
the  lower  and  outer  one,  which  is  the  strongest,  is 
chiefly  a continuation  of  Poupart’s  ligament  (Uessel- 
bachi  iiber  den  Ursprimff,  4-c.  der  Leisten-und-Schenkel- 
briicke^  p.  4),  and  is  fixed  into  the  angle  and  crista 
of  the  same  bone.  Some  tendinous  fibres  cross  the 
upper  and  outer  angle  of  the  ring,  so  as  to  diminish 
the  triangular  appearance  of  the  whole  aperture ; these 
are  said  to  be  very  strong  in  old  herniae.  The  anterior 
and  thicker  layer  of  the  aponeurosis  of  the  internal 
oblique  muscle  joins  the  tendon  of  the  external  oblique ; 
the  posterior  and  thinner  one  joins  that  of  the  transver- 
salis;  but  the  lower  portion  of  this  tendon,  together 
with  the  corresponding  part  of  the  transversalis,  goes 
wholly  in  front  of  the  rectus  muscle.  Thus,  the  infe- 
rior border  of  the  obliquus  internus  and  transversalis, 
which  originates  from  the  upper  part  of  Poupart’s  liga- 
ment, lies  behind  the  outer  pillar  of  the  abdominal 
ring.  Sir  A.  Cooper  first  noticed,  that  a thin  fascia 
proceeds  from  the  inner  edge  of  Poupart’s  ligament, 
and  spreads  over  the  posterior  surface  of  the  transver- 
salis. This  fascia  forms  the  only  partition  between  the 
peritoneum  and  the  outer  opening  of  the  abdominal 
ring,  and  were  it  not  for  its  existence,  inguinal  hernisB 
would  probably  be  much  more  frequent.  (The  partition 
in  question,  however,  is  said  by  Scarpa  to  be  formed 
by  the  aponeurosisof  the  internal  oblique  and  transverse 
muscles;  while  Hesselbach,  who  has  named  the  small 
smooth  point,  situated  directly  behind  the  outer  opening 
of  the  abdominal  ring,  its  crural  surface,  distinctly 
states,  that  it  is  formed  by  delicate  fleshy  and  tendinous 
fibres  of  the  internal  oblique  muscle  ( Ueber  den  Ur- 
sprung,  Src.  der  Lcislen  und- Schenkelbriiche,  p.  4) ; and 
that  behind  them  is  the  weakest  part  of  what  he  names 
the  internal  inguinal  ligament,  iti  the  rear  of  which  is 
the-ireritoneum,  with  the  intervention  of  a very  loose 
cellular  substance.— (Op.  cit.  p.  26.)  The  internal  in- 
guinal ligament  of  Hesselbach  is  therefore  clearly  the 
same  thing  as  the  above  fascia  pointed  out  by  Sir  A. 
Cooper.  This  point  of  the  abdomen  is  one  of  the  three 
weak  places  on  the  inside  of  the  inguinal  region,  where 
hernis  are  liable  to  occur ; yet,  weak  as  it  appears  to 
be,  it  is  not  the  most  common  situation  of  sucli  tumours. 
A computation  has  been  made  that,  in  a hundred  cases 
of  inguinal  hernia,  not  ten  occur  at  the  point  here 
specified. — (H.  J.  Driinningkausen,  Unterricht  iiber 
die  Briiche,  drc.  TVurzb.  1811.)  Mr.  Lawrence  ob- 
serves, that  if  we  trace  the  fascia  transversalis  from 
the  crural  arch  upwards,  we  shall  find  it  divided  im- 
mediately into  two  portions,  an  internal  and  external, 
which  leave  between  them  a considerable  interval  just 
in  the  middle  of  the  crural  arch.  The  former  of  these, 
which  is  the  strongest,  and  most  decidedly  fibrous,  is 
connected  by  its  inner  edge  to  the  outer  margin  of  the 
rwtus,  and  to  the  inferior  margin  of  the  tendon  of  the 
obli.^uus  internus  and  transversus ; and  both  are  gra- 
dually lost  above,  between  the  peritoneum  and  trans- 
ve^ns.— (On  Ruptures,  ed.  4,  p.  179.) 

The  .spermatic  vessels,  joined  by  the  vas  deferens. 


run  in  front  of  the  epigastric  artery,  very  near  the 
place  of  its  origin.  They  then  pass  through  the  above 
fascia,  go  under  the  edge  of  the  internal  oblique  and 
transverse  muscles,  and  next  obliquely  downwards 
and  forwards,  betvyeen  the  above  fascia  and  aponeu- 
roses of  the  external  oblique  muscle,  to  the  opening  of 
tlie  ring.  When  arrived  on  the  smooth  surface,  im- 
mediately behind  the  ring,  they  describe  an  obtuse 
angle,  and  pass  forwards  and  downwards  into  the 
scrotum. — {Hesselbach,  op.  cit.  p.  5.) 

Thus  we  see  that  the  spermatic  cord,  before  it  actu- 
ally emerges  at  what  is  named  the  abdominal  ring, 
runs  through  a kind  of  canal,  to  which  the  epithet 
inguinal  is  often  applied.  This  oblique  passage  of  the 
cord,  through  the  abdominal  parietes,  was  well  known 
to,  and  elegantly  delineated  by,  Albinus;  Gimbernat 
makes  distinct  mention  of  it  in  his  .Account  of  a JVeio 
Method  of  operating  for  Femoral  Hernia,  p.  19.  32; 
but  Sir  A.  Cooper  has  the  merit  of  having  given  the 
earliest  correct  account  of  the  inguinal  canal,  in  refer- 
ence to  hernia;  a subject  rendered  complete  by  the 
more  recent  elucidations  of  Hesselbach,  Scarpa,  and 
Langenbeck. 

The  abdominal  ring  is  then  only  the  outer  opening 
of  the  canal  or  passage,  through  which  the  spermatic 
cord  passes  before  it  emerges.  The  inner  one,  at  which 
the  viscera  first  protrude,  in  the  most  common  cases  of 
inguinal  hernia,  is  situated  about  an  inch  and  a half 
from  the  abdominal  ring,  in  the  direction  towards  the 
anterior  superior  spinous  process  of  the  ilium ; or,  ac- 
cording to  Hesselbach,  the  inguinal  canal  is  almost  an 
inch  and  a lialf  in  length,  the  average  distance  of  the 
outer  pillar  of  the  abdominal  ring,  from  the  inner  pillar 
of  what  he  terms  the  posterior  ring,  being  about  sixteen 
lines.— (Op.  crt.  p.  14.)  This  inner. opening  is  rather 
nearer  the  pubes  than  the  ilium,  and  its  upper  border 
is  formed  by  the  lower  edge  of  the  internal  oblique  and 
transverse  muscles,  which  can  be  plainly  felt  with  the 
finger,  introduced  upward  and  outward  into  the  abdo- 
minal ring. 

“ The  precise  point  at  which  the  liernia  most  com- 
monly begins,”  says  Scarpa,  “ is  that  which  corresponds, 
in  the  feetus,  to  the  communication  of  the  tunica  vagi- 
nalis with  the  peritoneum,  and,  in  the  adult,  to  the 
passage  of  the  spermatic  cord  under  the  transverse 
muscle.  In  the  sound  state,  the  peritoneum  .presents 
at  this  part  a small  funnel-like  depression,  the  depth 
of  which  increases  in  proportion  as  the  spermatic  cord 
is  pulled  from  above  downwards.  It  is  this  small 
pouch,  this  sort  of  digital  appendage,  whose  progressive 
augmentation  constitutes  the  hernial  sac.  Resting 
upon  the  anterior  surface  of  the  spermatic  cord,  it  first 
makes  its  appearance  under  the  inferior  edge  of  the 
transverse  muscle ; thence  it  extends  itself  in  the  sepa- 
ration of  the  inferior  fleshy  fibres  of  the  internal  oblique 
muscle,  always  following  the  spermatic  cord,  in  front 
of  which  it  is  situated ; and  after  having  in  this  manner 
passed  through  the  whole  of  the  canal,  which  extends 
from  the  iliac  region  to  the  pubes,  it  lastly  protrudes  at 
its  external  orifice,  which  is  the  inguinal  (or  abdominal) 
ring,  properly  so  called.  In  all  this  track,  the  hernial 
sac,  as  well  as  the  spermatic  cord,  is  situated  above 
the  femoral  arch,  the  direction  of  wliich  it  follows. 
The  canal  which  it  traverses  is  of  a conical  shape,  the 
apex  of  which  is  towards  the  flank,  and  the  base  .at  the 
external  orifice  of  the  ring.”— (Sca?^a,  Traiti  dcs 
Hernies,  p.  44,  45.) 

The  epigastric  artery  runs  behind  tlie  spermatic 
cord,  along  the  inner  margin  of  the  internal  opening 
of  the  above  canal,  then  upwards  and  inwards,  so  as 
to  pass  at  the  distance  of  half  an  inch,  or  an  inch,  from 
the  upper  extremity  of  the  outer  opening,  or  abdominal 
ring. 

In  common  cases  of  inguinal  hernia,  the  viscera, 
protruded  at  the  inner  opening  of  the  inguinal  canal, 
lie  over  the  spermatic  cord,  and  form  a tumour  on  the 
outside  of  the  abdominal  ring. 

When  the  viscera  have  entered  the  above  descritied 
digital  pouch  of  the  peritoneum,  but  do  not  protrude 
through  the  abdominal  ring,  the  ca.«e  is  sometimes 
termed  an  incomplete  inguinal  hernia-,  and  complete 
when  they  pass  out  of  that  opening.  The  viscera  may 
continue  for  a long  while  quite  within  the  inguinal 
canal,  and  even  become  strangulated  there : sometimes, 
also,  they  are  prevented  from  passing  farther  towards 
the  ring  by  some  kind  of  iinpedimerit ; and,  in  this  cir- 
cumstance, if  the  hernial  sac  liave  any  addition  made 


14 


HERNIA. 


to  its  contents,  it  may  expand  between  the  external 
and  internal  oblique  muscles,  as  Hesselbach  had  an 
opportunity  of  seeing  in  the  body  of  a female. — ( Ueber 
den  Ursprmig,  &-c.  der  jLeisten  und-Schenkelbriiche, 
p.  28.)  The  stricture  may  take  place  either  at  the  in- 
ternal or  e.Yternal  opening  of  the  inguinal  canal.  In 
recent  and  small  hernia;,  according  to  Sir  A-  Cooper, 
the  strangulation  is  most  frequently  situated  at  the  inner 
opening;  in  large  old  ruptures,  at  the  abdominal  ring. 
Even  when  the  parts  completely  protrude  out  of  the 
latter  opening,  the  strangulation  may  exist  at  the  inner 
one : but  there  may  occasionally  be  two  strictures,  viz. 
one  at  each  opening. — (See  Lawrence  on  Ruptures^ 
p.  183,  edit.  3.) 

The  hernial  sac  descends  through  the  abdominal 
ring,  over  the  spermatic  cord,  and  is  covered  by  a fas- 
cia, sent  otf  from  the  tendon  of  the  external  oblique 
muscle.  Beneath  this  fascia,  the  cremaster  muscle  is 
also  situated,  over  the  sac,  which,  after  it  has  descended 
a certain  way,  lies  on  tlie  tunica  vaginalis,  as  well  as 
the  spermatic  cord. 

As  the  epigastric  artery  naturally  runs  first  behind 
the  spermatic  cord,  and  then  along  the  inner  margin  of 
the  internal  opening  of  the  ring,  and  as  the  viscera  are 
protruded  over  the  cord,  they  must  be  situated  on  the 
outer  side  of  the  artery,  which  runs  first  behind  the 
neck  of  the  sac,  and  then  on  its  inner  side.  Hence, 
the  inner  margin  of  the  sac,  when  inspected  on  the  side 
towards  the  abdomen,  seems  to  be  formed,  as  it  were, 
by  the  track  of  the  vessel. — (See  Lawrence,  p.  179.) 
That  this  is  the  ordinary  situation  of  the  epigastric 
artery,  in  relation  to  the  inguinal  hernia,  is  confirmed 
by  the  concurrent  testitnonies  of  Camper,  Chopart, 
Desault,  Sabatier,  Sir  A.  Cooper,  Hesselbach,  Scarpa, 
&c.  and  by  preparations  to  be  seen  in  almost  every 
museum. 

In  recent  inguinal  hernise,  the  internal  and  external 
openings  of  the  ring  are  at  some  distance  from  each 
other,  the  first  being  situated  obliquely  upwards  and 
outwards  in  relation  to  the  former;  but  the  pressure 
of  the  protruded  viscera  gradually  forces  the  internal 
opening  more  towards  the  pubes,  and  nearer  to  the 
abdominal  ring,  so  as  to  retider  the  posterior  side  of 
the  tieck  of  the  hernial  sac,  and  of  the  inguinal  canal, 
very  short.— (//esseZiacA,  p.  29.)  Thus,  in  large 
hernise  of  long  standing,  the  opening  into  the  abdomen 
is  almost  direct,  and  the  epigastric  artery  becomes 
situated  nearer  the  pubes  than  in  the  natural  state. 

Though  such  is  the  ordinary  direction  in  which  a 
bubonocele  protrudes,  there  are  occasional  varieties. 
In  one  of  these,  the  viscera,  instead  of  descending 
through  the  canal  of  the  ring,  are  at  once  thrust  through 
the  abdominal  ring  itself,  and  the  opening  into  the  belly 
is  then  direct;  the  hernial  sac,  instead  of  passing  on 
the  external  side  of  the  spermatic  vessels,  as  is  usual, 
now  lies  on  their  inner  or  pubic  side ; and  the  epigastric 
artery,  which  is  commonly  situated  behind,  now  pur- 
sues its  course,  in  front  of  the  sac,  at  its  usual  dis- 
tance from  the  upper  and  outer  angle  of  the  abdominal 
ring. 

The  following  is  Scarpa’s  description  of  the  displace- 
ment of  the  epigastric  artery  in  the  greater  number  of 
cases  of  inguinal  hernia : “ This  artery,  which,  in  the 
natural  state,  runs  about  ten  lines  from  the  abdominal 
ring,  has  its  situation  and  direction  so  changed,  in 
subjects  affected  with  hernia,  that  it  crosses  the  poste- 
rior part  of  the  neck  of  the  hernial  sac,  and  is  pushed 
from  the  outer  to  the  inner  side  of  the  abdominal  i ing. 
In  order  to  comprehend  the  reason  of  this  displacement, 
it  is  necessary  to  recollect  what  I have  elsewhe’re  said 
of  the  formation  of  inguinal  hernia,  and  of  the  manner 
in  which  the  spermatic  cord  crosses  the  epigastric 
artery.  The  hernia  begins  to  form  at  the  very  place, 
where  the  spermatic  cord  passes  under  the  inferior 
margin  of  the  transverse  muscle;  and  this  place  is 
rather  nearer  the  flank,  than  that  where  the  epigastric 
artery  passes  towards  the  rectus  muscle.  In  its  pro- 
gressive extension,  the  hernial  sac  constantly  follows 
the  same  track  as  the  spermatic  cord,  since  it  is  situated 
upon  its  anterior  surface.  As  has  been  already  ex- 
plained, this  cord  crosses  the  epigastric  artery  ; conse- 
quently, the  hernial  sac  must  necessarily  pass  with  the 
cord  above  this  artery,  before  protruding  from  the  canal 
of  the  abdominal  ring.  At  the  same  time,  the  internal 
orifice  of  the  hernia  becoming  larger,  and  the  inguinal 
canal  shortened  by  the  approximation  of  its  two  orifices 
to  each  other,  it  follows,  that  at  the  period  when  the 


hernia  begins  to  make  its  appearance  in  the  groin,  the 
epigastric  artery  is  unavoidably  situated  behind  the 
neck  of  the  hernial  sac,  and  is  pushed  from  the  outer 
to  the  inner  side  of  the  ring.  Let  us  suppose  a piece 
of  string  to  be  passed  from  the  inside  of  the  abdomen 
into  the  scrotum,  all  through  the  inguinal  canal,  and 
the  middle  of  the  hernia ; and  that  this  string  is  pulled 
so  as  to  bring  out  the  internal  orifice  of  the  hernia, 
which  is  situated  beyond  the  point  where  thp  spermatic 
cord  crosses  the  epigastric  artery;  this  artery  will  im- 
mediately be  found  to  be  carried  from  the  outer  to  the 
inner  side  of  the  neck  of  the  hernial  sac.  The  same 
thing  happens  Ifom  the  effect  of  the  enlargement  of  the 
hernia.  The  removal  of  the  epigastric  artery,  from 
one  side  of  the  ring  to  the  other,  (says  Scarpa.)  is  a 
phenomenon  which  may  be  regarded  as  almost  constant 
in  the  inguinal  hernia.  I have  examined  the  bodies 
of  a great  number  of  subjects  affected  with  this  species 
of  hernia,  and  it  has  been  only  in  a very  few  that  I 
met  with  the  epigastric  artery  retaining  its  natural 
situation  on  the  outer  side  of  the  abdominal  ring.  In 
investigating  the  reason  of  this  exception,  I have  ob- 
served, in  all  the  individuals  who  presented  it,  a very 
remarkable  weakness  and  flaccidity  of  that  part  of  the 
abdominal  parietes  which  extends  from  the  flank  to 
the  pubes.  In  all,  the  displaced  viscera  had  passed 
through  the  aponeurosis  of  the  transverse  and  internal 
oblique  muscles ; not  in  the  vicinity  of  the  ilium,  as  is 
commonly  the  case,  but  at  a little  distance  from  the 
pzibes,  giving  to  the  upper  pillar  of  tlie  ring  a curvature 
that  is  extraordinary,  and  disproportioned  to  the 
smallness  of  the  hernia.  I observed,  also,  that  the 
neck  of  the  hernial  sac  did  not  pass  in  an  oblique 
direction,  from  the  flank  to  the  pubes,  but  that  it  pro- 
truded from  the  abdomen  almost  in  a direct  line  from 
behind  forwards.  In  short,  in  these  individuals,  the 
small  cul-de-sac  of  the  peritoneum,  which  constitutes 
the  origin  of  the  hernial  sac,  had  not  begun  to  be 
formed  under  the  edge  of  the  transverse  muscle,  at  the 
point  where  the  spermatic  cord  runs  outward  ; but  it 
had  passed  through  the  aponeurosis  of  the  internal 
oblique  and  transverse  muscles,  at  a little  distance 
from  the  pubes,  and  within  the  point  at  which  the  sper- 
matic cord  crosses  the  epigastric  artery.  The  small 
hernial  sac,  having  at  this  part  come  into  contact  with 
and  united  to  the  spermatic  cord,  protruded  at  the  ex- 
ternal orifice  of  the  inguinal  canal,  without  displacing 
the  epigastric  artery  from  its  natural  situation. 

“ This  species  of  henna,  properly  speaking,  is  a mix- 
ture of  the  ventral  and  inguinal.  It  resembles  the 
former,  inasmuch  as  the  hernial  sac  pierces  the  apo- 
neurosis of  the  transverse  and  internal  oblique  muscles ; 
the  latter,  inasmuch  as  it  passes  out  at  the  abdominal 
ring,  conjointly  with  the  spermatic  cord.” — (.Scarpa, 
Traite  des  Hernies,  p.  68,  ^c.) 

Hesselbach  particularly  adverts  to  a triangular 
space  to  be  seen  on  the  inside  of  the  inguinal  region: 
the  upper  boundary  of  it  is  formed  by  the  outer  edge 
of  the  rectus  muscle;  the  lower  by  the  horizontal 
branch  of  the  os  pubis  ; and  the  external  shortest 
boundary  by  the  crural  vein  and  epigastric  artery. 
Now',  says  he,  when  it  is  considered,  that  this  artery 
ascends  obliquely  inwards,  between  the  inner  opening 
of  the  ring,  and  the  above  triangular  space,  one  can- 
not fail  to  know  on  which  side  of  the  neck  of  the  sac 
the  artery  must  lie  in  the  tw'o  species  of  inguinal,  as 
well  as  the  crural,  hernia;  for,  in  those  hernia;,  wJiich 
originate  in  the  above  triangular  space,  this  artery  lies 
at  the  outer  side  of  the  neck  of  the  hernial  sac ; while, 
in  every  hernia,  that  takes  place  through  the  inner 
opening  of  the  inguinal  canal,  the  same  vessel  is  situ- 
ated at  the  inner  side  of  the  heck  of  the  sac.  To  one 
species  of  bubonocele,  Hesselbach  applies  the  epithet 
external;  and  to  the  other,  internal;  according  to  the 
situation  of  the  point  at  which  they  first  protrude.  By 
Sir  A.  Cooper,  they  are  Jnamed  oblique  and  direct, 
which  arc  also  very  proper  terms.  The  external  in- 
guinal hernia  is  much  more  frequent  than  the  internal, 
and  is  said  to  occur  oftener  on  the  riglit  than  the  left 
side  of  the  body;  a circumstance  coinciding  with 
another  observation,  viz.  that,  in  children,  the  tunics 
vaginalis  remains  longer  open  on  the  right  tlian  the 
left  side. 

The  circumstance  of  there  being  two  forms  of  in- 
guinal hernia  formerly  caused  considerable  perplexity: 
surgeons  knew,  that  the  epigastric  artery  lay  sometimes 
at  the  inner,  sometimes  at  the  outer,  side  of  the  nerk 


HERNIA. 


15 


of  the  hernial  sac,  but  knew  not  how  to  account  for 
this  variation.  Hence  arose  the  very  different  opinions 
about  the  proper  method  of  dividing  the  ring  when  tlie 
hernia  was  strangulated ; some  authors  directing  the 
incision  to  be  made  obliquely  inwards  and  upwards, 
and  others,  upwards  and  outwards.  But,  as  a modern 
writer  has  judiciously  remarked,  had  they  paid  greater 
attention  to  the  direction  of  the  swelling,  formed  by 
the  neck  and  body  of  the  hernial  sac  in  the  groin,  and 
to  the  position  of  the  spermatic  cord,  which  is  as  in- 
constant as  that  of  the  epigastric  artery;  and  had  they 
dissected  the  parts  in  the  diseased,  as  well  as  healthy 
state ; they  could  not  fail  soon  to  liave  suspected,  that 
every  inguinal  lierniadoes  not  originate  exactly  at  one 
and  the  same  pqint.  Though  the  internal  bubonocele 
was  occasionally  noticed  by  surgeons  many  years  [ago, 
and  Mr.  Cline  in  particular  saw  an  example  of  it  in  the 
year  1777,  and  always  mentioned  it  in  his  subsequent 
lectures,  yet  the  earliest  satisfactory  history  of  the  dif- 
ferences of  the  two  forms  of  inguinal  hernia  was  given 
by  Sir  A.  Cooper,  in  his  great  work  on  ruptures ; and 
the  tract,  in  which  Hesselbach  pointed  out  the  nature 
of  the  internal  bubonocele  in  a very  particular  man- 
ner, I believe  is  the  next  publication  in  which  the 
subject  is  explained. — {Anat.Ckir.Abhandlung  iiber  den 
Ursprung  der  I^eistenbriiche,  Wurzb.  1806 ; and  JVV'm- 
esteAnat.  Pathol.  Uhtersuch.ungen  iiber  den  Ursprung, 
&'C.  der  Leisten-und- Schenkelbriiche,  \to.  fVurzb.  1814, 
p.  18.  26.  28,  (J-c.)  According  to  the  latter  author,  since 
each  form  of  inguinal  hernia  also  presents  character- 
istic appearances  externally,  the  surgeon  can  have  no 
difficulty  in  determining  the  species  of  hernia ; which 
discrimination  must  be  highly  important  in  the  taxis, 
the  application  of  a truss,  and  especially  the  operation. 
The  sac  of  the  external  scrotal  hernia  can  only  pass 
down  within  the  expansion  of  the  cremaster  as  far  as 
this  part  is  separate  from  the  cord  and  tunica  vaginalis. 
Hence,  the  testis,  covered  by  its  tunica  vaginalis,  lies 
under  the  lowest  part  of  the  hernial  sac,  while  the  ves- 
sels of  the  spermatic  cord,  in  a more  or  less  separated 
form,  are  situated  behind  the  posterior  part  of  the  sac ; 
viz.  the  spermatic  veins  externally,  and  the  vas  de- 
ferens internally,  and  the  artery  in  the  middle.  Should 
the  hernia  descend  still  farther,  the  te.stis  being  included 
as  well  as  the  sac  within  the  tendinous  expansion  of 
the  cremaster,  it  cannot  glide  out  of  the  way,  but  must 
be  pressed  still  farther  downwards  by  the  sac,  so  as  to 
continue  invariably  under  its  fundus,  but  sometimes 
inclined  a little  behind  it. — {Hesselbach.,  p.  34.)  And, 
as  the  same  author  justly  observes,  the  position  of  the 
spermatic  cord  and  testis,  and  the  oblique  direction  of 
the  swelling  in  the  externai  species,  are  the  two  strong- 
est characters  by  which  every  case  of  inguinal  hernia 
may  be  discriminated.  I know  of  only  one  case  in 
which  the  cord  was  beliind  the  sac,  as  in  the  common 
external  bubonocele,  and  it  was  seen  by  Mr.  Lawrence. 
— ( On  Ruptures.,  p.  210,  edit.  A.) 

Although  the  spermatic  cord,  in  the  external  bubo- 
nocele, commonly  lies  behind,  or  under,  the  hernial  sac, 
there  are  cases  in  which  the  vas  deferens  is  found  on 
the  outer  side  of  it,  while  the  rest  of  the  spermatic  cord 
lies,  as  it  usually  does,  on  the  inner  side,  or  rather 
under  it.— (Cooper.)  Le  Dran,  Schmucker,  and  Bli- 
zard  found  the  whole  cord  situated  in  front  of  the  sac. 
Sometimes  the  vas  deferens  runs  on  the  front  and 
inner  part,  and  the  rest  of  the  cord  on  the  back  and 
external  part  of  the  swelling. — (Camper,  Hey.)  I’he 
cord  has  been  known  to  be  before,  and  the  vas  deferens 
behind,  the  sac. — {Camper,  A.  Cooper.) 

Upon  this  part  of  the  subject,  the  reader  may  deem 
the  following  passage  interesting.  “ While  the  hernia 
is  of  moderate  size  (says  Scarpa),  the  surrounding  cel- 
lular substance  is  not  very  greatly  compressed,  and  no 
change  is  observed  in  the  situation  of  the  spermatic 
vessels.  The  artery  and  veins  of  this  name  always 
form,  with  the  vas  deferens,  one  single  cord,  which  is 
intimately  adherent  to  the  posterior  surface  of  the  her- 
nial .sac.  But,  in  proportion  as  the  tumour  increases  in 
size,  the  cellular  substance,  which  immediately  sur- 
rounds it,  and  unites  it  to  the  spermatic  cord,  is  more 
and  more  distended  and  compressed.  At  length,  at  a 
certain  period,  the  distention  is  carried  to  such  a pitch, 
that  the  spermatic  vessels  are  separated  from  one 
another,  and  change  their  position  with  respect  to  the 
liernial  sac.  This  kind  of  gradual  unravelling  of  the 
spermatic  cord  is  quite  similar  to  that  which  would  be 
produced  by  pulling  the  surrounding  cellular  substance 


in  two  opposite  directions.  Such  Is  the  reason  why, 
in  scrotal  hernia  of  large  size,  the  spermatic  artery,  the 
vas  deferens,  and  the  spermatic  veins  are  found  se- 
parated upon  the  posterior  surface  of  the  sac.  All 
these  vessels,  instead  of  being  conjoined  in  one  cord, 
are  divided  by  interspaces,  which  are  sometimes  very 
considerable.  Ordinarily,  the  vas  deferens  is  less  se- 
parated from  the  spermatic  artery  than  from  the  vein 
of  this  name.  In  some  subjects.  Camper  has  seen  it 
situated  on  one  side  of  the  sac,  and  the  artery  and  veins 
on  the  other. — {leones  Herniarum,  tab.  5,  L.  O.  tab.  8. 
1,  2.)  The  displacement  and  splitting  of  the  spermatic 
cord  take  place  equally  in  adults  and  in  children 
affected  with  large  scrotal  hernia.— (Camper,  loco  cit.) 
In  general,,  towards  the  upper  part  and  neck  of  the 
hernia,  the  vessels  are  not  much  separated ; but,  as  they 
proceed  downwards,  they  diverge  more  and  more. 
Sometimes,  when  the  hernia  is  very  old  and  bulky, 
they  are  no  longer  found  at  the  posterior  part,  but 
rather  at  the  sides,  and  even  on  the  front  surface  of  the 
sac;  they  show  themselves  through  the  cremaster 
muscle,  which  covers  them,  and  form  a kind  of  vascular 
train,  which  arrests  the  hand  of  the  operator  at  the 
moment  when  he  is  about  to  open  the  hernial  sac.  Le 
Dran  relates,  that  in  operating  upon  a large  scrotal 
hernia,  he  found  the  spermatic  cord  on  the  anterior 
surface  of  the  hernial  sac. — {Operations  de  Chir. 
p.  127.)  This  fact  has  been  the  cause  of  numerous 
conjectures,  and  has  appeared  altogether  inconceivable 
to  such  surgeons  as  have  not  been  acquainted  with  the 
changes  to  which  the  spermatic  cord  is  exposed  in 
cases  of  large  scrotal  hernise.  Lassus  could  not  {Mid. 
Opirat.  1. 1,  p.  152)  conceive  the  possibility  of  the 
occurrence.  The  observation  of  Le  Dran  is  not  the 
less  true  and  exact:  it  exemplifies  a very  important 
fact,  of  which  it  is  easy  to  give  a true  explanation, 
when  the  state  of  the  spermatic  cord,  in  ordinary  in- 
guinal herniEe,  and  in  those  which  have  obtained  a 
considerable  size,  has  been  comparatively  examined. 
In  the  first,  the  spermatic  cord,  quite  entire,  is  always 
situated  on  the  posterior  surface  of  the  hernial  sac; 
but  in  the  second,  the  spermatic  vessels  are  so  sepa- 
rated from  one  another,  that  they  sometimes  extend 
over  the  sides  and  even  the  fore  part  of  the  hernial 
sac.” — {Scarpa,  Traiti  des  Hernies,  p.  61,  <S-c.) 

The  hernial  sac  is  commonly  described  as  an  elon- 
gation of  the  peritoneum.  When  more  minutely  ex- 
amined, however,  it  is  found,  in  cases  of  inguinal 
hernia,  to  consist  of  the  portion  of  peritoneum,  pushed 
out  with  the  viscera;  of  a layer  of  cellular  substance 
on  the  outside  of  this,  which  becomes  more  or  less 
thickened  by  the  pressure  of  the  rupture  in  different 
cases;  of  a fascia,  sent  off  from  the  tendon  of  the  ex- 
ternal oblique  muscle ; and  of  the  cremaster  muscle, 
which  latter  parts  form  the  exterior  covering,  which, 
consisting  of  several  layers,  often  leads  the  operator  to 
fancy  that  he  has  opened  the  cavity  of  the  sac,  when, 
in  reality,  he  has  not. 

It  is  observed  by  Professor  Scarpa,  that  “ the  cre- 
master muscle,  in  cases  of  old  large  scrotal  hernije, 
acquires  a thickness  which  is  really  surprising.  Its 
fibres,  which  are  naturally  very  thin,  become  from  four 
to  six  times  more  considerable.  Being  spread  over  the 
neck  and  body  of  the  hernial  sac,  they  sometimes  pre- 
sent a remarkable  consistence,  and  a yellowish  colour. 
Such  alteration,  however,  does  not  prevent  the  mus- 
cular texture  from  being  discovered,  and  Haller  was 
not  mistaken  about  it.”— ( Opusc.  Patholog.  p.  317.) 
Pathology  furnishes  us  with  several  examples  of  simi- 
lar changes  of  organization.  In  certain  cases,  the 
muscular  coat  of  the  bladder,  that  of  the  stomach  and 
intestines,  and  even  the  exceedingly  delicate  fleshy 
fibres  of  the  ligaments  of  the  colon,  are  found  to  have 
become  yellow  and  much  thickened. 

In  old  scrotal  hernite  (says  Scarpa)  it  is  not  unusual 
to  find  an  intimate  adhesion  of  the  fibres  of  the  cre- 
master muscle  to  the  edges  of  the  abdominal  ring. 
This  may  depend  on  the  pressure,  which  the  contents 
of  the  hernia  make  on  those  edges,  and  perhaps  it  may 
also  depend  on  the  union  of  the  cremaster  muscle  with 
the  prolongation  of  the  aponeurosis  of  the  fascia  lata, 
which  is  continued  from  the  margins  of  the  ring  to  the 
groin  and  scrotum.  Howsoever  it  may  bo,  certain  it 
is,  that  in  old  large  scrotal  hernise,  there  is  much  diffi- 
culty in  introducing  a probe  between  the  fleshy  fibres 
of  the  cremaster  and  the  margin  of  the  abdominal 
ring;  and  that,  on  the  contrary,  in  recent  herniie,  a 


16 


HERNIA. 


probe  passes  as  easily  between  the  edges  of  the  ring 
and  the  cremaster,  as  between  this  muscle  and  the 
hernial  sac. 

“Few  authors  (according  to  Scarpa)  have  spoken 
of  the  sheath  formed  by  the  cremaster  muscle,  ii\ 
which  are  enclosed  the  hernial  sac,  the  spermatic  cord, 
and  the  tunica  vaginalis  of  the  testicle.  Sharp  (in 
Critical  Inquinj)  and  Monro,  the  father  {Anat.  and 
Chirurg.  Works,  p.  553),  were  the  hist  to  dwell  upon 
this  important  pathological  point.  Monro  had  seen 
the  cremaster  muscle  covering  the  hernial  sac ; but  he 
did  not  believe  that  the  same  thing  occurred  in  all 
individuals  affected  with  inguinal  hernia.  In  this 
respect  he  was  mistaken;  for  this  disposition  of  the 
cremaster  muscle  is  one  of  the  essential  characters  of 
the  disease.  Petit  has  not  omitted  to  describe  the 
relations  which  exist  between  the  cremaster  and  the 
hernial  sac. — {(Euvres  Posthum.  1. 1, p.  288.)  On  this 
subject  he  even  relates  an  interesting  fact,  from  which 
it  results,  that,  in  certain  cases,  this  muscle  may  by  its 
contractions  alone  cause  a reduction  of  the  hernia. 
Gunz  explains,  with  tolerable  perspicuity,  how  the  cre- 
master and  its  aponeurosis  form  one  of  the  coverings  of 
the  inguinal  and  scrotal  \iQxuid..—{Libellus  dc  Plerniis, 
p.  50.)  Morgagni  once  saw  its  fleshy  fibres  extended 
over  the  hernial  sac  (De  Sed.  et  Cans.  Morb.  epist.  34, 
art.  9 ; epist.  31,  art.  15)  ; and  Neubaver  positively 
assures  us,  that  he  made  the  same  remark  upon  the 
dead  body  of  a man  affected  with  an  entero-epiplocele. 
— {Dissert,  de  Epiplo-osc/icocele.)  After  these  tacts,  so 
positively  and  accurately  observed,  I cannot  compre- 
hend (says  Scarpa)  how  in  our  time  Pott,  Ilicliter, 
and  several  other  authors  should  have  passed  over 
in  silence,  or  only  mentioned  vaguely,  this  point,  so 
important  in  the  history  of  the  inguinal  and  scrotal 
hernia.” — {Scarpa,  Traiti  des  Hcrnies,p.  48 — 50.) 

When  surgeons  speak  of  a hertiial  sac  being  usually 
thicker  and  stronger,  in  proportion  to  the  magnitude 
and  duration  of  the  hernia,  their  language  is  not  at  all 
correct ; for,  in  fact,  the  peritoneal  investment  of  the 
hernia  is  seldom  or  never  thus  altered.  I can  declare 
(says  Scarpa),  after  numerous  observations,  that,  in 
the  ntajority  of  cases,  the  hernial  sac,  strictly  so  called, 
is  not  perce[»tibly  thickened,  and  that  in  general  it  does 
not  differ  from  other  parts  of  the  peritoneum,  however 
large  and  old  the  scrotal  hernia  may  be. — {Traiti  des 
Hernics,p.  53.) 

In  a very  enormous  hernia,  the  pressure  of  the  con- 
tents is  so  great,  that  instead  of  thickening  the  sac,  it 
renders  it  thinner,  and  even  makes  it  ulcerate.  The 
protruded  viscera  have  been  met  with  immediately 
beneath  the  integuments,  when  the  sac  has  been  burst 
by  a blow.~(  Cooper,  J.  L.  Petit.) 

The  outer  surface  of  the  peritoneal  part  of  the  her- 
nial sac  is  always  most  closely  adherent  to  the  other 
more  external  covering  by  means  of  cellular  substance. 
This  connexion  is  formed  so  soon  after  the  first  oc- 
currence of  a hernia,  that  any  hopes  of  returning  a her- 
nial sac  into  the  abdomen  have  generally  been  con- 
sidered as  chimerical.  TJiere  must,  however,  be  a 
certain  space  of  time  before  adhesions  form,  though  it 
must  be  exceedingly  short. 

Upon  this  point,  Scarpa  does  not  adopt  the  opinion 
that  has  commonly  prevailed. 

There  is  no  doubt,  he  observes,  that  in  recent  and 
small  inguinal  hernia?,  the  intestine,  strangulated  by 
the  neck  of  the  hernial  sac,  has  been  known,  in  more 
instances  than  one,  to  have  been  reduced  by  the  taxis, 
and  carried  with  it  the  whole  of  the  sac  into  the  ab- 
domen. Observations  not  less  authentic  inform  us, 
that  after  the  operation  for  hernia,  when  the  viscera 
could  not  be  reduced  on  account  of  their  adhesions  to 
the  sac,  they  have  been  seen,  notwithstanding  such 
adhesions,  to  get  nearer  to  the  ring  daily,  and,  at  length, 
spontaneously  to  return  into  the  belly  together  with 
the  hernial  sac.  Louis,  he  thinks,  was  wrong  in  deny- 
ing the  possibility  of  these  facts. — {Acad.  Royale  dc 
Chir.  t.  11,  p.  480.) 

Scarpa  argues,  that  “under  certain  circumstances 
the  cellular  subsiauce  will  bear,  without  laceration,  a 
considerable  elongation,  and  afterward  shrink  again.” 
Thus  we  often  see  a viscus  which  has  suffered  a con- 
sideiable  displacement,  return  spontaneously  into  its 
natural  situation.  In  the  inguinal  hernia,  the  sper- 
matic cord  is  elongated,  and  descends  farther  than  in 
the  natural  state.  No  laceration  of  the  cellular  sub- 
stance. however,  is  then  occasioned  ; for  if  the  licrnia 


be  kept  reduced,  the  spermatic  cord  becomes  shoner, 
daily  retracts,  and  at  last  has  only  the  same  length 
which  it  had  previously  to  the  disease.  When  a sar- 
cocele  becomes  large  and  heavy,  the  portion  of  tlie 
spermatic  cord  naturally  situated  within  the  belly  ia 
by  degrees  drawn  out  into  the  scrotum  ; but  after  the 
tuinour  IS  extirpated,  this  portion  ascends  again,  and 
of  itself  returns  into  its  original  situation. 

The  same  thing  happens  after  the  operation  for  the 
strangulated  inguinal  hernia.  All  practitioners  have 
noticed,  that  the  hernial  .state  retracts  and  reascenda 
progressively  towards  the  ring.  This  alone  would 
prove,  that  the  cellular  substance  which  surrounds  the 
spermatic  cord,  and  unites  it  to  the  hernial  sac,  ia 
highly  endued  with  the  property  of  yielding,  and  after- 
ward returning  to  its  original  sac.  Cffn  the  same  pro- 
perty be  refused  to  the  cellular  substance  which  unites 
the  sac  to  the  cremaster  muscle  and  other  surrounding 
parts'? 

“While  the  inguinal  hernia  is  recent,  and  not  of 
much  size,  the  cellular  substance  in  question  possesses 
all  its  elasticity,  and  hence,  the  hernial  sac  and  the 
spermatic  cord  may  easily  ascend  towards  the  abdomi- 
nal ring.  I have  had  occasion  (says  Scarpa)  to  make 
this  observation  upon  the  dead  body  of  a man  who 
had  an  incipient  inguinal  hernia.  The  small  hernial 
sac  was  capable  of  being  pushed  back  iirto  the  ring 
with  the  ulnrost  facility  ; and  in  carefully  examining 
the  parts,  both  within  and  without  the  belly,  it  ap- 
peared to  me,  that  the  cellular  substance  which  united 
the  sac  to  the  spermatic  cord  and  cremaster  muscle, 
was  disposed  to  yield  equally  from  w ithout  inwards, 
and  in  the  direction  precisely  opposite ; that  is  to  say, 
it  made  an  equal  resistance  to  the  protrusion  and  the 
reduction  of  the  hernial  sac.  Monteggia  has  seen  a 
case  exactly  similar;  although,  according  to  his  own 
expressions  {Instituz.  Chirurg.  t.  3,  sec.  2,p.  249),  the 
hernial  sac  was  not  very  small,  it  adhered  very  loosely 
to  the  surrounding  parts,  and  it  admitted  of  being  en- 
tirely reduced  into  the  abdomen  with  great  facility.” 

In  large  old  scrotal  herniai,  Scarpa  allows,  that  such 
reduction  is  quite  impracticable : “ In  these,  the  cellu- 
I lar  substance  which  unites  the  sac  to  the  spermatic 
cord  and  cremaster  muscle,  has  acquired  such  a den- 
sity, that  it  does  not  oppose  less  resistance  to  the 
further  enlargement  of  the  hernia,  than  to  the  efforts 
of  the  surgeon  who  endeavours  to  effect  its  reduction.” 
— {Scarpa,  Traiti  des  Hernies,p.  57,  &c.) 

In  the  dead  subject,  Cloquet  found  the  sac  of  an 
internal  inguinal  hernia  reduced  into  the  abdomen, 
whither  it  seemed  to  have  been  drawn  by  a piece  of 
ometitum  adherent  to  what  had,  in  its  protruded  state, 
been  its  fundus. — {Recherches  sur  les  Causes,  &rc.  des 
Hernies,  p.  102.)  The  investigations  of  the  same 
author  prove,  that  complete  or  incomplete  inversions 
of  the  sac  may  also  happen  in  the  femoral  and  internal 
inguinal  hernia,  without  the  existence  of  any  adhesion  ; 
but  that  the  intimate  union  between  the  sac  and  sper- 
matic cord  hinders  the  event  in  external  or  common 
inguinal  ruptures.  Le  Dran  dissected  a case,  in  which 
the  sac  of  a femoral  hernia,  with  its  contents,  had 
been  returned  into  the  abdomen  in  a mass.  The  ob- 
servations of  Cloquet  also  tend  to  confirm  the  pos- 
sibility of  the  latter  occurrence,  which  he  describes  as 
happening  with  more  facility  in  the  internal  inguinal 
rupture  than  in  the  crural,  and  with  most  difficulty  in 
the  external  inguinal  hernia. 

We  shall  conclude  this  anatomical  account  of  the 
inguinal  hernia,  with  the  follow'ing  explanation  of  tlie 
parts  as  they  appear  on  dissection ; “ The  removal  of 
tlie  integuments  exposes  the  exterior  investmeiuof  the 
hertiial  tumour,  continuous  with  the  margins  of  the 
ring,  and  formed  of  tendinous  fibres  from  the  apo- 
neurosis, the  cremaster  muscle,  &c.  This  is  connected 
by  cellular  substance  with  the  proper  hernial  sac, 
formed  of  the  peritoneum.  This  production  of  the 
peritoneum  passes  within  the  ring  of  the  external 
oblique,  and  theti  goes  upwards  and  outwards.  Be- 
hind and  above  the  ring,  the  inferior  margin  of  the 
ohliquus  interims  and  transversalis  crosses  the  neck 
of  the  sac.  When  these  muscles  are  refiecte<I  towar<ls 
the  linea  alba,  the  fa.scia,  ascending  from  Poupart’s 
ligament,  and  forming  the  upper  opening  of  the  ring, 
is  exposed,  and  the  epigastric  artery  is  di.';cover((l 
emerging  from  the  inner  side  of  the  neck  of  the  lierniM 
sac  {Cainperi  leones,  tab.  x.  F.  J\I.),  which,  :it  this 
precise  point,  becomes  continuous  with  the  peritoneum 


HERNIA.  17 


lining  the  abdomen.  The  removal  of  the  hernial  sac 
will  disclose  the  course  of  the  spermatic  cord  in  its 
descent  towards  the  testicle;  and  when  tliis  is  also 
elevated,  the  first  part  of  the  course  of  the  epigastric 
artery,  and  its  origin  from  the  iliac  trunk,  are  exposed.” 
— ^Lawrence  on  Ruptures,  p.  203,  ed.  4.) 

In  females,  when  a bubonocele  occurs  (which  is  un- 
common), the  round  ligament  of  the  uterus  bears  the. 
same  relation  to  the  tumour,  as  the  spermatic  cord  in 
males.  According  to  Sir  Astley  Cooper,  the  sac  is 
much  more  considerable  above  the  abdominal  ring 
than  below  it;  and  hence  difficulty  in  the  operation. 
All  the  cases  which  he  has  seen  have  been  intestinal. 
The  stricture  is,  in  almost  all  cases,  at  a considerable 
distance  above  the  abdominal  ring  ; it  may  be  divided 
upwards  or  outwards  with  safety,  as  the  epigastric 
artery  is  situated  more  towards  the  linea  alba.— (See 
leanest,  vol.  2,p.  172.) 

Mr.  Lawrence  had  a very  rare  instance  pointed  out 
to  him,  in  which  a bubonocele  in  a female  was  situ- 
ated on  the  inner  side  of  the  epigastric  artery.  A still 
rarer  case  was  examined  by  Hesselbach : it  was  not 
only  an  example  of  internal  bubonocele  in  a woman, 
but  of  one  in  which  the  epiga.stric  artery  arose  from 
the  obturatrix  artery,  an  inch  from  the  origin  of  this 
latter  vessel  from  the  inner  side  of  the  external  iliac ; 
the  obturatrix  first  passed  an  inch  obliquely  down- 
wards and  inwards  over  the  crural  vein,  and  immedi- 
ately afterward,  on  the  horizontal  ramus  of  the  pubes, 
made  a sudden  turn  backwards  and  downwards  to  the 
obturator  foramen  ; and  at  this  bend  rose  the  epigas- 
tric artery,  which  ran  transversely  inwards  along  the 
horizontal  ramus  of  the  pubes,  behind  the  neck  of  the 
hernial  sac,  at  the  inner  side  of  which  it  ascended  to 
the  rectus  muscle,  accompanied  by  the  ligamentous 
remains  of  the  umbilical  arteries  which  were  close 
behind  it. — ( Ueber  den  Ursprung,  <S-c.  der  Leisten- 
und- Schenkelbrilche,  p.  17.) 

MARKS  OF  DISCRIMINATION  BETWEEN  INQUINAL 
HERNIA  AND  OTHER  DISEASES. 

The  disorders,  in  which  a mistake  may  possibly  be 
made,  are  Cirsocele,  Bubo,  Hydrocele,  and  Hernia  Hu- 
moralis,  or  Inflamed  Testicle. 

For  an  account  of  the  manner  of  distinguishing  the 
first  complaint  from  a bubonocele,  see  Cirsocele. 

“ The  circumscribed  incompressible  hardness,  the 
situation  of  the  tumour,  and  its  being  free  from  all 
connexion  with  the  spermatic  process,  will  sufficiently 
point  out  a bubo,  at  least  while  it  is  in  a recent  state  ; 
and  when  it  is  in  any  degree  suppurated,  he  must 
have  a very  small  share  of  the  tactus  eruditus,  who 
cannot  feel  the  difference  between  matter,  and  either 
a piece  of  intestine  or  omentum. 

“ The  perfect  equality  of  the  whole  tumour,  the  free- 
dom and  smallness  of  the  spermatic  process  above  it, 
the  power  of  feeling  the  spermatic  vessels  and  the  vas 
deferens  in  that  process,  its  being  void  of  pain  upon 
being  handled,  the  fluctuation  of  the  water,  the  gra- 
dual formation  of  the  swelling,  its  having  begun  below 
and.  proceeded  upwards,  its  not  being  affected  by  any 
posture  or  action  of  the  patient,  nor  increased  by  his 
coughing  or  sneezing,  together  with  the  absolute  im- 
possibilty  of  feeling  the  testicle  at  the  bottom  of  the 
scrotum,  will  always,  to  an  intelligent  person,  prove 
the  disease  to  be  a hydrocele.”  The  transparency  of  a 
hydrocele  is  also  another  criterion.  Mr.  Pott,  however, 
allows,  that  there  are  some  exceptions,  in  which  the 
testicle  cannot  be  felt  at  the  bottom  of  the  scrotum,  in 
cases  of  hernia.  “In  recent  bubonoceles,  while  the 
hernial  sac  is  thin,  has  not  been  long  or  very  much  dis- 
tended, and  the  scrotum  still  preserves  a regularity  of 
figure,  the  testicle  may  almost  always  be  easily  felt  at 
the  inferior  and  posterior  part  of  the  tumour.  But  in 
old  ruptures  which  have  been  long  down,  in  which 
the  quantity  of  contents  is  large,  the  sac  considerably 
thickened,  and  the  scrotum  of  an  irregular  figure,  the 
testicle  frequently  cannot  be  felt,  neither  is  it  in  gene- 
ral easily  felt  in  the  congenital  hernia  for  obvious 
reasons.” — {Pott.) 

Attention  to  these  circumstances  is  highly  necessary 
in  practice,  as  the  mistaking  of  a hernia  for  a hydro- 
cele may,  and  has  been,  the  cause  of  fatal  accidents. 
A case,  confirming  this  fact,  is  mentioned  by  Sir  A. 
(’ooper. — (See  Lancet,  vol.  2,  p.  112.)  Hydrocele  of 
tlie  spermatic  cord  is  another  case  still  more  likely  to 

Vol.  II.— B 


be  taken  for  a hernia,  than  the  common  form  of  hydro- 
cele.— (See  Hydrocele.) 

[This  is  an  error  of  more  frequent  occurrence  than 
is  generally  known  or  even  supposed.  Dr.  J.  B.  Da- 
vidge,  late  Professor  of  Anatomy  in  the  University  of 
Maryland,  related  in  his  lectures,  that  he  had  frequently 
been  consulted  by  persons  who  had  been  wearing 
trusses  for  years,  by  the  advice  of  surgeons  who  had 
accused  them  of  hernia,  when  the  disease  was  purely 
“ hydrocele  of  the  spermatic  cord ;”  and  in  one  case 
the  sac  had  been  burst  by  the  violent  efforts  made  to 
reduce  it.  I have  known  this  mistake  committed  se- 
veral limes,  and  shall  never  forget  one  instance  of  the 
performance  of  the  operation  % an  English  surgeon 
possessed  of  both  skill  and  experience,  and  after  dissect- 
ing down  to  the  hernial  sac,  as  he  thought,  with  suita- 
ble caution,  he  discovered  his  error;  not  however  until 
he  had  divided  the  tendon  of  the  external  oblique  for 
half  an  inch,  when  the  hydrocele  gave  way,  and  emp- 
tied its  contents.  He  was  deceived  by  the  long  and 
obstinate  constipation,  nausea,  vomiting,  hiccough,  ab- 
dominal distention,  and  other  symptoms  of  strangula- 
tion, which  indeed  were  sufficient,  with  the  tumour  in 
the  groin,  which  had  now  become  painful,  to  defeat  any 
ordinary  faculty  of  discrimination,  and  made  the  diag- 
nosis exceedingly  difficult.  And  it  is  but  just  to  add, 
that  he  was  scut  for  in  the  night  on  purpose  to  operate, 
after  the  taxis  had  been  ineffectually  applied,  and  the 
paiient  was  alarmingly  situated.  He  had  the  magna- 
nimity to  acknowledge  his  error,  and  the  patient  sub- 
sequently recovered  under  bleeding  and  the  antiphlo- 
gistic battery,  never  suffering  any  inconvenience  from 
the  wound  of  the  operation ; indeed  benefited  thereby, 
since  it  cured  his  hydrocele  of  the  cord. — Reese.'] 

“ In  the  hernia  humoralis,  the  pain  in  the  testicle,  its 
enlargement,  the  hardened  stale  of  the  epidydimis,  and 
the  exemption  of  spermatic  cord  from  all  unnatural 
fulness,  are  such  marks  as  cannot  easily  be  mistaken ; 
not  to  mention  the  generally  preceding  gonorrhma. 
But,  if  any  doubt  still  remains  of  the  true  nature  of 
the  disease,  the  progress  of  it  from  above  downwards, 
its  different  state  and  size  in  different  postures,  particu- 
larly lying  and  standing,  together  with  its  descent  and 
ascent,  will,  if  duly  attended  to,  put  it  out  of  all  doubt, 
that  the  tumour  is  a true  hernia." — {Pott.) 

INGUINAL  HERNIA  WITHIN  THE  CANAL. 

When  the  parts  only  protrude  into  the  inguinal  canal, 
and  not  out  of  its  lower  aperture,  they  are  covered  by 
the  aponeurosis  of  the  external  oblique  muscle.  The 
transverse  and  internal  oblique  muscles  pass  over  the 
neck  of  the  hernia,  and  cause  the  strangulation  when 
it  happens.  The  fumour  is  small ; for,  if  the  protrusion 
increases,  the  parts  escape  through  the  lower  opening 
of  the  canal.  Exceptions,  however,  are  on  record. 
Thus,  Mr.  Lawrence  dissected  a case  in  a female, 
where  the  aponeurosis  of  the  external  oblique  was  dis- 
tended by  a swelling  equal  in  bulk  to  two  fists,  while 
another  portion  of  the  sac,  as  large  as  an  egg,  projected 
through  the  ring.  Hesselbach’s  8th  plate  also  re- 
presents a hernia  within  the  canal,  of  considerable 
size,  in  a female.  As,  in  the  ordinary  circumstances 
of  this  form  of  inguinal  hernia,  there  is  no  very  mani- 
fest swelling,  the  case  is  no  doubt  very  often  looked 
upon  and  treated,  as  Sir  Astley  Cooper  remarks,  as  an 
inflammation  of  the  bowels. — {On  Inguinal  and  Con- 
genital Hernia,  p.  48.) 

When  an  inguinal  hernia  does  not  descend  through 
the  abdominal  ring,  but  only  into  the  canal  for  the 
spermatic  cord,  it  is  covered  by  the  aponeurosis  of  the 
external  oblique  muscle,  and  the  swelling  is  small  and 
undefined. 

Now  and  then,  the  testicle  does  not  descend  into  the 
scrotum  till  a late  period,  and  its  first  appearance  at  the 
ring,  in  order  to  get  into  its  natural  situation,  may  be 
mistaken  for  a hernia;  unless  the  surgeon  pay  atten- 
tion to  the  absence  of  the  testicle  from  the  scrotum, 
and  the  peculiar  sensation  occasioned  by  pressing  the 
swelling. 

POINTS  OF  DIFFERENCE  BETWEEN  THE  EXTERNAL  AND 
INTERNAL  INGUINAL  HERNIA,  &C. 

According  to  Hesselbach,  the  characteristic  marks  of 
the  external  bubonocele  and  scrotal  hernia,  are,  1st. 
The  direction  of  the  tumour  in  the  groin.  2dly.  The 
fleshy  fibres  of  the  cremaster.  3dly.  The  position  of 


18 


HERNIA. 


the  spermatic  cord  and  testis.  4thly.  The  situation 
of  the  epigastric  artery.  5thly.  The  origin  of  the  her- 
nia itself.  6llily.  A preternatural  shape  of  the  body  of 
the  hernial  sac. 

1.  Tlie  neck  of  the  hernial  sac,  distended  by  the  pro- 
truded viscera,  raises  up  the  front  side  of  the  inguinal 
canal,  and  superincumbent  integuments,  into  an  oblong 
swelling,  which  extends  obliquely  inwards  and  down- 
wards towards  the  abdominal  ring,  and  terminates  in 
the  tumour  formed  by  the  body  of  the  hernial  sac. 
From  its  origin  it  becomes  gradually  more  prominent 
and  broad;  and  the  greater  tlte  quantity  of  viscera  pro- 
truded, and  the  larger  the  body  of  the  sac,  the  more 
manifest  is  this  oblique  swelling,  particularly  when  the 
neck  of  the  hernia  is  of  its  natur.ai  length.  In  stran- 
gulated cases,  the  direction  of  the  tumour  is  still  more 
striking,  every  part  of  the  hernial  sac  being'  then  con- 
siderably distended.  When  the  inguinal  canal,  and  of 
course  the  neck  of  the  hernial  sac  is  shortened,  the 
swelling  undergoes  a proportional  diminution  in  its 
length ; and  then  its  resemblance  to  the  tumour  attend- 
ing an  internal  inguinal  hernia,  where  the  opening 
through  which  the  parts  pass  is  long  and  slanting,  is  so 
great,  that  the  cases  can  only  be  discriminated  by  one 
circumstance,  viz.  the  situatum  of  llie  spermatic  cord; 
and  even  this  criterion  is  of  course  wanting  in  females. 
— (Hesselback,p.  57, 58.)  Hesselbach  cloarly  e.xplains, 
that  the  obliquity  of  the  swelling  is  seated  in  liie  neck 
of  the  hernial  sac.  lie  observes,  that  when  an  inter 
nal  bubonocele  in  a female  subject  passes  into  the 
labium,  the  descent  takes  place  in  a very  sloping  direc- 
tion inwards,  and  therefore  may  at  first  be  supposed  to 
bean  external  case.  But  on  further  e.'tamination,  the 
oblique  swelling  will  be  found  to  occupy  the  body  of 
the  hernial  sac,  and  to  reach  upwards  and  outwards 
from  the  labium  to  the  abdominal  ring.  Now  this 
hernia  cannot  be  mistaken  for  an  external  bubonocele, 
the  course  of  which  from  the  ring  is  obliquely  upwards 
and  outwards.  As  Sir  A.  Cooper  has  remarked,  if 
there  be  any  obliquity  of  an  internal  inguinal  hernia,  it 
will  incline  towards  the  linea  alba. — (See  Lancet,  vol. 
2,  p.  109.) 

Hesselbach  reminds  us,  that  an  internal  inguinal  or 
scrotal  hernia,  m.ay  be  conjoined  with  an  external  in- 
complete bubonocele ; a kind  of  case  easily  made  out 
with  a liitie  attention;  for  the  place  of  division  be- 
tween the  two  sacs  is  indicated  by  a more  or  less  deep 
groove.  The  nature  of  the  disease  will  also  be  still 
clearer,  if  one  of  the  tumours  admit  of  reduction.  A 
specimen  of  such  a double  hernia  is  to  be  seen  in  the 
museum  at  VV’urzburg. 

It  is  further  noticed  by  Hesselbach,  that  when  the 
situations  of  the  external  and  internal  hernias  are  com- 
pared, the  first  of  these  swellings  will  be  found  to  be 
rather  farther  than  the  other  from  the  symphysis  of  the 
pubes  ; a difference  ascribed  to  the  effect  of  the  inter- 
nal oblique  muscle,  the  lower  fibres  of  which,  attached 
to  the  iiorizontal  ramus  of  the  pubes,  run  in  a curved 
direction  transversely  over  the  anterior  and  inner  part 
of  the  neck  of  the  hernial  sac,  atqj  are  applied  so 
closely  to  it,  that  it  cannot  approach  quite  so  much  to- 
wards the  sympiiysis  of  tlie  pubes,  as  the  neck  of  the 
internal  bubonocele  does.  The  muscular  fibres  in 
question  are  situated  directly  behind  the  inner  pillar 
of  the  abdominal  ring. 

2.  Most  of  the  fibres  of  tlie  cremaster  lie  on  the 
back  of  the  neck  of  the  sac,  but  others  are  also  scat- 
tered over  its  external  and  internal  sides.  Some  fibres 
may  also  be  perceived  on  its  fore  part,  which  are  re- 
markable, because  they  run  in  a transverse  curved  di- 
rection, with  their  convexity  downwards,  and  two  fas- 
ciculi of  which  descend  below  the  abdominal  ring. 
These  are  the  fibres  of  the  cremaster,  which  proceed 
within  the  ring  transversely  upwards  over  the  sperma- 
tic cord,  and  are  pushed  out  of  that  opening  by  the  her- 
nial sac.  These  arched  fleshy  fibres  are  not  always, 
though  generally,  perceptible;  and  when  they  are  pre- 
sent on  the  fore  part  of  the  hernial  sac,  Hesselbach  ac- 
counts them  a .sure  criterion  of  an  external  scrotal  her- 
nia; but  he  has  not  yet  ascertained  whether  they  are 
visible  while  the  rupture  is  confined  to  the  groin. 

3.  The  situation  of  the  spermatic  cord  and  testis  in 
the  external  inguinal  hernia,  and, 

4.  That  of  the  epigastric  artery,  and  its  displacement 
inwards  by  the  neck  of  the  sac,  have  been  sufficiently 
explained. 

5.  With  respect  to  the  mode  in  which  the  hernia  ori- 


Iginates,  the  disease  often  takes  place  suddenly,  without 
any  exciting  cause  being  observed  capable  of  account- 
ing for  the  effect.  Here,  says  Hesselbach,  the  predis- 
posing cause  must  have  been  great ; for  instance,  the 
communication  between  the  cavity  of  the  pe'.itoneum 
and  that  of  the  tunica  vaginalis  has  remained  a long 
while  unclosed;  and  when  a hernia  of  this  description 
is  examined,  the  other  marks  of  an  external  inguinal 
hernia  are  associated  with  the  sudden  formation  of  the 
disease.  In  this  quick  manner  the  congenital  hernia, 
which  is  one  of  the  external  cases,  frequently  arises. 
The  internal  inguinal  hernia  is  also  observed  ino.stly  to 
take  place  very  suddenly,  yet  only  after  violent  occa- 
sional causes.  According  to  Sit  Astley  Cooper,  it  arises 
more  frequently  from  the  efforts  made  to  expel  the  urine, 
in  castis  of  stricture,  tlmn  from  any  other  cause.— (See 
Lancet,  vol.  2,  p.  141.) 

6.  A preternatural  form  of  the  body  of  the  hernial 
sac,  Hesselbach  remarks,  is  particularly  seated  in  the 
sheath  of  the  spermatic  cord,  and  can  never  happen  in 
the  internal  scrotal  hernia;  for  it  is  only  in  external 
cases  that  the  above  sheath  is  ever  converted  into  the 
hernial  sac.  Hesselbach  here  refers  to  the  partial  con- 
traction often  noticed  at  the  lower  part  of  the  above 
sheath  in  cases  of  congenital  hernia;  a circumstance 
which  is  alw  ays  discovered  previously  to  the  business 
of  dividing  the  ring. 

In  adults,  an  external  inguinal  or  scrotal  hernia,  on 
the  right  side,  contains  some  of  the  ilium,  and,  when 
the  swelling  is  large,  it  may  include  the  ccecum,  and 
sometimes  a piece  of  omentum.  In  one  child,  ten 
weeks  old,  and  in  another  still  younger,  the  appendix 
vermiforniis  was  protruded  and  connected  by  a natural 
band  to  the  posterior  side  of  the  peritoneum.  When, 
in  these  ruptures  of  the  right  side,  the  ccecum,  or,  in 
those  of  the  left,  the  colon,  are  met  with  closely  adhe- 
rent to  the  hinder  side  of  the  hernial  sac,  the  adhesion 
is  not  to  be  looked  upon  as  the  effect  of  disease,  since 
it  is  the  perfectly  natural  connexion  of  those  bowels 
with  the  peritoneum.  On  the  left  side,  the  parts  most 
commonly  protruded  are  the  colon  and  omentum 
With  regard  to  the  internal  inguinal  hernia,  the 
place  of  its  first  protrusion  has  been  already  described. 
The  protruded  peritoneum  and  viscera,  according  to 
Hesselbach’s  account,  pass  from  behind  straight  for- 
wards, between  the  fibres  of  what  he  names  the  inter- 
nal inguinal  ligament,  and  the  fleshy  fibres  of  the  inter- 
nal oblique  muscle;  they  then  pass,  at  the  inner  side 
of  the  spermatic  cord,  out  of  the  abdominal  ring, 
where  the  hernia  presents  a circular  globular  swell- 
ing, suddenly  formed  in  consequence  of  some  violent 
effort.  The  neck  of  the  hernial  sac  is  very  short; 
shorter  than  it  can  ever  be  in  an  external  inguinal  her- 
nia; and  when  the  tumour  is  of  the  above  shape,  the 
passage  rhrough  which  it  passes  is  annular,  narrower 
in  some  instances  than  others,  and  its  margin  is  tendi- 
nous. From  the  few  cases  which  Hesselbach  has  seen 
of  this  form  of  the  disease,  he  is  led  to  conjecture, 
that  the  hernial  sac  i.s  rarely  so  large  as  in  the  external 
inguinal  hernia.— (P.  41.)  According  to  Sir  Astley 
Cooper,  the  internal  inguinal  hernia  ovxurs  when  the 
tendon  of  the  transversalis  is  unnaturally  weak,  does 
not  exist  at  all,  or  has  been  broken. — (^On  Inguinal 
Hernia,  p.  51.)  Cloquet  states,  that  the  sac  either  pro- 
pel.s  before  It,  and  thus  receives  a covering  from  the 
fascia  transversalis,  or  passes  through  an  opening  in  it. 
— (Recherches  Jlnat.  p.  83.)  Mr.  Lawrence  dissected  a 
case,  where  the  fascia  was  neither  thinner  than  usual, 
nor  broken,  but  it  had  been  protruded  before  the  peri- 
toneum, and  formed  a thick  aponeurotic  covering  to 
the  hernial  sac.  Mr.  Stanley  has  always  found  it  thus 
covered,  and  some  specimens,  illustrative  of  the  fact, 
have  been  placed  by  him  in  the  museum  of  St.  Bartho- 
lomew’s Hospital. — (On  Ruptures,  p.209.  211,  ed.  4.) 
According  to  Langeobeck,  this  is  the  usual  st.ate  of  the 
parts. — {Comment.  $ 105,  tab.  17,  18,  19.)  Sir  Astley 
Cooper,  in  his  lectures,  also  describes  the  hernia  as 
having  an  investment,  one  half  of  which  is  formed  by 
the  tendon  of  the  transversalis,  and  the  other  half  by 
the  fascia  transversalis. — (See  Lancet,  vol.  2,  p. 
140.)  The  earlier  dissections  made  by  Hesselb.ich,  led 
him  to  suppose,  that  in  the  internal  inguinal  hernia, 
the  opening  through  which  the  protrusion  happens  is 
always  annular,  and  the  swelling  in  front  of  the  ring 
globular  ; but  subsequent  cases  which  he  has  met  with 
have  informed  him  that  the  opening  is  frequently 
. sloping  and  longish ; in  which  circumstance,  the  re- 


HERNIA. 


19 


gemblance  of  the  tumour  to  that  of  the  external  bubo- 
nocele with  a shortened  neck  is  such,  that  the  only 
mark  of  distinction  between  the  two  cases  is  the  posi- 
tion of  the  spermatic  cord.  In  females,  ev'en  this  cri- 
terion is  of  course  deficient. — (Hesselbach,  p.  57.) 
Though  individuals  of  almost  every  age  are  subject  to 
internal  bubonoceles,  they  are  much  less  common  than 
external  cases.  According  to  Hesselbach,  they  may  be 
known  by  the  following  characters:  1.  The  swelling, 
formed  by  the  body  of  the  hernial  sac,  immediately  in 
front  of  the  abdominal  ring.  2.  The  situation  of  the 
spermatic  cord.  3.  That  of  the  epigastric  artery. 

1.  The  neck  of  the  hernial  sac,  besides  being  very 
short,  does  not,  like  that  of  an  external  inguinal  hernia, 
take  an  oblique  direction,  but  advances  straight  from 
behind  forwards  through  the  abdominal  ring  ; and  as 
the  body  of  the  sac  lies  directly  over  the  neck,  none  of 
the  swelling  formed  by  the  distention  of  the  latter  part, 
can  be  felt.  Nor  docs  any  other  tumour,  produced  by 
the  body  of  a hernial  sac,  ever  cause  a circular  sphe- 
rical swelling  directly  before  the  abdominal  ring.  The 
situation  of  the  neck  of  this  kind  of  hernia  must  al- 
ready apprize  us,  that  the  internal  bubonocele  is  nearer 
than  the  e.vternal  to  the  symphysis  of  the  pubes.  In 
women  the  shape  of  the  tumour  is  the  only  character, 
by  which  the  case  can  be  distinguished. — (^Hesselhac/i, 
p.  43.) 

2.  After  what  has  been  already  stated,  respecting  the 
situation  of  the  spermatic  cord  in  the  internal  inguinal 
hernia,  I shall  merely  notice  one  or  two  observations  of 
Hesselbach.  The  cord  lies  either  upon  the  outer  side,  or 
outer  halfof  the  fore  part  of  the  upper  portion  of  the  her- 
nial sac,  the  blood-vessels  forwards,  and  the  vas  deferens 
backwards.  When  the  sac  is  adherent  to  the  whole 
length  of  the  cord,  the  testis  is  not  situated  under  the 
fundus  of  the  sac,  as  in  the  external  scrotal  hernia,  but 
either  at  the  fore  part  or  outer  side  of  the  body  of  the 
sac.  The  hernial  sac,  as  far  as  the  abdominal  ring,  is 
excluded  from  the  common  peritoneal  covering  of  the 
spermatic  cord,  but,  at  this  opening,  it  descends  be- 
tween the  cord  and  the  internal  thin  part  of  the  sheath 
of  the  cremaster,  which,  however,  is  somewhat  stronger 
towards  the  front  and  outer  side  of  the  hernia,  over 
which  part  alone  the  fleshy  fibres  of  the  cremaster  are 
spread.— (P.  44.) 

3.  The  epigastric  artery  always  ascends  obliquely 
inwards  at  the  outer  side  of  the  neck  of  the  hernial 
sac.  Hesselbach  has  never  seen  but  one  case  of  in- 
ternal bubonocele,  in  which  there  was  a deviation  from 
this  rule.  The  example  has  been  already  mentioned, 
and  was  one  in  which  the  epigastric  artery  arose  from 
the  obturatrix  about  an  inch  from  the  origin  of  this 
last  vessel.  The  viscera  usually  contained  in  an  in- 
ternal inguinal  or  scrotal  hernia,  on  the  right  side,  are 
the  lower  part  of  the  small  intestines,  and  sometimes 
omentum ; on  the  left,  a part  of  the  small  intestines, 
frequently  omentum,  and,  when  the  tumour  is  large, 
the  colon  may  also  protrude.  A protrusion  of  the 
bladder  may  accompany  the  disease,  but  that  organ  is 
of  course  always  excluded  from  the  cavity  of  the  her- 
nial sac.  When  the  remains  of  the  umbilical  cord  are 
situated  more  outwards  than  usual,  and  lie  over  the 
centre  of  the  space  at  which  the  protrusion  happens, 
an  internal  bubonocele  may  be  double,  the  prolapsus 
happening  on  each  side  of  that  ligamentous  substance, 
which  is  itself  also  pushed  outwards.  Inconsequenee 
of  the  accidental  presence  of  some  very  strong  tendi- 
nous fibres  at  the  centre  of  the  fascia,  called  by  Hes- 
selbach the  internal  inguinal  ligament,  there  may  also 
be  two  distinct  protrusions,  with  separate  hernial  sacs. 
— (P.  46.) 

When  the  surgeon,  by  a due  consideration  of  the  fore- 
going circumstances,  has  formed  a judgment  respecting 
the  nature  of  the  hernia,  he  will  be  better  qualified  to 
reaulate  the  treatment  of  the  case.  Thus,  in  the  exter- 
nal inguinal  hernia,  he  will  know,  that  the  pressure  em- 
ployed for  the  reduction  of  the  bowels  should  be  made 
in  the  direction  of  the  neck  of  the  hernial  sac,  viz. 
obihiuely  upwards  and  outwards  towards  the  anterior 
sii[)erior  spinous  process  of  the  ilium;  but  that,  when 
the  neck  of  the  same  kind  of  hernia  is  very  short,  and 
the  posterior  side  of  the  inguinal  canal  has  been  re- 
iiioved,  the  pressure  should  he  made  nearly  in  a straight 
line  from  before  backwards.  For  what  Hesselbach 
terms  the  long-necked  e.xternal  inguinal  hernia,  the  pad 
of  a truss  should  be  so  constructed,  as  not  merely  to 
press  upon  tlie  abdominal  ring,  but  also  upon  the  neck 


of  the  sac  and  the  inner  opening  of  the  inguinal  canal. 
But  when  the  neck  of  the  hernia  is  very  short,  the 
pad  should  be  nearly  of  the  same  form  as  that  required 
for  an  internal  inguinal  hernia. — {Hesselbach-,  p.  38; 
and  Briinninghausen,  Oemeinniitziger  Uaterricht  iiber 
die  Bruche,Src.  tVurzU.  1811.)  In  attempting  the  reduc- 
tion of  an  internal  inguinal  hernia,  the  pressure  should 
be  directed  nearly  straight  backwards ; and  the  pad  of 
the  truss  should  only  act  upon  the  abdominal  ring. — 
{Hesselbach,  p-  46.)  It  is  a case  in  which  the  intestine 
often  continues  strangulated,  after  the  reduction,  within 
the  ring. — {Sir  A.  Cooper;  see  Lancet,  vol.  2,  p.  142.) 

THE  OPERATION  FOR  STRANGULATED  INGUINAL 
HERNIA,  OR  BUBONOCELE. 

Sir  Astley  Cooper  particularly  recommends  opera 
tions  for  strangulated  herniaj  to  be  performed  before 
any  peritoneal  tenderness  exists,  which  renders  the 
issue  very  doubtful,  though  the  parts  be  liberated  by 
the  division  of  the  stricture.  Such  tenderness  is  not 
to  be  confounded  with  the  tension  produced  by  the  in- 
flation of  the  intestines.  In  old  persons,  the  operation 
may  be  deferred  longer  than  in  the  young  or  the  mid- 
dle-aged.— (See  Lancet,  vol.  2,  p.  142.)  The  operation 
consists  in  dividing  the  integuments  ; dis.secting  down 
to  the  sac,  and  opening  it ; removing  the  stricture ; and 
replacing  the  protruded  viscera.  The  hair  is  first  to 
be  shaved  from  the  pubes. 

The  e.xternal  incision  should  begin  an  inch  above 
the  external  angle  of  the  ring,  and  extend  over  the 
middle  of  the  tumour  to  its  lower  part,  except  when 
the  swelling  is  large ; in  which  circumstance,  the  cut 
need  not  extend  so  far  down,  as  will  be  presently  no- 
ticed. The  advantage  of  beginning  the  wound  so  high, 
is  to  obtain  convenient  room  for  the  incision  of  the 
stricture.  By  this  first  cut,  the  external  pubic  branch 
of  the  femoral  artery  may  be  divided:  it  crosses  the 
hernial  sac  near  the  abdominal  Jing,  and  sometimes 
bleeds  so  freely  as  to  require  to  be  immediately  tied. 
In  general,  however,  a ligature  is  unnecessary. 

When  this  incision  is  carried  low  down,  the  caution, 
given  by  Camper,  should  always  be  remembered,  viz 
that  there  is  a possibility  of  dividing  the  spermatic  ves- 
sels, should  they  happen  to  be  situated,  as  they  some- 
times are,  in  front  of  the  hernia.  And  in  order  to 
avoid  such  an  accident,  which  is  particularly  apt  to 
occur  in  cases  of  internal  inguinal  or  scrotal  hernia 
the  incision  through  the  skin  should  be  made  obliquely 
downwards  and  inwards. — {Hesselbach,  p.  46.)  The 
division  of  the  integuments  brings  into  view  the  fascia, 
which  is  sent  off  from  the  tendum  of  the  external 
oblique  muscle,  and  covers  the  hernial  sac. 

The  layers  of  tendinous  fibres,  cellular  substance, 
&c.  intervening  between  the  skin  and  sac,  should  be 
carefully  divided,  one  after  another,  with  the  knife  and 
dissecting  forceps , the  edge  of  the  former  instrument 
being  turned  horizontally,  lest  the  incisions  be  carried 
too  deeply  at  once,  and  the  viscera  contained  in  the  sac 
wounded. 

After  making  a small  opening  through  a part  of  the 
fascia  covering  the  sac,  soij^  practitioners  introduce  a 
director,  and  divide  this  fascia  upwards  and  down  ward.s, 
as  far  as  the  tumour  extends.  The  same  manner  they 
next  pursue  with  regard  to  the  cremaster  muscle.  Thus 
the  sac  becomes  completely  exposed.  When  this  me- 
thod is  followed.  Sir  A.  Cooper  advises  the  incisions 
not  to  be  carried  upwards  nearer  than  one  inch  to  the 
abdominal  ring,  for  reasons  which  will  be  presently  ex- 
plained. 

However,  it  may  be  rationally  doubted,  whether 
there  is  any  good  in  these  formal  and  successive  divi- 
sions of  the  whole  length  of  the  coverings  of  the  sac ; 
and  it  is  certain  that  they  protract  the  operation  very 
much  ; for  the  manner  in  which  the  sac  adheres  to  the 
outer  investment  of  it,  prevents  the  latter  from  being 
raised  and  cut  without  trouble  and  delay.  As  the  grand 
object,  after  the  skin  has  been  divided,  is  to  make  a 
small  opening  into  the  sac,  sulficient  for  the  introduc- 
tion of  a director,  dissecting  down  at  one  particular 
place  answers  every  purpose,  and  enables  us,  in  the 
end,  to  lay  open  the  whole  of  the  sac  and  its  coverings 
in  the  shortest  time.  Let  the  operator  only  take  care 
to  raise  the  successive  layers  of  fibres  with  the  forceps, 
and  divide  the  apex  of  each  elevated  portion  with  the 
knife  held  horizontally.  As  there  is  commonly  a 
quantity  of  fluid  in  the  sac,  and  it.gravitates  to  the 
lower  part,  to  which  the  intestine  seldom  quite  de« 


20 


HERNIA. 


Bcends,  this  is  cevtainly  the  safest  situation  for  making 
the  first  opening  into  the  sac.  The  operator,  however, 
should  not  rely  upon  the  presence  of  such  fluid,  and 
cut  too  boldly ; for  sometimes  it  is  absent,  and  the  vis- 
cera may  be  in  immediate  contact  with,  nay,  adherent 
to,  the  inner  surface  of  the  sac. 

The  circular  arrangement  of  the  vessels  of  a piece 
of  intestine,  and  its  smooth  polished  surface,  suf- 
ficiently distinguish  it  from  the  hernial  sac,  which  has 
a rough  cellular  surface,  and  is  always  connected 
with  the  surrounding  parts,  although  these  adhesions, 
in  a very  recent  case,  may  be  but  slight. — {Lawrence 
on  Rupturesi  p.  232,  edit.  4.) 

I have  mentioned  that  Sir  A.  Cooper  only  advises 
cutting  the  fascia  and  other  coverings  of  the  sac,  under 
the  skin,  to  within  an  inch  of  the  abdominal  ring ; and, 
of  course,  he  also  recommends  limiting  the  division  of 
the  sac  itself  to  the  same  extent.  His  reasons  for  this 
practice  are,  to  avoid  making  the  closure  of  the  wound 
more  difficult,  and  to  lessen  tlie  danger  of  peritoneal 
inflammation. 

Having  laid  open  the  hernial  sac,  with  a probe- 
pointed  bistoury,  guided  by  a director,  or  the  fore- 
finger, introduced  into  the  opening  made  at  the  lower 
part  of  the  sac,  the  next  desideratum  is  to  divide  the 
stricture,  unless  the  viscera  admit  of  being  easily  re- 
duced, without  such  an  incision  being  made  as  occa- 
sionally happens. 

From  the  anatomical  account  which  has  been  given 
of  the  bubonocele,  it  appears,  that  the  stricture  may 
either  be  situated  at  the  abdominal  ring,  and  be  formed 
by  the  margins  of  this  opening,  or  else  at  the  inner 
aperture  of  the  canal,  about  one  inch  and  a half,  in  a 
direction  upwards  and  outwards,  from  the  outer  open- 
ing in  the  tendon  of  the  external  oblique  muscle.  This 
latter  strangulation  is  caused  by  the  semicircular  edge 
of  the  transversalis  muscle  and  its  tendon,  which  pass 
over  the  neck  of  the  hernial  sac,  and  by  a fascia,  arising 
from  Poupart’s  ligament,  the  semicircular  border  of 
which  passes  under  this  part  of  the  sac. 

The  common,  and  probably  the  best,  practice  is  to 
divide  the  hernial  sac,  together  with  the  stricture. 
When  this  is  situated  at  the  abdominal  ring,  the  sur- 
geon is  to  introduce  the  end  of  a director  a little  way  into 
the  neck  of  the  sac,  within  the  aperture  in  the  tendon, 
and  with  a probe-pointed  bistoury,  guided  on  the  latter- 
instrument,  he  is  to  cut  the  stricture  upwards  and  out- 
wards., or  else  directly  upwards  ; a manner  which  Sir 
A.  Cooper  recommends,  because  it  is  applicable  to  all 
cases,  even  the  less  frequent  ones,  in  which  the  hernia 
protrudes  at  the  inner  side  of  the  epigastric  artery ; and 
in  all  common  instances,  we  know,  that  this  vessel 
runs  upwards  round  the  inner  side  of  the  neck  of  the 
sac ; a course  prohibiting  the  division  of  the  stricture 
upwards  and  inw^ards. 

In  the  external  inguinal  hernia,  the  method  of  cutting 
the  stricture  upwards  and  outwards  is  perfectly  safe; 
but  when  the  case  is  what  Hesselbach  calls  internal, 
and  the  viscera  descend  on  the  inner  side  of  the  epi- 
gastric artery,  it  is  a plan  which  would  endanger  the 
latter  vessel,  and  ought  never  to  be  adopted,  notwith- 
standing any  statement  made  in  its  favour  by  Rud- 
torffer. — {Mhandlung  iiber  die  einfachste  und  sicherste 
Operations-Methode  eingesperrter  Leisten-und-Schen- 
kelbriiche.  Wien,  1808.)  In  this  work,  the  erroneous 
plan  of  cutting  the  ring  inwards  is  inculcated,  both  in 
the  external  and  internal  inguinal  rupture.  The  author, 
however,  seems  to  have  performed  many  operations  in 
this  manner,  without  any  accident  from  hemorrhage ; 
a piece  of  good  fortune  which  Professor  Langenbeck 
ascribes  to  the  circumstance  of  the  knife  having  al- 
ways been  applied,  as  RudtorflTer  directs, to  the  middle 
of  the  inner  pillar  of  the  ring,  and  to  the  cut  having 
been  very  limited.  Langenbeck  is  of  opinion,  that 
if  the  knife  had  been  applied  a little  lower,  and  the 
incision  carried  to  any  extent,  the  epigastric  artery,  in 
ordinary  cases,  would  not  have  escaped  injury.  Sir  A . 
Cooper’s  rule  of  always  cutting  in  one  direction,  viz. 
upwards,  which  I believe  was  first  advised  by  Rouge- 
mont,  and  afterward  by  Autenrieth  {Dissert.  Mo- 
ment. circa  Herniotom,  prmcipue  circa  evitandam  Jirt. 
Epigastr.  Lcesionem,T\ib.  1799),  is  perhaps  a very  good 
one,  because  it  is  at  least  easy  for  the  memory,  and 
will  answer  very  well,  even  when  it  is  not  in  the  power 
of  the  surceon  to  pronounce  positively,  whether  the 
case  is  a short-necked  external  btibonocele,  or  an  in- 
ternal one  with  an  oblong  oval  fissure,  cases  having  a 


great  external  resemblance,  especially  in  women,  Jfi 
whom  there  is  not  the  spermatic  cord  as  a criterion ; 
for,  after  all,  this  part,  when  present,  is  the  surest 
guide,  and  that  on  which  Desault  founded  his  perfectly 
safe  advice,  viz.  when  the  cord  is  at  the  posterior  or 
inner  side  of  the  neck  of  the  hernial  sac,  to  divide  the 
ring  upwards  and  outwards,  but  inwards  and  upwards 
when  it  lay  at  the  outer  or  on  the  fore  part  of  the  sac- 
— {CEuvres  Chir.par  Bichat,  t.  2.)  At  all  events,  this 
advice  is  subject  but  to  one  exception,  which  is  the 
very  rare  one  of  the  epigastric  running  round  the  inner 
side  of  the  neck  of  the  sac  in  an  internal  bubonocele  ; 
a possibility  which  has  been  already  explained,  and 
which  leads  Hesselbach  particularly  to  recommend  the 
division  of  the  ring,  in  every  internal  inguinal  hernia,  to 
be  made  straight  upwards. — (P.  47.)  Indeed,  the  long- 
necked external  bubonocele  is  the  only  case  in  which 
he  thinks  the  latter  plan  should  give  way  to  that  of 
cutting  upwards  and  outwards.  The  safety  and  pro- 
priety of  the  method  of  always  cutting  upwards  are 
strikingly  illustrated  by  what  Scarpa  observes:  he 
states,  that  the  right  direction  of  the  incision  of  the  ring 
is  directly  upwards,  parallel  to  the  linea  alba.  “ I have 
(says  he)  operated  in  the  way  which  1 recommend, 
upon  several  dead  subjects,  who  had  either  external  or 
internal  inguinal  hernise,  directing  my  incision  in  the 
course  of  a line  drawn  from  the  upper  part  of  the  ring 
parallel  to  the  linea  alba:  in  all,  I constantly  left  the 
epigastric  artery  untouched,  even  when  I extended  the 
cut  about  an  inch  above  the  inguinal  ring.” — {Scarpa, 
Traiti  Pratique  des  Hernies,  p.  111.)  Only  one  ob- 
jection, as  far  as  I know,  has  been  made  to  this  plan, 
and  it  is  founded  on  the  alleged  impossibility  of  intro- 
ducing the  knife,  so  as  to  cut  straight  upwards,  when 
the  neck  of  the  hernial  sac  is  long,  because  then  the 
posterior  side  of  the  inguinal  canal  is  in  the  way. — 
{Hesselbach,  p.  40.)  No  more  of  the  parts  forming  the 
stricture  should  be  cut  than  is  just  sufficient  for  al- 
lowing the  protruded  viscera  to  be  reduced,  without 
bruising  or  otherwise  hurting  them ; and  I consider  the 
middle  of  the  upper  margin  of  the  ring  the  safest  place 
for  making  the  necessary  incision. 

Sir  A.  Cooper,  in  his  valuable  work  on  the  Inguinal 
Hernia,  advises  a mode  of  dividing  the  stricture,  con- 
siderably different  from  the  usual  method.  He  directs 
the  finger  of  the  operator  to  be  introduced  into  the  sae 
(which  in  his  plan,  we  know,  is  left  undivided  for  the 
space  of  one  inch  below  the  ring).  When  the  stricture 
is  felt,  a probe-pointed  bistoury  is  to  be  conveyed  over 
the  front  of  the  sac  into  the  ring  (between  the  two 
parts),  and  the  latter  only  is  then  to  be  divided,  in  the 
direction  upwards,  opposite  the  middle  of  the  neck  of 
the  sac,  and  to  an  extent  just  sufficient  to  allow  the 
protruoed  parts  to  be  returned  into  the  abdomen,  with- 
out their  being  hurt.  The  two  chief  advantages  which 
Sir  A.  Cooper  imputes  to  this  melhod  are,  thal  the  dan- 
ger of  peritoneal  inflammation  will  be  less,  and  that 
the  epigastric  artery,  if  wounded,  would  not  bleed  into 
the  abdomen.  I am  of  opinion,  that  Mr.  Lawrence’s 
remarks  concerning  this  proposal  are  judicious : an 
accurate  comparative  trial  of  both  methods  wmuld  be 
necessary,  in  order  to  determine  the  weight  of  the  first 
reason.  The  second  circumstance  cannot  be  a matter 
of  any  importance,  if  we  cut  in  such  a direction  as 
will  avoid  the  risk  of  wounding  the  artery.  Many 
circumstances  present  themselves  as  objections  to  this 
proposal.  The  manreuvre  itself,  althouch  perhaps  easy 
to  the  experienced  hand  of  so  able  an  anatomist  as  Sir 
\.  Cooper,  would,  I am  convinced,  be  found  highly 
difficult,  if  ^t  impracticable,  by  the  generality  of  sur- 
geons. This  difficulty  arises  from  the  firm  manner  in 
which  the  sac  and  svirrounding  parts  are  connected, 
we  might  almost  say,  consolidated  together.  The  ex- 
perience of  Richter  {Train  des  Hernies, p.  118)  shows, 
that  this  objection  is  founded  in  reality.  He  once  tried 
to  divide  the  ring  without  cutting  the  sac,  but  he  found 
it  impracticable.  If  the  stricture  is  so  tight  as  to  pre- 
vent the  introduction  of  the  finger,  there  must  be  great 
danger  of  wounding  the  protruded  parts.  The  prac- 
tice would  siill  be  not  advisable,  even  if  it  could  be 
rendered  as  easy  as  the  common  method  of  operating. 
Sir  Astley  leaves  an  inch  of  the  sac  below  the  ring  un- 
divided: thus  a bag  remains  ready  to  receive  any 
future  protrusion,  and  the  chance  of  a radical  cure  is 
diminished.  It  would  be  better  to  follow  the  advice  of 
Richter,  and  scarify  the  neck  of  the  sac,  in  order  to 
promote  an  adhesion  of  its  sides.  He  has  found  this 


HERNIA. 


21 


practice  so  successful  in  accomplishing  a radical  cure, 
that  he  advises  ip.  191)  its  employment  in  every  ope- 
ration for  strangulated  hernia. — (See  Lawrence  on  Rup- 
tures, p.  249,  edit.  4.) 

If  the  stricture  should  be  at  the  inner  opening  of  the 
canal  for  the  spermatic  cord.  Sir  A.  Cooper  advises  the 
operator  to  introduce  his  finger  into  the  sac  as  far  as 
the  stricture,  and  then  to  insinuate  a probe-pointed 
bistoury,  with  the  flat  part  of  its  blade  turned  towards 
the  finger,  between  the  front  of  the  sac  and  the  abdo- 
minal ring,  till  it  arrives  under  the  stricture  formed  by 
the  lower  edge  of  the  transversalis  and  obliquus  in- 
ternus.  Then  the  edge  of  the  instrument  is  to  be 
turned  forwards,  and  the  stricture  cut  in  the  direction 
upwards.  This  plan  of  not  cutting  the  neck  of  the  sac 
is  liable  to  all  the  objections  stated  by  Mr.  Lawrence, 
in  regard  to  the  case  in  which  the  strangulation  takes 
place  at  the  abdominal  ring.  Sir  A.  Cooper’s  bistoury 
is  a very  proper  one  for  dividing  the  stricture,  as  it  only 
has  a cutting  edge  to  a certain  distance  from  the  point. 
Perhaps,  on  the  whole,  we  may  infer,  that  it  is  both 
most  easy  and  advantageous  to  divide  the  neck  of  the 
sac,  together  with  the  stricture,  whether  this  be  situated 
at  the  ring  or  more  inwards.  The  method  of  cutting 
the  stricture  from  without  inwards  I consider  objec- 
tionable, on  the  ground  of  the  risk  of  wounding  the 
bowels  in  this  mode  being  greater  than  that  of  any 
accident  from  wounding  the  epigastric  artery,  when  it 
arises  in  an  unusual  manner,  and  deviates  from  its  re- 
gular course  ; a reflection  which  has  made  Dr.  Hessel- 
bach,  junior,  an  advocate  for  the  practice. — (See  Si- 
cherste  des  Bruchschnittes,  Ato.  Bamberg,  1819.) 

When  the  stricture  is  at  the  upper  opening  of  the 
inguinal  canal,  the  ring  should  not  be  cut,  unless  it  pre- 
vent the  operator  from  reaching  the  more  deeply  seated 
strangulation,  as  happened  in  a case  recorded  by  Mr. 
Lawrence.— (On  Ruptures,  p.  241,  ed.  4.) 

Room  being  made  for  the  reduction  of  the  protruded 
parts  into  the  abdomen  by  the  division  of  the  stricture, 
they  are  to  be  immediately  returned,  if  sound  and  free 
from  adhesions.  This  object  is  considerably  facilitated 
by  bending  the  thigh.  The  intestines  are  to  be  reduced 
before  the  omentum ; but  when  a portion  of  mesentery 
is  protruded,  it  is  to  be  returned  before  either  of  the 
preceding  parts.  The  intestine  should  always  be  re- 
duced, unless  it  be  found  in  a state  of  actual  mortifica- 
tion. It  often  appears  so  altered  in  colour,  that  an  un- 
informed person  would  deem  it  improper  to  return  it 
into  the  abdomen.  However,  if  such  alteration  should 
not  amount  to  a real  mortification,  e.tperience  justifies 
the  reduction  of  the  part.  Sir  A.  Cooper  has  judi- 
ciously cautioned  the  operator  not  to  mistake  the  dark 
chocolate-brown  discolorations  for  a state  of  gangrene. 
With  these  the  protruded  part  is  frequently  found 
affected ; and  as  they  generally  produce  no  permanent 
mischief^  they  ought  to  be  carefully  discriminated  from 
the  biack-purple,  or  lead-coloured  spots  which  usually 
precede  mortification.  To  determine  whether  a dis- 
coloured portion  of  intestine  be  positively  mortified, 
some  recommend  pressing  forwards  the  blood  contained 
in  the  veins  ; and  if  they  fill  again,  it  is  looked  upon  as 
a proof  that  the  bowel  is  still  possessed  of  life. 

In  returning  a piece  of  intestine  into  the  abdomen, 
the  surgeon  should  fir.^t  introduce  the  part  nearest  the 
ring  into  this  aperture,  and  hold  it  there  till  another 
imrtion  has  succeeded  it.  This  method  is  to  be  con- 
tinued till  the  whole  of  the  protruded  bowel  is  reduced. 

I’he  employment  of  force  or  violence  in  the  endea- 
vours to  return  the  contents  of  a hernia  in  the  opera- 
tion, cannot  he  too  severely  reprobated;  a method  the 
more  pernicious  because  such  parts  are  more  or  less  in 
a slate  of  inflammation.  It  is  always  better  to  enlarge 
the  stricture,  than  pinch  and  bruise  tiie  bowel  in  trying 
to  get  it  through  an  opening  which  is  too  small.  Dis- 
tention of  the  intestine  sometimes  prevents  the  reduc- 
tion ; but  when  this  is  the  only  impediment,  the  part 
may  generally  be  returned  as  soon  as  its  contents  have 
been  compressed  into  the  intestinal  canal  within  the 
stricture.  It  is  better,  however,  to  dilate  the  strangu- 
lation a little  more,  than  use  any  force  in  trying  to  get 
the  intestine  back  into  the  abdomen  in  the  manner  just 
BUL'gested. 

Reduction  is  sometimes  impeded  by  the  protruded 
parts  adhering  to  each  other  or  to  the  hernial  sac.  The 
intestines  are  not  often  found  very  firmly  adherent  to- 
gether. The  omentum  and  inside  of  the  sac  are  the 
parts  which  are  most  subject  to  become  intimately 


connected  by  adhesions.  The  fingers  will  commonly 
serve  for  breaking  any  recent  sliglit  adhesions  which 
may  have  taken  place  between  the  intestines  and  in- 
side of  the  hernial  sac.  When  those  adhesions  are 
firm,  and  of  long  standing,  they  must  be  cautiously 
divided  with  the  knife ; an  object  which  can  be  most 
easily  and  safely  accomplished,  in  case  they  are  long 
enough  to  permit  the  intestine  to  be  elevated  a little 
way  from  the  surface  of  the  sac.  But,  provided  their 
firmness  and  shortness  keep  the  external  coat  of  the 
bowel  and  inner  surface  of  the  sac  in  close  contact,  the 
greatest  care  is  requisite  in  separating  the  parts  with  a 
knife,  so  as  to  avoid  wounding  the  intestine.  In  doing 
this,  the  most  prudent  and  safe  method  is  not  to  cut  too 
near  the  bowel,  but  rather  to  remove  the  adherent 
parts  of  the  sac,  and  return  them  with  the  intestine 
into  the  abdomen.  Every  preternatural  connexion 
should  always  be  separated  before  the  viscera  are  re- 
duced : Sir  A.  Cooper  mentions,  that  a fatal  obstruction 
to  the  passage  of  the  intestinal  matter  has  arisen  from 
the  mere  adhesion  of  the  two  sides  of  a fold  of  intes- 
tine together. — (P.  .31.)  When  the  adhesions  which 
prevent  reduction  are  situated  about  the  neck  of  the 
sac,  and  out  of  the  operator’s  view,  it  is  best  to  make 
the  wound  through  the  skin  and  abdominal  ring  some- 
what larger,  so  as  to  be  able  to  separate  the  adhesions 
with  more  safety. 

Having  reduced  the  parts,  the  operator  should  intro- 
duce his  finger,  for  the  purpose  of  being  sure  that  they 
are  fairly  and  freely  returned  into  the  abdomen,  and 
no  longer  suffer  constriction,  either  from  the  inner 
opening,  from  the  ring,  or  the  parts  just  within  the 
cavity  of  the  peritoneum. 

Sometimes  a strangulated  hernia  is  complicated  with 
a Iiydrocele;  a circumstance  which  may  render  it  ne- 
cessary either  to  cut  through  the  latter  swelling,  or  to 
limit  the  incision  into  the  hernial  sac,  according  as  the 
hydrocele  happens  to  cover  the  whole  of  the  front  of 
the  sac,  as  seen  by  M.  Cloquet  and  Mr.  Stanley,  or 
merely  to  advance  in  front  of  the  lower  part  of  the 
rupture. — (See  Lawrence  on  Ruptures,  p.  276,  edit.  4.) 

TREATMENT  OF  THE  OMENTU.M. 

In  an  entero-epiplocele,  this  part,  if  healthy  and  free 
from  gangrene,  is  to  be  reduced  after  the  intestine. 
When,  however,  it  is  much  diseased,  thickened,  and 
indurated,  as  it  frequently  is  found  to  be,  after  remain- 
ing any  considerable  4inie  in  a hernial  sac,  the  morbid 
part  should  be  cut  oft'.  Its  reduction  in  this  circum- 
stance would  be  highly  improper,  both  because  an  im- 
moderate enlargement  of  the  wound  would  be  neces- 
sary, in  order  to  be  able  to  put  the  diseased  mass  back 
into  the  abd«men,  and  because,  when  reduced,  it  would, 
in  all  probability,  excite  inflammation  of  the  surround- 
ing parts,  and  bring  on  dangerous  symptoms.— (See 
Hey,  p.  172.) 

The  diseased  omentum  should  always  be  cut  off 
with  a knife ; and  if  any  of  its  arteries  should  bleed, 
they  ought  to  be  taken  up  with  a tenaculum,  and  tied 
separately  with  a small  ligature.  An  unreasonable  ap- 
prehension of  hemorrhage  from  the  cut  end  of  the 
omentum  has  led  many  operators  to  put  a ligature  all 
round  this  part,  just  above  the  diseased  portion,  which 
they  were  about  to  remove.  This  practice  cannot  be 
reprobated  in  terms  too  severe ; for  a frequent  effect  of 
it  is  to  bring  on  a fatal  inflammation,  and  even  morti- 
fication of  the  omentum,  extending  within  the  abdo- 
men, as  high  as  the  stomach  and  transverse  arch  of 
the  colon.  Sir  Astley  Cooper  has  remarked,  with  great 
truth,  that  it  is  surprising  this  custom  should  ever  have 
prevailed.  The  very  object  of  the  operation  is  to  ex- 
tricate the  omentum  from  its  strangulated  state,  arising 
from  the  pressure  of  the  surrounding  tendon,  and  no 
sooner  has  this  been  done,  than  the  surgeon  includes  it 
in  a ligature,  which  produces  a more  perfect  constric- 
tion than  that  which  existed  before  the  operation  was 
undertaken. 

“ When  the  omentum  has  suffered  strangulation  for 
a few  days  (says  Mr.  Ijavvrence),  it  often  becomes  of  a 
dark  red  or  livid  colour;  and  there  is  an  appearance, 
on  cutting  it,  as  if  some  blood  were  extravasaled  in  its 
substance.  This,  I believe,  is  the  state  which  surgeons 
have  generally  described  under  the  term  of  gangrene.” 
— (P.2G2.) 

When  cut  in  this  state,  it  does  not  bleed.  I need 
hardly  observe,  that  the  dead  part  must  be  amputated, 
and  never  reduced.  Some  have  advised  leaving  the 


22 


HERNIA. 


omentum  in  the  wound,  especially  in  cases  of  old  her- 
niae,  in  which  it  has  been  a long  while  protruded.  Hey 
mentions  cases,  showing  that  granulations  form  very 
well,  and  that  the  wound  becomes  firmly  healed,  when 
this  plan  is  followed.— (P.  180,  4'c.)  Every  one,  how- 
ever, will  acknowledge  the  truth  of  what  Mr.  Lawrence 
says  on  this  subject.  The  method  “ is  attended  with 
no  particular  advantage,  but  certainly  exposes  the 
patient  to  the  possibility  of  ill  consequences.  The 
omentum,  left  in  the  wound,  must  be  liable  to  injury, 
inflammation,  or  disease.  Unnatural  adhesions,  formed 
by  this  part,  have  greatly  impaired  the  functions  of  the 
stomach.  Cases  are  recorded,  where  the  unfortunate 
patient  has  never  been  able  to  take  more  than  a certain 
quantity  of  food,  without  bringing  on  instant  vomiting ; 
and  even  where  it  has  been  necessary  for  all  the  meals 
to  be  taken  in  the  recumbent  position,  with  the  trunk 
curved,  and  the  thighs  bent. — (Gunz.)  To  avoid  the 
possibility  of  such  afflicting  consequences,  we  should, 
after  removing  any  diseased  portion,  carefully  replace 
the  sound  part  of  the  omentum  in  the  abdominal 
cavity.” — ( On  Ruptures,  p.  291,  ed.  4.) 

TREATMENT  WHEN  THE  INTESTINE  IN  THE  SAC 
IS  MORTIFIED. 

Sometimes,  on  opening  the  hernial  sac,  the  intestine 
is  found  to  be  in  a gangrenous  state,  although  the  oc- 
currence could  not  be  previously  known,  owing  lo  the 
integuments  and  the  hernial  sac  itself  not  being  affected 
with  the  same  mischief.  In  ordinary  cases,  however, 
both  the  skin  and  sac  become  gangrenous  at  the  same 
time  with  the  contents  of  the  iiernia.  The  tumour, 
which  was  previously  tense  and  elastic,  becomes  soft, 
doughy,  emphysematous,  and  of  a purple  colour. 
Sometimes  the  parts  also  now  spontaneously  return ; 
but  the  patient  generally  survives  only  a few  hours. 

Sir  A.  Cooper  has  accurately  remarked,  that,  in  other 
instances,  the  skin,  covering  the  sw'elling,  slouglis  to  a 
considerable  extent,  the  intestine  gives  way,  and,  as 
the  feces  find  vent  at  the  wound,  the  symptoms  of 
strangulation  soon  subside.  When  the  patient  con- 
tinues to  live  in  these  circumstances,  the  living  part  of 
the  intestine  becomes  adherent  to  the  hernial  sac,  the 
sloughs  separate  and  come  away,  and  thus  an  arti- 
ficial anus  is  established,  through  which  the  feces  are 
sometimes  discharged,  during  the  remainder  of  life. 
— (See  Anus,  artificial.) 

Frequently,  however,  things  take  a more  prosperous 
course  ; the  feces  gradually  resume  their  former  route 
to  the  rectum,  and,  in  proportion  as  the  artificial  anus 
becomes  unnecessary,  it  is  shut  up.  Many  instances 
of  this  sort  have  fallen  under  my  own  observation  in 
St.  Bartholomew’s  Hospital.  The  chance  of  a favour- 
able event  is  much  greater  in  some  kinds  of  hernia 
than  in  others.  When  the  strangulation  only  includes 
a part  of  the  diameter  of  the  gut,  the  feces  are  some- 
times only  partially  discharged  through  the  mortified 
opening.  This  quantity  lessens  as  the  wound  heals, 
and  the  patient  gets  perfectly  well.— (Loim's,  Mim.  de 
VAcad.  dc  Chir.  t.  3,  P.  S.  Palm.  De  Epiplo- enter ocele 
crurali  incarcerata  sphacelata,  cum  deperditione  no- 
iabili  substantia  intestini,  sponte  separati,  fcliciter 
curata  alvo  naturali  restituta,  Ato.  Tub.  1748.  Haller, 
Disp.  Chir.  t.  3.)  A .small  gangrenous  spot,  or  two, 
may  end  in  the  same  manner.  Mortification,  as  well 
as  wounds,  of  the  large  intestines,  is  much  more  fre- 
quently followed  by  a recovery,  than  the  same  affection 
and  similar  injuries  of  the  small  intestines.  Mortifi- 
cation of  the  ctEcum  and  its  appendix,  in  a hernial  sac, 
has  happened  several  times  without  materially  dis- 
turbing the  usual  course  of  the  feces  to  the  anus,  and 
Uie  patients  have  soon  recovered.— (Jl/crf.  Ohs.  and 
Ing.  vol.  3,  p.  162.  Hey's  Pract.  Obs.  p.  162,  Src.) 

The  grand  thing  on  which  the  establishment  of  the 
continuous  state  of  the  intestinal  canal  depends,  in  all 
these  cases,  is  the  adhesion  which  the  living  portion 
of  the  bowel,  adjoining  the  mortified  part,  contracts 
with  the  peritoneum  all  round.  In  this  manner,  the 
escape  of  the  contenis  of  the  bowels  into  the  cavity  of 
the  peritoneum  becomes  in  general  completely  pre- 
vented. The  two  ends  of  the  sound  portion  of  intes- 
tine, after  the  mortified  part  has  separated,  open  into  a 
membranous  cavity,  which  previously  constituted  a 
jxrrtion  of  the  peritoneal  sac,  and  now  unites  the  ex- 
tremities of  the  gut.  The  gradual  contraction  of  the 
wound  closes  the  membranous  cavity  externally,  and 
thus  the  continuity  of  llie  canal  is  restored.  TJie  two 


ends,  however,  are  not  joined  so  as  to  form  a continued 
cylindrical  tube,  like  that  of  the  natural  gut : but  they 
are  united  at  an  angle  more  or  less  acute,  and  the  mat- 
ter, which  goes  from  one  to  the  other,  describes  a half 
circle  in  a newly  formed  membranotis  cavity  that 
completes  the  canal;  a subject  which  has  been  more 
fully  explained  in  another  part  of  this  work. — (See 
Anus,  artificial.) 

It  is  an  observation  of  Sir  A.  Cooper’s,  that  tht*  de- 
gree of  danger,  attending  an  artificial  anus,  depends  on 
the  vicinity  of  the  sphacelated  part  of  the  intestinal 
canal  to  the  stomach.  Thus,  if  the  opening  be  in  the 
jejunum,  there  is  such  a small  extent  of  surface  for 
absorption,  between  it  and  the  stomach,  that  the  pa- 
tient dies  of  inanition. 

Let  us  now  suppose,  that  the  mortified  state  of  the 
intestine  has  only  been  discovered,  after  laying  open 
the  hernial  sac  in  the  operation.  The  mischief  may 
only  consist  of  one  or  more  spots;  or  of  the  whole 
diameter  of  the  protruded  bowel.  In  the  first  case,  the 
proper  practice  is  to  divide  the  stricture,  and  return  the 
intestine  into  the  abdomen,  with  the  mortified  spots 
towards  the  wound.  Mild  purgatives  and  clysters  are 
theii  to  be  exhibited.  The  most  favourable  mode  in 
which  a case  of  this  kind  ends,  is  when  the  intestinal 
matter  gradually  resumes  its  natural  course,  after  being 
either  partly  or  entirely  discharged  from  the  w’ound. 
But  sometimes  the  patient  sinks  under  the  disease,  or 
an  artificial  anus  continues  for  life. 

The  repeated  observations  of  modern  surgeons  have 
now  decided,  that  no  ligature,  passed  through  the  me- 
sentery, to  keep  the  gangrenous  part  of  the  bowel  near 
the  wound,  is  at  all  necessary.  The  parts  in  the  neigh- 
bourhood of  the  ring  have  all  become  adherent  to- 
gether, in  consequence  of  inflammation,  at  the  same 
time  that  the  parts  in  the  hernial  sac  mortified;  and, 
of  course,  the  partially  gangrenous  bowel,  when  re- 
duced, is  mechanically  hindered,  by  these  adhesion.s, 
from  slipping  far  from  the  wound.  Desault  and  De  la 
F:iye  both  confirm  the  fact,  that  the  intestine  never  re- 
cedes far  from  the  ring ; and,  even  were  it  to  do  so, 
the  adhesions,  which  it  soon  contracts  to  the  adjacent 
surfaces,  would,  as  Petit  has  explained,  completely  cir- 
cumscribe any  matter  which  might  be  effused,  and 
hinder  it  from  being  extensively  extravasated  among 
the  convolutions  of  the  viscera.— (Jlf^/n.  de  VAcad.  de 
Chir.  1. 1,  2.) 

Where  the  chief  part,  or  the  whole,  of  the  diameter 
of  the  protruded  bowel  is  mortified,  the  first  and  most 
urgent  indication  is  to  relieve  the  bad  symptoms  arising 
from  the  distenlion  of  the  intestinal  canal  above  the 
stricture.  “ Let  a free  incision  (says  Mr.  Lawrence) 
be  made  through  the  mortified  part  of  the  gut,  in  order 
to  procure  that  evacuation  of  the  loaded  canal,  which 
nature  attempts  by  the  process  of  gangrene.”  If  the 
mtestine  has  already  given  way,  a free  division  of  the 
inte.gumcnts  and  sac  allows  the  exit  of  the  accumu- 
lated matter;  and  the  opening  in  the  gut  may  be  en- 
larged, if  necessary.— (On  Ruptures,  p.  299,  ed.  4.) 
By  such  treatment,  Sir  Astley  Cooper  rescued  from  the 
grave  a female  who  was  pregnant  at  the  time  of  the 
operation,  and  was  some  months  afterward  safely 
brought  to  bed.— (See  Lancet,  vol.%p.  143.) 

Here  the  divi.sion  of  the  stricture  is  unnecessary, 
since  all  the  mischief,  which  the  bowel  can  receive 
from  it,  is  done.  This  subject  is  well  explained  by  Mr. 
Travers.— (See  Ing.  into  the  Process  of  J^alure  in  re- 
pairing Injuries  of  the  Intestines,  <S-c.  p.  300,  (S-c.) 
Mild  purgatives  and  clysters  will  be  proper  to  unload 
the  bowels,  and  determine  the  course  of  the  feces  to- 
wards the  anus.  Should,  however,  the  stricture  appear 
afier  the  mortification  to  impede  the  free  escape  of  the 
intestinal  contents,  a moderate  dilatation  of  it  must 
undoubtedly  be  proper. 

Mr.  Lawrence  has  clearly  exposed  the  impropriety  of 
sewing  the  ends  of  the  intestinal  canal  tosether,  intro- 
ducing one  within  the  other,  supported  by  a cylinder 
of  isinglass,  &c.  put  into  their  cavifv.in  those  cases  in 
which  the  whole  circle  of  the  intestine  has  mortified, 
and  been. cut  away,  as  was  advi.sed  by  former  writers! 
By  drawing  the  intestine  out  of  the  cavity,  in  order  to 
remove  the  dead  part,  the  adhesions  behind  the  ring, 
on  which  the  prospect  of  a cure  chiefly  depends,  must 
be  entirely  destroyed  ; and  m*w  irritation  and  inflam- 
mation must  be  unavoidably  produced,  by  handling 
and  sewing  an  inflamed  part.  The  adl.esi'nns  would 
even  be  likely  to  render  the  scheme  impracticable,  as 


HERNIA, 


23 


happened  in  a case  related  in  the  Journ.  de  M.  Le 
Jioux,  t.  21,  />.  260. — (Ore  Ruptures^  ;7.314,  ed.  4.) 

Instead  of  such  practice,  Mr.  Lawrence  judiciously 
recommends  dilating  the  stricture,  and  leaving  the  sub- 
sequent progress  of  the  cure  entirely  to  nature.  The 
sloughs  will  be  cast  off,  and  the  ends  of  the  gut  are 
retained  by  the  adhesive  process  in  a state  of  appo- 
sition to  each  other,  the  most  favourable  for  their  union. 
Thus,  there  is  a chance  of  the  continuity  of  the  intes- 
tinal canal  becoming  established  again. 

Whatever  experiments  it  may  be  allowable  to  make 
in  wounds  with  protrusion  and  division  of  the  bowels, 
nothing,  I think,  is  now  more  completely  established, 
than  the  absurdity  and  danger  of  attempting  to  stitch 
the  bowels  in  cases  of  hernia. 

OPERJI.TION  FOR  VERY  LARGE  INGUINAL  HKRNI.iE. 

When  the  tumour  is  of  long  standing,  exceedingly 
large,  perhaps  extending  half  way  down  to  the  knees, 
and  its  contents  have  never  admitted  of  being  com- 
pletely reduced,  the  indication  is  to  divide  the  stricture, 
provided  a strangulation  take  place ; but  without  lay- 
ing open  the  hernial  sac,  or  attempting  to  reduce  the 
parts. 

The  reasons  against  the  common  plan  of  operating, 
under  such  circumstances,  are,  the  difficulty  of  sepa- 
rating all  the  old  adhesions  ; the  hazardous  inflamma- 
tion which  would  be  excited  by  laying  open  so  vast  a 
tumour ; and  the  probability  that  parts,  so  long  pro- 
truded, might  even  bring  on  serious  complaints,  if 
reduced.  J.  L.  Petit,  and  afterward  Dr.  Monro,  ad- 
vised the  sac  not  to  be  opened. — (See  Mai.  Chir.  t.  2, 
p.  372.  Description  of  Bursce  Jlfrecoste,  1788.)  Mr. 
Lawrence  recommends  an  incision,  of  two  or  three 
inches  in  length,  to  be  made  through  the  integuments 
over  the  abdominal  ring.  The  fascia,  covering  the 
hernial  sac,  is  then  to  be  exposed  by  dissection,  and  an 
opening  made  in  it.  This  will  pennit  a grooved  direc- 
tion to  be  put  under  the  tendon ; and  the  probe-pointed 
bistoury  may  be  conducted,  by  means  of  the  groove,  to 
the  part  that  requires  division.  If  great  difficulty 
should  be  experienced  in  accomplishing  our  object  in 
this  manner,  a small  aperture  may  be  made  in  the  sac 
near  the  ring,  when  the  tendon  may  be  divided  with 
ease.  3'he  parts,  after  being  thus  liberated,  should  be 
returned  into  the  belly,  by  pressure  on  the  swelling,  if 
adhesions  do  not  prevent  it ; at  all  events,  they  gene- 
rally admit  of  being  replaced  in  part. — [^Lawrence  on 
Ruptures,  p.  269,  cd.4.)  A very  interesting  case  has 
been  recorded,  in  which  the  foregoing  advice  was  de- 
viated from,  and  a large  scrotal  hernia  laid  open ; when 
it  was  found  that  nearly  a foot  of  the  colon  was  con- 
tained in  the  swelling,  and  could  not  be  reduced.  The 
integuments  could  not  cover  it;  yet  its  surface  granu- 
lated, the  skin  extended  itself  as  the  cicatrix  contracted 
over  the  swelling,  which  also  diminished,  and,  in 
about  six  weeks  the  cure  was  completed. — (See  Journ. 
of  Foreign  Med.  JVo.  15,  p.  460.) 

OPERATION  WHEN  THE  HERNIA  IS  SO  SMALL  THAT 

IT  DOES  NOT  PROTRUDE  EXTERNALLY  THROUGH 

THE  RING. 

In  this  kind  of  case,  there  is  little  appearance  of  ex- 
ternal tumour;  consequently,  the  disease  is  very  apt  to 
be  overlooked  by  the  patient  and  surgeon,  and  some 
other  cause  assigned  for  the  series  of  symptoms.  The 
manner  of  operating,  in  this  form  of  the  disease,  dif- 
fers from  that  in  the  common  scrotal  hernia  : the  in- 
cision is  to  be  made  in  the  direction  of  the  spermatic 
cord,  and  the  stricture  will  be  found  at  the  internal 
ring. — Cooper  on  Inguinal  Hernia.) 

TREATMENT  AFTER  THE  OPERATION. 

Evacuations  from  the  bowels  should  be  immediately 
promoted  by  means  of  clysters,  oleum  ricini,  or  small 
doses  of  sulphate  of  magnesia,  dissolved  in  peppermint 
water;  but  the  patient  should  not  be  allowed  to  quit 
tile  recumbent  position,  or  get  on  the  night-stool,  as 
doing  so  is  apt  to  bring  on  a protrusion  of  the  bowels 
again. — (See  case  in  Lancet,  vol.  2,  p.  148.)  The  safest 
plan  is  to  let  something  be  put  under  him  for  the  re- 
ception of  the  feces.  In  the  course  of  another  day,  if 
cosiiveness  follow  the  effectsof  the  first  medicines,  and 
tenderness  and  tension  of  the  belly  come  on,  local  and 
general  bleeding,  with  the  exhibition  of  liberal  doses 
of  calomel  joineil  with  opium  are  strongly  indicated. 
Tor  some  time  the  diet  is  to  be  low.  Wiien  symptoms 


of  inflammation  of  the  bowels  and  peritoneum  threaten 
the  patient,  general  bleeding,  leeches  on  the  abdomen, 
fomentations,  blisters,  doses  of  the  oleum  ricini,  and 
clysters,  are  the  means  deserving  of  most  dependence, 
and  should  be  resorted  to  without  the  least  delay.  In 
these  circumstances,  tlie  warm  bath,  sometimes  recom- 
mended, I think  is  more  likely  to  do  harm  than  good, 
by  the  disturbance  to  which  it  subjects  the  patient. 
When  all  danger  of  peritoneal  inflammation  is  past, 
and  the  patient  is  very  low  and  weak,  bark,  wine,  cor- 
dials, and  a generous  diet  must  be  directed.  The  effer- 
vescing saline  draught,  with  opium,  is  the  best  medi- 
cine for  quieting  the  disturbance  of  the  stomach  after 
the  operation.  Opium  and  cordials  are  the  most  eli- 
gible for  checking  diarrhoea.  As  the  operation  does  not 
usually  prevent  the  parts  from  becoming  protruded 
again,  a truss  must  be  applied  before  the  patient  leaves 
his  bed,  and  afterward  constantly  worn. 

PROPOSALS  FOR  THE  RADICAL  CURE  OF  THE  BUBO- 
NOCELE. 

Of  castrating  the  patient,  applying  caustic,  or  of  the 
operation  of  the  punctum  aureum,  with  this  view,  I 
I need  only  say  that  they  are  barbarous,  and  not  at  all 
calculated  for  the  attainment  of  the  desired  end.  A 
description  of  these  methods  may  be  found  in  Par6, 
Wiseman,  &c. 

The  old  operation  termed  the  royal  stitch  was  one  of 
the  most  promising  plans.  It  consisted  in  putting  a 
ligature  under  the  neck  of  the  hernial  sac  close  to  the 
abdominal  ring,  and  then  tying  that  part  of  the  sac,  so 
as  to  render  it  impervious  by  the  adhesive  inflamma- 
tion thus  excited. 

The  royal  stitch  performed  in  this  manner,  has  been 
actually  attended  with  success.— 2.)  The 
umbilical  rupture  was  cured  by  Saviard,  on  similar 
principles  ; and  Desault  radically  cured  nine  cases  of 
the  exomphalos  in  children  by  tying  the  hernial  sac. 

Sclnnucker  cured  two  irreducible  ruptures,  free  fVom 
strangulation,  by  cutting  away  the  body  of  the  sac  after 
tying  its  neck. — {Chir.  Wahrnehmungen,  b.  2.)  In  one 
case.  Sir  A.  Cooper  found  cutting  away  the  sac  alone 
insufficient. 

Dissecting  away  the  whole  hernial  sac,  or  even  laying 
it  o[)en,  must  be  a formidable  operation,  compared  with 
merely  making  a small  incision  down  to  the  neck  of 
the  sac  and  applying  one  ligature.  If  the  hernia  were 
reducible,  and  the  upper  part  of  the  sac  could  be  ren- 
dered impervious  by  the  ligature,  all  other  more  severe 
plans  w'ould  be  superfluous.  However,  Petit,  Sharp, 
Acrel,  &c.  record  cases  which  tend  to  prove  the  danger 
and  inefficacy  of  the  royal  stitch ; though  it  is  true  that 
none  of  these  surgeons  operated  exactly  in  the  simple 
manner  above  suggested. 

Richter  recommends  scarifying  the  neck  of  the  sac, 
with  the  view  of  producing  an  adhesion  of  its  sides  to 
each  other ; a plan  which  he  says  he  found  very  suc- 
cessful. 

From  the  account,  however,  which  has  been  given  of 
the  anatomy  of  the  bubonocele,  it  is  obvious  that  none 
of  these  methods  could  do  more  than  obliterate  the  sac 
as  high  as  the  ring,  and  never  that  portion  of  it  which 
is  within  the  inguinal  canal.  Hence,  the  neck  of  the  sac 
must  still  remain  open  for  the  descent  of  the  viscera. 
This  consideration,  and  that  of  the  chances  of  bad  and 
fatal  symptoms  from  any  operation  undertaken  solely 
for  this  purpose,  and  not  urgently  required  for  the  relief 
of  strangulation,  are  the  grounds  on  which  these  expe- 
riments are  now  disapproved. 

■ CRURAL  OR  FEMORAL  HERNIA. 

Verheycii,  who  wrote  in  1710,  first  distinctly  pointed 
out  the  nature  of  crural  hernia,  which,  until  then,  had 
been  generally  confounded  with  bubonocele. 

The  parts  composing  this  kind  of  hernia  always  pro- 
trude under  Pou  part’s  ligament,  and  the  swelling  is  situ- 
ated towards  the  inner  part  of  the  bend  of  the  thigh. 
The  rupture  descends  on  the  inside  of  the  femoral 
artery  and  vein,  between  these  vessels  and  the  os  pubis, 
through  the  crural  ring,  or  canal  for  the  transmission 
of  the  same  vessels.  And,  as  Hesselbach  has  remarked, 
the  inner  opening  of  tnis  ring  or  canal  is  the  predispos- 
ing cause  of  the  disease,  the  peritoneum  spr  ead  over  it 
being  gradually  propelled  iirto  it  by  various  occasional 
carrses,  so  as  to  coitiplele  the  lertdency  to  hernia.  The 
actual  protrusion  of  the  bowels  ntay  be  formed  either 
suddenly  or  by  degrees.  As  soon  as  the  bowels  have 


24 


HERNIA. 


once  passed  the  outer  aperture,  or  what  Cloquet  terms 
^nore  properly  the  lower  opening  of  the  crural  canal, 
*he  hernia  has  more  room  for  extending  itself  forwards, 
and  to  each  side,  and  the  integuments  now  become 
elevated  into  an  oval  swelLing,  the  long  diameter  of 
whichis nearly  transverse. — '^H.esselbach,p.  47.)  Gim- 
bernat  names  the  passage  through  which  the  femoral 
hernia  protrudes  from  the  abdomen,  the  cj-ural ; Hey, 
the  femoral  ring ; and  Cloquet,  the  crural  canal. 

Females  are  particularly  subject  to  this  kind  of  rup- 
ture. It  has  been  computed,  that  nineteen  out  -of 
twenty  married  women  afflicted  with  hernia  have  this 
kind  ; but,  that  not  one  out  of  a hundred  unmarried 
femaies,  or  out  of  the  same  number  of  men  have  this 
form  of  the  disease. — {Arnaud.) 

“The  crural  hernia,”  says  Scarpa,  “is  frequently 
observed  in  women  who  have  had  several  children  ; it 
very  seldom  afflicts  young  girls ; and  still  more  rarely 
men.  In  the  latter,  the  viscera  can  more  easily  escape 
through  the  inguinal  ring  by  following  the  spermatic 
cord,  than  they  can  descend  along  the  crural  vessels,  and 
raise  the  margin  of  the  aponeurosis  of  the  external 
oblique  muscle  that  forms  the  crural  arch.  In  women, 
an  opposite  disposition  prevails,  in  consequence  of  the 
smallness  of  the  inguinal  ring,  which  in  them,  only 
gives  pas.sage  to  the  round  ligament  of  the  uterus,  and 
besides  is  situated  lower  down  and  nearer  the  pubes 
than  it  is  in  men,  while,  on  the  contrary,  the  crural 
arch  is  more  extensive  by  reason  of  the  wider  form  of 
the  pelvis.  Morgagni  expressly  says,  that  he  never 
met  with  the  crural  hernia  in  the  dead  body  of  any 
male  subject.  Mihi.,  ut  verum  falear.,  nisi  nondum  in 
faminis  accidit  ut  earn  viderem. — (Z)e  Sed.  et  Cans. 
Morb.  epist.  34,  15.)  Camper  gives  us  to  understand 
almost  the  same  thing. — [leones Herniarum,  in  Prafat.) 
H6vin  often  operated  for  this  kind  of  hernia  in  females, 
but  only  once  in  the  male  subject. — [Fathol.  et  Therap. 
p.  406.)  Sandifort  and  Waller  have  both  seen  but  a 
single  instance  of  it  in  the  dead  body  of  the  malesubject. 
— ( Obs.  Anat' Pathol,  cap.  4,  p.  72.  Sylloge  Comment. 
Anat.p.'i^.,  obs.’Ht.)  Arnaud  himself,  to  whom  mo- 
dern surgery  is  highly  indebted  for  many  important 
precepts  on  the  operation  for  the  strangulated  crural 
hernia  in  both  sexes,  candidly  confesses  that  he  had 
never  had  an  opportunity  of  dissecting  a hernia  of  this 
kind  in  the  male  subject.” — [Scarpa,  Traiti  des  Her- 
nies,  p.  201.) 

Scarpa  had  at  his  disposal  a male  subject  in  which 
there  was  a crural  hernia,  and  he  availed  himself  of 
the  opportunity  of  examining  the  parts  with  the  utmost 
care.  He  first  injected  the  blood-vessels ; he  afterward 
attentively  dissected  all  the  parts  concerned  in  the  dis- 
ease ; and  he  has  published  an  exact  description  of  the 
particulars,  illustrated  by  an  engraving. 

According  to  Hesselbach,  the  femoral  hernia,  though 
not  common  in  men,  is  more  frequent  than  is  generally 
believed,  and  often  overlooked  on  account  of  its  being 
very  small. — ( Ueber  den  Ursprung,  Src.  der  Leisten- 
und-Schenkelbriiche,  p.  47.)  Thus,  in  an  example  pub- 
lished in  a modern  work,  an  inguinal  and  femoral 
hernia  were  met  with  together  in  a gentleman  sixty- 
three  years  of  age.  On  examination  of  the  body  after 
death,  a small  piece  of  intestine  forming  a crural  hernia 
was  found  strangulated  and  concealed  under  an  ingui- 
nal rupture  and  a mass  of  fat.— (C.  Bell's  Surgical 
Ohs.  vol.  1,  p.  187.) 

Mr.  Lawrence  states  that  the  femoral  rupture  is  not 
so  uncommon  in  men  as  several  authors  would  lead 
us  to  suppose.  He  has  seen  many  instances  of  it. — 
[On  Ruptures,  p.  409,  note,  ed.  4.)  Dr.  breschet,  it 
seems,  has  also  seen  as  many  as  thirty  examples  of  it 
in  the  practice  of  Dupuytren.— f Consid.  et  Oi,s.  Anat. 
ire.  sur  la  Hernie  Fern,  in  his  Concours,  p.  42.) 

According  to  the  observations  of  Scarpa,  and  all  the 
best  modern  writers  upon  surgery,  tiie  crural  henvia 
forms  both  in  the  male  and  female  subject,  in  the  cel- 
lular substance,  which  accompanies  the  crural  vessels 
below  Poupart’s  ligament.  The  swelling  follows  the 
internal  side  of  those  vessels  and  gradually  descends 
into  the  fold  of  the  thigh,  between  the  sartorius,  gra- 
cilis, and  pectineus  muscles.  “ Many  surgeons  believe 
(says  Scarpa)  that  the  hernial  sac,  and  the  intestines 
which  it  contains,  are  ordinarily  situated  above  the 
crural  vessels  and  the  trunk  of  the  vena  saphena,  and 
sometimes  between  tlu'sc  uessels  .ind  the  anterior  su- 
perior spine  of  the  ilium.  But  as  far  as  my  knowledge 
extends,  this  assertion  is  not  supported  by  a single  ac- 


curate description  of  the  crural  liernia  in  the  early  stage. 
It  is  true,  that  when  the  tumour  has  in  time  acquired  a 
large  size,  and  its  fundus  is  inclined  in  a parallel  man- 
ner to  the  fold  of  the  thigh,  it  partly  or  entirely  covers 
the  crural  vessels,  and  even  the  crural  nerve,  as  Walter 
says  he  once  observed.— [S7jlloge  Comment.  Anat.  p. 
24.)  But,  it  is  not  thence  to  be  concluded,  that  the 
tumour  in  the  beginning  descended  over  the  crural  ves- 
sels, much  less  between  them  and  the  anterior  superior 
spinous  process  of  the  ilium.  Neither  must  it  be  ima- 
gined that  the  neck  of  the  hernial  sac  becomes  removed 
from  the  inner  to  the  outer  side  of  these  vessels.  If 
these  two  cases  ever  happen,  they  must  be  very  rare  ; 
and  the  best  authorswho  have  treated  of  crural  hernia 
concur  in  stating  that  in  performing  the  operation,  they 
have  constantly  found  the  viscera  situated  on  the  inside 
of  the  crural  vessels,  but  never  on  their  outside.  Even 
when  the  tumour,  after  acquiring  a considerable  size,  is 
situated  transversely  over  the  crural  vessels,  the  neck 
of  the  hernial  sac  has  always  been  found  upon  their 
inner  side,  that  is  to  say,  between  them  and  the  pubes. 
Le  Dran  ( Observ.  de  Chir.  t.  2,  p.  2),  La  Faye  [Cours 
d' Operations  de  Dionis,p.25Si),  Petit  [CEuvres  Pos- 
thumes,  t.  2,p.  219),  Morgagni  [De  Sed.  el  Cans.  Morb. 
epist.  34.  15),  Arnaud  [Mim.  de  Chir.  tom.  2,  p.  768), 
Gunz  [De  Herniis  Libellus,  p.  78),  Bertrandi  [Trat- 
tato  detle  Operazioni,  t.  1,  Annot.  p.  218),  Pott  [Chi- 
rurg.  Works,  vol.  2,  p.  152),  Desault  [Traiti  des  Mai. 
Chirurg.  p.  191 — 195),  B.  Bell  [A  System  of  Surgei-y, 
vol.  l,p.  387),  Richter  [Traiti  des  Hernies,  chap.  34), 
Nessi  [Instituz.  Chir.  t.%p.  198),  Lassus  [Mid.  Opir. 
t.  1,  p.  198),  and  many  other  writers  all  concur  upon 
this  point.  “ In  support  of  their  opinion  (says  Scarpa) , 
I could  cite  a great  number  of  cases  of  my  own,  which 
I have  collected  either  in  operating  on  several  indivi- 
duals for  crural  hernia,  or  in  dissecting  the  same  kind 
of  hernia  in  the  bodies  of  many  female  subjects,  and  in 
that  of  the  man  from  whom  I have  taken  the  8th  plate. 
Lastly,  also,  having  had  an  opportunity  of  dissecting 
in  a female  an  enormous  crural  hernia,  which  descended 
one  third  of  the  way  down  the  thigh,  I observed  that 
the  neck  of  the  sac  did  not  encroach  at  all  upon  the 
crural  vessels,  but  lay  entirely  on  their  inner  side.” — 
[Scarpa,  Traiti  des  Hernies,  p.  203.  206.) 

The  tumour,  on  account  of  its  situation,  is  liable  to 
be  mistaken  for  an  enlarged  inguinal  gland  ; and  many 
fatal  events  are  recorded  to  have  happened  from  the 
surgeon’s  ignorance  of  the  existence  of  the  disease. 
Mr.  Lawrence  once  saw  a hospital  surgeon  mistake 
a crural  hernia  for  a glandular  tumour,  and  the  patient 
died,  without  any  attempt  being  made  to  afford  relief 
by  the  operation.— (P.  413,  ed.  4.)  See  also  Petit, 
( Traiti  des  Mai.  Chir.  t.  2,  p.  293,  di-c.)  A gland  can 
only  become  enlarged  by  the  gradual  effects  of  infiam- 
mation  ; the  swelling  of  a crural  hernia  comes  on  in  a 
momentary  and  sudden  manner,  and,  when  strangu- 
lated, occasions  the  train  of  symptoms  already  de- 
scribed in  our  account  of  the  inguinal  hernia,  which 
symptoms  an  enlarged  gland  could  never  occasion. 
Such  circumstances  seem  to  be  sufficiently  discrimi- 
native ; though  the  feel  of  the  two  kinds  of  swelling  is 
often  not  of  itself  enough  to  make  the  surgeon  decided 
in  his  opinion.  It  is  particularly  remarked  by  Hessel- 
bach, that  while  a femoral  hernia  is  incomplete,  that  is 
to  say,  within  the  outer  opening  of  the  passage, 
through  which  the  parts  descend,  the  disease  presents 
itself  as  a round,  firm  swelling,  on  the  outer  side  of 
which  the  femoral  artery  can  be  felt  pulsating : this 
small  hernia  may  be  mistaken  for  an  inflamed  gland,  and 
the  case  can  only  be  discriminated  by  tlie  history  of  its 
origin  and  symptoms. — ( Ueber  den  Ursprung  der  Leis- 
ten-und-Schenkelbi-iiche,  p.  51.)  A femoral  hernia  may 
be  mistaken  for  a bubonocele,  when  the  expanded  part 
of  the  sw'elling  lies  over  Poupart’s  lisament.  As  the 
taxis  and  operation  for  the  first  case  ought  to  be  done  dif- 
ferently from  those  for  tire  latter,  the  error  may  lead  to 
very  bad  coiisiequences.  The  femoral  hernia,  however, 
may  always  be  discriminated,  by  the  neck  of  the  tumour 
having  Puupart's  ligament  above  it.  In  the  bubono- 
cele, the  spine  of  the  pubes  is  behind  and  below  this 
part  of  the  sac;  but  in  the  femoral  hernia,  it  is  on  the 
same  horizontal  level,  and  a little  on  the  inside  of  it. 
— (See  Lawrence  on  Ruptures,  p.  414,  ed.  4.) 

In  the  male  subject,  “ the  crural  hernia,  in  the  early 
stage  (says  Scarjra),  is  situated  so  deeply  in  the  bend  of 
the  thigii,  that  it  is  difficult,  even  in  tire  thinnest  per- 
sons, to  feel  its  neok ; and  in  examining  its  circum- 


HERNIA. 


25 


ftrence  wiili  the  extremity  of  the  finger,  the  tendinous 
margin  of  the  opening,  through  which  the  parts  are 
protruded, can  only  be  perceived  with  considerable  dif- 
ficulty. On  the  contrary,  the  inguinal  hernia,  however 
small  it  may  be,  is  always  less  deeply  situated ; it  is 
about  half  an  inch  above  the  bend  of  the  thigh.  In 
carrying  the  finger  round  its  neck,  the  tendinous  margin 
of  the  inguinal  ring  can  be  easily  felt  at  its  circum- 
ference; and  at  the  posterior  part  of  tlie  small  tumour, 
the  cord  composed  of  the  spermatic  vessels  is  distin- 
guishable. When  the  crtiral  hernia  has  acquired  a con- 
siderable size,  its  neck  is  always  deeply  situated  in  the 
bend  of  the  thigh ; but  its  body  and  fundus  asstime  an 
oval  form,  and  their  great  diameter  is  situated  trans- 
versely in  the  bend  of  the  thigh.  Whatever  may  be 
the  size  of  the  inguinal  hernia,  it  always  presents  a tu- 
mour of  a pyramidal  form,  the  base  or  fundus  of 
which,  far  from  being  direct^  towards  the  ilium,  fol- 
lows exactly  the  direction  of  the  spermatic  cord,  and 
descends  directly  into  the  scrotum.  Besides  the  symp- 
toms common  to  all  hernial  swellings,  the  crural  her- 
nia, when  it  has  attained  a certain  size,  presents  some 
others  which  are  peculiar  to  it,  such  as  a sense  of 
stupor  and  heaviness  in  the  thigh',  and  cedema  of  the 
leg,  and  even  of  the  foot,  of  the  same  side.”  The  rea- 
son why  oedema  and  numbness  of  the  limb  are  parti- 
cularly remarkable  in  cases  of  femoral  hernia,  is  justly 
referred  by  Hesselbach  to  the  circumstance  of  the  femo- 
ral vessels  and  nerves,  with  numerous  lymphatics, 
taking  their  course  through  the  crural  ring ; and,  ac- 
cording to  his  observations,  the  numbness  and  oedema 
are  especially  great  when  the  protrusion  is  omentum, 
which  makes  stronger  pressure  on  the  vessels  and 
nerves  than  commonly  Iiappens  in  a case  of  enterocele. 
-(P.  53.) 

“In  women,  however  (as  Scarpa  observes),  it  is  less 
easy  to  distinguish  the  crural  hernia  from  the  inguinal. 
In  fact,  the  absence  of  the  spermatic  cord,  and  the 
nearer  situation  of  the  ring  to  the  crural  arch,  may 
easily  occasion  a mistake.  Sometimes,  a woman  may 
even  be  supposed  to  have  a double  crural  hernia  of  the 
same  side,  while,  of  these  two  distinct,  though  neigh- 
bouring herniae,  one  may  be  inguinal,  and  the  other 
crural.  Arnaud  l_Mim.  deChir.  t.%p.  605)  relates  an 
instance  of  such  a mistake.” — {Scarpa,  Traiti  des 
Hernies,  p.  207,  208.) 

This  interesting  writer  lakes  occasion  to  observe 
further,  upon  this  part  of  the  subject,  that  the  portion 
of  the  inferior  pillar  of  the  abdominal  ring,  which 
separates  this  opening  from  the  internal  and  inferior 
angle  of  the  crural  arch,  is  so  slender  in  women,  that 
it  is  sometimes  hard  to  distinguish  the  crural  from  the 
ii^uinal  hernia,  which  is  not  the  case  in  male  pa- 
tients. 

Until  a few  years  ago,  the  stricture,  in  cases  of  femo- 
ral hernia,  was  always  supposed  to  be  produced  by  the 
lower  border  of  the  external  oblique  muscle,  or,  as  itis 
termed,  Poupart’s  ligament.  A total  change  of  opinion 
on  tills  subject,  however,  has  latterly  taken  place,  in 
consequence  of  the  observations  first  made  by  Gim- 
bertiat,  in  1793.  “ In  the  crural  hernia  (says  he),  the 
aperture  through  which  the  parts  issue  is  not  formed 
by  two  bands  fas  in  the  inguinal  hernia),  but  it  is  a fo- 
ramen almost  round,  proceeding  from  the  internal 
margin  of  the  crural  arch  (Poupart’s  ligament^,  near 
its  insertion  into  the  branch  of  the  os  pubis,  between 
this  bone  and  the  iliac  vein  : so  that,  in  this  hernia,  the 
branch  of  the  os  pnbis  is  situated  more  internally  Wian 
the  intestine,  and  a little  behind  ; the  vein,  externally, 
.tnd  behind;  and  the  internal  border  of  the  arch,  be.- 
fore.  Now,  it  is  this  border  which  always  forms  the 
strangulation.” — {SeeMJ\l'ew  Method  of  operating  for 
the  Femoral  Hernia.) 

The  utility  of  knowing  that  it  is  not  Poupart’s  liga- 
ment which  produces  the  strangulation  in  cases  of 
femoral  hernia,  is  important;  for  we  then  know,  that 
cutting  the  lower  and  outer  border  of  the  external  ob- 
lique muscle  is  quite  erroneous.  This  proceeding  is 
the  more  to  be  reprobated,  because  the  lower  pillar  of 
theahdominal  ring,  in  both  sexes,  will  be  divided  by  di- 
recting the  incision  upwards,  or  upwards  and  inwards  ; 
and  thus  the  abdominal  and  crural  rings  will  be  made 
into  one  common  aperture,  large  enough  to  make  the 
future  oaturrence  of  hernia  very  likely  to  happen.  In 
the  male  there  is  also  considerable  danger  of  the  sper- 
matic cord  being  cut.  Cutting  Poupart’s  ligament  ob- 
liiiuely  outwards  is  attended  with  still  more  danger ; 


for  the  epigastric  artery  will  infallibly  be  divided  at  its 
origin;  and  with  all  these  hazards,  the  incision  must 
be  quite  useless,  unless  carried  on  to  the  internal  edge 
of  the  crural  arch. — {Oimbernat,  p.  16.) 

The  inclination,  however,  of  several  modern  writers 
to  refer  the  strangulation  entirely  to  Gimbernat’s  liga- 
ment is  not  sanctioned  by  the  most  careful  observers, 
like  Hesselbach  and  Langenbeck. — {JVeue.  Bibl.  b.  2, 
p.  132.)  The  former  justly  remarks,  that  a complete 
femoral  hernia  may  be  strangulated  iti  two  places, 
either  at  the  outer  or  inner  opening  of  the  passage 
through  which  the  protrusion  happens.  Nay,  says  he, 
that  the  strangulation  is  sometimes  caused  by  the  outer 
opening  was  known  to  former  surgeons,  for  they  re- 
marked that  the  constriction  was  removed  by  dividing 
the  fascia. — {P.  53.)  And,  in  addition  to  these  two 
modes  of  strangulation,  is  to  be  enumerated  a third, 
in  which  the  viscera  are  constricted  by  protruding 
through  some  weaker  point,  or  accidental  opening,  in  the 
anterior  parictes  of  the  crural  canal; — (Hesselbach, p. 
48;  Cloquet,  Recher dies  .jinat.  p.  85  ■ also,  Langenbeck, 
op.  cit.p.  132),  or  even  through  an  aperture  in  the  inner 
side  of  this  passage,  as  we  find  depicted  in  the  twen- 
tieth plate  of  Langenbeck’s  treatise,  “De  Structura 
Peritonaei.” 

I know  of  no  surgical  writer  who  has  given  a clearer 
account  of  the  anatomy  of  the  femoral  hernia  tjian 
Langenbeck. — JVeue  Bibl.  b.  2,  p.  112,  ii-c.)  He  ob- 
serves, that  when  the  dissection  is  begun  at  the  inside 
of  the  inguinal  region,  the  following  circumstances  are 
noticed:  after  the  removal  of  the  peritoneum  from  the 
abdominal  muscles,  and  from  the  psoas,  iliacus  inter- 
nus,  and  the  great  vessels,  the  inner  surface  of  the 
transversalis  still  has  an  investment,  which  Cloquet 
terms  the  fascia  transversalis,  and  which  is  always  a 
white  glistening  aponeurosis.  From  the  place  where 
the  femoral  artery  lies  under  Poupart’s  ligament,  to  the 
anterior  superior  spine  of  the  ilium,  the  preceding  fas- 
cia is  extended  in  a strong  fibrous  form  behind  the  inner 
surface  of  Poupart’s  ligament,  and  a thin  continuation 
of  it  is  extended  over  the  iliacus  internus  and  psoas 
muscles,  where  it  is  named  by  Sir  A.  Cooper  and  Clo- 
quet the  fascia  iliaca.  The  fascia  of  the  transverse 
muscle  closes  the  belly  behind  Pouparfs  ligament,  as 
completely  as  the  peritoneum  does,  so  that  between  the 
femoral  artery  and  the  anterior  superior  spine  of  the 
ilium  none  of  the  bowels  can  protrude,  which  occur- 
rence is  still  further  prevented  by  the  fascia  lata, 
wnich,  below  Poupart’s  ligament,  is  closely  attached  to 
the  muscles  of  the  thigh.  By  the  pelvis  being  thus 
shut  up,  the  origin  of  a crural  hernia  on  the  outside  of 
the  femoral  vessels  is  rendered  quite  impossible. — 
(Langenbeck,  op.  cit.)  This  part  of  the  explanation 
very  nearly  resembles  that  delivered  by  Sir  A.  Cooper, 
except  that  the  latter  describes  the  iliac  fascia,  and  not 
what  Cloquet  calls  the  transverse  fascia,  as  closing  the 
pelvis  from  the  spine  of  the  ilium  to  the  crural  vessels. 
But  this  difference  is  easily  accounted  for  by  the  circum- 
stance ofSir  A.  Cooper  extending  the  name  fascia  iliaca 
beyond  the  limits  given  it  by  Cloquet  and  Langenbeck. 

Near  the  anterior  superior  spinous  process  of  the 
ilium,  Langenbeck  remarks,  that  the  fascia  of  the 
transverse  muscle  has  some  strong  fibres,  which  pro- 
ceed inwards  under  the  internal  opening  of  the  ingui- 
nal canal,  of  which  they  form,  as  it  were,  the  bottom, 
and  are  named  by  Hesselbach  the  internal  inguinal 
ligament.  They  go  over  the  femoral  artery  and  vein, 
are  connected  above  with  the  fascia  of  the  transverse 
muscle,  and  below  are  continued  into  the  fascia  of  the 
psoas  and  iliac  muscles.  Where  these  fibres  pass  over 
the  femoral  vessels,  they  expand  into  a firm  aponeuro- 
sis, which,  passing  downwards,  is  intimately  attached 
at  the  inner  side  of  the  femoral  vein  to  the  horizontal 
branch  of  the  os  pubis,  close  to  the  symphysis,  and 
then  joins  the  aponeurosis  of  the  recti  muscles.  The 
expanded  portion  of  the  foregoing  tendinous  fibres,  thus 
continued  along  the  crista  of  the  os  pubis  to  the  sheath 
of  the  rectus,  forms  the  inner  surface  of  Gimhernat's, 
or  the  femoral,  or  crural  ligament.  The  inner  edge  of 
this  ligament  is  falciform  and  concave,  the  concavity 
being  turned  towards  the  femoral  vein.  Now,  where 
the  fascia  of  the  transverse  muscle  extends  down- 
wards on  the  outer  side  of  the  crural  artery,  to  the  fas- 
cia of  the  psoas  and  iliac  muscles,  so  as  to  close  the 
pelvis  between  that  vessel  and  the  anterior  superior 
spinous  process  of  the  ilium,  it  also  forms,  like  Gimber- 
nat’s ligament,  a falciform  edge,  the  concavity  of 


26 


HERNIA. 


which  lies  close  over  the  external  convexity  of  the 
crural  artery.  Thus,  partly  by  the  concave  edge  of 
Gimbernat’s  ligament,  directed  towards  the  crural 
vein,  and  partly  by  the  concave  edge  of  the  extension 
of  the  fascia  of  the  transverse  muscle  to  the  fascia 
iliaca,  which  edge  is  turned  towards  the  crural  artery,- 
an  aperture  is  produced,  through  which  the  femoral 
vessels  pass  out  of  tiie  pelvis.  This  opening  is  named 
by  Cloquet  the  upper  opening  of  the  crural  canal, 
or,  as  many  English  surgeons  would  say,  of  the  crural 
or  femoral  ring.  By  Hesselbach,  it  is  called  themter- 
nal  opening  for  the  femoral  vessels.  However,  as 
these  vessels  do  not  lie  loosely  and  unconnectedly  in 
this  aperture,  the  opening  itself  is  shut  up,  as  it  were, 
and  cannot  be  seen  without  dissection. 

Oil  the  above-described  fasciae  there  is  a consider- 
able quantity  of  cellular  substance,  which  covers  the 
vessels  in  the  pelvis,  forms  a sort  of  sheath  tor  the  cru- 
ral artery  and  vein,  and  accompanies  these  vessels 
through  the  inner  opening  of  the  crural  canal,  or  ring, 
which  is  itself  accurately  shut  up  by  it.  When  this  cel- 
lular substance  is  removed,  the  white  glistening  fasciae 
are  plainly  seen  passing  through  the  same  opening,  and 
coming  nearer  together  in  a funnel-like  manner. 
Where  the  fascia  of  the  transverse  muscle  forms  the 
outer  falciform  edge  of  this  aperture,  and  is  passing 
over  the  arteria  circumllexa  iJii  to  the  psoais  and  iliac 
muscles,  it  sends  off  through  the  opening  a process, 
which  becomes  connected  with  the  outer  side  of  the 
crural  canal  or  ring;  while  from  the  internal  inguinal 
ligament,  which  lies  above  this  opening,  and  consti- 
tutes the  upper  edge  of  the  inner  aperture  of  the  cru- 
ral canal,  a production  is  sent,  which  is  connected 
with  the  anterior  side  of  this  canal.  As  for  the  pos- 
terior and  inner  sides,  they  have  a connexion  with  the 
fasciae  of  the  psoas  and  levator  ani. 

When  the  groin  is  externally  dissected,  in  order  to 
have  a view  of  the  crural  ring  or  canal,  on  the  outside 
of  the  pelvis,  the  following  appearances  present  them- 
selves : after  the  removal  of  the  common  integuments, 
one  finds  below  Poupart's  ligament  a quantity  of  fat, 
glands,  lymphatics,  veins,  and  arteries,  which  vessels 
come  out  through  small  openings  in  the  fascia  lata. 
As  soon  as  the  outer  surface  of  the  external  oblique 
muscle  is  cleared,  its  aponeurosis  is  found  to  become 
stronger  at  the  anterior  superior  spinous  process  of  the 
ilium,  and  its  fibres  to  collect  together,  and  assume  the 
form  of  a band,  which  is  Poupart’s  ligament,  called  by 
Hesselbach  the  external  inguinal  ligament,  and  by 
Gimbernat,  Cloquet,  and  others,  the  crural  arch.  This 
ligament,  as  is  well  known,  passes  obliquely,  inwards 
and  downwards,  towards  Lite  os  pubis,  and,  after  form- 
ing the  external  pillar  of  the  abdominal  ring,  is  first 
closely  inserted  into  the  angle  or  tubercle  of  the  os  pu- 
bis, aiid  then  being  continued  inwards,  or  backwards,  in 
the  form  of  a firm  fascia,  is  attached  to  the  horizontal 
ramus  of  that  bone,  making  the  anterior  or  outer  sur- 
face of  Gimbernat' s,  or  the  femoral  ligament,  which  is 
consequently  produced  by  the  junction  of  Poupart’s 
with  Hesselbach’s  internal  inguinal  ligament  along  the 
spine  of  the  os  pubis.  Thus,  just  as  the  internal  ingui- 
nal ligament  is  a strengthened  part  of  the  fascia  of  the 
transverse  muscle,  the  outer  inguinal  ligament  (or,  as 
it  is  here  commonly  called,  Poupart’s  ligament),  is 
produced  by  the  strengthened  fibres  of  the  lower  por- 
tion of  the  aponeurosis  of  the  external  oblique  muscle, 
the  fibres  of  it,  making  the  external  pillar  of  the  ring, 
being  continued  further  towards  the  symphysis  of  the 
pubes,  in  the  form  of  the  outer  surface  of  Gimber- 
nat’s ligament. — {Langenbeck,  JsTeue  Bibl.  h.  %p.  120, 
121.)  English  surgeons  make  the  formation  of  Gim- 
bernat’s  or  the  femoral  ligament  more  simple : thus, 
Mr.  Lawrence  states,  that  when  Poupart’s  ligament 
approaches  the  pubes,  “ it  becontes  suddenly  broader ; 
that  it  is  fixed  by  this  broad  portion,  along  the  whole 
length  of  the  angle  and  crista  of  the  pubes ; that  it  has 
a rounded  and  strong  anterior  edge,  a thin  and  sharp 
posterior  margin  ; and  that  the  former  of  these  is 
nearer  to  the  surface,  while  the  latter  is  comparatively 
deeply  seated.  The  breadth  of  this  part  varies  in  dif- 
ferent subjects ; it  is  generally  from  three  quarters  of 
an  inch  to  an  inch.  ” Sometimes,  as  Gimbernat  has 
stated,  it  measures  more  than  an  inch.  Dr.  Monro 
has  observed,  that  it  is  broader  in  the  male  than  in  the 
female  subject ; and  from  this  structure  he  explains  in 
part  the  more  rare  occitrrence  of  this  rupture  in  the 
male.”— (P.  368,  cd.  3.) 


The  fascia  lata,  which  is  spread  over  the  muscles  of 
the  thigh,  is  only  a continuation  of  the  aponeurosis 
of  the  external  oblique  muscle,  and,  as  it  proceeds 
downwards  from  Poupart’s  ligament,  is  very  closely 
attached  to  the  muscles  of  the  thigh,  all  the  way  from 
the  anterior  superior  spinous  process  of  the  ilium,  to 
the  femoral  artery,  drawing,  as  it  were,  Poupart’s  liga- 
ment downwards  and  inwards, or  backwards,  towards 
the  cavity  of  the  pelvis,  so  as  to  give  to  its  external 
edge  a convex  appearance,  and  shut  up  the  outside  of 
the  pelvis,  from  the  anterior  superior  spine  of  the  ilium 
as  far  as  the  crural  nerve  and  artery,  so  firmly,  that  the 
formation  of  a femoral  hernia  at  this  part  is  impossible. 
And  if  small  apertures  filled  with  fat  be  discernible 
in  this  portion  of  the  fascia  lata,  still  no  hernia  can 
here  take  place,  because,  as  Langenbeck  has  already 
explained,  here  the  interior  of  the  pelvis  is  again  shut 
up  by  fasciae  already  described. 

Under  the  fascia  lata  are  situated  the  anterior  crural 
nerve,  the  vein,  and  artery.  The  vena  saphena  magna 
lies  on  the  outside  of  it,  and  passes  through  an  opening 
in  it  into  the  femoral  vein.  This  aperture  in  the  fascia 
lata  is  at  the  inner  side  of  the  groin,  opposite  the  in- 
ternal opening  of  the  crural  ring  or  canal.  It  is  named 
by  Hesselbach  the  external  aperture  for  the  femoral 
vessels,  and  described  by  him  as  an  oblique  fissure 
about  fifteen  lines  in  length.  He  takes  notice  of  its 
external  semilunar  edge  and  two  horns  which  are 
directed  inwards ; the  parts  first  particularly  described 
by  Mr.  A.  Burns  of  Glasgow,  under  the  name  of  the 
semilunar,  or  falciform  process  of  the  fascia  lata.  The 
lower  horn  bends  rather  inwards  and  upwards,  and 
terminates  in  the  production  of  the  fascia  lata  spread 
over  the  pectinalis  muscle.  The  upper  horn,  which  is 
less  curved,  buries  itself  under  the  external  pillar  of 
the  abdominal  ring.  Over  the  lower  horn  of  the  open- 
ing, just  now  described,  the  vena  saphena  magna 
ascends  into  the  femoral  vein.  Through  the  same 
aperture  also  pass  nearly  all  the  superficial  lymphatics 
of  the  lower  extremity.  According  to  Cloquet,  the 
fascia  lata  consists  of  two  layers,  of  which  the  anterior 
superficial  one  is  closely  attached  to  the  crural  arch, 
extends  over  the  femoral  vessels,  and  forms  the  an- 
terior side  of  the  crural  canal.  The  other  layer,  near 
the  pubes,  quits  the  former,  a*id  covering  the  pectinalis 
muscle,  constitutes  the  hinder  side  of  that  canal.  The 
anterior  layer  of  the  fascia  then  forms  an  oval  aper- 
ture, through  which  the  vena  saidiena  passes,  and 
which  is  considered  by  Cloquet  as  the  lower  opening 
of  the  crural  canal.  This  opening,  called  by  Hessel- 
bach the  external  foramen  for  the  femoral  vessels,  is 
well  delineated  both  in  his  excellent  work,  and  in  the 
twenty-third  plate  of  Langenbeck's  book.— (Z)e  Struc- 
turd  Peritoncei,  Testiculorum  Tunicus,  Src.  Qvo.  GStt. 
1817.)  According  to  the  investigations  of  the  last 
anatomists,  as  soon  as  the  integuments  are  removed, 
this  opening  in  the  fascia  lata,  with  its  external  semi- 
lunar edge,  and  two  horns,  are  regularly  seen.  The 
frontside  of  the  crural  canal  is  formed  by  the  fascia 
lata.  Where  this  fascia  proceeds  in  the  form  of  Hes- 
selbach’s upper  horn  under  and  behind  the  external 
pillar  of  the  abdominal  ring,  and  makes  the  outer 
layer  of  Gimbernat’s  ligament,  it  is  continued  as  a 
thin  aponeurosis  over  the  vena  saphena,  so  that  it 
makes  not  merely  the  upper  horn,  but  reaches  further 
downw'ards  and  forms  the  outer  side  of  the  crural 
canal.  The  outer  side  then  of  the  crural  canal  or  ring, 
according  to  Langenbeck,  extends  from  the  outer  semi- 
lunar edge  of  the  external  opening  for  the  femoral 
vessels,  or,  as  English  surgeons  would  say,  from  the 
edge  of  the  falciform  process  of  the  fascia  lata.  The 
larger  the  preceding  thin  continuation  of  fascia  is,  the 
smaller  is  the  external  opening  for  the  femoral  vessels 
the  more  is  the  upper  horn  bent  downwards,  and  the 
more  determinate  is  the  form  of  the  canal.— (Lanp^cn- 
beck,  JVeue  Bibl.  b.  2,  p.  124,  125.)  ^ 

According  to  Mr.  Lawrence,  “At  the  upper  and 
anterior  part  of  the  limb,  the  fascia  lata  consists  of  tw'o 
portions,  an  e.vternal  and  an  internal,  with  distinct 
insertions.  The  former,  which  is  the  thickest  and 
strongest,  covers  the  sariorins  and  rectus  femoris,  and 
is  inserted  into  Poupart’s  ligament,  from  the  anterior 
superior  spine  of  the  ilium  to  the  inner  edge  of  the  fe- 
moral vein.  The  latter,  thinner  and  weaker,  covers 
the  pectineus  and  adductor  mu.'-cles,  and  is  inserted 
into  the  pubes,  in  front  of  the  origin  of  the  former.  It 
passes  bchiud  the  femoral  t esseis,  and  is  there  con- 


HERNIA. 


27 


tlnuous  with  the  iliac  fascia,  while  the  external  portion 
covers  these  vessels  anteriorly,  just  below  the  crural 
arch,  and  the  vessels  themselves  are  consequently 
situated  between  these  two  divisions  of  the  fascia.” — 
{On  Ruptures,  p.  391,  ed.  4.) 

Where  the  insertion  of  the  fascia  lata  into  Poupart’s 
ligament  ends,  it  forms  what  Mr.  Burns  of  Glasgow 
calls  the  falciform  process,  the  upper  part  of  which  is 
attached  to  the  above  ligament,  while  the  lower  pro- 
ceeds further  down  the  thigh.  The  concavity  of  the 
falciform  process  is  directed  towards  the  pubes.  This 
anatomical  connexion  is  one  chief  cause  why  extend- 
ing the  thigh,  and  rotating  it  outward,  render  the  crural 
arch  tense. 

The  hernia  being  situated  in  front  of  the  pectineus, 
must  of  course  be  exterior  to  the  fascia  lata.  In  my 
opinion,  surgeons  are  very  much  indebted  to  Mr.  Law- 
rence for  his  able  explanation  of  this  fact.  As  for 
myself  I am  candid  enough  to  own,  that  until  I read 
his  clear  and  concise  account  of  the  anatomy  of  the 
crural  hernia,  1 could  never  reap  any  accurate  notions 
concerning  the  relative  situations  of  the  hernial  sac 
and  fascia  of  the  thigh,  from  other  more  prolix  works, 
with  the  exception  of  those  of  Hesselbach  and  Langen- 
beck,  by  whom  the  anatomy  is  made  perfectly  intel- 
ligible. Mr.  Lawrence  reminds  us,  however,  that  the 
particular  crural  hernia,  contained  in  the  sheath  of  the 
femoral  vessels,  lies  under  the  fascia  ; p.  403,  edit.  4. 
And  he  mentions,  that  “ the  upper  end  of  the  falciform 
process  passes  over  the  upper  and  outer  part  of  the 
neck  of  the  tumour  ; it  is  then  folded  under  the  crural 
arch,  and  continues  into  the  thin  posterior  border. 
The  iliac  vein  is  placed  on  its  outer  side ; the  pubes  is 
directly  behind  it;  and  the  upper  and  inner  parts  are 
bounded  by  the  thin  posterior  edge  of  Poupart’s  liga- 
ment. It  is  this  part  which  forms  the  strangulation.” 
— ( On  Ruptures,  p.  404,  edit.  4.)  While,  however,  the 
latter  statement  is  made  by  this  gentleman  and  others. 
Sir  Astley  Cooper  as  positively  declares,  that  the  stric- 
ture is  never  situated  at  Giinbernat’s  ligament,  but  at 
the  crural  arch,  just  where  the  viscera  leave  the  ab- 
domen.— (See  Lancet,  vol.  2,  p.  182.)  He  also  men- 
tions, that  he  has  known  the  stricture  continue  after 
the  division  of  that  ligament,  and  the  patient  die.  The 
more  comprehensive  view  of  this  part  of  the  subject 
taken  by  Hesselbach  aitd  Langenbeck,  I have  already 
explained. 

'The  inner  side  of  the  crural  ring  or  canal,  as  already 
explained,  is  connected  with  the  fascia  of  the  trans- 
verse muscle.  And,  according  to  Langenbeck,  below 
the  part  of  the  fascia  lata,  which  forms  the  external 
foramen  for  the  femoral  vessels,  the  front  side  of  the 
crural  canal  is  sometimes  formed  by  a continuation  of 
the  fascia  of  the  transverse  muscle,  as  he  found  was 
the  case  in  both  groins  of  one  female  subject.  In  such 
a case  there  is  a good  deal  of  fat  between  the  fascia 
lata  and  the  aponeurosis  of  Ihe  tiansverse  muscle,  and 
the  two  parts  are  easily  separable.  Langenbeck  ad- 
mits, however,  that  the  same  appearance  may  arise 
from  a splitting  of  the  layers  of  the  fascia  lata.  Fre- 
quently the  front  side  of  the  crural  ring  is  so  short, 
that  the  opening  cannot  rightly  be  termed  a canal,  and 
it  is  always  shorter  than  the  po.sterior  side.  When 
the  outer  side  exists,  it  is  extended  across  the  inner, 
over  the  space  between  the  two  horns,  and  is  then 
connected  willi  the  aponeurosis  of  the  pectinalis  de- 
rived from  the  fascia  of  the  psoas  and  levator  ani 
muscles.  In  the  anterior  and  inner  sides  of  the  crural 
canal,  there  are  some  small  opening.s.  Doubtless,  this 
structure  is  referred  to  by  Hes.selbach,  when  he  says, 
that  in  the  male  subject  the  outer  openings  for  the 
femoral  vessels  is  further  closed  by  a net  like  web  of 
tendinous  fasciculi.  The  posterior  side  of  the  crural 
canal,  or  ring,  is  entirely  formed  by  the  part  of  the" 
fa.scia  of  the  psoas,  which  enters  its  inner  opening  and 
joins  the  aponeurosis  of  the  pectinalis  muscle.  The 
outer  side  of  the  canal  lies  under  the  fascia  lata,  and 
joins  the  anterior  and  posterior  sides,  where  the  apo- 
neurosis of  the  transverse  and  iliac  muscles  proceed 
to  the  outside  of  Ihe  femoral  artery.  Langenbeck 
thinks  the  opening  by  which  the  vena  saphena  passes 
over  the  lower  horn  of  the  falciform  process  of  the 
fascia  lata,  might  be  named  the  lower  aperture  of  the 
crural  canal. — (See  Lanfrenbeck's  J^eue  Bihl.  fur  die 
Chirurgie,  b.  2,  p.  126,  127,  8t)e.  Hanover,  I8li9.) 

According  to  Hesselbach,  in  femoral  hernia,  the  two 
opening.s  of  the  passage  now  termed  the  crural  or  fe- 


moral ring  are  one-half  larger  than  natural.  The 
outer  portion  of  the  inner  of  these  apertures  is  propelled 
more  outward,  and  with  it  the  epigastric  artery.  The 
femoral  vein  no  longer  lies  at  the  external  end  of  this 
opening,  but  rather  at  the  back  of  the  canal  or  passage. 
The  external  semilunar  edge  (the  falciform  process)  of 
the  outer  opening  is'  carried  more  outwards  and  up- 
wards, and  is  tightly  applied  over  the  distended  hernial 
sac.  Ill  this  state  of  the  parts,  the  outer  opening  forms 
an  oval  firm  tendinous  ring,  the  direction  of  which, 
like  that  of  the  inner  opening  for  the  passage  of  the 
femoral  vessels,  is  transverse.  The  neck  of  the  her- 
nial sac  is  that  portion  of  it  which  lies  within  the  canal 
b'dtween  the  two  openitigs.  The  posterior  side  of  this 
canal  or  passage,  now  frequently  named  the  crural  or 
femoral  ring,  is  longer  than  the  anterior.  In  one  large 
hernia,  Hesselbach  found  it  an  inch  and  a half  in  length, 
but  the  anterior  side  of  the  passage  more  than  one  third 
shorter.  The  greatest  diameter  of  the  inner  opening 
was  one  inch,  five  lines,  while  that  of  the  outer  one 
was  only  one  inch,  four  lines.  Most  of  the  posterior 
part  of  the  neck  of  the  hernial  sac,  with  the  hinder 
side  of  the  canal,  lies  upon  the  pectineus  muscle,  and 
towards  the  outer  side  upon  the  femoral  vein.  The 
neck  of  the  hernial  sac  adheres  more  firmly  to  the  an- 
terior than  to  the  [losterior  side  of  the  passage.  At  the 
outer  opening  of  the  passage,  the  neck  terminates  at 
almost  a right  angle  forwards  in  the  body  of  the  sac, 
the  upper  portion  of  which  lies  upon  Poupart’s  liga- 
ment ; but  the  largest  part  of  it  is  situated  on  the  deep- 
seated  layer  of  the  femoral  fascia,  by  w'hich  the  outer 
side  of  the  body  of  the  sac,  as  high  as  the  neck,  is 
separated  from  the  crural  vessels  and  nerves.  In  the 
male  subject,  when  the  tendinous  fibres,  mixed  with 
the  cellular  substance  covering  the  outer  opening  of 
the  passage,  make  great  resistance  at  particular  points, 
the  hernial  sac  of  a femoral  hernia  may  be  double,  or 
even  divided  into  several  pouches,  a preparation  ex- 
hibiting which  occurrence,  is  in  the  anatomical  mu- 
seum at  Wurzburg. — {Hesselbach,  48.)  Except  in  a 
few  cases  in  which  the  origin  and  course  of  the  epigas- 
tric artery  aie  unusual,  this  vessel  runs  very  close  to 
the  external  side  of  the  neck  of  the  hernial  sac,  much 
nearer  than  it  does  in  an  internal  bubonocele. 

The  sac  of  the  femoral  hernia  is  exceedingly  narrow 
at  its  neck  ; and  where  its  body  begins,  it  becomes  ex- 
panded in  a globular  form  ; the  sac  of  the  bubonocele 
is  generally  of  an  oblong  pyramidal  shape.  The  body 
of  the  sac  of  the  femoral  hernia  makes  a right  angle 
with  the  neck  by  being  thrown  forwards  and  upwards, 
a circumstance  very  necessary  to  be  known  in  trying 
to  reduce  the  parts  by  the  taxis.  Though  the  tumour 
formed  by  the  body  of  the  sac,  is  oval  and  nearly 
transverse,  it  is  found,  when  attentively  examined,  to 
take  the  direction  of  the  gtoin,  which  extends  obliquely 
downwards  and  inwards,  the  outer  rather  smaller  end 
of  the  swelling  being  somew'hat  higher  than  the  inner. 
— {Hesselbach,  p.  5(1.) 

The  sac  of  the  femoral  hernia  is  said  by  Sir  A. 
Cooper  to  be  covered  by  a kind  of  membranous  ex- 
pansion, consisting  of  condensed  cellular  substance, 
and  named  by  him  the  fascia  propria,  which  is  thus 
described;  “ A thin  fascia  naturally  covers  the  opening 
through  which  the  hernia  passes,  and  desends  on  the 
posterior  part  of  the  pubes.  When  the  hernia,  there- 
fore, enters  the  sheath,  it  pushes  this  fascia  before  it, 
so  that  the  sac  may  be  perfectly  drawn  from  its  inner 
side,  and  the  fascia  which  covers  it  left  distinct.  The 
fascia  which  forms  the  crural  sheath,  and  in  which  are 
placed  the  hole  or  holes  for  the  absorbent  vessels,  is 
also  protruded  forwards,  and  is  united  with  the  other, 
so  that  the  two  become  thus  consolidated  into  one.  If 
a large  hernia  is  examined,  the  fascia  is  only  found  to 
proceed  upwards,  as  far  as  the  edge  of  the  orifice  on 
the  inner  side  of  the  crural  sheath  by  which  the  hernia 
descends;  but  in  a small  hernia  it  passes  into  the  ab- 
domen, as  far  as  the  peritoneum,  and  forms  a pouch, 
from  which  the  hernial  sac  may  be  withdraw'ii,  leaving 
this,  forming  a complete  bag  over  the  hernia.”— (Ora 
Hernia,  part  2,p.6.)  However,  Mr.  Lawrence  has  not 
been  able  to  find,  on  dissection,  the  above  mentioned 
thin  fascia,  said  to  cover  the  opening  through  which 
the  hernia  passes;  nor  does  his  account  refer  any  co- 
vering of  the  hernia,  in  ordinary  cases,  to  an  elongated 
production  of  the  sheath  for  the  crural  vessels.  Ac- 
cording to  Sir  Astley  Cooper,  a weak  aponeurosis,  de- 
iivcii  from  tlie  superficial  fascia  of  the  bend  of  the 


28 


HERNIA. 


tljigh,  covers  the  swelling,  and  lies  immediately  beneath 
the  skin  and  adipose  substance.  Under  this  fascia  is 
the  condensed  cellular  substance  or  fascia  propria 
joined  with  the  expansion  of  the  crural  sheath,  then 
some  adipose  substance,  and  lastly,  the  true  peritoneal 
sac  itself.  It  is  of  infinite  use  to  remember  these  se- 
veral investments  in  operating,  lest  one  should  think 
the  hernial  sac  divided  when  it  is  not  so. 

All  late  writers  on  hernia  have  remarked  how  very 
small  the  aperture  is,  through  which  the  viscera  pro- 
trude in  the  femoral  rupture ; how  much  greater  the 
constriction  generally  is  than  in  the  bubonocele;  con- 
sequently, how  much  more  rapid  the  symptoms  ar.e ; 
how  much  less  frequently  the  taxis  succeeds ; and  how 
much  more  dangerous  delay  proves. — (See  Sir  A. 
Cooper,  Hey,  Lawrence,  drc.) 

Though  the  crural  ring  is  almost  always  small,  yet, 
in  a few  instances,  in  which  the  tumour  is  large,  and 
of  long  standing,  it  becomes  very  capacious,  just  as  the 
opening  often  becomes,  through  which  the  inguinal 
hernia  protrudes.  Dr.  Thomson  of  Edinburgh,  Mr. 
Hey,  and  Mr.  Lawrence  have  related  examples  of  this 
kind. 

The  remarks  already  made  concerning  the  treatment 
of  hernia,  before  having  recourse  to  the  knife,  are  all 
applicable  to  the  present  case,  and  need  not  be  repeated. 
In  attempting  to  reduce  the  femoral  hernia  by  the  taxis, 
the  surgeon  should  recollect,  however,  that  relaxing 
Poupart’s  ligament,  and  the  femoral  fascia,  is  of  the 
highest  consequence.  Hence  the  thigh  should  be  bent, 
and  rolled  inwards.  The  pressure  ought  also  to  be 
first  made  downwards  and  backwards,  in  order  to  push 
the  swelling  off  Poupart’s  ligament;  and  afterward, 
the  parts  should  be  propelled  upwards,  so  that  they 
may  return  through  the  crural  ring. 

operation  for  the  femoral  or  crural  hernia. 
Sir  A.  Cooper  says,  “ the  incision  of  the  integuments 
is  to  be  begun  an  inch  and  a half  above  the  crural  arch, 
in  a line  with  the  middle  of  the  tumour,  and  extended 
downwards  to  the  centre  of  the  tumour  below  the  arch. 
A second  incision,  nearly  at  right  angles  with  the  other, 
is  next  made,  beginning  from  the  middle  of  the  inner 
side  of  the  tumour,  and  extending  it  across  to  the  outer 
side,  so  that  the  form  of  this  double  incision  will  be 
that  of  the  letter  T reversed.”  The  angular  flaps  are, 
of  course,  to  be  next  dissected  off  and  reflected. 
Dupuytren  also  makes  the  external  wound  of  a similar 
shape,  the  first  cut  being  always  parallel  to  the  femoral 
vessels. — {Breschet.  op.  cit.p.  1G9.) 

The  making  of  two  incisions,  however,  is  not  deemed 
necessary  by  the  majority  of  surgeons;  and  in  all  the 
numerous  operations  which  I have  seen  performed  in 
St.  Bartholomew’s  Hospital,  during  my  apprenticeship 
there,  and  afterward,  a transverse  wound  was  not  ne- 
cessary. The  division  of  the  skin  should  begin  about 
an  inch  above  the  crural  ring,  and  be  continued 
obliquely  downwards  and  outwards.  In  this  manner 
we  cut  exactly  over  the  place  w here  the  incision  of 
the  stricture  should  be  made. — (See  Lawrence,  p.  425, 
ed.  4.) 

“The  first  incision  (Sir  A.  Cooper  remarks)  exposes 
the  supeificial  fascia,  which  is  given  off  by  the  external 
oblique  muscle,  and  which  covere  the  anterior  part  of 
the  hernial  sac;  but  if  the  patient  is  thin,  and  the  her- 
nia has  not  been  long  formed,  this  fascia  escapes  ob- 
servation, as  it  is  then  slight  and  delicate,  and  adheres 
closely  to  the  inner  side  of  the  skin.  When  this  fascia 
is  divided,  the  tiunour  is  so  far  exposed,  that  the  cir- 
cumscribed form  of  the  hernia  may  be  distinctly  seen  ;. 
and  a person  not  well  acquainted  with  the  anatomy  of 
the  parts,  would  readily  suppose  that  the  sac  itself 
was  now  laid  bare.  This,  however,  is  not  the  case ; 
for  it  is  still  enveloped  by  a membrane,  which  is  the 
fascia  that  the  hernial  sac  pushes  before  it,  as  it  passes 
through  the  inner  side  of  the  crural  sheath.  This  mem- 
brane, the  fascia  propria,  is  to  he  next  divided  longi- 
tudinally from  the  neck  to  the  fundus  of  the  sac;  and 
if  the  subject  is  fat,  an  adipose  membrane  lies  between 
it  and  the  sac,  from  which  it  may  be  distinguished,  by 
seeing  the  cellular  membrane  passing  from  its  inner 
side  to  the  surface  of  the  sac. 

“This  is,  in  my  opinion,  the  most  difficult  part  of 
the  operation ; for  the  fascia  propria  is  very  liable  to  be 
mistaken  for  the  sac  itself;  so  that  when  it  is  divided, 
it  is  supposed  that  the  sac  is  exposed,  and  the  intestine 
is  laid  bare;  following  upon  this  idea,  the  stricture  is 


divided  in  the  outer  part  of  the  sac,  and  the  intestine, 
still  strangulated,  is  pushed,  with  the  unopened  sac, 
into  the  cavity  of  the  abdomen. 

“ The  hernial  sac  being  exposed,  is  to  be  next  opened ; 
and  to  divide  it  with  safety,  it  is  best  to  pinch  up  a 
small  part  of  it  between  the  finger  and  thumb;  to 
move  the  thumb  upon  the  finger,  by  which  the  intes- 
tine is  distinctly  felt,  and  may  be  separated  from  the 
inner  side  of  the  sac  ; and  then  to  cut  into  the  sac,  by 
placing  the  blade  of  the  knife  horizontally.  Into  this 
opening  a director  should  be  passed,  and  the  sac  opened 
from  its  fundus  to  the  crural  sheath.” — ( On  Crural  and 
Umbilical  Hernia.) 

Sometimes  the  contents  of  the  hernia,  thus  exposed, 
admit  of  being  returned  without  the  further  use  of  the 
knife.  When  this  object,  however,  cannot  be  readily 
done,  the  protruded  parts  should  never  suffer  injury 
from  repeated  manual  attempts ; and  it  is  best  to  divide 
the  stricture  at  once. 

The  merit  of  having  first  proposed  the  safest  plan  of 
cutting  Poupart’s  ligament,  even  before  surgeons  were 
aware  of  the  parts  which  really  form  the  strangulation, 
is  assigned  by  Gimbernat  to  Mr.  B.  Bell,  who  intro- 
duced his  finger  below  Poupart’s  ligament,  between  the 
ligament  and  the  intestine  (an  evident  proof,  says  Gim- 
bernat, that  there  was  no  strangulation  there) ; he  then 
made  a very  superficial  incision  from  above  dowm- 
wards  into  the  thickest  part  of  the  ligament  to  its  lower 
edge ; and  without  cutting  quite  through  it,  he  con- 
tinued his  incision  about  an  inch.  He  rested  the  back 
of  the  scalpel  upon  his  finger,  which  served  as  a guide 
to  the  instrument,  and,  at  the  same  time,  as  a defence 
to  the  intestine.  The  incision,  however,  having  been 
continued  for  an  inch,  would,  as  Gimbernat  remarks, 
inevitably  cut  the  internal  edge  of  the  crural  arch. 
Now  cutting  this  only  for  a few  lines  gives  sufficient 
room  for  the  easy  reduction  of  the  parts;  and  there  is 
no  necessity  to  touch  the  ligament,  as  it  never  occa- 
sions the  strangulation. — (^Gimbernat,  p.  27.) 

Gimbernat’s  method  of  dividing  the  stricture,  in 
cases  of  femoral  herniae,  is  now  frequently  regarded 
as  the  safest  and  most  effectual.  “Introduce,  along 
the  internal  side  of  the  intestine,  a cannulated  or 
grooved  sound,  with  a blunt  end,  and  a channel  of  suf- 
ficientdepth.  This  is  to  be  directed  obliquely  inwards, 
till  it  enter  the  crural  ring,  which  will  be  known  by  the 
increased  re.sistance;  as  also  when  its  point  rests  upon 
the  branch  of  the  os  pubis.  Then  suspend  the  intro- 
duction; and  keeping  the  sound  (with  your  left  hand, 
if  you  are  operating  on  the  right  side,  and  v.  v.)  firmly 
resting  upon  the  branch  of  the  os  pubis,  so  that  its  back 
shall  be  turned  towards  the  intestine,  and  its  canal  to 
the  symphysis  pubis,  introduce  gently  with  your  other 
hand,  into  the  groove  of  the  sound,  a bistoury  with  a 
narrow  blade  and  blunt  end,  till  it  enter  the  ring.  Its 
entry  will  be  known,  as  before,  by  a little  increase  of 
resistance.  Cautiously  press  the  bistoury  to  the  end  of 
the  canal ; and  employing  your  two  hands  at  once, 
carry  both  instruments  close  along  the  branch  to  the 
body  of  the  pubis,  drawing  them  out  at  the  same  time. 
By  this  easy  operation,  you  will  divide  the  internal 
edge  of  the  crural  arch  at  its  extremity,  and  within  four 
or  five  lines  of  its  duplicature;  the  remainder  continu- 
ine  firmly  attached  by  the  inferior  band,  or  pillar,  of 
which  it  is  the  continuation.  This  simple  incision 
being  thus  made,  without  the  smallest  danger,  the  in- 
ternal border  of  the  arch,  which  forms  the  strangula- 
tion, will  be  considerably  relaxed,  and  the  parts  will 
be  reduced  with  the  greatest  ease. — {Gimbernat,  p. 
45,  46.) 

Mr.  Lawrence  thus  executes  Gimbernat’s  plan:  “It 
will  generally  be  practicable  ^says  he)  to  introduce  the 
tip  of  the  finger,  or  of  the  nail  under  the  edge  of  the 
tendon,  the  fibres  of  which  should  be  carefully  divided 
in  succession,  with  the  probe- pointed  knife,  until  we 
have  gained  just  sufficieut  room  to  replace  the  con- 
tents of  the  swelling.  When  the  tightness  of  the  stric- 
ture prevents  the  operator  from  using  his  finger  as  a 
guide,  he  will  employ  the  deeply-grooved  curved  direc- 
tor, introducing  it  as  near  as  he  can  to  the  pubes.  In 
both  cases,  the  blunt  end  only  of  the  curved  knife 
should  be  passed  beyond  the  stricture,  that  the  division 
may  be  effected  without  risk  to  the  arteries,  in  case 
they  should  not  follow  their  usual  course.”  The  in- 
testine should  be  protected  by  the  operator’s  left  fore- 
finger, or,  if  that  cannot  be  spared,  it  may  be  held 
aside  by  an  assistant.— ( Ort  Ruptures,  p.  432,  ed.  4.) 


HERNIA. 


29 


Sir  A.  Cooper  recommends  the  stricture  to  be  divided 
“ obliquely  inwards  and  upwards,  at  right  angles  to 
tire  crural  arch.”  In  consequence  of  the  very  deep 
situation  of  the  posterior  edge  of  the  crural  arch,  and 
the  tight  manner  in  which  the  protruded  viscera  are 
surrounded  by  the  tendon,  this  excellent  surgeon  con- 
siders, that  the  intestine  is  in  great  danger  of  being 
wounded  with  the  knife,  or,  if  held  aside  sufficiently, 
of  being  torn.  Hence,  his  custom  is  to  divide  the  stric- 
ture on  its  anterior  part,  as  far  as  the  front  margin  of 
the  crural  arch,  directing  the  edge  of  the  knife  up- 
wards and  inwards.  If  this  is  not  sufficient,  he  after- 
ward cuts  the  thin  posterior  border  of  the  tendon  in 
the  same  direction. 

After  advising  us  to  open  the  sac  of  a femoral  hernia 
with  particular  care,  on  account  of  its  being  much 
thinner  than  that  of  a bubonocele,  and  (as  might  be 
added)  on  account  of  its  seldom  containing  any  fluid, 
and  often  h.aying  no  omentum  in  it  covering  the  intes- 
tine, Mr.  Hey  remarks : “ The  stricture  made  upon 
the  prolapsed  parts  is  very  great,  as  I have  already 
observed  ; but  if  the  tip  of  the  finger  can  be  introduced 
withhi  the  femoral  ring  to  guide  the  bubonocele  knife, 
a small  incision  (for  the  ring  is  narrow)  will  be  suf- 
ficient to  set  the  parts  at  liberty.  If  the  tip  of  the  fin- 
ger cannot  be  introduced  at  the  proper  place,  a director 
with  a deep  groove  must  be  used  instead  of  the  finger; 
but  I prefer  the  latter.  The  finger  or  director  should 
not  be  introduced  very  near  the  great  vessels,  but  on 
that  side  of  the  intestine  or  omentum  which  is  near- 
est to  the  symphysis  of  the  ossa  pubis.  The  incision 
may  then  be  made  directly  upwards.  The  surgeon 
must  take  especial  care  to  introduce  his  finger  or 
director  within  that  part  where  he  finds  the  stricture 
to  be  the  greatest,  which,  in  this  species  of  hernia,  is 
the  most  interior  part  of  the  wound.” — (P.  15.5.) 

Gimbernat’s  mode  is  preferable  to  Mr.  Hey’s,  be- 
cause, were  the  operation  done  on  a male,  cutting 
directly  upwards  would  endanger  the  spermatic  cord. 
In  order  to  obviate  this  risk.  Sir  A.  Cooper  makes  a 
sm.all  incision  above  Poupart’s  ligament,  and  draws 
the  cord  out  of  the  way  of  the  knife,  with  a bent  probe. 

Mr.  Lawrence  has  noticed  that  an  “incision  of  the 
most  interior  part  of  the  stricture  is  free  from  all  dan- 
ger, in  the  ordinary  course  of  the  vessels.  But  that 
variety,  in  which  the  obturatrix  artery,  arising  from  the 
epigastric,  runs  along  the  inner  margin  of  the  sac, 
seems  to  preclude  us  from  cutting  even  in  this  direc- 
tion.” Hesselbach  met  with  a remarkable  instance  of 
such  irregularity  in  the  origin  and  course  of  the  obtu- 
ratrix artery  in  the  body  of  a female,  in  whom  there 
were  two  small  crural  liernitE.  On  the  right  side,  the 
epigastric  and  obturatrix  arteries  arose,  by  a common 
trunk,  from  the  crural  artery  below  Poupart’s  ligament. 
They  soon  separated  from  one  another  ; the  epigastric 
taking  its  ordinary  course  upwards  at  the  outer  side  of 
the  neck  of  the  hernial  3ac,  while  the  obturatrix  made 
a considerable  turn,  and  ran  transversely  inwards  over 
the  strong  fibres  of  the  femoral  ligament,  and  encircled 
the  anterior  and  inner  side  of  the  neck  of  the  hernia, 
whence  it  afterward  proceeded  obliquely  downwards 
and  outwards,  behind  the  horizontal  branch  of  the  oS 
pubis,  towards  the  obturator  foramen. — {Hesselbach, p. 
52.)  A mode  of  operating  has  lately  been  proposed 
(Edin.  Med.  and  Sur^.  .Journal,  vol.  2,  p.  205),  with  a 
view  of  avoiding  this  danger.  We  are  directed  to 
make  an  incision  through  the  aponeurosis  of  the  ex- 
ternal oblique  muscle,  just  above  the  crural  arch,  and 
in  a direction  parallel  to  that  part;  to  introduce  a di- 
rector under  the  stricture  from  this  opening,  and  to  di- 
vide the  tendon  to  the  requisite  extent,  by  means  of  a 
curved  knife  passed  along  the  groove. — {On  Ruptures, 
p.  430,  edit.  4.)  For  reasons  which  Mr.  Lawrence 
states,  this  plan  is  certainly  not  altogether  eligible,  and, 
upon  the  whole,  Gimbernat’s  method  of  cutting  the 
stricture  is  the  safest.  Dupuytren  uses  a curved  probe- 
pointed  bistoury,  that  cuts  with  its  convexity:  it  is 
conducted  flat  on  the  left  forefinger,  and  with  it  under 
the  stricture,  and  then  its  edge  is  turned  upwards,  the 
incision  being  extended  through  the  upper  end  of  the 
falciform  process  to  the  margin  of  the  crural  arch. — 
{Preschet  Concours,  Src.p.  182.) 

Monro  computes,  that  the  obturator  artery  may  arise 
from  the  epigastric,  once  in  twenty-five  or  thirty  sub- 
jects. Rut  allowing  that  it  originates  more  frequently. 
It  then  does  not  always  deviate  from  its  usual  course 
along  the  outside  of  the  sac.  Sir  A.  Cooper  says ; “ In 


all  cases  which  I have  myself  dissected,  where  this 
variety  existed  with  crural  hernia,  the  obturator  has 
passed  into  the  pelvis,  on  the  outer  side  of  the  neck  of 
the  sac,  entirely  out  of  the  reach  of  any  danger  of  the 
knife.”— ( On  Crural  Hernia,  p.  21.)  Mr.  Lawrence 
concludes,  that  the  comparative  number  of  instances, 
in  which  it  is  found  on  the  opposite  side,  cannot  be 
more  than  one  in  twenty,  and  consequently,  if  we  ad- 
mit that  the  obturatrix  artery  arises  from  the  epigastric 
once  in  five  times,  it  would  only  be  liable  to  be  wounded 
once  in  a hundred  operations. — (P.  412,  ed.  3.) 

When  the  origin  and  course  of  the  epigastric  artery 
diflfer  from  what  is  common,  this  vessel,  as  Hesselbach 
remarks,  sometimes  passes  inwards  along  the  hori- 
zontal branch  of  the  os  pubis,  ere  it  ascends  towards 
the  rectus  muscle;  and  when  this  variation  exists  in  a 
case  of  femoral  hernia,  the  artery  does  not  pass  over 
the  outer  side  of  the  neck  of  the  sac,  but  first  under  it, 
and  then  round  its  inner  side.  Hesselbach  has  seen 
only  one  instance  of  this  irregularity  of  the  epigastric 
artery  in  a female,  and  never  in  a male  subject. — ( Ueber 
den  Unsprung,  <j-c.  der  Leisten-und- Schenckelbriiche, 
p.  52.) 

The  industrious  Cloquet  examined  250  bodies  for  the 
purpose  of  estimating  the  average  number  of  cases,  in 
which  the  origin  and  course  of  the  obturatrix  artery 
are  different  from  what  is  most  common.  He  found, 
that  when  this  artery  and  the  epigastric  arise  by  one 
common  trunk,  they  sometimes  separate  from  each 
other  above,  and  rarely  below  the  upfrer  opening  of  the 
crural  canal.  In  the  first  case,  the  longer  their  common 
trunk  is,  the  closer  do  they  lie  toGiinbernat’s  ligament, 
and  to  the  inner  edge  of  the  upper  opening  of  the  above 
canal.  In  the  second  case,  the  common  trunk  of  these 
arteries  arises  within  this  canal,  and  the  tw'O  vessels 
then  return  into  the  abdomen.  In  160  bodies,  of  which 
87  were  male,  and  73  female,  the  obturatrix  artery  arose 
on  both  sides  from  the  hypogastric ; and  only  in  56,  of 
which  21  were  male,  and  3.5  female,  did  it  originate  on 
both  sides  from  the  epigastric.  In  28,  of  which  15 
were  male,  and  13  female,  the  obturatrix  arose  on  one 
side  from  the  hypogastric,  and  on  the  other  from  the 
epigastric.  In  si)(  bodies,  viz.  two  male  and  four  fe- 
male, it  originated  from  the  crural. — {Reck.  J3nat.  sur 
les  Hernies,  ito.  Paris.) 

It  is  observed  by  Professor  Scarpa  that  “ the  round 
ligament  of  the  uterus,  in  passing  through  the  abdo- 
minal muscles,  follows  precisely  the  same  track  as  the 
spermatic  cord.  It  is  equally  situated  behind  Poupart’s 
ligament,  with  the  difference,  that  it  does  not  become 
so  distinct  from  the  internal  extremity  of  this  ligament, 
as  the  spermatic  cord  does,  because  it  has  not  so  far  to 
run,  in  order  to  get  from  that  ligament  to  the  inguinal 
ring,  the  latter  opening  being  situated  lower  in  the  fe- 
male than  the  male  subject.  The  round  ligament,  like 
the  spermatic  cord,  also  crosses  the  epigastric  artery 
before  reaching  the  inguinal  ring.  And  as  the  crural 
hernia  alwa)'s  begins  at  the  internal  and  inferior  angle 
of  the  arch  of  this  name,  as  well  in  the  male  as  the  fe- 
male, it  follows  that,  in  the  two  sexes,  the  epigastric 
artery  remains  in  its  natural  situation,  and  invariably 
corresponds  to  the  external  side  of  the  neck  of  the  cru- 
ral hernia;  while  the  spermatic  cord  in  men,  and 
the  round  ligament  in  women,  pass  over  the  extren.ity 
of  the  front  of  the  neck  of  the  hernial  sac.  In  the 
operation  for  the  crural  hernia,  in  females,  the  in- 
cision of  the  neck  of  the  hernial  sac  and  crural 
arch,  when  directed  upwards  towards  the  linea  alba, 
cannot  wound  the  epigastric  artery,  wliich  it  is  of  the 
most  consequence  to  avoid ; but  it  always  divides, 
either  totally,  or  partially,  the  round  ligament  of  the 
uterus,  whici)  cannot  lead  to  any  dangerous  hemor- 
rhage; for,  except  in  the  period  of  pregnancy,  the  ar- 
teries of  the  round  ligament  are  very  small ; they  are 
almost  obliterated  in  women  advanced  in  years ; and, 
in  general,  they  are  quite  capillary  in  the  extremity  of 
the  ligament  adjoining  the  ring.  Hence,  it  cannot  be 
surprising  that  so  many  crural  hernia^  have  b(‘en  suc- 
cessfully operated  upon  in  women  by  cutting  the  hernial 
sac  and  crural  arch  directly  upward,  while  not  a single 
instance  can  be  cited  of  such  an  incision  being  made  in 
man  without  mischief,  although,  in  both  sexes,  the  epi- 
gastric artery  may  have  been  avoided  in  operating  by 
this  process. — {Scarpa,  Traiti  des  Hernies,  p.  240.) 

In  operating  upon  the  crural  hernia  in  males,  Scarpa 
recommends  us  to  follow  a method,  which  he  calls  new, 
but  which,  in  fact,  is  the  same  as  that  advised  by  Gim- 


30 


HERNIA. 


bernat.  “ I have  found  (says  Scarpa)  that,  in  man,  the 
neck  of  the  hernial  sac  may  be  divided  without  danger, 
by  giving  to  the  incision  a direction  exactly  contrary 
to  that  which  is  practised  in  the  female  subject.  After 
having  opened  the  hernial  sac,  it  is  to  be  drawn  out- 
wards by  one  of  its  sides  sufficiently  to  allow  the  intro- 
duction of  a small  director  between  its  neck  and  the 
strangulated  intestine,  the  groove  of  the  instrument 
being  turned  downwards  towards  the  internal  and  infe- 
rior angle  of  the  crural  arch.  A probe-pointed  bistoury, 
the  edge  of  which  is  also  to  be  directed  downwards  to- 
wards the  point  of  insertion  of  Poupart's  ligament  to 
tJie  pubes,  is  to  be  pushed  along  the  groove.  By  this 
means  the  neck  of  the  hernial  sac  will  be  divided  its 
whole  length  at  its  internal  and  inferior  side,  and  Pou- 
part's ligament  will  be  cut  close  to  its  attachment  to  the 
top  of  the  os  pubis.  The  epigastric  artery  wilt  cer- 
tainly be  avoided,  because  it  lies  upon  the  opposite  side 
of  the  hernial  sac.  As  for  the  spermatic  cord,  I have 
demonstrated,  that  it  is  situated  on  the  fore  part  of  the 
neck  of  the  hernial  sac ; consequently  it  cannot  be 
touched  by  an  incision  made  from  above  downwards, 
while  it  is  constantly  cut  in  the  ordinary  method,  since 
the  knife  is  carried  from  below  upwards.  In  the  first 
case  this  part  may  he  the  more  easily  avoided,  as  it  lies 
at  some  distance  from  the  internal  and  inferior  angle 
of  the  crural  arch.  In  fact,  it  is  at  this  place  thaf  it 
quits,  as  we  have  seen,  the  edge  of  Poupart’s  ligament, 
in  order  to  ascend  towards  the  inguinal  ring.  The  in- 
cision that  I propose  (says  Scarpa)  not  only  has  the 
advantage  of  slitting  open  the  neck  of  the  hernial  sac 
its  whole  length,  it  also  divides  a part  of  the  insertion 
of  Poupart’s  ligament  into  the  upper  part  of  the  os 
pubis,  a thing  that  greatly  contributes  to  relax  the  crural 
arch,  and  facilitate  the  reduction  of  the  viscera ; of 
those,  at  least,  which  are  not  adherent  to  tire  sac.” — 
(Scarpa,  op.  cit.  p.  235.) 

Although  this  accurate  anatomist  and  surgeon,  at  the 
time  when  he  first  published  on  hernia,  was  quite  un- 
acquainted with  the  valuable  works  on  the  same  sub- 
ject, which  had  made  their  appearance  in  this  country. 
It  is  curious  to  find,  both  in  his  account  of  the  in- 
guinal and  crural  hernia,  how  strongly  his  doctrines 
and  observations  tend  to  confirm  every  thing  that  has 
recently  been  insisted  upon  in  modern  works,  respecting 
the  place  where  the  bubonocele  first  protrudes,  its 
passing  through  a sort  of  canal  before  it  comes  out  of 
the  abdominal  ring,  the  advantage  of  cutting  in  the 
crural  hernia  the  internal  and  inferior  angle  of  Pou- 
part’s ligament,  or,  in  other  terms,  that  part  of  the  liga- 
ment which  was  first  particularly  pointed  out  by  Giin- 
bernat,  as  causing  the  principal  part  of  the  strangula- 
tion. 

Hesselbach  considers  an  incision  through  the  outer 
side  of  the  crural  ring  safer  than  one  through  Giinber- 
nat’s  ligament,  and  safer  in  women  than  men.  In 
women,  he  recommends  the  cut  to  be  made  through  the 
middle  of  the  fore  part  of  the  ring,  nearly  straight  up- 
wards, or  a little  inclined  inwards,  in  which  mode  the 
epigastric  artery  cannot  be  hurt,  whether  it  lie  at  the 
outer  or  inner  side  of  the  neck  of  the  sac.  In  men, 
this  incision,  directed  obliquely  upwards  and  inwards, 
he  says,  cannot  be  made,  on  account  of  the  nearness 
of  the  spermatic  cord ; therefore,  in  the  male  subject, 
he  advises  cutting  the  imierside  of  the  opening,  that  is 
to  say,  Gimbernat’s  or  the  femoral  ligament,  directly 
inwards  towards  the  symphysis  of  the  os  pubis. — 
( Ueber  den  Ur  sprung  der  Beisten  und-  Schenkelbruche, 
p.  54.)  When  the  epigastric  or  obturator  artery  de- 
viates from  its  usual  course,  and  surrounds  the  inner 
side  of  the  neck  of  the  hernia  (which  variety  can  never 
be  ascertained  a priori),  a woiuidof  the  vessel  Hessel 
bach  regards  as  unavoidable. 

From  the  views  taken  of  femoral  hernia  in  this  article, 
I consider  the  unrestricted  direction  always  to  cut 
Gimbernat’s  ligament  in  the  operation  perfectly  er- 
roneous. For,  as  Langenbeck  has  stated,  the  seat  of 
strangulation  may  either  be  in  the  external  aperture  of 
the  crural  canal,  or  in  an  opening  of  the  front  or  inner 
side  of  this  passage,  or  in  its  inner  opening,  where  in- 
deed Gimbernat’s  ligament  is  truly  concerned.  When 
the  strangulation  is  of  theTirst  two  descriptions,  only 
the  fascia  lata  need  be  cut;  but  in  the  third,  most  fre 
quent  case,  the  inner  semilunar  edge  of  the  internal 
opening  of  the  ring  must  of  course  be  divided.  Iti  all 
cases,  says  Langenbeck,  whether  the  strangulation  be 
caused  by  the  inner  or  external  opening  of  the  crural 


canal,  or  by  an  aperture  in  the  front  parietcs  of  this 
passage,  the  stricture  must  be  cut  inwards,  as  di- 
recting the  cut  in  the  least  outwards  would  injure  the 
epigastric  artery.  When  it  is  perceived,  in  the  opera- 
tion, that  the  neck  of  the  hernial  sac  is  strangulated 
close  below  and  behind  the  external  pillar  of  the  ab- 
dominal ring,  then  the  inner  opening  of  the  crural  canal 
must  be  divided  inwards,  with  the  knife  directed  along 
the  horizontal  ramus  of  the  os  pubis,  under  the  ex- 
ternal pillar  of  the  ring,  towards  the  symphysis  of  the 
pubes.  If,  in  such  a case,  the  knife  were  carried  in- 
wards and  upwards,  that  part  of  Poupart’s  ligament 
forming  the  upper  side  of  the  crural  canal,  might  be 
cut,  and  the  spermatic  artery  injured.— (JVcwe  Bibl  b. 
2,p.l33.) 

Dr.  Triistedt  has  published  some  remarks,  in  favour 
of  employing  dilatation,  instead  of  an  incision,  irt  the 
operation  for  the  strangulated  crural  hernia.  He  ob- 
serves, that  even  when  the  common  trunk  of  the  obtii- 
ratrix  and  epigastric  arteries  is  short,  the  bowels  may 
protrude  under  the  first  of  these  arteries,  which  will 
lie  upon  the  upper  and  inner  side  of  the  hernia.  In  an 
operation  performed  upon  a tvoman,  in  La  Chariffi  at 
Berlin,  for  a strangulated  femoral  hernia,  the  crural 
ligament  was  divided  in  Gimbernat’s  way  by  an  in- 
cision, exactly  parallel  to  the  horizontal  ramus  of  the 
os  pubis,  and  the  obturatrix  artery  was  wounded. 
The  patient  died  eight  days  after  the  operation,  having 
been  previously  attacked  by  trismus  and  opisthotonos. 
On  dissection,  about  six  ounces  of  putrid  blood  were 
found  in  the  lesser  cavity  of  the  pelvis,  and  the  above 
artery  cut.  The  vessel  arose  from  the  epigastric,  ran 
over  the  upper  edge  of  the  inner  opening  of  the  crural 
canal,  or  ring,  and  then  descended  along  its  inner  edge, 
towards  the  obturator  foramen.  This  occasional  course 
of  the  obturatrix  artery  leads  Dr.  Triistedt  to  suggest 
the  following  rules;  if,  after  the  hernial  sac  is  opened, 
the  bowels  cannot  be  returned,  the  outer  opening  of  the 
crural  canal  should  be  cut  directly  inwards,  in  order  to 
produce  a considerable  relaxation.  But,  if  the  reduc- 
tion should  yet  be  impracticable  (the  strangulation 
being  at  the  inner  opening  of  the  canal),  then  an  at- 
tempt is  to  be  made  to  insinuate  the  end  of  the  finger 
through  the  constriction,  a plan  said  to  have  answered 
very  often  in  Jhe  practice  of  surgeon-general  Rust. 
Should  the  resistance  be  too  great,  however,  for  this 
method  to  succeed,  Triistedt  advises  the  crural  liga- 
ment to  be  forcibly  drawn  inwards  and  upward.s,  to- 
wards the  navel,  with  Arnaud’s  tenaculum,  assisted 
by  the  introduction  of  the  finger,  or  with  two  hooks. 
VVhen  this  plan  fails,  he  recommends  Schreger’s  prac- 
tice of  dividing  the  anterior  edge  of  Poupart’s  liga- 
ment with  a pair  of  blunt- pointed  scissors,  and  then 
the  use  of  Arnaud’s  tenaculum  again.— (See  Rust's 
Magaiin  fiir  die  gesammte  Hrilkunde,  b.  3,  A.  2.) 
The  consideration,  however,  which  will  ever  prevent 
the  common  adoption  of  Dr.  Trustedt’s  suggestion,  is, 
that  fifty  times  more  lives  would  be  lost  by  the  mis- 
chief done  to  the  protruded  bowels  by  the  forcible  in- 
troduction of  the  fingers  and  hooks,  than  by  hemor- 
rhage from  the  obturatrix  or  epigastric  artery,  when 
the  course  of  the  vessel  is  irregular. 

Of  late  years,  a fact  of  considerable  interest  has  been 
ascertained  in  relation  to  femoral  hernia ; viz.  that  the 
constriction  of  the  bowel  by  the  smallness  of  the  aper- 
ture and  the  sharp  edge  of  Poupart’s  ligament,  is  so 
great,  that  either  a permanent  contraction  of  the  part, 
ulceration  of  the  internal  and  muscular  coats,  or  even 
that  of  the  serous  coat  also  may  occur,  followed  by 
fatal  extravasation,  after  the  reduction  of  the  hernia  by 
the  operation. — (Chevalier,  in  Med.  Chir.  Trans,  vol.4, 
p.  324  ; Breschet,  op.  cit.  obs.2  ; Lawrence,  p.  442,  ed. 
4.)  Hence,  the  latter  gentleman  is  an  advocate  for 
gently  drawing  nut  the  bowel,  after  liberating  it  from 
stricture;  if  no  reason  be  found  to  apprehend  perfora 
tion  of  the  tube,  he  advises  its  reduction  ; but,  in  the 
opposite  case,  he  directs  it  to  be  left  out  of  the  abdo- 
men, rather  than  that  the  patient  should  be  exposed  to 
the  danger  of  effusion  into  the  abdomen. — (P.  444.) 

rONGKNITAL  HERNIA. 

Before  the  beginning  of  the  sixth  month  of  the  foetal 
state,  the  testicle  is  .sHuated  near  the  kidney,  where  it 
receives  a covering  from  the  peritoneum,  just  like  the 
other  abdominal  viscera.  Between  the  beginning  of 
the  sixth  month,  and  end  of  the  seventh,  the  testicle 
has  either  descended  as  low  as  just  above  the  abdo- 


HERNIA, 


31 


minal  ring,  or  else  Is  passing  through  i t,  or  arrived  a little 
below  it. — ( Wrisberg,  Com.  Reg.  Societ.  Gbtting.  1785.) 

When  the  testicle  passes  through  the  abdominal  ring 
into  the  scrotum,  it  is  received  into  a production  of  the 
peritoneum,  which  afterward  constitutes  the  tunica 
vaginalis;  while  that  peritoneal  investment,  which 
was  given  to  the  testicle  in  the  loins,  is  closely  adhe- 
rent to  this  body,  and  forms  what  is  named  the  tunica 
albuginea. 

After  the  descent  of  the  testicle  into  the  scrotum,  the 
communication  between  the  cavity  of  the  tunica  vagi- 
nalis and  that  of  the  abdomen  commonly  becomes  ob- 
literated, which  latter  event  is  usually  effected  before 
birth,  sometimes  not  till  afterward,  and,  in  a few  sub- 
jects, even  as  late  as  the  adult  state. 

In  the  congenital  hernia  the  protruded  viscera  are 
situated  in  the  tunica  vaginalis,  in  contact  with  the  tes- 
ticle ; having  descended  into  this  position  before  the 
closure  of  the  communication  with  the  abdomen.  Of 
course,  the  tunica  vaginalis  itself  is  the  hernial  sac. 
The  nature  of  this  case  was  not  understood,  before  it 
was  elucidated  by  Haller  in  1755,  and  the  two  Hunters 
in  17(S2  and  1764. — (See  Hunter's  Med.  Comment. ; 
Haller's  Opuscula  Patholog.  and  Opera  Minora,  t.3.) 
Many  particulars,  relative  to  the  origin  and  formation 
of  this  hernia,  having  been  given  in  the  fifth  edition  of 
the  First  Lines  of  Surgery,  I shall  not  here  repeat 
them.  Before  the  periods  now  named,  surgeons  im- 
puted the  circumstance  of  the  contents  of  the  hernia 
and  testicle  being  in  contact,  to  the  bowels  having 
made  their  way,  by  laceration,  through  the  txnica  va- 
ginalis, from  the  ordinary  hernial  sac  of  a bubonocele. 
The  old  surgeons,  indeed,  frequently  cite  this  instance, 
in  proof  of  their  doctrine,  that  some  hernite  are  at- 
tended with  a laceration  of  the  peritoneum. — (See 
Sharp's  Inquiry.) 

From  the  term  congenital,  we  might  suppose,  that 
this  hernia  always  existed  at  the  time  of  birth.  The 
protrusion,  however,  seldom  occurs  till  after  this  pe- 
riod, on  the  operation  of  the  usual  exciting  causes  of 
heinias  in  general.  It  does  not  commonly  happen  till 
some  months  after  birth ; and,  in  certain  instances,  not 
till  a late  period.  Mr.  Hey  relates  a case,  in  which  a 
hernia  congenita  was  first  formed  in  a young  man, 
aged  sixteen,  whose  right  testis  had,  a little  while  be- 
fore the  attack  of  the  disease,  descended  into  the  scro- 
tum. In  the  generality  of  cases  which  actually  take 
place  when  the  testicle  descends  into  the  scrotum  be- 
fore birth,  the  event  may  be  referred  to  the  testicle 
having  contracted  an  adhesion  to  a piece  of  intestine, 
or  omentum,  in  its  passage  to  the  ring.  In  an  infant, 
which  died  a few  hours  after  birth,  Wrisberg  found 
one  testicle,  which  had  not  passed  the  ring,  adhering, 
by  means  of  a few  slender  filaments,  to  the  omentum, 
just  above  this  aperture.  Sometimes,  adhesions  of  the 
testicle  to  the  adjacent  viscera,  instead  of  leading  to 
the  formation  of  a congenital  hernia,  only  prevent  the 
descent  of  the  former  organ.  Cloquet  examined  the 
body  of  an  old  man,  in  which  the  left  testicle  lay  on 
the  psoas  and  iliacus  muscles,  connected  to  the  sigmoid 
flexure  of  the  colon,  while  an  inguinal  hernia  existed 
on  the  same  side. — (Recherches,  <S-c.  p.  24.)  Some- 
times, no  protrusion  at  all  happens,  even  though  the 
communication  between  the  tunica  vaginalis  and  ab- 
domen continue  open  in  the  adult  subject,  as  is  par- 
ticularly exemplified  in  a case  recorded  by  Hessolbach, 
where  such  communication  existed  on  each  side  in  a 
man  thirty-eight  years  of  age,  without  any  hernia. — 
(Med.  Chir.  Zeitung,  1819,  p.  110.  Also,  .A.  Cooper, 
in  Lancet,  vol.’i,  p.  173.) 

The  appearance  of  a hernia  in  very  early  infancy, 
Mr.  Pott  observes,  will  always  make  it  probable  that  it 
is  of  this  kind ; but  he  was  not  correct  in  asserting, 
that  in  an  adult  there  is  no  reason  for  supposing  his 
rupture  to  be  of  this  sort,  but  his  having  been  afflicted 
with  it  from  his  infancy  ; and  that  there  is  no  external 
mark  or  character  whereby  it  can  be  certainly  distin- 
guished from  one  contained  in  a common  hernial  sac. 
This  statement  is  erroneous,  inasmuch  as  the  hernia 
congenita  is  attended  with  an  impossibility  of  feeling 
the  testis,  which  part  in  the  common  scrotal  hernia  is 
always  distinguishable  under  the  fundus  of  the  hernial 
sac.  The  hernia  congenita,  when  returnable,  “ ought, 
like  all  other  kinds  of  ruptures,  to  be  reduced,  and  con- 
.stantly  kept  up  by  a proper  bandage;  and  when  at- 
tended with  symptoms  of  stricture,  it  requires  the  same 
chirurgic  assistance  as  the  common  hernia.” 


Mr.  Pott  notices,  that  “ in  very  young  children,  a 
piece  of  intestine,  or  omentum,  may  get  pretty  low 
down  in  the  sac,  while  the  testicle  is  still  in  the  groin, 
or  even  within  the  abdomen.  In  this  case,  the  appli- 
cation of  a truss  would  be  highly  improper;  for,  in  the 
latter,  it  might  prevent  the  descent  of  the  testicle  from 
the  belly  into  the  scrotum  ; in  the  former,  it  must  ne- 
cessarily bruise  and  injure  it,  give  a great  deal  of  un- 
necessary pain,  and  can  prove  of  no  real  use.  Such 
bandage,  therefore,  ought  never  to  be  applied  on  a rup- 
ture in  an  infant,  unless  the  testicle  can  be  fairly  felt  in 
the  scrotum,  after  the  gut  or  caul  is  replaced;  and, 
when  it  can  be  so  felt,  a truss  can  never  be  put  on  too 
soon.”  This  is  also  the  advice  delivered  by  Sir  A. 
Cooper. 

As  Mr.  Pott  has  explained,  an  old  rupture,  originally 
congenital,  is  subject  to  a stricture  made  by  the  sac 
itself,  as  well  as  to  that  produced  by  the  abdominal 
ring,  or,  as  might  have  been  added,  to  that  caused  by 
the  inner  opening  of  the  inguinal  canal. 

The  fact  he  noticed  several  times,  both  in  the  dead 
and  in  the  living.  “ I have  seen  (says  he)  such  stric- 
ture made  by  the  sac  of  one  of  these  herniae,  as  pro 
duced  all  those  bad  symptoms  which  render  the  ope- 
ration necessary:  and  I have  met  with  two  different 
strictures,  at  near  an  inch  distance  from  each  other,  in 
the  body  of  a dead  boy,  about  fourteen,  one  of  which 
begirt  the  intestine  so  tight  that  I could  not  disengage 
it  without  dividing  the  sac. 

“ In  this  kind  of  hernia  I have  also  more  frequently 
found  connexions  and  adhesions  of  the  parts  to  each 
other  than  in  the  common  one;  but  there  is  one  kind 
of  connexion  sometimes  met  with  in  the  congenital 
hernia,  which  can  never  be  found  in  that  which  is  in 
a common  hernial  sac,  and  which  may  require  all  the 
dexterity  of  an  operator  to  set  free ; I mean  that  of  the 
intestine  with  the  testicle. 

“ If  a large  quantity  of  fluid  should  be  collected  in 
the  sac  of  a congenital  hernia,  and,  by  adhesions  and 
connexions  of  the  parts  within,  the  entrance  into  it 
from  the  abdomen  should  be  totally  closed,  (a  case 
which  I have  twice  seen,)  the  tightness  of  the  tumour, 
the  difficulty  of  distinguishing  the  testicle,  and  the  fluc- 
tuation of  the  fluid,  may  occasion  it  to  be  mistaken  for 
a common  hydrocele;  and  if  without  attending  to 
other  circumstances,  but  trusting  merely  to  the  feel  and 
look  of  the  scrotum,  a puncture  be  hastily  made,  it 
may  create  a great  deal  of  trouble,  and  possibly  do 
fatal  mischief.” — ( Works,  vol.  2.) 

Mr.  Pott  also  believed,  that  common  ruptures,  or 
those  in  a peritoneal  sac,  are  generally  gradually 
formed,  that  is,  they  are  first  inguinal,  and  by  degrees 
become  scrotal ; but  that  the  congenital  are  seldom  re- 
membered by  the  patient  to  have  been  in  the  groin 
only.  As  the  tunica  vaginalis  is  thicker  than  the  peri- 
toneum, the  contents  of  a congenital  hernia  are  not  so 
easily  felt  as  those  of  a common  rupture.  In  children 
the  hernia  generally  contains  intestine  only,  the  omen- 
tum not  being  in  them  sufficiently  long  commonly  to 
protrude. 

The  sac  of  a congenital  hernia,  especially  when  the 
case  is  strangulated,  is  every  where  equally  tense, 
(Hesselbach,  p.  36,)  and  below  it  the  testis  cannot  be 
felt. 

The  reader  must  not  conclude,  however,  from  the 
above  account,  that  every  rupture  in  children  is  con- 
genital. Mr.  Lawrence  has  related  a case  of  strangu- 
lated bubonocele,  which  took  place  in  an  infant  only 
fourteen  months  old. — (P.65,  edit.  3.) 

The  common  inguinal  hernia,  which  first  protrudes 
at  the  inner  opening  of  the  inguinal  canal,  and  which 
has  the  epigastric  artery  on  the  inner  side  of  its  neck, 
has  been  named  by  Hesselbach  external;  while  the 
less  common  instance,  in  which  the  viscera  burst  di- 
rectly through  the  aponeuroses  of  the  transverse  and 
internal  oblique  muscles,  and  pass  directly  out  of  the 
abdominal  ring,  leaving  the  epigastric  artery  on  the 
outer  side  of  the  neck  of  the  sac,  is  distinguished  by 
the  epithet  internal. — (.Unat.  Chir.  Ahhavdlung  iiber 
den  Ursprung  der  Leistenbriiche ; W urzb.  1806.) 
“The  inguinal  congenital  hernia  (says  Scarpa)  cannot 
be  divided  into  external  and  internal;  it  is  evident 
that  it  must  always  be  external,  since  the  neck  of  the 
tunica  vaginalis  invariably  corresponds  to  the  point,  at 
which  the  spermatic  cord  passes  under  the  margin  of 
the  transverse  muscle.  As  for  other  circumstances, 
the  tunica  vaginalis  lies  in  its  whole  course  in  the  same 


32 


HERNIA. 


manner  as  the  sac  of  a common  inguinal  hernia : like 
this,  it  passes  completely  through  the  inguinal  canal 
from  one  end  to  the  other,  resting  upon  the  anterior 
surface  of  the  spermatic  cord.  Consequently  it  passes 
between  the  separation  of  the  inferior  fibres  of  the  ob- 
liquus  interims,  and  the  principal  origin  of  the  cre- 
master muscle. — (See  Wrisberg,  Syllog.  Comment. 
.Anat.  p.  23.)  After  coming  out  of  the  ring,  as  it  is 
always  united  to  the  spermatic  cord,  it  is  enclosed  in 
the  muscular  and  aponeurotic  sheath  of  the  cremaster 
muscle,  which  accompanies  it  to  the  bottom  of  the 
scrotum.  Since  the  tunica  vaginalis,  including  the  dis- 
placed viscera,  enters  the  inguinal  canal  on  the  outside 
of  the  point  at  which  the  spermatic  cord  crosses  the 
epigastric  artery,  it  is  manifest,  that,  as  it  follows  ex- 
actly the  direction  of  this  cord,  it  must  also  cross  the 
artery,  and  remove  it  from  the  outer  to  the  inner  side 
of  the  ring,  according  to  the  mechanism  already  ex- 
plained in  speaking  of  the  common  inguinal  hernia. 
Hence,  the  displacement  of  the  epigastric  artery  con- 
stantly happens  in  the  inguinal  congenital,  just  as  it 
does  in  the  ordinary  external  inguinal  hernia. 

“ But  if  these  two  species  of  inguinal  herniae  have 
some  analogy  to  each  other,  in  regard  to  the  parts 
which  constitute  them,  yet  they  present  some  remark- 
able differences.  1.  The  common  inguinal  hernia, 
whether  internal  or  external,  w'hen  it  extends  into  the 
scrotum,  cannot  descend  beyond  the  point  at  which  the 
spermatic  vessels  enter  the  testicle.  There  the  cellular 
substance  of  the  spermatic  cord  terminates.  There 
the  hernial  sac  must  also  unavoidably  terminate.  On 
the  contrary,  in  the  congenital  hernia,  the  viscera  may 
descend  lower  than  the  testicle,  with  which  they  are 
in  immedlftte  contact ; and,  at  length,  they  even  occupy 
the  situation  of  this  organ,  which  is  then  pushed  up- 
wards and  backwards.  2.  In  the  case  of  a congenital 
hernia,  the  descent  of  the  viscera  from  the  groin  to  the 
scrotum  commonly  lakes  place  in  a very  short  lime, 
and  in  some  measure  precipitately:  it  is  much  slower 
and  more  gradual  in  the  ordinary  inguinal  hernia. 
The  reason  of  this  difference  is  very  plain.  In  the  first 
case,  the  descent  of  the  testicle,  and  the  formation  of 
the  tunica  vaginalis,  have  opened  and  prepared  the 
way,  which  the  viscera  must  follow  in  forming  a pro- 
trusion ; while,  in  the  second,  the  hernial  sac  cannot 
descend  into  the  scrotum,  but  by  gradually  elongating 
the  layers  of  the  cellular  substance  which  joins  it  to 
the  surrounding  parts.  This  fact  is  so  generally 
known,  that  experienced  practitioners  consider  the 
promptitude  with  which  the  viscera  have  descended 
from  the  groin  to  the  bottom  of  the  scrotum,  as  a cha- 
racteristic sign  of  a scrotal  congenital  hernia.” — 
(Scarpa,  Traitd  des  Hernies,  p.  73,  tS-c. ; Hesselbach, 
p.  35 ; Pott,  (J-c.) 

In  the  hernia  congenita  the  spermatic  artery  and 
vein  are  sometimes  on  one  side  of  it,  and  the  vas  de- 
ferens behind  it.  A preparation,  exhibiting  this  alter- 
ation of  the  cord,  may  be  seen  in  the  museum  of  St. 
Thomas’s  Hospital. 

If  circumstances  will  admit  of  a truss  being  applied 
and  worn  in  cases  of  congenital  hernia,  in  young  sub- 
jects, there  will  be  a considerable  chance  of  a radical 
cure  being  effected,  in  consequence  of  the  natural 
propensity  of  the  opening  between  the  abdomen  and 
tunica  vn^inalis  to  become  closed. 

In  the  operation  the  surgeon  has  to  lay  open  the  tu- 
nica vaginalis,  instead  of  a common  hernial  sac;  but, 
as  Sir  Astley  Cooper  judiciously  recommends,  that 
membrane  should  not  be  opened  low  down;  1st,  be- 
cause a sufficiency  of  it  should  always  be  left  to  cover 
the  testicle ; and,  2dly,  because  the  spermatic  artery 
and  vein  are  situated  obliquely  on  the  front  and  lower 
portion  of  the  tumour.  He  therefore  directs  three 
inches  of  the  lower  part  of  the  tunica  vaginalis  to  be 
left  undivided.— (See  Lancet,  vol.  2,  p.  175.)  The 
stricture  is  to  be  divided  on  the  same  principle  as  that 
of  an  inguinal  hernia,  and  much  in  the  same  manner. 
As,  in  a case  of  congenital  hernia,  the  parts  are  always 
protruded  on  the  outside  of  the  epigastric  artery,  the 
stricture  may  be  safely  divided  towards  the  ilium,  as 
well  as  directly  upwards. — (Lawrence  on  Rttptures, 
p.  .507,  ed.  4.)  According’ to  Sir  Astley  Cooper,  the 
stricture  is  generally  about  an  inch  and  a half  from  the 
abdominal  ring,  except  in  large  cases,  when  it  is  nearer 
to  it.  The  pants  having  been  reduced,  the  edges  of  the 
wound  are  to  be  immediately  brought  together,  and  re- 
tained so  by  means  of  one  or  two  sutures  and  sticking 


plaster,  which  is  much  preferable  to  the  old  plan  of  ap 
plying  dressings  to  the  testicle  and  inside  of  the  tunica 
vaginalis,  so  as  to  heal  the  part  by  the  granulating 
process. 

A new  species  of  hernia  congenita  was  described  by 
the  late  Mr.  Hey,  in  which  a common  peritoneal  her- 
nial sac,  containing  the  viscera,  is  included  in  the  tu- 
nica vaginalis.  It  arises  from  the  parts  being  pro- 
truded, after  the  communication  between  the  abdomen 
and  tunica  vaginalis  is  closed,  so  that  the  peritoneum 
is  carried  down  along  with  the  intestine,  and  forms  a 
hernial  sac  within  the  tunica  vaginalis.  It  is  evident, 
also,  that  s>;ch  a hernia  can  only  be  produced  while 
the  original  tunica  vaginalis  remains,  in  the  form  of  a 
bag,  as  high  as  the  abdominal  ring.  Operators  should 
be  aware  of  the  possibility  of  having  a sac  to  divide 
after  laying  open  the  tunica  vaginalis.— (See  Hey's 
Practical  Obs.  p.  221 ; Dr.  Ballivgall,  in  Edin.  Med. 
Journ.  JVo.  87,  p.  464 ; and  Sir  A.  Cooper's  Work  on 
Inguinal  Hernia,  p.  59.) 

UMBILICAL  HERNIA,  OR  BXOMPHALOS. 

“ The  exomphalos,  or  umbilical  rupture,  (says  Pott,) 
is  so  called  from  its  situation,  and  has  (like  other  her- 
niie)  for  its  general  contents,  a portion  of  intestine,  or 
omentum,  or  both.  In  old  umbilical  ruptures  the 
quantity  of  omentum  is  sometimes  very  great.  Mr, 
Ranby  says,  that  he  found  two  ells  and  a half  of  in- 
testine in  one  of  these,  with  about  a third  part  of  the 
stomach,  all  adhering  together.  Mr.  Gay  and  Mr, 
Nourse  found  the  liver  in  the  sac  of  an  umbilical  her- 
nia; and  Bohnius  says  that  he  did  also.  But  whatever 
are  the  contents,  they  are  originally  contained  in  the 
sac,  formed  by  the  protrusion  of  the  peritoneum.  In 
recent  and  small  ruptures  this  sac  is  very  visible;  but 
in  old  and  large  ones,  U is  broken  through  at  the  knot 
of  the  navel,  by  the  pressure  and  weight  of  the  con- 
tents, and  is  not  always  to  be  distinguished  ; which  is 
the  reason  why  it  has  by  some  been  doubted  whether 
this  kind  of  rupture  has  a hernial  sac  or  not. 

“Infants  are  very  subject  to  this  disease  in  a small 
degree,  from  the  separation  of  the  funiculus  ; but  in 
general  they  either  get  rid  of  it  as  they  gather  strength, 
or  are  easily  cured  by  wearing  a proper  bandage.  It 
is  of  still  more  consequence  to  get  this  disorder  cured 
in  females,  even  than  in  males,  that  its  return,  when 
they  are  become  adult  and  pregnant,  may  be  prevented 
as  much  as  possible;  for  at  this  time  it  often  happens, 
from  the  too  great  distention  of  the  belly,  or  from  un- 
guarded motion  when  the  parts  are  upon  the  stretch. 
During  gestation  it  is  often  very  troublesome,  but  after 
delivery,  if  the  contents  have  contracted  no  adhesion, 
they  will  often  return,  and  may  be  kept  in  their  place 
by  a proper  bandage. 

“ If  such  bandage  was  always  put  on  in  time,  and 
worn  constantly,  the  disease  might  in  general  be  kept 
within  moderate  bounds,  and  some  of  the  very  terrible 
consequences  which  often  attend  it  might  be  prevented. 
The  woman  who  has  the  smallest  degree  of  it,  and 
who.  from  her  age  and  situation,  has  reason  to  expect 
children  after  its  appearance,  should  be  particularly 
careful  to  keep  it  restrained. 

“ In  some  the  entrance  of  the  sac  is  large,  and  the 
parts  easily  reducible ; in  others  they  are  difficult,  and 
in  some  absolutely  irreducible.  Of  the  last  kind  many 
have  been  suspended  for  years  in  a proper  bag,  and 
have  given  little  or  no  trouble.  They  who  are  afflicted 
with  this  disorder,  who  are  advanced  in  life,  and  in 
whom  it  is  large,  are  generally  subject  to  colics,  diar- 
rhoeas, and,  if  the  intestinal  canal  be  at  all  obstructed, 
to  very  troublesome  vomitings.  (Hence,  patients  are 
often  supposed  to  labour  under  a stricture  when  they 
really  do  not.)  It  therefore  behooves  such  to  take  great 
care  to  keep  that  tube  as  clean  and  free  as  possible, 
and  neither  to  eat  or  drink  any  thing  likely  to  make 
any  disturbance  in  that  part.” — (Pott  on  Ruptures, 
vol.  2.) 

Authors  who  have  published  since  the  time  of  this 
celebrated  surgeon,  have  not  added  much  to  the  stock 
of  information  which  he  left,  concerning  the  exompha- 
los. The  writings  of  Sir  A.  Cooper,  Scarpa,  (Traitd 
des  Hernies,  p.  327,)  and  all  tliemost  accurate  moderns, 
confirm  the  fact  described  by  Pott,  that  in  the  umbilical 
rupture  there  is  a hernial  sac,  just  as  in  other  instances 
of  herniae.  Every  one  acquainted  with  anatomy  knows, 
that  behind  the  opening  in  the  linea  alba  at  the  um- 
bilicus, the  peritoneum  is  complete,  and  consequently 


HERNIA. 


33 


must  protrude  along  with  the  viscera  in  cases  of  exoin- 
phalos.  In  the  only  two  cases  which  Sir  A.  Cooper  has 
seen  of  a deficiency  of  the  sac,  theinenibrane  Iiad  been 
partially  absorbed,  or  lacerated,  so  as  to  allow  the  pro- 
trusion of  its  contents,  and  threaten,  from  this  cause,  a 
double  stricture.  Similar  appearances,  less  closely  in- 
spected, probably  gave  rise  to  tlie  opinion  so  firmly 
maintained  by  Dionis,  De  la  Faye,  Garengeof,  and  J. 
L.  Petit,  that,  in  the  umbilical  hernia,  the  peritoneum 
was  always  lacerated,  and  there  was  no  hernial  sac. 
According  to  Bichat,  early  infancy  is  most  subject  to 
the  umbilical  hernia,  strictly  so  called,  in  which  the 
parts  protrude  through  the  navel ; while  the  other  pe- 
riods of  life  are  more  liable  to  false  umbilical  herniag, 
or  such  as  arise  in  the  vicinity  of  the  umbilicus. — 
{CEuvres  Chir.  de  Desault,  t.%  p.315.) 

Besides  a true  hernial  sac,  the  e.xomphalos  is  also 
covered  by  a more  superficial  expansion,  consisting  of 
condensed  cellular  substance.  In  operating,  however, 
a surgeon  should  always  cut  with  great  caution;  for 
the  integuments  and  hernial  sac  in  front  of  the  tumour 
are  inseparably  adherent;  and  sometimes,  in  large 
cases,  when  an  absorption  of  part  of  the  sac  has  been 
caused  by  the  pressure  of  the  bowels,  they  are  even 
found  adherent  to  the  integuments. 

Pregnant  women,  and  dropsical  and  corpulent  sub- 
jects, are  peculiarly  liable  to  the  exomphalos.  In  adults, 
when  there  is  intestine  in  the  sac,  there  is  almost  al- 
ways omentum.  The  transverse  arch  of  the  colon  is 
observed  to  be  particularly  often  contained  in  umbilical 
hernia,  but  the  small  intestines  are  not  unfrequently 
protruded : and  even  the  coecum  has  been  found  in  a 
rupture  at  the  navel. — (See  Lawrence  on  Ruptures, 
p.  454, 455,  ed.  4.) 

In  the  true  umbilical  hernia,  the  stricture  is  made  by 
the  tendinous  opening  in  the  linea  alba.  Let  us  next 
consider  the  umbilical  hernia  in  the  three  particular 
forms  in  which  it  has  been  noticed  by  the  latest 
writers. 

CONGENITAL  UMBILICAL  HERNIA. 

Dr.  Hamilton  has  met  with  about  two  cases  of  this 
kind  annually  for  the  space  of  seventeen  years;  and 
they  strictly  deserve  the  epithet  congenital,  as  they  ap- 
pear at  birth.  The  funis  ends  in  a sort  of  bag,  con- 
taining some  of  the  viscera,  which  pass  out  of  the  ab- 
domen through  an  aperture  in  the  situation  of  the 
navel.  The  swelling  is  not  covered  with  skin,  so  that 
the  contents  of  the  hernia  can  be  seen  through  the 
thin  distended  covering  of  the  cord.  The  disease  is 
owing  to  a preternatural  deficiency  in  the  abdominal 
muscles,  and  the  hope  of  cure  must  be  regulated  by  the 
size  of  the  malformation,  and  quantity  of  viscera  pro- 
truded. 

The  plans  of  cure  proposed  consist  of  the  employr 
ment  of  a ligature,  or  of  a bandage.  The  latter  seems 
preferable,  and  was  practised  by  Mr.  Hey,  as  follows: 
having  reduced  the  intestine,  he  desired  an  assistant  to 
hold  the  funis  compre.ssed  sufficiently  near  the  abdo- 
men to  keep  the  bowel  from  returning  into  the  hernial 
sac. 

“ I procured  (says  he)  some  plaster  spread  upon 
leather,  cut  into  circular  pieces,  and  laid  upon  one 
another  in  a conical  form.  This  compress  I ph'iced 
upon  the  navel,  after  I had  brought  the  skin  on  each 
side  of  the  aperture  into  contact,  and  had  laid  one  of 
the  lips  a little  over  the  other.  I then  put  round  the 
child’s  abdomen  a linen  belt;  and  placed  upon  the 
navel  a thick,  circular,  quilted  pad,  formed  about  two 
inches  from  one  extremity  of  the  belt. 

“This  bandage  kept  the  intestine  securely  within 
the  abdomen,  and  was  renewed  occasionally.  The 
funis  was  separated  about  a week  after  birth  ; and  at 
the  expiration  of  a fortnight  from  that  time  the  aper- 
ture at  the  navel  was  so  far  contracted,  that  the  crying 
of  the  child,  when  the  bandage  was  removed,  did  not 
cause  the  least  protrusion.  I thought  it  proper,  how- 
ever, to  continue  the  use  of  the  bandage  a little  while 
longer.  A small  substanpe,  like  fumrous  flesh,  iiro- 
jected,  after  the  funis  had  dropped  off,  about  half  an 
inch  from  the  bottom  of  that  depression  which  the 
navel  forms.  A dossil  of  lint  spread  with  ccrat.  e 
lapidc  calindnari,  and  assisted  by  the  pressure  of  the 
bandase,  brought  on  a complete  cicatrization.”  — 
(B.  227.) 

This  gentleman  has  related  another  example,  in 
which  the  intestines  were  rpiite  uncovered  and  in- 

II.  C 


flamed,  the  sac  having  burst  in  delivery.  The  parts 
were  reduced ; but  the  child  died. — (See  also  O. 
Fried  de  Feetu  Intcstiriis  plane  nudis  extra  Abdomen 
propendentibus  nato.  Argent.  1760.)  [See  p.  38.] 

U.MBILICAL  HERNIA  IN  CHILDREN. 

The  umbilical  hernia,  which  is  sometimes  formed  in 
the  foetus,  from  causes  difficult  of  explanation,  takes 
places  in  other  instances,  at  the  moment  of  delivery; 
and  then,  as  Sabatier  remarks,  should  it  be  tied  by 
mistake  with  the  funks,  death  would  be  the  conse- 
quence. Most  frequently,  however,  it  is  not  till  the 
second,  third,  or  fourth  month  after  birth  that  the  dis- 
ease occurs;  and  the  numerous  cases  collected  by  De- 
sault prove  that,  of  ten  infants  attacked  with  this  her- 
nia nine  become  afflicted  at  the  periods  just  mentioned. 

The  umbilicus,  still  open,  now  begins  to  contract, 
so  as  to  close  the  cicatrix,  which  soon  forms  an  obsta- 
cle capable  of  preventing  a protrusion  of  the  viscera. 
Sometimes,  however,  the  repeated  crying  of  the  child 
propels  the  viscera  through  the  opening,  and  thus  the 
closure  of  the  cicatrix  of  the  navel  is  prevented.  By 
degrees  the  umbilical  ring  becomes  more  and  more 
dilated,  the  quantity  of  protruded  bowel  increases, 
and  thus  a tumour  arises,  which,  from  being  of  trivial 
size  at  first,  at  length  attains  the  size  of  an  egg,  or 
lar^e  walnut,  and  presents  itself  with  all  the  charac- 
teristic marks  of  a hernia. 

The  presence  of  a piece  of  intestine  and  omentum  in 
the  tumour,  keeps  the  umbilicus  open,  and  opposes  the 
continual  tendency  which  it  has  to  close.  Such  ten- 
dency, however,  being  sometimes  superior  to  the  re- 
sistance of  the  protruded  parts,  forces  them  back  into 
the  abdomen,  obliterates  the  opening  through  which 
they  passed,  and  thus  the  spontaneous  cure  of  the 
umbilical  hernia  in  children  is  accomplished.  Two 
cases  illustrative  of  this  fact  are  related  by  Bichat. — 
((Euvres  Chir.  de  Desault,  t.  2,  p.  318.) 

Nature,  however,  does  not  effect  many  such  cures, 
and  when  the  case  is  left  to  her  alone,  she  not  only 
fails  in  bringing  about  a radical  cure,  but  gradually 
renders  it  impossible.  In  short,  the  propensity  of  the 
opening  to  close  diminishes,  and  is  lost  as  the  subject 
grows  older. 

Thus,  the  umbilical  hernia  of  children  seems  to  be 
essentially  different  from  that  of  adults,  in  the  tendency 
of  the  aperture  to  contract.  Hence  the  ease  of  effecting 
a radical  cure  in  children,  and  the  almost  utter  impos- 
sibility of  doing  so  in  adults.  In  the  former,  it  is 
enough  to  keep  the  intestines  from  protruding,  and  the 
opening  becomes  of  itself  obliterated;  in  the  latter, 
the  opening  always  remains,  whether  the  bowels  con- 
tinue in  it  or  not.  This  indisposition  of  the  aperture 
to  contract  in  the  adult,  also  frequently  depends  upon 
the  protrusion  not  being  through  the  umbilical  ring 
itself,  but  through  a fissure  in  the  vicinity  of  it,  not 
endued  with  the  same  natural  tendency  to  close,  which 
the  umbilicus  possesses  in  young  subjects.  In  fact,  it 
would  appear  from  the  observations  of  Scarpa,  that 
unless  a grown  up  person  has  had  the  protrusion  from 
infancy,  it  never  occurs  exactly  through  the  umbilical 
ring  itself. 

The  means  of  curing  the  umbilical  hernia  of  children, 
are  compression  and  the  ligature.  The  former  is  the 
most  modern ; the  latter  the  most  ancient  treatment, 
as  it  is  mentioned  by  Celsus.  The  design  of  both  is 
the  same,  viz.  to  prevent  the  lodgment  of  the  protruded 
viscera  in  the  opening  of  the  umbilicus,  and  thus 
facilitate  the  approximation  of  its  sides.  To  accom- 
plish this  end,  the  ligature  retrenches  the  hernial  sac 
and  skin  pushed  before  it ; and  by  the  union  of  the  cut 
parts  a cicatrix  is  produced,  which  hinders  the  pro- 
trusion of  the  viscera.  At  the  same  time,  the  sides  of 
the  opening  obeying  their  natural  tendency,  compre.s- 
sion  closes  the  deficiency  or  opening,  in  the  parietes  of 
the  abdomen,  hinders  the  protrusion  of  the  bowels, 
and  keeps  these  parts  from  resisting  the  contraction 
of  the  sac.  Desault  remarks,  that  though  compression 
occ.asions  no  i)ain,  it  is  irksome,  during  the  great  length 
of  time  its  employment  is  necessary.  The  ligature  (he. 
says)  produces  momentary  pain;  hut  it  is  jiot  at  all 
irksome,  and  it  effects  in  a few  days,  what  compres- 
sion, when  successful,  accomplishes  in  several  months. 
In  one  plan,  long  and  continued  attention  is  requisite, 
and  if  its  em[>loyiuent  he  only  for  a short  time  ne- 
glected, the  previous  effect  becomes  almost  destroyed. 
The  other  method  always  acconq)lishes  its  object  with 


34 


hernia. 


certainty,  independently  of  the  crying  of  the  child,  and 
the  care  of  its  attendants.  When  compression  is 
adopted,  it  is  executed  either  by  means  of  a flat  com- 
press applied  to  the  opening,  and  which  does  not  enter 
it,  or  else  by  means  of  some  round  or  oval  body,  such 
as  a ball  of  wax,  a nutmeg,  &c.  adapted  to  the  shape 
of  the  aperture,  and,  as  Platner  and  Richter  (in  his 
Treatise  on  Hernia)  advise,  continually  kept  within 
the  opening.  In  the  flrst  case,  Bichat  argues,  that  if 
the  bandage  be  exactly  aj  plied,  the  skin  and  sac  will 
form  a fold  in  the  aperture  of  the  navel,  hinder  its 
closure,  and  operate  in  the  same  manner,  from  without 
inwards,  as  the  protruded  intestines  did  from  within 
outwards.  In  the  second  case,  he  observes,  the  foreign 
body  being  depressed  into,  and  maintained  in  the  open- 
ing, will  occasion,  notwithstanding  what  Richter  says, 
the  same  inconveniences,  and,  in  a more  striking  man- 
ner, similar  consequences.  But,  on  the  contrary, 
when  the  ligature  is  employed,  the  sac  and  skin  of  the 
tumour  are  removed,  while  the  opening  remains  free, 
and  nothing  prevents  its  obliteration.  In  this  method, 
the  omentum  can  never  protrude  outwards ; but  in  the 
other,  if  the  compression  should  ever  be  inexact,  the 
parts  slip  out  again,  above  or  below,  and  the  disorder 
prevails  on  one  side  of  the  useless  application.  The 
ligature  is  also  commended  as  producing  an  adhesion 
of  the  sides  of  the  opening,  either  to  each  other,  or  the 
adjacent  parts.  This  adhesive  process  arises  from  the 
inflammation  excited,  and  occasions  a degree  of  firm- 
ness not  producible  by  any  other  mode  of  cure.  De- 
sault’s method,  which  much  resembles  that  of  Saviard, 
is  described  by  BicTiat. 

The  child  must  be  placed  on  its  back,  with  its  thighs 
a little  bent,  and  its  head  inclined  towards  the  chest. 
The  surgeon  is  to  reduce  the  protruded  parts,  and  to 
hold  them  so  with  his  finger,  at  the  same  time  that  he 
raises  the  hernial  sac,  and  rubs  its  sides  between  his 
fingers,  so  as  to  be  sure  that  there  is  nothing  conta  ned 
in  it.  Being  certain  that  the  parts  whiciriie  lifi,iup 
are  only  the  skin  and  sac,  he  is  to  direct  an  assistant 
to  surround  their  base  several  times  with  a tvaxed 
ligature  of  middling  size,  each  turn  being  tied  with  a 
double  knot,  in  such  a manner  as  only  to  occasion 
little  pain.  The  tumour  thus  tied,  is  to  be  covered 
with  lint,  which  is  to  be  supported  with  one  or  two 
compresses,  and  a circular  bandage,  secured  with  a 
scapulary.  By  the  following  day,  a slight  swelling 
has  commonly  taken  place  in  the  constricted  parts. 

On  the  second  or  third  day  the  parts  shrink,  and 
then  the  ligature  becomes  loose,  so  that  a fresh  one 
must  now  be  applied  in  the  same  manner  as  the  first, 
taking  care  to  draw  it  a little  more  tightly.  The  sen- 
sibility of  the  parts  increased  by  the  inflammation, 
which  the  constriction  of  the  ligature  has  already  pro- 
duced, usually  renders  this  second  ligature  more  pain- 
ful. After  the  operation,  the  same  dressings  as  at  first 
are  to  be  applied.  The  tun.our  soon  becomes  dis- 
coloured, livid,  and  smaller.  A third  ligature  put  on 
in  the  same  way  as  the  preceding  ones,  entirely  ob- 
structs the  circulation  in  it.  The  part  turns  black  and 
flaccid,  and  commonly  falls  off"  on  the  eighth  or  tenth 
day.  A small  ulcer  is  left,  which,  being  properly 
dressed,  very  soon  heals,  and  leaves  a cicatrix  suf- 
ficiently strong  to  resist  the  impulse  occasioned  by 
coughing,  or  other  efforts  of  the  abdominal  muscles.  For 
two  or  three  months,  however,  after  the  operation,  the 
child  should  wear  a circular  bandage,  in  order  to  pre- 
vent, with  still  greater  certainty,  the  viscera  from  being 
propelled  against  the  cicatrix,  so  as  to  interrupt  the 
process  of  nature,  which  is  now  producing  a giadual 
closure  of  the  umbilical  opening.  Numerous  cases 
might  here  be  adduced  in  confirmation  of  the  above 
practice ; but  several  (nine)  are  already  published  in 
the  Parisian  Chirurgical  Journ.al. 

One  may  doubt  (says  Sabatier),  quoting  the  article 
in  the  Journal,  w here  Desault  treats  of  the  present 
disease,  whether  the  infants  got  rid  of  the  hernia,  as  it 
might  have  returned  some  time  afterward.  To  this 
observation  Bichat  replies,  that  numerous  facts  remove 
the  doubt;  for  several  of  the  subjects  were  brought  to 
Desault’s  public  consultation  for  other  diseases,  a long 
while  after  they  had  been  operated  upon,  and  the 
great  number  of  students  who  e.\amined  them,  all 
acknowledged  that  the  ring  was  completely  obliter- 
ated, and  there  was  no  impulse  of  the  viscera  in 
coughing,  sneezing,  &.c.  Other  children,  in  the  know- 
ledge of  the  surgeons  of  the  Hotel  Dieu,  remained 


perfectly  cured,  and  Bichat  was  acquainted  with  two 
young  subjects  on  whom  the  operation  had  been  per- 
formed four  years,  and  they  had  had  no  relapse. 

In  young  infants  the  operation  almost  constantly 
answered;  but  in  proportion  as  tlieir  age  increased, 
it  was  found  to  be  less  certain.  Bichat  relates  Uiree 
cases  which  tend  to  prove,  that  success  may  be  com- 
pletely obtained  at  the  age  of  a year  and  a half ; that 
the  cure  is  difficult  when  the  child  is  four  years  old  ; 
and  impossible  when  it  is  nine. — (See  (Euvres  Chir.  de 
Desault,  t.  %p.  315,  (S-c.) 

Mr.  Pott  notices  the  plan  of  curing  the  exomphalos 
with  the  ligature,  and  expresses  himself  strongly 
against  the  practice  in  general.  To  adults  the  plan  is 
not  applicable,  particularly  when  the  tumour  is  large. 
Mr.  Pott  was  decidedly  in  favour  of  compression,  and 
he  observes,  tliat  in  young  subjects  and  small  herni®, 
a bandage  worn  a proper  time,  generally  proves  a 
perfect  cure. — {Vol.  2.) 

Anxious  that  this  work  should  be  strictly  impartial, 

I next  proceed  to  relate  what  has  been  more  recently 
urged  against  the  employment  of  the  ligature  for  tiie 
cure  of  tlie  umbilical  hernia  in  children. 

The  incessant  care  that  a bandage  requires,  either 
to  keep  it  clean,  or  to  make  it  always  keep  up  the 
proper  degree  of  pressure,  renders  its  employment 
difficult  in  the  children  of  the  poorer  classes.  Scarpa 
expresses  his  opinion,  that  this  was  what  induced  De- 
sault to  revive  the  operation  for  the  umbilical  hernia 
by  the  ligature,  nearly  such  as  is  described  by  Celsus; 
an  operation  (continues  Scarpa)  which  a long  while 
since,  and  for  good  reasons,  was  altogether  abandoned 
Desault  himself  has  put  some  restrictions  to  the  em 
ployment  of  the  ligature,  since  he  observes,  that  this 
method  does  not  radically  cure  the  umbilical  hernia 
of  children  arrived  at  the  age  of  four  years  ; and  that 
even  in  the  youngest  children,  a radical  cure  cannot 
be  effected  by  the  ligature,  unless  a methodical  com- 
pression of  the  navel,  by  means  of  a bandage,  be  kept 
up  immediately  after  the  operation,  and  for  two  or 
three  months.  It  is  perhaps  to  the  omission  of  this 
last  means,  tliat  a relapse  is  to  be  ascribed  in  several 
of  the  children  operated  upon  by  Desault.  “ Desault 
avoit  reviis  en  vigneur  la  ligature  tombie  e7i  disuitude. 

II  s'abusoit  sur  sa  valeur ; et  il  n'est  pas  difficile  d'en 
connoitre  la  cause.  Tous  les  enfans  qu'il  opiroit  d 
V Hdtel-Dieu  sortoient  guiris,  et  n'y  revenoient  plus  . 
oji  regardoit  alors  comme  radicale  une  guirison  mo- 
mentande.^' — {Rickerand,  JSTosographie  Chir.  t.  2,  p. 
453.)  “ I have  carefully  w atched  (says  Scarpa)  the 
immediate  efiects,  and  the  more  or  less  remote  con 
sequences  of  tying  the  umbilical  hernia,  either  simply, 
or  by  means  of  a needle  and  double  ligature;  and 
after  a consideiable  number  of  such  cases,  I believe  I 
can  assert,  that  this  operation,  howsoever  performed,  is 
not  always  exempt  from  grave  and  sometimes  danger- 
ous accidents.  I can  also  add,  that  it  never  procures 
a tndy  radical  cure,  unless  the  cicatrix,  occasioned  by 
it  in  the  umbilical  region, be  submitted  for  some  months 
to  a methodical  and  uninieri-upted  compression.  It  is 
not  so  uncommon  as  some  surgeons  pretend,  to  see 
arise,  after  the  application  of  the  ligature,  a fever 
attended  with  symptoms  of  most  violent  irritation,  and 
acute  sufferings,  which  cause  incessant  crying,  and 
sometimes  convulsions-  The  ulcer,  which  is  produced 
by  the  detachment  of  the  swelling,  is  always  very  large 
and  difficult  to  heal.  Every  now  and  then  it  becomes 
painful  and  emits  fungous  granulations,  even  though 
dressed  with  dry  applications. 

“Latterly  it  has  been  explained  by  a celebrated 
surgeon  (Palatta  J\Iemor.  del'  Instituto,  tom.  2,  part  1), 
that  the  umbilical  vein  and  tiie  sustiensory  ligament  of 
the  liver  being  included  in  the  ligature  of  the  umbilical 
hernia,  the  inflammation  which  originates  in  these 
parts  may,  perhaps,  in  certain  cases,  communicated 
to  the  liver,  so  as  to  put  the  child’s  life  in  great  danger. 
When,  in  consequence  of  the  ligature,  symptoms  of 
violent  irritation  come  on,  they  are  ordinarily  attributed 
to  certain  individual  circumstances,  such  as  extreme 
sensibility,  or  a particular  disposition  to  spasm.  Hence, 
it  is  believed,  that  they  should  be  considered  as  excep- 
tions which  do  not  e.xclude  the  general  rule,  and  prove 
nothing  against  the  utility  of  the  operation.  But  how 
(•■^ays  Scaipa)  can  the  surgeon  ascertain  the  existence 
or  none.\istence  of  these  individual  dispositions,  in  the 
children  upon  which  he  is  to  opertitel  Assuredly, 
those  subjrcls  in  which  I have  had  occasion  to  notice 


HERNIA. 


35 


the  above  accidents,  enjoyed,  before  the  operation, 
perfect  health  in  every  respect. 

“ Whatever  process  be  adopted  for  tying  the  umbili- 
cal hernia,  it  is  evident  that  the  tumour  can  only  be. 
constricted  as  far  as  a little  way  on  this  side  of  the 
aponeurotic  ring  of  the  umbilicus,  whence  it  follows, 
that  the  integuments  must  always  remain  prominent 
and  relaxed  for  a certain  extent,  at  the  front  and  cir- 
cumference of  this  opening.  Also,  after  the  separa- 
tion of  the  strangulated  portion,  there  necessarily  re- 
mains under  the  cicatrix,  a portion  of  the  hernial  sac, 
and  of  the  loose  integuments  which  covered  it;  and  as 
the  cicatrix  itself  never  acquires  sufficient  firmness  to 
resist  the  impulse  of  the  viscera,  which  tend  to  insi- 
nuate themselves  into  the  remains  of  the  hernial  sac, 
the  hernia  sooner  or  later  reappears,  and  in  a short 
time  becomes  larger  than  it  was  before  the  operation. 
If  the  subject  is  a little  girl,  it  may  be  apprehended  that 
the  first  pregnancy  will  cause  a recurrence  of  the  her- 
nia ; for,  it  is  known  that  during  gestation  the  external 
cicatrix  of  the  umbilicus  is  considerably  distended,  and 
much  disposed  to  give  way.” 

Scarpa  then  notices,  that  “ after  the  separation  of  the 
tumour,  there  always  remains  between  the  aponeuro- 
tic ring  of  the  navel  and  the  integuments  a small  ca- 
vity formed  by  the  neck  of  the  hernial  sac ; a cavity 
into  which  tiie  viscera  begin  to  insinuate  themselves 
after  the  operation,  so  as  to  hinder  the  complete  con- 
traction of  the  umbilical  ring.  The  demonstration  of 
what  1 have  advanced  is,  in  some  measure,  to  be  found 
in  the  old  method  of  operating  for  the  inguinal  hernia, 
not  in  a strangulated  state,  by  the  ligature  of  the  her- 
nial sac  and  spermatic  cord.  Most  of  the  herniae  ope- 
rated upon  by  tills  barbarous  process  were  subject  to 
relapses,  because,  in  all  probability,  the  cicatrix  was  not 
sufficiently  firm  to  resist  the  impulse  of  the  viscera, 
which  entered  the  remains  of  the  hernial  sac.  In  the 
same  manner,  after  the  common  operation  for  the  stran- 
gulated inguinal  hernia,  although  the  cicatrix  is  formed 
very  near  the  ring,  there  is  no  prudent  surgeon  who 
does  not  advise  the  patient  to  wear  a bandage  the  rest 
of  his  life,  observation  having  proved  that  the  hernia 
is  still  liable  to  recur. 

“The  experience  of  several  ages  leaves  no  doubt, 
that  compression  alone  is  an  extremely  efficacious  me- 
thod of  radically  curing  the  umbilical  hernia  of  young 
subjects.  It  is  attended  with  no  risk,  and,  provided  it 
be  executed  with  the  requisite  caution,  it  is  hardly  ever 
necessary  to  continue  it  longer  than  two  or  three 
months  for  the  purpose  of  obtaining  a complete  cure. 
On  the  other  side,  if  it  be  clearly  proved  by  all  that  I 
have  been  observing,  that  the  ligature  never  accom- 
plishes a perfect  cure  without  compression,  it  is  mani- 
fest, that  it  cannot  be  at  all  advantageous  for  the  chil- 
dren of  the  poor,  since  a bandage  cannot  be  dispensed 
with.  It  may  be  said,  that,  in  general,  it  does  not 
shorten  the  treatment;  for,  in  the  most  successful 
cases,  the  ulcer  caused  by  it  is  not  healed  in  less  than  a 
month,  and,  in  order  to  make  the  cure  certain,  an  exact 
compression  must  afterward  be  kept  up,  by  means  of 
a bandage,  two  months  longer.  It  has  already  been 
stated,  that  tliree  months  are  ordinarily  sufficient  for 
obtaining  a radical  cure  by  the  mere  employment  of  a 
compressive  bandage.”— (^carjaa,  Traite  des  Hernies. 
p.  344—349.) 

M.  Girard  published  a memoir  on  the  umbilical  her- 
nia of  children,  which  was  read  to  the  Medical  So- 
ciety of  Lyons  in  May,  1811,  and  the  object  of  which 
was  to  recommend  compression  as  an  effectual  means 
of  cure.  The  arguments  used  were  very  similar  to 
those  adduced  by  Scarpa.  In  the  course  of  the  discus- 
sion, M.  Cartier  affirmed,  that  he  had  seen  many 
children  operated  upon  by  Desault,  who  were  not 
cured  of  their  herniae. — (See  Journ.  Gin.  de  Mid.  t.  41, 
1811.) 

The  subject  was  afterward  taken  up  by  the  Medical 
Society  of  Paris,  and  the  result  of  the  debate  was,  that 
the  employment  of  the  ligature  ought  to  be  rejected. 
1.  Because  the  cure  of  umbilical  herniae  is  often  ac- 
complished by  nature  alone.  2.  Because  compression, 
either  alone  or  aided  by  tonic  remedies,  always  suc- 
ceeds. 3.  Because  the  operation  of  the  ligature  de- 
w;rves  the  triple  reproach  of  being  painful,  and  not 
free  from  danger,  if  unfortunately  a piece  of  intestine 
should  chance  to  be  included  in  the  ligature;  of  not 
succeeding  in  general,  except  with  the  assistance  of 
compression ; and  of  being  sometimes  usek'ssly  prac- 


tised, as  Desault  himself  gives  us  instances  of.  Ac- 
cording to  M.  Cayol,  the  insufficiency  of  the  ligature 
was  long  since  acknowledged  by  Sabatier,  Lassus, 
Rkherand,  &c. 

The  treatment  by  compression  is  universally  prefer- 
red by  British  surgeons. 

UMBILICAL  HERNIA  IN  ADULT  SUBJECTS. 

This  case  is  to  be  treated  on  the  principles  common 
to  all  ruptures.  When  reducible,  the  parts  should  be 
kept  up  with  a bandage  or  truss ; which  plan,  however, 
in  grown  up  persons,  affords  no  hope  of  a radical  cure. 
Mr.  Hey  has  described  some  very  good  trusses  for  the 
exomphalos,  which  are  applicable  to  children,  when 
compression  is  preferred,  as  well  as  to  adult  subjects. 
One  was  invented  by  the  late  Mr.  Marrison,  an  inge- 
nious mechanic  at  Leeds. 

“It  consists  of  two  pieces  of  thin  elastic  steel,  which 
surround  the  sides  of  the  abdomen,  and  nearly  meet 
behind.  At  their  anterior  extremity  they  form  con- 
jointly an  oval  ring,  to  one  side  of  which  is  fastened  a 
spring  of  steel  of  the  form  represented.  At  the  end  of 
this  spring  is  placed  the  pad  or  bolster  that  presses  upon 
the  hernia.  By  the  elasticity  of  this  spring,  the  hernia 
is  repressed  in  every  position  of  the  body,  and  is  there- 
by retained  constantly  within  the  abdomen.  A piece 
of  calico  or  jean  is  fastened  to  each  side  of  the  oval 
ring,  having  a continued  loop  at  its  edge,  through 
which  a piece  of  tape  is  put,  that  may  be  tied  behind 
the  body.  This  contrivance  helps  to  preserve  the  in- 
strument steady  in  its  proper  situation.” — {Practical 
Obs.  in  Surgery,  p.  231.)  And,  in  the  second  edition  of 
the  preceding  work,  another  truss  for  the  exomphalos  is 
described,  the  invention  of  Mr.  England,  of  Leeds ; 
but,  as  some  account  is  given  of  this  instrument,  with 
an  engraving,  in  the  last  editions  of  the  First  Lines  of 
Surgery,  I shall  not  here  repeat  the  description. 

When  the  exomphalos  is  irreducible  and  large,  the 
tumour  must  be  supported  with  bandages. 

It  is  observed  by  Scarpa,  that  the  umbilical  hernia, 
and  those  of  the  linea  alba,  are  less  subject  to  be  stran- 
gulated than  the  inguinal  and  femoral  herniae;  but 
that,  when  lliey  are  unfortunately  affected  with  stran- 
gulation, the  symptoms  are  more  intense,  and  gangrene 
comes  on  more  rapidly,  than  in  every  other  species  of 
rupture.  If  the  operations  be  performed,  the  event  is 
frequently  unfavourable,  because  it  is  generally  done 
too  late.  This  practical  fact  is  proved  by  the  expe- 
rience of  the  most  celebrated  surgeons  of  every  age. 
“ II  est  certain  (says  Dionis)  que  de  cette  oi>iration  iL 
en  pirit  plus  qu’il  n'en  richappe'' — Cours  d'  Opira- 
tions,  p.  98,  ed.  1777,  avec  les  notes  de  La  Faye.)  He 
also  adds,  that  tliey  who  have  the  misfortune  to  be  af- 
flicted with  an  exomphalos,  should  rather  dispense 
with  their  shirt,  than  a bandage.  Heister  says  nearly 
the  same  thing. — {Instit.  Chirurg.  t.  2,  cap.  94.) 

When  the  omentum  alone  is  strangulated  in  the  ex- 
omphalos, or  hernia  of  the  linea  alba,  observation 
proves  that  the  symptoms  are  not  less  intense  than 
when  the  intestine  is  also  incarcerated.  There  is  this 
difference,  however,  that  when  the  omentum  alone  is 
strangulated,  only  nausea  occurs,  and,  if  vomiting 
should  likewise  take  place,  it  is  less  frequent  and  vio- 
lent than  when  the  bowel  itself  is  strangulated.  In 
the  first  case,  the  stools  are  hardly  ever  entirely  sup- 
pressed. The  proximity  of  the  stomach  is,  no  doubt, 
the  reason  why  the  strangulation  of  the  omentum  in 
the  umbilical  hernia  occasions  far  more  intense 
symptoms  of  sympathetic  irritation  than  the  strangu- 
lation of  the  same  viscus  in  the  inguinal  or  crural 
hernia. 

Here  the  operation  is  not  only  always  necessary,  but 
urgently  required.  It  is  not  materially  different  from 
that  which  is  practised  for  strangulated  inguinal  and 
crural  herniae  ; but,  in  general,  it  demands  greater  cir- 
cumspection on  account  of  the  connexion,  or  intimate 
adhesions,  which  frequently  exist  between  the  integu- 
ments and  hernial  sac,  and  also  the  adhesions  which 
often  prevail  between  the  latter  part  and  the  omentum 
which  it  contains.  The  situation  of  the  intestine, 
which  is  frequently  covered  by,  and  enveloped  in,  the 
omentum,  is  another  circumstance  deserving  earnest 
attention. — {Scarpa,  Traiti  des  Hernies,  p.  361,  362.) 

Mr.  Poll  is  not  such  an  advocate  as  Scarpa  for  the 
early  performance  of  the  operation  in  cases  of  exotn- 
phalos;  “The  umbilical,  like  tlie  inguinal  hernia,  be- 
comes the  sul)jecl  of  chirurgic  opeiation,  when  the 


36 


HERNIA. 


parts  are  not  reducible  by  the  hand  only,  and  are  so 
bound  as  to  produce  bad  symptoms.  But  though  I 
have  in  the  inguinal  and  scrotal  hernise  advised  the 
early  use  of  the  knife,  I cannot  press  it  so  much  in  tlife : 
the  success  of  it  is  very  rare,  and  I should  make  it  the 
last  remedy.  Indeed,  I am  much  inclined  to  believe, 
that  the  bad  symptoms  which  attend  these  cases  are 
most  frequently  owing  to  disorders  in  the  intestinal 
canal,  and  not  so  often  to  a stricture  made  on  it  at  the 
iiavelj  as  is  supposed.  I do  not  say  that  the  latter  does 
not  sometimes  happen ; it  certainly  does ; butitisoften 
believed  to  be  the  case  when  it  is  not. 

“ When  the  operation  becomes  necessary,  it  consists 
in  dividing  the  skin  and  hernial  sac  in  such  manner  as 
shall  set  the  intestine  free  from  stricture,  and  enable  the 
surgeon  to  return  it  into  the  abdomen.” — {Pott  on  Rup- 
tures.) 

The  rest  of  the  conduct  of  the  surgeon  is  to  be  regu- 
lated by  the  usual  principles. 

The  division  of  the  stricture  is  properly  recommend- 
ed to  be  made  directly  upwards,  in  the  course  of  the 
linea  alba. 

In  consequence  of  the  great  fatality  of  the  usual  ope- 
ration for  the  exomphalos,  I think  the  plan  suggested, 
and  successfully  practised  by  Sir  A.  Cooper  in  two  in- 
stances, should  always  be  adopted  whenever  Uie  tu- 
mour is  large  and  free  from  gangrene  ; a plan  tliat  has 
also  received  the  high  sanction  of  that  distinguished 
anatomist  and  surgeon.  Professor  Scarpa. — {Traitides 
Hemics,  p.  362.)  Perhaps  I might  safely  add,  that 
when  the  parts  admit  of  being  reduced,  without  laying 
open  the  sac,  this  method  should  always  be  preferred^ 
It  consists  in  making  an  incision  just  sufficient  to  divide 
the  stricture,  without  opening  the  sac  at  all,  or,  at  all 
events,  no  more  of  it  than  is  inevitable. 

In  umbilical  hernia,  of  not  a large  size.  Sir  A. 
Cooper  recommends  the  following  plan  of  operating : 
“ As  the  opening  into  the  abdomen  is  placed  towards 
the  upper  part  of  the  tumour,  I began  the  incision  a 
little  below  it,  that  is,  at  the  middle  of  the  swelling, 
and  extended  it  to  its  lowest  part.  I then  made  a se- 
cond incision  at  the  upper  part  of  the  first,  and  at  right 
angles  with  it,  so  that  the  double  incision  was  in  the 
form  of  the  tetter  T,  the  top  of  which  crossed  the  mid- 
dle of  the  tumour.  The  integuments  being  thus  di- 
vided, the  angles  of  the  incision  were  turned  down, 
which  exposed  a considerable  portion  of  the  hernial 
sac.  This  being  then  carefully  opened,  the  finger  was 
passed  below  the  intestines  to  the  orifice  of  the  sac  at 
the  umbilicus,  and  the  probe-pointed  bistoury  being  in- 
troduced upon  it,  I directed  it  into  the  opening  at  the 
navel,  and  divided  the  linea  alba  downwards  to  the  re- 
quisite degree,  instead  of  upwards,  as  in  the  former 
operation.  Whr-n  the  omentum  and  intestine  are  re- 
turned, the  portion  of  integument  and  sac  which  is 
left  falls  over  the  opening  at  the  umbilicus,  covers  it, 
and  unites  to  its  edge,  and  thus  lessens  the  risk  of  pei  i- 
toneal  inflammation,  by  more  readily  closing^  the 
wound.” — [On  Crural  and  Umhilical  Hernia.) 

LESS  FREQUENT  KINDS  OF  HERNIA. 

The  ventral  hernia.,  described  by  Celsus,  is  not  com- 
mon ; it  may  appear  at  almost  any  point  of  the  ante- 
rior part  of  the  belly,  but  is  most  frequently  found  be- 
tween the  recti  muscles.  The  portion  of  intestine,  &c. 
is  always  contained  in  a sac,  made  by  the  protrusion  of 
the  peritoneum.  Sir  A.  Cooper  imputes  the  disease  to 
the  dilatation  of  Uie  natural  foramina  for  the  transmis- 
sion of  vessels,  to  congeniial  deficiencies,  lacerations 
and  wounds  of  the  abdominal  muscles  or  their  ten- 
dons. In  small  ventral  hernite,  a second  fascia  is  found 
beneath  the  superficial  one ; but,  in  large  cases,  the 
latter  is  the  only  one  covering  the  sac. 

Herniaj  in  the  course  of  the  linea  alba  sometimes  oc- 
cur so  near  the  umbilicus,  that  they  are  liable  to  be  mis- 
taken for  true  umbilical  ruptures.  They  may  lake 
place  either  above  or  below  the  navel.  I^ie  first  case, 
however,  is  more  frequent  than  the  second,  and  the  fol- 
lowing is  the  reiison  of  this  circumstance,  according  to 
the  opinion  of  Scarpa:  “The  upper  half  of  the  linea 
alba,  that  which  extends  from  theensiform  cartilage  to 
the  umbilicus,  is  naturally  broader  and  weaker  than 
the  lower  half,  the  recti  muscles  coming  nearer  and 
nearer  together,  as  they  descend  from  the  navel  to  the 
pubes.” — {Scarpa,  Traiti  des  Heruies,  p.  333.) 

The  hernial  sac  of  ruptures  at  the  upper  part  of  the 
linea  alba  may  contain  a noose  of  intcsune  and  a piece 


of  the  omentum,  though,  in  most  cases,  a portion  of 
the  latter  membrane  alone  forms  the  contents.  In  some 
subjects,  the  linea  alba  is  so  disposed  to  give  way,  that 
•several  hernia}  are  observed  to  be  formed  successively 
in  the  interspace  between  the  ensiform  cartilage  and 
the'urnbilicus. 

“ With  respect  to  the  small  hernia  (says  Scarpa) 
which  is  considered  as  formed  by  the  stomach,  and  con- 
cerning which  Iloin  and  Garengeot  have  written  so 
much  (without  either  of  them  having  related,  at  least 
to  my  knowledge,  a single  example  proved  by  dissec- 
tion), it  is  at  least  unproved,  that  it  was  exclusively 
formed  by  this  vi.scus.  I do  not  see  why  the  other  vis- 
cera, particularly  the  omentum  and  transverse  colon, 
might  not  also  contribute  to  it.  In  my  judgment,  it 
only  differs  from  other  hernia  of  the  linea  alba,  in  being 
situated  on  the  left  side  of  the  ensiform  cartilage,  a si- 
tuation that  must  materially  influence  the  symptoms  of 
the  case.  In  fact,  whatever  may  be  the  viscera  which 
form  it,  a sympathetic  irritation  of  the  stomach  is  occa- 
sioned, that  is  much  more  intense  than  that  which  or- 
dinarily accompanies  umbilical  herniae,  those  of  the 
lower  part  of  the  linea  alba,  or,  in  short,  all  other  her- 
niee,  which  are  more  remote  from  the  stomach. — {Op. 
cit.  p.  334.) 

The  following  are  said  to  be  the  circumstances  by 
which  the  umbilical  hernia,  and  that  which  occurs  in 
the  linea  alba  near  the  navel,  may  be  discriminated. 

The  first,  whether  in  the  infant,  or  the  adult,  has  a 
roundish  neck,  or  pedicle,  at  the  circumference  ol 
which  fhe  aponeurotic  edge  of  the  umbilical  ring  can 
be  felt.  Whatever  may  be  its  size,  its  body  always 
retains  nearly  a spherical  shape.  Neither  at  its  apex, 
nor  its  sides,  is  any  wrinkling  of  the  skin,  or  anything 
like  the  cicatrix  of  the  navel,  distinguishable.  At  some 
points  of  the  surface  of  the  tumour,  the  skin  is  merely 
somewhat  paler  and  thinner  than  elsewhere. 

On  the  contrary,  the  hernia  of  the  linea  alba  has  a 
neck,  or  pediclej  of  an  oval  form,  like  the  fissure 
through  w'hich  it  is  protruded.  The  body  of  the  tumoui 
is  also  constantly  oval.  If  the  finger  be  pressed  deeply 
round  its  neck,  the  edges  of  the  opening  in  the  linea 
alba  can  be  felt;  and  if  the  hernia  be  situated  very 
near  the  umbilical  ring,  the  cicatrix'of  the  navel  may 
be  observed  upon  one  side  of  it,  which  cicatrix  retains 
its  rugosity  and  all  its  natural  appearance ; a certain 
indication  that  the  viscera  are  not  protruded  through 
the  umbilical  ring. — {Scarpa,  Traiti  des  Hemies,  p 
336.) 

The  distinction  which  Scarpa  has  established  be 
tween  the  umbilical  hernia,  properly  so  called,  and 
those  of  the  linea  alba,  is  not  useless  in  regard  to 
practice.  Indeed,  when  the  latter  are  left  to  them 
selves  they  make  much  slower  progress  than  the  former 
On  account  of  their  smallness  they  frequently  escape 
notice,  particularly  in  fat  persons,  and  when  situated 
at  the  side  of  the  ensiform  cartilage.  They  occasion, 
however,  complaints  of  the  stomach,  habitual  colics, 
especially  after  meals ; and  unfortunately  for  the  pa- 
tient, he  may  be  tormented  a very  long  time  by  these 
indispositions,  before  the  true  cause  of  them  is  dis- 
covered. 

The  umbilical  hernia  may  be  known,  from  the 
earliest  period  of  its  formation,  by  the  alteration, 
which  it  produces  in  the  cicatrix  of  the  navel,  and  the 
rapidity  of  its  increase. 

In  other  respects,  these  two  kinds  of  herni®  demand 
the  same  means  of  cure  ; but  those  of  the  linea  alba, 
ccBterus  pariius,  are  more  difficult  to  cure  than  ruptures 
at  the  umbilicus.  This  is  probably  owing  to  the  na- 
tural tendency  which  the  umbilical  ring  has  to  close 
when  the  hernia  is  kept  well  reduced,  w’hile  acci- 
dental openings  in  the  linea  alba  have  not  the  same 
advantage. — (Scarpa,  p.  340.) 

When  a common  ventral  hernia  is  reduced,  it  should 
be  kept  in  its  place  by  means  of  a bandage  or  truss. 
When  strangulated,  it  admits,  more  frequently  than 
most  other  cases,  of  being  relieved  by  medical  treat- 
ment. If  attended  with  stricture,  which  cannot  other- 
wise be  relieved,  that  stricture  must  be  carefully  di- 
vided. Sir  A.  Cooper  recommends  the  valvular  incision 
and  the  dilatation  to  be  made,  either  upwards  or  down- 
wards, according  to  the  relative  situation  of  the  tumour 
and  eitigastric  artery,  which  crosses  the  lower  part  of 
the  linea  semilunaris. 

Pudendal  Hernia. — This  is  the  name  assigned  by 
Sir  Cooper  to  the  hernia  uluth  descends  between 


HERNIA. 


37 


the  vagina  and  ramus  isclui,and  forms  an  oblong  tu- 
mour in  the  labium,  capable  of  being  traced  within 
the  pelvis  as  far  as  the  os  uteri.  He  thinks,  that  this 
case  has  sometimes  been  mistaken  for  a Jiernia  of  the 
foramen  ovale.  When  reducible,  a common  female 
bandage,  or  the  truss  used  for  a prolapsis  ani  should  be 
worn.  A pessary,  unless  very  large,  coiild  not  well 
keep  the  parts  from  descending,  as  the  protrusion  hap- 
pens so  far  from  the  vagina.  Sir  A.  Cooper  is  of 
opinion,  that,  when  strangulated,  this  hernia,  in  con- 
sequence of  the  yielding  nature  of  the  parts,  may  ge- 
nerally be  reduced,  by  pressing  them,  with  gentle  and 
regular  force  against  the  inner  side  of  the  branch  of 
the  ischium.  If  not,  the  warm  bath,  bleeding,  and 
tobacco  clysters,  are  advised.  Were  an  operation  in- 
dispensable, the  incision  should  be  made  in  the  labium, 
the  lower  part  of  the  sac  carefully  opened,  and  with  a 
concealed  bistoury,  directed  by  the  finger,  in  the  vagina, 
the  stricture  should  be  cut  directly  inwards  towards  the 
vagina.  The  bladder  should  be  emptied  both  before 
the  manual  attempts  at  reduction  and  the  operation. — 
(On  Crural  Hernia^  Sre.p.  64.) 

Vaginal  Hernia— A.  tumour  occurs  within  the  os 
externum.  It  is  elastic  but  not  painful.  When  com- 
pressed, it  readily  recedes,  but  is  'reproduced  by  cough- 
ing, or  even  without  it  when  the  pressure  is  removed. 
The  inconveniences  produced  are  an  inability  to  un- 
dergo much  exercise  or  exertion ; for  every  effort  of 
this  sort  brings  on  a sense  of  bearing  down.  The 
vaginal  hernia  protrudes  in  the  space  left  between  the 
uterus  and  rectum.  This  space  is  bounded  below  by 
the  peritoneum,  which  membrane  is  forced  downwards 
towards  the  perineum ; but,  being  unable  to  protrude 
further  in  that  direction,  is  pushed  towards  the  back 
part  of  the  vagina.  In  one  case.  Sir  A.  Cooper  advised 
the  use  of  a pessary,  but  the  plan  was  neglected.  Pro- 
bably these  cases  are  always  intestinal. 

Some  herniae  protrude  at  the  anterior  part  of  the  va- 
gina.— (A.  Cooper  on  Crural  Hernia^  Src.  p.  65,  66.) 

Perineal  Hernia. — In  tnen,  the  parts  protrude  be- 
tween the  bladder  and  rectum  ; in  women,  between 
the  rectum  and  vagina.  The  hernia  does  not  project, 
so  as  to  form  an  external  tumour,  and,  in  men,  its  ex- 
istence can  only  be  distinguished  by  examining  in  the 
rectum.  In  women,  it  may  be  detected  both  from  tliis 
part  and  the  vagina. 

In  case  of  strangulation,  perhaps  this  hernia  might 
be  reduced  by  pressure  from  within  the  rectum.  An 
Interesting  case  of  perineal  hernia,  which  took  place 
from  the  peritoneum  being  wounded  with  the  gorgetin 
lothotomy,  is  related  by  Mr.  Bromfield. — (Chirurgical 
Ohs.p.  264.) 

The  reducible  perineal  hernia  in  women  may  be  kept 
from  descending,  by  means  of  a large  pessary.  Both 
this  kind  of  rupture  and  the  vaginal  may  prove  very 
dangerous  in  cases  of  pregnancy. — {See  Smellie's  Mid- 
wifery, case  5.) 

Sacro-rectal  Hernia.— In  a young  infant,  where  the 
ossification  of  the  sacrum  was  incomplete,  a protrusion 
is  said  to  have  been  met  with  through  an  opening  in 
that  bone.  The  possibility  of  such  a case  should  be 
remembered,  in  order  that  the  disease  may  not  be  mis- 
taken for  spina  bifida. — (See  Journ.  of  Foreign  Med. 
Mo.  VS,p.  61 G.) 

Thyroideal  Hernia,  or  Hernia  Foraminis  Ovale. — 
In  the  anterior  and  upper  part  of  the  obturator  liga- 
ment, there  is  an  opening,  through  which  the  obturator 
artery,  vein,  and  nerve  proceed,  and  through  which, 
occasionally,'  a piece  of  omentum  or  intestine  is  pro- 
truded, covered  with  a part  of  the  peritoneum,  which 
constitutes  the  hernial  sac. 

In  the  case  which  Sir  A.  Cooper  met  with,  the  her- 
nia descended  above  the  obturatores  muscles.  The 
os  pubis  was  in  front  of  the  neck  of  the  sac;  three- 
fourths  of  it  were  surrounded  by  the  obturator  liga- 
ment; and  the  fundus  of  the  sac  lay  beneath  the  pec- 
tineus  and  abductor  brevis  muscles.  The  obturator 
nerve  and  artery  were  situated  behind  the  neck  of  the 
sac,  a little  towards  its  inner  side.  This  species  of 
hernia  can  otdy  form  an  outward  tumour,  when  very 
large.  Gareiigeot,  however,  met  with  ati  instance,  in 
which  there  was  not  only  a swelling,  but  one  attended 
with  symptoms  of  strangulation  ; he  reduced  the  her- 
nia, which  went  up  with  a guggling  noise  ; the  .symp- 
toms were  slopped,  and  stools  soon  followed. 

The  hernia  of  the  foramen  ovale,  wheti  reducible, 
must  be  kept  up  with  a suitable  truss;  and  if  it  were 


strangulated,  and  not  capable  of  relief  from  the  usual 
means,  an  oi:^ration  would  be  requisite,  though  at- 
tended with  difficulties.  The  division  of  the  obturator 
ligament  and  mouth  of  the  sac  should  be  made  inwards 
to  avoid  the  obturator  artery.  If  this  vessel,  however 
were  to  arise  in  coiilmon  with  the  epigastric  artery,  it 
would  be  exposed  to  injury  by  following  this  plan. — 
(See  Garengeot  in  Mem.  de  I’Acad.  de  Chir.  1. 1.  A. 
Cooper  on  Crural  Hernia,  Src.  p.70.) 

Cystocele. — As  Mr.  Pott  observes,  “ the  urinary 
bladder  is  also  liable  to  be  thrust  forth  from  its  proper 
situation,  either  through  the  opening  in  the  oblique 
muscle,  like  the  inguinal  hernia,  or  under  Poupart’s 
ligament,  in  the  same  manner  as  the  femoral. 

“ This  is  not  a very  frequent  species  of  hernia,  but, 
does  happen,  and  has  as  plain  and  determined  a cha- 
racter as  any  other. 

“ It  has  been  mentioned  by  Bartholin,  T.  Dorn.  Sala, 
Platerus,  Bonetus,  Ruysch,  Petit,  Mery,  Verdier,  &c. 
In  one  of  the  histories  given  by  the  latter,  the  urachus, 
and  impervious  umbilical  artery  on  tJie  left  side  were 
drawn  through  the  tendon  into  the  scrotum,  with  the 
bladder;  in  another  he  found  four  calculi. 

“ Ruysch  gives  an  account  of  one  complicated  with 
a mortified  bubonocele.  Petit  says,  he  fell  several 
calculi  in  one,  which  were  afterward  disijiarged 
through  the  urethra. — (See  also  J.  O.  F.  John  de  inso- 
litd  Calculi  Ingentis  per  Scrotum  Exclusione.  Wit- 
tenberg, 1750.) 

“ Bartholin  speaks  of  T.  Dom.  Sala  as  the  first  dis- 
coverer of  the  disease,  and  quotes  a case  from  him,  in 
which  the  patient  had  all  the  symptoms  of  a stone  in 
his  bladder  ; the  stone  could  never  be  felt  by  the  sound, 
but  was  found  in  the  bladder  (which  had  passed  into 
the  groin)  after  death. 

“ As  the  bladder  is  only  covered  in  part  by  the  peri- 
toneuu!,  and  must  insinuate  itself  between  that  mem- 
brane and  the  obliciue  muscle,  in  order  to  pass  the 
opening  in  the  tendon,  it  is  plain  that  the  hernia  cystica 
can  have  no  sac,  and  that,  when  complicated  with  a 
bubonocele,  that  portion  of  the  bladder  which  forms 
the  cystic  hernia  must  lie  between  the  intestinal  hernia 
and  the  spermatic  cord,  that  is,  the  intestinal  hernia 
must  be  anterior  to  the  cystic. 

“ A cystic  hernia  may,  indeed,  be  the  cause  of  an  in- 
testinal one;  for  when  so  much  of  the  bladder  has 
passed  the  ring,  as  to  drag  in  tlie  upper  and  hinder 
part  of  it,  the  peritoneum  which  covers  that  part  must 
follow,  and  by  that  means  a sac  be  formed  for  the  re- 
ception of  a portion  of  gut  or  caul.  Hence  the  dif- 
ferent situation  of  the  two  hernias  in  the  same  subject. 

“ While  recent,  this  kind  of  hernia  is  easily  reducible, 
and  may,  like  the  others,  be  kept  within  by  a proper 
bandage;  but  when  it  is  of  any  date,  or  has  arrived  to 
any  considerable  size,  the  urine  cannot  be  discharged, 
without  lifting  up,  and  compressing  the  scrotum:  the 
outer  surface  of  the  bladder  is  now  become  adherent 
to  the  cellular  membrane,  and  the  patient  must  be  con- 
tented with  a suspensory  bag. 

“ In  case  of  complication  with  a bubonocele,  if  the 
operation  becomes  necessary,  great  care  must  be  taken 
not  to  ojien  the  bladder  instead  of  the  sac,  to  which  it 
will  always  be  found  to  be  posterior.  And  it  may  also 
sometimes  by  the  inattentive  be  mistaken  for  a hydro- 
cele, and  by  being,  treated  as  such  may  be  the  occasion 
of  greater  even  fatal  mischief.” — {Vol.  2.) 

The  cystocele  is  always  easily  distinguishable  by  the 
regular  diminution  of  the  swelling,  whenever  the  pa- 
tient makes  water. 

Verdier  and  Sharp  have  accurately  described  the 
cystocele.  Pott  has  offered  two  cases,  which  fell  under 
his  observation. — {Vol.  3.)  Pipelet  le  Jeune  mentions 
a cystic  hernia  in  perinajo,  and  several  cases  of  its 
occurrence  in  the  female. — {Acad,  de  Chir.  t.  4.)  Pott 
cut  into  one  cystocele  by  mistake.  Mention  is  made 
{Edin.  Surg.  .Jovrn.  vol.  4,  p.  512)  of  a cystic  hernia, 
which  protruded  between  the  origins  of  the  levator 
ani,  and  obturator  internus  muscles : the  tumour  made 
its  ap|)carance  in  the  pudendum  of  an  old  woman. 
Much  additional  information,  respecting  the  cystocele 
and  its  various  forms,  is  contained  in  the  second 
volume  of  the  First  Lines  of  Surgery,  p.  49,  ^c.  ed.  4, 
accc'mpanied  with  references  to  all  the  most  interesting 
writers  on  the  subject.  An  instance  of  protrusion  of 
the  bladder  through  a wound,  caused  by  a bullock’s 
horn,  is  recorded  by  Larrey.— (Jl/(f/K.  de  Chir.  Mil.  t.  4. 
P.  289.) 


38 


HERNIA. 


Ischiatic  Hernia. — This  disease  is  very  rare.  A 
case,  however,  which  was  strangulated,  and  undis- 
covered till  after  death,  is  related  in  Sir  A.  Cooper’s 
second  part  of  his  work  on  Iiernia.  ft  was  communi- 
cated by  Dr.  Jones,  so  celebrated  for  his  book  on 
hemorrhage.  The  disease  happened  in  a young  man, 
aged  27.  On  opening  the  abdomen,  the  ileum  was 
found  to  have  descended  on  the  right  side  of  the  rec- 
tum into  the  pelvis,  and  a fold  of  it  was  protruded  into 
a small  sac,  which  passed  out  of  the  pelvis  at  the  ischia- 
tic notch.  The  intestine  was  adherent  to  the  sac  at 
two  points:  the  strangulated  part,  and  about  three 
inches  on  each  side,  were  very  black.  The  intestines 
towards  the  stomach  were  very  much  distended  with 
air,  and  here  and  there  had  a livid  spot  on  them.  A 
dark  spot  was  even  found  on  the  stomach  itself  just 
above  the  pylorus.  The  colon  was  exceedingly  con- 
tracted, as  far  as  its  sigmoid  flexure.  A small  orifice 
was  found  in  the  side  of  the  pelvis,  in  front  of,  but  a 
little  above,  the  sciatic  nerve,  and  on  the  fore  part  of 
the  pyriformis  muscle.  The  sac  lay  under  the  glutaeus 
inaximus  m.uscle,  and  its  orifice  was  before  the  internal 
iliac  artery,  below  the  obturator  artery,  but  above  the 
vein.  Sir  A.  Cooper  remarks,  that  a reducible  case 
might  be  kept  up  with  a spring-truss;  and  that,  if  an 
operation  were  requisite,  the  orifice  of  the  sac  should 
be  dilated  directly  forwards. — [On  Crural  Hernia.,  4-c. 
p.  73.)  For  a further  account  of  the  ischiatic  hernia, 
and  references  to  the  most  iirteresting  works  on  the 
subject,  see  First  Lines  of  Surgery,  vol.  2,  p.  84,  &c. 

Phrenic  Hernia. — The  abdominal  viscera  are  occa- 
sionally protruded  through  the  diaphragm,  either 
through  some  of  the  natural  apertures  in  this  muscle, 
or  deficiencies,  or  wounds  and  lacerations  in  it.  The 
second  kind  of  case  is  the  most  frequent:  Morgagni 
furnishes  an  instance  of  the, first.  Two  cases,  related 
by  Dr.  Macauley  in  Med.  Obs.  and  Ing.  vol.  1,  two 
more  detailed  in  the  Medical  Records  and  Researches, 
and  two  others  published  by  Sir  A.  Cooper,  are  in- 
stances of  the  second  sort ; and  another  case  has  been 
lately  recorded  by  the  latter  gentleman,  affording  an 
example  of  the  third  kind.  A laceration  of  the  dia- 
phragm by  fractured  ribs,  has  produced  a hernia.  A 
case  of  this  kind  was  dissected  by  Mr.  Travers,  at 
Guy’s  Hospital. — (Med.,  Chir.  Trans,  vol.  6,  p.375.)  In 
this  last  volume  may  also  be  found  the  particulars  of 
an  interesting  example,  in  which  a considerable  part 
of  the  large  curvature  of  the  stomach  was  protruded 
through  a fissure  of  the  diaphragm.  The  accident  was 
unattended  with  any  fracture  of  the  ribs,  and  was 
caused  by  the  upsetting  of  a stage-coach,  on  which  the 
patient  was  an  outside  passenger.  Before  death,  he 
vomited  up  a large  quantity  of  blood,  and  a small  se- 
micircular aperture  was  discovered  on  dissection  in  the 
lower  part  of  the  strangulated  portion  of  the  stomach. 
— (P.  378,  379.)  See  also  B.  Stehelin,  Tentamen,  Med. 
quod  ventriculum,  qxii  in  thoracem  migraverat,  Src., 
describit,  1721  {in  Halleri  Disp.  Anal.  tom.  6.  p.  675). 
Hildanus,  Par6,  Petit,  Schenck,  &c.,  also  mention 
cases  of  phrenic  hernia.  The  disease  is  quite  out  of 
the  reach  of  art. 

Mesenteric  Hernia. — If  one  of  the  layers  of  the 
mesentery  be  torn  by  a blow,  while  the  other  re- 
mains in  its  natural  state,  the  intestines  may.  insinuate 
themselves  into  the  aperture,  and  forni  a kind  of  her- 
nia. The  same  consequence  may  result  from  a natural 
deficiency  in  one  of  these  layers.  Sir  A.  Cooper  re- 
cords a case,  in  which  all  the  small  intestines,  except 
• the  duodenum,  were  thus  circumstanced.  The  symp- 
toms during  life  were  unknown. — (On  Crural  Hernia, 
S,  c.,p.  82.) 

Mesocolic  Hernia.— So  named  by  Sir  Astley  Cooper, 
when  the  bowels  glide  between  the  layers  of  the  meso- 
cf)lon.  A specimen  of  this  disease  is  preserved  at  St. 
Thomas’s  Hospital. 

Every  surgeon  should  be  aware,  that  the  intestines 
may  be  strangulated  within  the  abdomen  from  the  fol- 
lowing causes:  1.  Apertures  in  the  omentum,  mesen- 
tery, or  mesocolon,  through  which  the  intestine  pro 
trudes.  2.  Adhesions,  leaving  an  aperture,  in  which 
a piece  of  intestine  becomes  confined.  3.  Membranous 
bands  at  the  mouths  of  hernial  sacs,  which,  becoming 
elongated  by  the  frequent  protrusion  and  return  of  the 
viscera,  surround  the  intestine,  so  as  to  strangulate 
them  within  the  abdomen,  when  returned  from  the 
sac. — {See  A.  Cooper  on  Crural  Hernia,  Si  C.,p.  85.) 

Pott  remarks,  that  “ Ruysch  gives  an  account  of  an 


impregnated  uterus  being  found  on  the  outside  of  the 
abdominal  opening  ; and  so  do  Hildanus  and  Sennertus. 
Ruysch  also  gives  an  account  of  an  entire  spleen  having 
passed  the  tendon  of  the  oblique  muscle.  And  I have 
myself  seen  the  ovaria  removed  by  incision,  after  they 
had  been  some  months  in  the  groin.” — ( Vol.  2.) 

[Two  formidable  cases  of  Congenital  Umbilical  Her- 
nia have  occurred  recently  in  IVew-York,  both  of 
which  were  irreducible,  and  operated  on  by  Professor 
Mott,  w'ithin  two  hours  after  birth.  The  first  of  these 
proved  fatal,  but  the  other  recovered. 

In  both  of  these  cases,  all  the  smaller  intestines,  the 
mesentery,  the  caput  coli,  and  transverse  arch,  with 
the  descending  colon  to  the  sigmoid  flexure,  were  con- 
tained in  the  umbilical  cord.  The  umbilical  aperture 
was  greatly  enlarged,  and  the  component  parts  of  the 
tumour  could  be  distinctly  recognised  through  the  trans- 
lucent coverings.  The  children  were  full-sized  and 
otherwise  healthy. 

The  operation  in  each  case  was  performed  in  the 
following  manner,  as  they  w'ere  very  similar  in  extent. 
The  intestines  were  exposed  by  cirtting  cautiously 
through  the  envelopes,  consisting  of  transparent  mem- 
brane, wdiich  was  a task  of  great  delicacy.  'I’he  arte- 
ries and  vein  were  each  tied  with  small  ligatures, 
about  half  an  inch  from  the  umbilical  aperture.  The 
quantity  of  intestiiies  protruded,  being  too  great  for  re- 
duction by  the  natural  opening,  this  was  enlarged  up- 
wards in  the  linea  alba  to  the  extent  of  half  an  inch, 
by  which  means  all  the  protruded  parts  were  returned 
into  the  abdomen,  and  each  intestine  placed  in  situ. 
The  opening  was  then  closed  by  the  interrupted  suture 
and  adhesive  plaster. 

The  adhesions  were  so  strong  and  numerous  in  the 
first  case,  and  the  intestines  so  much  contracted,  as 
to  afford  but  little  hope  of  succeeding  in  procuring  a 
discharge  through  them.  This  case  proverl  fatal,  as 
no  free  discharge  could  be  obtained  through  the 
bowels.  The  vomiting,  which  had  occurred  before  the 
operation, continued,  and  the  child  died  in  about  tw'enty- 
four  hours. 

In  the  second  case  the  adhesions  were  not  so  exten- 
sive, and  the  intestines  were  but  little  contracted.  This 
child  recovered  without  one  untoward  symptom,  and 
is  perfectly  well. — Rcese.'\ 

See  Franco,  Traitd  des  Hernies,  ^c.  Lyons,  1561. 
Lud.  von  Hammen,  De  Herniis,  Lugd.  1581.  Malach- 
Geiger,  Kelegraphia,  sive  Descriptio  Hemiarum,cum 
earundem  Curationibus,  tarn  Medicis,  quam  Chirurgi- 
cis,  \2mo.  Monachii,  1631.  Ant.  Le  Quin,  Le  Chirur- 
gien  Herniaire,  I'iino.  Paris,  1697.  Littre,  Observa- 
tion sur  une  Mouvelle  Espece  de  Hernie;  Mim.  de 
I' Acad,  des  Sciences,  1700.  Mery,  in  the  same  work, 
1701.  Littre  sur  une  Hemie  Rare ; same  work,  1714. 
Hcister,  Instit.  Chirurg.  et  de  Hernia  Incarceratd 
Suppuratd  non  semper  lethali.  Peyronie,  Observa- 
tions, ire.  sur  la  Cure  des  Hemies  avec  Gangrene ; 
Mem.  de  VAcad.  de  Chir.  t.  1.  J.  G.  Guvz,  Observa 
tionum  Anatomico-chirurgicarum  de  Herniis  Libellus, 
Lips.  1744 ; et  Prolusio  Invitatoria  in  qua  de  Entero- 
Epiplocele  agebat.  Lips.  1746.  P.  S.  Kok,  He  Herniis; 
Rvterod:  1782.  Arnaud  on  Hernias,  1748;  also  his 
Mini,  de  Chir.  Haller  de  Herniis  Congenitis,  1749. 
Garengeot  sur  plusieurs  Hemies  singuliires ; Mini, 
de  VAcad.  de  Chir.  t.  2.  Moreau  sur  les  Suites  d'une 
Hea-nie  Opirie ; Mini,  de  VAcad.  de  Chir.  t.  3.  Haller, 
Herniarum  Adnotationes ; extant,  in  Opuscul.  Pathol. 
1755.  Le  Blanc,  Mouvelle  Mitkode  d'opirer  les  Her- 
nies; avec  un  Essai  sur  les  Hernies,  par  M.  Hoin; 
Orleans,  1767. 8co.  Louis,  Riflfxions  sur  V Operation 
de  la  Hemic;  Mini,  de  VAcad.  de  Chir.  t.  A.  Hoin, 
Essai  sur  les  Hernies  rares  et  peu  connves,  1767. 
Medical  Observations  and  Inquiries.  Pott’s  Works, 
vols.  2 and  3.  Goursaud  sur  la  Difference  des  Causes 
de  V Etranglement  des  Hernies;  Mini,  de  VAcad.  de 
Chir.  i.  4.  Le  Hran,  Traiti  des  Opirat.ions  de  Chir 
et  Observations  de  Chir.  obs.  57.  F.  Hildanus,  cent.  5. 
obs.  54.  J.  L.  Petit,  Traiti  des  Mai.  Chir.  tom.  2.  5. 

Sharp  on  the  Operations,  and  his  Critical  Inquiry. 
Sir  Astley  Cooper  on  Inguinal  and  Congenital  Her- 
nia, folio,  London,  1804 ; and  on  Crural  and  Um- 
bilical Hernia,  folio,  London,  1807.  A.  Monro  on 
Crural  Hernia,  1803;  and  the  Morbid  Anatomy  of 
the  Human  Gullet,  Stomach,  and  Intestines,  8vo. 
Edinburgh,  1811.  Sabatier,  .Midecine.  Opiratuire,  t. 
1.  Chopart  et  Desault,  Parisian  Surgical  .Journal. 
JVrisberg,  in  Comment.  Reg.  Socict.  Getting.  1778 


HER 


HER 


S9 


Schmucker's  Vermischte  Chir.  Schriften.  Haller's 
Opera  Minora.,  and  Disputationes  Chir.  F.  X.  Rud- 
torffer,  Abhandluvg  iiber  die  einfachste  und  sicherste 
Operations-methode  F.ingesperrter  Leisten-und-Scken- 
kelbriiche,  2 bdnde,  8vo.  Wien,  1808.  SulVernie  Me- 
morie  Anatomico  chirurgiche  di  Jlntonio  Scarpa,  ediz. 
nuova,  1819;  or  the  French  transl.by  Cayol,  1812;  or 
the  English  by  Wishart.  C.  Bell's  Surgical  Observa- 
tions, pt.  2,  p.  177,  Src.  Eondon,  1816.  Lassus,  Patho- 
logie  Chir.  t.  l,p.  1,  <^c.  edit.  1^9.  Pelletan,  Clinique 
Chir.  t.  3.  B.  Travers  on  Injuries  of  the  Intestines, 
S,-c.  1812.  A case  of  Hernia  Fentriculi  through  d J.a- 
ceration  of  the  Diaphragm,  by  T.  Wheelwright,  in 
Med.  Chir.  Trans,  vol.  6,  p.374.  F.  C.  Hesselbach, 
Disquisitiones  Anatomico-pathologicae  de  Ortu  et  Pro- 
giessu  Herniarum  Inguinalium  et  Cruralium,  cum 
tab.  17,  ceneis,  4(o.  Wiirzburg,  1816:  the  original  edi- 
tion in  German  was  first  published  in  1806.  Also 
Beschreibung  und  Abbildung  eines  neucn  Instrumentes 
xur  sichern  Endeckung  nnd  Stilluvg  einer  beidem 
Briichschnitte  entstandenen  gcfdhrlichcn  Bliitung,  4to. 
Wiirzb.  1815.  Soemmering  iiber  die  Ursache,  S,-c.  der 
Briiche  am  Batichenund  Becken,  ausserder  Mabel  und 
Leistengegend,  8vo.  Frankof.  1811.  B.  G.  Schreger, 
Fersnche  Chirurgische,  t.  l.p.  149,  ^c.  Versiiche  zur 
Vervollkommung  der  Herniotomie,  8vo.  Miirnberg, 
1811.  Also  b.  2.  Ueber  einige  Hernien  ausser  der 
Mabel  und  Leistengegend,  p.  155,  8vo.  M'urnberg, 

1818.  F.  L.  Triistedt,  De  Extensionis  in  Solvendis 
Herniis  Cruralibus  incarceratis  prce  Incisione  proes- 
tantia,  ito.  Berol.  1816.  A.  C.  Hesselbach,  Die  Si- 
cherste Art  der  Bruchs chnittes  in  der  Leiste,  ^to. 
Bamb.  et  Wiirzb.  1819.  B.  G.  Seiler,  Observationes 
nonnullw  Testiculorum  ex  Abdomine  in  Scrotum  Des- 
censu,  et  Partium  Genitalium  Anomalis,  ito.  Lips. 
1817.  J.  Cloquet,  Recherches  Anat.  sur  les  Hernies, 
ito.  Paris,  1819.  C.  J.  M.  Langenbeck,  Commentarius 
de  Structurd  Peritoncei,  Testiculorum  Tunicis,  eorum- 
que  ex  Abdomine  in  Scrotum  Descensu  ad  illustrandam 
Herniarum  indolern,  8oo.  Gdtt.  1817.  For  some  valu- 
able remarks  on  the  two  preceding  works,  and  on  the 
anatomy  of  hernia,  see  Quarterly  Journal  of  Foreign 
Medicine,  vol.  \,p.  341,  Src.  Langenbeck,  Bibl.  fiirdie 
Chir.  b.  4,  St.  3 ; and  jsTeue  Bibl.  b.  2,  p.  112,  (S-c.  Gdtt. 

1819.  Walther  de  Hernid  Crurali,  ito.  Lips.  1820.  G. 
Breseket,  Considerations  stir  la  Hemie  Femorale,  in 
his  Concours,  d-c.  J.  Symes  on  the  Fascim  of  the 
Groin  ; Edin.  Med.  Journ.  Mo.  81,  p.  295.  But,  above 
all,  the  work  which  I feel  infinite  pleasure  in  recom- 
mending, from  a conviction  of  its  superior  merit,  is  a 
Treatise  on  Ruptures,  by  W.  Lawrence,  8vo.  ed.  i. 
Loud.  1824,  (S-c.  drc.  d'C. 

HERNIA  CEREB  RI.  Fungus  Cerebri.  Encepha- 
locele.)  There  are  two  principal  kinds  of  hernia  cere- 
bri : one  presents  itself  in  young  infants,  before  the 
ossification  of  the  skull  is  completed  ; the  other  takes 
place  after  the  destruction  of  a part  of  the  skull  by  the 
operation  of  the  trephine,  accidental  violence,  or  dis- 
ease. 

The  congenital  hernia  cerebri  of  infants  occurs,  how- 
eve'.,  in  two  very  different  forms  ; in  one,  it  is  covered 
by  the  scalp;  in  the  other,  the  corresponding  integu- 
ments of  the  head,  and  sometimes  even  the  dura  mater, 
are  deficient. 

The  common  encephalocele,  met  with  in  new-born 
children,  seems  to  originate  from  the  imperfect  ossifi- 
cation of  the  skull,  especially  in  the  situation  of  the 
fontanella  and  sutures.  This  case  is  characterized  by 
a soft  swelling,  of  an  equal  round  shape,  which  is 
attended  with  a pulsation  corresponding  to  that  of  the 
pulse : it  yields  and  disappears  under  pressure,  offers 
no  alteration  in  the  colour  of  the  skin,  and  is  circum- 
scribed by  the  margin  of  the  defective  portion  of  the 
skull. — {Ferrand,  in  Mini,  de  I'Acad.  de  Chir.  t.  13, 
12mo.  p.  102.)  In  general,  the  mental  faculties  are  not 
affected;  and  we  read  of  one  example,  in  which  a pa- 
tient had  such  a hernia  cerebri  thirty-three  years,  with- 
out his  intellects  ever  having  been  impaired  during  the 
whole  of  that  period. — {Op.  cit.  t.  5,  ito.  p.  863.) 

It  is  tolerably  well  established,  that  the  congenital 
hernia  cerebri,  which  arises  from  the  incomplete  ossi- 
fication of  the  skull,  and  is  covered  by  the  scalp,  ought 
to  be  treated  by  the  application  of  constant,  yet  mo- 
derate, pressure.  M.  Salleneuve  communicated  to  the 
Royal  Academy  of  Surgery  in  France  an  example  of 
the  good  effects  of  this  treatment,  which  reduces  the 
elze  of  the  tumour,  and  accomplishes  a perfect  cure  as  - 


soon  as  the  ossification  is  completed.  M.  Sallenetive 
put  a piece  of  thin  sheet  lead,  properly  covered  with 
soft  linen,  under  the  child’s  cap,  to  which  it  was 
sewed  in  a suitable  situation,  and  the  degree  of  pres- 
sure was  increased,  or  lessened,  according  as  ciicum- 
slances  required,  by  tightening  or  loosening  the  cap. — 
(Op.  cit.p.  103,  t.  13,  ed.  l^mo.) 

The  experience  of  Callisen  also  confirms  the  fact 
tliat  hernia  cerebri,  when  of  moderate  size,  may  be 
cured  by  the  foregoing  method,  the  aperture  becoming 
gradually  closed.  But  he  adds,  that  large  turhours  of 
this  description,  especially  when  situated  about  the 
occiput,  scarcely  admit  of  any  means  of  relief,  except 
the  employment  of  some  contrivance  to  protect  them 
from  external  injury. — (Callisen,  System.  Chir.  Ho- 
diernm,  vol.  2,p.  513,  514,  ed.  1800.) 

When  the  ossification  of  the  sutures  in  children  is 
late,  the  cerebellum,  as  well  as  the  cerebrum,  is  liable 
to  protrusion.  In  1813,  two  such  cases  occurred  at 
Paris.  In  one.  Professor  Lallement  mistook  the  dis- 
ease for  a common  tumour,  and  commenced  an  opera- 
tion for  its  removal,  when,  after  making  some  of  the 
necessary  incisions,  his  proceedings  were  stopped  by 
his  seeing  the  white  silvery  colour  of  the  dura  mater, 
and  that  the  swelling  came  out  of  an  aperture  in  the 
occipital  bone.  The  day  after  the  operation  the  child 
was  seized  with  violent  pain  in  the  head,  had  a hard 
pulse,  prostration  of  strength,  vomiting,  &;c.,  and  died 
in  the  course  of  a week.  On  dissection,  a part  of  the 
tentorium,  and  an  elongation  of  the  two  lobes  of  the 
cerebelluni,  about  as  large  as  a nut,  were  found  in 
the  protruded  sac  of  the  dura  mater.  Several  ab- 
scesses were  also  discovered  in  the  substance  of  the 
cerebeilum.  The  other  example  fell  under  the  obser- 
vation of  M.  Batfos,  principal  surgeon  to  the  Hdpital 
des  Enfans.  Upon  the  death  of  the  child,  the  dissec- 
tion evinced  similar  appearances. — (Richerand,  Moso- 
graphie  Chir.  t.  2,  p.  319,  ed.  4.) 

Such  facts  should  teach  the  surgeon  to  be  particu- 
larly cautious  in  ascertaining  the  nature  of  tumours 
about  the  back  part  of  the  head,  before  he  ventures  to 
attempt  their  removal. 

• The  second  kind  of  congenital  encephalocele  is  that 
in  which  not  only  large  portions  of  the  cranium,  but 
also  more  or  less  of  the  integuments  of  the  head,  are 
deficient.  It  is  rather  to  be  regarded  as  a malfornra- 
tion,  than  a disease,  and,  indeed,  in  most  instances, 
the  infants  are  stillborn.  The  case  sometimes  con- 
sists of  the  protrusion  of  most  of  the  brain  through  the 
inferior  and  posterior  fontanellse,  so  that  the  child  is 
born  with  a largish  bag,  on  the  back  of  its  head,  hang- 
ing down  over  the  posterior  part  of  the  neck.  Several 
specimens  of  these  malformations,  taken  from  infants 
born  in  the  Hospice  de  la  Maternity,  are  preserved  in 
the  museum  of  the  Facultd  de  M4decine  at  Paris. — 
(Richerand,  Mosogr.  Chir.  t.  2,  p.  316,  ed.  4.)  In  the 
year  1810,  a remarkable  case  of  this  last  description  of 
congenital  hernia  cerebri  was  published  by  Dr.  Bur- 
rows. “ The  whole  of  the  forehead,  summit,  and  a 
great  part  of  the  occiput,  were  deficient;  and  in  lieu  of 
them,  a substance  projected  of  a light  mulberry  colour, 
and  of  the  mushroom  form,  except  that  it  was  propor- 
tionably  broader.  From  the  deficiency  of  bone,  the 
eyes  appeared  to  project  much  more  than  usual.  The 
child  lived  six  days  without  either  taking  sustenance, 
or  having  any  evacuation.”  On  dissection,  the  scalp, 
the  os  frontis,  the  parietal,  and  a great  part  of  the  occi- 
pital bones,  were  wanting.  Through  the  parts,  at 
which  these  bones  were  deficient,  the  cerebrum  pro- 
jected, exhibiting  its  usual  convolutions.  In  was  co- 
vered with  the  pia  mater;  was  of  a mulberry  colour; 
appeared  to  be  more  vascular  than  the  pia  mater 
usually  is;  and  the  edge  of  the  scalp  adhered  to  the 
neck  of  the  tumour.  The  cerebellum  was  not  more 
than  one-fourth  of  its  usual  size;  for  the  posterior  part 
of  the  os  occipiiis  was  much  nearer  to  the  sella  tur- 
cica than  natural.  The  child  was  destitute  of  the 
power  of  voluntary  motion,  and  all  the  secretions  ap- 
peared to  be  stopped.— (See  Med.  Chir.  Trans,  vol. 
2,  ».  52.) 

The  most  interesting  species  of  hernia  cerebri  to  the 
practitioner,  is  that  which  sometimes  arises  after  the 
removal  of  a portion  of  the  skull  by  the  trephine,  or 
the  destruction  of  part  of  it  by  disease.  Various  ex- 
ample.s  of  this  disease  are  recorded  in  the  Hlemoirs  of 
the  French  Academy  of  Surgery,  snd  I have  myself 
seen  many  instances  of  it.  Although  the  case  has 


40 


HERNIA. 


attracted  considerable  notice,  modern  surgeons  are  fat 
from  entertaining  settled  opinions  concerning  the  ex- 
act nature  of  the  tumour. 

In  one  example,  recorded  by  Mr.  Abernethy,  the 
hernia  cerebri  arose  on  tlie  tentJi  day  after  trephining, 
and  was  as  large  as  a pigeon’s  egg.  The  pia  mater, 
covering  it,  was  inflamed;  and  a turbid  serum  was 
discharged  at  the  sides  of  the  swelling,  from  beneath 
the  dura  mater.  On  the  eleventh  day,  the  tumour 
was  as  large  as  a hen’s  egg,  smooth,  and  ready  to 
burst.  The  man  died  the  next  day.  On  examination, 
the  swelling  was  found  still  larger,  and  of  a dark  co- 
lour, with  an  irregular  granulated  surface.  This  ap- 
pearance was  owing  to  coagulated  blood,  which  ad- 
hered to  its  surface,  as  the  part  had  bled  so  much,  that 
the  patient’s  cap  was  rendered  quite  stiff  with  blood. 
The  pia  mater  was  in  general  much  inflamed,  and,  as 
well  as  the  dura  mater,  was  deficient  at  the  place  of 
the  tumour.  Tire  deeper  part  of  the  swelling  seemed  to 
consist  of  fibrous  coagulated  blood,  and  it  was  found 
to  originate  about  an  inch  below  the  surface  of  the 
brain. 

I Mr.  Abernethy  explains  the  formation  of  the  dis- 
ease as  follows;  “In  consequence  of  the  brain  being 
injured  to  some  depth  beneath  the  surface,  disease  of 
the  vessels  and  consequent  effusion  of  the  blood  had 
ensued  : the  effusion  was,  for  a lime,  restrained  by  the 
superincumbent  brain  and  its  membranes ; but,  these 
gradually  yielding  to  the  expansive  force  exerted  from 
within,  and  at  last  giving  way  altogether,  the  fluid 
blood  oozed  out  and  congealed  upon  the  surface  of 
the  tumour.”  An  organized  fungus  can  hardly  be 
produced  so  rapidly  as  these  tumours  are  formed. — 
(On  Injuries  of  the  Head,  in  Surgical  Works,  vol. 
2,  p.  53.) 

On  the  contrary,  Mr.  C.  Bell  declares,  that  the  swell- 
ing is  vascular  and  organized. — (Operative  Surgery, 
vol.  1.) 

' Dr.  John  Thomson  also  entertains  a different  opi- 
nion from  that  of  Mr.  Abernethy,  respecting  the  mode 
in  wliich  these  herniae  cerebri  are  formed  ; but  I ques- 
tion whether  he  may  not  iiave  confounded  with  Uie 
disease  now  under  consideration,  fungous  tumours  of 
the  dura  mater.  At  least,  some  of  the  cases  to  which 
he  alludes,  as  a reason  for  his  sentiment  concerning 
their  mode  of  formation,  irnist  have  been  the  disease 
60  well  described  by  M.  Louis. — (See  Dura  Mater.) 
Tlie  reader,  however,  must  judge  for  himself  from 
the  following  passage:  “In  a considerable  number  of 
those  who  had  the  cranium  severely  contused,  or  frac- 
tured by  musket-balls  (says  Dr.  Thomson),  fungous 
growths  took  place  through  the  openings,  which  had 
been  made  at  first  by  the  ball,  or  afterward  by  the 
trepan.  These  growths,  I am  inclined  to  believe,  are 
the  consequence  of  a conUision  of  the  substance  of 
the  brain,  and  of  the  membranes  that  cover  it,  wliich 
gives  rise  to  the  formation  of  a new  organized  sub 
stance,  different  in  its  texture  from  brain;  and  are 
not,  as  some  late  writers  would  endeavour  to  persuade 
us,  simply  protrusions  of  the  brain,  resulting  from  the 
removal  of  the  natural  resistance,  which  is  made  to 
them  by  the  dura  mater  and  cranium.  / have  known 
instances  of  substances,  similar  to  the.^c  growths, 
forming  on  the  surface  of  the  brain,  immediately  under 
the  place  where  the  cranium  had  received  a contusion, 
in  cases  in  which  the  trepan  had  not  been  applied,  or 
any  portion  of  the  cranium  removed. 

“ Fungus  of  the  brain,  in  the  greater  number  of  in- 
stances, in  which  we  had  an  opportunity  of  observing 
it,  was  accompanied  either  with  stupor  or  paralysis, 
and  other  symptoms  of  compressed  brain.  In  a frac- 
ture of  the  vertex  of  the  cranium,  produced  by  a mus- 
ket-ball, and  followed  by  a fungus  of  the  brain,  the 
paralysis  took  place  in  the  lower  extremities.  In  a 
case  of  wound,  made  by  a musket-ball  on  the  right  side 
of  the  forehead,  and  in  which  spiculac  of  bone  had  been 
driven  in  upon  the  brain,  a large  fungus  protruded. 
The  formation  of  this  fungus  was  followed  by  slow 
pulse,  stupor,  dilated  pupil.s(  slight  strabismus,  and  dis- 
tortion of  the  mouth.  In  the  progrc.ss  of  this  case,  es- 
charotics  were  applied  to  the  fungus,  portions  of  it 
were  torn  off  by  the  patient,  and  all  of  it  that  was  ex- 
terior to  the  cranium  was  twice'  pared  oft'  by  the  knife, 
with  an  apparent  alleviation,  rather  than  aggravation, 
of  the  symptoms.  On  the  death  of  this  patient,  nearly 
the  whole  of  the  right  hemisphere  of  the  brain  was 
found  converted  iuto  a soft  pulpy  mass.  Tire  left, 


hemisphere  was  not  changed  in  structure,  though 
much  vascular  turgescence  appeared  on  its  surface.” — 
(See  Dr.  .7.  Thomson's  Report  of  Observations  made 
in  the  Military  Hospitals  in  Belgium,  p.  57,  58.) 

From  the  investigations  of  Mr.  Stanley,  the  fact  is 
placed  beyond  all  doubt,  that  a part  of  the  brain  occa- 
sionally constitutes  the  substance  of  herniiE  cerebri 
and  he  thus  confirms  the  opinion  fbrmerly  entertained 
upon  this  i)oint  by  Quesnay  and  Louis.  Thus,  in  the 
first  case  which  Mr.  Stanley  has  recorded,  “ the  whole 
tumour  was  sliced  off  with  a scalpel.  During  the 
operation,  the  boy  gave  no  manifestation  of  positive 
pain,  although  not  unconscious  of  what  we  were 
doing.  Considerable  hemorrhage  took  place  from  the 
surface  of 'the  brain,  exposed  by  the  removal  of  the 
tumour,  the  blood  being  thrown  with  great  force,  and 
to  a considerable  distance,  from  numerous  vessels, 
which  were  attempted  to  be  secured,  but  ineffectually 
by  ligatures.  After  a short  time,  however,  the  bleeding 
ceased.  On  examination  of  the  part,  which  had  been 
cut  off,  its  exterior  was  found  to  consist  merely  of  a 
layer  of  the  coagulated  blood  ; the  rest  of  the  mass  was 
brain,  possessing  a natural  appearance,  the  distinction 
between  ike  cortical  and  medullary  matter  being  readily 
seen,  with  the  convolutions  and  pia  mater  dipping 
down  between  them.”  In  the  dissection  after  death, 
“ all  that  part  of  the  dura  mater  adjacent  to  the 
ulcerated  aperture,  through  which  the  brain  had 
protruded,  was  black,  sloughy,  and  much  thickened. 
Tlie  exposed  surface  of  the  brain,  from  which  the  por- 
tion had  been  cut  off,  exhibited  a softened  and  broken- 
down  texture;  a state  of  disorganization,  which  ex- 
tended deep  into  its  substance.  About  an  ounce  of 
fetid  and  dark-coloured  fluid  was  found  between  the 
dura  mater  and  arachnoid  membrane.  Several  small 
eflusions  of  blood  were  met  with,  both  between  the 
membranes  and  in  the  substance  of  the  brain.  The 
arachnoid  membrane  was  thickened  and  opaque  over 
each  hemisphere.  The  vessels  on  the  surface,  and  in 
the  substance  of  the  brain,  were  remarkably  free  from 
blood.  The  lateral  ventricles  were  large,  and  filled 
with  transparent  fluid,  and  there  was  some  found  be- 
tween the  membranes  at  the  basis,  so  that,  altogether, 
the  quantity  from  these  two  sources  was  very  con- 
siderable.”— (See  Med.  Chir.  Trans,  vol.  8,  p.  15 — 17.) 
In  another  dissection,  a considerable  quantity  of  pus 
was  found  on  the  arachnoid  membrane,  on  each  side 
of  the  falx.— (F.  27.)  In  most  of  the  cases  of  hernia 
cerebri,  which  I have  seen,  the  patient  was  at  first 
more  or  less  sensible,  but  labouring  under  severe  ner- 
vous agitation.  The  stupor,  paralysis,  and  other 
symptoms  of  compressed  brain,  noticed  by  Dr.  J. 
Thomson,  did  not  take  place  till  the  latter  stage  of 
the  disease,  and  then  convulsive  twitches  of  the  mus- 
cles and  strabismus  occasionally  came  on. — (See  Med. 
Chir.  Trans,  p.  26.)  The  disease  is  usually  attended 
with  great  frequency  of  the  pulse. 

With  regard  to  the  cause  of  the  protrusion,  it  is  a 
subject  very  difficult  of  explanation,  because  if  the 
origin  of  the  tumour  depended  simply  on  the  removal  of 
a portion  of  the  skull,  or  on  any  changes  of  the  di- 
mensions of  the  brain  in  expirationj  the  effect  would 
always  follow  such  causes,  and  prevail  in  all  patients. 
From  the  particulars  of  the  dissections,  performed  by 
Mr.  Abernethy  and  Mr.  Stanley,  and  those  referred  to 
by  Dr.  J.  Thomson,  it  is  clear,  that  the  hernia  cerebri 
is  a disease  connected  with  deep-seated  changes 
throughout  a great  part  of  the  brain.— (See  also  Lar- 
rey,  Mdm.  de  Chir.  Mai.  t.  4,  p.  206.)  The  substance 
of  this  organ  is  found  more  or  less  pulpy  and  disorgan- 
ized ; and  after  death  large  effusions  of  serum,  and 
even  sometimes  of  blood,  and  purulent  matter,  are 
observed.  These  appearances  leave  no  doubt  of  the 
disease  being  associated  with  inflammatory  action 
within  the  head.  It  is  highly  probable,  therefore,  that 
a hernia  cerebri  is  only  produced  when  these  deep- 
seated  changes  arc  conjoined  with  the  removal  of  bone. 
The  changes  alluded  to  may  be  supposed  to  cause  an 
increase  in  the  general  contents  of  the  skull,  and  thus 
a disposition  to  protrusion,  as  rapid  as  the  scrum  and 
Ollier  fluids  are  eflused.  This  statement,  however,  can 
only  be  received  :.s  an  hypothesis,  because  we  find, 
that  in  one  of  the  dissections,  described  by  Mr.  Stanley, 
“there  existed  a considerable  space  between  the  upper 
sill  face  of  the  right  hcniisi>hore,  all  around  the  situation 
of  the  protrusion,  and  the  internal  surface  of  the  dura 
mater,  while,  in  every  oilier  part,  the  brain  and  dura 


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41 


mater  were  inclose  contact.”— (See  Med.  Oar.  Trans, 
vol.  8,  p.  27.)  Now,  the  idea  of  an  empty  space  within 
the  cranium  is  rather  inconsistent  with  the  supposition, 
that  the  brain  is  tlirust  out,  in  consequence  of  clianges, 
which  augment  the  quantity  of  the  general  contents  of 
the  skull,  unless  such  space  were  filled  with  air,  that 
had  no  external  communication. 

When  the  bad  symptoms  disappear,  on  the  tumour 
being  no  longer  confined  by  the  dura  mater,  some  prac- 
titioners deem  it  best  to  interfere  as  little  as  possible, 
and  let  the  tumour  drop  off  in  pieces. — (See  Edinb. 
Med.  Comment,  vol.  1,  p.  98 ; Med.  Museum,  vol.  4, 
p.  463.)  The  mildest  dressings  are  to  be  employed; 
but  whether  the  protrusion  should  be  resisted  by  pres- 
sure or  not  seems  unsettled. 

When  the  tumour  acquires  considerable  size,  it  may 
be  pared  off  with  a knife,  as  was  done  by  Mr.  Hill,  in 
several  instances,  with  success. — {Cases  in  Surgery, 
8vo.  Edinb.  1772.) 

In  one  of  the  cases  published  by  Mr.  Stanley,  the 
patient,  a boy  about  eleven  years  of  age,  recovered 
after  the  upper  part  of  the  tumour  had  been  pared  off, 
and  some  of  the  removed  substance  was  found  to  con- 
sist decidedly  both  of  cortical  and  medullary  substance. 
In  this  instance,  the  reproduction  of  the  tumour  was 
checked  by  firm  pressure  with  graduated  compresses 
and  a bandage.  The  protruded  brain  gradually  lost 
its  natural  colour : it  acquired  a light  yellow  appear- 
ance, was  split  into  several  portions,  and  a very  fetid 
odour  exhaled  from  it.  Its  substance  daily  became 
softer,  ultimately  acquiring  almost  a semi-fluid  state, 
and,  in  this  condition,  the  whole  mass  gradually  wasted 
away.  Fresh  granulations  arose  to  fill  up  the  va- 
cancy, and  they  were  manifestly  produced  from  the 
exposed  substance  of  the  brain.  Compression  being 
continued,  the  part  now  quickly  healed  «p.— (See  Med. 
Chir.  Trans,  p.  20,  21.)  In  a third  case,  the  part  of 
the  tumour  cut  off  consisted  entirely  of  cortical  and 
medullary  substance,  quite  healthy  in  its  appearance 
(p.  24) ; and  subsequently  granulations  were  formed 
from  the  exposed  surface  of  the  brain.  The  case, 
however,  had  a fatal  termination.  By  the  removal  of 
the  swelling,  and  the  use  of  compression,  one  cure  was 
effected  by  Mr.  Pring. — (See  Edinb.  Med.  and  Surgical 
Jovm.  vol.  9.) 

Richerand  affirms,  indeed,  generally,  that  when  the 
brain  is  exposed,  in  consequence  of  an  injury  of  the 
head,  the  encephalocele  should  be  cut  down  with  a 
knife,  and  repressed  by  gentle  compression. — (See  Mo- 
sogr.  Chir.  t.  2,  p.  318,  ed.  4.) 

Sir  A.  Cooper  is  also  an  advocate  for  pressure,  made 
with  adhesive  plaster;  and  a compress  of  lint  wet  with 
liquor  calcis;  his  aim  is  to  reduce  the  swelling  to  a 
level  with  the  bone,  when,  he  says,  the  scalp  will  heal 
over  it. — {Lectures,  vol.  1,  p.  317.) 

The  eases  published  by  M r.  Stanley  are  rather  fa- 
vourable to  the  employment  of  pressure,  inasmuch  as 
it  appeared  evidently  to  check  the  protrusion,  and  was 
mostly  borne  without  inconvenience. 

The  idea,  however,  that  when  the  brain  protrudes 
through  the  dura  mater,  pressure  can  effect  its  return, 
is,  as  .Mr.  Stanley  judiciously  observes,  quite  untenable. 
— {Med.  Chir.  Trans,  vol.  8,  p.36.) 

(iuesnay  mentions  an  instance  in  which  a patient 
tore  off  the  protruded  mass  himself,  and  the  cavity 
healed  up.—{Mim.  de  I'Jicad.  de  Chir.  t.  1.)  Van 
Svvieten  relates  a case  in  which  the  swelling  was  re- 
peatedly removed  with  a ligature,  and  a cure  ensued. 
— {Comment,  t.  1,  p.  440.)  The  danger  of  applying 
styptics  and  irritating  applications  is  shown  by  Ilil- 
danus  {Obs.  14),  and  Mr.  Hill  {p.  198). 

Baron  Larrey  considers  the  treatment  by  excision, 
pressure,  and  spirituous  applications  hurtful  and  dan- 
gerous; his  advice  is  merely  to  apply  to  the  swelling  a 
pledget  of  slightly  camphorated  oil  of  chamomile;  to 
have  recourse  to  cooling  aperient  beverages;  to  re- 
move all  kinds  of  irritation  ; to  exclude  the  air;  and 
apply  the  dressings  with  great  gentleness.  By  these 
means,  the  only  case  which  Larrey  ever  saw  recover 
was  saved,  and  in  it  the  tumour  was  small.— (Af<^/n.  de 
Chir.  Mil.  t.4,  p.206  ) 

One  would  suppose  that  cases  of  this  kind  must  ge- 
nerally require  the  employment  of  every  thing  at  all 
likely  to  keep  off  and  diminish  inflammation  of  the 
brain.  Que.onay  sur  la  Mvltiplicite  des  Trepans,  in 
Mem.  de  V Jlcad.  Royale  de  Chirurgic,  t.  2,  p.  25.  56, 
edit.  l2mo.  M.  Corvin's  Dissert,  in  Haller's  Dis- 


putat.  Chir.  vol.  2.  Mimoire  sur  V Encephalocele,  par 
M.  Ferrand,  in  Mim.  de  V Jlcad.  de  Chir.  1. 13,  p.  96, 
ed.  \2mo.  Lassus,  Pathologic  Chir.  t.  2,  p.  140,  ed. 
1809.  Abernethy' s Essays  on  Injuries  of  the  Head. 
Hill's  Cases  in  Surgery.  Burrows,  in  Med.  Chir. 
Trans,  vol.  2.  Callisen,  Systema  Chirurgice  Hodier- 
nw,vol.2,  ;>.512,  ed.  1800.  C.  Bell's  Operative  Sur- 
gery, vol.  1.  Richter's  Anfangsgriinde  der  Wundari- 
ney/cunst,  b.  2,  p.  197,  ed.  1802.  Richerand,  FTosogra- 
phie  Chir.  t.  2,  p.  316,  ed.  4,  Paris,  1815.  Dr.  J. 
Thomson' s Report  of  Observat^ms  made  in  the  Mili- 
tary Hospitals  in  Belgium,  p.  57,  Edinb.  1816.  Del- 
pech,  Pricis  Elimentaire  des  Maladies  Chirurgicales, 
t.  2,  p.  447,  ct  seq.  Paris,  1816.  Crell  and  Sand,  in 
Haller's  Disput.  Chir.  t.  I.  E.  Stanley,  in  Med. 
Chir.  Trans,  vol.  8;  a paper  containing  many  valuable 
observations.  Larrey,  in  M^m.  de  Chir.  Mil.  t.  4,  p. 
203,  S'C.  Hennen's  Military  Surgery,  p.  311,  <!^c.  ed  2. 
A.  Solomons,  De  Cirebri  Tumoribus,  Edinb.  1810. 
.7.  C.  Schoenlein  von  der  Hirnmetamorphosc,  8vo. 
TViirzb.  1816. 

HERNIA  HUMORALIS.  An  inflammation  of  the 
testicle,  especially  when  produced  by  irritation  in  the 
urethra,  gonorrheea,  the  use  of  bougies,  &c.  As  the 
term  is  founded  upon  the  old  and  now  exploded  doc- 
trine of  the  translation  of  humours  from  one  part  to 
another,  the  sooner  its  employment  is  abandoned  the 
better.  The  case  is  considered  under  the  word  Tes- 
ticle. 

rit  would  seem  fVom  this  reference  to  the  word 
“ Testicle,”  and  from  the  entire  omission  of  the  article, 
contained  in  the  former  editions  of  the  dictionary,  on 
the  Hernia  Humoralis,  that  Mr.  Cooper  designed  to 
give  this  subject  a special  notice  under  the  word  “ Tes- 
ticle.” The  reader  will  be  surprised  to  find  that  he 
has  entirely  overlooked  this  his  obvious  design;  for 
under  that  word  this  disease  is  only  mentioned  once, 
and  that  incidentally.  As  Mr.  Cooper  doubtless  had 
good  reasons  for  considering  this  among  the  other  dis- 
eases of  the  testicle,  and  its  omission  there  is  the  effect 
of  accident,  I have  concluded  to  supply  the  omission 
under  that  word,  and  leave  the  reference  in  this  place 
as  I find  it.  I hope  in  this  particular  I shall  comply 
with  the  author’s  original  intention. — Reese.] 

HERPES.  (From  epna)  to  creep.) 

Nothing  could  be  more  confused  and  undefined  than 
the  idea  conveyed  by  the  term  herpes,  as  generally  em- 
ployed by  medical  men  until  a few  years  ago.  In  fact, 
numerous  cutaneous  diseases,  of  the  most  opposite 
kinds,  but  which  had  a tendency  to  creep  or  spread 
slowly  were  designated  as  specimens  of  herpes.  Thus, 
when  I first  entered  the  profession,  it  was  common  for 
some  of  the  most  eminent  surgeons  in  London  fre- 
quently to  call  noli  me  tangere,  or  lupus,  herpes  of  the 
nose ; and  to  apply  the  same  term  to  tinea  capitis,  or 
the  porrigo  favosa. 

Happily,  this  vague  mode  of  regarding  diseases  of 
the  skin  is  beginning  to  give  way  to  the  judicious  dis- 
tinctions proposed  by  the  late  Dr.  Willan,  and  so  ably 
perfected  by  Dr.  Bateman.  The  appellation  herpes  is 
limited  by  these  physicians  “to  a vesicular  disease, 
which  in  most  of  its  forms  passes  through  a regular 
course  of  increase,  maturation,  and  decline,  and  ter- 
minates in  about  ten,  twelve,  or  fourteen  days.  The 
vesicles  arise  in  distinct  but  irregular  clusters,  which 
commonly  appear  in  quick  succession,  and  they  are 
set  near  together,  upon  an  inflamed  base,  which  ex- 
tends a little  way  beyond  the  margin  of  each  cluster. 
The  eruption  is  preceded,  when  it  is  extensive,  by 
considerable  constitutional  disorder,  and  is  accom- 
panied with  a sensation  of  heat  and  tingling,  sometimes 
with  severe  deep-seated  pain,  in  the  parts  affected. 
The  lymph  of  the  vesicles,  which  is  at  first  clear  and 
colourless,  becomes  gradually  milky  and  opaque,  and 
ultimately  concretes  into  scabs:  but  in  some  cases  a 
copious  discharge  of  it  takes  place,  and  tedious  ulcer- 
ations ensue.  3’he  disorder  is  not  contagious  in  any 
of  its  forms.” — (See  Bateman's  Practical  Synopsis  of 
Cutaneous  Diseases,  p.  221,  222,  ed.  3.)  This  author 
notices  six  species  of  the  complaint : viz.  herpes 
phlyctaenodes  ; herpes  zoster ; herpes  circiriatns;  her- 
pes labialis;  herpes  pracputialis;  and  herpes  iris. 

As  most  of  these  cases  more  properly  belong  to  tlie 
physician  than  surgeon,  I shall  briefly  describe  thr.3e 
of  them. 

According  to  Dr.  Bateman,  the  herpes  zoster,  or 
shingles,  is  mostly  preceded  for  two  or  three  days  by 


43 


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languor  and  loss  of  appetite,  rigours,  headache,  sickness, 
and  a frequent  pulse,  together  with  a scalding  heat  and 
tingling  in  the  skin,  and  shooting  pains  through  the 
chest  and  epigastrium-  Sometimes,  however,  tlie 
precursory  febrile  symptoms  are  very  slight.  Upon 
some  part  of  the  trunk  several  red  patches  occur,  of 
an  irregular  form,  at  a little  distance  from  each  other, 
upon  each  of  which  numerous  small  elevations  appear 
clustered  together.  These,  if  examined  minutely,  are 
found  to  be  distinctly  vesicular;  and  in  the  course  of 
twenty-four  hours  they  enlarge  to  the  size  of  small 
pearls,  and  are  perfectly  transparent,  being  filled  with 
a limpid  fluid.  For  three  or  four  days  fresli  clusters 
continue  to  arise,  always  extending  themselves  nearly 
in  a line  with  the  first,  towards  the  spine  at  one  end, 
and  towards  the  linea  alba  at  the  other.  While  the  new 
clusters  are  appearing,  the  vesicles  of  the  first  lose 
their  transparency,  and,  on  the  fourth  day,  acquire  a 
milky  or  yellowish  hue,  which  is  soon  followed  by  a 
bluish  or  livid  colour  of  the  basis  of  the  vesicles,  and 
of  the  contained  fluid.  They  now  become  somewhat 
confluent,  and  flatten  or  subside.  About  this  time  they 
frequently  break  and  discharge,  for  three  or  four  days, 
a serous  fluid,  which  at  length  concretes  into  thin  dark 
scabs.  These  fall  ofl"  about  the  twelfth  or  fourteenth 
day,  leaving  the  surface  of  the  subjacent  skin  in  a red 
and  tender  state;  and  when  the  ulceration  and  dis- 
charge have  been  considerable,  numerous  cicatrices  or 
pits  are  left.  All  the  clusters  go  through  a similar  se- 
ries of  changes. 

Young  persons,  from  the  age  of  twelve  to  twenty- 
five,  are  most  frequently  affected;  although  aged  per- 
sons are  not  altogether  exempt  from  the  complaint, 
and  suffer  severely  from  the  pain  of  it.  Summer  and 
autumn  are  the  seasons  in  which  it  is  most  common. 
Sometimes  it  supervenes  to  bowel  complaints,  and  the 
chronic  pains  remaining  after  acute  pulmonary  dis- 
eases. In  the  treatment.  Dr.  Bateman  thinks  gentle 
laxatives  and  diaphoretics,  with  occasional  anodynes, 
when  the  severe  deep-sealed  pains  occur,  all  that  is 
necessary.  No  external  application  is  requisite,  unless 
the  vesicles  be  abraded  by  the  friction  of  the  clothes, 
which  are  then  liable  to  adhere  to  the  parts : in  this 
case,  a little  simple  ointment  may  be  interposed.  For 
a fuller  account,  see  Bateman's  Bract.  Synovsis,  p. 
226,  &c. 

Herpes  circinatus,  or  ringworm,  makes  its  appear- 
ance in  small  circular  patches,  in  which  the  vesicles 
arise  only  round  the  circumference;  these  are  small, 
with  moderately  red  bases,  and  contain  a transparent 
fluid,  which  is  discharged  in  three  or  four  days,  when 
little  prominent  dark  scabs  form  over  them.  The  cen- 
tral area  in  each  vesicular  ring  is  at  first  free  from  any 
eruption ; but  the  surface  becomes  somewhat  rough, 
and  of  a dull  red  colour,  and  throws  off  an  exfoliation, 
as  the  vesicular  eruption  declines,  which  terminates  in 
about  a week  with  a falling  off  of  the  scabs.  A suc- 
cession of  these  vesicular  circles  usually  arises  on  the 
face  and  neck,  or  arms  and  shoulders,  thus  protracting 
the  case  for  two  or  three  weeks. 

The  itching  and  tingling,  which  are  the  only  incon- 
veniences of  the  affection,  may  be  relieved  by  the 
application  of  the  popular  remedy,  ink,  solutions  of  the 
salts  of  iron,  copper,  zinc,  borax,  alum,  &c.  Some 
additional  interesting  observations  on  other  forms  of 
the  herpes  circinatus  may  be  found  in  Dr.  Bateman’s 
Synopsis,  from  which  I have  extracted  the  few  pre- 
ceding particulars. 

Herpes  prceputialis.  This  local  variety  of  herpes 
was  not  noticed  by  Dr.  Willan,  and  we  are  indebted  to 
Dr.  Bateman  for  a description  of  it.  The  complaint 
begins  with  extreme  itching,  and  with  some  sense  of 
heat  in  the  prepuce,  on  which  one  or  two  red  patches 
occur,  about  the  size  of  a silver  penny.  Upon  these 
are  clustered  five  or  six  minute  transparent  vesicles. 
In  twenty-four  or  thirty  hours  the  vesicles  enlarge, 
become  of  a milky  hue,  and  lose  their  transparency ; 
and  on  the  third  day  they  are  coherent,  and  have 
almost  a pustular  appearance.  If  the  eruption  is 
seated  on  that  surface  of  the  prepuce  w!)ich  is  next  the 
glans,  so  that  the  vesicles  are  kept  moist,  they  com- 
monly break  about  the  fourth  or  fifth  day,  and  form  a 
small  ulceration  upon  each  patch.  This  discharges  a 
little  turbid  serum,  and  has  a white  base,  with  a slight 
elevation  at  the  edges ; and  by  an  inaccurate  or  inex- 
perienced observer  it  may  readily  be  tnistaken  for 
cJiancre,  more  especially  if  any  escharotic  h.is  been 


applied,  which  produces  irritation,  and  a deep-seated 
hardness  like  that  of  a true  chancre.  If  not  irritated, 
the  slight  ulceration  begins  to  heal  about  the  ninth  or 
tenth  day.  When  the  patches  occur  on  the  outside  of 
the  prepuce,  the  duration  of  the  eruption  is  shorter, 
and  ulceration  does  not  actually  take  place. 

In  the  treatment.  Dr.  Bateman  recommends  the 
avoidance  of  all  stimulating,  and  moist,  or  unctuous 
applications ; and  if  the  complaint  be  within  the  pre- 
puce, he  advises  the  interposition  of  a little  bit  of  dry 
lint  belw'een  the  sore  and  the  glans. 

As  this  gentleman  has  truly  remarked,  this  case  is 
particularly  deserving  of  notice,  because  it  has  often 
been  considered  and  treated  as  a chancre. 

For  a great  deal  more  valuable  information  respecting 
herpes,  I beg  leave  to  refer  the  reader  to  the  publica- 
tions ofDrs.  Willan  and  Bateman,  and  also  to  the  arti- 
cle Herpes,  writteir  by  this  last  able  physician  for  Dr. 
Rees’s  Cyclopaedia. 

HORDEOLUM.  (Dim.  of  Aordewan,  barley.)  A little 
tumour  on  the  ey  elid,  resembling  a bat  ley-corn.  A stye. 
As  Scarpa  remarks,  the  stye  is  strictly  only  a little  boil, 
which  projects  from  tlieedgeof  the  eyelids,  frequently 
near  the  great  angle  of  the  eye.  Like  the  furunculus, 
it  is  of  a dark-red  colour,  much  inflamed,  and  a great 
deal  more  painful,  than  might  be  expected,  considering 
its  small  size.  The  latter  circumstance  is  partly  owing 
to  the  vehemence  of  the  inflammation,  and  partly  to 
the  exquisite  sensibility  and  tension  of  the  skin  covering 
th  e edge  of  the  eyelids.  On  th  is  account  the  hordeol  tun 
very  often  excites  fever  and  restlessness  in  delicate, 
irritable  constitutions  ; it  suppurates  slowly  and  imper- 
fectly ; and,  when  suppurated,  has  no  tendency  to  burst. 

The  stye,  like  other  furunculous  inflammations, 
forms  an  exception  to  the  general  rule,  that  the  best 
mode  in  which  inflammatory  swellings  can  end  is  re- 
solution. For,  whenever  a furunculous  inflammation 
extends  so  deeply  as  to  destroy  any  of  the  cellular  sub- 
stance, the  little  tumour  can  never  be  resolved,  or  only 
imperfectly  so.  This  event,  indeed,  would  rather  be 
hurtful,  since  there  would  still  remain  behind  a greater 
or  smaller  portion  of  dead  cellular  membrane ; which, 
sooner  or  later,  might  bring  on  a renewal  of  the  stye  in 
thesame  place  as  before,  or  else  become  converted  into  a 
hard  indolent  body,  deforming  the  edge  of  the  eyelid. 

The  resolution  of  the  incipient  hordeolum  may  be 
effected  in  that  stage  of  it  in  which  the  inflammation 
only  interests  the  skin,  and  not  the  cellular  substance 
underneath,  as  is  the  case  on  the  first  appearance  of 
the  disease.  Now  repellent  cold  applications  are  useful, 
particularly  ice.  But  when  the  hordeolum  has  affected 
and  destroyed  any  of  the  cellular  membrane  under- 
neath, every  topical  repellent  application  is  absolutely 
useless,  and  even  hurtful;  and  the  patient  should  have 
recourse  to  emollient  anodyne  remedies.  The  horde- 
olum and  eyelids  should  be  covered  with  a warm  soft 
bread  and  milk  poultice,  which  ought  to  be  renewed 
very  often.  When  a white  point  makes  its  appearance 
on  the  apex  of  the  little  tumour,  Scarpa  says,  the  sur- 
geon should  not  be  in  a hurry  to  let  out  the  small  quan- 
tity of  serous  matter,  which  exists  between  the  skin 
and  dead  portion  of  cellular  membrane.  It  is  better 
that  he  should  wait  till  the  skin  within  this  white 
point  has  become  somewhat  thinner,  so  as  to  burst  of 
itself,  and  give  ready  vent,  not  merely  to  tJie  little  se- 
rous matter,  but  to  all  the  dead  cellular  membrane 
which  constitutes  the  chief  part  of  the  disease.  When 
the  contents  of  the  little  tumour  are  slow  in  making 
their  way  outw'ards,  through  the  opening,  the  surgeon, 
gently  compressing  the  base  of  the  stye,  ought  to  force 
them  out.  After  this,  all  the  symptoms  of  the  disease 
will  disappear,  and  the  cavity,  left  by  the  dead  cellular 
membrane  in  the  centre  of  the  little  tumour,  will  be 
found  quite  filled  up  and  healed,  in  the  course  of  twenty- 
four  hours. 

Sometimes,  though  seldom,  this  process  of  nature, 
destined  to  detach  the  dead  from  the  living  cellular 
membrane,  only  takes  place  incompletely,  and  a small 
fragment  of  yellow  dead  cellular  substance  still  con- 
tinues fixed  in  the  cavity,  and  hinders  the  cure.  In  this 
circumstance,  the  further  employment  of  emollient 
poultices  is  of  little  or  no  service.  The  surgeon  should 
dip  the  point  of  a camel-hair  pencil  in  sulphuric  acid, 
and  touch  the  inside  of  the  stye  with  it,  one  or  more 
times,  until  the  sloughy  cellular  membrane  comes  away. 
After  thi<,  the  small  cavity  remainiiig  will  soon  cl«w. 
Should  the  eyelid  continue  afterward  a little  s\\  olltu 


HOS 


HOS 


43 


and  (Edematous,  this  affection  may  be  removed  by  ap- 
plying the  lotio  plumbi  acet.,  containing  a little  spirit 
of  wine.  Some  persons  are  often  annoyed  with  this 
disease.  According  to  Scarpa,  this  is  most  frequently 
owing  to  a disordered  state  of  ihc  privKS  m<z^  often  met 
with  in  persons  who  live  on  acrid  irritating  food,  and 
drink  too  much  spirits. — (.Scarpa,  Sulle  Malattie  degli 
Occhi,  cap.  2.  See  also  Guthrie's  Operative  Surgery 
of  the  Eye,p.  107,  ^c.) 

HOSPITAL  GANGRENE. — (Phagedeena  Gangrm- 
nosa;  Putrid  or  Malignant  Ulcer;  Hospital  Sore; 
Gangrcena  Contagiosa.)  A severe  and  peculiar  species 
of  humid  gangrene,  or  rather  a combination  of  this 
affection  with  phagedenic  ulceration.  It  is  particularly 
characterized  by  its  contagious  or  infectious  nature  ; 
its  disposition  to  attack  wounds,  or  ulcers,  in  crowded 
liospitals,  or  other  situations,  where  many  of  these 
cases  are  brought  together ; and  its  tendency  to  convert 
the  soft  parts  affected  into  a putrid  glutinous,  or  pulpy 
substance,  in  which  no  trace  of  their  original  texture 
is  discernible. — (Dclpech,  Pricis  EUm.  des  Mai.  Chir. 
t.  1,  p.  123.)  It  is  generally  believed  to  be  communi- 
cated from  one  sore  or  wound  to  another,  by  its  conta- 
gious nature  ; but,  whether  the  infection  can  be  trans- 
ferred only  by  actual  contact,  or  both  in  tliis  way  and 
through  the  medium  of  the  atmosphere,  is  a question 
on  which  the  best  authors  differ.  The  first  origin  of 
the  disease,  however,  is  a mysterious  subject,  which 
cannot  invariably  be  explained  on  any  certain  princi- 
ples, as  will  be  hereafter  noticed. 

From  the  researches  of  Mr.  Blackadder,  it  appears 
probable  that  several  of  the  ancient  writers,  in  their 
descriptions  of  foul  gangrenous  bleeding  ulcers,  must 
have  alluded  to  the  same  kind  of  disease  which  is  now 
usually  denominated  hospital  gangrene.  Besides  the 
use  of  the  actual  cautery,  which,  according  to  the 
modern  French  writers,  is  the  surest  means  of  arrest- 
ing this  distemper,  several  of  the  ancients  appear  also 
to  have  employed  for  its  cure  arsenical  applications  ; 
as,  for  instance,  .^tius,  Paulus,  Rolandus,  Avicenna, 
Guido,  &c.  The  only  doubt  whether  these  authors 
actually  referred  to  hospital  gangrene  depends  upon 
their  not  having  generally  described  its  contagious 
nature.  But  on  this  point,  I recommend  Mr.  Black- 
adder’s  valuable  treatise  to  be  consulted. — (P.  76,  «Stc.) 

Although  La  Motte  made  cursory  mention  of  hospi- 
tal gangrene  in  1722,  under  the  name  of  pourriture, 
and  stated  that  it  had  occurred  in  the  Hotel-Dieu  at 
Paris,  the  first  distinct  modern  account  of  this  disease 
is  contained  in  the  3d  vol.  of  the  posthumous  works 
of  Pouteau,  published  in  1783.  In  the  year  1788,  Dus- 
sassoy,  who  succeeded  Pouteau  as  chief  surgeon  of  the 
Hdtel-Dieu  at  Lyons,  also  published  a short  treatise 
on  the  disorder.  The  first  very  accurate  description  of 
hospital  gangrene  in  the  English  language  appeared  in 
the  6th  vol.  of  the  London  Medical  Journal,  printed  in 
1785.  The  account  is  entitled,  “ Observations  on  the 
Putrid  Ulcer,  by  Mr.  Gillespie,  surgeon  of  the  Royal 
Navy.”  In  the  edition  of  Dr.  Rollo’s  works  on  Diabe- 
tes, published  1797,  there  is  a section  on  this  subject, 
entitled,  “ A short  account  of  a morbid  poison,  acting 
on  sores,  and  of  the  metliod  of  destroying  it.”  In  1799 
Sir  Gilbert  Blane,  in  the  third  edition  of  his  book  on 
the  Diseases  of  Seamen,  gave  an  account  of  hospital 
gangrene  under  the  name  of  malignant  ulcer ; and  Dr. 
Trotter,  in  the  2d  volume  of  his  Medicina  Mautica, 
published  in  the  same  year,  described  that  affection  by 
the  same  appellation.  In  the  tliird  volume  of  the  same 
work,  Dr.  Trotter  added  to  his  first  account  several 
valuable  communications  relating  to  this  disease,  re- 
ceived from  surgeons  of  the  royal  navy.  Mr.  John 
Bell  also  made  hospital  gangrene  the  subject  of  particu- 
lar remark  in  the  first  volume  of  his  Principles  of 
Surgery,  published  in  1801.  According  to  Dr.  Thom- 
son, two  excellent  theses  were  likewise  published  on 
it  in  the  university  of  Edinburgh;  the  first,  entitled, 
“De  Gangreena  Contagiosa,”  by  Dr.  Leslie,  in  1804; 
the  second  by  Dr.  Charles  Johnson,  in  1805,  under  the 
title  of  “ De  GrangrainA  Contagiosi  Nosocomiale.” — 
(See  Lectures‘on  Inflammation,  p.  456 — 458.) 

Professor  Thomson’s  account  of  the  subject,  pub- 
lished in  1813,  contained  the  fullest  history  of  the  dis- 
ease at  that  time  collected.  Boyer  afterward  gave  a 
very  fair  account  of  the  distemper.— (See  Traiti  des 
Mai.  Chir.  t.  1,  p.  320,  8vo.  Paris,  1814.) 

I hese  descriptions  were  follow'ed  by  the  valuable 
essay  of  Delpech,  etitiiled,  “ M^moire  sur  la  Compli- 


cation des  Plates  et  ^es  Ulc^res  connue  sous  le  nom 
de  Pourriture  d’Hdpital,”  1815;  some  interesting  ob- 
servations by  Dr.  Hennen,  in  the  London  Medical 
Repository  for  March,  1815 ; a paper  by  Professor 
Brugmann,  of  Leyden,.in  the  “ Annales  de  Littirature 
M6d.”  vol.  19,  1815;  and  the  treatise  of  Mr.  Black- 
adder,  w'hich  contains  some  of  the  best  remarks  ever 
made  concerning  this  affection,  and  is  entitled  “ Obser- 
vations on  Phagedatna  Gangraenosa,  8vo.  Edinb.  1818.” 
To  these  publications  are  to  be  added  the  interesting 
remarks  of  Mr.  R.  Welbank  on  Sloughing  Phageda;na, 
contained  in  the  eleventh  volume  of  the  Med.  Chir. 
Trans. ; and  those  of  Dr.  Boggie,  recorded  in  the  third 
volume  of  the  Edin.  Med.  Chir.  Trans. 

According  to  Mr.  Blackadder,  who  is  a believer  in 
the  doctrine  of  the  complaint  being  only  communicable 
by  the  direct  application  of  the  infectious  matter,  when, 
the  morbific  matter  which  produces  the  disease,  has 
been  applied  to  some  part  of  the  surface  of  the  body, 
from  which  the  cuticle  has  been  removed,  as  by  a 
blister,  one  or  more  small  vesicles  first  appear,  which 
are  filled  with  a watery  fluid,  or  bloo(3y  serum  of  a 
livid  or  reddish-brown  colour.  The  situation  of  the 
vesicle  is  generally  at  the  edge  of  the  sore.  Its  size  is 
not  unfrequently  that  of  a split  garden  pea,  and  is 
easily  ruptuied,  the  pellicle  which  covers  it  being  very 
thin.  When  the  vesicle  is  filled  with  a watery  fluid, 
atid  has  not  been  ruptured,  it  assumes  the  appearance 
of  a grayish-white,  or  ash -coloured  slough;  but  when 
it  contains  a dark-coloured  fluid,  or  has  been  ruptured, 
it  puts  on  the  appearance  of  a thin  coagulum  of  blood, 
of  a dirty  brownish-black  colour.  During  the  forma- 
tion of  the  vesicle,  tliere  is  generally  a change  in  the 
sensation  of  the  sore,  accompanied  with  a painful  feel 
like  that  of  the  sting  of  a gnat. 

After  a slough  is  formed,  it  spreads  with  more  or  less 
rapidity,  until  it  occupies  the  whole  surface  of  the 
original  sore ; and  when  left  to  itself  (which  seldom 
happens),  there  is  little  or  no  discharge,  but  the  slough 
acquires  daily  greater  thickness. 

“ When  the  formation  of  the  slough  has  been  inter- 
rupted, the  stinging  sensation  becomes  more  frequent 
and  acute ; phagedenic  ulceration  quickly  commences ; 
and  such  is  frequently  the  rapidity  of  its  progress,  that 
even  in  the  course  of  a few  hours,  a very  considerable 
excavation  will  be  formed,  while  the  parts  in  the 
vicinity  retain  their  usual  healthy  appearance.”  The 
cavity,  the  edges  of  which  are  well  defined,  is  filled 
with  a thick  glutinous  matter,  which  adheres  strongly 
to  the  subjacent  parts.  When  this  matter  is  removetl, 
the  surface  underneath  presents  itself  of  a fine  granular 
texture,  which,  in  almost  all  instances,  is  possessed  of 
extreme  sensibility,  and  is  very  apt  to  bleed  when  the 
operation  of  cleaning  is  not  performed  with  great 
delicacy.  At  each  dressing,  the  circumference  of  the 
cavity  is  found  enlarged,  and  if  there  are  more  than 
one,  they  generally  run  into  each  other.  The  progress 
of  the  disease  is  niuch  quicker  in  some  individuals 
than  others,  but  it  never  ceases  until  the  whole  surface 
of  the  original  sore  is  occupied.  The  stinging  pain 
gradually  becomes  of  a darting  or  lancinating  kind ; 
and  either  about  the  fourth  or  sixth  day  from  the  time 
when  the  morbifle  matter  had  access  to  the  sore,  or 
afterward,  at  the  period  of  what  may  be  termed  second- 
ary  inflammation,  the  lymphatic  vessels  and  glands  are 
apt  to  become  affected.  The  discharge  becomes  more 
copious,  its  colour  varying  from  a dirty  yellowish- 
wbite,  to  a mixture  of  yellow,  black,  and  brown,  de- 
pending upon  the  quantity  of  blood  mixed  with  it. 

“The  soft  parts  in  the  immediate  vicinity  of  the 
sore,  daily  become  more  painful,  tumefied,  and  indu- 
rated ; and  in  a great  number  of  cases,  particularly  in 
those  of  plethoric  and  irritable  habits,  an  attack  of 
acute  inflammation  speedily  supervenes,  and  is  accom- 
panied by  a great  increase  of  pain,  the  sensation  being 
described  to  be  such  as  if  the  sore  were  burning.  The 
period  at  which  this  inflammation  begins  to  subside, 
is  by  no  means  regular.  Sometimes  it  subsitles  in  the 
course  of  two  days,  and  sometimes  it  continues  up- 
wards of  five;  depending  very  much  on  the  constitu- 
tion and  previous  habits  of  the  patient,  as  well  as  the 
treattnent  that  has  been  adopted.  During  its  progress, 
the  tliick,  putrid-looking,  and  frequently  spongy  slough 
which  is  formed  on  the  sore,  becomes  more  and  more 
moist,  and  of  a pulpy  consistence.  (Hence  this  form 
of  disease  is  actually  named  by  Gerson,  pulpy  gan- 
grene.) In  the  course  of  a few  days,  a very  oflensive 


44 


HOSPITAL  GANGRENE, 


matter  begins  to  be  discharged  at  its  edges.  The 
slough  then  begins  to  separate  ;^y-and- by  it  is  thrown 
off,  but  only  to  prepare  the  way  for  an  extension  of 
the  disease  by  a continued  process  of  ulceration,  and 
by  a recurrence  of  the  last  mentioned  symptoms.” — 
{Blackadder  on  Phagedmna  Gangrcsnosa,  p.  28 — 30.) 

The  first  symptoms  which  indicate  hospital  gan- 
grene in  a wound  or  ulcer,  are,  a more  or  less  acute 
pain,  and  a viscid  whitish  exudation  on  tlie  surface  of 
the  granulations,  which  lose  their  vermilion  colour, 
and  present  at  several  points,  spots  of  a grayish  or 
dirty-white  hue,  resembling  venereal  ulcers  or  aphthae. 
These  ulcerated  points,  thus  engrafted  (as  it  were)  upon 
the  original  ulcer,  soon  spread  and  join  together,  so  as 
to  give  to  the  whole  surface  of  the  solution  of  conti- 
nuity a gray  ash  colour.  The  surface  also  becomes 
more  or  less  indurated,  and  sometimes  bleeds.  A red 
purplish  oedematous  circle,  of  a greater  or  less  extent, 
is  next  formed  in  the  surrounding  skin.  Sometimes 
when  the  patient  is  of  a good  habit,  the  causes  of  infec- 
tion less  active,  and  the  constitution  sufficiently  strong, 
the  disorder  now  stops.  According  to  Boyer,  it  may 
not  even  extend  to  the  whole  surface  of  the  ulcer. 
But  most  frequently  its  progress  is  extremely  rapid, 
and  occasionally  quite  terrifying.  The  edges  of  the 
wound  or  ulcer  become  hardened  and  everted;  the 
granulations  are  large  and  tumid,  being  swelled  up,  as 
Boyer  asserts,  with  a considerable  quantity  of  gas. 
They  are  afterward  detached  in  the  form  of  soft  red- 
dish sloughs,  which  very  much  resemble  the  substance 
of  the  fcetal  brain,  in  a putrid  state.  From  day  to  day, 
until  either  nature  alone,  or  aided  by  art,  puts  limits  to 
the  disorder,  it  invades  new  parts  both  in  breadth  and 
depth,  so  that  its  ravages  extend  to  aponeuroses,  mus- 
cles, blood  vessels,  nerves,  tendons,  the  periosteum, 
and  even  the  bones  themselves. 

Among  a number  of  severe  cases  which  fell  under 
the  notice  of  Mr.  Blackadder,  “ there  was  one  in  which 
the  half  of  the  cranium  was  denuded,  the  bones  having 
become  black  as  charcoal,  and  the  integuments  de- 
tached posteriorly  to  the  second  cervical  vertebra,  and 
anteriorly  to  the  middle  of  the  zygomatic  process  of 
the  temporal  bone;  and  this  was  originally  a super- 
ficial wound  of  the  scalp.  In  another  case,  the  mus- 
cles, large  arteries,  and  nerves  of  both  thighs  were 
exposed  and  dissected,  the  integuments  and  cellular 
substance  being  entirely  removed,  with  the  exception 
of  only  a narrow  strip  of  the  former,  which  remained 
on  the  outer  side  of  the  thighs.  This  was  also  origi- 
nally a simple  flesh  wound.  In  other  instances,  the 
cavities  of  the  knee,  ankle,  elbow,  and  wrist  joints 
were  laid  extensively  open,  and,  in  one  unfortunate 
case,  the  integuments  and  cellular  substance  on  the 
anterior  [)arts  of  the  neck,  were  destroyed,  exhibiting 
a horrid  spectacle,  the  trachea  being  also  wounded.”— 
<On  Phagedana  Gangreenosa,  p.  3.) 

According  to  the  last  experienced  author,  when  the 
disease  attacks  an  old  sore,  where  a considerable  depth 
-of  new  flesh  has  been  formed,  the  first  thing  generally 
observed  is  a small  dark-coloured  spot,  usuafly  situated 
at  the  edge  of  the  sore.  But  he  states,  that  in  several 
-cases  of  ulcers,  the  disease,  when  carefully  watched, 
was  found  to  begin  in  the  form  of  a vesicle,  filled  with 
a livid  or  brownish-black  fluid,  which  afterward  burst 
and  assumed  the  appearance  of  the  dark-coloured  spot, 
which  is  commonly  first  noticed.  Mr.  Blackadder 
always  found,  that  when  there  had  been  a consider- 
able bed  of  new  flesh  formed,  the  phagedenic  ulceration 
made  comparatively  a very  slow  progress,  and  put  on 
rather  the  appearance  of  mercurial  phagedena,  until 
the  morbific  matter  had  found  access  to  the  natural 
texture  of  the  part,  when  the  progress  of  the  disease 
became  suddenly  accelerated ; acute  inflammation 
supervened;  and  a large  slough  was  formed. — (Op. 
cit.p.  31.)  lie  notices,  that  when  the  morbific  matter 
is  inserted  in  a puncture  or  scratch,  the  first  progress 
of  the  disease  bears  a resemblance  to  that  of  a part 
inoculated  with  vaccine  matter.  The  primary  inflam- 
mation in  gangrenous  phagedena  commences  at  the 
end  of  the  second,  or  early  on  the  third  day  ; the  in- 
flammation is  at  its  height  about  the  sixth  ; when  the 
scab  begins  to  form  iti  one  disease,  phagedenic  ulcera- 
tion begins  in  the  other,  and  when  allowed  to  proceed, 
ioon  affords  sufficient  proof  of  the  non-identity  of  the 
•wo  diseases.— (P.  33.) 

When  the  disease  attacks  a recent  gunshot  wound, 
me  discharge,  two  or  three  days  after  infection,  is 


found  to  be  lessened,  and  to  have  become  more  of  a 
sanious  than  purulent  nature.  The  sore  has  a certain 
dry  and  rigid  appearance;  its  edges  are  more  defined, 
somewhat  elevated  and  sharpened ; the  patient  is  sen- 
sible of  a change  in  the  usual  sensation  in  the  sore, 
and  complains  of  an  occasional  stinging  sensation, 
resembling  that  produced  by  the  sting  of  a gnat.  At 
this  period,  but  sotnetimes  a day  or  two  later,  the  in- 
teguments at  the  edge  of  the  sore  become  inflamed, 
and  the  surface  of  the  sore  itself  assumes  a livid  or 
purple  colour,  and  appears  as  if  covered  with  a fine 
pellicle,  such  as  is  formed  on  a coagulum  of  blood. — 
(On  Phagedmna  Gangreenosa,  p.  33.) 

At  Bilboa,  the  disease,  in  cases  of  wound,  is  said 
generally  to  have  commenced  with  a sudden  attack 
of  severe  pain  in  the  head  and  eyes,  lightness  about 
the  forehead,  want  of  sleep,  loss  of  appetite,  a quick 
pulse,  and  other  febrile  symptoms  ; while  the  wound, 
which  had  been  healthy  and  granulating,  at  once  be- 
came tumid,  dry,  and  painful,  losing  its  florid  colour, 
and  assuming  a dry  and  glossy  coat. — {Hennen  on 
Military  Surgery,  p.  214,  ed.  2.)  When  left  to  itself, 
the  above- described  pellicle  gradually  increases  in 
thickness,  forming  what  has  been  termed  a slough. 
But  Mr.  Blackadder  observes,  that  at  this  period  the 
progress  of  the  disease  is  hardly  in  any  two  instances 
precisely  alike.  Generally,  in  the  course  of  from  five 
to  ten  or  fifteen  days,  a thick  spongy  and  putrid-looking 
slough  is  formed  over  the  whole  surface  of  the  sore, 
and  which  is  more  or  less  of  an  ash,  or  blackish-brown 
colour.  When  the  pellicle  is  destroyed,  as  frequently 
happens  in  the  process  of  cleaning,  it  is  not  in  every 
case  reproduced ; but  an  offensive  matter  begins  to  be 
discharged,  which  becomes  daily  more  copious,  is  of  a 
dirty  yellow  colour  and  ropy  consistence,  and  is  very 
adherent  to  the  sore.  The  substance  which  formed 
the  apparent  bottom  of  the  wound  is  raised  up,  and 
pushing  back  the  edges,  makes  the  sore  appear  con- 
siderably enlarged.  The  edges,  which  are  usually 
jagged  or  pectinated,  become  extremely  irritable,  of  a 
deep-red  colour,  and  dotted  on  their  inner  surface,  with 
numerous  small,  elevated,  and  angry-looking  points, 
which  may  be  considered  as  one  of  the  characteristic 
marks  of  the  disease.  The  surrounding  integuments 
become  indurated  and  inflamed,  assuming,  not  un- 
frequently,  an  ansarine  appearance;  and  fhe  patient 
complains  of  a constant  burning  lancinating  pain.  In 
the  vicinity  of  the  sore,  the  integuments  become  more 
and  more  of  a dark-red  colour,  in  consequence  of  the 
violence  of  the  inflammation,  which  is  of  an  erysipela- 
tous nature,  and  apt  to  terminate  in  sloughing,  and 
carry  off  the  patient.  However,  the  inflammatory 
symptoms  are  sometimes  mild,  and  in  other  cases, 
exceedingly  violent ; a fact  accounted  for  by  differences 
of  constitution. — (Blackadder,  p.  34.) 

In  the  hospitals  at  Bilboa,  if  the  incipient  stage  was 
overlooked,  the  febrile  symptoms  very  soon  became 
aggravated ; the  skin  around  the  sore  assumed  a highly 
florid  colour,  which  shortly  became  darker,  then  blu- 
ish, and  at  last  black,  with  a disposition  to  vesicate ; 
while  the  rest  of  the  limb  betrayed  a tendency  to 
oedema.  All  these  threatening  appearances  occurred 
within  twenty-four  hours,  and  at  this  period  also,  the 
wound,  whatever  might  have  been  its  original  shape, 
soon  assumed  the  circular  form.  The  sore  now  ac- 
quired hard,  prominent,  ragged  edges,  giving  it  a cup- 
like appearance,  with  particular  points  of  the  lip  of  a 
dirty  yellow-  hue,  while  the  bottom  of  the  cavity  was 
lined  with  a flabby  blackish  slough.  The  gangrei.«j 
still  advancing,  fresh  sloughs  were  rapidly  formed  ; 
the  increasing  cup-like  cavity  w-as  filled  up  and  over- 
topped by  them,  and  the  erysipelatous  livor  and  vesi- 
cation of  the  surrounding  skin  gained  ground,  while 
chains  of  inflamed  lymphatics  could  be  traced  from 
the  sores  to  the  adjoining  glands,  these  exciting  inflam- 
mation and  suppuration,  w-hich  often  furnished  a new 
nidus  for  gangrene.  The  face  of  the  sufferer  assumed 
a ghastly  anxious  appearance:  his  e3’es  became  hag- 
gard and  deeply  tinged  \vilh  bile;  his  tongue  covered 
with  a browni.<h  or  blackish  fur  ; his  appetite  entirely 
failed ; and  his  pulse  was  feeble  and  accelerated.  In 
this  stage,  the  weakness  and  irritability  of  the  patient 
was  such,  that  the  slightest  change  of  posture  put  him 
to  torture,  iticreased  by  his  inability  to  steady  the 
limb,  which,  it  lifted  from  the  bed,  was  seized  with 
tremors  and  spasmodic  twitches. — ( JIcnnen's  Military 
Surgery,  p.  215,  216,  cd.  2.)  Authors  vary  consider- 


HOSPITAL 

ably  fn  their  descriptions  of  the  state  of  the  tongue. 
Dr.  Henneii  found  it  brownish  or  blackish  ; Delpech, 
wliitish  or  yellowish  (Precis  Elem.  t.  1,  p.  125.) ; and 
Mr.  Blackadder,  covered  with  a white  mucus.— 
(P.  39.) 

It  is  explained  by  Mr.  Blackadder,  that  when  the 
disease  attacks  a large  recent  wound,  the  whole  sur- 
face of  the  injury  is  sometimes  aftected  from  the  first ; 
while  in  other  instances,  the  disorder  commences  on  or 
near  the  lips  of  the  sore.  When  the  patient  is  of  an 
inflammatory  diathesis,  the  sore  is  generally  attacked 
with  acute  inflammation  between  the  seventh  and 
fourteenth  days  ; and  the  slough  is  softer  and  of  a 
pulpy  consistence;  matter  of  a strong  and  peculiar 
odour,  and  of  a dirty  brownish  gray  colour,  begins  to 
ooze  out  at  its  edges,  and  becomes  daily  more  copious. 
The  inflammation  gradually  subsides;  the  slough  be- 
comes loosened  and  finally  detached,  leaving  the  sub- 
jacent muscles,  bones,  fascia?,  or  ligaments,  completely 
exposed.  When  the  constitution  is  not  prone  to  acute 
inflammation,  the  slough  remains  long  adherent ; the 
discharge  is  very  copious,  and  burrows  under  the  skin, 
wliich  then  mortifies.  Sometimes,  after  the  detach- 
ment of  a slough,  florid  granulations  spring  up,  and 
notwithstanding  a slight  recurrence  of  the  phagedenic 
ulceration,  the  parts  heal  up  by  the  almost  unassisted 
operations  of  nature.  However,  most  commonly 
after  the  muscles  are  exposed,  they  continue  to  be 
gradually  dissected;  their  connecting  cellular  mem- 
brane is  completely  destroyed,  and  they  are  left  covered 
with  an  offensive  greasy-looking  matter. 

According  to  Mr.  Blackadder,  when  a muscle  has 
been  wounded,  it  swells  sometimes  to  a great  size,  and 
quickly  assumes  the  appearance  of  a large  coagulum, 
being  altogether  deprived  of  irritability.  When  it  has 
not  been  wounded,  but  has  become  inflamed,  it  gene- 
rally assumes  a pale  colour,  with  an  appearance  as 
if  distended  with  a fluid,  and  occasionally  before  losing 
its  vitality,  acquires  a very  surprising  bulk ; but  when 
no  inflammation  has  supervened,  the  muscles  become 
of  a pale  brick  colour,  waste  away  daily,  and  the 
patient  loses  all  power  in  them.  As  the  disease  ad- 
vances, the  integuments  are  undermined,  and  slough; 
and  hemorrhage  from  small  vessels  is  a common  oc- 
currence ; but  in  a more  advanced  stage,  some  of  the 
large  vessels  are  apt  to  give  way,  and  the  bleeding 
from  them  frequently  destroys  the  patient. 

“ When  a stump  is  the  site  of  the  disease,  and  the 
patient  is  of  a plethoric  habit,  or  accustomed  to  live 
freely,  the  symptoms  soon  begin  to  indicate  the  exist- 
ence of  an  intense  inflammatory  action  through  its 
whole  substance,  the  tumefaction,  pain,  and  heat 
mcrease  rapidly,  so  that  in  a few  days,  the  stump 
^all  have  acquired  more  than  twice  its  former  size, 
being  at  the  same  time  much  indurated,  and  causing 
the  most  excruciating  pain  In  this  state,  the  patient 
has,  in  some  instances,  become  delirious,  and  has  been 
cut  off  by  an  effusion  taking  place  into  some  of  the 
larger  cavities.  It  more  commonly  happens,  however, 
that  gangrene  seizes  upon  the  integuments  and  cellular 
snbstai.ee;  large  sloughs  are  thrown  off;  and  some 
of  the  large  blood-vessels  giving  way,  the  patient  sinks 
under  the  effects  of  repeated  hemorrhage.  For  it  is 
commonly  found,  that  the  usual  modes  of  stopping 
hemorrhage  from  a stump,  are,  in  such  cases,  either 
inadmissible  or  totally  inefficacious. 

“ Sometimes  the  progress  of  the  disease  in  a stump  is 
more  gradual,  but  in  the  end  nearly  as  fatal ; the  in- 
flammation is  much  less  acute;  there  is  comparatively 
but  little  tumefaction,  and  the  pain  is  much  less  severe ; 
but  the  discharge  is  much  more  copious,  and  the  cellu- 
lar substance  connecting  the  integuments  and  muscles 
is  rapidly  destroyed.  Hemorrhage  generally  comes  on 
later  than  in  the  preceding  instance,  but  it  is  the  most 
common  cause  of  {Blackadder  on  Phagedmna 

Oangrainosa,  p.  33—39.) 

It  IS  observed  by  another  writer,  that  artery  seems  to 
be  the  texture  which  resists  most  powerfully  the  de- 
structive action  of  hospital  gangrene  (Thomson's 
Lectures,  p.  4G0) : a remark  quite  at  variance  with  the 
statement  of  Delpech  (Precis  EUm.  t.  \,p.  129) ; but 
intended  to  refer,  as  I conceive,  to  cases  in  which  the 
femoral,  brachial,  or  other  large  artery  is  seen  for  seve- 
ral days  completely  denuded  in  the  midst  of  the  ra- 
vages of  the  distemper,  yet  not  giving  way.  I have 
seen  the  same  thing  frequently  exemplified  in  mercu- 
rial phagedena,  as  well  in  the  groin  as  in  the  arm. 


GANGRENE.  45 

As  for  the  smaller  arteries,  they  are  quickly  destroyed, 
together  with  other  parts. 

“ In  some  rare  cases  (says  Dr.  Hennen,)  I have  seen 
the  femoral  and  axillary  arteries  pulsating  awfully, 
and  ajiparently  unaffected  with  disease;  while  all  the 
surrounding  parts  were  completely  destroyed ; but  in  a 
vast  majority  of  cases  the  blood-vessels  partook  of  the 
general  disease  in  which  they  were  imbedded.  They 
were  not  only  completely  separated  from  their  natural 
connexions,  but  their  coats  sloughed  away  at  the  im- 
mediate point  of  disease,  while  the  disposition  extended 
far  beyond  the  apparently  affected  spot.  Hence,  our 
ligatures  but  too  often  failed  on  the  main  branches,  and 
any  attempt  on  the  smaller  was  invariably  injurious. 
We  were  here  naturally  induced  to  tie  the  artery  con- 
siderably above  the  seat  of  the  disease;  and  this  was 
done  once  on  the  femoral,  and  twice  on  the  axillary  ar- 
tery below  the  clavicle : the  former  burst  on  the  third, 
each  of  the  latter  on  the  second  day  afterward.”  Dr. 
Hennen  further  remarks,  that,  in  general,  the  great  ves- 
sels sloughed  long  after  the  new  acute  symptoms  of  the 
disease  had  abated,  and  that,  in  severe  cases,  the 
eleventh  day  of  the  disease  was  always  dreaded.— ( On 
Military  Surgery,  p.  221,  ed.  2.)  The  indisposition  of 
the  large  vessels  to  close,  when  taken  up  in  the  conr- 
mon  way,  appears  referable  to  three  causes : viz.  the 
tendency  to  rapid  ulceration  in  the  arteries  in  the  situ- 
ation of  the  ligatures ; the  formation  of  no  effectua 
coagulum  in  theextremityof  the  vessel,  like  what  hap 
pens  in  other  cases  of  mortification;  and  the  genera 
incapacity  of  nature  in  examples  of  hospital  gangrenr 
to  establish  any  process  which  can  be  accompaniet' 
with  healthy  adhesive  inflammation. 

In  the  last  stage  of  the  disease,  as  it  occurred  In  the 
military  hospitals  atBilboa,  the  surface  of  the  sore  war 
constantly  covered  with  a bloody  oozing,  and  on  liftin': 
up  the  edge  of  the  flabby  slough,  the  probe  was  tinge:' 
with  dark-coloured  grumous  blood,  with  which  also  it 
track  became  immediately  filled.  Repeated  and  copi 
ous  venous  bleedings  now  came  on,  which  rapidly  car 
tied  off  the  patient:  the  sloughs,  whether  they  fell  ofl 
spontaneously,  or  were  detached  by  art,  were  quickly 
succeeded  by  others,  and  brought  into  view  thickly 
studded  specks  of  arterial  blood.  At  length,  an  artery 
gave  way,  which  was  generally  torn  through  in  the  at 
tempt  to  secure  it  with  a ligature:  the  tourniquet,  o 
other  pressure,  was  now  applied,  but  in  vain;  for 
while  it  checked  the  bleeding,  it  accelerated  the  deat' 
of  the  limb,  which  became  frightfully  swelled  and  hot 
ribly  fetid.  Incessant  retchings  came  on,  and  with  co 
ma,  involuntary  stools,  and  hiccough,  closed  the  scene 
Often,  however,  the  patient  survived  this  acute  stat? 
of  the  disease,  and  sank  under  severe  irritation,  at 
sorption  of  putrid  matter,  and  extensive  loss  of  sub 
stance,  with  common  hectic  symptoms.— (See  Hen 
nen's  Mil.  S%irgery,  p.  217,  ed.  2.)  In  the  disease  a£ 
Bilboa,  the  skin  and  cellular  substance  seemed  to  be  the 
parts  originally  and  principally  affected.  This,  says 
Dr.  Hennen,  was  obvious,  even  in  the  living  body  ; but 
on  dissection  the  disease  of  these  parts  was  frequently 
observed  to  spread  much  further  than  external  ap- 
pearances indicated,  as  a diseased  track  was  often 
found  running  up  into  the  groin,  or  axilla,  and  com- 
pletely dissecting  the  muscles  and  great  vessels. — (On 
Military  Surgery,  p.  219,  ed.  2.)  When  the  disease 
had  occupied  the  outside  of  the  chest,  the  same  gen- 
tleman found  the  lungs  in  two  cases,  and  the  pericar- 
dium in  a third,  covered  with  gangrenous  spots;  and 
when  the  parietes  of  the  abdomen  had  been  attacked, 
he  often  observed  the  same  appearances  on  the  liver. 
— (P.  220.) 

Hospital  gangrene  must  be  regarded  as  one  of  the 
most  serious  and  dangerous  complications  to  which 
wounds  and  ulcers  are  liable.  When  the  solution  of 
continuity  is  large,  or  of  long  standing,  the  di.sorder 
commits  great  ravages,  renews  its  attacks  repeatedly, 
and  the  relapses  prove  exceedingly  obstinate.  The 
same  thing  is  said  to  happen  when  it  affects  persoms 
labouring  under  scorbutic  or  venereal  complaints. 
Hospital  gangrene  proves  particularly  dangerous,  and 
mostly  fatal,  when  it  complicates  large  contused 
wounds,  attended  with  badly  fractured  bones.  All  the 
soft  parts  of  the  injured  limb  are  then  frequently 
observed  to  be  progressively  destroyed,  and  the  unfortu- 
nate patient  falls  a victim  either  to  typhoid  symptoims, 
freipient  hemorrhages,  or  hectic  complaints.  From 
what  has  been  staled,  however,  the  disease  varies 


46 


HOSPITAL  GANGRENE. 


considerably  in  its  severity  in  different  cases,  being 
sometimes  of  small  extent,  and  even  capable  almost 
of  a spontaneous  cure.  Patients  have  been  known  to 
continue  aiflicted  more  tlian  a month;  and  when  the 
duration  of  the  disease  was  thus  lengthened,  the  cases 
almost  always  had  a fatal  termination.  In  a few  cases, 
the  wound  puts  on  a favourable  appearance  again  be- 
tween the  sixth  and  ninth  days:  and,  in  slight  exam- 
ples, the  amendment  is  manifested  between  the  third 
and  fifth.  Whatever  may  be  the  period  of  the  com- 
plaint, its  wished-for  termination  is  always  announced 
by  a diminution  of  pain  ; the  pus  acquiring  aw'hite  co- 
lour, and  more  consistence,  and  losing  its  fetid  nau- 
seous smell.  The  edges  of  the  ulcer  subside,  while  its 
surface  becomes  less  irregular,  and  puts  on  more  of  the 
vermilion  colour.  Tlie  red,  purplish,  oedemaious  circle, 
which  surrounds  the  disease,  assumes  a true  inflamma- 
tory nature;  and  the  solution  of  continuity,  restored 
to  a simple  slate,  heals  up  with  tolerable  quickness, 
even  when  the  destruction  of  soft  parts  is  sonrewhat 
considerable,  unless  any  fresh  untoward  circumstances 
occur  to  interrupt  cicatrization.  But  sometimes  when 
the  patient  is  on  the  point  of  being  completely  well 
again,  his  condition  is  suddenly  altered  for  the  worse  ; 
ulcerated  spots  make  their  appearance  on  the  cicatrix, 
and  these  spreading  in  different  directions  occasion  a 
relapse,  wliich  may  happen  several  times. 

According  to  Dr.  Boggie,  a relapse,  and  even  re- 
pealed relapses,  are  very  common,  as  his  own  expe- 
rience fully  convinced  him  ; and  he  adverts  to  a case 
reported  by  Dr.  Hennen,  in  which  the  patient  survived 
twelve  dilFerent  attacks,  and  sunk  under  the  tliirteenth. 
— (See  Edinb,  Med.  Chir.  Trans,  vol.  3,  p.  8.)  As  far 
as  the  observations  of  Dr.  Boggie  went,  hospital  gan- 
grene is  more  frequent  and  severe  in  hot  weather 
than  cold. — (See  Edinb.  Med.  Chir.  Trans,  vol.  3, 
p.  13.) 

From  numerous  cases  of  this  disease,  seen  by  Mr. 
Blackadder  at  Passage  in  Spain,  this  gentleman  made 
the  following  conclusions; 

1.  That  the  morbid  action  could  almost  always  be 
detected  in  the  wound,  or  sore,  previously  to  the  occur- 
rence of  any  constitutional  affection. 

2.  That  in  several  instances  the  constitution  did  not 
become  affected  until  some  considerable  lime  after  the 
disease  had  manifested  itself  in  the  sore. 

3.  That  when  the  disease  was  situated  on  the  inferior 
e.xtremities,  the  lymphatic  vessels  and  glands  in  the 
groin  were  observed  to  be  in  a state  of  irritation, 
giving  pain  on  pressure,  and  were  sometimes  enlarged, 
before  tiie  constitution  showed  evident  marks  of  de- 
rangement. 

4.  That  the  constitutional  affection,  though  some- 
times irregular,  was  in  many  cases  contemporary  with 
the  second  or  inflammatory  stage. 

5.  That  all  parts  of  the  body  were  equally  liable  to 
become  affected  with  this  disease. 

6.  That  when  a patient  had  more  than  one  wound, 
or  sore,  it  frequently  happened  that  the  disease  was 
confined  to  one  of  the  sores,  while  the  other  remained 
perfectly  healthy,  and  this  even  when  they  were  at  no 
great  distance  from  each  other. — (On  Phagedmna 
OangTtenosa,  p.  19.) 

Thus  Mr.  Blackadder  espouses  the  opinion  that  hospi- 
tal gangrene  is  at  first  local,  and  not  a a constitutional 
disease;  that  is  to  say,  not  necessarily  preceded,  or 
oriainully  accompanied  by,  any  diseased  action  in  the 
system.  It  is  highly  important  to  weigh  this  distinc- 
tion well ; not  only  because  it  is  yet  the  chief  point  of 
difference  among  the  best  writers  on  the  subject,  but 
because  it  involves  very  directly  every  theory  respect- 
ing the  causes  of  the  disease  and  the  great  question, 
whethet  its  ravages  are  to  be  resisted  principally  by 
local  or  constitutional  means,  or  by  remedies  of  both 
descriptions  together. 

In  the  hospital  gangrene,  observed  by  Dr.  Rollo  in 
the  Artillery  Hospital  at  Woolwich,  “the  action  of 
the  poison  seemed  to  be  limited  and  confined  to  specific 
effects.  The  first  were  local,  producing  only  a general 
affection  by  a more  extensive  operation  on  the  sore. 
Five  or  six  days  from  the  appearance  of  the  small 
ulcer  or  ulceration,  when  it  had  extended  over  one- 
third  of  the  former  sore,  with  pain  and  redless  in  the 
course  of  the  lymphatics  and  the  glands  through  which 
they  led,  with  enlargement  of  them,  general  indisposi- 
tion of  the  body  became  evident.”  Delpech,  in  his 
interesting  memoir,  particularly  notice.'’,  that  the  con- 


stitutional symptoms  always  occurred  the  last  inordei 
of  succession. 

Mr.  Blackadder  distinctly  declares,  that  in  no  instance 
which  he  had  had  an  opportunity  of  observing, did  the 
constitutional  symptoms  of  gangrenous  phagedena 
precede  the  local,  unless  the  case  be  held  an  exception, 
in  which  a stump  became  affected  after  amputation 
had  been  performed,  on  account  of  the  previous  effects 
of  the  disease.  The  period  at  which  the  constitution 
begins  to  exhibit  symptoms  of  irritation  (he  says)  is 
extremely  irregular, — sometimes  as  early  as  the  ihjrd 
or  fourth  day,  and  sometimes  even  as  late  as  the  twen- 
tieth. The  countenance  assumes  an  anxious  or  fe- 
verish aspect ; the  appetite  is  impaired  ; the  desire  for 
liquids  increases;  and  the  tongue  is  covered  with  a 
wliite  mucus.  The  bowels  are  generally  rather  consti- 
pated ; and  the  pulse  what  may  be  termed  rather  irri- 
tated than  accelerated.  But  the  general  symptoms 
may  assume  an  inflammatory,  or  typhoid  character, 
according  as  the  causes  of  one  of  these  modifications 
may  predominate.  According  to  Mr.  Blackadder, 
when  an  inflammatory  diathesis  prevails,  the  system 
becomes  gradually  more  irritated,  until  an  attack  of 
acute  inflammation  seizes  upon  the  sore,  and  which 
frequently  happens  about  the  end  of  the  second  week. 
At  this  period  the  pulse  is  frequent  and  sharp,  and  it  is 
not  uncommon  for  the  patient  to  be  seized  with  one  or 
more  shivering  fits,  succeeded  by  a great  increase  of 
heat,  but  seldom  or  never  terminating  in  a profuse 
perspiration.  The  cold  fit  is  sometimes  followed  by  a 
bilious  discharge  from  the  intestines  and  nitigation  of 
the  febrile  disorder.  If  the  local  mischief  be  not  ar- 
rested, the  strength  becomes  daily  more  and  more  ex- 
hausted ; the  fever  loses  its  inflammatory  chaiacter; 
and  unless  the  patient  be  cut  off  by  hemorrhage,  he 
falls  a victim  to  extreme  debility.  When  the  disease 
has  a typhoid  character,  the  pulse  is  small  and  fre- 
quent ; the  appetite  and  strength  gradually  fail ; and 
the  patient  at  last  sinks,  retaining  his  mental  faculties 
to  the  last.  No.  unfrequently  diarrhoea  hastens  the 
event. — (^Blackadder  on  Phagedwna  Gangrwnosa,  p. 
39,  40.) 

The  sloughing  phagedena  seen  by  Mr.  R.  Welbank, 
generally  in  the  cleft  of  the  nates,  in  the  groin,  or  at 
the  inner  and  upper  part  of  the  thigh,  in  the  lowest 
class  of  prostitutes,  and,  according  to  his  description, 
certainly  resembling  hospital  gangrene,  was  attended 
in  its  early  stages  with  little  or  no  disturbance  of  the 
system:  a circumstance  which  he  also  mentions  as 
favourable  to  the  doctrine  that  the  disease  Is  of  a local 
nature. — (See  Jl/ed.  Chir.  Trans,  roi.  11,  p.  365.) 

On  the  other  hand,  the  generality  of  writers,  nay, 
even  some  of  those  who  represent  the  disease  as  always 
proceeding  from  a species  of  infection  applied  to  the 
wound,  take  into  the  account  the  operation  of  consti- 
tutional causes,  as  predisposing  to,  and  of  course  pre- 
ceding, the  local  symptoms.  Dr.  J.  Thomson  believes 
that  the  constitutional  symptoms  mostly  precede  the 
local.— (On  Inflammation,  p.  459.)  The  same  senti- 
ment is  professed  throughout  Dr.  Hennen’s  remarks, 
who  placed  reliance  chiefly  upon  internal  remedies, 
and  regarded  external  applications  as  merely  a second- 
ary object. — (0?i  Military  Surgery,  p.  222,  ed.  2.)  To 
this  part  of  the  subject  I shall  return,  after  adverting 
to  the  causes  of  hospital  gangrene. 

The  hospital  gangrene  which  occured  in  the  Artil- 
lery Hospital  at  Woolwich,  and  was  described  by  Dr. 
Rollo,  did  not  attack  specific  sores  ; venereal,  scrofu- 
lous, and  variolous  ulcers  were  not  attacked,  although 
the  patients  lay  in  Uie  wards  where  the  disease  pre- 
vailed. 

Professor  Thontson  admits  that  specific  sores  are  less 
liable  to  attacks  of  hospital  gangrene  than  common 
wounds  and  ulcers;  but  he  declares,  that  he  has 
frequently  seen  it  attack  cancerous  and  venereal 
ulcers. — ( On  Inflammation,  p.  460.) 

Dr.  Hennen  mentions  a remarkable  instance,  which 
also  proves  the  possibility  of  a specific  sore  becoming 
affected,  and  fatal  from  this  cause  in  forty-eight  hours 
after  the  patient  had  first  been  exposed  to  the  infection. 
Dr.  Hennen  relates  the  fact  to  prove,  that  the  contagion 
may  be  received  without  a long  residence  in  a tainted 
air.  The  patient,  “ who  had  just  hinded  from  England, 
and  was  under  the  influence  of  mercury,  employed 
for  a venereal  comnlaint,  died  within  forty-eight  hours 
after  his  admission;  the  gangrene  having  seized  on  an 
open  bubo  in  his  groin,  eroding  the  great  vessels  in  the 


HOSPITAL  GANGRENE. 


47 


neighbourhood,  and  absolutely  destroying  the  abdo- 
minal parietes  to  a large  exlei\l."—{P7inciples  of 
jiftlitary  Surgery^  p.  218,  ed.  2.) 

The  effects  of  hospital  gangrene  should  be  carefully 
discriminated  from  those  of  the  scurvy.  Ulcers  at- 
tacked with  hospital  gangrene  are  not  affected  in  any 
degree,  like  scorbutic  ulcers,  by  the  use  of  vegetable 
diet  and  lemon  juice;  and  they  occur  among  men  who 
are  fed  upon  fresh  meat  and  vegetables,  as  readily  as 
they  do  among  those  who  have  been  fed  altogether 
upon  salt  provisions. — {Thomson's  Lectures  on  In- 
flammation, p.  482.)  Hospital  gangrene  is  almost 
always  accompanied  with  severe  febrile  symptoms; 
but  “ as  to  fevers  (says  Dr.  Lind),  it  may  indeed  be 
doubted  whether  there  be  any  such  as  are  purely  and 
truly  scorbutic.  The  disease  is  altogether  of  a chronic 
nature;  and  fevers  may  be  justly  reckoned  among  its 
adventitious  symptoms.” — {Treatise  on  the  Scurvy,  p. 
106.)  In  cases  of  hospital  gangrene,  the  general  symp- 
toms of  scurvy  are  also  absent,  such  as  soreness  and 
bleeding  of  the  gums,  livid  blotches  and  wheals  on  the 
fleshy  part  of  the  legs,  oedematous  ankles.  Sec. 

Hospital  gangrene  (says  Boyer)  is  a species  of  humid 
gangrene,  which  attacks  in  some  degree  epidemically 
the  wounds  and  ulcers  of  patients  who  happen  to  be 
crowded  together  in  an  unhealthy  place. 

Its  occasional  causes  are:  the  situation  of  an  hos- 
pital upon  a low  marshy  ground ; the  vicinity  of  some 
source  of  infection;  the  uncleanliness  of  the  indivi- 
duals, or  of  the  articles  for  their  use;  the  crowded 
state  of  the  wards,  especially  when  they  are  small  and 
badly  ventilated;  lastly,  every  thing  that  tends  to 
corrupt  the  air  which  the  patients  breathe.  An  in- 
fected atmosphere  may  produce  in  the  most  simple 
wounds  unfavourable  changes,  partly,  as  Boyei  con- 
ceives, by  its  immediate  action  on  the  surface  of  the 
wound,  but,  no  doubt,  principally,  by  its  hurtful  in- 
fluence upon  the  whole  animal  economy.  The  fore- 
going causes  have  also  sometimes  produced  alarming 
and  obstinate  gangrenes  of  an  epidemic  kind,  or,  at 
least,  a state  of  the  constitution,  under  the  influence  of 
which  all  wounds  and  ulcers  constantly  took  on  a bad 
aspect,  and  were  often  conrplicated  with  the  worst 
gangrenous  mischief.  Vigaroux  saw  sucli  an  epidemic 
disease  prevail  for  twenty  mouths  in  the  two  hospitals 
of  Montpellier,  and  he  states  that  the  most  powerful 
antiseptics  were  of  little  avail  against  the  disorder, 
which  often  invaded  the  slightest  scratches. 

In  general,  this  epidemic  species  of  gangrene  is  not 
observed  in  new-built  hospitals,  nor  in  those  which  are 
erected  out  of  the  central  parts  of  cities  upon  high 
ground.  Hospital  gangrene  may  occur  in  any  season ; 
but  it  is  most  common  after  the  sultry  heat  of  summer. 

A bilious  constitution,  mental  trouble,  unwholesome 
or  insufficient  food,  a scorbutic  diathesis,  great  debility, 
and  fevers  of  a dangerous  type,  are  also  reckoned  by 
the  French  surgeons  as  so  many  predisposing  causes  of 
hospital  gangrene. 

The  observations  of  Pouteau,  and  those  of  some 
other  practitioners,  convincingly  prove  that  hospital 
gangrene  may  be  communicated  to  the  most  simple 
wound  or  ulcer  in  a subject  of  the  best  constitution, 
and  breathing  the  purest  air,  by  merely  putting  into 
contact  with  such  wound  or  ulcer,  sponges,  lint,  or 
charpie,  impregnated  with  the  infection  of  this  peculiar 
disorder.  But  this  inoculation  is  conceived  to  be  the 
more  alarming,  and  to  take  effect  the  more  quickly,  in 
jirop<jrtion  as  patients  have  been  more  exposed  to  the 
influence  of  such  causes  as  are  themselves  capable  of 
producing  the  disease,  atid  also  in  proportion  as  the 
kind  of  constitution  predisposes  to  it. 

Although  the  contagious  nature  of  hospital  gangrene 
has  been  generally  admitted  by  all  the  best-informed 
writers  on  the  subject,  the  doctrine  was  not  considered 
by  Dr.  Trotter  as  having  a good  foundation.  Modern 
authors,  however,  have  not  joined  this  latter  gentle- 
man, and  Dr.  .1. Thomson,  Dr.  Ilennen,  Mr.  Blackadder, 
and  Mr.  R.  Welbank,  all  believe  that  the  disorder  is 
infectious.  “ The  contagious  nature  of  hospital  gan- 
grene (says  Professor  Thomson)  appears  to  me  to  be 
sufficiently  proved,  1st,  By  the  fact,  that  it  may  be 
comriiunicated  by  sponges,  charpie,  bandages,  and 
clothing,  to  persons  at  a distance  from  those  infected 
with  it.  2dly,  By  its  having  been  observed  to  attack 
the  sliaht  wounds  of  surgeon.s,  or  their  mates,  who  were 
employed  in  dre.ssing  infected  persons;  and  that  even 
in  circumstances  where  the  medical  men  so  employed 


did  not  live  in  the  same  apartment  with  the  infected. 
3dly,  By  our  being  able  often  to  trace  its  progress  dis- 
tinctly from  a single  individual  through  a succession 
of  patients.  4thly,  By  its  attacking  recent  wounds,  as 
well  as  old  sores,  and  that  in  a short  time  after  they 
are  brought  near  to  a patient  affected  with  the  disease. 
Stilly,  By  our  being  able  to  prevent  the  progress  of  the 
disease  in  particular  situations,  by  removing  the  in- 
fected person  before  the  contagion,  which  his  sores 
emit,  has  had  time  to  operate.  6thly,  By  its  continuing 
long  in  one  particular  ward  of  an  hospital,  or  in  one 
particular  ship,  without  appearing  in  other  wards,  or 
ships,  if  pains  be  taken  to  prevent  intercourse  between 
the  infected  and  uninfected.” — {Lectures  on  Inflamma- 
tion, p.  484.)  But  although  there  can  be  no  doubt  of 
the  disease  spreading  partly  by  its  contagious  nature, 
it  appears  to  me  equally  certain  that  the  number  of 
cases  is  also  often  increased  by  the  continued  operation 
oDhe  same  causes  which  produced  the  earliest  instance 
of  the  disorder  in  any  particular  hospital.  A similar 
belief  is  expressed  by  Dr.  Boggie.— (See  Edinb.  Med. 
Chir.  Trans,  vol.  3,  p.  25.) 

It  is  alleged,  that  when  once  a patient  has  taken  the 
infection,  he  cannot  avoid  the  consequences,  whatever 
precautions  he  may  adopt.  Thus,  Boyer  informs  us, 
that  he  has  seen  hospital  gangrene  take  place  in 
wounded  patients,  who,  in  the  liope  of  escaping  this 
epidemic  affection,  had  quitted  the  infected  hospital, 
and  retired  to  elevated  situations,  where  they  breathed 
the  most  salubrious  air. — (See  Traiti  des  Mai.  Chir. 
1. 1,  p.  322.) 

I'lie  bad  state  of  the  air  of  a crowded  hospital,  as 
Mr.  Blackadder  observes,  is  a ready  means  of  account 
ing  for  the  origin  of  phagedaena  gangitenosa;  but  there 
are  various  reasons  for  considering  such  explanation 
not  altogether  satisfactory ; and  he  mentions  a case,  in 
which  the  wound  of  a soldier  was  found  affeCUd  witil 
the  disease  on  his  first  arrival  at  an  hospital,  after 
having  been  accidentally  detained,  with  two  other 
wounded  comrades,  for  five  or  six  days,  partly  in  an 
open  building,  and  partly  in  a boat,  quite  exposed  to 
stormy  weather. — (P.  45.)  Dr.  Hennen  likewise  gives 
an  account  of  about  thirty  fresh  wounded  men,  in 
whom  hospital  gangrene  first  appeared  in  their  journey 
from  Vittoria  to  the  hospital  near  Bilboa. — {Principles 
of  Military  Surgery,  p.214,  ed.  2.)  Dr.  Rollo  also  re- 
marked, that  some  men  in  quarters  were  ajfected  with 
this  disease.  And,  according  to  Mr.  J.  Bell,  “ there  is 
no  hospital,  however  small,  airy,  or  well  regulated, 
where  this  epidemic  ulcer  is  not  to  be  found  at  times.” 
— {Principles  of  Surgery,  vol.  1,  p.  112.)  For  a refu- 
tation of  the  opinion,  that  the  disease  strictly  merits  the 
epithets  cndernial  and  epidemic,  I tnust  refer  the  reader 
to  the  observations  of  Mr.  Blackadder. — (P.  143,  ^-c.) 
Delpech  remarks,  that  the  causes  of  the  disease  do  not 
appear  to  have  depended  upon  the  state  of  the  atmo- 
sphere (p.25) ; and,  in  almost  every  instance,  he  traced 
the  propagation  of  the  disorder  to  the  direct  applica- 
tion of  the  morbific  matter  to  the  sores.  However,  lie 
joins  Pouteau  in  the  belief,  that  it  may  be  communi- 
cated through  the  medium  of  the  atmosphere;  arr 
occurrence  which  Mr.  Blackadder  doubts,  or  rather 
considers  as  very  rare,  and  only  possible  where  the 
effluvia  are  allowed  to  accumulate  in  a most  negligent 
manner,  so  as  to  resemble  a vapour  bath,  which  mode 
he  would  also  regard  "as  equivalent  to  inoculation. — 
{On  Phagedwna  Gangreenosa,  p.  156.)  On  the  whole, 
I am  disposed  to  think  the  views  which  Mr  Blackadder 
has  taken  of  the  manner  in  wliich  the  disease  is  com- 
municated the  most  correct,  and  that,  while  particular 
states  of  the  air  and  constitution  certainly  modify  the 
disorder,  they  cannot  generally  have  any  share  in 
giving  origin  to  the  disease  : I say  generally,  becau.se, 
as  various  facts  oblige  us  to  admit,  that  hospital  gan- 
grene sometimes  arises  without  having  been  communi- 
cated from  any  patient  previously  affected,  it  is  impos- 
sible to  assert,  that  the  earliest  example  of  it,  under 
such  circumstances,  may  not  arise  from  tlie  operation 
of  some  unknown  and  inexplicable  circumstances  on 
the  constitution,  or,  in  other  words,  from  the  state  of 
the  system  itself.  Nor  can  a doubt  be  entertained, 
that  at  all  events,  the  disorder  is  most  apt  to  break  out 
in  crowded,  badly  ventilated  hospitals,  and  in  them 
appear  more  extensively  and  malignantly  than  in 
others  w'hich  are  well  regulated,  properly  ventilaled, 
and  healthily  situated.  But  the  idea  entertained  by 
Delpecli,  that  hospital  gangrene  may  originate  from  the 


48  HOSPITAL 

same  contagion  as  typhus,  or  other  diseases,  is  merely 
ail  unsupported,  irrational  conjecture,  quite  as  destitute 
of  truth  as  the  suppositions  about  the  endemial  and 
epidemic  character  of  the  complaint,  independent  of 
its  infectious  nature.  The  question,  how  the  first 
example  of  the  disorder  originates,  is  at  present  a per- 
fect mystery ; but,  as  it  cannot  be  referred  to  contagion, 
or  inoculation,  we  should  recollect,  that  whatever  pro- 
duces it  in  one  individual  may  produce  it  in  another, 
similarly  circumstanced,  and,  on  this  principle,  the 
disorder  may  sometimes  be  formed  independently,  and 
at  the  same  time,  in  a greater  or  less  number  of  pa- 
tients in  the  same  hospital,  as  well  as  spread  from  these 
to  others  by  infection. 

With  the  view  of  preventing  the  disorder,  the  wards 
in  which  the  w’ounded  are  placed  should  not  be 
crowded:  they  ought  to  be  freely  ventilated,  and  if 
passible  not  communicate.  The  utmost  attention  to 
cleanliness  should  be  paid,  and  all  filth  and  stagnant 
water  removed.  It  has  been  asserted,  but  w ith  what 
accuracy  I cannot  determine,  that  the  predisposition 
of  the  W’ounded  to  this  species  of  gangrene  may  be 
lessened  by  a w'ell-chosen  diet,  by  drinks  acidulated 
with  vegetable  acids,  or  with  the  sulphuric  acid,  and 
by  the  moderate  use  of  wine.  The  state  of  the  sto- 
mach and  bowels  should  be  particularly  attended  to, 
and  if  out  of  order  emetics  and  purgatives  ought  to  be 
immediately  employed,  and  repeated  according  to  cir- 
cumstances. The  dressings  should  be  applied  with 
extreme  attention  to  cleanliness,  and  too  much  care 
cannot  be  taken  to  prevent  the  infectious  matter  of 
one  wound  from  coming  into  contact  with  another, 
through  the  medium  of  sponges  (see  JVelbank,  in 
Jiled.  Chir.  Trans,  vol.  11,  p.  365),  instruments,  &c. 
“ Whatever  may  be  the  source  of  this  disease  (says  a 
late  writer),  it  is  at  least  sufficiently  ascertained,  that 
when  it  occurs,  its  propagation  is  only  to  be  prevented 
by  the  most  rigid  attention  to  cleanliness,  and  by  insu- 
lating the  person  or  persons  affected,  so  as  to  prevent 
all  direct  intercourse  between  them  and  the  other  pa- 
tients; for,  so  far  as  I have  had  an  opportunity  of 
observing,  ninety-nine  cases  in  the  hundred  were  evi- 
dently produced  by  a direct  application  of  the  morbific 
matter  to  the  wounds,  dressings,  &.c. ; while  others, 
who  were  in  every  other  respect  equally  exposed  to  its 
operation,  never  caught  the  disease.  In  attempting  to 
prove  this  by  experiment,  1 have  placed  three  patients 
with  clean  w'ounds  alternately  between  tliree  other 
patients  severely  affected  with  the  disease.  They  lay 
in  a part  of  a ward  which  was  appropriated  for  patients 
who  were  labouring  under  the  disease,  and  of  whom 
there  were  at  the  time  a considerable  number.  Their 
beds  were  on  the  floor,  and  not  more  than  two  feet 
distant  from  each  other ; but  all  direct  intercourse  was 
forbidden,  and  they  were  made  fully  aware  of  the 
consequences  that  would  follow’  from  inattention  to 
their  instructions.  The  result  of  this  trial  was,  that 
not  one  of  the  clean  w’ounds  assumed  the  morbid  ac- 
tion peculiar  to  the  disease,  nor  w’as  the  curative  pro- 
cess in  any  degree  impeded.” — {Blackadder  on  Pha- 
gcedena  Oangrmnosa,  p.  40.) 

As  many  experienced  w’riters  assert,  that  the  dis- 
ease may  also  be  communicated  from  one  person  to 
another  through  the  medium  of  effluvia  in  the  air,  I 
am  firmly  persuaded  that,  in  Uie  present  state  of  our 
know’ledge  of  the  subject,  the  cautions  respecting  ven- 
tilation and  cleanliness  (the  chief  practical  deduction 
from  the  latter  doctrine)  are  highly  necessary  and  im- 
portant. This  sentiment  may  be  adopted,  without 
implicit  faith  being  rilaced  in  the  opinion,  that  the 
disorder  can  actually  be  transmitted  from  one  person 
to  another  llirough  contagion  in  the  air,  because, 
whether  the  last  idea  be  true  or  not,  attention  to  clean- 
liness and  ventilation  must  be  beneficial  to  the  health, 
in  this,  as  in  every  other  species  of  gangrene  ; and,  on 
this  principle,  it  must  be  serviceable  in  diminishing 
the  severity,  if  not  the  frequency  and  extent,  of  the 
disease,  as  I am  myself  disposed  to  believe  from  the 
consideration  of  all  the  evidence  adduced.  These 
observations  are  strenitthened  by  the  fact,  that  it  w’as 
chiefly  in  the  foul  wards  of  St.  Bartholomew’s  Hospital, 
that  the  disorder  committed  its  ravages  in  that  institu- 
tion.— (See  Med.  Chir.  Tran.^i.  vol.  11,  p.  365.)  Where 
circumstances  will  permit,  an  entire  removal  of  the 
patients  from  the  place,  in  w Inch  the  disease  has  either 
had  its  first  formation,  or  spread  to  any  extent,  appears 
likew’ise  to  be  a most  beneficial  measure.  But  when 


GANGRENE. 

this  change  of  the  wards,  or  hospital,  is  impracticable, 
the  air  which  the  patients  breathe  should  be  purified, 
by  renew  ing  it  as  much  as  possible,  fixing  ventilators, 
and  especially  by  using  the  oxygenated  muriatic  acid 
fumigations,  as  recommended  by  Guyton-Morveau,  or 
else  those  of  the  nitric  acid. 

The  nitric  acid  fumigations  are  made  by  putting  into 
a glass  vessel,  on  the  ground,  half  an  ounce  of  concen- 
trated sulphuric  acid,  to  w’hich  an  equal  quantity  of 
nitre  is  to  be  added  gradatim.  TJie  mixture  is  to  be 
stirred  with  a glass  tube,  when  an  abundance  of  white 
vapour  w’ill  be  produced. 

The  oxygenated  muriatic  acid  fumigations  are  made, 
by  mixing  three  ounces  two  drachms  of  common  salt 
with  five  drachms  of  the  black  oxyde  of  manganese  in 
powder.  These  tw’o  ingredients  are  to  be  triturated 
together;  IJiey  are  then  to  be  put  into  a glass  vessel; 
one  ounce  two  drachms  of  water  are  to  be  added,  and 
then,  if  the  ward  or  chamber  be  uninhabited,  one  ounce 
seven  drachms  of  sulphuric  acid  are  to  be  poured  upon 
the  mi.xture  all  at  once;  or,  gradually,  if  the  patients 
are  there.  This  quantity  will  be  sufficient  for  a very 
large  ward. 

When  one  or  more  of  the  patients  afflicted  with 
the  disorder,  before  it  has  become  general,  are  lying  in 
a badly  ventilated  part  of  the  ward,  the  surgeon  can 
partly  counterbalance  the  disadvantage  of  not  having 
a fresh  w ard,  by  causing  the  patients  to  be  put  into  a 
more  airy  part  of  the  ward,  and  as  far  as  possible  from 
the  quarter  in  which  they  contracted  the  disease. 

With  regard  to  internal  medicines,  while  irritation 
and  febrile  lieal  accompany  hospital  gangrene,  diluent 
acid  drinks  are  proper,  such  as  nitrated  whey  sweet- 
ened w ith  syrup  of  violets,  lemonade,  fcc.  Blood- 
letting is  admissible  in  but  few’  instances;  not  merely 
because  the  orifice  made  by  the  lancet  may,  according 
to  some  accounts,  become  gangrenous,  but  because  the 
fever,  which  accompanies  hospital  gangrene,  is  usually 
of  the  typhoid  character. — {Thomson,  p.  493.) 

Mr.  Blackadder,  like  Dr.  Thomson,  does  not  entertain 
a favourable  opinion  of  venesection,  as  a general  prac- 
tice, though  he  w’ould  not  object  to  the  abstraction  of 
a small  quantity  of  blood,  when,  ow  ing  to  the  plethoric 
habit  of  the  patient,  previous  treatment,  and  other 
causes,  an  inflammatory  action  in  the  system  is  present. 
The  same  practice,  under  similar  conditions.  Is  also 
sanctioned  by  Dr.  Boggie.— (Edmft.  Med.  Chir.  Trans, 
vol.  ^,p.  34.)  Mr.  Blackadder  conceives,  that  all  dan- 
ger of  the  disease  attacking  the  w’ound  made  with  the 
lancet  may  be  obviated,  if  care  be  taken,  that  the  arm 
of  the  patient,  the  hands  of  the  surgeon,  his  lancet,  and 
the  subsequent  dressings,  be  perfectly  free  from  con- 
tamination, and  that  the  patient  be  prevented  from 
undoing  the  bandage,  or  touching  the  incision  made 
with  the  lancet  before  it  is  cicatrized.— -(P.  135.)  Dr. 
Boggie  has  bled  many  in  this  disease,  but  never  seen  a 
single  instance  of  gangrene  after  the  operation. — 
{Edinh.  Med.  Chir.  Trans,  vol.  3,  p.  35.)  Mr.  Black- 
adder  thinks,  how’ever,  that  blood-letting  should  be 
avoided  as  much  as  possible,  particularly  when  Uie 
previous  injury  has  been  extensive.  “ A general  debi- 
lity of  the  system  is  one  of  the  symptoms  w’hich  are 
most  to  be  dreaded;  for,  when  once  it  takes  place, 
there  is  no  other  disease  in  which  it  is  removed  W’ith 
greater  difficulty.” — (P.  J37.)  How  different  these  sen- 
timents are  from  those  of  Dr.  Hennen,  who,  in  speaking 
of  the  effects  of  venesection,  w hen  the  disorder  was 
accompanied  with  an  inflammatory  diathesis,  employs 
the  following  expressions;  “The  very  patients  them- 
selves implored  the  use  of  the  lancet.”  For  several 
months  “ w’e  used  no  other  remedy,  either  as  a cure  or 
preventive.” — “ We  never  observed  any  of  the  lancet- 
wounds  assume  a gangrenous  appearance,  although 
previously,  in  almost  every  other  instance,  the  slightest 
puncture  festered.” — (Ora  Military  Surgery,  p. 
cd.  2.)  Mr.  Welbank  also  states,  that  moderate  ve- 
nesection may  be  adopted  with  advantage  while  the 
disease  is  superficial,  and  the  constitution  not  much 
affected,  particularly  in  plethoric  habits. — {Med.  Chir. 
Trans,  vol.  11,  p.  368.) 

In  the  beginning  of  the  constitutional  attack,  Pou- 
teau  and  Dussassoy  particularly  recommended  emetics; 
and  Mr.  Briggs,  lir.  J.  Thomson,  and  Dr.  Hennen  are 
all  advocates  for  this  practice,  though  the  latter  gen- 
tleman makes  his  evidence  rather  ambiguous  by  a 
subjoined  note,  in  which  he  mentions,  that  want  of 
success,  &c.  led  to  the  trial  of  venesection.— (Op ._cit. 


HOSPITAL  GANGRENE. 


49 


222.)  As  for  Mr.  Blackadder,  he  deems  the  employ- 
ment of  emetics  at  the  commencement  of  hospital 
gangrene  useful  only  when  the  stomach  is  foul.— (Ow 
Phagedcsna  OangrcBtiosa,  p.  134.)  Dr.  Boggie  found 
emetics  generally  very  inferior  to  purgatives.— (Bdm*. 
Med.  Chir.  Trans,  vol.  3,  p.  37.)  He  chiefly  approves 
of  them  when  the  stomach  is  loaded,  and  the  fever  of 
a bilious  character.  In  the  early  stage  of  the  case, 
writers  seem  all  to  agree  about  the  utility  of  purgative 
and  laxative  medicines.  When  there  is  debility,  good 
generous  wine  should  be  allowed,  either  by  itself  or 
mixed  with  lemonade,  according  to  circumstances. 
Bark  is  in  general  more  hurtful  than  useful : Mr.  Wel- 
bank  objects  to  it  generally,  on  account  of  the  common 
disposition  to  diarrhcEa  in  the  advanced  stages  of  the 
disease  ^Med.  Chir.  Trans,  vol.  11,  p.  3ti8)  ; and  Dr. 
Hennen  assures  us  that  he  has  seen  great  harm  done 
by  large  and  injudicious  doses  of  this  drug,  before  full 
evacuations  had  taken  place,  and  the  sloughs  begun  to 
separate.  Boyer  allows,  however,  that  it  may  be 
beneficially  given  when  the  feverish  heat  has  abated, 
and  the  debility  is  very  great. 

In  all  stages  of  this  disease,  unattended  with  diar- 
rhoea, acids  are  proper.  The  sulphuric  acid  is  that 
which  is  given  with  most  success ; but,  the  acidulous 
tartrate  of  potassa  is  also  an  excellent  medicine.  From 
two  drachms  to  half  an  ounce  may  be  given  every 
day,  and  the  best  plan  is  to  make  an  acid  drink  with 
it,  which  should  be  sweetened  and  strained. 

In  severe  cases,  attended  with  a quick  and  feeble 
ulse,  depression,  restlessness,  and  anxiety,  an  opiate 
ecomes  necessary.  “ So  long  as  we  wish  to  excite  a 
degree  of  moisture  on  the  skin  (says  Professor  Thom- 
son), Dover’s  powder,  or  laudanum  with  antimonial 
wine,  form  in  general  the  best  opiates.”  This  gentle- 
man, however,  is  not  an  advocate  for  the  employment 
of  opium,  in  the  early  stage  of  hospital  gangrene,  while 
the  heat  and  other  febrile  symptoms  are  at  their  height. 
— (See  Lectures  on  Ivfiammation.,  p.  494,  495.)  Ac- 
cording to  Mr.  Welbank’s  experience,  narcotics  are 
beneficial,  and  he  has  seen  a most  irritable  state  of  the 
stomach  improve  rapidly,  and  a foul,  furred  tongue 
become  clean,  on  the  administration  of  large  doses  of 
opium  at  regular  intervals. — (See  Med.  Chir.  Trans, 
vol.  11,7).  3G8.)  Camphor,  in  large  and  frequent  doses, 
was  highly  praised  by  Pouteaii. 

From  what  has  been  said  of  internal  remedies,  it  is 
evident  that  none  of  them  can  be  regarded  as  means  at 
all  to  be  depended  upon  for  arresting  the  ravages  of 
hospital  gangrene,  however  advantageous  they  may 
prove  in  palliating  general  symptoms,  removing  par- 
ticular complications,  enabling  the  system  to  support 
the  effects  of  the  local  disorder  for  a greater  length  of 
time,  or,  in  a few  cases,  even  placing  nature  in  a con- 
dition to  throw  off  the  diseased  parts  herself,  and 
communicate  to  the  subjacent  living  flesh  a healthy 
action. 

If  credit  can  be  given  to  several  of  the  authors  who 
have  had  the  most  extensive  opportunities  of  attending 
to  the  nature  of  hospital  gangrene,  the  local  treatment 
is  far  more  effectual  than  internal  medicines. 

“ I was  told  by  several  of  the  French  surgeons  (says 
a late  visiter  to  Paris),  that  they  did  not  rely  at  all  on 
internal  means  for  stopping  the  progress  of  hospital 
gangrene,  and  that  their  experience  had  proved  them 
to  be  insufficient,  if  not  wholly  inefficacious.  Dupuy- 
tren.  In  reply  to  the  account  I gave  hitn  of  the  practice 
and  opinions  of  English  surgeons  on  this  subject,  as- 
sured me  that  he  had  no  confidence  in  any  but  local 
applications,  and  that  internal  remedies  alone,  as  far  as 
he  had  found,  did  almost  nothing.”  The  same  remark 
has  been  made  in  a modern  publication  on  hospital 
gangrene  (Dclpech,  Mdm.  sur  la  Complication  des 
Flaies,  (S-c.  1815),  “ although  it  seems  to  be  rather  at 
variance  with  its  being  a constitutional  and  contagious 
di.sease,  which  the  author  has  admitted.” — (See 
Sketches  of  the  Medical  Schools  of  Paris,  by  J.  Cross, 
p.  83.) 

Perhaps  every  antiseptic  application  that  can  be 
mentioned  has  been  tried  as  a dressing  for  wounds,  or 
ulcers,  affected  with  hospital  gangrene.  All  watery 
applications,  and  common  poultices,  and  fomentations, 
are  generally  condemned,  as  inefficacious  and  even 
hurtful.  Dr.  Boggie,  however,  is  an  advocate  for  cold 
lotions  in  the  incipient  inflammatory  stage ; and,  per- 
haps, solutions  of  the  chlorides  of  lime  and  soda  may 
deserve  trial. 


Dussassoy  was  convinced,  by  the  observation  of  nu- 
merous cases,  that  the  best  application  is  powder  of 
bark.  He  recommends  the  wound  to  be  covered  with 
several  layers  of  this  powder,  which  are  then  to  be 
moistened  with  turpentine.  When  this  composition 
dries,  he  asserts,  that  It  forms  a fragile  sort  of  coat,  at 
the  sides  of  which,  and  through  which,  the  discharge 
escapes.  After  twenty-four  hours,  the  first  coat  is  to 
be  removed,  and  a fresh  one  applied.  In  general,  ac- 
cording to  this  writer,  four  or  five  such  dressings  are 
sufficient  in  simple  cases,  where  the  disorder  is  confined 
to  the  skin  and  cellular  substance.  Healthy  inflamma- 
tion then  occurs,  the  sloughs  come  away,  and  the 
wound  puts  on  a healing  appearance.  In  bad  cases, 
Dussassoy  sometimes  added  one-fifth  of  powdered 
muriate  of  ammonia  to  the  bark.  When  this  treat- 
ment failed,  the  actual  cautery  was  used. 

On  the  subject  of  bark,  as  a local  application  to  hos- 
pital gangrene,  I need  only  remark,  that  it  is  now  en- 
tirely relinquished,  either  as  possessing  no  efficacy 
{Delpech),  or  even  aggravating  the  symptoms  (.^Black- 
adder). 

The  milder  forms  of  the  disease  appear  sometimes 
to  have  yielded  to  the  application  of  the  vegetable  and 
diluted  mineral  acids;  viz.  lime-juice,  lemon-juice, 
vitiegar,  and  the  diluted  nitric  and  muriatic  acids. 
And  the  same  observation  may  be  made,  with  respect 
to  solutions  of  the  nitrates  of  silver  and  mercury. 
The  two  latter  substances,  and  the  oxygenated  mu- 
riatic acid,  and  gas,  were  found  by  Dr.  Kollo  to  be  ca- 
pable of  effecting  a cure.  Delpech,  in  particular, 
speaks  of  the  benefit  derived  from  the  application  of 
strong  vinegar,  after  all  the  pulpy  viscid  matter  has 
been  carefully  wiped  away  from  the  surface  of  the 
living  flesh.  The  vinegar  is  then  poured  on  the  ulcer, 
which  is  to  be  covered  with  charpie  wet  with  the  same 
liquid.  When  the  case  is  too  far  advanced  for  this 
treatment  to  answ'er,  Delpech  tries  caustics,  especially 
the  nitrate  of  silver ; and  if  these  fail,  he  has  recourse 
to  the  actual  cautery  ; and  when  the  sloughs  are  very 
thick,  so  as  to  hinder  the  cautery  from  acting  to  a suf- 
ficient depth,  he  prefers  thrusting  into  the  sloughs, 
down  to  the  living  flesh,  angular  pieces  of  caustic 
potash,  at  small  distances  from  each  other ! — {Precis 
Eldm.  des  Mai.  Chir.  t.  1,  p.  151.)  Surely  this  must  be 
far  more  torturing  and  less  certain  of  success,  than  re- 
moving the  sloughs,  and  applying  the  cautery. 

Though  the  actual  cautery  is  generally  admitted  to 
be  one  of  the  most  powerful  means  of  stopping  the 
progress  of  hospital  gangrene,  the  surgeons  of  this 
country  entertain  a strong  aversion  to  the  practice; 
and  I confess  that  my  own  dislike  to  it  is  such  as  would 
always  lead  me  to  prefer  any  other  treatment,  from 
which  equal  efficacy  would  result.  At  the  same  time, 
it  must  be  granted,  that  if  the  actual  cautery  will  more 
certainly  arrest  some  forms  of  hospital  gangrene,  than 
any  other  known  applications,  the  surgeon’s  duty  is  to 
put  out  of  the  question  his  own  prejudices  against  it, 
and  consider  only  his  patient’s  welfare.  I am  far  from 
thinking,  however,  that  while  there  are  such  powerful 
caustics  as  the  undiluted  mineral  acids,  and  a dressing 
so  effectual  as  a solution  of  arsenic,  it  can  often  be 
absolutely  necessary  to  employ  red-hot  irons. 

The  merit  of  having  pointed  out  in  modern  times  the 
great  efficacy  of  Fowler’s  solution  of  arsenic,  or  the 
liquor  arsenicalis  of  the  London  Pharmacopoeia,  as  an 
application  to  phagedsena  grangrtenosa,  belongs  to  Mr. 
Blackadder.  In  answer  to  the  objection,  that  the  ex- 
ternal use  of  arsenic  is  not  unattended  with  danger,  he 
assures  us,  that  he  has  heard  of  but  one  instance  of 
hospital  gangrene,  in  which  any  deleterious  effects 
were  supposed  to  arise  from  the  absorption  of  the 
arsenic;  and  the  patient  in  question  was  very  soon 
cured  of  his  uneasy,  and  possibly  merely  nervous  symp- 
toms.— {P.  50.) 

“ The  first  thing  to  be  attended  to  in  every  case  of 
disease  (says  Mr.  Blackadder)  is  cleanliness,  which,  if 
always  of  great  importance,  is  in  this  instance  indis- 
pensable. The  surface  of  the  body  ought  to  be  made, 
and  kept,  perfectly  clean,  by  means  of  the  tepid  bath, 
or  otherwise  by  a plentiful  use  of  soap  ; and  the  linen, 
and  bed-clothes,  should  be  frequently  changed,  par- 
ticularly when  soiled  with  matter  from  the  sore.”  In 
order  to  make  the  sore  perfectly  clean,  and  free  it 
from  the  viscous  discharge,  without  producing  con- 
siderable bleeding  and  pain,  Mr.  Blackadder  recom- 
mends two  large  tin  hospital  teapots  to  be  filled  with  a 


D 


50 


HOSPITAL  GANGRENE, 


weak  solution  of  the  subcarbonate  of  potass.  One  of 
these  solutions  is  to  be  cold,  the  other  tepid  ; because 
sometimes  one,  and  sometimes  the  other,  is  found  most 
agreeable  to  the  patient’s  feelings,  though  the  vvarm  is 
the  most  effectual  in  cleansing  the  sore.  The  liquid  is 
to  be  poured  over  the  sore  and  received  into  a basin, 
which  ought  to  be  immediately  emptied  into  another 
vessel  placed  at  a distance  from  the  patient.  During 
this  ablution,  the  glutinous  matter,  which  adheres  to 
the  sore,  may  be  gently  detached,  by  means  of  small 
dossils  of  fine  tow  or  lint;  but  these  (says  Mr.  Black- 
adder)  should  never  be  used  for  two  dilierent  patients, 
rigid  economy,  on  occasions  such  as  this,  being  a very 
mistaken  principle.  In  these  cases,  the  use  of  sponges 
(he  justly  observes)  ought  to  be  entirely  laid  aside,  as 
they  can  seldom  be  used  more  than  once  with  safety. 
When  the  sore  has  been  thus  cleaned,  a piece  of  fine 
dry  lint  is  to  be  spread  over  its  surface,  and  gently 
pressed  into  all  its  depressions  with  the  points  of  the 
fingers.  When  the  lint  is  removed,  a quantity  of  the 
discharge  will  be  found  adhering  to  it;  and  this  opera- 
tion must  be  repeated  with  fresh  pieces  of  lint,  until 
the  surface  of  the  sore  is  made  perfectly  clean  and  dry. 

According  to  Mr.  Blackadder,  the  solution  of  arsenic 
will  generally  be  found  strong  enough,  wl:en  diluted 
with  an  equal  part  of  water;  but  in  slight  cases  it 
answered,  when  weakened  with  twice  its  quantity  of 
water;  and,  in  a few  examples,  it  was  employed  with- 
out being  at  all  diluted.  Several  pieces  of  lint  of  the 
same  shape  as  the  sore,  but  a little  larger,  are  to  be  pre- 
pared ; one  of  these,  soaked  in  the  solution,  is  now  to 
be  applied  to  the  cleaned  surface  of  the  sore,  and  re- 
newed every  fifteen  or  thirty  minutes,  accordme  to  the 
time  in  which  it  becomes  dry.  When  the  heat  and  in- 
flammation are  considerable,  great  relief  will  be  de- 
rived from  the  frequent  application  of  linen  cloths, 
moistened  with  cold  w’aler,  which  must  be  kept  ^om 
weakening  the  arsenical  solution  by  means  of  a small 
piece  of  oil-skin  laid  over  the  pieces  of  lint.  When 
the  disease  extends  into  the  track  of  a gunshot  wound, 
Mr.  Blackadder  uses  a syringe  for  cleaning  the  sore 
and  introducing  the  solution.  “ A slip  of  fine  lint, 
w'ell  soaked  in  the  solution,  may  also  be  inserted,  by 
means  of  a probe,  into  the  bottom  of  the  wound ; and 
when  the  openings  are  at  no  great  distance  (from  each 
other),  and  not  in  the  immediate  vicinity  of  the  large 
nerves  and  blood-vessels,  the  lint  may  be  drawn  through 
the  wmund  in  the  form  of  a seton.” — (P.  53.)  When 
the  pain  caused  by  the  application  is  very  severe,  and 
the  constitution  is  irritable  and  debilitated,  Mr.  Black- 
adder prescribes  an  opiate,  though  he  remarks,  that  this 
practice  will  seldom  be  absolutely  necessary.  The 
morbid  action  in  the  sore  is  destroyed  by  the  arsenical 
solution  sooner  or  later  in  different  c ases : the  best  plan 
is  to  continue  the  application  until  an  insensible,  dark- 
coloured,  dry  slough  occupies  the  whole  surface  of  the 
sure,  and  until  the  patient  is  completely  relieved  from 
the  burning  and  lancinating  pain. 

After  the  slough  is  formed,  Sir.  Blackadder  emploj's 
an  ointment  composed  of  equal  parts  of  the  oil  of  tur- 
pentine and  the  yellow  resinous  ointment,  or  of  t^  o 
parts  of  Venice  turpentine  to  one  of  the  resinous  oint- 
ment. “ These  being  melted  and  mixed  together  are 
to  be  poured  over  the  sore,  as  hot  as  the  patient  can 
possibly  bear.”  A pledget  of  dry  lint  or  tow,  and  a 
bandage,  are  then  applied;  and  this  dressing  may  be 
renewed  two  or  three  times  a daj',  the  sore  being  each 
time  carefully  washed  w ith  the  solution  of  potass.  As 
soon  as  any  part  of  the  slough  is  loosened,  Mr.  Black- 
adder removes  it  with  a pair  of  curved  scissors.  With 
the  view  of  expediting  the  separation  of  the  slough, 
he  sometimes  employed  a linseed  meal  poultice,  which 
bad  the  desired  effect,  but  was  found  to  be  too  relaxing. 
When  it  is  used,  therefore,  Mr.  Blackadder  found  it 
expedient,  at  each  dressing,  to  touch  the  new  granula- 
tions with  the  nitrate  of  silver. 

After  the  detachment  of  the  slough,  Mr.  Backadder 
dresses  the  sore  with  the  above-mentioned  ointment 
cold,  or  with  the  .addition  of  a small  pro})ortion  of  the 
Fubacetate  of  copper.  The  pledget  of  this  ointment  is 
covered  with  a piece  of  oil-skin,  lightly  rubbed  over 
with  soap,  and  a firm  bandage  is  ajiplied  to  the  wiiole 
limb. — (See  Obs.  on  Phagedana  Gangr(Bnosa,p.  49,  d c. 
i*vo.  F.dinb.  1818.)  The  author  declares,  that  after  the 
introduction  of  the  above  treatment  (with  the  exception 
of  stumps  attacked  w ith  hospital  cangrene),  he  never 
saw  an  instance  in  which  the  remedy  failed,  when  ap- 


plied in  time  and  a proper  manner ; “ that  is,  before 
the  disease  had  made  such  progress  as  to  preclude  all 
rational  hope  of  success  from  that  or  any  other  mode 
of  treatment. ”~(jP.  23.) 

In  Doctor  Rollo’s  Treatise  on  Diabetes,  published  in 
1797,  the  opinion  is  plainly  stated,  that  the  progress  of 
hospital  gangrene  might  be  stopped  by  very  active  to- 
pical applications,  and,  in  the  same  wmrk,  Mr.  Cruik- 
shank  says,  that  if  an  actual  caustic  were  to  be  em- 
ployed, we  should  have  recourse  to  the  strong  nitrous 
acid.”  According  to  Mr.  Blackadder,  the  oxygenated 
muriate  of  mercury,  and  the  nitrous  acid,  were  much 
recommended  and  employed  by  surgeons  in  the  16th 
and  17th  centuries,  as  escharotics  in  cases  of  gangrene 
and  foul  ulcers. — (P.  113.)  Several  army  surgeons 
have  informed  me  that  the  undiluted  nitrous  acid  was 
successfully  used  as  an  application  to  hospital  gangrene 
in  the  military  hospitals  at  Antwerp,  in  the  year  1815  ; 
but  that  other  strong  acids  had  an  equally  good  efiect. 
Dr.  J.  Thompson  also  notices,  that  “ the  application  of 
caustic  substances,  such  as  the  strong  mineral  acids, 
the  solutions  of  potass,  corrosive  sublimate,  and  arsenic, 
seemed  at  Antw'erp  to  arrest  the  progress  of  this  sore, 
without  exciting  inflammation.” — {Report  of  Observa- 
tions made  in  the  Military  Hospitals  in  Belgium.) 

Delpech  was  informed  by  some  British  surgeons, 
belonging  to  the  Anglo-Portuguese  army  in  the  penin- 
sula, that  the  muriatic  acid  w^as  in  common  use  in  the 
hospitals  of  that  army,  as  a local  application  for  check- 
ing the  ravages  of  hospital  gangrene,  being  employed 
in  a diluted  state  for  slight  cases,  and  in  a concentrated 
caustic  form  for  others. 

In  St.  Bartholomew’s  Hospital,  the  undiluted  nitric 
acid  has  been  used  with  great  success  as  a local  appli- 
cation to  phagedenic  gangrenous  ulcers.  “ If  the  dis- 
ease be  not  far  advanced  (says  Mr.  Welbank),  I at 
once  apply  the  undiluted  acid,  after  cleansing  the  sur- 
face w’ith  tepid  water,  and  absorbing  the  moisture  with 
lint.  Where,  however,  there  is  a thick  and  pulpy 
slough,  it  is  better  to  remove  as  much  of  it  as  possible, 
with  forceps  and  scissors  before  the  application  is 
made.  The  surrounding  parts  being  then  protected  by 
a thick  coating  of  lard,  or  cerate,  I proceed  to  press 
steadily,  and  for  some  minutes,  a thick  pledget  of  lint, 
previously  immersed  in  the  undiluted  acid,  on  every 
point  of  the  diseased  surface,  till  it  appears  converted 
into  a firm  and  dry  mass.  Tlie  parts  may  be  then  co- 
vered with  simple  dressings,  and  evaporation  kept  up 
by  cooling  lotions.  As  the  application  occasions  more 
or  less  pain,  from  half  an  hour  to  one  or  tw'o  hours,  I 
have  generally  given  20  or  30  drops  of  laudanum  at 
the  time  of  using  it.  It  is  always  prudent,  often  ne- 
cessary, to  remove  the  eschar  at  the  end  of  16  or  20 
hours.”  When  the  patients  have  become  perfectly 
free  from  pain,  and  the  parts  below  the  slough  are 
found  healthy  and  florid,  Mr.  Welbank  treats  the  sore 
as  a common  wumnd  or  ulcer,  though  he  has  found 
stimulating  dressings  generally  the  best,  as  the  ceratum 
lapidis  calaininaris,  or  a solution  of  two  or  three  grains 
of  the  nitrate  of  silver  in  an  ounce  of  distilled  w'ater. 
But  w’hen  there  is  a recurrence  of  pain  at  any  point, 
or  over  the  general  surface  of  the  sore,  whether  the 
affection  be  slight  or  severe,  the  slough  sujierficial  or 
deep,  he  recommends  the  employment  of  the  undiluted 
acid  again.— (See  Med.  Chir.  Trans,  vol.  11,  p.  3C9.) 

Pouteau,  Dussassoy,  Boyer,  and  Delpech,  all  bear 
testimony  to  the  efficacy  of  the  actual  cautery,  and  they 
repeat  the  application  of  it,  until  the  whole  surface  of 
the  ulcer  is  converted  into  a firm  hard  eschar.  Even 
the  edges  of  the  solution  of  continuity  should  not  be 
spared — “ Rs  doivent  etre  torrefies  et  rbtis  pour  ainsi 
dire." — {Boyer,  Traiti  des  Maladies  Chir.  1. 1,  p.  332.) 
The  latter  surgeon  then  covers  the  eschar  with  a thick 
stratum  of  bark,  moistened  with  turpentine.  This  ap- 
plication is  to  be  removed,  in  twenty-four,  thirty-six, 
or  forty-eight  hours,  and  the  surgeon  is  then  to  judge 
from  the  appearance  of  the  flesh,  and  the  quality  of 
the  discharge,  whether  a further  repetition  of  the 
cautery  will  be  necessary. 

About  three  years  ago,  I attended,  at  Ilalliford,  a 
child  that  had  been  extensively  burnt ; find  when  the 
parts  were  nearly  healed,  the  sore  was  attacked  with 
hospital  gangrene,  the  ravages  of  which  soon  proved 
fatal.  The  cottage  in  which  this  case  happened  was 
noted  for  its  crowrled  and  uncleanly  state. 

Pouteau,  CEuvres  Posthiimes,  t.  3,  published  li83 
Dussassoy,  Dissertation  et  Observations  sur  la  dan 


HYD 


HYD 


61 


grtve  des  Hipitaux^  Src.  8vo.  GenSve,  1788.  Moreau 
et  Bardin,  Essai  sur  la  Oangrine  Humide  des  H6pi- 
taux,  1796.  Observations  on  the  Putrid  Ulcer,  by  L. 
Gillespie,  in  London  Medical  Journal,  vol.  6,  1785. 
Rollo  on  Diabetes,  1797.  Sir  Gilbert  Blane  on  the 
Diseases  of  Seamen,  ed.  3, 1797.  Trotter's  Medicina 
Mautica,  vols-  2 and  3,  published  1799.  John  Bell's 
Principles  of  Surgery,  vol.  1,  1801.  Wolf  Ploucquet, 
De  Gangrand  sic  dicta  JVosocomiorum,  Tub.  1802. 
Leslie,  De  Gangrcend  Contagiosd,  Edin.  1804.  John- 
son, De  Gangrcend  Contagiosd,  JVosocomiale,  Edin. 
1805.  J.  Thomson's  Lectures  on  Infiamrnation,  p.  456, 
et  seq.  Edin.  1813 ; and  Report  of  Observations  made 
in  the  Military  Hospitals  of  Belgium,  Svo.  Edin.  1816. 
J.  Hennen,  Principles  of  Military  Surgery,  p.  210, 
Src.  8vo.  Edin.  1820.  C.  ./.  M.  Langenbeck,  Mcue 
Bibl.  b.  2,  p.  611,  <^c.  Hanover,  1820.  Mimoire  sur  la 
Complication  des  Plaies  et  des  Ulcdres  connue  sous  le 
nom  de  Pourriture  d' Hdpital,  par  J.  Delpech,  8vo. 
Paris,  1815.  Mso  Precis  Elimentaire  des  Maladies 
Chir.  t.  1,  p.  123,  Src.  Paris,  1816.  Brugmanns  und 
Delpech  iiber  den  Hospitalbrand,  ubersezt  mit  Jinmer- 
kungen  und  Anhang  von  Kies er ; Jena,  1815.  Boyer, 
Traits  des  Maladies  Chir.  t 1,  p.  320,  Paris,  1814. 
Sketches  of  the  Medical  Schools  of  Paris,  by  J.  Cross, 
p.  82.  London,  1815.  H.  Home  Blackadder,  Observa- 
tions on  Phagedajia  Gangrcenosa,  8vo.  Edin.  1818; 
the  best  treatise  on  the  subject.  R.  Welbank  on 
Sloughing  Phagedena,  in  Med.  Chir.  Trans,  vol.  11. 
8vo.  Land.  1821;  a valuable  little  essay,  reflecting 
great  credit  on  its  author.  J.  Boggie,  in  Edin.  Med. 
Chir.  Trans,  vol.  3,  1828.  The  rest  of  the  subject  of 
Gangrene  is  treated  of  in  the  article  Mortification. 

HYDRARGYRIA.  A peculiar  eruption  occasioned 
by  the  use  of  mercury,  and  named  in  Dr.  Bateman’s 
Synopsis  cczemrt  (See  Mercury.) 

HYDROCELE.  (From  v6wp,  water,  and  nyXy,  a tu- 
mour.) The  term  hydrocele,  if  used  in  a literal  sense, 
means  any  tumour  containing  water ; but  surgeons 
have  always  confined  it  to  a collection  of  fluid  either 
in  the  cellular  membrane  of  the  scrotum ; in  a cyst, 
or  the  common  cellular  texture,  of  the  spermatic  cord  ; 
or  in  the  tunica  vaginalis  of  the  testicle. 

The  celebrated  Dr.  .Alexander  Monro  of  Edinburgh, 
and  Mr.  S.  Sharp,  were  almost  the  only  writers,  be- 
fore Mr.  Pott,  who  sensibly  and  rationally  explained 
the  true  nature  of  these  diseases. 

ANASARGOUS  TUMOUR  OF  THE  SCROTUM. 

The  hydrocele  by  infiltration  of  French  writers ; Mj- 
drocele  adeinatodes  ; is  most  frequently  only  a symp- 
tom of  a dropsical  habit,  and  very  often  accompanies 
both  anasarca  and  the  particular  collection  within 
the  abdomen  called  ascites.  Mr.  Pott  describes  it  as 
“ an  equal  soft  tumour,  possessing  every  part  of  the 
cellular  membrane,  in  which  both  the  testicles  are  enve- 
lo-ed,  and  consequently  it  is  generally  as  large  on  one 
side  as  on  the  other  ; it  leaves  the  skin  of  its  natural 
colour,  or,  to  speak  iwore  properly,  it  does  not  redden 
or  ir.flame  it;  if  the  quantity  of  water  be  not  large, 
nor  the  distention  great,  the  skin  preserves  some  degree 
of  rugosity;  the  tumour  has  a doughy  kind  of  feel ; easily 
receives,  and  for  a while  retains,  the  impression  of  the 
fingers  ; the  raphe,  or  seam,  of  the  scrotum  divides  the 
swelling  nearly  equally  ; the  spermatic  process  is  per- 
fectly free,  and  of  its  natural  size ; and  the  testicles 
seem  to  be  in  the  middle  of  the  loaded  membrane.  This 
is  the  appearance,  when  the  disease  is  in  a moderate 
degree.  But  if  the  quantity  of  extravasated  serum  be 
large,  or  the  disease  farther  advanced,  the  skin,  instead 
of  being  wrinkled,  is  smooth,  tense,  and  plainly  shows 
the  limpid  state  of  the  fluid  underneath:  it  is  cold -to 
the  touch,  does  not  so  long  retain  the  impression  of  the 
finger,  and  is  always  accompanied  v/ith  a similar  dis- 
tention of  the  skin  of  the  penis  ; the  preputium  of  which 
is  sometimes  so  enlarged,  and  so  twisted  and  distorted, 
as  to  make  a very  disagreeable  appearance.  These 
are  the  local  symptoms : to  which  it  may  be  added, 
that  a yellow  countenance,  a loss  of  appetite,  a defi- 
ciency of  urinary  secretion,  swelled  legs,  a hard  belly, 
and  mttcous  stools,  are  its  very  frequent  companions.” 

As  the  cellular  membrane  on  one  side  of  the  scrotum 
is  a continuation  of  that  which  is  situated  on  the 
other,  and  both  freely  communicate,  the  accounts,  de- 
livered by  certain  authors,  of  the  possibility  of  this 
species  of  hydrocele  being  confined  to  one  side  of  the 
scrotum,  are  not  credited  by  Bovcr.  At  all  events, 

D2 


such  a case  is  extremely  rare,  and  when  it  happens, 
is  probably  induced  by  the  irritation  of  the  urine  in  in- 
fants, or  of  the  friction  of  the  clothes  in  old  persons, 
only  acting  upon  a part  of  the  scrotum  ; for  occasion- 
ally, though  not  often,  the  disease  is  acknowledged  to 
proceed  from  these  local  causes. — (See  Diet,  des 
Sciences  M6d.  t.  22,  p.  193.) 

The  cure  of  the  original  disease,  when  it  arises  from 
constitutional  causes,  comes  within  the  province  of 
the  physician,  and  requires  a course  of  internal  medi- 
cine ; but  sometimes  the  loaded  scrotum  and  penis  are 
so  troublesome  to  the  patient,  and  in  such  danger  of 
mortification,  that  a reduction  of  their  size  becomes 
absolutely  necessary.  As  Mr.  Pott  observes,  the  means 
of  making  this  discharge  are  two,  viz.  puncture  and 
incision  : the  former  is  made  with  the  point  of  a lancet ; 
the  latter  with  the  same  instrument,  or  with  a knife. 
Wounds  in  anasarequs  or  dropsical  habits  are  apt  to 
inflame,  are  very  difficultly  brought  to  suppuration, 
and  often  prove  gangrenous.  But  the  larger  and 
deeper  the  wounds  are,  the  more  probable  are  these 
bad  consequences.  Simple  punctures,  with  the  point 
of  a lancet,  are  much  less  liable  to  be  attended  by  them, 
than  any  other  kind  of  wound  ; they  generally  leave 
the  skin  easy,  soft,  cool,  and  uninflamed,  and  in  a 
state  to  admit  a repetition  of  the  same  operation  if 
necessary.  Incisions  create  a painful,  crude,  hazard- 
ous sore,  requiring  constant  care.  Punctures  seldom 
produce  any  uneasiness  at  all,  and  stand  in  need  of 
only  a superficial  pledget  for  dressing. 

As  the  cavities  of  the  cellular  membrane  of.the  scro- 
tum all  communicate  together,  a small  puncture  serves, 
as  well  as  a large  incision,  for  the  discharge  of  the 
fluid  contained  in  them,  and  consequently,  upon  this 
ground,  no  reason  exists  for  making  any  extensive, 
painful,  and  hazardous  wound. 

With  respect  to  the  practice  of  making  punctures, 
in  cases  of  anasarcous  hydrocele,  I think  that  it  should 
always  be  avoided  as  much  as  possible ; because  it 
sometimes  happens,  that  the  slightest  pricks  of  the  lan- 
cet occasion  sloughing.  The  method  should  only  be 
adopted,  when  the  distention  of  the  skin  of  the  scrotum 
is  such  as  absolutely  to  require  the  fluid  to  be  dis- 
charged. Care  should  also  be  taken  not  to  multiply  the 
punctures  unnecessarily,  nor  to  let  them  be  made  too 
near  together.  Boyer  had  a case,  in  which  the  mak- 
ing of  very  slight  punctures  in  an  anasarcous  scrotum, 
was  followed  by  the  total  destruction  of  this  part,  de- 
nudation of  the  testis  and  cord,  and  the  patient’s  death, 
attended  with  dreadful  sutfering. — (See  Diet,  des 
Sciences  Mid.  t.  22,  p.  195,  196.) 

When  the  cedematous  stale  of  the  scrotum  is  not  the 
effect  of  a general  constitutional  disease,  but  proceeds 
entirely  from  a local  cause,  such  as  friction,  or  the  irri- 
tation of  the  urine,  the  mode  of  treatment  consists  in 
the  removal  of  the  cause,  the  use  of  astringent  lotions, 
and  the  exhibition  of  a dose  of  salts.  In  elderly  sub- 
jects the  wearing  of  a bag-truss  is  recommended  for 
the  prevention  of  the  complaint. 

HYDROCELE  OF  THE  SPERMATIC  CORD 

Is  of  two  kinds;  the  first  is  described  as  an  cedema- 
tous affection,  extending  to  more  or  less  of  the  cellular 
substance  round  the  spermatic  vessels,  and  sometimes 
named  the  diffused  hydrocele  of  the  cord  ; the  second 
form  of  the  disease  is  that  in  which  the  fluid  is  collected 
in  a particular  cavity  or  cyst,  which  has  no  communica- 
tion with  the  cavities  of  the  common  cellular  substance 
of  the  cord.  This  case  is  denominated,  accordingly, 
the  encysted  hydrocele  of  the  cord.  The  cellular  sub- 
stance, situated  behind  the  bag  of  the  peritoneum,  sur- 
rounds the  spermatic  vessels,  passes  with  them  through 
the  inguinal  ring,  and  accompanies  them  to  their  inser- 
tion in  the  testicle.  As  Scarpa  has  likewise  explained 
in  his  great  work  on  hernia,  the  spermatic  vessels, 
their  cellular  sheath,  and  the  tunica  vaginalis  are  all 
enclosed  in  the  niusculo-aponeurotic  sheath  of  tha 
cremaster.  When  a diffused  hydrocele  of  the  sperma- 
tic cord  is  dissected,  the  sheath  of  the  cremaster  is 
found  under  the  integuments,  varying  in  size  and  com- 
pactness according  to  the  duration  and  bulk  of  tha 
disease.  Under  it  appears  the  cellular  covering  of  tha 
cord,  thickened,  distended  with  fluid,  and  seeming  at 
first  somewhat  like  a hernial  sac.  When  cut,  a great 
deal  of  serum  is  discharged,  and  the  tumour  sinks  and 
disappears  in  a greater  or  less  degree.  The  sperma- 
tic vessels,  which  had  been  previously  concealed  by 


B2 


HYDROCELE. 


the  enlarged  cellular  mass,  now  become  visible.  The 
cells,  which,  in  their  natural  state,  are  scarcely  percep- 
tible to  the  unassisted  eye,  are  found  to  have  become 
vesicles  filled  tviih  fluid,  and  some  of  them  are  large 
enough  to  receive  the  end  of  a finger.  When  the 
tumour  is  large  and  of  long  standing,  the  cells  are  re- 
marked to  become  more  delicate  towards  its  bottom, 
and  in  this  situation  disappear,  only  one  large  cavity 
filled  with  fluid  being  here  found.  Hence,  according 
to  Scarpa,  a fluctuation  is  plainly  distinguishable  at 
the  lowest  part  of  the  swelling.  The  serum  contained 
in  the  cells  is  generally  limpid ; but  sometimes  yellow, 
albuminous,  or  gelatinous.  The  base  of  the  swelling, 
however  large  or  old  it  be,  corresponds  to  the  point, 
at  which  the  spermatic  vessels  join  the  testis,  or,  at 
most,  it  extends  a very  little  behind  this  organ,  and 
between  the  two  there  is  a semicircular  groove,  which 
varies  in  depth  and  extent.  Scarpa  farther  informs 
us,  that  if  the  tunica  vaginalis  be  opened,  a dense  sep- 
tum is  felt  at  its  inner  and  lower  part,  cutting  off  all 
communication  between  this  sac  and  the  base  of  the 
tumour. — {Memoria  suW  Idrocele  del  Cordons  Sper- 
matico,  Ato.  Pavice,  1823.) 

That  the  cellular  membrane  of  the  cord  is  often  dis- 
tended with  an  aqueous  fluid,  w’hen  the  scrotum  is  ana- 
sarcous,  and  the  habit  dropsical,  cannot  admit  of  doubt ; 
and  hence  it  is  a frequent  attendant  on  the  case,  which 
has  been  described  as  the  hydrocele  cedematodes.  But 
as  I have  never  seen  an  instance,  in  which  such  dis- 
ease was  restricted  to  the  cellular  texture  of  the  cord, 

I am  led  to  suppose  that  it  is  a very  uncommon  case. 
The  following  is  said  by  Mr.  Pott  to  be  the  state  of  the 
disease,  while  of  moderate  size.  The  scrotal  bag  is 
free  from  all  appearance  of  disease ; except  that  when 
the  skin  is  not  corrugated,  it  seems  rather  fuller,  and 
hangs  rather  low’er  on  that  side  than  on  the  other,  and 
if  suspended  lightly  on  the  palm  of  the  hand,  feels 
heavier:  the  testicle,  with  its  epididymis,  is  to  befell 
perfectly  distinct  below  this  fulness,  neither  enlarged, 
nor  in  any  manner  altered  from  its  natural  state:  the 
spermatic  process  is  considerably  larger  than  it  ought 
to  be,  and  fcels  like  a varix,  or  like  an  omental  hernia, 
according  to  the  diiferent  size  of  the  tumour : it  has  a 
pyramidal  kind  of  form,  broader  at  the  bottom  than  at 
the  top : by  gentle  and  continued  pressure  it  seems 
gradually  to  recede  or  go  up,  but  drops  dowm  again 
immediately  upon  removing  the  pressure  ; and  that  as 
freely  in  a supine,  as  in  an  erect  posture : it  is  at- 
tended with  a very  small  degree  of  pain  or  uneasiness; 
which  uneasiness  is  not  felt  in  the  scrotum,  where  the 
tumefaction  is,  but  in  the  loins. 

According  to  Scarpa,  its  shape  is  at  first  nearly  cy- 
lindrical, and  does  not  become  pyramidal  till  after- 
ward. How’ever  large  the  swelling  may  be,  the  penis 
never  appears  so  much  retracted  under  the  integu- 
ments of  the  pubes  as  in  a common  hydrocele  of  equal 
size.  When  the  lower  part  is  compressed,  the  fluid 
recedes  tow  ards  the  groin  slowly  and  difficultly,  w’hile, 
in  the  hydrocele  of  the  tunica  vaginalis,  the  same  kind 
of  pressure  at  once  forces  the  fluid  to  the  apex  of  the 
tumour,  and  distends  it,  and  the  testis  cannot  be  felt 
(as  in  the  diffused  hydrocele)  below'  the  sw'elling. 

When  a diffused  hydrocele  of  the  cord  extends  into 
the  ring,  it  is  not  easily  distinguished  from  an  omental 
hernia.  In  both  cases,  says  Scarpa,  the  tumour  is  at 
first  of  a cylindrical  shape,  and  afterward  becomes' 
pyramidal ; both  kinds  of  swelliii!.’  are  soft  and  flexible ; 
both  little,  if  at  all,  sensible  ; and  both  admit  of  reduc- 
tion with  difficulty.  No  doubt,  the  best  criterion  of 
the  hernia,  if  it  be  reducible,  wdll  be  derived  from  the 
circumstance  of  its  generally  not  reappearing,  w’hile 
the  patient  continues  to  lie  down,  though  Scarpa  has 
seen  a few  exceptions. 

While  it  is  small,  it  is  hardly  an  object  of  surgery, 
and  may  be  kept  from  being  troublesome  by  means  of  a 
suspensory ; hut  wdien  it  is  large,  it  is  very  inconve- 
nient both  from  size  and  weight,  and,  according  to 
Pott,  the  only  method  of  cure  which  it  admits,  viz. 
that  of  making  a free  incision  into  the  swelling,  is  far 
from  being  void  of  hazard.  This  is  especially  true, 
when  the  disease  is  complicated  with  constitutional 
disorder.  Thus  Pott  and  Scarpa  have  known  the  in- 
flammation consequent  to  an  extensive  incision  have 
a fatal  termination.  As  the  cavities  of  the  cellular 
lejiure,  in  which  this  hydrocele  forms,  all  commuui- 
rate  tw'^Uier,  it  appears  to  me,  that  the  necessity  of  a 
free  incision  f'.*r  til?  discharge  of  the  fluid  is  not  so 


manifest  as  the  observations  of  Pott  w’ould  lead  us  to 
suppose  ; and  that  a moderate  opening  would  be  likely 
to  answ'er  every  purpose,  with  much  greater  safety. 

THE  ENCYSTED  HYDROCELE  OF  THE  SPERMATIC  CORD 

Is  by  no  means  unfrequent,  especially  in  children. 
The  same  kind  of  disease  also  sometimes  occurs  in  the 
round  ligament  of  the  uterus,  and  accompanies  it 
through  the  abdominal  ring.  It  was  very  well  knoAvn 
to  many  of  the  ancients,  and  has  been  accurately  de- 
scribed by  Albucasis,  Celsus,  Paulus  .dEgineta,  &c. 
When  Mr.  Pott  says  that  the  disease  is  not  uufrequent, 
it  ought  to  be  understood,  that  its  frequency,  though 
much  greater  than  that  of  the  ditfused  hydrocele  of  the 
cord,  considered  as  a distinct  disease  independent  of 
general  anasarca,  is  not  at  all  equal  to  that  of  the  hydro 
cele  of  the  tunica  vaginalis.  Richerand  has  calculated, 
that  the  average  proportion  of  encysted  hydroceles  of  the 
cord,  to  those  of  the  latter  description,  is  not  more  than 
as  one  to  two  hundred. — {J^osogr.  Chir.  t.  4,  p.  262,  ed. 
4.)  According  to  Mr.  Pott,  the  swelling  is  mostly  si- 
tuated at  the  middle  part  of  the  cord,  between  the  tes- 
ticle and  groin,  and  is  generally  of  an  oblong  figure. 
Whether  it  be  large  or  small,  it  is  generally  pretty  tense, 
and  consequently  the  fluctuation  of  the  water  within 
it  not  always  immediately  or  easily  perceptible.  It 
gives  no  pain,  nor  (unless  it  be  very  large  indeed) 
does  it  hinder  any  necessary  action.  It  is  perfectly 
circumscribed ; and  has  no  communication,  either 
with  the  cavity  of  the  belly  above,  or  tliat  of  the  vagi- 
nal coat  of  the  testicle  below  it.  The  testis  and  its 
epididymis  are  perfectly  and  distinctly  to  be  felt  below 
the  tumour,  and  are  absolutely  independent  of  it.  The 
upper  part  of  the  spermatic  process  in  the  groin  is 
most  frequently  very  distinguishable.  The  swelling 
does  not  retain  the  impression  of  the  fingers ; and,  when 
lightly  struck  upon,  sounds  as  if  it  contained  wind 
only.  It  undergoes  no  alteration  from  change  of  the 
patient’s  posture ; it  is  not  alfected  by  his  coughing, 
sneezing,  &c. ; and  it  has  no  effect  on  the  discharge 
per  anum. 

Scarpa  observes,  that  the  diagnosis  is  more  difficult 
when  the  encysted  hydrocele  is  of  considerable  bulk, 
because  the  testis  is  buried,  as  it  were,  in  the  tumour. 
Here,  says  he,  if  that  portion  of  the  swelling  which 
projects  forwards  and  somewhat  laterally  at  its  lower 
part,  be  softish,  smooth,  and  very  sensible,  while  the 
rest  presents  the  character  of  a collection  of  fluid,  the 
first  and  smaller  portion  is  the  testis  in  its  healthy  st'ate ; 
and  the  other  portion  an  encysted  hydrocele  of  the  cord. 
This  kind  of  hydrocele  may  be  known  from  scirrhus 
of  the  testis  by  its  consistence,  smoothness,  and  free- 
dom from  pain. 

The  two  diseases,  however,  with  which  this  kind  of 
hydrocele  is  most  likely  to  be  combined  are,  a hydro- 
cele of  the  tunica  vaginalis,  and  a hernia.  The  cha- 
racters in  which  it  differs  from  the  first  have  been 
already  noticed. 

According  to  Pott,  the  free  state  of  the  upper  part  of 
the  spermatic  cord,  while  the  tumour  is  forming  below ; 
the  gradual  accumulation  of  the  fluid,  and  conse- 
quently the  gradual  growth  of  the  swelling;  the  indo- 
lent and  unaltering  state  of  it ; its  being  incapable  of 
reduction,  or  return  into  the  belly  from  the  first;  its 
being  always  unaffected  by  the  patient’s  coughing  or 
sneezing;  and  the  uninterrupted  freedom  of  the  fecal 
discharge  {rer  anum,  will  always  distinguish  it  from 
an  intestinal  hernia.  Its  liability  to  be  mistaken  for  an 
omental  hernia,  and  its  characteristic  difference,  I have 
already  mentioned. 

Mr.  Pott  met  with  an  encysted  hydrocele,  situated 
so  high  towards  the  groin,  as  to  render  perception  of  the 
spermatic  vessels  very  obscure,  or  even  impracticable; 
but  then,  the  state  and  appearance  of  the  testicle,  and 
the  absence  of  every  symptom  proceeding  from  con- 
finement of  the  intestinal  canal,  were  sufficient  marks 
of  the  true  nature  of  t!ie  complaint. 

The  cyst  is  described  by  Scarpa  as  consisting  of  two 
layers;  first,  the  sheath  of  the  cremaster,  and  under  it 
the  cellular  structure  of  the  sord,  more  or  less  thick- 
ened. Tile  under  surface  is  irregular,  fringed,  and  in 
some  places  villous. 

In  general,  the  pressure  of  an  encysted  hydrocele 
pushes  the  testis  a little  lower  in  the  scrotum  than 
natural,  and  rather  forwards.  Scarpa  found  this  organ, 
however,  in  one  instance,  considerably  wasted,  and  ad- 
herent to  the  tunica  vaginalis. 


Several  writers  describe  this  kind  of  hydrocele  as  in 
fact  a common  encysted  tumour,  formed  in  the  cellular 
substance,  between  the  vas  deferens  and  spermatic 
vessels. — {Delpech,  Pricis  EUm.  des  Mai.  Chir.  t.  2,p. 
464.)  Yet,  since  ordinary  encysted  swellings  are  very 
difficult  to  disperse,  there  is  probably  some  difference 
between  the  two  affections ; at  least,  if  the  observation 
of  Mr.  Pott  be  correct,  that  in  young  children  the  en- 
cysted hydrocele  of  the  cord  frequently  dissipates  in  a 
short  time,  especially  if  assisted  by  warm  fomentation 
and  an  open  belly. 

If  it  be  not  absorbed,  “ the  point  of  a lancet  will  give 
discharge  to  the  water;  and  in  young  children,  will 
most  frequently  produce  a cure : but  in  adults,  the  cyst 
formed  by  the  pressure  of  the  fluid  does  sometiiiies 
become  so  thick,  as  to  require  division  through  its 
w’hole  length ; which  operation  may  in  general  be  per- 
formed with  great  ease  and  perfect  safety.”  Mr.  Pott 
says  in  • general,  because  it  is  most  frequently  so ; 
though  he  has  seen  even  this,  slight  as  it  may  seem, 
prove  troublesome,  hazardous,  and  fatal. 

The  late  Sir  J.  Earle  proposed  treating  this  case  in 
the  same  way  as  the  hydrocele  of  the  tunica  vaginalis, 
viz.  by  an  injection  of  red  wine  and  water;  which 
method  is  often  successful. — {On  Hydrocele,  p.  154, 
edit.  2.)  However,  the  cure  of  an  encysted  hydrocele 
of  the  spermatic  cord,  by  means  of  an  injection,  is 
generally  regarded  by  modern  surgeons  as  less  certain 
and  advantageous  than  the  excision  of  a part  of  the 
cyst.  The  operation,  which  is  described  by  Bertrandi, 
Mr.  Hey,  Richerand,  &c.,  consists  in  cutting  down  to 
the  cyst,  and  removing  the  fore  part  of  it,  while  the 
portion,  closely  attached  to  the  cord,  is  to  be  allowed  to 
remain.  (For  additional  observations  on  this  species 
of  hydrocele,  see  the  First  Lines  of  the  Practice  of 
Surgery,  ed.  5,  p.  528.) 

HYDROCELE  OF  THE  TUNICA  VAGINALIS. 

If  the  quantity  of  limpid  fluid,  which  naturally 
moistens  the  surface  of  the  tunica  albuginea  and  the 
inside  of  the  tunica  vaginalis,  be  secreted  in  an  undue 
quantity,  or  if  regular  absorption  of  it  be  by  any  means 
prevented,  it  will  gradually  accumulate,  and  distend 
the  cavity  of  the  latter  membrane,  so  as  to  form  the 
present  species  of  hydrocele.  The  case  in  which  the 
fluid  is  supposed  to  descend  either  partly  or  entirely 
from  the  cavity  of  the  abdomen,  in  consequence  of  the 
communication  not  being  shut  up  in  the  usual  time 
between  the  cavity  of  the  peritoneum  and  that  of  the 
tunica  vaginalis,  is  well  known  to  surgeons  under  the 
aj)pe!lation  of  a congenital  hydrocele;  a disease,  of 
which  particular  notice  has  been  taken  in  the  2d  vol. 
of  the  fourth  edition  of  the  First  Lines  of  Surgery, 
8oo.  Land.  1820,  and  to  which  I shall  therefore  very 
briefly  advert  in  this  article.  Hydrocele  of  the  vaginal 
coat  is  a disease  from  which  no  time  of  life  is  exempt: 
not  only  adults  are  subject  to  it,  but  young  children  are 
frequently  afflicted  with  it,  and  infants  sometimes  born 
with  it. — (Pott.)  It  is  also  remarked  to  becommon  in 
old  men,  and  persons  who  ride  a good  deal  on  horse- 
back.— (Delpech,  Pricis  Elim.  des  Mai.  Chir.  t.  3, 

177.) 

The  causes  of  hydrocele  of  the  tunica  vaginalis  can 
scarcely  be  said  to  be  at  all  understood  ; and  when  Mr. 
Pott  observes,  that  whatever  tends  to  increase  the  se- 
cretion of  fluid  into  the  cavity  of  that  membrane,  be- 
yond the  due  and  necessary  quantity,  or  to  prevent  its 
being  taken  up  and  carried  off  by  the  absorbent  vessels, 
must  contribute  to  the  production  of  the  disease, 
nearly  as  much  is  staled,  as  can  be  advanced  with 
safety  in  the  present  state  of  our  knowledge.  Ruysch 
had  a suspicion,  that  this  hydrocele  might  arise  from  a 
varicose  state  of  the  spermatic  veins;  but  though  Mr. 
Pott  acknowledges,  that  these  vessels  are  very  fre- 
quently found  varicose  in  patients  afflicted  with  this 
disorder,  he  was  unable  to  pronounce  what  real  foun- 
dation might  exist  for  the  foregoing  conjecture,  or 
whether  the  varicyse  state  of  the  spermatic  veins  were 
a cause  or  an  effect  of  the  hydrocele.  In  most  in- 
stances, the  accumulation  of  fluid  takes  place  without 
any  evident  cause;  though,  in  a few  cases,  it  has  ap- 
peared to  be  the  effect  of  a contusion,  or  of  rough,  long- 
contiuned  friction  of  the  scrotum.  The  disease  is  ob- 
served to  affect  persons  of  the  best  health  and  most 
ri'bust  consiitiilions,  as  well  as  others;  and  its  exist- 
ence seeins  quite  unconnected  with  dropsy  or  debility. 
In  short,  it  may  be  regarded  as  a disease  entirely  of  a 


)CELE.  63 

local  nature.  As  Mr.  Pott  observes,  its  production  is 
so  slow  and  gradual,  and  at  the  same  time  so  void  of 
pain,  Diat  the  patient  seldom  attends  to  it  until  it  is  of 
some  size.  Sometimes,  however,  it  is  produced  very 
suddenly,  and  soon  attains  considerable  magnitude. 

Li  general,  at  its  first  beginning,  the  tumour  is  rather 
round ; but  as  it  increases,  it  frequently  assumes  a py- 
riform kind  of  figure,  with  its  larger  extremity  down- 
wards : sometimes  it  is  hard,  and  almost  incompressi- 
ble ; so  much  so,  that,  in  some  few  instances,  it  has 
been  mistaken  for  an  induration  of  the  testicle:  at 
other  times,  it  is  so  soft  and  lax,  that  both  the  testicle 
and  the  fluid  surrounding  it  are  easily  discoverable.  It 
is  perfectly  indolent  in  itself,  and  may  be  rather 
strongly  pressed  without  pain ; though  its  weight  some- 
times produces  some  small  degree  of  uneasiness  in  the 
back.  According  to  Mr.  Pott,  the  transparency  of  the 
tumour  is  the  most  fallible  and  uncertain  sign  belong- 
ing to  it:  it  is  a circumstance,  says  he,  which  does  not 
depend  upon  the  quantity,  colour,  or  consistence  of  the 
fluid  constituting  the  disease,  so  much  as  on  the  uncer- 
tain thickness  or  thinness  of  the  containing  bag,  atid 
of  the  common  membranes  of  the  scrotum. 

If  they  are  thin,  the  fluid  limpid,  and  the  accumula- 
tion made  so  thick  as  not  to  give  the  tunica  vaginalis 
time  to  thicken  much,  fherays  of  light  may  sometimes 
he  seen  to  pass  through  the  tumour : but  this  is  acci- 
dental, and  by  no  means  to  be  depended  upon.  The  fluid 
is  most  frequently  of  a pale  yellow  or  straw  colour; 
sometimes  it  is  inclined  to  a greenish  cast;  sometimes 
it  is  dark,  turbid,  and  bloody;  and  sometimes  it  is  per- 
fectly thin  and  limpid.  According  to  Boyer,  the  colour 
of  the  fluid  makes  no  difference  in  the  prognosis ; and 
he  tells  us,  that,  by  means  of  an  injection,  he  cured  a 
hydrocele  that  contained  a violet-coloured  fluid,  which 
deposited  a thick  sediment. — (Diet,  des  Sciences  Mid. 
t.  22,  p.  214.)  When  a hydrocele  has  existed  for  a very 
long  time,  cartilaginous  bodies  are  sometimes  found  in 
the  fluid. — (Sir  A.  Cooper,  Lancet,  vol.  2,  p.  79.) 

With  respect  to  Mr.  Pott’s  remarks  on  the  transpa- 
rency of  the  swelling,  as  a symptom  of  hydrocele,  Ujey 
are  correct,  inasmuch  as  the  absence  of  this  sign  is  no 
proof  that  the  disease  is  not  of  this  nature ; since  thick- 
ness of  the  tunica  vaginalis,  and,  as  ought  also  to  have 
been  admitted,  the  opaque  quality  of  the  fluid,  some- 
times prevent  the  rays  of  a candle  from  passing  through 
the  swelling.  But  on  the  other  hand,  it  should  have 
been  explained  by  Mr.  Pott,  that  when  the  transparency 
is  present,  it  is  one  of  the  surest  marks  of  this  species 
of  hydrocele. 

A thickened  state  of  the  vaginal  coat  is  chiefly  met 
with  in  old  cases,  and,  according  to  Sir  Astley  Cooper, 
in  patients  who  have  long  resided  in  hot  climates. — 
(See  vol.  cit.p.  46.) 

It  is  next  noticed  by  Mr.  Pott,  that  in  the  beginning 
of  the  disease,  if  the  water  has  accumulated  slowly, 
and  the  tunica  vaginalis  is  thin  and  lax,  the  testicle  may 
easily  be  perceived;  but  if  the  said  tunic  be  firm,  or 
the  water  accumulated  in  any  considerable  quantity, 
the  testis  cannot  be  felt  at  all.  In  most  cases,  tile 
spermatic  vessels  may  be  distinctly  felt  at  their  exit 
from  tne  abdominal  muscle,  or  in  the  groin ; which  will 
always  distinguish  this  complaint  from  an  intestinal 
hernia.  But  in  a few  examples,  the  vaginal  coat  is  dis- 
tended so  high,  and  is  so  full,  that  it  is  extremely  dif- 
ficult, na5'^,  almost  impossible,  to  feel  the  spermatic  cord : 
and  the  same  kind  of  obscurity  is  sometimes  occasioned 
by  the  addition  of  an  encysted  hydrocele  of  the  cofd  ; 
or  by  the  case  being  combined  with  a true  enterocele. 

In  a hydrocele  of  the  tunica  vaginalis,  the  sioelling 
is  first  noticed  at  the  lower  part  of  the  scrotwm,  whence 
it  ascends  in  front  of  the  testicle  and  spermatic  cord. 
The  progress  of  the  disease  is  generally  so  slow,  that 
six  or  even  eighteen  months  elapse  before  the  tumour 
approaches  the  abdominal  ring.  And  pmong  other 
characters  of  the  case,  are  to  be  noticed  the  disappear- 
ance of  the  corrugations  of  the  scrotum  by  the  effect 
of  the  distention  ; inclination  of  the  raphe  to  the  op- 
posite side;  a diminished  appearance  of  the  penis, 
from  a good  deal  of  its  integuments  being  drawn  over 
the  hydrocele,  when  this  is  bulky;  the  great  lightness 
of  the  swelling,  in  relation  to  its  size';  and  the  possi- 
bility of  feeling  a fluctuation,  when  the  fingers  of  one 
hand  are  applied  to  one  side  of  the  tumour,  and  the 
surgeon  slightly  taps  with  the  fingers  of  his  other  hand 
upon  an  opposite  point  of  the  swelling. 

With  respect  to  the  fluctuation,  however,  it  is,  as 


64 


HYDROCELE. 


Boyer  remarks,  sometimes  evident,  sometimes  obscure, 
and,  in  oilier  instances,  not  distinguislialile  at  all. — 
{Diet,  des  Sciences  Med.  t.  22,  p.  20O.)  These  differ- 
ences depend  much  on  the  quantity  of  fluid,  and  the 
thickness  or  thinness  of  the  vaginal  coat. 

In  the  hydroceles  of  children,  the  testis  occupies  a 
lower  situation  than  the  same  organ  in  the  hydroceles 
of  adult  persons,  and  the  swelling  passes  farther  up 
towards  the  abdominal  ring.  The  hydrocele,  in  fact, 
is  in  them  situated  rather  in  front  of  the  cord,  than  the 
testis,  which  is  always  at  the  lower  and  back  part  of 
the  swelling. — (See  Diet,  des  Sciences  Mid.  t.  22,  p. 
199.)  The  common  situation  of  the  testis  is  two- 
thirds  of  the  way  down  the  tumour  at  its  posterior 
part.  Cut,  as  Sir  Astley  Cooper  has  correctly  ex- 
plained, a great  deal  of  irregularity,  in  this  respect,  is 
met  with,  the  testis  being  sometimes  in  front  of  the  hy- 
•drocele ; a circumstance,  ariishig  from  the  existence  of 
adhesions  between  the  middle  and  outer  coat  of  that 
organ  at  its  fore  part,  previously  to  the  formation  of 
the  hydrocele.  The  testis  is  sometimes  found  at  the 
bottom  of  the  swelling,  as  is  exemplified  in  a prepara- 
tion shown  by  the  same  gentleman,  where  the  fluid 
had  been  prevented  from  descending  below  and  in  front 
of  the  testis,  by  the  middle  and  outer  coats  of  that 
organ  being  so  connected  together  by  the  adhesive  in- 
flammation. He  has  one  specimen  in  which  the  fluid 
was  situated  only  at  the  sides  of  the  testis,  adhesions 
having  prevented  its  accumulation  at  other  points  ; and 
another,  in  which  the  hydrocele  seems  as  if  it  had 
arisen  from  the  tunica  vaginalis,  in  the  same  manner 
as  an  aneurismal  sac  is  occasionally  formed  from  the 
coats  of  an  artery.— (See  Lancet,  vol.  2,  p.  78.)  These 
facts  prove  the  necessity  of  always  endeavouring  to 
learn  the  precise  situation  of  the  testis  by  manual  ex- 
amination, before  an  operation  is  attempted.  When 
the  surgeon  presses  rather  strongly  on  that  organ,  he 
will  feel  the  part  much  firmer  than  the  rest  of  the 
tumour,  and  the  patient  complains  of  a severe  and 
peculiar  pain. 

A hydrocele  of  the  tunica  vaginalis  may  be  com- 
plicated with  disease  of  the  testis,  hernia,  cirsocele, 
hydrocele  of  a hernial  sac,  or  encysted  hydrocele  of 
the  cord. 

A collection  of  fluid  in  the  tunica  vaginalis,  compli- 
cated with  a scirrhous  or  chronic  induration  and  en- 
largement of  the  testicle,  is  well  known  under  the 
name  of  hydro-sarcocele : a case  which  should  be  care- 
fully discriminated  from  a simple  hydrocele  ; “one  of 
the  marks  of  the  latter  being  the  natural,  eoft,  healthy 
state  of  the  testicle,  and  the  characteristic  of  the  former 
being  its  diseased  and  indurated  enlargement.” 

Mr.  Pott  does  not  mean,  that  in  a true  simple  hydro- 
cele the  testicle  is  never  altered  from  its  natural  stale. 
He  admits  the  contrary,  and  that  it  is  often  enlarged  in 
size,  and  relaxed  in  structure,  and  that  the  spermatic 
vessels  are  frequently  varicose.  But  the  testicle  is  not 
indurated.  These  two  diseases  are  extremely  unlike 
each  other,  and  require  very  different  treatment. 
That  which  would  cure  a simple  hydrocele,  would 
dangerously  aggravate  the  hydro-sarcocele. 

Mr.  Pott  observes,  that  it  may,  and  does,  sometimes 
become  necessary  to  let  out  the  water  from  the  vaginal 
coat  of  a testicle  in  some  degree  diseased ; but  this 
should  always  be  done  with  caution,  and  under  a 
guarded  prognostic ; lest  the  patient  be  not  only  disap- 
pointed by  not  having  that  permanent  relief  which,  for 
want  of  better  information,  he  n)ay  be  induced  to  ex- 
pect; but  be  also  (possibly)  subjected  to  other  unex- 
pected inconveniences  from  the  attempt. 

According  to  Richerand,  a hydrocele  may  be  known 
from  a sarcocele  by  the  following  circumstances : in  a 
sarcocele,  the  tumour  mostly  retains  the  shape  of  the 
testicle,  being  oval,  and  a little  flattened  at  the  sides, 
and  its  size  becomes  considerable  in  a short  time, 
without  ascending  so  near  the  abdominal  ring  as  a hy- 
drocele does  when  of  the  same  magnitude.  A large 
hydrocele  leaves  no  interspace  between  that  opening 
and  the  tumour,  so  that  it  is  difficult  to  take  hold  of 
and  lift  up  the  spermatic  cord ; but  in  a saicocele  there 
is  always  a space  between  the  tumour  and  the  ring, 
where  tlie  cord  can  be  distinctly  felt.  Hastly,  in  a sar- 
cocele the  tumour  is  always  opaque,  and  its  weight,  in 
reference  to  its  size,  much  more  considerable  than  that 
of  a hydrocele. — {Mosogr.  Chir  t.  4,  p.  267,  ed.  4.) 
The  latter  disease  generally  only  produces  inconve- 
nietice  by  its  bulk,  or  the  e.xcoriations  sometimes  1 


caused  between  the  scrotum  and  the  thigh ; but  a dis- 
eased testis  occasions  dragging  pains  in  the  loins  and 
neighbouring  hip.  The  hardness  is  not  a symptom 
which  can  be  trusted  alone  as  a criterion  of  a diseased 
testicle ; for  when  a hydrocele  is  extremely  distended, 
it  often  feels  so  indurated  as  to  deceive  practitioners  of 
great  experience,  and  a thickened,  hardened  state  of 
the  tunica  vaginalis  may  facilitate  the  mistake.  In 
some  instances  of  hydro-sarcocele,  the  nature  of  the 
disease  sometimes  remains  questionable  until  the  eva- 
cuation of  the  fluid  gives  the  surgeon  a fair  opportu- 
nity of  ascertaining  the  diseased  state  of  the  testicle. 

The  complication  of  a hydrocele  of  the  tunica  vagi 
nalis  with  an  encysted  one  of  the  spermatic  cord  may 
generally  be  known  by  the  swellings  having  begun  at 
two  diffbrent  points,  and  by  a kind  of  constriction  be- 
tween them.  The  latter  symptom,  however,  is  not  in- 
fallible, because  the  tunica  vaginalis  of  a common  hy- 
drocele is  sometimes  .more  or  less  contracted  at  the 
middle  of  the  tumour,  which  is  thus  made  to  appear  as 
if  there  were  two  distinct  pouches. 

When  there  are  two  swellings,  and  one  admits  of 
being  pushed  into  the  abdominal  ring,  the  case  is  pro- 
bably complicated  with  a rupture. — (See  Hernia.) 

The  size  of  a hydrocele,  and  the  thickness  of  the 
tunica  vaginalis,  are  generally  in  a ratio  to  the  lime 
which  the  disease  has  continued.  Sometimes  the  latter 
membrane  acquires  nearly  a cartilaginous  hardness; 
and  portions  of  it  have  been  found  in  an  ossified  state ; 
the  only  circumstance  in  which  any  free  excision  of  it 
is  now  accounted  necessary.  A hydrocele  has  been 
known  to  contain  four  pints  of  fluid. — {Voigtel, 
Handbuch,  der  Pract.  Anat.  b.  3,  p.  388.) 

TE.EATMENT  OF  THE  HYDROCELE  OF  THE  VAOINAL 
COAT. 

A hydrocele  is  by  no  means  a dangerous  complaint, 
though  its  weight  and  size  are  a disagreeable  encum- 
brance, and  the  patient  is  always  obliged  to  Wear  a 
bag-truss,  in  order  to  prevent  a painful  extension  of 
the  spermatic  cord.  Troublesome  excoriations  are 
also  frequently  caused  by  the  friction  offthe  tumour 
against  the  inside  of  the  thigh ; and  when  the  swelling 
is  very  large,  it  draws  over  itself  the  integuments  of 
the  penis,  which  appears  buried,  as  it  were,  in  the  tu- 
mour, and  its  functions  are  seriously  interrupted. 
Hence,  the  greater  number  of  patients  are  very  anxious 
for  relief. 

Cases  are  sometimes  met  with  in  which  an  acciden- 
tal inflammation  and  sloughing  of  the  scrotum  are  tbl- 
lowed  by  the  discharge  of  the  fluid,  an  obliteration  of 
the  cavity  in  which  it  had  collected,  and  a permanent 
cure. — (See  Lancet,  vol.  2,p.  81.)  The  accidental  rup- 
ture of  a hydrocele  by  violence,  however,  does  not 
always  lead*  to  a radical  cure;  one  instance  is  men- 
tioned by  Sir  Astley  Cooper,  in  which  the  fluid  col- 
lected again  ; and  another  is  quoted  by  him,  in  which 
the  blow  only  changed  the  hydrocele  into  haematocele. 
— {Op.  cit.  p.  83.) 

“The  methods  of  cure  (says  Pott),  though  various, 
are  reducible  to  two:  (viz.)  the  palliative,  or  that 
which  pretends  only  to  relieve  the  disease  in  present,  by 
discharging  the  fluid:  and  the  radical,  or  that  which 
aims  at  a perfect  cure,  without  leaving  a possibility  of 
relapse.  The  end  of  the  former  is  accomplished  by 
merely  opening  the  containing  bag  in  such  inauner  as 
to  let  out  the  water ; that  of  the  latter  cannot  be 
obtained  unless  the  cavity  of  that  bag  be  abolished,  and. 
no  receptacle  for  a future  accumulation  left  (which 
proposition,  though  generally  true,  is  subject  to  excep- 
tions, as  the  observations  of  Mr.  Ramsden  and  Mr. 
Wadd,  published  since  Mr.  Pott’s  time,  tend  to  prove). 
One  may  be  practised  at  all  limes  of  the  patient’s  life, 
and  in  almost  any  state  of  health  and  habit:  the  other 
lies  under  some  restraints  and  prohibitions,  arising 
from  the  circumstances  of  age,  constitution,  state  of 
the  j)arts.  Sec. 

“The  operation  by  which  the  fluid  is  let  outisavery 
simple  one.  The  only  circumstances  requiring  our  at- 
tention in  it  are,  the  instrument  wherewith  we  would 
perform  it;  and  the  place  or  part  of  the  tumour  into 
which  such  instrument  should  be  passed. 

“The  two  instruments  in  use  are  the  common 
bleeding-lancet  and  the  trocar. 

“'J’he  former  having  the  finer  point,  may  possibly 
pass  in  rather  more  easily  (though  the  difference  is 
hardly  perceptible),  but  is  liable  to  inconveniences, 


HYDROCELE. 


53 


to  which  the  latter  is  not.  The  trocar,  by  means  of  its 
cannula,  secures  the  exit  of  the  whole  fluid  without  a 
possibility  of  prevention ; the  lancet  cannot.  And 
therefore  it  frequently  happens,  when  this  instrument  is 
used,  either  tliat  some  of  the  water  is  left  behind,  or 
that  some  degree  of  handling  and  squeezing  is  required 
for  its  expulsion ; or  itiat  the  introduction  of  a probe, 
or  a director,  or  some  such  instrument,  becomes  neces- 
sary for  the  same  purpose.  Tlie  former  of  these  may 
in  some  habits  be  productive  of  inflammation : the  lat- 
ter prolongs  what  would  otherwise  be  a short  ope- 
ration, and  multiplies  the  necessary  instruments;  which, 
in  every  operation  in  surgery,  is  wrong.  To  which  it 
may  be  added,  that  if  any  of  the  fluid  be  left  in  the  va- 
ginal coat,  or  insinuates  itself  into  the  cells  of  the  scro- 
tum, the  patient  will  have  reason  to  think  the  ope- 
ration imperfect,  and  to  fear  that  he  shall  not  reap  even 
tlte  temporary  advantage  which  he  expected.  The 
place  where  this  puncture  ought  to  be  made  is  a cir- 
cumstance of  much  more  real  consequence ; the  success 
of  the  attempt,  the  ease,  and  even  sometimes  the  safety 
of  the  patient,  depending  upon  it.” 

As  the  testicle  is  usually  situated  at  the  upper  and 
back  part  of  the  cavity  of  the  hydrocele,  or,  according 
to  Sir  Astley  Cooper,  about  two-thirds  of  the  way 
downwards,  at  the  posterior  part  of  the  swelling,  the 
trocar  should  generally  be  introduced  at  the  fore  part 
of  the  tumour,  and  directed  obliquely  upwards.  How- 
ever, this  rule  is  subject  to  all  the  diflerence  which 
must  proceed  from  the  great  varieties  sometimes  met 
with  in  the  position  of  the  testicle,  and  already  speci- 
fied. Nothing  can  be  more  certain,  than  the  truth  of 
Sir  Astley  Cooper’s  remark,  that  the  trocar  never  can 
be  introduced  with  safety,  unless  the  exact  situation 
of  that  gland  has  been  first  ascertained.  Whether  the 
operation  be  done  for  the  palliative  or  radical  treat- 
ment, the  trocar  is  to  be  withdrawn  the  instant  the 
cannula  enters  the  tunica  vaginalis;  but  care  must  be 
taken  to  hinder  the  tube  from  slipping  out,  or  rather  to 
prevent  the  tunica  vaginalis  from  slipping  off  it,  which 
is  best  guarded  against  by  holding  the  tube  steadily 
within  the  puncture,  and  keeping  the  tunica  vaginalis 
tense  by  grasping  the  tumour  at  its  back  part,  until 
the  operation  is  finished. — (See  Lancet,  vol.  2,p,  81.) 

After  performing  this  operation,  a bit  of  lint  and 
soap-plaster  is  generally  applied;  and  if  the  scrotum 
lias  been  considerably  distended,  it  is  to  be  suspended 
in  a bag- truss. 

In  most  people,  the  orifice  heals  in  a few  hours  (like 
that  made  for  blood-letting) ; but  in  some  habits  and 
circumstances,  it  inflames  and  festers  : this  festering  is 
generally  superficial  only,  and  is  soon  quieted  by  any 
simple  dressing;  but  it  sometimes  is  so  considerable, 
and  extends  so  deeply,  as  to  affect  the  vaginal  coat, 
and  by  accident  produce  a radical  cure.  Mr.  Pott 
also  saw  it  prove  still  more  troublesome,  and  even 
fatal ; but  then  the  circumstances,  both  of  the  patient 
and  of  the  case,  were  particular.  Two  examples  are 
mentioned  by  Sir  Astley  Cooper,  in  which  gangrene 
arose  from  the  puncture,  and  ended  fatally:  the  pa- 
tients were  elderly  persons,  who  had  imprudently  ven- 
tured to  walk  out  the  day  after  the  operation. — {Lancet, 
vol.  2,  p.  82.)  Hence  the  prudence  of  advising  quietude 
in  bed  for  a few  days,  when  the  patients  are  of  ad- 
vanced age,  or  of  irritable  constitutions. 

“ Wiseman  and  others  have  advised  deferring  the 
puncture  till  a pint  of  fluid  has  collected.  When  there 
is  a sufficient  quantity,  however,  to  keep  the  testicle 
from  the  instrument,  there  can  be  no  reason  for  defer- 
ring the  discharge;  and  tlie  single  point  on  which  this 
argument  ought  to  rest  is  this : Whether  the  absorbent 
vessels  by  which  the  extravasation  should  be  prevented 
are  more  likely  to  reassume  their  office  while  the  vaginal 
coat  is  thin,  and  hassuffered  but  little  violence  from  dis- 
tention ; or  after  it  has  been  stretched  and  distended  to 
ten  or  perhaps  iw'enty  times  its  natural  capacity ; and  by 
such  distention  is  (like  all  other  membranes)  become 
thick,  hard,  and  tough?  Mr.  Pott  thinks  the  probabi- 
lity so  much  more  on  the  side  of  the  former,  that  he 
should  never  hesitate  a moment  about  letting  out  the 
water  as  soon  as  he  found  that  the  puncture  could  be 
m;ide  securely.  And  from  what  has  happened  within 
tire  small  circle  of  his  own  experience,  he  is  inclined  to 
believe,  that  if  it  were  performed  more  early  than  it 
generally  is,  it  might  sometimes  prevent  the  return  of 
the  disease.** 

The  foregoing  passage  deserves  to  be  particularly  re- 


collected, because  it  evidently  implies  a belief  by  Mr. 
Pott  himself,  that,  under  certain  circumstances,  a radi- 
cal cure  may  be  effected,  though  the  cavity  of  the 
tunica  vaginalis  be  not  obliterated ; an  opinion  since 
promulgated,  as  1 have  already  said,  by  Mr.  Ramsden, 
Mr.  Wadd,  and  Mr.  Kinder  Wood.  Indeed,  it  appears 
probable,  that  generally  when  a hydrocele  is  perma- 
nently cured  by  means  of  such  external  applications  as 
do  not  excite  inflammation,  but  operate  by  quickening 
the  action  of  the  absorbent  vessels,  the  cavity  of  the 
tunica  vaginalis  is  not  destroyed ; and  there  can  be  but 
little  doubt  of  the  same  thing  whenever  what  is  termed 
a spontaneous  cure  happens,  as  it  sometimes  does  in 
young  subjects.  It  u-sed  also  to  be  the  doctrine  of  De- 
sault, that  injections  did  not  obliterate  the  cavity  of 
the  hydrocele  by  adhesion,  but  only  brought  about  a 
change  in  the  vessels  of  the  tunica  vaginalis.  This 
conclusion  is  reported  by  Boyer  to  be  erroneous,  who 
had  an  opportunity  of  dissecting  the  scrotum  alter  a 
hydrocele  had  been  radically  cured,  and  the  cavity  was 
found  obliterated. — (See  Viet,  des  Sciences  Mid.  t.  22, 
p.  206.)  Now,  although  our  present  information  leads 
us  to  regard  the  latter  as  the  common  result,  it  does  not 
authorize  us  to  reject  the  inference  made  by  Desault: 
in  fact.  Sir  A.  Cooper  dissected  a case,  which  he  cured 
several  years  previously  by  an  injection ; yet  there 
w'ere  only  a few  adhesions,  and  the  removal  of  the 
disease  must  be  ascribed  to  some  cliange  eftected  in  the 
vessels  of  the  tunica  vaginalis. — (See  Lancet,  vol.  2,p. 
84.) 

The  palliative  cure  is  sometimes  deemed  most  eli- 
gible for  very  old  persons.  Its  repetition  will  be  ne 
cessary  once  every  six  months,  or  even  much  more 
frequently,  if  the  fluid  collect  again  very  rapidly,  and 
produce  great  distention,  as  sometimes  happens.  It 
should  in  general  be  performed  at  least  once  on  those 
who  determine  to  undergo  a radical  one,  as  it  gives  an 
opportunity  of  examining  the  state  of  the  testis,  and 
also  of  permitting  the  cavity  to  be  filled  again  only  to 
such  a size,  as  may  be  tiioiight  to  be  best  calculated  to 
ensure  success  in  any  future  operation.— (^I'rr  J.  Earle 
on  Hydrocele,  p.  13,  ed.  2.) 

Upon  the  subject  of  performing  the  operation  of 
tapjung  hydroceles,  Scarpa  offers  some  useful  cautions. 
The  analogy  which  exists  between  large  scrotal  her- 
niae  and  hydroceles  of  considerable  size,  led  this  writer 
to  suspect,  that,  in  the  latter  disease,  the  displacement 
and  separation  of  the  vessels  of  the  spermatic  cord 
from  each  other  might  also  happen.  Careful  investi- 
gations, made  upon  the  dead  subject,  fully  justified  the 
conjecture.  In  all  considerable  hydroceles,  he  found 
the  spermatic  vessels  so  displaced  and  separated,  and 
that  the  artery  and  vas  deferens  were  ordinarily  situ- 
ated on  one  side  of  the  tumour,  and  the  veins  on  the 
other.  Sometimes  these  vessels  all  extended  over  the 
lateral  parts  of  the  tumour,  as  far  as  its  anterior  sur- 
face, principally  tov/aids  the  bottom. 

It  is  well  known,  that,  in  many  instances,  the 
operation  of  puncturing  a hydrocele  has  been  followed 
by  a large  extravasation  of  blood  within  the  tunica 
vaginalis;  but  Scarpa  informs  us,  that  until  lately,  he 
w'as  unacquainted  with  any  case  of  this  kind,  which 
was  well  detailed,  and  authentic  enough  to  be  cited  as 
an  example  of  injury  of  the  spermatic  artery  in  the 
puncture  of  a hydrocele.  This  learned  professor, 
however,  has  had  such  a fact  recently  communicated 
to  liim  by  Gasparoli,  a distinguished  surgeon  of  Pal- 
lanza,  who,  in  introducing  the  trocar  into  the  lower 
part  of  the  swelling,  had  the  misfortune  to  injure  the 
spermatic  artery,  and  the  patient  was  afterward  cas- 
trated. The  wound  of  this  vessel  was  most  clearly 
proved  by  the  particulars  of  the  case,  as  detailed  in 
Scarpa’s  work,  to  wiiich  I must  refer  the  reader. 

From  the  accurate  knowledge  (says  Scarpa) 
which  we  now  have  upon  this  i)athological  point, 
such  an  accident  may  be  avoided,  by  observing  the 
rules,  which  are  elsewhere  given,  for  opening  the  sac 
of  a very  large  scrotal  hertiia.  In  this  last  operation, 
as  well  as  that  of  puncturing  an  old  and  voluminous 
hydrocele,  care  must  be  taken  to  introduce  the  instru- 
ment at  a considerable  distance  from  the  bottom  of  the 
tumour,  that  is  to  say,  a little  below  its  middle  part, 
and  on  a line  which  would  divide  the  swelling  longi- 
tudinally into  two  perfectly  eijual  parts.  Experience 
proves,  that  for  the  purpose  of  completely  emptying 
a hydrocele,  it  is  unnecessary  to  make  the  puncture 
very  near  tlie  bottom  of  the  tumour.  The  corrugation 


66 


HYDROCELE. 


of  the  Scrotum,  and  a slight  pressure;  made  by  the 
surgeon’s  hand,  will  suffice  for  discharging  all  the  fluid 
contained  in  the  tunica  vaginalis,  even  when  the 
puncture  is  made  at  the  middle  part  of  the  swelling.” 

(Scaj-pa,  Traits  des  Hernies,  p 61 — 68.)  On  account 
Of  the  lower  situation  of  the  testicle  in  the  hydrocele 
of  a child  than  in  that  of  a grown-up  person,  these 
directions  of  Scarpa  will  also  be  of  value. . 

RADICAL  CURE  OF  THIS  HYDROCELE, 

Besides  the  employment  of  external  applications, 
wherewith  a permanent  cure  has  occasionally  been 
accomplished,  on  the  principle  of  absorption,  six  dif- 
ferent operations  have  been  practised  for  the  same  pur- 
pose : viz.  incision  ; excision ; the  application  of  caus- 
tic ; the  introduction  of  a tent ; the  employment  of  a 
seton ; and  the  injection  of  a stimulating  fluid  into  the 
cavity  of  the  tunica  vaginalis. 

The  principle,  on  which  the  success  of  these  plans  is 
commonly  believed  to  depend,  is  the  excitement  of  such 
a degree  of  inflammation  within  that  cavity,  as  leads 
to  the  production  of  adhesions,  or  granulations, 
whereby  its  obliteration  is  affected,  and,  of  course,  no 
receptacle  for  a future  accumulation  of  fluid  reniainc. 

In  the  preceding  columns,  however,  I have  noticed 
the  possibility  of  a cure,  even  though  the  cavity  may 
not  be  completely  annihilated. 

All  the  above  plans  are  not  equally  eligible.  Some 
of  them,  indeed,  are  now  quite  exploded ; and  some, 
which  are  still  practised  by  a few,  are  not  more  suc- 
cessful, though  certainly  more  severe,  than  one  which 
will  be  presently  recommended ; while  others  are  very 
uncertain  in  their  eftect,  as  well  as  painful. 

Incision.  [ 

Making  an  incision,  so  as  to  lay  open  the  cavity 
containing  the  fluid,  is  the  most  ancient  method,  being 
described  by  Celsus.  Paulus  yEgineta  says,  the  in- 
cision is  to  commence  at  the  middle  of  the  tumour, 
and  be  carried  to  the  upper  part  of  it,  in  a line  parallel 
to  the  raphe.  This  incision  is  only  to  go  through  the 
integuments ; the  bag,  which  contains  the  water,  is 
then  to  be  opened,  and  part  of  the  sides  of  the  sac 
taken  away.  A director  is  next  to  be  introduced,  and 
a division  of  the  tunica  vaginalis  made  to  the  bottom 
of  the  swelling.  The  cavity  is  afterward  to  be  dressed 
with  lint,  and  healed  by  granulations.  Hildanus  Do- 
donagus,  Wiseman,  Cheselden,  Heister,  and  Sharp,  alt 
coincide  in  stating  the  dangerous  and  even  fatal  conse- 
quences sometimes  following  this  mode.  Mr.  B.  Bell, 
who  preferred  this  operation  to  every  other  one,  ac- 
knowledges that  he  has  seen  it  produce  great  pain  and 
tension  of  the  abdomen,  inflammation,  and  fever. 
Pott  observes,  that  it  can  never  be  said  to  be  totally 
void  of  danger,  and  that  it  bears  the  appearance  of  an 
operation  of  some  severity.  This  eminent  surgeon 
abandoned  the  method,  during  the  last  twenty-six 
years  of  his  life.  Sir  A.  Cooper  mentions  one  case,  in 
which  it  proved  fatal  in  an  elderly  person. — {Lancet, 
vol.  2,  p.  86.)  Severe  as  it  is,  it  has  also  been  known 
to  fail,  as  Sabatier  and  Earle  have  seen. , 

Excision. 

Albucasis  gave  the  first  clear  account  of  this  opera- 
tion, though  Celsus  has  certainly  mentioned  removing 
some  of  the  sac.  White  and  Douglas  used  to  adopt 
this  method.  Tlie  latter  advises  making  two  incisions, 
so  as  to  form  an  oval,  from  the  upper  to  the  lower  part 
of  the  tumour ; dissecting  otf  the  oval  piece  of  the 
scrotum,  and  then  making  an  opening  into  the  sac,  and 
enlarging  it  with  scissors.  The  tunica  vaginalis  was 
next  to  be  entirely  cut  away,  close  to  where  it  was  con- 
nected with  the  spermatic  vessels.  The  cavity  was  after- 
ward filled  with  lint.  Sir  James  Earle  justly  notices  that 
this  plan  must  have  been  tedious,  exquisitely  painful  in 
the  performance,  and,  as  subsequently  treated,  attended 
with  violent  and  dangerous  symptoms.  Sir  Astley 
Cooper  informs  us,  that  the  last  time  he  saw  this  ope- 
ration performed,  a violent  inflammation  and  slough- 
ing of  the  scrotum  ensued. — (See  Lancet,  vol.  2,  p.  84.) 
In  modern  days,  excision  is  only  sanctioned,  when  the 
tunica  vaginalis  is  more  or  less  in  an  ossified  state,  for 
a mere  thickening  of  it  does  not  prevent  the  success  of 
milder  plans  of  treatment.  With  respect  to  a mode  of 
excision,  recently  proposed  hy  Mr.  Kinder  Wood,  it 
ditfeis  entirely  from  the  ancient  method,  inasmuch  as 
it  is  perhaps  the  mildest  of  every  plan  yet  suggested 


for  the  radical  cure,  since  it  simply  consists  in  punctur- 
ing the  hydrocele  with  an  abscess  lancet,  drawing  out 
a little  bit  of  the  sac  with  a tenaculum,  and  cutting  it 
off. — (See  Med.  C/iir.  Trans,  vol.  9,p.33.)  But  farther 
experience  is  requisite  to  determine  whether  this  very 
easy  plan  is  as  certain  as  that  witii  an  injection.  Whe- 
ther the  cavity  is  obliterated  or  not,  as  Mr.  Kinder 
Wood  himself  believes,  appears  also  still  questionable 

Caustic. 

Paulus  iEgineta  advises  destroying  the  skin  with  a 
cautery  of  a particular  form,  dissecting  oflF  the  eschar, 
and  then  cauterizing  the  exposed  membrane.  Guido 
di  Cauliaco  is,  perhaps,  the  first  who  described  the  ap- 
plication of  Caustic  for  the  cure  of  hydrocele.  Wise- 
man practised  this  method.  Dionis  advises  it;  but  De 
la  Faye  and  Garengeot  make  objections  to  it.  Mr. 
Else  has  left  the  best  account  of  the  manner  of  using 
caustic.  He  recommends  laying  “ a small  caustic  upon 
the  anterior  and  inferior  part  of  the  scrotum,  which  is 
intended  to  aflTect,  and,  if  possible,  penetrate  through 
the  tunioe  vaginalis.” 

The  objections  to  the  employment  of  caustic  are,  its 
causing  an  unnecessary  destruction  of  parts,  and  pro- 
ducing a tedious  painful  sore.  The  action  of  caustic 
can  never  be  so  regulated  as  to  make  an  opening  with 
certainty  through  the  tunica  vaginalis,  so  that  either 
its  application  must  sometimes  be  repeated,  or  else  a 
lancet  or  trocar  used  after  all.  Its  success  is  also  less 
sure  than  that  of  an  injection.  In  one  case,  operated 
upon  by  Boyer,  the  disease  returned;  and  in  another 
example,  in  the  practice  of  the  same  surgeon,  the  cure 
was  accomplished  at  a great  risk,  as  it  was  long  du- 
bious whether  the  testis  would  be  saved. — {Diet,  des 
Sciences  Mid.  t.  22, j?. 210.)  An  instance  of  death  from 
the  use  of  caustic  is  mentioned  by  Sir  A.  Cooper  in  his 
valuable  lectures.— (See  Lancet,  vol.  2,  p 85.) 

Tent. 

This  was  first  mentioned  by  Franco.  The  opera- 
tion consists  in  making  an  opening  into  the  tunica  va- 
ginalis, and  keeping  the  wound  open  with  a tent  of 
lint,  linen,  or  sponge,  so  as  to  make  the  cavity  suppu- 
rate, in  which  the  water  was  contained.  Par^,  Guille- 
mau,  Covillard,  Ruysch,  Heister,  and  Marini  have  all 
described  the  plan,  with  some  variations,  one  of  which 
consisted  in  smearing  the  tents  with  irritating  sub- 
stances. Dr.  A.  Monro  senior  devised  the  plan  of 
keeping  a cannula  in  the  tunica  vaginalis,  so  as  to 
bring  on  a cohesion  of  the  parts,  without  suppuration. 
Fabricius  ab  Aquapendente,  however,  has  made  allu- 
sion to  some  surgeons  before  his  time,  who  used  to 
keep  the  wound  open  a few  days  with  a cannula.  Mr. 
Pott  tried  the  cannula,  but  found  it  very  inconvenient, 
as  its  inflexibility  hurt  the  testis  whenever  the  patient 
moved  with  inattention,  and,  consequently,  he  prefer- 
red a tent  or  bougie,  though  he  speaks  of  the  plan  as  a 
very  uncertain  one. 

Of  late,  Baron  Larrey,  in  consequence  of  having 
seen  several  instances,  in  which  the  symptoms,  follow- 
ing the  use  of  an  injection,  were  violent,  and  one  case 
in  which  a fatal  peritonitis  was  produced,  has  recom- 
mended exciting  the  necessary  degree  of  inflammation 
by  keeping  a short  piece  of  an  elastic  gum  catheter  in 
the  puncture,  which  instrument  also  serves  afterward 
to  let  any  fluid  escape  from  the  tunicavaginalis. — {MSm. 
de  Chir.  Militaire,  t.  3,  p.  409,  Src.)  This  author,  of 
course,  speaks  of  the  plan  as  having  fully  answered 
his  expectations  ; but  I much  doubt  whether  it  has  any 
particular  superiority  over  several  of  the  former  n)e- 
f hods  of  employing  the  tent;  methods,  which  the  wis- 
dom, arising  from  experience,  has  long  since  rejected. 

Seton 

Was  first  mentioned  by  Guido  di  Cauliaco,  in  1498, 
as  a means  of  curing  the  hydrocele.  In  modern  times, 
Pott  preferred  it  to  every  other  method,  if  we  except 
injection,  of  which,  according  to  Sir  J.  Earle,  he  ex- 
pressed his  approbation  before  his  decease.  Sir  A. 
Cooper  still  retains  a preference  to  the  seton  for  chil- 
dren, on  account  of  its  application  being  more  easy  in 
them  than  the  employment  of  injection. — {Lancet,  vol. 
2,  p.  85.)  Mr.  Pott  found,  that  the  best  mode  of  mak- 
inc  the  seton  was  as  follows.  He  employed  three  in- 
struments; the  first  was  a trocar,  the  cannulaof  which 
was  about  one-fourth  of  an  inch  broad.  The  second 
was  what  he  called  the  scion  cannula,  which  was 


HYDROCELE, 


67 


made  of  silver,  was  just  small  enouglj  to  pass  with 
ease  through  the  cannula  of  the  trocar,  and  five  inches 
long.  The  third  instrument  was  a probe  six  indies 
and  a half  long,  having  at  one  end  a fine  steel  trocar 
point  and  at  the  other  an  eye,  which  carried  the  se- 
ton.  The  seton  consisted  of  so  much  white  sewing 
silk,  as  would  just  pass  easily  through  the  cannula,  and 
yet  fill  it.  The  thickness  of  the  seton,  however,  was 
not  so  great  in  the  latter  part  of  his  practice.  Having 
pierced  the  inferior  and  anterior  part  of  the  tumour 
with  the  trocar,  withdrawn  the  perforator,  and  dis- 
charged the  water,  Mr.  Pott  used  to  pass  the  seton-can- 
nula  through  that  of  the  trocar,  to  the  upper  part  of 
the  tunica  vaginalis,  so  as  to  be  felt  there.  The  probe, 
armed  with  the  seton,  was  next  conveyed  through  the 
latter  cannula,  and  its  point  pushed  through  the  upper 
part  of  the  tunica  vaginalis  and  scrotum.  The  silk 
was  then  drawn  through  the  cannula,  until  a sufficient 
quantity  was  brought  out  of  the  upper  orifice.  The 
two  cannulae  being  withdrawn,  the  operation  was 
finished. 

Injection. 

Dr.  Monro  attributes  the  first  use  of  injections  for 
the  radical  cure  of  hydroceles  to  an  army  surgeon  of 
his  own  name,  who  employed  spirit  of  wine.  This 
produced  a cure ; but  the  inflammation  was  so  violent, 
that  he  afterward  tried  a milder  injection,  which  con- 
sisted of  wine.  However,  Lambert  in  his  (Euvrcs 
CAiV.,  published  at  Marseilles  early  in  the  seventeenth 
century,  advised  injecting  a solution  of  sublimate  in 
lime  water,  and  he  has  related  cases  of  success.  Mr. 
S.  Sharp  also  made  trial  of  spirit  of  wine,  which  cured 
the  hydrocele,  but  not  without  causing  dangerous 
symptoms,  and  two  subsequent  abscesses  in  the  scro- 
tum.— {Operations  of  Surgery.)  Douglas,  Le  Dran, 
and  Pott,  all  disapprove  of  injections  in  tlieir  works; 
though  Sir  James  Earle  informs  us,  that  the  latter 
lived  to  alter  his  opinion  on  the  subject. 

The  violence  of  the  inflammatory  symptoms,  conse- 
quent to  the  first  employment  of  injections  for  the 
radical  cure  of  hydroceles,  arose  from  the  fluids  used 
being  too  irritating.  Sir  James  Earle,  at  last,  pre- 
ferred wine  for  several  reasons.  He  found  that  it  had 
been  used  with  success  in  France ; its  strength  is  never 
so  great  as  to  render  it  unsafe ; and  it  may  be  readily 
weakened.  However,  as  the  strength  and  other  quali- 
ties of  port  wine  vary  considerably,  Sir  A.  Cooper 
prefers  using  a solution  of  the  sulphate  of  zinc,  3 j to  a 
pint  of  water. — {Lancet,  vol.  %p.  87.) 

“ I have  commonly  used  (says  Sir  James  Earle) 
about  two-thirds  of  wine  to  one-third  of  water : if  the 
parts  appeared  insensible,  and  no  pain  at  all  was  pro- 
duced by  the  first  quantity  thrown  in,  I have  withdrawn 
the  syringe,  and  added  to  the  proportion  of  wine ; on 
the  contrary,  if  the  complaint  was  recent,  and  the  parts 
irritable,  I have  increased  the  proportion  of  water ; so 
that  I have  hitherto  been  principally  guided  by  the 
degree  of  sensation  which  the  patient  has  expressed. 
I have  lately  used  pure  water  mixed  with  wine,  and 
found  it  answer  as  well  as  when  astringents  were 
added.” — {Treatise  on  the  Hydrocele,  p.  103,  ed.  2.) 
In  the  preface,  the  author  says,  that  he  has  long  disused 
the  pipe  with  a stop  cock,  which  he  once  employed,  on 
account  of  not  being  well  able  to  spare  a hand,  during 
the  operation,  to  turn  it,  and  its  consequently  being 
found  awkward.  A pipe,  one  end  of  which  is  made 
to  fit  into  the  cannula  of  a trocar,  the  other  adapted 
to  receive  the  neck  of  an  elastic  bottle,  with  a valve 
or  ball  in  the  centre  of  the  pipe,  to  permit  the  en- 
trance and  prevent  the  exit  of  the  injection,  will  be 
found  infinitely  more  convenient  and  useful.— (EarZe.) 
When  the  hydrocele  is  very  large.  Sir  James  recom- 
mends simply  letting  out  the  fluid,  and  waiting  until 
the  tumour  acquires  a more  moderate  size  before 
attempting  the  radical  cure  by  injection. 

It  appears  from  Sir  James  Earle’s  interesting  cases, 
that  a cure  may  be  accomplished  in  this  manner,  even 
when  the  tunica  vaginalis  is  considerably  thickened. 
In  the  course  of  a month,  Boyer  cured  a patient  with 
an  injection,  even  though  the  testicle  was  enlarged. — 
(See  Diet,  des  Sciences  M6d.  t.  22,  p.  214.)  Similar 
^seji  are  also  reported  in  the  Parisian  Chir.  .lourn. 
The  following  is  the  common  mode  of  operating;  the 
hydrocele  is  to  be  tapped  with  a trocar  at  its  anterior 
and  inferior  part,  and  when  the  whole  of  the  fluid  is 
evacuated,  the  cavity  of  the  tunica  vaginalis  is  to  be 


distended  to  its  former  dimensions  with  the  above 
injection.  This  is  to  be  allowed'  to  remain  in  the  part 
about  five  minutes,  upon  the  average,  after  which  it  is 
to  be  discharged  through  the  cannula.  The  patient 
usually  feels  some  pain  in  the  groin,  and  about  the 
kidneys,  on  the  injection  being  introduced ; which 
symptoms  are  rather  desirable,  as  they  evince,  that  the 
stimulus  of  the  fluid  is  likely  to  have  the  wished-for 
effect  of  exciting  the  necessary  degree  of  inflammation. 
This  plan,  which  was  brought  to  a high  pitch  of  per- 
fection by  the  late  Sir  James  Earle,  may  be  deemed 
almost  A sure  means  of  obtaining  a permanent  cure ; 
and  being  at  tlie  same  time  mild,  is  mostly  preferred 
in  England,  France,  and  Germany. 

The  treatment  after  the  operation  is  exactly  like 
that  of  the  common  swelled  testicle  (see  Hernia  Hu- 
moralis),  consisting  of  the  use  of  fomentations,  poul- 
tices, leeches,  saline  purges,  and,  above  all,  of  a bag 
truss  for  keeping  up  the  scrotum.  However,  a strict 
antiphlogistic  treatment  need  not  be  adopted,  unless 
the  inflammation  become  too  violent,  because  a certain 
degree  of  it  is  necessary  for  the  cure. . Sometimes,  Sir 
A.  Cooper  even  recommends  his  patients,  when  the 
inflammation  is  not  brisk  enough,  to  take  wine,  live 
well,  and  walk  about.  According  to  Boyer,  the  occa- 
sional failure  of  the  treatment  with  injections  is  owing 
to  the  premature  discontinuance  of  spirituous  applica- 
tions, and  the  too  quick  substitution  of  emollients  for 
them,  as  well  as  the  plan  of  not  letting  the  injection 
remain  in  the  tunica  vaginalis  long  enough. — (See 
Diet,  des  Sciences  M^d.  t.  '22,  p.  213.) 

One  caution  it  is  necessary  to  offer  before  taking  our 
leave  of  this  subject.  It  has  sometimes  happened 
during  the  operation,  that  the  cannula  has  slipped  out 
of  the  tunica  vaginalis,  and  its  inner  mouth  become 
situated  in  the  substance  of  the  scrotum,  in  which 
event  the  operator,  if  he  persists  in  propelling  out  the 
injection,  will  fill  the  cellular  texture  of  the  part  with  a 
stimulating  fluid,  which  may  cause  abscesses,  slough- 
ing, and  other  unpleasant  symptoms,  without  entering 
the  cavity  of  the  tunica  vaginalis,  or  producing  a radi- 
cal cure  of  the  hydrocele,  which,  however,  I have 
known  happen  from  this  cause,  as  I have  elsewhere 
related. — (See  First  Lines  of  Surgery,  vol.  2.)  When 
such  an  accident  happens,  it  is  better  to  defer  the  ope- 
ration till  a sufficient  quantity  of  fluid  has  collected 
again.  Sometimes,  when  the  injection  is  strong,  a 
great  deal  of  it  has  passed  into  the  cellular  membrane, 
and  the  constitution  is  irritable,  the  mischief  produced 
ends  in  the  patient’s  death.  Many  such  cases  are  on 
record,  and  two  are  noticed  by  Sir  A.  Cooper. — (See 
Lancet,  vol.  2,  p.  89.) 

Hydroceles  have  been  cured  by  applying  to  the  scro- 
tum a solution  of  muriate  of  ammonia  in  vinegar  and 
water. — {Keate.)  But  the  application  frequently  cre- 
ates a good  deal  of  pain  and  irritation,  and,  in  grown- 
up persons,  does  not  often  succeed,  to  say  the  best  of 
it. — {Earle.)  However,  in  young  persons  and  children, 
the  employment  of  brisk  purgatives,  discutient  lotions, 
and  a suspensory  bandage,  mostly  proves  successful, 
as  is  confirmed  by  the  testimony  of  Sir  Astley  Cooper. 
— {Lancet,  vol.  2,  p.  83.) 

Distending  the  tunica  vaginalis  with  air,  cold  water, 
or  even  the  fluid  discharged,  has  sometimes  effected  a 
radical  cure. — (See  Supplement  to  Ploucquet,  p.  103, 
Tub.  1814.) 

A case  is  mentioned  by  Sir  A.  Cooper,  in  which 
milk  was  injected,  on  the  supposition  of  its  being  a 
mild,  unirritating  fluid  : however,  very  severe  inflam- 
mation followed,  and  an  abscess  in  the  tunica  vagi- 
nalis. When  an  opening  was  made,  the  milk  came 
out  in  curds. 

There  is  a particular  case,  that  has  been  called  the 
congenital  hydrocele,  by  which  is  implied  a collection 
of  water  in  the  tunica  vaginalis,  with  a communication 
between  the  cavity  of  this  membrane  and  that  of  the 
peritoneum.  Desault  used  to  cure  this  disease  by  a 
red  wine  injection.  After  the  protruded  viscera  had 
been  returned  into  the  belly,  and  while  the  opening 
between  that  and  the  inside  of  the  tunica  vaginalis 
was  carefully  compressed  and  closed  by  a trusty  as- 
sistant, Desault,  after  letting  out  the  water  in  the  com- 
mon way,  used  to  throw  in  the  injection.  7’he  method, 
it  is  said,  succeeded,  without  causing  the  perilous  con- 
sequence one  might  a,  priori  expect,  viz.  inflammation 
of  the  peritoneum. 

This  kind  of  hydrocele  has  not  been  described  by 


58 


HYD 


HYD 


many  writers.  The  case  is  easily  distinguislied  by  the 
fluid  being  capable  of  being  pushed  into  the  belly.  By 
means  of  a vinous  injection,  Desault  cured  a boy  both 
of  a congenital  hydrocele  and  hernia. — (See  CEuvres 
Chir.  de  Desault,  t.  2,  p.  442.) 

The  niethf)d  wliich  I should  recommend  is  the 
constant  application  of  a truss;  by  whicli  means  Sir 
A.  Cooper  has  known  a cure  very  successfully  accom- 
plished.— (See  Lectures,  vol.2,p.  91.) 

Monroe  on  the  Tumours  of  the  Scrotum,  in  the  Edin. 
Med.  Essays,  vol.  5.  J.  Douglas,  a Treatise  on  Hy- 
drocele, 8vo.  Lond.  1755  ; and  Answer  to  Reitfarks  on 
that  work,  8vo.  Lond.  1758.  Tott  on  the  Hydrocele. 
Else  on  the  Hydrocele,  8«o.  London,  1776 ; and  the 
fVorks  of  .Joseph  Else,  8vo.  Lond.  1782.  W.  Dease 
on  the  Different  Kinds  of  Hydrocele,  8vo.  Lond.  1798. 
Keate.  B.  Bell  on  Hydrocele,  Sa>-cocele,  <^c.  8vo. 
Edin.  1794.  Loder,  in  Med.  Chir.  Bemerk.  th.  1,  cap. 
7.  Theden's  Meue  Bemerk.  th.  2 and  3.  Sir  James 
Earle,  Treatise  on  the  Hydrocele,  2d  ed.  8vo.  London, 
1803.  Schreger,  Chirurgische  Versiiche,  b.  1,  8co. 
iN'urnberg,\8\\:  a cure  effected  by  the  injection  of  air, 
p.  306.  Bertrandi,  hi  Mim.  de  I'Acad.  de  Chir.  t.  3 ; 
and  in  Tratlato  delle  Operuzioni  di  Chirurgia,  Mizza, 
1763.  Desault,  Remarques,  Src.  sur  Diverses  Especes 
d'Hydrocile;  CEuvres  Chir.  t.  2.  S.  Sharp's  Treatise 
on  the  Operations,  and  his  Critical  Inquiry.  J.  How- 
ard, Obs.  on  the  Method  of  curing  the  Hydrocele  by 
means  of  a Seton,  Svo.  Lond.  1783.  Sabatier,  Midecine 
Opiratoire,  t.  \,ed.  2.  Scarpa,  TraiU  des  Hernies,  p. 
64,  .S-c.  Larrey,  Mimoires  de  Chir.  Militaire,  t.  3,  p. 
409,  ^c.  T.  Ramsden,  Practical  Observations  on  the 
Sclerocele,  Src.  8vo.  Lond.  1811.  W.  Wadd,  Cases  of 
Diseased  Bladder  and  Testicle,  Ato.  London,  1815. 
Kinder  Wood,  Obs.  on  the  Cure  of  the  Hydrocele  of  the 
Tunim  Vaginalis,  without  procuring  an  Obliteration 
of  the  Sac ; in  Med.  Chir.  Trans,  vol.  9,  j).  38,  8vo. 
Lond.  1818.  A.  Scarpa,  Memoria  sulV  Idrocele  del 
Cordone  Spermatico,  Ato.  \Pavia,  1823.  A.  Cooper, 
Lectures  on  the  Principles,  S'c.  of  Surgery,  vol.  2,  p. 
86,  8vo.  Lond.  1825 ; and  the  First  Lines  of  the  Prac- 
tice of  Surgery,  ed.  5. 

HYDROPHOBIA.  (From  SScop,  water,  and  <p66og, 
fear.  A dread  of  water.)  This  being,  for  the  most 
part,  a striking  symptom  of  the  fatal  indisposition 
which  results  from  the  bite  of  a mad  dog,  and  some 
other  animals  affected  in  the  same  way,  the  disease 
itself  has  been  named  hydrophobia.  Some  have  used 
the  more  general  term,  hygrophobia,  from  {lypov,  liquid. 
But  strong  objection  has  been  made  to  both  these 
terms,  becau.se  derived  from  a symptom  which  does 
not  exclusively  belong  to  the  disease,  nor  constantly 
exist  in  it. 

I'he  old  writers,  as  we  learn  from  Ca3lius  Aurelianus, 
used  the  terms  aerophobia,  or  a dread  of  air,  andpaw- 
tephobia,  or  a fear  of  all  things,  since  the  impression 
of  cold  air  sometimes  excites  terror,  and  the  disorder  is 
marked  by  a singular  degree  of  general  timidity  and 
distrust.  Others  called  it  phobodipson  (Stipos  signifying 
thirst),  because  the  patient  is  thirsty,  yet  fears  to 
4rink.  Several  modern  authors,  however,  objecting 
to  any  appellation  expressive  only  of  one  symptom, 
denominate  the  disease  rabies,  and  rabies  canina,  or 
canine  madness.  The  French  call  it  la  rage. 

With  respect  to  hydrophobia,  or  the  dreadful  indis- 
position produced  by  the  bite  of  a dog,  or  other  animal, 
affected  with  rabies,  or  by  the  application  of  some  of 
the  secretions  of  such  animal  to  a part  of  the  body,  the 
first  clear  mention  of  it  is  generally  considered  to  be 
that  made  by  Aristotle  {Hist.  Animal,  lib.  7,  cap.  211) ; 
but  he  could  have  had  but  very  erroneous  notions  upon 
the  subject,  since  he  sets  down  man  as  incapable  of 
receiving  the  distemper  from  the  bite  of  a rabid  dog. 

Concerning  the  antiquity  of  hydrophobia,  however, 
I particularly  refer  to  Dr.  Decker’s  Observations,  who 
thinks  llie  fact  clearly  proved,  that  the  disease  existed 
at  least  400  years  before  Christ,  and  even  in  the  most 
remote  periods. — {Sec  Jour,  fur  Chir.  von  C.  F.  Graefe, 
Src.  b.  2,  p.  325,  S-c.) 

With  respect  to  a name  for  the  disorder,  as  the  pa- 
tient does  not  commonly  betray  any  tendency  to  fury, 
while  the  dread  of  water  is  really  a customary  attend- 
ant on  the  complaint,  the  terms  rabies  and  la  rage  seem 
strictly  even  more  exceptionable  than  the  word  hydro- 
phobia. At  the  same  time,  in  order  not  to  imbibe  con- 
fused notions,  whatever  name  be  thought  fittest  for  the 
illness  arising  in  the  human  subject  from  the  bite  of  a 


mad  dog,  and  some  other  animals  similarly  affected,  It 
is  necessary  to  understand  well,  that  hydrophobia,  in 
the  sense  of  a horrer  of  water  or  other  liquids,  is  an 
occasional  symptom  of  many  diseases,  and  neither  ex- 
clusively confined  to  the  indisposition  caused  by  the 
bite  of  a rabid  dog,  or  certain  other  animals,  nor  even 
constantly  attendant  upon  it.  And,  with  the  same 
view  of  avoiding  perplexity,  all  hydrophobic  complaints 
may  be  arranged  in  two  general  divisions. 

1.  The  first  comprising  all  cases  not  ascribable  to 
the  bite  of  a rabid  animal,  or  the  application  of  some 
of  its  secretions  to  a part  of  the  body. 

2.  The  second  comprehending  the  examples  preceded 
by  one  of  those  occurrences. 

The  cases  included  in  the  first  of  these  divisions  are 
subdivided  into  the  symptomatic  and  idiopathic  or 
spontaneous.  By  symptomatic  hydrophobia  is  under- 
stood an  aversion  or  dread  of  liquids,  presenting  itself 
as  an  occasional  symptom  of  various  diseases,  as  of 
certain  inflammatory,  febrile,  and  nervous  disorders, 
hysteria,  epilepsy,  injuries  of  the  brain  {Trecourt,  in 
Recueil  Piriodique,  Src.  t.  6 ; Acta  Matures  Curios,  vol. 
2,  obs.  205),  the  operation  of  particular  poisons  ( Viller- 
may,  Traiti  des  Mai.  Merveuses,  t.  1,  js.  90;  Harles, 
uberdie  Hundiswuth,  Frankf.  1809;  Schmiedel,  Diss.  de 
Hydrophobid  ex  Us  a Frnctuum  Fagi,  Erlang.  1762, 
Src.),  gastritis,  pneumonia,  hepatitis,  angina,  &c.  &c. 
In  many  of  the  instances  of  symptomatic  hydrophobia, 
the  aversion  or  dread  of  fluids  occurs  on  the  same 
day  as  the  cause  upon  which  it  depends,  or  a few  days 
afterward  ; and,  for  the  most  part,  may  be  cured  with 
the  disease  which  has  given  rise  to  it,  or  even  inde- 
pendently of  it.  On  the  contrary,  the  hydrophobia 
from  the  bite  or  infection  of  a rabid  animal,  does  not 
come  on  till  a long  time  after  the  occurrence  of  the 
cause,  and  when  once  formed,  has  hitherto  proved 
incurable.  Whatever  analogy,  therefore,  may  be  ima- 
gined to  exist  between  symptomatic  hydrophobia  and 
rabies,  they  differ  essentially  in  their  causes,  progress, 
degree  of  curability,  and  also  in  the  treatment  required. 
— (See  Diet,  des  Sciences  Mid.  t.  A,p.  38.) 

Spontaneous  or  idiopathic  hydrophobia  denotes  the 
questionable  form  of  the  complaint,  sometimes  sup- 
posed to  be  induced  by  violent  mental  commotion, 
anger,  fright,  &c.  unpreceded  by  any  other  primary 
disease,  to  which  it  can  be  referred  as  a syn)ptom. 

Numerous  facts  upon  record  leave  no  doubt  con- 
cerning the  reality  of  symptomatic  hydrophobia  ; but, 
perhaps,  none  of  the  cases  adduced  by  Raymond 
{Mem.  de  la  Soc.  Royale  de  Mid.  1.  2,  p.  457),  Roupe 
{JVova  Acta  Physico-Med.  t.  A),  or  Pouteau  {Essaisur 
la  Rage,  Lyons,  1763),  in  proof  of  the  possibility  of  a 
spontaneous  idiopathic  form  of  the  disease  in  the  human 
subject,  are  sufficiently  unequivocal  to  remove  all  sus- 
picion, either  that  the  complaint  had  been  preceded  by 
another  primary  disease  {Diet,  des  Sciences  Mid.  t. 
22,  p.  333),  or  had  been  the  result  of  an  unobserved 
or  forgotten  occasion,  on  which  the  infection  was  re- 
ceived from  handling  a dog  or  cat,  never  suspected  at 
the  time  to  be  affected  with  rabies.  Here  a wrong  con- 
clusion is  the  more  apt  to  be  made,  in  consequence  of 
the  disease  being  communicable  without  any  bite  to  fix 
the  patient’s  attention,  and  not  commencing  sometimes 
for  months  after  the  unnoticed  receipt  of  the  infection. 
Thus,  Francis  Stannier  died,  in  Nov.  1787,  with  symp- 
toms of  hydrophobia,  though  it  was  not  known  that 
he  had  ever  been  bitten  by  a mad  dog  {Lond.  Med. 
Journ.  vol.  9,  p.  256) ; yet,  what  safe  inference  can  be 
drawn  from  tliis  case,  when  the  above-mentioned  cir- 
cumstances are  recollected,  and  it  is  known  that  the 
man  was  often  drunk,  and  in  the  streets  at  night? 
These  and  other  considerations  even  throw  a doubt 
upon  a part  of  the  cases,  recorded  as  instances  of  symp- 
tomatic tetanus,  and  they  lead  the  generality  of  mo- 
dern writers  to  incline  to  the  sentiment  of  Dr.  J.  Hun- 
ter, that  a disease  similar  in  its  nature  to  what  is  pro- 
duced by  the  bite  of  a mad  dog,  never  arises  sponta- 
neously in  the  human  subject. — (See  Trans,  of  a Soc. 
for  the  Improvement  of  Med.  and  Chir.  Knowledge,  vol. 
1,  p.  299 — 303.)  Many  of  the  symptomatic  cases, 
however,  or  those  in  which  more  or  less  aversion  or 
dread  of  liquids  is  evinced  as  an  effect  of  another 
disease,  are  too  well  authenticated  to  admit  of  doubt. 
In  the  Diet,  des  Sciences  Mid.  t.  22,  art.  Hydrophobie, 
may  be  found  a great  deal  of  information  likely  to  in- 
terest such  readers  as  wish  to  follow  up  the  subject  of 
the  symptomatic  forms  of  the  disease.  However,  in 


HYDROPHOBIA. 


59 


looking  over  some  of  the  cases  there  detailed,  a sus- 
picion will  sometimes  arise  in  an  intelligent  mind,  that 
the  disorder  was  mistaken  ; for  it  will  be  noticea,  that 
sometimes  pain  shooting  up  the  limbs  preceded  the  ge- 
neral indisposition,  while  the  rapidity  of  the  disease, 
and  the  appearances  found  on  dissection,  corresponded 
precisely  to  what  is  usually  remarked  in  hydrophobia. 
In  particular,  one  patient  is  described  as  a man  habi- 
tuated to  drinking,  and,  as  a sportsman,  to  dogs  also  : 
he  died  on  the  third  day,  and  on  dissection,  the  stomach 
and  intestines  were  found  inflamed,  and  even  gangre- 
nous in  several  places,  the  oesophagus  and  lungs  also 
participating  in  the  inflammation. — {Commerc.  Litter. 
JsToremb.  1743,  hebd.  5.) 

Animals  of  the  dog  kind,  including  the  wolf  and  the 
fox,  are  most  frequently  the  subjects  of  rabies ; and 
certain  writers  have  maintained,  that  although  it  may 
be  received  and  propagated  by  other  animals,  yet  it 
always  originates  in  some  of  the  canine  race. — {Hil- 
lary on  Diseases  of  Barbadoes,  p.  246.)  However,  it 
is  asserted,  that  the  disease  sometimes  originates  spon- 
taneously in  cats,  that  is  to  say,  without  their  having 
been  previously  bitten  by  another  rabid  animal ; but 
the  moderns  do  not  incline  to  the  belief,  that  it  ever  has 
been  known  to  commence  in  this  manner  in  other  ani- 
mals, though  such  an  assertion  is  made  by  Ca;lius  Aure- 
lianus.  Porphyrins,  Avicenna,  Valeriola,  Vander  Wiel, 
&c.  not  oidy  with  respect  to  man,  but  horses,  asses, 
camels,  hogs,  bullocks,  bears,  monkeys,  and  even 
poultry. — (See  Diet,  des  Sciences  Mid.  t.  47,  p.  45.) 

It  is  interesting  to  inquire,  what  animals  are  capable 
of  communicating  rabies,  and  what  animals  of  re- 
ceiving it  ? As  far  as  our  knowledge  yet  extends,  it  ap- 
pears, that  animals  of  the  canine  species,  with  perhaps 
those  of  the  feline  race,  are  the  only  ones  in  which  this 
disorder  ever  arises  spontaneously,  and  they  may 
transmit  it  to  animals  of  their  own  kind,  to  other  quad- 
rupeds, and  to  man.  The  experiments  made  by  Dr. 
Zincke,  tend  to  prove  also  that  birds,  at  least  the  com- 
mon fowl,  may  have  the  disease  communicated  to 
them. — (JV’ewe  Ansichten  der  Hundswutli,  &rc.  Saa. 
Jena,  1804.) 

But  though  it  be  well  known  that  animals  of  the 
dog  and  cat  kinds  can  propagate  the  disorder,  it  is  not 
settled,  whether  it  can  be  cdmmunicated  by  other  ani- 
mals. In  a memoir,  read  to  the  French  Institute,  M. 
Huzard  explained,  that  herbivorous  quadrupeds  af- 
fected with  rabies,  are  incapable  of  transmitting  the 
disease;  a position  subsequently  confirmed  by  addi- 
tional experiments  and  observations  made  in  the  vete- 
rinary school  at  Alford.  M.  M.  Girard  and  Vatel  ino- 
culated with  the  saliva  of  a rabid  sheep  two  other 
sheep,  a young  dog,  and  a horse ; but  none  of  these 
animals  evinced  any  symptoms  of  the  disease,  and 
continued  well  four  months  after  the  experiment. — 
{Magendie,  in  Journ.  de  Physiol.  Expir.  t.  8,  p.  326, 
i'c.  8i’o.  Paris,  1828.)  Professor  Dupuy  could  never 
communicate  the  distemper  to  cows  and  sheep,  by 
rubbing  their  wounds  with  a sponge,  which  animals  of 
the  same  class,  already  labouring  under  the  disease, 
had  had  in  their  mouths ; though  the  same  experiment, 
made  with  a sponge  which  had  been  bitten  by  a rabid 
dog,  propagated  rabies  by  a kind  of  inoculation.  Du- 
puy has  likewise  seen,  among  several  flocks,  sheep 
atfected  with  rabies,  yet  the  distemper  was  never  com- 
municated by  them  to  other  sheep,  notwithstanding  the 
latter  were  bit  in  parts  stripped  of  wool.  Dr.  Gillman 
inoculated  two  rabbits  with  the  saliva  of  a rabid  pig; 
but  the  disease  was  not  communicated  to  them.— (Oa 
the  Bite  of  a Rabid  Animal,  p.  38.)  On  the  other  hand, 
Mr.  King,  of  Clifton,  is  stated  to  have  communicated 
rabies  to  a fowl  by  inoculating  it  with  the  saliva  of  an 
ox,  which  liad  just  fallen  a victim  to  the  disease.— (J. 
Ashburner,  Diss.  de  Hydrophobid,  p.  29.)  The  author 
of  the  article  Rage  {Diet,  des  Sciences  Mid.)  observes, 
respecting  this  singular  case,  that,  as  it  is  accompa- 
nied with  no  details,  doubts  must  remain,  whether  the 
fowl  actually  died  of  rabies.  A fatal  instance  of  hy- 
drophobia from  the  bite  of  a rabid  badger  has  been 
lately  recorded,  though  not  with  such  precision  as  to 
leave  no  doubts  about  tire  nature  of  the  case. — (See 
Hufeland's  .Tourn.for  1821.) 

As  for  some  extraordinary  cases,  in  which  the  dis- 
ease is  alleged  to  have  been  communicated  to  the 
human  subject  by  t|ie  bites  of  birds,  or  injuries  done 
with  the  claws  of  animals,  they  are  generally  dis- 
missed by  modern  writers,  with  the  inference,  that  (he 


complaint  thus  transmitted  was  not  true  hydrophobia 
or  rabies.  This  conclusion  is  made  with  respect  to 
the  cases  of  this  kind  reported  by  Cslius  Aurelianus 
and  Bader,  and  the  notorious  example  mentioned  by 
A.  Baccius,  of  a gardener  who  died  of  the  bite  of  a 
cock,  which,  according'  to  some,  was  rabid,  according 
to  others,  merely  enraged.  Hildanus  also  details  an 
instance,  in  which  a young  man  was  scratched  on  the 
great  toe  by  a cat;  and,  some  months  afterward,  was 
attacked  with  hydrophobia  {Obs.  Chir.  cent.  1,  obs. 
10) : but,  as  a modern  writer  observes,  if  the  patient 
were  really  affected  with  rabies,  it  is  conceivable  that 
the  cat’s  claw,  with  which  the  scratch  was  made, 
might  have  been  wet  with  the  animal’s  saliva.— (/Hc«. 
des.  Sciences  Mid.  t.  47,  p.  47.), 

Another  question  of  considerable  importance  is, 
whether  hydrophobia,  that  is  to  say,  rabies,  can  be 
communicated  from  one  human  being  to  another  1 or, 
whether,  in  man,  the  disease  is  iiifectious  or  conta- 
gious 1 Many  attempts  have  been  made,  in  vain,  to 
communicate  the  distemper  to  several  kinds  of  ani- 
mals, by  inoculating  them  with  the  saliva  of  patients 
who  had  perished  of  the  disease.  These  experiments 
were  made  in  this  country  by  Gauthier,  Vaugnan, 
Babington,  &c. ; butno  infection  was  the  consequence. 
In  France,  Giraud  inoculated  several  dogs  with  the 
saliva  of  a man  in  the  convulsed  stage  of  hydrophobia, 
but  none  of  them  afterward  took  the  distemper. — 
{Bosquillon,  Mim.  sur  les  Causes  de  V Hydrophobie, 
in  Mim.  de  la  Soc.  d' Emulation,  cinquiime  annte.) 
M.  Girard,  of  Lyons,  collected  some  of  the  frothy  sa- 
liva the  instant  it  was  discharged  from  a patient’s 
mouth,  and  he  inserted  some  of  it  into  eight  punc- 
tures, made  on  the  inside  of  a dog’s  fore  legs;  yet  six 
months  after  this  inoculation,  the  animal  had  not  suf- 
fered the  slightest  inconvenience. — {Essai  sur  le  Teta- 
nos  Rabiens,  p.  29.)  A similar  experiment  was  made 
on  three  dogs  by  M.  Paroisse,  who  kept  the  animals 
between  three  and  four  months  afterward,  during  all 
which  time  they  continued  quite  unaffected. — {Bibl. 
Mid.  t.  43.) 

Dr.  Bezard  published  the  following  experiments: 
pieces  of  the  flesh  of  a person  who  had  died  of  hydro- 
phobia, were  smeared  with  his  saliva,  and  given  to  a 
dog;  another  dog  was  suffered  to  eat  the  salivary 
glands ; and  a third  the  sides  of  a wound.  In  three 
other  dogs,  incisions  were  made;  the  cut  parts  were 
then  inoculated,  and  sewed  up.  Not  one  of  these  six 
animals  became  atfected  with  rabies. — (See  Mim  et 
Obs.  lus  d la  Soc.  Mid.  Philanthropique,  premiire 
annie,  1807,  p.  17.) 

The  preceding  experiments  only  furnish  negative  re 
suits;  but  one,  to  which  we  shall  now  advert,  tends  to 
establish  a contrary  opinion.  On  the  19th  June,  1813, 
in  the  H6lel-Dieu  at  Paris, Magendie  and  Breschettook 
some  of  the  saliva  of  a man,  who  died  a few  minutes 
afterward  of  hydrophobia,  and  by  means  of  a bit  of 
rag,  they  conveyed  this  saliva  to  the  short  distance  of 
twenty  paces  from  the  patient’s  bed,  and  inoculated 
with  it  two  healthy  dogs.  One  of  the  dogs  became 
rabid  on  the  27th  of  July,  and  bit  two  others,  one  of 
which  was  attacked  with  complete  rabies  on  the  26th 
of  August. — (C.  Busmuu,  see  Collect,  des  Thises,  in 
410.  de  la  Faculti  de  Paris,  1814.)  It  is  remarked,  in 
the  work  from  which  I have  collected  these  particulars, 
that  the  foregoing  is  one  of  the  best  authenticated 
experiments  on  the  subject ; for,  in  addition  to  the  con- 
sideration of  the  talents  and  characters  of  the  experi- 
menters themselves,  the  facts  were  witnessed  by  nu- 
merous medical  students.  And  notwithstanding  the 
objections  which  have  been  urged  against  the  account 
(see  Journ.  Oin.  de  Mid.  t.  52,  p.  13),  the  main  points 
are  declared  to  he  entitled  to  credit. — (See  Diet,  des  Sci- 
ences Mid.  t.  47,  p.  48.  Also  Journ.  de  Physiologic, 
var  F.  Magendie,  t.  i.,p.42.) 

With  these  relations,  it  is  proper  to  notice  certain 
cases,  too  credulously  promulgated  as  proofs  of  the 
possibility  of  the  disease  being  communicated  from  one 
human  being  to  another.  Neither  the  instance  of  the 
maid-servant,  who  died  merely  from  seeing  her  mistress 
vomit  while  labouring  under  hydrophobia  {Mich.  Ett- 
muller.  Op.  Mid.  t.  2) ; the  case  of  the  pea.sani’s 
children,  who  all  died  on  the  seventh  day,  as  is  alleged, 
from  embracing  their  dying  father;  the  example  of  a 
woman  contracting  hydrophobia  from  her  husband,  as 
detailed  by  Mangor  {Acta  Soc.  Reg.  Hqfniens,  vol.  2, 
obs.  32,  p.  408) ; nor  other  cases  of  a similar  tenuur ; 


60 


HYDROPHOBIA. 


are  now  regarded  as  proving  any  thing  more,  than  that 
the  patients,  supposed  to  have  cauglit  the  disease  by 
contagion,  fell  victims  either  to  violent  affections  of  the 
mind  and  nervoiissystem,  or  illnesses  accidentally  taking 
place  soon  after  the  death  of  a near  relation  or  mistress. 
]t  is  clear  enough  also,  that  some  of  the  cases  were,  at 
most,  only  instances  of  symptomatic  hydrophobia. 

With  regard  to  another  opinion,  that  the  bite  of  a 
man  or  other  animal,  when  merely  enraged,  may 
bring  on  hydrophobia,  it  is  now  entirely  discarded  as 
erroneous.  The  cases  in  support  of  it,  recorded  by  Cl. 
Pouteau,  Mangetus,  Malpighi,  Zuinger,  Le  Cat,  &c., 
when  critically  examined,  only  prove  that  the  patients 
w'ere  affected  with  tetanus  or  symptomatic  hydropho- 
bia, not  arising  from  ^ny  infection  ; for,  neither  the 
mode  of  attack,  nor  the  progress  of  the  symptoms,  in 
any  of  the  examples,  w’hich  are  related  with  sufficient 
minuteness,  lead  to  the  inference,  that  the  patients 
actually  died  of  rabies. — (See  Diet,  des  Sciences  Mid. 
t.  47.  p.  49.) 

Wrong  notions,  of  a very  dangerous  tendency,  have 
been  generally  entertained  in  regard  to  the  disease,  as 
it  appears  in  the  canine  race.  The  writer  of  the  article 
Dog,  in  Dr.  Rees’s  Cycloptedia,  appears  to  have  had 
extensive  opportunities  of  observing  the  disorder  in 
dogs:  from  his  remarks  I have  collected  the  following 
information. 

The  peculiar  symptom  which  often  attends  the  com- 
plaint in  the  human  subject,  has  been  applied  to  the 
disease  in  the  dog,  and  has  occasioned  it  to  be  called 
by  the  same  name,  hydrophobia.  This  is  a palpable 
misnomer ; for  in  no  instance  does  there  ever  exist  any 
dread  of  water:  on  the  contrary,  dogs  are  in  general 
very  greedy  after  it.  Neither  have  sheep,  when  rabid, 
any  dread  of  water,  but  frequently  take  it  with  great 
freedom,  as  is  proved  by  some  experiments,  of  which 
an  account  is  given  in  Magendie’s  Journal.— (T.  8, 
p.  328.)  Such  unfounded  supposition  has  often  con- 
duced to  a very  fatal  error : for,  it  being  the  received 
opinion,  Uiat  no  dog  is  mad  who  can  lap  water,  many 
persons  have  been  lulled  into  a dangerous  security. 
Another  equally  false  and  fatal  idea  has  prevailed,  that 
every  mad  dog  must  be  wild  and  furious;  but  this  is 
so  far  from  being  true,  that  in  the  greater  number  of 
instances  there  is  very  little  of  that  xvild,  savage  fury 
that  is  expected  by  the  generality  of  persons.  “ Hence,” 
says  this  author,  “ as  it  is  evident  that  the  term  hydro- 
phobia, characterizing  the  affection  in  tlte  dog,  is  a 
misnomer,  so  it  is  evident  that  the  term  madness  is 
■equally  so.  In  no  instance  have  I ever  observed  a total 
alienation  of  the  mind ; in  very  few  have  the  mental 
faculties  been  disturbed.  The  disposition  to  do  mis- 
ehief  is  rather  an  increased  irritability  than  absence  of 
sense;  for,  in  most  instances,  even  those  that  are 
furious  acknowledge  the  master’s  voice,  and  are  obedi- 
ent.” The  symptom  which  is  most  frequently  first 
observable  in  a rabid  dog  is  a certain  peculiarity  in  his 
manner ; some  strange  departure  from  his  usual  habits, 
fu  a very  great  number  of  instances  the  peculiarity 
consists  in  a disposition  to  pick  up  straws,  bits  of  paper, 
rag,  threads,  or  the  smallest  objects  which  may  happen 
to  be  on  the  floor.  This  is  said  to  be  particularly 
common  in  small  dogs.  “ Others  again  show  an  early 
peculiarity  by  licking  the  parts  of  another  dog.  In  one 
instance  the  approach  of  the  disease  was  foretold  by 
cur  observing  a very  uncommon  attachment  in  a pug- 
puppy  towards  a kitten,  which  he  was  constantly 
licking;  and  likewise  the  cold  nose  of  a healthy  pug, 
that  was  with  him.  An  attachment  to  the  sensation 
of  cold  appears  in  many  cases,  it  being  very  common 
to  observe  them  (the  dogs)  licking  the  cold  iron,  cold 
stones,  &c.  Some  dogs,  early  in  the  disease,  will  eat 
their  own  excrement,  and  lap  their  owm  urine.”  An 
early  antipathy  to  strange  dogs  and  cats  is  very  com- 
monly observed,  but  particularly  to  cats.  As  the  dis- 
ease advances,  the  affected  dogs  bite  those  with  which 
they  are  domesticated,  and,  lastly,  the  persons  around ; 
but,  except  in  a moment  of  irritirbility,  they  seldom 
attack  the  human  subject.  The  irritability  that  induces 
them  to  bite  is  very  strong;  but  is  devoid  of  wildness. 
It  is  more  like  peevishness  than  fury.  A stick  held 
up  at  them  always  excites  their  anger  in  a violent 
degree,  and  throughout  the  disease  there  is  generally  a 
w'onderful  impatience  of  control,  and  the  animals  are 
with  great  difficulty  frightened.— (See  art.  Dog,  in 
Ree.t's  Cyclopcedia.)  In  sheep,  as  well  as  dogs,  a pe- 
culiar change  of  the  voice  is  regarded  as  one  of  the 


most  unequivocal  signs  of  the  distemper.— (See  Ma- 
gendie's  .Toum.  de  Physiol.  Exp.  t.  S,p.  330.) 

Dr.  John  Hunter  calculated,  that  out  of  every  dozen 
of  rabid  dogs  about  one  evinces  no  particular  tendency 
to  bite.  That  these  animals,  and  wolves  also,  have  no 
particular  dread  of  fluid,  is  proved  by  facts.  Thus,  a 
rabid  wolf,  at  Frejus,  swam  across  several  rivers. — 
(Darluc,  Recueil  Piriod.  d'  Observ.  vol.  4.)  Duboueix 
has  seen  mad  dogs  drink  without  difficulty,  and  plenti- 
fully.— (Hist,  de  la  Soc.  de  Mid.  an.  1783.)  Rabid 
animals  will  sometimes  eat  as  well  as  drink.  Thus, 
the  wolf  which  bit  so  many  persons  at  Meyne,  in  1718, 
was  found  in  the  morning  devouring  a shepherd’s 
dog.  And  Dr.  Gillman  speaks  of  a dog  which  was  not 
deemed  rabid  because  it  eat  and  drank  well : but,  as  it 
seemed  indisftosed,  it  was  killed,  though  not  before  it 
had  bit  a man,  who  fell  a victim  to  hydrophobia. — 
(On  the  Bite  of  a Rabid  Animal,  p.  15.) 

When  a dog  bites  a person,  it  should  not  be  immedi- 
ately killed,  but  merely  chained  up,  because  by  destroy- 
ing it  at  once,  the  possibility  of  ascertaining  whether  it 
was  rabid  is  prevented,  and  great  alarm  is  thus  kept 
up  in  the  minds  of  the  wounded  person  and  his  friends. 
If  the  animal  be  affected  with  rabies  it  will  perish  in  a 
few  days.  At  the  veterinarj'  school  at  Alfort,  when  a 
dog  hcis  been  bit,  it  is  usual  to  chain  it  up  for  at  least 
fifty  days  before  it  is  restored  to  its  master,  about  six 
weeks  being  considered  the  period  when  a dog  gene- 
rally becomes  rabid  after  being  bitten. 

My  friend  Mr.  St.  Aubyn  had  a large  New’foundland 
dog,  however,  which  did  not  become  rabid  till  seventy 
days  had  elapsed  from  the  period  when  it  was  bitten 
by  another  dog.  As  I saw  this  case,  and  am  minutely 
acquainted  wnth  the  particulars,  I consider  it  as  fur- 
nishing a useful  caution  against  placing  too  much 
confidence  in  the  plan  adopted  at  the  veterinary  school 
at  Alfort. 

For  additional  details,  relating  to  the  disease  as  it 
appears  in  the  dog,  I must  refer  to  the  above-mentioned 
paper.  Enough,  I hope,  has  been  said,  to  make  the 
reader  aware,  that  mad  dogs  are  not  particularly  cha- 
racterized by  an  inability  to  lap  water,  nor  by  any 
degree  of  fury.  These  animals,  w’hen  actually  affected 
with  rabies,  from  their  quiet  manner  have  even  not 
been  suspected  of  having  the  disorder,  and  have  been 
allowed  to  run  about,  been  fondled,  and  even  slept 
with. — (See  Mem.  of  Swedish  Acad.  1777.) 

The  causes  of  this  peculiar  distemper  in  dogs  are  at 
present  unknowm,  and  little  more  than  conjecture 
prevails  upon  the  subject.  It  is  not  positively  known 
whether  rabies  sometimes  originates  spontaneously 
in  these  animals,  though  I believe  this  opinion  is  at 
present  gaining  ground ; or  whether,  like  small  pox  in 
the  human  species,  it  is  propagated  only  by  contagion. 
That  the  disease  is  frequently  imparted,  in  con.sequence 
of  one  dog  biting  another,  every  body  well  knows; 
yet  there  are  many  instances  in  which  this  mode  of 
propagation  cannot  be  suspected.  Several  facts  render 
it  probable,  that  among  dogs,  the  disease  is  often  com- 
municated by  contagion.  It  is  observed,  that  in  insular 
situations  dogs  are  seldom  affected,  and  this  circum- 
stance is  ascribed  to  such  animals  being  in  a kind  of 
quarantine.  The  celebrated  sportsman,  Mr.  Meynell, 
secured  his  dogs  from  the  malady,  by  making  every 
new  hound  perform  a quarantine  before  he  was  suffered 
to  join  the  pack. — (See  Trans,  for  the  Improvement  of 
Med.  and  Chir.  Knowledge,  vol.  1,  art.  17.)  Great 
heat  was  very  commonly  supposed  to  be  an  exciting 
cause  of  the  disease  in  dogs;  but  without  much  found- 
ation. “A  very  hot  climate,  or  one  exposed  to  the 
extremes  of  heat  and  cold ; a verj'  hot  and  diy  season; 
feeding  upon  putrid,  stinking,  and  maggoty  flesh; 
want  of  water;  worms  in  the  kidneys^  intestines, 
brain,  or  cavities  of  the  nose,”  are  set  down  by  Boer- 
haave  as  causes  of  the  disease.— (v^yAori.'rm,  1134.) 
We  learn  from  Dr.  J.  Hunter,  that  in  the  hot  island  of 
Jamaica,  where  dogs  are  e.xceedingly  numerous,  not 
one  was  known  to  go  mad  during  forty  years. — 
( Trans,  for  the  Improvement  of  Med.  Knowledge,  loc. 
cit.)  Cold  weather  has  also  been  set  down  as  con- 
ducive to  rabies  among  the  canine  race,  as  is  suggested, 
because,  the  ponds  being  frozen,  these  animals  cannot 
quench  their  thirst. — (Le  Roux.)  That  neither  of 
these  sentiments  about  heat  and  cold  being  the  cause  of 
the  origin  of  the  disease  in  do”s,  is  correct,  will  be 
manifest  enoush  to  anybody  w’ho  has  patience  to  Iot)k 
over  the  volume  of  the  .^[im.  dc  la  Soc.  Royale  de  Mid. 


HYDROPHOBIA. 


61 


devoted  entirely  to  the  consideration  of  rabies;  and 
from  the  investigations  of  M.  Andry  {Recherches  sur 
la  Rage,  8vo.  Paris,  1780),  it  appears,  that  January, 
the  coldest  month  in  the  year,  and  August,  the  hottest, 
are  those  which  furnish  the  fewest  instances  of  liydro- 
phobia.  On  the  contrary,  the  greatest  number  of  rabid 
wolves  is  in  March  and  April ; and  that  of  dogs  affected 
with  spontaneous  rabies,  in  May  and  September. 

According  to  Savary,  dogs  never  go  mad  in  the  island 
of  Cyprus,  nor  in  that  part  of  Syria  which  is  near  the 
sea;  and  Volney  assures  us,  that  these  animals  enjoy 
the  same  fortunate  exemption  both  in  the  latter  country 
and  in  Egypt. — {Voyage  in  Syrie,  1. 1.)  The  traveller 
Brown  also  declares,  that  in  Egypt  they  are  never,  or 
very  rarely,  attacked  with  rabies. 

“ Although  (says  Baron  Larrey)  hydrophobia  is  more 
frequent  in  warm  than  temperate  climates,  it  is  not 
observed  in  Egypt;  and  the  natives  assured  us  that 
they  knew  of  no  instance  in  which  this  disease  had 
manifested  itself  either  in  man  or  animals.  No  doubt 
this  is  owing  to  the  species  and  character  of  the  dogs 
of  this  country,  and  their  manner  of  living. 

“ It  is  remarked,  that  the  Egyptian  dogs  are  almost 
continually  in  a state  of  inaction ; during  the  day  they 
lie  down  in  the  shade,  near  vessels  full  of  fresh  water 
prepared  by  the  natives.  They  only  run  about  in  the 
night-time:  they  evince  the  signs  and  effects  of  their 
love  but  once  a year,  and  only  for  a few  instants. 
They  are  seldom  seen  coupled.  On  our  arrival,  there 
was  a vast  number  of  these  animals  in  Egypt,  because 
they  were  held,  like  many  others,  in  great  veneration, 
and  were  never  put  to  death.  They  do  not  go  into  the 
houses:  in  the  daytime  they  remain  at  the  sides  of  the 
streets,  and  they  only  wander  into  the  country  at  night, 
in  order  to  find  any  dead  animals  which  happen  to  be 
uiiburied.  Their  disposition  is  meek  and  peaceable, 
and  they  rarely  fight  with  each  other.  Possibly,  all 
these  causes  may  exempt  them  from  rabies.” — [Larrey, 
in  M^m.  de  Chir.  Militaire,  t.%p.  226.) 

This  observation  about  the  exemption  of  the  Egyp- 
tian dogs  from  rabies  is  very  ancient,  having  been  made 
by  Prosper  Alpinus. — [Rer.  JEgyptiarum,  lib.  4,  cap.  8.) 
According  to  Barrow,  the  dogs  in  the  vicinity  of  the 
Cape  of  Good  Hope,  and  in  Caffiaria,  very  rarely  go 
mad. — [Travels  into  the  Interior  of  .Africa.)  Several 
authors  assert  that  rabies  never  occurs  in  South  Ame- 
rica.— [Bibl.  Raisonnde,  1750.  Van  Swieten,  Comment, 
in  Aphor.  1129.  Portal,  Src.)  L.  Valentin  declares, 
that  it  is  exceedingly  rare  in  the  warm  regions  of 
America,  but  common  in  the  northern  part  of  that 
continent. — [Journ.  Gdn.  de  Jildd.  t.30.)  Dr.  Thomas, 
who  resided  a good  while  in  the  West  Indies,  never 
saw  nor  hoard  of  a case  of  rabies  there  [Practice  of 
Physic) ; and  Dr.  B.  Moseley  states,  that  the  disorder 
was  not  known  in  those  islands  down  to  1783.  On  the 
other  hand,  me  disease  sometimes  happens  in  the  East 
Indies,  though  not  with  such  frequency  as  at  all  to 
justify  the  doctrine  about  heat  being  the  cause  of  its 
production.  The  silence  of  Hippocrates  proves,  that 
in  his  days  hydrophobia  must  have  been  very  rare  in 
Greece;  and,  as  the  disorder  is  not  mentioned  in  the 
Scriptures,  an  inference  may  be  made,  that  it  could  not 
be  so  common  in  the  hot  tracts  of  the  globe,  inhabited 
by  the  Hebrews,  as  in  the  temperate  climate.?  of  Europe 
and  America. 

Neither  can  the  sentiment  be  received  as  correct,  that 
rabies  is  more  frequent  in  the  north  than  in  the  tem- 
perate parts  of  Europe ; for  De  la  Fontaine  particu- 
larly notices  how  extremely  rare  it  is  in  Poland.— 
[Chir.  Jiled.  Abhandl.  Breslau,  1792.)  The  disease  is 
reported  to  be  very  common  in  Prussian  Lithuania; 
but  mad  docs  are  seldom  or  never  heard  of  at  Arch- 
angel, Tobolsk,  or  in  the  country  north  of  St.  Peters- 
burg. 

In  Mr.  Meyncll’s  account,  which  was  communicated 
to  him  by  a physician,  it  is  asserted,  that  the  complaint 
never  arises  from  hot  weather,  nor  jmtrid  provisions, 
nor  from  any  cause  except  the  bite  ; for,  however  dogs 
have  been  confined,  Iiowever  fed,  or  whatever  may 
have  been  the  heat  of  the  season,  the  disorder  never 
commenced  with.out  a possibility  of  tracing  it  to  the 
preceding  cause,  nor  was  it  ever  introduced  into  the 
kennel,  except  by  the  bite  of  a mad  dog.  (See  art. 
Dog,  ill  Rees’s  Cyclopatdia.) 

Dr.  Gillman  endeavours  to  prove,  that  the  disease 
In  does  is  probably  excited  independently  of  particular 
climates,  of  putrid  aliment,  of  deficiency  of  water,  of 


want  of  perspiration,  or  of  the  worm  under  the  tongue, 
to  which  causes  it  has  been  at  different  times  ascribed  ; 
and  he  expresses  his  belief,  that  it  originates  some- 
what like  typhus  in  the  human  subject,  and  is  not  al- 
ways produced  by  inoculation,  or  by  means  of  a bite. 
He  thinks,  that  it  may  be  occasionally  brought  on  by 
the  confinement  of  dogs,  without  exercise,  in  close  and 
filthy  kennels  ; and  that  the  success  of  Mr.  Trevalyan, 
as  related  by  Dr.  Bardsiey,  in  clearing  Ids  kennel  of 
the  disease,  by  changing  even  the  pavement,  after 
other  means  of  purification  had  failed,  affords  pre- 
sumptive evidence  in  favour  of  the  opinion  ; and,  con- 
sequently, this  author  thinks,  that  the  method  of  qua- 
rantine, adopted  by  Mr..  Meynell,  and  recommended  by 
Dr.  Bardsiey,  on  the  supposition  that  the  disease  origi- 
nates exclusively  from  contagion,  will  not  be  a suffi- 
cient preventive  alone : and  he  infers,  from  some 
facts  reported  by  Mr.  Daniel,  that  the  poison  some- 
times lies  dormant  in  dogs,  four,  five,  and  six  months; 
and,  consequently,  that  the  period  of  two  months  is 
not  a sufficient  quarantine.— (See  Oillman’s  Diss.  on 
the  Bite  of  a Rabid  Animal.) 

In  opposition,  however,  to  some  of  the  sentiments 
contained  in  the  foregoing  passage,  it  should  be  known, 
that  Dupuytren,  Magendie,  and  Breschet  have  pur- 
posely kept  many  dog:s  for  a long  time  in  the  most 
disgusting  state  of  uncleanliness,  let  them  even  die  in 
this  condition  for  want  of  food  and  water,  or  even 
devour  each  other,  yet  without  exciting  rabies. — 
[Diet,  des  Sciences  Med.  t.  47,  p.  53.)  Yet  Professor 
Rossi,  of  Turin,  is  said  to  have  produced  this,  or  some 
similar  disease,  in  cats,  by  keeping  them  shut  up  in  a 
room. — [M6m.  de  VAcad.  Imp.  de  Turin,  1805  d 1808, 
j).  93.  dc  la  JVotice  des  Travaux.)  On  the  whole,  I con- 
sider it  well  proved,  that  neither  long  thirst,  hun- 
ger, eating  putrid  flesh,  nor  filth,  will  occasion  the 
disease  in  the  canine  race.  At  Aleppo,  where  these 
animals  perish  in  great  numbers  from  want  of  food 
and  water,  and  the  heat  of  the  climate,  the  distemper 
is  said  to  be  unknown.  Nor  is  rabies  found  to  attack 
dogs  and  cats  with  particular  frequency  during  the 
copulating  season,  and,  therefore,  the  oestrus  veneris 
cannot  be  admitted  to  have  any  share  in  its  production, 
as  some  writers  have  been  disposed  to  believe. — (See 
Diet,  des  Sciences  Mdd.  t.  47,  p.  55.) 

Although  most  writers  believe  in  the  reality  of  a 
poison,  or  specific  infectious  principle,  in  cases  of  ra- 
bies, the  fact  has  been  questioned,  or  absolutely  re- 
jected by  others.  Bosquillon  considered  the  disease 
always  as  the  effect  of  fear,  or  an  impression  upon  the 
imagination.  This  view  of  the  matter  is  far  from 
being  new,  and  has  been  ably  refuted  by  many  authors, 
and  especially  by  M.  Desault,  of  Bourdeaux,  who  re- 
marks, that  horses,  asses,  and  mules,  quibus  non  cst 
intellectus,  had  died  rabid  the  very  year  in  which  lie 
wrote;  and  it  is  observed  by  Dr.  J.  Vaughan,  that  an 
infant  in  the  cradle  is  sometimes  attacked,  while  many 
timorous  children  escape. 

A nother  notion  has  partially  prevailed,  that  rabies  does 
not  depend  upon  any  virus,  but  upon  the  continuance 
of  an  irritation  iti  the  bitten  parts,  affecting  the  whole 
nervous  system.— (P«-c?T;aI ; J.  Mease  ; Girord ; (J-c.) 
But  this  doctrine  confounds  rabies  and  tetanus  to- 
gether, and  can  only  apply  to  the  symptomatic  non- 
infectious  hydrophobia  from  an  ordinary  wound  or 
laceration. 

The  facts,  in  proof  of  the  reality  of  a peculiar  infec- 
tious principle  in  cases  of  rabies,  are  too  numerous  to 
leave  any  doubt  upon  the  subject.  Twenty-three  in- 
dividuals were  bit  one  morning  by  a female  wolf,  of 
whom  thirteen  died  in  the  course  of  a few  month.?, 
besides  several  cows,  which  had  been  injured  by  the 
same  animal.  How  could  all  these  unfortunate  per- 
sons have  had  similar  symptoms,  and  especially  a hor- 
ror of  fluids,  had  they  not  been  all  under  the  influence 
of  some  cause,  besides  the  bites?  The  patients  who 
died  were  bit  on  the  naked  skin  ; while  in  the  others, 
who  escaped  infection,  the  bites  happened  through 
their  clothes,  which  no  doubt  intercepted  the  saliva, 
the  vehicle  of  the  virus.  In  the  essay  by  Le  Roux, 
mention  is  made  of  three  persons,  bit  by  a rabid  wolf 
near  Autun,  in  July,  1781,  and,  uotwithstanding  mer- 
curial frictions,  they  all  died  of  hydrophobia.  Of  ten 
other  individuals  bit  by  a wolf,  nine  died  rabid. — 
[Rcy,  Mim.  dc  la  Soc.  Roy  ale  de  MM.  p.  147.)  Twen- 
ty-four persons  were  injured  in  the  satne  manner  near 
liochelle,  and  eighteen  of  them  perished.— (jSjidry, 


62 


HYDROPHOBIA. 


Recherchce  sur  Ic  Rage^  ed.  3,  p.  196.)  On  the  27th 
January,  1780,  fifteen  individuals  were  bit  by  a mad 
dog,  and  attended  at  Senlis  by  the  commissioners  of 
the  French  Royal  Society  of  PJiysic  ; ten  had  received 
the  bites  on  the  naked  flesh,  and  five  through  their 
clothes.  Of  the  first  ten,  only  five  lost  their  lives,  three 
of  them  dying  of  decided  rabies  between  the  27th  of 
February  and  the  3d  of  April ; and  the  other  two  be- 
tween the  29th  of  February  and  the  18th  of  March. 
Unless  the  opinion  be  adopted,  that  the  disease  is 
caused  by  an  infectious  principle,  a sort  of  inoculation, 
it  would  be  impossible  rationally  to  explain  the  cause 
of  so  many  deaths  from  the  bites  of  rabid  animals.  If 
the  idea,  that  rabies  originates  from  fear,  or  nervous 
irritation,  were  true,  how  could  we  account  for  there 
being  such  a difference  between  the  usual  consequences 
of  the  bite  of  a healthy  dog,  and  those  of  the  bite  of 
one  affected  with  rabies  1 Ilealtliy  dogs  are  inces- 
santly quarrelling,  and  biting  each  other  in  the  streets, 
yet  their  wounds  are  not  followed  by  rabies  ; and,  as 
a modern  author  remarks,  if  hydrophobia  were  refer- 
able to  nervous  irritation  derived  from  the  wounded 
part,  how  does  it  happen,  that,  among  the  thousands 
of  wounded  after  a great  battle,  hydrophobia  is  not 
seen  instead  of  tetanus  des  Sciences  Med. 

t.  47,  p.  61.)  But  if  it  were  yet  possible  to  entertain  a 
doubt  of  an  infectious  principle  in  hydrophobia,  this 
possibility  would  be  removed  by  the  reflection,  that 
the  disease  may  be  communicated  to  healthy  animals 
by  inoculating  them  with  the  saliva  of  certain  other 
rabid  animals.  In  fact,  as  I have  stated,  the  bites  of 
such  animals  are  in  every  point  of  view  only  an  inocu- 
lation ; and  the  same  remark  may  be  extended  to  the 
numerous  instances  on  record,  in  which  the  disease 
arose  in  the  human  subject,  as  a consequence  of  a rabid 
dog  or  cat  (not  suspected  to  be  in  this  state  at  the  time) 
having  been  played  with,  fondled,  or  suffered  to  lick 
the  naked  skin,  in  which  there  was  at  the  moment 
some  slight  scratch,  entirely  overlooked. 

Many  of  the  ancient  writers  not  only  believed  in  the 
hydrophobic  virus,  or  infectious  principle,  but  even  in 
its  diffusion  through  the  blood,  flesh,  and  secretions  in 
general ; and  this  hypothesis  was  professed  by  Boer- 
haave.  Van  Swieten,  Sauvages,  F.  Hoffman,  &c. ; but, 
in  proportion  as  the  humoral  pathology  lost  ground, 
the  foregoing  idea  was  abandoned,  and  the  opinion 
adopted,  that  the  infection  is  confined  to  the  saliva, 
and  wounded  part,  in  which  it  has  been  inserted. 

The  tales  of  some  old  authors  would  lead  one  to 
think,  that  hydrophobia  may  be  communicated  by  eat- 
ing the  flesh  of  a rabid  animal. — {Fer?ielius,  De  Obs. 
Rer.  Cans,  et  Morb.  Epidem.  lib.  2,  cap.  14 ; Schenck- 
ius  Mangetus,  (S'c.)  But  respecting  these  accounts,  it 
is  remarked,  that  they  are  not  entitled  to  much  confi- 
dence ; for  it  is  certain  that  rabies  never  begins,  as  is 
stated  with  regard  to  some  of  the  cases  in  question,  a 
few  hours  after  the  application  of  its  cause,  and  its 
early  stage  is  never  characterized  by  any  fury,  or  dis- 
position to  bite.  And,  besides,  how  can  such  relations 
be  reconciled  with  the  practice  of  the  ancients,  who, 
according  to  Pliny,  employed  the  liver  of  the  mad  dog, 
or  wolf,  as  a remedy  ? Palmarius  also  fed  his  patients 
for  three  days  with  the  dried  blood  of  the  rabid  ani- 
mal.— {M6m.  de  la  Soc.  de  Mid.p.  136  ; et  le  JVu.  178.) 
The  flesh  of  a bullock,  which  had  been  bit  by  a mad 
dog,  and  afterward  died  rabid,  was  sold  to  the  inhabit- 
ants of  Medola  near  Mantua,  yet  none  of  them 
were  attacked  with  hydrophobia. — iJivdry.,  Recherches 
sur  la  Rage.,  Src.  p.  30.)  Dr.  Le  Camus  informed  Lar- 
rey,  that  he  had  eaten  the  flesh  of  animals,  which  died 
rabid,  but  he  suffered  no  inconvenience  from  the  expe- 
riment. And  it  is  stated  in  the  letter  of  Dr.  L.  Valen- 
tin, that  certain  negroes  in  the  United  Statesof  America 
had  no  illness  from  eating  the  flesh  of  pigs  which  had 
died  of  rabies. — (Journ.  Gin.  de  Mid.  t.  30,  p.  417.)  As 
for  the  question,  whether  the  blood  is  infected  ? it  is  ge- 
nerally considered  to  be  settled  in  the  negative,  notwith- 
standing the  account  given  by  L^mery  of  a dog,  which 
was  attacked  with  rabies,  as  is  said,  from  lapping  the 
blood  of  a hydrophobic  patient,  who  had  been  bled. — 
{Hist,  de  I'Jlcad.  Roy  ale  des  Sciences,  1707,  p.  25.) 
Dupuytren,  Breschet,  and  Magendiewere  never  able 
to  communicate  rabies  by  rubbing  wounds  with  blond 
taken  from  mad  dogs;  and  they  even  several  times  in- 
jected such  blood  into  the  veins  of  other  healthy  dogs, 
yet  none  of  these  latter  animals  were  attacked  with 
rabies,  though  they  were  keot  for  a sufficient  length  of 


time  to  leave  no  doubt  upon  the  subject.— (See  DicL 
des  Sciences  Mid.  t.  47,  p.  63.) 

A point  of  greater  practical  interest  than  the  former 
is,  whether  the  drinking  of  the  milk  of  an  animal,  la- 
bouring under  rabies,  is  attended  with  any  risk  of  com- 
municating the  disease  1 It  is  asserted  by  Timteus, 
that  a peasant,  his  w ife,  children,  and  several  other 
persons,  were  seized  with  hydrophobia,  in  consequence 
of  drinking  the  milk  of  a rabid  cow  ; and  that  the  hus- 
band and  eldest  child  were  saved  by  medical  treatment ; 
but  that  the  v\’ife  and  four  of  the  children  died.  It  is 
farther  stated,  that  three  or  four  months  afterward, 
the  maid  and  a neighbour,  who  had  partaken  of  the 
milk  of  the  same  cow,  also  died  of  hydrophobia. — {Cons. 
7,  obs.  33.)  In  opposition  to  this  account,  however, 
several  facts,  reported  by  other  writers  of  greater  cre- 
dit, tend  to  prove,  that  hydrophobia  cannot  be  commu- 
nicated by  the  milk  of  a rabid  animal. — {Mova  .^cta 
JVat.  Cur.  voi.  1,  obs.  55;  Baudot,  in  Mini,  de  la  Soc. 
Roy  ale  de  Mid.  an.  1782  et  83,  t.  2,  p.  91./ 

The  cases  reported  by  F.  Hoffman  and  Chabert, 
with  the  view  of  proving  the  possibility  of  infection 
through  the  medium  of  the  semen,  are  of  no  weight, 
because,  on  a critical  examination  of  them,  it  will  be 
found,  that  the  infection  of  the  W'omen  is  stated  to 
have  taken  place  very  soon  after  their  husbands  had 
been  bit,  which  is  quite  at  variance  with  the  esta- 
blished character  of  the  disease,  as  it  never  commences, 
and  of  course  cannot  be  propagated  in  any  manner, 
soon  after  the  receipt  of  the  bite.  Besides,  these  his- 
tories are  refuted  by  others  of  greater  accuracy. — (See 
Baudot,  in  Mim.  de  la  Soc.  Royale  de  Mid.  an.  1782, 
<S-c.  p.  92.  Rioallier,  vol.  cit.  p.  136.  211.  Bouteille, 
p.  237.  Boissiire,  in  Journ.  Gin.  de  Mid.  1. 17,  p.  296.) 

Neither  can  hydrophobia  be  imparted  by  the  breath, 
notwithstanding  the  statements  of  Cajlius  Aurelianus, 
and  some  other  old  writers.  A nurse,  mentioned  by 
Dr.  J.  Vaughan,  repeatedly  kissed  a hydrophobic  in- 
fant, which  she  had  suckled,  and  exposed  herself  inces- 
santly to  its  breath,  but  without  the  least  ill  eflects. 
The  fear  which  has  also  been  entertained,  of  the  dis- 
order being  receivable  from  the  application  of  the 
patient’s  perspiration  to  the  skin,  is  not  founded  upon 
any  authentic  facts. 

Does  the  infectious  principle  of  rabies  reside  in  the 
salivary  secretion,  or  in  the  mucus  of  the  trachea  and 
bronchiae?  The  common  belief  is,  that,  in  hydropho- 
bia, the  salivary  glands  are  considerably  aftected.  But, 
it  has  been  remarked  by  a modern  writer,  that  if  these 
glands  exhibit  no  morbid  alteration  during  the  whole 
course  of  the  disorder ; if  they  are  found  healthy  after 
death;  if  the  air- passages  are  the  seat  of  inflamma- 
tion ; if  the  saliva  does  not  constitute  the  frothy  slaver 
about  the  lips ; and  if  such  slaver,  wherewith  the 
disease  may  be  communicated  by  inoculation,  is  de- 
rived from  the  inflamed  windpipe  and  bronchi®,  and 
consists  of  mucus  converted  into  a kind  of  foam  by 
the  convulsive  manner  in  which  the  patient  breathes  ; 
there  is  some  reason  for  questioning  whether  the  sa- 
liva, strictly  so  called,  undergoes  the  alteration  gene- 
rally supposed. — (See  Diet,  des  Sciences  Mid.  t.  47, 
p.  66.)  However,  this  writer  is  not  exactly  correct, 
when  he  describes  the  frothy  secretion  about  the  mouth, 
as  being  altogether  composed  of  mucus  from  the  tra- 
chea, since  a great  part  of  it  is  unquestionably  true 
saliva  and  mucus  secreted  in  the  fauces  and  mouth. 
In  the  stomachs  of  dogs,  which  died  rabid.  Dr.  Gillman 
constantly  observed  traces  of  inflammation,  and  he 
once  tried  to  communicate  the  disease  to  two  rabbits, 
by  inoculating  them  with  matter  taken  from  pustules 
found  in  the  stomach  of  a rabid  dog  ; but  no  infection 
took  place. — {On  the  Bite  of  a Rabid  .dnivial,  p.  32.) 

According  to  professor  Rossi  of  Turin,  the  nerves 
“before  they  grew  cold,  participated  with  the  saliva 
in  the  property  of  communicating  rabies.”  He  asserts, 
that  he  once  imparted  the  disease  by  inserting  in  a 
wound  a bit  of  the  sciatic  nerve,  immediately  after  it 
had  been  taken  from  a living  rabid  cat. — (See  Mim.de 
I'Jicad.  Imp.  de  Turin,  Sciences,  Phys.  et  Mat  him.  de 
1805  d 1808,  part  93,  de  la  Motice  des  Travaux.) 

After  all  which  has  been  stated  concerning  the  hypo- 
thesis of  the  infectious  principle  of  hydrophobia  being 
more  or  less  diffused  through  the  solids  and  fluids  of  a 
rabid  animal,  and  not  being  restricted  to  the  saliva, 
perhaps  the  safest  conclusion  to  be  made  is,  not  to 
reject  the  opinion  altogether,  but  to  consider  it  as  at 
[iresent  requiring  farlhev  proof.  And  from  observa- 


HYDROPHOBIA.  63 


Uons  of  what  happens  in  the  human  subject,  the  same 
inferences  should  not  always  be  drawn,  as  from  expe- 
riments on  animals,  which  are  liable  to  be  attacked 
with  spontaneous  rabies  of  a decidedly  infectious 
character. — (See  Diet,  des  Sciences  Med.  t.  4:7,  p.  67.) 

Although  many  cases  are  to  be  met  with  in  tlie 
records  of  medicine  and  surgery,  tending  to  convey  an 
idea,  that  the  mere  application  of  the  saliva  of  a rabid 
animal  to  the  sound  entire  skin  of  the  human  subject, 
may  give  rise  to  hydrophobia,  the  assertion  is  contrary 
to  general  experience,  and  liable  to  a reflection  which 
must  overturn  the  hypothesis;  viz.  the  slightest  prick, 
scratch,  abrasion,  or  broken  pimple  on  the  surface  of 
the  body,  such  as  would  not  be  likely  in  many  in- 
stances to  excite  notice,  may  render  the  application  of 
the  saliva  to  the  part  a positive  inoculation. 

Instances  are  also  reported,  the  tenour  of  which  is  to 
prove,  that  the  hydrophobic  virus  may  take  effect 
through  a sound  mucous  membrane. — {Palmarius,  de 
Morbis  Contag. ; Portal,  Obs.  sur  la  Rage,  p.  131  ; 
Matthieu  in  Mini,  de  la  Soc.  Royale  de  Mdd.  p.  310, 
^c.)  But  that  this  does  not  happen  in  the  human  sub- 
ject is  tolerably  well  proved  by  the  consideration,  that 
formerly  a class  of  men  made  it  their  business  to  suck 
the  wounds  cairsed  by  the  bites  of  rabid  animals;  yet 
none  of  them  contracted  hydrophobia  from  this  bold 
employment. — (Bosqtiillon,  Mim.  de  la  Soc.  d' Emula- 
tion, t.  5,  p.  1.)  'rire  example  of  the  nurse,  who  re- 
peatedly kissed  a child  without  the  least  ill  effect, 
while  it  was  dying  of  rabies,  as  recorded  by  Dr.  J. 
Vaughan,  has  been  already  noticed.  However,  if 
hydrophobia  were  apparently  to  arise  in  atry  rare  in- 
stance from  the  application  of  the  slaver  of  a rabid 
animal  to  the  inside  of  the  lips,  no  positive  inference 
could  be  drawn  from  the  fact,  unless  the  means  were 
also  possessed  of  ascertaining  that  there  were  no  slight 
abrasion  about  the  gums,  or  within  the  mouth,  pre- 
viously to  such  application. 

For  the  hydrophobic  virus  to  take  effect,  therefore, 
it  is  generally,  if  not  always  necessary,  that  the  infec- 
tious saliva  be  either  applied  to  an  abraded,  wounded, 
or  ulcerated  surface.  In  the  case  of  a bite,  the  teeth 
are  the  envenomed  weapons,  which  at  once  cause  the 
solution  of  continuity,  and  deposite  the  infection  in  the 
part.  But  the  mere  abrasion  of  the  cuticle,  and  the 
application  of  the  infectious  saliva  to  the  denuded 
cutis,  will  often  suffice  for  the  future  production  of  Jhe 
disease.  As  the  mode  of  communication,  therefore, 
is  a true  inoculation,  it  follows,  that  the  danger  must 
depend  very  much  upon  the  quantity  of  infectious 
matter  conveyed  into,  or  applied  to  the  part,  the  effec- 
tual manner  in  which  the  saliva  is  lodged  in  the  flesh, 
the  extent  and  number  of  the  wounds,  and  particularly 
the  circumstance  of  the  teeth  of  the  rabid  animal 
having  passed  through  no  clothes,  by  which  the  saliva 
might  possibly  be  effectually  prevented  from  entering 
the  wound  at  all.  Hence,  bites  on  the  hands  and  face 
are  well  known  to  be  of  the  most  dangerous  descrip- 
tion, especially  those  on  the  face,  the  hands  being 
sometimes  protected  with  gloves. 

Fro-n  what  has  been  observed,  however,  it  is  not  to 
be  concluded  that  the  disea.se  always  follows,  even 
when  the  animal  which  inflicts  the  bite  is  decidedly 
rabid,  and  some  of  its  saliva  is  actually  applied  to  the 
wounded  or  abraded  parts.  On  the  contrary,  experience 
fully  proves,  that  out  of  the  great  number  of  individu- 
als often  bit  by  the  same  mad  dog,  and  to  whom  no 
effectual  proidiylactic  measure  is  extended,  only  a 
greater  or  less  number  are  afterward  attacked  with 
hydrophobia.  When  tliis  diflerence  in  the  fate  of  the 
individuals  cannot  be  explained  by  the  intervention 
of  their  clothes,  the  thickness  of  the  cuticle  at  the  in- 
jured part,  the  small  size  and  superficial  nature  of  the 
bite,  the  ablution  of  the  pari,  or  some  other  mode  in 
which  any  actual  inoculation  may  have  been  rendered 
ineffectual,  it  can  only  be  referred  to  some  unknown 
peculiarities  or  differences  in  the  constitutions  of  the 
several  individuals.  The  latter  conjecture  seems  more 
probable  when  the  fact  is  recollected  that  some  ani- 
mals are  more  susceptible  of  rabies  than  others,  and 
some  appear  to  resist  the  infection  altogether. 

Dogs  are  more  susceptible  of  the  infection  than  the 
human  species.  Four  men  and  twelve  dogs  were^bit 
by  the  same  mad  dog,  and  every  one  of  the  dogs  died 
of  the  dih(;ase,  while  all  llie  four  lueti  escai)ed,  {hough 
they  used  no  other  means  of  |irevention  but  such  as 
we  see  every  day  fail.  There  is  also  an  instance  of 


twenty  persons  being  bit  by  the  same  mad  dog,  of  whom 
only  one  had  the  disease. 

Dr.  Heysham  has  defined  hydrophobia  to  be  an  aver- 
sion and  horror  at  liquids,  exciting  a painful  convulsion 
of  the  pharynx,  and  occurring  at  an  indeterminate 
period  after  the  canine  virus  has  been  received  into 
the  system.  Dr.  Cullen  places  it  in  the  class  neuroses, 
and  order  spasnii,  and  defines,  it,  a loathing  and  great 
dread  of  drinking  any  liquids,  from  their  creating  a 
painful  convulsion  of  the  pharynx,  occasioned  most 
commonly  by  the  bite  of  a mad  animal.  Others  have 
suggested  the  following  definition  as  more  complete: 
melancholy,  dread  of  cold  air,  of  any  thing  shining, 
and  particularly  of  water;  often  arising  from  the  bite 
of  a mad  animal. — {Parr's  Med.  Diet.)  However, 
the  latter  definition  is,  perhaps,  equally  objectionable, 
because  there  is  not  invariably  a dread  of  shining 
bodies. — (See  Dr.  Powell's  Case,  p.  8.)  While  some 
authors  represent  it  as  a nervous  disorder,  others, 
among  whom  is  Boethaave,  consider  it  as  one  of  an 
inflammatory  nature.  In  many  systems  of  surgery, 
hydrophobia  is  treated  of  with  poisoned  wounds,  of 
one  species  of  which  it  is  strictly  the  effect. 

With  regard  to  the  symptoms  of  hydrophobia,  they 
are  generally  tardy  in  making  their  appearance,  a con- 
siderable, but  a very  variable,  space  of  time  usually 
elapsing  between  their  commencement  and  the  receipt 
of  the  bite.  Out  of  a table  of  131  cases,  none  of  the 
patients  became  ill  before  the  eleventh  day  after  the 
bite,  and  only  three  before  the  eighteenth.  It  is  pre- 
tended by  Pouteau,  that  one  patient  was  bit  by  a dog 
in  the  morning,  and  was  attacked  with  hydrophobia  at 
three  o’clock  in  the  afternoon.  But  as  this  account 
was  communicated  to  the  author  a long  time  after  the 
occurrence,  and  not  by  a medical  man,  it  deserves 
little  confidence.  Another  case,  adverted  to  by  Mead,  is 
deprived  of  all  its  importance  by  the  same  consider- 
ation. These  examples,  as  well  as  another  reported 
by  Astruc,  in  which  the  patient  is  said  to  have  had 
hydrophobia  in  less  than  three  days,  after  being 
wounded  on  the  temples,  can  at  most  be  regarded  only 
as  specimens  of  symptomatic  hydrophobia.— (Z>?ct.  des 
Sciences  M6d.  t.  47,  p.  74.)  There  appears  to  be  no 
determinate  period  at  which  the  disorder  makes  its 
attack  after  the  bite;  but  it  is  calculated,  that  the 
symptoms  most  frequently  commence  between  the 
thirtieth  and  fortieth  days,  and  that  after  this  time  the 
chances  of  escape  increase.  Of  fifteen  patients,  whose 
ca.ses  Trolliet  was  acquainted  with,  seven  were  at- 
tacked between  the  fourteenth  and  thirtieth  days;  five 
between  the  thirtieth  and  fortieth ; two  a little  beyond 
the  latter  period ; and  one  after  fourteen  weeks.  In 
May,  1784,  seventeen  persons  were  bit  by  a rabid 
wolf  near  Brive,  of  whom  ten  were  afterward  at- 
tacked with  hydrophobia ; viz.  one  on  the  fifteenth 
day  after  the  bite;  one  on  the  eighteenth  ; one  on  the 
ninteenth ; one  on  the  twenty-eighth  ; one  on  the 
thirtieth;  one  on  the  thirty-third;  one  on  the  thirty- 
fifth  ; one  on  the  forty-fourth  ; one  on  the  fifty-second  ; 
and  the  last  on  the  sixty-eighth  day. — {Hist,  de  la 
Soc.  Royale  de  Med.  p.  209.)  Fothergill  and  Moseley 
mention  cases  in  which  the  disease  began  four  months 
after  the  bite;  and  M.  Matthey  of  Geneva  details  an 
instance  in  which  the  interval  was  117  days. — {.Journ. 
Gin.  t.  54,  p.  275.)  Haguenot  knew  of  a case  in 
which  the  interval,  between  the  bite  and  the  commence- 
ment of  the  illness,  was  five  months. — {Portal,  p.  183.) 
Dr.  J.  Vaughan  mentions  an  interval  of  nine  months ; 
Mead  of  eleven ; Galen,  Bauhin,  and  Brnssidre,  of  a 
year ; Nourse  of  nineteen  months;  and  R.  Lentilius,  of 
three  years. 

Dr.  Bardsley,  of  Manchester,  has  recorded  a case,  in 
which  the  most  careful  inquiries  tended  to  prove, 
that  the  patient  had  never  suffered  the  least  injury  front 
any  animal,  except  the  bile  inflicted  twelve  years  pre- 
viously to  the  commencement  of  the  hydrophobia,  by 
a dog  apparently  mad. — {Mem.  of  Liter,  and  Phil. 
Society  of  Manchester,  vol.  4,  part  ^2,,p.  431.) 

A merchant  of  Montpellier  is  also  stated  to  have  been 
attacked  with  hydrophobia  ten  years  after  the  bite  of  a 
rabid  dog,  which  also  bit  the  patient’s  brolher,  who 
died  hydrophobic  on  the  fortieth  day  after  the  accident. 
— (See  Diet,  des  Sciences  Mid.  t.  47,  p.  75 ) Here  may 
also  be  found  references  to  cases,  in  which  the  interval 
is  alleged  to  have  been  eighteen,  twenty,  and  even 
thirty  years.  It  is  certainly  ditfrcult  to  attach  any 
crediMo  these  very  lale  periods  of  attack.  Dr.  J.  Ifun- 


64 


HYDROPHOBIA. 


ter  considers  seventeen  months,  and  Dr.  Hamilton 
nineteen,  the  longest  interval  deserving  belief.— (Ow 
Hydrophobia.,  vol.  1,  p.  113.)  Exposure  to  the  heat  of 
the  sun,  violent  emotions  of  the  mind,  and  fear,  are 
believed  to  have  considerable  influence  in  accelerating 
the  commencement  of  the  symptoms.  Tliat  mental 
alarm  is  also  of  itself  sometimes  capable  of  bringing  on 
a simple  hydrophobia,  totally  unconnected  with  infec- 
tion, is  incontestable;  a case  which  has  not  always 
been  duly  discriminated.  A most  convincing  proof  of 
this  fact  is  recorded  by  Barbantini,in  the  Italian  Journ. 
of  Physic,  Chemistry,  Src.  for  January  and  February, 
1817.  A young  man  was  bit  by  a dog  which  he  fancied 
was  mad,  and  on  the  fifth  day  he  evinced  symptoms 
of  hydrophobia,  of  which  he  was  nearly  dying,  when 
the  dog  which  had  bit  him  was  shown  to  him  perfectly 
well,  and  the  intelligence  tranquillized  him  so  effectu- 
ally, that  he  was  quite  well  four  days  afterward.  Mr. 
John  Hunter  is  said  to  have  mentioned  in  his  lectures 
a very  similar  case,  in  which  he  believed  the  patient 
would  certainly  have  died,  if  the  dog,  which  inflicted 
the  bite,  had  not  been  found  and  shown  to  the  patient 
perfectly  well. — (See  Journ.  Oin.  de  MM.  t.  41,  p. 
215.)  It  is  to  the  effects  of  terror  that  several  modern 
writers  are  disposed  to  refer  the  instances  of  very 
late  attacks  of  hydrophobic  symptoms  after  the  period 
when  the  patients  were  bitten;  though,  unless  the  in- 
tellects be  changed  in  the  mean  time  by  other  causes, 
it  is  difficult  to  conceive,  why  the  alarm  should  not 
have  the  greatest  effect  earlier,  while  the  impression 
of  the  danger  is  undiminished  by  time.  The  idea,  that 
the  symptoms  begin  sooner  after  the  bite  of  a wolf 
than  that  of  a dog,  is  not  adopted  by  a writer  who  has 
taken  great  pains  to  collect  information  on  the  present 
interesting  disorder.— (See  Diet,  des  Sciences  MM.  t. 
47,  p.  77.) 

Cullen  has  divided  the  disease  into  two  stages,  the 
hydrophobia  simplex  rabiosa;  or  the  melancholy 
and  raving  stages  of  some  other  writers.  But  as  the 
early  stage  is  frequently  unattended  with  any  thing 
like  melancholy,  it  is  best  merely  to  adopt  the  distinc- 
tion of  the  first  and  second  stages ; one  comprehending 
the  effects  of  the  disorder  previously  to  the  occurrence 
of  a dread  or  decided  aversion  of  liquids;  the  other, 
the  subsequent  changes.  The  wound,  if  treated  by 
common  methods,  usually  heals  up  at  first  in  a favour- 
able manner.  At  some  indefinite  period,  and,  occa- 
sionally, long  after  the  bitten  part  seems  quite  well,  a 
slight  pain  begins  to  be  felt  in  it,  or  the  neighbouring 
parts,  now  and  then  attended  with  itching,  but  gene- 
rally resembling  a rheumatic  pain.  If  the  bite  took 
place  on  the  finger,  the  pain  successively  extends  from 
the  hand  to  the  forearm,  arm,  and  shoulder,  without 
any  redness  or  swelling  in  these  parts,  or  any  increase 
of  suffering  from  pressure  or  motion  of  the  limb.  In  a 
great  number  of  instances  the  trapezius  muscle,  and 
the  neck  on  the  same  side  as  the  bite,  are  the  points  to 
which  the  pain  principally  shoots.  The  cicatrix,  in  the 
mean  while,  begins  to  swell,  inflames,  and  often  festers 
and  discharges  an  ichorous  matter.  These  uneasy, 
painful  sensations  recur  from  time  to  time,  and  usually 
precede  any  dread  of  water  several  days;  and  tliey  are 
a just  reason  for  apprehension.  Sometimes  pains  of  a 
more  flying,  convulsive  kind,  are  felt  in  various  parts 
of  the  body.  As  the  disease  advances,  the  patient 
complains  of  the  pain  shooting  from  the  situation  of 
the  bite  towards  the  region  of  the  heart.  Sometimes, 
instead  of  pain,  there  is  rather  a feeling  of  heat,  a kind 
of  tingling,  or  even  a sensation  of  cold  extending  up  to 
the  chest  and  throat.  Occasionally  no  local  symptoms 
take  place;  thus  Sabatier,  in  giving  account  of  several 
cases,  remarks  it  as  worthy  of  notice,  that  the  bitten 
parts  did  not  become  painful  previously  to  the  acces- 
sion of  the  fatal  symptoms:  nor  did  any  swelling  or 
festering  occur. — (See  Mim.  de  VInstitut.  Motional,  t. 
2,  p.  249,  Src.) 

Dr.  Marcet  particularly  observed,  that  the  pain  fol- 
lows the  course  of  the  nerves,  rather  than  that  of  the 
absorbents.  In  the  case  which  he  has  related,  as  well 
as  in  one  of  the  cases  detailed  by  Dr.  Babington,  there 
W'as  pain  in  the  arm  and  shoulder,  but  without  any 
affection  of  the  axillary  glands;  and  in  another  case 
(see  Medical  Communications,  vol.  2),  the  pain,  occa- 
casioned  by  a bite  in  the  leg,  was  referred  to  the  hip 
and  loins,  without  any  affection  in  the  inguinal  ab- 
sorbents.— {Medico-Chir.  Trans,  vol.  1,  p.  J56.)  Of  the 
accuracy  of  the  foregoing  statement,  by  Dr.  Marcet, 


there  is  no  doubt;  the  observation,  however,  in  regard 
to  the  irritation  not  affecting  the  absorbents,  was  long 
ago  anticipated  by  several  authors,  who  urged  the 
freedom  of  the  lymphatic  glands  from  disease,  as  an 
argument  that  the  disorder  did  not  depend  upon  the  ab- 
sorption of  any  virus.  It  is  also  noticed  by  others, 
who  inclined  to  the  belief  in  thd  absorption  of  the  in- 
fectious principle.  “Resorptionem  virus  ope  systema- 
tis  lymphatici  fieri  verisimillimum  videtur;  neque 
tamen  nec  vasa  lymphatica,  nec  glandulte  vicinte  sti- 
mulo  morboso,  vel  tumore  adfici  videntur;  quod  in  aliis 
resorptionibus  virulentis  fieri  solet.” — {Callisen,  Syst. 
Chirurgice  Hodiernim,  vol.  1,  p.  595.  Hafnim,  1798.) 

Pain  and  heaviness  are  felt  in  the  head.  Sometimes 
the  headache  is  at  first  very  severe;  sometimes  but 
slight ; but  in  the  latter  case,  it  often  becomes  intense, 
general,  and  accompanied  with  a sense  of  pressure 
upon  the  temples.  In  certain  instances,  the  patient’s 
sleep  lasts  a good  while,  though  disturbed  by  dreams; 
while,  in  other  more  frequent  examples,  he  is  continu- 
ally restless.  The  intellectual  functions  generally  seem 
increased ; the  memory  stronger ; the  conception  more 
ready;  the  imagination  more  fertile ; and  the  conversa- 
tion more  animated.  However,  some  patients  are 
silent  and  dejected,  and  when  questions  are  pul  to 
them,  the  answers  are  short  and  peevish.  But  the 
greater  number  are  active,  lively,  and  talkative.  At 
the  same  time  the  organs  of  sense  betray  signs  of  in- 
creased sensibility;  and  the  eyes,  which  are  very  open 
and  bright,  avoid  a strong  light.  Sometimes  the  pupil 
is  found  to  be  considerably  dilated.  Extraordinary 
pains  are  felt  about  the  neck,  trunk,  and  limbs.  It  is 
not  uncommon,  also,  for  the  patient  to  evince  great 
anxiety,  or  to  fall  into  a state  of  dull  despair  and  me- 
lancholy. These  last  symptoms,  of  which  great  notice 
is  taken  by  writers,  are  particularly  ascribable  to  the 
effect  of  fear.  The  disorder  of  the  organs  of  digestion 
is  sometimes  manifested  in  various  ways,  though  it  is 
far  from  being  so  frequent  and  striking  as  the  affections 
of  the  head  which  precede  it.  The  disorder  referred 
to  consists  at  first  in  loss  of  appetite,  nausea,  vomit- 
ing, and  afterward  constipation,  and  sometimes  colic. 
In  the  first  stage  of  the  disease  the  pulse  is  generally 
somewhat  more  frequent  and  strong  than  in  health ; 
and  the  countenance  appears  more  animated. 

The  above  symptoms  precede  the  second  stage,  or 
that  of  decided  rabies,  only  by  a few  days,  usually  four 
or  six,  though  sometimes  but  two  or  three. — (.Diet,  des 
Sciences  MM.  t.  47,  p.  78.) 

The  second  stage  of  hydrophobia  commences  with 
the  first  manifestation  of  the  dread  or  aversion  of 
liquids.  The  ungovernable  agitation  and  distressing 
sense  of  suffocation  excited  by  the  sight  of  liquids,  the 
attempt  to  drink,  or  even  the  mere  idea  of  drinking,  is 
unquestionably  the  most  remarkable  symptom  of  the 
disorder.  The  patient  is  also  frequently  attacked  with 
the  same  kind  of  commotion  and  suffering  from  other 
causes,  such  as  the  least  agitation  of  the  air,  or  ex- 
posure to  a strong  light.  Indeed,  some  patients  are  so 
much  affected  by  a blast  of  wind,  that  they  have  been 
known  to  endeavour  to  elude  it  by  vvalking  with  their 
backs  towards  it  (Hist,  de  la  Soc.  Roy.  de  Mid.  p. 
157) ; while  others  scream  out  whenever  the  window 
or  door  of  their  room  is  opened.— (A/or^a^m,  De  Sed. 
et  Cans.  Morb.  Epist.  8,  Mo.  28.) 

Dr.  Marcet,  in  relating  the  case  of  the  patient  affected 
with  hydrophobia,  observes,  that  “on  our  proposing  to 
him  to  drink,  he  started  up,  and  recovered  his  breath 
by  a deep  convulsive  inspiration ; t'et  he  expressed 
much  regret  that  he  could  not  drink,  as  he  conceived  it 
would  give  him  great  relief,  his  mouth  being  extremely 
parched  and  clammy.  On  being  urged  to  try,  how- 
ever, he  took  up  a cup  of  water  in  one  hand,  and  a 
tea-spoon  in  the  other.  The  thought  of  drinking  out 
of  the  cup  appeared  to  him  intolerable ; hut  he  seemed 
determined  to  drink  with  the  spoon.  With  an  expres- 
sion of  terror,  yet  with  great  resolution,  he  filled  the 
spoon  and  proceeded  to  carry  it  to  his  lips;  but  before 
it  reached  his  mouth,  his  courage  forsook  him,  and  he 
was  forced  to  desist.  He  repeatedly  renewed  the 
attempt ; but  with  no  more  success.  llis  arm  became 
rigid  and  immoveable  whenever  he  tried  to  raise  it 
towards  his  mouth,  and  he  struggled  in  vain  against  this 
spasmodic  resistance.  At  last,  shutting  his  eyes,  and 
with  a kind  of  convulsive  etfort,  he  suddenly  threw 
into  his  mouth  a few  drops  of  the  fluid,  which  he 
actually  swallowed.  But  at  the  same  instant  he 


HYDROPHOBIA. 


65 


jumped  up  from  his  chair,  and  flew  to  the  end  of  the 
room  panting  for  breath,  and  in  a state  of  indescribable 
terror.” — (See  Med.  Ckir.  Trans,  vol.  1,  p.  158.)  Even 
the  splashing  or  running  of  any  liquid  causes  a great 
deal  of  inconvenience.  As  the  system  becomes  more 
and  more  alfected,  the  patient  loses  his  sleep  entirely, 
and  has  frequent  and  violent  fits  of  anxiety  and  loud 
screaming  from  slight  causes.  The  woman,  whom 
Dr-  Powell  attended,  was  often  attacked  in  this  way, 
in  consequence  of  so  trivial  a circumstance  as  a fly 
settling  on  her  face.  The  noise  of  tea  cups,  or  the 
mention  of  any  sort  of  drink,  greatly  disturbed  her, 
though  she  was  not  at  all  agitated  by  the  sound  of  her 
urine.  The  currents  of  air  entering  her  room,  when- 
ever the  door  opened,  became  very  distressing  to  her, 
and  this  more  and  more  so.  The  pain  in  her  neck 
became  so  great  that  she  could  scarcely  bear  it  to  be 
touched  ; but  she  made  use  of  a looking-gla.ss  without 
the  inconvenience  wliich  hydrophobic  patients  usually 
sufier  from  the  sight  of  shining  bodies.  Dr.  Powell 
states,  that  the  paroxysms,  which  this  poor  woman 
suffered,  resembled  those  of  hysteria,  and  increased  in 
duration  as  the  disorder  lasted.  “She  described  their 
commencement  to  be  in  the  stomach,  with  a working 
and  fulness  there;  and  that  a pricking  substance 
passed  up  into  her  throat  and  choked  her ; she  screamed 
suddenly,  and  grasped  firmly  hold  of  her  attendants, 
as  if  voluntarily  ; and  muscular  convulsions  came  on, 
which  were  sometimes  more,  sometimes  less,  general 
and  violent.  The  causes  from  which  these  paroxysms 
arose  were  extremely  slight;  the  passage  of  a fly  near 
her  face,  the  attempt  to  swallow  a pill,  a stream  of  air, 
the  sight  of  oil  or  wine,  or  any  other  liquids,  even  the 
sound  of  water,  ai\d  other  such  circumstances,  were 
sufficient ; she  now  also  complained  of  inconvenience 
from  light,  which  was  accordingly  moderated.  The 
effect  of  sounds  was  peculiar;  for,  though  in  the  sub- 
sequent stages  their  influence  became  more  general,  at 
this  period  the  effect  was  rather  proportionate  to  the 
ideas  they  excited  in  her  mind,  than  to  their  violence. 
Bells,  and  other  strong  noises,  did  not  agitate  lier ; but 
the  clatter  of  earthen  w’are,  the  noise  of  a distant 
pump,  or  any  thing  connected  with  liquids,  produced 
the  paroxysms  in  all  their  violence.”  She  could  swal- 
low fresh  currants  with  less  resistance  than  any  thing 
else,  taking  care  that  they  were  perfectly  dry.  Her 
mind  had,  till  now,  been  quite  calm  and  composed ; and 
her  conversation  and  behaviour  proper,  during  the 
intervals  of  the  convulsive  attacks.  But  Dr.  Powell 
was  obliged  to  discontinue  the  pills  of  argenium 
nilratum,  in  consequence  of  the  sufferings  which  the 
attempt  to  swallow  them  regularly  brought  on.  Fifteen 
grains  of  this  substance  had  been  given  without  any 
sensible  effect.  The  fits,  and  the  irritability  to  external 
objects,  increased.  Th,i  pain  shot  from  the  back  of  the 
neck  round  the  angles  of  the  jaws,  the  chin,  and 
throat.  At  length  the  paroxysms  became  more  frequent, 
and,  indeed,  might  be  said  to  come  on  spontaneously; 
seven  occurred  in  one  hour.  She  looked  pale  and 
exhausted,  and  a tremor  and  blueness  of  her  lips  and 
fingers  were  observable;  her  pulse  became  weaker  and 
more  rapid,  and  her  scalp  so  tender  that  touching  it 
brought  on  convulsions.  She  had,  latterly,  eructations 
of  wind,  and  spit  up  some  thick  viscid  saliva.  Her 
urine  now  came  away  involuntarily,  and  she  was  more 
and  more  irritable  and  uncontrollable.  Indeed,  she 
passed  two  hours  in  almost  constant  convulsions; 
became  extremely  irritable  and  impatient  of  every 
thing  about  her:  complained  of  failure  of  her  sight; 
wished  to  be  bled  to  death  ; her  words  were  fewer  and 
interrupted ; she  struck,  and  threatened  to  bite  her 
attendants;  had  copious  eructations  of  air ; discharged 
an  increased  quantity  of  viscid  saliva  with  much  con- 
vulsive effort;  said  the  affection  of  her  throat  and 
stomach  had  quite  left  her;  and  continued  in  a general 
perspiration,  with  a weak  pulse  from  140  to  150.  She 
afterward  bit  some  of  the  attendants,  and  was  there- 
fore confined  with  a waistcoat.  From  this  period  she 
had  lost  all  control  over  her  mind,  and  cotitinued  for 
almost  four  hours  in  a paroxysm  of  furious  insanity. 
She  now  swallowed,  with  an  effort,  near  half  a pint  of 
water;  but  this  was,  in  a few  seconds,  vomited  up, 
with  some  mucus  and  a greenish  fluid.  In  this  violent 
raving  stale  she  continued  fill  within  two  hours  of  her 
death,  which  took  place  forty-seven  hours  after  the 
first  marked  occurrence  of  hydrophobia.  In  the  course 
of  the  case, she  swallowed  once  or  twice  a little  porter; 

Vol.  II.— E ’ 


and  also  some  cinnamon  water,  with  tinct.  opii ; but 
they  were  always  vomited  up. — {Dr.  Powell's  Case  of 
Hydrophobia.) 

it  is  by  no  means  uncommon  for  a period  to  occur, 
when  the  horror  of  liquids  undergoes  a considera 
ble  diminution,  or  even  entirely  ceases;  the  patient 
quenching  his  thirst,  and  this  sometimes  as  well  as  if 
he  were  in  perfect  health,  and  so  as  to  raise  doubts  of 
the  existence  of  rabies.  But  after  a few  hours  the 
dread  of  fluids  comes  on  again,  and  with  it  the  con- 
vulsive paroxysms,  which  now  become  general,  vio- 
lent, and  incessant.  Dr.  Cayol  attended  a girl,  labour 
ing  under  rabies,  who  was  never  affected  with  any 
very  great  dread  of  liquids,  nor  an  absolute  inability 
to  swallow  them,  though  she  certainly  disliked  them, 
and  swallowed  them  with  difficulty. — {Journ.  de  Mid. 
Chir.  8rc.  Avril.,  1811,  p.  241.)  Nay,  patients  are 
sometimes  seen  who  can  mantle  to  swallow  red  wine 
and  broth,  though  their  aversion  to  water  is  already 
beyond  all  control ; and  other  patients  can  sometimes 
look  at  a liquid  in  a black  pot  without  inconvenience ; 
though  any  fluid  offered  to  them  in  a glass  will  bring 
on  a violent  paroxysm  of  spasm  and  sense  of  suf- 
focation. The  sight  of  tears  has  even  been  enough 
to  bring  on  the  attack. — (See  Diet,  des  Sciences  Mid.  t. 
47,p.79.) 

The  question  has  sometimes  been  entertained  whe- 
ther rabies  can  ever  exist  quite  unattended  throughout 
its  course  with  a dread  of  liquids?  The  possibility 
of  such  a case  was  believed  by  Mead  and  others ; 
and  an  instance  is  recorded  by  Mignot,  in  which 
the  patient  died,  without  having  manifested  any  sign 
of  hydrophobia. — (See  Hist,  de  la  Soc.  Roy.  de  Mid. 
an.  1783,  2me  Part,  p.  48.)  However,  it  is  asserted, 
that  a careful  perusal  of  this  case  must  produce  a con- 
viction that  the  disorder  was  not  rabies ; and  it  is  added, 
that  when  the  histories  of  this  disease  on  record  are 
critically  investigated,  none  will  be  found  complete, 
which  do  not  make  mention  of  a more  or  less  decided 
aversion  to  fluids.  It  also  appears,  from  facts  referred 
to,  that  the  dread  of  liquids  does  not  depend  upon  the 
pain  which  the  patient  has  already  suffered  from  his 
attempts  to  drink,  as  it  sometimes  occurs  before  any 
such  attempt  has  been  actually  made.— ( Vol.  cit.  p.  80.) 

An  inclination  to  bite  was  evinced  in  the  case  re- 
corded by  Dr.  Powell ; and  also  in  another  reported  by 
Magendie.  Yet,  this  disposition  is  far  from  being 
usual ; and  it  never  presented  itself  in  any  of  the  cases 
which  fell  under  the  observation  of  the  author  of  the 
article  Rage  in  the  foregoing  publication,  or  P.  De- 
sault, Duchoisel,  Dr.  J.  Vaughan,  Sabatier,  Dupuytren, 
&c.  And,  even  when  the  patient’s  imagination  is  so 
disordered  that  he  cannot  help  biting,  he  commonly 
warns  the  bystanders  to  avoid  the  danger.  The  frothy 
slaver,  which  is  voided  with  considerable  and  repealed 
efforts,  is  a symptom,  which  is  said  not  to  commence 
before  the  respiration  begins  to  be  convulsive.  As  the 
disease  advances,  there  is  no  remission  of  the  sputa- 
tion,  necessary  to  clear  the  throat  of  this  viscous  se- 
cretion ; and,  at  the  approach  of  death,  when  it  cannot 
be  expelled,  it  collects  in  the  mouth,  and  covers  the 
patient’s  lips. 

The  symptoms  of  what  is  termed  cerebral  excitement 
become  stronger  and  more  marked  in  the  second  stage 
of  the  disease.  The  eyes,  the  brightness  of  which  Is 
still  farther  increased,  appear,  as  it  were,  inflamed; 
the  patient  never  shuts  them  again ; and,  as  the  day- 
light and  brilliant  colours  are  offensive,  he  prefers 
darkness.  The  hearing  becomes  very  acute,  and,  as 
well  as  the  sight,  is  troubled  with  hallucinations.  The 
touch  is  extremely  fine  ; the  speech  abrupt  and  rapid  ; 
and  the  conversation  energetic,  and  often  expressive  of 
the  most  touching  sentiments.— (Drci.  des  Sciences 
Mid.  t.  47,  p.  12.) 

Dr.  Marshall  made  a very  just  distinction,  between 
the  real  convulsions  which  came  on  towards  the  ter- 
mination of  the  case  in  death,  and  the  strong  sudden 
action  of  the  muscles,  excited  in  the  course  of  the  dis- 
order by  the  light,  the  sight  of  liquids,  and  the  feel  of 
the  air. — {The  Morbid  Anatomy  of  the  Brain,  Src.  p. 
88.)  Convulsions  and  hiccough,  in  fact,  are  thesymj)- 
torns  of  dissolution. 

Delirium  is  far  from  being  a constant  symptom,  and 
only  happens  the  last  day  of  the  disorder.  Neither  is 
it  always  without  remissions;  for  the  patients  affected 
with  it  sometimes  give  rational  replies.  Every  case 
upon  record,  where  delirium  is  described  as  being  one 


66 


HYDROPHOBIA. 


of  the  first  symptoms,  or  as  coming  on  with  the  dread 
of  liquids,  is  set  down  on  good  authority,  not  as  true 
rabies,  but  a symptomatic  hydrophobia,  attended  with 
mania. 

The  dread  of  swallowing  liquids,  though  the  most 
singular  symptom  of  the  disease,  constitutes  but  a 
small  part  of  it.  It  is  true,  that  none,  or  very  few,  re- 
cover, who  have  this  symptom,  yet  they  certainly  do 
not  die,  in  consequence  of  the  difficulty  of  swallowing 
liquids;  for  the  human  body  could  easily  exist  double 
the  time,  at  theend  of  which  the  disease  usually  proves 
fatal,  without  food  or  drink.  Besides,  the  sick  can 
often  swallow  substances  that  are  nourishing,  in  a 
pulpy  state,  without  their  lives  being  thereby  at  all 
prolonged.  It  is  not,  therefore,  the  difficulty,  or  impos- 
sibility of  swallowing  liquids,  bnt  the  effects  of  the 
poisoii  upon  the  constitution  at  large,  w'hich  occasion 
death. — (Zir.  J Hunter  in  Trans,  for  the  Improve- 
ment of  Med.  Knowledge,  vol.  l,p.  305.) 

The  extreme  sensibility  of  the  sick  to  all  impressions, 
appears  in  the  displeasure  which  they  express  at  even 
the  air  blowing  upon  them;  in  their  dislike  to  a strong 
light;  in  their  aversion  to  new  faces,  or  even  the  sight 
of  their  friends  and  relations ; and  in  the  terror  they 
express  at  being  touched,  which  throws  them  into  con- 
vulsions. In  a case  related  by  Magendie,  the  slightest 
noise,  and  even  merely  touching  the  patient’s  hair,  ex- 
cited convulsions  of  incredible  violence.  As  the  dis- 
ease advances,  the  mind  is  more  and  more  filled  with 
dreadful  fears  and  apprehensions. — (Op.  cit.  p.  307.) 

In  the  second  stage,  the  epigastrium,  as  well  as  the 
chest,  is  the  seat  of  considerable  pain ; the  patient  is 
constipated,  but  the  urine  is  plentiful  and  high  co- 
loured. Before  a certain  period,  the  pulse  is  generally 
strong,  regular,  and  a little  accelerated ; but,  towards 
the  end  of  the  case,  it  becomes  small,  irregular,  feeble, 
and  rapid. — (See  Diet,  des  Sciences  Mid.  t.  ^l,p.  83.) 

The  duration  of  life,  from  the  appearance  of  hydro- 
phobia till  death,  varies  from  thirty-six  hours  to  four 
or  five  days:  the  most  common  period  is  from  two  to 
three  days. — {Dr.  J.  Hunter,  Op.  cit.  p.  308.)  The 
event  is  said  to  be  directly  caused  by  asphyxia,  or  the 
cessation  of  respiration.  Of  ten  persons  who  were 
bitten  by  the  sameanimal,  nine  died  on  the  second  and 
third  day,  from  the  commencement  of  the  horror  of 
fluids,  and  only  one  on  the  fifth  day.  There  is  an  ac- 
count of  a child  at  Senlis  who  lived  nine  days,  but 
the  description  of  the  case,  and  the  circumstance  of 
fourteen  worrits  being  found  in  the  intestines,  may 
raise  doubts  about  the  nature  o the  disease.— (See 
Hist,  de  la  Soc.  Roy.  de  Mid.p.  155.  209.) 

Whatever  may  be  the  resemblance  found  betw’een 
tetanus  and  hydrophobia,. with  regard  to  the  rapidity 
of  their  course,  their  causes,  and  some  of  their  symp- 
toms, the  following  considerations,  as  a modern  writer 
observes,  will  always  serve  for  the  discrimination  of 
one  disorder  from  the  other:  tetanus  attacks  the  mus- 
cles of  the  jaw,  which  remains  motionless,  while,  in 
rabies,  the  jaw  is  not  only  moveable,  but  incessantly 
moving,  in  consequence  of  the  efforts  unremittingly 
made  by  the  patient  to  free  his  mouth  from  the  thick 
saliva,  with  which  it  is  obstructed.  In  this  last  disor- 
der, the  muscles  are  alternately  contracted  and  relaxed ; 
but,  in  tetanus,  they  ahvays  continue  rigid.  Tetanus 
is  rarely  attended  with  any  aversion  to  liquids,  and  the 
patient  may  be  kept  for  a long  time  in  a bath  without 
inconvenience;  and  the  paroxysms  are  neither  excited 
nor  increased  by  a vivid  light,  a noise,  tlic  patient’s 
being  touched,  or  the  sight  of  water,  or  shining  sur- 
faces. In  addition  to  these  differences,  it  is  to  be  re- 
membered that  tetanus  is  most  frequent  in  warm 
climates,  and  that  it  mostly  comes  on  a few  days  after 
the  receipt  of  a local  injury,  and  may  occur  as  a com- 
plication of  any  kind  of  wouiid,  even  that  which  is 
made  in  a surgical  operation. — (See  Diet,  des  Sciences 
Mid.  t.Al,p.  68.) 

On  the  subject  of  prognosis,  with  respect  to  the  bile 
inflicted  by  a rabid  animal,  and  its  effects,  as  evinced 
in  the  decided  form  of  rabies,  there  are  several  things 
worthy  of  attention.  According  to  some  writers,  small 
wounds  are  not  less  dangerous  than  others,  and  an  at- 
tempt is  made  to  account  for  the  fact,  by  the  more 
copious  hemorrhage  Iroin  larger  wounds,  and  the  fre- 
quent neglect  of  less  injuries.  Terhaps  another  reason 
is,  that  the  virus  is  more  likely  to  be  confined  in  a 
wound  with  a small  orifice,  than  in  onew'hich  is  ample, 
and  admits  of  being  more  effectually  washed.  The 


more  numerous  the  wounds  are,  the  greater  is  the  risfe 
If  it  be  inquired,  what  is  the  average  number  of  per- 
sons attacked  with  rabies,  out  of  a given  number  who 
have  received  bites'? — the  question  can  only  be  an- 
swered by  referring  to  the  extremes.  Thus,  Dr.  J 
Vaughan  speaks  of  between  twenty  and  thirty  indi- 
viduals, bit  by  a mad  dog,  of  whom  only  one  was  af- 
terward attacked  with  rabies;  and  Dr.  J.  Hunter  tells 
us  of  an  instance,  in  which,  out  of  twenty-one  persons 
bit,  only  one  became  affected. — (See  also  Fotkergill  in 
Med.  Obs.  and  Inq.  vol.  5,  p.  195.)  On  the  otlrer  hand, 
out  of  fifteen  persons,  bit  by  a mad  dog,  and  taken  care 
of  at  Senlis,  three  at  least  were  seized  with  the  disorder 
{Hist,  de  la  Soc.  Roy.  de  Mid.  p.  130.)  Of  seventeen 
others,  bit  by  a wolf,  ten  were  attacked  {ib.  p.  130) ; 
and  of  twenty-three,  bit  by  a she-wolf,  thirteen  died  of 
rabies. — {D.  F.  Trolliet,  FTouveau  Traiti  de  la  Rage, 
>S-c.  Obs.  ChiruTg.  £,-c.  Mo.  25.) 

Two  important  facts  should  always  be  recollected, 
viz.  the  disease  may  often  be  prevented ; it  can  hardly 
ever  be  cured.  Experience  has  fully  proved,  that 
when  hydrophobia  once  begins,  it  generally  pursues 
its  dreadful  course  to  a fatal  terminatimr,  the  records 
of  medicine  furnishing  very  few'  unequivocal  and  w'ell 
authenticated  cases  to  the  contrary.  Hence,  the  impe- 
rious necessity  of  using  every  possible  means  for  the 
prevention  of  the  disorder. 

Probably,  however,  many  things  which  possess  the 
character  of  being  preventive  of  hydrophobia,  have  no 
real  claim  to  such  reputation.  I would  extend  this  ob- 
servation to  all  internal  medicines,  mercurial  frictions, 
and  plunging  the  patient  for  a considerable  time  under 
w'ater. 

The  instances,  in  which  a prevention  is  inferred  to 
have  taken  place  by  different  w'riters,  in  consequence 
of  such  means,  may  all  be  very  rationally  ascribed  to 
other  circumstances.  Facts  already  cited  sufficiently 
prove,  that  out  of  the  great  nunilrer  of  persons,  fre- 
quently bitten  by  the  same  dog,  oidy  a limited  propor- 
tion is  commonly  affected.  The  hydrophobic  poison 
is  knowm  to  reside  in  the  saliva  of  the  animal ; conse- 
quently, the  chance  of  being  affected  must  greatly  de- 
pend upon  the  quantity  of  this  fluid  which  is  insinuated 
into  the  wound ; and,  if  the  teeth  of  the  animal  should 
have  previously  pierced  a thick  boot,  or  other  clothing, 
before  entering  the  skin,  the  danger  must  obviously 
be  much  diminished.  Many  patients  w'ash  and  suck 
the  w’ound,  immediately  after  its  occurrence,  and  thus, 
no  doubt,  very  often  get  rid  of  the  poison.  Even  when 
it  is  lodged  in  the  w'ound,  it  may  not  be  directly  ab- 
sorbed, but  be  thrown  off  with  the  discharge.  All 
prudent  patients  submit  to  excision  of  the  bitten  part. 
Now,  under  each  of  the  above  ciicumstances,  escapes 
have  frequently  occurred,  wliile  internal  medicines, 
half  drowning;  or  salivating  the  patients,  had  also  not 
been  neglected,  so  that  all  the  efficacy  of  preventives 
has  too  often  been  most  unjustly  ascribed  to  means, 
which  probably  never  yet  had,  and  never  will  have, 
any  beneficial  effect  whatever.  What  confirms  the 
truth  of  the  preceding  statement  is  these  facts:  that 
persons  bitten  by  the  same  animal  have  sometimes 
been  treated  exactly  on  the  same  plan ; some  of  them 
escaped  the  disease ; others  had  it,  and,  of  cour  se,  pe- 
rished : on  other  occasions,  some  of  the  patients,  bitten 
by  the  same  animal,  have  been  treated  in  a particular 
way,  and  have  escaped  hydrophobia;  while  others 
bitten  at  the  same  lime  by  the  animal,  also  never  had 
any  constitutional  effects,  although  they  took  no  medi- 
cines, nor  followed  any  other  particular  plan. 

If  to  these  reflections  be  added  the  consideration, 
that  it  is  frequently  doubtful,  whether  the- bile  has 
actually  been  inflicted  by  a. truly  rabid  animal,  and  that 
the  mental  alarm  will  sometimes  bring  on  a symptom 
atic  hydrophobia,  it  is  easily  conceivable,  llow  mis- 
taken a person  may  be,  who  believes  that  he  has  pre- 
vented the  disorder,  and  how  unmerited  is  the  reputa- 
tion of  the  means  which  he  has  employed  for  the 
purpose. 

The  bite  of  a naturally  ferocious  beast  has  often 
been  thought  to  be  attended  with  more  risk,  than  that 
of  an  aniiDHl  naturally  tame;  and  hence,  the  bile  of  a 
wolf  is  said  to  be  more  frequently  followed  by  rabies 
than  that  of  a dog.  This  proposition  is  admitted  to  be 
true;  but  the  explanation  is  erroneous.  The  tine 
reason  of  the  difference  is,  that  a wolf  usually  seizes 
the  face,  and  inflicts  a deeiier  bite;  while  a dog  only 
snaps  as  he  runs  along,  and  mostly  bites  through  the 


HYDROPHOBIA. 


67 


c!othes.“(See  Diet,  des  Sciences  Med.  t.  47,  p.  88.) 
The  bite  of  a rabid  animal  may  be  rendered  mucli  more 
dangerous  by  being  situated  near  a part,  or  an  organ, 
which  increases  the  difficulty  or  risk  of  adopting  an 
effectual  mode  of  removing  the  whole  of  the  ffesli  in 
whicli  the  virus  may  be  lodged.  Thus,  bites  near  the 
large  arteries,  the  eyes,  the  joints,  &c.  are  of  a more 
serious  description  than  others.  Dr.  J.  Hunter  rated 
the  hazard  in  some  degree  by  the  vascularity  of  the 
bitten  parts.  The  prognosis  will  always  be  more  unfa- 
vourable, when  no  proper  measures  have  been  applied 
to  the  bite  soon  after  its  infliction,  and  perhaps  the 
risk  may  be  increased  by  certain  causes  not  having 
been  duly  avoided,  which,  as  already  stated,  are 
thought  to  have  a tendency  to  accelerate  the  attack  of 
rabies.  The  exact  time  after  a bile,  when  the  preven- 
tion of  rabies  is  no  longer  practicable,  is  quite  an  un- 
determined point;  but  every  fact,  known  upon  the 
subject,  evinces,  in  an  urgent  manner,  the  necessity  of 
adopting  preservative  measures  without  the  least  delay. 

In  almost  all  the  dissections  of  patients,  who  have 
died  of  rabies,  certain  indications  of  inflammation 
have  been  perceptible,  more  fiequcntly  in  some  part 
of  the  space  between  the  pharynx  and  the  cardiac  ori- 
fice of  the  stomach,  in  the  stomach  itself,  in  the  lungs, 
the  choroid  plexus,  and  membranes  of  the  brain. — (See 
Med.  Repository.,  vol.  3,  p.  51.)  M.  Trolliet  opened, 
with  the  greatest  care,  six  bodies  of  persons  destroyed 
by  this  disease.  The  mouth  and  fauces  in  each  sub- 
ject were  first  examined,  and  found  of  a pale  grayish 
colour,  scarcely  lubricated  with  mucus,  and  quite  free 
from  all  frothy  mailer.  All  the  salivary  glands  seemed 
perfectly  healthy.  When  the  larynx,  trachea,  and 
bronchise  were  opened,  they  appeared  to  have  been  the 
seat  of  inflammation,  the  traces  of  which  were  the 
most  marked  low  down,  where  the  mucous  membrane 
was  of  the  colour  of  wine-lees.  In  four  of  the  bodies, 
frothy  mucus  was  perceived  in  the  bronchise,  larynx, 
and  trachea.  Trolliet  infers  from  these  appearances, 
that  the  frothy  matter,  seen  about  the  mouth  and  lips 
of  patients  affected  with  rabies,  is  secreted  by  the  in- 
flamed mucous  membrane  of  the  bronchias,  and  that  it 
is  this  secretion,  and  not  the  real  saliva,  which  con- 
tains the  hydrophobic  poison. — {JVouveau  Traits  de  la 
Rage,  Src.)  In  giving  an  account  of  a dissection. 
Fame  also  long  ago  remarked,  that  the  frothy  matter 
was  only  met  with  in  the  air-passages,  that  the  salivary 
organs  were  unaffected,  and  that  the  saliva  itself  did 
not  contribute  to  the  formation  of  the  thick  slaver, 
which  appeared  to  have  issued  from  the  chest. — {Hist, 
de  la  Soc.  Roy.  de  M^d.  ann  1783,  p.  39.)  From  the 
preceding  observations,  and  those  of  Mignot  de  Ge- 
nety  {Vol.  cit.  p.  54),  Morgagni  {De  Sedib.  el  Cans. 
Morb.  Epist.  8,  art-  20, 25,  30),  Darlue  {Journ.  de  Med. 
de  Vandermonde,  t.  4,  p.  270),  B.  Rush,  and  Dupsey 
{Obs.  Inidites,  JVo.  1.38.),  it  would  appear; 

1.  That  the  mouth,  strictly  so  called,  and  the  salivary 
glands  are  without  any  alteration. 

2.  The  mucous  membrane  of  the  air-passages  is  af- 
fected with  inflammation,  which  in  its  highest  degree  ex- 
tends from  the  division  of  the  bronchise  to  the  pharynx. 
When  the  inflammation  is  of  less  extent,  the  pharynx 
appears  sound;  and  when  yet  more  limited,  it  is 
usually  not  to  be  traced  in  the  larynx.  The  point 
where  it  seems  to  commence  and  is  most  strongly 
marked,  is  at  the  lower  part  of  the  tiachea,  or  in  the 
bronchise.  Lastly,  when  none  of  these  parts  are  found 
inflamed,  the  lungs  themselves  present  vestiges  of 
inflammation. 

With  respect  to  the  theory  of  Trolliet,  wherein  the 
hydrophobic  poison  is  said  to  be  contained  in  the 
mucous  secretion  voided  from  the  lungs,  and  to  be  the 
product  of  inflammation  of  the  membrane  of  the 
bronchiaj,  and  not  derived  from  the  salivary  glands,  the 
question  requires  the  confirmation  of  experiment;  for, 
though  the  salivary  glands  are  not  the  seat  of  pain, 
swelling,  &c.,  it  by  no  means  follows,  that  their  secreting 
process  may  not  have  been  subject  to  some  peculiar 
modification,  on  which  the  production  of  the  hydropho- 
bic virus  depended.  Thus,  severe  and  obstinate 
ptyalisrns  often  occur,  and  yet  there  is  no  manifest 
change  in  the  state  of  the  salivary  glands.  According 
to  Van  Swieten  and  Mead,  there  are  sometimes  no 
morbid  appearances  either  in  the  head,  fauces,  chest, 
or  stomach. — {Comment.  inBoerh.  t.  3,p.  562.) 

The  dissections  of  two  rabid  sheep  have  been  lately 
published  in  France  and  it  is  particularly  noticed,  that 

E2 


in  these  animals  the  lungs  were  sound  {Magendie's 
Journ.  t.  8,  p.  330,  &-c.) ; a fact  that  is  very  repugnant 
to  the  hypothesis  adopted  by  Trolliet. 

In  three  cases  out  of  six,  the  lungs  were  found  em 
physematous,  that  is  to  .say,  their  interlobular  substance 
was  distended  with  air,  and  the  pleura  pulmonalis 
raised  into  a great  number  of  transparent  vesicles  on 
the  surface  of  the  lungs.  In  a fourth  instance,  the 
emphysema  was  not  observed  in  the  lungs  themselves, 
but  in  the  cellular  substance  between  the  two  layers 
of  the  mediastinum,  and  under  the  muscles  of  the 
neck.  Morgagni  also  noticed  vesicles  of  air  on  the 
surface  of  t'he  lungs  of  a person  who  died  of  hydro- 
phobia.— {De  Sed.  et  Cans.  Morb.  Epist.  8,  art.  30.) 
M.  Trolliet  presumes  that  this  emphysema  is  occa- 
sioned by  the  rupture  of  one  of  the  air-cells  in  the 
convulsive  efforts  of  respiration,  as  sometimes  happens 
when  a foreign  body  is  lodged  in  the  larynx.— (See 
Cases  by  Louis  and  Lescure  in  Mim.  de  I' Acad,  de 
Cliir.  t.  4,  p.  538 ; t.  5,p.  527.) 

I’he  lungs  were  of  a deep-red  colour  in  all  the  six 
subjects  dissected  by  Trolliet,  and  they  were  observed 
to  be  gorged  with  blood  in  cases  reported  by  numerous 
writers;  as  -Bonet  (See  Van  Swieten,  t. ‘i,  $ 1140); 
Boerhaave  ( Op.  Omn.  p.  215) ; Morgagni  {De  Sedibus 
et  Cans.  Morb.  Ep.  8,  art.  23,  Src.)\  Mead,  Darlue 
{Recueil  Period.  <^c.  t.  3 and  4) ; Faure  {Hist,  de  la 
Soc.  Roy.  de  Mid.  p.  33) ; De  la  Gaze  {ib.  p.  69) ; Por- 
tal, Oldknow,  Ballingall  {Edinb.  Med.  and  Surg. 
Journ.) ; Marshall  (Jl/orifd  Anatomy  of  the  Brain,  Src. 
p.  69) ; Gorey  {.Journ.  de  Mid.  Cliir.  t.  13,  p.  83)  ; Fer- 
riar  {Med.  Hist,  and  Reflections,  <^-c-.)  “Pultnones  in 
quinque  nigriex  totoaut  magnfl  parte  (says  Morgagni), 
in  quatuor  magn4  item  ex  parte  sanguine  pleni.”  In  a 
case  examined  by  M.  Ribes,  the  larynx,  trachea,  and 
bronchise,  besides  presenting  traces  of  inflammation, 
were  every  where  lined  with  a thick  white  frothy  mu- 
cus.— {Magendie's  Journ.  t.  8,  232.)  With  respect 

to  the  state  of  the  organs  of  the  circulation,  in  three 
of  the  cases  dissected  by  Trolliet,  a good  deal  of  air 
escaped  from  the  heart  and  aorta.  Morgagni  is  sup- 
posed to  be  the  only  other  writer  who  has  noticed  a 
similar  occurrence  {Epist.  8,  JVo.  30),  and  who  also  in 
another  case  saw  air  escape  from  beneath  the  dura 
mater.— (/6.  Mo.  23.)  In  two  of  Trolliet’s  cases,  some 
gelatinous  clots  were  found  in  the  heart  and  large  ves- 
sels ; but  the  great  mass  of  blood  was  black,  and  very 
fluid  in  the  heart,  arteries,  and  veins,  as  in  subjects 
who  have  died  of  asphyxia.  In  all  the  six  cases, 
traces  of  inflammation  were  noticed  in  the  brain  or  its 
membranes.  The  sinuses  were  filled  with  a dark- 
coloured  fluid  blood ; and  the  pia  mater  was  much 
injected,  and  of  a brownish  hue.  The  same  appear- 
ances were  found  upon  the  cerebellum,  and  the  vessels 
on  the  investment  of  the  medulla  spinalis  were  con 
siderably  enlarged.  The  surface  of  the  cerebrum  was 
also  studded  with  scarlet  spots,  which  appeared  *o 
arise  from  blood  eff  used  from  the  small  vessels  of  the 
pia  mater  into  its  cellular  substance.  In  two  subjects, 
blood  was  extravasated  towards  the  base  of  the  brain 
in  larger  quantity.  The  plexus  choroides  was  gorged 
with,  blood,  and  of  a brown  colour.  Besides  these  and 
other  changes,  Trolliet  remaiked  in  two  of  the  cases  a 
thickening  of  the  pia  mater.  The  substance  of  the 
brain  was  generally  softer  than  usual ; but  the  fluid  in 
the  lateral  ventricles  was  not  in  large  quantity,  though 
in  two  cases  it  had  a bloody  tinge.  The  late  Dr.  Mar 
shall  believed  that  in  rabies  the  brain  was  the  part 
principally  affected.— (O//.  cit.p.  145.) 

Hufeland  conjectured  that  in  hydrophobia  the 
medulla  spinalis  is  the  part  originally  affected,  whence 
the  effects  of  the  disease  are  propagated  to  the  nerves 
of  the  trunk. — {Bibl.  Mid.  t.  55,  p.  395,  Src.)  Dr.  R. 
Read  believed  that  an  alteration  of  the  spinal  marrow 
was  essentially  concerned  in  the  disease. — {On  the 
Mature,  Src.  of  Tetanus  and  Hydrophobia,  8vo.  Dublin, 
1817.)  A case  was  also  published  by  M.  Matthey  of 
Geneva,  in  which  a quantity  of  serum  was  found 
within  the  spinal  canal. — {.Journ.  Gin.  de  Mid.  t.  54,;;. 
279.)  See  on  this  subject  some  observations  by  Dr. 
Abercrombie. — {Edinb.  Med  and  Surg.  .Journ.  vol 
14,  p.  66.)  In  one  instance,  dissected  by  M.  Ribes,  the 
vessels  of  the  pia  mater,  brain,  and  medulla  spinalis, 
were  gorged  with  dark  blood,  Iflit  without  any  ap- 
pearance of  inflammation. — (See  Magendie's  Journ 
t.  8,  p.  232.) 

According  to  Trolliet,  the  trace#  of  inflammation 


68 


HYDROPHOBIA. 


in  the  digestive  organs  are  not  so  constant  as  in  the 
lungs  and  brain.  In  none  of  the  six  cases  dissected  by 
him  was  there  any  appearance  of  inflammation  in  the 
pharynx,  though  some  parts  of  the  alimentary  canal 
were  affected  in  this  manner.  The  cases  recorded, 
Jiowever,  in  which  the  digestive  organs  presented 
considerable  morbid  appearances,  are  very  numerous. 
Thus  Joseph  de  Aromatarius,  Darlue  {Recueil  Period, 
t.  3,p.  189,  et  t.  4,  p.270),  Sauvages  (p.  107),  Professor 
Rossi,  M.  Gorci  (Joum.  de  Mid.  Chir.  <J-c.  t.  13),  and 
Dr.  Powell  (Case  of  Hydrophobia).,  found  inflamma- 
tion either  in  the  pharynx,  or  oesophagus,  or  both  these 
tubes.  Dr.  Powell’s  words  are,  “ the  oesophagus  was 
rather  redder  than  natural,  and  covered  with  a thin 
layer  of  coagulable  lymph.”  A similar  coat  of  lymph 
was  also  found  by  OIdknow  {Edinb.  Med.  and  Surg. 
Journ.  vol.  5,  p.  280),  Ballingall  (Op.  cit.  vol.  11, p.  76), 
Dr.  Ferriar  (Med.  Hist.  Src.  vol.  3,  p.  27).  In  dogs,  Di. 
Gillman  found  the  pharynx  and  oesophagus  in  a state 
of  inflammation.— (On  th^  Bite  of  a Rabid  Animal,  p. 
13.  23. 26.  44.)  M.  Ribes  found  the  pharynx  and  soft 
palate  slightly  inflamed.  It  is  conjectured,  that,  in 
many  of  these  instances,  the  inflammation  extended  to 
the  oesophagus  from  the  trachea  and  bronchiae. — (Diet, 
des  Sciences  Mid.  t.  47,  p.  98.)  Inflammation  of  the 
mucous  membrane  of  the  stomach  and  small  intestines 
has  Ifkewise  been  very  generally  noticed,  as  may  be 
seen  by  referring  to  the  accounts  published  by  Mor- 
gagni, Powell,  OIdknow,  Ferriar,  Ballingall,  Marshall, 
&c.  In  dogs,  the  same  fact  was  remarked  by  Dr.  Gill- 
man  (p.  13.  31.  44) ; sometimes,  however,  according  to 
this  last  author,  no  vestiges  of  inflammation,  nor  any 
other  morbid  appearances,  are  discoverable  in  the  ex- 
amination of  animals  that  have  died  of  rabies. — (P. 
83.)  Dupuytren  is  stated  to  have  found  the  mucous 
membrane  of  the  stomach  and  bowels  inflamed  in 
several  places,  and  even  almost  gangrenous. — (Diet, 
des  Sciences  Mid.  t.  41,  p.  98.)  By  M.  Ribes,  the  gall- 
bladder was  found  empty;  the  mucous  coat  of  the 
stomach,  jejunum,  and  ileum  inflamed : and  these  or- 
gans much  contracted. — (See  Magendie's  Joum.  t.  8, 
p.  233.) 

From  recent  investigations,  made  at  the  veterinary 
school  at  Alfort,  by  Professor  Dupuy,  the  following  are 
the  usual  morbid  appearances  noticed  in  the  dissection 
of  dogs,  horses,  cows,  and  sheep,  destroyed  by  rabies. 

1.  The  lungs  and  biain  universally  gorged  with  blood. 

2.  Greater  or  less  marks  of  inflammation  in  the  mu- 
cous membrane  of  the  bronchiae,  trachea,  larynx, 
throat,  oesophagus,  stomach,  and  frequently  even  in 
that  of  the  bowels,  vagina,  uterus,  aqd  bladder.  Yet, 
in  two  dissections  more  recently  recorded,  no  particu- 
lar changes  were  discoverable  in  the  pharynx  and 
oesophagus. — (Magendie's  Journ.  t.  8,  p.  331,  332.)  3. 
The  air  passages  filled  with  frothy  mucus.  4.  A col- 
lection of  serum  in  the  ventricles  of  the  brain,  and 
sometimes  even  between  the  membranes  covering  the 
spinal  marrow.  5.  An  unusual  redness  of  the  invest- 
ment of  the  pneumogastric  and  trisidanchnic  nerves. — 
(See  Diet,  des  Sciences  Med.  t.  47,  p.  99.) 

Happily,  surgery  possesses  one  tolerably  certain 
means  of  preventing  hydrophobia,  when  it  is  practised 
in  time,  and  in  a complete  manner.  Every  reader  will 
know,  that  the  excision  of  the  bitten  parts  is  the  ope- 
ration to  which  1 allude.  Indeed,  as  hydrophobia  is 
often  several  months  before  it  begins,  the  wounded 
parts  should,  perhaps,  always  be  cut  out,  even  though 
they  are  healed,  and  some  weeks  have  elapsed  since 
the  accident,  provided  no  symptoms  of  hydrophobia 
have  actually  commenced.  The  operation  should  be 
done  completely ; for  a timorous  surgeon,  afraid  of  cut- 
ting deeply  enough,  or  of  removing  a sufficient  quan- 
tity of  the  surrounding  flesh,  would  be  a most  danger- 
ous one  for  the  patient.  All  hopes  of  life  depend  on 
the  prevention  of  the  disorder ; for,  in  the  present  state 
of  medical  knowledge,  none  can  rest  upon  the  efficacy 
of  any  plan,  except  the  extirpation  of  the  part.  For 
this  purpose,  caustics  have  sometimes  been  employed. 
However,  as  their  action  can  never  be  regulated  with 
the  same  precision  as  that  of  the  knife,  and,  conse- 
quently, they  may  not  destroy  the  flesh  to  a sufficient 
depth,  excision  should  always  be  preferred.  The  latter 
method  is  also  the  safest  for  another  important  reason, 
viz.  the  part,  and  poison  lodged  in  it,  are  removed 
frf'm  the  body  at  once ; but,  when  the  cautery  or  caus- 
tic is  used,  the  slough  must  remain  a certain  time  un- 
detached. Some  surgeons  are  not  content  with  cutting 


out  the  part,  but,  after  the  operation,  fill  the  wound 
with  the  liquor  ammonife,  or  cauterize  its  surface,  for 
the  sake  of  greater  security.  How  late  excision  may 
he  done  with  any  prospect  of  utility,  I am  not  prepared 
to  say ; but  there  are  practitioners  who  deem  excision 
right  even  when  heat,  irritation,  or  inflammation  is  ob- 
served in  the  bitten  part. — (See  Med.  Repository,  vol. 
3,  p.  54.) 

Cases  present  themselves  in  which  it  is  even  prefer- 
able to  amputate  the  limb  than  attempt  to  extirpate, 
either  with  the  knife  or  cautery,  the  whole  of  the  bitten 
parts;  an  endeavour  which  could  not  be  accomplished 
with  any  degree  of  certainty.  Thus,  as  Delpech  ob- 
serves, when  the  hand  or  foot  has  been  deeply  bitten  in 
several  places,  it  is  obvious  that  it  would  be  impossible 
to  make  caustic  (or  the  cautery)  certainly  reach  every 
part  which  the  saliva  of  the  rabid  animal  may  have 
touched.  Besides, the  mischief  resulting  both  from  the 
injury  and  the  other  proceedings  together,  might  be 
such  as  to  afford  no  prospect  of  saving  the  limb,  or  at 
least  of  preserving  it  in  a useful  state. — (See  Precis 
Elem.  des  Mai.  CMr.  t.  2,  p.  133.)  I have  knowm  of 
one  or  two  cases  in  which  the  patients  lost  their  lives 
in  consequence  of  the  excision  or  destruction  of  the 
bitten  parts  not  having  been  attempted,  on  account  of 
the  surgeon’s  reluctance  to  cut  tendons,  or  wound  a 
large  artery,  as  one  of  those  at  the  wrist.  In  such 
cases,  however,  the  fear  of  rendering  a muscle  useless, 
or  of  wounding  an  artery,  is  no  justification  of  leaving 
the  patient  exposed  to  a danger  so  surely  fatal  as  that 
of  the  hydrophobic  virus,  if  it  once  affect  the  constitu- 
tion. The  artery  should  be  exposed'  for  a suificient 
length,  and  secured  with  two  ligatures,  when  the  re- 
quisite extirpation  of  the  parts  between  them  may  be 
safely  performed. 

When  once  the  hydrophobic  symptoms  have  com- 
menced, there  is  little  or  no  hope  of  saving  the  patient, 
the  disease  having  almost  invariably  baffled  every  plan 
of  treatment  which  the  united  talents  r)f  numerous 
medical  generations  have  suggested.  All  the  most 
powerful  medicines  of  every  class  have  been  tried  again 
and  again  ; mercury,  opium,  musk,  camphor,  arsenic, 
the  nitrate  of  silver,  cantharides,  belladonna,  ammonia, 
plunging  the  patient  in  the  sea,  bleeding,  &c.  &cc. 

The  inefficacy  of  opium  is  now  generally  acknow- 
ledged : in  the  space  of  fourteen  hours.  Dr.  J.  Vaughan 
gave  one  patient  fifty-seven  grains  of  opium,  and  also 
half  an  ounce  of  laudanum  in  a glyster,  but  the  fatal 
termination  of  the  disease  was  iiot  prevented.  Dr. 
Babington  even  prescribed  the  enormous  quantity  of 
180  grains  in  eleven  hours,  without  the  least  amend- 
ment, or  even  any  narcotic  effect. — (Med.  Records  and 
Researches,  p.  12\.)  On  the  very  first  day  that  rabies 
decidedly  show’ed  itself  in  a man,  who  had  been  bit  by 
a mad  dog,  Dupuytren  injected  into  the  vena  saphena, 
by  means  of  Anel’s  syringe,  two  grains  of  the  extract 
of  opium  dissolved  in  distilled  water,  and  as  a degree 
of  calm  appeared  to  be  the  result,  four  grains  more 
were  thrown  into  the  cephalic  vein.  The  patient  re- 
mained perfectly  tranquil  three  hours  lotiger  ; but  the 
symptoms  afterward  recurred  with  increased  violence. 
The  next  morning,  about  six  or  eight  grains  more  were 
dissolved  and  thrown  into  the  circulation  ; but  all  was 
in  vain,  as  the  patient  died  in  three-quarters  of  an  hour 
after  the  last  injection. — (See  Diet,  des  Sciences  Mid. 
t.  47,  p.  131.)  By  Dr.  Brandreth,  a solution  of  the  ace- 
tate of  morphine  has  been  more  recently  tried,  without 
success.— (See  Edinb.  Med.  Joum.  JVo.  LXXXII. 
p.  76.) 

As  for  belladonna,  its  employment  for  the  prevention 
and  cure  of  liydrophobia  is  very  ancient,  its  external 
use  for  this  purpose  having  been  mentioned  by  Pliny, 
and  its  internal  exhibition,  with  the  same  view,  by 
Theod.  Turquetiis,  in  a posthumous  work  published 
in  1696. — (See  Praxeos  Medicee  Syntagma,  <S-c.)  In 
1763,  belladonna  was  recommended  by  Schmidt  as  a 
remedy  for  hydrophobia,  and  in  1779  by  J.  H.  Munch. 
— (See  Richter's  Chir.  Bibl.)  It  has  so  frequently 
failed,  that,  in  this  country,  very  little  confidence  is 
now  put  in  it ; but  in  Italy  it  is  still  employed,  and 
some  cases,  published  by  Brera,  where  it  was  exhibited 
in  very  powerful  doses,  in  conjunction  with  the  warm 
bath,  and  mercurial  friction,  lend  to  show,  that  if  will 
sometimes  arrest  the  disease  in  its  incipient  state. — 
(Mem.  Soc.  Ital.  Scimia  Modena,  t.  17.) 

A few'  years  ago,  the  public  hope  was  raised  by  the 
accounts  given  of  hydro-chlorine,  or  oxymuriatic  acid. 


HYDROPHOBIA. 


69 


Wendelstadt  even  'published  the  story  of  an  EngHsh- 
tnan,  who  allowed  himself  to  be  bit  several  times  by  a 
mad  dog,  and  then  saved  himself  by  washing  the  bites 
with  this  acid.  And,  still  more  recently,  Brugnatelli, 
in  the  Italian  Journ.  of  Physic,  Chemistry,  &c.  (f.  9,  p. 
324),  has  published  sonie  observations  tending  to  prove 
its  efficacy.  The  bites  are  washed  with  it,  and  then  co- 
vered with  charpie  wet  with  it.  And,  when  the  symp- 
toms commence,  if  it  cannot  be  swallowed  in  a tiuid 
form,  Brugnatelli  gives  bread  pills  imbued  with  it.  For 
a child  eight  years  old,  the  dose  is  3ij.  four  or  tive 
times  a day,  but  gradually  increased.  According  to 
Orfila,  hydro-chlorine  was  long  since  recommended  by 
Cluzel  as  an  internal  remedy  for  hydrophobia. — {Se- 
cours  d dunner  aux  Personnes  empoisonn^es,  6,-c.  Svo. 
Paris,  1818,  p.  153.)  With  regard  to  Brugnatelli’s 
cases,  they  are  said  to  be  so  destitute  of  precision,  that 
no  inference  can  be  drawn  from  them. — (Diet,  des 
Sciences  Mid.  t.  47,  p.  119.)  In  order  to  give  hydro- 
chlorine a fair  trial,  it  was  used  internally  and  exter- 
nally on  seven  patients  in  the  Hdtel  Dieu  at  Lyons,  in 
1817.  The  bites  were  washed  and  bathed  with  it,  and 
some  of  them  also  cauterized ; and  each  patient  took 
daily  a drachm  of  the  acid,  made  into  an  agreeable 
sweetened  drink.  All  these  unfortunate  individuals 
afterward  died  of  rabies,  though  the  treatment  was 
begun  the  day  after  the  receipt  of  the  wounds. — (L.  F. 
Trolliet,  Mouveau  Traiti  de  la  Rage,  Sec.)  The  ex 
cision  of  the  bites  70  hours  after  their  infliction,  and 
washing  the  wound  with  oxymuriatic  acid,  did  not,  in 
Dr.  Johnson’s  case,  prevent  the  disease. — (See  Edinb. 
Med.  and  Surg.  .Tourn.  vol.  15,  p.  212.)  In  America, 
the  plant  Scutellaria  laterifolia  has  been  greatly  extolled 
as  a certain  specific  for  hydrophobia. — (See  a History 
of  Scutellaria  Laterifolia,  as  a remedy  for  preventing 
and  curing  Hydrophobia,  by  Lyman  Spalding,  M.  D. 
Mew- York,  1819.)  And  M.  Marochetti,  of  Moscow, 
has  described  a new  treatment,  which  consists  in 
giving  large  doses  of  genista  tinctoria,  or  butcher’s 
broom,  and  pricking  with  a lancet,  and  then  cauterizing 
with  a hot  needle  some  little  pustules  said  by  him  to 
form  at  the  orifices  of  the  sub-maxillary  glands,  be- 
tween tlie  third  and  ninth  days  from  the  period  of  the 
bite,  the  mouth  being  afterward  well  washed  out  with 
the  decoct,  genislae.  M.  Magendie,  West,  and  various 
English  practitioners,  however,  have  not  been  able  to 
discern  these  sublingual  pustules,  possibly  in  conse- 
quence of  tlieir  having  looked  for  them  too  late,  that  is, 
after  the  accession  of  the  constitutional  disorder;  for 
it  appears  that  M.  Magistel,  of  Saintes,  has  noticed 
such  pustules  in  several  patients.  Some  arose  on  the 
6th  day,  others  later,  and  the  latest  on  the  32d  day. 
Of  ten  persons  bitten,  whom  M.  Magistel  attended,  five 
died,  notwithstanding  the  strict  adoption  of  Marochelti’s 
treatment. — (See  Journ.  Gin.  de  Mid.)  M.  Villerm^ 
also  observed  a transparent  pustule  under  the  left  side 
of  the  tongue,  in  the  case  of  a female,  on  the  eighth 
day  from  the  (Revue  Mid.  Anderson's  Quarterly 

Journ.  vol.  1,  p.  124.)  In  relation  to  this  part  of  the 
subject,  it  merits  notice,  tha{  the  vesicles  were  particu- 
larly sought  for  in  two  rabid  sheep  at  the  veterinary 
School  of  Alfort,  but  could  not  be  detected. — (Magen- 
dic's  Journ.  t.  8,  p.  .328.)  The  prussic  or  hydrocyanic 
acid  has  likewise  been  proposed,  on  account  of  its  re- 
puted anti-spasmodic  properties ; but  some  experiments 
made  with  it  on  dogs  by  Dupuytren,  Magendie,  and 
Breschet,  furnish  no  results  in  favour  of  its  being  likely 
to  prove  useful  in  the  present  disorder. — (See  Diet,  des 
Sciences  Mid.  t.  47,  p.  132.)  Indeed,  the  following 
statement,  if  correct,  leaves  little- hope  that  any  effect- 
ual medicine  for  hydrophobia  will  ever  be  discovered. 
“ The  most  active  substances,  the  most  powerful  nar- 
cotics (says  M.  Magendie),  have  no  eflect  upon  man 
or  animals  attacked  with  rabies.  I do  not  merely 
speak  of  substances  introduced  into  the  stomach,  and 
the  operation  of  which  may  be  prevented  or  dimi- 
nished by  so  many  circumstances:  Ispeakof  substances 
inj«'cted  into  the  veins,  and  the  effects  of  which  must 
lie  equally  prompt  and  energetic.  For  instance,  I have 
several  times  introduced  into  the  veins  of  rabid  dog.s 
very  strong  doses  of  opium  (10  grains),  without  produ- 
cing the  least  narcotic  effect,  while  a single  grain  of 
tlie  watery  extract,  injected  into  the  veins  of  a healthy 
dog,  immediately  makes  him  fall  asleep,  and  often 
continue  so  eight  or  ten  hours.  The  same  phenomena 
are  remarked  in  our  own  species.  M.  Dupuytren  and 
I injected  into  the  radial  vein  of  a young  man  labour- 


ing under  hydrophobia,  about  eight  grains  of  the 
gummy  extract  of  opium,  without  any  apparent  result. 
We  have  also  seen  mad  dogs  bear  the  introduction  of 
prussic  acid  into  their  veins,  without  an  instant’s  re- 
mission in  the  progress  of  their  disorder.” — (Journ.  de 
Physiologie,  t.\,p.  41.)  M.  Magendie  frequently  no- 
ticed in  liis  experiments,  that  an  artificial  aqueous 
plethora  manifestly  enfeebles  all  the  functions  of  the 
animals  subjected  to  it,  and  especially  those  of  the  ner- 
vous system.  Hence,  he  was  led  to  think  that  some 
benefit  might  arise  from  it  in  a case  where  the  activity 
of  the  nervous  system  is  at  its  greatest  height.  His 
idea  received  encouragement  also  from  considering 
that,  in  hydrophobia,  the  patient  lakes  no  drink  to  re- 
place the  fluid  separated  from  the  circulation  by  the 
cutaneous  and  pulmonary  perspiration,  and  that,  after 
venesection,  the  blood  seems  as  if  it  hardly  contained 
any  serum.  The  experiment  was  first  tried  on  a rabid 
dog,  from  which  about  a pound  of  blood  was  drawn, 
and  then  60  oz.  of  water  injected  into  the  left  jugular 
vein,  about  10  or  12  oz.  of  blood,  mixed  with  water, 
however,  being  purposely  allowed  to  flov*i^  out  during 
the  latter  part  of  the  operation.  The  animal,  whicti 
had  previously  been  quite  furious,  now  became  ran- 
quil;  but  five  hours  afterward  it  was  attacked  wiili 
difficulty  of  breathing,  which  ended  fatally  in  uait  aa 
hour.— (Fbl.  cit.  p.  44,  «S-c.)  On  the  15th  of  Oclober, 
1823,  M.  Magendie  injected  a Paris  pint  of  water, 
heated  to  30  deg.  Reaumur,  into  the  veins  of  a man’s 
arm,  who  was  labouring  under  hydrophobia  in  an  ad- 
vanced and  violent  form.  Directly  after  the  operation, 
the  patient,  from  being  furious,  became  tranquil;  the 
pulse  fell  trom  150  to  120,  then  to  100,  and  in  twenty 
minutes  to  80.  The  convulsive  motion  ceased,  and 
the  patient  drank  a glass  of  water  without  any  diffi- 
culty. Notwithstanding  a hemorrhage  from  the  bow- 
els, lie  continued  to  improve  till  the  5th  day,  when  he 
was  seized  with  acute  pains,  and  swelling  of  the  wrists, 
knees,  and  elbows,  and  threatened  with  an  extensive 
abscess  of  the  leg,  the  consequence  of  the  lodgment  in 
the  foot  of  two  pieces  of  lancets,  broken  in  the  attempt 
to  bleed  him,  while  he  was  suffering  violent  paroxysms 
in  a previous  stage  of  the  disorder.  Despondency  and 
mental  agitation  again  came  on,  and  he  died  early  on 
the  9th  day  from  the  experiment.  On  dissection,  the 
swelled  joints  were  found  filled  with  pus;  the  mucous 
membrane  of  a part  of  the  small  intestines  reddened  by 
the  expansion  of  veins;  several  small  ulcerations  in 
the  ileum  where  it  joins  the  emeum ; the  blood  in  a 
decidedly  putrefied  state;  the  heart  and  large  vessels 
distended  with  gas;  air  under  the  peritoneal  coat  of 
the  stomach  and  intestines ; posterior  part  of  the  lungs 
a little  sw'elled;  trachea  sound,  but  the  bronchiae  red. 
Magendie  considers  this  case  on  the  whole  very  fa- 
vourable to  the  practice ; and  when  it  is  reflected,  that 
the  patient  underwent,  directly  after  the  experiihent,  a 
great  and  sudden  change  for  the  better,  lived  eight  days 
after  the  injection,  and  then  possibly  died  rather  from 
other  accidental  complaints,  it  must  be  acknowledged, 
that  the  method  seerneff  well  deserving  of  farther  trials. 
I would  also  paticularly  recommend  its  adoption  in  an 
earlier  stage,  and  while  the  patient  is  less  reduced, 
than  the  one  on  whom  the  experiment  was  made  and 
failed,  in  one  of  the  borough  hospitals.  By  Dr.  Rossi, 
of  Turin,  the  trial  of  galvanism  was  suggested  (Ali- 
hert  JVouveaux  Elirnens  de  Thirapeutiqne,  t.  2,  p.  436, 
ed.  4) ; yet  the  only  fact  brought  forward,  as  an  en- 
couragement to  persevere  with  the  last  means,  appears 
to  a modern  author,  from  its  symptoms  and  progress, 
not  to  have  been  a case  of  true  rabies. — (Diet.  cit.  t. 
47,  p.  126.)  The  rapid  and  powerful  effects  of  the  bite 
of  a viper  on  the  whole  system,  and  perhaps  the  idea 
that  the  operation  of  this  animal’s  venom  might  coun- 
teract that  of  the  hydrophobic  virus,  led  some  experi- 
menters to  try  what  would  be  the  result  of  subjecting 
patients,  affected  with  rabies,  to  the  bite  of  thai  kind 
of  snake.  The  project,  however,  was  attended  with 
no  success.  Three  cases  of  this  description  were  com- 
municated to  the  Royal  Society  of  Medicine  (Hist.  p. 
201) ; two  additional  ones  were  recorded  by  Dr.  Gilibert, 
physician  to  the  Hfltel  Dieu  at  Lyons  (A doers.  Mid. 
Pract.  p.  2.57)  ; and  Viricel,  surgeon  of  the  same  hos- 
pital, repeated  the  experiment  on  a child,  which  yet 
fell  a victim  to  hydrophobia.  Other  trials  are  also 
said  to  have  been  made  in  France  and  Germany  with 
no  belter  success.  Dr.  de  Mathiis,  in  the  year  1783,  let 
a viper  bite  a rabid  dog  on  the  throat.  The  dog’s  head 


70 


HYDROPHOBIA. 


was  attacked  with  considerable  swelling,  the  hydro- 
phobia ceased,  and,  according  to  some  accounis,  ilie 
animal  perfectly  recovered,  but,  according  to  other 
statements,  tliough  it  drank  freely  as  soon  as  its  liead 
had  swelled,  it  only  survived  tire  experiment  a few 
liours. — (See  Diet,  des  Sciences  Med.  t.  47,  p.  126.) 

Some  facts,  which  occurred  a few  years  ago  in  the 
East  Indies,  tended  for  a time  to  raise  an  expectation, 
that  a copious  abstraction  of  blood  might  be  the  means 
of  preserving  patients  actually  attacked  with  this  fatal 
disorder.  Mr.  Tymon,  assistant  surgeon  of  the  22d 
light  dragoons,  tried  successfully  the  method  of  taking 
away  at  once  an  immense  quantity  of  blo6d  from  the 
patient.  “ I began  by  bleeding  him  (says  Mr.  Tymon) 
■U7itil  scarcely  a pulsation  could  be  felt  in  either  arm." 
Opium  was  afterward  given,  and  the  patient  salivated 
with  mercury.— (See  Jl/fldras  Gazetteof  Mov.HS,  1811.) 

Although  in  the  observations,  annexed  to  this  case 
by  Dr.  Berry,  there  are  some  circumstances  which  rea- 
der it  probable,  that  the  case  was  really  hydrophobia : 
yet,  as  the  successful  termination  of  it  is  an  evetit  so 
extraordinary,  1 much  regret  that  some  desirable  infor- 
mation is  omitted.  For  instance,  we  have  no  account 
of  any  pain  or  changes  in  the  bitten  part  or  limb,  at  the 
first  coining  on  of  the  indisposition.  The  early  consti- 
tutional symptoms  are  not  described,  and  the  violent 
spasms,  screaming,  &,c.,  are  the  first  things  mentioned. 
Some  particulars  of  the  dog  would  also  have  been 
interesting. 

Such  information,  ihdeed,  becomes  still  more  essen- 
tial, when  we  find  it  stated  that  another  man,  Serjeant 
Jackson,  was  also  bitten  by  the  same  dog,  and”  had 
liydrophobia  in  a mild  form,  from  which  he  recovered 
under  the  use  of  mercury,  blisters  to  the  head,  and 
cathartic  injections,  without  any  recourse  to  bleeding 
at  all.  This  last  case  is  even  more  contrary  than  the 
former  to  wdiat  general  experience  leaches ; because 
mercury,  blisters,  and  injections  have  been  tried  a 
thousand  times  unavailingly ; while,  perhaps,  blood- 
letting, in  the  m an ntr  practised  by  Mr.  Tymon,  is  a new 
treatment.  Dr.  Shoolbred,  of  Calcutta,  published  a 
second  case  of  hydrophobia  cured  by  bleeding  ad  deli- 
quiuin  animi,  and  afterward  exhibiting  calomel  and 
opium.  The  patient  being  threatened  with  a relapse, 
was  largely  bled  again.  The  whole  of  the  success  is 
imputed  by  Dr.  Schoolbred  to  the  venesection.  But 
this  gentleman  is  not  so  sanguine  as  to  believe  that 
bleeding  will  cure  every  case  of  hydrophobia.  It  is 
probable  that  there  is  a period,  beyond  which  its  cura- 
tive effect  cannot  extend,  and,  therefore,  it  is  upon  the 
first  appearance  of  unequivocal  symptoms  of  the  dis- 
ease, that  he  thinks  copious  bleeding  affords  a prospect 
of  success,  while  the  delay  of  only  a few  hours  may 
prove  fatal.  He  observes,  that  the  medical  profession, 
taught  by  numerous  disappointments,  admit  very  cau- 
tiously the  claims  of  any  new  practice  to  general 
adoption.  If  several  patients  in  hydrophobia,  there- 
fore, should  happen  to  be  bled  in  an  advanced  stage  of 
the  disease,  and  die  (as  they  inevitably  would  do, 
whether  they  had  been  bled  or  not),  sucli  cases  would 
be  quoted  against  the  new  practice,  as  failures.  But 
Dr.  Slioolbred  argues,  that  numerous  failures  in  an 
advanced  stage  of  the  disease,  can  form  no  just  ground 
for  the  rejection  of  a remedy  which  has  eftected  a cure 
in  an  earlier  stage.  He  insists  upon  the  necessity  of 
making  a large  orifice  in  the  vein,  so  as  to  evacuate  the 
blood  quickly,  which  must  he  allowed  to  flow,  without 
regard  to  quantity,  ad  deliquium  animi. 

Dr.  Shoolbred  was  well  aware  that  bleeding  had  often 
been  tried  in  hydrophobia;  but,  says  he,  owing  proba- 
bly to  the  evacuation  not  having  been  pushed  far 
enough,  when  used  in  the  early  stage  of  tlie  disease, 
or  to  the  period  for  its  beneficial  employment  having 
elapsed,  the  cases  in  which  it  was  tried  afforded  little 
or  no  encouragement  to  the  continuance  of  the  prac- 
tice. 

Since  the  preceding  cases,  the  effect  of  bleeding  has 
had  the  fairest  trials  made  of  it,  and  some  of  the  re- 
ports are  in  favour  of  its  occasional  utility.— (See  Par- 
ticulars of  the  sxiccessful  Treatment  of  a Case  of  Hy- 
drophobia, by  R.  TVxjnne,  8no.  Shrewsbury,  1813  ■,  also 
F.dmonstone  in  Loud.  Med.  Repository,  vol.  3 p.  03.) 
In  almost  every  instalice,  however,  it  fails. in  hindering 
the  usual  melancholy  event.— (See  Kerrison's  Case 
and  Obs.  in  Med.  Repository,  roLH.  p,  197.)  'I’his  un- 
pleasant truth  I think,  receives  confirmation  from  tlie 
fact,  that  the  practice  is  far  from  being  new. 


Dr.  Mead,  who  was  very  confident  that  he  had  found 
an  infallible  preventive  of  the  disease  in  a little 
liverwort  and  black  pepper,  aided  by  bleeding  and  cold 
oathing  before  the  commencement  of  the  course  of 
medicine,  says,  “ As  to  all  other  ways  of  curing  the 
hydrophobia,  I own  I have  not  been  so  happy  as  to 
find  any  success  from  the  many  I have  tried.  Bathing 
at  this  time  is  ineffectual.  / have  taken  away  large 
quantities  of  blood;  have  given  opiates,  volatile  salts, 
&;c.  All  has  beeii  in  vain,  because  too  late.”  PJot- 
withstanding  his  disappointment,  he  concludes,  “If 
any  relief  could  be  expected  in  this  desperate  state,  I 
think  it  would  be  from  bleeding,  even  ad  animi  deli- 
quium,” ^c. 

3'he  doctrines  of  Boerhaave  also  led  him  and  his 
pupils  to  recommend  and  practise  bleeding  in  hydro- 
phobia. “ The  distemper  (says  he)  is  to  be  treated  as 
one  highly  inflammatory,  upon  the  first  appearance  of 
the  signs  which  denote  its  invasion,  by  blood-letting 
from  a large  orifice,  continued  till  the  patient  faints 
away ; and  soon  after  by  enemata  of  warm  water  and 
vinegar,  &.c.  and  he  adds,  “ that  this  practice  is 
supported  by  some  small  number  of  trials.”  But 
the  particulars  of  the  success  alluded  to,  are  not 
given.  * 

Dr.  Shoolbred  finds,  that  a trial  of  it  was  made  at 
Edinburgh,  more  than  sixty  years  ago,  by  Dr.  Ruther- 
ford, who  took  away  gradually  sixty  ounces  of  blood 
from  a patient,  who  had  already  been  bled  the  same 
morning.  As  the  patient  lived  forty-eight  hours  after 
the  large  bleeding,  the  method  was  probably  tried  some- 
what early  in  the  disease;  and  the  case  may  therefore 
be  set  down  as  a fair  instance  of  the  failure  of  the 
practice.  The  trials  which  have  been  made  in  this 
country  of  the  practice  of  bleeding,  in  cases  of  hydro- 
phobia, since  the  receipt  of  the  above  reports  from 
India,  I am  sorry  to  say,  have  not  confirmed  its  efficacy. 

Bleeding  was  also  recommended  in  cases  of  hydro 
phobia,  by  Poupart. — (See  Hist,  de  I'Jlcad.  Royale  des 
Sciences  pour  Vannie  1699,  p.  48.)  The  practice  is 
likewise  mentioned  in  the  Medical  Essays  of  Edin- 
burgh, vol.  5,  part  2,  § 5;  and  in  the  writings  of  Dr. 
Rush.  See  also  Dr.  Burton's  Case,  Phil.  Mag.  Au- 
gust, 1805. 

Early  excision,  or  amputation  of  the  bitten  parts,  the 
application  of  cupping  glasses  to  the  wound,  or  the 
removal  of  atmospheric  pressure,  as  recommended  by 
Dr.  Barry  (See  Experimental  Researches,  d,-c.  Bond. 
1826) ; the  injection  of  warm  water  into  the  veins,  and 
bleeding  ad  deliquium  in  the  early  stage,  are  the  plans 
which  have  most  evidence  in  their  favour.  It  was 
observed  by  a critical  writer,  before  the  experiment  of 
injecting  water  had  been  made,  “That  experience 
authorises  the  placing  confidence  in  bleeding  ad  deli- 
quium ; on  vomiting ; and  perhaps  on  the  use  of  atropa 
belladonna ; and  on  tobacco  exhibited  as  a clyster. 
That  it  is  probable,  advantage  would  result  from  the 
combined  employment  of  bleeding,  vomiting  (See  Dr. 
Satterly's  Obs.  in  Medical  Trans,  vol.  4),  and  purging 
in  the  early  part  of  the  disease.  That  analogy  recom- 
mends the  trial  of  spirit  of  turpentine  in  the  convulsive 
stage  of  the  disease.” — {Med.  Repository,  vol.  3,  p.  54.) 
In  one  case,  in  which  oil  of  turpentine  was  copi- 
ously given,  both  in  electuary  and  clysters,  the  patient 
died  on  the  fourth  day. — Med.  Repository,  M'o.  for 
October,  1822. 

[In  the  last  republication  of  Mr.  Cooper’s  Dictionary 
in  this  country.  Dr.  Samuel  L.  Mitchill  furnished  a 
letter  addressed  to  himself,  enclosing  “ a memorial  read 
before  the  Medico-Physical  Society  of  Moscow,  by  Dr. 
Michel  Marochetti,  member  of  said  society,  and  at- 
tending physician  at  the  Gallitzir  Hospital.”  It  is 
entitled,  “Observations  on  Hydrophobia,  containing 
certain  indications  for  ascertaining  the  existence  of  the 
hydrophobic  poison  in  an  individual,  and  the  means  of 
preventing  its  development  by  destroying  its  germ.” 

The  “certain  indications”  to  which  this  Russian 
physician  refers,  and  on  which  he  relies  for  ascertaining 
the  existence  of  the  rabid  poison  in  an  individual,  are 
the  appearance  of  two  small  tumours,  one  on  either  side 
of  the  frenum  lingus,  within  six  weeks  of  the  bite  of 
a rabid  animal. 

He  states,  ns  the  result  of  his  observation,  that  it  is 
necessary  to  examine  the  lower  side  of  the  tongue 
twice  a llay  for  six  weeks  after  the  bite  ; and  this  fre- 
quent inspection  is  necessary,  because  the  tumours  only 
exist  twenty-four  hours,  when  tlie  virus  becomes  reab- 


HYI) 


HYD 


71 


wrbed,  and  these  two  irregular  tumours  disappear,  and 
the  case  terniinales  fatally. 

He  directs  that  tlrese  tumours  be  cauterized  so  soon 
as  they  are  visible,  or,  what  is  better,  opened  with  a 
small  sharp  lancet,  wlien  a sanious  lymph,  somewhat 
greenish^  will  escape,  which  is  tlie  true  poison,  and 
which  the  patient  must  spit  out.  The  mouth  is  then  to 
be  washed  with  a decoction  of  the  tops  and  flowers  of 
the  genista  iateo  tinctoria  (Dya’s  broom).  This  same 
decoction  is  to  be  drunk  to  the  extent  of  a pound  and  a 
half  per  day,  during  the  six  weeks  the  patient  is  under 
examination.  Aird  these  means,  Dr.  M.  asserts,  from 
his  personal  experience  in  the  treatment  of  numerous 
cases,  will  prevent  the  development  of  the  virus,  by 
destroying  its  germ. 

What  attention  this  Russian  practice,  which  may  be 
called  a discovery,  has  attracted  in  Great  Britain  or  the 
c<;ntinent,  ]\lr.  Cooper  must  have  had  the  means  of 
knowing,  and  yet  he  is  silent  on  the  subject ; whence  w'e 
may  conclude,  it  is  not  relied  on  in  Eirgland.  In  this 
country,  there  is  little  confidence  among  the  profession 
in  any  curative  for  hydrophobia;  and  physicians  in 
America  generally  concur  in  these  two  important 
facts,  as  Mr.  Cooper  calls  them  : first,  the  disease  may 
often  be  prevented ; secondly,  it  can  hardly  ever  be 
cured. 

There  is  so  much  ambiguity  about  this  subject,  that 
it  becomes  us  to  be  modest  in  deciding  a patient  to  have 
hydrophobia,  for  scarcely  a symptom  belonging  to  it  is 
invariable  in  every  case;  and  many  of  the  cures  re- 
ported, are,  doubtless,  modifications  of  hysteria.  I 
have  seen  more  than  one  of  these  so  called,  because 
the  patient  had  been  bitten  by  a dog,  months,  or  years 
before,  without  any  evidence  of  his  being  rabid.— Ree.9e.] 

See  Jos.  de  jlromatarius,  De  Rabie  Contagiosa.,  ito. 
Franco/.  1626.  Savvages  sur  la  Rage,  12mo.  Paris, 
1771.  James  on  Canine  Madness,  Svo.  Land.  1780. 
Mead  on  the  Bile  of  a Mad  Dog.  Jos.  S.  Dolby,  The 
Virtues  of  Cinnabar  and  Musk,  against  the  Bite  of  a 
Mad  Dog,  4to.  Birmingh.  1764.  J.  Heysham,  De 
Rabie  Canina,  Edinb.  1777.  B.  F.  Munch,  De  Bella- 
donna, Frank.  Del.  op.  1.  D.  P.  Layard,  Essay  on  the 
Bite  of  a Mad  Dog,  ‘id  ed.  1763.  R.  Hamilton,  Re- 
marks on  Hydrophobia,  id  ed.ivols.  8vo.  Loud.  1798. 
Medical  Museum,  vol.  2.  Land.  Med.  Trans,  vols.  2 and 
4,  ed.  2.  Med.  Obs.  and  Jny.  vol.  3;  and  Fothcrgill  in 
vol.  5 of  the  same  work.  C.  Mugenl,  Essay  on  Hydro- 
phobia; to  which  is  prefixed,  the  Case  of  a Person 
cured,  Boo.  Land.  1753.  Le  Roux,  sur  la  Rage,  8vo. 
Dijon,  1780.  Idem,  Traitement  local  de  la  Rage,  8vo. 
Paris,  1783.  Edinb.  Med.  Comment,  vol.  5,  p.  42.  .7. 
V avghan's  Cases  and  Obs.  on  Hydrophobia^  8vo.  Bond. 
1778.  Dr.  Powell's  Case  of  Hydrophobia.  Latta's 
System  of  Surgery,  vol.  3.  Cullen's  First  Lines,  vol. 
4.  Enaux  et  Chaussier,  Mdthode  de  trailer  les  Mor- 
sures  des  Jinimaux  enragis,  Src.  12/no.  Dijon,  1780. 
Memoirs  of  the  Med.  Society  of  London,  vol.  1,  p.  243. 
Medical  Communications , vol.  1.  .T.  Mease,  Jin  Essay 

on  the  Disease  produced  by  the  Bite  of  a Mad  Dog, 
with  a Preface,  <^c.  by  J.  C.  Lettsom,8vo.  Philadelphia, 
1793.  M^in.  fie  la  Sociiti  Roy  ale  de  Midecine  de  Paris, 
pour  C an.  1782  et  1783.  Ferriar's  Med.  Facts  and  Ob- 
servations, and  his  Med.  Histories,  Src.  2d  ed.  8vo. 
J.,ond.  1810.  Callisen's  Systema,  Chirurgice  Hodiernce, 
t.  \.  p.  593.  Hafniw,  1798.  Marcet,  in  Med.  Chir. 
Trans,  vol.  1,  p.  132,  Src.  Jesse  Foote,  Jin  Essay  on  the 
Bite  of  a Mad  Dog,  8iio.  Land.  1788.  Lassus,  Patho- 
logic Chir.  t.  2,  p.  239,  Src.  ed.  1809.  A valuable  Paper 
by  Dr.  .7.  Hunter,  in  Trans,  of  a Society  for  the  Im- 
provement of  Med.  and  Chir.  Knowledge,  vol.  1,  art.  17. 
James  Gillman's  Dissertation  on  the  Bite  of  a Rabid 
Jinimal,  8oo.  Lond.  1812.  S.  Bardsley  in  Memoirs  of 
the  lAterary  and  Philosophical  Society  of  Manchester, 
vol.  4,  part  2.  Medical  Reports,  Src. ; to  which  are  added, 
an  Inquiry  into  the  Origin  of  Canine  Madness,  and 
Thoughts  on  a Plan  for  its  Extermination  from  the 
British  Isles,  8vo.  J.,ond.  1807.  Babington  in  the 
Mrdicnl  Records  and  Researches,  Lond.  1798.  R.  Pear- 
son, Jirguments  in  favour  of  an  Inflammatory  Dia- 
thesis in  Hydrophobia  considered,  Birmingh.  1798. 
JIrt.  Hydrophobia,  in  Rees's  Cyclopcedia.  M.  Ward, 
facts  establishing  the  Efficacy  of  the  Opiate  Friction 
in  Spasmodic  and  Febrile  Diseases ; also  an  Attempt 
to  t^’e^tigate  the  Mature,  Causes,  and  Method  of  Cure 
of  Hydrophobia  and  Tetanus,  8vo.  Manchester,  1809. 
Ca.tes  and  Cures  of  Hydrophobia,  selected  from  the 
Uentleman  i Magazine,  8vo.  Lond.  1807.  O.  Pifickard, 


Case  of  Hydrophobia,  8vo.  Lond.  1808.  B.  Moseley,  on 
Hydrophobia,  its  Prevention  and  Cure,8oo.  Lond.  1809. 
J.  F.  A.  Lalouettc,  Essai  sur  la  Rage,  8vo.  Paris,  1812. 
A.  Portal,  Mimoircs  sur  la  Mature,  Src.  des  plusieurs 
Maladies,  t.2,p.  31, 8vo.  Paris,  1800.  O.  C.  Reich,  De 
la  Fiivre  en  gSniral,  de  la  Rage,  Src.  8vo.  Metz,  1800. 
Bosquillon,  MSm.  sur  les  Causes  de  V Hydrophobic,  8i>o. 
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la  Curadel  Idrophobia,  ossia  della  Malattia proveniente 
dal  Morso  del  Cane  rabbioso,8vo.  Bologna,  1806.  Dr. 
Berry's  Obs.  and  Mr.  Tymon's  Case  cured,  by  large 
blood-letting,  as  detailed  in  the  Madras  Gazette  of 
Movember  23, 1818;  and  Dr.  Slioolbred's  Case  success- 
fully treated  by  copious  bleeding,  as  related  in  one  of 
the  Asiatic  Mirrors  for  May,  1812.  O'Donnel's  Cases 
of  Hydrophobia,  1813.  T.  Arnold,  Case  of  Hydro- 
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The  Morbid  Anatomy  of  the  Brain  in  Mania  and  Hy- 
drophobia, with  the  Pathology  of  these  two  Diseases, 
ire.  8vo.  Lond.  1815.  R.  Reid,  on  the  Mature  and  Treat  ■ 
ment  of  Tetanus  and  Hydrophobia,  8oo.  Dublin,  1817. 
Autenrieth,  Diss.  de  hactenus  pratervisa  Mervorum 
Lustratione  in  Sectionibus  Hydrophoborum,  Ato.  Tub 
1802.  Gottfr.  Zinke,  Meue  Ansichten  der  Hundswuth, 
8vo.  Jena,  1804.  Diet,  des  Sciences  Med.  t.  22,  art. 
Hydrophobic,  et  t.  47,  art.  Rage.  G.  Lipscombe,  Cau- 
tions and  Reflections  on  Canine  Madness,  8vo.  Lond. 
1807.  C.  Giiber,  Tract.  Abhandl.iibcr  die  Vorbuegung, 
•Sr c.  der  Hundswuth,  8vo.  Wien.  1818;  this  author  has 
confidence  in  the  powder  of  meloe  maialis.  C.  F.  Harles, 
uber  die  Behandlung  der  Hundswuth,  Ato.  Frank/. 
1809:  Stramonium  recommended.  Brera,  Comm.  Cli- 
nico  per  la  Cura  del  Idrophobia,  in  Mem.  Soc.  Ital, 
Scienz.  Modena,  1. 17.  J.  M.  Axter,  Mouv,  Bibl,  Ger- 
man. Mid.  Chir.  1821 ; Can thar ides,  a preventive. 
Marochetti  in  Petersburgh  Miscellanies  of  Med.  Sci- 
ence. Magcndie,  Journ.  de  Physiologic  Experimentate, 
t.  1,  .S'C.  J.  Booth  on  Hydrophobia,  8vo.  Lond.  1824. 
Quarterly  Journ.  of  Foreign  Med.  vols.  3 and  4.  Da- 
vid Barry,  Exp.  Researches  on  the  Influence  of  Atmos- 
pheric Pressure  upon  the  Progression  of  the  Blood  in 
the  Veins,  upon  Absorption,  Src.  8vo.  Lond.  1826. 

HYDROPHTHALMIA.  (From  D6a/p,  water,  and 
6(l)Qa\pbs,  the  eye.)  Dropsy  of  the  Eye. 

Hydrophthalmvs ; Hydrophthalmos.  Also  Bupthal- 
mos,  or  ox-eye.  In  the  eye,  as  in  other  organs,  dropsy 
arises  from  a disproportion  taking  place  between  the 
action  of  the  secerning  arteries,  by  which  the  fluid  is 
deposited  in  the  part,  and  the  action  of  the  absorbent 
vessels,  by  which  it  is  taken  up,  and  returned  to  the 
circulation ; and  according  to  this  principle,  the  disease 
may  be  supposed  to  depend,  either  upon  the  spcreiion 
being  too  rapid,  or  absorption  slower,  lliatf 'is,  proper^ 
tionate  to  the  natural  activity  of  the  vessels  by  which 
the  secretion  of  the  humours  of  the  eye  is  effected. 

According  to  Beer,  dropsy  of  the  eye  is  seldom  en- 
tirely a local  disease,  but  at  least  is  generally  combined 
with  an  unhealthy  constitution,  or  is  a mere  sympto- 
matic effect  of  some  other  dropsical  affection,  anasarca, 
hydrocephalus,  &c.  Sometimes  it  appears  as  a symp- 
tom of  chlorosis.  Beer  adds,  that  the  disease  may 
originate  either  from  a preternatural  accumulation  of 
the  aqueous  humour ; from  that  ofthe  vitreous  humour ; 
or  from  an  immoderate  accumulation  of  both  these 
humours  together. — {Lrhre,  von  den  Augenkr.  b.  2,  p. 
616,  Wein,  1817.)  When  the  vitreous  humour  collects 
in  this  manner  it  usually  loses  its  natural  consistence, 
and  becomes  thinner  and  more  watery. — {Richter, 
Anfangsgr.  b.3,  p,  392.) 

Professor  Beer  states,  that  in  the  case  proceeding 
from  a morbid  quantity  of  the  aqueous  humour,  the  first 
indication  of  the  disease  is  an  increase  in  the  dimen- 
sions of  the  cornea,  attended  with  a manifest  enlarge- 
ment of  the  anterior  chamber.  The  cornea  may  be- 
come, in  this  manner,  two,  three,  or  even  four  times 
wider  than  natural,  without  bursting  or  losing  its  trans- 
part^cy  ; for,  though  a turbid  appearance  is  discernible, 
this  depends  rather  upon  the  state  of  the  aqueous 
humour  itself.  The  iris,  which  in  the  very  commence- 
ment of  the  disease  begins  to  lose  its  mobility,  soon 
becomes  completely  motionless,  and  acquires  a duller 
colour;  the  pupil  always  remaining  in  the  mid-state 


72 


HYDROPHTHALMIA. 


between  contraction  and  dilatation.  In  the  eyeball  an 
annoying  sense  of  pressure,  tension,  and  heaviness  is 
felt,  rather  than  actual  pain.  In  the  beginiiing  of  the 
disease  there  is  a considerable  degree  of  far-sightedness, 
or  presbyopia,  which  soon  changes  into  a true  amau- 
rotic weakness  of  sight,  but  never  terminates  in  perfect 
amaurosis.  The  free  motions  of  the  eyeball  are  more 
and  more  interrupted  in  proportion  as  the  organ  grows 
larger,  and  it  has  invariably  a hard  feel,  while  the 
sclerotica,  to  the  distance  of  two  lines  from  the  margin 
of  the  cornea,  is  as  bluish  as  it  is  in  the  new-born 
infant. 

Respecting  the  precise  cause  of  the  accumulation  of 
the  aqueous  humour.  Beer  offers  no  observation  worthy 
of  repetition,  excepting  perhaps  that  in  which  he 
reminds  us,  that  a similar  collection  happens  appa- 
rently as  an  effect  of  the  conical  staphyloma  of  the 
whole  cornea. — (See  also  Wardrop's  Essays  on  the 
Morbid  Anatomy  of  the  Eye,  vol.  5,  p.  19.)  Indeed, 
as  far  as  our  knowledge  yet  extends,  it  is  impossible  to 
say  whether  the  changes  of  the  cornea  are,  in  the 
present  disease,  to  be  regarded  as  the  cause  or  the 
effect  of  the  increased  quantity  of  the  aqueous  hu- 
mour, or  whether,  as  seems  to  be  most  probable,  both 
phenomena  are  only  effects  of  one  and  the  same  cause. 
The  examples  somewhat  repugnant  to  this  idea,  are 
those  referred  to  by  Beer  as  symptomatic  of  other 
dropsical  affections.  On  the  other  hand,  Rlr.  Wardrop 
has  never  seen  a preternatural  collection  of  the  aqueous 
humour  without  its  being  accompanied  with  disease 
of  the  coats  of  the  eye. — {Vol.  cit.  p.  20.) 

In  hydrophthalmia  the  prognosis  is  generally  unfa- 
vourable, and  when  the  sight  is  nearly  or  quite  lost, 
scarcely  any  hope  can  be  entertained,  either  of  restoring 
vision  or  preserving  the  shape  of  the  eye.  Yet,  ac- 
cording to  Beer,  things  are  not  always  quite  so  un- 
promising in  the  preceding  form  of  the  disease,  espe- 
cially when  the  surgeon  is  consulted  in  time,  and  the 
patient’s  constitution  is  not  exceeditigly  impaired.  The 
same  experienced  author  has  never  seen  any  instance 
in  which  the  eye  spontaneously  burst;  on  the  contrary, 
when  the  habit  was  decidedly  bad,  and  the  treatment 
ineffectual,  the  disease  became  gradually  conjoined 
with  the  second  species  of  dropsy  of  the  eye,  and 
terminated  in  a frightful  disfigurement  of  the  whole 
organ,  and  death.  On  dissection,  the  innermost  tex- 
tures of  the  part  were  found  spoiled  and  disorganized, 
and  sometimes  even  the  orbit  itself  carious. — {Vol.  cit. 
p.  619.)  With  respect  to  the  treatment.  Beer  thinks, 
that  this  must  depend  very  much  upon  the  nature  of 
the  primary  disease  to  which  the  dropsical  affection 
is  ascribable  as  an  effect.  He  has  known  great 
benefit  sometimes  produced  by  the  submuriate  of 
mercury,  combined  with  digitalis,  and  a drink  contain- 
ing supCTlartrate  of  potassa  and  borax.  When  the 
disease  has  been  preceded  by  the  sudden  cure  of  any 
cutaneous  disease,  he  has  faith  in  the  method  of 
attempting  to  restore  the  affection  of  the  skin  by  in- 
oculation, of  if  that  be  impracticable,  by  stimulating 
its  surface  with  antimonial  ointment,  or  making  an 
issue.  This  plan  is  to  be  aided  with  internal  alterative 
medicines,  such  as  camphor,  the  sulphur  auratum  anti- 
monii,  and  flowers  of  sulphur.  The  local  applications, 
which  he  prefers  in  the  early  stage,  are  warm  dry  bags 
filled  with  aromatic  herbs,  and  rubbing  the  parts  about 
the  eyebrow,  sometimes  with  mercurial  ointment,  some- 
times with  a mixture  of  aether  and  liquor  ammoniae. 
But  when  the  disease  has  made  considerable  progress, 
and  vision  is  either  weak  or  nearly  lost,  while  the 
sclerotica  near  the  cornea  is  not  much  discoloured, 
and  there  are  no  appearances  of  a varicose  affection 
of  the  blood-vessels  of  the  organ.  Beer  recommends 
making  a puncture  with  a small  lancet,  in  the  lowest 
part  of  the  cornea,  half  a line  from  the  sclerotica,  so 
as  to  discharge  the  aqueous  humour.  The  anterior 
chamber  is  then  to  be  kept  empty  for  several  days  or 
weeks,  if  possible,  by  re-opening  the  small  wound 
every  dav  with  the  point  of  the  lancet.— (See  also 
Richter's' Anfans-sffr.  b.  3,  p.  403.)  After  the  operation, 
the  eye  is  to  be  dressed  in  the  same  way  as  after  the 
e.xtr<action  of  a cataract. — (See  Cataract.)  Previously 
to  the  paracentesis.  Beer  has  often  seen  every  gei*eral 
and  local  means  perfectly  useless,  but  highly  beneficial, 
as  soon  as  that  operation  had  been  practised.  Even 
when  the  paracentesis  fails  in  bringing  about  a per- 
manent cure,  it  may  still  be  resorted  to  as  a palliative 
with  great  advantage,  and  be  often  beneficially  repeated. 


if  care  be  taken  not  to  make  the  puncture  too  larg« 
However,  when  the  blood-vessels  are  generally  vari- 
cose, and  the  constitution  very  bad,  such  operation  is 
apt  to  excite  violent  inflammation,  suppuration,  and 
even  sloughing  of  the  organ,  attended  with  imminent 
danger  to  the  patient’s  life.— (Reer,  vol.  cit.  p.  620. 
622.) 

With  regard  to  the  second  species  of  hydrophthalmia, 
or  that  depending  upon  a preternatural  accumulation 
of  the  vitreous  humour,  Beer  states  that,  in  this  case,  it 
is  chiefly  the  posterior  part  of  the  eyeball  which  is 
enlarged,  so  that  the  whole  organ  acquiies  a conical 
shape,  in  which  the  cornea  very  much  participates. 
The  latter  membrane  remains  unaltered  in  regard  to 
its  diameter;  but  it  is  more  convex  than  natural,  and 
its  transparency  is  perfect.  It  is  observed  by  Mr. 
Wardrop  {on  the  Morbid  Anatomy  of  the  Eye,  vol.  2, 
p.  126),  that  an  increase  in  the  quantity  of  the  vitreous 
humour  happens  not  unfrequently  in  staphyloma,  in 
which  disease,  he  says,  the  enlargement  of  the  eyeball 
will  generally  be  found  to  arise  more  from  an  increase 
in  the  quantity  of  the  vitreous  than  of  the  aqueous 
humour,  and  he  then  expresses  his  belief,  that  the  case 
adduced  by  Scarpa  to  illustrate  the  pathology  of  hy- 
drophthalmia, and  cited  in  the  ensuing  part  of  this 
article,  was  an  example  of  staphyloma.  Be  this  as  it 
may,  one  character  constant  in  staphyloma  is  often 
absent  in  hydrophthalmia;  I mean  opacity  of  the 
cornea.  In  the  case  which  consists  in  an  immoderate 
collection  of  the  aqueous  humour,  the  anterior  chamber 
is  always  enlarged:  on  the  contrary,  in  the  present 
form  of  the  disease,  that  cavity  is  manifestly  lessened, 
for  the  motionless  iris  is  gradually  forced  so  much 
towards  the  cornea,  that  at  length  the  chamber  in  ques- 
tion almost  completely  disappears.  However,  the 
colour  of  the  iris  undergoes  no  change,  and  the  pupil 
is  always  rather  diminutive.  Around  the  cornea,  the 
sclerotica  is  rendered  bluish  by  distention,  with  a 
somewhat  smutty  tinge.  In  the  early  stage  the  patient 
is  affected  with  short-sightedness,  myopia;  but  his 
power  of  vision  is  always  seriously  diminished,  and, 
at  last,  is  so  totally  destroyed,  that  not  a ray  of  light 
can  be  perceived.  The  motions  of  the  globe  of  the 
eye  and  eyelids  are  lessened  or  impeded  at  a still 
earlier  period  than  in  the  first  species  of  hydrophthal- 
mia, and  to  the  touch  the  organ  seems  like  an  egg- 
shaped  stone.  The  very  commencement  of  the  disease 
is  attended  with  pain,  winch  daily  becomes  more  and 
more  severe,  and  at  length  is  not  confined  to  the  eye 
and  its  vicinity,  but  affects  all  the  side  of  the  head,  the 
teeth,  and  neck,  being  sometimes  so  violent  as  almost 
to  bereave  the  patient  of  his  senses,  who  urgently  begs 
the  surgeon  to  puncture  the  eye,  or  even  is  driven  by 
desperation  to  do  it  himself,  as  Beer  once  knew  hap- 
pen. Even  while  the  pain  is  less  afilictin;i,  the  patient 
is  deprived  of  his  sleep  and  appetite. — {Beer,  vol.  cit. 
p.  623.)  Though  an  increase  in  the  quantity  of  the 
vitreous  or  aqueous  humour  has  generally  been  treated 
of  as  a distinct  disease,  and  denominated  hydropliihal- 
mia,  Mr.  Wardrop  has  never  seen  a dropsy  of  the  eye, 
without  an  accompanying  disease  of  the  sclerotic  coat, 
or  cornea. — ( On  the  Morbid  Anatomy  of  the  Eye,  vol. 
2,  p.  126.)  Beer  offers  no  valuable  remark  on  the 
causes  of  the  preceding  form  of  hydrophthalmia,  his 
account  of  the  connexion  with  scrofula  and  syphilis 
being  mere  conjecture,  though  delivered  as  a positive 
matter  of  fact.  However,  another  position  offered  in 
the  paragraph,  concerning  the  prognosis,  seems  more 
correct;  viz.  that  as  the  disease  is  almost  always  con- 
joined with  an  unhealthy  constitution,  there  can  be 
scarcely  any  hope  of  a radical  cure.  Beer’s  opinion 
also  is,  that  when  the  disease  has  made  such  progress, 
that  not  a ray  can  be  discerned,  and  the  pain  in  the  eye 
and  head  so  violent,  by  day  and  night,  that  the  sleep, 
appetite,  and  even  the  senses  are  lost ; it  is  fortunate, 
if  only  the  most  perilous  symptoms  can  be  obviated  by 
palliative  treatment;  for  the  preservation  of  a good- 
shaped eye  is  then  quite  out  of  the  question.  And 
even  in  the  most  favourable  cases,  the  utmost  which 
can  be  expected  is  to  stop  the  farther  advance  of  the 
disease ; a perfect  cure  being  extremely  rare. 

According  to  Beer,  the  first  indicaiion  is  to  improve 
the  state  of  the  health  by  medicines  and  regimen;  for 
unless  this  object  he  effected,  no  expectation  of  curing 
the  dropsical  affection  of  the  eye  can  be  entertained. 
For  this  purpose  a long  time  will  be  requisite;  and  as 
for  local  treatment  in  this  case,  little  or  nothing  can  be 


HYDROPHTHALMIA, 


ns 


accomplished  by  it.  Hence,  the  disease  often  continues 
to  grow  worse  and  worse,  and,  when  the  pain  becomes 
violent,  the  best  thing  which  the  surgeon  can  do,  both 
with  the  view  to  the  functions  of  the  organ,  and  its 
form,  is  to  let  out  the  aqueous  humour.  But  Beer  re- 
probates, in  the  strongest  terms,  the  plan  sometimes 
recommended,  of  plunging  a trocar  through  the  scle- 
rotica into  the  vitreous  humour,  and  keeping  the  tube 
introduced  until  a certain  quantity  of  that  humour  is 
disctiarged.  The  usual  result  of  such  practice  is  a 
carcinomatous  disease  of  the  eye,  terminating  in  death, 
which  the  removal  of  the  part  will  not  prevent.  The 
method  preferred  by  Beer  is  that  which  is  mentioned 
by  Richter  (^Anfangsg,  b.  3,  p.  400),  and  consists  in 
opening  the  cornea  and  capsule  of  the  lens,  as  in  the 
extraction  of  the  cataract,  discharging  the  lens  and 
vitreous  humour,  and  letting  the  coats  of  the  eye  col- 
lapse ; but  in  order  to  prevent  any  re  accumulation  of 
the  fluid,  he  afterward  cuts  away  a little  bit  of  the  flap 
of  the  cornea.  The  eye  is  then  to  be  dressed  in  the 
same  manner  as  after  the  extraction  of  the  cataract. — 
(See  Cataract.)  The  third  species  of  hydrophthalmia, 
or  that  produced  by  an  accumulation  both  of  the 
aqueous  and  vitreous  humours  together,  is  excellently 
described  by  Scarpa  He  observes,  that  in  every  case 
on  which  he  has  performed  the  operation,  and  in  other 
examinations  of  the  different  stages  of  the  disease  made 
on  the  dead  subject,  he  has  constantly  found  the 
vitreous  humour  more  or  less  altered  in  its  organiza- 
tion, liquefied,  and  converted  into  water,  according  as 
the  disease  was  ancient  or  recent.  In  some  instances 
he  could  not  distinguish  whether  the  increased  quan- 
tity of  the  vitreous  or  aqueous  humour  had  most  share 
in  the  formation  of  the  disease. 

Scarpa  also  dissected  a dropsical  eye  taken  from  the 
body  of  a child.  The  vitreous  humour  was  not  only 
wanting  in  this  eye,  and  the  cavity  destined  for  its  re- 
ception filled  with  water,  but  the  vitreous  tunic  was 
converted  into  a substance  partly  of  a spongy,  partly 
of  a fatty  nature.  This  dropsical  eye  was  one-third 
larger  than  natural.  The  sclerotica  was  not  thinner 
than  that  of  the  other  eye : but  in  consequence  of  being 
yielding,  flaccid,  and  separated  from  the  choroides,  it 
had  lost  its  plumpness  and  globular  shape.  The  cornea 
formed  a disc  one-third  larger  than  that  of  this  mem- 
brane in  a sound  state ; it  did  not  retain  its  natural 
pulpy  structure,  and  was  obviously  thinner  than  the 
cornea  of  the  healthy  eye.  There  was  a considerable 
quantity  of  an  aqueous,  reddish  fluid,  between  the 
cornea  and  iris.  The  crystalline  lens,  with  its  opaque 
capsule,  had  been  pushed  forward  a little  way  into  the 
anterior  chamber,  but  could  not  advance  farther,  on 
account  of  a firm  adhesion  which  the  capsule  had 
contracted  with  the  iris  around  the  edge  of  the  pn{)il. 
As  soon  as  the  capsule  was  opened  the  lens  issued  frnni 
it,  half  dissolved,  the  rest  e.xceedingly  soft.  It  was 
impossible  to  detach  the  whole  of  the  posterior  layer 
of  the  capsule  from  a hard  substance,  which  seemed 
to  be  the  altered  membrane  of  the  vitreous  hu  i.oiir. 
Scarpa,  therefore,  slit  open  the  choroides  from  the 
ciliary  iigamenl  to  the  bottom  of  the  eye,  wheti  a con- 
siderable quantity  of  a reddish  aqueous  fluid  gushed 
out,  without,  however,  one  particle  of  the  vitreous 
humour.  In  lieu  of  the  latter  body  there  was  found  a 
small  cylinder,  of  a substance,  partly  of  a fungous, 
partly  of  a fatly  nature,  surrounded  with  a good  deal 
of  water,  which  was  effused  in  the  longitudinal  axis 
of  the  eye,  from  the  entrance  of  the  optic  nerve,  as  far 
as  the  ciliary  ligament,  or  that  hard  substance  to  which 
the  posterior  layer  of  the  capsule  firmly  adhered.  This 
little  cylinder  was  covered,  for  the  extent  of  two  lines 
and  a half  forwards  from  the  entrance  of  the  optic 
nerve,  by  a stratum  of  whitish  matter  reflected  on 
itself,  like  the  epiploon,  when  raised  towards  the  fundus 
of  the  stomach.  Scarpa  conceived  that  this  stratum 
of  whitish  matter  was  the  relics  of  the  unorganized 
retina;  for,  on  pouring  rectified  spirits  of  wine'on  the 
whole  inner  surface  of  the  choroides,  and  the  little 
cylindrical  body,  he  found  no  vestiL'es  of  the  retina  on 
this  membrane,  and  that  the  whitish  substance,  which 
was  reflected  on  itself,  became  very  firm,  just  as  the 
retina  does  when  immersed  in  spirits  of  witie.  Both 
the  cylinder  and  the  indurated  substance  occupying 
the  place  of  the  ciliary  body  were  manifestly  only  the 
membrane  of  the  vitreous  humour,  destitute  of  water, 
and  converted,  as  was  described,  into  a substance, 
partly  of  a spongy,  partly  of  an  adipose  nature.  It  is 


not  easy  to  determine  whether  this  altered  state  of  the 
vitreous  tunic  had  preceded,  or  was  a consequence  of 
the  dropsy  of  the  eye.  However  it  may  be,  this 
fact,  in  conjunction  with  several  other  similar  ones 
that  Scarpa  has  met  with,  in  which  he  found  no 
vitreous  humour  in  the  posterior  cavity  of  the  eye,  but 
only  water  or  a bloody  lymph,  tends  very  much  to  es- 
tablish the  fact,  that  this  disease  principally  consists  of 
a morbific  secretion  of  the  vitreous  humour,  and  occa- 
sionally, also,  of  a strange  degeneration  of  the  alve- 
olary  membrane,  by  which  this  humour  is  formed. 
Scarpa  refers  to  a similar  case. — (See  Med.  Obs.  and 
Inquiries.,  vol.  3,  art.  14.) 

The  augmentation  in  the  secretion  of  the  aqueous 
fluid,  both  in  the  cells  of  the  vitreous  humour  and  out 
of  them,  after  they  have  been  ruptured  from  excessive 
distention,  together  with  a debilitated  action  of  the 
absorbent  system  of  the  eye  affected,  Scarpa  regards  as 
the  probable  cause  of  the  morbific  accumulation  of 
humours  in  the  eye.  From  such  a lodgment,  and 
successive  increase  of  the  vitreous  and  aqueous  hu- 
mours, the  eyeball  at  first  necessarily  assumes  an  oval 
shape,  ending  at  the  point  of  the  cornea;  the  organ 
enlarges  in  all  dimensions:  and  in  the  end,  it  projects 
from  the  orbit  in  such  a manner,  that  it  cannot  be 
covered  by  the  eyelids,  disfiguring  the  patient’s  face 
as  much  as  if  an  ox’s  eye  were  placed  in  the  orbit. 

This  disease  (says  Scarpa)  is  sometimes  preceded  by 
blows  on  the  eye  or  temple  ; sometimes  by  an  obstinate 
internal  ophthalmy.  In  other  instances,  it  is  preceded 
by  no  inconvenience,  except  an  uneasy  sensal ion  of 
tumefaction  and  distention  in  the  orbits,  a difficulty 
of  moving  the  eyeball,  and  a considerable  impairment 
of  sight.  Lastly,  it  is  sometimes  preceded  by  none  of 
these  causes,  or  no  other  obvious  one  whatever,  es- 
pecially when  the  complaint  occurs  in  children  of  very 
lender  age,  from  whom  no  information  can  be  ob- 
tained. As  soon  as  the  eye  has  assumed  an  oval  form, 
and  the  anterior  chamber  has  become  preternatuially 
capacious,  the  iris  seems  situated  farther  backward 
than  usual,  and  tremulates,  in  a very  singular  way, 
on  the  slightest  motion  of  the  eyeball.  The  pupil 
remains  dilated  in  every  degree  of  light,  while  the 
crystalline  is  sometimes  brownish  from  the  very 
beginning  of  the  disease;  and  sometimes  it  does  not 
become  cloudy  till  the  affection  has  arrived  at  its  high- 
est pitch.  The  complaint  then  becomes  stationary; 
and  as  Uie  crystalline  is  not  deeply  opaque,  the  patient 
can  distinguish  light  from  darkness,  and  in  some  de- 
gree, the  outlines  of  objects  and  brilliant  colours.  But 
when  the  eye  has  acquired  a larger  volume,  and  the 
whole  crystalline  has  become  opaque,  the  retina  at 
last  remains  in  a state  of  complete  paralysis. 

In  the  last  stage  of  the  disease,  to  which  the  term 
bupthalmos,  or  ox-eye,  is  properly  applicable,  when  the 
dropsical  eye  projects  from  the  orbit,  so  as  not  to  ad- 
mit of  beiiiii  covered  by  the  eyelids,  \vith  the  incon- 
veniences already  enumerated,  says  Scarpa,  others 
assor  iate  themselves,  arising  from  the  friction  of  the 
ciliar,  the  secretion  of  gum,  the  flux  of  tears,  the  ulcer- 
ation of  the  lower  eyelid,  on  which  the  eye  rests,  and 
the  excoriation  of  the  eye  itself.  Hence,  the  dropsical 
eye  is  gradually  attacked  with  violent  ophthalmies, 
attended  with  intolerable  pains  in  the  part  affected, 
and  the  whole  head.  The  ulceration,  also,  does  not 
always  confine  itself  within  certain  liujits;  but  con- 
tinues to  spread,  first  depriving  the  cornea  of  its  trans- 
parency, next  consuming  the  sclerotica,  and  lastly, 
destroying  progressively  the  other  component  parts  of 
the  eyeball. 

At  the  first  appearance  of  dropsy  of  the  eye,  many 
surgeons  recommend  mercurials,  the  extract  of  cicuia, 
and  of  pulsatilla  nigricans;  and  astringent  coJIyria,  a 
seton  in  the  na{)e  of  the  neck,  and  compression  of  the 
projecting  eye.  However,  Scarpa  has  never  yet  met 
with  a .single  well  detailed  history  of  a drop.sy  of  the 
eye  cured  by  means  of  the  above-mentioned  internal 
medicines.  With  regard  to  externals,  he  has  learned 
from  his  own  experience,  that  wrnm  the  disorder  is 
manifest,  astringent  and  corroborant  collyria,  as  well 
as  compression  of  the  protuberant  eye,  are  high'y 
prejudicial.  In  such  circumsiances,  making  a seton  in 
the  nape  of  the  neck,  frequently  bathing  the  eye  in  a 
lotion  of  mallows,  and  applying  to  it  a poultice,  com- 
posed of  the  same  plant,  have  enabled  him  to  calm, 
for  a time,  that  disagreeable  sense  of  distention  In  the 
orbit,  and  over  the  forehead  and  temple  of  the  same 


74 


HYDROPHTHALMIA. 


Bide,  of  which  patients  in  this  state  make  so  much 
coiriplaint,  especially  when  they  are  affected  with  a 
recurrence  of  ophthalniy.  But  as  soon  as  the  eyeball 
begins  lo  protrude  from  the  orbit,  and  project  beyond 
tJie  eyelids,  he  tliinks  there  is  no  means  of  opposing 
the  very  grievous  dangers  which  the  dropsy  of  the  eye 
threatens,  except  an  operation,  which  consisls  in  eva- 
cuating by  an  incision,  the  superabundant  humours, 
then  exciting  gentle  inflammation  of  the  membranes, 
and  suppuration  within  this  organ,  so  as  to  make  it 
contract  and  shrink  into  the  bottom  of  the  orbit.  To 
defer  the  operation  any  longer  would  be  abandoning 
the  patient  to  theconstant  inconvenience  of  an  habitual 
ophthalmy,  the  danger  of  an  ulceration  of  the  eyeball 
and  subjacent  eyelid,  and  what  is  worse,  of  carcinoma 
of  the  whole  eye,  with  great  peril  to  the  patient. 

Beer’s  prognosis  in  the  third«pecies  of  hydrophthalmia 
is  at  least  as  discouraging  as  that  made  by  Scarpa  ; for 
the  rapidity  of  the  disease  is  said  to  be  such  as  leaves 
scarcely  a possibility  of  benefit  being  effected  by  any 
mode  of  treatment,  and  the  case  usually  terminates  in 
a carcinomatous  exophthalmia  and  death.  These 
melancholy  events  are  said,  by  Beer,  to  be  accelerated 
by  paracentesis  of  the  eye,  however  executed ; and  he 
thinks,  that  the  sole  chance  of  stopping  the  progress  of 
the  disease  depends  upon  an  endeavour  being  made 
in  its  very  commencement  to  improve  the  general 
health,  though  he  owns,  that  success  is  to  be  regarded 
as  a very  rare  and  fortunate  occurrence.  The  same 
author  has  no  faith  in  any  local  treatment,  and  when 
the  disease  is  advanced,  he  considers  the  extirpation 
of  the  eye  the  only  rational  expedient,  though  very 
precarious  in  its  result. — {Lehre  von  den  Augenkr.  b. 
2,  p.  628,  629.) 

The  main  point  on  which  Scarpa  differs  from  Beer, 
is  that  respecting  the  effects  of  discharging  the  humours 
of  the  eye ; a practice  which  the  former  represents  as 
useful,  even  in  cases  where  the  hydroi)hthalmia  com- 
bines an  accumulation  both  of  the  aqueous  and  vitreous 
humours.  In  former  times,  says  Scarpa,  paracentesis 
of  the  eyeball  was  greatly  extolled.  Nuck,  one  of  the 
promoters  of  this  operation,  punctured  the  eye  with  a 
trocar,  exactly  in  the  centre  of  the  cornea. — {De  Duct. 
Ocul.  Aquos.  p.  120.)  It  has  since  been  thought  better 
to  puncture  the  sclerotica  about  two  lines  from  the 
junction  of  this  membrane  with  the  cornea,  and  such 
a small  quantity  of  the  vitreous  humour  may  be  more 
easily  discharged  at  the  same  time  with  the  aqueous, 
as  may  be  deemed  adequate  to  effect  a diminution  of 
the  eyeball. 

According  to  Scarpa,  paracentesis  of  the  eye,  done 
so  as  merely  'o  discharge  the  humours,  can  never  be  a 
means  of  cm  mg  dropsy  of  the  eye,  unless  the  puncture 
made  with  the  trocar  excite  inflammation  and  sup- 
puration, and  afterward  a concretion  of  the  mem- 
branes composing  the  eyeball.  In  a young  man  at 
Breda,  Nuck  was  obliged  to  puncture  the  eye  five 
several  times;  on  the  fifth  time  of  doing  this,  it  was 
necessary  to  suck  through  the  cannula  of  the  trocar,  in 
order  to  evacuate  the  greatest  possible  quantity  of  the 
vitreous  humour ; and,  lastly,  a plate  of  lead  was  pul 
between  the  eyelids  and  eyeball,  for  the  purpose  of 
making  continual  pressure  on  the  eye,  in  its  empty 
shrivelled  state.  In  a woman  at  the  Hague,  he  twice 
punctured  the  eye  in  vain;  and  she  submitted,  two  or 
three  times  afterward,  to  the  same  opeiation,  but  with 
what  degree  of  success  is  not  specified.  Scarpa  has 
no  difficulty  in  believing,  that  a radical  cure  of  the  drop- 
sy has  sometimes  been  accomplished  by  means  of  th% 
puncture,  after  the  trocar,  and  other  similar  hard  sub- 
stances, have  been  repeatedly  introduced  into  the  eye, 
through  the  cannula  of  that  instrument ; but  this  suc- 
cess can  never  be  attributed  to  the  mere  evacuation  of 
the  superabundance  of  the  vitreous  and  aqueous  hu- 
mour; though  it  may  be  referred  to  that  circumstance, 
conjoined  with  the  irritation  produced  by  the  can- 
nula, or  the  tents  with  which  Mauchart  kept  open  the 
wound. 

Scarpa  condemns  the  plan  of  making  a circular  in- 
cision through  the  sclerotica,  as  disadvantageous,  and 
ever,  dangerous.  In  fact,  this  circular  recision  is  con- 
stantly followed  by  the  most  aggravated  symptoms, 
particularly  frequent  hemorrhages,  an  accumulation 
of  grumous  blood  at  the  bottom  of  the  eyeball,  vehe- 
ment inflammation  of  the  eye,  eyelids,  and  head,  ob- 
stinate vomitings,  convulsions,  delirium,  and  the  most 
Imnjinent  danger  to  the  patient’s  life.  Such  modern 


surgeons  as  have  faithfully  published  the  results  of 
their  practice  on  this  point,  namely,  M.  Louis  {JVUm. 
de  I'Acad.  de  Chir.  t.  13,  p.  289,  290),  Marchan  \ jour~ 
nal  de  Mid.  de  Paris,  Janvier,  1770  ; Sur  deux  Exoph- 
thalmies,  ou  Grosseurs  centre  Mature  du  Globe  de 
VtEil),  and  Terras  {Ibidem,  Mars,  1776;  Sur  I’Hy- 
drophthalmie),  have  ingenuously  declared,  that  after 
performing  the  circular  recision  of  drojisical  eyes  iit 
the  sclerotica,  they  had  the  greatest  motives  for  repent- 
ing of  what  they  had  done.  Scarpa  prefers  making  a 
circular  section,  about  three  lines  in  breadth,  at  the 
summit  or  centre  of  the  cornea  of  the  dropsical  eye,  as 
directed  by  Celsus  in  cases  of  staphyloma. 

Whether  the  cornea  be  transparent  or  not,  as  sight 
is  irrevocably  lost,  the  surgeon  must  introduce  a small 
bistoury  across  the  apex,  or  middle  of  the  cornea,  at 
one  line  and  a half  from  its  central  point;  and  then,  by 
pushing  the  instrument  from  one  towards  the  other 
canthus  of  the  eye,  he  will  cut  the  lower  part  of  the 
cornea  in  a semicircular  manner.  The  segment  of  the 
cornea  being  next  elevated  with  the  forceps,  the 
operator  is  to  turn  the  edge  of  the  knife  upwards,  and 
complete  the  work  by  a circular  removal  of  as  much 
of  the  centre  of  the  cornea  as  is  equal  to  three  lines  in 
diameter.  Through  this  circular  opening  made  in  the 
centre  of  the  cornea,  the  surgeon  may,  by  means  of 
gentle  pressure,  discharge  as  much  of  the  superabun- 
dant humours  in  the  eye  as  is  requisite  lo  make  the 
eyeball  diminish,  and  return  into  tlie  orbit,  so  as  to  be 
covered  by  the  eyelids.  As  for  the  rest  of  the  humour 
lodged  in  the  eye,  it  will  gradually  escape  of  itself, 
through  the  circular  opening  in  the  cornea,  without 
any  more  pressure  being  made. 

Until  the  appearance  of  the  inflammation,  tlmt  is, 
until  the  third  or  fifth  day  after  the  operation,  the 
dressings  are  to  consist  of  the  application  of  a compress 
of  dry  lint  supported  by  a bandage.  As  soon  as  in- 
flammation and  tumefaction  invade  the  eye  operated 
on,  and  the  eyelids,  the  surgeon  is  to  employ  such 
internal  remedies  as  are  calculated  lo  moderate  the 
progress  of  inflammation  ; and  he  is  to  cover  the  eye- 
lids with  a bread  and  milk  poultice,  which  must  be 
renewed  at  least  once  every  two  hours.  It  is  a very 
frequent  result,  both  in  the  staphyloma  and  dropsy  of 
the  eye,  that  on  the  first  appearance  of  inflammation, 
the  eyeball  on  which  the  operation  has  been  done 
augments  and  protrudes  again  from  the  eyelids,  in  the 
same  way  as  before  the  operation.  In  this  circum- 
stance, Scarpa  directs  the  projecting  part  of  the  eyeball 
to  be  covered  with  a piece  of  fine  linen,  smeared  with 
a liniment  of  oil  and  wax,  or  the  yelk  of  an  egg  and 
oleum  hypetici;  the  application  of  the  bread  and  milk 
poultice  being  continued  over  such  dressing.  When 
the  ititerior  of  the  eye  begins  to  suppurate,  the  swelling 
of  the  eyelids  decreases,  and  the  eyeball  diminishes  in 
size,  and  returns  gradually  into  the  orbit.  This  state 
of  suppuration  may  be  known  by  observing,  that  the 
dressings  are  smeared  with  a viscid  lynijth,  blended 
with  a portion  of  the  humours  of  the  eye,  which  in- 
cessantly issue  from  the  centre  of  the  cornea ; and  by 
noticing  the  appearance  of  the  margin  of  the  recision, 
which  is  changed  into  a circle  of  a whitish  substance 
resembling  the  rind  of  bacon,  which  is  afterward  de- 
tached, like  a slough,  so  as  to  leave  a small  ulcer  of  a 
very  healthy  colour.  This  ulcer,  as  well  as  the  whole 
eyeball,  contracts  and  becomes  entirely  cicatrized, 
leaving  every  opportunity  for  the  placing  of  an  arti- 
ficial eye  between  the  eyelids  and  the  stump  of  the 
eyeball. 

If  a mild  inflammation  and  suppuration  in  the  in- 
terior of  the  eye  should  not  take  place  on  the  fifth  day, 
Scarpa  exposes  the  eye  to  the  air,  or  removes  a circular 
portion  of  the  cornea,  half  a line  in  breadth,  or  little 
more,  by  means  of  the  forceps  and  curved  scissors. 
The  foregoine  practice  is  certainly  jireferable  to  that 
advised  by  Richter,  who,  when  the  eyesight  is  lo.st,  and 
the  object  is  merely  to  discharge  the  humours  and  let 
the  eye  collapse,  sometimes  makes  a crucial  division 
of  the  cornea,  and  removes  the  four  flaps  or  angles,  or 
even  cuts  awtiy  the  whole  of  the  anterior  part  of  the 
eyeball  through  the  sclerotica. — {Anfuvgsgr.  b.  3,  p. 
404.)  In  order  to  lessen  the  bulk  of  the  eye,  the  late 
Mr.  Ford,  in  one  instance,  passed  a seton  through  the 
front  of  the  organ,  with  apparent  success.— (See  Med. 
Communications,  vol.  1.)  Consult  Mauchart,  De  Pa- 
racentesi  Oculi ; Tub.  Viii.  Conradi,  Handbuch  der 
Pathol.  Anat.  p.  523.  Fieliz,  in  Uufeland's  Joum.  ^ 


HYP 


HYP 


75 


b.  p.  208.  Flajani,  Colletione  d'  Osservazioniy  1. 1,  ois. 
43.  Gendron,  Mai.  des  Yeux,  t.  2.  Louis,  in  M^m. 
de  I'Jicad.  de  Chir.  t.  5,  Ato.  Marchan,  in  Journ.  de 
Mid.  t.  32,  p.  65.  Terras,  op.  cit.  vul.  45,  p.  239. 
Scarpa,  Sulle  principali  Malattie  degli  Occhi,  cap.  13. 
C.  P.  Beger,  De  Hydrophthalmia ; Haller,  Disp.  Chir. 
1,  575.  A.  Sarwey,  De  Paracentesi  Oculi  in  Hy- 
drophthalmia et  Amblyopia  Senum;  Haller,  Disp. 
Chir.  1, 587,  Tub.  1744.  Benedict,  de  Morbis  Humoris 
Vitrei.  Luke,  Diss.  de  Hydrophthalmia ; .Jen.  1803. 
Ridder  Anfangsgr.  b.  3,  p.  392,  Src.  Got.  1795.  Beer, 
Lehre  von  den  Augenkr.  b.  2,  fVien.  1817.  J.  fVardrop, 
Essays  on  the  Morbid  Anatomy  of  the  Human  Eye, 
chap.  18  and  40,  vol.  2,  8vo.  Loud.  1818.  A.  Smith,  in 
Edinb.  Med.  Journ.  Mo.  73.  B.  Travers,  Synopsis  of 
the  Diseases  of  the  Eye,  p.  195,  p.  200,  <^c.  8vo.  Lond. 
1820. 

HYDROPS.  (From  ?)5wp,  water.)  A dropsy,  or 
morbid  accumulation  of  water.  For  hydrops  articuli 
refer  to  Joints,  Diseases  of;  for  hydrops  oculi,see  the 
foregoing  article.  With  regard  to  hydrops  pectoris, 
hydrothorax,  or  dropsy  of  the  chest,  as  it  is  altogether 
a medical  case,  an  account  of  its  symptoms  and  treat- 
ment will  hardly  be  required  in  this  Dictionary.  The 
only  concern  which  a surgeon  has  with  the  disease  is, 
being  occasionally  required  to  make  an  opening  for  the 
discharge  of  the  water.— (See  Paracentesis  Thoracis.) 

HYDRO^ARCOCELE.  (From  water ; trdp^, 
flesh;  and  Kfiky,  a tumour.)  A sarcocele,  attended 
with  a collection  of  fluid  in  the  tunica  vaginalis. 

HYMEN,  IMPERFORATE.  The  inconveniences 
brought  on  by  such  a cause,  and  the  mode  of  relief, 
are  explained  in  the  article  Vagina. 

A continuation  of  the  hymen  over  a pari  of  the  ori- 
fice of  the  meatus  urinarius  may  produce  great  pain 
and  difficulty  in  making  water,  and  symptoms  which 
may  give  rise  to  suspicion  of  stone.  For  a case  illus- 
trating the'  truth  of  this  observation,  see  IVarner's 
Cases  in  Surgery,  p.  276,  edit.  4. 

H YPOPIUM,  or  HYPOPYON.  (From  hnd,  under ; 
and  TTvov,  pus.)  An  accumulation  of  the  glutinous 
yellowish  ffuid,  like  pus,  in  the  anterior  chamber  of 
the  aqueous  humour  ; and  frequently,  also,  in  (he  iios- 
terior  one,  i-n  consequence  of  severe  acute  ophihaimy, 
fmrticularly  the  internal  species,  or  what  is  now  so  well 
known  under  the  name  of  iritis. 

The  viscid  matter  of  hypopium,  though  commonly 
called  pus,  Scarpa  regards  as  coagulating  lymph.  'I’he 
symptoms  portending  an  extravasation  of  coagulating 
lymph  in  the  eye,  or  an  hypopium,  are  the  same  as 
those  which  occur  in  the  highest  stage  of  violent  acute 
ophthalmy ; viz.  prodigious  tumefaction  of  the  eyelids  ; 
the  same  redness  and  swelling  of  the  conjunctiva,  as  in 
chemosis;  burning  heat  and  pain  in  the  eye;  pains  in 
the  eyebrow  and  nape  of  the  neck  ; fever,  restlessness, 
aversion  to  the  faintest  light,  and  a contracted  state  of 
tlie  pupil. 

As  soon  as  the  hypopium  begins  to  form  (says 
Scarpa),  a yellowish  semilunar  streak  makes  its  ap 
pearance  at  the  bottom  of  the  anterior  chamber,  and 
regularly  as  the  glutinous  ffuid  is  secreted  from  the  in 
flamed  internal  membranes  of  the  eye,  so  as  to  jrass 
through  the  pupil  and  (all  into  the  aqneons  humour,  it 
increases  in  all  dimensions,  and  gradually  obscures  the 
iris,  first  at  its  inferior  part,  next  where  it  forms  the 
pupil,  and  lastly  the  whole  circumference  of  this  nrem- 
brarie.  As  long  as  the  inflammatory  stage  of  violent 
ophthalmy  lasts,  the  hypopium  never  fails  to  enlarge; 
but  immediately  this  stage  ceases,  and  the  ophthalmy 
enters  its  second  period,  or  that  dependent  on  local 
weakness,  the  quantity  of  coagulating  lymph,  forming 
the  hypopium,  leaves  oflT increasing,  and  from  that  mo- 
ment is  disposed  to  diminish. 

This  fact  sufficiently  evinces  (continues  this  eminent 
professor)  how  important  it  is,  in  order  to  check  the 
progress  of  the  hypopium,  to  employ,  with  the  utmost 
care,  the  most  effectual  means  for  checking  the  attack 
of  violent  ophthalmy  in  its  first  stage.  He  recommends 
copious  evacuations  of  blood,  both  generally  and 
topically,  to  be  speedily  put  in  practice;  and  when 
chemosis  exists,  the  conjunctiva  to  be  divided;  mild 
aperients  given,  blisters  applied  to  the  nape  of  the  neck, 
little  bags  of  emollient  herbs  to  the  eye,  and  other 
ineH'Ures  employed.  It  will  he  known  that  they  liave 
fulfilled  the  indication  by  noticing  that  some  days  after 
the  adoption  of  such  treatment,  though  (here  may  still 
be  redneus  of  the  conjunctiva  and  eyelids,  the  lanci- 


nating pains  in  the  eye  abate,  the  heat  considerably 
diminishes,  the  fever  subsides,  quietude  and  sleep  are 
restored,  the  motion  of  the  eye  becomes  free,  and  lastly, 
the  collection  of  viscid  matter  forming  the  hypopium 
becomes  stationary.  It  is  not  un frequent  to  see,  espe- 
cially among  the  lower  -orders  of  the  people,  persons 
affected  with  the  second  stage  of  severe  acute  ophthal- 
niy,  bearing  this  collection  of  coagulating  lymph,  in  the 
chambers  of  the  aqueous  humour,  with  the  greatest  in- 
difference, and  without  complaining  of  any  of  those 
symptoms  which  characterize  the  acute  stage  of  oph- 
thaliny.  It  is  only  at  this  crisis,  or  at  the  termination  of 
the  acute  stage  of  violent  inflammation  of  the  eye,  that 
the  enlargement  of  the  hypopium  ceases,  and  the  coagu- 
lating lymph  begins  to  be  abso.rbed,  provided  this  salu- 
tary operation  of  nature  be  not  impeded  nor  retarded  by 
any  injudicious  regimen.  However,  if  Scarpa  had  also 
been  aware  of  the  great  efficacy  of  mercury  in  arrest- 
ing the  effusion  of  lymph,  I can  hardly  doubt,  that  he 
would  have  modified  some  of  the  preceding  observa- 
tions as  well  as  his  practice ; a subject  to  which  I shall 
presently  return. 

Scarpa  states,  that  persons  little  versed  in  the  treat- 
ment of  diseases  of  the  eyes,  would  fancy,  mat  the 
most  expeditirjus  and  efficacious  mode  of  curing  an 
hypopium,  after  it  has  become  stationary  in  the  secotid 
stage  of  severe  acute  ophthalmy,  would  be  that  of 
opening  the  cornea  at  its  most  depending  part,  in  order 
to  procure  a speedy  exit  for  the  matter  collected  in  the 
chambers  of  the  aqueous  humour;  especially  as  this 
was  once  the  common  doctrine.  But  experience 
shows,  that  dividing  the  cornea  in  such  circumstances 
is  seldom  successful,  and  most  frequently  gives  rise  to 
evils  w'orse  than  the  hypopium  itself,  notwithstanding 
the  modification  suggested  by  Richter  {Obs.  Chir. 
fasc.  1,  chap.  12),  not  to  evacuate  the  whole  of  the 
matter  at  once,  nor  to  promote  its  discharge  by  repeated 
pressure  and  injections,  but  to  allow  it  to  flow  slowly 
out  of  itself.  I’he  wound  made  at  the  lower  pan  of 
the  cornea  for  evacuating  the  matter  of  the  hypoitinm, 
small  as  the  incision  may  be,  most  commonly  re[)ro- 
duces  severe  acute  ophthalmy,  and  a greater  effusion 
of  coagulating  lymph  into  the  chambers  of  the  aqueous 
humour.  Besides,  after  opening  the  cornea,  if  the 
matter  of  the  hypopium  were  allowed  to  escape  gra- 
dually of  itself,  it  would  be  several  days  in  being  com- 
pletely discharged,  on  account  of  its  viscidity.  During 
this  time  the  glutinous  lymph  w'ould  keep  the  edges  of 
the  wound  of  the  cornea  dilated,  and  make  them  sup- 
purate. Thus  the  incision  would  be  converted  into  an 
ulcer,  through  which  the  aqueous  humour  would 
escape,  and  even  a fold  of  the  iris.  Opening  the  cor- 
nea, therefore,  only  converts  the  hypcpinni  into  an 
ulcer  of  that  membrane,  attended  with  a prolapsus  of 
the  iris,  and  occasionally  of  the  crystalline  itself.  Nor 
can  any  inferetice  be  di-awn  in  favour  of  making  an 
artificial  opening,  during  the  stationary  stale  of  an 
hypopium  in  the  second  stage  of  severe  acme  oph- 
thalmy, from  the  matter  of  the  hypopium  having  some- 
times m.'.de  it-;  way  spontaneously  througli  a narrow 
aperture  in  the  cornea  with  a successful  result.  For 
there  is  a wide  difference  between  the  effects  of  a spon- 
taneous opening  in  a natural  or  preternatmal  cavity  of 
the  animal  body,  or  of  one  made  with  caustic,  and  the 
consequences  of  an  opening  made  with  a cutting  in- 
strument. In  the  first  two  methods  the  subsequent 
symptoms  are  constantly  milder  than  in  the  la.st.  Be- 
sides, even  in  the  instance  in  which  a spontaneous  dis- 
charge of  the  hypo()ium  takes  place  through  tlie  cor- 
nea, an  escajieof  the  aqueous  humour,  and  a prolapsus 
of  the  iris,  not  urifrcquently  ensue;  consequently,  the 
spontaneous  evacuation  of  the  hypopium  cannot  justly 
form  a rule  for  the  treatment  of  the  disease.  There  is 
only  one  case  in  which  dividing  the  cornea,  in  oider  to 
discharge  an  hypopium,  is  not  only  useful  but  indis- 
pensable; this  is,  when  there  is  such  an  immense 
quantity  of  coagulating  lymph,  extravasated  in  the 
eye,  that  the  excessive  distention  which  it  produces  of 
all  the  coats  of  this  organ,  occasions  symptoms  so  ve- 
hement as  not  only  Ihreateii  the  entire  destrnction  of 
the  eye,  hut  even  endancer  the  life  of  the  patient.  But 
this  partitmlar  case  cannot  serve  (says  Scarpa)  as  a 
model  for  the  treatment  of  ordinary  cases. 

'I’he  dispersion  of  the  hypopium,  by  means  of  ab- 
sorption, forms  the  primary  indication  at  which  the 
surgeon  should  aim.  In  order  to  stop  its  progress,  the 
most  efficacious  method  is  to  subdue  the  first  violence 


76 


HYPOPIUM. 


of  the  inflammation,  and  to  shorten  its  acute  stage,  by 
the  free  employment  of  antiphlogistic  treatment  and 
the  use  of  mild  emollient,  topical  remedies.  And,  in 
conjunction  with  these  means,  there  can  now  be  no 
doubt  that  the  practice  of  Briiel,  published  in  1809,  as 
will  be  mentioned  at  the  close  of  this  article,  ought  to 
be  followed:  I mean  the  quick  exhibition  of  the  sub- 
muriate  of  mercury,  which  has  also  been  found  at  the 
London  Ophthalmic  Infirmary  the  most  powerful 
means  of  checking  the  effusion  of  lymph  in  the  eye.— ■ 
(See  Saunders's  fVork  on  the  Eye,  e(L  2,  and  a Synopsis 
of  the  Diseases  of  the  Eye,  by  B.  Travers,  p.  135.) 

If  this  treatment  answer,  the  incipient  collection  of 
coagulating  lymph  at  the  bottom  of  the  anterior  cham- 
ber of  the  aqueous  humour,  not  only  ceases  to  aug- 
ment, but  also,  in  proportion  as  the  severe  ophthalmy 
disappears,  the  absorbent  system  takes  up  the  hetero- 
genous fluid  extravasated  in  the  eye,  and  the  white  or 
yellow  speck,  shaped  like  a crescent,  situated  at  the 
bottom  of  the  anterior  chamber,  gradually  diminishes, 
and  is  at  last  entirely  dispersed.  Such,  in  short,  is  the 
successful  termination  of  an  hypopium,  whenever  the 
disease  is  properly  treated  at  its  commencement,  and 
the  acute  stage  of  severe  ophthalmy  is  promptly 
checked  by  internal  antiphlogistic  means  and  emollient 
applications.  But,  in  consequence  of  the  inflamma- 
tory period  of  the  severe  ophthalmy  having  resisted,  in 
an  uncommon  manner,  the  best  means,  or  because 
such  means  have  been  employed  too  late,  it  sometimes 
happens  that  the  coagulating  lymph  collected  in  the 
anterior  chamber  is  so  abundant,  even  after  the  acute 
stage  of  ophthalmy,  that  it  continues  for  a long  time  to 
cloud  the  eye  and  intercept  vision.  Scarpa  has  often 
seen  patients,  especially  paupers,  who,  from  indolence, 
negligence,  or  ill  treatment,  remained  a long  time  after 
the  cessation  of  the  inflammatory  stage  of  ophthalmy, 
with  the  anterior  chamber  nearly  filled  with  the  glu- 
tinous matter  of  hypopium.  When  the  inflammation 
had  ceased,  these  unhappy  persons  wandered  about  the 
streets  almost  indifferent,  and  without  complaining  of 
pain,  or  any  other  inconvenience,  than  the  difficulty  of 
seeing  with  the  eye  affected.  In  this  second  stage  of 
the  ophthalmy,  the  resolution  of  hypopium  obviously 
cannot  be  accomplished  by  the  same  means,  nor  with 
equal  celerity,  as  in  the  first.  At  this  crisis,  the  great 
quantity  and  density  of  the  glutinous  matter  extrava- 
sated,  and  the  atony  of  the  vascular  system  of  the  eye, 
make  it  necessary  to  give  nature  sufficient  time  to  dis- 
sipate the  thick,  tenacious  matter,  and  at  length  to 
disiKise  it  to  be  insensibly  absorbed  with  the  aqueous 
humour,  which  is  continually  undergoing  a renovation. 
Hettce  it  is  right  (says  Scarpa)  to  adopt  those  means 
which  are  best  calculated  to  invigorate  the  vascular 
system  of  the  eye,  more  especially  the  lymphatics. 
This  requires  more  or  less  time,  according  as  the  (te,- 
tient  is  advanced  in  years,  of  a relaxed  fibre,  and  weak, 
or  a young  man  of  good  constitution. 

However,  according  to  Scarpa,  in  the  second  stage 
of  violent  acute  ophthalmy,  complicated  with  hypo- 
pium, the  surgeon  should  limit  his  efforts  to  the  remo- 
val of  every  thing  which  may  irritate  the  eye,  or  be 
likely  to  renew  the  inflammation;  and  he  should  only 
employ  such  means  as  are  conducive  to  the  resolution 
of  the  second  inflammatory  stage,  depending  on  relax- 
ation of  the  conjunctiva  and  its  vessels,  and  such  re- 
medies as  tend,  at  the  same  time,  to  invigorate  the 
action  of  the  absorbents.  Therefore,  in  this  state,  he 
ought  first  to  examine  carefully  the  degree  of  irritability 
in  the  eye  affected  with  the  hypopium,  by  introducing, 
berw'eeii  the  eye  and  eyelids,  a few  drops  of  vitriolic 
col  yriiim,  containing  the  mucilage  of  quince  seeds. 
Should  the  eye  seem  too  strongly  stimulated  by  this 
application,  it  must  not  be  used,  and  little  bags  of 
warm  mallows  with  a few  grains  of  camphor  are  to  be 
substituted  for  iL  In  the  intervals,  the  vapours  of 
the  liquor  ammon.  comp,  may  be  applied,  and  recourse 
had  again  to  a blister  on  the  nape  of  the  neck.  When 
the  extreme  sensibility  of  the  eye  is  overcome,  the 
zinc  collyrium  must  be  used  again,  afterward  strength- 
ened with  a few  drops  of  camphorated  spirit.  In  this 
country,  the  exhibition  of  mercury  would  be  generally 
deemed  better  practice  than  that  here  recommended  by 
Scarpa.  In  proportion  as  the  chronic  opthalmy  disap- 
pears, and  the  action  of  the  absorbents  is  re-excited, 
the  tenacious  matter  of  the  hypopium  divides  first  into 
several  small  masses;  then  dissolves  still  farther,  and 
afterward  decreases  in  quantity ; descending  towards 


the  inferior  segment  of  the  cornea;  and  finally  vanish- 
ing altogether.  But  Scarpa  accurately  observes,  that 
the  surgeon  cannot  always  expect  to  be  equally  suc- 
cessful, whether  the  disease  occur  during  the  first  or 
second  stage  of  violent  acute  ophthalmy,  if  the  tena- 
cious lymph,  suddenly  extravasated  in  the  interior  of 
the  eye,  prevail  in  such  quantity,  as  not  only  to  fill,  but 
strongly  distend,  the  two  chambers  of  the  aqueous 
humour  and  the  cornea  in  particular.  In  this  state 
notwithstanding  the  most  skilful  treatment,  the  un- 
pleasant complication  is  often  followed  by  another  in 
convenience,  still  w'orse  than  the  hypopium  itself;  viz. 
ulceration,  opacity,  and  bursting  of  the  cornea. 

The  ulceration  of  the  cornea  ordinarily  takes  place 
with  such  celerity',  that  the  surgeon  seldom  has  time 
to  prevent  it.  As  soon  as  an  aperture  has  been  formed, 
the  excessive  abundance  of  coagulating  lymph,  con- 
tained in  the  eye,  (sometimes  named  empyema  oculi) 
begins  to  escajre  through  it,  and  a degree  of  relief  is 
experienced.  But  this  melioration  is  not  of  long  con- 
tinuance ; for  scarcely  is  the  glutinous  fluid  evacuated 
that  distended  the  whole  eye,  and  especially  the  cornea, 
when  it  is  followed  by  a portion  of  Uie  iris,  which 
glides  through  the  ulcerated  aperture,  protrudes  exter- 
nally, and  constitutes  the  disease  termed  prolapsus  of 
the  iris. — (See  Iris,  Prolapsus  of.)  But  if  in  such  an 
emergency  the  cornea,  already  ulcerated,  opaque,  and 
greatly  deranged  in  its  organization,  should  not  imme- 
diately burst,  the  surgeon  is  then  constrained  by  the 
violence  of  the  symptoms,  depending  on  the  prodigious 
distention  of  the  eyeball,  to  make  an  opening  in  this 
membrane,  in  order  to  relieve  the  immense  constric- 
tion, and  even  the  danger  in  which  life  is  placed. 

Were  there  the  least  chance  of  restoring,  in  any  de- 
gree, the  transparency  of  the  cornea,  and  the  functions 
of  the  organs  of  vision,  after  opening  the  cornea, 
Scarpa  acknowledges,  that  it  would  certainly  be  more 
prudent  to  make  the  opening  at  the  lower  part  of  this 
membrane.  But  in  the  case  of  empyema  of  the  eye, 
now  considered,  in  which  the  cornea  is  universally 
menaced  with  ulceration  and  opacity,  and  seems  ready 
to  slough,  there  can  be  no  hope  of  its  resuming  its 
transparency  at  any  point,  and  he  therefore  deems  it 
the  best  and  most  expeditious  method  of  relief  to  di- 
vide its  centre  with  a small  bistoury  to  the  extent  of  a 
line  and  a half ; and  then  to  raise  with  a pair  of  forceps 
the  little  flap,  and  cut  it  away  all  round  with  one 
stroke  of  the  scissors  so  as  to  let  the  humours  escape 
without  any  pressure. 

The  eye  is  to  be  covered  w'ith  a bread  and  milk  poul- 
tice, which  is  to  be  renewed  every  two  hours,  the  use 
of  such  general  remedies  as  are  calculated  to  check  the 
progress  of  acute  inflammation,  and  to  quiet  the  ner- 
vous system,  not  being  omitted.  In  proportion  as  the 
interior  of  the  eye  suppurates,  the  eyeball  gradually 
diminishes,  shrinks  into  the  orbit,  and  at  length  cica- 
trizes, leaving  things  in  a favourable  state  for  the  ap- 
plication of  an  artifical  eye. 

When  Scarpa  delivers  his  opinion,  that  in  the  above 
aggravated  form  of  hypopium  there  can  be  no  chance 
of  the  cornea  resuming  its  transparency  at  any  point, 
I think  his  assertion  rather  imprudent.  Nor,  admit- 
ting its  general  truth,  does  it  follow,  as  a matter  of 
course,  that  it  is  necessary  and  right  to  cut  away  a 
piece  of  the  centre  of  the  cornea,  and  absolutely  de- 
stroy whatever  little  chance  may  yet  be  left  of  saving 
the  eye.  In  support  of  this  remark  let  me  contrast 
what  Mr.  Travers  has  said  with  the  advice  of  Scarpa. 
“ When  the  hypopium  is  so  large  as  to  rise  towards 
the  pupil,  and  the  ulceration  of  the  cornea  is  extending, 
I think  its  discharge  by  section  near  the  margin  ad- 
visable. If  not  too  long  delayed,  the  ulcerative  process 
is  checked  by  it,  which  w'ould  otherw’ise  run  into 
sloughing,  and  the  cornea  recovers  with  only  partial 
opacity  and  disfigurement." — {Synopsis  of  the  Dis- 
eases of  the  Eye,  p.  280.) 

JMauchart  de  Hypopyo  ; Tubingw,  1742.  C.  P.  Le- 
porin,  de  Hypopyo ; ‘llo.  GoBt,  1778.  Goeldin,  Diss. 
de  Hypopyo;  Erlang,  1810.  Walther  Jilerkwurdige, 
Heilung  eines  Eiterauges,  &'C.  8vo.  Eandshut,  1819. 
I observe,  that  in  Huf eland  and  Himley's  Journal  for 
October  1809,  p.  93,  there  is  an  account  of  the  treatmen  t 
of  an  hypopium,  or  case  of  effused  lymph  in  the  cham- 
bers of  the  eye,  by  exhibiting  from  12  to  18  grains  of 
the  submunateof  mercury  in  the  space  of  12  hours,  and 
then  giving  bark,  while  as  an  external  application  the 
tinct.  opii  crocat.  was  employed.  Thus  we  see  that  the 


INF 


INF 


77 


efficacy  of  mercury  in  checking  the  effusion  of  lymph  in 
the  eyfi,  and  promoting  its  absorption.,  has  been  known 
many  years  in  Germany.  A.  Scarpa,  Saggio  di  Osser- 
vazioni  e d' Esperienze,  sulle  Principali  Malattie  degli 
Occhi ; Venezia,  1802.  Richter,  Anfangsgriinde  der 


Wundarzneykunst,  b.  3,  1795.  J.  Wardrop,  Essays 
on  the  Morbid  Anatomy  of  the  Human  Eye,  chap.  6, 
Edinb.  Ie08. 

HYSTEROTOMIA.  (From  vorepa,  the  womb,  and 
Ttpvoi,  to  cut.)— See  Cwsarean  Operation. 


1 


IMPERFORATE  HYMEN.— (See  Vagina.) 

INCARCERATION.  This  term  is  usually  ap- 
plied to  cases  of  hernia,  in  the  same  sense  as  strangu- 
lation. When  the  viscera  are  pressed  upon  either  by 
the  opening  through  which  they  protrude,  or  by  the 
parts  themselves  within  the  hernial  sac,  in  such  a de- 
gree, that  the  course  of  the  intestinal  matter  to  the  anus 
is  obstructed,  and  nausea,  sickness,  pain,  and  tension 
of  the  swelling  and  abdomen,  &c.  are  occasioned,  the 
rupture  is  said  to  be  in  a state  of  incarceration,  or 
strangulation. 

According  to  Professor  Scarpa,  however,  an  incarce- 
rated and  a strangulated  hernia  do  not  imply  exactly 
the  same  thing.  In  the  first  case,  says  he,  the  course 
of  the  intestinal  matter  is  interrupted,  without  any 
considerable  impairment  of  the  texture  or  vitality  of 
the  bowel.  On  the  contrary,  in  the  strangulated  her- 
nia, besides  the  obstruction  to  the  course  of  the  fecal 
matter,  there  is  organic  injury  of  the  coats  of  the  inies- 
tiue,  with  loss  of  its  vitality.  The  bowel  that  is 
merely  incarcerated,  resumes  its  functions  immediately 
it  is  replaced  in  the  abdomen;  while  that  which  is  truly 
strangulated  never  returns  to  its  natural  state. — {Traiti 
des  Hernies,  p.  251.)  English  surgeons  do  not  adopt 
this  distinction. 

INCONTINENCE  OF  URINE.— (See  Urine,  In- 
continence of.) 

INFLAMMATION.  (From  rnjlawma,  to  burn.)  By 
the  term  inflammation,  is  generally  understood  the  state 
of  a part,  in  which  it  is  painful,  hotter,  redder,  and 
somewhat  more  turgid  than  it  naturally  is;  which 
topical  symptoms,  when  present  in  any  considerable 
degree,  or  when  they  affect  very  sensible  parts,  are  at- 
tended with  fever,  or  a general  disturbance  of  the  sys- 
tem.— (Burns.) 

The  susceptibility  of  the  body  for  inflammation  is 
of  two  kinds:  the  one  original,  constituting  a part  of 
the  animal  economy,  and  beyond  the  reach  of  Iraman 
investigation ; the  other  acquired,  from  the  influence  of 
climate,  habits  of  life,  and  state  of  the  mind  over  the 
constitution.— (//uTifer.)  The  first  kind  of  suscepti- 
bility, being  innate,  cannot  be  diminished  by  art;  the 
second  may  be  lessened  by  the  mere  avoidance  of  the 
particular  causes  on  which  it  depends. 

Inflammation  may,  with  great  propriety,  he  divided 
into  he ilthy  and  unhealthy.  Of  the  first,  there  can  only 
be  one  kind,  though  divisible  into  different  stages  ; of 
the  second,  there  must  be  an  infinite  number  of  species, 
according  to  the  peculiarities  of  different  constitutions, 
and  the  nature  of  diseases,  which  are  numberless. — 
(Hunter.)  Another  general  division  is  into  common 
and  specfic  inflammation,  the  latter  term  im|)lying  that 
the  affection  has  some  strongly  itiarked  particularity 
about  it,  rendering  it,  in  some  degree,  independent  of 
such  circumstances  as  would  control  and  regulate  the 
progress  of  comtnon  inflammation.  Such  are  venereal, 
variolous,  vaccine,  erysipelatous,  gouty,  and  rheu- 
matic inflammations,  &c.  Inflammation  may  also  be 
divided  into  the  acute  and  chronic.  This  division  of 
the  subject  is  one  of  the  most  ancient,  and  seems  to 
have  obtained  the  sanction  of  all  the  best  surgical 
writers.  Healthy  inflammation  is  invariably  quick  in 
its  progress,  for  which  reason  it  must  always  rank  as 
an  acute  species  of  the  affection.  However,  there  are 
numerous  inflammations,  controlled  by  a diseased 
principle,  which  are  quick  in  their  progress,  and  are, 
therefore,  to  be  considered  as  acute.  Chronic  inflam- 
mation, which  will  be  treated  of  when  I come  to  the 
subject  of  tumours,  is  always  accompanied  with  dis- 
eased action. 

My  friend,  Mr.  James,  of  Exeter,  justly  impressed 
with  the  utility  which  would  result  from  a good  noso- 


logical arrangement  of  inflammation,  has  attempted  to 
supply  what  must  generally  be  allowed  to  be  a great  de- 
sideratum. To  the  division  of  inflammation  into  the 
acute,  sub-acute,  or  chronic,  he  objects,  that  in  many 
instances  these  are  merely  different  stages  of  the  same 
disease.  The  arrangement  into  the  adhesive,  suppu- 
rative, ulcerative,  or  gangrenous  inflammation,  he 
does  not  altogether  approve,  because  it  is  merely 
founded  on  the  modes  iii  which  either  diflerent,  or,  in 
some  instances,  the  same  kinds  of  inflammation  ter- 
minate. Under  the  heads  of  phlegmonous,  erysipela- 
tous, and  gangrenous  inflammation,  he  argues,  that 
diseases  of  the  most  opposite  nature  have  been  indis- 
criminately brought  together.  The  disposition  to  ter- 
minate in  gangrene,  he  admits,  will  aflbrd  a basis  for 
subdivision,  but  not  for  primary  separation.  Mr. 
James  makes  some  judicious  observations  on  the  ar- 
rangement of  the  kinds  of  inflammation,  according  to 
the  elementary  tissue  in  which  they  occur,  as  profrosed 
by  Dr.  Carmichael  Smith,  Pinel,  and  Bichat.  .The 
tissues  in  question  are  five,  and  the  doctrine  supposes 
that  the  inflammation  of  each  is  essentially  diflerent. 
The  first  is  phlegmonous  inflammation,  which  affects 
the  cellular  membrane,  including  the  parenchyma  of 
the  several  viscera.  The  second  is  inflammation  of 
serous  membranes.  The  tliird,  of  mucous  membranes. 
The  fourth,  which  is  named  erysipelatous,  is  of  the 
skin:  and  the  fifth,  termed  rheumatic,  belongs  to 
fibrous  structure.  That  inflammations  differ  mate- 
rially from  the  circumstance  of  their  affecting  one  of 
these  elementary  tissues  rather  than  another,  Mr. 
James  freely  admits  ; but  the  following  objections  ap- 
pear to  him  fatal  to  this  system,  if  they  are  true.  1. 
Different  kinds  of  inflammation  are  liable  to  occur  in 
the  same  tissue.  2.  The  same  kind  of  inflammation 
is  often  met  with  in  different  tissues.  3.  The  same 
inflammation  may  be  transferred  from  one  to  another; 
an  argument,  however,  on  which  he  la}'s  less  stress, 
as  being  difficult  of  direct  proof.— (See  0/y.«.  on  the 
different  Species  of  Inflammation,  p.  3 — 7,  8i;o.  Land. 
1821.)  Althouith  difference  of  structure  unquestion- 
ably accounts  for  some  of  the  varieiies  in  the  appear- 
ance and  character  of  inflammation,  it  will  not  suffi- 
cieuily  explain  the  principal  diversities  of  this  affec- 
tion, to  be  taken  as  the  foundKtion  of  a no.‘<oiogical 
arrausement,  not  only  for  the  reasons  pointed  out  by 
.Mr.  James,  but  because  the  common  distinctions  of  in- 
flammation at  present  in  vogue,  and  some  of  which  at 
least  are  obvious  and  striking,  cannot  be  at  all  solved 
by  any  reference  merely  to  texture.  Nor  did  this  the- 
ory satisfy  Mr.  Hunter,  who  observed,  that  if  it  were 
true,  “ we  should  soon  be  made  acquainted  with  all  the 
different  inflammations  in  the  same  person,  at  the  same 
time,  and  even  in  the  same  wound.  For  instance,  in 
an  amputation  of  a leg,  where  we  cut  through  the  skin, 
cellular  membrane,  muscle,  tendon,  periosteum,  bone, 
and  marrow,  the  skin  should  give  us  inflammation  of 
its  kind  ; the  cellular  membrane  of  its  kind  ; the  mus- 
cles of  theirs,  &c.  &c.;  but  we  find  it  is  the  same  in- 
flammation in  them  all.”  However,  though  Mr.  Hunter 
did  not  admit  the  possibility  of  referring  the  different 
kinds  of  inflammation  to  peculiarities  of  texture,  his 
doctrines  assign  to  this  cause  considerable  influence 
over  every  form  of  the  disorder,  as  will  be  oresently 
explained. 

Indeed,  it  must  after  all  be  granted,  i.iat  the  inflam- 
mation of  a membrane  differs  very  much  from  that  of 
a muscle;  and  that  both  differ  from  that  of  the  skin. 
If  also  the  comnum  doctrine  be  true,  that  one  peculiar 
kind  of  inflammation  is  seen  in  no  other  organ  but 
the  skin,  we  must  here  also  admit  the  vast  influence 
either  of  structure  or  of  the  particular  nature  of  the 


78 


INFLAMMATION. 


part,  in  determining  at  all  events  the  seat  of  this  in- 
hainniation. 

Tile  mode  of  reasoning,  adopted  by  Mr.  James,  leads 
him  to  propose  ; 1st.  The  division  of  inflammations 
into  two  grea‘  classes,  according  to  their  disposition 
either  to  be  limited  by  the  etfusion  of  organizable  co- 
agulable  lymph,  or  to  spread.  2dly.  Tlie  orders  are 
established  on  tlie  principle  of  the  degree  of  connexion 
of  the  organ  with  the  vital  functions  of  the  animal; 
ano'tlior  cause,  which  exerts  a predominant  influence 
over  the  cliaracter  of  the  inflammation  ; acts  invaria- 
bly, and,  coeteris  paribus,  in  the  same  degree;  the 
constitutional  sympathy  being  in  proportion  to  the 
danger,  tlie  difficulty  of  resisting  that  danger,  and  of 
repairing  the  mischief  done.  3dly.  The  genera  are 
founded  on  the  original  disposition  of  inflammations 
to  Iwve  particular  modesof  termination  ; thus,saysMr. 
James,  in  boil  and  whitlow,  it  is  to  suppurate  ; in  car- 
buncle, to  slough  ; and  in  mumps,  to  resolve  ; and  this 
disposition  is  so  strong,  that  it  is  very  difficult  to  pro- 
cure any  other  termination.  It  may  happen,  however, 
that  there  shall  be  more  than  one  mode  in  which  it  (the 
inflammation)  is  disposed  to  terminate,  as  in  either  re- 
solution, or  suppuration,  in  sphacelus,  or  ulceration, 
&c. — {Op.  cit.p.  13—16.)  Mr.  James  conceives  “ that 
these  general  principles  will  perhajis  affiird  a sufficient 
basis  for  such  an  arrangement,  as  shall  be  both  natural 
and  useful  in  its  application  to  all  kinds  of  common 
inflammation  ; gout,  rheumatism,  and  scrofula  having 
peculiariiies,  which  require  them  to  be  separated. 
Also  with  respect  to  inflammations  arising  from  ex- 
ternal injuries,  as  they  are  more  simple  in  tlieir  nature, 
may  lake  place  in  sound  constitutions,  and  are  accom- 
panied with  disorganizations,  which  do  not  exist  in 
other  cases,  Mr.  James  considers  them  as  materially 
different.  This  author  purposely  excludes  from  his 
classification  inflammations  of  the  organs  of  sense, 
and  of  the  bones,  the  peculiarities  in  their  structure 
atid  functions  rendering  them  fit  subjects  for  separate 
description.  With  respect  to  Mr.  James’s  nosological 
table  of  inflammation,  I consider  it  very  ingenious,  and 
well  deserving  of  the  attention  of  the  profession  : I 
may  say  this,  without  afc  all  involving  myself  in  the 
hypothesis,  that  the  limitation  or  spreading  of  the  ge- 
nerality of  inflammations,  is  a circumstance  entirely 
dependent  upon  their  disposition  or  indisposition  to 
effuse  organizable  lymph.  Mr.  Hunter  was  w’ell  ac- 
quainted with  the  frequent  usefulness  of  the  adhesive 
inflammation  in  setting  limits  to  disease,  yet  he  did 
not  venture  to  refer  the  circumscription  of  every  in- 
flammation to  this  cause,  or  the  spreading  of  the  dis- 
order entirely  to  its  absence.  Nor,  indeed,  does  it  seem 
essential  to  Mr  James’s  classification,  that  any  cause 
should  be  assigned  for  the  disposition  of  one  class  of 
inflammations  to  be  limited,  and  of  another  to  spread  ; 
the  two  facts  themselves  being  sufficient  for  the  basis 
of  the  division. 

There  is  much  foundation  for  believing,  that  healthy 
inflammation  is  invariably  a homogeneous  process, 
obedient  to  ordained  principles,  and,  in  similar  struc- 
tures, similar  situatiotis,  and  in  constitutions  of  equal 
strength,  uniformly  assuming  the  same  features.  If 
experience  reveals  to  us,  that  here  it  is  cc-mmonly  pro- 
ductive of  certain  effects,  and  there  it  ordinarily  pro- 
duces different  ones,  the  same  unbounded  source  of 
wisdom  communicates  to  the  mind  a knowledge,  that 
there  is  some  difference  in  the  tone  of  the  constitution, 
or  in  the  structure  or  situuioti  of  the  parts  affected, 
assignable  as  the  cause  of  this  variety.  A modern 
author  {Dr.  Smith,  in  Med.  Communications,  vol.  2) 
makes  the  nature  of  the  exciting  cause  one  principal 
ground  of  the  specific  distinctions  in  inflammation; 
and  with  good  reason,  when  he  takes  into  the  account 
the  action  of  morbid  poisons,  and  the  qualities  of  dis- 
ease in  general. 

The  doctrine  also  receives  confirmation  from-whiit 
is  observed  in  -cases  of  burns  and  chilblains,  where 
the  inflammation  is  unquestionably  attended  with 
great  peculiarity,  requiring  different  treatment  from 
that  of  common  inflammation  in  general.  But  when 
the  exciting  cause  is  strictly  mechanical,  its  violence 
and  extent  may  cajise  differences  in  the  degree  and 
quantity  of  inflammation  ; but  with  respect  to  its  qua- 
lity, this  must  be  accounted  for  by  constitution,  or  other 
circumstances. 

The  attentive  observation  of  experience,  the  only 
Bolid  basis  of  all  medical,  as  well  as  other  knowledge, 


has  informed  the  praclilionef,  that  parts  which*  from 
their  vicinity  to  the  source  of  circulation,  erijoy  a 
vigorous  circulation  of  blood  through  them,  undergo 
inflammation  more  favourably,  and  resist  disease  bet- 
ter, than  other  parts,  of  similar  structure,  more  remote 
from  the  heart.  The  lower  extremities  are  more  prone 
to  inflammation,  and  disease  in  general,  than  parts 
about  the  chest ; when  inflamed,  they  are  longer  in 
getting  well ; and  the  circumstance  of  their  being  de- 
pending parts,  which  retards  the  return  of  blood  through 
the  veins,  must  also  increase  the  backwardness  of 
such  parts  in  any  salutary  process.  Healthy  inflamma- 
tion is  of  a pale  red ; when  less  healthy,  it  is  of  a 
darker  colour  ; but  in  every  constitution,  the  inflamed 
parts  will  partake  more  of  the  healthy  red,  the  nearer 
they  are  to  the  source  of  the  circulation.— (//mwjc?-.) 

Inflammation,  when  situated  in  highly  organized 
and  very  vascular  parts,  is  generally  more  disposed  to 
take  a prosperous  course,  and  is  more  governable  by 
art,  than  in  parts  of  an  opposite  texture.  The  nearer 
also  such  vascular  parts  are  to  the  heart,  the  greater 
will  be  their  tendency  to  do  well  in  inflammaiion.— 
{Hunter.)  Hence,  inflammation  of  the  skin,  cellular 
substance,  muscles,  &c.  more  frequently  ends  favoura- 
bly, than  the  same  affection  of  bones,  tendons,  fascia, 
ligaments,  &c.  It  is  also  more  manageable  by  sur- 
gery; for  those  parts  of  the  body,  which  are  not  what 
anatomists  term  vascular,  seem  to  possess  inferior 
powers  of  life,  and,  consequently,  when  excited  in  a 
preternatural  degree,  frequently  mortify. 

But  inflammation  of  vital  parts,  though  they  may 
be  exceedingly  vascular,  cannot  go  on  so  favourably 
as  in  other  parts  of  resembling  structure,  but  of  dif- 
ferent functions ; because  the  natural  operations  of 
universal  health  depend  so  much  upon  the  sound 
condition  of  such  organs. — {Hunter.)  The  truth  of 
this  observation  is  illustrated  in  gastritis,  peripneu- 
mony,  &c. 

All  new  formed  parts,  not  originally  entering  into 
the  fabric  of  the  body,  such  as  tumours,  both  of  the 
encysted  and  sarcomatous  kinds,  excrescences,  &c. 
cannot  endure  the  disturbance  of  inflammaiion  long, 
nor  in  a great  degree.  The  vital  powers  of  such  pans 
are  weak,  and,  when  irritated  by  the  presence  of  inflam- 
mation, these  adventitious  substances  are  sometimes 
removed  by  the  lymphatics,  but  more  commonly 
slough.  This  remark  applies  also  to  substance.s  gene- 
rated as  substitutes  for  the  original  ntatter  of  the  body  ; 
for  instance,  granulations  and  callus.  The  knowledge 
of  this  fact  leads  us  to  a rational  principle  of  cure  in 
the  treatment  of  several  surgical  diseases.  Do  we  noi 
here  perceive  the  cause,  why  large  wens  are  occa- 
sionally dispersed  by  the  application  of  urine,  brine, 
and  similar  things,  which  are  now  in  great  repute,  on 
this  account,  with  almost  every  one  out  of  the  profes- 
sion 1 How  many  verrucae,  wrongly  suspected  to  ori- 
ginate from  a syphilitic  cause,  are  diminished  and 
cured  by  a course  of  mercury  ! It  is  the  stimulus  of 
this  mineral  upon  the  whole  system,  that  accomplishes 
the  destruction  of  these  adventitious  substances — not 
its  antivenereal  quality.  Topical  stimulants  would 
fulfil  the  same  object,  not  only  with  greater  expedition, 
but  with  no  itijury  to  the  general  health. 

Inflammation,  cmteris  paribus,  always  proceeds 
more  favourably  in  strong  than  in  weak  constitutions  ; 
for  when  there  is  much  strength,  there  is  little  irritabi- 
lity. In  w’eak  constitutions,  the  operations  of  inflam- 
mation are  backwards,  notwithstanding  the  part  in 
which  it  is  seated  may,  comparatively  speaking,  possess 
considerable  organization,  and  powers  of  life. 

Healthy  inflammation,  wherever  situated,  is  always 
most  violent  on  that  side  of  the  point  of  inflammation 
which  is  next  to  the  external  surface  of  the  body. 
When  inflammaiion  attacks  the  socket  of  a tooth,  it 
does  not  take  place  on  the  inside  of  the  alveolary  pro- 
cess, but  towards  the  cheek.  When  inflammation 
attacks  the  cellular  substance  surronnding  the  rectum, 
near  the  anus,  the  affection  usually  extends  itself  to 
the  skin  of  the  buttock,  leaving  the  intestine  perfectly 
sound,  though  in  contact  with  the  inflamed  part. — 
{Hunter.) 

We  may  observe  the  influence  of  this  law  in  the 
diseases  of  the  lachrymal  sac  atid  duct,  in  those  of  the 
frontal  sinus,  and  antrum,  and  particularly  in  gunshot 
wounds.  Suppose  a ball  were  to  pass  into  the  thigh 
to  within  an  inch  of  the  opposite  side  of  the  limb,  we 
should  not  find  that  inflamniatiou  would  be  excited 


INFLAMMATION. 


79 


along  the  tiack'of  the  ball,  but  on  the  side  next  the 
skill  which  had  not  been  hurt.  If  a ball  were  to  pass 
quite  through  a limb,  and  carry  into  the  wound  a 
piece  of  cloth,  which  lodged  in  the  middle,  equidistant 
from  the  two  orifices,  the  skin  immediately  over  the 
extraneous  body  would  inflame,  if  the  passage  of  the 
ball  were  superficial. — {Hunter.)  Mr.  Hunter  com- 
pared this  law  with  llie  principle  by  which  vegetables 
approach  the  surface  of  the  earth ; but  the  solution  of 
it  was  too  arduous  even  for  his  strong  genius  and  pe- 
netration. • 

We  see  three  very  remarkable  effects  follow  inflam- 
mation ; viz.  adhesions  of  parts  of  the  body  to  each 
other;  the  formation  of  pus,  or  suppuration  ; and  ulcer- 
ation, a process  in  which  the  lymphatics  are  more 
concerned  than  the  blood-vessels.  Hence,  Mr.  Hunter 
termed  the  different  stages  of  inflammation,  the  adhe- 
sive., the  suppurative.,  and  the  ulcerative. 

All  parts  of  the  body  are  not  equally  liable  to  each 
of  the  preceding  consequences. 

In  the  cellular  membrane,  and  in  the  circumscribed 
cavities,  the  adhesive  stage  takes  place  more  readily 
than  the  others ; suppuration  may  be  said  to  follow 
next  ill  order  of  frequency  ; and  lastly,  ulceration. 

In  internal  canals,  on  the  inner  surfaces  of  the  eye- 
lids, nose,  mouth,  and  trachea,  in  the  air-cells  of  the 
lungs,  in  the  oesophagus,  stomach,  intestines,  pelvis  of 
the  .kidney,  ureters,  bladder,  urethra,  and  in  all  the 
ducts  and  outlets  of  the  organs  of  secretion,  being 
what  are  termed  mucous  membranes,  the  suppurative 
inflammation  comes  on  more  readily,  than  either  the 
adhesive  or  the  ulcerative  stage.  Adhesions,  which 
originate  from  the  slightest  degree  of  inflammation 
in  other  situations  and  stiuctures,  can  only  be  produced 
by  a violent  kind  in  the  above-mentioned  parts.  Ul- 
ceration is  more  freijuently  met  with  upon  mucous 
surfaces  than  adhesions.  The  cellular  membrane  ap- 
pears to  be  much  more  susceptible  of  the  adhesive 
inflammation  than  the  adipose,  and  much  more  readily 
passes  into  the  suppurative.  Thus  we  see  the  cellular 
substance,  connecting  the  muscles  together,  and  the 
adipose  membrane  to  the  muscles,  inflaming,  suppu- 
rating, and  the  matter  separating  the  muscles  from 
their  lateral  connexions,  and  even  the  fat  from  the 
muscles,  while  the  latter  substance  and  the  skin  are 
only  highly  inflamed. — {Hunter.)  But  it  must  be 
allowed,  that  in  situations  where  fat  abounds,  we  very 
frequently  meet  with  abscesses.  This  is  so  much  the 
case,  that  fat  has  been  accounted  a more  frequent  nidus 
for  collections  of  matter,  than  the  cellular  substance. — 
{.Brumfield.)  Abscesses  are  particularly  liable  to  form 
in  the  neighbourhood  of  the  anus,  mamma,  &c.  With 
resiiect  to  the  fat  being  highly  inflamed,  however,  the 
expression  is  not  strictly  true.  Fat  has  no  vessels, 
principle  of  life,  nor  action  of  its  own;  consequently, 
we  cannot  suppose  that  it  can  itself  either  inflame  or 
suppurate.  We  know  that  it  is  itself  a secretion,  and 
when  an  abscess  forms  in  it,  we  understand,  that  the 
inode  of  action  in  the  vessels,  naturally  dfstined  to  de- 
posite  fat,  has  been  altered  to  that  adapted  to  the  forma- 
tion of  pus.  When  then-fore  the  fat  is  stiid  to  be  in- 
flamed, it  is  only  meant,  that  the  membranous  cells,  in 
which  it  is  contained,  and  by  which  it  is  secreted,  are 
thus  affected. 

The  deeply-situated  parts  of  the  body,  more  espe- 
cially the  vital  ones,  very  readily  admit  of  the  adhesive 
stage  of  inflammation.  The  circumstance  of  deeply- 
seated  parts  not  so  readily  taking  on  the  suppurative 
stage  of  inflammation  as  the  superficial  ones  do,  is 
strikingly  illustrated  in  cases  of  extraneous  bodies, 
which,  if  deeply  lodged,  only  produce  the  adhesive  in- 
flammation. By  this  process  a cyst  is  formed,  in 
which  they  lie  without  much  inconvenience,  and  they 
may  even  gradually  change  their  situation,  without 
disturbing  the  parts  through  which  they  pass.  But  no 
sooner  do  those  same  bodies  approach  the  skin,  than 
abscesses  immediately  arise. 

All  inflammations,  attended  with  disease,  partake 
of  some  specific  (piality,  from  which  simple  inflamma- 
tion is  entirely  free.  When  the  constitution  allows 
the  true  adhesive  and  sui)purative  stages  to  occur,  it  is 
to  be  regarded  as  the  most  healthy.  Were  it  in  an  op- 
posite state,  we  should  see  the  very  same  irritation 
excite  some  other  kind  of  inflanimatioti,  such  as  the 
er>-sipelatou8,  scrofulous,  k.c,— {Hunter.) 

In  specific  inflammations,  the  position,  structure, 
and  distance  of  the  part  affected  from  the  source  of 


the  circulation,  as  well  as  from  the  surface  of  the  body, 
seem  also  to  have  as  much  influence  as  in  cases  of 
common  inflammation.  Upon  this  point,  I feel  con- 
scious of  being  a little  at  variance  with  what  Mr. 
Hunter  has  stated;  but  the  undecided  manner  in 
which  he  expresses  himself,  not  less  than  the  following 
reflections,  encourages  me  not  to  desert  my  own  ideas. 
We  see  that  venereal  eruptions  sooner  make  their  ap- 
pearance upon  the  chest  and  face  than  upon  the  extre- 
mities. No  organized  part  can  be  deemed  exempt 
from  the  attack  of  common  inflammation;  many  ap- 
pear to  be  totally  insusceptible  of  the  venereal.  We 
know  that  scrofulous  diseases  of  the  superior  extre- 
mities take  a more  favourable  course,  require  amputa- 
tion less  frequently,  and  get  well  oftener,  than  those 
of  the  inferior  limbs. — {Ford.)  The  venereal  disease 
makes  more  rapid  advances  in  the  skin  and  throat, 
than  in  the  bones  and  tendons ; we  often  see  it  pro- 
ducing a specific  inflammation,  and  an  enlargement  of 
the  superficial  parts  of  the  tibia,  ulna,  clavicle,  cra- 
nium, &c.,  while  other  bones,  covered  by  a considerable 
quantity  of  flesh,  are  very  rarely  affected.  Gouty  in- 
flammation is  prone  to  invade  the  small  joints;  rheu<- 
matic,  the  large. 

SYMPTOMS,  NATURE,  AND  CAUSES  OF  INFLAMMATION. 

Redness,  sxvelling,  heat,  and  pain,  the  four  principal 
symiitoms  of  the  phlegmonous  inflammation,  have 
been  accurately  noticed  by  Celsus.  J^uta  vero  in- 
flammatiunis  sunt  quatuor,  rubor,  et  tumor,  cum  calore 
et  dulore,  lib.  3,  cap.  10.  If  we  refer  to  any  writer  on 
this  interesting  part  of  surgery,  we  shall  find  the  above 
symptoms  enumerated  as  characterizing  phlegmon. 
In  short,  this  term  is  usually  applied  to  a circumscribed 
tumour,  attended  with  heat,  redness,  tension,  and  a 
throbbing  pain.  These  are  the  first  appearances  ob- 
served in  every  case  of  phlegmon ; and  when  they  are 
slight,  and  the  part  affected  is  of  no  great  extent,  they 
have  commonly  very  little,  and  sometimes  no  apparent, 
influence  on  the  general  system.  But  when  they  are 
mo-e  considerable,  and  the  inflammation  becomes  ex- 
tensive, a full,  quick,  and  generally  a flard  pulse  takes 
place,  and  the  patient,  at  the  same  time,  complains  of 
universal  heat,  thirst,  and  other  symptoms  of  fever. 
While  the  inflamed  part  becomes  red,  painful,  and 
swelled,  its  functions  are  also  impaired.  The  same 
degree  of  inflammation  is  said  to  produce  more  swell- 
ing in  soft  parts,  and  less  in  those  of  a harder  struc 
ture. — {Burns.) 

Though  the  redness,  swelling,  throbbing,  tension,’ 
and  other  symptoms  of  phlegmonous  inflammation,  are 
less  manifest  when  the  affection  is  deeply  situated,  yet 
their  existence  is  uudoubied. 

When  persons  die  of  peripneumony,  or  inflamma- 
tion of  the  lungs,  the  air  cells  of  these  organs  are  found 
crowded  with  a larger  number  of  turgid  blood  vessels, 
than  in  the  healthy  state,  and,  of  course,  the  parts 
must  appear  preternaturally  red.  Coagulating  lymph, 
and  even  blood,  are  extravasated  in  the  substance  of 
these  viscera,  which  become  heavier,  and  feel  more 
solid. -(Ra/7I/e.) 

The  extravasation  of  coagulating  lymph,  which  is 
one  of  the  chief  causes  of  the  swelling,  is  also  one  of 
the  most  characteristic  signs  of  phlegmonous  inflam- 
mation. 

Some  writers  {Smith  in  Med.  Commun.  vol.  2)  re- 
strict the  seat  of  phlegmon  to  the  cellular  membrane; 
but  this  idea  is  erroneous.  Had  such  authors  duly 
discriinina>3d  the  nature  of  common  inflammation, 
they  would  have  allowed,  that  this  affection  existed 
wherever  the  capillaries  appeared  to  be  more  nume- 
rous and  enlarged  than  in  the  natural  state,  accompa- 
nied with  an  effusion  of  coagulating  lymph,  whether 
upon  the  surface  of  a membrane  or  a bone,  or  in  the 
interstices  of  the  cellular  substance,  and  attended  with 
acute  pain,  and  a throbbing  pulsation  in  the  part. 

As  Dr.  Thomson  has  observed,  the  epithet  remote, 
as  applied  to  the  causes  of  inflammation,  does  not  ap- 
pear to  be  happily  chosen  ; for  under  this  term  are 
comprehended  all  thase  agents,  events,  and  slates, 
wliich  contribute  immediately  as  well  as  remotely,  di- 
rectly as  well  as  indirectly,  to  the  production  of  the 
affection. — {Lectures  on  Inflammation,  p.  50.) 

'I'he  remote  causes  of  inflammation  are  infinite  in 
number,  but  very  easy  of  comprehension,  becau.se  only 
divisible  into  two  general  classes.  The  first  includes 
all  such  agents  as  operate  by  their  stimulant  or  che 


80 


INFLAMMATION. 


mical  qualities ; for  instance,  cantliarides,  heat,  the  ac- 
tion of  concentrated  acids,  alkalies,  metallic  oxides, 
and  metallic  salts,  acrid  vapours,  such  as  ammoniacal 
eas,  the  nitrous,  sulphureous,  muriatic  gases,  &c.  alco- 
hol, ether,  and  all  acrid  vegetable  essential  oils,  ani- 
mal poisons,  and  the  whole  of  tnat  class  of  substances 
known  by  the  name  of  rubefacients. — {Thomson  on 
Inflammation^  p.  -^o.)  The  second  class  of  causes  are 
those  which  act  mechanically,  such  as  bruises,  wounds, 
pressure,  friction,  &.c. 

Fevers  often  seem  to  become  the  remote  causes  of 
local  inflammation.  In  other  instances,  inflammation 
appears  to  arise  spontaneously,  or,  as  I should  rather 
say,  without  any  perceptible  exciting  cause. 

The  principle,  on  which  the  application  of  cold  to  a 
part  becomes  the  remote  cause  of  inflammation,  is  not 
decidedly  known.  “No  subject  (says  a distinguished 
professor)  is  more  deserving  of  your  study,  than  the 
etfecis  which  are  produced  in  the  human  body  by  the 
operation  of  cold  applied  to  its  surface  ; but  the  sub- 
ject is,  at  the  same  time,  exceedingly  extetisive,  com- 
plicated, and  difficult.  These  effects  differ  according  to 
the  degree  in  which  the  cold  is  applied,  the  state  of 
the  system,  the  part  of  the  body  to  which  it  is  applied, 
and  the  mode  of  its  application.  So  diversified,  indeed, 
are  these  effects,  tiiat  it  requires  no  mean  confidence  in 
theoretical  reasoning  to  believe,  that  the  operation  of 
cold  in  producing  them  is  explicable  upon  any  single 
general  principle.” — (See  Thomson  on  Inflammation, 
p.  58.)  And  in  the  preceding  page  he  observes;  “The 
operation  of  cold  upon  the  human  body  affords  the 
best  example  which  I can  suggest  to  you,  of  the  pro- 
duction of  inflammation  from  the  operation  of  a power 
acting  upon  a parr  at  a distance  from  that  in  which 
the  inflammation  takes  place.  The  instances  formerly 
mentioned  of  inflammation  of  the  throat,  chest,  or 
belly,  from  the  application  of  cold  to  the  feet,  are  daily 
occurrences  in  these  climates,  of  which  it  is  impossible 
for  us,  in  the  present  state  of  our  knowledge  of  the 
animal  economy,  to  give  any  thing  like  a satisfactory 
explanation.  ^ 

“ In  some  instances,  cold,  or  a diminution  of  tern 
peraiure,  seems  to  act  more  directly  upon  the  parts 
with  which  it  comes  into  contact.  We  liave  examples 
of  this  in  the  inflammation  of  the  mucous  membranes 
of  the  nose,  fauces,  trachea,  and  bronchite,  from  the 
inhalation  of  cold  air;  and  in  the  production  of  rheu- 
matic inflammation  from  the  accidental  exposure  of 
some  part  or  other  of  the  body  to  cold.  The  applica- 
tion of  cold,  in  the  instances  I have  mentioned,  seems 
to  have  somewhat  of  a directly  exciting  effect;  and 
perhajis  the  same  remark  is  still  more  applicable  to  the 
local  elfects  of  cold  in  the  production  of  the  inflamma- 
tion accompanying  the  state  which  is  usually  denomi- 
nated frost-bite.  Touching  a solid  body,  as  a piece  of 
metal,  the  temperature  of  which  has  been  greatly  re- 
duced, produces  a sensation  like  that  of  burning,  and 
may  be  followed,  like  the  application  of  fire,  by  a blis- 
ter.”—(O/i.  cit.) 

Nn  nerous  opinions  have  been  entertained  respect- 
ing the  proximate  cause  of  inflammation;  but  almost 
every  theory  has  been  built  upon  the  supposition  of 
some  kind  of  obstruction  in  the  inflamed  part. 

While  the  circulation  of  the  blood  was  unknown, 
and  the  hypothetical  notions  of  the  power  of  the  liver, 
in  preparing  and  sending  forth  this  fluid,  continued  to 
prevail,  physicians  were  so  fully  persuaded  of  the  ex- 
istence and  influence  of  different  humours  and  spirits, 
and  so  little  did  they  know  of  the  regular  and  constant 
motion  of  the  blood,  that  they  believed  in  the  possi- 
bility of  depositions  and  congestions  of  the  blood,  the 
bile,  or  lymph  ; and  acknowledged  these  as  the  cause 
of  inflammation.  Their  anatomists  taught  them,  and 
their  professors  of  physic  supported  the  opinion,  that 
the  liver  was  the  centre  of  the  vascular  system,  from 
which  the  blood  went  forth  by  day  to  the  extremities, 
and  returned  again  by  night.  If  then  any  peccant 
matter  irritated  the  liver,  the  blood  was  sent  out  more 
forcibly  ; and  if  at  the  same  time  any  part  of  the  body 
were  weakened,  or  otherwise  disposed  to  receive  a 
greater  quantity  of  fluid  than  the  rest,  then  a swelling 
was  produced  by  the  flow  of  humours  to  this  place. 
Fluxions,  or  flows  of  humour  to  a place,  might  happen 
either  from  weakness  of  the  part,  which  allowed  the 
humours  to  enter  more  abundantly,  or  from  the  place 
attracting  the  humours,  in  consequence  of  the  applica- 
tion of  heat  or  other  agents.  The  peculiar  nature  of 


the  swelling  was  supposed  to  depend  upon  the  kind  of 
humour.  Blood  produced  the  true  phlegmon ; bile, 
erysipelas,  &c.  An  idea  was  also  entertained,  that 
the  blood  and  humours  might  slowly  stagnate  in  a 
part,  from  a want  of  expulsive  power,  and  this  affec- 
tion was  termed  a congestion,  while  the  expression 
fluxion  or  defluxion  was  used  to  denote  any  swelling 
arising  from  the  sudden  flow  of  humours  from  a dis- 
tant part. — {J.  Burns'  Dissertations  on  Inflammation.) 

From  the  theories  of  fluxion  and  congestion,  which 
were  quite  incompatible  with  the  laws  of  the  circula- 
tion of  the  blood,  we  turn  our  attention  to  the  doctrine 
of  obstruction, 

Boerhaave  inculcated  {.Bph.  375,  et  seq.),  that  inflam- 
mation was  caused  by  an  obstruction  to  the  free  circu- 
lation of  the  blood  in  the  minute  vessels,  and  this  ob- 
struction, he  supposed,  might  be  caused  by  heat, 
diarrhoea,  too  copious  flow  of  urine  and  sweat,  or 
whatever  could  dissipate  the  thinner  parts  of  the  blood, 
and  produce  a thickness  or  viscidity  of  that  fluid. 
When  the  lentordid  not  exist  before  the  production  of 
inflammation,  he  imagined  that  the  larger  globules  of 
the  blood  passed  into  the  small  vessels,  and  thus  plugged 
them  up.  This  circumstance  was  termed  an  error  loci. 
The  obstruction,  whether  caused  by  viscidity  or  an 
error  loci,  was  imagined  to  occasion  a resistance  to  the 
circulation  in  the  part  affected  ; and  hence,  an  increase 
of  the  flow  of  the  blood  in  the  other  vessels,  an  irrita- 
tion of  the  heart,  and  augmentation  of  the  force  or 
attraction  of  the  blood  in  that  part  of  the  vessel  which 
was  behind  the  obstruction.  This  caused  heat  and 
pain,  while  the  accumulation  of  the  blood  produced 
redness.  Boerhaave  also  brought  into  the  account  an 
acrimonious  state  of  the  fluids,  which  rendered  reso- 
lution out  of  the  question,  and  gangrene  likely  to  fol- 
low.—(./JpA.  388.) 

The  viscidity  of  the  blood  cannot  be  admitted  as  the 
proximate  cause  of  inflammation ; because  we  have 
no  proof  that  this  state  ever  exists ; or,  granting  that  it 
did,  it  would  not  explain  the  phenomena.  Were  a 
viscidity  to  occur,  it  would  exist  in  the  whole  mass  of 
blood,  would  affect  every  part  of  the  body  alike,  and 
could  not  be  sujiposed  to  produce  only  a local  disorder. 
How,  also,  could  such  a lentor  be  produced  by  causes 
which  bring  on  inflammation  suddenly,  without  there 
being  time  for  changes  of  the  fluids  to  take  place? 

With  regard  to  the  doctrine  of  error  loci,  or  of  red 
globules  going  into  vessels  which  did  not  formerly 
transmit  them,  the  fact  must  be  admitted,  at  the  same 
time  that  the  conclusion  is  denied.  When  the  eye 
becomes  inflamed,  the  tunica  conjunctiva  is  seen  with 
its  vessels  full  of  red  blood,  which  in  health  is  not  the 
case;  but  this  redness  never  appears  until  the  inflam- 
maiio’i  has  commenced,  and  must  therefore  be  con- 
sidered as  an  effect,  not  a cause.  Nor  can  this  error 
loci  occasion  any  obstruction  in  these  vessels ; for  if 
they  be  divided  the  blood  flows  freely,  which  shows 
that  they  are  large  enough  to  allow  an  easy  circulation. 
— {J.  Burns.) 

Boerhaave’s  theory  of  obstruction  was  too  circum- 
scribed and  too  mechanical ; it  reduced  all  inflamma- 
tions to  one  species:  the  only  distinctions  which  could 
have  arisen  must  have  proceeded  from  the  nature  of 
the  obstruction  itself;  and  it  was  a doctrine  that  never 
could  account  for  the  action  of  many  specific  diseases 
and  morbid  poisons. — {Hunter.) 

. As  for  the  supposition  of  the  co-operation  of  an 
acrimony  of  the  fluids,  the  proportion  of  the  saline 
matter  of  the  blood  has  never  been  proved  to  be  greater 
in  this  than  in  any  other  state  of  the  body. — {Burns.) 
Even  were  a general  disorder  of  this  kind  to  be  ad- 
mitted, no  rational  explanation  of  the  proximate  cause 
of  local  inflammation  could  be  deduced  from  it. 

The  decided  impossibility  of  giving  a rational  expla- 
nation of  the  immediate  cause  of  inflammation  by  any 
snpiiosed  state  of  the  blood  alone,  led  pathologists  to 
investigate  how  far  a change  in  the  blood-vessels  them- 
selves might  account  for  the  process.  It  belongs  more 
properly  to  a physiological  than  a surgical  vvork,  to 
explain  the  various  facts  and  experiments  in  support 
of  the  opinion,  that  the  arterial  tubes,  atid  especially 
the  capillaries,  possess  a high  degree  of  vital  contrac- 
tility, whereby  the  motion  of  the  fluids  in  them,  the 
process  of  secretion,  and  other  local  phenomena,  may 
be  importantly  affected,  in  a manner  not  at  all  explica- 
ble by  reference  only  to  the  action  and  power  of  the 
heart.  For  such  information,  I would  particularly 


L\FLAMx\IATlON. 


81 


advise  tlie  reader  to  Consult  the  publications  of  Dr. 
Wilson  Philip  and  Dr.  Hastings.  According  to  the 
latter  genilenian,  the  actual  agency  of  the  capillary 
vessels  “ is  not  only  supported  by  such  e.\periinents  as 
those  related,  it  is  also  countenanced  by  an  extensive 
series  of  phenomena  presented  during  disease  in  the 
human  subject.  Of  these  may  be  mentioned  irregular 
determinations  of  blood,  the  grovvtii  of  tumours,  in- 
creased pulsation  of  arteries  leading  to  inflamed  parts, 
of  whictrthe  following  is  a well marked  example,  the 
accuracy  of  which  may  be  entirely  relied  upon.  The 
carotids,  when  the  person  alluded  to  is  in  health,  beat 
equally  as  to  strength  and  frequency;  but  when  he  is 
attacked  with  inflammation  in  the  right  tonsil,  to  which 
he  is  particularly  subject,  and  which  proceeds  some- 
times so  far  as  nearly  to  prevent  deglutition,  each  pulsa- 
tion of  the  artery  gives  a throbbing  sensation  on  the 
right  side  of  the  head.  On  the  application  of  the  hand 
at  this  lime  to  each  carotid,  the  right  is  found  to  beat 
much  stronger  and  fuller  than  the  left.  Tliis  diversity 
of  action  in  these  two  arteries  cannot  arise  from  any 
impulse  given  by  the  blood  to  the  heart ; it  must  be  de- 
rived from  some  moditication  of  the  contractile  power 
of  the  artery.”  And  Dr.  Hastings  expresses  his  belief 
in  this  explanation,  notwithstanding  Dr.  C.  H.  Parry 
wishes  to  attribute  to  the  remote  influence  of  the  heart 
some  of  the  phenomena  of  local  congestion  and  mo- 
tion, and  to  show  that  the  different  states  of  vascular 
dilatation  are  still  more  conspicuously  connected  with 
the  diflerent  degrees  of  action  of  the  heart,  and  the 
consequent  momentum  of  the  blood,  than  with  local 
circumstances;  and  that  the  proneness  to  local  dilata- 
tion, or,  as  it  is  called,  action,  is  a consequence  of 
slowly  succeeding  but  continued  impulse. 

The  blood-vessels  through  every  part  of  the  system 
possess  a considerable  share  of  irritability,  by  which 
they  contract,  and  propel  forwards  their  contents. 
Hence,  the  blood,  by  the  action  of  tlie  vessels,  receives 
a new  impulse  in  the  most  minute  tubes,  and  a well- 
regulated  momentum  is  preserved  in  every  part  of  its 
course.  But  of  all  parts  of  the  sanguiferous  system,  the 
capillaries  seem  most  eininenily  endowed  with  this 
faculty,  and  are  least  indebted  to  the  presiding  influ- 
ence of  the  heart.  Yet  even  in  these  vessels  the  action 
of  the  heart  is  of  high  importance  in  sustaining  the 
healthy  circulation,  inasmuch  as  it  gives  the  first  im- 
pulse to  Uie  blood,  and  preserve.s  the  harmony  of  the 
sanguiferous  system. 

The  vessels  are  endowed  with  this  vital  property,  in 
order  that  each  organ  in  the  body  may  receive  such  a 
supply  of  blood  as  will  enable  it  duly  to  exercise  its 
functions.  Hence,  a healthy  state  of  this  property  is 
absolutely  necessary  for  the  preservation  of  the  animal 
functions;  for  if  the  vital  contraction  of  the  blood- 
vessels be  either  increased  or  diminished,  irregular  dis- 
tribution of  the  blood  inevitably  follows,  and  from  this 
source  numerous  diseases  arise,  and  none  more  fre- 
quently than  inflammation.  However,  though  these 
smiiimenis,  delivered  by  Dr.  Hastings,  may  be  generally 
correct,  I am  not  prepared  to  join  in  the  opinion,  that 
inflammation  is  ever  produced  simply  by  an  inequality 
in  tlie  .listributiori  of  tiie  blood;  a statement  which 
this  gentleman  probahly  does  not  mean  to  make  him- 
self, as  he  confesses,  that  some  of  the  phenomena  of 
this  disease  depend  upon  sympathy  between  the  san- 
guiferous and  nervous  systems. — {See  Hastings  on  In- 
flainmation  of  the  Mucous  Membrane  of  the  Lungs, 
^c-  p.  32,  64,  65,  8vo.  Land.  1820 ; and  C.  H.  Parry, 
Additional  Experiments  on  the  Arteries,  ^c.  p.  112, 
114;  al.io  fVnylt  on  the  Motion  of  the  Fluids  in  the 
small  Vessels}  Verschuir  de  Arteriarum  ct  Venarum 
Vi  irritabilii } Zimmerman  de  Jrritabilitate,  p.  24; 
Hunter  on  the  Blood,  Src.) 

Dr.  Cullen  attributed  the  proximate  cause  of  inflam- 
mation to  a ‘‘spasm  of  the  extreme  arteries  supporting 
an  increased  action  in  the  course  of  them.”  This 
theory  only  differs  from  that  of  Boerhaave  in  the  cause 
which  is  assigned  for  ihe  obstruction.  Dr.  Cullen  con- 
ceived, liowever,  that  some  causes  of  inequality  in  the 
distribution  of  the  blood  iiiiuht  throw  an  unusual 
qiianiiiy  of  it  into  particular  vessels,  to  which  it  must 
riecessarily  prove  a slimuhis;  and,  that  in  order  to  re- 
lieve tlie  conaestioii,  the  vis  medicatrix  tiaiiiriB  increases 
still  more  the  action  of  the  vessels:  which,  as  in  all 
rrther  febrile  diseases,  it  effects,  by  the  formation  of  a 
ppa.siii  on  ibeir  extremities.  “ A spasm  of  the  extreme 
arteries,  supporting  an  increased  action  in  the  course 
V'oL.  II.— F 


of  them,  may,  therefore,  be  considered  as  the  proximata 
cause  of  inflammation ; at  least,  in  all  cases  not  arising 
from  direct  stimuli  applied  ; and  even  in  this  case  the 
stimuli  may  be  supposed  to  produce  a spasm  of  the 
extreme  vessels.” — {Cullen.) 

The  inconsistencies  i-n  Cullen’s  theory  ate  very 
glaring.  The  congestion,  or  accumulation  of  blood, 
which  is  only  an  effect  or  consequence  of  inflamma- 
tion, is  set  down  as  the  cause  of  the  spasm  of  the  ves- 
sels, to  which  spasmodic  constriction  Cullen,  strangely 
enough,  assigns  lire  name  of  proximate  cause.  Tlie 
spasmodic  contraction  of  the  extremities  of  the  ves- 
sels, instead  of  propelling  the  accumulated  quantity  of 
blood,  would  render  the  passage  of  the  blood  from  the 
arterial  into  the  venous  system  still  more  difficult. — 
{Burns.) 

We  shall  now  notice  the  celebrated  and  very  original 
opinions  promulgated  on  this  subject  by  John  Hunter. 
According  to  him,  inflatnmaiion  is  to  be  considered  only 
as  a disturbed  state  of  the  parts,  which  requires  a new 
but  salutary  mode  of  action  to  restore  them  to  that 
stale,  wherein  a natural  mode  of  action  alone  is  neces- 
sary. From  such  a view  of  the  subject,  therelbre,  in 
flammation  in  itself  is  not  to  be  considered  as  a dis- 
ease, but  as  a salutary  operation,  consequent  either  to 
some  violence  or  some  disease.  Elsewhere,  the  au- 
thor remarks,  tlie  act  of  inflamniatioii  is  to  be  con- 
sidered as  an  increased  action  of  the  vessels,  which,  at 
first,  consists  simply  in  an  increase  or  distention  be- 
yond their  natural  size.  This  increase  seems  to  depend 
upon  a diminution  of  the  muscular  power  of  the  vessels, 
at  tlie  same  time  that  the  elastic  power  of  the  artery 
must  he  dilated  in  the  same  proportion.  This  is, 
therefore,  something  more  than  simply  a common  re- 
laxation : we  must  suppose  it  an  action  in  the  parts  to 
produce  an  increase  of  size  for  particular  purposes,  and 
this  Mr.  Hunter  would  call  an  act  of  dilatation.  The 
whole  is  to  be  considered  as  a necessary  ojieration  of 
nature.  Owing  to  this  dilatation,  there  Is  a greater 
quantity  of  blood  circulating  in  the  part,  which  is  ac- 
cording to  the  common  rules  of  the  animal  economy; 
for,  whenever  a part  has  more  to  do  than  simply  to 
support  itself,  the  blood  is  there  collected  in  larger 
quantity.  Tlie  swelling  is  produced  by  an  extravasa- 
tion of  coagulable  lymph,  with  some  serum  ; but  this 
lymph  differs  from  the  common  lyinpli,  in  consequence 
of  passing  through  inflamed  vessels.  It  is  this  lymph 
which  becomes  tlie  uniting  medium  of  inflamed  parts; 
vessels  shoot  into  it ; and  it  lias  even  the  power  of  be- 
coming vascular  itself.  The  pain  proceeds  from  spasm. 
Tile  redness  is  produced  either  by  tiie  arteries  lieing 
more  dilated  than  the  veins,  or  because  the  iilood  is  not 
changed  in  the  veins.  “As  the  vessels  become  larger, 
and  the  part  becomes  more  of  the  colour  of  blood,  it  is 
to  be  supposed  there  is  more  blood  in  the  part;  and  as 
the  true  inflammatory  colour  is  scarlet,  or  that  colour 
which  the  blood  has  when  in  the  arteries,  one  would 
from  hence  conclude,  either  that  the  arteries  were  prin- 
cipally dilated,  or,  at  least,  if  the  veins  are  equally 
distended,  that  the  blood  undergoes  no  change  in  such 
inflamniatioii  in  its  passage  from  the  arteries  into  the 
veins,  which  I think  (says  Mr.  Hunter)  most  probably 
the  case;  and  this  may  arise  from  the  quickness  af  its 
passage  through  those  vessels.  When  a part  cannot 
be  restored  to  health,  after  injury,  by  infiammation 
alone  or  by  adliesion,  then  suppuration,  as  a prepara- 
tory step  to  the  formation  of  granulations,  and  the 
consequent  vestorafion  of  the  part,  lakes  place.  The 
vessels  are  nearly  in  the  same  state  as  in  inflamma- 
tion; but  they  are  more  quiescent,  and  have  acquired 
a new  mode  of  action.” — {Hunter.) 

With  respect  to  Mr.  Hunter’s  theory,  which  has  de- 
servedly had  vast  influence  in  regnlatiiig  the  judgment 
of  professional  men  in  this  country  on  the  nature  of 
the  process  called  inflammation,  it  cannot  be  received 
in  the  present  state  of  knowledge  without  some  limita- 
tion. The  hypothesis,  that  the  blood-vessels  posse.sg 
an  active  power  of  dilatation,  independently  of  their 
elasiiciiy,  as  Dr.  Hasting.s  observe.^,  must  as  yet  be  re- 
garded as  devoid  of  proof,  and  therefore  should  not  be 
assumed  as  a basis  on  which  any  theory  of  inflamma- 
tion can  he  founded. — {On  Infiammation  of  the  Mu- 
cous Membrane  of  the  Lungs,  i\-c.  p.  70)  And,  as 
another  intelligent  writer  remarks,  how  diflerent  would 
have  been  Mr.  Hunter’s  inferences,  if,  instead  of  trust- 
ing to  the  unassisted  eye,  he  had  viewed  the  inflamed 
vessels  through  the  inicroseope!  He  w ould  tJien  have 


82 


INFLAMMATION. 


seen  the  blood  moving,  and  found,  that  “ instead  of  its 
passage  being  quickened  in  the  inflamed  vessels,  it  is 
uniformly  rendered  slower  in  proportion  to  the  degree 
of  inflammation,  and  in  the  most  inflamed  parts  stands 
still  altogether." — {On  the  Vital  Functions,  p.^S^  ed. 
2.)  And  in  another  part  of  his  writings,  Dr.  Philip 
has  endeavoured  to  prove,  from  several  facts  respect- 
ing the  colour  of  the  blood,  that,  within  certain  limits, 
the  accumulation  of  this  fluid  in  the  debilitated  vessels 
of  the  inflamed  part  necessarily  causes  the  blood  to  re- 
tain the  florid  colour. — ( On  Fevers,  part  2,  Introd.) 

In  modern  times,  the  vague  but  convenient  expression, 
increased  action  of  the  vessels,  has  been  very  generally 
used  as  an  adequate  explanation  of  the  proximate 
cause  of  inflammation.  The  doctrine,  it  is  said,  de- 
rives support  from  a review  of  the  several  exciting 
causes  of  the  affection,  which,  being  in  general  of  an 
irritating  nature,  must,  when  applied  to  any  living  or 
sensible  parts,  occasion  such  increased  action  of  the 
vessels ; while  the  method  of  cure  also  tends  to  confirm 
the  opinion.  But  before  one  can  judge  whether  this 
doctrine  is  correct,  and  supported  by  facts  and  obser- 
vation, it  is  necessary  to  understand  precisely  what  is 
implied  by  increased  action  of  vessels;  for  it  is  not 
every  affection  of  the  vessels,  capable  of  being  thus 
denominated,  which  will  of  itself  constitute  inflani- 
mation.  In  gestation,  the  arteries  of  the  womb  are 
eidarged,  and  a greater  quantity  of  blood  is  sent  into 
them;  yet  this  organ  is  not  inflamed.  The  carotids 
are  in  a similar  state  during  the  growth  of  the  stag’s 
horn;  but  no  inflammation  exists.  If  then  the  prox- 
imate cause  of  inflammation  is  to  he  called  an  increased 
action  of  the  vessels,  we  must  first  be  informed,  not 
only  what  is  meant  by  the  term,  but  what  particular 
vessels  are  spoken  of,  whether  the  arterial  trunks, 
branches,  or  capillaries.  Because,  if  the  phrase  is 
intended  to  signify  increased  alternate  expansions  and 
contractions  of  all  the  arteries  of  the  inflamed  part,  it 
is  an  hypothesis  entirely  destitute  of  foundation,  if  it 
be  meant  to  denote  an  increased  velocity  of  the  motion 
of  the  blood  in  the  part  affected,  the  doctrine  is  rather 
contradicted  than  confirmed  by  the  latest  and  most 
carefully  instituted  microscopical  experiments.  But  if 
the  expression  only  refers  to  the  dilated  state  of  the 
capillaries,  the  throbbing  of  the  arteries  leading  to  the 
seal  of  inflammation,  the  effusion  of  lymph,  &.c.,  less 
fault  can  be  found  with  the  language,  though  yet  re- 
quiring much  farther  explanation  ere  it  can  communi- 
cate any  very  precise  information. 

“There  are  (says  a learned  professor)  tw’o  hypo- 
theses which  at  present  divide  the  opinions  of  patho- 
logists, rejecting  the  state  of  the  capillary  vessels 
affected  with  inflammation.  According  to  the  first  of 
these  hypotheses,  the  inflamed  vessels  are  in  a stale  of 
increased  action;  according  to  the  second,  they  act 
with  less  force  than  the  trunks  front  which  they  are 
derived.” — (See  Thomson  on  Inflammation,  p.  64.) 

The  first  of  these  opinions,  according  to  Dr,  Thom- 
son, was  suggested  by  the  views  which  Stahl  took  of 
the  animal  economy,  and  his  ideas  respecting  the  tonic 
or  vital  action  of  the  capillary  vessels.  The  doctrine, 
however,  was  more  particularly  insisted  upon  by  his 
disciples  and  followers,  especially  De  Gorter,  who,  in 
one  place,  expressly  states,  “ that  the  proximate  cause 
of  inflainmaUon  consists  in  an  increased  vital  action 
of  some  particular  arteiy  or  arteries,  by  which  the 
blood  is  propelled  with  greater  force  than  usual  into 
the  communicating,  lymphatic,  and  colourless  vessels.” 
— (See  his  Compendium  JMedicinae  and  Chirurgia  Re- 
purgata.) 

The  doctrine  which  supposes  the  action  of  the  in- 
flamed vessels  to  be  diminished,  or  to  be  proportionably 
less  than  that  of  the  trunk  or  trunks  from  which  they 
are  derived,  was,  as  far  as  Dr.  Thomson  can  learn, 
ffrst  stated  by  Vacca,  an  Italian  physician,  in  a small 
treatise  on  inflammation,  published  at  Florence  in 
1765,  entitled,  “ Liber  de  Injlaniniationis  Jilorbosw, 
quce  in  humano  coipore  fit  ihTaturd,  Causis,  F.ffectibus, 
et  Curatione." 

For  an  account  of  the  arguments  with  which  Vacca 
supports  his  hypothesis,  my  limits  oblige  me  to  refer  to 
the  work  of  Dr.  Thomson.— (P.  6S,  v^-c.) 

As  this  gentleman  has  observed,  there  are  certain 
points  in  which  the  two  doctrines  agree,  as  well  as  in 
which  they  differ 

“ The  advocates  for  each  hypothesis  agree  in  admit- 
ting, Ist,  that  inflammation  has  its  seat  in  the  capillary 


vessels;  and,  2dly,  that  the  redness  in  inflammation  is 
owing  to  an  unusual  quantity  of  blood  in  the  vessels  of 
the  inflamed  part,  and  consequently  that  the  capillary 
arteries  are  much  dilated  during  the  state  of  inflam- 
mation. The  contractions  of  these  vessels,  indeed,  it 
has  been  said,  are  increased  also  in  a ratio  proportional 
to  the  dilatations;  but  this  is  an  assertion  which  has 
not  yet  been  proved,  either  in  the  way  of  experiment 
or  of  observation. 

“ The  sense  of  throbbing,  which  the  advocates  for 
the  hypothesis  of  increased  capillary  action  regard  as 
the  strongest  proof  of  that  action,  Mr.  Allen  is  disjiosed 
to  attribute  to  the  difficulty  which  the  blood  meets  wirli 
in  passing  from  the  trunk  into  the  capillary  branches. 
This  sensation  of  throbbing,  and  appearance  of  in- 
creased action,  may  be  produced  in  an  instant,  by  ap- 
plying a ligature  to  an  uninflamed  finger,  so  as  to 
obstruct  the  motion  of  the  blood  through  its  point. 
Besides,  this  throbbing  or  pulsatory  motion  can  afford 
us  no  criterion  by  which  to  judge  of  the  force  with 
which  the  artery  contracts,  for  it  is  produced  in  the 
dilatation  of  the  artery,  and  by  a power  foreign  to  the 
artery  itself.” — {Thomson  on  Inflammation,  p.l3.) 

Dr.  Wilson  Philip,  many  years  ago,  endeavoured  to 
ascertain,  by  means  of  the  microscope,  the  state  of  tlie 
vessels  in  the  various  stages  of  inflammation,  both  in 
the  warm  and  cold  blooded  animal.  1 have  put  the 
epithet  warm  in  Italics,  because  it  has  been  observed 
by  my  friend,  Mr.  James,  that  “analogies  between  tlie 
higher  and  lower  orders  of  animals,  the  chief  subjects 
of  these  experiments,  cannot  be  deemed  conclusive” 
{On  some  of  the  General  Principles  of  Inflammationf 
p.  29,  8vo.  Lond.  1821),  as  if  it  had  escaped  attention, 
that  many  of  the  experiments  were  really  made  on  the 
more  perfect  animals.  From  the  valuable  observations 
to  which  I here  allude  (see  Philip  on  Febrile  Diseases., 
part  2,  Introd.),  it  appears,  that  the  state  of  tlie  smaller 
vessels  in  an  inflamed  part  is  that  of  preternatural 
distention  and  debility.  As  for  the  larger  vessels, 
whose  state  may  be  ascertained  without  the  aid  of  the 
microscope,  “ they  do  not  undergo  a similar  distention, 
and  the  increased  pulsation  of  the  arteries  sufficiently 
evinces  their  increased  action.  In  inflammatory  af- 
fections of  the  jaw  and  the  head,  for  example,  a 
greatly  increased  action  of  the  maxillary  and  temporal 
arteries  is  readily  perceived  by  the  Anger.  It  is  to  be 
observed,  however,  that  although  inflammation,  a? 
was  evident  from  the  foregoing  experiments,  begins 
in  the  capillaries,  if  it  continues,  the  circulation  in  the 
smallest  vessels  becoming  very  languid,  those  imme- 
diately preceding  them  in  the  course  of  the  circulation 
begin  to  be  distended,  and  consequently  debilitated.” 
Dr.  Philip  adds,  that  such  distention  and  debility  of 
the  vessels  which  immediately  precede  the  capillaries, 
cannot  go  far,  because  when  the  former  lose  their 
power,  the  circulation  in  the  latter  is  not  supported, 
and  gangrene  soon  ensues.  “ In  short  (says  Dr.  Philip), 
inflammation  seems  to  consist  in  the  debility  of  the  ca- 
pillaries, followed  by  an  increased  action  of  the  larger 
arteries,"  and  is  terminated  by  resolution,  when  the 
capillaries  are  so  far  excited,  and  the  larger  arteries  so 
far  weakened,  by  the  preternatural  action  of  the  latter, 
that  the  power  of  the  capillaries  is  again  in  due  pro- 
portion to  the  vis  d tergo. 

“ Thus  far  (says  Dr.  Philip)  I cannot  help  thinking 
the  nature  of  inflammation  appears  sufficiently  evi- 
dent. The  motion  of  the  blood  is  retarded  in  the  ca- 
pillaries, in  consequence  of  the  debility  induced  in 
them ; an  unusual  obstacle  is  thus  opposed  to  its 
motion  in  the  arteries  preceding  them  in  the  course  of 
the  circulation  ; which  are  thus  excited  to  increased 
action.  Several  difficulties,  however,  remain,  on 
which  the  exiieriments  just  related  throw  no  light- 
Why  does  a failure  of  power,  of  small  extent  in  the 
capillaries  of  a vital  part,  strongly  excite  not  only  the 
larger  arteries  of  the  part  affected,  but  those  of  the 
whole  system  ; while  a more  extensive  debility  of  the 
capillaries  of  an  external  part  excites  less  increased 
action  in  the  larger  arteries  of  that  part,  and  often  none 
at  all  in  those  of  the  system  in  general?  Why  does 
inflammation  often  move  suddenly  from  one  part  to 
another,  when  we  see  no  cause,  either  increasing  the 
action  of  the  capillaries  of  the  inflamed  pan,  or  weak- 
ening those  of  tlie  part  now  affected?  Why  does  in- 
flammation otlen  arise  in  parts  only  sympttthetically 
affected,  and  consequently  far  removed  from  the  of- 
fending cause  ? Why  is  inflammation  often  as  apt  to 


INFLAMMATION.  «3 


Bpread  to  neighbouring  parts,  between  which  and  the 
part  first  atfected  there  is  no  direct  communication  of 
vessels,  as  to  parts  in  continuation  with  that  part  ? 

“ These  phetioinena,  it  is  evident  (says  Dr.  Philip), 
are  referable  to  the  agency  of  the  nervous  system,  atid 
seem  readily  explained  by  the  experiments,  which 
prove,  that  the  effects  of  both  stimuli  and  sedatives, 
acting  through  this  system,  are  felt  by  the  vessels,  and 
that  independently  of  the  intervention  of  any  effect 
produced  on  the  heart.— (Ex/?.  27,  28.)  Thus,  the  irri- 
tation of  the  nerves  of  the  inflamed  part  may  excite 
the  larger  arteries  of  this  part,  or  of  distant  parts,  or 
of  the  whole  sanguiferous  system.  It  will  of  course 
be  most  apt  to  do  so  where  the  irritation  excited  by  the 
inflammation  is  greatest,  and  consequently  in  the  more 
important  vital  parts.  It  cannot  appear  surprising, 
that  inflammation  should  suddenly  cease  in  one  part 
and  attack  another,  when  we  know  that  the  nerves 
are  capable  of  exciting  to  due  action  the  capillaries  of 
the  one  part,  and  in  the  other  of  impairing  the  vigour 
of  those  which  have  not  suffered.  In  the  same  way, 
we  account  for  parts  only  sympathetically  affected 
becoming  inflamed,  and  for  inflammation  readily 
spreading  to  neighbouring  parts,  which  always  sym- 
pathize, although  tiiere  is  no  direct  communication 
between  them,  either  of  vessels  or  nerves.” — ( On  the 
Vital  Functions,  p.  279,  &rc.  ed.  2.) 

Respecting  the  inference  made  by  Dr.  Philip  from 
his  experiments,  that  the  circulation  is  slower  in  in- 
flamed than  uninflamed  arteries;  Dr.  J.  Thomson 
conceives,  that  its  truth  “ is  not  necessary  to  the  esta- 
blishment of  Mr.  Allen’s  hypothesis;  and  from  a num- 
ber of  experiments  which  I have  at  different  times 
made  ui)on  frogs,  I am  inclined  to  believe,  that  a di- 
minished velocity  of  the  blood  in  the  capillary  branches, 
is  by  no  means  a necessary,  constant,  nor  even  the 
most  common  effect  of  incipient  and  moderate  degrees 
of  inflammation.” — {P.'(5.) 

In  order  to  reconcile  this  difference  in  the  statements 
made  by  the  only  two  writers  who  have  examined 
tiiis  subject  by  experiment,  Dr.  Hastings  repeated  their 
mode  of  investigation  with  the  aid  of  th.;  microscope. 
Mis  conclusions  aie,  “ that  certain  stimuli,  applied  to 
living  parts,  produce  an  increased  velocity  of  the 
blood’s  motion,  and  a contraction  of  the  blood-vessels. 
During  this  state  of  excitement,  the  part  affected  is  so 
far  from  giving  any  thimr  like  the  appearances  of  in- 
flammation, that  the  size  of  the  vessels  is  diminished, 
and  the  part  paler.  But  if  the  stimulus  be  long  con- 
tinued, or  increased  in  power,  the  small  vessels,  which 
in  the  natural  state  admit  only  of  one  series  of  glo- 
bules, become  so  dilated  as  to  allow  an  accumulation 
of  a much  lees  fluid  and  redder  blood  in  them,  which 
loses  Us  globular  appearance,  and  moves  much  more 
slowly  than  that  which  previously  passed  through  the 
vessels.  The  part  now  appears  inflamed.  If  the 
stimulus  be  removed,  the  vessels  do  not  soon  regain 
their  original  slate  ; time  is  necessary  to  allow  them  to 
recover  their  contractile  power,  so  as  to  prevent  the 
irnpeins,  with  which  the  blood  is  propelled  by  the 
heart  and  larger  ai  teiies,  from  keeping  up  the  dilated 
state  of  the  capillaries.  Here  then  we  are  obliged  to 
admit,  with  Boerhaave,  that  tlrere  is  an  eiTor  loci;  for 
a denser  and  redder  blood  passes  into  small  vessels, 
which  before  carried  much  tnore  fluid  contents;  but 
the  error  loci  does  not  cause  the  inflammation,  but 
results  from  tfie  previously  weakened  state  of  the  ca- 
illaries.  In  this  manner  the  blood  may  occasionally 
e extravasated  in  inflammation,  without  any  actual 
rupture  of  a vessel,  for  the  exhalents  may  be  so 
weakened  and  dilated  as  to  allow  globules  to  pass 
through  them. 

“ If  the  stimulus  which  produces  the  inflammation 
be  of  a very  acrid  nature,  debility  of  the  vessels  is  fre- 
quently induced  without  any  previous  excitement. 
Tiie  blood  in  all  the  smaller  vessels  becomes  very  red, 
circulates  very  slow'ly,  and  in  some  vessels  stag- 
nates. 

“ The  application  of  a stimulus,  different  from  that 
which  produced  inflamnnition,  will  sometimes  bring  on 
resolution.  When  this  rrccurs,  the  dilated  vessels 
contract;  they  no  longer  contain  a red,  dense,  homo- 
geneous fluid,  but  again  receive  blood,  con.sisting  of 
small,  nearly  colourless  globules,  which  float  in  a 
^lourles!:  fluid;  and  the  motion  of  these  globules  at 
length  becomes  as  quick  as  before  the  inflammation 
took  place.  If,  however,  the  inflammation  proceed. 


the  blood  becomes  nearly  stagnant ; it  continues  very 
red,  and  the  vessels  are  much  dilated. 

“ When  this  high  degree  of  inflammation  is  not  re- 
lieved, sphacelus  ensues.  The  part  then  feels  softer  to 
the  finger,  and  gives  way  with  less  force.  The  vessels 
are  much  dilated,  the  blood  does  not  move,  it  loses  its 
red  colour,  and  becomes  of  a j'ellowish  brown  hue. 
The  separation  of  the  dead  from  the  living  part  takes 
place  soon  after  this  change  in  the  colour  of  the  blood. 

“While  the  ulceration  produced  by  this  separation 
of  the  dead  from  the  living  part  of  the  web  is  healing, 
the  capillary  vessels,  distributed  on  the  ulcerated  sur« 
face,  and  the  contiguous  parts,  are  much  distended 
with  arterial  red  blood,  which  is  moved  very  slowly 
When  the  ulceration  is  healed,  the  vessels  become 
contracted,  and  circulate  the  fluid  with  the  same  degree 
of  velocity  as  before  the  inflammation  was  excited. 

“ With  respect  to  the  seat  of  inflammation,  it  may 
be  observed,  that  the  capillaries  are  first  affected;  but 
even  the  small  arteries  of  the  web  are  also  occasionally 
distended.” — {Hastings  on  Inflammation  of  the  Mu~ 
cous  Membrane  of  the  Lungs,  Src.  p.  90 — 1)2.) 

With  respect  to  the  doctrine  espoused  by  some  patho- 
logists, that  the  smaller  branches  of  veins  are  the  ex- 
clusive seat  of  inflammation,  the  same  author  observes, 
that  the  microscope  shows  us  that  the  most  minute 
arterial  branches,  though  far  less  numerous,  are  equally 
affected  with  weakness  and  distention.  But,  as  Mr. 
Lawrence  has  remarked  on  this  part  of  the  subject, 
how  can  we  tell  whether  the  arteries  or  the  veins  are 
exclusively  affected  1 Is  the  distinction  even  practica- 
ble ? If  we  trace  the  vessels  of  a part,  we  soon  come 
to  the  points  at  tvhich  we  can  no  longer  distinguish 
between  arteries  and  veins  ; we  find  a minute  net-work 
of  vascular  ramifications,  which  cannot  be  unravelled 
or  distinguished.— (See  Lancet,  vol.  9,  p.  339.) 

In  the  course  of  Dr.  Hastings’s  inquiry,  it  is  proved 
that  the  healthy  circulation  of  the  blood  essentially 
depends  upon  a due  degree  of  action  in  the  vessels 
throughout  the  system;  that  the  application  of  stimuli, 
while  it  increases  the  action  of  the  vessels,  produces 
none  of  the  symptoms  of  inflammation.  When,  how- 
ever, the  excessive  action  of  these  stimuli  has  impaired 
the  excitability  of  the  small  vessels,  the  phenomena  of 
inflammation  are  fully  manifested  ; and  wheri  their 
excitability  is  restored,  the  inflammation  subsides.  It 
may  be  logically  inferred,  therefore,  says  this  writer, 
that  inflammation  consists  in  a weakened  action  of  the 
capillaries,  by  which  the  equilibrium  between  th« 
’arger  and  smaller  vessels  is  destroyed,  and  the  latter 
become  distended.  And  with  respect  to  the  conclusion 
drawn  by  Dr.  Thomson  from  his  experiments,  that 
inflammation,  in  moderate  degrees,  consists  in  an  in- 
creased action  of  the  vessels.  Dr.  Hastings  argues,  that 
the  writer’s  belief  in  the  excitement  of  the  capillaries, 
in  some  cases  of  inflammation,  arises  from  his  having 
denominated  that  a state  of  inflammation  which  ought 
not  to  be  so  called.  “ The  application  of  the  salt  (says 
Dr.  Thomson)  produced  an  increased  velocity  in  the 
dilated  larger  and  smaller  arteries  and  capillary  vessels, 
to  which  it  is  more  immediately  applied.  In  nine 
experiments,  the  phenomena  of  which  I have  minutely 
recorded,  the  application  of  the  salt  was  not  only  fol- 
lowed by  a bright  red  colour,  visible  to  the  naked  eye, 
and  a sensible  enlargement  of  the  arterial  and  venous 
branches,  but  with  an  increased  rapidity  of  circulation 
in  the  capillary  vessels;  the  globules  becoming  less 
distinct  than  before  the  application  of  the  salt,  and  ob- 
viously less  distinct,  from  the  rapidity  of  their  motion, 
than  the  globules  in  the  capillary  vessels  in  the  unin- 
flamed part  of  the  web  in  the  same  animal.  The  re- 
peated application,  hotcever,  of  the  salt  to  the  same 
vessels,  was  always  sooner  or  later  followed  by  re- 
tarded capillary  circulation,  or  even  by  complete  stag- 
nation.— (See  Thomson's  I^ectures,  p.  68.)  The  results 
of  other  experiments  made  by  this  gentleman,  and 
which  coincide  with  the  sentiments  of  Dr.  W.  Philip 
and  Dr.  Hastings,  need  not  here  be  cited. 

Now,  with  regard  to  those  exjieriments  which 
seemed  to  Doctor  Thomson  to  justify  the  inference  that 
moderate  degrees  of  inflammation  may  be  attended 
with  an  increased  velocity  of  the  blood  in  the  inflamed 
vessels,  Dr.  Hastings,  as  I have  already  said,  objects, 
that  the  appearances  seen  while  such  velocity  of  the 
circulation  presented  itself  in  the  vessels  affected,  ought 
not  to  have  been  denominated  inflammation;  because 
“ it  constantly  happened  in  his  own  experiments,  that 


84 


INFLAMMATION. 


when  inflammation  commenced,  no  globules  could  be 
seen  even  in  the  blood  of  the  affected  vessels.  It  wa.s 
universally  converted  into  a bright  red  homogeneous 
fluid.  So  that  globules  could  never  he  seen  in  the  capil- 
laries of  a really  inflamed  party  much  less  moving  with 
great  velocity."  He  argues,  that  the  state  alluded  to 
by  Dr.  Thomson,  is  only  that  temporary  excitement  of 
the  capillaries,  generally  preceding  theii.tlebility,  which 
is  inseparable  from  inflammation.— (See  Hastings  on 
Ivflammationy  Src.  p.  98 — 101.) 

Of  course,  such  writers  as  believe  that  the  blood  in 
the  capillaries  is  not  propelled  by  these  vessels  vliem- 
selves,  but  by  the  impulse  received  from  the  heart, 
cannot  assent  to  the  foregoing  view,  in  which  the 
proximate  cause  of  the  inflammation  is  ascribed  to 
debility  of  those  vessels.  Dr.  Parry  argues,  that  the 
theory  which  represents  this  process  as  consisting  in  an 
increased  momentum  of  the  blood  in  the  part  affected, 
is  not  invalidated,  were  it  even  proved,  according  to 
the  opinion  of  Dr.  Philip,  that  the  velocity  of  the  blood 
in  the  vessels  of  an  inflamed  part  is  diminished,  unless 
it  be  also  proved  that  the  velocity  is  diniinished  in  a 
greater  proportion  than  the  quantity  is  increased. — 
(Elements  of  Paihologijy  vol.  1,  p.  84.)  As  far,  how- 
ever, as  I can  judge,  the  arguments  are  in  favour  of 
Dr.  Philip’s  view  of  the  stibject;  for  with  respect  to 
quantity  making  up  for  loss  of  velocity,  if  the  supposi- 
tion were  to  be  adopted,  surely  it  could  not  be  retained 
after  the  inflammation  has  arrived  at  that  state,  in 
which  the  fluid  in  the  capillaries  is  seen  with  the  mi- 
croscope to  be  nearly  or  quite  stagnant.  It  must  be 
confessed  at  the  same  time,  that  the  question  about 
the  proximate  cause  of  inflammation  is  still  a tonic  of 
endle-ss  controversy,  into  which  I consider  it  perfectly 
absurd  to  enter  any  farther  without  prosecutitig  the  in- 
quiry by  experiments.  In  one  sense  both  Dr.  Philip 
and  Dr.  Hastings  admit  that  an  increased  action  of 
the  vessels  may  exist  in  inflammation  ; but  then  this 
e.xcitement  or  increased  action  is  not  in  the  capillaries, 
but  the  larger  arteries;  and  Dr.  Philip  even  suggests, 
that  the  presence  or  absence  of  such  excitement  may 
make  the  difference  between  acute  and  chronic  inflam- 
mation. The  considerations  in  support  of  the  side  of 
the  question  to  which  I do  not  myself  incline,  may  be 
found  in  the  writings  of  Dr.  Parry,  Dr.  C.  H.  Parry, 
and  Mr.  James.  From  this  remark  I would  not  have 
it  inferred  that  I am  at  all  convinced  of  the  propriety 
of  referring  the  proximate  cause  of  inflammation  to 
debility  of  the  capillaries,  though  the  retarded  circula- 
tion in  them,  like  their  dilatation,  is  now  a fact  placed 
out  of  all  doubt.  The  points,  however,  on  which  I 
should  not  assent  to  Dr.  Philip’s  doctrine,  will  be  best 
understood,  when  the  treatment  is  considered.  In  the 
work  of  Mr.  James  may  be  perused  a g<'od  summary 
of  Bichat’s  doctrine,  which  I would  willingly  annex  if 
the  subject  were  intelligible  without  an  explanation 
of  some  physiological  opinions,  for  which  I have  not 
room. 

Redness. — This  is  manifestly  owing  to  the  increased 
quantity  of  blood  in  the  inflamed  part.  More  blood 
must  necessarily  be  contained  there,  because  the  ves- 
sels which  previously  conveyed  this  fluid  are  preterna- 
turally  distended,  and  the  small  vessels,  which  natu- 
rally contained  only  lymph,  are  now  so  enlarged  as  to 
be  capable  of  receiving  red  blood.  “ I froze  (says  Mr. 
Hunter)  the  ear  of  a rabbit,  and  thawed  it  again;  this 
occasioned  a considerable  inflammation,  an  increased 
heat,  and  thickening  of  the  part.  This  rabbit  was 
killed  when  the  ear  was  in  the  height  of  inflammation, 
and  the  head  being  injected,  the  two  ears  were  re- 
moved and  dried.  The  uninflamed  ear  dried  clear 
and  transparent,  the  vessels  were  distinctly  seen  rami- 
fying through  its  substance ; but  the  inflamed  ear  dried 
thicker  and  more  opaque,  and  its  arteries  were  consi- 
derably larger.” 

Many  have  supposed  that  the  redness  of  common 
inflammation  is  partly  occasioned  by  the  generation  of 
new  vessels.  'F’his  doctrine,  however,  seems  very 
questionable.  When  coagulated  lymph  is  extravasated 
upon  the  surface  of  a wound,  or  an  inflamed  mem- 
brane, unquestionably  it  often  becomes  v.ascular,  in 
other  words,  furnished  with  new  vessels.  But  in  the 
extravasated  lymph  of  a phlegmonous  tumoui,  we  have 
no  evidence  that  there  is  any  formation  of  new  ves.sels. 
Were  the  lymph  to  be  rendered  organized  and  vas- 
cular, the  sw'elling  and  redness  w’ould  probably  be 
more  permanent,  and  at  least  not  admit  so  easily  of 


resolution.  When  adhesions  are  formed  between  two 
inflamed  surfaces,  the  organized  substance  forming  the 
connexion  lives  after  the  subsidence  of  the  inflamma- 
tion, and  is  a permanent  effect.  In  the  experiments 
detailed  by  Dr.  Hastings,  when  the  inflammation  began 
and  terminated  without  any  lesion  of  the  part  affected^ 
new  vessels  were  never  formed. — (On  Inflammation, 
S,‘c.  p.  93.)  At  the  same  time  it  must  be  confessed,  that 
great  obscurity  prevails  in  this  very  difficult  part  of 
the  subject;  for  when  suppuration  happens  in  a phleg- 
monous tumour,  the  cavity  is  lined  by  a kind  of  cyst,  or 
meuibranous  layer  of  lymph,  which  is  unquestionably 
furnished  both  with  secreting  vessels  and  absorbents; 
for,  otherwise,  how  could  the  continued  secretion  of 
pus,  or  its  occasional  sudden  disappearance,  be  at  all 
explicable?  It  was  probably  the  enlargement  of  the 
small  vessels,  and  the  circumstance  of  their  being 
filled  with  red  blood,  that  led  to  the  theory  of  new 
vessels  being  usually  formed  in  inflammation.  It  has, 
however,  been  justly  observed,  that  the  supjrosiiioti 
easily  admits  of  refutation ; for  heat  and  many  other 
causes  of  inflammation  operate  so  quickly,  that  there 
can  be  no  time  for  the  formation  of  any  new  vessels ; 
and  yet  the  redness  is  as  great,  and  the  inflammation 
as  perfect,  in  a minute,  as  in  an  hour  or  a day  after 
the  application  of  the  exciting  cause. — (Burns.)  Mr. 
Hunter,  it  is  well  known,  believed  that  a coagulum  or 
layer  of  lymph  might  produce  vessels  within  itself. 
— ( On  the  Bloody  p.  92,  Src.)  Others,  however,  distrust 
this  hypothesis,  and  incline  to  the  opinion,  which  re 
fers  the  derivation  of  ve.ssels  for  the  organization  of 
deposites  to  parent  branches. — (Travers,  Synopsis  of 
Diseases  of  the  Eye,  p.  113.)  The  latter  sentiment 
is  corroborated  by  the  appearances  noticed  by  Dr.  Has- 
lingsin  his  experiments,  whodescribes  the  small  vessels 
first  seen  in  the  lymph  upon  the  surface  of  a wound, 
as  even  then  communicating  with  the  inflamed  capil- 
laries.— ( On  I/iflammationy  p.  94.)  Another  reason  as- 
signed for  the  redness  of  inflammation  is,  that  the 
blood,  after  it  has  become  venous,  retains,  more  or  less, 
its  bright  scarlet  colour. — (Hunter.)  And,  in  somelate 
very  carefully  conducted  experiments,  it  was  remarked, 
that  the  weakened  action  of  the  smaller  vessel  was 
always  accompanied  with  an  alteration  in  the  appear- 
ance of  the  blood.  In  the  natural  stale  of  this  fluid, 
globules  can  be  distinctly  seen ; but  after  ijiflammation 
has  commenced,  the  globular  structure  disappears,  the 
blood  becomes  redder,  and  the  most  minute  capillaries 
aredisteirded  with  it. — (Hastings  on  Inflammation,  Sy-c. 
p.  95.) 

Swelling. — This  effect  arises  from  several  causes ; 1. 
The  increased  quantity  of  blood  in  the  vessels.  2.  The 
effusion  of  coagulating  lymph,  and  serum,  and  deposi- 
tion of  new  matter.  3.  Theinteri  uption  of  absorption 
particularly  noticed  by  Soemmering. — (De  Morb.  Vus, 
Absorb.) 

Pain. — This  is  observed  to  be  the  greatest  during  the 
diastole  of  the  arteries,  'fhe  affection  is  prooably 
owing  to  the  unnatural  state  of  the  nerves,  and  not  to 
mere  distention,  as  many  have  asserted.  Were  the  lat- 
ter cause  a real  one,  the  pain  would  always  be  propor- 
tioned to  it. 

“ Parts,  which  in  the  sound  state  have  little  or  no 
sensibility  (as  Dr.  Thomson  remarks),  become  exqui- 
sitely sensible  in  the  inflamed.  That  this  is  the  case 
with  tendon,  ligament,  cartilage,  bone,  and  membrane, 
seems  to  be  fully  established  by  Dr.  Whytt  in  the  very 
instructive  controversy  carried  on  between  him  and 
Haller  respecting  the  sensibility  and  irritability  of  the 
different  parts  of  man  and  other  animals.” — (Lectures 
on  Inflammation,  p.  45.) 

Heat. — The  heat  or  real  increase  of  temperature  in 
an  inflamed  part,  when  judged  of  by  the  thermometer, 
is  generally  much  less  than  might  be  supposed  from  the 
patient’s  sensations.  It  is  said  never  to  exceed  the 
heat  of  the  blood  at  the  heart.  This  in  health  is 
usually  about  100°  Fahrenheit’s  thermometer;  but 
sometimes  in  diseases  it  rises  to  106°  or  even  lOT^J.  Mr. 
Hunter  artificially  excited  inflammation  in  the  chest 
of  a dog,  and  in  the  abdomen,  rectum,  and  vagina  of  an 
ass,  without  being  able  to  discover  any  obvious  rise  of 
teinper.ature  in  these  parts.  In  a patient,  however, on 
whom  he  operated  for  hydrocele,  the  thermometer,  in- 
troduced into  the  tunica  vaginalis,  and  kept  for  some 
time  close  to  the  side  of  the  testicle,  was  nidy  92®;  but 
rose  the  following  day,  when  inflammation  had  come 
on,  to  9Hp.  As  Dr.  Hastings  obrerves,  the  advocates  fbr 


INFLAMMATION. 


85 


excited  action  of  the  vessels  in  an  inflamed  part  have 
thought,  that  tlie  increase  of  teniperaiure  favours  liioir 
iiypotiiesis,  and  have  called  to  their  aid  tlie  ingenious 
calculations  of  Dr.  Crawford.  Tliey  have  even  gone 
60  far  as  to  say  what  state  of  the  arteries  enables  the 
blood  to  give  out  most  caloric.  They  tell  us,  that,  in 
consequence  of  excitemetu  of  the  vessels,  more  blood 
is  transmitted  into  the  minute  arteries;  the  capacity  of 
a greater  quantity  of  this  fluid  for  heat  is  of  course 
diminished,  and  more  caloric  is  evolved  in  the  in- 
flamed part. — {Hastings  on  Inflammation,  p.  JIO.) 
Yet  this  theory,  besides  involving  the  contradicted  hy- 
potiiesis  of  an  increased  and  accelerated  flow  of  blood 
through  the  vessels  of  the  inflamed  part,  cannot  be  re- 
conciled to  various  otlier  considerations.  “ Daily  ex- 
perience convinces  us  (says  tlie  above  writer),  that  the 
temperature  is  not  always  proportional  to  the  velocity 
of  the  circulation.  In  revws,  the  author  has  several 
times  ascertained,  with  the  thermometer,  that  the  heat 
was  101°,  when  the  pulse  beat  only  45  times  in  a mi- 
nute. In  hydrocephalus,  with  the  pulse  from  60  to  70, 
the  heat  is  often  above  the  degree  it  reaches  in  health. 
In  these  cases,  according  to  the  theory  of  Dr.  Craw- 
ford, the  heat  should  rather  be  under  than  above  the 
natural  standard.” — {Op.  cit.p.ll2.)  And,  as  another 
judicious  writer  has  noticed,  although  the  former 
mode  of  explaining  the  production  of  animal  heal  has 
been  held  adequate  to  account  for  the  phenomena  by 
such  philosophers  as  Black,  Crawford,  Lavoisier,  and 
Place,  the  evidence  on  which  it  rests  is  not  so  clear  as 
to  have  commanded  universal  assent,  or  entirely  set 
aside  objections.  It  has  indeed  been  generally  allowed, 
that  respiration  and  the  changes  it  produces  in  the  air 
and  animal  fluids,  are  essential  conditions  of  the  evo- 
lution of  caloric  in  animals;  but  it  has  been  thought 
that  there  are  other  circumstances,  hitherto,  perhaps, 
not  well  understood,  which  influence  the  phenomena. 
In  external  appearance,  the  blood  is  the  same  in  all  the 
vessels  of  the  foetus ; is  this  any  proof  that  its  tempera- 
ture is  owing  to  the  conversion  of  oxygen  gas  into  car- 
bonic acid  1 Is  the  uniformity  of  temperature  in  the 
higher  animals,  under  varying  states  of  respiration  and 
circulation,  and  the  consumption  of  various  quantities 
of  oxygen,  whether  in  the  same  or  different  indivi 
duals,  consistent  with  the  theory  1 And  can  local  va- 
riations of  temperature  be  ex|)lained  by  iti— (/fecs’s 
Cyclopedia,  art.  Respiration.)  Doubts  must  also 
spring  from  the  recollection  of  the  discordance  of  the 
experiments  related  by  Dr  Crawford,  Dr.  John  Davy, 
De  la  Roche,  and  Berard.  In  fact,  the  determinations 
of  the  specific  heats  of  oxygen  gas  and  carbonic  acid 
by  the  two  latter  experimenters  are  conceived  to  be 
very  much  against  the  probability  of  Dr.  Crawford’s 
theory.  Other  stronger  grounds  for  skepticism  in  this 
subject  are  the  results  of  Mr.  Brodie’s  investigations. 
Having  pithed  or  decapitated  animals,  he  kept  up  arti- 
ficial respiration, and  thus  mainUained  their  circulation. 
The  blood  continued  to  be  changed  in  the  lungs  from 
venous  to  arterial,  and  from  arterial  to  venous,  in  the 
general  circulation.  The  respective  colours  of  the  two 
kinds  of  blood  could  not  be  distinguished  from  those 
which  they  exhibit  in  living  and  healthy  animals. 
Yet  the  temperature  of  an  animal  thus  heated,  sunk 
faster  than  that  of  another  animal  simply  killed  and 
left  to  itself;  and  the  former  was  supposed  to  be  more 
quickly  cooled  by  the  air  conveyed  into  its  chest. 
Other  experiments,  detailed  by  Mr.  Brodie,  tend  to 
prove  that  the  o.xygen  of  the  air,  employed  in  artificial 
respiration,  underwent  its  usual  conversion  into  carbo- 
nic acid.  A living  rabbit  formed  50  or  56  cubic  inches 
of  carbonic  acid  in  an  hour.  A decapitated  animal, 
in  whom  artificial  respiration  was  kept  up,  emitted  40 
to  48  inches  in  the  same  lime.  The  thermometer  in 
the  rectum  of  the  latter  had  fallen  from  97  to  90,  while, 
in  another  rabbit  left  to  itself,  but  similarly  treated  in 
all  other  respects,  it  had  fallen  only  to  91  In  a rabbit 
poisoned  with  woorara,  or  the  essential  oil  of  bitter 
almonds,  not  decapitated,  and  in  which  artificial 
breath  ii«  was  kept  up,  51  cubic  inches  of  carbonic  acid 
were  emitted  in  an  hour.  The  thermometer  in  the 
rectum  h.id  sunk  to  91  in  30  minutes,  while  it  stood  at 
9*2  in  another  animal,  treated  exactly  in  the  same  way, 
with  the  omis.«ion  of  the  artificial  breathing.  From 
these  experiments,  Mr.  Brodie  infers,  “ that,  in  an  ani- 
mal in  which  the  brain  has  ceased  to  exercise  its  func- 
tions, although  respiration  continues  to  be  performed, 
and  the  circulation  of  the  blood  is  kept  up  to  the  natu- 


ral standard,  although  the  usual  changes  in  the  sensible 
qualities  of  the  blood  take  place  in  the  two  capillary 
systems,  and  the  same  quantity  of  carbonic  acid  is 
formed  as  under  ordinary  circumstances;  no  heat  is 
generated,  and  (in  consequence  of  the  cold  air  thrown 
into  the  lungs)  the  animal  cools  more  rapidly  than  one 
which  is  actually  dead.”— (See  Phil.  Trans,  for  1811, 
p.  36,  and  for  181‘2,  p.  378.)  It  appears  certain,  there- 
fore, that  the  generation  of  animal  heat,  either  in  an 
inflamed  or  an  uniiiffained  part,  can  never  be  satisfac- 
torily explained  by  aity  reference  merely  to  chemical 
principles,  and  that  the  process  is  essentially  connected 
with,  and  influenced  by,  the  state  of  the  functions  of 
the  brain  and  nervous  system,  and  no  doubt  also  by  the 
principle  of  life  itself.  Attiie  same  time,  1 think  that 
any  hypothesis  suggested  without  due  reference  to  the 
connexion  which  respiration  has  with  this  curious  and 
interesting  process,  will  never  be  established.  Neither 
would  I venture  so  far  as  Dr.  Philip,  who  believe.®  that 
animal  heat  is  evolved  by  the  same  means  by  which 
the  formation  of  the  secreted  fluids  is  effected,  viz.  the 
action  of  nervous  influence  on  the  blood,  and  that  the 
production  of  such  lie.'it  is  to  be  regarded  as  a secretion. 
— {On  the  Vital  Functions,  p.  169.)  However,  the  in- 
fluence of  the  nervous  system  over  this  process  must 
be  allowed  to  be  very  great,  and  may  aflford  a more 
(trobable  explanation  of  the  cause  of  the  local  change 
of  temperature  in  inflammaoon  than  Dr.  Crawford’s 
theory,  combined  with  the  doctrine  of  increased  action, 
and  an  accelerated  circulation  in  the  vessels  of  the 
part  affected. 

Bnffy  coat. — The  blood,  when  taken  out  of  the  living 
vessels,  spontaneously  separates  into  two  distinct 
parts,  the  serum  and  the  crassamentiim.  The  last  is  a 
conipound  substance,  consisting  chiefly  of  coagulating 
lymph  and  red  globules,  the  most  heavy  ingredients  in 
the  blood.  Blood,  taken  av\  ay  from  persons  affected  with 
inflammation,  is  longer  in  coagulating,  and  coagulates 
more  finiily,  than  in  other  instances.  Hence,  the  red 
globules,  not  being  so  soon  entangled  in  the  lymph,  de- 
scend, by  their  gravity,  more  deeiily  from  its  surface, 
which  being  more  or  less  divested  of  the  red  colouring 
matter,  is  from  its  appearance  termed  the  btiffy  coat, 
or  inflammatory  crust.  The  firmer  and  more  compact 
coagulation  of  the  lymph  compresses  out  an  unusual 
quantity  of  serum  from  it,  and  the  surface  of  the  sizy 
blood  is  often  formed  into  a hollow,  the  edges  being 
drawn  inwards. — {Hunter.)  In  some  cases  the.se 
changes  in  the  blood  are  deemed  a more  unequivocal 
proof  of  the  existence  of  inflammation,  than  the  stale 
of  the  pulse  itself.  They  are,  however,  only  a crite- 
rion of  some  unusual  operation  going  on  in  the  system; 
for  the  blood  taken  from  piegnant  women  is  always 
found  to  (iresent  the  same  phenomena.  In  perilonseal 
inflammation,  the  patient  sometimes  seems  to  be  in  the 
most  feeble  state,  atid  the  pulse,  abstractedly  consi- 
dered, would  rather  induce  the  practitioner  to  employ 
tonics  and  stimulants  than  evacuations;  but  should 
the  continuance  or  exasperation  of  the  disorder,  or  any 
other  reason,  lead  him  to  use  the  lancet,  then  the  buffy 
coat,  and  the  concave  surface,  of  the  blood,  materially 
obviate  any  doubt  of  the  existence  of  inflammation. 
Surgeons  should  never  forget,  however,  that  in  a few 
anomalous  constitutions,  the  blood,  when  drawn,  al- 
ways exhibits  the  above  peculiarities. 

Terminations. — Inflammation  is  said  to  have  three 
different  terminations ; or,  in  more  correct  latiguage,  we 
may  say,  that,  after  this  process  has  continued  a cer- 
tain time,  it  either  subsides  entirely,  induces  a disposi- 
tion in  the  vessels  to  form  pus,  or  completely  destroys 
the  vitality  of  the  part. 

When  the  inflammation  is  to  end  in  the  first  manner, 
which  is  the  most  favourable,  the  pain  becomes  less, 
the  swelling  subsides,  the  fever,  and  every  other  symp- 
tom, gradually  abate,  till  at  last  the  part  is  wholly  re- 
stored to  its  natural  size  and  colour.  There  is  no  for- 
mation of  pus,  nor  any  permanent  injury  of  structure; 
and,  if  Dr.  Philip’s  theory  of  inflammation  be  correct, 
the  debilitated  capillaries  are  excited  to  due  action  by 
the  increased  action  of  the  larger  arteries. — {On  the 
Vital  Functions,  p.  298.)  This  termination  of  inflam- 
mation i.s  termed  by  surgeons  resolution.  It  is  fortu- 
nately the  most  corntnon,  as  well  as  the  most  desirable, 
manner  in  which  the  affection  end.®. 

If,  however,  notwithstanding  the  application  of  the 
usual  remedies,  the  several  symptoms  of  bent,  pain,  and 
redness,  instead  of  diminishing,  rather  increase  ; if  the 


86 


INFLAMMATION. 


febrile  symptoms  ore  likewise  augmented,  and  the  tu- 
mour gradually  acquires  a larger  size,  turns  soft, 
somewhat  prominent  in  the  middle,  or  towards  its 
most  depending  part;  if  it  should  next  acquire  a clear 
shining  appearance,  and  become  less  paintul,  the  dif- 
ferent symptoms  of  fever  being  at  the  same  time  dimi- 
nished, and  a fluctuation  perceptible  in  the  tumour, 
Iheinflamntation  has  ended  in  suppuration. 

The  worst  but,  happily,  the  least  frequent  conse- 
quence of  common  inflammation,  is  the  death  or  mer- 
tification  of  the  part  aflfected.  In  the  microscopical 
experiments  of  Dr.  Hastings,  it  was  observed,  that,  on 
the  approach  of  gangrene,  the  blood  entirely  loses  its 
red  colour,  and  acquires  a yellowish-brown  tinge. — 
(On  Inflammation,  p.  97.)  The  part  which  was  of  a 
bright  red  becomes  of  a livid  hue;  small  vesicles, 
tilled  with  a thin  fetid  serum,  arise  on  its  surface,  and 
air  is  plainly  felt  within  the  cellular  membrane.  The 
pain  is  indeed  diminislied,  but  the  pulse  sinks,  while 
the  tumour  is  gradually  changed  into  a black  flbrous 
mass. 

These  are  the  three  common  terminations  of  inflam- 
mation. In  books,  scirrhus  is  sometimes  enumerated 
as  one  of  the  terminations  of  inflammation.  The  best 
modern  surgeons,  however,  do  not  regard  scirrhus  as 
one  of  the  usual  effects  of  ordinary  inflammation : “ the 
term  scirrhus,  as  used  by  the  older  medical  writers,  is 
extremely  indefinite,  having  been  sometimes  used  to 
express  every  kind  of  induration,  which  remained 
after  an  attack  of  inflammation,  as  well  as  the  morbid 
incipient  state  of  parts  about  to  become  affected  with 
cancer.  Surgeons  now  usually  limit  the  use  of  the 
term  to  the  last  of  these  significations.” — I^Thomson  on 
Inflammation,  p.  126.) 

Common  inflammation,  particularly  when  it  affects 
glandular  pans,  is  often  followed  by  induration,  which 
afterward  continues  for  a greater  or  less  time. 
Thus,  when  the  testis  has  been  inflamed,  a hardness 
of  the  epididymis  frequently  remains  during  life. 
Such  induration,  however,  is  not  at  all  malignant,  and, 
consequently,  very  different  from  what  is  implied  by  a 
real  scirrhus. 

TREATMENT  OF  INFLAMMATION. 

One  principal  difficulty  in  believing  the  fact  of  re- 
tardation of  the  circulation  in  the  capillaries  of  an  in- 
flamed part,  and  a strong  argument  against  the  suppo- 
sition of  their  being  in  a state  of  debility,  is,  that  the 
most  effectual  treatment  of  common  inflammation 
consists  of  means  which  are  generally  of  a debilita- 
ting nature,  as  bleeding,  purging,  &c.  And  surgeons 
are  still  farther  attached  to  the  theory  of  increased  ve- 
locity of  the  blood’s  motion  in  the  part  affected,  by  the 
recollection  of  the  local  augmentation  of  temperature, 
the  throbbing,  and  the  instantaneous  return  of  the  red 
colour,  after  the  discontinuance  of  any  pressure  by 
which  the  redness  has  been  momentarily  removed  at 
some  point  of  the  inflamed  surface.  These,  too,  are 
all  so  many  facts,  which,  as  far  as  I can  judge,  are  ad- 
mitted by  the  generality  of  reasoners,  whatever  may 
be  their  particular  theory.  At  the  same  time,  it  ap- 
pears equally  well  proved,  by  careful  microscopical  ex- 
periments, that,  in  the  capillaries  of  the  part  which  is 
directly  the  seat  of  inflammation,  there  is  a retard- 
ation, and  sometimes  even  a stagnation,  of  the  circu- 
lation. But  this  is  not  all  ; it  is  farther  manifested, 
that  the  capillaries  are  considerably  dilated,  the  blood 
in  them  materially  altered,  and  that  these  phenomena 
are  followed  by  an  increased  action  of  the  larger  arte- 
ries leading  to  the  part  affected.  Now,  I think,  if  we 
remain  contented  with  these  obvious  circumstances, 
and  dismiss  the  hypothesis  of  debility  of  the  capilla- 
ries, not  only  the  necessity  for  venturesome  conjec- 
tures may  be  avoided,  but  a more  rational  account  de- 
livered of  the  principles  of  the  efficacy  of  the  usual 
mode  of  treatment.  Thus,  I would  not  presume  to 
oflfer  any  supposition  why  the  capillaries  are  dilated, 
and  why  the  motion  of  the  fluid  in  them  is  retarded, 
but  would  be  satisfied  with  a knowledge  of  the  facts, 
so  as  to  elude  a source  of  endless  controversy,  viz.  the 
question,  whether  these  changes  proceed  from  de- 
bility of  the  said  vessels,  or  other  causes  ? In  the  view 
which  I take  of  the  nature  of  pblecmonous  inflamma- 
tion, I consider  the  following  circumstances  proved: 
1.  The  dilated  state  of  the  capillaries  in  the  immediate 
seat  of  inflammation.  2.  The  retaidation,  or  even 
stagnation,  of  the  circulation  in  them.  3.  The  in- 


creased action  or  excitement  of  the  larger  arteries  l«nl 
ing  to  the  inflamed  part.  All  these  three  main  points 
seem  to  me  to  be  fully  established  by  the  investigations 
and  experiments  both  of  Dr.  Wilson  Philip,  and  Dr. 
Hastings;  and  I may  make  the  observation,  though 
aware  that  the  latter  gentleman  does  not  regard  in- 
creased action  of  the  larger  arteries  as  a constituent 
and  necespry  part  of  inflammatiem,  because  cases  oc- 
cur in  which  no  such  excitement  can  be  detected  (Ow 
Inflammation,  p.  104) ; for  I here  put  out  of  consider 
alion  chronic  inflammation,  which  I believe  is  entirely 
a different  process,  bearing  no  resemblance  to  the  acute 
forms  of  the  disorder,  either  in  the  state  of  the  capilla- 
ries, or  of  the  larger  arteries.  Assuming  the  above 
points  as  proved,  it  is  to  be  inquired,  whether  other 
facts,  such  as  the  heat  and  throbbing  in  the  inflamed 
part,  the  instantaneous  return  of  redness  to  the  spot 
which  has  been  touched,  and  the  efficacy  of  common 
treatment,  are  reconcileable  with  them  or  not.  I am 
disposed  to  think  they  are;  for  it  is  only  asserted  that 
the  passage  of  the  blood  is  more  or  less  obstructed  in 
the  capillaries  in  the  seat  of  the  inflammation ; and  the 
larger  arteries  leading  to  them  are  for  the  most  part  ob- 
viously in  a state  of  increased  action,  whereby  a 
greater  quantity  of  blood  must  be  supposed  to  be  de- 
termined towards  the  part.  Now,  as  this  augmented 
quantity  of  blood  cannot  pass  freely  through  the 
smaller  vessels  in  the  immediate  place  of  inflamma- 
tion, it  must  be  thrown  into  such  arteries  in  the  neigh- 
bourhood as  are  capable  of  receiving  it,  so  that,  in 
fact,  the  theory  of  obstruction  of  the  capillaries  may 
not  be  altogether  incompatible  both  with  increased  ac- 
tion and  quickened  circulation  in  the  arteries  directly 
around  the  parts  in  which  there  is  a retarded  circula- 
tion in  the  capillaries.  This  view  of  the  subject,  I think, 
is  not  liable  to  greater  perplexity  in  the  explanation  of 
the  heat,  throbbing,  &c.  than  former  doctrines,  involv- 
ing the  contradicted  notion  of  there  being  an  in- 
creased action  and  an  augmented  velocity  of  the 
blood’s  motion  in  all  the  arteries  of  the  part  af- 
fected. 

Resolution  being  the  most  favourable  termination  of 
common  inflammation,  it  is  of  course  the  object  at 
which  the  surgeon  generally  aims  in  the  treatment. 
Dr.  Philip’s  very  ingenious  view  of  inflammation  leads 
him  to  suppose  that  resolution  arises  from  the  debili- 
tated capillaries  being  excited  to  due  action  by  the  in- 
creased action  of  the  larger  arteries. — (Ore  the  Vital 
Functions,  p.  298.)  But  I am  of  opinion,  that  the  doc- 
trine of  debility  of  the  capillaries,  and  the  hypothesis 
of  their  being  strengthened  by  the  excitement  or  in- 
creased action  of  the  larger  vessels,  are  by  no  means 
satisfactory,  and  perhaps  not  very  intelligible.  On  the 
contrary,  if  the  capillaries  are  already  so  weak  as  to 
be  distended  by  the  ordinary  impulse  of  the  blood, 
how  are  they  to  be  restored  to  their  natiual  dimensions 
and  functions  by  any  increased  action  of  the  larger 
arteries?  the  effect  of  which,  I should  conceive,  would 
be  to  gorge  them  still  more  with  blood,  and  produce 
even  a greater  dilatation  of  them.  Were  the  above 
reasoning  correct,  it  would  follow,  that  a principal  indi- 
cation in  the  treatment  would  be  to  promote  the  in- 
creased action  of  the  larger  arteries,  whereby  so  much 
supposed  benefit  is  communicated  to  the  debilitated 
capillaries.  Yet  such  practice  is  contrary  to  the  dic- 
tates of  experience,  and  is  even  inconsistent  with  the 
principles  on  which  Dr.  Philip  himself  thinks  the  treat- 
ment should  be  founded.  Indeed,  the  following  direc- 
tions are  such  as  I imagine  will  be  [terfectly  approved 
of  by  practitioners,  who,  far  from  looking  upon  the 
increased  action  of  the  arteries  as  a means  of  relief, 
are  accustomed  to  do  every  thing  in  their  power  to 
lessen  and  resist  it.  “ All  the  local  means  (says  Dr. 
Philip)  are  calculated  either  to  lessen  the  contents  of 
the  morbidly  distetided  ve.ssels,  or  to  excite  these  ves- 
sels to  expel  them.  The  general  means  are  regulated 
by  the  effects  produced  by  the  disease  on  the  more  dis- 
tant vessels,  through  the  medium  of  the  nervous  sys- 
tem ; the  objects  of  this  part  of  the  treatment  being, 
neither  to  allow  the  action  of  these  vessels  to  fall  so 
low  that  it  is  ir.capable  of  supporting  any  degree  of 
circulation  in  the  debilitated  vessels,  nor  to  become  so 
powerful  as  farther  to  distend  by  gorging  them  with 
blood.  Thus,  when  the  symptoms  of  active  inflamma- 
tion run  high,  we  lessen  the.  vis  d tergo ; when  gan- 
grene is  threatened,  we  increase  it.”— ( W.  Philip,  eii 
the  Vital  Functions,  p.  285,  ed.  2.)  In  short,  ^ 


INFLAMMATION. 


87 


soon  as  the  fact  is  established  that  a strong  flow  of 
blood  towards  an  inflamed  part  tends  to  aggravate  the 
disorder,  all  ditficulty  ceases  in  reconciling  the  usual 
means  of  relief  to  that  theory  of  inflammation,  which 
takes  into  the  account  a retarded  state  of  the  circula- 
tion in  the  distended  capillaries. 

Let  us  now  devote  a few  pages  to  the  consideration 
of  the  means  to  be  employed  for  the  relief  of  inflam- 
mation. 

• Removal  of  exciting  causes. — In  all  cases,  the  first 
circumstance  to  be  attended  to  is  the  removal  of  all 
such  exciting  causes  as  may  happen  to  present  them- 
selves. If  the  irritation  of  a splinter  were  to  excite 
phlegmonous  inflammation,  who  would  not  of  his  own 
accord  directly  take  away  the  extraneous  body  1 In 
wounds,  foreign  substances  frequently  excite  inflam- 
mation, and  ought  to  be  taken  away  as  speedily  as  pos- 
sible; splintered  pieces  of  bone  often  give  rise  to  the 
affection,  and  require  removal ; the  head  of  a bone, 
being  out  of  its  place,  may  press  and  inflame  the  part 
on  which  it  lies;  and  who  does  not  immediately  see 
the  propriety  of  putting  it  back  into  its  natural  situa- 
tion 1 These  and  other  similar  exciting  causes  may 
often  be  detected  and  removed  at  once,  and  this  is 
doing  a great  deal  towards  the  cure  and  even  the  pre- 
vention of  inflammation.  However,  many  of  the  ex- 
citing causes  of  this  affection  are  only  of  momentary 
application ; yet,  though  their  action  is  thus  short,  the 
process  of  inflammation  must  follow,  as  a kind  of  sa- 
lutary operation,  without  which,  the  injured  organiza- 
tion and  tone  of  the  parts,  still  remaining,  could  not  be 
rectified  again.  Hence,  besides  taking  away  the  re- 
mote cause,  whenever  this  can  be  done,  it  is  proper  to 
moderate,  by  other  means,  the  increased  action  of  the 
larger  arteries,  and  lessen  the  velocity  of  the  blood’s 
motion  towards  the  inflamed  part. 

Bleeding.— PiS  there  is  reason  to  believe  that  in  com- 
mon inflammation  a greater  quantity  of  blood  is  im- 
pelled towards  the  inflamed  part  than  in  the  natural 
state,  and  experience  proves  that  nothing  has  a more 
powerful  eftect  in  checking  the  disorder,  than  dimi- 
nishing the  determination  of  blood  to  the  part,  bleeding 
must  be  a principal  means  of  relieving  inflammation: 
it  lessens  the  action  of  the  whole  sanguiferous  sytem, 
and,  of  course,  of  that  part  of  it  which  is  directly  con- 
cerned in  regulating  the  quantity  of  blood  transmitted 
to  the  part  affected.  On  the  principle  also  of  lessen- 
ing the  whole  mass  of  blood  in  the  circulation,  it  must 
have  a similar  effect. 

Bleeding,  however,  is  often  misemployed,  especially 
when  regarded  as  the  only  remedy  for  inflammation, 
and  other  steps  are  neglected.  The  general  obstinacy 
and  venemence  of  the  process  in  weak  constitutions, 
prove  that  bleeding  is  not  invariably  proper,  and  in 
such  individuals  it  often  appears  as  if  their  general  ir- 
ritability and  the  difficulty  of  curing  the  inflammation, 
were  in  a ratio  to  their  weakness.  It  is  a common 
notion,  th.at  when  inflammation  is  complicated  with 
disorder  of  the  chylopoietic  organs,  blood  should  be 
taken  away  with  great  circumspection ; but  for  its 
correctness  I cannot  vouch,  anymore  than  I can  vouch 
for  the  truth  of  a common  supposition,  that  cases  of 
inflammation  in  London  do  not  require  bleeding  to 
the  same  extent  as  similar  cases  in  the  country.  The 
hypothesis  is  beginning  to  be  doubted  by  the  sagacious 
part  of  the  profession,  and  has  now  less  influence  than 
formerly  upon  practitioners,  who  are  getting  into  the 
wise  custom  of  examining  things  wifh  their  own 
senses,  and  thinking  for  themselves. 

A great  deal  of  induration,  with  little  pain  and  heat 
in  the  inflamed  part ; the  probability  of  a long  and  co- 
pious suppuration,  as  is  the  case  in  many  compound 
fractures;  and  the  connexion  of  the  inflammation 
with  a want  of  tone  in  the  part;  are  particular  in- 
stances in  which  the  practitioner  should  be  sparing  of 
this  evacn.ation.  Bleeding  is  sometimes  quite  unne- 
cessary, when  the  local  inflammation  and  symptomatic 
fever  are  trivial,  when  the  patient  is  feeble  or  very 
old,  and  when  the  cause  of  the  affection  can  be  en 
tirely  removed. — (Richter's  .^nfangsgr.  h.  1.)  How- 
ever, bleeding  is  as  necessary  in  old  as  in  young  per- 
sons, if  the  general  and  local  effects  of  genuine  phleg- 
monous inflammation  be  severe.  Also,  as  Langenbeck 
ha^  explained,  even  in  feeble  individuals,  the  inflam- 
mation may  depend  upon  occasional  causes,  wh.ch  are 
■o  powerful  in  their  operation  as  to  he  followed  by 
great  reaction.  Sometimes,  after  having  amputated 


the  limbs  of  patients,  already  labouring  under  hectical 
symptoms,  he  assures  us  he  has  practised  bleeding  in 
consequence  of  such  inflammatory  reaction,  with  the 
best  effect. — (JSI'osnlogie,  <S-c.  b.  1,  p.  261, 262.) 

On  the  other  liaud,  bleeding  is  highly  beneficial 
where  the  inflammation  is  uncomplicated  with  any 
previously  existing  disorder  of  the  gastric  system,  while 
it  is  considerable  in  extent  and  degree,  and  attended 
with  a good  deal  of  febrile  disturbance.  The  same 
practice  is  also  strongly  indicated,  when  the  part  af- 
fected is  very  sensible,  and  highly  important,  in  regard 
to  its  office  in  the  system.  Thus  the  lancet  must  be 
freely  employed  in  acute  ophthalmy,  or  inflammation 
of  the  eye,  which  is  a most  sensible  part,  and  in  in 
flammation  of  the  lungs,  brain,  or  stomach  ; organs, 
the  sound  state  of  which  is  essential  to  the  regular 
continuance  of  all  the  various  operations  in  the  ani- 
mal machine  ; and  if  asuccessful  eflbrt  be  not  promptly 
made  to.stop  such  inflammation  by  the  most  vigorous 
means,  death  itself  will  be  the  result. 

In  general,  bleeding  may  be  said  to  be  indicated 
when  the  patient  is  young,  robust,  and  plethoric; 
when  the  local  and  constitutional  symptoms  are  se- 
vere; when  the  patient  has  been  living  well  and  eat- 
ing a great  deal  of  animal  food,  so  as  to  have  a deci- 
dedly inflammatory  diathesis  (see  Lnngenbeck's  JVo- 
sologie,  drc.  b.  1,  p.  261) ; when  the  cause  of  the  dis- 
order can  neither  be  removed  nor  diminished : and 
when  there  is  a strong  motive  for  wishing  to  avoid  the 
formation  of  matter.  Inflammation  of  the  eye  is  a 
case  illustrative  of  the  truth  of  the  last  observation  ; 
for,  if  suppuration  take  place  in  this  organ,  the  com- 
mon consequence  is  so  serious  a destruction  of  its  in- 
ternal structure  and  organization,  that  the  future  resto- 
ration of  sight  is  totally  impossible.  . In  the  examples 
falling  under  the  conditions  specified  as  requiring 
blood  to  be  taken  away,  it  is  sometimes  necessary  fre- 
quently to  repeat  the  evacuation. 

The  efficacy  of  bleeding  is  greater  the  sooner  it  is 
practised,  and  the  more  suddenly  the  blood  is  evacu- 
ated. Bleeding  near  the  part  affected  is  usually  more 
effectual  than  when  done  in  a remote  situation.  Hence, 
in  inflammation  of  the  eye  or  brain,  it  is  often  con- 
sidered most  advantageous  to  lake  blood  from  the  tem- 
poral artery,  or  by  cupping  on  the  temples. 

“In  many  inflammations,  particularly  those  of  the 
parts  contained  in  the  three  great  cavities  of  the  head, 
chest,  and  belly,  general  blood-letting  (says  a judicious 
writer),  if  not  the  only,  is  the  principal  remedy,  to 
which  we  can  trust  for  a cure.  The  quantity  of  blood, 
which,  in  these  inflammations,  it  is  necessary  to  take 
away,  varies  according  to  the  violence  of  the  inflam- 
mation, the  temperament,  strength,  and  habits  of  the 
patient,  and  according  to  the  structure,  functions,  and 
situation  Of  the  organ  in  which  it  occurs.  From  twelve 
to  twenty  ounces,  or  even  more,  ought  generally  to  be 
drawn  every  time  we  have  occasion  to  use  the  lancet 
in  the  cure  of  inflammation,  and  bleeding  to  this  extent 
may  be  repeated  two  or  three  times  in  the  course  of 
the  first  twenty-four  hours,  according  to  the  effects 
which  it  seems  to  produce,  as  well  as  according  to  the 
violence  and  urgency  of  the  symptoms.  In  inflamma- 
tion of  internal  parts,  we  judge  of  the  effect  of  bleed- 
ing, and  of  the  necessity  of  a repetition,  from  the 
feeling  and  continuance  of  pain,  from  the  state  of  the 
pulse,  and  also  from  the  appearance  of  the  blood 
which  has  been  last  drawn. 

“A  partial,  and  in  some  instances  an  almost  com- 
plete, cessation  of  pain  takes  place  even  during  the 
operation  of  blood-letting.  This  is  always  a favour- 
able symptom,  and  indicates  that  the  inflammation 
has  made  no  great  nor  very  alarming  progress?.  In 
other  instances,  the  relief  from  pain,  though  incon- 
siderable at  the  time  of  bleeding,  becomes  afterward 
more  sensible  and  the  other  symptoms  of  inflammation 
abate  in  nearly  the  same  proportion ; while,  in  other 
instances  agaiti,  the  pain  is  either  not  relieved  by  the 
bleeding,  or,  if  relieved,  the  relief  is  but  of  short  dura- 
tion. These  last  are  cases  in  which,  the  other  symp- 
toms of  inflammation  continuing  unabated,  recourse 
must  be  had  again  to  the  use  of  the  lancet,  and  as 
much  blood  drawn  as  can  be  done  with  safety  to  the 
patient. 

“ The  changes  which  hike  place  in  the  state  of  the 
pulse,  either  with  regard  to  its  frequency  or  strength, 
during  or  soon  after  the  abstraction  of  blood,  though 
they  afford  criteria  by  which  we  may  judge  of  the 


83 


INFLAMMATION. 


state  of  the  inflaHunalion,  and  of  tlie  effects  of  the 
bleeding,  are  by  no  means  marks  so  sure  of  the  advan- 
tage which  has  been  obtained,  as  that  derived  from 
the  cessation  of  pain. 

“In  some  inflammations  of  the  head,  for  example, 
the  pulse  is  slower  than  natural,  though  it  beats  with 
its  accustomed,  or  even  with  an  increased,  degree  of 
strength.  In  inflammations  also  of  the  peritoneum 
and  of  the  intestinal  canal,  we  find  the  pulse  not 
much  quicker  than  natural,  small,  and  contracted. 
We  should  deceive  ourselves,  therefore,  were  we  to 
infer,  that  an  increase  of  inflammation  had  taken 
place,  because,  in  the  first  instance,  the  pulse  had  be- 
come quicker,  and,  in  the  second,  fuller  and  stronger, 
during  or  soon  after  the  abstraction  of  a quantity  of 
blood. 

“The  pulse,  it  may  be  remarked,  has  often  a con- 
tracted, cord-like  feel  in  inflammation,  and  it  may 
always  be  regarded  as  a favourable  event,  when  it 
becomes  softer,  fuller,  and  slower,  during  or  soon 
after  blood-letting.” — (See  Thomson's  Lectures  on  In- 
flammation^  p.  1156, 168^ 

Although  Professor  Langenbeclr,  in  common  with 
other  practitioners,  deems  tlie  change  of  the  pulse  and 
the  abatement  of  pain  as  important  considerations  for 
determiniiig  how  much  blood  should  be  taken  away, 
he  advises  the  surgeon  never  to  forget,  that  when 
certain  organs  are  inflamed,  bleeding  is  always  fol- 
lowed by  a rise  of  the  pulse.  This  reason  leads  him 
also  to  regard  the  cessatioti  or  continuance  of  pain,  as 
a better  criterion. — (_JVosologie,  ^c.  b.  1,  p.  265.) 

With  respect  to  the  butfy  coat  of  the  blood.  Dr. 
Thomson  states,  that  it  is  not  by  the  buffy  coat  alone, 
but  by  the  buffy  coat  in  conjunction  with  the  quantity 
and  firmness  of  the  coaguluin,  that  we  must  judge  of 
Ifie  propriety  of  any  farther  detraction.  Wheti  the 
bnfly  coat  has  a firm  and  tenacious  consistence,  and 
when  the  pain  continues  unabated,  we  may  conclude, 
that  the  inflammation  is  not  subdued.  But  when  the 
coagnlum  is  soft  and  easily  broken,  and  when  the 
colour  of  the  buffy  coat  is  changefl  from  a yellowish  to 
a greenish  hue.  Dr.  Thomson  thinks  that  little  or  no 
benefit  can  be  derived  from  bleeding.  But  as  already 
inentioned,  every  practitioner  should  remember,  that 
in  particular  constitutions,  and  in  pregnancy,  the  blood 
taken  away  naturally  exhibits  a buffy  appearance,  in- 
dependently of  inflammation. 

The  preceding  remarks  chiefly  relate  to  general 
bleeding;  for,  in  phlegmonous  inflammation,  topical 
bleeding  is  scarcely  ever  improper,  tt  is  always  a 
point  highly  worthy  of  the  surgeon’s  consideration, 
whether  bleeding  in  or  near  the  part  will  answer  bet- 
ter tliau  tJiking  the  blood  fioni  the  general  habit , 
for  certainly  less  may  be  removed  in  this  way,  so  as 
to  have  equal  effect  upon  the  part  inflamed,  and  pro- 
bably upon  every  other  disease  that  is  relieved  by 
bleeding,  with  less  injtirj'  to  the  constitution.  Although, 
in  many  cases,  the  general  habit  is  relieved  by  bleed- 
ing, yet  it  is  the  p:ut  affected  which  most  requires  this 
evacuation.  That  local  bleeding  has  very  consider- 
able effects  on  the  inflamed  part  is  proved  by  the  sud- 
den relief  which  is  often  produced  by  the  aitplication 
of  leeches  in  cases  of  gout.  The  mere  u.se  of  leeches, 
without  other  measure.®,  will  also  sometimes  remove  a 
tumour  in  the  breast,  having  all  the  appearance  of  a 
scirrhus,  which  cannot  be  considered  as  inflammatory, 
so  that  topical  bleeding  extends  its  power  farther  thati 
the  mere  checking  of  inflamiiiation.  Some  part  of  its 
effect  has  been  imputed  to  sympathy. — \Hunter.) 
There  are  three  modes  of  performing  topical  bleeding; 
by  cupping,  by  leeches,  and  by  dividing  or  scarifying 
the  dilated  vessels  leading  to  the  inflamed  part. — (See 
Bleeding.)  Upon  the  liead  and  face,  leeches  are  com- 
monly employed  ; upon  the  chest,  either  leeches  or 
cupping;  upon  the  abdomen,  leeches;  and  upon  the 
jf)ints,  either  cupping  or  leeches.  When  the  eye  is  in- 
flamed, leeches  may  either  be  applied  to  the  adjoining 
temple,  or  the  dilated  vessels  of  the  conjunctiva  may 
be  scarified  ; or  both  methods  may  be  adopted.  \Vhen 
the  inflammation  extends  quite  to  the  surface  of  the 
body,  leeches  are  always  most  eligible,  as  their  bites 
cause  less  irritation  in  inflamed  parts  than  the  punc- 
tures of  the  scarificator  or  the  pressure  of  cupping- 
gla.ssps. 

Purging.— The  exhibition  of  mild  laxative  medi- 
cine.s  and  saline  purgatives  is  a piincipal  means  of 
diminishing  inflammation.  Purging  does  not  produce 


such  lasting  weakness  as  is  the  consequence  of  bleed- 
ing, and,  therefore,  it  is  scarcely  ever  omitted,  even 
when  the  abstraction  of  blood  is  deemed  improper. 
Saline  purges  must  lessen  the  quantity  of  circulating 
blood,  inasmuch  as  they  increase  the  secretion  from 
the  intestinal  arteries;  and  therefore,  they  piobably 
operate  beneficially  in  the  cure  of  local  inflammation, 
much  upon  the  same  principle  as  bleeding.  Mr.  Hun- 
ter was  of  opinion,  that  imrging  lowers  action,  without 
diminishing  strength,  by  which  we  are  probably  to  un- 
derstand, without  producing  a very  lasiitig  or  perma- 
nent loss  of  strength.  With  respect  to  mild  laxative 
medicines,  none  are  superior  to  manna,  rhubarb,  oleum 
ricini,  and  the  like;  and  of  the  saline  purgatives  the 
best  are,  the  sulphate  of  soda,  tartrite  of  potass,  phos- 
phate of  soda,  and  sulphate  of  inagne.-^ia.  It  may 
here  be  remarked,  that  besides  the  benefit  which  the 
local  inflammation  derives  from  the  judicious  adminis- 
tration of  purgatives,  the  costiveness  and  heat  which 
usually  attend  the  symptomatic  fever,  are  also  re- 
moved by  the  same  means. 

“ Purgatives  (says  Dr.  Thomson)  are  more  or  le.ss 
required  in  almost  every  species  of  inflammation  ; but 
they  are  more  peculiarly  necessary  in  those  which  are 
accompanied  with  a high  degree  of  fever,  or  with  de- 
rangement of  the  digestive  or  biliary  organs.  In  cases 
of  inflammation  which  have  a tendency  to  sponta- 
neous resolution,  they  are  almpst  always  the  best,  and 
often  the  only  remedies  that  are  required.” — {Lectures 
on  Inflammation,  p.  171.) 

Considering  the  general  approbation  of  the  employ- 
ment of  mild  saline  purgatives  in  cases  of  inflamma- 
tion I confess  that  I was  not  a little  surprised  to  find 
merely  the  following  short  unfavourable  notice  taken 
of  them  by  a celebrated  foreign  professor,  in  iiis  ac- 
count of  the  treatment  of  inflammation  ; — “ As  for 
purgatives,  they  must  be  used  with  discretion.  Tiiere 
are  none  of  them  antiphlogistic,  as  has  been  pretended. 
They  always  produce  more  or  less  irritation,  and  can 
only  be  applicable  when  the  cause  of  the  inflamma- 
tion  is  in  the  intestinal  canal.  In  the  beginning  of  the 
complaint  we  ought,  therefore,  in  general  to  abstain 
from  them,  and  confine  ourselves  to  emollient  glys- 
ters.” — {Boyer,  Traiti  des  Maladies  ChirvrgicaleSf 
t.l,p.  39.) 

Diaphoretic  and  nauseating  medicines. — Medicines 
which  have  the  power  of  producing  sickness  lessen 
for  a time  the  action,  and  even  the  general  powers  of 
life.  This  is  in  consequence  of  every  part  of  the  body 
sympathizing  with  the  stomach;  and  the  effect  may 
be  very  quickly  excited.  Sickness  lowers  the  pulse, 
makes  the  small  vessels  contract,  and  rather  disposes 
the  skin  to  perspiration.  But  nothing  more  than 
nausea  should  be  caused  ; for  vomiting  rather  rouses 
than  depres.ses. — {Hunter.)  Nauseating  medicines, 
employed  after  bleeding  has  been  practised  once  or 
twice,  are  often  productive  of  considerable  benefit ; but 
there  are  some  affections  in  which  they  cannot  l)e  used, 
such  as  inflammation  of  the  stomach  and  intestines. 
In  all  superficial  inflammations,  however,  they  may 
be  safely  and  advantageously  exhibited,  as  well  as  in 
most  inflammatory  affections  internally  siluated.  In 
inflammation  of  the  dura  mater  and  brain,  and,  in- 
deed, in  every  instance  in  which  there  is  an  urgent 
reason  for  putting  as  sudden  a check  as  possible  to  the 
continuance  of  the  aflection,  the  employment  of  nau- 
seating doses  of  antimony  is  most  strongly  indicated. 
The  tartrite  of  antimony  (emetic  tartar)  is  the  medicine 
on  which  practitioners  place  the  greatest  reliance,  and 
it  is  to  be  prescribed  for  the  purpose  of  exciting  nausea 
as  follows: — fit.  Antimonii  tartarisati  grana  duo; 
aqua;  distillala;  uncias  quatuor.  Misce  et  cola.  Do- 
sis,  uncia  dimidia  sextfi  qu&que  horft. 

The  safest  diaphoretics  are  citrate  of  potass,  acetate 
of  ammonia,  and  tartrite  of  antimony,  and  James’s 
powder.  The  two  latter,  fVom  their  effects  in  pro- 
ducing nausea  and  weakening  the  pulse,  are  sometimes 
most  efficacious,  as  already  stated. 

“ The  warm  bath  seems  to  act  (as  a modern  writer 
says),  not  only  by  increasine  the  tendency  to  jterspira- 
tiori,  but  also  by  occasioning  a determination  of  blood 
to  those  parts  of  the  body  to  which  it  is  more  immedi- 
ately applied.  It  is  in  this  way  lljat  bathing  the  fee* 
seems  to  relieve  inflammatory  affections  of  the  brad 
and  throat.  I have  not  seen  any  experiments,  nor  am 
1 acquainted  with  any,  w’hich  have  been  made  with  a 
view  to  ascertain  its  use  in  the  inflammations  of  tht 


INFLAMMATION. 


m 


chest ; but  in  airinflaramations  of  the  belly,  and  of  the 
viscera  contained  within  that  cavity,  there  are  no  other 
means  of  cure,  blood-letting  excepted,  which  atfurd 
such  sudden  and  |wrinanenl  relief,  as  that  which  is  ob- 
tained from  hot  fonienlalions  and  warm  bathing.” — 
(See  7'homson  on  Inflammation,  p.  173.) 

Opium. — The  majority  of  surgeons  entertain  an  in- 
superable objection  to  the  adtiiinistration  of  opiates  in 
almost  all  cases  of  indammalion,  and  the  aversion  to 
this  practice  is  for  the  most  part  deducible  from  the 
recollection  of  opium  being  a ^ntwerful  stimulant.  The 
plan,  however,  has  its  advocates. — (fl.  Bell,  Richter, 
Src.)  One  of  its  strongest  partisans  tells  us,  that  opium 
particularly  lessens  the  disturbance  of  intlammation, 
and  allays  pain,  which  is  at  once  a principal  symptom 
of  the  process,  and  a cause  of  its  augmentation,  as  well 
as  that  of  the  fever.  Opium  also  quiets  the  inordinate 
action  of  the  solids,  the  menial  agitation  and  restless 
ness,  so  powerfully,  that  it  well  deserves  the  name  of 
the  grand  antiphlogistic  remedy.  It  likewise  occasions 
a moisture  on  the  surface  of  the  body,  which  experience 
shows  is  eminently  serviceable  in  all  inflammations 
aflecting  the  skin.  When  given  with  this  view,  it  is 
usually  conjoined  with  antimony,  camphor,  calomel, 
or  ipecacuanha.  The  administration  of  opium  is  a 
general  practice  in  all  painful  inflammaiious  arising 
from  external  causes,  and  it  is  attended  with  perfect 
safety  when  evacuations  from  the  bowels  and  bleeding 
have  been  previously  put  tn  practice.  Care  must  he 
taken  to  give  it  in  sufficient  doses ; for  small  quantities 
not  only  fail  in  fulfilling  the  object,  but  frequently  pro- 
duce quite  an  opposite  effect.  Duritig  its  employmeiit, 
the  bowels  slunild  be  kept  open  with  glysters.  'I’he 
efficacy  of  opium  chiefly  manifests  itself  in  the  early 
stage  of  the  affection;  for  as  soon  as  the  inflammatory 
fever  has  extended  itself  to  the  whole  system,  it  loses 
its  beneficial  virtues.  Hence,  in  cases  of  external  in- 
juries, it  is  to  be  given  the  first  two  days,  immediately 
after  bleeding.  It  is  to  be  given  as  soon  after  the  acci- 
dent .as  possible,  in  order  to  tranquillize  the  mental 
alarm,  and  if  convenient,  towards  the  evening,  for  the 
sake  of  procuring  a quiet  night. — {Richter.)  Ev<acu- 
alions  being  premised,  says  the  other  advocate  for  this 
medicine,  the  next  object  of  importance  is  to  procure 
ease  and  quietness  to  the  patient,  which,  in  cases  of 
inflammation,  are  often  of  more  real  service,  than  any 
other  circumstance  whatever.  The  most  efifcciual 
remedy  for  this  purpose  is  opium,  which,  when  the 
pain  and  irritation  are  considerable,  as  very  frequently 
happens  in  extensive  inflammations,  should  never  be 
omitted.  In  large  wounds,  especially  after  amputa- 
tions and  other  capital  oper<ations,  and  in  punctures  of 
all  kinds,  large  doses  of  opium  are  alwtiys  attended 
with  remarkably  good  effects.  In  all  such  cases,  how- 
ever, opium,  in  order  to  have  a proper  influence, 
should  be  administered  in  very  large  doses ; otherwise, 
instead  of  proving  serviceable,  it  seems  raiher  to  have 
the  ermtrary  effect. — {B.  Bell ) According  to  modern 
observations,  morphine  is  the  principle  in  opium,  that 
tranquillizes  without  producing  the  ill  effects  of  com- 
mon opium,  and  of  course  its  preparations  are  pecu- 
liarly suited  for  cases  of  inflammation. 

On  the  contrary,  those  who  are  averse  to  the  use  of 
opium  remark,  that  in  -acute  inflammation  daily  ex- 
perience shows,  independently  ofevery  theory,  that  the 
exhibition  of  this  medicine  increases  the  general  fever, 
.and  aggravates  the  local  action.  -Even  given  as  a pre- 
ventive of  inflammation,  after  operations,  anodynes 
are  almost  iinifo’-mly  hurtful,  producing  restlessness, 
heat,  thirst,  and  afterward  headache,  sickness,  and 
frequently  troublesome  vomiting — (Burns.) 

According  to  IJr.  Thomson,  “ those  diaphoretics, 
into  the  composition  of  which  opium  enters,  seem  trl 
be  better  adapted  for  inflammation  attended  with 
fever  of  a typhoid  char.acter,  or  for  cases  where  the 
inflammation  has  existed  for  a considerable  lime  before 
diaphoretics  are  employed.  Given  at  an  early  period 
in  acute  inflammatory  diseases,  opium  never  fails  to 
excite  vascular  action,  and  to  aggravate  all  the  symp- 
toms of  fever.  Opium,  therefore,  is  not  to  be  used, 
nnle.08  to  allay  the  pain  arid  irritation  from  a stirgical 
operation,  or  from  the  recent  infliction  of  an  external 
injury.  Iruleed,  unless  when  the  patient  is  very  ner- 
vous, and  complains  much  of  pain,  its  use,  even  after 
chinirgical  operations,  had,  I believe,  in  general,  better 
be  abstained  from,  as  it  almost  never  fails  to  add  to 
the  violence  of  the  symptomatic  fever  which  is  the 


necessary  consequence  of  the  operation.  Its  effects 
ate  often  very  beneficial,  when  the  period  of  this 
fever  has  passed  over.”  — (See  Lectures  on  Inflam- 
mation, p.  172.)  Upon  the  whole,  candour  obliges 
me  to  own,  that  the  majority  of  surgeons  in  this  coun- 
try are  decidedly  against  the  general  use  of  opium 
in  inflammation  ; but  after  the  performance  of  severe 
operations,  and  in  all  instances  attended  with  exces- 
sive pain,  truth,  I believe,  will  justify  my  saying,  tJiat 
they  are  in  favour  of  the  exhibition  of  this  remedy ; 
and,  nrt  doubt,  the  preparations  of  morphine,  or  those 
from  which  ilie  stimulating  principles  of  the  drug  have 
been  removed,  wliile  the  anodyne  are  retained,  ought 
here  to  be  preferred. 

Diet  and  Regimen. — In  all  cases,  the  surgeon  is  to 
forbid  the  use  of  wine  and  spirits;  and,  when  the  in- 
flammation is  at  all  considerable,  the  same  prohibition 
is  to  be  made  in  rega  d to  animal  food.  Watery,  cool- 
ing, mucilaginous  drinks  are  proper;  for  they  keep 
off  thirst  and  heat,  promote  perspiration,  and  tend  to 
sooth  the  increased  action  of  the  whole  arterial  sys- 
tem. For  this  purpose,  whey,  buttermilk,  barley- 
water,  decoctions  of  dried  fruits,  water-gruel,  &c.  may 
be  given. 

When  diluent  drinks  “ are  intended  to  allay  thirst, 
as  well  as  to  promote  perspiration,  the  addition  of 
some  vegetable  acid,  such  as  lemon  juice,  or  cream  of 
tartar,  renders  tliem  in  general  very  palatable  to  pa- 
tients. In  the  earlier  slages  of  inflammation,  and 
where  the  object  is  to  induce  a moisture  on  the  skin, 
the  mineral  acids,  though  they  might  serve  to  quench 
thirst,  are  not  to  be  employed,  as  they  tend  rai’her  to 
check  than  promote  the  flow  of  sweat.” — (Thom^n 
on  Inflammation,  p.  11%)  * 

The  chamber  in  which  the  patient  lies  should  not 
be  warmer  tlian  his  comfort  requires  ; for  heat  tends 
powerfully  to  keep  up  an  increased  action  of  the  san- 
guiferous system  For  the  same  reason,  the  patient 
should  not  be  covered  witli  a superfluous  quantity  of 
bed-clothes. 

The  whole  body,  but  more  especially  the  inflamed 
part,  should  be  preserved  in  as  complete  a state  of  rest 
as  possible.  Every  one  knows,  that  all  motion,  exer- 
cise, and  muscular  exertion  accelerate  the  circulation, 
and  hence  must  have  a pernicious  effect  on  inflam- 
mation, by  determining  a larger  quantity  of  blood  to 
the  part  affected. 

Jipplicationss — With  the  e.xception  of  what  has 
been  staled  concerning  topical  bleeding,  all  the  fove- 
Koing  remarks  relate  to  i\\Q.  general  treatment  of  in- 
flammation : the  local  means  remain  for  consideration. 

It  has  been  already  observed,  that  phlegmon  is  at- 
tended with  an  incre.ase  of  heat  in  the  part  affected, 
and  it  is  an  acknowledged  and  well  known  fact,  that 
the  action  of  the  arteries,  as  well  as  every  other  ope- 
ration in  the  animal  economy,  is  promoted  and  in- 
creased by  the  influence  of  heat.  For  this  reason,  an 
obvious  indication  arises,  viz.  to  reduce  the  tempera- 
ture of  the  inflamed  part,  by  the  topical  application  of 
cold,  and,  in  particular,  by  continually  abstracting  the 
heal  evolved  in  the  part,  by  keeping  up  a constant 
evaporation  from  its  surface. 

“ Of  the  local  remedies  applied  directly  to  inflamed 
parts  (s.ays  Dr.  Thomson),  cold  is  undoubtedly  one  of 
the  most  powerful.  In  reducing  the  temperature,  cold 
diminishes  the  morbid  setisibility  and  pain  of  inflamed 
parts;  and,  probably,  in  consequence  of  this,  the  action 
also  of  the  vessels  by  which  the  inflamed  parts  are 
supplied  with  blood.  The  most  common  mode  of 
employing  cold  is  by  the  application  to  the  part  in- 
flamed of  cloths  which  have  been  dipped  in  cold  water. 
These  are  to  be  repeated  as  often  .as  they  become 
warm,  or  any  relief  is  experienced  hj'  the  patient  from 
their  use.  When  the  inflammation  is  seated  in  the 
remote  parts  of  either  the  upper  or  lower  extremities 
of  the  body,  the  inflamed  pan  itself  may  be  immersed 
in  water.  This  immersion,  as  I shall  afterward  have 
occasion  to  mention,  has  often  b en  found  useful 
in  superficial  burns.  In  order  to  increase  the  effect 
produced  by  cold,  it  has  been  proposed  to  reduce  the 
temperature  of  the  water  below  that  of  the  surrounding 
atmosphere,  by  a proper  mixture  of  saline  bodies,  as 
some  of  these  are  known  to  produce  cold  during  their 
solution  in  water,  or  even  in  very  urgent  cases  to  apply 

Iice  or  snow.  The  ice,  however,  must  not  be  applied 
too  long,  nor  in  too  large  a quantity  ; for  it  very 
quickly  reduces  the  temperature  of  the  part  to  which 


90 


INFLAMMATION. 


it  is  applied,  and,  in  some  instances,  has  been  known 
to  occasion  gangrene,  &c.” — ( On  Jnflanimaiion,p.  180.) 

With  the  cold  water  applied  to  phlegmonous  iadam- 
matiun,  it  is  usual  to  blend  some  lemedies,  which  are 
astringent,  and  supposed  to  have  also  a sedative 
quality.  The  acetate  of  lead,  sulphate  of  zinc,  and 
vinegar  seem  now,  indeed,  to  have  acquired  [)ermaneni 
celebrity  for  their  efficacy  in  resolving  inflammation. 

Extensive  experience  and  long  established  trials, 
have  now  fully  confirmed  the  virtue  of  all  those  local 
remedies,  in  which  the  acetate  of  lead  is  the  active 
ingredient.  M.  Goulard,  and  other  French  surgeons, 
found,  that  the  objections  to  the  employment  of  many 
other  sedative  applications  in  the  treatment  of  inflam- 
mation did  not  exist  against  the  use  of  this  preparation 
of  lead.  The  universal  assent  of  modern  practi- 
tioners prove^  indeed,  that  the  acetate  of  lead,  as  a 
local  application  for  genuine  phlegmonous  inflamma- 
tion, is  certainly  unsurptassed,  if  not  unrivalled,  in 
pwint  of  efficacy. 

The  prepaiations  of  lead  are  recommended  by  M. 
Goulard,  as  applicable  to  almost  every  stage  of  inflam- 
mation. Wnen  swellings  have  fully  suppurated,  the 
employment  of  what  he  calls  the  extractum  satumiu 
will  generally  render  it  unnecessary  to  op)en  them. 
Even  in  gangrene,  the  solution  of  lead  is  represented, 
by  this  partial  writer,  as  a remedy  deserving  of  the 
greatest  confidence. 

But,  notwithstanding  the  above  exaggeration,  every 
man  of  experience  and  observation  will  allow,  tliat, 
while  there  is  a chance  of  accompilishing  resolution, 
no  local  applications  to  phlegmonous  inflammation 
are  in  general  so  proper  as  cold  lotions,  containing  the 
acetate  of  lead. 

“ The  manner  in  which  it  operates  in  curing  inflam- 
mation (as  Dr.  Thomson  observes)  is  not  known  to  us, 
nor  is  it  at  all  times  easy  to  distinguish  between  the 
share  which  the  lead  has  in  allaying  inflammation, 
and  that  which  is  to  be  attributed  to  the  coldness  of 
the  water  in  which  it  is  dissolved.  No  one,  however, 
will  doubt  the  efficacy  of  this  remedy,  who  hsis  ever 
felt  it  in  his  owmi  body,  or  witnessed  in  others  the 
soothing  and  agreeable  eflects  which  it  produces  in 
excoriations  of  the  skin,  or  in  inflammation  of  mucous 
membranes.  Lead  is  a remedy  which  is  often  highly 
useful  in  excoriations  from  friction,  in  punctured 
wounds  with  inflammation  of  absorbent  vessels,  veins, 
nerves,  &c.,  in  slight  burns,  in  cutaneous  heat,  erupr- 
lions  of  the  face,  in  fractures  and  dislocations,  in  the 
inflammation  attending  sciirhus  and  cancer,  syphilis 
and  gonorrhoea,  in  wounds  accompanied  with  excoria- 
tion from  the  discharges  they  emit,  and  in  wounds 
attended  with  a burning  sensation  of  pain.” — (P.  182.) 

From  the  pioisonous  qualities  of  lead,  when  taken 
into  the  system,  and  from  the  possibility  of  this  mineral 
being  absorbed  from  the  surface  of  the  body,  objections 
have  arisen  against  the  free  use  of  its  preparations, 
even  as  outward  remedies,  in  cases  of  inflammation. 
Certain  it  is,  however,  that  though  the  possibility  of 
such  absorption  is  proved  by  the  occurrence  of  the 
disorder  called  the  colica  pictanum.  which  originates 
in  painters  from  the  white  lead  absorbed  into  the  sys- 
tem, yet  any  ill  eflects  from  the  use  of  lead,  as  an 
application  to  inflamed  parts,  are  so  rare,  that  they 
can  hardly  form  a serious  objection  to  the  practice. 
It  is  a fact,  that  in  inflamed  parts  there  is  an  impe- 
diment to  absorption,  and  this  circumstance  must 
tend  to  render  the  employment  of  lead  a matter  of 
safety.  Mr.  B.  Bell  observes,  that  in  all  the  experience 
which  he  had  had  of  the  external  application  of  lead 
and  its  preparations,  and  in  many  cases,  particularly 
of  burns,  where  he  had  known  the  greatest  part  of  the 
surface  of  the  body  covered  with  applications  of  this 
description  for  days,  nay  for  weeks  together,  he  did  not 
recollect  a single  instance  of  any  disagreeable  symptom 
being  ever  produced  by  them.  Nor  has  Dr.  Thomson 
ever  seen  the  colica  pictonum  follow  the  use  of  Gou- 
lard.— (See  Lectures  on  Inflammation,  p.  183.) 

A lotion  composed  of  acetate  of  lead,  vinegar,  and 
W'ater,  is  very  commotdy  employed,  ft-  Plumbi  Ace- 
tatis  5^-  Solve  in  Acet.  pur.  3 iv.  Et  adde  Aq-  Fon- 
taiiae  disiill.  Ibij.  The  vinegar  makes  the  solution 
more  complete.  In  all  cointnon  cases,  a tea-spoonful 
of  the  litpior  plumhi  acetatis,  blended  with  a pint  of 
water,  to  which  an  ounce  of  spirit  of  wine  has  been 
added,  will  be  found  an  eligible  lotion.  Occasionally, 
bread-crumb  is  moistened  in  the  fluid,  and  applied  in 


the  form  of  a poultice ; but  linen  dipped  in  the  lotion, 
and  kept  constantly  wet  with  it,  is  mostly  preferred. 
Thus  a continual  evaporation  is  maintained,  and  of 
course  a regular  abstraction  of  heat. 

When  the  surgeon  is  afraid  of  employing  a solution 
of  lead,  he  may  try  one  of  the  sulphate  of  zinc.  One 
drachm  of  this  substance  is  to  be  dissolved  in  a pint  of 
water,  and  linen,  well  wet  with  the  lotion,  is  to  be 
applied  to  the  inflamed  part. 

Many  practitioners  impute  little  real  efficacy  either 
to  the  acetate  of  lead  or  sulphate  of  zinc  contained 
in  the  above  applications ; and  they  attribute  all  the 
good  that  is  produced  entirely  to  the  evaporation  kept 
up  from  the  surface  of  the  inflamed  part,  and  to  the 
coldness  of  the  fluid  in  which  the  metallic  salts  are 
dissolved.  Surgeons  who  entertain  these  sentiments 
often  apply  simple  cold  water,  or  spirit  of  wine  largely 
diluted. 

There  are  particular  cases  of  inflammation,  in  which 
the  extravasation  of  blood  and  lymph,  in  the  interstices 
of  the  inflamed  part,  is  exceedingly  copious,  and  the 
swelling  considerable,  but  the  pain  and  redness  not 
particularly  great.  In  such  instances,  it  is  an  indica- 
tion to  rouse  the  action  of  the  absorbents,  in  order 
that  tliose  vessels  may  remove  the  extravasated  fluid, 
and  with  this  view,  a more  powerful  discutient  lotion 
may  be  employed  than  in  other  cases,  and  sometimes 
it  is  even  better  to  use  embrocations  and  liniments, 
than  any  sort  of  lotion.  The  following  discutient 
lotions  are  often  employed: — Ammonise  Muriaue 
I ss.  Aceti ; Spiritus  Vini  rectificati ; sing.  Ibj.  M.  ft. 
Liq.  Ammon.  Acet.  Spir.  Vini  reciif.;  Aq.  Disiillatae  ; 
sing.  3 iv.  ;M.  The  Liq.  Amuioniae  Acet.  answers  very 
well  by  ibself. 

When  the  pan  aflfected  with  inflammation  is  not 
very  tender,  or  when  it  lies  deep,  applications  of  the 
vegetable  acid  are  often  had  recourse  to  with  conside- 
rable advantage  ; and  the  most  efl!ectual  form  of  using 
it  seems  to  be  a poultice  made  with  vinegar  and 
crumb  of  bread.  In  such  cases,  it  has  been  thought, 
that  an  alternate  use  of  this  remedy,  and  the  saturnine 
lotion,  has  produced  more  beneficial  effects  than  are 
commonly  observed  from  a continued  use  of  one  of 
them.— (B.  Bell.)  However,  surgeons  of  the  present 
day  seem  to  think,  that  vinegar  can  be  as  advantage- 
ously applied  in  the  form  of  a lotion,  as  in  that  of  a 
poultice,  and  certainly  with  less  i rouble. 

Alcohol  and  ether  have  acquired  some  celebrity  as 
local  remedies  for  inflammation.  No  doubt  one  great 
reason  why  they  are  not  more  extensively  used  for  this 
purpose  is,  the  expense  attending  such  treatment,  as 
these  fluids  evaporate  with  great  rapidity.  Alcohol 
niay  possibly  prove  useful  from  its  astringent  qualities; 
but' it  seems  much  more  rational  to  i:npute  both  its 
virtue,  and  that  of  ether,  to  the  manner  in  which  their 
evaporation  low'ers  the  temperature  of  the  inflamed 
part. 

TFarm  ..Applications.— The  absurdity  of  attempting 
to  reconcile  every  useful  practice  with  a philosophical 
theory,  is  in  no  instance  more  strikingly  exemplified, 
than  in  the  opposite  sorts  of  local  applications,  w’hich 
are  of  service  in  inflammation.  The  generality  of 
cases  undoubtedly  receive  most  relief  from  the  use  of 
cold  sedative  astringent  lotions;  but  there  are  consti- 
tutions and  parts  which  derive  most  service  from  the 
local  employment  of  warm  emollient  remediea 

Were  I to  endeavour  to  define  the  particular  in- 
stances in  which  the  latter  applications  avail  most,  I 
should  take  upon  me  a task  w'hich  has  baflled  all  the 
most  able  surgical  writers.  The  first  stage  of  acute 
nphthalmy,  and  ihe  hernia  humoralis,  or  inflamed  tes- 
ticle, may  be  specified,  however,  as  examples,  in  which, 
generally  speaking,  w'arm  emollient  applicauons  are 
better  than  cold  astritigent  ones.  Yet,  even  with  re- 
spect to  inflammation  of  the  testis,  there  is  some  dif- 
ference of  opiiMon  about  the  superiority  of  cold  or 
warm  applications.  Mr.  James’s  sentiments  are  as 
follows  ; in  the  treatment  it  is  of  importance  to  con- 
sider the  differences  of  the  cause ; thus,  in  mumps  and 
rheumatism,  the  constitution  is  chiefly  to  be  attended 
to,  and  cold  applications  are  certainly  improper.  When 
it  (the  inflammation  of  the  testis)  arises  from  a blow, 
after  leeches  have  been  freely  employed,  fomentations 
are  the  best  remedy.  But  Mr  James  thinks  that  this 
is  not  the  case,  in  many  instances  of  inflamed  testicle 
from  gonorrhoea,  where  cold  applications  are  prefer- 
able; but  he  owns  that  the  feelings  of  the  patient  will 


INFLAMMATION. 


91 


best  determine  tlie  point. — {James  on  Inflammation, 
p.  164.) 

“ Fomentations  or  embrocations  with  warm  water, 
(as  a judicious  writer  has  remarked)  are  olten  a very 
powerful  means  of  abating  internal  intiammation. 
This  effect  is  very  apparent  in  some  of  the  deeper- 
seated  inflammations,  as  in  the  inflammation  of  the 
urinary  bladder,  intestines,  or  other  viscera  contained 
within  the  cavity  of  the  abdomen.  The  warmth,  in 
this  case,  may  be  applied  to  the  surface  of  the  abdo- 
men, by  bath  or  fomentation,  or  in  the  way  of  injec- 
tion by  the  anus,  &c.  In  some  inflammations  of  the 
joints,  warmth  also  is  found  to  be  very  useful.  These, 
liowever,  are  inflammations  which  have  a tendency  to 
the  chronic  state.” — (See  Thomson  on  Inflammation, 

p.  188.) 

If  we  may  judge  by  the  feelings  of  certain  patients, 
there  are  undoubtedly  particular  constitutions  in  which 
the  local  use  of  warm  remedies  produces  greater  relief 
than  that  of  cold  ones.  This  circumstance,  however, 
does  not  generally  happen;  and,  as  warm  emollient 
applications  of  all  kinds  have  the  most  powerful  in- 
fluence in  promoting  suppuration,  a fact  admitted  by 
every  experienced  practitioner,  the  use  of  such  reme- 
dies, while  the  resolution  of  inflammation  is  practica- 
ble, must  be  highly  censurable.  But  I atn  ready  to 
grant,  that  in  all  cases  of  inflammation  which  mani- 
festly cannot  be  cured  without  suppuration,  the  emol- 
lient plan  of  treatment  ought  to  be  at  once  adopted  ; 
for  the  sooner  the  matter  is  formed  the  sooner  the 
inflammation  itself  is  stopped.  The  inflammation 
attending  contused  and  gun-shot  wounds,  and  that 
accompanying  boils  and  carbuncles,  are  of  this  descrip- 
tion. The  inflammation  originating  in  fevers  com- 
monly ends  in  suppuration ; and  in  such  instances, 
perhaps,  it  might  be  advantageous  also  to  employ  at 
once  the  emollient  treatment. 

Warmth  and  moisture  together,  in  other  words  fo- 
mentations, are  commonly  had  recourse  to ; but  it  is 
observed  by  Mr.  Hunter,  that  when  the  warmth  is  as 
much  as  the  sensitive  principle  can  bear,  it  excites  ac- 
tion. Whether  it  is  the  action  of  inflammation,  or  the 
action  of  the  contraction  of  the  vessels,  is  unknown. 
We  see  that  many  patients  cannot  bear  warmth,  and 
therefore  it  might  be  supp(jsed  to  increase  the  actioji 
of  dilatation  and  do  harm.  But  if  the  pain  should 
arise  from  the  contraction  of  the  inflamed  vessels,  be- 
nefit would  be  the  result;  though  we  must  doubt  that 
this  change  is  produced,  as  making  the  vessels  contract 
would  probably  give  ease. 

From  the  preceding  observations  we  must  perceive 
how  vain  it  is  to  theorize  on  this  subject,  which  even 
puzzled  the  genius  and  penetration  of  a Hunter.  In 
addition  to  what  has  been  already  observed,  I feel  to- 
tally incapable  of  giving  any  useful  practical  advice, 
with  respect  to  those  cases  in  which  warm  emollient 
applications  should  be  used  in  preference  to  cold 
astringent  ones.  I can,  however,  with  confidence  re- 
mark, that  the  surgeon  who  consults  the  feelings  and 
comfort  of  the  patient  on  this  point  will  seldom  commit 
any  serious  error.  Hence,  in  all  cases  in  which  the 
first  kind  of  topical  applications  seem  not  to  produce 
the  wonted  degree  of  relief,  let  the  second  sort  be  tried. 
From  the  opportunity  of  comparison  a right  judgment 
may  then  be  easily  formed. 

The  poultice,  made  of  the  powder  of  linseed,  is  so 
easily  prepared,  that  the  old  bread  and  milk  poultice  is 
now  seldom  employed.  As  much  hot  water  is  to  be 
pul  into  a basin  as  the  size  of  the  poultice  requires, 
and  then  the  linseed  powder  is  to  be  gradually  mixed 
with  the  water  till  the  mass  is  of  a proper  consistence. 
Frequently  a little  sweet  oil  is  also  added,  to  keep  the 
application  longer  soft  and  moist. 

Fomentations  are  only  to  be  considered  as  temporary 
applications,  while  the  emollient  poultices  are  the  per- 
manent ones.  The  former  are,  at  most,  never  used 
more  than  three  times  a day  for  the  space  of  about  half 
an  hour  each  time.  Two  of  the  best  are  the  follow- 
ing;— B:- Lini  contusi  5j-  CharnaBmeli  ^ij-  Aq.  dis- 
till. Ibvi.  Paulisper  coque  et  crda.  Or,  B-  Papaveris 
aibi  exsiccati  |iv.  Aq.  purse  Ibvi.  Coque  usque  re- 
maneat  Ibij.  et  cola. 

Some  practitioners,  however,  are  inclined  to  think 
warm  water  alone  quite  as  efficacious  as  the  decoc- 
tions of  particular  herbs.  I’hus  Dr.  Thomson  ob- 
serves, “ herbs  are  now  seldom  used  in  the  way  of  fo- 
mentation, unless  in  compliance  with  ancient  custom. 


or  with  the  prejudices  of  particular  individuals.  The 
discutient  power  of  the  warm  water  may  be  increased 
by  the  addition  of  various  substances,  such  as  vinegar, 
spirits  of  wine,  saline  substances,  such  as  common 
salt,  acetate  and  muriate  of  ammonia.  But  these 
warm  and  stimulating  einbrocaiions  are  used  chiefly 
in  the  passive,  chronic,  or  more  indolent  species  of  in- 
flammation.”— tSee  Lectures  on  Inflammation,  p.  189. 

By  pursuing  the  above  treatment,  the  resolution  of 
the  inflammation  will  in  general  begin  to  take  place, 
either  in  the  course  of  three  or  four  days,  or  in  a shorter 
space  of  lime.  At  all  events,  it  may  usually  be  known 
before  the  expiration  of  this  period  how  the  disorder 
will  terminate.  If  the  heat,  pain,  and  other  attending 
symptoms  abate,  and  especially  if  the  tumour  begin 
to  decrease,  without  the  occurrence  of  any  gangrenous 
appearances,  we  may  then  he  almost  certain,  that,  by 
a continuance  of  the  same  plan,  a total  resolution  will 
in  time  be  effected. 

On  the  other  hand,  when  all  the  different  symptoms 
increase,  and  particularly  when  the  tumour  becomes 
larger  and  sofiish,  attended  with  a more  violent  throb- 
bing pain,  we  may  conclude  that  the  case  will  proceed 
to  suppuration.  Hence  an  immediate  change  of  treat- 
ment is  indicated,  and  such  applications  as  were  proper 
while  lesolution  seemed  practicable,  are  to  be  left  off 
and  others  substituted.  This  remark  relates  to  the 
employment  of  cold  astringent  remedies,  which,  when 
suppuration  is  inevitable,  only  do  harm  by  retarding 
what  cannot  be  avoided,  and  affording  no  relief  of  the 
pain  and  other  symptoms.  If  the  inflammation,  how- 
ever, should  already  be  treated  with  emollients,  no 
alteration  of  the  topical  applications  is  requisite,  in 
consequence  of  the  inevitability  of  the  formation  of 
matter.  Indeed,  emollient  poultices  and  fomentations 
are  the  chief  local  means  both  of  promoting  suppura- 
tion, and  diminishing  the  pain,  violent  throbbing,  &c. 
which  always  precede  this  termination  of  phlegmonous 
inflammation. 

But  besides  the  substitution  of  warm  emollient  ap 
plications  for  cold  astringent  lotions,  practitioners  have 
decided,  that  it  is  also  prudent,  as  soon  as  the  certainty 
is  manifest,  to  relinquish  the  free  employment  of  eva- 
cuations, particularly  blood-letting,  and  to  allow  the 
patient  a more  generous  diet.  When  the  system  is  too 
much  reduced  by  the  injudicious  continuance  of  rigor- 
ous antiphlogistic  treatment,  the  progress  of  the  ensuing 
suppuration  is  always  retarded  in  a disadvantageous 
manner,  and  the  patient  is  rendered  too  weak  to  sup- 
port either  a long-continued  or  a profuse  discharge, 
which  it  may  not  be  possible  to  avoid. 

I shall  conclude  this  article  with  briefly  noticing 
blisters,  rubefacients,  issues,  and  synapisms,  as  means 
often  employed  for  the  relief  of  particular  cases  of  in- 
flammation. ” Blisters  (says  Dr.  Thomson)  are  never 
ajiplied  to  a part  which  is  actually  inflamed.  They 
seem  to  be  chiefly  useful  by  exciting  inflammation  in 
a contiguous  part.  It  is  from  this  tendency  which 
blisters  have  to  produce  inflammation,  and  of  course  a 
certain  degree  of  fever,  that  they  are  seldom  to  be  em- 
ployed in  acute  inflammatory  cases  till  the  constitu- 
tional symptoms  are  by  other  means  in  some  measure 
subdued.”— (P.  187.) 

“ Of  the  same  nature,  though  milder  in  their  opera- 
tion than  blisters,  are  the  whole  class  of  rubefacients. 
They  produce  a determination  of  blood  to  the  parts  to 
which  they  are  applied,  and,  in  a manner  not  yet  well 
understood,  occasion  a diminution  in  the  action  of  the 
vessels,  and  consequently  in  the  quantity  of  blood  with 
winch  the  inflamed  parts  are  supplied.  This  influence 
is  exerted  more  or  less  directly  in  different  instances. 
The  extremities  of  the  intercostal  arteries  may  open 
both  on  the  pleura  lining  the  chest,  and  on  the  surface 
of  the  skin  covering  it,  and  whatever  excites  an  in- 
creased flow  of  blood  into  one  of  these  textures,  may 
be  conceived  to  be  attended  with  a proportionally  di- 
minished flow  into  the  other  texture.  But  blisters  are 
found  by  experience  to  be  efficacious  in  removing  in- 
flammation where  no  communication  whatever  can  be 
traced  between  the  blood-vessels  of  the  inflamed  part 
and  that  to  which  the  blister  is  applied.  We  have  ex- 
amples of  this  mode  of  action  in  the  beneficial  effects 
obtained  from  the  application  of  blisters  in  inflamma- 
tion of  the  brain  and  the  membranes  immediately  co- 
vering it,  of  the  lungs  and  intestines,  or  of  any  of  the 
viscera  contained  in  the  cavity  of  the  abdomen.  The 
nearer  in  such  instances  the  blister  or  rubefacient  can 


92 


INJ 


INT 


be  applied  to  the  part  inflamed,  the  greater  is  the  relief  i 
obtained:  and  in  general,  1 believe,  it  may  be  laid 
down  as  a rule,  that  the  relief  which  Uiey  aiford  vvill 
be  proportional  to  the  degree  of  inflammation  which 
they  excite.” — (See  Thomson  on  Inflammation^  p. 
187.  189.) 

Synapisms,  blisters,  and  issues  are  in  many  instances 
applied  in  situations  which  are  so  remote  from  and  un- 
connected by  vessels  with  the  inflamed  parts,  that  it  is 
impo.’^sible  to  explain  their  mode  of  operation,  except 
through  the  medium  of  the  nervous  system.  “The 
irritation  of  a synapism  applied  to  tJie  foot  (says  Dr. 
Thomson)  may  relieve  an  attack  of  gout  in  the  head 
or  stomach.  Bathing  the  feet  and  legs  gives  relief  in 
inflammation  of  the  bowels ; and  the  application  of  a 
blister  or  caustic  to  the  neck  may  cure  an  inflamma- 
tion of  the  eyes,  &c.” — (P.  189.)  Here  counter-irrita- 
tion is  the  principle  by  which  an  explanation  is  usually 
attempted. — (See  Blisters.) 

Van  Swieten's  Commentaries ; Oorter's  Compen- 
dium Medicinee,  Ato.  Lugd.  1731 ; and  Chirurgia  Re- 
purgata,  Ato.  Bugd.  1742.  Vacca,  Liber  de  Jnflamma- 
tionis  morboste,  qaoe  in  humano  Carport  Jit,  J^Taiura, 
Causis,  Effectibus,  et  Curatione,  1765.  7J.  Magenisie, 
the  Doctrine  of  Inflammations,  founded  upon  reason 
and  experience  ; and  entirely  cleared  from  the  contra- 
dictory systems  of  Boerhaave,  Van  Swieten,  and  others, 
8vo.  Land.  1768.  Cullen's  First  Lines  of  the  Practice 
of  Physic,  vol.  1.  John  Hunter,  on  the  Blood,  Inflam- 
mation. 6rc.  Ato.  London,  1794.  Burns's  Dissertations, 
8vo.  Olasgow.  1800.  Thomson's  Lectures. on  Inflam- 
mations, Edinb.  1813.  Boyer,  Traiti  des  Maladies 
Chir.  t.  1.  Delpech,  Pricis  Elirn.  des  Mai.  Chir.  t.  1, 
chap.  1.  Paris,  1816.  John  Herdman,  Diss.  on  White 
Swelling,  and  the  doctrine  of  Inflammation,  8do.  Edin. 
1802.  F.  J.  V.  Bi  ou.-:sais,  Hist,  des  Phlegmasies,  on 
Inflammations  Chroniques,  &-c.  tom.2,  8do  Paris,  1808 
C.  Wenzel,  iiber  die  Induration  und  das  Geschwur  in 
indurioten  Theilen,  8vo.  Mainz,  1815.  Wilson  Philip, 
on  Febrile  Diseases,  part  2.  Introduction,  ex.  3 ; and 
an.  Experimental  Inquiry  into  the  Laws  of  the  Vital 
Functions,  ed  8oo.  Land.  1818.  Caleb  H.  Parry,  Ele- 
ments of  Pathology  and  Therapeutics,  8co.  Land.  1815. 
Jllso,  an  Experimental  Inquiry  into  the  Mature,  Src.  of 
the  Arterial  Pulse,  8vo.  London,  1816.  Charles  H. 
Parry,  Additional  Experiments  on  the  Arteries  of 
Warm-blooded  Animals,  Src.  8vo.  Land.  1819.  James 
Wilson,  Lectures  on  the  Blood,  and  on  the  Anatomy, 
Physiology,  and  Surgical  Pathology  of  the  Vascular 
System,  8vo.  Load.  1819.  C.  H.  Ronnefeld,  Animad- 
versiones  nonnullce  ad  Doctrinam  de  Inflammatione, 
Ato.  Lips.  1817.  C.  Hastings,  a Treatise  on  Inflam- 
mation of  the  Mucous  Membrane  of  the  Lungs,  &-c. 
Son.  Lond.  1820.  J.  H.  James,  Obs.  on  some  of  the  Ge- 
neral Principles,  and  on  the  Particular  Mature  and 
Treatment  of  the  different  Species  of  Inflammation, 
8no.  Lond.  1821.  C.  J.  M.  Langenbeck,  Mosologie,  Src. 
der  Chir.  Krankheiten ; b.  1,  Gott.  1822.  .I.Syme,  on 
the  Mature  of  Inflammation,  in  Edin.  Med.  Journ.  Mo. 
97;  p.316. 

INJECTION.  A fluid  intended  to  be  thrown  against, 
or  into  a part  of  the  body,  by  means  of  a syringe. 
Thus  port  wine  and  water  li)rm  an  injection,  w'hich  is 
used  by  surgeons  for  radically  curing  the  hydrocele, 
and  for  this  purpose  it  is  introduced  into  the  cavity  of 
the  tunica  vaginalis,  where  it  excites  the  degree  of  in- 
flammation necessary  to  produce  a universal  adhesion 
between  this  membrane  and  the  surface  of  the  testicle. 

Thus  many  fluid  remedies  are  introduced  into  the 
urethra  and  vagina  for  the  cure  of  gonorrhoea.  In 
the  article  Gonorrhoea  will  be  found  an  account  of  the 
best  injections  employed  for  its  relief.  A few  addi- 
tional remedies  of  this  class  are  here  subjoined. 

LVJECTITO  ACIDI  MURIATICI.  ft.  Aqu?e  distil. 

5 iv.  Acid.  Mur.  gutt.  vij.  Misce.  Has  been  used  for 
the  relief  of  the  ardor  urinae  in  ca.*es  of  gonorrhoea. 

IN.1ECTIO  ALUM  INIS.  ft.  Alum.  3j.  Aq.  pur. 

5 vij.  Misce  Successfully  employed  by  Or.  Cheston, 
in  affections  of  the  rectum,  either  when  the  internal 
coat  is  simply  relaxed  and  disposed  to  prolapsus,  or 
when  it  is  studded  with  loose  fungated  tumours. 

INJECTfO  CUPRI  AMMONIATl.  ft.  Liquoris 
Cupri  ammon.  eutt.  xx.  Aquae  rosa;  5 tv.  Misce. 

INJECTIO  CIUERCUS.  ft.  Decocti  quercds  Ibj. 
Aluminis  purificat.  jss.  Misce.  Used  when  the  rec- 
tum or  vagina  is  disposed  to  prolapsus  ftom  relaxation, 
jor  in  cases  of  gleet. 


I INOSCULATION  denotes  the  union  of  vessels  by 
conjunction  of  their  extremities.  It  is  generally  sy- 
nonymous with  anastomosis,  tiiough  sometimes  a dis- 
tinction is  made  ; anastomosis  signifying  the  union  of 
vessels  by  minute  ramitications,  and  inosculation  a 
direct  communication  by  trunks.  The  great  use  of 
inosculations  is  to  facilitate  and  ensure  the  continuance 
of  the  circulation,  when  the  large  trunks  of  vessels  are 
obstructed  by  pressure,  disease.  Sec.  Thus,  in  cases  of 
aneurism,  when  the  main  artery  of  a limb  is  tied,  the 
inosculations  of  the  branches  given  off  above  the 
ligature,  with  other  branches  arising  below  it,  form  at 
once  a channel,  through  which  the  lower  part  of  the 
limb  is  supplied  with  blood.  Were  there  no  such  ar- 
rangement in  the  human  body  as  inosculations,  aneu- 
risms could  never  be  cured  by  a surgical  operation. 
So  infinitely  numerous,  indeed,  are  these  inosculations, 
that  they  do  the  office  of  the  subclavian,  carotid,  and 
external  and  internal  iliac  arteries,  when  these  vessels 
ate  tied,  and  upon  this  fact  is  founded  the  success  of 
some  of  the  most  brilliant  operations  in  modern  sur- 
gery.— (See  Aneurism.)  Even  the  aorta  itself  may  be 
perfectly  obstructed,  the  ciiculation  go  on,  and  every 
part  be  fully  supplied  with  blood. — (See  Aorta.)  In 
dogs,  the  abdominal  aorta  has  been  tied,  without  riie 
circulation  in  the  hinder  extremities  being  slopped 
(see  the  Experiments  of  Sir  A.  Cooper  in  Med.  Chir. 
Trans,  vol.  2,  p.  258) ; and  the  operation  performed  a 
few  years  ago,  in  Guy’s  Hospital,  tends  to  prove  that 
the  same  thing  is  prrssible  in  the  human  subject. — (See 
Aorta.)  From  the  observations  of  the  same  distin- 
guished surgeon,  it  appears,  that  the  arteries  which 
lorm  the  new  circulation  in  a limb,  after  the  oblitera- 
tion of  the  principal  artery,  are  not  only  enlarged  but 
tortuous.  Any  great  increase,  however,  in  the  diame- 
ter of  the  anastomosing  vessels  is  but  slowly  produced  ; 
for  Sir  A.  Cooper  has  injected  a limb  several  weeks 
after  the  operation  for  popliteal  aneurism,  without  be- 
ing able  to  force  the  injection  through  communicating 
vessels  into  the  parts  below.  The  limb  must  have  ac- 
tive exercise  before  the  vessels  enlarge  much.  On 
account  of  the  arteries  not  very  readily  enlarging, 
the  limbs  of  persons  who  have  undeigone  the  opera- 
tion for  aneurism  are  for  a considerable  lime  w’eaker 
than  natural.  They  feel  the  influence  of  cold  more, 
and  are  more  disposed  to  ulcerate  from  slight  causes. 
Hence,  the  utility  of  covering  them  w’ith  flannel  or 
fleecy  hosiery.  Hence  the  ras'iness  of  applying  cold 
washes,  bandages,  &c. — (See  vol.  cit.  p.  249,  et 
seq.) 

In  another  place,  the  same  gentleman  has  published 
an  interesting  description  of  the  anastomoses  of  the 
arteries  of  the  groin.  “ Hypothesis  (says  he)  would  lead 
to  a belief,  that  anastomosing  vessels  would  be  nume- 
rous in  proportion  to  the  time  which  had  elapsed  from 
the  operation  ; but  the  reverse  of  this  is  the  fact;  for, 
at  first,  many  vessels  convey  the  blood,  originally  con- 
ducted by  the  principal  artery.  But,  gradually,  the 
number  of  these  channels  becomes  diminished,  and, 
after  a length  of  lime,  a few  vessels,  conveniently  situ- 
ated for  the  new  circulation,  become  so  much  enlarged, 
as  to  be  capable  of  conveying  an  equal  portion  of  biood 
to  that  which  passed  through  the  original  trunk.” 

The  experience  of  Sir  Cuoper  also  tends  to  con- 
firm the  important  fact,  that  “it  is  desirable  in  femoral 
aneurism,  if  not,  indeed,  in  all  others,  to  perform  the 
operation  in  an  early  state  of  the  disease,”  as  the  pa- 
tient then  recovers  the  use  of  the  litnb  much  more 
quickly  than  when  the  tumour  has  been  suffered  to 
attain  a large  size. — (See  Med.  Chir.  Trans,  vol.  A,p. 
425,  et.  srq.) 

INTERRUPTED  SUTURE.  See  Sutures. 

INTESTINES  WOUNDED.  See  Wounds  of  the 
Abdomen. 

INTROSUSCEPTION,  or  Intussusception.  Called 
also  Volvulus.  A disease,  produced  by  the  passing 
of  one  portion  of  an  intestine  into  another,  commotily 
the  upper  into  the  lower  part. — (.7.  Hunter.)  On  this 
subject,  Mr.  Langstafl'  has  published  an  interesting  pa- 
per, in  the  FAm.  Surg.  .Journal,  Mo.  XI.  ; which  I 
shall  take  the  liberty  of  freely  quoting.  He  remarks, 
that  the  small  intestines  of  children  are  so  often  af- 
fected with  introsnscepiion,  in  a slight  degree,  that 
most  practitioners  must  have  had  opportunities  of  ob- 
serving the  form  of  the  complaint.  'P he  greatest  jiart  of 
three  hundred  children. who  died  either  of  worms,  or  du- 
ring dentition,  at  the  Hdpital  de  la  Saltpetriere,  and  came 


IN'i’ROSUSCEPTION.  93 


under  the  examination  of  M.  Louis,  had  two,  three, 
four,  and  even  more  volvnli,  witliouiaiiy  inflaminatioii 
of  the  parts,  or  any  circumstances  leading  to  asusiticion 
that  these  atfections  had  t)een  injurious  during  life. 
“These  cases  (says  M.  Louis)  seem  lo  prove  that  in- 
trosusception  may  be  formed  and  di  st'oyed  agaif.  by 
the  mere  action  of  the  intestines.” — de  VAcad. 
de  Chirurg.  4to.  t.  4,  p.  2-22.)  This  opinion  is  con- 
firmed by  the  authority  of  Dr.  Baillie  {Morbid  Ana- 
tomy., 2d  edit.  p.  162),  who  observes  that  “in  opening 
bodies,  particularly  of  infants,  an  intussusception  is  not 
unfrequently  found,  vviiich  had  been  attended  with  no 
mischief;  the  parts  appear  perfectly  free  from  inflam- 
niation,  and  they  would  probably  have  been  easily 
disentangled  from  each  other  by  their  natural  peristaltic 
motion.”  A rare  example  is  on  record,  where  the  dis- 
placement existed  at  birth. — {Beireit,  De  Intcstinis  se 
intus  susciptentibtis,  •frc.  Helmst.  1769.) 

The  disease,  as  Mr.  Langstatf  remarks,  assumes  a 
more  dangerous,  and  indeed,  generally,  a fatal  form, 
when  it-  occurs  at  the  termination  of  the  small  intes- 
tines in  the  coecum.  A contracted  state  of  the  part  to 
be  introsuscepted,  and  a dilatation  of  that  portion  of 
the  canal  into  which  this  part  must  pass,  are  essential 
conditions  to  the  formation  of  a volvulus;  and  they 
exist  nowhere  so  completely  as  in  this  situation.  I'he 
extent  to  which  the  affection  here  proceeds  would  a|i- 
pear  almost  incredible,  if  it  were  not  proved  by  well 
authenticated  facts.  A person  who  considered  the 
natural  siluaiion  and  connexion  of  the  parts,  would 
of  course  require  the  strongest  evidence  before  he 
would  belfeve  that  the  ileum,  coecum,  ascending  and 
transverse  portions  of  the  colon,  may  descend  into  the 
sigmoid  fiexnreof  the  latter  intestine ; nay,  more,  that 
they  may  pass  through  the  rectuiti,  and  be  protruded 
in  the  form  of  a procidentia  ani.  Such  cases,  however, 
are  rectnded. — (See  Lellsom's  Case  in  Phil.  Trans, 
vol.  76,  and  Langstaff^  in  Edin.  Med.  and  Surg.  Jour- 
nal. Mo.  XL) 

This  gentleman  next  relates  the  case  of  a child  three 
months  old,  the  body  of  which  he  inspected  after 
death,  and  fbund  to  confirm  the  truth  of  the  preceding 
account.  The  example  was  particular  in  there  being, 
in  addition  to  ati  extensive  introstisception  in  theustial 
way,  a smaller  invagination  in  the  opposite  direction, 
like  what  probably  occurred  in  the  case  related  by  Mr. 
Spry'. — {Med.  and  Physical  Journal,  Mo.  XL)  Sir  E. 
Home  mentions  a retrograde  introsusception,  in  which 
a worm  was  found  coiled  up  rotind  the  introsuscepted 
part.  The  disease  look  place  in  a boy  who  had  swal- 
lowed arsenic. — (See  Trans,  for  the  Lmprovement  of 
Med.  and  Chir.  Knowledge,  vol  1 ) 

If  the  following  mode  of  accounting  for  introsuscep- 
tion be  just,  it  will  most  frequently  happen  down- 
wards, although  there  is  no  reason  why  it  may  not 
*ake  plate  in  a contrary  direction  ; in  which  case,  the 
chance  of  a cure  will  be  increased  by  the  nattiral  ac- 
ti  uis  of  the  intestinal  canal  tending  to  replace  the 
intestine  ; and  probably  from  this  circumstance  it  may 
of'ener  orctir  than  comtnoply  appears. 

When  the  intrasusception  is  downwards,  it  may  be 
called  p"  ogressive,  and  when  it  liappens  ufiwards,  re- 
trograde. n’hc  manner  in  which  it  may  take  place  is, 
by  one  portion  of  a loose  intr-stine  being  contracted, 
and  the  part  immediately  below  relaxed  and  dilated  ; 
under  which  circumstances,  it  might  very  readily  hap- 
pen by  the  contracted  portion  slipping  a little  way  into 
that  which  is  dilated,  not  from  any  action  in  either 
portion  of  intestine,  but  from  .some  additional  weight 
in  the  cut  above.  How  far  the  peristaltic  motion,  by 
pushinc  the  contents  on  lo  the  contracted  parts,  might 
force  these  into  the  relaxed,  Mr.  Hunter  could  not  de- 
termine, hut  he  was  inclined  to  suppose  that  it  did  not 
have  this  effect. 

By  this  mode  of  accounting  for  an  accidental  intro- 
susception,  it  may  take  place  either  upwards  or  down- 
wards ; but  if  a continuance  or  an  increase  of  it  arises 
from  the  action  of  the  intestines,  it  must  be  when  it  is 
d'  wnwards,  as  we  actually  find  to  be  the  case;  yet 
this  doe.s  not  explain  those  in  which  a considerable 
portion  of  intestine  appears  to  have  been  cturied  into 
the  cm  below ; to  understantl  these,  vve  must  consider 
the  different  parts  which  form  the  introsusception  It 
is  maile  up  of  three  folds  of  intestine;  the  inner,  which 
jin«sesdown,  and,  b"ing  reflected  upwards,  forms  the 
second  or  inverted  position,  which,  being  reflected 
down  again,  makes  the  third  or  containing  part,  that  I 


is,  the  outermost,  which  is  always  in  the  natural  posi- 
tion.— {J.  Hunter.) 

The  outward  fold  is  tlie  only  one  which  is  active, 
the  inverted  portion  being  perfectly  passive,  and 
squeezed  down  by  the  other,  which  inverts  more  of  it- 
self, so  that  the  angle  of  inversion  in  this  case  is  al- 
ways at  the  angle  of  reflection  of  the  outer  into  the 
middle  portion  or  inverted  one,  while  the  innermost  is 
drawn  in.  From  this  we  can  readily  see  how  an  in 
trosusception,  once  begun,  may  have  any  length  of  gu* 
drawn  into  it. 

'J’he  external  portion,  acting  upon  the  other  folds  in 
the  same  way  as  upon  any  extraneous  matter,  will  by 
its  peristaltic  motion  urce  them  farther;  and,  if  any 
extraneous  substance  is  detained  in  the  cavity  of  the 
inner  portion,  that  part  will  become  a fixed  point  for 
the  outer  or  containing  intestine  to  act  upon.  Thus  it 
will  be  squeezed  on,  till  at  last  the  mesentery  prevent- 
ing more  of  the  innermost  part  from  being  drawn  in, 
will  act  as  a kind  of  stay,  yet  without  entirely  hinder- 
ing the  inverted  outer  Ibid  from  g<iing  still  farther.  For 
it  being  the  middle  fold  that  is  acted  upon  by  theouter, 
and  this  action  continuing  after  the  inner  portion  l>e- 
comes  fixed,  the  gut  is  thrown  into  folds  upon  itself; 
so  that  a foot  in  length  of  intestine  shall  form  an  intro- 
susceplion  not  more  than  three  inches  long. 

The  outer  portion  of  intestine  is  alone  activein  aug- 
menting the  disease  when  once  begun  ; but  if  the  innei 
one  were  capable  of  equal  action  in  its  natuial  di- 
rection, the  etfecl  would  be  the  same,  that  of  endea- 
vouring to  invert  itself,  as  in  a prolapsus  ani ; the  outer 
and  inner  portions,  by  their  action,  would  tend  to 
draw  in  more  of  the  gut,  while  the  intermediate  part 
only  would,  by  its  action,  have  a contrary  tendency. 

The  action  of  the  abdominal  muscles  cannot  assist 
in  either  forming  or  continuing  this  disease,  as  it  must 
compre.ss  equally  both  above  and  below,  although  it  is 
capable  of  producing  the  prolapsus  ani. 

When  an  introsusception  begins  at  the  valve  of  the 
colon,  and  inverts  that  intestine,  w'e  find  the  ileum  is 
not  at  all  affected;  which  proves  that  the  mesentery, 
by  acting  as  a stay,  prevents  its  inversion. — {J.  Hun 
ter.) 

From  the  natural  attachment  of  the  mesentery  to  the 
intestines,  one  would,  at  the  first  view  of  the  subject, 
conceive  it  impossible  for  any  one  portion  of  gut  to  get 
far  within  another  ; as  the  greater  extent  of  mesentery 
that  is  carried  m along  with  it,  would  render  its  farther 
entrance  more  and  more  difficult,  and  we  should  ex- 
pect this  difficulty  to  be  greater  in  the  large  intestines 
than  in  the  small,  as  being  more  closely  confined  to 
their  situation  ; yet  one  of  the  largest  introsusceplions 
of  any  known  was  in  the  colon,  as  related  by  Mr. 
Whately.— (FrWe  Phil.  Trans,  vol.  76,  p.  305.) 

The  introsusception  appeared  to  have  begun  at  the 
insertion  of  the  ileum  into  the  colon,  and  to  have  car- 
ried in  the  coecum  with  its  appendix.  The  ileum 
passed  on  into  thecolon,  till  fhe  whole  of  the  ascending 
colon,  the  transverse  arch,  and  descending  colon  were 
carried  into  the  sigmoid  flexure  and  rectum.  7’he 
vlave  of  the  colon  being  the  leading  pait,  it  at  last  got 
as  low  as  the  anus  ; and  when  the  person  went  to" 
stool  he  only  emptied  the  ileum;  for  one-half  of  tlie 
large  intestines  being  filled  up  by  the  other,  the  ileum 
alone,  which  passed  through  the  centre,  discharged  its 
contents. — (.7.  Hunter.) 

'J’wo  questions  of  considerable  importance  present 
themselves  to  the  mind  in  considerinir  this  subject; 
whether  there  are  any  symptoms,  by  which  the  exist- 
ence of  the  affection  can  be  ascertained  during  liieT 
and  whether  we  possess  any  means  of  relieving  it, 
supposing  that  its  existence  could  he  discovered  ? The 
symptoms  attending  an  introsusception,  are  crrmmorr 
to  inflammation  of  the  intestines,  hernia,  and  ob 
struction  of  the  canal,  from  whatever  cause,  and  a 
volvulus  is  the  least  frequent  cause  of  such  symptoms. 
In  the  case  published  by  the  above  gentleman,  and  in 
those  related  by  Mr.  Hunter  and  Mr.  Spry,  the  seat  of 
the  disease  was  clearly  denoted  by  a hard  tumour  on 
the  left  side  of  the  abdomen.  This  circumstance,  to- 
gether with  the  impossibility  of  throw'ing  up  more 
than  a very  small  quatitity  of  fluid  in  clysters  (Hevin, 
Spry,  Ijang.'^toff),  and  the  presence  of  the  other  symp- 
toms, would  lead  us  to  suspect  the  nature  of  the  disor- 
der. If  the  invaginated  portion  desceiuled  so  low  as 
to  protrude  through  the  anus,  and  w'c  could  ascertain 
I that  it  was  not  an  inversion  of  the  gut,  the  case  might 


94 


INT 


be  considered  as  clear,  and  we  should  have  no  hesita- 
tion in  delivering  a prognosis,  which,  by  preparing  the 
friends  for  the  fatal  termination,  would  exonerate  us 
from  all  blame  on  its  occunence. — {Langstaff.) 

Mr.  Bullin,  of  Fleet-market,  lately  attended  a man 
Who  died  of  an  introsusception  of  the  ileum  and  coe- 
cum  into  the  colon,  in  which  latter  bowel  there  was  a 
very  close  stricture  by  which  the  farther  descent  of  the 
other  intestines  had  been  impeded.  The  cliief  symp- 
toms were  suppression  of  stools  and  violent  pain  in  the 
abdomen,  quite  unattended  with  vomiting,  and  at  first 
without  any  remarkable  change  in  tlie  pulse.  The 
preparation  which  is  in  Mr.  Bullin’s  possession,  is  in- 
teresting. It  is  to  be  presumed  that,  in  this  example, 
the  disease  and  stricture  of  the  colon  had  been  the  ori- 
ginal complaint. 

In  the  treatment  of  this  disease,  bleeding,  to  les- 
sen the  infiammation  that  might  be  brought  on,  and 
quicksilver,  to  remove  the  cause,  have  been  recom- 
mended. 

Quicksilver  woitld  have  little  effect  either  in  one 
way  or  the  other,  if  the  introsusception  were  down- 
wards; for  it  is  to  be  supposed  that  it  would  easily 
make  its  way  through  the  innermost  contained  gut, 
and  if  it  should  be  stopped  in  its  passage,  it  would,  by 
increasing  its  size,  become  a cause  (as  before  observed) 
of  assistitig  the  disease.  In  cases  of  the  retrograde 
kind,  quicksilver,  assisted  by  the  peristaltic  motion, 
might  be  expected  to  press  the  introsusception  back  ; 
but  even  under  such  circumstances  it  might  get  be- 
tween the  containing  and  inverted  gut  into  the  angle 
of  reflection,  and,  by  pushing  it  farther  on,  increase 
the  disease  it  is  intended  to  cure. — {J-  Hunter.) 

Every  thing  that  can  increase  the  action  of  the  intes- 
tine downwards,  is  to  be  particularly  avoided,  as  tend- 
ing to  increase  the  peristaltic  motion  of  the  outer  cor)- 
taining  gut,  and  thus  to  continue  the  disease.  Medi- 
cines can  never  come  into  contact  with  the  outer  fold, 
and,  having  passed  the  inner,  can  only  act  on  the 
outer  farther  down,  and  therefore  cannot  immediately 
affect  that  portion  of  the  outer  which  contains  the  in- 
trosusception ; but  we  must  suppose  that  whatever 
affects  or  comes  into  contact  with  the  larger  portion  of 
the  canal,  so  as  to  throw  it  into  action,  will  also  affect 
by  sympathy  any  part  that  may  escape  such  applica- 
tion. Mr.  Hunter  therefore  recommends  emetic?,  with 
the  view  of  inverting  the  peristaltic  motion  of  the  con- 
taining gut,  which  will  have  a tendency  to  bring  the 
intestines  into  their  natural  situation. 

If  this  practice  should  not  succeed,  it  might  be  pro- 
per to  consider  it  as  a retrograde  introsusception,  and 
by  administering  purges,  endeavour  to  increase  the  pe- 
ristaltic motion  downwards. — (J.  Hunter.) 

I cannot  agree  with  Mr.  Langstaff,  that  it  is  to  be 
regretted  Hunter’s  name  should  be  affixed  to  the  fore 
going  proposal,  or  that  it  is  an  absurd  one;  for  purga- 
tives and  emetics  were  only  recoinurended  to  increase 
the  peristaltic  action,  the  former  downwards,  the  latter 
upwards,  according  as  the  supposed  nature  of  the  case 
might  require,  and  this  effect  they  certainly  would 
have,  notwithstanding  vomiting  is  an  early  and  con- 
stant symptom  of  the  disease,  and  an  itisuperable  con- 
stipation an  equally  invariable  attendant.  The  me- 
thod, I allow,  however,  is  not  very  hopeful,  and  may 
sometimes  be  frustrated  by  the  formation  of  adhesions. 
According  to  Mr.  Langstaff,  the  Recherches  Histori- 
ques  sur  la  Gaslrotomie  dans  le  Cas  de  Volvulus,  par 
JH.  Hevin,  contain  many  interesting  facts,  and  a great 
doal  of  sound  reasoning.  There  we  find  a very  ample 
discussion  of  the  question  concerning  the  propriety  of 
opening  the  abdomen,  in  order  to  disentangle  the  intro- 
suscepted  intestine;  a proposal  which  M.  Hevin  very 
properly  condemns. 

If  the  equivocal  and  uncertain  nature  of  the  symp- 
toms of  volvulus  were  not  sufficient  to  deter  us  from 
undertaking  an  operation,  which,  under  the  most  fa- 
vourable circumstances,  could  not  fail  to  be  extremely 
difficult,  and  imminently  hazardous  to  the  patient,  the 
slate  of  the  invaginated  parts  would  entirely  banish  all 
thoughts  of  such  an  imprudent  attempt  ; fur  the  dif- 
ferent folds  of  the  intestine  often  become  agglutinated 
to  each  other,  so  that  they  can  hardly  be  withdrawn 
after  death  {Simpson,  Edinh.  Med.  E.ssays,  vol.  6, 
Hevin' s Ath  Obs. ; Malcolm,  Physical  and  lAt.  Essays, 
vol.  2,  p.  360 ; Hunter,  Me.d.  and  Chir.  Trans. ; and 
Soemmering  in  Transl.  of  Baillie’s  Morb.  Anat) ; nay, 
the  stricture  on  the  introsuscepled  part  may  cause  it  to 


lOD 

inflame,  and  even  mortify. — (Soemmering.)  It  is  very 
clear,  that  in  this  state  of  parts,  the  operation  of 
gastrotomy  would  be  totally  inadmissible,  even  if  the 
symptoms  could  clearly  indicate  the  nature  of  the 
case,  and  the  affected  part  could  be  easily  reached  and 
examined. 

The  forcible  injection  of  glyslers  was  found  useless 
by  Dr.  Monro,  and  the  agglutination  of  the  parts  ntust 
produce  an  insuperable  obstacle  to  the  bowels  being 
pushed  back  by  this  means.  Some  have  proposed  the 
employnrent  of  along  bougie,  or  a piece  of  whalebone, 
to  push  back  the  intestine ; and  this  pn)|)Osal  may  be 
adopted  when  we  are  furnished  with  an  instrument 
adapted  to  follow  tlie  windings  of  the  large  intestine  tu 
its  origin  in  the  right  ileum,  without  any  risk  of  perfo- 
rating the  gut  in  its  course. — (Langstaff.) 

It  must  be  confessed,  that  both  surgery  and  medicine 
are  almost  totally  unavailing  in  the  present  disease. 
Yet  here,  as  in  many  other  instances,  the  resources  of 
nature  are  exhibited  in  a most  wonderful  and  astonish- 
ing manner,  wlnle  those  of  art  completely  fail.  The 
invaginated  portion  of  intestine  sometimes  sloughs, 
and  is  discharged  per  anum,  while  the  agglutination 
of  the  prnrts  preserves  the  continuity  of  the  intestinal 
canal.  The  annals  of  medicine  furnish  numerous  in- 
stances, in  which  long  pieces  of  gut  have  been  dis- 
charged in  this  manner,  and  the  patient  has  recovered. 
Hence,  some  hope  may  be  allowed  under  the  most  un- 
promising circumstances.  In  a case  related  in  Dun- 
can’s Commentaries,  eighteen  inches  of  small  intestine 
were  voided  per  anum  ; vol.  9,  p.  278.  Three  similar 
insttwices  occur  in  M.  Hevin’s  Memoir  ; twenty-three 
inches  of  colon  came  away  in  one  of  these,  and  tweir- 
ty-eight  of  small  intestines  in  another.  Other  cases 
occur  in  the  Physical  and  Literary  Essays,  vol.  2,  j). 
361 : in  Duncan’s  Annals,  vol.  6,  p.  298;  in  the  Me(L 
Chir.  Trans,  vol.  2,  where  Dr.  Baillie  states  that  a 
yard  of  intestine  was  voided.  The  patients  did  not,^ 
however,  ultimately  survive  in  every  one  of  these  in- 
stances.— (Langstaff,  in  Edinb.  Med.  and  Surgical 
Journal.)  A very  interesting  case,  in  which  a reco- 
very w as  effected  on  this  principle,  and  in  which  from 
15  to  18  inches  of  the  ileum  were  discharged  from  the 
anus,  was  recorded  by  Mr.  Bush  last  year  (1823),  iu 
the  Med.  and  Phys.  Journ. 

Langenbeck  has  recorded  an  instance,  in  which  a 
prolapsus  of  the  large  intestines  protruded  half  an  ell 
out  of  the  anus.  The  disease  had  lasted  thirty  weeks. 
Langenbeck  made  an  incision  intu,  or  rather  through,- 
the  protruded  inverted  bowel,  immediately  below  the 
sphincter  ani.  He  first  divided  the  inner  vascular 
coat,  then  the  muscular,  and  lastly  the  outer  coat,  witlr 
great  caution.  He  now  discovered,  within  the  pro- 
truded inverted  bowel  which  he  had  ottened,  another 
part  of  the  intestinal  canal,  which  was  nru  yet  in- 
verted. He  remarked  upon  it  the  appendices  epiploic.'e, 
and  the  white  shining  peritomeal  coat.  This  last  por- 
tion would  also  have  become  inverted,  had  the  disease 
continued.  He  next  reduced  the  latter  uninverted 
part,  and  afterward  succeeded  in  replacing  the  rest  of 
the  protrusion  : which  did  not  Call  down  again  when 
the  boy  had  stools.  No  bad  symptoms  immediately 
followed  ; but  the  lad  being  very  weak,  survived  only 
eight  days.— (See  Bibl.fiirdie  Chir.  b.  2,p.  756.  6r6tL 
1811.) 

Hivin  in  Mim.  de  VAcad.  de  Chir.  vol.  4,  4to.  Hun- 
ter in  Trans,  for  the  Improvement  of  Medical  and 
Chir.  Knowledge,  vol.  1,  p.  103,  et  seq.  L' Encyclopi-  . 
die  MMiodique,  partie  Chir.  art.  Gastrotomie.  A.  Vo- 
ter, De  Invagivatione  Intestmorum.  (Haller,  Diap. 
Anat.  1,  481.)  C.  H.  Velse,  De  Mutuo  Intestinoruin 
Ingressu,  <S-c.  Lugd.  1742.  (Haller,  Disp.  Anat.  7, 
97.)  J.  C.  Lettsom,  The  History  of  an  Extraordinary 
In! ussusception,  with  an  account  of  the  dissection  by 
Mr.  T.  fVhately,  Ato.  Lond.  1786.  Baillie's  Ser  ies  of 
Engravings,  p.  4,  pi.  6.  Langstaff,  in  the  Edinb.  Med. 
and  Sursical  .Journal,  JVo.  XI. 

INVERSION  OF  THE  UTERUS.— (See  Uterus, 
Inversion  of.) 

IODINE.  The  following  are  the  formulce  recom- 
mended by  Brera  : — 1.  Tincture  of  iodine  made  by 
dissolving  48  grains  of  pure  iodine  in  an  ounce  of  al- 
cohol. The  dose  for  adults  is  from  5 to  20  drops  three 
times  a day.  The  tincture  is  subject  to  decomposition,, 
and  should  therefore  be  used  fresh.  Dr.  Manson's 
tincture  contains  one  drachm  of  iodine  in  5 >is8.  of 
rectified  spirit.  Of  this  he  commonly  prescribes  30 


mi 


mi 


95 


minimus  thrice  a day.  Mr.  Buchanan  puts  3j.  of 
iodine  to  5 iij*  of  rectified  spirit,  and  prefers  the  exter- 
nal to  the  internal  use  of  the  medicine,  as  more  effica- 
cious and  less  likely  to  create  nausea  and  other  un- 
pleasant symptoms.  He  has  often  observed,  that  when 
desquamation  of  the  cuticle,  and  great  itching  fol- 
lowed the  external  application  of  the  tincture,  the 
parts  received  more  benefit  than  when  the  cuticle  re- 
tained its  natural  appearance. — (Ore  Diseased  Joints, 
p.  86.)  2.  Piils  of  iodine,  made  by  forming  one  grqin 
of  iodine  into  two  pills,  with  elder-rob  and  liquorice 
root ; one  to  be  taken  every  morning  and  evening.  3. 
Iodine  ointment,  made  by  mixing  a drachm  of  pure 
iodine  with  an  ounce  of  lard,  or  half  a drachm  of  hy- 
driodate  of  potass  with  an  ounce  and  a half  of  lard  ; 
of  the  former  about  a scruple,  of  the  latter  a bit  about 
as  large  as  a filbert,  may  be  rubbed  on  the  part  to 
which  it  is  intended  to  be  ajiplied  Dr.  Manson’s  oint- 
ment has  3 ss.  of  the  hydriodate  to  an  ounce  of  lard. 
4.  Solution  of  hydriodate  of  potass,  formed  by  dis- 
solving .36  grs.  of  the  hydriodate  in  an  ounce  of  distilled 
water  : it  is  given  in  the  same  dose  as  the  tincture.  5. 
Solution  of  the  ioduretted  hydriodate  of  potass,  made 
by  dissolving  36  grs.  of  the  hydriodate  and  10  grs.  of 
pure  iodine  in  10  drachms  of  water.  The  dose,  in  the 
beginning  of  its  use,  should  not  be  more  than  5 or  6 
drops  three  times  a d.iy. 

From  Dr.  Keller’s  statement,  in  the  Revue  M^d.  for 
June,  1823,  it  appears,  that  the  ointment  is  made 
stronger  in  France  than  that  mentioned  by  Brera,  two 
drachms  of  the  hydriodate  being  mixed  with  an  ounce 
of  fat. 

In  administering  iodine,  care  must  be  taken  not  to 
combine  it  with  substances  calculated  to  decompose  it, 
and  only  to  let  the  patient  take  it  when  the  stomach  is 
etnpry.  The  liquid  preparations  are  generally  given 
by  Dr.  Coindet  in  syrup  and  water.  When  ill  effects 
arise  from  its  too  violent  operation,  such  as  pains  in  the 
stomach,  chest,  bowels,  defective  vision,  loss  of  sleep, 
palpitations,  tremours,  convulsions,  &c.,  or  even  in- 
conveniences of  a less  dangerous  kind,  the  medicine 
should  be  immediately  discontinued.  A strict  regimen, 
copious  mucilaginous  drinks,  the  tepid  bath,  and  some- 
times bleeding,  are  necessary.  It  is  hardly  necessary 
to  observe,  that  the  use  of  iodine  requires  a great  deal 
of  caution,  as  several  cases  have  happened  in  which 
the  patients  were  poisoned  with  it. — (See  Ed.  Med. 
Journ.  vol.  23,  p.  225,  drc.)  When  the  bronchocele, 
or  other  tumour,  is  also  in  too  great  a state  of  irrita- 
tion from  the  medicine,  fomentations,  poultices,  and 
leeches  are  indicated. 

Iodine  has  obtained  considerable  reputation  for  its 
efficacy  in  bronchocele,  scrofula,  various  chronic  tu- 
mours, diseased  joints,  enlargements  of  the  breast, 
bursse  mucosae,  testicle,  &c. — (See  Brera's  Saggio 
Clinico  sull'  lodio,  e suite  differenti  sue  comhinazioni, 
Padua,  1822 ; J.  R.  Coindet,  on  the  Effects  of  Iodine, 
in  Bronchocele  and  Scrofula;  a I'ranslation  of  his 
three  Memoirs,  by  Dr.  ./.  R.  Johnson,  Lond.  1821. 
Magendie’s  Formulary,  ed.  2,  Lond.  1824.  Medical 
Researches  on  the  Effects  of  Iodine  in  Bronchocele, 
Paralysis,  Chorea,  Scrofula,  Fistula  Ijachrymalis, 
Deafness,  Dysphagia,  White  Swelling,  and  Distor- 
tions of  the  Spine,  by  Jilex.  Mnnson,  8vo,  Lond.  1825. 
An  Essay  on  a Mew  Mode  of  Treatment  for  Diseased 
Joints,  ire.  by  Thomas  Buchanan,  Svo,  Lond.  1828.) 

IRIS,  PROLAPSUS  OF.  A small  tumour,  formed 
by  the  protrusion  of  a portion  of  the  iris  through  an 
opening  in  the  cornea.  It  is  sometimes  named  sta- 
phyloma of  the  iris. 

The  causes  of  this  complaint  are  such  wounds  and 
ulcers  of  the  cornea  as  make  an  opening  of  a certain 
extent  into  the  anterior  chamber  of  the  aqueous  hu- 
mour, and  such  violent  contusions  of  the  eyeball  as 
occasion  a rupture  of  the  cornea.  If  the  edges  of  a 
wound  in  this  situation,  whether  accidental,  made  for 
the  purpose  of  extracting  the  cataract,  or  evacuating 
the  matter  of  hypopyum,  be  not  brought  immediately 
afterward  into  reciprocal  contact,  or  continue  not 
sufficiently  agglutinated  toL'ether  to  prevent  the  esc.ape 
of  the  aqueous  humour  from  the  anterior  chamber, 
regularly  as  this  fluid  is  reproduced;  the  iris, drawn  by 
its  continual  flux  towards  the  cornea,  glides  between 
the  lips  of  the  wound,  becomes  eloncated,  and  a por- 
tirm  of  it  gradually  protrudes  beyond  the  cornea,  in  the 
form  of  a small  tumour.  The  same  thing  takes  place 
whenever  the  eyeball  unfortunately  receives  a blow. 


I or  is  too  muCll  compressed  by  bandages,  during  the  ex- 
istence of  a recent  wound  of  the  cornea.  Also,  if  the 
patient  should  be  affected,  in  this  circumstance,  with 
a spasm  of  the  muscles  of  the  eye,  with  violent  and 
repeated  vomiting,  or  with  strong  and  frequent  cough- 
ing, a prolapsus  of  the  iris- may  be  caused.  When  an 
ulcer  of  the  cornea  penetiates  the  anterior  chamber, 
tile  same  inconvenience  happens  more  frequently  than 
when  there  is  a recent  wound  of  that  membrane;  for 
the  solution  of  continuity  in  the  cornea,  arising  from 
an  ulcer,  is  attended  with  loss  of  substance,  and,  in  a 
membrane  so  tense  and  compact  as  this  is,  the  edges  of 
an  ulcer  do  not  admit  of  being  brought  into  mutual 
contact. 

In  purulent  and  scrofulous  ophthalmy,  where  a mi- 
nute ulceration  of  the  cornea  often  occurs,  the  exten- 
sive implication  of  the  iris,  and  consequent  strabismus, 
Mr.  R.  Welbank  conceives,  might  be  prevented  by  the 
early  application  of  belladonna;  and  “ perhaps  (he 
adds),  where  the  ulceration  is  remote  from  the  circum 
ference  of  the  cornea,  and  very  small,  the  iris  may  be 
kept  wholly  disengaged,  till  processes  of  reparation 
prevent  the  risk  of  protrusion.” — {Mote  in  Prick's 
Treatise  on  Diseases  of  the  Eye,  ed.  2,  p.  6.  11.) 

The  little  tumour  is  of  the  same  colour  as  the  iris, 
viz.  brown  or  grayish,  being  surrounded  at  its  base  by 
an  opaque  circle  of  the  cornea,  on  which  membrane 
there  is  an  ulcer,  or  a wound  of  not  a very  recent  de- 
scription. 

As  it  usually  happens  that  the  cornea  is  only  pene- 
trated at  one  part  of  its  circumference  by  a wound  or 
ulcer,  only  one  prolapsus  of  the  iris  is  commonly  met 
with  in  the  same  eye.  But  if  the  cornea  should  hap- 
pen to  be  wounded  or  ulcerated  at  several  distinct 
points,  the  iris  may  protrude  at  several  different  places 
of  the  same  eye,  forming  an  equal  number  of  small 
projecting  tumours  on  the  surface  of  the  cornea. 
Scarpa  has  seen  a patient  who  had  three  very  distinct 
protrusions  of  the  iris  on  the  same  cornea,  in  conse 
quence  of  three  separate  ulcers  penetrating  the  anterior 
chamber,  one  in  the  upper  and  two  in  the  lower  seg 
ment  of  the  cornea. 

If,  says  Scarpa,  the  delicate  structure  of  the  iris,  the 
great  quantity  of  blood-vessels  which  enter  it,  and  the 
numerous  nervous  filaments  which  proceed  to  be  dis- 
tributed to  it  as  a common  centre,  be  considered,  the 
nature  and  severity  of  those  symptoms  may  be  readily 
accounted  for,  which  are  wont  to  attend  this  disease, 
however  small  the  portion  of  the  iris  projecting  from 
the  cornea  may  be,  even  if  no  larger  than  a fly’s  head. 
The  hard  and  continual  frictions  to  which  this  delicate 
membrane  is  then  exposed,  in  consequence  of  the  mo- 
tions of  the  eyelids,  together  with  the  access  of  air, 
tears,  and  gum  to  it,  are  causes  quite  adequate  to  the 
production  of  continual  irritation  ; and  the  blood  which 
tends  to  the  point  of  the  greatest  irritation,  cannot  fail 
to  render  the  projecting  portion  of  the  iris  much  larger, 
almost  directly  after  its  protrusion,  than  it  was  at  the 
moment  of  its  first  passing  through  the  cornea.  Hence, 
it  soon  becomes  more  incarcerated  and  irritated.  In 
the  incipient  state  of  the  disease,  the  patient  complains 
of  a pain  similar  to  what  would  arise  from  a pin  pe- 
netrating the  eye;  next  he  begins  to  experience,  at  the 
same  time,  an  oppressive  sensation  of  tightness  nr 
constriction  over  the  whole  eyeball.  Inflammation  of 
the  conjunctiva  and  eyelids,  a burning  effusion  of  tears, 
and  an  absolute  inability  to  endure  the  light,  succes- 
sively take  place.  As  the  protruded  portion  of  the  iris 
drags  after  it  all  the  rest  of  this  membrane,  the  pupil 
assumes  of  mechanical  necessity  an  oval  shape,  and 
deviates  from  the  centre  of  the  iris  towards  the  seat 
of  the  prolapsus.  The  intensity  of  the  pain,  produced 
by  the  inflammation,  and  other  symptoms,  do  net,  how- 
ever, always  continue  to  increase. 

Indeed,  old  protrusions  of  the  iris  are  often  noticed, 
where,  after  the  disease  has  been  left  to  itself,  the  paiti 
and  inflammation  spontaneously  subside,  and  the  tu- 
mour becomes  nearly  insensible. 

In  the  early  stage,  some  direct  the  iris  to  be  replaced 
by  means  of  a whalebone  probe;  and,  in  case  of  dif 
ficulty,  a dilatation  of  the  wound  or  ulcer  of  the  cor- 
nea to  be  made  proportioned  to  the  exigency  of  the 
case,  as  is  done  for  the  return  of  a strangulated  intes- 
tinal hernia.  Others  only  recommend  stimulating  the 
prolapsed  portion  of  the  iris,  with  the  view  of  making 
it  contract  and  shrink  into  the  eye;  or  suddenly  ex- 
posing the  eye  affected  to  a very  vivid  light,  in  the 


96 


mis. 


belief  that,  as  the  pupil  then  forcibly  contracts,  the 
piece  of  tiie  iris,  engaged  between  the  lips  of  the 
wound,  or  ulcer  of  ibe  cornea,  will  rise  to  its  proper 
place.  However,  Scarpa  represents  all  such  methods 
as  absolutely  useless,  and  even  dangerous.  Supposing 
it  were  possible,  by  such  attempts,  to  reduce  the  iris  to 
its  proper  situation  without  tearing  or  injuring  it,  still 
the  aqueous  humour  would  escape  again  through  the 
wrturid  or  ulcer  of  the  cornea,  so  that  the  iris,  when 
replaced,  would  fall  down  the  moment  afterward,  and 
project  from  the  cornea  in  the  same  way  as  before  the 
operation.  Hence,  though  Scarpa  admits  that  tlie  pro- 
lapsus of  the  iris  is  a serious  accident,  he  argues,  that 
as  surgery  has  no  means  of  suppressing  at  once,  or  at 
least  of  suspending,  the  escape  of  the  aqueous  humour 
through  a wound,  much  less  through  an  ulcer  of  the 
cornea,  when  either  exceeds  certain  limits,  the  pro- 
la[isus  of  the  iris,  far  from  being  an  evil  in  such  unfa- 
vourable circujiistances,  is  rather  useful,  and,  perhaps, 
the  only  means  of  preventing  the  total  loss  of  the  organ 
of  sight;  for  the  flap  of  the  iris  insinuates  itself,  like  a 
plug,  between  the  edges  of  the  wound  or  ulcer  of  the 
cornea,  and  thus  completely  prevents  the  exit  of  the 
aqueous  humour. 

Here  I ought  to  observe,  that  Scarpa’s  unlimited 
condemnation  of  the  plan  of  ever  attempting  to  replace 
the  iris  is  contrary  to  the  advice  delivered  by  Beer,  as 
may  be  seen  by  referring  to  the  article  Cataract,  where 
the  treatment  of  the  protrusion  of  tlie  iris  after  the 
operation  of  extraction  is  noticed.  And  even  with 
respect  to  the  prolapsus  of  the  iris  from  ulceration 
making  its  way  through  the  cornea.  Beer  distinctly 
states,  that  a recent  prolapsus  of  this  kind,  formed  in 
the  second  still  existing  stage  of  ophthalmy,  may  not 
only  be  lessened  by  proper  treatment,  calculated  to 
produce  a quick  cicatrization  of  the  ulcer,  but  the  iris 
may  be  again  cmnpletely  removed  from  the  cornea, 
without  any  adhesion  to  the  edge  of  the  ulcer  taking 
place. — {B.2,  p.63.)  But  where  the  prolajisns  of  the 
iris  remains,  as  a consequence  of  previous  inflamma- 
tion of  the  eye.  Beer  confesses,  that  it  cannot  be  cured 
without  a partial  adhesion  of  the  iris  to  the  cornea 
being  left,  and  a dense  scar  on  the  latter  membrane  in 
the  situation  of  the  protruded  iris. — (yol.  cit.  p.66.) 

In  conformity  to  Scarpa’s  principles,  there  are  two 
principal  indications  in  the  treatment  of  the  recent 
prolapsus  of  the  iris  The  first  is,  to  diminish,  as 
speedily  as  possible,  the  exquisite  sensibility  in  the  pro- 
truded part  of  the  iris ; the  other  is  gradually  to  destroy 
the  projecting  portion  of  this  membrane,  to  such  a 
depth  as  shall  be  suflicient  to  prf;vent  the  little  tumour 
fiom  keeping  the  edges  of  the  wound  or  ulcer  of  the 
cornea  asunder,  and  retarding  cicatrization.  'J’he  ad- 
hesion, however,  which  connects  the  iris  with  the 
inside  of  the  cornea,  must  not  be  destroyed. 

For  fulfilling  these  indications,  touching  the  portion 
of  the  iris  projecting  from  the  cornea  with  the  oxygen- 
ated muriate  of  antimony,  or  with  what  is  more  ex- 
peditious and  convenient,  the  argentum  nitratum,  is 
recommended,  so  as  to  form  an  eschar  of  sufficient 
ilepth.  And  in  order  that  this  operation  may  be  et- 
fected  with  quickness  and  precision,  it  is  necessary 
that  an  assistant,  standing  behind  the  patient’s  head, 
should  support  the  upper  eyelid  with  Peiiier’s  elevator; 
and  that  the  patient  should  keep  his  eye  steadily  fixed 
on  one  objec.t. 

While  the  assistant  gently  raises  the  upper  eyelid, 
the  surgeon  must  depress  the  lower  one  with  the  index 
and  middle  fingers  of  his  left  hand ; and,  with  the 
right,  he  is  to  be  ready  to  touch  the  little  prominence 
formed  by  Ihe  iris  with  the  argentum  nitraium,  scraped 
to  a point  like  a pencil.  This  is  to  be  applied  to  the 
centre  of  the  little  tumour,  until  an  e.schar  of  suf- 
ficient depth  is  formed.  The  pain  which  the  patient 
experiences  at  this  moment  is  very  acute;  but  it  sub- 
sides as  soon  as  the  eye  is  bathed  with  warm  milk. 
The  caustic,  in  destroying  the  projecting  portion  of  the 
Iris,  de.stroys  the  principal  organ  of  sensibility,  by 
covering  it  with  an  eschar  of  sufficient  depth  to  protect 
the  part  affected  from  the  effect  of  the  friction  of  the 
eyelids,  and  from  coming  into  contact  with  the  air  and 
tears.  This  is  the  reason,  not  only  why  the  sense  of 
pricking  and  constiiction  in  the  eye  abates  after  the 
a[)plication  of  the  caustic,  but  also  why  the  inflamma- 
tion of  the  conjunctiva  undergrnrs  a considerable  di- 
minution •<>  well  as  the  burning  and  copious  effusion 
of  tea 


As  in  the  case  of  ulcer  of  the  cornea,  these  udvan 
tages  only  last  while  the  eschar  remains  adherent  to  the 
little  tumour  formed  by  the  iris;  when  it  falls  off,  as  i| 
usually  does  two  or  three  days  alter  the  use  of  the 
caustic,  all  the  above-mentioned  symptoms  are  re- 
kindled, with  this  difference,  that  they  are  less  intense 
and  acute  than  they  were  previously,  and  the  tumour 
of  the  iris  is  not  so  prominent  as  it  was  before  the 
caustic  was  applied.  When  these  symptoms  make 
their  appearance,  the  surgeon  must  once  mote  liave 
recourse  to  the  argentum  nitratum,  with  the  precau- 
tions explained  above;  and  he  is  to  employ  it  a third, 
and  even  a fourth  time,  as  occasion  may  require,  until 
the  prominent  portion  of  the  iris  is  sufficiently  reduced 
to  a level  with  the  edges  of  the  wound  or  ulcer  of  the 
cornea,  and  no  obstacle  is  left  to  the  granulating  pro- 
cess and  complete  cicatrization. 

There  is  a certain  period,  beyond  which  the  applica- 
tion of  caustic  to  the  protruded  iris  becomes  exceed- 
ingly dangerous,  though  at  first  it  may  have  been 
highly  beneficial;  beyond  which  the  eschar,  which 
previously  soothed  the  pain,  exasperates  it,  and  re- 
produces the  inflammation  of  the  conjunctiva,  in  almost 
as  vehement  a degree  as  in  the  beginning  of  the  dis- 
ease. This  appears  to  Scarpa  to  be  the  case  whenever 
the  surgeon  continues  to  employ  the  caustic,  after  the 
little  tumour  of  the  iris  has  been  destroyed  to  a level 
with  the  external  edges  of  the  wound  or  ulcer  of  the 
cornea,  and  the  application  begins  to  destroy  the  gra- 
nulations just  as  they  are  originating.  Hence,  as  soon 
as  the  surgeon  perceives  that  the  part  of  the  iris  pro- 
jecting from  the  cornea  is  sufficiently  lowered,  and  that 
the  application  of  the  argentum  nitratum,  far  from  al- 
laying, only  irritates  the  disease,  he  must  desist  entirely 
from  using  the  caustic,  and  be  content  with  intro- 
ducing between  the  eye  and  eyelids,  every  two  hours, 
the  collyrium  zinci  sulphatis  with  the  mucilage  of 
quince  seeds.  Every  morning  and  evening,  Janin’s 
ophthalmic  ointment,  weakened  with  a double  or  triple 
proportion  of  lard,  is  to  be  applied.  If  the  stimulus 
of  such  local  remedies  should  not  disturb  the  work  of 
nature,  the  ulcer  gradually  diminishes,  and  heals  in  the 
course  of  a fortnight. 

The  adhesion  which  the  projecting  part  of  the  iris 
contracts  to  the  internal  margin  of  the  wound  or  ulcer 
of  the  cornea  during  the  treatment,  continues  the 
same  after  the  perfection  of  the  external  cicatrix,  and 
of  course  during  the  rest  of  the  patient’s  life.  Hence, 
even  after  the  most  successful  treatment  of  the  pro- 
lapsus of  the  iris,  the  pupil  remains  a little  inclined  to- 
wards the  place  of  the  scar  in  the  cornea,  and  of  an 
oval  figure.  'J’he  change  in  the  situation  and  shape  of 
the  pupil,  however,  causes  little  or  no  diminution  of 
the  patient’s  faculty  of  discerning  distinctly  the  small- 
est objects,  and  is  much  le>s  detrimental  to  the  sight 
than  one  inexperienced  in  these  matters  might  con- 
ceive ; provided  the  scar  on  the  cornea  be  not  too  ex- 
tensive, nor  situated  exactly  in  the  centre  of  this  mem- 
brane. In  the  first  case,  the  sight  is  the  less  obstructed, 
as  the  pupil,  which,  on  the  first  t>ccurrence  of  the  pro- 
lapsus, xvas  natrow,  oblong,  and  drawn  considerably 
tow'ards  the  wound  or  ulcer,  gradually  enlarges,  and 
forms  a less  contracted  oval.  As  soon  as  the  wound 
is  completely  healed,  the  pupil  tends,  in  some  degree, 
to  occupy  its  former  situation  in  the  centre  of  the  cor- 
nea ; a fact  also  noticed  by  Richter. 

According  to  Scarpa,  the  recision  of  the  prottu.«ioii 
with  scissors  can  only  be  practised  with  success  when 
the  iris  has  contracted  a firm  adhesion  to  the  internal 
edge  of  the  wound  or  ulcer  of  the  cornea  ; and  more 
especially  in  that  ancient  prolapsusof  the  iri.s,  in  which 
the  projecting  portion  of  the  iris  has  become  with  time 
almost  insetisible,  hard,  and  callous,  with  its  base 
strangulated  between  the  edges  of  the  wound  or  tdeer 
of  the  cornea,  and  besides  being  adherent  to  them,  hav- 
ing also  a slender  pedicle.  Scarpa  indeed  has  seen 
an  incarcerated  one  fall  off  of  itself. 

In  such  circumstances,  the  recision  of  the  old  pro- 
lapsus of  the  iris  is  not  attended  with  the  least  danger; 
for,  after  removing  with  a stroke  of  the  scissors  that 
prominent  portion  of  the  iris  which  has  already  con- 
tracted iiitertial  adhesions  to  the  ulcerated  margin  of 
the  cornea,  so  as  to  ri  duce  it  to  a level  with  kite  ex- 
ternal edges  of  the  tilcer,  there  is  no  hazard  of  renew- 
ing the  eflitsion  of  the  aqueous  humour,  or  giving  an 
opportunity  for  another  piece  of  the  iris  to  be  pro- 
truded. One  or  two  applications  of  the  argentum  niti  a- 


IRIS. 


97 


turn  suffice  afterward  for  the  production  of  granula- 
tions on  the  ulcer  of  the  cornea,  and  the  formation  of  a 
cicatrix.  But  it  is  not  so  in  the  treatment  of  the  recent 
prolapsus  of  the  iris,  which  has  no  adhesions  to  the 
internal  edges  of  the  wound  or  ulcer  of  the  cornea. 

In  four  subjects  affected  with  recent  prolapsus  of  the 
iris,  after  Scarpa  had  removed,  with  a pair  of  convex- 
edged  scissors,  a portion  of  that  membrane  projecting 
beyond  the  cornea,  of  about  the  size  of  a fly’s  head, 
he  found,  on  the  ensuing  day,  that  a new  portion  of  Uie 
iris,  not  less  than  the  first,  had  made  its  way  through 
the  ulcer  of  the  cornea,  and  that  the  pupil  was  very 
much  contracted,  and  drawn  considerably  farther  to- 
wards the  ulcer  of  the  cornea.  These  circumstances 
took  place  notwithstanding  the  wound  was  touched 
immediately  afterward  with  the  argentum  nitratum. 
Hence  Scarpa  apprehends,  that  if  he  were  ever  to  di- 
vide such  a little  tumour  again,  it  would  reappear,  and 
always  with  an  additional  protrusion  of  the  iris,  and  a 
farther  distortion  of  the  pupil.  The  advantage  of 
caustic  in  the  recent  sensible  prolapsus  of  the  iris,  and 
the  use  of  scissors  only  in  old  callous  cases,  agree  also 
with  the  directions  given  both  by  Beer  and  Mr.  Tra- 
vers.— {Lchre  von  den  Augenkr.  b.  2,  p.  68 ; and  Synop- 
sis,p.  280.) 

Thereis  a particular  species  of  prolapsus,  much  less 
frequent,  indeed,  than  that  of  the  iris,  but  whicli  does 
occur,  and,  in  Scarpa’s  opinion,  is  very  improperly 
termed  by  modern  oculists,  '•'•prolapsus  of  the  tunic  of 
the  aqueous  humour." — {Janin,  Pcllier,  Gudrin,  Ole-ize, 
6rc.)  Neither  do  his  sentiments  upon  this  subject 
agree  with  those  of  Beer,  whose  explanation  of  the 
• nature  of  the  case  is  noticed  in  the  article  Cataract. 
VVe  shall  there  see  that  it  is  a case  which  he  terms 
ceratocele,  and  which  he  thinks  arises  from  a yielding 
of  the  inner  layers  of  the  cornea,  in  consequence  of  the 
outer  ones  not  having  united.  And  in  his  second  vol. 
p.  59,  he  has  given  a description  of  the  same  kind  of 
disease  from  the  support  of  the  outer  layers  of  the 
cornea  being  destroyed  by  ulceration.  This  is  a point 
on  which  the  most  experienced  men  differ  so  much, 
that  it  is  difficult  to  reconcile  their  statements.  Dr. 
Vetch  seems  to  have  full  reliance  upon  the  accuracy 
of  the  accounts  of  a protrusion  of  the  membrane  of 
the  aqueous  humour. — {^Treatise  on  Diseases  of  the 
Eye,  p.  54,  <S-c.)  Mr.  Travers  inclines  to  Beer’s  view 
of  the  subject,  and  details  reasons  for  doubting  that  the 
vesicle  is  a distinct  texture;  “its  appearance  corres- 
ponds accurately  to  that  of  the  innermost  lamella  of  the 
cornea.” — (Synopsis,  <J-c.  p.  116.) 

It  is,  says  Scat  pa,  a transparent  vesicle,  filled  with 
an  aqueous  fluid,  and  composed  of  a very  delicate 
membrane,  projecting  from  a wound  or  ulcer  of  the 
cornea,  much  in  the  same  way  as  the  iris  does  under 
similar  circumstances.  Scarpa  has  several  times  seen 
this  transparent  vesicle,  full  of  water,  elongating 
itself  beyond  the  cornea,  shortly  after  the  operation 
for  the  extraction  of  the  cataract,  and  sometimes  also 
in  consequence  of  an  ulcer  of  the  cornea,  especially  af- 
ter rescinding  a prolapsed  portion  of  the  iris. 

The  generality  of  oculists  believe,  that  this  little 
transparent  tumour  consists  of  the  delicate,  elastic,  dia- 
phanous membrane  which  invests  the  inner  surface  of 
the  cornea,  and  is  described  byDescemetand  Demours. 
“ As  soon  as  the  membrane  lining  the  cornea  (they 
say)  is  exposed  by  the  wound  or  ulcer  of  the  latter, 
and  the  delicate  pellicle  can  no  longer  resist  the  impulse 
of  the  humours  pressing  beliind  it,  it  is  necessitated  to 
yield  gradually,  to  become  elongated,  and  to  project 
from  the  wound  or  ulcer  of  the  cornea,  exactly  in  the 
form  of  a pellucid  vesicle.”  But,  says  Scarpa,  how 
remote  this  theory  is  from  the  truth  must  be  ma- 
nifest; 1.  The  delicate  and  elastic  pellicle  described  by 
Descemet  and  Demours,  is  not  separable  by  any  arti- 
fice from  the  inner  surface  of  the  cornea,  except  near 
where  the  cornea  and  sclerotica  unite.  Since  these 
protruded  vesicles  make  their  appearance  in  practice 
at  every  point  of  the  cornea,  and  even  at  its  very  cen- 
tre, where  the  above  pellicle  is  certainly  neither  sejja- 
rable  nor  distinct  from  the  compact  texture  of  the  cor- 
nea, it  may  at  least  be  asserted  that  the  tunic  of  the 
aqueous  humour  does  not  in  every  instance  constitute 
tlie  transparent  vesicle  in  question.  2.  It  is  a well- 
known  fart,  that  this  vesicular  pellucid  prolapsus  hap- 
pens more  frequently  after  the  extraction  of  the  cata- 

aet  tlian  on  any  other  orrasion.  In  this  case,  .since 
the  tunic  cf  the  aqueous  humour  has  certainly  been 

Vot.  II.— G 


divided  to  afford  an  exit  to  the  crystalline,  no  one  can 
be  of  opinion,  that  the  transparent  vesicle  which  pro- 
trudes from  the  cornea  after  this  operation  ought  to  be 
attributed  to  the  distention  and  protrusion  of  the  tunic 
of  the  aqueous  humour.  3.  If,  in  cases  of  ulcers  of 
the  cornea,  the  transparent  vesicle  should  sometimes 
appear  after  the  recision  of  the  prolapsus  of  the  iris, 
it  is  obvious,  that  if  it  consisted  of  the  tunic  of  the 
aqueous  humour,  it  ought  invariably  to  appear  before 
the  prolapsus  of  the  iris.  4.  Should  the  surgeon  re- 
move the  protruded  vesicle  to  a level  with  the  cornea 
by  a stroke  of  the  scissors,  a small  quantity  of  limpid 
water  is  seen  to  ooze  out,  at  the  moment  when  the  in- 
cision is  made,  without  any  part  of  the  aqueous  hu- 
mour escaping  from  the  anterior  chamber.  This  in- 
convenience would  be  inevitable  were  the  protruded  ve- 
sicle in  question  formed  by  the  delicate  elastic  pellicle, 
which  is  said  to  invest  the  inner  surface  of  the  cornea. 
Besides,  the  little  transparent  tumour  disappears  when 
the  incision  is  made ; but  often  another  one,  exactly 
sinjilar  to  what  w'as  cut  off,  is  found  in  the  very  same 
place  the  following  day.  Had  the  little  transparent 
tumour  been  composed  of  the  tunic  of  the  aqueous 
humour,  elongated  out  of  the  wound  or  ulcer  of  the 
cornea,  it  could  not  at  all  events  have  been  reproduced 
at  the  same  part  of  the  cornea. 

It  is  clear  to  Scarpa,  that  the  pretended  prolapsus  of 
the  tunic  of  the  aqueous  humour  is,  strictly  speaking, 
only  a forcible  protrusion  of  a portion  of  the  vitreous 
humour,  which,  from  too  much  pressure  being  made 
on  the  eye,  either  at  the  time  of  the  operation,  or  after- 
ward, or  from  a spasm  of  the  muscles  of  the  eye,  in- 
sinuates itself  betw'een  the  edges  of  the  wound  after 
the  extraction  of  the  cataract,  and  projects  in  the  form 
of  a transparent  vesicle.  The  same  thing  also  hap- 
pens after  ulcers  of  the  cornea,  wlienever  the  aqueous 
humour  has  escaped,  and  a portion  of  the  vitreous 
humour  is  urged  by  forcible  pressure  towards  the  ulcer 
facing  the  pupil ; or  whenever  an  elongated  piece  of 
the  vitreous  humour,  a’fter  the  recision  of  a prolapsed 
portion  of  the  iris,  passes  by  a shorter  route  than 
through  the  pupil,  between  the  lips  of  the  ulcer  of  the 
cornea.  At  length  we  understand  why  in  both  these 
instances  a transparent  vesicle  forms,  even  after  the 
recision  of  the  tunic  of  the  aqueous  humour  or  ulcera- 
tion of  the  cornea  ; and  why  it  very  often  reappears  in 
the  same  place,  though  it  has  been  cut  away  to  a level 
with  the  cornea.  It  is  because  one  or  more  cells  of 
tlie  vitreous  humour,  constituting  the  transparent  vesi- 
cle, are  succeeded  after  their  removal  by  other  cells  of 
the  same  liumour,  which  glide  between  the  lips  of  the 
wound  or  ulcer  of  tlie  cornea  into  the  same  situa- 
tion. 

The  treatment  of  this  species  of  prolapsus  consists 
in  removing  the  transparent  vesicle  projecting  from 
the  wound  or  ulcer,  by  means  of  a pair  of  curved 
scissors  with  convex  edges,  and  bringing  the  edges  of 
the  wound  of  the  cornea  immediately  afterward  into 
perfect  apposition,  in  order  that  they  may  unite  to- 
gether as  exactly  as  possible.  But  when  there  is  an 
ulcer  of  the  cornea,  as  soon  as  the  vesicle  is  removed, 
the  sore  must  be  touched  with  the  argentum  nitratum, 
so  that  the  eschar  may  resist  any  new  prolapsus  of  the 
vitreous  liumour,  and  at  the  same  time  dispose  the 
ulcer  of  the  cornea  to  granulate  and  heal. 

If,  in  some  particular  cases,  the  vesicle  should  not 
project  sufficiently  from  the  wound  or  ulcer  of  the  cor- 
nea to  be  included  in  the  scissors,  the  same  object  may 
be  accomplished  by  puncturing  the  tumour  with  a lan- 
cet or  couching  needle;  forwhen  the  limpid  fluid  which 
it  contains  is  discharged,  the  membrane  forming  it 
shrinks  within  the  edges  of  the  wound  or  ulcer  of  the 
cornea,  and  no  longer  hinders  the  union  of  the  former 
or  the  cicatrization  of  the  latter. 

Should  the  transparent  tumour  reappear  in  the  same 
situation  the  day  after  its  recision  or  puncture,  it  is 
right  to  repeat  one  of  these  operations,  and  to  adojit 
farther  measures  for  maintaining  the  edges  of  the 
wound  of  the  cornea  in  contact;  or,  if  it  should  be  an 
ulcer,  the  eschar  must  be  made  to  adhere  more  deeply 
to  its  bottom  and  sides,  so  as  form  a greater  obstacle  to 
the  escape  of  the  vitreous  humour.  In  these  circum- 
stances, the  surgeon  must  take  all  possible  care  to  ob- 
viate such  causes  as  have  a tendency  to  proiiel  the  vitre- 
ous humour  towards  the  wound  or  ulcer  of  the  cornea; 
pni  ticidarly  too  much  pressure  on  the  eyelids,  spasms 
of  the  muscles  ol  the  eye,  coughing,  sneezing,  efforts 


98 


ISS 


ISS 


at  stool,  and  other  similar  ones ; and  care  must  also  be 
taken  to  check  the  progress  of  inflammation. 

Scarpa  lias  seen  a prolapsus  of  the  choroid  coat,  two 
lines  from  the  union  of  the  cornea  with  the  sclerotica, 
in  the  inferior  hemisphere  of  the  eye.  It  was  preceded 
by  a small  abscess,  the  consequence  of  severe  oph- 
thalmy.  The  treatment  consisted  in  applying  the  ar- 
gentum nitratum  several  times  to  the  projecting  portion 
of  the  choroides,  until  it  was  consumed,  and  reduced 
to  a level  with  the  bottom  of  the  ulcer  of  the  cornea. 
The  part  then  healed.  The  eye  remained,  however, 
considerably  weakened,  and  the  pupil  afterward  be- 
came nearly  closed. — Scarpa  suite  Priucipuli  Malattie 
degli  Occhi,  Venezia^  1802.  Richter's  Anfangs.  der 
JVundarzneykunst,  b.  3 ; Von  den  Vorfalle  der  Regen- 
bogenhaut.  Pellier,  Obs.  sur  I'CEil,  p.  350.  C.  J.  Beer, 
Lehre  von  den  Augenkrankheiten,  b,  1,  § 402,  518, 
mid  592;  and  b.  2,  § 58,  62,  <S-c.  Svo.  Wien,  1813—1817. 
J.  Wardrop,  Essays  on  the  Morbid  Anatomy  of  the 
Human  Eye,  vol.  2,p.  51,  8wo.  Lond.  1818.  J.  Vetch, 
A Practical  Treatise  on  the  Diseases  of  the  Eye,  p.  53, 
«lS-c.  Eond.  8vo.  1820.  B.  Travers,  a Sijnopsis  of  the 
Diseases  of  the  Eye,  p.  116,  280,  ^c.  8vo.  Eond.  1820. 
Weller  on  Diseases  of  the  Eye,  Transl.  by  Dr.  Mon- 
teath,  8oo.  Glasgow,  1821.  Frick  on  Diseases  of  the 
Eye,  ed.  2,  by  R.  Wclbank,  8vo.  Eond.  1826. 

For  a description  of  the  manner  of  dividing  the  iris, 
in  order  to  make  an  artificial  pupil,  when  the  natural 
one  is  closed,  refer  to  Pupil,  Closure  of. 

Iris,  Effects  of  certain  Marcotics  upon  the.  See 
Belladonna  and  Cataract.  The  following  work 
upon  the  subject  also  merits  attention : — C.  Himly, 
de  la  Paralysie  de  V Iris  par  une  Application  locale  de 
la  Jusquiaume,  et  de  son  Utiliti  dans  le  Traiteiiient  de 
plusieurs  Maladies  des  Yeux,  2de  ed.  \2mo.  Altona,  1805. 

IRITIS.  Inflammation  of  the  iris. — See  Opiithalmy. 

ISCHU'RIA.  (From  rVxw,  to  restrain  ; and  ovpov, 
the  urine.)  A suppression  or  stoppage  of  the  urine. 

The  distinction  between  a suppression  and  reten- 
tion of  urine  is  practical  and  judicious.  The  former 
most  properly  points  out  a defect  in  the  secretion  of 
the  kidneys ; the  latter,  an  inability  of  e.xpelling  the 
urine  when  secreted. — i^Hey.) 

The  first  disease  is  not  very  common,  is  named  is- 
churia renalis,  or  suppression  of  urine,  and  belongs 
to  the  province  of  the  physician  ; the  second  is  an  ex- 
ceedingly frequent  disorder,  is  named  ischuria  vcsicalis, 
or  retention  of  urine,  and  its  treatment  is  altogether 
surgical. — (See  Catheter,  and  Urine,  Retention  of.) 

ISSUE  signifies  an  ulcer,  made  designedly  by  the 
practitioner,  and  kept  oi)en  a certain  time,  or  even 
the  patient’s  whole  life,  for  the  cure  or  prevention  of 
a variety  of  diseases. 

The  physician,  in  his  practice,  has  frequent  occasion 
to  recommend  the  making  of  an  issue,  and  the  surgeon 
finds  it  a principal  means  of  relief  in  several  important 
cases,  as  for  instance,  white  swellings,  disease  of  the 
hip-joint,  caries  of  the  vertebrEe,  &c.  Many  persons 
are  never  in  health,  or,  at  least,  fancy  themselves 
always  ill,  unless  they  have  an  issue  formed  in  some 
part  of  their  body  or  another.  The  making  of  an  is- 
sue, indeed,  is  not  unfrequently  considered  as  an  imi- 
tation of  nature,  who,  of  her  own  accord,  often  forms 
ulcers  and  abscesses  in  various  parts  of  the  body  (as 
is  not  uncommonly  conjectured)  for  the  purpose  of 
discharging  pernicious  humours,  whereby  people  are 
supposed  to  be  freed  from  grievous  disorders,  and  have 
their  health  preserved.  The  humoral  pathologists 
were  excessively  partial  to  these  notions,  whicli,  at 
the  present  time,  will  be  found  by  every  experienced 
practitioner  to  influence  the  mass  of  mankind,  and 
render  the  formation  of  issues  more  common  than 
perhaps  is  consistent  with  the  belter  establislied  prin- 
ciples of  medical  science.  Few  old  subjects  will  allow 
a sore  of  long  standing  to  be  dried  up  (as  the  expres- 
sion is),  without  requiring  the  surgeon  immediately 
afterward  to  make  an  issue  for  them.  When  an  ulcer 
has  existed  a great  length  of  time,  the  constitution, 
may  possibly  become  so  habituated  to  it,  that  the 
health  may  really  suffer  from  its  being  healed.  “ I 
have  often  (says  the  experienced  Dr.  Parry)  seen  va- 
rious thoracic  affections,  as  pulmonary  consumption, 
asthma,  carditis,  or  hydrothorax,  arise  from  the  spon- 
taneous, or  artificial  cure  of  ulcers,  perpetual  blisters, 
or  fistulBB.” — {Elements  of  Pathology,  <frc.  p.  386.) 
Asthmatic  complaints,  severe  headaches,  &c.  are  fre- 
quently obsjerved  to  follow’  the  cicatrization  of  an  old 


ulcer ; but  whether  they  would  have  happened  if  an 
issue  had  been  made  in  time,  is  a question  difficult  of 
positive  determination ; for  many  persons  with  old 
ulcers  are  not  prevented  from  suffering  from  asthma 
and  headache.  The  plan  of  making  an  issue,  Jiowever, 
is  commendable  both  as  rational  and  exempt  from  dan- 
ger. Whatever  may  be  the  solidity  of  the  theories, 
which  have  been  offered  by  medical  writers,  in  regard  to 
issues  the  practitioner  who  has  his  eyes  open  cannot 
fail  to  see  the  benefit  often  derived  from  such  means ; 
and  if  there  be  any  unquestionable  facts  in  medicine 
and  surgery,  we  may  confidently  set  down  among 
tliem  the  frequent  possibility  of  relieving  one  disease 
by  exciting  another  of  a less  grievous  and  more  cura- 
ble nature. 

There  are  two  ways  of  making  an  issue ; one  is  with 
a lancet,  or  scalpel ; the  other  with  caustic. 

The  place  for  the  issue  being  fixed  upon,  the  surgeon 
and  his  assistant  are  to  pinch  up  a fold  of  the  integu- 
ments, and,  with  a lancet  or  knife,  make  in  them  an 
incision  of  sufficient  size  to  hold  a pea,  or  as  many  peas 
as  may  be  thought  proper.  The  pea  or  peas  are  then 
to  be  placed  in  the  cut,  and  covered  with  a piece  of  ad- 
hesive plaster,  a compress,  and  bandage.  The  peas, 
first  inserted,  need  not  be  removed  for  three  or  four 
days,  when  suppuration  will  have  begun  ; btil  the  is- 
sue is  afterward  to  be  cleaned  and  dressed  every  day, 
and  have  fresh  peas  put  into  it.  The  preceding  is  the 
ordinary  method  of  making  such  issues  as  are  intended 
to  contain  only  one  or  two  peas. 

When  the  issue  is  to  be  larger,  which  is  generally 
proper  in  cases  of  diseased  vertebrie,  white  swellings. 
See.,  the  best  plan  is  to  destroy  a portion  of  the  integu- 
ments with  caustic.  The  caustic  potassa,  blended 
with  quicklime,  is  mostly  preferred  for  this  purpose. 
The  situation  and  size  of  the  issue  having  been  deter- 
mined, the  surgeon  is  to  take  care,  that  the  caustic 
does  not  extend  its  action  to  the  surrounding  parts. 
With  this  view,  he  is  to  take  a piece  of  adhesive  plas- 
ter, and  having  cut  a hole  in  it,  of  the  exact  shape  and 
size  of  the  issue  intended  to  be  made,  he  is  to  apply  it 
to  the  part.  Thus  the  plaster  will  defend  the  adjacent 
skin  from  the  effects  of  the  caustic,  while  the  uncovered 
portion  of  integuments,  corresponding  to  the  hole  in 
the  plaster,  is  that  which  is  to  be  destroyed.  The 
caustic  is  to  be  taken  hold  of  with  a bit  of  lint,  or  tow, 
and  its  end,  having  been  a little  moistened  with  water, 
is  to  be  steadily  rubbed  upon  the  part  of  the  skin  where 
the  issue  is  to  be  formed.  The  frictions  are  to  be  con- 
tinued, till  the  whole  surface,  intended  to  be  destroyed, 
assmnes  a darkish  corroded  appearance.  The  caustic 
matter  may  now  be  carefully  washed  off  with  some  wet 
tow.  The  plaster  is  to  be  removed,  and  a linseed  poultice 
applied.  As  soon  as  the  eschar  is  detached,  or  any 
part  of  it  is  loose  enough  to  be  cut  away,  without  pain  or 
bleeding,  tlie  peas  are  to  be  inserted  and  confined  in 
their  proper  place  with  a piece  of  adhesive  plaster. 
Some  use  beans  for  the  purpose  ; others  heads,  which 
answer  very  well,  and  have  the  advantage  of  .serving  for 
any  lengtii  of  time,  when  washed  and  cleaned  every 
(lay.  If  the  issue  is  of  a longitudinal  shape,  the  peas, 
beans,or  beads  may  be  more  easily  kept  in  their  places, 
when  a thread  is  passed  through  them. 

Issues  ought  always  to  be  made,  if  possible,  in  a situ- 
ation where  the  peas  will  not  be  much  disturbed  by 
the  ordinary  motions  of  the  body,  nor  interfere  w'ith 
the  action  of  muscles.  The  interspaces  between  the 
margins  and  insertions  of  muscles  are  deemed  the 
most  eligible  places.  Thus,  issues  in  the  arm  are 
usually  made  just  at  the  inferior  angle  of  the  deltoid 
muscle,  by  the  side  of  the  e.xternal  edge  of  the  biceps. 
In  the  lower  extremities,  issues  are  often  made  at  the 
inner  side  of  the  thigh,  immediately  above  the  kmie,  in 
a cavity  that  may  be  readily  felt  (here  with  the  fingers. 
Sometimes  issues  are  made  upon  the  inside  of  the  leg, 
just  below  the  knee.  For  the  relief  of  certain  afltec- 
tious  of  the  head  or  eye,  the  na|)e  of  the  neck  is  com- 
monly selected  as  a good  situation.  In  caries  of  the 
vertebra;,  they  are  made  on  each  side  of  the  spinous 
processes.  In  cases  of  diseased  hips,  they  are  tormed 
in  a depression  just  behind  and  below  the  trochatiter 
major.  W'hen  the  nature  of  the  disorder  does  not  par- 
ticularly indicate  the  situation  for  the  issue,  the  arm 
should  be  preferred  to  the  leg,  as  issues  itpon  the  upper 
extreinilies,  espi;cially  the  left  arm,  are  much  less  an- 
noying, than  upon  either  of  the  lower  limbs. 

The  ^reat  art  of  keeping  an  issue  open,  for  a long 


JAW 


while,  consists  in  maintaining  an  equal  and  effectual 
pressure  upon  the  peas,  by  which  means,  they  are 
coiihned  in  their  places,  little  depressions  are  made  for 
them,  and  the  granulations  hindered  from  rising. 
Compresses  of  pasteboard  and  sheet-lead  will  often  be 
found  highly  useful.  This  plan  is  the  surest  one  of 
preventing  the  issue  from  healing,  and  the  most  likely 
to  save  the  patient  all  the  severe  and  repeated  suffering, 
which  the  fresh  application  of  the  caustic,  or  the  use 
of  stimulating  powders,  in  order  to  renew  the  sore  and 
repress  the  fungous  flesh,  unavoidable  occasions. 

There  is  a method  of  making  issues  with  the  caustic 
made  into  a sort  of  paste,  which  is  laid  upon  the  part 
left  uncovered  by  the  adhesive  plaster.  It  seems  to 
me  to  be  a more  tedious  and  painful  plan,  and  I do  not 
recommend  it. 

It  has  been  suspected  that  the  pain  arising  from  the 
caustic  might  be  lessened,  by  mixing  opium  with  the 
application;  but  the  idea  seems  not  at  all  probable; 
the  destruction  of  a part  of  the  skin  must  inevitably 
cause  considerable  pain,  with  whatever  substance  it  is 
produced,  and  opium  itself,  so  far  from  being  likely  to 
diminish  the  agony,  is  itself  a violent  stimulus,  when- 


JOI  99 

ever  it  comes  into  contact  with  the  exposed  extremities 
of  the  nerves. 

[The  inconvenience  arising  from  pea  issues,  and  the 
difficulty  of  keeping  them  open  for  a length  of  time,  as 
is  often  needful,  have  long  since  suggested  to  surgeons  a 
variety  of  other  methods' of  making  issues,  less  trouble- 
some to  the  patient  and  his  medical  attendant.  Some 
of  these  expedients  are  here  alluded  to,  and  I will  add 
another  which  I have  adopted  for  a number  of  years 
most  satisfactorily,  and  for  which  I am  indebted  to  Dr. 
P.  K.  Rogers  of  William  and  Mary  College,  Virginia. 
The  issue  is  made  by  the  simple  process  of  rubbing  the 
skin  with  astick  of  the  potass,  pur.  vulgo  lapis  infernalis, 
until  as  much  of  the  surface  is  destroyed  as  is  neces- 
sary. The  process  is  effected  in  about  five  minutes,  if 
constantly  applied ; and  its  perfection  is  known  by  the 
black  and  horny  aspect  of  the  eschar.  Its  property 
may  be  instantly  neutralized  if  too  violent,  by  washing 
the  part  with  vinegar,  and  the  effect  ceases.  A poul- 
tice is  then  applied,  and  in  eight  or  ten  days  there 
is  a slough  comes  off;  when  it  may  be  dressed  with 
savin  ointment,  which  will  keep  it  open  indefinitely. — 
Reese.] 


J 


JAW-BONE,  AMPUTATION  OF  CONSIDERA- 
BLE PORTIONS  OF  THE  LOWER.  This  ope- 
ration, which  is  one  of  the  achievements  of  modern 
surgery,  was  first  performed,  by  Dr.  Mott,  in  America  ; 
and  it  has  since  been  done  by  Dupuytren,  Graefe,  Lal- 
lemand,  Syme,  M‘Clennan,  Lizars,  Crampton,  Cusack, 
Hodgson, [Wegner,  Randolph,  J.  K.  Rogers,  Reese,]  and 
others. 

[The  operation  of  amputation  of  the  lower  jaw,  one 
of  the  most  formidable  in  surgery,  was  doubtless 
performed  by  Dr.  Mott,  although  Mr.  Cooper,  in  his 
“ First  Lines,”  has  attributed  it  to  Dupuytren,  and  the 
“ Philadelphia  editor”  {slat  nomine  umbra)  of  the 
last  edition,  ascribes  it  to  Dr.  Deadrick  of  Tennessee. 
It  is  passing  strange,  that  surgical  writers  cannot  dis- 
tinguish between  removing  a '■'■part  of  the  lower  jaw” 
and  that  part  the  symphisis,  and  the  amputation  of  the 
bone  at  the  articulation.  They  may  ■write  these  two 
operations  among  their  synonymes,  but  I appreliend  if 
they  encounter  the  latter  operation  on  the  living  sub- 
ject, they  will  never  again  proclaim  their  identity. 
Palmam  qui  meruit,  ferat.  Dr.  Mott  is  not  only  the 
^r.st,but  the  only  surgeon,  who  has  amputated  the  bone 
successfully  at  the  articulation,  except  (since)  Dr.  Cu- 
sack, of  Dublin.  The  removal  of  a part  of  this 
bone  has  been  veiy  often  performed,  even  in  this 
country;  and  although  I am  one  of  those  who  have 
removed  a part  of  this  bone  successfully,  and  that  part 
extending  from  the  bicuspid  tooth  of  the  left  side  to 
the  angle  of  the  right,  yet  it  would  be  presumptuous 
to  insinuate  that  the  difficulty  and  hazard  of  removing 
it  at  the  joint  is  not  a vastly  different  and  more  formi- 
dable operation.  And,  reasoning  a priori,  it  may  be 
sa'ely  affirmed,  that  had  not  Dr.  Mott  demonstrated 
its  practicability,  many  of  those  who  now  discourse 
very  gravely  of  the  facility  of  its  performance,  and 
even  presume  to  give  instructions  as  to  the  mode  of 
operating,  and  condemn  certain  steps  in  his  operation, 
would  themselves  shudder  at  proposing  to  remove  this 
bone  at  the  joint,  even  after  the  carotid  artery  was 
secured. 

The  propriety  of  tying  the  carotid,  as  a preliminary 
step  in  this  operation,  or  its  necessity  at  least,  may  be 
questioned.  Dr.  Mott  has  since  performed  the  same 
operation  without  tying  the  carotid,  and  by  experience 
is  convinced  that  it  would  be  unnecessary  in  cases  in 
which  he  would  formerly  have  thought  it  indispensa- 
ble. There  may  be  cases  of  the  disease  for  which  this 
operation  is  necessary,  in  which,  from  the  extension  of 
the  disease,  and  the  state  of  the  vessels,  it  would  be  un- 
safe to  proceed  to  the  operation  without  tying  the  caro- 
tid ; in  general,  however,  it  may  be  dispensed  with. 
I recollect  some  years  since,  in  removing  a tumour  from 
the  neck,  1 commenced  by  tying  the  carotid,  and  from 
the  htimorrhage  I encountered  immediately  afterward, 
in  extirpating  the  tumour,  I was  well  satisfied  that  no 

G2 


advantage  whatever  bad  been  derived  from  the  liga- 
ture to  that  vessel ; and  I have  never  since  thought  it 
needful  to  repeat  it;  although  I have  often  removed 
tumours  of  the  jaw  and  neck,  for  which  it  is  said  to  be 
necessary  . But  to  tie  this  vessel  at  one  time,  and  then 
wait  a few  days  before  proceeding  to  the  o[)eiation, 
is  the  climax  of  surgical  folly  ; and  it  is  mortifying  to 
hear  this  course  recommended  by  very  high  authori- 
ties. Experience  will  convince  any  operator  that  the 
circulation  will  be  as  fully  restored  in  a few  hours,  as 
though  his  ligature  were  in  his  pocket. 

In  amputating  the  lower  jaw,  it  has  been  found  that 
the  subsequent  management  of  each  individual  case 
has  been  a work  requiring  much  skill  and  attention. 
More  than  one  of  the  cases  which  liave  resulted  unfa- 
vourably have  been  attributed  to  the  effort  of  degluti- 
tion, which  became  necessary  before  the  parts  had 
united.  Indeed,  the  wound  made  by  the  surgeon  is  so 
extensive,  and  the  adaptation  of  the  parts  so  important 
to  success,  that  many  days  ought  to  elapse  before  even 
the  saliva  should  be  suffered  to  pass  into  the  stomach. 
Hence  the  patient  is  directed  to  lie  on  the  side,  so  that 
the  saliva  may  flow  out  of  the  mouth,  instead  of  col- 
lecting in  the  throat. 

The  patient  on  whom  I operated  in  April,  1828,  was 
in  frail  health,  and  60  years  of  age.  At  the  time  of  the 
operation  he  was  so  reduced  by  starvation  and  loss  of 
sleep,  consequent  upon  an  osteo- sarcomatous  tumour 
of  the  jaw,  which  obstructed  deglutition,  and  impaired 
his  respiration,  that  I would  not  have  ventqred  upon 
its  removal,  if  I had  designed  to  deprive  him  of  food 
even  for  six  days,  as  surpeons  direct.  I knew  there 
would  be  a necessity  for  food  and  drink  of  cordial  and 
nutritious  character  ; and  accordingly  half  an  hour 
after  the  operation,  I introduced  the  stomach-tube  of 
elastic  gum,  and  thus  poured  into  the  stomach  half  a 
pint  of  wine  and  water.  It  was  passed,  without  in- 
convenience, several  times  a day  for  the  first  week, 
and  water,  coffee,  chocolate,  soup,  and  other  fluids 
thus  introduced,  until  the  eighth  day,  when  he  could 
swallow  with  ease ; entire  union  having  already  taken 
place,  from  the  quiet  state  in  which  the  parts  had  been 
kept.  I apprehend  the  use  of  the  stomach-tube,  in 
these  cases,  will  remove  much  of  the  hazard  attending 
them,  and  be  found  greatly  to  promote  the  rapid  reco- 
very of  the  patients. — (See  note  on  article  Ostco-Sar- 
coma.) — Reese.] 

JOINTS,  DISEASES  OF.  The  joints  are  subject 
to  numerous  diseases,  which  are  more  or  less  danger- 
ous, according  to  their  particular  nature.  Like  all 
other  parts,  the  joints  are  liable  to  inflammation  and 
abscesses  ; their  capsules  frequently  become  distended 
with  an  aqueous  secretion,  and  the  disease  termed 
hydrops  articuli  is  produced  ; but  the  most  important 
of  all  their  morbid  affections  are  the  cases  which  a 
few  years  ago  were  indiscriminately  called  white  swell' 


100 


JOINTS, 


ing3j  scrofulous  joints,  and  the  disease  of  the  hip-joint. 
Here,  as  Mr.  Brodie  remarks,  the  same  name  lias  been 
frequently  applied  to  different  diseases,  and  the  same 
disease  has  received  different  appellations.  And  con- 
fusion with  respect  to  the  diagnosis  always  gives  rise 
to  a corresponding  confusion  with  respect  to  the  em- 
ployment of  remedies.  Although,  says  he,  diseases 
in  their  advanced  stage  extend  to  all  the  dissimilar 
parts  of  which  the  joints  are  composed,  such  is  not 
the  case  in  the  beginning.  Here,  as  elsewhere,  the 
morbid  actions  commence,  sometimes  in  one  and  some- 
times in  another  texture,  differing  in  their  nature,  and, 
of  course,  requiring  to  be  differently  treated,  according 
to  the  mechanical  organization  and  vital  properties  of 
the  part  in  which  they  originate. — (See  Pathological 
and  Surgical  Obs.  on  Diseases  of  the  Joints,  p.  2, 8vo. 
J.ond.  1818.)  It  was  this  idea,  which  led  Mr.  Brodie 
to  trace  by  dissection  the  exact  parts  in  which  several 
of  the  principal  diseases  of  the  joints  commence,  and 
how  much  light  and  discrimination  his  successful  in- 
vestigations have  produced,  it  is  needless  for  me  here 
to  insist  upon,  as  his  merit  will  long  be  appreciated  by 
every  surgeon,  who  recollects  the  perplexity  and  igno- 
rance which  prevailed  only  a few  years  ago  in  this 
very  interesting  branch  of  surgery. 

Wonnds. — By  the  wound  of  a joint,  surgeons  mean 
a case  where  the  capsular  ligament  is  penetrated  or 
divided.  The  injury  is  often  accompanied  with  a divi- 
sion of  the  lateral  or  other  ligaments,  and  sometimes 
also  with  that  of  the  cartilages  and  bones.  I'kat  the 
capsular  ligament  is  wounded  may  generally  be  learned 
by  the  introduction  of  a probe,  and  frequently  by  a dis- 
charge of  a transparent  viscid  fluid,  called  the  synovia. 
But  as  a similar  discharge  may  proceed  from  mere 
wounds  of  the  bursre  muaoste,  we  might  form  an  erro- 
neous judgment,  were  we  unacquainted  with  the  situ- 
ation of  these  little  membranous  bags  I am,  at  this 
present  time,  (Aug.  1829,)  attending  a man,  whose  leg 
was  attacked  with  erysipelas  in  consequence  of  a super- 
ficial laceration  of  the  skin  of  the  knee  by  a fall.  A 
small  abscess  formed  below  tlie  patella ; and,  ever 
since  it  burst,  a considerable  quantity  of  fluid,  resem- 
bling white  of  egg,  and  evidently  secreted  by  the 
neighbouring  bursa,  has  been  daily  discharged  with  the 
pus.  Boyer  has  seen  several  cases,  in  which  a fluid, 
resembling  synovia,  was  discharged  from  wounds  of 
the  sheaths  of  tendons. — (See  Traiti  des  Maladies 
Chirurg.  t.  4,  p.  408.)  Here  the  advice  which  I have 
given  in  another  place  {sea  Wounds  of  the  Abdomen), 
respecting  the  temerity  of  being  too  officious  with  the 
probe,  is  equally  important,  inasmuch  as  the  rough 
introduction  of  this  instrument  into  a large  joint,  like 
the  knee,  would  be  likely  to  excite  inflammation  of  the 
synovial  membrane,  and  a train  of  dangerous  and  even 
fatal  consequences,  while  the  information  gained  by 
such  employment  of  the  probe  is  of  little  use  ; because 
whenever  a wound  is  suspected  to  reach  into  the  cap- 
sular ligament,  exactly  the  same  treatment  should  be 
followed  as  if  the  joint  were  positively  known  to  be 
penetrated. 

Notwithstanding  simple  wounds,  even  of  large 
joints,  often  heal  favourably  without  any  bad  symp- 
toms, this  is  not  constantly  the  case,  and  the  records  of 
surgery  furnish  many  examples  in  which  the  most 
alarming  and  fatal  consequences  ensued. — (See  Hun- 
ter's Commentaries,  part  1,  p.  69.)  When  properly 
treated,  punctured  wounds  of  the  joints  (says  Boyer) 
are  not  in  general  attended  with  danger;  but,  as  some 
of  these  wounds,  which  were  apparently  quite  simple, 
have  been  followed  by  very  bad  symptoms,  and  even 
death,  we  should  always  be  extremely  circumspect  in 
the  prognosis.-- -(See  Traite  des  Mai.  Chir.  t.  4,  p.  409.) 
The  treatment  consists  in  endeavouring  to  heal  the  in- 
jury by  the  first  intention;  in  applying  cold  lotions; 
forbidding  all  motion  of  the  part  ; and  employing 
bleeding  and  other  antiphlogistic  remedies. 

Baron  Boyer  relates  two  cases  of  punctureti  wounds 
ofthe  elbow  joint,  which  healed  up  in  a few  days,  w'ith 
out  any  unfavourable  symptom.  He  acknow'ledges, 
however,  that  these  accidents  do  not  always  go  on  so 
well,  and  that  the  consetpiences  are  sometimes  perilous. 

Simple  incised  wounds  jiresent  only  one  indication  : 
viz.  that  of  healing  the  part  by  the  first  inlention.  At 
the  moment  of  the  accident,  some  of  the  synovia  is 
discharged,  indicating  that  the  capsular  ligament  is 
wounded.  Should  this  circumstance  not  have  been 
noticed  at  first,  the  surgeon  may  see  the  synovia  flow 


out  again,  if  he  move  or  press  upon  the  joint.  But,  in 
making  this  examination,  the  greatest  gentleness 
should  be  used,  lest  the  irritation  of  the  capsular  liga- 
ment be  increased.  When  the  wound  is  large,  and 
there  is  no  considerable  thickness  of  soft  parts,  the  ar- 
ticular surfaces  are  exposed  to  view. 

The  prognosis  of  an  incised  wound  of  a joint  is  not 
generally  unfavourable,  when  the  edges  have  been  im- 
mediately brought  together,  the  cavity  of  the  joint  has 
not  been  long  exposed,  and  blood  is  not  extravasated 
in  it.  This  last  danger  is  also  exaggerated,  as  will  be 
noticed  in  speaking  of  collections  of  blood  in  joints. 
With  these  exceptions,  says  Boyer,  the  wound  may 
heal  as  readily  as  if  the  joint  were  not  opened;  and  he 
has  cited  several  facts  in  proof  of  this  statement.  Its 
truth  is  also  confirmed  by  the  success  which  attends 
operations  practised  for  the  purpose  of  extracting  car- 
tilaginous substances  from  the  knee.  Nay,  very  bad 
cases  sometimes  recover  under  judicious  management, 
even  though  the  joint  be  large,  and  abscesses  follow. 
'I'hus  I sa\V,  in  St.  Bartholomew’s  Hospital,  in  the  year 
1820,  two  examples  of  compound  fractures  of  the  pa- 
tella, where  the  opening  in  the  capsule  was  so  large, 
that  the  finger  could  readily  pass  into  the  cavity  of  the 
joint,  yet,  after  large  abscesses,  a great  deal  of  fever, 
and  separation  of  bone,  the  patients  recovered  with 
stift’^joints.  But  I would  advise  surgeons  not  to  letany 
facts  of  this  kind  prejudice  their  judgment  in  the  treat- 
ment of  gunshot  wounds  of  the  large  joints,  where, 
in  the  circumstances  elsewhere  explained  (see  Ampu- 
tation and  Gunshot  Wounds),  amputation  is  the  safest 
practice.  In  a sabre  or  cut  wound,  the  principal  object 
is  to  heal  the  wound  by  the  first  intention.  The  rest 
of  the  treatment  consists  in  using  every  possible  means 
for  the  prevention  of  inflammation,  by  iterfect  quietude 
of  the  part,  the  use  of  cold  applications,  &c. 

Let  it  be  remembered,  however,  that  wounds  of  the 
joints  do  not  always  heal  in  the  above  favourable  man- 
ner. Even  among  tho.se  cases  which  appear  the 
most  slight  and  simple,  there  are  but  too  many  which 
are  followed  by  such  aggravated  ^mptoms  as  either 
prove  fatal  or  occasion  a necessity  for  amputation. 
And  in  other  instances  of  a less  grievous  description, 
when  the  patient  is  cured,  the  termination  of  danger 
is  not  w'ithout  an  anchylosis,  by  which  the  motion 
and  functions  of  the  joint  are  permanently  destroyed. 

The  experienced  Mr.  Hey  has  noticed  wounds  of 
the  joints,  and  made  some  pertinent  remarks  on  the 
subject.  He  states,  that,  in  these  cases,  the  utmost 
care  should  be  taken  to  prevent  inflammation,  “ Upon 
this  circumstance  chiefly  depends  a successful  termina- 
tion. I have  seen  (says  he)  many  large  wounds  of  the 
great  joints  healed  without  the  supervention  of  any 
dangerous  symptoms,  where  due  care  has  been  taken  to 
prevent  inflammation;  while  injuries,  apparently  tri- 
fling, will  often  be  followed  by  a train  of  distressing 
and  dangerous  consequences,  where  such  care  has  been 
neglected.  It  is  generally  easier  to  prevent  inflamma- 
tion in  the  joints  after  a wound,  than  to  arrest  its  pro- 
gress when  once  begun.  I speak  now  of  inflammation 
affecting  the  capsular  ligament.  A slight  degree  of 
redness  and  tenderness  in  the  integuments  only  is  of 
little  consequence;  but  when  the  capsular  ligament  be- 
comes inflamed,  the  formation  of  abscesses,  attended 
with  a high  degree  of  fever,  and  ultimately  a stiffness 
of  the  joint,  are  the  common  consequences,  if  the  life 
of  the  jiatient  is  preserved.”— (See  Practical  Obs.  in 
Surgerrj,p.  354,  edit.  2.) 

For  facts  in  confirmation  of  the  foregoing  account, 
I particularly  refer  to  several  cases  recorded  in  this 
last  publication,  p.  355,  et  seq.,  and  by  Boyer. — (Traiti 
des  Mai.  Chir.  t.  4,  p.  426,  ^-c.) 

When  the  large  joints,  particularly  the  knee,  are 
wounded,  the  stomach  is  frequently  very  much  af- 
fected. I formerly  saw,  under  the  care  of  Mr.  Best  of 
Newbury,  a man  who,  in  his  occupation  as  a wheel- 
wright, iiai)pened  to  give  himself  a wound,  by  which 
one  side  of  the  knee  was  laid  open ; a good  deal  of 
constitutional  disturbance  and  of  inflammation  and 
suppuration  ensued  ; but  what  particularly  struck  me, 
was  the  manner  in  which  the  stomach  was  dis-^ 
ordered. 

In  speaking  of  cartilaginous  substances  in  the  joints 
I shall  hiive  occasion  to  advert  again  to  the  danger  at- 
tendant on  woniulsof  these  parts;  and  the  same  fact 
IS  still  farther  consi<leied  in  the  articles  Amputation, 
Dislocations,  hnctures,  and  Gunshot  Wounds,  in 


JOINTS. 


101 


which  last  part  of  the  Dictionary  the  seiitiitieiits  of 
Baron  Larrey,  and  other  writers  on  military  surgery, 
are  laid  before  the  reader. 

Inflammation  of  joints,  if  we  exclude  from  consider- 
ation specific  cases,  may  be  said  usually  to  be  the  con- 
sequence of  a contusion,  sprain,  wound  ,or  some  other 
kind  of  injury;  but  with  respect  to  the  iiiflamination 
of  the  synovial  membrane,  as  described  by  Mr.  Brodie, 
no  cause  is  so  frequent  as  the  application  of  cold,  and 
hence  he  explains  the  frequency  of  this  disease  in  the 
knee,  and  its  rarity  in  the  hip  and  shoulder,  which  are 
covered  by  a thick  mass  of  flesh.  As  a late  writer  ob- 
serves, the  inflammation  arising  from  a wound  is  infi- 
nitely the  most  severe  after  it  has  once  commenced. — 
(JrtT/fts  on  Inflammation,  p.  157.) 

The  inflamed  joint  shows  the  common  symptoms  of 
inflammation;  viz.  preternatural  redness,  increased 
heat,  throbbing,  pain,  and  swelling,  while  the  constitu- 
tion is  also  disturbed  by  the  common  symptoms  of  in- 
flammatory fever.  It  deserves  notice,  how’ever,  that  in 
these  cases  the  constitutional  symptoms  are  often  ex- 
ceedingly severe,  and  the  pulse  is  more  frequent,  and 
less  full  and  strong,  than  when  parts  more  disposed  to 
return  to  a state  of  health  are  affected.  The  inflam- 
mation first  attacks  some  part  of  the  capsular  ligament, 
and  very  quickly  spreads  over  its  whole  extent,  as 
usually  happens  in  all  inflammations  of  smooth  serous 
membranes. 

The  capsules  of  the  joints  are  naturally  not  very  sen- 
sible; but,  like  many  other  parts  similarly  circum- 
stanced, they  often  become  acutely  painful  when  in- 
flamed. The  complaint  is  accompanied  with  an  in- 
creased secretion  of  the  synovia,  which  becomes  of  a 
more  aqueous,  and  of  a less  albuminous  quality,  than 
it  is  in  the  healthy  state.  Hence,  it  is  not  so  well  cal- 
culated for  lubricating  the  articular  surfaces,  and  pre- 
venting the  effects  of  friction,  as  it  is  in  the  natural  con- 
dition of  the  joint ; a circumstance  which  may  explain 
why  a grating  sensation  is  often  perceived  on  moving 
the  patella. 

The  capsular  ligaments,  like  other  parts,  are  fre- 
quently thickened  by  inflammation,  and  sometimes 
coagulating  lymph  being  effused  on  their  internal  sur- 
faces, organized  cartilaginous  or  osseous  bodies  are 
formed  within  the  joints. 

It  has  been  explained  by  Mr.  Brodie,  that  the  usual 
consequences  of  inflammation  of  the  synovial  mem- 
brane, or  capsular  ligament,  are;  1,  a preternatural  se- 
cretion of  synovia ; 2,  an  effusion  of  coagulating  lymph 
into  the  cavity  of  the  joint;  3,  a thickening  of  the  sy- 
novial membrane,  a conversion  of  it  into  a substance 
resembling  gristle,  and  an  effusion  of  coagulable  lymph, 
and  probably  of  serum,  into  the  cellular  structure,  by 
which  it  is  connected  with  the  external  parts.  The 
same  gentleman  has  seen  several  cases  vvliere,  from  the 
appearance  of  the  joint  and  the  symptoms,  there  was 
every  reason  to  believe  that  the  inflammation  had  pro- 
duced adhesions  of  the  reflected  folds  of  the  membrane 
to  each  other ; and,  in  dissection,  he  has  occasionally 
observed  adhesions  which  might  have  arisen  from  in- 
flamination  at  some  former  period.  “ These  effects  of 
inflammation  of  the  synovial  very  much  resemble 
those  of  inflammation  of  the  serous  membranes. 
There  are,  however,  some  points  of  difterence.  In  the 
former,  I have  reason  to  believe  that  suppuration  rarely 
takes  place  independently  of  ulceration ; but  this  is  a 
frequent  occurrence  in  the  latter.  Inflammation  of  the 
peritoneum  or  pleura,  though  very  slight  in  degree, 
and  of  very  shortdiiration,  terminates  in  the  effusion  of 
coagulable  lymph;  but  itisonlyviolentor  long-continued 
inflammation  which  has  this  termination  in  the  mem- 
branes of  joints.” — (Med.  Chir.  Trans,  vol.  4,  p.  216.) 

When  the  inflammation  attains  a high  pitch,  an  ab- 
scess may  occur  in  the  capsular  ligament,  which  at 
length  ulcerates,  and  the  pus  makes  its  way  beneath 
the  skin,  and  is  sooner  or  later  discharged  through  ul- 
cerated openings. 

An  abscess  rarely  tekes  place  in  an  important  articu- 
lation in  consequence  of  acute  inflammation,  without 
the  system  being  also  so  deranged  that  life  itself  is  im- 
minently endangered.  Severe  febrile  symptoms  al- 
ways afflict  the  patient,  and  occasionally  delirium  and 
coma  taking  place,  death  itself  ensues.  7’wo  .rapidly 
fatal  cases  of  ulceration  of  the  synovial  membrane, 
where  matter  had  formed  within  it  fron)  a sprain  of  the 
hip,  and  a contusion  of  the  shoulder,  are  recorded  by 
Mr.  Biodie.  — (Sec  Pathol.  Chir.  Obs.p.  65.) 


Ip.  these  cases,  the  inflammatory  fever  is  very  quickly 
converted  into  the  hectic;  indeed,  when  an  abscess  has 
taken  place  in  a large  joint,  in  consequence  of  acute  in- 
flammation, hectic  symptoms  almost  immediately  be- 
gin to  show  themselves,  and  the  sti-ong  actions  of  the 
common  inflammatory  fever  suddenly  subside. 

Local  consequences,  even  worse  than  those  above 
described,  may  follow  inflammation  of  a joint.  As  the 
layer  of  the  capsular  ligament  reflected  over  the  car- 
tilages of  the  articulation  is  often  inflamed,  the  carti- 
lages themselves  may  have  the  inflammation  commu- 
nicated to  them.  Parts  of  a cartilaginous  structure,  be- 
ing very  incapable  of  bearing  the  irritation  of  disease, 
often  ulcerate,  or,  in  other  words,  are  absorbed,  so  as  to 
leave  a portion  or  the  whole  of  the  articular  surface  of 
the  bones  completely  denuded  of  its  natural  covering. 
At  length  the  heads  of  the  bones  themselves  inflame 
and  become  carious;  or  the  consequence  may  be  an- 
chylosis. IMr.  Brodie  has  seen  some  cases  in  which 
there  was  extensive  destruction  of  the  cartilages,  ap- 
parently in  consequence  of  neglected  inflammation  of 
the  synovial  membrane ; but  he  believes  that,  in  most 
cases  where  ulceration  of  the  cartilage  is  combined 
with  such  inflammation,  the  former  is  the  primary  af- 
fection, and  the  latter  takes  place  subsequently,  in  con- 
sequence of  the  formation  of  an  abscess  within  the 
joint. — (Pathol,  and  Surg.  Obs.Src.p.ll.)  According 
to  Mr.  Brodie,  who  speaks  chiefly  of  the  inflammation 
which  begins  in  the  synovial  membrane  itself,  and  is 
not  communicated  to  it  from  other  textures,  the  disease 
very  seldom  attacks  young  children,  but  is  frequent  in 
adult  persons,  the  reverse  of  what  happens  in  some 
other  diseases  of  the  joints. 

The  inflammation  of  the  capsular  ligament,  or  sy- 
novial membrane,  .ft  equenlly  assumes  the  chronic  form, 
and  is  then  very  often  confounded  with  other  more 
serious  maladies,  under  the  general  appellation  of 
white  swelling.  The  disease  often  arises  from  cold, 
and  hence  is  more  common  in  the  knee  and  ankle 
than  in  the  hip  orshonlder.  It  may  also  arise  from  the 
immoderate  use  of  mercury,  and,  in  particular  consti- 
tutions, from  rheumatism  and  general  debility  of  the 
system.  In  these  instances,  it  often  leaves  one  joint 
and  attacks  another  ; and  it  is  less  severe,  and  less  dis- 
posed to  produce  effusion  of  coagulating  lymph,  or  a 
thickened  state  of  the  membrane,  than  when  it  is  ap- 
parently a local  disease. — (Brodie,  in  Med.  Chir. 
Trans,  vol.  4,  p.  218.)  In  the  latter  case,  the  disorder 
is  more  likely  to  assume  a severe  character,  and  may 
be  of  long  duration,  leaving  the  joint  with  its  functions 
more  or  less  impaired,  and  occasionally  terminating  in 
its  total  destruction.  The  following  are  the  chief 
symptoms  of  the  complaint,  pointed  out  by  Mr.  Brodie. 
At  first,  although  some  pain  is  felt  over  the  whole  joint, 
the  patient  refers  it  principally  to  one  spot,  and  it  is  not 
at  its  height  before  the  end  of  a week  or  ten  days. 
Sometimes,  even  at  this  period,  the  pain  is  trifling,  but 
sometimes  it  is  considerable,  and  every  motion  of  the 
joint  is  distressing.  In  a day  or  two  after  the  com- 
mencement of  the  pain,  the  joint  is  affected  with 
swelling,  which  at  first  arises  entirely  from  a collection 
of  fluid  in  its  cavity,  and  in  the  superficial  joints  an 
undulation  may  be  distinguished.  However,  after  the 
inflammation  has  prevailed  some  lime,  the  fluid  is 
rendered  less  perceptible,  either  in  consequence  of  the 
synovial  membrane  being  thickened,  or  the  effusion  of 
lymph;  and  the  more  solid  the  swelling  is  the  more  is 
the  mobility  of  the  joint  impaired.  The  form  of  the 
diseased  joint  does  not  correspond  to  that  of  the  heads 
of  the  hones  ; but  as  the  swelling  is  chiefly  caused  by 
the  distention  of  the  synovial  membrane,  “ its  figure 
depends  in  a greal  measure  on  the  situation  of  the 
ligaments  and  tendons,  which  resist  it  in  certain  di- 
rections, and  allow  it  to  take  place  in  others.  Thu.s, 
when  the  knee  is  affected,  the  swelling  is  principally 
observable  on  the  anterior  and  lower  part  of  the  thigh,” 
where  there  is  oidy  a yielding  cellular  structure  be- 
tween the  extensor  muscles  and  the  bone.  It  is  also 
often  considerable  in  the  spaces  between  the  ligament 
of  the  patella  and  the  lateral  ligaments,  because  at 
the.se  points  the  fatty  substance  is  propelled  outwards 
by  the  collection  of  fluid.  In  the  elbow,  the  swelling 
occurs  principally  above  the  olecranon,  tinder  the  ex- 
tensor muscles  of  the  forearm;  and  in  the  atikle,  it  is 
between  the  lateral  ligaments  and  the  tendons  in  front 
of  the  joint.  In  the  hip  and  shoulder,  where  the  dis- 
ease is  less  frequent,  the  fluid  cannot  be  felt,  but  the 


102 


JOINTS. 


swelling  is  perceptible  through  the  muscles.  In  the 
beginning  of  this  disease  in  the  hip,  a fulness  both  in 
the  groin  and  nates  may  be  remarked  ; but  afterward 
the  nates  become  flattened,  and  the  glutei  wasted  from 
want  of  use.  Tire  pain  is  usually  confined  to  the  hip, 
but  Mr.  Brodie  has  seen  cases  in  which  it  was  also  re- 
ferred to  the  knee.  It  may  be  discriminated  from  the 
case  in  which  the  cartilages  of  the  hip  are  ulcerated, 
by  observing,  that  the  pain  is  more  severe  in  the  be- 
ginning than  in  the  advanced  stage  of  the  disease; 
it  never  amounts  to  the  excruciating  sensation  felt  in 
the  other  disease ; and  it  is  aggravated  by  motion,  but 
not  by  pressing  the  cartilaginous  surfaces  against  each 
other.  The  wasting  of  the  glutaei  is  also  preceded  by 
a fulness  of  the  nates.  After  the  inflammation  has 
subsided,  the  fluid  is  absorbed,  and  the  joint  frequently 
regains  its  natural  figure  and  mobility  ; but  in  the  ma- 
jority of  cases,  stiffness  and  swelling  remain,  and  the 
patient  continues  very  liable  to  relapse,  the  pain  re- 
turning, and  the  swelling  being  augmented,  whenever 
the  patient  exposes  himself  to  cold,  or  exercises  the 
limb  a great  deal.  In  cases  where  the  synovial  mem- 
brane is  thickened,  a slow  kind  of  inflammation  some- 
times continues  in  the  part,  notwithstanding  the  fluid 
has  been  absorbed,  and  the  principal  swelling  hassub- 
sided,  the  disease  at  length  extending  to  the  cartilages, 
suppuration  taking  place,  and  the  articular  surfaces 
being  completely  destroyed.  According  to  Mr.  Brodie,  in 
this  advanced  stage,  the  history  of  the  disease,  and  not 
its  present  appearance,  is  the  only  thing  by  which  one  can 
learn  whether  the  primary  affection  was  inflammation 
of  thesynovial  membraneor  ulceration  of  the  cartilages. 
Though  such  is  the  most  common  character  of  inflam- 
mation of  the  synovial  membrane,  it  isadmitted,  that  its 
nature  is  sometimes  more  acute,  exhibiting  the  symp- 
toms mentioned  at  the  beginning  of  this  section. — 
(See  Pathol,  and  Surg.  Obs.  p.  21,  ($-c.)  It  is  remarked 
by  Mr.  Wilson,  that,  whencoagulable  lymph  is  effused, 
the  whole  of  it  does  not  always  adhere  to  the  inflamed 
surface,  but  some  of  it  forms  flakes,  which  float  in  the 
fluid  within  the  joint,  in  masses  large  enough  to  be 
sometimes  felt  through  the  capsular  ligament.  In  other 
instances  the  lymph  becomes  solid,  adheres  to  the  in- 
side of  the  synovial  membrane,  atid  becomes  vascular. 
The  surface  of  this  adventitious  coating  is  sometimes 
smooth;  but  occasionally  it  forms  thick  projecting 
masses,  of  different  degrees  of  thickness  and  length, 
and  so  numerous  as  to  conceal  every  part  of  the 
original  smooth  surface  of  the  synovial  membrane,  as 
e.xemplified  in  a preparation  in  Windmill-street. — (On 
the  Skeleton  and  Diseases  of  Bones  and  Joints.,  p.  319.) 

When  inflammation  of  the  synovial  membrane  has 
arisen  from  a protracted  or  ill-conducted  course  of 
mercury,  Mr.  Brodie  recommends  a trial  of  sarsapa- 
rilla; and  when  the  disorder  is  connected  with  rheu- 
matism, the  medicines  advised  are  opium  with  dia- 
phoretics, Preparations  of  colchicum  autumnale,  and 
other  usual  remedies  for  rheumatic  complaints.  In 
some  instances,  however,  in  which  several  joints  were 
affected,  this  gentleman  has  known  benefit  derived 
from  moderate  doses  of  mercury. — (P.  31.)  But 
whether  the  disease  be  local,  or  dependent  on  the  state 
of  the  constitution,  Mr.  Brodie  considers  topical  reme- 
dies of  most  importance. 

It  will  considerably  shorten  what  we  have  to  say 
concerning  the  treatment  of  inflamed  joints,  to  observe, 
that,  in  the  acute  form  of  inflammation  of  the  synovial 
membrane,  the  antiphlogistic  plan,  in  the  full  sense  of 
the  expression,  is  to  be  strictly  adopted.  But  as  there 
is  a variety  of  means  often  adapted  to  the  same  pur- 
pose, it  seems  necessary  to  offer  a few  remarks  on  those 
which  lay  the  greatest  claim  to  our  commendations. 

There  are  not  many  surgical  cases  in  which  general 
and  especially  topical  bleeding  is  more  strongly  indi- 
cated. The  violence  of  the  inflammation,  and  the 
strength,  age,  and  pulse  of  the  patient,  must  deter- 
mine with  regard  to  the  use  of  the  lancet  ; but  the 
application  of  leeches  may  be  said  to  be  invariably 
proper.  When  the  leeches  fall  off,  the  bleeding  is  to  be 
promoted  by  fomenting  the  part.  The  surgeon  should 
daily  persist  in  this  practice  until  the  acute  stage  of  the 
inflammation  has  subsided.  As  Mr.  Brodie  observes, 
attention  should  also  be  paid  to  the  state  of  the  bowels, 
and  saline  draughts  and  diaphoretic  medicines  be  ex- 
hibited.— {Pathol,  and  Surg.  Obs.  p.  32.)  In  con- 
junction with  this  treatment  the  lotio  plumbi  acetatis 
piusi  be  employed. 


In  a few  instances,  however,  the  patient  seems  to 
derive  more  ease  and  benefit  from  the  employment  of 
fomentations  and  emollient  poultices,  which,  according 
to  Mr.  Brodie,  is  the  case  when  the  swelling  has  been 
produced  rapidly,  and  is  attended  with  considerable 
tension.  But  on  this  point,  as  I have  remarked  in 
speaking  of  inflammation,  the  feelings  of  the  afflicted 
should  always  be  consulted ; for  if  the  pain  be  mate- 
rially alleviated  by  this  or  that  application,  its  employ- 
ment will  hardly  ever  be  wrong. 

Nothing  more  need  be  said  concerning  the  rest  of  the 
treatment  proper  during  the  vehemence  of  the  inflam- 
mation, as  the  duty  of  the  surgeon  is  not  materially 
different  from  what  it  is  in  other  cases  where  organs 
of  importance  are  inflamed. 

As  soon  as  the  acute  stage  of  the  affection  has  sub- 
sided, the  grand  object  is  to  remove  its  effects.  These  are 
a thickened  state  of  the  capsular  ligament  and  parts 
surrounding  the  articulation;  a stiffness  of  the  joint, 
and  pain,  when  it  is  moved ; fluid  in  the  capsule,  &c. 

At  first,  as  Mr.  Brodie  has  observed,  the  joint  should 
be  kept  perfectly  quiet,  and  blood  should  be  several 
times  taken  from  the  part,  by  means  of  leeches  and 
cupping.  The  latter  is  the  method  to  which  the  pre- 
ceding writer  gives  the  preference.  The  use  of  cold 
evaporating  lotions  is  also  to  be  continued  until  the  in- 
flammation has  farther  abated,  when  a blister  may  be 
applied,  and  kept  open  with  the  savin  cerate,  or  a re- 
petition of  blisters  kept  up,  as  preferred  by  Mr.  Brodie. 
“ The  blisters  (he  says)  should  be  of  considerable  size; 
and  if  the  joint  be  deep-seated,  they  may  be  applied  as 
near  to  it  as  possible;  but  otherwise  at  a little  distance. 
Thus,  when  the  synovial  membrane  of  the  hip  is  af- 
fected, they  may  be  placed  on  the  groin  and  nates; 
but  when  that  of  the  wrist  is  inflamed,  they  should  be 
applied  to  the  lower  part  of  the  forearm.”  Mr.  Brodie 
tliinks  blisters  have  more  effect  than  any  other  means 
in  removing  the  swelling;  but,  excepting  in  very  slight 
cases,  he  very  rightly  condemns  their  use  unpreceded 
by  the  abstraction  of  blood.  After  the  subsidence  of 
the  inflammation,  moderate  exercise  of  the  joint  and 
stimulating  liniments  are  recommended.  The  camphor 
liniment  is  to  be  strengthened  with  the  addition  of 
liquor  ammoniae,  or  tinctura  lytte,  or  the  following 
formula,  adopted  as  that  to  which  the  above  gentleman 
seems  to  give  the  preference.  OJei  olivae  5 i^s.  acid, 
sulph.  1 ss.  M.  In  this  stage  of  the  disease,  I find  tlie 
tincture  of  iodine  possesses  considerable  efficacy,  parti- 
cularly when  blended  with  the  soap  liniment  in  the 
proportion  of  3j.  to  | ij.  Mr.  Buchanan  applies  the 
tincture  of  iodine  to  the  integuments,  and  his  accounts 
represent  it  as  being  rapidly  absorbed  from  the  surface 
of  the  skin,  and  acting  very  powerfully  in  di.spersing 
the  thickening  and  induration  of  various  diseases  and 
abscesses  of  the  joints.  Indeed,  he  prefers  such  ap- 
plication of  iodine  to  its  internal  exhibition,  and  states 
that  its  effects  are  produced  without  the  aid  of  friction, 
so  that  it  admits  of  being  employed  with  advantage 
even  when  inflammation  is  present. — {Essay  on  a 
Mew  Mode  of  Treatment  of  Diseased  Joints,  ire. 
Bond.  1828.)  Mr.  Brodie  speaks  favourably  of  the 
effects  of  the  antimonial  ointment,  in  the  proportion  of 
3j.  of  the  antim.  tart,  to  5j-  ung.  cetacei.  Pla.sters 
of  gum  ammoniac  he  regards  as  sometimes  useful  in 
preventing  relapses.  Issues  and  setons  are  never  ser- 
viceable, unless  ulceration  of  the  cartilages  has  begun. 
For  the  removal  of  the  remains  of  the  swelling  and. 
stiffness,  Mr.  Brodie  joins  other  v\riters  in  praising  the 
efficacy  of  friction  and  exercise.  The  friction  may  be 
made  with  camphorated  mercurial  ointment,  or  with 
powdered  starch ; but  the  friction  is  to  be  employed 
with  caution,  as  otherwise  it  may  produce  a return  of 
the  inflammation.  When  this  happens,  it  is  to  be  dis- 
continu(‘d,  and  blood  taken  from  the  part.  On  the 
whole,  Mr.  Brodie  appears  to  consider  friction  better 
adapted  to  cases  where  the  stiffness  depends  upon  the 
state  of  the  externa!  parts,  than  to  others  where  it 
arises  from  disease  in  the  joint  itself.  With  respect  to 
the  plan  of  allowing  a column  of  warm  water  to  fall 
on  the  part,  as  suggested  by  Le  Bran,  and  practised  at 
the  watering-places,  he  allows  that  it  is  beneficial,  but 
that  it  requires  the  same  caution  as  the  employment 
of  friction. — {Pathol,  and  Surg.  Obs.  p.  30,  ,^c.) 

I have  met  with  several  instances  in  which  lotions, 
composed  of  vinegar  and  muriate  of  ammonia,  suf- 
ficed for  the  removal  of  the  chronic  complaints,  left 
after  Lite  acute  stage  of  the  disorder.  The  tincture  and 


JOINTS. 


103 


ointment  of  iodine  are  also  valuable  applications ; and 
they  may  be  blended  with  other  liniments,  which  will 
thus  be  rendered  more  efficient. 

The  severity  of  the  constitutional  symptoms  is 
mostly,  if  not  always,  greater  when  the  inflammation 
of  a large  joint  arises  from  a wound,  than  when  it  is 
the  consequence  of  a bruise  or  sprain. 

Loose  Cartilages  in  Joints. — Hard,  roundish,  or  flat- 
tened bodies,  mostly  of  a cartilaginous  nature,  are 
sometimes  formed  within  the  capsular  ligaments,  occa- 
sioning more  or  less  pain  in  the  aflected  joints,  and  a 
considerable  impediment  to  the  freedom  of  their  move- 
ments. The  disorder,  though  not  noticed  by  any  of 
the  very  ancient  writers,  is  far  from  being  uncommon. 
Pari  is  the  first  who  speaks  of  it:  he  says,  that  a hard., 
polished,  white  body,  of  the  size  of  an  almond,  was  dis- 
charged from  the  knee  of  a patient,  in  the  year  1558, 
in  wfiich  he  had  made  an  incision  for  an  aqueous  apos- 
tume  (without  doubt  a hydrops  articuli). — {Liv.  25, 
chap.  15,  p.  7~2.)  A hundred  and  thirty-three  years 
afterward,  viz.  in  1691,  Pechlin  published  the  full  de- 
tails of  another  case,  in  which  a cartilaginous  body 
was  successfully  extracted  from  the  knee. — {Observai. 
Pkysice-Med.  ebs.  38,  306.)  Dr.  A.  Monro,  in  1726, 

dissected  Uie  knee-joint  of  a woman,  who  had  been 
hung,  and  found  in  the  articulation  a cartilaginous 
body,  of  the  shape  and  size  of  a small  bean.  These 
were  the  only  examples  of  the  disease  known  before 
the  year  1736,  at  which  period  Mr.  Simpson  cut  out  of 
the  knee  a similar  substance,  which  he  supposed  at  the 
time  of  the  operation  was  only  beneath  the  skin.— 
(See  Edinb.  Med.  Essays,  vol.  4.)  But  of  late  y'ears 
the  disease  has  been  freqviently  noticed  and  described, 
particularly  by  Bromfield,  Hewit,  Middleton,  Gooch, 
Ford,  Home,  Bell,  Abernethy,  and  Brodie,  in  England  ; 
by  Henckel,  'J’heden,  and  Loeffler,  in  Germany;  and  by 
Desault  and  Sabatier,  in  France.  Hence,  as  Boyer  re- 
marks, it  is  now  as  well  known,  as  most  others,  to 
which  the  joints  are  subject. — {Traitd  des  Mai.  Chir. 
t.  4,  p.  434.) 

Such  detached  and  moveabie  cartilages  are  not  pecu- 
liar to  the  knee,  as  they  occur  in  other  joints ; yet  they 
are  most  frequently  met  with  in  the  knee,  and  it  is  in 
tJiis  joint  that  they  produce  symptoms  which  render 
them  the  object  of  a surgical  operation.  Morgagni 
and  B.  Bell  met  with  them  in  the  ankle;  Haller  in  the 
joint  of  the  jaw ; and  Hey  in  the  elbow. 

According  to  Sir  Everard  Home,  these  substances 
are  analogous  in  their  structure  to  bone;  but  in  their 
external  appearance  they  bear  a greater  resemblance 
to  cartilage.  They  are  not,  however,  always  exactly 
of  the  same  structure,  being  in  some  instances  softer 
than  in  otliers.  Their  external  surface  is  smooth  and 
polished,  and,  being  lubricated  by  the  synovia,  allow's 
them  to  be  moved  readily  from  one  part  of  the  joint  to 
another.  They  seldom  remain  long  at  rest  w’hile  tlie 
limb  is  in  motion  ; and  w'hen  they  happen  to  be  in 
situations  where  they  are  pressed  upon  with  force  by 
the  different  parts  of  the  joint,  they  occasion  considera- 
ble pain,  and  materially  interfere  with  its  necessary 
motions. 

The  circumstance  of  tlieir  being  loose,  and  having 
no  visible  attachment,  made  it  difficult  to  offer  good 
conjectures  respecting  their  formation ; and  according 
to  Sir  E.  Home,  no  satisfactory  account  of  their  origin 
had  been  given  when  Mr.  Hunter  made  his  observa- 
tions. In  the  course  of  his  experiments,  instituted  with 
tlicview  of  proving  a living  principle  in  the  blood,  Mr. 
Hunter  was  naturally  induced  to  attend  to  the  pheno- 
mena which  took  place  w’hen  that  fluid  was  extrava- 
sated,  whether  in  consequence  of  accidental  violence 
or  other  circumstances.  The  first  change  he  found  to 
Ixf  conjiilation  ; and  the  coagulum  thus  formed,  if  in 
contact  with  living  parts,  did  not  produce  an  irritation 
similar  to  extraneous  matter,  nor  was  it  absorbed  and 
taken  back  into  the  constitution,  but  in  many  instances 
preserved  its  living  principle  and  became  vascular,  re- 
cj-iving  branches  from  the  neighbouring  blood-vessels 
for  its  support  ; it  afterward  underwent  changes,  ren- 
dering it  similar  to  the  parts  to  wliich  it  was  attached, 
and  which  supplied  it  with  nourishment.  When  a 
coagulum  adhered  to  a surface  which  varied  its  posi- 
tion, the  attachment  was  rendered  in  some  instances 
pendulous,  and  in  others  it  was  entirely  broken. 

Hence  it  was  easy  to  explain  the  mode  in  which 
those  pendulous  boilies  are  formed,  which  are  some- 
times attached  to  the  inside  of  circumscribed  cavities. 


and  the  principle  being  established,  it  became  equally 
easy  for  Mr.  Hunter  to  apply  it  under  other  circum- 
stances, since  it  is  evident  from  a known  law  in  the 
animal  economy,  that  extravasated  bloqd,  when  ren- 
dered an  organized  part  of  the  body,  can  assume  the 
nature  of  the  parts  into'  which  it  is  effused,  and  con- 
sequently the  same  coagulum  which  in  another  situa- 
'tion  might  form  a soft  tumour,  wmuld,  when  situated 
on  a hone  or  in  the  neighbourhood  of  bone,  often  form 
a hard  one.  The  cartilages  found  in  the  knee-joint, 
therefore,  appeared  to  him  to  originate  front  a deposite 
of  coagulated  blood  upon  the  end  of  one  of  the  bones, 
which  had  acquired  the  nature  of  cartilage  and  had 
afterward  been  separated.  This  opinion  was  farther 
confirmed  by  the  examination  of  joints  which  had  been 
violently  strained,  or  otherwise  injured,  where  the  pa- 
tients had  died  at  different  periods  after  the  accident. 
In  some  of  these  cases  there  were  small  projecting 
parts,  preternaturally  formed,  as  hard  as  cartilage,  and 
so  situated  as  to  be  readily  knocked  off  by  any  sudden 
or  violent  motion  of  the  joint. — {Trans,  for  the  Im- 
provement of  Med.  and  Chir.  Knowledge,  vol.  1.) 

Mr.  Brodie  met  with  two  cases,  however,  in  which 
the  loose  bodies  were  of  a different  nature,  and  had  a 
different  origin  from  that  referred  to  by  Sir  E.  Home. 
Sotnetimes  disease  causes  a bony  ridge  to  be  formed, 
like  a small  exostosis,  round  the  margin  of  the  carti- 
laginous surfaces  of  the  joint.  In  the  two  examples 
alluded  to,  this  preternatural  growth  of  bone  had  taken 
place,  and,  in  consequence  of  the  motion  of  the  parts, 
portions  of  it  had  been  broken  off  and  lay  loose  in  the 
cavity  of  the  joint. — {Med.  and  Chir.  Trans,  vol.  4,  p. 
276.)  And  in  a more  recent  publication  he  remarks, 
that  in  the  majority  of  cases  which  he  has  met  with, 
no  inflammation  preceded  the  formation  of  these  pre- 
ternatural substances,  and  therefore  he  thinks  it  pro- 
bable that,  in  some  instances,  they  are  generated  like 
other  tumours  by  some  different  process.  He  farther 
observes,  that  they  appear  to  be  situated  originally 
either  on  the  external  surface,  or  in  the  substance  of 
the  synovial  membrane,  since  before  they  become  de- 
tached, a thin  layer  of  the  latter  may  be  traced  over 
them. — {Pathological  and  Surgical  Obs.p.  298.) 

One  or  more  of  these  preternatural  bodies  may  be 
formed  in  the  same  joint.  Sir  E.  Home  mentions  one 
instance  in  which  there  were  three ; they  are  commonly 
about  the  size  of  a horse-bean,  often  much  smaller,  and 
sometimes  considerably  larger ; when  very  large,  they 
do  not  give  so  much  trouble  to  the  patient  as  the 
smaller  kind.  A soldier  of  the  56th  regiment  had  one 
nearly  as  big  as  the  patella,  which  occasioned  little 
uneasiness,  being  too  large  to  insinuate  itself  into  the 
moving  parts  of  the  joint.  Morgagni  saw  twenty-five 
in  the  left  knee  of  an  old  woman,  who  died  of  apo- 
plexy; and  Haller  met  with  no  less  than  twenty,  in  the 
articulation  of  the  lower  jaw.  When  there  are  several 
in  the  same  joint,  it  is  observed,  that  their  size  is 
generally  small.— (Boyer,  Traiti  des  Mai.  Chir.  t.  4, 
p.  436.) 

The  diagnosis  of  this  disease,  as  Boyer  observes,  is 
seldom  attended  with  any  difficulty.  When  the  forma- 
tion of  the  extraneous  substances  follows  a fall  or  blow 
upon  the  joint,  the  complaint  begins  with  a swelling  of 
the  surrounding  soft  parts,  and  upon  the  subsidence  of 
this  swelling,  which  lasts  for  a time  more  or  less  long, 
the  presence  of  the  little  cartilaginous  tumours  is  indi- 
cated by  certain  symptoms  which  are  peculiar  to  them. 
In  persons  who  have  had  no  blow  nor  fall  upon  the 
knee,  the  disease  sometimes  commences  with  a more 
or  less  acute  pain  in  the  joint,  with  or  without  swell- 
ing of  the  surrounding  soft  parts,  and  which  affection 
is  usually  regarded  as  rheumatism.  To  these  first 
symptoms,  which  are  common  both  to  cases  of  foreign 
bodies  in  the  joints,  and  other  diseases  of  these  parts, 
are  soon  added  other  particular  signs,  by  which  the 
nature  of  the  case  is  evinced. 

As  the  extraneous  bodies  are  in  general  free  and 
moveable  in  the  joint,  they  can  ea.sily  be  made  to  slip 
about  from  one  part  of  the  articulation  to  another ; a 
circumstance  which  is  facilitated  by  the  smoothness  of 
their  surface,  as  well  as  by  the  synovia,  which  is 
mostly  in  larger  quantity  than  natural.  According  to 
the  situation  which  they  happen  to  occupy,  sometimes 
they  produce  acute  pain  ; sometimes  no  pain  whatever. 
When  they  lodge  in  a depression  where  they  are  not 
compressed,  they  cause  no  pain;  and  if  they  could  be 
aUvava  kept  in  this  position,  their  presence  would  not 


104 


JOINTS.  ' 


he  likely  to  excite  any  inconveniences.  But  when 
tlicy  get  between  the  articular  surfaces,  which  in  cer- 
tain postures  of  the  limb  come  into  contact  with  each 
other,  the  following  are  the  eftects  of  the  compression. 
Sometimes  the  extraneous  substance  suddenly  glides 
between  the  condyles  of  the  thigh  bone  and  head  of 
the  tibia,  and  while  it  lodges  there,  excites  acute  pain 
in  certain  directions  of  the  limb,  and  instantaneous 
loss  of  the  power  of  moving  the  knee.  But  when  it 
shifts  its  place  again,  either  naturally  or  accidentally, 
during  an  examination  of  the  affected  part,  the  com- 
pression is  removed,  the  pain  all  at  once  ceases,  and 
the  functions  of  the  joint  are  as  suddenly  restored. 
Most  frequently  when  the  extraneous  body  gets  behind 
the  patella,  or  the  ligament  of  the  patella,  as  the  pa- 
tient is  walking,  he  is  compelled  to  make  a sudden 
stop,  and  would  fall  down  from  the  acuteness  of  the 
pain  if  nothing  were  at  hand  to  save  him.  Some  pa- 
tients have  been  observed,  however,  who  experienced 
no  pain  in  these  circumstances.  Reimaius  mentions 
a man  who  suffered  great  pain  and  could  not  move  his 
leg  when  the  extraneous  body  was  at  the  side  of  the 
joint;  but  was  immediately  relieved  by  pushing  it 
under  the  patella.  B.  Bell  met  with  cases  in  which 
the  pain  was  so  violent  at  the  instant  when  the  patients 
ut  their  legs  in  certain  postures,  that  fainting  was 
rought  on,  and  they  were  so  afraid  of  a return  of  the 
suffering,  that  they  preferred  remaining  perfectly  quiet 
to  running  any  risk  of  causing  the  pain  again.  He 
even  asserts,  that  he  had  known  some  persons  in  whom 
the  least  motion  of  the  limb  would  cause  such  pain  as 
awoke  them  out  of  the  deepest  sleep.  The  pain,  ex- 
cited by  the  situation  of  the  extraneous  body  between 
the  articular  surfaces,  recurs  at  intervals  more  or  less 
long,  and  always  in  consequence  of  some  motion  or 
exertion.  Sometimes  it  ceases  directly  by  the  effect  of 
a movement  contrary  to  that  which  produced  it ; but 
most  frequently  it  continues,  and  then  the  surrounding 
soft  parts  are  affected  with  swelling,  which  obliges  the 
patient  to  keep  his  bed  and  have  recourse  to  emollient 
anodyne  applications.  Sometimes,  as  I have  already 
noticed,  the  foreign  body  lies  at  a part  of  the  joint 
where  it  causes  no  inconvenience,  and  makes  no  pres- 
sure on  the  articular  surfaces.  In  this  case  all  the 
symptoms  have  been  known  to  cease  for  several 
months,  so  that  the  patient  imagined  himself  cured, 
when  suddenly  the  foreign  body  was  urged  by  some 
effort  into  another  situation,  where  it  occasioned  a re- 
newal of  all  the  former  pain. 

The  foregoing  circumstances  afford  strong  presump- 
tive evidence  of  the  presence  of  extraneous  carti- 
laginous substances  in  the  joint;  but  they  do  not 
amount  to  certainty ; this  can  only  be  acquired  by  the 
touch,  In  handling  the  knee  of  the  patient,  the  sur- 
geon feels  a hard,  prominent  substance,  which  slips 
about  under  his  fingers  and  glides  under  the  patella,  or 
the  ligament  of  this  bone,  and  sometimes  under  the 
tendon  of  the  extensor  muscles  of  the  leg,  from  one 
side  of  the  joint  to  the  oihei.  The  extraneous  body 
may  make  its  appearance  either  at  the  inside  or  the 
outside  of  the  articulation;  but  it  most  frequently 
presents  itself  at  the  former  part,  which  is  the  broadest 
and  most  sloping,  while  the  capsular  ligament  there  is 
loosest.  Desault  met  with  one  instance,  in  which  the 
capsular  ligament  and  soft  parts  were  so  lodse  that  the 
patient  could  turn  the  extraneous  substance  round  and 
round. 

In  general,  the  complaint  is  not  dangerous ; but  as  it 
is  painful,  and  obstructs  or  often  prevents  walking,  and 
usually  can  be  cured  only  by  an  operation  which  has 
sometimes  had  fatal  consequences,  we  cannot  be  too 
much  upon  our  guard  in  delivering  a prognosis. 

It  is  only  in  the  knee  that  the  disease  ever  becomes 
so  troublesome  as  to  require  an  operation,  or,  indeed, 
any  surgical  treatment. 

if  we  except  making  an  incision  into  the  joint,  for 
the  purpose  of  extracting  the  cartilaginous  tumours, 
we  are  not  acquainted  with  any  certain  means  of 
freeing  a patient  from  the  inconvenience  of  the  com- 
plaint. To  this  plan,  the  danger  attendant  on  all 
wounds  of  so  large  an  articulation  as  the  knee,  is  a 
very  serious  objection.  Middleton  and  Gooch  endea- 
voured Ito  conduct  the  extraneous  body  into  a situa- 
tion where  it  produced  no  pain,  and  to  retain  it  in  that 
position  a long  time  by  bandages,  under  the  idea  that 
the  cartilaginous  substance  would  adhere  to  the  con- 
tiguous parts,  and  occasion  no  future  trouble.  Some 


will  be  inclined  to  think,  that  no  positive  conclusion 
ought  to  be  drawn  from  the  cases  brought  forward  by 
these  gentlemen,  because  they  had  no  opportunity  of 
seeing  tbeir  patients  again  at  the  end  of  a reasonable 
length  of  time ; and  we  know  that  loose  cartilages  in 
the  joints  sometimes  disappear  for  half  a year,  and 
then  make  their  appearance  again.  Yet,  perhaps,  tlie 
very  circumstance  of  the  patients  not  applying  again, 
may  justify  the  inference  that  sullicient  relief  had  been 
obtained. 

However,  it  should  not  be  concealed  that  this  method 
was  also  tried  in  St.  George’s  Hospital  w'llioul  benefit, 
and  that  in  one  case  the  pain  was  increased  by  it. — 
(See  lieirnarus  de  Fungo  Articulorum^  ^ 27,  54,  ij-c.) 

Mr.  Hey,  aware  of  the  dangerous  symptoms  which 
have  occasionally  resulted  from  the  most  simple  wounds 
penetrating  the  knee-joint,  was  induced  to  try  the  effi- 
cacy of  a laced  knee-cap,  and  the  cases  which  he  has 
adduced  clearly  demonstrate,  that  the  benefit  thus  ob- 
tained is  not  temporary,  at  least  as  long  as  the  patient 
continues  to  wear  the  bandage.  In  one  case  the  me- 
thod had  been  tried  for  ten  years,  with  all  the  success 
which  the  patient  could  desire,  Boyer  also  made  one 
patient  use  a knee-cap  for  a year  ; after  which  it  w'as 
left  off,  the  patient  appearing  cured.  And,  in  a second 
instance,  the  same  practitioner  tried  the  plan,  which 
put  a stop  to  the  pain,  and  enabled  the  patient  to  walk 
with  ease;  but  it  was  not  known  whether  the  method 
was  properly  continued,  as  the  patient  had  not  latterly 
been  seen. — {Boyer,  Traiti  des  Mai.  Chir.  t.  4,p.  444.) 

Contemplating  tlie  evidence  upon  this  point,  and  the 
perilous  symptoms  sometimes  following  wounds  of  the 
knee-joint,  I am  decidedly  of  opinion,  that  the  effect 
of  a knee-cap,  or  of  a roller  and  compress,  applied  over 
the  loose  cartilage,  ought  generally  to  be  tried  before 
recourse  is  had  to  excision.  I say  generally,  because 
the  conduct  of  the  surgeon  ought,  in  such  cases,  to  be 
adapted  to  the  condition  and  inclination  of  the  patient. 
If  a man  be  deprived  of  his  livelihood  by  not  being 
able  to  use  his  knee ; if  he  canhot  or  will  not  take  the 
trouble  of  wearing  a bandage;  if  he  be  urgently  de- 
sirous of  running  the  risk  of  the  operation  after  things 
have  been  impartially  explained  to  him ; if  a bandage 
should  not  be  productive  of  sufficient  relief ; and  lastly, 
if  excessive  pain,  severe  inflammation  of  the  joint,  a 
great  deal  of  symptomatic  fever,  and  lameness,  should 
frequently  be  produced  by  the  complaint  (see  Brodie's 
Pathological  and  Surg.  Obs.  p.  299),  I think  it  is  the 
duty  of  asurgeon  to  operate'.  Under  such  circumstances 
I lately  removed  a loose  cartilage  of  considerable  size 
from  a gentleman’s  knee,  without  the  previous  trial  of 
pressure;  and  the  result  was  perfectly  successful.  It 
is  very  certain  that  success  has  generally  attended  the 
operation;  but  small  as  the  chance  is  of  losing  the 
limb,  and  even  life,  in  the  attempt  to  get  rid  of  the  dis- 
ease, since  the  inconveniences  of  the  complaint  are,  in 
most  cases,  very  bearable,  and  are  even  capable  of  pal- 
liation by  means  of  a bandage,  endangering  the  limb 
and  life  in  any  degree  must  seem  to  many  persons 
contrary  to  the  dictates  of  prudence.  At  all  events, 
we  must  agree  with  Boyer,  that,  as  the  laced  knee-cap 
can  do  no  harm,  we  ought  always  to  make  trial  of  it, 
and  never  perform  the  operation  except  when  pressure 
does  not  answer,  and  the  return  of  frequent  and  violent 
pain  makes  the  employment  of  the  knife  necessary. — 
(See  Traite  des  Mai.  Chir.  t.  4,  p.  445.) 

I am  ready  to  allow,  with  M.  Brochier,  that  the  dan- 
ger attendant  on  woundsof  the  laige  joints,  has  always 
been  exaggerated  in  consequence  of  ancient  preju- 
dices.—Journ.  vol.  2.)  But,  making  every 
allowance  for  the  influence  of  projiuiice,  a man  must 
be  very  skeptical  indeed  who  does  not  consider  the 
wound  of  so  large  a joint  as  the  knee  attended  with 
real  cause  for  the  apprehension  of  damrer.  At  the  end 
of  Mr.  Ford’s  case  {Med.  Ohs.  and  Inquiries,  vol.  5), 
we  read  on  the  subject  of  cutting  loose  cartilages  out 
of  the  knee  ; “ The  society  have  been  informed  of  se- 
veral cases  in  which  the  operation  has  been  performed  ; 
some,  like  tliis,  have  healed  up  without  any  trou- 
ble; others  have  been  followed  by  violent  inflamma- 
tion, fever,  and  death  itself.”  A case  was  lately  pub- 
lished, in  which  the  patient  very  nearly  lost  his  life  from 
suppuration  in  tlie  knee-joint  after  this  operation. — 
{See  Kirby's  Cases,  p.  75.)  In  the  same  work,  refer- 
ence is  also  made  to  two  other  cases,  which  actually 
had  a fatal  termination  {p.  82) ; and  even  in  Mr.  Kir- 
by’s own  instance,  the  recovery  was  not  eftected  with- 


JOINTS. 


105 


out  Uie'entirc  loss  of  the  motions  of  the  knee.  An  ex- 
ample, in  which  the  patient  died  after  the  operation, 
in  St.  Bartholomew’s  Hospital,  must  be  fresh  in  the  re- 
collection of  many  students. 

As  the  disorder  is  often  attended  with  a degree  of 
heat  and  tenderness  in  the  articulation ; as  the  danger 
of  the  operation  is,  in  a great  measure,  proportioned  to 
the  subsequent  inflammation  ; and  as  much  of  the 
danger  is  at  once  removed  if  the  wound  unite  by  the 
first  intention;  the  advice  to  keep  the  patient  in  bed  a 
few  days  before  operating,  to  apply  leeches  and  cold 
saturnine  lotions  to  the  knee  during  the  same  time, 
and  to  exhibit  beforehand  a saline  purgative,  is  highly 
prudent. 

I shall  next  introduce  an  account  of  the  plan  of  ope- 
rating, as  described  by  several  of  the  best  modern  sur- 
geons. 

As  these  loose  bodies  cannot  always  be  found,  no 
time  can  be  fixed  for  the  operation  ; but  the  patient, 
who  will  soon  become  familiar  with  his  own  complaint, 
must  arrest  them  when  in  a favourable  situation,  and 
retain  them  there  till  the  surgeon  can  be  sent  for. 

“ Before  the  operation,  the  limb  should  be  extended 
upon  a table  hi  a horizontal  position,  and  secured  by 
means  of  assistants;  the  loose  cartilages  are  to  be 
pushed  into  the  upper  part  of  the  joint  above  the  pa- 
tella, and  then  to  one  side ; the  inner  side  is  to  be  pre- 
ferred, as  in  that  situation  only  the  vastus  internus 
muscle  will  be  divided  in  the  operation.  Should 
there  be  several  of  these  bodies,  they  must  be  all  se- 
cured, or  the  operation  should  be  postponed  till  some 
more  favourable  opportunity,  since  the  leaving  of  one 
will  subject  the  patient  to  the  repetition  of  an  opera- 
tion not  only  painful  but  attended  with  some  degree 
of  danger. 

“ The  loose  bodies  are  to  be  secured  in  the  situation 
above  mentioned  by  an  assistant;  a task  not  easily 
performed  while  they  are  cut  upon,  from  their  being 
lucubrated  by  the  synovia ; and  if  allowed  to  escape 
into  the  general  cavity,  they  may  not  readily,  if  at  all, 
be  brought  back  into  the  same  situation. 

“ The  operation  consists  in  making  an  incision  upon 
the  loose  cartilage,  which  it  will  be  best  to  do  in  the  di- 
rection of  the  thigh,  as  the  wound  will  more  readily  be 
healed  by  the  first  intention.  If  the  skin  is  drawn  to 
one  side  previously  to  making  the  incision,  the  wound 
through  the  parts  underneath  will  not  correspond  with 
that  made  in  the  skin,  which  circumstance  will  favour 
their  union.  The  incision  upon  the  cartilage  must  be 
made  with  caution,  as  it  will  with  difficulty  be  re- 
tained in  its  situation  if  much  force  is  applied.  The 
assistant  is  to  endeavour  to  push  the  loose  body 
through  the  opening,  which  must  be  made  sufficiently 
large  tor  that  purpose;  but  as  this  cannot  always  be 
done,  the  broad  end  of  an  eyed  probe  may  be  passed 
under  it  so  as  to  lift  it  out,  or  a sharp-pointed  instru- 
ment may  be  struck  into  it,  which  will  fix  it  to  its  situ- 
ation, and  bring  it  more  within  the  management  of  the 
surgeon. 

“ The  cartilages  being  all  extracted,  the  cut  edges  of 
the  wound  are  to  be  brought  together,  and,  by  means 
of  a compress  of  lint,  not  only  pressed  close  to  one 
another,  but  also  to  the  parts  underneath,  in  tihich 
situation  they  are  to  be  retained  by  sticking  plaster, 
and  the  uniting  bandage. 

“ As  union  by  the  first  intention  is  of  the  utmost  con- 
sequence after  this  operation,  to  prevent  an  inflamma- 
tion of  the  joint,  the  patient  should  remain  in  bed  with 
the  leg  extended,  till  the  wound  is  perfectly  united,  or 
at  least  all  chance  of  inflammation  at  an  end.” — 
{Home  in  Trans,  for  the  Improvement  of  Med.  and 
Chir.  Knowledge,  vol.  1,  p.  239,  ^c.) 

Ill  one  instance,  Desault  proceeded  in  the  following 
manner;  the  surgeon,  after  relaxing  the  capsular  liga- 
ment by  extending  the  leg,  brought  the  extraneous  body 
on  the  inside  of  the  articulation  against  the  attachment 
of  the  capsular  ligament,  and  secured  it  in  this  situ- 
ation between  the  index  finger  and  thumb  of  the  left 
hand,  while  an  assistant  drew  the  integuments  for- 
wards towards  the  patella.  The  parts  covering  this 
extraneous  body  were  now  divided  by  an  incision  one 
inch  in  length,  and  its  extraction  accomplished  by 
pushing  it  from  above  downwards,  and  raising  it  infe- 
riorly  with  the  end  of  the  knife.  This  substance,  on 
examination,  was  found  similar  in  colour  to  the  car- 
tilages that  cover  the  articular  surfaces;  it  was  three 
quarters  of  an  inch  in  length,  six  lines  and  u half  in 


width,  and  three  lines  in  thickness ; its  surfaces  were 
smooth,  one  concave  and  the  other  convex;  its  circum- 
ference irregular,  disseminated  with  red  points,  form- 
ing small  depressions ; the  inside  was  ossified,  the  out- 
side of  a cartilaginous  texture.  As  soon  as  the  sub- 
stance was  extracted,  the  assistant  let  go  the  integu- 
ments which  he  had  drawn  forwards;  they  conse- 
quentljneturned  to  their  natural  situation  on  the  inner 
side  of  the  knee-joint,  in  such  a manner  that  the  exter- 
nal wound  in  the  integuments  was  situated  more  in- 
wards than  the  one  in  the  capsular  ligament.  Two 
advantages  were  procured  by  this  means ; on  the  one 
hand,  air  was  prevented  from  penetrating  into  the  arti- 
culation ; and  on  the  other,  the  floating  portion  of  cap- 
sular ligament,  retained  inwards  by  the  skin,  was  more 
likely  to  attach  itself  to  the  condyle,  in  case  it  did  not 
unite  to  the  other  portion  of  the  capsule  divided  near 
its  attachment.  The  edges  of  the  wound  were  brought 
into  contact  by  means  of  the  uniting  bandage;  dry  lint 
and  compresses  were  applied,  and  retained  on  the  part 
by  a slight  bandage ; and  the  limb  was  kept  in  a state 
of  extension. — {Desault's  Journal,  t.  2.)  According 
to  Mr.  Abernetliy,  the  inner  surface  of  the  internal 
condyle  of  the  os  femoris  presents  an  extensive  and 
nearly  a plain  surface,  which  terminates  in  front  and 
at  its  upper  part  by  an  edge  which  forms  a portion  of  a 
circle.  If  the  points  of  the  finger  be  firmly  pressed 
upon  this  edge  so  as  to  form  a kind  of  line  of  cir- 
cumvallation  round  these  (cartilaginous)  bodies,  they 
cannot  pass  into  the  joint  in  this  direction,  nor  can 
they  recede  in  any  other  on  account  of  the  tense  state 
of  the  internal  lateral  ligament.  Here  these  substances 
are  near  the  surface,  and  may  be  distinctly  felt;  and 
they  may  be  exposed  by  simply  dividing  the  integu- 
ments, fascia,  and  the  capsule  of  the  joint. 

In  an  interesting  case  which  Mr.  Abernetliy  relates, 
the  integuments  of  the  knee  were  gently  pressed  to- 
wards the  internal  condyle,  and  the  fingers  of  an  as- 
sistant applied  round  the  circular  edge  of  the  bone. 
The  integuments  were  gently  drawn  towards  the  inner 
hamstring,  and  longitudinally  divided  immediately  over 
the  loose  substance,  to  the  extent  of  an  inch  and  a half. 
This  withdrawing  of  the  integuments  from  their  natural 
situation  was  designed  to  prevent  a direct  correspond- 
ence of  the  external  wound  to  that  in  the  capsule  of 
the  joint ; for  when  the  integuments  were  suttered  to 
regain  their  natural  position,  the  wound  in  them  was 
nearer  to  the  patella  than  the  wound  in  the  capsule. 
The  fascia  which  covers  the  joint  having  been  exposed 
by  the  division  of  the  integuments,  it  was  divided  in  a 
similar  direction,  and  nearly  to  the  same  extent.  The 
capsule  is  now  laid  bare,  and  gently  divided  to  the  ex- 
tent of  half  an  inch*  where  it  covered  one  of  the  hard 
substances  which  suddenly  slipped  through  the  opening, 
and  by  pressing  gently  upon  the  other  it  was  also  dis- 
charged. The  bodies  thus  removed  were  about  three 
quarters  of  an  inch  in  length,  and  half  an  inch  in 
breadth.  They  had  a highly  polished  surface,  and 
were  hard  like  cartilage.  The  fluid  contained  in  the 
joint  was  pressed  towards  the  wound,  and  about  two 
ounces  of  synovia  were  discharged.  The  wound  of 
the  integuments  was  then  gently  drawn  towards  the 
patella,  and  accurately  closed  with  sticking  plaster. — 
{Surgical  Observations,  1804.) 

When  there  are  several  extraneous  cartilaginous  bo- 
dies in  the  joint  operated  upon,  the  surgeon  ought  to 
extract  them  all  through  the  same  wound,  if  it  can  be 
done  without  producing  too  much  irritation  of  the  cap- 
sular ligament,  and  they  will  admit  of  it.  But  fre- 
quently only  one  can  be  made  to  present  itself  at  a 
time,  or  can  be  easily  extracted.  Each  little  tumour 
will  then  require  a separate  operation,  which  is  a far 
safer  plan  than  disturbing  the  part  by  long  and  re- 
peated attempts  to  extract  them  all  at  onca.— {Boyer, 
Train  des  Mai.  Chir.  t.  4,  p.  448.)  The  surgeon  is  also 
often  obliged  to  make  his  incision  at  a particular  point, 
because  at  no  other  can  the  extraneous  substance  be 
fi.ved.  A case  confirming  all  these  latter  observations 
was  lately  published  by  l3r.  Clarke. — (See  Mid.  Chir. 
Trans,  vol.  5,  p.  C7.)  In  this  instance  the  operation 
was  thrice  performed  upon  the  same  knee-joint  with 
perfect  success.  Mr.  Brodie  also  extracted  five  loose 
cartilages,  by  three  different  operatfons,  without  any 
subseqmmt  unpleasant  symptoms,  although  the  patient 
appears  to  have  been  previously  subject  to  repeated 
attacks  of  severe  inflammation  of  the  joint. — {Pqthaii 
logical  and  Stirg.  Obs.  p.  299.) 


106 


JOINTS, 


On  the  preceding  subject,  some  observations  and  two 
successful  operations  have  been  lately  published  by 
Baron  Larrey. — (See  Mimoires  de  Chir.  Militaire,  t.2, 
p.  421,  ^c.)  With  the  exception  of  a few  wrong  theo- 
ries, he  appears  to  have  given  a fair  account  of  the 
disease. 

Hydrops  articuli  signifies  a collection  of  serous 
fluid  in  tire  capsular  ligament  of  a joint.  The  knee  is 
more  subject  than  other  joints  to  dropsical  disease, 
which  has  been  known,  however,  to  affect  the  wrist, 
ankle,  and  shoulder  joints. — {Boyer,  Traiti  des  Mai. 
Chir.  t.  4,  p.  456.) 

Mr.  Russell  adopts  the  opinion  that  some  cases  of 
this  kind  are  venereal,  and  others  scrofulous;  but  the 
doctrine  does  not  rest  upon  any  solid  foundation.  Hy- 
drops articuli  generally  arises  from  contusions,  rheu- 
matism, sprains,  exposure  to  severe  cold,  the  presence 
of  extraneous  cartilaginous  bodies  in  the  joint,  and  in 
general  from  any  thing  which  irritates  the  capsular 
ligament;  and,  as  already  explained,  it  is  a common 
attendant  on  inflammation  of  the  synovial  membrane; 
the  complaint  also  sometimes  follows  fevers;  hut  in 
most  instances  it  is  purely  a local  affection,  quite  inde- 
pendent of  general  debility. — {Boyer,  t.  4,  p.  467.) 

Hydrops  articuli  presents  itself  in  the  form  of  a soft 
tumour ; circumscribed  by  the  attachments  of  the  cap- 
sular ligament ; without  change  of  colour  in  the  skin  ; 
accompanied  with  a fluctuation  ; it  is  indolent,  and  very 
little  painful ; causing  hardly  any  impediment  to  the 
motion  of  the  joint;  yielding  to  the  pressure  of  the 
finger,  but  not  retaining  any  impression,  as  in  oedema. 
The  swelling  does  not  occupy  equally  every  side  of 
the  joint,  being  most  conspicuous  where  the  capsular 
ligament  is  loose  and  superficial.  In  the  wrist,  it  oc- 
curs at  the  anterior  and  posterior  parts  of  the  joint, 
but  especially  in  the  former  situation,  while  it  is  scarcely 
perceptible  at  the  sides.  In  the  ankle  it  is  more  appa- 
rent in  frontof  the  malleoli  than  any  where  else;  and  in 
the  shoulder  it  does  not  surround  the  joint,  but  is  al- 
most always  confined  to  the  forepart  of  it,  and  can 
only  be  seen  in  the  interspace  between  the  deltoid  and 
great  pectoral  muscles. 

In  the  knee-joint,  which  is  the  common  situation  of 
hydrops  articuli,  the  tumour  does  not  occur  behind  the 
articulation  ; but  at  the  front  and  sides.  Behind,  the 
capsular  ligament  is  too  narrow  to  admit  of  being 
much  distended  with  the  synovia;  while  in  front  and 
laterally  it  is  broad,  so  that  it  can  there  yield  consider- 
ably in  proportion  as  the  quantity  of  fluid  increases. 
The  swelling  is  at  first  circumscribed  by  the  attachments 
of  the  capsular  ligament;  but  in  consequence  of  the 
accumulation  of  fluid,  it  afterward  exceeds  these  limits 
above,  and  spreads  more  or  less  upwards  between  the 
tliigh  bone  and  the  extensor  muscles  of  the  leg,  wliich 
are  lifted  up  by  it.  Boyer  has.seen  it  reach  to  the  upper 
third  of  the  thigh.  The  swelling  is  ii regular  in  shape  : 
it  is  most  jirominent  where  the  capsular  ligament  is 
wide  and  loose,  and  it  is  in  some  measure  divided  lon- 
gitudinally into  two  lateral  portions,  by  the  patella,  the 
ligament  of  the  patella,  and  the  tendon  of  the  extensor 
muscles  of  the  leg;  all  which  parts  the  synovia  raises, 
and  pushes  forwards,  though  in  a much  less  degree 
than  the  capsular  ligament.  Of  these  lateral  portions, 
the  internal  is  broadest  and  most  prominent,  because 
the  part  of  the  capsule  between  the  patella  and  edge 
of  the  internal  condyle  being  larger  than  that  situated 
between  the  patella  and  edge  of  the  external  condyle, 
yields  in  a greater  degree  to  the  distending  fluid.  The 
motions  of  the  leg,  which  are  generally  little  inter- 
rupted by  this  disease,  make  a difference  in  the  shape 
and  consistence  of  the  swelling.  In  flexion,  the  tu- 
mour becomes  harder,  tenser,  and  broader,  and  more 
prominent  at  the  sides  of  the  knee-pan,  which  is 
somewhat  depressed  by  its  ligament.  In  extension, 
the  tumour  is  s<ifter,  and  the  fluctuation  plainer. 

In  order  to  feel  distinctly  tlie  fluctuation,  which  is 
one  of  the  best  symptoms  of  the  disease,  the  ends  of 
two  or  three  fingers  should  be  placed  on  one  side  of  the 
swelling,  while  the  opposite  side  is  to  be  struck  with 
the  end  of  the  middle  finger  of  the  other  hand. 

The  patella  being  pushed  forwards,  away  from  the 
arlicidar  pulley,  is  very  moveable,  and,  as  it  were, 
floating.  When  it  is  pressed  backwards,  while  the 
leg  is  extended,  it  can  be  felt  to  move  a certain  way, 
before  it  meets  with  the  resistance  of  the  articular  pul- 
ley. And  on  the  pressure  being  discontinued  it  imme- 
diately separates  from  this  part  again. 


By  such  symptoms,  hydrops  articuli  may  easily  be 
distinguished  from  other  diseases  of  the  joints,  from 
tumours  of  the  bursa  mucosa  under  the  extensor  ten- 
dons of  the  leg  ; from  ganglions  in  front  of  the  knee- 
pan  ; from  rheumatism,  oedema,  &c. 

The  prognosis  is  most  favourable  when  the  swelling 
is  recent  and  small,  and  has  been  quick  in  its  progress. 
On  the  contrary,  when  the  tumour  is  of  long  standing 
and  large,  the  effused  fluid  thick  and  viscid,  and  the 
synovial  membrane  thickened,  the  removal  of  the 
fluid  by  absorption,  and  the  restoration  of  the  parts 
to  their  natural  state,  will  be  .more  slow  and  diffi- 
cult. The  worst  case  is  that  which  is  complicated 
with  disease  of  the  capsular  ligament,  cartilages,  and 
bones. 

The  cure  of  the  above-described  dropsical  affection 
of  the  joints  depends  upon  the  absorption  of  the  ef- 
fused fluid.  And  when  the  case  is  combined  with 
acute  or  chronic  inflammation  of  the  synovial  mem- 
brane, the  treatment  is  the  same  as  that  already  re- 
commended for  those  particular  forms  of  disease. 
When  inflammation  subsides,  the  absorption  of  the  fluid 
is  sometimes  altogether  spontaneous,  and  it  may  al- 
ways be  promoted  by  friction,  by  rub^jing  the  joint 
with  camphorated  mercurial  ointment,  the  ointment  or 
tincture  of  iodine,  the  soap  liniment,  containing  3j. 
of  the  tincture  of  iodine  in  every  two  oz.  of  it,  and 
particularly  by  the  employment  of  blisters. 

The  operation  of  a blister  may  be  materially  assisted 
with  a moderately  tight  bandage.  Among  other  ef- 
fectual means  of  cure,  we  may  enumerate  frictions 
with  flannel  impregnated  with  the  fumes  of  vinegar, 
electricity,  and  the  exhibition  of  mercurial  purgatives. 
When  hydrops  articuli  occurs  during  the  debility  con- 
sequent to  typhoid  and  other  fevers,  The  complaint  can 
hardly  be  expected  to  get  well  before  the  patient  re- 
gains some  degree  of  strength. 

As,  however,  hydrops  articuli  is  generally  quite  a 
local  disease,  Boyer  contends  that  it  should  he  chiefly 
treated  with  topical  remedies;  and  he  sets  down  diu- 
retics, sudorifics,  hydragogues,  &c.  as  improper  or  in- 
efficient.—( Op.  cit.  p.  467.)  He  is  strongly  in  favour 
of  repeated  blisters,  both  for  the  prevention  and  cure 
of  the  disease. 

Circumstances  do  not  often  justify  the  making  of  an 
opening  into  the  joint;  but  excessive  distention,  in 
some  neglected  case.s,  might  certainly  be  an  urgent 
reason  for  such  an  operation.  Also,  if  the  complaint 
should  resist  all  other  plans  of  treatment,  and  the  irri- 
tation of  the  tumour  greatly  impair  a weak  constitu- 
tion, the  practice  would  be  justifiable.  An  interesting 
example  of  this  kind  is  related  by  Mr.  Latta.— (Sys- 
tem of  Surgery,  vol.  2,  p.  490.) 

It  is  best  to  make  the  opening  in  such  a way  that  the 
wound  in  the  capsular  ligament  after  the  operation 
will  not  remain  directly  opposite  the  wound  in  the 
skin.  For  this  purpose,  the  integuments  are  to  be  ' 
pushed  to  one  side,  before  the  surgeon  divides  them. — 
{Encyclopidie  Method,  part  Chir.  art.  Hydropisie 
des  Jointures.) 

The  operation  is  not  always  successful,  being  some- 
times followed  by  alarming  symptoms,  which  either 
end  fatally,  or  occasion  a necessity  for  amputation. 
The  fluid  also  generally  collects  again,  and  as  the  sy- 
novial membrane  is  mostly  thickened,  it  often  inflames, 
and  suppuration  in  the  joint  ensties.  Hence,  when 
hydrops  articuli  originates  from  rheumatism ; when 
it  is  recent,  indolent,  and  not  large  ; and  when  it  does 
not  seriously  impair  tire  functions  of  the  joint ; Boyer 
recommends  the  operation  not  to  be  done.  But  he 
sanctions  its  performance  when  the  disease  is  com- 
bined with  e.xtraneouscarlilasinous bodies  in  the  joint; 
or  when  it  is  very  considerable,  and  attended  with  se- 
vere pain  and  impairment  of  the  functions  of  the 
joint. — {Op.  cit.  t.  A,p.  473.) 

Collections  of  Blood  in  .Joints. — Most  systematic 
writers  speak  of  this  kind  of  case,  though  it  must  be  un- 
common. Tumours  about  the  joints,  composed  of  blood, 
and  set  down  in  numerous  surgical  works  as  extrava- 
sations within  the  capsular  ligaments,  are  generally  on 
the  outside  of  them. 

Were  blood  known  to  be  undoubtedly  effused  in  a 
large  articulation,  however,  no  man  would  be  justified 
in  making  an  opening  for  its  discharge.  No  bad  symp- 
toms are  likely  to  result  from  its  mere  presence,  and 
the  absorbents  will,  in  the  end,  take  it  away.  If  an 
incision  were  made  into  the  joint,  the  coagulated  state 


JOINTS. 


107 


of  the  extravasated  blood  would  not  allow  such  blood 
to  be  easily  discharged. 

The  best  plan  is  to  apply  discutient  remedies  ; lotion 
of  vinegar,  spirits  of  wine,  and  muriate  of  ammonia 
for  the  first  three  or  four  days  ; and  afterward,  friction 
with  camphorated  liniments  may  be  safely  adopted. 

Mr.  Hey  relates  a case  in  which  the  knee-joint  was 
wounded,  and  blood  insinuated  itself  into  the  capsular 
ligament ; yet,  though  the  occurrence  could  not  be  hin- 
dered, no  harm  resulted  from  the  extravasalioti,  which 
was  absorbed  without  having  created  the  smallest  in- 
convenience.— {Practical  Obs.  in  Surgery,  p.  354.) 

White  StDciling. — The  white  swelling,  or  spina  ven- 
tosa,  as  it  was  at  one  time  not  unfrequently  called,  in 
imitation  of  the  Arabian  writers,  Rhazes  and  Avi- 
cenna, has  been  a name  indiscriminately  applied  to 
many  diseases,  which  differ  widely  in  their  nature,  cu- 
rability, and  treatment.  Wiseman  was  the  first  who 
«sed  the  term  while  swelling ; ^ind  if  the  expression 
did  not  confound  together  complaints  of  very  different 
kinds,  not  much  fault  could  be  found  with  it,  because 
it  unquestionably  conveys  an  idea  of  one  mark  of  some 
of  these  distemp)ers,  which  is,  that  notwithstanding  the 
increase  of  size  in  the  joint,  the  skin  is  generally  not 
inflamed,  but  retains  its  natural  colour. — {Pott.)  • 

The  name  therefore  appears  objectionable  only  inas- 
much as  it  has  tended  to  prevent  the  introduction  of  a 
sufficient  number  of  well-founded  and  necessary  dis- 
tinctions. Systematic  writers  have  genei  ally  been  con- 
tent with  a distinction  into  two  kinds,  viz.  rheumatic 
and  scrof  ulous. 

The  last  species  of  the  disease  they  also  distinguish 
into  such  tumours,  as  primarily  affect  the  bones,  and 
then  the  ligaments  and  soft  parts ; and  into  other  cases 
in  which  the  cartilages,  ligaments,  and  soft  parts  be- 
come diseased,  before  there  is  any  morbid  affection  of 
the  bones. 

Mr.  Brodie  has  endeavoured  to  form  a more  correct 
classification  of  the  different  complaints  to  which  the 
term  white-swelling  is  applied;  and  his  descriptions 
are  valuable,  because  confirmed  by  extensive  observa- 
tion and  numerous  dissections.  With  respect  to  the 
disease  beginning  in  the  ligaments,  if  the  capsular  liga- 
ments be  put  out  of  consideration,  it  is,  as  this  gentle- 
man observes,  a rare  occurrence,  and  he  has  never 
met  with  a case  in  which  the  fact  was  proved  by  dis- 
section.— {Pathol,  and  Surgical  Obs.  p.  7.) 

1.  The  first  case  is  inflammation  of  the  synovial 
membrane,  as  described  in  the  foregoing  pages,  espe- 
cially that  form  of  the  disease  which  often  arises  from 
cold,  and  constitutes  the  disease  formerly  often  termed 
a rheumatic  white-swelling. 

2.  Another  form  of  disease,  ordinarily  comprised  un- 
der the  general  name  of  white-swelling,  has  been  par- 
ticularly described  by  Mr.  Brodie : the  disease  origi- 
nates in  the  synovial  membrane,  which  loses  its  natural 
organization,  and  becomes  converted  into  a thick, 
pulpy  substance,  of  a light  brown,  and  sometimes  of  a 
reddish  brown  colour,  intersected  by  while  membra 
nous  lines,  and  from  i to  ^ of  an  inch,  or  even  more 
than  ail  inch,  in  thickness.  As  this  disease  advances, 
it  involves  all  the  parts  of  which  the  joint  is  composed, 
producing  ulceration  of  the  cartilages,  caries  of  the 
bones,  wasting  of  the  ligaments,  and  abscesses  in  dif- 
ferent places.  The  complaint  has  invariably  proved 
slow  in  its  progress,  and  sometimes  has  remained 
nearly  in  an  indolent  state  for  many  rnonlh.s,  or  even 
for  one  or  two  years;  but  (says  Mr.  Brodie)  “I  have 
never  met  with  an  instance  in  which  a real  amendment 
was  produced  ; much  less  have  ( known  any  in  which 
a cure  was  effected.”— (See  Medico-Chir.  Trans,  vol. 
4,  p.  220,  (J-c.)  I’he  whole  or  nearly  the  whole  of  the 
synovial  membrane  has  always  been  found  affected; 
though  if  a very  early  examination  were  m.ade,  Mr. 
Brodie  conceives  that  this  might  not  be  the  case;  and 
in  one  example  he  found  only  a half  of  the  membrane 
thus  altered,  while  the  re.st  was  of  its  natural  struc- 
ture.— {Pathol,  and  Surg.  Obs.  p.  94.)  This  gentleman 
farther  acquaints  us,  that  the  preceding  affection  of  the 
synovial  membrane  is  rarely  met  with  except  in  the 
knee  ; that  he  has  never  known  an  instance  of  it  in 
the  hip  or  shoulder;  that  it  is  peculiar  to  the  synovial 
membrane  of  the  joints;  that  he  has  never  known  an 
instance  of  ii  in  other  serous  membranes,  nor  even  in 
the  synovial  membranes,  which  con.stitute  the  bur.sat 
mucosa:  and  sheaths  of  tendons ; and  that  it  generally 
takes  place  in  young  persons,  under,  or  not  much 


above,  the  age  of  puberty.  In  fact,  Mr.  Brodie  has 
not  met  with  more  than  one  instance  in  which  it  oc- 
curred after  the  middle  period  of  life.  Mr.  Hodgson, 
of  Birmingham,  it  seems,  has  met  with  one  example 
of  it  in  the  ankle ; and  another  in  one  of  the  joints  of 
the  fingers.  “ In  the  origin  of  this  disease,  there  is  a 
slight  degree  of  stiffness  and  tumefaction,  without 
pain,  and  producing  oidy  the  most  trifling  inconve- 
nience. These  symptoms  gradually  increase  : at  last, 
the  joint  scarcely  admits  of  the  smallest  motion,  the 
stiffness  being  greater  than  where  it  is  the  consequence 
of  simple  inflannnation.  The  form  of  the  swelling 
bears  some  resemblance  to  that  in  cases  of  inflamma- 
tion of  the  synovial  membrane,  but  it  is  less  regular. 
The  swelling  is  soft  and  elastic,  and  gives  to  the  hand 
a sensation  as  if  it  contained  fluid.  If  only  one  hand 
be  employed  in  making  the  examination,  the  deception 
may  be  complete,  and  the  most  experienced  surgeon 
may  be  led  to  suppose  there  is  a fluid  in  the  joint  when 
there  is  none ; but,  if  both  hands  be  employed  one  on 
each  side,  the  absence  of  fluid  is  distinguished  by  the 
want  of  fluctuation. 

“ The  patient  experiences  little  or  no  pain  until  ab- 
scesses begin  to  form,  and  the  cartilages  ulcerate;  and 
even  then  the  pain  is  not  so  severe  as  where  the  ulcer- 
ation of  the  cartilages  occurs  as  a primary  disease, 
and  the  abscesses  heal  more  readily,  and  discharge  a 
smaller  quantity  of  pus  than  in  cases  of  this  last  de- 
scription. At  this  period,  the  patient  becomes  affected 
with  hectic  fever,  loses  his  flesh,  and  gradually  sinks, 
unless  the  limb  be  removed  by  an  operation.” — {Med. 
Chir.  Trans,  vol.  5,  p.  251,^252.)  In  the  majority  of 
cases,  Mr.  Brodie  believes,  that  the  gradual  progress 
of  the  enlargement,  the  stiffness  of  the  joint,  without 
pain,  and  the  soft  elastic  swelling  without  fluctuation, 
will  enable  the  practitioirer  readily  to  distinguish  this 
from  all  other  diseases  of  the  joints.  However,  when 
the  diseased  synovial  membrane  happens  to  be  dis- 
tended with  a quantity  of  turbid  serum  and  flakes  of 
coagulable  lymph,  the  complaint  somewhat  resembles 
in  its  feel  and  appearance  that  stage  of  common  in- 
flammation of  the  synovial  membrane,  where  this  part 
is  less  thickened,  and  more  or  less  distended  with  co- 
agulable lymph;  but  the  impossibility  of  relieving  the 
former  case  by  the  same  means  which  cure  the  latter, 
and  due  attention  to  the  history  of  the  disease,  will 
prove  the  difference  between  them. — {Brodie,  PathoL 
and  Surg,  Obs.  p.  96.) 

3.  Ulceration  of  the  articular  cartilages  takes  place 
in  the  advanced  stage  of  several  diseases  of  the  joints, 
and  it  also  exists  in  many  instances  as  a primary  af- 
fection, in  the  early  stage  of  which  the  bones,  synovial 
membrane,  and  ligaments  are  in  a natural  state.  If 
neglected,  it  ultimately  occasions  the  entire  destruction 
of  the  articulation.  It  may  be  the  consequence  of  in- 
flammation of  the  cartilage  itself,  or  of  the  bony  sur- 
face with  which  it  is  connected ; but,  as  Mr.  Brodie 
farther  observes,  in  many  instances  there  are  no  evi- 
dent marks  of  the  disorder  being  preceded  by  any  in- 
flammatory action  in  one  part  or  the  other,  and  the 
inflammation,  which  afterward  takes  place,  appears 
rather  to  be  the  attendant  upon,  than  the  cause  of,  the 
ulcerative  process.  One  striking  peculiarity  of  ulcer- 
ation of  the  articular  cartilages  is,  that  the  process  may 
take  place  without  the  formation  of  pus;  for  the  dis- 
ease often  proceeds  so  far  as  to  cause  caries  of  the 
bones,  and  yet  no  purulent  matter  is  found  within  the 
joint. — {Pathol,  and  Surgical  Obs.  Src.  p.  117,  ed.  2.) 
The  investigations  of  the  same  author  dispose  him  to 
believe,  that  a conversion  of  these  cartilages  into  a 
soft  fibrous  structure  is  a frequent  though  not  constant 
forerunner  of  ulceration. — (F.  121.)  When  the  ulcer- 
ation of  the  cartilage  occurs  in  the  superficial  joints,  it 
constitutes  one  of  tlie  disea.ses  which  have  been  known 
by  the  name  of  white-swelling.  From  cases  which 
Mr.  Brodie  has  met  with,  he  is  led  to  conclude,  that 
when  it  takes  place  in  the  hip,  it  is  this  disease  which 
has  been  variously  designated  by  w'riters,  the  '•’•morbus 
coxarivs,"  the  “ di.«ease  of  the  hip,”  the  “•scrofulous 
hip,”  the  “ scrofulous  caries  of  the  hij)  joint.”  At 
least,  says  Mr.  Brodie,  it  is  to  this  disease  that  these 
names  have  been  principally  applied,  though  probably 
other  morbid  affections  have  been  occasionally  con- 
founded with  it. — {Med.  Chir.  Trans,  vol.  4,  p.  236.) 
The  ulceration  of  the  articular  cartilages  takes  place, 
as  a primary  disease,  chiefly  in  children,  or  adults 
under  the  [middle  age.  “ Of  sixty-eight  persons  af- 


108 


JOINTS. 


fected  with  tliis  disease,  fifty  six  (according  to  Mr. 
Brodie)  were  under  thirty  years  of  age : the  youngest 
was  an  infant  of  about  twelve  months;  the  oldest  was 
n woman  of  sixty.  As  the  knee  is  more  frequently 
affected  by  inflammation  of  the  synovial  membrane, 
so  is  the  hip  more  liable  than  other  joints  to  the  ulcer- 
ation of  the  cartilaginous  surfaces.  In  general  the 
disease  is  confined  to  a single  joint;  but  it  is  not  very 
unusual  to  find  two  or  three  joints  affected  in  the  same 
individual,  either  at  the  same  time,  or  in  succession. 
Sometimes  tlie  patient  traces  the  beginning  of  Ids 
symptoms  to  a local  injury,  or  to  his  having  been  ex- 
posed to  cold ; but,  for  the  most  part,  no  cause  can  be 
assigned  for  tlie  complaint.” — (See  Med.  Chir.  Trans, 
vol.  6,  p.  319.) 

The  symptoms  of  the  disease  of  the  hip-joint  will  be 
described  in  the  ensuing  section,  and  we  shall  here 
confine  our  remarks  to  the  symptoms  characterizing 
ulceration  of  the  cartilages  of  the  knee,  as  pointed  out 
by  Mr.  Brodie.  They  differ  from  those  of  inflamma- 
tion of  the  synovial  membrane,  by  the  pain  being  slight 
in  the  beginning,  and  gradually  becoming  very  intense, 
which  is  the  reverse  of  what  happens  in  the  latter  af- 
fection. The  pain  in  the  comnrencement  is  also  un- 
attended with  any  evident  swelling,  which  never 
comes  on  in  less  than  four  or  five  weeks,  and  often  not 
till  after  several  months.  It  is  not  to  be  inferred,  how- 
ever, that  every  slight  pain  of  the  joint,  unaccompanied 
with  swelling,  must  of  course  arise  from  ulceration  of 
the  cartilages.  But,  says  Mr.  Brodie,  when  the  pain 
continues  to  increase,  and  at  last  is  very  severe ; when 
it  is  aggravated  by  the  motion  of  the  bones  on  each 
other,  and  when,  after  a time,  a slight  tumefaction  of 
the  joint  takes  place,  we  may  conclude  that  the  disease 
consists  in  such  ulceration.  The  swelling  arises  from 
a slight  inflammation  of  the  cellular  membrane  on  the 
outside  of  the  joint ; it  has  the  form  of  the  articulating 
ends  of  the  bones;  and  for  the  most  part  it  appears 
greater  than  it  really  is,  in  consequence  of  the  muscles 
being  wasted.  No  fluctuation  is  perceptible,  as  where 
the  synovial  membrane  is  inflamed ; nor  is  there  the 
peculiar  elasticity  which  exists  where  the  synovial 
membrane  has  undergone  a morbid  alteration  of  its 
structure. 

Mr.  Brodie  has  explained,  however,  that  in  some 
cases  the  swelling  has  a tliflferent  shape,  and  commu- 
nicates the  feel  of  a fluctuation.  This  happens  when 
inflammation  of  the  synovial  membrane,  attended  with 
a collection  of  the  synovia  of  the  joint,  or  abscesses  in 
the  surrounding  soft  parts,  or  in  the  articulation  itself, 
occur  as  secondary  diseases.  When  there  has  been 
considerable  destruction  of  tlie  soft  parts  from  ab- 
scesses and  ulceration,  the  head  of  the.  tibia  may  be- 
come dislocated  and  drawn  towards  the  ham. — (See 
Med.  Chir.  Trans,  vol.  6,  p.  326,  Src.)  In  the  9th  vol. 
of  this  work,  Mr.  Mayo  has  described  an  acute  form 
of  ulceration  of  the  cartilages,  as  displayed  in  three 
cases  affecting  the  knee,  elbow,  and  ankle.  They  were 
all  attended  with  severe  pain  in  the  beginning:  two 
ended  in  anchylosis,  after  antiphlogistic  treatment  for 
two  months:  and  the  third  patient,  a boy,  died,  during 
the  existence  of  this  disease,  of  an  injury  of  the  head. 
The  bones  of  the  ankle-joint  were  found  almost 
stripped  of  cartilage;  what  remained  of  this  texture 
was  thinned,  and' that  unequally;  but  it  seemed  in 
other  respects  unchanged,  land  adhered  firmly  to  the 
bone. 

4.  I shall  pass  over  ulceration  of  the  synovial  mem- 
brane, which  Mr.  Brodie  considers  in  a separate  sec- 
tion, and  now  proceed  to  the  scrofulous  white  swelling. 
In  the  scrofulous  disease  of  the  joints,  the  bones  are 
primarily  affected,  in  consequence  of  which  ulceration 
takes  place  in  the  cartilages  covering  their  articular 
extremities.  The  cartilages  being  ulcerated,  the  sub- 
sequent progress  of  the  disease  (says  Mr.  Brodie)  is  the 
same  as  where  this  ulceration  takes  place  in  the  first 
instance. — {Medico-Chir.  Trans,  vol.  A.,  p.266.) 

By  Mr.  Lloyd,  scrofulous  white  swellings  are  divided 
into  three  stages;  the  first  being  that  in  which  the 
affection  is  confined  to  the  bone ; the  second,  that 
in  which  the  external  parts  become  thickened  atid 
swelled  ; and  the  third  being  what  he  names  the  sup- 
purative stage,  attended  with  ulceration  of  the  carti- 
lages, inflammation  of  the  synovial  membrane,  and 
abscesses. — (On  Scrofula,  p.  121.)  It  was  formerly  a 
common  notion,  that  in  white  swellings  the  heads  of 
the  bones  were  always  enlarged.  Mr.  Russell,  1 believe. 


is  the  first  writer  who  expressed  an  opposite  sentiment, 
and  he  distinctly  declares,  that  he  ha,d  never  heard  nor 
known  of  an  instance.^  in  whieh  the  tibia  was  enlarged 
from  an  atiaek  of  white  swelling. — ( P.  37.)  The  inac- 
curacy of- the  opinion  was  afterward  pointed  out  by 
Mr.  Lawrence,  to  the  late  Mr.  Crowther,  and  the  sub- 
ject was  mentioned  in  the  earliest  edition  of  the  “First 
Lines  of  the  Practice  of  Surgery.” 

Deceived  by  the  fee!  of  many  diseased  joints,  and 
influenced  by  general  opinion,  I once  supposed  that 
there  was  generally  a regular  expansion  of  the  heads 
of  scrofulous  bones.  But,  excepting  an  occasional  en- 
largement, which  arises  from  spiculae  of  bony  matter, 
deposited  on  the  outside  of  the  tibia,  ulna,  &:c.,  and 
which  alteration  cannot  be  called  an  expansion  of 
those  bones ; for  a long  time,  I never  met  with  the  head 
of  a bone  enlarged,  in  consequence  of  the  disease 
known  by  the  name  of  white  swelling.  I was  for- 
merly much  in  the  habit  off  inspecting  the  state  of  the 
numerous  diseased  joints  which  were  every  year  am- 
putated at  St.  Bartholomew’s  Hospital,  and  thmigh  I 
was  long  attentive  to  this  point,  my  searches  after  a 
really  enlarged  scrofulous  bone  always  proved  in  vain. 
Nor  was  there  at  that  period  any  specimen  of  an  ex- 
• panded  head  of  a scrofulous  bone  in  Mr.  Abernethy’s 
museum.  Within  the  last  few  years,  however,  a 
specimen  of  an  enlargement  of  the  upper  head  of  the 
I ulna  has  been  found,  and  it  was  some  time  ago  showm 
to  me  by  Mr.  Stanley.  Mr.  Langstatf  is  said  to  have 
in  his  possession  a knee-joint,  in  which  the  femur  and 
tibia  are  much  expanded,  “ the  external  lamin®  of  the 
bones  not  being  thicker  than  when  the  bones  are  of 
their  natural  size,  and  the  cancelli  healthy,  though  of 
rather  greater  solidity  than  natural." — {Lloyd  on 
Scrofula,  p.  148.)  However,  this  last  form  of  disease 
evidently  does  not  resemble  the  common  scrofulous 
affection  of  the  heads  of  the  bones.  I may  add,  that 
Mr.  Wilson,  whose  dissections  were  very  numerous, 
concurs  with  the  best  modern  writers  concerning  the 
rarity  of  an  actual  expansion  of  the  substance  of  the 
heads  of  the  bones. — ( On  the  Skeleton,  ^c.,  p.  336.)  I 
have  also  heard  of  a few  other  instances,  in  which 
the  heads  of  the  bones  were  actually  enlarged  in  cases 
of  white  swelling.  However,  I believe  the  occurrence 
is  far  from  being  usual,  and  doubts  may  yet  be  enter- 
tained whether  such  enlargement  is  combined  with  the 
following  alteration  of  structure.  The  change  which 
the  head  of  the  tibia  undergoes  in  many  cases  is  first 
a partial  absorption  of  the  phosphate  of  lime  through- 
out its  texture,  while  at  first  a transparent  fluid,  and 
afterward  a yellow  cheesy  substance,  are  deposited  in 
the  cancelli.  In  a more  advanced  stage,  and,  indeed, 
in  that  stage  which  most  frequently  takes  place  before 
a joint  is  amputated,  the  head  of  the  bone  has  deep 
excavations  in  consequence  of  caries,  and  its  structure 
is  now  so  softened,  that  when  an  instrument  is  pushed 
against  the  carious  part,  it  easily  penetrates  deeply  into 
the  bone.  Occasionally,  as  Mr.  Lloyd  has  observed, 
all  the  bones  of  a joint  are  affected  in  this  way ; but 
frequently  only  one  of  them. — {On  Scrofula,  p.  120.) 

According  to  a modern  writer,  “ The  morbid  affec- 
tion appears  to  have  its  origin  in  the  bones,  which 
become  preternaturally  vascular,  and  contain  a less 
than  usual  quantity  of  earthy  matter;  while  at  first  a 
transparent  fluid,  and  afterwmrd  a yellow  cheesy  sub- 
stance is  deposited  in  their  cancelli.  From  the  dis- 
eased bone,  vessels,  carrying  red  blood,  shoot  into  the 
cartilage,  which  afterward  ulcerates  in  spots,  the  ulcera- 
tion beginning  on  that  surface  which  is  connected  to 
the  bone.  As  the  caries  of  the  bones  advances,  pus  is 
collected  in  the  joint.  At  last  the  abscess  bursts  exter- 
nally, having  formed  numerous  and  circuitous  .sinuses.” 
— {Brodie,  in  Med.  Chir.  Trans,  vol.  4,  p.  272,  and 
Pathol.  Obs.  p.  227.)  The  above-described  alteration 
of  the  structure  of  the  bones  this  author  has  never 
seen  in  the  cranium,  nor  in  the  middle  of  the  cylin- 
drical bones;  but  it  is  asserted  by  another  late  wu'iler, 
that  the  cheesy  matter  sometimes  pervades  the  cancelli 
of  the  whole  bone,  and  is  deposited  in  innumerable 
portions  of  the  most  minute  size. — {K.  Ji.  JJoyd,  on 
Scrofula,  p.  120.)  Also,  with  respect  to  the  increased 
va.ecidarity  of  the  diseased  part  of  the  bone,  although 
Mr.  liloyd  assents  to  the  truth  of  this  statement,  as  ap- 
plied to  the  early  stace  of  the  disorder,  he  represents 
the  vascularity  as  afferward  being  diminished,  in  pro- 
portion as  thequantitv  of  cheese-like  deposite  increases. 
—{Fol.  cit.p.  122,  123.) 


JOINTS. 


109 


A cursory  examination  of  a diseased  joint,  even  when 
it  is  cut  open,  will  not  suffice  to  sliow  that  the  heads  of 
the  bones  have  not  acquired  an  increase  of  size.  In 
making  a dissection  of  this  kind,  in  the  presence  of  a 
medical  friend,  I found  that  even  after  the  joint  had 
been  opened,  the  swelling  had  every  appearance  of 
arising  from  an  actual  expansion  of  the  bones.  The 
gentleman  with  me  felt  the  ends  of  the  bones  after  the 
integuments  had  been' removed,  and  he  coincided  with 
me  that  the  feel  which  was  even  now  communicated 
seemed  to  be  caused  by  a swelling  of  the  bones  them- 
selves. But  on  cleaning  them,  the  enlargement  was 
demonstrated  to  arise  entirely  from  a thickening  of  the 
soft  parts.  So  unusual,  indeed,  is  the  expansion  of  the 
heads  of  the  bones,  that  the  late  Mr.  Crowther,  who 
I)aid  great  attention  to  these  cases,  joined  Mr.  Russell 
in  believing  that  such  a change  never  happened;  a 
conclusion  not  entirely  correct. — (See  Practical  Obs. 
on  While  Swelling,  ^c.  edit.  2,p.  l-l,  1808.) 

Mr.  Russell  has  particularly  noticed  how  much  the 
soft  parts  frequently  contribute  to  the  swelling.  He 
describes  the  appearances  on  dissection  thus:  “The 
great  mass  of  the  swelling  appears  to  arise  from  an 
affection  of  the  parts  exterior  to  the  cavity  of  the 
joint,  and  which,  besides  an  enlargement  in  size,  seem 
also  to  have  undergone  a material  change  in  structure. 
There  is  a larger  than  natural  proportion  of  a viscid 
fluid  intermixed  with  the  cellular  substance;  and  the 
cellular  substance  itself  has  become  thicker,  softer,  and 
of  a less  firm  consistence,  than  in  a state  of  health.”— 
{On  the  Morbid  .Affections  of  the  Knee,  30.)  The 
manner  in  which  the  soft  parts  are  affected  is  also  de- 
scribed by  Mr.  Brodie  ; “ Inflammation  takes  place  of 
the  cellular  membrane  external  to  the  joint.  Serum, 
and  afterward  coagulabie  lymph,  are  effused;  and 
hence  arises  a puffy  elastic  swelling  in  the  early,  and 
an  flcdernatous  swelling  in  the  advanced,  stage  of  the 
disease. 

“ Scrofula  attacks  only  tlrose  bones  or  portions  of 
hones  which  have  a spongy  texture,  as  the  extremities 
of  the  cylindrical  bones,  and  the  bones  of  the  carpus 
and  tarsus ; and  hence  tlie  joints  become  affected  from 
their  contiguity  to  the  parts  which  are  the  original 
scat  of  the  disease.” — (See  Medico- Chir.  Trans,  vol. 
4,;;.  273.) 

In  the  cavity  of  the  joint  we  sometimes  find  a quan- 
tity of  curd-like  matter,  and  the  cartilages  absorbed  in 
various  places,  but  more  particularly  round  the  edges 
of  the  articular  surfaces. 

As  the  name  of  the  disease  implies,  the  skin  is  not  at 
all  idtered  in  colour.  According  to  Mr.  Lloyd,  the  first 
decided  symptom  of  disease  in  the  articulating  extre- 
mity of  a bone,  is  an  occasional  deep-seated,  dull, 
heavy  pain,  unattended  by  swelling,  and  not  increased 
by  motion ; and  if  it  be  the  hip,  knee,  or  ankle  which 
is  affected,  the  patient  keeps  the  knee  rather  bent,  and 
never  fully  extends  it  in  progression. — {On  Scrofula,  p. 
138.)  In  some  instances  the  swelling  yields  in  a cer- 
tain degree  to  presstrre;  but  it  never  pits,  and  is  almost 
always  sufficiently  firm  to  make  an  uninformed  exa- 
miner believe  that  the  bones  contribute  to  the  tumour. 
It  is  remarked  by  Mr.  Brodie,  that  while  the  disease  is 
going  on  in  Ihe  cancellous  structure  of  the  bones,  be- 
fore its  effects  have  extended  to  the  other  textures,  and 
while  there  is  still  no  evident  swelling,  the  patient  ex- 
periences some  degree  of  pain,  which,  however,  is 
never  very  severe,  and  often  is  so  slight  that  it  is 
scarcely  noticed.  After  a time,  varying  from  a few 
weeks  to  several  months,  the  external  parts  begin  to 
swell,  and  serum  and  coagulated  lymph  to  be  effused 
in  the  cellular  membrane,  so  as  to  form  a puffy,  elastic 
ewe\Vm«.— {Pathol.  Obs.  p.  231.)  In  the  majority  of 
scrofulous  white  swellings,  let  the  pain  be  trivial  or 
more  severe,  it  is  particularly  situated  in  one  part  of 
the  joint ; viz.  either  the  centre  of  the  articulation  or 
the  head  of  the  tibia.  Sometimes  the  pain  continues 
without  interruption;  sometimes  there  are  iriterrriis- 
sioti-s;  and  in  other  instance.®,  the  pain  recurs  at  regu- 
lar times,  so  as  to  have  been  called  by  sonu:  writers 
periodical.  Almost  all  authors  describe  the  jratient  as 
suffering  more  unea.siness  in  the  diseased  part,  when 
he  is  warm,  and  particularly  when  he  is  in  this  con- 
dition in  bed. 

In  the  early  stage  of  the  disease  the  swelling  is 
ni'i^lly  very  inconsiderable,  or  there  is  even  no  visible 
enlaigeiiienl  whatever,  excepting  pcrliai»s  after  exer- 
cise. In  the  little  depressions,  naturally  situated  on 


each  side  of  the  patella,  a fulness  generally  first  shows 
itself,  and  gradually  spreads  all  over  the  affected  joint. 
According  to  Mr.  Lloyd,  however,  when  the  soft  parts 
on  the  outside  of  the  knee-joint  permanently  swell,  the 
swelling  often  commences  on  each  side,  just  behind  the 
condyles,  so  that  the  joint  appears  wider;  and  he  says, 
that  he  has  often  seen  the  enlargement  commence  by 
the  swelling  of  a gland,  immediately  above  the  inner 
condyle.  He  observes,  however,  that  there  is  no  point 
of  the  joint  where  the  swelling  may  not  begin. — {Op. 
cit.  p.  139.) 

The  patient,  unable  to  bear  the  weight  of  his  body 
on  the  disordered  joint,  in  consequence  of  the  great 
increase  of  pain  thus  created,  gets  into  the  habit  ot 
only  touching  the  ground  with  his  toes,  and  the  knee 
being  generally  kept  a little  bent  in  this  manner,  soon 
loses  the  capacity  of  being  completely  extended  again. 
When  white  swellings  have  lasted  a good  while,  the 
knee  is  almost  always  found  in  a permanent  state  of 
flexion.  In  scrofulous  cases,  the  pain  constantly  pre- 
cedes any  appearance  of  swelling ; but  the  interval 
between  the  two  symptoms  differs  very  much  in  dif- 
ferent subjects. 

The  morbid  joint,  in  the  course  of  time,  acquires  a 
vast  magnitude.  Still  the  integuments  retain  their 
natural  colour,  and  remain  unaffected.  The  enlarge- 
ment, however,  always  seems  greater  than  it  really  is, 
in  consequence  of  the  emaciation  of  the  limb  both 
above  and  below  liie  disease. 

An  appearance  of  blue  distended  veins,  and  a shin- 
ing smoollmess,  are  the  only  alterations  to  be  noticed 
in  the  skin  covering  the  enlarged  joint.  The  shining 
smoothness  seems  attributable  to  the  distention,  which 
obliterates  the  natural  furrows  and  wrinkles  of  the 
cutis.  When  the  joint  is  thus  swollen,  the  integuments 
cannot  be  pinched  up  into  a fold,  as  they  could  in  the 
state  of  health,  and  even  in  the  beginning  of  the  disease. 

As  the  distemper  of  the  articulation  advances,  the 
cartilages  ulcerate,  and  collections  of  matter  form 
around  the  part,  and  at  length  burst.  Their  progress, 
as  Mr.  Brodie  has  stated,  is  slow,  and  when  they  burst, 
dr  are  opened,  they  discharge  a thin  pus,  with  por- 
tions of  a curd-like  substance  floating  in  it.  The  dis- 
charge afterward  becomes  less  copious  and  thicker. — 
{Pathol.  06s. p. 234.)  The  ulcerated  openings  some- 
times heal  u|);  but  such  abscesses  are  generally  fol- 
lowed by  other  collections,  which  pursue  the  same 
course.  In  some  cases,  these  abscesses  form  a few 
months  after  the  first  affection  of  the  joint ; on  other 
occasions,  several  years  elapse,  and  no  suppuration  of 
this  kind  makes  its  appearance.  They  sometimes  com- 
municate with  the  cavity  of  the  diseased  joint,  or  lead 
down  to  diseased  bone,'portions  of  which  occasionally 
exfoliate.  In  the  generality  of  cases,  several  abscesses 
lake  place  in  succession,  some  healing  up,  and  others 
ending  in  sinuses. 

As  the  cartilages  continue  to  ulcerate,  Mr.  Brodie 
has  observed,  that  the  pain  becomes  aggravated,  though 
not  in  a very  great  degree,  and  he  says  that  it  is  not 
severe  until  an  abscess  has  formed,  and  the  parts 
over  it  are  distended  and  inflamed.— (PatAo/.  Obs. 
p.  234.) 

The  local  mischief  must  necessarily  produce  more 
or  less  constitutional  disturbance.  The  patient’s  health 
becomes  gradually  impaired,  he  loses  his  appetite  and 
natural  rest  and  sleep ; his  pulse  is  small  and  frequent ; 
an  obstinate  debilitating  diarrhoea  and  profuse  noctur- 
nal sweats  ensue.  These  complaints  are,  sof)ner  or 
later,  followed  by  dissolution,  unless  the  constitution 
be  relieved  in  time,  either  by  the  amendment  or  remo- 
val of  the  diseased  part.  In  different  patients,  how- 
ever, the  course  of  the  disease,  and  its  effects  upon  the 
system,  vary  considerably,  in  relation  to  the  rapidity 
with  which  they  occur. 

Rheumatic  white  swellings,  or  inflammations  and 
thickenings  of  the  synovial  membrane  from  cold  or 
other  causes,  are  very  distinct  diseases  from  the  scro- 
fulous distemper  of  the  large  joints.  In  the  first,  the 
pain  is  said  never  to  occur  without  being  attended 
with  swelling.  Scrofulous  white  swellings,  on  the 
other  hand,  are  always  preceded  by  a pain^  which  is 
particularly  confined  to  one  point  of  the  articulation. 
In  rheumatic  ca.ses,  the  pain  is  more  general,  and  dif- 
fused over  the  whole  joint. 

Mr.  Lloyd  thinks,  tliat  Ihe  scrofulous  wdiite  swell- 
ing maybe  distinguished  from  all  other  diseases  of  the 
joints,  by  its  being  attended  with  less  pain,  by  the 


110 


JOINTS. 


great  degree  of  external  swelling,  often  existing  for  a 
long  time  before  matter  forms  in  the  cavity  of  the  arti- 
culation, and  by  the  swelling  being  but  little  dimi- 
nished by  any  discharge  of  matter,  which  may  take 
place.  In  its  first  stage,  before  the  interior  of  the  joint 
is  affected,  it  may  be  distinguished  from  primary  ulcer- 
ation of  the  cartilages,  by  the  pain  not  being  mucli 
increased  by  motion.  The  grating  produced  by  mov- 
ing the  joint  is  also  commonly  less  in  this  disease  than 
in  ordinary  ulceration  of  the  cartilages.— (/.Zoyd  on 
Scrofula.,  p.  1-12.)  And  according  to  Mr.  Brodie,  the 
principal  criterion  between  scrofulous  diseases  of  joints 
and  the  primary  ulceration  of  cartilages,  is  the  little 
degree  of  pain  in  the  former  cases,  which  is  never 
much  complained  of  before  an  abscess  forms,  nor  par- 
ticulai  ly  severe,  “ except  in  a few  instances,  and  in  the 
m()st  advanced  stage  of  the  disease,  when  a portion  of 
ulcerated  bone  has  died,  and  having  exfoliated,  so  as 
to  lie  loose  in  the  cavity  of  the  joint,  irritates  the  parts 
with  which  it  is  in  contact,  and  thus  becomes  a 
source  of  constant  torment.” — {Brodie's  Pathol.  Obs. 
p.  236.) 

It  seems  probable,  that  cases  in  which  the  cancel- 
lous structure  of  the  bones  is  found  quite  undiseased, 
and  in  which  the  mass  of  disease  is  confined  to  the 
soft  parts,  are  not  scrofulous  white  swellings.  Few 
persons  who  have  attained  the  age  of  five  and  twenty, 
without  having  had  the  least  symptom  of  scroftria,  ever 
e.xperience  after  this  period  of  life,  a first  attack  of  the 
white  swelling  of  the  strumous  kind.  The  general 
correctness  of  this  observation,  I believe,  is  univer- 
sally admitted,  and  that  there  are  but  few  exceptions 
to  it  is  confirmed  by  the  statements  of  V^olpi,  of  Pavia. 
However,  Mr.  Lloyd  attended  a man,  who,  at  the  age 
of  between  forty  and  fifty,  died  of  phthisis,  and  had  at 
the  lime  a scrofulous  ankle,  besides  several  abscesses 
about  his  hip  and  groin.  And  the  same  gentleman 
met  with  another  patient  upwards  of  forty  years  old, 
with  a similar  disease. — {On  Scrofula,  p.  127.)  But 
if  these  patients  had  had  no  marks  of  scrofula  in  their 
younger  days,  a circumstance  not  specified,  they  form 
deviations  from  what  is  usual,  as  indeed  Mr.  Lloyd 
seems  to  admit.  My  own  observations  lead  me  to  con- 
cur with  Mr.  Brodie,  that  the  scrofulous  affections  of 
tha  joints,  so  frequent  in  children,  are  rare  after  the 
age  of  thirty. — {Pathol.  Obs.  p.  299.)  This  observation, 
however,  is  to  be  received  as  correct,  only  with  refer- 
ence to  persons  who  have  been  free  from  scrofula  up 
to  that  period  of  life.  I am  attending  at  this  moment 
(Aug.  1829),  a woman  who  is  nearly  forty,  and  was 
first  attacked  with  a scrofulous  white  swelling  of  the 
left  knee  about  a year  ago  ; but  then  she  had  had  en- 
larged glands  in  the  neck  in  her  youth,  and  a scrofulous 
ulcer  of  long  duration  is  still  open  on  one  of  her  legs. 
All  cases  in  which  the  internal  structure  of  the  heads 
of  the  bones  become  softened,  previously  to  the  affec- 
tion of  the  cartilages  and  soft  parts,  are  probably 
scrofulous. 

Mr.  Russell  has  noticed  the  frequent  enlargement  of 
the  lymphatic  glands  in  the  groin,  in  consequence  of 
the  irritation  of  the  disease  in  the  knee  ; but  he  justly 
adds,  that  the  secondary  affection  never  proves  long 
troublesome. 

When  the  bones  are  diseased,  the  head  of  the  tibia 
always  suffers  more  than  the  condyles  of  the  thigh- 
bone.— {Russell.)  The  articular  surface  of  the  femur 
sometimes  has  not  a single  rough  or  carious  point,  not- 
withstanding that  of  the  tibia  may  have  suffered  a 
great  deal.  The  cartilaginous  coverings  of  the  heads 
of  the  bones  are  generally  eroded  first  at  their  edges ; 
and  in  the  knee,  the  cartilage  of  the  tibia  is  always 
more  affected  than  that  covering  the  condyles  of  the 
thigh-bone.  Indeed,  when  white  swellings  have  their 
origin  in  the  bones,  and  the  knee  is  the  seat  of  the  dis- 
order, there  is  some  ground  for  supposing  that  it  is 
in  the  tibia  that  the  morbid  mischief  usually  first  com- 
mences. 

The  ligaments  of  the  knee  are  occasionally  so  weak- 
ened or  destroyed,  that  the  tibia  and  fibi^a  become 
more  or  less  dislocated  backwards,  and  drawn  towards 
the  tuberosity  of  the  ischium,  by  the  powerful  action 
of  the  flexor  muscles  of  the  leg.  It  is  observed  by  Mr. 
Brodie,  that  just  as  ulceration  of  the  cartilages  is 
sometimes  followed  by  dislocation  of  the  hip,  so  we 
find  that  dislocation  of  the  knee  occasionally  takes 
place  from  the  same  cause.  Where  there  has  been 
considerable  distention  of  the  soft  parts,  in  conse- 


quence of  ulceration  extending  to  them,  the  head  of 
the  tibia  is  gradually  drawn  backwards  by  the  action 
of  the^exor  muscles ; and  Mr.  Brodie  has  even  known 
tliis  happen,  previously  to  the  formation  of  any  ab- 
scesses.—(Pat  AoZ.  Obs.p.  172,  ed.2.) 

I have  seen  a curious  species  of  white  swelling,  in 
vvhich  the  leg  could  be  bent  to  each  side  for  a very  con- 
siderable distance,  both  when  the  knee  was  extended 
and  bent;  a state  implying  a preternatural  looseness, 
or  perhaps  a destruction  of  the  ligaments  of  the  articu- 
lation. 

Scrofulous  white  swellings,  no  doubt,  are  under  the 
influence  of  a particular  kind  of  constitution,  termed 
scrofulous  or  strumous  habit,  in  which  every  cause 
capable  of  exciting  inflammation,  or  any  morbid  and 
irritable  state  of  a large  joint,  may  bring  on  the  pre- 
sent severe  disease.  On  the  other  hand,  in  a man  of 
a sound  constitution,  a similar  irritation  would  only 
induce  common  healthy  inflammation  of  the  joins. 
In  scrofulous  habits,  it  also  seems  as  if  irritation  of  a 
joint  were  much  more  easily  produced  than  in  other 
constitutions;  and  no  one  can  doubt  that  when  once 
excited  in  the  former  class  of  subjects,  it  is  much 
more  dangerous  and  difficult  of  removal,  than  in  other 
patients. 

The  doctrine  of  particular  white  swellings  being 
scrofulous  diseases,  is  supported  by  many  weighty 
reasons,  the  opinions  of  the  most  accurate  observers, 
and  the  evidence  of  daily  experience.  Wiseman  (book 
4,  chap.  4,)  calls  the  spina  ventosa  a species  of  scro- 
fula, and  tells  us  that  infants  and  children  are  gene- 
rally the  subjects  of  this  disease.  The  disorder  is  said 
by  Severinus  to  be  exceedingly  frequent  in  young  sub- 
jects. Petrus  de  Marchettis  has  observed  both  male 
and  female  subjects  aflTected  with  what  are  called  stru- 
mous diseases  of  the  joints,  as  late  as  the  age  of  five- 
and-tvventy ; but  not  afterward,  unless  they  had  suf- 
fered from  scrofula  before  that  period  of  life,  and  had 
not  been  completely  cured.  R.  Lowerus  also  main- 
tains a similar  opinion.  Even  though  a few  persons 
have  scrofulous  diseases  of  the  joints,  for  the  first 
time,  after  the  age  of  tw'enty-five,  this  occurrence,  like 
the  first  attack  of  scrofula  after  this  period,  must  be 
considered  as  extremely  uncommon. 

Another  argument  in  favour  of  the  doctrine  which 
sets  down  particular  kinds  of  white  swellings  as  scro- 
fulous, is  founded  on  the  hereditary  nature  of  such 
forms  of  disease. 

Numerous  continental  surgeons,  particularly  Petit 
and  Brambilla,  have  noticed  how  subject  the  English 
are  both  to  scrofula  and  white  swellings  of  the  joints. 
We  every  day  see  that  young  persons  afflicted  w'ith  the 
present  disease,  are  in  general  manifestly  scrofulous, 
or  have  once  been  so.  Frequently  enlarged  lymphatic 
glands  in  the  neck  denote  this  fatal  peculiarity  of  con- 
stitution ; and  very  often  the  patients  are  known  to 
have  descended  from  parents  who  had  strumous  disor- 
ders.— {Crowther.)  The  disease  is  also  frequently  com- 
bined with  swelled  mesenteric  glands,  or  tuberculated 
lungs. — {Brodie's  Pathol.  Obs.  p.  221.)  As  the  same 
author  remarks,  since  the  disease  depends  upon  a cer- 
tain morbid  condition  of  the  general  system,  it  is  not 
surprising  that  w'e  should  sometimes  find  it  affecting 
several  joints  at  the  same  time,  or  that  it  should  show 
itself  in  different  joints  in  succession;  attacking  a 
second  joint  after  it  has  been  cured  in  the  first,  or 
after  the  first  has  been  removed  by  amputation. — 
(F.  230.) 

Besides  the  general  emblems  of  a scrofulous  consti- 
tution, which  will  be  noticed  in  the  ankle  Scrofula, 
we  may  often  observe  a shining,  coagulated,  flaky  sub- 
stance, like  white  of  egg,  blended  w'ith  the  contents  of 
such  abscesses  as  occur  in  the  progress  of  the  disease. 
This  kind  of  matter  is  almost  peculiar  to  scrofulous 
abscesses,  and  forms  another  argument  in  support  of 
the  foregoing  observations,  relative  to  the  share  which 
scrofula  frequently  lias  in  the  origin  and  course  of 
many  white  swellings. 

Mr.  Brodie’s  experience  leads  him  to  lielieve,  that  in 
scrofulous  cases,  the  chance  of  ultimate  recovery  is 
much  less,  when  the  disease  attacks  the  complicated 
joints  of  the  foot  and  hand,  than  w hen  it  issituated  in 
larger  articulations  of  a more  simple  siruciure. — (Pa- 
thol. and  Surg.  Obs.  p.  235.) 

Treatment  of  White  Swellings. — In  practice  we 
meet  with  all  these  cases,  both  scrofulous  and  rheu- 
matic, in  two  opposite  states ; sometimes  Uie  diseased 


JOINTS. 


Ill 


Joint  is  affected  witli  a degree  of  acute  inflammation; 
in  other  instances  the  malady  is  entirely  chronic. 

Tlie  imprudence  of  patients  in  walking  about  and 
disturbing  the  diseased  part,  is  often  the  occasion  of  a 
degree  of  acute  inflammation,  which  is  denoted  by  the 
tenderness  of  the  joint  when  handled  by  the  surgeon, 
and  also  by  the  integuments  feeling  hotter  than  those 
of  the  healthy  knee.  When  such  state  exists,  there 
can  be  no  doubt  that  topical  bleeding,  fomentations, 
emollient  poultices,  or  cold  saturnine  lotions,  are 
means  which  may  be  eminently  serviceable.  The  an- 
tiphlogistic regimen  is  now  strongly  indicated.  Cool- 
ing purges  of  the  saline  kind  should  also  be  exhibited. 
Blood  may  be  taken  fioni  the  arm,  and  also  from  the 
diseased  part,  either  by  means  of  leeches  or  cupping. 
Rlr.  Latta  gives  the  preference  to  tfie  latter  method, 
whenever  it  can  be  employed  ; and  he  very  properly 
remarks,  that  liltie  advantage  can  be  expected  from 
topical  bleeding  of  any  kind,  utiless  the  quantity  of 
blood  taken  away  be  considerable.  Ten  or  twelve 
ounces  by  cupping  should  be  taken  away  at  a time, 
and  the  operaiioti  should  be  repeated  at  proper  inter- 
vals till  the  tenderness  and  heat  of  the  skin  have  en- 
tirely subsided.  When  leeches  are  used,  the  number 
ought  to  be  considerable,  and  Mr.  Latta  recommends 
the  application  of  at  least  sixteen  or  twenty.— (Sysim 
of  Surgery,  vol.  1,  chap.  6.) 

Although  antiphlogistic  means  are  judicious  when 
acute  inflammation  prevails,  yet  such  practitioners  as 
lose  weeks  and  months  in  the  adoption  of  this  treat- 
ment are  highly  censurable.  While  the  skin  is  hot 
and  tender,  while  the  joint  is  aflected  with  very  acute 
and  general  pain,  and  while  the  patient  is  indisposed 
with  the  usual  symptoms  of  inflammaiory  fever,  great 
benefit  may  be  rationally  expected  Horn  the  above  plan. 
When,  however,  the  disease  is  truly  chionic,  difi'eient 
plans  are  indicated.  In  ordinary  cases  of  scrofulous 
disease  of  the  joints,  Mr.  Brodie  considers  topical 
bleeding  as  generally  unnecessary. — ^Pathol,  and  Surg. 
Obs.  p.  240.') 

It  is  quite  needless  to  expatiate  on  the  mode  of 
treating  white  swellings  complicated  with  acute  in- 
flammation, particularly  as  the  treatment  of  those 
cases  which  consist  of  inflammation  of  the  synovial 
membrane  has  been  already  noticed,  and  may  be  said 
to  be  applicable  toother  forms  of  white  swelling,  when 
they  are  attended  with  heat  and  inflammation  of  the 
soft  parts.  The  most  eligible  plan  of  arresting  the 
moibid  process  in  the  bones,  cartilages,  and  soft  parts 
surrounding  the  articulation,  and  the  most  successful 
method  of  lessening  the  chronic  enlargement  of  the 
joint,  are  the  subjects  at  present  demanding  our  earne.st 
investigation. 

The  works  of  Hippocrates,  Celsus,Rhazes,Hieron, Fa- 
bricius,  &c.  compared  with  modern  surgical  books,  will 
soon  convince  us,  thatthe  practice  of  the  ancients,  in  the 
treatment  of  diseased  joints,  does  not  differ  much  from 
the  plan  now  pursued  by  the  best  modern  surgeons. 
Mr.  Crowther  remarks,  that  the  ancients  used  local  and 
general  blood-letting,  the  actual  and  potential  cautery, 
with  vesicating  and  stimulating  applications  to  the 
skin.  They  farther  maintain,  that  sores  produced  by 
these  means  should  have  their  discharge  promoted  and 
continued  for  a considerable  length  of  time. 

With  regard  to  the  cases  which  Mr.  Brodie  describes 
as  depending  upon  a total  loss  of  the  natural  structure 
of  the  synovial  membrane,  which  is  converted  into  a 
puljiy  substance,  one  quarter  or  one  half  of  an  inch  in 
thickness,  though  the  progress  of  the  disease  may  be 
somewhat  checked  by  rest  and  cold  lotions,  it  is  accord- 
ing to  this  gentleman  incurable,  and  at  length  it  ends  in 
ulceration  of  the  cartilages,  ab.«cesses,  &c.  When 
there  is  considerable  pain  in  consequence  of  the  car- 
tilaur^  beginning  to  ulcerate,  partial  relief  may  be  de- 
rived from  fomentations  and  poultices  ; but  nothing 
will  effect  a cure.  Hence,  when  the  health  begins  to 
sutfer,  he  considers  amputation  to  be  indicated. — (Med. 
Chir.  Trans,  p.  254.)  Whether  the  local  use  of  iodine 
applications  would  be  beneficial  in  the  early  stage  of 
this  form  of  disease,  is  a question  that  deserves  farther 
investigation,  but  can  only  be  determined  by  careful 
ex[»erience. 

When  vvhite  swellings  arc  accompanied  with  ulcera- 
tion of  the  cartilages,  all  motion  of  the  joint  is  ex- 
tremely hurtful.  Indeed,  as  Mr.  Brodie  well  observes, 
keeping  the  lintib  in  a state  of  perfect  quietude  is  a 
very  important,  if  nut  the  most  important  circumstance, 


to  be  attended  to  in  the  treatment.  According  to  this 
gentleman,  it  is  in  these  cases,  in  which  ulceration  of 
the  cartilages  occurs  as  a primary  disease,  that  caustic 
issues  are  usually  productive  of  singular  benefit;  but 
he  deems  them  of  little  use  in  any  other  diseases  of 
the  joints.  He  thinks  setons  and  blisters,  kept  open 
with  savine  cerate,  may  also  be  used  with  advantage. 
Bleeding  is  indicated  only  when,  from  improper  exer- 
cise, the  articular  surfaces  are  inflamed,  and  there  is 
pain  atid  fever.  Mr.  Brodie  asserts  thatthe  warm  bath 
relieves  the  symptoms  in  the  early  stage,  if  it  does  not 
stop  the  progress  of  the  disease;  but  he  condemns 
plasters  of  gum  ammoniac,  embrocations,  liniments, 
and  frictions,  as  either  useless  or  hurtful. — (See  Med. 
Chir.  Trans,  vol.  6,  p.  332 — 334.) 

Topical  applications,  consisting  of  strong  astringents 
of  the  mineral  and  vegetable  kingdom,  are  of  no  ser- 
vice in  examples  of  ulceration  of  the  cartilages,  or  of 
the  scrofulous  form  of  the  disease,  though  they  often 
suffice  for  the  cure  of  some  mild  descriptions  of  white 
swelling,  depending  upon  a thickening  of  the  synovial 
membrane.  A decoction  of  oak  bark,  containing 
alum,  was  recommended  by  Mr.  Russell. 

Myovvn  experience  will  notallow  metosay  any  thing 
in  favour  of  electricity,  as  an  application  for  the  relief 
of  white  swellings;  and  it  must  be  more  likely  to  do 
harm  than  good,  whenever  the  indication  is  to  lessen 
irritation. 

“If  the  tumour  is  quite  indolent  (says  Richerand), 
the  application  of  galvanism  maybe  pro[)().-ed;  it  is 
not,  however,  exempt  fiom  danger,  and  on  one  occa- 
.'^ion  where  I employed  it,  lancinatinu  pains  and  swell- 
ing of  the  joint  wete  broughtonby  it. — (J^osogr.  Chir. 
t.  3,  p.  174,  ed.  2.) 

Mr.  J.  Hunter  had  confidence  in  cicuta  and  sea-bathing 
as  possessing  power  over  many  scrofulous  diseases, 
and  that  such  diseases  of  the  joints  are  often  mate- 
rially benefited  by  the  patient’s  going  to  the  sea-side 
and  bathing,  is  a fact  which  cannot  be  doubted,  what- 
ever may  be  the  mode  of  explaining  the  benefit  thus 
obtained.  I fully  believe  that  sea-air  and  sea-bathing 
have  a beneficial  influence  over  scrofulous  diseases  of 
the  joints  ; but  probably  their  effects  are  produced  on 
the  part  through  the  medium  of  the  constitution,  and 
they  should  only  be  recommended  as  an  auxiliary  plan, 
to  be  adopted  in  conjunction  with  other  still  more  effi- 
cacious measures. 

Every  one  is  w'ell  acquainted  with  the  efficacy  of 
friction  in  exciting  the  action  of  the  absorbents.  To 
this  principle  we  are  to  impute  the  great  benefit  which 
arises  from  what  is  termed  dry  rvhbing,  in  cases  of 
white  swellings.  This  kind  of  friction  is  performed 
by  the  naked  hands  of  an  attendant,  without  using  at 
the  same  time  any  kind  of  liniment  or  other  applica- 
tion whatsoever,  excepting  sometimes  a little  flour,  or 
powdered  starch,  and  the  ruhbing  is  continued  several 
hours  every  day.  At  Oxford,  many  poor  persons  used 
to  earn  their  livelihood  by  devoting  themselves  to  this 
species  of  labour,  for  which  they  were  paid  a stipulated 
sum  per  hour.  This  practice,  however,  is  chiefly  ad- 
vantageous in  the  chronic  stage  of  vvhite  swelling, 
arising  from  inflammation  of  the  synovial  membrane. 

I look  upon  all  merely  emollient  applications,  such  as 
fomentations  and  poultices,  as  quite  destitute  of  real 
efficacy,  except  when  great  pain  or  active  itiflamma- 
tion  is  present,  and,  though  they  serve  to  amuse  the 
patient,  they  ought  not  to  be  recommended.  That  sur- 
geon who  only  strives  to  please  his  patient’s  fancy, 
without  doing  any  real  good  to  him  in  regard  to  his  af- 
flict ion,  may  be  considered  as  doing  harm  ; because  the 
semblance  of  something  being  done  too  often  hinders 
other  really  useful  steps  from  being  ptirsued.  The 
French  surgeons  are  particularly  liberal  in  the  praises 
which  they  bestow  on  warm  emollient  remedies, 
poultices,  steam  of  hot  water,  fornetitations,  &c.,  and 
they  adduce  instances  of  white  swellings  being  cured 
in  this  manner.  But  the  cases  to  which  they  refer 
were  no  doubt  mere  inflammations,  and  thickening  of 
the  synovial  membrane;  a disease  which  in  general 
rearlily  yields  to  several  other  plans. 

The  only  method  of  treatment  which  my  own  per- 
sonal experience  enables  me  to  recommend  for  scrofu- 
lous white  swelliiiL's  in  a chronic  state,  consists  in  keep- 
ing up  a discharge  from  the  surface  of  the  diseased 
joints.  The  opportunities  which  I have  h.ad  of  ob- 
serving the  effects  of  blisters  and  caustic  issues,  rather 
incline  uie,  however,  to  prefer  the  former  to  the  latter. 


.12 


JOINTS. 


I have  seen  great  good  derived  from  both  ; but  more 
from  blisters  than  the  other  kind  of  issue.  There  are 
instances  in  which  I should  employ  vesicating  applica- 
tions ; there  are  others  in  whicli  I should  prefer  making 
an  eschar  with  caustic.  In  particular  individuals  blis- 
ters create  so  much  irritation,  heat,  fever,  and  sullering, 
that  a perseverance  in  them  would  be  rashness. 

The  blister  should  always  be  large.  Many  surgeons, 
instead  of  following  Mr.  Crowther’s  plan,  prefer  blis- 
tering first  on  one  side  of  the  joint  and  then  on  the 
other  alternately,  for  a considerable  length  of  time. 
“ Blisters  (says  Mr.  Lalta)  may  be  put  upon  each  side 
of  the  patella,  and  ought  to  be  of  such  a size  and 
shape  as  to  cover  the  whole  of  the  swelling,  on  the  in- 
side, from  the  hinder  part  of  the  joint,  at  the  edge  of 
the  hollow  of  the  thigh,  to  the  edge  of  the  patella,  over 
the  whole  e.xtent  of  the  swelling  above  and  below.  As 
soon  as  the  blister  is  taken  oft’  from  one  side,  it  ought 
to  be  applied  to  the  other,  and  thus  repealed  alternately 
until  both  swelling  and  pain  be  completely  removed. 
When  this  is  the  case,  the  patient  ought  to  be  directed 
to  rub  the  joint  w'ell  with  a liniment,  composed  of  half 
an  ounce  of  camphor  dissolv'ed  in  two  ounces  of  oil, 
with  the  addition  of  half  an  ounce  of  spir.  sal-ammon. 
canst,or,  as  it  is  now  called,  liquor  ammonia;.  This  is 
to  be  used  three  times  a day  ; and  in  this  way  (conti- 
nues Mr.  Latta)  I have  successfully  treated  many  cases 
of  white  swellings.” — {Syst.  of  Su7-gery,vel.l,ch'ip.6.) 

In  the  beginning,  caustic  issues  are  even  more  pain- 
ful than  blisters;  but  they  afteiward  become  more 
like  indolent  sores,  ainl  are  more  easily  kept  open  for  a 
length  of  lime  than  blisters.  Such  issues  are  com- 
monly made  on  each  side  of  the  diseased  joint,  and  of 
about  the  size  of  a half-crown.  The  manner  of  making 
the  eschars  and  keeping  issues  open,  has  been  already 
explained. — (See  Issue.) 

The  question  has  been  contested  among  surgical  wri- 
ters and  practitioners,  whether  blisters  and  issues  pro- 
duce benefit  upon  the  principle  of  counter-irritation,  or 
in  consequence  of  the  discharge  which  they  occasion. 
They  probably  Operate  efficaciously  fn  both  ways ; for 
there  is  no  doubt  that  simple  rubefacients  possess  the 
power  of  rousing  the  action  of  the  absorbents,  and 
they  may  also  modify  the  vascular  action  in  diseased 
parts.  Yet  it  is  obvious  that  they  canonly  act  upon  the 
principle  of  counter-irritation,  and  they  have  not  been 
here  recommended  partic\ilarly  for  white  swellings, 
because  it  seems  to  me,  that  whenever  some  good  might 
be  derived  from  their  employment,  much  mote  benefit 
might  always  be  obtained  from  blisters  and  issues. 
This  sentiment  is  confirmed  by  experience,  and  we 
must,  therefore,  impute  a great  degree  of  efficacy  to 
the  maintenance  of  a purulent  discharge  from  the  vi- 
cinity of  the  diseased  part. 

Though  my  owm  observations  have  led  me  to  think 
issue.s  and  blisters  as  efficient  as  any  means  hitherto 
devised  for  stopping  the  progress  of  scrofulous  disease 
of  the  heads  of  the  bones,  I am  far  from  meaning  to 
say  that  such  disease  can  generally  be  stopped  by 
these  or  any  other  remedies,  local  or  general.  Mr. 
Brodie  has  seldom  known  any  benefit  derived  from 
blisters  or  stimulating  liniments ; nor  has  he  seen  the 
same  degree  of  good  produced  by  issues  in  scrofulous 
cases,  as  in  examples  of  primary  ulceration  of  the  car- 
tilages. Cold  evaporating  lotions  in  the  early  stage  of 
the  complaint ; perfect  quietude  of  the  joint ; attention 
to  the  patient’s  health  ; and  riding  in  a carriage  in  the 
fresh  air,  are  the  means  which  this  gentleman  particu- 
larly recommends  in  scrofulous  diseases  of  the  joints. 
During  the  formation  of  abscesses,  he  approves  of  fo- 
mentations and  poultices. — {Pathol.  Obs.p.  242.) 

VVe  have  noticed  the  efficacy  of  friction  in  exciting 
the  action  of  the  absorbents,  by  which  the  thickened 
state  of  parts  around  the  affected  joint  may  be  consi- 
derably lessened,  and  on  this  principle  the  utility  of 
dry  rubbing  arises.  We  have  now  to  notice  tlie  method 
of  producing  the  same  effect  by  pressure.  In  St.  Bar- 
tholomew'’s  Hospital  I have  seen  a few  cases,  in  which 
the  swelling  of  the  joints  was  .materially  diminished  by 
encircling  them  with  strips  of  adhesive  plaster,  applied 
with  moderate  tightness. 

A somewhat  similar  plan,  though  its  modus  operand! 
is  differently  accounted  for,  apjiears  also  to  have  been 
tried  in  France.  “J’ai  dans  quelques  occasions  (says 
Riclierand)  ohtenu  les  plus  grands  avantnges  dc  I’ap- 
pMcation  d’un  taffetas  cire  autonr  de  rarticnlation  tn- 
in^liee.  On  coupe  un  morceau  de  cette  etofle,  assez 


large  pour  envelopper  la  totality  de  la  tumeur , on  en* 
duit  les  bords  d’une  gomme  dissoute  dans  le  vinaigre, 
et  susceptible  de  lafaire  adherer  inlimernent  a la  peau  ; 
un  I’applique  ensuite  de  manidre  que  tout  facets  soil 
interdit  d fair  entre  lui  et  les  teguments.  Lorsque  au 
bout  de  quelques  jours  on  Idve  cet  appareil,  on  trouve 
la  peau  liumide,  ramollie  par  I’humeur  de  la  tr-anspira- 
tion  condensee  en  goutelettes  d la  surface  interieuie  du 
taffetas.  Dans  ce  proedde  on  etablit  un  espdee  de  bain 
de  vapeur  autour  de  I’articulation  malade.”— (JVbso^r. 
Chir.  t.  3,p.  175,  edit.  2.) 

My  friend,  the  late  Mr.  Clement  Wilson  Criutwell, 
of  Bath,  sent  me  an  excellent  case  illustrative  of  the 
efficacy  of  treatment  by  pressure.  He  remarks,  that 
“after  cupping  the  part,  and  endeavouring  to  quiet  the 
inflammation,  I Used  blisters;  but  they  e.xcited  such 
intolerable  pain,  a!id  produced  so  great  a degree  of 
swelling  and  inflammation,  that  I was  under  the  neces- 
sity of  healing  them  immediately.  After  tw'o  months’ 
strict  confinement  to  bed,  and  the  use  of  leeches  and 
refrigerant  w'ashes,  the  inflammation  having  again  sub- 
sided, and  the  pain  being  removed,  I again  ventured  to 
apply  one  small  blister,  and  t^ain  a similar  attack  of 
pain,  swelling,  and  inflammation  was  produced.  The 
joint  became  distended  with  fluid,  of  which  it  had  al- 
wa3's  contained  a large  quantity,  and  the  irritation  of 
the  constitution  was  excessive.  By  the  liberal  use  of 
opium,  I once  more  succeeded  in  quieting  the  disturb- 
ance, and,  convinced  of  the  hazard  of  using  blisters  in 
such  a subject,  I applied  moderate  pressure  by  means 
of  a roller,  together  with  a wash,  containing  a large 
proportion  of  spirit,  in  order  to  keep  up  a constant 
evaporation.  The  skin,  which  was  before  much  in- 
flamed and  hard,  has  become  natural  and  flaccid,  the 
pain  has  ceased,  tlie  swelling  has  diminished,  and  I 
have  every  prospect  of  effecting  a cure,  wit.h  the  jire- 
servation  of  tolerably  free  motion  in  the  joint.” 

Mr.  Cruttvvell,  in  a subsequent  letter,  informed  me 
that  this  case  got  completely  well,  by  the  treatment 
with  pressure,  and  had  remained  so  for  upwards  of 
six  months,  under  full  and  free  exercise. 

This  example  clearly  evinces  the  impropriety  of 
using  blisters  in  certain  constitutions.  In  some  re- 
marks annexed  to  the  above  case,  Mr.  Cruttwell  e.x- 
presses  his  conviction  that  absolute  rest,  cold  applica- 
tions, and  pressure  would  succeed  in  very  many  cases 
without  local  counter-irritation.  Pressure,  he  adds, 
succeeds  best  when  fluid  is  effused,  and  the  disease  is 
indolent ; but  he  is  convinced  that  it  may  be  used  with 
advantage  in  later  stages,  when  abscesses  have  formed, 
and  sinuses  already  exist ; and  he  reminds  me  how 
very  serviceable  continued  pressure  is  to  the  scrofu- 
lous finger-joints  of  children. 

The  good  effects  of  pressure  in  scrofulous  cases  are 
confirmed  by  the  observations  of  Mr.  Brodie:  when, 
says  he,  after  several  abscesses  have  taken  place,  the 
tendency  to  suppuration  has  ceased,  and  the  swollen 
joint  has  become  diminished,  anchylosis  is  piobably 
disposed  to  take  place.  At  this  period,  pressure  by 
means  of  strips  of  linen,  spread  with  soap  cerate  or 
some  other  moderately  adhesive  plaster,  and  applied  in 
a circular  manner  round  the  limb,  will  be  productive 
of  benefit. — {Pathol,  and  Sura.  Obs.p.  243.) 

Analogous  to  the  plans  sometimes  followed  by  M. 
Riclierand,  Mr.  Cruttwell,  and  Mr.  Brodie,  is  that  de- 
scribed by  Mr.  Scott.  According  to  this  gentleman, 
issues,  peipetual  blisters,  and  other  irritating  remedies 
may  all  be  superseded  by  the  following  treatment. 
The  surface  of  the  joint  is.  first  to  be  cleaned  with  a 
sponge  and  soft  brown  soap  and  water,  and  then  tho- 
roughly dried.  It  is  next  to  be  rubbed  with  a sponge 
soaked  in  camphorated  spirit  of  wine,  until  it  begins  to 
feel  warm,  smart  a little,  and  assume  a red  appear- 
ance. It  is  now  to  be  covered  with  a cerate,  composed 
of  equal  parts  of  ceratum  saponis  and  the  ung.  hy- 
drarg.  fortius  cum  camphora.  This  is  thickly  spread 
on  large  square  pieces  of  lint,  and  applied  to  every  side 
of  the  joint,  and  this  in  the  knee  for  at  least  six  inches 
above  and  below  the  point  at  which  the  condyles  of 
the  femur  are  opposed  to  the  head  of  the  tibia.  The 
limb  is  ne.xt  to  be  supported  to  the  same  extent  with 
strips  of  calico,  spread  with  the  emiilastrum  plumbi, 
and  applied  so  as  to  prevent  motion  of  the  joint.  Then 
is  to  be  laid  on  an  additional  covering  of  emplastruni 
saponis,  spread  on  thick  leather,  and  cut  into  four 
bioad  piei  es;  one  for  the  front,  another  for  the  back, 
and  tlic  two  others  for  the  sides  of  the  joint:  lastly, 


JOINTS. 


113 


the  whole  is  secured  by  means  of  a calico  bandage, 
which  is  pot  on  very  gently,  and  rather  for  the  purpose 
of  securing  the  plaster,  and  giving  greater  thickness 
and  security  to  the  whole,  than  for  the  purpose  of 
coinpressing  the  joint. 

It  is  remarked  by  Mr.  Scott,  that  in  some  cases,  in 
which  the  skin  is  thick  and  indolent,  sufficient  irrita- 
tion will  scarcely  be  excited  by  the  above  applications, 
and  it  is  necessary  to  rub  on  the  part  a small  quantity 
of  tartar  emetic  ointment,  previously  to  the  applica- 
tion of  the  cerate.  In  some  instances,  and  particularly 
in  children,  it  is  proper  to  adopt  a plan  by  which  the 
motion  of  the  joint  may  be  more  effectually  hindered. 
This  is  done  by  applying  on  each  side  of  the  joint,  ex- 
ternally to  the  plasters,  a piece  of  pasteboard  softened 
in  warm  water,  and  cut  into  the  length,  breadth,  and 
form  of  splints,  and  when  dfy  it  will  be  found  to  make 
a firm  case  for  the  limb.— (See  Surg.  Obs.  on  the  Treat- 
vient  of  Chronic  Inflammation,  <S'C.  p-  133,  et  seq.  8vo. 
Load.  1828.)  The  applications  here  described  are 
stated  not  to  require  very  frequent  removal.  “ The 
time  during  which  they  may  be  left  undisturbed  (says 
Mr.  Scott)  will  depend  chiefly  on  the  necessity  for  a 
repetition  of  the  bleeding,  in  which  we  must  be  guided 
by  the  degree  of  pain;'or,  when  there  are  open  ab- 
scesses, by  the  quantity  of  the  discharge.  In  some 
cases  the  dressing  must  be  renewed  every  week  ; but 
in  the  generality  of  examples  this  may  remain  a fort- 
night, and  sometimes  longer.  Even  when  there  are 
sores  or  sinuses,  Mr.  Scott  lets  the  applications  continue 
on  the  part  several  days  or  a week,  as  he  finds  the 
presence  of  the  matter  do  less  harm  than  the  frequent 
disturbance  of  the  joint.  The  foregoing  method, 
combined  with  remedies  for  the  improvement  of  the 
health  in  general,  the  regulation  of  the  digestive  organs, 
the  prevention  of  costiveness,  tec.  and  with  occasional 
topical  bleeding,  when  the  slate  of  the  inflammation  re- 
quires it,  seems  to  be  employed  by  Mr.  Scott  in  several 
forms  of  disease  of  the  joints,  as  that  commencing  in 
the  synovial  membrane,  that  beginning  in  the  carti- 
lages, and  that  which  originates  in  the  cancellous  struc- 
ture of  the  heads  of  the  bones.  He  also  extends  the 
practice  to  diseases  of  the  hip,  and  to  various  examples 
of  induration  and  tumours,  the  result  of  chronic  in- 
flammation and  scrofula.  It  is  to  be  particularly  no- 
ticed, that  the  three  principles  on  which  it  acts  are, 
first,  its  mechanical  operation  of  supporting  and  steady- 
ing the  part;  secondly,  its  medicinal  action  on  the 
same  by  means  of  the  mercury  blended  with  the  ce- 
rate ; and  thirdly,  the  mild  degree  of  counter-irritation 
kept  up  in  the  skin  by  the  applications. 

When  the  knee  is  affected,  the  limb  has  a tendency  to 
become  permanently  bent.  It  must  undoubtedly  be 
judicious  to  prevent  this  position  by  means  of  paste- 
board or  splints,  which  will  also  serve  to  prevent  all 
motion  of  the  diseased  joint,  an  object  of  the  very 
highest  importance.  Were  the  disease  to  end  in  an- 
chylosis, the  advantage  of  having  the  limb  in  a state  of 
extension  is  certainly  very  important. 

In  cases  which  commence  in  the  cancellous  struc- 
ture jf  th^  heads  of  the  bones,  it  seems  rational  to 
combine  with  the  local  treatment  the  employment  of 
such  internal  remedies  as  have  been  known  to  do  good 
in  other  scrofulous  diseases.  “ It  is  to  be  supposed  (as 
Mr.  Brodie  observes)  that  the  air  of  a crowded  city 
must  be  more  or  less  unfavourable ; and  that  a resi- 
dence on  the  seacoast  is  likely  to  be  more  beneficial 
than  a residence  in  the  country  elsewhere.  The  pa- 
tient should  live  on  a nourishing  but  plain  diet;  he 
should  be  in  the  open  air  in  summer  as  much  as  he  can, 
without  exercising  the  joint.  His  mode  of  life  should, 
in  all  respects,  be  regular  and  uniform.”  Mr.  Brodie 
has  found  more  benefit  derived  from  the  long  use  of 
steel  medicines  than  any  others,  suspending  their  use, 
however,  and  substituting  the  mineral  acids  for  them, 
when  the  formation  of  abscesses  excites  febrile  action. 
VVith  such  means,  in  childien,  he  combines  the  occa- 
sional exhibition  »f  mercurial  purgatives.— (Pat/toi. 
Ohs.  p.  245.)  In  a work  which  Mr.  Lloyd  has  pub 
lished,  it  is  assumed  as  a fact,  that  in  scrofula  there  al- 
ways is  more  or  less  disorder  of  the  functions  of  the  di- 
gestive organs,  and  primarily  of  no  other  important 
function.  Hence  the  regulation  of  diet,  the  state  of 
the  bowels,  and  the  hepatic  secretions,  is  with  this  gen- 
tleman a principal  object ; and  with  the  latter  views, 
lie  employs,  after  Mr.  Abernethy’s  plan,  five  grains  of 
the  blue  pill  every  night,  and  half  a pint  of  decoct,  sars. 

VOL.  ll.-rll 


twice  a day,  with  opening  medicines,  if  necessary  to 
procure  regular  daily  evacuations.  When  acidity  of 
the  stomach  is  present,  he  gives  soda,  and  when  the 
stomach  is  weak,  cinchona,  steel,  and  mineral  acids. — 
{On  Scrofula,  p.  37,  &c.)  However,  no  doubt  can  be 
entertained  that  these  means,  like  many  others,  have 
no  specific  power  over  scrofulous  diseases,  and,  like 
sea-air  and  sea-bathing,  only  answer  by  sometimes  im- 
proving the  state  of  the  constitution.  In  the  local 
treatment  of  scrofulous  joints,  Mr.  Lloyd  commends 
quietude  of  the  limb,  which  is  to  be  confined  in  a sling, 
or  in  splints ; the  occasional  resistance  of  inflamma- 
tory action  by  leeches,  and  a diminution  of  tempe- 
rature; poultices  when  abscesses  form;  opening  such 
collections  of  matter  early ; and,  after  all  irritation  has 
ceased,  issues,  setons,  blisters,  or.  the  antimonial  oint- 
ment ; or  compression  upon  Mr.  Baynton’s  plan.— (P. 
152,  <fcc.)  With  respect  to  opening  these  abscesses 
early,  Mr.  Lloyd  differs  from  many  excellent  surgeons, 
especially  Dr.  Albers,  who  distinctly  states,  that  it  is 
generally  best  to  allow  them  to  burst  themselves.  On 
this  subject,  however,  great  diversity  of  opinion  pre- 
vails, and  Langenbeck  is  among  the  advocates  for 
making  an  early  opening. — {Bibl.  b.  2,  p.  39.)  Hectic 
symptoms  are  those  which  we  commonly  have  to  pal- 
liate in  these  cases.  When  the  appetite  is  impaired, 
and  the  stomach  will  bear  bark,  this  medicine  should 
be  given  with  the  aromatic  confection,  or  the  sul- 
phate of  quinine  may  be  exhibited.  Above  all,  opium 
claims  high  recommendation,  as  it  tends  to  keep  off  and 
relieve  a debilitating  diarrhoea,  which  too  frequently 
prevails,  at  the  same  time  that  it  alleviates  pain  and 
procures  sleep.  The  objection  made  against  its  exhibi- 
tion, on  the  ground  that  it  increases  perspiration,  seems 
exceedingly  frivolous,  when  the  above  important  bene- 
fits are  taken  into  consideration. 

The  internal  and  external  use  of  iodine  is  also  de- 
serving of  trial. — (See  Iodine.) 

Too  often,  however,  the  terrible  disease  of  which  we 
are  now  treating  baffles  all  human  skill  and  judg- 
ment, and  the  unhappy  patient's  health  having  declined 
to  the  lowest  rate,  he  is  necessitated  to  submit  to  am- 
putation, as  the  only  chance  of  preserving  life.  It  has 
been  explained,  in  speaking  of  Amputation,  that  the 
condition  of  the  patient’s  health,  and  not  of  the  dis- 
eased joint,  forms  the  principal  reason  for  recurring  to 
the  severe  operation  of  removing  the  limb.  If  the  pa- 
tient’s constitution  be  equal  to  a longer  struggle,  no 
man  can  pronounce  that  every  prospect  of  saving  the 
limb  is  at  an  end.  Many  diseased  joints,  appa- 
rently in  the  most  hopeless  condition,  frequently  take 
a favourable  turn,  and  after  all  allow  the  limb  to  be 
saved. 

The  proposal  of  cutting  out  diseased  joints,  has  been 
considered  in  the  article  Amputation. 

Disease  of  the  Hip-joint. — This  complaint  is  very 
analogous  in  its  nature  to  the  white  swelling  of  other 
articulations.  Like  the  latter  disorder,  it  seems  pro- 
bable that  the  disease  of  the  hip  has  its  varieties,  some 
of  which  may  be  connected  with  scrofula,  while 
others  cannot  be  suspected  to  have  any  concern  with 
it.  Mr.  Brodie’s  investigations  lead  him  to  believe, 
however,  that  the  disease  is  of  that  nature  in  which 
the  first  change  is  disease  and  ulceration  of  the  carti- 
jages.  The  present  complaint  is  most  frequently  seen 
in  children  under  the  age  of  fourteen  ; but  no  age,  no 
sex,  no  rank,  nor  condition  of  life,  is  exempt  from  the 
possibility  of  being  afflicted,  so  that  though  children 
form  a large  proportion  of  those  subjects  who  are  at- 
tacked, yet  the  number  of  adults,  and  even  of  old  per- 
sons, is  considerable. 

The  approach  of  the  disease  of  the  hip-joint  is  much 
more  insidious  than  that  of  a white  swelling.  Some 
degree  of  pain  always  precedes  the  latter  affection  ; 
but  the  only  forerunner  of  the  former  is  frequently  a 
slight  weakness  and  limping  of  the  aftected  limb. 
These  trivial  symptoms  are  very  often  not  sufficiently 
urgent  to  excite  much  notice,  and  when  observed  by 
superficial  practitioners,  are  commonly  neither  under- 
stood, nor  treated  according  to  the  dictates  of  surgical 
scietice.  As  there  is,  also,  sometimes  an  uneasiness  in 
the  kneewlien  the  hip  is  affected,  careless  practitioners 
frequently  mistake  the  seat  of  disease,  and  I have 
many  times  seen  patients  on  their  entrance  into  an  hos- 
pital, having  a poultice  on  their  knee,  while  the  wrong 
state  of  the  hip  was  not  at  all  suspected. 

This  mistake  is  extremely  detiimeiitulto  the  patient, 


114 


JOINTS. 


not  on  account  of  any  bad  effect  resulting  from  the  ap- 
plications so  employed  ; but  because  it  is  only  in  the 
incipient  period  of  the  complaint  tliat  a favourable 
prognosis  can  be  made.  In  this  stage  of  the  disease, 
mere  rest  and  repeated  topical  bleeding  will  do  more 
good  in  the  course  of  a fortnight,  than  large  painful 
issues  will  afterward  generally  accomplish  in  the  long 
space  of  a twelvemonth. 

The  symptoms  of  ilie  disease  of  the  hip-joint,  when 
only  looked  for  in  the  situation  of  that  articulation,  are 
not  very  obvious.  Though  in  some  instances  the  at- 
tention of  the  surgeon  is  soon  called  to  the  right  situ- 
ation of  the  disease,  by  the  existence  of  a fixed  pain 
behind  the  trochanter  major ; yet  it  is  too  often  the  case, 
that  mere  pain  about  an  articulation,  entirely  destitute 
of  visible  enlargement  and  change  of  colour,  is  quite 
disregarded  as  a complaint  of  no  importance  in  young 
subjects,  and  as  a rheumatic  or  gouty  affection  in 
adults.  Patients  frequently  complain  of  their  most 
painful  sensations  being  in  the  groin,  and  all  accurate 
observers  have  remarked,  that,  in  the  hip  disease,  the 
pain  is  not  confined  to  the  real  seat  of  disease,  but 
shoots  down  the  limb  in  the  course  of  the  vastus  ex- 
ternus  muscle  to  the  knee. 

The  pain,  says  Mr.  Brodie,  is  at  first  trifling,  and  only 
occasional ; but  it  afterward  becomes  severe  and  con- 
stant. It  resembles  a good  deal  the  pain  of  rheumatism, 
since  it  often  has  no  certain  seat.  As  the  disease  ad- 
vances, the  pain  becomes  exceedingly  severe,  particu- 
larly at  night,  when  the  patient  is  continually  roused 
from  his  sleep  by  painful  startings  of  the  limb.  Some- 
times he  experiences  a degree  of  relief  in  a particular 
position  of  the  joint,  and  no  other.  As  the  pain  in- 
creases in  intensity  it  becomes  more  fixed.  In  the 
greater  number  of  instances  it  is  referred  both  to  the 
hip  and  knee,  and  the  pain  in  the  latter  joint  is  gene- 
rally the  most  severe.  At  other  times,  there  is  pain  in 
the  knee,  and  none  in  the  hip.  A boy,  in  St.  George’s 
hospital,  complained  of  pain  in  the  inside  of  the  thigh, 
near  the  middle  ; and  another  patient  referred  the  pain 
to  the  sole  of  the  foot.  Wherever  the  pain  is  situated, 
it  is  aggravated  by  the  motion  of  the  joint,  and  espe- 
cially by  whatever  occasions  pressure  of  the  ulcerated 
cartilaginous  surfaces  against  each  other. — {Brodie's 
Pathol.  Obs.  p.  139.) 

The  early  symptoms  of  disease  in  the  hip-joint 
are  only  strongly  delineated  to  such  practitioners  as 
liave  acquired  the  necessary  information  relative  to 
this  part  of  surgery  from  careful  study  and  extensive 
experience. 

When  the  functions  of  a limb  are  obstructed  by 
disease,  the  bulk  of  the  member  generally  diminkshes, 
and  the  muscles  become  emaciated.  Nearly  as  soon  as 
the  least  degree  of  lameness  can  be  perceived,  the  leg 
and  thigh  have  actually  wasted,  and  their  circum- 
ference has  diminished. 

If  the  surgeon  make  pressure  on  the  front  of  the 
joint,  a little  on  the  outside  of  the  femoral  artery,  after 
it  has  descended  below  the  os  pubis,  great  pain  will  be 
experienced. 

“ Soon  after  the  commencement  of  the  complaint  fas 
Mr.  Brodie  remarks)  the  hip-joint  is  found  to  be  tender 
whenever  pressure  is  made  on  it  either  before  or  be- 
hind. The  absorbentglands  become  enlarged,  and  oc- 
casionally there  is  a slight  degree  of  general  tumefac- 
tion in  the  groin.”  The  same  gentleman  has  also  ad- 
verted to  the  curious  circumstance  of  there  being  in 
some  cases  a tenderness  of  the  parts,  to  which,  though 
not  diseased  themselves,  the  pain  is  referred  from 
sympathy  with  the  disease  of  the  hip.  This  occur- 
rence he  has  observed  in  the  knee  several  times,  and  in 
one  instance  in  the  course  of  the  peronajal  nerve.  He 
has  also  seen  a slight  degree  of  puffy  swelling  of 
the  knee,  in  a case  in  which  pain  was  referred  to 
this  joint,  in  consequence  of  disease  of  the  hip.— (P. 
142,  143.) 

The  limping  of  the  patient  is  a clear  proof  that 
something  about  the  limb  is  wrong;  and  if  such  limp- 
ing cannot  be  imputed  toduseased  vertebra*,  or  some  re- 
cent accident;  and  if,  at  the  same  time,  the  above- 
mentioned  emaciation  of  the  limb  exists,  there  is  great 
cause  to  suspect  that  the  hip  is  diseased,  particularly 
when  the  pain  is  augmented  by  pressing  the  front  of 
the  acetabulum 

Dis*>a3ed  vertebrar,  perhaps,  always  produce  a paraly- 
tic afl'ection  of  both  legs  at  once,  and  tin  y do  not  cause 
painful  sensations  about  the  knee,  as  the  hip  disease  does. 


The  increased  length  of  the  limb,  a symptom  that 
has  been  noticed  by  all  practitioners  since  De  Hacn,  ia 
a very  remarkable  and  curious  occurrence  in  the  early 
stage  of  the  present  disease.  This  symptom  is  easily 
delected  by  a comparison  of  the  condyles  of  the  os  fe- 
moris,  the  trochanter  major,  and  malleoli,  of  the  dis- 
eased limb,  with  those  parts  of  the  opposite  member, 
care  being  taken  that  the  patient’s  pelvis  is  evenly 
situated.  The  thing  is  the  more  striking,  as  the  in- 
creased length  of  the  member  is  frequently  as  much  as 
four  inches.  The  rationale  of  this  fact  John  Hunter 
used  to  explain  by  the  diseased  side  of  the  pelvis  be- 
coming lower  than 'the  other. — {Crowther,  p.  2C6.) 
The  same  thing  had  also  been  noticed  by  Falconer 
{On  Ischias,  p.  9),  long  before  the  period  when  Mr. 
Crowther  printed  his  second  edition. 

It  is  easy  (says  Mr.  Brodie)  to  understand  how  the 
crista  of  one  ileum  becomes  visibly  depressed  below 
the  level  of  the  other,  when  the  position  is  remem- 
bered in  which  the  patient  places  himself  when  he 
stands  erect.  “He  supports  the  weight  of  his  body 
upon  the  sound  limb,  the  hip  and  knee  of  which  are  in 
consequence  maintained  in  the  state  of  extension.  At 
the  same  time,  the  opposite  limb  is  inclined  forwards, 
and  the  foot  on  the  side  of  the  disease  is  placed  on  the 
ground  considerably  anterior  to  the  other,  not  for  the 
purpose  of  supporting  the  superincumbent  weight,  but 
for  that  of  keeping  the  person  steady,  and  preserving 
the  equilibrium.  Of  course,  this  cannot  be  done  with- 
out the  pelvis  on  the  same  side  being  depressed.  The 
inclination  of  the  pelvis  is  necessarily  attended  with  a 
lateral  curvature  of  the  spine,  and  hence  one  shoulder 
is  higher  than  the  other,  and  the  whole  figure  in  some 
degree  distorted. — {Pathol.  Obs.p.  146.)  These  effects, 
says  Mr.  Brodie,  are  in  general  all  removed  by  the 
patient’s  lying  in  bed  a few  weeks,  except  when  the 
deformity  has  continued  a long  time  in  a young  grow- 
ing subject. 

In  justice  to  the  memory  of  the  late  respected  Dr. 
Albers,  of  Bremen,  I ought  here  to  mention,  that  be 
appears  in  his  work  on  Coxalgia  to  have  first  pointed 
out  the  deformity  of  the  spine  in  this  disease,  and  the 
reason  of  such  change,  the  tenour  of  his  observations 
upon  this  point  agreeing  with  those  subsequently  made 
by  Mr.  Brodie. 

An  appearance  of  elongation  of  the  limb  is  not  ex- 
clusively confined  to  the  early  stage  of  the  morbus 
coxarius:  it  may  attend  oilier  cases.  I remember  in 
one  of  the  wards  of  St.  Bartholomew’s  Hospital,  a 
little  girl  with  a diseased  knee,  whose  pelvis  was  con- 
siderably distorted  in  this  manner,  so  that  the  limb  of 
the  same  side  appeared  much  elongated.  Her  hip- 
joint  was  quite  sound.  This  case  was  pointed  out  to 
Mr.  Lawrence  and  myself  by  Mr.  Cother  of  Glou- 
cester. 

Volpi,  Albers,  and  several  other  foreign  writers, 
dwell  upon  the  fact,  that  the  early  stage  of  this  disease 
is  sometimes  attended  with  an  appearance  of  elonga- 
tion, sometimes  with  that  of  a shortening  of  the  limb. 
An  explanation  of  the  circumstance  is  given  by  Mr. 
Brodie,  as  follows:  “ In  a few  cases,  where  the  patient 
is  in  the  erect  position,  it  may  be  observed,  that  the 
foot  which  belongs  to  the  affected  limb  is  not  inclined 
more  forwards  than  the  other,  but  the  toes  only  are  in 
contact  with  the  ground,  and  the  heel  raised,  at  the 
same  time  that  the  hip  and  knee  are  a little  bent.  This 
answers  to  the  patient  the  same  purpose  of  enabling 
him  to  throw  the  weight  of  his  body  on  the  other  fool; 
but  it  produces  an  inclination  of  tlie  pelvis  in  the  op- 
posite direction.  The  crista  of  the  ileum  is  higher 
than  natural,  and  there  is  an  apparent  shortening,  in- 
stead of  elongation  of  the  limb  on  the  side  of  the  dis 
ease.” — {Pathol,  and  Surg.  Ohs.  p.  147.) 

The  late  Mr.  Ford  called  the  attention  of  surgeons 
to  the  alteration,  with  respect  to  the  natural  fulness 
and  convexity  of  the  nates;  that  part  appearing  flat- 
tened which  is  usually  most  prominent.  The  glutspus 
magnus  becomes  emaciated,  and  its  edge  no  longer 
forms  so  bold  a line  as  it  naturally  does  at  the  upper 
and  back  part  of  the  thigh  in  the  sound  state  of  the 
limb. 

Although  this  symptom,  in  combination  with  others, 
is  of  importance  to  be  attended  to,  it  has  been  e.x- 
plained  by  Mr.  Brodie,  that  “ it  is  not  in  iUself  to  be 
regarded  as  a certain  diagnostic  mark  of  disease  in  the 
hip;  since,  in  its  early  stage,  this  symptom  is  wanting; 
and  it  is  met  with  in  other  discuses,  in  which  the 


JOINTS.  115 


muscles  in  the  neighbourhood  of  the  hip  are  not  called 
into  action,  although  the  joint  itself  is  unaffected.”— 
(See  Medico-Chir.  Trans,  vol.  6,  p.  322.) 

Though  there  may  be  more  pain  about  the  knee  than 
the  hip,  at  some  periods  of  the  malady  in  its  incipient 
state,  yet  the  former  articulation  may  be  bent  and  ex- 
tended wittiout  any  increase  of  uneasiness ; but  the  os 
femoris  cannot  be  moved  about  without  putting  the 
patient  to  immense  torture. 

The  patient  soon  gets  into  the  habit  of  bearing  the 
weight  of  his  body  chiefly  upon  the  opposite  limb, 
while  the  thigli  of  the  aflected  side  is  bent  a little  for- 
wards, that  the  ground  may  only  be  partially  touched 
with  the  foot.  This  position  is  found  to  be  the  most 
comfortable,  and  every  attempt  to  extend  the  limb  oc- 
casions an  increase  of  pain. 

This  is  the  first  stage  of  the  disease,  or  that  which 
is  unaccompanied  with  suppuration. 

The  symiitoms  which  precede  the  formation  of  pus 
vary  in  difterent  cases,  according  as  there  is  acute  or 
chronic  inflammation  present.  When  the  diseased 
joint  is  affected  with  acute  inflammation,  as  generally 
happens,  tlie  surrounding  parts  become  tense  arid  ex- 
tremely painful ; the  skin  is  even  reddish ; and  symp- 
toms of  inflammatory  fever  prevail.  When  the  se- 
verity of  the  pain  abates,  a swelling  occurs  in  the 
vicinity  of  the  joint,  and  a pointing  quickly  follows. 
In  this  stage,  startings  and  catchings  during  sleep  are 
said  to  be  among  the  most  certain  signs  of  the  form- 
ation of  matter.  “ Tlie  shortening  of  the  limb,”  says 
Mr.  Brodie,  “ which  usually  takes  place  in  the  advanced 
stage  of  the  disease,  is  usually,  but  not  always,  the 
precursor  of  abscess.  The  formation  of  matter  is  also 
indicated  by  an  aggravation  of  the  pain  ; by  more  fre- 
quent spasms  of  the  muscles,  by  greater  wasting  of  the 
whole  limb,  and  by  the  circumstance  of  the  thigh  be- 
coming bent  forwards,  and  being  incapable  of  exten- 
sion,” and  by  the  pulse  becoming  quick,  the  tongue 
furred,  and  the  whole  system,  being  in  a state  of  pre- 
ternatural excitement.  “The  abscess  usually  shows 
itself  in  the  form  of  a large  tumour  over  the  vastus 
externus  muscle ; sometimes  on  the  inside  of  the  thigh, 
near  the  middle;  and  occasionally  two  or  three  ab- 
scesses appear  in  different  parts,  and  burst  in  succes- 
sion.”— {Brodie' s Pathol.  Obs.p.  152.) 

We  have  noticed  the  commonly  lengthened  state  of 
the  limb,  in  the  first  periods  of  the  hip  disease.  This 
condition  is  not  of  very  long  duration,  and  is  sooner 
or  later  succeeded  by  a real  shortening  of  the  affected 
member.  The  foot  may  be  turned  inwards;  but,  as 
Mr.  Brodie  ob-serves,  if  left  to  itself,  it  is  generally 
turned  outwards.  In  other  cases,  the  limb  is  shortened ; 
the  thigh  is  bent  forwards ; the  toes  are  turned  inwards, 
and  do  not  admit  of  being  turned  outwards  {Pathol. 
Obs.  p.  148) ; and  all  the  symptoms  of  a luxation  of 
the  thigh  upwards  and  outwards  may  be  observed,  the 
head  of  the  bone,  indeed,  being  actually  drawn  into 
the  external  iliac  fossa,  and  carried  between  the  os  in- 
nominatum  and  glutteus  minimus,  which  is  raised  up 
by  h. — (See  Richerand.,  Kosogr.  Chir.  t.  3,  p.  171,  172, 
ed.  2.) 

When  the  retraction  is  very  considerable,  it  arises 
from  nothing  less  than  an  actual  dislocation  of  the 
head  of  the  thigh-bone,  in  consequence  of  the  destruc- 
tion of  the  cartilages,  ligaments,  and  articular  cavity. 
This  retraction  sometimes  comes  on  long  before  any 
suppuration  takes  place.  The  head  of  the  bone  may 
be  dislocated,  and  the  disease  terminate  in  anchylosis, 
without  any  abscess  whatever.  However,  if  suppura- 
tion has  not  taken  place,  Mr.  Brodie  believes  it  rarely 
happens  that  the  limb,  after  the  cure,  does  not  regain 
its  natural  degree  of  mobility. — (See  Med.  Chir.  Trans, 
vol.  6,  p.  325.) 

It  is  worthy  of  particular  notice,  that  the  head  of 
the  bone  is  always  luxated  upwards  and  outwards; 
and  the  only  exception  to  this  observation,  upon  record, 
i.s  a case  related  by  Cocchi,  in  which  a spontaneous 
dislocation  of  the  thigh-bone,  as  it  is  termed,  happened 
upwards,  forwards,  and  a little  inwards. — (See  JLe- 
viaiU,  ji'ouvelle  Doctrine  Chir.  t.  3,  p.  595.)  On  a 
4galement  vu  la  t6te  du  fimur  lux6e  en  dedans  et  en 
has,  et  plac^e  sur  le  trou  obturaieur,  inais  cette  mode 
de  d^placement  cons^cutif,  dans  lequel  le  membre  est 
along4,  est  infiniment  xd.xe.— {Richerand.  JSTosogr. 
Chir.  t.  2,  p.  172.) 

The  hip  disease  generally  induces  hectic  symptoms, 
after  it  has  existed  a certain  time.  In  some  subjects 

II  2 


they  soon  come  on ; in  others,  the  health  remains  un- 
affected a very  considerable  time. 

“ The  health  of  the  patient  (says  Mr.  Brodie)  usually 
suffers,  even  before  abscesses  have  formed,  from  the 
want  of  exercise,  pain,  and  particularly  from  the  con- 
tinued disturbance  of  his  natural  rest.  I recollect  no 
instance  of  an  adult,  in  whom  abscesses  had  formed, 
who  did  not  ultimately  sink  exhausted  by  the  hectic 
symptoms  which  these  induced.  Children  may  re- 
cover in  this  ultimate  stage  of  the  disease ; but  seldom 
without  a complete  anchylosis  of  the  joint.”— (Jlfed. 
Chir.  Trans,  vol.  6,  loco  cit.) 

When  abscesses  of  the  above  description  burst,  they 
continue  in  general  to  emit  an  unhealthy  thin  kind  of 
matter  for  a long  time  afterward ; and  portions  of 
bone  exfoliate  from  time  to  time. 

With  respect  to  the  morbid  anatomy  of  the  disease 
in  its  incipient  state,  until  lately  little  was  known.  A 
few  years  ago  two  dissections  related  by  Mr.  Ford, 
were,  perhaps,  the  only  ones  throwing  light  upon  this 
point.  In  one,  there  was  a tea-spoonful  of  matter  in 
the  cavity  of  the  hip-joint.  The  head  of  the  thigh- 
bone was  somewhat  inflamed,  the  capsular  ligament  a 
little  thickened,  and  the  ligamentum  teres  united  in  its 
natural  way  to  the  acetabulum.  The  cartilage  lining 
the  cotyloid  cavity  was  eroded  in  one  place,  with  a 
small  aperture,  through  which  a probe  might  be 
passed,  underneath  the  cartilage,  into  the  internal 
surface  of  the  os  pubis  on  one  side,  and  on  the  other 
into  the  os  ischii ; the  opposite  or  external  part  of  the' 
os  innominatum  showing  more  appearance  of  disease 
than  the  cotyloid  cavity.  In  the  other  instance,  the 
disease  was  more  advanced.  These  examples  are 
important,  inasmuch  as  they  prove,  that  what  is  com- 
monly called  the  disease  of  the  hip-joint,  primarily 
affects  the  cartilages,  ligaments,  and  bones,  and  not  the 
surrounding  soft  parts,  as  De  Haen  and  some  others 
would  lead  one  to  believe. 

As  the  disorder  advances,  the  portions  of  the  os 
ischium,  os  ileum,  and  os  pubis,  composing  the  ace- 
tabulum, together  with  the  investing  cartilage,  and 
synovial  gland,  are  destroyed.  The  cartilage  covering 
the  head  of  the  os  femoris,  the  ligamentum  teres,  and 
capsule  of  the  joint,  suffer  the  same  fate,  and  caries 
frequently  affects  not  only  the  adjacent  parts  of  the  ossa 
innoniinata'  but  also  the  head  and  neck  of  the  thigh- 
bone. The  bones  of  the  pelvis,  however,  are  always 
more  diseased  than  the  thigh-bone,  a fact  which  dis- 
plays the  absurdity  of  ever  thinking  of  amputation  in 
these  cases.  Mr.  Ford  observes,  “ In  every  case  of 
disease  of  the  hip  joint  which  has  terminated  fatally, 
I have  remarked,  that  the  os  innominatum  has  been 
affected  by  the  caries  in  a more  extensive  degree  than 
the  thigh-bone  itself.” — {Obs.  on  the  Disease  of  the 
Hip- Joint,  p.  107.) 

Sometimes,  however,  the  head  and  neck  of  the  thigh  - 
bone  are  annihilated,  as  well  as  the  acetabulum. 

Mr.  Brodie  has  had  opportunities  of  dissecting  some 
diseased  hip-jOints  both  in  the  incipient  and  advanced 
stage  of  the  complaint.  From  his  observations,  it 
appears,  1st.  That  the  disease  commences  with  ul- 
ceration of  the  cartilages,  generally  that  of  the  ace- 
tabul  um  first,  and  that  of  the  femur  afterward.  2.  That 
the  ulceration  extends  to  the  bones,  which  become 
carious;  the  head  of  the  femur  diminishing  in  size, 
and  the  acetabulum  becoming  deeper  and  wider.  3. 
That  an  abscess  forms  in  the  joint,  which  after  some 
time  makes  its  way  by  ulceration,  through  the  synovial 
membrane  and  capsular  ligament,  into  the  thigh  and 
nates,  or  even  through  the  bottom  of  the  acetabulum 
into  the  pelvis.  Sir  A.  Cooper  showed  Mr.  Brodie 
two  specimens,  in  which  the  abscess  had  burst  into  the 
rectum.  Sometimes  the  matter  makes  its  way  through 
the  acetabulum  into  the  pelvis.  Some  years  ago,  there 
was,  in  the  London  Hospital,  a case,  in  which  both 
hips  were  affected,  and  tlie  abscesses  communicated 
with  the  cavity  of  the  pelvis  through  the  acetabula. — 
(See  Scott  on  Chronic  Inflammation,  Src.p.  106.)  4.  In 
consequence  of  the  abscess,  the  synovial  membrane 
and  capsular  ligament  become  inflamed  and  thickened. 
The  muscles  are  altered  in  structure ; sinuses  are 
formed  in  various  parts,  and,  at  last,  all  the  soft  parts 
are  blended  together  in  one  confused  mass,  resembling 
the  parietes  of  an  ordinary  abscess. — {Medico-Chir. 
Trans,  vol.  4,  p.  24b,  247.) 

Such  are  the  beginning  and  progress  of  the  ordinary 
disease  of  tlie  hip- joint;  but  it  is  admitted  by  Mr. 


ne 


JOINTS. 


Brodie,  that  there  are  other  scrofulous  cases  in  which 
the  mischief  begins  in  the  cancellous  structure  of  the 
bones,  and  also  other  instances,  which  consist  in  chro- 
nic inflammation  and  abscesses  of  the  soft  parts  in 
the  neighbourhood  of  the  hip.— (0;?.  cit.  vol.  6,  p. 
326.) 

External  violence,  lying  down  on  the  damp  ground 
in  summer  time,  and  all  kinds  of  exposure  to  damp 
and  cold,  are  the  causes  to  which  the  disease  has 
sometimes  been  referred.  In  almost  all  the  cases 
which  I have  attended,  the  patients  were  decidedly 
scrofulous. 

Treatment  of  the  Disease  of  the  Hip-joint. — The 
writings  of  Hippocrates,  Celsus,  Caelius  Aurelianus, 
&c.  prove  that  the  ancients  treated  the  present  dis- 
ease much  in  the  same  way  as  it  is  treated  by  the 
moderns.  Forming  an  eschar,  and  keeping  the  sore 
open,  topical  bleeding,  cupping,  fomenting  the  part,  &c. 
were  all  proceedings  adopted  in  the  earliest  periods  of 
surgery.  Drs.  Charlton,  Oliver,  and  Falconer  have 
spoken  of  Bath  water  as  a most  efficacious  application 
to  diseased  hip-joints,  previously  to  the  suppurative 
stage.  However,  had  not  their  accounts  been  exag- 
gerated, alt  patients  of  this  kind  would  long  ago  have 
flocked  to  Bath,  and  the  surgeons  in  other  places  would 
never  have  had  farther  occasion  to  adopt  a more  pain- 
ful mode  of  treatment.  The  plan  pursued  at  Bath  is 
to  put  the  patient  in  a warm  bath  two  or  three  times  a 
week  for  fifteen  or  twenty-five  minutes. 

In  the  first  stage  of  coxalgia,  the  late  Dr.  Albers, 
however,  had  a high  opinion  of  warm  bathing,  foment- 
ations with  decoctions  of  herbs,  and  of  bathing  in  mi- 
neral waters  and  the  sea.  But  though  he  commenced 
the  treatment  with  the  frequent  use  of  the  warm 
bath,  and  continued  the  plan  a long  while,  it  is  to  be 
remarked,  that  he  also  combined  with  it  an  issue.  Af- 
ter the  patient  had  been  in  the  bath  a period  not  ex- 
ceeding half  an  hour,  he  was  taken  out,  and  his  whole 
body  well  rubbed  with  flannel.  It  appears  to  me  that 
one  objection  to  this  practice  must  be  the  considerable 
disturbance  occasioned  by  moving  the  patient  in  this 
manner  every  morning ; for  if  it  be  true  that  most  of 
these  diseases  commence  in  the  cartilages  of  the  joint, 
all  motion  of  the  limb  must  be  particularly  injurious. 

In  the  early  period  of  the  disease,  entire  rest,  the 
application  of  fomentations,  and  the  employment  of 
topical  bleeding,  particularly  cupping,  are  highly  pro- 
per. Such  practice,  also,  is  invariably  judicious, 
whenever  the  case  is  attended  with  symptoms  of  acute 
inflammation.  When  fomentations  are  not  applied, 
the  lotio  plumbi  acetatis  may  be  used. 

This  method  of  treatment  ought  never  to  be  employed 
unless  manifest  signs  of  active  inflammation  be  pre- 
sent. When  no  such  state  exists,  this  plan  can  only 
be  regarded  as  preventing  the  adoption  of  a more  effi- 
cacious one,  and  therefore  censurable. 

“ When  the  cartilages  of  the  hip  are  ulcerated  (says 
Mr.  Brodie),  the  patient  should, in  the  first  instance,  be 
confined  to  a couch,  if  not  to  his  bed ; and  if  the  dis- 
ease is  far  advanced,  the  limb  should  be  supported  by 
pillows  properly  disposed,  so  as  to  favour  the  produc- 
tion of  an  anchylosis,  by  allowing  it  to  vary  as  little  as 
possible  from  one  position.” — (See  Med.  Chir.  Trans, 
vol.  6,  p.  335.) 

Quibus  diuturno  dolore,  says  Hippocrates,  ischiadico 
vexatis  coxa  excidit,  iis  femur  contabescet  et  claudi- 
cant,  nisi  uranlur.  Forming  an  eschar  or  issue  is  the 
most  efficacious  plan  of  treating  the  disease  even  now 
known.  A caustic  issue  seems  to  me  more  beneficial 
than  a blister.  The  depression  just  behind  and  below 
the  trochanter  major  is  the  situation  in  which  surgeons 
usually  make  the  issue,  and  the  size  of  the  eschar 
should  be  nearly  as  large  as  a crowm  piece.  It  is  gene- 
rally necessary  to  keep  the  issue  open  a very  long  tinje. 
When  the  thigh  bone  is  dislocated,  and  the  patient 
survives,  the  case  mostly  ends  in  anchylosis. 

For  the  cure  of  the  disease  in  adults,  Mr.  Brodie  and 
Dr.  Albers  have  also  expressed  a preference  to  caustic 
issues;  but  in  children,  and  even  in  grown-up  persons, 
when  the  complaint  is  recent,  they  agree  in  thinking 
blisters  capable  of  affording  complete  relief.  Mr.  Bro- 
die states,  that  in  these  cases  they  are  more  efficacious 
when  kept  open  with  the  savine  ointment,  than  w'hen 
repeatedly  applied.  With  respect  to  issues,  he  acknow- 
ledges, that  behind  the  great  trochanter  is  the  most 
convenient  place  for  them  ; but  he  believes  that  they 
have  more  effect  wdien  made  on  the  outside  of  the 


joint,  on  the  front  edge  of  the  tensor  vaginie  femoris 
muscle.  Instead  of  keeping  the  issue  open  with  beans, 
Mr.  Brodie  Ixas  found  it  a more  effectual  practice  to 
rub  the  sore  two  or  three  times  a week,  with  the  po 
tassa  fu'-a,  or  sulphate  of  copper.  In  particular  cases, 
where  t„j  pain  was  very  severe,  this  gentleman  made 
a seton  in  the  groin,  over  the  trunk  of  the  anterior 
crural  nerve,  which  plan,Jie  says,  affords  quicker  relief, 
though  in  the  end  it  is  less  to  be  depended  upon  for  a 
cure  than  caustic  issues. 

In  Doctor  Alber’s  work,  the  great  efficacy  of  issues 
and  blisters  in  giving  immediate  relief  to  the  severe  pain 
in  the  knee,  is  illustrated  by  some  valuable  observa- 
tions. He  speaks  also  very  favourably  of  the  moxa, 
the  employment  of  which,  he  says,  is  not  very  painful; 
a remark  in  which  Langeubeck  concurs. — (See  Bibl.b. 
2,  p.  27.)  Dr.  Albers,  in  the  hectical  stages,  recom- 
mends opium  as  highly  useful,  especially  when  com- 
bined with  musk  or  camphor. 

The  occurrence  of  suppuration  makes  a vast  differ- 
ence in  the  prognosis.  “ The  formation  of  even  the 
smallest  quantity  of  pus  in  the  joint,  in  cases  of  this 
disease,  in  the  young  persons  considerably  diminishes, 
and  in  the  adult  almost  precludes,  the  hope  of  ultimate 
recovery.” — {Brodie  in  Medico-Chir.  Trans.  vol.G^p. 
347.)  This  gentleman  is  not  much  in  favour  of  open- 
ing the  abscesses  early,  at  least  before  the  joint  haa 
been  kept  for  some  time  perfectly  at  rest.  He  has  seen 
no  ill  consequences  arise  from  the  puncture  of  the  lan- 
cet remaining  open,  and  he  has  not  found  that  in  cases 
of  carious  joints,  the  method  of  evacuating  the  matter 
recommended  by  Mr.  Abernethy  (see  Lumber  Abscess)^ 
is  attended  with  any  particular  advantage. 

Mr.  Scott  treats  this  disease  on  the  same  principles 
as  white  swelling  and  other  chronic  inflammations; 
viz.  after  having  got  the  joint  into  a quiet  state  by 
means  of  aperient  medicines,  topical  bleeding,  quiet- 
ude, &c.  he  covers  the  skin  w'ilh  pledgets  of  the  ein- 
plastrum  saponis  and. strong  camphorated  mercurial 
ointment  in  equal  proportions.  These  are  next  covered 
with  strips  of  adhesive  plaster,  over  which  is  laid  some 
large  pieces  of  soap- plaster  spread  on  thick  leather. 
The  whole  is  then  supported  with  a bandage,  and  al- 
lowed to  remain  on  the  part  a week  or  two,  according 
to  tlie  circumstances  already  detailed  in  the  section  on 
white  swelling. — (See  Scott  on  Chronic  Inflammation, 
p.'i.^l,  <S-c.) 

Mr.  J.  Burns,  in  the  second  volume  of  his  “ Disser- 
tations on  Inflammation,”  p.  311,  has  recorded  a re- 
markable instance  in  which  this  joint  was  affected 
with  that  intractable  and  fatal  distemper,  fungus  hffi- 
matodes.  The  case  was  at  first  supposed  to  be  the  dis- 
ease of  which  we  have  just  been  treating  in  tlie  pre- 
ceding columns.  The  limb  seemed  to  be  elongated, 
and  issues  were  employed  without  any  material  benefit. 
The  upper  part  of  the  thigh  swelled,  while  the  lower 
wasted  away.  The  patient  lost  his  appetite,  had  a 
quick  pulse,  and  passed  sleepless  nights.  The  part 
was  rubbed  with  anodyne  balsam,  and  laudanum  given 
every  night ; but  these  means  were  only  productive  of 
temporary  benefit.  After  some  months,  a difficulty  of 
making  water  came  on,  which  ended  in  a complete 
retention.  It  being  found  impracticable  to  introduce  a 
catheter,  and  a large  elastic  tumour,  supposed  to  be  the 
distended  bladder,  being  felt  within  the  rectum,  a trocar 
was  pushed  into  the  swelling.  A good  deal  of  bloody 
fluid  was  thus  discharged.  Afterward,  a considerable 
quantity  of  high-coloured  fetid  urine  continued  to  es- 
cape from  the  uretha.  In  about  a week  after  this  ope- 
ration the  patient  died. 

On  dissection,  Mr.  Burns  found  the  hip-joint  com- 
pletely surrounded  with  a soft  matter  resembling  brain, 
enclosed  in  thin  cells,  and  here  and  there  other  cavities 
full  of  thin  bloody  water,  jjresented  themselves.  The 
acetabulum  and  head  of  the  os  femoris,  were  both 
carious.  The  muscles  were  quite  pale,  and  almost 
like  boiled  liver,  having  lost  their  fibrous  appearance. 
The  same  kind  of  substance  was  fmmd  in  the  pelvis, 
and  most  of  the  inside  of  the  aft’ected  bones  was  ca- 
rious. Large  cells,  containing  bloody  water,  were  ob- 
served in  tlie  diseased  substance,  and  it  was  into  one 
of  these  cavities  that  the  trocar  had  entered  when  the 
attempt  was  made  to  tap  the  bladder. — Gil  Budeeus, 
De  Curandis  Articularibus  Marbis,  12/no.  Paris, 
1539.  J.  O.  TViddmaUyDe  Gennum  Struct ur a eorum- 
que  Morb'is,  Hclm.stad,  1744  {Haller,  Disp.  Chir.  4, 
4S9).  Ford'^s  Observations  on  the  Disease  of  the  Hip- 


LAC 


jeint,  to  which  are  added  some  remarks  on  White  Swell- 
ings 8uo.  Lond.  1794.  Doerner,  De  Gravioribus  qui- 
busdam  Cartilaginum  MutationibuSs  Bvo.  TubingeB, 
1798.  Crowther  on  White  Swelling,  <Src.  edit.  2, 1808. 
J.  Burns  on  Inflammation,  vol.  2,  y.  311.  Wm.  Fal- 
coner, a Dissertation  on  Ischias,  and  on  the  Use  of  the 
Bath  Waters  as  a Remedy,  8vo.  Dond.  1805.  Russell 
on  Morbid  JJffections  of  the  Knee,  8vo.  Edinb.  1802. 
H.  Park,  An  Account  of  a Mew  Method  of  treating 
Diseases  of  the  Joints  of  the  Knee  and  Elbow,  8vo. 
Lond.  1783.  Also  H.  Park  and  P.  F.  Moureau,  Cases 
of  the  Excision  of  carious  Joints ; with  Obs.  by  Dr. 
J,  Jeffray,  Vimo.  Glasg.  1806.  J.  A.  Albers,  Abhand- 
langen  iiber  die  Coxalgie,  oder  das  sogenannte  frey- 
willige  Hinken  der  Kinder,  Ato.  Wien.  1807.  This 
work  includes  many  valuable  remarks,  G.  Wirth,  De 
Coxalgia,  12oto.  Wiceb.  1809.  Paletta,  Adversaria 
Chir.  Prima,  4to.  Hey's  Practical  Observations  in 
Surgery,  p.  354,  S,  c.  edit.  3.  Boyer,  Traiti  des  Mala- 
dies Chir.  t,  4,  Paris,  1814.  Reimarus,  De  Tumore 
Ligamentorum  circa  articulos,  Pungo  articulorum 
dicto ; Leydce,  1757.  Brambilla,  in  Acta  Acad.  Med. 
Chir.  Vindob.  t.  1.  Brodie's  Pathological  Researches 
respecting  the  Diseases  of  Joints,  in  vols.  4,  5,  and  6, 
of  the  Med.  Chir.  Trans.  Also  his  Pathological  and 
Surgical  Observations  on  the  Joints,  8vo.  Lond.  1818, 
and  ed.  2, 1822 ; a work  containing  a great  deal  of  cor- 
rect and  original  information,  and,  in  my  estimation, 
the  most  scientiflc  book  ever  published  on  the  subject. 
Schreger  Chirurgische  V ersiiche,  b.  2,  p.  209,  Src.  Bei- 
trdge  lur  Mosologie  der  Gelenkkrankheiten,  8vo. 
Murnberg,  1818.  J.  JV.  Rust,  Arthrokakologie  oder 
iiber  die  Verren  kungen  dxirch  innere  Bedingung,  4to. 
, Wien,  1817  : a publication  of  great  merit.  Dr.  To- 
maso Folpi,  Abhandl.  iiber  die  Coxalgie,  aus  dem  Ital. 
iibersetzt  von  Dr.  P.  Heineken : the  original  I have 
not  seen,  but  the  transl.  contains  copious  extracts  from 
the  prize  essay  which  I drew  up  some  years  ago,  with 
additional  observations  and  cases.  Richerand' s JVo- 
sogr.  Chir.  t.  3,  p.  170,  <S-c.  ed.  4.  Langenbeck,  JVeue 
Bibl.  b.  2,  p.  337.  G.  Gotz,  De  Morbis  Ligamentorum, 
4to.  Berol.  1799.  Delpech,  Pricis  Element,  des  Mai. 
Chir.  t.2,p.  377,  t.3,p.  194,  p.  470,  p.  711,  dS-c.  Paris, 
1816.  H.  Mayo  on  an  acute  Form  of  Ulceration  of 
the  Cartilages  of  Joints,  in  Med.  Chir.  Trans,  vol.  2,  p. 
104.  J.  Wilson,  Lectures  on  the  Structure  and  Phy- 
siology of  the  Skeleton,  and  Diseases  of  the  Bones  and 
Joints,  8vo.  London,  1820.  E.  A.  Lloyd,  A Treatise 
on  the  Mature,  Src.  of  Scrofula,  8vo.  Lond.  1821.  Alex. 
Manson,  on  the  Effects  of  Iodine  in  Bronchocele,  Pa- 
ralysis, Chorea,  Scrofula,  White  Swelling,  Src.  8vo. 
Lond.  1825.  John  Scott,  Surg.  Obs.  on  the  Treatment 
of  Chronic  Inflammations  in  various  Structures,  par- 
ticularly as  exemplified  in  Diseases  of  the  Joints,  8vo. 
Lond.  1828.  Thos.  Buchanan  on  the  Mew  Mode  of 


LAC  117 

Treatment  for  Diseased  Joints,  and  the  Mon-unim  of 
Fracture;  12mo.  Lond.  1828. 

JUGULAR  VEIN,  how  to  bleed  in.  (See  Bleeding.) 

Jugular  vein,  internal,  wounded.  Dr.  Giraud 
cursorily  mentions  a_case,  in  which  a French  surgeon 
at  the  military  hospital  of  Toulouse,  early  in  the  year 
1814,  passed  a ligature  round  the  trunks  of  the  com- 
mon carotid  artery  and  internal  jugular  vein.  Both 
these  vessels  had  been  wounded  by  a musket-shot. 
On  the  sixth  day  from  the  application  of  the  ligature, 
nothing  unfavourable  had  occurred ; but  the  final  re- 
sult of  the  case  is  not  related. — (See  Journ.  GinSrale 
de  Med.  S-c.par  Sedillot.) 

[J  UGUM  PENIS.  A contrivance  for  preventing  the 
inconvenience  of  an  incessant  dribbling  of  the  urine  in 
persons  who  are  unable  to  retain  this  fluid  in  the  blad- 
der. A jugum  penis,  strictly  speaking,  is  an  instrument 
that  operates  by  compressing  some  part  of  the  ure- 
thra. A jugum  of  this  kind,  which  was  invented  by 
Nuck,  is  described  in  Keister’s  Surgery. — (See  tab.  26 
fig.  8 et  9.)  But  when  erections  are  likely  to  take  place 
a jugum  constructed  on  this  principle  is  not  applicable, 
and  indeed  in  most  cases  it  creates  pain,  and  is  not 
found  to  answer.  Desault’s  contrivance  for  hindering 
a stillicidium  urinse,  is  noticed  in  the  article  Urine,  In- 
continence of;  and  a still  better  one  was  proposed  by 
Le  Rouge. — {.lourn.  de  Mid.  Chir.  ct  Pharmacie,  t. 
76,  p.  459.)  When  in  men  the  infirmity  is  incurable, 
and  a jugum  cannot  be  worn : an  apparatus  for  receiv- 
ing the  urine  directly  it  escapes  from  the  urethra,  is 
the  best  resource.  A description  of  such  a contrivance 
may  be  found  in  Juville’s  Traiti  de  Bandages.  The 
instrument  consists  of  three  pieces ; viz.  an  ivory 
mouth,  a neck  made  of  elastic  gum,  and  a silver  flask. 
It  is  fastened  with  pieces  of  tape  to  a leather  belt, 
which  goes  round  the  waist.  The  ivory  mouth  is 
round,  and  about  18  lines  in  diameter.  In  its  exter- 
nal edge  there  are  several  small  holes,  through  which 
the  tapes  are  passed,  which  fasten  it  to  the  belt.  Its 
inner  surface  is  slightly  excavated,  so  that  it  may  adapt 
itself  precisely  to  the  parts  above  the  pubes.  The  outer 
surface  is  rather  convex,  and  formed  with  a prominent 
border  perforated  in  several  places,  to  which  the  elastic 
gum  neck  or  tube  is  fastened.  This  latter  part  must 
be  four  or  five  inches  long,  and  wide  enough  to  hold 
the  penis;  its  convex  end  is  made  to  screw  on  to  the 
silver  flask.  At  the  upper  part  of  the  screw  are  three 
pegs,  which  cross  each  other  in  a stellated  form,  and 
serve  for  fixing  a sponge  within  the  neck.  The  silver 
flask  is  four  inches  wide,  and  of  a flat  shape  ; it  lies 
on  the  inside  of  the  thigh,  or  in  a pocket  made  in  the 
breeches.  If  necessary,  a larger  flask  may  be  used. 
According  to  Mr.  Mackenzie,  of  Glasgow,  a bandage 
binding  up  the  penis  to  the  abdomen  answers  very 
well  in  stillicidium  urinae  after  lithotomy. — Preface.] 


K 


l|^  ERATONYXIS.  The  term  keratonyxis,  derived 
from  Kcpai,  a horn,  and  vv\ig  a puncture,  is  em- 
ployed by  the  professors  in  Germany  to  denote  the  ope- 
ration of  couching  performed  through  the  cornea,  or 
horny  coat  of  the  eye,  the  opaque  lens  being  in  this 
manner  sometimes  depressed,  sometimes  broken  piece- 
meal, and  in  other  instances  merely  .turned,  so  as  to 


place  its  anterior  and  posterior  surface  in  the  horizon  i 
tal  position.  The  latter  method  is  what  the  German 
surgeons  particularly  imply  by  the  phrase  rcclination. 
— See  Cataract. 

KNEE,  DISEASES  AND  INJURIES  OF  THE.— 
See  Dislocations;  Fractures;  Gun-shot  Wounds; 
Joints,  S-c. 


L. 


T ACHRYMAL  ORGANS,  DISEASES  OF  THE. 

The  lachrymal  gland  cannot  be  said  to  be  a part 
which  is  frequently  the  seat  of  disease.  Richerand  has 
seen  no  instanceof  an  inflaminationof  this  gland,  \inless 
by  this  expression  be  implied  rases,  in  which  all  the 
contents  of  the  orbit  are  more  or  less  aflected. — {Mo- 
oogr  Chir.  (.  2,  p.  32.)  1 believe,  that  the  surrounding 


cellular  substance  is  more  frcqtiently  attacked  with 
inflammation  and  suppuration,  than  the  gland  itself. 
According  to  Professor  Beer  {Iwhre  von  den  Augenkr. 
b.  \ ,p.  319),  true  idiopathic  inflammations  of  the  la- 
chrymal gland  are  very  rare,  and  he  declares,  that  in 
the  course  of  a practice  of  twenty-seven  years,  he  has 
but  seldom  met  with  them.  On  tiiis  point  he  diflers 


118 


LACHRYMAL  ORGANS. 


from  Schmidt,  who  fancied  that  he  had  often  had 
under  his  care  cases  of  this  description  in  gouty  and 
scrofulous  subjects. — ( Ueber  die  Krankh.  des  I'hrdne- 
norgans^  p.  134.)  When  the  lachrymal  gland  is  at- 
tacked with  inflammation,  its  secretion,  far  from 
being  augmented,  as  Richerand  describes,  is  always 
considerably  lessened,  and  therefore  one  of  the  earliest 
symptoms  is  an  uneasy  dry  state  of  tlie  eye,  the  secre- 
tion from  the  Meibomian  glands  and  mucous  membrane 
of  the  eyelids  not  being  alone  sufiicient  for  keeping 
the  eye  duly  moist  and  lubricated.  This  state  is  suc- 
ceed^ by  a throbbing  acute  pain  in  the  temple,  shoot- 
ing to  the  eyeball,  forehead,  upper  and  lower  jaws,  and 
back  of  the  head.  In  the  mean  while,  the  temporal 
portion  of  the  upper  eyelid  becomes  swelled,  tense, 
red,  and  exceedingly  tender,  the  tunica  conjunctiva 
being  scarcely  at  all  affected,  and  merely  exhibiting 
a slight  degree  of  redness  and  tumefaction  tow'ards  the 
outer  canthus.  However,  as  the  swelling  of  the  gland 
increases,  the  eyeball  becomes  pushed  more  or  less 
downwards  and  inw’ards  towards  the  nose.  But 
though  there  is  little  or  no  redness,  nor  any  mark  of 
inflammation,  about  the  eye,  this  organ  is  tense,  and 
extremely  tender.  The  freedom  of  its  movements  to- 
wards the  temple  is  much  lessened  in  the  beginning 
of  the  complaint,  and  when  the  tumour  has  acquired 
a very  large  size,  is  quite  destroyed.  The  impairment 
of  vision  is  always  proportionate  to  the  protrusion  of 
the  eyeball,  the  pupil  being  diminished,  and  the  iris 
motionless.  The  second  or  suppurative  stage  Beer 
describes  as  ushered  in  by  fiery  appearances  before 
the  eye  ; an  increased  displacement  of  the  eyeball ; 
throbbing  pain ; great  increase  of  the  swelling  of  the 
upper  eyelid,  and  of  the  conjunctiva,  towards  the  tem- 
ple ; an  annoying  sensation  of  cold,  and  heaviness  in 
the  eye  and  orbit.  Now,  under  febrile  symptoms, 
rigors,  &c.  a yellowish  point  presents  itself,  either  on 
the  reddened  portion  of  the  conjunctiva,  or  on  the  out- 
side of  the  eyelid,  and  a fluctuation  becomes  distin- 
guishable.— {Beer,  Lehre,  ^c.  b.  1,  p.  350.)  Beer 
speaks  of  abscesses  sometimes  forming  in  the  vicinity 
of  the  lachrymal  gland,  and  terminating  in  a small 
sinus,  which  communicates  with  one  of  the  principal 
excretory  tubes,  and  discharges  occasionally  a thin 
limpid  fluid. — {Lehre  von  den  Augenkr.  b.  2,  p.  184.) 
The  experience  of  this  author  leads  him  to  consider 
these  sinuses  either  as  a consequence  of  an  unskilfully 
treated  abscess  of  the  upper  eyelid,  or  of  a similar 
neglected  aflection  of  the  ceilular  membrane,  near  the 
lachrynjal  gland  ; or,  lastly,  of  the  presence  of  a por- 
tion of  the  sac  of  a burst  encysted  tumour.  Accord- 
ing to  Mr.  Travers,  the  lachrymal  gland  often  suppu- 
rates in  children,  and  occasions  an  excessive  swelling 
above  the  upper  eyelid,  depressing  the  tarsus,  so  as 
completely  to  conceal  the  eye.  The  abscess,  he  says, 
may  be  conveniently  opened,  and  discharged  beneath 
the  eyelid. — {Synopsis  of  the  Diseases  of  the  Eye, 
p.  228.)  With  respect  to  the  treatment  of  any  local 
inflammatioh  in  and  about  the  lachrymal  gland,  the 
best  means  of  relief  would  be  leeches,  fomentations, 
emollient  poultices,  and  other  common  antiphlogistic 
remedies.  In  the  suppurative  stage,  Beer  recommends 
mixing  with  the  poultice  a good  deal  of  hemlock. 

The  lachrymal  gland  is  subject  to  scirrhous  enlarge- 
ment, and,  in  cases  of  carcinoma  of  the  eye,  it  is  one 
of  the  parts  in  which  a return  of  the  disease  is  apt  to 
occur.  Hence,  it  is  now  generally  considered  right  to 
remove  it,  as  soon  as  the  eyeball  has  been  taken  away. 
— (See  Kye.)  Sometimes,  though  rarely,  the  gland  is 
primarily  affected;  and  Guerin  removed  one  in  the 
state  of  scirrhus,  and  so  much  enlarged,  that  the  eye 
was  entirely  covered  by  it.  This  operation  was  per- 
formed with  such  dexterity,  that  the  external  straight 
muscle  was  not  at  all  injured.  Mr.  Travers  removed 
a scirrhous  and  enlarged  lachrymal  gland.  The  vision 
of  the  eye  had  suffered  considerably,  during  the  growth 
of  the  tumour.  The  only  deformity,  after  the  opera- 
tion, was  a slight  prolapsus  of  the  eyelid.  This  gen- 
tleman recommends  operations  of  this  kind  to  be 
always  done,  if  possible,  beneath  the  eyelid. — (Syaop- 
sis,&rc.p.^^.)  The  lachrymal  gland,  in  the  state  of 
scirrhus,  has  been  successfully  removed  by  Mr.  Todd 
{.see  Dublin  Hospital  Reports,  vol.  3),  and  by  Mr. 
O’Beirne,  of  Dublin. — (See  also  Guthrie's  Operative 
Surgery  of  the  Eye,  p.  159,  Src.  and  .7.  Schmidt  ueber 
die  Krankheiten  des  Thrduenorgnns.) 

The  caruncula  lachrymalis  is  liable  to  chronic  indu- 


ration and  enlargement,  constituting  the  disease  already 
spoken  of  in  a foregoing  part  of  this  w'ork,  under  the 
name  of  Encanthis,  of  which  there  is  also  a scirrhous, 
carcinomatous,  or  malignant  form,  quickly  extending 
its  effects  to  the  eyeball  and  the  adjacent  thin  bones  of 
the  orbit. — {Beer,  Lehre  von  den  Augenkr.  b.  2,p.  188.) 

From  these  subjects  I proceed  to  consider  the  dis- 
eases of  the  excreting  parts  of  the  lachrymal  oigaus; 
cases  which,  though  of  the  most  various  natures,  were 
formerly  all  confounded  together,  under  the  title  of 
fistula  lachrymalis,  and  it  is  only  within  the  last  few 
years,  that  these  complaints  have  been  subjected  to 
the  same  principles  and  distinctions,  which  are  con- 
ceived to  be  highly  useful  in  other  branches  of  surgery. 
As  Mr.  M‘Kenzie  has  judiciously  remarked,  the  con- 
sequence of  not  distinguishing  the  different  diseases  of 
the  excreting  parts  of  the  lachrymal  organs  from  each 
other,  has  been  an  attempt  to  discover  some  single 
successful  method  of  curing  them  all.  “ Now,  tliere  is 
no  one  method  of  treatment  by  which  this  can  be  ac- 
complished ; and  hence  it  is,  that  the  several  remedies 
which  have  been  proposed,  being  eminently  success- 
ful in  one  or  other  of  these  diseases,  but  not  adapted 
to  all  the  rest,  have  at  different  times  been  held  in 
such  various  degrees  of  estimation.” — ( On  Diseases 
of  the  Lachrymal  Organs,  p.  10,  8vo.  Land.  1819.) 
And  an  intelligent  critic  observes,  that  in  lachrymal 
diseases  obstruction  of  the  nasal  duct  appears  to  be 
almost  the  only  circumstance  against  which  the  treat- 
ment recommended  by  the  surgeons  of  France  and 
England  hcis  been  directed.  “ On  sail  qu’au  r^tr4- 
cissement  ou  a I’obliteration  du  canal  nasal,  produits 
par  une  cause  quelconque,  est  due,  dans  presque  tons 
les  cas,  la  maladie  qui  nous  occupe  ; sort  que,  resides 
intactes,  les  parois  du  sac  pr4sentetit  une  tumeur  la- 
chrymale,  d’ou  les  larmes  refluent  continuellement  sur 
les  joues,  5 travers  les  points  lachryraaux : soit  qu’en 
partie  detruites  et  ulc^r^es,  ces  parois  prtsentent  une 
fistule,  qui  ofl're  aux  larmes  un  passage  contre  nature, 
sans  cesse  entreteniie  par  elles  ; en  sorte  que  ces  deux 
4tats,  la  tumeur  et  la  fistule,  sont  presque  toujours  des 
degr^s  diffl^rens  d’une  m6me  affection,  et  que  le  traite- 
ment  qui  convient  4 Tune  repose  sur  les  m^mes  bases 
que  celui  indiqu4  dans  I’autre.” — {CEuvres  Chir.  de 
Desault,  t.  2,  p.  120.)  It  is  evident  from  the  writings 
of  Pott  and  Ware,  that  even  these  authors  considered 
the  obstruction  of  the  nasal  duct  as  the  foundation  of 
all  the  train  of  varied  symptoms  presented  by  the  ex- 
creting lachrymal  organs.  “ An  obstruction  in  the 
nasal  duct  is  most  frequently  the  primary  and  original 
cause  of  the  complaint.”  “ The  seat  of  this  disease  is 
the  same  in  almost  every  subject,”  says  Mr.  Pott  {Obs. 
on  the  Fistula  Lachrymalis)  ; and  Mr.  Ware,  in  his 
observations  on  the  same  disease,  sets  out  with  the 
same  assumption.  Now,  obstruction  of  the  nasal  duct 
is  an  occasional  consequence  merely  of  inflamma- 
tion of  the  excreting  lachrymal  organs ; in  most  of  their 
diseases  obstruction  of  the  nasal  duct  has  no  part ; and 
one  might  with  as  much  propriety  treat  all  the  affec- 
tions of  the  bladder  and  urethra  by  the  dilatation  of  the 
latter  part,  as  treat  all  the  diseases  of  the  excreting 
lachrymal  organs  by  dilating  the  nasal  duct.  The  false 
assumption  in  question  has  led  to  most  erroneous  treat- 
ment. For  instance,  in  blennorrhcea  of  tl;e  sac,  and 
in  hernia  of  the  sac,  though  in  both  these  diseases  the 
nasal  duct  is  free,  the  common  treatment  in  this  coun- 
try is  to  open  the  sac  with  a knife,  and  thrust  down  a 
style  or  some  other  instrument  into  the  nose;  thus  de- 
stroying the  organization  of  the  parts  which  are  af- 
fected merely  with  a gleety  secretion  in  the  one  case, 
and  with  extreme  relaxation  in  the  other.  Suppose 
(says  the  same  critical  writer)  that  some  charlatan 
should  make  oath  at  the  Mansion-house,  that  he  had 
cured  fifty  or  a hundred  cases  of  gonorrlima  by  opening 
the  urethra  in  the  perinteum,  and  passing  a bougie 
through  that  tube,  from  behind  forwards,  w'ho  would 
approve  of  such  an  operation  ? Yet  the  laying  open 
of  the  lachrymal  sac,  and  thrusting  a probe  down  into 
the  nose,  when  the  nasal  duct  is  either  perfectly  free, 
or  at  the  most  slightly  tumid  from  inflammation,  is 
neither  less  preposterous  nor  less  cruel. — (See  t^uar- 
terly  Journ.  of  Foreign  Medicine,  vol.  1,  p.  293.)  In- 
deed it  is  somewhat  surprising  that  errors  of  this  kind 
should  have  prevailed  so  long,  particularly  as  expe- 
rience had  taught  Mr.  Pott  that  slight  cases  might  be 
benefited  by  the  simple  employment  of  a vitriolic  col- 
lyriutu;  a fact  which  ought  to  have  convinced  him 


LACHRYMAL  ORGANS. 


119 


that  the  disease  did  not  always  depend  upon  obstruction 
of  the  nasal  duct.  It  is  curious,  therefore,  that  lie  did 
not  fully  see  lliis  mistake  ; for  that  he  knew  of  these 
diseases  having  great  variety  is  evident  from  tlie  fol- 
lowing remark  : — “ As  the  state  and  circumstances  of 
this  disease  are  really  various,  and  differ  very  essen- 
tially from  each  other,  the  general  custom  of  calling  them 
all  by  the  one  name  of  fistula  lachrymalis  is  absurd.” 
I believe  that  one  great  cause  of  deception  has  been 
the  fact,  that  though  laying  open  the  lachrymal  sac, 
and  the  introduction  of  instruments  down  the  nasal 
duct,  have  been  frequently  practised  when  milder 
plans  would  have  answered  every  purpose,  yet  a cure 
has  often  followed  the  practice,  and  thus  confirmed  the 
supposition  of  relief  having  been  effected  by  the  remo- 
val of  the  imaginary  obstruction  in  the  nasal  duct. 
Thus  the  late  Rlr.  Rarnsden,  of  St.  Bartholomew’s, 
with  whom  I served  my  apprenticeship,  always  fol- 
lowed the  common  plan  of  passing  a probe  down  the 
nasal  duct,  and  letting  the  patient  keep  a piece  of 
bougie  or  a style  in  the  part  for  two  or  three  months 
afterward  ; and  I scarcely  recollect  an  instance  in 
which  he  failed  to  accomplish  a cure,  though  I have 
no  doubt  that  the  same  benefit  might  sometimes  have 
been  obtained  without  any  operation  at  all.  And  a 
discerning  practitioner  should  never  forget  that  if  no 
permanent  obstruction  exists  in  the  nasal  duct,  a cure 
will  generally  follow  on  the  subsidence  of  inflamma- 
tion, and  a change  taking  place  in  the  action  of  the 
parts,  whether  a probe,  style,  cannula,  bougie,  or  seton 
he  employed  or  not. 

Erysipelas  of  the  Parts  covering  the  Lachrymal  Sac. 
— Beer  considers  it  highly  necessary  that  this  case 
should  be  discriminated  from  inflammation  of  the  sac 
itself,  which  is  often  but  little  affected,  and  this  even 
when  an  abscess  forms.  Unless  the  true  nature  of  the 
disease  be  comprehended,  the  surgeon  is  apt  to  sup- 
pose that  the  matter  is  in  the  sac  itself,  and  believes 
that  when  he  makes  am  opening  he  is  puncturing  that 
recejitacle,  whereas  he  is  in  reality  merely  dealing  with 
a superficial  abscess  of  the  integuments.  Nor,  as  Beer 
has  observed,  is  the  mistake  free  from  ill  consequences ; 
for  imagining  that  the  wound  is  made  into  the  sac,  the 
surgeon  pokes  about  with  his  probe  so  long,  that  a good 
deal  ofunnecessary  pain  and  inflammation  is  produced. 
According  to  lire  same  author,  the  case  is  not  very  fre- 
quent, and  is  mostly  met  with  in  scrofulous  subjects, 
who  have  had  for  a considerable  time  a blennorrhoea 
of  the  lachrymal  sac.  The  inflammation  partakes  of 
the  usual  characters  of  erysipelas,  and  commonly  ex- 
tends to  the  eyelids,  particularly  the  upper  one.  The 
absorption  and  conveyance  of  the  tears  into  the  lachry- 
mal sac  are  interrupted,  because  the  inflammation 
rxrnstanily  affects  the  lachrymal  ducts  and  papillae,  the 
latter  appearing  considerably.shrunk.  When  the  in- 
flammation spreads  over  the  side  of  the  face.  Beer 
says  there  is  usually  a discharge  of  thin  mucus  fro.m 
the  nose ; and  when  the  affection  extends  more  deeply, 
to  the  anterior  portion  of  the  lachrymal  sac,  as  may 
easily  happen  when  the  case  is  neglected,  or  treated  in 
its  first  stage  with  stimulating  applications,  a bean- 
shaped, circum-scribed,  hard,  painful  tumour  may  be 
felt  or  is  even  denoted  by  its  very  red  appearance.  The 
P'lncta  lachrymalia  are  now  completely  closed,  the  pa- 
pillse  shrivelled  up,  and  the  nostril  on  the  affected  side 
veiy  dry  and  tender. 

If  in  the  first  .stage  of  the  disorder,  the  lachrymal 
papillae  and  canals  have  not  been  too  violently  af- 
fected, the  former  parts  expand  again,  and  the  ab- 
porittion  of  the  tears  recommences  with  the  second 
stage.  But  at  this  period,  according  to  the  observa- 
tions of  Professor  Beer,  a good  deal  of  mucus  is  se- 
creted from  the  caruncula  lachrymalis  and  Meibomian 
glands,  and  collects  and  glues  the  eyelids  togethert,  es- 
pecially during  sleep.  At  the  same  time,  mucus  gene- 
rally accumulates  in  the  lachrymal  sac  itself,  and  may 
be  voided  both  through  the  puncta  lachrymalia  and 
nasal  duct  by  gentle  pressure.  The  mucous  discharge 
from  the  nostril  also  acquires  a thicker  consistence. 
Should  the  lachrymal  papillse  and  ducts  have  suffered 
more  severely  in  the  first  stage  of  the  disease,  the  due 
attsorption  of  the  tears  does  not  begin  after  the  sub 
sidence  of  the  inflammation,  and  a dropping  of  them 
over  the  cheek,  a stillicidium  lachriymarvm,  fre(|uently 
continues  a long  while  after  the  termination  of  the 
other  symptoms.  It  riepends  upon  the  atony. of  the  la- 
chrymal puncla  and  ducts,  and  is  very  troublesome  in 


cold  wet  weather.  And  when  the  lachrymal  sac  Itself 
has  been  a good  deal  inflamed  in  the  first  stage  of  the 
complaint,  a large  quantity  of  mucus  collects  within  it 
in  the  second  stage,  and  may  be  discharged  by  pres- 
sure. Sometimes  tire  subcutaneous  abscess  actually 
communicates  with  the  cavity  of  the  sac;  a case 
which  Beer  terms  a spurious  fistula  of  the  lachrymal 
sac,  the  matter  not  being  formed  in  that  receptacle 
itself,  but  getting  into  it  from  the  external  abscess.  As 
the  skin  is  generally  rendered  very  thin,  these  ab- 
scesses near  the  bridge  of  the  nose  usually  burst  by 
several  openings.  Beer  remarks,  that  it  is  easy  to  learn 
whether  the  ulceration  extends  tlirough  the  lachrymal 
sac ; for  when  this  has  happened,  the  slightest  pres- 
sure upon  the  superior  part  of  the,  sac  produces  a dis- 
charge of  pus  and  mucus  from  the  external  opening, 
and  if  the  lachrymal  canals  have  already  recommenced 
their  functions,  the  discharge  will  also  be  mixed  with 
tears. — (See  McKenzie  on  Diseases  of  the  Lachrymal 
Organs,  p.  22.)  The  quantity  of  matter  which  flows 
out  is  likewise  so  copious,  that  it  is  evident  it  could  not 
have  been  all  lodged  between  the  skin  and  orbicularis 
palpebrarum  muscle,  but  must  have  come  partly  out 
of  the  lachrymal  sac.  The  use  of  a fine  probe  will 
remove  any  doubt  which  may  be  left. — (Beer,  Lehre 
von  den  Augenkr.  b.  l,p.  332 — 335.) 

On  the  subject  of  the  causes  of  this  complaint,  the 
preceding  author  delivers  no  remark  worthy  of  notice. 
In  speaking  of  the  prognosis,  he  observes,  that  w'hen 
the  case  is  not  neglected,  nor  wrongly  treated  in  its  first 
stage,  and  the  inflammation  has  not  extended  to  the 
lachrymal  sac,  the  prognosis  is  very  favourable;  for, 
after  the  subsidence  of  the  inflammation,  a tem])orary 
atony  of  the  lachrymal  puncta  and  ducts,  an  imperfect 
conveyance  of  the  tears  into  the  nose,  and,  of  course, 
a slight  oozing  of  them  over  the  cheek,  most  trouble- 
some in  cold  wet  weather,  are  the  chief  inconveniences 
which  remain.  But  when  the  laclirymal  sac  partici- 
pates in  the  inflammaiion,  the  prognosis  is  much  less 
favourable;  because,  when  suppuration  takes  place, 
ulceration  is  apt  to  form  an  opening  in  the  front  part 
of  the  sac,  or  else,  during  the  second  stage,  a large 
quantity  of  mucus  may  collect  in  the  sac,  and  if  not 
skilfully  treated,  it  frequently  ends  in  a very  obstinate 
blennorrhoea  of  that  part.  As  Beer  observes,  this  is  a 
case  which  is  often,  though  quite  erroneously,  named 
a fistula  lachrymalis  — (R.  1,  p.  336.) 

The  prognosis  is  also  very  favourable  in  the  second 
stage  of  the  complaint,  as  long  as  the  suppuration  is  re- 
stricted to  the  integuments,  and  it  is  characterized  by 
desquamation  and  scabbing  ; but  the  case  is  more  se- 
rious when  a large  collection  of  matter  forms,  andpar- 
ticularly  when  the  abscess  makes  its  way  into  the  la- 
chrymal sac.  In  these  last  circumstances,  an  obsti- 
nate blennorrhoea  from  the  sac  often  follows,  notwith- 
standing the  fistulous  sore  be  treated  in  the  most  skil- 
ful manner,  and  sometimes  the  matter  spreads  so  far 
around  as  to  spoil,  and  even  annihilate,  the  lachrymal 
canals,  and  cause  an  irremediable  dropping  of  tears 
over  the  cheek  during  the  rest  of  the  patient’s  life.— 
{Beer.) 

The  suppuration  (says  Mr.  M'Kenzie)  may  destroy 
the  ligamentous  layer  of  the  lower  eyelid,  and  end  in 
the  total  obliteration  of  the  cavity  of  the  sac.  But 
when  the  sac  is  not  thus  annihilated,  and  the  lachry- 
mal canals  are  destroyed,  it  is  necessary  that  the  cavity 
of  the  sac  should  be  obliterated  by  artificial  means; 
for  otherwise  a form  of  disease  will  follow,  which 
Beer  denominates  hydrops  sacci  lachrymalis,  and  Mr. 
fiPKenzle, mucocele,  as  will  be  hereafter  noticed. 

“ In  common  cases,  a piece  of  folded  linen,  dipped 
in  cold  water,  and  applied  to  the  parts  affected,  and  (he. 
administration  of  gentle  doses  of  sulphate  of  magnesia, 
make  up  the  treatment.  In  severe  cases,  it  will  be 
found  nece.«sary  not  only  to  continue  the  cold  apjjlica- 
tions,  and  to  open  the  bowels,  but  to  administer  an 
emetic  of  tartrate  of  antimony,  to  purge  freely,  and 
even  sometimes  to  take  away  blood  frotti  the  arm.” — 
{J\PKcnzie,p.  24.) 

In  the  second  stage,  a warm  dry  air,  and  a linen  com- 
press, are  commended,  with  the  exhibition  of  diapho- 
retics. In  the  first  two  of  these  meatis,  I confess  that 
I should  place  little  or  no  confidence.  When  the 
formation  of  matter  cannot  be  prevented,  poultices  are 
to  be  used.  Beer  particularly  cautions  us  not  to  leave 
the  abscess  to  burst  of  itself,  but  to  open  it  immediately 
a fluctuation  can  be  felt,  so  as  to  prevent  an  ulceiatfui 


120 


LACHRYMAL  ORGANS. 


opening  from  taking  place  in  the  anterior  part  of  the 
lachrymal  sac.  And  if  the  surgeon  has  not  been  con- 
sulted before  such  a connnunication  has  been  esta- 
blished between  the  sac  and  subcutaneous  abscess,  he 
should  avoid  all  unnecessary  disturbance  of  the  parts 
with  probes  and  syringes,  and  at  most  only  wash  out 
the  abscess  once  a day  with  Anel’s  syringe,  filled  with 
lukewarm  water  and  a little  of  the  vinous  tincture  of 
opium.  Beer  also  recommends  introducing  into  the 
superficial  abscess,  but  not  into  the  sac,  a small  quantity 
of  lint,  dipped  in  the  tincture.  If  the  blennorrhoea  of 
the  sac  continue,  it  is  to  be  treated  in  the  way  which 
will  be  explained  in  considering  the  second  stage  of  in- 
flammation of  that  part. 

Injlainmation  of  the  Lachrymal  Sac. — According  to 
Beer,  the  symptoms  of  the  first  stage  of  this  complaint 
are  as  follows ; in  the  corner  of  tlie  eye,  precisely  in 
the  situation  of  the  lachrymal  sac,  a circumscribed, 
very  hard,  tender  swelling  arises,  of  the  shape  of  a 
bean,  producing  a lancinating  pain  when  it  is  touched, 
and  gradually  acquiring  considerable  redness.  The 
absorption  and  conveyance  of  the  tears  into  the  la- 
chrymal sac,  and  thence  into  the  nose,  are  completely 
interrupted;  the  lachrymal  papillae  are  shrunk;  the 
puncta  cannot  be  seen ; and  of  course  the  tears  fall 
over  the  cheek.  The  nostril  on  the  affected  side  is  at 
first  very  moist,  but  soon  becomes  perfectly  dry,  the 
mucous  membrane  being  a good  deal  affected.  As  the 
inflammation  also  constantly  spreads  to  the  orbicular 
muscle  and  integuments  in  the  corner  of  the  eye,  the 
complaint  often  presents  an  erysipelatous  appearance, 
extending  to  the  eyelids  and  down  the  cheek;  but  the 
circumscribed  swelling  caused  by  the  inflamed  sac  is 
still  not  only  capable  of  being  distinctly  felt,  but  even 
seen.  It  rarely  happens,  in  cases  of  common  inflam- 
mation, that  on  the  change  of  the  first  stage  into  the 
second,  the  nasal  duct  is  rendered  impervious  by  an 
effusion  of  lymph ; but  such  an  occurrence  is  more  fre- 
quent where  the  inflammation  is  not  of  a healthy  de- 
scription, and  the  patient  is  scrofulous.  Under  these 
circumstances,  the  lachrymal  canals  may  also  be  per- 
manently obliterated.  In  weak,  irritable  constitutions, 
towards  the  end  of  the  first  stage  of  the  inflammation,  a 
degree  ofsymptomatic  fever  prevails,  with  severe  head- 
ache, great  redness  and  swelling  of  the  whole  inner 
canthus  involving  the  caruncula  lachrymalis,  the  semi- 
lunar fold,  the  conjunctiva,  the  edges  of  the  eyelids, 
and  the  lachrymal  puncta. 

Here,  as  in  inflammation  of  every  mucous  mem- 
brane, at  the  very  commencement  of  the  second  stage, 
a copious  morbid  secretion  takes  place,  and  accumu- 
lates in  large  quantity  ; for,  either  in  consequence  of 
the  thickening  of  the"  mucous  membrane,  the  adhesion 
of  the  sides  of  the  nasal  duct  together,  or  there  being 
no  mixture  of  the  tears,  the  secretion  within  the  sac 
cannot  escape  either  into  the  nostril  or  out  of  the  la- 
chrymal puncta,  and  consequently  it  distends  in  a pro- 
digious degree  the  anterior  side  of  the  sac,  where  it  is 
uncovered  by  bone.  Hence,  the  swelling  is  here  very 
manifest,  and  a fluctuation  may  be  felt  in  it,  even  be- 
fore the  suppurative  stage  has  actually  begun.  Accord- 
ing to  Beer,  whoever  is  induced  by  the  fluctuation  to 
open  the  lachrymal  sac  at  this  period,  will  certainly 
bring  on  a very  hurtful  suppuration  of  the  part,  ex- 
ceedingly likely  to  render  the  excreting  parts  of  the 
lachrymal  organs  completely  unserviceable.  At  the 
beginning  of  the  second  stage,  there  is  also  a morbid 
secretion  from  the  mucous  membrane  of  the  nostril 
and  caruncula  lachrymalis.  Now,  not  only  the  swell- 
ing of  the  lachrymal  sac  increases  more  and  more,  but 
the  redness  acquires  a deeper  colour,  the  skin  becomes 
more  shining,  the  fluctuation  still  more  evident,  and 
at  length,  in  the  centre  of  the  tumour  formed  by  the 
lachrymal  sac,  a yellowish  soft  point  presents  itself. 
In  this  state  of  things,  in  order  to  prevent  a true  fistula, 
the  surgeon  should  make  an  opening  in  the  lachrymal 
sac,  without  the  least  delay ; for,  if  the  abscess  be  left 
to  itself,  the  pus  will  at  last  make  a passage  for  itself 
through  the  orbicular  muscle  and  integuments  ; but  it 
will  only  be  a small  fistulous  opening,  surrounded  with 
callous  hardness,  and  merely  capable  of  letting  some 
of  the  pus  and  mucus  of  the  sac  escape,  so  that  the 
thicker  part  of  the  matter  remains  behind,  and  conse- 
quently, though  the  swelling  diminishes  after  the 
formation  of  a spontaneous  opening,  it  does  not  en- 
tirely subside.  A quantity  of  blood  is  also  remarked 
to  be  blended  with  the  discharge  from  the  sac.  This 


last  is  the  case  which  Beer  denominates  a true  fistula 
of  lachrymal  sac.  When  the  abscess  bursts  of  itself, 
the  fistulous  opening  in  the  sac  is  not  always  exactly 
opposite  the  aperture  in  the  skin,  and  though  there  is 
commonly  but  one  communication  with  the  sac,  it 
sometimes  happens  that  several  small  external  open- 
ings are  produced  more  or  less  distant  from  the  sac. 
The  diagnosis  is  easy  enough  ; for,  on  pressing  upon 
the  upper  portion  of  that  receptacle,  mucus  and  pus 
blended  together  are  immediately  discharged  from  all 
the  fistulous  apertures.  After  the  disease  has  lasted  a 
good  while,  it  not  unfrequently  happens  that  tears  are 
also  voided  from  the  fistulous  opening  ; a circumstance 
indicating  the  restored  action  of  tlie  lachrymal  puncta 
and  canals ; but,  according  to  Beer,  such  tears  are  ne- 
ver duly  blended  with  the  mucous  and  purulent  mat- 
ter. He  farther  remarks,  that  when  the  second  period 
of  the  second  stage,  or  the  suppurative  process,  is  over, 
a morbid  secretion  of  mucus  still  continues  in  the  third 
period  of  the  second  stage,  that  secretion  becoming 
whitish,  thick,  opaque,  and  only  partly  resembling  pus. 
As,  in  consequence  of  its  thickness  and  the  swelling  of 
the  mucous  membrane  of  the  nasal  duct,  the  secretion 
cannot  descend  into  the  nose,  it  collects  in  the  sac,  and 
sometimes  pushes  off  any  piece  of  lint  or  plaster  with 
which  the  external  opening  in  the  sac  has  been  closed. 
At  length,  by  means  of  judicious  treatment,  this  third 
period  of  the  second  stage  is  also  brought  to  a termi- 
nation ; the  mucus  is  secreted  again  in  due  quantity ; 
it  becomes  transparent  like  white  of  egg,  and  viscid ; 
but  w'hite  streaks  may  be  for  some  time  perceived  in 
it.  Afterward  the  mucus  becomes  thinner,  and  if  the 
functions  of  the  lachrymal  puncta  and  ducts  are  not 
destroyed,  it  is  thoroughly  mixed  with  the  tears.  The 
opening  in  the  lachrymal  sac  now  either  heals  up  of 
itself,  or  under  skilful  treatment ; but  in  general  a mi- 
nute fistulous  aperture  still  remains,  from  which  the 
tears  and  mucus  are  occasionally  voided,  if  the  pas- 
sage through  the  nasal  duct  be  not  free.  However,  if 
the  small  fistulous  aperture  should  happen  to  heal  up 
completely,  the  mucus  and  tears  accumulate  in  the  sac, 
and  the  patient  is  obliged  to  press  them  out  through  the 
puncta  lachrymalia,  several  times  a day. 

When  the  surgeon  is  consulted  early  enough,  and 
proper  treatment  is  adopted.  Beer  sets  down  the  prog- 
nosis in  the  first  stage  of  the  inflammation  as  veiy  fa- 
vourable. But  if  the  practitioner  be  called  in  later,  it 
will  not  be  in  his  power  completely  to  disperse  the  in- 
flammation, and  prevent  the  morbid  secretion  and 
accumulation  of  mucus  in  the  lachrymal  sac;  the 
hlennorrhma  of  this  part  of  Professor  Beer,  or  the 
iacryoj>s  blennoideus  of  Schmidt ; a state,  however, 
which  soon  gives  way  to  judicious  treatment.  But 
when  the  case  is  neglected  or  wrongly  managed  at  the 
period  when  the  lachryiiial  sac  is  violently  inflamed,  a 
complete  or  partial  closure  of  the  nasal  duct,  by  adhe- 
sive inflammation,  is  apt  to  be  the  consequence.  And 
the  same  effect  may  also  be  produced  in  the  lachrymal 
canals,  in  which  event  the  absorption  of  the  tears  is 
for  ever  impeded,  and  the  patient  must  remain  the 
rest  of  his  life  afflicted  with  the  stillicidium  lachry- 
marum. 

With  regard  to  the  prognosis  in  the  second  stage  of 
inflammation  of  the  lachrymal  sac,  Beer  considers  it 
as  very  dubious,  on  account  of  the  impairment  of  the 
functions  of  the  excreting  parts  of  the  lachrymal  or- 
gans ; for,  says  he,  no  surgeon  can  exactly  know  what 
may  have  been  the  result  of  the  first  stage,  in  relation 
to  the  perviousness  of  the  nasal  duct  and  lachrymal 
canals,  and  an  officious  examination  of  the  parts  with 
a probe,  for  the  purpose  of  obtaining  information, 
would  be  attended  with  considerable  mischief.  How- 
ever, generally  speaking,  the  prognosis  is  most  hopeful 
at  the  first  period  of  the  second  stage,  just  when  the 
morbid  secretion  of  mucus  is  beginning ; the  suppura- 
tion may  yet  be  moderated  by  right  treatment,  and  the 
excreting  parts  of  the  lachrymal  organs  preserved. 
But  if  the  suppurative  stage  has  already  come  on, 
much  will  depend  upon  the  consideration,  w'hether  the 
matter  has  been  originally  formed  in  the  lachrymal 
sac,  has  lodged  there  a good  while,  and  the  sac  is  ready 
to  burst,  or  whether  there  is  actually  an  opening  in  the 
sac  opposite  that  in  the  skin,  or,  lastly,  whether  the 
openings  do  not  correspond.  In  the  first  casfc,  the  sup- 
puration yet  admits  of  being  regulated  by  judicious 
treatment,  and  the  lachrymal  sac  can  be  punctured ; 
but  in  the  other  circumstances,  the  managei.ient  of  the 


LACHRYMAL  ORGANS. 


121 


case  is  far  more  difficult,  especially  when  the  patient’s 
constitution  is  not  good.  However,  the  surgeon  should 
be  careful  not  to  disfigure  the  patient  with  a large 
scar ; and  the  aim  should  be  to  prevent  atony  of  the 
lachrymal  puncta  and  ducts,  and  a consequent  slillici- 
dium  lachrymarum.  These  are  the  least  serious  evils  to 
be  apprehended  from  mismanagement ; for,  if  the  case  be 
ill-treated  or  neglected,  in  the  later  stage  of  the  suppu- 
rative process,  necessarily  attending  a fistulous  state 
of  the  sac,  the  lachrymal  organs  may  be  rendered  quite 
useless,  or  even  entirely  destroyed,  and  the  nasal  duct 
obliterated  or  obstructed  by  the  effects  of  caries.  In 
some  few  instances,  indeed,  the  whole  lachrymal  sac 
is  destroyed,  or  will  require  to  be  so  by  art,  as  will  be 
presently  explained.  It  is  always  a favourable  cir- 
cumstance, when  the  tears  are  seen  to  issue  from  the 
fistulous  opening  with  the  mucus  and  pus,  as  it  is  a 
proof  that  the  absorption  and  conveyance  of  the  tears 
into  the  lachrymal  sac  are  established  again,  and  that 
now  the  only  question  is  about  the  state  of  the  nasal 
duct,  which  point  cannot  be  determined  before  the  fis- 
tula is  completely  healed,  and  the  third  period  of  the 
second  stage  is  entirely  obviated. — (Seer,  Lehre  von 
den  Augenkr.  b.  1,  p.  356—367.) 

In  the  first  stage,  the  indication  is  to  endeavour  to 
resolve  the  infiammation.  “It  is  (as  Mr.  M‘Kenzie 
observes)  by  combating  the  inflammation,  that  we  are 
to  cure  this  disease,  and  not  by  attacking  merely  one, 
or  even  several,  of  the  symptoms.  Dilatation,  for  in- 
stance, by  the  introduction  of  probes  through  the  canals 
into  the  sac,  and  even  into  the  nose,  would  only  be  sub- 
jecting the  inflamed  parts  to  a new  course  of  irritation, 
and  might  thus  produce  effects  which  would  render  a 
complete  cure  difficult  if  not  impossible.”  On  the  con- 
trary, in  the  first  stage,  Mr.  M'Kenzie  joins  Beer  in 
praise  of  antiphlogistic  measures ; the  application  of 
cold  lotions  to  the  part ; and,  in  severe  cases,  venesec- 
tion and  leeches  are  set  down  as  proper,  together  with 
opening  and  diaphoretic  medicines. — {On  Diseases  of 
the  Lachrymal  Organs,  p.  33,  34.) 

In  the  second  stage,  when  resolution  is  no  longer 
practicable,  emollient  applications  are  the  most  bene- 
ficial, and  all  debilitating  means  are  to  be  stopped,  by 
the  farther  use  of  which  an  incurable  blennorrhcea  of 
the  lachrymal  sac  would  be  likely  to  be  induced.  And, 
as  soon  as  the  sac  is  so  distended  with  mucus  and  mat- 
ter, that  the  centre  of  the  swelling  begins  to  be  soft, 
and  a fluctuation  is  perceptible,  the  sac  should  be 
freely  opened,  so  as  to  let  its  contents  have  a ready  out- 
let. If,  after  this  evacuation,  there  should  be  any 
deep-seated  hardness  of  the  lachrymal  sac.  Beer  re- 
commends the  application  of  a camphorated  hemlock 
poultice.  Afterward  the  wound  in  the  skin  and  sac  is 
to  have  introduced  into  it  a little  bit  of  lint,  dipped  in 
the  vinous  tincture  of  opium,  over  which  dressing  a 
piece  of  diachylon  plaster  may  be  placed.  When,  un- 
der such  treatment,  the  suppuration  diminishes,  but  a 
preternatural  secretion  of  mucus  yet  continues,  Beer 
introduces  into  the  wound  every  day  a piece  of  lint,  on 
whic.)  is  spread  a little  bit  of  the  following  ointment; 

Butyri  recentis  insulsi,  5ss-  Hydrargyri  Nitrico 
Oxydi,  gr.  x.  tutite,  pit.  gr.  vj.  M.  And,  on  changing 
the  dressings,  some  of  the  following  lotion  may  be 
dropped  into  the  inner  canthns,  and  injected  lukewarm 
into  the  sac  itself:  B;.  Subacetatis  Cupri,  Potassa3  Ni- 
tratis,  Aluminis,  Si  a gr.  iij.— vj.  Camphora;  tritae  gr. 
ij.— iv.  Aqu®"distillatiE  5ss.  Solve  et  cola.  Liquori 
colato,  adde  Vini  Opii  3 j.— 3 ij.  Aqiue  Bosae  |iv.  M. 
Professor  Beer  makes  a mass  of  the  first  three  articles 
melted  together  in  equal  proportions,  and  terms  it  the 
lapis  divinus,  of  which  he  makes  the  lotion,  and  then 
adds  the  other  ingredients.  When,  by  means  of  such 
treatment,  the  mucous  secretion  from  the  sac  has  been 
brought  into  a healthy  state,  and  all  the  induration  has 
subsided,  the  period  has  arrived  for  the  surgeon  to 
think  of  taking  measures  for  the  re-establishmeni  of 
the  passage  through  the  nasal  duct,  if  it  should  not  al- 
ready  have  become  pervious  of  itself,  which,  when 
the  inflammation  has  been  of  a healthy  kind,  and  the 
treatment  judicious,  very  frequently  happens.— (5ee»-, 
Lchre,  Src.  b.  1,  p.  369.  371.) 

Chronic  Blennorrhcea  of  the  excreting  Parts  of  the 
Dachrymal  Organs. — Mr.  M‘Kenzie,  whose  essay  con- 
tains a faithful  account  of  Beer’s  opinions  upon  the  pre- 
sent subject,  describes  the  inflammation  with  which 
this  torni  of  disease  commences,  as  seldom  consider- 
able, and  in  scrofulous  patients  it  is  said  to  be  not  un- 


frequently  quite  disregarded,  no  advice  being  taken 
until  the  lachrymal  sac  is  much  distended  with  mucus. 
By  means  of  pressure  upon  the  bean-shaped  tumour, 
caused  by  such  distention  of  the  sac,  a quantity  of  pu- 
riform  mucus  is  forced  out  of  the  puncta  lachrymalia, 
and  overflows  the  eye ; and  so  far  are  the  lachrymal 
canals  from  being  obstructed,  that,  excepting  when  any 
return  of  inflammation  happens,  they  even  absorb  and 
convey  the  tears  into  the  sac.  Pressure,  however, 
will  rarely  make  the  contents  of  the  sac  pass  through 
the  nasal  duct,  on  account  of  the  thickened  state  of  the 
mucous  membrane,  and  therefore  the  nostril  is  gene- 
rally very  dry.  “ In  the  course  of  this  tedious  disease, 
the  accumulated  mucus  varies  much  both  in  quantity 
and  quality.  For  instance,  the  mucus  accumulates 
more  rapidly,  and  is  much  thicker  after  a good  meal, 
than  at  other  times.  The  secretion  of  it  is  very  plen- 
tiful, but  thinner  than  usual,  when  the  patient  con- 
tinues long  in  a moist  cold  atmosphere.  In  this  case, 
the  overflowing  of  the  sac  takes  place  so  rapidly  that 
the  compression  of  the  orbicularis  palpebrarum  in  the 
action  of  winking  is  sufficient  to  evacuate  the  sac 
through  the  canals  to  such  a degree,  that  the  whole 
surface  of  the  eyeball  is  suddenly  overflowed,  and  the 
puriform  fluid  runs  down  upon  the  cheek.  After  the 
patient  remains  for  a short  time  in  a warm  and  dry  at- 
mosphere, the  morbid  secretion  becomes  sparing  and 
ropy.  We  find  that  this  chronic  blennorrhcea  almost 
completely  disappears  in  many  individuals  during 
warm  weather,  upon  which  the  yet  inexperienced 
patient  and  the  inexperienced  surgeon  are  apt  to  ex- 
press a great  but  premature  joy,  for,  on  the  very  first 
change  to  cold  and  wet  weather,  the  disease  most  fre- 
quently returns.” 

During  chronic  blennorrhcea,  the  lachrymal  sac  is 
extremely  liable  to  repeated  attacks  of  inflammation, 
and  sometimes  a fistula,  with  a good  deal  of  indura- 
tion of  the  surrounding  cellular  substance,  is  produced. 
Mr.  M‘Kenzie  represents  this  disease  as  the  most  fre- 
quent of  all  those  to  which  the  excreting  parts  of  the 
lachrymal  organs  are  liable,  and  as  consisting  in  in- 
flammation of  these  organs,  modified  by  scrofula,  gene- 
ral debility,  disorder  of  the  digestive  organs,  or  other 
constitutional  causes,  which  prolong  its  second  stage. 
“ Even  regarded  locally,  the  present  disease  is  seldom  a 
primary  affection,  but  is  most  frequently  excited  by 
catarrhal  inflammation  of  the  Schneiderian  membrane, 
or  by  a long-continued  disorder  of  the  Meibomian 
glands.” — {M'Kenzie  on  Diseases  of  the  Lachrymal 
Organs,  p.  37 — 40.) 

Scarpa’s  opinions  on  the  present  subject  are  in  some 
degree  peculiar  to  himself ; for  he  considers  the  affection 
of  the  Meibomian  glands  and  inside  of  the  eyelids,  the 
puriform  palpebral  discharge,  as  he  terms  it,  as  consti- 
tuting the  first  degree  of  all  those  complaints  which 
have  usually  gone  under  the  name  of  fistula  lachry- 
malis ; the  second  degree  or  effect  being  the  tumour 
of  the  lachrymal  sac;  and  the  third,  the  fistula  or 
ulcerated  opening  in  the  latter  part.  Scarpa  asserts 
that  the  chief  part  of  the  yellow  viscid  matter,  which 
accumulates  in  the  lachrymal  sac,  is  secreted  by  the 
lining  of  the  eyelids,  and  by  the  little  glands  of  Meibo- 
mius ; and  that  the  altered  quality  of  this  secretion  has 
a principal  share  in  the  cause  of  the  disease.  He 
states  that  the  truth  of  this  fact  may  at  once  be  ascer- 
tained by  everting  the  eyelids,  and  especially  the  lower 
one  of  the  affected  side  ; and  by  comparing  them  with 
those  of  the  opposite  eye.  The  former  will  always  ex- 
hibit an  unnatural  redness  of  the  internal  membrane, 
which  has  a villous  appearance  all  over  the  extent  of 
the  tarsus;  while  the  edge  of  the  lid  is  swolleq,  and 
numerous  varicose  vessels  are  distinguishable  on  it. 
The  follicles  of  Meibomius  are  also  turgid  and  promi- 
nent, and,  when  examined  with  a magnifying  glass,  not 
unfrequently  appear  to  be  slightly  ulcer.ated. 

“ The  villous  structure,  then,  which  the  surface  of 
the  internal  membrane  of  the  palpebra  assumes  in 
these  cases,  becomes  an  organ  secreting  a larger  quan- 
tify of  fluid  than  usual,  resembling  viscid  lymph, 
which,  as  before  stated,  being  mixed  with  the  ^a- 
ceous  matter,  copiously  eftused  from  the  glands  of  Mei 
bond  us,  constitutes  the  whole  of  the  viscid  fluid,  with 
which  the  eyelids  are  imbued,  and  which  is  continually 
carried  by  the  puncta  lachrymalia  into  the  sac,  so  as 
to  fill,  and  also  frequently  distend  it,  until  it  forms  a 
tumour. 

“ If,  indeed,  the  lachrymal  sac  is  emptied  of  this 


122 


LACHRYMAL  ORGANS. 


matter,  by  means  of  compression,  and  the  eye  and 
internal  surface  of  the  palpebrae  are  carefully  washed, 
so  that  none  of  the  glutinous  humour,  pressed  from  the 
sac,  may  remain  upon  them,  and  the  eyelids  are  everted 
half  an  hour  afterward,  the  internal  surface,  especially 
of  the  lower  one,  will  be  found  covered  with  a fresh 
effusion  of  mucus  mixed  with  sebaceous  matter,  which 
has  evidently  not  flowed  back  from  the  lachrymal  sac 
to  the  eye,  but  has  been  generated  between  the  eye 
and  the  palpebraj.”  Another  argument  brought  for- 
ward by  Scarpa,  in  support  of  his  theory,  is,  that  if 
the  morbid  secretion  of  the  eyelids  be  retarded  or  sup- 
pressed, either  accidentally  or  by  means  of  astringent 
applications,  little  or  none  of  the  viscid  secretion  col- 
lects in  the  lachrymal  sac,  or  can  be  forced  out  of  the 
puncta  lachrymalia.  He  has  also  constantly  observed, 
that  the  puritbrm  discharge  may  be  radically  cured  at 
its  commencement,  and  before  it  has  induced  any  flac- 
cidity  of  the  sac,  by  a timely  correction  of  the  morbid 
secretion  from  the  inside  of  the  eyelids,  and  keeping 
the  lachrymal  passages  cleansed,  by  means  of  injec- 
tions of  simple  water  through  the  puncta  lachrymalia 
into  the  nose.  As  for  tire  internal  membrane  of  the 
sac  itself,  he  argues  that  its  structure  does  not  qualify 
it  for  secreting  a tenacious  unctuous  matter,  like 
what  is  chiefly  discharged  from  it,  as  it  is  entirely  des- 
titute of  sebaceous  glands,  and  can  in  reality  only  fur- 
nish a thin  mucus.  However,  he  admits,  that  if  the 
sac  happen  to  be  inflamed  and  ulcerated,  a turbid  mat- 
ter may  issue  from  it  with  the  tears;  but,  says  he,  this 
matter  is  true  pus,  and  quite  different  from  the  curdy 
unctuous  fluid,  which  takes  place  in  the  puriform  pal- 
pebral discharge. — (On  the  Principal  Diseases  of  the 
Eyes,  transl.  by  Briggs,  ed.  2,  p.  3—7.) 

'Hie  foregoing  opinions  of  Scarpa  have  not  met  with 
universal  assent,  and  though  there  is  probably  much 
truth  in  them,  he  may  have  overlooked  too  much  the 
possible  simultaneous  affection  of  the  mucous  mem- 
brane of  the  lachrymal  sac  and  nasal  duct.  To  Scarpa’s 
hypothesis,  Himly  and  Flajani  have  made  the  following 
objections : First,  That  they  have  observed  the  fistula 
lachrymalis,  without  the  least  morbid  alteration  of  the 
eyelids  and  Meibomian  glands.  Secondly,  That  every 
puriform  discharge  of  the  eyelids  is  not  succeeded  by  a 
fistula  lachrymalis.  Lastly,  That  the  fistula  lachry- 
malis is  cureid  by  means  of  the  operation  alone,  without 
'any  attention  being  paid  to  the  morbid  state  of  the 
eyelids,  when  it  exists.  And  Mr.  Travers  also  regards 
Scarpa’s  account  of  the  origin  of  the  disease,  inde- 
pendently of  a permanent  stricture,  as  hypothetical ; 
for,  if  founded  in  fact,  the  distention  of  the  lachrymal 
sac,  and  the  regurgitation  of  the  fluid  on  pressure, 
would  attend  every  severe  lippitudo,  or  ophthalmia 
with  puriform  discharge,  which  is  not  the  case.  If 
Scarpa’s  account  were  correct,  Mr.  Travers  sees  no 
reason  why  the  fluid,  once  admitted,  should  be  arrested, 
or  regurgitate,  instead  of  passing  into  the  nose  (see 
also  J\ricod  in  Revue  Mid.  t.  l,p.  155)  ; and  lie  thinks 
there  is  every  reason  to  believe  that  the  fluid,  so  dis- 
charged, is  the  proper  secretion  of  the  sac,  and 
cases  are  frequent  in  which  it  is  retained  and  cannot 
be  expressed,  owing  to  strictures  both  of  the  lachrymal 
and  nasal  ducts. — {Synopsis  of  the  Diseases  of  the 
Eye,  p.  360.)  Some  of  the  arguments  with  which 
Scarpa  meets  this  reasoning  are  already  anticipated, 
especially  that  which  refers  to  the  difference  between 
the  secretion  of  the  sac  itself  and  that  of  the  seba- 
ceous glands  of  the  eyelids.  Also  in  asserting  that  the 
origin  of  the  fistula  lachrymalis  generally  manifests 
itself  on  the  eyelids,  before  the  lachrymal  passages  are 
affected,  Scarpa  declares  that  he  does  not  pretend 
thereby  to  exclude  altogether  the  possibility  of  a case, 
in  which  the  membranes  of  the  nasal  duct  and  lachry- 
mal sac  may  not  be  thickened  and  ulcerated,  inde- 
pendently of  the  disease  of  the  eyelids.  That  this  is 
the  case,  I think  is  evident  from  the  account  already 
delivered  in  the  first  two  sections  of  this  article,  of 
Beer’s  opinions,  respecting  the  consequences  of  in- 
flammation of  the  integuments  and  other  parts  about 
the  inner  angle  of  the  eye,  as  well  as  respecting  the 
effects  of  acute  inflammation  of  the  lachrymal  sac 
itself.  However,  Scarpa  admits  the  fact,  and  the  ques- 
tion left  is,  whether  he  is  right  in  assigning  the  morbid 
secretion  from  the  inside  of  the  eyelids,  as  the  most 
common  cause  of  the  swellitig,  ulceration,  &,c.  of  the 
lachrymal  sac?  That  every  puriform  discharge  from 
the  eyelids  is  not  followed  by  fistula  lachrymalis,  he 


allows  is  unquestionable ; and  this,  he  conceives,  most 
probably  happens  because  the  lippitudo  has  not  been 
entirely  neglected,  or  because  the  secretion  being  less 
dense  and  viscid  than  usual,  descends  freely  with  the 
tears  into  the  nose  through  the  lachrymal  canals,  which 
are  large  and  pervious.  But  in  the  acute  stage  of  the  pu- 
rulent ophthalmia,  he  asserts  that  the  reason  why  the 
discharge  is  not  conveyed  into  the  sac  is,  that  the  in- 
flammation and  swelling  actually  close  the  puncta  la- 
chrymalia, and  change  their  direction,  so  that  both  the 
puriform  matter  and  the  tears  fall  over  the  cheek,  and 
cannot  descend  into  the  sac. 

As  for  the  instances  of  cure,  without  any  remedies 
being  applied  for  the  correction  of  the  state  of  the  eye- 
lids, Scarpa  deems  the  argument  inconclusive,  because 
particular  vices  of  the  constitution,  under  the  use  of 
appropriate  internal  remedies  and  a well-regulated  diet, 
disappear,  or  are  transferred  to  other  parts,  without  the 
use  of  topical  remedies. 

For  my  own  part,  I am  disposed  to  believe,  that, 
whether  the  disease  begin  in  the  eyelids  or  elsewhere, 
generally  both  their  lining  and  that  of  the  sac  and  nasal 
duct  are  also  more  or  less  affected ; and  consequently, 
though  Scarpa’s  theory  may  not  be  in  every  respect 
satisfactory,  nor  at  all  applicable  to  certain  disorders  of 
the  excreting  parts  of  the  lachrymal  organs,  the  prac- 
tice, to  which  his  sentiments  lead,  will,  in  the  gene- 
rality of  cases,  which  Beer  denominates  chronic  blen- 
norrhcea,  be  highly  advantageous. 

According  to  Mr.  M‘Kenzie,  the  local  treatment  of 
chronic  blennorrhoea  does  not  differ  essentially  from 
that  of  inflammation  of  the  excreting  parts  of  the  la- 
chrymal organs.  But  every  possible  means  must  also 
be  employed  for  improving  the  general  health ; for 
otherwise,  all  local  remedies  will  be  unavailing.  In 
scrofulous  cases,  particular  attention  must  be  paid  to 
diet  and  mode  of  living.  In  weakly  persons,  the  pre- 
parations of  iron  will  be  highly  beneficial ; and  when 
the  disease  is  connected  with  disorder  of  the  digestive 
organs,  the  treatment  recommended  by  Mr.  Abernethy 
is  that  to  which  Mr.  M‘Kenzie  expresses  a preference. 
The  employment  of  Anel’s  syringe  and  probe  is  strongly 
reprobated.  “ I grant  (says  this  author)  that  the  appli- 
cation of  certain  substances  to  the  mucous  membrane 
affected,  is  one  of  the  most  powerful  means  which  we 
possess  of  correcting  its  disposition  to  chronic  blen- 
norrhoea.  But  he  who  believes  that  the  best  manner 
of  applying  these  substances  is  to  inject  them  with 
Anel’s  syringe,  introduced  through  the  puncta,  is  la- 
mentably mistaken.  He  is,  in  fact,  closing  his  eyes 
upon  what  he  must  know  of  the  functions  of  the  seve- 
ral parts  of  the  lachrymal  organs,  and  is  doing  that 
very  th.ng  which  is  calculated  to  prolong  and  exaspe- 
rate the  disease.  Except  at  the  time  of  a smart  renewal 
of  the  inflammation,  the  puncta  and  canals,  during  this 
disease,  continue  in  the  e.xercise  of  their  functions. 
Whatever  fluid,  therefore,  is  dropped  into  the  lacus 
lachrymarum,  will  be  taken  up  by  the  puncta,  con- 
veyed through  the  canals,  and  applied  to  the  whole 
internal  surface  of  the  sac.  Even  ointments  placed 
within  reach  of  the  puncta,  will  be  absorbed  in  the 
same  manner.  We  oiight  then,  fir.st  of  all,  to  empty 
the  sac  by  pressure,  and,  if  jrossible,  through  the  nasal 
duct  into  the  nose.  Having  placed  the  patient  upon  his 
back,  we  drop  into  the  lacus  lachrymarum  a small 
quantity  of  a weak  solution  of  corrosive  sublimate. 
A-  aq.  ros.  5 iv.  hydrarg.  oxymuriatis  gr.  ss.  gr.  j.  mucil. 
3 j.  vini  opii  3j.  M.  After  remaining  for  a quarter  of 
an  hour  in  that  position,  he  ought  to  rise,  but  without 
wiping  away  any  of  the  collyrinm  which  may  remain. 
After  another  quarter  of  an  hour,  the  eyelids  are  to  be 
carefully  dried,  and  a little  of  Janin’s  ophthalmic  oint- 
ment applied  with  a camel-hair  pencil  to  the  carun- 
cnla  lachrymalis  and  edges  of  the  eyelids.  All  this  is 
to  be  carefully  repeated  twice  a day.”  Professor  Schmidt 
recommendsthe  fitllowingcollyrium.  IJ;.  Aq.  rosas,  5 
acid  nitrici,  3j.  alcoholis,  3j.  M.  For  the  removal  of 
the  induration  over  the  sac,  gentle  friction,  with  can>- 
phorated  mercurial  ointment,  is  recommended.  And, 
says  Mr.  M Kenzie,  if  the  blennorrhoja  depend  upon 
chronic  inflammation  of  the  Meibomian  glands,  the  di- 
luted citron  ointment  is  to  be  applied  every  evening  at 
bedtime. — {On  Diseases  of  the  Eachrymal  Organs,  p. 
43,  <^  c.)  In  the  first  stage  of  what  Scarpa  terms  t^ 
puriform  discharge  of  the  palpebra?,  when  the  weep- 
ing is  incipient,  tiiis  author  states  that  a cure  may  be 
eriected  without  dividing  the  sac,  or  any  other  painful 


:^achrymal  organs. 


123 


operation.  His  practice  consists  in  restraining  the  im- 
moderate secretion  from  tiie  Meibomian  glands  and  in- 
ternal membrane  of  the  palpebrae,  and  in  cleansing  the 
vise  lachrymales  through  their  whole  extent  by  means 
of  injections  of  warm  water,  rendered  more  active  by 
the  addition  of  a little  spirit  of  wine,  and  thrown  into 
the  puncta  lachrymalia  every  morning  and  evening;  a 
measure  which,  as  already  stated,  is  disapproved  of 
by  Messrs.  M‘Kenzie,  Schmidt,  &c.  Scarpa  considers 
Janin’s  ophthalmic  ointment,  weakened  with  lard  or 
fresh  butter,  as  the  best  application  for  correcting  the 
morbid  secretion  of  the  eyelids.  A portion,  equal  to 
the  size  of  a barleycorn,  is  to  be  introduced  upon  the 
point  of  a blunt  probe,  every  morning  and  evening, 
between  the  eye  and  eyelids,  near  the  external  angle, 
and  the  edges  of  the  eyelids  are  to  be  smeared  with  it. 
The  eye  is  then  to  be  shut,  and  the  eyelids  gently  rubbed, 
so  that  the  ointment  maybe  distributed  upon  the  whole 
of  their  internal  surface.  A compress  and  bandage 
should  be  applied,  and  the  eyelids  kept  closed  for  two 
hours.  At  the  end  of  this  time,  the  eye  should  be 
washed  with  the  zinc  collyrium.  When  there  are  su- 
perficial ulcerations  at  the  edges  of  the  eyelids,  Scarpa 
applies  to  them  either  Janin’s  ointment,  or  the  unguen- 
tum  hydrarg.  nitrat.,  and  in  very  obstinate  cases,  the 
argentum  nitratum  itself.  If  the  vessels  of  the  con- 
junctiva are  varicose,  he  drops  into  the  eye  the  tinctura 
thebaica. — (Scarpa,  ed.  2,  by  Briggs,  chap.  1.) 

The  late  Mr.  Ware  was  earlier  than  Scarpa  in  point- 
ing out  the  advantage  of  making  applications  to  the 
inside  of  the  eyelids,  for  the  relief  of  certain  forms  of 
disease,  usually  classed  with  fistula  lachrymalis. 

“ When  an  epiphora,”  says  he,  “ is  occasioned  by  an 
acrimonious  discharge  from  the  sebaceous  glands  on 
the  edges  of  the  eyelids,  it  must  be  evident  that  injec- 
■ tions  into  the  sac  will  be  very  insufficient  to  accom- 
plish a cure,  because  the  sac  is  not  the  seat  of  the  dis- 
order. The  remedies  that  are  employed  must  be  di- 
rected, on  the  contrary,  to  the  ciliary  glands  themselves, 
in  order  to  correct  the  morbid  secretion  that  is  made  by 
them ; and  for  this  purpose,  I do  not  know  any  appli- 
, cation  that  is  likely  to  prove  so  effectual  as  the  unguen- 
lum  hydrargyri  nitrati,  of  the  new  London  Dispensa- 
tory, which  should  be  used  here  in  the  same  manner  in 
which  it  is  applied  in  common  cases  of  the  psoroph- 
thalmy.  It  will  be  proper  to  cleanse  the  eyelids  every 
morning  from  the  gum  that  collects  on  their  edges 
during  tlie  night  with  some  soft  unctuous  applications ; 
and  I usually  advise  to  apply  to  them,  two  or  three 
times  in  tlte  course  of  the  day,  a lotion  composed  of 
three  grains  of  white  vitriol,  in  two  ounces  of  rose  or 
elder-flower  water. — (Additional  Remarks  on  the  Epi- 
phora.) 

In  a modern  periodical  work  may  be  perused  some 
interesting  remarks  by  M.  Nicod,  which  perfectly  ac- 
cord with  the  sentiment  already  expressed,  that  what- 
ever may  be  its  primary  seat,  the  chronic  inflammation 
is  not  generally  limited  to  the  inside  of  the  eyelids,  but 
extends  throughout  the  membranous  lining  of  the  sac 
and  nasal  duct ; and  that  this  circumstance,  in  conjunc- 
tion with  the  altered  and  viscid  nature  of  the  secre- 
tions, .accounts  for  their  not  readily  descending  into  the 
nrxse,  hut  regurgitating  through  the  puncta.  M.  Nicod 
also  relates  cases  exemplifying  that  the  oinfment  ap- 
plied to  the  inside  of  the  eyelids  actually  passes  with 
the  matter  into  the  lachrymal  sac,  and  thence  into  the 
nose,  so  as  to  act  upon  and  cure  the  chronic  infl.anima- 
tion  of  the  sac  and  nasal  duct,  as  well  as  that  of  the 
Meibomian  glands  and  lining  of  the  eyelids. — (See  Re- 
vue Medicate  Historique,  ^c.  t.  1,  p.  156.  8t)0.  Paris, 
1820.)  The  proceedings  for  adoption,  when  the  nasal 
duct  is  obstructed,  will  now  be  considered. 

Obstruction  of  the  Masai  Duct. — That  a permanent 
closure  of  this  can.al  does  not  so  frequently  attend 
di.'jeases  of  the  lachrymal  organs  as  writers  have  gene- 
rally imaeined,  must  be  e\’ident  from  the  remarks  al- 
re.idy  delivered;  and  also  that  its  perviousness,  when 
interrupted  partly  by  inflammation  and  thickening  of 
its  lining,  and  partly  by  the  viscid  curdy  nature  of' the 
matter,  may  generally  be  restored,  without  thrusting 
any  probes,  tubes,  or  other  instruments  down  the  pas- 
sage (ineasure.s,  more  likely,  under  the.se  circumstances, 
to  do  harm  than  good),  is  a fact  which  is  no  longer 
questionable.  The  treatment  necessary  in  such  cases 
must  be  already  intelligible  from  what  has  been  said  in 
the  preceding  sections,  the  indication  being  the  diminu- 
tion of  the  thickened  state  of  the  mucous  membrane. 


by  means  adapted  to  the  acute  or  chronic  form  of  the 
inflammation,  and  in  many  cases,  the  correction  also  of 
the  morbid  state  of  the  Meibomian  glands  and  internal 
membrane  of  the  eyelids.  It  is  only  when  the  treat- 
ment, conducted  upon  these  mild  principles,  is  found 
ineffectual,  that  the  surgeon  should  think  of  examining 
the  state  of  the  nasal  duct,  and  learning,  by  the  intro- 
duction of  a fine  probe  into  the  passage,  whether  any 
permanent  stricture  or  obstruction  is  present.  It  does 
not  appear  to  me  that  it  is  a matter  of  much  importance, 
whether  the  probe  be  made  of  whalebone,  as  Beer  re- 
commends, or  of  silver;  but  that  it  should  not  be  too 
thick  is  a thing  certainly  deserving  greater  attention. 
Supposing  there  is  no  direct  opening  through  the  skin 
into  the  lachrymal  sac,  one  should  be  made  with  a 
lancet.  However,  a mere  puncture  will  suffice,  as  a 
large  incision,  beginning  just  below  the  tendon  of  the 
orbicularis  palpebrarum  muscle,  and  extending  in  a 
semilunar  form  nearly  an  inch  downwards  and  out- 
wards, as  used  to  be  the  old  practice,  can  here  answer 
no  rational  object,  the  surgeon  merely  having  occasion 
for  a small  direct  opening,  through  which  he  may  con- 
veniently pass  a small  probe  for  the  purpose  of  ascer- 
taining the  state  of  the  nasal  duct.  “The  probe  (as 
Mr.  M'Kenzie  observes)  is  to  be  introduced  horizon- 
tally, till  it  touches  the  nasal  side  of  the  sac  ; it  should 
then  be  raised  into  a vertical  position,  and  its  point  di- 
rected downwards  and  a little  backwards.  Turning 
the  probe  upon  its  axis,  we  pass  it  from  the  sac  into  the 
duct;  and  as  we  continue  to  press  it  gently  downwards, 
(he  instrument,  if  the  sac  is  pervious,  enters  the  nose. 
If  its  point  meets  with  some  obstruction,  we  must  not 
immediately  conclude,  that  there  is  an  obliteration  of 
the  duct.  We  must  press  down  the  probe  a little  more 
strongly,  yet  without  violence,  turning  it  round  between 
the  fingers,  and  giving  it  different  directions.  By  these 
means  the  obstacle  is  frequently  overcome,  and  the 
probe  suddenly  descends.  If  the  obstacle  remains  as 
before,  and  is  extremely  firm,  still  this  is  not  sufficient 
ground  for  us  to  conclude  that  there  is  a real  oblitera- 
tion,” because,  as  the  author  proceeds  to  point  out,  the 
difficulty  may  arise  from  a mere  thickening  of  the  mu- 
cous membrane,  and  swelling  and  induration  of  its 
cryptae. — (McKenzie  on  the  Lachrymal  Organs,  p.  78.) 

When  the  probe  has  entered  a good  way  down  the 
nasal  duct,  and  becomes  as  it  were  wedged.  Beer 
leaves  the  instrument  in  this  position,  until  the  next 
time  of  dressing,  taking  care,  however,  to  fix  it  to  the 
forehead,  so  that  it  may  not  slip  out  again.  At  the 
same  time  he  introduces  into  the  lachrymal  sac  a tent, 
which  he  keeps  in  with  a piece  of  sticking  plaster 
(Lrhre  von  den  Augenkr.  b.  2,  p.  168) ; a measure 
which,  I conceive,  may  be  advantageously  dispensed 
with.  When  at  length  the  probe  can  be  made  to  pass 
with  some  trouble  into  the  nostril.  Beer  recommends 
introducing  the  instrument  regularly  every  day,  until 
the  increased  diameter  of  the  passage  allows  it  to  be 
put  in  and  withdrawn  without  the  slightest  difficulty. 
The  period  is  now  arrived,  when  Beer  conceives  that 
some  measure  should  be  taken  for  rendering  the  per- 
viousness of  the  nasal  duct  complete  and  permanent, 
and  thus  entirely  re-establishing  the  efficiency  of  the 
excreting  parts  of  the  lachrymal  organs.  But,  says  this 
author,  whoever  nterely  aims  at  restoring  the  natural 
diameter  of  the  nasal  duct  by  mechanical  means,  fulfils 
only  one,  and  that  not  the  most  essential,  indication. 
And  in  order  that  the  duct  may  retain  its  natural  dia- 
meter, and  the  tears  and  mucus  descend  freely  into 
the  nose,  it  is  necessary  that  the  morbid  state  of  the 
mucous  membrane  be  first  removed,  and  the  action  of 
the  excreting  parts  of  the  lachrymal  organa  rectified 
.again  ; objects  which  cannot  be  performed  by  any  me- 
chanical means.  Hence,  Beer  pl.aces  considerable 
stress  upon  the  necessity  of  obviating  every  unfavour- 
able state  of  health  likely  to  affect  the  mucous  mem- 
brane of  the  lachrymal  sac.  For  the  purpose  of  re- 
storing the  natural  diameter  of  the  nasal  duct,  the  expe- 
rience of  many  years  has  convinced  him  that  pieces  of 
violin  catgut,  which  are  to  be  gradually  increa.sed  in 
size,  are  the  best.  The  end  of  the  piece  which  is  to 
he  introduced,  is  to  be  first  softened  a little  between  the 
teeth,  straightened,  and  dipped  in  sweet  oil.  Then  at 
least  six  inches  of  it  are  to  be  introduced,  so  that  its 
lower  end  may  be  easily  drawn  out  of  the  nostril ; a 
business  which  Beer  always  lets  the  patient  do  himself. 
The  upper  portion  of  the  catgut  is  coiled  up,  and  kept 
within  a little  linen  compress  on  the  patient’s  foro- 


124 


LACHRYMAL  ORGANS. 


head.  Beer  also  places  in  the  opening  of  the  sac  a 
small  dossil  of  lint,  and  covers  it  with  a bit  of  stick- 
ing plaster.  In  two  hours  the  patient  is  to  try  to  force 
the  lower  end  of  the  catgut  out  of  the  nostril,  by  driv- 
ing the  air  through  the  opening,  while  the  mouth  and 
opposite  nostril  are  shut.  As  soon  as  the  end  of  the 
catgut  is  secured,  it  is  to  be  turned  over  the  side  of 
the  nose,  and  fixed  there  with  a piece  of  sticking  plas- 
ter. The  next  day  tlie  bit  of  plaster  over  the  sac  is  to 
be  loosened  with  warm  water,  and,  together  with  the 
dossil  of  lint,  taken  away,  and  one  of  the  lotions  here- 
after specified  injected  down  the  passage.  The  upper 
end  of  the  catgut  on  the  forehead  is  next  to  be  unfast- 
ened, and  a fresh  portion  of  it  covered  with  some  of 
the  applications  presently  mentioned,  when  the  patient 
is  to  draw  it  into  the  sac  and  duct,  by  gently  pulling 
the  end  which  hangs  out  of  the  nostril.  The  superflu- 
ous lower  piece  of  catgut  is  now  cut  away,  and  the 
new  piece  turned  up,  and  fixed  to  the  side  of  the  nose. 
The  injection  is  again  repeated,  and  the  dressings 
applied  as  before.  The  same  method  is  to  be  continued 
until  the  whole  of  the  first  piece  of  catgut  is  expended. 
Some  water,  coloured  with  the  vinous  tincture  of 
opium,  is  now  to  be  thrown  down  the  sac,  in  order  to 
Bee  whether  any  part  of  the  fluid  will  pass  into  the 
nose,  and  what  progress  has  been  made.  Then  a 
larger  piece  of  catgut  is  employed  exactly  in  the  man- 
ner of  the  first ; and  when  it  is  all  exhausted  the  co- 
loured injection  is  to  be  used  again,iin  order  to  learn 
what  advance  has  been  made  in  the  re-establishment 
of  the  natural  diameter  of  the  passage  Lastly,  a cat- 
gut of  still  larger  size  is  to  be  used,  after  which  the 
coloured  injection  will  be  found,  when  the  patient  in- 
clines his  head  forwards,  to  run  freely  out  of  the  nos- 
tril, and  not  merely  drop  into  it  as  it  did  previously. 
When  this  is  the  state  of  things,  all  farther  dilatation 
becomes  unnecessary. — {Beer,  Lehre  von  den  Augenkr. 
6.  2,  p.  169—172.) 

This  author  then  repeats  his  decided  opinion  that  the 
mechanical  treatment  with  catgut,  bougies,  cannulae, 
&c.,  will  only  answer  when  attention  is  paid  to  recti- 
fying the  morbid  state  of  the  mucous  membrane  of  the 
lachrymal  sac  by  means  of  suitable  applications,  the 
use  of  which  he  thinks  ought  to  commence  with  the 
first  employment  of  the  catgut.  And  he  adds,  that 
even  such  treatment  will  only  succeed  when  the  dis- 
eased state  of  the  membrane  of  the  sac  is  entirely  a 
local  complaint,  and  uncomplicated  with  any  unfa- 
vourable condition  of  the  health.  In  the  beginning,  if 
the  probe  can  be  introduced  without  any  great  trou- 
ble, and  the  lining  of  the  duct  is  only  trivially  thick- 
ened, Beer  moistens  the  catgut  on  its  daily  introduction 
into  the  passage  with  the  vinous  tincture  of  opium, 
and  injects  into  the  sac  a lukewarm  lotion  containing 
the  proportions  of  subacetate  of  copper,  nitrate  of 
potass,  alum,  camphor,  and  vinum  opii,  specified  in 
one  of  the  preceding  columns.  The  lint,  which  Beer 
places  in  the  orifice  of  the  sac,  is  also  dipped  in  the 
vinum  opii.  When  the  probe  meets  with  more  resist- 
ance, the  catgut  is  smeared  with  the  unguentum  hy- 
drargyri  nitrati,  which  is  to  be  at  first  weakened  and 
afterward  gradually  increased  in  strength.  The  wound 
is  also  to  be  dressed  with  the  same  application,  and  some 
of  the  following  lotion  injected  down  the  sac  twice  a day ; 
B;-  Aq.  ros.  | iv.  hydrarg.  oxymur.  gr.  j.  ss.  gr.  j.  mucil. 
pur.  3 j.  vini  opii  3j.  M.  When  any  irregularities  and 
indurated  points  are  felt  with  the  probe  in  the  course 
of  the  nasal  duct.  Beer  smears  the  catgut  with  an  oint- 
ment containing  a small  quantity  of  red  precipitate, 
and  directs  frictions  with  a little  camphorated  mercu- 
rial ointment  to  be  employed  every  day  round  the  ex- 
ternal opening. 

Beer  joins  the  generality  of  writers  in  believing  that 
a long  perseverance  in  the  mechanical  means  is  neces- 
sary, in  order  to  remove  all  disposition  in  the  nasal 
duct  to  close  again. — {P.  176.)  And  as  the  use  of  the 
probes,  syringe,  catgut,  and  dossils  of  lint  may  be 
supposed  to  have  done  more  or  less  injury  to  the  la- 
chrymal ducts,  so  as  to  cause  some  impediment  to  the 
due  conveyance  of  the  tears  into  the  lachrymal  sac, 
Beer  advises  a trial  to  be  made,  whether  a couple  of 
drops  of  some  coloured  fluid,  introduced  into  the  inner 
canthus,  while  the  patient  is  lying  upon  his  back,  will 
pass  into  the  lachrymal  sac;  and  if  they  will  not  do 
so,  the  same  author  thinks  that  an  attempt  should  be 
immediately  made  to  clear  the  lachrymal  ducts  by 
means  of  Anel’s  probe.— (P.  177.) 


According  to  Beer,  the  foregoing  treatment  is  per- 
fectly useless  whenever  the  lachrymal  puncta  and  ducts 
are  obliterated ; because,  even  if  it  were  practicable  to 
restore  their  perviousness,  it  would  yet  be  impossible 
to  communicate  to  tlie  new-formed  apertures  and  ca- 
nals the  power  of  absorbing  the  tears  and  conveying 
them  into  the  lachrymal  sac.  He  thinks  that  in  this 
state  of  things  the  practitioner  need  not  trouble  him- 
self about  the  condition  of  the  nasal  duct ; because, 
even  if  it  were  rendered  duly  pervious,  this  improve- 
ment would  not  continue  long ; as  Beer’s  experience 
has  fully  convinced  him,  that  when  the  mucous  secre- 
tion of  the  lachrymal  sac  is  not  blended  with  the  tears, 
a closure  of  the  nasal  duct  sooner  or  later  ensues,  and 
of  course  an  accumulation  of  the  mucus  of  the  sac,  a 
disease  sometimes  termed,  under  such  circumstances, 
hydrops  sa^culi  lachrymalis.  And  in  order  to  prevent 
this  complaint  in  the  state  of  things  just  now  de- 
scribed, Beer  is  an  advocate  for  the  total  obliteration 
of  the  cavity  of  the  sac  with  escharotics. — {B.  2,p.  181.) 

Such  is  the  practice  of  Beer,  with  the  view  of  clear- 
ing away  obstruction  in  the  nasal  duct  and  restoring 
its  natural  diameter.  Let  us  now  consider  what  me- 
thods have  been  suggested  by  others.  Beginning  then 
with  the  screw,  invented  by  Fabricius  abAquapen- 
dente,  for  compressing  the  distended  lachrymal  sac,  I 
need  only  remark  with  M.  Nicod,  that  as  this  plan  was 
not  directed  against  the  cause  of  the  disease,  it  is  not 
surprising  that  it  should  have  been  unavailing,  and 
ultimately  banished  from  practice.  In  the  year  1716, 
Anel  invented  a probe  of  so  small  a size  that  it  was 
capable  of  passing  from  the  upper  punctum  lachrymale 
into  the  lachrymal  sac  and  nasal  duct,  the  obstructions 
in  which  latter  passage  it  was  intended  to  remove. 
Anel  also  invented  a syringe  whose  pipe  was  small 
enough  to  enter  one  of  the  puncta,  and  by  that  means 
to  furnish  an  opportunity  of  injecting  a liquor  into  the 
sac  and  duct ; and  with  these  two  instmments  he  pre- 
tended to  be  able  to  cure  the  disease  whenever  it  con- 
sisted in  obstruction  merely,  and  the  discharge  was  not 
much  discoloured.  “ The  first  of  these,  viz.  the  pas- 
sage of  a small  probe  through  the  puncta,  (says  Mr. 
Pott),  has  a plausible  appearance,  but  will,  upon  trial, 
be  found  very  unequal  to  the  task  assigned : the  very 
small  size  of  it,  its  necessary  flexibility,  and  the  very 
little  resistance  it  is  capable  of  making,  are  manifest 
deficiencies  in  the  instrument;  the  quick  sensation  in 
the  lining  of  the  sac  and  duct,  and  its  diseased  state, 
are  great  objections  on  the  side  of  the  parts,  supposing 
that  it  was  capable  of  answering  any  valuable  end, 
which  it  most  certainly  is  not.” — {Pott.) 

It  must  be  at  once  obvious,  that  Anel’s  instruments 
were  devised  with  the  view  of  avoiding  a puncture  in 
the  lachrymal  sac;  but  the  principle  has  been  strongly 
objected  to  by  Beer,  there  being  no  comparison  between 
the  inconveniences  of  a small  opening  made  in  the  sac 
and  the  injury  done  to  the  lachrymal  puncta  and  ca- 
nals, by  the  long  and  repeated  introduction  of  instru- 
ments through  them,  whereby  their  functions  are  likely 
to  be  for  ever  ruined,  of  which  Beer  has  known  some 
sad  examples. — {Lehre,  d c.  b.  2,  p.  169.) 

The  next  practice  deserving  notice  is  that  of  La 
forest,  who  used  to  introduce  into  the  termination  of 
the  nasal  duct  in  the  nostril  a probe,  with  which  he 
cleared  away  the  obstruction  in  the  passage.  He  also 
introduced  into  the  same  orifice  a curved  tube,  which 
was  left  in  the  part  three  or  four  months  for  the  pur- 
pose of  employing  injections.  The  method,  how- 
ever, was  found  not  only  troublesome  and  difficult, 
on  account  of  the  anatomical  varieties  to  which  the 
termination  of  the  nasal  canal  wasjjable,  but  also  on 
account  of  the  treatment,  when  practised,  being  subject 
to  frequen^failures. 

Following  up  the  principles  of  Anel,  another  French 
surgeon,  Mljean,  dilated  the  nasal  duct  with  a seton, 
which  was  drawn  up  intothg  lachrymal  sac  by  means 
of  a thread  first  introduced  from  the  upper  punctum 
lachrymale.  But  it  was  soon  discovered  that  what  was 
gained  on  one  side  was  lost  on  the  other;  the'lodge- 
ment  of  the  thread  in  the  lachrymal  duct  for  several 
months,  and  the  irritation  of  its  orifice  in  changing  the 
seton  every  day,  not  only  causing  inflammation  of  the 
punctum  lachrymale,  but  even  such  ulceration  and 
cicatrices,  as  sometimes  destroyed  the  functions  of  the 
part.5. 

J.  L.  Petit,  sensible  of  the  inconveniences  of  M^jean’s 
practice,  and  disgusted  witli  the  barbarous  imitation  of 


lachrymal  organs.  125 


the  ancients  in  cauterizing  ttie  fistula,  sac,  and  os  un- 
guis, conceived  tliat  instead  of  these  plans,  or  that  of 
perforating  the  os  unguis,  as  proposed  by  Woolhouse, 
it  would  be  better  to  endeavour  to  restore  the  natural 
passage  by  removing  the  obstruction  in  the  nasal  duct, 
which  obstruction  Petit  regarded  as  the  cause  of  the 
disease.  His  method  consisted  in  opening  the  lachry- 
mal sac  with  a small  bistoury,  introducing  through  the 
wound,  sac,  and  nasal  duct  a probe,  down  into  the 
nostril,  and  then  using  bougies  for  the  dilatation  of  the 
passage.  This  method  may  be  said  to  be  the  model  of 
that  which  has  been  most  extensively  followed,  even 
down  to  the  present  time.  Pellier  and  Wathen  recom- 
mended the  introduction  of  a metallic  tube  dowri  the 
ductus  nasal  is,  and  leaving  it  for  a time  in  that  situa- 
tion, with  a view  of  preventing  the  duct  from  closing 
again ; and  the  use  of  a cannula  is  even  now  preferred 
by  Dupuytren,  the  greatest  surgeon  of  France. 

The  desire  of  avoiding  any  puncture  of  the  sac  has 
influenced  many  practitioners  besides  Anel,  and  given 
rise  to  various  ingenious  inventions.  Thus,  in  1780, 
Sir  William  Blizard  proposed,  instead  of  injecting 
water,  to  introduce  quicksilver  through  a small  pipe, 
communicating  with  a long  tube  full  of  this  fluid. 
The  specific  gravity  of  the  quicksilver,  when  the  sac 
was  distended  with  it,  he  believed  would  have  more 
power  than  water  propelled  through  a syringe,  to  re- 
move the  lachrymal  obstruction. 

The  late  Mr.  Ware,  after  trying  Sir  William  Blizard’s 
plan,  gave  the  preference  to  Anel’s  syringe,  with  which 
he  generally  injected  warm  water  through  the  lower 
punctum  lachrymale  into  the  lachrymal  sac,  and  put 
a finger  over  the  superior  punctum  to  prevent  the  fluid 
from  escaping  through  it.  With  his  finger  he  also  oc- 
casionally compressed  the  lachrymal  sac,  in  order  to 
assist  in  propelling  the  water  down  into  the  nose.  He 
sometimes  used  the  injection  thrice  a day,  though  in 
general  much  less  frequently.— (See  Ware  ori  the  Epi- 
phora.) 

“ 1 in  general  begin  the  treatment  by  injecting  some 
warm  water,  through  the  inferior  punctum  lachry- 
male, and  I repeat  the  operation  four  or  five  days  in 
succession.  If,  in  this  space  of  time,  none  of  the 
water  pass  through  the  duct  into  the  nose,  and  if  the 
watering  of  the  eye  contitme  as  troublesome  as  it  was 
before  the  injection  was  employed,  I usually  open  the 
angular  vein,  or  direct  a leech  to  be  applied  near  the 
lachrymal  sac  ; adding  here  a caution,  that  the  leech 
be  not  suffered  to  fix  on  either  of  the  eyelids,  lest 
it  produce  an  extravasation  of  blood  in  the  adjacent 
cells.  About  the  same  time  that  blood  is  taken 
away  in  the  neighbourhood  of  the  eye,  I usually  vary 
the  injection,  and  try  the  effects  either  of  a weak  vitri- 
olic or  anodyne  lotion.  In  some  instances,  also,  w'hen 
I have  found  it  impossible,  after  several  attempts,  to 
inject  any  part  of  the  liquid  through  the  duct,  I have 
introduced  a golden  probe,  about  the  size  of  a bristle, 
through  the  superior  [lunctum  lachrymale,  and,  attend- 
ing to  the  direction  of  the  duct,  have  insinuated  its 
extremity  through  the  obstruction,  and  conveyed  it 
fully  into  the  nose  ; immediately  after  which  I have 
found,  that  a liquid,  injected  through  the  inferior  punc- 
tum, has  passed  without  any  difficulty  ; and  by  repeat- 
ing these  operations  for  a few  succe.ssive  days,  I have 
at  length  established  the  freedom  of  the  passage,  and 
completed  the  cure.  In  other  instances,  I have  recom- 
mended a strongly  stimulating  sternutatory  te  be 
snufled  up  the  nose,  about  an  hour  before  the  time  of 
the  patient’s  going  to  rest,  which,  by  exciting  a large 
discharge  from  the  Schneiderian  membrane,  has  some- 
times also  greatly  contributed  to  open  the  obstruction 
in  the  nasal  duct. 

“ Cases  occur  very  rarely  whicli  may  not  be  relieved 
by  some  of  the  means  above  related.” — {Ware's  Addi- 
tional Rernarhs  on  the  Epiphora.) 

When  the  discharge  was  fetid,  Mr.  Ware  sometimes 
found,  that  a vitriolic  lotion,  injected  into  the  sac, 
quickly  corrected  the  quality  of  the  matter. 

In  a subsequent  tract,  Mr.  Ware  observes,  that  if, 
after  “ about  a week  or  ten  days,  there  be  not  some 
perceptible  advance  towards  a cure,  or  if,  from  the  long 
continuance  of  the  obstruction,  there  be  reason  to  fear 
that  it  is  too  firmly  fixed  to  yield  to  this  easy  mode  of 
treatment,  1 do  not  hesitate  to  propose  the  operation 
which  is  now  to  be  described.  The  only  persons  with 
respect  to  whom  1 entertain  any  doubts  as  to  the  propri- 
ety of  this  opinion  are  infants.  In  such  subjects  I 


always  think  it  advisable  to  postpone  the  operation, 
unless  the  symptoms  be  particularly  urgent,  until  they 
are  eight  or  nine  years  old. 

“ If  the  disease  has  not  occasioned  an  aperture  in 
the  lachrymal  sac,  or  if  this  aperture  be  pot  situated 
in  a right  line  with  the  longitudinal  direction  of  the 
nasal  duct,  n puncture  should  be  made  into  the  sac,  at 
a small  distance  from  the  internal  juncture  of  the  pal- 
pebrsE,  and  nearly  in  a line  drawn  horizontally  from 
this  juncture  towards  the  nose,  with  a very  narrow 
spear-pointed  lancet.  The  blunt  end  of  a silver  probe, 
of  a size  rather  smaller  than  the  probes  that  are  com- 
monly used  by  surgeons,  should  then  be  introduced 
through  the  wound,  and  gently,  but  steadily,  be  pushed 
on  in  the  direction  of  tlie  nasal  duct,  with  a force  suf- 
ficient to  overcome  the  obstruction  in  this  canal,  and 
until  there  is  reason  to  believe  that  it  has  freely  entered 
into  the  cavity  of  the  nose.  The  position  of  the  probe, 
when  thus  introduced,  will  be  nearly  perpendicular ; 
its  side  will  touch  the  upper  edge  of  the  orbit ; and  the 
space  between  its  bulbous  end  in  the  nose  and  the 
wound  in  the  skin  will  usually  be  found,  in  a full-grown 
person,  to  be  about  an  inch  and  a quarter,  or  ari  inch 
and  three-eighths.  The  probe  is  tlien  to  be  withdrawn, 
and  a silver  style,  of  a size  nearly  similar  to  that  of  the 
probe,  but  rather  smaller,  about  ari  inch  and  three- 
eighths  in  length,  with  a flat  head  like  that  of  a nail, 
but  placed  obliquely,  that  it  may  sit  close  on  the  skin, 
is  to  be  introduced  through  the  duct,  in  place  of  the 
probe,  and  to  be  left  constantly  in  it.  For  the  first  day 
or  two  after  the  style  has  been  introduced,  it  is  some- 
times advisable  to  wash  the  eye  with  a weak  saturnine 
lotion,  in  order  to  obviate  any  tendency  to  inflamma- 
tion which  may  have  been  excited  by  the  operation ; 
but  this  in  general  is  so  slight,  that  I have  rarely  had 
occasion  to  use  any  application  to  remove  it.  The 
style  should  be  withdrawn  once  every  day  for  about  a 
week,  and  afterward  every  second  or  third  day. 
Some  warm  water  should  each  time  be  injected  through 
the  duct  into  the  nose,  and  the  instrument  be  afterward 
replaced  in  the  same  manner  as  before.  I formerly 
used  to  cover  the  head  of  the  style  with  a piece  of 
dyachylon  plaster  spread  on  black  silk,  but  have  of  late 
obviated  the  necessity  for  applying  any  plaster  by 
blackening  the  head  of  the  style  with  sealing  wax.” 

Mr.  Ware  did  not,  on  first  trying  this  method,  expect 
any  relief  till  the  style  was  left  off.  However,  he 
found,  that  the  watering  of  the  eye  ceased,  as  soon  as 
the  style  was  introduced,  and  the  sight  became  pro- 
portionably  more  useful  and  strong. 

The  wound,  which  Mr.  Ware  makes  in  the  sac, 
when  there  is  no  suitable  ulcerated  aperture,  is  only 
just  large  enough  to  admit  the  end  of  the  probe  or 
style ; and  this  soon  becomes  a fistulous  orifice,  through 
which  the  style  may  be  passed  without  the  least  pain. 
In  short,  in  about  a week  or  ten  days,  the  treatment 
becomes  so  easy,  that  the  patient,  or  any  friend,  is  fully 
competent  to  do  what  is  necessary.  It  merely  consists 
in  withdrawing  the  style  two  or  three  times  a week, 
occasionally  injecting  some  warm  water,  and  then  re- 
placing the  instrument  as  before. 

Some,  finding  no  inconvenience  from  the  style,  and 
being  afraid  to  leave  it  olf,  wear  it  for  years;  many 
others  disuse  it  in  about  a month  or  six  weeks,  and 
continue  quite  well.  The  ulcerations  sometimes  exist- 
ing over  the  lachrymal  sac  commonly  heal  as  soon 
as  the  tears  can  pass  down  into  the  nose ; but  Mr. 
Ware  mentions  two  instances,  in  which  such  sores  did 
not  heal  until  a weak  solution  of  the  hydrargyrus  mu- 
riatus  and  bark  were  administered. — (See  Ware  on  the 
Fistula  Lachrymalis.) 

Great  as  the  recommendation  of  the  foregoing  prac- 
tice is,  as  delivered  by  Mr.  Ware,  Mr.  Travers  is  strongly 
disposed  to  doubt  whether  any  permanent  benefit  was 
ever  derived  from  letting  the  style  remain  in  the  pas- 
sage When  an  abscess  over  the  sac  has  been  opened, 
this  gentleman,  instead  of  the  introduction  of  a style 
into  the  ductus  nasalis,  recommends  simply  the  exam^i- 
nation  of  the  duct  with  a fine  probe.  “ If  the  probe 
passes  without  resistance  into  the  nose,  the  case  requires 
no  farther  oper.ative  treatment,  the  integument  reco- 
vers its  healthy  condition  under  an  emollient  applica- 
tion, the  discharge  gradually  diminishes,  and  the  wound 
lieals.  If,  on  the  other  hand,  upon  examination  with 
the  probe,  introduced  through  the  wound  into  the  sac, 
resistance  is  offered  to  its  passage  into  the  nose,  no 
more  favourable  opportunity  will  be  presented,  for 


126  LACHRYMAL  ORGANS. 


overcoming  such  resistance.  This,  therefore,  should 
be  accoiui)lished,  but  to  this  the  operative  process 
should  be  limited,  and  the  wound  should  be  sulieied  to 
heal  without  farther  disturbance.”  When  there  is 
what  Mr.  Travers  terms  a stricture  in  the  nasal  duct, 
and  the  passage  of  the  probe  is  nrore  firmly  resisted,  he 
admits  that  some  means  must  be  employed  for  keeping 
the  duct  pervious  after  it  has  been  reopened.  He  never 
interferes  with  the  integuments,  except  in  the  case  of 
abscess  discolouring  the  skin,  and  threatening  to  pro- 
duce a fistula ; and  for  the  purpose  of  restoring  the  pas- 
sage, he  uses  a set  of  silver  probes,  of  about  five  inches 
long,  of  various  sizes,  flattened  atone  end,  and  slightly 
bulbous  at  the  point.  When  there  is  no  obstruction, 
these,  he  says,  may  be  introduced  with  perfect  facility 
from  either  of  the  puncta  lachrymalia  into  the  nostril. 
“ If  the  punctum  be  constricted,  it  is  readily  entered 
and  dilated  by  a common  pin ; and  upon  withdrawing 
it,  by  one  of  the  smaller  probes.  The  direction  and 
relative  situation  of  the  lachrymal  ducts,  the  sac,  and 
nasal  canal,  point  out  the  proper  course  of  the  instru- 
ment. It  is  confirmed  by  its  advance,  without  the  em- 
ployment of  force,  and  the  sensation  conveyed  by  the 
free  and  unencumbered  motion  of  its  point.  Until  the 
point  is  fairly  within  the  sac,  it  is  necessary  to  keep  the 
eyelid  gently  stretched  and  slightly  everted  ; the  upper 
lid  being  drawn  a little  upwards  towards  the  brow,  the 
lower,  as  much  downwaids  towards  the  zygoma.  The 
point  carried  home  to  the  sac,  and  touching  lightly  its 
nasal  side,  the  lids  may  be  left  at  liberty,  while  a half- 
circular motion  is  performed  by  the  instrument ; the 
surgeon  neither  suffering  the  point  to  recede,  nor,  on  the 
other  hand,  allowing  it  to  become  entangled  in  the  mem- 
brane. The  probe  now  rests  in  a perpendicular  direc- 
tion upon  the  eyebrow,  towards  its  inner  angle,  and, 
in  this  direction,  it  is  to  be  gently  depressed,  until  it 
strikes  upon  the  floor  of  the  nostril,  where  its  presence 
is  readily  ascertained  by  a common  probe  passed  be- 
neath the  inferior  turbinated  bone.  The  probe  of 
smallest  dimensions  is  of  sufficient  firmness  to  pre- 
serve its  figure  in  its  passage  through  the  healthy  duct, 
but  it  is  too  flexible  to  oppose  any  considerable  obstruc- 
tion. For  the  stricture  of  the  lachrymal  ducts,  it  is  of 
sufficient  strength.  Very  many  cases  of  recent  origin, 
and  in  which  the  stricture  has  no  great  degree  of  firm- 
ness (Mr.  Travers  says),  are  completely  cured  by  three 
or  four  introductions  of  the  probe  into  the  nostril,  at 
intervals  of  one  or  two  days.  I have  seldom  met  with 
a stricture  so  firm  as  not  to  yield  to  the  full-sized 
probe.”  When  the  resistance  is  not  altogether  re- 
moved, after  this  plan  has  been  tried  some  days,  Mr. 
Travers  introduces  a style,  having  a small  flat  head,  a 
little  sloped,  through  the  punctum  lachrymale  into  the 
nose,  and  leaves  it  in  the  nasal  duct  for  twenty-four 
hours.  If  worn  longer,  he  says  that  it  causes  ulcera- 
tion of  the  orifice.  A day  or  two  is  to  elapse  before  the 
style  is  again  introduced,  which  must  now  be  passed 
through  the  other  lachrymal  duct.  On  the  intervening 
days,  tepid  water  should  be  injected  with  Anel’s  syringe. 
— {Synopsis  of  the  Diseases  of  the  £ye,p.369,370.  372. 
374.) 

Thus  we  see,  that  Mr.  Travers’s  practice  bears  a 
considerable  resemblance  to  that  of  Anel,  inasmuch  as 
the  sac  is  never  opened,  except  when  likely  to  ulcerate, 
and  nearly  every  thing  is  done  with  probes  and  injec- 
tions, introduced  through  the  lachrymal  puncta  and 
ducts.  I wish  that  my  views  of  the  nature  of  these 
diseases,  and  of  the  parts  concerned,  would  allow  me 
to  think  the  latter  proceedings,  in  the  case  of  stricture 
of  the  nasal  duct,  as  commendable  as  another  part  of 
Mr.  Travers’s  practice,  where,  in  cases  of  slighter  ob- 
struction, he  contents  himself  witli  opening  the  sac, 
clearing  away  the  stoppage  of  the  nasal  duct  with  a 
probe,  and  healing  up  the  wound,  without  leaving  any 
style,  cannula,  or  seton,  in  the  passage.  When  the 
obstruction  is  very  slight,  such  practice  must  be  judi- 
cious. But  if,  in  other  cases,  it  be  deemed  right,  for  the 
prevention  of  a relapse,  that  the  nasal  duct  should  be 
either  filled  with  some  dilating  instrument  a certain 
time,  or  repeatedly  probed,  I am  decidedly  of  opinion, 
with  Professor  Beer,  M.  Nicod,  &c.,  that  the  object  of 
not  making  a small  opening  in  the  sac  is  attended  with 
no  advantage  at  all  likely  to  counterbalance  the  mis- 
chief which  must  be  done  to  the  lachrymal  puncta  and 
ducts,  not  only  by  the  repeated  introduction  of  probes 
and  of  ^vringes,  but  by  the  lodgement  of  the  former  in 
them  forVlte  space  of  twenty-four  hours  together.  If 


there  be  an  opening  in  the  sac,  its  convenience  in  per- 
mitting the  easy  use  of  a probe  is  generally  acknow- 
ledged ; and  in  order  to  gain  this  advantage,  and  avoid 
the  evils  which  are  inseparable  from  taking  too  much 
liberty  with  the  lachrymal  puncta  and  ducts,  surely  a 
slight  puncture  in  the  sac,  if  there  be  no  opening  already, 
must  be  the  most  rational,  simple,  and  successful  prac- 
tice. 

When  the  perviousness  of  the  nasal  duct  cannot  be 
restored  by  any  use  of  the  probe,  and  the  obstructed 
part  has  a very  elastic  feel,  is  of  inconsiderable  extent, 
and  near  the  termination  of  the  duct  in  the  nostril. 
Beer  recommends  a perforation  to  be  made  with  a 
trocar-shaped  probe,  the  pointof  which  is  to  be  covered 
with  a bit  of  wax,  in  order  that  it  may  not  hurt  the 
parts  in  its  passage  downwards.  Some  discharge  of 
blood  from  the  nose  indicates  that  the  perforation  is 
made.  The  sharp-pointed  probe  is  then  to  be  with- 
drawn, a blunt  one  used  for  the  purpose  of  dilating  the 
passage,  and,  at  length,  the  catgut, as  already  explained. 
— {Beer,  b.  2,  p.  181.) 

Supposing  the  nasal  duct  to  be  obliterated,  for  a con- 
siderable part  of  its  extent,  by  a firmer  substance, 
what  practice  should  then  be  followed  1 Ought  the 
formation  of  an  artificial  passage  to  be  attempted! 
On  this  point  modern  practitioners  differ,  but  as  the 
expedients  adopted  for  this  purpose  caimot  be  judged 
of  previously  to  their  description,  it  will  be  better  in 
the  first  place  briefly  to  notice  them.  As  Mr.  Pott  has 
remarked,  the  upper  and  hinder  part  of  the  lachrymal 
sac  is  firmly  attached  to  the  os  unguis,  a small  and 
very  thin  bone  just  within  the  orbit,  which  bone  is  so 
situated,  that  if  it  be  by  any  means  broken  through, 
the  two  cavities  of  the  nose  and  orbit  communicate 
with  each  other ; consequently  the  os  unguis  forms  the 
partition  between  the  hinder  part  of  the  lachrymal  sac 
and  the  upper  part  of  the  cavity  of  the  nose;  and  it 
is  by  making  a breach  in  this  partition,  that  the  form- 
ation of  an  artificial  passage  has  been  attempted.  In 
Mr.  Pott’s  time  the  cautery  had  long  been  disused  for 
making  an  aperture  in  the  os  unguis,  and  various  in- 
struments were  recommended  for  this  object,  such  as 
a large  strong  probe,  a kind  of  gimblet,  a curved  trocar, 
&c.,  each  of  which,  says  this  practical  writer,  if  dex- 
terously and  properly  applied,  will  do  the  business  very 
well : the  only  necessary  caution  is,  so  to  apply  what- 
ever instrument  is  used,  that  it  may  pierce  through 
that  part  of  the  bone  which  lies  immediately  behind 
the  sacculus  lachrymalis,  and  not  to  push  it  too  far  up 
into  the  nose,  for  fear  of  injuring  the  os  spongiosum 
behind,  while  it  breaks  its  way.  Mr.  Pott  adds,  that 
he  himself  has  always  used  a curved  trocar,  the  point 
of  which  should  be  turned  obliquely  downwards  from 
the  angle  of  the  eye  towards  the  inside  of  the  nose. 
The  accomplishment  of  the  breach  will  be  known  by 
the  discharge  of  blood  from  the  nostril,  and  of  air  from 
the  wound,  upon  blowing  the  nose.  Care  must  be 
taken  to  apply  the  instrument  to  the  part  of  the 
bone  anterior  to  the  perpendicular  ridge  which  di- 
vides it. 

As  soon  as  the  perforation  is  made,  a tent  of  list 
should  be  introduced,  of  such  size  as  to  fill  the  aperture, 
and  so  long  as  to  pass  through  it  into  the  cavity  of  the 
nose : this  should  be  permitted  to  remain  in  two,  three, 
or  four  days,  and  afterward  a fresh  one  should  be 
passed  every  day,  until  the  clean  granulating  appear- 
ance of  the  sore  makes  it  probable  that  the  edgeg  of 
the  divided  membrane  are  in  the  same  state.  The 
business  now  is  to  prevent  the  incarnation  from  closing 
the  orifice ; for  which  purpose,  the  end  of  the  lent  may 
be  moistened  with  diluted  vitriolic  acid ; or  a piece  of 
lunar  caustic,  so  included  in  a quill  as  to  leave  little 
more  than  the  extre'mity  naked,  may  at  each  dressing, 
or  every  other,  or  every  third  day,  be  introduced;  by 
which  the  granulations  will  be  repressed,  and  tlte 
opening  maintained  ; and  when  this  has  been  done  for 
some  little  time,  a piece  of  bougie  of  proper  size,  or  a 
leaden  cannula,  maybe  introduced  instead  of  the  tent; 
and  leaving  off  all  other  dressings,  the  sore  may  be 
suffered  to  contract  as  much  as  the  bougie  will  permit ; 
which  should  be  of  such  length,  that  one  extremity  of 
it  may  lie  level  with  the  skin  in  the  corner  of  the  eye, 
and  the  other  be  within  the  nose. 

The  longer  time  the  patient  can  be  prevailed  upon  to 
wear  the  bougie,  the  more  likely  will  be  the  continu- 
ance of  the  opening;  and  when  it  is  withdrawn,  the 
, e.xicriial  'orifice  should  be  covered  only  by  a superficial 


LACHRYMAL  ORGANS, 


127 


pledget  or  plaster,  and  suffered  to  heal  under  moderate 
pressure. — (Pott.) 

After  the  perforating  instrument  Avas  withdrawn, 
Mr.  Ware  recommended  a nail-headed  style,  about  an 
inch  long,  to  be  introduced  through  the  aperture,  in  the 
same  way  in  which  it  is  introduced  through  the  nasal 
duct,  in  cases  in  which  the  obstruction  is  not  so  great 
as  to  prevent  its  passing  in  this  direction  ; and  it  may 
remain  here  with  as  much  safety  as  in  this  last-men- 
tioned instance,  for  as  long  a time  as  its  continuance 
may  be  thought  necessary  to  establish  the  freedom  of 
the  communication. 

Unfortunately  for  the  scheme  of  making  an  artificial 
passage,  nature  was  generally  so  busy,  that  she  com- 
pletely frustrated  the  aim  of  the  surgeon  by  gradually 
filling  up  the  new  aperture  again.  Hence  some  prac- 
titioners were  not  content  with  drilling  a hole  through 
the  os  unguis,  but  actually  removed  a portion  of  this 
bone ; either  with  the  forceps  proposed  by  Lainorier  in 
17ii9  (see  JiUm.  de  VAcad.  dts  Sciences),  or  with  cutting 
instruments,  among  which  the  most  celebrated  is  the 
sharp-edged  kind  of  cannula  devised  by  Hunter. 
While  this  was  being  applied,  however,  it  was  neces- 
sary to  support  the  os  unguis  with  something  passed 
up  the  nose,  and  a piece  of  horn  was  found  to  answer 
very  well.  Instead  of  these  methods  Scarpa  prefers 
destroying  a portion  of  the  os  unguis  with  the  actual 
cautery  passed  through  a cannula;  a practice  long  age 
banished  from  good  surgery,  and  most  justly  condemned 
by  Richter. 

I do  not  feel  it  necessary  to  enter  very  particularly 
into  the  details  of  these  methods  of  forming  an  arti- 
ficial passage  between  the  lachrymal  sac  and  nostril. 

I have  never  seen  a case  in  which  I should  have 
deemed  such  practice  advisable ; and  that  the  necessity 
for  it  must  be  rare  may  be  inferred  from  what  Mr. 
Travers  has  observed,  viz.  that  he  does  not  believe  the 
perforation  of  the  os  unguis  ever  really  required.— 
(Synopsis,  v^c.  p.  379.)  Beer’s  remarks  are  also  de- 
cidedly against  the  practice;  for  he  states,  that  in  order 
that  the  new  opening  may  not  be  closed  with  lymph, 
it  must  be  made  too  high  up  to  serve  the  purpose  of  a 
drain,  through  which  the  mucus  can  descend  by  its 
own  gravity.  He  has  not  met  with  a single  case, 
either  in  his  owui  practice, or  among  the  patients  whom 
he  has  had  opportunities  of  seeing  under  otlier  prac- 
titioners, where  the  perforation  of  the  os  unguis  had  a 
successful  result.  On  the  contrary,  in  one  healthy  lad, 
the  operation,  which  had  been  done  by  an  experienced 
surgeon,  was  followed  by  the  destruction  of  the  nasal 
process  of  the  upper  maxillary  bone,  one  of  the  ossa 
nasi,  and  all  the  bones  contributing  to  the  formation  of 
the  passage  from  the  orbit  into  the  nose. — (See  Lehre 
von  den  Augenkr.  b.  2,  p.  Id2.)  Hence,  Beer  thinks 
that  the  patient  had  better  either  submit  to  the  incon- 
venience of  being  obliged  to  empty  the  distended  sac 
by  pressure  several  times  a day,  or  let  the  cavity  of  the 
sac  be  obliterated  by  means  calculated  to  excite  the 
adhesive  inflammation  in  it.  But  if  the  lachrymal 
puncla  and  ducts,  as  w’ell  as  the  nasal  duct,  are  obli- 
teratea,  Beer  conceives  that  there  is  no  alternative ; 
because  if  the  cavity  of  the  sac  be  left,  the  case  which 
he  terms  hydrops  sacculi  lachrymalis  will  ensue  when- 
ever the  fistula  is  closed. 

Of  Hernia  and  Hydrops  of  the  Lachrymal  Sac. — 
The  diseases  described  by  Beer  under  these  appella- 
tions are  not  discriminated  in  this  country,  although 
they  are  characterized  by  widely  different  symptoms, 
and  require  opposite  methods  of  treatment.  In  the 
case  of  hernia  or  simple  relaxation,  the  lachrymal  sac 
forms  a tumour  which  never  surpas.ses  the  size  of  a 
cormnon  horse-bean,  the  integuments  are  of  their  na- 
tural colour,  the  tumour  is  soft  and  yielding  to  pres- 
sure, by  which  the  contents  of  the  sac  are  readily 
discharged  through  the  puncta  or  nasal  duct.  Hydrops 
grow.-ito  the  size  of  a pigeon’s  egg,  is  purplish  from  the 
beginning,  very  hard,  and  incapable  of  being  emptied 
by  the  strongest  pre.'^sure.  Heinia  ki  cured  by  com- 
pression, and  the  application  of  astringents  to  the 
lelaxed  parts;  liydrops  requires  the  incision  of  the  sac. 
In  hernia  the  nasal  duct  is  natural,  in  hydrops,  it  and 
"^”>etimes  the  puncla  are  obstructed. 

Slillicidinm  Lachrymarum. — According  to  Beer,  the 
valuable  treatise  of  Schmidt  is  the  only  work  in  which 
^ P''*>ctical  distinction  is  drawn  between 

Blilliciduitn  lachrymarum  and  epiphora;  the  immediate 
caune  of  the  fiisi  complaint  being  some  impediment  to 


the  passage  of  the  tears  from  the  lacus  lachrymarum 
into  the  lachrymal  sac,  while  the  other  affection  con- 
sists in  a redundant  and  extraordinary  secretion  of  the 
tears.  The  curable  form  of  slillicidium,  here  to  be 
noticed,  arises  from  relaxation  of  the  lachrymal  puncta 
and  canals,  in  consequence  of  previous  inflammation 
of  the  parts.  The  puncta  are  widely  open;  but,  in 
other  respects,  have  quite  a natural  appearance.  When 
touched  with  Anel’s  probe  they  do  not  contract,  as  in 
the  healthy  state.  The  tears,  which  from  time  to  time 
fall  over  the  cheek,  are  not  in  considerable  quantity, 
only  trickling  from  the  inner  canthus  by  drops  at  in- 
tervals; and  the  nostril  on  the  affected  side  is  found  to 
be  rather  drier  than  natural. 

Erysipelatous  inflammation  of  the  eyelids  and  parts 
over  the  lachrymal  sac,  and  the  purulent  kinds  of  oph- 
thahny,  frequently  cause  this  sort  of  slillicidium.  The 
latter  cases,  indeed,  the  more  readily  produce  the  dis- 
order, itiasmuch  as  the  semilunar  fold  of  the  conjunc- 
tiva is  relaxed  and  swelled,  so  as  to  push  the  puncta 
out  of  their  right  position  for  the  due  performance  of 
the  absorption  of  the  tears,  and  obstruct  this  function 
more  than  would  be  the  case  if  the  diminished  action 
of  those  oiifices  and  the  lachrymal  ducts  were  the  only 
thing  concerned. 

Beer  delivers  an  exceedingly  favourable  prognosis, 
observing,  that  the  complaint  often  disappears  of  itself 
on  the  approach  of  warm  dry  weather,  and  may  al- 
most always  be  readily  cured  by  means  of  astringents. 
Among  other  remedies  specified  by  this  author,  I need 
only  mention  a solution  of  the  sulphate  of  iron,  to 
which  a small  quantity  of  camphorated  spirit  or  tinc- 
ture of  opium  has  been  added.  It  is  to  be  dropped  out 
of  a pen  into  the  inner  angle  frequently  in  the  course 
of  the  day,  the  patient  lying  upon  his  back  for  some 
time  after  each  application,  so  as  to  let  the  medicine 
have  more  effect  upon  the  parts. — (See  Lehre  von  den 
Augenkr.  b.  2,  p.  41—43.) 

Mr.  Travers  mentions  a constricted  state  of  the  la- 
chrymal juincla  and  canals,  which  is  curable  by  the 
introduction  of  a small  probe. — (Synopsis,  <S-c.  p.  366.) 
All  modern  writers  agree  that  the  obliterated  puncta 
and  canals  can  never  be  restored. — See  Mimoires  de 
V Academic  de  Chirurgie,  t.  5,  ed.  I2wie.  in  which  are 
several  essays  on  fistula  lachrymalis : viz.  one  by  M. 
Bordennve,  entitled,  '•'•Exanien  des  Reflexions  Critiques 
de  M.  MuUnelli,  inseries  dans  les  Mimoires  de  V In- 
stitut  de  Bologne,  centre  le  Mimoire  de  M.  Petit,  sur 
la  Fistula  Lachrymale,  insiri  parmi  ceux  de  I’Acad. 
Royale  des  Sciences  de  Paris,  annie  1734.”  Another 
essay,  by  M.  de  la  Forest,  styled  “ Muuvelle  Mithode 
de  trailer  les  Maladies  du  Sac  Lachrymal,  nommies 
communiment  Pistules  Lachry males.'’’  A third  by  M. 
Louis,  called  “ Riflexions  sur  V Operation  de  la  Pistule 
Lachrymale."  G.  E.  Stahl,  Programma  de  Fistula 
Lachrymali,  Halce,  1702.  J.  C.  Scholunger,  De  Fistula 
Lachrymali,  Basil,  1730.  J.  D.  Metzger,  Curationum 
Chir.  quee  ad  F'istulam  Lachrymalem  sive  usque  fuire 
adhibitce,  Historia  Critica,8vo.  Monasterii,  1172.  P. 
A.  Lepy,  Queestio,  <^c.  An  Fistula  Lachrymali  Cau- 
terium  actuule  ? Paris,  1738.  J.  L.  Petit,  Traiti  des 
Mai.  Chir.  1. 1,  p.  289,  Src.  8vo.  Paris,  1774.  M.  A. 
Magnabal,  De  Morbis  Viarum  Lachrymalium,  ac 
prcBcipue  de  Fistula  Lachrymali,  Montp.  1765.  A. 
Bertrandi,  Traiti  des  Operations,  p.  297,  8vo.  Paris, 
1784.  Anel  has  described  his  plan  of  treatment  in 
various  works : “ Observation  singuliire  sur  la  Fistule 
JMchrymale,  dans  laquelle  Von  apprenda  la  Mithode 
de  la  guirirradicalement."  Turin,  ni2,inito.  JVou- 
velle  Mithode  de  guerir  les  Fistules  Lachrymales." 
Turin,  1713,  in  4to.  “ Suite  de  la  Jfouvelle  Methods,” 
(S-c.  ibid.  1714,  in  Ato.  “ Dissertation  sur  la  Mozivelle 
Dicouverte  de  V Hydropisie  du  Conduit  Lacrymal." 
Paris,  1716,  in  12mo.  And,  lastly,  Anel  has  published, 
in  the  Mim  de  VAcad.  des  Sciences,  annee  1713,  “ Pri- 
cis  de  sa  Mouvelle  Maniire  de  guirir  les  Fistules  La- 
cryrnales."  Mejean,  in  Mem.  de  VAcad.  de  Chir.  t.  2, 
p.  193,  Ato.  Palucci,  Methodus  curanda  Fistula  La- 
chrymalis, Vindob.  1762;  a tube  preferred.  Sabatier, 
Midecine  Opiratoire,  t.  2,  ed.  2.  Richter’s  Anfangs- 
(rriinde  der  IVundarineykunst,  b.  2,  kap  11.  Pott’s 
Observations  relative  to  the  Disorder  of  the  Corner  of 
the  Eye,  commonly  called  the  Fistula  Lachrymalis,  8t>o. 
Land.  1758.  Sir  IV.  Blizard,  A Mew  Method  of 
treating  the  Fistula  Laehryrnalis,  Ato.  Land.  1780. 
IVare  on  the  Epiphora  and  Fistula  Lachrymalis,  8vo. 
Load.  1792  95.  Scarpa  sulle  principali  Malattie  degli 


128 


LEN 


LEU 


OeeAi,  capo  1.  Wathen's  J^Tew  and  Easy  Method  of 
applying  a Tube  for  the  Fistula  Lachrymalis,  Land. 
1781,  and  2d  ed.  1792.  Sprengel,  Oeschichte  der  Wich- 
tigsten  Chir.  Op er ationen,  p.  105.  Micod,  Memoire  sur 
la  Fistule  Lachryinale  in  Revue  Mid.  Historique,  <^c. 
livr.  1 et  2,  8vo.  Paris,  1820.  Fournier,  IDiss.  de 
I'Appareil  des  voies  Lachrymales,  Montpellier,  1803. 
J.  It.  Jingely,  Commentatio  Medica  de  Oculo  Organis- 
quue  JLachrymalibus  rations  cEtatis,  Sexus,  Gentis,  et 
Variorum  Animalium,  8vo.  Erlangce,  1803.  Reil, 
Diss.  de  Chir.  Fistulce  Lachrymalis  Curatione,  Berol. 
1812.  Flajani,  Collezione  d'  Osservaiioni,  t.  3.  Desault, 
(Euvres  Chir.  t.  2,  p.  119,  8vo.  Paris,  1801.  J.  C. 
Rosenmiiller,  Partium  Externarum  Oculi  Humani, 
imprimis  Organorum  Lachrymalium,  DescriptioAna- 
tomica;  iconibus  illustrata,  \to.  Dips.  1810.  C.  H.  T. 
Schreger,  Versuch  einer  Vergleichenden  Anatomie  des 
Auges  und  der  Thrdnenorgane  des  Menschen  und  der 
ubrigen  Thierklassen,  8j)o.  Eeipz.  1810.  Beer,  Lehre 
von  den  Augenkrankheiten,  b.  2,  8vo.  Wien,  1813 — 
1817.  Wm.  Mackenzie,  An  Essay  on  the  Diseases  of 
the  Excreting  Parts  of  the  Lachrymal  Organs,  8vo. 
Land.  1819 ; contains  many  valuable  observations 
from  the  writings  of  Beer.  B.  Travers,  A Synopsis 
of  the  Diseases  of  the  Eye,  p.  228 — 359,  ^c.  8vo.  Loud. 
1820.  PA.  V.  Walther  ueber  die  steinigen  Concretionen 
der  Thrdnenfiussigkeit,  in  Journ.  fur  Chirurgie  von 
C.  Oraefe,  b.  1,  p.  163,  8vo.  Berlin,  1820.  J.  A. 
Schmidt  iiber  die  Krankheiten  des  Thrdnenorgans  ; a 
work  of  the  highest  reputation. 

LAGOPHTHALMIA,  or  LAGOPHTHALMOS. 
(From  Xayos,  a hare;  and  difiOaXpdi,  an  eye.)  The 
Hare's  Eye.  O cuius  Leporinus.  A disease,  in  which 
the  eye  cannot  be  completely  shut.  The  following 
complaints  may  arise  from  it : a constant  weeping  of 
the  organ,  in  consequence  of  the  interruption  of  the 
alternate  closure  and  opening  of  the  eyelids,  which 
motions  so  materially  contribute  to  the  propulsion  of 
the  tears  into  the  nose ; blindness  in  a strong  light,  in 
consequence  of  the  inability  to  moderate  the  rays, 
which  enter  the  eye ; on  the  same  account,  the  sight 
becomes  gradually  very  much  weakened ; incapacity 
to  sleep  where  there  is  any  light;  irritation,  pain,  and 
redness  of  the  eye,  from  its  being  exposed  to  the  extra- 
neous substances  in  the  atmosphere. 

An  enlargement  or  protrusion  of  the  whole  eye,  or 
a staphyloma,  may  obviously  produce  lagophthalmos. 
But  affections  of  the  upper  eyelids  are  Ihe  common 
causes.  Heister  saw  the  complaint  produced  by  a 
disease  of  the  lower  one.  Now  and  then  lagophthal- 
mos depends  on  paralysis  of  the  orbicularis  muscle. 
A cicatrix,  after  a wound,  ulcer,  or  burn,  is  the  most 
frequent  cause. 

^ When  lagophthalmos  arises  from  a paral)nic  affec- 
tion of  the  orbicularis  palpebrarum,  the  eyelids  may 
be  rubbed  with  a liniment  containing  the  tinctura  lytta?, 
or  the  linimentum  camphorae.  Electricity  and  cold 
bathing  are  also  considered  the  principal  means  of 
cure  {Chandler),  together  with  the  exhibition  of  bark, 
the  use  of  the  shower-bath,  &c. 

When  the  affection  arises  from  spasm  of  the  levator 
palpebrae  superioris,  the  surgeon  may  try  electricity,  a 
small  blister  on  the  neighbouring  temple,  and  rubbing 
the  eyelid  and  eyebrow  with  the  tinctura  opii,  and  pre- 
scribe antispasmodic  medicines. 

When  lagophthalmos  arises  from  the  contraction  of  a 
cicatrix,  its  relief  is  to  be  attempted  precisely  on  the 
same  principles  as  are  applicable  to  ectropium. — (See 
Ectropium.)  However,  w’hen  the  eyelid  is  shortened 
as  well  as  everted,  nothing  will  remove  the  deformity. 

The  inconveniences  depending  on  the  eye  being  un- 
able to  shelter  itself  from  the  light,  are  to  be  obviated 
by  means  of  a green  shade. 

Whoever  is  acquainted  with  German,  and  is  desi- 
rous of  more  minute  information  on  this  subject,  may 
find  an  excellent  account  of  lagophthalmos  in  Richter’s 
Anfangsgr.  der  Wundarzn.  b.2\  vondem  Hasenauge. 
See  also  Beer's  Lehre  von  den  Augenkr.  b.  2,  p.  239, 
Src.  8vo.  Wien,  1817. 

LARYNGOTOMY.  (From  XdjDuy?,  the  larj’nx ; and 
Ttyvo),  to  cut.)  The  operation  of  making  an  opening 
into  the  larynx.— (See  Bronchotomy.) 

LATERAL  OPERATION.  One  mode  of  cutting 
for  the  stone.— (See  Lithotomy.) 

LENTICULAR.  (From  lenticulaire,  doubly  con- 
vex.) An  instrument  contained  in  every  trephining 
case,  and  employed  for  removing  the  irregularities  of 


bone  from  the  edge  of  the  perforation  made  in  the  era 
nium  with  the  trephine.  One  side  of  its  blade  is  con- 
vex, the  other  concave ; and  one  of  its  edges  is  sharp. 
On  the  end  of  the  blade  is  fixed  a little  shallow  cup, 
with  its  concavity  tow.ards  the  handle  of  the  instru- 
ment. This  part  serves  the  purposes  of  receiving  the 
little  pieces  of  bone,  when  detached,  keeping  the  end 
of  the  blade  from  hurting  the  dura  mater,  and,  when 
applied  under  the  margin  of  the  opening,  enables  the 
operator  to  guide  the  edge  of  the  instrument  all  round 
it  with  steadiness  and  security. 

LEUCOMA.  (From  XevKoj,  white.)  Leucoma  and 
albugo  are  often  used  synonymously,  to  denote  a white 
opacity  of  the  cornea.  Both  of  them,  as  Scarpa  re- 
marks, are  essentially  different  from  the  nebula  of  the 
cornea;  for  they  are  not  the  consequence  of  chro 
nic  ophthalmy,  with  varicose  veins,  and  an  efiU 
Sion  of  a milky  serum  into  the  texture  of  the.  deli- 
cate continuation  of  the  conjunctiva  over  the  cornea, 
but  are  the  result  of  violent  acute  ophthalmy.  In  this 
state,  a dense  coagulating  lymph  is  extravasated  from 
the  arteries ; sometimes  superficially,  at  other  times 
deeply  into  the  substance  of  the  cornea.  On  otlier  oc- 
casions, the  disease  consists  of  a firm  callous  cicatrix 
on  this  membrane,  the  eft’ect  of  an  ulcer  or  wound, 
with  loss  of  substance.  The  term  albugo  strictly  be- 
longs to  the  first  form  of  the  disease ; leucoma  to  the 
last,  more  particularly  when  the  opacity  occupies  the 
whole  or  the  chief  part  of  the  cornea. 

The  recent  albugo,  remaining  after  the  cure  of  se- 
vere acute  ophthalmy,  is  of  a clear  milky  colour ; but, 
when  of  ancient  date,  it  becomes  pearl-coloured. 

The  recent  albugo  (provided  the  organization  of  the 
cornea  be  not  destroyed)  may  generally  be  dispersed 
by  the  means  employed  for  the  relief  of  the  first  and 
second  stages  of  acute  ophthalmy  ; viz.  general  and 
topical  blood-letting,  with  internal  antiphlogistic  medi- 
cines and  topical  emollients  for  the  first ; slightly  irri- 
tating and  corroborant  applications  for  the  second.  As 
soon  as  the  infiammation  has  subsided,  the  latter 
should  be  employed ; for,  by  exciting  the  absorbents  to 
remove  the  coagulating  lymph,  deposited  in  the  cornea, 
they  restore  the  transparency  of  this  membrane. 

But,  though  this  may  often  be  accomplished  in  the 
recent  state  of  albugo,  it  is  more  difficult  when  the 
long  duration  of  the  disease  has  paralyzed  the  absorb- 
ents of  the  affected  part ; or  when  the  deposition  of  a 
dense  tenacious  substance  into  the  cornea  has  sub- 
verted its  organization. — (Scarpa.) 

The  recent  condition  of  the  disease,  without  disor- 
ganization of  the  structure  of  the  cornea ; its  occur- 
rence in  young  subjects  whose  absorbents  are  readily 
excited  by  external  stimulants,  are  circumstances  fa- 
vourable to  the  cure.  In  children,  the  albugo  arising 
from  severe  ophthalmy  after  the  small  pox,  and  insu- 
lated in  the  centre  of  the  cornea,  very  often  disappears 
of  itself  in  the  course  of  a few  months.  Heister, 
Langguth,  and  Richter  make  the  same  observation. 
The  event  can  only  be  imputed  to  the  vigorous  action 
of  the  lymphatics  in  children,  and  to  the  organization 
of  the  cornea  not  being  destroyed.  For  promoting  this 
absorption,  Scarpa  recommends  the  following  colly- 
rium;  R.  Ammon,  muriatae,  3ij.  Cupri  acetati,  gr.  iv. 
Aquas  calcis,  % viij.  Misce.  The  fluid  is  to  be  filtered 
after  standing  twenty-four  hours.  He  praises  also 
this  ointment : R.  Tutiae  praepar.  3j.  Aloes,  s.  p.  gr. 
ij.  Hydrargj'ri  submur.  gr.  ij.  Adipissuillae,  1 ss.  Misce ; 
and  the  unguentum  ophthalniicum  of  Janin.  He  men- 
tions the  gall  of  the  ox,  sheep,  pike,  and  barbel,  ap- 
plied to  the  cornea  two  or  three  times  a day,  with  a 
small  hair-pencil,  if  too  much  irritation  should  not  be 
produced.  In  some  subjects,  when  the  eyes  are  very 
irritable,  and  cannot  bear  the  latter  applications,  Scarpa 
hats  found  the  oil  of  walnuts  a useful  application.  But  it 
is  generally  necessary  to  persevere,  at  least  three  or  four 
months,  before  the  case  can  be  reckoned  incurable. 

All  the  expedients  proposed  for  the  inveterate  albugo 
or  leucoma  from  a cicatrix,  consisting  of  scraping  or 
perforating  the  layers  of  the  cornea,  and  exciting  ul- 
ceration there,  are  unavailing.  For,  though  the  en- 
largement of  the  cornea  should  be  lessened  by  such 
means,  its  diaphanous  state  could  not  be  restored ; or 
should  the  patient  perceive  a ray  or  two  of  light  im- 
mediately after  the  operation,  the  benefit  would  only 
be  transient ; for  as  soon  as  the  wound  had  healed, 
the  opacity  would  recur.  The  formation  of  an  arti- 
ficial ulcer  might  prove  useful,  if  leucoma  depended  on 


LIGATURE 


129 


s mere  extravasation  of  lymph ; but  the  fact  is,  the 
disease  arises  from  the  deposition  of  an  opaque  sub- 
stance, and  tlie  disorganization  of  the  texture  of  the 
cornea,  conjointly  ; in  this  lies  the  difference  between 
albugo  and  leucoma. 

See  Scarpa  suite  Malattie  degli  Occhi,  9vo.  Venezia^ 
1802.  Richter^  ^vfangsgriinae  dcr  Wundarzn.  b.  3. 
Essays  on  the  Morbid  Anatomy  of  the  Eye,  by  J. 
JVardrop,  Edin.  1808,  chap.  11. 

LIGATURE.  In  the  article  Hemorrhage,  it  has 
been  explained,  that  the  immediate  effect  of  a tight 
ligature  on  an  artery,  is  to  cut  through  its  middle  and 
internal  coats,  a circumstance  that  tends  very  much  to 
promote  the  adhesion  of  the  opposite  sides  of  the  ves- 
sel to  each  other.  Hence  I think  with  Dr.  Jones,  in 
opposition  to  Scarpa,  that  the  form  and  mode  of  ap- 
plying a ligature  to  an  artery  should  be  such  as  are 
most  certain  of  dividing  the  above  coats  of  the  vessel 
in  a regular  manner.  A broad  flat  ligature  does  not 
seem  likely  to  answer  this  purpose  well,  because  it  is 
scarcely  possible  to  tie  it  smoothly  round  the  artery, 
which  is  apt  to  be  thrown  into  folds,  or  to  be  puckered 
by  it,  and  consequently  to  have  an  irregular  bruised 
wound  made  in  its  middle  and  internal  coats. — {Jones.) 
A ligature  of  an  irregular  form  is  likely  to  cut  through 
these  coats  more  completely  at  some  parts  than  others ; 
and  if  it  does  not  perfectly  divide  them,  though  adhe- 
sion may  yet  take  place,  it  is  a slower  and  less  certain 
event,  and  secondary  hemorrhage  more  likely  to  fol- 
low. The  fear  of  tying  a ligature  too  tight  may  often 
lead  to  the  same  disadvantages.  These  and  many 
other  important  circumstances  are  noticed  in  the  article 
Hemorrhage. 

Ligatures  are  commonly  made  of  inkle,  and  rubbed 
with  white  wax.  They  should  be  round,  and  very 
firm,  so  as  to  admit  of  being  tied  with  some  force, 
without  risk  of  breaking. — (See  Jones  on  Hemorrhage, 
p.  172.) 

The  principles  which  should  guide  the  surgeon  in 
the  use  of  the  ligature  were  not  known  until  the  late 
Dr.  Jones  published  his  valuable  treatise  on  hemor- 
rhage. As  an  able  surgeon  has  observed,  “he  has 
banished  (at  least  in  this  country)  the  use  of  thick  and 
broad  threads^of  tapes,  of  reserve  ligatures,  of  cylin- 
ders of  cork  ^d  wood,  linen  compresses,  and  all  the 
contrivances  which,  employed  as  a security  against 
bleeding,  only  served  to  multiply  the  chances  of  its  occur- 
xeuCQ." -{Lawrence, in  Med.  Chir.  Trans,  vol.  6,  p.  162.) 

In  the  article  Amputation,  I have  noticed  the  method 
of  cutting  off  both  ends  of  the  ligature  close  to  the 
knot,  on  the  face  of  the  stump,  with  the  view  of  les- 
sening the  quantity  of  extraneous  matter  in  the  wound, 
and  promoting  a complete  union  of  the  divided  parts, 
without  suppuration. 

This  plan  has  been  tried  by  Mr.  Lawrence : “ The 
method  I have  adopted  (says  this  gentleman)  consists 
in  tying  the  vessels  with  fine  silk  ligatures,  and  cut- 
ting off  the  ends  as  close  to  the  knot  as  is  consistent 
with  its  security.  Thus  the  foreign  matter  is  reduced 
to  the  insignificant  quantity  which  forms  the  noose 
actually  surrounding  the  vessel,  and  the  knot  by  which 
that  noose  is  fastened.  Of  the  silk  which  I commonly 
employ,  a portion  sufficient  to  tie  a large  artery,  when 
the  ends  are  cut  off,  weighs  between  one-fiftieth  and 
one-sixtieth  of  a grain:  a similar  portion  of  the  thick- 
est kind  I have  tried,  weighs  one-twentieth  of  a grain, 
and  of  the  slenderest  one-eightieth.” 

The  kind  of  silk  twist  which  is  commonly  known  in 
the  shofts  by  the  name  of  dentists’  silk,  and  which  is 
used  in  making  fishing  lines,  is  the  strongest  material, 
in  proportion  to  its  size,  and  therefore  the  best  calcu- 
lated for  our  purpose,  which  requires  considerable 
force  in  drawing  the  thread  tight  enough  to  divide  the 
fibrous  and  internal  coats  of  the  arteries.  This  twist 
is  rendered  very  hard  and  stiff  by  means  of  gum, 
which  may  be  removed  by  boiling  it  in  soap  and  wa- 
ter ; but  the  twist  then  loses  a part  of  its  strength. 
The  stoutest  twist  which  Mr.  Lawrence  has  used,  is  a 
very  small  thread,  compared  wilh  ligatures  made  of 
inkle.  The  quantity  of  such  a thread,  nece.ssary  for 
the  nrwse  and  knot  on  the  iliac  artery,  weighs  one- 
iweniietli  of  a grain  ; or,  if  the  gum  has  been  removed, 
about  one-twenty  fifth.  But  the  finest  twist  kept  in 
the  silk  shops  is  strong  enough,  in  its  hard  state,  for 
.any  surgical  purpose;  and  the  noose  and  knot,  accord- 
ing to  Mr.  Lawrence’s  8tatement,wouId  not  weigh  one- 
fortieth  of  a grain. 

VoL.  II. -L 


It  farther  appears  from  the  report  of  this  gentleman 
on  the  subject,  that  there  is  no  danger  of  these  liga- 
tures cuttiiij^  completely  through  the  vessel,  as  some 
surgeons  have  apprehended  ; and  that,  although  he 
has  not  yet  ascertained  what  becomes  of  the  pieces  of 
ligature  after  the  wound  is  united,  he  has  never  seen 
abscess  nor  any  other  bad  symptom  occasioned  by 
them.  At  the  time  when  Mr.  Lawrence  wrote,  he 
had  employed  this  method  of  securing  the  arteries  in 
ten  or  eleven  amputations,  in  six  operations  on  the 
bfeast,  and  in  the  removal  of  two  testicles.  The  cases 
all  did  well,  excepting  a man  who  lost  his  thigh,  and 
who  died  of  an  affection  of  the  lungs. — (See  Lawrence 
on  a JVewMethod  of  Tying  the  Arteries  in  Aneurism,  ^-c. 
in  Medico- Chir.  Trans,  vol.  i3,p.  156,  Src.) 

The  foregoing  method  was  tried  by  myself  in  several 
amputations,  which  I perfoimed  in  1815  at  Brussels, 
and  ill  a larger  number  of  cases  by  my  friend  Mr.  Col- 
lier. Our  ligatures,  however,  though  small,  were  not 
so  small  as  those  judiciously  recommended  by  Mr. 
Lawrence  ; and  on  this  account,  no  accurate  inferences 
can  be  drawn  from  our  examples,  which,  however,  as 
far  as  I could  learn,  were  not  unfavourable  to  the 
practice. 

This  subject  was  mentioned  by  Mr.  Guthrie  as  fol- 
lows: “Some  military  surgeons,  both  French  and 
English,  have  lately  adopted  the  practice  of  cutting  off 
both  ends  of  the  ligatures  close  to  the  knot  on  the  ar- 
tery; uniting  the  parts,  if  possible,  over  them,  and  al- 
lowing the  knots  to  find  their  way  out  as  they  can. 
The  edges  of  the  wound  in  some  instances,  have  united 
thoroughly  in  a few  days ; and  when  the  knots  have 
come  off  the  ends  of  the  arteries,  they  have  caused 
small  abscesses  to  be  formed,  which  point  at  the  nearest 
external  surface,  and  are  discharged  with  little  uneasi- 
ness. I know  that  many  cases  treated  in  this  manner, 
in  the  campaign  of  1813,  ended  successfully,  and  healed 
in  as  short  a time  as  the  most  favourable  ones  by  the 
usual  method;  and  at  Montpellier,  in  June,  1814,  Mons. 
Delpech,  professor  of  surgery  in  that  university,  showed 
me  at  least  twenty  cases,  in  which  he  had  practised, 
and  was  still  practising,  this  method  with  success.  I 
have  seen,  however,  in  two  or  three  instances,  some 
ill-looking  abscesses  formed  by  them,  and  I suspect 
some  disagreeable  consequences  will  ensue,  if  this 
practice  be  continued. 

“ I consider  this  improvement  as  very  valuable  in  all 
cases  that  will  not  unite  by  the  first  intention.  The 
ligatures,  if  there  be  many,  form  into  ropes,  are  the 
cause  of  much  irritation,  and  are  frequently  pulled 
away  with  the  dressings  : by  cutting  them  off,  these 
evils  are  avoided,  and  the  knots  will  come  away  with 
the  discharge.” — {On  Oun-shot  Wounds  of  the  Extre- 
mities, p.  93,  94.) 

With  respect  to  the  abscesses  which  this  gentleman 
saw  produced  by  the  method,  it  is  properly  observed 
by  Mr.  Lawrence,  that  as  this  statement  is  not  accom- 
panied by  any  description  of  the  materials  or  size 
of  the  ligature,  nor  by  any  details  of  the  unfavourable 
cases,  we  cannot  judge  whether  the  events  alluded  to 
are  to  be  attributed  to  the  method  itself,  or  to  the  way 
in  which  it  was  executed. — (See  Med.  Chir.  Trans,  vol. 
6,  p.  171.) 

M.  Roux  tried  the  plan  in  three  operations  on  the 
breast:  the  cases  did  well,  and  no  ill  consequences 
arose  from  the  presence  of  the  bits  of  thread  under  the 
cicatrix. — (See  Relation  d'un  Voyage  fait  d Londres 
en  1814,  ou  ParalUle  de  la  Chirurgie  Angloise  avec  la 
Chirurgie  Francoise,p.  13i — 136.  Paris,  1815.)  Mr. 
Fielding,  of  Hull,  admits  that  this  method  occasions 
less  irritation  in  the  first  inst.ance,  than  the  usual  mode 
of  leaving  one  or  two  ends  of  silk  attached  to  the  knot, 
and  bringing  them  out  of  the  wound,  and  that  union  by 
the  first  intention  is  thus  more  certainly  effected  ; but 
he  assures  us,  that  in  a great  varietyof  cases,  in  which 
he  has  adopted  the  practice,  the  knots  of  silk  were  not 
absorbed,  and  were  ultimately  thrown  off  unchanged, 
after  a slow  suppuration,  attended  with  pain  and  irrita- 
tion for  several  weeks  or  months. — (See  Edinb.  Med. 
Chir.  Trans,  vol.  2,  p.  341.)  Ligatures  of  silk-worrn 
gut,  according  to  his  experience,  do  not  lead  to  the 
above  inconveniences. — (See  Amputation,  Aneurism, 
and  Hemorrhage.) 

[The  plan  of  Mr.  Lawrence  here  recommended,  of 
using  ligatures  made  of  fine  silk  twist,  and  cutting  off 
the  ends  as  close  to  the  knot  as  is  consistent  with  its 
security,  is  liable  to  many  objections,  and  the  young 


30 


LIG 


LIN 


surgeon  will  repent  it  if  he  adopt  this  method  indiscrimi- 
nately. He  will  not  only  be  liable  to  be  often  perplexed 
with  secondary  hemorrhage,  but  those  “ ill-looking  ab- 
scesses^''' to  which  Mr.  Guthrie  refers,  will  often  retard, 
and  may  prevent  the  union  of  the  divided  parts.  In- 
deed, the  attempts  made  in  this  country  have  demon- 
strated, that  this  practice  is  less  safe  and  less  successful 
than  the  old  but  sure  method,  of  leaving  one  end  of 
the  ligature  pendent  from  the  wound. 

Where  resolution  is  not  expected  nor  desirable,  the 
practice  is  less  exceptionable;  and  in  Certain  amputa- 
tions or  gun-shot  wounds,  where  the  escape  of  these 
knots  is  easy  from  the  exposed  condition  of  the  stump, 
this  method  may  be  safely  adopted.  But  in  Wounds 
made  by  the  surgeon  for  securing  arteiies  which  are 
deep-seated,  and  where  union  by  the  first  intention  is 
ofteti  important,  the  old  method  is  greatly  to  be  pre- 
ferred. Some  of  the  most  distinguished  surgeons  in  this 
country,  after  having  repeatedly  tried  Mr.  Lawrence’s 
plan,  with  attention  to  all  the  minute  particularity  which 
he  so  judiciously  enjoins,  as  regards  the  size  and  mate- 
rial of  the  ligature,  have  laid  it  aside  altogether,  and 
prefer  always  to  leave  the  end  of  their  ligatures  hang- 
ing from  the  wound  or  stump.  Among  these  is  Pro- 
fessor Mott,  of  New -York. 

To  our  distinguished  countryman.  Professor  Physick, 
of  the  University  of  Pennsylvania,  is  undoubtedly  due 
the  honour  of  having  first  introduced  what  is  known 
as  the  animal  ligaiure  into  surgical  practice.  His  liga- 
tures are  made  of  chamois  leather,  and  he  and  the  late 
Dr.  Dorsey  usually  rolled  their  ligatures  on  a slab  to 
make  them  hard  and  round.  The  advantages  proposed 
by  the  ligatures  of  Dr.  Physick  are,  that,  being  made  of 
animal  matter,  the  knot,  which  is  all  that  is  left  in  the 
wound,  will  serve  long  enough  to  obliterate  the  artery, 
and  be  speedily  removed  by  the  absorbents,  thus  avoid- 
ing the  difficulty  arising  front  a foreign  body  however 
minute.  These  ligatures  have  been  used  in  this  coun- 
try to  great  extent,  and  Sir  Astley  Cooper  has  demon- 
strated their  superiority  in  his  own  operations.  Dr. 
Hartshorn  used  strips  of  parchment  for  his  ligatures. 
My  friend.  Dr.  H.  G.  Jamieson,  professor  of  surgery 
in  Washington  Medical  College,  Baltimore,  has  for  a 
series  of  years  been  employing  the  animal  ligature 
in  an  extensive  surgical  practice;  a number  of  his 
operations  I have  witnessed.  He  has  used  it  in  many 
amputations  of  the  limbs  and  the  mamma  : he  has  tied 
the  carotid,  the  iliac,  the  femoral,  the  radial,  the  pos- 
terior libial,  the  spermatic,  and  other  arteries,  with  the 
buckskin  ligatures  ; and  in  no  instance  had  seconSlary 
hemorrhage;  and  he  states  that  he  has  never  seen  any 
thing  of  his  ligatures,  and  of  course  his  wounds  have 
generally  healed  by  the  first  intention. 

Dr.  Jamieson  gives  to  Dr.  Physick  the  honour  of  hav- 
ing first  introduced  the  animal  ligature ; but  he  contends 
that  the  practice  of  rolling  or  drawing,  to  harden  the 
leather,  is  highly  reprehensible.  He  advises  to  tie  the 
artery  with  a buckskin  ligature  very  soft,  and  a little 
broader  than  the  thickness  of  the  skin,  taking  care  not 
to  tie  it  too  tight.  He  states,  as  the  result  of  his  ob- 
servation and  experiments  upon  sheep,  dogs,  and  other 
animals,  that  a capsule  will  surround  the  ligature,  if 
the  capillary  vessels  be  not  much  disturbed,  or  the  ves- 
sel will  be  surrounded  by  an  abundance  of  lymph,  and 
the  ligature  dissolved. 

The  method  of  .^tius  and  Celsus,  revived  by  Aber- 
nethy,  of  applying  two  ligatures  and  dividing  the  artety 
between  them.  Dr.  Jamieson  condemns  as  unnecessary, 
since  by  a sinfle  flat  buckskin  ligature  the  artery  may 
be  obliterated  without  destroying  its  continuity.  Hence 
he  opposes  all  indissoluble  ligatures  of  whatever  ma- 
terial : he  declares  it  not  only  to  be  unnecessary,  but 
highly  hazardous,  to  cut  the  inner  coats  of  the  vessel, 
as  recommended  by  Jones,  &c. ; and  agrees  with  Scarpa 
as  regards  flat  ligatures ; but  by  the  use  of  the  buckskin, 
has  no  need  like  him  to  remove  his  ligatures  on  the 
fourth  day. 

For  a very  able  and  interesting  account  of  his  views, 
which  are  of  the  highest  practical  importance,  I would 
refer  to  the  37th  number  of  the  Medical  Recorder,  pub- 
lished at  Philadelphia,  for  January,  1827.  This  valua- 
ble paper  is  entitled,  “ Observations  upon  Traumatic 
Hemorrhage.,  illustrated  by  Erperiments  upon  Living 
.Animals.  By  Horatio  G.  Jamieson,  J\I.  D.,  Surgeon  to 
the  Baltimore  Hospital."  This  essay  obtained  the  pre- 
mjum  offered  for  the  best  paper  on  suppression  of  he 
morrhage. — Reese] 


[The  evils  of  reserve  ligatures  are  so  generally 
known,  that  no  chance  exists  of  their  ever  being  re- 
sorted to  again  by  any  well-educated  surgeon.  Mon». 
Delpech,  professor  of  surgery  at  Montpellier,  has  com- 
pletely abandoned  them,  though  (in  common  with  the 
continental  surgeons)  once  a great  advocate  for  their 
use.  The  disastrous  consequences  of  these  superflu- 
ous ligatures,  he  has  been  taught  by  fatal  experience. 
Some  of  the  cases  he  has  recently  published  demon- 
strate, that  nothing  is  so  likely  as  reserve  ligatures  to 
cause  ulceration  of  the  artery  and  secondaiy  hemor- 
rhage. He  however  is  a zealous  advocate  for  the  prin- 
ciples and  practice  of  Dr.  Jone.s,  and  strongly  insists 
on  the  propriety  of  letting  ligatures  cot  through  the 
inner  and  middle  coats  of  the  tied  vessels. — (See  Chir. 
Clinique,  t.  1.  Obs.  et  Reflexions  sur  la  Ligature  dea 
Principales  .^rtiries  ) — Preface.'] 

LINIMENTUM  ACIDI  SULPHURICI.— B;.  Olei 
oliv®,  5iss.  Acid,  sulph.  5ss.  M.  Recommended  by 
Mr.  Brodie  for  the  removal  of  the  effects  of  inflamma- 
tion of  the  synovial  membrane. — (See  Joints.) 

LINIMENTUM  AMMONIA  FORTIUS.— R.  Liq. 
amrnon.  5 j.  Olei  oliv®,  ^iij-Misce.  Properties  stimu- 
lating. 

LINIMENTUM  CALCIS.— R.  Aqtt®  calcis,  olei 
oliv®,  sing.  5viij.  Spirit,  vinosi  rectificati,  5 i-  Misce. 
A common  application  to  burns  and  scalds. 

LINIMENTUM  CAMPHOR^E  COMPOSITUM.— 
R.  Camph.  |ij.  Aq.  ammon.  ^vj.  Spirit,  lavend. 
^xvj.  Sixteen  ounces  are  to  be  distilled  of  the  last 
two  ingredients,  from  a glass  retort,  and  the  camphor 
then  dissolved  in  the  distilled  fluid.  For  bruises,  sprains, 
rigidities  of  the  joints,  incipient  chilblains,  &c. 

LINIMENTUM  CAMPHORiE  ^ETHEREUM.— 
R.  Camphor®  drach.  j.  .^theris  uric.  ss.  Oleivipera- 
rum  drach.  ij.  Misce.  The  camphor  is  to  be  dissolved 
in  the  ether,  and  the  oil  afterward  incorporated  with 
it.  The  late  Mr.  Ware  sometimes  used  this  applica- 
tion in  certain  obscure  affe'tions  of  the  eye,  in  which 
it  was  not  easy  to  determine  whether  the  imperfection 
of  the  sight  proceeded  from  an  incipient  cataract,  or  a 
defect  of  sensibility  in  the  optic  nerve.  The  outside 
and  edges  of  the  eyelids  were  rubbed  with  it  every 
morning  and  evening,  for  two  or  three  minutes. 

LINIMENTUM  HYDRARGYRI  COMPOSITUM. 
— R.  Ung.  hydrargyri  fortioris,  adipis  suill®,  sing.  |i. 
Camph.  3 ij.  Spirit,  vinos,  rectif.  3 ij.  Liq.  ammon, 
|j.  The  camphor  being  dissolved  in  the  spirit  of 
wine,  add  the  liq.  ammon.  and  the  ointment  pre- 
viously blended  with  the  hog’s  lard. — {Pharm.  Sancti, 
Barthol.)  An  excellent  formula  for  all  surgical  cases 
in  which  the  object  is  to  quicken  the  action  of  the  ab- 
sorbents and  gently  stimulate  the  surfaces  of  parts.  It 
is  a capital  application  for  diminishing  a chronic  indu- 
rated state  of  particular  muscles,  every  now  and  then 
met  with  in  practice  ; and  it  is  particularly  well  calcu- 
lated for  lessening  the  stiffness  and  chronic  thickening 
of  joints. 

LINIMENTUM  lODIN^E.— R.  Lin.  sapon.  c.  5j. 
Tinct.  iodin®,  3j.  Misce. — Manson's  Researches 
on  the  Effects  of  Iodine,  p.  451.) 

LINIMENTUM  POTASSiE  SULPHURETL— R. 
Saponis  albi,  | iv.  Olei  amygdal®,  5 viij.  Potass® 
sulphureti,  3 vj.  Olei  Thymi,  gr.  xv.  vel.  3j.  This 
liniment,  used  twice  a day,  will  cure  the  itch  in  five 
days,  or,  at  latest,  in  eight.  It  has  not  a very  unplea- 
sant smell,  and  would  be  preferable  to  sulphur  oint- 
ment, if  equally  efficacious.— (See  London  Medical 
Repository,  vol.  3,  p.242;  and  Cross's  Sketches  of  the 
Medical  Schools  of  Paris,  p.  176.1 

LINIMENTUM  SAPONIS  COMPOSITUM.-R. 
Sapon.  5'ij-  Camph.  5j-  Spirit,  rorismar.  Ibj.  Dis- 
solve the  soap  in  the  spirit,  and  then  add  the  camphor. 
Uses,  the  same  as  those  of  the  linimentum  camph. 

LINIMENTUM  SAPONIS  CUM  OPIO.— R.  Lin. 
sapon.  comp,  f vj.  Tinct.  opii,  5 >j-  Misce.  For  dis- 
persing indurations  and  swellings  attended  with  pain, 
but  no  acute  inflammation. 

LINIMENTUM  TEREBINTHIN.E.— R.  Ung.  re- 
sin® flav®,  jiv.  Ol.  terebinthina;,  q.  s.  Misce.  The 
well-known  application  for  burns,  recomntended  by 
Kentish. — (See  Burns.) 

LINIMENTUM  TEREBINTHINAE  SULPHURI 
CUM  — R.  Olei  oliv®,  3 X.  Ol.  terebinth.  3 iv.  Acidi. 
Snlph.  3 iij.  Misce.  Said  to  be  efficacious  in  chronic 
affections  of  the  joints,  and  in  the  removal  of  the  old 
effect."  of  sprains  and  bruises. — (Pharm.  Chirurgica  ) ^ 


LIP 


131 


LtP,  CANCER  OF.— The  lips  are  subject  to  ulcers, 
which  put  oti  a very  iiialignaiit  aspect,  altliough  some 
oftheui  are  not  in  reality  inalignanl ; and  many,  si- 
tuated Just  on  the  inside  of  these  parts,  will  be  found  to 
depend  on  the  bad  state  of  the  constitution,  and  the 
irritation  and  distuihance  which  the  sores  are  conti- 
nually suffering  from  the  incessant  motion  of  the  parts, 
and  their  rubbing  against  a projecting  or  rough  tooth. 

The  continual  irritation,  arising  from  the  introduc- 
tion of  food,  the  effort  of  speaking,  and  tlie  constant 
flow  of  saliva  (as  Mr.  Earle  remarks),  are  sufficient  to 
keep  up  the  morbid  disposition,  and  to  prevent  any 
reparative  effort  of  nature  from  being  carried  into 
effect.  After  a time,  the  neighbouring  glands  will  of- 
ten become  enlarged,  which  confirms  the  surgeon  in  the 
opinion  he  had  been  induced  to  form  of  the  nature  of 
the  affection. — (See  Med.  Chir.  Trans,  vol.  12,  p.272.') 
It  is  not  an  uncommon  belief,'  that  the  iiiitation  of  to- 
bacco-pipes frequently  gives  riilfe  to  malignant  and  even 
truly  cancerous  diseases  of  the  lip.  The  use^f  cigars 
may  have  the  same  effect.— (See  vol.  cit.  p.  278.) 

Arsenic  is  frequently  useful  in  subduing  the  obstinacy 
and  malignity  of  certain  ulcers  and  diseases  of  the  lip 
reputed  to  be  cancerous. — {Stark,  De  Cancero  Labii 
Jjiferiuris.)  Of  this  essay,  Professor  Langenbeck 
speaks  in  high  terms.  The  following  formula  is  re- 
commended. “ R.  Arsenici  albi  drachm,  dimid.  Aq. 

con stillaliciae  unc.  se.\.  M.  Digerantur  vase  vitreo 

causo  in  balneoarenae  justi  caloris  ope  per  horas  sex, 
turn  adde  potass®  Carbonatis  pur®  drachm,  dimid.  anlea 
solutv  in  Aq.  Cinnamon,  simpl.  unc.  duab.  M.  Digerantur 
denuo  per  aliquot  horas  in  loco  temperato.  Hac  solu- 
tione  bis  terve  quotidie  ad  guttas  8 — 10 — IS,  utimur.” 

When  cancer  takes  place,  it  is  usually  in  the  lower, 
and  very  seldom  in  the  upper  lip.  Sir  A.  Cooper  has 
seen  but  one  instance  in  the  latter  part. — {Lancet,  vol. 
3,  p.  109.) 

The  disease  sometimes  puts  on  the  appearance  of  an 
ulcerated  wart-like  e.xciescence,  occasionally  acquiring  a 
considerable  size.  Sometimes  it  is  seen  in  the  form  of 
a very  destructive  ulcer,  which  consumes  the  surround- 
ing substance  of  the  lip;  and  in  other  examples  the 
disease  resembles  a hard  lump,  which  at  length  ulcer- 
ates. The  disease,  in  its  infancy,  is  often  no  more  than 
a pimple,  which  gradually  becomes  malignant.  As  the 
disease  advances,  the  glands  under  the  jaw  enlarge. 
According  to  Mr.  Travers’s  observations,  cancer  of 
the  lower  lip  begins  in  the  cellular  tissue  between  the 
mucous  membrane  and  the  skin.  The  enlargement 
and  induration,  he  says,  render  it  conspicuous  before 
the  villous  surface  of  the  lip  cracks  transversely,  and  a 
thin  fluid  oozes;  it  then  exulcerates  and  scabs  by  turns, 
and  ultimately  penetrates  more  deeply,  and  throws 
out  a f ungus.  The  patient  is  generally  a healthy  male 
of  advanced  years,  and  accustomed  to  smoking.  Pus 
sometimes  escapes  when  the  fungus  is  divided ; but  the 
base  of  the  tumour  is  hard  and  granular.  The  skin  and 
mucous  membrane,  and  the  labial  glands,  now  promi- 
nent and  warty,  form  a close  compact  mass.  As  the 
ulcerat.on  proceeds,  the  induration  extends,  and  the 
salivary  glands,  and  the  lymphatic  glands  at  one  or 
both  angles  of  the  jaw,  become  enlarged  and  tender. — 

( Travers,  in.  Med.  Chir.  Trans,  vol.  15,  p.  239.)  When- 
ever there  is  reason  to  believe  that  the  disease  is  of 
an  unyielding  cancerous  nature,  and  it  does  not  soon 
give  way  to  arsenic,  iodine,  hemlock,  or  mercurials,  the 
sooner  it  is  extirpated  the  belter.  For  this  purpose 
some  surgeons  admit  the  propriety  of  using  caustic 
when  the  whole  disease  can  be  completely  destroyed 
by  one  application.  But  as  the  action  of  caustic  is  not 
capable  of  being  regulated  with  so  much  precision  as 
the  extent  of  a wound  can  he,  and  as  caustic  will  not 
allow  the  parts  to  be  united  again,  the  knife  is  the  only 
justifiable  means,  especially  as  it  also  occasions  less 
pain.  Two  incisions  are  to  be  made,  meeting  at  an  angle 
below  (supposing  it  to  be  the  lower  lip),  and  including 
the  whole  of  the  disease.  'Phe  sides  of  the  wound  are 
then  to  be  united  by  the  twisted  suture — (See  Harelip.) 
When  the  affection  is  extensive,  however,  the  surgeon 
is  frequently  necessitated  to  remove  the  whole  of  the 
lip,  or  too  much  of  it  to  admit  of  the  above  jilan  being 
followed.  This  circumstance  has  generally  been  re- 
garded as  particularly  unfavoui able ; and  it  has  been 
commonly  believed,  that  unless  some  attempt  can  be 
made  to  succour  the  patient  by  the  Taliacolian  prac- 
tice, in  the  manner  men  ioned  by  Mr.  Earle  (Jl/cff.  Chir. 
Trans,  vol.  12,  ;>.'276),  the  patient’s  spittle  would  con- 


LIQ 

tinually  run  over  his  chin,  or  only  admit  of  being  kept 
from  doing  so  by  some  artificial  contrivance.  It  was 
also  thought  that  the  delbrmity  would  be  very  great,  and 
that  pronunciation  andswallowing  would  be  but  imper- 
fectly performed.  Some  observations  lately  published 
by  Mr.  Travers,  however,  tend  to  prove  that  these  disad- 
vantages have  been  exaggerated ; and,  convinced  of  the 
prudence  of  a free  removal  of  the  disease  in  its  early 
stage,  he  prefers  “ a full  crescent-shaped  section  of  the 
substance  of  the  lip”  to  an  operation  resembling  that  lor 
the  cure  of  a harelip.  He  recommends  the  commissure 
of  the  mouth  to  be  spared,  if  possible.  “ The  contrac- 
tion during  the  healing  process  under  a double-headed 
bandage,  passing  over  the  vertex  and  occiput,  so  as  to 
keep  a little  moistened  lint  or  simple  ointment  on  the  cut 
surface,  shapes  and  adapts  the  lip  with  singular  neat- 
ness ; and  what  is  more  remarkable,  the  cut  surface 
takes  a depth  of  colour  and  a plumpness,  and  a defined 
border,  which  give  much  the  appearance  of  the  na- 
tural surface.”  In  one  case  of  malignant  ulcer,  pub- 
lished by  Mr.  Earle,  he  removed  the  angle  of  the  mouth 
and  a large  portion  of  each  lip,  together  w'ith  a consi- 
derable part\)f  the  cheek,  yet  succeeded  in  uniting  the 
wound,  which  object  was  facilitated  by  the  extraction 
of  five  teeth  from  the  lower  jaw  previously  to  the  ope- 
ration, which  were  useless  in  consequence  of  having 
no  corresponding  ones  in  the  upper  jaw. — {Med.  Chir. 
Trans,  vol.  12,  p.  274.) 

LIPPJTUDO.  (From  lippus,  blear-eyed.)  Blear- 
edness.  The  ciliary  glands  and  lining  of  the  eyelids 
only  secrete  in  the  sound  state  just  a sufficiency  of  a 
sebaceous  fluid  to  lubricate  the  parts  in  their  continual 
motions.  But  it  sometimes  happens  from  disease  that 
this  sebaceous  matter  is  secreted  in  too  great  a quan- 
tity, and  glues  the  eyelids  together  during  sleep,  so  that 
on  waking  they  cannot  be  easily  separated.  Hence 
the  margin  of  the  eyelids  becomes  red  all  round,  and 
the  sight  itself  even  weakened. 

The  best  remedies  are  the  unguentum  hydrargyri 
nitrati  smeared  at  night  on  the  edges  and  inside  of  the 
eyelid  with  a hair  pencil,  after  being  melted  in  a spoon 
the  unguentum  tuti®,  applied  in  the  same  way ; and 
a collyrium,  composed  of  3j.  of  the  sulphate  of  zinc  in 
5 viij.  of  rose  water. 

When  alterative  medicines  are  requisite,  a grain  of 
calomel  may  be  exhibited  daily,  or  the  compound  calo- 
mel pill,  containing  one  grain  of  calomel,  one  of  sulphur 
anlimonii  pr®cipitatum,and  two  of  guaiacum,  put  to- 
gether with  soap. 

Persons  who  have  lippitudo  and  cataracts  together, 
bear  couching  much  better  than  one  would  expect  from 
the  appearance  of  the  eyes;  and  Mr.  Hey  never  re- 
jected a patient  on  this  accouni,  provided  such  state 
were  habitual. — {Tract.  Obs.  p.  51.)  Scarpa,  however, 
recommends  the  lippitudo  to  be  removed  before  the 
operation  is  undertaken. 

LiaUOR  AMMON.  A GET.  (L.  P.)— This  is  given 
in  the  dose  of  half  an  ounce  in  many  surgical  cases, 
in  which  the  object  is  to  keep  up  a gentle  perspiration. 

LiaUOR  ARSENICALIS.— R.  Arsenici  Oxydi 
pr®paiati  in  pulverem  subtilissimurn  triti.  Potass® 
Subcarbonatis  ex  tartaro  singulorum  gr.  64.  Aq.  distill. 
Ibj.  coque  simul  hi  vase  vitreo,  donee  arsenicum  omne 
liquetur.  Liquori  frigefacto  adjice  Spiritfls  Lavandul® 
com.  3 iv.  Denique  adjice  insuper  Aq.  distil,  quan- 
tum satis  sit,  ul  mensuram  octarii  accurate  impleat. 
For  internal  use  the  dose  is  iv.  drops  gradually  in- 
creased to  XX.  twice  a day.  It  is  frequently  given  in 
cases  of  anomalous  ulcers,  and  cancerous  affections  of 
the  lip.  It  is  also  used  as  an  external  application  in 
similar  cases,  and  especially  in  hospital  gangrene.— 
(See  .Arsenic  and  Hospital  Gangrene.) 

LIGIUOR  CALCIS  (L.  P.]— Sometimes  used  as  an 
astringent  injection  or  lotion  ; also  in  gargles  ; it  has 
been  given  internally  as  a lithoniriptic. 

LIQUOR  CUPRI  SULPHATIS  CAMPHORA- 
TUS. — R.  Cupri  sulphatis.  Boli  Gallici  sing.  unc.  as. 
Camphor®  diach.  j.  Aqu®  ferventis,  lib.  iv.  Boiling 
water  is  to  be  added  to  the  other  ingredients,  and  the 
liquor  filtered  when  cold.  It  is  chiefly  employed  in  a 
diluted  stale  as  a collyrium  ; but  it  may  also  prove-of 
service  as  an  application  to  foul  ulcers. 

When  used  for  the  cure  of  the  purulent  ophtlialmy, 
the  lotion  is  to  be  injected  under  the  eyelids  by  means 
of  a blunt  syringe  ; and  if  necessary,  the  application 
may  be  repeated  once  or  twice  every  hour. — (See  OpA- 
thalmy.) 


132 


LIT 


LIT 


LIQUOR  POTASSiE  (L.  P.)— Has  been  given  with 
the  view  of  dissolving  stone  in  the  bladder. — (See  XJri- 
nary  Calculi.) 

The  dose  is  from  ten  to  twenty  drops,  twice  a day, 
in  some  linseed  tea,  veal  broth,  or  table  beer.  It  has 
been  found  useful  in  lepra,  psoriasis,  and  some  other 
cutaneous  diseases. — (See  Paris's  Pharmacologia,  vol. 
2,  ».  281,  ed.  5.'' 

LIQUOR  pOTASSiE  SUBCARBONATIS  (L.  P.) 
— This  remedy  is  principally  deserving  of  notice  on 
account  of  its  having  been  given  to  dissolve  calculi  in 
the  bladder,  so  as  to  remove  the  necessity  of  perform- 
ing the  dangerous  and  painful  operation  of  lithotomy. 
It  may  be  exhibited  in  doses  of  20  or  40  drops,  or  of  a 
drachm,  in  a basin  of  gruel.  Experience  does  not  seem 
to  justify  the  indulgence  of  much  hope  with  regard  to 
the  complete  efficacy  of  the  medicine  in  dissolving  uri- 
nary calculi,  and  on  some  kinds  it  is  not  calculated  to 
act  at  all  even  on  chemical  principles ; but  it  would 
appear  from  the  reports  of  writers,  that  it  has  often 
materially  palliated  the  pain  which  attends  the  presence 
of  a stone  in  the  bladder. — (See  Urinary  Calculi.) 

LIQUOR  POTASS^  ARSENICAT^.— R.  Potas- 
sae  arsenicatte,  grana  duo.  Aquae  menthae  sativae  un- 
ciasquatuor.  Spiritus  vinosi  tenuiorisunciam.  Rlisce 
et  cola.  Two  drachms  of  this  may  be  given  thrice  a day 
in  cases  of  cancer.  My  friend,  Mr.  Barnes,  of  E.\eter, 
once  showed  me  a lupus,  or  noli  me  tangere,which  was 
greatly  benefited  by  tliis  remedy  externally  applied.  He 
was  using  the  lotion  with  double  the  proportion  of  arse- 
nic. Certain  ulcerations  about  the  roots  of  the  nails 
of  the  fingers  and  toes,  to  which  Plunket’s  caustic  is 
sometimes  applied  might  be  much  benefited  by  this 
lotion,  which  is  certaiidy  a neater  application. 

LIQUOR  PLUMB!  ACETATIS— Is  used,  largely 
diluted  with  water,  as  a common  application’  to  in- 
flamed parts. — (See  Inflammation.)  One  drachm  to  a 
quart  of  water  is  quite  strong  enough  for  common 
purposes.  Mr.  Justamond  and  Dr.  Cheston  used  to 
apply  it,  mixed  with  an  equal  proportion  of  a spirit 
resembling  the  tinctura  ferri  muriati,  to  the  edges  of 
cancerous  sores. 

LITHONTRIPTICS.  (From  X(0of,  a stone ; and 
^pvKTU),  to  break.)  Medicines  for  dissolving  stones  in 
the  bladder. — (See  Urinary  Calculi.) 

LITHONTRIPTOR.  The  name  of  an  instrument 
for  reducing  calculi  in  the  bladder  into  small  particles 
or  a powder,  which  is  voided  with  the  urine,  and  litho- 
tomy thus  rendered  unnecessary.  According  to  some 
accounts,  it  was  invented  by  M.  Le  Roy  d’Etioles,  but 
first  brought  into  much  notice  by  the  exertions  of  Dr. 
Civiale  of  Paris.  It  is  not  for  me  to  enter  into  the 
dispute  concerning  the  degree  of  merit  which  may 
belong  in  this  subject  to  each  of  these  gentlemen,  or  to 
Baron  Heurteloup,  who  has  warmly  defended  the  pri- 
ority of  M.  Le  Roy’s  claim,  at  the  same  time  that  he 
has  himself  contributed  very  much  to  the  [)erfection 
of  the  instruments  and  the  success  of  the  practice. 
The  lithontriptor  consists  of  a straight  silver  catheter 
of  considerable  diameter,  and  enclosing  another  of 
steel,  the  lower  extremity  of  which  consists  of  three 
branches,  calculated  to  grasp  the  stone  on  withdrawing 
the  steel  catheter  a short  way  within  the  outer  one, 
when  they  become  approximated.  The  cavity  of  the 
inner  catheter  is  capable  of  admitting  a steel  rod,  to 
which  may  be  affixed,  at  the  surgeon’s  option,  a simple 
quadrangular  drill,  or  a strawberry-shaped  file,  or  a 
trephine.  By  means  of  a spring  the  latter  part  of  the  ap- 
paratus is  pressed  evenly  inwards,  and  it  is  made  to  re- 
volve with  velocity  through  the  medium  of  a bow,  after 
the  manner  of  a common  hand-drill.  Chaussier  and 
Percy  were  requested  by  the  Royal  Academy  of  Medi- 
cine at  Paris  to  examine  the  merits  of  this  new  inven- 
tion, and  to  draw  up  a report  on  the  subject.  “This 
report  (as  a respectable  journal  states)  speaks  in  very 
strong  terms  of  the  success  which  the  reporters  wit- 
nessed in  repeated  trials  by  the  inventor ; and  there 
can  be  no  doubt,  from  the  distinct  and  precise  evidence 
adduced  by  them,  that  none  of  the  nreans  previously 
suggested  for  the  same  purpose  can  compete  with  the 
instrument  now  proposed.  The  first  case  in  which 
the  reporters  witnessed  its  application,  was  that  of  a 
man  thirty-two  years  old,  who  had  a mulberry  calculus 
of  considerable  size.  The  experiment  was  made  in 
presence  of  Chaussier,  Percy,  liarrey,  and  several 
other  surgeons  of  eminence.  ’I'he  instrument  having 
been  introduced,  and  the  stone  caught  at  the  first 


attempt,  ‘ at  evei^  stroke  of  the  bow  those  present 
heard  a crackling  sound,  which  announced  both  the 
hardness  of  the  stone  and  the  rapidity  of  its  demoli- 
tion.’ The  operation  was  continued  at  occasional  in- 
tervals for  forty  minutes,  during  which  the  patient 
complained  rather  of  uneasiness  than  of  decided  pain. 
The  instrument  was  then  withdrawn,  and  the  patient 
immediately  discharged  with  his  urine  a quantity  of 
powdery  detritus,  which  was  supposed  to  form  a tiiird 
part  of  the  stone.  The  operation  was  renewed  eleven 
days  afterward,  in  presence  of  the  same  persons,  and 
of  Magendie  and  Serres;  and  again,  a third  time,  ten 
days  afterward.  The  quantity  of  powdery  matter 
then  discharged  appeared  to  be  equivalent  to  the  size 
of  the  stone,  and  no  calculus  could  be  afterward  dis- 
covered in  the  bladder  by  the  most  careful  sounding. 
The  second  case  was  that  of  a man  affected  with  a 
calculus,  of  which  the  nucleus  was  a kidney-bean. 
The  urethra  had  beeri  previously  dilated  by  the  suc- 
cessive introduction  of  sounds  of  larger  and  larger 
diameters.  The  sound  caused  in  this  instance  was 
dull  and  obscure.  The  bladder  being  irritable  and 
disposed  to  contract,  the  operation  was  continued  for 
a shorter  period  than  in  the  former  case,  and  was  re- 
sumed every  third  day.  Four  operations  removed  the 
whole  of  the  stonq  the  patient  being  sounded  after  the 
fourth  by  one  of  the  most  dexterous  lithotomists  in 
Paris.  The  stone  in  this  case  came  off  in  sundry  par- 
ticles, and  little  fragments  loosely  agglutinated  by  a 
viscous  animal  matter.  At  the  third  operation  the 
forceps  caught  and  brought  away  the  bean,  deprived 
of  its  epidermis;  and  at  the  next,  the  crust  came  away 
with  the  remaining  fragments  of  the  stone.  In  the 
third  case,  the  stone  was  of  the  size  of  a pigeon’s  egg, 
and  moderately  hard.  After  three  operations,  the 
cure,  at  the  period  of  the  delivery  of  the  report,  was 
considered  as  nearly  completed.  Nothing  unusual 
occurred  in  this  case,  except  that,  on  one  occasion,  the 
operator  failed  in  catching  hold  of  the  stone.  The 
plan  is  evidently  inadmissible  when  the  stone  is  too 
large  to  be  seized  with  the  forceps,  when  it  is  adherent, 
encysted,  or  formed  on  a nucleus  of  a metallic  or  bony 
nature.”— (See  Arch.  Gdn.  de  Mid.  May,  1824 ; and 
Edinb.  Med.  and  Surg.  Jo  urn.  Jan.  1825.) 

In  1813,  a German  surgeon,  Gruithuisen,  conceived, 
as  Desault  had  done  long  ago  for  calculi  in  the  urethra 
(see  Lithotomy),  that  the  principle  of  the  common 
bullet-forceps  might  be  adopted  in  the  construction  of 
an  instrument  for  taking  hold  of  stones  in  the  bladder  ; 
and  he  accordingly  formed  an  instrument  consisting  of 
a straight  cannula  of  the  diameter  of  four  lines,  and 
a central  steel  rod  terminating  in  three  elastic  claw's  or 
tenacala,  which  might  be  thrust  forwards  in  search  of 
the  calculus,  and  drawn  back  to  grasp  it.  Gruitbui- 
sen’s  merit  in  the  invention,  however,  extends  farther 
than  this ; for  he  first  demonstrated  the  practicable- 
ness of  introducing  a tube  that  was  nearly  straight 
through  the  urethra  into  the  bladder,  whereby  the 
facility  of  litliontriptic  measures  may  be  said  to  have 
been  first  made  manifest.  He  also  sugeested  commi- 
nuting the  stone  with  an  iron  rod  introduced  through 
the  tube. 

In  1823,  Dr.  Le  Roy  added  to  the  claws  of  Gruithui- 
sen’s  instrument  a drill  for  destroying  the  stone  when 
grasped.  But  of  late  the  apparatus  has  been  brought 
to  great  perfection,  partly  by  M.  Civiale  and  partly  by 
Baron  Heurteloup.  The  latter  remarked,  w'hen  he  was 
in  London,  that  his  instrument  would  not  at  present 
entirely  supersede  the  lateral  operation,  as  it  was  not 
adapted  to  destroy  a larger  atone  than  one  of  eighteen 
lines  diameter ; but  that  a more  attentive  regard  to  the 
diagnosis  of  this  painful  disease  would,  in  future,  by 
ensuring  the  discovery  of  calculi  while  small,  render 
a recourse  to  the  knife  perfectly  needless.  The  steit* 
of  the  process  are  the  follow'ing: 

1st.  The  injecting  of  the  bladder  with  warm  water, 
w’hich  is  done  by  means  of  a catheter  furnished  with  a 
stop  cock,  atid  a large  syringe  made  for  the  purpose. 

2d.  The  indicating  the  situation  of  the  stone;  the 
catheter  already  introduced  serves  the  purpose  of  a 
sound ; its  short  curve  very  much  facilitates  the  detec- 
tion of  calculi. 

3d.  The  seizure  of  the  stone.  This  is  done  by  the 
claw  s of  the  instrument. 

4ih.  The  perforation  by  Le  Roy’s  drill. 

5th.  The  excavation,  eflfected  by  an  instrument 
shot  tly  to  be  described. 


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133 


6th.  The  crushing  and  pulverization  of  the  shell, 
effected  by  an  instrument  to  be  described,  called  the 
“ shell-bieaker.” 

7ih.  The  ejection  of  the  powder  by  the  contractile 
force  of  the  bladder. 

8th.  For  small  stones  and  flat  stones  the  “ shell- 
bieaker”  only  is  used. 

Baron  Heurteloup  employs  anoperation  bed  or  table, 
about  the  height  ol  our  ordinary  operation  tables,  co- 
vered with  a mattress,  which  may  be  raised  into  an 
inclined  plane,  and  supported  by  a wedge-shaped  box. 
At  the  foot  of  this  bed  there  is  an  apparatus  which 
affords  a fulcrum  to  the  instrument  after  its  introduc- 
tion into  the  bladder.  The  head  of  the  bed,  and  con- 
sequently the  fundus  of  the  bladder,  may  be  depressed 
to  any  extent  desired,  the  legs  which  support  it  being 
hinged  and  capable  of  folding  under.  On  this  couch 
the  man  is  placed  nearly  in  the  position  for  the  lateral 
operation.  A strap  is  passed  round  the  shoulders  and 
buckled  to  the  sides;  the  feet  are  placed  in  slippers 
securely  fixed  at  the  foot  of  the  bed. 

The  Baron,  when  he  was  in  England  in  1829,  showed 
the  following  instruments  to  the  London  surgeons. 

1st.  The  catheter  of  the  usual  length,  with  a short 
and  rather  abrupt  curve  to  serve  as  a sound ; the 
shortness  of  the  curve  facilitating  its  motions  in  the 
bladder:  it  is  furnished  with  a stop-cock. 

2d.  The  syringe  of  silver,  capable  of  containing 
about  a pint  of  fluid;  furnished  with  two  rings,  one 
on  each  side  of  the  syphon,  for  the  insertion  of  two 
fingers,  rendering  it  manageable  with  one  hand  only. 

3d.  “ L'instrument  d trois  branches,  avec  un  foret 
simple,"  designed  by  Le  Roy,  adopted  byCiviale,  con- 
sisting of  a cannula,  three  tenacula,  and  the  drill. 
This  suffices  to  crush  stones  equal  in  diameter  to  the 
drill ; but  to  destroy  a larger  stone  several  perforations 
are  necessary,  wliich  consume  a great  deal  of  time, 
and  some  risk  is  incurred  from  the  entanglement  of 
the  claws.  To  obviate  these  difficulties,  the  Baron  has 
devised  the  following  means: — 

4th.  “ L'instrument  d t7-ois  branches,  avec  le  man- 
drin  d virgule"  is  applicable  to  stones  of  from  eight  to 
ten  lines  in  diameter.  By  an  ingenious  contrivance, 
a shoulder  (”  la  virgule")  is  thrown  out  sideways 
from  the  head  of  the  drill,  and  in  its  revolution  exca- 
vates the  calculus.  For  stones  of  larger  diameter 
another  contrivance  is  produced. 

5th.  “ L'instrument  d quatre  branches,"  or  “ pince 
d forceps."  Here  are  four  claws,  forceps-shaped, 
which  may  be  moved  conjointly  or  separately,  so  as  to 
obviate  every  chatige  of  etitanglernent.  One  of  the 
claws  has  a button  point,  and  may  be  thrust  farther 
forwards  than  the  rest,  and  prevent  (in  case  the  fluid 
escape)  the  bladder  from  embracing  the  instrument  too 
closely.  The  pince  d forceps"  is  adapted  to  stones 
of  from  twelve  to  eighteen  lines  in  diameter,  and  is 
furnished  with  a “ mandrind  virgule,"  the  "virgule" 
of  which  makes  a larger  excavation.  In  case  the 
stone,  or  a fragment  of  it,  should  escape  from  the 
claws  of  the  "pince,"  the  fruitful  imagination  of  the 
Baron  has  supplied  a remedy:  the  “ mandrin"  is 
withdrawn,  and  a very  delicate  instrument,  consisting 
of  a cannula,  a steel  rod,  and  three  very  fine  elastic 
tenacula,  is  introduced,  the  substance  is  seized  and 
replaced  within  the  jaws  of  the  larger  instrument,  and 
the  process  of  its  destruction  is  resumed.  Tiie  pre- 
hensile property  of  this  little  instrument  is  truly  ad- 
mirable. The  “/;?Vicc  d /erects”  consists  of  nineteen 
different  pieces. 

6th.  To  break  down  the  shell  thus  formed,  as  well 
as  small  and  flat  stones,  with  facility,  another  contri- 
vance was  necessary.  To  fulfil  this  intention,  the 
Baron  has  constructed  an  instrument  which  may  be 
termed  his  master-piece.  “ Lehrise  coque,"  or  “ shell- 
breaker,”  is  very  complicate  in  its  structure,  consisting 
of  not  less  than  twenty-five  pieces.  Its  primary  es- 
.sential  parts  appear  to  be  two  parallel  steel  rods,  con- 
tained in  a circular  silver  cannula  about  the  third  of 
an  inch  in  diameter:  the  extremities  of  these  rods, 
when  thrust  forwards  from  the  cannula,  expand  by 
their  own  elastic  force,  and  are  seen  to  be  force;)s- 
shafred  and  serrated  ; the  stone  is  grasped  with  facility, 
by  a motion  similai  to  the  lateral  morion  of  the  jaw, 
and  ground  to  powder  in  a few  minutes.  The  ma- 
chinery by  which  this  is  effected  is  concealed  from 
view'.  The  facility  of  using  the  “ brise  coque"  is, 
however,  very  evident;  after  its  introduction,  the  in- 


strument is  held  in  the  left  hand,  and  the  effect  desired 
is  produced  by  a movement  of  the  handle  from  side  to 
side  by  the  right  hand. 

The  Baron  showed  in  London  the  effects  of  these 
different  instruments  on  artificial  calculi.  On  the  24th 
of  July,  1829,  he  operated  on  a patient  sixty-four  years 
old,  at  the  house  of  Mr.  White;  the  stone  was  about 
fourteen  lines  in  diameter,  and  the  operation  was  con- 
cluded in  fourteen  minutes. — (See  Lancet,  1828-29, 
p.  568,  Src.)  It  must  not  be  supposed  that  the  lithon- 
triiitor  gives  no  pain ; for  in  several  instances  this  has 
been  so  severe  as  to  make  the  patient  refuse  to  submit 
to  the  experiment  again ; and  I have  heard  it  calcu- 
lated that  six  repetitions  of  the  application  sometimes 
cause  as  much  suffering  as  lithotomy.  But  on  this 
estimate  the  difference  is  much  against  the  latter; 
while  the  former  does  not  endanger  life,  as  lithotomy 
always  does,  and  this  even  with  the  most  skilful  ope- 
rators. The  lithontriptor,  as  the  foregoing  account 
proves,  will  effect  the  removal  of  much  larger  calculi 
than  can  be  drawn  out  with  the  urethral  forceps  made 
by  Mr.  Weiss  (see  Lithotomy),  and,  in  this  respect,  is 
superior  to  the  latter  instrument,  and  a truly  great  im- 
provement. But  for  other  cases,  in  which  the  calculi 
are  numerous,  and  not  too  large  to  be  drawn  out  in  an 
unbroken  state  through  the  urethra,  the  urethral  for- 
ceps may  merit  the  preference. 

LITHOTOMY.  (From  At0o5,  a stone,  andrfpi/w,  to 
cut.)  The  operation  of  cutting  into  the  bladder,  in 
order  to  extract  a stone. 

It  has  been  correctly  remarked,  that  no  single  ope- 
ration of  surgery  has  attracted  so  much  notice,  or  had 
so  much  written  upon  it,  as  lithotomy.  A full  and 
minute  account  of  the  sentiments  of  every  writer  who 
has  treated  of  it,  and  a detail  of  the  infinite  variety  of 
particular  modes  of  making  an  opening  into  the  bladder, 
would  occupy  as  many  pages  as  are  allotted  to  the 
whole  of  this  Dictionary.  It  must  be  my  endeavour, 
therefore,  rather  to  describe  what  is  most  interesting 
and  important,  than  pretend  to  offer  an  article  which 
is  to  comprehend  every  thing. 

Throughout  the  following  columns,  I suppose  the 
reader  to  be  already  well  informed  of  all  that  relates  to 
the  anatomy  of  the  bladder  and  adjacent  parts,  and 
that  of  the  perineum.  Without  correct  knowledge  of 
this  kind,  a man  must  be  presumptuous  indeed  to  set 
himself  up  for  a good  lithotomist;  and  if  he  were  to 
distinguish  himself  at  all,  it  would  only  be  by  the  mur- 
ders which  he  committed,  while  his  successful  feats,  if 
he  achieved  any,  could  redound  little  to  his  honour, 
since  every  young  student  would  soon  find  out  that 
they  were  not  the  effect  of  science  but  of  mechanical 
habit  and  imitation.  I would  particularly  recommend 
every  one  who  wishes  to  understand  well  the  anatomy 
of  the  pelvic  viscera  and  perineum,  with  a view  to 
lithotomy,  in  the  first  place  to  dissect  those  parts  him- 
self, and  then  avail  himself  of  the  valuable  instructions 
to  be  derived  on  the  subject  from  Winslow's  Anatomy; 
Le  Dran's  Parallile  de  la  Taille;  Le  Cat's  Deuxiime 
Ilecueil,  planches  5 ct  6 ; Haller's  Inst,  Med.  of  Boer- 
haave,  and  Elem.  Physiol,  t.  5 ; Morgagni,  Adversar, 
Anat,  3, 7>.  82.  97;  Camper's  plates  ; Lizars's  plates  ; 
John  Bell's  Principles  of  Surgery ; Deschamps's 
Traiti  Historique,  <S'c.  de  V Operation  de  la  Taille,  1. 1, 
p.  7,  Src. ; and  Langenbeck’s  description  of  the  parts, 
and  the  matchless  plate  which  he  has  given  of  them  in 
his  valuable  work  on  lithotomy,  cited  at  the  end  of 
this  article. 

A few  subjects  closely  connected  with  the  present 
will  be  found  in  otlier  parts  of  this  Dictionary.  For 
instance,  the  nature  of  stones  in  the  bladder  will  be 
considered  under  the  head  of  Urinary  Calculi,  where 
also  will  be  seen  some  observations  on  lithontriptics. 
The  manner  of  searching  for  the  stone,  or  as  it  is  now 
more  commonly  expressed  of  sounding,  will  be  ex- 
plained in  the  article  Sounding. 

Here  I shall  principally  confine  myself  to  the  symp- 
toms of  the  disease,  and  the  chief  methods  of  executing 
the  much-diversified  operation  of  lithotomy. 

SYMPTOMS  OF  THE  STONE. 

The  symptoms  of  a stone  in  the  bladder  are,  a sort 
of  itching  along  the  penis,  particularly  at  the  extremity 
of  the  glans;  and  hence  the  patient  often  acquires  the 
liabit  of  pulling  the  prepuce,  which  becomes  very  much 
elongated ; frequent  propensities  to  make  water,  and 
go  to  stool ; great  pain  in  voiding  the  urine,  and  dilfi- 


134 


LITHOTOMY. 


culty  of  retaining  it,  and  often  of  keeping  the  feces 
IVoin  being  discharged  at  the  same  time ; the  stream  of 
urine  is  liable  to  stop  suddenly,  while  flowing  in  a full 
current,  although  the  bladder  is  not  empty,  so  that  the 
fluid  is  expelled  by  fits  as  it  were ; the  pain  is  greatest 
towards  the  end  of  and  just  after  the  evacuation ; 
there  is  a dull  pain  about  the  neck  of  the  bladder,  to- 
gether with  a sense  of  weight  or  pressure  at  the  lower 
part  of  the  pelvis:  and  a large  quantity  of  mucus  is 
mixed  with  the  urine;  and  sometimes  the  latter  is 
tinged  with  blood,  especially  after  exercise. — {Sharp, 
Earle,  Sabatier.) 

Frequently  (says  Deschamps)  a patient  will  have  a 
stone  in  his  bladder  a long  while  without  the  occur- 
rence beinf  indicated  by  the  symptoms. — (See  Case  m 
Howship  on  Complaints  affecting  the  Secretion  and 
Excretion  of  the  Urine,  p.  125.)  Most  commonly, 
however,  the  presence  of  the  stone  is  announced  by 
pain  in  the  kidneys,  more  especially  in  adults  and  old 
persons  ; children  scarcely  ever  suftering  in  this  way, 
because  in  them  the  stone  is  hardly  detained  in  the 
kidneys  and  ureters  at  all,  but  descends  immediately 
into  the  bladder. 

It  seldom  happens  that  calculous  patients  void  blood 
with  their  urine  before  the  symptoms  usually  caused 
by  the  stone  have  taken  place.  It  is  not  till  affer  the 
foreign  body  has  descended  into  the  bladder,  acquired 
some  size,  and  presented  itself  at  the  orifice  of  that 
viscus,  that  pain  is  occasioned,  particularly  when  the 
surface  of  the  stone  is  unequal.  The  patient  then 
experiences  frequent  inclination  to  make  water,  at- 
tended with  pain.  The  jolting  of  a carriage,  riding  on 
horseback,  and  much  walking,  render  the  pain  more 
acute.  The  urine  appears  bloody,  and  its  course  is 
frequently  interrupted,  and  sabulous  matter  and  par- 
ticles of  stone  are  sometimes  discharged  willi  it.  The 
want  to  make  water  becomes  more  frequent  and  more 
insupportable.  The  bladder  is  irritated  and  inflames, 
its  pai  ietes  become  thickened  and  indurated,  and  its 
diameter  is  lessened.  A viscid,  more  or  less,  tenacious 
matter  is  observed  in  greater  or  less  quantity  in  the 
urine,  and  is  precipitated  to  the  bottom  of  the  vessel. 
The  urine  becomes  black  and  putrid,  and  exhales  an 
intolerable  alkalescent  smell,  which  is  perceived  at  the 
very  moment  of  the  evacuation,  and  is  much  stronger 
a little  while  afterward.  The  patient  can  no  longer 
use  any  exercise  without  all  his  complaints  being  re- 
doubled. Whenever  he  takes  much  exercise  the  urine 
becomes  bloody ; the  pain  about  the  hypochondria, 
which  was  dull  in  the  beginning,  grows  more  and  more 
acute ; the  ureters  and  kidneys  participate  in  the  irri- 
tation with  the  bladder;  they  inflame  and  suppurate, 
and  very  soon  the  urine  brings  away  with  it  purulent 
matter.  The  fever  increases,  and  changes  into  one  of 
a slow  type  ; the  patient  loses  his  sleep  and  appetite, 
becomes  emaciated  and  exhausted  ; and  death  at  length 
puts  a period  to  his  misery. — (See  Traitd  Historique 
et  Dogmatique  de  V Operation  de  la  Taille,  par  J.  F. 
E.  Deschamps,  t.  1,  p.  163.  Paris,  1796.) 

It  is  acknowledged  by  the  most  experienced  surgeons, 
that  the  symptoms  of  a stone  in  the  bladder  are  ex- 
ceedingly equivocal,  and  may  be  produced  by  several 
other  disorders.  “Pain  in  making  water,  and  not 
being  able  to  discharge  the  mine  without  the  feces, 
are  common  consequences  of  irritation  of  parts  about 
the  neck  of  the  bladder,  from  a diseased  prostate 
gland,  and  other  causes.  The  urine  stopping  in  a full 
stream  is  frequently  caused  by  a stone  altering  its  situ- 
ation so  as  to  obstruct  the  passage ; but  the  same  thing 
may  happen  from  a tumour  or  fungus  in  the  bladder. 

I have  seen  an  instance  of  this,  where  a tumour, 
hanging  by  a small  pedicle,  would  sometimes  cause 
obstruction,  and  by  altering  the  posture  would  retire 
and  give  a free  passage.  The  dull  pain  at  the  neck  of 
the  bladder,  and  the  sensation  of  pressure  on  the  rec- 
tum, are  frequently  owing  to  the  weight  of  the  stone, 
&c. ; l«it  these  may  proceed  from  a diseased  enlarge- 
ment of  the  prostate  gland.  Children  generally,  and 
grown  persons  frequently,  are  subject  to  a prolapsus 
ani,  from  the  irritation  of  a stone  in  the  bladder  ; but 
it  will  likewise  be  produced  by  any  irritation  in  those 
parts.” — {Earle.)  The  rest  of  the  symptoms  are 
equally  fallacious;  a schirrous  enlargement  of  the  os 
tincte  and  disease  of  the  kidneys  may  occasion  a co- 
pious quantity  of  mucus  in  the  urine,  with  pain,  irri- 
tation, &c.  “ The  least  fallible  sign  (says  Sir  Jame.s 
£urlc)  which  I have  remarlvcd,  is  tlie  patient  making 


the  first  portion  of  urine  with  ease,  and  complaining 
of  great  pain  coming  on  when  the  last  drops  arc  ex- 
pelled. This  may  readily  be  accounted  for,  from  the 
bladder  being  at  first  del'ended  from  contact  with  the 
stone  by  the  urine,  and  at  Mast  being  pressed  naked 
against  it.  But  to  put  the  matter  out  of  all  doubt,  and 
actually  to  prove  the  existence  of  a stone  in  the  bladder, 
we  must  have  recourse  to  the  operation  «f  sounding.” 

A stone  in  the  ureter  or  kidneys,  or  an  inflammation 
in  the  bladder  from  any  other  cause,  will  soineiimes 
produce  the  same  eftects : but  if  the  patient  cannot 
urinate,  except  in  a certain  posture,  it  is  almost  a sure 
sign  that  the  orifice  of  the  bladder  is  obstructed  by  a 
stone.  If  he  finds  ease  by  pressing  against  theperi- 
iiamm  with  liis  fingers,  or  sitting  with  that  part  upon  a 
hard  body,  there  is  little  doubt  the  ease  is  procured  by 
taking  olf  the  weight  of  the  stone;  or,  lastly,  if,  with 
the  other  symptoms,  he  thinks  he  can  feel  it  roll  in  his 
bladder,  it  is  hardly  possible  to  be  mistaken  ; however, 
the  only  sure  judgment  is  to  be  formed  from  searching. 

An  enlarged  prostate  gland  is  attended  with  symp- 
toms resembling  those  of  a stone  in  the  bladder ; but 
with  this  difference,  that  the  motion  of  a coach,  or 
horse,  does  not  increase  the  grievances  when  the  pros- 
tate is  affected,  while  it  does  so  in  an  intolerable  degree 
in  cases  of  stone.  It  also  generally  happens,  that  the 
fits  of  the  stone  come  on  at  intervals:  whereas  the 
pain  from  a diseased  prostate  is  neither  so  unequal 
nor  so  acute. — {Sharp  inCi-itical  Inq uii  y , ]>•  165,  edtt.  4.) 

Though  from  a consideration  of  all  the  circum- 
stances above  related,  the  surgeon  may  form  a probable 
opinion  of  there  being  a stone  in  the  bladder,  yet  he 
must  never  presume  to  deliver  a.  positive  one,  nor  ever 
be  so  rash  as  to  undertake  lithotomy,  without  having 
greater  reason  for  being  certain  that  there  is  a stone  to 
be  extracted.  Indeed,  all  prudent  surgeons,  for  centu- 
ries past,  have  laid  it  down  as  an  invariable  maxim, 
never  to  deliver  a decisive  judgment,  nor  undertake 
lithotomy,  without  having  previously  introduced  a me- 
tallic instrument,  called  a sound,  into  the  bladder,  and 
plainly  felt  the  stone. 

[There  are  frequently  cases  in  which  the  symptoms 
of  stone  in  the  bladder  are  all  present,  and  yet,  on  ex- 
amination with  the  sound,  the  surgeon  will  not  be  able 
to  feel  it  distinctly,  so  as  to  satisfy  himself  or  others. 
But  as  the  operation  should  never  be  attempted  until 
the  stone  is  plainly  felt,  when  any  difficulty  exists  in 
ascertaining  the  presence  of  the  calculus,  let  the  pa- 
tient be  placed  nearly  on  his  head  so  as  to  render  the 
fundus  of  the  bladder  the  lowest  part,  and  thus  bring 
the  foreign  body  into  contact  with  the  point  of  the 
sound.  This  method  was  first  suggested  by  Dr.  Physiefc, 
and  he  has  thus  detected  the  existence  of  calculi, 
where  other  surgeons  had  sounded  repeatedly  without 
success. — Reese.) 

I know  of  at  least  seven  cases,  and  at  two  of  them 
I was  present,  where  the  patients  were  subjected  to  all 
the  torture  and  perils  of  this  operation,  without  there 
being  any  ca’lculi  in  their  bladders.  The  maxim,  there- 
fore, cannot  be  too  strictly  enforced,  that  the  operation 
ought  never  to  be  attempted,  unless  the  stone  can  be 
distinctly  felt  with  the  sound  or  staff.  In  one  of  the 
examples,  of  which  I was  a spectator,  not  only  the 
symptoms,  but  the  feel  which  the  sound  itself  commu- 
nicated when  in  the  bladder,  made  the  surgeons  ima- 
gine that  there  was  a calculus,  or  some  extraneous 
body  in  this  organ.  Most  of  the  above  cases,  I under- 
stand, recovered,  which  may  be  considered  fortunate  ; 
because  when  the  stone  cannot  be  found,  the  disap- 
pointed operator  is  apt  to  persist  in  roughly  introducing 
his  fingers,  and  a variety  of  instruments,  so  long,  in  the 
hope  of  catching  what  cannot  be  got  hold  of,  that  in- 
flammation of  the  bladder  and  peritoneum  is  more 
likely  to  follow,  than  when  a stone  is  actually  present, 
soon  taken  out,  and  the  patient  kept  only  a short  lime 
upon  the  operating  table. 

In  a valuable  [)ractital  work  is  recorded  an  instance, 
in  which  « hat  is  called  a horny  cartilaginous  state  of 
the  bladder  made  the  sound  communicate  a sensation 
like  that  arising  from  the  instrument  actually  touching 
a stone,  and  the  surgeon  attempted  litiuuomy.  3'his 
jtatient  unfortunately  died  in  twenty-four  hours. — (See 
Desault's  Parisian  Chtr.  .fovriial,  vol.  2,  p.  125.) 

Ilowever,  were  the  symptoms  most  unequivocal, 
there  is  one  circumstance  which  would  always  render 
it  satisfactory  to  touch  the  stone  with  an  instrument, 
just  before  the  operation,  I mean  llie  possibility  of  a 


LITHOTOMY. 


135 


Slone  being  actually  in  the  bladder  to-day,  and  not  to- 
morrow. Stones  are  occasionally  forced,  by  the  vio- 
lent contractioiis  ol'  the  bladder,  during  fits  of  the  com- 
plaint, between  the  fasciculi  of  the  muscular  coat  of 
this  viscus,  together  witli  a portion  of  the  menibranous 
lining  of  the  part,  so  as  to  become  what  is  termed  en- 
cysted. Or,  as  there  is  reason  to  believe,  the  cyst  is 
sometiiiK's  produced  first,  and  the  calculus  is  formed  in 
it,  as  a kind  of  efiect  of  tiie  existence  of  the  separate 
pouch.  The  opening  into  the  cyst  is  frequently  very 
narrow,  so  that  the  stone  is  much  bigger  than  such 
orifice,  in  consequence  of  which  it  is  iihpossible  to  lay 
hold  of  the  extraneous  body  with  the  forceps,  and  the 
operation  would  necessarily  become  fruitless. — {Sharp's 
driticui  Inquiry,  p.  228,  edit.  4.) 

In  the  article  Urinary  CalcuM,  I have  noticed  the 
probability  of  this  having  occurred  in  some  of  the  in- 
stances in  which  Mrs.  Stevens’s  medicine  was  sup- 
posed to  have  actually  dissolved  the  stone  in  the 
bladder : for  an  encysted  stone  is  not  likely  to  be  hit 
with  the  sound,  nor  to  cause  any  inconvenience,  com- 
pared with  what  a calculus,  rolling  about  in  the  bladder, 
usually  occasions. 

It  is  remarked  by  Deschamps,  that  when  the  stone  is 
lodged  in  an  excavated  corner  of  the  bladder,  in  a par- 
ticular cyst,  or  depression ; when  it  projects  but  very 
little  ; when  it  cannot  shift  its  situation  in  the  bladder, 
so  as  to  fall  against  the  orifice  of  this  viscus  ; and  when 
it  is  also  smooth,  polished,  and  light ; the  patient  may 
have  it  a long  while,  without  experiencing  any  afflict- 
ing symptoms.  He  may  even  live  to  an  advanced  age, 
if  not  without  some  degree  of  suffering,  at  all  events, 
v.?ith  such  pain  as  is  very  supportable.  Daily  experi- 
ence proves,  that  persons  may  live  a considerable  time, 
with  one,  two,  or  even  three  stones  in  the  bladder,  and 
during  the  whole  of  their  lives  have  not  the  least  sus- 
picion of  the  existence  of  these  foreign  bodies. 

According  to  Deschamps,  this  must  have  been  the 
case  of  M.  Portalieu,  a tailor.  This  individual,  eighty 
years  old,  was  frequently  attacked  with  a retention  of 
urine  from  paralysis,  and  Deschamps  introduced  a 
sound  several  times,  and  distinctly  felt  a stone  in  the 
bladder.  The  patient,  however,  never  had  any  symp- 
tom of  the  disorder,  nor  even  at  the  end  of  two  years 
from  the  time  when  Deschamps  was  first  consulted. 
Very  large  and  exceedingly  rough  stones  have  also 
been  found  in  the  dead  bodies  of  persons,  who  had 
never  complained  of  the  s)inptoms  of  tlie  disease. 
Thus,  at  the  Anatomical  Theatreof  La  Charity,  Riche- 
rand  found  an  enormous  mulberry  stone  in  the  bladder 
of  a person,  who  died  altogether  of  another  disease, 
and  never  had  any  symptom  that  led  to  the  suspicion 
of  the  stone. — {JVosographie  Chir.  t.3,p.  530,  edit.  4.) 
But  cases  of  this  kind  must  be  rare,  because  it  is  well 
known  that  the  pain  which  a stone  produces  is  less  in 
a ratio  to  its  size  than  to  its  shape  and  situation.  A 
small  stone,  owing  to  its  situation,  may  be  more  painful 
than  an  enormous  calculus,  which  fills  the  bladder,  as 
is  proved  by  the  following  case  by  Deschamps. 

Pochet,  a watchmaker,  until  the  age  of  forty-five, 
had  never  had  any  infirmity,  except  that  of  not  being 
able  to  retain  his  water  a long  while.  One  day,  while 
he  was  carrying  a very  heavy  clock,  he  made  some  ex- 
ertions, which,  probably,  by  changing  the  situation  of 
the  calculus,  caused  at  the  instant  an  acute  pain  in  the 
hypogastrid  reeion.  Symptoms  of  the  stone  soon  came 
on;  the  pain  became  intolerable,  and  the  patient  went 
into  the  Hdpital  de  la  Cliaritd.  He  was  sounded  ; the 
stone  was  felt,  and  judged  to  be  of  considerable  size. 
The  incision  in  the  neck  of  the  bladder  not  sufficing 
for  its  extraction,  the  patient  was  put  to  bed  again. 
The  next  morning,  he  was  operated  upon  above  the 
pubes  by  Fi4re  C6me,  who  extracted  an  oval  calculus 
that  weighed  twenty-four  ounces.  The  patient  died 
four-and  twenty  hours  after  this  second  operation. 
This  case  proves  then  that  very  large  stones  may  lie  in 
the  bladder  without  occasioning  any  serious  com- 
plaints, since  the  preceding  patient  ap[iarently  had  had 
such  a calculus  a long  time,  without  suffering  inconve- 
nience from  it,  and  it  seems  likely  that  he  might  have 
continued  well  still  longer,  had  it  not  been  for  the  acci- 
dental effort  which  first  excited  the  symptoms. — {Traite 
Historique,  ^c.  de  la  Taille,  t.  1,  p.  166,  167.) 

A priest,  in  whom  Morand  had  ascertained  the  pre- 
sence of  a stone  by  sounding,  could  not  be  persuaded 
that  his  case  was  of  this  nature.  However,  he  be- 
queathed his  body  at  his  decease  to  the  surgeons,  and 


the  examination  of  the  bladder  fully  justified  Morand’s 
prognosis.  The  celebrated  D’Alembert  also  died  with 
a stone  in  his  bladder,  having  always  refused  to  be 
sounded. — {Richerand,  Op.  cit.  t.  3,  p.  538.) 

A question  may  here  suggest  itself;  ought  lithotomy 
to  be  practised  where  calculi  are  under  a certain  sizel 
Certainly  not,  because  they  frequently  admit  of  being 
extracted  through  the  urethra,  or  discharged  with  tlje 
urine,  without  any  operation  at  all,  even  from  the  male 
subject ; and  liow  much  more  likely  this  is  to  happen 
in  females,  must  be  plain  to  every  body  who  recollects 
the  direct  course,  the  shortness,  ample  size,  and  dilata- 
bility  of  the  meatus  urinarius.  On  this  subject,  various 
facts,  and,  in  particular,  the  dilator  used  by  Sir  A. 
Cooper,  will  be  adverted  to  in  considering  lithotomy 
in  women.  Sometimes,  also,  when  a calculus  is 
too  large  to  pass  completely  through  the  male  ure- 
thra, it  lodges  in  this  passage,  where  it  may  be  more 
safely  cut  upon  and  removed,  than  from  the  bladder ; 
and  sometimes  it  is  actually  discharged  by  an  ulcer- 
ative process.  Thus  Dr.  R.  A.  Langenbeck  has  pub- 
lished an  example,  in  which  a stone  made  its  way  out  by 
ulceration,  and  was  discharged  immediately  behind 
the  testes. — (See  J.  C.  Langenbeck' s Bibl.  fiir  die 
Chir.  Gott.  1809.)  And  G.  Coopmans  has  recorded  an 
almost  incredible  case,  in  which  a calculus,  weighing 
five  ounces  one  drachm  and  a half,  was  discharged  on 
the  left  side  of  the  urethra  of  an  elderly  man,  a little 
below  the  glans  penis.  In  fact,  without  some  farther 
explanation,  this  case  would  be  pronounced  impossible ; 
but  it  should  be  recollected,  that  after  a small  calculus 
has  made  its  way  out  of  the  urethra  by  ulceration,  if 
the  urine  have  still  access  to  it,  it  will  continue  to  in- 
crease in  size  in  its  new  situation ; and  this  is  what 
happened  in  the  present  example;  for  the  extraneous 
body,  when  first  felt  externally,  was  not  larger  than  a 
pea.  The  calculus  is  now  preserved  in  Camper’s 
museum. — {JVeurologia,  8vo.  Franequerm,  1795.)  I am 
not  meaning,  however,  to  recommend  surgeons  to  let 
the  patient  encounter  all  the  sufferings  which  must 
inevitably  attend  leaving  the  business  to  be  completed 
by  ulceration  ; because,  as  soon  as  the  nature  of  the 
case  is  known,  an  incision  should  be  made  into  the 
swelling,  and  the  foreign  body  taken  out.  In  many 
cases,  also,  small  calculi  may  be  voided  by  dilating  the 
male  urethra  with  elastic  gum  catheters  of  very  large 
diameter,  and  then  desiring  the  patient  to  expel  his 
urine,  with  considerable  force,  a plan  which  Baron 
Larrey  has  found  repeatedly  answer.  The  idea  of 
withdrawing  calculi  from  the  bladder  through  the 
urethra  by  suction  and  dilatation  of  the  passage, 
seems  to  have  been  entertained  by  several  practitioners 
of  former  days,  especially  Alpinus,  Muys,  Verduc, 
Mayerne,  and  Le  Dran. — (See  Dr.  Kerrison's  Paper  in 
Med.  Chir.  Trans,  vol.  12,^.  315.)  Desault  even  tried 
experiments  with  a kind  of  forceps,  which  admitted 
of  being  protruded,  and  of  opening  and  shutting  at  the 
extremity  of  a cannula,  which  was  i.ntroduced  into  the 
bladder;  but  no  instance  of  his  success  on  the  human 
subject  is  recorded. — (See  Journ.  de  Chir.  t.  2,  p.  375, 
Paris,  1791.)  The  honour  of  bringing  the  plan  to  per- 
fection was  reserved  for  Sir  Astley  Cooper:  “The  in- 
strument (says  he)  which  I first  had  made  for  the  pur- 
pose of  retnoving  these  stones  from  Mr.  Buffer,  were 
merely  common  forceps,  made  of  the  size  of  a sound, 
and  similarly  curved ; but  Mr.  Weiss,  surgeons’  instru- 
ment maker  in  the  Strand,  showed  me  a pair  of  bullet 
forceps,  which,  he  thought,  would  with  a litile  altera- 
tion better  answer  the  purpose  I had  in  view.  He 
removed  two  of  the  blades  of  these  forceps  (for  there 
were  four),  and  gave  them  the  form  of  the  forceps 
which  I had  had  constructed : the  blades  of  this  instru- 
ment could  he  opened  while  in  the  bladder,  by  means 
of  a stilette,  so  as  to  grasp  and  confine  the  stone,  and 
they  appeared  so  well  constructed  for  the  purpose  as 
to  induce  me  to  make  a trial  of  them,  on  the  23d  of 
November,  1820 ; and  the  manner  in  which  they  were 
used  was  as  follows:  Mr. Buffer  was  placed  across  his 
bed,  with  his  feet  resting  on  the  floor,  and  a silver 
catheter  was  then  introduced,  and  the  bladder  emptied 
of  urine.  I then  passed  the  forceps  into  the  bladder, 
and  was  so  fortunate  in  my  first  operation  as  to  extract 
eight  calculi.  The  instrument  gave  but  little  pain  on 
its  introduction  but  yvhen  opened  to  Its  greatest  ex- 
tent, and  the  stones  admitted  between  its  blades,  their 
removal  was  painful,  moreespecially  at  the  glans  penis, 
which  appears  to  be  the  portion  of  the  urethra  w hlcl^ 


136 


LITHOTOMY. 


makes  the  greatest  resistance  to  the  removal  of  the 
stones.  A dose  of  opium  was  given  after  each  opera- 
tion.”— {Med.  Chir.  Trans,  vol.  11,  p-  358.)  Sir  A. 
Cooper  thus  removed  from  the  above  patient  84  calculi 
at  different  times.  From  one  patient,  Mr.  Brodie  also 
extracted  in  the  same  manner  about  sixty  calculi,  of 
various  sizes  ; but  the  largest  measured  half  an  inch 
in  one  diameter,  and  five-eighths  in  the  other. — ( Op. 
cit.  vol.  12,  p.  383.)  In  one  case.  Sir  A.  Cooper  took 
out  with  the  urethral  forceps  a calculus  that  weighed 
fifty-four  grains,  after  having  gradually  dilated  the 
urethra  with  bougies — {Fol.cit.p.387.)  Other  con- 
vincing examples  of  the  practicableness  and  success 
of  the  practice  are  also  related  by  the  same  distin- 
guished surgeon.  According  to  his  valuable  observa- 
tions, when  a great  number  of  calculi  are  found  in  the 
bladder,  they  are  generally  attended  with  an  enlarge- 
ment of  the  prostate  gland,  and  are  lodged  in  a sacculus 
formed  directly  behind  it.— (FoZ.  11,  p.  357.) 

To  me  the  establishment  of  the  preceding  practice 
by  Sir  Astley  Cooper,  and  the  invention  of  the  lithon- 
triptor,  seem  two  of  the  greatest  triumphs  of  mo- 
dern surgery;  and  I have  no  doubt  that  the  names 
of  all  concerned  m bringing  them  about,  will  receive 
from  the  latest  posterity  the  honour  which  cannot  fail 
to  attach  itself  to  improvements,  by  which  the  neces.sity 
for  a severe  and  highly  dangerous  operation  is  rendered 
considerably  less  frequent.  Even  when  the  stone 
cannot  be  drawn  completely  out  of  the  urethra  by  the 
forceps,  but  only  into  it,  the  advantage  is  great,  be- 
cause it  may  then  be  easily  cut  down  to  and  extracted 
without  any  wound  or  injury  of  the  bladder.— (See 
Med.  Chir.  Trans,  vol.  11.)  And  in  cases  where  a 
calculus  is  larger  than  can  be  extracted  by  the  urethral 
forceps,  but  not  too  large  to  be  seized  and  pulverized 
by  the  lithrontriptor  (see  this  word),  I am  disposed  to 
believe  that,  except  when  the  stone  is  above  a certain 
size,  the  severe  and  perilous  operation  of  lithotomy 
should  not  be  undertaken  without  first  trying  what  re- 
lief can  be  obtained  by  the  use  of  the  latter  ingenious 
instrument. 

I shall  next  describe  the  various  methods  of  cutting 
for  the  stone,  beginning  with  the  most  ancient,  called 
the  apparatus  minor,  and  ending  with  the  modern  pro- 
posal of  employing  a knife  in  preference  to  a gorget. 

or  THE  APPARATUS  MINOR  CUTTINO  ON  THE  GRIPE, 
OR  CELSUS’S  METHOD. 

The  most  ancient  kind  of  lithotomy  was  that  prac- 
tised upwards  of  two  thousand  years  ago  by  Ammo- 
nius,  at  Alexandria,  in  the  time  of  Herophilus  and 
Erasistratus,  and  by  Meges  at  Rome,  during  the  reign 
of  Augustus ; and  being  described  by  Celsus,  is  named 
Lithotomia  Celsiani.  As  the  stone,  fixed  by  the  pres- 
sure of  the  fingers  in  the  anus,  was  cut  directly  upon, 
it  has  been  called  cutting  on  the  gripe,  a knife  and  a 
hook  being  the  only  instruments  used.  The  appella- 
tion of  the  less  apparatus  was  given  to  it  by  Mari- 
anus  in  order  to  distinguish  it  from  a method  which  he 
described,  called  the  apparatus  major,  from  the  many 
instruments  employed. 

The  operation  was  done  in  the  following  way.  The 
rectum  was  emptied  by  a glyster,  a.  few  hours  previ- 
ously ; and,  immediately  before  cutting,  the  patient  was 
desired  to  walk  about  his  chamber,  to  bring  the  stone 
down  to  the  neck  of  the  bladder ; he  was  then  placed 
in  the  lap  of  an  assistant,  or  secured  in  the  manner 
now  practised  in  the  lateral  operation.  The  surgeon 
then  introduced  the  fore  and  middle  fingers  of  liis  left 
hand,  well  oiled,  into  the  anus;  while  he  pressed  with 
the  palm  of  his  right  hand  on  the  lower  part  of  the 
abdomen,  above  the  pubes,  in  order  to  promote  the  de- 
scent of  the  stone.  With  the  fingers  the  calculus  was 
next  griped,  pushed  forwards  towards  the  neck  of  the 
bladder,  and  made  to  protrude  and  form  a tumour  on 
the  left  side  of  the  perinoeum.  The  operator  then  took 
a scalpel  and  made  a lunated  incision  through  the  skin 
and  cellular  substance,  directly  on  the  stone  near  the 
anus,  down  to  the  neck  of  the  bladder,  with  the  horns 
towards  the  hip.  Then,  in  the  deeper  and  narrower 
part  of  the  wound,  a second  transverse  incision  was 
made  on  the  stone  into  the  neck  of  the  bladder  itself, 
till  the  flowing  out  of  the  urine  showed  that  the  i»ici- 
sion  exceeded  in  some  degree  the  size  of  the  stone.  The 
calculus,  being  strongly  pressed  upon  with  the  fingers, 
next  started  out  of  itself,  or  was  extracted  with  a hook 


for  the  purpose.— (CeZsMS,  lib.  7,  cap.  26.  J.  BelVs 
Principles,  vol  2,  p.  42.  jillan  on  Lithotomy,  p.  10.) 

The  objections  to  cutting  on  the  gripe  are,  the  im- 
possibility of  always  dividing  the  same  parts;  for 
those  which  are  cut  will  vary  according  to  the  degree 
of  force  employed  in  making  the  stone  project  in  the 
perinceum. ' When  little  e.xertion  is  made,  if  the  inci- 
sion be  begun  just  behind  the  scrotum,  the  ureihia  may 
be  altogether  detached  from  the  prostate ; if  the  stone  be 
much  pushed  out,  the  bladder  may  be  entered  beyond 
the  prostate,  and  both  the  vesiculai  seminales  and  vasa 
deferentia  inevitably  suffer.  Lastly,  if  the  parts  are 
just  sufficiently  protruded,  the  neck  of  the  bladder  will 
be  cut,  through  the  substance  of  the  prostate  gland. — 
{Mian  on  Lithotomy.  Burns,  in  Edinb.  Surg.  Jour- 
nal, Mo.  XIII.  J.  Bell,  vol  2,  p.  59.) 

The  preceding  dangers  were  known  to  Fabricius  Hil- 
danus,  who  attempted  to  obviate  them  by  cutting  on  a 
staff  introduced  through  the  urethra  into  the  bladder. 
He  began  his  incision  in  the  periiiceum,  about  half  an 
inch  on  the  side  of  the  raphe;  and  he  continued  the 
cut,  inclining  the  knife,  as  he  proceeded,  towards  the 
hip.  He  continued  to  divide  the  parts  till  he  reached 
the  staff,  after  which  he  enlarged  the  wound  to  such  an 
extent  as  permitted  him  easily  with  a hook  to  extract 
the  stone,  which  he  had  previously  brought  into  the 
neck  of  the  bladder  by  pressure  with  the  fingers  in  the 
rectum.— (Burns.)  In  this  way  Mr.  C.  Bell  has  ope- 
rated with  success. — {J.  Bell.) 

The  apparatus  minor,  as  practised  by  Fabricius,  with 
the  aid  of  a staff,  is  certainly  a very  simple  operation 
on  children,  and  some  judicious  surgeons  doubt  the 
propriety  of  its  present  neglected  state.  You  cut,  says 
an  eminent  writer,  upon  the  stone,  and  make  of  course 
with  perfect  security  an  incision  exactly  proportioned 
to  its  size.  There  is  no  difficult  nor  dangerous  dissec- 
tion ; no  gorget  nor  other  dangerous  instrument  thrust 
into  the  bladder,  with  the  risk  of  its  passing  between 
that  and  the  rectum ; you  are  performing  expressly  the 
lateraj  incision  of  Raw  and  Cheselden,  in  the  most  sim- 
ple and  favourable  way.  The  prisca  simplicitas  in- 
strumentorum  saems  to  have  been  deserted  for  the  sake 
of  inventing  more  ingenious  and  complicated  opera- 
tions.— (J.  Bell.) 

Celsus  has  delivered  one  memorable  precept  in  his 
description  of  lithotomy,  ut  plaga  paulo  major  qudm 
calculus  sit ; and  he  seems  to  have  known  very  well 
that  there  was  more  danger  in  lacerating  than  cutting 
the  parts. 

The  simplicity  of  the  apparatus  minor,  however, 
formerly  emboldened  every  quack  to  undertake  it;  and 
as  this  was  followed  by  the  evils  and  blunders  un- 
avoidably originating  from  ignorance,  at  the  same  time 
that  it  diminished  the  emolument  of  regular  practi- 
tioners, the  operation  fell  into  disrepute. — (See  Heis- 
ter.)  It  was  longer  practised,  however,  than  all  the 
other  methods,  having  been  continued  to  the  comnience- 
ment  of  the  16th  century ; and  it  was  performed  at 
Bordeaux,  PariSj  and  other  places  in  France,  on  pa- 
tients of  all  ages,  by  Raoux,  even  as  late  as  150  years 
ago.  Frdre  Jaques  occasionally  had  recourse  to  it; 
and  it  was  successfully  executed  by  Heister. — {Part  2, 
cAap.  140.)  A modern  author  recommends  it  always  to 
be  preferred  on  boys  under  fourteen. — {Allan,  p.  12.) 

APPARATUS  MAJOR. 

So  named  from  the  multiplicity  of  instruments  em- 
ployed; or  the  Marian  method,  from  having  been  first 
published  by  Marianus  Sanctus,  in  1524,  as  the  inven- 
tion of  his  master  Johannes  de  Romanis. 

Tliis  operation,  which  came  into  vogue,  as  we  have 
noticed,  from  avaricious  causes,  was  rude  and  painful 
in  its  performance,  and  very  fatal  in  its  consequences. 
The  apology  for  its  introduction  was  the  declaration  of 
Hippocrates,  that  the  wounds  of  membranous  parts  are 
mortal.  It  was  contended,  however,  that  such  parts 
might  be  dilated  with  impunity ; and  on  this  principle 
of  dilatation  Romanis  invented  a complex  and  danger- 
ous plan  of  operating;  one  very  incompetent  to  fulfil 
the  end  proposed;  one  which,  though  su|»posed  only 
to  dilate,  really  lacerated  the  parts. — (Burns.) 

'I'he  operator,  kneeling  on  one  knee,  made  an  inci- 
sion w'ith  his  razor  along  the  perinamm,  on  one  side  of 
the  raphe  ; and  feeling  with  his  little  finirt.'r  for  the 
curve  of  the  staff,  he  opened  tin;  membranous  part  of 
the  urethra;  and  living  the  point  of  the  knife  in  the 
groove  of  the  stalf,  gave  it  to  an  assistant  to  hold,  while 


LITHOTOMY. 


137 


he  passed  a probe  along  the  knife  into  the  groove  of  the 
statF,  and  thus  into  the  bladder.  The  urine  now  flowed 
out,  and  the  staff  was  withdrawn.  The  operator  next 
took  two  conductors,  a sort  of  strong  iron  probes  ; one, 
named  a female  conductor,  having  in  it  a groove,  like 
one  of  our  common  directors ; the  other,  the  male  con- 
ductor, having  a probe  point  corresponding  with  tlial 
groove.  The  grooved,  or  female  conductor,  being  in 
troduced  along  the  probe  into  the  bladder,  the  probe 
was  withdrawn,  and  the  male  conductor  passed  along 
the  groove  of  the  female  one  into  the  bladder.  Then 
commenced  the  operation  of  dilating.  The  lithotomisi 
took  a conductor  in  each  hand,  and  by  making  their 
shafts  diverge,  dilated,  or,  in  plain  language,  tore  open 
Uie  prostate  gland.— (J.  Bell.) 

It  would  be  absurd  in  me  to  trace  the  various  dila- 
ting instruments  contrived  for  the  improvement  of  this 
barbarous  operation,  by  the  Colots,  Marichal,  Le  Dran, 
Par^,  &c.  Among  the  numerous  glaiing  objections  to 
the  apparatus  major,  we  need  only  notice  the  cutting  of 
the  bulb  of  the  urethra,  not  sufficiently  dividing  the 
membranous  part  of  the  urethra,  nor  the  transversalis 
pt^rineei  muscle,  which  forms  a kind  of  bar  across  the 
place  where  the  stone  should  be  extracted  ; violent  dis 
tention  of  the  membranous  part  of  the  urethra  and 
neck  of  the  bladder ; laceration  of  these  latter  parts  ; 
large  abscesses,  extravasation  of  urine,  and  gangrene; 
frequent  im potency  afterward  ; and  extensive  fatality. 
Bertrandi  even  saw  the  urethra  and  neck  of  the  blad- 
der torn  from  the  prostate  by  the  violence  employed  iti 
this  vile  method  of  operating. — {Operations  de  C/iir.p. 
169.)  However,  Par^,  Le  Dran,  Le  Cat,  Mery,  Mo- 
rand,  Mar4chal,  Raw,  and  all  the  best  surgeons  in  Eu- 
rope, most  strangely  practised  this  rash  method  for  two 
hundred  years,  till  Fr^re  Jacques,  in  1697,  taught  at 
Paris  the  original  model  of  lithotomy,  as  commonly 
adopted  at  the  present  day. 

THE  HIGH  OPERATION 

Was  first  practised  in  Paris  in  1475,  by  Colot,  as  an  ex- 
periment on  a criminal,  by  permission  of  Louis  the  XI. ; 
and  the  patient  recovered  in  a fortnight.  'I’he  earliest 
account  of  this  method  of  operating  was  published  in 
1356,  by  Pierre  Franco,  in  his  Treatise  on  Hernia,  cd. 

1.  He  performed  it  on  a child  two  years  old,  after 
finding  the  calculus  too  large  to  admit  of  beint;  extracted 
from  the  perinapurn,  where  he  had  first  nr.Hde  an  open- 
ing ; his  remarks,  how'ever,  tend  to  discourage  the 
ractice.  Rossetus  recommended  it  with  great  zeal  in 
is  book  entitled  Partus  Casarius,  printed  in  1591 ; 
•but  he  never  performed  the  operation  himself.  Tolet 
mentions  the  trial  of  it  iti  the  Hdtel-Dieu,  but,  without 
entering  into  the  particular  causes  of  its  discontinu- 
ance, merely  says  that  it  w'as  found  inconvenient. 
About  the  year  1719,  it  was  first  done  in  England  by 
Mr.  Douglas;  and  after  him  practised  by  others.— 
{Sharp's  Operations.) 

The  patient  being  laid  on  a square  table,  with  his  legs 
hanging  off,  and  fastened  to  the  sides  of  it  by  a liga- 
ture passed  above  the  knee,  his  head  and  body  lilted 
up  a little  by  pillows,  so  as  to  relax  the  abdominal 
muscles,  and  his  hands  held  steady  by  some  assistants  ; 
as  much  barley-water  as  he  could  bear,  which  was 
often  about  eight  ounces,  and  sometimes  twelve,  was 
injected  through  a catheter  into  the  bladder. 

In  order  to  prevent  the  reflux  of  the  water,  an  assist- 
ant grasped  the  penis  the  moment  the  catheter  was 
withdrawn,  holding  it  on  one  side  in  such  a manner  as 
not  Id  stretch  the  skin  of  the  abdomen  ; then  with  a 
round-edged  knife  an  incision,  about  four  inches  long, 
w.as  made  between  the  recti  and  pyramidal  muscles, 
through  the  mernbrana  adiposa,  as  deep  as  the  bladder, 
bringing  its  extremity  almost  down  to  the  penis  ; after 
this,  with  a crooked  knite,  the  incision  was  continued 
into  the  bladder,  and  carried  a little  under  the  os  pubis  ; 
and  immediately  upon  the  water’s  flowing  out,  the  fore- 
finger of  the  left  hand  was  introduced,  which  directed 
the  forceps  to  the  stone. — (Sharp's  Operations.)  Saba- 
tier disapprovesof  making  the  cut  in  the  bladder  from 
below  upwards,  lest  the  knife  injure  the  peritoneum. — 
(Mid.  Opiratoire,l.'H,p.  160.) 

Although  this  method  of  operating  appears  at  first 
view  fe^ible  enough,  several  objections  soon  brought 
It  into  disuse.  1.  q’he  irritation  of  a stone  often  causes 
such  a thickened  and  contracted  slate  of  the  bladder, 
that  this  viscus  will  not  admit  of  being  distended  so  as 
to  rise  above  the  pubes.  2.  If  the  operator  should  break 


the  stone,  the  fragments  cannot  be  easily  washed  away, 
but,  remaining  behind,  form  a nucleus  for  a future 
stone.  3.  Experience  has  proved  that  the  high  ope- 
ration is  very  commonly  followed  by  extravasation  of 
urine,  attended  with  suppuration  and  gangrenous  mis- 
chief in  the  cellular  membrane  of  the  pelvis.  This 
happens  because  the  urine  more  readily  escapes  out  of 
the  wound  in  the  bladder  than  through  the  urethra; 
and  also  because,  when  the  bladder  contracts  and  sinks 
behind  the  os  pubis,  the  wound  in  it  ceases  to  be 
parallel  to  that  in  the  liuea  alba  and  integuments,  and 
becomes  deeper  and  deeper.  For  the  pieventiun  of 
these  ill  consequences,  says  Sabatiei,  it  will  be  in  vain 
to  nnake  the  patient  lie  in  a horizontal  iiosture,  and 
keep  a catheter  introduced,  as  Rousset  and  Morand  re- 
commended; the  bad  effects  being  still  neither  less  fre- 
quent nor  less  fatal. — (See  Medecine  Operatoire,  t.  3,p. 
161,  edit.  2.)  And  Sir  Everard  Home  confesses,  that 
while  the  high  operation  for  the  stone  had  no  other 
channel  but  the  wound  for  carrying  off  the  uiine,  it 
seemed  to  him  a method  which  ought  never  to  be 
adopted  ; “ the  urine  almost  always  insinuating  itself 
into  the  cellular  membrane  behind  the  pubes,  pro- 
ducing sloughs,  and  consequently  ab.-cesses.” — (On 
Strictures,  vol.  3,  p.  359,  Qvo.  Land.  1821.)  4.  The  dan- 
ger of  exciting  inflammation  of  the  peritoneum.  5. 
The  injection  itself  is  exceedingly  painful,  and  however 
slow  the  fluid  be  injected,  the  bladder  can  seldom  be  di- 
lated enough  to. make  the  operation  absolutely  secure  ; 
and  when  hastily  dilated,  its  tone  may  be  destroyed.— 
(See  Sharp,  Lilian,  Sabatier,  4’c.) 

Some  judicious  surgeons  of  the  present  day  are  de 
cidedly  of  opinion,  that  when  a stone  in  the  bladder  is 
known  to  be  very  large,  no  attempt  ought  ever  to  be 
made  to  extract  it  from  the  perinaeum.  Scarpa  de- 
clares, that  the  lateral  operation  should  not  be  prac- 
tised when  the  calculus  exceeds  twenty  lines  in  its 
small  diameter. — (See  Memoir  on  the  Cutting  Gorget 
of  Hawkins,  p.  8,  transl.  by  Briggs.)  In  such  cases, 
it  is  true,  the  surgeon  may  do  the  lateral  operation,  and 
try  to  break  the  stone.  But  ought  this  proceeding  to  be 
[•referred  to  the  high  operation  1 I speak  particularly 
of  cases  in  which  the  stone  is  known  to  be  of  very 
large  dimensions  before  any  operation  is  begun. 
Were  the  lateral  operation  commenced,  the  stone,  if 
loo  large  for  extraction,  must  of  course  be  broken  ; for 
it  is  then  too  late  to  adopt  the  high  operation  with  ad- 
vantage. That  such  things  have  been  done,  however, 
and  yet  the  patients  escaped,  is  a truth  which  cannot  be 
denied.  Deschamps  mentions  an  instance  in  which 
M.  Lassus,  after  using  Hawkins’s  gorget,  could  not  draw 
out  the  calculus,  and  he  therefore  immediately  did  the 
high  operation,  and  the  patient  recovered.  Indeed, 
the  second  example  of  the  high  operation  on  retard, 
was  done  by  Franco  under  similar  circumstances,  and 
the  patient  was  saved.  I have  also  heard  of  a modern 
French  surgeon  who  began  with  the  lateral  operation, 
but  finding  a large  calculus,  ended  with  performing  the 
high  operation,  without  the  least  delay  or  hesitation : 
the  patient  dit  d. 

Mr.  S.  Sharp,  an  excellent  practical  surgeon  in  his 
time,  after  noticing,  with  great  impartiality,  the  objec- 
tions which  were  then  urged  against  the  high  operation, 
says,  that  he  should  not  be  surprised  if  hereafter  it 
were  revived  and  practised  with  success;  an  obser- 
vation which  implied  that  he  foresaw  that  the  method 
was  capable  of  being  so  improved  as  to  free  it  from  its 
most  serious  inconveniences.  In  fact  since  his  time, 
various  attempts  have  been  made  to  introduce  the  high 
operation  anew,  and  upon  improved  principles.  Frdre 
Cdme,  in  particular,  knew  very  well  that  there  were 
circumstances,  as,  for  instance,  a calculus  above  a cer- 
tain size,  disease  of  the  urethra,  or  prostate  gland,  &c., 
where  the  lateral  operation  was  liable  to  great  difficul- 
ties and  disadvantages,  and  where  the  high  operation. 

If  it  could  be  perfected,  would  be  a fitter  and  safer 
mode  of  proceeding.  However,  it  was  only  in  such 
cases,  and  not  in  all,  that  Fr^re  Cdme  thought  the  me- 
thod better  than  the  lateral  operation.  He  had  also  dis- 
cernment enough  to  perceive  that  it  was  extremely  de- 
sirable to  invent  some  means  whereby  the  painful  and 
hurtful  distention  of  the  bladder,  for  the  purpose  of 
making  this  organ  rise  behind  the  pubes,  would  be 
tendered  unnecessary,  at  the  same  time  that  some  mea- 
sure was  adopted  for  letting  the  urine  have  a more  de- 
pending outlet,  than  the  wound  in  the  hypogastric  re» 
gion.  In  the  early  editions  of  this  Dictionary,  the 


138 


LITHOTOMY. 


error  was  committed  of  representing  C6ine  to  have  cut 
the  neck  of  the  bladder  as  well  as  its  fundus;  a mis- 
take which  I first  became  aware  of  upon  the  perusal 
of  Mr.  Carpiie’s  interesting  work  on  lithotomy.  The 
fact  is,  that  Come  did  not  wound  the  bladder  in  two 
places,  but  opera. ed  after  the  following  way : he  first 
introduced  through  the  urethra  into  the  bladder  a staff, 
which  was  then  held  by  an  assistant.  An  incision,  an 
inch  in  length,  was  now  made  in  the  perinteutn,  in  the 
same  direction  as  in  the  lateral  operation.  Another 
incision  was  made  in  the  membranous  part  of  the  ure- 
thra along  the  groove  of  the  staff,  as  far  as  the  prostate 
gland.  A very  deeply  grooved  director  was  then 
passed  along  the  staff  into  the  bladder,  and  the  latter 
instrument  was  withdrawn.  By  means  of  the  direc- 
tor, a sunde  d dard,  or  kind  of  catheter  furnished  with 
a stilelte,  was  now  introduced  into  the  bladder,  and  the 
diiector  taken  out.  An  incision  was  then  made,  about 
three  or  four  inches  in  length,  just  above  the  symphy- 
sis of  the  pubes,  down  to,  and  in  the  direction  of,  the 
linea  alba.  A trocar,  in  which  there  was  a concealed 
bistoury,  was  next  passed  into  the  linea  alba,  close  to 
the  pubes,  and  the  blade  of  the  knife  then  started  from 
its  sheath  towards  the  handle  of  the  instrument,  while 
its  other  end  remained  stationary.  In  this  manner  the 
lower  part  of  the  linea  alba  was  cut  from  below  up- 
wards, and  an  aperture  was  made,  which  was  now  en- 
larged with  a probe-pointed  curved  knife,  behind 
which  a finger  was  kept,  so  as  to  push  the  peritoneum 
out  of  the  way.  C6me  then  took  hold  of  the  sonde  d 
dard  with  his  right  hand,  and  elevating  its  extremity, 
lifted  up  the  fundus  of  the  bladder,  while  with  the 
fingers  of  his  left  hand  he  endeavoured  to  feel  its  ex- 
tremity in  the  wound.  As  soon  as  the  end  of  the  in- 
strument was  perceived,  it  was  taken  hold  of  between 
the  thumb  and  middle  finger,  the  peritoneum  was 
carefully  kept  up  out  of  the  way,  and  the  stilette  was 
pushed  by  an  assistant  from  within  outwards  through 
the  fundus  of  the  bladder.  The  bladder  being  thus 
pierced,  the  operator  introduced  into  a groove  in  the 
stilette  a curved  bistoury,  with  w'hich  he  divided  the 
front  of  the  bladder  from  above  downwards,  nearly  to 
its  neck.  He  then  passed  his  fingers  into  the  opening, 
and  keeping  up  the  bladder  with  them,  withdrew  the 
sonde  d dard  altogether.  But  as  it  was  desirable  that 
both  his  hands  should  be  free,  the  bladder  was  pre 
vented  from  slipping  away  by  means  of  a suspensory 
hook,  held  by  an  assistant  as  soon  as  the  opening  was 
found  to  be  already  ample  enough,  or  had  been  en- 
larged to  the  necessary  extent.  Come  next  introduced 
the  forceps,  took  out  the  stone,  and  passed  a cannula, 
or  elastic  gum  catheter,  through  the  wound  in  the  peri- 
nsBiyp  into  the  bladder,  so  as  to  maintain  a ready  out- 
let for  the  urine,  and  divert  this  fluid  from  the  wound 
in  the  bladder.  In  women,  of  course,  the  catheter  was 
passed  through  the  meatus  uritiarius.  And  I ought 
here  to  observe,  that  Come,  like  Scarpa,  thought  the 
high  operation  especially  advisable  for  females,  be- 
cause his  experience  had  taught  him,  that  the  division, 
or  dilatation,  of  the  meatus  urinarius  was  generally 
followed  by  an  incontinence  of  urine. — (See  J^ouvelle 
Mefhnde  d'extraire  la  Pierre  de  la  Vassie  par  dessus 
le  Pubis,  £rc.  8vo.  Bruxelles,  1779.) 

Another  modification  of  the  high  operation  was  sug- 
gested by  Deschainps,  who,  instead  of  opening  the 
membranous  part  of  the  uiethra,  as  Cdme  did,  perfo- 
rated the  bladder  from  the  rectum,  and  through  the  can- 
nula of  the  trocar  effected  the  same  objects  which  the 
latter  lithotomist  accomplished  by  means  of  the  inci 
sion  in  the  membranous  part  of  the  urethra.  Of  the 
two  plans,  that  devised  by  Come  is  unquestionably  the 
best  because  not  attended  with  a double  wound  of  the 
bladder,  a thing  which,  I conceive,  must  always  be 
highly  objectionable. 

Dr.  Souberbielle,  who  practises  C6me’s  method,  in- 
troduces a silver  wirethrouiih  the  cannula  of  the  sonde 
d dard,  and  passes  it  through  the  wound  made  in  the 
linea  alba.  The  wire  is  then  held  while  the  sonde  d 
dard  is  withdrawn,  and  a flexible  gum-catheter  is 
passed  by  means  of  the  wire  into  the  bladder  through 
the  wound  in  the  membranous  part  of  the  urethra. 
The  wire  is  now  withdrawn,  and  the  catheter  is  fixed 
with  tapes,  passed  round  the  thighs  and  pelvis,  and  a 
bladder  is  tied  to  it  for  the  reception  of  the  urine.  “ A 
piece  of  soft  linen,  half  an  inch  wide,  and  six  or  eight 
inches  long,  is  to  be  introduced  by  means  of  a pair  of 
forceps  into  the  bottom  of  the  bladder the  object  of 


which  slip  of  linen  is  to  carry  off  such  urine  as  may  not 
escape  through  the  catheter.  Lint  and  light  dressings 
are  applied,  and  a bandage  round  the  abdomen.  Great 
care  is  to  be  taken  to  keep  the  catheter  pervious,  and, 
usually  on  the  third  day,  the  slip  of  linen  may  be  taken 
out,  and  the  wound  closed  with  adhesive  plaster. — (See 
Carpue's  History  of  the  High  Operation,  p.  171,  172.) 

Sir  Everard  Home  made  trial  of  Dr.  Souberbielle’s 
method  in  St.  George’s  Hospital,  and  though  some  dif- 
ficulty and  delay  occurred  in  the  operation,  on  account 
of  the  stone  being  encysted,  the  result  was  successful. 
Subsequetitly  to  this  case,  however.  Sir  Everard  had 
invented  and  practised  another  method,  which,  as  far 
as  I can  judge,  is  better  than  that  of  Cdme  or  Souber- 
bielle, though  its  principles  are  the  same.  When  it  is 
considered,  that  in  the  operation  of  these  last  lithoto- 
mists,  the  neck  of  the  bladder  is  not  opened,  and  the 
catheter  enters  this  receptacle  through  the  prostatic 
portion  of  the  urethra,  it  must  be  immediately  obvious 
that  the  incision  in  the  perinaeuin  cannot  answ  er  any 
material  object,  because  a tube  may  be  placed  in  the 
same  position  by  passing  it  through  the  urethra  from 
the  orifice  in  the  glans.  The  retainer,  or  bracelet,  in- 
vented for  keeping  the  catheter  in  the  bladder  in  caste 
of  enlargement  of  the  prostate  gland,  seemed  to  Sir 
Everard  Home  peculiarly  applicable  to  the  high  ope- 
ration, since  it  keet>s  the  tube  steadily  in  the  natural 
canal,  and  renders  the  wound  in  the  perinteum  unne- 
cessaiy.  Bracelets  for  this  purpose,  extremely  elastic, 
and  producing  no  irritation,  are  sold  by  Mr.  Weiss, 
of  the  Strand.  They  are  furtiished  with  small  rings, 
to  which  the  outer  end  of  the  catheter  is  fixed  by 
means  of  string. 

Sir  Everard  Home  performed  his  new  operation  for 
the  first  lime  in  St.  George’s  Hospital,  on  the  26lh  of 
May,  1820.  “An  incision  was  made  in  the  direction 
of  the  linea  alba,  between  the  pyramidales  muscles, 
beginning  at  the  pubes,  and  extending  four  inches  in 
length:  it  was  continued  down  to  the  tendon.  The 
linea  alba  was  theti  pierced  close  to  the  pubes,  and  di- 
vided by  a probe  pointed  bistoury  to  the  extent  of  three 
inches.  The  pyramidales  muscles  had  a portion  of 
their  origin  at  the  symphysis  pubis  detached  to  make 
room.  When  the  finger  was  passed  down  under  the 
linea  alba,  the  fundus  of  the  bladder  was  felt 
covered  with  loose,  fatty,  cellular  membrane.  A silver 
catheter,  open  at  the  end,  was  now  passed  along  the 
urethra  into  the  bladder,  and  when  the  point  was  felt 
by  the  finger  in  the  w ound,  pressing  up  the  fundus,  a 
stilei  that  had  been  concealed  was  forced  through  the 
coats  of  the  bladder,  and  followed  by  the  end  of  the 
catheter.  The  stilet  w'as  then  withdrawn,  and  the 
opening  through  the  fundus  of  the  bladder  enlarged  to- 
wards the  pubes,  by  a probe-pointed  bistoury,  suffi- 
ciently to  admit  tw’o  fingers,  and  then  the  catheter  w'as 
withdiawn.  The  fundus  of  the  bladder  was  held  up 
by  one  finger,  and  the  stone  examined  by  the  fore- 
finger of  the  right  hand.  A pair  of  forceps,  with  a net 
attached,  was  passed  down  into  the  bladder,  and  the 
stone  directed  into  it  by  the  finger:  the  surface  being 
very  rough,  the  stone  struck  upon  the  opening  of  the 
forceps,  and  being  retained  there  by  the  finger,  w-as  ex- 
tracted. A slip  of  linen  had  one  end  introduced  into 
the  bladder,  and  the  other  was  left  hanging  out  of  the 
wound,  the  edges  of  which  w'ere  brought  together  by 
adhesive  plaster.  A flexible  gum  catheter,  w ithout  the 
stilet,  was  passed  into  the  bladder  by  the  urethra,  and 
kept  there  by  an  elastic  retainer  surrounding  the  penis. 
The  patient  was  put  to  bed,  and  laid  upon  his  side,  in 
which  position  the  urine  escaped  freely  through  the 
catheter.”  As  no  blood  had  been  lost  in  the  operation, 
twelve  ounces  were  taken  from  the  arm.  The  next 
day  the  slip  of  linen  was  withdrawn,  as  useless  and 
irritating,  the  catheter,  while  pervious,  preventing  any 
urine  from  escaping  by  the  wound.  Sir  Everard 
thinks,  that  in  future  the  linen  need  only  be  left  in  the 
external  wound,  so  as  to  prevent  collections  of  matter, 
and  carry  off  any  urine  which  may  issue  from  the 
opening  in  the  bladder  when  the  catheter  happens  to  be 
stopped  up.  For  this  operation.  Sir  Everard  particu- 
larly recommends  catheters,  with  their  insides  polished 
like  their  outsides,  in  order  that  they  may  better  resist 
the  effects  of  the  urine.  Suffice  it  to  add,  w ith  lespect 
to  the  above  case,  that  the  boy  soon  recovered,  the 
bladder  having  resumed  its  healthy  functions  in  ten 
days,  although  the  calculus  was  of  the  roughest  possi- 
ble kind. 


LITHOTOMY. 


139 


sir  Eveiard  Home  repeated  his  new  method  on  a 
gentleman,  who  went  out  in  his  carriage  with  the  ex- 
ternal wound  completely  healed,  on  the  14th  day  after 
theoperation.  The  only  particulars  wliich  need  here 
be  noticed,  in  regard  to  the  latter  case,  are,  that  sojue 
difficulty  was  experienced  in  bringing  the  point  of  the 
catheter  forwards  towards  the  pubes,  and  the  slit  in  the 
front  of  the  instrument  made  it  so  incapable  of  bearing 
lateral  motion,  that  the  two  sides  were  twisted  over 
■one  another. — { On  Strictures,  vol.  3,  p.  359, 8vo.  Lund. 
1820.)  Some  otlrer  cases,  however,  winch  have  oc- 
curred in  St.  George’s  Hospital,  have  had  the  effect  of 
satisfying  numerous  very  good  judges,  that,  as  a ge- 
neral practice,  the  high  operation  ought  to  be  aban- 
doned. 

Whoever  follows  this  method  of  operating  should 
always  be  provided  with  several  tubes  and  stilets  of 
different  lengths  and  curvatures;  for,  in  the  only  case 
iu  which  I have  seen  the  operation  attempted,  the  ex- 
tremity of  the  catheter  could  not  be  made  to  project 
the  fundus  of  the  bladder  towards  the  pubes,  and  after 
Iqjig  protracted  endeavours  had  been  made  to  bring  the 
end  of  the  instrument  upwards  and  forwards,  the  tube 
broke,  and  the  operation  was  left  unfinished.  The 
impression  upon  my  mind  was,  tliat  no  resistance  of 
the  bladder  could  account  for  what  happened,  and  that 
the  fault  lay  in  the  instrument  itself,  which  should 
have  been  exchanged  for  another  of  more  suitable  form, 
as  soon  as  it  was  found  to  be  inapplicable.  And  I be- 
lieve that  if  attention  be  paid  to  the  suggestion  of  al- 
ways having  at  hand  a sufficient  number  of  tubes  and 
stilets  of  different  lengths  and  curvatures.  Sir  Everard 
Home’s  new  method  will  be  the  best  modification  of 
the  high  operation  yet  proposed.  The  slip  of  linen, 
however,  [ think  is  more  likely  to  do  harm  by  its  irrita- 
tion than  any  good,  as  a conductor  of  the  urine  or  mat- 
ter out  of  the  wound.  At  all  events,  as  Sir  Everard 
has  observed,  it  should  never  be  passed  into  the  blad- 
der itself.  Whenever  I atn  asked  my  opinion  of  the 
high  operation,  I always  restrict  my  approval  of  far- 
ther trials  of  it  to  cases  in  which  the  calculus  is  known 
beforehand  to  be  of  very  large  size,  or  the  urethra  and 
prostate  gland  are  di.seased.  The  reasons  urged  by 
Mr.  Carpue,  in  favour  of  the  high  opeiation  in  most 
cases  are:  1.  Because  it  is  generally  perfortned  in  less 
time;  a point  which  may  be  disputed,  though  it  is  per- 
haps not  worth  contesting,  since  the  danger  of  an  ope- 
ration cannot  always  be  truly  estimated  by  the  length 
of  time  which  the  patient  remains  in  the  operating 
room,  slow  and  gentle  proceedings  sometimes  contri- 
buting to  his  safety.  2.  There  is  less  pain  ; a remark, 
the  justness  of  which  must  depend,  perhaps,  upon  the 
manner  in  which  each  operation  is  done.  3.  There  is 
no  fear  of  a fatal  hemorrhage;  a consideration  which 
I admit  is  one  good  reason  in  favour  of  the  high  opera- 
tion; though  the  lateral  operation  is  only  subject  to 
risk  of  hemorrhage  when  the  incisions  are  directed  in 
a manner  not  sanctioned  in  this  Dictionary.  4.  There 
is  no  division  of  the  prostate  and  inferior  part  of  the 
bladder;  no,  but  there  is  one  of  the  fundus,  so  that 
perhaps  on  this  point  the  two  operations  stand  upon 
an  equality.  As  for  there  being  no  danger  in  the  hieh 
operation  of  wounding  the  rectum,  it  is  undoubtedly 
an  advantage,  though  the  accident,  as  far  as  I have 
seen,  is  not  followed  by  any  serious  consequences,  and 
cati  only  happen  from  inattention  to  rules  easily  fol- 
lowed. 5.  The  stone,  if  of  a certain  size,  cannot  be 
extracted  by  the  lateral  operation,  but  admits  of  being 
so  by  the  high  operation.  Of  all  the  reasons  for  the 
latter  practice,  this  appears  to  me  the  strongest,  with 
the  exception,  perhaps,  of  disease  in  the  urethra  and 
prostate.  6.  A small  stone  is  more  readily  discovered 
in  this  method  than  in  the  lateral  nperatioti ; a point 
which  I consider  questionable,  and,  at  all  events,  tH)t 
sufficiently  important  to  form  a ground  for  the  high 
of>eration.  Irwleed,  the  long  time  which  several  jia- 
tientsin  St.  George’s  Ho.spital  were  subjected  to  the 
agony  caused  by  repeatedly  groping  and  fishintr  for  the 
stmie  in  vain,  has  now  filled  a great  many  judicious 
Burgeons  with  strong  aversion  to  a continuance  of  the 
attempts  to  revive  in  this  country  the  pr.actice  of  the 
high  operation.  7.  If  a stone  breaks,  the  particles  can 
be  extracted  with  more  certainty  than  in  the  lateral 
operation;  on  this  question  authors  differ,  and  the  re- 
marks in  the  foregoing  passage  are  rather  against  the 
correctness  of  the  statement.  8.  The  high  operation 
enables  the  surgeon  to  remove  encysted  calculi  with 


greater  ease ; a reason  which  may  perhaps  be  generally 
true,  but  which  is  somewhat  weakened  by  the  con- 
sideration that  encysted  calculi  are  not  very  frequent. 
Mr.  Uarpue  allows  that  the  high  operation  should  not 
he  selected  when  the  patient  is  corpulent,  and  the  blad- 
der is  thickened  and  diseased,  so  that  its  fundus  cantmt 
be  raised  above  the  pubes. — (See  Hist,  of  the  High 
Operation,  p.  173,  8vo.  Land.  1819.) 

Although  Scarpa  thinks  the  lateral  operation  un- 
likely to  answer  when  the  calculus  exceeds  twenty 
lines  in  its  less  diameter,  he  considers  the  high  ope- 
ration also  useless  in  such  a case,  and  even  fatal ; be- 
cause, according  to  his  observations,  when  tiie  stone 
is  very  large,  the  bladder  and  kidneys  are  almost  al- 
ways too  much  diseased  for  the  patient  to  recover.— 
{,Observazioni  sul  Taglio  Retto  Vesicate,  p.  3 and  48, 
iio.^Pavia,  1823.)  He  has  only  met  with  two  cases  to 
the  contrary.  However,  in  another  place,  in  consider- 
ing the  advantages  and  disadvantages  of  the  high  ope- 
ration, as  compared  with  that  performed  through  the 
rectum,  in  cases  where  the  stone  is  loo  large  to  be  ex- 
tracted by  the  perinaeum,  he  gives  his  decided  prefer- 
ence to  the  former. — (P.47.)  The  high  operation  he 
also  considers  the  only  method  by  which  women  can 
be  cured  without  leaving  the:n  afflicted  with  an  incon- 
tinence of  urine.— (P.  49.)  However,  after  the  facts 
related  by  Sir  A.  Cooper,  Mr.  Thomas  and  others 
{Lovd.  Med.  Lhir.  Trans.),  and  Dr.  Hamilton  {F.din 
Med.  Chir.  Ttans.  vol.%p.  117),  few  surgeons  w'oiild 
think  of  having  recourse  to  so  dangerous  an  operation 
in  preference  to  the  simple  and  safe  plan  of  dilating 
the  meatus  urinarius.  I decline  entering  into  any 
strict  consideration  ef  the  inconveniences  to  which 
this  method  is  exclusively  subject,  especially  the  greater 
vicinity  of  the  woulid  to  the  peritoneum  and  small 
intestines,  and  the  division  of  that  membrane  and  pro- 
trusion of  the  viscera:  accidents,  which  will  be  found 
by  any  body  who  chooses  to  look  over  the  cases  on 
record,  not  to  have  been  unfreqnent. 

In  December,  1818,  Mr.  Kirby,  of  Dublin,  performed 
the  high  operation  for  the  extraction  of  an  elastic  gum 
catheter,  which  had  slipped  into  the  bladder  through 
the  cannula  of  a trocar,  with  which  paracentesis  had 
been  performed.  No  contrivance  was  found  necessary 
for  lifting  up  the  fundus  of  the  bladder.  The  punc- 
ture already  made  was  enlarged,  and  after  the  opera- 
tion was  finished,  a catheter  was  placed  in  the  wound, 
but  was  withdrawn  on  the  4th  day,  as  the  urine  passed 
out  by  the  side  of  it.  The  case  terminated  well. — (See 
Kirby's  Cases,  p.  92,  ^c.  800.  Dublin,  1819.)  In  an 
example,  in  which  the  calculus  was  lodged  in  the  fun- 
dus of  a little  boy’s  bladder,  aged  six  years.  Dr.  Bal- 
litigall  undertook  the  high  operation,  in  the  expecta- 
tion that  the  stone  might  have  been  more  easily  ex- 
tracted above  the  pubes  than  from  the  perinseum. 
Great  difficulties  were  experienced,  however,  in  getting 
it  out;  and  the  peritoneal  inflammation  which  ensued 
had  a fatal  termination.  The  stone  measured  more 
than  two  inches  in  one  diameter,  and  one  inch  and  a 
half  in  the  otlier ; while  the  sjtace  between  the  tubero- 
sities of  the  ischium  was  oidy  two  and  a half  inches. — 
(See  Edin.  Med.  (.  hir.  Trans,  vol.  2.)  Lithotomy,  in 
whatever  way  performed,  when  the  stone  is  encysted 
(a  ciic'ims  ance  that  tinavoidabiy  lemithens  the  opera- 
tion and  leads  to  great  disturbance  of  the  parts),  is 
generally  unsuccessful ; and  I do  not,  therefore,  con- 
sider this  exam|)le  as  more  against  the  hi”h  than  the 
lateral  o|)ei  ation,  which  might  have  been  attended,  as 
Dr  Ballingall  observes,  with  even  greater  diffictilties. 

[The  high  operation  of  lithotomy  was  first  per- 
fortned in  this  country  by  Dr.  Gibson,  Professor  of 
Sumery  in  the  University  of  Pentisylvatiia,  and  since 
by  Dr.  M‘Clellan  and  others.  It  was  preferred  because 
of  the  great  size  of  the  stone  in  these  cases,  rendering 
it  improbable  that  extraction  could  be  effected  through 
tjie  perineum. — Reese.] 

LATERAL  OPERATION. 

So  named  from  the  prostate  gland  and  neck  of  the 
bladder  being  laterally  cut. 

From  some  quotations  made  by  Mr.  Carpue  from 
the  works  of  Franco,  it  appears  clear  enough  that  the 
latter  was  not  only  the  invetitor  of  the  lateral  0[iera* 
tion,  but  that  he  placed  his  patients  in  the  [losition 
adojiied  at  the  present  time,  used  similar  instruments 
to  those  now  employed  (excepting  that  his  gorget  had 
no  sharp  side),  and  made  the  same  incisions.  Now, 


140 


LITHOTOMY. 


as  this  claim  of  Franco  to  an  invention  of  such  im- 
portance had  been  nearly  or  quite  forgotten,  when  Mr. 
Carpue’s  work  made  its  a|)peaiance,  the  latter  gentle- 
man deserves  much  piaisetor  reminding  the  profession 
of  what  is  due  to  the  memory  of  an  old  surgeon  whose 
name  must  flourish  as  long  as  the  history  of  the  rise 
and  progress  of  surgery  is  interesting  to  mankind.  But 
though  Franco  appears  probably  to  have  practised  the 
lateral  operaiion,  or  something  very  much  like  it,  he 
never  esiablished  the  method  as  a permanent  improve- 
ment in  surgery,  which  measure  was  left  to  be  com- 
pleted long  alierward  by  an  ecclesiastic,  who  called 
himself  Fi^re  Jacques:  he  came  to  Paris  in  1697, 
bringing  will)  him  abundance  of  certificates  of  his  dex- 
terity in  operating;  and  having  made  his  history 
known  to  the  court  and  magistrates,  he  got  an  order  to 
cut  at  the  Hdtel-Dieu  and  the  Chariti,  where  he  ope- 
rated on  about  fifty  persons.  His  success,  however, 
did  not  equal  his  promises,  and  according  to  Dionis, 
some  loss  of  reputation  was  the  consequence. 

Fr^re  Jacques  used  a large  round  staff  without  a 
groove,  and  when  it  was  introduced  into  the  bladder, 
he  depressed  its  handle,  with  an  intention  of  making 
the  portion  of  this  viscus,  which  he  wished  to  cut,  ap- 
proach the  perinteum.  He  then  plunged  a long  dag- 
ger-shaped knife  into  the  left  hip,  near  the  tuber  ischii, 
two  finger-breadths  from  the  perinaturn,  and  pushing  it 
Towards  the  bladder,  opened  it  in  its  body,  or  as  near 
the  neck  as  he  could,  directing  bis  incision  upwards 
from  the  anus.  He  never  withdrew  his  knife  till  a 
sufficient  opetiing  had  been  made  for  the  extraction  of 
the  stone.  Sometimes  he  used  a conductor  to  guide 
the  forceps,  but  more  commonly  directed  them  with 
his  finger,  which  he  passed  into  the  wound  after  with- 
drawing the  knife.  When  he  had  hold  of  the  stone, 
he  used  to  draw  it  out  in  a quick  rough  manner,  heed- 
less of  the  bad  consequences.  His  only  object  was  to 
get  the  stone  extracted,  atid  he  disregarded  every  thing 
else;  all  preparatory  means,  all  dressings,  all  after- 
treatment. — (j?//an,  p.  23.) 

But  although  Frdre  Jacques,  totally  ignorant  of  ana- 
tomy, and  rude  and  indiscriminate  in  practice,  sunk 
into  disrepute,  some  eminent  surgeons  conceived,  from 
a consideration  of  the  parts  which  he  cut,  that  his  me- 
thod might  be  converted  into  a most  useful  operation. 

The  principal  defect  in  his  first  manner  of  cutting 
was  the  want  of  a groove  in  his  staff,  and  the  conse- 
quent difficulty  of  carrying  the  knife  into  the  bladder. 
At  letigth  Fi^re  Jacques  was  prevailed  upon  to  study 
anatomy,  by  which  his  judgment  was  corrected,  and 
he  readily  embraced  several  improvements,  which 
were  suggested  to  him.  Indeed,  we  are  informed,  that 
he  now  succeeded  better  and  knew  more  than  is  gene- 
rally imagined  Mr.  Sharp  says,  that  when  he  himself 
was  in  France  in  1702,  he  saw  a pamphlet  published 
by  this  celebrated  character,  in  which  his  method  of 
operating  appeared  so  much  improved,  that  it  scarcely 
differed  from  later  practice.  Fr4re  Jacqueshad  learned 
the  necessity  of  dressing  the  wound  after  the  opera- 
tion, and  had  profited  so  much  from  the  criticisms  of 
Mery,  Fagon,  Felix,  and  Hunauld,  that  he  then  used  a 
staff’  with  a groove,  and,  what  is  more  extraordinary, 
had  cut  thirty-eight  patients  successively,  without 
losing  one. — {Sharp's  Operations.) 

In  short,  as  a modern  writer  has  observed,  he  lost 
fewer  patients  than  we  do  at  the  present  day,  in  ope- 
rating with  a gorget.  He  is  said  to  have  cut  nearly 
5000  patients  in  the  course  of  his  life,  and  though  per- 
secuted by  the  regular  lithotomists,  he  was  imitated 
by  Mai4chal  at  Paris,  Raw  in  Holland,  and  by  Bamber 
and  Cheselden  in  Eiigland,  where  his  operation  was 
perfected. — IMlan.) 

For  a particular  history  of  Frdre  Jacques,  and  his 
operations,  Allan  refers  us  to  Bussiere's  Letter  to  Sir 
Hans  Sloane,  Philos.  Trarts.  1699.  Observations  sur 
la  Mainire  de  Tailler  dans  les  deux  Sexes,  pour  V Ex- 
traction de  la  Pierre,  pratiquie  pur  F.  Jacques,  par  J 
Mery.  Lister's  .Tourney  to  Paris  in  1698.  Cours 
d'  Operations  de  Chirurgie,  par  Dionis.  Garengeot, 
Traiti  des  Operations,  t.  3.  Morand,  Opuscules  de 
Chirurgie,  part  2. 

Among  the  many  who  saw  Fr^re  Jacques  operate, 
was  the  famous  Raw,  who  carried  his  method  into 
Holland,  and  practised  it  with  amazing  success.  He 
never  published  atiy  account  of  it  himself,  though  he 
admitted  several  to  his  operations:  but  after  his  death, 
his  successor,  Albinus,  gave  tlie  world  a very  circum- 


stantial detail  of  ail  the  processes ; and  mentions,  as 
one  of  Raw’s  improvements,  that  he  used  to  open  the 
bladder  between  its  neck  and  the  ureter.  But  either 
Albinus  in  his  relation,  or  Raw  himself  in  his  suppo- 
sition, was  mistaken ; since  it  is  almost  impossible  to 
cut  the  bladder  in  that  part  upon  the  common  staff, 
without  also  wounding  the  neck.— (SAarj?,  in  Opera- 
tions and  Critical  Inquiry.) 

Raw’s  method  was  objectionable  even  when  accom- 
plished, as  the  urine  could  not  readily  escape,  and  it 
became  extravasated  around  the  rectum  so  as  to  pro- 
duce terrible  mischief.  There  is  little  doubt  that  Raw’s 
really  successful  plan  was  only  imitative  of  Fr4ie  Jac- 
ques’s second  improved  one,  though  he  was  not  honour- 
able enough  to  confess  it. 

Dr.  Bamber  was  the  first  man  in  England  who  made 
a trial  of  Raw’s  method  on  the  living  subject,  which  he 
did  in  St.  Bartholomew’s  Hospital.  Cheselden,  who 
had  been  in  the  habit  of  practising  the  high  operation, 
gladly  abandoned  it  on  receiving  the  account  of  Raw’s 
plan  and  success ; and,  a few  days  after  Bamber,  he 
began  to  cut  in  this  way  in  St.  Thomas’s  Hospital. 

Cheselden  used  at  first  to  operate  in  the  Ibllowing 
manner.  The  patient  being  placed  and  tied  much  in 
the  same  way  as  is  done  at  this  day,  the  operator  intro- 
duces a hollow  grooved  steel  catheter  into  the  bladder, 
and  with  a syringe,  mounted  with  an  ox’s  ureter,  in- 
jects as  much  warm  water  into  it  as  the  patient  can 
bear  without  pain:  the  water  being  kept  from  running 
out  by  a slip  of  flannel  tied  round  the  penis,  the  etid  of 
the  catheter  is  to  be  held  by  an  assistant,  whose  prin- 
cipal care  is  to  keep  it  from  rising,  but  not  at  all  to  di- 
rect the  groove  to  the  place  where  the  incision  is  to  be 
made. 

With  a pointed  convex-edged  knife,  the  operator,  be- 
ginning about  an  inch  above  the  anus,  on  the  left  side 
of  the  raphe,  between  the  accelerator  urinse,  and  erec- 
tor penis,  makes  an  incision  downwards  by  the  side  of 
the  sphincter  ani,  a little  obliquely  outwards  as  it  de- 
scends, from  two  and  a half  to  four  inches  in  length, 
according  to  the  age  of  the  patient,  or  size  and  struc- 
ture of  the  parts.  This  incision  he  endeavours  to 
make  all  at  one  stroke,  so  as  to  cut  through  the  skin, 
fat,  and  all,  or  part  of  the  levator  ani,  which  lies  in 
his  way.  This  done,  he  passes  his  left  fore-finger  into 
the  middle  of  the  wound,  in  order  to  press  the  rectum 
to  one  side,  that  it  may  he  in  less  danger  of  being  cut ; 
and  taking  a crooked  knife  in  his  other  hand,  with  the 
edge  on  the  concave  side,  he  thrusts  the  point  of  it 
through  the  wound,  close  by  his  finger,  into  the  bladder, 
between  thevesicula  serninalis  and  os  ischium  of  the 
same  side.  This  second  incisioti  is  continued  upwards 
till  the  point  of  the  knife  comes  out  at  the  upper  part  of 
the  first.  'I’he  incision  being  completed,  the  operator 
passes  his  left  fore-finger  through  the  wound  into  the 
bladder,  and  having  felt  and  secured  the  stone,  he  in- 
troduces the  forceps,  pulls  out  his  finger,  and  extracts 
the  stone. 

As  the  bladder  was  distended,  Cheselden  thought  it 
unnecessary  to  cut  on  the  groove  of  the  staff,  and  that 
as  this  viscus  was  sufficiently  pressed  down  by  the  in- 
strument, the  forceps  could  be  very  well  introduced 
without  the  use  of  any  director  except  the  finger, 
— {Postscript  to  Douglas's  History  of  the  Lateral  Ope- 
ration, 1726.) 

With  respect  to  this  first  of  Cheselden’s  plans.  Sharp 
says,  the  operations  were  exceeding  dexterous  ; but  the 
wound  of  the  bladder,  retiring  back  when  it  was  empty, 
did  not  leave  a ready  issue  for  the  urine,  which  insinu- 
ated itself  among  the  neighboring  muscles  and  cellu- 
lar substance,  and  four  out  of  the  ten  patients  on  whom 
the  operation  was  done,  perished,  and  some  of  the 
others  narrowly  escaped. — {Sharp's  Operations.) 

Cheselden,  finding  that  he  lost  so  many  patients  in 
imitating  Raw,  according  to  the  directions  given  by 
Albinus,  began  a new  manner  of  operating,  which  he 
thus  describes:  “ I first  make  as  long  an  incision  as  I 
well  can,  beginning  near  the  place  where  the  old  ope- 
ration ends,  and  cutting  down  between  the  musculus 
accelerator  urinar  and  erector  perns,  and  by  the  side  of 
the  intestinum  rectum  . I then  feel  for  the  staff,  and 
cut  upon  it  the  length  of  the  pr<*state  gland  straight 
on  to  the  bladder,  holdinc  down  the  gut  all  the  while 
with  one  or  two  fingers  of  my  left  hand.” — {J^natomy 
of  the  Human  Body,  ed.  1730.) 

It  deserves  remark,  that  it  was  Cheselden’s  second 
manner  of  cutting,  which  was  described  in  the  Opus 


LITHOTOMY. 


141 


tules  de  Chirurgie  of  Morand,  who  was  deputed,  and 
had  his  expenses  defrayed,  by  the  Royal  Academy  of 
Sciences  in  Paris,  to  come  over  to  England,  and  learn 
from  Mr.  Cheselden  himself,  his  way  of  operating  for 
the  Slone ; and  accordingly  we  find  that  most  French 
authors  taking  their  account  from  Morand,describe  Che- 
selden’s  second,  not  his  third  operation,  as  that  which 
he  invented,  and  bears  his  name.  But  that  Mr.  Che- 
selden never  resumed  his  second  mariner  of  cutting, 
may  be  inferred  from  his  continuing  to  describe  the 
third  only  in  all  the  editions  of  his  anatomy  publislied 
after  1730. — (See  a note  by  J.  TJionison,  M.!)..,  annexed 
to  his  new  edition  of  Douglas's  Appendix.  Edinburgh., 
1808.) 

The  instruments  which  Cheselden  employed  in  his 
third  and  most  improved  mode  of  cutting  for  the  stone, 
were  a staft’,  an  incision  knife,  a gorget,  a pair  of  for- 
ceps, and  a crooked  needle  carrying  a waxed  thread. 
The  patient  being  placed  on  a table,  his  wrists  are 
brought  down  to  the  outsides  of  his  ankles,  and  secured 
there  by  proper  bandages,  his  knees  having  first  been 
bent,  and  his  heels  brought  back  near  his  buttocks. 

Cheselden  used  then  to  take  a catheter,  first  dipped 
in  oil,  and  introduce  it  into  the  bladder,  where  having 
searched  for  and  discovered  the  stone,  he  gave  the  in- 
strument to  one  of  his  colleagues,  whom  he  desired  to 
satisfy  himself  whether  there  was  a stone  or  not.  The 
assistant,  standing  on  his  right-hand,  held  the  handle 
of  the  staff  between  his  fingers  and  thumb,  inclined  it  a 
little  towards  the  patient’s  right  thigh,  and  diew  the 
concave  side  close  up  to  the  os  pubis,  in  order  to  re- 
move the  urethra  as  far  as  j.'ossible  from  the  rectum. 

The  groove  of  the  staft"  being  thus  turned  outwardly 
and  laterally,  Cheselden  sat  down  in  a low  chair,  and 
keeping  the  skin  of  the  perinaeum  steady  with  the 
thumb  and  fore-finger  of  his  left  hand,  he  made  the 
first  or  outward  incision  through  tlie  integuments  from 
above,  dow'nwards,  beginning  on  the  left  side  of  the 
raphe,  between  the  scrotum  and  verge  of  the  anus, 
almost  as  high  up  as  where  the  skin  of  the  perinaeum 
begins  to  form  the  bag  containing.the  testicles.  Thence 
he  continued  the  w'ound  obliquely  outwards,  as  low 
down  as  the  middle  of  the  margin  of  the  anus,  at 
about  half  an  inch  distance  from  it,  and  consequently 
beyond  the  tuberosity  of  the  ischium.  He  was  alwaj's 
careful  to  make  this  outward  wound  as  larae  as  he 
could  with  safety.  Having  cut  the  fat  rather  deeply, 
especially  near  the  rectum,  he  used  to  put  his  left  fore- 
finger into  the  wound,  and  keep  it  there  tili  the  internal 
incision  w'as  quite  finished  ; first  to  direct  the  point  of 
his  knife  into  the  groove  of  the  staft',  which  he  now  felt 
with  the  end  of  his  finger  ; and  secondly,  to  hold  and 
prevent  the  rectum  from  being  wounded,  by  the  side  of 
which  his  knife  was  to  pa.ss.  This  inward  incision 
Cheselden  made  with  more  caution  than  the  former. 
His  knife  first  entered  the  groove  of  the  rostrated  or 
straiuhi  part  of  the  staff,  through  the  side  of  the  blad- 
der, immediately  above  th.e  prostate,  and  its  point  was 
afterwaid  brought  along  the  same  groove  in  the  direc- 
tion downwards  and  forwards,  or  towards  himself. 
Chese  den  thus  divided  that  part  of  the  sphincter  of 
the  bladder  which  lay  upon  the  prostate  gland,  of 
which  he  next  cut  the  outside  of  one-half  obliquely, 
according  to  the  direction  and  whole  length  of  the  ure- 
thra within  it,  and  finished  the  internal  incision,  by  di- 
viding the  membranous  portion  of  the  urethra,  on  the 
convex  part  of  his  staff 

A sufficient  ojiening  being  made,  Cheselden  used  to 
rise  from  his  chair,  his  finger  still  remaining  in  the 
wound.  Next  he  put  the  beak  of  his  gorget  in  the 
groove  of  the  staff,  and  then  thrust  it  into  the  bladder. 
The  staff  w'as  now  withdrawn,  and,  while  he  held  the 
gorget  with  his  left  hand,  he  introduced  the  forceps 
with  the  flat  side  uppermost,  with  great  caution,  along 
the  cmicavity  of  the  gorget.  When  the  forceps  were  in 
the  bladder,  he  withdrew  the  gorget,  and  taking  hold  of 
the  two  handles  of  the  forceps  with  both  his  hands,  he 
searched  gently  for  the  stone,  w'hile  the  blades  were 
still  k<  pt  shut.  As  soon  as  the  calculus  was  felt,  the 
forceps  were  opened,  and  an  attempt  made  to  get  the 
lower  blade  under  the  stone,  in  order  that  it  might  be 
more  conveniently  laid  hold  of.  ft'his  being  done,  the 
stone  was  extracted  with  a very  slow  motion,  in  order 
to  give  the  parts  lime  to  dilate,  and  the  firceps  were 
genily  turned  in  all  directions. 

When  the  stone  was  very  small  and  did  not  lie  well 
in  the  fotce[».s,  Cheselden  used  to  withdraw  this  instru- 


ment, and  introduce  his  finger  into  the  bladder,  for  the 
purpose  of  turning  the  stone,  and  disengaging  it  from 
the  folds  of  the  lining  of  the  bladder,  in  which  it  was 
sometimes  entangled.  Then  the  gorget  was  passed  in 
again  on  the  upper  side  of  his  finger,  and  turned  as  soon 
as  the  latter  was  pulled  out.  Lastly,  the  forceps  were 
introduced  and  the  stone  extracted.  With  the  view  of 
hindering  a soft  stone  from  breaking  during  its  extrac- 
tion, Cheselden  used  to  put  one  or  more  of  his  fingers 
between  the  branches  of  his  forceps,  so  as  to  prevent 
any  greater  pressure  upon  it,  than  what  was  just  ne- 
cessary to  hold  it  together.  But  when  it  did  break,  or 
there  were  more  calculi  than  one,  he  used  to  extract 
the  single  stones  or  fragments  one  after  another,  re- 
peating the  introduction  of  his  fingers  and  forceps  as 
often  as  there  was  occasion.  Cheselden  took  care  not 
to  thrust  the  forceps  so  far  into  the  bladder  as  to  bruise 
or  wound  its  opposite  side  ; and  he  was  equally  careful 
not  to  pinch  any  folds  of  its  inner  coat.  In  this  way 
Cheselden  saved  fifty  patients  out  of  fifty-two,  whom 
he  cut  successively  in  St.  Thomas’s  Hospital. — {jSppen- 
dix  to  the  History  of  the  Lateral  Operation,  by  J. 
Douglas.  1731.) 

Cheselden,  with  all  the  enthusiasm  of  an  inventor, 
believed  that  he  had  discovered  an  operation  which 
was  not  susceiHible  of  improvement;  yet  he  himself 
changed  the  manner  of  his  incision  not  iess  than  three 
times,  in  the  course  of  a few  years.  Isl.  He  cut  into 
the  body  of  the  bladder,  behind  the  prostate,  when  he 
imitated  Raw.  2dly.  He  cut  another  part  of  the  blad- 
der, viz.,  the  neck,  and  the  thick  substance  of  the  pros- 
tate; this  is  his  lateral  mode  of  incision.  3diy,  He 
changed  a third  time,  not  the  essential  form  of  the  in- 
cision, but  the  direction  in  which  he  moved  the  knife; 
for,  in  his  first  operation,  when  imitating  the  supposed 
operation  of  Raw  and  Fr^re  Jacques,  he  passed  his 
knife  into  the  body  of  the  bladder,  between  the  tuber 
ischii  and  the  vesiculae  seminales,  and  all  his  incision 
lay  behind  the  prostate  gland.  In  this  second  opera- 
tion, he  pushed  his  knife  into  the  membranous  pan  of 
the  urethra,  immediately  behind  the  bulb,  and  ran  it 
down  through  the  sub.stance  of  the  gland;  but  his  in- 
cision stopped  at  the  membranous  part  or  body  of  the 
bladder.  But  in  his  third  operation,  after  very  large 
external  incisions,  he  passed  his  knife  deeply  into  the 
great  hollow  under  the  tuber  ischii,  entered  it  into  the 
body  of  the  bladder  immediately  behind  the  gland, 
and,  drawing  it  towards  himself,  cut  through  the  whole 
substance  of  the  gland,  and  even  a part  of  the  urethra, 
“cutting  the  same  parts  the  contrary  way.”  By  carry- 
ing the  fore-finger  of  the  left  hand  before  the  knife,  in 
dissecting  towards  the  body  of  the  bladder,  he  protected 
the  rectum  more  perfectly  than  he  could  do  in  running 
the  knife  backwards  along  the  groove  of  the  staff;  and 
by  striking  bis  knife  into  the  body  of  the  bladder,  and 
drawing  it  towards  him  through  the  whole  thickness 
of  the  gland,  he  was  sure  to  make  an  ample  wound. — 
(J.  Bell's  Principles  of  Surgery,  vol.  2,  part  1,  p.  152.) 
And,  as  Mr.  Key  has  correctly  staled,  Cheselden’s  aim 
was  to  to  divide  the  prostate,  in  the  depending  part  of 
its  left  lobe ; the  edge  of  the  knife  was  turned  upwards, 
and  in  this  position  carried  into  the  neck  of  the  blad- 
der behind  the  prostate  gland. — ( On  the  Section  of  the 
Prostate  Gland,  Src.  p.  10.) 

LATERAL  OPERATION  AS  PERFORMED  AT  THE  PRESENT 
DAY  WITH  CUTTING  GORGETS. 

The  gorget  has  the  same  kind  of  form  as  one  of  the 
instrurnents  used  by  F.  Colot  and  others,  in  the  per- 
formance of  the  apparatus  major,  and  the  common 
opinion  that  the  conductor  of  Hildanus  was  the  first 
model  of  it,  is  not  exactly  true  ; but  it  differs  from  the 
instruments  employed  by  these  ancient  surgeons,  in 
having  a cutting  edge.  Sir  Csesar  Hawkins  thought, 
that  if  its  right  side  were  sharpened  into  a cutting 
edge,  it  might  be  safely  pushed  into  the  bladder,  guided 
by  the  staff',  so  as  to  make  the  true  lateral  inci.sion  in 
the  left  side  of  the  prostate  gland  more  easily,  and  with 
less  risk  of  injuring  the  adjacent  parts,  than  Cheselden 
could  do  with  the  knife;  and  surgeons  were  pleased 
with  a connivance,  which  saved  them  from  the  respon- 
sibility of  dissecting  parts,  with  the  anatomy  of  which 
ill!  were  not  equally  well  acquainted. — {J  Kell,  Allan.) 

As  Scarpa  observes;  To  render  the  execution  of  the 
lateral  o))eration  easier  to  surgeons  of  less  experience 
than  Cheselden,  was  the  motive  which  induced  Haw- 
kins to  propose  his  gorget.  He  thought,  that  two 


142 


LITHOTOMY. 


great  advantages  would  be  gained  by  the  use  of  this 
iiislrumenl;  one,  of  executing  invariably  the  lateral 
incision  of  Cheselden  ; the  oilier,  ot  constantly  guard- 
ing the  patient,  through  the  whole  course  of  the  opeia- 
tion,  from  injury  of  the  rectum,  and  of  the  ai  teria 
pudica  profunda.  The  utility  of  the  latter  object 
(says  Scarpa)  cannot  be  disputed,  as  it  is  evident  that 
tke  convexity  of  the  director  of  the  instrument  defends 
the  rectum  from  injury.,  and  that  its  cutting  edge  not 
being  inclined  horizontally  towards  the  tuberosity  and 
ramus  of  the  ischium,  but  turned  upwards  in  the  direc- 
tion of  the  longitudinal  axis  of  the  neck  of  the  urethra, 
cannot  wound  the  pudic  artery.  But  witli  respect  to 
the  first  advantage,  or  that  of  executing  precisely  the 
lateral  incision  of  Cheselden,  it  must  be  admitied  that 
it  does  not  completely  fulfil  the  intention  which  he 
proposed,  not  only  on  account  of  the  cutting  edge  of 
liis  instrument  not  being  raised  enough  above  the  level 
of  the  staff,  to  penetrate  sufficiently  tiie  substance  of 
the  prostate  gland,  and  consequently  to  divide  it  to  a 
proper  depth  ; but  because,  being  too  much  turned  up- 
wards at  that  part  of  it  which  is  to  lay  open  the  base 
of  the  prostate  gland,  it  does  not  divide  it  laterally, 
but  rather  at  its  upper  part,  towards  the  summit  of  the 
ramus  of  the  ischium,  and  the  arch  of  the  pubes;  an 
opening  of  all  others  in  the  perinaeum  the  most  con- 
fined, and  piesenting  the  greatest  impediment  to  the 
passage  of  the  stone  from  the  bladder. — (See  also  Key 
on  Lithotomy,  p.  10.)  The  breadth  of  the  point  of  the 
director  is,  besides,  so  disproportionate  to  the  diameter 
of  the  membranous, pat  t of  the  urethra,  that,  from  the 
great  lesistance  witli  which  it  meets,  the  instrument 
may  easily  slip  from  the  groove  of  the  staff,  and  pass 
between  the  bladder  and  rectum,  a serious  accident, 
which  has  very  often  happened  even  in  the  hands  of 
experienced  surgeons. 

Scarpa  considers  all  the  modifications  of  Hawkins’s 
gorget  proposed  by  B.  Bell,  Desault,  Cline,  and  Cruik- 
shank  as  deteriorations  of  the  original  instrument.  B. 
Bell  (he  observes)  has  diminished  the  breadth  of  the 
director,  but  given  the  cutting  edge  a horizontal  direc 
tion.  The  horizontal  direction  of  the  cutting  edge  is 
also  preferred  by  Desault,  Cline,  and  Cruikshank ; 
but  they  have  enlarged  the  director  and  flattened  the 
part  which  was  previously  concave.  Aware  of  tite 
danger  of  wounding  the  pudic  artery  by  the  horizontal 
direction  of  the  gorget,  they  direct  the  handle  of  the 
staff  to  be  inclined  towards  the  patient’s  right  groin, 
and  the  gorget  to  be  pushed  along  it,  inclined  in  such 
a manner  that  its  obtuse  edge  may  be  directed  towards 
the  rectum,  and  its  cutting  edge  placed  at  a sufficient 
distance  from  the  tuberosity  and  ramus  of  the  ischium 
to  avoid  wounding  the  artery.  Scarpa  contends,  how- 
ever, that  it  is  difficult  to  give  a proper  degree  of  obli- 
quity to  the  staff,  and  that  such  inclination  of  the 
instrument  must  be  incommodious,  arbitrary,  and  un- 
stable, in  comparison  with  that  position  of  it  in  which 
the  handle  of  the  staff  is  held  in  a line  perpendicular 
to  the  body  of  the  patient,  and  its  concavity  placed 
against  the  arch  of  the  pubes;  on  which  stability  of  the 
instrument  (says  Scarpa)  the  safety  and  precision  of 
the  lateral  operation  depend.  According  to  this  emi- 
nent professor,  the  defects  of  Hawkins’s  original  gorget 
arise  from  the  excessive  breadth  of  the  director,  par- 
ticularly at  thq  point;  the  want  of  sufficient  elevation 
of  the  cutting  edge  above  the  level  of  the  groove  of  the 
staff,  and  the  uncertain  inclination  of  the  edge  to  the 
axis  of  the  urethra  and  prostate  gland.  The  cervix  of 
the  urethra  in  a man  between  thirty  and  forty  years  of 
age  is  only  three  lines  in  diameter  at  the  apex  of  the 
prostate  gland,  four  lines  in  its  centre,  and  five  near 
the  orifice  of  the  bladder.  The  apex  of  the  prostate 
gland  is  rather  more  than  twm  lines  in  thickness,  the 
body  or  centre  four,  and  the  base  six  and  sometimes 
eight,  which  surrounds  the  orifice  of  the  bladder.  In 
an  adult  of  middle  stature,  from  eighteen  to  twenty 
years  of  age,  the  thickness  of  the  base  of  the  prostate 
gland  is  about  two  lines  less,  compared  W’ith  that  of  a 
man  of  forty,  and  of  a large  size.  The  precise  line 
in  which  the  lateral  incision  of  the  prostate  gland 
should  be  made  in  an  adult  (says  Scarpa),  is  found  to 
be  inclined  to  the  longitudin.il  axis  of  the  cervix  oflhe 
urethra,  and  of  the  gland  itself,  at  an  angle  of  69°. 
Now,  from  these  data,  drawn  from  the  structure  of  the 
parts,  Scarpa  makes  the  director  of  his  gorget  only  four 
lines  broad  and  two  deep;  the  breadth  decreasing  at 
the  beak.  The  cutting  edge  of  the  instrument  Is 


straight  near  its  point,  but  gradually  rises,  and  becomes 
convex  above  the  level  of  the  staff  so  that  its  greatest 
convexity  is  seven  lines  broad.  Lastly,  the  inclination' 
of  the  cutting  edge  to  the  longitudinal  axis  of  the  di- 
rector is  exactly  at  an  angle  of  69°;  that  is  to  say,  the 
same  as  the  left  side  of  the  prostate  gland  to  the  lon- 
gitudinal axis  of  the  neck  of  the  urethra.— (See  Scar- 
pa's Memoir  on  Hawkins's  Gorget  : transl.  by  Mr. 
Briggs,  p.  12.  17.) 

For  more  than  twenty  years  the  instrument  makers 
in  London  have  been  in  the  habit  of  selling  a gorget, 

. which  Mr.  Abernethy  invented,  and  which,  in  the  par- 
ticularity of  its  cutting  edge  turning  up  at  an  angle  of 
45°,  bears  much  analogy  to  the  instrument  lately  rccom 
mended  by  Scarpa.  The  cutting  edge  is  straight,  and 
that  useless  and  dangerous  part  of  a gorget,  sometimes 
called  the  shoulder,  is  removed.  Admitting  that  the 
principles  of  the  lateral  operation,  as  inculcated  by 
Scarpa,  are  correct,  and  of  which  I shall  presently 
speak,  it  appears  to  me  that  Mr.  Abernethy’s  gorget  is 
far  preferable  to  that  very  recently  proposed  by  Scarpa. 
Its  edge  is  not  so  immoderately  turned  up,  and  it  will 
enter  with  more  ease,  and  less  risk  of  slipping  from  the 
staff,  because  it  has  not  any  projecting  shoulder, 
which,  while  the  staff  is  firmly  held  with  the  beak  of 
the  gorget  in  it,  can  have  no  other  effect  but  that  of 
obstructing  the  passage  of  the  last  instrument. 

Gorgets  which  cut  on  both  sides  have  also  been 
sometimes  employed  in  England,  and  as  a larger  open- 
ing can  be  obtained  by  them,  even  without  trespassing 
the  limits  of  the  incision  fixed  by  Scarpa,  that  i.s  to  say, 
without  cutting  any  part  of  the  body  of  the  bladder, 
they  appear  to  promise  utility,  especially  when  the 
stone  is  suspected  to  be  large.  However,  they  are  less 
used  now  than  they  were  some  years  ago,  when  Sir 
Astley  Cooper  employed  them  in  Guy’s  Hospital ; but 
I am  unacquainted  with  the  particular  reasons  of  this 
change. 

[In  the  United  States,  when  the  gorget  is  used,  that 
of  Dr.  Physick  is  preferred,  it  being  capable  of  re- 
ceiving a much  keener  edge  near  the  point.  Dr.  Gib- 
son has  improved  the  gorget  of  Dr.  Physick,  by  con- 
structing the  blade  so  as  to  taper  from  the  outer  corner 
of  the  cutting  edge  to  the  handle  of  the  instrument. 
Professor  Stevens,  in  his  note  on  Cooper’s  First  Lives, 
p.  508,  vol.  2,  says,  “ It  has  been  urged  that  the  blades 
are  too  broad,  and  that  they  endanger  the  cutting  of 
what  has  been  called  the  prostate  fascia,  or  the  par- 
tition between  the  pelvis  and  the  abdomen.  Such  fears 
can  only  arise  from  mistaken  ideas  of  the  anatomy  of 
the  parts.” — (See  Vol.  6 of  the  Medical  Repository.) — 
Reese.'] 

Some  criticisms  on  Scarpa’s  method  of  operating,, 
and  a few  remarks  on  the  size  and  direction  of  the 
lateral  incision,  will  be  found  in  a subsequent  section 
of  the  present  article. 

Sir  A.  Cooper,  as  I think  with  considerable  reason, 
recommends  putting  the  patient  on  vegetable  diet  for  a 
little  while  previously  to  the  operation.  He  disapproves 
of  operating  when  the  kidneys  are  diseased,  the  blad- 
der is  ulcerated,  and  disease  in  the  chest,  asthma,  or 
any  irregularity  of  the  circulation  prevails.  He  has 
found  the  operation  generally  more  successful  in  the" 
poor  and  labouring  classes,  than  in  the  rich  and  ln.x- 
urious.  Old  age  is  not  considered  by  him  as  on  objec- 
tion to  the  operation,  which  he  even  believes  most 
successful  in  persons  from  sixty-one  to  sixty-three  years 
of  age.  If  the  patient  is  loaded  with  fat,  he  says,  the 
chance  of  peritoneal  inflammation  is  always’great. 
According  to  his  experience,  convulsions,  having  a fatal 
result,  are  frequent  after  operations  on  children,  par- 
ticularly when  much  blood  has  been  lost. — (See  Lancet 
vol.  2,  p.  316,  Src.)  When  a stone  of  considerable  mag- 
n itude  is  accompanied  with  an  enlarged  prostate  gland 
the  patient  (he  says)  rarely  recovers  from  the  operation! 
— (Vol.  cit.  p.  345.) 

As  inflammation  of  the  bladder  and  peritoneum  is 
the  principal  danger  of  this  operation,  and,  under  an 
equal  degree  of  injury  and  violence,  is  most  likely  to 
happen  in  a plethoric  subject,  it  has  been  a question 
whether  venesection  should  not  be  practised  a day  or 
tvvo  before  the  patient  is  operated  iqKm,  supposing  that 
his  age  and  weakness  form  no  prohibition.  The  chief 
reason  which  prevents  the  common  observance  of  this 
practice  is,  that  a great  deal  of  blood  i.s  sometimes  lost 
in  the  operation  itself.  A vegetable  diet  for  a week  or 
two  before  the  operation  seems  to  be  a better  plan. 


LITHOTOMY.  143 


When,  however,  the  loss  of  blood  in  the  operation  has 
been  inconsiderable,  the  patient  is  young  and  strong, 
and  particularly  when  the  operation  has  been  tedious, 
and  the  bladder  has  sutlered  a good  deal,  I atn  disposed 
to  think  very  favourably  of  the  rule  of  bleeding  the 
patient  as  soon  as  he  is  put  to  bed,  and  recovered  from 
the  first  depressing  effects  of  the  operation.  An  open- 
ing medicine  should  be  given  the  day  before  the  pa- 
tient is  cut,  and  a clyster  injected  a couple  of  hours 
before  the  time  fixed  upon  for  the  operation,  in  order  to 
empty  the  rectum,  and  thus  diminish  the  chance  of  its 
being  wounded. 

It  is  generally  considered  advantageous  to  let  the 
bladder  be  somewhat  distended,  and  the  patient  is 
therefore  directed  to  retain  his  urine  a certain  time 
before  he  is  cut.  Formerly,  a jugum  penis  was  some- 
times used  for  confining  the  urine  in  the  bladder;  but 
since  my  entrance  into  the  profession,  I have  never 
lieard  of  this  contrivance  being  employed.  Tlie  pre- 
sence of  urine  in  the  bladder,  it  is  conceived,  may 
lessen  the  chance  of  the  fundus  of  that  organ  being 
injured  by  the  gorget ; but  as  the  beak  of  this  instru- 
ment should  always  be  in  the  groove  of  the  staff,  I am 
not  sure  that  the  reason  for  the  practice  is  good.  The 
plan  is  disapproved  of  by  Sir  A.  Cooper,  who  says, 
that  when  the  urine  collected  gushes  out,  the  bladder 
contracts,  and  einbiaces  the  stone  so  closely  that  it  is 
difficult  lo  get  hold  of  the  foreign  body  with  the  for- 
ceps.—(See  Lancet,  vol.2,  p.  347.) 

Before  the  operation,  the  following  instruments 
should  all  be  arranged  ready  on  a table;  a start'  of  as 
large  a diameter  as  will  easily  admit  of  introduction, 
and  the  groove  of  which  is  very  deep,  and  closed  at 
the  extremity.  A sharp  gorget,  with  a beak  nicely  and 
accurately  adapted  to  the  deep  groove  of  the  pieceding 
instrument,  so  as  to  glide  easily  and  securely.  A large 
scalpel  for  ntaking  the  first  incisimis.  Forceps  of 
various  sizes  and  forms  for  extracting  the  stone.  A 
blunt  pointed  curved  bistoury  for  enlarging  the  wound 
in  the  prostate,  if  the  incision  of  the  gorget  be  not 
sufficiently  large,  as  tlie  parts  should  never  be  lacerated. 
A pair  of  Le  Cat’s  forceps  with  teeth  tor  breaking  the 
stone  if  too  large  to  conie  through  any  wound  reason- 
ably dilated.  A syringe  for  washing  out  clots  of  blood 
or  particles  of  the  stone:  a practice,  however,  not 
considered  necessary  by  Sir  A.  Cooper  {Lancet,  vol.  2, 
p.  347) ; a scoop  for  the  removal  of  small  calculi  or 
fragments.  Two  strong  garters  or  bands,  with  which 
the  patient’s  hands  and  feet  are  tied  together. 

The  curvature  of  the  staff  is  a matter  of  consider- 
able importance;  because  the  direction  of  the  incision 
through  the  prostate  gland  and  neck  of  the  bladder  is 
partly  determined  by  it.  The  French  surgeons,  con- 
vinced of  the  advantage  of  introducitig  the  gorget  in 
the  direction  of  the  axis  of  the  bladder,  always  use  a 
staff,  which  is  much  more  curved  than  what  English 
surgeons  employ. — (See  Roux,  Voyage  fait  d Londres 
en  1814,  ou  Parallile  dc  la  C/iir.  ^ngloise,  <§-c.  p.  319.) 
But  I am  inclined  to  believe  with  Scarpa,  that  u[ion 
the  whole  it  is  best  to  let  the  curvature  of  the  staff 
corre.-^jKjnd  exactly  to  that  of  the  axis  of  the  neck  of 
the  urethra  and  prostate  gland. — (Opusculi  di  Chirur- 
gia,  vol.  1,  p.  39.) 

After  introducing  the  staff,  and  feeling  that  the  stone 
is  certainly  in  tlie  bladder,  tlie  patient  is  to  be  secured 
in  the  same  jiosition  as  was  described  in  t/Te  account 
of  Cheselden’s  latest  method  of  operating. 

The  assistant,  holding  up  the  scrotum  with  his  left 
hand,  is  with  his  right  to  hold  the  staff,  inclining  its 
handle  towards  the  right  groin,  so  as  to  make  the 
grooved  convexity  of  the  instrument  turn  towards  the 
left  side  of  the  jierinaEum.  Some  operators  also  like 
the  assistant  to  depress  the  handle  of  the  staff  towards 
the  patient’s  abdomen,  in  order  to  make  its  convexity 
project  in  the  perinaeum,  while  others  condemn  this 
plan,  asserting,  that  it  withdraws  the  instrument  from 
the  bladder.— (./?ll(i7i,  Src.) 

Scarpa  disapproves  of  inclining  the  handle  of  the 
staff  towards  the  patient’s  right  groin,  and  he  expressly 
lecotninends  this  instrument  to  be  lield  firmly  against 
the  arch  of  the  pubes,  in  a line  perpendicular  to  the 
body  of  the  patient,  so  that  the  convex  part  of  the  di- 
rector may  be  placed  towards  the  rectum,  and  take  the 
exact  course  of  the  axis  of  the  neck  of  the  urethra  and 
prostate  gland.- (OpMscwli,  (S-c.  p.  40.)  This  position 
of  the  start'  i.s  the  firmest  and  most  commodious  to  the 
surgeon,  atid  Scarpa  maintains,  that  on  such  stability 


of  the  instrument  the  safety  and  precision  of  the  lateral 
operation  depettd. 

Sir  A.  Cooper  directs  the  operator  to  hold  the  staff 
perpendicularly,  and  to  let  it  rest  on  the  stone,  as  he  has 
seen  many  instances  iji  which  the  gorget  has  not 
etitered  the  bladder,  owing  to  thestafl'not  having  itself 
passed  into  it,  but  rested  against  the  prostate  gland. — 
(See  Lancet,  vol.  2,  p.  319.) 

The  first  incision  should  always  commence  below 
the  bulb  of  the  urethra,  over  the  membranous  part  of 
this  canal,  at  the  place  where  the  operator  means  to 
make  his  first  cut  into  the  groove  of  the  staff,  and  the 
cut  should  extend  at  least  three  inches,  obliquely  down- 
wards to  the  left  of  the  raphe  of  the  perinseum,  at  an 
equal  distance  from  the  tuberosity  of  the  ischium  and 
the  anus.  The  first  cut  should  descend  rather  beyond 
the  level  of  the  centre  of  the  anus  ; for  it  is  a general 
rule  in  surgery  to  make  free  external  incisions,  by 
which  the  surgeon  is  enabled  to  conduct  the  remaining 
steps  of  his  operation  with  greater  facility,  and  now  here 
is  it  so  nece.'isary  as  where  a stone  is  to  be  extracted. — 
{JHhin.)  That  excellent  surgical  writer,  Callisen,  lays 
it  down  as  a rule  to  be  observed  in  the  lateral  operation, 
that  the  incision  ought  not  to  extend  to  such  parts  as 
can  make  no  impediment  to  the  extraction  of  the  stone  ; 
and,  therefore  (says  tie),  the  bulb,  and  that  part  of  the 
urethra  which  is  surrounded,  by  the  corpus  spongiosum, 
should  never  be  cut.  Only  those  parts  ought  lo  be 
divided,  which  firmly  resist  the  sale  introduciion  of 
instruments  into  the  bladder,  and  the  extraction  of  the 
stone.  Hence,  the  irrleguments  must  be  opened  by  an 
ample  incision,  and  the  meriibranous  part  of  the  ure- 
thra, transversus  perinaii  muscle,  levator  ani,  and 
prostate  gland  be  properly  divided. — {Systema  Chi- 
TurgicR  Hodiernce,  pars  2,  p.  655  ) Like  Scarpa,  Irow- 
ever,  he  is  fearful  of  making  a free  cut  through  the 
neck  of  the  bladder,  and,  in  lieu  of  doing  so,  jnefers 
a slow  and  cautious  dilatation  of  the  parts.  When 
the  external  cut  through  the  integuments,  fat,  and 
accelerator  uiin®  muscle  has  been  executed,  the  next 
object  is  to  divide  the  transversus  perinari  muscle, 
which  stands,  like  a bar,  across  the  triangular  hollow, 
out  of  which  alone  the  stone  can  be  easily  extracted. 
A part  of  the  membranous  portion  of  the  urethra, 
adjoining  the  prostate  gland,  is  next  to  be  laid  open  ; 
but  an  extensive  cut  through  it,  as  far  forwards  as  the 
bulb,  is  quite  unnecessary,  because  it  will  not  at  all 
faciliiate  the  passage  of  the  stone  outwards. 

Having  placed  the  beak  of  the  gorget  in  the  groove 
of  the  start;  the  operator  takes  hold  of  the  latter  instru- 
ment firmly  with  his  left  hand,  raises  its  handle  from 
the  abdomen,  so  tiial  it  may  form  nearly  a right  angle 
with  the  body,  and  stands  up.  Before  altemptiiig  to 
push  the  gorget  into  the  bladder,  however,  he  should 
slide  it  backwards  and  forwards,  with  a wriggling 
motion,  that  he  may  first  be  sure  of  its  beak  being  in 
the  groove  of  the  staff.  The  bringing  forwards  of  the 
handle  of  the  latter  instrument,  so  as  to  elevate  its 
point,  before  introducing  the  gorget  into  the  bladder 
is  also  considered ■ of  great  importance;  for  it  is  by 
this  means  that  the  gorget  is  introduced  along  the 
groove  of  the  staff  in  the  axis  of  the  bladder,  the  only 
direction  unattended  with  risk  of  wounding  the 
rectum.  In  fact,  the  gorget  should  be  introduced 
nearly  in  a direction  corresponding  to  a line  drawn 
from  tire  os  coccygis  to  the  umbilicus.  It  is  obvious, 
however,  that  the  degree  in  w hich  the  handle  of  the 
staff  should  be  depressed  must  depend  very  much  upon 
the  curvature  of  the  instrument. 

The  utmost  attention  to  the  rule  last  noticed  is  espe- 
cially necessary,  when  a staff  with  a groove  not  closed 
at  the  end  is  employed.  The  neglect  of  it  in  this  case 
might  make  the  operator  cut  the  bladder  with  the 
gorget  in  several  places,  as,  according  lo  Mr.  B.  Bejl,  has 
actually  happened.  But  since  the  gorget,  when  intro- 
duced  as  nearly  as  possible  in  the  axis  of  the  bladder, 
may  transfix  and  otherwise  injure  this  organ,  if  intro- 
duced either  too  far,  or  at  all  beyond  the  extremity  of 
the  staff,  I am  decidedly  of  opinion,  that  every  surgeon, 
who  chooses  to  perform  the  lateral  ojieration  with  a 
gorget,  should  employ  a staff,  the  groove  of  which  is 
closed  at  the  extremity,  as  is  invariably  done  in  France, 
and  is  expressly  enjoined  by  Professor  Scarjia. — (See 
Sabatier's  Mddecine  Operatoire,  t.  3,  p.  233,  edit.  2] 
and  Scarpa's  Opusculi  di  Chirurgia,  vol.  1,  p.  .39.) 
I’herc  can  also  be  no  doubt  of  the  prudence  of  endea- 
vouring lo  have  only  a fixed  and  limited  length  of  the 


144 


LITHOTOMY. 


staff  in  the  bladder.  Scarpa  specifies  an  inch  and  a 
half  as  the  proper  distance  to  which  tlie  end  of  the 
stall'  should  enter  the  bladder.  However,  as  it  is 
known  that  this  disiinguisln.d  professor  is  an  advocate 
for  a very  iiniited  incision,  and  that  consequently  he 
would  not  require  the  staff  to  extend  farther  than  an 
inch  and  a half  into  the  bladder,  I infer,  that  operators 
who  prefer  making  a freer  opening  must  use  a staff 
that  reaches  into  this  viscus  rather  farther.  Much, 
however,  will  depend  upon  the  kind  of  gorget  em- 
ployed, particularly  its  breadth,  and,  if  it  is  to  rest 
against  the  stone,  as  advised  by  Sir  A.  Cooper,  but 
which  method  I do  not  recommend  ; of  course  the  ex- 
tent to  which  it  passes,  will  be  determined  by  the  situ- 
ation of  the  cqlculus. 

As  soon  as  the  gorget  is  introduced,  the  staff  is  to  be 
withdrawn.  Some  operators  next  pass  the  forceps 
along  the  concave  surface  of  the  gorget,  into  the  blad- 
der : while  others  recommend  the  cutting  gorget  to  be 
withdrawn  immediately  it  has  completed  the  wound  ; 
for  then  the  bladder  contracts,  and  its  fungus  is  liable 
to  be  cut.  The  gorget  should  be  withdrawn  in  the 
same  line  in  which  it  is  entered,  pressing  it  towards 
the  right  side,  in  order  to  prevent  its  making  a second 
wound.  If,  however,  the  operator  should  prefer  passing 
the  forceps  into  the  bladder,  along  the  gorget,  the  latter 
instrument  must  be  kept  quite  motionless,  lest  its  sharp 
edge  do  mischief ; and,  at  alt  events,  as  soon  as  the 
forceps  is  in  the  bladder,  the  cutting  gorget  is  to  be 
withdrawn. 

Some  operators  withdraw  the  cutting  gorget,  and 
introduce  a blunt  one  for  the  guidance  of  the  forceps  ; 
a step  certainly  unnecessary,  as  the  latter  instrument 
will  easily  pass,  when  the  incision  into  the  bladder  is 
ample  and  direct,  as  it  ought  always  to  be. 

[Professor  Stevens,  of  the  University  of  New-York, 
always  withdraws  both  the  sound  and  the  gorget  im- 
mediately after  making  the  incision  with  the  latter, 
and  has  never  found  any  difficulty  in  introducing  the 
forceps  without  any  other  guide  than  the  fore-finger  of 
the  left  hand.  The  point  of  the  forceps  he  directs  to 
be  inclined  a little  upwards  to  avoid  a little  pouch 
formed  by  the  receding  of  the  loose  cellular  membrane 
between  the  prostate  and  the  rectum. — Reese,] 

The  operator  has  next  to  grasp  the  stone  with  the 
blades  of  the  forceps  : for  which  purpose  he  is  not  to 
expand  the  instrument  as  soon  as  it  has  arrived  in  the 
bladder ; but  he  should  first  make  use  of  the  instru- 
ment as  a kind  of  probe,  for  ascertaining  the  exact 
situation  of  the  stone.  If  this  body  should  be  lodged 
at  the  lower  part  of  the  bladder,  just  behind  its  neck, 
the  operator  is  to  open  the  forceps  immediately  over 
the  Slone,  and  after  depressing  the  blades  a little,  is 
gently  to  shut  them  so  as  to  grasp  it.  Certainly,  it  is 
much  more  scientific  to  use  the  forceps  at  first,  merely 
for  ascertaining  the  position  of  the  stone  ; for  when  this 
is  known,  the  surgeon  is  much  more  able  to  grasp  the 
extraneous  body  in  a skilful  manner,  than  if  he  were 
to  open  the  blades  of  the  instrument  immediately, 
without  knowing  where  they  ought  next  to  be  placed, 
or  when  shut.  No  man  of  experience  can  doubt,  that 
the  injury  which  the  bladder  frequently  suffers  from 
rough,  reiterated  awkward  movements  of  the  forceps, 
is  not  an  uncommon  cause  of  such  infiammation  of 
this  viscus,  as  extends  to  the  peritoneum,  and  occa- 
sions death. 

If  the  surgeon  cannot  readily  take  hold  of  the  stone 
with  the  forceps,  he  should  introduce  his  fore-finger 
into  the  rectum  and  raise  up  the  extraneous  body,  when 
it  may  generally  be  easily  grasped.  The  stone  should 
be  held  with  sufficient  firmness  to  keep  it  from  slipping 
away  from  the  blades,  but  not  so  forcibly  as  to  incur 
the  risk  of  its  breaking. 

[Dr.  J.  Rhea  Barton,  of  Philadelphia,  has  invented  a 
forceps  for  extracting  the  calculus  from  the  bladder, 
which  is  a valuable  improvement.  Each  blade  has  an 
oval  hole  in  it,  resembling  the  forceps  employed  in  par- 
turition, so  that  when  the  surgeon  grasps  the  stone,  it 
becomes  immoveably  fixed  by  entering  into  the  vacui- 
ties in  the  blades.  The  size  of  the  calculus  is  there- 
fore not  increased  by  this  instrument,  and  it  is  effectu- 
ally prevetiied  from  slipping. — Reese.] 

Sometimes  the  extraction  of  the  stone  is  attended 
with  difficulty,  owing  to  the  operator  having  chanced 
to  grasp  it  in  a transverse  position,  in  which  circum- 
stance, it  is  better  to  try  to  change  its  direction,  or  let  it 
go  altogether,  and  take  hold  of  it  in  another  manner. 


When  the  stone  is  so  large  that  it  cannot  be  extracted 
from  the  wound  without  violence  and  laceration,  the 
surgeon  may  either  break  the  stone  by  means  of  a 
strong  pair  of  forceps,  with  teeth  constructed  for  the 
purpose ; or  he  may  enlarge  the  wound  with  a probe- 
pointed  crooked  bistoury,  introduced  under  the  guidance 
of  the  fore-finger  of  the  left  hand.  The  latter  plan  is 
generally  the  best  of  the  twd  ; for  breaking  the  stone 
always  creates  serious  danger  of  calculous  fragment.! 
remaining  behind. 

However,  as  nothing  can  justify  the  exertion  of  force 
in  pulling  out  a stone,  if  the  operator  should  be  afraid 
of  making  the  wound  more  ample  (it  being  already 
large  and  direct),  he  must  break  the  stone  as  above  de- 
scribed. As  many  of  the  fragments  are  then  to  be 
extracted  with  the  common  lithotomy  forceps,  as  can 
be  taken  away  in  this  method,  after  which  the  surgeon 
should  introduce  his  finger,  in  order  to  feel  whether 
any  pieces  of  the  stone  still  remain  behind.  Perhaps 
some  of  these  may  be  most  conveniently  taken  out 
with  the  scoop  ; but  if  they  are  very  small,  it  is  best  to 
inject  lukewarm  water  w’ith  moderate  force  into  the 
wound,  for  the  purpose  of  w-ashing  them  out. 

[Dr.  Jameson  has  invented  a forceps  for  breaking 
calculi  when  too  large  to  be  extracted  through  the 
incision,  which  will  greatly  facilitate  this  process. 
This  instrument  is  very  accurately  described  in  the  8th 
volume  of  the  American  Medical  Recorder.  No  sur- 
geon should  be  without  it,  as  the  necessity  for  the  high 
operation  is  thus  annihilated,  and  this  forceps  w'ould 
succeed  when  the  calculus  is  too  large  to  be  extracted 
above  the  pubis,  as  is  sometimes  the  case. — Reese.] 

The  surgeon,  however,  cannot  be  too  strongly  im 
pressed  with  the  absolute  necessity  of  using  the  greatest 
care  not  to  remove  the  patient  from  the  operating  table 
while  any  calculus  or  fragment  remains  in  the  bladder. 
For  the  distressing  pain  of  the  disorder  has  been  known 
to  recur  upon  the  healing  of  the  wound,  and  a second 
operation  become  necessary.  It  is  a melancholy  truth, 
however,  that  a fresh  calculus  may  form  again  in  the 
short  space  of  a few  months.  I have  seen  several 
patients  who  have  been  cut  for  the  stone  more  than 
once  ; and  Richerand  mentions  the  case  of  a surgical 
instrument-maker,  resident  at  the  gate  of  La  Charity, 
in  Paris,  who  has  undergone  the  operation  three  times 
in  the  course  of  a year  and  a half,  although,  after  each 
operation,  several  eminent  surgeons  carefully  exa- 
mined the  bladder,  and  could  not  detect  a calculus. — 
(See  JVosogr.  Chir.  t.  3,  p.  549,  ed.  4.) 

The  stone  should  always  be  attentively  examined 
immediately  it  is  extracted;  because  its  appearance 
conveys  some  information,  though  not  positive,  con- 
cerning the  existence  of  others.  If  the  stone  is  smooth 
on  one  surface,  the  smoothness  is  generally  found  to 
arise  from  the  friction  of  other  stones  still  in  the 
bladder;  but  when  it  is  uniformly  rough,  it  is  a pre- 
sumptive sign  that  there  is  no  other  one  remaining 
behind.  In  every  instance,  however,  the  surgeon 
should  gently  examine  the  cavity  of  the  bladder  with 
his  fore  finger;  for  it  would  be  an  inexcusable  neglect 
to  put  the  patient  to  bed  with  another  stone  in  his 
bladder. 

After  the  operation,  a simple  pledget  is  commonly 
laid  on  the  wound,  supported  by  a T bandage ; the 
patient  is  laid  in  bed  on  his  back,  with  his  thighs  closed  ; 
a piece  of  oil-cloth  and  some  folded  napkins  should  be 
laid  under  him  for  the  reception  of  the  urine,  and  an 
opiate  administered.  However,  with  respect  to  tire 
application  of  a pledget  and  bandage,  and  keeping  the 
thighs  closed,  1 confess  that  my  own  ideas  lead  me  to 
regard  them  as  Sir  A.  Cooper  and  many  other  e.vcellent 
surgeons  do,  as  rather  disadvantageous : indeed,  I be- 
lieve the  best  plan  is  to  leave  the  wound  quite  open,  so 
that  the  urine  may  have  a free  outlet,  strict  attention 
being  paid  to  keeping  the  parts  clean. 

An  occasional  embarrassment  to  lithotomists  is  the 
circumstance  of  stones  in  the  bladder  not  being  always 
free  and  detached;  some  are  tightly  embraced  by  its 
coats;  others  are  partially  engaged  in  the  ureters; 
they  are  sometimes  fixed  in  the  neck  of  the  bladder; 
and  are  not  nnfrequently  found  lodged  in  sacculi  acci- 
dentally formed.  These  cysts  are  of  different  sizes : 
some  are  small,  and  e.\ist  in  a considerable  number  ; 
some  are  dee|>er,  with  an  orifice  smaller  than  their 
base.  They  app(>ar  to  be  formed  by  a proloncaiion  of 
the  internal  coat  of  the  bladder.  Other  s.acculi  are  oc- 
casionally found,  which  seem  to  be  composed  of  all 


LITHOTOMY, 


145 


tb«  tunici  of  the  bladder,  and  they  are  sometlnies  of 
such  magnitude,  that  tlie  bladder  aitpears  as  if  it  were 
divided  into  two  or  more  cavities  of  nearly  equal  size. 
Stones  found  in  these  sacculi  sometimes  present  depres- 
sions and  irregularities,  in  which  lungi  of  the  bladder 
have  been  received.  When  this  happens,  a portion  ot 
such  fuirgous  productions  is  often  extracted  with  the 
stone  ; a circumstance  that  has  deceived  some  practi- 
tioners, and  led  them  to  suppose  that  the  calculi  actu- 
ally adhered  to  the  coat  of  the  bladder. — (See  Desault's 
Paris  Ckiriirgical  Journ.  vol.  2,  p.  386,  387.) 

The  extraction  of  encysted  stones  requires  different 
modes  of  pn.ceeding  I'rom  those  which  have  been  re- 
lated. Littre  coticeived,  that  they  might  be  removed  in 
two  wa3’s.  When  they  made  only  an  inconsiderable 
projection  into  the  bladder,  he  recommended  the  intro- 
duction of'a  probe,  w ith  which  the  membrane  covering 
tile  calculus  was  to  be  rubbed,  a finger  being  put  iiito 
the  rectutn,  in  order  to  keep  it  down,  and  facilitate  the 
action  of  the  probe  in  opening  the  cyst.  When  the 
calculi  were  very  prominent,  Liwre  recommended  tak- 
ing hold  of  them  with  a pair  of  forceiis,  and  contusing 
and  breakitig  the  membranous  pouch,  with  the  points 
and  asperities  upon  the  inside  of  the  blades  of  th.e  in- 
strument. He  conceived  that  suppuration  would  then 
destroy  the  internal  parietes  of  the  cyst,  and  that  the 
stone  would  fall  into  the  bladder,  and  admit  of  being 
easily  extracted.  As  Sabatier  observes,  it  is  plain  that 
this  theory,  which  is  founded  on  the  idea  entertained 
by  Littre  of  the  manner  in  which  stones  become  en- 
cysted, is  totally  inadmissible  in  practice. 

Garengeot  ventured  to  pass  a bistoury  into  the  blad- 
der for  the  purpose  of  disengaging  a calculus  lodged  in 
a particular  cyst  at  the  fundus  of  this  organ,  behind  the 
pubes.  The  knife  had  some  tape  twisted  round  the 
greatest  pan  of  its  length,  and  was  introduced  under 
the  guidance  of  the  left  index  finger,  which  was  passed 
in  as  far  as  it  could  reach.  The  patient  was  not  more 
than  ten  or  eleven  years  old,  and  consequently  of  a 
size  which  favoured  the  operation.  The  stone  was 
loosened  and  taken  out,  and  the  child  recovered. 
However,  as  Sabatier  remarks,  there  are  many  in- 
stances in  which  this  mode  of  proceeding  cannot  be 
imitated;  for,  if  the  calculus  should  be  in  a sort «)f  cul- 
de-sac,  as  often  happens,  the  entrance  of  which  is 
narrower  than  its  bottom,  and  the  stone  be  of  consider- 
able size,  the  incision  cannot  be  made  large  enough, 
without  risk  of  cutting  through  the  whole  thickness  of 
the  bladder,  and  producing  certain  death  by  the  effu- 
sion of  urine  in  the  abdomen. 

Other  practitioners  fancied  that  the  calculus  might 
be  taken  hold  of  with  the  forceps,  and  turned  about 
in  different  directions  so  as  to  lacerate  its  connexions, 
or  even  that  it  might  be  forcibly  extracted,  without  any 
serious  ill  consequences.  Houstet  mentions  (see 
de  VAcad.  de  Chir.  1.  2,  p.  .307,  <S'C.  edit.  I2we.), 
that  Peyronie  adopted  this  method'on  a patient,  Uiirty- 
one  years  of  age.  The  calculus  did  not  resist  long, 
and  its  surface  w’as  found  covered  with  fleshy  sub- 
stances. which  formerl  the  adhesions  to  the  bladder. 
Tiie  o[)eratiori  was  painful,  followed  by  considerable 
hemorrhage,  tension  of  the  belly,  hiccough,  cold  extre- 
mities, and  death. 

There  are  some  examples,  however,  in  which  this 
bold  practice  had  better  success.  In  17.30,  Le  Dran  ex- 
tracted from  a woman  an  enormous  stone,  adherent  to 
that  part  of  the  bl.addcr  which  lies  upon  the  rectum. 
The  irritation  of  the  inequalities  of  the  stone  had  pro- 
duced ulceration  of  the  bladder,  and  fungous  grow  ths, 
which  insinuated  themselves  into  tiie  substance  of  the 
extraneous  body.  The  adhesions  readily  yielded,  and 
the  excrescences  came  away  with  the  calculus.  Ten 
days  alterward,  some  thick  membranous  sloughs  were 
voided.  'Phis  calailus  is  engraved  in  Le  Bran’s  Trea- 
tise on  the  Operations. 

Le  Dran  afterward  extracted  .similar  stones,  which 
adhered  by  a le.se  extensive  surface;  and  lie  relates  an 
operation  done  by  Mar^chal,  who,  in  1715,  extracted, 
with  a (lair  of  forceps,  a stone  shaped  like  a calabash, 
and  having  its  narrow  [lart  surrounded  by  a fungus. 
In  one  case,  the  position  of  the  calculus  led  Le  Dran 
to  snsiKici  that  it  was  fixed  in  the  extremity  of  the  me 
ter;  he  shook  it  occasiomilly  with  a pair  of  forceps: 
and,  lastly,  it  fell  into  the  bladder,  whence  it  was  ex- 
tracted wiilioiitdifficulty.  It  resembled  a cncundierin 
6ha(te,  and  its  large  extremity  bad  been  lodged  in  the 
ureter,  fmm  which  it  could  only  be  gradually  removed. 


Sabatier  befieres  that  a case  of  this  description,  which 
must  be  very  uncommon,  is  the  only  one  in  which 
there  is  any  prospect  of  removing  an  encysted  stone 
with  success.  In  other  examples,  he  conceives  that  it 
is  more  prudent  to  leave  the  stone  and  let  the  wound 
heal,  than  expose  the  patient  to  an  almost  certain  death 
by  repeated  attempts  to  extract  it. — <,J\Ddecine  Opira- 
toire,  t.  3,  p.  190.  194,  ed.  2.)  Desault  employed  a sort 
of  concealed  knife,  called  a coupe-bride^  for  opening 
the  cavity  or  cyst;  and  he  has  recorded  one  example, 
in  which  he  thus  successfully  extracted  from  a woman, 
aged  sixty-two,  a stone  lodged  at  the  insertion  of  the 
ureter  into  the  bladder.  3’he  bistouiy,  used  by  Garen- 
geot, Desault  did  not  consider  a safe  instrument,  as  the 
stones  are  round,  and  the  knife  may  slipand  pierce  the 
bladder;  an  objection  to  wliich  he  says  the  coupe-bride 
is  not  liable.  No  injury  can  be  received  from  its  point, 
as  the  blade  is  concealed,  nor  can  any  part  be  divided 
except  what  the  surgeon  intends.  If  the  incision 
should  not  be  complemd  at  first,  the  blade  may  be 
witiidruwn,  the  semicircular  notch  of  the  instrument 
pushed  more  forwards,  and  the  incision  prosecuted  to 
any  extent.  This  insffument  was  invented  for  the  ex- 
press purpose  of  dividing  membranous  bands  in  the 
rectum ; but  it  was  afterward  employed  with  the 
greatest  succe.ss  for  the  excision  of  diseased  tonsils,  and 
fungous  tumours  situated  in  cavities.  The  blade  is  so 
coiitrived  that  when  it  passes  through  the  semicircular 
notch,  it  firndy  fixes  the  parts  which  are  to  be  divided: 
a thing  that  cannot  be  done  either  with  the  scissors  or 
bistoury,  as  the  moveable  parts  recede,  and  render  the 
section  didicult. — (See  Parisian  Chirurgical  Journal, 
vol.  hp.  33,  <S-c.) 

Sir  A.  Cooper  mentions,  that  when  the  stone  is  partly 
in  the  cyst  and  partly  in  the  bladder,  it  may  sometimes 
be  removed  without  opening  the  latter  organ.  In  the 
case  of  a child,  he  passed  his  finger  into  the  rectum, 
and  felt  tiie  stone,  confined  in  a bag  above  it.  On 
raising  the  calculus,  it  struck  firmly  against  the  sound. 
While  the  finger  was  in  the  rectnni,  the  knife  was  car- 
ried through  the  perinaeum  above  the  bowel,  tlie  cyst 
opened,  and  the  stone  taken  out,  w'ithout  any  farther 
opening  of  the  bladder  it.-^ell.-(See  Lancet,  vol.%  p.  346.) 

A stone  perfectly  encysted  would  not  be  expected  to 
produce  symptoms  equal  in  severity  to  those  which 
arise  from  an  extraneous  body  actually  in  the  cavity  of 
the  bladder,  and  generally  they  do  not  have  this  ef- 
fect; yet,  in  Houstet’s  interesting  dissertation,  several 
cases  are  recorded,  which  prove  that  encysted  stones 
do  sometimes  cause  the  same  distressing  symptoms 
which  proceed  from  tlie  presence  of  a loose  calculus  in 
the  bladder.  Hence,  the  patients  were  sounded,  and 
in  consequence  of  the  sacs  or  pouches  in  which  the 
-Stones  lay  not  being  entirely  closed,  the  calculi  were 
distinctly  struck  by  the  instrument,  and  lithotomy  at- 
tempted. It  deserves  particular  remark,  also,  that  in  a 
large  proportion  of  these  cases,  the  pouches  or  cysts 
were  not  single,  but  numerous,  occupying  different 
parts  of  the  bladder.  In  some  dissections,  referred  to 
by  Ilou.stet,  cysts  of  this  kind  were  found  not  contain- 
ing any  stones  whatever;  a circumstance  that  would 
rather  lead  one  to  suspect  that,  in  general,  the  forma- 
tion of  these  sacs  precedes  that  of  the  calculi  com- 
monly found  in  them. — (See  Obs.  sur  les  Piirres  En- 
cysfdcs  et  Adherentes  d la  Vessie  par  M.  Houstet,  in 
Mdm.  de  I'Acad.  de  Chir.  t.  2,p.  268,  cd.  in  i2ino.) 

OF  SOME  PARTICULAR  METHODS  AND  INSTRUMENTS. 

M.  Fonbert,  an  eminent  surgeon  at  Paris,  devised 
and  piJictiseda  plan  of  his  own,  which,  however,  has 
not  been  considered  by  others  as  wort  by  of  being  imi- 
tated. 'I'he  [ciiient  having  retained  his  urine,  sx)  as  to 
distend  his  bladder,  an  assistant,  with  a convenient  bol- 
ster, pr(;sses  the  abdomen  a liitle  below  the  navel,  in 
such  a manner,  that  by  pushing  the  bladdei  forwards, 
he  may  make  that  [lai  t of  it  protubeiant  which  lies  be- 
tween the  neck  ami  the  nreu-r.  'PIk;  opeiator,  at  the 
same  time,  iniiodnce,-.  the  fore-fingerof  his  left  hand  np 
(he  recium,  tind  drawing  it  down  towards  the  right 
buttock,  pushes  in  a trocar  on  the  left  side  ol  the  peri- 
uamm,  near  the  gi<-at  tuberosity  of  the  ischium,  and 
about  an  inch  .above  the  anu-s.  'I’hen  the  trocar  is  to 
be  carrieri  on  parallel  to  the  1(011:111,  exactly  bet  ween 
the  enu'.ior  penis  and  ticcelerator  niina;  muscles,  so  as 
to  enter  the  blaiider  on  one  side  of  its  neck.  As  soon 
as  the  bhulder  is  wounded,  the  operaior  v^'ithdraws  hi§ 
fore  finger  from  the  anns. 


146 


LITHOTOMY. 


In  the  upper  part  of  the  cannula  of  the  trocar,  there 
is  a groove,  the  use  of  wliicli  is  to  allow  some  urine  to 
escape,  immediately  the  instrument  enters  the  bladder, 
so  that  the  trocar  may  not  be  pushed  in  any  farther ; 
but  its  piincipal  use  is  for  guiding  the  incision.  As 
soon  as  the  urine  began  to  flow,  Foubert,  retracting  tlie 
trocar  a little,  without  drawing  it  quite  out  of  the  can 
nula,  introduced  the  point  of  a slender  knife  into  the 
groove  in  the  cannula;  and  by  the  guidance  of  this 
groove  he  ran  it  onwards  into  the  bladder,  and  was 
aware  of  the  knife  having  actually  entered  this  viscus, 
by  the  urine  flowing  still  more  freely.  Then  raising 
the  knife  from  tlie  groove,  he  made  hrs  incision,  about 
an  inch  and  a hall  in  length,  through  the  neck  of  the 
bladder,  by  moving  the  knife  from  that  point  at  which 
it  had  entered,  upwards  towards  the  pubes.  And, 
finally,  by  moving  the  handle  more  largely  than  the 
point  of  the  knife,  he  opened  the  cuter  part  of  the 
wound  to  whatever  extent  tlie  size  of  the  stone  seemed 
to  require,  and  then  withdrawing  the  knife,  he  intro- 
duced a blunt  gorget  to  guide  the  forceps. 

.^n  eflbrt  was  made  by  Thomas  to  improve  this  me- 
thod ; but  he  failed,  and  it  was  never  much  adopted. 
The  inability  of  many  bladders  to  bear  distention  is 
an  insuperable  objection;  for,  without  this,  the  trocar 
is  liable  to  pass  between  the  bladder  and  rectum,  and 
even  through  the  bladder  into  the  pelvis. — {JMimoirs  de 
V Acad,  de  Chir.  663,  vol.  2.  Ae  Dran's  ParalW.e. 
Sharp's  Critical  Inquiry.  ,7.  Bell's  Principles.,  vul.  2.) 

In  the  year  1743,  Frdre  Cdme’s  method  of  perform- 
ing the  lateral  operation  began  to  attract  considerable 
notice.  The  operation  was  done  with  a particular  in- 
strument, called  the  lithotome  cache,  by  means  of 
which  the  prostate  gland  and  orifice  of  the  bladder 
were  divided,  from  within  outwards.  The  lithotome 
cachi  is  entitled  to  much  attention  because  it  is  still 
generally  used  in  several  parts  of  the  continent  and 
sometimes  in  this  country,  especially  by  the  surgeons 
of  the  Westminster  Hospital.  “In  France  (says  M. 
Roux)  if  there  is  any  mode  of  operating  more  com- 
mon than  others,  and  preferred  by  the  majority  of  prac- 
titioner:?, it  is  that  in  which  the  instrument  named  the 
lithotome  cachi  is  employed.” — (See  Parallile  de  la 
Ckirurgie  Angloise,  6rc.p.  318.)  Frdre  Cdme  does  not 
ascribe  the  invention  of  this  instrument  to  Jiimself; 
but  acknowledges  that  it  resembles  the  knife  for  ope- 
rating upon  hernioB,  said  to  have  been  devised  by  a 
French  surgeon  of  the  name  of  Bienaise.  It  consists 
of  a handle  and  the  blade  part.  The  latter  is  slightly 
curved,  about  as  thick  as  a quill,  furnished  with  a 
beak,  and  excavated  so  as  to  form  a sheath  for  a knife 
of  its  own  length.  By  means  of  a kind  of  lever,  the 
knife  can  be  made  to  pass  out  of  the  sheath,  and  the 
distance  to  which  the  blade  piojects,  also  admits  of 
being  regulated  with  precision.  For  tnis  purpose,  the 
handle  is  divided  into  six  sides,  numbered  6,  7,  9,  11, 
13,  and  15,  and  which,  according  as  they  are  more  or 
less  elevated,  allow  the  lever  to  be  depressed  in  differ- 
ent degrees,  and  the  knife  to  move  out  of  its  sheath  in 
the  same  proportion.  Thus,  the  surgeon  can  at  his  op- 
tion make  an  incision  through  the  prostatic  portion  of 
the  urethra  and  orifice  of  the  bladder  of  six  different 
lencths. 

When  the  lithotome  cach^  is  to  be  used,  the  fiatient 
must  be  placed  in  the  same  posture  as  in  every  other 
mode  of  practising  the  lateral  operation ; and  after  a 
staff  has  been  introduced,  an  oblique  incision  is  to  be 
made  from  the  raphe  of  the  perinaeum,  to  a point  situ- 
ated rather  more  towards  the  anus  than  the  innermost 
part  of  the  tuberosity  of  the  ischium.  The  bulb  of 
the  urethra  should  not  be  cut,  and  not  too  much  of  the 
membranous  part  of  the  urethra.  The  fat  and  trans- 
verse muscles  having  been  divided,  and  the  urethra 
opened,  exactly  as  in  the  common  operation,  the  scal- 
pel is  to  be  put  down,  and  the  beak  of  the  lithotome 
introduced  into  the  groove  of  the  staff.  Of  course  the 
surgeon,  previously  to  the  operation,  will  have  settled 
the  distance  to  which  the  blade  of  the  instrument  is  to 
pass  out  of  the  sheath,  and  which  must  necessarily  de- 
jiend  upon  the  age  of  the  subject,  and  the  presumed 
size  of  the  calculus.  When  the  beak  of  the  lithotome 
has  been  inserted  in  the  groove  of  the  staff’  the  sur- 
geon is  to  take  hold  of  the  handle  of  the  latter  instru- 
ment with  his  left  hand,  and  bring  it  a little  towards 
himself,  at  the  same  time  pushing  the  lithotome  into 
the  bladder,  wirir'the  handle  depressed  as  much  aspos- 
fible.  The  staffs  now  to  be  withdrawn,  and  the  sur- 


geon is  to  try  to  feel  the  stone  with  the  eheatlt  of  tlMf 
other  instrument,  in  order  to  be  able  to  judge  of  the 
size  of  the  calculus,  and  whether  the  distance  to 
which  the  blade  of  the  knife  is  intended  to  move  out 
of  the  sheath,  is  such  as  is  likely  to  make  an  opening 
of  due  but  not  unnecessary  magnitude.  Things  being 
properly  determined,  the  lithotome  is  to  be  held  in  a 
position  calculated  to  make  a division  of  the  parts 
which  is  parallel  to  the  cut  in  the  integuments,  and,  by 
means  of  the  lever,  the  cutting  blade  of  the  instrument 
is  then  to  be  disengaged  from  its  sheath.  The  surgeon 
is  next  to  draw  the  opened  lithotome  towards  himself, 
in  a perfectly  horizontal  maimer,  so  as  to  make  the  re- 
quisite division  of  the  prostate  gland  and  orifice  of  the 
bladder. 

As  Sabatier  observes,  Frdre  Cdme’s  method  undoubt- 
edly possesses  all  the  advantages  of  the  lateral  opera- 
tion, besides  being  more  easy  than  Cheselden’s  plan, 
and  most  of  the  other  modes  subsequently  proposed 
for  cutting  the  prostate  gland  and  orifice  of  the  bladder 
with  perfect  smoothness,  and  to  a sufficient  extent  tO' 
allow  the  calculus  to  be  removed  without  any  laceration 
of  the  parts. — {Medecine  Operatoire,  t.  3,p.  199.) 

Several  objections  have  been  urged  against  the  use 
of  the  lithotome  cach6. 

1.  It  is  said  that  the  size  of  the  incision  is  not  always 
proportioned  to  the  distance  to  which  the  knife  moves 
out  of  the  sheath ; and  that  the  instrument,  when 
opened  to  No.  13  or  15,  sometimes  makes  a smaller  in- 
cision than  when  opened  to  No.  5 or  7.  This  uncer- 
tainly is  said  to  depend  upon  the  greater  or  less  con- 
traction of  the  bladder  in  different  subjects. 

For  my  own  part,  I confess  that  I am  not  inclined  ta 
put  much  credit  in  the  accuracy  of  this  last  explanation, 
and  suspect  that  the  difference  sometimes  observed' 
must  depend  upon  the  operator  not  taking  care  to 
draw  out  the  instrument  in  a horizontal  direction,  s 
thing  which  may  alwa3S  be  easily  done. 

2.  Frdre  Cdme  himself  made  his  incision  loo  high, 
so  that  an  extravasation  of  urine  in  the  scrotum  fol- 
lowed some  of  his  operations  ; but  the  above  method 
of  operating  is  free  from  any  objeciions  of  this  kind. 

3.  Some  surgical  writers  exaggerate  the  danger  of 
cutting  the  body  of  the  bladder  too  extensively  with  the 
lithotome,  and  thus  producing  internal  hemorrhage. 
However,  this  cannot  happen  unless  the  surgeon  raise 
the  handle  of  the  instrument  improperly  at  the  moment 
of  withdrawing  it,  and,  as  Sabatier  himself  allows,  it 
is  rather  the  fault  of  the  operator  than  of  the  operation, 

4.  The  arteria  pudica  profunda  and  the  rectum, 
which  some  authors  conceive  to  be  endangered,  must 
always  be  in  absolute  safety,  if  the  edge  of  the  knife 
of  the  lithotome  be  turned  in  the  direction  above  re* 
commended. 

I think  that  for  a surgeon  v'  ho  understands  the  right 
principles  of  lithotomy,  this  is  one  of  the  best  ways  of 
performing  the  operation. 

When  I was  at  Paris,  in  1815, 1 saw  Dr.  Souberbieile 
operate  very  skilfully  with  the  lithotome  cach^.  A 
stone  of  considerable  size  w as  extracted  from  a gen- 
tleman who  was,  I .'should  think,  not  less  than  70.  No 
apprehensions  were  entertained  of  ill  success,  as  I un- 
derstood that  this  operator  hardly  ever  lost  a patient. 

M.  Roux,  when  he  visited  Eiuiland,  seems  not  to 
have  been  informed,  that  at  the  Westminster  Hospital, 
the  lithotome  cach6  has  been  commonly  employed  for 
many  years  past.  It  has  also  been  sometimes  used  at 
Guy’s  Hospital  by  Sir  A.  Cooper.  When  M.  Roux 
likewise  finds  fault  w'ith  the  bad  construction  of  this 
instrument,  as  made  in  London,  I susjHCt  that  he 
cannot  have  seen  those  w hich  are  made  and  sold  by 
Mr.  Evans. — (See  Voyage  fait  d Lovdres,  ou  Paral- 
lile de  la  Chirurgie  Augloise,  Src.  p.  318.) 

Dupuytren  has  sometimes  employed  a lithotome 
cach4,  formed  with  two  blades,  with  which  the  prostate 
gland  is  completely  divided  into  an  anterior  and  poste 
rior  portion  : the  staff  is  introduced  ; the  membranous 
part  of  the  urethra  opened  so  as  to  let  the  lithotome  be 
passed  into  the  bladder;  and  when  the  instrument  is 
withdrawn  it  divides  the  prostate  on  eai  h side.  In  this 
method  the  vtisa  deferentia,  rectum,  transverse  arteries 
of  the  perinsenm,  and  the  pudic  artery,  are  avoided. 

Le  Cat,  a surueon  of  Rouen  in  Normandy,  devised  a 
mode  of  lithotomy,  which  would  be  too  aiisurd  to  be 
described,  were  it  iess  renowned.  He  thought  the  neck 
of  the  bladder  might  be  dilated  like  the  wound,  and 
his  operation  was  deformed  witJt  all  the  cruelty  of  tb« 


LITHOTOMY. 


147 


Marian  method,  and  every  error  attendant  on  the  In- 
iant  state  of  the  latter  operation.  He  fust  introduced 
a long  wide  staft':  he  cut  forwards  with  a common  scal- 
pel through  the  skin  and  fat,  till  he  could  distinguish 
the  bulb,  the  naked  urethra,  and  the  prostate  gland. 
Secondiy,  with  another  knife,  the  urethrotome,  having 
a groove  on  one  side,  he  opened  the  urethra  just  before 
the  prostate,  and  fixing  the  urethrotome  in  the  groove 
of  the  staff,  and  holding  it  steady,  rose  from  the  kneel- 
ing posture  in  which  he  performed  the  outward  inci- 
sion. Thirdly,  holding  the  urelhrotonre  in  the  left  hand, 
he  passed  another  knife,  the  cystotome,  along  the 
groove  of  the  urethrotome  ; and  the  beak  of  the  cysto- 
tome being  lodged  in  the  groove  of  the  urethrotome,  it 
was  pushed  forwards  through  the  substance  of  the 
prostate  gland  into  the  bladder.  Fourthly,  drawing  the 
cystotome  a little  backwards,  he  gave  the  staff  to  an 
assistant  to  be  held  steadily,  and  lifting  a blunt  gorget 
in  the  right  hand,  he  placed  the  beak  of  it  in  the  groove 
of  the  cystotome,  and  pushed  it  onwards  till  it  glided 
from  the  groove  of  the  cystotome,  along  the  groove  of 
the  staff  into  the  bladder.  Then,  true  to  the  principles 
of  the  apparatus  major,  and  never  forgetting  his  own 
peculiar  theory,  liult  incision  and  much  dilatation^  he 
forced  his  fingers  along  the  gorget,  dilated  the  neck  of 
the  bladder,  and  so  made  way  for  the  forceps. — (J. 
BedVs  Principles,  vol.  2.) 

In  1741,  Le  Dran  described  an  operation,  the  intro- 
duction of  which  has  been  claimed  by  several  since  his 
time.  A staff  being  introduced,  and  two  assistants 
keeping  open  the  patient’s  knees,  while  a third  stands 
on  one  side  of  him  on  a chair  (Le  Dran  says),  “ I then 
raise  up  the  scrotum,  and  directing  the  last  assistant  to 
support  it  with  both  hands,  so  as  to  avoid  bruising  it, 
by  pressing  it  either  against  the  staff  or  the  os  (.ubis,  I 
place  his  two  fore-fingers  on  each  side  of  the  part 
where  the  incision  is  to  be  made;  one  of  the  fingers 
being  laid  exactly  along  that  branch  of  the  ischium, 
w'hich  rises  towards  the  pubes,  and  the  other  pressed 
upon  the  raphe,  that  the  skin  may  be  kept  fixed  and 
tight.  While  I thus  place  the  fingers  of  the  assistant 
Who  supports  the  scrotum,  I still  keep  hold  of  the  han- 
dle of  the  staff,  and  direct  it  so  as  to  form  a right  atigle 
with  the  patient’s  body  ; at  the  same  time  taking  care 
that  the  end  of  it  is  in  the  bladder.  This  position  is 
the  more  essential,  as  all  the  other  instruments  are  to 
be  conducted  along  the  gioove  of  this.  If  the  handle 
of  the  staff  were  kept  inclined  towards  the  belly,  the 
end  of  it  would  come  out  of  the  bladder,  and  the  gor- 
get, missing  its  guide,  would  slip  between  that  and  the 
rectum. 

“ I’he  staff  being  rightly  placed,  I take  the  knife  from 
the  as6i.stant  who  holds  the  instruments,  and  put  It  into 
my  mouth;  then  pressing  the  beak  of  the  staff  against 
the  tectum,  I feel  the  curvature  of  it  throuuh  the  peri- 
nseum.  The  incision  ought  to  terminate  an  inch  and  a 
half  below  where  we  feel  the  bottoui  of  the  curvature. 
If  we  do  not  carry  this  incision  sufficiently  iow,  it  may 
happen  not  to  be  of  a size  to  allow  the  extraction  of  a 
large  stone,  and  might  lay  us  under  the  necessity  of 
ext(!iiding  it  farther'  afterwaid,  for  the  skin  will  not 
lacerate  here,  nor  easily  give  way  for  the  passage  of 
tne  stone.  I therefore  begin  the  incision  from  the  lower 
part  of  the  os  pubis,  continuing  it  down  to  the  pi, ace 
that  I before  directed  for  its  termination  ; after  which 
1 jinss  the  [mint  of  the  knife  into  the  groove  of  the 
staff,  and  cutting  from  below  u[iwaids,  without  taking 
the  point  out  of  the  groove,  I open  the  anterior  part  of 
the  urethra  as  far  as  the  incision  that  is  in  the  skin. 

“The  beak  of  the  staff,  which  was  pressed  upon  the 
rectum,  must  now  be  raised  and  [iressed  against  the 
08  piibis.  At  the  same  time  I turn  the  h.andle  towards 
the  rit'lit  groin,  that  the  groove,  which  is  at  the  beak  of 
the  staff,  may  face  the  space,  between  the  amis  and  the 
tuberciilum  ischii  on  the  left  side.  Then  carrying  the 
point  of  the  knife  down  the  groove,  I slide  it  along  the 
beak,  turning  the  edue  that  it  may  face  the  ap.ace  be- 
tween the  anus  and  tuberosity  of  the  ischium.  By 
thi.s  incision.  I exactly  divide  the  bulb  of  the  urethra; 
and  by  doing  this  on  its  side  we  are  sure  to  avoid 
\youridin"  the  rectum,  which,  for  want  of  this  precau- 
tion, has  been  olleri  cut  This  first  incision  being  made, 

I auain  i)ass  the  point  of  the  knife  into  the  curvature 
of  the  staff  to  the  part  where  it  bears  acainst  the  jieri- 
n^iim,  and  direct  it  to  be  held  there  by  the  assistant, 
who  Biipporu  the  scrotum.  Thi.s  done,  I take  a large 
director,  the  end  of  which  is  made  with  a beak,  like 

H2 


that  of  a gorget,  and  conveying  this  beak  upon  the 
blade  of  the  knife,  into  the  groove  of  the  staff,  1 draw 
the  knife  out.  I then  slide  the  beak  of  this  director 
along  the  groove  of  the  staff  imo  the  bladder,  and  I 
withdraw  the  staff  by  turning  the  handle  towards  the 
patient’s  belly.  The  following  circumstances  will  suf- 
ficiently satisfy  us  that  the  director  is  iiTroduced  into 
the  bladder;  first,  if  it  strikes  against  the  end  of  the 
staff,  which  is  closed  ; secondly,  if  the  urine  tuns  along 
the  groove.  I next  feel  for  the  stone  with  this  director, 
and,  having  found  it,  endeavour  to  distinguish  its  size 
and  surface,  in  order  to  make  choice  of  a proper  pair 
of  forceps  ; that  is,  one  of  a stronger  or  weaker  make, 
or  of  a large  or  small  size,  agreeably  to  that  of  the 
stone  ; after  which  I turn  the  groove  towards  the  space 
between  the  anus  and  tuberosity  of  the  ischium,  and, 
resting  it  there,  convey  a bistoury  along  the  groove,  the 
blade  of  which  is  half  an  inch  broad,  and  about  three- 
quarters  of  an  inch  long.  I continue  the  incision  made 
by  the  knife  in  the  urethra,  and  entirely  divide  the 
prostate  gland  laterally,  as  also  the  orifice  of  the  blad- 
der ; and  I am  very  certain  that  th''  introducing  the 
use  of  these  two  instruments,  which  are  not  employed 
by  other  lithotomists,  does  not  prolong  the  operation  a 
quarter  of  a minute,  but  rather  shortens  the  time,  both 
by  facilitating  the  dilatation  that  is  afterward  to  be 
made  with  the  finger,  and  by  rendering  the  extraction 
of  the  stone  more  easy.  The  bistoury  being  with- 
drawn, the  groove  of  the  director  serves  to  guide  the 
gorget  into  the  bladder.  1 then  introduce  my  fore- 
finger along  the  gorget  (which  is  now  easily  done,  as 
tlie  urethra  and  prostate,  being  divided,  do  not  oppose 
its  entrance),  and  with  it  I dilate  the  passage  for  the 
stone  in  [uoportion  to  the  size  of  which  I discover  it  to 
be.  This  dilatation  being  made,  I withdraw  my  finger 
and  use  the  proper  forceps.” — (Le  Bran's  Operations^ 
ed.  5,  1784,  London.) 

Pajola,  of  Venice,  was  the  pupil  of  Le  Cat,  and  his 
method  resembles  that  of  his  master.  He  is  stated  to 
have  cut  for  the  stone  550  patients  with  success ; which 
deserves  notice,  because  his  operation  has  for  its  prin- 
ciples dilatation  and  no  division  of  any  part  of  the 
bladder.  He  makes  an  incision  into  the  groove  of  the 
staff  with  a lancet-pointed,  double-edged  knife,  called 
an  urethrotome,  the  blade  of  which  has  upon  its  centre 
a groove  that  is  continued  to  its  very  point,  and  serves 
to' guide  the  beak  of  another  instrument,  called  the 
cystotome,  into  the  groove  of  the  staff.  As  the  pro- 
fessed intention  of  the  cystotome  is  only  to  cut  the 
prostate  gland,  its  name  is  ridiculous.  It  consists  of  a 
handle  and  very  slender  blade,  which  is  not  connected 
with  the  handle,  but  with  its  sheath,  by  means  of  a 
little  joint  close  to  the  beak  of  the  instrument.  When 
the  cystotome  is  opened  as  fbr  as  possible,  the  end  of 
the  blade  farthest  from  the  beak  is  twelve  lines  from 
the  sheath.  In  this  position  it  is  held  by  a transverse 
piece  of  st«tel,  which  admits  of  being  pushed  more  or 
less  out  at  the  option  of  the  surgeon,  and  can  be  fixed 
by  means  of  a screw.  Pajola,  like  Scarpa,  considers 
cutting  the  neck  of  the  bladder  dangerous,  and  he 
tnerely  divides  the  prostate,  after  which  he  introduces 
a blunt  gorget,  and  along  this  a species  of  forceps  for 
dilating  the  neck  of  the  bladder  in  all  directions. — (X. 
F.  Rudtnrffer  nber  die  Operation  des  Blasensteins 
nach  Pajola's  Methode.)  As  Langenbeck  observes, 
great  as  the  success  of  this  lithotomist  has  been,  his 
method  of  operating  has  little  to  recommend  it;  and 
every  thing  must  be  ascribed  to  his  individual  skill  and 
intimate  knowledge  of  the  parts.  Langenbetk  even 
prefers  Le  (.'at’s  method,  in  which  there  is  no  need  of 
such  a multiplicity  of  instruments.  The  blunt  gorget 
and  dilator  are  perfectly  unnecessary,  as  the  finger 
would  do  the  purpose  of  both. 

In  some  former  editions  of  this  Dictionary,  I omitted 
to  notice  what  has  been  termed  by  the  French,  “ OpS- 
ration  d.  deux  temps,"  and  which  was  first  mentioned 
by  Franco.  If  by  this  plan  it  be  intended,  that  the  in- 
cision should  be  made  at  one  period,  and  the  extrac- 
tion of  the  stone  not  attempted  till  a subsequent  period, 

I cannot  too  strongly  reprobate  the  pr.actice.  But  if  I 
am  to  understand,  that  the  [rostprrnement  of  the  com- 
(tletion  of  the  operation  is  only  to  beado[)ted  as  a matter 
of  necessity,  when  the  patient  cannot  bear  the  longer 
continuance  of  the  unsuccessful  efforts  to  extract  the 
stone,  of  course  I can  only  say,  that  every  endeavour 
should  be  used  to  avoid  this  very  disagreeable  diremma, 
by  making  in  tiie  first  instance  an  adequate  opening, 


148 


LITHOTOMY. 


and  (If  this  cannot  b«  done)  by  breaking  the  calculus, 
and  carefully  removing  all  the  fragments.  Some  far- 
ther considerations  against  delaying  the  completion  of 
the  operation,  wull  be  found  in  the  last  two  editions  of 
the  First  Lines  of  Surgery. 

The  danger  of  the  beak  of  the  gorget  slipping  out  of 
the  groove  of  the  staff,  is  one  of  the  chief  objections 
urged  against  the  employment  of  the  first  of  tiiese  in- 
struments. In  order  to  obviate  tijis  inconvenience. 
Sir  Charles  Blicke  had  the  groove  of  the  staff  and  the 
beak  of  the  gorget  so  conslrncted,  that  tiiey  locked  into 
each  otJier,  and  continued  fixed  till  near  the  extremity 
of  the  staff.  The  contrivance,  though  plausible  and 
ingenious,  is  not  much  used ; the  point  of  contact  of 
the  beak  and  body  of  the  instrument  is  necessarily  so 
small  that  it  is  liable  to  break.  It  is  allowed, however, 
that  this  objection  might  be  removed  ; but  another  one 
is  still  urged,  viz.  the  beak  ami  groove  catching  on 
each  other,  so  as  to  resist  the  efforts  made  to  introduce 
the  gorget  into  the  bladder.  Every  operator  knows, 
that 'much  of  the  safety  of  the  lateral  operation,  as  per- 
formed at  present,  depends  on  tlie  ease  with  which 
the  beak  of  the  gorget  slides  along  the  groove  of  the 
staff.  Le  Cat,  in  1747,  is  said  to  have  devised  a similar 
instrument. 

Some  operators  have  a good  deal  of  trouble  in  dis- 
secting into  the  groove  of  the  staff.  Sir  James  Earle 
invented  an  instrument  to  render  this  part  of  the  ope- 
ration more  easy  It  consists  of  a short  staff,  with  an 
open  groove,  connected  by  a hinge  with  the  handle  of 
another  staff  of  the  usual  size,  shape,  curvature,  ai.d 
length,  which  maj’  be  called  the  long  stuff.  The  hinge, 
by  means  of  a pin,  is  capable  of  being  disjointed  at 
pleasure.  The  short  stall’  is  sufficiently  curved  to  go 
over  the  penis  and  scrotum,  and  long  eitongh  to  reach 
to  that  part  of  the  long  staff  which  is  just  below  the 
beginning  of  its  curvature.  The  end  of  the  short  staff, 
made  somewhat  like  a pen,  with  the  sides  sharpened 
and  finely  pointed,  is  adapted  to  snut  into  the  groove 
of  the  long  staff,  and  its  culling  edges  are  defended 
from  being  injured  by  a proper  receptacle,  which  is 
prepared  for  it  in  the  groove  of  the  long  staff.  When 
the  instrument  is  shut,  tlie  groove  of  the  short  staff 
leads  into  that  of  the  long  one,  so  as  to  form  one  con- 
nected and  continued  groove.  The  short  staff  is  ren- 
dered steady  by  the  segment  of  an  arch,  projecting  from 
the  long  one  through  it. 

The  long  staff,  separated  from  the  short  one,  is  first  in- 
troduced in  the  usual  manner,  and  ihestone  having  been 
felt,  the  short  stall’  is  to  be  put  on  the  ot  Iter  at  the  hinge. 
The  incision  is  then  to  be  made  in  tue  usual  manner 
through  the  skin  and  cellular  menibrane,  and  a second 
incision  through  the  muscles,  so  as  m arly  to  lay  bare 
the  urethra.  The  operator  then  being  perfectly  con- 
vinced that  the  extremity  of  the  long  staff  is  suh'iciently 
within  the  bladder,  must  bring  the  end  of  the  short  sttiff 
down,  and  press  it  against  the  ureihia,  which  it  will 
readily  pierce,  and  pass  into  the  cavity  prepared  for  it 
in  the  groove  of  the  long  staff  The  two  pieces  beinsr 
now'  firndy  held  together  by  tlie  operator’s  left  hand, 
nothing  remains  to  be  done  except  applying  the  beak  of 
the  gorget  to  the  groove  of  the  short  staff,  and  |)ushiiig 
it  on  till  it  is  received  in  the  groove  of  the  long  one; 
and  if  this  latter  be  made  with  a contracted  groove,  it 
will  just  enter  where  the  contraction  begins,  and  thus 
must  be  safely  conducted  into  the  bladder. — XF.arle  on 
the  Stone;  ..^ppenUiz,  ed.  2, 17y6.)  Deschami>s  describes 
an  instrument  invented  by  Jardaa,  surgeon  of  IMontpel- 
lier,  which  bears  a resemblance  to  Earle’s  double  staff, 
but  was  more  complicated,  being  designed  to  .mpjKirt  the 
scrotum,  and  also  press  the  rectum  out  of  the  way. 

The  late  Mr.  Dease  of  Dublin,  and  Ali.  IMnir  of 
Glaseow',  considering  that  the  gorget  was  mo  e aj»t  to 
slip  from  the  staff  in  conse<iuence  of  the  latter  being 
curved,  and  that  its  beak  never  slips  from  the  groove 
of  the  staff  in  operating  on  w omen,  proposetl,  like  Le 
Dran,  to  convert  the  male  into  the  female  urethra. 
They  introduce,  as  usual,  a curved  srooved  staff  into 
the  bladder,  make  the  common  incisions,  and  open  the 
membranous  part  of  the  urelhia  ; hut  instead  of  in- 
troducing a gorget  on  the  curved  staff,  they  conduct 
along  the  groove  a straight  director  or  staff  into  the 
bladder,  and  immediately  withdraw  the  other.  The 
gorget  is  then  introduced.  In  this  manner  the  opera- 
tion may  be  very  well  performed  with  a nanow  bis- 
toury, as  was  advised  by  Mr.  A.  Burns.  Mr.  Key, 
who  adheres  to  the  valuable  principles  of  Cht'selden, 


but  uses  a knife  instead  of  a gorget,  ht  also  an  advo- 
cate tor  a director  w hich  is  straight  except  towaids  its 
termination,  a part  never  conceintd  in  guiding  the 
knife,  and  which  is  introduced  like  the  common  staff 
— ( On  the  Section  of  the  Prostate  Gland,  p.  23.) 

LITHOTOMY,  AS  PERFORMED  WITH  A KNIFE  INSTEAD 

OF  A CUTTING  GORGET  BY  SEVERAL  OF  THE  MO- 
DERNS. 

^ We  have  already  described  how  Fr^re  Jacques  and 
Chesclden  used  lo  operate  w iih  a kniie,  without  any 
cutting  gorget,  in  the  early  siateof  the  lateral  operation. 
The  success  whicli  attended  the  excellent  practice  of 
the  la. ter  surgeon  certainly  tar  exceeds  what  aiiends 
the  present  employment  of  the  gorget ; for  out  of  52 
patients,  whom  he  cut  successively'for  the  stone,  he 
lost  only  two;  and  out  of 213  of  all  ages,  constitutions, 
&c.  only  20.  These  facts  are  strongly  in  (avour  of 
abandoning  the  use  of  the  gorget,  and  doing  its  office 
with  a knife. 

The  objections  to  the  gorget  are  numerous  and  w'ell 
founded.  In  the  hand.-  of  many  skilful  operators,  its 
beak  has  .slipped  out  of  the  giooveof  the  staff’,  and  the 
instrument  has  heeii  driven  either  between  the  lectuin 
and  the  bladder  into  the  intestine  instead  of  the  latter 
visc'.is,  or  else  between  the  bladder  and  the  pubes. 
“ III  were  to  be  asked  (says  Sir  A. Cooper)  how  many 
limes  I have  known  the  g<irgel  slip  ami  pa>5  betw  een 
the  bladder  and  re'cturn,  1 should  say  at  least  a dozen 
times,  and  in  each  case  the  most  Ian  entable  and  latal 
consequences  ensued ; for  the  operator  now  lays  hold 
of  the  stone  and  blaiider  together ; the  forceps  slip  ; the 
stone,  enclosed  in  the  bladder,  is  again  laid  hold  of;  and 
thus  he  continues  to  pull,  bruise,  and  injure  the  blad 
der,  till  the  patient  is  at  length  carried  back  to  his  bed 
with  the  stone  unextracled,  violent  inflammation  su 
pervenes  from  tlie  injury  done  lo  the  bladder,  and  in  a 
few  dat  s the  patient  is  no  mote.”— (See  Lancet,  vol. 
2,  7>.  238.)  Sir  James  Earle  remarks . “1  have  more 
than  once  know'll  a goigel,  though  passed  in  the  right 
direction,  pushed  on  so  far,  and  with  such  violence,'as 
to  go  through  the  opposite  side  of  the  bladder.”  Broni- 
field,  even  when  operating  with  a blunt  gorget,  perfo- 
rated the  bladder  and  peritoneum,  so  iliat  the  abdo- 
minal viscera  came  out  of  the  wound. — (P.  270.)  ! 
now  know  of  at  least  threp  instances  in  wiiich  the 
gorget,  slipping  from  the  staff’,  completely  severed  the 
urethra  from  the  bladder;  the  stone  was  not  taken  out, 
and  the  patients  died. 

We  will  suppose,  how'ever,  that  the  precedmu'  dan- 
geis  of  the  aoiget  are  surmounted,  as  they  certainly 
may  be,  by  paiticular  dexterity,  seconded  by  the  confi- 
dence of  expeiictice.  The  goiget  is  introduced  but 
whatever  kind  of  one  has  been  used,  the  wound  is 
never  suffic; -ntly  large  for  the  ea.sy  passage  of  any 
stone,  except  such  as  are  below  the  ordinary  size. 
Campi  r has  noticed  this  fact : “ Ha^^  kemius  solo  con- 
ductore,  cujus  margo  dexter  in  aciem  assurgit,  idem 
praistal;  omves  plagam  dilutant  ut  culcvlum  extra- 
hunt  : dilacerentur  igitur  semper  resicte  o.'^^iium  et 
prostata." — (P.  114.)  Dease  says:  “ In  all  the  trials 
that  I have  made  with  the  gorget  on  the  dead  subject,  I 
have  never  found  the  opening  into  the  bladder  suffi- 
ciently larsre  for  the  extraction  of  a stone  of  a middling 
size,  without  a considerable  laceration  of  the  parts.  I 
have  frequently  taken  the  largest  sized  gorset,  and 
could  not  find,  in  the  adult  snbjt  ct.  I ever  entirely  di- 
vided the  prostate  gland,  if  it  was  any  way  large;  and 
in  the  operations  that  were  peiformid  here  oti  the  liv- 
ing subject,  if  the  stone  vi  as  large  the  extraction  w as 
painfully  tedious,  and  efl'ected  w’iih  great  difficulty, 
and  in  some  cases  not  at  all.” 

1 shall  dismiss  this  pail  of  the  subject  with  referring 
the  reader  to  the  spirited  and  correct  remarks  on  the 
objections  to  the  gorget  in  Mr.  John  Bell’s  Principles, 
vol.  2,  part  2. 

The  latter  author  recommends  the  external  incision 
in  a laige  man  to  comnience  about  an  inch  behind  the 
sciotum,  and  to  be  carried  downwaids  three  inches 
and  a half,  midw'ay  betw  I'en  the  anus  and  tuberosity 
of  tin*  i.-chimu.  'I'he  fincers  of  the  left  hand,  w'bich 
at  first  kept  the  skin  tense,  are  now  applied  to  other 
purposes.  The  fore-fincer  ninv  guides  the  knife,  and 
the  operator  proceeds  to  dis-ect  tlnonuh  fat  and  cellu- 
lar snb>iance,  ami  muscnlnr  .t  d ligamentous  fibres,  till 
the  wound  is  free  and  open,  till  all  sense  of  siricttirei» 
gone;  for  it  is  only  by  feeling  opposition  and  stricture 


LITHOTOMY. 


149 


that  we  recognise  the  transverse  muscle.  When  this 
hollow  Is  fairly  laid  open,  the  external  incision,  which 
relates  viercly  to  the  free  extraction  of  the  stone,  is 
completed.  )f  it  weie  the  surgeon’s  design  to  operate 
only  with  the  knife,  he  would  now  push  his  lingers 
deeply  into  the  wound,  and,  by  the  help  of  the  fore- 
finger, dissect  from  the  urethra  along  the  body  of  the 
gland,  till  he  distinguished  its  thickness  and  solidity, 
and  reached  its  back  part.  Then  plunging  his  knife 
through  I he  posterior  portion  of  the  gland,  xand  settling 
it  in  the  grove  of  the  staff,  he  would  draw  it  firmly  and 
steadily  towards  him,  at  the  same  time  pressing  it  into 
the  groove  ol  this  instrument , and  then  the  free  dis- 
charge of  the  urine  assuring  him  that  the  prostate  and 
orifice  of  the  bladder  were  divided,  he  would  lay  aside 
his  knife,  pass  the  left  fore-finger  into  the  bladder,  with- 
draw tile  staff,  and  introduce  the  forceps. — {John  Bell, 
p.  197.; 

Ml  . C.  Bell  describes  the  following  method  of  ope- 
rating with  a knife  instead  of  a gorget.  A staft'grooved 
on  the  right  side,  a scalpel  with  a straight  back,  and 
the  common  lithotomy  forceps  are  the  indispensable 
instruments.  The  staff  is  kept  in  the  centre,  and  well 
home  into  the  bladder.  The  surgeon  making  his  in- 
cision under  the  arch  of  the  pubes  and  by  the  side  of 
the  anus,  carries  it  deeper  towards  the  face  of  the 
prostate  gland ; cutting  near  to  the  stafl",  but  yet  not 
cutting  into  it,  and  avoiding  the  rectum  by  pressing  it 
down  with  the  finger.  Now  carrying  the  knife  along 
ttie  staff,  the  prostate  gland  is  felt.  The  point  of  the 
knife  is  run  somewhat  obliquely  into  the  urethra,  and 
into  the  lateral  groove  of  the  staff,  just  before  the  pros- 
tate gland.  It  is  run  on  until  the  urine  flow's.  The 
fore-finger  follows  the  knife,  and  it  is  slipped  along  the 
back  of  it,  until  it  is  in  the  bladder.  Having  carried 
the  fore-finger  into  the  bladder,  it  is  kept  there  and  the 
knife  is  wiihdravvn.  Then  the  forceps,  directed  by  the 
finger,  are  introduced. — {OpeVative  Surgery,  vol.  1,  n. 
361.) 

Mr.  A'lan  Burns  recommends  the  following  method: 
“ The  plan  (says  he)  introduced  by  Cheselden,  and  re- 
vived by  Mr.  J Bell,  I would  assume  as  the  basis  of 
the  operation ; but  still,  along  with  their  mode  I would 
blend  that  of  Mr.  Dease,  by  which,  1 imagine,  we  may 
overcome  some  of  the  disadvantages  attendant  on  each 
considered  individually. 

“ For  more  than  twelve  months  I have  been  in  the 
habit  of  showing  such  an  operation,  which  is  as  simple 
in  its  perforniance  as  the  one  in  general  use,  is  attein'ed 
with  less  dangei  to  the  patient,  permits  of  an  incision 
varying  in  size  according  to  the  wish  of  the  operator, 
and  completely  prevents  injury  of  th'  rectum  or  pndic 
artery.  To  perform  this  operation,  I introduce  into 
tile  urethra  a common  curved  siaff,  then  make  the 
usual  incision  into  the  perinamm,  divide  fully  and 
freely  the  levator  ani,  so  as  to  expose  the  whole  extent 
of  the  membranous  part  of  the  urethra,  the  complete 
extent  of  the  prostate  gland,  and  a portion  of  the  side 
of  the  neck  of  the  bladder.  When  this  part  of  the 
operation  is  fiiushed,  I ojien  the  menibranous  part  of 
the  urethra,  and  introduce  through  the  slit  a straight 
or  female  staff,  with  which  I feel  the  stone,  and  then 
withdraw  the  curved  staff.  This  done,  I grasp  the 
handle  of  the  siafffirmly  in  my  left  hand,  and  witii  the 
right  lay  hold  of  the  knife.  Having  ascertained  that 
lire  two  instruments  are  in  fair  contact,  I rest  the  one 
band  upon  the  other,  pressing  them  together,  and  then, 
by  a steady  extraction,  I pull  out  the  kiiil'e  and  staff 
together,  which  is  pieferabl**  to  drawing  the  knife 
along  the  staff:  it  prevetits  the  risk  of  the  one  slipping 
from  the  other;  it  uuards  the  bulb  of  the  urethra,  and 
every  other  part,  from  itijniy;  for  between  tlnmi  and 
the  cittiing  instrument  the  staff  is  iiiterprtsed,”  <Stc. 
“Whet!  introducing  the  ktiife,  the  side  of  the  blade 
must  be  laid  flatalo'ig  the  forc-fitiger  of  the  right  hand, 
which  is  to  project  a little  heyotid  the  [Ktitit.  Itt  tliis 
state  the  finger  and  knife  are  to  enter  the  wound  oppo- 
si'e  the  titber  ischii ; hut  in  pioportion  as  they  pass 
along,  they  are  to  be  inclined  forwards,  till  at  last,  w'iih 
the  point  of  the  tineer,  the  staff  is  to  he  felt  throngli  the 
coats  of  the  bladder,  a little  beyond  the  prostate,  and 
railwr  highe.r  than  the  orifice  of  the  urethra.  Here  the 
knife  is  to  be  pushed  with  the  finiu-r  through  the  blad- 
der, and  when  the  point  is  fairlv  fixed  in  the  eroove  of 
the  staff,  the  opi-ration  is  to  be  finished  by  the  steady 
extraction  of  both  instruments.” — (See  Bdin.  Surg. 
Journal,  JTo.  13.)  * 


The  knife  of  Cheselden  does  not  require  so  much 
violence  to  divide  the  parts  as  the  gorget  does; 
cannot  slip  in  some  instances  before,  in  others  behind, 
the  bladder;  and  it  will  make  a wound  sufficiently 
ample  for  the  easy  extraction  of  the  stone,  without  the 
least  laceration.  The  possibility  of  its  wounding  the 
rectum,  Dr.  'J’homson  thinks  might  be  obviated  by  em- 
ploying it  as  follows;  “After  having  made  the  exter- 
nal incisions,  and  divided  the  membranous  part  of  the 
urethra  in  the  way  that  it  is  usualiy  done  for  the  intro- 
duction of  the  beak  of  the  gorget,  a straight  grooved 
staff  is  to  be  introduced  into  the  groove  of  the  curved 
stafl',  and  pushed  along  it  into  the  biadder.  The 
curved  staff  is  then  to  be  withdrawn,  and  the  surgeon, 
laying  hold  of  the  handle  of  the  straight  stafl'  w ith  his 
lell  hand,  and  turning  the  groove  upwards  and  a little 
outwards,  presses  the  back  of  it  downwards  towards  the 
right  tuber  ischii,  and  holds  it  steadily  in  tlret  posi- 
tion. The  point  of  a straight-backed  scal[iel  being 
now  introduced  into  the  groove  of  the  staff,  with  its 
cutting  edge  inclined  upwards  and  a little  outwards,  is 
to  be  pushed  gently  forwards  into  the  bladder.  The 
size  of  the  scalpel  need  only  be  such  as  will  make  a 
wound  in  tiie  prostate  gland  and  neck  of  the  bladder, 
sufficienily  large  to  admit  the  fore-finger  of  the  left 
hand.  Tiie  scalpel  being  removed,  this  finger  is  to  be 
introduced  into  the  bladder  through  the  wound  which 
has  been  made,  and  the  staff  may  then  be  withdrawn. 
With  the  finger  the  surgeon  endeavours  to  ascertain 
the  size  and  situation  of  the  stone.  If  after  this  ex- 
amination he  judges  the  incision  in  the  neck  of  the 
bladder  to  be  too  small  for  the  easy  extraction  of  the 
stoiK!,  he  next  introduces  into  the  bladder  a straight 
probe-pointed  bistoury,  with  its  side  close  to  the  fore 
part  of  his  finger,  and  its  cittiing  edge  upwards.  By 
turning  this  edge  towards  the  left  side,  and  by  keeping 
the  point  of  his  finger  always  beyond  the  point  of  the 
bistoury,  he  may  safely  divide,  in  the  direction  of  the 
first  incision,  as  much  of  the  prostate  gland  and  neck 
of  the  bladder  as  he  shall  deem  necessary.” — (See  Ohs. 
on  Lithotomy,  Src.with  a Proposal  for  a JVew  Manner 
of  Cutting  for  the  Stone,  F.din.  1808.) 

Mr.  Allan,  who  is  a strenuous  advocate  for  using  the 
knife  instead  of  the  gorget,  directs  us,  after  laying  bare 
the  urethra,  and  bringing  the  staff  so  as  to  form  a right 
angle  with  the  patient’s  body,  to  feel  that  the  in- 
strument is  fairly  lodged  in  the  bladder.  The  operator 
is  to  use  the  fore-finger  of  his  left  iiand  as  a director  in 
feeling  for  the  groove  in  the  staff,  a.id  in  distinguishing 
the  prostate  gland ; and  with  this  finger  he  is  to  de- 
press the  rectum,  and  direct  the  deeper  part  of  his  dis- 
section. “Feeling  the  gland  with  thepointof  tire  fore- 
finger of  the  left  hand,  and  the  groove  of  the  staff'  in 
the  upper  part  of  the  wound,  the  assistant  is  desired 
to  steady  his  hand,  and  the  operator,  holding  his  knife 
as  he  does  a writing  pen,  liis  fingers  an  inch  and  a 
half  from  the  point,  turns  up  its  edge  towards  the  staff, 
and  strikes  its  point  through  the  menibranous  part  of 
the  urethra  into  its  groove,  half  an  inch  betore  the  pros- 
tate gland.  He  now  turns  the  back  of  the  knife  to 
the  staff',  slides  it  a little  backwards  and  forwards  in 
tlie groove,  that  he  may  be  sure  it  has  fairly  entered; 
then  shifts  the  fore  linger,  with  which  he  guides  the 
incision,  places  it  under  the  knife,  and  always  keeps  it 
before  its  point,  so  as  to  prevent  tlie  reclnin  fiom  being 
wounded  ; he  then  lateralizes  the  knife,  enters  the  sub- 
stance of  the  jirostate,  is  conscious  of  running  the  scal- 
pel through  its  solid  and  fleshy  snlislance,  and  judges 
by  the  finger  of  the  extent  of  the  incision  which  he 
now  makes.  'I'he  urine  flows  out;  he  slips  his  finger 
into  the  opening,  withdraws  the  scalpel,  and  gives  it 
to  an  a.ssisianl,  who  hands  him  the  forceps,  which  he 
passes  into  the  bhidder,  using  the  (bre-linger  of  his  left 
liand,  which  is  still  within  the  wound,  as  a conductor. 
'I'he  forceps  instantly  encounter  Hie  staff,  which  serves 
to  conduct  them  safely  into  the  bladder,  while  the 
finger  guides  them  through  the  wound,  &c.” — {Lilian 
on  Lithotomy,  p.  48,  Kdiv.  1808.) 

I leave  the  reader  to  judge,  which  of  the  foregoing 
modes  of  operating  with  a common  knife  claims  the 
preference.  Perhaps  Che.seldeti’s  manner,  which  is 
also  Mr.  John  Bell’s,  is  as  deserving  of  recommenda- 
tion as  any.  When  it  is  adopted,  a largish  scalpel, 
with  a long  handle,  will  be  found  more  convenient 
than  a common  one,  on  account  of  the  depth  of  the 
parts  requiring  division,  especially  in  adults  and  fat 
subjects. 


150 


LITHOTOMY. 


I would  also  beg  the  attention  of  surgeons  to  the  mo- 
dification ill  the  manner  of  performing  Cheselden’s 
operation,  proposed  by  Mr.  Key,  and  executed  with  a 
eiaff  of  nearly  a straight  form,  and  a scalpel  that  has 
a slightly  convex  back  near  its  point,  in  order  that  it 
may  run  with  more  facility  in  the  groove  of  the  staff. 
— ( On  the  Section  of  the  Prostate  Oland,  p.  26.) 

The  methods  of  operating  with  a knife,  as  practised 
by  Klein  and  Langenbeck,  I shall  not  here  repeat,  as 
they  are  described  in  the  last  edition  of  the  First  Lines 
of  Surgery,  accompanied  with  many  valuable  prac- 
tical observations  made  by  these  judicious  and  skilful 
surgeons. 

That  the  performance  of  lithotomy  with  a knife, 
when  the  operator  has  the  assistance  of  a proper  staff, 
cannot  be  diliicult,  may  be  inferred  from  there  being 
no  particular  difficulty  in  the  method,  even  when  no 
staff  at  all  is  employed.  In  the  spring  of  the  year  1814, 
when  at  Oudenbosch  in  Holland,  I was  requested  by 
Sergeant  Ryan,  of  the  1st  Foreign  Veteran  Battalion,  to 
see  his  little  boy,  about  four  years  old,  who  was 
troubled  with  symptoms  which  made  me  immediately 
suspect  that  there  was  a stone  in  the  bladder.  As  I had 
no  sound,  I introduced  into  this  viscns  a small  silver 
catheter,  which  distinctly  struck  against  a calculus. 
Without  taking  the  instrument  out  again,  I determined 
to  perform  lithotomy  with  a common  scalpel.  Indeed, 
no  other  mode  could  be  adopted,  as  we  had  neither 
staff,  gorget,  nor  lithotomy  instruments  of  any  kind. 
After  making  the  external  part  of  the  incision  in  the 
common  way,  I found  that  the  catheter  afforded  me  no 
guidance.  I therefore  withdrew  it,  and  dissected 
deeply  by  the  side  of  the  prostate  gland,  till  the  fore- 
finger of  my  left  hand  passed  rather  beyond  it.  The 
scalpel  was  then  plunged  into  the  bladder,  behind  this 
gland,  under  the  guidance  of  my  left  fore-finger,  and 
with  the  edge  turned  towards  the  urethra.  The  neces- 
sary division  of  the  prostate  and  neck  of  the  bladder 
was  then  made  by  cutting  inwards  and  upwards  in  the 
direction  of  the  rest  of  the  wound.  With  a small  pair 
of  ordinary  dressing  forceps,  a calculus,  rather  larger 
than  the  end  of  the  thumb,  was  easily  extracted. 
This  operation  was  done  at  the  Military  Hospital,  in 
the  presence  of  Dr.  Shanks,  of  the  56th  regiment,  and 
several  other  medical  officers.  Not  a single  bad  symp- 
tom ensued,  although  the  army  unexpectedly  moved 
into  the  field  three  days  afterward,  and  the  child  tra- 
velled about  for  some  time  in  a baggage  cart,  in  an 
exposed  and  neglected  state.  Tlie  wound  w'as  conse- 
quently rather  longer  in  healing  than  usual;  but  this 
W'as  the  only  ill  effect.  The  little  boy  in  the  end  com- 
pletely recovered. 

Of  late  years,  many  surgeons  have  chosen  to  perform 
lithotomy  with  beaked  scalpels.  The  practice,  indeed, 
is  still  gaining  ground.  Mr.  Blizard’s  knife  is  one  of 
the  best.  Its  blade  is  long,  straight,  and  narrow,  and, 
like  the  gorget,  is  furnijlied  with  a beak,  by  means  of 
which  it  admits  of  being  cotiducted  along  the  groove 
of  the  staff  into  the  bladder,  after  the  external  inci- 
sions have  been  made.  The  staff  is  then  withdrawn, 
and  the  operator  has  now  the  power  of  making  the  inci- 
sion through  the  prostate  gland  and  orifice  of  the  blad- 
der downwards  and  outwarils  to  any  extent  which  the 
parts  will  allow'  or  the  case  require.  7’his  is  one  of  the 
principal  advantages  which  beaked  long  narrow  knives 
have  over  gorgets,  which,  after  their  introduction, 
cannot  he  farther  used  for  the  enlargement  of  the 
wound.  The  narrow  knife  will  also  cut  more  safely 
downwards  and  oiitw'ards  than  any  gorget:  nor  is  it 
subject  to  the  serious  danger  of  slipping  away  from  the 
staff,  and  going  we  know  not  where ; because  the  mo- 
ment its  beak  and  extremity  have  entered  the  bladder, 
the  staff  is  no  longer  necessary,  as  the  proper  extent  of 
the  blade  will  then  readily  pass  in  without  the  aid  of 
any  conductor  at  all.  I need  hardly  observe,  also,  that 
in  this  method  we  have  nothing  like  the  perilous  and 
violent  thrust  of  the  gorget,  which,  in  the  event  of  a 
little  unsteadiness  in  the  operator’s  hand,  or  of  awy 
fault  either  in  the  position  of  the  staff,  or  the  direc- 
tion of  the  gorget,  will  do  irremediable  and  fatal 
mischief. 

Sir  A.  Cooper  admits,  that  the  operation  may  be  done 
very  w’ell  with  a knife  in  children;  but  he  prefers  a 
gorget,  or  the  histoire  cacA^,  forold  persons,  on  account 
of  the  prostate  gland  and  bladder  being  frequently  so 
rigid  in  them,  that  the  scalpel  does  not  easily  make  an 
impression  nprni  those  parts.  Also,  for  adults,  he  has 


relinquished  the  use  of  the  knife,  hi  consequence  of 
the  unfitness  of  it  to  do  what  is  necessary  in  a deep 
peiiiioeum. — (See  Lancet,  vol.  2,p.  340.) 

A FEW  GENERAL  REMARKS  ON  THE  BEST  MODE  OF 

MAKING  THE  INCISION  IN  THE  LATERAL  OPE- 
RATION ; AND  SOME  REFLECTIONS  ON  THE  PRINCI- 
PLES INCULCATED  BY  PROFESSOR  SCARPA. 

Perhaps,  of  all  the  great  operations  in  surgery,  litho- 
tomy is  thr.t  in  which  great  awkwardness,  mortifying 
failures,  and  dangerous  blunders,  are  most  frequently 
observed.  Many  a surgeon,  who  contrives  to  cut  off 
limbs,  extirpate  large  tumours,  and  even  tie  aneuris- 
mal  arteries,  with  eclat,  cannot  get  through  the  busi- 
ness of  taking  a stone  out  of  the  bladder  in  a decent, 
much  less  a masterly,  style.  This  fact  is  so  familiarly 
known  in  the  profession,  and  its  truth  so  often  exem- 
plified, that  I may  well  be  excused  the  unpleasant  task 
of  relating  in  proof  of  it  all  the  disasters  which  have 
fallen  under  my  own  notice.  But  I must  take  the 
liberty  of  remarking,  that  in  this  branch  of  surgery,  a 
great  number  of  individuals  do  not  profit  by  these  in- 
structive lessons  of  experience.  The  more  they  see 
of  lithotomy,  the  more  they  are  convinced  of  its  dan- 
gers; yet,  too  often,  instead  of  studying  the  causes  of 
III  success,  they  merely  derive  from  the  examples  before 
them  a suspicion  of  the  unskilfulness  of  the  operator,  or 
some  discouraging  conjectures  about  the  difficulties  of 
the  operation. 

The  establishment  of  certain  principles  to  be  ob- 
served in  lithotomy,  appears  the  most  profitable  way  of 
diminishing  the  frequency  of  the  accidents  and  failures 
of  this  common  operation.  If  these  principles  are  not 
violated,  it  is  of  less  consequence  what  instrument  is 
employed;  for  the  surgeon  may  do  nearly  the  same 
thing  with  an  ordinary  dissecting  knife,  a concealed 
bistoury,  a beaked  scalpel;  or  a well-made  gorget. 

After  the  very  opposite  principles  and  different  me- 
thods of  cutting  for  the  stone  which  are  explained  in 
the  preceding  columns,  as  preferred  by  different  sur- 
geons, I think  it  may  be  useful  to  offer  a few  general 
observations  on  the  proper  direction  and  size  of  the  in- 
cision. These  points,  which  are  of  the  highest  practi- 
cal consequence  in  regulating  the  principles  which 
oughttobeobservedin  lithotomy,  are  far  from  being  set- 
tled, as  must  be  plain  to  every  body  who  recollects  that 
Desault,  Mr.  John  Bell,  Klein,  and  Langenbeck  have 
recommended  a free  opening;  Scarpa,  Callisen,  and 
others,  a small  one;  or,  as  Scarpa  objects  strongly  to 
my  calling  his  incision  small,  I w'ill  say  one  extending 
from  the  apex  of  the  prostate  gland  to  the  orifice  of  the 
bladder,  no  part  of  which  is  divided;  that  Mr.  Aber- 
nethy  and  Scarpa  employ  gorgets,  which  cut  upwards 
and  outwards,  at  angles  of  45°  and  69°  from  the  axis  of 
the  urethra;  and  that  the  gorgets  of  Cruikshank,  B. 
Bell,  Desault,  Mr.  Cline,  and  most  other  surgeons, 
are  intended  to  cut  either  directly  outwards,  or  out- 
wards and  downwards. 

The  incision  through  the  whole  of  the  parts  cut  in 
litliotomy,  should  always  be  made  in  a straight,  regular, 
direct  manner,  from  the  surface  of  the  skin  in  theperi- 
naBum  to  the  termination  of  the  wound  in  the  urethra 
and  bladder.  In  an  adult  subject,  the  external  wound 
should  commence  about  an  inch  above  the  anus.  The 
impropriety  of  beginning  it  higher  up  has  been  duly  in- 
sisted upon  by  Sharp,  Bertrandi,  Callisen,  and  every 
good  writer  on  the  operation.  “ II  ne  faut  couper 
i’uri^tre  que  Ic  moins  qn’on  pent,  parceqn’on  obtient 
par  ce  moyen  une  meilleure  voie  pour  p^n^trer  dans  la 
vessie  sous  I’angle  du  pubis.  C’est  avec  raison  que 
Sharp  dit  que  I’incision  de  I’ur^tre  faite  au-dessns  de 
cet  angle  est  si  pen  utile  pour  I’extraction  de  la  pi^rre, 
qii’on  n’en  retireroit  pas  plus  d’avantageen  leconpant 
presqiie  dans  toutc  sa  longueur.” — {Bertrandi,  TraifS 
des  Operations, p.  127.)  And  Callisen  lays  it  down  as 
a maxim:  “Utete  partes  hand  seciione  attingantur, 
qnai  pro  calculi  egressu  nihil  faciunt ; adeoqne  bnibus 
urethriE,  et  hujus  pars  corpore  spongioso  circumdata 
intacta  relinquatnr.” — {Systema  Chirurgiis  Jiodiern<E, 
pars  posterior,  p.  655.) 

Extraordinary  as  it  may  seem,  it  is  not  the  less  true, 
that  cutting  too  much  of  the  nieihra  is  one  of  the  most 
common  faults  still  committed  by  modern  surgeons. 
The  incision  in  the  integuments  is  to  he  large,  that  is  to 
'lay,  at  least  three  inches  in  lenclh  in  an  adult  subject, 
because  a free  opening  in  the  skin  is  not  only  exempt 
from  danger  but  attended  with  many  advantages,  e* 


LITHOTOMY. 


151 


pecially  those  of  facilitating  the  other  steps  of  the 
operation,  and  preventing  any  future  lodgement  and 
effusion  of  urine.  Tlie  external  wound  ought  to  be 
directed  towards  a point  situated  a very  little  towards 
the  anus  from  the  innermost  part  of  the  tuberosity  of 
the  iscliium.  From  the  line  thus  made  the  incision 
sliould  be  carried  inwards  and  upwards  through  all  the 
parts  between  it  and  the  side  of  the  prostate  gland. 
Another  line,  extending  from  the  inferior  angle  of  the 
wound  to  the  termination  of  the  cut  in  the  bladder, 
forms  the  precise  limits  to  which  tire  depth  of  the  in- 
cisions should  reach,  and  no  farther. 

The  great  principle  of  making  the  axis  of  the  wound 
as  straight  and  direct  as  possible,  should  always  be 
kept  in  view,  whether  the  surgeon  employ  a common 
scalpei,  which  cuts  into  the  bladder  from  without  in- 
wards, nr  other  instruments  which  divide  the  prostate 
g:land  and  neck  of  the  bladder  from  witliin  outwards, 
like  the  bistoire  cach^,  beaked  knives,  and  every  kind 
of  cutting  gor  get.  In  the  latter  circumstance,  the  only 
difference  consists  in  cutting,  from  the  bladder  and 
urethra,  downwards  and  outwards  towards  a point 
situated  between  the  anus  and  the  tuberosity  of  the 
ischium,  instead  of  carrying  the  incision  from  this 
point,  upwards  and  inwards,  through  the  side  of  the 
prostate  gland  and  the  orifice  of  the  bladder.  The  fol- 
lowing may  be  enumerated  as  important  advantages 
of  attending  to  the  foregoing  principle; 

h The  wound  is  made  in  that  direction  which  af- 
fords tne  greatest  room  for  the  extraction  of  large 
stones;  and  the  axis  of  the  incision  being  also  as 
nearly  straight  as  possible,  the  introduction  of  forceps, 
and  the  pas.sage  of  the  calculus  outwards,  are  mate- 
rially facilitated. 

That  these  are  important  advantages  I think  every 
surgeon  will  allow,  who  knows  how  much  the  pain 
and  dainrer  of  lithotomy  depend  upon  the  injury  which 
the  parts  suffer  from  the  force  sometimes  used  in  the 
extraction  of  the  stone,  and  the  repeated  introduction 
of  the  forcp|)s.  Cheselden,  one  of  the  most  successful 
lithotomists  England  ever  produced,  made  the  incision 
in  the  direction  here  recommended ; sometimes  inwards 
and  upwards,  sometimes  outwards  and  downwards. — 
(See  Key  on  the  Section  of  the  Prostate  Gland,  p.  27.) 
The  following  remarks  of  another  excellent  surgeon 
merit  particular  attention; — “J’ai  vu  plusieurs  fois 
dans  les  hdpitauxde  Paris, qiieles  chirurgiens.coupant 
trop  en  haul  vers  I’angle  du  pubis,  sentoient  une  grande 
resistance  an  purine,  quand  ils  vouloient  retirer  le 
calcul  avec  les  tenettes;  on  voyoit  le  perin6  se  tum^- 
fier  par  la  pression  qu’y  faisoit  la  pi^rre ; en  ce  cas, 
quelques  operateurs  plus  sages  abandonnoientla  pi^rre, 
introdiiisoient  de  nouveau  le  gorgeret,  et  en  tournant 
en  dessnus  la  cannelure  de  celui-ci,  prolongeoient  I'in- 
cisiou  obliquement  vers  la  tuberosity  de  I’os  ischion; 
et  enfin,  a la  faveur  de  cette  plus  grande  ouverlure, 
retiroient  la  pierre  sans  causer  de  dychiremens.” — 
{Bcrtrandi,  Traiti  des  Operations,  p.  133.)  Larger 
stones  may  likewise  be  thus  extracted,  without  being 
broken,  than  in  any  other  mode  of  making  the  lateral 
incision,  as  must  be  obvious  to  every  practitioner  who 
recollects  the  very  limited  room  afforded  at  the  upper 
part  of  the  triangular  space,  between  the  arch  of  the 
pubis,  the  ramus  of  the  ischium,  and  the  neck  of  the 
bladder.  Thi.-  consider, ation  cannot  fail  to  have  great 
weight  with  all  surgeons  who  feel  duly  convinced  how 
unsatisfactory  a method  it  is  to  break  a calculus  in 
order  to  get  it  out  of  the  bladder.  The  measures  ne- 
cessary for  the  removal  of  all  the  fragments  protract 
the  completion  of  the  operation,  and  seriously  iticrease 
its  danger:  while  the  continuance  of  a single  part  of 
the  stone  behind  may  cause  a renewal  of  all  the  griev- 
ances for  the  cure  of  which  the  patient  submitted  to 
the  operatK)n.  By  these  remarks,  however,  lam  far 
from  meaning  to  say  that  large  calculi  should 'not  be 
broken ; on  the  contrary,  my  only  wish  is  that  the  ne- 
cessity for  the  practice  may  be  avoided  as  much  as 
possible,  by  makine  a free  incision  into  the  bladder,  and 
even  enlarcing  the  oj)ening,  if  necessary,  as  far  as  cm 
be  done  with  safety.  In  short,  instead  of  breaking  the 
etone,  I prefer  the  practice  of  the  late  Mr.  Martineau, 
of  Norwich,  perhaps  the  most  successful  lithotondst 
that  ever  lived,  as  otif  of  84  patients  whom  he  cut,  two 
only  died  ; a statement  hisrhly  favourable  to  operating 
with  a knife,  and  making  an  adequate  openinir. 
‘‘  Should  the  stone  be  large.  Or  there  be  any  dilRculty 
in  the  extraction,  rather  titan  use  much  force,  while 


the  forceps  have  a firm  hold  of  the  stone  (says  Mr. 
Martineau),  I give  the  handles  to  an  assistant,  who  is 
to  draw  them-outwards  and  upwaids,  while  the  part 
forming  the  stricture  is  cut;  which  is  easily  done,  as 
the  broad  part  of  the  Wade  becomes  a director  to  the 
knife;  and  rather  than  lacerate,  I have  often  repeated 
this  eidargement  of  the  inner  woutvd  two  or  three 
times.” — (See  Med.  Chir.  Trans,  ml.  11,  p.  411.)  The 
great  advantage  of  the  knife  over  the  gorget,  and  even 
the  necessity  of  employing  it  to  adapt  the  size  of  the 
opening  in  the  bladder  to  the  magnitude  of  the  stone 
or  its  fragments,  are  most  convincingly  exemplified  in 
several  cases  recently  put  upon  record.  Thus  Klein, 
with  the  aid  of  a common  scalpel,  extracted  a calculus 
which  weighed  twelve  ounces  thirty  grains,  and  the 
{tatient  recovered. — {Pract.  Ansichtcn  Bedeutendsten 
Operationen,  h.  1.)  In  1818,  Mr.  Mayo  of  Winchester 
operated  with  a knife,  and  extracted  a calculus,  which 
broke  in  the  forceps,  w'eighing  fourteen  ounces  twm 
drachms  avoirdupois,  and  the  patient  recovered. — (See 
Med.  Chir.  Trans,  vol.  11,  p.  54,  (S  c.)  Mr.  W.  B.  Dick- 
enson of  Macclesfield,  also  succeeded,  with  Mr.  Gibson’s 
knife,  in  taking  out  of  the  bladder  a calculus,  the  frag- 
mentsofwhich  weighed  eight  and  ahalf ounces,  and  the 
patient  was  saved. — ( Fol.  cit.  p.  61.)  And  in  the  same 
volume  may  be  seen  other  instances,  in  whicfi  immense 
calcidi  were  removed  from  the  bladder  with  vaiious 
results,  but  particularly  one,  which  weighed  sixteen 
ounces,  and  which  Sir  A.  Cooper  could  not  succeed  in 
breaking;  he  was  therefore  obliged  to  enlarge  the 
wound  first  made  with  the  gorget  “ to  the  sacro-sciatic 
ligament,”  when  with  the  aid  of  a hook  applied  to  the 
fore  part  of  the  stone  behind  the  pubes,  and  the  simul- 
taneous assistance  of  the  forceps,  he  succeeded  with 
considerable  diificulty  in  removing  this  immense  mass. 
The  patient  lived,  however,  oidy  four  hours  after  the 
operation. — (See  Med.  Chir.  Trans,  vol.  11,  p.  73.) 

2.  The  arteria  pudica  profunda  can  never  be  injured, 
because  the  surgeon  does  not  let  the  knife  or  gorget 
approach  nearer  to  the  ischium  than  a point  which  is 
situated  some  way  from  the  tuberosity  of  that  bone  to- 
wards the  anus;  and  consequently  the  edge  of  the 
instrument  cannot  come  into  contact  with  the  inside 
of  the  tuberosity  and  ramus  of  the  ischium  where  the 
great  pudic  artery  is  situated. 

3.  The  rectum  will  not  be  wounded,  because  the 
direction  of  the  axis  of  the  incision,  either  downwards 
and  outw'ards  to  the  above mentioned  point,  or  from 
that  point  inwards  and  upwards,  sufficiently  removes 
the  edge  of  the  knife  or  gorget  from  the  intestine.  But 
the  rectum  will  be  in  still  greater  safety,  if  it  be  pressed 
downwards  with  the  fore-finger  of  the  left  hand  in  the 
w’oiind,  and  the  prudent  custom  of  emptying  it  by 
means  of  a clyster,  a shor*  time  before  the  operation, 
be  not  omitted;  for  no  litiiotornist  should  ever  forget, 
that  when  this  bowel  is  considerably  distended  with 
feces,  it  rises  up  a little  way  on  each  side  of  the  pros- 
tate gland. 

4.  As  the  seminal  duct  penetrates  the  lower  part  of 
the  substance  of  the  prostate  gland  in  order  to  reach 
the  urethra,  and  the  knife  or  other  instrumenternployed 
divides  the  side  of  that  gland  obliquely  inwards  and 
upwards,  or  outwards  and  downwards,  the  duct  will 
not  be  in  danger  of  being  cut. 

The  judicious  Callisen  is  well  aware  of  the  ad- 
vantages of  making  a smooth,  even,  direct  incision 
into  the  bladder;*  but,  like  Professor  Scarpa,  he  is 
averse  to  making  a free  cut  through  the  neck  of  that 
viscus.  Indeed,  as  we  shall  presently  notice,  f?carpa 
does  not  sanction  cutting  any  portion  of  the  bladder 
whatever. 

Every  practitioner  who  will  take  the  trouble  to  look 
over  the  history  of  the  lateral  operation,  will  find  that 
the  greater  number  of  lithotomists  who  have  particu- 
larly distinguished  themselves  by  their  unparalleled 
success,  as  Fr^re  Jacques,  Gheselden,  Chine,  Mr.  Mar- 
tineau, Dr.  Souberbielle,  &cc.  made  a free  incision  into 
the  bladder.  This  fact  alone  is  enough  to  raise  doubts 
of  the  goodness  of  the  advice  delivered  u|)on  this  sub- 
ject by  Callisen  and  ficarpa;  especially  as  neither  they 
nor  any  other  modern  surgeon  (with  the  exception, 


* Vulnus  sit  a'quale,  baud  angnlalurn,cotdcffifigurrE, 
apice  vesicam  respicienie,  externa  plaga  ainjila,  et 
quatuor  pollicum  longitudine,  unde  effluxiis  sanguinis, 
puris,  lotii,  arente,  facilitatur. — (See  Syst.ema  Ckirvr- 
gia  Hodierna;,  pars  posterior,  p.  650.  Hafniw,  180(k) 


LITHOTOMY. 


153 

perhaps,  of  Pajola,  whose  individual  skill  Is  said  by 
Langeiibeck  to  make  amends  for  the  disadvantages  of 
this  method),  can  boast  of  having  cut  patients  for  the 
stone  with  a degree  of  success  at  all  equal  to  that  of 
the  above  mentioned  operators.  The  extraordinary 
success  which  cliaracterized  Cheselden’s  practice,  we 
have  already  detailed.  The  accounts  of  the  successful 
operations  done  by  Fr^re  Jacques  and  C6me  are 
equally  remarkable. 

Mr.  Martineau,  as  I have  noticed,  lost  but  two  pa- 
tients out  of  84  on  whom  he  operated,  and  this  without 
making  any  selection,  as  he  never  rejected  any  case. 
His  patients  were  always  kept  a week  in  the  house 
before  they  were  operated  upon  ; and  this  precaution, 
with  a regulated  diet,  and  perhaps  a dose  or  two  of 
opening  medicine  was  the  only  preparatory  treatment. 
—{Med.  Chir.  Trans,  vol.  11,  p.  409.) 

During  my  stay  at  Paris,  in  1815,  I saw  Dr.  Souher- 
bielle  extract  a stone  of  considerable  size  on  the  plan 
of  his  well-known  ancestor.  The  incision  was  ample 
and  direct,  so  that  the  calculus  w'as  taken  out  with 
perfect  ease.  Now,  as  the  operations  of  this  professed 
iithotomist  are  very  nutnerous,  and  he  enjoys  the  repu- 
tation of  scarcely  ever  losing  a patient,  are  we  not 
justified  in  inferring,  that  the  advocates  for  a small 
opening  are  promulgating  the  worst  advice  which  can 
be  ofiered  to  the  practitioner  1 My  own  observations 
certainly  tend  to  such  a conclusion,  as  will  be  presently 
explained.  The  tract  lately  published  by  Sctirpa 
{Memoir  on  the  Cutting  Gorget  of  Hawkins,  «S*c. 
trans.  by  TVishart)  has  for  its  main  objects  the  re- 
commendation of  a modification  of  Hawkins’s  gorget, 
and  the  inculcation  of  the  propiiety  of  making  a 
limited  incision  in  the  prostate  gland  without  cutting 
any  part  of  the  bladder.  As  sufficient  room  cannot 
thus  be  obtained  for  the  extraction  of  even  a stone  of 
moderate  size,  he  is  an  advocate  for  the  gradual  dila- 
tation of  the  urethra  and  orifice  of  the  bladder.  He 
observes,  that  the  lateral  operation,  though  executed 
with  the  greatest  precision,  does  not  exempt  the  sur- 
geon from  dilating  in  a certain  degree  the  orifice  of  the 
bladder  and  cervix  of  the  urethra,  the  dilatation  of 
those  parts,  however  moderate,  being  always  neces- 
sary even  where  the  calculus  is  of  middling  size.  He 
states  that  in  the  adult  the  orifice  of  the  bladder  dilates 
almost  spontaneously  to  the  diameter  of  five  lines ; and 
he  adds,  that  the  lateral  incision,  within  proper  limits, 
divides  the  body  and  base  of  the  prostate  gland  to  the 
depth  of  four  or  at  most  five  lines,  forming  with  the 
five,  to  which  the  orifice  of  the  bladder  naturally 
yields,  an  aperture  of  ten  lines.  But,  sa3  s Scarpa,  in 
an  adult,  a stone  of  ordinary  size  and  oval  figure  is 
sixteen  lines  in  the  small  diameter,  to  which  must  be 
added  the  thickne.'S  of  the  blades  of  the  forceps:  con- 
sequently, even  after  the  incision  has  been  made  with 
the  most  scrupulous  exactness,  the  stone,  though  of 
moderate  size,  cannot  pass  out  of  the  bladder,  unless 
the  dilatation  of  the  base  of  the  gland  and  orifice  of 
the  bladder  be  carried  to  the  extent  of  nearly  eight 
lines  beyond  the  size  of  the  aperture  made  with  the 
knife.  But,  says  Scarpa,  if  in  order  to  avoid  distend- 
ing the  parts  to  the  extent  of  eight  iine.^,  the  base  of 
the  prostate  gland,  together  with  the  orifice  of  the 
bladder  and  a part  of  its  ftindus,  be  divided  to  a depth 
equivalent  to  it,  the  event  would  necessarily  be  an  ef- 
fusion of  urine  into  the  cellular  membrane,  between  the 
rectum  and  bladder,  and  consequei.tly  suppuration, 
gangrene,  fistulw,  and  other  serious  evils. — {P.  4,  5.) 

According  to  Scarpa,  the  apex  of  the  prostate  "land 
forms  the  greatest  resistance  to  the  introduction  of  the 
forceps  and  the  exti  action  of  the  stone,  and  therefore 
ought  to  be  completely  divided  {p.  7)  ; but  he  con- 
tends that  two,  and  sometimes  three  lines  of  the  sub 
stance  of  the  base  of  the  gland  should  be  left  undi- 
vided ; which,  he  asserts,  is  a matter  of  great  impor- 
tance, because  the  untouched  portion  around  the  orifice 
of  the  bladder,  prevents  the  effusion  of  urine,  and  the 
formation  of  gangrene  or  fistula,  between  that  part 
and  the  rectum.— (P.  22.) 

After  this  statement  of  one  of  the  great  principles 
which  Scarpa  wishes  to  be  observed  in  the  performance 
of  the  lateral  operation,  a question  or  two  naturally 
arise.  Are  we  then  to  conclude,  that  the  plan  of  mak- 
ing a free  and  direct  incision  into  the  bladder  ought  to 
be  abandoned  1 Must  we  forget  that  it  is  this  meihod 
which  has  answered  so  well  in  the  handsof  Cheselden 
and  the  several  renowned  litiiotomists  already  enume- 


rated ? And  must  we  believe  that  the  advice  delivered 
upon  this  point  by  Bertrandi,  Desault,  Mr.  John  Bell, 
and  all  the  best  modern  surgeons  in  this  country.  Is 
founded  only  upon  a capricious  partiality  to  the  free 
use  of  cutting  instruments'? 

Earnestly  as  I respect  the  names  of  a Callisen  and 
a Scar  pa,  their  authority  cannot  influence  me  farther 
than  I find  it  coincide  with  the  dictates  of  experi- 
ence,—the  great  arbitrator  of  every  disputed  point  in 
practice. 

We  have  seen,  that  an  apprehension  of  effusion  of 
urine,  gangrene,  fistula?,  &c.  is  the  only  reason  as- 
signed by  Scarpa  for  his  aversion  to  making  a com- 
plete division  of  the  side  of  the  prostate  gland  and 
orifice  of  the  bladder.  But  I would  inquire,  do  we 
find  extravasation  of  the  urine  between  the  rectum  and 
bladder,  and  gangrene,  and  fistulas,  so  frequent  after 
lithotomy  in  England,  as  to  render  it  probable  that 
these  ill  consequences  can  ever  proceed  from  our  usual 
mode  of  dividing  completely,  not  only  the  side  of  the 
prostate  gland,  but  also  the  adjoining  part  of  the  blad- 
der ? Are  such  bad  effects  so  often  experienced  in  this 
country,  as  to  constitute  a material  source  of  uneasi- 
ness in  the  mind  of  a surgeon  about  to  undertake  litho- 
tomy ? Do  they  form  a substantial  reason  for  aban- 
doning the  maxim  of  always  endeavouring,  as  far  as 
circumstances  will  allow,  to  make  an  imfision  of  suffi- 
cient size  for  the  easy  removal  of  the  calculus?  And 
would  not  Scat  pa’s  method  of  stretching  and  dilating 
the  wound,  in  order  to  get  the  stone  out  of  the  blad- 
der, often  dangerously  prolong  the  operation;  lead  to 
much  mischief  from  the  repeated  use  of  the  forceps; 
cause  serious  contusion  and  laceration  of  the  parts; 
and,  for  all  these  reasons,  render  inflammation  of  the 
bladder  and  peritoneum  very  likely  to  follow  ? 

I have  seen  the  lateral  operation  performed  an  im- 
mense number  of  times,  either  with  various  kinds  of 
gorgets,  beaked  knives,  the  lithotome  cache,  or  com- 
mon scalpels.  In  all  these  examples,  the  avowed  in- 
tention of  the  surgeon  was  to  make  a free  opening  into 
the  bladder.  I do  not  mean,  however,  to  say,  that  this 
was  always  actually  accomplished,  since  the  bad  con- 
struction of  the  instruments  employed,  and  other 
causes,  sometimes  frustrated  the  wise  design  of  the 
operator.  But  what  was  the  consequence?  Generally 
speaking,  those  surgeons  who  made  only  a small  in- 
cision into  the  bladder,  and  kept  their  patients  a long 
while  upon  the  operating  table,  ere  they  succeeded  in 
getting  out  the  stone,  by  liie  repeated  and  forcible  use 
of  the  forceps,  haa  the  mortification  to  see  very  few  of 
their  patients  recover;  a large  proftoriion  of  them  be- 
ing carried  off  by  peritonitis,  on  the  third  or  fourth  day 
after  the  operation. 

On  the  contrary,  when  the  incision  was  ample  and 
direct,  so  that  the  calculus  could  be  easily  and  gently 
removed,  the  patients  were  almost  always  saved. 

For  the  fiist  six  or  seven  years  of  the  long  time  dur- 
ing which  I enjoyed  frequent  opportunities  of  seeing 
lithotomy  performed  in  St.  Bartholomew’s  Hospital, 
gorgets  were  invariably  used,  most  of  which  made  an 
insufficient  opening.  The  consequence  was,  that  many 
of  the  patients  were  detained  a long  while  upon  the 
operating  table,  before  the  stone  could  be  extracted, 
and  some  considerable  numbers  were  lost  by  perito- 
nitis. Afterward,  however,  in  the  same  institution, 
common  scaljtels  and  beaked  knives  were  generally 
used;  a freer  opening  was  mostly  made;  and  the 
proportion  of  deaths  from  peritonitis  was  strikingly 
les.-:ened. 

'J'he  following  observation,  made  by  Mr.  Martineau, 
is  also  worthy  of  particular  attention In  the  first 
years  of  my  practice,”  says  he,  “ I was  not  very  suc- 
cessful ; and  often  witnessing  many  untoward  circum- 
stances in  myself  and  others,  which  appeared  to  arise 
from  file  use  of  the  cutting  gorget,  I determined  to  lay 
that  instrument  aside,  and  employ  the  knife  only,  and 
the  blunt  gorget,  as  a conductor  for  the  forceps.” — 
Med.  Chir.  I'rnns.  p.  405.) 

Now,  when  we  remember  that  this  gentleman  lost 
only  two  out  of  eighty-four  patients  on  whom  he  ope- 
rated, his  remarks  are  of  great  impr)rtance;  and  his 
cases  and  the  otiier  facts  which  I have  specified, 
strongly  impress  my  mind  with  the  truth  of  all  that  I 
have  urged  respecting  the  advantages  of  making  the 
opening  large,  and  in  the  best  direction  for  the  easy 
passage  of  the  stone  outwards. 

In  Mr.  Martineau'!  manner  of  operating,  it  is  true, 


LITHOTOMY. 


153 


he  does  not  make  the  externa!  wound  parallel  to  that 
in  the  bladdei,  as  i venture  to  recoiiiinend,  but  directs 
it  nearly  in  a line  with  the  raphe;  a circuinsiance 
which  may.  perhaps,  account  lor  his  continuing  tlie 
use  of  the  blunt  gorget  as  a conductor  for  the  loiceps. 
Neither  is  his  internal  incision  carried  downwards  and 
outwards,  as  Berfrandi,  Desanli,  and  many  other  judi- 
cious surgeons  consider  most  advantageous.  But  these 
defects  (if  I may  presume  to  call  them  so)  aie  ren- 
dered of  less  consequence  by  tlie  rule  which  Mr.  Mar 
tineau  observes,  of  making  his  first  mcision  long  and 
deepi  and  avoiding  all  slieiching  and  laceration  of  the 
parts.  Like  Langenbeck,  he  uses  a stalf,  the  groove 
of  which  is  much  wider  and  deeper  than  usual,  and 
therefore  more  easily  felt.  This  instrument  his  assist- 
ant holds,  in  the  way  preferred  by  Scarpa,  nearly  in  an 
upright  straight  direction.  “Alter  the  first  incision 
(says  Mr.  Mai  tineau),  I look  if  the  stalf  is  not  altered 
in  its  situation,  and  then  feeling  for  the  groove,  1 intro 
duce  the  point  of  the  knife  into  it,  as  low  down  as  I 
can,  and  cut  the  membranous  part  of  the  urethra,  con- 
tinuing my  knife  through  the  prostate  into  the  bladder; 
when,  instead  of  enlarging  the  wound  downwards,  and 
endangering  the  rectum,  J turn  the  edge  of  the  blade 
towards  the  ischium,  and  make  a lateral  enlargement 
of  the  wound  in  withdrawing  the  knife." — (See  Med. 
Chir.  Trans,  vol.  11,  p.  409.)  This  description  is  par- 
ticularly interesting,  as  coming  from  a gentleman  wlio 
had  so  mtich  experience  and  success. 

With  respect  to  the  degree  of  importance  which 
ought  to  be  attached  to  the  fear  of  effusion  of  mine, 
between  the  bladder  and  rectum,  gangrene,  fistulac,  &c., 
I can  only  say,  that  they  are  inconveniences  wliich  are 
not  commonly  observed  alter  lithotomy  in  this  country. 
In  two  or  three  instances  only,  I have  known  the  urine 
come  through  the  wound  longer  ilian  usual,  and  these 
cases  ended  well.  As  for  the  extravasation  of  urine 
and  sloughing,  I shall  merely  remark,  that  although 
there  cannot  be  a doubt  of  their  occa.'ional  occurrence, 
they  have  not  taken  place  after  any  of  the  numerous 
operations,  with  the  results  of  which  I have  been  ac- 
quainted. 

All  these  facts  and  considerations,  therefore,  incline 
me  to  doubt  whether  the  apprehension  of  the  effusion 
of  urine,  fisiulae,  &c.  be  sntficiently  serious  and  well 
founded  to  make  it  advisable  for  smgeonsto  reiinqnisii 
the  plan  of  making  a complete  division  of  the  side  of 
the  prostate  gland  and  neck  of  the  bladder,  in  the  ope- 
ration of  lithotomy.  Nor  is  it  at  all  clear  to  my  mind, 
that  effusion  of  urine  and  sloughing  are  likely  to  be 
the  effect  of  practising  a free  opening.  Indeed,  when- 
ever they  do  happen,  I believe  they  proceed  from  a to 
tally  diffen  lit  cause,  viz.  from  the  incision  in  the  skin 
being  too  small  and  too  high  up,  and  from  the  axis  of 
the  internal  part  of  the  incision  not  corresponding  with 
that  of  the  external  wound.  Hence  ihe  urine  does  not 
readily  find  its  way  outwards,  and  some  of  it  passes 
into  the  neighbouring  cellular  membrane. 

In  confirmation  of  the  foregoing  remarks,  1 beg  leave 
to  cite  the  sentimenis  of  one  of  the  greatest  and  most 
experienced  of  modern  sumeons.  Speaking  of  the  de- 
fects of  Hawkins’s  goreet,  Desault  observes,  “ I.a  ni^- 
thode  de  I’enforcer  horizontalement  dans  la  vessie  sm 
la  catheter  tenn  A angle  dmit  avec  le  cor[>s,  a deux 
grands  d^savani ages;  d’un  c6  4,  celui  de  | ^n^trer  par 
I’endroit  le  pins  i4ii4ci  du  pubis,  et  par  cont^qmmi  de 
ne  faire  qne  difficilement  urie  onverture  snffi.'-ante ; 
d’un  autre  (di4,  celni  de  ne  pas4tablir  de  paia!l4!isme 
entre  I’inci.-ion  ex:4rieiire  des  l4mmiens  qiii  est  oblique 
el  celle  du  col  de  la  vessii;  et  de  la  prostate,  ejni  so  iron  ve 
alors  horizontale.  Dela  la  possibilii4  des  infiltrations 
par  les  obstacles  que  les  mines  trouveroni  A s’Acouler.” 

No  doubt  also  some  of  the  worst  and  most  danger- 
0118  urinary  extravasations  after  lithotomy,  have  pro- 
ceeded from  another  cause,  pointed  out  by  the  same 
excellent  surgeon.  “ Impi  udemment  poit4  dans  la  ves- 
sie,  le  gorgeret  pent  aller,  par  le  stylet  bcaucoup  trop 
long  qiii  le  teiiiiine,  heiirter,  dAchirer,  perforer  nieme 
la  membrane  de  la  vessie,  et  donner  lieu  a des  infiltra- 
tions, d’autant  plus  darigi  reuses  que  le  lieu  d'oii  elh  s 
partent  e.st  plus  inaccessible.  Get  accident  est  surtont 
A craindre,  lorsque,  comnie  les  Anglais,  on  se  sert  de 
catheter  sans  ciil  de  sac.”— (See  CEuvres  Chir.  de  De- 
sault par  Bichat,  t.  2,  p.  4C0,  461.) 

I reereiiliat  the  observations  published  by  me,  rela 
live  to  Scarpa’.a  niettiod  of  performing  lithotomy,  should 
not  have  seemed  to  him  a fair  account  of  the  subject, 


and  that  he  should  have  deemed  it  necessary  to  declare 
my  slaiemeot  of  his  incision  being  loo  small,  and  in- 
adequate u.  are  passage  of  any  but  calculi  under  the 
middling  size,  manifestly  false. — {Upuscoli  di  Chirur- 
gia.  vol.  1,  p.  52.)  Hesujiposesihat  Cheselden,  Frtre 
Jacques,  and  t 6me,  in  their  successful  opeiations, 
made  the  limited  kind  of  incision  which  he  himself  re- 
commends, and  did  not  cut  the  bladder  itself;  a posi- 
tion that  does  not  appear  to  me  coriect.  He  asserts, 
that  after  the  side  of  the  prostate  gland  is  divided,  tlie 
orifice  of  the  bladder  is  capable  of  yielding  so  as  to  al- 
low the  stone  to  pass  out  without  danger,  if  this  part 
of  the  operation  be  done  slowly  and  gradually  ; and  he 
sup[iotts  his  declaration  on  this  point  by  a reference  to 
the  safety  with  which  the  orifice  of  the  female  bladder 
is  dilated  for  the  extraction  of  calculi  of  considerable 
size:  a case  hardly  pieseiiting  an  analogy;  first,  be- 
cause there  is  no  wound  made  whatever,  and  secondly, 
because  lithotomy  itself,  in  women,  is  a safe  measure, 
compared  with  what  it  is  in  men.  The  frequent  evils 
of  dilating  the  orifice  of  the  femoral  bladder,  however, 
he  frankly  acknowledges  in  another  part  of  his  wri- 
tings, and  enumerates  as  the  ground  of  his  disapproba- 
tion of  the  practice.— (See  Opuscolt,  4^c.  vol.  1,  p.  105.) 
It  does  not  appi  at  to  me  that  Sctirpa’s  gorget  can  make 
the  division  of  the  pi  estate  in  a diieclion  corresponding 
to  that  of  the  external  [larts.  This  view,  he  thinks,  is 
not  founded  on  correct  principles;  and  he  maintains 
that  his  incision  in  the  prostate  does  correspond  to  the 
outer  wound,  because,  when  the  bladder  is  empty,  the 
prostate  is  naturally  placed  in  a line  slo|)ing  fiom  the 
arch  of  the  pubes  to  the  coccyx,  and  with  its  posterior 
surface  resting  on  the  rectum,  as  is  represented  in 
Camper's  Demonst.  Jinat.  Pathol,  lib.  2,  tab.  3,  fig.  2. 
This  explanation  is  not  satisfactory  to  myself;  but  I 
have  great  pleasure  in  mentioning  it,  as  ithas  appeared 
to  Scarpa  to  amonntlo  a refutation  of  my  observation, 
tliat  his  gorget  does  not  make  a division  of  the  prostalic 
portion  of  the  urethra  in  a direction  corresponding  to 
the  axis  of  the  wound  of  liie  external  parts. — {Opus 
coii  di  Chirurgia,  vol.  1,  p.  52  ) 

LITHOTOMY  THROUGH  THK  RECTUM. 

This  method  may  be  said  to  have  been  first  suggested 
in  a work  published  at  PAle,  in  the  16th  century,  by  an 
author  who  a^sunled  the  name  ofVegetius: — “Jubet 
per  vulnus  recti  inteslini,  et  vesica;  aculeo  lapidein  eji- 
cere,”  says  Haller,  in  speaking  of  this  writer. — (Bibl. 
Chir.  vol-  l,p.  102.)  But  the  jiroposal  never  received 
much  attention  until  the  year  1816,  when  M.  Sanson, 
in  France,  gave  an  account  of  this  manner  of  opera- 
ting, and  urged  several  considerations  in  favour  of  it. 
In  that  country,  however,  the  operation  has  been  per- 
formed only  by  Sanson  and  Dupuytren,  and  though 
the  first  trial  made  by  the  latter  proved  successful,  the 
otlier  French  surgeons  do  not  appear  to  have  imitated 
him.  Dupuytren  himself  has  also  now  given  up  the 
piactice.  Almost  as  soon  as  this  method  was  heard 
of  on  the  other  side  of  Ihe  Alps,  it  was  put  to  the  test 
of  expeiience  by  Barbaniini,  in  a case  where  every 
other  plan  of  operaiing  a()i)eared  hardly  practicable, 
“The  connexion  of  ihe  urethra  will)  the  rectum,  pros- 
tate gland,  and  posleiior  part  of  the  bladder  (sttys  M. 
Sanson),  made  me  easily  perceive,  that  by  dividing  the 
sfihincter  ani  and  some  of  the  rectum  near  the  root  of 
the  penis, . I .should  expo.se  not  only  the  ajtex  of  the 
prostate  gland,  but  a more  or  less  considerable  portion 
of  this  body,  and  that  I should  then  be  able  to  pencr 
trate  into  the  cavity  of  the  bladder,  either  at  the  neck 
throiich  the  prostate,  or  at  iis  posterior  part.”  It  was 
the  latter  method  which  M.  Sanson  fiist  tried  upon  the 
drad  subject.  The  body  was  jtlaced  in  the  position 
usntilly  chosen  for  the  common  ways  of  operating,  and 
a staff  was  introd'nced  and  held  perpendiculatly  by  an 
assistant.  A bistoury,  with  iis  blade  kept  flat  on  the 
left  fore  finger,  was  now  introduced  into  the  rectum, 
and  the  edge  bein!>  turned  upwards,  M.  Sanson,  with 
one  stroke,  in  the  direciion  olThe raphe,  cut  the  sphinc- 
ler  ani,  and  ihe  lower  jiart  of  the  rectum.  The  bottom 
of  the  prostate  gland  being  thus  exposed,  the  fin- 
ger was  next  pa.>;sed  beyond  its  solid  substance,  where 
the  stall' wa.s  readily  perceptible  through  the  thin  pa- 
rietes  of  the  rectum  and  bladder.  While  the  latter 
in.'tiument  was  steadily  maintained  in  its  original  po- 
sition, M.  Sanson  here  introduced  Ihe  knife  into  the 
bladder,  and,  following  the  groove  of  the  stall',  made 
an  incision  about  an  inch  in  length.  At  this  instant, 


154 


LITHOTOMY. 


the  flow  of  urine  from  the  wound  indicated  that  the 
bladder  had  bad  an  opening  made  in  it.  On  examina- 
tion, tlie  parts  divided  were  found  to  be  tlie  sphincter, 
the  lower  part  of  the  rectum,  tlie  back  part  of  tlie 
prostate,  and  the  adjacent  portion  of  the  bladder.  An- 
other mode,  contemplated  by  M.  Sanson,  was,  after 
dividing  the  sphincter  ani,  to  cut  the  termination  of 
the  membranous  part  of  the  urethra  along  the  groove 
of  the  statf  held  perpendicularly,  and  by  the  same 
guidance  to  extend  the  incision  in  the  median  line 
through  the  prostate  gland  and  neck  of  the  bladder. 

In  Barbantini’s  case  the  calculus  was  so  large  that  it 
made  a considerable  prominence  in  the  rectum,  where 
it  was  felt  extending  across  from  one  tuberosity  of  the 
ischium  to  the  other.  On  account  of  its  size,  its  ex- 
traction by  the  lateral  operation  was  considered  im- 
practicable ; and  as  it  was  not  thought  advisable  or  easy 
to  break  such  a mass,  and  Barbantini  regarded  tlie 
high  operation  as  more  difficult  and  uncertain  in  its 
results  tliaii  the  common  method,  it  was  determined  to 
operate  through  the  rectum.  The  attempt  was  de- 
layed some  days  by  the  impossibility  of  introducing  the 
staff  effectually,  which  was  sioptied  at  its  enliance 
into  the  bladder  by  the  calculus.  But  as  a grooved  in- 
strument was  judged  to  be  an  essential  guide,  Barban- 
tin;  caused  a long  director  to  be  constructed,  which  he 
thought  might  be  passed  more  conveniently  than  tire 
staff  into  the  first  incision.  He  aisc  provided  himself 
with  loiig  forceps,  the  blades  of  which  were  very  broad, 
and  admitted  of  being  put  separately  over  the  stone. 
A staff  having  been  introduced,  the  operation  was 
done  after  M.  Sanson’s  manner,  ex(;ept  that  a wooden 
gorget  was  introduced  for  the  protection  of  the  rectum, 
and  the  prostate  gland  was  left  undivided  at  the  fore 
pan  of  the  wound.  When  the  bladder  has  been  opened 
at  the  lower  part  of  the  rectum,  as  far  as  the  groove 
of  the  staft’ served  as  a guide,  the  latter  instrument  was 
withdrawn,  and  the  long  director  introduced  into  the 
incision,  which,  under  its  guidance,  was  then  enlarged 
to  the  necessary  extent.  With  some  difficulty  the  stone 
was  then  extracted,  and  found  to  weigh  nine  ounces 
and  a half.  For  about  eighteen  days  the  urine  passed 
away  by  the  anus,  only  a few  drops  occasionally  issuing 
from  the  urethra.  As  this  circun>stance  gave  Barban- 
tini some  uneasiness,  he  introduced  his  finger  into  the 
bladder,  the  inner  surface  of  which,  near  the  wound, 
he  found  covered  with  encysted  calculous  matter,  which 
w a.s  very  adherent.  At  length,  however,  it  was  gra- 
<]ually  removed,  witli  a portion  of  new-formed  mem- 
brane, by  attempts  repeated  with  the  finger  several 
days  in  succession  A catheter  was  then  introduced, 
through  which,  at  first,  almost  the  whole  of  the  urine 
flowed.  But  the  tube  being  afterward  obstructed 
with  mucus,  it  became  necessary  frequently  to  clear  it 
by  injecting  tepid  water.  The  cure  now'  seemed  to 
proceed  with  rapidity.  When  the  feces  were  hard, 
none  of  them  passed  into  the  bladder;  but  when  they 
were  liquid,  a part  of  them  w’ere  voided  with  the  urine 
through  the  tube,  though  vxithout  any  inconvenience. 
At  the  end  of  fifty  days,  scarcely  any  urine  passed 
out  of  the  wound  ; the  patient,  therefore,  wetrt  into  the 
country,  where,  in  the  course  of  another  month,  the 
cure  was  complete. 

A few  years  ago  I saw  an  example,  in  which  a cal- 
culus had  made  its  way  through  the  prostatic  portion 
of  the  urethra,  and  formed,  with  the  sw’elling  of  the 
soft  parts,  a considerable  prominence  within  the  rectum. 
If  the  patient  had  been  under  my  care,  I should  cer- 
tainly have  made  an  incision  directly  on  the  tumour 
just  within  the  sphincter,  by  which  means  the  calculus 
might  liave  been  removed  with  great  ease,  and  less 
risk  than  dividing  the  prostate.  However,  the  latter 
method  was  followed,  and  the  case  had  a very  favour- 
able termination.  In  this  instance,  as  tlie  sound,  in  its 
passage,  only  occasionally  touched  a small  point  of 
the  calculus  which  approached  the  urethra,  and  this 
ju.<t  at  the  instant  before  its  entrance  into  the  cavity  of 
the  bladder,  the  «-xact  nature  of  the  case  was  for  some 
time  a matter  of  doubt  to  several  skilful  surgeons  who 
were  consulted. 

Rerpecting  the  merits  of  lithotomy  throucli  tire  rec- 
tum, I think  the  practice  well  deserving  the  consider- 
ation of  the  profession,  where  the  calculus  is  known 
beforehand  to  be  of  unusual  size.  It  must  be  less 
painful.  I appieheitd,  than  the  high  operation,  and  per- 
Inrps  more  easy  of  execution.  F.ven  Scarpa,  who  de- 
cidedly condeuins  ll:e  recto-vesicai  operation,  as  it  is 


termed,  acknowledges  that  a large  calculus  may  indeed 
be  thus  extracted  more  speedily,  and  with  less  rbk  of 
ir.jury  to  important  parts,  tlian  by  the  high  oireration; 
but,  says  he,  in  addition  to  the  consideration  that  in 
such  cases  every  mode  of  operating  is  contraindicated 
by  the  morbid  slate  of  the  bladder,  it  is  to  be  recol- 
lected, that  after  the  recto-vesical  method  there  is  al- 
ways left  an  o|)en  passage  for  the  feces  from  the  rectum 
into  the  bladder,  and  for  the  urine  from  the  bladder  into 
the  rectum.  Of  three  individuals  within  his  know- 
ledge, who  have  been  operated  upon  in  this  manner  for 
very  large  stones,  two  died  soon  afterward  of  slough- 
ing of  the  bladder,  and  the  third  led  for  some  time  a mi- 
serable existence,  dischaiging  fecal  urine,  and  urine 
mixed  with  excrement.  Instructed  by  these  disasters, 
some  Italian  surgeons,  not  declared  advocates  for  the 
new  method,  very  laudably  endeavoured  to  obviate 
them  in  future;  and  having  ascertained  that  for  the 
extraction  of  a stone  of  moderate  size,  such  as  can  be 
conveniently  taken  out  by  the  perina;uni,  it  is  not  at  all 
necessary  to  open  the  fundus  of  the  bladder,  they  adopt- 
ed .Sanson’s  method,  viz.  tliat  of  cutting  the  sphincter 
ani  from  below  upwards,  and  then  to  lay  open  verti- 
cally, from  above  downwards,  the  membranous  part 
of  the  urethra  and  the  prostate  gland,  so  as  to  let  the 
knife  meet  the  first  wound  in  the  sphincter.  “ In  fact 
(says  Scarpa),  they  really  attained  the  object,  namely, 
that  of  liinde,ring  tire  feces  from  entering  the  bladder 
after  the  extraction  of  the  stone.  This  was,  no  doubt, 
of  great  importance  in  their  operation,  yet,  as  it  seems 
to  me,  not  a consiueralion  that  ought  to  make  the  recto- 
vesical preferable  to  the  lateral  operation  whenever  the 
stone  can  be  taken  out  through  the  perin.-eum  ; first,  be- 
cause the  vertical  sectiwn  of  the  membranous  part  of 
the  urethra  and  the  prostate  gland  cannot  be  e.xecuted 
without  separating  the  left  seminal  duct,  and  some- 
times the  right  one,  from  the  vas  deferens  and  vesicula 
semiualis  of  the  same  side;  secondly,  because  the 
wound  is  still  exposed  to  the  contact  of  the  feces.” — 
{Sul  Tdglio  Relto-Vesicale,  p.  4.  Also  Oj.uscoli  di 
Chirurgia^  vol.  1,  p.  69.)  In  reply  to  Vacca’s  obser- 
vations he  urges  also  against  the  recto  vesical  opera- 
tion, when  the  wound  must  be  made  extensive  enough 
foi  the  removal  of  a large  calculus,  the  risk  there  is  of 
wounding  the  fold  of  the  peritoneum,  which,  if  the 
bladder  is  thickened  and  cdniracted,  descends  lower 
than  is  generally  supposed. — {P.  36.)  This  accident 
really  haiipened  in  one  case  which  was  dissected  by 
Geri  of  Turin. — {Rtpu  t.  Med  Chir.  de  To-'  inu.  Mo.  18.) 

Here  we  discern  a strong  reason  agtiinst  Mr.  Sleigh’s 
modification  of  the  operation,  in  addition  to  the  pro- 
bability of  an  incurable  communication  between  the 
rectum  and  the  bladder,  as  sufficiently  proved  in  the 
history  of  the  recio-vesical  operation. — (See  Scarpa's 
Opuscoli,  vol.  1.)  The  part  of  tlie  bladder  which  Mr. 
Sleigh  projioses  to  divide  is  bounded  laterally  by  the 
vasa  deferentia  and  vesiculte  seminales  ; superiorly  by 
ihe  cvl-dr-snc  of  the  peritoneum  ; and  inferiorly  by  the 
prostate  gland,  and  the  union  of  the  seminal  tubes.  The 
chief  peculiarity  in  the  plan  is  that  of  not  dividing  the 
sphincter  ani  and  tlie  prostate  L'land.  Cutting  the  first 
part,  he  conceives,  perhaps  without  sufficient  founda- 
tion, must  seriously  increase  the  patient’s  sufferings, 
while  dividing  ii:e  prostate  gland  vertically  cannot  be 
donewiihout  injuring  one  of  the  seminal  ducts;  a point 
on  which  he  is  nioie  correct,  and  in  agieenient  with 
Scarpa.  In  endeavouring  to  avoid  this  danger,  how- 
ever, he  runs  into  a still  more  fiirn.idable one,  viz.  that 
of  wounding  the  cul  de-suc  of  the  peiiloneuni,  and  ex- 
citing fatal  inflammation  w ithin  the  abdomen. — (See 
Sleigh's  F.ssay  on  an  improved  Method  of  Cutting  for 
Urinary  Calculi ; or  the  Posterior  Operation  of  Li- 
thotomy ; 8vo.  Land.  ]8'J4.) 

Even  w hen  the  stone  is  of  extraordinary  magnitude, 
it  may  be  doubted  whether  the  rectcevesical  inetln  d 
ought  to  be  prefers  d either  to  the  high  orthelateral  ope- 
ra’ion:  by  which  last,  stonesof  larger  size  than  ihatrx- 
tracted  by  Baibantini  have  been  successfully  taken  out 
by  Sir  A.  Coo()er,  Mr.  Mayo  of  Winchester,  Dr.  Klein 
of  Sliittgard,  and  others.  The  most  serious  consider- 
ation is,  w hether  a large  incision,  forming  a coinnui- 
nication  between  the  bladder  and  rectiiie,  will  gene- 
rally heal  up,  as  well  or  even  more  favourably  than  in 
Barbantini's  case.  A smaller  wound  in  the  same  part, 
it  apiiears,  may  be  soon  cured  ; tor  in  Ihe  instance  re- 
porn  d by  Sanson,  the  boy  was  quite  well  on  the  twen- 
tieth day.  Oil  U:is  {aiial,  it  must  be  confessed,  modem 


LITHOTOMY. 


155 


reports  are  becoming  extremely  unfavourable.  Of 
seven  patients,  operated  upon  with  division  of  llie 
fundus  of  the  bladder  (says  Professor  Vacca),  four 
were  left  with  a recto-vesirai  fistula,  and  the  filth 
was  in  danger  of  one.  In  four  cases  operated  upon, 
Professor  Geri  knew  of  three  such  terminations.  Be 
sides  these  facts,  observes  Scarpa,  of  which  I could 
increase  the  number  by  others  within  my  knowledge, 
it  is  to  be  taken  into  the  account,  that  in  some  indivi- 
duals the  fecal  and  urinary  fistula,  after  seeming  to  be 
closed  for*some  time,  has  opened  again. — {Hvl  Taglio 
Retto- Vesicate.,  p 40.)  I n the  School  of  Practical  Sur- 
gery at  Turin,  out  of  five  operated  upon  through  the 
rectum,  three  died,  although  eleven  other  patients  cut 
in  the  lateral  way  all  lecovered  in  a short  time.  Only 
one  had  rather  severe  symptoms,  which  were  ascribed 
to  a wound  of  the  rectum.  Dupuytren,  who  tried  the 
recto- vesical  operation  in  six  instances,  as  performed 
by  Vacca,  lost  three  of  his  patients  of  inflammation 
within  the  pelvis.  The  first  patient  died  a fortnight 
after  the  operation  ; and  two  on  the  third  day.  The 
three  otiiers  remained  with  iticurable  fistulte,  through 
which  the  urine  either  continually  dribbled,  or  was 
partially  expelled  when  the  bladder  contracted. — (See 
M.  Luuis  Henn,  Parallile  de  la  TaiUe,  Paris,  1824  ; 
Scarpa,  Opuscoli  di  Chirurgia,  vol.  1,  p.  1115.)  Du- 
puytren, on  being  asked  one  day  if  he  would  still  try 
the  plan,  made  no  answer,  but  shook  his  head.  Bar- 
bantini,  who  first  put  the  operation  to  the  test  of  expe- 
rieiice  in  Italy,  has,  after  farther  trials  of  it,  and  the 
mature  consideration  of  Scarpa’s  objections  to  it,  can- 
didly acknowledged  its  great  disadvantages  in  com- 
parison with  the  lateral  operation. — (See  Scarpa’s 
Opuscoli  di  Chirurgia,  vol.  1,  p.  100.)  Riberi  also  saw 
two  children  cut  by  Sanson  at  Paris  ; one  died  a few 
days  afterward  of  peritonitis ; and  the  other  was  given 
up  before  his  departure  from  that  city. — (Ragguaglio 
di  tredici  Cistutomie,  Torino,  1822;  and  Scarpa  svl 
Taglio  Retto- Vesicate,  p.  55.)  Sanson,  Des  Moyens 
ds  Parvenir  d la  Vessie  par  le  Rectum,  4to.  Paris, 
1817 ; JV*.  Barbantini,  Obs.  relative  d V Extraction 
d’v.n  Calciil  Urinaire  tris  voluniineux,  operie  au  moyen 
de  la  Taille  Vesico- Reel  ale,  8co.  Lucques,  1819;  .Journ. 
Complim.  da  Diet,  des  Sciences  Med.  t.  6,  p.  79,  8vo. 
Paris,  1820;  Diet,  des  Sciences  Med.  t.  28,  p.  422,  c'f-c. 
.d.  Scarpa  sill  Taglio  Retto- Vesicate,  4to.  182.3, 

and  Opuscoli  di  Chirurgia,  vol.  1,  4tc».  Pavia,  1825. 
Jilso  Memoire  del  Prof.  Vacca  relativa  al  Taglio  Retto- 
Vesicale. 

LITHOTOMY  IN  WOMEN. 

Women  suflTerless  from  the  stone  than  men,  and  far 
less  frequently  stand  in  need  of  lithotomy.  It  is  not, 
how'cver,  that  their  urine  will  not  so  readily  produce 
the  concretions  which  are  termed  urinary  calculi. 
The  reason  is  altogether  owing  to  the  shortness,  large- 
ness, and  very  dilatable  nature  of  the  female  urethra; 
circumstances  vvliich  in  general  render  the  expulsion 
of  the  stone  with  the  urine  almost  a matter  of  cer- 
tainty. The  records  of  surgery  present  us  with  nu- 
merous instances  where  calculi  of  vast  size  have  been 
8|)ontaneous{y  voided  through  the  meatus  urinarius, 
either  suddenly  without  pain,  or  after  more  or  less  time 
and  suflering.  Uei.vier  mentions  several  well  authen- 
ticated examples.  Middleton  has  also  related  a case, 
where  a stone,  weighing  four  ounces,  was  expelled  in 
a fit  of  coughing,  after  lodging  in  the  passage  a week. 
Colot  speaks  of  another  instance,  where  a stone  about 
as  large  as  a goose’s  ecg,  after  lyiiig  in  the  meatus  uri- 
narius seven  or  eight  days,  and  causing  a retention  of 
urine,  was  voided  in  a i)aro.\ysm  of  pain.  A remark- 
able case  is  related  by  Dr.  Molineux  in  the  early  part 
of  the  Philosophical  Transactions ; a woman  voided 
a stone,  the  circumference  of  which  measured  the 
longest  way  seven  inches  and  six-tenths,  and  round 
about,  where  it  was  thickest,  five  inches  and  three- 
quarters;  its  weight  being  near  two  ounces  and  a half 
troy.  And  Dr.  Yelloly  has  related  an  interesting  exam- 
ple, in  which  a calculus  weighing  three  ounces  three 
and  a h.Tlf  drachms  troy,  and  lodged  in  the  meatus 
urinarius,  was  easily  taken  out  with  the  fingers. — (See 
Med.  C/iir.  Trans,  vol.  6,  p.  511.)  Dr.  Yelloly  also  re- 
fers to  several  very  remarkable  instances,  de.scrihed  in 
the  Phil.  Tron.s.  vols.  12,  15,  17,  20,  34,  42,  and  .55, 
proving  what  large  stones  will  ptiss  <)nt  of  the  female 
urethra,  either  spontaneously  or  with  the  aid  of  dila- 
tation and  manual  assistance.  Were  any  doubts  now 


left  of  this  fact,  they  w’ould  be  Immediately  removed 
by  other  hisloiies,  especially  those  contained  in  the  pa- 
pers published  by  Sir  A.  Cooper. — (See  Med.  Chir. 
Trans,  vols.  8 and  12.) 

Sometimes,  after  the  • passage  of  large  calculi,  the 
patient  has  been  afflicted  with  an  incontinence  of  urine; 
but,  in  general,  this  grievance  lasts  oidy  a short  time. 

The  occasional  spontaneous  discharge  of  very  large 
calculi  through  the  meatus  urinarius,  led  Frederic  de 
Leauson  to  deliver  the  advice  not  to  interfere  with 
them,  as  he  thought  they  would  all  present  themselves 
sooner  or  later  at  the  orifice  of  that  passage,  and  admit 
of  being  taken  away  with  the  fingers. — (See  Traite 
Mouveau  pour  aisement  parvenir  d la  Vraie  Curation 
de  phtsieurs  belles  Opirations,  Sec.  Gineve,\^\.) 

When  surgeons  began  to  consider  what  very  large 
calculi  were  sometimes  spontaneously  voided,  and  the 
large  size  and  dilatable  nature  of  the  female  urethra, 
they  suspected  that  it  would  be  a good  practice  to  di- 
late this  passage  by  mechanical  conirivances,  until  it 
would  allow  the  stone  to  be  extracted,  and  thus  ail  oc- 
casion for  cutting  instruments  might  be  superseded. 
With  this  view,  Tolet  first  proposed  suddenly  dilating 
the  passage  with  two  steel  instruments,  called  a male 
and  female  conductor,  between  which  the  fingers  or 
force[)s  were  passed  fitr  the  removal  of  the  calculus. — 
{Traite  de  la  Eithotomie,  Paris,  1681.)  But  as  it  was 
afterward  rightly  judged,  that  the  dilatation  would 
produce  less  suffering  and  injury,  if  more  gradually 
effected,  Douglas  suggested  the  practice  of  dilating  the 
meatus  urinarius  with  sponge  or  dried  gentian  root. 

Mr.  Bromfield  published  the  case  of  a young  girl,  in 
whom  he  effected  the  necessary  dilatation  by  intro- 
ducing into  the  meatus  urinarius  the  appendicula  coed 
of  a small  animal  in  a collapsed  state,  and  then  filling 
it  with  water,  by  means  of  a syringe;  thus  furnishing 
a hint  for  the  construction  of  instruments  on  the  prin- 
ciple of  Mr.  Arnott’s  dilator.  The  piece  of  gut  thus 
distended  was  drawn  out  in  proportion  as  the  cervix 
vesiccE  opened,  and,  in  a few  hours,  the  dilatation  w'as 
so  far  acconqtlislied,  that  the  calculus  had  room  to 
pass  out. — (See  Chir.  Obs.  and  Cases,  vol.  2,  p.  276.) 

Mr.  Thomas  met  with  a case  in  which,  after  dilating 
the  meatus  urinarius  with  a sjionge  tent,  he  succeeded 
in  extracting  an  earpicker  which  lay  across  the  neck 
of  the  bladder.  The  passage  was  so  much  enlarged, 
that  the  left  fore  finger  was  most  easily  introduced,  and 
(says  this  gentleman),  “ I believe  had  the  case  required 
it,  both  thumb  and  finger  would  have  passed  into  the 
bladder  without  thesmallest  difficulty.”  After  advert- 
ing to  this  and  other  facts,  proving  the  ease  with  which 
the  female  urethra  can  be  dilated,  Mr.  Thomas  re- 
marks: “If  the.«e  relations  can  be  credited,  and  there 
is  no  reason  why  they  should  nor,  l can  hardly  con- 
ceive any  case  in  a youm;  and  healthy  female  subject, 
and  where  the  bladder  is  free  from  disease,  where  a 
very  large  stone  may  not  be  extracted,  without  the  use 
of  any  other  instrument  than  the  forceps,  the  urethra 
having  first  been  stifficiently  dilated  by  means  of  the 
sponge  tents.  For  this  purpose,  the  blades  of  the  for- 
ceps need  not  be  so  thick  and  strong  as  those  com- 
monly employed.” — (See  Med.  Chir.  Trans.  vo\.  1,  p. 
123 — 129.)  Many  facts  of  a similar  kind  are  on  re 
cord,  and  one,  in  w#iich  a large  needle  case  was  ex 
traded,  is  referred  to  in  a modern  periodical  work.— 
(See  (Quarterly  Journ.  of  Foreign  Med.  vol.  2,p.  331.) 

Some  surgeons  have  extracted  stones  from  the  fe- 
male bladder  in  the  following  manner;  the  patient 
having  been  placed  in  the  position  commonly  adopted 
in  the  lateral  operation,  a straight  staff,  with  a blunt 
end,  is  introduced  into  the  bladder  through  the  meatus 
itrinarius.  The  surgeon  then  passes  along  the  groove 
of  the  instrument  the  beak  of  a blunt  gorget,  which 
instrument  becoming  wider  towards  the  handle,  effects 
a part  of  the  necessary  dilatation.  The  staff  being 
withdrawn,  and  the  handle  of  the  gorget  taken  hold 
of  with  the  left  hand,  the  right  fore  finger,  with  the 
nail  turned  downwards,  is  now  introduced  slowly 
along  the  concavity  of  the  instrument.  When  the 
urethra  and  neck  of  the  bladder  have  thus  been  suffi- 
ciently dilated,  the  fitiger  is  withdrawn,  and  a small 
pair  of  forceps  p.assed  into  the  bladder.  'I'lie  gorget  is 
now  removed,  and  the  stone  taken  hold  of  and  ex- 
tracted.— {Sabatier,  Midecine  Opirutoire,  t.  2,  p.  103.) 

'I'liis  plan,  however,  has  been  objected  toon  account 
of  the  dilatation  being  too  siidilenly  effected  ; and  the 
practice  of  gradually  expanding  the  meatus  urinarius 


156 


-lithotomy, 


with  the  sponge  tent  preferred.  The  retention  of  urine 
during  ilie  cuntinuance  ot  tliespoiige,  ceriainly  causes 
great  nrilation,  and  if  this  nieiliod  he  lollowed,  iliere- 
fore,  I consider  iMr.  C.  Hutcliison’s  suggestion  of 
placing  acallielerin  its  ceiitre,  as  nieniioned  ity  Sir  A. 
Cooper,  worthy  of  attention. — fSee  Jltd.  Ckir.  'I'/  aun. 
vuL.  8,  p.  433.) 

Sir  A.  Cooper,  who  is  an  advocate  for  the  practice 
of  removing  calculi  from  the  female  bladder  by  dila- 
ting the  ineaius  ui  inarius,  now  employs  lor  iliis  pur- 
pose “an  instriinieiit  consiructed  upon  the  principle  of 
the  speculum  am  and  speculum  oris,”  and  which  has 
the  advantage  of  pei  luitiing  the  urine  to  escape,  while 
it  dilates  the  passage  sulhcienily  for  the  entrance  of  the 
foiceps,  a-id  the  leiuoval  of  a stone  of  considerable  di- 
mensions. He  beln:ves  that,  “ if  toe  stone  be  small, 
the  dilatation  should  be  accomplished  in  a few  mi 
nules,  but  that  if  it  be  large,  it  will  be  belter  to  dilaie 
but  little,  from  day  to  day,  until  the  gieatesidegree  ot  ex- 
tension is  accomplished;  carefully  avoiding  contusion, 
which  is  much  to  be  dreaded.” — (See  Med.  Ckir. 
Trans,  vol.  12,  p.  240.) 

Notwiilislanding  ihese  favourable  accounts  of  the 
practice  of  dilating  the  femaie  urethia,  lor  the  purpose 
of  removing  calculi  from  the  bladder,  iliere  are  very 
good  surgeons  w liodeeni  an  incision  tiie  best  practice. 
It  is  ceriain  that  some  paiients  have  found  the  method 
insuSerahly  tedious  ami  painful.  But  tlie  strongest  ob 
jection  is  the  ineontinence  ot  mine,  which  occasion- 
ally follows  agieai  distention  of  the  urethra  and  neck 
of  the  bladder.  Klein,  one  of  the  most  experienced 
operative  surgeons  in  Germany,  states  iliat  he  has  ti  ied 
both  plans,  and  that  the  use  of  the  kniie  is  much  less 
frequently  frdlowed  by  incontinence  of  urine.  And 
Scarpa  declares,  that  when  the  Ccilculus  is  large,  and 
not  soft  and  liagile,  the  method  of  extracting  it  by 
dilatation  is  almost  always  followed  by  incontinence 
of  urine. — {Sul  I'agliu  hettu-k'esirale,  p.‘i'-J.)  On  the 
Other  hand,  Mr.  Thomas  believes,  that  this  unpleasant 
symptom  is  quite  as  olteii  a consequence  of  the  opeia- 
licn  of  lithotomy,  as  now  usually  peiloimed  {Med 
Ckir.  Trans,  vul.  1,;?.  127);  and  Sir  A.  Cooper  ex- 
pressly states,  that  tlie  greatest  advantage  of  his  mode 
of  extracting  calculi  w ith  a dilating  insirumeiu,-  is  the 
pi'eservation  of  tlie  povi'er  of  retaining  the  urine. — 
(See  Med.  Ckir.  Trans,  vol.  12,  y/.  24{1.)  Of  the  pro- 
priety of  removing  calculi  under  a certain  size,  and 
also  pieces  of  broken  catheter,  iScc.,  in  this  manner,  no 
doubt  can  be  entertained;  but  if  the  foreign  body  were 
very  large,  t should  consider  an  incision  tlie  safest  and 
least  painful  practice. 

In  females,  lithotomy  is  much  more  easy  of  execu- 
tion, and  less  dangerous,  than  in  male  subjects.  It  may 
be  done  in  various  ways;  but  the  surgeons  of  the  pre- 
sent lime  constantly  follow  the  mode  of  making  the  re- 
quisite opening  by  dividing  the  urethra  and  neck  of  the 
bladder.  Louis  employed  for  this  purpose  a kiiiie, 
which  cut  on  each  side,  and  was  contained  in  a 
sheath;  Le  Blanc,  a concealed  bistoury,  wliich  had 
only  one  cittiing  edge;  Le  Cat,  his goigeret-cystoioine  ; 
Frere  C6me,  his  litholonie  cach^.  Of  these  instru- 
ments, the  best  I think  is  that  of  Fr#re  Cdme.  But, 
at  present,  every  surgeon  knows  that  the  operation 
may  be  done  as  conveniently  as  possible  w'ith  a com- 
mon director,  and  a knife  that  has  a long,  narrow, 
straight  blaile.  A straight  stall’,  or  director,  is  intro- 
duced through  the  meatus  ui  inarius;  Hie  groove  is 
turned  obliquely  downwards  and  outwards,  in  a diiec- 
tion  parallel  to  the  ramus  of  the  lettos  pubis;  and  the 
knife  is  thus  conducted  into  the  bladder,  and  makes  the 
necessary  incision  ihroueh  the  whole  extent  of  the 
passage  and  neck  of  the  bladder. 

Louis  and  Fleiirant,  as  1 have  said,  tvere  the  in- 
ventors of  particular  bistouries  for  dividing  both  sides 
of  the  female  urethia  at  once.  The  instrumeiit  of  the 
formet  etfected  this  purpose  in  passing  from  without 
inwards;  tnat  of  ihe  lailer,  in  passing  from  within 
oulw’ards.  Flenrani’s  bistoui y bears  some  resemblance 
in  principle  lo  l'’idie  (7bme's  liihoiome  cacli^,  or  to  the 
culling  forceps  with  which  Franco  divided  the  neck  of 
the  bladder.  'J'lie  n-ason  assigned  as  a recommenda 
lion  of  these  bi>iouiies  is,  that  they  serve  to  make  a 
freer  opening  for  the  passage  of  laige  stones  than  can 
be  safely  made  by  culling  only  in  one  direction.  When 
the  calctilu'  is  large,  it  is  certainly  difficult  to  procure 
a free  opening  without  cutting  the  vagina,  in  liont  of 
which  passage  there  is  but  little  space  under  the  pubes 


for  the  removal  of  the  stone.  Hence,  Dubois  Invented 
a new  niethod,  which  consists  in  dividing  the  meatus 
UI  inarius  directly  upwards  towards  the  symphysis  of 
the  pubes,  dilating  the  wound,  and  keeping  the  vagina 
out  of  the  way  by  means  of  a blunt  gorget,  and  then 
taking  out  the  calculus  with  the  forceps.  This  plan  is 
acknowledged  lo  be  very  painful,  yet  generally  success- 
ful, and  not  toltowed  by  any  serious  symptoms  or  in- 
continence of  urine. — (See  Diet,  des  Sciences  Mid.  t. 
28,  p.  436.)  Lisli  anc  also  carries  the  incision  upwards, 
and  a little  to  one  side  of  the  symphysis  of  the  pubes, 
because  this  mode  of  opeialnig  is  found  to  be  less  fre- 
quently followed  by  retention  of  urine.  When  the 
opening  thus  made  is  not  laige  enough,  he  makes  an- 
other cut  obliquely  downwards  and  outwards.  When 
the  stone  is  known  to  be  very  large,  Sabatier  and 
some  other  modern  surgeons  prefer  the  apparatus 
alitis. 

['[’he  very  powerful  objections  having  been  stated  to 
the  dilatation  of  the  female  urethra  by  either  of  the 
methods  proposed,  and  the  fact  being  admitted  that  the 
operations  lieie  described  are  so  frequently  followed  by 
incontinence  of  urine  and  other  unjileasanl  results,  it 
is  surprising  that  Mr  Goopei  has  nrjl  mentioned  the 
opeiaiion  of  M.  Dubois,  which  is  not  only  free  from 
these  olijeci ions,  but  entirely  void  of  danger.  Having 
witnessed  its  success,  1 esteem  it  as  one  of  the  most 
important  improvements  ever  made  on  this  interesting 
subject. 

'I'his  operation  is  to  be  performed  thus  : the  surgeon 
introduces  a director  througli  the  meatus  urinarius  into 
the  bladder,  w'iih  the  groove  directly  upwards.  An  in- 
cision is  then  made  directly  upwards  by  the  straight 
bistoury  towards  the  symphysis,  extending  through  the 
w hole  cour  re  o(  the  urethra,  and  the  neck  of  tlie  blad- 
der, after  which  the  calculus  may  be  readily  extracted 
by  a pair  oi  iorceps  guided  by  the  left  index  finger  in  the 
same  manner  as  in  the  laieral  operation.  One  advan- 
tage of  1.0  small  importance  is,  that  in  this  operation 
the  surgeon  needs  no  assistant,  and  paiients  will  sub- 
mit to  i he  operation  much  ea  iier,  when  their  native 
delicacy  would  otherwise  revolt  at  exposure. — Reese.'\ 

A case  may  present  itself  in  which  the  posterior 
part  of  the  bladder,  draw-n  downwards  by  the  weight 
ot  Ihe  Slone,  may  displace  a portion  of  the  vagina, 
and  make  it  protrude  at  the  vulva  in  the  tbrm  of  a 
swelling.  Here  there  would  be  no  doubt  of  the  pro- 
[irieiy  of  cutting  inio  the  tumour,  and  taking  out  the 
foreign  body  contained  in  it.  Roussel  performed  such 
an  opeiation,  and  Fabricius  Hildanus,  in  acase  wdiere 
the  stone  had  partly  made  its  way  into  the  vagina,  en- 
larged the  opening,  and  successfully  extracted  the  fo- 
reign body. 

IMery  proposed  to  cut  into  the  posterior  part  of  the 
bladder,  through  the  vagina,  after  introducing  a com- 
mon curved  siaft';  but  the  apprehension  of  urinary  fis- 
lulse  made  him  abandon  the  project. 

Extraordinary  circumstances  may  always  render  a 
deviaii.m  from  the  common  modes  of  operating  not 
only  justifiable,  but  absolutely  necessary.  Tims,  Tolet 
met  w iih  a case,  where  a woman  had  a prolapsus  of 
the  uterus,  vv  iih  w'hich  the  bladder  was  also  displaced. 
In  the  latter  viscus,  several  calculi  w’ere  felt : an  inci- 
sion was  made  into  it,  and  the  stones  extracted  : after 
w hich  operation,  the  displaced  parts  were  reduced,  and 
a speedy  cure  follow  ed. — {Sabatier,  Medecine  Opera- 
toil  e,  t.  2,  p.  107.) 

'I'he  incontinence  of  urine,  consequent  to  lithotomy 
in  women,  is  by  no  means  an  untrequent  occnirence. 
iMr.  Hey  cm  two  female  paiients  for  Ihe  stone,  both  of 
whom  were  afterw'ard  unable  to  retain  their  urine, 
and  w'ere  not  quite  well  when  discharged  from  the 
Leeds  Infirmary.  These  cases  led  him  in  a ihiid  ex- 
ample to  endeavour  to  prevent  the  evil  by  introducing 
into  the  vagina  a cylindrical  linen  tent,  two  inches  long 
and  one  broad,  with  a view  of  bringing  the  edges  of  the 
incision  together  without  obstructing  the  passage  of 
urine  through  the  urethra.  The  plan  answered,  if  it  be 
allowable  to  make  such  an  inference  from  a single  trial. 
— (See  IJey's  Practical  Obs.  in  Surgery,  p.  560,  cd. 
1810.) 

TREATMENT  AFTER  THE  OPERATION. 

If  the  interyal  pudendal  artery  stmuld  be  w'oiinded 
and  bleed  prot  usely,  the  best  plan  is,  if  possible,  first  to 
take  out  the  stone,  and  then  introduce  itito  the  wound 
a piece  of  firm  sponge,  with  a large  cannula  passed 


LITHOTOxMY. 


m 


through  it*  centre.  The  expanding  property  of  the 
sponge,  on  its  becoming  wet,  wiii  make  tlie  necessary 
degree  of  compression  of  tiie  ves.'el,  wliicli  lies  loo 
deeply  to  be  tied.  Linen,  wet  with  cold  water,  should 
at  the  same  time  be  applied  to  the  perinajum  and  liypo- 
gastric  region. 

( caniioi  say  that  it  has  fallen  to  my  lot  to  see  any 
cases  (out  of  the  great  number  which  1 have  seen)  in 
which  death  c(»uld  be  imputed  to  hemorrhage,  noiwitli- 
standing  the  bleeding  has  olten  been  so  proluse,  and 
from  so  deep  a source,  just  after  the  operation,  as  to 
create  suspicion  that  it  proceeded  fiom  the  internal  pu- 
dendal artery.  Such  hemorrhage  generally  slopped  be- 
fore the  patient  was  put  to  bed. 

[The  internal  pudendal  artery  was  tied  by  Dr.  PJiy- 
sick,  after  its  being  wounded  iu  lithotomy,  nearly  30 
years  since. — Reese.] 

The  majority  of  patients  who  die  after  lithotomy, 
perish  of  peritonea!  intiamination.  Hence,  on  the  least 
occurience  of  tenderness  over  tlie  tibdomeii,  copious 
venesection  should  be  put  in  p.actice.  At  the  same 
time,  eight  or  ten  leeches  should  be  applied  to  the  hy- 
pogastric region.  The  belly  should  be  lomeiited,  and 
the  bowels  kept  open  with  the  oleum  ricini.  The  fee- 
bleness of  the  pulse  should  not  deter  the  practitioner 
from  using  the  lancet:  this  symptom  is  only  fallacious, 
and  generally  attendant  on  all  intiamination  within  the 
abdomen.  Itisacurious  fact,  that  Mr.  Martiiiean,  who 
lost  only  two  out  of  84  patients  whom  he  operated 
uiton  for  the  stone,  should  never  have  found  it  requi- 
site to  bleed ; but  it  appears  to  me,  that  it  is  a much 
better  argument  in  favour  of  the  superior  safely  of 
operating  with  the  knife  and  making  a free  opening, 
than  a reason  for  discouiaging  venesection,  vvlieii  in- 
flamniation  of  the  peritoneum  has  come  on,  which, 
however,  may  not  be  this  gentleman’s  meaning,  as  he 
says,  “1  believe  it  will  be  found  in  adults,  that  death 
follows  oftener  from  exhaustion,  after  a tedious  ope 
ration,  or  from  despondency,  &c.  than  Irom  acute  dis 
ease”  {Med.  Chir.  Trans,  vol.  11,  p.  412) ; a sentiment 
which,  I am  sure,  this  gentleman  would  not  have  en 
teriained  had  he  been  present  w ith  me  at  the  opening 
of  the  many  unlortunate  cases  which  used  formeily 
to  occur  in  the  practice  with  badly  made  gorgets  in  St. 
Bartholomew’s  Hospital.  Together  wiili  the  above 
measures,  tlie  warm  bath,  a blister  on  the  lower  part 
of  the  abdomen,  and  emollient  clysters,  aie  highly  pro- 
per. I have  seen  several  old  subjects  die  of  the  irri- 
tation of  a diseased  thickened  bladder,  continuing  after 
the  stone  was  extracted.  Tliey  had  not  the  acute 
symptoms,  the  inflammatory  fever,  the  general  tender- 
ness and  tension  of  the  abdomen,  as  in  cases  of  peiito- 
nitis;  but  they  referred  their  uneasiness  to  the  lower 
part  of  the  pelvis  ; and  instead  of  dying  in  the  course 
of  two  or  three  days,  as  those  usually  do  w'ho  perish 
of  peritoneal  inflamination.  they,  for  the  most  part, 
lingered  for  two  or  three  weeks  after  theoperalion.  In 
these  cases,  opiate  clysters,  and  bli.>tering  the  hypogas- 
tric region,  are  the  best  measures.  In  some  in- 
stances of  this  kind,  abscesses  form  about  the  neck  of 
the  bladder. 

[The  following  communication  on  tlii.s  prolific  sub- 
ject is  from  Professor  Jameson  of  Baltimore.  As  it 
contains  a brief  notice  of  the  comparaiive  merits  of 
lithontrity  and  the  lateral  operation,  and  suggests 
many  practical  hints  deduced  from  his  extensive  expe- 
rience, I have  been  unwilling  lo  curtail  it  (though  ils 
length  exceeds  the  limits  assigned  me  by  ihe  publishers) ; 
and  have  therefore  concluded  to  in.sert  it  entire,  in 
order  that  the  points  of  difierence  fietween  him  and 
his  predecessors  or  contemporaries  may  be  fairly  stated 
in  his  own  language.  It  will  be  found  to  possess  a 
simplicity  and  anlessness,  which  will  make  it  accept- 
able to  younger  surgeons,  since  these  characteristics 
are  too  seldom  found  in  the  descriptions  of  this  opera- 
tion by  surgical  writers.  Having  witnessed  a number 
of  Dr.  J.’s  operations  w’hen  I re.sided  in  Haltimore,  1 
have  been  both  surprised  and  pleased  at  his  successful 
etiorts  in  producing  “union  by  the  fii si  intention”  in 
surgical  wounds,  as  well  in  this,  as  in  other  operations. 
The  periodicals  of  the  day  have  recorded  many  of  his 
valuable  contributions  to  this  department  of  surgical 
knowledge,  to  some  of  which  posterity  will  award 
liim  the  merit  of  originality. 

“ It  may  be  recollected,  that  so  flattering  were  the 
reports  from  France  respecting  the  operation  of  li- 
thonlrity,  in  the  hands  of  M.  Civiali,  that,  in  the  year 


1824-5,  some  of  the  most  distinguished  surgeons  of 
America  attempted  its  performance;  in  all  which  at- 
tempts theie  were  complete  failures;  nor  did  the  avidity 
with  which  this  operation  was  received  by  operating 
surgeons  remain  within  flie  sphere  of  their  action  ; on 
the  contrary,  some  of  the  highly  respectable  medical 
journals  of  this  country  sebmed  to  vie  with  each 
other  which  was  entitled  to  the  meed  of  praise  for 
having  first  announced  the  important  intelligence  asso- 
ciated with  this  operation 

Anxious  as  we  always  have  been  to  investigate 
every  thing  wearing  the  appearance  of  improvement, 
and  influenced  as  wm  always  have  been  by  feelings  of 
humanity  in  our  researches,  ue  did  not  lose  any  time 
in  e.xtending  our  inquiries  into  the  history,  character, 
and  ineiils  of  the  operation  of  lithontrity.  Our  in- 
vestigations resulted  in  a publication  in  the  late  Medical 
Recorder  of  Pliiladel[)liia,  in  which  we  endeavoured 
to  show  the  inapplicability  of  the  new  operation,  under 
so  many  circnmsiances,  as  to  come  to  the  conclusion, 
that  the  advantages  of  lithontrity  were  greatly  over- 
rated ; and  would  never,  as  a general  rule  of  practice, 
supersede  the  lateral  opeialion.  From  that  time  to  the 
present,  we  have  endeavoured,  free  from  prejudice, 
to  keep  pace  with  the  presumed  improvements  in 
lithontrity,  and  we  are  compelled  to  say,  that  we  have 
seen  nothing  calculated  to  change  former  opinions. 

One  thing  we  think  will  be  conceded  on  all  hands; 
that  lithontrity  will  never  do  aw’ay  the  necessity  for  the 
lateral  operation.  And  as  it  has  been  our  lot  to  differ 
with  a large  proportion  of  the  profe.ssion,  respecting 
the  merits  of  the  new  operation,  ao  has  it  also  been 
onr  lot  to  differ  essentially  with  all  authorities  which 
have  come  within  onr  observation,  as  to  the  plan  of 
operation,  both  in  the  male  and  female  patient. 

The  limits  assigned  us  w ill  not  admit  of  our  insti- 
tuting any  minute  investigation,  nor  of  entering  gene- 
rally into  the  merits  or  demeiits  of  the  several  ope- 
rations; we  shall  therefore  proceed  to  offer  our  own 
e.xpeiience,  and  leave  the  reader  to  appreciate  as  to 
him  may  seem  pro|ier.  We  w'ill  only  say  farther,  that 
it  i.-f  our  ambition  to  write  for  posterity  ; and,  aware  as 
w'e  aieof  the  fleeting  character  w'hich  has  so  much 
beset  medical  science  from  its  dawn,  we  are  not  dis- 
[losed,  lightly,  to  place  ourselves  in  the  list  of  rash 
specuiatists. 

Believing,  as  we  do,  that  we  have  materially  im- 
proved the  operation  of  lithotomy  in  both  sexes  we 
purpose  laying  our  views  before  the  jiublic ; we  will  as 
briefly  as  possible  describe  our  method.  In  doing  this, 
we  may  have  occasion  to  notice  some  facts  connected 
with  the  history  of  this  operation. 

We  need  not  go  far  back  into  the  records  of  surgery, 
to  see  the  profession  altogether  ignorant  of  healing 
wounds  by  lhe^?-s<  intention.  This  applies  more  par- 
ticularly to  surgical  wounds.  Among  the  greater  ope- 
rations, amputation  was  the  first  to  claim  attention,  iti 
respect  to  saving  skin,  and  thus  facilitate  the  cure  of 
stumps;  next,  w'e  notice  similar  atiem|)ts  to  expedite 
Ihe  cure  of  wounds  ntade  in  the  amputation  of  the 
female  mamma;  then  attention  was  called  toa  similar 
plan  of  piocediire  in  wounds,  surgical  or  others,  of  Ihe 
scalp;  nor  w’as  this  important  method  of  healing  by 
the  Jirst  intention  nv!i\o.cU‘(\  in  the  treatment  of  wounds 
geneially  that  .^eemed  rationally  to  ailmit  of  it;  but  by 
some  sluinge  fatality,  it  so  ha[)pened  that  no  one 
thought  of  employing  this  salutary  practice  in  the 
wound  made  in  operating  for  the  stone,  till  it  fell  to  us 
to  te.st  this  method,  and  to  realize  iherein  our  most 
saiiLoiine  exjieciations. 

We  have  been  in  the  habit  of  performhig  this  ope- 
ration, tifter  our  own  method,  for  six  or  seven  years: 
and  onr  success  has  been  such  as  lo  make  us  extremely 
desirous  to  ticquaint  the  profession  with  our  plan,  and 
sustain  it  with  two  or  three  cases,  by  way  of  illustra- 
ting onr  method  of  itrocedure,  and  of  showing  the  su- 
periority of  that  nieth(Mi. 

So  f:ir  as  w(t  recollect,  the  better  authorities  on  swr- 
g(  ry  advise  free  external  incisions,  not  only  for  the 
pur|)Ose  of  gaining  easy  access  to  the  blailder,  but  also 
with  a view  of  ol)tainiug  a free  outlet  lor  Ihe  urine, 
which  is  expected  to  flow  through  the  wound  We  are 
rlirected  by  m.'iny  lo  carry  our  incision  an  inch  and 
a half  posterior  to  the  anus,  or  down  to  the  tuber 
ischii. 

We  are  decidedly  of  the  opinion  that  this  procedure 
is  attended  with  several  disadvantagi^;  and  affordii 


158  LITHOTOMY. 


nothing  salutary.  The  following  are  some  of  the  ob- 
jections to  this  method  of  operation. 

1st.  By  culling  so  far  back,  we  cut  deep  into  the  mass 
of  cellular  and  fatty  structures,  which  till  up  the  deep 
space  between  llie  tuber  ischii,  the  urethra,  and  the  rec- 
tum ; this  creates  an  unnecessary  extent  of  wound  ; and 
greatly  increases  the  risk  of  wounding  the  rectum, 
while  it  also  lessens  tlie  chances  of  healing  the  woutid 
by  the  first  intention. 

2d.  As  it  is  our  object  to  heal  by  the  first  intention, 
this  is  a matter  of  primary  importance.  And  we  know, 
from  repeated  observation,  that  there  is  no  advantage 
as  regards  the  extraction  of  the  stone  in  dividing  this 
fatty  structure : it  is  the  muscles  which  form  the  re- 
sistance to  extraction. 

The  following  is  our  plan  of  procedure  in  the  male 
subject.  'I'he  existence  of  stone  ascertained  by  the 
sound,  and  our  patient  in  as  good  health  as  we  can 
reasonably  expect  him  to  be,  we  introduce  the  usual 
curved  stall',  grooved  on  its  right  side. 

The  patient  is  now  to  be  tied  ; this  securely  done  ; 
while  an  assistant  surgeon  holds  the  staff  firmly,  the 
surgeon  spreading  his  hand  over  the  perineum,  by 
placing  his  tliumh  on  one  side  of  the  raphse,  and  his 
fingers  of  the  left  hand  on  the  other,  he  commences  his 
incision  about  half  an  inch  from  the  raphte,  leftside; 
and  at  a point  about  two  inches  in  advance  of  tl.te  anus 
in  the  adult,  and  about  an  inch  and  a quarter  in  a boy 
of  five  or  six  years,  and  terminates  it  opposite  the  centre 
of  the  anus;  two  or  three  strokes  of  the  scalpel  will 
enable  him  to  divide  the  jnuscles  of  the  perineum; 
and  he  may  now  observe,  that  by  dividing  the  liga 
mentoiis  union  of  the  several  muscles,  just  behind  the 
bulb  of  the  urethra,  that  the  parts  are  sufficiently 
dilated  or  relaxed.  Feeling  now  for  the  groove  of  the 
staff',  which  the  assistant  holds  a liiile  turned  to  the 
right  side  of  the  patient,  so  as  to  bring  the  groove  be- 
tween the  lateral  and  lower  aspects  of  the  wound,  he 
pushes  the  point  of  the  same  scalpel  through  the  ure- 
thra, j/tsf  behind  the  bulb;  then  taking  the  staff'  in  his 
left  hand,  he  turns  its  convex  side  to  the  inferior  aspect 
of  the  wound,  ascertains  that  the  end  of  the  Stas'  is 
well  home  in  the  bladder.  This  arranged,  he  now 
slowly  passes  the  scalpel  along  the  groove  of  the 
staff,  till  he  perceives  a gush  of  urine,  or  till  he  feels 
that  the  knife  meets  no  farther  resistance. 

Before  withdrawing  the  staff,  the  surgeon  should  pass 
in  his  finger  to  ascertain  that  the  wound  is  sufficiently 
large  ; and  to  ascertain,  as  nearly  as  may  be,  the  size 
of  the  calculus.  7’his  done,  provided  the  calculus  is 
of  such  size  as  to  admit  of  removal  without  risk  of 
bruising  the  parts.  Barton’s  forceps  are  to  be  introduced  ; 
and  the  stone  removed  in  the  most  gentle  manner,  both 
with  a view  of  avoiding  bruising  the  parts,  and  of 
avoiding  the  breaking  otf  of  fragments  of  the  stone. 
Should  any  be  broken  off,  after  removing  whatever 
number  of  calculi  may  be  present,  and  larger  frag- 
ments, the  smaller  particles  may  be  readily  washed  out 
with  warm  water,  by  means  of  a syringe. 

The  operation  thus  completed,  we  pass  a pretty  large 
flexible  catheter;  in  a boy  of  five  or  six  years  of  age, 
about  the  size  of  the  ordinary  silver  catheier  ; in  men, 
about  the  size  of  the  female  catheter.  This  will  be 
most  easily  introduced  by  (iiitiing  into  the  tube  a stylet, 
having  the  usual  curve  of  the  silver  catheter.  The 
lube  must  be  tied  by  means  of  a small  soft  strip  of  rag 
to  t’le  penis. 

The  patient,  being  untied,  is  laid  on  his  right  side; 
his  knees  brought  together,  and  tied  by  means  of  a silk 
handkerchief,  or  other  soft  bandage.  No  sutures  will 
be  necessary;  but  it  is  alrsolutely  essential  that  the 
patient  lie  quietly  on  his  side  for  two  or  three  days,  so 
as  to  obtain  the  effect  of  a syphon  from  the  tube.  He 
may,  however,  after  some  hours,  if  paiticniaily  desi- 
rous, turn  upon  his  left  side,  never  forgetting,  however, 
that  the  outer  end  of  the  tube  must  be  lower  than  the 
inner.  The  patient  may  be  kept  comfortably  dry,  by 
using  a cup  or  large  sponge  to  contain  the  water,  as  it 
drops  from  the  tube. 

We  shall  now  state  a few  cases,  and  conclude  our 
observations  with  a recapitulation  of  some  of  the  more 
important  steps  of  our  operation. 

These  cases  are  selected  from  others  equally  success- 
ful; but  we  have  no  disposition  to  conceal  the  fact, 
that  in  some  instances  we  have  not  succeeded  .so  well; 
of  the  laiter  we  shall  presently  take  some  notice. 

A boy  aged  about  eight  years  had  euffered  several 


years  with  stone;  his  aspect  was  sickly;  his  suffer* 
ings  extreme ; and  his  growth  much  retarded ; mostly 
incapacitated  for  going  to  school. 

Tlie  necessary  wound  was  made  agreeably  to  our 
method,  the  forceps  introduced,  and  two  calculi,  of  the 
size  of  the  largest  filbert,  caught  in  the  chops  of  the 
instrument  at  once.  The  tube  was  introduced,  &c.  &c. 

There  were  no  constitutional  symptoms  ; on  the  con- 
trary, the  patient  was  calm  and  cheerful,  after  the 
shock  of  the  operation  passed  over,  which  look  place 
in  a few  hours  ; of  course  there  was  no  constitutional 
treatment,  e.xcept  the  enforcement  tif  a low  diet.  The 
wound  was  neither  painful,  red,  heated,  or  swelled  at 
any  period ; on  the  contrary,  it  closed  the  first  night, 
and  continued  so,  not  affording  any  discharge  what- 
ever; no  dressing  was  applied,  except  washing  the 
parts  once  a day  with  cold  water.  On  the  eighth  day 
after  the  operation,  we  met  him  in  full  dress  at  the 
street  door  ; and  the  next  day  found  him  playing  tricks 
with  his  brother,  at  the  hydrant  in  the  yard. 

In  the  last  month  (March,  1830),  we  operated  on  a 
lad,  between  six  and  seven  years  of  age,  who  liad  suf- 
fered severely  for  about  eighteen  months  with  stone ; 
and  who  came  from  an  aguish  neighbourhood,  on  the 
eastern  shore  of  this  state. 

Nothing  remarkable  occurred  in  the  operation,  except 
an  unusual  amount  of  hemorrhage.  Tliis  proceeded 
however,  from  the  vessels  of  the  perineum,  and  ceased 
as  soon  as  the  operation  was  over.  On  the  day  suc- 
ceeding the  operation,  he  was  so  well  as  to  play  with 
tile  children  of  the  house  in  which  he  lay,  and  his  at- 
tendants, though  extremely  kind  and  attentive,  forgot 
themselves,  and  suffered  the  patient  to  turn  on  his 
back,  till  the  water  accumulated  in  the  bladder,  and 
caused  him  to  pass  it  off,  part  of  which  escaped  through 
tlie  wound.  I felt  much  concerned,  and  apprehensive 
that  this  would  interrupt  the  healing  of  the  wound  by 
the  first  intention  ; in  this,  however,  I was  agreeably 
disappointed ; the  healing  of  the  wound  progressed 
very  kindly,  although  there  was  a slight  purulent  dis- 
charge from  the  outer  part  of  the  wound,  and  a little 
tumefaction  and  tenderness.  No  interruption  farther 
took  place  ; tlie  tube  performed  its  office  well;  the  pa- 
tient took  one  dose  of  castor  oil  to  remove  a consti- 
pated state  of  the  bowels,  and  had  not  one  unplea- 
sant symptom.  Day  after  day  as  we  inquired  how  he 
was,  he  answered  that  he  was  “ better.” 

On  the  eighth  day  we  placed  our  little  patient  upon 
a chair;  on  the  ninth  we  found  him  in  full  dress  on  the 
jiavement,  at  play  in  the  street.  Indeed,  it  would  not 
have  been  essential  whether  we  had  seen  him  after  the 
operation,  as  there  w'as  no  occasion  for  attention  on 
our  part,  except  by  way  of  precaution. 

We  operated  u[»on  a very  respectable  member  of 
our  profession  from  thestate  of  Virginia,  in  1827.  We 
extracted  through  the  w'onnd  w'e  usually  make,  a stone 
about  the  size  of  a very  large  nipple  glass,  being  cir- 
cular, but  flat  shaped  ; a good  deal  like  the  nipple  glass, 
but  thicker.  A shape  so  unfavimrable  induced  us  at 
once  to  break  the  stone  ; this  done,  the  fragments 
were  removed  in  a few  minutes,  by  means  of  the  for- 
ceps, scoops,  and  the  syringe. 

A tube  was  introduced  and  left  in  the  bladder  as 
usual  after  our  operation  for  the  stone.  The  patient 
got  on  very  w'ell  till  the  fourth  or  fifth  day  ; we  be- 
lieved the  wound  to  be  pretty  well  healed,  being  free 
from  pain,  swelling,  or  inflamniaiion  ; nor  was  there 
any  uneasiness  or  leakage  wdiatever  through  the 
wound.  The  patient  was  an  invalid  from  disease  of 
the  spine,  and  could  not  lie  comfortably  on  his  side, 
which  is  essential,  that  the  outer  end  of  the  tube  may 
be  kept  lower  than  that  w’ithin  the  bladder,  so  that  the 
water  may  pass  off  guttatim. 

The  patient  became  impatient,  and  begged  for  per- 
mission to  lie  on  his  back ; this,  on  account  of  his 
not  being  able  to  lie  comfortably  on  his  side,  vvas 
granted  occasionally  through  the  day,  suffering  him  to 
turn  upon  his  back  for  half  an  hour,  and  sometimes 
perhaps  longer ; when  he  w.as  again  turned  on  his  side, 
and  the  water  .suffered  to  run  out  of  the  tube  before 
the  bladder  acted  to  expel  it. 

He  became  anxious  to  sleep  on  his  back,  and  assured 
me  his  sleep  was  habitually  so  imperfect,  and  his  kind 
relatives  who  were  with  him  were  so  vigilant,  that  he 
could  certairdy  torn  every  hour  ; under  such  circum- 
stances he  was  indulged.  It  turned  out  that  he  slept 
Bouttdly,  and  bii  friends,  who  for  many  long  montha 


LITHOTOMY. 


159 


had  never  left  him  an  hour  alone,  happened  to  fall 
asleep.  The  patient  slept  about  two  hours,  awoke 
with  a desire  to  pass  water,  the  bladder  conti  acted 
spasmodically,  and  the  tube  not  affording  sufficient 
outlet,  forced  the  water  through  the  wound. 

The  escape  of  water  in  this  way  was  no  doubt 
facilitated  by  the  languid  and  feeble  state  of  the  parts 
involved  in  the  wound.  Had  there  been  more  vigour 
of  constitution  and  of  the  parts  involved  in  the  para- 
lysis from  the  spinal  disease,  the  union  would  have 
been  too  firm  in  this  time  to  yield  to  the  force  of  the 
bladder  upon  the  urine.  The  water  under  more  fa- 
vourable circumstances  would  have  passed  along  the 
outside  of  the  tube  as  we  have  sometimes  seen,  after 
the  tube  was  worn  for  a considerable  time. 

The  parts  were  well  cleansed  from  the  urine,  and  the 
lips  of  the  wound,  which  did  not  now  exceed  three- 
fourths  of  an  inch  in  leti^th,  being  pressed  gently  to- 
gether with  the  thumb  ana  fore  finger,  a small  oblong 
concave  pad  was  put  on  and  bound  on  pretty  firmly, 
by  tapes  jire-ssing  up  before  and  behind,  to  be  fastened 
to  a bandage  around  the  body.  This  pad  had  the  effect 
of  holding  the  lips  of  the  wound  together,  and  thus 
facilitated  its  closure.  The  tube  being  replaced,  and 
kept  running,  the  wound  very  soon  healed  up  without 
the  employment  of  any  other  means  for  that  purpose, 
notwithstanding  there  was  a little  weeping  of  urine  at 
times,  attention  merely  being  paid  to  keeping  the  part 
perfectly  clean,  by  applying  occasionally  a compress 
of  dry  rag  under  the  pad. 

When  we  look  at  the  whole  aspect  of  this  case  vve 
must  see,  that  there  was  great  risk  of  fistula  in  perineo; 
but  this  unpleasant  occurrence  was  prevented  by  the 
simple  contrivance  we  have  mentioned,  aided  by  the 
precaution  of  not  letting  the  bladder  fill  with  water, 
but  by  means  of  the  tube  conveying  it  away  as  fast  as 
it  descended  into  the  bladder. 

We  shall  now  recapitulate  some  of  the  more  impor- 
tant points  connected  with  the  operation  of  litho- 
tomy. 

1.  Let  the  external  incision  be  of  moderate  extent, 
and  terminate  opposite  the  centre  of  the  anus. 

2.  Let  the  incision  in  the  adult  be  about  two  inches  ; 
never  exceeding  two  and  a half  in  length  ; its  course 
directly  parallel  with  the rapAe  of  the  perinaeum. 

3.  The  central  point  of  union  of  the  perineal  mus- 
cles being  divided,  when  aitached  to  the  ligamentous 
point  of  the  triangular  ligament,  will  aflhid  room 
enough  for  the  forceps. 

4.  If  the  patient  is  properly  secured,  and  the  knees 
kept  wide  apart,  the  incision  will  gape  open  and  the  staff 
will  be  quite  easily  distinguished  by  feeling  with  the 
left  fore-finger;  with  this  finger  on  the  instrument 
enter  the  point  of  a scalpel  into  the  groove ; then  keep- 
ing the  knife  steadily  in  the  groove,  take  hold  of  the 
handle  of  the  staff  with  the  left  hand,  then  pass  the 
knife  slowiy  and  steadily,  until  the  necessary  W'ound  is 
made  in  the  neck  of  the  bladder,  which,  as  nearly  as 
we  can  measure,  should  never  pass  bevond  the  base 
of  the  p ostate  gland. 

The  cutting  edge  of  the  scalpel  should  not  ex- 
ceed an  inch,  or  an  inch  and  a quarter;  this  will  pre- 
vent us  from  wounding  external  pans  while  we  are 
cutting  within,  and  thus  prevent  all  risk  of  wounding 
the  internal  pudic  artery.  The  most  favourable  divi- 
sion of  the  prostate,  and  other  parts,  will  be  made  by 
holdii.g  the  knife  laterally,  midway  between  the  hori- 
zontal and  perpendicular  lines,  which  may  be  ima- 
gined as  passing  through  the  middle  of  the  prostate 
gland. 

0.  In  introducing  the  tube  into  the  bladder,  let  the 
end  of  it  be  slipped  on  a finger  passed  into  the  wound, 
and  so  placed  at  the  neck  of  the  bladrler,  as  to  ascer- 
tain by  it  how  far  the  tube  passes  into  the  bladder; 
it  may,  however,  be  passed  on  gently  till  the  end  reaches 
the  fundus  of  the  bladder.  If  it  is  properly  placed,  and 
the  patient  put  upon  his  right  side,  the  urine  will  soon 
commence  dropping  from  the  tube ; this  assures  us  that 
all  is  right.- 

7.  If  the  wound  in  the  neck  of  the  bladder  is  large 
enough  to  admit  the  forceps  easily,  it  is  sufficiently 
stone  he  too  large  for  extraction,  it 
should  be  broken  ; for  which  purpose,  in  most  cases, 

may  use  common  strong  lithotomy  forceps.  When 
ttw  size  of  the  atone  is  enormous,  lite  forceps  which 
\ve  contrived  for  the  purpose  of  breaking  such  calculi, 
■hould  be  used.  By  introducing  the  bladea  of  these , 


separately,  we  can  easily  grasp  a stone  of  any  size 
tlirough  the  ordinary  wound,  and  drill  the  mass  to 
pieces. 

8.  In  the  selection  of  a tube,  we  should  choose  those 
that  are  most  flexible,  having  regard,  however,  to  their 
being  sufficiently  thick  in  their  structure,  so  as  not  to 
collapse.  The  eyes  should  be  large,  and  their  edges  as 
smooth  as  possible.  The  common  gum  elastic  catJielers 
of  the  shops,  when  of  good  quality,  answer  very  well. 
Never  pass  the  tube  into  the  bladder  without  having  a 
stylet  in  it,  and  it  will  be  best  to  have  it  fill  the  caliber 
of  the  tube. 

9.  We  have  always  found  a soft  string  tied  to  the 
outer  end  of  the  tube,  and  carried  back  and  tied  around 
the  root  of  the  penis,  to  answer  very  well  for  confin- 
ing the  tube  in  its  place.  The  penis  will  generally  be- 
come somewhat  swelled  in  a few  hours,  and  the  string, 
must  be  loosened  should  it  become  too  tight. 

10.  Should  it  happen  that  the  water  does  not  drop 
well  from  the  tube,  some  warm  water  may  be  very 
gently  passed  into  the  bladder  through  the  tube,  and 
drawn  out  again  by  means  of  a penis  syringe.  Or,, 
sometimes  passing  in  a very  limber  wire  to  the  eyes  of 
the  tube,  and  thereby  removing  some  clot  of  blood,  or 
mucus,  will  answer.  Should  all  this  fail,  withdraw 
the  tube,  and  introduce  another. 

11  It  will  sometimes  happen,  that  owing  to  careless- 
ness of  nurses,  or  inattention  of  patients,  the  precau- 
tion of  lying  on  the  side  is  neglected  ; the  water  accu- 
mulates in  tiie  bladder;  and  wlieii  the  bladder  is  stimu- 
lated into  action,  the  woitnd  is  toreed  open  by  the 
urine.  We  liave  seen,  by  the  facts  already  stated^ 
that  if  this  does  not  advance  too  far  before  we  are 
aware  of  the  occurrence,  we  may  so  manage  the 
affair  as  to  lieal  up  the  wound  sooner  than  by  the  or- 
dinary method. 

12.  It  has  happened  once,  that  a tube  which  we 
passed  became  kinked,  as  the  mechanics  call  it, 
which  is  a breaking  in  of  one  side  so  as  to  close  the 
caliber  of  the  tube.  In  this  case  we  were  foiled  in 
our  attempt  to  heal  ihe  wound  by  the  first  intention; 
but  no  evil  arose  from  the  accident.  It  has  also  hap- 
pened, perhaps  twice,  that  the  tube  became  clogged  at 
the  e7jes,  and  would  not  convey  off  the  urine.  With 
boys  it  will  be  almost  impossible  to  renew  the  tube. 
Should  we  be  disappointed,  which  will  seldom  happen 
if  we  conduct  the  operation  well,  we  should  withdraw 
the  tube : in  the  adult  we  should  insist  on  its  removal. 
The  operation  of  replacing  the  tube  is  more  frightful 
than  painful ; it  cannot  therefore  be  so  well  performed 
upon  small  boys. 

13.  The  tube  should  not  be  left  in  more  than  a week 
without  examination  : in  some  cases  a calcareous  crust 
will  form  in  a few  days;  and  if  there  be  such  a pre- 
dis(iosition,  there  might  be  some  risk  of  forming  a 
nucleus.  In  most  instances,  however,  the  tube  might 
he  worn  a long  time  without  the  formation  of  any  such 
concrete. 

Lastly,  to  obtain  the  advantages  of  this  operation  it 
must  he  correctly  understood : where  it  is  conducted  in  a 
careless  manner,  without  due  attention  to  the  several 
points  which  we  have  suggested,  success  cannot  be  ex- 
pected.” 

By  the  note  I have  appended  to  the  article  of  Li- 
thotomy on  the  Female,  p.  156,  it  will  be  found  that  Dr. 
J.’.s  operation  is  the  same  as  that  practised  by  M.  Du- 
bois. fi’lie  question  of  originality  I cannot  decide,  not 
being  in  possession  of  tlie  dates  in  which  it  was  per- 
formed by  the  two  surgeons. 

OPERATION  OF  LITHOTOMY  ON  THE  FEMALE. 

“ It  is  well  known  that  considerable  difficulties  have 
attended  this  operation  on  tlie  female,  arising  princi- 
pally from  the  circumstance  of  incontinence  almost  ne- 
cessarily succeeding  every  method  of  operation  which 
has  been  practised,  wbetlier  by  passing  a gorget  di- 
rectly along  the  urethra  and  cutting  the  membranous 
siructiire,  oil  the  upper  side  of  the  vagina ; by  direct  or 
immediate  dila*aiion  by  means  of  instruments;  or  dila- 
tation by  means  of  Ihe  sponge  tent. 

M.  Lisfrauc,  it  will  be  recollected,  has  proposed  and 
practised  a new  method  within  the  last  few  years,  con- 
trived with  the  view  of  obviating  this  truly  lament- 
able misfortune  to  the  female;  we  mean  incontinence. 
We  liavecarefully  examined  the  operation  as  described 
by  that  author.  We  think  it  much  superior  to  any  of 
the  methods  formerly  practised,  but  we  nevertheless 


160 


LITHOTOMY, 


think  ft  13  unnecessarily  severe  and  complex;  and  al- 
Itiough  ingeniously  contrived,  it  is  inleiior  to  a method 
which  w e liave  employed  tw  ice,  much  to  our  salislac 
lion.  This  operation  was  announced  in  the  laie  Me- 
dical Recorder;  and  wlieii  last  in  Philadelphia,  a 
very  respectable  member  of  the  profession  informed 
us,  that  our  friend  Doctor  Physick  had  once  performed 
it  to  his  entire  satisfaction. 

Every  man  acquainted  with  disease  of  the  bladder 
in  the  female  must  be  aware,  that  they  are  disposed, 
in  most  instances,  to  conceal  such  disease,  till  they  ex- 
perience very  great  sutlerings.  In  this  way,  the  blad- 
der and  urethra  are  rendert'd  so  exquisitely  sensible  to 
the  touch,  that  the  use  of  the  sound,  sponge  tent,  &c. 
is  attended  with  severe  pain. 

At  first  sight  it  might  be  supposed  that  the  operation 
of  Civial6  woidd  succeed  well  in  tlie  female  ; and  pro- 
bably in  some  cases  it  may  succeed  very  well : it  will 
not  always, as  we  know,  in  a case  of  encysted  stone; 
and  I am  inclined  to  believe  that,  in  most  cases,  we 
shall  be  enabled  more  easily  lo  relieve  females  by  the 
operation  we  are  about  to  describe,  than  by  lithontrity. 
VVe  believe  that  any  advantage  which  may  grow  out 
of  the  straightness,  shortness,  &c.  of  the  female  ure 
thra,  is  counterbalanced  by  the  extreme  sensibility  ge- 
nerally attendant  on  cases  of  calculus. 

We  perforin  the  operation  in  the  following  man- 
ner:— Introduce  a common  director  into  the  tirethra ; 
set  a small  scalpel  into  its  groove,  w ith  the  edge  turned 
upwards;  make  a wound  about  three  fourths  of  an 
inch  directly  towards  the  clitoris;  then  turn  the  groove 
of  the  director  and  the  cutting  edge  of  the  scalpel  lo 
the  left  lateral  aspect;  press  the  knife  into  the  bladder, 
taking  cate  to  keep  the  edge  a little  downwards;  and 
to  start  the  transverse  incision  at  the  upper  angle  of 
the  first  or  vertical  incision ; and,  also,  that  the  cutting 
edge  of  your  knife  do  not  exceed  an  inch.  VVe  will 
thus  avoid  all  risk  of  wounding  the  internal  pudic  ar- 
tery, and  obtain  an  opening  amply  sufficient  for  the 
forceps,  &c.  without  in  any  degree  injuring  the  vagina. 
Having  p.assed  the  knife  into  the  bladder,  we  may 
now  enlarge  the  wound  a little  at  the  neck  of  the 
bladder,  as  we  withdraw  the  instrumen'.  We  shall 
thus  obtain  quite  a sufficient  opening,  since  the  outer 
parts  will  be  found  to  dilate  with  the  readiest  facility. 

Having  made  the  incision,  we  extract  the  stone 
agreeably  to  the  rules  laid  down  for  the  male  subject. 
VVe  may  either  introduce  the  tube,  as  in  the  male,  or 
ass  a pretty  deep  suture  or  two  to  close  the  wound. 
Ve  have  practised  both  methods,  and  found  them  to 
succeed  alike.  There  is,  however,  considerable  diffi 
culty  in  keeping  a tube  well  fastened,  and  we  think, 
upon  the  whole,  that  the  suture,  without  the  tube,  will 
be  found  to  be  the  better  method. 

We  have  been  led  to  conclude,  that  by  this  method 
of  procedure  we  shall  succeed  most  readily  in  obtaining 
a restoration  of  parts  by  the  first  intention;  by  this 
more  than  half  the  usual  sulferings  will  be  avoided; 
and,  therefore,  all  things  considered,  the  method  by 
incision  being  easy,  expeditious,  safe,  and  suited  to 
every  circumstance  of  such  cases  admitting  of  relief, 
is  preferable  to  lithontrity. 

It  would  be  superfluous  to  enter  into  any  particular 
anatomical  desciiption  in  relation  to  an  operation  so 
simple,  and  where  the  necessary  anaiomy  must  be 
perffictly  familiar  to  every  man  qualified  to  operate. 
It  may  not  be  amiss,  however,  to  state,  that  we  need 
not  injure  the  clitoris,  there  being  a sufficient  spare 
between  the  urethra  and  that  body  to  admit  of  the 
necessary  incision  upwards;  and,  indeed,  little  more 
is  really  necessary  in  this  direction  than  dividing  the 
urethral  tube  Iti  cutting  across,  we  will,  in  a slight 
degree,  cut  into  the  crus  clitoris,  on  the  left  side.  But 
the  integumetits  and  cellular  sti  uctures  are  so  dilatable 
in  the  {larts  under  consideration,  that  small  incisions 
answer,  and  yet  the  parts  have  sufficient  body  and 
firtnness,  especially  when  they  becotne  tutnid,  to  statiil 
up  firmly  ; and  are  easily  kept  in  contact  when  divided. 
The  incision  being  on  the  upper  side  of  the  urethra, 
there  is  little  risk  of  the  uritie  lodging  in  the  wound. 
And  as  any  risk  which  may  arise  of  iticontinetice  frotn 
cutting  the  urethra,  must  be  ow’ing  to  splitting  the 
urethra  on  the  lower  side,  and  also  the  vagina,  every 
thing  will  be  obtained  that  is  to  be  expected  from  the 
operation  of  M.  Lisfranc,  and  our  o[ieralion  is  much 
more  simple  than  his,  and  will  more  readily  admit  of 
healing  by  the  first  intention. 


We  would  not,  under  any  circumstances,  make  a 
large  tvound ; if  the  stone  he  large  it  niay  be  easily 
and  safely  broken.  I use  quite  small  scalpels  in  my 
operations,  and  would  prefer  passing  in  the  left  fore- 
finger to  direct  the  knife  in  enlarging  the  wound,  lather 
than  run  the  risk  of  making  a wound  too  large  at  first. 
It  is  only  wounds  of  reasonable  extent  in  lithotomy 
that  we  can  heal  by  the  first  intention,  and  siicn 
wounds  will  always  answer  our  purposes  best;  and  the 
advantages  of  securing  such  a healing  of  the  wound 
are  incalculable.” — ReeseJ] 

Whoever  wishes  to  acquire  a perfect  knowledge  of 
the  history  of  lithotomy,  should  consult  the  following 
works : Celsus  de  Re  Jllcdicd,  lib.  7,  cap.  26.  Re 
marques  sur  la  Ckiriirgie  de  Chauliac,  par  Jl.  Simon  de 
Mingelouzeaux,tom.2  ; Bourdeaiix,lQ&^.  J.a  Legende 
da  Gascon,  par  Drelincourt ; Paris,  1665.  Van 
Horne's  Opuscula.  Jilarianus  de  Rapide  VesiccB  par 
Incisionem  extrahendo,  1552.  G.  Fabr.  Hildavus,Li- 
Ihotomia  Veaic(B,8oo.  Land.  1640.  J\I.  S.  Barolttauus, 
De  Lapide  Renitni : Ejusdein  de  Lapide  V csicee  per  In^ 
cisionem  extrahendo,  4tt;.  Paris,  1540.  , Re  Drun,  Pa 
rallile  des  Differentes  Maniires  de  tirer  la  Piirre  hors 
de  la  Vessie,  2 vols-  8vo.  1730.  Sharp's  Operations. 
Sharp's  Critical  Inquiry.  Re  Dran's  Operatioas, 
ed.  5,  Rondun,  1781.  Franco's  Traite  des  Htrnies, 
1561.  Rusetus  de  Partu  Ccesario.  Traite  de  la  Ritho- 
lomie,par  F.  Tulet ; Paris,  bieme  ed.  1708  Heister's 
Surgery, part2.  Rilhotomia  Douglassiana,  1123.  J. 
Douglas,  History  of  the  J.aterul  Operation,  4to. 
Rond.  1726.  Fr.  M.  Colot,  Ti  aite  de  V Operation  de 
la  Taille,  <S-c.  12//(o.  Paris,  1727.  Maraud,  Traite  de 
la  Taille,  an  haul  Jippareil,  12/no.  Paris,  1728.  J. 
Meiy,  Observations  sur  la  Maine  re  de  Tailler,  <S-c. 
pratiquee  par  Frire  .Jacques,  12//to.  Paris,  1700 
Cours  d'  Operations  de  Chirurgie  par  Dionis.  Traiti 
des  Operations  par  Garengeot,  t.  2.  Morund,  Opus- 
cules de  Chirurgie.  Bertrandi,  Traite  des  Operations. 
J.  G.  Ilsemann,  De  Rilhotamice  Cdsiana;,  Pnestantia  ; 
Helmst.  1745.  Re  Cat,  Recueil  de  Piices  sur  V Opera- 
tion de  la  Taille,  part  1,  Rouen,  1749.  Cosine,  Re- 
cueil de  Pieces  Jinotomiques  importantes  sur  I' Opera- 
tion de  la  Taille  i Paris,  1751 — 1753.  ./.  Douglas, 

Postscript  to  Hist,  of  the  Ro.teral  Operation,  1726.  J 
Douglas,  .Appendix  to  Hist,  of  the  Raterul  Operation, 
1731.  Ji  Short  Historical  Account  of  Cutting  for  the 
Stone,  by  fV.  Cheselden,  in  his  own  last  edition  of  his 
Anatomy.  Falconet,  in  Thi.s.  Chirurg.  Halltri,  thes 
103,  t.  4,  p.  196.  Traiti  Historiqiie  et  Dogmatique  dt 
I'  Opirution  de  la  Taille,  par  ,J.  F R.  Deschavips, 
tom.  4, 8vo.  Paris,  1796.  This  last  work  is  a very  com 
plete  and  full  account  of  the  subject,  up  to  the  time  of 
its  publication,  and  well  merits  careful  perusal. 
Richerand's  jVosogr.  Chir.  i.  2,p.  538,  4-c.  ed.  4.  John 
Bell's  Principles  of  Surgery,  vol  2,  part  1.  A.  Burns, 
in  Kdm.  Med.  and  Surg.  Journal,  Januaiy,  1808.  C. 
Bell's  Operative  Surgery,  vol.  1,  1807.  Sabatier  de  la 
Medecine  Operatoire,  tom.  3,  ed.  2,  1810.  Dr.  John 
Thomson's  Observations  on  Rithotomy,  Fain.  1808. 
Also  an  Appendix  lo  a Proposal  for  a J^Tew  Manner 
of  Cutting  for  the  Stone,  8uo.  Edin.  1810.  Allan's 
T realise  on  Rithotomy,  Edin.  1808.  Earle's  Practical 
Observations  on  Operations  for  the  Stone,  2d  ed.  with 
an  Appendix  containing  a description  of  an  ivstru^ 
ment  calculated  to  improve  that  operation,  8oo.  Rond, 
1803.  Wm.  Dease,  Obs.  on  the  Different  Methods  for 
the  Radical  Cure  of  the  Hydrocele,  S,-c.  To  which  is 
added  a comparative  View  of  the  diff'erent  Methods 
of  Cutting  for  the  Stone,  &-c.  8co.  J^ond.  1798.  (Euvres 
C/iir.  de  Desault, par  Bichat,t. 2.  Wm.  Simmons, Cases 
and  Ob.s.  on  Rithotomy,  8vo.  Manchester,  1808.  C.  B. 
Trye,  Essay  on  some  of  the  Stages  of  the  Operation 
of  Cutting  for  the  Stone,  8vo.  Rond.  1811.  RouXf 
Voyage  fait  d /..ondres  en  1814,  on  Parullele  de  la 
Chirurgie  Angloise  aue.c  la  Chirurgie  Fruvcoisc,  p 
315, .S-c  Prtris,l8l8.  Schreger,  Chirurgische  Ver.^uche, 
b.  2,  von  Stein.schnitten  an  Weibern,  p.  135,  6,-c.  8do. 
FTiirnberg^  1818.  C.  .7.  M.  Rangenbcck,  uber  eine 
einf  jche  and  sirhere  Methode  des  Strinschnittes,  Ato 
Wurzburg,  1802.  This  work  contains  an  excellmi 
anatomical  engraving  of  the  parts  in  the  perniwum. 
F.  X.  Rudtorffer,  Abhandlung  Uber  die  Operation  des 
Blasenstcines  nach  Pajola's  Methude,  ito.  Reipz.  1608 
A.  Scarpa,  A Memoir  on  the  Cutting  (rorget  of  Haw- 
kins, S,-c.  translated  by  J.  H.  Wishart,  8vo.  Edin.  I81fl 
H.  Mayo,  W.  Dickenson,  H.  Earle,  and  P.  M.  Martis 
neau,  in  Med.  Chir.  Trans,  vol.  11.  Klein,  PracUAnr 


LOT 


skhtenbedeutendsten  Operatiunen,  ito.  Sluigart,  1816. 
J.  S.  Carpue,  Uist.  of  the  High  Operation,  and  An  Ac- 
countof  the  Various  Methods  of  Lithotomy, 8vo.  Land. 
1819.  Sir  E.  Horne  on  Strictures,  i^c.  vol.  3, 800.  Lond. 
1821.  A.  Scarpa,  Mern.  sul  Taglio  Jpogastrico,  in  Imp. 
R.  Instituto  di  Scienzeed  Arti  di  Milano,  vol.  1.  Also, 
Observ.sul  Taglio- Retto  Vesicale,  Ato.  Pavia,  1823; 
and  Opuscoli  di  Chirurgia,  vol.  I,  Pavia,  1825, 4to.  W. 
W.  Sleigh,  Essay  on  an  Improved  Method  of  Cutting  for 
Urinary  Calculi ; or  the  Posterior  Operation  of  Lithoto- 
my ; 800.  Lond.  1824.  C.  A.  Key,  A Short  Treatise  on 
the  Section  of  the  Prostate  Gland  in  Lithotomy,  4to. 
Lond.  1824.  For  a minute  description  and  delineations 
of  the  parts  concerned  in  the  operation,  see  Camper's  De- 
monstrationes  A/iatomico-pathologicce,  lib.  2.  Also,  L. 
F.  Von  Froriep  iiberdie  Lage  der  Eingeweide  an  Becken 
nebst  einer  Darstclluvg  derselben,  4to.  fVeimar,  1815. 

LOriO  ALUMINIS. — Aluminis  purif.  ^ss. 
Aqua-  distillatte  Ibj.  Misce. — Sometimes  used  as  an  as- 
tringent injection ; sometimes  as  an  application  to  in- 
damed  parts. 

LOTIO  AMMONITE  ACETATE.— Jl.  Liq.  am- 
nion. acetaiae;  Spirit,  vin.  rectif. ; Aquai  distillatte  ; 
sing.  3 iv.  Misce. — Properties  discutient. 

LOTIO  AMMONIA  MURIATE.— R.  Ammon, 
murialaj  3j.  Spirit  rosmarini  Ibj.— Has  the  same  vir- 
tues as  the  preceding.  Justamond  recommended  it  in 
the  early  stage  of  the  milk-breast. 

LOTIO  AMMO^IyE  MURIATE  CUM  ACE- 
TO.— R.  Ammon,  mur.  5ss.  Aceti,  Spirit,  vinos, 
rectif.  sing.  ibj.  Misce. — This  is  one  of  the  most  effica- 
cious discutient  lotions.  It  is,  perhaps,  the  best  appli- 
cation for  promoting  the  absorption  of  extravasated 
blood,  in  cases  of  ecchymosis,  contusions,  sprains,  &c. 

LOTIO  AM  MON  LE  OPIATA.— R.  Spiritus,  am- 
mon.  comp.  3 iiiss.  Aqua;  distillatae  3 iv.  Tinct.  opii 
5ss.  Misce. — Applied  by  Kirkland  to  some  suspicious 
swellings  in  the  breast,  soda  and  bark  being  also  given 
internally. 

LOTIO  BORACIS.— R.  Boracis  3j.  Aq.  simplicis 
I iiis.  Spir.  vinos.  5ss.  Misce. — This  lotion  is  recom- 
mended by  Sir  Astley  Cooper  as  one  of  the  best  appli 
cations  to  sore  nipples. 

LOTIO  ACIUI  PYROLTGNEI.-R.  Acid,  pyrolign. 
3 ij.  Aq.  disiillat.  5 vj.  Misce. — This  is  injected  into 
the  meatus  auditorius  by  Mr.  Buchanan,  for  tlie  pur- 
pose of  improving  the  secretion  within  the  passage, 
and  stopping  morbid  discharge  from  it. — (.See  his  Illus- 
trations of  Acoustic  Surgery,  8vo.  Lond.  1825.)  In 
particular  cases,  attended  with  muclj  irritability,  he 
uses  the  following  formula; — R.  Plumbi  acet.  gr.  x. 
Acid,  pyrolign.  gutt.  xx.  Aq.  distillat.  ^vj.  Misce. 

LOTIO  CALCIS  COMPOSITA.— R.  Liq.  calcis 
Ibj.  Hydrargyri  submuriatis  3 j.  Misce. — Ring-worms, 
tetters,  and  some  other  cutaneous  affections,  are  bene- 
fitled  by  this  application. 

LOTIO  GALL^.— R.  Gallarum  contusarum  3 ij. 
Aquae  ferventis  Ibj.  To  be  macerated  one  hour,  and 
strained  —This  astringent  lotion  is  sometimes  used 
with  the  view  of  removing  the  relaxed  state  of  the 
parts,  in  cases  of  prolapsus  ani,  prolapsus  uteri,  &c. 

LOTIO  HYDRARGYRI  AMYGDALINA.— R. 
Amygdalarumaniararum  5 ij-  Aquae  distill.  Ibij.  Hy- 
drarg.  oxyniiiriatis  3j.  Rub  down  the  almonds  with 
tlie  water,  which  is  to  be  gradually  poured  on  them  ; 
strain  the  liquor,  and  then  add  the  oxymuriate  of  mer- 
cury.—This  will  cure  several  cutaneous  affections. 

LOTIO  HYDRARGYRI  OXYMURTATIS.-R. 
Hydrargyri  oxymuriatis  gr.  ijss.  Arabic!  gummi  ^ss. 
Aquae  distillatae  Ibj.  Misce. 

LOTIO  HYDRARGYRI  OXYMURIATIS  COM- 
POSITA.—R.  Hydrarg.  oxymur.  gr.  X.  Aq.  distillat. 
bullientis  588-  Tinct.  canthar.  3 ss  Misce.— Ajiplied  by 
Dr.  H.  Smith  to  scrofulous  swellings. 

LOTIO  HELLEBORI  ALBI. — R.  Decocti  hel/ebori 
albi  Ibj.  Potassae  sulphureti  5 ss.  Ol.  Lavend.  guit.  iv. 
Miste.— Occasionally  applied  to  tinea  capitis,  and  some 
other  cutaneous  diseases. 

LOTIO  PLUMBI  ACETATIS.— R.  Liq.  plumbi 
acet.  3 ij.  Aq.  distill.  Ibij.  Spirit,  vinos,  tenuioris  3 ij. 
<rhe  first  and  last  ingredients  are  to  be  mixed  before  the 
water  is  added.— The  common  white  wash;  an  appli- 
cation universally  known. 

LOTIO  POTASSiE  SULPHURETI.— R.  Potassse 
sulph.  3 ij.  Aquse.  distill.  Ibj.  Ol.  Lavend.  gutt.  iv. 

— Used  in  cases  of  porrigo,  psoriasis,  lepra,  &c. 

LOTKy  OPII.— R.  Opii  purif  3 jss.  Aquae  distillatte 


LUM  161 

Ibj.  Misce.— A good  application  to  irritable  painful  ul- 
cers. It  is  best  to  dilute  it,  esf>ecially  at  first. 

liOTIO  PICIS. — R.  Picis  liquidae  | iv.  Calcis  5 vj. 
Aque  ferventis  Ibiij.  To  be  boiled  till  half  the  water 
is  evaporated.  The  rest  is  then  to  be  poured  ofi’  for 
use. — This  application  is  sometimes  employed  in  tinea 
capitis;  and  for  the  removal  of  an  extensive  redness 
frequently  surrounding  old  ulcers  of  the  legs,  in  persons 
whose  constitutions  are  impaired  by  copious  porter 
drinking,  gluttony,  and  other  forms  of  intemperance. 

LOTIO  ZINCI  SULPHATIS.— R.  Zinci  sulphatis 
3ij.  Aq.  ferventis  Ibj.  Misce.— Sometimes  used  in 
lieu  of  the  lotio  plumbi  acet.  It  forms  a good  astrin- 
gent application  for  a variety  of  cases.  When  diluted 
with  one  additional  pint  of  water,  it  is  the  common 
injection  for  gonorrhoea. 

LUES  VENEREA. — (See  Venereal  Disease.) 

LUMBAR  ABSCESS.— Psoas  Abscess.— these 
terms  are  understood  chronic  collections  of  matter, 
which  form  in  the  cellular  substance  of  the  loins,  be- 
hind the  peritoneum,  and  descend  in  the  course  of  the 
psoas  muscle.  According  to  professor  Gibson,  this 
disease,  which  is  remarkably  common  in  Europe,  is 
rarely  met  with  in  the  United  States.  In  the  course  of 
thirteen  years,  during  which  he  has  been  connected 
with  extensive  hospitals,  he  has  seen  only  four  cases  ; 
and  Dr.Physick  had  never  attended  an  instance  of  psoas 
abscess  in  America,  unconnected  with  disease  of  the 
spine< — (See  Gibson's  Institutes,  ^c.  of  Surgery,  vol.  I, 
p.  214,  8«o.  Philadelphia,  1824.)  Patients  in  the  incipi- 
ent stage  of  the  disease,  cannot  walk  so  well  as  usual : 
they  feel  a degree  of  uneasiness  about  the  lumbar  re- 
gion ; but  in  general  there  is  no  acute  pain,  even  though 
the  abscess  may  have  acquired  such  a size  as  to  fortn 
a large  tumour,  protruding  externally.  In  short,  the 
psoas  abscess  is  the  best  instance  which  can  possibly 
be  adduced,  in  order  to  illustrate  the  nature  of  those 
collections  of  matter,  which  are  called  chronic,  and 
which  form  in  an  insidious  manner,  without  serious 
pain  or  any  other  attendant  of  acute  inflammation. 

The  abscess  sometimes  forms  a swelling  above  Pou- 
part’s  ligament ; sometimes  below  it ; and  frequently 
the  matter  glides  under  the  fascia  of  the  thigh.  Occa- 
sionally it  makes  its  way  through  the  sacro-ischiatic 
foramen,  and  assumes  rather  the  appearance  of  a fis- 
tula in  ano.  When  the  matter  gravitates  into  the 
thigh,  beneath  the  fascia,  Mr.  Hunter  would  have 
termed  it  a disease  in,  not  of,  the  part.  The  uneasiness 
in  the  loins,  and  the  impulse  communicated  to  the  tu- 
mour by  coughing,  evince  that  the  disease  arises  in  the 
lumbar  region  ; but  it  must  be  confessed,  that  we  can 
hardly  ever  be  sure  of  the  existence  of  the  disorder, 
until  the  tumour,  by  presenting  itself  externally,  leads 
us  to  such  information.  The  lumbar  abscess  is  some- 
times connected  with  diseased  vertebrae,  which  may 
either  be  a cause,  or  an  effect,  of  the  collection  of  mat- 
ter. The  disease,  however,  is  frequently  unattended 
with  this  complication. 

The  disease  of  the  spine,  we  may  infer,  is  not  of  the 
same  nature  as  that  treated  of  by  Pott,  as  there  is  usually 
no  paralysis.  When  the  bodies  of  patients  with 
lumbar  abscesses  are  opened,  it  is  found,  that  the  matter 
is  completely  enclosed  in  a cyst,  which,  in  many  cases, 
is  of  course  very  extensive-  If  the  contents  of  such 
abscesses  were  not  circumscribed  by  a membranous 
boundary  in  this  manner,  we  should  find  that  they 
would  spread  among  the  cells  of  the  cellular  substance 
just  like  the  water  in  anasarca.  The  cysts  are  both 
secreting  and  absorbing  surfaces,  as  is  proved  by  the 
great  quantity  of  matter  which  soon  collects  again 
after  the  abscess  has  been  emptied,  and  by  the  occa- 
sional disappearance  of  large  palnable  collections  of 
matter  of  this  kind,  either  spontaueou.sly,  or  in  conse- 
quence of  means  which  are  known  to  operate  by  ex- 
citing the  action  of  the  absorbents.  In  short,  the  cyst 
becomes  the  suppurating  surface,  and  suppuration  is 
now  well  ascertained  to  be  a process  similar  to  glandular 
secretion.  While  the  abscess  remains  unopened,  its 
contents  are  always  undergoing  a change;  fresh  mat- 
ter is  continually  forming,  and  a portion  of  what  was 
previously  in  the  cyst  is  undergoing  the  nece.ssary  re- 
moval by  the  absorbents.  This  is  not  peculiar  to  lum- 
bar abscesses ; it  is  common  to  all,  both  chronic  and 
qcute,  buboes  and  suppurations  in  general.  It  is  true, 
that  in  acute  abscesses,  there  often  has  not  been  time 
for  the  formation  of  so  distinct  a membrane  as  the  cyst 
of  a large  chronic  abscess;  but  their  matter  is  equally 


162 


LUMBAR  ABSCESS, 


circumscribed  by  the  cavities  of  the  cellular  substance 
being  filled  with  a dense  coagulating  lymph ; and 
though  it  generally  soon  makes  its  way  to  the  surface, 
it  also  is  sometimes  absorbed. 

The  best  modern  surgeons  make  it  a common  maxim 
to  open  few  acute  abscesses;  for  the  matter  naturally 
tends  with  great  celerity  to  the  surface  of  the  body, 
where  ulceration  allows  it  to  escape  spontaneously; 
after  which,  the  case  generally  goes  on  better  than  if  it 
had  been  opened  by  art.  But  in  chronic  abscesses,  the 
matter  has  not  that  strong  tendency  to  make  its  way 
outward;  its  quantity  is  continually  increasing;  the 
cyst  is,  of  course,  incessantly  growing  larger  and  larger ; 
in  short,  the  matter,  from  one  ounce,  often  gradually  in- 
creases to  the  quantity  of  a gallon.  When  the  disease 
is  at  length  opened,  or  bursts  by  ulceration,  the  surface 
of  the  cyst  inflames ; and  its  great  extent  in  this  cir- 
cumstance, is  enough  to  account  for  the  terrible  consti- 
tutional disorder,  and  fatal  consequences,  which  too 
frequently  soon  follow  the  evacuation  of  the  contents 
of  such  an  abscess.  Hence,  in  cases  of  chronic  suppu- 
rations of  every  kind,  and  not  merely  in  lumbar  ab- 
scesses, it  is  the  surgeon’s  duty  to  observe  the  opposite 
rule  to  that  applicable  to  acute  cases  ; and  he  is  called 
upon  to  open  the  collection  of  matter,  as  soon  as  he  is 
aware  of  its  existence,  and  its  situation  will  allow  it  to 
be  done. 

This  view  of  the  principle  on  which  the  treatment 
of*a  lumbar  abscess  should  be  conducted,  is  not,  how- 
ever, adopted  by  all  surgeons.  Kirkland  believed,  that 
the  patient  had  the  best  chance  of  recovery,  when  the 
abscess  was  allowed  to  burst  spontaneously,  and  tlie 
matter  to  be  gradually  discharged  through  a small 
opening  {Kirkland's  Medical  Surgery^  vol.  2,  p.  199)  ; 
and  Mr.  Pearson,  in  comparing  tire  results  of  his  own 
experience,  declares  them  to  be  in  favour  of  the  same 
piactice.  The  generality  of  modern  surgeons  in  this 
country,  differ  on  this  point  from  Kirkland  and  Pear-, 
son  ; yet,  while  they  advocate  the  utility  of  an  early 
puncture,  they  admit  the  danger  of  suddenly  dis- 
charging the  contents  of  the  abscess  through  a large 
one,  which  is  afterward  left  unclosed. 

Certainly,  it  would  be  highly  advantageous  to  have 
some  means  of  ascertaining  whether  the  vertebrae  are 
diseased  ; for,  as  in  this  instance  the  morbid  bones 
would  keep  up  suppuration  until  their  affection  had 
ceased,  and  there  would  be  no  reasonable  hope  of 
curing  the  abscess  sooner,  it  might  be  better  to  avoid 
puncturing  it  under  such  circumstances.  The  pro- 
priety of  this  conduct  seems  the  more  obvious,  as  is- 
sues, which  are  the  means  most  likely  to  stop  and  re- 
move the  disease  of  the  spine,  are  also  such  as  afford 
the  best  chance  of  bringing  about  the  absorption  of  the 
abscess  itself.  However,  if  the  collection  cannot  be 
prevented  from  discharging  itself,  and  ulceration  is  at 
hand,  it  is  best  to  meet  the  daijger,  make  an  opening 
with  the  lancet  in  a place  at  some  distance  from  where 
the  pointing  threatens,  and  afterward  heal  it  in  the 
way  which  will  be  presently  detailed. 

Though  we  have  praised  the  prudence  of  opening 
all  chronic  abscesses  while  small,  the  deep  situation  of 
the  lumbar  one,  and  the  degree  of  doubt  always  in- 
volving its  early  state,  unfortunately  prevent  us  from 
taking  this  beneficial  step  in  the  present  case.  But  still 
the  principle  is  equally  praiseworthy,  and  should  urge 
us  to  open  the  tumour  as  soon  as  the  fluctuation  of  the 
matter  is  distinct,  and  the  nature  of  the  case  is  evident. 
For  this  purpose  Mr.  Abernethy  employs  an  abscess 
lancet,  which  will  make  an  opening  large  enough  for 
the  discharge  of  those  flaky  substances  so  frequetiily 
found  blended  with  the  matter  of  lumbar  abscesses, 
and  by  some  conceived  to  be  an  emblem  of  the  disease 
being  scrofulous.  Such  flakes  seem  to  consist  of  a part 
of  the  coagulating  matter  of  the  blood,  and  are  very 
commonly  secreted  by  the  peculiar  cysts  of  scrofulous 
abscesses.  The  puncture  must  also  be  of  a certain 
size,  in  order  to  allow  the  clots  of  blood,  occasionally 
mixed  with  the  matter,  to  escape.  Mr.  Abernethy 
considers  the  opening  of  a lumbar  abscess  a very  deli- 
cate oj)eration.  Former  surgeons  used  to  make  large 
openings  in  these  cases,  let  out  the  contents,  and  leave 
the  wound  open ; the  usual  consequences  of  which 
w'ere,  great  irritation  and  inflammation  of  the  cyst, 
immense  disturbance  of  the  constitution,  putrefaction 
of  the  efficients  of  tiie  abscess  in  consciiuence  of  the 
ttf;rei4'3  air  into  ts  cavity-  and,  too  often,  death. 
^ a.  * practice  t/evailed,  very  few  afflicted  with 


lumbar  abscesses  were  fortunate  etiougb  to  eseape. 
The  same  alarming  effects  resulted  from  alloWiirg  the 
abscess  to  attain  its  utmost  magnitude,  and  then  burst 
by  ulceration.  If  then  a more  happy  train  of  events 
depend  upon  the  manner  in  which  lumbar  abscesses 
are  punctured,  the  operation  is  certainly  a matter  of 
great  delicacy. 

Until  the  collection  is  opened,  or  bursts,  the  patient’s 
health  is  usually  little  or  not  at  all  impaired;  indeed, 
we  see  in  the  faces  of  many  persons  with  such  ab- 
scesses what  is  usually  understood  by  the  picture  of 
health.  Hence,  how  likely  our  professional  conduct  is 
to  be  arraigned,  when  great  changes  for  the  worse,  and 
even  death,  occur  very  soon  after  we  have  let  out  the 
matter,  seemingly,  and  truly,  in  consequence  of  the 
operation.  Every  plan,  therefore,  which  is  most  likely 
to  prevent  these  alarming  effects,  is  entitled  to  infinite 
praise;  and  such,  I conceive,  is  the  practice  leconv- 
mended  by  Mr.  Abernethy. 

This  gentleman’s  method  is  to  let  out  the  matter,  and 
heal  the  wound  immediately  afterw^ard  by  the  first 
intention.  He  justly  condemns  all  introductions  of 
probes,  and  other  instruments,  which  only  irritate  the 
edges  of  the  puncture,  and  render  them  unlikely  to  grow 
together  again.  The  wound  is  to  be  carefully  closed 
with  sticking  plaster,  and  it  will  almost  always  heal. 

These  proceedings  do  not  put  a stop  to  the  secretion 
of  matter  within  the  cavity  of  the  abscess.  Of  course 
a fresh  accumulation  takes  place;  but  it  is  obvious, 
that  the  matter,  as  fast  as  it  is  produced,  will  gravitate 
to  the  lowest  part  of  the  cyst,  and  consequently  the 
upper  part  will  remain  for  some  time  undistended,  and 
have  an  opportunity  of  contracting. 

When  a certain  quantity  of  matter  has  again  accu- 
mulated, and  presents  itself  in  the  groin,  or  elsewhere, 
which  may  be  in  about  a fortnight  after  the  first  punc- 
ture, the  abscess  is  to  be  punctured  again  in  the  same 
manner  as  before,  and  the  wound  healed  in  the  same 
way.  The  quantity  of  matter  will  now  be  found 
much  less,  than  what  was  at  first  discharged.  Thus 
the  abscess  is  to  be  repeatedly  punctured  at  intervals, 
and  the  wounds  as  regularly  healed  by  the  first  inten- 
tion, by  which  method  irritation  and  inflammation  of 
the  cyst  will  not  be  induced,  the  cavity  of  the  matter 
will  never  be  allowed  to  become  distended,  and  it  will 
be  rendered  smaller  and  smaller,  till  the  cure  is  com- 
plete. 

In  a few  instances,  the  surgeon  may,  perhaps,  be  un- 
able to  persevere  in  healing  the  repeated  punctures 
which  it  may  be  necessary  to  make;  "but  after  suc- 
ceeding once  or  twice,  the  cyst  will  probably  have  had 
sufficient  opportunity  to  contract  so  much,  that  its  sur- 
face will  not  now  be  of  alarming  extent.  It  is  also  a 
fact,  that  the  cyst  loses  its  irritability,  becomes  more 
indolent  and  less  apt  to  inflame,  after  the  contents  have 
been  once  or  twice  evacuated  in  the  above  way.  Its 
disposition  to  absorb  becomes  also  stronger. 

The  knowledge  of  the  fact,  that  the  cysts  of  all  ab- 
scesses are  absorbing  surfaces,  should  lead  us  never  to 
neglect  other  means,  which  Mr.  Abernethy  suggests, 
as  likely  to  promote  the  dispersion  of  the  abscess,  by 
quickening  the  action  of  the  absorbents.  Blisters  kept 
open  with  savine  cerate,  issues,  electricity,  occasional 
vomits  of  the  sulphate  of  zinc,  are  the  means  most 
conducive  to  this  object.  When  the  vertebraj  are  dis- 
eased, issues  are  doubly  indicated. 

In  the  latter  complication  the  case  is  always  dan- 
gerous. If  an  opening  be  made  in  the  abscess,  the 
cyst  is  at  first  more  likely  to  be  irritated  than  when 
the  bones  are  not  diseased,  and  the  affection  of  the 
spine  is  rendered  much  less  likely  to  undergo  any  im- 
provement, in  consequence  of  the  mere  formation  of 
an  outward  communication.  The  same  bad  effect  at- 
tends necrosis ; in  which  case,  the  absorption  of  the  dead 
bone  is  always  retarded  by  the  presence  of  unhealed 
fistula;  and  sores,  which  lead  down  to  the  disease. 

Mr.  Crowther  succeeded  in  dispersing  some  large 
lumbar  abscesses  without  opening  them.  Large  blis- 
ters applied  to  the  integuments  covering  the  swelling, 
and  kept  open  with  the  savine  cerate,  effected  the  cure. 
When  this  gentleinau  punctured  such  collections  of 
matter,  he  used  a small  trocar,  which  he  introduced  at 
the  same  place  as  often  as  necessary.  He  observes, 
that  the  aperture  so  made  does  not  ulcerate,  and  allows 
no  matter  to  escape  after  being  dres.sed.  I cannot, 
however,  discover  any  reason  for  his  prefening  the 
trocar  to  the  abscess  lancet,  except  that  the  cannula 


MAMMA. 


163 


enables  the  surgeon  to  push  back  with  a probe  any 
flakes  of  lymph,  &c.  which  may  obstruct  its  inner 
orifice.  But  this  is  scarcely  a reason,  when  Mr.  Aber- 
nethy  informs  us  that  the  opening  made  with  an  ab- 
scess lancet  is  large  enough  to  allow  such  flakes  to  he 
discharged;  and  when  they  stop  up  the  aperture  a 
probe  might  also  be  employed  to  push  them  back.  A 
wound  made  with  a cutting  instrument  will,  emteris 
paribus,  always  unite  more  certainly  by  the  first  in- 
tention than  one  made  with  such  an  instrument  as  a 
trocar.  Mr.  Crowther  may  always  have  succeeded  in 
healing  the  aperture;  but  I do  not  believe  that  other 
practitioners  would  experience  equal  success.  Were 
the  tumour  not  very  prominent,  from  the  quantity  of 
matter  being  small,  suddenly  plunging  in  a trocar 
might  even  endanger  parts  which  should  on  no  account 
be  injured. 

Some  surgeons  open  lumbar  abscesses  with  a seton. 
The  matter  being  made  to  form  as  prominent  a swelling 
as  pos.sible,  by  pressing  the  abdomen,  and  putting  the 
patient  in  a position  which  will  make  the  contents  of 
the  abscess  gravitate  towards  the  part  where  the  seton 
is  to  be  introduced,  a transverse  cut  is  first  to  be  made 
in  the  integuments  down  to  the  fascia.  A flat  trocar 
is  next  to  be  introduced  within  the  incision,  which 
should  only  be  just  large  enough  to  allow  the  instru- 
ment to  pass  freely  under  the  skin  for  at  least  three 
quarters  of  an  inch;  when  tl'.e  hand  is  to  be  raised, 
and  the  trocar  pushed  obliquely  and  gently  upwards 
till  the  cannula  is  within  the  lower  part  of  the  sac. 
The  trocar  must  now  be  withdrawn,  and  the  matter 
allowed  to  flow  out  gently,  stopping  it  every  now  and 
then  for  some  minutes.  The  assistant  must  now 
withdraw  his  hand  to  take  away  the  pressure,  and 
place  the  thumb  of  his  left  hand  upon  the  opening  of 
the  cannula,  holding  it  between  his  fore  and  middle 
fingers.  It  must  then  be  pushed  upwards,  nearly  to 
the  top  of  the  tumour,  where  its  end  may  be  distinctly 
felt  with  the  fore-finger  of  the  right  hand.  As  soon  as 
it  can  be  plainly  felt,  it  must  be  held  steadily  in  the 
stune  position,  and  the  trocar  is  to  be  introduced  into 
it  again  and  pushed  through  the  skin  at  the  place 
where  it  is  felt,  and  the  cannula  along  with  it.  The 
trocar  being  next  withdrawn,  a probe  with  a skein  of 
fine  soft  silk  dipped  in  oil  must  be  passed  through  the 
cannula,  which  being  now  taken  away  leaves  the  seton 
in  its  place.  A pledget  of  mild  ointment  is  then  to  be 
applied  over  the  two  openings,  the  more  completely  to 
exclude  the  air.  A fresh  piece  of  the  silk  is  to  be 
drawn  into  the  abscess,  and  that  which  was  in  before 
cut  off,  as  often  as  necessary.— (See  Latta's  System  of 
Surgery,  vol.  3,  p.  307.) 


Deckers,  who  wrote  in  1696,  discharged  a large  ab- 
scess in  a gradual  manner  with  a trocar,  the  cannula 
of  which  was  not  withdrawn,  but  stopped -up  with  a 
cork  and  the  matter  let  out  at  intervals.  B.  Bell  also 
advises  the  cannula  not'to  be  taken  out. 

I cannot  quit  this  subject  without  mentioning  a re- 
markable case  of  lumbar  abscess,  which  I once  saw  in 
Christ’s  Hospital,  under  the  care  of  the  late  Mr.  Rams- 
den.  The  tumour  extended  from  the  ileum  and  sacrum 
below,  as  high  up  as  the  ribs.  The  diameter  of  the 
swelling,  from  behind  forwards,  might  be  about  six  or 
eight  inches.  It  was  attended  with  so  strong  a pulsa- 
tion corresponding  with  that  of  the  arteries,  that  several 
eminent  surgeons  in  this  city  considered  the  case  as  an 
aneurism  of  the  aorta.  After  some  weeks,  as  the 
tumour  increased  in  size,  the  throbbing  of  the  whole 
swelling  gradually  became  fainter  and  fainter,  and  at 
length  could  not  be  felt  at  all.  The  tumour  was  nearly 
on  the  point  of  bursting.  Mr.  Ramsden  suspected  that 
it  was  an  abscess,  and  determined  to  make  a small 
puncture  in  it.  The  experiment  verified  the  accuracy 
of  his  opinion  ; a large  quantity  of  pus  was  evacuated 
at  intervals ; but  the  boy’s  health  suffering,  he  went  to 
his  friends  at  Newbury,  and  I did  not  afterward  hear 
the  event.  I have  never  seen  any  popliteal  aneurism 
whose  pulsations  could  be  more  plainly  seen  and 
strongly  felt,  than  those  of  the  abscess  we  have  just 
been  describing.  A singular  case  is  related  by  Mr. 
Wilmot  of  a psoas  abscess,  the  matter  of  which  was 
at  length  absorbed,  and  its  cavity  filled  with  air,  at- 
tended with  a considerable  increase  in  the  size  of  the 
tumour,  a conical  elongated  shape,  and  elastic  feel, 
instead  of  a fluctuation,  previously  quite  evident,  and 
the  subsidence  of  all  the  hectical  symptoms.  A com- 
plete dispersion  of  the  swelling  was  effected  by  a 
bandage  and  compress  wet  with  a strong  decoction  of 
oak  bark  and  alum.— (See  Kirkland's  Med.  Surgery, 
vol.  2.  Trans,  of  the  King's  and  Queen's  College  of 
Physicians  in  Ireland,  vol.  2,  p.  26,  <S-c.  8vo.  Dublin, 
1818.  F.  Schoenmezel,  Obs.  de  Musculis  Psoa  et 
Iliaco  suppuratis,  Frank.  Del.  Op.  V.  R.  Beckwith 
de  Morbo  Psoadico.  Edinb.  1784.  Mernethy's  Sur- 
gical and  Physiological  Essays,  parts  1 and  2.  Crow- 
ther's  Observations  on  White  Swelling,  &re.  1808. 
Latta's  System  of  Surgery,  vol.  3.  Callisen's  System.a 
Chir.  Hodiernce,  vol.  1,  p.  370.  Pearson's  Princi- 
ples of  Surgery,  p.  102,  edit.  2.  Richter's  Anfangs- 
grunde  der  Wundarzpeykunst,  b.  5.  113.  OSttingen, 
1801.) 

LUNAR  CAUSTIC. — (See  Argentum  Jfitratum.) 

LUPUS. — (See  Mali  me  tangere.) 

LUXATION. — (See  Dislocation.) 


M 


MAMMA,  REMOVAL  OF,  AND  DISEASES  OF. 

The  operation  of  cutting  away  a diseased  breast 
is  done  nearly  in  the  same  manner  as  the  removal  of 
tumours  in  general,  and  is  indicated  whenever  the 
part  is  affected  with  a disease  which  is  incurable  by 
external  or  internal  remedies,  but  admits  of  being  en- 
tirely removed  with  the  knife.  When  the  breast  is 
affected  with  scirrhns,  or  ulcerated  cancer,  the  impru- 
dence of  tampering  with  the  disease  cannot  be  too 
severely  censured.  Were  the  disorder  unattended  with 
a continual  tendency  to  increa.se,  some  time  might 
properly  he  dedicated  to  the  trial  of  the  internal  reme- 
dies andextenial  applications  which  have  acquired  any 
character  for  doing  good  in  these  unpromising  cases. 
But,  unfortunately,  by  endeavouring  to  cure  the  disease 
by  medicine,  we  only  afford  time  for  it  to  increase  in 
matmitude,  and  at  length  attain  a condition  in  which 
even  the  knife  cannot  be  employed  so  as  to  take  away 
the  whole  of  the  diseased  parts.  When  the  case  is 
marked  by  the  characteristic  features  of  scirrhns, 
noticed  in  the  article  Cancer,  the  sooner  the  tumour  is 
file  better.  There  are  also  some  malignant 
K.nds  of  sarcoma,  to  which  the  female  breast,  is  sub- 
ject (as  will  be  explained  in  thearticle  Ttfwejw),  which 
cannot  be  removed  at  too  early  a period  after  their 
nature  is  8usj)€cted  or  known.  Indeed,  though  there 


is  not  equal  urgency  for  the  operation  when  the  tumour 
is  only  an  indolent,  simple,  fatty,  hydatid,  or  sarcoma- 
tous disease,  yet  as  all  these  tumours  are  continually 
growing  larger,  and  little  success  attends  the  attempt 
to  disperse  them,  the  practitioner  should  never  devote 
much  time  to  the  trial  of  unavailing  medicines  and  ap- 
plications, and  let  the  swelling  attain  a size  which 
would  require  a formidable  operation  for  its  excision. 
It  is  also  to  be  remembered,  that  many  simple,  fleshy, 
indolent  tumours  are  accompanied  with  a certain  de- 
gree of  hazard  of  changing  into  very  malignant  forms 
of  disease. 

With  respect  to  what  Sir  A.  Cooper  c&Us the  hydatid, 
or  encysted  swelling  of  the  breast,  he  describes  two 
forms  of  it;  one  containing  a fluid  like  serum,  in  cells, 
the  other  being  a globular  hydatid,  such  as  is  found  in 
the  liver  and  other  parts.  The  breast  gradually  swells, 
and  in  the  beginning  is  entirely  free  from  pain  or  ten- 
derness. It  becomes  hard  ; no  fluctuation  can  then  be 
discovered  in  it;  and  it  continues  to  grow  slowly  for 
Jtionths,  and  even  for  years.  The  part  is  painful  only 
just  before  the  period  of  the  menses.  After  a time, 
some  points  of  the  swelling  feel  as  if  they  contained 
fluid,  while  the  rest  continues  firm.  The  skin  is  quite 
free  from  discoloration,  except  inirnediamly  before  it 
begins  to  ulcerate.  The  constitution  sutfers  no  par- 


164 


MAMMA. 


ticular  disturbance  except  when  ulceration  commences, 
and  then  it  is  only  slight.  Sir  A.  Cooper  has  never  seen 
an  instance  of  lliis  disease  being  cured  by  a natural 
process;  it  remains  for  months  and  years;  the  cysts 
breaking  one  after  another,  and  the  breast  wasting,  till 
little  of  it  remains.  He  has  seen  more  cases  of  this 
complaint  between  the  ages  of  fifteen  and  twenty-five 
than  at  other  periods  of  lile ; but  he  has  also  sometimes 
met  with  it  in  older  subjects,  and  one  case  in  an  indi- 
vidual more  than  sixty.  The  disease  sometimes  ac- 
quires an  extraordinary  magnitude.  The  tumour  is 
extremely  moveable  upon  the  pectoral  muscle,  and 
very  pendulous.  It  never  requires  to  be  removed  on 
account  of  any  malignancy  in  its  character;  but  the 
operation  is  done  to  relieve  the  patient  from  its  incon- 
venience, and  to  satisfy  her  mind.  Although  the  whole 
breast  should  be  involved  in  the  disease,  and  the  swell- 
ing discharge  largely,  put  on  a formidable  appearance, 
and  even  become  of  enormous  size,  the  glands  in  the 
axilla  remain  entirely  free  from  disease;  or  if  one  be 
slightly  enlarged,  it  is  merely  from  simple  irritation, 
and  it  disappears  when  the  complaint  in  the  breast  is 
removed.'  There  is  no  danger  of  the  disease  extending 
by  absorption,  or  of  its  producing  any  mischief  beyond 
tire  breast ; nor  has  Sir  Astley  Cooper  ever  known  it 
attack  both  mammffi  at  the  same  time.  But,  though 
such  is  the  unmalignant  nature  of  the  disease,  all  the 
tumour  and  induration  must  be  removed  if  an  opera- 
tion be  necessary  ; for,  otherwise,  any  hydatid  cyst  left 
behind  will  continue  to  grow,  and  the  hydatid  swelling 
of  the  breast  to  enlarge. — {Illustrations  of  Diseases 
of  the  Breast,  p.  22 — 26.)  When  the  cyst  has  been 
single,  Sir  A.  Cooper  has  sometimes  let  out  the  fluid 
with  a lancet,  and  the  adhesive  and  suppurative  in- 
flammation, thus  excited,  has  terminated  in  a cure. — 
(See  Lancet,  vol.  2,  p.  36&— 370.) 

The  disetise  in  its  first  stage  resembles  simple  chronic 
inflammation;  but  it  may  be  distinguished  from  it  by 
the  absence  of  tenderness  on  pressure ; and  the  perfect 
health  in  which  the  patient  remains  marks  it  as  quite 
a local  disease.  In  its  second  stage,  wlien  it  fluctuates, 
its  nature  is  indicated  by  theseveral  distinct  seats  of 
the  fluctuation ; but,  as  Sir  Astley  Cooper  adds,  the 
best  criterion  is  afforded  by  the  puncture  of  tl.-e  cyst, 
whereby  a clear  serum  is  let  out,  and  not  a purulent 
fluid. — {Illustrations  of  Diseases  of  the  Breast,  />.24.) 
It  is  distinguished  from  scirrhus  by  its  freedom  from 
the  occasional  acute  darting  pains,  and  great  hardness 
of  the  latter  affection,  and  by  the  heaith  being  undis- 
turbed. Sir  Astley  Cooper,  however,  has  seen  a case 
in  which  a scirrhus  was  complicated  with  hydatids; 
and  so  has  the  author  of  this  work.  In  such  examples, 
of  course,  the  disease  is  attended  with  the  usual  lan- 
cinating pains,  and  all  the  other  evils  of  a carcinoma- 
tous tumour. 

Besides  this  and  other  hydatid  swellings  of  the 
breast,  and  scirrhus  and  fungus  hiematodes  (see  Cancer 
and  Fungus),  Sir  A.  Cooper  notices  the  case  named 
Simple  Chronic  Tumour  of  the  Breast.  It  is  generally 
met  with  in  persons  from  seventeen  to  thirty  years  of 
age,  and  of  healthy  appearance,  is  exceedingly  move- 
able,  more  diffused  in  the  surrounding  substance  than 
scirrhus,  and  has  alobulated  feel.  Pike  that  of  a fatty 
swelling.  He  affirms  that  it  is  a disease  which  never 
becomes  cancerous,  or  rather  never  unless  it  continue 
till  the  period  of  life  when  the  uterine  secretion  ter- 
minates (see  Illustrations  of  Diseases  of  the  Breast, 
p.  63),  though  it  may  attain  a large  size,  and  be  at- 
tended with  pain  at  the  period  of  menstruation.  Its 
ordinary  size  is  from  that  of  a filbert  to  that  of  a bil- 
liard-ball. It  does  not  admit  of  being  dispersed  by 
medicine,  but  can  easily  be  taken  away  by  incision. 
It  seems  to  grow  on  the  surface  of  the  breast,  rather 
than  from  its  interior ; and  it  therefore  appears  to  be 
very  superficial,  unless  when  it  arises  from  the  posterior 
surface  of  the  mammary  gland,  in  which  case  it  is 
deejily  seated,  and  its  peculiar  features  less  clear. 

This  chronic  mammary  tumour  may  continue  nearly 
stationary  for  many  years,  and  then  gradually  dimi- 
nish. Sir  Astley  Cooper  has  known  a gland  enlarge  in 
the  axilla,  and  I am  now  attending  a patient  with 
a similar  change  (August,  1829),  but  it  is  considered  a 
rare  occurrence,  and  merely  the  result  of  irritation.— 
(See  Illustrations  of  Diseases  of  the  Breast,  p.  53.) 
The  same  surgeon  regards  the  disease  as  sympathetic 
with  the  state  of  the  uterus ; and  although  he  does  not 
think  the  case  much  within  the  power  of  medicine,  he 


prescribes,  if  the  digestive  functions  be  disordered,  the 
compound  calomel  pill  to  be  taken  at  night,  and  the 
infusion  of  columba  with  rhubarb  and  the  carbonate 
of  soda,  twice  a day.  When  the  uterine  secretion  is 
defective,  he  exhibits  small  doses  of  the  blue  pill  and 
colocynth  with  steel  medicines.  As  local  applications, 
he  prefers  the  emplastr.  ammon.  cum  hydrargyro,  and 
the  iodine  ointment.  The  disease,  however,  rarely 
yields  till  the  uterine  excitement  ceases,  or  the  part  is 
required  to  furnish  its  own  natural  secretion.  Hence, 
Sir  Astley  Cooper  deems  the  complaint  no  objection  to 
matrimony,  as  it  is  likely  to  be  benefited  by  \\..—{Vol, 
cit.p.  57.) 

The  same  excellent  surgeon  has  also  described  an- 
other form  of  disease,  which  he  calls  the  Irritable  Tu- 
mour of  the  Breast.  It  occurs  in  persons  aged  from  15 
to  25,  a period  of  life  scarcely  liable  to  cancer;  the 
part  is  so  extremely  sensible,  t);at  the  patient  starts  on 
its  being  touched,  and  although  it  is  commonly  painful, 
yet  just  before  the  time  of  the  menses  the  agony  from 
it  is  almost  incredible,  the  pain  extending  from  the 
breast  to  the  arm  down  to  the  fingers’  ends,  and  even 
sometimes  afteciing  the  sight.  The  removal  of  the 
breast,  on  account  of  this  atfection,  is  completely  un- 
necessary. 

The  treatment  consists  in  lessening  the  irritability  of 
the  system,  diminishing  the  pain,  and  restoring  men 
struation.  As  local  applications.  Sir  A.  Coofier  re 
commends  a plaster  composed  of  equal  parts  of  soap 
plaster  and  extract  of  belladonna,  or  a poultice  with 
solution  of  belladonna  and  bread.  Oil-skin  or  hare-skin 
worn  upon  the  breast,  he  also  deems  useful.  When 
the  pain  is  excessive,  he  sanctions  the  employment  of 
leeches;  but  thinks  them  productive  of  weakness  and 
of  an  increase  of  irritability,  when  too  often  used.  As 
constitutional  remedies,  he  gives  the  submuriale  of 
mercury  with  opium  and  conium ; or,  for  lessening 
the  irritability  of  the  part,  a pill  composed  of  two  grs. 
of  the  extract  of  conium,  two  grs.  of  the  extract  of 
poppy,  and  one-half  of  a gr.  of  the  extract  of  stramo- 
nium, two  or  three  times  a day.  For  restoring  the 
uterine  secretion,  he  prescribes  the  carbonate  of  iron 
ferrurn  ammoniatum,  or  the  mixtura  ferri  comp.  Each 
of  these  may  be  combined  with  aloes.  He  also  re- 
commends a hip-bath  of  sea  or  salt  water,  heated  to 
100  or  105°. — (See  Illustrations  of  Diseases  of  the 
Breast,  p.  79.) 

The  breast  is  also  liable  to  scrofulous  sw'ellings,  to  a 
morbid  growth  called  by  Sir  Astley  Cooper  the  large 
and  pendulous  breast,  to  adipose  tumours,  and  to  toe 
cartilaginous,  as  well  as  some  other  diseases  de- 
scribed in  the  articles  Cancer,  Fungus  Hamatodes,  and 
Tumour. 

It  cannot  be  denied  that  there  are  many  sw'ellings 
and  indurations  of  the  breast,  which  it  would  be  highly 
injudicious  and  unnecessary  to  extirpate,  because  they 
generally  admit  of  being  discussed.  Such  are  many 
tumours  which  are  called  scrofulous,  from  their  alfect- 
ing  patients  of  this  peculiar  constitution,  cases  in  which 
the  trial  of  iodine  internally  and  externally  may  very 
properly  be  made. — (See  Iodine.)  Such  are  nearly  all 
those  indurations  which  remain  after  a sudden  and 
general  inflammatory  enlargement  of  the  mamma ; 
such  are  most  other  tumours,  which  acquire  their  full 
size  in  a few  days,  attended  with  pain,  redness,  &c. ; 
and  of  this  kind,  also,  are  the  hardnesses  in  the  breast, 
occasioned  by  the  mammary  abscess. 

In  the  removal  of  all  malignant  or  cancerous  tu* 
mours,  their  nature  makes  it  necessary  to  observe  one 
important  caution  in  the  operation,  viz.  not  to  rest  sa- 
tisfied with  cutting  aw'ay  the  tumours  just  at  their 
circumference;  but  to  take  away  also  a considerable 
portion  of  the  substance  in  which  they  lie,  and  with 
which  they  are  surrounded.  In  cutting  out  a cancer- 
ous breast,  if  the  operator  were  to  be  content  with 
merely  dissecting  out  the  disease  just  where  his  eyes 
and  fingers  might  equally  lead  him  to«uppose  its  bound- 
ary to  be  situated,  there  would  siill  be  left  behind 
white  diseased  bands,  which  radiate  from  the  tumour 
into  the  surrounding  fat,  and  which  would  ineviiably 
occasion  a relapse.  In  a vast  proportion  of  the  cases 
also  in  which  cancer  of  the  breast  unforiunaiely  re- 
curs after  the  ojtetation,  it  is  found  that  the  skin  is  the 
part  in  which  the  disease  makes  its  reappearance. 
Hence  the  creal  prudence  of  taking  away  a good  deal 
of  it  in  every  case  suspected  to  be  a truly  scirrhous  or 
cancerous  disease.  This  may  also  be  done  no  as  not  to 


MAMMA. 


165 


prevent  the  important  objects  of  uniting  the  wound  by 
the  first  intention,  Slid  covering  the  whole  of  its  surface 
with  sound  integuments.  So  frequently  does  cancer 
recur  in  the  nipple,  whenever  it  does  recur  any  where, 
that  many  of  the  best  modern  operators  always  make  a 
point  of  removing  this  part  in  every  instance  in  which 
it  is  judged  expedient  to  take  away  any  portion  of  the 
skin  at  all.  The  surgeon  indeed  would  be  inexcusable 
were  he  to  neglect  to  take  away  such  portion  of  the  in- 
tegument^ covering  scirrhous  tumours  as  is  evidently 
atfected,  appearing  to  be  discoloured,  puckered,  and 
closely  attached  to  the  diseased  lum[)  beneath.  Nor 
should  any  gland  in  the  axilla  at  all  diseased,  nor  any 
fibres  of  the  pectoral  muscle  in  the  same  state,  be  ever 
left  behind.  There  is  no  doubt  that  notliing  has 
stamped  operations  for  cancers  with  disrepute  so  much 
as  the  neglect  to  make  a free  removal  of  the  skin  and 
parts  surrounding  every  side  of  the  tumour.  Hence 
the  disease  has  Ifequently  appeared  lo  recur,  when  in 
fact  it  has  never  been  thoroughly  extirpated  ; the  dis- 
ease, though  perhaps  a local  atlection,  has  been  deemed 
a constitutional  one;  and  the  operation  frequently  re- 
jected as  ineffectual  and  useless. 

But  strongly  as  1 have  urged  the  prudence,  the  ne- 
cessity, of  making  a free  removal  of  the  skin  covering, 
and  of  the  parts  surrounding,  every  cancerous  or  ma- 
lignant tumour,  tire  same  plan  may  certainly  be  re- 
garded as  unnecessary,  and  therefore  unscientific,  in 
most  o(»erations  for  the  removal  of  simple,  fatty,  fleshy 
or  encysted  tumours,  to  which  the  breast  and  almost 
every  other  part  is  liable.  However,  even  in  the  latter 
cases,  when  the  swelling  is  very  large,  it  is  better  lo 
take  away  a portion  of  skin  ; for  otherwise,  after  the 
excision  of  the  tunlour,  there  would  be  a redundance  of 
integuments,  the  cavity  of  which  would  only  serve  for 
the  lixlgement  of  matter.  The  loose  superfluous  skin 
also  would  lie  in  folds,  and  not  apply  itself  evenly  to 
the  parts  beneath,  so  as  to  unite  favourably  by  the  first 
intention;  nor  could  the  line  of  the  cicatrix  itself  be 
arranged  with  such  nice  evenness  as  it  might  have 
been,  if  a part  of  the  redundant  skin  had  been  taken 
away  at  the  time  of  operating. 

The  best  method  of  removing  a diseased  breast  is  as 
follows:  the  patient  is  usually  placed  in  a sitting  pos- 
ture, well  supported  by  pillows  and  assistants;  but  the 
operator  will  find  it  equally  convenient,  if  not  more 
BO,  to  remove  the  tumour  while  his  patient  is  in  a re- 
cumbent position : and  this  posture  is  best  whenever 
the  operation  is  likely  to  be  long,  or  much  blood  to  be 
lost,  which  circumstances  are  very  apt  to  bring  on 
faintine.  I remember  that  Mr.  Abernethy,  in  his  lec- 
tures, used  to  recommend  the  latter  plan  ; which,  how- 
ever, without  the  sanction  of  any  great  name  or  au- 
thority, possesses  such  obvious  advantages  as  will  al- 
ways entitle  it  to  approbation. 

If  the  patient  be  in  a sitting  posture,  the  arms  should 
be  confined  back  by  placing  a stick  between  them  and 
the  body,  by  which  means  the  fibres  of  the  great  pec- 
toral muscle  will  be  kept  on  the  stretch,  a state  most 
favourable  for  the  dissection  of  the  tumour  off  its  sur- 
face. The  stick  also  prevents  the  patient  from  moving 
her  arm  about,  and  interrupting  the  progress  of  ope- 
ration. 

When  the  tumour  is  not  large,  and  only  a simple 
sarcoma,  free  from  malignancy,  it  will  be  quite  unne- 
cessary to  remove  any  of  the  skin,  and  of  course  this 
need  otdy  be  divided  by  one  incision  of  a length  pro- 
portionate to  the  tumour.  The  cut  must  be  made  with 
a common  dissecting  knife;  and  as  the  division  of  the 
parts  is  chiefly  accomplished  with  the  part  of  the  edge 
towards  the  point,  the  instrument  will  be  found  lo  do 
its  office  best  when  the  extremity  of  the  edge  is  made 
of  a convex  shape,  and  this  part  of  the  blade  is  turned 
a little  hack  in  the  way  in  which  dissecting  knives  are 
now  often  constructed.  The  direction  of  the  incision 
through  the  skin  should  be  made  according  to  the  great- 
est diameter  of  the  tumour  to  be  removed,  by  which 
means  it  will  be  most  easily  dissected  out. 

'J'he  direction  of  llie  incision  is  various  with  differ- 
ent nractitioners;  some  making  it  perpendicular, others 
transverse.  In  general,  the  shape  of  the  tumour 
must  determine  which  is  the  best.  In  France  it  has 
been  said  that  when  the  incision  follows  the  second 
direction  it  heals  .more  expeditiously,  because  the  skin 
is  more  extensible  from  above  downwards  than  later- 
ally, particularly  towards  the  sternum,  and  conse- 
quently allows  the  sides  of  the  wound  the  more  readily 


to  be  placed  in  contact;  and  that  the  action  of  the 
pectoral  muscle  tends  lo  separate  the  edges  of  the 
wound  when  it  is  perpendicular.  On  the  other  hand, 
it  hi  allowed  that  the  wound  made  in  the  latter  man- 
ner is  the  most  favourable  for  the  escape  of  the  dis- 
charge, if  suppuration  shcmld  occur. — (See  CEuvres  de 
Desault,  par  Bichat,  p.  312,  t.  2.) 

The  cut  through  the  skin  should  always  be  some- 
what longer  than  the  tumour,  and  as  it  is  perhaps  the 
most  painful  part  of  the  operation,  and  one  attended 
with  no  danger  whatever,  it  should  be  executed  with 
the  utmost  celerity,  pain  being  tnore  or  less  dreaded 
according  to  its  duration,  as  well  as  its  degree.  The 
fear,  however,  of  giving  pain  has  probably  led  many 
operators  to  err,  in  not  making  their  first  incision 
through  the  integuments  large  enough,  the  consequence 
of  which  has  often  been,  that  there  was  not  sufficient 
room  for  the  dissection  of  the  tumour  with  facility  ; 
the  patient  has  been  kept  nearly  an  hour  in  the  ope- 
rating room,  instead  of  five  minutes,  and  the  surgeon 
censured  by  the  spectators  as  awkward  and  tedious. 
It  is  clear  also  that  besides  the  larger  quantity  of  blood 
lost  from  this  error  than  would  otlierwise  happen,  the 
vessels  being  commonly  not  tied  till  all  the  cutting  is 
finished,  the  avoidance  of  pain,  that  fear  which  led  to 
the  blunder,  is  not  effected,  and  the  patient  suffers  much 
more  and  for  a much  longer  time,  in  consequence  of  the 
embarrassment  and  obstacles  in  the  way  of  the  whole 
operation. 

When  the  disease  is  of  a scirrhous  or  malignant  na- 
ture, the  skin  covering  the  tumour  should,  at  all  events, 
be  in  part  removed.  As  I have  said  before,  all  that 
portion  which  is  discoloured,  puckered,  tuberculated, 
or  otherwise  altered,  should  be  taken  away.  Some 
must  also  be  removed  in  order  to  prevent  a redun- 
dance in  all  cases  in  which  the  tumour  is  large.  We 
have  said  too,  that  in  cases  of  scirrhus  and  cancer 
of  the  breast,  the  nipple  is  considered  a dangerous 
part  to  be  left  behind.  For  the  purpose  of  removing 
the  necessary  portion  of  skin,  the  surgeon  must  obvi- 
ously pursue  a different  mode  from  that  above  de- 
scribed ; and  instead  of  one  straight  incision  he  is  to 
make  two  semicircular  cuts,  one  immediately  after  the 
other,  and  which  are  to  meet  at  their  extremities. 
The  size  of  these  wounds  must  be  determined  by  that 
of  the  disease  to  be  removed,  and  by  the  quantity  of 
skin  which  it  is  deemed  prudent  to  take  away  ; for  the 
part  which  is  included  in  the  two  semicircular  cuts  is 
that  which  is  not  to  be  separated  from  the  upper  sur- 
face of  the  swelling,  but  taken  away  with  it.  The 
shape  of  the  two  cuts  together  may  approach  that  either 
of  a circle  or  oval,  as  the  figure  of  the  tumour  ilself 
may  indicate  as  most  convenient.  The  direction  of  the 
incisions  is  to  be  regulated  by  the  same  consideration. 

In  the  above  ways,  the  first  division  of  the  integu- 
ments is  to  be  made  in  removing  tumours  of  every  de- 
scription covered  with  skin.  The  same  principles  and 
practice  should  prevail  in  all  these  operations;  and 
whether  the  swelling  be  the  mamma  or  any  other  dis- 
eased mass,  whether  situated  on  the  chest,  the  back, 
the  header  extremities,  the  same  considerations  should 
always  guide  the  operator’s  hand. 

The  incision  or  incisions  in  the  skin  having  been 
made,  the  next  object  is  to  detach  every  side  of  the  tu- 
mour from  its  connexions,  and  the  separation  of  its 
base  will  then  be  the  last  and  only  thing  remaining  to 
be  done.  When  the  tumour  is  a scirrhous  or  other 
malignant  disease,  the  operator  must  not  dissect  close 
to  the  swelling,  but  make  his  incisions  on  each  side,  at 
a prudent  distance  from  it,  so  as  to  be  sure  to  remove, 
with  the  diseased  mass,  every  atom  of  morbid  mischief 
in  its  vicinity.  But  when  the  tumour  is  only  a mere 
fatty  or  other  mass,  perfectly  free  from  malignancy, 
the  cellular  bands  and  vessels  forming  its  connexions, 
may  be  divided  clo.se  to  its  circumference.  It  is  asto- 
nishing with  what  ease  fatty  tumours  are  removed, 
after  the  necessary  division  is  made  in  the  skin;  they 
may  almost  be  turned  out  with  the  fingers  without  any 
cutting  at  all.  When  they  have  been  inflamed,  how- 
ever, they  are  considerably  more  adherent  to  the  sur- 
rounding parts. 

Th'.is  we  see  that  the  first  stage  of  operation  cf  re- 
moving a tumour,  is  the  division  of  the  skin;  the  se- 
cond, the  separation  of  the  swelling  from  the  surround- 
ing parts  on  every  side  ; the  third  and  last,  the  division 
of  the  parls  to  which  its  under  surface  or  base  is  at- 
tached. The  latter  object  should  be  accomplished  by 


166  MAM 

cutting  regularly  from  above  downwards,  till  every 
part  is  divided. 

It  is  a common  thing  to  see  many  operators  con- 
stantly embarrassed  and  confused,  whenever  they  have 
to  remove  a large  tumour,  on  account  of  their  having 
no  particular  method  in  tliir  proceedings.  They  first 
cut  a few  fibres  on  one  side  ; then  on  another ; and, 
turning  the  mass  of  disease  now  to  this  side,  now  to 
that,  without  any  fixed  design,  they  both  prolong  the 
operation  very  tediously,  and  present  to  the  bystanders 
a complete  specimen  of  surgical  awkwardness.  On  the 
contrary,  when  the  practitioner  divides  the  cutting  part 
of  the  operation  into  the  three  methodical  stages  above 
recommended,  in  each  of  which  there  is  a distinct  ob- 
ject to  be  fulfilled,  he  proceeds  with  a confidence  of 
knowing  what  he  is  about,  and  soon  effects  what  is  to 
be  done  with  equal  expedition  and  adroitness. 

Having  taken  out  the  tumour,  the  operator  is  imme- 
diately to  tie  such  large  vessels  as  may  be  pouiing  out 
blood ; indeed,  when  the  removal  of  the  swelling  will 
necessar  ily  occupy  more  than  three  or  four  minutes,  it 
is  better  to  tie  all  the  large  arteries  as  soon  as  they  are 
divided,  and  then  proceed  with  their  dissection.  This 
was  the  celebrated  Desault’s  plan,  and  it  is  highly  de- 
serving of  imitation,  not  only  because  many  subjects 
cannot  afford  to  lose  much  blood,  but  also  because  the 
profuse  effusion  of  this  fluid  keeps  the  operator  from 
seeing  what  parts  he  is  dividing.  For  the  same  reasons, 
Mr.  Morgan’s  plan  of  compressing  tlie  subclavian  ar- 
tery from  above  the  clavicle,  during  the  operation,  so 
as  to  prevent  hemorrhage,  is  entitled  to  praise,  espe- 
cially when  the  tumour  is  large,  the  patient  already  de- 
bilitated, and  the  operation  likely  to  be  tedious. 

The  largest  arteries  being  tied,  the  surgeon  should 
not  be  immediately  solicitous  about  tying  every  bleed- 
ing point  which  may  be  observed.  Instead  of  this  let 
him  employ  a little  while  in  examining  every  part  of 
the  surface  of  the  wound,  in  order  to  ascertain  that  no 
portion  of  the  swelling,  no  hardened  lump,  nor  dis- 
eased fibres  remain  behind.  Even  if  any  part  of  the 
surface  of  the  pectoral  muscle  should  present  a morbid 
feel  or  appearance,  it  must,  on  every  account,  be  cut 
away.  Also,  if  any  of  the  axillary  glands  should  be 
diseased,  the  operator  now  ought  to  proceed  to  remove 
them.  After  the  time  spent  in  such  measures,  many 
of  the  small  vessels,  which  bled  just  after  the  excision 
of  the  swelling,  will  now  have  stopped,  the  necessity 
for  several  ligatiyres  will  be  done  away,  and,  of  course, 
the  patient  saved  a great  deal  of  pain,  and  more  of  the 
wound  be  likely  to  heal  by  the  first  intention. 

Some  information  may  be  derived  respecting  whe- 
ther any  of  the  tumour  is  left  behind,  hy  examining 
its  surfaces  when  taken  out,  and  observing  whether  any 
part  of  them  is  cut  oflT ; for,  if  it  is,  it  may  always  be 
found  in  the  corresponding  part  of  the  wound. 

The  axillary  glands  may  invariably  be  taken  out, 
without  the  least  risk,  if  the  plan  pursued  by  Desault 
in  France,  and  the  late  Sir  Charles  Blicke,  and  other 
eminent  surgeons  in  this  country,  be  adopted.  The 
method  alluded  to  is,  after  dividing  the  skin  covering 
tlie  gland,  and  freeing  the  indurated  part  from  its  la- 
teral connexions,  to  tie  its  root  or  base,  by  which  it  is 
connected  with  the  parts  on  the  side  towards  the  cavity 
of  the  axilla.  Then  the  indurated  gland  itself  may  be 
safely  cut  off)  just  above  the  ligature.  Were  the  gland 
cut  off  in  the  first  instance,  the  artery  which  supplies 
it  with  blood  w'ould  be  exceedingly  difficult  to  tie,  on 
account  of  its  deep  situation ; and  by  reason  of  its 
shortness  and  vicinity  to  the  heart,  it  would  bleed  al- 
most like  a wound  of  the  thoracic  artery  itself.  In 
this  way,  there  is  also  not  the  least  hazard  of  injuring 
tlie  lateral  vessel.  It  would  be  a great  improvement 
in  the  mode  of  operating  for  the  removal  of  these 
glands,  if  surgeons  were  always  to  make  the  patient 
lie  down,  with  the  arm  placed  in  such  a position  as 
would  let  the  light  fall  into  the  axilla.  How  much  the 
steps  of  the  operation  would  be  facilitated  in  this  way, 
I need  not  attempt  to  explain. 

The  above  directions  will  enable  a surgeon  to  remove 
tumours  in  general.  They  apply  also  in  a great  mea- 
sure to  encysted  tumours  ; but  a few  particular  rules 
how  to  operate  in  the  latter  cases,  will  be  found  in 
the  article  Tumours.  One-half  of  each  ligature  is  al- 
ways to  be  cut  off  before  dressing  the  wound.  The 
edges  of  the  incision  are  to  be  brought  together  with 
strips  of  adhesive  plaster;  and  before  this  can  be  done 
with  ease,  the  stick  confining  the  arm  back  must  be 


MAM 

removed,  and  the  osbrachii  brought  forwards,  so  as  to 
relax  the  pectoral  muscle  and  integuments  of  the 
breast.  No  sutures  should  ever  be  employed,  as  they 
are  useless,  painful,  and  irritating.  Tlie  wound  being 
closed  with  sticking  plaster  and  a pledget  of  simple  ce- 
rate, a compress  of  folded  linen  or  fiannel  may  be  put 
over  the  dressings;  these  are  to  be  secured  with  a 
broad  piece  of  linen,  w hich  is  to  encircle  the  chest,  be 
fastened  w'ith  pins  or  stitches,  and  kept  from  slipping 
down  by  two  tapes,  one  of  which  is  to  go  from  behind 
forwards,  over  each  shoulder,  and  be  stitched  to  the 
upper  part  of  the  bandage,  both  in  front  and  behind. 
The  arm  on  the  same  side  as  that  on  which  the  opera- 
tion has  been  done,  should  be  kept  perfectly  motionless 
in  a sling ; for  every  motion  of  the  limb  must  evidently 
disturb  the  wound,  by  putting  the  great  pectoral  muscle 
into  action,  or  rendering  its  fibres  sometimes  tense, 
sometimes  relaxed.  It  is  scarcely  necessary  to  say, 
that  after  so  considerable  an  operation  as  the  removal 
of  a large  breast,  or  any  other  tumour  of  magnitude, 
the  patient  should  be  given  about  thirty  drops  of  the 
tinctura  opii.  A smaller  dose  always  creates  restless- 
ness, headache,  and  fever,  after  operations,  instead  of 
having  the  desired  effect. 

Here  it  becomes  me  to  state,  that  as  I could  not  find 
in  any  surgical  book  with  which  I am  acquainted, 
what  I conceived  to  be  a proper  description  of  the 
mode  of  removing  a disetised  breast,  and  tumours  in 
general,  the  foregoing  remarks  are  given  chiefly  on  my 
own  authority.  Whether  they  are  just  or  not,  must  be 
decided  by  the  profession. 

The  removal  of  a diseased  breast  rarely  proves  fatal 
of  itself,  unless  the  parts  cut  away  extend  to  a consi- 
derable depth,  and  occupy  a very  large  space,  or  the 
patient  is  much  reduced  before  the  operation.  How- 
ever, I have  known  one  or  two  patients  in  St.  Bartholo- 
mew’s Hospital  die,  without  any  very  apparent  cause, 
very  soon  after  the  operation;  and  Schmucker  has  re- 
corded an  instance  in  which  the  operation  was  fol- 
lowed by  tetanus. — (fVahmehmungen,  b.  2,  p.  80.)  I 
believe,  that  within  the  last  five  years,  one  case  has 
terminated  fatally  from  a similar  cause,  in  St.  Bartho- 
lomew’s. 

With  respect  to  the  average  success  following  the  re- 
moval of  cancerous  diseases,  this  is  a topic  w'hich  has 
been  noticed  in  the  article  Cancer.  The  statement 
made  by  Baron  Boyer,  is  exceedingly  unfavourable; 
for,  in  one  hundred  cases,  in  which  he  has  removed  the 
diseased  parts,  only  four  or  five  of  the  patients  con- 
tinued radically  cured. — {Traiti  des  Mai.  Chir.  t,  7,  p. 
237,  8i)0.  Paris,  1821.) 

MAMxMARY  ABSCESS.  Milk  abscess.  With  re- 
gard to  inflammations  of  the  mamma,  as  my  friend 
Mr.  James  has  observed,  there  is  “ either  simple  phleg- 
mon, or  mammary  abscess,  which,  as  it  depends  upon 
a peculiarity  of  state  and  function,  ought  to  stand 
alone.  Mr.  Hey  also  describes  a deep-seated  abscess, 
to  which  this  gland  is  liable,  of  rather  a chronic  cha- 
racter, and  is  the  same,  perhaps,  as  that  which  Dr. 
Kirkland  has  described  as  the  encysted.  Dr.  K.  de- 
scribes also  two  others,  under  the  titles  of  chronic  and 
encysted.”  Certain  cases,  most  frequently  occurring 
in  unmarried  females,  and  having  very  little  tendency 
to  suppuration,  Mr.  James  suspects  are  the  result  of 
infl.ammation  of  the  glandular  part  of  the  breast  from 
disorder  in  the  digestive  organs,  uterine  system,  oi 
both. — ( On  Inflammation,  p.  171.)  The  lacteal  or  lac- 
tiferous tumour,  as  it  is  called  hy  Sir  Astley  Cooper, 
though  attended  with  fluctuation,  is  very  different  from 
an  abscess,  and  should  never  be  confounded  with  it. 
The  cause  of  this  swelling  is  a chronic  inflammation 
and  obstruction  of  one  of  the  lactiferous  tubes  near 
the  nipple.  When  the  distention  is  excessive,  ulcera- 
tion sometimes  takes  place,  and  the  milk  is  discharged 
through  a small  aperture;  and  when  the  infant  sucks, 
most  of  this  nutritious  fluid  is  lost  toil.  The  following 
treatment  of  the  lactiferous  swelling  is  advised  by  Sir 
Astley  Cooper.  If  the  child  can  be  weaned,  a simple 
puncture  will  suffice  ; but  if  suckling  be  continued,  a 
larger  opening  must  be  made,  and  the  milk  suffered  to 
escape  at  the  artificial  aperture  while  the  infant  is 
sucking.  Relief  may  thus  be  obtained  until  the  child  is 
weaneil,  and  the  secretion  of  milk  is  slopped  hy  pur- 
gatives.— (See  Illustrations  of  Diseases  of  the  Breast, 

p.  16.) 

Women  who  suckle  are  particularly  subject  to  in- 
flammation and  suppuration  of  the  breast.  The  part 


MAMMARY  ABSCESS.  167 


enJarges,  becomes  tense,  heavy,  and  painful.  The  in- 
teguments of  the  breast  sometimes  assume  a uniform 
redness;  sometimes  they  are  only  red  in  particular 
places.  I'he  inflammation  may  affect  the  mammary 
gland  Itself,  or  be  confined  to  the  skin  and  surround- 
ing cellular  substance.  In  the  latter  case,  the  inflamed 
part  is  equally  tense ; but  when  the  glandular  struc- 
ture of  the  breast  is  also  affected,  the  enlargement  is 
irregular,  and  seems  to  consist  of  one  or  more  large 
tumours,  situated  in  the  substance  of  the  part.  The 
pain  often  extends  to  the  axillary  glands.  The  secre- 
tion of  the  milk  is  not  always  suppressed  when  the 
inflammation  is  confined  to  the  integuments,  and  sup- 
puration is  said  to  come  on  more  quickly  than  in  the 
affections  of  the  mammary  gland  itself.  When  the 
symptoms  of  inflammation  continue  to  increase  for 
four  or  five  days,  suppuration  may  be  expected ; unless 
the  progress  ot  the  inflammation  be  slow,  and  its  de- 
gree moderate,  in  which  circumstances  resolution  may 
often  be  obtained,  even  as  late  as  a fortnight  after  the 
first  attack.  Acute  inflammation  of  the  breast  Is  ge- 
nerally attended  with  more  or  less  sympathetic  inflam- 
matory fever. — (See  Fevers.)  According  to  the  valu- 
able description  lately  given  of  the  case  by  Sir  Astley 
Cooper,  it  is  adhesive  in  the  first  stage,  suppurative  in 
the  second,  and  ulcerative  in  the  third.  Swelling  is 
followed  by  a blush  of  inflammation  upon  the  surface 
of  the  breast,  and  throbbing  very  acute  pain.  “ A 
particular  prominence  and  smoothness  are  observed  at 
one  part  of  the  tumour,  with  a sense  of  fluctuation 
from  the  presence  of  matter.  The  constitution  is  also 
highly  irritated,  which  is  evinced  by  the  occurrence  of 
shivering,  succeeded  by  heat  and  profuse  perspiration. 
Over  the  most  prominent  part  of  the  swelling,  the  cu- 
ticle separates,  ulceration  follows  in  the  cutis,  and  the 
matter  becomes  discharged  through  the  aperture  thus 
produced.” — {Illustrations  of  Diseases  of  the  Breast, 
j).  7.) 

Women  are  most  liable  to  mammary  abscesses 
within  the  first  three  months  after  parturition ; but  they 
are  also  much  exposed  to  the  disorder  as  long  as  they 
continue  to  suckle. 

The  most  common  causes  of  mammary  abscess, 
as  enumerated  by  writers  in  general,  are,  repressing 
the  secretion  of  milk  at  an  early  period,  mental  dis- 
turbance, fright,  Sec. ; exposure  to  cold,  moving  the 
arms  too  much  While  the  breasts  are  large  and  dis- 
tended, bruises,  and  other  external  injuries.  The 
causes  are  not  always  obvious.  In  Sir  Astley  Cooper’s 
opinion,  the  principal  cause  of  acute  inflammation  and 
suppuration  of  the  breast,  is  “ the  rush  of  blood,  which 
takes  place  each  time  the  child  is  applied  to  the  bo- 
som, and  which  by  nurses  is  called  the  draught,  and  is 
the  preparatory  step  to  the  secretion  of  milk.”  He 
also  adverts  to  the  frequent  exposure  of  the  bosom  in 
suckling,  and  the  active  exertions  of  the  child  in  suck- 
ing, as  promoting  the  origin  of  the  complaint.  The 
nurse,  he  says,  often  produces  these  abscesses  imme- 
diately after  the  lying-in,  by  not  putting  the  child  soon 
enough  to  the  breast,  and  by  giving  the  mother  strong 
drink. — iSce  Illustrations  of  Diseases  of  the  Breast, 
V-  8-) 

The  matter  is  sometimes  contained  in  one  cyst  or 
cavity;  sometimes  in  several;  but  the  abscess  gene- 
rally breaks  near  the  nipple. 

As  all  inflammations  of  the  mamma  are  attended 
with  considerable  induration,  these  ca-ses  should  be 
carefully  distinguished  from  other  swellings  of  a more 
incurable  kind.  It  is  said  that  scrofulous  tumours  of 
the  mamma,  which  have  existed  a long  while,  often 
disappear  after  the  occurrence  of  a milk  abscess. 
Women  who  have  never  been  pregnant  are  sometimes 
affected  with  suppuration  in  the  breast,  supposed  by 
Mr.  James  to  be  connected  with  uterine  or  gastric  dis- 
order. Even  men  are  liable  to  abscesses  of  the  breast. 

In  the  early  period  of  the  affection,  resolution  should 
be  attempted.  The  following  are  the  principal  means 
for  this  purpose: — venesection,  leeches;  purges  of 
castor  oil,  or  sulphate  of  magnesia ; low  diet,  keeping 
the  inflamed  breast  from  hanging  down ; resting  the 
arm  in  a sling;  fomentations;  having  the  milk  tenderly 
sucked  out  at  proper  intervals  ; saturnine  applications, 
containing  spirit  of  wine;  or  lotions  of  the  muriate  of 
ammonia.  “ If  the  patient  suffer  from  the  cold  pro- 
duced by  the  evaporation  of  the  spirit,  a simple  tepid 
poultice  may  be  substituted  for  it,  occasionally  apply- 
ing leeches,  and  still  recollecting  that  the  chief  depend- 


ence is  upon  purging.” — (See  Ji.  CoopeFs  Illustrations 
of  Diseases  of  the  Breast,  p.  9.) 

When  matter  cannot  be  prevented  from  forming,  an 
emollient  poultice  is  a good  application;  or  the  surgeon 
may  apply  “ fomentations  of  poppy  decoction,  and 
poultices  made  with  the  same  decoction,  mixed  with 
bread,”  which  last  .should  be  renewed  three  or  four 
times  a day.  In  order  to  lessen  the  patient’s  sufferings, 
Sir  Astley  Cooper  prescribes  opium  combined  with  the 
liquor  ammoniBB  acetatis,  or  simple  saline  draughts 
with  small  doses  of  sulphate  of  magnesia.  In  general, 
the  abscess  should  be  allowed  to  break  of  itself,  unless 
it  should  be  rather  of  a chronic  nature,  in  which  case 
it  may  be  opened  in  a depending  part  with  a lancet. 
Much  difference  of  opitiion  prevails  respecting  the 
practice  of  opening  absce.sses  of  the  breast.  I consider 
Sir  Astley  Cooper’s  directions  extremely  useful.  “ If 
(says  he)  the  abscess  be  quick  in  its  progress,  if  it  be 
placed  on  the  anterior  surface  of  the  breast,  and  if  the 
sufferings  which  it  occasions  are  not  excessively 
severe,  it  is  best  to  leave  it  to  its  natural  course.  But 
if,  on  the  contrary,  the  abscess  in  its  commencement 
be  very  deeply  placed,'if  its  progress  be  tedious,  if  the 
local  sufferings  be  excessively  severe,  if  there  be  a high 
degree  of  irritative  fever,  and  the  patient  suffer  from 
profuse  perspiration  and  want  of  rest,  much  time  is 
saved,  and  pain  avoided,  by  discharging  the  matter 
with  a lancet.” — (See  Illustrations  of  Diseases  of  the 
Breast,  p.  10.)  'The  same  experienced  surgeon  disap- 
proves, however,  of  introducing  the  lancet  through  a 
thick  covering  of  the  abscess,  as  the  opening  will  not 
procure  a free  discharge  of  the  matter,  but  will  heal 
by  adhesion,  after  which  the  accumulation  of  matter 
Will  continue.  The  opening,  he  says,  should  be  made 
where  the  matter  is  most  superficial,  and  tiie  fluctua- 
tion is  distinct,  and  its  size  should  be  in  proportion  to 
its  depth.  Sinuses  sometimes  form,  and  will  not  heal 
till  freely  opened  with  a director  and  curved  bistoury. 
When  the  cavity  of  the  abscess  begins  to  be  filled  up 
with  granulations,  the  poultice  may  be  left  ofiT,  and  su- 
perficial dressings  applied. 

For  dispersing  the  considerable  induration,  which 
sometimes  continues  a long  while  after  the  abscess  is 
cured,  the  most  effectual  plans  are  friction  with  cam- 
phorated mercurial  ointment,  the  iodine  ointment,  or 
the  soap  liniment  with  3 j of  the  tinct.  iodine  to  each 
ounce  of  it,  and  the  occasional  exhibition  of  purgative 
medicines,  with  tonics,  or  the  compound  calomel  pill, 
according  to  the  state  of  the  constitution. 

If  the  abscess  be  small,  Sir  Astley  Cooper  allows  the 
child  to  suck  the  affected  breast  as  well  as  the  otb''r; 
but  if  much  of  the  mamma  be  involved  in  the  disease, 
he  lets  the  infant  suck  the  other  breast,  and  directs  the 
mother  to  draw  the  other  herself  by  means  of  the 
glass  tube  constructed  for  the  purpose.  When  the 
child  is  prevented  from  sucking  by  excoriations  or 
ulcers  of  the  nipple,  the  milk  accumulates  in  large 
quantity,  and  inflammation  is  excited.  Here  Sir  Astley 
also  recommends  the  breast  to  be  drawn;  but  he 
thinks,  that  the  sooner  the  child  can  be  restored  to  it 
the  better.  He  deems  a solution  of  a drachm  of  borax 
in  three  ounces  and  a half  of  water,  and  half  an  ounce 
of  spirit  of  wine,  the  best  application  for  a sore  nipple. 
Many  practitioners  use  diluted  brandy,  lotions  of  zinc 
or  alum,  or  that  of  calomel  and  lime-water.  Sir 
Astley  finds  that  ointments  do  not  generally  agree  with 
the  part ; but  if  used,  he  prefers  that  of  bismuth,  or 
zinc,  or  simple  cerate. 

Sometimes,  when  the  swelling  is  opened,  a consider- 
able quantity  of  milk  is  discharged  ; in  this  case,  Sir 
A.  Cooper  recommends  a sponge  tent  to  be  introduced 
into  the  puncture,  by  which  means  the  adhesive  in- 
flammation and  obliteration  of  the  cavity  will  be  pro- 
duced.—(See  Lancet,  vol.  2,  p.  406.) 

Mr.  Hey  describes  a very  deep-seated  abscess  of  the 
breast  not  of  flequent  occurrence,  and  not  confined  to 
pregnant  nor  suckling  women.  Its  situation  renders 
all  superficial  applications  ineffectual.  The  inflam- 
matory stage  is  tedious;  and  when  the  matter  has 
made  its  way  outwards,  the  discharge  continues,  and 
there  is  no  tendency  to  healing.  Sometimes  the  matter 
lodges  behind  the  mamma,  as  well  as  in  the  substance 
of  the  gland,  and  breaks  out  in  different  places,  the  in- 
termediate parts  of  the  breast  feeling  as  if  affected  with 
a scirrhous  hardness.  Numerous  sinuses  run  in  dif- 
ferent directions,  and  »rhen  caeL'tjd,  a fe.!#ft  purple 
fungus  appears  within  *le  tljease  rcv>( 'ri  in 


MER 


168  MER 

this  state,  for  a long  while,  keeping  up  hectic  symp- 
toms. 

Mr.  Key’s  practice  was  to  trace  the  course  of  all  the 
numerous  sinuses,  and  lay  them  open,  and  he  asserts, 
that  unless  tnis  be  done  with  respect  to  every  one  of 
them,  the  cure  cannot  be  accomplished.  If  he  found 
any  two  sinuses  running  in  such  directions,  that  when 
fully  opened  they  left  a small  part  of  the  mamma  in  a 
pendtilous  state,  he  removed  such  part  entirely.  As 
the  sinuses  are  filled  with  fungus,  their  continuations 
present  no  visible  cavity,  and  can  only  be  detected  by 
the  greater  softness  of  parts  of  the  wound,  where,  oil 
breaking  down  the  fungus,  the  orifice  of  the  collateral 
sinus  may  be  found.  Mr.  Hey  has  found,  that  even  in 
the  most  unfavourable  subjects,  the  wounds  heal 
quickly,  and  the  natural  shape  of  the  breast  is  pre- 
served. 

The  foregoing  treatment,  it  must  be  confessed,  is  se- 
vere; and  if  milder  measures  will  answer,  they  should 
be  preferred.  Instead  of  laying  all  the  sinuses  open. 
Sir  Astley  Cooper  injects  them  with  a lotion  composed 
of  rose-water  and  two  or  three  drops  of  strong  sul- 
phuric acid  to  each  ounce  of  it,  folded  linen,  wet  with 
the  same  application,  being  also  laid  over  the  breast. 
When  a deep-seated  abscess  forms  between  the  ribs 
and  the  posterior  surface  of  the  breast  and  bursts,  so 
as  to  be  attended  with  a sinus,  and  a tedious  exfoli- 
ation of  the  ribs.  Sir  Astley  Cooper  considers  the  injec- 
tion of  diluted  acids  the  best  practice;  for,  unless  the 
dead  bone  be  loose,  no  advantage  can  result  from  the 
division  of  the  sinus. — {Illustrations  of  Diseases  of 
the  Breast,  p.  11.) 

The  breast  is  also  liable  to  chronic  abscesses,  the 
formation  of  which  is  sometimes  so  slow  and  free  from 
pain,  that  the  cases  are  mistaken  for  fleshy  solid  tu- 
mours. The  treatment  recommended  by  Sir  A.  Cooper 
consists  in  letting  out  the  matter,  and  giving  tonic  me- 
dicines ; but  if  the  disease  be  in  an  early  stage,  and 
matter  should  not  yet  have  been  formed,  the  pil.  hy- 
drarg.  submur.  comp,  may  be  prescribed  with  bark  aiid 
soda,  or  the  compound  infusion  of  gentian  with  soda 
and  rhubarb.  To  the  tumour  itself  the  emplastrum 
ammoniac!  cum  hydrargyro,  or  a lotion  containing 
muriate  of  ammonia  and  spirit  of  wine,  may  be  ap- 
plied.— (See  Sir  A.  Cooper's  Illustrations  of  Diseases 
of  the  Breast,  p.  14,  <^c.) 

Pearson's  Principles,  chap.  3.  Hey's  Practical  Ob- 
servations, p.  504.  Kirkland  has  also  treated  of 
several  kinds  of  abscesses  of  the  breast  in  his  Inquiry 
into  the  present  State  of  Medical  Surgery,  vol.  2,  p. 
161.  Callisen,  Sysfema  Chirurgice  Hodiernm,  vol.  1, 
^.332.  Gibbons,  De  Mulierum  Mammis  et  Morbis 
Quibus  obnoxicB  sunt,  8vo.  Edinb.  1775.  J.  Clubbe, 
Treatise  on  the  Inflammation  of  the  Breasts  peculiar 
to  Lying-in  Women,  Src.  8vo.  Ipswich,  1799.  M.  Un- 
derwood, Treatise  upon  Ulcers,  Src.,  and  on  the  Mam- 
mary Abscess,  Src.  8vo.  Land.  1783.  J,  H.  .James,  on 
the  Principles  of  Inflammation,  p.  171,  Lond. 
1821.  Boyer,  Traiti  des  Mai.  Chir.  t.  7,  p.  211,  ^c. 
8vo.  Paris,  1821.  Richter's  Anfangsgr.  der  Wun- 
darzn.  b.  4,  c.  16.  Sir  Astley  Cooper's  Illustrations  of 
Diseases  of  the  Breast,  ito.  Lond.  1829. 

MELICERIS,  (From  ue\i,  honey,  and  Kypog,  wax.) 
A tumour  of  the  encysted  kind,  filled  with  a substance 
resembling  wax  or  honey  in  consistence. — (See  Tu- 
mours, Encysted.) 

MENINGOPHYLAX.  (From  prjviyl,  a membrane, 
and  ^vXaaao),  to  guard.)  An  instrument  used  by  the 
ancients  tor  guarding  the  dura  mater  and  brain  from 
injury  in  their  mode  of  trepanning.  It  seems  to  have 
been  something  like  the  lenticular,  only  its  blade  was 
completely  round  without  an  edge.  It  ended  in  a len- 
tiform  cup,  like  the  latter. — {Encyclopedic  Mithodique, 
Partie  Chlr.'t  Pott  gives  an  engraving  of  a menin»o- 
phylax  which  resembles  a common  elevator. — (See 
Kol.  1 of  his  Works.) 

MERCURY.  {Quicksilver,  Mercurius,  Hydrargy- 
rus.)  The  medicinal  virtues  of  this  mineral  were 
almost  totally  unknown  to  the  ancients,  who  consi- 
dered it  as  a poison.  It  was  first  employed  for  pur- 
poses of  medicine  by  the  Arabians,  who  made  use  of 
it  in  the  form  of  ointments  for  the  cure  of  certain  dis- 
eases of  the  skin  and  the  killing  of  vermin.  In  mo- 
dern limes,  mercury  is  one  of  the  most  im(iortant 
articles  of  the  materia  medica;  and  perhaps,  though 
recent  investigations  will  not  strictly  allow  it  to  be 
regarded  as  a specific  for  the  venereal  disease,  which 


may  be  cured  by  other  means,  or  sometimes  even  spon- 
taneously, while 'mercury,  so  far  from  being  always 
a certain  cure,  is  sometimes  highly  detrimental,  yet 
notwithstanding  these  facts,  mercury  still  retains  the 
character  of  being  generally  the  most  expeditious 
means  of  relief.  The  possibility  of  curing  the  ve- 
nereal disease  without  mercury  by  no  means  esta- 
blishes the  propriety  of  abandoning  this  remedy,  any 
more  than  its  unfitness  for  certain  states  of  the  same 
disease  ought  to  be  a reason  for  not  availing  ourselves 
of  its  superior  utility  in  others. 

Mercury  taken  into  the  stomach  in  its  metallic  state 
has  no  action  on  the  body,  except  what  arises  from  its 
weight  or  bulk.  It  is  not  poisonous,  as  was  vulgarly 
supposed,  but  perfectly  inert.  But  in  its  various  states 
oft. combination  it  produces  certain  sensible  effects.  It 
is  a powerful  and  general  stimulant,  quickening  the 
circulation,  and  increasing  all  the  secretions  and  ex- 
cretions. According  to  circumstances,  the  habit  of  the 
patient,  the  temperature  in  which  he  is  kept,  the  na- 
ture of  the  preparation,  and  the  quantity  in  which  it  is 
exhibited,  its  etfecls  are  indeed  various.  Sometimes  it 
more  particularly  increases  one  secretion,  sometimes 
another;  but  its  most  characteristic  effect  is  the  in- 
creased flow  of  saliva  which  it  generally  e.xciies  if 
given  in  sufficient  quantity. — {Edinb.  Dispensatory.) 

From  the  writings  of  Theodoric  it  appears  that  mer- 
cury was  employed  in  the  practice  of  medicine  and 
surgery  as  early  as  the  thirteenth  century.  But  its  use 
in  venereal  cases  was  first  mentioned  in  a tract  by 
Almenar,  published  in  1516. — (See  Thompson's  Dis 
pensatory,  p.  205,  edit.  2.) 

It  has  been  said  that  the  efficacy  of  mercury  in 
curing  the  venereal  disease  was  an  accidental  disco- 
very ; but  it  seems  more  probable  that  the  good  effects 
which  it  produced  in  cutaneous  diseases  first  led  to  the 
trial  of  it  in  venereal  cases,  which,  being  frequently 
attended  with  eruptions,  ulcers,  &c.  seemed  to  present 
an  analogy  to  the  affections,  in  which  mercury  had 
already  been  found  successful. 

In  the  times  immediately  following  the  supposed 
origin  of  the  venereal  disease,  practitioners  only  ven- 
tured to  employ  this  remedy  with  timorous  caution,  so 
that,  of  several  of  their  formulae,  mercury  scarcely 
composed  a fourteenth  part,  and  either  on  this  account, 
or  some  difference  in  the  disease  itself  at  that  period 
from  what  is  now  remarked,  few  cures  were  effected. 
On  the  other  hand,  the  empirics  who  noticed  the  little 
efficacy  of  these  small  doses  ran  into  the  opposite  ex- 
treme, and  exhibited  mercury  in  quantities  so  large, 
and  with  so  little  care,  that  most  of  their  patients  were 
suddenly  attacked  with  violent  salivations,  frequently 
attended  with  very  dangerous  and  even  fatal  symp- 
toms; or  such  as  after  making  them  lose  their  teeth, 
left  them  pale,  emaciated,  exhausied,  and  subject,  for 
the  rest  of  their  lives,  to  tremblings,  or  other  more  or 
less  dangerous  affections.  From  these  two  very  oppo- 
site modes  of  practice  there  originated  such  uncer- 
tainty respecting  what  could  be  expected  from  mer- 
cury, and  such  fears  of  the  consequences  which  might 
result  from  its  employment,  that  every  plan  was  ea- 
gerly adopted  which  offered  the  least  chance  of  cure 
without  having  recourse  to  this  mineral. 

A medicine,  however,  so  powerful,  and  whose  salu- 
tary effects  had  been  watched  by  attentive  practition- 
ers amid  all  its  inconveniences,  could  not  sink  into 
oblivion.  After  efforts  liad  been  made  to  discover  an 
equally  efficacious  substitute  for  it,  and  it  had  been 
seen  how  inferior  other  means  were,  on  which  the 
highest  praises  had  been  lavished,  the  attempts  to  ex- 
tend its  utility  were  renewed.  A mediuin  was  pur- 
sued between  the  two  timid  methods  of  those  physi- 
cians, who  had  first  administered  it,  and  the  incon- 
siderate boldness  of  empirics.  Thus  the  causes  from 
which  boih  parties  failed,  were  avoided;  the  character 
of  the  medicine  was  revived  in  a more  durable  way, 
and  from  this  period,  its  reputation  has  always  been 
maintained. 

The  renowned  Paracelsus  first  taught  practitioners, 
that  mercury  might  be  given  internally  with  safety ; 
for,  before  he  set  the  example,  it  had  only  been  exter- 
nally employed,  in  three  manners.  The  first  was  in 
the  form  of  an  ointment  or  liniment;  the  second,  as  a 
plaster;  and  the  third,  as  a fumigation. 

The  basis  of  the  ointment  or  liniment  was  quick- 
silver, which  was  blended  by  means  of  trituratiou, 
with  hog’s  lard,  goose’s  fat,  &.c.  and  composed  scarcely 


MERCURY. 


169 


one-sixth  or  one-eighth  of  the  whole;  a proportion, 
however,  much  greater  than  what  had  been  at  first 
employed.  But  from  a fear  that  the  mineral  might 
prove  hurtful  to  the  nerves,  by  the  cold  property  which 
they  fancied  it  to  possess,  and  that  it  might  occasion 
numbness,  tremblings,  or  palsies,  they  combined  with 
it  a multitude  of  ingredients  of  a warm  aromatic  na- 
ture, or  supposed  to  possess  such ; for  example,  oil  of 
camomile,  sesame-seeds,  aniseeds,  the  roots  of  zedoary, 
the  florentine  iris,  and  a thousand  other  substances, 
which  were  incorporated  with  the  ointment.  The 
members,  joints,  atid  the  whole  of  the  body,  except  the 
head,  belly,  and  chest,  were  rubbed  with  this  compo- 
sition ; and  the  frictions  were  repeated  at  suitable  in- 
tervals, until  obvious  signs  of  salivation  appeared. 

The  ingredients  of  the  plasters  resembled  those  of 
the  ointments,  only  they  contained  less  fat,  for  which 
was  substituted  a sufficient  quantity  of  wax,  to  give 
them  a proper  consi.stence.  This  composition  was  ap- 
plied to  the  skin,  and  the  whole  body  was  covered  with 
it,  excepting  the  parts  on  which  it  was  not  usual  to 
put  ointment.  The  plasters  were  kept  on  till  salivation 
began. 

The  fumigations  were  made  with  quicksilver,  tritu- 
rated with  turpentine  or  saliva,  or  else  with  cinnabar. 
These  substances  were  mixed  with  fatty  or  resinous 
ones,  such  as  myrrh,  nutmeg,  &.C.,  and  all  the  ingre- 
dients being  reduced  to  powder,  were  made  into  a 
paste,  with  a sufficient  quantity  of  turpentine  or  gum 
tragacanth.  The  patient  was  then  placed  in  a box 
made  on  purpose,  or  under  a little  kind  of  tent,  out  of 
which  the  head  was  generally  allowed  to  protrude.  A 
chafing-dish,  containing  burning  coals,  was  placed  near 
his  feet,  and  every  now  and  then  bits  of  mercurial 
paste  were  thrown  into  the  vessel.  The  patient  was 
left  exposed  to  the  fumes,  which  arose  until  he  broke 
out  in  a profuse  perspiration,  which  they  took  great 
pains  to  keep  up  and  increase,  by  putting  him  into  a 
warm  bed,  loading  him  with  bedding,  for  about  two 
hours,  after  which  he  was  rubbed  quite  dry  and  given 
some  food.  This  plan  was  persisted  in  every  d<ay,  till 
a salivation  was  produced,  which  was  kept  up  as  long 
as  necessary.  The  method  of  fumigation  is  described 
by  Astruc,  and  particular  preparations,  and  appara- 
tuses for  the  purpose,  have  been  since  recommended  by 
Lalonette  in  France,  and,  more  recently,  by  Abernethy 
in  England. 

Of  the  three  methods  which  have  just  been  described, 
only  the  first  is  at  present  much  in  use,  and  even  this 
is  considerably  altered.  It  was  found,  not  only  that 
niercurial  plasters  caused  heat,  redness,  itching,  and 
disagreeable  eruptions,  but  that  the  method  was  ex- 
ceedingly slow  and  uncertain.  Hence,  plasters  are  now 
only  used  as  topical  discutient  applications. 

Fumigations,  considered  as  tiie  only  means  of  cure, 
fell  also  into  discredit,  because,  although  they  formed  a 
method  of  applyitig  mercury  in  a very  active  manner, 
they  were,  a8  anciently  managed,  liable  to  several  ob- 
jections. In  this  way,  it  was  next  to  impossible  to  re- 
gulate the  quantity  of  mercury  used,  which  varied 
according  to  the  greater  or  less  activity  of  the  fire, 
the  position  of  the  patient,  and  other  circumstances. 
The  effect  of  the  vapour  on  the  organs  of  respiration 
also  frequently  proved  very  oppressive ; and  mercury, 
applied  in  the  way  of  fumigation,  more  fiequently  oc- 
casioned tremblings,  palsies,  &c.  than  in  any  other 
manner.  In  Mr.  Abernethy’s  mode,  however,  fumiga- 
tion is,  under  certain  circumstances,  not  only  an  eligi- 
ble, but  the  very  best  way  of  affecting  the  constitution. 

Frictions  with  ointment  have  always  been  regarded 
as  the  most  efficacious.  They  have  undergone  consi- 
derable change,  and  by  being  rendered  more  simple, 
have  been  greatly  perfected.  All  the  warm  aromatic 
substances  have  been  retrenched  from  the  ointment, 
not  only  as  useles.s,  but  as  irritating  and  inflaming  to 
the  skin.  In  modern  times,  the  proportion  of  mercury 
tj  the  fat  has  also  been  very  much  increased. 

OZNERAL  REMARKS  ON  THE  ADMINISTRATION  OF  MER- 
CURY, ITS  OCCASIONAL  CONSEQUENCES,  ETC. 

With  regard  to  the  preparations  of  the  medicine,  and 
the  modes  of  applying  it,  we  are  to  consider  two  things ; 
first,  the  preparation  and  mode  attended  with  the  least 
trouble,  or  inconvenience  to  the  patient ; and,  secondly, 
the  preparation  and  mode  of  administering  it,  that 
most  readily  conveys  the  necessary  quantity  into  the 
constitution.  Mercury  is  carried  into  the  constitution 


in  the  same  way  as  other  substances,  either  by  being 
absorbed  from  the  surface  of  the  body,  or  that  of  the 
alimentary  canal.  It  cannot,  however,  in  all  cases,  be 
taken  into  the  constitution  in  both  ways;  forsometimes 
the  absorbents  of  the  skin  will  not  readily  receive  it, 
at  least,  no  ettect  is  produced,  either  on  the  disease  or 
constitution,  from  lliis  mode  of  application.  In  this 
circumstance,  mercury  must  be  given  by  the  mouth, 
although  the  plan  may  be  very  improper  in  other  re- 
spects, and  often  inconvenient.  On  the  other  hand, 
the  internal  absorbents  sometimes  will  not  take  up  the 
medicine,  or,  at  least,  no  effect  is  produced  on  the  dis- 
ease, or  the  constitution. 

In  such  cases,  all  the  different  preparations  of  the 
medicine  should  be  tried;  for  sometimes  one  succeeds 
when  another  will  not.  In  some  cases,  mercury  seems 
to  have  no  effect,  either  applied  outwardly,  or  taken 
into  the  stomach.  Many  surfaces  seem  to  absorb  mer- 
cury better  than  others  ; such  are  probably  all  internal 
surfaces  and  sores.  Thirty  grains  of  calomel,  rubbed 
in  on  the  skin,  have  not  more  effect  than  three  or  four 
taken  by  the  mouth.  Dressing  small  ulcers  with  red 
precipitate  sometimes  causes  a salivation. — (See  Hun- 
ter on  the  Venereal  Disease,  p.  335,  336.) 

B<‘sides  the  practicableness  of  getting  the  medicine 
into  the  constitution  in  either  way,  it  is  projier  to  con- 
sider the  easiest  for  the  patient,  each  mode  having  its 
convenience  and  inconvenience,  depending  on  the  na- 
ture of  the  parts  to  which  it  is  applied,  or  on  certain 
situations  of  life  at  the  time.  Hence,  it  should  be 
given  in  the  way  most  suitable  to  such  circumstances. 

In  many,  the  bowels  can  hardly  bear  mercuiy  at  ail, 
and  it  should  then  be  given  in  the  mildest  form  possi- 
ble, conjoined  with  such  medicines  as  will  lessen  or 
correct  its  violent  local  effects,  although  not  its  specific 
ones  on  the  constitution. 

When  mercury  can  be  thrown  into  the  constitution 
with  propiiety  by  the  external  method,  it  is  prefeiable 
to  the  internal  plan,  because  the  skin  is  not  nearly  so 
essential  to  life  as  the  stomach,  and  therefore  is  capa- 
ble in  itself  of  bearing  much  more  than  the  stomach. 
The  constitution  is  also  less  injured.  Many  courses  of 
mercury  would  kill  the  patient,  if  the  medicine  were 
only  given  internally,  because  it  proves  hurtful  to  the 
stomach  and  intestines,  when  given  in  any  form,  or 
joined  with  the  greatest  correctors.  Every  one,  how- 
ever, has  not  opportunities  of  rubbing  in  mercury,  and 
is  therefore  obliged,  if  possible,  to  take  it  by  the  mouth. 
— ( Hunter,  p.  338.) 

Mercury  has  two  effects : one  as  a stimulus  on  the 
constitution  and  particular  parts;  the  other  as  a spe- 
cific against  a diseased  action  of  the  whole  body,  tir  of 
parts.  The  latter  action  can  only  be  computed  by  the 
disease  disappearing. 

When  mercury  is  given  in  venereal  cases,  the  first 
attention  should  be  to  the  quantity,  and  its  visible  effects 
in  a given  time,  which,  when  brought  to  a proper  pitch, 
are  only  to  be  kept  up,  and  the  decline  of  the  disease 
to  be  watched;  for  by  this  we  judge  of  the  invisible 
or  specific  effects  of  the  medicine,  and  know  what  va- 
riation in  the  quantity  may  be  necessary.  The  visible 
effects  of  mercury  affect  either  the  whole  constitution, 
or  some  parts  capable  of  secretion.  In  the  first,  it  pro- 
duces universal  irritability,  making  it  more  susceptible 
of  all  impressions.  It  quickens  the  pulse,  increases  its 
hardnes.s,  and  occasions  a kind  of  temporary  fever.  In 
some  constitutions,  it  operates  like  a poison  ; while,  in 
others,  it  produces  a kind  of  hectic  fever,  that  is,  a 
a small,  quick  pulse,  loss  of  appetite,  restlessness,  want 
of  sleep,  and  a sallow  complexion,  with  a number  of 
consequent  symptoms;  but  such  effects  commonly  di- 
minish. on  the  patient  becoming  a little  accustomed  to 
the  medicine.  Mercury  often  produces  pains  like  those 
of  rheumatism,  and  nodes  of  a scrofulous  nature. — 
(//ttnter,p.33!),  340.) 

The  quantity  of  mercury  to  be  thrown  into  the  con- 
stitution for  the  cure  of  any  venereal  complaint,  must 
be  proportioned  to  the  violence  of  the  disea-se.  How- 
ever, we  are  to  be  guided  by  two  circumstances,  namely, 
the  time  in  which  any  given  quantity  is  to  be  thrown 
in,  and  the  effects  it  has  on  some  parts  of  the  body,  as 
the  salivary  glands,  skin,  or  intestines.  For  mercury 
may  be  thrown  into  the  same  constitution  in  very  dif- 
ferent quantities,  so  as  to  produce  the  sanie  ultimate 
effect  ; but  the  two  very  different  quantities  must  also 
be  in  different  times;  for  instance,  one  ounce  of  mer- 
curial ointment,  used  in  two  days,  will  have  more 


170 


MERCURY. 


effect  upon  the  constitution,  than  two  ounces  used  in  ten. 
The  effects  of  one  ounce,  used  in  two  days,  on  the 
constitution  and  diseased  parts,  are  considerable.  A 
small  quantity,  used  quickly,  will  have  equal  effects  to 
those  of  a large  one  employed  slowly ; but,  if  these 
effects  are  principally  local,  that  is,  upon  the  glands  of 
the  mouth,  the  constitution  at  large  not  being  equally 
stimulated,  the  effect  upon  the  diseased  parts  must  be 
less,  which  may  be  known  by  the  local  disease  not 
giving  way  in  proportion  to  the  effects  of  mercury  on 
some  particular  part.  If  it  is  given  in  very  small  quan- 
tities, and  increased  gradually,  so  as  to  steal  insensibly 
on  the  constitution,  a vast  quantity  at  a time  may  at 
letigth  be  used,  without  any  visible  effect  at  all.— (//an- 
ter,  p.  341.) 

These  circumstances  being  known,  mercury  becomes 
a much  more  efficacious,  manageable,  and  safe  medi- 
cine, than  it  was  formerly  thought  to  be ; but  unluckily, 
its  visible  effects  upon  the  mouth  and  the  intestines 
are  sometimes  much  more  violent  than  its  general 
etfect  upon  the  constitution  at  large.  These  parts  must 
therefore  not  be  stimulated  so  quickly,  as  to  hinder  the 
necessary  quantity  of  mercury  from  being  used. 

The  constitution  or  parts  are  more  susceptible  of 
mercury  at  first  than  afterward.  If  the  mouth  is  made 
sore,  and  allowed  to  recover,  a much  greater  quantity 
may  be  thrown  in  a second  time,  before  the  same  sore- 
ness is  produced.  However,  anomalous  cases  occur, 
in  which,  from  unknown  causes,  mercury  cannot  at 
one  time  be  made  to  produce  any  visible  effects ; but 
afterward  the  mouth  and  intestines  are  all  at  once 
affected. — {^Hunter,  p.  342.) 

Mercury  occasionally  attacks  the  bowels,  and  causes 
violent  purging,  even  of  blood.  This  effect  is  remedied 
by  discontinuing  the  use  of  the  medicine  and  exhibit- 
ing opium.  At  other  times,  it  is  suddenly  determined 
to  the  mouth,  and  produces  inflammation,  ulceration, 
and  an  excessive  flow  of  saliva.  To  obtain  relief  in 
this  circumstance,  purgatives,  nitre,  sulphur,  gum- 
arabic,  lime-water,  camphor,  bark,  the  sulphuret  of 
potash,  blisters,  &e.  have  been  advised.  Mr.  Pearson, 
however,  does  not  seem  to  place  much  confidence  in 
the  efficacy  of  such  means,  and  the  mercury  being  dis- 
continued for  a time,  he  recommends  the  patient  to  be 
freely  exposed  to  a dry  cold  air,  with  the  occasional  use 
of  cathartics,  Peruvian  bark,  and  mineral  acids,  and 
the  assiduous  application  of  astringent  gargles.  “ The 
most  material  objection  (says  Mr.  Pearson),  which  I 
foresee  against  the  method  of  treatment  I have  recom- 
mended, is  the  hazard  to  which  the  patient  will  be  ex- 
posed of  having  the  saliva  suddeidy  checked,  and 
of  suffering  some  other  disease  in  consequence  of  it. 

“ That  tlie  hasty  suppression  of  a ptyalism  may  be 
followed  by  serious  inconveniences,  has  been  proved 
by  Dr.  Silvester  (Med.  Obs.  and  Inq.  vol.  3),  who  pub- 
lished the  cases  of  three  persons,  who  had  been  under 
his  own  care;  two  of  whom  were  afflicted  with  vio- 
lent pains ; and  the  third  scarcely  retained  any  food  in 
her  stomach  for  the  space  of  three  months.  I have 
seen  not  only  pains,  but  even  general  convulsions,  pro- 
duced from  the  same  cause.  But  this  singular  kind  of 
metastasis  of  the  mercurial  irritation  does  not  appear 
to  me  to  owe  its  appearance  to  simple  exposure  to  cold 
and  dry  air;  because,  I have  known  it  occur  in  differ- 
en  forms,  where  patients  continued  to  breathe  a warm 
atmosphere,  but  used  a bath,  the  water  of  which  was 
not  sufficiently  heated.  Cold  liquids,  taken  in  a large 
quantity  into  the  stomach,  or  exposure  of  the  body  to 
cold  and  moisture,  will  also  prove  extremely  injurious 
to  those  who  are  fully  under  the  influence  of  mercury; 
whereas  breathing  a cool  air,  while  the  body  is  pro- 
perly covered  with  apparel,  has  certainly  no  tendency 
to  produce  any  distressing  or  dangerous  con.sequences. 

“ If,  however,  a suppression  of  the  ptyalism  should 
be  occasioned  by  any  act  of  indiscretion,  the  remedy  is 
easy  and  certain ; it  consists  only  in  the  quick  intro- 
duction of  mercury  into  the  body  so  as  to  produce  a 
soreness  of  the  gums,  with  the  occasional  use  of  a hot 
bath.” — (Pearson  on  the  Effect  of  various  Articles  in 
the  Cure  of  Lues  Venerea.,  ed.  2,  p.  163, 164.) 

Mercury,  when  it  falls  on  the  mouth,  produces,  in 
many  constitutions,  violent  inflainmatior.,  which  some- 
times terminates  in  mortification.  In  these  habits, 
great  caution  is  necessary.  The  ordinary  operation  of 
inercury  does  not  peimanently  injure  the  constitution ; 
but  occasionally,  the  impairment  is  very  material ; 
mercury  may  even  produce  local  disease,  and  retard  the 


cure  of  chancres,  buboes,  and  certain  effects  of  the  luea 
venerea,  after  the  poison  has  been  destroyed. — (Hunter, 
/I.342.) 

From  mercury  occasionally  acting  on  the  system  as 
a poison,  quite  unconnected  with  its  agency  as  a re- 
medy, and  neither  proportionate  to  the  inflammation 
of  the  mouth,  nor  the  actual  quantity  of  the  mineral 
absorbed,  Mr.  Pearson  noticed  that  one  or  two  patients 
in  general  died  suddenly  every  year  in  the  Lock  Hos- 
pital. The  morbid  state  of  the  system,  which  tends  to 
the  fatal  event  during  a mercurial  course,  is  named  by 
Mr.  Pearson  erethismus,anA  is  characterized  by  great 
depression  of  strength,  a sense  of  anxiety  about  the 
praecordia,  irregular  action  of  the  heart,  frequent  sigh- 
ing, trembling,  a small,  quick,  and  sometimes  an  inter- 
mitting pulse,  occasional  vomiting,  a pale  contracted 
countenance,  a sense  of  coldness ; but  the  tongue  is 
seldom  furred,  and  neither  the  vital  nor  natural  func- 
tions are  much  disordered ; a statement,  however,  ac- 
cording to  my  notions,  not  very  consistent  with  the 
alleged  irregular  action  of  the  heart.  They  who  die 
suddenly  of  the  mercurial  erethismus  have  frequently 
been  making  some  little  exertion  just  before.  To  pre- 
vent the  dangerous  consequences  of  this  state  of  the 
system,  the  use  of  mercury  must  be  discontinued, 
whatever  may  be  the  stage,  extent,  or  violence  of  the 
venereal  symptoms.  The  patient  should  be  directed 
to  expose  himself  freely  to  a dry  and  cool  air,  in  such 
a manner  as  shall  be  attended  with  the  least  fatigue, 
and  he  should  have  a generous  diet.  In  this  manner, 
patients  often  recover  sufficiently  in  ten  or  fourteen 
days,  to  resume  the  use  of  mercury  with  safety.  In 
the  early  stage,  the  mercurial  erethismus  may  often  be 
averted  by  leaving  off  the  mercury,  and  giving  the  mis- 
tura  camphorata  with  large  doses  of  ammonia.  When 
the  stomach  is  unaffected,  sarsaparilla  sometimes  does 
good. — (Pearson,  p.  154,  <J-c.) 

Occasionally  the  use  of  mercury  brings  on  a peculiar 
eruption,  which  has  received  the  several  names  of  hy- 
drargyria, mercurial  rash,  eczema  mercuriale,  eczema 
rubrum,  lepra  mercurialis,  mercurial  disease,  and  ery- 
thema mercuriale. 

“ Eruptions  of  various  kinds  are  very  common  symp. 
toms  of  syphilis,  but  a very  unusual  effect  of  mercury. 
Therefore,  until  the  real  nature  of  this  erythema  was 
lately  discovered,  whenever  it  occurred  in  patients un- 
dergoing a mercurial  course  for  syphilitic  complaints, 
it  was  naturally  enough  considered  as  an  anomalous 
form  of  lues  venerea.  The  mercury  was  conse- 
quently pushed  fo  a greater  extent,  in  proportion  to  the 
violence  of  the  symptoms;  and  from  the  cause  of  tlie 
disease  being  thus  unconsciously  applied  for  its  removal, 
it  could  not  fail  to  be  aggravated  and  hurried  on  to 
a fatal  termination.  The  observation  of  this  fact, 
conjoined  with  another  of  less  frequent  occurrence, 
namely,  that  a similar  eruption  did  sometimes  appear 
in  patients  using  mercury  for  other  complaints,  and  in 
whom  no  suspicion  of  syphilis  could  be  entertained,  at 
last  led  some  judicious  practitioners  in  Dublin  to  the 
important  discovery,  that  the  eruption  was  entirely  an 
effect  of  mercury,  and  not  at  all  connected  with  the  ori- 
ginal disease.  This  discovery  was  not  published  till 
1804.” — (M^Mullin  in  Edinburgh  Medical  and  Surgi- 
cal Journal,  Mo.  5.)  Mr.  Pearson  states,  ho.wever, 
that  he  has  been  acquainted  with  the  disease  ever 
since  1781,  and  has  always  described  its  history  and 
treatment  in  his  lectures  since  1783. 

The  eruption  is  attended  with  more  or  less  indi'nosi 
tion,  is  not  confined  to  either  sex,  or  any  pa-ticular 
constitution,  and  seems  to  be  equally  produced  by  mer- 
cury applied  externally,  and  by  any  of  its  preparations 
taken  inwardly.  Mr.  Pearson  has  never  seen  it  in 
subjects  above  fifty;  and  he  says,  its  occurrence  is 
more  common  about  eight  or  ten  days  after  beginning 
a mercurial  course. — (P.  166.) 

Dr.  M'Mullin  has  described  three  distinct  stages  of 
the  erythema  mercuriale.  “ The  first  stage  commences 
with  languor,  lassitude,  and  cold  shiverings;  these 
symptoms  are  succeeded  by  increased  temperature  of 
the  body,  quick  pulse,  nausea,  headache,  and  thirst. 
The  patient  is  troubled  with  a dry  cough,  and  com- 
plains of  difficult  respiration,  anxiety,  and  sense  of 
stricture  about  the  pra'cordia.  The  tongue  is  usually 
moist,  and  covered  with  a wliite  glutinous  slime-  it 
sometimes  appears  clean,  and  brightly  red  in  .he  centre, 
while  the  margins  remain  foul.  The  skin  feels  un- 
usually hut  and  itchy,  with  a sense  of  prick’ing;  not 


MERCURY. 


unlike  the  sensation  experienced  from  the  application 
of  nettles.  The  belly  is  generally  costive  ; but  a diar- 
rhoea is  often  produced  by  very  slight  causes. 

“Ob  the  twsl  or  second  day,  an  eruption  most  com- 
monly shows  itself,  the  colour  of  which  is  either  dark 
or  bright  red : the  papulae  are  at  first  distinct  and  ele- 
vated, resembling  very  much  those  in  rubeola.  Sonie- 
time^  but  rarely,  the  eruption  apjiears  like  urticaria, 
and  in  such  instances  the  disease  is  observed  to  be  very 
mild.  The  papulae  very  speedily  run  together,  in  such 
a manner  as  to  form  a suffused  redness,  which  disap- 
pears on  pressure.  In  most  cases,  it  begins  first  on  the 
scrotum,  inside  of  the  thighs,  forearm,  or  where  mer- 
curial friction  has  been  applied,  and  the  integuments  of 
the  parts  affected  become  much  swollen.  There  have 
also  been  observed  instances,  where  an  eruption  of  a 
purplish  colour,  and  unaccompanied  by  papulte,  has 
■diffused  itself  suddenly  over  the  entire  body.  Tlris, 
however,  may  be  considered  as  uncommon.  In  every 
instance  which  came  under  my  observation,  it  was 
confined  at  first  to  a few  places,  and  from  thence  gra- 
dually extended,  until  the  different  portions  of  the 
eruption  had  united,  and  the  papulae  were  also  rough. 
But  in  those  cases  which  resemble  urticaria,  a number 
of  minute  vesicles,  which  contain  a serous  fluid,  ap- 
pear, from  the  commencement,  interspersed  among  the 
papulae.  Contrary  to  what  Jiappens  in  most  diseases 
accompanied  with  cuttmeous  affections,  the  febrile 
symptoms  are  much  aggravated,  and  continue  to  in- 
crease after  the  eruption  has  been  completed.  The 
pulse  in  general  beats  from  120  to  130  in  a minute,  the 
thirst  continues  urgent,  and  the  patient,  extremely  rest- 
less, seldom  enjoys  quiet  sleep.  When  the  eruption 
has  continued  in  this  manner  for  a certaiti  period,  the 
cuticle  begins  to  peel  off  in  thin,  whitish,  scurfy  exfolia- 
tions, not  unlike  those  observed  in  rubeola.  This  de- 
squamation has  not  been  attended  to  by  Dr.  Moriarty  or 
Mr.  Alley,  if  they  have  not,  by  giving  the  same  name 
to  the  decrustation  which  occurs  in  the  last  stage,  con- 
founded both  together.  It  commences  in  those  places 
where  the  eruption  first  made  its  appearance,  and  in 
this  order  spreads  to  other  parts.  About  this  period  the 
fauces  become  sore,  the  tongue  swells,  and  the  eyes 
appear  somewhat  itiflamed. 

“ The  duration  of  this  stage  is  very  various  ; some- 
times it  continues  from  ten  to  fourteen  days,  and  in 
other  cases  it  terminates  in  half  that  time.  When  the 
disease  has  appeared  in  its  mildest  form,  the  patient 
recovers  immediately  after  the  desquamation,  a new 
cuticle  having  formed  underneath ; but,  if  severe,  he 
has  only  experienced  the  smallest  part  of  his  sufferings, 
and  the  skin  now  assumes  a new  appearance,  which  I 
have  considered  as  the  second  stage. 

“The  skin  at  this  period  appears  as  if  studded  with 
innumerable  minute  vesicles,  which  are  filled  with  a 
pellucid  fluid.  These  vesicles  may  be  expected,  if  the 
patient,  at  the  close  of  the  first  stage,  complains  of  in- 
creased itching,  and  sense  of  burning  heat,  in  those 
parts  from  which  the  cuticular  exfoliations  have  fallen. 
They  remain  sometimes  for  a day  or  two,  but  are  most 
commonly  burst,  immediately  after  their  formation,  by 
the  patient  rubbing  them,  in  order  to  relieve  the  trou- 
blesome itchiness  with  which  these  parts  are  affected. 
They  discharge  a serou.s,  acrimonious  fluid,  which  po.s- 
sesses  such  a very  disagreeable  odour  as  to  iiuiuce 
nausea  in  the  patient  himself,  and  those  who  approach 
near  his  bedside.  I'he  odour  is  so  peculiar  that  it  can 
easily  be  recognised  by  any  person  who  has  once  ex- 
perienced it. 

“ This  fluid  is  poured  out  most  copiously  from  the 
scrotum,  groin,  inside  of  the  thighs,  or  wherever  the 
skin  forms  folds,  and  the  sebaceous  glands  are  most 
numerous.  The  serous  discharge  from  these  minute 
vesicles  forms,  with  the  cuticle,  an  incrustation,  which 
may  be  considered  as  the  third  or  last  state. 

“These  crusts  are  generally  very  large,  and,  when 
detached,  retain  the  figure  of  the  parts  from  which 
they  have  fallen.  Their  colour  is  yellowish ; but  some- 
times appears  dark  and  dirty.  This  period  of  the  dis- 
ease might  be  termed,  1 think,  with  much  propriety, 
the  stage  of  decrustation^  in  order  to  distinguish  it 
more  fully  from  the  desquamation^  which  has  been 
already  noticed.  From  the  use  of  the  last  two  terms 
indiscriminately,  those  who  have  described  the  disease 
have  introduced  into  their  descriptions  a degree  of  con- 
fusion which  has  caused  its  progress  not  to  be  well  un- 
derstood. When  this  stage  appears,  the  fauces  become 


171 

more  affected,  the  eyes  intolerant  of  light,  and  the  tarsi 
tender,  inflamed,  and  sometimes  inverted.  The  crusts 
formed  on  the  face,  as  in  other  parts  of  the  body,  be- 
fore falling  off,  divide  asunder,  so  as  to  leave  cracks 
and  fissures,  which  produce  a hideous  expression  of 
countenance ; and  the  eyelids  are  also,  from  the  gene- 
ral swelling  of  the  face,  completely  closed.  The  back 
and  hairy  scalp  are  last  affected,  and,  even  in  very 
severe  cases,  these  parts  are  sometimes  observed  to 
escape  entirely.  The  patient,  while  in  this  stale,  is 
compelled  to  desist  from  every  kind  of  motion,  on  ac- 
count of  the  pain  which  he  experiences  on  the  slightest 
exertion,  and  which  he  describes  as  if  his  flesh  were 
cracking.  The  crusts  also  fall  off  in  such  abundance, 
that  the  bed  appears  as  if  strewed  with  the  cones  of 
hops.  While  the  eruption  is  only  making  its  appear- 
ance in  one  place,  another  part  may  have  arrived  at  its 
most  advanced  form ; so  that  all  the  different  stages  of 
the  disease  may  be  present  at  one  time  in  the  same  in- 
dividual. It  is  attended  with  typhus  through  its  entire 
course;  but  it  is  very  curious  to  observe,  that  the  ap- 
petite for  food,  in  most  cases,  remains  unimpaired,  and 
sometimes  is  even  voracious.  This  circumstance  was 
particularly  remarkable  in  a patient  who  laboured 
under  the  disease,  in  its  worst  form,  for  the  space  of 
three  months,  in  tlie  Royal  Infirmary  of  Edinburgh ; 
for  double  the  usual  hospital  allowance  of  food  was 
scarcely  sufficient  to  satisfy  his  hunger.  When  the 
catarrhal  symptoms  have  continued  during  the  pro- 
gress of  the  complaint,  they  are  at  tiiis  advanced  pe- 
riod particularly  aggravated  ; the  anxiety  and  pain  of 
the  breast  are  also  very  severe,  attended  with  cough, 
and  bloody  expectoration,  and  the  patient  always  feels 
languid  and  dejected.  The  pulse  becomes  frequent, 
feeble,  and  irregular,  the  tongue  black  and  parched, 
and  at  length  diarrhoea,  delirium,  convulsions,  gan- 
grene of  the  surface  of  the  body,  and  death,  supervene. 
In  its  mild  form  it  only  goes  through  the  first  stage,  and 
terminates,  as  we  have  already  stated,  in  a few  days, 
by  a slight  desquamation.  But  when  severe,  it  is  often 
protracted  more  than  two  months,  every  stage  of  the 
eruption  continuing  proportionably  longer;  and  when, 
in  this  manner,  it  lias  run  its  course,  it  repeatedly 
breaks  out  on  the  new  surface,  and  passes  through  the 
same  stages.” — {M'^Mullin  in  Edinb.  Med.  and  Surg. 
Journal,  Mo.  5.) 

The  remote  cause  is  the  employment  of  mercury. 
Dr.  M‘Mullin  is  inclined  to  believe  with  Dr.  Gregory, 
that  the  application  of  cold  to  the  body  while  under  the 
action  of  mercury,  is  absolutely  necessary  for  its  pro- 
duction ; an  opinion  strengthened  by  the  constant  pre- 
valence of  catarrhal  symptoms.  However,  Mr.  Pear- 
son thinks  that  cold  has  no  concern  in  bringing  on  the 
complaint  in  patients  under  the  influence  of  mercury. 
At  the  same  time  it  merits  particular  attention,  that  the 
disease  is  not  exclusively  occasioned  by  mercury, 
either  in  its  general  or  more  partial  attacks ; it  has 
been  observed  to  follow  exposure  to  cold,  and  to  recur 
in  the  same  individual  at  regular  intervals,  without 
any  obvious  or  adequate  cause. — (Bateman's  Synopsis, 
p.  256,  ed,  3 ; Rutter  in  Edin.  Med.  and  .Surg.  Journ. 
vol.  5,  p.  143;  Marcet  in  Med.  Chir.  Trans,  vol.  2, 
art.  9.) 

In  tlie  early  stage,  Mr.  Pearson  recommends  small 
doses  of  antimoniai  powder,  with  saline  draughts,  or 
the  ammonia  acatata.  A gentle  purgative  should  be 
given  every  three  or  four  days,  and  opium  to  procure 
sleep.  The  latter  medicine  sometimes  does  most  good, 
when  joined  with  camphor,  or  Hoffman’s  anodyne 
liquor.  Sarsaparilla  and  bark  may  be  given  when  the 
discharge  is  no  longer  ichorous,  and  the  tumefaction 
has  subsided.  Vitriolic  acid  has  .seemed  to  give  relief. 
The  diet  may  be  light  and  nutritive,  without  fermented 
liquors,  however,  till  the  desquamation  has  somewhat 
advanced.  Frequent  use  of  the  warm  bath,  and  often 
changing  the  patient’s  linen  and  sheets,  which  soon 
become  stiff  and  rough  with  the  discharge,  afford  much 
benefit.  If  the  warm  bath  cannot  be  had,  Mr.  Pear- 
sou  advises  washing  the  body  very  tenderly  with  warm 
water-gruel  ; he  also  covers  parts  from  which  the  cu- 
ticle is  detached,  with  a mild  cerate,  and  renews  the 
application  twice  a day. — (P.  178.) 

Dr.  M‘Mullin  advises  the  immediate  discontinuance 
of  mercury  ; the  removal  of  the  patient  from  wards 
where  this  mineral  is  in  use  ; emetics  and  diaphoretics ; 
but,  on  account  of  the  very  irritable  state  of  the  bowels, 
he  says,  antimoniuls  arc  hardly  admissible,  and  that 


172 


MERCURY. 


■when  purgatives  are  indicated,  only  the  mildest  ones, 
such  as  ol.  ricini,  sulphate  of  magnesia,  &c.  ought  to 
be  given.  He  advises  mucilaginous  draughts  with 
opium  f(»r  relieving  the  soreness  of  the  fauces.  In  the 
second  stage,  the  cold  infusion  of  bark  with  aromatics 
and  opium,  or,  what  is  more  praised,  wine,  porter,  &c. 
I’o  relieve  the  ophtlialmia  tarsi,  the  unguentum  oxidi 
zinci,  and  to  appease  the  painful  sensation  of  the  skin 
cracking,  the  linimenlum  calcis,  which  should  be  li- 
berally applied  as  soon  as  crusts  appear. 

Consult  Essay  on.  a Pecvliar  Eruptive  Disease,  ari- 
sing from  the  Exhibition  of  Mercury,  by  O.  ^lley,  Svo. 
Dublin,  1804:  also  Observations  on  the  Hydrargyria, 
or  that  Vesicular  Disease  arising  from  the  Exhibition 
of  Mercury,  4to.  Lond.  1810.  Ji  Description  of  the 
Mercurial  Lepra,  by  Dr.  Moriarty,  Vinio.'  Dublin, 
1804.  Upens  and  M'Mullin,  in  Edinburgh  Med.  and 
SurgicalJournal,Mos.  I and  5.  Pearson  on  Lues  Ve- 
nerea, edit.  2.  Bateman's  Synopsis, p.  256,  ^c.  ed.  3. 

Frictions  with  Mercurial  Ointment. 

No  metal  acts  in  its  pure  metallic  state  ; it  must  first 
be  more  or  less  combined  with  oxygen.  The  mercury 
contained  in  the  unguentum  hydrargyri  becomes  in  a 
certain  degree  oxydaled,  when  triturated  for  the  pur- 
pose of  blending  it  with  the  fat.  The  metal,  howev  er, 
in  mercurial  oinlmenl,  is  in  the  most  simple  and  least 
combined  form  of  all  its  preparations,  and  hence  it  not 
only  generally  operates  with  more  mildness  on  the 
system,  but  with  more  specific  effect  on  the  disease. 
Various  salts  of  mercury,  when  given  internally,  ope- 
rate more  quickly  than  mercurial  frictions;  yet  some 
practitioners,  erroneously,  I believe,  do  not  confide  in 
any  internal  preparations  for  curing  the  venereal  dis- 
ease, particularly  when  the  virus  has  produced  effects 
in  consequence  of  absorption.  We  shall  only  just 
mention  in  this  part  of  the  work,  that  rubbing  in  mer- 
curial ointment  is  the  mode  of  affecting  the  system 
with  mercury,  which  is  generally  considered  to  agree 
best  with  most  constitutions,  and  to  act  with  most  cer- 
tainty on  the  venereal  disease.  The  plan,  however, 
on  account  of  its  uncleanliness,  is  frequently  omitted. 

Mercurial  Fumigations. 

We  have  mentioned  this  method  as  being  one  of  the 
most  ancient  plans  of  affecting  the  constitution  with 
mercury,  and  Lalonette  and  Abernethy  have  stated 
circumstances  in  its  favour,  which  certainly  render  it 
sometimes  a very  eligible  mode.  The  latter  is  of  opi- 
nion, that  if  the  peculiar  advantages  of  mercurial  fumi- 
gation were  generally  known  to  practitioners,  they 
would  be  much  more  frequently  employed.  The  ad- 
vantages of  the  method  consist  in  its  affecting  the  con- 
stitution when  other  means  have  failed,  and  in  pro- 
ducing its  effects  in  a much  shorter  time,  than  any 
other  mode  requires.  How  desirable  this  celerity  of 
operation  must  often  be  when  venereal  ulceration  is 
making  great  ravages  in  the  palate,  throat,  i.Vc.  it  is 
needless  to  insist  upon.  In  patients  who  have  not 
strength  to  rub  in  dintment,  and  whose  bowels  will  not 
bear  the  internal  exhibition  of  mercury,  the  mode  of 
fumiiiation  may  prove  of  great  service. 

“ In  the  year  1776,  the  Chevalier  Lalonette,  a phy- 
sician at  Pari.s,  laid  before  the  public  an  account  of  a 
new  mode  of  mercurial  fumigation,  free  from  the  in- 
conveniences of  former  ones,  and  which  in  the  space 
of  thirty-five  years  he  had  successfully  employed  in 
mftre  than  four  hundred  cases  that  had  resisted  all  the 
ordinary  methods  of  cure.  His  method  consisted  in 
enclosing  the  patient,  previously  undressed,  in  a kind 
of  box  resembling  a sedan-chair,  with  an  opening  at 
tlie  top  to  let  out  the  head,  and  another  at  the  bottom, 
to  which  was  fitted  a small  grate  or  furnace,  having  in 
it  a heated  iron  for  converting  the  mercurial  remedy  into 
fume.  The  preparation  he  made  use  of  was  a kind  of 
calomel,  which,  by  repeated  sublimation  from  iron 
filings,  was  so  far  deprived  of  its  muriatic  acid,  as  to 
be  in  part  reduced  into  running  quicksilver;  and  while 
it  possessed  considerable  volatility,  was  perfectly  uurr- 
I itating.  Some  of  this  powder  being  strewed  upon  the 
hot  iron  placed  below,  was  immediately  converted  into 
smoke,  which  surrounded  the  patient’s  body,  and  after 
some  time  settled  on  his  skin  in  the  form  of  a white 
and  very  fine  calx  of  quicksilver;  a complete  dress, 
having  its  inner  surface  fumigated  with  the  same  pow- 
der, was  then  put  on.  The  remedy  being  thus  gene- 
rally applied  to  the  mouths  of  the  cutaneous  absorbents, 


soon  got  admission  into  the  circulating  fluids,  and  the 
constitution  became  tliereby  more  speedily  affected  than 
•by  any  process  known  heioxe..— {.Abernethy' s Surgical 
and  Physiological  Essay. =, part  3.) 

As  the  fumigating  powder  used  by  M.  Lalonette  was 
very  operose,  and  consequently  an  expensive  p/epara- 
tion,  and  appeared  to  have  no  advantage  over  one 
made  by  abstracting  the  muriatic  acid  from  calomei  by 
means  of  ammonia,  Mr.  Abernethy  employed  the  lat- 
ter, which  was  prepared  in  the  following  manner; 
Two  drachms  of  liquor  ammonias  are  added  to  six 
ounces  of  distilled  water,  and  four  ounces  of  calomel 
are  thrown  into  this  liquor,  and  shaken  up  with  it; 
the  powder  is  afterward  separated  by  a filler  and 
dried. 

The  powder  thus  obtained  is  of  a gray  colour,  and 
contains  a good  deal  of  quicksilver  in  its  metallic  state, 
which  of  course  is  extremely  volatile,  but  becomes 
oxydated  when  raised  into  fume,  and  afterward  con- 
densed into  a while  subtile  powder. 

In  local  disease  of  the  joints,  such  for  instance  as  a 
thickened  state  of  the  synovial  membrane,  and  in  sar- 
comatous enlargements  of  the  breast  in  women,  the 
late  Mr.  Sharpe  and  Sir  C.  Blicke  were  accustotned  to 
direct  fumigated  stockings  or  under-waistcoats  to  be 
worn,  by  which  these  complaints  were  relieved  and 
the  constitutions  of  the  patients  affected,  without  the 
trouble  and  uiqdeasantness  arising  from  the  use  of  the 
common  mercurial  ointment.— (See  Swr- 

gicul  and  Physiological  Essays,  part  3.) 

Mr.  Pearson  procured  Lalonette’s  machine,  and  made 
a consideiable  number  of  experiments  to  determine 
the  comparative  advantages  of  this  method  and  mer- 
curial frictions.  He  found  that  the  gums  became  tur- 
gid and  tender  very  quickly,  and  that  the  local  appear- 
ances were  sooner  removed,  than  by  the  other  modes 
of  introducing  mercury  into  the  system  ; but  that  it 
soon  brought  on  debility,  a rapid  and  premature  sali- 
vation, and,  of  course,  that  the  medicine  could  not  be 
steadily  continued.  This  gentleman  concludes,  that 
when  checking  the  progress  of  the  disease  suddenly  is 
an  object  of  great  moment,  when  the  body  is  covered 
with  venereal  ulcers,  or  when  the  eruptions  are  large 
and  numerous,  so  that  there  scarcely  remains  a surface 
large  enough  to  absorb  the  ointment,  the  vapour  of 
mercury  will  be  advantageous.  But  he  thinks  it  ex- 
tremely difficult  thus  to  introduce  a sufficient  quantity 
of  mercury  into  the  system  to  secure  the  patient  from 
a relapse,  and  therefore  the  plan  by  no  means  eligible 
as  a general  practice.  The  vapour  of  meicury,  he 
says,  is  singularly  efficacious,  wlien  applied  to  vene- 
real ulcers,  fungi,  and  excrescences ; but  this  plan  re- 
quires an  equal  quantity  of  mercury  to  be  given  in 
other  ways,  as  if  the  local  application  itself  were  not 
a mercurial  one. — {Pearson  on  Lucs  Venerea,  p.  145, 
(S-c.)  'Phis  last  observation  is  certainly  not  correct. 

For  the  purpose  of  fumigating  sores,  the  hydrargyri 
sulphuretum  rubrum  is  commonly  used.  Ulcers  and 
excrescences  about  the  pudendum  and  anus  in  women 
are  said  to  he  particularly  benefited  in  this  way ; and  in 
these  cases  the  fumes  are  most  conveniently  applied  by 
placing  a red-hot  heater  at  the  bottom  of  a nighi-slool 
pan,  and  after  Sprinkling  on  it  a few  grains  of  the  red 
sulphuret  of  quicksilver,  placing  the  patient  on  the 
stool.  On  other  occasions,  a small  apparatus  sold  at 
the  shops,  is  used,  which  enables  the  surgeon  to  direct 
the  fumes  through  a funnel  against  the  ulcer  in  any  si- 
tuation. 

Though  mention  has  just  been  made  of  venereal  ex- 
crescences, I am  of  opinion,  with  Mr.  Abernethy,  that 
it  is  very  questionable  whether  any  are  ever  really  of 
this  nature.  I know  that  many  excrescences  and  ver- 
ructe  about  the  anus  and  parts  of  generation,  diminish 
and  are  cured  by  a course  of  mercury.  This  is  the 
only  argument  in  favour  of  their  being  venereal ; for 
when  tied,  cut  otT,  or  made  to  fall  off"  by  stimulating 
them  with  pulv.  sabime  and  the  subacetaie  of  copper,  or 
the  acetic  acid,  they  are  as  effectually  cured  as  if  mer- 
cury had  been  given.  In  the  military  hospital  at  Catti- 
bray,  I remember  a man  whose  scrotum  was  covered 
with  watery  e.xcrescences,  some  of  which  were  of 
considerable  size.  Mr.  Booty,  assistant  staff  surgeon, 
prescribed  mercury,  by  which  they  were  certainly 
cured  with  surprising  expedition.  In  this  paiticulat 
case  I think  the  plan  of  treatment  adopted  was  the 
best,  because  on  account  of  the  number  of  excres- 
cences, and  the  situation  of  some  of  them  at  the  lower 


MER 


MOL 


173 


and  back  part  of  the  scrotum,  it  would  have  been  dif- 
ficult to  have  treated  them  altogether  by  local  applica- 
tions. 

VRKPARA.TIONS  FOR  INTERNAL  EXHIBITION. 

When  it  is  wished  to  excite  a salivation  quickly, and 
mercurial  ointment  alone  will  not  produce  this  effect, 
or  cannot  be  employed,  and  when  fumigations  are  not 
convenient  or  agreeable,  the  hydrargyri  oxydum  ru- 
brum  is  often  prescribed.  The  common  dose  is  a grain, 
which  may  be  increased  to  two,  a day.  It  isapt,  how- 
ever, to  disagree  with  the  stomachs  and  bowels  of 
many  patients;  an  inconvenience  sometimes  obviated 
by  conjoining  the  preparation  with  opium. 

At  present  tlie  hydrargyrus  cum  creta  is  rarely  or 
never  [»rescribed  for  the  cure  of  the  venereal  disease. 
But  it  is  frequently  prescribed  as  a mild  alterative  for 
children  in  doses  of  from  gr.  v.  to  gr.  x.  twice  a day, 
blended  with  any  viscid  substance. 

The  oxyinuriate  of  mercury  (corrosive  sublimate) 
\vas  a medicine  highly  praised  for  its  antisyphilitic 
virtues  by  the  celebrated  Van  Swieten,  and  indeed 
there  is  no  doubt  that  like  other  preparations  of  mer- 
cury it  possesses  such  qualities.  It  retains  great  repu- 
tation even  now,  and  probably  will  always  do  so. 
However,  like  the  red  oxide,  it  sometimes  deranges 
the  stomach  and  bowels.  Some  surgeons  are  also  re- 
luctant to  give  it  the  same  degree  of  confidence  in  re- 
spect to  its  power  over  syphilis,  as  they  give  to  mercu- 
rial-fiictions.  IMr.  Pearson  remarks,  that  “when  the 
sublimate  is  given  to  cure  the  primary  symptoms  of 
syphilis,  it  will  sometimes  succeed,  more  especially 
wlien  it  produces  a considerable  degree  of  soreness  of 
the  gums,  and  the  common  specific  effect  of  mercury 
in  the  animal  system.  But  it  will  often  fail  of  remov- 
ing even  a recent  chancre;  and  where  the  symptom 
has  vanished  during  the  administration  of  corrosive 
sublimate,  I have  known  a three  months’  course  of 
that  medicine  fail  to  secure  the  patient  from  a consti- 
tutional affection.  The  result  of  my  observations  is 
that  simple  mercury,  calomel,  or  calcined  mercury  are 
preitarations  more  to  be  confided  in  for  the  cure  of  pri- 
mary symptoms  than  corrosive  sublimate.  The  latter 
wilt  often  check  the  progress  of  secondary  symptoms 
very  conveniently,  and  I think  it  is  pecidiaily  effica- 
cious in  relievitig  venereal  pains,  in  healing  ulcers  of 
the  throat,  and  in  promotiiiK  the  desquamation  of  erup- 
tions Yet  even  in  these  cases,  it  never  confers  per- 
manent benefit;  for  new  symptoms  will  appear  during 
the  use  of  it ; and  on  many  occasions  it  will  fail  of 
affording  the  least  advantage  to  the  patient  from  first  to 
last.  I do  sometimes,  indeed,  employ  this  preparation 
in  venereal  cases ; but  it  is  either  at  the  beginning  of  a 
mercurial  course,  to  bring  the  constitution  under  the 
influence  of  mercury  at  an  early  period,  or  during  a 
course  of  inunction,  with  the  intention  of  increasing 
the  action  of  simple  mercury.  1 sometimes  also  pre- 
scribe it  after  the  conclusion  of  a course  of  frictions,  to 
support  the  mercurial  influence  in  the  habit,  in  order 
to  guard  against  the  danger  of  a relapse.  But  on  no 
occasion  whatever  do  I think  ii  safe  to  confide  in  this 
P'-eparation  singly  and  uncombined,  for  the  cure  of  any 
truly  venereal  symptom.’’ — \,Pcarson  on  LuesVenerea.^ 

The  dose  of  oxyrnuriate  is  a quarter  of  a grain. 

The  following  is  a common  mode  of  ordering  it:  fit- 
Hydrargyri  oxymnriatis.  gr.  i.  Aquse  Nucis  Mos- 
chalffi,  5ij-  Misce.  Dosis  uncia  dimidia. 

The  submuriale  of  mercury  (calomel)  is  not  very 
much  u.<ed  by  modern  surgeons  for  the  cure  of  the  ve- 
nereal disease.  Sometimes,  indeed,  it  is  given  in  cases 
of  gonorrhoea,  both  with  the  view  of  preserving  the 
constitution  from  infection,  and  keeping  the  bowels 
regular.  It  is  more  extensively  given  as  a (uirgalive 
and  an  alterative,  and  for  the  cure  of  surirical  diseases 
requiring  the  system  to  be  slightly  under  the  influence 
of  mercury.  It  generally  proves  actively  purgative, 
when  more  than  two  or  three  grains  are  given. 

The  most  sitrqile  preparations  of  pnerenry  have 
generally  been  deemed  the  upost  efb-ctppal  iip  eradicating 
the  vepiereal  disi-ase.  The  pihplae  hydrapgyri  are  the 
most  sipipple  of  the  internal  fortnula-,  being  merely 
mercury  iritpprated  with  mptcilaginous  or  saccharpne 
substatpces.  Next  lo  merciprial  fpiciions,  they  ape,  per- 
haps, iiposi  freqpienlly  eptpployed  for  the  cure  of  the  in- 
cipient fi)rni  of  the  venepeal  disease,  that  is,  while  a 
chancre  is  the  only  complaint.  They  are  also  very 
commonly  given  in  all  stages  of  the  disease,  to  aid  mer- 


curial frictions  in  bringing  the  system  under  the  in- 
fluence of  the  specific  remedy.  Ten  grains  of  the  mass 
kept  for  these  pills  is  the  usual  dose.  When  they  piip  ge, 
opiipiu  will  sometimes  prevent  this  effect. — (See  Vtne- 
real  Disease.) 

Mercury  is  employed  both  constitutionally  and 
locally  in  numerous  surgical  cases;  for  the  removal 
of  irniolent  thickenings  and  indurations  of  the  parts; 
for  the  relief  of  porrigo,  herpetic  diseases,  tetanus,  hy- 
dp  ops  articuli,  iritis,  apid  a multitude  of  other  affec- 
tiopps,  which  ipeed  not  here  be  specified. 

MEROCELE.  (From  ^epos,  the  thigh,  and  ajjA?/,  a 
tumour.)  A femoral  or  crural  hernia. — (See  Hernia.) 

MEZEREON  was  recommended  by  Dr.  A.  Russell 
for  a particular  class  of  venereal  syppipiom.s,  in  the  Ibl- 
lowippg  teripps:  “'I’he  disease  for  which  1 pritpcipally 
pecommeppd  the  decoction  of  the  mezereon  root  as  a 
cure,  is  the  venereal  node  that  proceeds  from  a thicken- 
ipig  of  the  membrane  of  the  bones.  In  a thickening  of 
the  periosteum,  from  other  causes,  I have  .seepp  very 
good  effects  from  it;  and  it  is  frequently  of  service  in 
the  repipoval  of  those  nocturnal  pains  with  which  vene- 
real jpatients  are  afflicted;  though  in  this  last  case,  ex- 
cepting with  regard  to  the  pain  that  is  occasioned  by  the 
ppode,  I own  I have  not  found  its  effects  so  certain,  as 
I at  fiist  thought  I had  reasoti  to  believe.  I do  not  find 
it  of  service  in  the  cure  of  aipy  other  symptom  of  the 
veppereal  disease.” — {Med.  Obs.  and  Inq.  vol.  3,  p.  134, 
195.)  Mr.  Pearson,  however,  asserts  upiequivocally, 
that  mezereon  has  rtot  the  power  of  curipig  the  vene- 
real disease  in  any  one  stage,  or  under  any  one  form  , 
and  if  the  decoction  should  ever  reduce  the  veppcp  cal 
node,  yet  there  will  be  a necessity  for  taking  iipercmy 
in  as  large  quantity,  and  for  as  long  a time,  as  if  no 
ppiezeieon  had  been  exhibited.  Cullepi  found  this  me- 
dicine of  use  in  some  cutaipeous  aff'eclioips,  but,  except- 
itig  an  instance  or  two  of  lepra,  Mr.  Pearson  has  very 
seldom  fouipd  it  possessed  of  medicinal  virtue,  either 
ipp  syphilis,  or  the  sequelte  of  that  disease,  scrofula,  or 
cutappeous  affections. — {Pearson  on  Lues  Venerea.,  p. 
55—59.) 

As  \\\e  possibility  of  curing  most  forms  of  the  vene- 
peal disease,  not  only  without  iipetcury,  but  w ithout 
any  internal  pppedicitpes  whatever,  is  now  well  esta- 
blished, it  is  difficult  to  know  what  degree  of  importance 
to  attach  to  observatiopps  declapippg  certain  articles 
of  the  pppateria  npeplica  efficient  or  ippetficient  in  the  cure 
of  that  di.-;ease;  because,  if  it  admit  of  a spontappeous 
cure,  but  will  ppot  get  well  when  ipiezereoii  or  any  other 
particpplar  tipedicine  is  exhibited,  we  are  necessarily 
obliged  to  suppose  that  such  medicine  is  worse  than 
useless. 

MODIOLUS.  The  crown  or  saw  of  a trepan. 

MOLLITIES  OSSIUM.  A morbid  softness  of  the 
bones,  which  become  preternatpprally  flexible,  inconse- 
quence either  of  the  inordinate  absorption  of  the  phos- 
phate of  lime,  from  which  their  natupal  solidity  is  de- 
rived, or  else  of  this  matter  not  being  duly  secreted  inta 
their  texture.  The  bones  affected  becopppe  specifically 
liglpter. — {Saillant,' Hist,  de  la  Soc.  Royale  de  Med.  t. 
8.)  Ur.  Bostock  made  some  experinpents,  with  the 
view  of  ascertaining  the  proportion  of  earthy  ippatter 
in  bones  affi  cted  with  mollities;  he  examined  a dorsal 
vertebra  of  a woman,  whose  bones  were  fouppd  .soft  appd 
flexible  after  her  decease.  In  one  part  of  the  diseased 
bone,  he  found  that  the  quantity  of  earthy  matter  opply 
amounted  to  one-fifth  of  its  weight,  and,  in  appolhep-, 
only  to  one-eighth,  while  the  proportion  ipp  healthy 
bones  amoppppted  to  upore  than  otpe-half  of  their  whole 
wei'.'ht. — (See  Med.  Chir.  Trans,  vol.  4,  and  Wilson 
on  the  Bones  and  .Joints,  p.  253.)  Ipp  rtekeis,  the  boppes 
yield  appd  becoupe  distorted  opply  by  slow  deg.-ees,  appd 
retaipp  their  natPtral  ippflexibility ; bppt  ipp  the  preseppt  dis- 
ease, they  pipay  be  at  once  beppt  in  any  directiopp,  appd 
freqppently  adpppit  of  beippg  readily  divided  with  a ktpife. 
3’lpe  pipollities  o.ssippin  is  an  exceedippgiy  pptpcomnpotp  dis- 
ease, appd  its  capises  are  bppr  ied  in  ob.scup  ity.  It  is  sipp- 
posed,  however,  to  depend  upon  sonpe  pecpiliar  state 
of  the  cpppp.'titpplion,  and  the  individttals  attacked  with 
it  have  been  retpparked  to  be  ntoslly  aboppt,  or  rather  be- 
yoppd  the  tptiddle  period  of  life  (./.  Wilson,  vol.  cit.  p, 
2.52),  attd  generally,  if  not  always,  wonten.— (JV’eatt- 
mann  in.  .dbhandl.  der  K.  K.  .Josephs  JJead.  b.  2,  p.  173. 
Portal  Cours  d' Jlnatomie,  t.  1,  p.  1.5.)  Otte  itpstattce, 
however,  is  reported,  in  which  the  patiettt  wasayottng 
pppan,  seventeeip  years  of  age. — {Thomassw,  in  Journ. 
dc  Med.  t.  43,  p.  222.)  Surgical  writers  have  usually 


174 


MOLLITIES  OSSIUM. 


considered  mollitles  and  fragilitas  ossium  as  two  dis- 
tinct and  different  affections.  Boyer  thinks,  however, 
tliat  this  point  is  by  no  means  well  established.  He 
admits  that  there  have  been  a few  rare  instances  of 
inollities,  where  the  bones  were  completely  flexible, 
without  any  degree  of  fragility.  But  he  contends,  that 
in  almost  all  the  cases  on  record,  the  fragilitas  and 
mollities  have  been  combined.  He  regrets  that  bcmes, 
affected  with  fragility,  have  never  been  chemically  and 
anatomically  e-xamined,  particularly  as  there  have  been 
persons,  who  while  living  merely  betrayed  the  symp- 
toms of  mollities  ossium,  yet  in  whom  unsuspected, 
fractures,  evidently  of  long  standing,  were  discovered 
after  death  ; while  other  fractures  also  happened  from 
the  slightest  causes  during  the  examination  of  the 
same  bodies. — (See  Boyer,  Traiti  des  Maladies  Chir. 
t.  3,p.  COT— 609.)  The  truth  of  these  observations  is 
well  illustrated  in  the  case  reported  by  Mr.  Wilson. — 
(O/i  the  Bones, ‘^rc.  p.  354.)  In  the  present  place,  I shall 
merely  describe  the  pure  mollities  ossium,  or  that  dis- 
order of  the  bones  in  which  they  become  completely 
flexible,  and  lose  all  their  natural  firmness.  And  in  or- 
der to  give  an  idea  of  the  disorder,  I shall  quote  the 
case  of  Madame  Supiot.  In  the  year  1747  she  had  a 
fall,  which  occasioned  her  to  keep  her  bed  for  some 
time,  and  left  great  pain  and  weakness  in  her  loins  and 
lower  extremities.  ' In  about  a year  and  a half  after- 
ward, she  began  to  perceive  her  left  leg  particularly 
affected.  Along  with  this  weakness,  she  had  violent 
pains  over  her  whole  body,  which  increased  after  a 
miscarriage,  and  still  more  after  a natural  delivery,  in 
the  year  1751.  She  was  now  seized  with  startings, 
great  inquietude,  and  such  violent  heats,  that  she  was 
almost  continually  in  a sweat,  and  could  not  bear  the 
least  covering,  even  in  the  coldest  w'eather,  and  while 
her  pains  continually  increased,  she  took  notice  that 
her  urine  precipitated  a white  sediment.  Her  pains 
abated  on  the  appearance  of  the  sediment,  but  she  now 
observed  that  her  limbs  began  to  bend,  and  from  this 
time  the  softness  of  them  gradually  increased  till  her 
death.  In  the  month  of  April,  1752,  the  trunk  of  lier 
body  did  not  exceed  23  inches  in  length,  the  thorax 
was  exceedingly  ill  formed,  and  the  bones  of  the  upper 
part  were  very  much  distorted ; those  of  the  lower  part 
were  considerably  bent.  At  length  the  thigh-bones  be- 
came so  pliable,  that  her  feet  could  easily  be  laid  on 
each  side  of  her  head.  The  right  side  did  not,  till  after 
some  lime,  become  so  deformed  as  the  left ; but  it  was 
surprising  to  observe  the  alteration  which  daily  took 
place,  and  the  different  figures  assumed  by  the  limbs, 
in  consequence  of  the  increased  softness  of  the  bones  ; 
so  that  when  the  sediment  in  the  urine  was  considera- 
ble, the  disease  of  the  bones  seemed  to  be  at  a stand, 
increasing  considerably  when  it  was  suppressed.  Be- 
sides this,  she  had  violent  pains,  startings,  difficulty  of 
breathing,  spitting  of  blood,  and,  lastly,  a fever,  with 
convulsions.  She  died  in  the  beginning  of  November, 
1752,  and  on  dissecting  her  body,  the  following  appear- 
ances were  observed ; 1.  The  muscles  in  general  w'ere 
of  a very  soft  and  pale  consistence;  the  vastus  exter- 
nus  fascialis,  quadriceps,  biceps,  and  external  parts  of 
the  gracilis,  were  much  shorter  than  in  their  natural 
state,  and  more  firm  and  tense ; while  those  on  the  op- 
posite side  W’ere  much  elongated,  thin,  and  very  tender ; 
in  short,  the  whole  muscular  system  had  suffered  more 
or  iess,  according  to  the  action  of  the  muscles  in  her 
lifetime.  2.  The  bones  were  entirely  dissolved,  the 
periosteum  remaining  unhurt,  so  that  they  exhibited 
only  the  form  of  a cylinder.  3.  The  heart  and  princi- 
pal blood-vessels,  both  veins  and  arteries,  contained 
large  black  polypi,  of  a viscid  consistence,  and  very 
unlike  those  usually  found  in  dead  bodies. 

A case  of  softness  of  the  bones  is  related  by  Mr. 
Gooch,  but  considerably  different  from  the  above,  as  it 
was  attended  with  a remarkable  fragility  of  them  be- 
fore they  became  soft  It  likewise  began  with  pains 
through  the  whole  body,  attended  with  feverish  symp- 
toms ; but,  after  some  weeks,  these  pains  were  confined 
chiefly  to  the  legs  and  thighs,  and  they  were  not  in- 
creased by  pressure.  This  fragility  of  the  bones  does 
not  appear  to  have  been  the  case  with  Madame  Supiot. 
In  the  month  of  June,  1749,  Mr.  Gooch’s  patient  broke 
her  leg  in  w alking  from  her  bed  to  a chair,  and  heard 
the  bone  snap.  No  callus  w.is  formed,  though  the 
fracture  was  instantly  reduced,  and  treated  by  one  of 
the  best  surgeons  in  her  part  of  the  country ; but,  in- 
stead of  this,  the  bones  began  to  grow  fle.\ible,  and  in 


a few  months  were  so  from  the  knee  to  tiie  ankle. 
The  disease  still  continued  to  increase,  so  that  mi  a 
short  time  the  other  leg  and  thigh  were  affected  in  the 
same  manner,  after  which  both  legs  and  thighs  became 
(Edematous,  liable  to  excoriations,  and  discharged  a 
thin  yellow  ichor.  Scorbutic  symptoms  began  to  ap- 
pear in  the  winter  after  the  leg  was  broken,  and  her 
gums  began  to  bleed.  Tonic  medicines  were  exhibited 
without  any  success,  except  that  her  menstruation  was 
more  regular,  and  her  appetite  and  digestion  w ere  im- 
proved ; bm  towards  the  end  of  her  life,  her  breathing 
became  difficult,  the  spine  distorted,  and  a pain  in  the 
loins  took  place  upon  every  motion  of  the  veilebi  ae  : 
and  as  her  limbs  were  now  quite  useless,  she  was  ob- 
liged to  sit  upright  in  bed.  At  last  the  ends  of  the 
bones  on  which  she  sat  having  become  also  very  soft, 
spread  much,  and  the  ends  of  her  fingers  and  thumbs, 
by  frequent  endeavours  to  raise  herself,  became  also 
very  broad,  and  the  phalanges  crooked.  The  flexibi- 
lity of  the  bones  gradually  increased,  and  became  more 
general,  attended  with  a wasting  of  the  flesh,  and  ex- 
cessive difficulty  of  breathing.  The  menstrual  flux 
totally  ceased  four  months  before  her-death;  her  legs, 
w’hich  were  very  anasarcous,  and  excoriated  almost  all 
over,  became  erysipelatous;  but  she  retained  her  senses 
to  the  last.  She  expired  suddenly,  having  talked  in  a 
composed  manner  concerning  her  miserable  situation 
and  approaching  end,  only  a few  moments  before  her 
death. 

On  examining  the  body,  she  was  found  to  have  lost 
two  feet  two  inches  of  her  natural  stature.  The  heart 
and  lungs  appeared  sound,  but  had  been  much  confined, 
principally  by  the  liver,  which  was  enlarged  in  an  ex- 
traordinary degree;  it  was  not  however,  scirrhous,  nor 
in  any  other  way  diseased.  The  spleen  was  very 
small,  and  the  mesentery  had  one  large  scirrhous  gland. 
All  the  bones  except  the  teeth  were  softened,  so  that 
scarcely  any  of  them  could  resist  the  knife  ; but  those 
of  the  lower  extremities  were  the  most  dissolved,  being 
changed  into  a kind  of  parenchymous  substance,  like 
soft  dark-coloured  liver,  without  any  offensive  smell. 
So  completely,  indeed,  were  they  decomposed,  that  the 
knife  met  with  less  resistance  in  cutting  through  them 
than  sound  muscular  flesh,  though  some  bony  lamellse 
were  here  and  there  to  be  met  with,  but  as  thin  as  an 
egg-shell.  The  most  compact  bones,  and  those  which 
contained  the  greatest  quantity  of  marrow,  were  the 
most  dissolved  ; and  it  was  observable  that  the  disso- 
lution began  internally,  for  the  bony  laminae  remained 
here  and  there  on  the  outside  and  nowhere  else.  The 
periosteum  was  rather  thicker  than  ordinary,  and  the 
cartilages  thinner ; but  not  in  a stale  of  dissolution. 
The  bones  were  found  to  contain  a great  quantity  of 
oily  matter  and  little  earth.  No  cause  could  be  as- 
signed for  the  disease ; and  in  the  case  of  Madame 
Supiot,  the  one  assigned,  viz.  that  of  her  eating  too 
much  salt,  seems  totally  inadequate  to  explain  the 
origin  of  the  disorder.  All  the  cases  of  mollities  ossium 
on  record  have  proved  fatal,  and  no  means  of  cure  are 
yet  known. 

For  additional  observations  connected  with  this 
subject,  refer  to  Fraffilitas  Ossium  and  Rickets. 
Boyer  and  Richerand  treat  of  mollities  ossium  and 
rickets,  as  one  and  the  same  disease.  But  as  Mr.  Wil- 
son observes,  the  first  diffeis  from  rickets  in  attacking 
people  of  middle  age  or  rather  older,  and  not  particu- 
larly children ; and  it  differs  also  in  the  change  pro- 
duced in  the  bones  themselves,  which,  when  dried,  do 
not  appear  as  if  they  had  been  long  steeped  in  weak 
acid,  with  their  animal  part  nearly  unchanged ; but 
both  the  phosphate  of  lime  and  the  animal  matter 
appear  to  have  been  absorbed,  so  as  to  leave  mere 
shells,  which  are  also  softer  than  natural  bones  of  tlie 
same  thickness.  Mr.  Wilson  farther  informs  us,  that 
large  cavities  are  met  with  in  the  substance  of  Uie 
bones,  and  sometimes  communicate  with  the  soft  parts 
surrounding  them.  In  some  of  these  cavities  is  con- 
tained oily  matter,  like  boiled  marrow;  and  in  others, 
masses  of  coagulated  blood,  and  a soft  inorganic  animal 
substance. — (./.  Wilson  on  the  Bones,  S-c.  p.  253.  Acrel, 
Diss.  Descriptionem  et  Casus  aliquot  Osteomalacia 
sistens  Upsal,  1788.  Morand,  in  Journ.  des  Savans, 
1792,  et  Mem  dc  VJicad.  des  Sciences,  1752.  Morand, 
junr.  in  Mem.  de  VJicad.  des  Sciences,  17f)4,  p.  206.  See 
also  T.  Lambert,  Relation  de  la  Maladie  de  Bernard 
d'.drmaenac,suru7i  Ramollissementdes  Os;  Toulouse, 
1700.  Fernclius,  in  lib.  de  abditis  rerum  eausis.  Th. 


MOR 


MOR 


175 


Bartholinus,  Hist.  .^nat.  cent.  4.  Petit  Histoire  de 
VAcad.  des  Sciences,  1722.  Hoin,  ibid.  1764.  Oagli- 
ardi,  Anatomes  Ossium  f Romm,  1789.  C.  G.  Ludwig, 
Programma,  quo  observata  in  sectione  Cadaveris 
Fceminm  cujus  Ossa  emoUita  erant  proponit;  Lips. 
1757.  Fries,  Dissert,  de  Emollitione  Ossium  / Argen- 
tor.  1775.  Thomson,  in  Med.  Obs.  and  Inquiries,  vol. 
5.  p.  259.  Chirurgical  Obs.  and  Cases,  by  fVilliam 
Bromjield,  vol.  2,  p.  50,  ^c.  Boyer,  Traitedes  Mala- 
dies Chir.  t.  3,  p.  607,  iS'c.  Pans,  1814.  Richerand, 
Mosogr.  Chir.  t.  3,  p.  142.  What  these  two  writers 
say,  however,  chiefly  relates  to  rickets.  We  meet  with 
eases  of  Mollities  Ossium  in  the  Philosophical  Trans- 
actions ; Act.  Haffniens. ; Ephem.  Mat.  Cur.;  Savi- 
ard's  Obs.  Chir. ; the  writings  of  Forestus ; Gooch's 
Chirurgical  Works,  vol.  2,  p.  393 — 399,  ed.  1792,  ire. 
J.  Wilson,  on  the  Structure  and  Physiology  of  the 
Skeleton ; and  on  the  Diseases  of  the  Bones  and  .Joints, 
p.  252,  4-c.  8vo.  Land.  1820.  Good's  Study  of  Medi- 
cine, vol.  5,  p.  384,  ed.  3.  J.  Howship,  in  Edin.  Med. 
Chir.  Trans,  vol.  2,  p.  137.) 

MONOCULUS.  (From  povog,  single,  and  oculus, 
the  eye.)  A bandage  formerly  applied  to  the  fistula 
lachrymalis,  and  diseases  of  the  eye.  It  consists  of  a 
single- headed  roller,  the  end  of  which  is  to  be  put  on 
the  back  of  the  neck,  and  one  turn  made  over  the 
forehead  so  as  to  meet  the  extremity  of  the  bandage. 
The  roller  is  then  to  descend  under  the  ear  of  the  side 
alfected,  and  to  pass  obliquely  over  the  cheek  under- 
neath the  eye,  and  next  over  the  root  of  the  nose  and 
the  parietal  bone,  to  the  nape  of  the  neck.  The  third 
turn  of  the  roller  is  to  overlap  the  second  a little;  the 
third,  the  fourth;  making  what  the  French  call  do- 
'oires } and  the  application  of  the  bandage  is  com- 
pleted by  making  turns  round  the  head. 

MORTIFICATION  is  of  two  kinds  ; the  one  with- 
out inflammation ; the  other  preceded  by  it.  To  this 
last  species  of  mortification,  the  terms  inflammatory, 
humid,  or  acute  gangrene,  are  often  applied  ; while  the 
second,  or  that  which  is  not  preceded  by  any  or  much 
inflammation,  has  been  distinguished  by  the  epithets 
dry  or  chronic,  and  sometimes  idiopathic,  when  no 
cause  for  the  origin  of  the  disease  can  be  assigned. 
According  to  Mr.  Hunter,  inflammation  is  an  increased 
action  of  that  power  which  a part  naturally  possesses  ; 
and,  in  healthy  inflammations  at  least,  it  is  probably 
attended  with  an  increase  of  power.  In  cases,  how- 
ever, which  are  to  terminate  in  mortification,  there  is 
no  increase  of  power;  but  on  the  contrary,  a diminu- 
tion of  it.  This,  when  joined  to  an  increased  action, 
becomes  a cause  of  mortification,  by  destroying  the 
balance  which  ought  to  subsist  between  the  power 
and  action  of  every  part.  There  are,  besides,  cases 
of  mortification  preceded  by  inflammation,  which  do 
not  arise  wholly  from  that  as  a cause:  of  tliis  kind 
are  the  carbuncle  and  the  slough  formed  in  the  small- 
pox pustule. — {Hunter.) 

The  first  general  division  of  mortification,  therefore, 
is  into  two  kinds;  first,  into  the  inflammatory,  humid, 
or  acute ; and  secondly,  into  the  dry  or  chronic.  But 
the  disorder  is  also  subdivided  into  many  species, 
which  are  determined  by  the  nature  of  their  particular 
exciting  causes,  as  will  be  presently  detailed. 

However,  it  is  remarked,  that  acute  or  rapid  mortifi- 
cations are  not  necessarily  humid,  as  the  slough  from 
the  application  of  caustic  potassa  proves,  and  the  con- 
verse also  is  true  in  some  cases  of  sphacelus  senilis. — 
{James  on  Inflammation,  p.  96.)  Mr.  Guthrie  also  as- 
serts, that  mortification  from  wounds  and  external 
injuries  may  be  either  humid  or  dry,  or  of  both  kinds 
together,  where  the  circumstances  are  particular. — 
{On  Gun-shot  Wounds,  Src.  p.  122,  ed.  2.)  The  doctrine 
that  any  case  of  mortification  is  entirely  without  in- 
flammation, has  sometimes  been  deemed  questionable  ; 
and  Mr.  James  expresses  his  belief  that  the  disorder  is 
generally  preceded  hy  inflammation,  and  invariably 
accompanied  with  some  degree  of  it.  And,  says  he, 

“ whether  mortification  be  a consequence  of  inflam- 
mation or  not,  it  lariy,  perhaps,  with  reason  be  consi- 
dered as  standing  in  the  same  relation  to  inflamma- 
tion as  adhesion,  suppuration,  or  ulceration  ; they  may 
all  be  preceded  by  a high  degree,  or  it  may  be  scarcely 
sensible.”— (P.  84,  8.5.) 

When  any  part  of  the  body  loses  all  motion,  sensi- 
bility, and  natural  heat,  and  becomes  of  a brown,  livid, 
or  blat  k colour,  it  is  said  to  be  affected  with  sphacelus, 
that  is,  complete  mortification.  Aslong  as  any  sensibility, 


motion,  and  warmth  continue,  the  state  of  the  disorder 
is  termed  gangrene.  This  word  is  here  made  use  of  to 
signify  only  a degree  of  sphacelus,  or  rather  the  pro- 
ce.ss  by  which  any  local  disorder  falls  into  the  stale  of 
complete  mortification.  -Many  authors  use  both  terms 
synonymously ; but  it  is  to  be  observed,  that  gangrene 
does  not  invariably  end  in  sphacelus  ; nor  is  the  latter 
always  preceded  by  the  former. — {Richter,  .dnfangsgr. 
der  Wundarzn.  b.  1,  kap.  3.)  There  are  some  surgical 
writers,  who  make  the  distinguishing  circumstances  of 
sphacelus  to  be  the  extension  of  the  disorder  to  the 
bones  as  well  as  the  soft  parts. — {Lassus,  Pathologie 
Chir.  t.\,p.  30,  cd.  1809.) 

At  present,  however,  this  last  application  of  the  term 
sphacelus  is  never  made  ; for,  as  Mr.  Pearson  has 
rightly  observed,  the  distinctions  “ which  are  founded 
merely  upon  the  parts  that  suffer,  or  upon  the  profun- 
dity to  which  the  disease  has  penetrated  seem  inade- 
quate and  useless.” — {Principles  of  Surgery,  p,  115,  ed. 
2.)  The  manner  in  which  Dr.  J.  Thomson  views 
the  subject,  may  be  considered  as  coinciding  with  the 
general  sentiments  of  the  best  modern  surgeons.  “ I 
shall  employ  the  term  gangrene  (says  he)  to  express 
that  state  of  mortification  in  inflamed  parts,  which 
precedes  the  death  of  the  part ; a stage  in  which  there 
is  a diminution,  but  not  a total  destruction  of  the 
powers  of  life  ; in  which  the  blood  appears  to  circu- 
late through  the  larger  vessels;  in  Which  the  nerves 
retain  a portion  of  their  sensibility  ; and  in  which,  per- 
haps, the  part  aftected  may  still  be  supposed  to  be  ca- 
pable of  recovery.  The  word  sphacelus  I shall  use  to 
denote  the  complete  death  or  mortification  of  apart; 
that  state,  in  which  the  powers  of  life  have  become 
extinct ; in  which  the  blood  ceases  to  circulate  ; and  in 
which  the  sensibility  of  the  nerves  is  lost,  whether  the 
dead  or  mortified  part  has  or  has  not  become  actually 
putrid,  or  shown  any  tendency  to  separate  and  fall 
away  from  the  living  and  sound  parts.  Putrefaction, 
or  the  spontaneous  process  by  which  animal  bodies  are 
decomposed,  is  an  accidental,  and  not  necessary  effect 
of  the  state  of  mortification.  It  takes  place  at  very 
different  periods,  after  the  death  of  particular  parts ; 
and  these  periods,  it  may  be  remarked,  are  always 
regulated,  not  only  by  external  circumstances,  such  as 
the  humidity  and  temperature  of  the  atmosphere,  but 
also  by  the  peculiar  structure  and  morbid  conditions 
of  the  animal  texture,  or  organ,  in  which  the  putrefac- 
tion occurs.  The  term  sphacelus  has,  I know,  been 
employed  to  express  that  a part  is  not  only  completely 
dead,  or  mortified,  but  also  that  that  part  has  become 
putrid,  and  is  in  a state  of  separation  from  the  sur- 
rounding  and  living  parts.  But  as  putrefaction  is  not  a 
necessary  or  immediate  consequence  of  mortification 
or  partial  death  in  animal  bodies,  this  use  of  the  term 
sphacelus  is  obviously  improper.” — {On  Inflammation, 
p.  504.) 

The  causes  of  mortification  are  either  internal  or  ex- 
ternal. It  is  commonly  taught  in  the  medical  schools  on 
the  continent,  that  the  internal  causes  probably  operate 
after  the  manner  of  a deleterious  substance,  which, 
being  introduced  into  the  circulation,  occasions  a putre- 
faction of  the  fluids. — {Lassus,  op.  et  loc.  cit.) — Boyer 
also  professes  a similar  notion  (see  Traitd  des  Mala- 
dies Chir.  t.  1,  p.  140),  as  well  as  Larrey  in  his  account 
of  traumatic  gangrene ; a statement  which  has  drawn 
forth  the  criticisms  of  Mr.  Guthrie.  The  doctrine  is 
supported  by  no  sort  of  proof,  and  may  be  considered 
as  entirely  hypothetical,  if  not  decidedly  erroneous. 
There  are,  indeed,  as  Boyer  has  noticed,  some  sponta- 
neous mortifications,  the  primitive  cause  of  which  is  not 
always  well  understood:  an  inflammation,  apparently 
slight,  may  become  gangrenous  immediately  it  has 
made  its  appearance.  In  scorbutic,  venereal,  and 
small-pox  cases,  we  have  daily  instances  of  this  fact. 
Other  internal  causes,  without  any  very  evident  pre- 
existent disease,  sometimes  destroy  persons  by  gangre- 
nous mischief,  who  are  but  little  advanced  in  yeans. — 
{Saviard,  Obs.  16.  Haller,  Disput.  Chir.  t.  4,  p.  551.) 
Certain  poisonous,  acrid,  caustic  substances  taken  in- 
wardly, or  introduced  under  the  skin,  may  have  the 
same  effect,  by  annihilating  the  vital  action,  or  de- 
stroying the  texture  of  the  parts. — {Lassus,  Pathologie 
Chir.  t.  1,  p.  31.)  But  though  these  observations  may 
all  be  entirely  correct,  they  by  no  means  justify  the 
conclusion,  that  the  internal  causes  of  mortification 
ever  act  like  a deleterious  matter  producing  a putrefac- 
tion of  the  fluids.  The  mortification  of  the  toes  and 


176 


MORTIFICATION. 


feet,  so  well  described  by  Mr.  Pott,  is  supposed  to  pro- 
ceed chiefly  from  unknown  internal  causes,  though 
sometimes  attended  with  an  ossified  stated  the  arteries. 

Anotlier  remarkable  specimen  of  mortification  from 
an  internal  cause,  is  that  originating  from  eating  bread 
made  of  bad  black  wheat  or  rye.  Besides  occurring 
as  an  original  idiopathic  disease,  and  from  obstruction 
of  arteries,  chronic  or  dry  gangrene  (observes  Dr. 
Thomson)  may  be  induced  by  the  action  of  substances 
taken  into  the  stomach,  which  seem  to  produce  it  as  a 
specific  effect  in  parts  remote  from  the  source  of  the 
circulation.  Ttie  most  singular  example  which  we 
have  of  this  is  in  the  gangrene  produced  by  the  eating 
of  a particular  kind  of  unsound  or  diseased  rye.  This 
species  of  mortification  has  been  rarely  observed  in 
England ; but  it  lias  been  frequently  seen  on  the  con- 
tinent, where  it  has  been  repeatedly  known  to  prevail 
in  some  districts,  where  rye  forms  a principal  article 
of  food,  as  an  endeinial  disease.  Ft  occurs,  however, 
in  such  districts  only  after  wet  seasons,  in  which  that 
grain  is  affected  with  a particular  disease,  well  known 
in  France  by  the  name  of  the  Ergot,  or  cockspur  rye. 
In  this  disease,  the  grains  of  rye  grow  to  a large  size, 
acquire  a black  colour,  and  have  a compact  horny  con- 
sistence. The  species  of  mortification  produced  by 
eating  this  substance,  was  first  particularly  described 
by  Dodard. — (See  Journ.  des  Savans,  an.  1676.)  The 
part  affected  becahie  at  first  insensible  and  cold,  and  in 
the  progress  of  the  disorder,  dry,  hard,  and  withered. 
In  very  malignant  cases,  there  was  delirium.  Dodard’s 
description  of  the  complaint  was  very  imperfect;  but 
he  has  mentioned  a circumstance  lending  strongly  to 
prove  that  the  disease  actually  arose  from  the  alleged 
cause;  viz.  that  fowls  fed  with  cockspur  rye  are  killed 
by  it.  Saviard  informs  us,  that  he  saw  this  disease  in 
the  year  1694,  at  the  Hdtel-Dieu  of  Orleans.  It  at- 
tacked the  upper  and  lower  extremities,  which  were 
rendered,  in  the  course  of  the  disorder,  as  dry  as  touch- 
wood,  and  as  emaciated  as  the  limbs  of  Egyptian 
mummies.  In  1710,  Noel,  surgeon  to  the  Hdtel-Dieu 
at  Orleans,  transmitted  to  the  Royal  Academy  of  Sci- 
ences at  Paris  an  account  of  this  peculiar  mortifica- 
tion. About  fifty  people,  men  and  children,  had  come 
that  season  into  his  hospital  with  the  affliction.  Ac- 
cording to  Noel,  the  disorder  always  began  in  the  toes, 
and  extended  itself  gradually  along  the  foot  and  leg, 
till  it  sometimes  rose  to  the  upper  part  of  the  thigh. 
He  had  never  seen  any  of  the  female  sex  affected  with 
It,  and  had  observed  only  one  instance  of  it  in  the 
upper  extremities.  The  Academy  received  the  history 
of  one  casein  which  the  lower  extremities  were  sepa- 
rated from  the  body  in  the  articulations  of  the  thigh- 
bones with  the  acetabula ; the  first  example  (Dr. 
Thomson  believes)  of  this  separation  upon  record ; 
and  it  was  the  occurrence  of  this,  and  of  similar  cases, 
that  probably  first  suggested  the  operation  of  amputa- 
tion at  the  hip-joint. — (See  Thomson' s Lectures  on  In- 
Jlammation,  p.  541.)  As  Noel’s  patients  did  not  come 
under  his  care  till  after  the  disease  had  existed  some 
time,  he  could  not  describe  from  his  own  observation 
the  early  symptoms;  but  the  patients  had  often  told 
him,  that  the  disease  generally  began  in  one  or  both 
feet,  with  pain,  redness,  and  a sensation  of  heat,  as 
burning  as  the  fire;  and  that,  at  the  end  of  some  days, 
these  syiiqitoms  ceased  as  quickly  as  they  had  come 
on,  when  the  extreme  sensation  of  heal,  which  they 
had  formerly  felt,  was  changed  into  cold.  The  part 
affected  (adds  Noel)  was  black,  like  a piece  of  char- 
coal, and  as  dry  as  if  it  had  passed  through  the  fire. 
After  some  time,  a line  of  separation  was  formed  be- 
tween the  dead  and  living  parts,  like  that  which  ap- 
pears in  the  separation  of  a slough  produced  by  the 
cautery;  and  the  complete  separation  of  the  limb  was, 
in  many  cases,  effected  by  nature  alone.  In  others, 
Noel  was  obliged  to  have  recourse  to  amputation. 

'I’his  disease  appeared  in  Switzerland  in  1709  and 
1716,  and  its  symptoms  and  progress  in  that  country 
have  been  accurately  described  by  Langius  in  a disser- 
tation entitled  “ Desr.riptio  Morborum  ex  Esu  Clavo- 
rum  Secalinorum." 

Gassaud,  physician  in  Dauphiny,  where  this  disease 
appeared  also  in  1709,  states,  that  many  of  the  patients 
were  affected  with  swellings  of  the  feet  and  legs,  and 
of  the  hands  and  arms,  which  degenerated  into  a gan- 
grene that  penetrated  to  the  bone,  and  produced  a sepa- 
ration of  theaffecied  limb.  The  disorder  was  attended 
with  different  symptoms  indifferent  individuals.  Some 


suffered  very  violent  pain,  accompanied  by  an  insuf- 
ferable sensation  of  heal,  although  the  part  affected 
often  felt  cold  to  the  touch.  In  other  patients,  redness, 
with  much  swelling,  supetvened,  attended  with  lever 
and  delirium.  Other  patients  were  without  any  fever 
or  delirium,  though  they  seemed  to  suffer  equal  pain. 
In  some  patients,  the  parts  affected  became  withered, 
dry,  and  black,  like  charcoal.  The  separation  of  the 
dead  parts  from  the  living  took  place  with  the  most  ex- 
cruciating pain,  and  a sensation  resembling  that  pro- 
duced by  the  direct  application  of  fire.  This  sensation 
was  sometimes  intermittent,  and  in  other  instances  it 
was  succeeded  by  unequally  harassingsensaiionof  cold. 

According  to  Bassau,  surgeon  to  the  hospital  of  St. 
Antoine  in  Dauphiny,  the  cases  which  he  saw  were 
not  all  of  the  dry  kind;  the  limb  sometimes  becoming 
putrid,  and  maggots  being  generated.  He  says  that 
the  disease  was  not  infectious,  and  it  attacked  indis- 
criminately men,  women,  and  children. 

The  degree  of  fatality  caused  by  this  species  of  mor- 
tification, seems  to  have  been  extremely  various.  In 
the  Memoirs  of  the  Royal  .Academy  of  Sciences  for 
1748,  M.  Duhamel  mentions,  that  of  120  persons  af- 
flicted, scarcely  four  or  five  recovered  with  their  lives. 
According  to  Langius,  it  was  equally  fatal  in  Switzer- 
land. 

Dr.  Thomson  believes  that  the  preceding  sort  of  gan- 
grene has  never  occurred  in  this  country,  excepting, 
perhaps,  the  cases  recorded  by  Dr.  Charlton  Woolaston, 
in  the  Phil.  Trans,  for  1762;  and  which  proceeded  from 
eating  unsound  wheat,  not  rye. — (See  Lectures  on  In- 
flammation, p.  548.)  For  farther  particulars  relating 
to  this  curious  kind  mortification,  I must  refer  the 
reader  to  this  valuable  work. 

The  external  causes  of  mortification  which  are  ma- 
nifest, and  act  mechanically  or  chemically,  are  burns  ; 
excessive  cold  ; the  application  of  caustics ; the  pre- 
sence of  any  ichorous,  urinary,  or  fecal  matter  etfused 
in  the  cellular  substance;  violent  contusions,  such  as 
are  produced  by  gun-shot  wounds,  or  bad  fractures; 
the  strangulation  of  a part,  as  in  cases  of  hernia,  or 
when  polypi  or  other  tumours  are  tied  ; a high  degree 
of  inflammation;  and,  lastly,  every  thing  that  has  the 
power  of  stopping  the  circulation  and  nervous  energy 
in  parts. — {Lassus,  Pathologic  Chir.  t.  l,p.  34,  35.) 

Inflammation  is  one  of  the  most  frequent  occasional 
causes  of  mortification.  But,  as  I have  already  re- 
marked, the  death  of  a part  may  take  place  without 
any  well  marked  appearance  of  previous  inflammatory 
disorder;  and  the  latter,  even  when  present,  has  fre- 
quently less  share  in  the  mischief  than  otlier  inci- 
dental circumstances,  and  is,  in  reality,  only  an  effect 
of  the  very  same  cause  which  produces  the  sphacelus 
itself.  It  is  often  a matter  of  doubt  whether  actual  in- 
flammation precedes  the  occurrence  or  not ; for  a part, 
before  it  mortifies,  is  in  certain  instances  only  affected 
with  pain,  and  with  no  degree  of  preternatural  redness. 
Lastly,  when  mortification  is  unquestionably  preceded 
by  inflammation,  there  are  so  many  varieties  of  the 
disorder  depending  on  incidental  causes,  that  these  lat- 
ter demand  more  attention  than  the  inflammation. — 
{Richter,  jinfangsgr.  b.  1,  kap.  3.) 

Mr.  James  enumerates  the  following  circumstances, 
as  capable  of  influencing,  in  a very  great  degree,  the 
disposition  of  inflammation  to  ternnuate  in  mortifica- 
tion. 1.  The  powers  of  the  part  in  which  the  inflam- 
mation occurs,  being  naturally  weak,  as  in  fibrous 
membranes,  the  scrotum,  &c.  2.  The  remote  supply  of 
blood  or  nervous  energy,  as  in  the  lowCT  e.xtremiiies. 
3.  Obstruction  to  the  return  of  blood.  4.  To  the  sup- 
fily  of  blood.  5.  Disease  in  the  heart  or  vessels.  6. 
Debility  from  age,  habits  of  life,  disorder  of  the  di- 
gestive organs,  or  fever.  7.  Poor  living,  foul  air.  im- 
proper food,  scurvy,  &c.  8.  Impairment  of  organiza- 
tion from  external  injury.  9.  Of  the  nervous  power 
by  poisons.  10.  Undue  excitement  of  weakened  parts. 
11.  Depressing  remedies.  12.  Pressure  and  tension. 
13.  Excessive  violence  of  inflammatory  action.  14. 
Peculiar  disposition  in  the  constitution.— (James  on 
Inflammation,  p.  102.) 

Healthy  phlegmonous  inflammation  seldom  ends  in 
mortification,  c.\cept  when  it  Is  unusually  violent  and 
extensive. 

Of  all  the  inflammatory  complaints  to  which  the 
system  is  liable,  phlegmonous  erysipelas  is  observed 
most  frequently  to  terminate  in  gangrene.  It  is  a case 
that  detnands  the  prompt  emplbyuieut  of  active  antP 


MORTIFICATION. 


177 


phlogistic  means,  and  early  free  incisions  when  the 
^hular  membrane  and  fasciae  slough,  and  a conibina- 
iron  of  suppuration  and  mortification  is  beginning 
Under  the  skin. 

The  symptoms  of  mortification  from  inflammation 
take  place  variously,  yet  generally  as  follows The 
pain  and  sympathetic  fever  suddenly  diminish,  the  part 
affected  becomes  soft,  and  of  a livid  colour,  losing,  at 
the  same  time,  more  or  less  of  its  natural  warmth  and 
sensibility.  In  some  places,  the  cuticle  is  detached ; 
while  in  other  situations  vesicles  arise,  filled  with  a 
clear  or  turbid  fluid.  Such  is  the  state  to  which  we 
apply  the  term  gangrene^  and  which  stage  of  the  dis- 
order too  often  rapidly  advances  to  sphacelus,  when 
the  part  becomes  a cold,  black,  fibrous,  senseless  sub- 
stance, called  in  technical  language  a slough. 

It  merits  notice,  however,  that  “in  cases  in  which 
gangrene  immediately  succeeds  inflammation,  these 
two  morbid  states  may,  in  some  measure,  be  regarded 
as  stages  or  periods  of  the  same  disease.  They  pass 
insensibly  into  one  another ; nor  is  it  possible  to  say 
precisely  where  the  one  state  ends,  and  the  other  com- 
mences. The  symptoms  of  inflammation  in  these 
cases  do  not  disappear  before  those  of  gangrene  come 
on  ; but  seem  rather  to  undergo  a gradual  and  almost 
imperceptible  change,  or  conversion,  into  one  another. 
The  redness  acquires  a deeper  tinge,  and  spreads  far- 
ther than  formerly  ; the  sioelling  increases  and  becomes 
more  doughy ; and  in  this  incipient  stage,  the  gan- 
grene, particularly  when  it  attacks  the  cutaneous  tex- 
ture, often  bears  a considerable  resemblance  to  ery- 
sipelas.”— (See  Thomson's  Lectures  on  Inflammation, 
p.  506.) 

It  is  to  be  observed,  also,  that  “ the  part  of  the  body 
which  becomes  affected  with  gangrene  does  not. im- 
mediately lose  its  sensibility,  for  the  pain,  on  the  con- 
trary, is  often  very  much  aggravated  by  the  approach 
of  this  state.  The  blood  also  still  continues  to  circu- 
late, at  least  in  the  larger  vessels  of  the  part,  but  per- 
haps with  less  force ; and  from  the  resistance  which 
it  meets  with  in  passing  through  the  capillaries,  m less 
quantity  than  formerly.  The  serous  effusion  into  the 
cellular  membrane . continuing  to  increase,  and  the 
action  of  the  absorbent  and  sanguiferous  vessels  to  di- 
minish, the  part  becomes  at  length  incapable  of  being 
restored  to  its  former  office  in  the  animal  economy.  It 
is,  therefore,  in  its  earlier  stages  only,  that  gangrene 
is  to  be  considered  as  an  affection  admitting  of  cure  ; 
for  there  are  limits,  beyond  which,  if  it  pass,  recovery 
becomes  impossible.  These  limits  it  may  not,  in  every 
instance,  be  easy  to  define ; but  they  form  the  bounda- 
ries between  incipient  gangrene  and  the  ultimate  ter- 
mination of  that  state  in  sphacelus.”— (TAowisc/w,  op. 
cit.  p.  507.) 

The  causes  which  produce  mortification  by  impeding 
the  return  of  blood  from  the  part  affected,  for  the  most 
part  operate  by  making  pressure  on  the  trunk  or  prin- 
cipal branches  of  a vein.  In  these  instances,  there  is 
always  an  accumulation  of  blood  in  the  part  which 
first  sweds,  becomes  of  a livid  colour,  tense,  and  very 
painful.  Soon  afterward  blisters  arise,  and  the  part 
becomes  soft,  oedematous,  cold,  insensible,  emphyse- 
matous, black,  and  fetid.  Such  are  the  circumstances 
which  happen  in  strangulated  hernia,  in  tied  polypi, 
and  in  a limb  in  which  the  veins  have  been  so  com- 
pressed by  any  hard  swelling,  such  as  the  head  of  a 
dislocated  bone,  as  to  excite  mortification. 

Other  causes  operate  by  preventing  the  entrance  of 
arterial  blood.  The  application  of  a ligature  to  an  ar- 
tery, as  practised  in  several  surgical  cases,  and  all 
external  pressure,  that  closes  the  artery  or  arteries  on 
which  a part  entirely  depends  for  its  supply  of  blood, 
have  this  effect.  Mortification  does  not,  however,  al- 
ways take  place  when  the  trunk  of  an  artery  is  ren- 
dered impervious,  because  nature  furnishes  the  neces- 
sary supply  of  blood,  through  collateral  ramifications. 
But  when  the  disorder  does  happen,  the  part  com- 
monly first  becomes  pale,  flaccid,  and  cold,  and  soon 
afterward  shrinks,  loses  its  sensibility,  grow's  black, 
and  perishes. 

In  some  cases,  the  mortification  proceeds  not  simply 
from  the  interruption  of  the  course  of  the  blood  through 
the  principal  artery  or  arteries,  but  its  occurrence  is 
promoted  by  great  violence  done  to  the  limb,  and  in 
particular  by  the  injection  and  distention  of  the  cellular 
membrane  with  effused  blood.  No  doubt  all  these 
causes  operated  in  the  fatal  example  of  mortification 

VoL.  II.— M 


which  followed  a fracture  of  the  thigh,  attended  with 
laceration  of  the  femoral  artery,  as  related  by  Sir  A. 
Cooper. — (SeeZ.ancet,  vol.  l,p.  296.) 

It  is  usually  represented  by  writers,  that  mortifica- 
tion may  proceed  from  a mere  lessening  of  the  com- 
munication of  blood  and  nervous  energy  to  a part. 
However,  it  is  to  bt  observed,  that  parts  deprived  of 
all  connexion  with  the  sensorium,  by  the  division  or 
paralytic  state  of  their  nerves,  do  not  frequently  perish 
on  this  account.  But  as  their  functions  are  carried  on 
with  less  vigour,  and  their  vitality  is  weakened,  the 
same  causes  which  sometimes  produce  mortification 
in  parts  differently  circumstanced,  must  much  more 
readily  occasion  it  in  them.  Among  the  causes  of  the 
present  species  of  mortification  may  be  mentioned, 
great  debility,  extreme  old  age,  a thickening  and  ossi- 
fication of  the  coats  of  the  arteries,  and  a consequent 
diminution  of  their  capacity,  and  of  their  muscular 
and  elastic  power. 

Cowper,  the  anatomist,  was  one  of  the  earliest 
writers  who  took  notice  of  this  ossification  of  the  ar- 
teries of  the  leg,  in  persons  who  had  died  of  mortifica- 
lion  of  the  feet  and  toes. — (See  Phil.  Trans,  vol.  23,  p. 
1195,  and  vol.  24,  p.  1970.)  A similar  case  was  re- 
marked by  Mr.  Becket,  of  which  he  has  given  an  ac- 
count in  his  Chirurgical  Observations.  The  occur- 
rence was  also  mentioned  by  Naish. — (See  Phil.  Trans, 
vol.  31,  p.  226.)  Dr.  J.  Thomson  has  seen  one  example 
of  a very  complete  ossification  of  the  arteries  of  the 
leg,  accompanying  a mortification  of  the  feet  and  toes. 
— {On  Inflammation,  p.537.)  Speaking  of  the  same 
subject,  Mr.  Hodgson  remarks;  “Experience  has 
proved  this  condition  of  the  arteries  to  be  at  least  a 
constant  attendant  upon  one  species  of  gangrene,  to 
which  the  extremities  of  old  subjects  are  liable;  and  I 
have  found  the  three  principal  arteries  of  the  leg  nearly 
obliterated  by  calcareous  matter  in  two  fatal  cases  of 
this  disease.  But  our  knowledge  of  the  power  of  col- 
lateral circulation,  in  every  part  of  the  body,  will  not 
allow  us  to  admit  the  obliteration  of  the  trunks  as  a 
sufficient  cause  of  mortification,  from  a deficient  sup- 
ply of  blood.  It  is  therefore  necessary  for  us  to  re- 
member, that  the  same  disease  may  probably  exist  in 
the  collateral  branches,  upon  which  it  has  produced 
similar  effects.  But  if  an  extent  of  vessel  be  converted 
into  a calcareous  cylinder,  it  loses  its  elasticity  and  or- 
ganic powers,  so  as  to  be  unable  to  afford  any  assist- 
ance to  the  propulsion  of  the  blood ; and  the  existence 
of  parts,  supplied  by  vessels  in  this  state,  constitutes  a 
strong  argument  against  the  agency  of  the  arteries  in 
the  circulation  of  the  blood.  The  above  observations, 
on  the  cause  of  this  species  of  gangrene,  at  once  ex- 
pose its  incurable  nature ; and  this  state  of  the  blood- 
vessels renders  the  danger  of  amputation  very  con- 
siderable, unless  fortunately  the  disease  in  the  arteries 
does  not  extend  to  the  part  at  which  the  ligature  is  ap- 
plied.”— (See  Hodgson  on  Diseases  of  the  Arteries  and 
Veins,  p.  41.)  However,  although  the  ossified  state  of 
an  artery  must  certainly  be  unfavourable  to  its  healing, 
it  does  not  constantly  prevent  this  desirable  event. — 
(See  Case  in  Medico- Chir.  Trans,  vol.  6,  p.  193.) 

The  preceding  facts  are  particularly  entitled  to  aiten 
tion,  because,  as  we  shall  presently  find,  the  opinion 
that  the  mortification  of  the  toes  and  feet  arose  from 
an  ossification  of  the  arteries  was  considered  by  Mr. 
Pott  as  destitute  of  foundation. 

It  is  probable,  however,  that  sometimes  other  causes 
are  concerned.  Fabricius  Hildanus  mentions  a fatal 
case  of  mortification  of  the  feet  and  legs,  where  the 
patient  was  in  the  vigour  of  life,  and  apparently  of 
good  constitution.  After  death,  a scirrhous  tumour 
was  found  surrounding  and  compressing  the  inferior 
vena  cava  and  aorta,  near  their  bifurcation,  so  as  to 
prevent  the  free  circulation  of  the  blood  in  the  lower 
extremities.  Mortification  of  the  extremities  also 
sometimes  occurs  from  deficient  circulation  in  the  pro- 
gress of  diseases  of  the  heart.  In  a case  of  dropsy  of 
the  chest.  Sir  A.  Cooper  has  seen  a small  spot  on  the 
leg  become  all  at  once  black,  without  any  appearance 
of  inflammation. — (See  Lancet,  vol.  1,  p.  296.) 

The  mortification  arising  from  long  continuance  in 
the  same  posture,  is  chiefly  attributable  to  debility  and 
the  unremitted  pressure  which  parts  sustain,  and 
which  obstructs  the  circulation.  Surgeons  have  fre- 
quent occasion  to  see  melancholy  examples  of  this  kind 
of  mortification,  particularly  in  cases  of  fractures,  pa- 
ralysis from  disease  of  the  vertebrte,  injuries  of  the 


178 


MORTIFICATION. 


spine  or  pelvis,  &c.  The  mischief  most  readily  occurs 
where  the  bones  liave  the  least  flesli  upon  them,  and, 
consequently,  where  all  external  pressure  has  the 
greatest  effect;  as,  for  instance,  about  the  os  sacrum, 
os  ileum,  spines  of  the  scapulte,  &c.  The  disordered 
part  always  first  becomes  soft,  livid,  red  at  the  circum- 
ference, and  cfidematous,  afterward  losing  its  sensibi- 
lity, and  acquiring  a black  appearance;  at  length  it  is 
converted  into  a foul  sloughing  ulcer. 

Though  long  continuance  in  the  same  posture  is  the 
grand  cause  of  this  kind  of  mortification,  yet  inci- 
dental circumstances  are  frequently  combined  with  it, 
and  have  great  influence  over  the  disorder.  These  are, 
great  debility,  the  same  state  of  the  system,  as  exists  in 
typhus  fever,  impure  air,  unclean  bedding,  &c.  Ac- 
cording to  Sir  A.  Cooper,  some  fevers  have  a greater 
tendency  than  others  to  produce  gangrene,  as  is  the 
case  with  scarlatina.  In  slight  cases  of  this  disorder, 
he  says,  the  most  horrible  effects  will  sometimes  arise 
from  gangrene.  The  tonsils  will  slough  to  a great  ex- 
tent ; parts  of  the  Eustachian  tube,  and  even  the  tym- 
panum will  separate,  and  large  portions  of  bone  ex- 
foliate. He  also  adverts  to  the  dangerous  sloughing 
frequently  brought  on  in  the  measles  by  the  application 
of  large  blisters  to  the  chests  of  children,  and  points 
out  the  disposition  to  sloughing,  occasioned  by  the  im- 
moderate use  of  mercury,  or  by  whatever  tends  to 
weaken  the  constitution. — (See  Lancet,  vol.  1,  p.  295.) 

There  are  some  causes  which  produce  death  in  a part 
at  once,  by  the  violence  of  their  operation.  A very 
powerful  blow  on  any  portion  of  the  body  may  destroy 
its  vitality  in  this  sudden  manner.  Lightning,  strong 
concentrated  acids,  and  gun-shot  violence  sometimes 
act  in  a similar  way.  When  a ball  enters  parts  with 
great  force  and  rapidity,  many  of  the  fibres  which  are 
in  its  track  are  frequently  killed  at  once,  and  must  be 
thrown  off  in  the  form  of  sloughs,  before  the  wound 
can  granulate  and  heal. — (See  Hunter  on  Gun-shot 
TVounds.) 

Cold  is  often  another  cause  of  mortification,  and, 
when  parts  which  have  been  frozen  or  frost  bitten  are 
suddenly  warmed,  they  are  particularly  apt  to  slough. 

I find  in  Baron  Larrey’s  valuable  publication  some 
interesting  observations  on  the  gangrene  from  cold. 
He  acquaints  us,  that  after  the  battle  of  Eylau,  one  of 
the  most  grievous  events  to  w'hich  the  French  soldiers 
were  exposed,  was  the  freezing  of  their  feet,  toes, 
noses,  and  ears;  few  of  the  vanguard  escaped  the 
affliction.  In  some,  the  mortification  was  confined,  to 
the  surface  of  the  integuments  of  the  toes  or  heels ; in 
some,  the  skin  mortified  more  deeply,  and  to  a greater 
or  less  extent;  while  in  others,  the  whole  of  the  toes 
or  foot  was  destroyed. — (See  Progranima  quo  frigoris 
acrioris  in  corpora  humano  effectus  expendit,  Haller, 
JDi'sp.  ad  Morb.  Lips.  1775.) 

“All  the  writers  on  this  species  of  mortification 
(says  Larrey)  have  considered  cold  as  the  determining 
cause ; but  if  we  attend  to  the  period  when  the  com- 
plaint begins,  and  the  phenomena  which  accompany  it, 
we  shall  be  convinced  that  cold  is  merely  the  predis- 
posing cause.  In  fact,  during  the  three  or  four  ex- 
ceedingly cold  days  which  preceded  the  battle  of  Eylau 
(the  mercury  having  then  fallen  to  10,  11,  12,  13,  14, 
and  15  degrees  below  zero  of  Reaumur’s  thermometer), 
and  until  the  second  day  after  the  battle,  not  a soldier 
complained  of  any  symptom  depending  upon  the 
freezing  of  parts.  Nevertheless,  they  had  passed  these 
days,  and  a great  portion  of  the  nights  of  the  5th,  6th, 
7th,  8th,  and- 9th  of  February  in  the  snow  and  the 
most  severe  frost.  The  imperial  guard  especially  had 
remained  upon  watch  in  the  snow,  hardly  moving  at 
all  for  more  than  four-and-twenty  hours,  yet  no  soldier 
presented  himself  at  the  ambulance,*  nor  did  any  one 
complain  of  his  feet  being  frozen.  In  the  night  of  the 
9th  and  10th  of  February  the  temperature  suddeidy 
rose,  the  mercury  ascending  to  3,4,  and  5 degrees  above 
zero.  A great  quantity  of  sleet,  that  fell  on  the  morn- 
ing of  the  10th,  was  the  forerunner  of  the  thaw,  which 


* The  ambulances  of  the  French  army  are  caravans, 
furnished  with  an  adequate  number  of  surgeons,  and 
every  requisite  for  the  dressing  of  wounds,  and  the 
immediate  performance  of  operations,  upon  which  last 
circumstance,  in  particular,  the  life  of  the  wounded 
soldier  often  depends.  They  follow  the  most  rapid 
movements  of  the  army,  and  are  capable  of  keeping 
up  with  the  vanguard. 


took  place  in  the  course  of  that  dhy,  and  continued 
the  same  degree  for  several  days.  From  this  moment, 
many  soldiers  of  the  guards  and  the  line  applied  for 
succour,  complaining  of  acute  pain  in  the  feet,  and  of 
numbness,  heaviness,  and  prickings  in  the  extremities. 
The  parts  were  scarcely  swollen,  and  of  an  obscure 
red  colour.  In  some  cases  a slight  redness  was  per- 
ceptible about  the  roots  of  the  toes  and  on  the  back  of 
the  foot.  In  others,  the  toes  were  destitute  of  motion^ 
sensibility,  and  warmth,  being  already  black,  and,  as 
it  were,  dried.  All  the  patients  assured  me  that  they 
had  not  experienced  any  painful  sensation  during  the 
severe  cold,  to  which  they  had  been  exposed  on  the 
night  watches  of  the  5th,  6th,  7th,  8th,  and  9th  of  Feb- 
ruary, and  that  it  was  not  till  the  night  of  the  lOlh,  when 
the  temperature  had  risen  from  18  to  20  degrees,  that 
they  felt  the  first  effects  of  the  cold.”  It  is  farther  no- 
ticed by  Larrey,  that  such  patients  as  had  opportuni- 
ties of  warming  themselves  in  the  town,  or  at  the  fires 
of  the  night  watches,  suffered  in  the  greatest  degree. — 
(See  Memoires  de  Chirurgie  Militaire,  t.  3,  p.  60 — 62.) 

Sometimes  mortification  seems  to  depend  either  upon 
the  operation  of  some  infectious  principle,  or,  at  all 
events,  upon  causes  wTiich  simultaneously  affect  nu- 
merous individuals;  for  instances  have  been  knowir, 
in  which  almost  all  the  ulcers  and  wounds  in  large  ho£?- 
pitals  became  nearly  at  the  same  time  affected  with 
gangrenous  mischief. — (See  Hospital  Gangrene.) 

Mortification  is  very  frequently  occasioned  by  the 
injury  which  parts  sustain  from  the  application  of  fire 
and  heated  sulistances  to  them.  When  the  heat  is 
very  great,  the  substance  of  the  body  is  even  decom- 
posed, and  of  course  killed  at  once.  On  other  occa- 
sions, when  the  heat  has  not  been  so  violent,  nor  suffi- 
ciently long  applied,  inflammatory  symptoms  precede 
the  sloughing. 

Cutaneous  texture  is  that  in  which  we  have  the  best 
opportunity  of  observing  the  phenomena  and  progress 
of  gangrene.  When  it  occurs  as  a consequence  of  in- 
flammation, the  colour  of  the  skin  changes  from  the 
florid  red  to  a darker  shade ; and  in  the  progress  of  the 
disease  it  acquires  a livid  hue.  The  cuticle  often  se- 
parates at  certain  points  from  the  skin,  and  the  vesica- 
tions,  termed  phlyctence,  are  formed,  which  usually 
contain  a bloody-coloured  serum.  As  sphacelus  comes 
on,  the  livid  hue  disappears,  and  a slough  is  formed, 
which  is  sometimes  ash-coloured ; sometimes  black. 
It  is  not  always  easy  to  judge  of  the  extent  of  mortifi- 
cation from  the  appearance  of  the  skin ; for  when  the 
subjacent  cellular  membrane  is  affected,  the  disorder 
may  occupy  a greater  extent  internally  than  upon  the 
surface. 

In  a spreading  gangrene,  the  red  colour  of  the  affected 
skin  is  insensibly  lost  in  the  surrounding  integuments ; 
but  when  gangrene,  followed  by  sphacelus,  stops,  a red 
line,  of  a colour  more  lively  than  that  of  gangrene,  is 
generally  perceptible  be(ween  the  dead  and  living  parts. 
It  is  at  the  inner  edge  of  this  inflamed  line  where  we 
usually  see  the  ulcerating  process  begin,  by  which  the 
separation  of  the  dead  from  the  living  parts  is  effected. 
— (See  Thomson's  Lectures  on  Inflammation,  p.  511, 
512.) 

Mortification  frequently  takes  place  in  cellular  tex- 
ture. The  skin  which  covers  dead  cellular  substance 
generally  has  a gangrenous  appearance,  and  afterward 
either  ulcerates  or  sloughs.  In  some  cases,  the  portion 
of  sphacelated  cellular  te.xture  is  small,  as  in  the  ma- 
lignant boil;  in  others,  extensive,  as  in  cases  of  car- 
buncle. In  erysipelas  phlegtnonoides,  the  cellular  niem- 
brano>  connecting  together  the  muscles,  tendons,  nerves, 
blood-vessels,  &c.  often  perishes  to  a great  extent. 
Here  large  punions  of  skin  are  frequently  also  destroyed 
by  sloughing  or  ulceration,  so  that  muscle,  blood-ves- 
sel, tendon,  nerve,  &c.  are  exposed  to  view,  quite  de- 
nuded of  their  proper  coverings,  and  in  different  states 
of  disease. 

Artery  is  the  texture  endowed  with  the  greatest 
power  of  resisting  its  own  destruction  by  mortification. 
“ I have  (says  Dr.  Thomson)  in  various  instances  of 
erysipelas  phleginonoides,  seen  several  inches  of  the 
femoral  artery  laid  completely  bare  by  the  gangrene, 
ulceration,  and  sphacelus  of  the  parts  covering  it, 
without  its  giving  way  before  death.  The  arteries  in 
these,  and  other  similar  instances,  in  which  I have 
seen  them  laid  bare  in  the  neck  and  arm,  by  abscess 
terminating  in  mortification,  had  the  apiK^arance  of 
raw  flesh,  and  were  obviously  thicker  and  more  vas- 


MORTIFICATION. 


179 


cular  than  natural.  The  blood  circulated  through 
them,  and  assisted  in  supplying  with  nourishment  the 
parts  upon  which  they  vvere  distributed.”— (P.  523.)  I 
have  often  seen  the  truth  of  the  foregoing  statement 
sadly  illustrated  in  cases  of  sloughing  buboe.s,  by 
which  several  inches  of  the  femoral  artery  were  ex- 
posed. I have  seen  the  throbbing  brachial  artery  de- 
nuded for  more  than  a month,  nearly  its  whole  extent 
along  the  inside  of  the  arm,  by  the  ravages  of  malig- 
nant and  pseudo-syphilitic  ulceration,  attended  with 
repeated  sloughing;  and  yet  hemorrhage  had  no  share 
in  carrying  off  the  unfortunate  patient. 

It  is  a curious  fact,  that  the  blood  coagulates  in  the 
large  arteries  which  lead  to  a mortified  part.  This  oc- 
currence takes  place  for  some  distance  front  the  slough, 
and  is  the  reason  why  the  separation  of  a mortified 
limb  is  seldom  followed  by  hemorrhage. 

The  same  occurrence  also  affords  hn  explanation 
why,  in  the  amputation  of  a mortified  limb,  there  is 
sometimes  ho  hemorrhage  from  the  vessels,  although 
the  incisions  are  made  in  the  living  part.  This  fact 
%vas  first  particularly  pointed  out  by  Petit,  the  surgeon. 
— (See  Mem.  de  I' .Scad,  des  Sciences,  1732.)  “ VVhen 

a gangrened  limb  (says  this  celebrated  surgeon)  is  cut 
off  in  the  dead  part,  no  hemorrhage  occurs,  because 
the  blood  is  coagulated  a great  way  in  the  vessels.” 
He  adds,  “ We  have  several  examples  of  limbs  ampu- 
tated, on  account  of  gangrene,  in  which  no  hemorrhage 
occurred,  although  the  amputation  was  made  a con- 
siderable Way  in  the  living  parts ; because  the  clot  was 
not  confined  in  these  cases  to  the  dead  part,  but  was 
continued  forwards  into  the  living,  as  far  as  the  in- 
flammatory disposition  extended.” 

According  to  Dr.  Thomson,  cases  in  confirmation  of 
the  foregoing  statement  are  recorded  by  other  prac- 
tical writers,  especially  Quesnay,  and  Mr.  O’Halloran. 
In  one  of  the  cases  mentioned  by  the  latter  gentleman, 
and  in  which  no  hemorrhage  followed- the  removal  of 
the  limb,  the  incisions  were  made  four  inches  above 
the  division  of  the  dead  from  the  living  parts.  Dr. 
Thomson  has  seen  a still  longer  portion  of  femoral  ar- 
tery closed  up  with  coagulated  blood,  after  a mortifica- 
tion of  the  foot  and  leg;  and,  in  one  example,  where 
the  mortification  began  in  the  thigh,  he  saw  the  coagu- 
lation of  the  blood  in  the  external  iliac,  extending  up 
to  the  origin  of  this  vessel  from  the  aorta.  “So 
common,  indeed,  is  this  coagulation  of  the  blood  in  the 
limbs  affected  with  mortification  (observes  Dr.  Thom- 
son), that  it  has  been  supposed  to  be  a necessary  and 
constant  effect  of  this  disease.  This  opinion,  however, 
does  not  appear  to  be  tvell  founded  ; forlhavenowseen 
■several  instances  in  which  a limb  h.as  mortified  and 
dropped  off,  without  hemorrhage  having  occurred  from 
the  vessels  divided  by  nature:  and  yet,  in  examining 
the  vessels  of  the  stumps  of  these  patients  after  death, 
I have  not  been  able  to  find  any  clots,  either  of  coagu- 
lated blood,  or  of  coagulable  lymph.  In  the  cases  to 
which  I allude,  the  adhesive  inflammation,  occuring  in 
the  line  of  separation  between  the  dead  and  living 
parts,  had  extended  to  the  blood-vessels,  and  their 
inner  surfaces,  being  inflamed  and  pressed  together  by 
the  swelling  which  occurs,  had  adhered  so  as  to  close 
up  their  extremities.  It  is  in  this  way  we  shall  find 
that  the  common  ligature  acts,  which  is  applied  to  the 
divided  extremities  of  arteries  and  veins;  and  it  is 
this  obliteration  by  the  process  of  adhesion  of  the 
extremities  of  the  arteries  and  veins  in  the  neigh- 
bourhood of  the  sphacelated  parts,  that  in  reality  pre- 
vents the  occurrence  of  hemorrhage  when  the  mortified 
limbs  fall  off,  or  .are  removed  by  the  knife.  The  coagu- 
lation of  the  blood  in  the  canal  of  the  vessel  is  not  alone 
sufficient.  It  may  tend,  in  the  cases  in  which  it  occurs, 
for  a time,  to  restrain  hemorrhage;  but  it  is  by  the  obli- 
teration by  adhesion  of  the  canal  in  the  extremities  of 
the  arteries  and  veins  that  the  occurrence  of  hemor- 
rhage can  be  securely  and  permanently  provided 
against.  Indeed,  to  me,  it  seems  doubtful,  whether 
the  co.agulation  of  the  blood,  which  takes  place  in 
mortified  limbs,  ever  lakes  place  in  the  canal  of  the 
vessel,  till  its  extremity  and  Lateral  communications 
have  been  plugged  up  by  the  coagulating  lymph, 
which  is  extended  during  the  state  of  the  adhesive  in- 
flammation.”— (See  Thomson's  Lectures  on  Inflamma- 
tion, p.  .5.54.) 

If  gangrene  and  sphacelus  happen  to  any  extent, 
the  patient  is  usually  troubled  with  an  oppressive 
hiccough ; a symptom  well  known  to  the  surtreon 

ftl  2 ■■ 


of  experience,  and  often  an  indication  of  the  mischief, 
Vvhen  external  signs  are  less  instructive.  The  truth 
of  this  remark  is  fiequently  seen  in  strangulated  hernia. 

The  constitution  also  suffers  immediately  a con- 
siderable dejection.  The  patient’s  countenance  sud- 
denly assumes  a wild  cadaverous  look;  the  pulse 
becoUies  small,  rapid,  and  sometimes  irregular ; cold 
perspirations  come  on,  and  the  patient  is  often  affected 
With  vomiting,  diarrhoea,  and  delirium. 

As  Dr.  7’homson  observes,  the  constitutional  symp- 
toms “form  fevers,  which  partake  in  individual  cases, 
more  or  less,  of  an  inflammatory,  typhoid,  or  bilious 
character.  But  the  degree  of  these  fevers  varies  in 
every  particular  case,  from  their  almost  total  absence 
to  the  highest  degree  of  intensity.  The  skin  is  usually 
hot  and  dry  at  the  commencement  of  the  attack  ; the 
tongue  is  without  moisture,  brown  and  h.ard ; the  pulse 
is  quicker,  and  less  full  and  strong,  than  in  inflamma- 
tion ; and  this  state  of  the  pulse  is  often  attended  by 
flattering  intermissions,  and  a considerable  degree  of 
subsultus  tendinum.  The  fever  has,  in  general,  more 
of  the  asthenic  than  of  the  sthenic  character;  or  it  is 
more  of  the  typhoid  than  of  the  inflammatory  type ; a 
circumstance  of  great  importance  in  the  constitutional 
treatment  of  mortification.  The  fever  in  gangrenous 
affections  is  often  accompanied  with  great  uneasiness 
and  restlessness,  dejection  of  spirits,  wildness  of  the 
looks;  and,  in  severe  cases,  with  almost  always  more 
or  less  delirium.  In  the  progress  of  the  disease,  cold 
sweats,  palpitations,  and  convulsions  sometimes-occur ; 
a hiccough,  accompanied  with  nausea,  often  comes  on, 
and  proves  a most  distressing  symptom  to  the  patient. 
Frequently  this  hiccough  is  the  forerunner  of  death. 
Some  patients  die  comatose;  others,  after  suffering 
severe  pains,  spasms,  and  delirium.  But  in  some,  a 
slow,  in  others,  a sudden  abatement  of  the  constitu- 
tional symptoms  takes  place,  accompanied  also  with 
the  amelioration  of  the  local  affection.  The  gangre- 
nous inflammation  stops,  and  a red  line  is  formed  by  the 
adhesive  inflammation  in  the  extreme  verge  of  the 
living  parts;  the  dead  part  separates,  and  granula- 
tions form ; and  when  the  constitution  has  strength  to 
sustain  the  injury  it  has  received,  recovery  takes 
place.” — (See  Lectures  on  Inflamhiation,  p.  509.) 

It  is  an  erroneous  supposition,  that  mortification, 
arising  from  an  external  local  cause,  is  more  easily 
stopped  and  cured  than  that  originating  from  an  in- 
tern.al  cause.  The  local  cause  is  sometimes  extremely 
difficult,  or  even  incapable  of  removal ; and  a sphacelus, 
which  is  at  first  entirely  local,  may  afterward  become 
a general  disorder,  by  the  universal  debifity  and  de- 
rangement of  the  system,  resulting  from  the  complaint. 
Hence,  it  is  obvious,  that  a sphacelus  may  easily  ex- 
tend beyond  the  bounds  of  its  outward  local  cause. 
On  the  other  hand,  a mortification  may  be  reduced  to 
one  of  a nature  entirely  local ; though  it  arose  at  first 
from  constitutional  causes.  Sphacelus  from  extreme 
debility,  or  from  such  a state  of  the  system  as  attends 
the  scurvy,  typhoid  fevers,  &c.,  is  constantly  perilous, 
because  these  causes  are  very  difficult  to  remove.  It 
is  also  a fact,  that  when  numerous  causes  are  com- 
bined, it  is  an  unfavourable  occurrence,  not  merely 
because  the  surgeon  isapt  tooverlook  someof  them,  but 
because  there  are  in  reality  more  obstacles  to  the  cure. 

Humid  gangrenes,  which  are  frequently  accompanied 
with  emphysema  of  the  cellular  membrane,  usually 
spread  with  great  rapidity. — (See  James  on  Inflamma- 
tion, p.  96.) 

Sometimes  a mortification  spreads  .eo  slowly,  that  it 
does  not  occupy  much  extent  at  the  end  of  several 
months,  or  even  a whole  year.  The  case,  however,  is 
often  not  the  less  fatal  on  this  account.  The  danger  is 
never  altogether  over,  until  the  dead  part  has  com- 
pletely separated.  The  entrance  of  juitrid  matter  into 
the  circulation  (says  Richter)  is  so  injurious,  that  pa- 
tients'sometimes  perish  from  this  cause,  long  after  the 
mortification  has  ceased  to  spread. — {Mnfangsgr.  der 
TVvndarin.  h.  1,  kap.  3,  p.  78,79.) 

This  last  circumstance  is  very  much  insisted  upon 
by  all  the  modern  continental  surgeons ; but  the  doc- 
trine has  never  gained  ground  among  English  sur- 
geons, who  entertain  little  apprehension  of  the  bad 
effects  of  the  absorption  of  putrid  matter  in  cases  of 
mortification  ; and  the  opinion  of  Mr.  Guthrie  may  be 
more  correct,  that  nature  receives  the  shock  through 
the  nervous  system,  and  not  through  the  absorbents.— 
(Ott  Gun-shot  Wounds,  p.  123,  ed.  2.) 


180 


MORTIFICATION. 


The  idea  of  a deleterious  principle  being  absorbed 
was  long  ago  well  refuted  by  Mr.  J.  Burns,  who 
pointed  out,  that  the  impression  upon  the  constitution 
was  in  no  degree  commensurate  with  the  size  of  the 
slough,  and  consequently  with  the  quantity  of  putrid 
matter,  as  the  effects  produced  by  a small  slough  of  in- 
testine, or  cornea,  will  exemplify.  But  when  the 
sloughs  are  of  equal  size,  and  in  the  same  parts,  the 
differences  of  constitutional  sympathy,  as  Mr.  James 
observes,  may  depend  upon  the  nature  of  the  surround- 
ing inflammation,  which,  however,  he  conceives,  may 
itself  be  affected  by  the  quantity  of  putrid  irritating 
fluids. — (On  Inflammation,  p.  98.) 

The  danger  of  sphacelus  materially  depends  upon 
the  size  and  importance  of  the  part  affected,  and  upon 
the  patient’s  age  and  constitution.  The  indications 
already  specified  of  the  stoppage  of  mortification,  must 
also  considerably  influence  the  prognosis,  especially 
the  red  line  at  the  edge  of  the  living  parts,  and  the 
incipient  separation  of  the  dead  from  the  living  parts. 

Sphacelus  implies  the  total  loss  of  life  in  the  part 
affected,  the  de.struclion  of  its  organization,  the  aboli- 
tion of  all  its  functions,  and  an  absolute  inability  to 
resume  them  again.  However,  even  when  w'e  see  the 
surface  of  a part  manifestly  sphacelated,  we  must  not 
always  conclude  that  the  entire  destruction  of  its 
whole  substance  or  thickness  is  certain ; for,  in  many 
cases,  the  disorder  only  affects  the  skin  and  cellular 
substance.  In  this  state,  the  integuments  frequently 
slough  away,  leaving  the  tendons,  muscles,  and  other 
organs  perfectly  sound. 

TREATMENT  OF  MORTIFICATION. 

I shall  arrange  under  two  heads  what  is  to  be  said  of 
the  treatment  of  mortification.  Under  the  first  will 
be  comprehended  every  thing  which  relates  to  in- 
ternal remedies,  and  such  other  means  as  are  indicated 
by  the  general  state  of  the  system  ; under  the  second, 
topical  remedies,  and  the  local  treatment  of  the  parts 
affected. 

In  the  treatment,  the  surgeon  will  always  have  one 
thing  for  immediate  consideration;  viz.  whether  the 
case  before  him  is  one  of  acute  mortification,  attended 
with  inflammation  and  inflammatory  fever ; or  whe- 
ther it  is  a chronic  mortification,  beginning  without 
fever,  or  attended  with  a fever  of  a typhoid  nature 
and  great  prostration  of  strength  1 By  making  up  his 
mind  upon  this  point,  the  practitioner  will  establish  a 
useful  general  principle  for  his  guidance,  especially  in 
tlie  commencement  of  the  treatment. 

1.  When  mortification  is  acute,  and  seems  to  depend 
on  the  violence  of  inflammation,  the  first  indication  is 
to  moderate  the  inordinate  action  of  the  sanguiferous 
system,  by  the  prudent  employment  of  such  means  as 
are  proper  for  counteracting  inflammation.  In  short, 
relief  is  to  be  sought  in  the  antiphlogistic  regimen, 
which  consists  in  the  employment  of  blood  letting, 
purgatives,  diaphoretics,  and  diluents,  and  in  absti- 
nence from  all  vegetable  or  animal  substances,  which 
have  a tendency  to  excite,  or  to  augment  the  febrile  ac- 
tion. This  regimen  must  be  pursued  as  long  as  in- 
flammatory fever  continues.  It  is  only  in  cases  in 
which  the  fever  from  the  first  assumes  a typhoid 
character,  or  where  the  mortification  takes  place  with- 
out the  previous  occurrence  of  fever,  that  any  devia- 
tion from  the  antiphlogistic  regimen  can  be  allowed. 

Dr.  Thomson,  from  whom  I have  borrowed  the  fore- 
going passage,  also  notices  the  present  common  aver- 
sion to  bleeding  in  compound  fractures,  erysipelas, 
carbuncles,  hospital  gangrene,  burns,  and  frost-bite; 
cases  in  which  the  patient,  it  is  said,  can  seldom  bear 
with  impunity  any  considerable  loss  of  blood.  “ In 
many  instances  of  these  injuries  and  affections  (says 
lie)  blood-letting,  I know,  is  not  required;  but  I am 
doubtful,  even  if  it  were  generally  employed,  whether 
it  would  produce  all  the  mischiefs  which  have  of  late 
years  been  ascribed  to  it.  I believe  it  to  be  the  most 
efficacious  of  any  of  the  remedies  that  can  be  em- 
ployed in  all  cases  of  inflammatory  fever  threatening 
to  terminate  in  gangrene,  and  that  its  use  in  such 
cases  ought  never  to  be  omitted  in  the  young,  strong, 
and  plethoric.” — (See  L.ectnres  on  Inflammation,  p. 
559.)  When  bleeding  has  not  been  sufficiently  prac- 
tised, during  the  inflammation  antecedent  to  mortifica- 
tion ; when  the  general  symptoms,  which  point  out  the 
existence  of  this  state,  continue  violent;  and  espe- 
cially when  the  pulse  is  still  quick,  hard,  or  full ; it  is 


absolutely  necessary  to  empty  the  vessels  a little  more, 
even  though  mortification  may  have  begun,  particularly 
if  the  patient  be  young  and  plethoric.  Bleeding,  by 
diminishing  the  fever,  and  abating  the  general  heat,  is 
frequently  the  best  means  of  all.  It  may  then  be  con- 
sidered better  than  all  antiseptics  for  stopping  the  pro- 
gress of  the  disorder.  But  this  evacuation  is  to  be  em- 
ployed with  a great  deal  of  circumspection  ; for,  should 
it  be  injudiciously  resorted  to,  from  the  true  state  of 
the  system  not  being  understood,  the  error  may  be  fol- 
lowed by  the  most  fatal  consequences.  Owing  to  the 
constitution  being  generally  broken  by  intemperance, 
or  enfeebled  by  an  impure  atmosphere,  Sir  A.  Cooper 
considers  it  rarely  safe  in  this  metropolis  to  take  blood 
from  the  arm,  with  a view  of  checking  gangrene ; 
though  he  acknowledges  that  the  removal  of  a few 
ounces  of  blood  is  a practice  which  sometimes  answers 
in  the  country.  It  should  also  be  well  remembered, 
that  however  strongly  bleeding  may  be  indicated,  the 
moment  is  not  far  off  when  this  evacuation  is  totally 
inadmissible,  especially  if  the  mortification  make 
much  progress. 

In  cases  of  acute  mortification,  after  as  much  blood 
has  been  taken  away  as  may  be  deemed  safe  or  proper, 
the  other  parts  of  the  antiphlogistic  regimen  must  be 
continued  as  long  as  any  increased  action  of  the  heart 
and  arteries  continues.  “ The  use  of  purgatives  seems 
to  be  particularly  required  in  those  cases  in  which  the 
local  inflammatory  affection  is  accompanied  with  de- 
rangement of  the  digestive  and  biliary  organs.  Anti- 
monial  diaphoretics  are  those  from  whichTl  should  be 
inclined  to  expect  most  advantage  in  the  commence- 
ment of  the  attack;  but  after  the  inflammatory  action 
has  been  subdued,  opiates,  either  alone  or  combined 
with  antimony,  or,  what  is  still  better,  with  ipecacu- 
anha, as  in  Dover’s  powder,  are  frequently  ofsingular 
service,  not  only  by  ditninishiiig  pain,  but  also  by  in- 
ducing a soft  and  moist  state  of  the  skin.”— -( Thomson, 
p.  5G0  ) A strict  regimen,  which  may  have  been  use- 
ful and  even  necessary  during  the  inflammatory  stage, 
may  have  a very  bad  effect  if  continued  too  long,  by 
diminishing  the  patient’s  strength,  which,  on  the  con- 
trary, should  be  supported  by  the  most  nourishing  food. 

Sir  A.  Cooper  recommends  two  or  three  grains  of 
the  submuriate  of  mercury  at  night,  in  order  to  restore 
the  secretions  of  the  intestinal  canal  and  liver;  and 
the  liquor  ammoniae  acetatis,  with  a few  drops  of  the 
tinct.  opii,  several  times  a day,  with  the  view  of  les- 
sening irritability,  and  tranquillizing  the  system. 

A vegetable  diet,  as  Dr.  Thom.«on  observes,  is  to  be 
preferred  in  the  commencement  both  of  acute  gan- 
grene with  inflammatory  fever,  and  of  chronic  gan- 
grene with  a fever  from  the  first  of  a typhoid  nature. 
Wine  and  animal  food  given  too  early  in  diseases 
which  have  a tendency  to  gangrene  increase  the  febrile 
heat  and  frequency  of  the  pulse,  oppress  the  stomach, 
render  the  tongue  foul,  the  patient  restless  and  de- 
lirious, and  his  situation  dangerous,  if  not  hopeless. 
In  the  transition  from  gangrene  to  sphacelus  an  abate- 
ment of  the  symptomatic  fever  usually  takes  place  in 
almost  all  cases  which  have  ultimately  a favourable 
termination.  Dr.  Thomson  believes  that  this  is  the 
flrst  period  at  which  it  is  safe  to  allow  vinous  liquors, 
or  diet  chiefly  animal. — (P.  561.) 

I next  come  to  a second  very  essential  and  important 
indication  to  be  fulfilled  as  soon  as  the  symptoms,  an- 
nouncing the  existence  of  the  inflammatory  state,  ap- 
pear to  abate,  and  the  patient  begins  to  be  debilitated. 
This  indication  is  to  prevent  excessive  weakness  by  the 
suitable  employment  of  cordials,  and  particularly  of 
tonics.  These  same  means  also  contribute  to  place  the 
system  in  a proper  state  for  freeing  itself  from  the 
mortified  parts,  or  in  other  w'ords  for  detaching  them. 
For  inflammation  is  the  preparatory  step  which  nature 
takes  to  accomplish  the  separation  of  mortified  parts 
from  the  living  ones,  and  this  salutary  inflammation 
cannot  take  place  if  the  energies  of  life  be  too  much 
depressed. 

In  order  to  fulfil  the  above  indication,  it  is  neces- 
sary to  prescribe  a nourishing  diet,  wiih  a certain 
quantity  of  good  wine,  proportioned  to  the  patient’s 
strength  and  the  symptoms  of  the  complaint.  This 
diet  is  generally  productive  of  moie  real  benefit  than 
the  whole  cla.«s  of  cordial  and  stimulating  medicines. 
However,  when  the  patient  is  much  weakened,  when 
the  mortification  of  the  part  affected  is  complete,  and 
the  disorder  is  spreading  to  others,  some  of  the  follow- 


MORTIFICATION. 


181 


ing  remedies  may  be  ordered:  ammonia,  aromatic 
eojifection,  ether,  &c.  In  general,  liowever,  wine  is 
better,  because  more  agreeable  than  cordials  ; and  for 
this  purpose  we  ouglit  to  prefer  tlie  most  perfect  wines, 
such  as  those  of  Spain  and  Madeira. 

Of  all  the  medicines  hitherto  recommended  for  the 
stoppage  of  mortification,  none  ever  acquired  such  a 
cliaracter  for  efficacy  as  the  Peruvian  bark.  It  is  said 
that  this  remedy  often  stops  in  a very  evident  and  ex- 
peditious manner  the  course  of  the  disorder.  Being 
a very  powerful  tonic,  it  is  thought  to  operate  by 
strengthening  the  system,  and  thus  maintaining  in 
every  part  the  necessary  tone  for  resisting  the  progress 
of  mortification.  But  whatever  may  be  its  mode  of 
acting,  the  advocates  for  this  medicine  contend  that  it 
ought  to  be  employed  in  almost  all  cases  of  mortifica- 
tion, as  soon  as  the  violence  of  the  inflammatory  symp- 
toms has  been  appeased. 

It  was  Mr.  Rushworth,  a surgeon  at  Northampton, 
who  made  this  discovery  in  the  year  1715.  Amyand 
and  Douglas,  two  surgeons  in  London,  soon  afterward 
confirmed  the  virtue  of  this  remedy.  Mr.  Shipton, 
another  English  surgeon,  also  described,  in  the  Philo- 
sophical Transactions,  the  good  effects  which  he  saw 
produced  by  it.  In  the  Medical  Essays  of  Edinburgh, 
Drs.  Monro  and  Paisley  published  several  case  illustra- 
tive of  its  efficacy.  We  are  there  informed,  that  when 
its  exhibition  was  interrupted,  the  separation  of  the 
eschars  was  retarded,  and  that  on  the  medirine  being 
resorted  to  again,  the  separation  went  on  again  more 
quickly.  Since  this  period,  all  practitioners  in  England 
and  elsewhere  have  employed  bark  very  freely  in  the 
treatment  of  mortification ; and  the  exaggerated  state- 
ments of  its  eflfects  led  to  ns  exhibition  in  all  cases  of 
this  nature  without  discrimination  of  the  varying 
states  of  the  general  health  and  local  disorder  in  the 
different  stages  of  the  complaint,  and  without  any 
reference  to  its  causes  and  nature,  which  are  subject 
to  variety. 

We  cannot  indeed  doubt  that  bark  has  frequently 
had  the  most  salutary  effect  in  cases  of  mortification, 
though  sometimes  it  may  probably  have  had  imputed 
to  it  effects  which  were  entirely  produced  by  nature. 
The  following  observation  made  by  Dr.  Thomson  is 
highly  worthy  of  recollection : “ In  attending  to  the 
effects  supposed  to  result  from  the  operation  of  the  ex- 
ternal and  internal  remedies  which  are  daily  employed 
for  the  cure  of  mortification,  there  are  two  facts,  well 
ascertained,  which  appear  to  me  to  be  peculiarly  de- 
serving of  your  regard.  The  first  of  these  is,  that 
mortification  often  stops  spontaneously,  without  any 
assistance  whatever  from  medicine;  the  second  that  it 
often  begins  and  continues  to  spread,  or  even  after  it 
has  stopped  for  a while  recommences,  and  proceeds  to 
a fatal  termination  in  spite  of  the  best  directed  efforts 
of  the  healing  art.” — (See  Lectures  on  Ihjlamination, 
p.  557.) 

Ii  is  quite  wrong  to  prescribe  bark  in  every  instance, 
for  there  are  many  cases  in  which  it  is  unnecessary, 
some  in  which  it  does  harm,  and  others  in  which  it  is 
totally  inefficacious.  It  is  a medicine  obviously  of  no 
service  when  the  mortification  arises  from  an  external 
cause,  and  is  the  only  complaint  in  a healthy,  strong 
constitution.  It  is  equally  unnecessary  when  the  spha- 
celus is  of  the  dry  sort,  and  has  ceased  to  spread,  at  the 
same  time  that  tlie  living  margin  appears  to  be  in  a 
state  of  inflammation  without  any  universal  debility. 
But  it  deserves  particular  notice,  that  the  circum- 
stances of  each  individual  case  are  liable  to  so  consi- 
derable a variation,  that  though  bark  may  be  at  first 
unnecessary,  it  may  afterward  be  indicated. 

When  mortification  is  complicated  with  serious  dis- 
order of  the  functions  of  the  abdominal  viscera,  a very 
frequent  case,  bark  is  manifestly  pernicious.  Here, 
the  indication  is  lo  correct  the  state  of  the  stomach  and 
bowels  with  mild  opening  medicines,  and  especially 
calomel.  When  this  has  been  done,  if  bark  should  be 
indicated  by  any  of  the  circumstances  already  pointed 
out,  it  may  be  safely  administered. 

Sometimes  mortification  is  accompanied  with  a low 
typhoid  kind  of  fever,  which,  whether  the  cause  or 
the  consequence  of  the  local  mischief,  may  require  the 
exhibition  of  bark. 

However,  mortification  may  be  attended  with  com- 
mon inflammatory  fever,  and  then  the  living  margin  is 
generally  inflamed  and  painful.  This  is  particularly 
the  case^  wlien  mortification  is  tho  consequence  of 


genuine  acute  inflammation,  or  of  an  external  injury, 
in  a healthy  subject.  Here  bark  must  obviously  be  in- 
jurious. Still  it  is  wrong  to  regard  this  medicine  as 
invariably  hurtful  whenever  sphacelus  is  the  effect  of 
inflammation.  It  has  already  been  observed,  that  the 
inflammation  frequently  has  less  share  in  the  origin  of 
the  disorder,  than  some  incidental  cause,  which  often 
requires  the  exhibition  of  bark.  Even  when  mortifi- 
cation is  the  pure  effect  of  inflammation,  great  prostra- 
tion of  strength  may  subsequently  arise,  and  indeed 
does  mostly  take  place  at  a certain  period  of  the  dis- 
order. In  this  circumstance  the  voice  of  experience 
loudly  proclaims  the  utility  of  bark,  though  its  exhi- 
bition would  have  been  at  first  useless  or  hurtful. 
While  genuine  inflammatory  fever  and  local  inflam- 
mation areco  existent  with  mortification,  antiphlogistic 
means  are  undoubtedly  useful ; but  great  caution  is 
requisite,  since,  in  cases  of  humid  gangrene,  as  it  is 
termed,  the  inflammatory  state  very  soon  changes  into 
one  in  which  the  great  feature  is  prostration  of 
strength. 

When  there  is  mere  prostration  of  strength  without 
any  symptom  of  gastric  disorder,  or  of  inflammation, 
or  typlioid  fever,  bark  is  evidently  proper,  though  sel- 
dom effectual  alone;  diaphoretic  and  nervous  medi- 
cines being  also  necessary,  opium,  wine,  camphor,  am- 
monia, brandy,  &c. 

We  meet  with  one  species  of  mortification  in  which 
the  patient  experiences  severe  pain  in  the  part,  with- 
out the  smallest  appearance  of  inflammation.  Here 
bark  is  never  of  much  use,  and  opium  has  been  repre- 
sented as  tlie  medicine  in  which  we  should  principally 
confide.  Tliis  subject  will  be  more  fully  considered 
presently,  when  Mr.  Pott’s  remarks  on  a peculiar  mor- 
tification of  the  toes  and  feet  will  be  introduced. 

Bark  sometimes  occasions  purging,  and  then  it  must 
be  immediately  discontinued,  unless  that  hurtful  effect 
can  be  prevented  by  the  addition  of  a few  drops  of 
laudanum  to  each  dose,  or  by  employing  the  suhihate 
of  quinine,  instead  of  the  common  preparations. 
Bark  frequently  disagrees  with  the  stomach  ; in  which 
case,  I should  say,  that  it  ought  not  to  be  continued  at 
all ; though,  in  this  circumstance,  the  usual  plan  has 
been  to  give,  instead  of  the  decoction,  the  infusion  or 
the  powder  finely  divided,  and  mixed  with  wine,  or 
some  aromatic  water.  Here  the  sulphate  of  quinine  is 
likely  to  prove  the  safest  preparation  of  bark  ; but  far- 
ther experience  with  respect  to  its  real  efficacy  is  still 
needed. 

Several  years  ago  I published  a critique  on  the  in- 
discriminate employment  of  bark  in  cases  of  mortifi- 
cation, and  my  remarks  were  inserted  in  the  article 
Gangrene  in  Dr.  Rees's  Cyclopedia.  Many  of  them 
were  introduced  into  the  second  edition  of  this  Sur- 
gical Dictionary,  printed  in  1813. — (See  Cinchona.) 
Since  this  period,  I am  happy  to  find  that  the  blind  en- 
thusiasm with  which  bark  w'as  prescribed  is  beginning 
to  subside,  and  that  on  this  subject  some  eminent  sur- 
geons have  of  late  publicly  avowed  sentiments  which 
entirely  coincide  with  my  former  statements.  “ I think 
(says  Dr.  Thomson)  I have  frequently  seen  it  prove 
hurtful  when  administered  in  cases  of  mortification, 
by  loading  the  stomach  of  the  patient,  creating  a dislike 
lo  food,  and  sometimes  by  exciting  an  obstinate  diar- 
rhoea. I believe  it  to  be  in  mortification  a medicine 
completely  inert  and  inefficacious." — (See  Lectures  on 
Inflammation,  p.  563.)  By  this  expression.  Professor 
Thomson  does  not  mean  that  bark  can  never  be  useful 
in  cases  of  mortification,  but  only  that  it  has  no  specific 
pow'er  in  checking  the  disorder,  as  many  have  erro- 
neously inculcated. 

“ Bark  (says  Boyer)  has  been  considered,  by  several 
distinguished  English  practitioners,  as  a true  specific 
against  gangrene  in  general,  and  especially  ngainsl 
that  which  depends  upon  an  internal  cause;  but  sub- 
sequent observations  to  those  published  in  England 
have  proved,  that  it  has  no  power  over  the  immediate 
cause  of  gangrene,  and  that  it  only  acts  as  a powerful 
tonic  in  stopping  the  progress  of  the  disorder,  and  [iro- 
rnoting  the  separation  of  the  mortified  parts.” — (See 
Maladies  Chir.  t.  \,p.  151,  Paris,  1814.)  Boyer  al.so 
particularly  objects  to  bark  being  given  while  inflam- 
matory fever  prevails;  hut  whenever  he  presciibes 
bark  in  cases  of  mortification,  he  seems  to  entertain 
the  old  prejudice  of  expecting  benefit  in  proportion  to 
the  quantity  which  can  begot  into  the  stomach.  On 
the  contrary,  Mr.  Guthrie  declines  that  he  has  not  found 


182 


MORTIFICATION. 


bark  useful,  “ farther  than  as  a tonic,  and  given  in 
such  quantities  as  not  to  overload  the  stomach”  ( On 
Gun-shot  Wounds,  p.  148,  ed.  2),  a plan  which  I have 
always  recommended.  For  farther  observations  on 
bark,  the  reader  is  referred  to  the  article  Cinchona. 

Sulphuric  acid  may  sometimes  be  advantageously 
given  with  bark  or  quinine;  and  the  citric,  muriatic, 
and  nitric  acids  are  occasionally  prescribed. 

Carbonic  acid  gas  is  another  remedy  of  tlie  highest 
efficacy  in  chronic  mortification.  It  has  even  been 
known  to  produce  highly  beneficial  effects  when  bark 
has  been  of  no  service.  Water  impregnated  with  it 
may  be  recommended  as  common  drink. 

Hospital  gangrene  is  a case  for  which  bark  has  been 
recommended.  The  best  mode  of  treating  this  parti- 
cular case,  however,  has  been  detailed  in  a separate 
article. — (See  Hospital  Gangrene.) 

A third  indicatioti,  which  should  be  observed  to- 
gether with  the  second,  or  which  should  even  precede 
it  in  many  instances,  is  to  lessen  the  irritability  and 
sufferings  of  the  patient,  by  the  use  of  opium.  At- 
tention to  this  desideratum  frequently  contributes  more 
than  any  thing  else  to  stop  the  progress  of  the  disorder, 
and  is  often  indispensable,  in  order  to  promote  the 
operation  of  other  remedies.  In  all  cases  of  mortifi- 
cation, every  thing  which  heats,  irritates,  or  adds  to 
the  patient’s  sufferings,  appears,  in  general,  to  augment 
the  disorder  and  increase  the  rapidity  of  its  progress. 
On  the  other  hand,  every  thing  which  tends  to  .calm, 
assuage,  and  relax,  frequently  retards  the  progress  of 
mortification,  if  it  produce  no  greater  good.  The  pain 
also,  which  is  a constant  mark  of  too  much  irritation, 
contributes  of  itself  to  increase  such  irritation,  and  in 
this  double  point  of  view,  we  cannot  do  better  in  the 
majority  of  cases,  than  endeavour  to  appease  it  by  the 
judicious  and  liberal  use  of  opium.  When  the  inflam- 
matory stage  evidently  prevails,  this  medicine  may  be 
conjoined  with  antiphlogistic  remedies,  such  as  the 
nitrate  of  potassa,  antimony,  &c.  In  other  instances, 
attended  with  debility,  it  may  be  given  with  bark  and 
cordials. 

Mr.  Pott  describes  a species  of  mortification,  for 
which  he  sets  down  bark  as  ineffectual,  and  opium  the 
remedy  which  ought  to  be  chiefly  depended  upon. 
The  case  here  alluded  to  is  very  unlike  the  mortifica- 
tion from  inflammation,  that  from  external  cold,  from 
ligature,  or  bandage,  or  from  any  known  and  visible 
cause,  and  this  as  well  in  its  attack  as  in  its  progress. 
In  some  few  instances,  it  makes  its  appearance  with 
little  or  no  pain  ; but  in  the  majority  of  the  cases,  the 
patients  feel  great  uneasiness  through  the  whole  foot 
and  joint  of  the  ankle,  particularly  in  the  night,  even 
before  these  parts  show  any  mark  of  distemper,  or 
before  there  is  any  other  than  a small  discoloured  spot 
on  the  end  of  one  of  the  little  toes.  It  generally  makes 
its  first  appearance  on  the  inside,  or  at  the  extremity 
of  one  of  the  smaller  toes,  by  a small  black  or  bluish 
spot ; from  this  spot  the  cuticle  is  always  found  to  be 
detached,  and  the  skin  under  it  to  be  of  a dark  red 
colour.  If  the  patient  has  lately  cut  his  nails,  or  corn, 
it  is  most  frequently,  though  very  unjustly,  ascribed  to 
such  operation.  In  some  patients,  it  is  slow  and  long 
in  passing  from  toe  to  toe,  and  from  thence  to  the  foot 
and  ankle  ; in  others,  its  progress  is  rapid  and  horridly 
painful : it  generally  begins  on  the  inside  of  each  small 
toe  before  it  is  visible  either  on  its  under  or  upper  part; 
and  when  it  makes  its  attack  on  the  foot,  the  upper 
part  of  it  first  shows  its  distempered  state  by  tumefac- 
tion, change  of  colour,  and  sometimes  by  vesication  ; 
but  wherever  it  is,  one  of  the  first  marks  of  it  is  a se- 
paration or  detachment  of  the  cuticle. 

Each  sex  is  liable  to  it ; but  (says  IMr.  Pott),  “ for  one 
female  in  whom  I have  met  with  it,  I think  I may  say 
that  I have  seen  it  in  at  least  twenty  males.  I think 
also  that  I have  much  piore  often  found  it  in  the  rich 
and  voluptuous  than  in  the  labouring  poor ; more 
ofien  in  great  eaters  than  free  drinkers.  It  frequently 
happens  to  persons  advanced  in  life,  but  it  is  by  no 
means  peculiar  to  old  age.  It  is  not  in  general  pre- 
ceded or  accompanied  by  apparent  distempeiatiire 
either  of  the  part  or  of  the  habit.  I do  not  know  any 
particular  kind  of  constitution  which  is  iiiore  liable  to 
it  than  another  ; but  as  far  as  my  observation  goes,  I 
think  that  I have  most  frequently  observed  it  to  at- 
tack those  who  have  been  subject  to  flying  uncertain 
pains  in  their  feet,  which  they  have  called  gouty,  and 
hut  seldom  in  those  wlio  have  been  accustomed  to 


have  the  gout  regularly  and  fairly.  It  has  by  some 
been  supposed  to  arise  from  an  ossification  of  vessels  ; 
but  for  this  opinion  I never  could  find  any  foundation 
but  mere  conjecture.” 

In  this  article,  I have  already  stated  the  observations 
of  Cowper,  Dr.  Thomson,  and  Mr.  Hodgson,  upon  tlie 
ossified  state  of  the  arteries  in  this  species  of  mortifica- 
tion. The  facts  recorded  by  the  two  latter  writers  at 
least  prove,  that  the  opinion  is  founded  not  upon  mere 
conjecture,  as  Mr.  Pott  alleges,  but  upon  actual  obser- 
vation and  experience. 

In  this  particular  kind  of  mortification,  Mr.  Pott 
found  bark,  used  internally  or  externally  by  itself,  or 
joined  with  other  medicines,  completely  ineffectual. 

Mr.  Pott  afterward  relates  the  first  cases  in  which  he 
gave  opium.  His  plan  was  generally  to  give  one  grain 
every  three  or  four  hours  ; but  never  less  than  three  or 
four  grains  in  the  course  of  four- and-1  wen ty  hours. 
However,  he  did  not  propose  opium  as  a universal  in- 
fallible specific:  but  only  as  a medicine,  which  would 
cure  many  cases  not  to  be  saved  by  bark. 

The  observations  of  Mr.  Pott  on  the  local  treatment 
of  these  cases  are  of  great  practical  importance : no 
part  of  his  writings  Itas  a stronger  claim  to  attention. 

“ I have  found  (says  he)  more  advantage  from  fre- 
quently soaking  the  foot  and  ankle  in  warm  milk,  than 
from  any  spirituous  or  aromatic  fomentations  what- 
ever ; that  is,  I have  found  the  one  more  capable  of  al- 
leviating the  pain  which  such  patients  almost  always 
feel,  than  the  other ; which  circumstance  I regard  as  a 
very  material  one.  Pain  is  always  an  evil,  but  in  this 
particular  case,  I look  upon  it  as  being  singularly  so- 
Whatever  heats,  irritates,  stimulates,  or  gives  uneasi- 
ness, appears  to  me  always  to  increase  the  disorder, 
and  to  add  to  the  rapidity  of  its  progress  ; and,  on  the 
contrary,  I have  always’found  that  whatever  tended 
merely  to  calm,  to  appease,  and  to  relax,  at  least  re- 
tarded the  mischief,  if  it  did  no  more.” 

Mr.  Pott  afterward  observes : “ Cases  exactly  similar, 
in  all  circumstances,  are  not  to  be  met  with  every  day, 
but  I am  from  experience  convinced,  that  of  two,  as 
nearly  similar  as  may  be  in  point  of  pain,  if  the  one  be 
treated  in  the  usual  manner,  with  a warm,  stimulating 
cataplasm,  and  the  other  only  with  a poultice  made  of 
the  fine  farina  seminis  lini,  in  boiling  milk  or  water, 
mixed  with  ung.  sambuc.  or  fresh  butter,  that  the  pain 
and  the  progress  of  the  distemper  will  be  much  greater 
and  quicker  in  the  former  than  in  the  latter. 

“When  the  black  or  mortified  spot  has  fairly  made 
its  appearance  on  one  or  more  of  the  toes,  it  is  the 
general  practice  to  scarify  or  cut  into  such  altered  part 
with  the  point  of  a knife  or  lancet.  If  this  incision  be 
made  merely  to  learn  whether  the  part  he  mortified  or 
not,  it  is  altogether  unnecessary  ; the  detachment  of 
the  cuticle,  and  the  colour  of  the  skin,  render  that  a 
decided  point:  if  it  be  not  made  quite  through  the 
eschar  it  can  serve  no  purpose  at  all ; if  it  be  made 
quite  through,  as  there  is  no  confined  fluid  to  give  dis- 
charge to,  it  can  only  serve  to  convey  such  medicines 
as  may  be  applied  for  the  purpose  of  procuring  diges- 
tion to  parts  capable  of  feeling  their  influence,  and  on 
this  account  they  are  supposed  to  be  beneficial,  and 
therefore  right. 

“When  the  upper  part  of  the  foot  begins  to  part 
with  its  cuticle  and  to  change  colour,  it  is  a practice 
with  many  to  scarify  immediately  ; here,  as  in  the 
preceding  instance,  if  the  scarifications  be  too  super- 
ficial, they  must  be  useless ; if  they  be  so  deep  as  to 
cause  a slight  hemorrhage,  and  to  roach  the  parts  which 
have  not  yet  lost  their  sensibility,  they  must  do  what 
indeed  they  are  generally  intended  to  do.  that  is,  give 
the  medicines  which  shall  be  applied  an  opportunity  of 
actine  on  such  parts. 

“ The  medicines  most  frequently  made  use  of  for 
this  purpose  are,  like  the  theriaca,  chosen  for  their 
supposed  activity;  and  consist  of  the  warm  pungent 
oils  and  balsams,  whose  action  must  necessarily  he  to 
stimulate  and  irritate:  from  these  qualities  they  most 
frequently  excite  pain,  which,  according  to  my  idea  of 
the  disease,  is  diametrically  opposite  to  the  projrer 
curative  intention:  and  this  I am  convinced  of  from 
repeated  experience. 

“The  dressings  cannot  consist  of  materials  which 
are  too  soft  and  lenient ; nor  are  any  scarifications  ne- 
cessary for  their  application.  But  I would  go  farther, 
and  say,  that  scarifications  are  not  only  useless,  but  in 
my  opinion  prejudicial,  by  e.xciting  pain,  the  great  and 


MORTIFICATIOxNf. 


183 


chiefly  to  be  di^aded  evil  iii  this  complaint.  The  poul- 
tice sliould  be  also  soft,  smooth,  and  unirritating  ; its 
intention  should  be  merely  to  soften  and  relax ; it  should 
ooinprehend  the  whole  foot,  ankle,  and  part  of  the  leg ; 
and  should  always  be  so  moist  or  greasy  as  not  to  he 
likely  to  become  at  all  dry  or  hard  between  one  dres.s- 
ing  and  another.” 

Sir  A.  Cooper  generally  recommends  a poultice  com- 
posed of  port  wine  and  oatmeal,  or  that  made  with 
stale  beer-grounds ; but  in  one  case  which  I attended 
with  him  in  private  practice,  and  which  will  be  pre- 
sently mentioned,  a camphorated  lotion,  fomentations, 
occasionally  a solution  of  the  chloruret  of  soda,  and 
emollient  {wultices,  were  all  tried  in  vain.  Indeed, 
the  very  nature  of  the  disease  leaves  little  hope  of  es- 
sential good  from  topical  applications.  All  that  can  be 
expected  from  the  best  of  them  is  some  diminution  of 
.pain,  and  from  the  worst  of  them  an  increase  of  it, 
with  a more  rapid  extension  of  the  gangrenous  mis- 
ehief. 

When  the  toes  are  to  all  appearance,  perfectly  mor- 
tified, and  seem  so  loose  as  to  be  capable  of  being 
easily  taken  away,  it  is  in  general  thought  right  to 
remove  them.  But  however  loose  the.y  may  seem,  if 
they  be  violently  twisted  olF,  or  tlie  parts  by  which 
they  hang  be  divided,  a very  considerable  degree  of 
pain  will  tnost  commonly  attend  such  operation,  which 
therefore  had  much  better  be  avoided ; for  Mr.  Pott 
has  seen  this  very  pain  thus  produced  bring  on  fresh 
mischief,  and  that  of  the  gangrenous  kind.  If  the 
patient  does  well,  these  parts  will  certainly  drop  off;  if 
he  does  not,  no  good  can  arise  from  removing  them. 

When  the  disorder  is  attended  with  a great  deal  of 
irritation,  many  subsequent  practitioners  have  attested 
the  efficacy  of  opium ; though  it  has  not  always  had 
the  same  success  in  their  hands,  when  the  mortification 
depended  chiefly  on  constitutional  debility.  Dr.  Kirk- 
land observes,  that  we  must  be  careful  not  to  force  the 
doses,  especially  at  first ; and  that  the  medicine  does 
more  harm  than  good  when  its  soporific  effects  go  so 
far  as  to  occasion  delirmm,  take  away  the  appetite,  or 
cause  affections  of  the  heart.  Sir  A.  Cooper  joins 
opium  with  subcarbonate  of  ammonia,  and  in  a case 
which  I lately  attended  with  him,  he  also  prescribed 
musk,  and  wine  and  porter  were  allowed.  As  far  as 
^ could  Judge,  the  medicines  which  seemed  to  have  the 
most  effect  in  prolonging  the  patient’s  existence  were 
opium,  the  sulphate  of  quinine,  and  castor  oil,  w'ith 
other  mild  aperients. 

Some  authors  recommend  camphor.  Pouteau  attri- 
butes considerable  efficacy  to  it  when  given  in  the  dose 
of  five  grains,  with  a double  quantity  of  nitre,  every 
four  hours. 

Few  surgeons  of  the  present  day  believe  that  opium 
IMjssesses  as  much  power  in  the  preceding  cases  as  Mr. 
Pott  represented.  While  Dr.  Thomson  allows  that 
opium  is  much  more  entitled  to  the  attention  of  practi- 
tioners than  bark  in  the  treatment  of  mortification,  yet 
(he  observes)  “ I would  not  by  any  means  have  you  to 
place  the  same  reliance  on  its  powers  for  stopping  even 
the  mortification  of  the  toes  and  feet  in  old  people, 
which  appears  to  have  been  done  by  Mr.  Pott.  From 
the  trials  which  I have  made,  and  which  I have  seen 
made  by  others,  I cannot  allow  myself  to  believe  that 
its  pov\  ers  in  stoppitig  this  particular  sort  of  mortifica- 
tion are  greater  than  in  stopping  any  other  form  or 
variety  of  the  disease.  It  js  obvious,  however,  f^rorn 
Mr.  Pott’s  account,  that  his  mind  was  strongly  im- 
pressed with  a very  different  opinion.  His  opinion 
seems  to  me  to  have  been  formed  from  the  results  of  a 
very  small  number  of  cases,  and  in  complete  forgetful- 
ness of  the  invaluable  observations  of  his  preceptor 
Mr.  Sharp,  with  regard  to  the  fre«iuent  spontaneous 
stoppage  of  mortification  in  cases  in  which  no  medi- 
cines whatever  are  used.”— (See  Thomson's  Lectures 
on  Inflammation,  y.  568.) 

I believe  that  this  species  of  mortification  very  rarely 
attacks  both  feet.  One  remarkable  instance  of  such 
an  occurrence,  however,  I attended  in  the  summer  of 
1828  with  Mr.  Hughes  of  Holborn;  and  the  gentleman 
who  was  the  subject  of  the  disease  was  also  visited 
by  Sir  Astley  Cooper.  Both  feet  and  legs  were  at- 
tacked,and  gradually  destroyed  nearly  up  to  the  knees. 
The  patient  lived  a month  after  the  commencement  of 
the  disorder.  During  most  of  this  time  the  pulse  was 
from  10(tt.)130;  and  the  stomach  so  little  disturbed, 
tliat  the  patient  used  generally  to  eat  a mutton  chop 


for  dinner  until  the  last  two  or  three  da3's  preceding  his 
death.-  Until  the  final  stage,  there  was  scarcely  any 
delirium.  Two  circumstances  were  particularly  no- 
ticed ; first,  that  the  disease  never  extend(!d  itself 
without  being  preceded  by  violent  pains  in  the  parts 
about  to  be  destroyed,  so  that  a judgment  could  always 
be  formed  beforehand  from  tiie  degree  of  suftering, 
whether  the  spreading  of  the  disorder  would  be  consi- 
derable or  not.  Secondly,  that  the  process  of  mortifi- 
cation, and  its  appearances  in  one  leg,  w ere  totally  dif- 
ferent from  those  exhibited  in  the  other.  In  the  left, 
the  disorder  began  on  the  inside  of  one  of  the  toes, 
and  followed  the  course  described  by  Pott ; in  the  right, 
a general  diminution  of  the  temperature  of  the  foot 
and  leg  was  the  first  thing  noticed,  without  any  disco- 
louration of  the  skin,  or  any  vesications  or  spot  on  the 
toes.  The  coldness,  afte-r  increasing  very  much,  was 
followed  by  total  loss  of  sensibility  in  the  parts,  and 
the  cessation  of  the  circulation  and  every  other  action 
in  them;  tlie  flesh  being  little  more  changed  in  its  ap- 
pearance than  that  of  the  limb  of  a dead  subject. 

2.  With  respect  to  the  external  or  local  treatment  of 
mortification,  the  first  indication  consists  in  removing, 
if  possible,  such  external  causes  as  may  have  occa- 
sioned, or  kept  up  the  disorder ; as  the  compression  of 
bandages,  ligatures,  tumours,  all  irritating  substances, 
&c. 

When  mortification  arises  from  inflammation,  which 
still  prevails  in  a considerable  degree,  it  is  evident  that 
the  dead  part  itself  only  claims  secondary  considera- 
tion, and  that  the  principal  desideratum  is  to  prevent 
the  mortification  from  spreading  to  the  living  circum- 
ference, by  lessening  the  inflammation  present.  Hence, 
under  such  circumstances,  the  application  of  linen  wet 
with  the  saturnine  lotion,  and  the  maintenance  of  a 
continued  evaporation,  from  the  inflamed  parts  sur- 
rounding the  mortified  flesh,  nnjst  be  just  as  proper  as 
if  the  mortification  itself  did  not  exist,  and-  were  quite 
out  of  all  consideration. 

It  has  been  justly  remarked  by  an  eminent  man 
{Hunter),  that  the  local  treatment  of  mortification 
(meaning  that  in  consequence  of  inflammation)  has 
been  as  absurd  as  the  constitutional ; scarifications 
have  been  made  down  to  the  living  parts,  in  order  that 
stimulating  and  antiseptic  medicines  might  be  applied 
to  them ; such  as  turpentines,  the  wanner  balsams, 
and  sometimes  the  essential  oils.  Warm  fomentations 
have  been  also  applied,  as  being  congenial  to  life ; but 
v’armth  always  increases  action,  and  should  therefore 
be  well  adjusted  to  the  case  ; while,  on  the  other  hand, 
cold  debilitates  or  lessens  powers,  when  carried  too 
far,  though  it  first  lessens  action.  Stimulants  are  like- 
wise improper,  as  the  actions  are  already  too  violent. 
It  is  proper  to  keep  the  parts  cool,  and  all  tlie  applica- 
tions should  be  cold.  In  cases  of  mortification  from 
inflammation,  good  effects  have  also  been  seen  to 
arise  from  the  topical  as  well  as  internal  employment 
of  opium. 

But  it  must  be  acknowledged,  that  however  proper 
the  employment  of  cold  applications  may  be  in  prin 
ciple,  in  cases  of  mortification  attended  with  inflam- 
mation, fomentations  and  emollient  poultices  are  most 
commonly  preferred  in  practice. 

Besides  common  poultices,  there  are  several  others 
which  have  acquired  great  celebrity  as  topical  applica- 
tions in  cases  of  mortification.  Of  this  kind  are  the 
cataplasma  cai  bonis,*  cataplasma  cerevisi8e,t  and  the 
cataplasma  eflervescens.J  In  nine  cases  out  of  ten., 
perhaps,  they  answer  better  than  any  others. 

With  respect  to  stimulating  and  spirituous  appHca,- 
tions,  such  as  brandy,  spirit  of  wine,  balsams,  resins, 
and  aromatic  substances,  which  have  been  recom- 
mended by  a vast  number  of  authors,  they  are  nearly 
abandoned  by  modern  ])ractitloners.  Though  such 
things  are  indeed  really  useful  In  preserving  dead  ani- 
mal substances  from  becoming  putrid,  a very  little 


* Prepared  by  mixing  about  5 ij-  of  finely  jiowdered 
wood-charcoal  with  half  a pound  of  the  common  lin- 
seed poultice. 

1 Prepared  by  stirring  into  the  grounds  of  strong 
beer  as  m\ich  oatmeal  as  will  make  the  mass  of  a suit- 
able consistence. 

^ Prepared  by  stirring  into  nn  infusion  of  malt  aa 
much  oatmeal  as  will  render  the  substance  of  a pro- 
per thickness,  and  then  adding  about  a spoonful  o( 
yest. 


184 


MORTIFICATION.  ‘ 


knowledge  ofthe  animal  economy  is  requisite  lo  make  us 
understand  that  they  cannot  act  in  tliis  manner  dn  parts 
still  endued  with  vitality ; but,  on  the  contrary,  that  they 
must  have  highly  prejudicial  effects  in  the  cases  under 
consideration,  by  reason  of  the  violent  irritation  which 
they  always  excite,  when  applied  to  the  living  fibres. 
It  may  indeed  be  justifiable  now  and  then  to  apply 
spirituous  applications  to  the  dead  parts  themselves, 
with  a view  of  diminishing  the  fetid  effluvia,  which, 
by  contaminating  the  air,  liave  some  share  in  injuring 
the  patient’s  health : but  the  greatest  care  is  requisite 
to  keep  these  stimulants  from  coming  into  contact 
with  the  living  surfaces  around  and  beneath  the 
sloughs. 

A few  surgeons,  however,  still  place  confidence  in 
stimulating  applications.  “In  the  less  acute  and  more 
chronic  cases  of  gangrenous  inflammation,  as  in  ma- 
lignant erysipelas  and  carbuncle,  in  the  gangrene  of  the 
toes  and  feet  of  old  people,  in  the  sphacelating  state  of 
hospital  gangrene,  and  in  severely  contused  wounds, 
in  which  gangrene  and  sphacelus  have  supervened, 
the  emollient  poultice,  which  is  applied  to  promote  the 
separation  of  the  dead  parts,  may  have  an  addition 
made  to  it  of  a greater  or  less  quantity  of  the  unguen- 
tum  resinosum,  or  even  of  oil  of  turpentine  itself.  In 
the  more  severe  of  these  cases,  where  we  have  reason 
to  dread  the  extension  of  the  sphacelus,  warm  dress- 
ings, as  they  have  been  termed,  which  are  formed  by 
dipping  pledgets  of  charpic  in  a mixture  of  equal 
parts  of  the  unguentum  resinosum  and  oil  of  turpen- 
tine, may  be  applied,  of  a temperature  as  hot  as  the 
patient  can  bear  without  pain;  and  over  these  we 
may  lay  an  emollient  poultice,  of  a large  size  and  soft 
consistence. 

“After  the  sphacelus  stops,  and  the  process  of  ul- 
ceration begins  in  the  inflamed  line  of  contact,  between 
the  dead  and  living  parts,  it  will  often  be  found  that 
the  turpentine  dressings  are  too  stimulating,  and  occa- 
sion a considerable  degree  of  pain.  When  this  hap- 
pens, we  must  either  diminish  the  quantity  of  the  tur- 
pentine in  the  dressings,  or  remove  it  altogether,  ac- 
cording to  circumstances.  Besides  the  pain,  a consi- 
derable extension  of  the  ulceration  would  be,  in  gene- 
ral, the  effect  of  continuing  these  applications  after 
they  begin  to  produce  uneasiness.  The  ulcerating  sur- 
face is,  in  the  progress  of  separation,  liable  to  pass, 
under  every  mode  of  treatment,  into  the  state  of  a 
painful  and  irritable  ulcer ; and  in  this  state  it  may  re- 
quire (o  be  treated  with  decoctions  of  poppy  heads,  or 
with  the  application  of  the  turnip,  carrot,  fresh  hem- 
lock leaf,  stale  beer,  fermenting  poultices,  &.c.’’ — (See 
Thomson's  Lectwres^'p.  577,  578.) 

Hospital  gangrene  is  undoubtedly  a case  that  re- 
quires powerful  applications,  like  Fowler’s  solution  of 
arsenic,  or  the  undiluted  mineral  acids  ; and,  in  Guy’s 
Hospital,  phagedenic  sloughing  ulcers  are  usually 
treated  by  Sir  A.  Cooper  with  the  nitric  acid  lotion,  50 
drops  to  a pint  of  water,  and  the  internal  exhibition  of 
the  subcarbonate  of  ammonia.  He  speaks  also  of  a 
port  wine  poultice  as  an  excellent  application.  The 
cases  termed  sloughing  phagedena  by  Mr.  Welbank, 
and  considered  by  him  as  analogous  to  hospital  gan- 
grene, may  be  cured  by  dressing  them  with  the  undi- 
luted nitric  acid. — (See  Hospital  Gangrene.)  I con- 
ceive that  it  has  only  been  in  hospital  gangrene,  and 
other  cases  of  toughing  phagedenic  ulcers,  that  va- 
rious acids,  diluted  or  undiluted,  other  caustic  sub- 
stances, and  the  actual  cautery,  have  proved  really 
serviceable.  The  muriatic  acid,  diluted  with  six  times 
its  quantity  of  water,  was  particularly  recommended 
by  Van  Swieten,  W'ho  applied  it  after  making  scarifi- 
cations. In  this  manner,  he  stopped  a sloughing  dis- 
ease extending  all  over  the  scrotum  and  penis.  This 
author  strongly  recommends  the  same  topical  applica- 
tion to  the  gangrenous  state  of  the  gums  in  cases  of 
scurvy.  In  this  kind  of  case,  he  mixed  the  muriatic 
acid  with  honey,  in  various  proportions;  sometimes  he 
even  employed  the  pure  acid  itself  for  touching  the 
parts  which  were  likely  to  slough.  It  is  also  by  sup- 
posing th.at  tile  disea.ses  referred  to  were  of  a phage- 
denic character,  that  I account  for  the  good  effects  im- 
puted by  Dr.  Kirkland  and  others,  in  cases  of  mortifi- 
cation, to  another  still  tnore  active  caustic,  namely,  a 
solution  of  mercury  in  nitrous  acid,  with  which  tlie 
edaes  of  the  living  flesh  were  touched.  At  all  events, 
if  the  diseases  were  common  cases  of  sloughing,  I in- 
fer that  such  remedies  were  not  really  necessary,  and , 


that  nature  triumphed  both  over  the  disease  and  the 
supposed  remedy.  The  following  is  a case  related  by 
Dr.  Kirkland  ; 

A man  met  with  a fracture  of  the  forearm,  and  the 
ends  of  the  bones  projected  through  the  integuments. 
The  fracture  was  very  expeditiously  reduced  ; but  at 
the  end  of  five  or  six  days  the  whole  arm  seemed  to 
be  completely  mortified  up  to  the  shoulder.  Amputa- 
tion was  performed  as  near  the  joint  as  possible,  and 
the  stump,  which  had  mortified  as  far  as  the  acromion, 
was  cauterized.  The  following  day  the  mortification 
had  reached  the  inferior  extremity  of  the  scapula.  A 
little  of  the  solution  of  mercury  in  nitrous  acid  w^as 
now  applied  by  means  of  a probe  along  the  edges  of 
the  parts  affected,  and  from  this  moment  the  disorder 
made  no  farther  progress.  This  cauterizing  was  re- 
peated every  day  for  seventeen  or  eighteen  days.  The 
sloughs  and  even  the  scapula  itself  w'ere  detached,  and 
the  patient  got  well. 

On  the  continent  liquid  caustics  are  sometimes  used 
as  topical  applications  to  gangrenous  diseases,  more 
especially,  however,  in  cases  of  hospital  gangrene  and 
malignant  carbuncle.  Of  this  last  disorder  Larrey  has 
recorded  a very  dangerous  example,  in  which  he  ef- 
fected a cure  by  first  cutting  away  as  much  of  the 
sloughs  as  possible,  and  then  applying  to  the  disorgan- 
ized surface  liquid  caustics.  Under  the  use  of  emol- 
lients two  persons  had  already  fallen  victims  to  the 
disease  in  the  same  family. — (See  Mim.  de  CJnr.  Mili- 
taire^  t.  \,p.  53.) 

With  respect  to  the  actual  cautery,  Celsus  recom- 
mended it  to  be  applied  to  the  line  which  separates 
the  dead  parts  from  those  which  are  still  living,  when- 
ever medicines,  and  particularly  topical  emollient  ap- 
plications, failed  in  stopping  the  progress  of  the  dis- 
order. Pouteau  ventured  to  revive  this  practice,  which 
had  been  entirely  exploded  from  modern  surgery,  and 
he  was  of  opinion  that  the  method  would  have  the 
most  beneficial  effects  in  cases  of  erysipelatous  gan- 
grene, which  is  so  often  seen  in  hospitals  in  conse- 
quence of  wounds.  For  this  purpose  he  recommends 
cauterizing  chiefly  the  edges  of  such  parts  as  are  of  a 
dark  red  colour,  and  are  on  the  point  of  perishing : and 
he  advises  this  to  be  done  with  a heated  iron  or  boil- 
ing oil,  and  to  repeat  the  cauterizing  of  the  dead  parts 
at  every  time  of  dressing  them,  until  the  sensation  of 
heat  is  even  felt  with  a certain  degree  of  force  in  the 
sound  parts.  The  whole  of  the  affected  part  is  after- 
ward to  be  covered  with  a large  emollient  poultice. 

Pouteau  relates  a case  of  anthrax  which  took  place 
on  a woman’s  cheek,  and  which  he  cured  in  the 
above  manner.  The  tumour,  which  on  the  third  day 
was  quite  black,  and  as  large  as  a walnut,  was  accom- 
panied by  an  erysipelatous  oedema,  which  extended 
over  the  whole  cheek,  eyelids,  and  front  of  the  neck. 
Pouteau,  after  having  opened  the  tumour  in  different 
directions  with  a lancet,  introduced  the  red-hot  cautery, 
and  repeated  the  application  several  times,  until  the 
heat  was  felt  by  the  sound  flesh.  The  patient  felt  her- 
self very  much  relieved  immediately  after  this  had 
been  done ; an  oppressive  headache,  and  a very  afflict- 
ing sense  of  strangulation,  which  she  had  before  expe- 
rienced, were  got  rid  of,  and  in  ten  days  more  the 
slough  was  detached  on  the  occurrence  of  suppuration. 
—{Encyclopidie  J\Iethodtque,  Partie  Chirurgicale,  Art. 
Gangrene.) 

But,  perhaps,  of  all  the  species  of  mortification,  hos- 
pital gangrene  is  that  for  which  the  use  of  caustics  and 
the  actual  cautery  itself  has  had  the  most  numerous 
and  respectable  advocates.  The  healed  iron  is  even 
now  employed  by  the  first  surgeons  of  Paris  for  this 
particular  case. — (See  Sketches  of  the  Medical  Schools 
of  Paris,  by  J.  Gross,  p.  84  ; and  Hospital  Gangrene.) 

The  foregoing  observations  are  introduced  into  this 
work,  that  the  reader  may  not  be  left  entirely  ignorant 
of  what  violent  measures  have  been  adojtted  in  cases 
of  mortification,  and  the  account  is  not  given  in  order 
that  such  practice  may  be  again  imitated,  except  per- 
haps in  certain  cases  of  phagedena  and  hospital  gan- 
grene, cases  in  which  the  most  powerful  local  applica- 
tions seem  indispensable. — (See  Hospital  Gangrene 
and  Mitric  Acid.)  The  common  employment  of  these 
terrible  applications,  viz.  the  actual  cautery,  the  undi- 
luted mineral  acids  and  boiling  oils,  is  as  unscientific 
and  utuiecessarily  painful  as  it  is  unproductive  of  any 
essential  good.  The  grand  object  in  almost  every  ca«e 
of  mortification  is  to  diminish  the  irritation  of  lire  parts 


MORTIFICATION. 


185 


In  Imniediate  contact  with  those  already  dead.  This 
is  indicated,  lest  the  parts  still  alive  and  so  situated 
should  experience  the  same  fate  as  the  contiguous  ones. 
In  most  of  the  other  cases  specified  by  Dr.  Thomson, 
my  e.vperience  leads  me  to  prefer  emollient  soothing 
applications,  none  of  which  are  stronger  than  the 
cataplasma  carbonis,  or  the  stale  beer,  fermenting, 
hemlock,  or  carrot  poultices.  When  the  process  by 
which  a slough  is  detached  is  somewhat  advanced,  I 
have  seen  a weak  solution  of  the  extract  of  opium  in 
water  put  under  the  emollient  poultice,  along  the  line 
of  separation,  give  considerable  ease,  at  the  satne  time 
that  it  seemed  to  promote  the  changes  by  which  llie 
dead  parts  were  loosened. 

In  the  gangrene  produced  by  pressure  and  weakness, 
in  persons  who  are  compelled  by  diseases  and  injuries 
to  lie  for  weeks  and  months  in  one  posture,  the  mode 
of  treatment  is  a matter  of  extreme  importance,  and 
frequently  makes  the  difference  of  life  or  death  to  the 
poor  sufferer.  This  affection  usually  ha.s  its  seat  in 
parts  which  are  but  thinly  covered  with  muscular 
flesh.  It  occurs  towards  the  latter  stages  of  long-con- 
tinued febrile  diseases,  as  after  typhus  or  hectic  fever, 
attended  with  tedious  suppurations  ; or  even  without 
these  fevers,  as  in  paralysis,  and  in  very  bad  compound 
fractures.  However,  as  Dr.  Thomson  observes,  there 
are  two  forms  of  disease  arising  from  pressure  which 
have  not  always  been  accurately  discriminated.  One 
of  these  is  the  preceding  sort  of  sloughing ; the  other 
is  a chafed,  excoriated,  and  ulcerated  state  of  the 
parts. 

Sometimes  uncleanliness  tends  to  cause  this  sort  of 
mortification,  that  is,  when  the  urine  wets  the  patient’s 
clothes.  When  this  is  the  case,  such  irritation  must  be 
prevented  by  every  possible  means.  If  the  skin  be 
excoriated  and  broken,  the  powder  of  tutty,  or  lapis 
calaminaris,  should  be  sprinkled  over  the  part ; or  if 
an  ointment  be  required,  says  Dr.  Thomson,  those 
which  contain  zinc  or  lead  are  the  best.  But  when 
the  ulceration  threatens  to  extend,  these  remedies  are 
to  be  laid  aside,  and  an  emollient,  hemlock,  carrot,  or 
fermenting  poultice  used.— (P.580.)  I have  seen,  in  the 
irritable  state  of  such  ulceration,  the  solution  of  opium 
under  a common  linseed  poultice  do  more  good  than 
any  other  application. 

Sir  A.  Cooper  recommends  the  application  of  tur- 
pentine. Sometimes  he  uses  a mixture  of  vinegar  and 
camphorated  spirit. 

But  no  topical  remedies  will  in  any  of  these  cases 
avail,  unless  the  chief  cause  of  the  disorder  be  re- 
moved. This  is  to  be  effected  by  change  of  position, 
and  laying  pillows  and  cushions  of  the  softest  mate- 
rials in  convenient  places  under  the  patient;  not  di- 
rectly under  the  disease  itself,  but  in  situations  where 
they  will  tend  to  raise  the  parts  affected  from  the  con- 
tact of  the  bedding.  A circular  hollow  pillow  will 
often  accomplish  this  important  object ; but  when  pos- 
sible an  entire  change  of  posture  is  to  be  preferred. 

When  sphacelus  succeeds  to  gangrene  from  pressure, 

I have  often  seen  camphorated  spirit  applied ; but 
never  with  decided  advantage.  .A  common  emollient 
poultice,  and  in  very  had  cases  the  topical  use  of  the 
solution  of  opium  along  the  living  margin,  are  the 
means  upon  which  I place  the  most  reliance,  care 
being  taken  to  improve  the  general  health,  without 
which  grand  indication  neither  the  removal  of  the 
pressure  nor  the  virtues  of  any  dressings  will  answer. 
Dr.  Thomson  speaks  most  highly  of  the  fermenting 
poultice,  which  I believe  to  be  in  these  cases  an  excel- 
lent application.  He  confesses,  however,  that  he  has 
sometimes  found  it  too  stimulating,  and  been  obliged  to 
substitute  the  simple  emollient,  carrot,  or  turnip  poul- 
tice.— (P.  580.) 

When  mortification  arises  from  cold,  every  sort  of 
warm  emollient  application  must  be  avoided,  and  cold 
water,  or  even  snow  or  ice,  employed.— (See  Chil 
blaiiiH.) 

The  local  treatment  of  the  mortification  of  the  toes 
and  feet,  as  described  by  Mr.  Pott,  has  been  already 
considered,  and  is  that  to  which  my  observations  in- 
cline me  to  give  the  preference. 

The  gangrenous  affection  of  the  pudenda,  to  which 
fetnale  children  are  liable,  was  successfully  treated  by 
Mr  K.  Wood,  by  applying  the  liquor  pliimbi  acet. 
dilutus  in  a tepid  slate,  and  bread  [Kmltices  made  with 
the  same  lotion.  As  soon  as  the  ulcers  became  clean, 
they  Were  dressed  with  the  ungue'ntum  zinci. — (See 


Med.  Chir.  Trans,  vol.  7.)  Other  cases  which  also 
ended  well  have  been  dressed  with  lint  dipped  in  cam- 
phorated spirit,  and  covered  with  a poultice;  or,  at 
first,  poultices  made  with  the  opium  lotion,  and  after 
the  separation  of  the  sloughs  the  ulcer  was  dressed 
with  port  wine  and  decoction  of  bark  in  equal  pro- 
portions. In  some  cases,  however,  mild  stimuli  proved 
injurious.— (James  on  Inflammation,  p.  289.) 

Deep  scarifications  in  the  integuments.  The  ma- 
jority of  authors  who  treat  of  mortification  recom- 
mend this  plan  in  all  cases.  They  even  advise  the 
incisions  to  be  made  down  to  the  sound  parts,  in  order 
to  facilitate  the  application  of  topical  stimulants,  and 
to  favour  the  operation  of  the  supposed  antiseptic 
qualities  of  these  dressings.  But  with  the  exception 
of  cases  in  which  the  gangrenous  parts  lie  under  an 
aponeurosis,  or  others  in  which  the  integuments  which 
have  escaped  destruction  cover  a mixture  of  matter 
and  sloughy  cellular  substance,  either  in  consequence 
of  foregoing  inflammation  or  any  other  cause,  such  as 
the  extravasation  of  urine  in  the  scrotum,  all  scarifi- 
cations which  penetrate  as  far  as  the  living  parts,  are 
often  productive  of  the  most  serious  mischief  instead 
of  advantage.  Such  incisions  cannot  be  practised 
without  occasioning  a great  deal,  of  pain,  and  pro- 
ducing inflammation,  which  often  makes  the  mortifi 
cation  spread  still  farther.  But  as  parts  which  are  in 
a complete  state  of  sphacelus  are  absolutely  extraneous 
substances  in  regard  to  those  which  still  retain  their 
vitality,  all  such  portion  of  them  as  is  already  loose 
should  be  removed.  By  lessening  the  size  of  the  putrid 
mass  the  fetor  is  diminished,  an  outlet  may  sometimes 
be  made  for  the  escape  of  a great  deal  of  putrid  dis- 
charge, which  being  confined  might  have  a bad  effect 
on  the  neighbouring  living  parts,  and  the  latter  are 
enabled  to  free  themselves  more  easily  from  the  rest  of 
the  sloughs. 

The  too  common  practice  of  accelerating  with  a 
cutting  instrument  the  separation  of  the  mortified 
parts,  previously  to  the  completion  of  the  process  by 
which  nature  breaks  the  connexion  between  them  and 
the  living  flesh,  in  general  ought  to  be  strongly  repro- 
bated, as  causing  unnecessary  pain  and  irritation,  and 
creating  the  risk  of  a renewal  of  the  sloughing.  As 
far  as  my  experience  goes,  gangrenous  phagede  a is 
the  only  instance  in  which  it  seems  useful  to  remove 
the  sloughs  before  they  are  loose,  so  as  to  let  the  topical 
applications  extend  their  action  without  delay  to  the 
subjacent  living  surface. — (See  Hospital  Oangrene.) 
Pott’s  sentiments  with  respect  to  the  danger  and  in- 
utility of  cutting  the  tendons  and  ligaments,  in  the 
mortification  of  the  toes  and  feet,  have  been  already 
stated. 

If  the  surgeon  prudently  let  nature  work,  without 
disturbing  her,  the  separation  of  the  mortified  from  the 
living  parts  will  soon  follow  the  establishment  of  in- 
flammation and  suppuration  at  the  edges  of  the  slough. 

But  when  the  whole  thickness  of  a limb  is  affected 
with  mortification,  ought  the  surgeon  to  leave  things 
to  nature  1 or  ought  he  to  have  recourse  to  amputa- 
tion 1 

In  general,  the  performance  of  amputation  is  indis- 
pensable ; not  that  nature  would  not  in  many  instances 
detach  the  sphacelated  part,  but  because  a great  length 
of  time  would  be  required  for  the  completion  of  the 
process,  and  a serviceable  stump  would  rarely  be  left. 

Another  important  question  then  arises,  should  the 
surgeon  amputate  while  the  mortification  is  in  aspread- 
ing state  7 Or  ought  he  to  defer  the  operation  until  the 
line  of  separation  begins  to  form  between  the  dead 
and  living  parts? 

In  the  mortification  of  the  toes  and  foot,  in  old  per- 
sons, Sir  A.  Cooper  forbids  amputation  whether  there 
be  healthy  granulations  or  not,  and  he  declares  that  if 
the  operation  be  done,  mortification  of  the  stump  and 
the  patient’s  death  will  certainly  follow. 

“Amputation  (says  a distinguished  professor)  was 
long  regarded  as  one  of  the  most  effectual  means  which 
could  be  employed  to  prevent  the  extension  of  gan- 
grene. This  practice,  however,  has  not  received  the 
sanction  of  experience ; on  the  contrary,  it  has  been 
generally  found,  wherever  it  has  been  practised,  in 
either  acute  or  chronic  gangrene,  to  accelerate  much 
the  progress  of  the  disease;  and  in  this  way  to  h.asten 
the  death  of  the  patient.  The  parts  which  were  di- 
vided in  amputation,  though  at  a distance  from  a 
spieading  gangrene  and  from  sphacelus,  were, found 


186 


MORTIFICATION. 


speedily  lo  assume  the  appearance  of  the  affection  for 
which  the  operation  had  been  performed.  Till^  there- 
fore, the  adhesive  ihfiamviation  comes  on,  and  a dis- 
tinctly marked  separation  of  the  dead  from  the  sound 
parts  takes  place,  amputation  is  in  few  if  in  any  cases 
of  mortification  admissible.  We  never  know  pre- 
viously to  this  where  a gangrene  or  sphacelus  is  to 
stop,  nor  whether  the  powers  of  the  constitution  be 
sufficient  to  sustain  the  injury  that  the  mortification 
has  inflicted.  Even  when  the  adhesive  inflammation 
comes  on,  it  is  in  most  cases  best  to  allow  some  time 
to  elapse  before  we  operate,  partly  with  a view  to  give 
time  for  the  constitutional  symptoms  lo  abate ; in  other 
instances,  to  allow  the  patient’s  strength  to  be  recruited 
by  nourishment  and  cordials;  and  partly  also  with  a 
view  to  learn  whether  the  constitution  of  the  patient 
be  indeed  capable  of  so  great  a fresh  shock  as  that 
which  amputation  must  necessarily  occasion.” — (See 
Thomson's  Lectures,  p.  582.) 

According  to  Richter,  there  is  never  any  certainty 
that  we  are  amputating  in  living  parts.  Mortification 
rapidly  ascends  along  the  cellular  substance  surround- 
ing the  large  blood-vessels,  and  is  frequently  much 
more  extensive  internally  than  external  appearances 
would  lead  one  to  suppose.  The  adjacent  surface, 
still  apparently  alive,  is  often  so  affected  that  it  must 
inevitably  slough,  though  at  present  it  may  not  actually 
have  sphacelated.  The  surgeon  imagines  that  ampu- 
tation is  performed  on  living  parts,  but  soon  afterward 
discovers  that  he  has  been  dividing  those  which  are 
dead.  The  operation,  he  observes,  can  do  no  good, 
while  the  mortification  is  in  a spreading  state,  and  it 
may  do  considerable  mischief.  The  disorder  continues 
to  extend,  because  its  cause  still  operates,  and  this  is 
not  removable  by  amputation.  If  the  operation  be 
now  injudiciously  undertaken,  the  sphacelus  invades 
the  wound,  and  is  the  more  certainly  mortal,  as  the 
stance  has  been  farther  weakened  by  amputation  and 
Its  consequences. 

Many  mortifications,  especially  those  which  arise 
from  external  causes,  very  often  spontaneously  stop 
and  separate.  But  the  place  where  this  will  happen 
can  never  be  foreseen.  By  amputating  in  this  circum- 
stance we  run  the  risk  of  disturbing  nature  in  her 
salutary  work,  and  rendering  the  disorder  fatal. 

The  following  are  the  only  cases  in  which  Richter 
allows  that  the  use  of  the  knife  is  justifiable  and  proper. 
There  exists  a species  of  sphacelus  which  rapidly  oc- 
casions death  before  it  is  yet  of  great  extent.  Here, 
indeed,  amputation  might  be  really  advisable;  but  the 
nature  of  the  case  is  unfortunately  never  disclosed  be- 
fore the  fatal  catastrophe.  Were  it  not  for  the  opera- 
tion, some  external  injuries  would  be  inevitably  fol- 
lowed by  mortification.  In  such  cases,  early  amputa- 
tion is  evidently  proper;  for  the  simple  incision  is  at 
tended  with  less dangerthan  sphacelus.  Sometimes,  says 
Richter,  a sphacelus  spontaneously  stops.  This  hap- 
pens most  frequently  in  cases  which  originate  from  an 
external  cause,  such  as  a violent  contusion,  burn,  &c. 
But  the  occurrence  is  not  restricted  to  this  kind  of 
case,  nor  is  it  invariably  attendant  on  it.  When  there 
are  no  otlier  occasional  causes  present,  the  mortifica- 
tion does  not  readily  go  beyond  the  limits  of  the  con- 
tusion or  violent  burn ; but  the  interference  of  surgery 
can  hardly  ever  put  a stop  to  its  progress,  before  it  has 
spread  as  far  as  the  extent  of  the  local  injury. — i,An- 
fangsgriinde  der  Wundarxneykunst,  b.  I,  kap.  3.) 

How  different  are  the  doctrinesof  Baron  Larrey  upon 
this  subject  from  those  entertained  by  Richter,  and, 
indeed,  the  generality  of  eminent  modern  surgeons! 
“ Writers  on  gangrene,  or  sphacelus  of  the  extremities 
(says  Larrey),  indiscriminately  recommend  the  ampu- 
tation of  a sphacelated  limb  never  to  be  undertaken 
before  the  mortification  is  bounded  or  limited  by  a 
reddish  circle,  forming  a true  line  of  separation  be- 
tween the  dead  and  living  parts.  This  circumstance 
can  only  occur  in  a case  of  spontaneous  gangrene 
from  an  internal  cause;  or  if  it  happens,  as  is  very 
unusual,  in  a case  arising  from  a wound,  its  progress  is 
different,  and  it  would  be  exceedingly  imprudent  to 
wait  for  it.  The  gangrene  from  external  injuries 
almost  always  continues  to  spread ; the  infection  be- 
comes general ; and  the  patient  dies." — {J\Iem.  de  Chir. 
jMilitaire,  t.  3,  p.  142.)  Respecting  the  want  of  found.a- 
tion  for  this  hypothesis  of  infection,  I need  here  offer 
no  remarks,  having  already  expressed  my  opinion  upon 
it  in  a foregoing  page.  Ou  the  other  hand,  Larrey 


asserts,  that,  in  the  dry  or  spontaneous  gangrene,  ab- 
sorption takes  place  with  more  difficulty,  and  it  is  not 
uncommon  to  see  the  sphacelated  parts  separate  from 
the  living  ones  by  the  powers  of  nature  alone,  without 
the  general  functions  being  impaired.  He  argues  that 
there  is  a manifest  difference  between  what  he  terms 
the  traumatic  and  the  spontaneous  gangrene,  or,  in 
other  words,  between  the  humid  gangrene  from  an  ex- 
ternal cause,  and  the  dry  gangrene,  which  ordinarily 
proceeds  from  an  internal  cause. — (P.  148.) 

In  cases  of  mortification,  arising  from  external  in- 
juries, Larrey  maintains,  that,  “ notwithstanding  any 
thing  that  writers  and  practitioners  may  allege  to  the 
contrary,  we  should  not  hesitate  about  promptly  per- 
forming amputation,  as  soon  as  the  necessity  for  the 
operation  is  decidedly  established.  There  is  no  rea- 
son to  apprehend  that  the  stump  will  be  seized 
with  gangrene,  as  in  the  spontaneous  mortification, 
which  has  not  ceased  to  spread,  because  the  trau- 
matic gangrene,  after  having  arisen  from  a local 
cause,  is  only  propagated  by  absorption,  and  a suc- 
cessive affection  of  the  texture  of  parts  by  continuity 
of  the  vessels.  Amputation,  performed  in  a proper 
situation,  stops  the  progress  and  fatal  consequences  of 
the  disorder. 

“ Supposing  then  the  lower  half  of  the  leg  should  be 
affected  with  sphacelus,  in  consequence  of  a gun-shot 
injury,  attended  with  a violent  contusion  of  the  part, 
and  a forcible  concussion  of  the  vessels,  nerves,  and 
ligaments,  if  the  skin  is  elsewhere  uninjured,  the  ope- 
ration may  be  done  in  the  place  of  election,  without 
any  fear  of  the  stump  becoming  gangrenous,  notwith- 
standing the  cellular  membrane  of  the  upper  part  of 
the  member  may  be  already  affected.  But  wiien  the 
skin  of  the  whole  leg  is  struck  with  mortification,  the 
operation  must  be  done  ou  the  thigh  and  no  time 
should  be  lost.  The  same  practice  is  applicable  to  the 
upper  extremities.  We  must  be  careful  not  to  mistake 
a limb  affected  with  stupor  for  one  that  is  actually 
sphacelated.  In  the  first  case  warmth,  motion,  and 
sensibility  are  still  retained,  although  the  skin  may  be 
blackish  and  the  parts  may  be  swollen.  Besides,  if 
there  were  any  doubt,  it  would  be  proper  to  try  at 
first  tonic  repellent  applications,  and  cordial  medi- 
cines, &c.” — (See  Mim.  de  Chir,  Militaire,  t.  3,  p. 
152,  153.) 

When  amputation  has  been  practised,  this  author 
recommends  the  exhibition  of  bark,  good  wine,  tonics, 
&.C.  in  order  to  promote  the  good  effects  of  the  opera- 
tion.—(P.  154.) 

“The  facts  (says  Larrey)  which  I shall  relate  in  the 
course  of  this  dissertation  will  prove,  I think,  in  an 
incontestable  manner,  the  truth  of  the  principle  whicli 
I lay  down,  that  when  gangrene  is  the  result  of  a me- 
chanical cause,  and  puts  the  patient's  life  in  danger, 
amputation  ought  to  be  performed  without  waiting 
until  the  disorder  has  ceased  to  spread. 

“ I have  been  a witness  of  the  death  of  several  in- 
dividuals, from  too  rigorous  an  adherence  to  the  con- 
trary precept ; and,  at  length,  grievously  impressed 
with  this  loss,  I had  long  ago  determined  to  depart 
from  an  axiom  which  was  always  considered  by  me  as 
false.  Besides,  following  the  maxim  of  Celsus,  I pre- 
ferred employing  an  uncertain  remedy,  rather  than 
abandon  the  patient  to  an  inevitable  death.  Satius  est 
enim  anceps  auzilium  experiri  qudm  nullum. 

“I  made  the  first  attempt  at  Toulon,  in  the  year 
1796,  upon  a soldier,  who,  in  consequence  of  a violent 
contusion  of  the  foot,  was  afflicted  w'ith  a gangrenous 
ulcer,  which  soon  threw  the  whole  part  into  a sphace- 
lated state.  While  the  mortification  was  yet  spreadiiig, 
I resolved  to  amputate  the  leg.  The  success  of  tire 
operation  surpassed  my  expectations;  the  stump 
healed ; and  in  less  than  forty-five  days  the  patient  got 
quite  well.  This  case  served  lo  encourage  me. 

“ During  the  siege  of  Alexandria,  in  Egypt,  in  1801, 
a second  case,  very  analogous  to  the  preceding,  oc- 
curred in  my  practice;  it  happened  in  a draeoon  of  tl)e 
18th  regiment,  whose  forearm  and  afterward  arm  spha- 
celated, in  consequence  of  a gun-shot  wound  in  the 
articulation  of  the  left  arm.  The  mortification  had 
extended  nearly  as  high  as  the  shoulder,  and  the  pa- 
tient’s life  was  in  great  danger,  when  I determined  to 
amputate  the  limb  at  the  shoulder- joint.  The  disorder 
was  manifestly  spreadins,  and  the  patient’s  brain 
already  atfecied,  for  he  had  symptoms  of  ataxia;  the 
operation,  however,  arrested  the  progress  of  the  slough- 


MORTIFICATION. 


187 


tng,  and  saved  his  life,  so  that  at  the  conclusion  of  the 
siege  of  Alexandria  he  was  quite  cured. 

“ After  the  taking  of  Ulm,  M.  Ivan,  surgeon  to  his 
majesty  the  emperor,  performed  in  my  presence,  a«id 
at  my  ambulance  established  at  Elchingen,  the  ampu- 
tation of  the  thigh  of  a soldier  belonging  to  the  76th 
regiment  of  the  line,  the  leg  having  sphacelated  in  con- 
sequence of  a gun-shot  injury.  The  gangrene  was  not 
limited,  and  evidently  extending  itself;  yet  the  effects 
of  the  disorder  were  destroyed,  and  the  patient  was 
quite  cured  on  our  return  to  Austerlitz. 

“ A fourth  patient,  an  officer  in  the  same  regiment, 
shot  in  tlie  ankle  at  the  capture  of  the  same  town,  was 
conveyed  to  my  ambulance,  in  order  to  be  dressed  : it 
was  the  third  day  after  the  accident;  the  foot  was  gan- 
grenous, and  the  leg  was  swelled,  and  threatened  like- 
wise with  mortiheation.  Febrile  symptoms  had  also 
come  on.  I hastened  to  amputate  the  leg  a little  above 
the  place  of  election.  The  cellular  membrane  of  the 
stump,  of  a yellow  blackish  colour,  was  already  in- 
fected with  the  gangrenous  principle  (as  Larrey  terms 
it).  The  operation,  however,  stopped  the  progress  of 
the  mischief;  suppuration  took  place  in  the  stump; 
some  sloughs  were  detached;  the  wound  assumed  a 
cleaner  appearance ; and  cicatrization  was  completed 
on  the  fifty-second  day.  The  patient  could  already 
walk  with  a wooden  leg,  when  he  caught  the  hospital 
fever,  which  was  epidemic  at  Ulm,  where  he  awaited 
his  regiment,  and,  to  my  great  regret,  he  was  carried 
off  by  this  disease,  after  having  escaped  the  former 
danger. 

“ After  the  battles  of  Austerlitz  and  Jena  (continues 
Larrey),  several  of  my  colleagues,  surgeons  of  the  first 
class,  undertook,  in  consequence  of  my  advice  and 
the  examples  of  success  which  I had  recited  to  them, 
tlie  amputation  of  limbs  equally  sphacelated,  although 
the  mortification  was  not  limited,  rather  than  abandon 
the  patients  to  a death  which  appeared  inevitable.  In 
general,  these  practitioners  experienced  the  same  suc- 
cess as  I did  myself.” — {Mem.  de  Chir.  Militaire,  t.  5, 
p.  154—157.) 

In  Larrey’s  memoir  upon  this  subject  there  are  some 
additional  facts  and  arguments  in  favour  of  what  he 
endeavours  to  prove,  viz.  that  in  cases  of  mortification 
from  external  injuries,  if  the  patient’s  life  be  in  danger, 
amputation  ought  to  be  performed,  although  the  slough- 
ing may  yet  be  in  a spreading  state.  I must  be  content, 
hoyvever,  with  having  stated  the  particulars  already 
explained;  and  the  reader,  desirous  of  more,  must 
refer  to  Larrey’s  own  publication.  Certainly  the  facts 
which  he  has  adduced  are  highly  important ; they  tend , 
to  subvert  a doctrine  and  to  prove  the  error  of  a prac- 
tice which  have  been  urged  in  forcible  terms  by  most 
of  the  distinguished  surgeons  of  nK)dern  times.  The 
sentiments  of  Mr.  Sharp  are  rendered  questionable  ; 
and  the  truth  of  the  positive  assertions  of  Mr.  Pott  is 
yet  a matter  to  be  examined.  The  latter,  it  is  well 
known,  tells  us,  that  he  has  often  seen  the  experiment 
made  of  amputating,  while  a mortification  was  spread- 
ing, but  never  knew  it  answer.  Are  we  to  conclude, 
that  all  these  cases  which  Pott  alludes  to,  were  morti- 
fications from  an  internal  cause"?  Or  are  we  to  sup- 
pose, that  the  operation  failed  from  having  been  delayed 
too  long?  Or  must  we  imagine,  that  the  nature  of 
the  human  constitution  has  been  changed  between  the 
era  of  Pott  and  that  of  Larrey? 

It  should  be  remarked,  that  the  practice  of  amputa- 
tion, in  cases  of  spreading  mortification,  has  generally 
had  some  partisans  for  many  years  past;  but  the 
weight  of  authorities  has  unquestionably  been  against 
it,  and  few  surgeons  in  this  country  have  ventured  to 
deviate  from  the  advice  of  Sharp  and  Pott.  It  is 
curious,  however,  that  Mehee,  a writer,  who  wrote  for 
the  express  purpose  of  declaring  his  disapprobation  of 
the  early  performance  of  amputation  in  gun-shot 
wounds,  should  have  admitted  of  only  one  case  in 
which  the  operation  is  proper,  namely,  gangrene  suc- 
ceeding the  wound  made  by  a cannon-shot.  Here  he 
thinks  that  amputation  ought  to  be  performed  on  the 
first  appearance  of  the  gangrene,  in  order  to  prevent  it 
from  spreading  up  the  limb. — (See  Traiti  des  Plaies 
d'Jirmes  d feu,  Paris,  1799.)  It  appears  that  about 
the  year  1809,  Mr.  A.  C.  Hutchinson  performed  with 
success  two  amputations  in  cases  of  spreading  gan- 
grene from  gun-shot  wounds.— (See  Practical  Obs.  on 
Surgery,  p.  72.) 

Jlly  friend  Mr.  Lawrence  has  also  successfully  am- 


putated at  the  shoulder-joint  in  a spreading  mortifica- 
tion of  the  arm,  the  consequence  of  external  violence. 
“ The  skin  of  the  amputated  limb  was  greenish  and 
livid  ; but  the  cuticle  pot  yet  detached.  The  cellular 
substance  distended  with  air,  and  with  a discoloured 
offensive  sanies;  its  appearance  was  not  quite  natural 
where  the  incision  took  place ; it  was  yellowish  and 
anasarcous.  Small  effusions  of  blood  were  observed 
here  and  there  in  the  course  of  the  nerves ; even  as 
high  as  the  amputated  part.  No  coagulation  of  blood 
in  any  of  the  arteries,  even  down  to  the  ulnar  and 
digital  branches.  All  the  soil  parts  were  discoloured, 
dark  red,  and  livid,  and  a frothy,  reddish  fluid  issued 
on  incision.”  This  case  had  the  most  favourable  ter- 
mination, and  it  clearly  proves,  that  the  humid  kind  of 
gangrene  which  occurs  in  a healthy  subject  from  severe 
local  injury,  which  so  rapidly  affects  a whole  limb, 
and  reaches  the  trunk  in  a few  hours,  must  constitute 
an  exception  to  the  general  maxim,  that  amputation 
should  never  be  done  before  a line  of  separation  is 
established  between  the  dead  and  living  parts.  Mr. 
Lawrence,  however,  would  not  be  understood  as 
meaning  to  recommend  the  practice  in  all  instances  of 
mortification  from  local  injury.  He  conceives,  that  a 
gangrene  may  arise,  in  an  unsound  constitution,  from 
a comparatively  slight  accident;  so  that  it  may  be  re- 
garded as  the  result  of  constitutional  disposition  rather 
than  of  the  local  cause.  Amputation  would  be  hope- 
less under  such  circumstances.  It  is  particularly  in  mor- 
tification following  very  severe  injury  in  a subject  other- 
wise healthy,  that  Mr.  Lawrence  believes  the  operation 
to  be  proper. — (See  Medico- Chir.  Trans,  vol.  6,  p.  184.) 

He  also  reports  another  instance,  in  which  he  saw 
the  operation  succeed,  though  the  mortification  was  in 
a spreading  state.  I was  once  consulted  in  private 
practice  about  the  propriety  of  amputating  at  the 
shoulder  in  a spreading  mortification  of  the  arm  from 
external  violence.  The  operation  was  done,  and  the 
patient,  who  without  it  would  certainly  have  perished 
in  a few  hours,  lived  a fortnight;  at  one  time  he  had  a 
fair  prospect  of  recovery,  and  died,  not  of  gangrene  of 
the  stump,  but  in  consequence  of  a large  abscess  over 
the  scapula. 

Among  the  experienced  approvers  of  Larrey’s  ad- 
vice, I must  not  omit  to  mention  Dr.  Hennen,  who  has 
repeatedly  amputated  under  the  circumstances  above 
pointed  out,  without  waiting  for  the  line  of  separation ; 
“ and  (says  he)  although  I certainly  was  not  uniformly 
successful,  I have  no  reason  to  imagine  that  death 
was  occasioned  by  a departure  from  the  rule  so  gene- 
rally laid  down  by  authors.” — (On  Military  Surgery y 
p.  243,  ed.  2.) 

With  regard  to  the  early  performance  of  amputa- 
tion, where  the  substance  of  a limb  perishes  after  ex- 
posure to  cold,  I find  some  difference  of  sentiment 
between  two  very  high  authorities.  Thus  Schmucker 
observes:  “ The  mortification  which  comes  on  after  a 
part  has  been  frozen,  increases  so  rapidly  if  the  limb 
be  exposed  to  warmth,  that  in  the  space  of  twenty - 
four  hours  its  vitality  and  organization  are  quite  de- 
stroyed, and  nothing  will  now  avail  in  restoring  its 
sensibility.  Here  the  speedy  performance  of  amputa- 
tion is  the  only  means  of  preservation  to  be  depended 
upon.  In  mortification  from  an  internal  cause,  the 
case  is  different. — (See  Vermischte  Chirurgische  Schrif- 
ten,  b.  1,  p.  15,  8vo.  Berlin,  1785.)  According  to  Lar- 
rey, however,  this  species  of  gangrene  at  length  stops, 
and  a line  of  separation  forms  between  the  dead  and 
healthy  parts.  If  the  disorder  be  superficial,  the 
sloughs  are  usually  thrown  off  between  the  ninth  and 
thirteenth  days,  leaving  an  ulcer  of  proportionate  extent, 
that  soon  heals  up.  If  the  whole  of  the  limb  be  spha- 
celated, nature  cannot  of  herself  effect  a cure,  or  but 
very  rarely,  the  patient  mostly  falling  a victim  to  the 
effects  of  absorption,  when  the  sloughs  are  detached, 
and  the  mouths  of  the  lymphatics  are  opened  on  the 
occurrence  of  suppuration.  Larrey  assures  us,  that 
he  has  seen  numerous  patients  carried  off  by  this 
cause,  while  the  examples  of  a spontaneous  cure  were 
exceedingly  few,  and  in  these  the  stump  was  left 
irregular,  and  unfit  for  bearing  the  pressure  of  a 
wooden  leg.  He  agrees,  therefore,  with  the  generality 
of  surgeons,  that  it  is  in  these  instances  advantageous 
to  ami)Utate  the  mortified  portion  of  the  limb,  but  not 
before  the  extension  of  the  gangrene  has  ceased,  and  the 
mischief  is  bounded  by  an  inflammatory  line. — (See 
Mim.  de  Chir.  Mil.  t.  3,p.  65 — 72.) 


188 


MOX 


MOX 


In  the  article  notice  has  been  taken  of  a 

sloughing  which  commences  in  the  foot,  and  extends 
up  the  leg,  and  sometimes  follows  gun-shot  injuries  of 
the  thigh,  which  involve  the  femoral  artery  ; this  is  a 
case  particularly  instanced  by  Mr.  Guthrie,  as  re- 
quiring the  very  early  performance  of  amputation. 
Sir  Astley  Cooper  also  refers  to  cases  in  which  the  rule 
was  successfully  deviated  from,  of  not  amputating  be- 
fore limits  are  set  to  the  spreading  of  mortification ; 
the  instances  in  question  arose  from  injury  of  blood- 
vessels, and  other  local  violence,  in  patients  of  a 
healthy  constitution.  In  such  cases,  it  is  admitted  by 
this  very  experienced  surgeon,  that  the  practice  should 
be  ditferent  from  what  is  usually  pursued  in  mortifica- 
tion from  constitutional  causes. — {^Surgical  Essays, 
part  2,  p.  186.) 

[Dr.  Physick  was  the  first  surgeon  who  suggested 
the  application  of  blisters  in  strips  over  the  sound  parts 
of  a limb  next  to  those  which  are  gangrenous,  and  its 
success  in  this  country  and  in  Europe  is  a matterof  no- 
toriety. The  pyroligneous  acid  has  also  been  applied 
topically  in  cases  of  mortification,  sloughing,  and  fetid 
ulcers.  In  many  ulcers  it  is  preferred  by  Professor 
Stevens  to  the  nitric  acid  or  yest  poultice,  and  In  its 
antiseptic  powers  is  superior  to  either  of  them.  The 
chloride  of  soda  is  becoming  an  article  of  general  use 
for  these  purposes,  and  is  of  great  value. — Reese.] 

Fabricii  Hildani  Tract.  Methodicus  de  Oangrmna 
et  Sphacelo.  Quesnai,  Traits  de  la  Gangrene,  12mo. 
Paris,  1749.  Encyclopidie  Methodique,  partie  Chi- 
rurgicale,  art.  Gangrene.  Kirkland  on  Gangrene, 
and  on  the  Present  State  of  Medical  Surgery.  Rich- 
ter, Anfangsgr.  der  fVundarzn.  b.  1,  kap.  3.  Various 
parts  of  Hunter  on  Inflammation,  <S-c.  Sharp's  Cri- 
tical Inquiry  into  the  present  State  of  Surgery,  chap. 
8.  Rickerand,  JVosographie  Ckir.  1. 1,  p.  215,  ^c.  edit. 
4.  Lassus,  Pathologic  Chir.  t.  1,  p.  30,  Src.  edit.  1809. 
Leviilli,  JVouvelle  Doctrine  Chir.  t.  4,  p.  321,  df-c.  Pa- 
ris, 1812.  Larrey,  Mimoires  de  Chirurgie  Militaire, 
i.  3;  particularly  the  Mim.  sur  la  Gangrene  de  Con- 
gelation, p.  60,  and  that  sur  la  Oangrine  Trauma- 
tique,  p.  141.  Gallisen,  Systema  Chirurgim  Hodiernce, 
vol.  2,  p.  374,  edit.  1800.  Dr.  J.  Thomson' s Lectures 
on  Inflammation,  p.  501,  Edinb.  1813.  O'  Halloran  on 
Gangrene  and  Sphacelus,  ?>vo.  Dublin,  1765.  Pott's 
Obs.  on  the  Mortiflcation  of  the  Toes  and  Feet,  in  his 
Chirurg.  Works,  vol.  3.  J.  Kirkland,  Thoughts  on 
Amputation,  &-c.  with  a short  Essay  on  the  Use  of 
Opium  in  Mortification,  8vo.  Lond.  1780.  J.  Harri- 
son, The  remarkable  Effects  of  fixed  Air  in  Mortifi- 
cations of  the  Extremities,  8vo.  Lond.  1785.  J.  A. 
Murray,  in  Gangrcenam  Scroti  Obs.  {Frank.  Del.  op: 
10.)  C.  White  Observations  on  Gangrenes  and  Mor- 
tifications, accompanied,  drc.  with  convulsive  Spasms, 
8v(i.  1790.  Pearson's  Principles  of  Surgery,  p.  114, 
edit.  2.  Lawrence  in  Med.  Chir.  Trans,  vol.  6,  p.  184, 
Sec.  Delpech,  Mimoire  sur  la  Complication  des  Plaies 
et  des  Ulceres,  connue  sur  le  Mom  de  Pourriture  d'H6- 
pital:  also,  Pricis  Elementaire  des  Maladies  riputies 
Chirurgicales,  t.  1,  p.  73,  df-c.  Paris,  1816.  Boyer, 
Traitis  des  Maladies  Chir.  t.  1,  p.  105,  Src.  Paris, 
1814.  John  Bell's  Principles  of  Surgery.  Himly's 
Abhandlung  iiber  der  Brand  der  Weichen  und  harten 
Theile,  Gott.  1800.  For  an  account  of  the  dry  gan 
grene,  see  particularly  the  writings  of  Hildanus,  Tul- 
pius,  Quesnai,  Mim.  de  la  Soc.  Royale  de  Midecine, 
t.  1,  Opere  di  Bertrandi ; Medical  Museum,  Src.  For 
a description  of  the  mortification  caused  by  eating 
cockspur-rye,  see  Dodard's  letter  in  Journal  des  Sa- 
vans,  1676.  Moel,  in  Mim.  de  I'Acad,  des  Sciences, 
1710.  Langius,  “ Descriptio  Morborum  ex  Esu  Cla- 
vorum  Secalinorum."  Duhamel,  in  Mem.  de  I'Acad. 
des  Sciences,  1748.  Dr.  C.  Wollaston  in  Philosophical 
Trans.  1762.  Tessier,  in  Mim.  de  la  Societi  Royale 
de  MHecine,  t.  1,  and  2,  Src.  O.  Prescott,  A Disserta- 
tion on  the  Matural  History  and  Medicinal  Effects  of 
the  Secale  Cornutum,  or  Ergot,  8vo.  Lond.  1813.  D. 
F.  Hcffter,  Doctrince  de  Gangrcena  brevis  Expositio, 
4to.  Lips.  1807.  C.  L.  G.  Liessehing,  De  Gangrwna, 
4to.  Gott.  1811.  Hennen's  Principles  of  Military 
Surgery,  p 241,  ^c.  ed.  2,  8oo.  Lond.  1820.  G.  J. 
Guthrie  on  Gun-shot  Wounds, ^c.  p.  lU,  ^-c.  ed.  2, 
8no.  Lond.  1820.  J.  H.  .Tames,  Obs.  on  the  Principles 
of  Injlammntion,  p.  84,281,  &-C.8VO.  Lond.  1821.  Sir 
A^^oper,  Surgical  Essays,  part  2,  p.  186,  8vo.  Lond. 

MOXA.  Tlie  Chinese  inoxa  consists  of  the  tomen- . 


turn  of  the  leaves  of  the  artemisia  latifolia.  That 
wiiich  Baron  Percy  employs  is  made  of  the  stalk  of 
the  great  sunflower,  soaked  in  a solution  of  nitre,  and 
afterward  well  dried;  cotton,  however,  similarly  pre- 
pared, completely  answers  the  purpose.  Mr.  Dungli- 
son,  who  has  translated  Larrey’s  memoir  on  this  sub- 
ject, and  added  to  it  some  interesting  matter,  shows 
that  the  moxa  has  been  used  in  the  eastern  parts  of  the 
world  many  centuries.  The  cone  or  cylinder  of  moxa 
is  composed  of  a certain  quantity  of  cotton  wool,  over 
which  a piece  of  fine  linen  is  rolled,  and  fastened  at 
the  side  by  a few  stitches.  This  conical  cylinder  should 
be  about  an  inch  long,  and  of  a proportionate  thick 
ness;  the  size,  however,  may  be  varied  according  to 
circumstances. 

A porte  moxa  is  intended  to  fix  the  cylinder  upon  the 
precise  spot  where  the  application  is  to  be  made.  I'Ac 
metallic  ring  of  this  instrument  is  kept  from  touching 
the  skin  by  means  of  three  small  supports  of  ebony, 
which  is  a bad  conductor  of  caloric.  After  the  extre- 
mity of  the  cone  has  been  set  fire  to,  the  combustion  is 
kept  up  by  means  of  a blow-pipe;  however,  it  should 
not  be  too  much  hastened,  but  allowed  to  proceed 
slowly.  The  precise  spot  to  which  the  moxa  is  to  be 
applied,  ought  to  be  first  marked  with  a little  ink,  and 
all  the  surrounding  surface  covered  with  a wet  rag, 
that  has  a hole  in  the  middle,  so  as  to  leave  the  part 
bare  which  has  been  marked.  After  the  top  of  the 
moxa  has  been  set  on  fire,  the  base  of  it,  held  in  the 
porte  moxa,  must  be  placed  upon  the  intended  part, 
and  the  combustion  kept  up  with  the  blow-pipe,  until 
the  whole  is  consumed.  In  order  to  prevent  the  sub- 
sequent inflammation  and  suppuration  from  being  too 
considerable,  the  liquor  ammonise  should  be  immedi- 
ately applied  to  tire  burnt  part. 

The  diseases  in  which  Baron  Larrey  has  found  the 
moxa  efficacious,  are  amaurosis,  and  incipient  cata- 
ract (cases  in  which  he  applies  it  over  the  course  of 
the  facial  nerve,  just  behind  the  angle  of  the  jaw) ; 
deafness  and  aphonia  arising  from  cold ; tic  douloureux, 
and  partial  paralysis  of  the  muscles  of  the  face ; palsy 
of  the  lower  extremities ; phthisis ; diseased  spine ; 
disease  of  the  hip-joint,  &c. 

M.  Roux,  when  he  visited  the  London  hospitals,  had 
two  opportunities  afforded  him  of  applying  the  moxa, 
in  order  to  convince  the  rising  generation  of  surgeons 
in  this  country  of  its  superior  efficacy.  The  first  was 
in  a case  of  spontaneous  paralysis  of  the  deltoid  muscle 
at  St.  Bartholomew’s.  The  moxa  was  applied  a little 
below  the  acromion,  and  a few  days  afterward  the 
motion  of  the  arm  began  to  be  restored.  This,  how- 
ever, was  a case  which,  according  to  the  account  of 
Roux  li.mself,  had  relapsed  after  having  been  cured  by 
other  means.  I think  one  of  the  surgeons  of- St.  Bar- 
tholomew’s informed  me,  that  notwithstanding  the 
moxa,  the  relief  proved  again  only  temporary.  If; 
however,  the  moxa  had  succeeded,  a caustic  issue,  a 
blister,  or  the  volatile  liniment  would  probably  have 
answered  equally  well.  The  second  instance  in  which 
M.  Roux  applied  the  moxa,  was  a case  of  white  swell 
ing  at  Guy’s  Hospital;  but  the  disease  and  advanced 
too  far  to  allow  any  hope  of  a favourable  issue. — (See 
Voyage  fait  d Londres  en  1814,  ou  Parallile  de  la  Chi- 
rurgie Angloise  avecla  Chirurgie  Francaise,p.  19,  20.) 
M.  Roux  flatters  himself  that  “ les  chiriirgicns  Anglois 
ripugncront  sans  doute  moins  d V avenir  dfaire  usage 
du  moxa."  The  truth  is,  English  surgeons,  as  welTas 
English  farriers,  knew  very  well  before  the  arrival  of 
M.  Roux  what  might  be  done  with  moxa  and  the  actual 
cautery.  But  though  the  application  of  fire  still  pre- 
vails in  the  veterinary  art,  as  a mode  of  curing  diseases, 
it  has  long  been  abandoned  as  a means  of  relief  in  the 
English  practice  of  surgery  ; not  on  the  ground  of  its 
being  always  ineffectual,  but  because  equal  good  has 
been  found  to  result  from  measures  which  are  milder, 
always  less  terrific,  and  frequently  less  painful.  In 
order  to  convince  an  English  surgeon  that  moxa  and 
the  actual  cautery  ought  to  be  introduced  into  practice, 
M.  Roux  should  prove,  that  there  is  at  least  some  par- 
ticular disease  which  may  in  this  manner  be  cured, 
but  which  cannot  be  cured  by  other  means,  ordinarily 
employed  in  our  practice.  He  should  also  make  us 
forget  that  the  application  of  actual  fire  was  once  ns 
common  in  English  sorcery  as  in  French ; but  that  it 
had  not  attractions  enouch  to  maintain  itscround. 

However,  that  the  reader  may  know  the  arguments 
used  by  tlie  advocates  for  the  practice,  I submit  to  him 


MUR 


MUR 


the  following  observations,  which  are  contained  in  a 
periodical  work.  All  the  world  knows  that  counter- 
irritation is  of  great  use  in  the  treatment  of  disease ; 
and  almost  all  the  world  knows  that  different  forms  of 
counter-irritation  produce  different  effects  on  the  hu- 
man body.  We  do  not  pretend  to  specify  what  is  the 
reason  of  these  different  effects,  simply  because  we  do 
not  know.  But  while  such  men  as  Percy  and  Larrey, 
and  twenty  others  of  character,  speak  so  highly  in  fa- 
vour of  the  actual  cautery,  we  perhaps  are  scarcely 
authorized  to  say,  that  the  action  of  the  potential  cau- 
tery can  be  made  to  resemble  it  in  all  cases.  We  can 
easily  understand  how  the  actual  cautery  should  fall 
into  disuse,  however  good  a remedy  it  might  be;  for, 
if  we  ourselves  were  patients,  we  should  be  slow  in 
believing  that  the  pain  of  the  application  was  not  so 
severe  as  our  fears  point  out ; but  the  skepticism  of  the 
medical  man  ought  to  rest  on  different  grounds.  We 
may  say,  respecting  the  moxa,  that  its  action  may  be 
more  easily  regulated  than  that  of  caustics,  so  that  by 
the  more  or  less  sedulous  use  of  the  blow-pipe,  we  may 
create  a superficial  eschar,  or  a deep  suppurating 
wound.  In  fact,  in  all  cases  where  more  than  a mere 
irritation  of  the  skin  is  required,  the  moxa  affords  a 
certainty  in  its  applications  possessed  by  none  of  the 
other  caustics.  Of  course  it  would  be  improper  to 
compare  the  moxa  with  blisters,  or  with  any  other 
counter-irritant,  which  acts  by  irritating  the  skin  with- 
out destroying  if.  if  we  compare  it,  therefore,  with  the 
emetic  tartar  ointment,  issues,  setons,  and  the  caustics, 
properly  so  called,  we  shall  find  that  it  possesses  greater 
advantages  than  they  do.  The  first  oPthese  is  a long 
time  in  destroying  the  cutis,  and  it  is  very  uncertain  in 
the  quantity  of  its  effect;  moreover,  whether  the  ef- 
fect be  produced  at  all,  generally  de[)ends  on  the  dili- 
gence and  knowledge  of  the  patient’s  attendants,  and 
not  on  the  medical  man.  Hence  it  is  not  likely  often 
to  be  properly  applied.  Issues  and  setons  produce  but 
little  instantaneous  effect;  their  efficacy,  therefore,  de- 
pends on  the  irritation  and  discharge  daily  kept  up. 
Indeed,  these  also,  if  they  are  left  to  the  care  of  the 
patient,  which  tliey  almost  always  are,  soon  become 
inert  and  useless.  The  different  caustics  approach  to 
the  moxa  in  their  properties.  Their  effect  is,  in  some 
degree,  rapidly  produced,  and  a suppurating  ulcer  is 
formed  ; but  still,  to  produce  their  smallest  effect,  a 
longer  time  is  necessary  than  the  surgeon  can  conve- 
niently stay  with  his  patient ; so  that,  as  the  operation 
of  the  remedy  is  dependent  on  time,  and  that  time  va- 
ries according  to  the  constitution  of  the  patient,  the 
quantity  of  effect  produced  can  never  be  calculated 
upon.  It  is  very  different,  however,  with  the  moxa.  The 
effect  is  almost  instantaneous,  and  the  surgeon’s  hand 
regulates  the  quantum  of  action ; so  that  not  only  is 
the  moxa  the  most  manageable  of  counter-irritants 
that  destroy  the  skin,  but,  as  many  medical  men  be- 
lieve that  suddenness  of  operation  forms  not  a small 
part  of  the  efficacy  of  counter-irritants,  the  moxa 
stands  also  pre-eminent  on  this  ground.— (See  Med.  In- 
lelligeTtcer,  vol.  3,  p.  578:  also  Larrey,  Recueil  de 
Memoircs  de  Chirurg-ie,  Paris,  1821 ; and  particu- 
larly Mr.  Dunglison's  Translation  of  the  first  me- 
moir.) 

MURIATIC  ACID.  Gargles  containing  this  acid 
are  often  made  use  of  with  advantage  in  various  cases 
of  sore  throat,  and  the  disease  known  by  the  name  of 
cancrumcris.  The  following  formula  is  employed  at 
St.  Bartholomew’s  Hospital.  Roste  rubrse  exsic- 
catae  3 ij.  Aquae  ferventis  Ibj.  Infunde  per  horam 
dimidiam,  dein  cola,  et  adde  Acidi  muriatici  3j. 
Mellis  Rosffi  | ij.  Sacchari  purificati  3 vj.  Misce. 

Muriatic  acid  appears  to  have  been  tried  in  syphilis 
earlier  than  the  nitric.  Dr.  Zeller  of  Vienna  having 
employed  it  as  a successful  remedy  for  this  disease 
ever  since  the  year  1789.— (Fide  Sim.  Zeller's  Prakt. 
Bemerk  iiber  den  vorzugl.  Muticn  d.  allerem,  bekannt. 
Hadeschwamens,  S,  e.  Mebst.  cinem  Jinhange  v.  d.  Salz- 
saure,  Src.  Wien.  1797.) 

As  a medicine  capable  of  improving  the  appearance 
of  venereal  ulcers,  and  of  restraining  for  a time  the 
progress  of  the  disease,  it  was  known  to  Mr.  Pearson 
many  years.  He  says  that  he  wa.s  first  induced  to 
give  this  acid  in  venereal  ulcers  of  the  tongue  and  of 
the  throat,  in  conseqtience  of  the  great  benefit  which 
he  had  .seen  result  from  its  use  in  examples  of  cancrum 
oris:  and  without  viewing  it  as  an  antidote  for  lues 
venerea,  he  has  frequently  availed  himself  of  its  use- 


189 

ful  qualities,  when  it  was  desirable  to  gain  a little  time 
previously  to  the  commencement  of  a mercurial  course. 
— {Obs.  on  the  Effects  of  various  Jlrticles  in  the  Cure 
of  Lues  Venerea,  p.  193,  ed.  2.)  From  what  he  saw, 
however,  he  never  inferred  that  the  sulphuric  and  mu- 
riatic acids  could  radically  cure  the  venereal  disease; 
and  he  ascribed  the  benefit  derived  from  them  partly 
to  their  salutary  effects  on  the  stomach  and  constitu- 
tion, and  partly  to  their  agency  on  ulcers  of  the  throat 
and  tongue,  as  local  applications. — (P.  117.)  When 
Mr.  Pearson  made  these  observations,  the  fact  which 
has  now  been  so  unequivocally  demonstrated  in  the 
army  hospitals,  that  nearly,  if  not  all,  the  forms  of  dis- 
ease going  under  the  name  of  syphilis,  may  be  cured 
without  mercury,  had  not  undergone  the  strict  and  im- 
partial investigations  which  have  of  late  years  been 
devoted  to  the  subject. — (See  particularly  Obs.  on  the 
Treatment  of  Syphilis,  xoith  an  account  of  several 
cases  of  that  disease  in  which  a cure  was  effected  with- 
out the  use  of  mercury,  by  T.  Rose,  in  Medico-Chir. 
Trans,  vol.  8,  p.  349.)  If  this  point  be  admitted  as 
fully  established,  the  question  about  the  antisyphilitic 
virtues  of  various  articles  of  the  materia  medica  re- 
quires to  be  taken  up  in  a very  different  light,  not 
clouded  with  a notion  that  the  disease  will  certainly 
get  worse  and  worse,  if  no  remedy  whatever  be 
exhibited,  or  that  it  cannot  finally  get  well  of  itself. 
While  these  doctrines  prevailed,  the  amendment  of 
any  syphilitic  affection  during  the  use  of  muriatic 
or  any  other  acid,  was  entirely  referred  to  some 
specific  effect  supposed  to  appertain  to  such  me- 
dicine. But  now  the  question  involves  several  consi- 
derations; first,  the  actual  virtue  of  the  medicine  in 
expediting  the  cure  of  the  disease;  secondly,  the 
changes  which  might  happen  if  the  complaint  were 
left  to  itself ; and  thirdly,  the  benefit  sometimes  as- 
cribable  to  the  improvement  produced  in  the  consti- 
tution under  particular  circumstances,  by  the  discon- 
tinuance of  mercury.  The  latter  mineral  no  longer 
claims  the  name  of  a specific  for  the  venereal  diseascj 
either  in  the  sense  of  the  only  or  a completely  certain 
antidote;  because  nature  herself  would  in  time  bring 
most  cases  to  a favourable  conclusion:  because  the 
cure  can  be  completed  by  a variety  of  other  medicines 
noticed  in  this  publication ; and  lastly,  because  mer- 
cury, though  it  may  be  generally  the  quickest  means 
of  cure,  is,  in  particular  cases,  complicated  with  much 
debility  and  constitutional  irritability,  the  surest  medi- 
cine to  aggravate  the  complaint  and  prevent  any  pro- 
gress towards  a favourable  termination.  Here  it  is 
enough  to  know  (and  Mr.  Pearson  himself  acknow- 
ledges the  fact)  that  in  the  circumstances  above  spe- 
cified, muriatic  acid  is  a safer  medicine  than  mercury. 
The  dose  is  from  ten  to  twenty  drops,  which  are  to  be 
mixed  with  a proper  quantity  of  water. 

Muriatic  acid  has  sometimes  been  employed  as  the 
active  ingredient  in  injections  for  the  cure  of  gonor- 
rhoea, in  the  proportion  of  eight  or  ten  drops  to  four 
ounces  of  distilled  water. 

In  cases  of  poison  from  muriatic  acid,  the  experi- 
ments made  by  Orfila,  lead  him  to  consider  calcined 
magnesia  and  prepared  soap  the  most  fit  substances  for 
neutralizing  such  portion  of  the  acid  as  may  not  yet  be 
combined  with  the  texture  of  the  oesophagus,  stomach,. 
&c.  They  should  be  given  as  soon  as  possible  after  the 
corrosive  poison  has  been  swallowed,  care  being  taken 
to  let  the  patient  drink  copiously  of  warm  water,  milk, 
broth,  or  some  mucilaginous  diluting  liquid.  When 
from  the  symptoms  there  is  reason  to  believe  that  in- 
flammation exists  in  the  viscera,  or  when  spa.sms  and 
convulsions  come  on,  antiphlogistic  remedies  and  anti- 
spasmodics  are  indicated. — (Traite  des  Poisons,  p. 
476,  vol.  1,  ed.  2,  Paris,  1818.)  In  order  to  detect  the 
presence  of  muriatic  acid  when  mixed  with  wine  or 
other  fluids,  we  are  recommended  to  distil  a portion  of 
it  from  a small  retort  over  a candle  into  a phial  con- 
taining a solution  of  nitrate  of  silver.  The  precipita- 
tion of  muriate  of  silver,  which  is  soluble  in  ammonia, 
but  not  in  nitric  acid,  will  take  place  if  the  poison  con- 
tain muriatic  acid. — {Thomson's  Dispensatory,  p.  434, 
ed.  2.) 

By  Morveau,  who  employed  himself  in  investigating 
the  merils  of  Dr.  Carmichael  Smith’s  mode  of  de- 
stroying infection,  the  muriatic  acid  in  the  new  form 
of  gas  wa.s  alleged  to  have  the  very  important  quality 
of  neutralizing  putrid  miasmata.  The  gas  is  extri- 
cated from  common  salt  by  means  of  sulphuric  acid 


190 

In  this  way  it  is  often  employed  in  hospitals  as  a mode 
of  preventing  and  obviating  infection. 

The  use  of  muriatic  acid  as  an  application  to  cer- 
tain cases  of  sloughing  and  phagedena,  has  been  ex- 


N^V 

plained  in  the  articles  Hospital  Oan^rene  and  Jllor-’ 

tification. 

MYDRI'ASIS.  (From  to  abound  in  mois- 

tnre.)  A preternal  dilatation  of  the  pupil. 


N 


.^VUS.  {Congenita  J^ota;  Envies;  Mutter- 
mahl;  Mother-spots,  &-c.)  A mole,  or  congenital 
mark,  or  excrescence  of  the  skin.  Nsevi  materni  signify 
the  little  spots,  excrescences,  or  swellings,  with  which 
many  children  are  born.  Some  of  them  (says  Dr. 
Bateman)  are  merely  superficial  or  stain-like  spots,  and 
appear  to  consist  of  a partial  thickening  of  the  rete 
mucosum,  sonretimes  of  a yellow  or  yellowish-brown, 
sometimes  of  a bluish,  livid,  or  nearly  black  colour. 
To  these  the  term  spilus  has  been  more  particularly 
appropriated.  Others  again  exhibit  various  degrees 
of  thickening,  elevation,  and  altered  structure  of  the 
skin  itself,  and  consist  of  clusters  of  enlarged  and  con- 
torted veins,  freely  anastomosing,  and  forming  little 
sacs  of  blood.  These  are  sometimes  spread  more  or 
less  extensively  over  the  surface,  occasionally  covering 
even  the  whole  of  an  extremity,  or  one-half  of  the 
trunk  of  the  body  ; and  sometimes  they  are  elevated 
into  prominences  of  various  forms  and  magnitude. 
Occasionally  these  marks  are  nearly  of  the  usual  co- 
lour of  the  skin;  but  most  commonly  they  are  of  a pur- 
plish red  colour,  of  varying  degrees  of  intensity  ; such 
as  the  presence  of  a considerable  collection  of  blood- 
vessels situated  near  the  surface,  and  covered  with  a 
thin  cuticle,  naturally  occasions. — (See  Bateman's 
Practical  Synopsis  of  Cutaneous  Diseases,  p.  324,  ed.  4.) 
When  a naevus  is  of  a dark  red  colour,  its  intensity  is 
generally  augmented  by  every  thing  which  tends  to  ac- 
celerate the  circulation  of  the  blood.  Fits  of  anger, 
hot  weather,  fevers,  and  the  period  of  menstruation  in 
particular,  are  observed  to  be  attended  with  an  in- 
creased turgescence  and  discolouration  of  the  part 
affected.  Indeed,  the  excrescence  sometimes  bursts, 
and  pours  out  a dangerous  quantity  of  blood,  and  in 
females  it  has  been  known  to  become  the  seat  of  a re- 
gular menstrual  discharge. — {Boyer,  Traite  des  Mala- 
dies Chir.  t.  2,  p.  'ill ; and  John  Bell’s  Principles,  Dis- 
course 9.)  Some  nsevi,  especially  those  usually  called 
moles,  frequently  have  long,  irregular  hairs  growing 
upon  them  ; while  the  surface  of  others  is  streaked, 
and  even  granulated.  Such  as  appear  in  the  form  of 
a mete  red,  purplish  stain,  have  been  absurdly  sup- 
posed tc  arise  from  a desire  for  claret,  or  some  other  wine 
of  that  colour,  entertained  by  the  mother  of  the  patient 
during  her  pregnancy.  The  granulated  naevi  liave 
been  compared  with  raspberries,  strawberries,  mulber- 
ries, &c.  for  which  the  mother’s  longing  is  ascribed  by 
the  vulgar  as  a cause.  The  truth  is,  however,  that 
this  doctrine,  imputing  the  origin  of  naevi  to  fancies  of 
the  mother,  is  neither  consistent  with  experience  nor 
sound  physiology.  The  causes  (as  Callisen  observes) 
“ potius  autem  in  evolutione  primorum  fiaminum,  a 
naturae  solita  via  aberrante,  uti  in  aliis  rebus  mon- 
Btrosis  quaerendas  erunt.” — {Syst.  Chir.  Hodierna,  vol. 

2,p.  201.) 

From  what  has  been  said,  then,  it  appears  that  cer- 
tain naevi  are  merely  cutaneous  spots  of  a red  violet 
or  purplish  colour  of  greater  or  less  extent,  and  with 
scarcely  any  perceptible  elevation.  They  are  an  or- 
ganic malformation  of  the  skin,  the  natural  texture  of 
which  does  not  exist,  but  a plexus  of  vessels  is  substi- 
tuted for  it,  not  endued  with  the  natural  sensibility  of 
the  cutis  itself.  These  naevi  generally  continue  sta- 
tionary during  life,  and  may  be  regarded  rather  as  a 
deformity  than  a disease.— {Lassus,  Pathologic  Chir. 
tom.  1,  p.  477.)  Other  naevi  are  either  of  the  same  na- 
ture as  the  disease,  well  known  by  the  name  of  tlie 
aneurism  by  anastomosis,  or  bear  a considerable  re- 
semblance to  it.  They  are  sometimes  of  great  size  ; 
and  their  shape  is  subject  to  much  variety.  They  are 
soft  and  indolent,  and  of  a violet  or  dark  red  colour. 
The  skin  which  covers  them  is  very  thin,  and  when 
ihej’  are  opened  their  structure  is  like  that  of  a spleen 


whose  blood-vessels  are  varicose.  Some  are  covered 
with  a delicate  white  skin,  and  do  not  increase  with 
age.  Others  are  more  disposed  to  grow  large.  These 
tumours  frequently  occur  in  the  skin  of  the  face,  and 
in  other  parts  of  the  integuments  on  the  inside  of  the 
labia  pudendi  and  cheeks,  and  in  the  substance  of  the 
upper  and  lower  lip,  where  they  sometimes  form  a kind* 
of  elongation  attended  with  great  disfigurement.  Naevi 
of  this  kind,  so  situated  in  new-born  infants,  may  pro- 
duce a serious  obstacle  to  the  action  of  sucking.  M. 
A.  Severinus  has  particularly  described  them  under 
the  appellation  of  “ tuberculum  atro-cruentum  labii 
inferioris.” — {De  Abscessuum  JVatura,  cap.^,  p.  803.) 

The  naevi  which  form  in  the  subcutaneous  cellular 
substance,  and  were  named  by  Petit  “ loupes  vari- 
queuses”  {(Euvres  Posthumes,  tom.  1,  p.276),  are  also 
of  the  same  nature  as  the  aneurism  by  anastomosis. 
In  time  they  attain  a very  large  size.  Mr.  Latta  says, 
he  once  saw  in  a child  two  years  old  a tumour  of  this 
kind,  weighing  fourteen  ounces,  which  at  the  time  of 
birth  was  only  equal  in  size  to  a large  bean.  During 
the  first  year  it  did  not  enlarge  much;  but  it  after- 
ward grew  rapidly  to  the  size  already  specified.— (.Sys- 
tem of  Surgery,  vol.  2,  chap.  22.)  Lassus  has  even 
seen  a tumour  of  this  description  as  large  as  a man’s 
head. — {Pathologic  Chir.  tom.  1,  p.  479.)  Having 
treated  particularly  of  the  “ aneurism  by  anastomosis,” 
in  another  place  (see  Aneurism),  I shall  merely  repeat 
the  necessity  there  is  for  cutting  every  particle  of  the 
disease  away,  every  portion  of  the  congeries  of  vessels 
and  cells  of  which  it  consists,  whenever  it  is  meddled 
with  at  all.  Puncturing  the  swelling,  or  the  partial  re- 
moval of  it,  has  cost  many  persons  their  lives  by  he- 
morrhage, as  the  records  of  surgery  fully  prove. — {Petit, 
Traite  des  Maladies  Chir.  t.  1;  Lassus,  Pathologic 
Chir.  t.  1.  p.  484,  <S-c.) 

Although  the  original  causes  of  naevi  are  buried  in 
obscurity,  experience  proves  that  whatever  produces 
irritation  in  the  part  affected,  or  an  increased  deter- 
mination of  blood  to  it,  has  generally  the  effect  of  ac- 
celerating the  growth  and  enlargement  of  the  swelling. 
Thus,  a trifling  bruise,  or  a tight  hat,  will  sometimes 
excite  a mere  stain-like  speck,  or  a minute  livid  tu- 
bercle, into  that  diseased  action  which  occasions  its 
growth. — {Bateman's  Pract.  Synopsis,  6rc.  p,  327, 
ed.  3.) 

When  these  marks  or  swellings  are  superficial,  with- 
out any  disposition  to  enlarge  or  spread,  and  their 
trivial  elevation  does  not  expose  them  to  accidental 
rupture,  there  appears  to  be  no  good  reason  for  inter- 
fering with  them.  Indeed,  they  could  only  be  de- 
stroyed with  caustic,  the  knife,  or  a ligature,  and  these 
severe  means  would  leave  scars,  accompanied  with 
nearly  the  same  degree  of  disfigurement. 

But,  as  a valuable  writer  observes,  when  nsvi 
evince  a tetidency  to  enlarge,  or  are  very  prominent 
excrescences,  and  either  troublesome  from  their  situa- 
tion, or  liable  to  be  ruptured,  either  their  growth  must 
be  repressed  by  sedative  applications,  or  the  whole 
congeries  of  vessels  extirpated  with  the  knife.  Mr. 
Abernethy  has  proposed  the  application  of  cold  washes, 
and  the  pressure  of  a bandage.  This  practice  w'a» 
found  by  him  in  several  instances  to  have  the  desired 
effect  of  checking  the  growth  of  the  tumours,  which 
afterward  shrunk,  and  became  no  longer  objects  of 
any  consequence. — {Surgical  Works,  vol.  2,  p.  224.) 
Boyer  also  knew  of  a case  in  which  a iijevus  of  the 
upper  lip  was  cured  by  the  mother  pressing  the  part 
with  hei  finger  unremittingly  forseveral  hours  at  a time, 
and  the  use  of  alum  wash — {Traite  des  Maladies 

I Chir.  t.%p.  269.)  Boyer,  however,  is  not  generally  an 
advocate  for  this  mode  of  treatment ; and  Dr.  Bateman 
expressly  states,  that,  in  the  majority  of  cases,  pressur* 


NiEV 


NEC 


191 


is  the  source  of  great  irritation  to  these  maculse,  and 
cannot  be  employed. — (P.  329.) 

Modern  experience  tends  to  prove,  that  superficial 
nJBvi  may  sometimes  be  successfully  treated  by  plans 
calculated  to  produce  an  eflusion  of  lymph  in  their 
structure,  and  perhaps  an  obliteration  of  their  vessels. 
It  must  be,  I presume,  on  this  principle  that  some  ntevi 
have  yielded  to  the  effects  produced  by  the  insertion 
of  vaccine  matter  into  several  points  of  the  tumour ; 
and  it  is  not  impossible  that  the  same  result  might  fol- 
low the  injection  of  a stimulating  lotion  into  the  tex- 
ture of  the  part  affected. 

For  all  those  examples,  which  partake  of  the  nature 
of  aneurism  by  anastomosis,  and  are  disposed  to  grow, 
the  best  general  mode  of  cure  is  extirpation.  The  ex- 
ceptions to  this  plan  are  certain  examples,  in  which  the 
tumour  seems  to  derive  its  main  supply  of  blood  from 
some  large  artery,  the  trunk  of  which  will  admit  of 
being  tied.  The  prudence  of  extirpating  the  disease, 
ere  it  extend  too  far,  and  the  necessity  of  taking  away 
every  particle  of  the  disease,  has  been  already  ex- 
plained; this  is  what  was  advised  by  F.  Hildanus 
{Cent.  5,  Obs.  46);  what  was  strongly  urged  by  the 
celebrated  Petit  {(Euvres  Posthumes,t.l)  \ what  was 
recommended  in  still  more  animated  terms  by  Mr.  John 
BtW  {Principles  of  Surgery,  Discoursed) and  it  is 
what  is  particularly  insisted  upon  in  another  part  of 
this  Dictionary.— (See  Aneurism.) 

The  hemorrhage  from  'the  excision  of  some  naevi, 
however,  is  so  profuse,  and  the  difficulty  of  cutting  all 
the  disease  so  great,  that  my  frietids  Mr.  White,  of  the 
Westminster  Hospital,  and  Mr.  Lawrence,  of  St.  Bar- 
tholoipew’s,  have  sometimes  preferred  the  plan  of  ex- 
tirpating ntevi  by  the  introduction  of  a double  ligature 
through  their  substance,  and  then  tying  each  half  of 
the  swelling  with  sufficient  tightness  to  make  it  slough. 
— (See  Med.  Chir.  Trans,  vol.  13.)  This  treatment 
certainly  seems  safer  than  excision,  when  the  tu- 
mour is  of  considerable  size. 

Mere  thickenings,  and  discolourations  of  the  rete 
mucosum,  have  sometimes  been  removed  by  a mix- 
ture of  spirit  and  the  liquor  potassse. — {Bateman,  p. 
330.) 

I was  lately  consulted  by  Mr.  Smith  of  Tottenham 
Court,  about  a superficial  najvus  on  the  neck  of  a fe- 
male infant ; I recommended  it  to  be  frequently  touched 
with  diluted  nitric  acid,  by  which  means  it  has  been 
gradually  reduced  to  one-half  of  its  original  size,  with- 
out ulceration ; and  I have  no  doubt  that  perseverance 
in  the  plan  will  complete  the  cure. 

Formerly,  caustic  was  much  in  vogue  for  the  re- 
moval of  ntevi ; but  unless  its  action  extend  deeply 
enough  to  destroy  every  part  of  the  disease,  it  may 
cause  a dangerous  and  useless  degree  of  irritation,  co- 
pious hemorrhages,  and  a sudden  and  fatal  enlarge- 
ment of  the  tumour.  It  c.annot  be  denied,  however, 
that  the  old  surgeons  had  success  with  their  caustics, 
where  the  naevi  were  altogether  superficial.  Thus,  in 
speaking  of  caustic  remedies,  Callisen  observes : “ inter 
quae  exirnio  cum  successn  adhibetur  sapo  cum  aequali 
parte  calcis  viva  subtilissime  commixtus,  n®vo  per 
emplastrum  perforatum  admoveiidus,et  alio  emplastro 
imposito  firmandus ; hoc  remedio  eschara  inuritur  qua 
soluta,  cicatrix  alba  remanere  sDlet.” — {Syst.  Oii- 
rurgicB  HodieriKB,  vol.  2,  p.  202.) 

Mr.  Wardrop,  having  seen  cases  in  which  naevi  were 
cured  Iry  accidental  attacks  of  ulceration  and  slough- 
ing, which  destroyed  a great  part  of  the  tumour,  and 
brought  on  such  inflammation  as  consolidated  the  rest, 
was  led  to  imitate  this  process  by  adopting  the  an- 
cient practice  of  applying  the  kalipurutn.  He  found 
the  method  answer  in  several  instances;  but  it  is 
evidently  only  calculated  for  naevi  below  a certain 
size. 

[Vaccination  has  been  proposed  as  a remedy  for  the 
removal  of  those  small  nmvi  materni,  when  found  on 
the  face  or  neck,  and,  so  far  as  the  experiments  have 
been  reported,  the  result  is  favourable  to  the  practice. 
Dr.  Pendleton  of  this  city  informs  me,  that  he  has 
lately  tried  it  in  a case,  in  a new-born  infant,  thenasvus 
being  situated  in  the  face.  He  introduced  the  vaccine 
virus  at  two  opposite  points  on  the  margin  of  the  tu- 
mour; the  infection  was  communicated,  and  had  the 
two  (lustules  met,  the  deformity  would  have  been  en- 
tirely removed.  The  only  portion  of  the  disease  left 
is  that  between  the  two  cicatrices  left  by  the  pustules, 
and  is  very  inconsiderable.  It  surely  merits  a trial  in 


every  such  case ; and  If  three  or  more  points  of  infec- 
tion could  be  obtained,  so  as  to  envelope  the  tumour,  it 
w'ill  doubtless  succeed,  and  is  preferable  to  excision  by 
the  knife  or  ligature. 

When  these  ntevi  areobviously  belonging  to  the  class 
of  aneuris’m  by  anastomosis,  situated  on  the  head,  if 
they  be  very  prominent  excrescences,  and  evince  a ten- 
dency to  grow,  as  they  often  do  with  great  rapidity, 
their  extirpation  becomes  indispensable.  And  in  such 
cases  the  method  practised  by  Dr.  Physick  is,  to  run 
round  the  tumour  with  a scalpel,  cutting  down  to  the 
pericranium,  and  then  tying  the  arteries  separately. 
Lint  is  then  interposed  to  prevent  union  by  the  first 
intention.  The  circulation  being  thus  cut  oft'  entirely, 
the  case  is  readily  disposed  of  by  the  other  methods 
named  by  Mr.  Cooper.  This  method  has  been  very 
successful  in  this  country  in  the  hands  of  Drs.  Mott 
and  Jamieson,  as  well  as  Dr.  Physick,  and  is  greatly  to 
be  preferred  to  the  cruel  and  equivocal  plan  of  Mr. 
White,  by  the  ligature.— ileese.] 

Consult  Petit's  CEuvres  Posthumes,  1. 1.  Lassus,  Pa- 
thologie  Chir.  1. 1,  p.476,  Src.  ed.  1809.  Callisen' s Sys- 
tema  Chirurgim  Hodierna;,  vol.  2,  p.  201,  Hafnice,  1800, 
Abernethy's  Surgical  Works,  vol.  2,  p.  224,  Src.  Latta's 
System  of  Surgery,  vol.  2,  chap.  22.  J.  Bell's  Princi- 
ples of  Surgery,  vol.  1,  Discourse  9.  Boyer,  TraiU 
des  Maladies  Chirurgicales,  t.  2,  p.  225,  Src.  Paris, 
1814.  A Practical  Synopsis  of  Cutaneous  Diseases, 
by  T.  Bateman,  ed.  3,  1814.  Delpech  Precis  EUmen- 
taire  des  Maladies  Chir.  t.  3,  p.  244,  Paris,  1816. 
Scarpa,  Opuscoli  de  Chirurgia,  vol.  2,  Obs.  374,  Pa- 
via, 1825.  .7.  Wardrop,  on  one  Species  of  JVavus, 
with  the  case  of  an  Infant,  where  the  Carotid  Artery 
was  tied,  in  Med.  Chir.  Trans,  vol.  9,  p.  199,  6rc.  W. 
Lawrence,  in  vol.  13  of  the  smnc  work. 

NECROSIS.  (From  vcKpoo),  to  destroy.)  This 
word,  the  strict  meaning  of  which  is  only  mortification, 
is,  by  the  general  consent  of  surgeons,  confined  to  this 
atfection  of  the  bones.  It  was  first  used  in  this  parti- 
cular sense  by  the  celebrated  M.  Louis,  who  restricted 
its  application,  however,  to  examples  in  which  the 
whole  thickness  of  a bone  was  destroyed. — (See  Mem. 
de  I'Arad.  Roy  ale  de  Chirurgie,  t.  5,  4to.)  Ily  the  an- 
cients, the  death  of  parts  of  bones  was  not  distin- 
guished fiom  caries.  However,  necrosis  and  caries  are 
essentially  different;  for,  in  the  first,  the  attected  part 
of  the  bone  is  deprived  of  the  vital  principle  ; but  this 
is  not  the  case  when  it  is  simply  carious.  Caries  is 
very  analogous  to  ulceration,  while  necrosis  closely  re- 
semBles  mortification  of  the  soft  parts. 

Between  caries  and  necrosis,  says  Weidmann,  there 
is  all  that  difference  which  exists  between  ulcers  and 
gangrene,  or  sphacelus  of  the  soft  parts.  In  caries, 
the  nutrition  of  the  bone  is  only  impaired,  and  an  irre- 
gular action  disunites  the  elements  of  the  bony  struc- 
ture, which  consequently  sustains  a loss  of  substance; 
but  every  remaining  part  of  it  is  yet  alive.  In  necrosis, 
on  the  contrary,  the  vitality  and  nutritive  functions 
cease  altogether  in  a certain  portion  of  the  bone,  the 
separation  of  which  then  becomes  indispensable. — 
{De  JVecrosi  Ossium,  p.  7.) 

I have  mentioned  that  M.  Louis  confined  the  term 
necrosis  to  cases  in  which  the  whole  thickne,ss  of  a 
bone  perished ; but  Weidmann  judiciously  criticises  this 
limitation  of  the  word,  and  maintains  that  the  nature 
of  the  disorder  is  the  same,  whether  it  affect  a single 
scale,  the  whole,  or  a mere  point  of  the  bone.  He 
also  objects  to  the  definition  of  necrosis  proposed  by 
Chopart  {Dissert,  de  JVecrosi  Ossium,  Paris,  1765), 
and  adopted  by  David. — {Obs.sur  une  Malndie  connue 
sous  le  nom  de  JVecrose,  Paris,  1782.)  These  two 
authors  have  defined  necrosis  to  be  a disorder  in  which 
a portion  of  bone  perishes,  and  turns  dry,  in  order  to 
be  soon  separated  from  the  living  parts,  and  replaced 
by  a new  bony  substance,  which  is  to  perform  its 
functions.  But,  as  Weidmann  observes,  it  may  hap- 
pen that  a piece  of  bone,  which  dies  and  separates, 
may  not  be  replaced  by  any  new  formation  of  bone, 
though  the  disease  is  of  the  same  character,  and 
merely  varies  in  some  modifications.  He  therefore 
argues,  and  every  rational  surgeon  will  agree  with 
him,  that  a true  necrosis  must  always  be  said  to  exist, 
whenever  a dead  portion  of  bone  has  either  separated, 
or  is  about  to  separate.  “ F'era  dcmum  necrosis  sem- 
per est,  si  aliquod  ossis  romentum,  in  quo  vis  vita,  ez- 
tincta  est,  ab.scessit,  vel  proxime  abscessurum,  est."— 

1 {B.  7.) 


192 


NECROSIS, 


The  tibia,  femur,  lower  jaw,  clavicle,  humerus, 
fibula,  radius,  and  ulna,  are  the  bones  most  frequently 
affected  with  necrosis.  Excepting  the  lower  jaw  and 
scapula,  the  process  of  regeneration  has  only  been  no- 
ticed in  the  cylindrical  bones.  From  12  to  18  years  of 
age  is  the  time  of  life  most  subject  to  necrosis.  Ne- 
crosis of  the  lower  jaw,  however,  seldom  occurs  before 
the  age  of  30. 

No  climate,  age,  sex,  mode  of  life,  nor  condition 
(says  Weidmann),  is  exempt  from  this  disorder  Child- 
hood and  puberty,  however,  are  the  periods  most 
liable  to  it.  The  same  thing  may  be  said  of  persons 
who  labour  hard,  and  are  much  exposed  to  external  in- 
juries. Every  bone  of  the  human  body  is  subject  to 
necrosis ; but  those  which  are  superficial,  and  enter 
into  the  formation  of  the  extremities,  are  more  fre- 
quently affected  than  others  whose  situation  is  deeper. 
Necrosis  less  commonly  attacks  the  spongy  substance 
of  the  bones,  because  this  being  endued  with  a higher 
degree  of  vascularity  and  life,  suppuration  is  most  apt 
? to  occur.  Necrosis,  on  the  contrary,  is  oftener  seen  in 
the  compact  substance,  where  the  vital  principle  is 
less  energetic,  and  more  readily  extinguished.  As  a 
modern  writer  has  remarked,  a very  slight  injury  will 
freijuently  occasion  an  extensive  exfoliation  from  the 
surface  of  the  cylinder  of  a long  bone;  but  a musket- 
ball  may  pass  through  the  cellular  structure  of  an  epi- 
physis, or  lodge  in  its  substance,  without  giving  rise  to 
necrosis,  suppurative  inflammation  being  much  more 
likely  to  occur  than  the  latter  affection.— -(5eW  on 
Diseases  of  the  Bones,  ^c.  p.  49.)  Lastly,  necrosis 
may  affect  the  long  bones  or  the  broad,  the  large  or 
small,  and  even  those  of  the  very  least  size;  since  it  is 
well  known  that  the  ossicula  of  the  ear  may  be  de- 
stroyed by  necrosis,  and  separate.  I have  seen  this 
happeti  in  two  instances,  and  the  fact  is  recorded  by 
several  writers. — (See  Astruc  de  Morhis  Venereis,  lib. 
4,  cap.  1.  Henri,  Journal  de  Medecine,  t.  15,  p.  363.) 

Though  necrosis  mostly  attacks  the  cylindrical 
bones,  the  flat  ones  are  not  exempt  from  the  disease. 
Pott  makes  mention  of  a parietal  bone,  the  whole  of 
which  was  detached,  and  of  an  os  frontis,  the  greatest 
part  of  which  came  away.  In  a thesis  on  necrosis, 
written  in  1776,  may  be  found  the  case  of  a young 
man,  a very  large  part  of  whose  scapula  perished  and 
separated.  Chopart,  who  relates  the  case,  mentions, 
that  he  saw  the  patient  quite  recovered,  and  felt  a new 
triangular  moveable  bone,  firmly  supporting  the  clavi- 
cle, bulsmaller  and  flatter  than  natural,  and  without 
any  spinous  process.  The  same  has  happened  fo  the 
lower  jaw,  as  may  be  seen  by  referring  to  the  Epheme- 
rides  Hat.  Cur.  and  Mem.  de  VAcad.  de  Chirurgie. 
In  the  fifth  volume  of  the  latter  work,  is  an  account  of 
a woman  who  applied  to  be  relieved  of  some  venereal 
complaints.  From  the  beginning  of  the  treatment,  the 
bone  was  discovered  to  be  loose  just  under  the  gums, 
and  seemed  shortly  afterward  to  move  backwards  and 
forwards  with  a tooth.  Mr.  Guernery  took  hold  of 
the  tooth  with  a key-instrument,  and  found  it  firmly  in- 
serted in  tlte  moveable  jaw ; he  made  with  caution  the 
necessary  manceuvres  forextracting  the  portion  of  bone ; 
but  was  greatly  surprised  on  finding  what  an  extensive 
part  yielded  to  his  very  moderate  efforts.  It  was  the 
whole  of  the  lower  jaw,  above  its  right  angle,  from  its 
division  into  the  coronoid  and  condyloid  processes  to 
the  space  between  the  first  and  second  of  the  front 
grinders  of  the  left  side.  On  the  right,  there  only  re- 
mained the  condyle  in  the  articular  cavity  of  the  tem- 
poral bone.  This  destruction  left  a considerable 
empty  space,  from  which  great  deformity  was  appre- 
hended, in  consequence  of  the  unsupported  soft  parts 
falling  down.  Tiie  woman,  however,  got  well  in  two 
months,  and  had  the  most  perfect  use  of  a new  jaw. 
A similar  fact  is  recorded  in  the  Journal  de  Medecine, 
1791. 

When  the  body  of  a cylindrical  bone,  or  the  middle 
portion  of  a flat  bone,  is  destroyed  by  necrosis,  their 
extremities,  which  are  of  a cellular  texture,  generally 
continue  unaffected,  so  that,  for  example,  in  the  cylin- 
drical bones,  the  articular  ends  are  always  formed  of 
portions  of  the  original  bone,  which  are  engrafted  as 
it  were  on  the  new  production.  There  are,  however, 
a few  bad  cases,  in  which  the  necrosis  does  not  alto- 
gether spare  the  heads  of  the  bones,  and  the  disease 
communicates  with  the  joint.  These  examples  are 
very  uncommon,  and  are  attended  with  considerable 
danger  to  the  limb : indeed,  they  generally  require  am- 


putation.—(See  .Boyer,  Train  des  Mat.  Cftir.  i.  2,p. 
442.)  Mr.  Brodie  has  known  an  instance,  in  which, 
without  any  obvious  cause,  a large  portion  of  the  head 
of  the  tibia  died  and  exfoliated,  and  the  destruction  of 
the  knee-joint  was  the  consequence.— (PatAoi.  and 
Surg.  Obs.  on  the  Joints,  p.  269.) 

It  is  not,  therefore,  correct  to  assert  absolutely,  as 
Mr.  C.  Bell  has  done,  “ that  the  extremities  of  bone  arc 
not  subject  to  necrosis.” — {Surg.  Obs.  p.321.)  It  would 
be  more  accurate  to  say,  that  these  parts  are  not  fre- 
quently attacked. 

Besides  the  differences  arising  from  the  particular 
bones  affected,  necrosis  also  varies  according  as  the 
portion  of  bone  attacked  happens  to  be  thin  and  of 
little  extent,  or  large  and  of  considerable  thickness. 
The  disease  is  simple  when  it  is  confined  to  one  bone, 
and  the  patient  is  in  other  respects  healthy;  compound, 
when  several  different  parts  of  the  same  bone,  or  seve- 
ral distinct  bones,  are  affected  at  the  same  time ; when 
the  health  is  bad ; and  other  parts  of  the  body  are  also 
diseased.  It  should  also  be  known,  because  the  in- 
formation is  of  practical  importance  in  the  treatment, 
that  necrosis  has  three  different  stages  or  periods.  In 
the  first,  the  bone  affected  perishes ; in  the  second,  the 
process  of  exfoliation  or  separation  of  the  dead  bone 
from  the  living,  is  going  on  ; and  in  the  third,  the  sepa- 
ration is  completed. — (See  IVeidmann,  p.  8.) 

Necrosis  is  divided  by  some  writers  into  the  trau- 
matic and  idiopathic.  In  the  latter,  the  exfoliations 
are  generally  more  extensive  and  deep  than  in  the 
former,  and  frequently  comprehend  the  whole  thick- 
ness of  a bone.  The  idiopathic  is  also  that  which  is 
mostly  met  with  in  the  flat  bones. — (See  Bell  on  Dis- 
eases of  the  Bones,  p.  50.) 

The  causes  of  necrosis  are  not  essentially  different 
from  those  which  produce  ulcers  and  gangrene  of  the 
soft  parts.  As,  however,  the  vitality  of  the  bones  is 
weaker,  we  may  infer,  that  necrosis  may  be  occasioned 
in  them  by  causes  which  are  less  numerous  and  in- 
tense, and  such  as  would  only  give  rise  to  suppuration 
in  the  soft  parts.  Every  thing,  whether  in  the  perios- 
teum or  the  substance  of  the  bone  itself,  that  tends  to 
interrupt  the  nutrition  of  the  bone,  must  be  regarded  as 
conducive  to  the  origin  of  necrosis.  It  is  observed, 
however,  that  when  the  mischief  in  the  periosteum, 
medulla,  or  substance  of  the  bone  is  of  trivial  extent, 
the  consequence  is  merely  an  abscess.  Some  of  the 
causes  of  necrosis  are  external,  while  others  are  inter- 
nal or  constitutional.  Sometimes  the  life  of  the  bone 
is  instantaneously  destroyed  by  them;  but  in  other 
instances,  the  bone  is  first  stimulated  and  enlarged,  so 
that  its  death  is  preceded  by  true  inflammation. 

The  external  causes  which  injure  the  periosteum 
and  medullary  structure,  and  thus  produce  necrosis,  are 
wounds,  contusions,  pressure,  fractures,  comminutions, 
acrid  substances,  caustics,  arid  extreme  degrees  of  heat 
or  cold. 

When  the  periosteum  in  consequence  of  an  external 
cause  inflames  and  sloughs,  or  is  at  once  deprived  of 
its  vitality,  as  it  may  be  by  the  action  of  caustic,  fire, 
or  intense  cold,  the  vessels  which  conveyed  nourish- 
ment to  the  bone  are  destroyed,  and  the  death  and  ex- 
foliation of  the  denuded  portion  of  the  bone  are  in- 
evitable. But  if  the  detachment  of  the  periosteum  is  of 
little  extent,  the  patient  young  and  healthy,  and  the 
treatment  calculated  to  prevent  inflammation  and  pre- 
serve uninjured  the  vessels  distributed  to  the  bone, 
hopes  may  be  entertained  that  no  part  of  the  bone 
will  die,  but  that  granulations  will  very  soon  arise 
from  its  surface,  being  adherent  to  it  as  the  periosteum 
was,  and  that  they  will  grow  to  and  cicatrize  with  the 
surrounding  parts.  Weidmann  has  explained,  that 
this  fact  of  bones  not  always  exfoliating  when  de- 
prived of  the  periosteum,  which  is  of  great  practical 
importance  in  the  treatment  of  wounds,  was  incul- 
cated by  Felix  Wurtz,  Ctesar  Magatus,  and  Belloste,  at 
a time  when  the  contrary  opinion  prevailed.  Weid- 
mann also  adverts  to  his  own  experience  and  to  the 
experiments  of  Tenon,  in  farther  proof  of  the  preced- 
ing  fact. — {Mini,  de  I’ Acad,  des  Sciences,  17.58,  p.  372.) 

On  the  other  hand,  when  the  detached  piece  of  the 
periosteum  is  extensive ; when  the  bone  itself  is  con- 
tused ; or  when  it  has  been  long  exposed  to  the  air,  the 
effect  of  which  is  to  dry  up  the  few  vessels  which  be- 
long to  it : when  the  inflammation  is  violent  and  exten- 
sive ; when  the  patient  is  old,  decrepit,  or  of  bad  con- 
stitution ; and  more  especially,  when  improper  appli- 


NECROSIS. 


193 


cations  are  used,  as  was  almost  always  the  case  in 
foimer  times,  necrosis  cannot  be  avoided. 

An  internal  necrosis,  artectmg  the  simngy  texture  of 
bones,  generally  arises  from  constitutional  causes, 
though  sometimes  an  e.xternal  cause,  which  seems  to 
alfect  only  the  surface  of  a bone,  extends  its  action 
to  the  interior,  so  as  to  destroy  the  medullary  meiu- 
brane,  and  produce  an  internal  necrosis. 

(n  external  injuries  of  the  head,  where  the  pericra- 
nium is  lacerated,  contused,  or  otherwise  hurt,  or 
where  the  outer  table,  or  the  diploe  of  the  skull,  is  in- 
jured, the  inflammation  frequently  extends  to  the 
inner  table,  and  the  dura  mater  becomes  detached. 
Hence,  a collection  of  matter  forms,  which  may  occa- 
sion many  bad  symptoms,  and  even  death  iiseli  • or,  if 
the  patient  survive,  exfoliation  of  part  of  both  tables 
of  the  skull  is  the  consequence.— (See  Pott’s  C/ur. 
Works,  Lund.  1779,  vol.  1,  p.  32.) 

The  same  thing  may  occur  in  ether  bones,  as  well  as 
those  of  the  cranium.  Bromfiehl  had  an  opportunity 
of  seeing  a necrosis  of  the  spongy  substance  of  the 
upper  and  internal  part  of  the  tibia,  brought  on  by  the 
improper  mode  in  which  an  issue  was  dressed.  In 
order  to  keep  the  peas  from  slipping  out  of  their  places, 
a compress  with  a shilling  in  it,  and  a tight  bandage, 
were  applied  ; but  the  part  was  attacked  with  excruci- 
ating pain,  and  the  spongy  texture  of  the  tibia  in  the 
vicinity  became  affected  with  necrosis. — {Chir.  Obser- 
vations and  Cases,  vol.  2,  p.  9.) 

Tins  circumstance,  as  Weidmann  observes,  ought 
not  to  surprise  us;  as  numerous  vessels  quit  the  peri- 
osteum to  descend  flito  the  substance  of  the  bone,  to 
ramify  on  the  medullary  cells  themselves,  and  freely 
anastomose  there,  it  cannot  be  difficult  to  conceive  how 
inflammation,  which  is  ai  first  confined  to  the  outside 
of  the  bone,  may  (through  the  medium  of  the  vessels 
which  serve  as  conductors  to  it)  penetrate  more  deeply, 
and  extend  its  ravages  in  every  direction. 

But  necrosis  may  proceed  from  another  description 
of  causes  which  are  of  a constitutional  nature.  In 
fevers  of  bad  type,  in  the  small-pox,  and  in  the  mea- 
sles, experience  has  fully  proved  that  the  bones  are 
sometimes  attacked  with  necrosis.  Scrofula,  lues 
venerea,  and  the  scurvy  are  also  diseases,  which,  ac- 
cording to  the  testimony  of  all  surgical  wi iters,  lie 
quently  produce  such  mischief  in  the  bones  as  teiuii- 
naies  in  necrosis.  It  is  likewise  well  ascertained,  that 
mercury  may  itself  give  rise  to  the  disorder,  especially 
in  the  lower  jaw-bone — (See  Mdni  de  I'Acad.  de  Chir. 
t.  5,  p.  356,  4t</.) 

This  happens  either  in  consequence  of  mercury 
having  been  introduced  too  quickly  into  the  system,  or 
because  the  patient  ex()oses  himself  to  cold,  or  deviates 
in  some  other  respect  from  a proper  regimen.  Certain 
necroses  of  the  lower  jaw,  however,  appear  also  to 
have  been  caused  by  blows,  and  the  application  of 
acrid  substances  to  carious  teeth.  But,  says  Weid- 
mann, “ I feel  it  incumbent  upon  me  particularly  to 
declare,  that  the  irrational  treatment  pursued  by  the 
ancient  practitioners,  who  neither  understood  the  na- 
ture of  the  bones,  nor  the  differences  of  their  diseases, 
and  which  treatment  is  too  confidently  ado[)ted  in  our 
own  days,  had  frequently  the  effect  of  killing  these 
parts,  by  attacking  with  spirituous,  acrid,  or  caustic 
remedies,  or  even  with  the  knife,  diseases  which  re 
quired  the  mildest  applications,  and  to  be  left  in  a great 
measure  to  nature.  The  old  surgeons  were  afraid  of 
laying  on  the  exposed  injured  surface  of  a bone  unctu- 
ous emollient  dressings,  and  yet,  for  what  reason  I 
know  not,  they  snbjectfd  the  part  to  the  action  of  spi- 
rituous, acrid,  drying  applications.  As  for  myself,  I 
deem  it  proved  by  infallible  and  frequently  repeated 
trials,  not  only  that  an  exposed  injured  bone  may  be 
dressed  with  a mild  ointment  without  any  ill  ennse 
rjuences,  but  even  with  the  greatest  advantage.  Why 
should  tliat  which  is  beneficial  to  the  soft  parts  be  so 
prejudicial  to  the  bones?  In  ulcers  of  the  soft  pans, 
indeed,  the  employment  of  the  remedy  wliich  I recoin 
mend  is  less  important,  because  these  parts  are  natu- 
rally humid,  and  there  is  no  risk  of  their  becoming  dry. 
But  with  regard  to  the  bones,  whose  dry  texture  is  only 
penetiair  d by  few  vessels,  which  may  easily  be  de- 
stroyed if  they  be  suffered  to  become  quite  dry,  it  is 
absolutely  necessary  to  use  an  emollient  runlment,  as 
a dre-sing  well  calculat'  d to  defend  these  vessels,  which 
an-  the  support  of  life,  arid  preserve  them  from  the  bad 
effects  of  ex|)osure  to  the  air.  Therefore,  observes 
Vol.  II.-x\  ’ 


Weidmann,  if  a surgeon  would  avoid  producing  a ne- 
crosis himself,  and  not  neglect  any  means  that  tend  to 
prevent  such  disorder,  he  should  make  it  a rule  never  to 
apply  any  thing  acrid  to  exposed  bones,  but  on  the  con- 
trary to  defend  them  loith  a dressing  of  some  unirri- 
tating ointment." — {De  Kecrosi  Ossiuin,  p.  11.) 

It  was  formerly  supposed,  that  purulent  matter,  col- 
lected near  a bone,  might  in  time  become  acrimonious 
corrode  it,  and  produce  necrosis.  Hence,  it  was  a rule 
to  open  such  an  abscess  as  soon  as  its  existence  was 
known.  But  Weidmann  questions  whether  there 
was  any  real  necessity  for  this  practice.  No  doubt, 
says  he,  the  preceding  erroneous  opinion  arose  from  the 
circumstance  of  the  bones  being  often  found  hare,  ca- 
rious, or  even  alFected  with  necrosis,  when  abscesses 
were  near  them  ; but  things  happened  thus,  because 
the  inflammation  which  caused  the  suppuration  had 
also  extended  its  effects  to  the  periosteum  and  bone. 
He  affirms,  that  he  has  witnessed  ulcers,  in  which  the 
surface  of  bones,  bare  and  uncovered  by  the  perios- 
teum, lay  bathed  in  pus  for  a very  considerable  time; 
yet,  being  dressed  with  a mild  ointment,  they  coniinued 
entire,  giannlaiions  grew  from  them,  and  cicatrization 
followed.  He  had  also  in  his  possession  portions  of 
bones  affected  with  necrosis,  which  liad  lain  for  years 
ill  pus;  still  their  surface  was  smooth,  and  presented 
no  marks  of  erosion.  If,  then,  these  pieces  of  bone 
underwent  no  alteration,  how  much  less  likely  to  do 
so  are  bones  which  are  endued  with  life! 

But,  though  Weidmann  wisely  rejects  the  doctrine 
of  pus  being  capable  of  destroying  the  periosteum  and 
bones  by  any  corrosive  qualities,  he  acknowledges  his 
belief,  that  the  matter  of  an  abscess  may  by  its  quantity 
compress  and  inflame  the  adjacent  parts,  and  occasion 
their  removal  by  the  absorbents.  While  the  perios- 
teum intervenes  between  an  abscess  and  the  bone,  he 
does  not  see  how  the  latter  can  be  hurt  by  the  pus ; but 
when  the  abscess  is  copious  and  lodged  between  that 
membrane  and  the  bone,  the  vessels  passing  from  the 
former  will  be  destroyed,  and  either  caries  or  necrosis 
ensue. 

The  inflammation,  arising  from  the  causes  which 
e.xcite  necrosis,  may  be  either  acute  or  chronic.  It  is 
chronic  when  it  begins  and  passes  through  its  different 
stages  slowly,  qnd  when  the  mildness  of  the  symptoms 
may  lead  us  to  mistake  the  nature  of  the  case.  This 
sort  of  inffammation  chiefly  happens  in  debilitated  con- 
stitutions, in  which  the  necrosis  only  affects  the  exter- 
nal part  of  a bone,  and  originates  from  some  chronic 
cause,  such  as  scrofula,  lues  venerea,  and  the  scurvy. 
But  when  necrosis  attacks  the  interior,  and  the  disease 
occurs  in  a strong,  irritable,  plethoric  subject,  inflam- 
mation is  immediately  kindled,  attended  with  the  most 
acute  symptoms,  severe  pain,  considerable  fever,  rest- 
lessness, delirium,  &c.  Chronic  inflammation  is  more 
supportable ; but  its  duration  is  longer : acute  inflam- 
ination  is  more  afflicting,  but  sooner  comes  to  a crisis. 

The  part  in  which  a necrosis  is  situated,  is  affected 
with  swelling.  What  has  been  observed  respecting  the 
inflammation  is  also  applicable  to  this  tumour,  which 
most  frequently  forms  gradually,  but  sometimes  with 
great  rapidity.  In  the  first  case,  the  accompanying 
pain  is  dull  and  inconsiderable ; in  the  second,  it  is 
violent.  The  swelling  has  not,  like  that  of  abscesses, 
an  elevated  apex.  On  the  contrary,  it  is  so  widely 
diffused,  that  the  limits  which  circumscribe  it  can 
hardly  be  distinguished. 

This  diffusion  of  the  swelling  is  the  greater  in  pro- 
portion as  the  diseased  bone  is  more  deeply  buried  in 
soft  parts:  it  may  extend  over  the  whole  morbid  bone, 
or  even  over  the  whole  limb. 

The  swelling  comes  on  at  the  very  beginning  of  the 
disorder,  and  continues  to  increase  until  the  matter 
which  it  contains  finds  its  way  out,  when  the  evacu- 
ation is  followed  by  a partial  subsidence  of  the  tumour. 
The  swelling  is  sometimes  also  combined  with  oedema, 
especially  in  persons  whose  conslitutions  have  been 
impaired  by  the  severity  of  the  disease,  the  violence 
of  the  sufferings,  and  the  long  and  profuse  discharge. 

When  the  inflammation  is  acute,  purulent  matter  of 
good  quality  soon  collects  in  the  vicinity  of  the  necro- 
sis. In  the  contrary  case,  the  pus  forms  slowly,  and  is 
thinner  and  less  healthy. 

The  abscess  which  accompanies  a necrosis  natu- 
rally soon  bursts,  when  it  arises  from  intense  inflam- 
mation, and  is  situated  near  the  skin,  which  is  itself 
inflamed.  But  when  the  bone  is  surrounded  by  a 


194 


NECROSIS. 


great  thickness  of  soft  parts,  and  tlie  inflammation  is 
chronic,  the  quantity  of  matter  daily  increases,  the 
cavity  which  it  occupies  becomes  larger  and  larger, 
and  considerable  pressure  is  made  by  the  abscess  on 
every  side.  The  bones  and  tendons  resist  for  a long 
while  the  progress  of  the  matter;  but  the  cellular  sub- 
stance yields,  and  different  sinuses  form,  which  some- 
times run  to  a vast  distance  from  the  main  collec- 
tion of  matter,  especially  when  the  abscess  lies  under 
an  aponeurosis. 

It  was  supposed,  a few  years  ago,  that  in  cases  of 
necrosis  the  matter  was  invariably  sanious,  acrid,  and 
fetid.  But  the  celebrated  Weidmann  exposed  the  error 
of  this  opinion.  He  had  often  seen  abscesses  and 
ulcers  arising  from  necrosis  discharge  a whitish,  in- 
odorous, thick  pus,  absolutely  devoid  of  any  bad  qua- 
lity whatsoever.  He  had  particularly  seen  this  happen 
in  patients  whose  necroses  proceeded  from  an  external 
cause,  or  an  internal  one  of  a slight  nature,  and  whose 
health  was  generally  good. — {De  JVecrosi  Ossium,  p. 
16.)  If,  says  the  same  excellent  writer,  we  sometimes 
find  in  practice  the  suppuration  dark  and  fetid,  we 
must  not  ascribe  it  to  the  affection  of  the  bone;  but  to 
the  weakness  and  bad  state  of  the  patient’s  health. 
Under  the  same  circumstances  common  sores  of  the 
soft  parts  would  also  emit  a discharge  of  bad  quality. 

After  the  ulcerated  openings  have  emitted  for  some 
time  a profuse  discharge,  the  sinuses,  if  considerable, 
receive  the  appellation  of  fistula;,  on  account  of  their 
edges  putting  on  a callous  appearance,  throwing  out 
fungous  granulations,  and  there  being  impediments  to 
cicatrization.  These  impediments  are  caused  by  the 
dead  portions  of  bone,  which,  whether  loose  or'  ad- 
herent, act  as  extraneous  bodies  in  hindering  the  sores 
from  healing.  In  some  instances,  also,  the  ulcers  will 
not  heal,  though  the  dead  bone  has  come  away,  be- 
cause they  run  to  a great  depth,  and  such  a quantity  of 
pus  is  secreted  from  every  point  of  their  surface  as 
prevents  all  contact,  and  the  adhesions  which  would 
result  from  it. 

The  fistulae  vary  in  number;  but  they  are  fewer  in 
proportion  as  the  disease  is  slighter.  In  an  extensive 
necrosis  several  of  these  openings  are  seen,  either  near 
together  or  separated  by  considerable  spaces ; and  when 
file  necrosis  affects  every  side  of  the  bone,  the  fistulte 
in  the  integuments  occur  on  every  side  of  the  limb. 

Besides  the  inflammatory  fever  which  attends  the 
beginning  of  every  severe  case  of  necrosis,  which  is 
sometimes  accompanied  with  exceedingly  violent  symp- 
toms, and  which  usually  abates  when  matter  is  formed, 
the  patient  is  subject  to  another  fever  of  a slow,  hectic 
type.  This  takes  place  in  the  decline  of  the  disease, 
is  the  effect  of  the  long-continued  profuse  suppuration, 
gradually  reduces  the  patient,  and  at  length  brings  him 
to  the  grave,  unless  the  timely  removal  of  the  seques- 
trum be  effected  either  by  nature  or  art. 

Let  us  next  endeavour  to  trace  the  signs  by  which 
we  may  not  only  ascertain  the  presence  of  the  disease, 
but  its  modifications. 

In  the  first  place,  we  should  make  ourselves  ac- 
quainted with  every  thing  which  may  have  predisposed 
to  the  disorder;  as,  for  instance,  what  accidental  cir- 
cumstances have  occurred,  and  what  symptoms  fol- 
lowed them.  We  should  also  inquire  into  any  pre- 
vious treatment  which  may  have  been  adopted ; for, 
as  Weidmann  truly  remarks,  injudicious  retnedies  have 
caused  many  a necrosis  that  would  not  have  occurred 
at  all  if  the  case  had  been  properly  treated  or  confided 
to  nature. 

The  kind  of  inflammation  with  which  the  disease 
commences  may  afford  grounds  for  suspecting  that  ne- 
crosis will  happen : it  is  generally  slow  and  deeply 
seated,  passing  through  its  stages  tardily,  and  the  at- 
tendant symptoms  are  severe.  The  skin  retains  its 
natural  colour  a long  while;  but  at  length  exhibits  a 
reddish  or  livid  discoloration.  The  matter  does  not 
reach  the  skin  till  a considerable  lime  has  elapsed,  and 
when  the  abscess  bursts,  the  inflammatory  symptoms 
are  still  slow  in  subsidirur.  When  the  inflammation  is 
acute,  the  patient  suffers  intolerabf'  pain  a loiur  time. 

There  are  also  other  symptoms  of  anecrosi.s;  viz. 
the  swelling  which  accompanies  the  inflammation  is 
situated  upon  a bone,  or  rather  the  bone  is  included  in 
the  tumour;  the  swelling  is  at  the  same  lime  very  dif- 
fused; and  the  suppuration  lies  deeply,  and  can  only 
be  felt  in  an  obscure  way. 

The  ulcers,  beneath  which  a necrosis  is  situated. 


discharge  a large  quantity  of  matter,  and  their  edges 
are  bent  inwards.  The  granulations  are  either  yel 
lowish  and  pale,  or  else  of  an  intense  red  colour;  they 
are  also  irregular,  and  generally  not  very  tender, 
though  sometimes  extremely  painful,  and  on  being 
slightly  touched  they  bleed. 

It  has  been  already  noticed,  that  some  years  ago  the 
discharge  from  the  sores  which  attend  necrosis  was 
described  as  being  always  thin,  fetid,  and  sanious; 
and  such  qualities  of  the  matter  were  regarded  as  a 
symptom  of  the  disease  of  the  bone.  But  as  that  e.\- 
cellent  practical  writer  Weidmann  has  explained,  it  is 
a symptom  undeserving  of  confidence.  In  necrosis, 
the  pus  is  often  thick,  white,  and  inodorous;  while 
other  ulcers,  unattended  with  diseased  bone,  sometimes 
discharge  thin  fetid  matter.  Weidmann,  at  the  same 
time,  does  not  mean  to  assert,  that  in  necrosis  the  sores 
never  emit  unhealthy  pus;  hut  he  firmly  believes,  that 
such  discharge  is  not  always  the  result  of  a disease  of 
the  bone.  As  far  as  he  could  judge,  the  suppuration 
from  ulcers  situated  over  diseased  bones,  continues 
white  and  laudable  as  long  as  the  patient’s  general 
health  is  good  ; but  that  it  deviates  from  these  prof»er- 
ties  in  proportion  as  the  health  becomes  impaired. 

Neither  is  the  black  colour  imparted  to  the  dressings 
of  ulcers  a circumstance  which  necessarily  indicates 
the  existence  of  necrosis ; for  it  may  occur  when  the 
bone  is  sound,  and  may  not  happen  when  the  bone  is 
affected. 

None  of  the  preceding  symptoms  convey  such  in- 
formation as  leaves  no  doubt  of  the  positive  existence 
of  necrosis.  The  touch  is  the  only  thing  which  can 
give  us  this  knowledge,  when  the  bone  is  not  loo 
deeply  situated,  and  the  sinuses  not  tortuous,  nor  ob- 
structed with  fungous  growths. 

When  the  openings  of  the  ulcers  are  considerable, 
the  finger  may  be  introduced.  If  in  this  way  the  b«ne 
can  be  felt  to  be  extensively  uncovered  by  the  perios- 
teum, the  surgeon  may  conclude  that  all  such  portion 
of  the  bone  has  perished.  He  may  be  still  more  cer- 
tain of  the  fact  when  he  finds  the  edges  of  the  denuded 
bone  unequal  and  rough. 

The  examinations  made  directly  with  the  finger  give 
the  most  correct  and  exact  information  of  the  stale  of 
the  bone;  but  the  orifices  of  the  sores  are  sometimes 
so  small  that  the  finger  cannot  be  introduced  without 
causing  great  pain.  A probe  must  then  be  used  for  the 
purpose  of  ascertaining  the  extent  of  the  denudation 
of  the  bone  ; whether  its  edges  are  rough  ; whether  the 
dead  portion  is  loose,  and  likely  to  separate  soon. 

Sometimes  the  dead  fragment  of  bone  protrudes 
from  the  ulcer,  or  is  visible  on  separating  its  edges. 
When  it  is  black,  there  cannot  be  a doubt  of  its  being 
actually  dead  ; but  on  the  other  hand,  when  its  white- 
ness is  increased,  the  diagnosis  is  difficult,  because 
bones  being  naturally  white,  much  experience  is  neces- 
sary to  be  able  to  judge  whether  they  are  so  in  excess. 

It  merits  attention,  also,  that  the  black  colour  of  the 
bone  isnot  owing  to  the  necrosis  itself,  but  seems  rather 
to  depend  upon  the  fragment  having  been  exposed  to 
the  air.  In  fact,  dead  pieces  of  bone  with  which  the 
air  comes  into  contact  turn  black,  while  those  which 
are  covered  with  matter  retain  their  whitene.ss.  'J'he 
cylindrical  portion  of  a humerus,  which  was  almost 
totally  affected  with  necrosis,  was  universally  black  at 
the  part  which  protruded  through  the  flesh;  but  the 
rest,  which  lay  under  the  integuments,  was  white. — 
( fVfidmavn  de  JsTccrosi  Ossium,  p.  19,  el  tab.  1.) 

When  the  early  symptoms  of  the  disease  are  mild, 
the  surgeon  may  infer  that  it  is  only  a superficial  poi  ■ 
tion  of  the  bone  which  is  about  to  be  sepaiaied.  But 
this  judgment  will  be  more  certain  if  confirmed  by  ex- 
amination with  the  finger  or  probe  ; or  if  the  swelling 
which  occurred  in  the  beeinning  has  not  spread  beyond 
the  affected  point,  and  if  the  pain  affects  only  the  outer 
part  of  the  bone.  In  this  sort  of  case  there  is  also 
great  probability  that  the  dead  bone  will  be  separated 
within  a moderate  lime. 

It  is  also  of  importance  to  ascertain  the  existence  of 
an  internal  necrosis,  and  to  learn  whether  it  is  situated 
in  the  sponey  substance,  or  in  the  internal  parietes  of 
the  canal  of  the  bone;  whether  it  affects  only  a part 
or  extends  to  the  whole  body  of  the  bone.  When 
there  is  an  internal  necrosis,  says  Weidmann,  the  dis- 
ease is  generally  more  acgiavated,  and  of  longer  dura- 
tion; and  in  the  first  stage  the  patient  is  afl'ecterl  with 
severe  symptoms,  intolerable  pain,  loss  of  rest,  a great 


NECROSIS. 


195 


deal  of  fever,  profuse  perspirations,  and  such  disorder 
of  the  system  as  may  prove  fatal,  unless  the  patient  be 
young  and  strong.  The  hard  swelling  which  w’as  ob- 
servable at  the  coininencement  of  the  disease,  increases 
but  slowly,  and  extends  very  gradually  over  the  cir- 
cumference of  the  limb,  while  the  skin  yet  remains 
free  from  redness  and  tension.  If  the  part  be  some- 
what roughly  handled,  the  pain  which  is  fixed  in  the 
bone  is  not  rendered  more  acute,  as  would  happen  we^re 
the  case  an  ex'temal  inflammation.  In  this  suffering 
corjdition  the  patient  continues  a good  while  before  the 
formation  of  matter  brings  a degree  of  relief.  When 
the  matter  is  formed,  it  spreads  through  the  adjacent 
cellular  substance,  among  the  muscles  and  other  parts, 
and  the  abscess  generally  bursts,  after  a considerable 
time,  by  several  openings  very  distant  from  the  main 
collection  of  matter,  as  also  remote  from  each  other, 
sometimes  in  diametrically  opposite  situations.  The 
evacuation  of  the  matter,  however,  does  not  produce 
any  material  subsidence  of  the  swelling.  The  pus  is 
of  good  quality,  and  issues  in  large  quantities  frosn  the 
ulcerated  apertures,  the  quantity,  however,  not  being 
increased  when  pressure  is  made.  If  some  of  the 
openings  heal,  others  are  formed  ; but,  in  general,  the 
edges  become  callous,  and  they  lose  all  disposition  to 
cicatrize.  When  the  case  presents  the  foregoing  cir- 
cumstances, and  the  weakened  limb  can  neither  bear 
the  action  of  the  muscles  nor  the  weight  of  the  body, 
and  by  either  of  these  causes  its  sliape  becomes  al- 
tered, the  surgeon  may  conclude  that  the  disease  is  an 
internal  necrosis.  But  in  older  to  avoid  mistake,  he 
should  introduce  into  the  sinuses  a probe,  which,  pass- 
ing through  the  openings  in  the  subjacent  bone,  will 
touch  the  dead  piece  whfch  it  contains,  and  which  will 
sometimes  be  even  distinguished  to  be  loose  and  move- 
able.  The  extent  of  the  sequestrum  must  be  judged  of 
by  the  extent  of  the  swelling,  and  the  distances  between 
the  apertures  in  the  bony  shell  which  includes  the  se- 
questrum. 

The  surgeon  should  also  endeavour  to  ascertain  with 
the  probe  whether  there  is  only  a single  sequestrum  or 
several.  When  there  are  several,  they  may  be  felt 
with  the  probe  in  different  places,  down  to  which  this 
instrument  is  passed,  and  the  removal  of  one  or  two 
of  the  fragments  is  not  followed  by  a cure.  It  ought 
to  be  remembered,  however,  that  the  same  fragment 
may  be  touched  by  the  probe  in  several  different  places 
when  it  is  very  extensive.  If  there  are  several  dead 
pieces  of  bone  situated  at  a distance  from  each  other, 
each  of  them  is  generally  accompanied  with  a distinct 
swelling  and  sinuses.  Frequently  tliese  fragments  are 
so  concealed  that  they  cannot  he  felt  with  a probe ; 
but  their  existence  may  then  be  suspected,  from  the  ul- 
cers not  healing,  which  can  be  ascribed  to  nothing  else. 

It  is  also  necessary  to  distinguish  with  the  greatest 
attention  the  different  stages  of  the  disease.  The  first 
stage  may  be  considered  as  existing  when  the  ait.ack  is 
yet  recent,  and  the  inflamm.ation  and  its  concomitant 
symptoms,  the  pain,  swelling,  and  symptomatic  fever, 
prevail  in  a high  degree,  and  when  no  suppuration  has 
taken  place,  or  at  least  no  discharge  of  matter.  The 
second  period,  in  which  the  dead  hone  is  undergoing 
the  process  of  separation,  is  indicated  by  a diminution 
of  tire  inflammation,  a partial  subsidence  of  the  swell- 
ing, and  the  discharge  of  purulent  matter.  When  a 
probe  is  passed  into  the  ulcers,  the  bone  is  felt  bare  and 
dry,  and  towards  the  limits  of  the  swelling  it  is  rough, 
where,  a§  will  be  afterward  noticed,  an  excavation  is 
formed.  Every  part  of  the  bone,  however,  which  is 
to  be  detached,  still  continues  adherent  to  the  rest  of 
the  living  bone.  At  length  the  surgeon  knows  that  the 
disease  has  reached  its  last  stage,  or  that  in  which  the 
dead  portion  of  bone  is  entirely  separated,  when  suffi- 
cient time  for  the  completion  of  this  separation  has 
transpired,  and  when  the  dead  bone  can  be  distin- 
guished with  the  finger,  probe,  or  even  the  eye,  to  be 
loose  and  free  from  all  connexions. 

Although  a necrosis  must  generally  be,classed  with 
diseases  which  are  serious  and  of  long  duration  ; yet 
the  character  of  the  disorder  is  not  essentially  bad, 
since  it  is  often  cured  by  nature,  or  with  the  nssistance 
31  surgery.  Confident  hopes  of  a cure  may  be  enter- 
tained when  the  necrosis  is  confined  to  the  external 
pait  tf  a bone  ; when  it  is  simple  and  of  moderate  ex- 
tent ; when  it  is  not  situated  in  a bone  destined  for  irn- 
p<e  tant  us«  or  near  any  viscus,  or  organ,  that  may  be 
injured  by  it ; and  when  it  proceeds  from  an  external 


cause,  and  the  general  health  is  good.  On  the  con- 
trary, the  cure  is  difficult  and  the  prognosis  doubtful, 
when  the  disease  is  extensive,  and  complicated  with 
other  affections,  either  of  the  same  or  different  bones  ; 
when  it  attacks  bones  which  are  of  liigh  importance 
on  account  of  their  functions  or  situation  ; when  it  is 
situated  in  the  interior  of  the  bone,  and  affects  several 
parts  of  it;  when  it  arises  from  an  internal  cause,  for 
which  there  is  no  certain  and  quick-acting  specific; 
when  the  patient  is  weakened  by  age  or  disease ; and  es- 
pecially, w'hen  the  sinuses  extend  into  the  neighbouring 
articulations. — ( fVeidmann  de  JVecrosi  Ossium,  p.22.) 

The  process  of  cure  is  said  to  take  place  with  more 
celerity  in  the  lower  jaw  than  any  other  bone,  and  may 
be  completed  in  three  months.  Mr.  Russell  h.as  never 
known  a necrosis  of  the  tibia  get  well  in  less  than  a 
year ; but  in  general  nearly  tw’o  years  elapse  first ; and 
sometimes  the  case  is  protracted  to  a much  greater 
length  of  time.  , 

Necrosis  of  the  lower  jaw  and  clavicle  never  proves 
fatal ; that  of  the  lower  extremities,  which  is  the  worst 
case,  dods  so  very  seldom,  and  only  from  the  violence 
of  the  first  inflammatory  symptoms,  which  rapidly 
bring  on  hectic  fever,  which  proves  incurable,  unless 
its  local  cause  be  removed  by  timely  recourse  to  ampu- 
tation. When  the  violence  of  the  first  stage,  however, 
has  abated,  the  irritation  ceases,  atid  the  hectic  symp- 
toms, if  there  are  any,  are  generally  moderate.  Nor 
is  this  state  of  tranquillity  disturbed,  till  the  seques- 
trum, in  making  its  way  outwards,  again  produces  irri- 
tation. At.  this  second  period  of  urgency,  extensive 
inflammation  may  originate,  ulcerations  spread  all  over 
the  surface  of  the  limb,  assume  an  unhealthy  appear- 
ance, violent  fever  succeed,  and  the  patient  eitlier  pe- 
rish or  sink  into  a state  in  which  he  must  consent  to 
amptitation,  as  the  only  means  of  saving  his  life.  This 
is  the  last  crisis  of  imminent  danger  ; but  in  general  it 
is  less  perilous  than  when  the  inflammation  comes  on 
in  the  incipient  stage  of  necrosis. — (Russell.) 

In  the  treatment  of  necrosis,  the  first  grand  object 
of  the  surgeon  should  be  to  aid  nature  in  her  endea- 
vours to  effect  a cure,  and  not  to  disturb  her  operations 
by  any  superfluous  or  unseasonable  interference.  The 
second  should  be  to  assist  her  sometimes  by  the  boldest 
proceedings,  when  she  loses  her  way,  and  cannot  by 
herself  accomplish  what  is  necessary. 

But  in  order  not  to  attempt  any  thing  wrong,  the 
surgeon  must  understand  correctly  what  nature  does 
in  this  disease;  what  it  is  in  her  power  to  perform; 
what  she  either  cannot  accomplish  at  all,  or  not  with 
any  degree  of  certainty;  and,  lastly,  the  circum- 
stances in  which  she  may  err,  and  endanger  the  pa- 
tient’s life. 

When  a portion  of  bone  dies,  nature  uses  all  her  en- 
deavours to  bring  about  its  separation  from  the  part  of 
the  bone  which  still  remains  alive.  Surgeons  have  de- 
nominated this  process  exfoliation  (see  this  word), 
which  resembles  the  separation  of  parts  affected  with 
gangrene  and  sphacelus  from  the  living  flesh.  The 
exfoliation  of  bone,  however,  happens  itiuch  more 
slowly  than  the  separation  of  a slotigh  of  the  soft 
parts.  Neither  are  all  exfoliations  completed  at  a re- 
gular period;  for  they  proceed  most  quickly  during 
youth,  when  the  constitution  is  usually  more  full  of 
energy,  the  bones  more  vascular,  and  less  re|tlete  with 
solid,  inorganic,  earthy  matter.  On  the  other  hand,  the 
process  is  slower  in  old,  debilitated  subjects,  whose 
vitality  is  less  active.  A thin  small  scale  of  bone  se- 
parates sooner  than  a large  thick  portion ; and  the 
most  tedious  exfoliation  is  that  of  a thick  bone,  from 
which  a portion,  including  its  entire  diameter,  is  com- 
ing away.  The  separation  of  a necrosis  takes  place 
more  expeditiously  in  bones  of  a light  texture  than  in 
those  of  a solid  structure;  and  sooner  in  the  less  com- 
pact parts  of  bones,  such  as  the  epiphyses  and  spongy 
substance,  than  in  those  of  greater  density. 

When  a necrosis  has  originated  from  the  scurvy,  sy- 
philis, &c.,  and  appropriate  remedies  are  not  adminis- 
tered, nature  cannot  effectually  aocompli.sh  the  process 
by  which  the  dead  bone  is  separated  ; the  case  becomes 
worse  ; and  life  endangered. 

The  separation  happens  precisely  at  the  different 
points  where  the  living  and  dead  parts  of  the  bone 
come  into  contact;  and  it  is  obvious,  that  the  parti- 
cles of  thedead  bone,  which  are  at  a distance  from  the 
part  that  retains  its  vitality,  cannot  be  acted  upon  by  it. 

A variety  of  opinions  have  been  entertained  con- 


196 


NECROSIS. 


ceming  the  means  employed  by  nature  in  effecting 
this  separation.  Hippocrates  believed  that  the  dead 
part  was  pushed  away  by  a fleshy  substance  which  grew 
underneath  it. — (Z)e  Cap.  vuln.  cap.  xxiv.)  Ludwig, 
Aitken,  Boini,  and  many  otljers,  adopted  the  same  idea. 
— (riee  Jldversaria  Mtd.  Pract.  vol.  3,  p.  63.  Systematic 
Elements  of  Surgery, p.'iiil.  Thesaur.  Oss.  Morb.p.  1.) 

Van  Swieten  conceived  tliat  the  dead  jrart  was 
forced  away  by  the  incessant  btiating  of  ttie  arteries. — 
{Comment,  in  JJphor.  Boerrhavii,  § 252.)  M.  Fabre 
ascribed  the  separation  to  the  e.\tension  and  expansion 
of  the  vessels. — (Mem.  de  VJicad.  de  Ckir.  tom.  4,  p. 
91.)  Others  supposed  that  the  exfoliating  piece  of  bone 
became  loosened  partly  by  the  suppuration,  and  partly 
by  the  rising  of  the  new  granulations.— (See  B.  Bell  on 
Ulcers.) 

As  Weidmann  observes,  there  is  unquestionably  a 
reddish  fleshy  substance  formed  between  the  dead  and 
living  bone,  aiid  which  Celsus  has  noticed  under  the 
appellation  of  caruncula, — {De  Medicina,  lib.  8,  cap. 
3.)  But  it  would  be  erroneous  to  refer  the  expulsion 
of  the  dead  portion  of  bone  to  it,  since  it  can 'never  be 
produced  before  a change  has  taken  place  in  the  struc- 
ture of  bone,  there  being  in  fact  no  space  for  it  to  grow 
in  ; and  hence  it  is  never  seen  before  the  disunion  of 
the  parts  has  considerably  advanced.  There  must  con- 
sequently be  some  other  power  wliich  destroys  the  co- 
hesion between  the  dead  and  living  bone,  and  produces 
the  groove,  or  interspace,  in  which  the  soft  granula- 
tions arise.  Besides,  among  other  facts  proving  the  fal- 
sity of  the  idea,  that  the  granulations  push  off  the 
dead  bone,  Weidmann  particularly  adverts  to  the  oc- 
casional exfoliations  of  the  whole  circumference  of  a 
cylindrical  bone.  Here,  if  the  granulations  had  the 
power  of  causing  a disunion  on  one  side,  they  could 
not  have  the  same  eflect  on  the  opposite  one;  but 
would  tend  to  make  the  contact  more  intimate. 

The  separation  also  cannot  be  made  by  the  pulsation 
of  the  small  arteries,  nor  by  the  weak  expansive  mo- 
tion of  the  vessels  of  the  bone.  Weidmann  knows  not 
what  motives  have  induced  certain  writers  to  impute 
the  effect  to  suppuration,  and  observes  that,  as  the  doc- 
trine is  not  founded  upon  reasoning,  it  is  superfluous  to 
offer  any  arguments  against  it.  If  the  least  attention 
be  paid  to  what  nature  really  tries  and  accomplishes 
in  this  operation,  nothing  will  be  more  manifest  than 
that  it  is  completed  in  a very  different  manner.  Swell- 
ing first  affects  the  periosteum  and  bone,  which  by  de- 
grees softens. — {Fid.  Truja,  passim  ; Bonn.  Thesaur. 
Oss.  JUorbos,  p,  122,  and  Weidmann  de  JVecrosi  Os- 
sium,  tab.  4,  Jigs.  1 and  3.)  At  the  margins  of  the  ne- 
crosis, the  bony  surfaces,  which  were  smooth,  become 
rough  and  irregular.  A fi.<sure  is  there  produced, 
which  extends  in  every  direction  under  the  piece  of 
bone  that  is  about  to  be  detached.  The  bony  texture 
is  also  daily  rendered  less  solid,  so  that  the  number  of 
adhesions  between  the  dead  and  living  parts  ditninish, 
and  in  the  end  are  totally  destroyed.  Weidmann  then 
explains,  that  the  true  mode  by  which  the  separation  is 
effected,  consists  in  the  absorption  of  the  particles  situ- 
ated between  the  living  and  dead  parts  of  the  bone,  in 
such  a way,  however,  that  the  first  loses  a great  deal 
of  its  substance  ; the  last,  scarcely  any  thing. — (P.  25.) 
After  the  dead  bone  has  come  away,  the  swelling  of 
the  periosteutn  subsides,  and  the  living  bone  recovers 
its  original  hardness  and  solidity. — ( Troja,  p.  67.) 

For  a farther  account  of  the  process  by  which  dead 
portions  of  bone  are  separated  from  the  living,  see 
Exfoliation. 

When  dead  portions  of  bone  are  separated  and 
loose,  they  still  lodge  in  the  cavities  of  the  ulcers,  and, 
like  all  other  extraneous  bodies,  occasion  irritation  of 
the  soft  parts,  and  keep  up  a discharge  of  matter. 
Sometimes,  however,  nature  of  herself  succeeds  in  ex- 
pelling them.  This  happens  in  cases  where  the  size  and 
shape  of  the  ulcer  are  calculated  t«  facilitate  the  issue  of 
the  dead  bone,  which  does  not  lie  too  deeply,  and  is  pro- 
pelled outwards  by  its  own  weight.  In  necrosis  of  tri- 
vial size,  indeed,  it  is  asserted  that  the  small  fragments 
of  bone  may  be  dissolved  in  the  pus  and  come  away  with 
it  {David;  Bousselin,  Hi»C  d'-)ia  Society  Royale  de 
Medecine,  tom.  4,  p.  308  ; de  JVecrosi  Os- 

siuni,  p.  26)  ; but  such  an  ewnt  caa  never  be  expected 
when  the  dead  portion  of  bone  is  at  all  extensive. 

The  last  thing  which  nature  does  is  to  restore  the  loss 
of  substance  which  the  bone  has  suffered.  Although 
this  operation  is  so  extraordinary  and  wonderful  that 


one  might  be  disposed  to  doubt  its  reality,  numerous 
examples,  recorded  in  the  annals  of  surgery,  piove  noi 
only  its  possibility,  but  also  its  fiequency. 

In  works  refened  to  at  the  conclusion  of  this  article, 
the  following  autliors  speak  of  the  regeneration  of  a 
part,  or  the  whole  of  the  lower  jaw-bone;  viz.  Bone- 
tus,  Bayer,  Guernery,  Belmain,  Acrel,  Van  Wy,  Ti  loeii, 
Bonn,  Reiplein,  Desault,  Henkel,  and  Dussaus.soir.  A 
student  showed  Weidmann  a lower  jaw-bone,  w hich 
had  been  thus  regenerated  and  taken  from  the  body  of 
a man,  whom  the  latter  distinguished  writer  had  been 
well  acquainted  with.  The  bone  could  not  be  freely 
depressed  ; yet  it  performed  its  functions  tolei  ably  well. 

Moreau  saw  a case  in  which  the  clavicle  was  rege- 
nerated, and  the  new  bone  was  presented  by  Danger- 
ville,  after  the  patient’s  decease,  to  the  Academy  of 
Surgery  at  Paris. — t De  JVecrosi  Ossium  Theses,  Pru.s. 
F,  Chopart,  resp.  P.  G.  Robert,  Parisiis,  1776.) 

Chopart  liad  an  opiiortunity  of  witnessing  the  death 
and  reproduction  of  scapula. 

Weidmann  saw  an  instance  in  which  nearly  the 
whole  cylindrical  shaft  of  the  humerus  perished  and  was 
afterward  regenerated ; a phenomenon  that  had  been 
observed  at  earlier  periods  by  Job  of  Mekten,  C'ajetano 
Taconi,  E.  Blancard,  Duhamel,  David,  Acrel,  Boeh- 
mer,  Clieselden,  and  Vigaroux,  whose  respective  works 
are  cited  at  the  end  of  this  article. 

Morand,  Cheselden,  and  Bromfield  published  en- 
gravings respecting  a reproduction  of  the  upper  part  of 
the  hutnerus,  w here  the  old  dead  bone  was  included  in 
a sort  of  bony  tube. 

Regenerations  of  the  ulna  have  been  observed  by 
Ruysch,  Duverney,  and  Fowles. — (See  Thesaur.  X. 
iN'o.  176.  Truite  des  Mai.  des  Os,  Pans,  1751 ; and 
Phil.  Trans.  JVo.  312.) 

A similar  reproduction  of  the  lower  ends  of  the  radius 
and  ulna  was  witnessed  by  Acrel. — {Chirurgische 
Vorfdllevon  Murray,  vol.  1,  p.  194.) 

Similar  reproductions  of  the  thigh-bone  are  recorded 
by  Wedel,  Battus,  Koschius,  Hofmann,  Scnitetus, 
Diemerbroeck,  Wright,  Fabricius  Hildanus,  Raw',  Do- 
byns,  M’Kenzie,  Ludwig,  David,  Bousselin,  Larrey, 
Hutchison,  &c.,  in  (mblications  specified  at  the  conclu- 
sion of  this  subject. 

The  follow'ing  case  of  necrosis  of  the  thigh-bone  is 
related  by  Dr.  M‘Kenzie.  William  Baxter,  a boy  thir- 
teen years  old,  received  a blow  on  his  thigh  at  school, 
of  which  he  at  first  hardly  com|)lained  ; but  in  a few 
months  he  began  to  have  pain  in  the  part,  which  in- 
flamed, sw'elled,  and  appeared  to  have  matter  in  it. 
'J'he  parents  being  poor,  no  surgeon  was  called,  and 
the  boy  was  allowed  to  linger  for  a great  w'hiie.  At 
length  the  matter  made  its  way  through  the  skin  by  a 
small  opening,  on  the  interior  part  of  the  thigh,  about 
three  inches  above  the  knee,  and  a thin  sanies  con- 
tinued to  be  discharged  for  eighteen  or  twenty  months. 
The  hole  in  the  skin  enlarged,  and  the  point  of  a por- 
tion of  bone  began  to  protrude,  and  give  a good  deal 
of  pain,  when  the  clothes  rubbed  against  it.  After 
suffering  in  this  manner  for  two  years  and  a half,  the 
boy,  as  he  lay  in  bed  one  morning,  felt  the  bone  looser, 
and  projecting  more  than  ordinary.  He  gave  it  a strong 
pull,  and  brought  the  piece  aw'ay  entirely,  which  proved 
to  be  seven  inches  and  a half  of  the  thigh-bone.  A 
good  deal  of  bleeding  followed;  but  the  W'oimd  soon 
healed,  and  he  had  never  afterward  the  least  incon- 
venience. Dr.  M'Kenzie,  hearing  of  this  singular  case, 
sent  for  him,  carefully  examined  his  thigh,  and  found  it 
as  firm  as  the  other.  The  only  difference  was,  that  it 
was  somewhat  thicker,  and  a little  more  curved  The 
muscles  retained  their  natural  softness  and  looseness 
on  the  bone.  The  detached  piece  of  bom;  was  a por- 
tion of  its  whole  circumference. — (See  Med.  Obs.  and 
Inquiries,  vol.  2.) 

We  may  infer,  that  the  occurrence  is  more  frequent 
in  the  tibia  than  any  other  bone,  from  the  accumulated 
facts  mentioned  by  Albucasis,  La  Marche,  Mm  alto, 
De  La  Motte;  Ellinclmys,  Ruysch,  'I’acconi,  Laing, 
Johnson,  Hunter,  David,  Boelmier,  Sigw  art,  Th.  Bar- 
tholine,  Hofmann,  Saviard,  Le  Dian,  Duviiney, 
'I'rioen,  Gunther,  Lndwig,  IMichael,  Bousselin,  Weid- 
mann, Russell,  Whately,  Desault,  &c.  See  the  works 
cited  at  the  end. 

Dr.  Huntet  describes  a tibia  which  had  been  am- 
putated. On  examination,  the  case  at  first  sight  seemed 
to  be  a sw'ellitig  of  the  whole  bone,  with  a loos  internal 
exfoliation.  However,  it  proved  to  be  a remarkable 


NECROSIS. 


197 


Instance  of  the  separation  of  the  greatest  part  of  the 
original  bone,  whose  place  was  supplied  by  a callus. 
7’he  external  surface  of  the  enclosed  loose  piece  of 
bone  was  smooth.  A small  part  of  the  surrounding 
bony  substance  being  removed,  the  contained  piece  was 
taken  out,  and  found  to  be  the  whole  body  of  the  tibia. 
It  had  sepaiated  from  the  epiphysis  at  each  extremity. 
The  middle  part  of  the  bone  had  perished,  consequentiy 
bad  lost  its  connexion  with  the  periosteum,  and  was 
gradually  thrown  oif  from  the  living  parts  of  the  bone 
at  each  end.  A callus,  extending  from  end  to  end, 
united  the  two  extremities  of  the  original  tibia,  pre- 
served the  length  and  gave  firmness  and  inflexibility  to 
the  limb.  The  exfoliation  was  so  encompassed  by  the 
new  bony  case,  that,  though  quite  loose,  it  could  not 
be  thrown  out. — {Med.  Obs.  and  luq.vol.  2.) 

Weidmann  saw  a shoemaker,  who,  after  much  suf- 
fering, extracted,  with  his  own  hands,  the  greatest  part 
of  the  diaphysis  of  the  tibia  ; yet  the  loss  was  so  well 
repaired,  that  the  man  could  walk  afterward  nearly  as 
ably  as  ever. — (De  Mecrusi  0.ssium,‘p.29.) 

“We  are  not  to  imagine  (says  Weidmann)  that 
these  regenerations  happen  by  chance:  experiments 
made  upon  living  animals  by  Troja,  Blumenbach, 
Koehler,  Desault,  and  myself,  prove  that  they  invaria- 
bly follow  certain  laws.” 

In  fact,  whenever  the  medullary  structure  of  the 
long  bones  of  pigeons  or  dogs  is  destroyed,  these  bones 
become  afiected  with  necrosis,  and  are  afterward  re- 
produced to  the  full  extent  of  their  destruction. 

The  observations  and  experiments  cited  by  Weid- 
mann also  prove,  that  it  is  the  long  bones  which  are 
usually  reproduced ; though  the  flat  ones  are  not  en- 
tirely destitute  of  the  power  of  regeneration,  since  ex- 
perience fully  evincr;s,  that,  when  a portion  of  the  skull 
is  removed,  either  by  a wound,  by  disease,  or  by  the 
trepan,  nature  always  endeavours  to  cover  the  de- 
ficiency, the  edges  of  the  aperture  extending  them- 
selves by  means  of  a bony  substance,  furnished  by  the 
periosteum,  ihedura  mater,  and  cranium  itself.-(  Tenon, 
Mem.  de  I' Acad  des  Scie7ices,  1758,  p.  412,  4L‘l.  415, 
416.418.)  But  still  the  reproduction  is  imperfect,  as 
an  unossified  place  is  always  left,  even  when  the  bone 
has  lost  only  a small  piece,  like  what  is  taken  out  by 
the  trephine;  and  when  the  destruction  of  the  cranium 
is  very  extensive,  no  reproduction  at  all  happens.  This 
fact,  which  is  proved  by  the  observations  of  Saviard, 
Pott,  Sabatier,  &c.  is  particularly  noticed  by  Sir  A. 
Cooper. 

When,  in  a case  of  necrosis,  sa5’s  Weidmann,  a 
scale  or  table  of  either  a long  or  flat  bone  is  separated, 
no  regeneration  follows,  because  the  granulations 
which  rise  up  under  the  sequestrum  then  serve  as  a 
periosteum,  and  as  soon  as  the  dead  bone  is  removed, 
they  become  united  to  the  adjacent  parts. 

It  is  likewise  ascertained  that  the  power  of  repro- 
duction in  the  bones  is  particularly  .active  in  the  early 
periods  of  life,  atid  in  healthy  subjects:  and  that  it  is 
languid  and  even  annihilated  in  old  persons,  pregnant 
women  {Bonn's  Thesavr.  p.  174),  and  in  venereal, 
cancerous,  and  ricketty  patients. — {Callisen,  Sijst.  Chir. 
Hndiervee,  pars  1,  p (536.) 

In  order  that  a new  bone  may  form,  Weidmann 
thought  that  the  periosteum  and  other  membranes  con- 
certied  in  the  nutrition  of  the  original  bone,  must  have 
been  spared  from  destruction.  In  (act,  says  he,  we 
observe,  that  in  cases  where  the  tube  of  a long  bone 
has  suffered  necrosis,  the  bone  is  never  reproduced,  if 
the  periosteum  has  been  destroyed  by  inflammation  or 
other  causes.  Surgeons  ought  also  to  understand,  that 
it  is  not  always  a reproduction  which  has  happened 
when  a part  of  the  bone  jrerishes;  not  even  when  a 
tubular  portion  of  a long  bone  dies  and  is  contained  in 
the  medullary  canal  For.  according  to  Weidmann,  if 
the  innermost  layers  of  a long  bone  perish,  while  those 
which  compose,  as  it  were,  the  bark,  are  preserved,  the 
latter  swell  and  soften  as  if  they  were  actually  a new 
bone.  Several  round  apertures  are  observable  upon 
their  surface,  which  serve  for  the  transmission  of  ves- 
sels, and  are  larger  than  those  which  perforin  this 
office  in  the  natural  state.  Large  openings  or  fistultE  are 
likewise  formed,  which,  as  in  a new  hone,  lead  tothe  me- 
dullary cantil.  Here  it  would  be  erroneous  to  conclude 
that  a new  hone  has  been  produced;  and  a very  little 
attention  will  discover  that  all  is  limited  to  some 
changes  in  the  external  part  of  the  bone  which  the  ne- 
crosis has  not  affected. 


When,  therefore,  the  interior  of  the  canal  of  a long 
bone  is  destroyed  by  a necrosis  which  does  not  extend 
to  the  external  layers,  the  case  is  not  a reproduction  of 
the  bone. 

When,  however,  we  find  the  tube  of  any  long  bone 
included  in  a sort  of  osseous  shell,  and  the  surface  of 
this  tube  smooth,  like  that  of  a bone  in  the  natural 
slate,  we  may  be  certain  that  it  has  been  detached 
directly  from  the  periosteum,  and  that  the  bony  shell 
which  contains  it  is  a new  production.  On  the  con- 
trary, if  the  surface  of  the  dead  tube  be  rough,  we 
may  infer,  that  the  separation  has  taken  place  between 
the  innermost  layers  of  the  bone,  and  those  which  are 
superficial,  the  latter  composing  now  the  osseous  slfell 
in  which  the  Sequestrum  is  included. — {Weidmann  de 
Mecrosi  Ossium,  p.2\.) 

This  last  theory,  concerning  the  production  of  the 
osseous  shell  in  necroses  of  the  long  cylindrical  bones, 
is  adopted  by  Richerand  as  the  true  one,  not  only  in  the 
instances  specified  by  Weidmann,  but  in  every  other 
example  where  the  old  bones  seem  to  be  included  in 
another,  which  has  the  appearance  of  being  a new 
production,  and  which  was  supposed  by  Troja,  David, 
&c.,  to  be  formed  by  the  vessels  of  the  periosteum. — 
(See  Mosographie  Chir.  t.  3,  p.  158.  161,  ed.  4.) 

As  far  as  Weidmann’s  information  reached,  the  short 
or  cuboid  bones  are  not  capable  of  reproduction.-— (P. 
31.)  Duverney  mentions  an  astragalus  which  was  de- 
stroyed by  necrosis;  but  does  not  state  that  any  substi 
tute  for  it  was  afterward  formed. — {Maladies  des  Os, 
p.  458.) 

Weidmann  also  never  witnessed  a reproduction  of 
the  spongy  substance,  such  as  it  was  before  its  destruc- 
tion, round  the  medulla.  He  always  found  the  sub- 
stituted matter  dense  and  compact,  at  least  for  some 
time  after  its  formation. 

It  is  now  admitted,  however,  that  in  process  of  time 
the  inner  surface  of  the  new  bone  becomes  cellular, 
and  is  lined  with  a membrane  containing  medulla. 
The  regeneration  of  the  medulla  w'as  first  observed  by 
Koehler,  and  afterward  by  Dr.  J.  Thomson,  in  an  ex- 
tensive series  of  experiments  which  he  made  with  Dr. 
Alexander  M‘Donald,  and  which  were  published  in  the 
latter  gentleman’s  inaugural  dissertation  in  1799.— 
(See  Thomson's  Tectures  on  Inflammation,  p.393.)  Mr. 
Russell  was  not  aware  of  the  regeneration  of  the  me- 
dulla; for  he  states,  that  after  the  absorption  or  re- 
moval of  the  sequestrum,  the  cavity  of  the  new  bone 
becomes  filled  up  with  granulations  which  are  at 
length  converted  into  bony  matter.  Thus,  he  says,  the 
new  bone  differs  from  the  original  one,  in  being  solid 
instead  of  hollow.  Authorities,  however,  are  decidedly 
against  Mr.  Russell  on  this  point:  in  the  5th  vol.  of  the 
Mem.  de  I' Acad,  de  Chir.  is  the  history  of  a man,  the 
whole  of  whose  clavicle  came  away,  without  his  being 
deprived  of  any  of  the  motions  of  the  arm.  The 
death  of  this  patient,  which  happened  shortly  after- 
ward, afforded  an  opportunity  of  examining  how  na- 
ture had  repaired  the  loss.  Another  clavicle  was  found 
regenerated,  which  neither  difl'ered  from  the  original 
one  in  length  nor  solidity;  but  only  in  shape,  being 
flatter,  and  not  so  round.  It  was  connected  with  the 
acromion  and  sternum  just  like  the  primitive  bone. 

3’he  power  which  thus  reproduces  bones  is  only  a 
modification  of  that  which  unites  fractures.  Indeed, 
what  consolidates  broken  bones,  and  is  known  by  the 
name  of  callus,  presents  all  the  characters  of  new 
bone,  begins  and  grows  in  the  same  way,  atul  may  be 
impeded  and  retarded  in  its  formation  by  the  same 
causes. — (See  Callus  and  Fractures.)  It  is  farther 
highly  probable,  as  Weidmann  remarks,  that  the  power 
which  effects  the  reproduction  of  bones,  is  the  same  as 
that  which,  in  the  sound  stale,  nourishes  and  supports 
these  parts.  But  to  what  organ  appertains  the  func- 
tion of  reproducing  bones? 

Many  able  meti  have  ascribed  the  whole  work  to  the 
periosteum.  {C.  Havers;  Dvhamcl,  Mem  de  I' Acad, 
des  Sciences,  1739,  1741,  1742, 1747.  Fovgerovx,  MSm. 
snr  les  Os;  Pans,  1760.  Swencke,  Harlemcr,  Ab- 
hnvdluvgen,  th.  1,  p.  39.  Bertin,  Osteologie  Mari- 
gues,  Abhandlung  vo.  a r JVatur  und  Erzeugung  des 
Callus,  p.  199.) 

Haller  {Elini.  Physiol,  t.  8,  p.  352),  Callisen  {Col- 
lect. Hafn.  t.  2,  p.  187),  Tenon  {Mem.,  de  I'Acnd.  des 
Sciences,  1758,  p.  415),  Bordenave  {M^m.  sur  les  Os, 
p.  227),  and  many  others,  have  seen  a part  of  the  new 
production  spring  up  from  the  substance  of  the  old 


198 


NECROSIS. 


bone ; a thing,  says  Weidmann,  wliich  one  is  also  led 
to  believe  by  the  fact,  that,  when  the  whole  tube  of  a 
long  bone  is  affected  with  necrosis,  the  epiphyses, 
which  remain  sound  and  untouched,  unite  and  grow 
to  the  new  tube,  though  no  periosteum  exists  in  the 
situation  of  the  union. 

Nor  does  Weidmann  think,  that  the  specimen  of  a 
fractured  thigh,  of  which  Blumenbach  has  published 
an  engraving,  proves  the  contrary. — {Geschichte  und 
Bersckreibung  der  Knocker;  Gottingen,  1786,  tab.  1, 
fig.  1.)  This  preparation  exhibits  a union,  which 
had  taken  place  by  means  of  a very  broad  osseous  ring, 
encompassing  the  ends  of  the  fracture,  which  lie  far 
asunder.  The  event  appears  to  Weidmann  to  have 
been  the  result  of  rachitis,  or  lues  vener#a,  with  which 
the  young  patient,  according  to  Blumenbach  himself, 
had  been  affected,  and  by  which  the  nutrition  of  this 
bone  had  been  disordered.  For,  says  Weidmann,  in 
other  examples  of  united  fractures  the  ends  of  the 
bone  are  so  connected  together  by  tiie  callus,  that  there 
does  not  exist  a single  point  between  them  where  this 
substance  is  not  effused,  and  the  medullary  canal  itself 
is  obstructed  and  filled  with  it.  In  the  Journ.  Com- 
pUjn.  du  Diet,  des  Sciences  Med.  t.  8,  may  be  found 
some  considerations  offered  by  Larrey  against  the 
doctrine,  that  the  periosteum  is  the  organ  of  ossifi- 
cation. 

Paletta  records  a case,  in  which  five  inches  of  the 
tibia  were  regenerated;  and  he  concludes,  that  the 
new  osseous  substance  was  not  formed  from  the  pe- 
riosteum, which  had  been  destroyed,  but  from  the  re- 
maining portion  of  healthy  bone. — (See  Exercitationes 
PathologiccB,  Mo.  Mediolani.)  Dr.  R.  Knox  has  also 
seen  an  instance  of  caries  of  the  trochanter  major, 
where  nature  had  attempted  to  repair  the  injury  by  a 
secretion  of  new  bony  matter  round  the  ulcerated  part 
of  the  bone,  and  where  the  new  osseous  substance  was 
evidently  formed  by  the  vessels  of  the  old  bone,  the  pe 
riosteum  remaining  perfectly  sound  and  unchanged. 
His  remarks  are  all  in  favour  of  the  doctrine  which 
refers  the  production  of  new  bone  to  the  vessels  of  the 
remaining  portion  of  living  bone. — (See  Edinb.  Med. 
Surg.  Journ.  vol.  18.)  The  concurring  opinion  of  Mr. 
Liston,  on  the  same  point,  1 have  mentioned  in  another 
place.— (See  Fracture.)  And  Mr.  B.  Bell  has  very  re- 
cently expressed  his  agreement  with  those  authors, 
“ who  do  not  assert,  that  the  periosteum  is  endowed 
with  such  complicated  functions  as  to  be  able,  not  only 
to  repair  its  owii  lesions,  but  at  the  same  time  to  secrete 
osseous  matter.”  The  membrane  that  lines  the  cavity 
of  the  new  bone,  he  also  observes,  differs  from  the  pe- 
riosteum in  being  less  dense  and  fibrous. — (OZ»s.  on 
Diseases  of  the  Bones,  p.  54,  55.) 

That,  however,  the  periosteum  is  frequently  the 
organ  of  the  reproduction  of  the  bones,  seems  proved 
by  the  experiments  of  Troja,  Blumenbach,  Desault, 
and  Koehler,  since  in  these  the  bones  were  invariably 
regenerated,  though  there  was  nothing  left  of  the  old 
bone  that  could  furnish  the  new  reproduction,  except 
the  periosteum. 

If  we  examine  the  new  bone  at  different  periods  of 
its  developement,  it  appears  in  the  earliest  state  in  the 
form  of  a reddish  fluid,  as  has  been  observed  by  Du- 
hamel,  Fougeroux,  Bordenave,  Haller,  Callisen,  and 
others.  If  we  also  attend  to  the  progressive  changes 
which  this  fluid  undergoes,  we  cannot  but  believe  that, 
as  in  the  embryo,  an  organic  and  fixed  arrangement  of 
parts  takes  place.  Indeed,  it  would  be  erroneous  to 
consider  such  fluid  as  destitute  of  organization  and  ex- 
travasated  at  random.  Thin  and  little  in  quantity  on 
its  first  appearance,  its  consistence  and  quantity  after- 
ward gradually  increase  {IVoja,  p.  42,  44),  so  that 
what  at  first  afipeared  like  a liquid,  soon  becomes  a ge- 
latinous  substance,  in  which  are  developed,  especially 
at  its  inner  surface  and  towards  its  lower  part,  bony 
fibres  which  incessantly  become  more  and  more  nu- 
merous. These  fibres  in  a short  time  form  little  layers 
and  cells,  and  extend  themselves  every  where,  so  that 
at  length  all  which  was  fluid  disappears,  and  the  new 
bone  is  produced.  While  young,  however,  it  is  still 
spongy  and  reddish  {Trnja  p.  44),  but  soon  becomes 
denser,  harder,  and  more  solid,  than  that  was  for  which 
it  is  a substitute,  and  it  acquires  the  ordinary  colour  of 
the  rest  of  the  bones. 

The  external  surface  of  the  new  bone,  which,  during 
the  period  of  its  formation,  was  irregular  and  studded 
with  several  excrescences  of  various  sizes,  and  pierced 


with  apertures  of  different  dimensions,  becomes  in  the 
course  of  time  smooth  and  regular,  especially  after  the 
expulsion  of  the  sequestrum. 

The  sides  or  walls  of  the  new  bone,  which  at  first 
were  of  considerable  thickness,  in  time  also  grow  thin- 
ner.—(7V<ya,p.  21.)  When  the  entire  dead  bony  cy- 
linder continues  in  its  cavity,  the  new  bone  is  neither 
shorter  nor  longer  than  the  original.  But  should  one 
of  the  ends  of  the  dead  tube  protrude  from  the  cavity 
while,  by  the  side  of  the  affected  bone,  there  is  not  an- 
other one  capable  of  resisting  the  action  of  the  mus- 
cles, the  new  bone  will  be  shortened,  and  undergo 
some  change  in  its  shape  and  diiection.  Indeed,  says 
Weidmann,  the  new  bone  in  its  early  state,  from  want 
of  consistence,  must  yield  to  the  efforts  of  the  muscles. 

Its  shape  is  not  exactly  like  that  of  the  original  bone : 
the  sides  are  flatter ; the  usual  angles,  depressions,  and 
eminences  are  not  observable,  and  sometimes  others 
are  formed. 

How  admirable  is  the  process  by  which  the  muscles, 
detached  from  a bone  affected  with  necrosis,  have 
other  insertioirs  given  to  them,  and  are  thus  rendered 
capable  of  performing  their  functions. — {Troja,  p.21.) 

The  periosteum,  which  swells  as  soon  as  the  exfo- 
liation of  the  old  bone  commences,  shrinks,  and  is  not 
at  all  thickened  when  the  exfoliation  fs  finished.  Tr  oja, 
having  destroyed  the  medullary  structure  of  a long 
bone,  found  tire  periosteum  swelled  at  the  end  of  36 
hours  ; but  he  observed  that  the  w'hole  of  such  swell- 
ing disappeared  before  the  25th  day. — (P.  43.  67.) 

The  periosteum  which  thus  survives  adheres  to  the 
irew  bone  as  it  did  to  the  old  otre;  its  vessels,  which  are 
now  increased  in  diameter,  and  emrvey  a larger  quan- 
tity of  blood,  dive  into  large  apertures  in  the  regerte- 
rated  bone,  ramify  every  where  in  its  substarree,  and 
nourish  it. 

Dr.  Macartney’s  observations  nearly  agree  with  those 
of  Troja  and  Weidmann  respecting  the  formation  of 
the  new  bone  by  the  periosteum,  with  this  difference, 
however,  that  he  does  not  describe  the  original  perios- 
teum as  becoming  afterward  attached  to  the  new  bone, 
but  as  disappearing.  Dr.  Macartney  remarks,  “ Uiat 
the  first  and  most  importantcircumstance  is  the  change 
which  takes  place  in  the  organization  of  the  {)erios- 
teum:  this  membrane  acquires  the  highest  degree  of 
vascularity,  becomes  considerably  thickened,  soft, 
spongy,  and  loosely  adherent  to  the  bone.  The  cellular 
substance,  also,  which  is  immediately  connected  with 
the  periosteum,  suffers  a similar  alteration:  it  puts  on 
the  appearance  of  being  inflamed,  its  vessels  eidarge, 
lymph  is  shed  into  its  interstices,  and  it  becomes  conso- 
lidated with  the  periosteum.  These  changes  are  pre- 
paratory to  the  abscuption  of  the  old  bone,  and  the  se- 
cretion of  the  new  osseous  matter,  and  even  previous 
to  the  death  of  the  bone  which  is  to  be  removed.  In 
one  instance  I found  the  periosteum  vascular  and 
pulpy,  when  the  only  affection  was  a small  abscess  of 
the  medulla,  the  bone  still  retaining  its  connexion  with 
the  neighbouring  parts,  as  it  readily  received  injection. 
The  newly  organized  periosteum,  &c.  separates  en- 
tirely from  the  bone,  after  which  it  begins  to  remove 
the  latter  by  absorption and  while  this  is  going  on 
its  inner  surface  becomes  covered  with  little  emi- 
nences resembling  granulations.  “ In  proportion  as  the 
old  bone  is  removed,  new  osseous  matter  is  dispersed 
in  the  substance  of  the  granulations,  while  they  con- 
tinue to  grow  upon  the  old  bone,  until  the  whole  or  a 
part  of  it  is  completely  absorbed,  according  to  the  cir- 
cumstances of  the  case.  What  remains  of  the  invest- 
ment after  the  absorption  of  the  old  bone  and  the  form- 
ation of  the  osseous  tube  which  is  to  replace  it,  dege- 
nerates, loses  its  vascularity,  and  appears  like  a lace- 
rated membrane.  I have  never  had  an  opportunity  of 
examining  a limb,  a sufficient  lime  after  the  termina- 
tion of  the  disease,  to  ascertain  whether  the  investment 
be  at  last  totally  absorbed  ; but  in  some  instances  I have 
seen  very  little  remaining.  During  the  iirogress  of  the 
disease,  the  thickened  cellular  substance  which  sur- 
rounded the  original  periosteum  becomes  gradually 
thinner;  its  vessels  diminish,  and  it  adheres  strictly  to 
the  new-formed  bone,  to  which  it  ultimately  serves  as 
a periosteum.”  Dr.  Macartney  slates,  that  the  anato- 
mical preparations  which  authenticate  the  above  ob- 
servations were  preserved  at  St.  Bartholomew’s  Hos- 
pital.-^(See  Crowlher  on  Mhitc  Swelling,  p.  183,  ed.2.) 

Mr.  Stanlei',  however,  lately  showed  me  in  the  same 
museum  a preparation  which  tends  to  confirm  the  ac- 


NECROSIS. 


199 


euracy  of  Troja’s  account  of  the  old  periosteum  be- 
coming adherent  to  the  new  bone.  In  this  example  the 
periostenin  is  perfectly  continuous  with  that  covering 
the  epiphyses.  If  this  were  not  the  fact,  we  should  liave 
to  explain  in  what  way  tlie  periosteum  of  the  new 
bone  IS  formed.  We  know  that  the  vessels  of  the  ori- 
ginal periosteum  enter  the  new  bone,  in  order  to  com- 
plete its  formation  ; and  it  seems  more  consonant  witfi 
the  uniform  simplicity  of  nature’s  operations,  to  sup- 
pose that  this  connexion  is  kept  up,  than  that  the  old 
periosteum  should  be  totally  removed  after  the  produc- 
tion of  the  new  bone,  and  anoUier  membrane  of  the 
same  kind  be  then  generated. 

An  interesting  example  of  necrosis  of  the  thi<»h  bone, 
published  some  time  ago  by  Mr.  C.  Hutchison,  tends  also 
to  prove  that  the  new  osseous  shell  is  commonly  formed 
by  the  periosteum,  as  in  this  case  the  medullary  ba^s 
or  cells  were  found  completely  ossified  {Practical  Obs. 
in  Surgery, p.  135),  and  could  not  therefore  be  supposed 
to  be  capable  of  the  work.  Among  the  moderns.  Dr. 
M'Donald  deserves  to  be  mentioned  as  one  of  the  most 
distinguished  advocates  for  the  truth  of  Troja’s  e.x- 
planation  of  this  subject.— (See  McDonald's  Thesis  'de 
Mecrosi  ac  Callo ; Edinb.  1799.)  Another  late  writer 
has  adduced  many  arguments  to  prove  that  the  pulpy 
mass  which  extends  from  one  epiphysis  to  tiie  other, 
and  is  itself  at  last  converted  into  bone,  is  formed 
quite  independently  both  of  the  original  bone  and  of 
the  periosteum  — (See  Russell’s  Practical  Essay  on 
Mecrosis,  p.  27,  Edinb.  1795.)  This  account,  how- 
ever, is  contrary  to  the  observations  of  Troja,  David, 
Weidmann,  M'Donald,  Macartney,  and  numerousother 
observers.  Indeed,  Mr.  Hutchison  seems  to  think  the 
periosteum  so  essential  to  ossification,  or  the  produc- 
tion of  a new  bone,  that  he  altempts  to  explain  the 
cause  of  fractures  of  the  patella  not  becoming  umted 
by  a bony  substance,  by  adverting  to  the  deficiency  of 
periosteum  upon  it ; a circumstance  which  he  deems 
also  a strong  arL'ument  against  Mr.  Russell’s  doctrine. 
-(See  Practical  Observ.  in  Surgery,  p.  141,  142.) 

These  very  same  cases,  however,  fractures  of  the 
patella,  do  sometimes  unite  by  bone,  and  therefore, 
while  Mr.  Hutchison  is  urging  them  as  facts  against 
Mr.  Russell’s  opinion,  Baron  Larrey  is  actually  adduc- 
ing them  in  its  support.— (See  .Journ.  Complem.  du 
Diet,  des  Sciences  MH.  t.  8.)  The  experiments  of 
Breschet  and  Villerm^  (see  Fracture)  are  decidedly 
against  the  periosteum  being  exclusively  the  organ  of 
ossification. 

Boyer  does  not  refer  all  the  work  of  reproducing 
hones  exclusively  to  the  periosteum  in  every  instance; 
but  joins  Weidmann  in  believing,  that  what  seems  a 
new  bone  is  sometimes  only  a separation  and  thicken- 
ing of  the  external  layers  of  the  original  bone,  which 
haveescaped  destruction.  He  notices  the  modifications 
to  which  the  phenomena  of  necrosis  are  subject  when 
the  disorder  affects  the  whole  thickness,  and  the  whole 
or  the  greater  part  of  the  circumference  of  a long  cy- 
lindrical bone.  When  the  periosteum  is  destroyed 
togethe-  with  the  bone,  and  the  medullary  membrane, 
which  does  the  office  of  an  internal  periosteum,  is  pre- 
served, Boyer  represents  the  latter  membrane  as  under- 
going similar  changes  to  those  which  we  have  men- 
tioned as  taking  place,  under  other  circumstances,  in 
the  external  periosteum,  and  he  describes  it  as  becoming 
the  organ  by  which  the  new  bone  is  formed.— (See 
Traiti  des  Maladies  Chir.  t.  3,  p.  432.)  But  when 
the  whole  thickness  and  circumference  of  a long  bone 
are  destroyed,  together  with  the  medullary  membrane, 
while  the  periosteum  survives,  Boyer  agrees  with 
Troja,  &.C.  in  believing  the  latter  membrane  to  be  the 
means  by  which  the  new  bone  is  generated. 

The  internal  surface  of  the  new  bone  is  lined  by  a 
new  membrane,  which  serves  as  a periosteum,  and  is 
at  first  hardly  distinguishable.-.'  Troja,  p.  56.)  In  the 
early  state,  it  is  soft  and  pulpy  (ibid.  p.  ■,  but,  by 
degrees,  it  grows  thicker  and  firmer,  and  is  at  length 
converted  into  a true  membrane,  which  sends  a great 
number  of  vessels  into  the  substance  of  the  bone. 
When  this  membrane  is  torn  off,  the  surface  which  it 
covered  is  found  somewhat  smooth,  the  edges  of  the 
bony  layers  and  projections  of  the  fibres  being  blunt 
and  rounded. 

The  cavity  of  the  new  bone  includes,  and  almost  en 
tirely  conceals,  the  dead  fragments.  Sometimes,  how- 
ever, the  new  bone  forms  a sort  of  bridge  over  the  se- 
quc-drum,  in  such  a manner  that  the  cavity  is  open 


above  and  below,  in  both  which  situations  the  se- 
questrum can  be  felt. — {Hunter,  in  Med.  Obs.  and  In~ 
quiries,  vol.  2,  p.  418.) 

Sometimes  it  is  only  a narrow  cross-piece,  which 
forms  the  bridge  retainifig  the  sequestrum — {Weid- 
mann, vid.  tab.  5,  Jig.  1,  a.) 

The  new  bone  may  also  have  an  opening  in  it,  out 
of  which  the  dead  portion  protrudes. — {Ib.p.  35.) 

Sometimes  the  cavity  of  the  new  bone  is  single : 
while,  in  other  instances,  there  are  several  successive 
cavities  in  the  direction  of  the  length  of  the  bone,  with 
transverse  interspaces  between  them  ; or  else  the  cavi- 
ties are  situated  laterally  with  respect  to  each  other, 
and  divided  by  partitions. — ( Weidmann,  tab.  "7,  Jig.  2.) 

These  cavities  are  proportioned  in  size  and  shape  to 
the  fragments  of  dead  bone  which  lodge  in  them.  It 
occasionally  happens,  that  they  open  into  some  neigh 
bouring  joint,  and  bring  on  suppuration  there:  a very 
unfavourable  complication. — {Ibid.  p.  34,  and  tab.  6, 
Jig.  3 ; also  Boyer,  Traiti  des  Mai.  Chir.  tom.  3,  p. 
4;f5.) 

Let  us  next  follow  Weidmann,  and  take  notice  of 
the  holes,  by  which  the  cavities  including  the  dead 
I'ieces  of  bone  open  externally,  which  Troja  denomi- 
nated the  large  foramina,  and  which  the  preceding  ex- 
cellent wriver  preferred  calling  the  cloacee,  because 
they  serve  to  coiivf^y  outwards  the  matter  and  any  sepa- 
rated pieces  of  bone.  In  the  beginning  of  the  disorder 
they  are  not  observable,  a certain  space  of  time  ap- 
pearing to  be  requisite  for  their  formation.  They  are 
noticed  in  long  cylindrical  bones,  whether  original,  or 
of  new  production,  whose  cavities  contain  dead  frag- 
ments. 

These  openings  vary  in  number  ; when  the  seques- 
trum is  small,  only  one  is  found ; but  when  the  piece 
of  dead  bone  is  extensive,  there  may  be  two,  three,  or 
four.  Weidmann  never  saw  more  than  five.  But 
Troja  met  with  eight. — (P.  58.)  Weidmann  possessed 
a small  portion  of  the  diploe  of  the  os  innominaturn, 
which  was  affected  with  necrosis,  and  contained  in  a 
bony  cavity,  that  had  no  external  opening  whatever. 

When  there  are  several  distinct  cavities  in  the  same 
bone,  containing  dead  fragments,  each  cavity  has  at 
least  one  external  opening. 

These  cloacce,  or  apertures,  are  commonly  situated 
at  the  lower  and  lateral  parts  of  the  cavities;  pass 
obliquely  outwards ; and  communicate  with  fistulous 
ulcers,  which  open  on  the  surface  of  the  skin. — {Da- 
vid, p.  186.)  Some  of  the  cloacae,  however,  form  at 
the  middle,  or  (what  is  exceedingly  rare)  at  the  upper 
part  of  the  cavities,  and  proceeding  outwards,  without 
any  oblique  track,  go  to  the  front,  back,  or  lateral 
parts  of  the  limb. 

They  are  of  a round  or  oval  shape,  or  nearly  so. 
Their  usual  size  is  such  that  it  will  just  admit  a quill, 
and  they  vary  very  little  from  this  dimension. 

They  terminate  internally  by  converging  approach- 
ing edges,  in  the  manner  of  a funnel ; while,  on  the 
contrary,  the  margins  of  their  outer  extremity  expand. 
The  canal  between  these  two  orifices  is  sometimes 
long,  sometimes  short,  and,  in  certain  cases,  of  no  ex- 
tent at  all. 

Different  opinions  have  been  broached  respecting 
the  causes  which  produce  the  apertures  in  the  new 
bone,  termed  by  Weidmann  the  cloacce. 

M.  David  says  that  the  pus,  collecting  in  an  early 
stage  of  the  disease  between  the  bone  and  the  perios- 
teum, distends  and  corrodes  this  membrane,  and  that 
the  openings  which  form  in  it  become  afterward  a 
cause  of  fistnlre  in  the  new  bone. — (P.  186.)  But  it  is 
observed  by  Weidmann,  that  this  explanation  is  inad- 
missible, since  the  existence  of  the  collection  of  pus, 
mentioned  by  M.  David,  is  not  proved  by  observation  : 
in  fact,  it  was  never  met  with  by  Troja,  Blumenbach, 
Desault,  Koehler,  and  many  others,  in  repeated  expe- 
riments on  the  subject. — {Troja,  p.  56  and  66;  Weid- 
mann, p.  36.) 

Koehler  thought  he  had  seen  the  new  bone  itself  de- 
stroved  by  the  pus,  and  cloacce  thus  produced. — (P. 
68--72.) 

Weidmann,  however,  deems  this  opinion  quite  as 
improbable  as  the  preceding,  for  the  fact  of  the  surface 
of  these  bony  apertures  being  always  smooth,  always 
formed  in  one  manner,  and  constantly  lined  by  the  pe- 
riosteum, decidedly  proves  that  they  cannot  arise  from 
erosion. 

Troja,  in  his  third  experiment  upon  the  regeneration 


200 


NECROSIS, 


of  bones,  remarked,  that  forty-two  hours  after  the  de- 
struction of  the  medulla,  there  took  place,  between 
the  bone  and  the  periosteum,  an  effusion  of  lymph, 
which  was  at  first  thin  and  in  small  quantity,  but  af- 
terward became  thicker.  He  noticed,  in  the  midst  of 
this  gelatinous  substance,  some  small  spaces,  where  it 
was  deficient,  and  which  had,  instead  of  it,  a sxibtle, 
whitish,  dry  incrustation,  which,  though  tolerably  ad- 
herent, could  be  rubbed  off.  These  small  spaces,  accord- 
ing to  Troja,  produce  the  apertures  called  the  cloacce. 
— ( Troja,  p.  45.) 

In  another  experiment,  he  had  an  opportunity  of 
examining  the  above  little  spaces  at  the  end  of  forty- 
eight  hours  : he  affirms  that  they  were  replaced  by  the 
large  apertures  or  cloacae  of  the  new  bone  (P.  47),  and 
that  such  openings  were  invariably  formed  in  the 
place  of  the  small  incrusted  spaces  already  described. 
— (P.  58.)  As  Troja  took  notice  that  no  lymph  was 
effused  at  these  particular  points,  he  was  inclined  to 
impute  the  circumstance  to  adefectin  the  ossification, 
and,  perhaps,  to  the  death  of  some  parts  of  the  perios- 
teum.  Weidmann  acknowledges  that  the  mode  in 
which  the  formation  of  the  cloacae  happens  is  exceed- 
ingly obscure;  and  expresses  his  belief  that  Troja’s 
account  of  it  is  the  nearest  to  the  truth.  But,  says*  tie, 
one  filing  is  certain,  namely,  that  these  openings  have 
no  other  use  but  that  of  conveying  outwards  the  pus, 
which  collects  in  the  cavity,  and  tbc  small  bony  frag- 
ments, since,  as  soon  as  every  atom  of  dead  bone  has 
passed  out,  they  diminish,  and,  at  length  are  totally 
obliterated. — ( Weidmann,  De  JVecrosi  Ossium,  p.  36.) 

It  is  a remarkable  circumstance  in  the  history  of  ne 
crosis,  that,  in  favourable  instances  of  the  disease,  the 
inflexibility  and  firmness  of  the  limb  are  preserved, 
during  the  whole  of  the  process  by  which  the  new 
bone  is  formed.  Consequently  the  new  bone  must 
have  begun  to  grow  and  have  acquired  firmness  before 
the  old  bone  separated  or  was  absorbed.  Were  this 
not  the  case,  the  limb  mus*t  become  flexible  and  useless 
the  moment  the  dead  bone  is  removed.  Another  con- 
sequence of  the  new  bone  being  formed  before  the  re- 
moval of  the  old  one,  is  that  the  former  must  surround 
and  include  the  latter.  For,  since  the  lifeless  portion 
of  bone  completely  occupies  the  space  between  the 
two  living  ends,  these  cannot  be  immediately  con- 
nected by  the  new  bony  matter.  The  connexion  can 
alone  be  completed  by  the  new  bone  being  deposited 
on  the  outside  of  the  old  one,  from  one  end  to  the  other, 
and  attaching  itself  to  the  portions  which  still  remain 
alive.  The  new  bone  must  also  be  necessarily  larger 
than  tlie  old  one,  because  externally  situated ; and 
hence  the  affected  limb,  after  the  cure  is  complete, 
will  always  continue  larger,  clumsier,  and  less  shapely 
than  the  other.  The  length  of  it,  however,  remains 
unaltered,  because  the  old  bone  retains  its  attachment, 
while  the  rudiments  of  the  new  bone  are  lying  on  its 
outside,  and  connect  the  living  ends  of  the  old  one,  by 
an  inflexible  mass,  equal  in  length  to  the  portion  which 
is  destroyed. 

Thus  we  see,  that  in  the  process  which  nature  fol- 
lows in  the  formation  of  the  new  osseous  shell,  the  old 
bone  serves  as  a mould  for  the  new  one,  and  the  firsi 
step  of  the  process  is  to  surround  the  old  bone  with  an 
effusion  of  coagulating  lymph. — (See  Russell  on  JVe- 
crosis,  p.  2 — 7.) 

When  the  sequestrum  is  thrown  off  slowly,  the' in- 
flammation is  moderate  ; but  when  itseparates  quickly, 
while  the  new  bone  is  in  a soft  state,  the  detachment  is 
always  preceded  by  severe  inflammatory  sym|)toms, 
and  followed  by  a temporary  loss  of  the  naiural  firm- 
ness of  the  limb.  This  premature  separation  of  the 
sequestrum  often  occurs  in  necrosis  of  the  lower  jaw, 
and  the  chin  consequently  falls  down  on  the  neck.  In 
certain  cases,  the  sequestrum  separates  at  each  end 
from  the  living  portions  of  the  old  bone,  before  the 
new  osseous  shell  has  acquired  firmness,  so  that  the 
limb  feels  as  if  it  were  broken  in  two  places. — {Russell.) 

Let  us  next  consider  the  states  and  circumstances  of 
necrosis,  in  which  the  art  of  surgery  may  be  advan- 
tageously exerted  in  the  assistance  of  nature,  and  the 
means  which  may  be  employed  for  the  purpose. 

A common  error  of  medical  and  surgical  practi- 
tioners is  always  to  impute  the  cure  of  every  disease 
to  whatever  remedies  happen  to  be  employed,  and  suc- 
cesses are  too  often  boasted  of,  the  merit  of  which  be- 
longs entirely  to  nature.  Iti.-,  indeed,  not  very  unfre- 
quent to  hear  remedies  panegyrically  spoken  of,  which 


counteract  the  salutary  efforts  of  nature,  who,  in  this 
case,  is  obliged  to  overcome  both  the  disease  and  the 
irrational  treatment  which  is  applied  to  it.  As  Weid- 
mann observes,  this  erroneous  inode  of  considering 
things  has  happened  paiticularly  often  among  sur- 
geons who  have  had  cases  of  necrosis  under  their 
care,  all  of  whom  boast  of  the  cuies  which  they  have 
accomplished,  although  some  employed  ab.-iorbent 
earths;  others,  aromatics ; some,  spirituous  applica- 
tions; others,  balsams;  some,  acids;  others,  causiics ; 
and  some,  armed  with  a wimble,  made  numerous  per- 
forations in  the  dead  bone;  while  many  others  rasped 
the  part,  or  attacked  it  with  the  trepan,  cutting  for- 
ceps, the  gouge  and  mallet,  or  even  the  actual  cautery; 
and  a certain  number  did  nothing  more  than  apply  dry 
lint.  Nature,  who  was  favouiable  to  all,  did  her  own 
work  in  silence,  whatever  were  the  remedies  employed 
for  her  assistance:  whether  mild  and  inert,  acrid  and 
corrosive,  or  hurtful  and  improper. 

We  have  already  noticed,  that  a dead  portion  of 
bone  separates  from  the  living  exactly  in  the  same  way 
as  gangrenous  soft  parts  spontaneously  drop  off  with- 
out the  interference  of  art.  The  separation  happens 
precisely  at  the  points  to  which  death  has  extended  ; 
limits  which  are  well  understood  only  by  nature,  and 
of  course  can  be  measured  only  by  her.  Art  would 
incur  great  risk  of  either  going  beyond  them,  or  else  of 
not  reaching  them  at  all.  Perhaps  it  may  be  deemed 
unsafe  to  confide  the  process  of  separation  or  exiolia- 
tion  to  nature  But  in  what  other  manner  could  it  be 
more  safely  accomplished,  without  hemorrhage  or  pain 
to  the  patient — without  any  risk  of  a recurrence  of  in- 
flammation, or  of  a fresh  necrosis  ? 

Is  there  reason  to  fear,  that  when  every  thing  is  left 
to  nature,  the  separation  cannot  be  finished  till  after  a 
very  long  period  of  time  I It  is  true,  says  Weidmann, 
that  the  process  frequently  requires  a considerable 
time;  but  as  the  vitality  of  the  bones  is  not  possessed 
of  much  energy,  and  their  com[)onent  parts  strongly 
cohere,  slowness  is  inevitable  in  an  operation  which 
depends  entirely  upon  the  vital  power.  What  is  it 
then  which  surgery  can  do  to  accelerate  the  process  1 

Will  any  of  the  above-mentioned  topical  applica- 
tions have  this  effect"?  They  are  put  upon  the  inert 
surface  of  a dead  piece  of  bone,  in  which  no  vi- 
tal power  or  action  can  be  again  excited.  When 
acrid,  they  prove  irritating,  inflaming,  and  destructive 
of  the  neighbouring  flesh,  without  any  utility — and 
cause  pain  to  the  patient,  which  is  compensated  by  no 
good.  Would  the  perforations  recommended  by  Cel- 
sus,  Bellosfe,  and  many  others,  have  the  desired  effect"? 
If,  says  Weidmann,  they  are  confined  to  the  dead 
bone,  they  cannot  have  more  effect  than  the  scarifica- 
tions which  were  formerly  practised  by  ignorant  sur- 
geons in  cases  of  gangrene  : and,  if  they  extend  to  the 
living  bone,  this  w'ill  be  injured,  or  at  least  run  the 
risk  of  being  so.  Lastly,  Weidmann  demands,  if  the 
separation  can  be  accelerated  by  the  actual  cautery, 
which  cannot  act  upon  every  point  of  the  necrosis, 
and  which,  unless  applied  with  the  greatest  precau- 
tions, will  burn  the  subjacent  parts,  and  biing  on  a 
new  attack  of  inflammation,  without  forwarding  the 
exfoliation  in  the  smallest  degree? 

Of  what  use  can  rasping  and  scraping  instruments 
be,  which  act  merely  upon  the  dead  parts?  Or  will 
the  gouge,  and  other  cutting  instruments,  do  more 
good?  They  cannot  take  away  the  whole  of  the 
dead  portion,  without  injuring  the  adjacent  living 
bone,  and  causing  a risk  of  another  necrosis.  And  il 
they  leave  any  pieces  of  the  old  dead  bone  behind,  na 
tnre  will  be  as  long  in  effecting  the  separation  ot 
these,  as  she  would  have  been  in  detaching  the  entire 
necrosis. 

Weidmann  mentions  a ca.ee  which  occurred  in  the 
hospital  of  St.  Roch  at  Mentz.  A tnan’s  legs  were 
seized  with  mortification  in  consequence  of  exposure 
to  cold  ; the  whole  of  the  dead  parts  separated  ; and 
the  bones  were  sawn  through  on  a level  with  the  living 
flesh.  A portion  of  the  end  of.etich  bone,  however, 
was  afterward  thrown  off  altogether  by  nature;  and 
Weidmann  thence  concludes,  that  the  previous  use  of 
the  saw  had  been  fruitless.  Weidmann  then  cites  an- 
other case  of  moitifii-ation  of  the  leg  and  half  of  the 
thigh,  which  was  the  consequence  of  a ptitrid  fever 
The  leg  sloughed  away,  leaving  the  lower  portion  of 
the  thigh-bone  uncovcied  and  projecting-  Fndcr  a 
tonic  plan  of  treatment,  this  part  of  the  bone  sironta 


NECROSIS.  201 


neously  separated.  A.s,  however,  a considerable  quan- 
tity of  iiiteifuments  liad  been  destroyed,  the  ulcer  was 
slow  in  healing ; but  it  cicatrized  at  last,  and  the  young 
woman  continued  well  long  afterward. 

Weidmanti  has  quoted  the  memorable  casein  which 
Mr.  C.  White  first  sawed  off  the  upper  part  of  a dis- 
eased tiumerus. — (riee  imputation.)  As  in  this  in 
stance  nature  accottiplished  of  lierself  the  separation 
of  another  dead  poriion  of  the  same  bone,  two  months 
after  tlie  operation,  Weidmann  seems  disposed  to  think 
the  cure  would  have  happened  equally  well  without  it. 

In  cases  of  slight. superficial  necrosis,  surgeons  have 
frequetit  opportunities  of  trying  evi-ry  kind  of  topical 
application;  and  when  the  cure  takes  place  during  the 
use  of  any  of  them,  the  benefit  is  ascribed  to  whatever 
happens  to  be  in  use.  But,  says  Weidmann,  in  nu- 
merous more  serious  e.\am pies  of  necrosis,  it  is  impos- 
sible to  make  these  applications  reach  the  whole  sur- 
face of  the  dead  bone;  but,  notwithstanding  this  cir- 
cninstance,  the  separation  is  not  impeded.  Some  ex- 
foliations happen,  without  our  knowing  of  their  occur- 
rence, and  without  a thought  having  been  entertained 
of  promoting  them  by  any  vaunted  a|)[)licaiions.  We 
even  see  necroses  separate,  whose  situaiioti  rendered 
theitt  inaccessible  to  our  remedies;  such  are  the  ne- 
croses which  occur  within  the  long  boties,  and  compre- 
hend the  whole  of  their  cylindrical  shaft  or  body. 
What  surgeon  can  boast  of  having  effected,  by  topical 
applications,  the  separation  of  the  whole  low'er  jaw- 
hotie  ? a thing  which  nature  has  very  frequentl.t  ac 
coinplished.  And  when,  as  often  happens,  the  entire 
diaphysis  of  the  thigh-bone,  tibia,  or  other  long  bone, 
comes  away  ; or,  split  longitudinally,  such  bone  loses 
a half  of  its  cylinder;  how  is  it  possible  for  any  to- 
pical applications  to  reach  every  point  at  which  the 
separation  occurs? 

The  internal  remedies,  such  as  asafoetida,  madder, 
sarsaparilla,  hemlock,  belladonna,  onopordum,  lime- 
water,  &c.  recommended  by  numerous  practitioners, 
have  in  reality  no  direct  efficacy  in  promoting  the  se- 
paration of  necroses:  if,  says  VVeidmann,  they  do  any 
good,  it  can  only  be  by  their  tonic  and  alterative  qua- 
lities, nr  rather  by  keepitvg  the  patient  amused,  so  as  to 
gain  the  requisite  time  for  the  completion  of  the  pro- 
cess of  exfoliation.  The  employment  of  all  these  in 
effectual  tneans,  Weidmann  conceives,  must  have  ori- 
ginated from  ignorance  of  the  process  followeil  by 
nature  in  separating  dead  portions  of  bone,  and  from 
ascribing  to  the  arterial  pulsations,  or  the  power  of  the 
granulations,  what  certainly  depends  upon  the  action 
of  the  absorbetit  vessels. 

A question  here  naturally  presents  itself— Would 
there  be  any  utility  in  exciting  by  stimulants  the  action 
of  the  lymphatic  vessels,  in  order  to  accelerate  the  se- 
paration, of  which  it  is  the  efficient  cause  ? 

Weidmann  thinks  that  very  beneficial  effects  might 
result  from  the  plan.  But,  he  asks,  what  means  should 
be  used  for  this  object ? Cold?  Purgative  medicines? 
Repeated  vomits ? Squills?  Catnphor?  N'eutral  salts? 
Issues? — (Vide  IVrisberff,  Cunimevt.  Sac.  Reg-  Gott. 
vol.  9,  p.  136,  1789.)  The  internal  and  external  em- 
ployment of  the  preparations  of  iodine,  a medicine 
which  ha.s  extraordinaiy  power  in  increasing  the  ac- 
tivity of  the  absorbents,  might  deserve  a trial. 

The  reasons  already  detailed,  and  a variety  of  ex- 
periments succe.'sfully  made  by  Weidmann,  lead  him 
to  >.et  it  down  as  an  established  principle,  that  the  se- 
paration of  a necrosis  is  almost  etitirely  the  work  of 
nature,  and  that  surgery  can  do  very  little  in  the  busi- 
ness. 

Ignorance  of  this  important  fact  paved  the  way  to 
the  wrong  practice  ttf  making  incisions,  for  the  purpose 
of  exposing  the  whole  surface  of  a necrosis,  immedi- 
ately the  existence  of  the  disorder  was  known.  As 
such  incisions  very  soon  closed  up  again,  so  as  to  leave 
only  a .small  outlet  for  the  matter,  they  were  in  many 
cases  repeatedly  practised  before  the  dead  bone  became 
loose. 

The  avowed  design  of  the  incisions  was  to  make 
room  for  the  topical  remedies  which  were  to  render 
the  exfoliation  quicker ; but  as  these  remedies  prrs.sess 
no  n iii  efficacy,  it  follows,  that  making  inci.sions  be- 
fore the  dead  bone  is  loose,  only  torments  the  patient 
without  prr>ducing  the  least  benefit. 

The  orifices  of  the  ulcers,  then,  which  allow  the  dis- 
charge to  escape  freely,  are,  says  Weidmann,  sufficient 
as  long  as  the  fragments  of  bone  are  not  entirely  de- 


tached, and  the  surgeon  should  all  this  period  abstain 
from  I he  use  of  the  knife. 

Alihouiih  Weidmann  condemns  every  mode  of  treat- 
ment which  is  inefficacious,  painful,  and  sometimes 
even  hurtful,  he  would  "not  have  it  supposed  that  he 
altogether  rejects  all  as.sistance  from  medicine.  On  the 
contrary,  he  approves  of  all  those  means  which  aie 
consistent  with  the  views  of  nature,  which  really  as- 
sist her,  and  do  not  tease  the  patient  to  no  purpose.  In 
short,  says  he,  the  indications  are  limited  to  remoning 
the  original  cause  of  the  disease ; to  alleviating  ihe 
symptoms  ; to  supporting  the  patient's  strength,  and 
improving  the  state  of  the  constitution,  in  whatever 
respect  it  may  be  bad;  and,  lastly,  removing  the  dead 
portions  of  bane  when  they  become  loose. 

Above  all  things  (continues  this  sensible  practitioner), 
the  surgeon  must  not  regaid  every  piece  of  exposi  d 
bone  as  necessarily  affected  with  necrosi.s,  and,  in  con- 
sequence of  such  idea,  have  recourse  to  ac.id,  diying, 
caustic  applications.  Such  means  are  not  only  useless, 
but  absolutely  pernicious;  because  they  may  actually 
Cciuse  a necrosis  which  did  not  exist  before  they  were 
used,  and  which  wonid  not  have  taken  place  at  all  if 
only  mild  simple  dressinsrs  had  been  employed. 

When  the  ilisease  piesents  itself  with  violent  symp 
toms,  the  infiannnaiion  and  fever  being  intense,  tlie 
seventy  of  the  case  is  to  be  assuaged  by  low  diet,  an- 
tiphlogistic lemedies,  emollient  applications,  and  vene 
section  in  moderation,  the  disease  being  one  wtiich  is 
ol  long  duration,  and  apt  to  wear  out  the  patient’s 
strength.  Here,  perhaps,  topical  bleeding  ought  alu  ays 
to  be  preferred  to  venesection.  When  the  necrosis 
has  arisen  frotn  .syphilis,  scrofula,  or  scurvy,  &c.  the 
medicines  calculated  for  the  cure  of  these  aii’ections 
must  be  exhibited  ere  any  favourable  changes  ctin  be 
expected  in  the  state  of  the  diseased  bone. 

Lastly,  it  is  the  duty  of  the  practitioner  to  extract 
the  fragments  of  dead  bone,  in  o der  that  the  defi- 
ciencies produced  by  them  may  be  filled  up,  and  the 
ulcers  of  the  soft  paits  heal. 

Nature,  who  succeeds  by  herself  in  demcliing  the 
dead  pieces  of  bone,  can  do  very  little  in  promoting 
their  passage  outwards.  Frequently,  indeed,  she  has 
no  power  at  all  in  this  process,  and  it  is  only  from  sur- 
gery that  assistance  can  be  derived.  When  a dead 
piece  of  bone  is  still  adherent  at  some  points,  its  ex- 
traction should  be  postponed  until  it  has  become  com- 
pletely loose.  If  it  were  forcibly  pulled  away,  there 
would  be  danger  of  ItWing  a part  of  it  behind,  which 
must  have  time  to  separate  ere  the  cure  can  be  accom- 
plished. 

But  when  a fragment  is  entirely  detached,  and  the 
orifices  Ol' the  sores  are  sufficienily  large,  it  is  to  be 
taken  hold  of  with  a pair  of  forceps,  and  extracted. 

When  the  ulcer  has  only  a very  narrow  opmiing, 
suitable  incisions  must  be  practised,  in  order  to  facili- 
tate the  removal  of  the  loose  dead  bone. 

Sometimes  the  dead  fragment  protrudes  from  the 
nicer,  and  projects  externally,  so  that,  if  loose,  it  ad- 
mits of  being  taken  hold  of  with  the  fingers  and  re- 
moved. In  this  way  Weidmann  took  away  a large 
dead  piece  of  the  humerus,  which  p otruded  nearly 
iw'o  inches  out  of  an  ulcer  in  the  middle  of  the  arm. 
The  patient  was  a young  lad,  fourteen  years  of  age; 
and  the  limb  concave  within,  convex  externally, 
thicker  and  one  inch  shorter  than  its  fellow.  He  got 
quite  well  three  weeks  after  the  removal  of  the  dead 
bone. 

We  have  already  adverted  to  the  example  recorded 
by  Weidmann,  iti  which  a shoemaker  rr!moved  by 
himself  neatly  the  whole  body  of  the  tibia.  Doubtless, 
the  projection  of  the  bone,  and  its  looseness,  enabled 
the  man  to  do  this  easily  with  his  fingers.  But  there 
are  cases  which  present  more  difficulty : such  are  those 
in  which  the  sequestrum  is  included  in  a cavity  either 
of  the  original  or  new  bone. 

The  old  surgeons  were  in  the  habit  of  amputating 
limbs  which  were  in  this  state;  although  instances 
were  not  wanting  in  their  days  to  prove  the  possibility 
of  relieving  the  disease  without  am[)utation.  3’his 
blameable  custom  of  rettioving  every  limb  thus  affected 
is  justly  ex()loded  from  modern  surgery.  Albiicasis  was 
the  first  who  atlettipted  to  cure  such  a necrosis  by  the 
judicious  employment  of  the  knife  and  saw. — {Lib. 2, 
ca/o88.)  1'he  same  kind  of  practice  was  succe.esfully 
adopted  in  two  instances  by  the  celebrated  Scultetus. 
— (ISee  Armament.  Chirurg.  tab.  *16,  and  oOs.  81.)  Thi» 


202 


NECROSIS. 


commendable  method,  however,  afterward  fell  into 
ditiiise,  until  M.  David,  by  twenty  examples  of  success, 
refuted  all  the  objections  which  had  beeti  urged  against 
it.— (P.  197.)  Since  the  period  of  this  distinguished 
author  the  practice  has  been  imitated  by  all  enlightened 
surgeons,  so  that  the  case  is  no  longer  regarded  as  a 
disease  necessarily  requiring  amputation.  M.  Bousse- 
lin  cut  out  the  sequestrum  eight  times  from  the  tibia 
and  four  times  from  the  thigh-bone  with  perfect  suc- 
cess.— {Vide  Mini,  de  la  Sucieti  Roy  ale  de  Medecine, 
t.  4.) 

The  method  consists  in  exposing  the  bone,  and 
making  in  it  an  o|)ening  of  sufficient  size  for  the  re- 
moval of  the  loose  dead  fragments. 

Experience  has  proved,  not  only  that  patients  af- 
fected with  necrosis  easily  bear  this  operation,  but 
also,  that  after  its  performance,  the  ulcers  commonly 
heal  very  favourably,  the  health  becomes  re-esta- 
blished, and  the  functions  of  the  part  alfected  are 
hardly  at  all  impaired. 

Surgeons,  however,  are  not  indiscriminately  to 
choose  any  period  for  doing  the  operation.  If  they 
are  too  hasty,  they  will  run  a risk  of  finding  the  dead 
portion  of  bone  still  adherent  to  the  adjacent  parts: 
and  if  they  delay  too  long,  the  patient  may  be  irreco- 
verably reduced,  while  the  rtew  bone,  on  account  of 
the  hardness  which  it  has  now  acquired,  cannot  be  so 
easily  perforated. 

Patients  are  met  with  who  have  been  afflicted  with 
necrosis  several  years.  In  such  cases  great  circum- 
spection is  necessary,  and  the  practitioner  should  care- 
fully endeavour  to  ascertain  that  the  dead  pieces  of 
bone  have  not  been  absorbed,  nor  come  away  piece- 
meal in  the  discharge,  lest  a useless  operation  should 
be  done,  as  once  happened  in  the  practice  of  M.  Bous- 
selin. — (Mim.  de  la  Societi  Royale  de  Medecine,  t.4,p. 
^.)  Therefore,  when  the  disease  is  of  long  conti- 
nuance, when  the  discharge  is  much  less  than  it  was 
at  the  commencement,  when  small  pieces  of  bone  have 
at  times  been  voided,  and  the  sequestrum  cannot  be 
felt  with  a probe,  it  is  doubtless,  says  Weidmann,  most 
prudent  to  abandon  all  idea  of  operating,  and  allow 
nature  to  finish  what  she  has  so  well  begun.  In  short, 
when  the  sequestra  are  undergoing  a gradual  absorp- 
tion without  ever  making  their  appearance  externally, 
or  giving  any  considerable  disturbance  to  the  constitu- 
tion, or  when  the  dead  bone  is  making  its  way  out- 
wards without  occasioning  urgent  inconveniences,  the 
surgeon  should  interfere  very  little  with  the  natural 
progress  of  the  case.  When  the  dead  bone  does  not 
tend  to  make  its  way  through  the  skin,  but  lies  quietly 
concealed  in  the  new  osseous  shell,  extensive  suppu 
rations  may  be  prevented,  by  occasionally  applying 
leeches,  and  keeping  open  a blister  with  the  savine 
cerate,  as  recommended  by  Mr.  Abernethy  in  his  Lec- 
tures, and  Mr.  Crow'ther  in  his  work  on  the  White 
Swelling.  The  blister  will  at  the  same  time  have 
great  effect  in  promoting  the  absorption  of  the  seques- 
trum, and  of  course  in  accelerating  the  progress  of 
cure. 

If  the  surgeon  operate  as  soon  as  the  sequestrum  be- 
comes loose,  he  will  find  the  new  bone  so  soft  that  it 
can  be  divided  with  a knife;  a circumstance  w'hich 
materially  facilitates  and  shortens  the  operation. 

Keeping  in  mind  the  foregoing  precepts,  the  surgeon 
is  to  begin  with  exposing  the  bone  in  which  the  seques- 
trum is  contained.  When  the  bone  lies  immediately 
under  the  skin,  Weidmann  recommends  making  such 
incisions  as  will  lay  bare  the  whole  of  its  surface ; and 
when  its  situation  is  deeper  beneath  the  muscles,  he 
even  sanctions  cutting  aw’ay  as  much  of  the  flesh  as 
may  be  necessary  to  allow  the  instruments  to  be  freely 
worked  upon  the  bone.  I cannot,  however,  see  the 
propriety  of  this  advice : exposing  the  whole  surface 
of  the  bone  in  the  first  instance,  before  it  is  known 
whether  the  saw  need  be  so  extensively  used  as  to  re- 
quire such  a denudation,  certainly  appears  irrational. 
And  as  for  cutting  away  any  portions  of  muscle,  this 
can  be  no  more  necessary  here  than  it  is  in  the  opera- 
tion of  trephining.  But  it  is  unquestionably  proper  to 
make  with  the  bistoury  sufficient  space  for  the  use  of 
whatever  instrument  is  employed  for  the  division  of 
the  bone.  Yet  it  is  only  necessary  to  make  this  ex- 
posure in  the  first  instance  in  one  place.  The  surgeon 
can  afterward  enlarge  the  incision,  or  practise  others, 
as  circumstauces  may  indicate.  The  surface  of  the 
bone  being  brought  into  view,  if  the  cavities  in  which 


Uie  dead  fragments  lodge  present  apertures  which  are 
too  narrow,  these  apertures  must  be  rendered  larger  by 
means  of  small  tiephines,  or  saws  constructed  on  the 
principles  of  those  described  by  Mr.  Hey,  of  Leeds. 
The  perpendicularly  acting  wheel-like  saw,  turned  by 
machinery,  and  invented  by  Mr.  Machell,  here  pro- 
mises also  to  be  of  important  assistance.  It  has  been 
used  by  Sir  A.  Cooper,  who  has  given  an  engraving  of 
it  in  his  Surgical  Essays,  part  1,  pi.  8,  fig.T.  And 
another  saw,  constructed  on  somewhat  similar  prin- 
ciples, has  been  employed  by  Graefe  of  Berlin  with 
great  advantage  for  several  years.  A tract  by  Schwalb 
(De  Serra  Orbiculari,  4to.  Beroi.  1819),  giving  an  ac- 
count of  it,  w'as  sent  to  me  by  the  late  Dr.  Albers  a 
little  before  his  death : it  is  turned  by  means  of  a 
handle  which  projects  horizontally  from  the  cutting 
pan  of  the  instrument,  and  it  has  a frame  or  fulcrum 
on  which  it  works.  Professor  Thai’s  rotation  saw, 
and  Mr.  Liston’s  bone-forceps  may  also  prove  of  es- 
sential  service. — (See  Edinb.  Med.  Juurn.  Mo.  78.) 

With  such  instruments,  the  pieces  of  bone  extending 
across  the  above  openings,  and  impeding  the  extraction 
of  the  sequestra,  may  likewise  be  removed. 

But  when  the  preceding  cavities  are  closed  on  every 
side,  and  it  is  impossible  to  reach  into  them  in  any  other 
way  than  through  the  cloacae,  a trephine  is  to  be  ap- 
plied, which  must  comprise  within  its  circle  a half  of 
the  fistulous  opening.  The  crown  of  the  trephine, 
however,  must  not  be  broader  than  the  cavity  of  the 
bone,  nor  yet  narrower  than  the  sequ&«trum. 

If,  after  making  a perforation  in  this  manner,  the 
sequestrum  should  be  found  too  large  to  pass  through 
the  opening,  a small  saw  must  be  employed  for  enlarg- 
ing the  aperture.  When  the  bone  is  so  hard  and  thick, 
that  it  cannot  be  well  cut  with  a saw,  the  surgeon  has 
the  sanction  of  authority  and  experience,  for  using  a 
gouge  and  mallet. 

When  the  sequestrum  is  found  to  be  very  large,  it 
will  be  necessary  to  expose  more  of  the  surface  of  the 
bone  by  incisions.  In  this  sort  of  case,  Weidmann  re- 
commends applying  the  trephine  to  the  upper  and  lower 
parts  of  the  cavity,  and  then  cutting  away  the  inter- 
vening portion  of  bone  with  the  saw  or  gouge.  But 
there  can  be  no  doubt,  that  a more  prudent  way  would 
be  to  go  on  with  the  enlargement  of  the  aperture  in  the 
bone,  at  the  place  where  the  first  perforation  took 
place,  if  the  sequestrum  presented  itself  equally  well 
there  ; because,  by  proceeding  in  this  manner,  the  sur- 
geon  might  discover  that  the  dead  fragment  could  be 
taken  out  without  so  great  a destruction  of  bone  as 
is  caused  in  the  other  mode;  and  if  this  were  not  to 
be  the  case,  no  harm  is  done,  as  the  necessary  removal 
of  bone  can  be  continued. 

When  the  bone  which  includes  the  sequestrum  is 
a new  production,  and  the  operation  is  not  too  long 
deferred,  the  soft  state  of  the  bone  will  enable  the  ope- 
rator to  perform  the  needful  excisions  with  llie  bistoury 
alone. 

When  the  sides  of  the  cavity  in  the  original  bone 
are  thin,  fragile,  and  pierced  with  numerous  holes, 
the  surgeon  can  break  away  a sufficient  portion  with  a 
pair  of  forceps. 

When  several  sinuses  exist  in  the  bone,  each  may  be 
dilated,  in  the  manner  which  seems  most  advantageous. 

Sufficient  openings  having  been  made  into  the  cavi- 
ties including  the  sequestra,  the  ne.xt  object  is  to  extract 
these  dead  portions  of  bone.  In  accomplishing  tlris 
part  of  the  operation,  Weidmann  particularly  advises 
two  things:  first,  that  no  piece  of  the  sequestrutn  be 
left  behind ; secondly,  that  no  injury  be  done  to  the 
tnembrane  which  lines  the  cavity  in  which  the  dead 
bone  is  lodged. 

This  author  observes,  that  there  are  examples,  in 
which  thevicinity  of  certain  parts  impedes  the  surgeon 
from  making  an  opening  in  the  botie  large  enough  for 
the  extraction  of  a voluminous  sequestrum  in  an  en- 
tire state.  In  this  circumstance,  he  recommends  the 
sequestrum  to  be  broken  into  pieces  by  any  convenient 
means,  and  the  freagments  to  be  separately  removed. 

Weidmann  has  recorded  an  extremely  interesting 
case,  to  prove  how  much  may  sometimes  Ire  effected 
by  taking  away  the  sequestrum.  A man,  34  years  of 
age,  who  had  an  internal  necrosis  of  the  tibia,  with 
abscesses  and  tedema  of  the  whole  limb,  and  who  was 
reduced  to  the  lowest  ebb  of  wt>akness,  was  put  under 
this  excellent  surgeon’s  care.  A perforation  was  made 
with  a trephine  in  the  upper  head  of  the  tibia ; but 


NEC 


NEP 


203 


this  opening  not  proving  anjple  enough,  it  was  en- 
Jargcd  with  a small  saw,  and  a gouge  and  mallet. 
The  seriuestrum  was  then  extracted.  The  patient’s 
state  atterward  gradually  improved,  and  in  nine 
months  he  was  completely  well. 

It  is  not  to  be  dissembled,  howe'ver,  that  cases  do 
exist,  in  which  amputation  affords  the  only  cliance  of 
saving  the  patient’s  life.  In  fact,  it  sometimes  hap- 
pens, that  the  cavities,  in  which  the  sequestra  are  con- 
tained, communicate  with  those  of  the  neighbouring 
joints,  which  then  become  filled  with  matter,  and  ca 
ries  attacks  parts  of  the  bones,  to  which  the  necrosis 
does  not  extend.  On  some  occasions,  the  dead  pieces 
of  bone  are  very  numerous,  and  each  has  a separate 
cavity;  while,  in  other  instances,  the  sequestia  lie  so 
deeply,  that  a passage  for  their  extraction  cannot  be 
prudently  attempted.  Sometimes,  also,  a necrosis  is 
complicated  with  another  disease  in  its  vicinity. 
Lastly,  such  may  be  the  reduced  slate  of  the  patient’s 
health,  and  the  particular  condition  of  the  neciosis  itself, 
that  the  constitution  cannot  hold  out  during  the  whole 
time  which  would  be  requisite  for  the  detachment  of 
the  sequestrum.  Under  circumstances  like  these,  am- 
putation is  necessary,  and  ought  not  to  be  delayed. 

For  the  authorities  of  many  of  the  observations  and 
cases  in  the  foregoing  article,  and  for  additional  in- 
formation on  the  subject,  see  ^Ibucasis,  lib.  2,  cap.  88. 
Scultetus,  Jirmament.  Chir.  tab.  46,  and  obs.  81.  Bel- 
loste,  Le  Chirurgien  d' Hdpital,  part  1,  chap.  12.  J. 
L/Ouis  Petit,  'Praite  des  Maladies  des  Os,  tom.  2,  chap. 
16.  Monro's  Works,  by  his  Son.  Tenon,  in  M6m.  de 
VJicad.  des  Sciences,  1758.  Ailken,  Systematic  Ele- 
ments of  the  Theory  and  Practice  of  Sujgery,  Edinb. 
1'779,  p.  288.  Some  interesting  cases  and  remarks, 
chiefly  about  the  question  of  amputation,  are  contained 
in  Schmucker's  Vermischte  Chir.  Schriften,  b.  1,  p.  17, 
6rc.  ed.  2.  Callisen,  Systema  Chirurgim  Hodiei~ntB, 
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Med.  Obs.  and  Inquiries,  vol  2,  p.  303.  Sigwurt, 
Diss.  de  Carie  consumpta;  tibioi  notubiU  jactnra,  tab. 
1756.  T.  Bartholine,  Act.  Med.  et  Phil.  Hafn.  vol.  3, 
obs.  114,  p.  287.  Hofmann,  Mantissa,  Obs.  Select, 
obs.  28.  iaviard,  Mouveau  Recueil  d'Observ.  Chir. 
Paris,  1702,  obs.  126.  Lp  Dran,  Obs.  de  Chirurgie, 
t.  2,  obs.  104.  Michael,  in  Richter's  Bibliothek,  t.  5. 
Troja,  De  Movorum  Ossium  in  integris  aut  maximis, 
ob  Marbos,  Depirditionibus,  Regeneration e,  Experi- 
nienta.  Luletice  Parisiorum,  1775.  Troja' s work, 
though  drawn  up  in  an  incorrect  style,  as  Weidmann 
remarks,  contains  many  highly  interesting  experiments. 
Blumenbach,  in  A.  O.  Richter's  Bibliothek,  t.  4,p.  107. 
Desault's  Parisian  Chirurg.  Journal,  vol.  1,  p.  100, 
and  vol.  2,  p 199.  Koehler,  Experimenta  circa  Reg e- 
neratioiievi  Ossium,  Gott.  1786.  7'his  is  a valuable 
work,  and  contains  the  original  discoveiy  of  the  repro- 
duction of  medullary  structure.  I.  P.  Weidmann,  De 
Mecrosi  Ossium,  fol.  Francofurti  ad  Moenum,  1793; 
et  De  Mecrosi  Ossium  adnotatio,  Frank,  del.  4.  Per- 
haps the  best  general  account  of  the  whole  subject  of 
necrosis.  It  is  not  only  enriched  with  the  observations 
of  numerous  other  writers  on  the  disease,  but  contains 
the  most  approved  theories  and  opinions,  respecting 
many  other  affections  of  the  bones,  caries,  exfoliations, 
Src.  It  was  of  great  assistance  to  me  in  the  foregoing 
article.  Consult  also  Richerand,  Mosogr.  Chir.  t 3, 
p.  15.3,  S-c.  ed.  4,  Paris,  1815.  Dr.  Alex.  McDonald's 
Thesis  de  Mecrosi  ac  Callo,  Edinb.  1799.  Hutchison's 
Pract.  Obs.  in  Surgery,  p.  180,  <J-c.  London,  1816. 
James  Russell's  Practical  Essay  on  a certain  Disease 
of  the  Bones,  termed  Mecrosis,  1794.  Wliately's  Pract. 
Obs.  on  Mecrosis  of  the  Tibia,  1815.  Macartney,  in 
Crowther's  Obs.  on  White  Swelling,  <S'C.  edit.  2.  En- 
cyclopedie  Methodique,  partie  Chir.  art.  Mecrose. 
Leveille,  Mouvelle  Doctrine  Chir.  t.  4,  p.  321,  <S*c. 
Paris,  1812.  Larrey's  Mem.  de  Chirurgie  Militaire, 
t.  3,  p.  367,  dec.  Thomson's  Lectures  on  Inflamma- 
tion, p.  39,  <^c.  Edinb.  1813.  Boyer's  Traite  des 
Maladies  Chirurgicalcs,  t.  3,  p.  418.  drc.  Paris,  1814. 
Delpech,  Precis  Elcmcntaire  des  Mai.  Chir.  t.  1,  chap. 
3 ; Paris,  1816.  R.  Knox  on  the  Pathology  and  Treat- 
ment of  Mecrosis,  and  on  Regeneration  of  Bone,  Src. 
Edinb.  Med.  Surg.  .Journ.  vol.  18,  p.  62,  drc.  and  vol. 
19,  p.  210.  R.  Liston,  Essay  on  Caries,  drc.  in  Edinb. 
Med.  Journ.  Mo.  78  E.  Lebel,  in  Med.  Phys.  Jov-rn. 
Avg.  1820.  Meding.  Diss.  de  Regencratione  Ossium, 
per  Experimenta  illustrata ; Lips.  1823.  Kortum, 
Exp.  et  Obs.  circa  Regenerationem  Ossium;  Berol. 
1824.  B.  Bell  on  Diseases  of  Bones,  \2mo.  Edinb. 
1828. 

NEPHROTOMY.  (From  vtiPpbg,  a kidney ; and 
Ttpvo),  to  cut.)  The  operation  of  cutting  a stone  out 
of  the  kidney  ; a proceeditig  wliich,  perhaps,  has  never 
been  actually  put  in  practice.  In  iheAbrege  Chrono- 
logique  de  I'Histoire  de  France,  par  Mezerai,  and  in 
the  Phil.  Irans.  for  1696,  two  cases  of  what  is  called 
ne(ihrolomy  are  mentioned  ; but  several  circumstances 
in  the  accounts  led  Haller  and  others  to  conclude,  that 
the  operation  alluded  to  in  the  first  work  was  nothing 
more  than  tlie  high  operation  for  the  stone.  With  re- 
spect to  the  example  in  the  latter  work,  the  particulars 
are  not  detailed  enough  to  prove  that  an  inci>ion  was 
really  made  into  the  kidney.  There  is  no  doubt  that 
stones  liave  oflen  been  extracted  from  abscesses  about 
the  region  of  the  kidney,  after  being  touched  with  a 
probe.  But  with  regard  to  cutting  into  the  kidney, 
the  deep  situation  of  this  viscus,  and  the  want  of  symp- 
toms, by  which  the  lodgement  of  a stone  in  it  can  be 
certainly  di.scovered,  will  always  be  strong  tdijections 
to  the  practice.  When  a stone,  from  its  size,  cannot 
pass  from  the  kidney,  and  excites  inflammation  and 
su[(pniation,  no  doubt,  the  surgeon  may  make  an  in- 
cision into  the  tumour,  and  extract  the  calculus.  In 
this  sense,  nephrotomy  is  certainly  a practicable  ope- 
ration. Warner  contends,  that  it  can  only  be  practised 
in  such  circumstances,  notwithsiatiding  v\  hatever  may 
have  been  said  by  Marchetti,  or  others,  upon  the  sub- 
ject. In  such  a case,  the  operation  would  not  be  at- 
tended with  any  greater  difficulty,  titan  the  opening  an 
abscess  in  any  other  part  of  the  body. — (See  Wamer'a 
Cases  in  Surgery,  p.  241,  edit.  4.) 


204 


NITRIC  AND  NITROUS  ACIDS. 


NITRIC  and  NITROUS  ACIDS.  As  these  are 
medicines  of  considerable  importance  in  surgery,  they 
claim  particular  notice.  Nitrous  acid  is  a yellow  or 
orange-coloured  fluid,  emitting,  when  exposed  to  the 
air,  deep  orange  coloured,  extremely  suffocating  fumes. 
It  consists  of  nitrous  gas,  loosely  combitied  with  nitric 
acid  and  water ; and  the  colour  varies  according  to  the 
proportion  of  nitrous  gas  which  is  present. 

Nitric  acid  is  a colourless,  or  very  pale  yellow,  limpid 
fluid,  emitting,  when  exposed  to  the  air,  white  suffo- 
cating vapours.  It  is  highly  corrosive,  and  tinges  the 
skin  yrllow,  the  tint  remaining  till  the  epidermis  peels 
oif.  The  constituents  of  nitric  acid,  independent  of 
the  water  which  gives  it  the  fluid  form,  are  25.97  azote, 
and  74  03  oxygen  in  100  parts. — (See  Thomson  s Dis- 
ptnsatory,  p.  438,  439,  ed.  2.) 

Botli  these  acids  in  a diluted  state  have  been  exten- 
sively iried,  as  a substitute  for  quicksilver,  in  the  cure 
of  lues  venerea;  and  really,  upon  looking  over  the 
mass  of  evidence  brought  forward  in  proof  of  the 
power  which  they  seem  to  possess  over  this  disease,  it 
is  ai  rir.-it  difticult  to  entertain  the  slightest  doubt  of  their 
etficai  y.  The  cases  adduced  are  numerous,  some  of 
tm-m  miinitely  detailed  ; the  genllenien  who  have  pub- 
lished them  men  of  reputation  and  abilities;  and  (what 
especially  claims  attention)  these  examples  of  sue- 
ce.'sthl  treat iiieiit  are  generally  allowed  to  have  been 
syphilitic,  or,  at  all  events,  complaints,  the  differences 
oi  wliicli  from  the  venereal  disease  have  not  been,  and 
could  not  be,  specified.  Whoever  impartially  con- 
siders the  iinmense  body  of  facts  published  by  Dr. 
Rollo,  Mr.  Cruickshank,  Dr.  Beddoes,  Dr.  P.  G.  Prio- 
leaii,  of  Charleston,  South  Carolina,  and  others,  ex- 
emplifying the  success  with  which  the  venereal  disease 
may  be  treated  by  the  nitrous  or  nitric  acid,  must  be 
surprised  to  find,  that  the  accounts  delivered  by  these 
gentlemen  by  no  means  correspond  to  those  of  some 
other  eminent  practitioners.  How  to  reconcile  these 
seemingly  discordant  statements,  whether  by  supposing 
some  undefined  differences  in  the  nature  of  the  cases 
adduced,  or  some  variation  in  the  goodness  of  the  me 
diciiie  itself,  is  indeed  perple.xing.  Nor  is  a solution  of 
the  question  at  all  facilitated  by  the  results  of  later  in- 
vesi  igaiions,  tending  to  prove  the  general  curability  of 
syphilis  without  mercury  or  any  medicine  whatever; 
because,  if  we  admit  this  as  a fact,  the  circumstance 
of  a considerable  proportion  of  cases  not  yielding  or 
being  radically  cured  when  the  nitric  and  nitrous  acids 
are  exhibited,  as  asserted  by  Mr.  Pearson  and  others, 
would  argue,  that  giving  such  acids  is  worse  than 
leaving  the  disease  entirely  to  itself.  The  more  I re- 
flect upon  all  that  we  know  about  the  venereal  disease, 
however,  the  more  I am  inclined  to  adopt  the  senti- 
ment, that  it  is  not  one  disorder,  but  probably  many, 
which  go  under  this  name,  their  exact  shades  of  dif- 
ference not  having  yet  been  detected  nor  described. 
If  this  supposition  be  admissible,  the  contradictory 
statements  given  by  various  authors  about  what  their 
exjierience  has  taught  them  of  this  or  that  mode  of 
treating  the  disease,  may  all  be  immediately  reconciled. 

The  practice  of  exhibiting  nitric  acid,  in  lieu  of  quick- 
silver, began  with  Mr.  Wm.  Scott,  a surgeon  at  Bom- 
liay,  who  is  said  to  have  been  led  to  the  experiment  by 
a suu'gestion  thrown  out  by  Girtanner,  that  the  efficacy 
of  the  various  preparations  of  quicksilver  probably 
depended  upon  the  quantity  of  oxygen  combined  with 
I hem. — (^Grevs.  Journ.  de  Physick.  b.  3,  p.  31,  1790.) 
In  August,  1793,  Mr.  Scott  being  himself  afilicted  with 
chronic  hepaiitis,  resolved  to  take  a quantity  of  oxy- 
iten,  united  to  some  substance  for  which  it  has  no  great 
attraction  ; and  after  some  reflection,  nothing  appeared 
to  him  belter  than  nitric  acid.  September  llth  he  took 
ai  different  times  about  a drachm  of  the  strong  nitric 
acid  diluted  with  water.  Soon  after  drinking  it  he 
felt  a sense  of  warmth  in  his  stomach  and  chest;  but 
no  disagreeable  sensation  nor  any  other  material  effect. 
The  two  following  days  the  medicine  was  continued, 
the  gums  beginning  to  be  somewhat  red  and  enlarged. 
He  slept  ill ; but  could  lie  for  a length  of  time  on  his 
left  side,  which  the  disease  of  the  liver  had  prevented 
him  from  doing  during  many  months  previous  to  this 
period.  He  also  felt  a pain  in  the  back  of  his  head, 
rese  iibling  what  he  had  commonly  experienced  when 
taking  mercury.  On  the  fourth  day  his  gums  were  a 
little  tender;  the  headache  and  pain  about  his  jaws 
still  troubled  him;  but  the  symptoms  of  his  liver-com- 
plaint had  already  left  him.  Tire  acid  was  continued 


on  the  4th,  5th,  and  6th  days ; the  soreness  of  the 
mou^th  increasing,  and  a salivation  taking  place.  On 
the  7ih  day  he  felt  his  mouth  so  troublesome  that  he 
took  no  more  acid.  His  mouth  got  gradually  well,  and 
he  found  his  health  considerably  improved. 

Mr.  Scott  likewise  administered  the  nitric  acid  in 
several  cases  of  tedious  iiiiermiiients,  in  two  cases  of 
diabetes,  and  in  many  syphilitic  cases,  with  the  hap- 
piest effect.  His  account  of  the  nitrous  acid  was  first 
published  in  the  Bombay  Courier  of  Apiil  30ih,  1796, 
and  soon  afterward  republished  in  this  country. — (See 
“ Account  of  the  Effects  of  the  J^itrous  Acid  on  the 
Human  Body,”  by  IV.  Hcott,  in  Duncan's  Annals  of 
J\fedicine  fur  1796,  vol.  1,  p 375 — 383.)  The  hypo- 
thesis suggested  by  Girtanner  in  1790,  that  the  efficacy 
of  mercury  in  the  treatment  of  the  venereal  disease 
depended  upon  the  oxygen  combined  w’iththis  mineial, 
required  but  little  extension  to  lead  to  the  discovery  of 
the  antisyphilitic  virtues  of  the  acids.  Yet  Gii tanner 
had  all  his  attention  so  fixed  on  mercury,  that  it  never 
struck  him  that  the  principle  on  which  he  explained 
the  efficacy  of  this  medicine  might  apply  to  other  sub- 
stances which  abound  with  oxygen,  and  are  leadily 
separable  from  it.  This  was  the  idea  which  made  Mr. 
Wm.  Scott  begin  to  suspect,  that  the  nitric  acid  might 
be  as  efficacious  as  mercury  in  venereal  cases;  and  as 
he  had  already  observed  a great  analogy  between  the 
effects  of  this  acid  and  mercury  in  the  experiments 
wliich  he  made  w’ith  the  first  of  these  medicines  in  his 
own  case  of  chronic  hepatitis  and  other  diseases,  he 
ventured  to  recommend  the  trial  of  it  in  syphili.s.  The 
result  was,  that  the  acid  was  found  not  only  to  equal 
the  preparations  of  mercury,  but  sometimes  to  surpass 
them  ; for  it  had  the  best  effect  in  some  cases  where 
mercury  had  been  tried  in  vain,  and  it  was  observed  to 
remove  the  disease  in  less  lime  than  the  common  re- 
medy Nor  were  any  of  the  iticonveniences,  usually 
known  under  the  names  of  mercurial  symptoms,  mer- 
curial fever,  found  to  be  the  consequence  of  its  em- 
ployment however  long  continued.  With  it  alone 
many  syphilitic  cases  are  stated  to  have  been  cured,  the 
disease  not  having  returned  at  the  end  of  two  years. — 
(See  Duncan's  Annals  of  Medicine,  Src.  vol.  1,  1796,  p. 
383,  <S-c.) 

ThS  letter  from  Mr.  Scott  to  Sir  Joseph  Banks,  de 
scribing  these  effects  of  the  nitric  acid  in  India,  soon 
excited  the  attention  of  medical  practitioners  both  in 
Europe  and  America,  the  inquiry  being  taken  up  w ith 
all  the  zeal  which  the  preceding  accounts  were  calcu- 
lated to  inspire.  In  1797,  Mr.  G.  Kellie,  a surgeon  of 
the  navy,  gave  the  nitric  acid  to  five  sailors,  affected 
with  gonorrhoea,  venereal  sores,  and  buboes.  Three 
of  them  were  perfectly  cured.  A fourth,  w'ho  had 
.sores  on  the  glans,  and  who  had  been  much  debilitated 
by  the  long  use  of  mercury,  recovered  nearly  his  ori- 
ginal strength  while  taking  the  acid  ; but  the  sores  w ere 
not  healed  before  mercury  had  been  repeatedly  ex- 
hibited. In  the  fifth  patient,  who  was  also  scrofulous, 
the  nitric  acid  cotitributed  very  essentially  to  heal  the 
sores.  On  the  whole,  Mr.  Kellie  seems  to  regard  this 
medicine  as  possessing  very  efficient  power  of  stopping 
and  eradicating  the  venereal  disease. — (See  Letters 
from  G.  Kellie,  respecting  the  Effects  of  Mitrous  Acid 
in  the  Cure  of  Syphilis,  Duncan's  Annals  of  Medicine 
for  1797,  p.  254. 277.) 

In  the  same  year  appeared  a letter,  in  a German  pe- 
riodical work  (Huf  eland's  Joum.  der  Prakt.  Heilk.  bd. 
4,  p.  356 — 359),  written  by  Albers  ,giving  the  history 
of  a venereal  ulcer  on  the  breast,  successfully  treated 
by  the  nitric  acid. 

The  reports  of  Dr.  Prioleau,  who  tried  the  nitric  acid 
in  the  autumn  of  1797,  are  particularly  favourable  to 
the  practice.  “We  have  seen  (says  he)  every  stage 
and  form  of  syphilis  cured  by  this  tnedicine,  and  even 
in  habits  broken  down  by  the  antecedent  use  of  mer- 
cury, under  which  the  disorder  had  gained  groiitid. 
The  patients  recovered  their  health  and  strength  in  a 
short  time,  without  the  use  of  diet-drinks,  ba  k,  or  any 
other  tonic  medicine  whatever.” — (See  Cnldicell's  Me- 
dical Theses,  p.  103,  8vo.  Philadelphia,  1805.) 

The  praise  of  the  nitric  acid  fiom  numerous  quar- 
ters induced  Dr.  Rolio  to  try  it  in  the  military  hospital 
at  Woolwich,  and  in  ctmjunction  with  Mr.  Cruickshank 
to  examine  farther  into  the  antisy()liilitic  virtues  of 
oxygenated  substances.  The  result.--  of  Mr.  Cruick- 
sliank’s  investigations  constitute  the  second  part  of 
Rollo’s  work  on  diabetes,  published  in  1797.  The  me- 


NITRIC  AND  NITROUS  ACIDS. 


205 


dlcines,  which  were  selected  for  the  experiments,  were 
the  nitric,  citric,  and  inuiiaiic  acids,  and  oxygenated 
muriate  of  potash.  Of  tiiese,  the  nitric  acid  and  tlie 
oxygenated  niuiiate  of  potash  were  found  to  possess 
the  greatest  efficacy ; tlie  first  acting  in  many  cases  with 
remarkable  mildness;  the  second,  with  greater  expedi- 
tion and  certainty.  The  new  plan  was  tried  upon 
young  persons  afi'ecied  with  primary  venereal  com- 
plaints, who  had  never  used  mercury;  and  no  otlier 
internal  medicine  was  given  except  opium  when  re- 
quited for  diarrhoja  or  colic.  'I’he  liquor  plumbi  ace- 
tatis  dilutus  was  used  as  a wash  for  chancres.  In  de- 
bilitated subjects,  sure  and  speedy  good  efi'ects  were 
observed  uniformly  to  follow ; and  hence,  previously 
to  giving  the  acid  to  strong,  plethoric  patients,  the  me- 
thod of  preparing  them  for  this  treatment  by  purging 
and  bleeding  was  adopted,  as  is  alleged,  with  great 
success.  In  some  cases,  after  the  nitric  acid  had  been 
continued  a good  while  without  producing  asalivation, 
the  exhibition  of  mercury  for  a short  time  completed 
the  cure.  Mr.  Cruicksliank’s  opinion  in  favour  of  the 
new  remedies  was  on  the  wliole  extremely  sanguine, 
as  he  ventures  to  express  his  conviction,  that  tliey 
would  render  the  employment  of  mercury  in  the  cure 
of  the  venereal  disease  unnecessary. — (See  ./in  Account 
of  two  Cases  of  Diabetes  Jilellitus,  with  Remarks,  Sec. 
by  John  Rollo,  M.D.  vol.  il,  800.  Lund.  1797.) 

In  the  same  year  Dr.  Beddoes  published  a valuable 
work,  compiising  all  the  information  which  had  then 
transpired  respecting  the  aniisyphilitic  virtues  of  the 
nitric  acid,  with  additional  communications  from  his 
medical  friends. — (See  Reports  principally  concerning 
the  Effects  of  J^Titrous  Acid  in  the  Venereal  Disease, 
by  Thom.  Beddoes,  Bristol,  1797.)  And  two  years 
afterward  the  same  author  finished  a still  more  com- 
prehensive volume  on  the  subject. — {A  Collection  of 
Testimonies  respecting  the  Treatment  of  the  Venereal 
Disease  by  JVttruas  Acid,  Land.  1799.) 

From  the  pieceding  work  we  learn,  that  in  the  Ply- 
niouih  Hospital  Mr.  Hanimick  gave  the  nitric  acid  to 
between  sixty  and  seventy  venereal  patients,  and  that 
the  cures  were  generally  more  speedily  accomplished 
than  with  mercury,  no  ill  effects  being  produced  on  tiie 
system  similar  to  those  usually  retnaining  after  the  use 
of  the  latter  mineral.  He  assures  us,  that  after  the  re- 
moval of  the  symptoms,  the  disease  never  returned; 
and  that  for  debilitated,  scorbutic,  or  scrofulous  pa- 
tients, affected  with  venereal  complaints,  the  acid  was 
found  a most  valuable  means  of  relief. 

Dr.  Geacli  of  the  same  hospital  is  also  stated  to  have 
employed  the  nitric  acid  with  such  effect  that  he  rarely 
had  occasion  for  mercury;  the  livid  colour  of  the 
countenatice,  sordid  fetid  excoriations  of  the  scrotum, 
and  other  symptoms,  which  had  Iona  resisted  the  latter 
mineral,  all  quickly  giving  way  to  the  new  medicitie. 
Another  practitioner  of  the  name  of  Giedlestone,  how- 
ever, had  not  equal  success  in  his  experiments  ; for,  in 
several  cases,  the  acid  did  not  bring  about  a cure,  and 
after  being  continued  eight  or  ten  days,  and  inducing  a 
salivatif  It,  it  even  rendered  the  condition  of  some  pa- 
tients worse.  On  the  other  hand,  Mr.  fiandford,  a sur- 
geon at  Worcester,  found  the  acid  a very  useful  and 
effectual  medicine  iti  venereal  cases,  w’liere  mercurials 
had  been  long  exhibited  in  vain.  'I’he  trials  of  the  nitric 
acid,  rnatle  byProfe.esor  Rutherford  at  Edinburgh,  Intd 
various  results;  the  medicine  sometimes  proving  com 
pletely  ineffectual,  and  in  other  instances  appearing  to 
be  a [lerfect  antidote  for  the  woi.st  sy  [iliilitic  complaints. 

Dr.  Beddoesconclndes  with  some  ob.'ervatiotis  in  an- 
swer to  Mr.  Blair,  who  had  become  averse  to  the  new 
practice. 

In  1798,  Dr.  Ferriar  published  some  remarks  on  the 
nitrou.s  acid. — tSee  Medical  Histories  nnd  Reflections, 
Vol.'S,  p.  290—310.)  He  tried  this  medicine  in  various 
ways,  either  alone,  or  after  or  in  conjunction  with  the 
exhibition  of  mercury.  His  inferences  are,  that  in  the 
tn  atment  of  the  venereal  disease,  the  nitrous  acid  is 
iisetul  otdy  in  protracted  cases.  He  corioborates,  how- 
ever, the  generally  received  .tpinion,  that  where  the 
patient  has  ber  n considerably  reduced  by  the  long  or 
injudicious  employment  of  mercury,  the  nitrous  acid  is 
a most  beneficial  medicine. 

In  this  year,  Mr  Blair  wrote  some  observations  on 
the  venereal  disease,  and  the  new  niethod  of  trr-ating 
(.Essays  on  the  Venereal  Disease  and  its  concomi- 
tant Affections,  Land.  1797.)  In  this  work,  the  new' 
remedies  are  generally  condemned  as  ineffectual ; and 


hence  originated  a paper  war  between  this  writer  and 
Dr.  Beddoes,  “ lilerarium  cerlainen,  non  sine  bile  ges- 
tum,”  as  Dr.  Holst  has  expressi  d it. — {.De  Acidi  Mih  id 
Usu  Medico,  p.  73,  800.  Chnstiance,  1816.;  In  this 
controversy  numerous  'other  practitioners  retidily 
joined,  as  for  instance.  Macartney,  Rowley,  Philips, 
Hooper,  Lidderdale,  &c  , all  of  whom  adduced  cases  in 
proof  of  the  frequent  inefficacy  ol  nitrous  acid ; and 
these  were  collected  and  |iublished  by  Mr.  Blair,  who, 
suspecting  the  cases  of  failure  with  this  medicine  to 
be  more  numerous  than  those  of  success,  considers 
hiinself  unjustified  in  regarding  it  as  an  antisypliilitic 
to  be  depended  upon.  At  the  same  time,  he  bears  tes- 
timony to  the  virtues  of  the  acids,  exhibited  in  venereal 
cases  either  singly  or  alternately  w ilh  mercury  where 
the  patient’s  strength  had  been  much  reduced;  and  he 
conlesses  that  venereal  buboes,  indurated  glands,  noc- 
turnal pains  in  the  bones,  and  gononhcea  yielded  to 
these  remedies. 

Seven  years  after  the  appearance  of  Mr.  Blair’s 
work,  Mr.  Pearson  delivered  iiis  sentiments  in  a book 
of  considerable  merit. — t^Obs.  on  the  Effects  of  various 
Articles  of  the  Materia  Medica  in  the  cure  of  Imcs 
Venerea,  id  ed.  Land.  1807,  p.  198,  ^c.)  He  relates  a 
very  few  examples,  in  which  the  nitrous  acid  aiipeared 
effectual  in  curing  chancres,  and  one  of  its  viitues  in 
gonorrhcea;  the  only  one  which  this  gentleman  had 
ever  seen.  The  rest  of  his  observations  are  unfavour- 
able to  the  character  of  the  medicine  as  an  antisyphi- 
litic  meriting  confidence.  The  first  trials  which  Mr. 
Pearson  made,  were  of  the  nitric  acid  ; but  as  he  did 
not  remark  any  of  ils  effects  to  be  different  from  those 
produced  by  the  nitrous  acid,  he  commonly  employed 
the  latter  in  the  lollowing  form: — Nitrous  acid,  two 
drachms ; pure  water,  a pint  and  a half ; syrup,  four 
ounces.  This  mixture  was  usually  taken  in  the  space 
of  twenty-four  hours.  As  local  applications,  he  em- 
ployed a saturnine  lotion  to  the  sores,  and  emollient 
poultices  to  tumours  and  inflamed  [larts.  All  mercu- 
rial applications  were  absolutely  prohibited. — (P.200.) 
In  making  his  inlerences  in  a subseipient  page,  he  says, 
“The  nitric  and  nitrous  acids  have  removed  both  pri- 
mary and  secondary  symptoms  of  syphilis;  and  in 
some  instances  it  seems  that  the  former  have  not  re 
curred,  nor  have  secondary  symptoms  aiipeared  at  the 
period  they  commonly  show  themselves,  when  the 
cure  has  been  imp^fect.  But  as  far  as  iny  own  expe- 
rience extends,  and  that  of  many  respectable  friends, 
who  aie  connected  with  large  hospitals,  a permanent 
cure  has  never  been  accomplished  by  these  acids, 
where  secondary  symptoms  have  been  present.  The 
same  acids,  when  exhibited  with  the  utmost  care  and 
attention  to  many  patients,  labouring  under  the  pri- 
mary symptoms  of  the  venereal  disease,  and  where 
they  have  agreed  perfectly  well  with  the  stomach,  have 
been  nevertheless  found  inadequate  to  the  cure  of 
those  .symptoms.  Indeed,  the  failures  which  have  oc- 
curred, both  in  my  own  piactice  and  that  of  many  of 
my  surgical  friends,  have  been  so  numerous,  that  I do 
not  think  it  eligible  to  rely  on  the  nitrous  acid  in  the 
treatment  of  anyone  form  of  the  lues  venerea.”  How- 
ever, Mr.  Pearson  joins  several  other  writers  in  bear- 
ing witnests  to  the  good  effects  of  this  medicine,  where 
impairment  of  the  constitution  renders  the  employment 
of  mercury  inconvenient  or  improper.  Here,  he  says, 
it  will  restrain  the  progress  of  the  disease,  and  improve 
the  health  and  strength.  On  some  occasions,  he  thinks 
that  it  may  be  given  in  conjunction  with  a course  of 
mercurial  inunction  ; and  he  agrees  with  other  practi- 
tioners about  ils  supporting  the  tone  of  the  stomach, 
acting  as  a diuretic,  and  counteracting  the  effects  of 
mercury  on  the  mouth  and  fauces. — (P.  236—238.) 

While  these  inquires  were  going  on  in  England,  nu- 
merous experiments  on  the  same  subject  weie  under- 
taken in  France.  In  a work  published  in  1797,  Alyon 
positively  declares  that  mercury  ought  to  be  entirely 
relinquished  in  the  cure  of  the  venereal  disease. — (Es 
sai  sur  les  Proprietes  Medecin ales  de  1'  Oxypine,  ct  sur 
I' Application  de  ce  Principe  dans  les  Maladies  veneri- 
enncs  psoriques,  et  dartreuses ; Pari.',  an  5, 8ru.  Here 
we  find  a relation  of  many  cases  successfully  tieated 
in  the  hospitals  of  Val-de-Grace  and  St.  Dennis,  by 
the  oxygenated  muriate  of  potash,  the  nitric,  oxyinu- 
ri.itic,  and  citric  acids,  an  ointment  of  the  author’s 
own  invention,  called  the  nnguentuni  oxygenaium, 
being  applied  to  the  sores. — (See  Vnguevtum  ) In  a 
second  edition  of  the  above  book,  which  came  out  iu 


206 


NITRIC  AND 

1799,  the  same  doctrine  and  practice  are  corroborated 
by  fartlier  observations. 

In  1798,  Dr.  Swediaur  brought  out  the  third  edition 
of  his  treatise  on  the  venereal  disease  ( Traite  Complet 
sur  les  Sympldmes,  les  Effets,  la  J\rature,  et  le  Traite- 
ment  des  Maladies  Syphilitiques),  in  which  he  highly 
commended  the  virtues  of  the  nitrous  acid,  and  oxy- 
genated acid,  as  expediting  the  cure  with  very  few  ex- 
ceptions. But  in  the  fourth  edition  he  retracts,  and 
details  the  results  of  the  new  practice,  as  tried  upon 
twenty-six  venereal  patients  in  the  Hospice  d'Huma- 
niti : of  these  only  seven  cases  remained  permatiently 
cured ; the  issue  of  seven  others  was  doubtful ; and 
in  twelve,  no  ametidment  was  observed. 

Nor  were  the  statements  of  Lagneau  much  more  fa- 
vourable to  the  reputation  of  the  nitrous  acid  as  an 
antisy^ihilitic  ; for,  from  the  trials  which  he  had  seen 
made  of  it,  he  concluded  that  it  was  not  unfrequently 
inefFectual,  while  it  was  apt  to  excite  an  obstinate 
cough  and  ha;moptysis.— (£a;pose  des  Symptdmes  de  la 
Maladie  E^nerienne,  des  diverses  Mithodes  de  Traite- 
ment,  ire.  3me  ed.  Paris,  1812.) 

The  reports  of  Dr.  Odier,  of  Geneva,  however, 
were  rather  more  propitious;  as  he  says  the  nitrous 
acid  increases  the  efficacy  of  mercury,  and  lessens  or 
removes  the  inconveniences  arising  from  its  unskilful 
administration.  But  he  candidly  acknowledged,  that 
his  experience  had  not  been  great  enough  to  enable  him 
to  pronounce  what  degree  of  confidence  ought  to  be 
put  in  the  acid  as  a remedy  for  syphilis.— (Jl/are.  de 
Mid.  Pratique’,  Oenive, 

The  practice  of  exhibiting  the  nitric  acid  for  the  cure 
of  syphilitic  affections  was  not  tried  in  Germany  so 
soon  as  in  England  and  France.  Albers,  however,  in 
1797,  gave  an  account  of  Scott’s  successful  experi- 
ments, and  of  the  efficacy  which  they  evinced  in  some 
cases  seen  by  that  gentleman  in  the  Infirmary  at  Edin- 
burgh {Haftiand,  Journ,  d.  Prakt.  Heilk.  vol.  20,  p. 
68)  ; while  Belin,  who  had  visited  Paris  in  the  winters 
ofl797  and  1798,  briefly  noticed  the  various  results  of 
the  trials  which  he  had  seen  made  of  this  acid,  in  the 
“Clinique  de  Perfectionneinent,”  for  the  cure  of  ob- 
stinate syphilitic  cases — {Erinnerungen  an  Paris, 
zuvdchst  fiir  Jierzte  geschrieben  von  G.  H.  Behn  Erst. 
Heft.  Berl.  1799,  p.  110.)  At  length,  in  1799,  Struve, 
who  translated  Mr.  Blair’s  first  publication  into  Ger- 
man, communicated  to  the  profession  the  particulars  of 
some  experiments  made  by  himself  with  the  acid : he 
declares,  that  he  had  very  often  found  it  an  excellent 
remedy  for  inveterate  pains  in  the  bones  and  derange- 
ment of  the  constitution,  produced  either  by  the  sy- 
philitic virus,  or  the  injudicious  employment  of  mer- 
cury. However,  in  common  cases,  mercury  is  repre- 
sented as  the  best  antisyphilitic  medicine, 

.Afterward  Professor  Wiirzer  was  induced  to  try  the 
nitrous  acid  in  a case  that  had  resisted  mercury  for  six 
months;  the  patient  having  got  rid  of  some  chancres 
and  a sore  throat,  but  being  left  with  violent  nocturnal 
pains,  blotches  and  sores  all  over  his  body,  atid  in  a 
very  reduced  condition,  without  the  least  appetite. 
Here,  in  27  days,  the  acid,  together  with  sarsaparilla 
and  the  warm  bath,  not  only  removed  all  the  com- 
plaints, but  actually  restored  the  patient’s  original 
strength  and  healthy  appearance.  In  a short  note  an- 
nexed to  this  case,  Hufeland  gives  it  as  his  opinion,  de- 
rived from  experience,  that  the  nitrons  acid  is  effectual 
in  obviating  the  sequelae  and  anomalous  diseases  in- 
duced by  lues  venerea,  but  that  it  does  not  permanently 
cure  the  latter  affection  itself. — {Etwas  iiber  die  Keil 
kraft  der  Salpetersaiire  in  venerischen  Kranhheitm, 
Hiifcl.  Journ.  d.  Prakt.  Heilk.  bd.  8,  st.  4,  p.  139 
— 143.) 

These  vague  and  endless  contradictions  induced 
Schmidt,  an  eminent  professor  at  Vienna,  to  make  a 
series  of  experiments  with  the  nitric  acid,  for  the  pur- 
pose of  ascertaining  its  power  in  cases  of  syphilis. — 
(See  Beobacht,  der  Kaisepl.  Konigl.  Med.  Chir.  Jo- 
sephs Jteademie  zu  fV/en.  bd.  1,  TVien,  1807,  p.  147 — 
189.)  Under  his  directions,  the  acid  was  given  in  the 
winter  of  1799  to  five  soldiers  affected  with  the  ve- 
nereal disease  in  various  degrees  and  forms.  In  every 
one  of  these  cases,  the  medicine  was  found  efficacious ; 
but  the  degree  of  efficacy  was  remarked  to  vary  con- 
siderably, according  to  the  nature  of  the  constitution, 
and  the  kind  of  local  complaints.  Thus,  in  robust  pa- 
tients, moderate  doses  of  the  acid  soon  produced 
benefit ; while,  in  weak  persons,  disposed  to  scurvy  or 


NITROUS  ACID. 

scrofula,  a larger  quantity  of  the  medicine  and  more 
time  were  requisite.  This  assertion  we  see  is  exactly 
the  reverse  of  what  appeared  to  happen  in  the  cases 
treated  by  Mr.  Cruickshank.  However,  professor 
Schmidt  entertains  strong  doubts  whether  the  nitric 
acid  is  adequate  to  the  cure  of  all  the  forms  of  syphi 
lis;  and  he  thinks  that  neither  this  nor  any  similar 
medicines  will  ever  supersede  the  necessity  for  mer 
cury. 

Ontyd,  a Dutch  practitioner,  approves  of  the  use  of 
the  nitric  acid,  with  some  limitation  : while  he  admits 
its  efficacy  in  removing  local  symptoms,  he  is  strongly 
against  its  employment  in  cases  of  confirmed  lues. 
The  latter  assertion,  I conceive,  is  exactly  contrary  to 
the  results  of* modern  experience,  most  of  these  pro- 
tracted bad  cases  being  those  which  are  pariiculaily 
benefited  by  this  acid. — {JTieuwe  scheidekundige  Bibl. 
te  jSmsterdam ; by  Doll,  Gde  st.  1799,  p.  166.)  The 
tracts  of  Boetticher  {Berner k.  iiber  Medicinal-verf ass. 
Hospit.  u.  Curarten,  2tes  Hefr.  Kbnigsb.  1800,  8.),  of 
Ritter  {Erfahr  iiber  die  inncrl  u.  aiisserl.  Anwendang 
d.  Salpcters.  Hufel.  Journ.  b.  10,  st.  3,  p.  191 — 197), 
and  of  Frankenfeld  {Hufeland's  Journ.  der  Prakt. 
Heilk.  bd.  22,  st.  4,  p.  96— 98),  need  only  be  specified 
here,  as  decidedly  unfavourable  to  the  character  of  the 
nitrous  acid,  as  a remedy  for  syphilis. 

Another  German  author,  who  has  entered  into  the 
present  inquiry,  is  F.  A.  Walch,  whose  statements  are 
very  unfavourable  to  the  use  of  the  nitrous  acid,  as  he 
absolutely  denies  that  it  ever  accomplishes  a lasting 
cure. — (Ausfiihrl.  Darstell.  d.  Urspr.  ire.  d.  Vene 
risch.  Kravkh.  Jena,  1811,  p.  197,  198  ) 

In  a periodical  work,  mention  is  made  of  one  case, 
which,  after  resisting  a long  course  of  mercury,  and 
also  the  nitric  acid,  was  ultimately  cured  by  restrict- 
ing the  patient  for  a few  weeks  to  a very  reduced 
diet. — {Hufel.  Journ.  d.  Prakt.  Heilk.  bd.  34,  st.  2, 
p.  56.) 

For  much  of  the  foregoing  historical  account,  I am 
indebted  to  Holst,  Diss.  de  Acidi  JTitrici  Usu  Medico, 
Qoo.  Christ.  1816;  in  which  an  explanation  of  the  re- 
sults of* farther  trials  of  the  medicine  in  Denmark  and 
Sweden  may  be  perused.  From  these  countries  the 
reports  are  mostly  less  favourable  to  the  reputation  of 
the  medicine,  than  the  accounts  already  delivered. 

According  to  Holst,  the  following  are  the  chief  cir 
cumstances  under  which  the  employment  of  nitrous  or 
nitric  acid  is  generally  sanctioned. 

1.  Where  the  disease  is  complicated  with  scurvy. 

2.  Where  it  is  attended  with  scrofulous  enlargement 
of  the  glands,  and  other  strumous  symptoms.  I may 
remark,  however,  that  these  complaints  are  often  as 
undefinable,  as  some  of  the  forms  of  syphilis,  and 
therefore  the  rule  is  frequently  difficult  of  application. 

3.  Where  the  disease  is  accompanied  with  conside- 
rable debility,  either  brouglit  on  by  mercury  or  febrile 
indisposition. 

4.  Where,  from  idiosyncrasy,  mercury  cannot  be 
safely  exhibited.  Experience  fully  proves  that  there 
are  some  patients,  more  especially  females,  in  whom 
a few  grains  of  mercury  taken  inwardly,  or  mercurial 
frictions  on  the  most  limited  scale,  bring  on  vomiting, 
rheumatic  pains,  nervous  febrile  symptoms,  colic, 
spasms,  severe  headache,  and  a rapid  immoderate 
salivation. 

5 Several  practitioners  forbid  the  use  of  mercury 
during  the  latter  months  of  pregnancy.— Praz. 
Med.  Hafv.  1789,  p.  570;  Swediaur;  Aronsoun  Vollst. 
Abhdl.  allcr  Ven  Krkht.  Berlin,  1811,  p.  211.)  Holst 
observes  that  the  reason  of  this  advice  is  not  stated, 
though  no  doubt  it  must  proceed  from  an  apprehension 
of  mercury  exciting  a miscarriage. 

Mr.  Pearson’s  mode  of  exhibiting  the  nitrous  acid 
has  been  already  mentioned.  Some  practitioners  give 
it  as  follows;  R.  Gum.  arab.  3 iv.  aquae  menth.  $ viij. 
acid,  nitrosi,  vel  nitrici  3 ij.  3 iij.  F.  M.  Of  this  mix- 
ture, a table  spoonful  is  to  be  taken  every  hour,  mixed 
with  some  sweetened  water.  Should  the  acid  occa- 
sion colic  or  diarrhfEa,  its  quantity  must  be  lessened, 
and  opium  added  to  the  mixture. 

As  the  nitrous  and  nitric  acids  decompose  and  destroy 
the  teeth,  the  utmost  care  must  be  taken  to  prevent  so 
serious  an  effect.  Their  being  properly  diluted,  and 
blended  with  sugar,  svrup,  or  mucilage,  will  materially 
tend  to  hinder  the  evil.  But  the  safest  way  is  always 
to  drink  the  mixture  through  a glass  tube,  and  wash 
the  tnouth  well  immediately  after  every  dose. 


NOL 


NOL 


207 


Strong  nitrous  acid,  extricated  in  tlie  form  of  vapour, 
ifl  olten  employed  as  a means  of  purifying  the  air  of 
large  crowned  liospiials  and  sick  rooms;  a subject  on 
which  the  observations  of  Dr.J.C.  Smyth  and  G.  de 
Morveau  are  particularly  interesting.  'I'he  nitrous  acid 
is  sometimes  taken  by  accident,  or  design,  as  a poison. 
Here,  according  to  the  observations  of  Tartra,  Orfila, 
&c.,  tlie  best  antidote  is  calcined  magnesia  or  soap. 
If  the  first  of  these  articles  be  at  hand,  a drachm  of  it, 
suspended  in  a glass  of  water,  is  to  be  instantly  given, 
followed  by  copious  draughts  of  some  mucilaginous 
drink,  the  design  of  which  is  to  fill  the  stomach  and 
excite  it  to  reject  the  diluted  poison.  While  the  vo- 
miting is  going  on,  the  doses  of  magnesia  are  to  be 
repealed,  and  follow.ed  as  in  the  first  instance  by 
draughts  of  linseed-tea,  solution  of  gum  arable,  milk, 
or  broth. 

The  nitrous  acid  has  also  been  extensively  tried  as  a 
means  of  curing  syphilitic  complaints,  in  the  form  of 
what  is  termed  the  nitro-muriatic  bath,  of  w'hich  a 
description  will  be  given  in  speaking  of  the  Venereal 
Disease. 

When  reiterated  courses  of  mercury  induce  dropsy, 
as  not  unfrequently  happens  in  very  impaired  consti- 
tutions, Mr.  Carmichael  prescribes  the  nitrous  acid  in 
as  large  doses  as  the  stomach  will  bear,  conjoined  with 
digitalis. — {Essays  on  Venereal  Diseases,  4-c.)  'J'aken 
in  doses  of  eight,  ten,  or  fifteen  drops,  two  or  three 
limes  a day,  it  is  alleged  to  be  efficacious  in  the  cure  of 
some  eruptive  complaints,  especially  of  the  lower 
extremilies,  connected  with  disorder  of  the  liver. — 

( Wilson's  Pharm.  Chir.  p.  6.)  Another  well-informed 
writer  also  bears  testimony  to  its  good  effects  when 
used  together  wniti  mercury  for  old  obstinate  ulcera- 
tions of  the  legs,  though  no  venereal  taint  can  be  sus- 
pected ; and,  he  says,  it  may  be  applied  with  benefit  as 
a local  stimulant  to  fetid  ulcers,  attended  with  a thin 
ichorous  discharge,  and  in  some  exanqiles  of  caries. 
In  such  cases,  3 ij.  of  the  diluted  acid  is  to  be  mixed 
with  Ij. of  water. — {See  .d.  T-  Thomson's  Dispensa- 
tory, j».441,  ed.  2 ) With  respect  to  caries  in  the  sense 
of  necrosis,  however,  the  reader  will  understand  fiom 
what  is  said  in  the  article  on  the  subject,  that  it  can 
rarely  be  advisable  to  apply  this  or  any  other  acid, 
either  to  the  exfoliating  portion  of  bone,  or  to  that 
which  is  yet  alive.  The  nitrous  acid  has  sometimes 
been  used  for  destroying  warts,  condylomata,  and 
other  excrescences  ; and  the  nitric  acid,  ajiplied  to  the 
skin,  has  been  proposed  as  a means  of  producing  an 
immediate  vesication  of  the  pan.  By  Sir  E.  Home,  it 
is  praised  as  a local  application  for  certain  ulcers  when 
properly  diluted. — (See  Ulcers.)  It  is  likewise  com- 
mended by  some  writers  as  a very  useful  local  applica- 
tion in  cases  of  hospital  gangrene : and  an  interesting 
paper  was  lately  published  by  Mr.  R.  Welbank,  detail- 
ing the  excellent  effects  of  the  undiluted  nitric  acid, 
as  an  apitlicalion  to  diseases,  which  he  has  described 
under  the  name  of  sloughing  phagedena,  and  which 
he  considers  as  identical  with  hospital  gangrene. — (See 
jlfed.  Chir.  Trans,  vol.  11,  p.  369,  and  Hospital  Gan- 
grene.) The  cases  reported  by  this  gentleman,  are 
highly  favourable  to  the  practice,  which,  as  may  be 
seen  by  reference  to  the  article  Hospital  Gangrene, 
is  not  entirely  new  with  respect  to  this  disea.se  ; and  in 
streaking  of  mortification,  I have  mentioned  tnat  it  was 
Dr.  Kirklarnl’s  practice  sometimes  even  to  dress  certain 
sloughing  diseases  with  a solution  of  mercury  in  ni- 
trous acid.  But  notwithstanding  these  facts,  and  the 
well-known  custom  of  Sir  A.  Coojrer  to  apply  to 
sloughing  phagedenic  ulcers  the  nitric  acid  lotion,  com- 
posed of  M drops  of  the  acid,  and  a [rint  of  distilled 
water,  I feel  that  Mr.  Welbank  has  rendered  a service 
to  the  jirofession  by  drawing  their  attention  still  more 
particularly  to  the  use  of  undiluted  nitric  acid  in  the 
forms  of  phagedena,  which  he  has  so  well  described. 

NITRO-MURIATIC  BATH.— (See  Venereal  Dis- 
ease., 

NODE.  A swelling  of  a bone,  or  a thickening  of 
the  pr  riosteiim  from  a venereal  cause.— (See  Exostosis 
and  Venereal  Disease.) 

NOLI  ME  7’ANGERE.  A species  of  under 

which  term  Dr.  Willan  intended  to  comprise,  together 
with  the  noli  me  tangere.  affecting  the  nose  and  lip.s, 
other  slow  tubercular  affections,  especially  about  the 
face,  commonly  ending  in  ragged  ulcerations  of  the 
cheeks,  forehead,  eyelids,  and  lips,  and  sometimes  oc- 
curring in  other  parts  of  the  body,  where  they  gradu- 


ally destroy  the  skin  and  muscular  parts  to  a conside 
rable  depth. — {Bateman's  Synopsis  of  Cutaneous  Dts 
eases,  p.  296,  ed.  3.) 

Sir  E.  Home  says,  that  the  ulcers  for  which  he  has 
been  led  to  employ  arsenic,  are  named,  from  the  viru- 
lence of  their  disposition,  noli  me  tangere,  and  are 
very  nearly  allied  to  cancer ; differing  from  it  in  not 
contaminating  the  neighbouring  parts  by  absorption, 
but  only  spreading  by  immediate  contact.  Ulcers  of 
this  kind  difl'er  exceedingly  from  one  another  in  their 
degree  of  virulence;  but  they  are  all  so  (arof  the  same 
nature,  that  arsenic  in  general  agrees  with  them,  and 
puts  a stop  to  their  progress,  while  they  are  aggravated 
by  milder  dressings. — {Home  on  Ulcers,ed.  2,  p.  267.) 

The  disease  generally  commences  with  small  tu- 
bercles, which  change  after  a time  into  superficial 
spreading  ulcerations  on  the  alae  of  the  nose,  more  or 
less  concealed  beneath  furfuraceous  scabs.  Sir  A. 
Cooper  believes,  that  the  disease  consists  in  ulceration 
of  the  sebaceous  glands,  or  follicles  of  the  nose.  'I'he 
cartilages  and  even  the  whole  nose  are  frequently 
destroyed  by  the  progressive  ravages  of  this  peculiar 
disorder,  which  sometimes  cannot  be  stopped  or  re- 
tarded by  any  treatment,  external  or  internal. 

The  specific  ulcerations  do  not  generally  extend  to  the 
parts  far  within  the  nostrils ; but  at  the  time  that  I am 
writing  this  article,  there  is  in  St.  Bartholomew’s  Hos- 
pital a curious  example,  in  which  the  greatest  part  of 
the  nose  is  destroyed,  and  the  ulceration  proceeds  even 
through  the  front  part  of  the  palate  into  the  mouth. 
Tlie  morbid  process  sometimes  stops  for  a considerable 
lime,  and  then  is  renewed  with  increased  violence. 
The  following  case  illustrates  the  nature  of  noli  me 
tangere,  and  one  mode  of  treatment  to  which  it  yielded. 
Jane  Chatillon,  45  years  of  age,  was  attacked  in  the 
course  of  September,  1788,  with  an  inflammation  on 
the  left  ala  of  the  nose.  Some  time  afterward  the  part 
ulcerated,  which  occasioned  a troublesome  and  some- 
times a painful  itching:  different  means  were  unsuc- 
cessfully employed,  and  the  case  remained  nearly  in 
the  same  situation  until  the  month  of  September  in 
the  following  year.  At  this  period,  the  ulcer  spread 
very  fast ; the  septum  nasi,  the  muscles,  and  cartilages 
of  both  sides  were  in  a short  space  of  time  destroyed. 
The  ulceration  extended  on  the  left  side,  along  the 
loose  edge  of  the  upper  lip.  This  was  the  slate  of  her 
case  on  her  admission  into  the  Hospital  of  St.  Louis, 
in  the  month  of  October,  1789. 

A poultice  moistened  with  aq.  veg.  was  applied 
twice  a day  to  the  ulcer;  a sudorific  ptisan  prescribed  ; 
and  a pill,  composed  of  one  grain  of  calomel,  and  one 
grain  of  sulph.  aiirat.  antimonii,  ordered  to  be  taken 
every  day.  From  the  fifth  day  the  inflammation  les- 
sened. No  other  sensible  alteration  took  place  till  the 
21st.  The  suppuration,  which  till  tliis  lime  had  been 
black  and  putrid,  now  became  white  and  inodorous 

On  the  37th  the  discharge  was  trifling,  and  the  part 
was  dressed  with  pledgets,  dipped  in  a solution  of 
verdigris  and  corrosive  sublimate,  in  the  proporiion 
of  six  grains  of  each  to  a pint  of  water.  On  the  40th 
day,  cicatrization  negan  to  take  place,  and  was  finished 
by  the  60th. 

Some  time  before  the  disease  was  completely  cica- 
trized, an  issue  w'as  made  in  the  arm,  which  was 
healed  up,  without  any  inconvenience  to  the  patient,  six 
months  after  the  cure. — {Parisian  Chirurgical  Jour- 
nal, vol.  1.) 

One  of  the  best  external  applications  to  noli  me  tan 
gere  is  the  following  lotion  : R.  potassae  arseniaiis,  gr. 
iv.  Aq.  menthae  sativae,  5 iv.  Spirilus  vini  lenuioris, 
5j.  Misce  et  cola.  I have  seen  several  cases  in  St. 
Bartholomew’s  Hospital,  which  were  either  cured  or 
seemed  disposed  to  get  well  with  this  useful  applica- 
tion. The  solution  of  arsenic  which  SirE.  Home  has 
always  used,  is  made  by  boiling  white  arsenic  in  water 
for  several  hours,  in  a sand  heat.  When  given  inter- 
nally, the  dose  is  from  three  to  ten  drops ; when  for 
external  application,  a drachm  is  to  be  diluted  with  Ibij. 
of  water;  and  this  solution  is  gradually  made  stronger 
as  the  parts  become  accustomed  to  it,  till  it  is  of  double 
strength.  However,  this  mode  of  using  arsenic  is  by 
no  means  a well-regulated  one;  and  Plunket’s  caustic 
(see  Arsenic)  for  outward  employment  is  not  nearly  so 
neat  an  application  as  the  above-mentioned  lotion. 
Sir  A.  Cooper  applies  the  firllowing  ointment:  ft- 
Arsen,  oxydi  sulph.  flor.  a a 3 j.  Ung.  cetacei  5 U- 
In  24  hours  it  produces  a slough,  which,  being  covered 


208 


NYC 


NYC 


with  any  simple  dressing,  separates,  and  the  part  then 
frequently  heals. — (See  Lancet,  vul.  1,  p.  264.)  At  St. 
Baitholomew’s  Hospital,  arsenic  is  administered  inter- 
nally ill  the  following  formula;  Bi.  Potassse  arseniaiis 
gr.  ij.  Aqute  inenihte  sativae  5iv.  Spiritus  vin.  ten. 
5j.  Misce  et  cola.  Dosis  3 ij.  ter  quotidie.  In  this 
way,  the  quantity  of  arsenic  is  nicely  deiewnined. 
The  generality  of  practitioners  prescribe  the  liquor 
arsenicalis  of  the  London  PharmacopoBia  ; a formula 
that  is  nearly  the  same  as  that  recommended  by  Dr. 
Fowler,  and  very  convenient.  One  scruple  of  the  ar- 
gentum nitratum,  dissolved  in  half  an  ounce  of  dis- 
tilled water,  makes  a very  good  application,  which, 
although  generally  inferior  in  point  of  efficacy  to  arse- 
nical ones  in  the  present  disease,  occasionally  does 
good  when  nothing  else  seems  to  produce  any  benefit. 
The  above  case  makes  us  acquainted  with  another 
lotion  which  deserves  farther  trial.  All  fluid  remedies 
must  be  applied  to  the  part  by  dipping  little  bits  of  lint 
in  them,  placing  these  on  the  ulcerations,  and  covering 
the  whole  with  a pledget. 

The  ointments  which  seem  most  likely  to  prove  useful 
applications  to  noli  me  iangere  are,  the  unguentum 
hydrargyri  nitrati,  the  unguentum  picis,  and  unguentiiin 
sulphuris.  As  far  as  my  experience  extends,  they  are 
generally  less  efficacious  than  lotions  in  the  present 
cases ; but  in  particular  instances,  they  prove  superiorly 
useful : and  it  deserves  especial  notice,  that  surgeons 
can  often  make  no  progress  against  this  inveterate 
disease,  unless  they  apply  a different  sort  of  dressing 
every  day  ; sometimes  a lotion,  at  other  times  an  oint- 
ment. The  little  ulcers  may  occasionally  be  touched 
with  the  argentum  nitratum,  ora  strong  solution  of  it. 
The  small  furfuraceous  scabs  v.'hich  are  continually 
forming  on  the  part  affected,  should  be  softened  with 
a lilile  of  the  unguentum’spermatis  celi,  and  removed 
with  as  much  tenderness  as  possible. 

We  have  already  remarked  that  arsenic  is  a good 
medicine  to  be  given  internally,  and  the  best  mode  of 
exhibiting  it  has  been  already  explained.  Another 
medicine  which  is  often  useful  in  these  cases,  is  what 
is  know'll  by  the  name  of  Plummer’s  pill,  or  the  com- 
pound calomel  pill.  R-  Hydrargyri  submuriatis,  sul- 
phurisantimonii  piEecipitati  singulomnqgr.  xii.  Guaiaci 
guinmi  resinae,  gr.  xxiv.  Sapouis  quod  satis  sit.  Misce; 
fiant  piliilat  diiodecim.  Dosis  una  bis  quotidie. — In  other 
instances,  we  may  try  the  decoctum  nimi  or  sarsapa- 
rilltE,  w'ilh  one  of  the  following  pilL  thrice  a day.  fit. 
Hydrargyri  submuriatis  gr.  vj.  Succi  spissati  cicuiae  3j. 
Misce;  fiant  pilulae  duodecim.  The  tiydrargyrus  sul- 
phurains  has  occasionally  been  given  as  an  alterative 
medicine,  (or  the  relief  of  noli  me  tangere  ; with  what 
good  effect  I cannot  pretend  to  say. 

In  three  or  four  le.<s  severe  cases  of  lupous  tubercles  on 
the  face,  which  had  made  no  progress  towards  ulcera- 
tion, Dr.  Bateman  saw  the  solution  of  mnnate  of  ba- 
rytes, taken  internally,  materially  amend  ihecomplaint. 
Sometimes,  also,  a separation  of  the  diseased  parts 
from  the  sound  has  been  effected  with  the  knife,  or  caus- 
tic, and  the  progress  of  the  complaint  been  stopped. 
— [Synopsis  of  Cutaneous  Diseases,  p.  296,  edit.  3.) 

NYCTALOPI  \.  (From  vil,  night;  and  the 
eye,  or  oVro),  to  see.)  An  affection  of  the  sight,  in 
which  the  patient  is  blind  in  thedaylight,  but  sees  very 
well  at  night. 

Nyctalopia,  visas  nocturnus,  or  day-blindness,  vul- 
garly called  owl-sight  (says  M.  Lassus),  is  an  affection 
in  which  the  patient  either  cannot  see  at  all,  or  sees  but 
very  feebly,  objects  which  are  in  the  open  daylight,  or 
situations  where  there  is  a strong  light;  but  discerns 
them  very  well  when  they  are  in  a darki.^h  place,  or  at 
sunset,  or  in  the  night-time,  if  not  immoderately  dark. 
— (See  Pathologic  Chir.  t.  2,  p.  539,  540.) 

'J’he  Greek  physicians  are  divided  in  their  opinions 
concerning  the  now  uncommon  disease  nyctalopia.  Hiy 
pocrates  expressly  says,  “we  call  those  nycialoi»es  who 
see  by  night.”  The  author  of  Dejin.  Medic,  states, 
“ that  they  see  nothing  in  the  daytime,  but  have  iheii 
sight  by  night.”  On  the  contrary,  Paulus  .®gineta  and 
Aciuariiis  are  as  explicit  in  asserting  that  their  sight  is 
perfect  in  the  daytime,  but  that  they  are  blind  by  night. 
.(Eiius  is  of  the  same  mind,  though  he  is  thought  to  fa- 
vour the  contrary  opinion,  when  he  says,  “ they  see 
heller  by  night  ilnin  in  the  (lay,  and  if  the  moon  shines 
they  are  blind.”  The  author  of  Isagoge  embraces  both 
opiiiions,  when  he  says,  “they  call  those  nyctalope.s 
who,  in  the  daytime,  see  more  obscurely,  at  the  set- 


ting of  the  sun  more  clearly,  but  when  it  is  night  mtteli 
belter  ; or,  on  the  contrary,  by  day  they  see  a little,  bnl 
in  the  evening,  or  at  night,  they  are  blind  ” Galen  ex- 
plains the  word  by  a night-blindness.  Pliny,  Varro, 
Nonius,  Festus,  Celsus,  and  other  writers,  give  equally 
opposite  definitions  of  the  disorder.  Dr.  Pye  questions 
whether  these  two  descriptions  of  nyctalopia,  so  dia 
metrically  opposite  to  each  other,  may  not  be  reconciled 
by  considering  the  disorder  as  an  iniermiitetii  one.  The 
difference  then  will  only  consist  in  the  different  times 
of  the  approach  of  the  disease;  that  of  Hippocrates 
came  on  in  the  morning ; that. of  ^Egineta  in  ilie  even- 
ing ; both  were  expressly  periodical,  and  the  distance 
of  time  between  the  paroxysms  in  both  was  respect- 
ively the  same  ; a whole  day  or  a whole  night.  The 
various  shape  in  which  interniittents  appear,  very  much 
favour,  says  Dr.  Pye,  such  an  opinion  ; and  the  appa- 
rent success  of  bark  in  the  case  which  he  has  related, 
notwithstanding  the  unfavourable  circumstances  of  the 
evacuations  his  patient  laboured  under,  and  the  con- 
sequent necessity  of  its  disuse,  seem  to  confirm  it  in 
this  gentleman's  mind. — {Med.  Obs.  and  lag.  vul.  1 ) 

In  this  work  I shall  follow  Callisen,  Richter,  and  the 
best  modern  surgical  writers,  in  calling  day-blindness 
nyctalopia,SLnd  night  hViudaess hemeralopia — (Se%  Cal- 
lisen, Syst.  Chir.  Hodiernce,  vol.  2,  p.  392;  and  Richter, 
Jhifangsgr.  der  Wundarzn.  b.  3,  p.  479.) 

Nyctalopia,  in  the  sense  of  day-blindness,  is  a very 
rare  disease,  in  comparison  with  hemeralopia,  which 
is  a common  disorder  in  warm  climaies.  According  to 
Dr.  Hillary,  there  are  persons  in  Siam,  in  the  East 
Indies,  and  also  in  Africa,  who  are  all  of  this  cat-eyed 
species,  or  subject  to  the  disease  of  being  blind  in  the 
daytime  and  seeing  well  by  night.— (JIfod  Univ.  Hist, 
vol.  7.)  The  same  author  notices  the  general  rarity  of 
the  disorder,  and  mentions  his  having  met  with  but 
two  examples  of  it. 

With  respect  to  the  causes  of  the  complaint.  Dr.  Hil- 
lary observes,  that  it  proceeds  from  loo  great  a tender- 
ness and  sensibility  of  the  iris  and  retina.  M.  Lassus 
thinks  the  causes  may  be  of  different  kinds.  “ If,  for 
instance  (says  he),  there  were  a very  small  opacity,  like 
a point,  exactly  opposite  the  pupil,  or  centre  of  the 
crystalline  lens,  the  pupil  contracting  in  the  open  day- 
light, would  stop  the  entrance  of  the  rays  of  light  into 
the  eye,  and  a day-blindness  arise,  which  would  be 
diminished  by  the  expansion  of  the  pn|)il  in  the  shade. 
Here  the  cure  would  depend  upon  the  removal  of  the 
opacity. 

“ Persons,  whose  pupils  do  not  move  freely,  but  re- 
main much  dilated,  and  do  not  sufficiently  contract  in 
light  situations,  are  also  affected  w-ith  nyctalopia;  for 
so  large  a quantity  of  the  rays  of  light  pass  into  their 
eves,  that  it  serves  rather  to  destroy  than  assist  vision. 
Such  persons  see  tolerably  well,  and  better  than  the 
preceding  class  of  patients  in  a darkish  place,  and  they 
ought  to  wear  green  spectacles  in  the  daytime,  in  or- 
der to  weaken  the  impressions  of  the  rays  of  light. 
When  a person  is  shut  up  a long  while  in  a dark  place, 
the  pupils  become  habitually  dilated,  and  if  he  exposes 
himself  suddenly  and  incautiously  to  a strong  light,  the 
eyesight  may  be  destroyed.  There  are  other  individu- 
als, who,  from  excessive  sensibility  of  the  iris,  cannot 
bear  much  light;  their  pupils  instantly  contract  and 
close.  This  case  (continues  M.  Lassus)  may  be  brought 
on  by  too  great  indulgence  in  venereal  pleasures,  and  in 
persons  who  have  debilitated  their  constitutions  during 
their  youth.”  The  same  author  mentions  other  cases, 
which  seetn  to  depend  upon  a species  of  irritahiliiy  of 
the  iris.  In  one  itistance  ati  issue  iti  the  arm  effectf'd  a 
cure,  and  he  mentions  the  utility  of  blisters.  He  admits 
likewise,  with  Dr.  Pye,  cases ofintermittentor  periodical 
nyctalopia,  which  begin  regularly  in  the  morning,  and 
go  off  in  the  evening,  the  patient  coniitiuitig  blind  \yhe- 
ther  he  keep  himself  in  a dark  or  a light  place.  The 
cause  of  these  instances,  which  he  observes  are  very  un- 
common, is  generally  sealed  in  the  primte  via>,  and  re- 
quires emetics,  resolvents,  purgatives,  and  bark. — See 
Palhologie  Chir.  t.  2,  p.  540 — 542.  A\sn  Richter  .dn- 
favg.'igr.  der  Wundarzn.  6.  S,  p.  481.)  In  1787,  Raton 
Larrev  met  with  a case  of  day-blindness  in  an  old  man, 
one  of  the  galley-slaves  at  Brest,  who  had  been  shut  up 
iticessanily  for  thirty-three  years  in  a subterraneous 
dungeon.  His  lottg  residence  in  darkness  had  had  sttch 
an  effect  on  the  organs  of  vision,  that  he  could  only 
see  in  the  dark,  and  was  completely  blind  in  the  dav- 
time.— (See  Mim.  de  Chir.  Militaire,  1. 1,  p.  6.) 


GES 


CES 


209 


Nyctalopia  may  sometimes  depend  on  a peculiarity 
in  Uie  structure  and  organization  of  tlie  eye ; by  rea 
son  of  which,  the  quantity  of  light,  which  only  suffices 
for  vision  in  an  eye  of  natural  formation,  proves  too 
abundant  for  a nyctalops,  and  absolutely  prevents  liim 
from  seeing  at  all.  We  know  that  in  the  eye  there  is 
a black  substance,  named  the pigmentum  nigrum;  one 


supposed  use  of  which  is  to  absorb  the  redundant  rays 
of  light,  which  enter  the  pupil.  A deficiency  of  it 
might  perhaps  account  for  a nyctalops  being  blinded 
with  daylight,  and  seeing  best  at  night.  ‘ 

For  an  account  of  nyctalopia,  in  the  sense  of  night 
blindness,  refer  to  Hemeralopia. 


o 


^X;^DEMA.  (From  olMoi  to  swell.)  A swelling  aris- 
ing  from  the  effusion  of  a serous  fluid  in  the 
cellular  substance  of  a part;  the  affection,  when  more 
extensive,  and  accompanied  with  a general  dropsi- 
cal tendency,  receiving  the  name  of  anasarca.  An 
oedematous  part  is  usually  cold  and  of  a pale  colour  ; 
and  as  it  is  little  or  not  at  all  elastic,  itjoi'ts,  as  surgeons 
express  themselves,  or,  iti  other  words,  it  retains  for  some 
time  the  impression  of  the  finger,  after  being  handled 
or  pressed.  CEdematous  swellings  are  often  connected 
with  constitutional  causes.  In  many  cases,  however, 
they  seem  to  be  entirely  local  affections,  arising  from 
such  causes  as  only  act  upon  the  parts  in  which  the 
disease  is  situated.  Thus  we  observe  that  after  violent 
sprains  of  the  wrist  or  ankle-joint,  the  hands  and  feet 
often  become  oedematous:  and  limbs  are  frequently 
affected  w ith  oedema,  in  consequence  of  the  return  of 
blood  through  the  veins  being  obstructed  by  the  pres- 
sure ol  tumours  on  them,  or  that  of  splints,  bandages, 
&c.  Pregnant  women  are  known  to  be  particularly 
subject  to  oedema  of  the  legs,  owing  to  the  pressure  of 
the  gravid  uterus  on  the  iliac  veins.  Persons  who  have 
been  confined  in  bed,  with  fractured  thighs  or  legs,  ge- 
nerally have  more  or  less  oedema  in  their  feet  and  an- 
kles on  first  getting  up  again;  and  the  affection  in 
these  cases  is  probably  dependent  on  the  loss  of  tone  in 
the  vessels  of  the  limb. 

In  the  treatment  of  oedema,  great  attention  must  al- 
ways be  paid  to  the  nature  of  the  cause,  in  order  to 
determine  whether  the  disease  originate  from  a mere 
local  or  a general  constitutional  affection.  When  it  de- 
pends on  the  pressure  of  a tumour  on  the  veins,  as  we 
often  see  happen  in  cases  of  aneurisms,  the  effect  can- 
not be  got  rid  of  till  the  cause  is  removed;  and  the 
aneurismal  swelling  must  be  lessened,  before  the  oede- 
matous one  can  admit  of  the  same  beneficial  change. 
When  oedema  is  the  effect  of  vascular  weakness  in  a 
limb,  in  consequence  of  sprains,  contusions,  &.c.  the 
best  means  of  relief  is  to  support  the  parts  affected, 
with  a laced  stocking  or  a flannel  roller,  while  they  are 
also  to  be  rubbed  with  liniments,  and  bathed  with  cold 
spring  water,  till  they  have  perfectly  recovered  their 
tone. 

With  regard  to  the  oedema  attendant  on  the  advanced 
stage  of  pregnancy,  a complete  cure  cannot  be  expect- 
ed till  after  delivery.  The  affection  is  generally  more 
considerable  in  the  afternoon  than  the  morning,  owing  to 
thedifferenteffecisof  an  erect  and  arecumbeni  position. 
Some  relief  may  be  obtained  by  the  patient  keeping  as 
much  as  possible  in  a horizontal  posture ; and  when 
great  inconvenience  and  pain  are  felt,  tiie  parts  may 
be  fomented  with  any  aromatic  or  spirituous  applica- 
tion. 

Frequently  oedema  is  one  of  the  symptoms  of  suppu- 
ration, and  when  the  collection  of  matter  is  very  deeply 
situated,  sometimes  leads  to  its  discovery,  as  is  exem- 
plified in  cases  of  em(»yema. 

There  is  a species  of  oedema,  accompanied  with  a 
degree  of  heat,  pain,  &c.  in  the  part,  and  which,  in 
short,  seems  combined  with  phlegmon.  In  this  case, 
cold  evaporating  lotions,  the  application  of  leeches, 
and  the  exhibition  of  saline  purgatives  are  proper.  An 
erysipelatous  oedema  is  also  nret  with,  in  which  the 
treatment  should  very  much  resemble  what  is  explained 
in  the  article  Erysipelas. 

CESOPH  AGOTOM  Y.  (From  cesophagvs,  und  Tfyvu), 
to  cut.)  The  operation  of  cutting  into  the  oesophagus, 
in  order  to  'ake  out  of  it  any  foreign  body  which  lodges 
in  it,  and  can  neither  be  extracted  through  the  mouth, 
nor  pushed  down  into  the  stomach,  though  its  temoval  is 
absolutely  necessary  for  the  preservation  of  the  pa- 
tient’s life.  A substance,  above  a certain  size,  lodged 

VoL.  II.-O 


in  the  upper  part  of  the  oesophagus,  not  only  obstructs 
deglutition,  but  by  its  pressure  against  the  trachea,  pro- 
duces the  most  urgent  symptoms  of  suffocation.  In 
this  circumstatice,  if  relief  cannot  be  expeditiously 
aft’orded  in  any  other  manner,  and  the  situation  of  the 
foreign  body  is  denoted  by  a prominence  distinguisha- 
ble in  the  neck.,  oesophagotomy  should  be  practised  with- 
out delay.  However,  when  the  symptoms  are  pressing, 
yet  unattended  with  any  possibility  of  feeling  the  foreign 
body,  either  externally  or  with  a probang,  desperate  as 
the  situation  of  the  patient  may  be,  modern  surgeons 
do  not  sanction  the  practice.  And  this  difference  from 
the  opinion  of  the  first  proposers  of  oesophagotomy,  does 
not  arise  so  much  from  any  reflections  upon  the  greater 
difficulty  of  the  operation  in  this  circumstance,  as  from 
the  consideration  of  its  being  unlikely  to  answer  the 
only  purpose  which  makes  its  perfortnance  at  anytime 
proper,  viz.  that  of  enabling  the  practitioner  to  extract 
with  reasontible  certainty  the  substance,  whose  conti- 
nuance and  pressure  iii  the  oesophagus  are  the  imme- 
diate cause  of  the  patient’s  danger.  Hence,  when  the 
symptoms  of  suffocation  are  extremely  urgent,  but  the 
foreign  body  produces  no  external  prominence  in  the 
neck,  the  surgeon  should  in  the  first  instance  perform 
tracheotomy,  so  as  to  obviate  the  imminent  peril  aris- 
ing from  the  impeded  state  of  respiration,  and  after- 
ward try  such  measures  for  the  removal  of  the  sub- 
stance lodged  in  the  oesophagus,  as  experience  points 
out  as  most  likely  to  prove  successful.  Though  oeso- 
phagotomy was  cursorily  mentionc^by  Verduc  in  his 
“ Pathologie  Chirurgicale,”  Guattani,  formerly  a distin- 
guished surgeon  at  Rome,  is  entitled  to  the  honour  of 
having  published  the  first  valuable  observations  on  the 
subject. — {Mim.  de  VAcad.  de  Chir.  t.  3,  Ato.)  Guat- 
tani proved  by  experiments  that  the  operation  might 
be  safely  performed  upon  dog.s,  which  recovered  after 
it  very  well,  and  he  demonstrated  on  the  dead  body  that 
it  was  equally  practicable  on  the  human  subject.  Nay, 
what  is  still  more  to  the  point,  he  brought  forward  two 
instances,  in  which  the  practice  had  been  successfully 
adopted  on  living  patients.  “ In  May,  1738,  Goursauld, 
a surgeon  at  Coussat-Bonneval,  in  Limousin,  was  called 
to  a man,  in  w'ho.se  ossophagus  a bone  was  lodged, 
an  inch  long  and  half  an  inch  broad.  Various  ineffect- 
ual endeavours  were  made  to  force  it  down  into  the 
stomach,  and,  as  it  was  perceptible  on  the  left  side  of 
the  neck,  Goursauld  ventured  to  make  an  incision  for 
its  extraction,  fl'he  bone  was  thus  easily  taken  out,  no 
bad  symptoms  followed,  and  the  wound  healed  up  fa- 
vourably with  the  aid  of  a uniting  bandage.  For  six 
days  the  patient  was  not  allowed  to  swallow  any  kind 
of  food,  but  was  nourished  entirely  with  clysters.  Ac- 
cording to  Morand,  a similar  operation  was  performed 
with  equal  success  by  Roland,  surgeon-major  of  the  re- 
giment of  Mailly.” — {M6m.  de  I'Acad.  de  Chir.  t.  3.) 

Although  tlie  deep  situation  of  the  oesophagus  among 
the  most  important  parts  of  the  neck,  makes  cesopha- 
gotomy  an  operation  of  considerable  delicacy  in  the 
hands  even  of  a skilful  surgeon,  and  one  of  great 
danger  in  those  of  a man  deficient  in  atiatomical  ktiow- 
ledge,-  and  ignorant  of  the  right  way  of  proceeding, 
yet  the  propriety  of  performing  it,  under  the  circum- 
stances which  have  been  specified,  is  universally  ad- 
mitted. When,  however,  I refer  to  the  delicacy  and 
difficulty  of  the  operation,  I am  meanitig  a case  in 
which  a deliberate  dissection  is  tnade  down  to  the  ceso 
phagits  without  atiy  guidance  frotn  the  projection  of 
the  foreign  body  within  it;  a case  in  which  my  views 
of  the  subject  lead  me  to  think,  contrarily  lo  those  of 
Guattatii,  that  the  experiment  would  generally  be  at- 
tended with  no  practical  benefit;  which  is  also  the 
sentiment  of  Baron  Boyer.  For  with  respect  to  open- 


210 


CES 


ing  the  oesophagus,  with  the  view  of  tracing  a sulf* 
stance  in  it  not  externally  perceptible,  and  either  of 
taking  hold  of  the  same  substance  with  forceps,  or 
pushing  it  down  into  the  stomach  with  other  instru- 
ments introduced  through  tlie  incision,  as  suggested  by 
Guaitani,  the  chatices  of  success  must  be  too  small  to 
justify  a practice  in  which  it  is  above  all  things  of  con- 
sequence to  have  the  guidance  afforded  by  the  promi- 
nence in  the  throat,  as  a test  of  the  foreign  body  being 
actually  lodged  in  the  oesophagus,  and  capable  of  being 
removed  from  it  by  the  proposed  operation.  Indeed, 
the  uncertainty  of  being  able  to  reach  and  extract  the 
foreign  body,  when  its  precise  situation  is  not  indi- 
cated by  any  external  swelling,  appears  to  me  an  objec- 
tion'of  greater  validity  than  any  consideration  either 
of  the  increased  difficulty  of  cutting  into  the  oesopha- 
gus under  these  circumstances,  or  of  the  usual  conse- 
quences of  such  an  incision  after  it  has  been  accom- 
plished; because  the  practicable  nature  of  the  opera- 
tion, and  the  tendency  of  wounds  of  the  oesophagus  to 
heal  favourably,  when  not  complicated  with  other 
mischief  of  too  serious  a description,  are  facts  proved 
bet  ond  the  possibility  of  dispute.  In  attempts  at  sui- 
cide and  murder,  and  in  cases  of  gunshot  injury,  the 
oesophagus  is  sometimes  wounded,  together  with  other 
parts  in  the  neck,  and  yet  the  patients  frequently  re- 
cover; and  when  they  die  their  fate  seems  to  depend 
rather  upon  other  unfavourable  circumstances  in  their 
cases,  than  upon  the  accidental  injury  of  the  gullet. 
The  cures  of  wounds  of  the  neck,  involving  the  latter 
tube  as  well  as  the  trachea,  are  reported  by  numerous 
writers,  B.  Bell,  Desault,  Bohnius,  &c.,  and  some  have 
fallen  under  my  own  observation.  If  it  were  neces- 
pry  to  substantiate  this  point  farther,  I might  cite  the 
instance  recorded  on  the  authority  of  Dr.  James  John- 
son, where  a man  recovered  after  the  larynx  had  been 
completely  severed  between  the  thyroid  and  cricoid 
cartilages,  and  one-half  of  the  caliber  of  the  oesopha- 
gus divided. — (See  Hennen's  Military  Surgery,  p.  364, 
cd.  2.)  But  .supposing  a wound  of  the  oesophagus,  ab- 
stractedly considered,  were  more  dangerous  than  it 
really  is,  the  question  of  the  propriety  of  oesophagotomy 
would  not  be  materially  affected  by  it;  because  the  ope- 
tion  is  never  remmmended,  except  as  a matter  of  ne- 
cessity, and  witlrout  which  the  patient  would  have  no 
chance  of  preservation. 

As  the  oesophagus  does  not  descend  exactly  in  a 
straight  line,  between  the  trachea  and  vertebrce,  but 
inclines  rather  to  the  left  side  of  the  spine,  Guatiani 
directs  the  left  side  of  the  neck  to  be  preferred  for  the 
performance  of  oesophagotomy.  But  Boyer  has  justly 
remarked,  that  as  the  operation  should  never  be  at- 
tempted unless  there  be  projection  of  the  foreign  body, 
the  place  for  the  incision  is  always  to  be  determined 
by  the  situation  of  the  projection,  the  left  side  being 
chosen  only  when  the  prominence  is  either  most  dis- 
tinguishable there,  or  at  all  events  not  less  than  on  the 
opposite  side  of  the  neck.— (Tcafte  des  Mai.  Chir.  t.l, 
p.  192.) 

The  parts  which  cover  the  oesophagus  from  the  mid- 
dle and  external  part  of  the  neck  to  the  upper  part  of 
the  sternum,  are  the  skin,  fat,  cellular  substance,  mus- 
cles proceeding  from  the  sternum  to  the  larynx,  the  thy- 
roid gland,  the  thyroid  arteries  and  veins,  the  trachea, 
the  recurrent  nerve,  &c.  Guattani,  who  preferred  the 
left  side  of  the  neck,  recommended  the  fallowing  mode 
of  operating.  The  patient  is  to  sit  on  a chair,  with 
his  head  inclined  backwards,  and  steadily  supported 
by  an  assistant.  The  skin  having  been  pinched  up 
into  a transverse  fold,  an  incision  is  to  be  made  in  the 
integuments  from  the  upper  part  of  the  sternum.  The 
cellular  substance  between  the  sterno-hyoideus  and 
sterno-thyroideus  muscles  and  trachea  is  next  to  be 
divided.  With  two  blunt  liooks  the  lips  of  the  wound 
are  to  be  kept  open;  and  on  separating  tlie  cellular 
substance  at  the  side  of  the  trachea  with  the  aid  of  the 
fincer  and  a few  strokes  of  the  knife,  the  oesophagus 
will  be  seen.  The  lower  part  of  this  tube  is  then  to  be 
opened,  and  the  w'ound  in  it  enlarged  with  a pair  of 
curved  blunt-pointed  scissors,  a director  being  em- 
ployed if  any  difficulty  arise.  With  a small  pair  of 
curved  forceps,  similar  to  those  used  for  the  extraction 
of  polypi,  the  foreign  body  may  then  be  removed.  Ac- 
cording to  Guattani,  the  wound  will  serve  for  the  ex- 
traction of  the  foreign  body,  whether  this  be  situated 
above  or  below  it,  and  he  asserts  that  the  opening  will 
even  be  useful  when  the  extraneous  substance  has 


(ES 

passed  so  far  down  that  it  cannot  be  taken  out,  as  it 
can  now  be  easily  pushed  into  the  stomach.  Guattani 
Ia3’s  great  stress  on  the  usefulness  of  endeavouring  to 
unite  the  wound,  and  adverts  to  his  experiments, 
proving  that,  in  animals,  wounds  of  the  eesophagns 
heal  very  favourably.  If,  says  he,  the  vein  which 
brings  back  the  blood  from  the  inferior  parts  of  the 
thyroid  gland,  and  runs  into  the  subclavian,  happen  to 
be  cut,  the  hemorrhage  may  be  stopped  with  a dossil 
of  lint  held  upon  the  aperture  in  the  vein  during  the 
operation,  and  afterward,  if  the  bleeding  continue, 
compression  or  a ligature  is  to  be  employed.  The  re- 
current nerve,  if  at  all  likely  to  be  touched  with  the 
knife,  is  to  be  cautiously  drawn  a little  out  of  the  way 
with  the  blunt  tenacniuni.  Guattani  also  particularly 
insists  upon  opening  the  oesophagus  as  near  as  possible 
to  the  trachea,  especially  at  its  upper  part,  w here  the 
artery  which  goes  from  the  subclavian  to  the  thyroid 
gland’  sometimes  runs.  When  the  foreign  body  re- 
quires an  ample  opening,  and  paiticularly  when  the 
thyroid  gland  is  enlarged,  Guattani  approves  of  sepa- 
rating this  part  a little  from  the  side  of  the  trachea. — 
(See  Mem.  de  I'Acad.  Chir.  t.  3,  Ato.i 

There  can  be  no  doubt  that  Guattaiii’s  directions  for 
finding  the  oesophagus  are  very  good  ; but  his  chief 
defect  is  that  of  representing  the  place  for  the  incision 
as  being  always  the  same,  whereas  it  ought  to  be 
partly  regulated  by  the  situation  of  the  foreign  body 
itself.  How’ever,  his  advice  to  make  the  incisions  close 
to  the  trachea  appears  to  me  more  judicious  than  that 
recently  delivered  by  Mr.  Boyer,  who  directs  them  to 
be  made  through  the  cellular  substance  between  the 
sterno-bv’oideus  and  sterno-thyroideus  muscles,  and 
the  onio-hyoideus  (see  Trait6  des  Mai.  Chir.  t.  7,  p. 
193,  Sno.  Paris,  1821) ; in  which  method  he  quits  the 
trachea,  which  is  the  best  guide  to  the  oesophagus,  and 
approaches  unnecessarily  the  large  blood-vessels  of  the 
neck.  Yet  1 agree  with  Boyer  respecting  the  general 
impropriety  of  attempting  oesophagotomy  when  the 
situation  of  the  foreign  body  is  not  indicated  by  any 
prominence  in  the  neck,  and  the  prudence  of  determin- 
ing the  place  of  the  incision  in  a great  measure  by 
such  projection.  Boyer  also  cautions  the  operator  to 
let  his  incisions  always  be  made  in  such  manner  as  to 
leave  unhurt  the  trachea  and  recurrent  nerve  at  the 
inner  edge  of  the  wound;  the  carotid  and  internal  ju- 
gular vein  at  its  outer  edge;  the  superior  thyroideal 
vessels  above;  and  the  inferior  ones  below.  With  this 
view,  the  cellular  substance  is  to  be  slowly  divided 
layer  by  layer,  and  the  blood  repeatedly  absorbed  with 
a sponge;  but  if  any  vessel  bleed  freely  it  is  to  be  im- 
mediately lied. 

After  the  operation,  an  elastic  gum  catheter  should 
be  passed  from  one  of  the  nostrils  down  the  pharynx 
and  oesophagus,  by  which  means  the  requisite  Ibod  and 
medicines  may  be  injected  into  the  stomach  without 
any  risk  of  their  passing  through  the  incision  and  re- 
tarding the  cure.  But  a still  stronger  motive  for  this 
practice  is  the  avoidance  of  the  convulsive  action  of 
the  muscles  in  deglutition;  a source  of  very  hurtful 
disturbance  to  the  jiarts.  Before  the  advantages  of 
this  contrivance  were  duly  appreciated,  the  patient,  for 
the  first  week,  w'as  allowed  to  swallow  scarcely  any 
thing,  and  was  kept  alive  with  broths  injected  up  the 
rectum. 

In  Graefe  and  Walter’s  Journ.  {b.  5,  p.  712),  Vacca- 
Berlinghieri  has  described  an  instrument  with  w Inch 
he  conceives  that  this  operation  may  be  more  easily 
and  safely  done  than  in  any  other  manner.  It  is  passed 
into  the  oesophagus  as  far  as  the  lower  angle  of  the  ex- 
ternal incision,  and  then  by  means  of  ati  olive  shaped 
knob,  which  is  moved  by  a spring,  it  makes  the  pari- 
etes  of  the  oesophagus  protrude  at  the  wound. 

CESOPHAGUS,  Foreign  Bodies  in  the.  There  are 
few  situations  in  which  foreign  bodies  lodge  more  fre- 
quently than  in  the  ce.sophagus;  a fact  explicable  by 
the  consideration  of  the  function  of  this  tube,  the  near- 
ness of  jiart  of  which  to  the  windpipe  at  the  same  time 
accounts  for  the  frequent  danger  of  sufTocation,  wlien 
a substance  above  a certain  size  is  lodged  in  it.  'i’he 
lodgement  often  takes  place  at  the  lower  part  of  tlie 
pharynx  or  beginning  of  the  eesophagns,  and  sometimes 
just  above  lh(‘  diaphragm  ; but  very  rarely  in  the  inter- 
vening portion  of  that  canal. 

Foreign  bodies  liable  to  lodge  in  the  ORsophagus  are, 
not  onlv  articles  of  food,  sttch  ns  pieces  of  entst  or 
meat  imperfectly  chewed,  the  yolk  ofati  egg  boiled  very 


(ESOPHAGUS.  211 


hard,  and  not  masticated,  a chestnut,  or  small  apple, 
&c.;  but  also  various  substances  which  are  acci 
dentally  swallowed  either  alone  or  together  with  the 
tbod,  such  as  pieces  of  bone,  stones,  pins,  needles,  but- 
tons, pieces  of  money,  knives,  forks,  scissors,  spoons, 
keys,  &c.  These  latter  articles,  by  lodging  in  the  pha- 
rynx or  oesophagus,  may  occasion  very  bad  and  latal 
symjitoms,  and  if  forced  down  into  the  stomach  may 
produce  effects  of  a not  less  serious  description.  Hence 
an  immediate  attempt  should  always  be  made  to  ex- 
tract them.  For  tliis  purpose  the  ringers  may  be  em- 
ployed, and,  if  they  will  not  reach  far  enough,  a pair 
of  long  curved  forceps  should  be  used.  But  no  instru- 
ment seems  better  calculated  for  cases  in  which  the 
body  lodged  in  liie  oesophagus  is  not  too  wide,  than  the 
ureihra-forceps  invented  by  Mr.  Weiss  of  the  Strand, 
and  used  by  Sir  A.  Cooper  for  the  removal  of  calculi, 
under  a certain  size,  from  the  bladder. — (See  Med. 
Chir,  Trans,  vol.  11.)  Nooses  of  wire,  and  bunches 
of  thread  with  a multitude  of  nooses,  fastened  upon 
the  end  of  a probang,  and  a piece  of  sponge  rixed  on 
the  extremity  of  the  same  instrument,  or  on  that  of  the 
strong  wire  stilet  of  a long  elastic  gum  catheter,  and 
various  other  contrivances  have  been  made  with  the 
view  of  extracting  different  articles  from  the  oesopha- 
gus. Tiie  buncli  of  thread  seems  well  calculated  for 
catching  hold  of  small  substances,  like  fish  bones, 
needles,  &e. ; and  the  sponge,  when  expanded  witli 
moisture  and  withdrawn,  will  sometimes  bring  up  ar- 
ticles, which,  on  its  introduction,  it  had  passed  in  its 
dry  and  diminished  state.  When  the  stomach  is  full, 
the  excitement  of  vomiting  has  sometimes  answered ; 
but  if  the  foreign  body  be  sharp  and  pointed,  the  me- 
thod js  not  free  from  danger,  and,  instead  of  relieving 
the  patient,  may  put  him  to  great  pain,  and  bring  on 
violent  infiatnmation  of  the  passage,  and  the  most  dis- 
tressing symptoms.  Some  practitioners,  however,  are 
adv<K;ates  for  an  emetic,  and  wlten  the  patient  is  to- 
tally incapable  of  swallowing,  it  has  been  proposed  to 
inject  a solution  of  tartarized  antimony  into  the  veins. 
— (See  Chelius,  Handb.  der  Chirurgie,  b.  2,  p.  105.) 

When  the  substances  are  not  of  a very  hurtful  kind, 
and  catmot  be  extracted,  they  must  be  pushed  down 
into  the  stomach  with  a large  bougie,  or  a whalebone 
probang,  fifteen  or  sixteen  inches  long,  and  to  the  end 
of  which  a piece  of  fine  sponge  is  securely  fastened. 
But  such  practice  is  not  advisable,  wlien  the  foreign 
bodies  have  a sharp,  pointed  form,  so  as  to  be  likely  to 
prove  a source  of  at  least  equal  danger  and  suffering, 
if  placed  in  contact  with  the  inner  surface  of  the  sto- 
mach. Experience  proves,  that  hard  angular  sub- 
stances and  pointed  bodies,  like  nails,  pins,  needles, 
&.C.  which  sui-geons  have  not  ventured,  or  not  been 
able,  to  force  down  into  the  stomach,  have  often  made 
their  way  after  a time  to  the  surface  of  the  body, 
where  an  abscess  has  formed,  out  of  which  tliey  have 
been  discharged. 

When  hard,  irritating  bodies  have  either  passed  of 
themselves,  or  been  pushed  with  a probang  into  the 
stomach,  their  ill  effects  should  be  coutiteracted,  and 
their  passage  through  the  bowels  promoted  with  mu- 
cilaginous draughts,  containing  the  oleum  amygdala- 
rum,  or  oleum  ricini.  Wlien  the  substances  lodged  in 
the  oe.sophagus,  can  neithei  be  extracted,  nor  pushed 
down  itito  the  stomach,  if  respiration  be  not  danger- 
ously obstructed,  and  liquids  can  yet  beswallowed, the 
wisest  plan  is  to  avoid  irritating  the  passage  with  the 
farther  use  of  instruments,  and  leave  the  case  to  na- 
ture, that  is  to  say,  as  far  as  manuai  interference  is 
concerned;  for  bleeding  and  mucilaginous  oily  draughts 
may  Ire  in  some  cases  uselul.  But  when  the  lodgement 
of  a foreign  body  in  the  OBsophagus  dangerously  ob- 
structs le.^piration,  and  the  substance  itself  cannot  be 
felt  externally,  the  patient  would  perish,  if  some  means 
of  facilitating  the  breathing  were  not  imirrediately 
adopKal;  and,  under  these  circumstance.®,  perhaps,  the 
most  pruderrt  plan  would  be  to  make  an  rrpening  in  the 
tiachea.— (See  Bronchotomy.)  The  subsequent  treat- 
ment, with  reference  to  the  foreign  body  itself,  might 
be  determined  by  the  circumstances  of  lire  case. 

In  ‘iris  pan  of  surgery,  one  fact  deserves  to  be  par- 
ticularly remembered,  which  is,  that  after  a sharp, 
hard  substatree  has  been  either  ejected,  or  pro[)elled 
into  the  stomach  by  nature  or  art,  the  same  painful 
sensations  in  the  throat  frequently  continue  a certain 
time  afte-ward,  which  were  experienced  while  the 
loreign  body  was  actually  lodged  in  the  I'assage. 


These  sensations,  however,  are  only  owing  to  tiie 
maimer  in  whicli  tiie  oesophagus  has  been  irritated, 
and,  consequently,  would  be  seriously  aggravated  by 
the  farther  unnecessary  introduction  of  probangs  and 
other  instruments. 

'J'here  may  be  cases  in  which  tiie  patient  would  lose 
his  life  by  suffocation,  if  a foreign  body  of  consider- 
able size  were  not  taken  out  of  the  oesophagus,  so  as 
to  remove  the  compression  of  the  tiacliea.  Here,  if  it 
could  neither  be  extracted,  nor  pushed  into  the  sto- 
mach by  common  means,  audits  situation  were  indi- 
cated by  any  liardness  or  prominence  in  tiie  neck,  an 
operation  would  be  necessary  for  its  removal. — (See 
(Bsophagotomy.) 

A foreign  body,  not  large  enough  to  cause  danger  of 
suffocation  by  pressure  on  the  trachea,  may  yet  bring 
on  fatal  symptoms,  as  is  exemplified  in  a case  which 
feii  under  tlie  notice  of  Guattani.  As  a man  was 
throwing  up  a boiled  chestnut  in  the  air,  and  catching 
it  in  his  mouth,  it  passed  down  his  throat,  and  he  was 
immediately  seized  with  a difficulty  of  swallowing, 
and  sent  to  tiie  hospital.  However,  as  iie  bieaihed 
and  spoke  witlt  facihty,  and  had  vomited  since  ilie 
accident,  which  happened  when  he  was  tipsy,  the  story 
of  liis  liaving  swallowed  the  chestnut  was  disbelieved. 
His  symptoms  grew  worse,  and  lie  died  on  the  19th 
day.  Guattani  made  an  incision  in  the  left  side  ol  the 
neck,  lielow  the  larynx  and  thyroid  gland,  w iiich  w'as 
considerably  swelled,  and  soon  came  to  a large  abscess 
formed  around  the  portion  of  the  OBsophagus  enclosing 
the  chestnut. 

When  the  extraneous  body  is  sharp  and  pointed,  so 
as  to  stick  in  the  mucous  membrane  of  the  passage, 
and  it  cannot  be  removed,  nature  will  sometimes  ex- 
pel it  herself,  without  any  dangerous  symptoms  being 
the  consequence.  The  foreign  body  is  gradually  loos- 
ened by  ulceration,  and  is  then  either  ejected  by  vomit- 
ing, or  descends  into  the  stomach,  whence  it  is  voided 
either  through  the  bowels  with  the  feces,  or,  as  is 
more  common,  by  making  its  w'ay  through  some  part 
of  the  alimentary  canal,  and  approaching  the  surlace 
of  the  body  wliere  an  abscess  forms,  out  of  which  it 
is  discliarged.  In  other  instances,  foreign  bodies,  like 
pins  and  needles,  which  cannot  be  removed,  pierce  the 
oesophagus  itself,  gradually  pass  completely  out  of  this 
canal,  and  afterward  travel  to  remote  parts  of  the 
body,  without  exciting  much  inconvenience,  until, 
perhaps,  at  the  end  of  some  years,  they  come  near  the 
surface  of  tiie  body  in  a very  remote  situation  from  the 
throat ; and  an  abscess  is  produced,  in  which  they  are 
unexpectedly  found.  However,  this  transportation  of 
sharji-pointed  substances  from  one  part  of  tiie  body  to 
another,  which  is  effected  by  a process  in  which  the 
absorbents  have  a principal  share  in  the  work,  is  not 
conducted  in  every  instance  with  so  little  disturbance, 
and  when  foreign  bodies  of  this  description  come  into 
contact  with  particular  organs,  symptoms  of  a danger- 
ous and  fatal  kind  may  be  excited. 

The  great  art  of  passing  any  instrument  down  the 
cesopliagus  for  sqrgical  purposes,  consists  in  putting  its 
extremity  at  once  directly  against  the  posterior  part  of 
the  pharynx,  and  keeping  it  closely  against  theverte- 
bicB,  so  as  to  avoid  touching  the  ejiiglottis.  The 
knowledge  of  this  circumstance  will  be  found  extremely 
useful  in  passing  piobangs  and  bougies.  When  elastic 
gum-catheters  are  intended  to  be  left  in  the  passage, 
they  are  introduced  down  the  pharynx  from  one  of  the 
nostrils,  and,  being  secured,  they  serve  for  the  convey- 
ance of  liquid  food  and  medicines  into  the  stomach 
with  great  advantage  in  many  ca.se.s,  either  where  the 
patient  cannot  swallow  at  all,  or  where  the  disturb- 
ance of  swallowing  would  be  attended  with  consider- 
able harm.  When,  however,  the  jilan  is  not  to  leave 
the  instruments  introduced,  as  Boyer  observes,  they 
may  be  passed  throiigli  the  mouth. 

(ESOi'HAGUS,  IStricturcs.,  and  other  Diseases  of 
the.  Pro[)erly  speaking,  a difficulty  or  impossibility  of 
swallowing  sliould  not  be  regarded  as  a disease  it.self; 
but  only  as  a symptom  of  different  affections,  to  which 
the  organs  of  deglutition  are  liable,  or  of  other  di.^ea.'es 
in  tiie  vicinity  of  the  [ihaiynx  and  cpsophasus.  'I’he 
object  of  the  present  article  is  not  the  consideration  of 
all  the  diseases  which  may  produce  dysphagia,  as  a 
symptom,  but  chiefly  to  notice  this  effect,  as  depending 
upon  spasm,  paralysis,  or  some  morbid  change  of  struc- 
ture affecting  the  pharynx  or  (Esophagus. 

Spasmodic  dysphagia,  as  Baron  Boyer  has  remarked. 


212 


OESOPHAGUS. 


principally  occurs  in  nervous  individuals,  hysterical 
females,  and  hypochondriacal  men.  It  is  sometimes 
an  attendant  on  fevers  ; it  is  declared  to  be  constant  in 
hydrophobia  and  epilepsy,  and  occasionally  present 
in  particular  forms  of  mania. — (TV  aite  des  Mai.  Chir. 
t.  7,  p.  151.)  However,  with  respect  to  hydrophobia, 
the  foregoing  assertion  should  be  received  with  some 
qualification,  for  reasons  so  fully  detailed  in  another 
part  of  this  work  (see  Hydrophobia).!  that  it  is  unne- 
cessary here  to  dwell  upon  the  subject.  Spasmodic 
dysphagia  is  said  also  to  be  sometimes  a consequence 
of  taking  cold  drink  after  a violent  fit  of  anger;  of 
strong  impressions  on  the  imagination;  of  worms  in 
the  stomach,  &.c. 

When  the  spasm  is  situated  in  the  pharynx  and  upper 
part  of  the  (Esophagus,  and  is  consitlerable,  neither  so- 
lids nor  liquids  can  be  swallowed,  and  the  jiaiient  has 
great  pain  and  a sense  of  constriction  in  his  throat. 
When  he  tries  to  swallow  any  thing  soft,  or  even 
fluid,  he  is  seized  with  acute  pain,  insuflerable  nau- 
sea, and  violent  agitation  of  the  whole  frame.  In  this 
case,  the  spasm  is  never  restricted  to  the  pharynx  and 
upper  portion  of  the  oesophagus,  but  e.vlends  to  other  or- 
gans, the  inability  of  swallowing  coming  on  in  the  midst 
of  numerous  other  spasmodic  symptoms  exceedingly 
complicated,  and  sometimes  of  a very  alarming  nature. 
When  it  is  the  middle,  or  lower  part  of  the  oesophagus, 
which  is  concerned,  as  is  frequently  the  case  in  hyste- 
rical women,  the  food  passes  through  the  pharynx  and 
unaffected  portion  of  the  oeso()hagus  with  tolerable  fa- 
cility : but  as  soon  as  it  reaches  the  seat  of  the  spasm, 
it  is  either  stopped  or  descends  farther  with  great  diffi- 
culty and  effort.  Liquids,  especially  when  warm  and 
swallowed  slowly  in  sanall  quantities  at  a time,  usually 
pass  down  with  more  ease  than  solid  substances. 
When  the  matter  to  be  conveyed  info  the  stomach 
reaches  the  point  of  obstruction,  the  generality  of  pa- 
tients are  attacked  with  pain  extending  along  the  spine 
between  the  shoulders,  and  sometimes  shooting  to  the 
stomach,  which  is  considerably  disturbed,  and  often 
discharges  its  contents.  la  some  cases,  however,  no 
no  such  pain  is  experienced,  and  whatever  the  patients 
try  to  convey  into  their  stomachs  regurgitates  quietly 
into  their  mouths.  Although  spasmodic  dysphagia  is 
mostly  complicated  with  other  marks  of  disorder  of 
the  nervous  system,  it  is  sometimes  unattended  with 
any  particular  impairment  of  the  health. — {Boyer,  t. 
7,  p.  152.) 

As  the  treat.ment  of  spasmodic  affections  of  the  pha- 
rynx and  cesophagus  belongs  rather  to  the  physician 
than  the  surgeon,  I shall  be  very  brief  on  the  subject. 
The  removal  of  the  cause  of  the  infirmity,  that  is  to 
say,  of  the  particular  state  of  the  mind  or  constitution 
giving  rise  to  the  spasm,  is  the  principal  thing  at  which 
the  practitioner  should  first  aim.  Thus  Boyer  cured 
an  hysterical  woman  of  a difficulty  and  dread  of  swal- 
lowing solid  food  by  attending  her  at  her  meals  twice 
evety  day  for  a month,  and  gradually  convincing  her 
of  the  absurdity  of  her  apprehension  of  being  suffocated 
by  attempting  to  swallow  solid  alimpnt.— (Fol.  cil.  p. 
154.)  Sauvages  makes  mention  of  an  hysterical  fe- 
male, whose  difficulty  of  swallowing  was  cured  by  a 
regimen  consisting  of  regular  exercise,  cold  bathing, 
and  milk-diet.  The  most  successful  remedies,  however, 
are  said  to  have  been  camphor  in  large  doses,  and 
opium  taken  in  draughts  or  pills,  or  administered  in 
clysters:  blisters  and  cupping-glasses  applied  to  the 
nape  of  the  neck,  or  to  the  epigastrium.  Anodyne 
embrocations  are  also  stated  to  have  been  useful.  At 
the  present  day,  the  common  idea,  that  many  anoma- 
lous affections  depend  upon  disorder  of  the  liver  and 
digestive  organs,  leads  to  the  frequent  employment  of 
the  compound  calomel  pill,  and  decoct,  sarsaparillsp, 
with  draughts  of  senna,  rhubarb,  and  gentian  pro  re 
nutd. 

* Dysphagia  may  originate  from  a weakened  or  para- 
lytic state  of  the  muscular  fibres,  which  enter  into  the 
structure  of  the  pharynx  and  oesophagus.  The  affec- 
tion may  be  either  symptomatic  or  idiopathic.  The 
first  case  frequently  occurs  in  febrile  diseases,  and  is 
generally  set  down  by  writers  as  a very  unfavourable 
omen.  The  idiopathic  form  of  the  complaint  may  be 
complete  or  incomplete,  and  is  chiefly  seen  in  persons 
of  advanced  age,  though  occasionally  the  patients  are 
young  and  in  the  prime  of  life.  The  causes  may  be 
said  to  be  little  or  not  at  all  understood,  and  the  only 
remark  which  can  be  safely  made  respecting  them  is 


that  they  are  usually  connected  with  constitutional  de- 
rangement. 

With  regard  to  the  symptoms  of  paralysis  of  the 
oisophagus,  when  the  disorder  is  complete,  deglutition 
is  absolutely  prevented,  and,  if  the  patient  tries  to  swal- 
low, Uie  food  lodges  in  the  pharynx,  and  someiimes 
produces  violent  tits  of  coughing.  Some  patients  eat 
solid  substances  with  moderate  facility  ; but  find  more 
or  less  difficulty  in  taking  liquids.  Others  can  swallow 
hastily  a large  quantity  of  fluid  at  a time,  yet  cannot 
drink  slowly  and  a little  at  once.  Woigagni  relates  an 
instance  of  still  greater  singularity,  which  was  an 
ability  to  swallow  all  kinds  of  food  very  well,  except 
the  last  mouthful,  which  alw  ays  remained  in  the  oeso- 
phagus until  the  next  repast.— (/ve  Scd.  et  Cans.  Morb. 
epist.  28,  art.  14.)  In  cases  of  dysjihagia  from  jtara- 
lysis  the  patient  suffers  no  pain,  nor  sense  of  choking; 
if  the  neck  be  examined,  no  haidness  nor  swelling  can 
be  felt ; and  a probang  descends  down  the  gullet  with- 
out the  slightest  impediment. — {Boyer,  t.  7,  p.  153.) 

In  its  duration  and  termination  dysphagia  from  para- 
lysis presents  considerable  variety ; the  complete  para- 
lysis sometimes  proves  rapidly  fatal,  not  however,  as 
I conceive,  on  account  of  the  affection  of  the  cesopha- 
gus alone,  but  other  complications,  and  the  exhaustion 
arising  from  inadequate  nutrition.  Thus,  Tulpius  re- 
lates an  instance,  in  which  a w’oman  died  on  i he  se- 
venth day  from  the  commencement  of  the  inability  to 
swallow,  notwithstanding  every  endeavour  was  made 
to  support  her  with  nourishment  thrown  up  the  rectum, 
which  was  the  only  thing  that  could  be  done,  as  she 
would  not  allow'  a tube  to  be  passed  down  the  (Esopha- 
gus. In  other  cases,  the  patients  live  a consideiable 
time,  and  afterward  perfectly  recover,  and  this  some- 
times under  the  disadvantage  of  having  been  entirely 
supported  for  several  weeks  with  broth-clysters,  as  we 
find  exemplified  in  a case  recorded  by  Ramazzini. 
Certain  examples  are  also  reported,  in  which  the  pa- 
tients had  their  food  forced  into  the  stomach  by  means 
of  probangs  for  years,  and  either  ultimately  recovered 
their  power  of  swallowing,  or  in  this  manner  pro- 
longed their  days  without  any  cure  taking  place. — 
{StalpartvanderfVeil,vol.2,  06s.  28;  Willis,  P harm. 
Rat.  sect.  2,  cap.  1,  p.  45.) 

Paralysis  of  the  oesoiihagus  is  to  be  treated  on  the 
same  principles  as  other  paralytic  affections;  a sub- 
ject which  I shall  not  be  expected  to  discuss;  but  it  is 
of  importance  that  practitioners  recollect,  in  these 
cases,  the  very  essential  service  derived  from  the  use 
of  elastic  gum  catheters,  with  which  the  requisite  food 
and  medicines  may  be  injected  into  the  stomach. 

Dysphagia,  from  organic  disease  or  mot  bid  change 
of  structure,  is  the  most  frequent  case,  and  generally 
the  most  difficult  of  cure.  In  dissections,  the  parietes 
of  the  oesophagus  are  often  found  considerably  iliick- 
ened,  indurated,  and  scirrhous,  or  sonietinies  almost 
cartilaginous,  and  even  ossified.  The  parts  where  the 
pharynx  terminates  in  the  oesophagus  and  w heie  the 
latter  lube  joins  the  stomach,  are  occasionally  con- 
verted into  thick  scirrhous  rings,  with  or  without 
ulceration,  exactly  in  the  same  manner  as  the  pvlorns. 
In  one  fatal  case  of  dysphagia  from  disease  of  the  car- 
diac orifice  of  the  stomach,  the  cesophagus  was  found 
distended  into  a sac,  reaching  from  two  inches  below 
the  pharynx  down  to  the  diseased  part,  and  capable  of 
holding  two  quarts. — (T.  Piirton,  in  Med.  Phys.  .Tuum. 
Dec.,  1821.)  But  such  diseases  are  not  restricted  to  the 
abovementioned  parts  of  the  oesophagus,  but  some- 
times occupy  other  points  of  the  passage.  Neither  is 
the  organic  disease  producing  a difficulty  or  inipo.-oi- 
bility  of  deglutition  always  situated  in  the  coats  of  the 
oesophagus  itself ; for  the  surrounding  (larts  are  subject 
to  various  diseases  which  may  have  the  same  effect. 
Thus,  dysphagia  may  de(iend  upon  enlargement  of  the 
thyroid  gland;  tumours  formed  between  the  tra(hc|| 
and  oesophagus,  or  at  some  other  point  near  the  latief 
lube;  swelling  and  induration  of  the  thyiims  gland) 
aneurism  of  the  aorta;  enoriiioiis  enlaigement  of  the 
liver;  and  disoa.-^ed  lymphatic  glands  in  the  viriniiy  of 
that  portioti  of  the  oesophagus  which  is  covered  by  the 
periioneuni,  and  the  largest  of  which  glands  are  situ- 
ated near  the  fifth  dorsal  vertebra,  just  at  the  point 
when'  the  oesophagus  inclines  a liiile  to  the  right  side 
to  make  way  for  the  aorta. — {Boyer,  t.  7,  p.  1G2.) 

This  last  author  sets  down  every  case  of  dysphagia 
depending  upon  organic  disease  of  the  cesophagus  as 
incurable ; and  w iih  respect  to  the  cure  of  other  ex- 


(ESOPHAGUS. 


213 


amples,  in  which  that  tube  is  compressed  by  swellings 
ill  its  vicinity,  as  these  are  almost  always  beyond  the 
power  of  medicine  and  surgery,  the  prognosis  is  nearly 
as  unfavourable  as  where  there  is  a change  of  struc- 
ture in  the  oesophagus  itself.  There  are  no  unequivo- 
cal symptoms  by  which  a case  of  dysphagia  from  en- 
largement of  glands  in  the  vicinity  of  the  oesophagus 
can  be  known  from  several  other  forms  of  the  com- 
plaint. Hence,  it  is  difficult  to  estimate  the  correctness 
of  certain  cases  recorded  by  Ruysch  {Jidvers.  Jinat. 
Med.  C/iir.  dec.  1,  art.  10,^.  24),  and  Haller  {Opusctil. 
PaikoL.  obs.  71),  wheie  dysphagia,  stated  to  have  been 
produced  by  enlarged  lymphatic  glands,  was  cured  by 
mercurial  frictions,  or  pills  composed  of  calomel,  aloes, 
and  camphor.  As  Boyer  justly  remarks,  these  ac- 
counts of  the  nature  of  the  diseases  thus  cured  are  the 
more  doubtful,  inasmuch  as  the  resolution  of  chronic 
swellings  of  lymphatic  glands,  even  when  externally 
situated,  is  very  difficult  and  frequently  impracticable, 
notwithstanding  the  use  of  topical  applications  may 
here  be  combined  with  the  exhibition  of  internal  me- 
dicines.— {T.  7,  p.  169.)  However,  dismissing  the 
question,  whether  the  cases  really  arose  from  the  pres- 
sure of  enlarged  lymphatic  glands  or  not,  the  facts  of 
the  cures  having  taken  place  under  the  use  of  mer- 
curial medicines^  are  of  themselves  interesting.  Seve- 
ral writers  consider  that  there  is  a great  analogy  be- 
tween certain  forms  of  constriction  of  the  msophagus, 
and  strictures  of  the  urethra, ‘and  Maiichart  recom- 
mended the  two  diseases  to  be  treated  on  the  same 

Srinciples  with  bougies  and  elastic  gum  catheters. 

aron  Boyer,  however,  represents  this  doctrine  as 
completely  erroneous,  declaring  that  the  aflection  of 
the  oesophagus  is  of  the  nature  of  scirrhus,  and  abso- 
lutely incurable.  He  relates  one  case  in  which  a 
woman’s  life  was  prolonged  by  the  use  of  an  elastic 
gum  catheter,  though  it  proved  of  no  service  as  a 
means  of  permanently  dilating  the  diseased  part ; and; 
notwithstanding  nourishing  liquids  were  plentifully 
injected  into  the  stomach,  the  patient  suffered  a good 
deal  from  hunger,  and  died  exhausted  about  three  years 
after  the  beginning  of  the  disorder.  This  case,  how- 
ever, cannot  be  received  as  a proof  of  the  inefficacy  of 
bougies  for  what  is  cominonly  implied  by  a stricture 
of  the  ocsophajgus,  because  the  nature  of  the  disease 
was  not  ascertained  by  an  inspection  of  the  oesophagus 
affer  death,  and  the  case  might  have  depended  upon 
some  organic  disease  either  of  this  tube  or  the  parts  in 
its  vicinity  not  classed  by  the  generality  of  modern 
writers  with  strictures  of  the  passage. 

The  following  are  some  of  Sir  Everard  Home’s  sen- 
timents respecting  these  last  cases. 

As  the  CBsophagus  is  required  to  be  wider  at  one 
time  and  narrower  at  another,  in  order  to  be  fitted  for 
conveying  the  different  kinds  of  food  into  the  stomach, 
it  is  nearly  under  the  same  circumstances  with  respect 
to  the  formation  of  stricture  as  the  urethra.  For  ob- 
vious reasons,  strictures  of  the  oesophagus  are  much 
less  frequent  than  those  of  the  urethra.  However, 
they  are  by  no  means  uncommon,  and  produce  symp- 
toms even  much  more  distressing  and  dangerous  than 
those  which  ordinarily  arise  from  analogous  obstruc- 
tions in  the  passage  for  the  urine. 

Of  course,  the  most  remarkable  symptom  of  a stric- 
ture in  the  oesopliaims  is  the  difficulty  of  swallowing, 
which  must  be  greater  or  less  according  as  the  ob.^truc- 
tioii  is  more  or  less  comjilete.  Sometimes  no  solid  food 
whatever  can  pass  down  into  the  stomach,  and  fluids 
can  only  descend  with  great  difficulty  and  in  very  small 
qiianlities.  This  is,  in  some  instances,  attended  with 
considerable  pain,  which  extends  along  the  fauces  to 
the  basis  of  the  skull,  and  through  the  Eustachian  tube 
to  the  ear.  I'he  pain  sometimes  returns  at  intervals 
and  lasts  a considerable  time,  even  wiien  no  effort  is 
made  to  swallow.  If  a bougie  of  proper  size  be  intro- 
duced down  the  pharynx,  it  will  often  be  stopped  by 
the  stricture  just  behind  the  thyroid  or  cricoid  cartilage; 
for,  from  Sir  Everard  Home’s  remarks,  it  appears  that 
the  obstruction  is  generally  as  high  upa.s  this  situation. 
However,  there  are  other  cases  in  which  the  obstriic 
lion  is  only  of  a spasmodic  nature,  and  in  these  a 
bougie  may  be  passed  quite  down.  It  is  curious,  that 
strictures  high  up  in  the  (Esophagus  often  occasion 
ulceration  in  this  tube  very  low  down  towards  the 
Btomach,  just  as  strictures  in  the  urethra  occasion 
ulceration  in  that  passage  towards  the  bladder.  This 
is  most  apt  to  occur  when  strictures  of  the  oesophagus 


have  been  of  long  continuance,  and  may  arise  from  the 
efforts  in  retching,  which  frequently  come  on,  and 
must  strain  the  parts  already  deprived  of  their  natural 
actions,  and  of  the  benefit  of  the  secretions  with  which 
they  are  lubricated  in  a'healihy  state.  When  such 
ulceration  takes  place,  the  characters  of  the  original 
disease  are  lost;  and  when  the  ulceration  extends  up- 
wards, the  stricture  itself  may  be  destroyed.  A bougie 
introduced  under  such  circumstances  will,  in  general, 
have  its  point  entangled  in  the  ulcer;  and  when  so 
skilfully  directed  as  to  go  down  into  the  oesophagus,  it 
will  meet  with  a difficulty  while  it  is  passing  the  com- 
mencement of  the  ulcerated  part  of  the  oesophagus, 
and  another  impediment  where  it  leaves  the  ulcer,  and 
enters  the  sound  portion  of  the  oesophagus  below. 
These  two  resistances  may  lead  to  the  supposition,  that 
there  are  two  strictures  while,  in  fact  there  is  not  one, 
only  ulceration  as  above  described. 

Strictures  in  the  oesophagus  are  sometimes  so  com- 
plete, that  swallowing  even  fluids  is  utterly  prevented ; 
the  patient  is  obliged  to  have  all  nourishment  injected 
inlra  ajium,  and  in  general  soon  perishes  in  a most 
emaciated  condition. 

Though  any  part  of  the  oesophagus  is  liable  to  the 
kind  of  contractions  forming  strictures,  the  part  imme- 
diately behind  the  cricoid  cartilage,  where  the  pharynx 
ends  and  the  oesophagus  begins,  is  the  most  frequent 
seat  of  the  obstruction.  Tiiose  which  are  situated 
farther  down  do  not  so  easily  admit  of  being  examined 
and  relieved  by  any  surgical  operation.  Strictures  of 
the  oesophagus  occupy  but  a small  extent  of  the  pas- 
sage, consist  of  a transverse  fold  of  the  internal  mem- 
brane, and  are  attended  with  little  thickening  of  the 
adjacent  parts.  These  latter  circumstances  are  such 
as  render  the  disease  capable  of  receiving  relief  either 
from  simple  or  armed  bougies. 

There  are  two  other  diseases  of  the  oesophagus 
which  have  symptoms  similar  to  those  of  strictures. 
One  is  a thickening  of  the  coats  of  the  oesophagus, 
which  extends  to  tlie  surrounding  parts,  and  generally 
ends  in  a cancer  or  an  incurable  (lisease.  The  other 
affection  is  an  ulcer  of  the  lining  of  the  passage,  com 
monly  situated  a little  below  the  seat  of  the  stricture 
on  the  back  part  of  the  tube.  In  the  early  state,  these 
diseases  can  only  be  distinguished  from  a stricture  by 
an  examinaiion  with  a bougie;  afterward  their  nature 
becomes  clear  enough  from  other  symptoms  which 
arise.  Strictures  also  take  place  more  commonly  in 
young  subjects;  the  other  two  diseases  in  the  more  ad- 
vanced periods  of  life. 

Sir  E.  Home  has  found,  that  a bougie  can  be  more 
easily  introduced  into  the  oesophagus  when  the  tongue 
is  brought  forwards  out  of  the  mouth.  This  gentleman 
remarks,  that  when  a bougie  is  passed,  with  a view  of 
learning  the  nature  of  the  case,  if  it  passes  down  to 
the  distance  of  eight  inches,  measuring  from  the  cutting 
edge  of  the  front  teeth  in  the  upper  jaw,  its  extremity 
has  gone  beyond  the  usual  seat  of  stricture.  If  it  be 
withdrawn  without  any  resistance,  the  aperture  in  the 
oesophagus  must  then  be  larger  than  the  bougie  em- 
ployed. But  if  the  bougie  stops  at  the  distance  of  six 
inches  and  a half,  or  even  lower,  it  must  be  retained 
there  with  a uniform  pressure  for  half  a minute,  so  as 
to  receive  on  its  point  an  impression  of  the  surface  by 
which  it  was  opiiosed.  If  the  end  of  the  bougie  re- 
tains its  natural  form,  or  nearly  so,  and  there  is  an  in- 
dentation on  one  side  of  it,  or  all  around  it,  the  sur- 
geon may  conclude  there  is  a stricture.  On  the  other 
liand,  should  the  bougie  descend  without  impediment 
as  far  as  seven  inches  and  a half,  and  when  withdrawn 
the  surface  of  its  point  appear  irregular  and  jagged,  the 
disease  is  an  ulcer  on  the  posterior  part  of  the 
oesophagus. 

The  mode  of  treatment  adopted  by  Sir  E.  Home 
consists  either  in  passing  a common  bougie  occasionally 
through  the  stricture,  and  employing  one  of  a larger 
size,,  in  proportion  as  the  dilatation  of  the  obstruction  is 
effected ; or  else  in  introducing  an  armed  bougie  at 
convenient  intervals.  The  views  which  I lake  of  the 
disease  would  lead  me  to  (irefer  giving  a full  and  fait 
trial  to  the  employment  of  elastic  gum  catheters. 
Consult  Practical  Observations  on  the  Treatment  of 
Strictures  in  the  Urethra  and  tKsophag-us,  3 vols.  ed. 
3,  1805,  vol.  2,  1803,  and  vol.  3,  1821,  by  Sir  E.  Home. 
Ph.  H.  Beuttcl  de  Struma  (Esophagi ; hujusque  Coalitu 
difficili  ac  abolitm  heglutitionis  Cansis  (in  Haller's 
Disp  Chir.  2,  395),  Tubing.  1742.  Mauchart  do 


214 


(ESOPHAGUS. 


Struma  CEsopka-Jji,  Tilling'.  1742.  J-  Warner,  Cases 
in  Surgery,  **.  ed.  4.  P.  J-  Zinckernagel,  de 
Clysterum  iN'utr’entium  Antiquitate,  et  Usu  {Trilleri 
Opusc.  I.  399).  A.  Vater,  et  F.  A.  Zinckernagel  de  De- 
glutitionis  difficilis  et  iinpeditie  Causis  abditis  {Halleri 
£>isp.  ad  JMorb.  1,  577).  E.  F.  Bulisius  de  Fame  Icthali 
ex  callosa  Oris  Ventriculi  Angustia.  J.  M.  Eccardua, 
De  his  qiii  diuvivunt  sine  Alimento,  4to.  Kilice  Holsat. 
1711.  Boyer,  Traiti  de  Mai.  Chir.  t.  7,  8«o.  Paris, 
1821.  G Bell,  Surgical  Obs.  vol.  1. 

[The  following  judicious  and  practical  observations 
on  the  treatment  of  stricture  of  the  oesophagus  are 
communicated  to  me  by  Professor  Jameson  of  Balti- 
more, to  whose  ingenuity  I have  already  borne  testi- 
mony in  other  parts  of  this  work,  and  to  whom  our 
profession  is  largely  indebted  for  many  original  and 
important  improvements.  As  so  little  is  said  on  tliis 
subject  by  surgical  authors,  and  so  much  less  known 
by  practitioners,  I have  been  unwilling  to  deteriorate 
from  the  utility  of  his  communication,  and  have  tliere- 
fore  inserted  it  entire.  But  as  this  Dictionary  neces- 
sarily excludes  cuts  and  engravings  of  every  kind,  I 
am  under  the  necessity  of  referring  for  the  size  and 
configuration  of  his  ball-probes,  bougies,  and  probangs 
to  the  Medical  Recorder  for  1825. 

STRICTURE  OF  THE  (ESOPHAGUS. 

“ There  are  perhaps  few  subjects  connected  with  sur- 
gery upon  which  we  have  less  information  of  a prac- 
tical nature  than  stricture  of  the  oesophagus,  and  yet 
we  know  by  the  reports  of  post-obituary  appearances 
that  such  diseases  are  sometimes  met  with;  and  we 
cannot  well  imagine  a more  distressing  form  of  dis- 
ease than  the  gradual  obliteration  of  the  oesophageal 
tube.  We  find  some  notice  of  its  treatment  in  the 
works  of  Boyer  and  other  French  authorities;  also  in 
the  works  of  Mr.  Home  and  Mr.  C.  Bell.  These  au- 
thorities recommend  bougies,  tubes,  caustic,  &c.  Our 
observation  has  led  us  to  believe  that  none  of  these 
means  are  well  suited  to  the  removal  of  oesophageal 
stricture.  And  for  ourselves,  we  should  shudder  at 
the  idea  of  applying  caustic  to  a tube  so  much  out  of 
reach,  and  so  very  important  to  our  existence. 

We  shall  not  detain  the  reader,  however,  with  any 
detail  of  the  various  methods  practised  and  recom- 
mended by  authors;  but  shall  briefly  state  our  own 
method,  which  we  think  better  suited  to  the  malady  in 
view  than  any  other  which  we  have  heard  of  or  tested. 

In  order  to  point  out  the  advantages  of  our  method 
of  treating  stricture  of  the  throat,  it  will  be  necessary 
to  state  some  of  the  particulars  of  a very  interesting 
ease.  The  subject  of  this  case  was  a lady  of  refined 
mind  and  feeble  and  delicate  habit  of  body,  aged  up- 
wards of  forty  years.  She  has  experienced  much  dif- 
ficulty in  swallowing  solids  for  two  years,  but  can 
swallow  liquids  with  tolerable  facility.  Her  food 
must  be  chewed  with  much  care,  and  even  then  it  is 
only  pulpy  articles  that  can  be  managed  with  any  sort 
of  comfort:  animal  food  can  only  betaken  at  times, 
and  with  great  difficulty.  There  is  no  pain  or  sore- 
ness in  the  part,  nor  is  there  any  interruption  in  her 
breathing;  but  at  times,  after  eating,  she  feels  an  un- 
pleasant stinging  sensation  just  below  the  lobe  of 
the  left  ear.  She  has  been  dyspeptic,  and  the  affection 
of  the  throat  ascribed  by  several  respectable  physicians 
to  that  disease,  to  imagination,  &c. 

The  patient  is  not  aware  of  the  cause  of  the  disease, 
but  dates  its  commencement  from  an  accidental  chok- 
ing in  swallowing  a piece  of  beef.  From  that  time 
there  has  been  more  or  less  disability  in  swallowing, 
and  she  has  been  subject  to  occasional  choking  at  table. 
The  disease  formed  suddenly  to  considerable  extent ; 
but  has  been  gradually  incretising,  and  at  this  time  she 
is  seriously  threatened  with  starvation.  In  examining 
the  throat  we  perceived  a sort  of  crepitus  from  wind ; 
and  we  were  informed,  that  the  patient  was  greatly 
annoyed  by  a strange  noise  which  proceedexl  from 
about  the  part  upon  which  we  pressed.  We  were  con- 
vinced from  this  circumstance,  that  the  oesophagus  was 
somewhat  dilated  below  the  stricture,  and  afforded  a 
lodgement  for  air  which  might  occasionally  rise  up 
from  the  stomach. 

We  ascertained,  by  feeling,  that  there  was  no  tu- 
mour at  this  point  in  the  tul>e,  or  which  might  iiress 
upon  it.  We  now  attempted  to  pass  down  a probang, 
but  found  it  arrested  about  the  cricoid  cartilage ; a com- 
mon flexible  bougie  was  next  tried  but  could  not  be 


passed  through  the  stricture.  This  e.Tamination  wsi 
made  on  the  2d  December,  1823.  'I’lie  next  day,  trials 
were  again  ineffectually  maue  vviih  the  bougies. 

We  shall  not  stop  to  detail  ihe  daily  remarks  upon 
this  case ; let  it  suffice  to  say,  that  after  trying  various 
expedients,  we  devised  the  probangs,  which  may  be 
seen  in  the  Medical  Recorder  for  1825.  On  the  6ih  of 
December,  we  succeeded  in  passing  the  ball-jnobe 
marked  No.  2;  but  not  till  after  long  trials  with  it  and 
No.  1.  The  ball  passed  the  stricture  with  a jerk,  and 
we  now  satisfied  ourselves  that  the  stricture  was  con- 
fined to  a small  extent ; and  hence  we  perceive  one  of 
the  advantages  of  using  the  ball-probe,  as  we  could 
thereby  measure  the  sides  of  the  tube  far  better  than 
wkh  a flexible  tube  or  bougie.  We  also  ascertained 
that  there  was  no  very  remarkable  induration,  although 
the  parts  were  obviously  much  closed  by  swelling.  It 
was  several  days  before  either  of  the  ball  probes  could 
be  passed  again. 

By  the  22d  of  the  month,  the  parts  having  lost  some- 
thing of  their  sensibility,  and  the  patient,  su|)ported  by 
her  good  sense,  had  acquired  the  power  of  bearing  the 
presence  of  the  probatig  much  better  than  at  first. 
Having  by  this  succeeded  pretty  well  in  the  practice  of 
introducing  the  ball- probes,  but  finding  no  improvement, 
if  occurred  to  us,  that  as  we  could  get  the  ball-probe 
through  the  stricture,  we  might  pass  a suitable  probang 
on  the  same  wire,  and  thus  apply  a little  pressure,  pre- 
suming on  the  certaint;?,  that  the  wire  would  guide  the 
probang  through  the  contracted  part.  For  this  pur- 
pose we  contrived  the  probang  No.  1. 

We  operated  by  passing  the  ball- probe  about  two 
inches  through  the  stricture,  then  its  outer  end  was 
slipped  through  the  hole  in  the  probang,  and  having 
passed  it  (the  probang)  as  far  as  the  root  of  the  tongue, 
the  wire  of  the  ball-probe  and  the  staff  of  the  probang 
were  brought  together,  and  the  whole  passed  through 
the  stricture.  This  was  repeated  for  some  time  every 
second  day,  afterward  every  day,  and  at  each  time  the 
probang  was  made  to  pass  three  or  four  times  through 
the  stricture. 

After  using  the  probang  about  three  or  four  w'eeks, 
we  could  pass  the  ball-probe  with  facility ; whereas,  at 
first,  the  use  of  the  ball-probe  was  attended  with  much 
difficulty  and  occasional  disappointment.  'J’he  pro- 
bang passing  freely  through  the  stricture,  and  the 
power  of  deglutition  having  considerably  improved, 
we  commenced  the  use  of  the  probang  No.  2. 

A few  weeks  were  employed  in  the  use  of  this  se- 
cond instrument.  It  was  passed  through  the  stricture 
with  tolerable  ease,  but  it  was  somewhat  difficult  to 
withdraw  it.  Some  strain  was  put  on  the  parts  in 
drawmg  out  the  instrument,  and  in  some  degree  inter- 
fered with  her  swaHowing  for  some  little  time  after- 
ward. On  one  or  two  occasions,  a little  blood  ap- 
peared in  the  mucus  which  was  spit  up,  but  it  was 
mere  streaks.  The  soreness  was  not  considerable  at 
any  time,  and  although  we  were  extremely  anxious  to 
avoid  producing  any  soreness,  we  persisted  in  the  use 
of  the  probang.  We  were  soon  led  to  believe,  that  an 
instrument  so  perfectly  smooth,  if  cautiously  managed, 
would  tend  to  smoothen  and  heal  the  parts.  We  were 
aware  of  the  advantages  attending  the  use  of  well- 
polished  sounds  in  stricture  of  the  urethra. 

No.  2 having  been  brought  to  pass  through  the  stric- 
ture with  great  ease,  after  some  weeks’  employment  of 
it,  we  commenced  the  use  of  No.  3.  This  instrument 
also  passed  with  facility,  and  produced  no  soreness, 
but  could  only  be  passed  through  the  obstruction  by  the 
aid  of  the  ball  probe  or  guide.  We  now  began  from 
time  to  rime  to  try  the  probang  without  the  guide,  but 
could  never  succeed. 

As  with  No.  2 so  with  No.  3,  we  continued  its  em 
ployment  some  weeks,  aud  then  becan  with  No.  4. 
This  passed  with  tolerable  facility,  but  if  passed  a little 
too  low  it  occasioned  very  painful  and  indescribable 
feelings  in  the  thorax  ; this  we  attributed  to  the  disten- 
tion of  the  tierves  surrounding  the  oesophaL’us. 

We  have  remat  ked  iti  our  notes  of  this  case,  th.nt 
' some  weeks  after  usinc  the  probang  No.  4,  that  thepa- 
j tient  swallowed  much  better;  but  the  stricture  still 
closes  after  withdrawitm  the  probtiu!',  so  as  to  render  it 
I still  somewhat  diffietdt  at  times  to  introduce  either  of 
the  ball-probes;  the  difficulty  is,  however,  slight  in 
comparison  to  what  it  was  some  weeks  ago.  No.  5 
j wa.s  now  passed;  it.s  introduction  was  very  painful  for 
1 a few  times,  in  consequence  of  which  we  left  longer 


CESOPHAGUS. 


215 


intervals  between  tlie  times  of  using  the  instrument, 
but  never  more  tlian  two  or  three  days  From  lliis  time 
nothing  remarkable  occurred  in  the  case;  the  patient 
is  quite  coinfoi table  in  regard  to  swallowing,  but, 
owing  to  our  not  being  able  to  pass  tlie  pfobang  witli- 
out  the  guide,  she  was  desirous  of  coiiiiuuing  the  dila- 
tation. And,  indeed,  we  were  fully  impressed  with  the 
necessity  of  continuing  to  dilate  for  a length  of  time. 
The  use  of  Ihe  instrunients  was  coniitmed  once  a day, 
Sundays  excepted,  till  about  the  middle  of  September, 
at  which  time  we  were  cotifined  by  fever,  and  there 
was  a suspension  of  two  months. 

Upon  our  recovery,  we  resumed  the  use  of  the  pro- 
bang, and  being  desirous  of  ascertaining  whether  any 
material  alieraiion  had  taken  place,  we  passed  the  in- 
strument lower  than  usual,  perhaps  a little  lower  than 
the  sternum  : she  instantly  started  forwards,  as  if  much 
alarmed,  and  stated  that  she  had  felt  a most  violent 
shock  through  lire  spine, 

Tlie  case  was  about  a year  under  treatment,  de- 
ducting two  months  of  lost  time.  The  probangs  would 
still  not  pass  without  the  guide,  but  they  could  be 
passed  through  the  stricture  together  with  great  faci- 
lity. The  patient  could  at  this  time  partake  with  com- 
fort of  all  sorts  of  diet,  and  swallow  it  with  readiness. 
In  short,  there  was  a complete  removal  of  the  stric- 
ture, but  there  was  some  peculiar  derangement  at  the 
termination  of  the  pharynx,  by  which  some  part  was 
made  to  act  as  a valve;  but  wheti  the  muscles  of  de- 
glutition acted,  this  was  removed  or  lifted,  and  the 
food  descended;  there  was  not  now  any  traces  of  in- 
duration or  thickening. 

It  seems  proper  to  hiention,  that  we  could  never  suc- 
ceed in  making  the  probang  pass  into  the  pharynx  by 
sliding  it  along  the  wire  of  the  guide  ; but  when  it  had 
reached  the  root  of  the  tongue,  the  wire  of  the  guide, 
already  through  the  stricture,  and  the  staff  of  the  pro- 
bang were  held  together,  and  thus  introduced.  By  this 
procedure,  the  ball  of  the  probe  passed  considerably 
lower  than  the  probang,  and  probably  went  into  the 
stomach  ; the  wire,  however,  was  too  limber,  and, 
armed  as  it  was  with  its  ball,  it  could  not  do  any  mis- 
chief. The  wire  is  steel,  and  quite  flexible,  and  much 
more  free  from  sudden  bends,  which  so  readily  take 
place  in  common  iron  wire. 

We  have  deemed  it  necessary  to  give  the  foregoing 
case  somewhat  in  detail,  as  well  on  account  of  its  in- 
teresting peculiarities,  as  with  a view  of  showing,  that 
while  the  instrument  which  we  used  is  probably  the 
only  thing  which  could  have  succeeded  in  this  case,  it 
has  also  the  advantage  of  being  well  suited  to  all  cases 
where  dilatation  is  likely  to  succeed. 

We  tried  various  kinds  of  tubes  in  this  case,  but 
could  not  make  them  pass  the  stricture,  though  accus- 
tomed to  pass  the  tube  into  the  oesophagus.  The  stric- 
ture being  mostly  at  the  beginning  of  the  oesophagus 
(that  is,  under  the  cricoid  cartilage),  the  curvature  of 
the  stilet  by  which  the  tube  must  be  passed,  if  made 
to  suit  the  curvature  of  the  pharynx  and  fauces,  will 
strike  against  the  anterior  part  of  the  lower  part  of  the 
pharynx,  and  will  not,  therefore,  be  likely  to  pass  down- 
wards through  the  gullet.  If  we  draw  out  the  stilet, 
after  fairly  entering  the  tube  into  the  pharynx,  it  will 
be  too  flexible  to  pass  through  any  considerable  stric- 
ture. 

A material  advantage  possessed  by  the  probang  over 
the  tube,  is  that  of  giving  less  interruption  to  the  re- 
spiration. The  tube,  by  pressing  on  the  root  of  the 
tongue  and  epiglottis,  will  greatly  obstruct  the  trachea, 
but  the  probang,  having  but  a small  shaft  or  handle,  will 
only  press  moderately  on  the  posterior  side  of  the  tra- 
chea at  one  point  ; and  being  guided  through  the  stric- 
ture by  the  guiding  wire,  we  can  pass  the  probang  with 
rapidity  through  the  stricture. 

The  above  •ase  will  serve  to  show  with  how  much 
caution  we  proceeded,  lest  we  might  produce  a sore  in 
the  strictured  part.  We  did  not  venture  to  enlarge  till 
several  weeks  use  of  each  less  size;  this  will  appear 
obvious,  by  the  fact  of  our  continuing  the  treatment 
twelve  months;  and  by  the  gradual  manner  in  which 
we  enlarged  our  probangs.  Indeed,  we  hold  it  to  be 
imiiortant,  that  the  whalebone  used  for  the  handles  of 
the  probang  should  be  slender,  that  they  may  not  be 
forced  in  too  hard. 

We  are  persuaded  that  this  method  of  treating  stric- 
ture of  the  oesophagus  will,  in  most  cases  at  least,  do 
ttway  the  necessity  for  the  prfctice  recommended  of 


wearing  a flexible  tube  in  the  part.  At  all  events,  in 
the  case  under  notice,  the  tube  could  not  have  been 
made  available,  since  nothing  of  the  kind,  nor  even  a 
probang,  could  be  passed  without  the  guide. 

We  have  met  with  t\vo  very  formidable  cases  of 
stricture  since  we  treated  the  one  above  noticed.  Be- 
fore proceeding  to  notice  them,  it  may  be  proper  to 
state,  that  we  saw  our  patient  about  a year  since,  when 
she  was  sufiering  very  little  inconvenience  from  her 
disease;  and  we  readily  passed  our  largest  probang 
through  the  stricture.  She  is  still  alive,  and  we  have 
no  doubt  still  comfortable,  as  no  report  has  been  made 
to  us. 

The  second  case  we  saw  was  a woman  engaged  in 
a cotton  factory  in  this  city ; she  was  suffering  greatly 
from  inanition,  and  the  throat  so  contracted  that  our 
smallest  probang  was  made  to  pass  with  some  difficulty. 
After  a few  repetitions,  the  probang  somewhat  larger 
could  be  passed  with  facility ; exact  size  not  recollected. 

Our  attention  was  called  to  this  case  by  our  excel- 
lent friend  the  late  Dr.  Charles  Smith  of  this  city,  who 
look  charge  of  the  case.  In  this  case  the  prebang 
seemed  to  answer  extremely  well ; but  Dr.  Smith  dying 
some  months  afterward,  we  lost -sight  of  the  patient, 
and  know  not  the  termination  of  the  case.  Here,  it 
may  be  observed,  there  was  no  necessity  for  the  guide 
or  ball-probe. 

Our  attention  was  called  to  a case  of  deplorable 
.stricture  of  the  oesophagus  in  the  spring  of  1829. 
Patient,  a man  about  thirty  years  of  age,  of  delicate 
make,  and  now  much  emaciated  and  debilitated  from 
inanition.  There  was  not  much  pain,  but  some  sore- 
ness in  the  part;  and  when  the  probang  was  wilh» 
drawn,  for  several  weeks  it  had  a very  fetid  smell. 

The  patient  was  now  reduced  to  very  small  quanti- 
ties of  milk,  the  only  article  containing  nourishment 
that  he  could  swallow ; and  often  for  many  hours  ho 
could  not  swallow  a drop  of  it  or  any  thing  else. 

We  commenced  the  treatment  with  our  smallest  ball- 
probe  ; it  entered  with  considerable  difficulty,  and,  in- 
deed, required  a degree  of  force  which  we  did  not 
much  like  to  apply;  but  there  was  no  alternative.  A 
few  repetitions  rendered  its  passage  more  easy;  and 
the  patient,  already  aware  of  some  relief,  became  re- 
conciled to  the  instrument,  and  sat  more  quietly.  The 
probang  No.  1 was  used  after  some  lime.  Continuing 
our  operations  every  second  day,  we  very  gradually 
enlarged  till  we  could  pass  through  the  probang  No.  4 
with  facility.  In  a few  weeks,  amendment  was  evi- 
dent; the  fetor  of  the  throat  disappeared ; the  patient 
began  to  take  a little  thick  paste,  made  by  beating  gin- 
gerbread in  milk;  the  consistence  was  gradually  in- 
creased ; afterward  he  could  take  bread,  soaked  soft  in 
milk,  or  other  fluids.  His  health  and  strength  im- 
proved rapidly;  and  two  months  since  he  discontinued 
his  calls,  and  removed  to  a factory  a few  miles  from 
town. 

In  a word,  then,  we  are  persuaded,  that  by  a patient 
and  careful  employment  of  the  probang  of  smooth 
ivory,  we  shall  frequently  succeed  in  curing  stricture 
of  the  oesophagus,  even  after  the  disease  is  far  ad- 
vanced. In  the  incipient  stage  of  this  disease,  pro- 
vided there  be  nothing  specific  in  the  diseased  action, 
we  will  be  sure  to  succeed. 

We  have  been  induced  fo  believe  that  this  tube  (the 
oesopliagus)  is  very  little  disposed  to  diseased  action, 
except  paralysis,  and  contraction  with  some  induration 
from  wounding  or  overstraining  in  swallowing  hard 
or  harsh  articles  of  food. 

Any  explanation  of  the  drawings  seems  to  be  unne- 
cessary, as  the  application  of  them  has  been  explained 
already;  and  a simple  inspection  of  the  plates  is  suffi- 
cient to  convey  a clear  conception  of  the  mechanism 
of  the  probang  and  the  compound  probang,  with  its 
guide  or  ball-probe.  The  handles  are  about  fourteen 
inches  long,  a little  more  or  less  is  not  material,  but  of 
course  it  is  essential  that  Ihe  ivory  be  turned  by  a good 
workmafi  and  thoroughly  polished. 

N.B.  Be  careful  that  the  handle  of  whalebone  is 
fastened  to  the  ivory  in  such  a way  as  to  obviate  all 
risk  of  its  coming  out  as  you  withdraw  the  probang; 
inattention  to  this  circumstance  might  lead  to  dis- 
astrous consequences,  as  the  patient  might  suffocate 
before  you  could  remove  the  ball  of  ivory,  should  it 
happen  to  gel  loose  and  be  left  in  the  throat.  Mine  are 
secured  by  a screw  on  the  whalebone,  fitting  into  a 
female  screw  in  the  ivory,  and,  after  screwing  as 


216 


OPH 


OPH 


tightly  as  possible,  a rivet  is  passed  through,  so  as  to 
make  all  doubly  sure. 

We  need  hardly  remark,  that  the  tube  is  indispensa- 
bly necessary  in  cases  of  paralysis  of  tlie  oesophagus.” 
— ReeseA 

OLEUM  CAMPHORATUM.  BL-  Olei  olivae,  Ibj. 
Camphorae  3 iv.  Misce  ui  solvaiur  camphora.  Some- 
times employed  for  promoting  the  suppuration  of  in- 
dolent, particularly  scrofulous  swellings,  which  are  to 
be  rubbed  with  it  once,  twice,  or  thrice  a day  according 
to  circumstances. 

OLEUM  LINE  In  surgery,  linseed  oil  is  sometimes 
used  as  an  application  to  burns,  either  alone  or  mixed 
with  an  equal  quantity  of  the  liquor  calcis.  It  has 
also  been  applied  to  cancerous  ulcers. 

OLEUM  ORIGANI.  The  oil  of  marjoram  is  often 
used  for  dispersing  ganglions:  the  tumours  are  to  be 
rubbed  with  it  two  or  three  times  a dav. 

OLEUM  PALM^  CAMPHORATUM.  JL.  Cam- 
phorse  | ij.  Olei  palmte  Ibj.  The  camphor  is  to  be 
reduced  to  powder,  and  the  palm  oil  being  melted,  and 
suffered  to  become  almost  cold,  is  to  be  mixed  with 
it.  A mild  topical  stimulant,  sometimes  used  for  pro- 
moting indolent  suppurations,  especially  those  of  a 
scrofulous  nature  under  the  jaw. 

OLEUM  RICINI.  In  surgical  cases  requiring  the 
bowels  to  be  opened  with  the  slightest  degree  of- irrita- 
tion possible,  the  oleum  ricini  is  the  best  and  safest  me- 
dicine. yhe  usual  dose  is  one  large  table-spoonful, 
which  must  be  repealed  every  two  or  three  hours,  till 
the  desired  effect  is  produced. 

OLEUM  TEREBINTHINUE.  Oil  of  turpentine  is 
employed  externally  as  a stimulating  liniment,  and  a 
styptic.  In  the  article  Liniment  may  be  seen  some 
formulae,  in  which  turpentine  is  the  most  active  ingre- 
dient. It  is  sometimes  exhibited  internally  for  the  cure 
of  gleets. 

OLEUM  TEREBINTHINATUM.  R.  Olei  amyg- 
dalae 3SS.  Olei  terebinthinae  gutt.  xl.  Misce.  in 
deafness  occasioned  by  defective  or  diseased  action  of 
the  glandulae  cerumineae,  Mr.  Maule  directs  a little  of 
this  oil  to  be  dropped  into  the  patient’s  ear,  or  applied 
at  the  end  of  a small  dossil  of  cotton.  When  a thin 
secretion  takes  place,  the  cure  is  also  promrrted  by  a 
small  blister,  which  is  placed  as  near  the  ear  as  con- 
venient, and  kept  open  with  the  savine  cerate.  The 
meatus  auditoi  ius  externus  must  also  be  cleansed  every 
day  with  a bit  of  soft  cotton,  affixed  to  a probe. — (See 
Pharmacop.  Chiriwgica.) 

OMPHALOCELE.  (From  6p(paXds,  the  navel,  and 
Kt’iXt},  a rupture.)  A rupture  or  hernia  at  the  navel. — 
(See  Hernia.) 

ONYCHIA.  (From  ow^,  the  nail.)  An  abscess  near 
the  nail  of  the  finger. — (See  fVhitloic.) 

ONYX.  (From  the  nail.)  A smallcollection 
of  matter,  situated  in  the  anterior  chamber  of  the 
aqueous  hunmur,  and  so  named  from  iu  being  shaped 
like  a nail.  It  is  of  the  same  nature  as  Hypopium. 
Maitre  Jean,  Mauchart,  and  others,  imply  by  the 
term  onyx,  a small  abscess  between  the  layers  of  the 
cornea. 

OPHTHALMY.  (From  d^daXpbc,  the  eye.)  Oph- 
thalmia. Ophthalmitis.  Infiainmation  of  the  eye. 
This  is  not  only  a consequence  of  several  affections  of 
the  eye  and  adjacent  parts,  on  the  existence  of  which 
its  continuance  entirely  depends;  it  is  frequently  the 
primary  complaint,  and  loo  often  the  forerunner  of 
such  irreparable  mischief  as  for  ever  bereaves  the  pa- 
tient of  vision. 

Since  every  disease  of  the  eye  presents  some  differ- 
ences, depending  upon  the  nature  of  the  disorder  itself, 
and  others,  arising  from  the  peculiar  organization  of 
the  texture  which  happens  to  be  principally  affected, 
the  characteristic  appearances  of  ophthalmy  must  be 
subject  to  a vast  number  of  modifications,  according  to 
the  particular  structure  which  is  inflamed  , and  hence, 
sometimes  one  symptom  of  inflammation,  sometimes 
another,  chiefly  predominates,  while  others  are  less 
conspicuous,  and  often  scarcely  distinauishable.  Yet, 
says  Beer,  none  of  the  characteristic  marks  of  inflam- 
mation are  ever  entirely  absent.  This  author  repre- 
sents the  deuree  of  pain  as  being  proportioned  in  a 
great  measure  to  the  tough  unyielding  nature  of  the 
parts  immediately  around  the  inflamed  te.xture  of  the 
eye,  to  the  firm  nature  of  the  inflamed  texture  itself, 
and  to  the  quantity  of  nerves  with  which  ^ucIl  texture 
and  the  parts  in  its  immediate  vicinity  are  supplied. 


In  proof  of  the  truth  of  this  doctrine,  he  instances  whit- 
lows and  internal  ophthaliiiy,  where  the  pain  i»  very 
severe;  while  inflammaiioiis  of  the  conjuiiciiva,  imi 
extending  to  the  deeper  textures  of  the  eye,  are  de- 
scribed as  cases  in  which  the  pain  is  slight,  because  the 
structure  affected  is  loose  and  yielding.  But  without 
scrutinizing  every  reason  assigned  by  B'eerfoi  the  varie- 
ties observable  in  the  symptoms  according  to  the  tex- 
ture which  happens  to  be  most  affected,  1 shall  Iniefly 
state  a few  other  examples  quoted  by  the  same  auilmr. 
That  the  degree  of  redness  as  well  as  of  pain  vaiies 
considerably  in  different  states  of  ophthalmy,  is  a fact 
universally  known.  In  the  beginning  of  the  com- 
plaint, such  redness  is  generally  less  perceptible  than 
when  the  inflammation  has  attained  its  highest  pitch  ; 
but  it  is  not  equally  great  in  every  individual  nor  in 
every  species  of  ophthalmy,  being  sometimes  more  in- 
tense and  diffused,  sometimes  less  both  in  di-gree  and 
extent.  This  diversity  is  referied  by  Beer,  and  pro- 
bably with  reason,  to  the  texture  aflected  in  the  eye 
being  furnished  with  many  considerable  blood-vessels, 
obvious  to  the  sight,  or  only  containing  vessels  more  con- 
cealed and  rather  filled  with  a colourless  fluid  than 
with  red  blood.  The  looseness  or  unyielding  nature 
of  the  texture,  is  also  represented  as  making  a dif- 
ference in  the  degree  of  redness.  In  inflammaiion 
principally  affecting  the  conjimciiva  and  sclerotica, 
says  Beer,  the  redness  is  so  intense  as  to  give  the  eye 
a frightful  appearance,  as  is  seen  in  chemosis;  \\hile 
in  inflammation  of  the  innermost  textures  of  the  organ, 
the  redness  is  scarcely  perceptible,  and  in  the  erysipe- 
latous inflammation  of  the  eyelids,  the  redness  is  veiy 
faint. — {Lchre  von  den  .^ugenkranhheiten  .,b.  34-36.) 

Dr.  Vetch  remarks,  that  the  conjunctiva  is  capable 
of  being  stretched  to  a great  extent,  owing  to  the  loose 
structure  of  the  cellular  membrane  on  which  it  lies, 
and  consequently  little  resistance  is  made  to  the  en- 
largement of  its  vessels.  From  slight  irritation  they 
soon  become  distended  with  red  blood,  “but  their  tone 
or  power  of  reaction  is  speedily  exhausted,  and  if  the 
exciting  cause  is  not  kept  up  iu  an  increasing  ratio, 
they  quickly  fall  into  a chronic  or  varicose  enlarge- 
ment, or  again  contract  to  the  diameter  of  the  serous 
vessels.”  On  the  other  hand  (as  the  same  exi>eriericed 
writer  has  pointed  out),  inflammation  of  ihe  sclerotic 
coat  is  slow  in  its  commencement,  and  often  insidious 
in  its  progress,  even  when  its  ultimate  violence  is 
great.  In  the  early  stage  of  conjunctival  ophthalmia, 
th^inflammation  is  most  observable  at  a distance  from 
the  cornea,  around  which  the  membrane  often  pre- 
serves for  a length  of  time  its  natural  appearance. 
Precisely  the  reverse  takes  place  in  the  case  of  scle- 
rotic inflammation,  which  invariably  appears  at  the 
circumference  of  the  cornea,  forming  a zone  more  or 
less  complete  about  it,  and  mo<t  conspicuous  above  it; 
the  form  and  colour  of  the  vessels  being  ht  the  same  time 
wholly  different  from  those  which  appear  in  the  course 
of  conjunctival  inflammation.  Intolerance  of  light 
(says  Dr.  Vetch)  invariably  accompanies  sclerotic  in- 
flammation, and  is  entirely  unconnected  with  that  rtf 
the  conjunctiva. — (On  the  Diseases  of  theEye.p.  10.)  If 
the  latter  observation  be  strictly  correct,  it  is  to  be  in- 
ferred that  in  all  common  cases  of  acute  ophthalmy, 
involving  the  conjunctiva  on  the  froi.t  of  the  eyeball, 
the  sclerotica  is  more  or  le:-s  affected,  as  in  the  begin- 
ning of  the  disorder,  light  may  be  said  to  be  seriously 
annoying  to  every'  patient. 

According  to  Mr.  Travers,  v hen  the  sclerotica  par- 
takes of  the  inflammation  of  the  conjunctiva,  the  ves- 
sels which  pursue  a straight  course  to  the  margin  of 
the  cornea,  are  strongly  distinguished,  and  have  a 
somewhat  darker  hue  than  the  areolar  vessels  upon 
the  loose  portion  of  the  conjunctiva. — {Synopsis  of 
the  Disea.ses  of  the  Eye,  p.  1'28.) 

Diversified  as  the  pain,  redness,  swelling,  and  heat, 
the  four  characteristic  symptoms  of  inflammation, 
may  be  in  cases  of  ophthalmy.  the  incidental  appear- 
ances in  the  eye  are  »»ot  less  subject  to  numerous  modi- 
fications. Thus,  sometimes  an  extraordinary  involun- 
tary action  of  the  muscles  of  the  eyeball  and  eyelids, 
or  of  the  secretin"  and  excretinc  lachrymal  organs, 
and  of  the  .Meibomian  elands,  may  be  noticed  : and 
sometimes  the  action  r>f  all  these  parts  is  either  dind- 
nished  or  completely  stopped.  These  differences  Beer 
relVrs  to  the  latter  parts  being  either  themselves  in- 
flamed, or  sympathizing  with  th<»  inflamed  texture  of 
the  eye.  In  the  first  case,  ilie  action  of  the  musclet 


OPHTHALMY. 


217 


and  the  functions  of  the  lachrymal  organs  and  Mei- 
bomian glands,  are  more  and  more  interrupted  in  pro- 
portion as  tlie  inflammation  increases,  and  must  thus 
remain,  while  the  inflammation  lasts  in  its  genuine 
form  ; but  in  the  second  case,  they  go  on,  and  this  even 
with  greater  activity,  while  the  inflammation  con- 
tinues, and  until  it  has  ceased  to  become  more  violent. 
—{B.  l,p.  39.) 

Acute  ophthalmy,  in  general,  when  at  all  severe, 
and  particularly  when  the  inner  te.vtures  of  the  eye  are 
affected,  produces  a febrile  disturbance  of  the  whole 
constitution.  This  change  from  a local  to  a general 
indisposition  takes  place  with  greater  certainty  and 
quickness,  in  proportion  us  the  inflammation  is  exten- 
sive, the  constitution  irritable,  the  disorder  of  the  eye 
neglected,  and  the  mischief  considerable,  wfliich  is  ac- 
tually produced  in  the  orsan,  whether  accidentally 
or  in  consequence  of  unskilful  treatment. — (Beer,  vol. 
cit.  p.  42.) 

Many  of  the  appearances  and  effects  of  ophthalmy 
are  different,  as  the  inffammation  happens  to  be  of  an 
acute  or  chronic  nature.  And,  as  Scarpa  has  taken 
particular  pains  to  impress  upon  the  minds  of  sur- 
gical practitioners,  every  acute  ophthalmy,  though 
treated  in  the  best  possible  manner,  is  never  so  com- 
pletely resolved  as  not  to  be  followed  by  a certain  pe- 
riod, at  which  all  active  disturbance  ceases,  in  the 
place  of  which  a degree  of  chronic  ophthalmy  remains 
in  the  conjunctiva  or  lining  of  the  eyelids;  the  effect 
either  of  local  weakness  in  the  vessels  or  of  the  con- 
tinuance of  a morbid  irritability  in  the  eye.  As  it  oc- 
casions a diseased  secretion  in  the  organ,  and  a slow 
accumulation  of  blood  and  coagulating  lymph,  the  in- 
experienced are  apt  to  suppose  that  the  acute  stage  is 
not  yet  entirely  subdued,  while  it  is  completely  so. 
Now,  if  the  inculcations  of  Richter  and  Scarpa  be 
correct,  immediately  the  critical  moment  arrives  when 
the  acute  stage  changes  into  the  chronic,  attended  with 
local  weakness,  it  is  of  the  highest  importance  to  alter 
the  treatment  without  delay,  and  to  substitute  for 
emollient  relaxing  applications,  such  as  partake  of  an 
astringent  corroborant  quality,  as  the  former  only  pro- 
tract the  turgescence  of  the  vessels  and  the  redness  of 
the  conjunctiva.  “ Quo  major  autem  fuit  inflamma- 
tionis  vehementia  (says  Richter),  eo  major  plernmque 
sequitur  partium  affectarum  aionia,  eoque  major  opus 
est  adstringentium  et  roborantium  longo  usu,  nt  aufe- 
rantur  penitus  reliquite  morbi,”  fcc.—lFascicul.  Obs. 
Chir.  1,  p.  109.) 

Itison  the  accession  of  the  second  stage  of  ophthalmy 
that  one  may  remark  the  sudden  increase  of  redness 
in  the  inflamed  texture,  with  a brown  and  afterward  a 
blue  tinge ; actual  e.xtravasations  of  blood  in  the 
chambers  of  the  aqueous  humour;  ecchymosis  of  the 
conjunctiva;  a considerable  increase  of  swelling;  the 
decline  and  irregularity  of  the  pain  ; the  decrease  of 
the  inflammatory  heat  and  throbbing ; a sensation  of 
cold  and  heaviness  in  the  organ  ; and  more  or  less  oede- 
matons  swelling  of  the  surrounding  parts.  It  is  also 
in  the  second  stage  that  suppuration  is  liable  to  hap- 
pen.—(fieer,  I^kre,  ^-c.  6.  1,  p.  46.)  And  in  another 
page  the  same  author  observes,  that  the  characteristic 
signs  of  the  second  stage  of  ophthalmy  consist  in  the 
following  appearances;  while  the  redness  and  swell 
ing  undergo  a sudden  and  striking  increase,  the  hard- 
ness manifestly  diminishes,  and  the  pain  becomes  very 
unequal,  aiid  not  continual;  the  secretions  and  excre- 
tions also,  which,  during  the  first  stage,  were  ettm- 
pletely  stopped,  commence  again,  but  more  copiously, 
and  are  of  a very  different  quality  from  what  they 
were  in  the  state  of  health.  The  disorder  is  now  quite 
in  its  second  stage,  and  this  is  the  time  w'hen  purulent 
matter  may  begin  to  be  formed. — {B.  1,  p.  50.)  Ac- 
cording to  Beer,  the  duration  of  idiopathic  ophthalmy 
depends  upon  the  circumstances  of  each  individtial 
case  ; first,  the  nature  of  the  catises  giving  rise  to  the 
affection;  secondly,  the  irritability  of  the  patient,  in 
relation  to  constitution,  sex,  and  age;  thirdly,  what 
may  he  termed  the  constitution  of  the  affected  eye  it- 
self, and  the  texture  in  it  immediately  inflamed.  Thus 
ophthalmy  is  likely  to  be  attetided  with  great  severity 
when  it  attacks  plethoric  individuals,  in  whom  there 
has  been  for  some  time  previously  a great  determina- 
tion of  blond  to  the  head  and  eyes,  or  whose  sight  has 
been  strained  by  looking  at  shining  objects,  or  who  e 
constitutions  have  been  hurt  by  good  living  and  hard 
drinking.  Every  severe  ophthalmy  runs  through  its 


first  stage  much  more  rapidly  in  weak,  irritable  sub- 
jects and  children,  than  iti  robust  individuals,  it  is 
also  another  remark  made  by  Beer,  that  every  inflam- 
mation of  the  eye,  at  all  ponsiderable,  is  generally  of 
shorter  continuance  in  gray  or  blue-eyed,  than  in  dark 
or  black-eyed  peisons;  and  in  the  same  manner  in- 
flammation of  the  internal,  sensible  and  tender  tex- 
tures of  the  eyeball  always  passes  through  its  first 
stage  more  quickly  than  inflammation  of  the  eyelids. 

With  respect  to  the  causes  of  ophthalmy  in  general^ 
as  the  disorder  frequently  affects  the  innermost  parts 
of  the  eye,  and,  when  severe,  is  attended  with  some 
risk  of  the  loss  of  the  organ,  the  annihilation  of  its 
functions,  or  the  spoiling  of  some  of  its  textures;  and 
also,  as  inflammation  is  the  most  frequent  complaint  to 
which  the  eye  is  subject,  it  is  important  to  learn,  as  far 
as  possible,  the  causes  which,  either  directly  or  indi- 
rectly, give  rise  to  it. 

The  atmospheric  air  and  light  have  a direct  and 
powerful  operation  upon  the  eyes;  and  in  order  that 
the  former  may  have  no  hurtful  effect  upon  the.^e 
organs,  it  should  be  pure;  that  is  to  say,  its  regular  com- 
ponent parts  should  not  be  altered,  nor  blended  with 
extraneous  substances.  The  temperature  of  the  air  is 
likewise  described  by  Beer  as  making  a good  deal  of 
difference  in  the  susceptibility  of  the  eyes  for  inflam- 
mation, either  a very  warm  or  cold  air  being  in  this 
respect  hurtful.  The  observation,  however,  is  qualified 
with  the  admission,  that  the  terms  warm  and  cold  have 
only  a relative  signification  to  individual  circumstances. 
The  effect  of  a blast  of  cold  air  on  the  eye  in  exciting 
inflammation  is  universally  known,  and  needs  no  com- 
ment. It  is  an  opinion  of  Beer,  that  the  eye  is  much 
affected  by  the  quantity  of  electricity  in  the  atmos- 
phere; and  he  says,  that  on  this  account,  no  experi- 
enced practitioner  would  undertake  the  extraction  of  a 
cataract  during  or  on  the  approach  of  a storm. — {B  1, 
p.  65.) 

Passing  over  many  interesting  observations  made  by 
Beer  on  the  contamination  of  the  atmospheric  air  by 
the  admixture  of  other  gases,  and  the  injurious  effect  of 
this  change  upon  the  eyes,  I come  to  his  remarks  on 
the  operation  of  light  upon  these  organs.  Though 
light,  he  observes,  is  indispensable  to  the  functions  of 
the  eye,  it  becomes  pernicious  when  suddenly  increased 
beyond  what  the  organ  can  bear,  so  as  to  be  a source 
of  irritation.  As  a proof  of  this  fact  he  cites  an  in- 
instance in  which  a young,  plethoric,  strong  man, 
whose  eyeshad  been  for  some  time  unavoidably  strained 
by  immoderate  exercise  of  them,  was  suddenly  at- 
tacked with  a violent  ophthalmy,  while  looking  at  an 
optical  repre.seniation  of  the  rising  sun,  and  carried 
home  in  great  agony.  But  with  respect  to  the  influ- 
ence of  light,  Beer  observes  that  every  statement  is  to 
be  received  only  in  a relative  sense  ; for  the  degree  of 
lisrhl  which  would  an.swer  very  well  for  the  eye  of  an 
African,  would  destroy  many  European  eyes  ; and  the 
same  light  which  is  borne  without  inconvenience  by 
the  eye  of  an  adult,  would  excite  in  the  eye  of  a new- 
born infant  the  ophthalmia  neonatorum^  by  which  so 
many  children  are  deprived  of  the  most  valuable  of 
the  senses  in  the  first  days  of  their  existence.  Beer 
farther  explains,  that  the  same  desrreeof  liaht  produces 
a stronger  or  weaker  effect,  according  to  the  greater  or 
less  irritability  of  the  eye  of  the  same  person  at  dif- 
ferent times,  as  we  see  exemplified  in  every  individual 
in  the  tenderness  of  his  eye  to  lieht  when  he  first 
awakes  in  the  morning.  Light  is  also  not  hurtful  to 
the  eyes,  merely  according  to  its  quantity ; for  the  di- 
rection of  the  rays  makes  a great  deal  of  difference, 
the  eye  being  less  capable  of  bearing  them  with  impu- 
nity the  more  they  recede  from  a perpendicular  line, 
and  strike  the  organ  slopinaly  or  horizontally.  Much 
likewise  depends  upon  the  kind  of  licht ; that  which  is 
reflected  from  a scarlet  surface,  being  even  more  pre- 
judicial than  the  sunshine  which  is  reflected  from  a 
country  covered  with  snow  : another  convincing  proof 
that  the  bad  effects  are  not  always  in  proportion  to  the 
quantity  of  rays.  The  light  of  burning-glasses,  con- 
cave mirrors,  while  screens,  the  full  moon,  &c.,  and 
the  shining  of  diamonds,  are  well  known  to  render  the 
eyes  weak,  and  prone  to  inflammation.  Among  other 
occasional  causes  of  ophthalmy.  Beer  enumerates  the 
custom  of  washing  the  eyes  immoderately  with  cold 
water,  a remark  in  whicii  I do  not  place  much  confi- 
dence myself;  the  ap[)lication  of  various  stimulating 
medicated  substances  to  them ; compresses  and  band- 


218 


OPHTHALMY, 


ages  ; the  badness  of  instruments  employed  in  opera- 
tions upon  the  eyes ; the  employment  ot  spectacles 
unnecessarily,  or  of  such  as  are  not  adapted  to  the 
eyes  of  the  individual;  and  every  immoderate  exer- 
tion of  the  eyesight. 

But  among  the  most  important  and  frequent  excit- 
ing causes  of  ophthalmy,  are  extraneous  bodies,  which 
insinuate  themselves  between  the  eyeball  and  eyelids, 
and  every  kind  of  wound  or  injury  of  the  eye. 

Fureian  bodies  liable  to  enter  under  the  eyelids  are 
of  three  kinds;  first,  such  as  are  in  themselves  com- 
pletely innoxious  to  the  eye  ; or  such  as  are  likely  to 
hurl  the  eye  only  when  strongly  pressed  upon  by  the 
spasmodic  closure  of  the  eyelids,  or  by  the  patient’s 
imprudently  rubbing  the  eye;  or  they  may  be  of  a 
quality  which  injures  the  eye  the  moment  they  come 
into  contact  with  it.  Foreign  bodies  of  the  first  de- 
scription lie  loose  under  one  of  the  eyelids,  and  for  the 
most  pan,  either  immediately  behind  its  edge  in  the 
groove  destined  for  the  conveyance  of  the  tears,  or  else 
in  the  fold,  seen  when  the  eyelid  is  everted,  exactly  at 
the  line  where  the  palpebra  and  sclerotic  conjunctiva 
join  together.  'I’hey  never  actually  lodge  in  the  coats 
of  the  eye;  but  they  irritaie  it  mechanically,  or  chemi- 
cally or  in  both  ways  Urgether,  according  to  tlieir  size, 
shape,  and  chemicaJ  properties. 

Ill  the  list  of  such  extraneous  substances  are  inverted 
eyelashes;  particles  of  dust;  snuff:  pepper;  minute 
insects;  and  other  small  things  generally  carried  under 
tire  eyelids  by  the  wind. 

As  the^e  foreign  bodies  are  all  of  them  more  or  less 
irritating  to  the  eye,  they  must  be  considered  as  a prin- 
cipal exciting  cause  of  ophthalmy,  which  frequently 
follows  their  entrance  under  the  eyelids  with  extraordi- 
nary rapidity-  However,  the  redness  and  effusion  of 
tears  sometimes  instantly  following  the  insinuation 
of  extraneous  substances  under  the  palpebrae,  and  as 
suddenly  ceasing  on  their  removal,  Beer  considers 
rather  as  preliminaries  to  inflammation,  than  as  this 
disorder  itself. — (B.  l,p.  92.) 

Wounds  and  other  injuries  of  the  eye,  regarded  as 
causes  of  ophthalmy,  Beer  divides  into  three  kinds; 
viz.  vieckanir.al,  chemical,  and  vtixed.  A prick  of  the 
eye  with  a fine  needle  is  an  example  of  a simple  me- 
chanical injury;  the  action  of  quicklime  upon  the 
organ  is  an  instance  of  one  purely  chemical ; and  the 
violent  propulsion  of  a red  hot  bit  of  iron  against  the 
eye  is  a lesion  which  may  be  said  to  be  both  me- 
chanical and  chemical.  The  sanfe  author  makes  a 
variety  of  original  reflections  upon  the  differences  con- 
nected with  the  extent  and  intensity  of  such  injuries. 
Their  intensity  he  views  only  as  something  relative; 
thus,  either  the  force  with  which  the  eye  is  injured,  is 
of  itself  too  great  ever  to  be  resisted,  as  is  seen  in  a 
gun-shot  wound;  or  the  organic  powers  of  the  patient 
are,  from  age,  sex,  or  constitution,  much  too  feeble  for 
the  eye  to  bear  favourably  any  considerable  injury,  as 
is  the  case  with  children,  and  weak  unhealthy  females: 
or  the  organization  of  the  eye  it.self  may  be  weak,  and 
the  effects  of  the  violence  therefore  greater,  as  exem- 
plified in  the  fact  of  a brown  or  black  eye  generally 
bearing  a wound  better  than  a gray  or  blue  one;  or, 
lastly,  the  organic  powers  of  the  texture  of  the  eye 
immediately  injured  may  be  too  feeble  to  bear  even  a 
slight  lesion,  as  is  the  case  with  the  retina. — {B.  1, 
p.  95.) 

Mechanical  injuries  of  the  eye  may  be  made  either 
with  sharp  or  obtuse  bodies.  Sharp-pointed  and  cut- 
ting instruments  are  capable  of  readily  penetrating  the 
eye,  without  occasioning  at  the  moment  of  their  en- 
trance, any  violent  compression  or  laceration  of  the 
neighbouring  textures;  and  consequently  the  injury 
inflicted  is  a simple  puncture,  or  an  incision.  Sabre- 
cuts  of  the  eye,  however,  are  to  be  excepted  ; for 
though  the  weapon  may  be  sharp,  the  blow  is  always 
attended  with  more  or  less  concussion,  and  injury  of 
the  textures  adjoining  the  wound,  which  are  very  deli- 
cate and  readily  spoiled.  Blunt  weapons  or  bodies 
can  only  enter  the  texture  of  the  eye  by  dint  of  great 
force,  and,  in  this  case,  always  cause  a serious  degree 
of  compression,  stretching,  and  laceration  ; but  some- 
times, when  they  do  not  penetrate  the  organ,  the  con- 
tusion is  such  as  is  productive  of  not  less  mischief. 

In  the  case  of  a simple  puncture  or  incision  of  the 
eye.  Beer  seems  to  think,  that  the  subsequent  ophthalmy 
is  generally  more  owing  to  the  incapacity  of  the 
wounded  organ  to  bear  the  effects  of  the  light,  air,  &c., 


than  to  the  injury  itself  abstractedly  considered.  He 
observes,  that  a proof  of  the  truth  of  this  opinion 
is  seen  in  the  extraction  of  the  cataract ; for  if  the 
operator  is  careless  in  the  operation  itself,  opening  the 
flap  of  the  cornea  veiy  wide,  so  as  to  let  the  aimos- 
jtheric  air  have  free  access  to  the  inner  textures  of  the 
eye ; or  if,  after  the  operation  is  finished,  he  do  not 
apply  the  dressings  with  caution,  and  properly  darken 
the  patient’s  chamber,  he  is  letting  the  eye  be  sub- 
jected to  some  of  the  most  active  causes  of  inflamma- 
tion. But  though  Beer  is  unquestionably  correct,  in 
regard  to  the  itijurious  effects  of  light  on  the  wounded 
eye,  it  may  be  doubted  whether  his  tlieories  do  not 
make  him  attribute  too  much  to  the  irritation  of  the 
air,  and  too  little  to  the  mechanical  division  of  the 
parts. 

Passing  over  many  of  Beer’s  observations  on  injuries 
of  the  eye  produced  by  blunt  bodies,  and  substances 
acting  chemically  upon  it,  I leave  the  topic  of  the  direct 
exciting  causes  of  ophthalmy,  and  come  to  the  consi- 
deration of  those  which  he  regards  as  indirect.  And 
the  first  to  which  he  adverts  is  every  thing  that  has  a 
tendency  to  keep  up  a determination  of  a large  quan- 
tity of  blood  into  the  vessels  of  the  head  and  eyes. 
Immoderate  bodily  exercise,  violent  emotions  of  the 
mind,  injudicious  clothing,  and  high  living  are  af- 
terward enumerated  as  having  an  indirect  effect  in 
the  production  of  ophthalmy : but  it  does  not  appear 
to  me,  that  Beer’s  sentiments  upon  these  points  are  en- 
titled to  much  attention.  With  respect  to  infection  and 
contagion  as  causes  of  inflammation  of  the  eye.  Beer 
understands  by  infection  what  at  fiist  takes  effect  only 
upon  a small  point  of  the  body,  but  never  upon  the 
whole  animal  economy  directly,  that  is  to  say,  before 
absorption  has  taken  place.  Hence,  says  he,  infectious 
diseases  are  very  seldom  the  cause  of  ophthalmy, 
unless  some  of  their  matter  be  applied  immediately  to 
the  eye  itself ; but  he  admits  that  they  often  dispose 
this  organ  to  inflame  from  slight  causes,  by  the  impair- 
ment which  they  produce  of  the  general  health.  On 
the  other  hand,  he  considers  all  contagions  as  very 
quickly  affecting  the  whole  of  the  constitution,  directly 
through  the  medium  of  the  skin,  or  the  trachea,  lungs, 
oesophagus,  &c.  Hence,  contagion  is  set  down  as  being 
much  more  frequently  than  infection  the  indirect 
cause  of  ophthalmy.  Beer  conceives,  however,  that 
as  the  contagious  principle  is  blended  with  the  atmos- 
phere, it  may  also  have  an  immediate  operation  upon 
the  eyes,  and’  thus  he  attempts  to  account  for  the  organs 
not  unfrequently  exhibiting  a tendency  to  inflamma- 
tion at  Uie  very  moment  of  the  contagion  taking  effect. 
—{B.  1,  p.  121.)  But  this  is  a difficult  and  obscure  sub- 
ject, which  can  be  view’ed  to  more  advantage,  when 
partictilar  kinds  of  ophthalmy  are  considered. 

In  Beer’s  general  observations  on  the  treatment  of 
inflammations  of  the  eyes,  the  first  indication  specified, 
is  to  remove  immediately  every  thing  which  is  obviously 
producing  an  irritating  effect  upon  the  eye,  and  to  take 
care  that  no  fresh  source  of  irritation  to  the  organ 
incidentally  take  place.  A nd  as  it  frequently  happens, 
even  in  healthy,  stVong  individuals,  that  ophthalmy  is 
occasioned  by  foreign  bodies,  either  lodged  under  the 
eyeballs,  or  inserted  in  some  part  of  the  eyeball,  and 
not  suspected  to  be  there,  the  earliest  attention  should 
always  be  paid  to  their  gentle  and  skilful  removal. 
Easy  as  this  object  is  of  accomplishment  when  not 
delayed,  when  the  eye  has  not  been  seriously  irritated 
by  friction  and  pressure,  and  the  patient  is  not  of  a 
weak,  irritable  constitution,  it  is  often  attended  with 
great  difficulty  under  one  or  the  other  of  these  circum- 
stances, especially  the  last.  In  this  case,  strong  con- 
vulsive rotations  of  the  eyeball,  followed  by  a violent 
and  obstinate  spasmodic  closure  of  the  eyelids,  render 
it  imix)ssible  to  seitarate  them  ; and  the  spasm  is  the 
stronger  and  more  lasting,  the  more  the  extraneous 
substances  are  calculated,  by  their  shape  and  chemical 
quality,  to  irritate  the  eye:  and  the  greater  the  irrita- 
bility of  the  patient  is.  In  this  state  of  things,  every 
attempt  forcibly  to  open  the  eye,  or  to  examine  it  in 
the  light,  is  not  only  useless,  but  increases  and  keeps  up 
tlm  spasm,  which  nothing  will  lessen  and  shorten,  ex- 
cept darkness  and  perfect  repose.  But  as  timid,  irrita- 
ble persons  are  exceedingly  apprehensive  of  the  conse- 
quences of  the  lodgement  of  extraneou.s  substances  in 
he  eye,  the  surgeon  should  endeavour  to  lessen  their 
inquietude,  by  assuring  them  that  every  thing  will  be 
right  again,  which  is  strictly  true,  when  the  foreign 


OPHTHALMY. 


219 


bodies  are  of  the  first  class.  Then  the  spasmodic  do 
sure  of  the  eyelids  will  cease,  and  the  extraneous  sub- 
stance admit  of  being  properly  taken  away. 

Success,  however,  does  not  always  attend  this  simple 
method  ; for  in  very  weak  subjects,  the  spasm  of  the 
orbicularis  palpebrarum  is  so  violent  and  obstinate,  es- 
pecially when  a foreign  body  lodges  in  the  eye,  and  at 
the  same  time  mechanically  and  chemically  irritates  it 
(as  is  the  case  with  particles  of  snuff.),  that  it  becomes  in- 
dispensable to  have  recourse  to  medicinal  applications. 
For  tliis  purpose.  Beer’s  experience  hasconvinced  him, 
that  the  best  thing  is  a bread  poultice,  made  either  with 
milk  or  water,  and  containing  some  of  the  vinous  tinc- 
ture of  opium.  Care  is  to  be  taken,  however,  never  to 
let  it  become  quite  cold  during  its  application  ; for  then 
the  spasm  would  only  be  aggravated  by  it;  and  if  such 
spasm  has  been  of  long  continuance,  when  the  surgeon 
is  first  sent  for,  the  poultice,  accoiding  to  Beer,  may  be 
rendered  more  efficacious  by  the  addition  of  hyoscia- 
itnis  to  it.  In  very  irritable,  hysterical,  and  hypochon 
diiacal  persons,  such  local  i reatmeni  alone  is  frequently 
insufficient,  and  recourse  must  be  liad  to  the  internal 
exhibition  of  antispasmodic  anodyne  medicines.  At 
length,  when  the  spasm  of  the  orbicular  muscle  is  so 
far  diminished  that  the  eyelidscanbe  effectually  opened 
without  any  force  for  the  extraction  of  the  foreign 
body,  great  caution  and  gentleness  will  yet  be  neces- 
sary, and,  in  particular,  the  eye  should  be  kept  in  a very 
moderate  light,  as  the  spasm  would  be  immediately  ex- 
cited again,  either  by  sudden  exposure  of  the  eye  to  too 
much  light,  or  rough  handling  of  the  eyelids. 

Sometimes  a person  rubs  his  eye  at  first  awaking  in 
the  morning,  and  if  the  eyelashes  are  very  numerous 
and  rigid,  one  of  them  will  lodge  between  the  eyeball 
and  lower  eyelid  : it  may  readily  be  taken  away  with 
the  end  of  a fine  moist  sponge  or  camel-hair  pencil,  the 
eyelid  being  depressed  as  much  as  jKJSsible,  and  the  eye 
itself  turned  upwards,  so  that  the  hair  may  not  be  con- 
cealed in  the  fold  of  the  conjunctiva.  When  the  hair 
is  situated  under  the  upper  eyelid  (which  Beer  says 
rarely  happens),  it  always  lodges  in  the  fold  of  the  pre- 
ceding membrane,  whence  it  may  be  extracted  in  the 
manner  above  directed,  with  the  difference  that  the  eye- 
lid must  be  raised  or  everted,  and  thd eye  rotated  down- 
wards.— {,Lehre  von  den  Augenkr.  6.  1,  p.  128 — 130.) 

For  directions  respecting  the  treatment  of  redundant 
and  inverted  ciliae,  see  Distichiasis  and  Trichiasis. 

Small  globular  smooth  extraneous  bodies,  lodged  un- 
der the  eyelids,  are  very  ea.-iily  extracted,  when  the  eye- 
lid is  gently  taken  hold  of  both  by  its  edge  and  the  eye- 
lashes, and  lifted  up  from  the  eye,  while  the  [latient 
inclines  his  head  forwards  and  the  eye  is  turned  com 
plelely  downwards ; the  effusion  of  tears  excited  by  tliese 
maiKEMvres  will  now  generally  wash  these  extraneous 
substances  out  of  the  eye,  as  they  are  not  at  all  fixed. 
When  the  fissure  between  the  eyelids  is  wide  and  open, 
but  the  eyeball  at  the  same  time  very  prominent,  the 
object  may  also  be  easily  accomiilished,  when  (he  up 
per  eyelid  is  gently  and  repeatedly  stroked  with  the 
finirer  from  the  outer  towards  the  inner  canthus;  in 
which  case,  the  round  smooth  foreign  body  soon  makes 
its  appearance  above  the  caruncular  lachrymalis, 
whence  it  falls  out  of  itself,  or  may  be  taken  with  the 
corner  of  a pocket  handkerchief. 

The  worst  cases  are  those  in  which  the  eyes  are  very 
prominent,  and  the  fissure  of  the  eyelids  small,  as  all 
the  above  methods  are  then  useless,  and  only  produc- 
tive of  irritation.  In  this  circumstance,  therefore,  Beei 
recommends  the  surgeon  to  take  hold  of  the  eyelid  by 
the  ciliae  and  its  edge  with  the  thumb  and  fore-finger, 
and  separate  it  from  the  eyeball,  which  is  to  be  turni'd 
downwards,  while,  with  Daviel’s  small  .scoop,  or  the 
head  of  any  large  curved  needle,  introduced  straight 
under  the  eyelid,  at  the  outer  canthus,  as  high  as  pos- 
sible, the  extraneous  suhsiarice  is  to  be  extracted  with 
a semicircular  movement,  directed  towards  the  nose. 

Instead  of  this  painful,  irritating  plan,  I recommend 
the  eyelid  to  he  simply  everted  by  taking  hold  of  the 
cilia;,  and  drawing  them  forwards  and  upwards,  while 
a probe  is  u.-ed  tor  pressing  back  the  upper  portion  of 
the  tarsus.  The  foreign  Imdy  may  then  be  plainly  seen, 
and  easily  removed. 

Particles  of  common  dust,  and  of  the  sand  and  pow- 
dt  rs  frequently  thrown  over  letters,  ate  very  apt  to 
ger  into  the  eyes  of  persons  who  open  their  letters  care- 
lessly, or  from  short-sightedness  are  obliged  to  brirm 
them  close  to  the  nose,  are  generally  more  difficult  of 


extraction.  In  the  attempt,  however,  the  eye  must 
never  be  subjected  to  too  much  irritation.  According 
to  Beer,  these  extraneous  particles  of  dust  or  sand 
may  sometimes  be  removed  by  washing  the  eye  well, 
or  by  dropi)ing  into  it  milk,  or  some  other  viscid  fluid, 
while  the  patient  lies  upon  his  back,  and  the  eyelid  is 
lifted  up  from  the  eye.  But  the  most  expeditious  and 
certain  plan  is  to  employ  a syringe,  the  pipe  of  which 
is  to  be  introduced  under  the  upper  eyelid  near  the 
outer  canthus,  and  the  fluid  thrown  briskly  in  the  di- 
rection towards  the  nose.  If  all  the  extraneous  mat- 
ter cannot  be  thus  removed,  the  resrmay  someiimes  be 
taken  out,  if  the  eyelid  be  everted  in  the  manner  above 
directed,  which  seems  to  me  the  right  method  to  be 
adopted  in  several  cases,  for  which  Beer  r ecommends 
other  proceedings. 

When  particles  of  sugar,  or  other  soluble,  not  very 
irritating  substances,  happen  to  insinnaie  themselves 
into  the  eye,  professional  aid  is  seldom  requisite,  as 
they  generally  dissolve  in  the  tears,  and  are  voided  be- 
fore a surgeon  can  arrive.  Snufl',  pepper,  and  other 
miiiute  irritating  bodies,  as  well  as  small  winged  in- 
sects, are  to  be  removed  in  the  same  manner  as  parti- 
cles of  dust  and  letter-sand;  but  particular  care  is  to 
be  taken  afterward  to  wash  the  eye  well  with  some 
lukewarm  mucilaginous  collyrium,  until  the  irritation 
caused  by  the  chemical  eflect  of  such  foreign  bodies 
has  been  cotnpleiely  obviated. 

The  removal  of  foreign  bodies  of  the  second  class  is 
usually  attended  with  more  difficulty,  because  they,  as 
well  as  those  of  the  third  class,  more  frequently  pro- 
duce a violent  and  obstinate  spasmodic  closure  of  the 
eyelids,  and  are  seldom  loose,  being  generally  fixed  in 
the  cornea.  However,  when  they  happen  to  be  de- 
tached, they  may  be  extracted  in  the  same  way  as  small 
round  smooiii  extraneous  bodies,  except  that  the  strok- 
ing of  the  eyelid  with  the  finger  should  be  omitted 
not  only  as  useless,  but  likely  to  press  any  of  tliese 
substances,  which  are  of  a poinied  shape,  into  the 
loo.«;e  conjunctiva,  so  as  to  injure  the  eye  itself,  which 
would  otherwise  not  be  hurt.  The  nibs  of  pens,  the 
parings  of  the  nails,  and  small  hard-winged  insects, 
when  lodged  in  a depression  of  the  cornea,  or  white  of 
the  eye,  Beer  says,  may  be  easily  dislodged  by  means 
of  a small  silver  spatula.  Other  foreign  bodies  of  the 
second  class  are  not  only  fixed  in  a depression,  but 
even  penetrate  more  deeply  than  the  conjunctiva  ; and 
in  old  subjects  in  particular,  they  often  insinuate  them- 
selves into  the  loose  cellular  membrane  under  the  con- 
junctiva in  the  white  of  the  eye,  partly  in  consequence 
of  the  convulsive  motions  of  the  eyeball  and  eyelids, 
and  partly  by  reason  of  the  attempts  made  to  loosen 
the.'ii.  Hence,  they  frequently  become  situated  a great 
way  from  ttie  place  ot  their  entrance,  and  are  com- 
pletely covered  by  the  conjunctiva.  But  even  when 
they  lie  immediately  in  the  wound,  they  are  so  inti- 
mately connected  with  the  subjacent  loo.se  cellular 
membrane  of  the  conjtrnctiva,  that  every  attempt  to 
remove  them  with  forceps  is  not  only  unavailing,  hut 
hurtful  to  the  eye,  inasmuch  as  the  injury  is  thereby 
rendered  deeper.  They  may  be  taken  away  with  faci- 
lity, however,  when  lifted  up  with  a pair  of  small  for- 
ceps, attd  cut  away  with  a pair  of  scissors,  together 
with  the  piece  of  cellular  membrane  with  which  they 
are  directly  connected.  If  sttch  extraneotis  substance 
should  be  actually  underneath  the  sclerotic  conjunctiva, 
Beer  recommends  the  eyelids  to  be  well  opened,  and 
the  eye  to  be  brought  into  a position,  in  which  the  part 
of  the  conjunctiva  covering  the  foreign  body  is  ren- 
dered tense,  when  an  incision  is  to  be  made  with  a 
lancet  down  to  the  extraneous  snb.stance,  which  is  to 
be  taken  hold  of'and  removed  with  a pair  of  scissors, 
the  assistant  being  careful  to  keep  hold  of  the  eyelids 
during  the  operation.  On  the  other  hand,  when  the 
foreign  body  is  actually  lodged  between  the  layers  of 
the  cornea.  Beer  considers  that  its  exti  action  may  be 
best  accomplished  with  a lancet-pointed  couching  nee- 
dle. ftut  whatever  instrument  be  used,  its  point  must 
he  passed  with  great  caution  closely  and  obliquely  un- 
der the  foreign  body  ; and  care  must  be  taken  not  to 
introduce  it  too  deeply,  lest  the  anterior  chamber  be 
opened,  which  may  readily  happen  in  young  subjects; 
and  when  it  does,  the  aqueous  humour  flows  out,  and 
the  cornea  becomes  so  flaccid,  that  the  removal  of  the 
extraneous  substance  is  quite  impracticable,  before  the 
puncture  has  healed,  and  the  anterior  chamber  is  again 
distended. 


220 


OPHTHALMY. 


The  removal  of  foreign  bodies  of  the  third  class 
mostly  demands  very  great  caution ; first,  because,  as 
Beer  observes,  no  panicles  of  them  should  be  allowed 
to  remain  in  the  eye,  which,  without  the  utmost  vigi- 
lance, is  apt  to  be  the  case;  and  secondly,  because  the 
wound  of  the  eye,  already  considerable,  should  not  be 
made  larger  than  can  be  avoided.  The  extraction  of 
small  bits  of  glass  is  particularly  difficult,  as  they  can- 
not be  seen,  but  must  be  found  out  entirely  by  the  feel- 
ings of  the  patient,  or  the  tactus  eruditus  of  the  surgeon 
assisted  with  a probe.  When  in  this  way  a particle 
of  glass  is  detected.  Beer  directs  us  to  take  hold  of  it 
with  a pair  of  forceps,  and  cut  it  away  with  scissors. 
The  place  from  which  it  has  been  removed  must  then 
be  caiefully  probed,  in  order  that  no  other  fragmetii 
may  be  left  in  it. 

Accoidiiig  to  the  same  author,  pieces  of  iron  and 
steel,  which  strike  the  eye  so  forcibly  as  to  enter  it,  as 
well  as  all  other  fragments  of  metals,  which  are  readily 
oxydated,  should  be  as  carefully  removed  as  bits  of 
glass  ; for  the  more  easily  they  cotnbine  with  oxygen, 
and  the  longer  they  remain,  the  more  brittle  they  be- 
come, and  the  more  apt  are  minute  panicles  to  be  left 
in  the  eye,  especially  in  the  cornea.  A speck  on  the 
part  of  this  membrane  where  the  splititer  has  lodged, 
is  the  least  serious  consequence  of  such  an  event. 
When  fragments  of  steel  which  have  quite  a black 
appearance  remain  fi.xed  in  the  cornea  several  hours, 
it  is  found,  after  their  removal,  that  the  whole  cir- 
cumference of  the  depression,  from  which  they  have 
been  extracted  is  of  a reddish-brown  colour,  produced 
by  the  rust  left  behind,  and  firmly  adhering  to  the  cor- 
nea. Every  particle  of  rust  must  bd  carefully  removed 
with  a couching  needle,  or  else  a permanent  speck  will 
ensue;  but  caution  must  be  used  not  to  puncture  the 
anterior  chamber.  The  extraction  of  particles  of  lead 
and  gunpowder  is  generally  difficult,  as  they  have 
mostly  been  projected  with  great  force  against  the  eye- 
lids, so  as  to  produce  not  only  a great  deal  of  spasm, 
but  instantaneous  swelling  of  those  parts.  Hence, 
Beer  says,  that  they  should  commonly  be  taken  hold  of 
with  forcefts  and  cut  away.  Particles  of  caniharides 
are  easily  removed  with  a small  silver  spatula,  or  the 
end  of  an  eye-probe;  but  their  violent  chemical  effect 
must  be  obviated,  by  frequently  applying  to  the  part  a 
little  fresh  butter,  touching  it  with  a camel-hair  pencil 
dipped  in  diluted  liquor  ainmoniEe,  or  dropping  into  the 
eye  lukewarm  mucilaginous  collyria. 

The  attemi  t to  wash  panicles  of  quicklime,  mortar, 
&c  from  the  eye.  Beer  says,  only  has  the  effect  of  ren- 
dering their  violent  chemical  operation  more  diffused, 
and  he  recommends  them  to  be  taken  out  by  means  of 
a fine  hair-pencil,  dipped  in  fresh  butter  or  oil.  This 
is  the  only  way  of  immediately  counteracting  their 
chemical  effect;  and  after  their  extraction,  the  applica- 
tion of  unctuous  substances  to  the  part  should  still  be 
continued. 

The  stings  of  small  insects,  when  lodged  in  the  scle- 
rotic conjunctiva,  are  often  very  difficult  of  detection  ; 
but  they  are  more  readily  seen  on  the  skin  of  the  eye- 
lids. Beer  directs  us  to  remove  them  with  a pairof  for- 
ceps, or  a couching  needle,  and  then  to  have  leconrse 
to  means  calculated  to  diminish  the  ophthalmy,  which, 
in  these  cases,  always  begins  on  the  first  occurrence  of 
the  accident.  Small  shots  lodged  in  the  loose  cellular 
texture  of  the  conjunctiva  must  be  cut  out.  In  gene- 
ral, says  Beer,  it  is  nece-sary  to  divide  the  conjunctiva, 
as  they  are  mostly  situated  some  distance  from  the 
place  of  their  entrance,  and  of  course  are  quite  covered 
by  that  membrane. 

As  soon  as  a foreign  body  has  been  extracted  from 
the  eye,  all  precursors  of  ophthalmy  diminish  ; as,  for 
in.siance,  the  redness,  intolerance  of  light,  and  the  in 
creased  secretion  and  effusion  of  tears.  Even  the  in- 
flamtnation  itself,  when  already  developed,  subsides; 
but  this  affection  is  slight,  if  the  eye  has  not  itself  heeti 
injured  by  the  extratieons  body.  On  the  other  hand, 
when  the  eye  has  suffered  more  or  less  irritation  from 
the  nature  of  the  substance  itself,  and  the  treatment 
requisite  for  its  cotnplete  extraction,  the  itittamtnation 
may  become  more  severe,  unless  the  surgeon  pay  im- 
mediate attention  to  the  injury  lefton  the  eye. — \Beer.) 

According  to  the  principles  laid  down  in  the  fore- 
going columns,  the  fiist  imlication  iti  the  treatment  of 
wounds  of  the  eye  in  general  is,  to  remove  every  kind 
of  extraneous  substance  which  may  impede  the  cure. 
Hence,  the  necessity  of  observing  whether  the  inslru- . 


ment  with  which  the  wound  has  been  inflicted,  or  any 
part  of  it,  is  lodged  in  the  eye.  When  this  is  the  case, 
the  foreign  body  sliould  be  quickly  extracted,  or  else  no 
recovery  of  the  organ  can  take  place.  But,  says  Beer, 
this  is  more  easily  said  than  done ; for,  in  many  instatices 
it  is  very  difficult  to  find  and  leiuove  the  fiagmenis 
of  instruments,  on  account  of  the  great  delicacy  of  the 
organ,  the  irritability  and  alarm  of  the  paiieni,  and  the 
bleeding  from  the  part.  However,  the  attempt  must 
be  made  with  the  greatest  gentleness  possible;  and 
Beer  particularly  advises  a fine  elastic  wlialebone  probe 
to  be  used,  instead  of  a silver  onef  for  tlie  purpose  of 
detecting  the  fragment  He  also  sanctions  making  an 
incision,  for  facilitating  the  finding  of  tfie  extianeous 
substance,  provided  it  is  certainly  lodged,  and  cannot 
otherwise  be  traced.  This  author  attaches  great  im- 
portance to  the  fulfilment  of  this  first  indication  in  ail 
w'ouiids  of  the  eye,  and  relates  a case,  to  w hich  he  was 
called,  where  a piece  of  tobacco  pipe  had  been  driven 
so  forcibly  and  deeply  at  the  external  caiuhus  between 
the  eyeball  and  orbit  of  a young  student,  aged  19,  and 
of  delicate  make,  that  the  eye  was  immediately  pushed 
out  of  its  socket,  and  on  Beer’s  arrival  it  lay  with  the 
cornea  quite  against  the  nose.  Its  very  position  led 
Beer  to  suspect,  that  some  extraneous  body  was  lodged 
in  the  orbit;  and  nolwitlistanding  the  assurances  of  all 
the  bystanders  to  the  contrary,  and  the  patient’s  being 
aflected  with  violent  spasms,  the  part  was  examined 
with  a fine  flexible  whalebone  probe,  by  which  means 
a piece  of  the  pipe,  nearly  an  inch  in  length,  was  felt, 
and  iinmediately  extracted  with  a pair  of  forceps. 
Scarcely  had  this  substance  been  removed,  when  the 
eyeball  was  spontaneously  drawn  back  into  the  orbit, 
though  with  The  cornea  still  lui;ned  towards  the  nose, 
and  the  twiicliings  of  the  muscles  also  instantly  ceased : 
but  the  eye  was  blind,  and  had  but  a very  faint  percep- 
tion of  light.  By  very  careful  treatment,  the  eyesight 
was  restored  in  five  weeks  ; but  the  eye  could  not  turn 
towards  the  temple,  owing  to  the  considerable  injury, 
which  the  external  straight  muscle  liad  sustained. 
With  the  aid  of  electricity,  the  power  of  rotating  the 
eye  about  half  its  natural  extent  outwards  was  in  the 
end  regained,  and  the  remaining  infirmity  resisted  every 
method  deemed  worthy  of  trial. — {Beer,  b.  1,  p.  146. 
See  Exophthalniia.) 

Fragments  of  broken  instruments  are  not  the  only 
kind  of  extraneous  substances  which  may  lodge  in  the 
Wounded  eye  : for,  as  Beer  ob.^erves,  when  the  injury 
is  extensive,  contused,  and  lacerated,  there  may  be 
splinters  of  bone,  or  pieces  of  membrane,  cellularsub- 
sianca,  muscle,  &c.  so  detached  as  to  be  quite  incapable 
of  reunion;  on  which  account,  this  author  sets  them 
down  as  foreign  bodies  requiring  to  be  taken  away. 
However,  I conceive  that  with  respect  to  the  soft 
parts,  the  advice  here  delivered  should  be  received  with 
much  limitation. 

Wounds  of  ilie  eye,  like  those  of  most  other  parts  of 
tliebody,  may  be  healed  either  by  direct  union,  or  a 
slower  process,  in  which  suppuration,  the  filling  up  of  the 
chasm  by  granulations,  and  the  gradual,  but  not  com- 
plete, approximation  of  its  edges  to  each  other,  are  the 
most  conspicuous  effects.  Clean  incised  wounds  may 
be  cured  in  the  first  way  (see  Cataract)  ; and  lacerated, 
contusi'd  wounds,  or  such  as  are  attended  with  loss  of 
substance,  in  the  second.  But  whichever  plan  be  at- 
tempted, the  eye  must  be  kept  quiet,  and  excluded  from 
the  air  and  light,  vvitii  a light  suitable  bandage.  As  in 
wounds  and  chemical  injuries  of  the  eyeball  itself,  not 
admitting  of  reunion,  the  eyelids,  \\  ben  closed,  com- 
pletely cover  the  wounded  part,  the  application  of  dress- 
ings to  it  becomes  both  unnecessary  and  impracticable, 
and  all  that  can  be  done  is  to  drop  frequently  into  the 
eye  a mucilaginous  collyrinm,  and  cover  the  organ  with 
a light  bandage,  which  will  not  make  any  hurtful  pres- 
sure. In  simple  contusions  of  the  eye,  unaccompanied 
with  wound.  Beer  deems  a bandage  the  only  requisite 
applicatic'i ; but  when  these  accidents  arc  conjoined 
with  eifnsions  of  blood,  he  recommends  the  use  of 
spiiitnons  aromatic  fomentations,  with  the  view  of 
promoting  absorption. 

In  healthy  individuals,  small  ptmctnres  of  the  eye, 
made  with  inslrnmenls  like  needles,  and  perf  »raiing 
only  the  conjunctiva,  or  cornea,  but  not  reaching  the 
deeper  textures  of  the  organ,  are  generally  followed  by 
no  serious  consequences,  even  when  all  the  aqueous 
hnnionr  is  voided.  It  is  only  necessary  to  keep  the  eye 
quiet,  and  the  air  and  light  excluded  from  it  by  means 


OPHTHALMY. 


221 


of  a light  compress,  suspended  over  it  from  the  fore- 
head. Under  this  treatment,  such  punctures  are  so 
firmly  closed  in  twenty-limr  hours,  without  any  opa 
city,  that  the  chambers  are  nearly  filled  auain  with 
aqueous  humour,  and  the  intolerance  of  light,  which 
was  only  the  effect  of  the  loss  of  that  fluid,  is  entirely 
removed. 

In  large  clean  cut  wounds  of  the  eye,  whether  acci- 
dental or  made  in  the  extraction  of  the  cataract,  the 
prognosis  must  be  very  cautious,  and  the  treaiment 
conducted  with  the  utmost  care  ; for,  says  Beer,  it  too 
^padily  happens,  that  though  the  wound  is  not  im- 
portant in  itself,  its  effects  become  from  the  least  mis- 
management highly  dangerous  to  the  eye.  Hence, 
when  the  patient  is  known  to  be  either  an  individual 
not  likely  to  take  proper  care  of  himself,  or  one  ton 
much  alarmed  about  the  fate  of  his  vye,  the  prognosis 
should  be  very  guaided,  even  where  the  constitution  is 
of  the  best  description,  because  a violent  and  d.inger- 
ous  attack  of  ophthalmy  is  apt  to  ensue,  and  destroy 
the  eye  sooner  than  effectual  succour  can  be  adtoinis- 
tered.  On  the  other  hand,  when  the  patient  is  steady 
and  intelligent,  and  the  case  is  properly  tieated,  the 
prognosis  is  very  favourable. 

In  considerable  cuts  of  the  eye,  it  is  only  possible  to 
promote  their  union  with  a suitable  bandage,  and  by 
effectually  preventing  all  motion  of  the  eye  and  eye- 
lids, which  is  best  accomplished  when  the  sound  as 
well  as  the  injured  eye  is  covered,  and  the  patient  kept 
quiet  in  bed  until  tlte  sides  of  the  wound  have  grown 
together.— (Beer,  b.  1,  p.  164.) 

As  cases  of  deeply-penetrating  wounds  of  the  eyeball 
itself.  Beer  enumerates  the  punctures  made  in  the  de- 
pression and  reclination  of  the  cataract,  and  in  every 
mode  of  forming  artificial  pupils;  lacerations  of  the 
conjunctiva  w'ith  ears  of  corn,  pointed  pieces  of  iron, 
splinters  of  wood,  &c.  In  these  cases,  the  prognosis, 
he  says,  is  always  very  favourable,  wlien  the  patient 
can  put  himself  under  all  the  conditions  which  the  treat- 
ment requires,  and  his  constitution  is  good.  The  first 
thing  here  to  be  carefully  fulfilled  is,  the  removal  of 
any  fragments  of  the  instrument  or  body  with  which 
the  injury  has  been  inflicted;  and  it  should  be  recol- 
lected, that  in  these  cases,  minute  splinters,  which  are 
scarcely  discernible,  frequently  lodgein  the  conjunctiva, 
and,  if  not  immediately  traced  and  removed,  produce 
the  very  worst  consequences.  By  the  weapon  being 
suddetdy  withdiavvn,  pieces  of  the  conjunctiva  are 
sometimes  nearly  torn  away,  and  hang  from  the  eye  ; 
these  Beer  directs  to  be  cut  off  with  scissors.  The  best 
applications,  he  says,  are  either  lukewarm  mucilagi- 
nous lotions,  or  (when  blood  is  effused  under  the  con- 
junctiva; vinous  spirituous  collyria.  To  these  cases, 
he  thinks  fomentations  scaicely  applicable.  When  the 
quantity  of  blood  effused  in  the  loose  cellular  texture 
under  the  conjunctiva  is  very  considerable,  he  recom- 
mends scarifications ; but  where  this  practice  does  not 
seem  likely  to  answer,  and  vinous  spirituous  collyria 
are  ineffectual,  some  of  the  liquor  ammonisE  should  be 
added  to  them.  When  atiy  fiagmentof  the  instrument 
has  been  overlooked,  and  remains  in  the  part,  either  a 
copious  suppuration  ensues,  and  the  fragment  is  at 
length  detached,  or  else  in  a patient  of  inferior  sensibi- 
lity, a .soft,  spongy,  readily  bleeding,  pale-red  excres- 
cence is  formed  ail  round  the  extraneous  body,  and 
sometimes  even  projects  between  the  eyelids.  Here, 
according  to  Beer,  the  first  requisite  step  is  to  cut  away 
the  fungus  w'ilh  a knife,  so  as  to  reach  the  irritating 
fragment  under  it,  and  then  the  rest  of  the  excrescence 
may  be  removed  by  touching  it  with  the  tinctura  the- 
baica,  or  vinous  tincture  of  opium. 

With  respect  to  lacerated  wounds  of  the  cornea, 
they  either  penetrate  the  anterior  chamber,  or  not- 
They  are  all  of  them  attended  with  more  or  less  con- 
cussion, laceration,  stretcliinL',  and  partial  contusion, 
of  the  delicate  anterior  textures  of  the  eyeball;  a con- 
sidi-ration,  as  Beer  observes,  materially  affecting  the 
proeuosis.  When  in  such  injuries  of  the  cornea  in- 
fl.immation  and  suppuration  cannot  be  prevented,  or 
the  discharge  is  protracted,  an  obvious  scar  is  always 
the  consequence,  which,  when  situated  in  the  centre  of 
the  cornea,  is  a serious  impediment  to  vision.  F-very 
endeavour  should  therefore  be  made  to  unite  the  wound 
bv  the  first  intention;  and  the  best  chance  will  be 
anorded  by  treating  the  eye  precisely  in  the  same  man 
ner  ns  after  the  extraction  of  the  cataract. — (See  Cata- 
ract.) And  when  the  plan  fortunately  succeeds,  the 


flow  of  the  aqueous  humour  out  of  the  eye  censes  in 
about  36  or  48  hours,  and  the  anterior  chamber  becomes 
distended  again;  but  the  site  of  the  injury  coutiuues 
visible  for  some  time  afterward.  The  sfieck,  however, 
ultimately  disappears,  though  much  sooner  in  young, 
healthy  subjects,  than  in  the  aged  and  feeble.  Wbeii 
the  opacity  does  not  go  off  of  itself.  Beer  finds  a colly- 
rium,  containing  some  of  the  lapis  divinus  (see  La- 
chrymal  Organs).,  and  the  vinous  tincture  of  opium, 
the  most  ett'ectual  means  of  disprnsing  it.  'I’lirough 
large  wounds,  penetrating  the  cornea  near  its  edge,  a 
fold  of  ihe  iris  is  apt  to  protrude,  and  when  it  diies,  it 
should  be  replaced,  which  can  only  be  effected  without 
mischiet  to  the  eye  by  gently  rubbing  the  upper  eyelid, 
and  then  letting  a strong  light  suddenly  strike  the  organ. 
In  this  case,  the  employment  of  instruments  is  con- 
sideied  by  Beer  highly  objectionable.  When  Ihe  iris  is 
not  iininediaiely  reduced,  it,  as  well  as  the  cornea,  is 
attacked  with  inflammation,  and  soon  beconie.s  firmly 
adherent  to  the  edges  of  the  wound. — (See  Iris,  Pro- 
lapsus of  the.) 

Large  wounds  penetrating  the  eyeball,  and  reaching 
the  iiis,  are  always  of  a very  serious  natuie,  even 
though  the  latter  part  may  have  received  only  a puck, 
or  cut,  because  as  the  injury  has  been  produced  by  ac- 
cident, and  not  by  art,  the  wound  of  the  iris  cannot  be 
free  from  all  laceration  and  contusion.  It  is  incredible, 
says  Beer,  what  extensive  injuries  the  iris  will  bear  in 
healthy  individuals  at  its  pupillary  and  ciliary  edges, 
esjiecielly  when  produced  by  very  sharp  instruments  ; 
nay,  rents  may  happen  at  both  its  edges,  without  any 
ill  consequences,  if  the  constitution  be  favourable:  a 
proof  of  which  fact  is  seen  in  the  tw  o common  me- 
thods of  forming  an  artificial  pupil,  viz.  the  excision  of 
a piece  of  the  iris,  and  the  detachment  of  the  iris  from 
the  ciliary  ligament,  as  practised  both  by  Sebmidt  and 
Scarpa.  But,  according  to  Beer,  all  violent  pressure,  or 
actual  contusion,  particularly  w’hen  it  aflecisthe  poition 
of  this  organ  between  its  two  circles,  cannot  be  borne 
even  in  the  best  constitutions,  and  the  least  grievous 
consequence  is  inflammation,  soon  followed  by  a par- 
tial, or  complete  closure  of  the  pupil,  or  suppuiation  in 
the  eyeball.  When  the  instrument  causing  such  in- 
jury passes  to  the  iris  through  the  cornea,  as  is  mostly 
the  case,  and  the  wound  in  the  latter  tunic  is  extensive, 
the  torn  iris  is  frequently  pulled  between  the  edges  of 
the  wound,  at  the  moment  when  the  weapon  is  with- 
drawn!, and  protrudes  in  a lacerated  state.  In  this 
case.  Beer  recommends  the  torn  projecting  piece  of  the 
iris  to  be  cut  away  with  scissors  close  to  ihe  wound  in 
the  cornea,  when  the  rest,  he  says,  is  generally  retracted 
within  the  eye.  Thus,  an  adhesion  of  the  iris  to  the 
cornea,  termed  synechia  anterior,  may  often  be  pre- 
vented, which,  when  the  lacerated  iris  is  suffered  to 
hang  out  of  the  cornea,  is  inevitable,  surrounded  by  a 
large  opaque  cicatrix. 

Some  violent  blows  on  the  eye,  though  they  cause  no 
wound,  are  attended  with  such  a concussion  of  the  an- 
terior hemisphere  of  the  organ,  that  more  or  less  of  the 
iris  is  instantaneously  separated  from  the  part  of  the 
ciliary  ligament  where  the  force  is  most  vehement. 
The  consequence  of  this  accident  is  either  a double 
pupil,  or  the  natural  pupil  closes,  and  the  artificial  one 
remaitis  open.  Such  injuries  may  be  pioduced  by  the 
lash  of  a whip,  or  a horse’s  tail  (a  common  accident 
in  the  narrow  streets  of  Vienna),  or  ihe  thrust  of  any 
bluntish  weapon  against  the  outer  part  of  the  cor- 
nea ; and  they  are  purposely  inflicted  in  the  method 
of  forming  an  artificial  pupil,  recommended  both  by 
Schtnidt  and  Scarpa. 

Wounds  which  enter  the  eye  through  the  sclerotica 
near  the  cornea  usually  (iroduce  a considerable  effu- 
sion of  blood  in  the  chambers  of  the  aqueous  humour  ; 
but  Beer  thinks,  that  there  is  never  any  necessity  for 
making  an  opening  for  its  discharge  at  the  lower  part 
of  the  cornea,  except  when  it  is  so  considerable  as 
completely  to  hide  the  iris,  at  the  same  time  that  the 
eyeball  is  aflected  with  very  painful  tension  and 
hardness.  In  all  wounds  of  tire  iris  it  is  likewise  prrqier 
to  follow  Ihe  same  treatment  as  applies  to  peneiraiing 
wounds  of  the  cornea,  with  this  difference,  thai  when 
the  effusion  of  blood  in  the  chambers  ot  Ihe  eye  is  con- 
siderable, the  action  of  Ihe  absorbents  should  be  jiro- 
moied  by  Ihe  immediate  emidoyment  of  vinous  aro- 
malic  collyria,  and  afterw'ard  warm  spirituous  lotions. 

Wounds  of  the  eyeball  affecting  the  corpus  ciliare 
are  set  down  by  Beer  as  extremely  dangerous,  inde- 


222 


OPHTHALMY. 


pendently  of  the  inflammation  which  quickly  follows. 
However,  such  injuries  are  most  serious  when  they 
con>ist  ill  a real  contusion  or  laceration  of  the  corpus 
ciliare,  wliicli  can  hardly  take  place  without  a seveie 
concussion  or  actual  disorganization  of  the  retina,  and 
laceration  of  the  principal  ciliary  nerves  and  vessels. 
Hence,  besides  an  effusion  of  blood  in  the  chambers  of 
the  aqueous  humour,  a partial  or  complete  amaurotic 
bliirdness  is  instantly  produced,  and  the  iris  in  the 
vicinity  of  the  place  where  the  instrument  entered  is 
so  retracted  towards  the  margin  of  the  cornea,  that 
neither  of  its  circles  can  beseem  In  cases  of  this  de- 
scription, it  also  frequently  happens,  says  Beer,  tha 
the  patient,  or  the  person  who  inflicted  the  wound, 
suddenly  and  roughly  pulls  the  weapon  out  of  the  eye 
again,  and  together  with  it  a part  of  the  corpus  ciliare, 
which  is  then  to  be  regarded  as  an  extraneous  sub- 
stance, and  immediately  cut  off.  With  respect  to  the 
prognosis  and  treatment,  the  observations  already  made 
on  these  topics  in  reference  to  wounds  of  the  his  are 
here  quite  applicable;  excepting  that,  as  the  effused 
blood  is  less  copious  than  in  the  latter  cases,  there  can 
never  be  here  any  necessity  for  letting  it  out  by  a de- 
pending opening  in  the  cornea. 

Wounds  of  the  eye  affecting  the  crystalline  lens  are 
not  unfrequently  followed  by  the  formation  of  a cata- 
ract, and  so  are  blows  on  the  eye,  which  may  be  sup- 
posed to  produce  this  effect  by  destroying  some  of  the 
minute  nutrient  vessels  naturally  connecting  the  cap 
sule  with  the  lens. — (ficer,  b.  1,  p.  218.  Tift:  treat- 
ment of  these  accidents  resembles  that  of  injuries  of 
the  iris,  except  that  the  surgeon  has  rarely  any  extrava- 
sation nf  blood  to  deal  with.  However,  when  the  lens 
has  slipped  into  the  anterior  chamber.  Beer  recom- 
mends its  immediate  extraction  through  an  incision  in 
the  cornea,  in  order  to  prevent  the  eye  from  being  de- 
stroyed by  a violent  attack  of  traumatic  inflainniation 
and  suppuration.  Nor  witen  inflammation  has  come 
on  should  this  measure  be  postponed,  as  Beer  has  con- 
stantly found  the  disorder  lessen  after  the  lens  has  been 
taken  out. 

Considerable  wounds  of  the  eye,  attended  with  loss 
of  the  vitreous  humour,  are  described  by  Beer  as  of  a 
very  serious  nature ; but  they  rarely  take  place  acci- 
dentally, being  almost  always  the  consequence  of  a 
surgical  operation.  Accidental  injuries  of  this  kind 
are  generally  combined  with  so  large  or  complete  a 
discharge  of  the  vitreous  humour,  and  with  such  mis- 
chief to  the  organization  of  the  eye,  that  the  conse- 
quence is  a loss  of  the  eyeball,  or  such  a dwindling 
of  it,  that  the  fissure  of  the  eyelids  becomes  nearly- 
closed.  According  to  Beer’s  experience,  injuries  of  the 
foregoing  kind,  arising  from  accident,  are  mostly  pro- 
duced by  the  horns  of  cows.  On  the  contrary,  lire 
effusion  of  the  vitreous  humour  in  operations  upon 
the  eye,  he  observes,  is  .seldom  followed  by  the  loss  of 
vision.  Kortum,  in  his  Manual  on  the  Diseases  of  the 
Eye,  adverts  to  some  instances  which  he  had  seen,  or 
fancies  that  he  had  seen,  where  the  whole  of  the  vi- 
treous humour  was  losU  and  yet  the  eyesight  afterward 
became  as  strong  as  if  no  such  accident  had  happened. 
On  the  other  hand.  Beer  never  met  with  any  of  these 
forlunate  cases  ; but  always  found  the  sight  seriously 
impaired  when  the  quantity  of  vitreous  humour  lost 
amounted  to  nearly  its  half,  and  complete  blindness 
the  result  when  the  loss  much  exceeded  ilrat  quantity. 
He  conceives  also,  that  Kortum  had  probably  oeen  but 
few  cases  of  this  nature,  and  therefore  might  have  been 
mistaken  as  lo  the  proportion  of  the  vitreous  humour 
discharged,  which  to  the  inexperienced  seems  larger 
than  it  really  is,  and  he  cautions  surgeons  not  lo  pro- 
mi.se  too  much  in  cases  of  this  description. — {B.  1,  p. 
222.  See  Cataract.) 

Considerable  injurlesof  the  eyeball,  complicated  with 
a concussion,  bruise,  or  actual  wound  of  the  retina, 
produce  either  gradually  or  immediately  an  amaurosis, 
which  is  almost  always  incurable.  When  the  concus- 
sion of  the  retina  is  less  violent,  and  does  not  affect 
every  part  of  this  texture,  it  may  occasion  only  an 
amaurotic  weakness  of  sight.  In  worse  cases  the  sur- 
geon may  think  himself  very  successful,  if  he  can  pre- 
vent the  figure  of  the  eye  from  being  destroyed  by  the 
subsequent  inflammation,  all  idea  of  the  recovery  of 
the  eyesight  being  out  of  the  question.  The  treatment 
is  the  same  as  that  commonly  adopted  after  operations 
for  the  removal  of  an  opaque  lens  (see  Cataract)-, 
but  there  is  one  particular  circumstance  sometimes  at-. 


tending  injuries  of  the  retina  and  ciliary  nerves  claim- 
ing notice,  VIZ.  violent  vomiting;  a sjinptoin  wliii  li 
Beei  says  may  even  attend  contusions  ol  the  sclemtica 
and  of  the  ciliary  nerves  and  retina,  w ithout  any 
wound.  Injuries  of  the  ciliary  neives,  he  ob.-erves, 
aie denoted  by  a very  peculiar  appearance ; for,  near  the 
mjuied  iiart,  the  ins  is  drawn  up  so  close  to  the  edge  of 
the  cornea,  that  its  colour  can  scarcely  be  seen.  VVherr 
the  suigeoii  is  consulted  in  a case  of  this  kind,  though 
some  inflammation  may  have  commenced,  the  progno- 
sis is  yet  favourable  in  regard  tothe  preservation  ol  thc- 
eye  ; for  a gentle  opiate  will  relieve  the  vomiting 
when  merely  a nervous  effect,  not  depending  upon  the 
loaded  stale  of  the  gastric  organs;  but  if  the  case  be  of 
this  last  description,  the  primae  viat  should  first  be  emp- 
tied. However,  when  a traumatic  infiainmation  is 
completely  established  before  the  treatment  is  begun,  the 
eye  is  generally  destroyed,  as  the  repeated  and  violent 
vomitings  cause  a great  determination  of  blood  to  the 
head  and  eyes,  and  increase  of  the  inflammation ; an 
eftect  which  the  opiates  given  for  the  relief  of  the  vomit- 
ing also  tend  to  produce. 

Beer  has  seen  two  cases  in  which  the  eye  was  pi  icked 
with  a needle  near  the  insertion  of  the  external  sn  aight 
muscle  into  the  sclerotica  : in  both  insiances  the  punc- 
tures were  so  small,  that  they  would  scarcely  have  been 
found,  had  not  the  patients  known  their  situation  ex- 
actly by  the  pain,  and  they  were  then  only  perceptible 
with  a magiiifying-glass.  The  punctures  were  soon 
followed  by  a convulsive  rolling  of  the  eyeball,  and 
afterward  by  trismus,  which  continued  severe  in  one 
patient  a day  and  a half,  and  in  another  two  days,  but 
yielded  to  large  doses  of  musk  and  opium  given  at  short 
intervals,  the  w’aim  bath,  and  the  application  of  warm 
poultices  cmitaining  hyosciamus. 

As  chemical  injuiiesof  the  eye  produce  an  actual 
loss  of  substance,  they  are  even  more  serious  than  com- 
mon mechanical  leskms.  However,  chemical  injuries 
of  little  extent  are  generaJiy  repaired  with  tolerable 
facility, and  expedition.  Quietude  of  the  organ,  and 
moderating  the  outward  noxious  effects  by  lukew'arm 
mucilaginousapplications,  either  in  the  form  of  fomenl- 
ations  or  eye-waters,  are  the  only  requisite  measures. 
If  the  cornea  itself  be  hurt,  as  frequently  happens 
when  boiling-hot  fluids  strike  the  eye,  a kind  of  vesicle 
appears  on  the  injured  part,  whicli  becomes  more  and 
more  white.  The  vesicle  either  bursts  of  iuself,  or  sub- 
sides without  breaking.  In  birth  cases  the  production 
of  the  conjunctiva,  of  which  the  cyst  of  tire  vesicle  is 
composed,  shrivels  up  and  peels  off,  a new  membrane 
of  a similar  nature  being  regenerated  underneath.  An 
opaque  speck  is  frequently  apprehended;  but,  says 
Beer,  if  the  surgeon  w ill  merely  avoid  being  too  much 
in  a hurry  to  open  the  vesicle,  and  not  disturb  the  work 
of  nature  by  applying  various  remedies  to  the  eye, 
there  will  be  no  danger  of  such  an  occurrence. 

More  extensive  chemical  injuries  of  the  eye,  which 
at  first  are  not  in  themselves  very  severe,  frequently 
become  dangerous,  in  consequence  of  care  not  beinir 
taken  to  prevent  the  influence  of  external  stimuli.  To 
this  class  of  cases  belongs  the  accidental  sprinkling  of 
the  eye  w'iili  boiling  fluids  or  strongish  mineral  acids. 
And  even  in  these  examples,  says  Beer,  the  prognosis 
is  not  unfavourable,  and  a complete  recovery  may  be 
elfecied,  when  the  treatment  is  conducted  according  to 
the  directions  already  given  with  respect  to  such  acci- 
dents in  general.  While  this  author  approves  of  cut- 
ting away  any  substance  w'hich  is  dead  and  iiartially 
detached,  he  strongly  cautions  surgeons  not  to  remove 
the  thin  layer  of  the  conjunctiva,  nor  to  puncture  aiiv 
vesicle  which  may  form. 

When  the  burning  or  corrosion  is  not  limited  to  the 
nonjunctiva  of  the  eyeball,  but  extends  to  the  lining  of 
one  or  both  ej^elids.  Beer  recomnieiiils  covering  the  in- 
jured parts  with  mucilaginous  applications  and  mildly 
astringent  ointments,  containing  tutty  or  the  white 
oxyde  of  lead.  In  these  cases,  keeping  the  eye  per- 
fectly motionless  must  be  hurtful,  as  it  tends  to  pro- 
mote the  formation  of  adhesions  either  beiw’een  the 
eye  and  eyelids  (Symblepharon),  or  between  the  eye- 
lids themselves  (Ancliyloblcpliaron). 

Extensive  deeply-penetrating  chemical  injuries  of 
the  eyeball.  Beer  describes  as  being  almost  aiw.nys  fol- 
lowed by  more  or  less  impairment  of  the  fiinctions^f 
tile  organ,  or  of  some  of  its  particular  textures;  because 
such  accidents  never  happen  without  a loss  of  sub- 
stance. Thus  a part  or  the  wliolc  of  the  cornea  may 


OPHTHALMY. 


223 


be  entirely  destroyed,  as  in  injuries  caused  by  quick- 
lime; and  fiequeiilly  adhesions  beivveen  the  eye  and 
eyelids,  or  between  llie  two  latter  parts,  cannot  be  pre- 
vented by  any  kind  ol' skill. — {Beer.)  These  seiious 
degrees  of  mischief,  as  the  same  author  observes,  are 
mostly  occasioned  by  slaked  or  unslaked  lime,  concen- 
trated mineral  acids,  tire,  &c.  Unelaked  lime,  espe 
cially  when  extensively  diffused  over  the  eye  by  ihe 
iinmediaie  application  of  water,  not  unfrequently  pro- 
duces a sudden  destruction  of  the  whole  of  the  cornea, 
which  is  changed  into  a grayish,  pappy  substance,  ca- 
pable of  being  removed  from  the  subjacent  iris  with  a 
camel-hair  pencil.  Such  an  annihilation  of  texture, 
however,  is  generally  restricted  to  particular  points,  or 
the  surface  of  the  cornea.  Wherever  this  membrane 
has  been  so  much  decomposed,  that  a manifest  depre.s- 
sion  is  directly  perceptible  in  it,  when  inspected  side- 
ways, a snow-white  shining  speck  must  be  expected  to 
be  the  consequence.  Slaked  lime  never  operates  upon 
the  cornea  with  so  much  violence,  usually  causing  (as 
Beer  states)  only  a superficial  corrosion,  or  a coagula- 
tion of  the  lymirh  hetweeu  the  layers  of  the  cornea. 
Nor  are  mineral  acids,  even  when  concentrated,  gene- 
rail}’ so  destructive  to  the  cornea  as  quicklime;  first, 
because,  as  fluids,  they  do  not  long  remain  in  contact 
with  the  eye;  and  secondly,  because  the  immediate 
mixture  of  the  tears  with  them  weakens  their  opera- 
tion, whereas  it  only  increases  that  of  unslaked  lime. 
The  local  treatment  here  consists  in  carefully  removing 
every  particle  of  the  hurtful  substance,  afterward  drop- 
ping frequently  into  the  eye  lukewarm  mucilaginous 
decoctions  or  collyria,  or  covering  the  injured  place 
with  a mild  cerate,  and  excluding  the  air  and  light  from 
the  eye.  Every  endeavour  must  also  be  made  to  pre- 
vent the  formation  of  adhesions  between  the  injured 
surfaces. 

In  very  severe  burns  of  the  eyeball,  of  course,  all 
idea  of  restoring  its  functions  is  out  of  the  question. 
I'he  violence  of  the  injury  is  the  greater,  the  more 
numerous  the  vesicles  are  upon  the  conjunctiva,  and 
the  more  the  eyeball  and  the  iris  are  incapable  of  mo- 
tion. Here  the  only  indication  is  to  moderate  the  in- 
flammation, and  avert  such  additional  mischief  as 
might  otherwise  be  produced  by  it.  With  this  view, 
the  eye  should  be  kept  at  rest,  and  excluded  from  the 
light  and  air.  According  to  Beer,  the  most  common 
injuries  of  the  eye,  partaking  both  of  a mechanical 
and  chemical  nature,  are  those  caused  by  mortar,  or 
the  accidental  touching  the  eye  with  hot  curling-iions. 
When  the  mortar  contains  no  particles  of  quicklime,  it 
often  occasions,  at  particular  points  of  the  cornea,  very 
white  specks,  which  Beer  describes  as  being  compo.^ed 
of  coagulated  lymph,  and  admitting  of  dispersion. 
He  even  declares,  that  when  the  whole  of  the  cornea 
is  in  this  state,  its  transparency  may  be  restoied  by 
proper  treatment,  as  has  been  frequently  exemplified 
to  the  tientlemen  attending  his  clinical  lectures. — {B. 
1,  p.  234.)  The  pricking  of  the  eyeball  with  a red-hot 
needle,  and  the  stiniiing  of  it  by  bees,  wasps,  and  other 
insects,  are  also  both  chemical  and  mechanical  injuries. 
Whether  the  sling  be  left  in  the  skiti  of  the  eyelid,  or  in 
the  conjitnciiva,  or  not,  a considerable  itiflammatoiy 
swelling  immediately  takes  place;  and  if  the  sting  be 
lodged  and  not  now  taken  away,  the  infla.-nmaiion 
spreads,  and  the  eye  itself  is  endangered.  In  two  cases, 
where  the  stinirs  of  bees  were  left  in  the  skin  of  the 
npiier  eyelid,  Beer  has  known  gatigrene  arise  in  the 
short  space  of  a day  and  a half,  and  the  patients  were 
saved  with  great  difficulty.  The  treatment  of  such 
casrs  consists  in  immediately  extracting  the  sting,  if 
lodged,  and  applying  folds  of  linen  over  the  eye,  wet 
with  Cold  water. 

After  noticing  the  destructive  effects  of  burning  sub- 
stances, the  explosion  of  gunpowder,  and  fulmina- 
ting silver  on  the  eye  (cases  in  which,  when  the  func- 
tions of  the  organ  are  annihilated,  the  only  indication 
is  to  diminish  Ihe  subsequent  inflammation  and  its 
consequences).  Beer  inquires,  what  is  Ihe  reason  why 
the  slightest  mechanical  or  chemical  injuries  of  the 
eye  in  an  apparently  healthy  subject  are  sometimes 
followed  by  an  immoderate  degiee  of  inflammation, 
and  even  the  loss  of  the  organ  from  suppnrtition  ? It 
Is,  says  he,  an  observation  made  by  Schmidt  that  there 
are  some  eyes  which  the  greatest  bunglers  may  abuse 
for  hours  at  a time  without  being  spoiled,  their  power- 
ful organization  defying  all  such  unskilful  disturbance  ; 
while  other  eyes  are  tnet  with,  which  the  most  skilful 


operators  can  hardly  touch  without  inducing  a destruc- 
tive degree  of  inflammation  and  suiqnnation.  Ii  was 
to  tins  peculiar  idiosyncrasy  tliat  iSclimidt  applied  the 
term  vulnerability.  {Verwundbarkeit).  Patients  of 
this  habit  are  said  to  possess  an  e.vceedingly  line  soft 
.'kill,  with  a reddish  jiolish  upon  it:  and  their  cheeks 
are  not  only  red,  but  exhibit  a net-work  of  very  minute 
vessels,  which  seem  as  if  injected.  Such  individuals 
apiiear  as  if  they  were  in  the  bloom  of  health;  and, 
says  Beer,  in  some  respects  they  are  really  so.  When 
their  spirits  are  raised  by  the  slighiesi  causes,  their 
complexion  is  universally  reddened;  but  the  least  fear 
turns  them  as  pale  as  a corpse.  Their  skin  is  desciibed 
as  being  uncommonly  irritable,  sensible  of  every  im- 
pression, and  attacked  with  an  erysipelatous  redness 
whenever  any  fatly  substance  touches  it.  In  such 
habits,  the  utmost  caution  is  necessary  whenever  the 
eyes  have  been  injured,  and  the  prognosis  should  be 
leserved.  And  when  an  operation  is  to  be  done  on 
their  eyes,  Beer  recommends  tlie  previous  exhibi- 
tion of  opium,  and  the  application  of  a blister  to  some 
part  of  the  skin,  at  a considerable  distance  from  them. 
As  a prophylactic  measure,  he  also  directs  regular  fric- 
tion of  the  surface  of  the  body. 

In  severe  ophthalmies,  particularly  those  which  af- 
fect the  eyeball  itself,  all  mental  emotions,  anger,  joy, 
&c.  should  be  avoided.  Hence,  no  talkative  nor  quar- 
relsome persons  should  be  suffered  to  remain  with  liie 
patient ; and  noisy  children  ought  to  be  kept  away 
from  him.  The  apartment  should  be  ventilated  at 
least  once  a day,  without  the  patient  being  exposed  to 
anycurrentof  wind.  All  touching  of  the  eye,  or  rub- 
bing it  with  the  bed-clothes  during  sleep,  must  be 
strictly  prohibited.  Stimulating,  spicy  food,  spirituous 
drinks,  and  great  bodily  exercise,  are  likewise  to  be  for- 
bidden. In  the  list  of  things  which  have  a hurtful  ef- 
fect, Beer  also  includes  all  exertions  of  the  luims,  every 
kind  of  disturbance,  an  atmosphere  impregnated  with 
tobacco-smoke,  &c. 

Having  fulfilled  the  first  general  indication  by  re- 
moving, if  possible,  every  kind  of  irritation  acting 
upon  the  eye,^he  second  general  indication  specified 
by  Beer  as  proper  in  Ihe  first  stage  of  ophthalmy,  is  to 
be  observed  ; which  is,  to  moderate^  according  to  the  de- 
gree of  inflammation,  the  agency  of  several  things  to 
the  effect  of  which  the  organ  is  naturally  subjected. 
Thus  the  inflamed  eye  should  not  be  exercised,  even 
though  the  eyeball  itself  may  not  be  immediately  in- 
flamed ; and  the  operation  of  the  light  and  air  should  be 
diminished  partly  by  green  silk  eye-shades  and  partly  by 
window-blinds.  Ailention  to  this  rule  is  still  more  ne- 
cessary when  the  eyeball  itself  is  affected  With  respect 
to  the  exclusion  of  light,  it  is  to  he  well  remembered, 
that  it  is  only  advisable,  as  Dr.  Vetch  observes,  in  the 
very  early  stage  of  inflammation,  the  eye  becoming 
more  irritable  and  less  manageable,  when  the  access 
of  a moderate  deL'ree  of  light  is  afterward  prevented.- 
{On  Diseases  of  the  Eye,  p.  16.) 

The  third  general  indication  mentioned  by  Beer,  as 
proper  in  the  first  stage  of  ophthalmy,  when  the  dis- 
order threatens  to  extend  to  the  whole  organ,  and  to 
bring  on  a febrile  disturbance  of  the  system,  is  to  coun- 
teract these  effects  by  covering  the  eye  with  folded 
linen  wet  with  simple  cold  water,  or  vinegar  and 
water;  and  having  recourse  to  leeches,  or,  when  the 
nature  of  the  case  allows,  to  scarificatjoiis. — {B.  \,p. 
242.)  Here,  however,  it  merits  particular  notice,  that 
Beer,  in  expressing  a general  preference  to  cold  lotions 
in  Ihe  first  stage  of  ophthalmy  differs  from  Kichter, 
Scarpa,  and  Mr.  Travers  {Synopsis  of  the  Diseases  of 
the  Eye,  p.  250)  ; all  of  whom,  in  the  painfully  ccuie 
stage,  recommend  tepid  emollient  applications. 

With  regard  to  leeches,  the  late  Mr.  Ware  objected 
to  their  being  put  on  or  very  near  the  eyelids,  ns  they 
sometimes  cause  a considerable  swelling  of  these 
parts,  and  increase  instead  of  lessening  the  initaiion. 
Ill  ordinary  cases,  his  method  was  to  apply  three  on 
the  temple,  about  an  inch  and  a half  from  the  outer 
part  of  the  orbit.  Scarpa  recommends  applying  the 
leeches  to  the  vicinity  of  the  eyelids,  especially  about 
the  inner  canthus,  on  the  vena  angnlaris,  wh<  re  it 
joins  the  frontal,  deep  orbitar,  and  transverse  vein  of 
the  face.  Beer  prefers  nearly  the  same  situation  as 
that  specified  by  Scarpa,  viz.  the  inner  canihns,  imme- 
diately below  the  under  eyelid  ; and  he  forbids  the  ap- 
plication of  leeches  above  either  catithus,  as  likely  to 
produce  a disagreeable  ecchytnosis  in  the  cellular 


224 


OPHTHALMY, 


membrane  of  the  upper  eyelid.  The  number  of 
leeches,  and  the  lime  which  ttiey  should  be  allowed  to 
suck,  he  thinks,  ought  to  depend  upon  the  severity  of 
the  iiiflammaiioii.  According  to  Beer,  when  this  mode 
of  bleeding  is  to  be  of  any  service,  tlie  patient  will  ex- 
perience a considerable  abatement  of  the  throbbing 
pain,  tension,  &c.  in  the  affected  eye.  Hence,  when 
any  of  the  leeches  fall  off  prematurely,  the  bleeding 
from  the  bites  is  to  be  kept  up  with  a sponge  dipped  in 
warm  water,  until  such  relief  is  felt.  In  the  acute 
stage.  Beer  considers  the  abstraction  of  blood  by 
means  of  scarifications  rarely  admissible.— (B.  1,  p. 
24:1.)  By  Mr.  Lawrence  it  is  decidedly  condemned; 
and  it  is  a method  to  which  1 never  have  recourse  in 
my  own  practice.  Mr.  Travers  also  sets  dow’n  scarifi- 
cations of  the  conjunctiva  as  mostly  objectionable  in 
the  acute  stage;  though  highly  beneficial  in  the  chronic, 
where  the  lining  of  the  eyelids  is  thickened  and  over- 
vascular;  and  a considerable  discharge  of  blood  may 
be  thus  obtained,  if  the  operation  be  briskly  done  with 
a sharp  lancet,  and  the  low'er  lid  kept  everted  and  fo- 
mented. The  same  gentleman  states,  that  cupping 
has  a decided  superiority  over  leeches,  but  that  both 
are  w'ell  adapted  to  relieve  local  congestion.  Yet  he 
deems  these  metiinds  too  indirect  to  answer  as  substi- 
tutes for  the  lancet,  where  it  is  desirable  to  make  t!ie 
system  “sustain  and  feel  a reduction  of  power;”  in 
which  case  blood  must  be  taken  from  a vein  or 
the  temporal  arteij'.— (Sywopsts,  ^-c.  p.  249.)  The 
taking  away  of  blood  by  cupping  the  temples  is  con- 
sidered by  many  modern  surgeons  a very  efficacious 
plan  ; quite  as  much  so  as  that  of  opening  the  tem- 
poral artery,  the  hemorrhage  from  which  is  sometimes 
difficult  to  suppress.  While  inflammation  of  the  con- 
junctiva is  described  by  Df.  Vetch,  as  not  much  af- 
fected by  bleeding  unless  the  quantity  of  blood  taken 
away  be  such  as  to  occasion  syncope,  he  states  that 
the  abstraction  of  blood  in  quantities  proportioned  to 
the  violence  of  the  symptoms,  more  especially  by 
means  of  cupping  and  leeches,  has  for  the  most  part 
sufficient  control  over  the  various  states  and  indi- 
vidual symptoms  of  sclerotic  inflammation.  In  some 
obscure  cases  of  what  this  author  terms  amaurotic  in- 
flammation, he  has  seen  great  benefit  derived  from  the 
application  of  leeches  to  the  septum  nasi ; and  he  re- 
presents their  being  put  directly  on  the  conjunctival 
lining  of  the  eyelids,  as  being  sr.metimes  more  advan- 
tageous than  on  the  adjacent  integuments,  the  orifices 
bleeding  with  great  freedom. — (Ore  Diseases  of  the 
Eye,  p.  15.) 

The  fourth  general  indication  enumerated  by  Beer, 
is  that  which  has  for  its  objects  a diet  and  regimen 
suited  to  the  state  of  the  case  after  it  has  attained  a 
degree  in  w'hich  its  eflfects  begin  to  be  felt  througliout 
the  system.  When  therefore  the  plan  is  to  be  rigor- 
ously practised,  the  patient’s  ordinary  diet  is  to  be  re- 
duced, and  he  is  to  be  allowed  only  vegetable  food,  cool- 
ing drinks,  w’ater,  weak  lemonade,  &c.  And  not  merely 
the  eye  itself  is  to  be  kept  at  rest,  but  the  whole  body. 

Should  the  disorder  be  farther  advanced,  and  at- 
tended with  a great  deal  of  inflammatory  fever,  the 
observance  of  the  foregoing  indications  will  not  suffice 
for  checking  the  inflammation  and  preventing  suppu- 
ration, unless  the  fifth  indication  laid  down  by  Beer  be 
fulfilled  ; which  is,  to  employ  such  remedies  as  operate 
upon  the  whole  constitution.  1.  Purgative  and  gently 
aperient  medicines,  which  will  empty  the  bowels  well, 
and  lessen  the  determination  of  blood  to  the  head  and 
eyes.  2.  Clysters,  which  are  useful  on  the  same  prin- 
ciples. 3 The  frequent  exhibition  of  the  niiras  po- 
tassae.  4.  General  bleeding,  the  efficacy  of  which  will 
much  depend  upon  the  blood  being  voided  in  a full 
stream.  Beer  seems  to  prefer  opening  a vein  on  the 
foot;  but  in  England  the  most  experienced  practi- 
tioners generally  open  a vein  in  the  arm,  and  some- 
titnes  the  temporal  artery.  The  blood,  as  Beer  re- 
marks, should  be  allowed  to  flow  until  the  hard  small 
pulse  rises  and  becomes  plainly  softer ; for  otherwise 
the  operation  will  be  completely  useless.  Also,  when 
in  lhe.se  cases  general  bleeding  is  no  longer  indicated, 
the  employment  of  leeches  will  yet  be  advantageous, 
and  afterward  scarifications  may  be  practised,  which, 
at  an  earlier  period,  would  have  aggravated  all  the  in- 
flammatory symi>toms. 

Respecting  the  prognosis  and  indications  in  the  se- 
cond stage  of  ophthalmy,  Beer  offers  many  interesting 
remarks.  He  observes,  tliat  when  ophthalmy  has 


reached  its  second  stage,  wlitcli  may  be  known  by  cir- 
cumstances already  referred  to  in  the  preceding  co- 
lumns, it  must  be  clear  that  the  above  indications  are 
no  longer  valid,  and  the  lultilment  of  them  would  de- 
stroy the  eye. 

In  the  second  stage,  every  tiling  which  has  a ten- 
dency to  pioduce  farther  weakne.*s  of  the  eye  must  he 
avoided,  or  suppuration  will  be  the  consequence  ; the 
first  indication,  therelbre,  specified  by  Beer,  is  to  let 
the  eye  be  cautiously  exposed,  according  as  its  ten- 
dency will  allow,  toils  wonted  stimuli  ogam.  1.  By 
letting  fresh,  dry,  and,  if  possible,  a warmish  air  have 
free  access  to  the  organ.  2.  By  exposing  the  eye  to  as 
much  light  (not  of  a reflected  description)  as  can  be 
borne,  not  only  w'ithout  difficulty  but  with  pleasure.  3. 
By  moderately  exercising  the  organ,  especially  in  the 
inspection  of  agreeable^  diversified  objects ; a plan 
which  is  of  infinite  service,  when  the  eyeball  itself  has 
been  affected. 

The  second  indication  proposed  by  Beer  in  the  se- 
cond stage  of  ophthalmy  in  general,  is  10  apply  tonic 
remedies,  particularly  those  of  a volatile  kind,  to  the 
eye,  which  are  to  be  discontinued  in  the  event  of  sup- 
puration. 1.  Beer  praises  the  application  of  well- 
warmed  linen  compresses,  which,  if  necessary,  may  be 
sprinkled  with  camiihor  ; or  in  urgentcases  he  uses  little 
bagsofaromatic  herbs  and  camphor;  a practice  in  which 
I am  di.-^posed  to  think  surgeons  here  w ill  have  little  or 
no  confidence.  2.  However,  w’hen  the  eye  is  too  irritable 
to  bear  the  application  of  bags  of  aromatic  substances, 
Beer  sanctions  the  employment  of  poultices  made  of 
bread-crumb  and  warm  herbs,  or  the  pulp  of  a roasted 
apple.  But  this  experienced  author  is  very  particular 
in  qualifying  his  approbation  of  moist  applications 
with  a caution,  that  they  must  never  be  allowed  to  be- 
come completely  cold  on  the  eye,  whereby  they  would 
do  tnore  harm  in  a quarter  of  an  hour,  than  any  good 
w'hich  may  have  been  attained  in  many  hours  by  their 
previous  use.  Hence,  Beer  employs  poultices  only  in 
cases  of  necessity.  In  this  country,  “ when  the  ex- 
treme vascular  congestion  and  excessive  sensibility  are 
reduced,  and  the  inflammation  tends  to  become  chro- 
nic, the  use  of  cold  lotions,  of  a slightly  tonic  quality, 
is  substituted  with  great  advantage  for  ablutions  of 
warm  water.  The  sulphates  of  alum  and  zinc  are  the 
best.”— ( Travers,  Synopsis,  iS'c.  p.  252.)  The  employ- 
ment of  astringents  also  agrees  with  the  advice  de- 
livered by  Richter  and  Scarpa.  Here  then  we  find  a 
point  on  which  Beet  differs  from  the  generality  of  w ri- 
ters ; but  nothing  is  clearer  to  me  than  that  his  alarm 
about  the  ill  effect  of  cold  upon  the  eye  in  the  second 
stage  of  ophthalmy,  is  only  the  fruit  of  some  theories 
W'hich  he  entertains,  and  not  of  impartial  experience. 
3.  Wlien  there  are  small  ulcers  or  pustules  on  the  eye- 
ball itself,  Beer  assures  us,  that  great  benefit  is  derived 
from  dropping  between  it  and  the  eyelids  a tepid  solu- 
tion of  the  lapis  divinus,  the  composition  of  which  is  else- 
where described  (see  Lachrymal  Organs),  and  bathing 
the  eye  with  the  same  application,  to  which  a little  of  the 
vinous  tincture  of  opium  is  added.  Should  this  re- 
medy fail  in  checking  the  progress  of  t]ie  ulcers  or  pus- 
tules, Beer  recommends  the  addition  of  acetate  of 
lead.  4.  And,  says  the  .eame  author,  when  no  decided 
amendment  is  produced  within  twenty-four  horn  s,  the 
suppurating  points  must  be  touched  once  or  twice  a 
day,  according  to  the  urgency  of  the  danger,  with  a 
camel-hair  pencil,  dipped  either  in  a watery  solution 
of  opium,  or  the  vinous  tincture  of  opium.  In  the 
worst  rases,  he  even  directs  Hoffman’s  balsam,  naphtha, 
or  the  Peruvian  balsam  to  be  mixed  w-iih  the  latter  a(>- 
plication. 

But  Beer  observes,  that  when  these  remedies  have 
been  too  precipitately  employed,  and  any  granulations 
or  excrescences  form,  the  treatment  must  be  less  active, 
and  then  these  new  productions  will  frequently  recede 
of  themselves:  but  if  they  should  not  do  so,  they  may 
be  removed  with  burnt  alum  or  caustic.— (5.  1,  p.252.) 

The  third  rule  laid  down  by  Beer  in  the  treatment  of 
the  second  stage  of  ophthalmy,  CMitvins  the  practitioner 
not  to  apply  the  caustic  or  the  knife  to  any  of  the  mor- 
bid changes,  which  either  originate  during  the  first 
stage,  and  continue  in  the  second,  or  make  their  first 
ap:iearance  at  the  period  of  suppuration,  as,  for  in- 
stance, opacities  of  the  cornea,  eversion  of  one  or  both 
eyelids,  &c.  How'ever,  as  exceptions  to  this  advice, 
Beer  adverts  to  the  treatment  of  new  growths  under 
the  circumstances  above  specified,  and  to  that  of  ab- 


OPHTHALMY. 


225 


Bcesses  of  the  eyeball,  where  the  matter  is  of  an  un- 
healthy quality  and  so  copious  as  to  make  an  opening 
advisable,  which  practice,  however,  as  a general  one, 
he  condemns.  Tlie  other  morbid  changes,  already 
alluded  to,  the  practitioner  must  endeavour  to  remove 
simply  by  proper  treatment  of  the  second  stage.— 
(jBee?-,  b.  1,  p.  254.) 

Beer’s  fourth  rule  in  the  treatment  of  the  second 
stage  of  ophthulmy  in  general,  and  of  idiopathic  oph- 
Ihalmy  in  particular,  when  the  suppurative  process  is 
extending  itself  and  threatening  to  impair  the  health, 
is,  1st.  To  allow  the  patient  such  food  as 4s  both  easy 
of  digestion,  and  of  a very  nutritious  quality,  and 
even  a moderate  quantity  of  wine  and  spirituous 
drinks,  if  he  has  been  accustomed  to  them.  2dly.  To 
direct  the  patient  to  keep  his  eye  exposed  the  greater 
part  of  the  day,  in  a fresh,  dry,  and  (if  possible)  mild 
air,  and  take  just  exercise  enough  in  various  ways  to 
produce  a slight  degree  of  fatigue.  3dly.  When  the 
eye  itself  is  affected  with  suppuration,  and  the  sight  is 
either  thereby  much  impaired  or  quite  lost,  and,  of 
course,  the  patient  very  unhappy  and  depressed,  Beer 
considers  it  higly  beneficial  to  let  his  spirits  be  im- 
proved by  society. 

The  fifth  rule  or  general  indication  in  the  second 
stage  laid  down  by  Beer,  refers  to  the  necessity  of 
sup^portitig  the  constitution  when  the  suppurative  pro- 
cess is  attended  with  a general  febrile  disturbance. 
For  this  purpose,  he  recommends,  1st.  The  exhibition 
ofcalamusaromaticus,  naphtha,  and  camphor.  2dly.  If 
they  prove  ineffectual  alone,  they  are  to  be  Joined  with 
other  tonics,  especially  bark.  3dly.  The  warm  bath, 
which,  in  consequence  of  the  sympathy  between  the 
skin  and  eyes,  is  particularly  efficacious.  4thly.  Ru- 
befacients applied  not  far  from  the  eye. — {B.  1,  p.257.) 

As  an  appendix  to  these  general  remarks,  delivered 
by  Beer,  on  the  general  treatment  of  ophthalmy  in  its 
first  and  second  stages,  I annex  the  sentiments  of  some 
other  writers,  as  either  confirming  or  rendering  ques- 
tionable some  of  his  statements. 

• According  to  Scarpa,  when  bleeding  and  other  eva- 
cuations have  been  practised,  the  next  most  useful 
measure  is  the  application  of  a blister  to  the  nape  of 
the  neck.  He  observes,  that  the  skin  here  and  behind 
the  ears  has  a stronger  sympathy  with  the  eyes  than 
any  other  part  of  the  integuments.  "On  the  other  hand, 
the  late  Mr.  Ware  preferred  blistering  the  temples,  and 
says,  “When  the  leeches  have  fallen  off",  and  the  con- 
sequent hemorrhage  has  ceased,  I would  advise  a 
blister  of  the  size  of  half  a crown  to  be  applied  on  the 
temples,  directly  over  the  orifices  made  by  the  leeches ; 
and  I have  found,  that  the  sooner  the  blister  has  fol- 
lowed the  bleeding,  the  more  efficacious  both  have 
proved."  He  adds,  that  when  ophthalmy  is  very  vio-. 
lent,  and  resists  common  methods,  the  most  beneficial 
effects  are  sometintes  produced  by  the  application  of  a 
blister  large  enough  to  cover  the  whole  head.— 
(P.  43,  44.) 

With  respect  to  blisters,  another  modern  writer  par- 
ticularly objects  to  their  being  applied  near  the  eye,  or 
on  the  temples,  “ where  they  never  fail  to  prove  in- 
jurious.” There  is  (says  he)  “ but  one  exception  to 
this  as  a general  rule ; for  it  would  seem,  that  blisters 
applied  to  the  external  surface  of  fhe  palpebrje,  in  cases 
of  purulent  ophthalmia,  tend  considerably  to  diminish 
the  purulency  and  chemosis.” — {Vetch  on  Diseases  of 
the  Eye,  p.  17.) 

In  the  second  stage  of  acute  ophthalmy,  the  vinous 
tincture  of  opium  (the  tinctura  thebaica)  has  been  very 
extensively  used  as  a topical  application.  In  common 
cases,  two  or  three  drops  may  be  insinuated  between 
the  eyelids  and  globe  of  the  eye  twice  a day ; but  in 
other  instances,  attended  with  more  sensibility,  once  at 
first  will  be  sufficient.  The  late  Mr.  Ware,  who 
brought  this  application  into  great  repute,  found  that 
introducing  two  or  three  drops  of  this  medicine  at  the 
inner  canthus,  and  letting  them  glide  gradually  over 
the  eye  by  gently  drawing  down  the  lower  eyelid, 
proved  equally  beneficial  and  less  painful  than  letting 
them  fall  directly  upon  the  eyeball.  Immediately  the 
application  is  made,  it  usually  creates  a copious  flow 
of  tears,  a stnarting,  and  a sense  of  heat  in  the  eyes ; 
which  inconveniences,  however,  soon  cease,  and  the 
eyes  become  clearer  and  feel  decidedly  improved.  But 
notwithstanding  every  exaggeration,  unbiassed  sur- 
geons are  now  fully  convinced,  that  the  vinous  tincture 
of  opium  is  a proper  application  only  when  the  in- 

VoL.  II.— P 


flanimatory  action  has  been  previously  diminished  by 
blood-letting,  aperient  medicines,  and  blisters,  and 
w hen  the  action  of  the  vessels  has  been  weakened  by  the 
continuance  of  the  disease.  JMor  is  any  doubt  enter- 
tained, that  the  late  Mr.  Ware  went  much  too  far  when 
he  recommended  the  vinous  tincture  of  opium  as  a 
most  effectual  application  in  every  species  and  stage 
of  the  disorder,  frogn  the  most  mild  and  recent  to  the 
most  obstinate  and  inveterate. — (P.  51.)  Scarpa  has 
seen  the  necessity  of  limiting  the  use  of  the  remedy  in 
question,  and  has  expressly  pointed  out,  that  it  is  useful 
only  when  the  violence  of  the  pain  and  the  aversion 
to  light  have  abated.  Indeed  Mr.  Ware  himself,  a 
little  before  sanctioning  its  employment  in  all  cases, 
has  acknowledged,  that  in  certain  instances,  in  which 
the  complaint  is  generally  recent,  the  eyes  appear 
shining  and  glossy,  and  feel  exquisite  pain  on  exposure 
to  the  light,  no  relief  at  all  is  obtained  — (P.  48,  49.) 
Mr. Travers  has  remarked,  that  “there  are  inflamma- 
tions, which  assume  a chronic  character  in  their  com- 
mencement, evidently  depending  on  a state  of  atony, 
of  very  partial  extent,  void  of  pain,  and  scarcely  pos- 
sessing any  sign  of  inflammation  except  the  congestion 
of  the  vessels,  or,  if  any,  so  feebly  marked  as  to  en- 
courage us  to  disregard  them  in  the  treatment.  In 
such  cases  a single  stimulus  will  often  restore  the 
healthy  action  at  once.  The  vinous  tincture  of  opium 
has  acquired  a nostrum-like  importance  from  its  re- 
storative operation  in  such  cases  ; a virtue,  I believe, 
not  proper  to  it.  A drop  or  two  of  the  zinc,  or  the 
lunar  caustic  solution,  or  water  impregnated  with 
calomel,  or  a minute  portion  of  the  citrine  ointment, 
or  any  other  stimulant,  would  do  as  much.” — {Synop- 
sis, Src.  p.  252.) 

Whenever  the  patient  can  easily  bear  a moderate 
degree  of  light,  Scarpa  directs  all  coverings  to  be  re- 
moved from  the  eyes,  except  a shade  of  green  or  black 
silk.  A brighter  light  should  be  gradually  admitted 
into  the  chamber  every  day,  so  that  the  eyes  may  be 
come  habituated  as  soon  as  possible  to  the  open  day- 
light ; for,  as  Scarpa  truly  states,  nothing  has  a greater 
tendency  to  prolong  and  increase  the  morbid  irrita- 
bility of  the  eyes,  than  keeping  them  unnecessarily 
long  in  a dark  situation,  or  covered  with  compresses 
and  bandages. 

Dr.  "Vetch  has  such  a dislike  to  the  plan  of  covering 
the  eye,  that  he  never  suffers  a shade  to  be  worn,  con- 
ceiving that,  in  conjunctival  inflammation,  it  always 
does  a great  deal  of  harm,  by  preventing  a free  ex- 
posure of  the  eye  to  a temperate  atmosphere. — (Ore 
Diseases  of  the  Eye,  p.  17.) 

Besides  the  common  remedies  for  inflammation, 
there  are  some  very  powerful  means  which  may  be 
employed  for  the  relief  of  particular  states  of  ophthal- 
my with  great  effect.  Thus,  as  the  latter  author  has 
observed,  by  means  of  hyosciamus,  belladonna,  and 
stramonium,(see  Belladonna),  the  important  structure 
of  the  iris  may  be  secured  from  injury,  at  the  same 
time  that  other  measures  are  adopted  for  checking  the 
inflammation.  Such  medicines  may  even  be  applied, 
as  a mechanical  force,  for  detaching  any  recent  ad- 
hesion.— {Op.  cit.p.  18.) 

The  uses  of  the  argentum  nitratnm  are  also  very 
extensive ; “ the  slightest  application  of  it  in  substance 
(says  Dr.  Vetch)  can  often  remove  the  highest  degree 
of  morbid  sensibility  to  light,  and  instantaneously  re- 
store quietude  to  the  organ  ; it  can  prevent  incipient 
changes,  and  obviate  advanced  ones ; and  may  also  be 
used  in  solution  as  a valuable  sedative.” 

The  mention  of  so  stimulating  tfnd  active  a sub- 
stance as  the  nitrate  of  silver  having  a sedative  effect 
may  excite  surprise;  but  the  fact  is  unquestionable, 
and  well  illustrated  in  the  treatment  of  several  dis- 
eases.— (See  Cornea  and  Iris.)  As  another  modern 
writer  correctly  states,  it  is  remarkable  that  even  the 
weaker  forms  of  medicated  lotions  irritate,  and  none 
more  than  such  as  contain  opium.  The  relief  afforded 
by  anodyne  fomentations  in  general  is  very  various. 
“ I have  known  them  (says  Mr.  Travers)  objected  to 
as  painful,  and  patients  inquire  if  they  might  not  sub- 
stitute warm  water  for  the  aqueous  solution  of  opium, 
and  infusions  of  poppy  and  hemlock.  The  same  ob- 
servation applies  especially  to  painful  herpetic  cutane- 
ous affections,  and  acutely  irritable  ulcers.  Upon 
these  a solution  of  opium  often  acts  as  a stimulant  and 
augments  pain,  while  the  lunar  caustic  solution  as 
often  assuages  It.”  At  the  same  time,  Mr.  Travers 


226 


OPHTHALMY. 


admita,  that  exceptions  occur,  and  that  he  has  met 
with  cases,  “ in  which  no  other  application  than  the 
aqueous  solution  of  opium  could  be  borne.”  He  has 
also  known  the  vapour  of  laudanum  afford  the  most 
marked  relief  to  the  irritability  to  light  accompanying 
strumous  ophthalmy. — {Syiwpsis  of  the  Diseases  of 
the  Eye,  p.251.) 

According  to  Dr.  Vetch,  it  is  impossible  in  cases  of. 
conjunctival  ophthalmia,  to  possess  an  application  of 
greater  efficacy  than  the  undiluted  liquor  plumbi  sub- 
acetatis,  for  altering  the  morbid  and  purulent  stale  of 
that  membrane : he  also  describes  nicotiana,  e.xter- 
nally  employed,  as  a narcotic  and  astringent,  of  singu- 
lar service  in  lessening  the  pain  and  tumefaction. — (P. 
J9.)  However,  the  discordance  among  the  best  writers 
about  the  effects  of  favourite  local  applications,  would 
lead  me  to  enjoin  rather  attention  to  the  leading  prin- 
ciples of  the  treatment,  than  confidence  in  the  supe- 
rior efficacy  of  any  particular  drug  or  composition.  As 
also  the  local  applications  should  vary  in  the  different 
stages  of  purulent  ophthalmy,  no  single  one  will 
always  be  right.  If  Beer  had  delivered  no  observa- 
tions of  greater  importance  than  his  condemnation 
of  Bates’s  camphorated  lotion,  and  his  praise  of 
other  styptic  stimulating  applications,  his  remarks 
would  be  of  little  value ; but  as  he  has  pointed  out  the 
different  stages  of  purulent  ophthalmia  in  a very  cor- 
rect manner,  and  adapted  his  remedies  to  these  various 
states  of  the  disease,  his  information  comprehends 
scientific  principles,  and  becomes  peculiarly  interesting. 
The  same  praise  belongs  also  to  Dr.  Vetch’s  obsei-va- 
tions  on  purulent  ophthalmy,  who,  in  some  points, 
both  of  the  description  of  the  complaint  and  its  treat- 
ment, has  surpassed  Beer. 

Of  the  different  kinds  of  ophthalmy,  Beer’s  classi- 
fication is  very  comprehensive.  According  to  the  si- 
tuations in  which  ophthalmic  inflammation  first  origi- 
nates, he  proposes  a general  division  of  it  into  three 
forms,  as  suggested  by  some  of  the  older  writers;  viz. 
inflammation  of  the  eyelids,  or  blepharophlhalmitis ; 
inflammation  of  the  parts  between  the  orbit  and  globe 
of  the  eye;  and,  lastly,  inflammation  of  the  eyeball  it- 
self, or  ophthalmitis.  He  observes,  however,  that 
these  distinctions  seem  to  assign  a considerable  extent 
to  the  original  seat  of  the  affection;  for  the  expression 
inflammation  of  the  eyelids  can  only  denote  a case  in 
which  the  disorder  begins  at  once  in  all  the  parts  com- 
posing the  eyelids.  In  the  same  way,  inflammation 
of  the  parts  between  the  eyeball  and  orbit  appears  to 
signify,  that  all  those  parts  constitute  the  original 
sphere  of  the  complaint;  while  inflammation  of  the 
eyeball  seems  to  denote  that  the  disorder  has  begun  at 
once  in  all  the  textures  of  which  this  organ  is  com- 
posed. But,  ‘fortunately,  as  Beer  remarks,  the  extent 
of  the  original  seat  of  genuine  idiopathic  inflammation 
of  the  eye  is  seldom  thus  considerable : being  mostly 
restricted  to  particular  textures,  from  which  it  first 
spreads  farther  only  when  neglected  or  Injudiciously 
treated.  Hence,  certain  subdivisions  of  the  complaint 
are  necessary;  and,  accordingly,  Beer  subdivides  in- 
flammation of  the  eyelids,  first,  into  the  erysipelatous, 
or  blepharophlhalmitis  erysipelatosa,  which  com- 
mences in  the  integuments  of  these  parts.  Secondly, 
into  that  which  originates  at  the  edges  of  the  palpe- 
brse,  in  the  conjunctiva  lining  these  parts  and  the 
Meibomian  glands,  and  which  Beer  denominates  glan- 
dular inflammation  of  the  eyelids,  or  blepharophthal- 
milis  glandulosa;  a case  described  by  writers  under 
an  infinite  number  of  names,  and  often  confounded 
with  complaints  t»f  a totally  different  nature.  Thirdly, 
when  the  effects  of  the  inflammation  are  confined  to 
a small  portion  of  the  eyelid,  it  constitutes  the  disease 
termed  the  inflammatory  stye,  or  hordeolum,  which 
Beer  says  is  rarely  a simple  inflammation,  but  compli- 
cated with  a scrofulous  habit;  a proposition  which  I 
think  will  not  receive  any  credit  in  England.  Fourthly, 
as  there  is  one  more  form  of  inflammation  of  the  eye- 
lids, Beer  gives  it  the  name  of  the  erysipelatous  swell- 
ing  of  the  corner  of  the  eye,  or  anchylops  erysipelatosa, 
which  affects  the  skin  of  the  inner  canthus  imme- 
diately over  the  lachrymal  sac.  The  name  here  sug- 
gested expresses  precisely  the  seat  of  the  inflammation, 
and,  as  Beer  thinks,  will  tend  to  prevent  the  case  from 
being  mistaken  for  inflammation  of  the  lachrymal  sac. 
Inflammation  of  the  parts  in  the  orbit  comprehends, 
first,  inflammation  of  the  lachrymal  gland;  secondly, 
inflammation  of  the  lachrymal  sac,  a disorder  which 


begins  in  the  lachrymal  sac  and  nasal  ducty  and  genc^ 
rally  extends  with  great  rapidity  over  all  the  excretirVg 
parts  of  the  lachrymal  organa ; and,  thirdly,  inflamma- 
tion of  the  caruncula  lachrymalis,  or  the  encanihia 
inflammatoria. 

In  the  same  way  inflarnmationsof  the  eyeball  adrrrit 
of  a classification,  which  is  of  the  highest  practical 
importance,  first,  into  the  erysipelatous  inflammation 
of  the  sclerotic  conjunctiva,  the  ophthalmitis  erysip&- 
latosa,  which  denotes  that  form  of  the  disorder  which 
is  at  first  entirely  confined  to  the  membrane  connecting 
together  the  eyelids  and  eyeball.  Secondly,  into  in- 
flammation of  the  outer  textures  of  the  eyeball,  the 
ophthalmitis  externa,  originating  in  the  cornea  and 
sclerotica.  Thirdly,  into  inflammation  of  the  innermost 
textures  of  the  eyeball,  the  ophthalmitis  interna,  which 
has  two  forms  highly  necessary  to  be  recollected  in 
practice ; for  the  inflammation  may  begin  immediately 
in  the  retina,  choroides,  the  membrane  of  vitreous  hu- 
mour, &c.  and  spread  from  these  textures  to  all  the  rest 
of  the  eyeball,  being  named  true  intei-nal  inflammation 
of  the  eyeball,  or  ophthalmitis  interna  vera,  and  thus 
discriminated  from  another  case,  which  is  originally 
seated  in  the  iris,  the  adjoining  corpus  ciliare,  the  lens 
and  its  capsule,  and  afterward  extends  from  these  parts 
to  the  more  deeply-situated  coats,  and  to  the  texture 
of  the  vitreous  humour.  This  last  form  of  internal 
inflammation  of  the  eyeball  is  named,  both  by  Schmidt 
and  Beer,  iritis.  The  classification  then  embraces  a 
view  of  the  different  forms  of  ophthalmy,  as  modified 
by  constitutional  causes;  as  the  effect  of  contagious 
and  infectious  diseases,  measles,  small-pox,  &c. ; and 
as  a complication  of  certain  cachexiae,  like  gout,  rheu- 
matism, and  scurvy. 

Although  I have  thus  given  a brief  delineation  of 
Beer’s  classification  of  ophthalmic  inflammations,  it  is 
not  my  design,  in  the  subsequent  columns,  to  enter 
into  a full  consideration  of  every  particular  case  above 
enumerated  ; first,  because  the  limits  of  this  volume 
will  not  permit  me  to  do  so ; and,  secondly,  because 
some  of  these  cases  have  been  already  considered  in, 
other  parts  of  the  work. — (See  Lachrymal  Organs.) 

Common  Inflammation  of  the  Eyelids.  This  form  of 
disease  is  said  by  Beer  to  affect  the  upper  much  more 
frequently  than  the  lower  eyelid,  because  the  former 
obviously  has  a lai^er  surface  exposed  to  injuries  from 
without ; nor  does  the  complaint  always  spread  to  the 
latter.  From  the  margin  of  the  eyelid,  a very  red, 
tense,  painful  swelling  arises,  attended  with  heat, 
throbbing,  and  a great  deal  of  tenderness  when  touched. 
It  gradually  extends  over  the  whole  eyelid;  but  seems 
to  be  plainly  bounded  by  the  edge  of  the  orbit.  The 
motion  of  tire  eyelid  is  always  more  or  less  obstructed, 
and,  at  length,  when  the  inflammation  has  reached  Us 
greatest  degree,  it  is  completely  prevented.  Nor  is  there 
any  difficulty  in  comprehending  why,  when  the  in- 
flammation has  become  severe,  the  eye  should  be  ex- 
cessively dry,  and  every  attempt  on  the  part  of  the  pa- 
tient to  move  the  eyelid  should  be  productive  of  con- 
siderable pain,  and  of  a sensation  as  if  some  sharp 
extraneous  substances  lay  under  the  lid;  for,  at  this 
period,  the  palpebral  conjunctiva  is  already  severely 
inflamed,  and,  consequently,  the  secretion  of  mucus 
from  the  Meibomian  glands  is  immediately  stopped 
by  the  inflammation  itself,  while  that  of  the  tears 
is  interrupted  partly  by  the  extension  of  the  in- 
flammation to  the  sclerotic  conjunctiva,  and  partly 
by  the  effect  of  the  sympathetic  connexion  existing 
between  the  conjunctiva  of  the  eyelid  and  that  of 
the  eyeball.  To  this  last  cause,  viz.  sympathy.  Beer 
refers  the  supervening  dryness  and  shrivelling  up  of 
the  lachrymal  papillae,  as  well  as  the  apparent  closure 
of  the  puncta  lachrymalia,  and  the  uneasy  dry  slate 
of  the  edges  of  the  eyelids.  Hence,  also,  the  dryness 
of  the  adjacent  nostril,  and  a very  disagreeable  smell 
of  dust,  obliging  the  patient  to  sneeze  repeatedly, 
which  act  is  constantly  attended  with  a great  increase 
of  pain  in  the  swelling,  a transient  shooting  of  it  to  the 
eye  and  head,  and  a sensation  as  if  flashes  of  light  were 
elicited  within  the  eyeball ; a kind  of  hallucination, 
technically  named  photopsia.  As  the  original  seat  of 
the  inflammation  is  already  extensive,  one  may  readily 
understand,  says  Beer,  why  the  affection  in  its  first 
stage,  particularly  when  neglected  or  badly  treated, 
should  frequently  give  rise  to  some  febrile  disturbance 
of  the  system. 

In  the  second  stage  of  the  case,  or  that  of  suppura- 


OPHTHALMT. 


227 


tJon,  which  follows  when  the  inflammation  is  violent 
and  not  soon  dispersed,  matter  forms  with  the  annexed 
train  of  symptoms  The  redness  suddenly  iticreases 
very  much,  the  eyelid  becomitig  of  a brownish-red, 
and  lastly  of  a purplish-red  colour.  The  swelling  be- 
comes more  prominent,  and  presents  a conical  emi- 
nence, either  in  the  middle  of  the  eyelid  or  close  to  the 
outer  or  inner  canthus.  The  pain  is  irregular,  and  of 
a stinging,  burning  kind,  a throbbing  being  felt  only  in 
the  deeper  part  of  the  tumour.  At  length  the  swelling 
becomes  somewhat  softer  and  less  sensible  at  its  most 
projecting  point.  The  secretion  from  the  Meibomian 
and  lachrymal  glands,  which,  in  the  first  stage  of  the 
disorder,  was  suppressed,  is  now  quite  re-established, 
but  more  copiously  than  in  the  healthy  slate.  During 
sleep,  a quantity  of  mucus  accumulates  between  the 
edges  of  the  eyes,  and  glues  them  together.  An  extra- 
ordinary sensation  of  cold  and  heaviness  is  felt  all 
about  the  eye.  Ultimately,  the  most  prominent  point 
of  the  swelling  presents  a pale-red  colour,  followed  by 
a yellowish  livid  tinge.  As  the  abscess  is  now  com- 
pletely formed,  the  fluctuation  of  matter  can  be  plainly 
felt. — i^BeeXy  b.  1,  p.  269,  (S-c.) 

According  to  the  same  author,  nothing  very  par- 
ticular is  known  respecting  the  causes  of  the  preceding 
form  of  ophthalmic  inflammation,  and,  with  the  ex- 
ception of  blows,  he  has  not  been  able  to  discover  the 
precise  circumstances  which  give  rise  to  it. 

With  regard  to  the  prognosis,  if  the  treatment  be 
neglected  or  injudicious,  the  inflammation  may  sud- 
denly become  so  violent  as  to  produce  in  weak  subjects 
gangrenous  mischief.  But  when  the  case  is  properly 
managed  in  its  first  stage,  the  second,  or  that  of  sup- 
puration, never  ensues;  yet,  says  Beer,  the  curative 
measures  must  be  decisive,  and  no  time  wasted  on  tri- 
fling means,  though  due  regard  must  be  paid  to  the 
constitution.  When  the  inflammation  subsides  fa- 
vourably, no  vestiges  of  it  remain,  and  even  the  red- 
ness, which  is  the  latest  in  disappearing,  completely 
goes  ofif  in  a few  days,  and  the  function  of  the  eyelid 
becomes  perfect  again. 

If  gangrene  and  sloughing  take  place,  the  outer  cover- 
ings of  the  eyelid  are  quite  destroyed,  and  the  conse- 
quences are  an  incurable  eversion  of  the  part  (see  Kc- 
tropium),  or  a hare-eye  (see  Lagophthalmus).  When 
suppuration  happens  favourably,  the  abscess  some-, 
times  breaks  very  well  of  itself  in  the  upper  eyelid; 
but,  according  to  Beer,  this  does  not  readily  occur  on 
the  lower  one,  nor  without  the  formation  of  sinuses, 
which  sometimes  run  quite  into  the  orbit.  After  the 
abscess  has  burst,  or  been  opened,  the  part  heals  up 
with  great  celerity  in  favourable  constitutions,  but 
slowly  in  others;  vermilion  granulations  arise  from  the 
bottom  of  the  cavity,  and  a cicatrix  follows  which  is 
scarcely  perceptible.  When  the  abscess  is  very  large, 
however,  and  bursts  of  itself,  the  upper  eyelid  con- 
tinues for  some  time  very  much  weakened.  If  the 
collection  of  matter  be  neglected,  or  wrongly  treated, 
or  the  subject  be  unhealthy,  or  the  disease  be  aggra- 
vated by  the  efTects  of  a damp  atmosphere,  hurtful  food, 
severe  mental  trouble,  wet  poultices,  or  too  long  con- 
finement of  the  matter,  then,  says  Beer,  fistulae  are  apt 
to  be  produced,  sometimes  complicated  with  necrosis 
of  the  bone,  the  certain  effects  of  which  are  some  per- 
manent and  mostly  incurable  disease  of  the  eyelid,  and 
impairment  of- its  functions:  1st.  A closure  of  the  la- 
chrymal canals  with  a permanent  stillicidium.  2.  A 
complete  obliteration  of  the  same  tubes,  with  an  in- 
curable stillicidium.  3.  A prolapsus  of  the  upper  eye- 
lid, from  distention  of  the  skin  by  the  long  confinement 
of  the  matter.  4.  Inversion  of  the  edge  of  the  eyelid, 
from  a shrinking  of  its  cartilage.  5.  Eversion  of  the 
eyelid,  and  hare-eye,  from  loss  of  skin. 

As  in  this  species  of  inflammation  the  organ  of  sight 
cannot  well  be  affected,  unless  the  disorder  extend  it- 
self very  much,  the  exclusion  of  air  and  light  is  here 
but  of  little  use.  Linen  compresses  well  wet  with  very 
cold  water,  or  vinegar  and  water,  are  to  be  applied  ; 
and,  while  the  complaint  is  local,  leeches  are  to  be 
used ; but  if  the  constitution  be  threatened  with  febrile 
symptoms,  then  Beer  urges  the  necessity  of  venesec- 
tion, low  diet,  purgatives,  and  general  antiphlogistic 
meaHur«*8.— (B.  1,  p.  275.) 

In  the  second  stage,  with  the  exception  of  a few 
points.  Beer  states,  that  the  case  is  to  be  treated  like 
any  other  common  abscess.  When  the  matter  is  situ- 
ated m the  middle  of  the  upper  eyelid,  not  far  beneath 

pa 


the  skin,  the  abscess  may  be  allowed  to  burst  of  Itself, 
especially  if  the  patient  have  a great  dread  of  the 
knife.  But  if  the  matter  lie  near  the  outer  or  inner 
canthus,  it  should  be  let  out  with  a lancet  as  soon  as 
its  fluctuation  is  quite  distinct,  the  incision  being  made 
in  the  direction  of  the  fibres  of  the  orbicular  muscle. 
When  fisiulte  or  gangrene  have  already  taken  place, 
the  treatment  should  be  like  that  which  is  applicable 
to  the  same  kind  of  mischief  in  most  other  parts  of  the 
skin. 

Erysipelatous  Inflammation  of  the  Eijelids  usually 
affects  both  these  parts  together,  very  seldom  only  the 
upper  one,  and  never  the  lower  alone.  When  also 
both  are  affected,  the  disorder  always  presents  itself  in 
the  greatest  degree  in  the  upper  eyelid.  A pale,  yel- 
lowish-red, seemingly  transparent,  shining  swelling 
arises  from  the  edges  of  the  eyelids,  and  rapidly  ex- 
tends itself  without  any  determinate  boundary,  the 
faint-red  colour  being  gradually  lost  upon  the  eyebrow 
above,  and  not  unfrequently  upon  the  cheek  below. 
When  the  inflamed  part  is  gently  touched,  the  redness 
disappears,  but  only  for  a moment.  At  length  the 
swelling  towards  the  margins  of  the  eyelids  becomes 
exceedingly  soft,  and  feels  like  a vesicle  that  has  been 
raised  by  a blistering  plaster.  The  pain  is  inconsider- 
able, not  attended  with  throbbing,  but  rather  with  a 
sense  of  heat  and  stiffness;  when  the  part  is  slightly 
touched,  the  patient  experiences  a lancinating  sensa- 
tion in  it.  Its  temperature  is  not  much  increased. 
The  secretions  from  the  Meibomian  glands,  lachrymal 
gland,  and  mucous  membrane  of  the  nostrils  are  much 
augmented.  In  a strong  subject,  the  disorder,  if  ge- 
nuine and  idiopathic,  is  not  productive  of  any  consti- 
tutional disturbance;  but  in  bad  habits,  and  weak  fe- 
males and  children,  it  is  sometimes  attended  with  fever. 
However,  when  the  complaint  partakes  of  the  phleg- 
monous character,  and  is  badly  treated,  the  general 
symptoms  are  occasionally  very  severe  at  the  change 
from  the  first  to  the  second  stage,  and  the  case  may 
then  terminate  in  a gangrenous  kind  of  suppuration. 
In  irritable,  delicate  children,  says  Beer,  when  the  dis- 
ease spreads  over  the  face,  the  case  requires  the  most 
skilful  treatment  to  prevent  a disastrous  termination. 

In  strong  persons,  the  second  stage  of  this  disorder 
rarely  ends  in  a manifest  suppuration,  but  is  rather  in 
an  exudation  of  lymph,  which,  becoming  dry,  forms 
small,  delicate,  branny  scales,  in  the  composition  of 
which  the  desquamated  cuticle  has  also  a considerable 
share.  In  other  instances,  vesications  of  various  sizes 
are  formed  on  the  erysipelatous  surface,  and  burst, 
and  discharge  a fluid,  which  is  converted  into  yellowish 
scabs. 

According  to  Beer,  the  skin  of  the  eyelids  is  particu- 
larly prone  to  erysipelatous  inflammation.  Recon- 
siders the  sudden  effect  of  a cold  blast  of  air,  or  of 
very  cold  water  upon  the  skin  of  the  eyelid,  while  in 
astate  of  free  perspiration,  as  the  most  common  cause 
of  its  being  attacked  with  erysipelas,  particularly  in 
weak  subjects.  He  states,  however,  that  the  complaint 
maybe  occasioned  by  the  sling  of  bees,  wasps,  and 
other  insects ; accidents,  which,  when  the  stings  are 
not  extracted,  are  liable  to  be  followed  by  a violent  and 
dangerous  general  inflammation  of  the  eyelid,  not  un- 
frequently extending  in  a perilous  degree  to  the  eyeball 
itself— (B.  lyp.  281.) 

With  regard  to  the  prognosis,  no  other  case  of  oph- 
thalmic inflammation  so  frequently  subsides  without 
the  aid  of  surgery  as  this,  provided  the  constitution  be 
healthy  and  strong ; and  when  the  complaint  is  resolved 
in  its  first  stage,  the  vestiges  of  it  afterward  are  as  little 
as  those  consequent  to  common  inflammation  of  the 
eyelids. 

The  second  stage,  however  well  treated,  is  followed 
for  a long  time  by  a peculiar  sensibility  of  the  skin  to 
the  impression  of  cold  damp  air,  and  a strong  pro- 
pensity to  relapses.  If,  when  the  cuticle  peels  off,  a 
patient  of  weak  constitution  sit  in  a current  of  damp 
cold  air,  or  try  to  wash  away  the  scales  and  .scabs  with 
cold  water.  Beer  stales  that  an  cedematous  affection  of 
the  eyelid  will  be  produced,  which  is  often  very  obsti- 
nate, and  apt  to  occasion  a temporary  inversion  of  the 
cilisB  (Trichiasis)y  or  a similar  state  of  the  edge  of  the 
eyelid  (.Entropium).  And  he  observes,  that  wlien  from 
neglect  or  bad  treatment  an  erysipelatous  inflammation 
of  the  eyelid  terminates  in  suppuration,  the  abscess  is 
not  like  a common  one,  but  the  matter  rapidly  makes 
its  way  out  through  several  openings  in  the  already 


228 


OPHTHALMY. 


partially  disorganized  skin,  and,  in  general,  this,  state 
is  followed  by  ill-conditioned  tedious  ulcerations, 
whereby  a good  deal  of  skin  is  always  destroyed. 
Under  these  eircuinstances,  all  those  consequences 
may  be  produced,  which  have  been  described  as  liable 
to  take  place  from  the  second  or  suppurative  stage  of 
common  inflammation  of  the  eyelid.  Gangrene  and 
sloughing  may  even  occur,  when  erysipelas  of  the 
eyelids  is  brought  on  by  the  unremoved  sting  of  an 
insect,  and  efficient  treatment  is  delayed. 

The  treatment  recommended  by  Beer  in  the  first 
stage  consists  in  the  application  of  cold  water ; and  he 
remarks,  that  exposure  of  the  part  for  a time  to  a cool, 
moist,  but  in  other  respects  pure,  atmosphere  will  often 
suffice  for  the  removal  of  the  complaint.  When,  how- 
ever, the  disorder  increases  and  assumes  a phlegmon- 
ous character,  the  directions  given  for  the  treatment 
of  common  inflammation  of  the  eyelids  are  to  be  fol- 
lowed. 

In  the  second  stage  of  erysipelas  of  the  eyelids.  Beer 
praises  the  good  effects  of  a mild,  dry  air,  of  an  equal 
temperature,  and  recommends  covering  the  parts  with 
a light  bandage,  under  which  are  to  be  put  wcll- 
warmed  linen  compresses,  which,  for  weak  persons, 
should  be  sprinkled  with  camphor ; or  he  directs  the 
eyelids  to  be  covered  with  bags  of  aromatic  herbs; 
generally  a very  favourite  plan  with  Beer,  whenever 
he  objects  to  moist  applications.  In  such  individuals, 
he  observes  that  the  cure  will  be  promoted  by  gentle 
diaphoretic  medicines,  with  which,  when  the  debility 
is  very  great,  camphor  should  be  joined.  In  this  country, 
erysipelatous  inflammation  of  the  eyelids  is  treated 
according  to  the  principles  applicable  to  other  cases  of 
erysipelas,  with  cold  applications,  leeches,  purgatives, 
antimonials,  and,  if  necessary,  venesection.  Should 
an  abscess  form,  the  same  treatment  is  proper  as  in  the 
second  stage  of  common  inflammation  of  the  eyelids. 

Glandular  Inflammation  of  the  Eyelids  is  considered 
by  Beer  as  the  disease  of  which  all  the  various  cases 
of  purulent  oplithalmy  are  only  modifications,  which 
he  describes  under  the  names  of  idiopathic  catarrhal 
ophthalmy ; idiopathic  catarrhal-rheumatic  ophthalmy ; 
and  blepharo-blennorrhoea,  or  ophthalmo-blenorrheea. 
The  two  latter  terms  comprehend  the  purulent  oph- 
thalmy of  infants,  the  Egyptian  ophthalmy,  the  go- 
norrhoeal ophthalmy,  &c. 

Glandular  Inflammation  of  the  Eyelids,  Beer  knew 
very  w'ell,  was  so  far  a defective  term,  that  it  seemed 
to  imply  merely  an  affection  of  the  Meibomian  and 
mucous  glands  of  those  'parts,  whereas  he  means  to 
express  by  this  name  the  kind  of  inflammation,  of 
which  all  the  cases,  usually  called  in  this  country  puru- 
lent ophthalmies,  are  varieties  and  modifications,  and 
in  which  the  conjunctiva  is  also  particularly  affected. 

^cute  suppurative  Inflammation  of  the  Conjunctiva, 
divisible  into  the  mild  and  severe  forms,  as  proposed 
by  Mr.  Travers,  appears,  perhaps,  a better  name. — 
{Synopsis,  6rc.  p.  96,  <J-c.)  Dr.  Vetch,  who  also  prefers 
the  general  term  conjunctival  inflammation,  observes, 
that  from  many  internal  and  external  causes,  the  mem- 
brane of  the  conjunctiva  is  liable  to  become  the  seat 
of  inflammation,  more  especially  that  portion  of  it 
which  gives  a lining  to  the  inner  surface  of  the  eyelids. 
The  disease  in  its  general  nature,  he  says,  differs  little 
from  that  which  is  met  with  in  other  parts  having  a 
similar  surface,  as  the  nose,  the  fauces,  the  bronchial 
cells,  and  the  urethra ; but  the  continuation  of  the 
membrane  forwards  upon  the  anterior  portion  of  the 
eye,  and  the  consequent  liability  of  the  inflammation 
to  affect  this  important  organ,  attach  much  interest  to 
all  the  circumstances  capable  of  producing  it. — {On 
Diseases  of  the  Eye,  p.  148.)  In  the  common  gland- 
ular inflammation  of  the  eyelids  described  by  Beer, 
which  seems  to  me  to  correspond  to  the  more  moderate 
forms  of  purulent  ophthalmy  met  with  in  this  country, 
either  the  whole,  or  only  that  part  of  their  edges  which 
is  near  one  or  both  canthi,  is  affected  with  a very  red, 
hardish,  sensible  swelling,  attended  with  a violent 
annoying  degree  of  itching.  This  swelling.  Beer  ob- 
serves, does  not  extend  far  over  the  outside  of  the  eyelid 
upwards  or  downwards,  at  most  not  more  than  a few 
lines ; but  it  spreads  over  the  palpebral  conjunctiva, 
especially  when  neglected  or  badly  treated,  and  the 
constitution  is  weak.  This,  he  says,  can  only  be  dis- 
covered when  the  eyelid  is  everted.  The  farther  the 
swelling  extends  over  the  inside  of  the  eyelid,  the  more 
is  the  motion  of  the  part  obstructed  ; not  on  account 


of  any  w-ant  of  power  in  the  orbicular  muscle,  but 
trom  a tear  of  the  pain  with  which  every  attempt  to 
move  the  ey'elid  is  accompanied.  The  itching  which 
conunually  distresses  the  patient  more  or  less,  is  often 
succeeded  by  an  irritating  burning  kind  of  pain,  which 
IS  particularly  experienced  when  the  eyelids  are  moved, 
snd  li6ncG  the  p&tiGnt  is  obliged)  £ls  ii  were  to  keep  liis 
eye  closed.  While  llie  iiihamination  is  restricted  to 
the  edges  and  conjunctiva  of  the  eyelids,  and  the  Mei- 
bomian glands  situated  under  it,  though  the  secretion 
from  these  glands  is  entirely  stopped,  that  from  the 
lachrymal  gland  is  much  augmented,  and  consequently 
the  disease  is  associated  with  a true  epiphora,  which  is 
seriously  aggravated  whenever  the  eye  is  exposed  to  a 
strong  light.  As  under  these  circumstances,  the  tears 
are  not  properly  blended  with  the  Meibomian  secretion, 
they  must  of  course  be  very  irritating  to  the  eye  and 
its  surrounding  parts,  and  less  fitted  for  properly  lubri- 
cating its  surface.  Hence,  the  pain  now  becomes 
burning,  and  not  unfrequently  the  cheek  over  which 
the  tears  run  is  excoriated.  As  soon  as  the  inflamma- 
tion of  the  eyelids  spreads  farther,  and  begins  to  affect 
tlie  sclerotic  conjunctiva,  the  effusion  of  tears  ceases, 
the  eye  becomes  pretei naturally  dry,  and  the  patient 
constantly  thinks  that  he  feels  sand  under  the  eyelids, 
which  sensation  is  rendered  almost  intolerable  by  any 
motion  of  the  eye  or  eyelids.  Children  and  w'omen 
have  so  great  a dread  of  this  painful  feel,  that  much 
persuasion  is  often  requisite  to  induce  them  to  let  the 
eye  be  properly  examined.  If  the  glandular  inflam- 
mation of  the  eyelids  attain  a considerable  degree,  the 
lachrymal  papillae  shrink,  and  the  puncta  seem 
closed,  which  is  particularly  the  case  when  the  disorder 
begins  at  the  inner  canlhus. 

In  the  second  stage  of  the  complaint.  Beer  describe* 
the  itching,  burning  sensation,  and  dryness  of  the  eye 
as  undergoing  a remarkable  diminution,  as  either  the 
canthi,  or  the  whole  extent  of  the  edges  of  the  eyelids 
become  more  and  more  moist  and  smeared  with  mucus, 
an  increased  secretion  of  a purifoimi  sebaceous  fluid 
from  the  Meibomian  glands  being  the  first  symptom 
(denoting  the  commencement  of  the  second  stage  of  the 
inflammation.  As  this  mucous  secretion  is  not  mixed 
with  an  adequate  quantity  of  tears,  it  inspissates  in 
the  form  of  white,  thin,  delicate  layers,  which  from 
time  to  time  cover  the  cornea,  and  make  the  patient 
very  apprehensive  of  becoming  blind,  as  the  flame  of 
a candle  in  the  evening,  and  other  objects,  appear  to 
him  more  or  less  concealed  by  a dense  mist.  When 
under  these  circumstances,  however,  the  eyelids  are 
repeatedly  and  briskly  moved,  or  the  eye  is  wiped,  these 
appearances  soon  go  q^,  the  flakes  of  mucus  being  re- 
moved from  the  cornea.  These  accumulations  of 
thickened  mucus.  Beer  remarks,  are  apt  to  be  most 
frequent  and  troublesome  some  time  after  a meal ; and 
the  eyelids  become  so  firmly  glued  together  during 
sleep  with  yellowish  crusts,  that  when  the  patient 
awakes  in  the  morning,  it  is  not  till  after  a great  deal 
of  washing  and  bathing  of  his  eyes  with  warm  water 
that  he  is  able  to  open  them  again.  The  above-de- 
scribed change  in  the  quantity  and  quality  of  the 
secreted  matter  as  already  mentioned,  indicates  the 
first  period  of  the  second  stage ; for  Beer  wishes  it  to 
be  particularly  noticed,  that  here,  as  in  all  inflamma- 
tions of  mucous  membranes,  the  second  stage  of  the 
disorder  has  three  periods,  to  which  the  practitioner 
cannot  be  too  attentive. 

This  morbid  secretion  of  a mucous  sebaceous  matter 
does  not  continue  long  unattended  with  other  effects; 
and  very  soon  the  peculiar  appearances  of  suppuration 
are  seen,  at  the  same  time  that  the  conjunctiva  of  the 
eyelids  becomes  more  considerably  swelled,  and  a dis- 
charge takes  place,  not  only  from  the  canthi  or  margins 
of  the  eyelids,  but  from  the  whole  of  the  thickened 
villous  surface  of  the  palpebral  conjunctiva,  and 
which  discharge  is  distinguishable  at  first  view  from 
the  mucus,  which,  at  an  earlier  period,  accumulated  in 
much  smaller  quantity  only  between  the  edges  of  the 
eyelids  and  at  the  canthi.  It  is  now  no  longer  white, 
but  yellow,  completely  like  pus,  with  which  it  is  in 
reality  blended  ; and  so  viscid  is  it,  that  the  crusts 
which  collect  on  the  eyelids  in  the  night  time,  cannot 
be  removed  without  pulling  the  eyelashes  away  with 
them.  Sometimes,  says  Beer,  at  the  moment  of  sup 
puration,  minute  pustules,  which  are  scarcely  distin- 
guishable, form  either  at  the  canthi  or  along  the  edges 
of  tire  ev'dids,  and  are  soon  buret  by  the  constant  fric- 


OPHTHALMY. 


tion  of  the  parts.  These  pustules  indicate  the  second 
or  suppurative  period  of  the  second  stage  of  the  case, 
when  either  merely  the  canthus,  or  the  whole  of  the 
margin  of  the  eyelid  constantly  becomes  excoriated, 
and  secretes  mucus  and  purulent  matter,  the  sore  fretted 
places  smarting  so  severely  on  exposure  to  the  air,  par- 
ticularly to  such  as  contains  a large  proportion  of  car- 
bonic acid  gas  and  nitrogen,  that  the  patient  is  afraid 
of  opening  his  eye.  When  the  patient  neglects  him- 
self, and  continues  in  an  unhealthy  atmosphere,  these 
excoriations  of  the  skin  occurring  in  the  suppurative 
stage  are  always  more  extensive;  nay,  they  sometimes 
sitread  over  the  lower  eyelid  and  down  the  cheek. 

At  length,  after  the  excoriations  have  lasted,  perhaps, 
several  weeks,  the  suppurative  process  is  checked  and 
suppressed,  either  by  surgical  treatment,  or  accidental 
favourable  circumstances,  as  change  of  regimen,  wea- 
ther, climate,  &c.,  and  then  the  excoriations  immedi- 
ately diminish.  However,  a morbid  secretion  from 
the  Meibomian  glands  still  continues,  making  the  third 
period  of  the  second  stage,  and  is  apt  to  become  habit- 
ual, if  nrtt  rectified  by  art,  or  removed  by  the  effect  of 
accidental  favourable  circumstances,  when  it  changes 
into  a thin  serous  discharge,  and  then  terminates. 

Beer  refers  the  causes  of  glandular  inflammation 
of  the  eyelids,  or  simple  purulent  ophlhalmy,  to  the  im- 
mediate operation  of  various  stimuli  acting  chemically 
upon  the  edge  of  the  eyelid,  and  upon  the  exposed  fol- 
licles of  the  glands  of  the  eyelid  towards  the  inner  can- 
thus. Hence,  says  he,  when  many  men  are  living 
together  in  a polluted,  noxious  air,  impregnated  with 
extraneous  substances,  this  form  of  inflammation  is 
found  to  occur  even  in  the  strongest  constitutions  with 
such  frequency,  that  it  seems  as  if  it  were  epidemic. 
And,  according  to  Beer,  the  principal  cause  of  the 
disease  will  be  found  to  be  in  the  atmosphere,  and  the 
next  most  frequent  occasion  of  it,  he  observes,  is  un- 
cleanliness, as  washing  the  eyes  with  foul  water,  &c. 
At  the  same  time,  he  seems  aware  that  this  explana- 
tion would  not  of  itself  be  always  quite  satisfactory; 
for  he  adds,  that  although  under  the  above  circum- 
stances no  constitution,  no  sex,  nor  age  is  spared,  there 
must  be  some  particular  condition  which  is  conducive 
to  the  disorder,  or  at  all  events  to  its  more  rapid  and 
severe  course,  and  the  quick  extension  of  the  inflam- 
mation in  certain  individuals,  which  condition,  he  sup- 
poses, must  der)end  either  upon  weakness  of  constitu- 
tion, or  upon  excessive  irritability,  or,  as  he  terms  it, 
vulnerability  of  the  whole  surface  of  the  body.  Beer 
makes  no  q;iention  of  the  effect  of  damp  nocturnal  air 
in  warm  countries  as  giving  origin  to  purulent  oph- 
thahny,  so  much  insisted  upon  by  Asalitii  and  Dr. 
Vetch  ; but  which  doctrine,  in -reference  to  the  origin 
of  purulent  ophthalmies  in  England,  I think, completely 
fails ; and  w’hat  is  still  more  worthy  of  notice.  Beer 
never  attempts  to  explain  the  propagation  of  thedisease 
by  its  infectious  nature.  It  is  observed  by  Dr.  Vetch, 
that  the  history  of  all  diseases  originating  from  some 
particular  irni)ression  received  from  the  atmosphere, 
but  capaole  when  formed  of  propagating  themselves 
by  contagion,  is  rendered  particularly  difficult ; be- 
cause the  same  circumstances,  which  favour  the  com- 
munication by  contagion,  produce  also  a predisposition 
to  be  acted  upon  by  the  more  general  causes  existing  in 
the  atmosphere.  The  principal  cause  which  gives 
force  and  opportunity  to  the  acti(/n  of  contagion, 
is  the  crowding  individuals  together  into  too  limited 
spaces.  The  same  circumstance  Dr.  Vetch  has  seen 
give  a predisposition  to  diseases  of  an  epidemic,  but 
not  a contagious  nature  ; and  hence  he  infers,  that  it 
may  produce  the  same  predisposition  to  diseases,  which 
are  both  contatrious  and  atmospheric. — “The  appear- 
ance of  ophthalmia  among  the  crews  of  shi[)s  and  in  bar- 
racks was  often  met  with  long  before  the  late  destruc- 
tive and  virulent  disease  (presently  to  be  described). 
In  the  army,  such  an  ophthalmia  has  extended  to  whole 
regiments,  without  any  appearance  of  the  disease 
among  the  inhabitants  of  the  neighbourhood ; and  while 
the  free  intercourse  which  subsists  among  the  men,  as 
to  wa.shing  in  the  same  water,  using  the  sanid  towels, 
and  sleeping  more  than  one  in  a bed,  readily  accounts 
for  the  rapid  extension  of  the  disease  in  the  same 
corps,  yet  the  excessive  crowding  together  of  men  will 
often  of  itself  engender  inflammation  of  the  conjunc- 
tiva.”— (On  Diseases  of  the  Eyes,  p.  171.)  I believe, 
with  respect  to  the  causes  of  all  purulent  ophthalmies, 
our  present  knowledge  will  permit  us  to  venture  no 


farther  tnan  the  tenor  of  the  preceding  observations, 
which  is,  that  they  originate  epidemically,  but  probably 
multiply  both  in  this  manner,  and  by  the  infectious 
matter  of  the  disease  being  inadvertently  applied  in  va- 
rious ways  to  the  eyelids  of  other  persons.  This 
species  of  inflammation  of  the  eyelids  is  rarely  met 
with  by  the  surgeon  in  its  first  stage,  because  only  very 
timorous  patients  then  seek  medical  advice ; and  most 
individuals,  who  feel  in  other  respects  well,  relieve 
themselves  by  washing  the  eyes  with  cold  water,  and 
applying  cold  poultices,  made  of  bread-crumb  softened 
in  water.  Besides,  when  the  disease  is  not  very  se- 
vere, it  frequently  subsides  of  itself;  as  in  afavourable 
constitution,  a better  air  is  sometimes  capable  of  re- 
storing the  healthy  state  of  the  eye.  If,  however, 
the  disease  at  its  commencement  should  be  violent,  or 
attack  an  individual  of  very  weak  habit.  Beer  states 
that  it  may  immediately  affect  not  only  the  Meibo- 
mian glands,  but  the  perichondrium  of  the  cartilage 
of  the  eyelid,  and  produce  an  incurable  entropium, 
which  is  also  sure  of  taking  place  when  the  case  is 
neglected,  and  followed  by  deeply  extending  ulcerative 
mischief.  When  the  complaint  is  strictly  idiopathic, 
it  never  brings  on  any  general  indisposition,  except,  by 
improper  treatment,  it  should  happen  to  be  converted 
into  a violent  isflammation  of  the  whole  eyelid,  which, 
according  to  Beer,  only  happens  in  weak  subjects,  and 
women  and  children,  whose  skin  is  in  a very  irritable 
state,  or  when  a person  of  apparently  good  constitution 
remains  under  the  influence  of  circumstances  which 
lend  to  augment  the  inflammation,  as,  for  instance,  ex- 
posed to  the  air  of  a stable,  privy,  &c.,  in  which  event. 
Beer  describes  the  inflammation  of  the  eyelids  as  being 
quite  of  a peculiar  description. 

As  for  the  prognosis  in  the  second  stage.  Beer  ob- 
serves, that  if  the  excoriations  at  the  suppurative  pe- 
riod should  spread  all  over  the  edges  of  the  eyelids,  and 
compel  the  patient  to  keep  his  eye  incessantly  shut,  a 
partial  adhesion  of  the  eyelids  to  each  other  (anc/iylo- 
blepharon)  may  be  the  result.  Also,  when,  at  either 
of  the  periods  of  the  secretion  of  mucus,  or  at  that  of 
suppuration,  the  patient  is  content  with  merely  soften- 
ing with  warm  water  the  thick  matter  glueing  the  eye- 
lids together,  so  as"  just  to  be  able  to  open  his  eye,  and 
does  not  completely  free  the  eyelashes  from  the  crusts, 
clusters  of  hairs  will  project  inwards  (see  Trichiasis), 
whereby  a secondary  inflammation  of  the  conjunctiva 
of  the  eyeball  will  be  excited,  which,  Beer  says,  should 
be  carefully  discriminated  from  a mere  extension  of 
the  glandular  inflammation  of  the  eyelid.  Such  a tri- 
chiasis, he  observes,  may  easily  become  incurable, 
when  the  edge  of  the  eyelid  is  seriously  injured  by  the 
depth  of  the  excoriations.  But  if  the  suppurative 
process  be  restricted  chiefly  to  the  canthus,  especially 
the  outer  one  (which  case,  according  to  Beer,  is  not 
unfrequent  in  old,  debilitated  subjects  of  a relaxed 
constitution),  and  if  the  excoriations  should  deeply  pe- 
netrate the  commissure  of  the  eyelids,  this  may  be 
completely  destroyed,  and  the  lower  eyelid  everted. 

As  the  state  of  the  atmosphere,  uncleanliness, 
crowded  and  close  places,  &c.  are  considered  by  Beer 
to  be  the  principal  causes  of  the  glandular  inflamma- 
tion of  the  eyelids,  or  simple  purulent  ophthalmy,  one 
of  the  most  important  indications  in  the  first  stage  of 
the  disorder,  seems  to  him  to  be  the  removal  of  these 
hurtful  circumstances.  And  he  declares,  that  if  imme- 
diate attention  be  not  paid  to  such  indication,  it  will 
be  quite  impossible  to  prevent  a dangerous  increase  of 
the  disorder.  A cool  fresh  air,  and  bathing  the  eye 
with  cold  water,  or  a weak  lotion  of  vinegar  and 
water.  Beer  represents  to  be  means  usually  adequate 
to  stifle  this  inflammation  in  its  birth.  In  the  second 
stage,  he  says,  the  indication  is  entirely  different. 

But  also  in  the  beginning  of  this  stage,  and  even  at 
its  second  period,  namely,  that  of  suppuration,  taking 
place,  the  disorder,  according  to  Beer,  seems  for  a short 
time  to  be  benefited  by  the  employment  of  cold  water; 
but  the  consequences  are  rendered  by  such  treatment  a 
great  deal  worse;  for  a fresh  much  more  extensive 
inflammation  of  the  same  kind  again  takes  place.  At 
the  first  period  of  the  second  stage,  viz.  while  the  se- 
cretion is  a pure  mucous  and  sebaceous  matter.  Beer 
says,  that  it  is  absolutely  necessary  to  employ  such  ex- 
ternal means,  as  are  calculated  to  promote  the  action  of 
the  veins  and  absorbents.  For  this  purpose  he  recom- 
mends the  following  collyrium;  R.  Aq.  rosfc  ^iv. 
Hydrarg.  oxymur.  gr.  j.  vel  gr.  dimidium.  Mucil.  sem. 


230 


OPHTHALMY. 


cydon.  3j.  Tinct.  opii  vinos.  3j.  Misce.  This  eye- 
water is  to  be  used  lukewarm  from  four  to  six  times  a 
day,  and  the  eye  afterward  carefully  and  porapletely 
dried.  No  eye  in  this  state,  he  says,  will  bear  more 
than  the  proportion  of  one  grain  of  the  oxyrnuriate  of 
quicksilver,  and  only  seldom  more  than  half  a grain. 

But  as  soon  as  the  suppurative  period  commences, 
attended  with  excoriations,  gentle  astringents,  like  the 
liquor  plumbi  subacetatis,  in  a solution  of  the  lapis  di- 
vinus  (see  Lachrymal  Organs),  should  be  added  to  the 
above  lotion,  for  which  they  may  at  length  be  entirely 
substituted.  And  when  the  suppurative  period  has  ter- 
minated, but  a morbid  secretion  of  mucus  yet  obsti- 
nately continues,  and  threatens  to  become  habitual,  re- 
course should  be  had  without  the  least  delay  to  one  of 
the  following  eye-salves,  a bit  of  which,  about  the  size 
of  a small  pea.  Beer  directs  to  besmeared  once  a day  over 
the  edgesof  the  eyelids.  5;.  Butyr.  recentis  insulsi  1 ss. 
Hydrargyri  nitrico-oxydi  gr.  x.  Tutiee  pit.  gr.  vj. 
Misce.  This  ointment,  he  says,  will  sometimes  answer ; 
but,  that  it  is  mostly  necessary  to  use  Janin’s  salve, 
composed  as  follows ; R.  Butyri  recentis  insulsi  ^ss. 
Hydrargyri  praecipitati  albi  gr.  xv,  Boli  albi  3j.  Misce. 
I According  to  Mr.  Travers,  the  mild  acute  suppura- 
tive inflammation  of  the  conjunctiva  is  not  attended 
with  that  excessive  swelling  of  the  eyelids,  that  intense 
pain,  nor  that  profuse  secretion,  with  which  the  vehe- 
ment acute  form  of  the  disease  is  characterized.  In 
the  treatment,  he  directs  a solution  of  alum  to  be  early 
substituted  for  emollient  fomentations,  which  he  re- 
commends to  be  freely  used  during  the  acute  period. 
Simple  purging  and  abstinence,  he  says,  are  generally 
sufficient  to  allay  the  febrile  irritation,  which  is  mode- 
rate. Topical  bleedings,  and  blisters,  kept  open  on  the 
back  of  the  neck,  are  also  staled  to  be  of  great  efficacy. 
“ When  the  pain  and  irritability  to  light  subside,  and 
the  discharge  becomes  gleety,  the  conjunctiva  pale  and 
flaccid,  tonics,  especially  the  extract  of  bark  and  the 
acids,  do  great  gooA."— (^Synopsis,  Src.  p.  264.) 

Catarrhal  ophthalmy,  so  called  by  Beer,  is  described 
by  him  as  a species  of  glandular  inflammation  of  the 
eyelids,  attended  with  a simultaneous  affection  of  the 
mucous  membrane  of  the  nose,  trachea,  &c.,  brought 
on  by  particular  states  of  the  weather,  and  attacking 
so  many  persons  at  once,  as  to  appear  epidemic.  The 
prognosis  and  indications  are  the  same  as  those  in 
common  glandular  inflammation  of  the  eyelids;  with 
this  exception,  that  attention  must  be  paid  to  the  affec- 
tion of  other  organs,  and  both  at  the  first  and  second 
periods  of  the  second  stage,  such  remedies  given  as 
operate  powerfully  on  the  mucous  membranes  and 
skin,  and,  in  general,  during  the  second  stage,  an  equal, 
warm  temperature,  and  gentle  diaphoretics,  with  cam- 
phor, are  highly  beneficial. 

Severe  Purulent  Ophthalmy. — The  Blepharo-hlen- 
norrhoea  and  Ophthalmo-blennoiThxa,  of  Schmidt  and 
Beer;  including  the  ophthalmia  neonatorum,  Ih^  Egyp- 
tian ophthalmy,  the  gonorrhceal  ophthalmy,  Src. ; on 
which  varieties,  however,  I shall  annex  to  this  ac- 
count some  further  particulars,  as  they  relate  to  each 
of  these  cases  individually;  because,  though  the  fol- 
lowing history  contains  an  excellent  geneial  descrip- 
tion of  the  severe  forms  of  suppurative  inflammation 
of  the  conjunctiva,  it  leaves  unexplained  some  of  the 
circumstances  on  which  its  varieties  depend. 

The  vehement  acute  suppurative  inflammation  of 
the  conjunctiva  is  described  by  Mr.  Travers  as  being 
sudden  in  its  attack  ; a feature  in  which  it  particularly 
differs  from  the  milder  cases,  usually  met  with  in 
schools. — (See  Lloyd  on  Scrof  ula,  p.  32J .)  It  is  accom- 
panied with  most  severe  darting  pains ; and  the  upper 
eyelid  is  sometimes  in  a few  hours  prolonged  upon  the 
cheek,  owing  to  the  infiltration  and  enormous  swelling 
of  the  tissue,  connecting  the  conjunctiva  to  the  tarsus. 
— {Travers,  Synopsis,  ^c.  p.  265.) 

According  to  Beer,  the  modification  of  glandular  in- 
flammation of  the  eyelids,  here  to  be  considered,  con- 
sists entirely  in  the  rapid  extension  of  the  inflammation 
and  suppuration,  the  disorder  affecting,  ere  it  is  suspect- 
ed, not  only  the  w hole  of  the  conjunctiva  of  the  eye- 
lid, but  also  that  of  the  eyeball,  and  the  sclerotica  and 
cornea.  The  swelling  of  the  palpebral  conjunctiva  is 
described  by  Beer  as  being  unusually  great;  at  first  soft, 
somewhat  elastic,  smooth,  and  readily  ble.eding;  but 
afterward,  in  the  second  stage,  hard  and  granulated, 
or,  as  another  writer  says,  it  “ becomes  preiernaiurally 
vascular,  thickened,  and  scabrous,  or  forms  fleshy  emi- 


nences.”—(Travers,  Synopsis,  i-c.  p.  96.)  The  first 
stage  is  rapidly  over.  At  the  first  period  of  the  second 
stage,  the  secretion  both  of  mucus  aiid  pus  is  surprisingly 
copious.  First,  the  mucus  is  whitish  and  thin  ; but  as 
soon  as  the  suppurative  process  begins,  it  becomes  yel- 
lowish and  thick,  and  when  an  attempt  is  made  to 
open  the  eyelids,  it  gushes  out  with  such  force,  and  in 
so  large  a quantity,  as  frequently  to  cover  in  an  instant 
the  whole  cheek.  Sometimes  this  mixture  of  mucus 
and  matter  contains  light-coloured  streaks  of  blood ; 
but  in  worse  cases,  these  streaks  are  dark  and  brown- 
ish, or  else  a thin  iefior  is  discharged,  in  which  case  the 
progress  of  the  disease  is  so  rapid,  that  the  eye  can  sel- 
dom be  saved.  The  swelling  of  the  conjunctiva  of  the 
eyelids,  especially  of  that  of  the  upper  one,  always  in- 
creases during  the  first  period  of  suppuration,  and, 
when  the  discharge  is  more  ichorous,  the  membrane  is 
more  granulated,  so  that,  if  the  eyelid  be  opened  care- 
lessly, or  during  the  child’s  crying,  fits  of  paiti,  &c.,  the 
whole  tumefied -conjunctiva  of  the  upper  eyelid  is  im- 
mediately thrown  outward,  in  the  form  of  ecuopium, 
and  it  is  sometimes  difficult,  and  even  impracticable,  fo 
turn  the  part  inward  again,  especially  when  the  con- 
junctiva is  already  changed  into  a hard  sarcomatous 
substance.  While  the  swelling  at  the  inner  surface  of 
the  eyelids  continues  to  increase,  their  outer  surface, 
particularly  that  of  the  upper  one,  becomes  reddened; 
but  the  redness  is  dark-coloured,  inclining  to  brown, 
and  when  the  child  cries  to  blue.  In  children,  the 
whole  cheek  on  the  affected  side  is  very  often  swelled, 
and  sometimes  the  mucous  membrane  of  the  lachrymal 
sac,  and  even  of  the  nose,  participates  in  the  effects  of 
the  disorder.  Sometimes  at  first,  only  one  eye  is  affect 
ed,  and  the  other  is  afterward  attacked.  And,  ac- 
cording to  Beer,  just  before  the  period  of  suppuration, 
it  is  by  no  means  uncommon  for  rather  a profuse  bleed- 
ing to  lake  place  from  the  eye  ; an  event  which,  though 
it  seriously  alarm  the  parents  of  the  child,  or  an  adult 
patient,  is  hailed  by  the  experienced  surgeon  as  a fa 
vourable  omen  ; for  in  such  cases,  the  suppuration  is  ge- 
nerally very  mild,  and  not  of  a destructive  kind,  and  the 
swelling  of  the  conjunctiva  of  the  eyelids,  as  well  as 
that  of  the  sclerotic  conjunctiva,  if  already  present,  soon 
undergoes  a remarkable  diminution  after  such  hemor 
rhage,  which  often  occurs  two  or  three  limes.  When, 
during  the  first  very  short  and  transient  stage,  the  in 
flammation  extends  also  to  the  sclerotic  conjunctiva, 
this  membrane  forms  a pale-red,  soft,  irregular  swell 
ing,  all  round  the  cornea,  which  at  length  seems  so 
buried,  that,  at  the  period  of  the  mucous  secretion,  its 
centre  can  hardly  be  discerned ; and,  when  Suppuration 
begins,  both  mucus  and  pus  are  discharged  from  the 
conjunctiva  of  the  eyeball  in  profuse  quantity,  particu 
larly  accumulating  over  the  cornea,  and  not  uiifre- 
quently  drying  into  a thick  pellicle,  wlien  long  detained 
in  the  eye.  Hence,  the  case  looks  as  if  the  whole  eye- 
ball, or,  at  least,  all  the  cornea,  were  in  a state  of  com- 
plete suppuration.  At  length,  the  tumefied  conjunc 
tiva  of  the  eyeball  becomes  sarcomatous,  though  never 
in  such  a degree  as  that  of  the  eyelids.  When  the  sup- 
purative period  ceases,  and  with  it  the  most  urgent 
danger  to  the  eye,  the  secretion  of  mucus  alone  con- 
tinues, as  at  the  first  period  of  the  second  stage ; the 
swelling  of  the  conjunctiva  of  the  eyelids,  and  of  the 
sclerotic  conjunctiva  when  this  has  also  been  affected, 
diminishes;  and  the  disorder  ends  in  an  increased  effu- 
sion of  tears,  or  true  epiphoia.  When  the  effects  of 
the  suppuration  upon  the  conjunctiva  of  the  eyeball  are 
more  severe,  the  corneal  production  of  this  membrane 
in  the  most  favourable  cases  is  raised  from  the  subja- 
cent cornea,  and  so  opaque,  that  the  eyesight  is  lost,  or  at 
all  events  seriously  impaired,  until  the  transparency  re- 
turns, which  is  sometimes  late,  especially  when' effi- 
cient treatment  is  not  put  in  practice.  Should  the  sup- 
puration be  very  deep,  the  cornea,  which  ahvays  turns 
whiter  and  whiter,  presents  near  the  edge  of  the  swell- 
ing of  the  conjunctiva  an  arrangement  similar  to  that 
of  the  leaves  of  an  old  book,  and  at  length  seems  con- 
verted into  a mass  of  purulent  matter,  which  projects 
more  and  more  out  of  the  depression  in  the  swelled 
conjunctiva,  and  then  bursts  in  its  centre  either  quickly 
and  with  very  violent  pain,  or  slowly  without  any  suf- 
fering, an  oval  hole  being  left,  behind  which  the  yet 
transparent  crystalline  lens  ajtpears,  included  in  its  un- 
damaged capsule.  At  this  period,  adults  can  often  see 
very  plainly,  and  fancy  their  recovery  near  at  hand,  or, 
at  least,  all  danger  over.  Already,  however,  every 


OPHTHALMY. 


231 


part  of  the  cornea  has  been  more  or  less  perforated  by 
utceration,  the  iris  protrudes  through  all  these  apertures 
so  as  to  form  what  has  sometimes  been  named  the  sta- 
phyloma racemosum.  In  a.  very  short  time,  not  ex- 
ceeding a few  hours,  the  capsule  of  the  lens  is  atfected 
and  burns  like  the  cornea,  when  it  is  discharged,  either 
with  or  without  a portion  of  the  vitreous  humour. 
At  length,  the  suppuration  subsides,  and  with  it  the 
protrusions  of  the  iris,  the  opening  in  the  cornea  be- 
coming closed  with  a brown  or  bluish  opaque  flat  cica- 
trix. But  if  in  this  destructive  form  of  suppuration, 
nothing  is  done  for  the  relief  of  the  disease,  the  whole 
eyeball  suppurates,  the  eyelids  become  concave  instead 
of  convex,  and  the  fissure  between  thenr  closes  for  ever. 
In  adults  of  feeble  constitution,  when  the  case  is  not 
properly  treated,  but  particularly  in  weak  children,  this 
excessively  violent  form  of  conjunctival  inflammation 
and  suppuration  spreads  with  such  rapidity,  that  a con- 
siderable general  disturbairce  of  the  system  is  occa- 
sioned. Indeed,  according  to  Mr.  Travers,  in  the  com- 
mon course  of  this  vehement  form  of  conjunctival  sup- 
purative ophthalmy,  the  system  sympathizes;  chilliness 
is  succeeded  by  a hot  and  dry  skin  ; and  the  pulse  is 
frequent  and  hard.  Yet  it  is  particularly  pointed  out 
by  the  army  surgeons,  that  one  peculiarity  of  the  Egyp- 
tian purulent  ophthalmy  is  its  being  generally  attended 
with  little  constitutional  disturbance.  When  the  above- 
described  annihilation  of  the  eyeball  takes  place,  it  al 
ways  creates  violent  general  indisposition  in  unhealthy, 
weak  children,  and  even  leaves  adults  for  a long  while 
afterward  in  an  impaired  state  of  health. 

According  to  Beer,  who  appears  to  have  no  idea  of 
infection  being  concerned,  the  particular  cause  of  this 
unfortunate  extension  of  idiopathic  glandular  inflam- 
mation of  the  eyelids,  both  in  infants  and  adults,  fre- 
quently depends  altogether  upon  the  foul  atmosphere 
in  which  they  are  residing,' and  hence,  says  he,  the  dis- 
order is,  as  it  were,  endemic  in  lying-in  and  foundling 
hospitals,  where  the  air  is  much  contaminated  by 
efiduvia  from  the  lochia,  the  crowding  together  of  many 
uncleanly  persons,  dirty  clouts,  &c.  The  unjustifi- 
able folly  of  exposing  the  eyes  of  new-born  infants 
to  every  degree  of  light ; a tedious  labour,  in  which  the 
child’s  head  is  detained  a long  while  in  the  vagina,  and 
« roughly  washing  the  eyes  after  birth  with  a coarse 
sponge,  are  other  circumstances  supposed  by  Beer  to 
be  conducive  to  the  origin  of  the  complaint  in  new- 
born infants.  The  reality  of  many  of  these  causes  I 
regard  myself  with  a great  deal  of  doubt ; and  as  for 
his  conjecture,  that  sprinkling  cold  water  on  the  head 
in  baptism,  while  in  a state  of  perspiration,  may  produce 
the  complaint,  it  is  too  absurd  to  need  any  serious  re- 
futation. The  disorder,  he  says,  is  always  more  rapid 
and  {)erilous  in  new-born  infants  than  adults  {B.  l.p. 
318) ; a remark  which  does  not  agree  with  the  state- 
ments usually  made,  if  the  Egyptian  ophthalmy,  as 
seen  in  the  army,  be  comprehended.  It  is  observed  by 
Mr.  Travers,  that  the  highly  contagious  nature  of  the 
suppurative  ophthalmia,  whether  in  the  mild  or  vehe- 
ment acute  form,  is  sufficiently  proved.  For  one  per- 
son, affected  with  this  disease,  above  three  months  old, 
he  thinks  at  least  twenty  are  attacked  under  that  age. 
“The  mother  is  the  subject  of  fluor  albus,  or  gonor- 
rhoea, and  the  discharge  is  usually  perceived  about  the 
third  day.’’ — {Synopsis,  irc.'p.  97.)  Some  farther  ob- 
servations on  the  causes  of  some  of  these  severe  modifi- 
cations of  glandular  inflammation  of  the  eyelids  will  be 
introduced,  after  the  prognosis  and  treatment  have  been 
considered.  This  will  be  the  more  necessary,  as  the  pro- 
pagation of  the  disorder  by  infection  is  here  entirely 
overlooked. 

According  to  Beer,  whenever  an  idiopathic  inflam- 
mation of  the  glands  of  the  eyelids  attains  the  severe 
forms  exhibited  in  the  purulent  ophthalmy  of  infants, 
the  Egyptian  ophthalmy,  and  gonorrhoeal  ophthalmy, 
the  prognosis  must  naturally  be  unfavourable,  and  this 
in  a greater  degree,  the  more  the  inflammation  and  sup- 
puration have  extended  to  the  eyeball  itself.  The  cases 
are  still  more  unpromising,  when  they  happen  in  poor, 
half-starved,  distressed  individuals  whom  it  is  impos- 
sible completely  to  extricate  from  the  circumstances 
which  either  cause,  or  have  a pernicious  effect  upon, 
the  disease.  Should  an  incidental  ectropium  not  be 
immediately  rectified,  says  Beer,  it  will  continue  until 
the  end  of  the  second  stage,  and  even  frequently  longer, 
BO  as  to  require  particular  treatment.  When  at  the  pe- 
riod of  auppuration,  merely  the  layer  of  the  conjunctiva 


spread  over  the  cornea  is  destroyed,  the  prognosis,  in 
respect  to  the  complete  recovery  of  the  eyesight,  is  fa- 
vourable, although  it  takes  place  but  slowly.  If  the 
effects  of  the  disease  at  this  period  should  be  deeper, 
yet  the  cornea  not  destroyed,  only  rendered  flat  and 
somewhat  opaque  ; or  if  the  cornea  should  be  ulcer- 
ated at  a very  limited  point,  there  will  remain,  in  the 
first  case,  an  opacity  of  the  cornea ; but  in  the  second, 
a partial  adhesion  of  the  iris  to  the  latter  membrane 
(synechia  anterior)  is  apt  to  follow,  with  a more  or  less 
extensive  cicatrix  on  the  cornea,  covering  in  a greater 
or  less  degree  the  lessened  and  displaced  pupil,  and 
thus  diminishing  or  preventing  vision.  When,  during 
the  inflammation  and  suppuration,  a considerable  part 
or  the  whole  of  the  iris  adheres  to  the  cornea,  and  this 
is  not  penetrated  by  ulceration,  the  result,  in  the  first 
case,  is  a partial,  in  the  second,  a complete  staphyloma 
of  the  cornea,  which  does  not  fully  develope  itself  until 
towards  the  decline  of  the  second  stage  of  the  ophthal- 
mo-blennorrhcea.  If  the  inflammation  should  spread 
to  the  textures  of  the  eyeball  itself,  so  as  to  produce  se- 
vere constitutional  disturbance,  the  eye  wastes  away  in 
the  midst  of  the  profuse  discharge,  the  eyelids  sink  in- 
wards, and  the  fissure  ttitween  them  becomes  perma- 
nently closed. — {Beer,  b.  l,p.  319.) 

Beer  notices  the  opinion  of  the  celebrated  Schmidt, 
which  was,  that  the  ophthalmo-blennorrhoea,  or  puru- 
lent ophthalmy  involving  the  sclerotic  conjunctiva,  al- 
ways has  a fixed  duration  of  a month,  in  new-born 
infants,  and  of  six,  eight,  or  twelve  weeks  in  debilitated 
individuals.  Beer  acknowledges  the  correctness  of 
this  opinion,  only  in  cases  where  the  surgeon  has  to 
deal  with  a completely  formed  ophthalmo-blennorrhoea, 
and  not  in  a more  recent  case,  or  one  in  which  the  dis- 
ease is  chiefly  confined  to  the  inside  of  the  eyelids, — 
iBlepharo-blcnnorrhaa.)  When  the  disorder  is  met 
with  in  the  first  period  of  the  second  stage,  or  it  is  con- 
fined to  the  palpebral  conjunctiva  and  Meibomian 
glands,  and  truly  idiopathic,  Beer  asserts  that  its  course 
may  be  restricted  bjf  efficient  treatment  to  a few  days, 
as  he  has  often  proved  in  the  establishment  for  found- 
lings at  Vienna. 

It  is  farther  remarked  by  Beer,  that  in  this  modifica- 
tion of  genuine  idiopathic  glandular  inflammation  of 
the  eyelids,  the  indications  have  something  peculiar  in 
them.  If,  by  chance,  the  surgeon  meet  with  the  dis- 
ease in  its  first  stage,  it  will  be  most  benefited  by  the 
application  of  folded  linen  wet  with  cold  water ; and 
sometimes  a brisk  purge  of  jalap  and  calomel,  and  put- 
ting a leech  over  the  lachrymal  sac  at  the  inner  canthus, 
will  promote  the  subsidence  of  this  dangerous  species 
of  ophthalmy.  The  case,  however,  rarely  presents 
itself  for  medical  treatment  thus  early,  and  in  hospitals, 
Beer  says,  antiphlogistic  treatment  is,  on  this  account, 
hardly  ever  indicated. 

With  some  exceptions  of  importance,  the  treatment 
advised  by  Beer,  for  the  second  stage  of  these  severer 
forms  of  purulent  ophthalmy,  resembles  that  proposed 
by  him  for  the  second  stage  of  simple  glandular  inflam- 
mation of  the  eyelids,  or  the  milder  varieties.  These 
more  severe  kinds  of  purulent  inflammation  of  the  eye, 
implied  by  blepharo-blennorrhcea  and  ophthalmo-bJen- 
norrhcea,  he  says,  should  never  be  viewed  and  treated 
merely  as  local  disorders;  but  that,  both  in  children 
and  adults,  internal  remedies  should  be  exhibited,  parti- 
cularly volatile  tonic  medicines.  In  cases  where  the 
cornea  is  already  attacked  by  a destructive  ulcerative 
process,  manifold  experience  has  convinced  him  that 
bark,  combined  with  naphtha,  and  the  tincture  of  opi- 
um, is  the  only  means  of  saving  the  eye ; but  that,  if 
the  suppuration  be  confined  to  the  eyelids,  the  decoction 
of  calamus  aromaticus  with  naphtha  and  opium  will 
mostly  answer.  When,  on  the  supervention  of  sup- 
puration, the  pain  in  the  eye  and  neighbouring  parts  is 
excessively  severe.  Beer  assures  us,  that  friction  with 
a liniment  of  opium  will  give  great  relief.  In  new- 
born infants,  the  maternal  milk  of  right  quality  will 
mostly  do  more  good  than  internal  medicines : but  if 
the  case  be  urgent,  and  the  child  feeble.  Beer  thinks  vo- 
latile medicines  may  sometimes  be  useful. 

With  respect  to  particularities,  made  necessary  in 
the  local  treatment  by  the  modified  nature  of  the  in- 
flammation, Beer  otfers  the  following  information: 
first,  in  new-born  infants,  or  very  young  children,  the 
oxymuriaie  of  mercury  cannot  be  used  without  dan- 
ger, though  blunted  with  mucilage;  abd  even  in  adults 
it  should  be  employed  in  these  cases  with  great  circum 


232 


OPHTHALMY. 


spection.  Secondly,  the  mucus  and  purulent  matter 
should  not  be  allowed  to  remain  long  under  the  eyelids, 
as  such  lodgement  is  found  to  promote  the  destruction 
of  the  layer  of  the  conjunctiva  situated  on  the  cor- 
nea; but  at  the  same  time.  Beer  thinks,  that  leaving 
any  water  on  the  eyes,  after  cleaning  them,  and  letting 
it  become  cold  there,  will  have  quite  as  pernicious 
an  effect.  Hence,  he  is  very  particular  in  directing  all 
the  mucus  and  purulent  matter  to  be  wiped  away  from 
the  eye  with  a bit  of  fine  sponge,  moistened  with  a 
warm  mucilaginous  collyrium,  but  not  so  wet  as  to  let 
the  fluid  drop  out  of  it ; or  when  they  are-very  copious 
and  in  large  flakes,  he  even  recommends  them  to  ba 
washed  away  by  means  of  Anel’s  syringe ; but  he  says 
that  every  part  about  the  eye  should  be  immediately 
afterward  well  dried  with  a warm  napkin,  and  then 
covered  with  a warm  camphorated  compress.  Thirdly, 
during  the  suppurative  period,  according  to  Beer,  com- 
mon tincture  of  opium,  or  the  vinous  tincture,  is  the 
best  local  application,  the  parts  being  smeared  with  it 
twice  a day,  by  means  of  a fine  camel-hair  brush.  It 
is  only  in  a few  instances,  that  a small  proportion  of 
the  lapis  divinus  {see  Lachrrymal  Organs),  mixed  with 
the  mucilaginous  collyrium,  caj;i  be  endured.  Beer  de- 
clares, that  he  has  never  seen  any  good  produced  by 
Bates’s  camphorated  lotion,  which  was  so  highly  praised 
by  the  late  Mr.  Ware.  Fourthly,  when  the  suppurative 
period  has  terminated,  the  mucous  secretion  again  be- 
comes white  and  thin,  as  at  the  very  commencement 
of  the  second  stage,  but  it  is  always  more  copious  ; 
now  is  the  time  (as  in  ihp  last  stage  of  simple  glandu- 
lar inflammation  of  the  eyelids)  when  the  topical  use 
of  mercury,  joined  with  styptics,  especially  in  the  form 
of  an  eye-salve,  is  indicated.  Fifthly,  if  an  eversfon 
of  the  upper  eyelid  should  happen  from  washing  thj 
eye  carelessly,  or  the  mere  crying  of  the  infant,  in  con- 
sequence of-  the  thickened  granulated  state  of  the  pal- 
pebral conjunctiva,  the  position  of  the  eyelid  must,  if 
possible,  be  immediately  rectified ; for  afterward  this 
cannot  be  done.  In  order  to  avoid  this  ectropium,  the 
eyelids  should  never  be  opened  while  the  child  is  cry- 
ing, or  in  .any  way  agitated;  for  at  such  periods,  the 
thickened  scabrous  conjunctiva  will  suddenly  pro- 
trude, and  cannot  be  kept  back.  Beer  says,  that  the 
eyelid  should  be  replaced  in  the  manner  directed  by 
Schmidt. — {Ophthal.  Bibl.  3,  b.  2,  Stiick,  p.  149.)  The 
surgeon,  having  smeared  the  ends  of  the  thumb  and 
fore-finger  of  each  of  his  hands  with  fresh  butter,  is 
to  take  hold  of  the  everted  cartilage  of  the  eyelid  at 
the  outer  and  inner  canthus,  draw  it  slowly  a little  up- 
wards, and  then  suddenly  downwards.  Thus  the  thick- 
ened conjunctiva,  if  not  too  fleshy  and  granulated,  may 
be  quickly  reduced,  and  the  ectropium  removed.  But 
if  the  swelling  of  this  membrane  should  be  already 
very  considerable,  and  have  begun  to  be  hard  and  stud- 
ded with  excrescences,  the  thumbs  should  be  placed  so 
as  to  compress  rather  the  middle  of  the  eyelid.  How- 
ever, if  the  ectropium  cannot  be  at  once  removed,  it  is 
to  be  treated,  after  the  termination  of  the  second  stage 
of  the  purulent  ophthalmy,  as  a sequel  of  this  disorder. 
— (See  Ectropium.) 

In  the  ophthalmo-blennorrhcea,  the  alteration  of  the 
sclerotic  conjunctiva  is  said  by  Beer  to  be  very  differ- 
ent from  chemosis ; a remark  whicji  is  strictly  correct, 
inasmuch  as  ordinary  chemosis  is  not  attended  with 
that  change  in  the  surface  of  the  sclerotic  conjunctiva, 
which  fits  it  for  the  secretion  of  pus.  But  if  we  are  to 
understand  by  chemosis  a copious  effusion  of  lymph  in 
the  loose  cellular  substance  between  the  conjunctiva 
and  the  eyeball,  this  state  must  be  admitted  as  one  of 
the  usual  effects  of  severe  purulent  ophthalmy. 

“ It  is  after  this  morbid  condition,  which  is  charac- 
teristic of  the  suppurative  ophthalmia  (says  Mr.  Tra- 
vers), that  the  conjunctiva  forms  fungous  excrescences, 
pendulous  flaps,  or  hard  callous  rolls  protruding  be- 
tween the  palpebrre  and  globe,  and  everting  the  former, 
or,  if  not  protruding,  causing  the  turning  of  the  lid 
over  against  the  globe.  The  tarsal  portion  takes  on 
from  the  same  cause  the  hard  granulated  surface,  which 
keeps  up  incessant  irritation  of  the  sclerotic  conjunc- 
tiva, and  at  length  renders  the  cornea  opaque.” — {Sy- 
nopsis, Src.  p.  98.) 

The  treatment  recommended  by  Mr.  Travers  for  the 
vehement  acute  suppurative  inflammation  of  the  con- 
junctiva, consist^  in  a very  copious  venesection,  by 
which,  he  says,  the  pain  is  mitigated,  if  not  removed  ; 
the  pulse  softened  ; and  the  patient  sinks  into  a sound 


sleep,  and  perspires  freely.  The  high  scarlet  hue  and 
bulk  of  the  chemosis  are  sensibly  reduced,  and  the  cor- 
nea is  brighter.  The  blood-letting,  if  necessary,  is  to 
be  repeated,  and  the  patient  briskly  purged,  every  dose 
of  the  opening  medicine  being  followed  by  a tea-spoon- 
ful of  a solution  of  emetic  tartar,  so  as  to  keep  up  a 
state  of  nausea,  perspiration,  and  faintness.  When 
the  discharge  becomes  thin,  gleety,  and  more  abundant, 
the  swelling  of  the  eyelid  subsides,  the  conjunctiva 
sinks  and  becomes  pale  and  flabby,  the  pain  and  febrile 
irritation  are  past,  and  the  cornea  retains  its  tone  and 
brightness,  Mr.  Travers  considers  the  case  safe,  and 
stales  that  the  prompt  exhibition  of  tonics,  with  the 
use  of  cooling  astringent  lotions,  will  prevent  its  laps- 
ing into  a chronic  form.  “ But  if,  when  the  lowering 
practice  has  been  pushed  to  the  extent  of  arresting 
acute  inflammation,  the  patient  being  at  the  same  time 
sunk  and  exhausted,  the  cornea  shows  a lack  lustre 
and  raggedness  of  its  whole  surface,  as  if  shrunk  by 
immersion  in  an  acid,  or  a gray  patch  in  the  centie,  or 
a line  encircling  or  half-encircling  its  base,  assuming  a 
similar  appearance,  the  portion  so  marked  out  will  in- 
fallibly be  detached  by  a rapid  slough,  unless  by  a suc- 
cessful rally  of  the  patient’s  powers,  we  can  set  up  the 
adhesive  inflammation,  so  as  to  preserve  in  situ  that 
which  may  remain  transparent.” — {Synopsis,  <S-c.  p. 
266.)  Here  we  find  some  approximation  of  practice 
between  Mr.  Travers  and  Professor  Beer ; but  it  is  al- 
most the  only  point  in  which  any  resemblance  can  be 
found  in  their  modes  of  treatment. 

The  granulated  or  fungous  state  of  the  palpebral 
conjunctiva,  produced  by  purulent  ophthalmy,  sonre- 
times  demands  particular  treatment  after  the  original 
disease  is  subdued.  If  such  stale  of  the  eyelid  be  not 
rectified,  it  often  keeps  up  a “ gleety  discharge,  irrita- 
bility to  light,  drooping  of  the  upper  lid,  a pricking 
sensation  as  of  sand  in  the  eye,  and  a preternalurally 
irritable  and  vascular  slate  of  the  sclerotic  conjunctiva ; 
with  these  are  frequently  combined  opacities  of  the 
cornea.” — {Travers,  op.  cit.  p.  271.)  The  affection,  as 
conjoined  with  opaque  cornea,  is  particularly  noticed 
by  Dr.  Vetch,  who  describes  the  disease  of  the  pal- 
pebrse  as  consisting,  at  first,  in  a highly  villous  state  of 
their  membranous  lining,  which,  if  not  treated  by  ap- 
propriate remedies,  gives  birth  to  granulations,  which 
in  process  of  time  become  more  deeply  sulcated,  hard,  * 
or  warty.  Along  with  the  villous  and  fleshy  appear 
ance  of  the  lining  of  the  eyelids,  there  is  a general 
oozing  of  purulent  matter,  which  may  at  any  time  be 
squeezed  out  by  pressing  the  finger  on  the  part.  The 
diseased  structure  is  highly  vascular,  and  bleeds  most 
profusely  when  cut.  It  possesses,  as  all  granulated  sub- 
stances do,  a very  great  power  of  growth,  or  reproduc- 
tion. Dr.  Vetch  has  seen  many  cases  in  which  it  has 
been  removed  with  more  zeal  than  discretion,  twenty 
or  thirty  times  successively,  without  this  disposition  to 
reproduction  having  suffered  any  diminution.  Indeed, 
he  assures  us  that  the  operation  was  very  unfavour- 
able to  the  ultimate  recovery  of  the  part;  “ a new  sur- 
face is  produced  of  a bright  velvety  appearance,  much 
less  susceptible  of  cure  than  the  original  disease,  and 
which,  even  if  at  length  healed,  does  not  assume  the 
natural  appearance  of  the  part,  but  that  of  a cicatrized 
surface,”  not  attended  with  a return  of  the  transpa- 
rency of  the  cornea.  It  is-satisfar.torily  proved  by  the 
observations  of  Dr.  Vetch,  that  this  diseased  stale  of  the 
inner  surface  of  the  eyelid  was  not  only  known  to  Rhases 
and  other  old  practitioners,  under  the  names  of  sycosis, 
trachoma,  scabies  palpebrarum,  &c.,  but  that  its  treat- 
ment by  the  actual  cautery,  excision,  and  friction  was 
also  recommended  by  them.  The  honour  of  having 
introduced  the  preferable  mode  of  cure  with  escharo- 
tics.  Dr.  Vetch  assigns  to  St.  Ives.  No  substances 
appear  to  Dr.  Vetch  more  effectual  for  this  purpo.se 
than  the  sulphate  of  copper  and  nitrate  of  silver.  He 
says  that  they  should  be  pointed  in  the  form  of  a pen- 
cil, atid  fixed  in  a port-crayon.  “They  are  to  be  ap- 
plied, not  as  some  have  conceived,  with  the  view  of 
producing  a slough  over  the  whole  surface,  but  with 
great  delicacy,  and  in  so  many  points  only  as  will  pro- 
duce a gradual  change  in  the  condition  and  disposition 
of  the  part.”  As  long  as  any  purulency  remains.  Dr. 
Vetch  states  that  the  above  a|iplications  will  be  much 
aided  by  the  daily  use  of  the  liquor  plumbi  subacefntis. 
When  the  di.sease  resists  the.se  remedies,  and  the  sur- 
face is  hard  and  warty,  he  applies  very  minute  quanti- 
ties of  finely-levigated  powder  of  verdigris,  or,  burnt 


OPHTHALMY. 


233 


alum,  to  the  everted  surface  with  a fine  camel’s-hair 
ncil,  but  carefully  washes  them  off  with  a syringe 
fore  the  eyelid  is  returned.  The  caustic  potassa, 
lightly  applied  to  the  more  prominent  parts  of  the  dis- 
eased surface,  will  also  answer. — (See  Vetch  on  Dis- 
eases of  the  Eye,  p,  73,  Src.)  Mr.  Lloyd  also  gives  his 
testimony  ■ in  favour  of  the  superiority  of  the  nitrate 
of  silver,  which  he  has  employed  in  the  form  of  a sa- 
turated solution  for  restoring  the  healthy  state  of  the 
inner  surface  of  the  eyelid. — {On  Scrofula,  p.328.) 
The  practice  of  excision  was  followed  by  the  ancients, 
and  revived  of  late  years  in  England  by  Mr.  Saun- 
ders, who  did  with  scissors  what  Sir  W.  Adams  and 
others  have  subsequently  performed  with  a knife  or 
lancet.  Mr.  Travers,  I may  observe,  is  also  one  of  the 
advocates  for  the  excision  of  the  granulations  and 
hardened  excrescences  of  the  conjunctiva.  If  there 
be  a nebula  of  the  cornea,  with  a plexus  of  vessels  ex- 
tending to  it,  these  are  then  divided  near  the  edge  of 
the  cornea,  in  the  manner  recommended  by  Scarpa. 
Mr.  Travers  afterward  applies  a solution  of  the  sul- 
phate of  copper,  the  liquor  plunibi  subacetatis,  or  the 
vinous  tincture  of  opium.  One  remark  which  he 
makes  tends  very  much  to  confirm  the  general  advan- 
tage of  the  practice  inculcated  by  Dr.  Vetch  ; for,  it  is 
observed,  “ the  application  of  the  blue-stone,  or  of  the 
lunar  caustic,  is  often  useful  in  preventing  the  regene- 
ration of  the  granulations  after  their  excision.”— (Sy- 
nopsis, (S-c.  p.  272.)  My  friend  Mr.  Lawrence,  whose 
experience  in  diseases  of  the  eye  is  very  considerable, 
informs  me  that  he  finds  caustic  the  sure  mode  of  per- 
manently removing  the  granulated  fungous  state  of 
the  inner  surface  of  the  eyelid,  and  that,  when  the 
granulations  are  cut  away,  they  are  frequently  repro- 
duced ; a fact  on  which  Dr.  Vetch  has  particularly  in- 
sisted. 

Egyptian  Ophthalmy.  One  of  the  best  accounts  of 
this  disease,  as  it  appeared  in  the  army,  is  that  deli- 
vered by  Dr.  Vetch.  Although  there  can  be  no  doubt 
that  the  disorder,  in  all  its  general  characters,  closely 
corresimnds  to  the  severe  form  of  acute  suppurative 
inflammation  of  the  conjunctiva,  as  described  by 
Beer,  yet  it  has  some  peculiarities.  Thus,  one  thing 
noticed  in  the  Egyptian  oi>hthalmy,  but  not  in  other 
purulent  ophthalmies,  is,  that  the  first  appearance  of 
inflammation  was  observable  in  the  lining  of  the  lower 
eyelid. — {Peach,  in  Edin.  Med.  and  Surgical  Journ. 
for  January,  1807  ; Vetch,  on  Diseases  of  the  Eye,  p. 
196.)  According  to  the  latter  writer,  the  feeling  of 
dirt  or  sand  rolling  in  the  eye,  is  a symptom  requiring 
particular  attention,  as  its  accession  is  a certain  index 
of  the  disease  being  on  the  increase.  It  is  subject  to 
exacerbations  and  remissions,  the  attacks  always  tak- 
ing place  in  the  evening,  or  very  early  in  the  morning. 
The  first  stage  of  the  disease  is  said  by  Dr.  Vetch  to  be 
characterized  by  its  great  and  uniform  redness,  without 
that  pain,  tension,  or  intolerance  of  light,  which  ac- 
companies most  other  forms  of  ocular  inflammation  ; 
and,  in  particular,  that  in  which  the  sclerotic  coat  is 
affecleij.  From  the  very  beginning  of  the  complaint, 
there  is  a dispo.«iiion  to  puffiness  in  the  cellular  texture 
between  the  conjunctiva  and  the  globe  of  the  eye, often 
suddenly  swelling  out  into  a state  of  complete  chemosis, 
and  at  other  times  making  a more  gradual  approach  to 
the  cornea.  While  effusion  is  thus  taking  place  upon 
the  eye,  oedema  is  likewise  going  on  beneath  the  in- 
tegumenu  of  the  eyelids.  This  enormous  tumefaction 
of  the  eyelids  is  said  to  be  generally  consentaneous 
with  the  complete  formation  of  chemosis;  entropium 
is  produced,  and  the  integuments  of  the  two  eyelids 
meet,  leaving  a deep  sulcus  between  them.  When  the 
external  swelling  begins,  the  discharge,  which  was  pre- 
viously moderate,  and  consisted  of  pus  floating  in  a 
watery  fluid,  changes  into  a continued  stream  of  yel- 
low matter,  which,  diluted  with  the  lachrymal  secre- 
tion, greatly  exceeds  in  quantity  that  derived  from  any 
gonorrhoea.  Although,  says  Dr.  Vetch,  the  tumefac- 
tion may  be  at  first  farther  advanced  in  one  eye  than 
the  other,  it  generally  reaches  its  greatest  height  in 
both  about  the  same.  The  patient  now  begins  to  suf 
fer  attacks  of  excruciating  pain  in  the  eye;  a certain 
indication  of  the  extension  of  the  mischief.  "An  oc- 
casional sensation,  a.s  if  needles  were  thrust  into  the 
eye,  accompanied  with  fulness  and  throbbing  of  the 
temples,  often  precedes  the  deeper-seated  pain.”  This 
la.st  is  often  of  an  intermitting  nature,  and  a period  of 
excruciating  torture  is  succeeded  by  an  interval  of  per- 


fect ease.  Sometimes,  the  pain  shifts  instantaneously 
from  one  eye  to  the  other,  and  is  seldom  or  never 
equally  severe  in  both  at  the  same  time;  and  some- 
times, instead  of  being  in  the  eye,  it  occurs  in  a circum- 
scribed spot  of  the  head,- which  the  patient  describes 
by  saying  he  can  cover  the  part  with  his  finger.  Sooner 
or  later,  one  of  these  attacks  of  pain  is  terminated  by 
a sensation  of  rupture  of  the  cornea,  with  a gush  of 
scalding  water,  succeeded  by  immediate  relief  to  the 
eye,  in  which  this  event  has  happened,  but  generally 
soon  followed  by  an  increased  violence  of  the  symp- 
toms in  the  other.  At  length,  the  attacks  of  pain  be- 
come shorter  and  less  severe,  though  they  do  not  cease 
altogether  till  after  the  lapse  of  many  weeks  and  even 
months.  During  this  stage  of  the  disease,  according 
to  Dr.  Vetch,  there  is  seldom  the  slightest  alteration  of 
the  pulse,  unless  the  lancet  have  been  freely  employed. 
The  patient’s  general  health  is  little  impaired,  his  ap- 
petite continues  natural,  but  sleep  almost  totally  for- 
sakes him. 

As  the  pain  abates,  the  external  tumefaction  also 
subsides,  and  a gaping  appearance  of  the  eyelids  suc- 
ceeds ; their  edges,  instead  of  being  inverted,  now  be- 
coming everted.  This  is  what  Dr.  Vetch  designates  as 
the  third  stage  of  the  disease. 

After  the  swelling  of  the  second  stage  has  subsided, 
the  eyelids  are  prevented  from  returning  to  their  natu- 
ral state  by  the  granulated  change  of  the  conjunctiva 
which  lines  them  ; and  an  eversion  of  them  now  oc- 
curs in  a greater  or  less  decree.— { Vetch  on  Diseases 
of  the  Eye,  p.  196.  202.)  Among  other  interesting 
remarks  made  by  the  same  author,  he  states,  that 
there  is  no  reason  to  warrant  the  idea  that  the  ulcera- 
tion ever  proceeds  from  within  outwards.  He  observes, 
that  when  any  large  portion  of  the  cornea  sloughs,  an 
adventitious  and  vascular  membrane  is  often  produced, 
which  finally  forms  a staphyloma.  In  some  few 
cases,  (says  he),  I have  seen  the  lens  and  its  capsule 
exposed  without  any  extertial  covering  whatever,  and, 
for  a short  time,  the  patient  saw  every  thing  with 
wonderful  accuracy  ; but,  as  soon  as  the  capsule  gives 
way,  the  lens  and  more  or  less  of  the  vitreous  humour 
escape,  the  eye  shrinks,  and  the  cornea  contracts  into 
a small  horn  coloured  speck.”  This  total  destruction 
of  the  globe  of  the  eye  is  said  generally  to  ensure  the 
other,  and  renders  it  less  liable  to  be  affected  by  future 
attacks  of  inflammation. 

A few  years  ago  an  ophthalmy,  supposed  to  be  of 
the  same  nature  as  the  Egyptian,  though  milder,  like 
that  which  has  geneially  been  observed  in  schools,  oc- 
curred to  a great  extent  in  the  Eoyal  Military  Asylum 
at  Chelsea,  and  Sir  Patrick  M‘Gregor,  the  surgeon,  fa- 
voured the  public  with  an  excellent  description  of  the 
disease,  and  some  highly  interesting  facts  and  reflec 
tions  upon  the  subject.  The  symptoms  generally  made 
their  appearance  in  the  following  order : “ A consider 
able  degree  of  itching  was  first  felt  in  the  evening  ; this 
was  succeeded  by  a sticking  together  of  the  eyelids, 
principally  complained  of  by  the  patient  on  waking  in 
the  morning.  The  eyelids  appeared  fuller  externally 
than  they  naturally  are;  and  on  examining  their  inter- 
nal surface  this  was  found  inflamed.  The  sebaceous 
glands  of  the  tarsi  were  considerably  enlarged,  and  of  a 
redder  colour  than  usual.  The  cat  uncula  lachrymalis 
had  a similar  appearance. 

“ In  24  or  30  hours  after  the  appearance  of  the  above 
mentioned  symptoms,  a viscid  mucous  discharge  took 
place  from  the  internal  surfaceof  each  eyelid,  and  lodged 
attheinner  canthus,tillthequantity  was  sufficient  to  be 
pressed  over  the  cheek  by  the  motions  of  the  eye.  The 
ve.ssels  of  the  tunica  conjunctiva  covering  the  eyeball 
were  distended  with  red  blood,  and  the  tunica  con- 
jiuictiva  was  generally  so  thickened  and  raised  as  to 
form  an  elevated  border  round  the  transparetit  cornea. 
Tills  state  was  often  accompanied  with  redness  of  the 
skin  around  the  eye ; which  sotneiimes  extended  to  a 
considerable  dis'ance,  and  resembled  in  colour  and 
form  very  much  what  takes  place  in  the  cow  po;i  pus- 
tule, between  the  ninth  and  twelfth  days  after  inocu- 
lation. 

“ When  the  purulent  discharge  was  considerable, 
there  was  a swelling  of  the  external  eyelids,  which 
often  prevented  the  patient  from  opening  them  for 
several  days.  The  discharge  also  frequently  excoriated 
the  cheeks  as  it  trickled  down.  Exposure  to  light 
caused  pain.  When  light  was  excluded,  and  the  eye 
kept  from  motion,  pain  was  seldom  much  complained  of. 


234 


OPHTHALMY. 


“ These  symptoms  in  many  subsided  without  much 
aid  from  medicine,  in  10,  12,  or  14  days ; leaving  the 
eye  for  a considerable  lime  in  an  irritable  state.  In 
several,  however,  the  disease  continued  for  a much 
longer  time,  and  ulceration  took  place  on  the  internal 
surface  of  the  eyelids,  and  in  different  parts  on  the  eye- 
ball. If  one  of  those  small  ulcers  happened  to  be  situ- 
ated on  the  transparent  coriiea,  it  generally,  on  healing, 
left  a white  speck,  which,  however,  in  the  young  sub- 
jects under  our  care,  was  commonly  soon  removed. 
In  some  few  instances  an  abscess  took  place  in  the 
substance  of  the  eyeball,  which,  bursting  externally, 
produced  irrecoverable  blindness.” — (See  Trans,  for 
the  Improvement  of  Med.  and  Chir.  Knowledge,  vol.  3, 
p.  .<1—40.) 

When  the  local  symptoms  had  prevailed  two  or  three 
days,  some  febrile  disturbance  occurred;  but,  except  in 
severe  cases,  it  was  scarcely  observable. 

Sir  P.  M‘Gregor  considered  this  ophthalmy  to  be  of 
the  same  nature  as  that  which  raged  with  such  vio- 
lence in  the  army  at  different  periods,  after  the  return 
of  our  troops  from  Egypt  in  1800,  1801,  and  1802. 
However,  he  found  that  its  consequences  were  not  so 
injurious  to  children  as  to  adults  ; for,  out  of  the  great 
number  of  children  afflicted  with  the  disease  at  the 
Military  Asylum,  only  six  lost  the  sight  of  both  eyes, 
and  twelve  the  sight  of  one  eye. — (Op.  cii.  p.  49.)  On 
the  other  hand.  Dr.  Vetch  informs  us,  that  in  the  second 
battalion  of  the  52d  regiment,  which  consisted  of  some- 
what more  than  700  men,  636  cases  of  ophthalmia  were 
admitted  into  the  hospital  between  August,  1805,  and 
August,  1806 ; and  that  “ of  this  number,  fifty  were 
dismissed  with  the  loss  of  both  eyes,  and  forty  with 
that  of  one.”  And  as  Sir  P.  M'Gregor  observes,  it  is  a 
melancholy  fact,  as  appears  from  the  returns  of  Chelsea 
and  Kilmainham  hospitals,  that  2317  soldiers  were,  on 
the  Isl  of  December,  1810,  a burden  upon  the  public, 
from  blindness  in  consequence  of  ophthalmia.  The 
cases  in  which  only  one  eye  was  lost  are  not  here  in- 
cluded. 

The  attacks  of  the  disease  appear  to  be  much  more 
frequent,  severe,  and  obstinate,  in  hot  sultry  weather, 
than  in  cold  or  temperate  seasons. — ( Op.  cit.  p.  37.  54, 
d-c.) 

Sir  P.  M'Gregor  also  observed,  that  the  ophthalmy 
was  more  severe  and  protracted  in  persons  of  red  hair 
or  a scrofulous  habit  than  in  others.  The  right  eye 
was  more  frequently  and  violently  affected  than  the 
left.  In  females,  the  symptoms  were  greatly  aggra- 
vated for  some  days  previous  to  the  catamenia;  but 
on  this  evacuation  ttirking  place,  they  were  quickly 
lessened.  Sir  P.  M'Giegor  farther  remarked,  that  the 
measles,  cow-pox,  and  mumps  went  through  their 
course  as  regularly  in  persons  affected  with  this  species 
of  ophthalmia,  as  when  no  other  disease  was  present ; 
a circumstance  which,  with  some  others,  prove  that 
the  disorder  was  entirely  local. — (P.  54,  55.) 

With  respect  to  the  causes  of  the  Egyptian  Purulent 
Ophthalmy,  much  difference  of  opinion  has  prevailed, 
and  indeed  there  was  a time  when  the  disease  was  re- 
garded by  the  majority  of  army-surgeons,  who  alone 
had  opportunities  of  judging  of  it,  as  not  being  in  reality 
contagious,  but  dependent  upon  local  epidemic  causes  ; 
the  irritation  of  sand;  peculiarity  of  climate,  4'C. 
The  late  Mr.  Ware  even  doubled  the  propriety  of  call- 
ing this  ophthalmy  Egyptian,  and  he  contended  that 
a disease,  precisely  similar  in  its  symptoms  and  pro- 
gress, had  been  noticed  long  ago  in  this  and  other 
countries ; and  that,  in  Egypt,  several  varieties  of  oph- 
thalmy prevail.  He  preferred  calling  the  disease  the 
Epidemic  Purulent  Ophthalmy.  On  the  other  hand, 
Sir  W.  Adams  conceives,  that  it  ought  rather  to  be 
called  Jlsiatic  Ophthalmy,  as  recent  investigations 
prove  that  it  prevails  in  the  greater  part  of  Asia,  and 
was  long  ago  described  by  A vicenna.-^ Grae/e,  Joum. 
der  Chir.  b.  1,  p.  170.) 

That  there  has  been  long  known  in  this  country  an 
infectious  species  of  purulent  ophthalmy,  cannot  be 
doubted.  The  case  described  by  many  surgeons,  as 
proceeding  from  the  sudden  stoppage  of  gonorrhoea,  or 
the  inadvertent  application  of  gonorrhoeal  matter  to  the 
eyes,  which  disorder  will  be  presently  noticed,  is  cer- 
tainly an  infectious  purulent  ophthalmy.  It  is  also 
admitted,  that  it  resembles  Egyptian  ophthalmy,  by  the 
intensity  and  rapidity  of  its  symptoms;  but  the  latter 
case  is  strongly  characterized  by  the  quickness  with 
which  it  causes,  especially  in  adults,  opacities,  or  ul- 


cerations of  the  cornea ; the  long-continued  irritability 
of  the  eyes  after  the  subsidence  of  inflammation  ; but 
more  particularly  its  very  infectious  nature,  by  which 
it  spreads  to  an  extent  that  has  never  been  observed 
with  regard  to  any  other  species  of  purulent  ophthalmy. 
There  have  been  epidemic  ophthalmies  of  other  kinds, 
which  have  been  known  to  affect  the  greater  part  of 
the  population  of  certain  districts  and  towns  in  Eng- 
land. The  celebrated  ophthalmy  which  happened  at 
Newbury,  in  Berks,  some  years  ago,  is  an  instance  that 
must  be  known  to  every  body.  But  I know  of  no  pu~ 
rulent  inflammation  of  the  eyes,  which  ever  spread  to 
a great  extent  in  England,  before  the  return  of  our 
troops  from  Egypt. 

The  reflections  and  observations  of  Sir  P.  M'Gregor, 
as  well  as  those  of  Dr.  Vetch  and  Dr.  Edmonslone, 
I think,  leave  no  doubt  of  two  facts : first,  that  this 
ophthalmy  was  at  all  events  brought  from  Egypt ; 
and,  secondly,  that  it  is  infectious,  but  only  capable  of 
being  communicated  from  one  person  to  another  by  ac- 
tual contact  of  the  discharge.  “ If  (says  Dr.  Vetch) 
any  belief  were  entertained  by  the  officers  of  the  Bri- 
tish army,  during  the  first  expedition  to  Egypt,  that  the 
disease  was  contagious,  it  was  of  a nature  very  vague 
and  indefinite.  Combined  as  its  operations  necessarily 
must  be  in  that  country  with  other  exciting  causes, 
there  would  be  more  difficulty  in  the  first  recognition  of 
the  fact.  But  the  continuance  of  the  complaint  with 
the  troops  after  their  departure  from  the  country, 
could  scarcely  fail  to  lead  to  the  obvious  conclusion  of 
its  possessing  a power  of  propagation.  Before  the  dis- 
ease reached  this  country,  the  opinion  of  its  being  con- 
tagious was  adopted  by  many.  Er.  Edmonstone,  in 
the  account  which  he  published  of  the  disease  us  it  ap- 
peared in  the  regiment  to  which  he  was  surgeon  after 
its  return  to  England,  frst  inade  the  public  acquainted 
with  the  fact  of  the  disease  being  communicable.  In 
an  account  of  the  Egyptian  ophthalmia,  as  it  appeared 
in  this  country,  printed  in  the  early  part  of  1807,  I first 
established,  that  the  communication  of  the  disease  was 
exclusively  produced  by  the  application  of  the  discharge 
from  the  eyes  of  the  diseased  to  those  of  the  healthy." — 
(Ora  Diseases  of  the  Eye,p.  178.) 

The  opinion,  that  the  disease  is  ever  communicated 
from  one  person  to  another,  through  the  medium  of  the 
atmosphere,  is  at  present  nearly  abandoned.  During 
the  whole  lime  that  Dr.  Vetch  had  the  management  of 
the  ophthalmic  hospitals,  there  never  was  an  instance 
of  any  medical  officer  contracting  the  disease,  although 
exposed  to  what  might  be  supposed  to  be  the  greate.st 
concentration  of  any  conta^on  that  could  arise  in  the 
worst  stage  of  the  complaint.  Two  orderlies  only  con- 
tracted the  disease,  and  both  in  consequence  of  the  ac- 
cidental application  of  the  virus.  However,  Sir  W. 
Adams  maintains,  that  he  has  seen  many  cases,  which 
prove  that  the  disor  der,  like  small-pox,  may  spread  conta- 
giously without  any  kind  of  inoculation.— (See  Oraefe's 
Journ.  b.  1,  p.  174.)  That  the  disease  may  also  be  partly 
propagated  by  epidemic  causes  in  particular  situations,  I 
think  as  certain  and  clear,  as  that  there  must  be  a cause 
for  the  first  commencement  of  the  disorder  in  situations 
where  infection  by  contact  is  out  of  the  question.  And 
as  Dr.  Vetch  has  observed,  “ from  whatever  cause  in- 
flammaiion  of  the  conjunctiva  may  originate,  when 
the  action  is  of  that  nature,  or  degr  ee  of  violence,  as  to 
pr  oduce  a puriform  or  purulent  discharge,  the  discharge 
so  produced  operates  as  an  animal  virus,  when  applied 
to  the  conjunctiva  of  a healthy  eye.  Considering  the 
various  modes  by  which  such  a contact  must  inevitably 
occur  in  the  usual  relations  of  life,  it  must  be  obvious, 
that  wherever  ophthalmia  prevails,  whether  it  be  the 
effect  of  local  conditions  of  the  soil  or  of  the  atmo- 
sphere, naturally  or'  artificiaily  produced,  this  conta- 
gious effect  must  sooner  or  later  mix  or  unite  its  ope- 
ration with  that  of  the  more  general  and  original  one; 
and  hence,  without  regard  to  this  property  of  the  dis- 
ease, its  occurrence  must  often  lemain  inexplicable, 
and  at  variance  with  the  more  general  cause  existing 
in  external  circumstances.  And,  farther,  as  the  disease 
produced  by  infection  is  of  a nature  more  violent  and 
malignant  than  that  produced  by  the  impression  of  at 
mospheric  causes,  it  will,  in  every  instance  of  exten- 
sively-prevailing ophthalmia,  occasion  two  different 
forms  of  disease,  which,  as  long  as  they  are  considered 
as  one  and  the  same,  will  produce,  according  as  tho 
one  or  the  other  predominates,  very  discordant  results.’* 
—(On  Diseases  of  the  Eye,  p.  175.) 


OPHTHALMY. 


235 


Sir  P.  M'Gregor  relates  three  cases,  which  prove  that 
the  matter,  after  its  application,  produces  its  effects  in 
a very  short  time.  I shall  only  cite  the  following  ex- 
ample: — On  the  21st  of  October,  1809,  about  four 
o’clock,  p.  M.,  Nurse  Flannelly,  while  syringing  the  eyes 
of  a boy,  let  some  of  the  lotion  which  had  already 
washed  the  diseased  eyes  pass  out  of  the  syringe  into 
her  own  right  eye.  She  felt  little  or  no  smarting  at  the 
time;  but  towards  nine  o’clock  the  same  evening,  her 
right  eye  became  red  and  somewhat  painful,  and  when 
she  awoke  next  morning,  her  eyelids  were  swelled, 
there  was  a purulent  discharge,  pain,  &c. — ( Op.  cit. 
p.  51.) 

The  late  Mr.  Ware,  though  he  admitted  that  the  in- 
fection was  brought  into  this  country  from  Egypt  by 
the  troops,  conceived  that  the  same  disease  also  some- 
times arose  from  the  matter  of  gonorrhoea  being  ap- 
plied to  the  eyes,  and  that  it  had  been  prevalent  in  this 
country  before  the  return  of  the  army  from  Egypt. 
He  thought,  however,  that  the  infection  was  generally 
communicated  by  contact.  Mr.  Ware  observes,  some 
of  the  worst  cases  of  the  purulent  ophthalmy  of  chil- 
dren have  happened  in  those  whose  mothers  were  sub- 
ject to  an  acrimonious  discharge  from  the  vagina  at 
the  time  of  parturition.  Some  of  the  worst  forms  of 
the  purulent  ophthalmy  in  adults  have  occurred  in 
those  who,  either  shortly  before  the  attack  of  the  oph- 
thalmy or  at  that  very  time,  laboured  either  under  a 
gonorrhoea  or  a gleet.  Mr.  Ware  does  not  mean  to 
impute  every  purulent  ophthalmy  to  such  a cause; 
but  in  the  majority  of  adults  whom  he  has  seen  affected, 
if  the  disorder  had  not  been  produced  by  the  application 
of  morbid  matter  from  a diseased  eye,  it  could  be  traced 
to  a connexion  between  the  ophthalmy  and  disease  of 
the  urethra.  Other  causes,  Mr.  Ware  acknowledges, 
may  contribute  to  aggravate,  and,  perhaps,  produce 
the  disorder,  and  the  purulent  ophthalmy  in  Egypt  has 
been  attributed  to  a great  number.  The  combined  in- 
fluence of  heat  and  light,  of  a burning  dust,  continu- 
ally raised  by  the  wind,  and  of  the  heavy  dews  of  the 
night,  may  powerfuly  tend  to  excite  inffammatiotis  of 
the  eyes.  Yet  something  more  must  operate  in  causing 
the  malignant  ophthalmy  now  under  consideration ; 
for  the  same  causes  operate  with  equal  violence  in 
some  other  countries  besides  Egypt,  and  yet  do  not 
produce  the  same  effect;  and  in  this  country  (says 
Mr.  Ware),  the  disorder  prevailed  during  the  last  sum- 
mer to  as  great  a degree,  and  upon  as  great  a number 
of  persons,  within  a small  district  of  less  than  a mile, 
as  it  ever  did  in  Egypt;  and  yet,  beyond  this  space  on 
either  side,  scarcely  a person  was  affected  with  it. 
The  disorder  was  certainly  brought  into  this  country  by 
the  soldiers  who  returned  from  Egypt,  and  was  proba- 
bly communicated  from  them  to  many  others.  Now, 
as  the  action  of  the  atmosphere  alone  cannot  account 
for  the  spreading  of  the  disease,  &c.,  Mr.  Ware  is  led 
to  believe,  that  this  particular  disorder  is  only  commu- 
nicable by  absolute  contact ; that  is,  by  the  application 
of  some  part  of  the  discharge  which  issues  either  from 
the  conjunctiva  of  an  affected  eye,  or  from  some  other 
membrane  secreting  a similar  poison,  to  the  conjunc- 
tiva of  the  eye  of  another  person.  In  schools  and 
nurseries,  in  consequence  of  children  using  the  same 
basins  and  towels  as  others  who  had  the  complaint,  tlie 
disease  has  been  communicated  to  nearly  twenty  in 
one  academy.  Hence,  Mr.  Ware  censures  the  indis- 
criminate use  of  those  articles  in  schools,  nurseries, 
hospitals,  ships,  and  barracks.— (P.  14,  15.) 

That  in  Egypt  the  origin  of  the  disease  cannot 
rightly  be  imputed  to  the  effect  of  the  sand* and  hot 
Windsor  the  country  is  clearly  proved;  1st.  Because, 
it  this  were  the  case,  the  disease  would  not  be  most 
prevalent  in  the  autumnal  season  during  the  inunda- 
tion of  the  Nile.  2dly.  The  inhabitants  of  the  Delta 
would  not  be  more  subject  to  it  than  the  Bedouin 
Arabs,  who  live  on  the  sarids  of  the  desert.  Not  only 
the  Bedouin  Arabs,  says  Dr.  Vetch,  remain  free  from 
the  disease,  but  Europeans  who  are  not  particularly 
^posed  to  the  night  air,  are  also  safe  from  its  attacks.” 
The  nature  of  military  duty  prevented  our  soldiers 
fr<fiii  using  this  precaution,  and  in  a particular  manner 
they  became  victims  to  the  complaint.  I’he  men  suf 
fered  more  in  proportion  to  the  officers  of  the  English 
army;  as  the  latter  enjoyed  a better  though  often  an 
Incomplete  defence  from  the  coldness  and  dampne.«s 
, ’ ^"*1  officers  employed  in  strictly  military 

duty  suffereil  more  than  those  attached  to  the  civil  de- 


partments.”—( Fetch  on  Diseases  of  the  Eyes,  p.  157.) 
And  Assalini  remarks,  that  if  the  dust  or  sand  were 
the  sole  cause  of  ophthalmia,  we  ought  to  be  exempted 
from  the  disease  where  the  cause  does  not  exist.  The 
contrary,  however,  was  the  case  in  the  Delta,  and  prin 
cipally  on  the  cultivated  borders  of  the  Nile  during  its 
inundations.  When  we  were  exposed  to  the  air  ditring 
the  night,  we  were  immediately  attacked  with  ophthal- 
mia, though  the  dust  and  sand  were  then  under  water 
Larrey  also  imputes  the  origin  of  the  disease  to  the 
cold,  damp  nocturnal  air  after  the  great  heats  of  the 
day.—{Graefe's  Journ.  b.  1,  p.  179.) 

Whoever  reads  the  account  of  the  Egyptian  oph- 
thalmia, as  given  by  Sir  P.  M-Gregor  and  Dr.  Vetch, 
will  be  convinced,  that  the  disorder  is  only  communi- 
cable from  one  person  to  another  by  the  application 
of  the  infectious  matter  to  the  eyes.  Probably  the 
common  mode  of  propagation  is  the  inadvertent  use 
of  the  same  towels,  or  even  merely  touching  the  same 
articles  which  have  been  in  the  hands  of  infected  per- 
sons, who  must  be  supposed  occasionally  to  apply  ttieir 
fingers  more  or  less  to  the  eyelids.  In  this  last  W'ay, 
the  commencement  of  the  disease  may  be  accounted 
for  in  regiments  upon  their  entering  into  barracks 
which  have  been  quitted  by  other  infected  soldiers. 
“Flies,  in  warm  weather  (says  Sir  P.  M’Gregor),  are 
seen  in  great  numbers  surrounding  patients  labouring 
under  ophthalmia;  and  I much  suspect  are  very  fre- 
quently the  medium  by  which  the  disease  is  comniuni 
cated.” — (P.  54.)  The  matter  is  observed  to  be  most 
infectious  when  the  disease  is  in  an  acute  state. 

Dr.  Vetch  adverts  to  two  important  questions,  con 
nected  with  the  history  of  the  Egyptian  ophthalmy 
The  first  relates  to  the  length  of  time  which  the  dis 
ease  has,  at  different  periods,  lain  dormant,  and  espe 
cially  between  the  return  of  the  troops  from  Egypt 
and  the  breaking  out  of  the  disease  in  the  52»1  regi 
ment.  An  explanation  of  this  fact  is  attempted  by 
supposing  that  the  complaint  exists,  and  is  liable  to  Si 
renewal  of  its  infectious  quality,  long  after  the  eye 
seems  to  have  recovered  its  natural  and  healthy  ap- 
pearance. Perhaps  it  would  be  as  well  to  be  content 
with  the  fact,  that  in  crowded  barracks,  under  par- 
ticular circumstances,  soldiers  who  have  once  had  the 
disease  are  very  liable  to  relapses.  The  other  question 
is,  why  has  the  disease  produced  such  ravages  in  the 
army  in  England,  and  not  in  that  of  Frarice?  It  is 
well  known  that  the  French  soldiers  in  Eiiypt  suffered 
as  much  as  our  own  troops  from  the  affection,  and 
great  numbers  of  them  returned  to  France  with  the 
disease  in  a chronic  form.  “In  many  (says  M.  Roux) 
the  influence  of  their  native  climate  has  sufficed  for 
the  removal  of  all  vestige  of  the  disorder.  On  the  con- 
trary, in  others  it  has  continued  in  a chronic  state, 
either  attended  with  the  loss  of  one  or  of  both  eyes: 
and  many  of  our  invalids  remain  with  the  affliction. 
But  it  has  not  been  found,  that  those  soldiers  who  re- 
turned from  Egypt  have  ever  commu^cated  a conta- 
gious ophthalmia,  either  in  regimerts  in  which  many 
of  them  have  been  incorporated,  or  in  invalid  houses, 
where  others  have  obtained  their  retiremetit,  or  in  the 
individuals  belonging  to  the  different  classes  of  society. 
Such  is  the  objection  that  has  been  made,  and  may 
always  be  again  urged,  agaiast  the  opinions  and  re- 
marks of  the  English,  respecting  the  Egyptian  oph 
thalmy.” — {Voyage  failed  Londres  en  1814, om  Paral- 
Ule  de  la  Chir.  Singloise,  Src.  p.  49.) 

Larrey,  who  admits  that  the  disease  may  be  com- 
municated by  application  of  the  matter,  argues  that  it 
is  not  contagions  in  any  other  way,  because,  in  Egypt, 
for  want  of  sufficient  hospital  room,  patients  with  this 
and  other  diseases  were  mixed  together  without  the 
ophthalmia  being  propagated  to  any  of  the  patients, 
who  were  careful  to  avoid  the  above  mode  of  infection. 
—{Oroefe's  .Journ.  b.  1,  p.  179.)  Larrey,  however, 
need  not  have  used  this  reasoning  with  us,  because  it 
is  a mistake  in  him  to  suppose,  that  the  disease  is  here 
commonly  regarded  as  communicable  through  the  me- 
dium of  the  atmosphere.  While,  however,  English 
surgeons  chiefly  explain  the  extension  of  the  disease 
by  the  infectious  nature  of  the  discharge  when  applied 
to  the  eyelids,  and  I>arrey  admits  that  the  matter  is 
thus  infectious,  the  latter,  as  wejl  as  Roux,  assures  u.s, 
that  none  of  the  healthy  soldiers  who  came  home  with 
the  blind  invalids  from  Egypt  were  attacked  with  this 
species  of  ophthalmy.  A great  number  of  those  in- 
valids were  received  in  the  hospital  of  the  guards  at 


236 


OPHTHALMY. 


Paris,  and  treated  there  without  any  of  the  other  pa- 
tients being  infected. — (Graefe's  Joum.  loe.  cit.)  On 
niy  return  from  the  Mediterranean  through  France,  in 
1802,  I saw  many  of  the  French  troops  at  Aix  and 
Avignon  with  bad  eyes,  coniracted  in  Egypt,  asso- 
ciating with  other  soldiers,  whose  eyes  were  perfectly 
healthy,  and  living  in  the  same  barracks;  a proof  that 
the  French  soldiers,  with  tlie  exception  of  climatg,  or 
some  other  protecting  cause,  were  placed  apparently  in 
circumstances  in  which  the  disease  here  made  such  ex- 
tensive ravages.  This  is  a point  which  I humbly  con- 
ceive is  not  at  all  solved  by  Dr.  Vetch’s  belief,  that  the 
difference  is  explicable  by  the  French  troops  being  sent 
into  the  field;  for,  in  fact,  the  soldiers  with  diseased 
eyes  were  in  barracks  or  hospitals  as  well  as  our  own 
troops. 

But  notwithstanding  it  seems  proved,  that  the  dis- 
charge from  the  eyes  in  the  Egyptian  ophthalmy  is  so 
actively  infectious  in  England,  it  appears  from  an 
experiment,  made  by  Mr.  Mackesy,  that  its  applica- 
tion may  sometimes  be  made  to  a healthy  eye  without 
the  disease  following  as  a matter  of  certainty ; for  he 
applied  to  his  own  eyes  linen  impregnated  with  matter 
discharged  froni  the  eyes  of  patients  in  the  fully  formed 
stage  of  the  disease,  and  even  allowed  some  of  the 
matter  to  pass  under  the  eyelids;  yet  the  complaint 
was  not  communicated. — (See  Edinb.  Med.  and  Surg. 
Joum.  vol.  12,  p.  411.) 

One  of  the  most  material  circumstances  in  which 
the  practice  of  English  surgeons  diffeis  from  that  of 
foreign  practitioners  in  cases  of  severe  purulent  and 
especially  Egyptian  ophthalmy,  is  the  freedom  and 
boldness  with  which  the  former  attack  the  disease  in 
its  first  stage.  Mr.  Peach  recommends  taking  away  at 
once  as  much  as  60  ounces  of  blood  {Edinb.  Med.  and 
Surg.  Journ.  for  January.,  1807) ; and  Dr.  Vetch  lays 
great  stress  on  the  striking  benefit  of  bleeding  the  pa- 
tient till  syncope  is  produced.  “When  inflammation 
has  its  seat  in  the  sclerotic  coat  (says  he),  general 
blood-letting  may  for  the  most  part  be  dispensed  with, 
and  even  when  employed  to  the  greatest  extent,  the 
same  benefit  does  not  ensue.  In  the  purulent  inflam- 
mation of  the  conjunctiva,  however,  although  some 
good  may  be  derived  from  depletion,  yet  a perfect  com- 
mand over  the  disease  depends  less  on  lowering  the 
system  than  on  the  temporary  cessation  of  arterial  ac- 
tion by  syncope,  which  it  becomes  the  object  of  the 
operation  to  produce.  This  practice,  besides  its  effi- 
cacy, will  accomplish  the  cure  with  a much  less  ex- 
penditure of  blood  than  is  occasioned  by  the  repeated 
bleedings  generally  had  recourse  to  where  this  method 
of  rendering  one  equal  to  the  cure  of  the  complaint 
has  been  neglected.  Some  time  before  the  approach  of 
faintness  the  redness  of  the  conjunctiva  for  the  most 
part  disappears;  but  this  is  no  security  against  the  re- 
turn of  the  disease,  if  the  flow  of  blood  be  stopped, 
without  deliqnium  animi  succeeding.” — {On  Diseases 
of  the  Eye,  p.  2^6.)  The  attacks  of  a painful  sensation, 
as  if  gravel  were  in  the  eye,  he  considers  as  a proof 
of  the  disease  increasing,  and,  in  the  early  stage  of  the 
disease,  as  a better  indication  of  the  necessity  for 
bleeding,  than  the  appearance  of  the  eye  itself. 

With  respect  to  applications.  Dr.  Vetch  speaks  very 
highly  of  the  beneficial  effects  produced  in  the  begin- 
ning of  the  case  by  dropping  into  the  eye  the  undiluted 
liquor  plumbi  subacetatis,  which,  he  says,  diminishes 
the  discharge,  lessens  the  inflammatiot»,  and  is  incapa- 
ble of  doing  harm  in  any  stage  of  the  disease.  He 
places  cteat  confidence  in  the  salutary  results  of  a free 
exposure  of  the  eye  to  the  atmosphere;  and  sj)eaks  in 
high  terms  of  the  good  derived  from  applying  at  night 
to  the  eye  an  infusion  of  tobacco,  two  drachms  of  the 
leaves  to  eight  ounces  of  water.  “ It  pr>ssesses  (says 
Dr.  Vetch)  the  valuable  properties  of  acting  as  a pow- 
erful astringent,  restraining  the  purulent  discharge, 
and  diminishing  the  (Edema  or  e.xternal  swelling  of  the 
palpebrae;  at  the  same  time  that  its  narcotic  qualities 
often  relieve  the  pain  and  the  perpetual  watchfulness 
which  the  largest  doses  of  opium  cannot  subdue.” — 
(P.211.)  Bleeding,  however,  is  the  “ sheet  anchor,” 
and  the  only  means  of  preventing  the  destruction  of 
the  cornea,  whenever  attacks  of  pain  in  the  eye  or 
oihit  denote  the  unsubdued  state  of  the  disea.se. — 
(P.212.)  When  the  disease  shifts  its  violence  from 
one  eye  to  the  other,  and  is  of  long  duration.  Dr.  Vetch 
reconi  mends  cupping,  and  the  eye  to  be  more  carefully 
cleaned  by  the  injection  of  teind  water  or  any  gentle 


astringent  lotion,  and  afterward  wiped  dry.  When 
the  discharge  continues  acrid  and  scalding,  he  directs 
blisters  to  be  applied  to  the  nape  of  the  neck  and  be- 
hind the  ears.  He  wishes  it  to  be  distinctly  kept  in 
mind,  that  the  time  for  the  employment  of  bleeding, 
with  the  view  of  saving  the  eye,  is  during  the  first 
stage,  or  early  part  of  the  second  ; and  when  ulcera. 
tion  of  the  cornea  has  commenced,  the  case  is  to  be 
treated  on  the  principles  applicable  to  sclerotic  inflam- 
mation. 

With  regard  to  the  plan  of  diminishing  inflamma- 
tory action  by  medicines  which  excite  nausea  and 
sickness,  instead  of  having  recourse  to  the  lancet.  Dr. 
Vetch  states,  that  in  soldiers  it  does  not  answer  so  well, 
and  in  the  end  proves  more  debilitating. 

As  soon  as  the  external  oedema  of  the  eyelids  sub- 
sides, and  they  begin  to  be  everted.  Dr.  Vetch  represses 
the  granulations  and  general  villosity,  by  a very  light 
and  careful  application  of  the  argentum  nitratum. 
The  everted  portion  is  then  to  be  returned,  and  secured 
in  its  place  with  a compress  and  bandage.  This  me- 
thod is  to  be  repeated  every  time  the  eye  is  cleaned, 
and  in  the  course  of  a fortnight  the  tendency  to  ectro- 
pium  will  be  removed. — (P.  ^29.) 

Assalini  found  venesection,  all  emollient  applica- 
tions, and  eyewaters  hurtful.  He  first  purged  his  pa- 
tients, and  tlien  introduced  into  their  eyes  a few  drops 
of  a solution  of  the  lapis  divinus  (see  Lachrymal  Or- 
gans), to  which  was  sometimes  added  a small  quantity 
of  the  acetate  of  lead.  He  speaks  favourably  of 
leeches,  and  sometimes  he  put  a small  blister  on  the 
temple  or  behind  the  ears. — (See  Manuals  di  Chirur 
gta;  Milano,  1812.) 

Perhaps  the  best  mode  of  putting  an  immediate  stop 
to  the  Egyptian  ophthalmy,  when  it  prevails  exten- 
sively in  a regiment  in  garrison  or  barracks,  is  to  put 
the  men  actually  affected  into  a detached  hospital  at  a 
considerable  distance  from  the  rest  of  the  corps,  which 
should  be  dispersed  as  much  as  possible  in  separate 
billets  and  villages.  Purulent  ophthalmy  is  a disease 
which  makes  great  progress  only  when  large  numbers 
of  persons  are  either  exposed  together  to  the  epidemic 
causes  which  first  give  birth  to  it,  or  to  the  causes 
which  occasion  the  disease  to  be  communicated  from 
one  individual  to  another,  as  when  soldiers  are  crowded 
together  in  the  same  building,  using  the  same  towels 
and  water,  &c.  Notwithstanding  the  reports  of  Roux 
and  Larrey  prove  that  the  disease  did  not  spread  in  the 
French  army,  after  the  return  of  uncured  soldiers  from 
Egypt  to  France,  though  these  were  freely  mixed  with 
their  comrades  in  hospitals  and  barracks,  the  same  se- 
curity did  not  extend  to  the  British  troops  of  the  army 
of  occupation  in  that  countiy  in  1816,  who  were 
threatened  with  a very  extensive  renewal  of  the  Egyp- 
tian ophthalmy  among  them,  but  which  was  wisely 
checked  by  attention  to  the  principles  above  specified, 
and  in  which  Sir  James  Grant,  the  head  of  the  medical 
department  of  that  army,  had  the  greatest  confidence. 

In  the  cases  under  Sir  P.  M'Gregor,  local  applica- 
tions were  found  most  advantageous.  During  the  in- 
flammatory stage,  however,  this  gentleman  also  had 
recourse  to  antiphlogistic  means,  spare  diet,  bleeding, 
neutral  salts,  &c.  The  topical  treatment  was  as  fol- 
lows: leeches  were  freely  and  repeatedly  applied  near 
the  eye.  But  while  there  was  much  surrounding  red- 
ness, instead  of  leeches,  which  created  too  much  iiri- 
tation,  fomentations  with  a weak  decoction  of  poppy 
heads,  and  a little  brandy,  were  used.  A weak  solu- 
tion of  acetate  of  lead  an<i  sulphate  of  zinc  had  mostly 
a good  effect  when  applied  to  the  eye.  The  vinous 
tincture  of  opium  did  not  answer  the  expectations  en- 
tertained of  it.  But  of  all  the  remedies,  the  ung.  hy- 
drarg.  nitrat.  was  found  most  frequently  successful.  It 
was  applied  by  means  of  a camel-hair  pencil,  and  at 
first  weakenecl  with  twice  its  quantity  of  lard.  The 
red  precipitate,  well  levigated,  and  mixed  with  simple 
ointment,  sometimes  answered  when  the  ung.  hydrarg. 
nitrat.  failed.  Well-levigated  verdigris,  and  a quack 
medicine  called  the  golden  ointment,  proved  also  some- 
times efficacious. — {P.  41—43.)  According  to  Sir  P. 
M‘Gregor,  blisters  behind  the  ears  and  upon  the  neek 
are  useful ; but  hurtful  when  put  nearer  to  the  eye.  In 
cases  where  the  disease  seems  to  resist  antiphlogistic 
means,  and  ulceration  has  commenced  on  the  external 
surface  of  the  cornea,  this  gentleman  approves  of  dis- 
charging the  aqueous  humour  by  a puncture,  as  ad- 
vised by  Mr.  Wardtop. 


OPHTHALMY. 


237 


When  the  violence  of  the  inflammation  has  sub- 
sided, Sir  P.  M‘Gregor  recommends  the  use  of  Bates’s 
campliorated  water,  diluted  with  four,  five,  or  six  times 
its  quantity  of  water.  But  the  astringent  collyrium, 
from  which  he  saw  most  good  derived,  was  a soluiion 
of  the  nitrate  of  silver,  in  the  proportion  of  half  a 
grain  to  every  ounce  of  distilled  water.  In  some 
cases  it  may  be  used  stronger. 

Tepid  sea-water  sometimes  proved  serviceable  in 
removing  the  relics  of  the  cotnplaint. — (P.  56,  <V-c.) 

Purulent  Ophthalmy  of  Infants.  Dr.  Vetch  de- 
scribes the  external  appearances  of  this  case  as  not 
materially  different  from  those  of  the  purulent  oph- 
thalmy of  adults;  but  he  states,  that  its  nature  is  con 
siderably  modified  by  the  more  delicate  texture  and 
greater  vascularity  of  the  parts  affected,  and  the  more 
intimate  connexion  subsisting  between  the  vessels  of 
the  conjunctiva  and  those  of  the  sclerotic  coat.  Hence, 
he  says,  the  inflammation  is  sooner  communicated  to 
this  coat,  and  sloughing  and  ulceration  of  the  cornea 
occur  earlier  in  infants  than  adults.  When  the  cederna 
ceases,  the  inner  surface  of  the  paljtebrae  becomes  sar- 
comatous, and  this  diseased  surface,  when  the  eyelids 
are  opened,  forms  an  exterior  fleshy  circle,  beyond 
which  the  relaxed  conjunctiva  of  the  eye  comes  for- 
wards as  a second ; and  often  the  caruncula  lachry- 
malis  adds  still  farther  to  the  valvular  appearance 
which  the  part  presents. — {On  Diseases  of  the  Eye,v- 
256-258.) 

According  to  the  late  Mr.  Ware,  the  principal  dif- 
ference between  the  purulent  ophthalmy  in  infants  and 
that  in  adults,  consists  in  the  different  stales  of  the  tu- 
nica conjunctiva:  in  the  former,  notwithstanding  the 
quantity  of  matter  confined  within  the  eyelids  is  often 
profuse,  the  inflammation  of  the  conjunctiv«  is  rarely 
considerable,  and  whenever  the  cornea  becomes  im- 
paired, it  is  rather  owing  to  the  lodgement  of  such 
matter  on  it  than  to  inflammation  ; a statement  which 
appears  to  me  very  questionable.  But  in  the  purulent 
ophthalmy  of  adults,  the  discharge  is  always  accom- 
panied with  a violent  inflammation,  and  generally  with 
a tumefaction  of  the  conjunctiva,  by  which  its  mem- 
branous appearance  is  destroyed,  and  the  cornea  is 
ntade  to  seem  sunk  in  the  eyeball. — ( Ware  on  Epidemic 
Purulent  Ophthalmy,  p.  23.)  In  children,  the  affection 
of  the  eyes  is  occasionally  accompanied  with  eruptions 
on  the  head,  and  with  marks  of  a scrofulous  constitu- 
tion.— (See  Waie,  p.  138,  Src.)  The  only  inference  to 
be  drawn  from  this  fact  is,  that  scrofulous  as  well  as 
other  children  are  liable  to  this  disorder  of  the  eyes. 

The  following  is  the  treatment  recommended  by  Mr. 
Ware.  If  the  disease  be  in  its  first  stage,  the  temporal 
arteries  are  to  be  opened,  or  leeches  applied  to  the 
temples,  or  neighbourhood  of  the  eyelids,  and  a blis- 
ter put  on  the  nape  of  the  neck  or  temples.  The 
child  should  be  kept  in  a cool  room,  not  covered 
with  much  clothes,  and,  if  no  diarrhoea  prevail,  a little 
rhubarb  or  magnesia  in  syrup  of  violets  should  be  pre- 
scribed. 

A surgeon,  however,  is  seldom  called  in  before  the 
first  short  inflammatory  stage  has  ceased,  and  an  im- 
mense discharge  of  matter  from  the  eyes  hcis  com- 
menced. Of  course,  says  Mr.  Ware,  eaiollient  appli- 
cations must  generally  not  be  used.  On  the  contrary, 
astringents  and  corroborants  are  immediately  indicated, 
in  order  to  restore  to  the  vessels  of  the  cofijunctiva  and 
eyelids  their  original  tone,  to  rectify  the  villous  and 
fungous  appearance  of  the  lining  of  the  palpebrae,  and 
thus  finally  to  check  the  morbid  secretion  of  matter. 
For  this  purpose,  Mr.  Ware  strongly  recommends  the 
aqua  camphorata  of  Bates’s  Dispensatory:  Bfc.  Cupri 
siilphatis,  bol.armen.  a a 5iv.  Camphorae  5j-  M.  & f. 
pulvis,  de  quo  projice  fj.  in  aqiite  bullientis 
amove  ab  igne,  et  snbsidant  fceces.  Mr.  Ware,  in  his 
late  Remarks  on  Purulent  Ophthalmy,  1803,  observes, 
that  he  usually  directs  the  aqua  camphorata,  as  fol- 
lows: Bt-  Cupri  sulphati.s,  bol.  armen.  a a gr.  viij. 
CamphortB  gr.  ij.  Misce,  et  alfunde  aquae  bullientis 
tviij.  Ciim  lolio  sit  frigida,  effundatur  limpidus  li- 
quor, et  sffipissim^  injicialur  paululum  inter  oculum  et 
palpebras.  This  remedy  posse.ese6a  very  styptic  qua- 
lity ; but,  as  directed  in  Bates’s  Dispensatory,  it  is  much 
tf*o  strong  for  use  before  it  is  diluted  ; and  the  degree 
of  its  dilution  must  always  be  determined  by  the  pe- 
culiar circumstances  of  each  case.  Mr.  Ware  ventures 
to  recommend  bbout  one  drachm  of  it  to  be  mixed  with 
an  ounce  of  cold  clear  water,  as  a medium  or  standard, 


to  be  strengthened  or  weakened  as  occasion  may  re~ 
quire. — (P.  143.)  The  remedy  must  be  applied  by 
means  of  a sntall  ivory  or  pewter  syringe,  the  end  of 
which  is  a blunt-pointed  cone.  The  extremity  of  this 
instrument  is  to  be  placed  between  the  edges  of  the 
eyelids  in  such  a manner  that  the  medicated  liquor 
may  be  carried  over  the  whole  surface  of  the  eye. 
Thus  the  matter  will  be  entirely  washed  away,  and 
enough  of  the  styptic  medicine  left  behind  to  interrupt 
and  diminish  the  excessive  discharge.  According  to 
the  quantity  of  matter,  and  the  rapidity  with  which  it 
is  secreted,  the  strength  of  the  application,  and  the  fre- 
quency of  repealing  it,  must  be  regulated.  In  mild 
recent  cases  the  lotion  may  be.used  once  or  twice  a 
day,  and  rather  weaker  than  the  above  proportions ; 
but,  in  inveterate  cases,  it  is  necessary  to  apply  it  once 
or  twice  every  hour,  and  to  increase  its  styptic  power 
in  proportion;  and  when  the  complaint  is  somewhat 
relieved,  the  strength  of  the  lotion  may  be  lessened^ 
and  its  application  be  less  frequent. 

“ The  reasons  for  a frequent  repetition  of  the  means 
just  mentioned,  in  bad  cases,  are,  indeed,  of  the  most 
urgent  nature.  Until  the  conjunctiva  is  somewhat 
thinned,  and  the  quantity  of  the  discharge  diminished, 
it  is  impossible  to  know  in  what  state  the  eye  is: 
whether  it  is  more  or  le.ss  injured,  totally  lost,  or  capa- 
ble of  any  relief.  The  continuance  or  extinction  of 
the  sight  frequently  depends  on  the  space  of  a few 
hours:  nor  can  we  be  relieved  from  the  greatest  un- 
certainty, in  these  respects,  until  the  cornea  becomes 
visible.” — (Ware,  p.  145.) 

This  author  condemns  the  use  of  emollient  poultices, 
which  must  have  a tendency  to  increase  the  swelling 
and  relaxation  of  the  conjunctiva.  If  poultices  are 
preferred,  he  particularly  recommends  sucit  as  possess 
a tonic  or  mild  astringent  property ; as  one  made  of  the 
curds  of  milk,  turned  with  alum  and  an  equal  part  of 
unguentum  sambuci,  or  axungia  porcini.  3’his  is  to 
be  put  on  cold,  and  frequently  renewed,  without  omit- 
ting the  use  of  the  injection. — ( Ware,  p.  147.) 

When  the  secreted  matter  is  glutinous,  and  makes 
the  eyelids  so  adherent  together  that  they  cannot  be 
opened  after  being  shut  for  any  length  of  time,  the  ad- 
hesive matter  mu-st  be  softened  with  a little  fresh  but- 
ter mixed  with  warm  milk,  or  by  means  of  any  other 
soft  oleaginous  liquor,  after  the  poultice  is  taken  ofiT, 
and  before  using  the  lotion. — (P.  147.) 

If  the  eversion  of  the  eyelids  only  occurs  when  the 
child  cries,  and  then  goes^rff,  nothing  need  be  done  in 
addition  to  the  above  means.  When,  how'ever,  the 
eversion  is  constant,  the  injection  must  be  repeated 
more  frequently  than  in  other  cases;  the  eyelids  put  in 
their  natural  position  after  its  use ; and  an  attendant 
directed  to  hold  on  them  with  his  finger,  for  some 
length  of  time,  a compress  dipped  in  the  diluted  aqua 
camphorata. — (P.  148.) 

In  some  cases,  when  the  inside  of  the  eyelids  has 
been  very  much  inflamed,  the  tinctura  thebaica,  in- 
sinuated .between  the  eye  and  eyelids,  has  been  useful. 
If,  after  the  morbid  secretion  is  checked,  any  part  of 
the  cornea  should  be  opaque,  the  unguentum  hydrar- 
gyri  nitrati,  melted  in  a spoon,  and  applied  accurately 
on  the  speck  with  a fine  hair-pencil,  or  Janin’s  oph- 
thalmic ointment,  lowered  and  used  in  the  same  man- 
ner, may  produce  a cure,  if  the  opacity  be  not  of  too 
deep  a kind.  When  the  local  disease  seems  to  be  kept 
up  by  a bad  habit,  alteratives  should  be  exhibited,  par- 
ticularly the  black  sulphuret  of  mercury,  or  small  doses 
of  calomel. 

The  treatment  recommended  by  Dr.  Vetch  is  as  fol- 
lows: if  the  inflammation  have  not  extended  to  the 
conjunctiva  of  the  eye,  its  farther  progress  may  be 
checked  by  removing  the  infant  to  a healthy  atmos- 
phere, and  washing  the  eye  with  any  mild  collyrium. 
Leeches  are  commended  throughout  the  whole  course 
of  the  complaint.  On  the  first  accession  of  the  tume- 
faction, the  best  effect  will  often  be  produced  by  the 
application  of  a small  portion  of  ointment,  composed 
of  lard  or  butter  3 vj.,  and  x.  gr.  of  the  rod  nitrate  of 
mercury,  without  any  wax.  As  the  purulency  advance.s, 
the  liquor  plurnbi  subacelatia,  he  says,  will  be  found  not 
less  serviceable  than  in  other  instances  of  purulent 
ophthalmy.  For  promoting  the  separation  of  any 
8lo\igh,  he  recommends  a solution  of  the  nitrate  of 
silver;  and  for  curing  the  relaxed  state  of  the  con- 
junctiva, a solution  of  alum,  or  of  the  sulphate  of  cop- 
per.—(Om  Diseases  of  the  Eye,  p.  260.) 


238 


OPHTHALMY. 


The  pui'nlent  ophthalmy,  arising  either  from  sup- 
pression of  gonorrhaay  or  from  the  inadvertent  con- 
veyance of  gonorrhoeal  matter  to  the  eyes^  is  said  to 
produce  rather  a swellina;  of  the  conjunctiva  than  of 
the  eyelids,  which  is  followed  by  a discharge  of  a yel- 
low greenish  matter,  similar  to  that  of  clap.  The  heal 
and  pain  in  the  eyes  are  considerable ; an  aversion  to 
light  prevails,  and  in  some  instances,  an  appearance 
of  hypopion  is  visible  in  the  anterior  chamber  of  the 
aqueous  humour.  When  the  complaint  proceeds  from 
the  second  cause,  it  is  described  as  being  less  severe 
than  when  it  arises  from  the  first.  However,  by  such 
gentlemen  ( /fare,  Travers^  Src.)  as  have  seen  une- 
quivocal instances  of  purulent  ophthalmy  excited  in 
the  second  way,  the  disease  is  said  to  be  remarkable 
for  its  violence  and  intensity.  The  reality  of  cases  of 
purulent  ophthalmy  f rom  the  application  of  gonorrhoeal 
matter  to  the  eyes,  seems  supported  by  such  a mass  of 
evidence,  that  I believe  the  fact  must  be  admitted. 
Yet,  from  somestatements lately  published  by  Dr.Vetch, 
it  would  appear,  that  the  frequency  of  this  mode  of 
infection  must  be  very  much  lessened  by  the  circum- 
stance of  the  matter  taken  from  the  urethra  not  being 
capable  of  communicating  the  disease  to  the  eyes  of 
the  individual  by  whom  such  matter  is  secreted,  though 
probably  capable  of  doing  so  to  the  eyes  of  another 
person. 

In  the  same  way  the  urethra  cannot  be  affected  by 
the  application  of  matter  taken  from  the  purulent  eyes 
of  the  individual  on  whom  the  experiment  is  made. 
At  least,  of  these  circumstances  there  is  a negative 
proof  in  some  facts  recorded  by  Dr.  Vetch.  “ In  the 
case  of  a soldier,  received  in  a very  advanced  stage 
of  the  Egyptian  ophthalmia,  in  whom  destruction  of 
the  cornea  had  to  a certain  extent  taken  place,  I took 
occasion  to  represent  the  possibility  of  diverting  the 
disease  from  the  eyes  to  the  urethra,  by  applying  the 
discharge  to  the  latter  surface.  Accordingly,  some 
of  the  matter  taken  from  the  eyes  was  freely  applied 
to  the  orifice  of  the  urethra.  No  effect  followed  this 
trial  which  was  repealed  on  some  other  patients,  all 
labouring  under  the  most  virulent  state  of  the  Egy  ptian 
disease,  and  in  all  the  application  was  perfectly  inno- 
cuous. But  in  another  case,  where  the  matter  was 
taken  from  the  eye  of  one  man  labouring  under  puru- 
lent ophthalmia,  and  applied  to  the  urethra  of  another, 
the  purulent  inflammation  of  the  urethra  commenced 
in  36  hours  afterward,  and  became  a very  severe  attack 
of  gonorrhoea.  From  the  result  of  these  cases  (says 
Dr  Vetch)  I could  no  longer  admit  the  possibility  of  in- 
fection being  conveyed  to  the  eyes  from  the  gonorrhoeal 
discharge  of  the  same  person.  Some  time  after  this, 
the  improbability,  or  rather  impossibility,  of  this  effect 
was  rendered  decisive  by  an  hospital  assistant,  who 
conveyed  the  matter  of  gonorrhoea  to  his  eyes,  without 
any  affection  of  the  conjunctiva  being  the  conse- 
quence.”— (See  Vetch  on  Diseases  of  the  Eye^  p.  242.) 
Hence,  this  gentleman  is  led  to  refer  the  connexion 
between  gonorrhoea  and  ophthalmia  in  the  same 
person,  to  peculiarity  of  constitution  ; but  the  the- 
ories on  which  this  opinion  rests,  my  limits  will  not 
allow  me  to  examine. 

If  it  be  actually  true  that,  in  adults,  a species  of 
purulent  ophthalmy  does  originate  from  the  sudden 
suppression  of  gonorrhoea,  are  we  to  consider  the  com- 
plaint so  produced  as  a metastasis  of  the  disease  from 
the  urethra  to  the  eyes  1 This  ophthalmy  does  not 
regularly  follow  the  suppression  of  gonorrhoea,  nay,  it 
is  even  a rare  occurrence : also,  when  it  is  decidedly 
known  that  the  purulent  ophthalmy  has  arisen  from 
the  infection  of  gonorrhoea,  namely,  in  those  instances 
in  which  the  matter  has  been  incautiously  communi- 
cated to  the  eyes,  it  appears  that  such  an  affection  of 
these  organs,  so  produced,  is  different  from  the  one 
alluded  to,  inasmuch  as  it  is  slower  in  its  progress, 
and  less  threatening  in  its  aspect.  When  the  eyes  are 
affected,  the  disease  of  the  urethra  is  not  always  sus- 
pended.— {Vetch  on  Diseases  of  the  Eye,  p.  2.39.) 
Hence,  there  is  good  reason  for  supposing  that  no  me- 
tastasis takes  place  in  this  species  of  purulent  oph- 
thalmy, supposed  to  be  connected  with  a suppressed 
gonurrhrea ; but  we  must  be  content  with  inferring 
that,  if  it  really  has  such  a cause,  it  originates  from  a 
sympathy  prevailing  between  the  urethra  and  eyes; 
and  that  the  difference  of  irritability  in  different  people. 
Is  the  reason  why  it  is  not  an  invariable  consequence 
of  the  sudden  stoppage  of  a gonorrhoea. 


The  injection  of  warm  oil,  the  introduction  of  a 
bougie  into  the  urethra,  and  the  application  of  cata- 
plasms to  the  perinffium,  with  a viewi  of  renewing  the 
discharge  from  the  urethra,  form  the  outline  of  the 
practice  of  those  who  place  implicit  reliance  in  the 
suppression  of  gonorrhoea  being  the  cause  of  the  com- 
plaint. The  rarity  of  the  occurrence;  the  frequency 
of  the  sudden  cessation  of  the  urethral  dischaige  ; the 
possibility  of  an  ophtlialmy  arising  as  well  at  this  par- 
ticular moment  as  at  any  other,  totally  independent  of 
the  other  complaint,  cannot  fail  to  raise  in  a discern- 
ing mind  a degree  of  doubt  concerning  the  veracity 
of  the  assigned  cause.  Besides,  admitting  tiiat  there 
is  a sympathy  between  the  urethra  and  eyes,  bow 
are  we  to  ascertain  whether  the  suppression  of  gonor- 
rhoea be  the  cause  orthe  effect  of  the  ophthalmy,  sup 
posing  that  the  one  ceases,  and  the  other  commences 
about  the  same  lime  1 Actuated  by  such  reflections,  I 
am  induced  to  dissuade  surgeons  from  adopting  any 
means  calculated  to  renew  a discharge  of  matter  from 
the  urethra.  When  the  purulent  ophthalmy,  in  adult 
subjects,  is  decidedly  occasioned  by  the  actual  contact 
and  infection  of  gonorrhoeal  matter,  applied  accident- 
ally to  the  eyes,  no  one  has  recommended  this  unneces- 
sary and  improper  practice. 

The  first  indication  in  the  treatment  of  the  disease 
from  either  cause,  is  to  oppose  the  violence  of  the  in- 
flammation, and  thus  resist  the  destruction  of  the  eye 
and  opacity  of  the  cornea.  A copious  quantity  of 
blood  should  be  taken  away  both  topically  and  gene- 
rally ; mild  laxatives  should  be  exhibited,  and  a blister 
applied  to  the  nape  of  the  neck,  or  temples.  The  eyes 
ought  to  be  often  fomented  with  a decoction  of  white 
poppy  heads,  and  warm  milk  repeatedly  injected 
beneath  tlie  eyelids.  To  prevent  the  palpebr®  from 
becoming  agglutinated  together  during  sleep,  the  sper- 
maceti cerate  should  be  smeared  on  the  margins  of  the 
tarsi  every  night. 

When  the  heat  and  pain  in  the  eyes,  and  febrile 
symptoms,  have  subsided ; when  an  abundant  discharge 
of  pus  has  commenced  : all  topical  emollients  are  to  be 
relinquished,  and  a collyrium  of  aq.  roste  jx.  coritain- 
ing  hydrarg.  oxy.  mur.  gr.  j.  used  in  their  place.  Scarpa 
slates,  that  in  the  ophthalmy  originating  from  the  in- 
advertent communication  of  the  matter  of  gonorrhoea 
to  the  eyes,  applications  in  the  form  of  ointment,  such 
as  the  ung.  hydrarg.  and  Janin’s  salve,  to  which  might 
be  added  the  ung.  hyd.  nitrat.,  avail  more  than  fluid 
remedies. 

Inflammation  of  the  Eyeball  in  general.  From  cases 
in  which  the  eyelids  are  at  first  chiefly  affected,  I pass 
to  the  consideration  of  inflammation,  as  comiuenciirg 
in  the  eyeball  itself.  As  Beer  remarks,  fortunately  it  is 
only  very  seldom  that  the  whole  of  the  organ  is  at  once 
attacked  with  genuine  idiopathic  inflammation,  with- 
out any  part  of  its  texture  being  spared.  Although 
this  kind  of  ophthalmy  is  far  more  frequent  than  com- 
mon inflammation  of  the  orbit,  it  is  much  more  rare 
than  the  same  disorder  of  the  eyelids.  For  the  most 
part,  healthy  inflammation  of  the  eyeball  has  a limited 
point  of  origin,  from  which  it  spreads,  sometimes 
quickly,  sometimes  slowly,  over  the  whole  organ. 
During  an  exceedingly  violent,  tense,  throbbing  pain, 
affecting  not  only  the  eye  itself,  but  extending  to  all  the 
surrounding  parts,  the  bottom  of  the  orbit,  and  within 
the  head,  the  white  of  the  eye  becomes  suffused  with 
a uniform  redness,  which,  on  attentive  examination, 
is  found  to  be  seated  not  only  in  the  conjunctiva  of  the 
eyeball,  but  also  in  the  sclerotica,  and  to  exhibit  at  first 
a very  fine  vascular  net-work,  which,  as  the  redness 
grows  more  intense,  assumes  the  appearance  of  scarlet 
cloth,  forming  all  round  the  cornea  a uniform  circular 
prominent  fold,  which  has  a very  firm  feel,  and  is  so 
tender,  that  when  touched  in  the  gentlest  manner,  the 
patient  cries  out  in  agony.  The  circu.mference  of  the 
cornea  continues  to  be  more  and  more  covered  by  this 
increasing  swelling  of  the  conjunctiva,  until  at  length 
only  a portion  of  its  centre  remains  visible.  At  the 
same  lime,  the  pupil  is  very  much  contracted  ; the  iris 
motionless;  and  though  vision  is  nearly  or  entirely 
lost,  the  patient  is  seriously  disturbed  by  fiery  appear- 
ances before  the  eye.  When  the  iris  is  naturally  gray 
or  blue,  it  turns  greenish,  and  when  browq  or  black,  it 
becomes  reddish.  Every  movement  of  the  eyeball  and 
upper  eyelid  is  suspended,  and  the  ofbit  feels  to  the 
patient  as  if  it  were  too  small,  which.  Beer  says,  is  in 
reality  the  case,  because  the  whole  of  the  eyeball,  and 


OPHTHALMY. 


239 


jiot  merely  the  conjunctiva  is  enlarged,  so  as  to  project 
like  a lump  of  raw  flesh  farther  and  farther  between 
the  edges  of  tlie  palpebrie,  and  completely  fill  every 
part  of  the  orbit.  While  the  eyeball  enlarges,  the 
cornea  always  loses  its  transparency,  and  the  inflam- 
mation spreads  to  the  eyelids,  the  lower  one  at  last 
becoming  everted  by  the  excessive  and  firm  tumefac- 
tion of  the  parts  behind  it,  and  the  upper  one  present- 
ing the  most  unequivocal  marks  of  phlegmonous  in- 
flammation. The  secretion  of  tears  and  mucus  is  now 
entirely  suppressed,  and  of  course  the  eye  preternatu- 
rally  dry.  At  the  very  commencement  of  this  violent 
farm  of  ophthalmy,  the  constitution  is  disturbed  by  a 
severe  attack  of  inflammatory  fever,  and  irritable 
patients  are  not  unfrequently  seized  with  delirium. 
Here,  says  Beer,  terminates  the  first  stage  of  this  very 
dangerous  disorde.*-. 

When  the  disease  is  left  to  itself,  suppuration  comes 
on,  attended  with  fever  and  constant  shiverings;  the 
swelling  of  the  sclerotic  conjunctiva  undergoes  a 
remarkable  increase,  and  assumes  a dark-red  colour  at 
the  same  time  that  it  becomes  softer.  The  pain  becomes 
irregular,  throbbing,  and  when  the  eye  or  eyelids  are 
touched,  of  a lancinating  description.  As  a morbid 
secretion  now  begins  to  take  place  from  the  Meibomian 
glands,  the  swelled  conjunctiva  has  a more  moist  ap 
pearance.  The  upper  eyelid  has  a purple  hue,  and,  on 
account  of  the  continually-increasing  size  of  the  eyeball, 
is  pushed  farther  and  farther  outwards.  The  portion 
of  the  cornea,  still  discernible  in  the  middle  of  the 
protuberant  conjunctiva,  acquires  a snowy  whiteness, 
which  afterward  changes  to  yellow.  The  patient  feels 
an  oppressive  sense  of  heaviness  in  the  orbit,  and  a 
disagreeable  kind  of  coldness  all  round  the  eye.  At 
length,  the  throbbing  and  tension  are  so  agonizing,  that 
the  patient  often  expresses  a wish  to  have  the  eyeball 
extirpated.  If  no  effectual  treatment  be  adopted,  the  eye 
now  bursts,  and  a mixture  of  matter  and  blood,  to- 
gether with  the  scarcely  perceptible  remains  of  the 
lens  and  vitreous'  humour,  is  discharged  with  consider- 
able force  to  some  distance  in  front  of  the  patient ; an 
occurrence,  sometimes  termed  rhcxis  or  rhegma  oculi. 
From  this  moment,  the  pain  all  at  once  subsides  into 
a very  moderate  feel  of  burning  in  the  eye  ; and  sup- 
puration goes  on  until  all  the  textures  of  the  organ  are 
annihilated,  the  orbit  has  an  empty  appearance,  and 
the  closed  eyelids  sink  into  a concavity.  Thus  ends, 
as  Beer  observes,  the  second  stage,  after  much  tedious 
and  general  indisposition.  But  he  remarks,  that  the 
course  of  the  case  is  quite  different  when  it  has  been 
wrongly  treated  in  its  first  stage  with  stimulants,  or 
exposed  to  the  ill  effects  of  tobacco-smoke,  the  drink- 
ing of  spirits,  improper  diet,  immoderate  exercise,  &c. ; 
for,  under  the  operation  of  these  unfavourable  circum- 
stances, the  second  stage  may  commence  with  dreadful 
gangrenous  mischief,  every  vestige  of  the  organization 
of  the  eye  disappearing,  and  the  parts  at  length  spha- 
celating, while  large  abscesses  form  around,  and,  unless 
efficient  medical  aid  be  promptly  given,  the  patient  loses 
his  life. 

With  re-spect  to  the  causes  of  such  an  attack  of  the 
>vhole  eyeball  at  once  by  common  inflammation  in  a 
healthy  subject,  they  must  be  of  an  exceedingly  violent 
description,  such  as  injuries  produced  by  gunpowder, 
burns,  and  lesions  either  of  a mechanical  kind,  or  acting 
both  chemically  and  mechanically  together ; a subject 
already  fully  treated  of  in  the  foregoing  columns. 

The  following  are  the  observations,  which  Beer  de- 
livers on  the  prognosis : — While,  in  the  first  stage  of 
this  dangerous  form  of  ophthalmy,  the  eyesight  yet  re- 
mains, and  the  eyeball  itself  is  not  enlarged,  if  the  pa- 
tient can  be  properly  taken  care  of,  some  hope  may  be 
entertained  of  dispersing  the  inflammation  so  favour- 
ably that,  with  the  exception  of  a weakness  of  sight, 
of  longer  or  shorter  continuance,  no  ill  effects  will  be 
left.  It  is  manifest,  however,  that  under  these  circum- 
stances the  surgeon  should  not  be  too  bold  in  promising 
a perfect  cure ; for  the  very  commencement  of  such 
an  inflammation  of  the  whole  eyeball,  even  when  the 
disorder  is  purely  idiopathic,  is  unavoidably  attended 
with  some  risk,  not  only  of  permanent  blindness,  but 
of  the  eye  itself  being  destroyed  in  the  most  painful 
manner;  and  when  things  turn  out  rather  better,  a 
tolerably  favourable  termination  of  the  case  is  uncom- 
mon. But  as  soon  as  the  power  of  seeing  is  quite  lost, 
the  pupil  nearly  closed,  and  the  eyeball  prodigiously 
swelled,  it  will  be  fortunate  if  the  inflammation  can  be 


/ 

resolved  so  as  to  preserve  the  shape  of  the  organ ; for 
the  restoration  of  the  eyesight  is  entirely  out  of  the 
question.  But  besides  the  irremediable  loss  of  vision, 
the  disorder  under  these  circumstances  always  pro- 
duces a greater  or  less  closure  of  the  pupil,  which, 
however,  has  no  share  in  causing  the  blindness. 

In  the  second  stage  of  the  case,  of  course,  the  hope 
of  restoring  vision  is  quite  past,  and  if  the  eyeball  it- 
self, and  not  merely  the  conjunctiva,  has  been  con- 
siderably swelled  in  the  first  stage  of  the  case,  the 
chance  of  preserving  the  natural  shape  of  the  organ  is 
extremely  unpromising.  But  when  the  eye  bursts,  the 
latter  desideratum  is  impossible.  If  the  first  stage 
should  have  been  so  violent  as  to  induce  gangrene,  the 
practitioner  will  have  enough  to  do  iii  preventing 
sphacelus  and  death ; the  danger  of  which  is  con- 
siderable, on  account  of  the  intimate  connexion  be- 
tween the  eye  and  parts  in  the  orbit,  and  the  brain  and 
its  membranes. 

In  the  first  stage,  antiphlogistic  treatment,  in  the 
general  sense  of  the  expression,  is  indicated,  and  the 
case  is  not  to  be  regarded  merely  as  a local  disorder. 
However,  with  respect  to  topical  bleedings,  the  sur- 
geon, says  Beer,  should  be  more  active  than  in  other 
examples  of  ophthalmy,  and,  after  copious  venesection 
and  the  use  of  leeches  have  produced  some  relief,  the 
protuberant  conjunctiva  round  the  cornea  should  be 
deeply  scarified  with  a lancet.  If  in  the  first  stage  de- 
lirium come  on,  as  it  sometimes  does  during  the  vio- 
letfte  of  the  inflammatory  fever.  Beer  directs  one  of 
the  external  jugular  veins  to  be  opened  : or  blood  might 
be  taken  from  the  temporal  artery. 

In  the  second  stage  of  the  case,  when  the  re-establish- 
ment of  vision  is  quite  impossible,  and  the  objects  are 
to  endeavour  to  keep  the  ey’e  of  a good  shape,  and 
quickly  lessen  the  suppuration,  warm  emollient  poul- 
tices, and  particularly  those  made  of  apples,  are  the 
applications  on  which  Beer  bestows  his  praises.  This 
topical  treatment  is  to  be  assisted  with  internal  means, 
as  explained  in  the  preceding  pages,  because  the  disor- 
der is  attended  with  a general  disturbance  of  the  con- 
stitution. When  matter  is  fully  formed,  and  its  fluc- 
tuation can  be  distinctly  felt,  Beer  approves  of  opening 
the  abscess  with  a lancet;  for  it  is  only  by  this  means 
that  the  annihilation  of  the  eyeball  can  be  prevented. 
If  the  eye  has  already  burst,  the  preservation  of  its 
form  is  no  longer  possible,  and  according  to  Beer,  both 
the  topical  and  general  treatment  should  be  partly  of  a 
tonic  description.  When  gangrenous  mischief  has 
occurred,  the  practice  ought  to  conform  to  the  principles 
explained  in  the  article  Mortification. 

External  Ophthalmy.  Inflammation  of  the  Outer 
Coats  of  the  Eye.  Ophthalmitis  Externa  Jdiupathica, 
of  Beer.  The  modifications  of  this  common  species 
of  ophthalmy,  as  the  latter  author  observes,  have  a 
variety  of  names  applied  to  them,  as  ophthalmia  levis, 
ophthalmia  angularis,  taraxis,  and  sometimes  chemo- 
sis,  and  ophthalmia  sicca.  Together  with  a preter- 
natural dryness  of  the  eye,  and  a sensation  as  if  the 
eyeball  were  compressed  on  every  side,  the  white  of  the 
eye  becomes  covered  with  a general  redness,  which, 
though  it  affect  both  the  sclerotica  and  the  conjunctiva, 
will  be  found  on  attentive  examination  to  be  much 
more  considerable  in  the  former  than  the  latter  mem- 
brane, in  which  only  a delicate  plexus  of  blood-vessels 
is  at  first  perceptible.  The  motions  of  the  eye  and  eye- 
lids are  not  absolutely  prevented ; yet  the  patient  never 
moves  these  parts,  except  when  he  is  actually  obliged 
to  do  so,  as  every  motion  of  them,  if  not  actually  pain- 
ful, occasions  a good  deal  of  annoyance.  Though  the 
cornea  cannot  be  said  to  become  opaque,  its  clearness 
is  always  much  diminished ; and  this  change  is  the 
greater  the  redder  the  white  of  the  eye  appears.  These 
effects,  which  occur  almost  simultaneously,  are  fol- 
lowed by  pain,  which  increases  every  moment,  at  first 
extending  over  the  whole  eyeball,  and  then  to  the  sur- 
rounding parts,  and  to  the  top  of  the  head.  As  the  pain 
grows  more  severe,  every  movement  of  the  eyeball  and 
palpebrae  becomes  more  distressing,  the  dryness  of  the 
e)'e  greater,  and  the  redness  of  the  sclerotic  conjunctiva 
augments  either  more  slowly  or  quickly,  according  to 
the  degree  of  inflammation,  until  the  net-work  of 
blood-vessels,  which  was  at  first  distinguishable,  en- 
tirely disappears  and  the  conjunctiva  looks  like  a piece 
of  red  cloth,  quite  concealing  the  sclerotica,  and  form- 
ing round  the  cornea  a very  painful,  firm,  uniform,  cir- 
cular projection.  Thus  the  cornea  seems  as  if  it  lay  in 


240 


OPHTHALMY. 


a depression,  with  its  margin  partly  covered  by  this  in- 
flammatory swelling  of  the  conjunctiva.  At  the  period 
when  the  protuberance  of  the  latter  membrane  takes 
place,  the  cornea  itself  always  becomes  less  and  less 
clear,  and  of  a reddish-gray  colour,  so  that  neither  the  iris 
nor  the  pupil  can  be  any  longer  distinguished,  and  the 
power  of  vision  is  reduced  to  a faint  perception  of 
light.  The  pain,  which  was  that  of  heaviness  and 
tension,  now  becomes  of  a throbbing  description,  and 
the  eyelids,  which  now  begin  to  participate  in  the 
effects  of  the  inflammation,  are  no  longer  capable  of 
covering  properly  the  swelled  conjunctiva.  The  eye- 
ball and  eyelids  are  perfectly  motionless;  and  if  an 
attempt  be  made  by  the  patient  to  move  them,  the 
efl()rts  of  the  muscles  may  be  perceived,  but  still  no 
movement  of  the  parts  intended  is  performed.  The 
orbit  feels  as  if  it  were  too  small  for  the  eye,  and  the 
constitution  suffers  a severe  attack  of  inflammatory 
fever.  Thus,  says  Beer,  does  the  first  stage  of  this 
form  of  ophihalmy  gradually  rise  to  its  highest  degree, 
to  which  he  applies  the  name  of  true  chemosis. 

However,  it  is  observed,  that  idiopathic  external 
ophthalmy  does  not  always  become  so  violent;  as,  for 
instance,  when  the  complaint  has  been  excited  merely 
by  the  lodgement  of  some  small  foreign  body  under  the 
eyelids;  for  though,  in  such  a case,  the  conjunctiva 
and  sclerotica  are  both  reddened  together,  yet  even 
when  no  aid  is  afforded,  if  no  other  sources  of  greater 
irritation  are  present,  the  redness  does  not  readily  in- 
crease so  as  quite  to  conceal  the  sclerotica,  or  t<t  be 
attended  with  an  inflammatory  swelling  all  round  the 
cornea.  This  milder  form  of  external  ophihalmy  has 
sometimes  received  the  name  of  taraxis.  It  is  the 
mild  acute  ophthalmy  of  Scarpa,  characterized,  as  this 
author  says,  by  redness  of  the  conjunctiva  and  lining 
of  the  eyelids,  an  unnatural  sensation  of  heat  in  the 
eyes,  uneasiness,  itching,  and  shooting  pains,  as  if 
sand  were  lodged  between  the  eye  and  eyelids.  At 
the  place  where  the  pain  seems  most  severe,  Scarpa 
remarks,  that  some  blood-vessels  appear  more  promi- 
nent and  turgid  than  other  vessels  of  the  same  class. 
The  patient  keeps  his  eyelids  closed;  for  he  feels  a 
weariness  and  restraint  in  opening  them,  and  by  this 
means  he  also  moderates  the  action  of  the  light,  to 
which  he  cannot  expose  himself  without  increasing  the 
burning  sensation,  lancinating  pain,  and  effusion  of 
tears.  If  the  constitution  be  irritable,  the  pulse  will  be 
a little  accelerated,  particularly  towards  the  evening; 
the  skin  dry  ; and  sometimes  slight  shiverings  and 
nausea  and  sickness  take  place. 

According  to  Scarpa,  mild  acute  ophthalmy  is  often 
the  consequence  of  a cold,  in  which  the  eyes,  as  well  as 
the  pituitary  cavities,  fauces,  and  trachea,  are  affected. 
It  is  not  unfrequenlly  occasioned  by  change  of  weather, 
sudden  transitions  from  heat  to  cold,  the  prevalence  of 
easterly  winds,  journeys  through  damp,  unhealthy, 
sandy  countries,  in  the  hot  season  of  the  year,  expo- 
sure of  the  eyes  to  the  vivid  rays  of  the  sun,  draughts 
of  cold  air,  dust,  &c.  Hence,  it  does  not  seem  extra 
ordinary  that  it  should  often  make  its  appearance  as  an 
epidemic,  and  afflict  persons  of  every  age  and  sex.  As 
additions  to  the  list  of  remote  causes,  authors  enume- 
rate the  suppression  of  some  habitual  evacuation,  as 
bleedings  from  the  nose,  or  piles,  the  menses,  &c.,  a 
disordered  state  of  the  primae  vi®,  worms,  denti- 
tion, &c. 

Between  Beer  and  some  late  writers,  there  is  either 
one  point  of  difference  in  their  descriptions  of  external 
ophthalmy,  or  else  they  mean  different  cases ; for  while 
Beer  represents  the  redness  as  affecting  the  sclerotica 
at  first  more  than  the  conjunctiva,  other  writers  de- 
scribe the  affection  of  the  sclerotica  as  generally  second- 
ary when  it  happens  at  all;  for  according  to  modern 
observations  it  is  not  unavoidably  either  an  attendant 
upon  or  an  effect  of  simple  inflammation  of  the  con- 
junctiva. 

As  the  second  stage  of  external  ophthalmy  comes  on, 
the  symptoms  vary  according  to  the  degree  of  the  com- 
plaint in  its  first  stage;  but  when  what  Beer  calls  a true 
chemosis  is  produced,  the  following  are  described  by  him 
as  the  usual  appearances.  The  circular  prominent  fold 
of  the  conjunctiva  round  the  cornea  becomes  of  a dark- 
red  colour  and  the  swelling  increases,  but  it  becomes 
softer  and  less  painful.  The  hardly  visible  portion  of 
the  cornea,  s'tnated  in  the  depression  formed  by  the 
circular  protuberance  of  the  conjunctiva,  seems  at 
first  perfectly  white  and  afterward  yellowish,  being 


the  seat  of  more  or  less  purulent  matter.  Though  fh« 
swelled  coijjunctiva  is  every  where  moistened  with  a 
thin  whitish  mucus,  this  secretion,  says  Beer,  is  never 
so  copious  as  to  run  over  the  face,  as  in  the  case  of  oph- 
thalmo-blennorrhoea.  In  this  stage  the  lowei  eyelid  is 
turned  somewhat  outwards,  in  consequence  of  its 
lining  becoming  more  swelled.  While  suppuration  is 
taking  place  in  the  cornea,  attended  with  the  febrile 
symptoms  which  usually  accompany  the  formation  of 
acute  abscesses,  little  collections  of  matter  sometimes 
occur  at  different  points  of  the  conjunctiva,  and,  after 
they  have  burst,  a probe  may  easily  be  passed  rather 
deeply  into  them  without  any  particular  pain.— (Beer 
b.  I,  p.  412.)  The  suppuration  continually  advancing' 
the  swelling  of  the  conjunctiva,  and  of  the  whole  eye- 
ball, now  diminishes,  the  effects  of  the  inflammation 
penetrate  deeply  into  the  organ,  and  the  structure  of 
the  eye  is  so  altered  as  not  to  be  cognizable,  the 
part  shrivelling  up,  as  Beer  says,  into  a motionless 
whitish  mass.  However,  according  to  this  author, 
these  deep  effects  of  suppuration  are  sometimes  pro- 
duced only  in  a certain  part  of  the  eyeball,  espe- 
cially when  the  chemosis  is  the  consequence  of  an 
external  injury ; and  in  this  circumstance  the  rest  of 
the  circumference  of  the  globe  of  tlie  eye  exhibits  its 
natural  organization,  while  in  the  part  above  alluded 
to  there  is  a funnel-like  depression,  attended  with  a 
considerable  diminution  in  the  size  of  the  organ. 

But,  says  Beer,  when  an  idiopathic  external  inflam- 
mation of  the  eye  has  only  attained  the  milder  degree 
expressed  by  the  term  taraxis  / as,  for  instance,  when 
the  complaint  is  principally  owing  to  the  lodgement  of 
some  mechanically  or  chemically  irritating  substance 
under  the  eyelids;  the  redness  of  the  conjunctiva  and 
sclerotica  undergoes  a remarkable  increase  on  the  ac- 
cession of  the  second  stage  : the  first  of  these  mem- 
branes become  somewhat  swelled  ; the  pain  is  lanci- 
nating and  irregular,  and  the  secretion  of  tears  unusually 
profuse ; but  at  the  point  where  the  extraneous  sub- 
stance lodges,  an  open  superficial  suppuration  occurs, 
and,  according  to  Beer,  the  c*ase,  both  in  the  first  and 
second  stage,  is  generally  accompanied  with  no  febrile 
symptoms. 

In  the  first  stage.  Beer  represents  the  prognosis  as 
very  favourable,  provided  the  disorder  does  not  exceed 
that  degree  to  which  the  name  of  taraxis  is  applied  ; 
for  with  the  aid  of  proper  treatment  the  inflammation, 
when  of  a healthy  kind,  may  be  soon  so  favourably  re- 
moved as  not  to  leave  a vestige  of  it  behind.  If  the 
cause  of  the  disorder  be  not  greater  than  a moderate  in- 
jury or  wound  of  the  eye,  any  traces  of  the  lesion 
which  are,  perhaps,  still  remaining,  will  disappear  as 
soon  as  the  inflammation  subsides.  On  the  other 
hand,  when  this  kind  of  ophthalmy  presents  itself  in 
the  form  of  true  chemosis,  the  prognosis  is  serious  and 
must  be  made  tyilh  great  reserve,  especially  when  the 
patient  is  of  a weak  irritable  constitution,  a child  very 
stubborn  and  unmanageable,  or  incapable  of  following 
strictly  the  advice  which  he  receives  from  his  medical 
attendant ; for  under  these  circumstances  it  will  not  be 
in  the  power  of  the  latter  to  prevent  the  complaint  from 
advaacing  unremittingly  to  its  second  stage,  in  which 
event  the  ill  consequences  of  suppuration  will  be 
incalculable.  But  if  these  unfavourable  conditions 
are  not  present,  though  the  genuine  idiopathic  che- 
mosis may  really  have  attained  a violent  and  almost 
its  highest  degree  in  the  first  stage,  not  only  the  eye 
may  be  saved  by  prompt  and  judicious  treatment,  but 
also  the  eyesight;  nor  will  the  result  be  different  even 
when  the  cornea  continues  for  some  time  deprived  of 
its  transparency,  and  the  power  of  vision  impaired  by 
a slight  varicose  affection  of  its  conjunctival  covering. 
These  effects,  says  Beer,  at  length  completely  disap- 
pear, less  in  consequence  of  the  aid  of  medicine  than 
of  a proper  regimen,  the  uninterrupted  enjoyment  of  a 
fresh  dry  air,  &c. 

'I'he  prognosis  in  the  second  stage,  is  under  very  dif- 
ferent circumstances;  for,  as  Beer  observe.s,  though 
the  inflammation  in  the  first  stage  may  really  not  ex- 
ceed that  degree  which  is  implied  by  the  term  taraxis, 
yet  if  any  suppurating  point  occasioned  by  some  slight 
preceding  injury  be  not  efficiently  treated,  or  if  there 
be  any  loss  of  substance  already  produced  by  the  in- 
jury itself,  a more  or  less  opaque  white  cicatrix  is  apt 
to  remain  on  the  cornea,  and  cause  a permanent  impe- 
diment to  vision  in  a degree  determined  by  the  situa- 
tion and  extent  of  the  opacity.  And  in  addition  to  thi* 


OPHTHALMY. 


241 


risk,  it  is  to  be  remembered,  that  if  the  suppurating 
point  be  entirely  neglected,  or  erroneously  treated,  the 
cornea  or  sclerotica  may  be  penetrated  by  ulceration, 
and,  in  the  first  case,  a prolapsus  of  the  iris,  an  adhe- 
sion of  this  organ  to  the  cornea  (synechia  anterior),  a 
disfigurement  of  the  pupil,  or  an  irregularity  of  the 
cornea,  be  produced ; while,  in  the  second,  the  conse- 
quences may  be  a partial  wasting  away  of  the  eyeball, 
attended  with  loss  of  sight  and  of  the  natural  shape 
of  the  part. — {Beer,  b.  1,  p.  417.) 

Beer  farther  observes,  that  when  this  species  of  oph- 
thahny  presents  itself  in  its  first  stage  in  the  form  of 
true  chemosis,  the  prognosis  in  the  second  stage  is  very 
unfavourable ; for,  when  the  cornea  is  generally  per- 
vaded by  suppuration,  the  eyesight,  and  in  some  de- 
gree the  form  of  the  eyeball,  are  for  ever  lost,  and  it 
will  be  lucky  if  the  case  can  be  brought  to  a conclu- 
sion with  the  mere  destruction  of  the  cornea.  But 
when  the  matter  points  at  once  in  several  places  of  the 
conjunctiva,  round  the  cornea,  all  idea  of  preserving 
the  shape  of  the  eye  sufficiently  for  the  application  of 
an  artificial  eye  is  out  of  the  question,  and  the  suigeon 
will  be  very  successful  if  he  can  now  check  in  mode- 
rate time  the  suppuration,  which  continues,  with  a 
good  deal  of  general  indisposition.  An  extraordinary 
relaxation  of  the  conjunctiva  of  the  lower  eyelid,  and 
a consequent  ectropium,  are  the  least  disastrous  effects 
of  the  abscesses  of  the  eye  thus  produced.  Lastly, 
Beer  remarks,  that  when  chemosis  is  in  the  second 
stage,  that  is  to  say,  attended  with  suppuration  of  the 
eye,  it  rarely  happens,  under  the  most  favourable  cir- 
cumstances, that  the  eyesight  and  shape  of  the  organ 
can  be  preserved  entirely  free  from  permanent  injury. 
— (B.  l,p.  418.) 

Let  us  next  consider  the  treatment  of  idiopathic  ex- 
ternal ophihalmy  in  its  modifications  of  simple  inflam- 
mation of  the  conjunctiva,  mild  acute  ophthalmy, 
or  taraxis,  and  severe  acute  ophihalmy,  with  che- 
mosis. 

According  to  Mr.  Travers,  simple  inflammation  of 
the  conjunctiva,  unconnected  with  injury  of  the  eye, 
and  neither  depending  upon  any  established  disorder 
of  the  system,  nor  modified  by  a scrofulous  diathesis, 
may  be  easily  and  speedily  reduced,  even  in  its  most 
acute  form,  by  bleeding,  and  some  brisk  doses  of  pur- 
gative medicine. — {Synopsis  of  the  Diseases  of  the 
Eye,  p.  247.)  For  the  relief  of  mild  acute  ophihalmy, 
Scarpa  recommends  low  diet,  gentle  purging,  with 
small  repeated  doses  of  antimonium  tartarizatum,  the 
removal  of  any  extraneous  body  lodged  under  the  eye- 
lid, and  frequently  washing  the  eye  with  a warm  de- 
coction of  mallow-leaves,  and  covering  it  with  a very 
soft  emollient  poultice,  included  in  a fine  little  muslin 
bag.  Mr.  Travers  also  expresses  his  decided  preference 
to  a tepid  application  in  the  painfully  acute  stage  of  in- 
flammation, and  considers  simple  warm  water  gene- 
rally belter  than  medicated  lotions,  like  the  aqueous 
solution  of  opium,  or  infusions  of  poppy  and  hem- 
lock. 

When  the  disease  presents  itself  in  its  first  stage,  in 
the  mild  form  of  taraxis,  says  Beer,  it  usually  runs  its 
course  quite  uncomplicated  with  any  general  indispo- 
sition, and  may  be  cured  by  moderate  antiphlogistic 
treatment,  in  which,  indeed,  since  the  eyeball  itself  is 
affected,  particular  attention  must  be  paid  to  lessening 
the  action  of  the  light  and  air  upon  the  organ.  But 
when  a true  chemosis  is  present,  every  antiphlogis- 
tic means  must  be  promptly  and  rigorously  put  in 
practice,  internal  as  well  as  external  remedies  beitig 
employed,  and,  besides  common  measures,  the  con- 
junctiva, round  the  cornea,  is  to  be  scarified;  a pro- 
ceeding never  necessary  in  the  cpse  of  taraxis.  Such 
scarifications,  Beer  observes,  have  a wonderful  effect 
when  practised  at  the  proper  period,  after  venesection 
and  topical  bleeding  with  leeches  have  been  fully  put 
in  execution,  and  when  the  cuts  are  made  deep,  so  as 
to  produce  immediately  a copious  discharge  of  blood. 

“ liy  means  of  such  scarifications  (says  he)  I have 
seen  the  inflammation  and  all  its  threatening  effects 
recede,  as  it  were,  before  my  face,  when  no  material 
relief  could  be  effected  by  other  measures.” — {B.  1,  p. 
419.)  In  this  country,  the  best  practitioners  rarely 
have  recourse  either  to  incisions  or  scarifications  in 
chemosis;  and  have  more  confidence  in  general  than 
local  treatment.— ( Welbank  ; note  in  Frick  on  Dis.  of 
the  Eyeii,p.  15,  ed.  2 ) 

of  the  vapour  of  ^tlier,  or  of  the 


juice  of  lettuces  to  the  eye  and  eyelids,  for  the  relief 
of  chemosis,  as  recommended  by  Mr.  Ware  {p.  54),  I 
shall  only  say,  that  they  are  plans  which  do  not  retain 
the  approbation  of  modern  practitioners. 

General  and  local  bleeding  having  been  put  in  prac 
tice,  the  treatment  is  to  be  continued  by  administering 
purgatives  of  the  mildest  description,  and  after  their 
operation  applying  blisters,  according  to  the  directions 
given  ill  a preceding  part  of  this  article.  In  the  first 
stage  of  severe  acute  ophthalmy,  Scarpa  considers  to 
pical  emollient  applications  to  the  eye  most  beneficial ; 
such  as  mallows  boiled  in  new  milk;  bread  and  milk 
poultices;  or  the  soft  pulp  of  a baked  apple;  all  in- 
cluded in  fine  little  muslin  bags.  Remedies  of  this 
description  should  be  renewed  at  least  every  two  hours. 
'I'he  patient  should  be  directed  to  observe  perfect  qui- 
etude, and  to  lie  with  his  head  in  an  elevated  position. 
To  keep  the  eyelids  from  adhering  together  in  the  night- 
time, the  spermaceti  cerate  is  proper.  When  oph- 
ihalmy is  accompanied  with  a violent  pain  in  the 
head,  the  late  Mr.  Ware  recommended  a strong  decoc- 
tion of  poppy-heads  as  a fomentation.— (P.  51.) 

Under  the  preceding  plan  of  treatment,  the  first 
stage  of  severe  ophthalmy  commonly  abates  in  about 
a week.  The  burning  heat  and  darling  pains  in  the 
eyes,  and  the  febrile  disturbance  of  the  constitution 
subside.  The  patient  is  comparatively  easy,  and  re- 
gains his  appetite.  The  eyes  become  moist  again,  and 
can  now  be  opened  without  experiencing  vast  irrita- 
tion from  a moderate  light.  In  this  state,  notwith- 
standing they  may  continue  red,  and  the  conjunctiva 
swelled,  all  evacuations  are  to  be  left  off,  as  well  as 
the  use  of  topical  emollients,  for  which  latter  astrin- 
gent, corroborant  collyria  are  to  be  substituted.  Scarpa 
recommends  the  following  application  : R.  Zinci  sul- 
phatis  gr.  vj.  Aquae  distillatae  | vj.  Mucil.  sem.  cy- 
dori.  mali  |ss.  Spiritus  vini  camphor,  guttas  paucas. 
Misce  ei  cola.  This  collyrium  may  be  injected  with  a 
syringe,  between  the  eye  and  eyelids,  once  every  two 
hours;  or  the  eye  may  be  bathed  in  it,  by  means  of  an 
eye-cup.  Such  persons  as  cannot  bear  cold  applica- 
tions to  the  eye,  must  have  the  same  kind  of  collyrium 
a little  warmed  ; but  as  soon  as  the  irritability  is  les- 
sened, it  may  be  used  cold. 

Scarpa  then  speaks  of  the  good  effects  produced  in 
the  second  stage  of  ophthalmy  by  the  application  to 
the  eye  of  two  or  three  drops  of  the  vinous  tincture  of 
opium,  once  or  twice  a day  ; a subject  already  consi- 
dered in  the  foregoing  columns.  'I'he  utility  of  letting 
the  eye  be  habituated  to  the  light  as  soon  as  it  can  bear 
It,  is  next  strongly  commended ; a rule  of  great  impor- 
tance, but  on  which  I need  not  here  dwell,  because 
it  has  been  already  insisted  upon  in  the  general  ob- 
servations. 

When  idiopathic  external  ophthalmy  has  terminated 
in  suppuration  of  little  extent.  Beer  speaks  highly  of 
the  benefit  derived  from  a solution  of  the  lapis  divi- 
nus  (see  Lachrymal  Organs),  containing  the  liquor 
plumbi  subacetatis,  or  from  smearing  the  suppurating 
points  with  a little  laudanum.  In  worse  cases,  Beer 
states,  that  when  such  local  treatment  is  combined 
with  the  internal  exhibition  of  bark  and  naphtha,  and 
a diet  and  regimen  conducive  to  the  support  of  the 
system,  its  efficacy  is  very  great.  And  here,  says  he, 
it  is  worth  observing,  that  while  the  solution  of  the 
lapis  divinus  is  of  great  service  in  the  second  stage  of 
true  chemosis,  it  is  more  or  less  detrimental  in  the  kind 
of  chemosis  which  accompanies  purulent  ophthalmy, 
especially  if  not  blended  with  mucilage,  and  even 
when  thus  qualified,  it  cannot  be  endured  by  weak  and 
irritable  subjects,  affected  with  the  latter  complaint ; a 
fact  not  observed  in  other  instances  of  chemosis.— (B. 
1,  p.  420.) 

When  pustules  or  abscesses  in  the  swelled  conjunc- 
tiva point  round  the  cornea,  a free  outlet  to  the  matter 
must  be  immediately  made  in  each  of  them  with  a lan- 
cet ; for  if  this  be  not  done,  as  Beer  observes,  the  mat- 
ter will  spread  extensively,  and  the  eyeball  be  in  dan- 
ger of  being  destroyed.  For  an  account  of  the  method 
of  treating  the  eversion  of  the  lower  eyelids,  some- 
times remaining  as  a consequence  of  the  disorder,  see 
Ectropium. 

Inflammation  of  the  Sclerotica.  The  modern  at- 
tempts to  class  ophthalmies,  according  to  the  texture 
of  the  eye  first  or  chiefly  nflected,  promises,  I think,  to 
lead  to  clearer  views  of  the  subject,  and  sounder  prac- 
tice. One  circumstance  particularly  adverted  to,  both 


242 


OFHTHALMY. 


by  Dr.  Vetch  and  Mr.  Travers,  in  inflammation  of  the 
sclerotica,  is  the  appearance  of  a vascular  zone  at  the 
margin  of  the  cornea.  By  the  latter  gentleman,  this 
etfect  is  ascribed  to  the  particular  distribution  of  the 
vessels.  “ Branches  from  the  straight  vessels  of  the 
conjunctiva  penetrate  the  sclerotica  obliquely  towards 
the  margin  of  the  cornea,  and  Uie  long  ciliary  vessels 
pass  in  sulci  of  this  membrane  to  the  plexus  ciliaris  at 
the  root  of  the  iris.  At  the  interior  border  of  the  scle- 
rotica, where  the  annulus  ciliaris  is  adhering  closely  to 
this  tunic,  the  ciliary  communicate  with  the  muscular 
branches,  and  being  in  deep-seated  inflammation  fully 
injected  with  red  blood,  the  condensation  of  colour 
gives  the  well-known  and  remarkable  appearance  of  a 
vascular  zone  at  the  margin  of  the  cornea.” — (Sy- 
nopsis, Src.  p.  126.)  According  to  Dr.  Vetch,  only  a 
lew  interspersed  trunks  are  posteriorly  observed, 
“which  do  not  affect  the  natural  appearance  of  the 
intermediate  space,  but  these,  diverging  as  they  come 
forwards,  produce  a zone,  more  or  less  complete,  of 
minute  hair-like  vessels,  distinguished  by  their  recti- 
linear direction,  and  their  uniform  concentration  to- 
wards the  margin  of  the  cornea ; their  colour  advances 
with  the  progress  of  the  disease,  from  that  of  a de- 
licate pink  or  damask  rose  to  a deeper  hue,  and  im- 
parting a faint  blush  to  the  part  immediately  surround- 
ing it.” — (On  Diseases  of  the  Eye,  p.  27.)  There  ap- 
pears, however,  to  be  a good  deal  of  variety  in  the 
symptoms  of  sclerotic  inflammation ; for  rheumatic 
inflammation  of  the  eye,  described  by  Beer  and  Ward- 
rop,  as  particularly  affecting  the  sclerotica,  in  common 
with  other  fibrous  membranes,  is  not  noticed  by  these 
authors  as  characterized  by  the  red  zone  round  the 
edge  of  the  cornea.  Indeed,  instead  of  there  be- 
ing posteriorly  only  a few  interspersed  trunks,  Mr. 
Wardrop  states,  “that  fin  rheumatic  ophthalmy)  the 
blood-vessels  are  generally  equally  numerous  over  the 
whole  white  of  the  eye,  passing  forwards  in  nearly 
straight  lines  from  the  posterior  part  of  the  eyeball,  and 
advancing  close  to  the  cornea ; but  neither  passing 
over  it,  nor  leavmg  the  pale  circle  around  it,  which  is 
so  striking  when  either  the  choroid  coat  or  iris  is  in- 
flamed. If  the  vessels  be  closely  examined,  the  gene- 
ral redness  will  be  found  produced  more  from  nume- 
rous small  ramifications,  than  a few  large  trunks.” — 
(Med.  Chir.  Trans,  vol.  10,  p.  H.)  However,  as  if  there 
must  be  no  harmony  on  this  subject.  Beer  describes  the 
blood-vessels  in  rheumatic  ophthalmy,  not  as  being 
equally  numerous  over  the  whole  white  of  the  eye, 
but  as  being  in  some  places  collected  in  larger  numbers 
or  clusters,  and  he  diflers  again  from  Mr.  Wardrop,  in 
describing  the  redness  as  coming  on  with  considerable 
intolerance  of  light  (Lehre  von  den  Augenkr.  b.  1,  p. 
397,  398),  while  the  latter  author  distinctly  mentions, 
that  “ the  eye  does  not  seem  to  suffer  from  exposure  to 
light.” — (Med.  Chir.  Trans,  vol.  10,  p.  6.)  I can  only 
reconcile  these  accounts  by  concluding  that  sclerotic  in- 
flammation, like  that  of  other  textures  of  the  eye,  has 
stages  and  modifications  which  account  for  these  seem- 
ing contradictions.  And  with  respect  to  the  vascular 
zone  round  the  edge  of  the  cornea,  it  would  appear,  at 
all  events,  to  belong  to  iritis,  as  well  as  sclerotic  inflam- 
mation. The  vessels  of  the  sclerotic  coat  are  ob- 
served by  Dr.  Vetch  to  follow  the  motion  of  the  eye, 
and  he  says  that  they  may,  by  this  circumstance,  be 
distinguished  from  those  of  the  conjunctiva,  “ the  ves- 
sels of  the  latter,  independent  of  their  darker  colour, 
their  more  tortuous  form,  and  varying  size,  have  like- 
wise a more  longitudinal  direction,  and  as  they  pro- 
ceed from  the  angles  of  the  orbit,  they  form  radii  of  a 
larger  circle.  The  distinction  between  the  inflamed 
vessels  of  the  conjunctiva  and  the  sclerotica  (says  Dr. 
Vfcich)  I consider  to  be,  therefore,  obvious  ; but,  that 
any  difference  can  be  observed  in  the  arrangement  or 
appearance  of  the  vessels  of  the  latter,  sufficiently  dis- 
tinct to  indicate  the  peculiarity  of  the  exciting  cause 
or  specific  nature  of  the  case,  is  more  than  I have  been 
able  to  perceive.  The  general  character,  as  it  arises 
out  of  the  structure  of  the  part,  will  be  found  the  same, 
whether  the  cause  be  gout,  rheumatism,  or  syphilis. 
The  vessels,  such  as  I have  described  them,  will  al- 
ways be  most  observable  on  the  upper  portion  of  the 
eye,  as  it  is  in  that  place  that  the  inflammation  is  most 
intense,  except  when  its  locality  is  affected  by  any  ex- 
ternal exciting  cause,  in  which  case  it  will  be  greatest 
near  the  injured  part.”— (On  Diseases  of  the  Eye, 


While  Dr.  Vetch  describes  the  vessels  of  the  cos 
junctiva  as  exhibiting  in  sclerotic  inflammation  a 
darker  colour  than  that  of  the  vessels  of  the  sclerotic 
coat  itself,  Mr.  Travers  represents  the  vessels  of  the 
latter  membrane,  which  pursue  a straight  course  to  lire 
margin  of  the  cornea,  as  having  a somewhat  darker 
hue  than  the  areolar  vessels  upon  the  loose  portion  of 
the  conjunctiva. 

It  should  be  mentioned,  however,  that  by  sclerotic 
inflammation.  Dr.  Vetch  signifies  inflammation  of  the 
eye  itself,  as  contrasted  with  conjunctival  inflamma- 
tion; but  how  far  this  will  account  for  the  differences 
above  pointed  out  between  his  description  and  that  of 
Mr.  Travers,  I am  not  prepared  to  say.  According  to 
Mr.  Travers,  ordinary  inflammation  of  the  sclerotica  is 
secondary ; that  is  to  say,  this  membrane  is  usually 
affected  only  as  intermediate  to  the  conjunctiva  and 
the  other  tunics.  However,  he  has  occasionally  ob- 
served, in  a recent  ophthalmia,  a turgeseence  of  the 
vessels  which  pursue  a straight  course  to  the  cornea, 
unaccompanied  with  any  affection  of  the  iris,  and  so 
slight  a vascularity  of  the  loose  conjunctiva,  that  he 
was  disposed  to  regard  the  case  as  a primary  sclerotitis. 
The  inflammation,  he  says,  is  not  acute,  and  the  mo- 
tions of  the  eyeball  are  painful.  It  sometimes,  accom- 
panies, and  sometimes  follows,  rheumatic  inflamma- 
tion. If  continued,  it  presents  the  vascular  zone  and  a 
pupil  contracted,  or  drawn  a little  to  one  side.  It  is 
often  seen  in  company  with  eruptions  or  sore  throat  of 
a pseudo-syphilitic  character,  or  is  secondary  to  gonor- 
rhoea.— (Travers,  Synopsis,  i^c.  p.  128.) 

The  practice  recommended  by  this  genlleman  is  as 
follows : obtuse  pain  in  the  eyeball,  he  says,  may  be 
materially  relieved  by  blood-letting,  and  by  antimony 
and  ipecacuanha  with  opiates.  Mercury  is  stated  to 
have  much  less  power  over  this  case  than  iritis.  In 
general,  the  patient  is  seriously  reduced,  and  very  irri- 
table, from  suffering  rheumatic  inflammation  in  the 
elbow,  knee,  or  ankle ; a state,  to  the  production  of 
which  the  previous  use  of  mercury  has  commonly  con- 
tributed. But  though  such  is  stated  to  be  the  case,  the 
moderate  and  cautious  employment  of  this  mineral  is 
set  down  as  generally  indispensable  in  the  treatment. 
And,  in  the  interval  of  the  mercurial  action,  the  nitric 
aeid  is  alleged  to  be  often  of  great  service.  The  pre- 
parations of  mercury  preferred  by  Mr.  Travers  in  these 
cases  are  the  oxymuriate  in  doses  of  one-twelfth  or 
one-eighth  of  a grain,  and  the  hydrargyrus  cum  creia,  in 
doses  of  from  five  to  ten  grains,  twice  or  thrice  a day. 
As  auxiliaries  for  allaying  irritation,  he  prescribes  the 
pulv.  ipecac,  comp.,  hemlock,  hyoscyamus,  and  the  ex- 
tract of  sarsaparilla,  either  dissolved  in  the  decoction 
or  taken  solid. — (Vol.  cit.  p. 289.)  On  rheumatic  iitr 
flammation  of  the  eye,  a few  observations  will  be  here- 
after inserted. 

Idiopathic  Inflammation  of  the  Internal  Textures  of 
the  Eyeball,  or  Internal  Ophthalmy  in  general.  Ac- 
cording to  Beer,  internal  inflammation  of  the  eye  does 
not  always  originate  in  one  particular  texture,  but,  in 
some  instances,  commences  in  the  retina,  choroides, 
&c. ; while,  on  other  occasions,  its  principal  seat  is  in 
the  iris,  from  which  membrane  it  quickly  extends  itself 
to  the  corpus  ciliare,  and  the  crystalline  lens  and  its 
capsule,  or  else  in  another  direction  to  the  sclerotica, 
cornea,  &;c.  These  differences  in  the  seat  of  the  dis- 
order obviously  depend  upon  the  way  in  which  the  ex- 
citing causes  have  operated  ; for,  when  they  are  such 
as  immediately  affect  the  retina  only,  the  inflammation 
must  have  its  origin  in  this  texture,  as  when  the  disor- 
der is  produced  by  the  effect  of  the  sudden  entrance  of 
any  very  strong  vivid  or  reflected  light  into  the  or- 
gan. This  case  Beer  denominates  ophthalmitis  interna 
idiopathica,  proprie  sic  dicta. 

The  exciting  causes,  however,  may  not  affect  directly 
the  retina,  and  parts  immediately  next  to  it,  but  may 
operate  chiefly  upon  the  iris,  in  which  event,  this  part 
is  th^  chief  seat  ot  the  inflammaiion,  and  the  complaint 
is  named,  both  by  Schmidt  and  Beer,  zrrtis  idiopathica. 
Tnis  form  of  inflammation.  Beer  says,  is  seen  after  the 
extraction  of  the  cataract,  atid  accidental  injuries  of 
the  eye,  where  the  weapon  with  which  they  were  pro- 
duced has  either  penetrated  directly  to  the  iris,  and 
more  or  less  contused  it,  or  roughly  entered  the  eye- 
ball near  the  ciliary  edge  of  this  membrane,  witliout 
actually  wounding  it. — (Lehre  von  den  Augenkrankh. 
b.  1,  p.  421.) 

Symptoms  ef  the  first  stage  of  idiopathic  internal 


243 


OPHTHALMY. 


(tphtkalmy^  properly  so  called.  While  a very  uneasy 
beiisation  ol’  general  constriction  and  tension  affects 
the  whole  eyeball,  and  soon  changes  into  an  obtuse, 
deep-throbbing  pain,  increasing  every  instant,  and 
quickly  propagating  itself  over  the  eyebrows  to  the  top 
of  the  head,  the  power  of  vision  graduadly  declines, 
and,  at  the  same  time,  the  pupil,  which  plainly  loses  its 
clear  shining  blackness,  contracts,  without  being  de- 
prived of  its  circular  figure,  or  drawn  out  of  its  natural 
position,  until,  at  length,  it  is  so  completely  closed,  that 
the  iris  seems  as  if  it  had  no  aperture  whatever.  But 
long  before  this  perfect  closure  of  the  pupil  has  taken 
place,  the  power  of  seeing  is  entirely  gone,  though, 
after  the  faculty  of  perceiving  the  external  light  is  ex- 
tinguished, fiery  appearatices,  which  seriously  trouble 
the  patient,  are  seen  at  each  pulsation  of  the  blood- 
vessels within  the  eye.  As  the  developement  of  these 
symptoms  is  going  on,  the  iris  evidently  loses  its  natu- 
ral colour;  becoming,  as  Beer  says,  greetiish,  when  it 
it  was  gray  or  blue;  and  reddish,  when  it  was  brown 
or  black.  In  consequence  of  the  iris  svvelling,  and  pro- 
jecting towards  the  cornea,  the  anterior  cliamber  be- 
comes considerably  diminished.  Immediately  the  least 
mark  of  the  swelling  of  the  iris  is  seen,  together  with  a 
moderate  degree  of  contraction  of  the  pupil,  the  vyhole 
sclerotica  assumes  a pink-red  colour  ; a plexus  of  innu- 
merable blood-vessels  is  seen  in  the  conjunctiva;  and 
the  cornea  loses  a good  deal  of  its  natural  brilliancy, 
without  being  actually  opaque.  The  latter  symptoms 
of  this  form  of  ophthalmy  are  attended  with  manifest 
general  indisposition,  and  intolerable  headache.  Some- 
times, in  the  first  stage  of  the  case,  the  pupil,  though 
much  lessened,  is  not  absolutely  closed,  but  thickish, 
and,  if  examined  with  a magnifying  glass,  it  has  a red- 
dish-gray appearance,  and  the  power  of  vision,  not- 
withstanding the  continuance  of  the  aperture,  is  quite 
lost. 

Symptoms  in  the  second  st^e.  According  to  the  same 
author,  while  the  eye  is  suffering  very  irregular  throb- 
bing pain,  attended  with  a sensation  of  heaviness  and 
cold  in  it,  an  increase  of  the  redness  of  the  conjunctiva, 
severe  constitutional  disturbance,  and  constant  shiver- 
ing, there  is  suddenly  formed  at  the  bottom  of  the  an- 
terior chamber  a collection  of  matter  which  above  pre- 
sents a horizontal  line,  but  on  every  inclination  of  the 
head  sidewise  changes  its  position.  This  matter  con- 
tinues to  accumulate  more  and  more,  until  it  not  only 
reaches  the  pupil,  but  fills  the  whole  of  the  anterior 
chamber,  constituting  the  case  termed  hypopium.  If 
the  disease  be  left  to  itself,  says  Beer,  the  matter  col- 
lects in  such  quantity,  that  the  cornea  is  rendered  more 
prominent,  and  afterward  conical,  very  like  an  ab- 
scess, ultimately  bursting  during  an  aggravated  attack 
of  pain,  when  the  eye  shrinks,  and  the  sufferings  gra- 
dually cease.  This  kind  of  hypopium  Beer  names  true, 
in  order'to  distinguish  it  from  the  case  in  which  the 
matter  passes  into  the  anterior  chamber  out  of  an  ab- 
scess in  the  cornea,  and  which  he  terms  a false  hypo- 
pium. When,  at  the  end  of  the  first  stage,  the  pupil  is 
not  entirely  closed,  one  may  discern  in  the  second  stage, 
at  the  period  of  matter  presenting  itself  at  the  bottom 
of  the  anterior  chamber  (though  not  easily  with  the 
unassisted  eye),  whitish  filaments,  extending  from  the 
edge  of  that  opening  towards  its  centre,  produced  by 
the  coagulable  lymph  effused  in  the  aqueous  humour, 
the  secretion  of  which  was  interrupted  in  the  first  stage, 
but  now  commences  again.  And,  continues  Beer, 
one  may  perceive,  with  a good  magnifying-glass,  a very 
delicate  cobweb-like  membrane,  which,  when  the 
matter  collected  lies  over  the  pupil,  and  remains  for  a 
good  while  unabsorbed,  at  length  becomes  quite  yellow, 
the  matter  being  really  encysted  by  it  in  the  form  of  a 
small  lump,  which  remains  in  the  pupil,  and  partly  pro- 
jects into  the  anterior  chamber,  forming  the  case, 
which  Beer  denominates  a spurious  purulent  cataract, 
to  which  the  edge  of  the  iris  is  so  closely  adherent, 
that  sooner  than  a separation  could  be  effected,  the  whole 
of  the  iris  would  be  torn  in  pieces.  When  the  pupil 
has  been  completely  closed  in  the  first  stage,  these 
effects  of  course  cannot  take  place. 

With  respect  to  the  causes  of  this  form  of  ophthalmy. 
Beer  remarks,  that  as  there  are  not  many  circum- 
stances which  can  produce  it,  the  case  belongs  rather 
to  the  less  frequent  kinds  of  inflammation  of  the  eye. 
As  predisposing,  he  mentions  plethora,  and  irritability 
of  the  eyes  occasioned  by  little  exercise  of  them.  Ex- 
perience has  convinced  him,  however,  that  by  far  the 


most  usual  cause  of  this  internal  ophthalmy  is  an  ex 
traordinary,  long-continued  straining  of  the  eye  in  the 
inspection  of  small  microscopic  objects  in  a strong  re- 
flected light. 

Respecting  the  prognosis,  he  represents  it  as  not  un- 
favourable, when  the  inflammation  of  the  eyeball  is 
moderate,  proper  treatment  immediately  employed,  the 
pupil  not  yet  very  much  contracted,  and  the  power  of 
seeing  not  considerably  impaired.  But  if  the  power  of 
vision  should  seem  as  if  it  were  abolished,  the  progno- 
sis is  extremely  uncertain.  And  if  the  pupil  should 
close  after  the  entire  stoppage  of  vision,  no  hope  can  be 
entertained  of  the  recovery  of  the  sight : for  if  the 
pupil  open  again  on  the  subsidence  of  the  inflamma- 
tion, it  will  yet  continue  very  small  and  motionless, 
and  the  eye  blind.  When  the  case  is  mistaken  in  its 
first  stage,  and  neglected  or  erroneously  treated.  Beer 
says,  it  changes  into  a very  perilous  general  inflamma- 
tion of  the  whole  eyeball ; a disorder  already  consi- 
dered. 

In  the  second  stage,  the  prognosis  is  constantly  un- 
favourable ; for  the  eyesight  has  always  been  already 
destroyed  at  the  end  of  the  first  one,  and  the  only  ex- 
pectation of  the  practitioner  can  now  be  to  preserve 
the  shape  of  the  eye,  while  as  speedy  a check  as  pos- 
sible is  put  to  the  suppuration.  If  the  case  has  been  so 
mismanaged  in  its  first  stage,  that  a violent  inflamma- 
tion of  the  whole  eyeball  is  inevitable,  and  traces  of 
chemosis  are  already  present,  the  chances  of  the  figure 
of  the  eye  being  lost  in  the  second  stage  are  still  greater, 
and,  as  Beer  observes,  the  surgeon  will  be  fortunate, 
if  he  can  now  prevent  a frightful  morbid  change  of 
the  organ. 

In  the  treatment  of  the  first  stage.  Beer  describes  the 
indications  as  being  exactly  the  same  as  in  common 
ophthalmy,  except  that  no  scarification.s  are  necessary, 
unless  the  case  change  into  a violent  inflammation  of 
the  whole  eyeball.  However,  great  promptitude  in  the 
application  of  proper  curative  measures  is  here  parti- 
cularly called  for,  as  the  least  delay  is  apt  to  cause 
either  a total  loss  of  sight,  or  at  least  a serious  impair- 
ment of  it. 

With  few  exceptions,  the  treatment  of  the  second 
stage  is  also  like  that  of  ophthalmy  in  general.  Warm 
poultices.  Beer  says,  can  only  be  employed  with  great 
circumspection.  When  matter  collects  in  the  anterior 
chamber,  he  strongly  condemns  making  an  opening  in 
the  cornea,  by  which  practice,  he  states,  that  the  eye 
would  certainly  be  rendered  quite  deformed.  He  recom- 
mends leaving  every  thing  to  the  absorbents,  the  action 
of  which  is  to  be  invigorated  by  general  and  local 
remedies.  Poultices  are  now  to  be  laid  entirely  aside, 
and  the  effect  of  warmth  tried.  Blisters  are  to  be  ap- 
plied alternately  behind  the  ear  and  on  the  temple. 
The  eye  is  to  be  smeared  with  the  vinous  tincture  of 
opium  two  or  three  times  a day,  by  means  of  a camel- 
hair  brush,  or  even  four  times,  when  the  anterior 
chamber  is  filled  to  the  extent  of  one-half  of  it.  Beer’s 
experience  leads  him  to  approve  of  opening  the  cornea 
only  in  very  urgent  cases,  that  is  to  say,  when  the  eye 
is  so  distended  with  matter,  that  the  cornea  is  in  a 
slate  of  an  abscess,  which  threatens  to  burst.  In  one 
part  of  his  observations.  Beer  describes  the  matter  in 
these  instances  as  fluid;  a point  on  which  he  differs 
from  Scarpa ; but  he  afterward  confesses,  that  when 
an  opening  is  practised,  the  matter  mu^  not  be  ex- 
pected to  flow  out  immediately,  like  that  of  a common 
abscess. — (See  Hypopium.) 

Idiopathic  Iritis.  The  following  is  Beer’s  descrip- 
tion of  the  disease.  Together  witli  an  obtuse,  heavy, 
deep  . pain  in  the  eye,  producing  a sensation  as  if  the 
eyeball  were  continually  pressed  upon  by  one  of  the 
fingers,  a manifest  and  incessantly-increasing  uniform 
contraction  of  the  pupil  lakes  place,  as  well  as  a gra- 
dual diminution  of  the  movements  of  the  iris ; yet  the 
pupil  neither  loses  its  circular  shape,  nor  changes  its 
position  in  the  eye,  and,  at  the  same  time,  an  intole- 
rance of  light  commences.  When  the  pupil  is  ex- 
amined with  a glass,  it  is  found  to  have  already  lost 
the  shining  blackness  which  is  peculiar  to  it  in  the 
healthy  state.  While  these  changes  are  occurring  in 
the  pupil,  the  colour  of  the  iris  undergoes  a material 
alteration,  first  at  its  lesser  circle,  which  grows  much 
darker,  and  afterward  at  its  greater  circle,  which  turns 
greenish  when  it  was  gray  or  blue,  but  reddish  when 
it  was  brown  or  black.  At  the  same  time,  the  margin 
of  the  pupil  becomes  indistinct,  and  appears  not  so 


244 


OBHTHALMY. 


sharp  as  natural.  As  soon  as  the  greater  ring  of  the 
iris  has  undergone  a considerable  change  of  colour, 
this  membrane  becomes  evidently  swelled,  and  projects 
towards  the  cornea,  so  that  the  anterior  chamber  is 
Tery  much  lessened.  As  early  as  the  period  when  tJie 
contraction  of  the  pupil  and  the  immobility  of  the  iris 
are  observable,  a serious  diminution  of  the  power  of 
vision  occurs;  because,  in  all  cases,  the  indammation 
extends  more  or  less  over  tlie  anterior  layer  of  tlie 
crystalline  capsule,  and  afterward,  when  the  case  is 
somewhat  more  advanced,  says  Beer,  one  may  per- 
ceive quite  plainly,  with  the  unassisted  eye,  those  ef- 
fects of  inflammation  on  the  capsule  which  have  been 
so  excellently  described  by  Waliher. — {Abhandl.  aus 
dem  Gebiethe  der  Practischen  Medicin,  b.  1,  Landshut, 
1810.)  In  proportion  as  the  inflammation  makes  pro- 
gress the  pain  grows  more  severe  and  extensive,  and 
towards  the  end  of  the  first  stage  it  shoots  particularly 
up  to  the  top  of  the  head;  a circumstance  strikingly 
proved  whenever  any  thing  like  slight  pressure  aggra- 
vates the  pain  in  the  eye.  The  redness  perceptible  in 
the  eye  during  the  whole  of  the  first  stage  is  incon- 
siderable, and  seems  to  be  not  at  all  proportioned  to 
the  violence  and  danger  of  the  inflammation ; for  the 
sclerotica  is  only  of  a rose-red  colour,  and  even  this 
pale  redness  fades  towards  the  circumference  of  the 
eyeball.— (fi.  1,  p.  434.) 

According  to  Beer,  idiopathic  iritis  is  always  at- 
tended with  a corresponding  general  disturbance  of  the 
system  ; but  a good  deal  depends  upon  whether  the 
inflammation  spreads  immediately  to  the  deeper  tex- 
tures of  the  eye,  or  to  its  outer  coats,  or  in  boih  direc- 
tions at  once.  In  the  first  case,  the  constitutional  in- 
disposition is  always  more  severe,  and  the  danger  of 
the  disease  increases  every  moment ; in  the  second  in- 
stance, the  augmentation  of  the  general  symptoms  is 
less  striking;  but  in  the  third,  the  inflammation,  and 
the  corre.sponding  febrile  symptoms  soon  rise  in  such  a 
degree,  that  the  possibility  of  preserving  the  eyesight 
becomes  very  doubtful.  The  continued  operation  of 
hidden  exciting  causes,  neglect,  and  erroneous  manage- 
ment of  the  disease,  also  produce  considerable  differ- 
ences; and,  as  Beer  observes,  it  not  unfrequently 
happens,  that  a genuine  idiopathic  iritis,  which  does 
not  appear  at  first  very  dangerous,  nor  rapid  in  its  pro- 
gress, will  suddenly  change,  under  the  unfortunate 
concurrence  of  the  circumstances  above  alluded  to, 
into  a complete  inflammation  of  the  whole  eyebtill, 
destroying  the  organ  in  a few  days,  unless  the  most  ef- 
ficient treatment  he  speedily  adopted. 

In  the  second  stage,  says  Beer,  in  conjunction  with 
a corresponding  still  more  manifest  general  indisposi- 
tion, the  pain  in  the  eye  grows  very  irregular ; lumi- 
nous appearances  flash  within  the  organ  and  seriously 
annoy  the  patient,  especially  in  the  dark,  while  the 
power  of  seeing  tlie  external  light  undergoes  a great 
decrease;  the  redness,  even  in  the  conjunctiva,  in- 
creases; and  the  pupil,  which  hitherto  has  been  per- 
fectly circular,  becomes  more  nr  less  angular.  At  these 
angles,  something  of  a light-grayish  colour  may  be 
seen  projecting  behind  the  pupillary  edge  of  the  iris, 
and,  on  examination  with  a glass,  jdainly  appears  to  be 
a very  delicate  layer  of  coagulating  lymph,  by  which, 
first  the  lesser  ring  of  the  uvea,  and  (if  proper  treat- 
ment be  nm  exfreditiously  employed)  also  its  greater 
ring,  are  soon  rendered  adhewmt  to  the  anterior  por- 
tion of  the  capsule  of  tlie  lens  {synechia  posterior)^ 
which  membrane,  as  the  disease  advances,  becomes 
more  and  more  deprived  of  its  transparency.  Under 
these  circumstances,  it  is  evident  that  the  power  of 
vision  must  daily  decline,  and  that  if  this  process  of 
the  eft’usion  of  lymph  and  its  organization  be  not  re- 
sisted by  powerful  measures,  the  patient  will  soon  be 
left  just  capable  of  faintly  distinguishing  the  light. 
While  the  above-described  change's  are  taking  place 
between  the  uvea  and  anterior  portion  of  the  capsule, 
very  peculiar  effects  are  occurring  in  the  anterior 
chamber:  for  as  the  iris  continues  to  project  farther 
towards  the  cornea,  the  latter  membratie  grows  less 
and  less  transparent,  and  the  iris  seems  as  concealed 
in  a mist,  at  the  same  time  that  a small,  yenowish-red, 
round  prominence  is  formed  at  one  or  more  places  to- 
gether, generally  between  the  greater  and  lesser  rings 
of  the  iris,  and  proves  afterward  to  be  a small  abscess, 
which,  ultimately  bursting,  pours  its  contents  into  the 
anterior  chamber,  and  thus  occasions  a true  hypopium. 
For  several  days,  the  flakes  of  the  burst  little  cyst,  still 


connected  with  the  iris,  may  be  seen  floating  in  tlie 
aqueous  humour,  until  they  gradually  disappear 
When  there  is  not  merely  one  but  several  of  tJiese  lit- 
tle abscesses,  says  Beer,  the  greater  part  of  the  anterior 
chamber  maybe  filled  with  matter,  so  that  little  more 
of  the  iris  can  be  distinguished.  In  weak  subjects,  at 
this  period  of  suppuration,  blood  may  not  unfrequently 
be  perceived  in  the  chamber  of  the  eye;  a circum- 
stance regarded  by  Beer  as  a very  unfavourable  omen 
in  respect  to  the  recovery  of  sight,  as,  in  such  cases, 
portions  of  blood  and  matter  are  apt  to  he  in  the  pos- 
terior chamber  entangled  in  the  lymph.  According  to 
the  same  author,  the  matter  in  the  anterior  chamber  is 
at  last  absorbed ; the  pupil,  if  it  has  been  concealed, 
can  again  be  seen,  but  it  appears  angular  and  very 
turbid;  and  in  consequence  of  the  layer  of  lymph  in 
the  posterior  chamber,  the  eyesight  is  exceedingly  di- 
minished, or  even  reduced  to  the  mere  power  of  know- 
ing light  fronr  darkness.  Such,  says  Beer,  is  the  course 
of  the  second  stage  of  idiopathic  iritis,  when  the  in- 
flammation has  not  extended  far  beyond  its  proper 
focus,  and  has  been  principally  confined  to  the  iris, 
corpus  ciliare,  the  letis  and  its  capsule,  and  the  ante- 
rior part  of  the  sclerotica.  But  if  it  should  spiead 
more  deeply  to  the  vitreous  humour,  the  retina,  the 
membrana  Ruyschiana,  and  the  choroides,  symptoms 
of  internal  ophihalmy  (strictly  so  called)  then  occur 
with  great  vehemence  in  the  first  stage,  and,  at  the  ter- 
mination of  the  second,  the  eyesight  is  for  ever  cer- 
tainly destroyed  in  such  a degree  that  not  the  least 
perception  of  light  remains;  and  even  if  the  patient 
should  think  that  he  can  distinguish  it,  the  feel  is  only 
a deception  ; a developement  of  light  within  the  eye 
itself;  of  which  the  surgeon  may  easily  assure  himself, 
by  placing  the  patient  with  his  back  towards  the  light, 
and  asking  him  to  point  out  where  it  is;  or  by  putting 
him  directly  opposite  a window,  and  moving  the  hand 
slowly  along  before  his  eyes;  of  which  proceeding  the 
patient  will  be  quite  unconscious.  The  effects  left  in 
the  eye  after  such  an  iritis,  and  indicating  its  mis- 
chievous extension,  are  so  characteristic,  that  on  the 
first  inspection  of  the  eye  no  surgeon  can  entertain  a 
doubt  of  the  deeper  textures  of  the  eye  having  been  in- 
volved in  the  inflammation.  But  when  idiopathic  iritis 
extends  rather  to  the  external  than  the  deep  textures  of 
the  eye,  the  swelled  iris,  as  early  as  the  end  of  the  first 
stage,  approaches  so  near  the  cornea,  which  grows  less 
and  less  clear,  that  they  seem  as  if  they  were  adheient 
ere  the  second  stage  has  commenced.  And,  indeed, 
on  the  accession  of  this  stage,  they  actually  adhere 
together  at  every  point,  either  directly  or  with  the  in- 
tervention of  a mass  of  coagulatitrg’  lymph.  In  the 
first  event,  at  the  end  of  the  second  stage,  the  cornea 
forms  a conical  protuberance,  and  a total  staphyloma 
arises  (see  Staphyloma) ; but  in  the  second,  the  cornea 
is  said  not  to  undergo  this  change.  On  the  contrary, 
it  becomes  rather  flat,  and  on  account  of  the  layer  of 
organized  lymph  which  fills  up  the  space  between  the 
cornea  and  iris,  little  of  the  latter  membrane  can  be 
discerned,  and  what  can  be  seen  appears  to  have  its 
organization  entirely  subverted.  When  idiopathic 
iritis  in  its  first  stage  extends  its  effects  directly  over 
the  whole  eyeball,  the  eye  becomes  nearly  or  quite  de- 
stroyed in  the  same  manner  as.in  cases  of  violent  acute 
ophthalmy. 

The  causes  which  give  rise  to  idiopathic  iritis  must 
always  be  such  as  operate  directly  upon  the  iris;  and 
hence  the  disorder  is  usually  a consequence  of  injuries 
and  wounds  of  the  eye,  produced  by  accident  or  in 
rrperations.  And,  says  Beer,  altlutugh  rheumatic  in- 
flammation of  the  eye,  when  neglected  or  wrongly 
treated,  may  at  length  affect  the  iris  and  adjacent  tex- 
tures, yet  such  an  iritis  is  but  a secondary  effect,  de- 
rived from  the  pre-existing  rheumatic  ophthalmy.  All 
injuries  in  which  the  weapon  or  instrument  has  more 
or  less  pressed  against,  pushed,  irritated,  or  violently 
bruised,  or  torn  the  iris  ilself,  and  all  largish  wounds 
of  the  cornea,  are  to  be  accounted  the  principal  ex- 
citing causes  of  idiopathic  iritis.  Hence  extraction  of 
the  cataract  is  not  nnfreqtiently  followed  by  this  in- 
flammation, when  the  flap  of  the  cornea  is  kept  too 
long  opened,  and  the  iris  is  hurt  with  any  blunt  instru- 
ment; when  the  incision  in  the  cornea  is  too  small, 
and  a hard  cafar.act  pushes  the  iris  between  the  lips  of 
the  wound,  and  is  slowly  pressed  out  of  the  eye ; when 
many  pieces  of  the  cataract  break  off,  and  it  is  neces- 
sary repeatedly  to  introduce  Daniel’s  scoop  for  their 


OPHTHALMY, 


245 


removal ; or  when,  notwithstanding  the  operator  pro- 1 
ceeds  with  the  utmost  delicacy,  the  patient  is  exces- 
sively timid  and  unmanageable,  or  particularly  irrita- 
ble and  prone  to  inflammation.  This  form  of  iritis  is 
also  produced  by  couching,  reclination  through  the 
sclerotica,  keraionyxis,  and  operations  for  artificial 
pupil.  Nor,  as  Beer  observes,  is  it  at  all  surprising 
that  iritis  should  follow  these  last  opeiations,  as  the  sur- 
geon has  often  to  ineddle  with  an  iris  that  has  been 
already  violently  infiained. 

Proffnosis  in  the  first  stage.  Serious  as  the  disorder 
always  is,  important  as  the  textures  are  in  which  the 
inflammation  is  most  severe,  and  quickly  ns  vision  may 
be  for  ever  annihilaied  by  it,  yet,  says  Beer,  the  prog- 
nosis in  the  first  stage  is  very  favourable,  when  the 
true  nature  of  the  < ase  is  at  on.ce  understood,  and 
treated  as  it  ought  to  be.  The  prognosis  is  the  most 
favourable  when  the  inflammation  is  not  extensive; 
but  it  must  be  very  reserved  when  the  inflammation 
extends  either  deeply  backwaids,  forwards,  or  in  both 
directions.  Beer  remarks,  that  when  iritis  is  purely 
idiopathic,  and  judiciously  treated  in  its  first  stage,  it 
is  incredible  with  what  rapidity  its  effects  recede. 
When  it  is  produced  immediately  by  an  injury  of  the 
iris  itself,  and  some  part  of  this  membrane  is  torn,  llie 
risk  of  the  inffammation  is  not  the  oidy  thing  for  con- 
sideration ; for  the  chance  of  the  function  of  the  iris 
beitig  permanently  impaired  by  the  injury  must  also  be 
taken  into  the  account.  And,  says  Beer,  as  in  these 
severe  itijuries  of  the  eyeball,  it  is  impossible  to  foretel 
what  may  be  the  result  of  the  inflammation,  it  is  a 
good  maxim  always  either  to  defer  making  any  prog- 
nosis, or  to  deliver  only  a doubtful  one.  When  idio- 
patitic  iritis  has  already  changed  either  into  a complete 
internal  ophthalmy,  or  into  a violent  inflammation  of 
the  whole  eyeball,  no  incautious  promises  should  be 
made  about  the  recovery  of  the  eyesight,  or  even  about 
preserving  the  shafie  of  the  eye. 

Prognosis  in  the  second  stage.  Though,  says  Beer, 
this  is  much  less  favourable  than  in  the  first  stage,  yet, 
if  proi>er  measures  be  not  deferred,  a perfect  recovery 
of  the  eye  may  often  be  effected.  Here  a great  deal  de- 
pends upon  the  state  of  the  layer  of  lymph  effused  in 
the  posteiior  chamber,  and  of  suppuration.  If  it  be 
plain  to  the  naked  eye,  that  no  coagulating  lymph  lies 
in  that  chamber  behind  the  contracted  pupil,  but  slight 
grayish  filaments  are  discernible  with  a magnifying- 
glass,  projecting  only  a little  way  fiom  behind  the  pu- 
pillary edge  of  the  iris  ; if  the  colour  merely  of  the 
lesser  circle  of  the  iris  be  changed,  while  no  little  cyst  of 
matter  is  yet  formed  on  the  latter  membrane,  and  the 
sight  is  lessened  only  in  a small  degree,  being  somewhat 
cloudy;  the  complaint  may  be  so  completely  cured  by 

Kro|)er  means,  that  not  a vestige  of  it  will  remain. 

fowever,  for  some  time  after  the  termination  of  the 
second  stage,  the  motions  of  the  iris  will  be  more 
sluggish  th.an  natural,  though  the  pupil  effectually 
adapt  itself  to  the  variations  of  light.  On  the  other 
hand,  when  a considerable,  though  fine,  web-like 
membrane  can  be  plainly  seen  behind  ihe  pupil  ; 
when  the  colour  of  the  larger  circle  of  the  iris  is  some- 
what altered  ; and  Ihe  power  of  vision  is  seriously  les- 
sened ; though  by  effectual  treatment,  the  sight  may 
be  re-established  sufficiently  to  enable  the  patient  to 
read  and  write;  yet,  says  Beer,  it  will  for  ever  conti- 
nue weak;  the  pupillary  edge  of  the  iris  will  never 
regain  its  perfect  freedom,  but  constantly  remain  more 
or  less  angular,  and  the  pupil  never  assume  again  the 
clear  shining  blackness,  which,  in  persons  not  of  great 
age,  it  naturally  exhibits.  Still  more  remarkable  are 
the  sequelae  of  idiopathic  iritis,  when  a small  cyst  of 
matter  has  been  formed  on  the  iris,  and  discharged  its 
contents  into  the  anterior  chamber;  for,  in  this  case, 
under  the  best  circumstances,  the  former  colour  of  the 
Iris  never  entirely  reiurns.  According  to  Beer,  when 
at  the  first  visit  of  the  surgeon,  vision  is  quite  interrupt 
ed  by  the  effusion  of  lynqih  in  the  posterior  chamber, 
so  that  the  patient  can  no  longer  perceive  any  object 
with  the  affected  eye,  though  capable  of  distinguishing 
the  light,  and  the  outlines  of  somethings;  when  the 
pupil  is  at  the  same  time  very  contracted,  and  tlie  co- 
lour of  the  greater  circle  of  the  iris  entirely  changed  ; 
there  is  no  hope  of  recovery  of  the  sight  at  first,  though 
BOiiie  chance  of  benefit  may  be  subsequently  afforded 
by  the  formation  of  an  artificial  pupil.  If,  says  Beer, 
in  such  a car^,  matter  has  been  effused,  from  several 
little  suppurating  points  of  the  iris,  so  copiously  into  the 


anterior  chamber,  that  nearly  all  this  cavity,  or  at  least 
the  half  of  it,  is  filled  up,  though  after  absorption  some 
power  of  distinguishing  light  may  return,  littie  or  no 
hope  can  be  entertained  of  any  effectual  benefit  from  a 
future  operation  for  an  artificial  pupil.  When,  at  the 
termination  of  the  first  stage,  the  cornea  is  so  severely 
inflamed,  that  the  iris  almost  touches  this  membrane  in 
its  untransparent  thickened  state,  all  prospect  of  sav- 
ing the  eyesight  is  over,  and  it  will  be  fortunate  if  the 
natural  shape  of  the  eye  can  now  be  preserved,  and  the 
formation  of  a staphyloma  of  the  cornea  prevented. 
When  the  layer  of  lymph  between  the  cornea  and  the 
iris  is  extensive,  and  considerable  blood-vessels  can 
be  seen  proceeding  into  it  from  the  iris.  Beer  says,  no- 
thing will  succeed  in  re-establishing  vision.  And  he  ob- 
serves, that  when  an  idiopathic  iritis,  at  the  close  of  its 
first  stage,  has  changed  into  a true  internal  ophthalmy, 
and  the  pupil  is  already  quite  blocked  up,  so  that  even 
the  light  cannot  be  distinguished,  the  recovery  of  sight 
is  quite  Impossible,  and  the  surgeon  must  make  every 
exertion  to  prevent  the  shape  of  the  organ  from  being 
destroyed.  In  this  disease,  says  Beer,  a relapse,  even 
when  the  inflammation  has  not  been  very  considerable 
in  the  first  attack,  almost  constantly  ends  in  partial  or 
complete  blindness  of  the  affected  eye,  as  the  progress 
of  the  case  is  so  rapid  that  there  is  not  time  enough  to 
render  effectual  assistance. 

Beer  directs  idiopathic  iritis  to  be  treated  in  its  first 
stage  like  a case  of  pure  internal  ophihalmy,  the  prac- 
tice being  somewhat  modified,  however,  according  to 
the  direction  and  degree  in  which  the  inflammation  has 
spread,  when  the  surgeon  is  first  consulted.  When  the 
uiflammation  continues  a good  while  limited,  or  spreads 
Out  very‘giadualiy  to  the  outer  texture  of  the  eyeball, 
general  aiid'local  antiphlogistic  remedies  are  to  be  em- 
ployed with  moderation;  but  if  it  immediately  extend 
itself  to  the  innermost  parts  of  the  eye,  or  both  inwards 
and  outwards  together,  and  threatens  to  end  in  a uni- 
versal inflammation  of  the  eyeball,  antiphlogistic  treat- 
ment must  be  most.rigorously  adopted.— (i?ccr.)  This 
author  then  notices  the  unfortunate  state  of  the  case, 
when,  towards  the  end  of  the  first  stage,  the  eyesight 
happens  to  be  entirely  destroyed,  the  iris  is  close  to  the 
cornea,  and  there  is  danger  of  a staphyloma.  In  this 
desperate  state  of  things,  his  apprehensions  of  this  last 
disease  lead  him  to  suggest  a plan  (the  propriety  of 
which  I regard  with  much  suspicion),  which  is  nothing 
less  than  actually  trying  to  increase  the  inflammation, 
by  stimulating  the  eye  several  times  a day  with  lauda- 
num, sulphuric  ether,  &c.  with  a view  of  doing  what? 
Why,  of  obliterating  the  sources  of  the  aqueous  hu- 
mour! the  continuance  of  the  secretion  of  w'hich  is 
set  tlovvn  as  one  of  the  essentials  to  the  production  of 
staphyloma. — (B.  1,  p.  447.) 

The  treatment  of  idiopathic  iritis  in  its  second  stage, 
as  recommended  by  Beer,  is,  on  the  whole,  both  gene- 
rally and  locally,  like  what  has  been  advised  for  the 
same  stage  of  pure  internal  ophthalmy;  but  here,  he 
says,  it  is  necessary  to  pay  particular  attention  to  the 
direction  in  which  the  inflammation  extends  itself  in 
the  first  stage,  so  that  the  treatment  may  be  regulated 
with  greater  precision.  Beer  also  advises  great  atten- 
tion to  be  paid  to  the  elFusion  of  lymph  in  the  posterior 
chamber;  as,  towards  the  end  of  the  second  stage, 
much  may  be  done  which  would  afierward  be  too 
late.  Thus,  when  the  surgeon  perceives,  low'ards  the 
end  of  the  second  ctage,  that  the  layer  of  lymph  in  the 
posteriorchamberdees  not  completely  prevent,  though  it 
seriously  diminishes  vision,  and  that  it  is  likely  to  re- 
main in  tlie  same  state  after  the  termination  of  the  se- 
cond stage.  Beer  recommends  topical  applications  to  tlie 
eye,  and,  if  these  prove  unavailing,  internal  alterative 
medicines,  and  even  mercury,  which,  he  says,  when 
the  treatment  is  judiciously  conducted,  ought  not  to  be 
omitted.  Here,  also,  he  observes,  another  deviation 
must  be  made  from  the  usual  practice  in  the  second 
stage  of  ophthalmy:  calomel  joined  witli  oiiiuin,  is  to 
be  exhibited  with  calamus  aromaticus,  bark,  &.c.  Ex- 
ternally, Beer  speaks  highly  of  the  benefit  of  a colly- 
rium,  containing  the  oxymuriateof  mercury,  without 
any  mucilage,  but  with  a considerable  addition  of  the 
vinous  tincture  of  opium.  When  these  remedies  cease 
to  be  efficacious,  or  the  eye  caimot  bear  fluid  applica- 
tions, as  is  sometimes  the  case,  Beer  recommends  a bit 
of  the  following  salve  to  be  smeared  once  a day  be- 
tween the  edges  of  the  eyelids,  and  allowed  slow'ly  to 
melt  there,  and  become  dilTueed  over  the  eye  : B:-  Ba- 


246 


OPHTHALMY. 


tyri  recentis  insulsi  Z ij.  Hydrargyrl  nitrico-oxydi  ru- 
bri  gr.  vj.  Extract.  o{iii  gr.  viij.  M.  Beer  also  states, 
that  rubbing  a little  mercurial  ointment,  with  which 
some  opium  is  blended,  once  a day  into  the  eyebrow, 
will  greatly  promote  the  removal  of  the  lymph  effused 
in  the  posterior  chamber. — {B.  1,  p.  450.) 

Excellent  as  Beer’s  description  of  idiopathic  iritis 
certainly  is,  there  are  some  imperfections  in  his  method 
of  treatment.  1st,  It  does  not  appear  to  me,  that  he 
insists  sufficiently  upon  the  necessity  of  taking  away 
a very  large  quantity  of  blood  at  the  commencement  of 
the  case,  and  of  repeating  the  general  and  topical  bleed- 
ing, until  the  circulation  is  duly  lowered,  and  the  vio- 
lence of  the  inflammation  checked.  2dly,  Though 
his  recommendation  of  rigorous  antiphlogistic  treat- 
ment implies  the  approbation  both  of  bleeding  and  ca- 
thartics, he  says  nothing  of  the  use  of  moderate  doses 
of  tartarized  antimony,  in  weakening  the  pulse,  a prac- 
tice highly  praised  by  the  late  Mr.  Saunders. — ( On  Dis- 
eases of  the  Eye,  p.  26, 8«o.  1811.)  3dly,  If  mercury  has 
th*  power  of  arresting  acute  inflammation  of  the  iris, 
“both  prior  to  and  after  the  effusion  of  adhesive  mat- 
ter,” and  of  rapidly  removing,  “ by  an  excitement  of 
the  absorbing  system,  peculiar  to  itself,  the  newly- 
eff’used  matter”  (^Travers,  Synopsis,  &rc.  p.  2^1),  then 
Beer  must  delay  too  long  the  employment  of  this  pow- 
erful medicine,  since  he  does  not  commence  its  use  un- 
til the  close  of  the  second  stage,  when  he  has  found 
that  the  absorption  of  the  effused  lymph  cannot  be  ef- 
fected by  other  means.  4thly,  Beer  entirely  overlooks 
the  important  utility  of  belladonna  and  hyoscyamus  in 
producing  a dilatation  of  the  pupil,  whereby  adhesions 
of  the  iris  to  the  capsule  of  the  lens,  or  to  the  cornea 
itself,  may  frequently  be  prevented,  or  their  ill  effects 
considerably  lessened.  Belladonna  (says  Mr.  Saun- 
ders), “if  properly  applied  to  the  eye,  during  the  adhe- 
sive process  of  inflammation,  will  cause  the  inner  mar- 
gin of  the  iris  to  expand  and  recede  from  the  axis  of 
the  pupil,  and  will  thus  overcome  the  restraint  arising 
from  the  agglutination  of  lymph,  by  elongating  the  or- 
ganized bands  which  connect  the  iris  and  capsule,  if 
they  have  not  been  of  long  duration.  Thus,  the  adhe- 
sions are  drawn  out  to  a degree  of  tenuity,  and  conse- 
quently transparency,  and  a considerable  quantity  of 
light  is  admitted.  If  the  effect  of  the  inflammation  has 
been  slight,  the  adhesions  will  be  trivial,  and  the  pupil 
only  slightly  irregular.  The  iris  will  retain  a certain 
power  of  action,  and  vision  will  be  very  little  injured. 
In  general,  the  pupil  is  misshapen,  and  the  iris  per- 
fectly fixed;  but  if  the  aperfure  be  of  sufficient  size, 
and  the  capsule  not  rendered  too  opaque,  the  patient 
will  enjoy  a very  useful  degree  of  sight.” — {Saunders, 
p.  32.)  Respecting  belladonna,  it  is  observed  by  Lan- 
genbeck,  that,  as  all  applications  directly  to  the  inflamed 
eye  itself  are  frequently  hurtful,  and  render  it  still  more 
painful  and  irritable,  it  is  a good  plan  to  let  the  extract 
of  belladonna  be  smeared  upon  the  eyebrow,  instead 
of  puting  a solution  of  it  immediately  in  contact  with 
the  conjunctiva. — {iN'eue  Bibl.  b.  2,  p.  236.)  The  same 
author  expresses  his  attachment  to  Beer’s  method  of  rub- 
bing mercurial  ointment  with  opium  into  the  eyebrows  ; 
and  after  dwelling,  with  due  force,  on  the  necessity  of  co- 
pious and  repeated  bleedings,  leeches,  evacuations,  &c. 
he  cautions  practitioners  not  to  be  led  into  the  suppo- 
sition, that  the  efficacy  of  belladonna  will  supersede 
the  occasion  for  taking  away  blood.  He  even  declares, 
that,  during  the-  first  vehemence  of  the  inflammation, 
the  application  is  quite  inefficient,  and  that  it  frequently 
will  not  succeed  in  producing  a dilatation  of  the  pupil, 
before  bleeding  has  been  practised.  “ If  (says  Langen- 
beck)  bleeding  is  to  be  useful  in  iritis,  it  must  be  copi- 
ous, and  often  repeated.” 

Specific  Cases  of  Iritis.  The  foregoing  observations 
refer  to  idiopathic  iritis,  or  inflammation  of  the  iris  un- 
complicated with  any  specific  disease.  But  there  is  an 
iritis,  which  “ appears  in  company  with  rheumatism  of 
the  chronic  form  ; sometimes  with  gout;  with  the  con- 
stitutional signs  of  the  lues  venerea  ; and  during  or  fol- 
lowing the  action  of  mercuiy  upon  the  system.”— 
{Travers,  Siirgical  Essays,  part  l,p.  59.) 

Mr.  Hunter  entertains  doubts  whether  any  inflam- 
mations of  the  eyes  are  syphilitic,  and  he  appears  to 
found  his  opinion  upon  two  circumstances;  one  is, 
that  if  such  cases  be  venereal,  the  disease  is  very  dif- 
ferent from  w'hat  it  is  when  it  attacks  other  parts,  and 
Is  attended  with  more  pain  than  venereal  inflamma- 
tion arising  from  an  affection  of  the  constitution ; the , 


second  is,  that  he  never  saw  these  cases  attended  whli 
such  ulceration  as  occurs  when  the  complaint  invades 
the  moutJi,  throat,  and  tongue.— (/furiter  on  the  Vene- 
real Disease,  p.  324.)  On  the  other  hand,  the  gene- 
rality of  modern  surgeons  believe  in  the  reality  of 
venereal  ophthalmy,  though  their  accounts  of  the 
symptoms  and  appearances  of  the  complaint  are  in 
some  respects  discordant.  Scarpa  says,  the  venereal 
ophthalmy  is  peculiar  in  not  discovering  manifest  signs 
of  inflammation,  stealing  on  clandestinely,  without 
much  uneasiness.  It  afterward  relaxes  the  vessels  of 
the  conjunctiva  and  lining  of  the  palpebras,  and  changes 
the  secretion  of  Meibomius’s  glands.  In  time,  it  causes 
ulceration  of  the  margins  of  the  eyelids;  the  ciliae  fall 
off,  and  the  cornea  grows  opaque.  In  the  worst  stage 
it  excites  itching  in  the  eyes,  which  is  exasperated  at 
night,  and  abates  in  violence  towards  morning,  as  do 
almost  all  the  effects  of  syphilis.  It  never  attains  the 
state  of  chemosis.  With  the  exception  of  the  venereal 
ophthalmy  in  the  form  of  iritis,  I cannot  discover  that 
any  thing  very  certain  has  yet  been  made  out.  By  this 
observation,  however,  it  is  not  meant  to  assert,  that 
cases  corresponding  to  Scarpa’s  description  do  not  pre- 
sent themselves,  and  may  not  be  relieved  by  his  method 
of  treatment;  but  that  their  venereal  character  is  not 
fairly  proved.  In  examples  like  those  described  hy 
Scarpa,  the  decoct,  sarsap.,  the  oxymuriate  of  mer- 
cury, mezereon,  guaiacum,  and  even  mercurial  fric- 
tions, may  be  employed  with  leeches  and  blisters. 
Scarpa  particularly  recommends  a collyrium  madn 
with  the  oxymuriate  of  mercury.  When  the  eyelids 
are  ulcerated,  theunguentum  hydrargyri  nitrati,  weak- 
ened at  first  with  twice  or  thrice  its  quantity  of  the 
unguentum  cetaceum,  is  the  best  topical  application 

The  iris  is  now  supposed  to  be  more  liable  than  any 
other  part  of  the  eye  to  venereal  inflammation. — 
( Wardrop's  Essays  on  the  Morbid  Anat.  of  the  Eye, 
vol.  2,p.  36.)  The  case  is  mentioned  by  Mr.  Saunders, 
who  recommends  the  vigorous  exhibition  of  mercury 
and  the  use  of  belladonna.  Its  symptoms  and  treat- 
ment, however,  have  been  more  particularly  detailed 
by  Beer. — {Lehre  von  den  Augenkr.b.  1,  p.  553.)  As 
this  case  and  some  other  specific  forms  of  iritis  are 
described  in  the  two  last  editions  of  the  First  Lines  of 
Surgery,  I need  here  only  refer  the  reader  to  that  pub- 
lication, and  to  a few  works  containing  additional  in- 
formation on  iritis  in  general ; as  Saunders's  Treatise 
on  some  Practical  Points,  relating  to  Diseases  of  the 
Eye,  p.  21,  8vo.  1811;  and  particularly  the  later  edi- 
tions, in  which  the  utility  of  mercurials  is  noticed. 

In  the  article  Hypopium  I have  referred  to  an  early 
case,  in  which  the  quick  exhibition  of  mercury  and  its 
good  effects  were  exemplified  in  Germany.  But  what- 
ever claims  the  continental  surgeons  may  have  respect- 
ing the  first  administration  of  mercury  in  iritis,  I be- 
lieve it  a justice  due  to  Dr.  Farre  and  Mr.  Travers  to 
state,  that  these  gentlemen  have  undoubtedly  given,  not 
only  the  best  practical  directions  on  the  subject,  but 
laid  the  greatest  stress  upon  the  necessity  of  the  prac- 
tice, establishing  the  efficacy  of  mercury,  as  a means 
as  well  of  resisting  the  effusion  of  lympht  'm  the  eye  as 
of  exciting  the  absorption  of  it  after  it  has  been  effused. 
— (See  Travers,  in  Surgical  Essays,  part  l.l  Con- 
sult also  J.  Vetch,  A Practical  Treatise  on  the  Diseases 
of  the  Eye,  p.  88,  <S-c.  8vo.  Lond.  1820.  Weller's  Ma- 
nual of  the  Diseases  of  the  Human  Eye,  transl.  by 
Monteath,  8vo.  Glasgow,  1821.  J.  Wardrop,  Morbid 
Anatomy  of  the  Eye,  vol.  2,  chap.  20,  8vo.  Lond.  1818' 
H.  B.  Schindler,  De  Iritide  Chronica.  Vratislaviw, 
1819.  ./.  A.  Schmidt,  uber  JVachstaar  und  Litis  nach 

Staar-  Operationen,  Ato.  Wein,  1801 ; a work  of  high 
repute.  Carmichael,  in  Obs.  on  the  Specific  Distinc- 
tions of  Venereal  Diseases,  p.  31.  Quarterly  Jovrn. 
of  Foreign  Medicine,  Mov.  1818.  G.  Thick  on  Dis- 
eases of  the  Eye,  p.  65,  <S-c.  ed.  2,  with  notes  by  Welbank. 
8vo.  Lond.  1826. 

Rheumatic  Inflammation  of  the  Eye.  According  to 
Mr.  Wardrop,  the  albuginea  acquires  a brick'red 
tinge  or  an  admixture  of  yellow  with  crimson  red, 
which  colour,  he  supposes,  is  probably  caused  by  the 
serous  part  of  the  blood  being  tinged  with  bile;  “an 
effect  likely  to  take  place  from  the  marked  derange- 
ment of  the  biliary  organs  which  usually  accompanies 
this  disease.”  Contrary  to  the  statement  of  Beer,  who 
describes  the  blood  vessels  as  being  in  clusters,  Mr. 
Wardrop  observes,  that  they  are  generally  equally  nu- 
merous over  the  whole  white  of  the  eye,  passing  fo^ 


OPHTHALMY. 


247 


wards  in  nearly  straight  lines  from  the  posterior  part  of 
the  eyeball,  and  advancing  close  to  the  cornea;  but 
treiiher  passing  over  it,  nor  leaving  the  pale  circle 
aroand  it,  which  is  so  striking  when  either  the  choroid 
coat  or  the  iris  is  indanied.  If  the  vessels  be  closely 
examined,  the  general  redness  will  be  found  produced 
more  by  numerous  small  ramifications  than  a few 
large  trunks.  There  is  frequently  a little  swelling  of 
the  conjunctiva  which  sometimes  forms  a slightly  ele- 
vated ring  round  the  cornea.  In  mild  cases,  little 
change  takes  place  in  the  anterior  chamber  in  the  early 
stage ; but  as  the  disease  advances,  the  cornea  becomes 
dull  and  turbid.  U pon  close  examination,  one  or  more 
of  the  layers  of  the  conjunctiva  on  the  cornea  will 
generally  be  found  to  be  abraded,  especially  towards  its 
circumference.  At  the  commencement  of  the  disease 
there  is  often  a disagreeable  feeling  of  dryness  of  the 
eye;  but  sooner  or  later  a very  copious  secretion  of 
tears  takes  place.  The  eyelids  are  observed  to  be  very 
little  affected.  At  first,  the  chief  seat  of  pain  is  gene- 
rally in  the  head,  though  sometimes  in  the  eyeball 
Itself.  Mr.  Wardrop  describes  the  pain  as  usually  most 
severe  in  the  temple  of  the  aflfected  side,  but  he  says 
that  it  is  often  seated  in  the  brow,  the  cheek-bone,  the 
teeth,  or  the  lower  jaw.  “ Sometimes  the  pain  is  pre- 
cisely confined  to  one-half  of  the  head,  and  sometimes 
there  is  a severe  pain  in  the  cavity  of  the  nose  or  in 
the  ear.  The  pains  are  more  of  a dull  agonizing  kind 
than  acute,  and,  though  unceasing,  they  vary  much  in 
degree,  coming  on  at  times  in  very  severe  paro.\ysms, 
and  with  great  violence  when  the  head  is  bent  down- 
wards. Sometimes  the  pain  is  excited  by  merely 
touching  the  scalp,  and  the  patient  is  unable  to  rest  his 
head  on  the  affected  aide  or  even  lean  it  on  a pillow. 
In  most  cases  the  pain  is  said  to  be  remittent,  the  pa- 
roxysm coming  on  in  the  evening,  continuing  during 
the  night,  being  most  severe  about  midnight,  and 
abating  towards  morning. 

In  the  eyeball,  says  Mr.  Wardrop,  the  patient  gene- 
rally complains  more  of  a sense  of  fulness  and  disten- 
tion than  of  pain ; and  though  there  is  a great  degree 
of  external  redness,  the  eye  does  not  seem  to  svffer 
from  exposure  to  light  ■,  a point  on  which  Professor 
Beer  delivers  a directly  opposite  statement,  at  least,  in 
relation  to  the  first  stage  of  the  disease.  However, 
these  authors  both  agree  in  considering  the  sclerotica 
as  generally  the  chief  seat  of  rheumatic  inflammation  ; 
but  Beer  sets  down  the  iris  as  likewise  subject  to  be 
attacked.  He  admits  also,  that,  in  the  second  stage, 
the  aversion  to  light  undergoes  a considerable  diminu- 
tion. According  to  Mr.  Wardrop,  rheumatic  ophthal- 
my  is  always  accompanied  with  more  or  less  symp- 
tomatic fever,  severe  paroxysms  of  which  take  place 
towards  evening,  and  the  functions  of  the  primae  vire 
are  much  deranged,  “ the  appetite  being  impaired,  and 
the  evacuation  always  changed  in  quality.”  In  severe 
cases,  the  pain  in  the  head  soon  becomes  agonizing, 
the  redness  of  the  eyeball  increases,  the  whole  white 
of  the  eye  is  crowded  with  blood-vessels,  and  the  con- 
junctiva swelled.  At  length  ulceration  commences  in 
the  cornea,  through  which  the  aqueous  humour  is  dis- 
charged, and  the  eyeball  collapses,  when  all  pain  ceases ; 
or  abscesses  may  form  within  the  posterior  chamber 
and  burst  through  the  sclerotic  coat. — {fVardrop,  in 
Jiled.  Chir.  Trans,  vol.  10.)  Beer  describes  small  wa- 
tery vesicles  as  forming  on  the  cornea  or  white  of  the 
eye,  and  changing  during  severe  pains  into  small  ulcers, 
which  occasion  an  appearance,  as  if  a small  piece 
were  torn  out  of  the  surface  of  the  cornea.  He  adds, 
that  they  seldom  leave  scars  behind ; but  generally  little 
pits,  which  are  soon  filled  up  in  healthy  subjects. — (See 
fVeller  on  Diseases  of  the  Eye,  vol.  2,  p.  217.) 

The  causes  of  rheumatic  ophthalmy^enumerated  by 
writers  are,  change  of  weather,  variatron  of  tempera 
tore,  exposure  to  damp,  a cold  current  of  air  directly 
striking  the  eye,  and  a constitution  disposed  to  rheu- 
matism. Mr.  Wardrop  states,  that  both  sexes  are 
equally  subject  to  the  disease;  but  that  he  has  ob- 
served it  most  frequently  in  adults,  and  persons  of 
rather  advanced  age.  Only  one  eye  is  usually  affected  ; 
and  when  the  second  is  attacked,  the  disease  is  almost 
always  less  severe  in  it  than  that  which  is  first  in- 
flamed. 

According  to  Mr.  Wardrop,  rheumatic  ophthalmy 
resembles  syphilitic  more  than  any  other  kind  of  in- 
flammation of  the  eye.  But  he  notices,  that  in  rheu- 
matic ophthalmy  the  proper  vessels  of  the  sclerotic  coat 


are  enlarged,  which  is  the  cause  of  the  redness  being 
generally  diffused  over  the  whole  albuginea,  whereas, 
in  syphilitic  inflammation  it  is  the  anterior  ciliary  ar- 
teries passing  along  the  sclerotica  on  their  way  to  the 
iris,  which  are  chiefly  affected ; and  hence  the  pale 
ring  which  is  always  observed  between  the  cornea 
and  the  enlarged  vessels.  Mr.  Wardrop  farther  ex- 
plains, that  though  these  diseases  resemble  each  other 
in  the  pains  round  the  orbit  and  their  evening  exacer- 
bation, patients  with  syphilitic  ophthalmy  always  have 
the  constitutional  symptoms  of  syphilis. 

Wnen  the  disease  has  made  much  progress,  and  the 
symptoms  have  not  yet  yielded  to  other  remedies,  Mr. 
Wardrop  recommends  the  evacuation  of  the  aqueous 
humour,  as  a practice  from  which  the  most  beneficial 
effects  may  be  expected.  After  the  operation,  fomenta- 
tions are  the  only  necessary  applications ; but  if  the  eye 
continue  long  irritable,  the  vinous  tincture  of  opium  is 
to  be  used.  He  enjoins  attention  to  the  state  of  the 
biliary  organs  in  every  stage  of  the  disease,  and  speaks 
highly  of  the  sudden  relief  sometimes  afforded  by  an 
emetic,  care  being  taken  to  empty  the  bowels  afterward 
with  calomel  and  rhubarb,  or  other  purgatives.  If  the 
functions  of  the  skin  were  suddenly  interrupted  by  a 
chill  just  before  the  attack,  this  author  prescribes  a 
couple  of  grains  of  antimonial  powder,  alone,  or  com- 
bined with  opium,  to  be  taken  every  four  or  six 
hours.  Little  advantage,  he  says,  is  derived  from  local 
bleeding,  and  where  venesection  may  become  neces- 
sary on  account  of  the  complaint  resisting  otiier  means, 
it  is  to  be  practised  with  moderation. 

In  the  early  stage,  Mr.  Wardrop  has  found,  that  the 
pain  in  the  eye  and  eyebrow  is  sometimes  much  alle- 
viated by  a fomentation  with  the  decoction  of  poppy- 
heads.  He  also  praises  blisters  to  the  nape  of  the 
neck  or  behind  the  ear;  but  disapproves  of  their  being 
put  near  the  eye  itself.  The  vinous  tincture  of  opium, 
he  says,  is  the  only  local  application  which  he  has  ever 
seen  decidedly  beneficial ; but  its  use  is  to  be  deferred 
till  a late  stage  of  the  inflammation,  when  all  febrile 
symptoms  have  been  subdued.  “ After  the  primae  viae 
have  been  well  evacuated,  the  tongue  may  still  remain 
very  wh'ite,  and  the  pulse  quicker  than  natural.”  In 
this  state,  small  doses  of  bark,  either  alone  or  with 
the  mineral  acids,  will  be  most  serviceable. — ( Wardrop, 
in  Med.  Ghir.  Trans,  vol.  10.)  The  outlines  of  Beer’s 
practice  may  be  given  very  briefly:  in  the  first  stage, 
he  applies  a leech  to  the  inner  canthus,  and  covers  the 
eye  with  a cold  poultice,  with  a small  proportion  of 
vinegar  in  the  water  with  which  it  is  made.  Diapho- 
retics are  also  prescribed.  In  the  second  stage,  guaia- 
cum,  camphor,  arnica,  antimonials,  blisters  to  the 
neck,  or  behind  the  ears,  frictions  with  opium  over  the 
eyebrows,  and  covering  the  eyes  with  bags  of  aromatic 
herbs  and  camphor,  are  the  means  of  relief.  When 
abrasions  or  ulcerations  exist  on  the  conjunctiva,  scle- 
rotica, or  cornea,  a collyrium  of  the  lapis  divinus,  with 
a large  addition  of  the  vinous  tincture  of  opium,  is 
commended ; or  if  the  ulcers  are  large,  and  on  the 
cornea  itself,  they  may  be  touched  with  the  latter  tinc- 
ture by  means  of  a camel-hair  pencil.  After  each  use 
of  the  collyrium.  Beer  covers  the  eye  again  with  the 
bags  of  aromatic  herbs  and  camphor. — (See  Weller  on 
Diseases  of  the  Eye,  vol.  2,  p.  218.)  Respecting  the 
last  application,  I have  already  expressed  my  belief, 
that  it  is  one  which  is  not  likely  to  obtain  credit  among 
English  surgeons. 

Scrofulous  Ophthalmy.  One  of  the  peculiarities  of 
this  case  is,  that  it  is  not  attended  with  pain.  As  Dr. 
Frick  observes,  the  same  fact  is  remarked  with  respect 
to  scrofulous  inflammation  in  other  parts : it  is  every 
where  characterized  by  a dulness  of  sensibility.— ( On 
Dis.  of  the  Eye,  p.  33,  ed.  2.)  According  to  Mr.  Tra- 
vers, when  strumous  inflammation  of  the  conjunctiva 
lias  not  proceeded  to  change  of  texture,  it  is  not 
marked  by  any  proniinent  local  character.  “ The  vas- 
cularity is  inconsiderable.  This  inflammation  some- 
times accompanies  pustule  of  the  sclerotic  conjunc- 
tiva, in  which  case  the  vascularity  is  diffu.sed,  instead 
of  being  partial  as  in  pure  pustular  inflammation,  and 
the  intolerance  of  light  characteristic  of  the  strumous 
inflammation  is  present  in  a greater  or  less  degree. 
It  accompanies  also  the  morbid  secretion  of  the  lids 
when  the  eyeball  becomes  affected  by  the  acuteness 
and  duration  of  that  disease,  and  the  pustule  on  the 
cornea,  especially  the  variolous  pustule.  In  its  simplest 
form,  it  is  almost  peculiar  to  young  children,  sta- 


248 


OPHTHALMY. 


tionary,  marked  by  a very  slight  redness  of  the  scle- 
rotic conjunctiva,  and  the  greatest  possible  degree  of 
intolerance  (of  light)."  The  same  author  attributes 
the  disease  to  a morbid  sympathy  of  the  retina  with 
the  secreting  surfaces  of  the  primte  vite  and  skin. 
The  following  is  the  treatment  proposed  by  Mr.  Tra- 
vers, for  each  form  of  scrofulous  ophthalmy ; 

1.  Strumous  inflammation  without  change  of  texture, 
vascularity  more  or  less,  intolerance  (of  light)  exces- 
sive. Calomel  and  opiunt  at  night ; emetic  tartar  to 
continued  nausea;  getitle  alvine  evacuants;  diapho- 
retic drinks;  large  open  blister  on  the  nape  of  the 
neck;  leeches;  tepid  bath;  tepid  or  cold  water  washes 
as  most  agreeable;  vapour  of  opium;  large  bonnet 
shade;  no  bandages;  spacious  airy  apartments;  and 
light  bed  clothing. 

2.  With  recent  diffused  opacity  of  the  corneal  con- 
junctiva, and  vessels  raised  upon  and  over  shooting 
the  comeal  margin.  Calomel  and  opium  to  slight  ptya- 
lism  ; purgatives  on  alternate  days ; leeches ; blisters 
alternated  behind  the  ears  and  on  the  nape  of  the  neck 
and  temples.  As  the  acute  stage  passes  off,  repeated 
circular  sections  of  the  vessels  on  the  sclerotica,  near 
the  margin  of  the  cornea. 

3.  With  herpetic  ulcers  of  the  cornea.  The  same ; 
blisters  on  the  temples:  as  the  inflammation  yields, 
Bolut.  argent,  nitrat. ; vin.  opii ; solut.  cupr.  sulph. ; di- 
lute zinc  lotion. 

4.  With  pustules.  If  partial,  weak  zinc,  or  alum 
lotion ; ung.  hydrarg.  nitrat. ; occasional  brisk  purga- 
tives ; infusion  of  roses  with  additional  acids ; tonic 
bitters  ; columba  ; gentian,  &c. ; blisters  behind  the 
ears,  repeated  if  necessary ; if  the  vascularity  is  dif- 
fused by  the  multiplication  of  pustules  or  the  duration 
of  inflammation,  with  irritability  to  light,  treatment  as 
in  strumous  inflammation  without  breach.  Ung.  sub- 
acei.  plumbi. 

5.  With  inflammation  of  the  follicles  and  puriform 
discharge.  Active  measures  at  first,  but  not  long  con- 
tinued. Blisters;  when  becoming  chronic,  with  thick- 
ened lids,  scarifications  ; zinc,  alum,  or  copper  wash, 
dilute ; ung.  hydr.  nitrat. ; hydr.  nitr.  oxyd.  ; subacet. 
cupri ; tonics  and  sedatives : if  obstinate,  issue  or 
seton. 

6.  Convalescent  state.  Infusion  of  roses ; casca- 
rilla ; columba;  decoction  of  bark,  with  dilute  sul- 
phuric or  nitric  acid ; steel,  rhubarb,  and  soda  ; or 
magnesia,  as  aperients ; tonic  collyria  and  gently  sti- 
mulant ointments ; nutritive  diet;  country  air;  shower 
or  sea-bath  in  the  warm  months.— (Trauers’s  Synopsis, 
Sre.  p.  92 — 260,  (S-c.) 

When  I look  at  the  discordant  accounts  of  what  are 
called  scrofulous  affections  of  the  eye,  and  the  differ- 
ence of  practice  laid  down  by  different  writers,  I leave 
the  subject  with  an  impression  that  the  terms  scrofu- 
lous and  strumous  are  here  employed  as  much  at  ran- 
dom as  in  any  other  cases  which  can  be  specified.  In- 
deed, the  attempt  to  reconcile  the  various  statements 
and  descriptions  of  scrofulous  ophthalmy,  would  puz- 
zle the  niost  able  man  in  the  profession ; and  it  is  with 
this  belief,  that  I avoid  contrasting  the  sentiments  of 
Beer,  Weller,  Lloyd,  Frick,  and  other  modern  writers, 
with  those  already  delivered. — (See  particularly  Beer's 
Lehre  von  den  Augenkr.  b.  1,  p.  588,  Src.;  Weller's 
Manual  of  the  Diseases  of  the  Eye,  vol.  2,  p.  285,  <S-c.  ; 
Lloyd  on  Scrofula,  p.  312;  and  Frick  on  the  Eye, 
ed.  2.) 

Chronic  Ophthalmy.  Unfavourable  peculiarities  are 
met  with  in  practice,  which  prevent  the  complete  cure 
of  the  second  stage  of  acute  ophthalmy,  or  that  con- 
nected with  a weak  vascular  action  in  the  part  af- 
fected; whence  the  protracted  disease  becomes  purely 
chronic,  and  threatens  the  slow  destruction  of  the  eye. 

These  peculiarities  may  be  chiefly  referred  to  three 
causes;  1.  To  an  increased  irritability  continuing  in 
the  eye  after  the  cessation  of  acute  inflammation.  2. 
To  some  other  existing  affection  of  the  eye  or  neigh- 
bouring parts,  of  which  the  chronic  ophthalmy  is  only 
an  effect.  3.  To  constitutional  disease. 

1.  That  chronic  ophthalmy  may  depend  upon  a 
morbid  irritability  of  the  eye  is  evinced,  not  only  from 
its  resisting  topical  astringents  and  corroborants,  to 
which  the  disease  from  simple  relaxation  and  weak- 
ness yields,  but  from  its  being  exasperated  by  them, 
and  even  by  cold  water.  The  patient  complains  of  a 
sense  of  weight  in  the  upper  eyelid,  and  restraint  in 
opening  it;  the  conjunctiva  has  a yellowish  cast,  and 


when  exposed  to  the  damp  cold  air,  or  a brilliant  light, 
or  when  the  patient  studies  by  candle- light,  its  vessels 
become  injected  and  turgid  with  blood.  If,  in  combi- 
nation with  such  symptoms,  the  habit  of  body  be  weak 
and  irritable  ; subject  to  spasms,  hypochondriasis,  &c. ; 
then  it  is  manifest,  that  the  chronic  ophthalmy  is 
connected  with  a general  impairment  of  the  nervous 
system. 

2.  Besides  extraneous  bodies  lodged  between  the 
palpebrae  and  eyeball,  the  inversion  of  the  cilise,  and 
hairs  growing  from  the  caruncula  Lachrymalis;  ulcers 
of  the  cornea  ; prolapsus  of  the  iris ; herpetic  ulcera 
tions  of  l4)e  margins  of  the  eyelids  ; a morbid  secre 
tion  from  the  Meibomian  glands ; a diseased  enlarge- 
ment of  the  cornea,  or  of  the  whole  globe  of  the  eye, 
&c.,  may  occasion  and  maintain  chronic  ophthalmy. — 
It  is  only  my  part  here  to  mention  such  remote  causes; 
for  the  particular  treatment  of  them  is  described  in 
other  articles — (See  Cornea,  Ulcers  of;  Iris,  Prolap- 
sus of;  Lippitudo  ; Staphyloma ; Uydrophthalmia  ; 
Trichiasis,  Src.) 

3.  The  cure  of  the  second  stage  of  acute  ophthalmy 
may  be  retarded  by  the  prevalence  of  scrofula  in  the  sys- 
tem, or  by  small  pox  affecting  the  eyes.  According 
to  Scarpa,  chronic  ophthalmy  is  also  sometimes  a con- 
seqiience  of  lues  venerea;  but  I know  nothing  certain 
on  this  subject  in  addition  to  what  has  been  stated  in 
the  foregoing  columns. 

When  chronic  ophthalmy  depends  upon  preterna- 
tural irritability,  the  internal  exhibition  of  bark  with 
valerian  is  proper;  animal  food  of  easy  digestion; 
gelatinous  and  farinaceous  broths  ; wine  in  modera- 
tion; gentle  exercise  ; living  in  salubrious  and  mild 
situations  ; are  all  severally  productive  of  benefit.  Ex- 
ternally, the  applications  should  be  of  the  sedative  and 
corroborant  kind;  such  as  aromatic  spirituous  vapours 
(from  the  spiritus  ammon.  comp.)  aiiplied  to  the  eye 
through  a funnel  for  half  an  hour,  three  or  four  times 
a day  ; and  the  eyelids  and  eyebrows  may  also  be 
rubbed  with  the  linimentum  camphorae. 

Patients,  both  during  the  treatment  and  after  the 
cure,  must  refrain  from  straining  the  eye,  and  imme- 
diately the  .least  uneasiness  is  felt,  must  desist  from 
exercising  it.  When  thfty  write  or  read,  it  should  con- 
stantly be  in  a steady,  uniform  light ; and  too  little,  as 
well  as  too  much  exercise  of  the  organ,  aggravates  the 
disease.  Having  once  begun  to  use  spectacles,  they 
should  never  study,  nor  survey  minute  objects  without 
them. — (Scarpa.) 

Intermittent  Ophthalmy.  It  is  the  character  of  cer- 
tain forms  of  ophthalmy,  like  the  rheumatic  and  vene- 
real, to  be  liable  to  periodical  exacerbations ; but  I am 
not  certain  that  there  are  any  cases  specifically  claim- 
ing the  name  of  intermittent  ophthalmy.  The  late  Mr. 
Ware,  however,  has  noticed  s.ime  examples  which  in- 
termitted, or  at  least  remitted,  at  stated  periods.  In 
these,  he  did  not  find  bark  so  useful  as  in  scrofulous 
ophthalmy  ; but  he  had  seen  the  most  beneficial  effects 
produced  by  the  o.xymuriate  of  mercury,  sometimes 
joined  with  the  compound  decoction  of  sarsaparilla. 

Variolous  Ophthalmy.  As  the  smak-pox  inoculation 
has  at  present  almost  generally  been  abandoned  by  the 
faculty  in  favour  of  the  vaccine  di.sease,  there  seems 
less  occasion  now  for  detailing  circumstantially  a %'ery 
obstinate  species  of  ophthalmy,  induced  by  the  former 
complaint.  When  the  small-pox  eruption  is  very  abun- 
dant in  the  face,  it  t^uses  a considerable  swelling  of  this 
part  of  the  body  ; the  eyelids  become  tumefied,  the  eyes 
redden,  and  there  ensues  a discharge  of  a very  thick 
adhesive  matter,  which  agslutinates  the  palpebrre  to- 
gether : so  that,  if  no  steps  be  taken,  the  eyes  will  con- 
tinue closed  for  several  days  in  succes.sioii.  The  mat- 
ter confined  bet^veen  the  eyelids  and  globe  of  the  eye, 
being  perhajis  of  an  irritating  quality,  and  injurious 
from  the  pressure  it  occasions  on  the  surrounding 
parts,  seems  capable  of  exciting  ulceration  of  the  cor- 
nea, and  even  of  irremediably  destroying  vision. 
When  the  pustules  of  the  small-pox  in  other  parts  of 
the  body  have  suppurated,  they  cicatrize;  but  those 
which  happen  within  the  margin  of  the  cartilage  of 
the  eyelids  are  prevented  from  healing  by  the  dis'  ased 
secretion,  which  is  then  made  from  the  Meibomian 
elands,  and  such  ulcers  result,  as  will  sometimes  last 
for  several  years,  and  even  during  life,  if  unremedied 
bv  art. — (.St.  Ynes  snr  les  Mai.  des  Yevx,  p.  216,  edit. 
12oto.)  After  the  employment  of  the  antiphlogistic 
treatment,  should  the  disease,  when  treated  with  topi- 


OPHTHALMY. 


249 


cal  astringents  and  corroborants,  yet  baffle  the  efforts 
of  the  surgeon,  setons  in  the  nape  of  the  neck,  kepi 
open  for  a long  while,  prove  one  of  the  most  useful  re- 
medies. Scarpa  has  experienced  much  advantage 
from  giving,  every  morning  and  evening,  to  a cliild  len 
years  old,  a pill  containing  one  grain  of  calomel,  one 
grain  of  the  sulph.  aur.  antim.  and  four  grains  of  ci- 
cuta  in  powder.  It  is  obvious,  that  so  potent  an  altera 
tive,  if  ever  serviceable  in  this  case,  will  soon  evince 
its  efficacy ; nor  would  it  be  jusiitiable  to  sport  with 
the  patient’s  constitution  by  continuing  its  use  beyond 
a certain  perhtd,  unless  sanctioned  by  evident  signs  of 
its  salutary  effects  on  the  disease  oi  liie  eyes. 

When  great  irritability  prevails,  a mixture  of  three 
drachms  of  the  vinuin  antimoniale,  and  one  drachm  of 
the  tinctura  tliebaica,  given  in  doses  of  five  or  six  drops, 
in  any  convenient  vehicle,  and,  at  the  same  time,  ap 
plying  externally  the  vapours  of  the  spiriins  ammon. 
comp,  to  the  eye,  constitute  an  excellent  plan  of  treat- 
ment. In  other  cases,  saturnine  collyria,  with  a little 
camphorated  spirit  of  wine  or  white  wine,  in  which  a 
little  sugar  is  dissolved ; tinct.  tliebaica;  Janin’s  oini- 
nient,  &c.  avail  most.  This  treatment  is  also  appli- 
cable to  the  chronic  ophthalmy  from  measles. 

When  inveterate  ulcers  lemain  upon  the  edges  of 
the  palpebrae,  the  disease  may  then  be  regarded  as  the 
psorophlhalniy,  described  by  Mr.  Ware,  and  will  de 
mand  the  same  method  of  cure. — (See  Psoropk- 
thalmy.) 

Operation  of  discharging  the  aqueous  humour.  To 
this  practice,  some  allusion  has  been  already  made  in 
the  preceding  columns  ; and  as  the  proposal  is  intended 
to  apply  to  several  forms  of  inflammation  of  the  eye, 

I have  not  given  any  particular  account  of  it  in  treat- 
ing of  the  various  cases.  Mr.  Wardrop  remarked, 
that  if  the  eye  of  a sheep  or  ox  be  squeezed  in  the 
hand,  the  whole  cornea  instantly  becomes  cloudy,  and 
whenever  the  pressure  is  removed,  this  membrane 
completely  regains  its  transpaiency. — From  this  cu- 
rious phenomenon  in  the  dead  eye,  it  was  evident  thai 
in  the  living  body  the  transparency  of  the  cornea 
might  vary  according  to  the  degree  of  its  distention  ; 
and  that,  in  cases  of  opacity  of  the  cornea,  accompa 
nied  with  fulness  of  the  eyeball,  its  transparency  might 
be  restored  by  the  evacuation  of  the  aqueous  humour. 
The  cornea  is  little  sensible,  and,  as  every  body  knows, 
its  wounds  are  free  from  danger.  Mr.  Wardrop  soon 
met  with  a case  favourable  for  making  the  experi- 
ment: the  cornea  was  milky  and  opaque,  and  the  eye 
ball  distended  and  prominent,  attended  with  acute  in 
flammatory  symptoms.  The  aqueous  humour  was 
discharged  by  a small  incision,  and  the  operation  pro- 
duced not  only  a removal  of  the  cloudiness  of  the  cor- 
nea, but  an  abatement  of  the  pain,  and  a sudden  check 
to  all  the  inflammatory  symptoms.  From  the  success 
of  this  case,  Mr.  Wardrop  was  led  to  perform  the  ope- 
ration on  others,  not  only  with  a view  of  diminishinu 
the  opacity  of  the  cornea,  but  also  of  alleviating  the 
inflammation.  Four  interesting  cases  are  related  by 
this  gentleman,  very  much  in  favour  of  the  practice 
when  the  eye  is  severely  inflamed,  attended  with  ful- 
ness of  the  organ,  a cloudy  state  of  the  cornea,  and  a 
turbidness  of  the  aqueous  humour.  Mr.  Wardrop  also 
advises  the  operation  whenever  there  is  the  smallest 
quantity  of  pus  in  the  anterior  chamber,  accompanied 
with  violent  symptoms  of  inflammation.  He  thinks 
that  the  great  and  immediate  relief  which  the  method 
affords,  is  imputable  to  the  sudden  removal  of  tension  ; 
and  he  perforins  the  operation  with  a small  knife, 
such  as  is  used  for  extracting  the  cataract.  The  in- 
strument is  to  be  oiled,  and  introduced  so  as  to  make  a 
wound  of  its  own  breadth,  at  the  usual  place  of  mak- 
ing an  incision  in  the  extraction  of  the  cataract.  By 
turning  the  blade  a little  on  its  axis,  the  aqueous  hu- 
mour flows  out. — (See  Edinb.  Med.  Surg.  .Journal, 
•Jan.  1807  ; also  Med.  Chir.  Trans,  vol.  4.)  Mr.  Law- 
rer>ce  has  tried  this  plan  in  some  instances;  but  his 
opinion  of  it  is  by  no  means  favourable ; for  he  says, 
that  so  little  benefit  resulted  from  it,  that  he  has  not 
been  induced  to  persist  in  the  practice;  and  he  has 
been  the  less  inclined  to  do  so  in  severe  inflammations 
of  the  eye,  because  they  are  completely  controlled  by 
ordinary  antiphlogistic  means.  Consult  .Avicenna, 
Canon.  1.  3,  fen.  3,  tract.  1,  cap.  6.  Muitre-.Jan. 
Traite  des  Maladies  del' (Eil,V2.mo.  Paris,  1722.  St. 
Ynes,  Traiti  des  Mai.  des  Yeux,  p.  176,  <S-c.  Janin, 
Mem.sur  I'CEil,  drc.  8«ff.  Paris,  1772.  L.  F.  Oendron, 


Traiti  des  Mai.  des  Yeux,  2 t.  12m0.  Paris,  J770.  C. 
F.  Reuss,  Dissertationes,  Med.  Selectee  TuOivgenses 
Ociili  Huwani  .dffectiis  medico-chirvrgice  cuvsidtraUis 
sistentes,  3 vols.  Boo.  Tub.  1783.  Trnka  de  Krzowitz, 
Hist.  Ophtkuliiiiee  omnis  cevi  ubservata  medica  covti- 
nens,  8oo.  Findob.  1783.  O.  Power,  Atteuipl  to  inves- 
tigate the  Causes  of  the  Egyptian  Ophthalmy : with 
Obs.  on  its  Mature  and  Cure,  8vo.  J^ovd.  180;i.  H. 
Read,  An  Essay  on  Ophthalmia,  8vo.  Portsea,  1806-7. 
J.  B.  Serney,  Treatise  on  Loctil  Injlanimation,  more 
particularly  applied  to  Diseases  of  the  Eye,  irc.  8oo. 
Land.  1809.  J.  P.  Marat,  An  Inquiry  into  the  Mature, 
Cause,  and  Cure  of  a singular  Disease  of  the  Eyes, 
hitherto  unknown,  and  yet  common,  produced  by  the 
Use  of  certain  Mercurial  Preparations,  \to.  Eond. 
1770.  James  Ware,  Chir.  Observations  rclutiiie  to 
the  Ifye,  2 vols.  8vo.  Land.  1805.  Richter,  Anfangsgr. 
der  Wundarzn.  b.  3.  O.  Peach,  and  J.  Wardrop,  in 
Edinb.  Med.  Surg.  Journal  for  .January,  1807.  Also 
./.  Wardrop,  in  Med.  Chir.  Trans,  vols.  and  10;  and 
Essays  on  the  Morbid  Anatomy  of  the  Eye,  2 vols.  8vo. 
1808-— 1818.  .lohn  Vetch,  An  Account  of  the  Oph- 
thalmia which  has  ajipeared  in  England  since  the  Re- 
turn of  the  British  Army  from  Egypt,  8/  o.  Land. 
1807.  Also,  Obs.  relative  to  the  Treatment  of  Sir 
Win.  Adams  of  the  Ophthalmic  Cases  of  the  Army, 
8oo.  J.ond.  1818.  Ertter  on  the  Ophthalmic  Institu- 
tion for  the  Cure  of  Chelsea  Pensioners,  4to.  Eond. 
1819.  And  a Practical  Treatise  on  the  Diseases  of 
the  Eye,  8vo.  Eond.  1820  W.  Thomas,  Obs.  on  the 
Egyptian  Ophthalmia,  and  Ophthalmia  Purulenta, 
8vo.  Eond.  1805.  P.  Assalini  on  the  Plague,  Dysen- 
tery, and  Ophthalmy  of  Egypt,  <S-c.  Transl.  by  A. 
Meale,  J.ond.  1804.  Also,  Manuule  di  Chirurgiu,  8vo. 
Milano,  1812.  F.  Vasani  Storia  dal'  Ottalmia  conta- 
giosa dello  Spednle  Militare  d'Ancona,  8vo.  In  Ve- 
rona, 1816.  Also,  Risposta  d do  che  la  rigiiaida  net 
Cenni  del  Dr.  Omodei  null'  Ottalmia  d'Egitto  et  sulla 
sua  propagazione  in  Italia,  i2mo.  In  Verona,  1818. 
T.  I'.  Bultz  de  Ophthalmia  Catarrhali  Bellica,  4to. 
Heidrlb.  1816.  .drthur  Edmonstone,  Treatise  on 
the  Varieties  and  Consequences  of  Ophthalmia,  with  a 
Preliminary  Inquiry  into  its  contagious  Mature,  8vo. 
Edi7ib.i8m.  De  Wenzel,  Manuel  de  l'Ociiliste,2  t. 
8vo.  Paris,  1808.  C.  Farrell,  On  Ophthalmia  and  its 
Consequences,  8vo  Eond.  1811.  On  the  Utility  of 
Blisters  in  the  Ophthalmia  of  Infants,  in  Ed  Med. 
Hiirg.  Journ  Mo.  58,  p.  156.  R.  C.  Graefe,  .Journ. 
der  Chir.  b.  1.  Also,  Repertorium  augenarzlicher  Heil- 
formeln,  8vo.  Berlin,  1817.  G .'Benedict,  De  Morbis 
Oddi  Humani  Inflammutoriis,  4to.  Eips.  1811.  J.  C. 
Saundrrs,  on  Diseases  of  the  Eye,  edited  by  Dr.  Farre, 
J.ond.  1811,  or  rather  the  later  editions.  K.  Himly, 
Ophthalmologische  Beobachtungen,  ^r.  \2mo.  Bremen, 
1801.  Also,  Einleitung  in  die  Aiigenheilkunde,  l2mo. 
.Jena,  1806,  and  his  Bibliothek  fiir  Ophthalmologie, 
&rc.  \2mo.  Hanov.  1816.  F.  .J.  Wallroth,  Syntagma 
de  Ophthalmologia  Veterum,  8vo  Halee,  1818.  C.  J. 
M.  J.angenbeck,  in  Bihl.  and  Meue  Bild.  fur  die  Chi- 
rurgie.  in  various  places.  Ant.  Scarpa  sulle  Principali 
Maiaitie.  degli  Occhi  ; Venez.  ediz.  5ta  ; or  the  Transl. 
by  Mr.  Briggs,  2d  ed.  Roux,  Voyage  fait  en  Angle- 
terre  en  1814.  ou  Parallite  de  la  Chirurgie  Angloise 
avec  la  Chirurgie  Francoise,  p.  37,  iS-c.  P.  M'  Gregor, 
in  Trans,  of  a Society  for  the  Improvement  of  Med. 
and  Chirurgical  Knowledge,  vol.  3,  p.  30,  &-c.  Ear- 
rey,  Mimoires  de  Chir.  Militaire,  t.  1,  p.  202,  <S-c.  J. 
A Schmidt,  iiber  Machstaar  und  Iritis,  4to.  Wein, 
1801.  G.  J.  Beer,  Eehre  von  den  An genkrankheiten, 
2 b.  8vo.  Wein,  1813—1817.  C.  H.  Weller,  A Manual 
of  the  Diseases  of  the  Human  Eye,  Transl.  with  notes, 
by  G.  C.  Monteath,  2 vols.  8vo.  Glasgow,  1821.  B. 
Travers  on  Iritis,  in  Surgical  Essays,  part  1.  Also, 
a Synopsis  of  the  Diseases  of  the  Human  Eye,  8vo. 
J.ond.  1820.  E.  A.  J.loyd,  A Treatise  on  Scrofula, 
8vo.  Eond.  1821.  W.  Eawrence,  I.ectures  on  Diseases 
of  the  Eye ; J.ancet,  vol.  9.  O.  Prick,  on  Diseases  of 
the  Eye,  ed.  2,  by  Welbank. 

[Professor  Sewall,  of  Columbian  College,  D.  C.,  a 
distinguished  practitioner  of  Washington  City,  has  ob- 
tained extensive  reputation  by  his  success  in  the  treat- 
ment of  ophthalmia,  and  particularly  the  purulent  form 
of  this  disease.  By  a communication  with  which  he 
has  recently  favotired  me,  I learn  that  after  a previous 
course  of  depletion,  which  he  pursues  with  great  energy, 
in  all  cases  of  ophthalmia,  he  relies  chiefly  upon  pres- 
sure in  almost  every  form  of  the  disease,  and  especially 


260 


OST 


OST 

in  the  purulent  kind.  So  soon  as  the  active  symptoms 
are  subdued  by  the  antiphlogistic  regimen,  he  applies 
over  the  eye  a pad  of  silk  or  soft  linen,  then  a bat  of 
carded  cotton,  or  scraped  lint,  which  he  confines  by  a 
thin  light  bandage  so  tight  as  to  afford  gentle  and  coin- 
fortable  compression  to  the  eye,  so  as  not  to  produce  pain 
or  uneasiness,  however,  by  its  intensity.  Tliis  com- 
press he  removes  twice  in  the  twenty-four  hours,  and 
replaces  it  immediately  by  another  of  similar  material. 
By  this  course  he  thinks  he  fulfils  three  indications,  viz : 

1st.  Effectually  to  exclude  the  light  from  the  eye ; 

2d.  The  globe  of  the  eye  is  prevented  from  rolling ; 
and, 

3d.  The  distended  vessels  are  compressed  and  dis- 
gorged. 

His  observation  has  detected,  in  most  cases  of  oph- 
thalmy,  that  there  is  a portion  of  the  globe  of  the  eye 
in  which  the  vessels  are  more  turgid  than  elsewhere, 
and  this  is  in  a line  extending  from  the  inner  and  outer 
canthus  of  the  eye  and  corresponds  to  the  triangular 
groove  formed  by  the  lids  when  closed ; and  arises,  as 
he  conceives,  from  a want  of  pressure  from  the  lids  of 
the  eye. 

This  practice  was,  I believe,  originally  proposed  and 
adopted  by  Dr.  Francis  Moore,  of  Massachusetts,  a 
gentleman  of  high  reputation  both  as  a physician  and 
surgeon.  Professor  Sew  all,  however,  has  for  sixteen 
years  tested  its  utility,  and  recommends  it  to  his  class 
with  great  confidence.  From  the  few  trials  I liave 
seen  of  this  method,  I am  inclined  to  judge  favourably 
of  its  merits. 

During  the  time  he  is  using  compression,  a minute 
quantity  of  a cerate  is  introduced  into  the  eye,  to 
which  Dr.  S.  attributes  great  virtues  in  almost  every 
violent  form  of  the  disease.  It  is  prepared  in  the  fol- 
lowing manner,  viz: 

Bi.  Hydarg.  oxyd.  rub.  grs.  xlv.  ; lapis  calamina- 
ris,  grs.  xxx. ; cinnabar  native,  grs.  xv. ; litharge, 
grs.  XXX  ; axungia  porc.oz.  j. ; levigate  separately  and 
mix. 

This  cerate  may,  of  course,  be  diluted  with  lard  to 
adapt  it  to  milder  cases  of  the  disease,  if  it  should  be 
thought  too  active. — Reese.] 

OSCHEOCELE.  (From  dcryceov,  the  scrotum,  and 
KnM,  a tumour.)  A hernia  which  has  descended  into 
the  scrotum. 

OSTEOSARCOMA,  or  Ostkosarcosis.  (From 
dcriov,  a bone,  and  adp\,  flesh.)  This  term  signifies 
the  change  of  a bone  into  a substance  of  the  con- 
sistence of  flesh,  or  rather  the  growth  of  a fleshy,  me- 
dullary, or  cartilaginous  mass  within  the  bone,  whereby 
at  first  an  enlargement  of  the  original  bony  cylinder  or 
shell  is  produced,  and  at  length  its  partial  absorption, 
and  sometimes  fracture.  Bones  are  sometimes  con- 
verted into  a substance,  resembling  that  of  a cancerous 
gland;  and  it  is  this  affection  to  which  Boyer  thinks 
that  the  appellation  ought  to  be  confined. 

Callisen  seems  also  to  regard  the  osteosarcosis  as  a 
disorder  by  which  the  texture  of  the  boneg  is  converted 
into  a fleshy  or  fatty  substance,  accompanied  with  a ten- 
dency to  carcinoma. — {System.  Chirurgim  Hodiernce., 
p.  204,  vol.  2.  edit.  1800.)  We  are  to  understand  by 
osteosarcoma,  says  Boyer,  an  alteration  of  the  osseous 
structure,  in  which,  after  more  or  less  distention,  the 
substance  of  the  bone  degenerates,  and  is  transformed 
into  a diversified  mass,  but  more  or  less  analogous  to 
that  of  cancer  of  the  soft  parts ; while  the  local  and 
general  symptoms  still  more  strikingly  resemble  those 
of  the  latter  disease.— (See  Traiti  des  Mai.  Ckir.  t.  3, 
p.  587.) 

According  to  this  writer,  all  the  bones  are  liable  to 
such  a disease ; but  it  has  been  more  frequently  ob- 
served in  the  bones  of  the  face,  those  of  the  base  of  the 
skull,  the  long  bones  of  the  limbs,  and  particularly  the 
ossa  innominata,  which  are  perhaps  oftener  affected 
than  any  other  bones  of  the  body. — ( Op.  cit.  p.  588.) 

Foreign  surgeons  do  not  appear  to  entertain  pre- 
cisely the  same  ideas  respecting  cancer  which  prevail 
in  England  : at  least,  they  apply  the  term  to  many  com- 
plaints in  which  there  are  no  vestiges  of  a carcinoma- 
tous structure,  and  numerous  diseases  of  an  incurable 
nature  receive  abroad  very  indiscriminately  the  name  . 
of  cancer.  Thus,  the  French  surgeons  have  not  yet 
distinguished  the  strongly  marked  differences  between 
carcinoma  and  fungus  ha’matodes. — (See  Roux,  Pa- 
rallile  do  la  Chir.  Angloise,  Src. ; and  the  article  Fun- 
gus Hmmatodes.) 


Mr.  Bell,  of  Edinburgh,  has  very  different  opinions 
of  cancer  of  the  bones  from  those  delivered  by  the  pre- 
ceding writers.  Cancer,  he  says,  seldom  occurs  in 
bone  as  a primary  affection,  but  is  in  almost  every 
case  the  re.sult  of  that  kind  of  degeneration  in  the 
neighbouring  soft  parts.  He  believes,  also,  that  it  is 
propagated  through  the  medium  of  the  cellular  tisstte, 
winch  lines  the  canals  and  cells  of  bones. — {On  Diseases 
of  Bones,  p.  146.)  In  treating  of  cancer  of  the  breast, 
I have  adverted  to  examples,  in  which  the  bones  par- 
ticipated in  the  disease.  In  the  museum  of  the  Col- 
lege of  Surgeons  at  Edinburgh,  are  two  specimens  of 
the  sternum  similarly  affected’  Mr.  Bell’s  views  of  the 
cancer  of  the  bones,  however,  do  not  correspond  to 
those  taken  by  Sir  Astley  Cooper ; and  it  is  question- 
able whether  the  morbid  change  of  a bone  in  the  vici- 
nity of  a cancerous  part  be  itself  really  malignant. 
At  all  events,  the  kind  of  caries  with  fetid  discharge, 
described  by  Mr.  Bell,  is  very  different  from  the  disease 
spoken  of  by  Sir  A.  Cooper,  where  the  peculiarity  con- 
sists in  the  deposition  of  a scirrhous  substance  into 
the  texture  of  the  bone  in  the  advanced  stage  of  car- 
cinoma. 

Fungous  diseases  in  the  antrum  expand  the  bones  of 
the  face,  make  their  way  out,  and  present  a frightful 
specimen  of  disease.  This  change  of  the  bones,  though 
known  to  li^ve  nothing  to  do  with  cancer  (see  An- 
trum), is  considered  by  Boyer  as  a kind  of  osteosar- 
coma, proceeding  ffom  carcinomatous  mischief  in  the 
neighbouring  soft  parts  ; and  this  he  adduces  as  an  ex- 
ample of  his  first  species  of  osteosarcoma,  or  that 
arising. in  consequence  of  previous  disease  in  other 
parts.  In  the  second  species,  the  disorder  commences 
in  the  bones,  and  the  soft  parts  are  secondarily  af- 
fected. In  all  cases,  osteosarcoma  comes  on  with 
deeply-seated  pain,  which  sometimes  lasts  a consider- 
able time  before  any  swelling  is  manifest.  Sometimes 
the  pain  becomes  more  and  more  afflicting,  and  of  the 
lancinating  kind,  impairing  the  health  even  before 
there  is  any  change  in  the  form  of  the  limb.  At  length 
the  swelling  takes  place,  occupying  the  whole  circum- 
ference of  the  member.  Its  nature  and  situation  are  in 
some  measure  indicated  by  its  hardness  and  depth.  It 
is  unequal  and  tuberculated,  as  it  were.  Pressure 
does  not  lessen  its  size  nor  make  the  pain  worse.  The 
soft  parts  are  still  in  their  natural  state.  The  tumour, 
however,  grows  more  or  less  rapidly,  and  the  lancina- 
ting pains  become  more  severe.  In  time,  the  soft  parts 
themselves  inflame  and  become  painful.  Sometimes 
the  skin  ulcerates,  and  in  this  very  uncommon  case  the 
sore  presents  a cancerous  appearance.  Hectic  symp- 
toms are  induced,  the  patient  gradually  loses  his 
strength,  and  at  length  falls  a victim  to  the  disease. 

The  alteration  which  the  structure  of  the  bones  un- 
dergoes in  osteosarcoma  (says  Boyer),  deserves  great 
attention.  Most  frequently,  when  the  disease  has 
made  considerable  progress,  and  the  tumour  has  ex- 
isted a long  while,  the  bony  texture  has  disappeared 
more  or  less  completely ; in  lieu  of  it,  a homogeneous, 
grayish,  yellowish,  lard-like  substance  is  found,  the 
surface  of  a slice  of  which  is  smooth,  much  like  that 
of  a very  hard  white  of  egg,  or  old  cheese,  the  con- 
sistence varying  from  that  of  cartilage  to  that  of  very 
thick  bouillie.  The  surrounding  soft  parts,  which  have 
participated  in  the  disease  of  the  bones,  are  converted 
into  a similar  matter : muscles,  tendons,  periosteum,  li- 
gaments, vessels, cellular  substance,  all  are  confounded 
in  the  same  homogeneous  mass,  and  have  undergone 
the  same  degeneration. 

In  some  examples,  the  disease  is  less  advanced; 
portions  of  the  bone  are  then  met  with  whose  texture 
and  consistence  are  nearly  natural,  and  which  are 
merely  somewhat  enlarged.  Butin  proceeding  towards 
the  centre  of  the  disease,  the  substance  of  the  bone  is 
found  softened,  and  its  consistenceless  than  that  of  car- 
tilage, still  manifestly  retaining,  however,  a fibrous 
texture  ; while,  more  deeply,  it  is  converted  into  a lard- 
like substance,  resembling  (says  Boyer)  that  of  parts 
affected  with  carcinoma.  In  these  tumours  cysts  are 
often  found  sontetimes  containing  a fetid  ichor, — some- 
times a matter  like  clear  bouillie ; atid,  in  certain  cases, 
,a  quantity  of  semi-transparent,  tremulous,  gelatinous 
matter  is  found  in  the  middle  of  the  lard  like  medul- 
lary, or  cerebral  substance.  Boyer  records  an  instance 
in  which  nearly  the  whole  humerus  was  changed  into 
a gelatinous  mass.— (See  Mai.  des  Os,  t.  1,  chap.  22.) 
From  the  variety  of  substances  found  to  contpose  dif- 


OSTEOSARCOMA. 


251 


fcvent  osteosai'comatous  swellings,  various  names  have 
been  assigned  to  them  ; as  the  cartilaginous  degenera- 
tion of  hone,  the  fleshy,  the  cystic  sarcoma,  the  en- 
cysted medullary  sarcoma,  &c. — (See  Bell  on  Bones, 
jr.  133.) 

With  the  view  of  removing  some  of  the  obscurity 
of  the  present  subject,  Dr.  Cumin,  of  Glasgow,  pro- 
poses that  the  term  osteosarcoma  should  be  limited  to  a 
degeneration  and  morbid  growth  of  the  lining  mem- 
branes of  the  longitudinal  canals,  or  cancelli  of  bones, 
accompanied  in  all  cases  by  absorption  of  the  solid  os- 
seous substance.  “ The  disease  (he  says)  is,  there- 
fore, essentially  one  of  destruction  of  the  affected  bone, 
which  is  produced  partly  by  the  pressure  of  the  en- 
larging tumour,  and  partly  by  the  diversion  of  the  fluid 
circulating  within  the  bone  to  the  support  of  this  mor- 
bid growth.  It  always  originates  within  the  peri- 
osteum, and  retains  that  as  its  investing  membrane.” 
It  is  generally  slow  in  its  progress ; and,  in  its  com- 
mencement, the  symptoms  cannot  be  readily  distin- 
guished from  those  of  chronic  rheumatism,  or  syphi- 
litic pains.  After  some  time  a tumour  is  perceived,  at 
first  firm,  hut  afterward  becoming  softer,  and,  in  certain 
cases,  communicating  to  the  surgeon’s  hand  the  feel  of 
a distinct  pulsation,  synchronous  with  that  of  the 
artery  of  the  limb,  and  capable  of  being  interrupted 
by  compressing  the  trunk' of  the  vessel.  In  time,  hectic 
f#ver,  colliquative  perspirations,  and  diarrhoea  come 
on,  and  the  patient  sinks.  Towards  the  close  of  the 
illness,  fracture  of  the  bone  at  the  affected  part  very 
commonly  takes  place  on  some  slight  e.vertion,  aggra- 
vating in  a remarkable  manner  the  patient’s  general 
distress,  hut  rather  lessening  than  increasing  the  pain 
in  the  bone,  connected  with  distention  of  its  texture. — 
{Cumin,  in  Edinb.  Med.  Journ.  JSTo.  82,  p.  13.) 

This  gentleman,  in  considering  the  question  whether 
osteosarcoma  is  of  a cancerous  nature,  expresses  his 
belief,  that  although  all  the  varieties  of  the  disease  are 
highly  formidable,  they  are  not  all  truly  cancerous. 
One  case,  which  he  has  himself  related,  he  sets  down 
as  cancerous  on  account  of  the  whole  of  the  symp- 
toms, and  “ more  especially  from  the  disease  having 
shown  itself  in  two  different  places  at  the  same  time 
which,  however,  abstractedly  considered,  is  not  a very 
good  criterion  of  cancer.  Another  case,  described  by 
him,  he  does  not  regard  as  having  exhibited  any  fea- 
tures of  the  latter  disease.  The  osteosarcoma  of  Dr. 
Cumin  is,  in  fact,  as  he  has  himself  explained,  the  fun- 
gous exostosis  of  the  medullary  membrane  of  Sir.^stley 
Cooper. — (See  Edinb.  Med.  Joum.  Mo.  82,  p.  17.) 

The  prognosis  of  this  disease  must  always  be  unfa- 
vourable ; for  it  is  equally  inctirable,  and  disposed  to 
bring  on  fatal  consequences,  whether  Boyer’s  opinion 
concerning  its  being  cancer  of  the  hones  be  true  or  not. 
This  author  notices  that,  even  after  amputation,  the 
complaint  almost  always  recurs. — (P.  591.)  The  only 
chance  of  relief,  however,  obviously  depends  upon  the 
possibility  and  success  of  the  operation.  In  the  Traite 
ties  Mai.  Chir.  t.  3,  p.  594 — 605,  Boyer  records  two 
cases  of  osteosarcoma;  one  of  the  thigh  ; the  other  of 
the  os  innominatum.  The  first  patient  was  saved  by 
amputation.  Osteosarcoma  is  the  disease  for  which 
Dr.  Mott  successfully  removed  one-half  of  the  lower 
jaw,  very  nearly  as  far  as  the  joint. — (See  American 
Med.  Recorder.)  And  Dr.  M‘Clellan,  of  Philadelphia, 
a few  years  ago,  favoured  me  with  the  particulars  of 
another  case  of  osteosarcoma  of  the  lower  jaw,  where 
the  same  opeiation  was  very  skilfully  executed. — (See 
Boyer,  Traiti  des  Maladies  Chir.  t.  3.  Haller's  Ele- 
ment. Physiol,  t.  8,  p.  2,  page  5.  S.  A.  Kulmus.  Diss. 
de  Exostosi  Steatomatode  Claviculce : Gedan.  1732. 
5.  F.  Hundertmark,  Diss.  sistens  Osteosteatomatis 
Casum rariorem ; Lips.  1752.  5.  G.  Hermann,  Diss. 

de  Osteosteatomate,  Lips.  1767.  S.  C.  Plenck,  de  Osteo- 
sarcosi ; Tub.  1781,  <Src.  B.  C Brodie,  in  Pathol,  and 
Surgical  Obs.  on  the  Joints,  p.  301.  Dr.  Cumin,  in 
Edinb.  Med.  Joum.  Jan.  1825.  B.  Bell,  on  Diseases 
of  the  Bones,  12/«o.  Edmb.  1828. 

[This  disease,  the  osteosarcom-a  of  Boyer,  and  the 
malignant  exostosis  of  Sir  .‘\stley  Cooper,  has  at- 
tracted a large  share  of  public  attention  during  the 
last  few  years,  and  especially  in  this  country,  in  con- 
sequence of  the  extensive  and  formidable  operations 
to  which  it  has  given  origin,  and  the  great  success 
which  has  attended  them. 

'The  etiology  and  pathology  of  the  disease  is  still  a 
•ubjcct  of  controversy.  By  some  it  is  viewed  as  scro- 


fulous, by  others  carcinomatous,  while  many  consider 
it  identical  with  fungus  hasinatodes.  Cases  are  re- 
ported, however,  in  which  the  disease  was  purely 
local,  without  exhibiting  any  malignant  or  specific 
character:  these,  however,  are  esteemed  by  those  who 
contend  for  its  being  always  constitutional,  as  not  be- 
longing to  the  genus  osteosarcoma.  A more  probable 
theory  is,  that  the  disease  is  generally,  if  not  always, 
local  in  its  commencement,  but  very  soon  affects  the 
constitution  secondarily  ; at  the  same  time  it  must  be 
conceded  that  it  is  seldom  found  except  in  persons  of 
depraved  habit  of  body,  either  by  age,  hardships,  ex- 
posure, or  intemperance. 

Osteosarcoma  is  almost  universally  incurable  except 
by  the  amputation  or  excision  of  the  morbid  tumour, 
atid  the  frequent  success  of  these  operations  may  be 
considered  a conclusive  argument  in  favour  of  its  local 
origin ; while  the  instances  of  the  return  of  the  dis- 
ease, not  a few  of  which  are  admitted  to  have  taken 
place  after  the  operation,  may  be  attributed  to  the  late 
period  at  which  the  knife  is  resorted  the  constitu- 
tion having  been  involved  in  the  morbid  action  by  its 
long  continuance.  In  these  cases,  it  cannot  be  ex- 
pected that  the  removal  of  the  tumour  by  the  operation 
should  always  protect  the  patient  from  a return  of  the 
disease.  ’ 

Under  the  article  Jaw-bone,  in  this  Dictionary,  I 
have  referred  to  numerous  cases  of  amputation  of  con- 
siderable portions  of  the  lower  jaw,  all  of  which,  so 
far  as  I am  informed,  were  rendered  necessary  by  this 
disease,  so  that  it  would  seem  thatitis  most  frequently 
found  in  this  bone.  Dr.  Mott  has  performed  this  ope- 
ration six  times  on  the  lower  jaw,  and  twice  taken  out 
the  bone  at  the  articulation. 

Dr.  David  L.  Rogers  of  this  city,  was  among  the  first 
in  this  country  who  removed  theupper  jaw-bone,  which 
he  did  in  a case  of  osteosarcoma  in  the  year  1824. 
This  case  is  recorded  in  the  N.  Y.  Medical  and  Phy- 
sical Journal,  vol.  3,  page  301.  It  has  since  been  very 
frequently  repeated  in  this  country  and  in  Europe. 
Dr.  Mott  has  performed  it  thirteen  times,  but,  so  far  as  I 
am  informed;  none  of  these  cases  have  as  yet  been  pub- 
lished. 

In  the  American  Journal  of  the  Medical  Sciences 
for  Nov.  1828,  a case  of  osteosarcoma  of  the  left  cla- 
vicle, in  which  exsection  of  that  bone  was  successfully 
performed  by  Dr.  Mott,  is  reported  at  length.  This  is 
the  first  and  probably  the  only  operation  of  the  kind 
ever  attempted  ; and  as  it  is  undoubtedly  the  most  dif- 
ficult and  formidable  in  ancient  or  modern  surgery,  I 
have  thought  proper  in  this  place  to  give  a descrip- 
tion of  its  performance  in  the  operator’s  own  wotds, 
he  having  politely  complied  with  my  request  in  fur- 
nishing me  his  notes  and  those  of  his  pupils  on  the  pro- 
gress of  the  case. 

The  tumour  was  of  a conical  form,  of  about  four 
inches  in  diameter  at  its  base,  and  of  an  incompressible 
hardness,  situate  on  the  anterior  portion  of  the  cla- 
vicle, to  which  it  was  firmly  attached.  The  apex  of 
the  tumour  was  covered  with  luxuriant  fungous  gra- 
nulations, the  consequence  of  escharotics  previously 
applied,  from  which  profuse  bleedings  took  place  at 
short  intervals. 

“ An  incision  was  commenced  over  the  articulation 
of  the  clavicle  with  the  sternum,  and  carried,  in  a se- 
micircular direction,  as  close  to  the  fungous  projections 
as  the  sound  integuments  would  admit  of,  until  it  ter- 
minated on  the  top  of  the  shoulder,  near  the  junction 
of  the  clavicle  with  the  acromion  process  of  the  sca- 
pula. This  incision  exposed  the  fibres  of  the  pectora- 
lis  major,  which  was  divided  as  near  the  tumour  as 
possible:  in  accomplishing  this,  as  well  as  the  first  in- 
cision, arteries  sprung  in  every  direction,  and  required 
ligatures.  A number  of  large  branches  of  veins,  under 
this  muscle,  emitted  blood  freely,  and  required  to  be 
tied. 

In  conducting  the  incision  through  the  pectoral 
muscle,  towards  the  scapular  extremity  of  the  clavicle, 
care  was  taken  to  avoid  the  cephalic  vein,  as  it  passes 
between  this  and  the  deltoid  muscle.  A small  portion 
of  the  latter  mu.scle  was  detached  from  the  clavicle, 
which  readily  allowed  the  vein  to  be  drawn  outwards 
towards  the  shoulder. 

On  attempting  to  pass  the  fore  finger  tinder  the  vein 
and  deltoid  to  the  lower  edge  of  the  clavicle,  it  was 
found  impracticable,  as  the  hard  osseous  part  of  the 
tumour  extended  beyond  this  point,  and  was  com- 


252 


OSTEOSARCOMA. 


pletely  Is  contact  with  the  coracoid  process  of  the  sca- 
pula. 

Pinning  it  impossible,  from  the  size  of  the  tumour, 
and  its  (iroximiiy  to  the  coracoid  process,  to  get  under 
the  clavicle  in  this  direction,  an  incision  was  made 
from  the  outer  edge  of  the  external  jugular  vein,  over 
the  tumour,  to  tlie  top  of  the  shoulder.  After  dividing 
the  skin,  platysma  inyoides,  arid  a portion  of  the  tra- 
pezius muscle,  a sound  part  of  the  clavicle  was  laid 
bare  at  a point  nearer  the  acromion  than  a line  with 
the  coracoid  process : a steel  director,  very  much 
curved,  was  now  cautiously  passed  under  the  bone 
from  above;  which,  from  the  firm,  bony  state  of  the 
tumour  at  this  part,  had  a considerable  obliquity  out- 
wards. Great  care  was  taken  to  keep  the  instrument 
in  close  contact  with  the  under  surface  of  the  bone. 
I'lie  depth  of  the  bone  from  the  surface  renderrd  it  some- 
what ditficull  to  accomplish  this  safely  : an  eyed- 
prolie,  similarly  curved,  conveyed  along  the  groove  of 
the  director  a chain  saw,  which,  when  moved  a little, 
showed  that  nothing  intervened  between  it  and  the 
bone;  the  clavicle  was  then  readily  sawed  through. 

The  dissection  was  now  continued  along  the  under 
sill  face  of  the  tumour,  below  the  pectoialis  major; 
here  a number  of  very  large  arteries  and  veins  re- 
quired tying.  The  first  rib  being  next  exposed  under 
the  sternal  extremity  of  the  clavicle,  the  costo  clavi- 
cular or  rhoinhoid  ligament  was  divided,  and  tne  joint 
opened  from  the  lower  part.  This  gave  considerable 
mobility  to  the  diseased  mass,  and  encouraged  us  to 
believe  that  its  complete  removal  would  be  practicable. 

By  means  of  a double  hook  and  elevator,  with  the 
assistance  of  our  strong  and  very  broad  spatulas  pro- 
perly curved,  we  were  enabled  to  elevate  a little  the 
sawed  end  of  the  clavicle.  After  loosening  the  parts 
about  it,  by  keeping  close  to  the  tumour,  we  wished  to 
discover  the  subclaviiis  muscle,  as  it  is  inserted  iii 
the  bone  about  this  situation  ; but  it  could  not  be  seen, 
as  it  was  incorporated  with  the  diseased  mass.  Had 
this  niii.scle  been  found,  the  separation  of  the  tumour 
would  have  been  much  less  difficult  and  tedious,  as, 
by  keeping  above  it,  the  subclavian  vein  is  of  course 
protected  The  origin  of  this  muscle,  from  the  cur- 
tilage of  the  first  rib,  was  seen  and  divided,  but  it  was 
almost  immediately  obliterated  in  the  tumour. 

Continuing  the  removal  of  the  tumour  at  the  upper 
and  outer  part,  the  omo-hyoideus  was  found  lying 
under  it,  which  we  exposed  from  where  it  passes 
under  the  mastoid  muscle,  to  near  its  origin  from  the 
superior  costa  of  the  scapula.  In  separating  the  tu- 
mour from  the  cellular  and  fatty  structure,  between 
the  onio  hyoid  muscle  and  the  subclavian  vessels,  a 
number  of  large  arteries  were  divided,  which  bled 
freely,  and  particularly  a large  branch  from  the  inferior 
thyroidal. 

'I'he  anterior  part  of  the  upper  incision  was  now 
made  from  the  sternal  end  of  the  clavicle,  and  carried 
over  the  tumour,  until  it  met  the  other  at  the  external 
jugular  vein.  After  cutting  through  the  pl.atysma 
inyoides,  this  vein  was  carefidly  separated  from  the 
surrounding  parts,  and  two  fine  ligatures  passed  be- 
neath it,  and  tied  a short  distance  from  each  other ; 
the  vein  was  then  cut  between  the  ligatures. 

The  clavicular  part  of  the  sterno-cleido-mastoideus 
was  next  divided,  about  three  inches  above  the  cla- 
vicle in  the  direction  of  this  incision.  The  deep- 
eealed  fascia  of  the  neck  being  now  exposed,  the  mas- 
toid muscle  and  the  diseased  mass,  were  very  cau- 
tiously separated  from  it,  until  the  anterior  scalenus 
was  exposed. 

The  subclavian  vein,  from  the  edge  of  the  scalenus 
amicus  to  the  coracoid  process,  was  so  firmly  adherent 
to  the  tumour,  as  to  lead  me  at  one  moment  to  believe 
that  the  coats  of  the  vein  were  so  intimately  involved 
in  ihe  diseased  structure,  as  to  render  the  complete  re- 
moval of  the  morbid  part  utterly  impracticable.  By 
the  most  cautious  proceeding,  however,  alternately 
with  the  handle  and  blade  of  the  knife,  we  finally  suc- 
ceeded in  detaching  the  tumour,  without  the  least  in- 
jury to  the  vein.  Tlris  part  of  the  operation  was 
attended  with  peculiar  danger  and  difficulty.  Atevery 
cut  either  an  artery  or  vein  would  spring,  and  deluge 
the  parts  until  secured  by  ligatures.  Besides  several 
large  veins,  the  external  jugular  was  so  situated  in  the 
midst -of  the  bony  mass,  as  to  require  two  more  liga- 
tures in  this  place,  near  to  the  subclavian,  and  it  was 
again  divided  in  the  interspace.  Near  the  sternal  end 


of  the  clavicle,  a large  artery  and  vein  required  tying’ 
they  were  considered  as  branches  of  the  inferior  thy 
roidal  artery  and  vein. 

From  having  cut  through  the  clavicular  portion  of 
the  mastoideus  muscle,  obliquely  upwards  and  out- 
wards a little  above  the  tumour,  we  were  enabled,  by 
turning  this  down,  and  keeping  close  to  the  fascia  pro- 
funda, to  detach  the  tumour  from  over  the  sit.naliouof 
the  thoracic  duct  and  junction  of  the  internal  jugular 
and  left  subclavian,  without  the  least  injury  to  these 
important  parts. 

To  reach  the  lower  part  of  the  tumour,  as  it  extended 
upon  the  thorax,  it  was  ttecessary  to  separate  the  pec- 
toralis  major  in  a line  with  the  fourth  rib,  and  to  make 
a transverse  incision  two  inches  in  length  through  the 
integuments  and  muscles  at  about  its  centre.  The  in- 
cision upon  the  neck  extended  from  the  sterno-clavi- 
cular  junction  in  a semicircular  direction,  to  within  an 
inch  of  the  thyroid  cartilage  and  base  of  the  lower 
jaw,  and  two  inches  from  the  lobe  of  the  ear,  and  ter- 
minated near  the  junction  of  the  clavicle  and  scapu'a. 

'I’he  fungous  and  bleeding  chaiMcier  of  the  apex  of 
the  tumour  implied  that  it  was  freely  supplied  with 
vessels.  'J'he  discharge  of  blood  was  so  free  at  every 
step  of  the  operation,  that  about  forty  ligatures  were 
ap])lied.  It  was  estimated  that  the  patient  lost  from 
sixteen  to  twenty  ounces  of  blood. 

All  the  parts  now  presenting  a healthy  appearance, 
the  ligatures  were  cut  close  to  the  knots,  and  the  cavity 
of  the  wound  filled  with  lint.  Long  strips  of  adhesive 
plaster  were  applied  to  prevent  the  edges  of  this  ex- 
tensive wound  from  farther  retracting ; a light  com- 
press, a single-headed  roller  loosely  applied  around  the 
chest  and  shoulders,  completed  the  dressing. 

He  was  placed  in  bed  upon  his  back,  inclining  a little 
to  the  right  side,  with  the  head  considerably  elevated, 
while  the  left  sJioulder  and  arm  were  supported  by  a 
pillow. 

To  the  unwearied  attentions  of  two  of  my  pufrils  I 
am  indebted  for  the  following  report  of  his  symptoms. 

June  17<A,  18*28,  7 o’clock,  p.  m.  Feels  comfortable, 
except  being  nauseated  by  the  wine  and  water  given 
him  during  the  operation,  which  he  says  generally  pro- 
duces this  effect  upon  him.  Some  reaction  is  indicated. 
Between  7 and  8 p.  m.  took  two  cups  of  gruel,  and  has 
since  vomited  a little.  9 p.m.  Pulse  110;  skin  moist 
and  cool.  He  feels  tolerably  comfortable,  and  is  much 
gratified  that  the  operation  has  been  performed.  Took 
a little  mint  tea,  which  was  grateful  to  him.  12  p.  m. 
Has  had  a short  repose ; dratik  some  mint  tea,  and  feels 
quite  comfortable;  pulse  128;  thirst  considerable. 

June  l8tA,  3 a.  m.  Has  had  a comfortable  sleep, 
during  which  there  was  considerable  hemorrhage 
from  the  wound ; pulse  120,  hard  and  full.  8 a.  m. 
Took  a cup  of  lea,  ate  a piece  of  toast,  with  a few 
strawberries;  feels  better  than  previous  to  the  opera- 
tion; pulse  124.  ,12  p.  M.  Has  slept  during  two  hours, 
and  is  now  in  a comfortable  sleep;  pulse  130;  skin 
moist  and  warm.” 

From  this  time  nothing  occurred  to  interrupt  his  re- 
covery, and  it  would  therefore  be  unnecessary  to  insert 
here  the  minutes  taken  of  the  daily  improvement 
which  was  manifest  under  the  judicious  management 
to  which  he  was  subjected.  It  will  be  sufficient  to  say 
that  the  patient  entirely  recovered,  and  has  ever  since 
enjoyed  excellent  health.  The  concluding  remarks  ac- 
companying Dr.  Mott’s  report  of  the  case,  are  perhaps 
too  important  to  be  omitted. 

“ The  tumour  is  about  the  size  of  a man’s  doubled 
fists,  or  of  a circumference  just  to  allow  me  to  grasp  it 
with  my  fingers  fully  extended.  It  consists  of  a bony 
cup,  incompreb-sibly  hard  at  all  parts,  except  supe- 
riorly and  inferiorly  to  a small  extent.  From  an  open- 
ing of  an  elliptical  shape  at  the  upper  part,  protruded 
a bleeding  fungus  of  the  size  and  shape  of  half  a hen’s 
egg.  At  the  under  surface,  as  it  lay  upon  the  great 
subclavian  vessels,  the  bony  character  is  le.ss  manifest; 
the  structure  about  the  centre  particularly  appearing 
to  be  cartilaginous  or  semi-osseous.  This  bony  en- 
largement occupies  the  clavicle  from  the  sternal  articu- 
lation to  within  half  an  inch  perhaps  of  the  acromial 
extremity.  From  the  motion  which  can  be  given  to 
each  end  of  the  clavicle,  the  natural  structure  of  the 
bone  seems  to  be  eniiiely  destroyed. 

This  operation  far  surpassed  in  ledrousness,  diffi- 
culty, and  danger,  any  thing  which  I have  ever  wit- 
nessed or  performed.  It  is  impossible  for  any  descrip- 


OVA 


OVA 


253 


tion  which  we  are  capable  of  giving,  to  convey  an  ac- 
curate idea  of  its  for;iiidable  tiature.  The  attachiiieut 
ofthenuubid  mass  to  ttie  important  stnicture  of  the 
neck  and  shoulder  of  the  left  side^  and  to  so  great  an 
extent,  is  sufficient  to  indicate  its  magnitude  and  dif- 
ficulty. 

The  extensive  nature  of  this  operation  led  us  to  take 
the  precaution  of  securing  the  external  jugular  with  a 
double  ligature,  and  dividing  it  between  them.  Though 
in  operating  upon  the  neck  we  have  several  limes  cut 
these  veins  without  any  unpleasant  consequences,  we 
however  think  we  have  witnessed  almost  fatal  eiTecis 
from  the  division  of  a large  vein,  and  the  admission 
of  air  into  the  circulation. 

The  case  of  Baron  Dnpuytren’s,  in  which  a young 
woman  suddenly  died  under  an  operation,  from  the 
division  of  a large  vein  in  the  neck,  while  he  was  en- 
gaged in  removing  a tumour,  contributed,  with  my  own 
experience,  to  make  me  take  the  precaution  of  pre- 
viously tying  the  vein  in  this  operation. 

In  an  attempt  which  I made  to  remove  the  parotid 
gland  in  an  enlarged  and  scirrhous  state,  the  facial 
vein,  where  it  passes  over  the  base  of  the  lower  jaw, 
was  opened  in  dissecting  the  integuments  from  the 
tumour,  in  tlie  early  stage  of  the  operation,  before 
a single  artery  was  tied.  At  the  instant  this  vessel 
was  opetied,  the  attention  of  all  present  was  arrested 
by  the  gurgling  noise  of  air  passing  into  some  small 
0[>ening.  The  breathing  of  the  patient  immediately 
became  difficult  and  laborious,  the  heart  beat  violently 
and  irregularly,  his  features  were  distorted,  and  con- 
vulsions of  the  whole  body  soon  followed  to  so  great 
an  extent  as  to  make  it  impossible  to  keep  him  on  the 
table.  He  lay  upon  the  floor  in  this  condition  for  near 
half  an  hour,  as  all  supposed  in  urticula  mortis.  As 
the  convulsions  gradually  left  him,  his  mouth  was 
permanently  distorted,  and  complete  hemiplegia  wa.s 
found  to  have  ensued.  An  hour  and  more  elapsed  be- 
fore he  could  articulate,  and  it  was  nearly  a whole  day 
before  he  recovered  the  use  of  his  arm  and  leg.  From 
a belief  that  these  effects  arose  from  the  admission  of 
air  into  the  blood-vessels,  which  was  not  doubled  by 
any  person  present,  I instantly  called  to  mind  a set  of 
experiments  which  I made  some  twenty  years  since 
upon  dogs,  by  blowing  air  into  the  circulation,  by  in- 
serting a blow-pipe  into  a large  superficial  vein  upon 
the  thigh,  and  was  forcibly  struck  with  the  similarity 
of  result. 

No  adverse  symptoms  of  a general  or  local  nature 
tortk  place  to  interrupt  the  process  of  granulation  in 
the  wound.  The  immense  chasm  which  was  left,  and 
such  important  parts  as  have  been  described,  only  co- 
vered with  lint,  necessarily  occasioned  me  great  solici- 
tude, until  I saw  suppuration  fully  established  and  the 
great  vessels  covered  by  granulations. 

No  difficulty  attended  keeping  his  shoulder  in  a pro- 
per position  by  the  u.se  of  the  common  apparatus  for 
fractured  clavicle.  With  this  he  walked  about  without 
any  inconvenience,  after  four  weeks  elapsed,  and  two 
inontbs  from  the  time  of  the  operation,  he  was  able  to 
discontinue  the  sling,  and  by  means  of  an  apparatus 
contrived  by  Mr.  James  Kent,  a most  ingenious  and 
inventive  artist,  to  supply  the  want  of  clavicle,  he  was 
so  fitted  as  to  have  his  shoulder  in  its  proper  position, 
at  the  same  time  that  the  full  motion  of  his  arm  was 
preserved.” — Reese.] 

[OVARIAN  TUMOUR.  The  following  highly  im- 
portant and  interesting  case,  having  been  politely  com- 
municated to  me  by  Dr.  David  L.  Rogers  of  this  city,  is 
of  so  great  practical  importance,  that  I have  concluded 
it  would  he  acceptable  to  the  profession  to  have  the 
description  of  the  operation  and  its  result  inserted 
entire.  Very  many  are  annually  falling  victims  to  this 
disease,  who  might  be  preserved  by  a similar  opera- 
tion. 

“ In  July,  1829, 1 was  requested  to  operate  on  a wo- 
man for  peritoneal  dropsy  ; after  drawing  off  the  water, 
I observed  that  the  abdomen  remained  unusually  large; 
upon  examination  I discovered  a large  tumour  occupying 
the  left  iliac  region,  and  extending  to  the  right  side. 
She  gave  the  following  history  of  its  origin  and  growth. 
Two  years  since,  in  her  passage  from  Ireland  to  this 
country,  after  being  two  weeks  at  sea,  she  had  a sup- 
pression of  the  catamenia,  which  was  soon  followed 
by  a -harp  lancinating  pain  in  the  left  iliac  region  ; 
previous  to  which,  her  health  had  always  been  good. 
On  landing,  the  pain  increased,  and  the  abdomen  began 


to  swell ; first,  on  the  left,  and  then  extending  to  the 
right ; her  stomach  became  affected,  and  although 
unmarried,  her  friends  accused  her  of  being  preg- 
nant. 

In  consequence  of  this  impression,  the  disease  was 
allowed  to  proceed  without  any  medical  advice,  until 
time  had  satisfied  her  friends  to  the  contrary,  when  a 
physician  was  called,  who  pronounced  the  disease  a 
dropsy,  and  recommended  her  to  be  lapped. 

A large  quantity  of  water  was  drawn  off,  but  in  two 
months  it  had  reaccumulated,  and  the  operation  was 
repeated  five  limes  previous  to  my  seeing  her.  It  is 
computed  that  within  the  two  years,  eighteen  gallons 
of  fluid  were  drawn  off. 

I observed  in  this  case,  what  I have  remarked  in 
several  others,  that  the  fluid  discharged  differed  from 
the  water  in  common  ascites.  It  is  much  more  muci- 
lagmous;  of  the  consistence  of  honey;  of  a milky 
colour,  and  differs  from  any  other  secretion  that  I am 
acquainted  with.  After  deliberately  examining  the 
tumour,  and  as  far  as  possible  ascertaining  its  cliaracter 
and  connexions,  I suggested  to  her  the  possibility  of  its 
being  cured  by  an  operation,  at  the  same  time  staling 
the  great  risk  of  life  attending  the  performance,  and 
the  slight  chance  of  her  recovery.  I likewi.-e  requested 
Professor  Mott,  who  was  consulted  in  this  case,  to  make 
a similar  statement.  Her  good  constitution  and  ge- 
neral health  all  urged  the  obligation  of  making  an 
attempt  to  save  her.  After  the  first  suggestion,  nothing- 
could  alter  her  determination  to  forego  the  chance  of 
relief  which  even  so  desperate  an  ope*,  ation  might  af- 
ford, and,  as  she  expressed  it,  “ I would  rather  die  than 
live  in  my  present  situation.” 

On  the  I4th  of  September,  she  was  laid  on  a table  of 
convenient  height,  and  with  a large  scalpel  I com- 
menced an  inci.<ion  a little  below  the  ensiform  cartilage, 
carrying  it  parallel  with  the  linea  alba,  and  terminating 
at  the  symphysis  pubis.  The  integuments  being  divided, 
the  dissection  was  continued  through  the  tendon  of  the 
linea  alba  to  the  peritoneum.  This  was  at  first  sup- 
posed to  be  much  thickened,  but  by  a cautious  dissection 
through  a membranous  texture  to  the  dc|)lh  of  a quarter 
of  an  inch,  the  water  gushed  out  with  considerable  (orce. 
With  a probe-pointed  bistoury,  the  opening  was  en- 
larged to  the  full  extent  of  the  external  incision,  and  to 
our  surprise  we  found  that  a sac  was  opened  which 
appeared  to  fill  the  whole  circumference  of  the  abdo- 
men, and  at  first  its  attachment  appeared  commensu- 
rate with  its  size.  It  lay  in  connexion  with  the  liver, 
stomach,  spleen,  and  bladder.  By  pulling  up  the  sac 
it  was  found  that  the  adhesions  were  much  less  than  at 
first  expected.  It  was  determined,  therefore,  to  dissect 
them  from  the  peritoneum  and  omentum  : some  of  the 
.adhesions  were  so  slight  as  to  be  separated  by  the 
finger,  others  by  the  handle  of  the  scalpel,  hut  the 
greater  part  required  to  be  separated  by  a tedious  dis- 
section, and  in  some  parts  the  adhesions  were  so  close 
that  portions  of  the  peritoneal  membrane  were  re- 
moved. These  adhesions  extended  for  three  or  four 
inches  around  the  umbilicus.  After  completing  this 
part  of  the  dissection,  the  tumour  was  drawn  out  and 
supported  by  an  assistant,  and  the  dissection  con- 
tinued : separating  it  from  the  ovarian  ligament,  which 
required  much  care,  from  the  large  and  numerous  ves- 
sels going  to  it  from  this  source:  the  laigest  was  at 
least  the  size  of  a goose-quill.  After  occupying  two 
hours  in  the  operation,  this  huge  mass  of  disease  was 
safely  removed,  and  laid  on  the  table.  The  ligatures 
were  all  cut  close  to  the  knot,  and  left  to  absorption. 
The  wound  was  closed  by  sutures,  dressed  with  ;idhe- 
sive  straps,  lint,  a compress  and  a bandage  applied 
firmly  to  the  abdomen.  I place  some  confidence  in  the 
close  application  of  a bandage,  as  it  brings  the  divided 
surfaces  in  contact  for  the  purpose  of  adhesion,  and 
likewise  as  an  important  auxiliary  in  preventing  inflam 
niation.  She  was  then  removed  to  bed  ; her  pulse  at 
this  time  was  feeble,  but  regular.  In  the  course  of  the 
evening,  considerable  reaction  came  on,  with  some 
heat  of  skin.” 

Without  pursuing  the  detail  of  the  progress  of  the 
case,  it  will  be  only  necessary  to  add  that  the  c.a.se  pro- 
gressed without  any  untoward  symptom,  and  m six 
weeks  from  the  period  of  the  operation  her  catamenia 
had  returned  and  her  health  entirely  recovered. 

“'I'he  tumour  was  composed  of  a large  sac,  which 
contained  the  fluid  drawn  off  in  different  operations 
for  lapping.  One  third  of  the  tumour  was  solid,  cou- 


254 


PAR 


PAR 


taining  a fibro-cartilaginous  substance.  It  weighed 
Uiree  and  a half  pounds. 

In  offering  this  case,  it  may  be  proper  briefly  to  sum 
up  a history  of  the  operations  for  diseased  ovaria. 
It  may  assist  others  in  forming  an  opinion  of  the  rela- 
tive chance  of  success  in  future  cases.  The  removal 
of  these  tumours  by  an  operation  had  its  advocates  in 
the  last  century ; but  the  authority  of  De  Haen  and 
Morgagni  was  raised  against  them,  as  doubtful  in  their 
results,  and  impossible  in  their  execution.  The  first 
attempt  to  remove  them  by  an  operation  was  made  in 
1776,  by  L.  Autnonier,  surgeon  in  chief  of  the  Hospital 
of  Rouen,  and  is  reported  as  a successful  case. — (See 
Good's  Study  of  Medicine^  p.  423.) 

Dr.  M'Dowel  of  Kentucky,  has  reported  three  cases 
in  which  he  operated  successfully  for  tumours  in  the 
abdomen,  ovarian,  and  hydatid.  A doubt  exists  in  re- 
lation to  these  cases ; and  certainly  the  mode  of  de- 
scribing them  is  calculated  to  confirm  that  doubt.  We 
are  bound,  however,  upon  the  authority  of  others,  to 
believe  them,  notwithstanding  the  improbabilities  con 
nected  with  their  details;  and  it  is  much  to  be  re- 
gretted that  a more  circumstantial  account  of  these 
cases  has  not  been  given  to  the  profession. — (See  Med. 
Chir.  Rev.  vot.  5,  p.  216.) 

Professor  Smith,  of  Yale  College,  has  given  an  in- 
teresting case  of  the  successful  removal  of  an  ovarian 
dropsy  by  an  operation.  The  tumour  was  small,  weigh- 
ing from  two  to  three  ounces,  and  requiring  an  inci- 
sion of  three  inches  in  length.— (See  .Mm.  Med.  Rec. 
1822.) 

In  the  London  Medical  Gazette,  for  1829,  Dr.  Hopfer, 
of  Biberback,  has  reported  three  cases  of  extirpation 
of  diseased  ovaria,  by  Carysman.  The  first  was  per- 
formed in  1819,  and  proved  fatal  in  thirty-six  hours 
after  the  operation.  The  second  in  1820.  This  case  was 
successful,  and  the  woman  has  since  borne  children. 
The  third  case  occurred  in  the  same  year,  and  never 
recovered  from  the  shock  of  the  operation.  Thus  of 
the  three  cases,  but  one  recovered. 

M.  Lizars,  in  the  Edinburgh  Journal  for  October, 
1820,  relates  an  attempt  to  extirpate  an  ovarian  tumour, 
but,  unfortunately,  on  cutting  into  the  abdomen,  he 
found  no  tumour  to  remove.  This  case  certainly  should 
not  be  included  in  the  unsuccessful  operations  for  this 
disease.  The  same  distinguished  surgeon  has  since 
reported  two  cases  of  the  operation,  but  their  results 
have  not  been  known. 

Thus  we  find  in  the  twelve  operations  that  have  been 
performed  for  the  removal  of  this  disease,  seven  have 
been  successful,  and  two  remain  doubtful.” — Reese.] 

OXYMURIATIC  ACID.  Besides  the  nitrous  and 
nitric  acids,  other  medicines,  containing  a large  propor- 
tion of  oxygen,  and  easy  of  decomposition,  have  been 
recommended  to  be  tried  as  remedies  for  the  venereal 
disease ; viz.oxygeiiated  vinegar,  oxalic  acid,  oxygenated 
muriate  of  potash,  &c.— (See  Caldwell's  Medical  The- 
sis., vol.  1,  p.  111.)  But  perhaps  nothing  has  been  put 
to  the  test  of  experiment  with  greater  expectation  of 
success  than  the  oxygenated  muriatic  acid.  Mr.  Cruick- 
shank  made  a very  early  trial  of  it  in  syphilitic  cases, 
and,  as  is  alleged,  with  the  utmost  benefit.  He  also 
employed  the  nitric  acid  and  the  oxygenated  muriate 
of  potash,  and  found  them  eligible  remedies.  The 


latter  medicine  was  likewise  given  by  M.  Alyot?-  m 
cases  of  chancre  and  secondary  ulcers,  who  found  tfie 
good  effects  from  it  more  expeditious  and  more  certain 
than  those  of  any  mercurial  preparation. — {Essai  sur 
les  Propriitis  Medicinales  de  VOxygine,  S'C.  8vo, 
Paris,  an  ’mime.)  On  the  other  hand,  as  much  contra- 
riety of  sentiment  respecting  the  real  and  permanent 
efficacy  of  all  these  medicines  prevails  in  the  nume- 
rous reports  about  them,  as  in  the  accounts  delivered 
of  the  effects  of  the  muriatic  and  nitric  acid ; and 
therefore  I do  not  think  that  the  reader,  after  the  co- 
pious statements  given  in  this  book  concerning  the 
nitric  and  nitrous  acids  (see  tAesc  zcords),  would  be 
pleased  to  hear  again  a repetition  of  very  similar  con- 
tradictions respecting  the  oxygenated  muriatic  acid, 
I may  observe,  however,  that  if  oxygen  be  the  principle 
on  which  the  eflicacy  of  many  antisyphilitic  remedies 
truly  depend,  this  acid  must  possess  greater  virtue  than 
the  common  muriatic  acid.  From  3 ss.  to  3 ij.  mixed 
in  1 viij.  of  water  sweetened  with  syrup,  may  be  taken 
in  divided  doses  in  the  course  of  the  day. 

Oxygenated  muriatic  acid  was  strongly  praised  by 
Guyton  de  Morveau,  as  a means  of  disinfecting  sick 
rooms  and  purifying  the  air  of  crowded  hospitals. 

OZASNA.  (From  a stench.)  An  ulcer  situated 
in  the  nose,  discharging  a fetid  purulent  matter,  and 
sometimes  accompanied  with  caries  of  the  bones. 
Some  authors  have  signified  by  the  term,  an  ill-con- 
ditioned ulcer  in  the  antrum.  The  first  meaning  is 
that  which  mostly  prevails.  The  disease  is  described 
as  coming  on  with  a trifling  tumefaction  and  redness 
about  the  ala  nasi,  accompanied  with  a discharge  of 
mucus,  with  which  the  nostril  becomes  obstructed. 
The  matter  gradually  assumes  the  appearance  of  pus, 
is  most  copious  in  the  morning,  and  is  sometimes  at- 
tended with  sneezing  and  a little  bleeding.  The  ulcer- 
ation occasionally  extends  around  the  ala  nasi  to  the 
cheek,  but  seldom  far  from  the  nose,  the  ala  of  which, 
also,  it  rarely  destroys.  The  ozaena  is  often  connected 
with  scrofulous  and  venereal  complaints.  In  the  latter 
cases,  portions  of  the  ossa  spongiosa  often  come  away. 
After  the  complete  cure  of  all  venereal  complaints,  an 
exfoliating  dead  piece  of  bone  will  often  keep  up  symp- 
toms similar  to  those  of  the  ozaena,  until  it  is  detached. 
Mr.  Pearson  remarks,  that  the  ozaena  frequently  occurs 
as  a symptom  of  the  cachexia  syphilcidea.  It  may 
perforate  the  septum  nasi,  destroy  the  ossa  spongiosa, 
and  even  the  ossa  nasi.  Such  mischief  is  now  more 
frequently  the  effect  of  the  cachexia  syphiloidea,  than 
of  luo6  venerea.  The  ozaena  must  not  be  confounded 
with  abscesses  in  the  upper  jaw-bone. — (See  .Mntrum.) 

The  constitutional  disease  on  which  the  ozaena  gene- 
rally depends,  and  which  acts  as  the  remote  cause, 
must  bs  relieved  before  a cure  of  the  local  effect  can 
be  expected.  The  internal  medicines  which  may  be 
necessary  are,  preparations  of  mercury  and  antimony; 
sarsaparilla,  elm,  bark,  Peruvian  bark,  muriated  ba- 
rytes, and  muriate  of  lime.  Sea  bathing  may  also  do- 
good  by  improving  the  health.  The  best  external  ap- 
plications are  said  to  be  preparations  of  copper,  zinc, 
arsenic,  mercury,  the  pulvis  sternutatories,  and  diluted 
sulphuric  acid. — (Pearson's  Principles  of  Surgery, 
chap.  12.  F.  A.  Mayer,  Commenlatio  de  Ozana,  Frank. 
Del.  op.  11.) 


P 


PANA'RTS.  (From  napd,  near,  and  dwl,  the  nail.) 
See  fVhitlow. 

P ANNUS.  When  two  or  three  pterygia  of  different 
sizes  occurred  on  the  same  eye,  with  their  points 
directed  towards  the  centre  of  the  cornea,  where  they 
met,  and  covered  all  the  surface  of  this  transparent 
membrane  with  a dense  pellicle,  the  ancients  named  the 
disease  pannus. — (Scarpa,  chap.  14.) 

PARACENTE'SIS.  (From  ixapaKcvrew,  to  perfo- 
rate.) The  operation  of  tapping  or  making  an  opening 
into  the  abdomen,  thorax,  or  bladder,  for  the  i»urpose 
of  discharging  the  fluid  confined  in  these  parts  in  cases 
of  ascites,  empyema,  hydrothorax,  and  retention  of 
urine.  Effused  blood  may  also  require  an  opening  to 


be  made  into  the  chest ; and  so  may  confined  air  in  the 
instance  of  emphysema. 

TAPPING,  OR  PARACENTKSIS  ABDOMINIS. 

When  the  swelling  extends  equally  over  the  whole 
abdomen,  the  fluid  is  usually  diffused  among  all  the 
viscera,  and  is  only  circumscribed  by  the  boundaries 
of  the  peritoneum.  The  water  is  occasionally  in- 
cluded in  different  cysts,  which  are  generally  formed 
in  one  of  the  ovaries  ; and  in  this  case,  the  tumour 
which  is  produced  is  not  so  uniform,  and  the  fluctua- 
tion not  so  distinct,  as  in  .peritoneal  dropsy,  at  least, 
while  the  disease  has  not  made  great  progress.  The 
difference  also  in  the  consistence  of  the  fluid,  may 


PARACENTESIS. 


255 


render  the  fluctuation  more  or  less  difficult  of  detection. 
When  the  water  is  contained  in  difterent  cysts,  it  is 
frequently  thick  and  gelatinous ; but  when  it  is  uni- 
formly ditfused  all  over  the  cavity  of  the  peritoneum, 
it  is  generally  thinner,  and  even  quite  limpid.  Some- 
times a considerable  number  of  hydatids  are  found 
floating  in  the  fluids.  With  regard  to  the  symptoms 
of  common  ascites,  the  disease  is  attended  with  great 
uneasiness,  from  all  kinds  of  pressure  on  the  abdomen; 
a gradual  swelling  of  this  part  of  the  body,  not  inclin- 
ing more  to  one  side  than  the  other  ; a fluctuation  per- 
ceptible when  the  surgeon  lays  his  hand  on  one  side  of 
thej-umour  and  gently  taps  on  the  opposite  side  of  it ; 
considerable  ditficuliy  of  breathing  caused  by  the  col- 
lection of  fluid  interrupting  the  action  of  the  diaphragm, 
and  obliging  the  patient  to  lie  with  his  chest  very  much 
raised ; constant  thirst,  &c.  According  to  gir  A. 
Cooper,  the  most  common  cause  of  ascites  is  disease 
of  the  liver,  which  has  the  eflect  of  impeding  the  cir 
culation  of  the  blood  in  the  vessels  of  most  of  the  other 
abdominal  viscera.  He  also  enumerates  as  other 
causes,  an  enlargement  of  the  spleen,  which  presses 
upon  and  irritates  the  peritoneum,  so  as  to  determine 
an  increased  flow  of  blood  to  it,  and  an  effusion  of  se- 
rum ; great  debility  of  the  system  induced  by  fevers  or 
mercury;  diseases  of  the  heart  and  lungs;  in  which 
cases,  the  ascites  is  generally  combined  with  hydro- 
Ihorax.— (See  Lancet^  vol.  3,  p.  2.) 

Whatever  may  be  the  efficacy  of  digitalis,  mercury, 
diuretics,  and  calomel,  elaterium,  squills,  and  other 
evacuants,  in  ascites,  they  are  rarely  of  any  service  in 
cases  of  local  and  encysted  dropsies.  When  such 
swellings  continue  to  enlarge,  notwithstanding  the 
adoption  of  a few  measures  which  will  presently  be 
suggested,  the  sooner  the  fluid  is  evacuated  the  better. 
It  is  also  well  known,  that  all  efforts  to  produce  a radical 
cure,  even  of  dropsies  which  are  not  encysted,  too  fre- 
quently fail.  I am  decidedly  of  opinion,  however, 
with  Dr.  Fothergill,  that  physicians  would  meet  with 
much  more  success  in  the  treatment  of  ascites  if  they 
were  to  recommend  paracentesis  to  be  done  sooner 
than  they  generally  do.  This  operation  is,  for  the  most 
part,  much  too  long  delayed;  and  during  a long  space, 
the  bowels  are  continually  suffering  more  and  more, 
from  the  effect  of  the  large  quantity  of  fluid  which 
oppresses  lhe;n.  What  ought  to  render  the  practice 
of  early  tapping  more  entitled  to  approbation  is,  that 
the  operation,  when  done  in  the  situation  which  will  be 
presently  advised,  is  perfectly  free  from  danger,  at- 
tended with  very  little  pain,  and  need  not  interrupt  the 
farther  trial  of  such  medicines  as  the  physician  may 
place  confidence  in.  Paracentesis  only  becomes  a se- 
rious measure  when  the  disease  has  existed  for  a great 
length  of  lime,  and  the  patient  has  been  much  weak- 
ened by  it.  Indeed,  there  seems  much  reason  to  sus- 
pect that  the  operation  should  be  done  as  soon  as  the 
tension  of  the  abdomen  and  the  fluctuation  leave  no 
doubt  concerning  the  nature  of  the  malady;  especially 
when  the  first  trials  which  have  been  made  of  internal 
remedies  seem  to  promise  no  success.  Dr.  Fothergill 
has  demonstrated  by  facts,  the  advantages  of  this  me- 
thod. On  the  commencement  of  an  ascites,  this  cele- 
brated practitioner  advises  the  trial  of  diuretics  atid 
otlier  evacuants.  He  then  adds,  that  “ if  by  a reason, 
able  perseverance  in  this  course  no  considerable  benefit 
accrues ; if  the  viscera  do  not  evidently  appear  to  be  ob- 
structed, and  unfit  for  the  purposes  of  life  ; if  the  com- 
plaints have  not  been  brought  on  by  a long  habitual  train 
of  intemperance,  and  from  which  there  seems  little  hope 
of  reclaiming  the  patient ; if  the  strength  and  time  of 
life  are  not  altogether  against  us ; I desist  from  medicine, 
except  of  the  cordial  kind,  and  let  the  disease  proceed, 
till  the  operation  become.s  safely  practicable.  When 
this  is  done,  by  the  moderate  use  of  the  warmer  diure- 
tics, chalybeates  and  bitters,  also  the  preparations  of 
squills  in  doses  below  that  point  at  which  the-stomach 
would  be  effected,  I endeavour  to  prevent  the  abdomen 
from  filling  again.”— (Jf/ed.  Obs.  avd  Inq.  vol.  A,  p. 
112.)  The  same  author  remarks,  with  regard  to  en- 
cysted dropsies,  that  tapping  sometimes  effects  a ra- 
dical cure. 

The  operation  should  not  "'only  be  performed  in  as 
early  a stage  of  the  disease  as  is  compatible  with  the 
safety  ot  the  parts  within  the  abdomen,  it  should  also  be 
repeated  as  sorin  as  the  quantity  of  fluid  accumulated 
ogam  is  sufficient  to  make  the  puncture  practicable 
without  danger.  Desault  used  to  tap  dropsical  patients 


once  a week,  and  in  many  cases,  after  he  had  performed 
the  operation  twoorthreetimes,  the  disease  was  slopped. 

However,  with  respect  to  early  tapping  in  ascites, 
one  fact,  mentioned  by  Sir  A.  Cooper  in  his  lecluies, 
ought  to  be  known,  namely,  that  dropsy  arising  from 
the  debility  caused  by  fever  or  a course  of  mercury, 
and  attended  with  diseased  liver,  spleen,  or  disorgani- 
zation of  other  important  organs,  may  ofien  be  cured  by 
medical  treatment  without  any  operation  at  all;  and 
he  therefore  disapproves  of  paracentesis  in  such  cases, 
as  long  as  the  fluid  is  not  sufficiently  copious  to  hinder 
the  risk  of  the  bowels  being  hurt  by  the  trocar.  As 
soon  as  this  risk  ceases,  however,  the  practice  seems 
commendable,  because  it  will  rather  promote  than 
retard  the  good  effect  of  any  other  means  which  may 
be  deemed  advisable.  At  the  same  time,  I ought  to 
mention  the  opinion  of  the  above  distinguished  practi- 
tioner, that  the  operation  itself  will  never  bring  about 
a cure,  except  where  the  disease  has  proceeded  from 
the  debility  left  by  some  kind  of  fever  or  the  abuse  of 
mercury. 

The  great  number  of  times  that  the  operation  has 
been  repeated  in  some  individuals  is  surprising:  for 
instance,  twenty- nine  times  {Schviucker,  fVahrneh- 
mungen,  b.  2,  p.  102) ; forty-one  {Med.  Communica- 
tions., vol.  2) ; fifty-two  {Schmucker,  vul.  cil.  p.  187)  ; 
sixty-five  {Mead) ; one  hundred  {Oallisen,  Syst.  Chir. 
Hodiernm,  vol.  2,  p.  55) ; one-hundred  and  fifty-five 
{Phil.  Trans,  vol.  69);  and  if  it  be  possible  to  credit 
Bezard,  even  six  hundred  and  sixty-five  times  upon  one 
woman  in  the  course  of  thirteen  years.  When  the  pa- 
tient died,  the  peritoneum  was  found  to  be  three  lines 
in  thickness.  The  omentum  mesentery,  and  even  the 
liver,  gall-bladder,  spleen,  pancreas,  kidneys,  and  blad- 
der, had  almost  disappeared,  a schirrous  mass  contain- 
ing pus  occupying  their  place  towards  the  right  side. — 
(See  Bulletin  de  la  SociHe  Med.  d'  Emulation,  JVo.  12, 
Dec.  1815.) 

Whenever  a considerable  quantity  of  fluid  is  sud- 
denly let  out  of  the  abdomen  by  tapping,  the  quick  re- 
moval of  the  pressure  of  the  water  off  the  large  blood- 
vessels and  viscera  may  produce  swooning,  convul- 
sions, and  even  sudden  death.  These  consequences 
led  the  ancients  to  consider  paracentesis  as  a very  dan- 
gerous operation,  and  when  they  ventured  to  perform 
it,  they  only  let  out  the  water  gradually,  and  at  intervals. 

Dr.  Mead,  after  considering  what  might  occasion  the 
bad  symptoms  resulting  from  too  sudden  an  evacuation 
of  a large  quantity  of  fluid  from  the  abdomen,  was  led 
to  try  whether  external  pressure  would  prevent  such 
consequences.  It  was  conceived,  that  in  this  way  he 
might  keep  up  the  same  degree  of  pressure  which  the 
fluid  made  on  the  viscera.  The  success  attending  some 
trials  of  this  plan  fully  justified  the  opinion  Dr.  Mead 
had  entertained  ; for  when  the  compression  is  carefully 
made,  the  whole  of  the  water  contained  in  the  abdo- 
men of  a dropsical  patient  may  be  safely  discharged  as 
quickly  as  the  surgeon  chooses.  For  this  purpose, 
however,  the  whole  abdomen  must  be  equally  com- 
pressed, the  pressure  increased  in  proportion  as  the 
evacuation  takes  place,  and  kept  up  in  the  same  de- 
gree for  several  days  afterward.  While  the  water  is 
flowing  out,  the  necessary  degree  of  pressure  is  usually 
made  with  the  sheet  which  is  put  round  the  abdomen. 
Two  assistants,  who  hold  the  ends  of  the  sheet,  gra- 
dually tighten  it,  in  proportion  as  the  fluid  is  dis- 
charged. Immediately  after  the  operation,  some  folded 
flannel,  sprinkled  with  spirit  of  wine,  is  laid  over  the 
whole  anterior  part  of  the  belly,  and  covered  with  a 
broad  linen  roller,  applied  with  due  tightness  round  the 
body.  Dr.  Monro  invented  a particular  kind  of  belt 
for  the  purpose ; but  though  it  may  be  well  adapted  to 
the  object  in  view,  it  is,  perhaps,  unnecessary,  as  the 
above  method  seems  to  answer  every  end. 

The  instrument  used  for  tapping  the  abdomen  is 
called  a trocar. — (See  Trocar.)  Of  this  there  are  se- 
veral varieties;  but  Richter  and  many  other  expe- 
rienced surgeons  give  a decided  preference  lo  the  com- 
mon trocar.  Most  of  the  modern  alterations  which 
have  been  made  in  the  construction  of  trocars  have 
only  tetided,  says  Richter,  to  render  their  employment 
more  difficult.  There  is  no  reason  for  the  ordinary 
objection,  that  the  common  trocar  cann«)t  be  intro- 
duced without  considerable  force.  If  the  part  into 
which  it  is  about  to  be  passed  be  made  tense,  very  lit- 
tle force  will  be  necessary,  especially  if  care  be  taken 
to  rotate  the  instrument  gently,  as  well  as  push  it  for- 


256 


PARACENTESIS. 


wards.  Hence,  all  the  inventions  which  have  origi- 
nated from  this  supposed  imperfection,  are  represented 
by  Ricliter  to  be  entirely  useless.  He  condemns  the 
trocar  with  a double-edged  point  as  a bad  instrument. 
The  proposal  of  Mr.  Cline,  to  make  a puncture  with  a 
lancet  fiist,  and  then  to  introduce  into  the  opening  a 
blunt-pointed  trocar  is  alleged  to  be  superfluous.  Nay, 
these  innovations  are  declared  to  be  worse  than  useless. 
A cutting  instrument  is  liable  to  injure  blood-vessels, 
and  bring  on  a weakening  degree  of  hemorrhage;  and 
it  is  said,  that  the  wound  thus  made  does  not  heal  so 
readily  as  that  made  with  a common  trocar.  That 
sharp  edged  instruments  are  attended  with  the  incon- 
venience of  being  apt  to  wound  enlarged  veins,  and 
produce  an  unpleasant  degree  of  hemorrhage,  is  a truth 
of  which  I have  myself  met  with  a convincing  exam- 
ple. A female,  who  had  a strong  aversion  to  being 
tapped  with  a trocar,  prevailed  upon  me  to  make  the 
opening  with  a lancet.  The  puncture  was  made  in 
the  liiiea  alba,  about  three  inches  below  the  navel.  A 
stream  of  daik-coloured  venous  blood  continued  to  run 
from  the  wound  the  whole  time  the  water  was  flowing 
out  of  the  cannula,  and  did  not  cease  until  a compress 
was  applied.  The  quantity  of  blood  lost  could  not  be 
less  than  a pint,  or  a pint  and  a half.  In  many  cases, 
the  loss  of  so  much  blood  would  piove  fatal  to  dropsi- 
cal patients,  and  is  what  one  must  always  feel  anxious 
to  avoid. 

The  position  commonly  selected  for  the  operation  is 
that  in  which  the  patient  sits  in  an  arm-chair.  How- 
ever, weakness  and  other  circumstances  frequently 
make  it  necessary  to  operate  on  the  patient  as  he  lies 
on  his  side  sufficiently  near  the  edge  of  the  bed;  and 
this  posture  has  one  decided  advantage,  viz.  that  it 
tends  to  prevent  the  alarming  syncope,  which  the  sud- 
den removal  of  the  pressure  of  the  fluid  from  the  dia- 
phragm and  abdominal  viscera  almost  always  brings 
on  in  the  erect  position. 

Until  of  late,  the  place  in  which  surgeons  used  to 
puncture  the  abdomen,  in  cases  of  ascites,  was  the  cen- 
tre of  a line  drawn  from  the  navel  to  the  anterior  su- 
perior spinous  process  of  the  ileum,  and  on  the  left 
side,  which  was  preferred,  in  consequence  of  the  liver 
not  being  there.  The  place  for  the  puncture  was 
usually  marked  with  ink,  and  was  supposed  to  be  al- 
ways sitnaled  just  over  a part  of  the  linea  semilunaris, 
where  there  is  no  fleshy  substance,  nor  any  large  blood- 
vessel, exposed  to  injury.  This  calculation,  however, 
was  made  without  considering  that,  in  dropsy,  the  pa- 
rietps  of  the  abdomen  do  not  yield  equally  in  every 
situation.  On  the  contrary,  it  is  known  that  the  frotit 
is  alwaj's  more  distended  than  the  lateral  parts,  and 
that  the  recti  muscles  in  particular  are  soniPtimes  very 
much  widened.  In  consequence  of  these  alterations, 
induced  by  the  disease,  no  dependence  can  be  put  on 
any  measurement  made  with  the  view  of  ascertaining 
the  precise  situation  of  the  linea  semilunaris.  Thesur- 
geon  who  trusts  to  his  being  able  to  introduce  the  trocar 
exactly  in  this  place,  from  any  calculation  of  the  above 
kind,  will  frequently  wound  a great  thickness  of  mus- 
cle, instead  of  a part  where  the  abdominal  parietes  are 
thiimesit.  But  a still  stronger  objection  is  to  be  urged 
against  the  practice  of  attempting  to  tap  in  the  linea 
semilunari-^.  Men  well  acquainted  with  anatomy 
have  frequently  been  deceived  in  their  reckoning,  and, 
instead  of  hitting  the  intended  line  with  their  trocars, 
they  have  introduced  these  instruments  through  the 
rectus  muscle,  and  wounded  the  epigastric  artery.  Pa- 
tients have  died  from  this  error  with  large  extravasa- 
tions of  blood  in  the  cavity  of  the  peritoneum.  In  a 
dropsical  person  who  has  been  tapped,  it  is  to  be  ob- 
served also,  that  an  eflfusion  of  blood  in  the  abdomen 
will  of  course  more  readily  take  place,  in  consequence 
of  the  parts  not  being  in  the  same  close,  compact  state 
in  which  they  are  in  the  healthy  condition. 

Henceforth,  therefore,  let  every  prudent  practitioner 
abandon  the  plan  of  tapping  in  the  linea  semilunaris; 
atid  he  may  the  more  easily  make  up  his  mind  to  do 
so,  as  there  is  another  place  where  the  operation  may 
be  done  with  the  utmost  facility  and  safety.  The  linea 
alba  is  now  commonly  preferred  by  the  best  surgeons; 
because  here  no  muscular  fibres  need  be  wounded,  the 
place  ran  he  hit  with  certainty,  and  no  laige  blood- 
vessel can  be  injured.  About  the  middle  point  between 
the  navel  and  pubes,  is  as  good  a situation  for  making 
the  puncture  as  can  possibly  be  chosen.  The  surgeon 
should  introduce  the  trocar  in  a steady,  firm  manner, 


never  in  nn  incautious,  sudden  way,  lest  parts  cob* 
lained  in  the  peritoneum  should  be  rashly  wounded. 
For  the  same  reason,  immediately  the  point  of  the  tro- 
car has  entered  the  abdomen,  a itiing  always  known  at 
oticeby  the  sudden  cessation  of  resistance  to  its  passing 
inwards,  it  should  be  introduced  no  farther,  and  its 
ofiice  of  niaking  a passage  for  the  cannula  is  already 
accomplished.  The  surgeon,  consequently,  is  now  to 
take  hold  of  the  cannula  with  the  ihunih  and  :ndex 
fitiger  of  his  left  hand,  and  gently  insinuale  it  farther 
into  the  cavity  of  the  peritoneum,  while  with  his  right 
hand  he  is  to  withdraw  the  stilei.  The  fluid  now 
gushes  out,  and  regularly  as  it  escapes,  the  sheet  which 
is  round  the  patient’s  body  is  to  be  tightened.  Aft  the 
water  having  been  evacuated,  a piece  of  flannel  and  a 
roller  are  to  be  immediately  applied,  as  above  ex- 
plained, a piece  of  lint  and  soaj^plasier  having  been 
previously  applied  to  the  wound. 

It  is  not  uncommon  for  the  water  suddenly  to  stop 
long  before  the  full  quantity  is  discharged.  Sometimes 
this  happens  from  a piece  of  intestine  or  omentum  ob- 
striictitig  the  canriula.  This  kind  of  stoppage  may  be 
removed  by  just  introducitig  a probe  or  director,  and 
holding  the  portion  of  bowel  back.  Wlien  the  water 
is  viscid,  the  only  thing  we  can  do  is  to  introduce  a 
large  trocar,  if  doing  so  should  promise  to  facilitate  the 
evacuation.  Also,  when  hydatids  obstruct  the  can- 
nula, a larger  instrument  miglit  allow  them  to  escape. 
In  encysted  dnipsies,  the  practitioner  of  course  can 
only  let  the  fluid  out  of  tho.se  cavities  which  be  can 
safely  puncture.  According  to  Sir  Astley  Cooper,  the 
water  of  encysted  dropsy  is  at  first  contained,  not  in  a 
single  bag,  but  in  several,  the  partitions  between  which 
are  in  time  gradually  absorbed,  and  the  number  of  dis- 
titict  cavities  consequenily  dimitiisbed.  Hence  anotlier 
reason  why  the  fluctuation  becomes  more  evident  as 
the  disease  advances. — {Lectures,  ^c.  vol.  2,  p,  373.) 
The  fact  should  also  influence  the  surgeon  not  to  make 
too  early  a puncture,  which  con  Id  only  discharge  the  flu  id 
from  one  cyst,  while  several  others,  not  having  yet  atty 
communication  with  it,  would  remain  distended. 

The  abdomen  of  a female  was  tapped  by  Dr.  Andrew 
Buchanan  through  the  fundus  of  the  bladder,  for  which 
purpose  a tube  with  a stilet  was  introduced  by  the 
meatus  urinarius.  The  method  was  adopted  chiefly 
for  the  purpose  of  trying  what  would  be  the  result  of 
tnaintaiiiing,  in  ascites,  a communication  between  the 
cavity  of  the  peritoneum  and  that  of  the  bladder.  In 
the  case  referred  to,  the  water  was  discharged;  but 
success  did  not  attend  the  endeavour  to  keep  the  punc- 
ture in  the  fundus  of  the  bladder  open. — (^Buchanan, 
in  Glasgow  Med.  Journ.  vol.  1,  p,  195.)  It  seems  to 
me,  that  any  means  calculated  to  perpetuate  the  open- 
ing would  be  likely  to  cause  peritonitis.  The  conti- 
nuance of  an  opening  between  the  cavity  of  the  blad- 
der and  that  of  the  abdomen,  owing  to  the  irritating 
qualities  of  the  urine,  can  hardly  be  viewed  as  free 
from  .serious  risk.  There  is  an  analogy  between  this 
suggestion  and  that  rrf  Mr.  Guy  of  Chichester,  who 
proposed  leaving  the  cannula  in  the  wound,  and  occa- 
sionally letting  the  water  flow  out  after  the  ordinary 
mode  of  paracentesis;  a plan,  however,  which  is  at- 
tended with  less  risk,  and  has  sometimes  been  followed 
by  a cure. — (See  Sir  Astley  Cooper's  Lectures,  vol.  2, 
p.  383.) 

Wlien  a dropsy  of  the  ovary  is  very  large,  it  also 
admits  of  being  tapped  in  the  linea  alba;  but  in  this 
pariicniar  case,  it  is  generally  best  to  make  the  punc- 
ture where  the  swelling  is  most  prominent.  In  this 
disease,  the  ovary  is  either  converted  into  one  large 
cavity,  filled  with  fluid,  or  else  it  contains  several  dis- 
tinct cells.  Sometimes  the  cyst  consists  of  the  ineni- 
branons  covering  of  the  ovary;  sometimes  of  an  enor- 
mous hydatid.  The  contents  are  sometimes  exceed- 
ingly vi.ecid.  In  the  early  stages  of  the  case,  the  tumour 
is  situated  towards  one  side  of  the  abdomen,  just  above 
Poiipart’s  lieament,  and  seems  to  ascend  ontof  the  pel- 
vis. 'Phis  kind  of  progress  at  once  distinguishes  the 
dise.ase  from  a common  ascites,  wliicb  is  attended  from 
the  first  with  an  equal,  gradual,  universal  swelling  of 
the  abdomen.  The  magiiiimle  (which  the  disease  may 
attain)  may  be  jiidiied  of  by  the  fact,  that  twelve  or 
fifteen  gallons  of  fluid  have  sometimes  been  contained 
in  the  cavity  or  cavities  of  the  cyst.  Tlie  cyst  of  the 
ovary,  when  it  has  attained  a large  size,  generally  ad- 
heres, in  different  places,  to  the  inner  surface  of  the 
peritoneum,  and  in  tliis  state  Uie  whole  abdomen  often 


PARACENTESIS- 


257 


seems  uniformly  swollen,  in  consequence  of  the  im- 
mense magnitude  of  the  disease. — (See  G.  D.  Motz, 
De  Structurd,  Usu,  et  Morbis  Ovariorum,  Ato.  Jeum, 
1783.)  It  is  an  observation  made  by  Sir  A.  Cooper, 
that  one  of  the  principal  differences  between  ascites 
and  ovarial  dropsy,  is  that  the  latter  is  in  itself  quite  a 
local  disease,  just  like  a hydrocele.  This  observation, 
I believe,  is  perfectly  correct;  and  though  great  illness 
frequently  arises,  it  is  generally  tlie  result  of  the  pres- 
sure made  by  the  swelling  on  the  parts  within  the  ab- 
domen and  pelvis.  The  impairment  of  lire  health, 
arising  from  the  pressure  of  the  viscera  and  interruj)- 
tion  of  their  functions,  and  the  great  difficulty  of 
breathing  produced  by  the  pressure  of  the  diaphragm, 
indeed  make  it  necessary  to  let  out  the  fluid,  and  para- 
centesis must  he  done  in  the  way  already  related.  The 
disease  is  often  attended  with  an  almost  total  stoppage 
of  the  secretion  of  urine.  Sometimes  the  urine  is  duly 
secreted,  but  a retention  occurs,  so  that  the  use  of  the 
catheter  becomes  indispensable.  With  few  e.vceptions, 
tapping  can  only  be  regarded  as  a palliative  measure: 
the  water  collects  again,  the  same  grievances  recur, 
and  the  operation  must  be  repeated.  While  an  ova- 
rial  dropsy  is  recent,  and  even  after  it  has  been  tapped, 
some  attempts  may  be  made  to  effect  a radical  cure. 
But  this  is  not  to  be  done  with  mercury,  or  any  other 
medicine  yet  known.  Blistering  the  surface  of  the  ab- 
domen, keeping  up  a discharge  with  the  savine  cerate, 
and  applying  a tight  roller,  have  been  known  to  do 
good.  In  France,  the  celebrated  Le  Dran  laid  open 
the  cysts  of  ovarial  dropsies.  His  patients  did  not  die 
of  the  consequent  inflammation,  and  the  dropsy,  in- 
deed, was  cured ; but  there  remained  either  a sarco- 
matous enlargement  of  the  ovary,  which  continued  to 
increase  till  death,  or  else  incurable  fistulae,  leading 
into  the  cyst.  The  large  size  of  a wound  necessary 
for  this  purpose,  the  danger  of  inducing  inflammation 
in  so  extensive  a surface  as  the  cyst  of  a large  ovarial 
drop.sy,  and  the  events  of  Le  Dran’s  cases,  are  circum- 
stances, on  tlie  whole,  which  ought  to  keep  the  practice 
from  ever  being  revived. 

A still  more  absurd  plan  has  been  attempted,  viz.  to 
cure  the  disease  by  injections  like  hydroceles.  I for- 
merly saw  two  cases  in  which  port  wine  and  water 
were  injected  by  the  late  Mr.  Ramsden  of  St.  Bartho- 
lomew’s Hospital:  one  patient  died  very  soon  after- 
ward of  inflammation,  and  the  other  perished  more 
lingeringly  from  the  same  cause.  Setons  liave  been 
tried  without  success. 

In  the  American  Recorder,  a case  is  published,  in 
which  a cure  was  effected  by  the  excision  of  the  sac. 
Dr.  N.  Smith  also  performed  such  an  operation  with 
success:  after  exposing  the  tumour  by  an  incision,  and 
discharging  seven  pints  of  a daik,  ropy  fluid  with  a 
trocar,  lie  extracted  the  whole  cyst,  and  the  patient  re- 
covered.— (See  Edin.  Med.  and  Surg.  Jonrn.  Wo.  73.) 
The  sac  brought  out  with  it  a considerable  portion  of 
adherent  omentum,  which  required  to  be  separated 
with  the  knife,  and  two  bleeding  vessels  were  tied. 
I'he  omentum  was  then  reduced,  and  the  adhesions  of 
the  sac  to  one  point  of  the  parietes  of  the  abdomen 
also  separated  partly  with  the  scalpel  and  partly  with 
the  finger.  These  few  particulars  show,  that  though 
the  operation  may  be  practicable,  and  even  end  well,  it 
is  liable  to  great  difficulties  in  its  execution,  and  dan- 
gerous and  fatal  consequences  in  its  result.  In  fact, 
one  surgeon,  mentioned  by  Sir  A.  Cooper,  who  began 
an  operation  of  this  kind,  was  prevented  by  the  extent 
of  the  adhesions  from  completing  it.  Whenever  the 
attempt  is  made,  it  ought  to  be  while  the  cyst  is  of  mo- 
derate size.  An  instance  in  which  the  operation  was 
attempted  while  the  disease  did  not  exist,  has  been 
fairly  and  candidly  laid  before  the  public  by  M.  Lizars, 
with  other  interesting  observations  and  cases  in  favour 
of  the  practice  of  extiipating  dLseased  ovaries. — 
{Edinb.  Med.  Surg.  .TotLm.  Wo.  81.) 

An  example  is  mentioned  by  Dr.  Granville,  in  wliich 
several  encysted  tumours  of  the  right  ovarium  (one  as 
large  as  a full  grown  foetus’s  head)  were  discharged, 
with  a collection  of  matter,  through  an  ulcerated  oi)eti- 
ing  in  the  parietes  of  the  abdomen.— (See  Med.  Phys. 
Journal,  .Tune,  1822.) 

Sir  A.  Cooper  has  known  several  examples  of  the 
spontaneous  cure  of  ovarian  dropsy.  In  one  case,  the 
fluid  was  fora  long  lime  voided  through  an  ulcerated 
opening  at  the  umbilicus.  He  has  also  known  the 
water  to  he  discharged  by  tite  Fallopian  tube;  and  he  1 

VoL.  If.— R 


attended  a lady  in  whom  an  ovarian  cyst  buret  into 
the  intestinal  canal : for  several  years  afterward  she 
was  subject  to  occasional  returns  of  the  disease,  but 
ultimately  recovered. — ^Lectures,  vol.2,  p.  384.) 

PARACENTESIS  OF  THE  THORAX. 

The  necessity  for  this  operation  is  indicated  when 
the  heart  or  lungs  are  oppressed  by  atiy  kind  of  fluid 
confined  in  the  cavity  of  the  chest.  Every  bijdy  knows 
that  the  free  and  uninterrupted  performance  of  the 
functions  of  these  organs  is  essential  to  the  support  of 
life.  When  their  action  is  perilously  disturbed  by  the 
lodgement  of  fluid  in  the  thorax,  no  internal  medicines 
can  be  much  depended  upon  for  procuring  relief.  The 
only  means  from  wfliich  benefit  can  be  rationally  ex- 
pected, is  letting  out  the  fluid  by  making  an  opening  in 
the  parietes  of  the  chest. 

The  nature  of  the  effused  fluid  can  make  no  differ- 
ence in  regard  to  the  propriety  of  discharging  it  in  this 
manner;  and  though  some  authors  describe  this  ope- 
ration as  only  applicable  to  cases  of  hj'drops  pectoris 
and  empyema,  it  may  also  be  of  the  greatest  service 
when  air  is  confined  in  the  chest  (see  Emphysema),  or 
blood  extravasated  there  (see  Wounds  of  the  Thorax), 
so  as  to  make  dangerous  pressure  on  the  lungs  and  dia- 
phragm. The  case  in  which  it  is  least  likely  to  be  fol- 
lowed by  a perfect  recovery  is  hydrothorax;  arid  Sir 
A.  Cooler,  in  his  vast  experience,  has  not  known  more 
than  one  operation  performed  for  it,  whiqh  proved  un- 
successful. This  he  considers  by  no  means  surprising, 
as  the  collection  of  fluid  is  the  eflect  of  disease  of  the 
thoracic  viscera,  the  heart,  or  lungs,  &c. — (^Lectures, 
vol.  2,  p.  385.)  A case  of  success,  however,  is  men- 
tioned in  the  references  at  the  enil  of  the  present  arti- 
cle; and  in  the  Berlin  Med.  Trans,  a case  is  recorded, 
in  which  a cure  was  effected  by  an  accidental  wound 
of  the  chest,  by  which  the  whole  of  the  water  escaped 
at  once. — {.Met.  Med.  Berol,  t.  x,  dec.  1,  p.  44.) 

The  idiopathic  form  of  hydrothorax,  or  that  case  in 
which  it  constitutes  the  original  disease,  is  set  down 
by  Laennec  as  very  rare.  He  has  often  known  hyper- 
trophy of  the  heart,  aneurism  of  the  aorta,  irregular 
consumption,  and  even  schirrhus  of  the  stomach  or 
liver  mistaken  for  this  disorder,  when  there  was  no  co- 
existing effusion  in  the  pleura,  or  at  least  none  excejrt 
what  took  place  immediately  before  death.  Sym|>- 
tomaiic  hydrothorax,  he  admits,  is  very  frequent. — 
(On  Diseases  of  the  Chest,  p.  484,  ed.  2.)  In  this 
work,  the  learnt  translator  Dr.  Forbes  recommends 
the  use  of  the  stethdscope  for  discriminating  diseases 
of  the  heart  from  hydrothorax,  as  the  means  adapted 
to  the  relief  of  droiisy  of  the  chest  would  be  useless 
with  regard  to  them. 

In  this  place  I shall  content  myself  with  describing 
the  best  method  of  performing  paracentesis  thoracis, 
referring  the  reader  to  the  above  articles  and  the  valua- 
ble vvoik  of  Laennec,  for  the  particular  symptoms  and 
circumstances  which  may  render  the  operation  proper, 
and  the  rest  of  the  surgical  treatment  peculiar  to  each 
affection. 

The  safest  and  most  convenient  situation  for  making 
an  opening  into  the  chest,  is  between  the  sixth  and 
seventh  true  ribs,  on  either  side,  as  circumstances  may 
render  necessary.  The  surgeon  should  always  recol- 
lect, that  the  two  cavities  of  the  pleura  are  completely 
distinct  from  each  other  and  have  no  communication 
whatsoever;  so  that  if  fluid  were  contained  on  the 
left  side  of  the  thorax,  making  an  opening  into  the 
right  cavity  would  not  serve  fur  discharging  the  accu- 
mulated matter.  The  practitioner  should  also  remem- 
ber, that  when  there  is  a fluid  on  both  sides  of  the 
chest,  paracentesis  must  never  be  done  for  the  relief 
of  the  two  collections  at  the  same  time ; because  there 
is  great  reason  to  believe,  that,  as  the  lungs  on  one  side 
usually  collapse  when  there  is  a free  communication 
between  the  air  and  inside  of  the  thorax,  they  would 
do  so  on  both  sides  were  an  opening  made  at  the  same 
time  into  each  bag  of  the  jileura.  !l  is  hardly  neces- 
sary to  remark,  that  in  this  condition  the  patient  could 
not  bieathe.  and  would  die  suffocated.  The  operation 
consists  in  making  an  incision,  about  two  inches  lone, 
through  the  inlegnnients  which  cover  the  space  be- 
tween the  sixth  and  seventh  true  ribs,  just  where  the 
indigitatioiis  of  the  serratus  major  amicus  muscle  meet 
those  of  the  externus  obliquus.  Here  it  is  uniiecessjiry 
to  divide  any  muscular  tihres  excejit  those  of  the  inter- 
1 costal  muscles,  and,  by  jniUiug  the  patient  in  a proper 


258 


PAR 


posture,  the  opening  that  is  to  be  made  will  be  depend; 
ing  enough  for  any  purpose  whatsoever.  The  surgeon, 
avoiding  the  lower  edge  of  the  upper  rib  where  the 
intercostal  artery  lies,  is  then  cautiously  to  divide  the 
layers  of  the  intercostal  muscles  till  he  brings  the 
pleura  into  view,  when  this  membrane  is  to  be  very 
carefully  divided  with  a lancet.  The  instrument  should 
never  be  introduced  deeply,  lest  the  lungs  be  injured. 
The  size  of  the  opening  in  the  pleura  should  never 
be  larger  than  necessary.  The  discharge  of  blood  and 
matter  will  of  course  require  a freer  aperture  than  that 
of  air  or  water.  If  requisite,  a cannula  may  be  intro- 
duced into  the  wound,  for  the  purpose  of  facilitating 
the  evacuation  of  the  fluid  ; and  it  may  even  in  some 
cases  be  proper  to  let  this  instrument  remain  in  the 
part,  in  order  to  let  the  water  or  pus  escape  as  often  as 
another  accumulation  takes  place.  It  is  obvious,  how- 
ever, that  a cannula,  for  this  object,  should  only  be  just 
long  enough  to  enter  the  cavity  of  the  pleura,  and 
should  have  a broad  rim  to  keep  it  from  slipping  into 
the  chest.  A piece  of  sticking-plaster  would  easily  fix 
the  cannula,  which  might  be  stopped  up  with  a cork  or 
any  other  convenient  thing,  or  left  open,  according  as 
the  circumstances  of  the  case  and  the  judgment  of  the 
surgeon  should  direct. 

Paracentesis  of  the  abdomen,  and  that  of  the  thorax, 
are  described  in  all  treatises  on  the  operations  and 
systems  of  surgery.  The  works  of  Sharp,  Le  Dr  an, 
Bertrandi,  Callisen,  Richter,  Sabatier,  Larrey,  and 
Boyer,  are  particularly  deserving  attention.  A case 
in  which  eleven  pints  of  a fluid,  resembling  whey,  were 
discharged  from  the  chest  by  paracentesis,  and  the  pa- 
tient recovered,  is  detailed  by  Dr.  Archer  in  the  Trans, 
of  the  King's  and  Queen's  Colleges  of  Physicians  in 
Ireland,  vol.  1,  art.  1.  Jackson,  in  Philadelphia  Jour- 
nal of  the  Med.  Sciences,  vol.  ].  JVew  Series,  p.  119; 
operation  performed  in  a Case  of  Effusion.  Ji".  Fried- 
reich, Voriiige  dcs  B anchstiches  in  der  Bauchwasser- 
sucht,  12mo.  Wiufj,b.  181G,  1817.  Laennec  on  Diseases 
of  the  Chest,  ed.  2,  by  Forbes.  Oood's  Study  of  Medi- 
cine, vol.  5,  ed.  3. 

For  an  account  of  the  paracentesis  of  the  bladder 
refer  to  Bladder,  Puncture  of.  Consult  also  Emphy- 
sema, Empyema,  and  Wounds  of  the  Thorax. 

P.\RAPHYMO'SIS,  or  Paraphimosis.  (From  irapu, 
back,  and  (pipdo),  to  bridle.)  This  signifies  the  case  in 
which  the  prepuce  is  drawn  quite  behind  the  glans 
penis  and  cannot  be  brought  forward  again.  See  Phy- 
niosis,  with  which  it  will  be  considered. 

PARONY'CHIA.  (From  napd,  near,  and  Hvvl,  the 
nail.)  An  abscess  at  the  end  of  the  finger  near  the 
nail.  See  Wkitloio. 

PAROTID  DUCT.  Every  one  acquainted  with 
anatomy  is  aware,  that  behind  the  jaw,  on  each  side, 
a large  conglomerate  gland  is  situated,  the  principal  of 
such  as  are  destined  to  secrete  the  saliva  with  which 
the  cavity  of  the  mouth,  and  the  food  which  we  swal- 
low, are  continually  moistened.  The  parotid  duct 
crosses  the  cheek,  being  situated  about  one-third  from 
the  zygoma,  and  two-thirds  from  the  basis  of  the  jaw. 
After  passing  over  the  masseter  muscle,  it  pierces  the 
buccinator,  and  terminates  in  the  mouth  by  a con- 
siderable orifice,  opposite  the  space  between  the 
second  and  third  bicuspid  grinders  of  the  upper  jaw. 
As  soon  as  it  has  passed  the  masseter,  it  dives  deeply 
into  the  fat  of  the  cheek,  and,  as  Rl.  Louis  observes, 
makes  an  angle  before  it  opens  into  the  mouth. — 
{Mem.  de  I'Acad.  de  Chir.  t.  3,  p.457.) 

On  account  of  its  situation,  the  parotid  duct  is  liable 
to  be  wounded,  and  this  has  even  been  done  with  the 
surgeon’s  lancet  through  ignorance. — (See  Monro's 
Works,  p.  520.)  In  cases  of  this  kind,  the  continual 
escape  of  saliva  may  prevent  the  wound  from  healing, 
and  what  is  called  a salivary  fistula  would  be  the  per- 
petual consequence  if  no  steps  were  taken  to  afford  re- 
lief. The  parotid  duct  has  sometimes  been  ruptured 
by  blows. — {(Euvres  Chir.  de  Desault,  t.  2,  p.  221.) 
Cases  also  occur,  in  which  the  face  becomes  considera- 
bly swollen,  in  consequence  of  the  saliva  insinuating 
itself  into  the  cellular  substance,  just  as  air  does  in 
em|)hysema.  Respecting  the  last  circumstance,  I shall 
only  just  mention,  that  mischief  of  this  kind  may 
always  be  pi  evented  from  becoming  very  extensive, 
by  making  a depending  opening  for  the  ready  escape 
of  the  fluid. 

With  regard  to  the  treatment  of  salivary  fistula:,  if 
t!ie  division  of  the  parotid  duct  is  recent,  the  sides  of 


PAR 

the  wound  should  be  brought  into  contact,  and  a 
steady  pressure  maintained  on  that  nart  of  the  cheek 
by  means  of  suitable  compresses  and  a roller.  In  this 
manner  a salivary  fistula  may  often  be  prevented  alto- 
gether ; either  the  divided  ends  of  the  duct  reunite,  and 
the  spittle  resumes  its  original  course  into  the  mouth ; 
or  what  is  more  probable,  the  wound  in  the  face  heals 
at  every  part,  with  the  exception  of  a small  fistulous 
track,  which  serves  as  a continuation  of  the  duct  into 
the  cavity  of  the  mouth.  The  latter  kind  of  cure, 
however,  can  only  take  place  when  the  wound  extends 
quite  through  the  cheek ; but  the  chance  of  the  twa 
portions  of  the  duct  uniting  and  becoming  continuous 
again,  should  always  be  taken  in  recent  cases. 

When  a salivary  fistula  is  actually  formed,  a seton 
introduced  from  the  external  fistulous  orifice  into  the 
mouth,  is  a method  which  has  justly  received  consider 
able  approbation.  RIonro  adopted  it  with  success  : he 
kept  in  the  seton  till  the  channel  which  it  had  formed 
had  become  fistulous,  after  which  it  was  withdrawn: 
the  external  orifice  being  touched  with  the  argentum 
nitratum  healed  up,  and  the  saliva  in  future  flowed 
through  the  artificial  fistulous  channel  into  the  mouth. 

Desault  used  to  practise  the  seton  as  follows  : he  in- 
troduced two  fingers  of  his  left  hand  into  the  patient’s 
mouth,  and  placing  them  between  the  teeth  and  the 
cheek,  opposite  the  fistula,  thus  kept  the  integuments 
tense,  and  the  gums  from  being  injured.  He  then  in- 
troduced a small  hydrocele  trocar  with  its  cannula  just 
before  the  opening  of  the  posterior  part  of  the  duct,  and 
pushed  it  through  the  cheek  in  a direction  a little  in- 
clined forward.  An  assistant  now  took  hold  of  the 
cannula,  while  Desault  withdrew  the  perforator,  and 
passed  through  the  tube  a bit  of  thread  into  the  cavity 
of  the  mouth.  The  cannula  was  then  taken  out,  and 
a seton,  which  was  then  fastened  to  the  end  of  the 
thread  in  the  mouth,  was  drawn  from  within  outwards ; 
but  not  so  far  as  to  come  between  the  edges  of  the  ex- 
ternal opening,  where  the  thread  alone  lodged,  and 
this  was  fastened  with  sticking-plaster  to  the  outside  of 
the  cheek.  The  outer  wound  w'as  dressed  with  lint 
and  compresses.  Desault  used  to  change  the  seton 
daily,  introducing  regularly  rather  a larger  one,  and 
taking  especial  care  not  to  bring  it  between  the  edges  of 
the  wound,  which  was  afterward  covered  with  stick- 
ing-plaster. He  enjoined  the  patient  not  to  move  the 
jaw  much,  and  only  allowed  him,  for  some  time,  liquid 
food.  In  about  six  weeks  he  used  to  omit  the  seton, 
leaving  in  the  thread,  however,  fora  little  while  longer. 
This  being  taken  away,  he  used  to  fiiiish  the  cure,  by 
touching  the  little  aperture  remaining  with  caustic. 

The  making  of  an  artificial  passage  is  one  of  the 
most  ancient  plans  of  curing  salivary  fistula;.  Every 
author  has  had  his  particular  method  of  doing  it,  and 
numerous  variations  are  to  be  met  with,  either  in  the 
instrument  employed  for  piercing  the  cheek,  or  in  the 
substance  intended  for  maintaining  the  opening.  For 
the  first  step  of  the  operation,  surgeons  sometimes  used 
the  actual  cautery,  as  Saviard  furnishes  us  an  instance 
of;  sometimes  an  awl,  as  RIonro  did;  sometimes  a 
common  knife  or  lancet;  sometimes  a straight  needle, 
which  drew  in  the  thread  after  it ; but  Desault’s  trocar 
is  to  be  preferred  to  such  means,  because  the  cannula, 
by  remaining  in  the  wound  after  the  perforator  is  with- 
drawn, allows  the  thread  to  be  introduced,  which  in 
every  other  way  is  either  difficult  to  accomplish,  or  re- 
quires the  use  of  several  instruments. 

For  the  second  step  of  the  operation,  viz.  keeping  the 
opening  distended,  cannula;  were  employed  by  Duplie- 
nix,  who  used  to  make  a suture  over  them  ; a plan  ob- 
jectionable, inasmuch  as  it  was  attended  with  the  in- 
convenience of  a solid  body  left  in  the  parts,  and  also 
that  of  the  instrument  being  apt  to  slip  into  the  mouth. 
RI.  Reclard  lately  cured  a salivary  fistula  by  the  forma- 
tion of  a new  passage  at  the  inside  of  the  cheek,  by 
moans  of  a leaden  style,  which  was  made  to  reach  the 
excretory  duct,  at  the  point  where  its  continuation  was 
interrupted.  The  outer  opening  was  then  made  a fresh 
bleeding  vvound,  and  united  with  the  twisted  suture. 
This  is  the  second  example  of  the  succe.ss  of  the  me- 
thod in  the  hands  of  this  able  practitioner.  When  the 
case  will  admit  of  the  employment  of  the  twisted  su- 
ture, Bedard’s  plan  is  a good  one,  because  tlie  cure 
will  be  more  speedily  eft'ected  by  it  than  the  seion. 
(See  Monro's  Works.  (Euvrc.s  Chir.  de  Desault,  par 
Bichat.  1.  2,  ;».221.  Also  Mem.  ae  I'Acad.  de  Chir.  t. 
3.  B S.ebold,  Dies  sistens  Hisloriam  Systematis 


PAR 


PEiN 


259 


Salivalis  physiulogice  ct  pathologice  considerati,  fol. 
Jen<B,  1797.  Bedard,  in  Archives  Oen.  de  Med.  Jain, 
1823.) 

PAROTID  GLAND,  EXTIRPATION  OF.— (See 
Tumours.) 

[This  organ  was  successfully  removed  in  1826  by  Dr. 
Piieger,  on  account  of  a carcinomatous  affection  of  it. 
The  mass  taken  out  weighed  two  pounds  and  three 
quarters.  The  patient,  a woman  35  years  of  age,  com- 
pletely recovered.  The  operation  was  finished  in  seven 
minutes.  About  16  or  18  ounces  of  blood  were  lost. 
The  large  arteries  were  tied  as  soon  as  divided  ; viz. 
the  auricular,  the  external  maxillary,  and  the  blanches 
of  the  external  carotid  distributed  to  the  gland  itself. — 
(See  Journ.  fiir  Chirurg.,  Src.,  herausgeben  von  D.  L. 
Graefe,  <S-c.,  D.  P.  F.  Walther,  b.  2,  st.  3.)— Pre/.] 

[For  the  Ibllowing  remarks  on  the  extirpation  of  the 
parotid  gland,  I am  indebted  chiefly  to  Dr.  Gross’s  edi- 
tion of  “ Tavernier’s  Operative  Surgery,”  and  the  New- 
York  Medical  and  Physical  Joutnal ; never  having 
witnessed  the  operation  myself.  Indeed,  until  entire 
success  had  attended  the  operation  in  Europe,  and 
again  in  Philadelphia,  I confess  myself  to  have  been 
among  those  who  doubted  the  practicability  of  the  ope- 
ration, atid  very  much  questioned  the  fact  of  its  having 
ever  been  removed.  It  is  well  known,  that  Allan  Burns, 
Boyer,  Richeratid,  and  other  distinguished  surgeons, 
have  all  expressed  themselves  strongly  against  the  pos- 
sibility of  this  operation.  But  the  paper  of  M.  Pillet, 
of  Lyons,  sustained  before  the  Medical  Faculty  of  Paris 
in  1828,  has  fully  established  the  possibility  of  the  ope- 
ration, and  he  has  cited  a number  of  successful  cases. 

To  deny  that  the  parotid  gland  has  ever  been  exlir- 
pated,  would  be  to  impeach  the  veracity  of  some  of 
the  most  skilful  anatomists  and  surgeons  who  adorn  the 
present  age.  That  the  operation  is  dangerous  and  dif- 
ficult of  execution,  no  one  will  presume  to  dispute;  but 
to  assert  that  it  cannot  be  performed,  is  not  only  absurd, 
but  altogether  incompatible  with  the  present  state  of 
surgery.  Can  it  be  supposed  that  such  men  as  Bedard 
and  Sir  Astley  Cooper,  whose  names  are  known  in 
every  part  of  the  world  where  medicine  is  cultivated 
as  a science,  would  be  guilty  of  publishing  cases  which 
never  had  any  existence  1 Those  who  will  candidly 
examine  the  cases  on  record,  will  be  convinced,  not 
only  that  the  operation  is  practicable,  but  that  it  has 
been  actually  performed. 

In  the  year  1823,  Professor  Bedard  performed  this 
operation.  This  patient  died  a few  days  afterward, 
and  it  was  readily  ascertained  that  the  surgeon  was  not 
deceived.  The  year  following  it  was  repeated  by  M. 
Gensoul,  and  a second  time  in  1828,  successfully  in  both 
instances.  Without  referring  to  the  numerous  cases 
reported,  in  relation  to  some  of  which  there  is  room  to 
doubt,  I will  only  mention  the  cases  of  Goodlad,  Car- 
michael, Lisfranc,  Manfredini,Idrae,  Kirby,  Sir  Astley 
Cooper,  the  two  cases  of  Professor  M‘Clellan  of  Phila- 
delphia, and  a case  within  a few  weeks  by  Professor 
Busheof  New-York,  in  all  which  there  is  no  possibility 
of  doubt,  but"  the  whole  parotid  gland  was  removed  by 
the  knife,  and  in  most  of  them  with  entire  success. 

The  conclusions  drawn  from  this  mass  of  testimony 
are  these ; viz.  1st,  That  the  parotid,  in  a scirrhous 
state,  can  be  entirely  extirpated ; 2d,  that  the  carotid 
and  its  larger  branches  are  necessarily  implicated  in  the 
operation  ; and,  3dly,  that  it  is  impossible  to  spare  the 
fascial  nerve,  and  therefore  that  paralysis  is  an  inevita- 
ble ctmsequence. 

With  regard  to  the  propriety  of  securing  the  carotid 
before  commencing  the  operation,  it  is  worthy  of  re- 
mark, that  Mr.  Goodlad’s  case  was  the  only  one  in 
which  it  was  performed.  In  MM.  Bedard’s,  Ijisfranc’s, 
Gensoul’s,  Carmichael’s,  one  of  M'Clellan’s,  and 
P.nshe’.*",  it  was  tied  during  the  operation,  while  in  Dr. 
Prieger’s,  Mr.  Kilby’s,  and  one  of  Dr.  M'Clellan’s,  the 
trunk  of  the  external  carotid  was  left  untouched.  Al- 
though it  may  bo  a measure  of  security,  yet  there  is  no 
urgent  reason  why  it  should  precede  the  removal  of 
the  parotid,  and  there  must  bo  many  cases  in  which, 
from  the  size  of  tumour,  it  would  be  impracticable. 

It  is  not  generally  known,  and  though  strictly  true, 
it  will  he  very  reluctantly  admitted,  that  this  operation 
was  first  performed  in  this  country.  Professor  Samuel 
White,  of  Hudson,  successfully  extirpated  the  whole 
of  the  parotid  for  a scirrhous  tumour  as  early  as  the 
year  1808,  and  although  the  case  was  soon  after  pub- 
lished, and  the  patient  has  been  frequently  examined 


since  by  the  most  distinguished  surgeons  ol  the  state, 
all  of  w'hom  satisfied  themselves  that  the  whole  of  the 
gland  is  removed,  yet  it  will  be  found  that  the  opera- 
tion was  not  subsequently  attempted  in  Europe  until 
1823,  nor  in  America  until  1826.  Dr.  White  is  now 
professor  of  surgery,  jointly  with  his  son,  in  the  Berk- 
shire Medical  Institution,  to  both  of  whom  I have  had 
occasion  to  refer  in  my  notes  of  American  surgery. — 
Reese.] 

PARU'LIS.  (Prom  rapd,  near,  and  ovAov,  the  gum.) 
An  inflammation,  boil,  or  abscess  in  the  gums. 

PENIS,  AMPUTATION  OF.  No  part  of  the  penis 
should  ever  be  amputated,  on  account  of  a mortifica- 
tion, because  the  dead  portion  will  be  naturally  thrown 
off,  and  the  ulcer  heal,  without  the  least  occasion  for 
putting  the  patient  to  any  pain  by  the  employment  of 
the  knife.  Some  cancerous  and  fungous  diseases  are 
the  cases  in  which  it  is  often  really  proper  and  neces- 
sary to  amputate  more  or  less  of  this  organ. 

However,  before  a surgeon  ventures  to  do  the  opera* 
tion.  Tie  ought  to  be  certain  that  it  is  the  substance  of 
the  penis  which  is  incurably  diseased ; for,  as  that  ju- 
dicious surgeon,  Callisen,  remarks,  tumours,  excres- 
cences, ulcers,  and  gangrenous  mischief  of  the  prepuce, 
sometimes  present  appearances  which  may  lead  an  in- 
experienced practitioner  to  fancy  the  whole  thickness 
of  the  part  afl'ecled  with  irremediable  disorder,  while 
the  glans  is  actually  in  a sound  state.  Hence,  when 
ever  the  least  doubt  exists,  it  is  better  to  remove  first 
the  prepuce  and  skin,  in  order  that  the  true  condition 
of  the  glansimay  be  detected. — (Systema  Chirurgiee 
IJodierncB,  pars  posterior,  p.  420.  Hafnia,  1800.) 

The  old  surgeons,  fearful  of  hemorrhage,  used  some- 
times to  extirpate  a part  of  the  penis,  by  tying  ligatures 
round  it  with  sufficient  tightness  to  make  it  mortify 
and  slough  off.  Thus  Ruysch  once  performed  the  ope- 
ration.— (See  Obs.  30.)  The  plan,  however,  is  exceed- 
ingly painful,  and,  notwithstanding  the  authority  of 
Heister,  has  been  most  properly  rejected  from  modarn 
surgery. 

The  amputation  may  be  done  in  the  following  man* 
ner; — A circular  incision  is  to  be  made  through  the 
skin,  about  a finger-breadth  from  the  cancerous  part. 
As  Callisen  observes,  it  is  hardly  ever  requisite  to  draw 
the  skin  back  before  it  is  cut ; because,  after  the  cor- 
pora cavernosa  are  divided,  they  retract  so  consider- 
ably, that  there  is  always  a sufficiency  of  the  integu- 
ments.— (,Syst.  Chir.  Hodiernce,  pars  posterior,  p.421.) 
As  soon,  therefore,  as  the  circular  incision  through  the 
skin  has  been  made,  the  corpora  cavernosa  and  urethra 
are  to  be  cut  through,  by  one  stroke  of  the  knife,  on  a 
level  with  the  cut  edges  of  the  integuments.  Sabatier 
even  advises  us  to  draw  the  skin  towards  the  glans 
penis,  before  we  employ  the  knife  ; so  convinced  is  he 
of  the  inutility  of  saving  any  of  it,  and  of  the  inconve- 
niences which  may  result  from  its  lying  over  and  ob- 
structing the  orifice  of  the  urethra.  His  mode  of  ope- 
rating is  also  particularly  simple,  as  he  cuts  through 
the  integuments  and  penis  together  by  one  stroke  of 
the  knife,  without  making  any  preliminary  circular 
division  of  the  skin.  {Medecine  Opiratoire,  t.  3,  p.  305, 
edit.  2.) 

The  bleeding  arteries  are  now  to  be  immediately 
tied  : the  chief  are,  one  on  the  dorsum  of  the  penis,  and 
one  in  each  corpus  cavernosum.  When-  a general 
oozing  from  the  wound  still  continues,  some  recom- 
mend ( White,  Hey,  Src.)  applying  sponge  to  its  surface ; 
others  (Latta)  finely-scraped  agaric,  with  a small  pro- 
portion of  pounded  white  sugar,  or  gum-arabic.  Per- 
haps, however,  finely-scraped  lint  supported  with  com- 
presses would  be  quite  as  effectual  as  any  styptics, 
and  certainly,  the  latter  applications  should  be  avoided, 
if  possible,  because  stimulating  and  productive  of  pain 
and  inflammation.  A surer  and  preferable  method  of 
stopping  the  oozing  of  blood,  and  at  the  same  of  heal- 
ing the  wound,  might  be  to  bring  the  skin  forwards  over 
the  end  of  the  stump,  with  two  strips  of  sticking- 
plaster,  after  introducing  a flexible  gum  catheter  into 
the  continuation  of  the  urethra,  so  as  to  keep  its  orifice 
unobstructed,  and  the  urine  from  coming  into  contact 
with  the  wound.  There  can  be  little  doubt,  that  the 
gum  catheter  would  be  better  than  a silver  one,  or  any 
metallic  cannula,  commonly  advised  for  the  above 
{Uirposes,  because  it  lies  in  tlie  passage  with  le.ss  irrita- 
tion. It  is  but  justice  to  Callisen  to  slate,  that  he  seems 
to  be  one  of  the  few  good  surgii  al  wi iters  who  have 
particularly  recommended  in  the.se  cases  the  elastic 


260 


PEN 


PHY 


gum  catheter,  in  preference  to  that  made  of  sifver. — 
(Op.  cit.p.  421.)  The  French  method  of  fixing  the 
catheter  in  the  urethra  is  an  excellent  one,  and  has 
been  described  in  the  article  Catheter.  In  oiie  case  in 
which  Mr.  Hey  operated,  he  made  a longitudinal  divi- 
sion of  the  integuments  at  the  inferior  part  of  the  penis, 
so  as  to  make  them  cover  its  extremity  without  pucker- 
ing, or  lying  over  the  orifice  of  the  urethra.  The  cor- 
pora cavernosa,  however,  do  not  readily  granulate,  and 
unite  to  the  skin  by  the  first  intention.— p.  452.) 
After  the  first  dre.*sings  have  been  removed,  the  part 
should  be  dressed  with  the  unguentum  cetaceum. 

In  consequence  of  the  introduction  of  a cannula  be- 
ing neglected,  Le  Dran  saw  the  orifice  of  the  urethra 
close  a few  hours  after  the  operation,  so  that  the  pa- 
tient could  not  make  water.  The  orifice  of  the  passage 
could  not  be  discovered  without  great  difficulty.  A 
lancet  being  introduced  at  the  point  against  which  the 
urine  seemed  to  be  forced,  a quantity  of  it  gushed  out, 
and,  as  a cannula  was  not  at  hand,  a sound  was  intro- 
duced till  one  could  be  procured. — {Traiti  desVpcr. 
de  Chirurgie.) 

Mr.  Pearson  advises  the  skin  riot  to  be  drawn  back, 
because,  when  saved  in  this  manner,  it  impedes  the 
free  exit  of  the  urine.  He  also  disapproves  of  intro- 
ducing cannulae,  as  painful  and  unnecessary  {On  Can- 
cerous Complaints.,  p.  103) ; but  Le  Bran’s  experience, 
and  that  of  the  best  modern  practitioners,  will  not  jus- 
tify the  latter  statement. 

When  the  penis  is  amputated  near  the  mibes,  the  re- 
mainder shrinks  under  that  bone  and  wiftin  the  inte- 
guments so  far,  that  it  is  difficult  to  tie  the  arteries.  In 
order  to  obviate  this  inconvenience,  Schreger  recom- 
mends the  skin  to  be  drawn  forw'ards  and  fixed  with  a 
band ; then  an  incision  to  be  made  just  deep  enough  to 
divide  the  dorsal  arteries,  whicti  are  to  be  tied  before 
the  knife  is  used  again.  The  incision  is  then  to  be 
continued  perpendicularly  till  the  tw’o  arteries  of  the 
corpora  cavernosa  are  cut.  These  are  now  to  be  tied. 
Then  the  corpus  spongiosum  and  its  two  arteries  are  to 
be  cut  through,  which  last  are  to  be  secured.  Lastly, 
the  rest  of  the  skin  of  the  penis  is  to  be  divided.  In 
this  way  Schreger  amputated  a diseased  penis,  of 
which  only  a part,  about  an  inch  in  length,  was  sound. 

Sharp,  Le  Dran,  Bertrandi,  Sabatier,  and  C.  Bell’s 
books  on  the  operations,  may  he  consulted.  Hey's  Prac- 
tical Obs.  in  Surgery,  p.  445.  Pearson  on  Cancerous 
Complaints,  p.  103,  ij-c.  Warner's  Cases  in  Surgery, 
p.  278,  ed.  4.  E.  C.  Biever,  De  Extirpatiune  Penis 
per  Ligaturam,  4to.  l.ips.  1816.  Roux,  Voyage  d 
Londres,  Src.  fait  en  1814.  Wadd,  Cases  of  Dis,  of 
the  Prepuce  and  Scrotum.  J.  H.  Thnut,  Diss.  de 
Virg(B  Virilis  Statu  savo  et  morb.  ejasdem  imprimis 
Jlmputaiione.  B.  G.  Schreger' s Chir.  Versuche: 
J^Teue  Methode  den  Ptrnis  zu  Jlmputiren,  b.  1,  p.  242, 
8vo.  iN'urnberg.  1801. 

PENIS,  CANCER  OF.  A wart  or  a tubercle  on 
tlie  prepuce,  the  fra-num,  or  the  glans  penis,  is  generally 
the  first  symptom,  and  it  often  remains  in  a quiefstate 
for  many  years.  When  irritated,  however,  it  becomes 
painful,  and  enlarges,  sometimes  enormously,  in  a very 
short  time.  At  the  same  time,  ulceration  and  a dis- 
charge of  sanious  fetid  matter  take  place.  The  dis- 
ease sometimes  also  occasions  in  the  urethra  fistulous 
openings,  crut  of  which  the  urine  escapes,  and  the  lym- 
phatic glands  in  the  groin  may  become  affected  as  the 
disease  advances.  Mr.  Pearson  says,  that  “ cancerous 
excrescences  have  a broad  base,  often  more  extensive 
than  their  superficies  ; they  seem  to  germinate  deeply 
from  within,  or  rather  to  be  a continuation  of  the  sub- 
stance of  the  part;  and,  in  their  progressive  state,  the 
contiguous  surface  has  a morbid  appearance.”  What 
he  considers  as  a venereal  wart,  has  a basis  smaller 
than  its  surface;  its  roots  have  rather  a superficial  at- 
tachment, and  the  contiguous  parts  have  a natural  ap- 
pearance.—^?. 97.)  Such  are  this  gentleman’s  marks 
of  discrimination.  We  might  question,  however,  wtie- 
ther  Mr.  Pearson,  notwithstanding  his  great  opportu- 
nities, ever  saw  a really  venereal  wart.  For  many 
years  I never  saw  any  excrescences  of  this  kind  in  St. 
Bartholomew’s  Hospital  which  truly  required  mercury 
for  their  cure,  or  which,  when  cured  without  it,  were 
followed  bv  any  mconvenience.  If  my  memory  does 
not  fail  me*,  Mr.  Abernethy  also  disbelieves  in  the  doc- 
trine of  venereal  warts. 

Foul,  spreading,  sloughy  tilcers  of  the  penis  should 
be  discriminated  from  cancer;  and  likewise  diseases 


produced  and  kept  up  by  local  irritation  of  the  prepuce. 
(See  Earle's  Obs.  in  Med.  Chir.  Trans,  vol.  12,  p.  287, 
<Vc.)  It  is  worthy  of  attention,  that  almost  all  the  cases 
of  cancer  of  the  penis  recorded  by  Mr.  Hey  were  at- 
tended with  a congenital  phymosis.  The  same  com- 
plication also  existed  in  another  example,  in  which 
Boyer  performed  amputation  of  the  penis  in  La  Charity 
on  account  of  a cancerous  aflfection  of  the  part.  In  the 
only  two  opportunities  of  doing  this  operation  which 
M.  Roux  has  had,  the  cases  were  likewise  accompanied 
with  a natural  phymosis.  Hence  this  author  considers 
such  a slate  of  the  prepuce  particularly  conducive  to 
cancer  of  the  penis,  and  earnestly  enjoins  surgeons  to 
recommend  their  patients  to  have  the  first  inconve- 
nience rectified,  so  that  no  risk  of  the  other  more 
serious  affection  may  be  encountered. — (See  Parallcle 
dela  Chirurgie  Jingloise,  ^-c.  p.  306,  307.)  In  two  out 
of  three  cases  which  were  reported  to  be  cancerous,  and 
for  which  ampulatioti  was  done  under  my  notice,  it  did 
not  appear  that  any  degree  of  phymosis  existed. — (See 
Pearson  on  Cancerous  Complaints.  Hey's  Practical 
Obs.  in  Surgery.  Roux,  Voyage  fait  en  Angkterre 
en  1814,  ou  Parallele  de  la  Chir.  Jingloise,  Sec.  p.  .306.) 

PERINiE'UM,  FISTULA  OF.— (See  Fistulec  in 
Per  in  (SO.) 

PE'RNIO.  (From  rr/pva,  or  rrrfjwa,  the  heel.)  A chil- 
blain, especially  one  on  the  heel. — (See  Chilblain.) 

PESSARY.  (From  ntoau),  to  soften.)  The  inten- 
tion of  pessaries,  among  the  old  practitioners,  was  to 
keep  medicinal  substances  applied  within  the  pudenda. 
They  are  now  never  made  use  of,  except  for  preventing 
a prolapsus  of  the  uterus  or  vagina,  or  for  keeping  up 
a very  uncommon  kind  of  rupture,  explained  in  the  ar- 
ticle Hernia. 

PHAGED./E'NA.  (From  ^dyw,  to  eat.)  An  ulcer 
which  spreads,  and,  as  it  were,  eats  away  the  flesh» 
Hence  the  Q\n\i\ei phagedenic,  so  common  among  suit 
geons.  For  an  account  of  i\\%  phagedana  gangreeno- 
sa,  see  Hospital  Gangrene. 

PHARYNGO'TOMY.  {From  cpdpvyX,  the  pharynx, 
and  riproy,  to  cut.) — (See  (Esophagutomy.) 

PH  ARYNGO'TOMUS.  (From  didpvy(,  the  throat, 
and  Topy,  an  incision.)  An  instrutnent  for  scarifying 
tlie  tonsils,  and  for  opening  abscesses  about  the  fauces. 
It  was  invented  by  Petit,  and  is  nothing  more  Chan  a 
sort  of  lancet,  enclosed  in  a sheath.  By  means  of  a 
spring,  the  point  is  capable  of  darting  out  to  a determi- 
nate extent,  so  as  to  make  the  necessary  wound,  with- 
out risk  of  injuring  other  parts. 

PHLEBO  TOMY.  (From  a vain,  and  r/pvw, 
to  cut.)  'Phe  operation  of  opening  a vein  for  the  pur- 
pose of  taking  away  blood. — (See  Bleedins'.) 

PHLE'GMON.  (From  i^Afyw,  to  burn.)  Heallhjr 
inflammation. — (See  Inflammatiun.) 

PHLOGO'SIS-  (From  ^Aoyew,  to  inflame.)  An  in- 
flammation. A flusiiing. 

PHRENl'TIS.  (From  0pfv£s,  the  diaphragm,  sup- 
posed by  the  ancients  to  be  the  seat  of  the  mind.)  An 
inflammation  of  the  brain.  Phrensy. 

Inflammation  of  the  brain  is  a frequent  Consequence 
of  injuries  of  the  head.  The  general  symptoms  are, 
an  increased  and  disordered  state  of  the  sensibility 
of  the  whole  nervous  system  : the  retina  cannot  bear 
the  usual  stimulus  of  light;  the  pupils  are  contracted  ;. 
the  pulse  is  frequent  and  small;  the  eyes  are  red 
and  turgid,  and  the  iris  sometimes  actually  inflamed: 

( Wardrop,  Essays  on  the  Morbid  Jinat.  of  the.  Eye,voL 
2) ; the  countenance  is  flushed,  and  the  patient  is  rest- 
less, mutters  iircoherently,  and  grows  w ild  and  delirious. 
The  symptoms,  however,  are  very  much  modified  by 
the  degree,  extent,  and  stage  of  the  disorder.  Whoever 
wishes  to  have  a scientific  conception  of  tlie  subject, 
ought  to  consult  Abercrombie’s  excellent  work,  entitled, 
Pathological  and  Practical  Researches  on  Diseases  of 
the  Brain,  p.  5,  8vo.  Edin.  1828. 

Phrenilis  is  treated  on  the  antiphlogistic  plan.  Co- 
pious bleedings  and  other  evacuations  are  highly  pro- 
per. Blood  should  be  taken  from  Uie  temporal  arteries, 
or  by  cupping  the  temples.  The  skin  ought  to  be  kept 
moist  with  aniimonials,  and  after  free  bleeding  and 
purging,  counter-irritation  should  be  excited  on  the  scalp 
with  blisters. 

PIIY'MA.  (From  Aaw,  to  grow.)  Tubercles  compre- 
hend eight  genera,  ana  we  learn  from  Dr.  Bateman,  that 
under  the  genus  phyma,  the  late  Dr.  lYillan  intended 
to  comprise  the  termintlius,  the  epinyctis,  the  furuncu- 
lus,  and  tlie  carbuncle. — (See  Bateman's  Synopsis  of 


PHYMOSIS. 


261 


CutaneoKS  Diseases,  p 270,  edit.  3.)  According  to 
Pott,  this  term  was  formerly  applied  to  an  inflaimnalion 
■near  the  anus. — (See  jSnus,  .Abscesses  of.) 

PHYMO'SIS,  or  rather  Pijimosis.  (From  <pipdg,  a 
muzzle.)  A case  in  which  tlie  prepuce  camioi  be 
drawn  back,  so  as  to  uncover  the  glans  penis.  It  is  of 
two  kinds,  viz.  accidental.^  and  natural  or  congenital. 
Both  the  accidental  phyinosis  and  paraphymosis,  ac- 
'cording  to  Mr.  Hunter,  arise  from  a thickening  of  the 
cellular  membrane  of  the  prepuce,  in  consequence  of 
an  irritation,  capable  of  producing  considerable  and 
diffused  inflammation.  A chancre  is  a frequent  cause ; 
but  a mere  inflatmuation  and  discharge  from  the  glans 
and  prepuce,  and  also  a gonorrhoea,  may  bring  on  these 
affections.  The  inflammation  often  runs  high,  and  is 
frequently  of  the  erysipelatous  kind.  The  cellular 
membrane  being  loose,  the  tumefaction  becomes  consi- 
derable; and  the  end  of  the  prepuce  being  a depend- 
ing part,  the  serum  often  lodges  in  it,  and  makes  it  cede- 
inatous.  A congenital  contraction  of  the  aperture  of 
the  prepuce  is  very  common,  and  persons  so  aft'ected 
have  a natural  and  constant  phymosis.  Such  a state 
of  parts  (says  Mr.  Hunter)  isoften  attended  with  chan- 
cres, and  u produces  very  great  inconveniences  during 
the  treatment.  When  there  is  considerable  diffused 
inflammation,  a diseased  phymosis,  similar  to  the  natu- 
ral one,  unavoidably  follows;  and,  whether  diseased  or 
natural,  it  may  produce  a paraphymosis,  simply  by  the 
prepuce  being  brought  back  upon  the  penis.  This 
light  part  then  acting  a» a ligature  round  the  body  of 
the  penis,  behind  the  glans,  retards  the  circulation  be- 
yond the  constriction,  so  as  to  produce  an  cedematous 
'inflammation  on  the  inverted  part  of  the  prepuce. 

When  the  prepuce  is  very  long,  phymosis  may  also 
arise  from  the  swelling  of  the  glans  penis,  produced  by 
sores  on  the  latter  part,  or  the  irritation  of  a sevete 
gonorrhoea. — {Travers,  in  Surgical  Essays,  part  1,  p. 
132.)  My  own  observations  lead  me  to  consider  an  ir- 
ritation and  swelling  of  the  prepuce  itself  as  by  far  the 
most  common  causes  of  the  accidental  phymosis. 

In  some  children,  the  natural  or  congenital  phymosis 
is  so  considerable,  that  the  urine  cannot  pass  with  ease ; 
•but  the  aperture  of  the  prepuce  generally  becomes 
larger  :!S  they  grow  older,  and  the  bad  consequences 
which  the  phymosis  might  have  occasioned  in  disease 
are  thus  avoided. 

In  certain  individuals,  especially  old  men,  the  pre- 
puce sometimes  contracts  without  any  visible  cause 
whatever,  and  becomes  so  narrow  as  to  hinder  the  wa- 
ter from  getting  out,  even  after  it  has  passed  out  of  the 
urethra,  and,  consequently,  the  whole  cavity  of  the 
prepuce  becomes  filled  with  urine,  attended  with  great 
pain. 

In  phymosis,  when  the  prepuce  swells  and  thickens, 
more  and  more  of  the  skin  of  the  penis  is  drawn  for- 
wards over  the  glans,  and  the  latter  part  becomes  at 
the  same  time  pushed  backwards  by  the  swelling 
against  its  end.  From  such  a cause,  Mr.  lluiuer  has 
seen  the  prepuce  projecting  more  than  three  inches  be- 
yond the  glans,  with  its  aperture  much  diminished. 

Mr.  Hunter  also  notices,  that  the  prepuce  olteii  be- 
comes, in  some  degree,  inverted,  by  the  innerskin  yield- 
ing njore  than  the  outer,  and  the  part  seems  to  have  a 
kind  of  neck,  where  the  outer  skin  naturally  termi- 
nates. From  the  tightness  and  distention  of  the  parts, 
the  prepuce  now  cannot  be  drawn  more  back,  so  as  to 
e.Tpose  any  sores  which  may  be  situated  under  it.  'J'his 
state  is  frequently  productive  of  bad  consequences,  es- 
pecially when  there  are  chancres  behind  the  glans;  for 
the  glans  being  between  the  orifice  of  the  prepuce  and 
the  sores,  the  matter  sometimes  cannot  get  a passage  f<)r- 
wards,  between  the  glans  and  prepuce,  and,  conse- 
quently, it  accumulates  behind  the  corona  gJandis  so  as 
to  fopm  a kind  of  abscess,  which  produces  ulceration 
on  the  inside  of  the  prepuce.  This  abscess  bursts  ex- 
ternally, and  the  glans  often  protruding  through  the 
opening,  the  whole  prepuce  becomes  thrown  towards 
the  opposite  .«ide,  and  the  {renis  seems  to  have  two  ter- 
minations. On  the  other  hand  (says  Mr  Hunter),  if 
the  prepuce  is  loose  and  wide,  and  is  either  accustomed 
to  be  kept  back  in  its  sound  state,  or  is  pulled  back 
to  admit  of  the  chancres  being  dressed,  and  is  allowed 
to  remain  in  this  situation  till  the  above  tumefaction 
takes  place,  the  case  is  then  named  a paraphymo.iis. 
A 1-0,  '.'  hen  the  prejiuce  is  pulled  forcibly  back,  after  it 
i-  swell!  d,  it  is  then  brought  from  the  state  of  a phy- 
inosis to  iluit  of  a paiaphyniosis.  'J’he  latter  case  is 


often  attended  with  worse  symptoms  than  the  former, 
especially  when  it  has  first  been  a phymosis.  Accord- 
ing to  Mr.  Hunter,  the  reason  of  this  is,  that  the  aper- 
ture of  the  prepuce  is  naturally  less  elastic  than  any 
other  part  of  it;  therefore,  when  the  prepuce  is  pulled 
back  upon  the  body  of  the  penis,  that  part  grasps  it 
more  tightly  than  any  other  portion  of  the  skin  of  the 
penis,  and  more  so,  accordmg  to  the  inflammatioiL 
Hence,  there  are  two  swellings  of  the  prepuce ; one 
close  to  the  glans,  the  other  behind  the  stricture.  The 
constriction  is  often  so  great  as  to  interrupt  the  circu- 
lation beyond  it.  This  increases  the  swelling,  adds  to 
the  stricture,  and  olten  produces  a mortification  of  the 
prepuce  itself,  by  which  means  the  whole  diseased  part, 
together  with  the  stricture,  is  sometimes  removed,  form- 
ing, as  Hunter  ably  expresses  himself,  a natural  cute. 
In  many  cases,  the  skin  and  prepuce  are  not  the  only 
parts  affected;  adhesions  and  even  mortifications  may 
also  take  place  in  the  glans,  corpora  cavernosa,  &;c. — 
(See  Hunter  on  the  Veneral  Disease,  p.^^2\,  <S-c.) 

An  accidental  phymosis  should  always  be  prevented 
if  possible,  and  therefore,  says  Mr.  Hunter,  upoti  the 
least  signs  of  a thickening  of  the  prepuce,  which  is 
known  by  its  being  retracted  with  difficulty  and  pain, 
the  patient  should  be  kept  quiet ; if  in  bed,  so  much 
the  better,  in  a horizontal  position,  the  end  of  the 
penis  will  not  be  so  depending.  If  confinement  in  bed 
cannot  be  complied  with,  the  end  of  the  penis  should 
be  kept  up,  though  this  can  hardly  be  done  when  the 
patient  is  walking  about.  The  object  of  this  plan  is  to 
keep  the  extravasaied  fluids  from  gravitating  to  the 
piepuce,  which  they  would  hinder  from  being  drawn 
back  again  even  more  than  the  inflammation  itself. 

When  phymosis  is  recent,  and  attended  with  swell- 
ing of  the  glans  or  prepuce  from  inflammation,  Mr. 
n’ravers  recommends  injections  of  tepid  water,  or  pnilk 
and  water,  beneath  the  foreskin  ; and  the  immersion  of 
the  penis,  three  or  four  limes  a day,  in  a tepid  bath, 
keeping  the  end  of  the  penis  upwards;  and  the  use  of 
leeches;  which,  I think  with  him  and  other  writers  (see 
Diet,  des  Sciences  Med.  t.  41,  p.  334),  should  never  be 
put  exactly  on  the  swelled  prepuce  itself.  As  the  in- 
flammation subsides,  injections  of  weak  goulard,  or  the 
solution  of  alum,  or  liquor  calcis  and  calomel,  may  be 
substituted. — {Travers,  Surgical  Essays,  part  1,  p. 
138.)  Instead  of  warm  applications,  some  practition- 
ers prefer  cold ; and  it  is  yet  an  unsettled  question  which 
remedies  answer  best. 

When  the  inflammation  is  of  longer  standing,  Uie 
swelling  compresses  the  urethra,  and  there  is  tendettcy 
to  abscess,  ulceration  of  the  latter  passage,  extravasa- 
tion of  urine,  and  gangrene  of  the  skin,  Mr.  Travers 
advises  the  employment  of  emollient  poultices  and  fo- 
mentations (the  common  practice,  I believe),  and  the 
introduction  of  a small  elastic  gum  catheter  into  the 
bladder.  “ This  (says  he)  is  not  a practice  indicated  by 
the  degree  of  stricture,  which  is  seldom  considerable 
enough  to  require  it;  but  by  the  approaching  danger  of 
extravasation.  It  should  not  therefore  be  taken  up,  un- 
less the  cellular  membrane  of  the  penis  has  advanced  to 
suppuration." 

As  when  there  are  sores  they  cannot  be  dressed  in 
the  common  way,  injections  must  frequently  be  thrown 
under  the  prepuce,  or  the  operation  for  phymosis  per- 
formed. Mr.  Hunter  advises  mercurial  injections; 
either  crude  mercury,  rubbed  down  with  a thick  solu- 
tion of  gum  arabic ; or  calomel  with  the  same,  and  a 
proportion  of  opium  ; or  else  a solution  of  one  grain  of 
the  oxymuriate  of  merctiry  in  one  ounce  of  water.  Mr. 
Hunter  also  recommends  the  application  of  emollient 
poultices,  with  laudanum  in  them,  and  to  let  the  part, 
previously  to  the  application  being  ntade,  hang  over 
the  steam  of  hot  water,  with  a little  vinegar  and  spirit 
of  wine  in  it. 

When,  in  a case  of  phymosis,  chancres  bleed,  Mr. 
Hunter  recommends  the  oil  of  turpentine  as  the  be.«t 
stimulus  for  making  the  vessels  contract ; but  when  the 
hemorrhage  proceeds  from  irritation,  he  recommends 
sedatives.  Whatever  is  used,  he  says,  must  be  in- 
jected under  the  prepuce.  Under  such  circumstances 
it  has  always  been  a rule  with  me  to  avoid  irritating 
tipplicaiions,  and  on  this  account  I have  never  u.sod 
turpentine,  particularly  as  any  troublesome  bleeding 
from  chancres  may  always  be  effectually  checked  b3' 
covering  the  penis  with  linen  kept  wet  with  very  cold 
water.  WIntn  the  inflammation  has  abated,  Mr.  Jlun- 
ler  advises  moving  the  prepuce  occasionally,  so  as  to 


262 


PHYMOSIS. 


prevent  its  becoming  adherent  to  the  glans.  He  says 
he  has  seen  the  opening  of  the  prepuce  so  much  con- 
tracted, from  the  internal  ulcers  healing  and  uniting, 
that  there  was  hardly  any  passage  for  the  water.  If 
the  passage  in  the  prepuce,  so  contracted,  be  in  a direct 
line  with  the  orifice  of  the  urethra,  a bougie  must  be 
used.  If  otherwise,  the  operation  of  slitting  up,  or  re- 
moving part  of  the  prepuce,  becomes  necessary. 

When  matter  is  confined  under  the  prepuce  in  the 
manner  above  described,  Mr.  Hunter  recommends  lay- 
ing the  prepuce  open  from  the  external  orifice  to  the 
bottom,  where  the  matter  lies  as  in  a sinus  or  fistula. 
However,  he  thinks  the  performance  of  this  operation 
for  the  mere  purpose  of  applying  dressings  unneces- 
sary, as  the  sores  may  be  washed  with  injections  by 
means  of  a syringe. 

I happened  to  serve  my  apprenticeship  at  St.  Bar- 
tholomew’s at  a time  when  the  fashion  of  cutting 
every  phymosis,  infiamed  or  not,  was  far  loo  common  ; 
and  I had  abundant  opportunities  of  witnessing  the  ir- 
reparable gangrenous  mischief  frequently  thus  pro- 
duced. It  gives  me  pleasure,  therefore,  to  find  this  vil- 
lanous  practice  justly  disapproved  of  by  a modern 
writer.  “ It  is  not  advisable  (says  Mr.  Travers)  to  cut 
the  inflamed  prepuce,  nor  indeed  any  inflamed  part. 
I lately  saw  a phymosis  induced  by  a thickened  and 
rigid  state  of  the  membrane  of  the  prepuce  during  the 
free  use  of  mercury,  constitutionally  and  locally,  for 
the  cure  of  two  sores,  each  of  the  size  of  a split  pea, 
situated  one  on  each  side  of  the  anterior  fold  of  the 
prepuce.  It  was  the  opinion  of  an  eminent  surgeon, 
that  those  sores,  which  were  thoroughly  intractable, 
would  not  heal  unless  the  prepuce  was  freely  divided; 
and  impressed  with  the  same  idea,  after  poulticing  for 
some  days,  I slit  it  up.  The  sores  immediately  healed; 
but  the  wound  as  ([uickly  assumed  the  same  indolent 
and  intractable  character  which  had  belonged  to  the 
sores,  and  was  so  slow  in  healing  that  it  seemed  to  be 
only  a transfer  of  thedisease  from  one  part  to  another.” 
— (P.  139.)  I have  not  only  witnessed  the  same  fact, 
in  several  cases  under  the  late  Mr.  Ramsden,  and  in  St. 
Bartholomew’s  Hospital,  but  have  seen  mortification 
brought  on  by  the  still  more  rash  practice  of  cutting 
Ihe  prepuce,  either  when  the  part  was  in  a state  of 
acute  inflammation,  or  there  were  ulcers  within  it, 
when  the  constitution  was  in  a reduced  and  very  dis- 
ordered state  from  the  injudicious  and  immoderate  use 
of  mercury. 

The  common  operation  for  the  cure  of  phymosis 
consists  in  slitting  open  the  prepuce  nearly  its  whole 
length  in  the  direction  of  the  penis.  This  plan  is  cer- 
tainly the  most  eligible  when  the  matter  of  a chancre 
cannot  escape  from  under  the  prepuce;  because  cir- 
cumcision, which  many  surgeons  since  Mr.  Hunter’s 
time  have  preferred,  would  not  suffice  for  giving  vent 
to  the  accumulated  pus.  In  many  cases  of  phymosis, 
says  Mr.  Hunter,  an  operation  is  improper;  for  while 
the  inflammation  is  very  considerable,  such  a measure 
might  bring  on  mortification.  He  acknowledges,  how- 
ever, that  there  are  cases  in  which  a freedom  given  to 
the  parts  would  prevent  the  latter  event.  When  mat- 
ter is  confined  under  the  prepuce,  he  deems  an  opening 
indispensable ; and  if  the  patient  should  object  to  the 
common  operation,  he  advises  an  opening  to  be  made 
with  a lancet  directly  through  the  prepuce,  or  else  with 
caustic. — (See  Hunter  on  the  Venereal  Disease,  p.  232, 
et  see.) 

when  the  prepuce  is  to  be  slit  open,  a director  is 
first  to  be  introduced  under  it,  and  the  division  is  then 
to  be  made  with  a curved  pointed  bistoury  from  within 
upwards. 

Many  surgeons  object  to  this  operation,  because  the 
prepuce  continues  aflerward  in  a very  deformed  state; 
and  they  perform  circumcision,  or  amputation  of  the 
prepuce,  in  the  following  manner.  The  prepuce  is  first 
taken  hold  of  with  a pair  of  forceps,  as  much  of  the 
part  being  left  out  as  is  judged  necessai^  to  be  removed. 
The  removal  is  then  accomplished  by  one  sweep  of 
the  knife,  which,  directed  by  the  blades  of  the  forceps, 
is  sure  of  making  the  incision  in  a straight  and  regular 
manner.  A fine  suture  is  next  passed  through  the 
edges  of  the  inner  and  outer  portions  of  the  skin  of  the 
pre{)uce,  so  as  to  keep  them  together.  The  only  neces- 
sary dressings  are  lint,  and  over  it  an  emollient  poultice. 

Dr.  Ryan  lately  mentioned  to  me  a new  plan  of 
operating  on  phymosis,  which  is  less  severe  tlran  the 
common  ones,  attended  with  tto  mutilation,  and,  ac- 


cording to  this  gentleman,  very  effectual.  It  constsfs 
in  drawing  back,  as  far  as  practicable,  the  external 
skin  ot  the  prepuce,  and  then  insinuating  a director 
under  its  internal  duplicature,  and  dividing  it  with  a 
narrow  curved  bistoucy.  In  some  cases,  I have  no 
doubt  that  this  method  would  completely  answer,  and 
enable  the  surgeon  to  throw  a lotion  under  the  pre- 
puce, and  even  to  uncover  the  glans  sufficiently  to  bring 
a chancre  into  view.  The  method  of  M.  J.  Cloquet 
also  merits  notice:  it  consists  in  slitting  the  under  sur- 
face of  the  prepuce  upon  a director,  in  a line  parallel 
with  the  frfienum.  When  this  latter  pan  is  very  short, 
it  is  to  be  divided  with  the  scissors.  I'he  longitudinal 
wound  thus  made  becomes  transverse  when  the  pre- 
puce is  drawn  back ; and  scarcely  any  deformity  is  the 
consequence. 

At  the  period  when  I first  entered  the  profession,  it 
was  the  custesn  to  salivate  every  ptitient  who  hap- 
pened to  have  a phymosis.  However,  now  that  the 
fact  of  any  irritation  about  the  prepuce  and  glans  pe- 
nis, even  that  of  common  warts,  being  capable  of  pro- 
ducing the  complaint  is  well  known,  such  absurd  prac- 
tice has  been  relinquished,  and  theXause  and  condition 
of  the  disease  are  always  considered  previously  to  the 
determination  for  any  particular  method  of  treatment 
Nay,  even  when  phymosis  does  arise  from  chancres,  if 
there  be  a great  deal  of  inflammation,  the  use  of  mer- 
cury may  rather  do  harm  than  good,  and  the  practi- 
tioner should  not  be  precipitate  in  its  administration. 
On  this  point  I fully  coincide  with  Mr.  Travers. 
“ Upon  many  occasions  (says  he),  ])raclitioners  arc  too 
anxious  to  contend  with  the  specific  character  of  the 
venereal  disease,  to  the  neglect  of  Ihe  inflammatory 
state  of  the  affected  parts  exhibited  during  its  height. 
The  abuse  of  administering  mercury  for  an  acute  go- 
norrhoea and  recent  sores,  accompanied  by  phymosis, 
or  an  approach  to  that  slate,  is  of  common  occurrence ; 
and  it  is  far  from  being  recognised  by  the  profe.ssion 
as  an  established  rule  of  practice,  that  its  constitutional 
administration  is  inadmissible  during  the  existence  of 
active  inflammation  in  cellular  textures.” — {Surgical 
Essays,  part  1,  p.  131.) 

In  nine  cases  out  of  twelve,  in  which  the  experienced 
Mr.  Hey  had  occasion  to  amputate  the  penis  for  can- 
cerous disease,  the  patients  were  also  affected  with  a 
natural  phymosis. — (Pract.  Obs,  in  Surgery.)  Roux 
has  noticed  the  same  thing  in  three  similar  examples; 
and  as  he  conceives  that  phymosis  may  be  conducive 
to  carcinoma  of  the  penis,  he  thinks  that  it  should 
always  be  remedied  in  time. — {Farallele  de  la  Chir. 
Angloise,  p.  306.) 

TREATMENT  OF  PARAPHYMOSIS. 

The  removal  of  the  stricture  in  this  case  should 
always  be  effected,  because  i's  continuation  is  apt  to 
produce  a mortification  in  the  parts  between  the  stric- 
ture and  the  glans.  It  may  be  done  in  two  ways: 
either  by  compressing  with  the  fingers  all  the  blood  out 
of  the  swelled  glans,  so  as  to  render  this  part  suffi- 
ciently small  to  allow  the  constricting  prepuce  to  be 
brought  forwards  over  it  with  the  aid  of  the  two  fin- 
gers; or  by  dividing  the  stricture  with  a knife.  In  a 
former  edition  of  this  work,  as  Mr.  Dunn  of  Scar- 
borough has  reminded  me,  the  power  of  cold  applica- 
tions, in  promoting  the  reduction  of  the  glans,  should 
have  been  mentioned.  This  method  should  always  be 
put  in  practice  before  the  reduction  by  compression  is 
attempted,  as  a preliminary  measure,  which  sometimes 
succeeds  of  itself,  and  renders  unnecessary  any  painful 
handling  of  the  parts.  From  the  great  success  which 
I have  seen  attend  the  first  mode,  I should  not  conceive 
the  second  one  to  be  so  frequently  necessary  as  Mr. 
Hunter  seems  to  lay  down.  This  operation  is  always 
troublesome  to  accomplish,  because  the  swelling  on 
each  side  of  the  stricture  covers  or  closes  the'  light 
part,  which  cannot  be  got  at  without  difficulty.  Mr. 
Hunter  says,  the  best  way  is  to  separate  the  two  swell- 
ings as  much  as  possible  where  you  mean  to  cut,  so  as 
to  expose  the  constricted  part;  then  take  a crooked 
pointed  bistoury,  pass  it  under  the  constriction,  and 
divide  it.  None  of  the  swollen  skin  on  each  side 
should  be  cut.  The  prepuce  may  now  be  brought  for- 
wards, unless  it  be  thought  more  convenient,  for  the 
purpose  of  dressing  the  chancres,  to  let  it  remain  in  its 
present  situation. — (See  Hunter  on  the  Venereal  Dis- 
ease, p.  238,  239.) 

The  original  disease  producing  phymosis  and  para- 


PIL 


pTiymosis  must  always  he  attended  to,  and  the  employ- 
inenl  of  mercury  must  be  necessary  or  unnecessary 
according  to  the  nature  of  the  atfection  of  which  these 
are  only  effects. 

One  of  the  most  interesting  writers  on  phymosis  and 
paraphymosis  is  J.  L.  Petit,  Traiti  des  Mai.  Chir.  t.  2. 
Consult  also  J.  Hunter  on  the  Venereal  Disease.  Sa- 
batier, Medecine  Opcratoire,  t.  3,  8no.  Paris,  1810. 
Travers,  in  Surgic^  Essays,  part  1,  8vo.  Lond.  1818. 
There  is  also  a valuable  chapter  on  this  subject  in 
Richter's  Jlnfangsgr.  der  Wundarzn.  b.  6. 

PILES. — (See  Hemorrhoids.) 

PlLUL.dS  ARGENTI  NITRATIS.  R.  Argenti 
nitralis  gr.  iij.  Aquae  distillataj  gutt.  aliquot.  Micae 
paiiis  q.  s.  ut  fiant  pil.  xx.  The  author  of  the  Pharma- 
copoeia Chirurgica  suggests  the  trial  of  these  pills  in  ob- 
stinate leprous  and  other  cutaneous  aflTections,  and 
phagedenic,  anomalous  ulcers  connected  with  constitu- 
tional causes.  Two  or  three  tnay  be  given  twice  a day. 
Dr.  Powell  gave  the  argentum  nitratum  internally  in 
a case  of  hydrophobia,  but  without  anv  sensible  effect. 

PILULiG  COLOCYNTHIDIS  CUM  HYDRAR. 
SUBM.  R.  Extracti  colocynlh.  comp.  3ij.  Hydr. 
submur.  gr.  xii.  Saponis  3j.  Misce  ut  fiant  pilulae 
duodecim.  Two  of  these  pills  operate  as  a purgative, 
and  they  are  often  prescribed  in  various  surgical  cases. 

PILUL.®  CONII.  R.  Extracti  conii  3 ss.  Pulv. 
herb,  cicute  q.  s.  fiant  pil.  Ix.  These  are  the  liemlock 
pills  in  use  at  Guy’s  Hospital.  They  are  occasionally 
given  in  scrofulous,  cancerous,  and  venereal  cases. 
The  surgeon  should  begin  with  small  doses,  and  in- 
crease them  gradually  till  nausea  and  lieadache  arise. 
From  one  to  a greater  number  of  these  pills  may  be 
given  in  this  manner  every  day. 

PILULE  CUPRI  SULPHATIS.  R.  Cupri  sul- 
phatis  gr.  xv.  Olibani,  extracti  cinchonae,  sing.  3 ij. 
Syrup,  simpl.  q.  s.  fiant  pil.  lx.  From  one  to  four  of 
these  pills  may  be  given  in  a day  for  gleets. — {Pharm. 
Chirurg.) 

PILUL.®  HYDRARGYRI.  Of  these  I need  only 
observe  here,  that  the  full  dose  is  ten  grains  (see  Mer- 
cury), but  when  prescribed  as  an  alterative,  from  three 
to  five  grains  will  suffice. 

PILULiE  HYDRARGYRI  OXYDI  RUBRI.  One 
grain  of  this  preparation  in  each  pill  is  the  dose,  which 
is  commonly  taken  at  bedtime. — (See  Mercury.) 

PILULE  HYDRARGYRI  CUM  CONII.  R.  Hy- 
drargyri  purificati  drach.  j,  Arabici  gumrai  pulveri- 
saii  drach.  ij.  Extracti  conii  drach.  j.  Conii  foliorum 
in  pulverem  tritorum,  q.  s.  The  quicksilver  is  to  be 
first  reduced  by  triture  with  the  gum  arabic,  moistened 
with  a little  rain-water.  The  inspissated  juice  of 
hemlock  is  afterward  to  be  added,  and,  lastly,  the  pow- 
dered leaves  in  sufficient  quantity  to  make  a suitable 
mass  for  pills.  These,  with  a slight  variation  in  tire 
proportion  of  the  hemlock,  are  the  pilulce  mercurinles 
of  Plenck,  who  directs  three  or  four  pills,  each  of  three 
grains,  to  be  given  every  night  and  morning. 

No  doubt  there  are  many  cases  to  which  this  for- 
mula must  be  very  suitable;  for  instance,  the  enlarged 
prostate  gland,  and  some  forms  of  bronchocele,  &c. 
For  such  diseases.  Dr.  Saunders,  in  his  Furmulw  Se- 
lectee, directs  equal  parts  of  pil.  hydrarg.  and  extrac- 
tum  conii. — {Pharm.  Chirurg.) 

PILULE  HYDRARG.  SUBMUR.  R.  Hydrarg. 
submur.  gr.  xij.  Conservae  cynosbati  quod  satis  sit. 
M.  fiant  pil.  xii.  These  are  the  calomel  pills  in  com- 
mon use.  Surgeons  give  otie  or  two  of  them  daily,  as 
alteratives,  in  numerous  cases.  At  Guy’s  Hospital  they 
add  three  grains  of  the  pulvis  opiatus  to  each  pill, 
using  syrup  instead  of  the  conserve. 

PILUL.E  HYDRARG.  SUBMUR.  CUM  CONIO. 
R.  Hydrarg.  submur.  gr.  Vj.  Extracti  conii  3j.  M, 
fiant.  |nl.  xii.  One  may  be  given  thrice  a day,  in 
scirrhous,  cancerous,  scrofulous,  and  some  anomalous 
diseases,  resembling  venereal  diseases. 

PILULA3  HYDRARGYRI  SUBMUR.  CUM  AN- 
TIMONIOTARTARIZATO.  R.  Hydrarg.  submur. 
3j.  Antimon.  tart.  gr.  xv.  Opii  pur.  3ss.  Syrupi 
simpl.  q.  8.  fiant.  pit  lx. 

PIEULA5  HYDRARG.  SUBMUR.  COMPOSlTiE. 
R.  Hydrarg.  subni.  sulph.  antim.  prajcip.  sing.  gr. 
xii.  Guaiaci  gumma  resinae  gr.  xxiv.  Saponis  q.  s. 
M.  fiant  pil.  xii.  Similar  to  Plummer’s  pills.  In  por- 
rign,  herpetic  affections,  and  many  anomalous  diseases, 
they  are  exceedingly  useful.  Some  diseases  of  the 
bn.'.'ist  and  testicle  are  also  benefited  by  them. 


POL  263 

PILULiE  OPII.  These  need  only  be  mentioned 
among  such  as  are  of  eminent  utility  in  surgery. 

PILUL.,®  OPII  COMPOSITA3.  R.  Opii  purif. 
camphoras,  sing.  3 j:  Antim.  tart.  gr.  .xv.  Syrup, 
simpl.  q.  s.  fiant  pil.  lx.  Used  for  alleviating  pain,  and 
keeping  up  a gentle  perspiration  ; are  particularly  use- 
ful in  preventitig  painful  erections  in  cases  of  go- 
norrhoea, chordee,  &c. — (See  Pharm.  Chir.) 

PILULiE  aUlNIN.®.  R.  auininae  sulphatis  gr. 
xxiv.  Confect,  rosae  3 ss.  Misce  et  div.  in  pilulas 
duodecim.  When  an  alterative  treatment  is  neces- 
sary, in  conjunction  with  a tonic  plan,  I frequently 
join  the  sulphate  of  quinine  with  the  pil.  hydrarg.  sub- 
muriat.  comp.,  the  extractum  conii,  or  the  blue  pill ; 
and  in  other  cases  with  opium,  the  pil  scillae  c.,  or  the 
extractum  hyoscyami,  according  to  circumstances. 

PILULiE  SODiE  CUM  SAPONE.  R.  Sodae  sub- 
carbonatis  exsiccatae  3j.  Saponis  3j.  M.  fiant  pil. 
xii.  Four  may  be  given  thrice  a day  in  cases  of 
bronchocele,  and  indurations  of  the  absorbent  glands 
from  scrofula. 

PILUL.®  ZINCI  SULPHATIS.  R.  Zinci  sul- 
phatis, 3 ij.  Tercbinthinae  q.  s.  fiant  pil.  lx.  One  or 
two  are  occasionally  given  in  cases  of  gleets  thrice  a day. 

PLANTARIS  MUSCLE.  This  long  slender  muscle 
of  the  leg  is  sometimes  ruptured  in.dancing  and  leap- 
ing. The  surgeon  can  do  little  more  than  advise  rest, 
antiphlogistic  remedies,  and  the  same  posture  of  the 
limb  as  in  the  rupture  of  the  tendo  achillis.— (See 
Tendon.) 

POLYPUS.  A tumour,  generally  of  a pyriform 
shape,  most  commonly  met  with  in  the  nose,  uterus, 
vagina,  and  antrum,  and  named  from  an  erroneous 
idea  that  it  has  several  roots,  or  feet,  like  polypi. 

Polypi  more  frequently  grow  In  the  cavity  of  the 
nose,  than  in  any  other  situation,  and  are  visibly  of 
different  kinds.  One  polypus  is  red,  soft,  and  sensible  ; 
but  free  from  pain,  and  exactly  like  a piece  of  healthy 
flesh ; it  is  the  fleshy  polypus  of  various  writers.  When 
this  kind  of  polypus  is  of  a softer  consistence,  semi- 
transparent, and  of  a paler  yellowish  colour,  in  conse- 
quence of  being  less  vascular,  it  is  called  the  gelatinous 
polypus,  and  usually  arises  from  the  mucous  mem- 
brane of  the  side  of  the  antrum,  or  the  middle  of  the 
cavity  of  the  nostril,  between  the  upper  and  lower 
turbinated  bones.  Sir  Astley  Cooper  has  never  seen  a 
polypus  growing  from  the  mucous  membrane  of  the 
septum  narium. — {Lectures,  Src.  vol.  2,  p.  348.)  Other 
polypi  are  called  malignant,  being  hard,  scirrhous,  and 
painful:  the  carcinomatous  polypi,  as  they  are  named 
by  Sir  A.  Cooper,  and  which,  according  to  his  state- 
ment, are  a disease  of  old  age.  He  also  describes 
another  malignant  polypus,  which  he  calls  fungoid, 
and  occurs,  as  he  represents,  at  all  periods  of  life.  It 
bleeds  copiously,  but  is  not  so  painful  as  the  cancer- 
ous disease. — {Lectures,  ^c.  vol.  2,  p.  354.)  'J’his  di.— 
tinguished  surgeon  likewise  describes  hydatid  polypi, 
which  generally  occur  in  young  people,  and  the  cysts 
of  which  may  be  buist  by  pressure,  and  the  fluid  in 
them  discharged.  Richter  describes  another  kind  of 
nasal  polypus,  which  is  pale,  very  tough,  and  se- 
cretes a viscid  discharge  ; which  undergoes  an  altera- 
tion of  its  size  with  every  change  of  the  weather : and 
which  is  rather  a relaxation,  or  elongation,  of  a part 
of  the  Schneiderian  membrane,  than  a polypous  ex- 
crescence. The  whole  membranous  lining  of  the  nos- 
trils is  sometimes  thus  relaxed  and  thickened. — {Jln- 
fangsgr. der  Wundarzn.  b.  1,  kap.  21.)  Besides  the 
preceding  varieties  of  polypi,  children  are  subject,  as 
Sir  A.  Cooper  has  explained,  to  red  projections  within 
the  nose,  which  are  liable  to  be  mistaken  for  polypi, 
but  are  of  a different  nature,  and  may  be  cured  l>y 
touching  tiiem  with  the  end  of  a bougie,  armed  witii 
the  argentum  nitratum. 

Mr.  Pott  has  taken  great  pains  to  explain  that  there 
is  one  kind  of  polypus  originally  benign;  another  ori- 
ginally malignant.  He  states,  that  those  which  begin 
with,  or  are  preceded  by,  considerable  or  frequent  pain 
in  the  forehead  and  upper  part  of  the  nose,  and  which, 
as  soon  as  they  can  be  seen,  are  either  liighly  red,  or  of 
a dark  purple  colour;  those  which,  from  the  time  of 
their  Ireing  first  noticed,  have  never  been  observed 
to  be  sometimes  bigger,  sometimes  less,  but  have 
constantly  rather  increased;  those  in  which  cough- 
ing, sneezing,  or  blowing  the  nose  gives  pain  or 
produce.*)  a very  disagreeable  sensation  in  the  nostril 
or  forehead ; tho.se  which,  when  within  reach,  are 


264 


POLYPUS. 


painful  to  the  touch,  or  which,  upon  being  slightly 
touched,  are  apt  to  bleed ; those  which  seem  to  be 
fixed,  and  not  moveable  by  the  action  of  blowing  the 
nose,  or  of  driving  the  air  through  the  affected  nostril 
only  (when  the  polypus  is  only  on  one  side) ; those 
whicfs  are  incompressibiy  hard,  and  which  when 
pressed  occasion  pain  in  the  corner  of  the  eye  and 
forehead,  and  which,  if  they  shed  any  thing,  shed 
blood ; those  which  by  adliesion  occupy  a very  con- 
siderable space,  and  seem  to  consist  of  a thickening,  or 
of  an  enlargement  of  all  the  membrane  covering  the 
septum  narium ; tliose  which  sometimes  shed  an 
ichorous,  offensive,  discoloured  discharge  ; those  round 
whose  lower  part,  within  the  nose,  a probe  cannot 
easily  and  freely  be  passed,  and  that  to  some  height ; 
ought  not  to  be  attempted  at  least  by  the  forceps,  rtor, 
indeed,  by  any  other  means  ; and  tliis  for  reasons  ob- 
viously deducible  from  the  nature  and  circumstances 
of  the  polypus.  On  the  one  hand,  the  very  large  ex- 
tent and  quantity  of  adhesion  will  render  extirpation 
impracticable,  even  if  the  disease  could  be  compre- 
hended witliin  the  forceps,  which  it  very  frequently 
cannot ; and  on  the  other,  the  malignant  nature  of  the 
distemper  may  render  all  partial  removal,  all  unsuc- 
cessful attacks  on  it,  and,  indeed,  any  degree  of  irrita- 
tion, productive  of  the  most  disagreeable  consequences. 

But  the  polypi  which  are  of  a palish  or  grayish  light- 
brown  colour,  or  look  like  a membrane  just  going  to  be 
slt)ughy  ; which  are  seldom  or  never  painful,  nor  be- 
come so  upon  being  pressed;  which  have  appeared  to 
be  at  one  time  larger,  at  another  less,  as  the  air  has 
happened  to  be  moist  or  dry;  which  ascend  and  de- 
scend freely  by  the  action  of  respiration  through  the 
nose;  which  the  patient  can  make  to  descend  by  stop- 
ping the  nostril  which  is  free,  or  even  most  free,  and 
then  driving  the  air  through  that  which  the  polypus 
possesses  ; which  when  pressed  give  no  pain,  easily 
yield  to  such  pressure,  become  flat  thereby,  and  distil  a 
clear  lymph  ; and  round  whose  lower  and  visible  part 
a probe  can  easily,  and  that  to  some  height,  be  passed, 
are  fair  and  fit  for  extraction  ; the  polypus,  in  these  cir- 
cumstances, frequently  coming  away  entire ; or  if  it 
does  not,  yet  it  is  removeable  without  pain,  hemor- 
rhage, or  hazard  of  any  kind  ; the  second  of  which 
circumstances,  Mr.  Pott  can  with  strict  truth  affirm,  he 
never  met  with  when  the  disease  was  at  all  fit  for  the 
operation. 

Of  the  benign  kind  of  polypus  fit  for  extraction, 
there  are  (says  Mr.  Pott)  two  sorts,  whose  principal 
difference  from  each  other  consists  is  their  different 
origin  or  attachment.  That  which  is  most  freely 
moveable  within  the  nostril  upon  forcible  respiration  ; 
which  has  been  found  to  be  most  liable  to  change  in 
size  at  different  times  and  seasons;  which  has  in- 
creased the  most  in  the  same  space  of  time ; which 
seems  most  limpid,  and  most  freely  yields  lymph  upon 
pressure;  has  its  origin  most  commonly  by  a stalk  or 
kind  of  peduncle,  which  is  very  small  compared  with 
the  size  of  tlie  polypus.  I'he  other,  which,  although 
plainly  moveable,  is  much  lesi  so  than  the  one  just 
mentioned,  which  has  been  less  fiable  to  alteration 
from  air  and  seasons,  and  which  has  been  rather  slow 
in  arriving  at  a very  troublesome  size,  is  most  fre- 
quently an  elongation  of  the  membrane  covering  one 
of  the  ossa  spo.igiosa.  These  latter  may  be  extracted 
with  no  kind  of  hazard,  and  with  very  little  pain,  and 
hemorrhage:  but  the  former  require  the  least  ftnce, 
and  mostly  come  away  entire ; while  the  others  often 
break,  come  away  piecemeal,  and  stand  in  need  of  the 
repeated  use  of  the  forceps. 

Mr.  John  Bell  criticises  the  distinctions  drawn  by 
the  preceding  writer,  and  still  adopted  in  the  best 
schools  of  surgery : he  says,  that  a polypus  is  never 
mild  and  never  malignant;  time,  and  the  natural 
growth  of  the  tumour,  and  the  pressure  it  occasions 
within  the  soft  and  bony  cells  of  the  nostrils  and  jaws, 
must  bring  every  polypus  to  one  invariable  form  in  its 
last  and  fatal  stage.  Polypus,  he  admits,  is  indeed  a 
dreadful  disease;  but  it  becomes  so  by  a slow  pro- 
gression, and  advances  by  gradations  easily  charac- 
terized. Every  polypus  in  its  early  stage  is,  according 
to  this  writer,  a small  moveable  tumour,  attended  with 
a sneezing  and  watering  of  the  eyes ; swelling  in  moist 
weather ; descending  with  the  breath ; but  easily  re- 
pressed with  the  pohit  of  the  finger.  It  is  void  of  pain, 
and  not  at  all  alarming;  it  may  also  be  easily  ex- 
tracted, so  as  to  clear  for  a time  the  passage  for  the 


breath.  Yet  this  little  tumour,  simple  .as  it  may  ap- 
pear, is  the  germ  of  a very  fatal  and  loathsome  disease, 
and  this  easy  extraction  often  the  very  cause  of  its  ap- 
pearing in  its  most  malignant  form.  The  more  easily  it  is 
extracted  (says  Mr.  J.  Bell),  the  more  easily  does  it  re- 
turn ; and,  whether  carelessly  extracted,  or  altogther 
neglected,  it  soon  returns.  But  when  it  does  return,  U 
has  not  really  changed  its  nature ; it  has  not  ceased  to 
be  in  itself  mild  ; it  is  then  to  be  feared,  not  from  its 
malignity,  but  from  its  pressure  among  the  delicate 
cells  and  membranes  of  the  nose.  It  soon  fills  the 
nostrils,  obstructs  the  breathing,  and  causes  indescri- 
bable anxieties.  The  tears  are  obstructed,  and  the 
eyes  become  watery  from  the  pressure  on  the  lachry- 
mal sac  ; the  hearing  is  in  like  manner  injured,  by  tne 
pressure  of  the  tumour  against  the  mouth  of  the  Eusta- 
chian tube;  the  voice  is  changed,  and  its  resonance 
and  tone  entirely  lost,  by  the  sound  no  longer  pa^smg 
through  the  cells  of  the  nose  and  face.  The  swallow- 
ing is  in  some  degree  affected  by  the  soft  palate  being 
depressed  by  the  tumour.  The  pains  arising  from  such 
slow  and  irresistible  pressure  are  unceasing.  I'lom 
the  same  pressure,  the  bones  become  carious,  and  the 
cells  of  the  face  and  nose  are  destroyed  by  the  slow 
growth  of  the  swelling.  It  is  not  long  before  the  tu- 
mour begins  to  project  from  the  nostril  in  front,  and 
over  the  arch  of  the  palate  behind.  One  nostril  be- 
comes widened  and  thickened ; the  nose  is  turned 
tow'ards  the  opposite  side  of  the  face,  and  the  whole 
countenance  seems  distorted.  The  lOot  of  the  nose 
swells  and  becomes  puffy,  the  features  tumid  and 
flabby,  the  face  yellow,  and  the  parts  round  the  eye 
livid.  The  patient  is  affected  with  headaches,which 
seem  to  rend  the  bones  asunder,  and  w'ith  perpetual 
stupor  and  dozing.  The  bones  are  now  absorbed,  and 
the  membranes  ulcerate ; a foul  and  fetid  matter, 
blackened  with  blood,  is  discharged  from  the  nostrils, 
and  excoriates  them.  The  blood-vessels  next  give 
way,  and  sudden  impetuous  hemorrhages  weaken  the 
patient ; the  teeth  fall  from  the  sockets,  and,  through 
the  empty  sockets,  a foul  and  fetid  matter  issues  from 
the  antrum. 

Now  the  disease  verges  to  its  conclusion.  The  pa- 
tient has  terrible  nights,  and  experiences  a sense  of 
suffocation.  The  repeated  loss  of  blood  renders  him 
so  weak  that  he  cannot  quit  his  bed  for  several  days 
together;  and  when  he  does  get  up  he  is  (to  use  Air. 
Bell’s  words)  pale  as  a spectre,  his  lips  colourless,  and 
his  face  like  wax,  yellow  and  transparent.  He  now 
suffers  intolerable  pain,  while  his  saliva  is  continually 
dribbling  from  his  month,  and  a fetid  discharge  from 
his  nose.  In  this  slate  he  survives  a few  weeks;  du- 
ring the  last  days  of  his  illness  lying  in  a state  of  per- 
petual stupor,  and* dying  lethargic.  Mr.  J.  Bell  after- 
ward observes,  that  “ if  hf)rrid  symptoms  could  esta- 
blish the  fact  of  malignity,  there  is  not  to  be  found  in 
all  nosology  a more  imilignant  disease  than  this  : but 
aneurism,  though  it  destroys  the  thigh  bone,  the  ster- 
num, or  the  craiiium,  is  not  accounted  malignant ; 
neither  is  polypus  malignant,  though  it  destroys  the 
cells  of  the  face,  and  penetrates  even  through  the  eth- 
moid bone  to  the  brain.  These  consequences  resnlt 
merely  from  pressure.” — [John  Bell's  Principles  of 
Surgery^  vol.  3,  pai-t  \,p.  90 — 92.) 

In  .April,  1817,  there  was  a boy  in  St- Bartholomew’s 
Ho.«pital,  only  twelve  years  old,  who  fell  a victim  to  the 
ravages  of  the  largest  and  most  di.-figuring  di.sease 
within  tlie  nose,  which  I ever  had  an  opportunity  of 
beholding.  The  tiimour  before  death  had  expanded  the 
upper  part  of  the  nose  to  an  enormous  size ; while  be- 
low, the  left  nostril  was  immensely  enlarged.  The  dis. 
tance  between  the  eyes  was  extraordinary,  being  rnore 
than  four  inches.  The  left  eye  was  aft'ected  with  amau- 
rosis, brought  on  by  the  pressure  of  the  swelling;  the 
right  retained  to  the  last  the  faculty  of  seeing.  J’lio 
tnmonr  nearly  covered  the  month,  so  that  food  could 
only  be  introduced  with  a spoon,  and  an  examination 
of  the  state  of  the  palate  was  impossible.  About  a 
fortnight  before  death,  the  legs  became  paralytic,  and 
during  the  last  week  of  the  boy’s  existence,  an  inconti- 
nence of  tlie  urine  and  feces  prevailed.  On  examina- 
tion of  the  head  after  death,  a good  deal  of  tiie  tumour 
was  found  to  be  of  a cartilaginous  consistence,  and, 
what  was  most  remarkable,  a portion  of  it,  which  was 
as  large  as  an  orange,  extended  within  the  cranimn, 
where  it  had  annihilated  the  anterior  lobe  of  the  left 
hemisphere  of  the  brain.  Yet,  nolwitlistanditig  ihia 


POLYPUS. 


265 


effect,  the  boy  was  not  comatose,  nor  insensible,  till  a 
few  hours  before  his  decease.  All  the  surrounding 
bones  had  been  iiioje  or  less  absorbed,  and  the  place 
from  which  the  excrescence  first  grew  could  not  be  de- 
termined. 

Richter  has  denied  the  validity  of  the  objections, 
urged  by  Pott  against  attempting  to  relieve  the  patient : 
and  he  declares,  that  neither  the  malignant  nature  of  a 
polypus,  its  adliesions,  immoveableness,  ulcerations,  nor 
disposition  to  hemorrhage,  &.C.,  are  any  just  reason  for 
leaving  the  disease  to  itself. — (See  jinfangsgr.  der 
fVundarin.  b.  1,  kap.  21.)  This  declaration,  however, 
at  least  with  reference  to  any  operation,  is  quite  lepug- 
iiant  to  the  advice  delivered  by  all  the  most  experienced 
surgeons  in  England,  who,  in  cases  of  decideuly  malig- 
nant polypi,  always  restrict  their  interference  to  pallia- 
tive means. 

Mr.  J.  Bell  refutes  the  common  notions,  that  polypi 
may  be  caused  by  picking  the  nose,  blowing  it  too  forci- 
bly, colds,  and  local  injuries.  He  asserts  that  a poly- 
pus is  not  in  general  a local,  solitaiy  tumour:  he  hasoiily 
i'ound  it  so  in  three  or  four  instances.  Both  nostrils  are 
usually  affected.  He  states,  that  no  finger  can  reach 
that  part  of  the  nostril,  where  the  root  of  the  swelling 
is  situated,  as  it  is  deep  and  high  in  the  nostrils,  towards 
the  throat,  and  near  the  opening  of  the  Eustachian 
tube.  The  finger  cannot  be  introduced  farther  than 
the  cartilaginous  wing  of  the  nose  extends,  and  can 
hardly  touch  the  anterior  point  of  the  lower  spongy 
bone.  The  anterior  and  posterior  chambers  of  the  nos- 
tril are  separated  from  each  other  by  a narrow  slit, 
which  the  finger  can  never  pass,  and  which  is  divided 
in  consequence  of  the  projection  of  the  lower  spongy 
bone  into  two  openings,  one  above,  the  other  below. 
Through  these  the  heads  of  the  polypus  project.  TJiese 
tangible  parts  of  the  tumour,  however,  are  very  dis- 
tant from  its  root,  which  is  in  the  highest  and  narrowest 
part  of  the  nostril.— (Seep.  103,  104.)  Mr.  J.  Bell  also 
aays,  that  three  or  four  polypi  are  often  crowded  to- 
gether in  one  nostril,  w'hile  more  are  formed  or  form- 
ing in  the  other. 

He  dwells  upon  the  difficulty  and  impracticableness 
of  tying  the  root  of  a polypus;  and  explains,  that  in 
all  attempts  to  extirpate  such  tumours,  the  surgeon’s  aim 
should  be  to  reach  a point,  nearly  under  the  socket  of 
the  eye,  in  the  deepest  and  highest  part  of  the  nostrils, 
and  that  instruments  can  only  do  good  when  introduced 
beyond  the  narrow  cleft,  formed  by  the  projection  of 
the  spongy  bone. — (P.  108.) 

Though  Mr.  John  Bell  is  probably  right  in  his  opi- 
nion, that  polypi  do  not  proceed  from  the  several  circum- 
stances which  have  been  above  noticed,  yet  they  are, 
in  most  instances,  diseases  of  an  entirely  local  nature. 
Certainly,  in  general,  it  is  very  difficult  to  describe 
what  is  the  cause  of  a nasal  polypus.  Frequently,  the 
patient  is  in  other  respects  [rerfeclly  well;  and  after 
the  removal  of  the  tumour  no  new  one  makes  its  ap- 
pearance. In  this  circumstance,  it  must  origitiate  from  a 
local  cause,  though  it  is  generally  difficult  to  define  what 
the  nature  of  this  is.  Sometimes  several  catarriial 
symptoms  precede  the  polypus,  and  perhaps  consti- 
tute its  cause.  It  is  pos.«ible,  they  may  only  be  an  effect 
of  the  same  cause  which  gives  birth  to  the  tumour;  but 
no  doubt,  they  are  .sometimes  the  effect  of  the  polypus 
itself  Sometimes,  perhaps,  a faulty  state  of  the  consti- 
tution really  contributes  to  the  disease;  for  several  po- 
lypi frequently  grow  in  both  nostrils,  and  even  in  other 
situations,  at  the  same  time ; are  reproduced  immedi- 
ately after  their  removal ; and  the  patient  often  has  an 
unhealihy  appearance. 

There  are  four  modes  of  extirpating  nasal  polypi : viz. 
extracting  them  with  forceps,  tying  them  with  a ligature, 
cutting  them  out,  and  ikstroying  them  with  caustic. 

Ejctrar.tion  is  the  most  common  and  proper  method. 
It  is  performed  with  the  ordinary  polypus-foicep.«,  the 
blades  of  which  have  holes  in  them,  and  are  iniei  iially 
rather  rough,  in  order  that  they  may  take  hold  of  the 
tumour  more  firmly,  and  not  easily  slip  off  it.  'I’he  front 
edge  of  each  blade  must  not  be  too  thin  and  sharp,  lest 
with  its  fellow  it  should  jiinch  off  a portion  of  the  po- 
ypns.  The  blades  must  necessarily  have  a certain 
breadth  ; for,  when  they  are  too  small,  they  cannot  pro- 
perly take  hold  of  and  twist  the  tumour.  When  the  han- 
dles are  rather  long,  the  instrument  may  be  more 
firmly  closed,  and  more  conveniently  twistrui. 

ft  is  generally  deemed  of  importance  to  take  hold  of 
the  polypus  with  the  forceps  close  to  its  root ; and  in- 


deed, when  this  rule  is  observed,  the  whole  of  the  po- 
lypus, together  with  its  root,  is  commonly  extracted, 
and  there  is  less  reason  to  apprehend  hemorrhage, 
which  is  naturally  more  profuse  wlien  the  polypus  is 
broken  at  the  thick,  middle  portion  of  its  body.  It  is 
also  a rule  frequently  easy  of  observance,  especially 
wlien  the  polypus  is  not  too  large.  With  respect  to 
common  fienhy  or  gelatinous  polypi^  it  should  be  re- 
membered, tliat  they  usually  originate  from  between 
the  upper  and  lower  turbinated  bones,  on  the  side  of 
the  antrum  ; and  the  best  plan  is,  first  to  endeavour  to 
ascertain  with  a probe  the  precise  situation  of  the  per- 
dicie,  which  tlie  forceps,  guided  by  the  probe,  will  their 
more  readily  grasp.  Sir  A.  Cooper  has  never  known 
an  instance  of  the  growth  of  a gelatinous  polypus  from 
the  septum  nariuiu  ; a fact  liighly  worthy  of  the  prac- 
titionci ’s  recollection.  In  many  instances,  the  tumour  is 
so  large,  and  the  nostril  so  completely  occupied  by  it, 
that  its  root  can  neitlier  be  felt,  nor  taken  hold  of  with 
forceps.  The  polypus  should  tiien  be  grasped  as  high 
as  possible.  The  consequences  are  of  two  kinds.  U’he 
tumour  sometimes  gives  way  at  its  root,  though  it  be  only 
taken  hold  of  at  its  anterior  part ; and,  in  other  cases, 
breaks  where  it  is  gr.asped,  a portion  being  left  behind, 
and  a profuse  hemorrhage  ensuing.  This  is,  however, 
void  of  danger,  if  the  surgeon  does  not  waste  time  in 
endeavouring  to  suppress  the  effusion  of  blood  ; but 
immediately  introduces  the  forceps  again,  grasps  the 
remnant  piece,  and  extracts  it.  The  most  infallible  me- 
thod of  diminishing  the  bleeding,  is  to  extract  what 
remains  behind  at  its  root.  In  this  way  a large  polypus 
is  frequently  extracted,  piecemeal,  without  any  particu- 
lar loss  of  blood. 

After  the  polypus  has  been  propelled  as  far  forwards, 
into  the  nostrils  as  it  can  be,  by  blow  ing  strongly  through 
the  nose,  and  the  place  of  its  root  felt  with  a probe,  its 
anterior  part  is  to  be  taken  hold  of  with  a small  pair 
of  common  forcejis  held  in  the  left  hand,  and  is  to  be 
drawn  gradually  and  slowly  out,  to  make  room  for  the 
introduction  of  the  polypus-forceps  into  the  nostril. 
The  more  slowly  we  proceed  in  this  manoeuvre,  the  more 
the  polypus  is  elotigated,  the  narrower  it  becomes,  the 
greater  is  the  space  in  the  nostril  for  the  introduction 
of  the  polypus-forceps,  and  the  higher  can  this  instru- 
ment grasp  the  tumour.  After  the  root  of  the  polypus 
has  been  taken  hold  of  with  the  polypus-forceps,  or  if 
this  cannot  be  done,  after  the  tumour  has  been  grasped 
with  the  latter  forceps  as  high  as  possible,  it  is  to  be  twist- 
ed slowly  round,  and  at  the  same  time  pulled  outwards 
till  it  breaks.  When  the  body  of  the  polypus,  and  not 
the  root,  is  grasped,  it  is  a very  important  maxim,  rather 
to  twist  the  instrument  than  pull  it,  and  tlius,  rather  to 
w'rithe  the  polypus  off  than  to  drag  it  out.  The  longer 
and  more  slowly  the  polypus-forceps  is  twisted,  tlie  more 
the  part  where  the  excrescence  separates  is  bruised,  the 
less  is  the  danger  of  hemorrhage,  and  the  more  certainly 
does  the  tumour  break  at  its  thinnest  part  or  toot.  Whett 
the  extraction  is  done  with  violence  and  celerity,  only 
a piece  is  usually  brought  away,  and  we  run  hazard  of 
occasioning  a copious  bleeding.  Sir  A.  Cooper  recoin^ 
mends  tearing  polypi  from  their  attachment  with  a sud- 
den jerk,  as  the  most  likely  mode  to  bring  away  the 
whole  of  the  root,  and  even  a portion  of  the  Schtteide- 
rian  niembiaite  attd  bone,  so  as  to  hinder  a relapse : a 
piece  of  advice,  however,  wMiich  he  seems  to  intend  for 
cases  in  which  the  pedicle  is  grasped  by  the  forceps,  as 
it  ought  always  to  be  if  possible ; but  when  circum- 
stances oblige  the  surgeon  to  lake  hold  of  any  other 
more  accessible  portion  of  the  turrmur,  the  rule  of  slow- 
ly and  gradtrally  twistirrg  off  the  polyjrrts.,  instead  of 
usirtg  a srrdden  jerk,  is  what  I cottsider  the  nrost  likely 
nrethod  of  extractirrg  tlie  tumour  itr  a mass. 

As  soon  as  the  polypus  has  given  way,  the  surgeon  is 
to  examirre  whetber'arry  part  lenraiiis  behind.  When 
the  polyptrs  is  very  nar  row  at  the  place  where  it  has 
been  bimken,  and  the  palietrt  carr  breathe  through  the 
nose  freely,  there  is  rea.<otr  to  presume,  that  the  poly- 
pirs  has  giverr  way  at  its  root  arrd  that  itoire  continue.s 
behirrd.  The  fnrger,  if  it  carr  be  irttroduced,  procures 
ih(!  nrost  certain  irrfornratiorr ; or  the  probe,  when  the 
firrger  tirr  warrt  of  roorrr  cannot  be  employ'ed.  When  a 
jriece  of  the  root  is  left,  it  is  best  to  introduce  the  for- 
ceps agaitr,  utrder  the  grridance  of  the  firrger  or  probe, 
and  thus  pirrch  and  twist  off  the  remnarri  of  the  disease 

Some  Iternorr  banr-  always  follou  stbe  o)tei  aiion;  and 
by  many  wr  iters  ii  is  repr  e.serrted  as  perilous  arrd  alarm- 
ing. But  this  is  not  the  case  in  common  fleshy  gelati 


•266 


POLYPUS. 


nous  polypi,  which  are  not  furnished  with  large  vessels 
and  are  the  instances  in  wliich  the  operation  is  most 
proper.  Cases  are  met  with,  however,  in  which  the 
bleeding  is  really  serious;  and  therefore  the  surgeon 
should  always  furnish  himself  before  the  operation  with 
the  most  effectual  means  for  its  suppression.  The  dan- 
ger of  hemorrhage  may  always  be  lessened,  as  was  be- 
fore mentioned,  by  slowly  twisting  the  polypus  at  its 
root,  in  preference  topullingitdirectlyout.  When  only 
a portion  of  the  tumour  has  been  extracted,  the  surest 
mode  of  stopping  the  effusion  of  blood  is  to  extract  the 
remaining  part  without  delay.  After  the  polypus  has 
.given  way  at  its  root,  if  the  bleeding  should  still  be  pro- 
f use,  ice-cold  water  or  strong  brandy  may  be  sucked  or 
injected  into  the  nose.  These  applications  mostly  prove 
effectual.  If  the  hemorrhage  should  still  prevail,  it  may 
always  be  checked  with  certainty,  how  copious  soever 
it  may  be,  in  the  following  manner.  Roll  a considerable 
piece  of  lint  as  fast  as  possible  round  the  extremity  of 
a probe;  wet  it  completely  through  with  a strong  solu- 
tion of  the  sulphate  of  zinc  ; introduce  it  into  the  nos- 
tril, and  press  it  as  strongly  as  possible  against  the  part 
whence  the  blood  issues.  When  the  nostril  is  very 
much  dilated,  the  fingers  may  be  used  for  this  purpose, 
with  more  advantage  than  the  probe.  The  point  froni 
which  the  blood  is  effused  nmy  easily  be  ascertained 
by  pressing  the  finger  on  various  points.  As  soon  as 
the  blood  ceases  to  flow,  we  may  conclude  that  the  fin- 
ger is  on  the  situation  of  the  hemorrhage. 

When  this  metliod  fails,  a piece  of  catgut  may  be  in- 
troduced into  the  nostril,  and,  by  means  of  a pair  of  for- 
ceps, be  brought  out  of  the  mouth.  A roll  of  lint  is 
then  to  be  attached  to  it,  and  drawn  through  the  mouth 
into  the  nose;  thus  the  posterior  aperture  of  the  nos- 
tril may  be  stopped  up.  Then  the  nostril  in  front  is  to 
be  filled  with  lint. 

Sometimes  the  greatest  part  of  the  polypus  extends 
backwards,  hanging  down  behind  the  palatum  molle  to- 
wards the  pharyn.x.  If  there  should  be  but  little  of  the 
jiolypus  visible  in  the  nostril,  its  extraction  must  be  per- 
Jformed  backwards,  in  the  throat.  This  is  usually  done 
with  a pair  of  curved  polypus  forceps,  which  are  to  be 
introduced  through  the  mouth,  in  order  to  seize  and 
tear  oft’  the  tumour  as  high  as  possible  above  the  soft 
palate.  Care  must  be  taken  not  to  irritate  the  root  of 
the  tongue,  or  else  a vomiting  is  produced  which  dis- 
turbs the  operation.  When  the  polypus  cannot  be  pro- 
perly taken  hold  of,  some  surgeons  divide  the  soft  pa- 
late. But  this  can  hardly  ever  be  necessary.  As  by 
this  mode,  the  polypus  is  not  twisted,  but  pulled  away, 
the  hemorrhage  is,  in  general,  rather  copious.  If  a 
fragment  of  the  tumour  should  remain  behind,  it  may 
commonly  be  e.vtracted  through  the  nose. 

Some  recommend  for  the  extraction  of  polypi  in  the 
throat,  a ring,  consisting  of  two  semicircular  portions, , 
with  a kind  of  groove  externally,  which  are  capable  of 
being  opened  and  shut,  by  being  fixed  on  the  ends  of 
an  instrument,  constructed  like  forceps.  A ligature  is 
to  be  placed  round  the  ring,  and  its  end  is  to  be  brought 
to  the  handle  of  the  instrument,  and  held  with  it  in  the 
hand.  The  instrument  is  to  be  introduced  into  the 
mouth,  under  the  polypus,  and  expanded  as  much  as 
the  size  of  the  tumour  requires.  Its  ring  is  then  to  be 
carried  upwards,  over  the  polypus,  so  as  to  embrace  it; 
and  afterward  is  to  be  shut,  whereby  the  noose,  after 
being  carried  upwards  is  disengaged  from  the  ring.  The 
noose  is  to  be  pushed  as  high  as  possible  over  the  tumour 
by  means  of  forceps,  and  the  extremity  of  the  pack- 
thread is  then  to  be  drawn,  so  as  to  apply  the  noose 
tightly  round  the  polypus.  When  this  is  done,  the  ring 
of  the  instrument  is  to  be  turned  round,  firmly  closed, 
and  placed  in  front  of  the  polypus,  on  the  noose,  in 
such  a way  that  the  packthread  is  to  lie  between  two 
little  pegs,  made  for  the  purpose,  at  the  ends  of  the  ring. 
On  drawing  the  packthread  firmly,  and  pressing  the  in- 
strument at  the  same  time  downwards,  so  as  to  make  it 
act  like  a lever,  the  polypus,  in  general,  easily  breaks. 
Another  peg  projects  in  the  direction  of  the  ring,  so  as 
to  prevent  the  ligature  from  insinuating  itself  with- 
in the  circle. — (See  Theden's  Bemerk.  part  2;  and 
plated,  fig.  1,  in  Richter's  Anfangsgr.) 

This  instrument  is  at  present  rarely  or  never  em- 
ployed, and  Richter,  who  sets  down  its  use  as  attended 
with  difficulty,  recommends  the  extraction  to  be  per- 
formed with  forceps  through  the  mouth.  When  the 
tumour  carinot  be  drawn  completely  out  without  con- 
siderable force,  a spatula  is  to  be  introduced  into  the 


mouth,  and  to  becarried  as  high  as  possible  oehind  the 
polypus,  in  order  to  press  it  down  towards  the  root  of 
the  tongue.  When  the  tumour  js  now  forcibly  pulled 
out  with  the  forceps,  it  usually  gives  way. 

When  the  polypus  is  situated  partly  in  the  throat 
and  partly  in  the  nostril,  it  admits  of  being  extracted  in 
the  same  way,  through  the  mouth;  but  its  anterior 
pan  often  continues  attached,  and  must  afterward  be 
separately  removed  through  the  nostril.  It  is  also  fre- 
quently advisable  to  twist  off  the  anterior  portion  of  tiie 
polypus  first,  by  which  the  mass  in  the  throat  is  often 
rendered  so  loose,  that  it  can  be  easily  extracted 
Whenever  it  is  conjectured  that  the  polypus  will  come 
away  in  two  pieces,  it  is  always  preferable  first  to  ex- 
tract the  part  in  the  nostril,  and  afterward  that  in  the 
throat ; because  the  separation  of  the  last  is  constantly 
productive  of  more  bleeding  than  the  removal  of  the 
first.  Sometimes  the  following  plan  succeeds  in  de- 
taching the  whole  polypus  at  once.  Both  the  part  in 
the  nostril,  and  that  in  the  throat  are  to  be  firmly  taken 
hold  of  with  forceps,  and  drawn  at  first  gently,  atnl 
then  more  forcibly,  backwards  and  forwards.  By  such 
repeated  movements,  the  root  is  not  unfrequenlly 
broken,  and  the  whole  polypus  brought  away  from  ilie 
mouth. 

Frequently  the  polypus  grows  again.  Policy  re- 
quires that  the  patient  should  be  apprized  of  this 
beforehand.  Some  of  the  root  remaining  behind  may 
often  be  a cause  of  the  relapse.  Hence,  after  the  ope- 
ration, the  surgeon  should  carefully  examine  the  part 
at  which  the  root  of  the  polypus  was  situated,  and  se- 
parate and  twist  off  most  diligently  with  the  forceps 
any  fragments  that  may  still  continue  attached.  Or 
if,  in  the  operation  itself,  the  root  can  be  grasped  with 
the  forceps,  it  may  be  torn  away  with  a sudden  jerk, 
as  recommended  by  Sir  A.  Cooper,  for  the  express  pur- 
pose of  bringing  away  with  the  root  the  portion  of 
Schneiderian  membrane  and  even  bone  fron)  wliich 
the  tumour  originates,  so  as  to  prevent  ils  growing 
again.  The  recurrence  of  the  disease,  however,  may 
arise  from  other  causes.  The  tumour  is  occasionally 
reproduced  after  it  has  been  extr.acted  in  the  most  com- 
plete manner;  and,  doubtless,  this  circumstance  is 
sometimes  owing  to  the  continued  agency  of  constitu- 
tional causes,  which  so  often  remain  undiscovered  and 
unremoved.  Sometimes  also,  the  recurrence  of  the 
disease  is  owing  to  a local  morbid  affection  of  the 
Schneiderian  membrane,  or  of  the  bones  situated  be- 
neath the  root  of  the  polypus.  Richter,  in  this  case, 
approves  of  the  cautery;  but  few  English  surgeons  will 
coincide  with  him.  The  polypus,  sometimes  observed 
subsequently  to  the  operation,  is  frequently  not,  in  fact,- 
a new  substance,  but  only  a part  of  the  original  tumour, 
not  previously  noticed  by  the  surgeon.  Sometimes  it 
occurs,  that  a smaller  and  a larger  polypus  are  found 
in  the  nose  at  the  same  time.  The  larger  one  is  ex- 
tracted while  the  other  remains  undiscovered;  and, 
when  it  has  increased  in  magnitude,  it  is  apt  to  be  mis- 
taken for  a reproduction  of  the  one  previously  extir- 
pated.— (See  Aijtfangsgr.  der  Wnndarzn.  b.  1,  h.  21.) 

Ligature.  The  hemorrhage  that  has  occasionally 
arisen  from  attempts  to  extract  certain  polypi,  and  moi  e 
especially  from  the  imperfect  removal  of  them  ifi  this 
manner,  led  to  the  proposal  of  extirpating  them  with  a 
ligature.  The  plan  is,  to  tie  the  root  of  the  tumour,  by 
which  means  the  polypus  is  thrown  into  the  stale  of 
sphacelus,  and  at  length  becomes  detached.  Many 
instruments  have  been  invented  for  this  purpose,  but 
Levret’s  double  cannula  seems  to  be  the  best.  Through 
this  a silver  wire  is  to  be  introduced,  so  as  to  fornr  a 
noose  at  the  upper  end  of  the  instrument,  proporiioned 
in  size  to  the  anterior  part  of  the  tumour,  situated  in 
the  nostril.  The  twm  ends  of  the  wire  are  to  hang  out 
of  the  two  lower  apertures  of  the  double  cannula : and 
one  of  them  is  to  be  fastened  to  a small  ring  on  its  owui 
side  of  the  instrument.  The  other  is  to  remain  loose. 
The  wire  must  be  made  of  the  purest  silver,  and  ought 
to  be  as  flexible  as  possible,  that  it  may  not  readily 
break.  It  must  also  not  be  too  thin,  lest  it  cut  through 
the  root  of  the  polypus.  The  cannula  is  to  be  some- 
what less  than  five  inches  long.  By  the  assistance  of 
this  cannula,  the  noose  is  to  be  introduced  into  the  nose, 
and  put  round  the  polypus.  But  as  the  cannula,  w hich 
is  usually  constructed  of  silver,  is  straight  and  inflexible, 
w'hile  the  inner  surface  of  the  nostril  is  preternaturally 
arched,  especially  when  much  distended  by  the  polypus, 
its  introduction  must  be  attended  with  considerable 


POLYPUS. 


267 


difficulty.  In  fact,  it  can  seldom  be  introduced  as 
deeply  as  the  root  of  the  polypus. 

The  noose  is  to  be  applied  in  the  following  manner. 
The  polypus  is  to  be  taken  hold  of  with  the  forceps, 
and  drawn  a little  out  of  the  nose.  The  noose  is  then 
to  be  carried  over  the  forceps  and  polypus,  into  the  nos- 
tril. In  order  to  carry  it  as  high  as  possible,  it  is  neces- 
sary not  to  push  the  cannula  straight  forwards  into  the 
nose,  but  to  move  it  from  one  side  of  the  polypus  to 
the  other.  The  more  deeply  the  instrument  has  entered 
the  nose,  the  more  of  the  loose  end  of  the  wire  must 
be  drawn  out  of  the  lower  aperture  of  the  cannula,  so 
as  to  contract  the  noose,  which  otherwise  might  stop 
in  the  nostril,  and  not  be  carried  sufficiently  high.  The 
elasticity  of  the  silver  wire  tends  to  raise  it  over  the 
polypus,  and  hence  it  is  more  easy  of  application  than 
a more  flaccid  kind  of  ligature.  When  there  is  cause 
to  conclude,  that  the  polypus  is  complicated  with  adhe- 
sions, they  must  be  previously  broken  in  the  way  al- 
ready mentioned. 

As  soon  as  the  noose  has  been  introduced  as  deeply 
as  possible,  the  loose  extremity  of  the  wire  is  to  be 
drawn  out  of  the  lower  aperture  of  the  cannula,  and 
rolled  round  the  ring  on  that  side  of  the  instrument. 
Thus  the  root  of  the  polypus  is  constricted.  The  wire 
must  not  be  pulled  too  forcibly,  nor  yet  too  feebly.  In 
the  first  circumstance,  it  readily  cuts  through  the  root 
of  the  polypus ; in  the  second,  great  tumefaction  of  the 
excrescence,  and  many  inconveniences  arise,  which  a 
tenser  state  of  the  wire  prevents.  As  the  noose  gra- 
dually makes  a furrow,  where  it  surrounds  the  poly- 
pus, it  grows  slack  after  a short  time,  and  no  longer 
constricts  the  tumour.  One  end  of  the  wire,  therefore, 
is  to  be  daily  unfastened,  and  drawn  more  tightly. 
The  more  tense  it  is  kept,  the  sooner  the  separation  oP 
the  polypus  is  brought  about.  Hence,  when  it  is  par- 
ticularly indicated  to  produce  a speedy  detachment  of 
the  polypus,  the  wire  should  be  tightened  at  least  once 
a day. 

In  this  manner  the  cannula  is  to  remain  in  the  nose, 
until  the  noose  is  detached  together  with  the  polypus. 
There  is  another  method  of  tying  the  tumour,  without 
leaving  the  cannula  in  the  nose.  After  the  noose  has 
been  introduced  as  far  as  possible  into  the  nostril,  tlie 
two  ends  of  the  wire  are  to  be  twisted  round  the  two 
rings,  and  the  cannula  is  to  be  turned  round  a couple 
of  times.  The  wire  is  then  to  be  unfastened  from  the 
rings,  and  the  cannpla  withdrawn.  In  this  way,  the 
noose  is  made  to  embrace  the  polypus,  round  which  it 
remains  firmly  applied.  When  it  is  wished  to  produce 
a greater  constriction,  the  cannula  is  again  introduced 
into  the  nose,  the  ends  of  the  wire  fastened  to  the  rings, 
and  the  instrument  turned  round  again ; after  which  it 
is  taken  away  as  before. 

When  the  tumour  has  begun  to  slough,  and  a fetid 
discharge  has  commenced,  a solution  of  alum,  or  of 
chloride  of  lime  or  soda,  should  be  repeatedly  injected 
into  the  nostril  for  the  sake  of  cleanliness;  and  imme- 
diately the  dead  mass  is  sufficiently  loose  it  should  be 
removed. 

Although  the  ligature  has  been  very  much  praised  by 
some  of  the  moderns,  it  is  attended  with  so  many  dif- 
ficulties, that,  in  the  majority  of  cases,  the  use  of  for- 
ceps is  infinitely  preferable.  Hemorrhage  is  the  only 
inconvenience  for  which  extraction  is  abandoned  for 
the  employment  of  the  ligature.  But  this  is  much  less 
dangerous  than  is  represented.  The  inconveniences  of 
the  ligature  are  far  more  serious  and  numerous.  The 
cure  by  the  ligature  is  always  accomplished  with  much 
less  expedition  than  that  by  extraction.  When  the 
polypus  is  of  such  a siee  as  to  occupy  the  whole  of  the 
nostril,  it  is  generally  impracticable  to  introduce  the 
noose  to  a sufficient  depth.  The  figure  of  tlie  polypus 
renders  it  almost  impossible  to  tie  its  root;  for,  com- 
monly, the  tumour  expands  very  much  before  and  be- 
hind, and  the  wire  must  be  brought  over  the  posterior 
part  of  the  polypus  ere  it  can  be  applied  to  its  root.  In 
general  also,  the  noose  only  includes  the  front  part  of 
the  polypus,  while  the  root  and  back  portion  remain 
untied,  and  consequently  are  not  destroyed. 

As  soon  as  the  noose  is  drawn  tight,  not  only  the 
|)olypus  inflames,  but  the  whole  extent  of  the  Schnei- 
derian membrane.  The  pain  and  inflammation  fre- 
quently extend  even  to  distant  parts,  as  the  throat, 
eyes,  ice.,  attended  with  a great  deal  of  fever. 

When  the  polypus  is  tied,  it  swells  very  much,  and 
all  the  complaints  which  it  previously  caused  are  e.\as- 


perated.  But,  in  particular,  the  part  situated  in  the 
throat  sometimes  obstructs  deglutition  and  respiration 
in  such  a degree,  that  prompt  relief  becomes  necessary ; 
and  one  of  tlie  best  plans  for  affording  it  is,  to  make  a 
few  punctures  in  the  tumour. 

The  wire  sometimes  breaks  off  close  to  the  lower 
aperture  of  the  cannula,  in  consequence  of  being  twisted 
so  much,  and  thus  the  progress  of  the  cure  is  interrupted. 
A new  wire  may  be  introduced;  but  it  is  difficult  to 
apply  it  exactly  in  the  situation  ofthe  other.  A fresh 
place  is  commonly  tied,  which  is  almost  the  same  thing 
as  commencing  the  cure  anew. 

After  enumerating  so  many  inconveniences  of  the 
ligature,  as  a means  of  curing  nasal  polypi,  I shall  only 
remark,  that  it  is  not  surprising,  that  the  plan  should 
now  be  hardly  ever  adopted  by  any  good  surgeons  in 
this  country.  Among  other  authorities,  I may  cite 
that  of  Sir  A.  Cooper,  who  has  tried  the  ligature  un- 
availingly,  and  pronounces  its  application  to  these 
cases  to  be  decidedly  unadvisable. 

Caustics.  The  cautery,  formerly  recommended  for 
the  cure  of  the  polypus  nasi,  is  now  entirely  rejected, 
and  indeed,  in  the  manner  it  was  customary  to  use  it, 
little  good  could  be  done.  It  was  applied  to  the  ante- 
rior surface  of  the  tumour  in  the  nostril,  and  its  em- 
ployment was  repeated  every  time  the  slough  separated. 
Its  operation  could  naturally  be  but  of  small  extent,  as 
it  only  came  into  contact  with  a trivial  portion  of  the 
polypus.  Its  irritation  augmented  the  determination  of 
blood  to  the  excrescence,  and  accelerated  its  growth ; 
while  as  much  of  the  tumour  was  reproduced,  ere  the 
slough  separated,  as  was  destroyed  ; and  the  design  of 
completely  extirpating  the  disease  in  this  way  seldom 
or  never  proved  successful. 

There  are  some  nasal  polypi  much  disposed  to  pro- 
fuse bleeding.  Touching  them  in  the  gentlest  manner, 
and  every  trivial  concussion  of  the  body,  give  rise  to 
hemorrhage.  The  patient  is  exceedingly  debilitated  by 
repeated  loss  of  blood;  his  countenance  is  pallid;  his 
feet  swollen ; he  is  affected  with  hectic  fever ; and 
faints  whenever  any  considerable  bleeding  arises. 
Doubtless,  extraction  in  this  case  is  a very  precarious 
method,  as  the  patient  is  so  circumstanced,  that  any 
copious  etfusion  of  blood  must  be  highly  perilous. 
Sometimes  the  polypus  is  at  the  same  time  so  large, 
and  the  nostril  so  completely  occupied  and  distended, 
that  it  is  impossible  to  apply  a ligature.  Such  is  the 
only  case  in  which  even  Richter  sanctions  the  use  of 
the  cautery. 

In  employing  the  cautery  (says  the  latter  author), 
the  object  is  not  to  effect,  by  its  direct  agency,  a sud- 
den destruction  of  the  polypus  ; but  to  excite  such  an 
inflammation  and  suppuration  of  the  whole  of  it,  as 
shall  lead  to  this  event.  To  fulfil  this  purpose,  a com- 
mon trocar,  three  inches  long,  may  be  used.  The  can- 
nula ought  to  be  two  inches  shorter  than  the  trocar 
whereby  the  latter  may  protrude  from  it  so  far ; and  u 
should  be  constructed  with  a handle.  The  cannula 
should  be  made  wider  than  it  is  in  common,  so  as  to 
allow  the  trocar  to  be  introduced  and  wUhdrawn  with 
facility.  It  is  to  be  wrapped  round  with  a piece  of 
wet  linen,  and  applied  to  the  polypus.  The  red-hot 
trocar  is  then  to  be  pushed  into  the  tumour  as  far  as 
the  cannula  will  allow,  which  is,  of  course,  two  inches. 

When  the  patient  entertains  a dread  of  the  actual 
cautery,  Richter  recommends  the  introduction  of  a 
tent  of  the  emplastrum  cantharidum,  or  a tent  smeared 
with  butter  of  antirnony,  into  the  puncture  of  the  un- 
heated trocar,  and  as  soon  as  suppuration  has  taken 
place,  emollient  and  detergent  lotions  are  to  be  injected. 
—(Richter's  Anfangsgr.)  In  England,  actual  and  po- 
tential cauteries  are  never  used  for  the  destruction  of 
common  nasal  poly[ii ; but  red  projections,  not  of  a 
polypous  nature,  sometimes  noticed  within  the  nos- 
trils of  children.  Sir  A.  Cooper  cures  by  touching 
them  with  a bougie  armed  with  the  argentum  nitra- 
turn.  The  cysts  of  the  hydatid  polypus  the  same  gen- 
tleman also  destroys,  by  applying  the  muriate  of  anti- 
mony to  them  with  a camel-hair  pencil. 

Excision.  In  the  treatment  of  the  polypus,  the  use 
of  cutting  instruments  has  always  been  repiobated, 
because  they  usually  occasion  a profuse  hemorrhage, 
and  can  hardly  ever  be  passed  without  mischief  to  a 
sufficient  depth  into  the  nose  to  divide  the  root  of  the 
tumour.  Yet  there  are  instances  in  which  their  uso 
might  be  productive  of  advantage.  The  anterior  part 
of  the  polypus,  situated  in  the  nostril,  is  sometimes  so 


POLYPUS. 


^8 

thick  and  hard,  that  it  is  utterly  impracticable  to  intro- 
duce the  forceps  for  the  performance  of  extraction,  or 
the  cannula  for  the  application  of  the  ligature.  In 
such  a case,  it  might  be  a judicious  step  to  cut  off  the 
front  of  the  pcdypus,  with  a sharp  instrument  of  a suit- 
able shape,  in  order  to  make  room  for  the  use  of  the 
ligature  or  forceps. 

Sir  A.  Cooper  sometimes  removes  polypi  by  dividing 
their  pedicle  with  a pair  of  probe-pointed  scissors  ; hut 
his  experience  has  taught  him  that  the  disease,  when 
thus  extirpated,  is  more  likely  to  return  than  when 
cured  by  extraction.  When  a polypus  is  very  large, 
■and  the  pedicle  grows  from  the  side  of  the  antrum,  he 
.also  sometimes  cuts  through  the  root  with  a pair  of 
curved  scissors,  and  presses  down  the  polypus  at  the 
back  of  the  mouth  with  his  finger,  from  over  the  ve- 
lum pendulum  palati,  and  thus  removes  it.  He  has 
never  seen  danger  or  difliculty  arise  from  the  plan,  but, 
on  the  contrary,  has  known  it  answer  in  several  in- 
stances, in  which  the  forceps  had  been  employed 
through  the  nostrils  in  vain. — {JLectures,  ^-c.  vol.  2,  p. 
352.) 

Mr.  Whately,  after  failing  in  several  attempts  to 
extract  and  tie  a considerable  polypus  of  the  nose,  suc- 
ceeded in  cutting  it  out.  He  used  “ a narrow,  straight 
bistoury,  with  a probe  point,  having  a sheath  fixed  upon 
its  edge,  by  a screw  put  into  a hole  in  the  handle.  An 
eye  was  made  at  its  point,  to  receive  one  end  of  a 
thread  intended  to  be  passed  round  the  polypus,  for  the 
purpose  of  directing  the  knife  to  the  extremity  of  the 
tumour.  There  was  also  a contrivance  by  which  the 
knife  could  be  unsheathed  at  its  extremity,  the  length 
of  three-quarters  of  an  inch.  3'his  was  done  by 
means  of  the  screw,  which  might  be  fixed  in  another 
hole,  by  drawing  back  the  sheath.  By  exposing  such 
a length  of  edge  only,  the  anterior  parts  of  the  nose 
were  defended  from  the  danger  of  being  wounded.” 
Whoever  wishes  a particular  account  of  the  manner 
of  using  the  instrument,  must  consult  Mr.  Wiiately’s 
Cases  of  two  extraordinartj  Polypi,  S,‘C.  1805. 

In  the  polypus  which  arises  from  a relaxation  of 
the  Schneiderian  membrane,  external  astringent  appli- 
cations may  be  first  tried;  such  as  ice-cold  water,  so- 
lutions of  acetate  of  lead,  alum,  muriate  of  ammo- 
nia, &.C.  These  remedies  (says  Richter)  commonly 
lessen  it,  and  frequently,  when  it  is  not  very'  large,  ac- 
complish its  entire  removal.  If  this  should  not  hap- 
pen, there  is  no  reason  against  pulling  a ligature  round 
it.  Here,  also,  we  may  venture  to  employ  a cutting  in- 
strument, if  it  be  in  our  power  to  do  so  ; which,  as  far 
as  my  experience  goes,  will  very  rarely  be  the  case.  But 
.the  practice  of  extraction  is  here  prohibited.  A strong 
solution  of  alum,  introduced  into  the  nostril  with  a 
.dossil  of  lint,  will  also  remove  the  hydatid  polypus  of 
young  persons,  as  Sir  Astley  Cooper  has  explained. 
These  polypi  he  compares  to  wet  bladders  hanging 
within  the  nose : they  are  not  attended  with  pain, 
.tliough  with  the  inconvenience  of  obstruction.  When 
pressed  with  the  forceps  they  burst,  and  discharge  a 
.fluid  resembling  mucus.  The  nose  may  be  frequently 
cleared  of  them  by  instruments  ; but  they  are  always 
regenerated.  Whether  astringents  will  cure  them  per- 
jnanently,  he  cannot  say  positively. — (.Lectures,  <S-c. 
vol.  2,  p.  353.) 

POLYPI  or  THE  UTERUS. 

Polypi  of  the  uterus  are  of  three  kinds,  in  respect  of 
situation;  they  grow  either  from' the  fundus,  the  in- 
side of  the  cervix,  or  the  lower  edge  of  the  os  uteri. 
"The  first  case  is  the  most  frequent;  the  last  the  most 
uncommon.  Polypi  of  the  uterus  are  of  a pyriform 
shape,  and  have  a thin  pedicle.  They  are  almost  in- 
variably of  that  species  which  is  denominated  fleshy, 
.hardly  ever  being  scirrhous,  cancerous,  or  ulcerated. 
Sometimes  they  contain  a cavity  filled  with  fluid,  re- 
sembling mucus  or  lymph.  They  originate  under  the 
mucous  membrane,  which  still  covers  them  ; a circum- 
stance in  which  they  difler  from  sarcoma  and  slea- 
toma  of  the  uterus,  which  are  situated  in  its  sub- 
stance, or  on  its  external  surface. 

A polypus  of  the  fundus  uteri  is  very  difficult  to  de- 
tect in  its  incipient  state.  While  small,  it  produces 
not  the  smallest  perceptible  change  in  the  organs  of' 
generation  As  it  enlarges,  it  distends  the  uterus, 
and  often  excites  a suspicion  of  pregnancy,  which, 
however,  an  attentive  inquiry  soon  dispels.  The 
-Bwelling  of  the  abdomen  does  not  lake  place  in  the  de- 


gree and  space  of  time  which  it  does  in  pregnancy ; 
the  menstrual  discharge  generally  continues,  though 
often  irregular  and  profuse  ; the  breasts  do  not  become 
full;  and,  in  the  progress  of  the  case,  no  motion  is  to 
be  felt.  While  the  polypus  lies  in  the  uterus,  its  growth 
is  slow.  At  this  early  period,  it  frequently  occasions 
profuse  bleeding.  Women  afflicted  with  the  disease 
are  seldom  pregnant,  and  when  they  are  so,  a miscar- 
riage mostly  follows.  However,  they  sometimes  hold 
out  till  the  end  of  the  regular  time,  atid  the  labour  is 
easy  and  safe.  Levret,  Bach,  and  Jorg  have  recorded 
ca.ses,  in  which  the  foetus  reached  its  full  term.  In 
Bach’s  case,  the  placenta  was  attached  to  the  [wlypus ; 
a fact,  I should  think,  quite  sufficient  to  disi)el  all 
doubt  about  the  vascularity  of  uterine  polypi. 

In  some  instances,  however,  the  case  is  more  per- 
plexing; the  catamenia  disappear,  and  other  marks  of 
pregnancy  are  present,  such  as  nausea,  vomiting,  and 
enlargement  of  the  breasts.  By  degrees  the  uterus, 
and  sometimes  even  the  abdomen,  is  distended.  The 
cervical  portion  of  the  uterus  is  shortened,  and  be- 
comes thick  and  tumid,  but,  instead  of  the  softness 
peculiar  to  pregnancy,  it  retains  a solid  feel.  A sen- 
sation of  weight  about  the  genitals,  and  of  bearing 
down,  is  also  experienced  : frequently  the  bowels  are 
constipated,  and  there  is  difficulty  in  voiding  the  urine. 
— {Mayer,  De  Polypis  Uteri,  BeroUni,  1821.) 

As  the  polypus  increases,  it  expands  the  os  uteri,  and 
at  length  protrudes  into  the  vagina.  This  change  hap- 
pens sooner  or  later,  according  as  the  polypus  is  at- 
tached to  the  cervix  or  the  fundus  uteri ; for,  in  the 
first  case,  the  polypus  generally  protrudes  when  it  has 
attained  the  size  of  a finger,  but,  in  the  second,  it  may 
remain  in  the  uterus  several  years,  and  be  as  large  as 
a child’s  head  before  its  protrusion  commences.  The 
dilatation  of  the  os  uteri  by  the  swelling  is  also  mostly 
attended  with  a discharge  of  mucus  mixed  with  blood, 
and  sometimes  with  dangerously  profuse  bleeding. 
The  protrusion  happens  either  suddenly  from  an  acci- 
dental concussion  of  the  body,  or  slowly  and  gradu- 
ally, attended  with  pains  similar  to  those  of  labour. 
As  soon  as  it  has  arrived  in  the  vagina,  and  is  no 
longer  confined  and  compressed  by  the  uterus,  it  be- 
gins to  grow  more  rapidly,  and  gives  rise  to  far  more 
troublesome  complaints;  Ibr  it  presses  the  bladder  and 
rectum,  and  seriously  disturbs  the  evacuation  of  the 
urine  and  feces.  But,  in  particular,  it  causes  repeated 
and  profuse  hemorrhages,  which  weaken  the  patient 
exceedingly,  and  often  bring  her'to  the  brink  of  the 
grave.  The  root  of  the  polypus  is  situated  in  the  os 
uteri,  and  is  there  so  compiessed,  that  the  blood  in  the 
tumour  is  prevented  from  returning  through  the  veins; 
consequently,  all  the  vessels  become  turgid,  and  the 
above  effusions  of  blood  are  the  result.  Though  they 
generally  cease  spontaneously,  the  least  circumstances 
cause  their  recurrence  ; such  as  slight  concussions  of 
the  body  in  riding,  walking,  &c.  In  the  mean  while,  a 
quantity  of  mucous  and  aqueous  fluid  is  voided,  by 
which  the  patient’s  strength  is  more  reduced;  and  at 
length  hectic  fever  and  anasarca  come  on.  The  poly- 
pus, the  source  of  the  bloody  and  mucous  discharge,  as 
well  as  of  all  the  patient’s  illness,  is  frequently  misun- 
derstood, and  the  case  is  really  attended  with  great 
danger,  irom  its  nature  not  being  comprehended  by 
the  practitioner:  so  necessary  is  it,  in  cases  of  preter- 
natural discharge  from  the  uterus,  always  to  examine 
with  the  finger,  per  vagiiiam. 

At  lengtii,  after  the  polypus  has  been  some  time  in 
the  vacina,  it  begins  to  protrude  externally.  This 
happens  gradually  or  suddenly  from  some  effort  or  con- 
cussion of  the  body.  Additional  grievances  are  now 
excited.  As  the  polypus  cannot  descend  so  low,  with- 
out dragging  the  fundus  of  the  uterus  downwards  with 
it,  and  occasioning  a prolapsus  of  this  organ,  the  pa- 
tient, in  walking  or  standing,  commonly  experiences  a 
very  pain.ful  sense  of  dragging  or  stretching  in  the 
pelvis.  As  the  bladder  and  ureters  are  also  forced  into 
a deranged  position,  the  evacuation  of  the  urine  is 
more  or  less  disturbed,  or  rendered  difficult.  Lastly, 
the  dribbling  of  the  urine  over  the  polypus,  and  the 
friction  which  the  part  accidentally  suffers,  frequently 
cause  it  to  inflame,  and  become  painful  and  ulcerated. 

A polypus  situated  in  the  vagina,  or  protruding  from 
it  externally,  may  easily  be  mistaken  for  a prola[isu8 
uteri ; an  error,  which,  though  not  difficult  to  avoid 
when  a careful  examination  is  made,  may  have  very 
perilous  consequences,  Tlie  oolypus  is  softer  and  less 


POLYPUS. 


269- 


sensible  than  tlie  uterus  in  llie  staie  of  a prolapsus. 
The  imperfect  prolapsus  uteri,  in  which  this  visciis  is 
not  turned  inside  out,  is  betrayed  by  the  os  tincae,  at 
the  lower  part  of  which  it  is  plainly  perceptible.  In 
this  situation,  the  polypus  may  occasionally  have  a 
depression,  resembling  the  mouth  of  the  womb,  but 
easy  of  discrimination  from  it.  A probe  can  be  passed 
deeply  into  the  os  uteri;  but  not  so  into  this  other 
opening.  The  polypus  resembles  an  inverted  pear ; 
that  is,  it  is  thickest  below,  and  becomes  gradually 
thinner  upwards.  The  above  species  of  the  prolapsus 
uteri  is  thinnest  below,  and  gradually  increases  in 
width  upw'ards.  The  fallen  uterus  may  easily  be 
pressed  back,  and  when  it  is  so,  the  patient  experiences 
relief.  The  polypus  does  not  admit  of  being  pressed 
back,  and,  during  an  attempt  to  do  this,  the  patient  is 
put  to  much  inconvenience.  A probe  may  be  intro- 
duced by  the  side  of  the  polypus  deeply  to  the  fundus 
uteri.  iVlien  passed  by  the  side  of  the  fallen  uterus, 
it  is  very  soon  stopped  at  the  upper  part  of  the  vagina, 
which  has  sunk  down  with  the  cervix  of  this  organ. 

A polypus,  protruding  externally  from  the  vagin.a, 
may  be  much  more  easily  distinguished  from  a perfect 
prolapsus  uteri,  without  inversion.  The  os  uteri  at 
once  characterizes  the  uterus,  as  it  can  not  only  be  felt, 
but  seen.  A probe  may  be  passed  deejily  into  the  va- 
gina, along  the  side  of  the  polypus;  but  not  so  by  the 
side  of  the  uterus,  for  reasons  easy  of  comprehension. 
The  figure  of  the  tumour,  and  the  state  of  the  patient, 
on  an  effort  being  made  to  reduce  the  protruded  part, 
also  betray  its  real  nature. 

With  the  exception  of  a few  examples,  in  which  an 
inversion  of  the  uterus  is  caused  by  the  descent  of  a 
large  polypus  into  the  vagina,  it  happens  only  in  wo- 
men who  have  been  recently  delivered,  and  has  gene- 
rally been  preceded  by  a very  rapid  delivery,  or  the 
use  of  too  much  violence  in  the  extraction  of  the  pla- 
centa. While  the  inverted  uterus  lies  in  the  vagina, 
its  shape  is  broad  above  and  narrow  below;  whereas 
the  polypus  is  thin  above,  and  broad  below.  Hence, 
in  cases  of  very  large  polypi  in  the  vagina,  the  os  uteri 
is  but  little  dilated  ; while  it  is  extremely  distended  by 
the  incomplete  descent  of  the  inverted  uterus  itself. 
Here,  likewise,  the  reduction  of  the  part  is  attended 
with  relief ; while  every  effort  to  push  back  a polypus 
causes  an  aggravation  of  all  the  complaints. 

When  the  inverted  uterus  hangs  out  of  the  vagina, 
its  figure,  like  that  of  the  polypus,  is  thin  upwards  and 
broad  downwards;  and  like  the  latter  tumour,  has  no 
aperture  at  its  lowest  part.  An  attentive  observer, 
however,  will  easily  avoid  a mistake.  The  inverted 
uterus  includes  a circular  fold  at  its  upper  part,  next  to 
Ihe  orifice  of  the  vagina.  This  fold  is  nothing  less 
than  the  os  uteri  itself,  through  which  the  body  of  this 
viscus  has  descended.  There  is  nothing  of  this  kind 
to  be  felt  in  cases  of  prilypi.  By  the  side  of  a polypus 
the  finger  or  probe  may  be  passed  deeply  into  the  va- 
gina; but  not  so  by  the  side  of  the  uterus.  The  root 
of  the  polypus  is  firm  and  hard  to  the  touch  ; the  upper 
tliiu  part  of  the  uterus,  which  is  hollow,  has  a soft, 
flabby  feel.  Useful  light  is  also  generally  thrown  on 
the  case  by  the  common  occasional  cause  of  prolapsus 
uteri  with  inversion.  The  symptoms  of  a complete 
inversion  are  a red,  fleshy  tumour,  as  large  as  a fist  or 
a child’s  head,  protruding  from  the  genitals,  with  vio- 
lent pains,  and  profii.^e  hemorrhage,  often  causing  syn- 
cope, convulsions,  and  death.  The  uterus  feels  rough, 
elastic,  and  painful;  the  uterine  tumour  ordinarily 
felt  above  the  pubes  is  wanting  ; the  inversion,  though 
with  difficulty,  may  be  returned.  On  the  other  hand, 
a polypus  is  insensible,  hard,  and  smooth  ; it  may  be 
returned  into  the  vagina  with  considerable  pain,  but  is 
immediately  expelled  .again.  On  the  inverted  uterus 
the  mouths  of  the  bleeding  vessels  and  the  placenta,  or 
place  of  its  insertion,  may  be  seen. — {Muyer^  see  Quar- 
terly Jnurv.  of  Foreign  J\Ied.  rnl.  4,  pAlG.)  However, 
in  particular  cases  the  diagnosis  is  much  more  difficult, 
and  the  observations  of  a modern  writer  fully  prove, 
that  it  is  always  difficult  and  perhaps  sometimes  im- 
p<issihle  to  distinguish  a partial  and  chronic  inversion 
of  the  titerusfrom  a {>n\y\>ns.—  {JV.  iN'ewnham  on  In- 
versin  Uteri,  with  the.  History  of  the  successf  ul  Rztir- 
pntion  of  that  Organ,  during  the  Chronic  Stage  of  the 
Jhsense,  p.  82,  S,  c.  8vo.  Loud.  1818:  also.  First  Jdnes 
of  th.  I’rnrtice  of  Surgery,  vol.  2,  p.  317.) 

Under  Professor  Siebold,  however,  IMayer  has  had 
several  oppurtuidties  of  seeing  chronic  incomplete  in- 


version, and  he  mentions  the  following  circumstances, 
in  addition  to  some  others  already  specified,  as  form- 
ing the  diagnosis  between  it  and  polypus.  Polypus 
not  unfrequently  occurs,  in  women  who  are  barren; 
inversion  in  those  who  have  borne  children.  The 
symptoms  of  polypus,  commencing  with  disorder  of 
tlie  menses,  and  frequently  with  their  suppression,  in- 
crease constantly,  and  when  the  tumour  is  passing  into 
the  vagina,  are  accompanied  with  pains  like  those  of 
labour.  On  the  contrary,  the  symptoms  of  inversion 
date  their  origin  from  the  time  of  delivery;  menor* 
rhagia,  unusually  violent  pains,  and  excess  of  the 
lochia  in  quantity  and  duration,  succeeding  to  a very 
rapid  labour,  or  to  a rough  and  violent  extraction  of 
the  placenta.  In  cases  of  polypus,  a discharge  of  mu- 
cous fluids,  iiiixed  w ith  blood  and  membranous  frag- 
ments, is  always  present,  occasiofially  alternating  with 
copious  hemorrhage;  while,  in  examples  of  inversion, 
there  is,  in  fact,  an  excess  of  the  mei.ses  ; the  hemor- 
rhage appears  every  second  or  third  week,  is  very  co- 
pious for  some  days,  and  is  succeeded  by  a serous,  thin 
discharge,  as  clear  as  spring  water.  A polypus  is  alto- 
gether insensible;  but  the  uterus,  however  its  sensibility 
may  be  le.«sened  by  tbe  duration  of  the  disease,  the 
effect  of  astringent  applications,  &c.,  is  always  capable 
of  sensation  when  gently  scratched  with  the  nail. — 
(See  Mayer's  Work,  and  the  Quarterly  Journ.  of 
Foreign  Med.  Src.  vol.  4,  p.  477.) 

In  cases  of  uterine  polypi,  situated  either  on  the 
inside  of  the  cervix,  or  at  the  margin  of  the  os  uteri, 
the  disease  is,  as  it  were,  from  its  commencement,  in 
the  vagina,  .and  the  tumour,  w'hen  large,  produces  all 
the  complaints  attending  polypi  of  the  first  kind,  except 
frequent  profuse  bleedings.  These  seldom  occur,  and 
when  they  do,  are  slight,  because  the  root  of  the  poly- 
pus suffers  no  constriction  in  the  os  uteri.  The  di.s- 
charge  of  mucus,  however,  is  more  profuse  than  when 
the  (lolypus  is  att.ached  to  the  fundus  uteri.  As  the 
tumour  descends  out  of  the  vagina,  it  occasions  a pro- 
lapsus uteri  without  inversion,  in  addition  to  the  other 
inconveniences.  Cases  sometimes  occur,  in  which 
polyi)i  of  the  uterus  are  detached  by  sphacelation,  and 
a cure  is  thus  spontaneously  produced.  These  are 
facts  well  calculated  to  obviate  the  doubts  entertained 
by  Mayer  respecting  the  vascularity  of  tumours.  In- 
deed, the  mode  of  cure  by  ligature  can  only  be  explained 
by  its  interrupting  the  supply  of  blood  to  them. 

With  regard  to  the  treatment  of  uterine  polypi,  no 
attempt  can  be  made  to  extirpate  them  until  the  os 
uteri  is  sufficiently  dilated  to  permit  the  application  of 
a ligature  or  the  practice  of  excision.  In  the  mean 
time,  the  attacks  of  hemorrhage  are  to  be  checked  by 
strict  repose;  the  supine  posture;  small  doses  of 
opium;  mineral  acids,  particularly  the  phosphoric; 
alum;  and  cold  injections  of  vinegar.  When  these^ 
means  fail,  however,  and  the  hernonhage  endangers 
life,  the  os  uteri  shoitid  be  artificially  dilated  and  the- 
polypus  immediately  removed.  Constipation  and  re- 
tetriion  of  mitre  may  also  sometinres  require  special 
attention,  before  the  os  uteri  has  become  dilated  enouglj 
for  the  extirpation  of  the  tumoitr. — {Mayer.) 

According  to  the  latter  experienced  practitioner,  Ihe 
best  period  for  undertaking  either  to  tie  or  cut  away  » 
poly|)its  of  the  uterirs,  is  soon  after  the  menses  or  after 
hemorrhage,  the  genitals  beirtg  then  lax  and  the  flow 
of  blood  to  them  diminished.  . 

Experience  proves  that  uterine  polypi,  wdren  once  ex 
tirpated,  have  trot  that  propensity  to  be  reproduced* 
w’hich  those  of  the  nose  have.  Here,  for  obvious  rea- 
sons, extraction  is  not  the  right  practice. 

For  the  extirpation  of  polypi  of  the  ttferus,  all  the 
methods  nreirtioned  for  the  eradication  of  nasal  polypi 
have  been  proposed  ; but  modern  practitioirers  hardly 
ever  enrploy  more  than  two,  viz.  the  ligature  aird  ex- 
cisiort. 

The  ligature  is  generally  the  most  proper  nteans  for 
extii  patiirg  uterine  polypi,  atrd  is  here  ttrtreh  more  easy 
of  atrplication  than  in  the  ito.«e.  Large  as  the  polypus 
trtay  be,  there  is  always  abund.ance  of  roonr  for  the  in- 
trodirction  of  the  rreces.«ar  y.  instrunrents.  The  polypus 
of  the  irterus  has  conrntonly  a thinirer  pedicle  than 
that  of  Ihe  nose ; hettce  its  cure  by  the  ligature  is  iirore 
expeditions;  arrd  on  accotrnt  of  the  greater  room  and 
nrore  yielding  n.atirie  of  the  parts,  the  swelliirg  of  the 
tuirrour,  after  the  ligature  is  apfrlicd,  produces  less  in- 
convenietree  than  in  the  sante  iirode  of  treatmeirt  of 
nasal  polypi.  The  inconveniences  wliich  do  arise  are 


270 


POLYPUS. 


easy  of  removal ; for  instance,  the  retention  of  urine 
may  be  relieved  by  the  catheter;  costiveness  by  glys- 
ters,  &c.  Uterine  polypi  are  also  less  sensible  than 
those  of  the  nose,  and  hence  less  pain  and  fever  follow 
the  application  of  a ligature  to  them.  The  fetid  mat- 
ter, formed  as  soon  as  the  polypus  sphacelates,  has  a 
free  vent  out,  and  may  easily  be  washed  away  by 
injections. 

That  the  polypus  cannot  be  tied  while  it  lies  in  llie 
uterus,  is  easily  comprehensible.  But  immediately  it 
has  descended  into  the  vagina,  the  operation  may  be 
undertaken,  and  may  be  performed  with  the  same 
kind  of  double  cannula  as  is  employed  in  the  nose. 
However,  here  it  is  extremely  requisite  that  the  can- 
nula should  be  rather  longer  than  that  already  de- 
scribed, and  somewhat  curved.  But  as  the  silver  wire 
sometimes  breaks,  two  other  very  convenient  instru- 
ments have  been  invented. 

The  first  is  Levret’s  instrument.  It  consists  of  two 
silver  cannulie  which  are  curved  in  such  a manner, 
and  so  united  by  a joint  that  they  are  shaped  like  a pair 
of  forceps.  After  introducing  a ligature  through  the 
two  tubes,  so  that  its  ends  hang  out  of  their  lower 
apertures,  the  instrument  is  to  be  shut  and  passed  up- 
wards into  the  vagina,  over  the  polypus,  on  whichever 
side  seems  most  convenient  Then  it  is  to  be  opened, 
and  the  polypus  is  to  be  pushed  through  the  two 
branches  of  the  instrument,  which  is  to  be  brought 
over  the  opposite  side  of  the  tumour.  In  doing  this, 
the  ligature  becomes  applied  round  the  root  of  the 
polypus,  and  forms  a noose.  The  extremities  of  the 
ligature  are  next  drawn  as  tightly  as  possible  out  of  the 
lower  opetiings  of  the  cannulte,  and  tied  first  in  a sur- 
gical knot,  and  then  in  a slip-knot.  The  instrument  is 
then  shut,  and  the  ligature  constricts  the  root  of  the 
polypus.  Afterward  it  is  to  be  tightened  daily  until  the 
tumour  sep.arates. 

Another  instrument  described  by  Nissen,  De  Polijins 
Uteri  (see  Richter's  Chir.  Bibl.  b.  9,  s.  613),  is  some- 
times preferred.  It  consists  of  two  silver  tubes,  twelve 
inches  in  length,  and  as  thick  as  an  ordinary  writing- 
pen.  Both  are  curved  about  as  much  as  the  os  sacrum ; 
but  as  they  are  made  of  pure  silver,  the  curvature  may 
easily  be  increased  or  diminished  according  to  circum- 
stances. Through  each  of  the  cannulae  a strong  liga- 
ture is  to  be  passed,  so  that  its  ends  hang  out  of  the 
lower  apertures,  while  its  middle  portion  forms  a noose 
between  the  upper  apertures  of  the  cannul®. 

The  tubes  are  to  be  kept  together  until  they  have 
been  introduced  into  the  vagina  as  far  as  the  root  of 
the  polypus.  One  is  then  to  be  held  fast,  while  the 
other  is  to  be  carried  round  the  tumour,  or  to  the  op- 
posite side  of  the  cannula  that  remains  stationary. 
Thus  the  ligature  becomes  applied  round  the  root  of 
the  polypus.  After  introducing  the  finger  into  the  va- 
gina, to  ascertain  that  the  ligature  lies  in  its  proper 
situation,  its  ends  are  to  be  drawn  through  a small 
double  cannula,  which  is  only  one-third  of  an  inch 
long,  but  so  wide  that  it  can  be  pushed  over  both  the 
tubes  a certain  way  with  the  finger  and  the  upper  end 
of  the  long  cannular,  with  the  aid  of  a sort  of  long  probe 
with  a forked  extremity.  Then  a third  double  cannula, 
through  which  the  ends  of  the  ligatures  have  likewise 
been  passed,  and  the  width  of  which  is  sufficient,  is  to 
be  pushed  over  the  lower  ends  of  the  long  cannut;e  so 
as  to  unite  them.  The  ligatures  are  next  to  be  drawn 
tight  in  the  ordinary  way,  and  fastened  to  the  rings. 
The  management  of  this  instrument  is  so  easy  as  to 
need  no  farther  explanation. 

Besides  the  above  instruments,  many  others  have 
been  devised  and  recommended  for  tying  pol)'pi  of  the 
uterus.  In  particular,  one  invented  by  Desault,  and 
another,  which  is  preferred  by  Mayer,  claim  the  atten- 
tion of  such  surgeons  as  wish  to  be  informed  of  others. 

The  ligature  sometimes  brings  on  acute  symptoms 
of  an  inflammatory  or  spasmodic  kind.  The  former 
require  antiphlogistic  treatment.  Sometimes  fever 
arises,  and  the  polypus  becomes  exceedingly  painful : 
in  this  case  venesection  is  necessary.  Spasmodic 
symptoms  require  the  exhibition  of  opium.  When 
this  is  ineflectual,  and  the  symptoms  are  severe,  it  may 
be  proper  to  slacken  the  ligature  a little.  As  the  poly- 
pus at  first  always  swells,  it  produces  great  pressure  on 
the  adjacent  parts.  For  this  reason  it  is  generally  ne- 
cessary, for  the  first  few  days,  to  draw  off  the  urine 
with  tile  catheter,  and  to  oinm  ilte  bowels  with  clysters. 
Sometimes  hcmorrliage  takes  place.  This  may  gene- 


rally be  suppressed  by  the  means  aiready  specified; 
but  when  they  prove  ineffectual,  the  ligature  must  be 
tightened. 

During  the  sphacelation  and  separation  of  the  poly- 
pus, the  frequent  use  of  injections  will  be  necessary 
for  the  sake  of  cleanliness,  and,  as  soon  as  the  mass  is 
loose  enough,  it  should  be  removed  with  a suitable 
pair  of  forceps. 

Richter,  in  common  with  most  practical  writers, 
disapproves  of  cutting  instruments  as  generally  im- 
proper for  polypi  of  the  uterus,  because  likely  to  injure 
the  vagina  and  occasion  a dangerous  hemorrhage.  He 
sanctions  the  use  of  the  knife,  however,  when  the  po- 
lypus has  a ligamentous  pedicle,  and  cannot  be  made 
to  separate  with  a ligature.  In  this  instance,  he  says, 
the  surgeon  may  either  cut  off  the  polypus  closely  ter 
its  root  in  the  vagina ; or  he  may  first  draw  it  gradually 
downwards  out  of  this  situation,  and  then  remove  it: 
perhaps  the  first  object  might  be  performed  with  a 
sharp  hook,  somewhat  curved  at  its  side,  and  similar 
to  what  is  used  for  tearing  the  foetus  piecemeal  in  the 
uterus;  or  with  what  seems  better,  a pair  of  long, 
curved,  blunt-pointed  scissors.  The  last  object  may 
be  accomplished  with  an  instrument  resembling  Smel- 
lie’s  midwifery-forceps,  which  is  to  be  introduced  into 
the  vagina  in  the  ordinary  way.  The  polypus  is  their 
to  be  taken  hold  of,  atid  very  gradually  drawn  so  far  out 
of  the  vagina,  that  its  pedicle  may  be  divided  with  a 
knife.  This  is,  indeed,  not  done  without  pain,  and  a 
forcible  inversion  of  tlie  uterus;  but  it  has  been  suc- 
cessfully practised.— (See  Herbiniaux,  Farallile  des 
differens  fnstrumens  pour  la  Ligature  des  Polypes.) 

When  a pol)  pu.s,  with  a pedicle  attached  to  the  fun- 
dus uteri,  suddenly  falls  downwards,  it  occasions  a 
sudden  inversion  of  this  viscus.  In  order  to  relieve, 
as  speedily  as  possible,  the  great  pain  and  danger  of 
this  case,  the  surgeon  must  lie  the  root  of  the  polypus 
as  soon  and  as  firmly  as  he  can,  and  pass  the  ligature, 
by  means  of  a needle,  through  the  pedicle,  before  the 
place  where  it  is  tied,  allowing  the  ends  afterward  to 
hang  down  for  some  length.  Then  the  polypus  is  to 
be  amputated  below  the  ligature,  and  the  uterus  im- 
mediately reduced. 

Siebold  and  Mayer,  of  Berlin,  only  approve  of  the 
ligature  in  two  cases : 1st,  when  an  artery  can  be  felt 
pulsating  in  the  neck  of  the  polypus;  2dly,  when  the 
neck  of  the  tumour  is  so  thick  that  it  probably  contains 
large  vessels.  In  all  other  examples  they  prefer  ex- 
cision, on  the  ground  of  the  difficulty  of  applying  a 
ligature,  and  because,  when  applied,  the  symptome 
are  apt  to  be  more  severe,  and  the  annoyance  greater, 
than  after  excision.  They  operate  with  round  pointed 
scissors,  curved  like  a Roman  S both  in  the  blades  and 
handles,  and  from  9 to  10^  French  inches  in  length. 
The  division  of  the  neck  of  the  tumour  is  to  be~  ef- 
fected not  all  at  once,  but  by  repeated  strokes  of  the 
instrument.  In  Mayer’s  work  six  cases  are  related  in 
which  polypi  of  the  uterus  were  thus  successfully  re- 
moved by  Siebold  and  himself. 

Fleshy  excrescences  occasionally  form  in  the  vagina, 
some  of  which  have  a broad  basi.s,  and  others  a thin 
pedicle.  The  last  merit  the  appellation  of  polypi. 
Their  existence  is  easily  ascertained  by  the  touch.  By 
making  pressure  on  the  bladder  and  rectum,  they  oc- 
casion several  impediments  to  the  evacuation  of  the 
urine  and  feces.  They  may  be  conveniently  tied  by 
means  of  the  double  cannula.  Should  the  polypus  be 
situated  at  the  lower  part  of  the  vagina,  this  instru- 
ment would  not  be  required.  The  ligature  might  be 
applied  with  the  hand,  and  the  tumour  cut  oflT^elow 
the  constricted  part. 

A polypus  in  the  oesophagus  renders  deglutition  dif- 
ficult: and  when  of  lar^e  size,  puts  an  entire  stop  to 
it.  When  an  inclination  to  vomit  is  excited  by  irri- 
tating the  throat  with  the  finger  or  a feather,  the  po- 
lypus, if  situated  towards  the  uptier  part  of  the  tube, 
ascends  into  the  mouth,  so  as  to  become  visible.  But 
as  it  impedes  respiration  during  its  residence  in  the 
mouth,  the  patient  is  soon  necessitated,  as  it  were,  to 
swallow  it  again.  When  it  is  situated  far  down  the 
oesophagus,  of  course  it  cannot  be  brought  infjo  the 
mouth,  and  is  very  difficult  to  detect.  The  difficulty 
of  swallowing,  its  only  symptom,  may  result  from 
other  causes.  In  this  case  it  is  also  incurable ; for  it  is 
impossible  to  take  hold  of  it  with  instruments.  An 
operation  can  only  be  practised  when  the  polypus  is 
situated  at  the  upper  part  of  the  oesophagus.  The 


POR 


lumour  cannot  be  extracted ; and  the  tying  of  it  is  diffi- 
cult. Sir  Astley  Cooper,  however,  has  succeeded  with 
a ligature  in  two  examples. — {Lecturesy  <S-c.  vol.  2, 
p.  356.) 

Polypi  in  the  rectum  may  be  tied  with  the  aid  of  the 
cannuliE.  Excrescences  in  the  meatus  audilorius  ex- 
ternus,  resembling  polypi,  have  been  successfully  ex- 
tirpated by  extraction,  or  rather  by  twisting  them  off. 

Richtevy  Anfangsgr.  der  Wundarin.  b.  1,  kap.  21.  J. 

B.  de  LavisweerdCy  Historia  JVaturalis  Malorum 
Uleriy  12/mo.  Lugd.  1700.  P.  G.  Schacher,  Programma 
de  PolypiSy  Lips.  1721.  C.  F.  Kaltschmidy  l)e  Mola 
scirrhosa  in  Utero  inverse  extirpatay  JenWy  1754.  C. 
Schencky  De  Polype  post  Febrem  Epidemicum  ex  Utero 
egressoy  Wittemb.  1739.  A.  Levrety  Obs.  sur  la  Cure 
radicate  de  plusieurs  Polypes  de  la  MatricCy  de  la 
GorgCy  et  da  JVez,  8ao.  PariSy  1749.  M.  O.  HerbiniauXy 
Traiti  sur  divers  Accoxichemens  laborieuxy  et  sur  les 
Polypes  de  la  Matricey  Src.  2 tom.  8vo.  Bruxellesy  1782 
— 1794.  E.  Grainger y Medical  and  Surgical  Remarks, 
including  a description  of  a simple  and  effectual  me- 
thod of  removing  Polypi  from  the  Uterus,  »S-c.  8vo. 
Land.  1815.  Denman's  Plates  of  a Polypus,  with  an 
Inversion  of  the  Uterus,  and  of  a Polypus  of  the  Ute- 
rus, fol.  1801.  F.  A.  Walter,  Annotationes  Academic(P.y 
Ato.  Berol.  1786.  W.  JVewnham,  An  Essay  on  the 
Symptoms,  Src.  of  Inversio  Uteri,  with  a History  of  the 
successful  Extirpation  of  that  Organ,  8vo.  Lond. 
1818.  Wenzel,  Krankheiten  des  Uterus,  Mainz,  1816. 

C.  G.  Mayer,  De  Polypis  Uteri,  Ato.  Berol.  1821. 
Pott's  Remarks  on  the  Polypus  of  the  Mose.  Whately's 
Two  Cases  of  extraordinary  Polypi,  8vo.  Lond.  1805. 
John  Bell's  Principles  of  Surgery,  vol.  3,  part  1.  En- 
cyclopidie  Methodique,  art.  Polype.  J.  G.  Haase,  De 
JTarium  Morbis  Comment.  Lips.  1794 — 1797.  Lassus, 
Pathologie  Chir.  1. 1,  p.  528 — 538,  6rc.  edit.  1809.  Cal- 
lisen's  Systema  Chirurgice  Hodiernee,  vol.  2,  p.  169,  SfC. 
J.  L.  Deschamps,  Traiti  des  Maladies  des  F'osses  JVa- 
sales,  et  de  leur  Sinus,  8vo.  Paris,  1804.  Mauche,  des 
Mai.  de  V Uterus,  8vo.  Paris,  1816.  S.  Schneider, 
Schediasma  de  Polypo  (Esophagivermiformirarissimo, 
Src.  Delitii,  1717.  Sir  Astley  Cooper's  Lectures,  ^c. 
vol.  2,  8oo.  Land.  1825. 

PORRIGO,  TINEA  CAPITIS  (called  also  Ring- 
worm of  the  Scalp,  Scald-head,  ire.),  is,  according  to 
Dr.  Bateman’s  excellent  account  of  the  subject,  a con- 
tagious disease,  principally  characterized  by  an  erup- 
tion of  the  pustules  denominated  favi  and  achores.. 
The  achor  is  defined  to  be  a small  acuminated  pustule, 
containing  a straw-coloured  matter,  which  has  the  ap- 
pearance and  nearly  the  consistence  of  honey,  and  is 
succeeded  by  a thin  brown  or  yellowish  scab.  The 
favus  is  larger,  flatter,  and  not  acuminated,  and  con- 
tains a more  viscid  matter ; its  base,  which  is  often 
irregular,  is  slightly  inflamed  ; and  it  is  succeeded  by  a 
yellow,  semi-transparent  and  sometimes  cellular  scab, 
like  a honey-comb;  whence  it  has  obtained  its  name. 
— (See  Bateman's  Synopsis  of  Cutaneous  Diseases,  p. 
xxiv.  and  159,  edit.  3.) 

This  intelligent  physician  has  noticed  six  species  of 
porrigo,  of  which  my  limits  will  allow  me  to  give  only 
a very  abridged  description. 

1.  The  porrigo  larvalis,  or  crusta  lactea  of  authors, 
begins  with  an  eruption  of  numerous  minute  v.  ’ Hish 
achores,  upon  a red  surface.  These  pustules  sooi! 
break,  and  discharge  a viscid  fluid,  which  concretes 
into  thin  yellowish  or  greenish  scabs.  The  disease  in- 
creases in  extent,  and  the  scabs  become  thicker  and 
larger,  until  the  forehead  and  cheeks,  even  the  whole 
face,  excepting  the  eyelids  and  nose,  become  enveloped 
ns  it  were  in  a mask,  whence  the  epithet  larvalis. 
Pinall  patches  of  the  disease  sometimes  appear  about 
the  neck  and  breast,  and  on  the  extremities;  and  the 
ears  and  scalp  are  usually  affected  in  the  progress  of 
the  ca.se.  The  infant  suffers  more  or  less  from  the 
itching  and  irritation.  When  the  discharge  is  copious 
and  acrid.  Dr.  Bateman  recommends  the  part  to  be 
wa.shed  two  or  three  times  a day  with  tepid  milk  and 
water,  and  the  application  of  the  unguentum  zinci 
alone,  or  mi.Tcd  with  the  saturnine  cerate.  The  latter, 
he  says,  will  be  useful  for  the  relief  of  the  excoriation 
lefl  after  the  ces.sation  of  the  discharge.  Small  d/)ses 
of  the  siibinuriate  of  mercury,  either  alone  or  in  com- 
bination with  a testaceous  powder,  will  also  expedite 
the  cure.  If  the  bowels  are  very  irritable,  the  hydrar- 
gyj:ijs  emn  crera,  or  the  cinereous  oxyde,  may  be  ex- 
htl/itcd  instead  of  the  calomel.  When  the  health  is 


POR  271^ 

good,  soda,  precipitated  sulphur,  and  the  tcstacea  will 
lessen  the  local  inflammation  and  discharge. 

When  the  irritation  is  removed,  and  the  crusts  are 
dry  and  falling  off,  tlie  unguentum  hydrarg.  nitrat. 
much  diluted  may  be  used,  and  the  decoction  of  bark, 
or  the  vinum  ferri,  prescribed. 

2.  Porrigo  furfurans  begins  with  an  eruption  of 
small  achores : the  excoriation  is  slight,  and  the  dis- 
charge, w'hich  is  not  abundant,  soon  concretes,  and  falls 
ofl’  in  innumerable  thin  laminated  scabs.  At  irregu- 
lar periods,  fresh  pustules  arise,  and  follow  the  course 
of  the  preceding.  The  complaint  is  confined  to  the 
scalp,  which  is  affected  with  itching  and  soreness ; and 
the  hair,  which  partly  falls  off,  becomes  thin,  less 
strong,  and  sometimes  of  a lighter  colour  than  natural. 
This  species  of  porrigo  occurs  principally  in  adults, 
and  it  is  sometimes  attended  with  swelling  of  the 
glands  in  the  neck.  Dr.  Bateman  observes,  that  the 
treatment  requires  the  hair  to  be  closely  cut  off  the 
scalp.  The  branny  scabs  are  then  to  be  gently  washed 
away  with  some  mild  soap  and  water  twice  a day; 
and  an  oil  silk  cap  should  be  worn.  In  the  beginning, 
when  the  surface  is  moist,  tender,  and  inflamed,  the 
zinc  ointment,  or  one  made  with  3 ij.  of  the  cocoulus 
indicus  and  5j-  of  lard.  Afterward,  when  the  scalp 
is  dry  and  free  from  ffritation,  it  may  be  washed  with 
common  soft  soap  and  water ; or  with  a mixture  of 
equal  parts  of  soft  soap  and  unguentum  sulphuris. 
Then  the  unguentum  hydrargyri  nitrati,  the  ung.  hy- 
drarg. nitrico-oxydi,  the  tar  and  sulphur  ointments,  or 
the  ung.  acidi  nitrosi  of  the  Edinb.  Pharm.,  may  be 
employed.  These  last  stimulant  applications,  how- 
ever, must  be  left  off  if  the  inflammation  and  discharge 
return. 

3.  Porrigo  lupinosa  is  characterized,  according  to 
Dr.  Bateman,  by  dry,  circular,  yellowish-white  scabs, 
set  deeply  in  the  skin,  with  elevated  edges,  and  a cen- 
tral depression,  and  somewhat  resembling,  on  the 
whole,  the  seeds  of  lupines.  These  scabs  are  formed 
upon  separate  clusters  of  achores,  and  attain  on  the 
scalp  the  size  of  a sixpence;  but  when  on  the  ex- 
tremities they  are  not  more  than  two  lines  in  diameter. 

In  the  treatment  of  the  porrigo  lupinosa,  the  scabs 
are  first  to  be  gently  washed  off  with  some  soap  and 
water,  and  the  scalp  is  to  be  shaved  if  it  be  the  part 
affected.  When  the  scabs  are  difficult  of  removal,  the 
liquor  potassoe,  or  a weak  lotion  of  muriatic  acid,  may 
be  used  fl/r  loosening  them.  Then  the  ointment  of 
cocculus  indicus  is  to  be  applied  to  the  red  cuticle,  and 
afterward  any  of  the  more  stimulant  ointments  above 
enumerated. 

4.  Porrigo  scutulata,  or  ringworm  of  the  scalp,  as 
Dr.  Bateman  has  observed,  makes  its  appearance  in 
separate  patches  of  an  irregular  circular  shape  upon 
the  scalp,  forehead,  and  neck.  It  commences  with 
clusters  of  small,  light-yellow  pustules,  which  soon 
break  and  form  thin  scabs,  which  if  neglected  become 
thick  and  hard.  If  the  scabs  are  removed,  however, 
the  surface  underneath  is  left  red  and  shining,  but 
studded  with  slightly  elevated  points  or  pustules. 
When  the  disorder  is  neglected,  the  patches  become 
confluent,  and  the  whole  head  affected.  Where  the 
disease  is  situated,  the  hair  becomes  lighter  in  its  colour, 
it  falls  off,  and  its  roots  are  destroyed.  The  porrigo 
scutulata  generally  occurs  in  children  three  or  four 
years  old  and  upwards,  and  frequently  proves  exceed 
ingly  obstinate.  According  to  Dr.  Bateman,  it  seems 
to  originate  spontaneously  in  children  of  feeble  and 
flabby  habit,  and  who  are  ill  fed,  uncleanly,  and  not 
sufficiently  exercised ; but  he  thinks  that  it  is  chiefly 
propagated  by  contagion,  i.e.  by  the  actual  conveyance 
of  the  matter  from  the  diseased  to  the  healthy,  as  may 
happen  in  the  frequent  contact  of  the  heads  of  chil- 
dren, the  use  of  the  same  towels,  combs,  caps,  and 
hats. 

While  the  patches  are  inflamed  and  irritable,  it  is 
necessary  to  limit  the  lotal  applications  to  washing  the- 
parts  with  warm  water.  Even  shaving  the  scalp, 
which  must  be  repeated  at  intervals  of  eight  or  ten 
days,  produces  a temporary  irritation.  Nothing  but  a 
light  linen  cap  is  now  to  be  worn,  and  it  must  be  often 
changed. 

The  disease  afterward  forms  dry  scabs,  and  becomes 
for  a time  less  irritable;  but  a fresh  eruption  of  achores 
soon  follows,  and  the  inflainmation  and  redtiess  return. 

In  Ihe  inflamed  stales.  Dr.  Hiiternan  recommends 
the  use  of  ointments  made  either  with  the  cocculus- 


272 


POT 


PRO 


liidicu?,  submuriate  of  mercury,  oxyde  of  zinc,  super- 
acetate  of  lead,  opium,  or  tobacco;  or  else  the  infusion 
of  poppy  lieads  or  tobacco.  When  there  is  an  acri- 
monious discharge.  Dr.  Bateman  prescribes  the  zinc, 
or  saturnine  ointments,  the  ung.  liydrarg.  praecip.,  ca- 
lomel ointment,  or  a lotion  of  lime-water  and  calomel. 

In  the  less  irritable  stages,  the  ung.  hydrarg.  praecip., 
the  ung.  hydrarg.  iiitrico  oxydi,  and  especially  the  ung. 
hydrarg.  nitrat.,  are  often  effectual  remedies.  So  are 
the  ointments  of  sulphur,  tar,  hellebore,  and  turpen- 
tine, and  lotions  of  the  sulphates  of  zinc  and  copper, 
or  the  oxyinuriate  of  mercury.  I have  often  seen  a 
solution  of  3 j.  of  the  sulphuret  of  potassa  in  a pint  of 
lime  water  succeed  when  most  other  applications  had 
failed.  In  the  very  dry  and  inert  state  of  the  patches. 
Dr.  Bateman  has  seen  the  disease  removed  by  a lotion, 
cotitaining  from  three  to  six  grains  of  the  nitrate  of 
silver  in  an  ounce  of  distilled  water.  The  application 
of  the  diluted  mineral  acids,  or  of  a blister,  has  also 
been  known  to  put  a permanent  stoppage  to  the  mor- 
bid action. 

In  general,  no  local  application  agrees  well  if  long 
continued,  and  it  is  necessary  to  have  several  which 
must* be  alternately  employed. 

The  cure  may  often  be  expedited  by  cinchona,  chaly- 
beate, and  alterative  medicines;  and  attention  must  be 
paid  to  the  patient’s  diet,  exercise,  &c. 

5.  Porrigo  dccalvans  consist  in  bald  patches,  sur- 
rounded by  hair,  which  is  as  thick  as  usual.  It  is  not 
known  whether  any  eruption  of  minute  anchores  actu- 
ally precedes  the  detachment  of  the  hair. 

Dr.  Bateman  remarks,  that  if  the  scalp  be  regularly 
shaved,  and  some  stimulating  liniment  be  applied  to  it, 
this  obstinate  affection  may  at  length  be  overcome,  and 
the  hair  will  regaiti  its  usual  strength  and  colour.  Two 
drachms  of  oil  of  rnace  in  three  or  four  ounces  of  al- 
cohol are  said  to  make  an  excellent  liniment.  • 

6.  Porrigo  favosa  consists  of  an  erufition  of  the 
large,  soft,  straw-coloured,  flattened  pustules,  denomi- 
nated/aaf,  which  may  occur  on  any  part  of  the  body; 
but  most  commonly  spread  from  the  scalp,  especially 
behind  the  ears  to  the  face,  or  from  the  lips  and  chin  to 
the  scalp.  They  arc  attended  with  considerable  itch- 
ing, and  are  most  frequently  seen  in  children  from  six 
months  to  four  years  of  age,  though  adults  are  also 
often  affected.  The  pustules  pour  out  a viscid  matter, 
which  concretes  into  greenish  or  yellowish  semi-trans- 
parent ^cabs.  When  the  hair  and  moist  scabs  are 
matted  together,  pediculi  are  often  generated  in  great 
number.®,  and  aggravate  the  itching  and  irritation.  If 
the  disease  be  allowed  to  increase,  the  scabs  are  thick- 
ened into  irregular  masses  not  unlike  honey-comb ; 
and  considerable  ulcerations  somelimes  form,  espe- 
cially when  the  heel  and  toes  or  other  parts  of  the 
lower  extremities  are  affected.  The  ulcerating  blotches 
tire  generally  soon  followed  by  irritation  and.  swelling 
of  the  lymphatic  glands,  which  sometimes  slowly  sup- 
purate. The  contact  of  the  discharge  innoculates  the 
disease  ; thus,  in  young  children,  the  breast  is  innocu- 
lated  by  the  chin  ; and  the  arm  and  bre<ast  of  the  nurse 
may  be  infected  in  the  same  way;  though  adults  do 
not  take  the  complaint  so  quickly  as  children. 

The  porrigo  favosa  requires  the  same  alteratives  in- 
ternally as  the  porrigo  larvalis.  The  diet  should  cori- 
si.st  of  milk,  puddings,  and  a little  plain  animal  food. 
When  the  habit  is  bad  and  the  glands  swelled,  bark, 
chalybeates,  and  a solution  of  the  muriate  of  barytes 
are  proper. 

As  local  applications.  Dr.  B-ateman  prefers  the  un- 
guentum  zinci,orthe  ung.  hydrarg.  iii  tecip.  mixed  with 
this  or  the  saturnine  ointment,  especially  when  the  di.s- 
charge  is  copious.  He  also  speaks  favourably  of  the 
ung.  hydrarg.  nitrat.,  the  strength  of  which  is  to  be  di- 
minished by  an  addition  of  simple  cerate,  according  to 
the  degree  of  irritation  present. 

For  the  preceding  particulars  I am  indebted  to  Dr. 
Bateman’s  valuable  Synopsis  of  Cutaneous  Diseases, 
where  the  reader,  desirous  of  additional  information 
••especting  porrigo,  will  be  amply  gratified. 

POTASSA  ARSENICATA;  Kali  ^rsenicatuw. 
Arsenias  Kali.  R.  Oxydi  albi  arsenici,  potasste  ni- 
tratis  sing.  5 j.  Crucibnlo  amplo  igne  candenti  injice 
nitrum,  el  liquefacto  adde  gradalim  arsenicum  in  frus- 
tulis  donee  vapores  nitrosi  oriri  cessaverint.  Solve 
materiam  in  aqiite  distillatie  Ibiv.,  et  post  idoneam  eva- 
porationem  sepone  ut  fianr  crystalli.  These  crystals 
may  be  given  in  the  dose  of  one  tenth  of  a grain, 


thrice  a day. — {Pkarin.  Sancti  Barthol.  1799.)  Justd* 
mond  strongly  recommended  the  internal  exhibition  of 
arsenic  in  cases  of  cancer.— (See  Cancer.) 

POTASSiE  CARBONAS.  Somelimes  given  as  a 
palliative  in  cases  of  stone;  the  dose  is  3 ij.  in  Ibj.  of 
distilled  water,  twice  a day. 

POTASS.'^  CUM  CALCE.  This  is  a strong  kind 
of  caustic,  chiefly  used  for  making  the  eschars,  when 
issues  are  formed  in  cases  of  diseased  vertebrae,  white 
swellings,  morbid  hip-joints,  &c.— (See  Vertebrm.)  It 
is  alsf»  sometimes  used,  though  not  so  often  as  it  was 
formerly,  for  opening  buboes  and  other  absces.ses.  Some 
are  in  the  habit  of  making  it  into  a paste  with  soft 
soap;  they  cover  the  part  affected  with  adhesive  plas- 
ter, in  which  there  is  a hole  of  the  size  of  the  eschar 
intended  to  be  made;  and  into  this  aperluie  they  press 
the  paste  till  it  touches  the  skin.  A bandage  is  then 
applied  to  secure  the  caustic  substance  in  its  situation 
till  the  intended  effect  is  produced. 

The  action  of  calx  cum  potassa  in  this  way,  how- 
ever, is  more  inert  and  tedious,  and  perhaps  on  this  ac- 
count more  painful.  Hence,  many  of  the  best  modern 
surgeons  never  adopt  this  method;  but, after  covering 
the  surrounding  parts  with  sticking  plaster,  rub  the 
caustic  on  the  situation  where  it  is  desired  to  produce 
an  eschar  till  the  skin  turns  brown.  The  end  of  the 
caustic  must  first  be  a little  moistened. 

The  calx  cum  potassa  is  sometimes  employed,  also, 
for  destroying  fungous  excrescences. 

Before  the  port  wine  injection  was  found  • •)  answer 
best  for  the  radical  cure  of  hydrocele,  this  ca.isiic  was 
often  used  as  a means  of  cure. — (See  Hydroeex.  c.)  Mr. 
Else,  a chief  advocate  for  the  latter  method,  used  to 
mix  the  caustic  with  powdered  opium,  by  whi:h  con- 
trivance, it  is  said,  though  not  with  much  appojii  ance 
of  truth,  that  the  sloughs  were  made  with  little  or  no 
pain  to  the  patient. 

Some  assert  that  the  potassa  alone  acts  more  qwickly 
than  when  mixed  with  quicklime.  I have  not  found 
this  to  he  the  fact;  and,  after  trying  both,  give  the  pre- 
ference to  the  calx  cum  potassa. 

POTASSA  FUSA.  Caustic  Potassa  One  of  the 
most  useful  caustics  for  destroying  fungi  and  making 
issues ; and  it  was  recommended  to  be  used  in  a parti- 
cular manner,  by  Mr.  Whately,  for  the  cure  of  stric- 
tures in  the  urethra.  When  surgeons  prefer  opening 
buboes  or  any  other  abscesses  with  caustic,  the  caustic 
potassa  is  very  commonly  employed.  When  surgeons 
used  to  cure  hydroceles,  by  destroying  a part  of  the 
scrotum  and  tunica  vaginalis  with  caustic,  the  potassa 
fusa  either  alone  or  mixed  with  quicklime  was  mads 
use  of — (See  Kertebree,  Urethra,  Strictures  of,  <S-c.) 

POTASS^  SULPHURETUM . Sulphuret  of  Pot- 
ash, JAver  of  Sulphur.  Two  drachms,  dissolved  in  a 
pint  of  lime  or  distilled  water,  make  an  excellent  lo- 
tion for  the  cure  of  porrigo.  Many  other  cutaneous 
affectionsyield  also  to  the  same  remedy.  When  arsenic 
has  been  swallowed  as  a poison,  twenty  grains  of  the 
sulphate  of  zinc  may  be  given  as  an  emetic  of  the 
quickest  operation  : and  after  keeping  up  the  vomiting 
by  drinking  warm  water,  and,  what  is  better,  sweet  oil, 
some  authors  recommend  making  the  patient  drink  as 
much  as  possible  of  a solution  of  the  sulphuret  of  potash. 

PREGNANCY  is  set  down  by  some  writers  as  pre- 
ventive of  the  union  of  broken  bones  ; but  many  ex- 
ceptions to  the  remark  present  themselves  in  practice: 

I have  attended  myself  a female,  six  months  gone  with 
child,  who  broke  both  bones  of  her  leg,  yet  they  grew 
together  again  in  the  usual  time. — (See  Fractures.) 
Pregnant  women  also  frequently  bear  operations  much 
belter  than  might  be  expected.  Thus  M.  Nicod  has 
published  a successful  amputation  of  tlie  left  leg  during 
pregnancy,  in  a case  where  the  right  lendo  achillis 
was  also  ruptured.  Both  the  wound  and  the  broken 
tendon  united  very  well. — (See  Annuaire,  Med.  Chir. 
des  Hdpitaux  de  Paris,  p.  509,  ito.  Pai  is,  1819.) 
However,  though  a severe  accidental  injury  may  jus- 
tify an  operation  in  pregnancy,  I consider  the  removal 
of  a diseased  joint,  breast,  or  other  important  part, 
quite  unjustifiable  in  this  slate  of  the  constitution. 

PROBANG.  A long  slender  bit  of  whalebone,  with 
a bit  of  sponge  at  its  extremity,  intended  for  the  exa- 
mination of  the  oesophagus,  or  the  remeval  of  obstruc- 
tions in  it. 

PROCIDE'NTIA.  Prolapsus.  A falling  down  of 
any  jiaii. — (See  Anus,  Prolapsus  of;  Uterus,  Prolap- 
sus of,  S,-c.) 


PROSTATE  GLAND. 


273 


prostate  gland,  diseases  of.  It  is  an 

observation  made  by  Mr.  Hunter,  that  the  use  of  this 
gland  is  not  sufficiently  known  to  enable  us  to  judge  of 
the  bad  consequences  of  its  diseased  state,  abstracted 
from  swelling.  Its  situation  (says  he)  is  such,  that  the 
bad  effects  of  its  being  swelled  must  be  evident,  as  it 
may  be  said  to  make  a jmrt  of  the  canal  of  the  ure- 
thra, and,  therefore,  when  it  is  so  diseased  that  its  shape 
and  size  are  altered,  it  must  obstruct  the  passage  of  the 
urine. — {On  the  Venereal  Disease^  p.  169.)  A swelling 
of  the  prostate  gland,  however,  may  be  of  very  differ- 
ent kinds  i thus  it  may  depend  either  upon  common  in- 
flammation of  the  part,  abscesses,  calculi  formed  within 
its  substance,  a varicose  enlargement  of  its  vessels,  or 
a scirrhous  chronic  induration. — (See  (Euvres  Chir.  de 
Desault  par  Bichat^  t.  3,  p.  220.) 

Modern  anatomists  describe  the  prostate  gland  as 
not  being  itself  a very  sensible  part,  and  hence  it  is 
more  subject  to  chronic  than  acute  disease,  to  which, 
however,  it  is  also  liable.  We  have  the  authority  of 
Desault,  Hunter,  and  Dr.  Baillie,  for  setting  it  down  as 
the  occasional  seat  of  scrofula.  The  latter  physician, 
after  stating  that  he  has  seen  a common  abscess  si- 
tuated in  it,  adds,  that  it  is  also  subject  to  scrofulous 
disease,  as  on  cutting  into  it,  he  has  met  with  the  same 
white  curdy  matter  which  is  formed  in  a scrofulous  ab- 
sorbent gland  : he  has  likewise  forced  out  of  its  duct 
scrofulous  pus. — {Morbid  Anatomy,  ire.) 

Mr.  Lloyd  has  met  with  fleshy  enlargements  of  the 
gland,  in  the  substance  of  which  several  small  ab- 
scesses were  formed,  containing  “ a complete  scrofu- 
lous matter.”  He  has  also  known  enormous  enlarge- 
ments of  this  gland  happen  in  young  men,  who  were 
labouring  at  the  same  time  under  other  scrofulous  dis- 
ease. Other  instances  of  supposed  scrofulous  swell- 
ings of  the  same  part  in  young  patients  are  likewise 
cited  by  this  author,  one  of  which  is  particularly  re- 
markable, as  in  it  the  gland  was  found  after  death  to  be 
of  the  size  of  a child’s  head,  though  its  natural  consist- 
ence was  not  much  changed. — {On  Scrofula,  p.  107.) 
Other  chronic  or,  as  they  are  more  often  called,  scir- 
rhous enlargements  of  the  prostate  gland,  rarely  occur 
in  subjects  under  the  age  of  fifty.  To  these  cases  1 
shall  presently  return. 

Like  every  other  partof  the  body,  the  prostate  gland 
is  sometimes,  but  not  often,  the  seat  of  common  phleg- 
monous inflammation.  Mr.  Wilson  has  known  two 
or  three  instances  of  this  kind  take  place  soon  after  pu- 
berty ; one  case  was  from  a fall ; the  other  arose  with- 
out any  assignable  cause. — {On  the  Male  Urinary  and 
Genital  Organs,  p.  327.)  There  is  also  a phlegmon- 
ous swelling  of  the  prostate  gland,  sometimes  an  effect 
of  strictures,  as  will  presently  be  noticed.  As  Desault 
observes,  the  retention  of  urine,  arising  from  such 
a cause,  comes  on  very  suddenly,  and  rapidly  increases. 
The  patient  at  first  complains  of  a sense  of  heat  and 
weight  about  the  perinaeum : and  soon  afterward  of  a 
continual  throbbing  pain  about  the  neck  of  the  bladder. 
The  pain  is  severely  increased  when  the  patient  goes 
to  stool ; and  there  is  tenesmus  and  frequent  inclina- 
tion to  make  water.  However,  according  to  Mr.  Wil- 
son, the  desire  to  evacuate  the  urine  is  here  less  con- 
stant, than  in  cases  where  the  inner  membrane  of  the 
bladder  is  inflamed. — {Vol.  cit.p. 327.)  The  patient  feels 
also  as  if  a large  mass  of  excrement  filled  the  ex- 
tremity of  the  rectum,  and  were  ready  to  come  out. 
If  a finger  be  introduced  within  the  rectum,  the  swell- 
ing of  the  gland  is  plainly  distinguishable ; and,  accord- 
ing to  J.  L.  Petit,  the  projection  of  the  prostate  gland 
in  the  bowel  makes  a corresponding  hollow  groove  along 
the  concave  side  of  the  excrement,  as  may  be  noticed 
when  what  is  voided  is  hard.  However,  Bichat  con- 
ceives that  such  an  appearance  must  generally  be 
obliterated  as  the  excrement  is  passing  through  the 
sphincter.  When  the  patient  attempts  to  make  water. 
It  is  a long  while  before  the  first  drops  come  out ; and 
as  straining  has  the  effect  of  propelling  the  swelled 
prostate  more  against  the  neck  of  the  bladder,  it  only 
Increases  the  difficulty,  and  no  urine  will  come  out 
until  such  efforts  are  discontinued.  The  more  violent 
the  inflammation  is,  the  smaller  is  the  stream  of  urine, 
and  the  more  acute  the  pain  felt  during  its  expulsion. 
According  to  Desault,  it  is  likewise  particularly  rernark- 
iihle  in  such  cases,  that  if  an  attempt  be  made  to  inlro- 
(iUce  a catheter,  the  instrument  passes  without  the 
least  resi.stance  as  far  as  the  prostate  gland,  where 
“ antlgCauses  great  pain.  The  pulse  is  hard 


and  frequent ; and  the  patient  is  exceedingly  thirsty 
and  feverish.  Desault  considered  the  retention  of 
urine  in  cases  of  this  kind,  and,  indeed,  in  all  enlarge* 
ments  of  the  prostaiejland,  or  other  obstructions  of  the 
urethra,  as  generally  "more  dangerous  than  other  reten- 
tions, merely  depending  upon  weakness  of  the  bladder, 
where  there  is  little  risk  of  this  organ  giving  way. 
When  the  urethra  is  free  from  obstruction,  the  urine, 
after  distending  the  bladder  in  a certain  degree,  gene- 
rally oozes  through  that  canal,  and  the  patient  may  live 
in  this  condition  for  years  without  any  alarming  symp- 
toms. But  the  case  is  different  when  the  retention  of 
urine  depends  upon  any  stoppage  or  stricture  in  the 
urethra.  The  urine  does  not  then  partially  escape,  but 
stagnates  in  tlie  bladder  ; the  distention  increases  ; and 
if  speedy  relief  be  not  afforded,  a perilous  extravasation 
follows.  The  danger,  however,  of  such  a retention 
of  urine  depends  very  much  upon  the  extent  and  seve* 
rity  of  the  inflammL.iion.  However,  this  statement 
will  not  apply  to  the  chronic  scirrhous  enlargement  of 
the  prostate,  because,  as  will  be  presently  explained,  in 
this  affection  some  of  the  urine  begins  to  dribble  away 
after  the  bladder  has  become  distended  in  a certain 
degree. 

In  cases  of  phlegmonous  inflammation  of  the  pros- 
tate gland,  antiphlogistic  treatment  is  indicated ; espe- 
cially venesection,  leeches  to  the  perinseum  and  near 
the  anus,  the  warm  bath,  emollient  clysters,  poultices 
and  fomentations,  and  a low  regimen.  However,  as 
Desault  admits,  the  efficacy  of  these  means  is  often 
too  slow,  and  the  symptoms  too  urgent,  to  allow  the 
surgeon  to  wait  for  the  urine  to  flow  of  itself.  Fre- 
quently, also,  the  distention  has  so  weakened  the  blad- 
der, that  this  organ  cannot  expel  its  contents;  in  which 
event  the  catheter  must  be  used,  though  the  diminished 
diameter  and  altered  course  of  the  prostatic  portion  of 
the  urethra  sometimes  render  its  introduction  difficult, 
and  always  very  painful.  The  practical  observations 
respecting  the  best  kind  of  catheters,  and  the  mode  of 
introducing  them  in  cases  of  swelled  prostate  gland, 
will  be  more  conveniently  introduced  when  the  chronic 
enlargement  of  this  part  is  considered. — (See  also  Ca- 
theter, and  Urine,  Retention  of.)  In  every  instance  of 
retention  of  urine  from  acute  inflammation  about  the 
neck  of  the  bladder,  whether  the  case  be  an  abscess 
forming  near  the  anus,  or  a phlegmonous  inflammation 
of  the  prostate  gland,  or  other  adjacent  part,  it  has 
always  appeared  to  me,  that  antiphlogistic  and  ano- 
dyne remedies  should  first  be  fairly  tried,  and  the  ca- 
theter, which  always  increases  the  pain  and  irritation, 
only  used  when  such  means  do  not  afford  relief  with 
sufficient  expedition. 

When  a catheter  has  been  introduced  ought  it  to  be 
left  in  the  bladder,  or  withdrawn,  after  the  discharge 
of  the  urine?  Its  presence,  no  doubt,  will  increase  the 
irritation  about  the  neck  of  the  bladder ; but,  on  the 
other  hand,  if  it  be  taken  out,  the  surgeon  may  not  be 
able  to  introduce  it  again.  No  general  precept,  says 
Desault,  can  be  laid  down  on  this  point.  The  course 
which  the  practitioner  will  pursue,  must  depend  upon 
the  difficulty  he  has  experienced  in  getting  the  instru- 
ment into  the  bladder,  and  upon  the  confidence  which 
he  may  have  in  his  own  skill,  and  which  must  be 
founded  upon  constant  success  in  analogous  instances. 

According  to  Desault,  when  an  abscess  follows  in- 
flammation of  the  prostate,  the  body  of  the  gland  itself 
does  not  suppurate,  but  only  the  surrounding  parts  and 
the  cellular  substance  which  connects  its  lobes  together. 
This,  at  least,  was  what  was  observed  in  examining 
several  dead  subjects,  who  were  publicly  opened  in  the 
amphitheatre  of  the  H6tel-Dieu. 

When  the  symptoms  of  inflammation  have  lasted  a 
week,  and  all  this  time  have  continued  to  increase; 
when,  after  this  period,  they  have  abated  a little,  and 
then  become  violent  again ; and  when  the  febrile 
symptoms  grow  worse  in  the  evening,  and  have  been 
preceded  by  shiverings ; there  is  reason  to  suspect  the 
formation  of  matter.  It  cannot  be  known  whether  the 
pus  is  collected  in  one  particular  place,  or  diffused. 
When  the  matter  is  external  to  the  gland,  the  ca.se  is 
less  serious  than  when  it  occupies  the  cellular  substance 
connecting  the  lobes.  According  to  Desault,  the  latter 
form  of  the  disease  seldom  gets  well.  'I’here  are  no 
peculiar  symptoms  which  denote  it ; the  matter  does 
not  readily  make  its  way  outward.s  ; and  the  state  of 
things  is  not  clear  enough  to  admit  of  .'in  incision  lieing 
made.  Besides,  Desault  doubled  whether  an  incision 


274 


PROSTATE  GLAND. 


could  b€  of  much  use,  since  it  would  probably  only 
discharge  the  matter  in  its  vicinity. 

Things  are  different  when  the  pus  is  collected  in  one 
place,  and  is  more  superficial.  If  situated  between  the 
gland  and  neck  of  the  bladder,  Desault  says  it  will 
often  spontaneously  burst  into  this  viscus,  or  it  may  be 
let  out  with  the  point  of  the  catheter.  It  will  then 
either  be  discharged  through  the  instrument,  or  come 
away  with  the  urine.  However,  according  to  Mr. 
Wilson,  abscesses  of  the  prostate  gland  generally  burst 
into  the  urethra  behind  the  caput  gallinaginis,  but  some- 
times before  it ; and  he  has  seen  nrore  than  one  in- 
stance in  which  they  have  burst  in  the  perinteum. — 
( On  the  Male  Urinary  and  Genital  Organs,  p.  329.) 
Should  the  abscess  lie  near  the  rectum  and  perinteum, 
and  admit  of  being  distinctly  felt,  Desault  conceived 
that  a free  opening  would  expedite  the  cure.  Several 
cases  of  this  description,  I have  treated  in  this  way 
with  success  : they  mostly  arose  from  strictures. 

In  many  cases  the  use  of  the  catheter  is  requisite  in 
order  to  let  out  the  urine,  and  as  the  instrument  must 
be  left  in  the  passage  some  time,  Desault  preferred  one 
made  of  elastic  gum.  As  Mr.  Wilson  has  remarked, 
soothing  means  should  also  be  employed ; internal 
narcotic  medicines,  anodyne  clysters,  the  mixtura 
amygdalarum,  &c. 

Morgagni  has  taken  notice  of  the  retentions  of  urine 
arising  from  the  presence  of  calculi  in  the  prostate 
gland.  The  nature  of  these  concretions  will  be  de- 
scribed in  the  article  Urinary  Calculi.  Calculi  also 
sometimes  form  in  or  about  the  prostate  gland,  when, 
after  lithotomy,  the  outer  part  of  the  wound  heals 
sooner  than  the  bottom.  A kind  of  urinary  fistula 
then  ensues  : and  as  the  extraneous  substance  is  con- 
stantly exposed  to  the  contact  of  fresh  urine,  it  may 
increase  to  a large  size.  The  d-agnosis  of  prostatic 
calculi  is  seldom  very  clear.  A retention  of  urine  and 
an  impediment  to  the  emission  of  the  semen  are  said 
to  be  the  only  symptoms,  and  these  are  common  to 
several  other  affections  of  tiie  prostate  gland  and  ure- 
thra. When  the  finger  is  introduced  into  the  rectum, 
the  gland  may  indeed, be  felt  to  be  enl.arged  ; but  the 
nature  and  cause  of  such  enlargement  cannot  in  general 
be  distingnished.  In  one  instance,  however,  recorded 
by  Dr.  Marcet,  the  calculi  could  be  plainly  felt  through 
the  coats  of  the  rectum,  and  a proposal  was  made  to 
extract  them  by  an  incision  in  that  situation  ; but  the 
patient  did  not  accede  to  so  judicious  a measure. — 
{Med.  and  diem.  Hist,  of  Calculous  Disorders,  Boo. 
1817.)  When  a calculus  projects  from  the  prostate 
gland  into  the  urethra,  the  end  of  a sound  will  strike 
against  it ; but  then  it  can  rarely  be  known  whether 
the  extraneous  substance  may  not  be  a calculus  that 
has  passed  out  of  the  bladder  into  the  urethra,  or  lies 
close  to  the  neck  of  this  viscus. 

Whether  the  case  be  of  one  description  or  the  other, 
however,  the  treatment  should  be  tire  same ; viz.  the 
calculus  should  be  extracted  by  an  incision  ; and  if  the 
situation  of  the  calculi  will  admit  of  their  being  taken 
out  without  the  bladder  itself  being  cut,  this  plan  should 
undoubtedly  be  pursued. 

A considerable  varicose  affection  of  the  vessels  of 
the  prostate  gland,  which  is  also  itself  generally  some- 
what enlarged,  is  another  disease  treated  of  by  writers 
as  one  cause  of  a retention  of  urine.  In  this  case,  the 
water  should  be  drawn  off  with  an  elastic  gum  catheter, 
which  should  be  kept  in  the  urethra  ; and  a large  in- 
strument is  to  bo  preferred  to  a smaller  one.  For  an 
account  of  the  symptoms  of  this  case,  I must  refer  to 
Des  (Euvres  Chir.  de  Desault,  t.  3,  p.  234.  The  prac- 
tice of  this  author  was  gradually  to  dilate  the  portion 
of  the  urethra  which  passes  through  the  prostate  with 
bougies  or  elastic  catheters,  which  were  worn  a long 
while,  and  cleaned  and  changed  at  proper  intervals.  I 
am  not  aware,  that  these  cases  are  recognised  in  the 
practice  of  surgery  in  England. 

The  most  frequent  disease  of  the  prostate  gland,  and 
of  course  that  which  is  most  interesting  to  the  practical 
surgeon,  is  a slow  hardening  and  enlargement  of  it, 
sonietimes  denominated  scirrhus,  whereby  its  natural 
size,  which  is  that  of  a common  chestnut,  is  sometimes 
gradually  changed  to  that  of  a man’s  fist. — (.7.  L.  Petit.) 
According  to  the  observations  of  Hunter,  Desault,  and 
Sir  Everard  Home,  this  chronic  swelling  of  the  pros- 
tate gland  is  most  common  in  the  decline  of  life; 
one  circumstance  in  which  it  differs  from  scrofulous 
diseases  of  the  same  part,  which  ate  well  known  to 


happen  chiefly  in  youngish  persons.  It  is  observed  by 
Mr.  Hunter,  that  when  the  prostate  gland  swells,  it  does 
not  lessen  tlie  surface  of  the  urethra  at  the  part  like  a 
stricture;  on  the  contrary,  it  rather  increases  it;  but 
the  sides  of  the  canal  are  compressed  together,  produc- 
ing an  obstruction  to  the  passage  of  the  urine,  which 
irritates  the  bladder  and  brings  on  all  the  symptoms  in 
that  viscus  usually  arising  from  a stricture  or  stone. 
From  the  situation  of  the  gland,  which  is  principally  on 
the  two  sides  of  the  canal,  and  but  little  if  at  all  on 
the  fore  part,  as  also  very  little  on  the  posterior  side,  it 
can  only  swell  laterally,  whereby  it  presses  the  two 
sides  of  the  canal  together,  and  at  the  same  time 
stretches  it  from  the  anterior  edge  or  side  to  the  pos- 
terior, so  that  the  canal,  instead  of  being  round,  is  flat- 
tened into  a narrow  groove,  and  sometimes  the  gland 
swells  more  on  one  side  than  the  other,  which  tnakes  an 
obliquity  in  the  canal  passing  through  it. 

“ Besides  this  effect  of  the  lateral  parts  swelling,  a 
small  portion  of  the  gland  which  lies  behind  the  very 
beginning  of  the  urethra,  swells  forwards  like  a point, 
as  it  were,  into  the  bladder,  acting  like  a valve  to  the 
mouth  of  the  urethra,  which  can  be  seen  even  when 
the  swelling  is  not  considerable,  by  looking  upon  the 
mouth  of  the  urethra  from  the  cavity  of  the  bladder  in 
a dead  body.  It  sometimes  increases  so  much  as  to 
form  a tumour,  projecting  into  the  bladder  some  inches. 
This  projection  tuins  or  bends  the  urethra  forwards, 
becoming  an  obstruction  to  the  passage  of  a catheter, 
bougie,  or  any  such  instrument ; and  it  often  raises  the 
sound  over  a small  stone  in  the  bladder,  so  as  to  pre- 
vent its  being  felt.” — {Hunter,  On  the  Venereal  Dis- 
ease, p.  169.)  The  valvular  production  just  behind  the 
beginning  of  the  urethra  here  described,  particularly 
merits  attention,  because  it  is  represented  by  Sir  Eve- 
rard Home  as  arising  from  the  enlargement  of  what  he 
considers  a newly-discovered  part  in  anatomy,  viz.  a 
third  or  middle  lobe  of  the  prostate  gland. — (See  Phil. 
7'rans.  1806.)  In  the  dissections  which  Sir  Everard 
mentions  as  having  led  to  this  discovery,  “ the  urinary 
bladder  was  distended  with  water,  and  the  surfaces  of 
the  prostate  gland,  vesicul®  seminales,  and  vasa  defe- 
rentia  were  fairly  exposed.  This  being  done,  the  vasa 
deferentia  and  vesiculas  seminales  were  carefully  dis- 
sected off  from  the  bladder,  without  removing  any 
other  part.  These  were  turned  down  upon  the  body 
of  the  prostate  gland.  An  accurate  dissection  was 
then  made  of  the  circumference  of  the  two  posterior 
portions  of  the  prostate  gland,  and  the  space  between 
them  was  particularly  examined.  In  doing  this,  a 
small  rounded  substance  was  discovered,  so  much  de- 
tached that  it  seemed  a distinct  gland,  and  so  nearly 
resembling  Cowper’s  glands  in  size  and  shape,  as  they 
appeared  in  the  same  subject,  in  which  they  were  un- 
usually large,  that  it  appeared  to  be  a gland  of  that  kind. 
It  could  not,  however,  be  satisfactorily  separated  from 
the  prostate  gland,  nor  could  any  distinct  duct  be  found 
leading  into  the  bladder, 

“ A similar  examination  was  made  of  this  part  in 
five  different  subjects.  The  appearance  was  not  ex- 
actly the  same  in  any  two  of  them.  In  one,  there  was 
710  apparent  glandular  substance,  but  a mass  of  con- 
densed cellula'>‘  membr-ane ; this,  however,  on  being  cut 
into,  differed  from  the  surrounding  fat.  In  another 
there  was  a lobe,  blended  laterally  with  the  sides  of 
the  prostate  gland.  These  facts  (says  Sir  Everard 
Home)  are  mentioned,  in  proof  of  its  not  being  always 
of  the  same  size,  or  having  exactly  the  same  appear- 
ance.” 

This  is  found  also  to  be  the  case  with  Cowper’s 
glands:  they  are  sometimes  large  and  distinct;  in 
other  subjects  they  are  scarcely  to  be  detected  ; and  in 
others  again,  are  in  all  the  intermediate  states.  The 
most  distinct  and  natural  appearance  of  this  part  was 
in  a healthy  subject,  twenty-five  years  of  age,  of  which 
the  following  is  an  account.  On  turning  off  the  vasa 
deferentia  and  vesiculae  seminales,  exactly  in  the 
middle  of  the  sulcus,  between  the  two  lateral  portions 
of  the  prostate  gland,  there  was  a rounded  prominent 
body,  the  base  of  which  adhered  to  the  coats  of  the 
bladder.  It  was  imbedded  not  only  between  the  vasa 
deferentia  and  the  bladder,  but  also  in  some  measure 
between  the  lateral  portions  of  the  prostate  gland  and 
the  bladder,  since  they  were  in  part  spread  over  it,  so 
as  to  prevent  its  circumference  from  being  seen,  and 
they  adhered  so  closely  as  to  require  dissection  to  re- 
move them  ; nor  could  this  be  done  beyond  a certain 


PROSTATE  GLAND. 


extent,  after  which  the  same  substance  was  continued 
from  one  to  the  other.  Tliis  proved  it  to  be  a lobe  of 
the  prostate  gland:  its  middle  had  a rounded  form 
united  to  the  gland  at  the  base  next  the  bladder,  but 
rendered  a separate  lobe  by  two  fissures  on  its  opposite 
surface.  Its  ducts  passed  directly  through  the  coats  of 
the  bladder  on  which  it  lay,  and  opened  immediately 
behind  the  verumontanurn.  By  means  of  this  lobe,  a 
circular  aperture  is  formed  in  the  prostate  gland,  which 
gives  passage  to  the  vasa  defereniia.  “ Previous  to 
this  investigation  (says  Sir  Everard),  it  was  not  known 
to  nte,  that  any  distinct  portion  of  the  prostate  gland 
was  situated  between  the  vasa  deferentia  and  the 
bladder.” — (Ow  Diseases  of  the  Prostate  Gland.,  p.  9, 
8eo.  Land.  1811.)  Notwithstanding  this  explanation, 
to  the  correctness  of  which  most  English  anatomists 
have  acceded,  it  is  worthy  of  notice,  that  Langenbeck, 
the  present  distinguished  professor  of  Anatomy  and 
Surgery  at  Gottingen,  in  a review  of  Sit  Everard’s  ac- 
count, declares,  that  he  has  never  in  the  natural  state 
of  the  parts,  found  the  middle  lobe,  as  it  is  called, 
which  he  considers  as  a partial  induration,  rising  up  in 
the  shape  of  a lobe.— (JV«Me  Bibl.  b.l^p.  360, 12/no.  Ha- 
nover, 1818.)  This  dissent  would  seem  extraordinary, 
if  it  were  not  possible  to  suppose,  that  it  may  proceed 
not  from  all  the  subjects  at  Gottingen  difiering  from 
Londoners  in  being  destitute  of  what  Sir  Everard  Home 
has  named  the  middle  lobe  of  the  prostate  gland,  but 
from  Langenbeck’s  not  having  traced  in  the  healthy 
state  of  the  gland,  any  portion  which  he  thought  de- 
serving of  that  name.  But  though  differences  of  opi- 
nion may  be  entertained  about  the  name,  none,  I pre- 
sume, can  remain  about  the  thing  itself,  which  appears 
to  have  been  long  ago  mentioned,  though  not  perfectly 
described,  by  Morgagni. — {Adversaria  Anat A.  animad. 
15.)  The  paper  by  Mr.  C.  Bell,  illustrating  how  far  our 
predecessors  had  a knowledge  of  this  portion  of  the 
gland,  seems  to  me  one  of  his  best  productions  ; and  it 
is  therefore  with  pleasure  that  I refer  to  it. — (See  An 
Account  of  the  Jiluscles  of  the  Ureters,  in  Med.  Chir. 
TVans.  vol.  3,  p.  171,  tS-c.) — However,  as  this  author  im- 
partially acknowledges,  it  is  not  because  a fact  was 
anciently  known,  or  perhaps  only  cursorily  noticed, 
that  there  may  not  be  great  merit  in  reviving  the  recol- 
lection, or  perfecting  the  description  of  it ; and,  as  far 
as  I can  learn,  none  of  the  anatomical  teachers  in  this 
city,  previously  to  Sir  Everard’s  j/aper,  particularly 
adverted,  in  the  healthy  original  state  of  the  prostate 
gland,  to  the  structure  which  he  has  pointed  out,  by 
whatever  name  it  be  distinguished. 

According  to  Sir  Everard  Home,  this  lobe,  in  the 
earlier  periods  of  life,  when  the  body  of  the  gland  is 
in  a sound  state,  is  small ; nor  does  it  appear  to  be- 
come enlarged,  even  when  the  body  and  the  lateral 
lobes  have  been  considerably  increased  in  size ; but, 
in  subjects  of  advanced  age,  this  part,  as  well  as  the 
rest  of  the  gland,  is  usually  found  .somewliat  enlarged, 
even  in  cases  where  no  disease  has  been  suspected 
during  life. — (P.17.)  When  the  middle  lobe  begins 
to  enlarge,  it  presses  inwards  towards  the  cavity  of  the 
bladder,  putting  the  internal  membrane  upon  the 
stretch,  and  communicating  to  it,  by  immediate  con- 
tact, the  infiarnmation  which  occasioned  its  own  en- 
largement. Hence,  pain  in  making  water,  particularly 
after  the  last  drops  are  voided,  and  a desire  and  strain- 
ing to  discharge  more,  after  the  bladder  is  empty. 

As  this  organ  cannot  now  retain  much  urine,  the  de- 
sire to  make  water  becomes  frequent,  and  there  is 
commonly  more  or  less  constitutional  disturbance,  or 
symptomatic  fever.  In  proportion  as  the  middle  lobe 
increases  in  size,  it  projects  into  the  cavity  of  the  blad- 
der in  the  form  of  a nipple  ; but  after  a farther  aug- 
mentation, it  loses  the  nipple-like  appearance,  be- 
comes broader,  and  forms  a transverse  fold  by  push- 
ing forwards  and  stretching  the  membrane,  connecting 
it  to  the  lateral  lobes.  “ As  the  tumour  and  the  trans- 
verse fold  are  situated  immediately  behind  the  orifice 
of  the  urethra,  they  are  pushed  forwards  before  the 
urine  in  every  attempt  that  is  made  to  void  it,  acting 
like  a valve,  and  closing  up  the  opening,  till  the  cavity 
of  the  bladder  is  very  much  distended,  when  the  ante- 
rior part  of  the  bladder  being  pushed  forwards,  and  the 
tumour  being  drawn  back,  in  consequence  of  the  mem- 
brane of  the  jio.sterior  part  of  the  bladder  being  put 
on.  the  stretch,  the  valve  is  opened,  so  that  a certain 
quantity  of  water  is  allowed  to  escape,  but  the  bladder 
is  not  completely  emptied,”— P.  19.)  Sir  Everard  J 


275 

Home  allerward  explains,  that,  as  the  tumour  en- 
larges, the  quantity  voided  at  each  time  becomes 
smaller,  and  that  which  is  retained  i.s  increased,  until 
at  length  tlte  disease.btcomes  so  nmeh  aggravated,  that 
there  is  a complete  retention  of  urine.  The  body  of 
the  gland  and  the  lateral  lobes,  though  less  disturbed 
than  the  middle  lobe  by  the  patient’s  repeated  efl’orts 
to  void  the  urine,  become  more  or  less  enlarged  ; but 
it  is  remarked,  that  they  do  not  preserve  either  their 
natural  or  any  regula:  proportion  to  the  middle  lobe, 
nor  do  they  always  swell  equally  together,  the  left  in 
some  instances  becoming  much  larger  than  the  right. — 
(P.22.)  When  he  published  his  first  vol.  on  diseases 
of  the  prostate  gland,  he  had  seen  only  the  left  lobe 
form  the  greatest  projection  within  the  bladder ; but 
in  his  second  vol.,  published  in  1818,  there  is  an  en- 
graving, representing  the  right  lobe  thus  altered  ; and 
he  mentions  two  instances,  in  which  a similar  enlarge- 
ment of  the  same  lobe  had  taken  place.  Mr.  Wilson 
has  also  more  than  once  met  with  this  greater  swell- 
ing of  the  right  lobe. — [On  the  Male  Urinary  and 
Genital  Organs,  p.  336.)  The  recollection  of  these 
facts  will  often  enable  the  practitioner  to  incline  the 
beak  of  a callieter  in  the  direction  by  which  it  may 
be  conducted  into  the  bladder ; and  tiius,  as  Sir  Eve 
rard  Home  has  remarked,  the  surgeon,  after  trying 
gently  on  the  left  side,  and  not  succeeding,  is  not  to 
persevere  in  that  direction,  but  try  whether  the  pas- 
sage will  offer  less  resistance  on  the  opposite  side. 

The  diseased  state  of  the  body  of  the  prostate  gland, 
and  of  the  lateral  lobes,  here  alluded  to  by  Sir  Everard 
Hon  e,  he  says,  is  very  difterent  from  that  which  is 
met  with  in  the  earlier  periods  of  life,  in  consequence 
of  strictures  of  the  urethra,  and  which  subsides  when 
the  obstruction  in  that  canal  is  removed.  This  en- 
largement of  the  prostate  gland  from  strictures,  he 
observes,  may  not  be  unaptly  compared  to  the  swell- 
ing of  the  testicle  in  gonorrhoea,  a case  of  accidental 
inflammation  in  a healthy  testicle ; while  the  other 
disease  of  the  prostate  is  analogotis  to  the  more  per- 
manent disease  of  the  latter  organ.  This  author  ad- 
verts, however,  to  a few  instances,  in  which  the  en- 
largement of  the  body  of  tlie  proslale  gland  from  stric- 
tures, in  persons  fifty  years  of  age,  did  not  subside  im- 
ntediately  the  latter  affection  was  cured,  a common 
bougie  stopping  at  the  neck  of  the  bladder,  although  a 
catheter,  which  had  a regular  curve,  readily  passed. 
According  to  Sir  Everard  Home,  as,  in  such  cases,  the 
patients  were  able  to  empty  their  bladders,  it  is  evi- 
dent, that  there  could  be  no  enlargement  of  the  mid- 
dle lobe.  Incases  like  these,  no  symptom  of  impor- 
tance is  produced,  and  whether  the  swelling  of  the 
prostate  readily  subsides  or  not,  is  of  no  consequence; 
though,  if  the  stricture  do  not  return,  it  will  always 
ultimately  diminish. — {On  Diseases  of  the  Prostate 
Gland,  vol.  1,  p.  24.)  In  patients  under  fifty  years  of 
age,  Sir  Everard  Home  has  rarely  found  the  middle 
lobe  so  swelled  as  to  p.mduce  retention  of  urine,  or  an 
inability  to  empty  the  bladder,  notwithstanding  thq 
rest  of  the  gland  might  be  much  enlarged.— (P.  23.; 
When  the  middle  and  one  of  the  lateral  lobes  project 
considerably  into  the  bladder  U/gether,  their  surface  is 
sometimes  excoriated,  and  has  an  ulcerated  appear- 
ance. Under  such  circumstances,  the  pain,  after  void- 
ing the  last  drops  of  urine,  is  said  to  be  very  severe, 
and  attended  with  spasmodic  affections  of  the  neck  of 
the  bladder,  of  the  most  distressing  kind. 

According  to  Sir  Everard  Home,  another  effect  of  a 
similar  enlargement  of  the  prostate  gland  is,  to  render 
its  secretion  extremely  viscid  and  very  abundant.  A 
question  might  arise  about  the  real  source  of  this  ropy 
mucus,  and  some  might  infer  that  it  was  secreted  by 
the  bladder;  but  that  it  comes  entirely  from  the  in- 
flamed prostate  gland  is  proved,  says  this  gentleman, 
by  its  having  been  found  in  one  instance  with  one  ex- 
tremity floating  in  the  bladder  in  the  dead  body,  while 
the  other  extremity  appeared  divided  into  small  fila- 
ments, terminating  in  the  orificesof  the  excretoiy  ducts 
of  the  gland  at  the  verumontanurn.  'I'he  quantity  of 
secretion  is  observed  to  depend  more  upon  the  degree 
of  irritation,  than  the  actual  enlargement  of  the  gland, 
and,  as  this  increased  secretion  happens  in  cases  of 
swelling  of  this  part  from  strictures,  where  the  body 
and  lateral  lobes  are  alone  affected,  it  is  inferred,  thiit 
the  disease  of  the  middle  lobe  oidy  cotitribnles  to  this 
effect  by  kee|iing  up  a straining  and  dislnrbanceof  every 
[tart  of  the  gland. — (P.  32.)  The  internal  membrane 


27G 


PROSTATE  GLAND. 


of  the  bladder  inflames,  and  becomes  extremely  ini- 
table,  so  that,  even  vi’hen  the  quantity  of  urine  is 
small,  there  is  a great  deal  of  straining.  When  the 
size  and  form  of  the  tumour  are  such  as  to  allow  the 
greater  part  of  the  urine  to  pass,  though  with  great 
efibrt.  Sir  Everard  states,  that  the  symptoms  may  con- 
tinue nearly  the  same  for  months  ; liable,  however,  to 
occasional  aggravations  from  slight  causes,  and  be- 
coming more  or  less  relieved,  w'hen  these  are  removed. 
Nay,  he  observes,  that  the  symptoms  may  even  lessen, 
although  the  disease  is  not  at  all  diminished ; a cir- 
cumstance which  is  ascribed  to  the  muscular  coats  of 
the  bladder  having  acquired  greater  strength,  and  the 
internal  membrane  having  lost,  from  habit,  the  sensi- 
bility which  it  possessed  in  the  earlier  stage.— (P.  :14.) 
He  farther  explains,  that,  in  this  disease,  when  the 
inside  of  the  bladder  is  inflamed,  filamentous  por- 
tions of  coagulating  lymph  are  thrown  off  from  it, 
which,  when  the  inflammation  increases,  subside  in 
the  urine  evacuated,  looking  not  unlike  white  hair- 
powder;  and  when  the  irritation  is  very  violent,  per- 
fectly formed  pus  is  met  with  in  the  urine. — (P.  35.) 
After  the  inflammation  subsides,  the  bladder  becomes 
again  capable  of  retaining  a larger  quantity  of  urine, 
though  its  power  of  completely  emptying  itself  is  still 
farther  diminished. 

According  to  Mr.  Wilson,  the  symptoms  which  gene- 
rally attend  an  enlarged  prostate  gland,  are  similar  to 
thoseof  an  irritable  bladder : — constant,  heavy , dull  pain 
in  the  gland,  and  sometimes  sharp  lancinating  pains, 
darting  from  it  to  the  urethra,  and  occasionally  to  the 
bladder  and  ureters.  Frequent  calls  to  void  the  urine, 
which  is  passed  with  difficulty,  only  a small  quantity 
being  discharged  at  a time,  as  more  or  less  always  re- 
mains behind  in  the  bladder.  A complete  retention  of 
urine  may  be  produced,  so  that  not  one  drop  will  pass, 
although  much  straining  is  used.  Great  difficulty  in 
expelling  the  feces ; and  after  each  evacuation,  a feel- 
ing is  still  experienced,  as  if  the  gut  were  not  yet  emp- 
tied. During  the  efforts  to  expel  the  urine  and  feces,  a 
quantity  of  the  mucous  secretion  of  the  prostate  gland 
is  not  unfrequently  forced  out.  Most  of  these  symp- 
toms, as  Mr.  Wilson  observes,  are  similar  to  those 
produced  by  stone,  and,  therefore,  when  they  occur, 
the  gland  should  be  examined  by  the  rectum,  and  if 
it  be  not  found  diseased,  a sound  should  be  introduced 
into  the  bladder. — ( On  the  Male  Urinary  and  Genital 
Organs,  p.  339.)  The  particular  differences  between 
the  symptoms  of  stone,  and  those  arising  from  dis- 
ease of  the  prostate  gland,  are  explained  in  the  article 
Lithotomy. 

Mr.  Hunter  first  pointed  out  a fact,  which  the  practi- 
cal surgeon  should  never  forget,  viz.  that  the  swelling 
of  what  is  now  called  the  middle  lobe  of  the  prostate 
gland,  often  raises  the  sound  over  a small  stone  in  the 
bladder,  and  prevents  it  from  being  felt.— (Oir  the 
Venereal  Disease,  p.  170.)  Hunter  also  first  noticed 
another  circumstance  well  deserving  recollection,  viz. 
that  an  ejilargement  of  the  same  part  may  account  for 
the  disappearance  of  all  the  symptoms  of  stone  in  pa- 
tients who  have  already  suffered  greatly  from  them,  as 
the  swelling  prevents  the  calculi  from  falling  down 
upon  and  irritating  the  neck  of  the  bladder.  These 
truths  are  exemplified  by  cases,  which  are  highly  in- 
teresting. It  appears  also  probable,  from  the  observa- 
tions of  Sir  Everard  Home,  that  an  enlargement  of 
the  middle  lobe  conduces  to  the  formation  and  lodge- 
ment of  calculi  in  the  bladder,  partly  by  preventing 
tlie  evacuation  of  small  ones  through  the  urethra,  and 
partly  by  hindering  the  bladder  from  completely  dis- 
charging its  contfents. — {Vol.  1,;?.40.)  Lastly,  it  is  ex- 
plained, that  in  disease  of  the  prostate  gland,  patients 
secrete  less  urine  than  natural,  and  that  death  is 
sometimes  produced  by  the  retention  of  urine  suppress- 
ing the  secretion  altogether.  In  cases  of  enlargement 
of  the  middle  lobe,  one  symptom  on  which  Sir  Eve- 
rard Home  lays  great  stress  is,  hemorrhage  produced 
by  riding  on  horseback. — {Vol.  2,  p.  27.)  Inflamma- 
tion and  even  ulceration  of  the  membrane  covering 
the  middle  lobe,  he  says,  are  more  frequent  than  he 
was  at  first  aware  of,  and  are  produced  by  the  rough 
introduction  of  instruments.  Hence,  the  burning  heat 
at  the  neck  of  the  bladder,  the  great  pain  and  distiess 
attending  the  passage  and  the  continuance  of  an  in- 
strument, the  occasional  necessity  of  taking  it  out,  and 
the  duration  of  the  pain  for  some  time  afterward.— 
{Vol.cit.p.<2Q.) 


According  to  Mr.  Wilson,  in  a case  of  what  is  named 
scirrhous  prostate  gland,  the  enlargement  at  first  takes 
place  slow'ly,  attended  with  pain,  and  no  particular  al- 
teration of  the  structure  is  apparent  in  the  gland  when 
examined  in  this  stage  after  death,  nor  is  any  change 
discoverable,  when  the  part  is  felt  from  the  rectum  in 
the  living  patient.  As  the  disease  proceeds,  the  struc- 
ture of  the  whole  gland  changes,  and  the  part  enlarges 
sometimes  regularly,  so  as  to  preserve  its  shape,  to  the 
size  of  a moderate  orange ; sometimes  very  irregularly, 
projecting  in  a lobulated  manner.  When  the  gland  iii 
this  state  is  cut  into,  its  substance  feels  firm,  the  cut  sur- 
face is  of  a whitish-brown  colour,  and  the  membranous 
septa  e.xtending  through  it  in  various  directions  are 
often  very  strongly  marked.  In  general,  before  the 
urethra  and  bladder  are  opened,  the  gland  appears  most 
enlarged  laterally.  It  also  swells  backwards  towards 
the  rectum,  producing  that  appearance  of  the  excre- 
ment particularly  noticed  by  J.  L.  Petit,  and  already 
mentioned  in  speaking  of  common  inflammation  of  the 
gland.  Mr.  Wilson  farther  states,  that  its  anterior  part 
is  generally  least  enlarged,  because  its  conne.xion  with 
the  pubes  prevents  it  from  passing  far  forw  aids.  How- 
ever, this  gentleman  has  seen  some  instances,  in  which 
the  enlargement  above  or  in  front  of  the  urethra  was 
considerable.  The  extent  of  the  lateral  and  posterior 
swelling  may  be  readily  felt  with  the  finger,  introduced 
within  the  rectum.  That  these  very  irregular  wind- 
ings in  the  progtatic  portion  of  the  urethra  are  fre- 
quently occasioned  by  the  disease,  is  also  confirmed  by 
Mr.  Wilson’s  experience,  and  numerous  prepetrations 
in  the  museum  of  the  College  of  Surgeons.  “ In  the  pro- 
gress of  the  enlargement,  the  two  sides  do  not  always 
swell  equally ; one  often  enlarges  most,  and  often  swells 
more  in  one  particular  part  than  another.  This  produces 
a lateral  bend,  or  obliquity  in  the  passage,  which  will 
of  course  increase  the  difficulty  of  passing  the  urine, 
and  of  introducing  the  catheter.  I have  seen,  from  the 
irregularity  of  the  lateral  swelling,  the  passage  through 
the  gland  bend  in  succession  to  both  sides.” — (On  the 
Male  Urinary  and  Genital  Organs,  p.  332.) 

As  every  considerable  enlargement  of  the  prostate 
gland  is  attended  with  great  difficulty  of  voiding  the 
urine,  the  muscular  coat  of  the  bladder  always  becomes 
more  or  less  thickened,  in  consequence  of  the  efforts 
which  it  is  obliged  to  make. 

In  relation  to  the  third  or  middle  lobe,  it  is  to  be  ob- 
served, that,  from  some  dissections  made  by  Mr.  Shaw, 
it  would  appear,  that  in  many  cases  the  enlarged  por- 
tion of  the  prostate  projecting  into  the  bladder,  is  not  the 
third  lobe,  but  a part  of  the  gland  situated  more  for- 
wards.— (See  Bell's  Surgical  Obs.  vol.  1,  p.  223,  d-c.) 

According  to  Sir  Everard  Home,  a stricture  may  be 
distinguished  from  an  enla  gement  of  the  prostate 
gland  by  the  following  circumstances ; the  distance  of 
the  obstruction  from  the  external  orifice  is  to  be  deter- 
mined by  pa.ssing  a soft  bougie,  which  is  to  be  left  in 
the  canal  for  a minute,  so  as  to  receive  an  impression 
from  the  obstruction.  If  the  bougie  does  not  pass  far- 
ther than  seven  inches,  and  the  end  is  marked  by  an 
orifice  of  a circular  form  (it  is  immaterial  as  to  the 
size  of  the  orifice),  the  disease  is  certainly  a stricture  ; 
but  if  it  passes  farther  on,  and  the  end  is  blunted,  a dis- 
ease in  the  prostate  gland  is  to  be  suspected.  This  ia 
general  may  be  ascertained  by  the  possibility  of  passing 
into  the  bladder  a flexible  gum  catheter  with  a stilet, 
very  much  curved,  which  in  most  cases  of  enlargement 
of  the  gland  may  be  accomplished. 

On  the  subject  of  the  causes  of  a scirrhous  enlarge- 
ment of  the  prostate  gland,  it  appears  to  me,  that  little 
certain  is  known,  excepting  that  it  is  a disease  seldom 
met  with  under  the  age  of  fifty.  Desault  suspected 
that  it  w'as  sometimes  venereal,  and  common  in  indivi- 
duals, who  had  repeatedly  had  gonorrhoea. — ( Traite 
des  Mai.  Chir.  t.  3,  p.  238.)  I believe  neither  of  these 
sentiments  is  entertained  by  the  best  surgeons  of  the 
present  day.  According  to  Sir  Everard  Home,  it  is  a 
rare  occurrence  for  a man  to  arrive  at  eighty  years  of 
age,  without  suffering  more  or  less  under  disease  of  this 
part.  “ The  more  common  causes  (says  he)  of  inflam- 
mation of  the  prostate  gland  are,  full  living  of  every 
kind,  inebriety,  indulgence  to  excess  w’ith  w’omen,  a 
confined  state  of  the  bowels,  and  exposure  to  the  effects 
of  cold  ; indeed,  whatever  increases  the  circulation  of 
the  blood  in  these  parts  (the  genitals,  I suppose)  beyond 
the  healthy  standaid,  may  become  a cause  of  inflamma- 
tion in  this  gland,  the  blood-vessels  of  which  lose  thew 


PROSTATE  GLAND. 


277 


tone  in  the  latter  periods  of  life.” — ( On  Diseases  of  the 
Prostate  Gland,  vol.  l,p.  18,  19.)  If  we  are  to  credit 
another  statement,  the  disease  occurs  most  frequently 
either  in  persons  who  have  not  used  the  genital  organs 
so  much  as  nature  intended,  or  in  others  who  liave  led  a 
life  of  excess. — ( Wilson  on  the  Urinary  and  Genital 
Organs,  p-  332.)  It  seems  to  me  better  to  confess  that 
the  etiology  of  this  complaint  is  unknown.  Nor  are 
we  rendered  much  wiser  by  conjectures  about  the  ef- 
fects of  horse  exercise,  or  those  of  a retarded  venous 
circulation  in  old  subjects,  in  creating  a tendency  to  the 
disease.  I have  known  several  persons  afflicted,  who 
had  led  very  sedentary  lives. 

I am  afraid  that  the  observation  formerly  made  by 
Mr.  Hunter  still  continues  true,  which  is,  that  a certain 
cure  for  the  scirrhous  enlargement  of  the  prostate  gland 
is  not  yet  discovered.  But  though  such  is  the  fact,  sur- 
gery is  undoubtedly  capable  of  affording  a great  deal 
of  relief,  so  as  to  lengthen  the  patient’s  days,  and  ren- 
der them  much  more  comfortable.  This  is  accom- 
plished principally  by  anodyne  medicines,  and  draw- 
ing off  the  patient’s  water,  when  he  cannot  void  it  him- 
self, either  at  all,  or  but  imperfectly,  and  with  consi- 
derable straining  and  suffering.  As  a temporary  relief 
from  pain,  and  also  as  a means  of  removing  spasm, 
opiate  clysters  should  be  administered  once  or  twice  a 
day. — {Hunter,  p.  174.)  Scrofulous  enlargements  of 
the  prostate  gland,  occurring  in  younger  subjects,  are 
probably  more  under  the  control  of  judicious  treat- 
ment. Thus,  Mr.  Hunter  informs  us  that  in  several 
cases  he  had  seen  hemlock  of  service.  “ It  was  given 
upon  a supposition  of  a scrofulous  habit.  On  the  same 
principle  (he  adds),  I have  recommended  sea-bathing; 
and  have  seen  considerable  advantages  from  it,  and  in 
two  cases,  a cute  of  some  standing.”  In  one  case,  burnt 
sponge  had  reduced  the  swelling  ; and  in  another,  the 
same  effect  was  produced,  and  the  irritability  of  the 
bladder  lessened,  by  means  of  a seton  in  the  perinaium. 
After  the  healing  of  tlie  seton,  however,  the  symptoms 
returned,  and  on  a trial  of  the  plan  again,  the  former 
good  effects  were  not  experienced  from  it.  Some  years 
ago,  I attended  a gentleman  under  Mr.  Lawrence,  who 
was  try i fig  the  effect  of  an  issue  in  the  same  situation. 
In  these  cases,  the  pilulte  hydrargyri  cum  conio  (see  Pi- 
lula)  have  been  very  commonly  prescribed,  as  an  eligi- 
ble alterative.  Sir  Everard  Home  mentions  an  in- 
stance in  which  suppositories  of  opium  and  hemlock, 
passed  up  the  fundament  and  allowed  to  dissolve  there, 
gave  more  relief  than  any  other  plan  ; not  only  lessen- 
ing the  irritation,  but  producing  a diminution  of  the 
projection  of  the  gland. 

Jn  the  first  stage  of  the  enlargement  of  the  middle 
lobe,  when  there  is  no  absolute  obstruction  to  the  pas- 
sage of  the  urine.  Sir  Everard  recommends  bleeding 
from  the  loins,  opiate  clysters,  and  t!ie  pulv.  ipecac, 
comp. — {On  Diseases  of  the  Prostate  Gland,  vol.  1, p. 
70.)  The  tepid  bath,  the  use  of  which  he  formerly  ad- 
vised, he  now  condemns,  as  a practice  “ aslittle  applica- 
ble to  this  disease,  as  putting  the  head  in  warm  water 
would  be  to  remove  the  symptoms  of  apoplexy  ; if  any 
applications  are  to  be  made  to  the  parts,  they  should  be 
such  as  produce  cold.” — {Vol.  2,  p.  83.)  In  this  stage, 
he  observes  that  catheters  and  bougies  should  on  no 
account  be  introduced,  more  especially  those  of  the  me- 
tallic kind,  since  they  produce  a degree  of  disturbance, 
which  the  parts  are  not  in  a state  to  bear,  and  if  un- 
skilfullyemployed,  they  will  increase  the  swelling  and 
bring  on  a complete  retention  of  urine.  Sir  Everard  is 
an  advocate  for  keeping  the  bowels  open,  for  which 
purpose  he  prefers  the  infusion  and  tincture  of  senna, 
with  the  tartrate  of  potash. — ( Vol.  2,  p.  84.)  If,  in  de- 
fiance of  these  means,  the  patient  becomes  unable  to 
make  any  water,  or  although  able  to  pass  a few  ounces, 
is  every  hour  obliged  to  make  the  attempt,  and,  after 
much  straining,  discharges  only  the  same  quantity.  Sir 
Eve;  ard  directs  a flexible  gum  catheter,  without  a stilet, 
to  be  passed  into  the  bladder,  in  the  gentlest  manner 
possible.  This  instrument  is  to  be  kept  introduced  with 
the  catheter  bracelet,  or  retainer,  made  and  sold  by  Mr. 
Weiss,  of  the  Strand,  and  the  water  drawn  off  at  regu- 
lar intervals,  not  only  till  the  first  symptoms  go  ofl',  but 
till  the  bladder  can  retain  the  urine  for  the  Usual  length 
of  time,  and  what  is  voided  has  the  appearance  of 
healthy  urine.  If,  when  the  catheter  is  withdrawn,  the 
paiieui  should  not  be  able  to  einpty  his  bladder,  it  must 
he  reiniroiluced,  and  after  six  or  seven  days  taken  out 
again.  When  the  disease  is  somewhat  more  advanced 


and  the  patient  cannot  keep  himself  quiet,  the  above 
practice  of  course  cannot  be  adopted,  and  it  becomes 
necessary  to  pass  the  catheter  three  or  four  times  a day. 
But  even  in  such  A case,  when  irritation  is  brought  on 
by  accidental  circumstances.  Sir  Everard  recommends 
keeping  the  instrument  in  the  bladder  until  the  attack 
has  subsided. — {Vol.  2,  p.  92,  96.)  This  gentleman 
finds,  that  for  cases  of  diseased  prostate,  the  common 
flexible  gum  catheters,  originally  made  straight,  are 
disadvantageous,  as  it  is  a long  while  before  they  can 
be  made  to  keep  a permanent  curved  form.  “ When 
(says  he)  the  curvature  of  the  catheter  is  no  part  of  its 
original  formation,  although  it  may  have  been  produced 
by  being  long  kept  in  a curved  state,  yet,  when  al- 
lowed to  remain  in  the  bladder,  it  gradually  returns  to 
its  straight  form  by  being  moistened,  and  when  it  has 
acquired  it,  the  point  is  no  longer  kept  directed  u[)ward8 
in  the  cavity  of  the  bladder,  but  is  constantly  pressing 
against  the  posterior  coats,  pushing  itself  out  of  the 
urethra,  and  the  irritation  it  gives  the  muscular  coat  of 
the  bladder  will  often  be  tlie  means  of  its  being  expelled 
by  a spasm  with  considerable  violence.” — {On  Diseases 
of  the  Prostate  Gland,  vol.  2,  chap.  5.)  Sir  Everard 
fai  ther  informs  us,  that  Mr.  Weiss,  No.  33,  in  the  Strand, 
has  at  length  succeeded  in  making  flexible  gum  cathe- 
ters, oriuinally  curved,  so  that  they  always  retain  their 
shape.  Their  polish  is  great,  and  they  can  be  had  of 
any  size : they  are  also  made  particularly  strong,  as  a 
quality  necessary  to  secure  them  from  being  broken  in 
violent  attacks  of  spasm.  Sir  Everard  states,  that  he 
has  kept  them  fifteen  days  in  the  bladder,  without  their 
being  spoiled  by  the  urine  or  mucus;  whereas,  com- 
mon French  and  English  catheters  become  in  a shorter 
period  so  rough  as  to  be  unfit  for  farther  use.  Metal 
catheters,  he  asserts,  should  never  be  employed  but  in 
cases  of  necessity,  where  the  patient  cannot  be  relieved 
by  milder  means. — {Vol.  2,  p.  87.)  To  such  instru- 
ments he  ascribes  the  frequently-noticed  ulceration  of 
the  middle  lobe,  the  abrasion  of  its  surface,  the  wounds 
through  its  substance,  the  general  inflammation  of  the 
whole  internal  membrane  of  the  bladder,  and  quick  de- 
struction of  the  patient’s  life.  The  gum  catheter,  how- 
ever, is  to  be  as  large  as  the  urethra  will  easily  admit, 
in  order  that  it  may  more  readily  disengage  itself  at  the 
turns  into  the  bladder.— (Foi.  \,p.  75.) 

According  to  Desault,  a large  catheter  generally  an- 
swers better  than  a small  one,  and  it  may  either  be  of 
silver  or  elastic  gum.  The  latter,  though  the  best  for 
the  purpose  of  being  kept  in  the  passage,  he  says,  has 
not  always  sufficient  firmness  to  get  through  the  ob- 
struction in  the  canal,  not  even  with  the  aid  of  a stilet. 
In  this  respect,  a silver  catheter  is  sometimes  prefera- 
ble. But  whatever  may  be  the  kind  of  catheter  eni- 
ployed,  it  generally  passes  as  far  as  the  prostate  with 
perfect  facility,  where  it  is  stopped,  noion'y  by  the  nar- 
rowness, but  also  by  the  new  curvature  of  the  passage. 

For  the  prostate  cannot  be  enlarged,  without  pushing 
forwards  and  upwards,  or  to  one  side,  that  portion  of  the 
urethra  behind  which  it  is  situated.  This  circumstance 
ought  never  to  be  forgotten  in  regulating  the  length  and 
direction  of  the  beak  of  the  catheter,  which  should  also 
be  longer,  have  a more  considerable  curvature,  and  be 
more  elevated  at  the  time  of  its  introduction,  than  in 
other  cases  of  obstruction  in  the  urethra. 

In  swellings  of  the  prostate  gland,  Mr.  Hey  has  parti- 
cularly pointed  out  one  advantage,  which  belongs  to 
elastic  catheters,  viz.  that  their  curvature  may  Ite  in- 
creased while  they  are  in  the  urethra.  This  gentleman 
was  introducing  an  elastic  gum  catheter  in  a patient, 
whose  prostate  gland  was  much  enlarged,  and  finding 
some  obstruction  near  the  neck  of  the  bladder,  he  with- 
drew the  stilet,  indoing  which,  he  accidentally  repressed 
the  tube,  which  then  went  into  the  bladder.  In  fact, 
he  found  that  the  act  of  withdrawing  the  stilet  increases, 
the  curvature,  and  lifts  up  the  point  of  the  catheter.  I 
—{PracL  Obs.  in  Surgery, p.  399,  edit.  2.)  For  farther! 
remarks  connected  with  this  subject,  see  the  articles 
Catheter,  and  Urine,  Retention  of.  Sir  Everard  Home 
slates  with  confidence,  that  if  the  symptoms  of  the 
foregoing  disease  be  prevented  in  their  early  stage  from 
increasing  by  the  treatment  which  he  has  recotnmended^ 
the  disea.se  will  get  well. — (See  .7.  Hunter's  Treatise 
on  the  Venereal  Disease,  p.  169,  ^-c.  '2d  ed.  Ato.  Dond. 
1788.  liaillie's  Morbid  Jlnntoniy.  P.  .7.  Desault, 
(Euvres  Chir.  t.  3,  p.  220,  <X  c.  8vo.  Paris,  1803.  Sir 
Kverard  Home,  on  Diseases  of  the  Prostate  Gland, 
2 vols\  8u£>.  l..ond.  1811—1818.  Jilso  On  Strictures, 


278 


PSO 


PTE 


3 vols.  8vo.  3d  ed.  1805—1621.  C.  Bell,  On  the  Muscles 
of  the  Ureters,  in  Med.  Chir.  Trans-  vol.  3.  J.  Shaw, 
On  the  Structure  of  the  Prostate  Gland,  in  C.  Bell's 
Sureical  Obs.  vol.  l,8vo.  1816.  E.  Ji.  Lloyd, On  Scro- 
fula, p.  lOT,  ^-c.  8oo.  Land.  1821.  J.  Howship,  Practi- 
cal Obs.  on  Diseases  of  the  Urinary  Organs,  ^c.  8vo. 
Lund.  1816.  J.  fVilson,  On  the  Male  Urinary  and 
Genital  Organs,  8co.  Land.  1821.  J.  Howship,  On 
Complaints  affecting  the  Secretion  and  Excretion  of 
Urine,  Lond.  1823.) 

PSEUDOSYPHILIS.  (From  'pevhrit,  false,  and  sy- 
vhilis,  ihe  venereal  disease.)  Disease  resembling  the 
venereal,  but  not  really  of  this  nature. — (See  Venereal 
Disease.)  

PSOAS  ABSCESS.  See  Lumbar  Mscess. 

PSORIASIS.  Scaly  Tetter.  A disease  of  the  order 
squamae,  in  Dr.  Bateman’s  Synopsis.  It  is  attended 
wilJi  more  or  less  roughness  and  scaliness  of  the  cu- 
ticle, and  a subjacent  redness.  The  skin  is  often  di- 
vided by  deep  fissures  ; and  the  complaint  is  generally 
attended  with  constitutional  disorder,  and  liable  to 
cease  and  return  at  certain  seasons.  For  a particular 
account  of  its  varieties  and  treatment,  see  the  above 
ivork. 

PSOROPIITHALMY.  (From  xj-upa,  the  itch,  and 
i-bdaXpia,  an  inflammation  of  the  eye.)  An  inflamma- 
tion ot  the  eyelids,  attended  with  ulcerations  which 
itch  very  much.  Beer  actually  understands  by  the  ex- 
pression, such  a disease,  from  the  sudden  repression  of 
the  itch,  or  the  infection  of  those  parts  with  psoric 
matter. — {Lchre  von  den  Jiugtnkr.  b.  1,  p.  566.)  Wel- 
ler not  only  adopts  the  same  notion,  but  makes  an  ad- 
dition to  it,  by  extending  the  term  also  to  cases  in 
which  the  eyelids  are  aflected  with  psoriasis,  porrigo, 
and  jinpetigines. — {Manual  of  the  Diseases  of  the  Eye, 
vol.  2,  p.  264.)  By  psorophthahny,  the  late  Mr.  Ware 
meant  a case  in  which  the  inflammation  of  the  eyelids 
is  attended  with  an  ulceration  of  their  edges,  upon 
which  a glutinous  matter  lodges,  incrusts,  and  becomes 
hard,  so  that  in  sleep,  when  they  have  been  long  in 
contact  they  become  so  adheretit  that  they  cannot  be 
separated  without  pain.  He  has  remarked,  that  “ the 
ulceration  in  the  psorophthahny  is  usually  confined  to 
the  edges  of  the  eyelids  ; but  sometimes  it  is  seen  to 
extend  over  their  whole  external  surface,  and  even  to 
excoriate  the  greater  part  of  the  cheek.  In  cases  of  the 
latter  kind,  the  inflamiiiation  which  accompanies  them 
has  often  much  the  Appearance  of  an  erysipelas,  and 
will  receive  most  relief  from  cooling  applications.  The 
use  of  the  citrine  ointment,  which  will  hereafter  be  re- 
commended, must  in  such  instances  be  deferred  until 
Ihe  irritability  of  the  skin  is  in  a good  degree  abated. 

“ This  di.sorder  is  also  sometimes  attended  with  a 
contraction  of  the  skin  of  the  lower  eyelid  ; in  conse- 
quence of  which,  that  lid  is  drawn  down  and  the  inner 
part  turned  outwards,  so  as  to  form  a red,  fleshy,  and 
most  disagreeable  appearance,  called  ectropium.  When- 
ever this  happens,  it  proves  the  coinplaiut  to  be  of  the 
most  obstinate  nature  ; though  it  is  generally  removed 
by  the  cure  of  the  psorophthahny,  which  is  the  occasion 
of  it.” — {Remarks  on  Ophthaliny,  &-c.  p.  112.)  Mr. 
Ware  recommended  for  the  cure  of  this  disease  the  un- 
guentum  hydrargyri  nitrati  melted  and  rubbed  with 
the  end  of  the  fore  finger,  or  the  point  of  a small  pencil 
brush,  into  the  edges  of  the  affeciqd  eyelids  every  night 
at  bedtime.  A jilaster  of  ceratum  album  was  then  put 
over  the  eyelids  to  keep  them  from  adhering  together. 
If  they  still  adhered  in  the  morning,  they  w ere  cleaned 
with  milk  and  butter  well  mixed  together.  In  a few 
cases  it  is  necessary  to  touch  the  ulcers  formed  on  the 
edge  of  the  eyelid,  after  the  small-pox,  with  the  argen- 
tum nitratum.  When  the  globe  of  the  eye  is  inflamed, 
the  vinous  tincture  of  opium  is  applied,  as  directed  in 
the  article  Ophthalmy.  In  scrofulous  subjects,  alter- 
ative medicines,  an  issue  or  perpetual  blister,  and 
attention  to  diet,  &c.,  are  necessary. — (See  Ware  on 
Ophthalmy,  ire.) 

In  the  treatment  of  psorophthalmy.  Beer  lays  consi- 
derable stress  upon  the  necessity  of  cleanliness.  The 
itchy  places  he  directs  to  be  frequently  washed  with  a 
tepid  infusion  of  scordiuin,  and  afterw  ard  well  dried. 
When  the  uneasiness  and  tension  of  the  skin  are  thus 
quite  removed,  Beer  adds  to  tire  preceding  infusion 
some  of  the  sulphuret  of  potash,  the  proportion  being  at 
first  small,  and  gradually  increased.  This  plan  is  to 
be  followed  until  the  ulcerations  dry,  and  the  scabs 
fall  off  of  themselves,  leaving  the  subjacent  skin  yet. 


red  and  sensible,  and  sometimes  moist ; in  this  state,  a 
small  bit  of  the  annexed  salve  may  be  smeared  with  a 
camel-hair  pencil  along  the  edges  of  the  eyelids,  and 
ufron  the  aflected  points  of  the  skin;  R.  Butyri  recen- 
tis  insulsi,  jss.  Cupri  sulphatis,  gr.  x.  Camphurffi, 
gr.  iv.  Tutia:  ptt.  gr.  vj.  Miseq.  If  the  disease  prove 
obstinate,  Beer  recommends  Hufeland’s  salve,  which 
consists  of  equal  parts  of  fresh  butter,  yellow  wax,  and 
the  pulv.  h)drarg.  nitrico-oxydi  rubr. ;.  and,  in  still 
more  inveterate  cases,  Janin’s  eye-saive,  which  he 
says  nmst  rarely  be  used  oftener  than  every  other  day. 
In  the  psorophthalmy,  conjectured  by  Beer  to  depr-nd 
upon  the  sudden  cure  of  the  itch,  he  states,  that  internal 
medicines  are  necessary,  as  antimonials  joined  with 
sulphur  and  camphor.  He  also  praises  sulphur  baths, 
and  irritating  the  part  of  the  skin  where  the  itch  has 
receded,  by  the  application  of  antimonial  ointment ; or, 
if  such  part  should  be  very  far  from  the  eyes,  he  ad- 
vises such  ointment  to  be  rubbed  on  the  skin  behind 
the  ears.  Attention  to  diet  is  particularly  enjoined, 
and  eating  pork,  lard,  and  substances  ditficult  of  diges- 
tion is  prohibited. — {B.  1,  p.  569,  Src.) 

PTERYGIUM.  (Dim.of  TrTfpv^,  a wing.)  As  Scarpa 
remarks,  surgeons  usually  apply  the  term  “ pterygium" 
to  that  preternatural,  reddish,  ash-coloured,  triangular 
little  membrane  which  most  frequently  grows  from  Ihe 
internal  angle  of  the  eye,  near  the  caruncula  lachry 
malis,  and  gradually  extends  over  the  cornea,  so  as  to 
cause  consideiable  impediment  to  vision. 

The  disease,  however,  presents  itself  sometimes  in 
the  form  of  a semitransparent  thin  grayish  membrane, 
not  furnished  with  many  visible  vessels;  and  some- 
times as  a thick,  red,  fibrous  mass,  very  like  muscle, 
being  very  prominent  even  on  the  cornea,  where  it 
seems  to  terminate  in  a substance  like  tendon,  and  it 
is  observed  to  be  pervaded  by  numerous  blood-vessels. 
The  first  is  the  pterygium  tenue  of  Beer ; the  second, 
the  pterygium  crassuin  {Lehre  von  den  .9ugtnkr.  b.  2, 
p.  636),  or  the  membranous  and  fleshy  pterygia  of  other 
writers. 

Though  the  pterygium  most  commonly  proceeds  from 
the  internal  angle  (also  Beer,  b.  2,  p.  637),  sometimes  it 
arises  from  the  external  one,  and  in  rare  instances  from 
the  superior  or  inferior  hemisphere  of  the  eyeball. 
But  whatever  be  its  origin,  its  figure  is  invariably  that 
of  a triangle,  with  its  base  on  the  white  of  the  eye,  and 
its  apex  more  or  less  advanced  over  the  cornea,  towards 
its  centre,  and  that  of  the  pupil.  Indeed,  there  are  a 
few  cases  in  which  two  or  three  pterygia  of  different 
sizes  occur  on  the  same  eye,  and  are  arranged  round 
its  circumference  at  interspaces  of  various  breadths. 
Their  points  are  directed  tow'ards  the  centre  of  the 
cornea,  where,  if  they  unfortunately  conjoin,  the  whole 
of  that  transparent  membrane  becomes  covered  with  an 
opaque  veil,  and  a total  loss  of  sight  is  the  consequence. 
The  occurrence  of  more  than  one  pterygium  on  the 
same  eye  is  very  rare : Beer,  in  all  his  practice,  met 
with  but  two  cases  of  double  pterygium,  and  with  only 
one  of  three  pterygia  on  the  eye. — (B.  2,  p.  638.) 

According  to  Scarpa  (whose  observations  apply 
chiefly  to  the  membranous  form  of  thedisea.se),  chronic 
varicose  ophthalmy,  with  relaxation  and  thickening 
of  the  conjunctiva,  opacity  of  the  cornea,  and  the  pte- 
rygium, only  differ  in  the  degree  of  the  disease.  In 
reality,  all  the  three  complaints  consist  of  a more  or 
less  extensive  varicose  slate  of  the  vessels  of  the  con- 
junctiva, combined  with  a degree  of  preternatural  re- 
laxation and  thickening  of  that  membrane. 

In  chronic  varicose  ophthalmy,  the  extraordinary 
amplitude  and  knottiness  of  the  vessels,  tlie  flaccidity 
and  thickening  of  the  conjunctiva,  are  limited  to  the 
white  of  the  eye.  In  opacity  of  the  cornea  certain 
veins  even  dilate,  and  beconie  knotty  for  some  way 
over  that  delicate  layer  of  the  conjunctiva  which  is 
continued  over  the  surface  of  the  cornea.  In  Ihe  pterj’- 
giuin  an  extraordinary  swelling  of  this  subtile  meni'' 
branous  expansion  is  added  to  the  varicose  state  of  its 
veins.  Hence  the  pterygium  seems  at  first  like  a new 
membrane  formed  on  the  cornea,  while  it  is  really  no- 
thing more  than  the  delicate  continuation  of  the  con- 
junctiva just  mentioised,  deprived  of  its  transparency, 
and  degena  ated  in  consequence  of  chronic  ophthalmy 
into  a thick  opaque  membrane,  on  which  there  is  a 
plexus  of  varicose  blood-vessels.  Con.sequentl\',  in  the 
case  of  pterygium,  there  is  no  new  production,  but  only 
an  alteration  of  one  of  the  thin  transparent  menibramai 
which  naturally  cover  the  eye.  The  following  circuiu' 


stance  illustrates,  says  Scarpa,  the  veracity  of  the  pre- 
ceding statement.  The  incipient  pterygium  may  be 
cured  in  the  same  manner  as  opacity  of  the  cornea,  viz. 
by  merely  cutting  otf  that  portion  of  it  which  is  situated 
at  the  junction  of  the  cornea  with  the  sclerotica,  with- 
out detaching  the  whole  of  it  from  the  surface  of  the 
former  membrane;  just  as  is  practised  in  the  opacity 
of  the  cornea,  in  order  to  destroy  tiie  communication 
of  the  varicose  veins  of  the  conjunctiva  with  their 
trunks,  the  ramifications  of  which  produce  and  main- 
tain the  disease. 

That  the  pterygium  is  only  the  natural,  delicate, 
transparent  expansion  of  tite  conjunctiva  on  the  cornea, 
converted  for  a certain  extent  into  a pulpy  flaccid  vari- 
cose membrane,  may  be  inferred  (continues  Scarpa) 
from  the  folds  which  the  pterygium  and  conjunctiva 
form  at  the  same  time,  when  the  morbid  eye  is  turned 
towards  the  origin  of  the  disease.  The  same  inference 
is  equally  deducible  from  the  tension  occasioned  in 
hath  these  parts  whenever  the  eye  is  moved  in  the  op- 
posite direction.  We  become  stilt  more  convinced  of 
the  fact  on  observing,  that  in  the  first  position  of  the 
eye,  both  the  pterygium  and  the  corresponding  portion 
of  the  conjunctiva  (which  is  equally  relaxed,  varicose, 
and  reddish,  may  be  easily  taken  hold  of  with  a small 
pair  of  forceps  and  raised  together  in  the  form  of  a 
fold. 

Mr.  Guthrie  does  not  agree  with  Scarpa,  that  chronic 
varicose  ophihalmy  with  relaxation  and  thickening  of 
the  conjunctiva,  nebula  of  the  cornea,  and  pterygium 
are  diseases  differing  only  in  degree.  On  the  contrary, 
he  asserts  that  a true  pterygium  is  very  rarely  the  con- 
sequence of  chronic  inflammation.  Tlie  nebula,  he  ob- 
serves, is  never  of  the  spear-formed  shape  of  the  ptery- 
gium, but  always  irregular,  its  progress  rather  from  than 
towards  the  cornea,  and  the  width  of  its  base  not  equal 
to  that  of  the  latter  disease. — (See  Operative  Surgery 
of  the  F.ye,p.  128.) 

The  pterygium  is  observed  by  Mr.  Travers  to  be  most 
prevalent  in  warm  climates. — {Synopsis,  i^c.  p.  101.) 
It  is  also  said  to  be  most  frequent  in  old  people,  though 
Mr.  Wardrop  and  Dr.  Monteath  have  seen  it  in  very 
young  infants. — ( ffeller's  Manual  of  the  Diseases  of 
the  Eye,  vol.  \,p.  218.) 

The  constancy  of  the  triangular  figure  of  the  ptery- 
gium, with  its  basis  on  the  white  of  the  eye,  and  its 
apex  on  the  cornea,  is  one  of  its  principal  diagnostic 
characters,  by  which  the  true  disease  may  be  discri- 
minated fixim  every  other  soft,  fungous,  reddish  excres- 
cence ob.«curing  tire  cornea. 

Another  distinguishing  character  of  pterygium,  as 
Scarpa  has  observed,  is  the  facility  with  which  the 
whole  of  it  may  be  taken  hold  of  with  a pair  of  forceps, 
and  raised  into  a fold  on  the  cornea.  Every  other  kind 
of  excrescence  attached  to  this  membrane  continues 
firmly  adherent  to  it,  and  cannot  be  folded  and  raised 
from  the  surface  of  the  cornea  in  any  manner  what- 
ever. This  particularity  is  of  the  liighest  importance  in 
the  treatment ; for  the  genuine  pterygium  may  be  cured 
by  simple  means,  while  fungous  excrescences  of  the 
cornea  can  only  be  radically  removed  and  perfectly 
cicatrized  with  the  utmost  difficulty. 

Scarpa’s  belief  in  the  realiiv  of  a vmUirnant  or  can- 
cerous  pterygium  must  appear  a doctrine  requiring  con- 
firmation, when  it  is  considered  that  Mr.Travers  makes 
no  mention  of  the  di.sease  assumim’  this  character,  and 
Beer  di.stinctly  state.s,  that  in  a practice  of  thirty-two 
years,  he  has  cured  376  jiterygia  of  various  sizes  and 
thickness,  without  one  bad  symptom  or  consequence. 
And  hence  he  justly  ct  ncludcs,  that  the  disease  is 
strictly  local. — {B.  2,  p.  641.1 

The  true  benign  pterygium,  says  Scarpa,  which  has  a 
triangular  figure,  is  ash-colouiedor  pale- red,  is  (fee  from 
pain,  and  admits  of  being  raised  in  the  form  of  a fold  on 
the  surface  of  the  cornea,  may  be  cured  by  cutting  the 
opaque  triangular  little  membrane  accurately  from  the 
surface  of  the  cornea,  which  is  in  part  covered  by  it. 
l)Ut  as  the  pterygium  is  nothing  but  a portion  of  the 
rlelicatr;  transparent  layer  of  the  conjunctiva,  con- 
verted into  a thick,  opaque  tunic,  it  follows  that  the 
pterygium  cannot  be  removed  in  any  way  without  the 
aiiot  which  it  occupies  on  the  cornea  being  bereft  of  Us 
natural  external  covering,  and  this  part  of  the  mem- 
brane rendered  more  or  less  opaque. 

Si  arpa’s  experience  enables  him  to  state,  however, 
that  ihi'  superficial  indelible  speck  remaining  on  the 
coini-a  after  the  removal  of  the  pterygium  is  always 


i^GlUM.  279 

less  extensive  than  the  space  previously  occupied  by 
the  disease. 

It  is  customary  (says  Scarpa)  to  remove  the  ptery- 
gium by  making  the  incision  on  the  cornea,  and  ex- 
tending it  over  the  while  of  the  eye  as  far  as  the  base 
of  the  disease  reaches  on  the  conjunctiva;  so  that 
when  the  pterygium  grows  from  the  internal  angle  of 
the  eye,  most  surgeons  continue  the  section  as  far  as 
the  caruncula.  This  practice  is  disadvantageous,  first, 
because  it  denmles  too  much  of  the  white  of  the  eye  ; 
secondly,  because,  in  consequence  of  the  large  por- 
tion of  the  conjunctiva  removed  at  the  base  of  the  ptery- 
gium, and  in  consequence  of  the  direction  of  the  wound, 
the  cicatrix  in  the  white  of  the  eye  forms  an  elevated 
frainum,  which,  like  a litile  cord,  keeps  the  eyeball  ap- 
proximated to  the  caruncula  lachrymalis,  and  destroys 
the  freedom  of  its  motions,  particularly  towards  the  ex- 
ternal angle. 

In  the  treatment  of  pterygia  with -bases  extending  far 
in  the  white  of  the  eye,  Scarpa  prefers  detaching  them 
at  their  apex,  as  far  as  the  junction  of  the  cornea  with 
the  sclerotica,  and  then  to  separate  them  at  their  base  by 
a semicircular  incision,  comprehending  one  line  in 
breadth  of  the  substance  of  the  conjunctiva,  and  made 
in  a direction  concentrical  with  the  edge  of  the  cornea. 
Scarpa  has  observed,  that  in  this  mode  of  operating, 
the  subsequent  cure  takes  place  sooner  than  when  the 
common  method  is  adopted  ; the  cicatrix  occasions  no 
sort  of  fraenum,  and  the  conjunctiva,  circularly  stretched 
by  the  cicatrix,  lies  smoothly  over  the  white  of  the  eye, 
and  loses  that  relaxation  and  varicose  stale  which  he 
considers  as  the  groundwork  of  the  pterygium.  Such 
attention,  however,  is  not  requisite  when  the  pterygium 
is  small,  and  its  base  does  not  extend  far  in  the  white 
of  the  eye. 

The  operator,  after  desiring  the  patient  to  move  his 
eyeball  towards  the  part  corresponding  to  the  base  of 
the  pterygium,  is  to  lake  hold  of  the  membrane  with  a 
pair  of  forceps  held  in  his  left  hand,  and  pinch  it  into  a 
fold,  at  about  one  line  from  its  apex.  The  duplicature 
is  now  to  be  raised  and  drawn  out  gently,  until  a sen- 
sation of  something  giving  way  is  felt,  which  indicates 
the  detachment  of  the  pterygium  Irom  the  delicate  cel- 
lular texture,  by  which  it  is  connected  with  the  subja- 
cent cornea.  Ne.xi,  by  means  of  a pair  of  scissors,  the 
surgeon  must  dissect  this  fold  as  closely  as  possible 
from  the  cornea,  proceeding  from  the  apex  towards  the 
base  of  the  pterygium.  The  section  being  completed 
to  where  the  cornea  and  sclerotica  meet,  the  fold  is  to 
be  again  elevated  still  more,  and  with  one  stroke  of 
the  scissors  the  pterygium  and  the  relaxed  portion  of 
the  conjunctiva  forming  its  base  are  to  be  detached,  as 
concentrically  and  closely  to  the  cornea  as  possible. 
This  second  incision  will  have  a semilunar  shape,  the 
horns  of  which  ought  to  extend  two  lines  beyond  the 
relaxed  part  of  the  conjunctiva  in  following  the  curva 
lure  of  the  eyeball. 

When  the  operation  is  finished,  the  surgeon  must 
promote  the  hemorrhage  by  washing  the  part  with 
warm  water,  and  then  cover  the  eye  with  dry  lint,  or 
lint  moistened  in  the  liquor  plumbi  acet.  dilutus,  kept  on 
will)  a bandage  that  dues  not  make  too  much  pressure. 

If  no  particular  symptoms  arise,  such  as  pain,  tension 
of  the  eye,  considerable  tumefaction  of  the  eyelids.  It 
is  sufficient  to  wash  the  eye  and  inside  of  the  eyelids 
three  or  four  times  a day  with  a warm  lotion  of  mal 
lows,  and  carefully  keep  these  parts  from  being  ex- 
posed to  the  air  without  compressing  them.  If  the 
symptoms  just  mentioned  should  occur,  antiphlogistic 
treatment  must  be  adopted. 

On  the  fifth  or  si.xth  day,  at  latest,  after  the  operation, 
all  the  surface  from  which  the  pterygium  was  cut  ap- 
pears yellowish,  and  covered  with  a fluid  like  mucus. 
The  edges  of  the  wound,  and  the  adjoining  part  of  the 
conjunctiva,  assume  a reddish  colour.  Afterward,  tfxe 
surface  of  the  wound  contracts  more  and  more  daily, 
and  at  length  completely  closes. 

All  local  stimulants  are  to  be  avoided,  and  it  is  not 
till  the  wound  is  healed  that  the  zinc  collyrium,  con- 
taining a few  drops  of  camphorated  spirit  of  wine, 
should  be  used  three  or  four  times  a day,  for  the  pur- 
pose of  obviating  the  relaxation  of  the  conjunctiva  and 
its  ve.s.sels. 

In  the  early  stage  of  pterygium,  while  the  mem- 
brane is  as  thin  as  a cobweb,  Scarpa  considers  it  un- 
necessary to  deprive  the  cornea  ofil.«  natural  covering; 
and  that  it  is  quite  enough  to  cut  oft'  a portion  of  it,  in 


280 


PTO 


PUN 


order  to  intercept  all  communication  between  the  di- 
lated venous  ramifications  of  the  pterygium  and  the 
varicose  trunks  in  the  white  of  the  eye.  This  is  ac- 
complished by  cutting  out,  with  a pair  of  forceps  and 
scissors,  a semilunar  piece  of  the  conjunctiva,  at  the 
point  where  the  cornea  and  sclerotica  conjoin,  and  ex- 
actly at  the  base  of  the  incipient  pterygium,  just  as  is 
practised  for  opacity  of  the  cornea.  The  recent  pte- 
rygium is  observed  to  disappear  gradually  after  the 
operation,  or  to  change  into  a slight  dimness  of  the 
cornea,  extending  over  a part  of  the  space  previously 
occupied  by  the  disease.  This  opacity  is  commonly 
much  more  trivial  than  what  follows  a cicatrix.  Acrel, 
in  his  Surgical  Oiseruations,  mentions  having  success- 
fully treated  an  incipient  pterygium  in  this  manner. 
Scarpa  has  also  tried  tire  plan  several  times  with  suc- 
cess. Such  treatment  must  be  better  than  merely  making 
two  or  three  deep  cuts  or  scarifications,  in  the  mem- 
brane, near  the  edge  of  the  cornea,  as  advised  by  Beer. 
— (B.  2,  p.  641.)  And  in  proof  of  the  uncertainty  of 
the  latter  method,  we  find  Beer  himself  speaking  of  the 
necessity  of  using  stimulating  applicatiotis,  like  pow- 
dered sugar,  alum,  the  vinous  tincture  of  opium,  &c.  if 
the  operation  is  not  of  itself  sufficient.  In  the  ptery- 
gium crassum,  Beer  recommends  the  knife  as  the  best 
means  of  cure  ; but  he  differs  essentially  from  Scarpa, 
not  merely  in  preferring  a knife  to  the  scissors,  but  in 
beginning  the  operation  by  making  a deep  cut  through 
the  base  of  the  pterygium  in  the  white  of  the  eye,  from 
which  point  he  continues  the  dissection  of  the  ptery- 
gium till  this  is  all  removed  as  far  as  its  apex  on  the 
cornea,  when  he  either  uses  the  knife  or  scissors,  as 
most  convenient.— (.B.  1,  p.  643.) 

Mr.  Guthrie,  who  acknowledges  the  correctness  of 
Scarpa’s  objections  to  removing  a large  pterygium  to  a 
great  extent  towards  the  caruncula  lachrymalis,  adopts 
a middle  course  between  the  methods  of  Beer  and 
Scarpa,  and  removes  half  of  the  pterygium  from  the 
apex  towards  the  base.— ( Vol.  cit.  p.  130.) 

Beer  nrentions,  that  it  sometimes  happens,  especially 
in  cases  of  thin  pterygia,  that  the  disease  stops  at  the 
edge  of  the  cornea,  and  spreads  no  farther  as  long  as 
the  patient  lives. — (B.  2,  p.  641.)  Under  such  circum- 
stances, of  course,  the  complaint  will  give  no  trouble, 
and  may  be  left  to  itself,  as  particularly  advised  by  Mr. 
Travers. — {Synopsis,  >^c.  p.  274.)  When,  however, 
it  encroaches  upon  the  sight,  this  gentleman  says  that 
“ it  should  be  raised  by  dissection  as  close  as  possible  to 
the  margin  of  the  cornea,  and  the  relaxed  portion  of 
the  membrane  removed  by  an  incision  midway  between 
the  base  of  the  pterygium  and  the  cornea,  and  concentric 
to  that  membrane.”  For  farther  information,  consult  J. 
Wardrop,  Essays  on  the  Morbid  Anatomy  of  the  Hu- 
man Eye,  vol.  1,  p.  22,  ^c.  8vo.  Edinb.  1^8.  Scarpa 
suite  Malattie  degli  Occhi,  cap.  11.  Richter's  An- 
fangsgr,  der  fVundarineykunst,  b.  3,  p.  141,  Src.  Got- 
tingen, 1795.  Beer's  Lehre  von  den  Augenkr.  b.  2,  p, 
636,  <S-c.  8uo.  Wien,\8\l.  B.  Travers,  Synopsis  of  the 
Diseases  of  the  Eye,  8vo.  Land.  1820.  Weller's  Ma- 
nual, vol.  1,  8vo.  Glasgow,  1^1.  G.  .J.  Guthrie  on 
the  Operative  Surgery  of  the  Eye,  p.  124,  Src.  8vo. 
Land.  1823. 

PTOSIS.  (From  mrcTw,  to  fall  down.)  Blepharop- 
tosis.  An  inability  of  raising  the  upper  eyelid.  Ac- 
cording to  Beer,  ptosis  always  arises  from  a consider- 
able relaxation  and  extension  of  the  common  integu- 
ments of  the  upper  eyelid,  which  hang  down  in  a kind 
of  fold  over  the  fissure  of  the  closed  palpebraa,  and 
when  the  levator  muscle  has  been  more  or  less  weak- 
ened by  the  same  causes  which  have  produced  this 
state  of  the  skin,  the  weight  of  the  redundant  integu- 
ments prevents  the  eyelid  from  being  properly  opened. 
Hence,  when  the  patient  tries  to  raise  the  eyelid,. the 
efforts  of  the  levator  muscle  may  be  seen ; but  the  ob- 
ject cannot  be  perfectly  accomplished.  With  the  ex- 
ception of  the  inability  of  raising  the  upper  eyelid,  the 
patient  has  not  the  slightest  ailment;  the  eye  is  not  at 
all  red,  though,  when  opened,  it  does  not  bear  the  light 
well,  on  account  of  not  being  accustomed  to  the  stimu- 
lus; nostillicidiura  lachrymarum  is  observable;  and  the 
edge  of  the  eyelid,  with  all  the  eyelashes  quite  dry,  is 
seen  directly  the  part  is  elevated  with  the  thumb. 
When  the  relaxed  fold  of  the  skin  is  taken  hold  of  be- 
tween the  thumb  and  fore-finger,  without  pulling  or 
stretching  it,  but  only  just  so  as  to  take  off  the  weight 
opposed  to  the  levator  muscle  by  the  redundance  of 
skin,  the  patient  is  immediately  able  to  raise  the  eyelid 


without  any  difficulty ; but  as  soon  as  the  surgeon  re- 
linquishes his  hold  of  the  skin,  the  part  falls  down 
again.  The  relaxed  fold  of  skin  is  sometimes  si- 
tuated rather  over  the  outer  commissure  than  the  mid- 
dle of  the  eyelid,  in  which  case,  the  latter  part  can  be 
opened  towards  the  nasal  commissure,  and  the  eyeball 
becomes  habitually  rotated  towards  the  nose  for  the 
purpose  of  vision,  whereby  strabismus  and,  if  the  dis- 
order be  not  soon  rectified,  an  obliquity  of  sight  are 
occasioned. 

A prolapsus  of  the  upper  eyelid.  Beer  observes,  may 
be  the  consequence  of  any  infiammation  of  the  part, 
accompanied  with  considerable  oedema  or  ecchymosis, 
as  happens  from  severe  wounds  of  the  forehead,  eye- 
brow, or  the  eyelid  itself,  particularly  when  no  attempt 
is  made  to  unite  the  parts  by  the  first  intention.  The 
infirmity  may  also  be  the  consequence  of  ophthalmy, 
that  has  been  either  long  neglected  or  badly  treated 
witli  relaxing  poultices;  and  it  is  said,  that  scrofulous 
patients  have  a disposition  to  the  complaint. — {Beer, 
b.  2,p.  109—111.) 

The  case,  as  described  by  this  author,  may  be  cured 
by  the  excision  of  a long  slip  of  skin  from  the  eyelid, 
just  broad  enough  for  the  removal  of  the  redundant 
quantity.  For  taking  hold  of  the  portion  of  integu- 
ments, Beer  employs  forceps,  the  extremities  of  which 
are  broad,  with  a somewhat  concave  edge.  As  much 
of  the  superfluous  skin  is  to  be  taken  hold  of  and  raised 
as  will  enable  the  patient  to  open  the  eyelid,  which  cir- 
cumstance is  the  criterion  of  the  quantity  selected  for 
the  removal  being  enough.  • The  excision  may  then  be 
performed  with  scissors,  as  Beer  directs,  or  with  a 
knife,  as  others  may  prefer;  and  the  w’ound  is  to  be 
closed  with  a suture.  The  slip  of  skin  chosen  for  re- 
moval should  not  be  too  near  the  edge  of  the  eyelid,  for 
then  the  skin  of  the  lower  edge  of  the  wound  would  be 
too  narrow  for  the  application  of  the  suture. — ( Beer,  b. 
2,  p,  115.)  Some  writers  refer  particular  cases  of  ptosis 
altogether  to  paralysis  of  the  levator,  and  other  in- 
stances to  spasm  of  the  orbicular  muscle.  When  the 
disease  depends  on  paralysis,  it  is  mostly  an  effect  of 
apoplexy,  upon  the  relief  of  which  its  cure  also  de- 
pends. The  treatment  directed  particularly  against 
the  paralytic  aflection  of  the  levator,  consists  in  fre- 
quently bathing  the  eye  and  surrounding  parts  with 
cold  spring  water,  and  rubbing  the  eyelid  and  eyebrow 
with  the  camphor  liniment,  to  which  a little  of  the 
tinctura  lyttije  is  added.  The  shower  bath,  bark,  and 
other  tonics  are  also  indicated.  If  these  means  fail,  an 
issue  may  be  made  with  the  moxa  or  potassa,  between 
the  mastoid  process  and  angle  of  the  jaw,  and  kept  open 
two  or  three  weeks.  The  cure  of  spasmodic  ptosis, 
which  is  rather  a symptom  of  other  diseases,  like  hys- 
teria, chorea,  worms,  &c.  than  a distinct  affection,  con- 
sists in  the  removal  of  the  original  complaint.  How- 
ever, generally  speaking,  anti-spasmodic  medicines ; 
blisters  on  the  temple,  or  behind  the  ear ; an  issue  be- 
tween the  mastoid  process  and  angle  of  the  jaw,  as  re- 
commended by  J.  A.  Schmidt,  on  account  of  some  ner- 
vous ramifications  of  the  third  branch  of  the  fifth  pair, 
which  give  twigs  to  the  eyelids  lying  in  that  situation ; 
and  fomenting  and  bathing  the  eye,  eyelids,  and  face 
•with  a decoction  of  poppy-heads  and  cicuta  ; are  the 
means  which  merit  the  consideration  of  the  practi 
tioner. — (See  Richter's  Anfangsgr.  der  Wundarzn.  b, 
4,  p.  488,  8«o.  2d  edit.  Gbtt.  1802.  J.  A.  Schmidt,  in 
Abhandl.  der  Konigl.  Med.  Chir.  Jos.  Acad,  zu  Wien, 
b.  2,p.  365, 1801.  Weller's  Manual,  Transl.  by  Mon- 
teath,  vol.  1,  p.  97,  «J-c.  8vo.  Glasgow,  1821.  G.J. 
Beer,  Lehre  von  den  Augenkr.  b.  2,  p.  109,  Src.  8vo. 
Wien,  1817.  G.  J.  Guthrie,  Operative  Surgery  of 
the  Eye,  p,  41,  Src.  8vo.  Land.  18^.) 

[PULSATION. — (See  Abdomen.)  Mr.  Loudon,  of 
Leamington  Spa,  did  me  the  favour  of  transmitting  to 
me  last  spring,  some  particulars  of  a case  where  the 
pulsations  of  the  aorta  against  a diseased  liver,  which 
had  extended  itself  into  the  epigastrium,  and  which 
during  life,  was  manifested  by  a well-defined  tu- 
mour at  the  pit  of  the  stomach,  were  mistaken  by 
several  of  the  most  eminent  medical  men  in  the  neigh- 
bourhood of  Leamington,  as  indicative  of  an  enlarge- 
ment of  the  aorta  immediately  behind  the  stomach. 
Dissection  proved  the  vessel  to  be  perfectly  sound. 
The  frequent  occurrence  of  such  cases  as  explained  in 
this  Dictionary  should  be  well  remembered  in  practice. 
-Pref] 

PUNCTURED  WOUNDS.  See  Wounds. 


PUPIL. 


281 


rUPlL.  When  the  opening  in  the  centre  of  the 
iris  is  preternaturally  large,  and  this  organ  more  or  less 
deprived  of  its  power  of  motion,  the  disease  is  tech- 
nically named  mydriasis,  which  is  either  symptomatic 
or  idiopathic.  The  first  form  of  the  complaint,  as 
Weller  observes,  is  exemplified  in  cases  of  hydroce- 
phalus, hydrophthalmia,  pressure  on  the  brain  from 
various  causes,  worms,  amaurosis,  &c.  The  second 
often  presents  itself  as  a paralytic  affection  of  the  iris  ; 
a state  frequently  induced  by  the  application  of  cer- 
tain narcotics,  like  belladonna  and  hyoscyamus.  Con- 
genital cases  of  mydriasis  are  also  met  with,  as  well 
as  instances  brought  on  by  a long  residence  in  dark- 
ness. A dilat  tion  of  the  pupil  may  likewise  be  the 
consequence  of  an  adhesion  of  the  uvea  to  the  ante- 
rior capsule  of  the  lens.  When  the  retina  continues 
sensible,  the  inconveniences  produced  by  mydriasis, 
are  intolerance  of  light,  complete  blindness  in  the  day- 
time, and  in  the  end  amaurotic  mischief,  occasioned 
by  the  irritation  of  the  immoderate  quantity  of  the 
rays  of  light  admitted  within  the  eye.  The  kind  of 
prognosis,  and  the  mode  of  treatment,  must  often  de- 
pend entirely  upon  the  primary  affection,  of  which 
many  cases  of  mydriasis  are  only  symptomatic.  Of 
course,  the  original  disorder  must  always  be  cured,  it 
possible.  When  mydriasis  appears  to  rise  from  pa- 
ralysis of  the  iris,  blisters  may  be  applied  over  the 
eyebrows,  and  the  same  remedies  tried  which  are  usu- 
ally employed  in  other  local  paralytic  disorders.  The 
entrance  of  too  much  light  into  the  eye  may  be  mode- 
rated with  shades  and  tubulated  spectacles. 

The  case  which  is  the  reverse  of  the  preceding  is 
a preternaturally  contracted,  more  or  less  immoveable 
state  of  the  pupil,  termed  myosis.  According  to  Wel- 
ler, it  is  sometimes  congenital.  It  is  often  met  with  as 
a symptom  of  other  disorders,  especially  ophthalmy, 
inflammation  of  the  dura  mater,  phrenitis,  concussion 
of  the  brain,  &c.  Persons  whose  business  is  to  be 
looking  at  small  shining  objects,  as  watchmakers, often 
acquire  a myosis  from  habit,  and  they  cannot  be  cured 
of  it,  unless  they  avoid  the  causes  which  brought  it 
on,  keep  themselves  in  a darkish  room,  and  use  a green 
shade  or  tubulated  spectacles. — (See  jVcller's  Ma- 
nual, iS-c.  Transl.  by  Monteath,  vol.  2,  p.  54.)  It  is  no- 
ticed by  Beer,  that  myosis,  when  a sequel  of  oph- 
thalmy, is  less  obvious  than  most  other  consequences 
of  ocular  inflammation ; for  though  the  iris  is  mo- 
tionless, and  the  pupil  considerably  diminished,  this 
opening  is  perfectly  clear  and  black,  and  not  drawn 
out  of  its  usual  position,  nor  its  pupillary  edge  in  the 
slightest  degree  angular.  The  patient,  though  he  is 
continually  complaining  of  weakness  of  sight,  is  able 
to  distinguish  (with  some  trouble  indeed)  even  the 
smallest  objects  in  the  daytime,  and  in  very  light  si- 
tuations ; but  his  sight  is  evidently  worse  in  the  eve- 
ning, and  ill  darkish  places  in  the  daytime;  for, 
when  both  his  eyes  are  affected,  he  is  in  the  dusk 
nearly  blind,  and  can  scarcely  find  his  way.  Beer 
remarks,  that  almost  every  considerable  internal  oph- 
thalmy, or  iritis,  however  favourably  the  disorder  may 
be  cured,  and  the  eyesight  restored,  always  leaves 
after  it  more  or  less  contraction  of  the  pupil,  which  af- 
fection, though  not  the  least  portion  ol’  coagulating 
lymph  can  be  perceived  in  the  posterior  chamber,  is 
combined  with  a partial  or  complete  immobility  of  the 
iris.  Beer  assures  us,  that  every  expedient  which  he 
has  yet  tried  for  the  permanent  removal  of  this  com- 
plaint has  failed,  the  dilatation  of  the  pupil  thus  pro- 
duced being  but  temporary.  And  with  respect  to  the 
most  powerful  narcotics,  he  states,  that  in  two  cases 
they  were  worse  than  useless,  as  they  caused  a still 
greater  contraction  of  the  pupil,  which,  however,  after 
a few  hours,  resumed  its  former  diameter.  Hence, 
this  experienced  oculist  is  disposed  to  set  down  the 
myosis  following  internal  ophthalmy  as  an  incurable 
complaint. — (See  Lehre  von  den  Augenkr.  b.  2,  p. 
2(il,  (S-c.) 

The  next  case  demanding  some  notice  in  this  work 
is  a closure  of  the  pupil  (atresia  pupillce).  Accord- 
ing to  Beer’s  observations,  there  is  only  one  exception, 
in  which  in  the  .adult  patient  a closure  of  the  pupil  is 
not  the  consequence  of  ophthalmy,  and  the  case  here 
signified  is  tcirmed  a collapse  of  the  pupil,  or  synizesis 
pupillm,  the  causes  of  which  are  said-  to  be,  either  a 
very  considerable  loss  of  the  vitreous  humour  from  a 
wound  of  the  eye,  or  else  a dissolved  or  rather  disor- 
ganized state  of  the  same  humour,  known  under  the 


name  of  synchisis. — (Lehre,  (S  c.  b.  2,  p.  190.)  Every 
internal  ophthalmy,  extending  to  the  retina  and  cho- 
roides,  when  in  its  highest  degree,  is  apt  to  produce  a 
complete  closure  of  the  pupil.  However,  the  oblitera- 
tion of  this  opening  is  not  the  only  cause  of  blindness  ; 
for,  long  before  this  state  of  the  iris  happens,  the  sight 
is  destroyed  by  considerable  and  frequently  irreme- 
diable injury  of  the  retina  and  neighbouring  textures, 
in  which  the  inflammation  is  directly  situated.  An 
incomplete  closure  of  the  pupil.  Beer  says,  is  still  more 
disposed  to  take  place  at  the  period  when  iritis  passes 
from  its  first  into  its  secemd  stage,  and  syphilitic  iritis 
is  said  to  be  particularly  apt  to  leave  after  it  this  dis- 
agreeable consequence. — (Vol.  cit.  p.  191.)  In  cases  of 
the  latter  description,  vision  is  not  always  quite  pre- 
vented, but  only  more  or  less  diminished,  the  coagu- 
lating lymph  effused  in  the  posterior  chamber  having 
formed  only  a delicate,  semitransparent  web.  How- 
ever, if,  in  the  second  stage  of  the  inflammation,  such 
lymph  should  be  converted  into  a dense  membrane, 
with  opacity  of  the  lens  and  its  capsule,  the  eye  then 
only  retains  more  or  less  perfectly  the  faculty  of  just 
distinguishing  the  light.  But  when,  in  such  a case, 
the  patient  is  completely  insensible  of  the  difference 
between  light  and  darkness,  tfte  blindness,  as  in  the 
examples  mentioned  above,  is  not  owing  to  the  clo- 
sure of  the  pupil,  or  to  the  cataract,  but  to  other  mor- 
bid changes  resulting  from  the  same  inflammation 
which  caused  the  defect  in  the  pupil  itself,  and  ca- 
pable of  being  ascertained  by  peculiar  appearances  in 
the  eye.  Passing  over  obstructions  of  the  pupil  by  the 
unabsorbed  matter  of  hypo[»ium,  and  by  the  continu- 
ance of  effused  blood  in  the  chambers  of  the  eye,  I 
come  to  the  case  next  noticed  by  Beer,  in  which  a 
closure  of  the  pupil  arises  from  a partial  adhesion  of 
the  iris  to  the  cornea  (synechia  anterior),  and  will  in- 
evitably happen,  when  a considerable  portion  of  the 
iris,  or  a great  part  or  the  whole  of  its  pupillary  edge 
protrudes  through  an  opening  in  the  cornea,  and  be- 
comes adherent  to  it.  However,  sometimes  in  these 
cases,  the  pupil  becomes  completely  obstructed,  though 
the  protrusion  of  the  iris  is  inconsiderable,  and  its  pu- 
pillary edge  not  engaged  in  the  cicatrix;  a circum- 
stance exemplified  when  the  cicatrix  over  the  adhe- 
rent part  of  the  iris  expands  very  much,  and  has  an 
extensive  leucomatous  surface,  so  that,  though  the 
pupil  may  be  of  considerable  size,  it  is  concealed,  and 
vision  impeded.  And  even  when  there  is  no  adhesion 
of  the  iris  to  the  cornea,  no  synechia  anterior,  as  it  is 
termed,  and  no  distortion  of  the  pupil,  a large  dense 
cicatrix  of  the  cornea  may  obstruct  vision  by  lying  ex- 
actly over  that  aperture.  Lastly,  as  Beer  has  ex- 
plained, the  greater  part  of  the  cornea  may  be  in  an 
opaque,  spoiled  condition,  so  that  the  healthy  iris  can 
be  discerned  only  at  certain  points  behind  its  circum- 
ference, no  vestige  of  the  pupil  itself  being  distinguish- 
able ; and  such  concealment  of  this  opening  may  bo 
either  combined  or  not  with  a partial  adhesion  of  the 
iris  to  the  cornea.  In  such  cases,  the  patient  can  fre- 
quently perceive  the  light  very  well. — (B.  2,  p.  194, 
195.) 

From  what  has  been  stated  it  is  manifest,  says  Beer, 
that  in  many  cases  of  atresia  iridis  the  prognosis 
must  be  highly  unfavourable,  and  that  no  attempt  to 
form  an  artificial  pupil  should  ever  be  made,  when  the 
patient’s  blindness  proceeds  from  other  causes  be-sides 
the  imperforate  state  of  the  iris.  Such  an  operation, 
Beer  observes,  can  only  be  proper  when  the  blindness 
is  entirely  owing  to  the  closed  or  concealed  state  of  the 
pupil ; when  the  different  degrees  of  light  c<an  be 
plainly  distinguished;  when  the  case  is  uncomplicated 
with  any  disease  of  other  important  textures  of  the 
eye,  capable  of  rendering  the  manual  proceedings  diffi- 
cult or  impracticable;  when  the  eye  has  been  for  a 
long  time  perfectly  free  from  inflammation  ; when  the 
patient  is  healthy,  without  any  tendency  to  scrofula, 
syphilis,  or  gout ; and  both  his  eyes  are  completely 
blind. — (B.  2,  p.  196.)  Some  questions  may  be  enter- 
tained respectitig  this  absolute  prohibition  of  the  ope- 
ration in  unhealthy  subjects,  because  the  line  between 
the  degrees  of  health  and  disease,  requisite  for  the 
success  of  the  operation,  is  difficult  to  specify,  and 
gout,  syphilis,  and  scrofula  are  often  vtigue  expres- 
sions. Yet,  no  doubt  can  exist,  I think,  about  the  pro- 
priety of  Beer’s  advice,  never  to  attempt  the  forma- 
tion of  an  artificial  pupil,  when  the  patient  enjoys 
vision  with  one  of  his  eyes  ; for,  when  the  new  open- 


^82 


PUPIL. 


iiig  is  made,  as  it  is  not  in  the  axis  of  vision,  the 
sight  is  confused  in  tlie  oilier  eye,  unless  the  imper- 
fect eye  be  kept  closed ; and  the  operation  can  never 
be  done  withfiut  exposing  the  patient  to  the  risk  of 
more  or  less  inflainination  in  the  eye,  which  is  at  pre- 
sent so  useful  to  him.  Whatever  inay  be  the  differ- 
ences of  opinion  about  operating  in  cases  of  single 
cataract,  I believe  that  all  surgeons  will  unanimously 
join  Beer  in  the  foregoing  advice,  respecting  the  im- 
prudence of  attempting  to  make  an  artificial  pupil 
when  the  patient  can  see  with  one  eye. 

When  vision  is  totally  lost  in  one  eye,  and  mate- 
rially impaired  in  the  other,  Mr.  Guthrie  very  judi- 
ciously observes,  that  the  question,  whether  an  opera- 
tion ought  to  he  performed  or  not,  is  important ; for 
if  the  patient  still  enjoys  sufficient  power  of  vision  to 
guide  himself,  the  surgeon  would  be  more  than  hardy 
who  would  put  that  portion  of  the  faculty  of  sight  in 
jeopardy  by  attempting  an  operation  : which  may  fail, 
however  skilfully  done.  Yet  Mr.  Guthrie  does  not  ab- 
solutely denounce  the  operation ; he  adds,  “ In  such 
circumstances,  the  operation  should  not  be  attempted 
upon  any  grounds,  unless  the  case  is  so  simple  as  to 
require  only  an  opening  in  the  cornea,  and  the  removal 
of  a portion  of  the  iris,  for  the  purpose  of  enlarging  the 
natural  pupil.  If  the  patient  cannot  see  sufficiently 
well  to  guide  himself,  the  conditions  are  very  essen- 
tially altered,  since  an  unsuccessful  operation  involves 
the  loss  of  very  little,  whereas  much  is  to  be  gained  by 
the  successful  issue  of  it.  Where  opacities  in  the  cen- 
tre of  the  cornea  occasion  tlie  impediment  to  vision,  it 
is  prudent  to  dilate  the  pupil  beyond  the  edge  of  the 
opacity,  by  the  daily  application  of  the  belladonna, 
which  may  possibly  enlarge  the  sphere  of  vision  so  as 
to  supersede,  in  a doubtful  or  dangerous  case,  the  ne- 
cessity of  an  operation.”^(See  Operative  Surgery  of 
the  Eye,  p.  444.) 

Beer  represents  the  event  of  the  operation  as  being 
very  uncertain,  when  the  patient  cannot  plainly  dis- 
cern the  various  degrees  of  light ; when  the  cornea  is 
affected  with  leucoma,  or  scarred  and  spoiled  nearly  to 
its  very  circumference ; when  there  is  only  a partial 
staphyloma  of  it;  or  the  constitution  is  unhealthy,  or 
impaired  by  the  effects  of  former  attacks  of  .scrofula, 
syphilis,  or  gout.  Lastly,  Beer  sets  down  the  opera- 
tioii  as  certainly  useless,  or  even  as  likely  to  cause  an 
entire  destruction  of  the  eye,  when  the  patient  is  quite 
insensible  of  light;  when  the  iris  and  neighbouring 
textures,  such  as  the  corpus  ciliare,  corona  ciliaris,  the 
membrane  of  the  vitreous  humour,  this  humour  itself, 
and  the  blood-vessels  of  the  organ,  are  in  a morbid 
state,  or  the  whole  eyeball  manifestly  in  a preternatural 
condition.  However,  an  opacity  of  the  lens,  and  its 
capsule,  even  when  the  latter  is  completely  adherent  to 
the  uvea,  forms  no  prohibition  to  the  formation  of  an 
artiffeial  pupil,  though  it  is  a circumstance  that  has 
great  weight  in  the  selection  of  the  method  of  opera- 
ting.— {Beer,  b.  2,p.  197.) 

The  following  information,  from  the  same  source,  is 
highly  important  to  the  praclitioner  : the  morbid  stale 
of  the  iris,  and  other  adjacent  textures  of  the  eyeball, 
prohibiting  the  operation,  may  be  known  by  the  an- 
nexed circumstances.  Together  with  the  smaller  cir- 
cle of  the  iris,  the  larger  one  is  strikingly  changed,  in 
respect  to  its  colour,  its  consistence,  and  its  layers. 
Its  radiated  fibres  are  collected  into  dark-blue  or  black- 
ish fasciculi,  between  which  there  is  an  appearance  of 
empty  interspaces,  produced  by  the  indentations  of  the 
iris,  and  actually  semitransparent,  in  consequence  of 
the  tapetum  of  the  uvea  having  always  been  in  these 
ea.ses  more  or  less  annihilated  by  the  previous  inflam- 
mation. Around  the  cornea  the  sclerotica  seems 
bluish,  or  rather  of  a smutty  grayish-blue  colour ; and 
sometimes  certain  points  of  this  membrane  are  protu- 
berant. The  inorbid  stales  of  the  whole  eyeball, 
which  may  complicate  the  atresia  iridis,  and  render 
the  operation  not  only  useless  but  hazardous  to  the 
preservation  of  the  eye,  are  its  dropsical  enlargement 
(see  Hydrvphthaimia) its  atrophy ; its  preternatural 
firmness,  from  a general  varicose  affection  of  its  blood- 
vessels; and  its  morbid  softness,  from  a disorganiza- 
tion of  the  vitreous  humour. — (Beer,  vol.  cit.  p.  198  ) 

Before  proceeding  farther  into  the  subject,  I think  it 
will  simplify  it  very  much  to  slate,  that  numerous  as 
the  plans  are  of  making  an  artificial  pupil,  if  we  ex- 
cept the  occasional  practice  of  forming  a kind  of  arli- 
licial  prolapsus  of  the  iris,  in  order  to  change  the  posi- 


tion or  shape  of  the  impcrfectly-closed  pupil,  they  may 
all  be  classed  into  three  principal  methods.  l.The  sim- 
ple transverse,  perpendicular,  or  otherwise  directed 
incision  in  the  iiis,  now  termed  curotumia,  performed 
either  through  the  sclerotica  or  the  cornea.  2.  The 
excision  of  a piece  of  the  iris,  technically  named  corec- 
tomia.  3.  The  separation  of  a part  of  its  circumfe- 
rence from  the  ciliary  ligament,  called  in  the  language 
of  oculists  corodialysis,  with  which  the  last  method, 
or  the  operation  of  corectomia,  is  combined  in  the  plans 
suggested  by  Asselini  and  Reisinger.  The  excision 
ol  a portion  of  sclerotica  close  to  the  cornea,  with  the 
view  of  forming  an  inlet  for  the  rays  of  light  to  the 
retina,  as  proposed  by  Autenrieih,  when  the  cornea  is 
entirely  opaque,  may  be  considered  a hopeless  pro- 
ceeding. With  respect  also  to  the  three  other  methods, 
it  is  now  well  understood  by  all  impartial  surgeons,  that 
the  choice  of  them  must  depend  upon  the  particulai  cir- 
cumstances of  the  case,  and  that  here  it  would  be  as 
absurd  to  think  of  employing  in  all  instances  only  one 
plan,  as  to  have  the  idea  of  extending  the  same  prin- 
ciple to  all  the  forms  and  varieties  of  cataract. 

When  the  thing  is  possible,  it  is  considered  by  Beer 
most  advantageous  to  make  the  artificial  pupil  rather 
towards  the  inner  canlhus ; though  others  express  a 
preference  to  the  centre  of  the  ins.  But,  as  he  very 
truly  remarks,  since  the  new  opening  must  be  where 
the  cornea  is  transparent,  the  operator  is  frequently 
obliged  to  form  it  either  below,  or  towards  the  temple, 
or  quite  above;  for  there  is  often  only  just  room  enough 
left  at  one  point  for  conducting  the  necessary  manceu- 
vres  with  any  degree  of  precision. 

The  following  remarks  by  Mr.  Guthrie  I consider 
interesting:  “An  opening  must  be  inad^  in  the  iris,  of 
an  extent  equal,  at  least,  to  the  natural  size  of  the 
pupil  when  moderately  dilated;  for,  if  it  be  le^s,  there 
will  not  be  sulBcienl  room  for  the  rays  of  light  to  act 
with  effect  on  the  retina  in  a moderate  light ; and  it 
must  not  be  forgotten,  that  the  artificial  pupil  never 
acquires  the  motions  of  dilatation  and  contraction,  so 
eminently  useful  in  the  natural  one.  It  should  not,  on 
the  other  hand,  be  too  large  ; because  it  would  prove 
detrimental  to  vision,  by  admitting  too  many  rays  of 
light  to  the  retina.  It  should  resemble  the  natural 
opening  in  form  as  nearly  as  possible  ; for  there  can- 
not be  a doubt  of  the  advantage  derived  in  man  from 
a circular  pupil,  where  the  axis  of  vision  is  directly 
forwards;  and,  although  an  artificial  one  is  seldom 
made  in  a circular  form,  and  in  the  centre  of  the  iris, 
still  that  process  will  be  the  best  the  result  of  which 
most  nearly  resembles  the  natural  state. 

“ When  an  artificial  pupil  cannot  be  made  in  the 
cenlie  of  the  iris  (from  whatever  cause),  the  other 
parts  of  it  are  eligible  in  the  following  order.  1.  The 
inferior  part  of  the  iris  inclining  inwards.  2.  The  in- 
ternal, a little  below  tlie  transverse  diameter  of  the 
eye.  3.  The  inferior  and  external ; the  upper  part  be- 
ing the  least  eligible,  from  the  eyelid  covering  that 
portion  of  the  cornea  in  the  natural  slate  of  the  eye.” 
— {Operative  Surgery  of  the  Eye, p.  4.^2.) 

Mr.  Guthrie  agrees  with  Beer,  that  the  place  in 
which  the  iris  is  to  be  perforated  generally  depends 
more  on  the  transparency  of  the  cornea  than  the 
choice  of  the  operator.  It  is  also  remarked,  that  a 
small  artificial  pupil,  at  the  lower  part  of  the  iris,  is 
infinitely  more  valuable  than  a large  one  at  any  other, 
which,  in  the  natural  state  of  the  eye,  is  covered  by 
the  eyelid,  or  much  out  of  the  axis  of  vision.  If  the 
state  of  the  cornea  will  permit  it,  Mr.  Guthrie  says,  a 
sound  part  of  the  iris  should  be  selected. — (P.  443.) 
Reconsiders  the  external  and  internal  margin.-;  of  the 
iris,  immediately  on  a line  with  the  central  transveise 
diameter,  particularly  unfavourable  for  the  method  in 
which  the  iris  is  separated  from  the  ciliary  ligament, 
because  there  the  long  ciliary  arteries  enter,  and  the 
attachment  of  the  iris  is  firmer  than  at  other  points. 

Cheselden  first  devised  a .section  of  the  iris,  for  the 
purpose  of  forming  an  artificial  pupil.  He  pioposed 
the  introduction  of  a couching  needle,  with  a sharp 
edge  ordy  on  one  side,  through  the  sclerotica,  about 
half  a line  from  the  cornea,  into  the  posterior  chamber. 
After  the  iris  had  been  perforated  towards  the  external 
angle,  and  the  point  of  the  needle  then  pushed  through 
liie  anterior  chamlrer,  as  far  as  that  side  of  the  iris 
which  is  nearest  the  nose,  the  edge  was  turned  back- 
wards, ai  d the  instrument  withdrawif*  so  as  to  make  a 
transverse  division  of  that  membrane. 


PUPIL. 


283 


T]ie  account  of  the  proposal,  given  by  Cheselden 
iiimself  in  the  Philosop/dcal  Trans,  for  1723,  is  very 
incomplete;  and  according  to  Mr.  Guthrie,  ite  did  not 
actually  perforin  llie  operation  on  the  person  whose 
history  he  there  relates,  but  only  annexed  to  it  an  ac- 
count of  a particular  operation  which  he  considered 
worthy  of  record : a circumstance  which,  from  not 
being  attended  to,  has  been  the  source  of  considerable 
errors. — {Operative  Surgery  of  the  Eye,p.  395.)  Mo- 
rand,  when  he  was  in  London,  saw  Cheselden  form  an 
artificial  pupil;  but  the  process,  as  described  by  Mo- 
rand,  differs  from  the  above,  inasmuch  as  the  needle 
passed  as  far  across  the  posterior  chamber  as  two- 
thirds  of  the  iris,  when  its  edge  was  turned  towards 
this  membiane,  which  was  thus  cut,  and  as  much  of 
it  divided,  in  withdrawing  the  instrument  horizontally, 
as  left  an  artificial  pupil  of  an  oblong  form. 

Janin  performed  Cheselden’s  method,  as  described 
by  Mofand,  on  two  subjects  with  the  utmost  care  pos- 
sible, but  not  the  smallest  benefit  followed  : for  after 
the  subsidence  of  the  symptoms  produced  by  the  ope- 
ration, the  transverse  section  made,  in  the  iris  by  the 
edge  of  the  needle  reunited. — {Mem.  sur  I’CEil.)  Mr. 
S.  Sharp  also  saw  a failure  from  the  same  cause. — {On 
Operations,  chap.  29.) 

All  accident  occurred  to  Janin,  in  the  act  of  extract- 
ing a cataract ; viz.  he  included  the  iris  together  with 
the  cornea,  in  David’s  scissors,  and  cut  it  perpendicu- 
larly, and  the  division  remained  permanent.  This  led 
him  to  propose  a perpendicular  incision  as  the  best 
expedient  for  making  an  artificial  pupil.  His  plan  con- 
sisted in  opening  the  cornea,  as  is  practised  for  the 
extraction  of  the  cataract,  and  in  dividing  the  iris 
perpendicularly  with  scissors  near  that  part  of  the 
pupil  which  is  ne.xt  to  the  nose  ; for  he  affirms,  that  he 
has  seen  strabismus  result  from  making  the  section  to 
wards  the  external  side,  on  account  of  the  too  great 
divarication  of  the  optical  axes. 

Although  the  practice  of  making  an  incision  in  the 
iris  or  corotomia  is  severely  disapproved  of  by  Beer, 
who  stat  that  it  admits  of  being  practised  only  in 
very  few  cases,  and  is  rendered  quite  unnecessary  by 
what  he  denominates  the  two  other  better  plans  {h.  2, 
V.  199),  it  is  still  considered  by  some  men  of  experi- 
ence as  having  recommendations,  and  they  have  there- 
foie  endeavoured  to  improve  it.  However,  it  will  only 
be  in  my  power  to  notice  in  this  work  a few  of  its 
modifications. 

In  1812,  Sir  W.  Adams  recommended  the  revival  of 
Cheselden’s  method  of  forming  an  artificial  pupil, 
with  the  difference  of  using  for  the  jiurpose  a particular 
sort  of  knife.  “ With  a cataract  needle  (says  this  ocu- 
list) I could  not  cut  through  the  iris  by  a gentle  force  ; 
and  if  I ventured  to  apply  a greater  force,  the  iris  se- 
parated from  its  attachment  to  the  ciliary  ligament, 
which  rendeied  all  farther  attempts  to  effect  a central 
aperture  useless.  The  same  accident  appears  to  have 
happened  to  Mr.  Sharp  in  his  trials  of  this  operation, 
in  the  hopes  of  procuring  an  appropriate  instrument,  I 
twice  went  to  London,  at  the  interval  of  a few  months ; 
but  though  I described  to  dift'eient  instrument  makers 
the  purposes  for  which  it  was  intended,  still  I could 
only  procure  the  needle  which  cuts  on  one  edge,  and 
the  speai-pointod  knife  of  difleient  sizes,  described  by 
Cheselden.  At  length  it  occurred  to  me  that  the  curved 
edge  of  the  common  dissecting  scalpel  was  well  adapted 
to  cut  with  facility.  I therefore,  when  in  London  a 
third  time,  got  a small  knife  made,  two-thiids  of  an 
inch  in  length,  and  nearly  a line  in  width,  with  a 
straight  back,  sharp  poitit,  and  a curved  edge,  which 
cuts  back  towards  the  handle  for  about  three  lines.” 
— {.‘Jdanis's  Pracl.  Obs.on  Ectr opium,  Src.p.  30.)  Ac- 
cording to  this  writer,  in  all  cases  where  there  is  no 
crystalline  lens,  and  the  cornea  is  free  from  opacity, 
the  division  of  the  iris  should  be  made  in  the  centre, 
artd  shouhl  extend  across  at  least  two-thirds  of  its 
ti  arts  verse  diatrreter.  In  a later  work,  however,  he 
Slates,  that  experieitce  has  convinced  him,  that  so  ex 
tensive  a division  of  the  iris  is  unnecessary  for  the  pre- 
veriiiort  of  the  reunion  of  this  nrentbrane,  and  that  a 
ctit  through  orre-third  of  its  diameter  is  sufficient.  The 
ey<;  l>eing  gently  fixed,  either  with  the  finger  of  the  as- 
sL'iant,  wh(»  supports  the  upper  eyelid,  or  with  a con- 
cave son  <if  8|)eculum  placed  under  the  upper  eyehd, 
the  ariifieial  pupil  knife  is  to  be  introduced  through 
the  coat.s  r»f  the  eye,  about  a line  behirtd  the  iris,  with 
its  cutting  eiige  turned  backwards  The  point  is  next 


to  be  brought  forwards  through  the  iris,  somewhat 
more  than  a lirre  from  its  tenrporal  ciliary  attachment, 
aitd  cautiously  carried  through  the  arrterior  chamber, 
until  it  has  nearly  readied  the  irmeredge  of  that  mem- 
braire  (or  as  is  expressed  in  a later  description),  “ un- 
til it  has  traversed  more  than  two-thirds  of  ilie  width 
of  the  iris,”  when  it  should  be  almost  withdrawn  out 
of  the  eye,  geiitle  pressure  being  made  with  the  curved 
part  of  the  cutting  edge  of  the  instrument  against  the 
iris,  in  the  line  of  its  transverse  diameter.  If  in  the 
first  attempt  the  iris  should  not  be  sufficiently  cut,  the 
point  of  the  knife  is  to  be  again  carried  forwards,  and 
similarly  withdrawn,  until  the  incision  is  of  a proper 
length.  After  the  operation,  the  eye  is  to  be  covered 
with  a plaster  of  simple  ointment,  and  the  patient  put 
into  bed,  with  his  head  raised. — {P.  36,  37.)  When 
the  closure  of  the  pupil  is  attended  with  a cataract, 
the  primary  steps  of  the  operation  are  the  same  ; but 
Sir  W.  Adams  lakes  care  also  to  cut  the  cataract  into 
pieces,  some  of  which  he  brings  forw  ards  into  the  an- 
terior clj^mber,  while  others  he  leaves  in  the  opening 
of  the  iris,  where  they  at  fir.st  serve  as  a plug,  hinder- 
ing union  by  the  first  intention  {p.  38),  and  are  after- 
ward absorbed.  For  an  account  of  his  particular 
methods  for  all  the  various  complications  of  cases,  the 
reader  must  consult  his  publications,  where  many  suc- 
cessful examples  of  the  operation  are  recorded. 

That  Cheselden’s  method  ought  not  to  be  entirely 
rejected,  there  can  now  be  no  doubt.  Like  all  other 
modes  of  forming  an  artificial  pupil,  it  certainly  does 
not  merit  exclusive  preference.  In  addition  to  the 
testimony  of  Sir  W.  Adams,  w'e  have  that  of  Mr. 
Ware,  to  [)rove  that  Cheseldeii’s  operation  frequently 
succeeds.  When  the  pupil  had  become  closed,  after 
an  unsuccessful  extraction  of  the  cataract,  Mr.  Ware 
in  several  instances  made  a new  pupil  agreeably  to 
Cheselden’s  mode,  with  the  most  perfect  success. 
“ The  fibres  of  the  iris  retracted  as  soon  as  they  were 
divided,  and  left  the  pupil  very  nearly  of  its  natural 
size>  Its  shape  was  not  quite  round ; hut  the  sight 
was  immediately  restored,  and  to  so  great  a degree  as 
to  enable  the  patient,  by  the  help  of  suitable  convex 
glasses,  to  see  distinctly  both  near  and  distant  objects, 
neither  pain  nor  infiammation  being  consequent  to  the 
operation.” 

Where  there  is  a prolapsus  of  the  iris,  tlirough  a 
breach  of  the  cornea,  involving  more  or  less  of  the  pu- 
pillary margin,  Mr.  Travers  considers  Cheselden’s 
method  the  most  applicable  ; viz.  “ the  transverse  divi- 
sion of  the  stretched  fibres  of  the  iris,  and  which,  if 
the  section  be  made  in  front  of  Uie  membrane,  i.  e. 
from  before  backwards,  admits  of  no  improvement. 
The  edges  of  the  section  instantly  recede  and  form 
an  excellent  pupil.”  How'ever,  he  afterward  adds, 
“that  a partial  adhesion  of  the  pupillary  margin  may 
be  combined  with  a healthy  lens.  In  this  case,  the 
removal  of  the  free  border  of  the  pupil,  drawn  by 
means  of  forceps  through  an  incision  in  the  cornea, 
will  be  preferable,  on  account  of  preserving  the  trans- 
parency of  the  lens.” — {Synopsis  of  the  Discuses  of 
the  Eye,  p.  343.) 

In  a modern  work,  Professor  Maunoir,  of  Geneva, 
has  published  a very  successful  case,  in  which  an  ar- 
tificial pupil  was  formed  and  a caseous  cataract  e.\- 
iracted.  “ I operated  (says  he)  on  the  right  eye  in  the 
following  manner.  The  patient  being  seated  on  a 
chair,  and  having  the  head  inclined  upon  a cushion,  I 
placed  myself  behind  liim,  and,  with  the  fore  finger  of 
the  left  hand  confining  the  tipper  eyelid,  while  tin  as- 
sistant depressed  the  lower,  1 made  with  the  right 
hand  a semicircular  incision  in  the  lower  and  external 
part  of  the  cornea.  This  incision  occupied  a full  third 
of  the  circumference  of  the  membrane.  .On  re-opening 
the  eye,  the  iris  was  seen  projecting  a little  from  the 
wound  in  the  cornea.  I replaced  it  with  the  blunt 
point  of  my  scissois.  Introducing  the  two  blades 
closed  into  the  anterior  chamber,  and  then  opening 
them,  1 caused  the  pointed  blade  to  penetrate  the  iris, 
leaving  the  blunt  blade  between  that  membrane  and 
the  cornea;  then  closing  the  scissors,  a perpendicular 
incisioiv  of  the  iris  resulted,  describing  a little  more 
than  half  the  choid  of  an  arc  of  two-fifths  of  the  cir- 
cumference of  the  iris  tract  d on  the  side  of  the  temple. 
The  first  incision  imt  having  occasioned  the  formation 
of  a pupil  of  the  necessaiy  size,  I introduced  thi;  scis- 
.^ors  into  the  iris  a second  time  a little  oblitpiely ; and 
immediately  the  pupil  appeared  of  a satisfactory  form 


284 


PUPIL. 


and  size,  but  exhibiting  the  crystalline  entirely  opaque. 
The  second  stroke  of  the  scissors  hart  divided  tlie  cap- 
sula : I therefore  introduced  the  small  curette,  in  order 
to  endeavour  to  destroy  what  adhered  of  the  crystal- 
line to  the  shrunk  and  contracted  circuiftference  of  the 
old  pupil.  This  attempt  did  not  succeed.  Lastly,  I 
effected  a passage  of  a portion  of  the  opaque  lens,  by 
means  of  a slight  pressure  with  a large  scoop,  exer- 
cised on  the  lower  part  of  the  globe  of  the  eye.  The 
crystalline,  which  was  of  a cheesy  consistence,  came 
out  with  the  greatest  ease,  and  though  it  was  not  en- 
tirely removed,  yet  a sufficient  quantity  was  discharged 
to  leave  the  artificial  pupil  of  a most  perfect  black. 
This  new  pupil  was  on  the  side  of  the  temple ; and  at 
the  exterior  and  tower  part  of  the  iris.” — (See  Med. 
Chir.  Trans,  vol.  7,  p.  305,  et  seq.)  In  this  communi- 
cation are  also  two  other  cases,  in  which  Maunoir  ope- 
rated with  success,  though  they  were  complicated  with 
cataracts  and  adhesions  of  the  lens  to  the  iris.  In 
some  remarks  annexed  by  Scarpa  to  the  preceding  ac- 
count, the  latter  expresses  his  opinion,  that  it  is  not 
necessary  to  be  scrupulous  whether  the  crystalline  be 
partly  or  entirely  opaque,  whenever  the  capsule  is 
opaque  and  adheres  to  the  iris  behind  the  edge  of  the 
interior  and  enclosed  pupil.  “ In  this  case  only  one 
remedy  can  be  pointed  out,  namely,  the  removal  of  the 
opaque  adherent  capsule,  and  consequently  of  the  crys- 
talline, whether  it  be  transparent  or  opaque.  In  the 
second  place  (says  Scarpa),  I think  there  is  no  reason 
to  doubt,  that  in  similar  cases,  it  is  advisable  to  make 
an  incision  upon  the  iris,  proportioned  to  the  size  of 
the  body  to  be  extracted,  rather  than  to  make  it  small, 
which  obliges  the  operator  to  divide  the  crystalline  and 
the  capsule,  with  the  intention  of  extracting  a part  and 
of  abandoning  the  rest  to  the  powers  of  absorption. 
Thirdly:  I would  establish  as  a fundamental  principle, 
in  similar  cases,  that  after  the  co.mplete  extraction  of 
the  crystalline,  with  its  opaque  capsule,  by  means  of 
the  least  possible  introduction  of  the  instruments,  the 
artificial  pupil  ought  not  to  be  too  near  the  incision  in 
the  cornea,  and  consequently  not  too  near  the  cicatrix 
occasioned  by  it.” — {P.  317.)  Scarpa  then  recom- 
mends a particular  method  of  operating  in  cases  where 
there  are  cataracts:  after  having  made,  in  the  rpanner 
of  Wenzel,  a transverse  incision  in  the  iris  and  in  the 
cornea,  he  would  introduce  Maunoir’s  scissors,  blunted 
at  both  points,  into  the  anterior  chamber  of  the  aque- 
ous humour,  and  make  an  incision  in  the  iris,  diverging 
from  the  cut  made  with  the  knife.  The  aperture  thus 
made,  Scarpa  thinks,  would  be  large  enough  for  the 
easy  passage  of  the  opaque  lens. 

Among  other  late  opinions  professed  by  Scarpa,  we 
find  the  following:  that  no  instrument  is  so  proper  as 
the  scissors  for  making  an  incision  in  the  iris;  that 
when  the  case  is  not  complicated  by  cataract,  a very 
small  wound  in  the  cornea  is  sufficient;  that  the 
formation  of  a triangular  edge  in  the  iris,  by  means  of 
a double  incision  with  the  scissors,  is  the  most  easy  and 
least  painful  of  all  the  methods  hitherto  proposed  for 
obtaining  a permanent  artificial  pupil ; and,  lastly,  that 
specks  of  the  cornea  present  no  obstacle,  because  the 
artificial  pupil  may  be  made  opposite  the  transparent 
part  of  that  membrane. — [Med.  Chir.  Trans,  vol.  7,  p. 
320,  .321.) 

As  I have  already  noticed,  the  contraction  of  the 
natural  pupil  is  sometimes  occasioned  by  the  iris  being 
stretched  towards  some  point  of  the  cornea  to  which 
it  is  adherent.  This  state,  as  Scarpa  observes,  is  most 
frequently  accompanied  with  partial  opacity  of  the 
cornea  around  the  adhesion,  or  prolapsus  of  the  iris,  as 
well  as  with  opacity  of  the  lens  and  its  capsule.  At 
other  times,  however,  these  internal  parts  preserve 
their  natural  transparency,  notwithstanding  the  de 
viation  of  the  natural  pupil.  In  the  latter  case,  the 
pupil,  though  removed  from  its  situation,  is  not  in 
reality  obliterated,  but  merely  very  much  contracted, 
and  incapable  of  admitting  the  quantity  of  light  ne- 
cessary for  vision,  especially  if  the  opposite  part  of  the 
cornea  be  slightly  opaque.  In  such  an  example,  Scarpa 
recommends  making  a small  incision  in  the  cornea  at 
tlie  most  commodious  part,  when  with  Maunoir’s 
scissors  closed,  and  constructed  with  little  buttons  at 
the  ends  of  both  the  blades,  an  endeavour  is  to  be 
made  to  break  the  adhe.-ion  existing  between  the  iris 
and  ther  cornea.  If  this  can  be  effected,  the  natural 
pupil  generally  recovers  its  former  situation  and  size; 
but  if  the  adhesion  be  very  firm,  Scarpa  introduces  one 


of  the  blades  within  the  contracted  pupil,  behind  the 
posterior  surface  of  the  iris,  until  the  other  blade  has 
reached  the  confines  of  the  cornea  with  the  sclerotica. 
The  iris  is  then  to  be  divided  in  the  form  of  the 
letter  V,  without  at  all  injuring  the  capsule  or  lens, 
both  of  which  are  transparent.— ( On  Diseases  of  the 
Eyes,  p 384,  ed.  2,  transl.  by  Briggs.)  When,  after 
extraction  of  the  cataract,  the  pupil  has  been  dragged 
down  in  this  manner  by  adhesion  to  the  lower  third  of 
the  cornea,  the  upper  two-thirds  of  which  are  trans- 
parent, Dr.  Monteath,  of  Glasgow,  has  succeeded  five 
times  in  forming  an  artificial  pupil,  and  restoring 
vision,  by  making  a small  opening  in  the  upper  and 
outer  part  of  the  edge  of  the  cornea,  capable  of  ad- 
mitting Maunoir’s  eye-scissors,  with  which  the  over- 
stretched fibres  of  the  iris  are  to  be  cut  across  by  one 
simple  incision  three  lines  in  length.  The  cut  edges 
instantly  recede  and  leave  an  oval  pupil  of  sufficient 
size. — (See  Weller's  Manual,  vol.  2,  p.  70.)  In  the 
cases  above  specified  by  Scarpa,  Sir  Wm.  Adams,  in- 
stead of  performing  corotomia,  endeavours  to  separate 
the  iris  from  the  cornea,  and  then  to  alter  the  position 
of  the  pupil  by  drawing  it  towards  that  part  of  the 
cornea  which  has  remained  transparent.  For  this 
purpose  he  punctures  the  cornea  about  one  line  in  front 
of  the  iris,  separates  the  adhesion,  and  then  makes  the 
disengaged  portion  of  the  iris  protrude  through  the 
puncture  and  leaves  it  there,  even  using  the  forceps, 
if  necessary,  for  drawing  it  out  as  far  as  is  deemed  ne- 
cessary for  its  being  securely  fixed.  This  method  is 
disapproved  of  by  Scarpa,  because  a second  prolapsus 
of  the  iris  in  the  same  eye  appears  to  him  a very 
serious  disease,  and  rather  calculated  to  increase  the 
opacity  of  the  cornea,  and  augment  the  contraction  of 
the  pupil,  than  afford  relief.  ' 

According  to  Beer,  in  the  excision  of  a portion  of  the 
iris,  corectoniia  is  particularly  indicated  in  all  cases  in 
which  there  is  a sound  transparent  lens,  as  in  many 
examples  of  synechia  anterior,  concealment  of  the 
natural  pupil  by  a central  opacity  of  the  cornea,  &.c. 
Beer  admits,  however,  as  an  exception,  the  Instances  in 
which  the  transparent  portion  of  the  cornea  is  so  small 
that  no  opening  can  be  made  in  it  with  the  knife  large 
enough  to  permit  the  iris  to  be  taken  hold  of  with  a 
small  hook  or  forceps,  and  a piece  of  it  cut  out  above 
the  ciliary  processes. — (B.  2,  p.  200.)  The  reason  here 
given  does  not  appear  to  myself  very  strong,  because  it 
may  be  asked,  why  not  acquire  more  room  by  cutting 
a portion  of  the  opaque  part  of  the  cornea?  Weller 
assigns  a better  reason  against  corectomia,  viz.  when 
he  refers  to  the  risk  of  a sufficient  piece  of  the  coinea 
not  being  left  transparent,  opposite  the  new  pupil  after 
the  cicatrization  of  that  membrane. — (FbZ.  2,  p.  65.) 
Beer  farther  states,  that  corectomia  may  be  performed 
in  cases  of  atresia  iridis  consequent  to  the  operation  of 
extracting  the  cataract,  when  the  surgeon  is  certain 
that  no  coagulating  lymph,  effused  during  the  previous 
inflammation  in  the  posterior  chamber,  reaches  above 
the  lesser  circle  of  the  uvea,  or  is  conjoined  with  opacity 
of  the  remaining  capkule  of  the  lens.  The  first  state 
may  be  learned  from  the  singular  colour  and  form  of 
the  greater  ring  of  the  iris;  the  second,  from  the  very 
indistinct  manner  in  which  the  patient  is  sensible  of 
the  different  degrees  of  light.— (/?ee7-,  h.  2,  p.  200.) 

The  excision  of  a piece  of  the  iris,  says  Beer,  re- 
quires the  preliminary  formation  of  a flap  in  the  cornea, 
one  line  in  length,  with  the  cataract  knife,  and  as  close 
as  possible  to  the  sclerotica,  so  that  no  subsequent 
opaque  cicatrix  may  interfere  with  the  success  of  the 
operation.  The  second  part  of  the  business,  viz.  the 
excision  of  a piece  of  the  iris,  must  be  done  in  three 
ways,  according  to  circumstances.  1.  The  iris  may 
not  be  any  where  adherent  to  the  cornea,  in  which 
ca.se,  after  an  opening  has  been  made  in  the  latter 
membrane,  the  iris  is  propelled  out  between  the  edges 
of  the  wound  by  the  aqueous  humour,  yet  left  in  the 
posterior  chamber,  which  opportunity  the  surgeon 
must  immediately  avail  himself  of  for  taking  hol'd  of 
the  projecting  piece  of  the  iris  with  a very  fine  hook, 
and  cutting  it  off  with  David’s  scissors.  The  re- 
mainder of  the  iris  is  instantly  retracted  behind  the 
cornea,  and  a well-formed  pupil  is  immediately  seen. 
2.  Only  the  part  of  the  edge  of  the  pupil  may  remain 
not  adherent  to  and  drawn  towards  the  cornea,  where 
it  is  intended  to  form  the  artificial  pupil ; a state  best 
ascertained  by  a lateral  inspection  of  the  eye.  In  this 
cate,  after  opening  the  cornea,  Beer  says,  the  operator 


PUPIL. 


285 


is  directly  to  introduce  a small  hook  between  the  iris 
and  cornea,  so  as  not  to  injure  either  of  these  parts 
with  its  point,  and  he  is  then,  with  the  instrument  di- 
rected obliquely,  to  get  hold  of  the  pupillary  edge  of  the 
iris,  and,  while  the  iris  is  drawn  out  between  the  edges 
of  the  incision,  the  projecting  piece  is  to  be  cut  off 
with  Daviel’s  scissors.  Thus  the  natural  pupil  is  to  be 
extended  behind  the  transparent  part  of  the  cornea 
towards  the  edge  of  this  membrane.  3.  The  pupillary 
edge  of  the  iris  may  be  adherent  to  the  cornea  ex- 
actly in  the  situation  where  the  artificial  pupil  is  to  be 
formed : in  this  case.  Beer  directs  the  iris  to  be  taken 
hold  of  at  its  greater  circle  with  the  hook,  or  (if  this 
should  tear  its  way  out)  with  a pair  of  fine-pointed 
forceps  with  teeth  drawn  out  between  the  edges  of  ihe 
wound,  and  the  point  of  the  cone  thus  produced  cut 
off  somewhat  within  the  edges  of  the  wound,  as  draw- 
ing the  iris  farther  out  might  tear  it  and  have  a preju- 
dicial effect.  In  all  these  cases,  says  Beer,  the  undis- 
eased lens  and  its  capsule  will  not  be  injured  if  the  pa- 
tient keep  tolerably  steady,  and  the  operator  have 
already  acquired  dexterity  in  the  extraction  of  the 
c ataract.  Theoperation  being  finished,  the  subsequent 
treatment  is  like  that  generally  adopted  after  the  ex- 
traction of  the  cataract.— (See  Cataract.)  When  co- 
reclomia  is  to  oe  performed  for  a closure  of  the  pupil, 
consequent  to  extraction  of  the  cataract,  Beer  particu- 
larly recommends  the  forceps  to  be  used,  though  he 
adds,  that  such  operation  is  applicable  oidy  when  the 
remaining  capsule  has  not  been  spoiled  by  inflamma- 
tion, and  the  quantity  of  lymph  in  the  posterior  cham- 
ber is  not  so  great  as  to  reach  above  the  lesser  circle 
of  the  uvea. 

The  only  other  species  of  corectomia  which  I deem 
it  necessary  to  notice,  is  what  was  proposed,  in  the 
year  1811,  by  the  late  Mr.  Gibson  of  Mandhester.  It  is 
described  as  follows:  “ The  first  step  of  the  operation 
is  to  secure  the  eyelids,  as  in  the  operation  for  extract- 
ing a cataract.  A puncture  is  then  to  be  made  in  the 
cornea,  with  a broad  cornea-knife,  within  a line  of  the 
sclerotica,  to  the  extent  of  about  three  lines.  All 
pressure  is  now  to  be  removed  from  the  eyeball,  and 
the  cornea-knife  gently  withdrawn.  The  consequence 
of  this  is,  that  a portion  of  the  aqueous  humour 
escapes,  and  the  iris  falls  into  contact  with  the  opening 
in  the  cornea,  and  closes  it  like  a valve.  A slight  pres- 
sure must  now  be  made  upon  the  superior  and  nasal 
part  of  the  eyeball,  with  the  fore  and  middle  finger  of 
the  left  hand,  till  at  length,  by  an  occasional  and  gentle 
increase  of  the  pressure,  or  by  varying  its  direction, 
the  iris  gradually  protrudes,  so  as  to  present  a bag  of 
the  size  of  a large  pin’s  head.  This  protruded  portion 
must  be  cut  ofl!’  with  a pair  of  fine  curved  scissors,  and 
all  pressure  at  the  same  time  removed ; the  iris  will 
then  recede  within  the  eye,  and  the  portion  which  has 
been  removed  will  leave  an  artificial  pupil  more  or 
less  circular.” — {Gibson  on  Artificial  Pupil,  <Src. 
Land.  1811.)  Such  was  this  surgeon’s  mode  of  ope- 
rating, when  the  closure  of  the  pupil  was  attended 
with  central  opacity  of  the  cornea,  uncombined  with 
adhesions.  The  effect  of  a slight  adhesion  of  the 
inner  border  of  the  iris  to  the  cornea  will  be,  to  pre- 
vent the  protrusion  of  the  first  of  these  membranes 
through  the  puncture  in  the  cornea,  which  protrusion 
so  much  facilitates  the  operation.  In  this  case,  a por- 
tion which  does  not  adhere  must  be  drawn  out  with  a 
small  hook,  and  then  removed.  Sometimes  the  ad- 
hesion may  be  separated  at  the  time  of  making  the 
puncture,  and  then  the  iris  will  protrude.  When  the 
whole  or  greater  part  of  the  inner  border  of  the  iris 
is  involved  in  adhesions  to  the  cornea,  thqse  must  be 
separated  with  the  cornea-knife,  after  making  the 
puncture,  and  the  iris  may  then  either  be  drawn  out 
with  the  hook,  or  a portion  of  it  be  removed  by  means 
of  very  minute  scissors.  In  every  case,  however,  the 
removal  of  a portion  is  essential  to  success. 

When  a cataract  is  known  to  exist,  Mr.  Gibson  re- 
commends it  to  be  depressed,  or  broken  to  pieces  with 
the  needle,  before  making  the  artificial  pupil;  and 
when  the  whole  cornea  is  transparent,  he  directs  a flap 
to  be  made  in  the  centre  of  the  iris  with  the  cornea- 
knife,  and  then  cut  oflT  with  the  iris  scissors. — (Gibson, 
op.  cit.) 

Coredinlysis,  or  the  mode  of  forming  an  artificial 
pupil  by  detaching  a portion  of  the  iris  from  the  ciliary 
ligament,  is  said  to  have  been  devised  by  Ad.  Schmidt 
and  Scarpa  altout  ihe  same  tirne,  and  has  been  va- 


riously modified  by  Reisinger,  Langenbeck,  Himly, 
Graefe,  and  others. — ( Weller  on  Diseases  of  the  Eye, 
vol.  2,  p.  65.)  According  to  Beer,  this  plan  of  operating 
is  indicated,  first,  only  when  the  coagulating  lymph, 
effused  in  the  posterior  chamber  after  the  extraction  of 
the  cataract,  or  reclination  (see  this  word),  reaches 
from  above  the  lesser  circle  of  the  uvea  towards  the 
ciliary  processes;  a circumstance  which  may  be  known 
by  the  considerable  change  of  colour  in  the  greater 
circle  of  the  iris,  and  by  the  indistinct  manner  in  which 
the  patient  perceives  the  light.  Secondly,  when  the 
uvea  is  every  where  adherent  to  a secondary  capsular 
cataract,  or  capsulo-lenticular  cataract,  or  the  closure 
of  the  pupil  has  been  occasioned  by  a purulent  or 
bloody  cataract.  Whenever  the  attempt  is  made  in 
these  last  cases,  however,  the  patient  should  be  capa- 
ble, as  he  sometimes  is,  of  plainly  discerning  the  light. 
Lastly,  coredialysis  is  sanctioned  by  Beer,  when  the 
cornea  is  every  where  incurably  opaque,  excepting  so 
small  a part  of  it  that  it  could  not  well  be  opened  for 
the  excision  of  a portion  of  the  iris.— (R.  2,  p.  203.) 

When  the  closed  pupil  is  the  result  of  inflammation 
from  an  injury,  the  lens  has  been  absorbed,  and  the  an- 
terior cai)sule,  or  both  the  anterior  and  posterior,  are 
thickened  and  firmly  attached  to  the  iris  with  only  an 
indistinct  perception  of  light,  and  a discoloration  of 
the  lesser  circle  of  the  iris,  indicating  a deposition  of 
lymph  behind  it,  Mr.  Guthrie  sets  dowui  coredialysis  as 
the  proper  operation  ; “ for  the  formation  of  a trian- 
gular opening  by  the  scissors  would  not  be  easily  ac- 
complished to  a sufficient  extent;  and  the  simple  di- 
vision of  the  central  part  of  the  iris  would  in  general 
be  ineffectual,  in  consequence  of  the  thickened  cap- 
sule preventing  the  necessary  retraction  of  the  fibres  of 
the  iris.” — ( Operative  Surg-ery  of  the  Eye,  p.  466.) 

The  feeble  union  of  the  iris  with  the  ciliary  ligament, 
and  consequently  the  greater  facility  of  detaching  its 
edge  from  that  ligament,  with  which  it  is  connected, 
than  or'lacerating  its  body,  induced  Scarpa  to  try  a 
new  method  of  forming  an  artificial  pupil  when  the 
natural  one  had  become  too  much  contracted,  or  quite 
obliterated,  after  the  extraction  or  depression  of  the 
cataract.  His  method  of  operating  consists  in  detach- 
ing, by  means  of  a couching  needle,  a certain  extent  of 
the  circumference  of  the  iris  from  the  ciliary  ligament, 
without  dividing  the  cornea.  The  attempt  met  with 
success. 

The  patient  being  seated  and  supported,  as  if  he  were 
about  to  have  the  operation  for  the  cataract  performed, 
a straight  slender  couching  needle  is  to  be  introduced 
through  the  sclerotica,  at  the  external  angle  of  the  eye, 
about  two  lines  from  the  union  of  this  membrane  with 
the  cornea ; and  its  point  is  to  be  pushed  as  far  as  the 
upper  and  inner  edge  of  the  iris ; in  other  words,  as 
far  as  that  side  of  the  iris  which  is  nearest  the  nose. 
The  needle  advances  nearly  to  the  ciliary  ligament, 
and  the  surgeon  perforates  the  interna  edge  of  the 
iris  at  its  upper  part,  so  that  the  point  of  the  instru- 
ment scarcely  appears  in  the  anterior  chamber,  because 
that  part  of  it  being  very  narrow,  the  point  of  the  in- 
strument, however  little  it  advance  beyond  the  iris, 
would  enter  the  substance  of  the  cornea.  The  mo- 
ment the  needle  appears  in  the  anterior  chamber,  the 
instrument  must  be  pressed  on  the  iris  from  above 
downwards,  and  from  the  internal  towards  the  exter- 
nal angle,  so  as  to  bring  it  in  a parallel  line  to  the  an- 
terior surface  of  the  iris,  for  the  purpose  of  detaching 
a portion  of  the  edge  of  this  membrane  from  the  ciliary 
ligament.  This  separation  being  effected,  the  operator 
must  depress  the  point  of  the  needle,  in  order  to  apply 
it  to  the  inferior  angle  of  the  slit  that  he  has  begun  to- 
make.  Then  the  aperture  may  be  enlarged  at  plea- 
sure, by  pushing  the  iris  towards  the  temple,  and  with- 
drawing the  needle  from  before  backwards,  parallel 
to  the  anterior  surface  of  the  iris  and  the  greatest  axis 
of  the  eye.  If,  when  this  detachment  has  been  ac- 
complished, no  opaque  body  appear  at  the  bottom  of 
the  eye,  the  needle  is  to  be  withdrawn  altogether.  If 
any  portion  of  opaque  capsule  left  behind  after  the  de- 
pression or  extraction  of  the  cataract  should  afterward 
advance,  and  present  itself  in  the  vicinity  of  the  new 
pupil,  the  little  opaque  membrane  must  be  reduced  to 
fragment.s,  and  pushed  through  the  artificial  opening 
into  the  anterior  chamber,  where,  Scarpa  says,  they 
will  in  time  be  dissolved  and  absorbed. 

This  separation  of  the  iris  from  the  ciliary  ligament 
invariably  occasions  an  extravasation  of  blood,  which 


286 


PUPIL. 


always  renders  the  aqueous  humour  more  or  less  tur- 
bid; but  the  tiirbidness  is  afterward  absorbed,  and  the 
eye  recovers  its  original  transparency. 

The  patient,  says  Scarpa,  complains  during  the  ope- 
ration of  a vast  deal  more  suffering  than  at  the  time 
when  he  undergoes  the  extraction  or  depression  of  a 
cataract.  It  cannot  be  otherwise  ; for  in  detaching  a 
part  of  the  edge  of  the  iris  from  the  ciliary  ligament, 
some  filaments  of  the  ciliary  nerves,  which  proceed  to 
be  distributed  to  the  iris,  must  at  least  be  dragged  or 
lacerated.  However,  on  the  whole,  the  symptoms 
consequent  to  this  opei  ation  were  neither  obstinate  nor 
fatal  in  the  two  cases  which  Scarpa  has  seen.  From 
some  experiments  made  on  the  dead  subject,  Scarpa 
thinks  the  curved  needle  which  he  uses  for  the  de- 
pression of  the  cataract,  would  also  be  better  than  the 
straight  one  for  making  an  artificial  pupil. — {Scarpa 
sulle  Mulattie  degli  Occhi,  capo  16.) 

The  celebrated  Ad.  Schmidt  performed  coredialysis 
with  a lancet- pointed  curved  needle,  which  was  intro- 
duced through  the  sclerotica  into  the  posterior  cham- 
ber, with  its  concavity  towards  llie  uvea.  Its  point  is 
to  pass  as  far  as  the  portion  of  the  ciliary  ligament, 
where  it  is  designed  to  make  the  artificial  pupil.  The 
iris  is  then  to  be  pierced  from  behind  forwards,  about 
the  fourth  part  of  a line  from  the  ciliary  ligament, 
from  which  it  is  to  be  separated,  the  surgeon  taking 
care  at  the  moment  to  catch  well  hold  of  the  iris  with 
tlie  point  of  the  instrument,  which  is  then  to  be  with- 
drawn a little  from  the  eye.  If  the  new  pupil  should 
not  be  now  large  enough,  the  iris  is  to  be  again  hooked 
with  the  needle  near  the  ciliary  ligament,  and  the  open- 
ing enlarged  at  its  upper  or  lower  angle,  as  may  appear 
most  advantageous.  This  plan  is  said  to  be  advisable 
when  the  whole  cornea  is  opaque,  excepting  a small 
spot. 

When,  however,  the  diseased  state  of  the  cornea 
does  not  forbid  it.  Beer  and  Schmidt  very  properly  re- 
commend the  needle  to  be  introduced  into  the  anterior 
chamber,  and  the  iris  thus  separated  from  the  ciliary 
ligament ; a plan  which,  as  Weller  observes,  has  proved 
more  successful  than  the  preceding  method.  In  both 
modes,  the  lens  will  be  pushed  away  from  the  new 
pupil  by  the  movement  of  the  needle,  so  that  whether 
it  be  opaque  already,  or  become  so  afterward,  vision 
will  not  be  obstructed  by  it. — (See  Beer's  Lehre^  Src. 
b 2,  p.  204 — 206 ; and  Weller's  Manual^  transl.  by  Dr. 
JHovteath,  vol.  2,  p.  66,  df-c.) 

With  the  view  of  removing  all  risk  of  the  new 
opening  becoming  closed  again,  Reisinger  forms  an  ar- 
tificial pupil  by  making  a small  incision  in  the  cornea, 
and  introducing  a minute  double  hook  which  opens 
and  shuts  like  a pair  of  forceps.  After  passing  the 
hook  closed  into  the  anterior  chamber  as  far  as  the 
greater  circle  of  the  iris,  he  turns  the  points  of  both 
the  small  hooks  towards  this  membrane,  then  opens 
the  instrument  a little,  and  hooks  hold  of  the  iris, 
which  is  to  be  separated  from  the  ciliary  ligament, 
w'hen  the  instrument  is  to  be  shut  again,  and  the  part 
of  the  iris  taken  hold  of  drawn  a little  through  the 
opening  of  the  cornea,  where  it  adheres,  and  cannot 
recede  again  towards  the  ciliary  li^nient.— (See  Dar- 
stellung  eines  neuen  Virfahrens  die  Jilastdarwjistel  zu 
unterbinden.  und  einer  leichten  und  sichem  metkodc 
kiinstliche  Pupillen  zu  bilden.  VHmo.  .Augsburg,  1816.) 
Under  certain  circumstances,  however,  as  there  may 
be  difficulty  in  drawing  the  iris  through  the  cornea,  or 
apprehensions  may  be  entertained  of  the  opacity  of 
the  curnea  being  increased  by  the  protrusion  and  ad- 
hesion of  the  iris  (the  great  consideration  unquestion- 
ably against  this  method),  Reisinger  approves  of  obvi- 
ating the  chance  of  the  new  opening  being  closed 
again,  by  removing  a part  of  the  iris  after  its  detach- 
ment from  the  ciliary  ligament;  a combination  of  co- 
redialysis with  corectomia.  Were  I a patient,  and  co- 
redialysis were  deemed  most  applicable  to  the  circum- 
stances of  my  case,  I should  dispense  with  any  exci- 
sion of  the  iris,  preferring  the  chance  of  the  new 
opening  being  permanent  to  the  dangers  of  too  com- 
plicated and  protracted  an  operation. 

Langenbeck  is  the  inventor  of  an  instrument  for  the 
formation  of  an  artificial  pupil:  it  is  a silver  tube,  to 
one  end  of  which  is  attached  a very  small  gold  one, 
containing  a minute  hook,  capable  of  being  moved 
backwards  or  forwards  to  the  extent  of  only  two  lines, 
by  means  of  a spring  in  the  silver  tube.  The  follow- 
ing Is  the  account  of  Langcnbeck’s  method,  as  ex- 


tracted by  Mr.  Guthrie  from  his  writings.  “A  very 
small  opening  is  to  be  made  in  the  cornea,  in  order 
that  the  iris,  when  brought  out,  may  not  recede.  The 
hook  enclosed  in  the  golden  tube  (to  prevent  its  bend- 
ing from  its  tenuity),  is  to  be  directed  to  the  spot  where 
the  iris  is  to  be  laid  hold  of.  The  hook  is  then  to  be 
pushed  out  by  the  spring  to  the  exicnl  of  one  line, 
which  will  be  sufficient  to  enable  it  to  i)enetrate  the 
iris.  As  soon  as  the  hook  is  affixed,  it  is  to  be  allowed 
to  recede  to  its  usual  place  in  the  golden  tulre,  drawing 
with  it  the  iris,  which  will  be  caught  between  it  and 
the  end  of  the  tube,  something  in  the  manner  of  a 
pair  offorceps.  As  soon  as  the  hook  begins  to  recede, 
a small  black  spot  will  be  seen  at  the  f dL’e  of  the  iris 
from  its  incipient  separation ; and  care  should  be  taken 
to  insert  the  hook  at  or  even  under  tire  edge  of  the 
sclerotica,  and  as  near  as  possible  to  the  ciliary  pro- 
cesses. The  hook  must  recede  gradually,  the  finger 
being  kept  steadily  on,  and  moved  slowly,  with  the 
knob  regulating  the  spring  in  the  silver  tube.  As  the 
chance  of  tearing  off  a part  of  the  iris  is  proportionate 
to  the  distance  it  has  to  be  drawn  out,  the  openiitg  is 
to  he  made  as  near  as  possible  to  the  spot  where  the 
separation  is  to  be  effected,  taking  care  that  the  pupil 
shall  be  large  enough,  so  that  the  prolapsed  iris,  and 
subsequent  opacity  of  the  cornea,  cannot  obstruct  the 
entrance  of  the  rays  of  light.  The  great  advantage  of 
this  instrument,  in  Langenbeck’s  opinion,  is,  that  the 
separation  is  effected,  by  means  of  the  spring,  more 
gently  and  gradually  than  by  the  finger  alone;  so  that 
if  a commencement  of  the  separation  be  effected,  the 
completion  of  it  is  certain,  without  any  risk  of  tearing 
the  iris.  As  soon  as  the  hook  has  receded  to  the  golden 
tube,  carrying  with  it  the  iris,  the  whole  .iiistrument  is 
to  be  trently  withdrawn, moving  it  slow  ly  up  and  down, 
in  order  to  loosen  the  upper  and  low’er  attachment  of 
the  iris;  for  this  membrane  may  be  torn,  if  there  has 
been  much  previous  inflammation,  or  if  direct  force  be 
employed  in  withdrawing  it.  The  instrument  alw  ays 
keeps  its  hold  as  firmly  as  the  best  forceps,  and  with 
much  more  advantage,  for  it  occupies  less  space,  and 
enables  the  operator  to  make  the  incision  in  the  cor- 
nea small,  on  which  the  correct  strangulation  of  the 
iris  depends.  In  all  liis  operations,  the  capsule  of  the 
lens  has  never  been  injured  by  this  instrument,  wdiiclj 
he  considers  another  advantage,  and  he  conceives  that 
it  may  be  used  through  the  sclerotica  without  render- 
ing the  lens  opaque,  as  by  the  methods  of  Scarpa  and 
Schmidt.”  (The  latter  author,  however,  as  I have 
explained  in  this  article,  did  not  operate  through  the 
sclerotica  when  the  lens  was  transparent.)  When  the 
cornea  is  transparent  only  at  its  outer  edge,  Langen- 
beck  sometimes  performs  excision;  but  when  this 
membrane  is  opaque  opposite  the  natural  pupil,  he 
opens  the  cornea  near  the  edge  of  the  sclerotica,  and 
if  the  iris  will  not  protrude,  he  takes  hold  of  its  pu- 
pillary edge  W'ith  the  hook,  and  draws  it  between  the 
lips  of  the  wound,  where  he  leaves  it  strangulated. — 
(See  O.  F.  Guthrie  on  Artificial  Pupil,  p, 63,  S-c.  8vo. 
Land.  1819;  also  J.angcnbeck' s JVeue  Bibl.  b,l,p,  'i, 
454  and  676,  8co.  Hanover,  1817"19,  and  b.i,  p.  13  and 
106,  where  he  answers  some  objections  made  to  his  in- 
strument by  Schlagintweit.)  Doiiblles.*,  one  cause  of 
the  failure  of  many  operations  for  artificial  pupil  is 
one  to  which  Mr.  Guthrie  has  adverted,  viz.  the  omis- 
sion to  keep  dowtr  the  subsequent  inflammation  of  the 
iris  and  adjacent  textures  by  the  timely  employment 
of  the  lancet,  and  other  antiphlogistic  measures.  Ot> 
this  subject,  however,  I need  not  here  dw’ell,  as  the 
proper  treatment  is  already  described  in  that  part  of 
the  article  Ophthalmy  which  refers  to  iritis.  Consult 
Cheselden,in  Phil.  Trans,  for  M3b,j)A3'l,£rc.  Shmp's 
Operations,  chap.  29.  .Janin,  Mem.  svr  I'CEil.  Richter 
von  der  Verschlosseven  Pvpille,  in  Anfangsgr.  dcr 
Wvndarzn.  b.  3,  Gbtt.  1795.  Scarpa  sulle  Mulattie 
degli  Occhi,  cap.  16;  or  the  English  Transl  by  Mr. 
Briggs.  Gibson's  Pract.  Obs.  on  the  Formation  of 
an  Artificial  Pupil,  S,-c.  Boo.  J^ond.  1811  ; a work  of 
considerable  merit.  Weuzel  on  the  Cataract.  Sir  W 
Adams,  Pract.  Obs.  on  Ketropium,  and  on  the  Modes 
of  forming  on  Artificial  Pupil,  &c.  Bvo.  Bond.  1812, 
also.  On  Artificial  Pupil,  Bra.  Bond.  1819.  Roux, 
Parallile  dela  Chirurgir.  Angloise,  (J-c.  p.2®3,  (S-c.  Bvo. 
Paris,  1815  Mannoir  and  Scarpa,  in  Med.  Chir. 
Trans,  vol.  7,  p.  301,  Sec.  G.  .7.  Beer,  Ansicht  der 
Staphylomatoscn  Melamorphosen  des  Avges,  vvd  der 
kunstiichen  Pvpillenbildung,  ll  icn,  1815;  and  Bihrs 


RAN 


RAN 


287 


von  den  .dugenhr.  1.  2,  fVien.  1817.  P.  jlssalini,  Ri- 
cerche  suite  Pupille  JIrtijiciali ; in  Milano^  1811.  This 
author  practises  the  detachment  of  the  iris  from  the 
ciliary  ligament  with  a particular  kind  of  forceps. 
He  must  have  an  early  claim  to  the  invention.,  as  he 
began  the  method  in  1786.  Jules  Cloquet,  Mim.  sur  la 
Membrane  Pupillaire.  Pa Ws,  1818.  Maunoir  sur  I Or- 
ganization  de  VIris,  8vo.  Paris,  1812.  Benedict,  De 
Pupillm  Artificialis  Conformaiione.  Ups.  1810.  R 
Muter,  Pract.  Obs.  on  Various  JTovel  Modes  of  Opera- 
ting on  Cataract,  and  of  forming  an  -Artificial  Pupil, 
8vo.  Wisbeach,  1811.  O.  F.  D.  Evans,  Pract.  Obs. 
on  Cataract  and  Closed  Pupil,  Src.  8vo.  J.ond.  1815. 
Ch.  .Jiingken,  Das  Coreoncion,  ein  Beitrag.zur  Kiinst- 
lichen  Fupillenbildung.  12mo,  Berlin,  1817.  G.  JVag- 
ner,  Commentatio  de  Coromorphosi,  sistens  Brevem 
Method,  ad  Papillw  Artific.  Conformationem,  novique 
ad  Tridodialysin  Instruvienti  Descriptionem,  cum  tab. 
cen.  8vo.  Brunswig.  1818.  Schmidt  and  Himly  Oph- 
thal.  Bibl.  b.  2 and  3.  Flajani,  Collezione  di  Osserva- 
zioni,  t.  4,  8vo.  Roma,  1801.  Ryan,  in  Dublin  Hos 
pital  Reports,  1818.  Quadri  Annotazioni  Pratichc 


sulle  Malattie  degli  Occhi,  Ato.  In  JVeapol.i,  1818 
Eangenbeck,  JVeue  Bibl.  f Ur  die  Chir.  b.  1 et  2,  12»(o 
Gdti.  1817 — 1819.  Reisinger,  D arstellung,  Src.  eincr 
leichten,  Src.  Methode  Kunstliche,  Pupillcn  zu  bilden, 
12/reo.  Augsb.  1816.  Schlagintweit,  Ueber  den  gegen- 
wartigen  Zustand  der  Kunstlichen,  Pupillenbildung 
in  Deutschland,  8vo.  Munich,  1818.  Donegana,  Ru- 
gionamento  sidla  Pupille  Artificiali ; Milano,  1809: 
this  work  suggests  themethod  of  opening  the  sclerotica, 
under  certain  circumstances,  for  the  purpose  of  di- 
viding the  iris  from  behind  forwards.  Q.  F.  Guthrie 
on  the  Operations  for  the  Formation  of  an  Artificial 
Pupil,  8vo.  Bond.  1819 ; or  Operative  Surgery  of  the 
Eye,  8vo.  Eond.  1823;  works  containing  a very  ample 
account  of  the  subject,  and  manrj  judicious  observa- 
tions. B.  TVavers,  Synopsis  of  the  Diseases  of  the 
Eye,  p.  334,  Src.  8vo.  Loud.  1820.  C.  H.  Wilier,  A 
Manual  of  the  Diseases  of  the  Human  Eye,  transl. 
by  Dr.  Monteath,  vul.  2,  p.  55,  ij-c.  8vo.  Glasgow, 

\m. 

PUS.  (From  rtvov,  matter.)  The  fluid  formed  by 
the  process  of  suppuration. — (See  Suppuration.) 


a 


Quinine,  sulphate  of.  This  valuable  prepa- 
ration of  bark,  which  is  now  beginning  to  be  pre- 
scribed in  a large  number  of  surgical  cases  where  loss  of 
appetite  and  great  debility  are  present,  may  be  exhibited 
in  doses  of  from  one  to  five  grains,  three  or  four  times  a 
day,  according  to  circumstances.  As  its  solubility  in 
water  is  increased  by  an  excess  of  acid,  one  drop  of  sul- 
phuric acid  is  frequently  added  for  every  grain  of  qui- 
nine. When,  however  the  circumstances  of  the  case 


render  it  advisable  to  dispense  with  the  acid,  the  sul- 
phate of  quinine  may  be  prescribed  without  it  in  any 
aromatic  water,  like  the  aqua  carui,  or  in  the  form  of 
pills,  either  by  itself  or  combined  with  opium,  blue  pill, 
squills,  the  extractum  conii,  or  such  other  medicines  as 
circumstances  may  require.  It  may  also  be  given  la 
children,  mixed  with  syrup.  Other  preparations  are 
the  wine  and  tincture. 


R 


ACHITIS.  (From  pdxGr  the  spine  of  the  back, 
because  the  disease  was  once  supposed  to  depend 
on  disease  of  the  spinal  marrow.)  The  rickets.  See 
this  word. 

RANULA.  (Dim.  of  rana,  a frog.)  A tumour 
under  the  tongue,  ari.«ing  from  an  accumulation  of  sa 
liva  and  mucus  in  the  ducts  of  the  sublingual  gland. 
The  term  has  been  derived  either  from  an  imaginary 
resemblance  of  the  swelling  to  a frog,  or  from  the  dis- 
ease making  the  patient,  as  it  were,  croak  when  he  at- 
tempts to  articulate.  Such  writers  as  have  treated  of 
this  disease,  before  it  was  known  that  the  parts  affected 
by  it  were  dpslined  for  the  secretion  of  llie  saliva, 
could  have  no  accurate  notions  of  its  true  nature. 
Celsus  is  supposed  to  have  alluded  to  the  ranula,  in  the 
fifth  section  of  hi.s  seventh  book,  where,  after  treating 
of  the  disea.ses  of  the  tongue,  he  introduces  the  fol- 
lowing passage : sub  lingua  quoque  interdurn  aliquid 
abcedit,  quod  fere  consistit  in  tunica,  doluresqne  magnos 
movet.  The  latter  circtinistance,  however,  renders  it 
probable,  that  some  other  affection  was  signified,  as  a 
ranula  is  rather  attended  with  a sense  of  restraint,  than 
of  pain.  Fabricius  ab  Aquapendenle  and  Dionis  con- 
sidered a ranula  as  an  encysted  tumour  of  the  meli- 
ceris  kind.  Mnnick,  better  acquainted  with  the  modern 
discoveries  of  anatomy,  does  not  mistake  the  nature 
of  the  present  disease  ; and  he  expressly  says,  that  the 
aflectioti  originates  from  a thick  saliva,  which,  not 
being  able  to  pass  out  of  the  salivary  ducts,  accumu- 
lates under  the  tongue,  so  as  to  canse  a swelling  in 
that  situation.  Far  from  adopting  the  opinion  of  Mu- 
nick,  Heister  fell  back  to  that  of  Fabricius,  and  borrows 
every  thing  from  this  author.  Lastly,  De  la  Faye  in 
his  notes  on  Dionis,  adopted  Munick’s  sentiments  : he 
says,  “There  are  two  sorts  of  ranulas ; some,  which  are 
round,  and  situated  beneath  the  tongue,  seem  only  to 
be  produced  by  a dilatation  of  the  excretory  duct  of  the 
sublingual  gland  ; the  others  are  longer  than  they  are 
round,  are  situated  at  the  side  of  the  tongue,  and  are 
formed  by  a dilatation  of  the  excretory  duct  of  the  in- 


ferior maxillary  gland.  The  fluid  which  fills  such  lu 
mours  is  the  saliva,  which  gradually  accumulates  in 
them,  in  consequence  of  its  viscidity  and  the  atony  of 
the  duct.” 

Persons  who  move  their  tongues  a great  deal,  and 
those  who  sing,  have  been'  set  down  as  very  liable  to 
the  present  complaint ; but  this  opinion,  I believe,  rests 
on  no  good  foundation.  The  fluid  in  the  tumour  is 
precisely  like  w hite  of  egg ; but  it  is  thicker  after  having 
remained  a long  w’hile  in  the  swelling ; and  it  is  oc- 
casionally of  a calcareous,  and  even  stony  nature. 
Ranula  doe.s  not  proceed  from  an  inspissalion  of  the 
saliva,  asDe  la  Faye  supposed,  but  from  an  obstruction 
of  the  duct  or  orifices  of  this  tube.  The  collection 
often  produces  a tumour  of  very  large  size ; but  the 
sw'elling  generally  bursts  when  it  has  attained  the  di- 
mensions of  a walnut,  and  then  leaves  an  ulcer  whicb 
cannot  be  healed  while  the  real  cause  of  the  disorder 
remains  unknown. 

Mr.  B.  Bell  saw  an  ulcer  of  this  kind,  which  was 
treated  with  the  utmost  care  for  several  months : va- 
rious detergent  and  corrxtsive  applications  were  em- 
ployed ; and  even  a mercurial  cour.se;  but  all  in  vain. 
At  length,  the  true  cause  of  the  disease  having  been 
ascertained,  a cure  w’as  accomplished  in  a few  days  by 
remt)ving  a piece  of  calcareous  matter,  which,  by  ob- 
structing the  ducts,  had  first  caused  the  swelling,  and 
then  ulceration. 

The  opening,  when  made  with  a lancet,  and  not  of 
sufficient  size,  frequently  closes  up  agaiei.  In  this  case, 
the  swelling  reappears  some  time  afterward.  The 
ancients  made  the  same  remark  ; and  hence,  Par4  pre- 
ferred the  actual  cautery  to  the  lancet.  Dionis  had 
also  seen  ranulte  recur,  after  they  liad  been  simply 
opened  with  a lancet ; and  he  recommetids,  for  the  pre- 
vention of  this  inconvenience,  the  applicati«*n  of  a 
mixture  of  honey  of  roses  and  sulphuric  acid  to  the 
inside  of  the  cyst,  so  as  to  destroy  it.  As  Louis  re- 
marks, all  authors  seetn  to  regret  that  the  situation  of 
the  tumour  should  prevent  the  sac  frotn  being  totally 


288 


RAN 


dissected  out.  The  success  whic!i  Fabricius  ab  Aqua- 
pendente  experienced,  wlien  he  merely  opened  the  tu- 
mour its  wliole  length,  did  not  free  him  from  this  pre- 
judice ; and  Heister  says  he  should  prefer  extirpation, 
if  the  nature  of  the  adjacent  parts,  liable  to  be  wounded, 
were  not  a formidable  objection.  But  if  this  pretended 
cyst,  this  pouch,  is  nothing  else  than  the  gland  itself,  or 
its  duct,  dilated  by  the  retention  of  the  saliva,  it  should 
not  be  irritated.  Whenever  a sufficient  opening  is 
made,  no  relapse  takes  place.  Munich  particularly 
advises  such  an  incision,  and  Rossius  mentions  the 
smallness  of  the  opening  among  the  defects  of  the 
treatment,  and  its  being  a cause  of  the  disease  return- 
ing. However,  he  also  recommends  destroying  the 
sac;  but  specifies  for  the  purpose  only  astringent,  dry- 
ing applications,  which  act  in  a less  powerful  manner. 

In  a ranula  of  moderate  size,  there  is  nothing  like  a 
cyst  absolutely  requiring  extirpation.  It  is  generally 
enough  to  lay  the  cavity  open,  and  cut  off  the  edges 
of  the  incision,  when  they  will  not  otherwise  unite. 
M.  Louis  always  observed  that  the  radical  cure  de- 
pended on  a fistulous  aperture,  through  which  the  saliva 
continued  to  flow ; and  that  when  this  opening  was 
situated  behind  the  lower  incisor  teeth,  a very  annoy- 
ing ejection  of  the  salivatook  place  in  certain  motions  of 
the  tongue.  The  cure  cannot  be  complete  unless  this 
inconvenience  be  obviated.  For  this  purpose  such  an 
opening  for  the  saliva  must  be  made  as  will  not  close. 

[The  most  successful  method  of  fulfilling  this  indica- 
tion is  by  passing  a needleful  of  thread  through  the 
body  of  the  tumour,  and  suffering  it  to  remain  there  as 
a seton.  This  practice  I have  uniformly  pursued  with 
success,  and  at  the  same  time  evacuating  the  contents 
of  the  sac  This  method  results  in  a radical  cure  with 
as  much  certainty  as  the  injection  or  seton  in  hydro- 
cele, by  obliterating  the  sac.  Great  care  must  be  taken 
in  introducing  the  seton  not  to  wound  the  lingual  artery, 
a branch  of  which  often  runs  along  the  frenum.  I 
knew  one  instance  in  which  this  accident  was  followed 
by  a hemorrhage  so  alarming  as  to  require  the  actual 
cautery  for  its  suppression, — Reese.] 

A ranula,  when  of  long  standing,  is  sometimes  so 
large  as  absolutely  to  hinder  a person  from  articulating. 
Le  Clerc  has  recorded  a case  in  which  the  root  of  the 
swelling  extended  under  the  tongue  ; the  tumour  filled 
the  whole  mouth  ; the  prominence  which  it  formed 
outwardly  was  as  large  as  a duck’s  egg ; and  the  disease 
in  its  progress  had  made  the  teeth  of  both  jaws  project 
outwards.  At  some  parts  of  its  surface,  a fluctuation 
was  perceptible ; other  places  were  exceedingly  hard. 
The  patient,  who  could  scarcely  breathe,  demanded 
assistance ; and  a puncture  was  made  in  the  softest 
part  of  the  outside  of  the  swelling.  A thick  yellowish 
fluid  issued  out  of  the  ranula.  The  opening  was  en- 
larged with  a knife,  and  about  a pint  of  gritty  inodo- 
rous matter  was  extracted.  There  was  no  hemorrhage 
from  the  cut ; and  no  sooner  had  the  contents  of  the 
swelling  been  let  out,  than  the  patient  began  to  articu- 
late, which  he  had  not  been  able  to  do  for  a long  while. 
The  sides  of  the  Kimour  being  so  prodigiously  distended, 
Le  Clerc  thought  proper  to  destroy  the  inside  of  the 
cavity’  with  a tent,  dipped  in  a mercurial  solution. 
The  cure  was  completed  in  a month,  and  the  tongue 
gifadually  regained  its  original  size,  a part  of  which  it 
had  lost. 

But,  as  M.  Louis  observes,  fortunate  as  the  termina- 
tion of  this  case  was,  it  must  not  be  indiscriminately 
set  down,  that  destroying  the  cyst  or  even  opening  the 
tumour,  is  always  requisite.  A more  simple  method 
will  sometimes  succeed.  In  a particular  case,  which 
this  gentleman  has  related,  a sinuosity,  which  divided 
the  swelling  into  a right  and  left  portion,  made  him 
suspect  that  it  consisted  of  two  sacs  in  contact  with 
each  other.  On  each  side,  in  front,  and  in  the  same 
line,  there  was  a point,  which  was  the  orifice  of  the 
salivary  duct  somewhat  dilated,  and  blocked  up  with 
a vi.scid  matter.  Having  very  easily  passed  a small 
probe  into  the  orifices,  a matter  similar  to  white  of  egg 
made  its  escape.  A small  leaden  probe  was  passed 
into  each  opening,  and  two  days  afterward  the  sacs 
were  emptied  again,  and  two  pieces  of  lead  somewhat 
larger  introduced.  The  patient  was  advised  to  take 
out  the  pieces  of  lead  every  morning,  empty  the  swell- 
ing, and  then  replace  them.  In  a fortnight,  the  open- 
ings having  been  kept  continually  dilated,  had  no  ten- 
dency to  close;  the  saliva  did  not  accumulate,  and  the 
ranulae  never  appeared  again. 


REO 

In  certain  cases,  the  above  means  are  quite  inade- 
quate, and  the  tumour  must  be  totally  extirpated^ 
Boinet  related  to  the  French  .'Academy  a case,  in 
which  the  swelling  not  only  filled  the  whole  mouth, 
but  one-half  of  the  tumour  projected  out,  and  a cure 
could  only  be  accomplished  in  the  latter  manner.  The 
two  upper  incisor  teeth  on  the  left  side  were  lodged 
in  a depression  observable  there  ; and  the  canine  tooth 
of  the  same  side,  forced  outwards  by  the  mass  of  the 
disease,  had  pierced  the  lip  near  its  commissure.  A 
fluid,  resembling  mucus,  flowed  from  a narrow  aper- 
ture at  the  lower  part  of  the  swelling.  The  tongue 
could  not  be  seen,  so  much  was  it  pusired  backwards, 
and  for  some  time  the  patient  had  only  subsisted  on 
liquid  food,  which  he  was  first  obliged  to  convey  to 
the  back  of  the  throat  with  some  mechanical  contri- 
vance. The  four  incisor  teeth,  two  canine,  and  first 
grinders  of  the  lower  jaw,  had  been  pushed  out 
of  their  sockets,  by  the  pressure  of  the  swelling.  The 
patient’s  aspect  was  alarming,  and  he  was  threatened 
with  suffocation.  Extirpation  was  deemed  necessary, 
and  it  was  performed  with  all  due  caution.  The  large 
cavity  thus  occasioned  was  filled  with  lint.  The 
lower  jaw  being  diseased,  Boinet  scraped  some  of  its 
surface  off,  and  covered  the  places  with  lint,  either  dry 
or  dipped  in  spirit  of  wine.  Some  exfoliations  fol- 
lowed, and  the  fungous  granulations  which  grew  were 
repressed  with  proper  applications.  In  three  months, 
the  parts  were  healed  in  so  regular  a manner,  that  the 
motion  of  the  tongue  was  not  in  the  least  obstructed, 
and  no  change  continued,  except  the  alteration  of  the 
voice,  occasioned  by  the  loss  of  teeth. — (See  Encyclo- 
pidie  M^thodique,  art.  Grenouillette.  Mim.  de  I'Jlcad. 
de  Chirurgie,  t.  3.  Sabatier,  Medecine  Opiratoire,  t. 
2,  p.  19,  Src.  edit.  2.  Callisen,  Systema  Chirurgice  Ho~ 
dierncB,  vol.  2,  p.  106,  .S-c.  Hafnim,  1800.  Eassus,  Pa- 
thologie  Chir.  t.  1,  p.  402,  (S-c.  8vo.  Paris,  1809.  Rich- 
ter, Anfangsgr.  der.  Wundarzn.  b.  4,  kap.  1,  Gottin- 
gen, 1800.  J.  J.  Stahl  et  J.  F.  E.  de  Schoenerben  de 
Ranula,  sub  Lingud,  speciali  cum  Casu,  Erford,  1734. 
Bell's  Operative  Surgery,  vol.  2. 

RECLINATION.  A term  employed  in  Germany, 
to  denote  the  operation  of  turning  a cataract,  so  as  to 
change  the  position  of  its  anterior  and  posterior  sur- 
faces.— (See  Cataract.) 

RECTUM.  Many  cases,  in  which  this  bowel  is 
more  or  less  concerned,  are  treated  of  in  other  parts  in 
this  Dictionary,  and  therefore  it  will  only  be  necessary 
for  me  here  to  refer  to  them,  and  then  notice  some  dis- 
eases of  the  same  bowel,  which  are  not  considered  in 
other  articles.  For  an  account  of  piles,  hemorrhoidal 
excrescence,  and  other  tumours  of  the  rectum,  see  He- 
morrhoids ; and  for  that  of  prolapsus  ani,  fistula  in 
ano,  and  imperforate  anus,  see  Anus.  Under  the  head 
of  Alvine  Concretions,  I have  noticed  the  dangerous 
obstruction  of  the  rectum  by  masses  of  indurated  mat- 
ter. In  the  article  Lithotomy,  the  mode  of  cutting 
through  the  rectum  into  the  bladder,  for  the  purpose  of 
extracting  a calculus  from  the  latter  organ,  is  ex- 
plained ; and  if  the  reader  refer  to  Bladder,  he  will 
there  find  a description  of  the  method  of  tapping  it 
from  the  rectum. 

Scirrhus,  or  stricture  of  the  rectum,  sometimes 
called  the  scirrho-contracted  rectum,  and  sometimes 
cancer,  especially  when  the  case  is  inveterate  and  in 
a state  of  ulceration,  is  a disease  which  has  received 
much  elucidation  from  the  writings  of  Desault,  Sir 
Everard  Home,  Dr.  Sherwin,  Mr.  White,  Mr.  Cope- 
land, Mr.  Calvert,  and  Mr.  Salmon.  Most  of  the  ordi- 
nary unmalignant  strictures  which  have  fallen  under 
the  care  of  Mr.  Salmon  were  situated  between  five 
and  six  inches  from  the  anus.  Their  next  most  fre- 
quent situation,  he  says,  is  at  the  junction  of  the  sig- 
moid flexure  of  the  colon  with  the  rectum  ; “ the  very 
reverse  of  which  happens  in  the  true  carcinomatous 
affection  of  the  rectum,  which  will  most  commonly  be 
found  near  the  orifice;  the  disease  in  all  probability 
originating  in  the  mucous  glands  of  the  intestine, 
which  are  most  prevalent  towards  the  inferior  part  of 
the  bowel.” — (Salmon,  On  Stricture  of  the  Rectum,  p. 
21.)  In  the  various  descriptions  given  of  the  com- 
plaint by  these  and  other  writers,  one  great  point  of 
difference  is  remarkable,  viz.  that  some  of  them  repre- 
sent the  case  as  always  of  an  incurable  nature,  while 
others  consider  it  as  admitting  of  relief,  at  least  when 
it  has  not  made  considerable  progress,  and  the  parts 
are  free  from  ulceration.  “ Many  strictures  of  the  rec- 


RECTUM. 


289 


turn  (as  a judicious  writer  has  remarked)  are  in  their 
nature  quite  harmless,  injurious  only  inasmuch  as  they 
jTiesent  a mechanical  obstruction,  or  disorder  the  func- 
tions of  the  alimentary  canal,  and  fatal  only  from  ne- 
glect. In  many  cases,  also,  great  thickening  and  indu- 
ration prevail,  without  the  least  tendency  to  cancer ; 
at  least,  the  latter  disease  has  not  supervened,  even 
after  an  interval  of  many  years.” — {On  Hemorrhoids, 
Strictures,  i^c.  of  the  Rectum,  p.  120.)  According  to 
Desault,  scirrhus  of  the  rectum  is  not  uncommon  at  an 
advanced  period  of  life,  and  the  disease  is  said  to  af- 
flict women  more  frequently  than  men,  as,  from  a 
table  kept  at  the  Hdiel-Dieu,  it  appeared  that  ten  cases 
out  of  eleven  occurred  in  females ; a proportion  far 
exceeding  what  has  been  noticed  in  this  country.  In- 
deed, Mr.  Calvert,  speaking  of  strictures  of  the  rectum 
generally,  sets  down  their  greater  frequency  in  one 
sex  than  the  other  as  doubtful,  and  scarcely  worthy  of 
notice. — {Op.  cit.p.  122.)  If  it  were  not  for  the  fact 
that  Desault  sometimes  eflected  a cure  of  the  disease 
in  its  early  stage,  I should  venture  to  conclude,  that  his 
observations  apply  entirely  to  the  true  scirrhus  or  can- 
cer of  the  rectum,  which  I believe  rarely  or  never  oc- 
curs in  young  patients,  but,  a.s  Desault  states,  is  not 
very  unfrequent  in  elderly  persons.  My  friend,  Mr. 
Copeland,  in  his  practical  remarks,  does  not  confine 
himself  to  really  scirrhous  and  cancerous  affections, 
but  comprehends  strictures  of  the  rectum  from  a va- 
riety of  causes ; and  this  accounts  for  his  statement, 
that  the  disease  “ attacks  people  of  almost  ail  ages, 
but  is  most  common  about  the  middle  age.”  How- 
ever, he  agrees  with  Desault  that  w’omen  are  more  fre- 
quently affected  than  men.  He  admits  that  it  is  some- 
times cancerous,  though  not  so  often  as  is  generally 
imagined,  the  mere  induration  not  being  an  unequivo- 
cal proof  of  it.  When  the  disease  is  really  cancer,  it 
is  usually  attended  with  more  severe  pain,  darting 
through  the  {^Ivis  to  the  bladder  and  the  groin.  The 
countenance  is  of  a sallow  leaden  cast. — ( On  the  prin- 
cipal Diseases  of  the  Rectum  and  Anus,  p.  15 — 17.) 

Sometimes  the  disease  extends  over  a considerable 
length  of  the  gut,  but  is  generally  more  circumscribed. 
The  coats  of  the  bowel  become  much  thicker  and 
harder  than  natural.  The  muscular  is  subdivided  by 
membranous  sepia,  and  the  internal  coat  is  sometimes 
formed  into  hard,  irregular  folds.  The  surface  of  the 
inner  membrane  is  occasionally  ulcerated,  so  as  to 
form  a cancerous  disease.  Every  Vestige  of  the  na- 
tural structure  is  sometimes  lost,  and  the  gut  is  changed 
into  a gristly  substance.  The  cavity  of  the  bowel  is 
always  rendered  narrow  at  the  scirrlious  part,  and  is 
sometimes  almost  obliterated.  When  the  passage 
through  the  gut  is  very  much  obstructed,  the  bowel  is 
always  a good  deal  enlarged  just  above  the  stoppage 
or  stricture,  from  the  accumulation  of  the  feces  there. 
As  the  disease  advances,  adhesions  form  between  the 
rectum  and  adjacent  parts,  and  ulcerations  produce 
communications  between  them. 

Besides  a spasmodic  form  of  stricture  of  the  rectum, 
a case,  the  real  existence  of  which  is  perhaps  ques- 
tionable, Mr.  Calvert  notices'  the  examples  attended 
with  change  of  structure.  In  some  cases,  he  says,  the 
contraction  is  chiefly  owing  to  a thickened  and  indu- 
rated state  of  the  mucous  membrane,  arising  from  in- 
flammation, or  .some  chronic  alteration  of  texture;  but 
that  when  the  disease  has  existed  a considerable  time, 
the  mucous,  cellular,  and  muscular  coats  become  more 
or  less  affected  ; so  that,  on  dissection,  it  is  often  im- 
possible to  determine  in  which  the  disease  originally 
commenced.  He  describes  other  cases,  in  which  the 
cavity  of  the  rectum  is  nearly  obliterated  by  the  pre- 
sence of  hard,  painful  tubercles.  “ This  disease  (he 
observes)  bears  some  resemblance  to  the  first  stage  of 
malignant  stricture,  at  least  as  it  appears  in  some 
cases ; but  it  is  evidently  of  quite  a different  nature,  as 
it  is  easily  cured  by  compression.” — {P.  129.)  Lastly, 
he  adverts  to  carcinomatous  strictures  of  the  rectum 
which  are  deemed  incurable.  The  disease  is  described 
by  him  as  generally  commencing  nt  one  side  of  the 
gut,  just  above  the  upper  part  of  the  internal  sphinc- 
ter, where  a smooth,  but  hard  and  knotty  projection 
may  be  felt.  Mr.  Salmon  also  represents  carcinoma- 
tous disease  of  the  rectum  as  being  generally  within 
reach  of  the  finger. — {On  Stricture  of  the  Rectum,  p. 
62.)  By  degrees,  the  disease,  which  was  probably 
confined  at  first  to  the  glandular  structure  of  the  inter- 
iial  membrane,  extends  around  the  gut,  changing  the. 
VoL.  II.-T 


structure  of  the  adjacent  parts.  However,  Mr.  Cah 
vert  explains,  that  carcinomatous  stricture  is  not  con- 
fined to  the  lower  part  of  the  rectum,  but  is  often  met 
with  higher  up,  and  especially  in  the  sigmoid  flexure 
of  the  colon.  He  remarks,  that  a considerable  oblite- 
ration of  the  cavity  of  the  rectum  may  proceed  from 
an  inflammation  or  ulceration,  and  subsequent  adhe- 
sion of  hemorrhoidal  tumours,  resembling,  when  the 
•swellings  are  not  of  long  standing,  that  form  of  stric- 
ture which  arises  from  an  infiltration  of  coagulable 
lymph  in  the  relaxed  folds  of  the  mucous  membrane 
of  the  bowel ; but,  in  other  instances,  where  such  tu- 
mours are  of  older  date  and  more  solid,  resembling  the 
tubercular  form  of  stricture. — (F.  138.) 

Mr.  Salmon  describes  the  surface  of  the  rectum  as 
sometimes  feeling  indurated  and  irregularly  thickened 
to  a considerable  extent.  By  degrees,  the  prominences 
ulcerate,  and  an  absorption  of  the  inner  coat  ol'the  bowel 
is  produced  by  the  pressure  oftfiegi  owthofa  new  sub- 
stance. He  refers  to  two  preparations  of  the  scirrho-con* 
tracted  rectum  in  a very  advanced  stage  of  the  disease. 
In  both,  the  mucous  and  the  muscular  coats  of  the  bowel 
are  absorbed,  in  consequence  of  the  pressure  of  a new 
substance,  which,  in  one  instance,  has  made  its  way 
through  the  bladder  ; in  the  other,  through  the  vagina. 
— ( Salmon  on  Stricture  of  the  Rectum,  p.  63.) 

As  the  disease  at  first  is  not  very  painful,  it  is  usually 
not  much  noticed  till  somewhat  advanced.  There  is 
perhaps  no  disease,  as  Mr.  Calvert  has  noticed,  in 
which  the  symptoms,  arising  from  derangement  of 
other  parts,  are  so  predominant  over  the  local ; and 
“ there  can  be  no  doubt  that  in  many  cases  of  iliac  pas- 
sion, and  obstinate  constipation,  arising  from  this 
source,  death  takes  place  without  the  slightest  suspi- 
cion of  the  cause.  In  other  cases,  especially  when  the 
disease  is  of  a malignant  nature,  it  is  not  unfrequently 
confounded  with  scirrhus  of  the  uterus.” — (F.  123.) 
He  also  adverts  to  a case,  in  which  a stricture  of  the 
rectum  was  lately  mistaken  for  an  intus-susceptlon,  by 
some  practitioners  “at  the  pinnacle  of  professional 
eminence.”  Mr.  C.  Bell,  in  oiie  case  where  he  at- 
tempted to  puncture  the  bladder,  and  in  another  where 
he  was  about  to  divide  a fistula  in  ano,  felt  his  finger 
stopped  by  strictures  of  the  rectum,  of  which  the  pa- 
tients had  no  suspicion.  The  patient  is  at  first  iiabit- 
ually  costive,  or  affected  with  what  is  called  a torpid 
state  of  the  bowels,  and  usually  voids  his  stools  with  a 
little  difficulty.  In  time,  a good  deal  of  pain  is  felt  in 
the  part  afl'ected,  especially  at  stool,  after  which  some 
relief  is  experienced.  “ As  the  gut  continues  to  de- 
crease in  diameter  (says  Mr.  Copeland),  the  efforts  to 
expel  the  feces  become  more  violent,  and  the  conse- 
quent progress  of  the  disease  more  rapid.  The  stools, 
which  have  been  long  evacuated  with  difficulty,  be- 
come contracted  in  size, "appearing  like  earth-worms 
in  their  form,  or  small  pellets;”  and,  if  the  finger  be 
introduced  into  the  rectum,  “the  gut  will  be  found 
either  obstructed  with  small  tubercles,  or  intersected 
with  membranous  filaments  ; or  else  the  introduction 
of  the  finger  will  be  opposed  by  a hard  ring  of  a car- 
tilaginous feel,  composed  of  the  diseased  inner  mem- 
brane of  the  intestines.”  These  states,  as  Mr.  Cope- 
land observes,  are  very  diflerent  from  the  regular  tu- 
mour, on  the  anterior  part  of  the  rectum,  occasioned 
^ an  enlargement  of  the  prostate  gland  ; a case  apt  to 
be  suspected.  “As  the  disease  advances  (says  tlie 
same  author),  the  feces  become  more  fluid,  and  tlicre 
is  a thin  sanious  discharge  from  the  anus,  accompanied 
with  tenesmus.”  Mr.  Calvert  notices,  as  the  most 
characteristic  symptoms,  an  unusual  distention  of  the 
colon  ; the  extension  of  pain,  fell  about  the  upper  part 
of  the  sacrum,  down  to  the  feel,  in  the  course  of  the 
large  nervous  trunks;  the  decrease  of  the  tenesmus 
after  a sufficient  evacuation ; and  the  scanty  motions 
of  irregular  or  figured  appearances.  The  latter  eflect, 
however,  he  says,  is  not  always  present  throughout 
the  disease,  for  if  the  contraction  be  at  the  upper  part 
of  the  rectum,  the  motion  may  be  of  the  usual  size 
and  appearance. — (F.  147.)  According  to  Desault,  pus 
and  blood  may  sometimes  be  noticed  with  the  excre- 
ment, pariiculaily  when  the  disease  has  advaiiced  to 
the  ulcerated  .<taie.  The  carcinomatous  stricture  is 
said  to  be  always  attended  with  more  or  less  of  a burn- 
ing .sensation,  or  acute  shooting  pain.s  at  the  seat  of  the 
disease,  except  at  its  very  beginning.  Sometimes, 
when  a gicat  part  of  the  stiiclnre  has  been  destroyed 
by  ulceration,  the  motions  aie  voided  without  much 


250 


RECTUM. 


effort,  but  not  without  intense  suffering. — {Calvert,  p. 
148—150.)  The  patient  at  lengtli  becomes  sallow ; fre- 
quent eructations  of  air  from  the  bowels  torment  the 
patient,  and  render  his  life  miserable  ; the  constitution 
suffers,  and  dissolution  follows.  Severe  tenesmus  at- 
tends the  whole  course  of  the  disease. — {CEuvres  Chir. 
par  Bichat,  t.  2.) 

Sometimes  a small  fistulous  orifice  at  the  verge  of 
the  anus  communicates  with  the  inferior  portion  of 
the  diseased  part.  Such  a fistula,  in  a case  recorded 
by  Sir  Everard  Home,  was  half  an  inch  in  length. — 
( Obs.  on  Cancer,  p.  133.) 

Desault  often  saw'  the  disease  form  a communica- 
tion between  the  rectum  and  vagina,  and  the  feces 
passed  through  the  latter  part.  In  the  latter  stage  of 
the  affliction,  the  rectum,  bladder,  vagina,  uterus,  and 
adjacent  parts,  are  all  involved  in  one  common  ulcera- 
tion. And,  according  to  Mr.  Calvert,  the  surface  of 
the  os  sacrum,  or  even  that  of  the  lumbar  vertebrae, 
may  become  involved  in  the  extent  of  the  disease,  the 
rectum  being  sometimes  so  firmly  connected  with  the 
former  bone  as  to  be  very  difficultly  separable  from  it 
even  with  a knife. — {P.  137.) 

When  the  disease  has  attained  the  ulcerated  state, 
it  is  probably  always  incurable.  Palliatives  can  only 
now  be  resorted  to,  such  as  anodyne  and  emollient 
clysters,  the  warm-bath,  &c.,  with  the  exhibition  of 
medicines  like  opium,  cicuta,  uva  ursi,  ice.  Claudinus 
applied  his  remedies  to  the  inside  of  the  bow'el,  by 
means  of  tents,  and  did  not  employ  the  latter  as  a mode 
of  curing  the  disease  when  less  advanced.  Valsalva 
introduced  a cannula,  pierced  with  numerous  holes, 
and  then  made  his  patient  get  into  a bath,  so  as  to  let 
the  fluid  enter  the  intestine.  Numerous  practition- 
ers, among  whom  is  Morgagni,  made  mercurials  the 
base  of  their  treatment,  from  a supposition  that  the 
complaint  was  of  venereal  origin.  I believe  the  latter 
opinion  is,  at  present,  entirely  abandoned  by  all  the 
most  judicious  surgeons  in  England,  and  this,  whether 
mercury  ever  prove  useful  or  not. 

When  the  disease  is  not  attended  with  ulceration, 
the  contraction  and  thickening  of  the  gut  may  be  di- 
minished by  introducing  bougies,  keeping  them  for  a 
certain  lime,  every  day,  so  introduced,  and  increasing 
their  size  gradually.  I'he  pressure  of  these  instru- 
ments seems  to  lessen  the  disease,  and  stop  ,its  pro- 
gress ; a proof,  at  all  events,  that  the  nature  of  one 
form  of  scirrho  contracted  rectum  differs  from  that  of 
a common  malignant  scirrhus.  Desault  used  to  em- 
ploy long  tents,  made  of  lint,  smeared  with  cerate,  and 
passed  into  the  bow'el  by  means  of  a probe,  with  a 
forked  end.  Their  size  was  gradually  increased,  so  as 
to  keep  up  the  compression,  to  w hich  it  was  conceived 
all  the  good  was  owing.  Their  length  was  also  aug- 
mented by  degrees.  At  first,  fresh  ones  were  intro- 
duced twice  a day.  When  any  hardnesses  were  situ- 
ated on  the  outside  of  the  anus,  Desault  cured  them  on 
the  same  principle,  viz.  by  making  pressure  on  them 
with  compresses  and  a bandage.  In  this  manner,  he 
effected  the  cure  of  a scirrho-contracted  rectum.  The 
patient  was  taught  to  pass  occasionally  the  tents,  with- 
out assistance,  in  order  to  prevent  a relapse. 

Instead  of  tents,  modern  surgeons  employ  bougies 
for  the  dilatation  of  strictures  in  the  rectum.  When 
from  habitual  costiveness,  the  altered  ficuire  of  the 
stools,  and  other  circumstairces,  there  is  retison  to  sus- 
pect organic  obstruction  to  the  passage  of  the  feces, 
and  this  suspicion  is  confirmed  by  an  examination  of 
the  rectum  with  tlie  finger,  “ the  first  object  of  the 
surgeon  (says  Mr.  Copeland)  should  be  an  enlarge- 
ment of  the  obstructed  part,  by  the  introduction  of  a 
bougie.  This  should  be  of  such  a size,  as  to  pass, 
when  well  lubricated  with  oil,  without  much  dif- 
ficulty or  pain.  Sometimes,  when  the  disease  has 
been  of  long  continuance,  it  will  be  necessary  to  begin 
even  with  a large-sized  urethra  bougie,  or  one  of  the 
same  size  as  those  which  are  made  for  a stricture  of 
the  oesophagus,  and  of  a length  that  is  likely  to  pass 
beyond  the  end  of  the  stricture,  that  is,  about  six,  or 
seven,  or  eight  inches.  But  I think  it  of  consequence 
to  use  a bougie  at  first,  w’hich  is  rather  too  small,  than 
too  large.” — (P.  29.)  When  it  has  remained  for  half 
an  hour,  or  more,  it  is  to  be  removed,  and  passed  again 
the  next  day,  the  same-sized  bougie  being  continued 
for  several  days.  In  the  introduction  of  the  bougie, 
Mr.  Copeland  cautions  the  practitioner  not  lo  mistake 
tlte  projection  of  the  saeram  for  a stricture  of  llte  gut ; 


a mistake  which,  he  says,  has  often  been  made,  and*, 
as  1 bt^ve,  too  often  wilfully,  and  from  motives  of 
imposition.  Pressure  on  the  rectum  by  the  retroverled 
uterus  (C.  Bell),  an  enlarged  ovarium,  or  other  tu- 
mour, may  also  lead  an  inattentive  surgeon  to  mistake 
the  case  for  a stricture.  Mr.  Calvert  has  seen  the 
bougie  employed  a long  w Idle  in  one  example,  w’here 
the  real  disorder  arose  from  a biliary  concretion  im- 
bedded in  the  parietes  of  the  rectum.— (Ow  Hemor- 
rhoids, and  other  Diseases  of  the  Rectum,  p.  167.)  This 
gentleman  conceives,  that  an  ivory  ball,  a.ffixed  to  the 
end  of  a silver  wire,  is  a good  instrument  for  ascer- 
taining the  exact  situation  and  extent  of  strictures  of 
the  rectum. — (P.  169.)  When  the  stricture  is  just 
above  the  sphincter,  some  information  of  the  state  of 
the  parts,  he  says,  may  be  gained  by  employing  the 
speculum  ani , but  he  adds,  that  whenever  there  is 
organic  stricture  near  tlie  anus,  this  instrument  should 
be  used  with  caution,  as  any  sudden  distention  of  the 
parts  is  al\\  ays  very  injurious. — (P.  170.)  Mr,  Cope- 
land advises  the  bowels  to  be  kept  constantly  lax,  by 
the  use  of  castor  oil,  or  electuary  of  senna,  during  the 
wliole  of  the  treatment. — (P.  30.)  Whatever  be  the 
nature  of  the  stricture,  whether  it  be  that  kind  in 
which  the  rectnm  is  obstructed  by  tubercles,  by  mem- 
branous filaments  intersecting  its  canal  (which  twa 
species,  Mr.  Copeland  says,  are  the  most  easily  re- 
lieved), or  whether  it  be  the  indurated  stricture,  from 
the  thickening  of  the  coats  of  the  intestine,  this  local 
treatment  is  equally  necessary.  The  plan  is  to  be  per- 
sisted in  until  a full-sized  bougie  will  readily  pass^ 
and  even  after  all  symptom.®  have  disappeared,  it  is 
recommended  to  introduce  the  bougie,  and  withdraw  it 
again,  once  every  two  or  three  days,  for  some  time,  in 
order  to  prevent  a relapse.  The  indurated,  annular 
stricture,  which  long  resists  the  bougie,  Mr.  Copeland 
sometimes  divides  with  a probe-pointed  curved  bis- 
toury on  the  side  which  is  contiguous  lo  the  os  sacrum ; 
and  he  has  frequently  seen  the  late  Mr.  Ford  perform 
the  same  operation. — (P.  34.)  This  practice,  which 
originated  with  Wiseman,  has  also  been  practised  by 
others  with  success. — (See  Dr.  Jamieson's  Case,  in 
American  Recorder,  April,  1822.)  When  the  disease 
is  either  combined  with  venereal  symptoms,  or  there  is 
any  reason  for  suspecting  it  to  be  itself  “ the  solitary 
symptom”  of  lues,  Mr.  Copeland  joins  Desault  in  re- 
commending a trial  of  the  effect  of  mercury,  in  con- 
junction with  bougies. — (P.  44.)  The  formation 
of  abscesses,  he  remarks,  is  very  frequent  in  the  ad- 
vanced stages  of  the  disease,  and  be  has  often  seen 
the  common  operation  for  fistula  done  under  such  cir- 
cumstances without  success. — (P.  35.) 

The  use  of  castor  oil  and  electuary  of  senna,  and 
throwing  into  the  rectum  a pint  of  thin  vyater-gruel 
and  a dessert-spoonful  of  castor  oil,  with  the  com- 
mon elastic  bottle  and  pipe,  are  also  recommended  by 
Mr.  Salmon.  It  is  only  when  the  bowels  are  very 
inert,  and  the  lower  part  of  the  belly  hard  and  fuff, 
that  he  has  recourse  to  aperient  draughts  of  rhubarb,^ 
sulphate  of  poiassa,  and  senna. 

Besides  tents  and  bougies,  which  latter  Mr.  Calvert 
thinks  may  be  sometimes  usefully  made  the  vehicle 
of  local  applications,  or  be  w'hat  is  called  medicated, 
this  gentleman  enumerates  among  the  plans  of  dilat- 
ing the  stricture  a prepared  gut,  introduced  bevond 
the  stricture,  and  then  dkr'ended  with  water;  in  other 
words,  Mr.  Arnot’s  dilator.  This  method,  he  says, 
may  be  adopted  where  the  bougie  causes  great  irrila- 
tion.— (P.  173.) 

When  a stoppage  '^f  nrine  occurs  in  the  advanced 
stage  of  the  disease,  Mr.  Copeland  advises  surgeons 
not  to  use  the  catheter  hastily. — (P.  39.)  And  in  the 
event  of  great  pain  and  irritation  in  the  recttim,  he  has 
seen  the  greatest  benefit  derived  from  the  local  appli- 
cation of  opium,  either  in  a clyster,  or  by  the  introduc- 
tion of  one  or  two  grains  of  the  medicine  within  the 
anus.  He  also  speaks  favourably  of  th?'  effects  of  the 
w’arm  bath  and  fomentations,  in  giving  temporary 
relief;  and  he  has  also  exhibited  in  these  cases  the  pil. 
extracti  conii  cum  hydrarg.  submur.  with  considerable 
advantage. 

When  stricture  of  the  rectum  is  of  a cancerous  na 
ture,  Mr.  Calvert  sets  down  every  known  remedy  as 
inadequate  to  arrest  its  progress.  A mitigation  of  suf- 
ferings is  all  that  can  be  aimed  at.  “ Diluent  injection.s, 
combined  with  opium,  conium,  or  similar  remedies, 
may  afford  a temporary  relief  in  the  ulcerative  stage 


RIG 


RIG 


291 


iiut,  says  this  writer,  “ the  greatest  advantage  is  de- 
rived from  carefully  introducing  a hollow  tube  of 
elastic  gum,  through  which  the  feces  are  drawn  off 
by  injecting  tepid  water.”  Dilating  the  passage  with 
any  other  view  than  that  of  maintaining  an  outlet  for 
the  feces,  he  considers  quite  useless.  “ A soft  lent, 
composed  of  lint,  smeared  with  some  mild  fresh  oint- 
ment, will  in  general  answer  this  purpose.  If  there  be 
hiuch  pain  and  inflammation,  fomentations  may  be 
Used  ; and  leeches  applied  in  the  vicinity  of  the  anus 
or  over  the  sacrum.  The  bowels  should  be  kept  mo- 
derately open  with  castor  oil,  or  some  other  mild  laxa- 
tive, which,  if  it  is  thought  necessary,  may  be  com- 
bined with  theexlractof  hyoscyamus,cicuta,  oropium; 
but  the  latter  is  in  general  less  admissible,  because  it  is 
more  liable  to  counteract  the  effect  of  the  laxative,  and 
produce  a torpid  state  of  the  bowels.” — (P.  187.) 

According  to  Mr.  Salmon,  in  true  carcinoma  of 
the  rectum,  the  use  of  bougies  dangerously  aggravates 
the  disease.  The  only  palliative  means  recommended 
by  him  are,  leeches  to  the  anus,  the  introduction  of  a 
grain  or  two  of  opium  into  the  rectum,  and  perseve- 
rance, night  and  morning,  in  injections  containing  from 
forty  to  sixty  drops  of  laudanum.  He  particularly 
cautions  the  surgeon  not  to  introduce  the  clyster-pipe 
more  thhn  an  inch,  or  an  inch  and  a half,  witliin  the 
sphincter,  lest  too  much  irritation  of  the  parts  be  ex- 
cited.—(P.  65.)  This  gentleman  differs  from  most 
writers  on  the  subject,  in  advising  the  bougie  to  be 
passed  at  intervals  of  from  three  to  five  days,  instead 
of  daily.  His  bougies  (which  are  eleven  inches  long) 
are  composed  of  fine  linen,  very  heavily  coaled  with 
wax  and  diachylon  plaster,  mixed  with  a small  quan- 
tity of  lampblack.  They  are  to  be  softened  in  very 
hot  water,  just  before  they  are  employed. — (See  Sal- 
mon on  Strictures  of  the  Rectum.,  p.  49.)  When  the 
stricture  is  attended  with  great  local  irritation,  he 
smears  the  bougie  with  a salve  composed  of  one  ounce 
of  elder  ointment,  and  a scruple  of  very  finely  pow- 
dered opium  ; and  when  the  stricture  is  suspected  to 
be  connected  with  syphilis  (a  doctrine,  however,  he 
in  another  place  renounces),  he  smears  ire  bougie  with 
mercurial  ointment.— (P.  51.) 

A fatal  case  of  mortification  of  the  rectum  is  de- 
tailed by  Larrey.  Parisian  Chirnrgical  Journal,  vol. 
2.  p , 398,  (J-c.  See  .7.  L.  Petit,  CEuvres  Posthum.  t.  2. 
Dr.  Sherwin  on  the  Scirrho-contr acted  Rectum,  in 
Mem.  of  the  Dondon  Medical  Society,  vol.  2.  Sir  Eve- 
rard  Home,  Obs.  on  Cancer,  p.  129,  <S-c.  8ao.  Jaond. 
1805.  L.  F.  J.  Duchadoz,  De  Proctostenia,  seu  de 
Morbosis  Intestini  Recti  .Mngustiis,  Monsp.  1771.  C. 
G.  Siebold  de  Morbis  Intestini  Recti.  Baillie's  Mor- 
bid Anatomy,  p.  116.  (Eiwres  Chir.  de  Desault,  par 
Bichat,  t.  2,  p.  422.  Obs.  on  the  principal  Diseases 
of  the  Rectum,  drc.,  by  T.  Copeland,  1814.  W.  White, 
Obs.  on  the  Contracted  Intestinum  Rectum,  8uo.  Bath, 
1812.  Also,  his  farther  Obs.  on  the  same  subject. 
Bath,  1822.  Monro's  Morbid  Anal,  of  the  Gullet,  Src. 
p.  347.  G.  Calvert  on  Hemorrhoids,  Strictures,  and 
other  Diseases  of  the  Rectum,  8vo.  Bond.  1824.  W. 
Gibson,  Institutes,  S,-c.,  of  Surgery,  vol.  1,  p.  292. 
Philadelphia,  1824.  F.  Salmon,  on  Stricture  of  the 
Rectum,  8»h).  Bond.  1826. 

RESOLUTION.  The  subsidence  of  inflammation 
without  abscess,  ulceration,  mortification,  &c.  Also 
the  disjiersion  of  swellings,  indurations,  &c. 

RETENTION  OF  URINE.  See  Urine,  Reten- 
tion of. 

RETROVERSrO  UTERI.  A turning  backward  of 
the  womb.  See  Uterus,  Retroversion  of. 

RICKETS.  {Rachitis.)  Is  mostly  met  with  in 
young  children  ; seldom  in  adults.  Morand,  however, 
{Acad,  dee  Sciences,  1753),  mentions  an  instance,  in 
which  an  adult  became  affected.  The  disease,  it  is 
said,  may  even  take  place  in  the  foetus  in  utero ; but 
the  most  common  period  of  its  commencement  is  in 
children,  between  the  ages  of  seven  or  eight  months 
and  two  years.  Hence,  as  Mr.  Wilson  observes,  ifs 
origin  has  f requently  been  imputed  to  the  effects  of  den- 
tition. He  adds,  that  be  has  often  known  it  make  its 
appearance  after  this  time,  and  that  it  not  imfrequently 
attacks  the  spine  a little  v/hile  before  puberty,  and  may 
do  so  even  later. — {On  the  Structure  and  Physiology  of 
the  Skeleton,  <^c.  p.  162.)  Pinel  has  given  a description 
of  the  .ekeleion  of  a rickety  foetus. — {Fourcroy's  .Jour- 
nal.) The  disease  .seems  to  consist  of  a want  of  due 
urmness  in  the  bones,  in  consequence  of  a deficiency 


in  the  phosphate  of  lime  in  their  structure.  The  causes 
of  the  aflection  are  involved  in  great  obscurity.  Au- 
thors have  referred  them  to  scrofula,  scurvy,  lues  vene- 
rea, difficult  dentitiom,  &;c. ; and  Richerand  still  firmly 
believes,  that  rachitis  is  only  one  of  the  eftects  of  .scro- 
fula in  its  woist  forms. — {JSTosographie  Chir.  t.  3,  pt 
148,  edit.  4.)  But  these  are  merely  conjectures,  which 
will  not  bear  a rigorous  investigation.  Boyer,  in  par- 
ticular, has  well  exposed  their  invalidity. — {Traite  des 
Mai.  Chir.  t.  2,p.  611.) 

Rickety  subjects  are  often  at  the  same  lime  scrofu- 
lous ; and  this  is,  probably,  the  only  reason  for  scrofula 
being  accounted  a cause  of  the  other  affection.  The 
particular  appearances  of  rickety  children  we  need  not 
detail,  as  every  one  is  familiarly  acquainted  with  them ; 
such  children  are  usually  of  a bad,  weak  constitution, 
and  their  limbs  and  bones  become  bent  in  directions  de- 
termined by  the  action  of  the  muscles,  and  the  weight 
and  pressure  which  they  have  to  sustain.  When  the 
affection  is  very  general,  the  spine  becomes  shorter, 
and  is  curved  in  various  directions ; the  breast  becomes 
deformed,  not  only  in  consequence  of  the  curvature  of 
the  spine,  but  by  the  depression  of  the  ribs,  and  pro- 
jection of  the  sternum.  The  bones  of  the  pelvis  fall 
inwards,  and  the  os  pubis  generally  approaches  the 
sacrum.  The  latter  circumstance  is  one  of  the  causes 
of  difficult  parturition.  The  clavicles  become  more 
bent  and  prominent  forwards;  the  os  humeri  is  distorted 
outwards  ; the  lower  ends  of  the  radius  and  ulna  are 
twisted  in  the  same  direction  ; the  thighs  are  curved 
forwardsor  outwards ; the  knees  fall  inwards  ; the  spine 
and  front  surface  of  the  tibia  become  convex ; and 
the  feet  are  thrown  outwards. 

According  to  Mr.  Stanley,  when  the  tibia  and  fibula 
become  curved,  they  sometimes  “acquire  increased 
breadth  in  the  direction  of  the  curve,  losing  a proper* 
tionate  degree  of  thickness  in  the  opposite  direction. 
Hence  the  bones  become,  as  it  were,  newly  modelled, 
passing  from  the  cylindrical  into  the  flattened  form. 
This  would  seem  to  be  designed  for  the  purpose  of  en- 
abling them  to  support  more  efficiently  the  weight  of 
the  body,  since  by  this  alteration  they  acquire  increased 
breadth  and  power  of  resistance  in  that  direction 
w'here  the  greatest  strength  is  required.  I have  never 
noticed  (says  Mr.  Stanley)  any  expansion  in  thearticular 
ends  of  rickety  bones,  as  is  mentioned  by  some  authors. 
I should  therefore  feel  inclined  to  believe  that  there  has 
existed  only  the  appearance  of  such  a phenomenon, 
the  ends  of  the  bones  having  appeared  swollen,  in 
consequence  of  the  emaciation  of  the  surrounding 
soft  parts.— (See  Med.  Chir.  Trans,  vol.  7,  p.  402— 
405.) 

When  the  thoracic  viscera  are  considerably  oppressed 
by  the  alteration  in  the  figure  of  the  chest,  produced  by 
rickets,  the  disease  may  bring  on  fatal  consequences. 

Boyer  has  thus  described  the  appearances  of  rickety 
bones  : — They  are  lighter  than  natural,  and  of  a red  or 
brown  colour.  They  are  penetrated  by  many  enlarged 
blood-vessels,  being  porous,  and,  as  it  were,  spongy,  soft, 
and  compressible.  They  are  moistened  by  a kind  of 
sanies,  which  may  be  pressed  out  of  their  texture,  as 
out  of  a sponge,  or  rather  a macerated  hide  after  it  has 
been  tanned.  I'he  walls  of  the  medullary  cylinder  of 
the  great  bones  of  the  extremities  are  very  thin,  while 
the  bones  of  the  skull  are  considerably  increased  in 
thickness,  and  become  spongy  and  reticular.  All 
the  affected  bones,  especially  the  long  ones,  acquire  a 
remarkable  suppleness  ; but  if  they  are  bent  beyond  a 
certain  point,  they  break,  &c.  Instead  of  being  filled 
with  medulla,  the  medullary  cavity  of  the  long  bones 
contains  only  a reddish  serum,  totally  devoid  of  the 
fat,  oily  nature  of  the  other  secretion  in  the  natural 
state. — (See  Rcyc?-,  Traite  des  Maladies  Chir.  t.  3,p, 
619.)  The  consistence  of  several  rickety  bones,  ex- 
amined by  Mr.  Stanley,  was  nearly  that  of  common  car- 
tilage. They  presented  throughout  an  areolated  texture, 
and  the  cells  were  in  some  parts  large,  and  contained 
a brownish  gelatinous  substance.  This  gentleman  did 
not  fitid  the  periosteum  thickened,  as  Bichat  has  de* 
scribed  it. — {Anatomic  Genirale,  t.  3.)  The  investiga- 
tions of  Mr.  Statde-y  have  also  discovered,  that  in  the 
process  by  which  rickety  bones  acquire  strength  and 
solidity,  there  is  always  an  undeviating  regularity  in 
the  situation,  extent,  and  direction  of  the  de|)osited 
earthy  matter.  “Thus  it  is  obvious  (says  this  gentle- 
man) that,  in  the  curved  bone,  llie  part  where  there  ie 
the  greatest  need  of  strength  to  prevent  its  further 


292 


SAL 


SAR 


yielding,  is  in  the  middle  of  its  concavity,  or  in  other 
words,  in  the  line  of  its  interior  curve ; and  it  is  just  in 
this  situation,  that  strength  and  compactness  will  be 
first  imparted  to  the  bone  by  the  deposition  of  phospliate 
of  lime.  It  will  be  farther  found,  that  the  greatest  re- 
sistance being  wanted  at  this  part,  the  walls  are  ac- 
cordingly rendered  thicker  here  than  elsewhere,  and 
the  degree  to  which  this  excess  in  thickness  is  carried, 
bears  an  exact  ratio  to  the  degree  of  curvature  which 
the  bone  has  undergone.” 

Mr.  Stanley’s  observations  also  prove,  that  the  bony 
fibres  are  arranged  obliquely  across  the  axis  of  the 
bone,  in  a direction  calculated  to  augment  its  strength. 
La.stly,  we  learn  from  the  same  authority,  that  if  a 
long  bone,  like  the  tibia,  be  very  much  bent,  while  it 
has  to  support  a great  superincumbent  w'eight,  the  de- 
position of  the  bony  matter  may  not  be  confined  to  the 
thickening  of  the  walls  of  the  concave  side,  but  may 
extend  across  themedullary  cavity,  rendering  the  bone 
here  perfectly  solid,  and  thereby  greatly  strengthened. 
— (See  Obs.  on  the  Condition  of  the  Bones  in  Rickets, 
(S'C.  by  E.  Stanley,  in  Medico-Chir.  Trans,  vol.  7,  p. 
404,  et  seq.) 

We  learn  from  the  late  Mr.  Wilson,  that,  for  many 
years,  he  had  also  exhibited  in  his  lectures  preparations 
illustrating  the  fact  of  the  abundant  deposition  of  os- 
seous matter,  “ when  the  bones  begin  to  recover  from 
the  disease,  at  the  part  where  it  is  most  wanted,  viz. 
on  the  inner  part  of  the  concave  surface  of  their  curve.” 
— (On  the  Skeleton,  trc.  p.  167.) 

Many  very  rickety  and  deformed  infants  improve  as 
they  grow  up,  and  acquire  strength.  The  deformity  of 
their  limbs  spontaneously  diminishes,  and  the  bones 
gain  a proper  degree  of  firmness,  a due  quantity  of  the 
phosphate  of  lime  being  deposited  in  their  texture. 

It  is  a question,  whether  the  restoration  of  the  pro- 
per figure  of  the  bones  can  be  promoted  by  the  constant 
pressure  of  bandages,  and  mechanical  contrivances 
sold  in  the  shops.  Some  authors  contend,  that  in  very 
young  children,  machines  are  useless,  as  the  confine- 
ment and  inactivity  of  the  muscles,  necessarily  occa- 
sioned by  such  contrivances,  must  increase»the  general 
debility,  and  consequently  the  disease. 

Notwithstanding  the  praises  which  have  been  be- 
stowed on  those  mechanical  means  by  their  inven- 
tors, and  even  by  respectable  authors,  says  Boyer,  they 
are  not  now  used  by  any  enlightened,  judicious  practi- 
tioners, it  being  generally  agreed  that  it  is  best  to  leave 
to  nature  alone,  aided  by  good  medical  treatment,  the 
duty  of  rectifying  bones  deformed  by  the  rickets. — 
( Traiti  des  Mai.  Chir.  t.  3,  p.  627.)  Delpech  ex- 
presses himself  still  more  strongly  against  the  employ- 
ment of  machinery. — (See  Precis  EUmentaire  des  Ma- 
ladies Chir.  t.  3,  p.740,  ^-c.)  However,  these  opinions 


against  mechanicle  contrivances  for  the  imjirovemeitl 
of  rickety  bones  are  not  meant  to  apply  to  machines 
for  rectilying  distortions  of  the  foot.  In  such  cases, 
the  malformation  does  not  depend  on  constitutional 
causes,  and  mechanical  means  will  do  whatever  is  pos- 
sible. 

No  medicine  is  known  that  possesses  any  direct  ef 
ficacy  in  rickets.— Tonics  are  indicated,  and  should  be 
employed.  Bark,  especially  the  sulphate  of  quinine, 
may  be  tried,  as  well  as  steel  medicines  ; to  iron  filings 
a great  deal  of  efficacy  has  been  ascribed. — (See  Med. 
Comment,  vol.  2,  p.  48.)  In  particular,  the  functions 
of  the  bowels  should  be  duly  regulated  by  medicine. 
The  disease  appearing  to  consist  in  a deficiency  of  lime 
in  the  bones,  proposals  have  been  made  to  exhibit  in- 
ternally the  phosphate  of  lime;  but  this  chemical  pro- 
ject has  had  no  success. — (See  Bonhomme's  Memoir  on 
Rachitis,  in  Duncan's  .Annals  for  1797.) 

Several  circumstances,  considered  by  Mr.  Wilson, 
tend  to  prove,  that  this  scheme  could  prt«ent  no  chance 
of  benefit,  because  there  is  no  proof  of  a deficiency  of 
lime  in  the  system,  though  the  arteries  of  the  bones  do- 
not  deposite  it  in  the  natural  degree. — (See  Wilson  on 
the  Skeleton,  Sre.p.  163,  (Src.) 

More  good  is  generally  effected  by  keeping  children 
in  healthy  situations,  and  in  a salubrious  air,  than  by 
any  medicines  whatever.  Light,  wholesome,  nutri- 
tious, easily-digestible  food  ; cold  bathing ; good  nurs- 
ing  ; regular  gentle  exercise  ; or  airings  in  a carriage  ; 
the  use  of  the  flesh-brush,  &cc.  are  also  highly  service- 
able. The  constitutional  treatment  of  rickets  belongs- 
more  properly  to  the  physician  than  the  surgeon  ; and' 
it  is  not  necessary  to  introduce  more  of  the  subject  into 
a Dictionary  expressly  allotted  to  surgery. — (See  Molli- 
ties  Ossimn.)  Consult  Buchner  de  Rachitide,  Argent. 
1754.  Olisson  de  Rachitide,  sive  Morbo  Puerili,  Ludg. 
Batav.  1671.  Bonhomme's  Mem.  on  Rachitis,  in  Dun- 
can's Medical  Annals  for  1797.  Richerand,  JsTosogra- 
phie  Chir.  t.  3,  p.  142,  ^c.  edit.  4.  Leveille,  in  Mem.  de 
Physiologic  et  de  Ghirurgie,  par  Scarpa,  irc.  Boyer, 
Traite  des  Maladies  Chir.  t.  3,  p.  607,  Src.  Stanley's 
Obs.  in  Med.  Chir.  Trans,  vol.  7,  p.  404.  Delpech, 
Precis  EUmentaire  des  Maladies  Chir.  t.  3,  p.  739,  Src. 
Trnka  de  Krzowiti,  Historia  Rachitidis,  8vo.  Vindob. 
1787.  Rt  Hamilton  on  Scrofulous  Ajfections,  ire.  8vo. 
Bond.  1791.  A.  Portal,  Obs.  sur  la  M'ature  et  sur  le 
Traitement  du  Rachitisme  ou  des  Courbures  de  la  Co- 
lonne  Vertibrale  et  de  celles  des  Extremites,  800.  Pams, 
1797.  .7.  Wilson  on  the  Structure  and  Physiology  of 

the  Skeleton,  Diseases  of  Bones,  dS-c.  p.  159,  ^c.  8vo. 
Bond.  1820. 

RINGWORM.  See  Herpes. 

R U FT U RE.  A protrusion  of  the  abdominal  viscera. 
See  Hernia. 


S 


JR  ABINA.  S’avine.  The  use  of  the  leaves  of  this 
^ plant,  in  forming  the  active  ingredient  in  the  oint- 
ment commonly  preferred  for  keeping  open  blisters,  has 
been  explained  in  the  article  Blisters.  The  other  chief 
surgical  use  of  savine  is  as  a stimulating  application 
for  destroying  warts,  and  other  excrescences.  For  the 
latter  purpose,  it  is  generally  powdered,  and  mixed  with 
an  equal  proportion  of  subacetate  of  copper.  The 
same  powder  is  also  sometimes  employed  by  surgeons 
for  maintaining  the  hollows  in  which  peas  are  inserted 
in  issues.  The  best  plan  is,  first  to  wet  the  peas,  then 
roll  them  in  Uie  powder  and  put  them  in  this  state  on 
the  issue.  But  when  the  whole  surface  of  the  issue 
has  risen  high  above  the  level  of  the  skin,  the  powder 
must  be  sprinkled  all  over  the  sore,  so  as  to  produce  an 
absorption  of  the  high  granulations.  Indeed,  even  in 
this  manner,  a good  cavity  often  cannot  be  obtained  ; 
and  it  becomes  necessary  to  destroy  the  surface  of  the 
issue,  by  rubbing  it  with  caustic  potassa  or  potassa 
cum  calce. 

SAL-AMMONIAC.  Ammonia  Muriata.  .Muriate 
of  Ammonia.  Employed  a good  deal  by  surgeons,  as 
an  ingredient  in  disentient  lotions. — (See  Botio  Ammon. 
Mur.) 

SALINARY  FlSTHl^iE.  See  Parotid  Duct. 


SANIES.  (Batin.)  A thin,  serons,  fetid  matter, 
discharged  from  fistute,  unhealthy  sores,  &.c.  It  is 
sometimes  tinned  with  blood. 

SAPO  TEREBINTHIN7E.  (Starkey's  Soap.)  R. 
Potass®  subcarbonis  calidi  5 j-  Olei  terebinth.  5 iij. — 
The  turpentine  is  gradually  blended  with  the  hot  sub- 
carbonate of  potassa  in  a heated  mortar.  Indolent 
swellings  were  formerly  rubbed  with  this  application, 
and,  perhaps,  some  fchronic  affections  of  the  joints 
might  still  be  benefited  by  it. 

SARCOCE'LE.  (Froin  adpl,  flesh;  and  Ky^v,  a 
tumour.)  A fleshy  enlargement  of  the  testicle. — (See 
Testicle,  Diseases  of.) 

SARCO'MA,  or  Saredsis.  (From  <r«p^,  flesh.)  A 
fleshy  tumour. — (See  Tumours,  Sarcomatous.) 

SARSAPARI'LLA.  The  root  of  sarsaparilla  was 
brought  into  Europe  about  1530.  It  was  at  first  re- 
puted to  possess  singular  efficacy  in  venereal  cases ; 
but  afterw.ard  lost  all  its  fame.  It  was  again  brought 
into  notice  by  Dr.  W.  Hunter,  who  advised  Dr.  Chap- 
man to  make  trial  of  it  in  a bad  case  of  phagedenie 
bubo;  and  the  benefit  obtained  in  this  instance  led  Dr. 
Hunter  to  extend  the  recommendation  of  the  medicine. 
Sir  W.  Fordyce  stated  that  sarsaparilla  would  quickly 
relieve  venereal  headaches  and  nocturnal  pains,  and. 


SCR 


SCR 


293 


If  persisted  in,  cure  them ; that  in  emaciated  or  con- 
sumptive habits  from  venereal  cause,  it  was  the  greatest 
restorer  of  appetite,  flesh,  colour,  and  streiigtli  which 
he  knew  of;  that  when  mercurial  frictions  had  been 
previously  employed,  it  would  generally  complete  the 
cure  of  the  disease  of  the  throat,  nose,  palate,  or  spongy 
bones ; and  that  it  would  promote  the  cure  of  blotches 
and  ulcers,  and  sometimes  accomplish  it,  even  without 
mercury;  though  in  this  circumstance  there  was  dan- 
ger of  a relapse.  Sir  W.  Fordyce  pronounced  sarsa- 
parilla to  be  of  little  use  in  chancres;  but  that,  when 
these  or  buboes  could  not  be  healed  by  mercury,  it 
would  often  cure,  and  always  do  good.  He  allows, 
however,  that  in  all  venereal  cases  sarsaparilla  is  not 
to  be  trusted,  miless  preceded  by,  or  combined  with,  the 
use  of  mercury ; and  he  thought  sarsaparilla  would, 
probably,  always  cure  what  resisted  mercury. — {,Medi- 
cal  Obs.  and  Inq.  vol.  1.) 

Cullen  considered  sansaparilla  as  possessing  no  vir- 
tues of  any  kind  ; for,  says  he,  “ tried  in  every  shape, 
1 have  never  found  it  an  effectual  medicine  in  syphilis, 
or  any  other  disease.’ — {Mat.  Med.  vol.  2.) 

Mr.  Bromfield  declares,  that  he  never  saw  a single 
instance  in  which  sarsaparilla  cured  the  venereal  dis- 
ease without  the  aid  of  mercury,  either  given  before  or 
in  conjunction  with  it. — (Pract.  Obs.  on  the  Use  of  Cor- 
rosive Sublimate,  irc-,  p.  78.)  Mr.  Pearson  also  con- 
tends, that  sarsaparilla  has  not  the  power  of  curing 
any  one  form  of  the  lues  venerea;  but  he  allows  that 
it  may  suspend  for  a time  the  ravages  of  that  conta- 
gion, the  disease  returning,  if  no  mercury  should  have 
been  used.  This  gentleman  admits  also,  that  sarsa- 
parilla will  alleviate  symptoms  derived  from  the  vene- 
real virus.  He  maintains,  that  the  exhibition  of  sar- 
saparilla does  not  diminish  the  necessity  forgiving  less 
mercury.  Nocturnal  pains  in  the  limbs,  painful  en- 
largements of  the  elbow  and  knee,  membranous  nodes, 
cutaneous  ulcerations,  and  certain  other  symptoms  re- 
sembling venereal  ones,  are  often  experienced  after  a 
firll  course  of  mercury.  Such  complaints,  Mr.  Pearson 
allows,  are  greatly  benefited  by  sarsaparilla  and  exas- 
perated by  mercury;  and  he  observes,  that  it  is  from 
these  complaints  having  been  mistaken  for  venereal 
ones,  that  the  idea  has- arisen  tliat  sarsaparilla  has 
cured  syphilis  when  mercury  had  failed.  Mercury  and 
the  venereal  poison  may  jointly  produce  in  certain  con- 
stitutions symptoms  which  are  not  strictly  venereal, 
and  are  sometimes  more  dreadful  than  the  simple 
effects  of  syphilis.  Some  of  the  worst  of  these  appear- 
ances are  capable  of  being  cured  by  sarsaparilla,  while 
the  venereal  virus  still  remains  in  the  system.  When 
this  latter  disease  has  been  eradicated  by  mercury, 
sarsaparilla  will  also  cure  the  sequelte  of  a course  of 
the  other  medicine.— (Pearson  on  the  Effects  of  various 
..Articles  in  the  Cure  of  Jmcs  Venerea,  1807.) 

The  value  of  many  of  the  foregoing  opinions  is  much 
affected  by  the  results  of  modern  inquiries  into  the  na- 
ture of  the  venereal  disease,  the  possibility  of  generally 
curing  which,  without  the  aid  of  mercury,  seems  well 
est-iblished,  though  the  expediency  of  the  method  is 
another  question. 

SCA'LPEL.  (From  ^alpo,  to  scrape.)  Originally 
a raspatory,  or  instrument  for  scraping  diseased  bones, 
fee.  The  term  now  generally  signifies  a common, 
straight,  surgical  knife. 

SCA'RIFICATION.  (From  sca.rifico,  to  scarify.) 
The  operation  of  making  little  cuts  or  punctures  in  a 
part  for  the  purpose  of  taking  away  blood,  letting  out 
fluid  in  anasarcous  cases,  or  the  air  of  emphysema. 

SCIRRHUS  ; SCIRRHOMA ; SCIRRHOSIS. 
(From  (jKiQ^boi,  to  harden.)  The  etymological  import 
of  these  terms  seems  merely  to  be  any  induration.  The 
first  is  now  generally  restricted  to  the  induration, 
which  precedes  cancer  in  the  ulcerated  state. 

SCLERIASIS  ; SCLEROSIS.  (From  axXt^pow,  to 
harden.)  A hard  tumour  or  induration. 

SCRO'FULA,  or  SCROPHULA.  {From  scrof  a,  a 
sow.)  So  named,  as  is  commonly  supposed,  because 
swine  are  said  to  be  subject  to  it,  though  the  correct- 
ness of  this  etymology  is  rendered  very  questionable  by 
the  remarks  of  Dr.  Henning;  and  the  statement  that 
jiies  a»-e  really  liable  to  scrofula,  would  appear  to  be 
♦■rroneous. — (See  Critical  Inquiry  into  the  Pathology 
of  Scrofula,  f,'c  , p.  I,  9 ) Called  also  struma,  and  the 
king's  evil,  from  the  custom  of  submitting  jiatients 
f'lrinerly  to  the  supposed  beneficial  effects  of  the  royal 
touch.  A disease,  one  of  the  chief  or  most  palpable 


symptoms  of  which  is  a chronic  swelling  of  the  absorb- 
ent glands  in  various  parts  of  the  body,  which  glands 
generally  tend  very  slowly  to  imperfect  suppuration. 
Our  notions  of  scrofula,  however,  would  be  very  im- 
perfect were  we  to  define  the  disorder  to  be  a morbid 
state  of  the  lymphatic  glandular  system.  The  first  ap- 
pearances, indeed,  frequently  consist  of  spots  on  differ- 
ent parts  of  the  body,  and  of  eruptions  and  ulcerations 
behind  the  ears.  As  a judicious  author  remarks,  tlie 
system  of  absorbent  glands,  it  is  true,  seldom  or  never 
fails  to  become  affected  in  the  progress  of  the  disease ; 
but  there  is  reason  to  believe,  that  scrofula  frequently 
appears  for  the  first  time  in  parts  which  are  not  of  a 
glandular  nature.  There  are,  perhaps,  but  few,  if  any, 
of  the  textures  of  the  human  body,  or  of  the  organs 
which  these  textures  form,  that  are  not  liable  to  at- 
tacks of  scrofula,  and  to  scrofula  as  an  original  idio- 
pathic affection. — {Thomson  on  Inflammation,  p.  184.) 
These  sentinrents  are  entirely  at  variance  with  those 
of  Alibert,  and  many  other  moderns,  who  describe  the 
disease  as  having  its  commencement  in  the  conglobate 
glands,  especially  those  of  the  neck  (JVbsoZ.  Maturelle, 
t.  \,  p.  441,  4fo.  Paris,  1817) ; and  they  are  equally  op- 
posite to  the  doctrine  of  Dr.  Henning,  who  argues  that 
the  superficial  absorbent  glairds  alone  are  susceptible  of 
the  original  action  of  the  cause  of  this  di.sease,  and  that 
if  other  parts  become  affected  by  it,  such  affection  is 
consequential. — ( On  the  Pathology  of  Scrofula,  chap.  6.) 

Scrofula  generally  shows  itself  during  infancy,  be- 
tween the  age  of  three  and  seven  ; sometimes  rather 
sooner;  but  frequently  as  late  as  puberty,  and  in  some 
instances,  though  a very  few,  not  till  a much  more 
advanced  period  of  life.  In  the  latter  cases,  the  dis- 
ease is  said  to  be  rarely  so  complete  or  well  marked 
as  it  is  in  young  subjects.  Sir  A.  Cooper  mentions  the 
period  of  growth  generally,  as  the  time  of  life  for  scro- 
fula; and  its  commencement  afterward,  he  agrees 
with  most  writers  in  pronouncing  very  uncommon. 
“ Cette  maladie  (says  Alibert)  est  communement  le 
partage  de  la  premidre  enfance.  II  est  rare  qu’elle  se 
ddveloppe  chez  les  adultes.  Je  I’ai  pourtant  observde 
chez  des  septuagenaires  ; mais  presqne  toujours  ce  sont 
les  effdts  dfe  la  dentition,  qui  la  font  eclore,  et  ceux  de 
la  pubertd,  qui  la  font  dvanouir.”— (JVbsoZ.  Jfaturelle, 
p.  448.) 

By  some  authors  it  is  stated,  that  the  disease  seldom 
attacks  the  glands  in  children  under  two  years  of  age. 
Dr.  Thomson,  however,  has  s/en  the  glands  affected 
before  this  period,  and  Dr.  Cullen  used  to  mention  a 
case,  in  which  the  disease  broke  out  in  an  infant  only 
three  months  old ; which  is  uncommon.  But  though 
glandular  scrofula  occurs  most  frequently  in  children, 
it  is  by  no  means  confined  to  that  period  of  life.  Dr. 
Thomson  has  even  found  the  lacteal  glands  affected 
with  scrofulous  inflammation  in  persons  of  very  ad- 
vanced age. — {Lectures  on  Inflammation,  p.  136.) 
Probably,  however,  such  patients  had  laboured  under 
scrofulous  conqdaints  in  their  earlier  days;  and  it  me- 
rits notice,  that  some  authors,  like  Dr.  Henning  {p.  110), 
do  not  regard  enlargements  of  the  mesenteric  glands  as 
an  unequivocal  specimen  of  scrofula.  It  is  observed 
by  Mr.  Lloyd,  that  the  susceptibility  of  different  parts 
to  the  disease  “ is  altered  by  age : thus,  in  children  the 
upper  lip,  eyes,  glands  of  the  neck,  and  those  of  the  me- 
sentery are  generally  the  parts  first  affected:  the  lungs, 
bones,  and  other  parts  being  subsequently  attacked. 
It  happens  sometimes  too  in  children,  that  small  lumps 
form  under  the  skin  in  various  parts  of  the  body, 
which  suppurate,  ulcerate,  and  pursue  the  same  course 
with  scrofulous  abscesses  in  general.” — {On  Scrofula, 
p.  5.)  A species  of  warts,  he  says,  also  often  forms 
about  the  face  and  neck  of  children  of  a scrofulous  ha- 
bit, but  seldom  in  adults.  “ In  more  advanced  age,  the 
eyes,  upper  lip,  and  lymphatic  glands  are  compara- 
tively seldom  affected;  while  the  lungs,  the  other  vis- 
cera, and  the  spongy  parts  of  the  bones  are  frequently 
attacked.” 

Scrofula  is  also  as  hereditary  as  any  disea.«e  can  be; 
that  is  to  say,  it  is  so  as  far  as  any  particular  kind  of 
temperament  or  constitution  can  descend,  more  or  less 
completely,  from  parents  to  children.  Mr.  While,  Dr. 
Jlenning,  and  others  have  stronyly  censured  calling  the 
disease  hereditary  ; but  their  observations  only  leiul  to 
these  conclusions,  that  children  born  of  scrofulous  pa- 
rents are  not  invariably  affected  with  scrofulous  dis- 
eases ; and  Ituif  sometimes  oiii-  child  has  some  stru- 
mous affection,  while  the  parents  and  all  tlie  rest  of  the 


294 


SCROFULA. 


family  have  no  appearance  of  scrofulous  habits.  How- 
ever, I still  conceive,  that  neither  Mr.  White  nor  any 
other  writer  will  maintain  the  opinion  that  scrofula  does 
not  much  more  frequently  afflict  the  children  of  scrofu- 
lous parents,  than  the  offspring  of  persons  who  have  al- 
ways been  perfectly  free  from  every  tendency  to  any 
form  of  this  affliction.  Too  numerous  are  the  facts  which 
occur  to  my  own  mind  to  allow  me  to  entertain  the 
smallest  doubt  that  scrofula  prevails  in  certain  families, 
in  this  sense,  I think  the  term  hereditary  perfectly  accu- 
rate and  allowable.  But,  at  the  same  time,  I beg  the 
reader  to  understand,  that  I have  no  iittention  of  ques- 
tioning what  seem  to  be  irrefragable  truths,  viz.  that 
the  children  of  scrofulous  parents  often  continue  as 
long  as  they  live  entirely  free  from  the  disease ; and 
that  one  child  is  sometimes  afflicted,  while  its  father, 
mother,  brothers,  sisters,  and  all  the  rest  of  its  relations 
have  never  had  any  tendency  to  strumous  di.^orders. 
It  should  also  be  recollected,  that  the  doctrine  of  a con- 
genital tendency  to  the  disease  in  particular  families  is 
one  which  interferes  with  some  theories  which  have 
been  offered  about  the  predisposing  cause  of  the  disease, 
as  for  instance  with  that  of  Dr.  Henning,  who  declares 
that  such  cause  is  foreign  to  the  body,  and  depends 
upon  peculiarities  of  climate  (On  the  Pathology  of  Scro- 
fula, p.  69,  ■Src.) ; an  opinion  which  is  incorrect  only  in 
respect  to  its  exclusion  of  the  influence  of  other  cir- 
cumstances. Two  curious  specimens  of  tnberculated 
lungs  in  the  foetus  are  preserved  in  Mr.  Langstaff’s 
museum,  and  have  been  adduced  by  Mr.  Lloyd  as  po- 
sitive proofs  of  scrofula  being  hereditary  ( On  Scrofula, 
p.  23) : however,  I am  not  certain  that  they  will  be  ad- 
mitted as  such  by  all  parties,  as  tubercles  of  the  lungs 
are  not  constantly  regarded  as  a scrofulous  disease. 
Yet  the  facts  and  arguments  on  this  point,  I think,  are 
decidedly  in  favour  of  the  doctrine;  and  Dr.  Alison, 
who  has  treated  very  ably  of  the  pathology  of  scrofula, 
has  remarked,  that  “ in  most  cases  in  which  scrofu- 
lous diseases  are  fatal,  the  diseased  action  is  in  inter- 
nal pans,  and  the  first  symptoms  are  obscure  and 
equivocal.  The  chief  and  certaitdy  the  most  charac- 
teristic appearances  on  dissection  are  tubercles  in  dif- 
ferent stages  of  their  progress.” — (See  Edinh.  Med. 
Chir.  Trans,  vol.  1,  p.  403.)  The  same  writer  every 
where  treats  of  phthisis  as  decidedly  a scrofulous  dis- 
ease. 

When  scrofula  does  not  actually  take  place  at  a very 
early  period  of  life,  it  is  geneially  stated  by  writers, 
that  the  particular  constitutions  in  which  there  is  a 
disposition  to  the  disease  are,  in  a certain  degree,  dis- 
tinguishable. In  the  individuals  possessing  the  dispo- 
sition in  question,  a peculiar  softness  and  flaccidity  of 
fibre  are  remarkable;  their  hair  is  more  frequently 
light-coloured  chan  dark ; and  their  eyes  are  said  to  be 
more  often  of  a blue  than  any  other  colour.  The  eye- 
lashes are  frequently  long,  and  the  pupils  large.  Their 
skin  is  generally  very  fine,  and  even  handsome,  both 
jn  regafd  to  its  outward  texture  and  complexion. 
When  pinched,  it  feels  (as  Sir  A.  Cooper  observes) 
thinner  than  that  of  a healthy  child,  and  the  vessels 
may  often  be  seen  meandering  under  it.  Subjects 
with  scrofulous  constitutions  frequently  have  a thick- 
ening of  the  upper  lip ; this  swelling  is  sometimes  very 
considerable,  and  occasionally  extends  as  far  as  within 
the  nostrils.  The  extremities  of  the  fingers  are  broad 
and  flat,  or  clubbed,  as  the  phrase  is,  just  like  what  is 
seen  in  phthisical  persons.  Scrofula  is  also  very  often 
complicated  with  rachitis,  or  follows  the  latter  affec- 
tion ; but  there  is  as  little  reason  for  supposing  rickets 
to  arise  from  scrofula,  as  this  latter  from  rickets.  In 
some  instances,  however,  the  complexion  is  dark,  and 
the  skin  coarse;  but  in  these  subjects,  at  least  when 
young,  the  face  is  generally  tumid,  and  the  look  un- 
healthy.— {Burns  on  Inflammation,  vol.%  p.232.) 

In  many  instances,  the  last  joints  of  the  fingers  have 
been  observed  to  be  enlarged,  and  the  belly  is  generally 
larger  than  usual. — {Thomson,  p.  134.) 

Mr.  White  denies  that  gray  or  blue  eyes,  light  hair, 
and  a fair  complexion,  ought  to  be  considered  as  marks 
of  a scrofulous  disposition;  for  the  majority  of  chil- 
dren in  this  country  have  light  hair  and  eyes  while 
young,  which  become  darker  as  they  advance  in  life. 
Now,  as  the  majority  of  scrofulous  patients  are  chil- 
dren and  young  subjects,  and  as  most  children  in  this 
country  have  naturally  the  kind  of  hair  and  eyes 
above  de.scribed,  TVIr.  White  considers  if  inaccurate  to 
lay  any  stress  on  persons  affected  with  struma,  or  pre- 


disposed to  this  disease,  having  stich  appearances.— 
{On  the  Struma  or  Scrofula,  p.  38,  ed.3.)  However, 
it  is  to  recollected,  that  the  greater  frequency  or 
scrofula  in  fair  people  is  noticed  in  France,  where  the 
eyes  are  mostly  dark.  Thus  Alibert,  in  his  descrip- 
tion of  a patient  disposed  to  the  disease,  takes  notice 
of  his  swelled  nostrils  and  upper  lip;  his  florid  com- 
plexion ; his  fair,  delicate,  and  glossy  skin;  his  cheeks 
of  a lively -red  colour;  circumscribed,  however,  by  a 
pallid  bloatedness  of  the  rest  of  the  face;  his  blue 
eyes-;  dilated  pupils;  light  hair;  short  neck;  large 
head  and  lower  jaw;  flabby  flesh  ; large,  protuberant 
belly  ; strong  intellectual  powers,  &c. — {JVosol.  J^Tatu- 
relle,  p.  442 ; also  Diet,  des  Sciences  Med.  t.  59,  p.  231.) 

Dr.  Thomson  expressly  declares,  that  some  of  the 
worst  cases  of  scrofula  which  he  has  seen,  occurred  in 
persons  whose  complexion  and  hair  were  of  a very 
dark  colour.— (Lectures,  p.  134.)  And  every  man  of 
experience  must  be  aware  of  one  remarkable  fact, 
namely,  that  many  n^roes  are  afflicted  in  this  coun- 
try with  scrofula  in  its  worst  forms.  Does  not  this 
fact  indicate,  at  the  same  time,  that  it  is  climate  which 
is  most  powerfully  concerned  in  the  production  of  the 
disease?  since  the  African  black,  in  his  own  country 
is  nearly  exempt  from  scrofula.  After  all,  however, 
as  the  disease  is  undoubtedly  very  frequent  in  persona 
of  fair  skit),  light  eyes,  &c.  the  term  alike,  at  least  in 
the  sense  of  equally,  may  not  be  altogether  correct  in 
the  following  inference,  viz.  “that  persons  of  every 
variety  of  complexion  are  alike  subject  to  this  disease, 
and  that  it  is  only  necessary  to  place  them  in  circum- 
stances favourable  to  its  developernent  to  have  it  fully 
formoA."— {Lloyd  on  Scrofula,  p.  7.)  The  truth  I be- 
lieve is,  that  though  children  of  dark  hair  and  com- 
plexion are  often  attacked  by  scrofula,  those  of  light 
hair  and  fair  complexion  are  still  more  frequently  af- 
flicted, and  this  even  in  France,  where  the  fact  cannot 
possibly  be  referred  to  the  number  of  fair  children  ex- 
ceeding that  of  such  as  naturally  have  dark  hair  and 
complexion. 

I believe  the  fact  is  now  almost  generally  admitted, 
that  females  are  rather  more  subject  than  males  to 
scrofulous  disease. — (See  Alibert,  Mosol.  Maturelle, 
p.  449.) 

According  to  Mr.  White,  struma  prevails  more  ex- 
tensively in  temperate  latitudes  than  in  very  hot  or 
very  cold  climates.  It  is  also  more  frequent  in  some 
parts  of  Europe  than  others ; and  in  this  country.  It 
has  been  found  to  be  most  prevalent  in  the  counties  of 
Suffolk  and  Lancashire.  At  all  periods,  it  seems  to 
have  been  a very  common  complaint  in  this  island. 
From  h’story  we  learn  that  it  was  denominated  the 
king’s  evil  in  the  time  of  Edward  the  Confessor,  who 
is  supposed  to  have  been  the  first  that  attempted  to 
cure  it  by  the  royal  touch.  From  a register  kept  in  the 
royal  chapel,  we  find  that  Charles  II.  touched  92,107 
persons  ua  a certain  number  of  years;  and  this  equally 
bigoted  and  useless  practice  was  not  discontinued  till 
a recent  period,  when  kings  were  found  to  be,  as  well 
as  their  poorest  subjects,  totally  destitute  of  all  super- 
natural power. 

Scrofula  is  not  communi^ble  from  one  person  to 
another;  neither  can  it  be  conveyed  into  the  system 
by  inoculation.  The  opinion  also,  that  scrofulous 
nurses  may  infect  children,  seems  quite  destitute  of 
foundation. — (See  White,  p.  26,  ^-c.) 

Pinel  and  Alibert  have  purposely  kept  scrofulous 
and  healthy  children  together  in  the  same  ward,  with- 
out any  of  the  latter  receiving  the  complaint.  H6- 
br6ard  could  not  communicate  the  disease  to  dogs  by 
inoculation.  And  G.  T.  Kortum,  whose  valuable  work 
contains  every  thing  .known  about  scrofula  at  the  pe- 
riod when  it  was  written,  tried  in  vain  to  impart  the 
distemper  to  a child,  by  rubbing  Ks  neck  every  day 
wkh  the  pus  discharged  from  scrofulous  ulcers.  Le- 
pelletier,  desirous  of  ascertaining  the  correctness  of 
such  experiments,  has  of  late  repeated  them : he  has 
made  guinea-pigs  swallow  scrofulous  matter;  and  ho 
has  injected  it  into  the  veins,  and  applied  it  to  wo)inds ; 
but  in  no  instance  was  there  even  a temporaiy  ap- 
pearance of  the  disease  being  communicated.  The 
same  author  also  ))iixed  scrofulous  with  vaccine  mat 
ter,  and  inoculated  with  it;  yet  he  never  found  the 
vaccine  vesicle,  thus  produced,  deviate  in  the  least 
from  its  regular  course.  Lastly,  Lepelletier  inoculated 
himself  with  pus  discharged  from  scrofulous  sores,  as 
well  aa  with  the  serum  collected  under  the  cuticle  of 


SCROFULA. 


295 


a strumous  patient  after  the  application  of  a blister; 
but  lie  remained  free  fron?  every  scrofulous  ailment. — 
(See  Diet,  des  Scietices  Med.  t.  50,  ;r.294.)  Our  coun- 
tryman, Mr.  Goodlad,  inoculated  himself  several  limes 
with  the  discharge  from  scrofulous  sores  and  abscesses, 
and  the  result  was,  that  the  disease  could  not  be  thus 
transmitted. — {On  the  Diseases  of  the  Vessels  and 
Glands  of  the  .Absorbent  System,  p.  113.) 

The  parts  which  are  most  frequently  affected  by 
sciofula,  next  to  the  lymphatic  glands,  and  perhaps  the 
•skin,  are  tlie  spongy  heads  of  the  bones  and  the  joints. 
The  form  which  the  disease  assumes  in  the  latter  parts 
•is  particularly  described  in  the  article  Joints.  The  dis- 
order of  the  spine,  attended  with  a paralytic  affection 
of  the  lower  extremities,  is,  no  doubt,  very  frequently 
of  scrofulous  origin. — (See  Vertebra.)  Spina  bifida  is 
lx.  congenital  disease,  most  frequently  seen  in  children, 
whose  parents  are  scrofulous. — {Thomson's  Lectures, 
p.  133.)  The  abscess  which  forms  in  the  cellular  sub- 
stance, between  the  peritoneum  and  psoas  muscle,  is 
often  regarded  as  a strumous  disease;  and  when  the 
contents  of  the  abscess  are  found  to  contain  flakes  of  a 
emd-hke  matter,  somewhat  resemoling  while  of  egg, 
a substance  peculiar  to  scrofulous  abscesses,  no  one 
can  doubt  that  the  complaint  is  connected  with  this 
constitutional  affection. — (See  Lumbar  Abscess.)  The 
chronic  enlargement  of  the  thyroid  gland  is  sometimes 
considered  as  scrofulous ; but,  though  patients  with  this 
affliction,  very  often  have,  at  the  same  time,  other  com- 
plaints, which  are  unequivocally  strumous,  though  the 
eiilargemeut  of  the  thyroid  gland  most  frequently  com- 
mences at  an  early  period  of  life,  like  scrofulous  dis- 
eases, and  though  like  them  it  is  sonretimes  benefited 
by  the  carbonate  of  soda,  burnt  sponge,  and  iodine,  the 
opinion,  I think,  is  rather  on  the  decline. — (See  Bron- 
chocele.)  Scrofula  also  frequently  makes  its  appear- 
ance in  the  form  of  imperfect  suppurations,  in  various 
parts  of  the  body  ; the  contents  of  such  abscesses  being 
a curd-like  matter,  and  the  skin  covering  them  having 
an  unhealthy  red  appearance,  and  a thickened  doughy 
feel.  The  mesenteric  glands  are  often  found  univer- 
sally diseased  and  enlarged  in  scrofulous  subjects  ; and, 
us  all  nutriment  has  to  pass  through  the.se  parts,  before 
it  can  arrive  in  the  circulation,  we  cannot  be  surprised 
at  the  many  ill  effects  which  must  be  produced  on  the 
system,  w'hen  such  glands  are  thus  diseased.  How- 
ever, as  I have  alre^y  hinted,  doubts  are  entertained 
by  Dr.  Henning,  whether  enlarged  mesenteric  glands 
are  decidedly  scrofulous ; but  if  his  sentiment  be  incor- 
rect, I fear  he  has  been  led  to  adopt  it  by  his  particular 
theory,  which  limits  the  origin  of  scrofula  to  the  su- 
perficial absorbent  glands.  Scrofula  fiequently  makes 
its-  attack  on  the  testicles. — (See  Testicles,  Diseases 
of.)  The  female  breast  is  also  subject  to  scrofulous 
tumours  and  abscesses. 

According  to  Sir  A.  Cooper,  scrofulous  persons  fre- 
quently have  follicles  on  different  parts  of  the  body,  in- 
crusted  with  inspissated  matter.  He  agrees  with  most 
othe."  writers  in  considering  the  absorbent  glands  and 
joints  as  the  parts  most  freqitently  attacked,  especially 
the  glands  of  the  neck  and  mesentery.  Various  other 
parts  of  the  body  he  enumerates  as  liable  to  it — the 
lungs,  the  brain,  the  eyes ; but  the  heart,  he  believe.s,  is 
never  affected.  The  secreting  glands,  he  also  says,  are 
rarely  the  seat  of  scrofula,  at  least  the  liver  and  kid- 
neys ; for  the  breast  and  testicle  are  exceptions. 

Dr.  Thomson  believes,  that  more  or  less  local  inflam- 
mation occurs  in  overy  form  and  stage  of  scrofulous 
diseases.  He  observes,  that  the  swellings  are  very  of- 
ten from  the  first  altSnded  with  a sensible  increase  of ' 
heat  and  redness,  and  that  the  pain,  though  seldom 
acute,  is  always  present  in  a greater  or  less  degree. 
Pressure  on  scrofulous  swellings  never  fails  to  create 
pain ; and  the  temperature  of  the  skin  covering  them,  is 
usually  two  or  three  degrees  higher  than  that  of  the 
contiguous  parts. — {Lectures,  ^c.p.  131.) 

Scrofulous  inflammation  (as  Mr.  John  Burns  ob- 
serves) is  marked  by  a soft  swelling  of  the  affected 
part,  which  very  frequently  is  one  of  the  lymphatic 
glands.  The  covering  or  coat  of  the  gland  becomes 
slightly  thickened,  and  its  substance  more  porous  and 
doughy.  The  swelling  increases,  and  the  doughy  feel 
changes  by  degrees  into  that  of  elasticity,  or  fluctua- 
tion, and  a firm,  circumscribed,  hardened  margin,  can 
be  felt  round  the  base  of  the  tumour.  The  skin  is 
slightly  red.  If,  at  this  lime,  an  incision  or  puncture 
be  imnle,  cither  no  matter  or  very  little  is  evacualea  ; 


the  lips  of  the  wound  inflame  aiffl  open,  displaying  a 
sloughy-looking  substance  within ; and  between  this 
and  the  skin  a probe  can  often  be  introduced  for  some 
way  all  round.  It,  however,  the  disease  should  have 
advanced  farther,  then  there  is  very  little  elasticity  in 
the  tumour  ; it  is  quite  soft,  rather  flaccid,  and  fluctu- 
ates freely;  the  skin  becomes  of  a light-purple  colour., 
and  small  veins  may  be  seen  ramifying  on  its  surface. 
Some  time  after  these  appearances,  the  skin  becomes 
tiiinner  atone  particular  part,  and  here  it  is  also  gene- 
rally rendered  of  a darker  colour.  It  afterward  bursts, 
and  discharges  a thin  fluid,  like  whey,  mixed  with  a 
curdy  matter,  or  thick  wiiite  flocculi.  The  redness  of 
the  skin  still  continues ; but  the  aperture  enlarges  as 
the  tumour  subsides,  and  thus  a scrofulous  ulcer  is  pro- 
duced. The  margins  of  this  kind  of  sore  are  gene- 
rally smooth,  obtuse,  and  overlap  the  ulcer ; they  are 
of  a purple  colour,  and  rather  hard  and  tumid.  The 
surface  of  the  sore  is  of  a light-red  colour ; the  granu- 
lations are  flabby  and  indistinct ; and  the  aspect  is  of 
a peculiar  kind,  which,  says  Mr.  Burns,  cannot  be  de- 
scribed. The  discharge  is  thin,  slightly  ropy,  and  co- 
pious, with  curdy  flakes.  The  pain  is  inconsiderable. 
When  this  ulcer  has  continued  for  some  time,  it  either 
begins  slowly  to  cicatrize,  or,  as  more  frequently  hap- 
pens, the  discharge  diminishes  and  becomes  thicker. 
An  elevated  scab  is  next  formed,  of  a dirty  white  or 
yellowish  colour.  'I'his  continues  on  the  part  a good 
while;  and  when  it  falls  off,  leaves  the  place  covered 
with  a small  purple  cicatrix.  Mr.  Burns  adds,  that  the 
preceding  description  corresponds  to  the  mild  scrofula, 
or  the  struma  mansueta  of  the  old  writers.  Some- 
times, especially  if  a bone  be  diseased  below  the  ulcer, 
the  sore  has  a more  fiery  appearance,  the  surface  is 
dark-coloured,  the  margins  soft,  elevated,  and  inflamed, 
and  somerimes  retorted.  The  discharge  is  watery,  the 
pain  very  considerable,  and  the  surrounding  skin  in- 
flamed. This  has  been  called  the  struma  maligna. 
Such  overacting  scrofulous  sores  are  most  frequently 
met  with  over  the  smaller  joints,  particularly  those  of 
the  toes.  Sometimes  a scrofulous  abscess,  after  it  has 
burst,  forms  a sinus  ; the  mouth  of  whicli  ulcerates, 
and  assumes  the  specific  scrofulous  appearance,  while 
the  track  of  the  sinus  still  continues  to  emit  a dis- 
charge. Scrofulous  swellings  are  often  disposed  to 
subside  in  winter,  and  recur  on  the  approach  of  sum- 
mer ; but  this  is  not  an  invariable  law.  Glandular 
enlargements  are  very  apt  to  become  smaller,  in  a 
short  time,  in  one  place,  while  other  glandular  swellings 
originate  with  equal  suddenness,  somewhere  in  the  vi- 
cinity of  the  former  ones.  Ulcers  also  very  often 
heal  upon  the  appearance  of  the  disease  in  other  parts. 
— {Burns's  Dissertations  on  Inflammation,  vol.  2, 
1800.) 

The  glandular  swellings  which  occur  in  syphilis, 
says  Dr.  Thomson,  are  of  a more  acute  character 
than  those  which  proceed  from  scrofula.  They  arise 
from  the  absorption  of  a specific  poison  ; and  they  do 
not,  like  those  of  scrofula,  admit  of  a spontaneous 
cure;  a belief,  however,  now  known  not  to  be  ex- 
actly correct.— (See  Venereal  Disease.)  Chronic 
swellings  of  the  lymphatic  absorbent  glands  occur  also 
in  carcinoma;  but  these  manifest  little  or  no  disposi- 
tion to  suppuration:  they  succeed  most  fiequently  to 
carcinomatous  indurations,  or  ulcers  existing  in  the 
neighbourhood  of  the  glands  affected ; and  they  are 
accompanied  in  their  progress  and  growth  by  a pecu- 
liar lancinating  pain. — {On  Inflammation,  p.  135.) 

With  regard  to  the  proximate  cause  of  scrofula,  me- 
dical men  "may  be  said  to  remain,  even  at  the  present 
day,  in  entire  ignorance  of  it.  After  the  ridiculous 
theory,  referring  scrofula  to  certain  humours  in  the 
constitution,  or  chemical  changes  in  the  blood,  had 
been  exploded,  the  opinion  gradually  aro.se,  that  it  was 
a disea.se  of  the  lymjihatic  system  ; and,  indeed,  that 
the  absorbent  glands  are  often  visibly  the  seat  of  its 
attack,  when  no  changes  are  distinguishable  in  other 
textures,  is  a fact  that  admits  of  no  dispute.  I be- 
lieve, at  the  same  time,  that  whoever  supposes  scro- 
fula to  be  exclusively  confined  to  the  lymphatic  sys- 
tem, must  have  a very  imperfect  conception  of  what 
is  really  the  case.  On  the  contrary,  I fully  participate 
in  the  sentiments  of  Professor  Thomson,  already  ad- 
duced upon  this  point,  and  in  the  belief  of  another 
modern  writer,  that  strumous  complaints  “are  not  to 
be  considered  as  depmident  on  disease  of  any  particu- 
lar systetn,  as  the  lyihphaiic.” — {Lloyd,  p.  10.)  Such 


296 


SCROFULA. 


writers  as  have  fixed  upon  the  absorbent  vessels  as 
the  particular  seat  of  scrofula,  can  tlrrow  no  useful 
light  upon  its  origin,  by  following  up  the  theory, 
whether  they  imagine  the  cause  to  be  obstruction  of 
the  vessels  and  glands,  or  take  up  the  wild  speculation 
of  Cabani,  that  in  scrofula  the  mouths  of  the  lym- 
phatics are  in  a state  of  increased  activity,  while  the 
vessels  themselves  are  in  a state  of  atony  ; or  the  doc- 
trine of  Soemmering,  that  scrofula  depends  upon  a 
passive  relaxation  and  dilatation  of  the  absorbents ; 
or  the  hypothesis  of  Girtanner,  that  these  vessels  are 
in  a state  of  increased  ir^itabilit3^  The  idea  of  ob- 
struction being  the  cause  has  of  late  years  been  much 
on  the  decline  ; and  that  the  convolutions  of  lymphatic 
vessels  forming  the  glands  are  quite  pervious,  and  may 
readily  be  injected,  even  when  diseased,  is  a fact  first 
demonstrated  by  Soemmering,  which  must  w’eigh 
Ireavily  against  this  opinion.  Sir  A.  Cooper  describes 
the  disease  as  proceeding  from  congenital  debility, 
which  attends  its  w hole  course,  and  imparts  to  it  a pe- 
culiar character,  rendering  the  various  processes  of  in- 
flammation in  it  slow  and  imperfect. — \Lancet,  vol.  4, 
p.  65.)  Of  the  exciting  causes,  very  little  is  also 
known.  Mr.  John  Hunter  remarks,  that  “ in  this  coun- 
try, the  tendency  to  scrofula  arises  from  the  climate, 
which  is  in  many  a predisposing  cause,  and  only  re- 
quires some  derangement  to  become  an  immediate 
cause,  and  produce  the  whole  disease.” — (On  the  Ve~ 
nereal  Disease,  p.  26.)  The  disease  is  remarked  to  be 
most  common  in  females;  in  cold,  damp,  marshy 
countries,  and  in  all  places,  near  high  mountains,  where 
the  tempei  alure  is  subject  to  great  vicissitude.  “ Nous 
voyons  presque  toujours  (says  Alibert),  que  les  tu- 
meurs  et  les  ukdres  se  rouvrent  au  printemps  pour  se 
former  ensuite  vers  la  canicule.”— (JVosoZ.  J^Taturelle, 
p.  449.) 

In  the  W'ork  quoted  the  last  but  one,  Mr.  Hunter 
takes  notice  of  slight  fevers,  colds,  smalUpox,  and  mea- 
sles, efeiling  scrofulous  diseases.  lie  observes,  that  in 
particular  countries,  and  in  young  people,  there  will 
eometjmes  be  a predisposition  to  scrofula ; and  that,  in 
such  subjects,  buboes  will  more  readily  become  scro- 
fulous.— (P.37.)  In  short,  it  was  one  of  Mr.  Hunter’s 
opinions,  that  the  venereal  disease  is  capable  of  call- 
ing into  action  such  susceptibilities  as  are  remarkably 
strong,  and  peculiar  to  certain  constitutions  and  coun- 
tries; and  that,  as  scrofula  is  predominant  in  this 
country,  some  effects  of  other  diseases  may  partake  of 
a scrof^ulous  nature. — (P.96.)  Mr.  Hunter,  speaking 
of  venereal  buboes,  mentions  his  having  long  sus- 
pected a mixed  case,  and  adds,  “ I am  now  certain  that 
such  exists.  I have  seen  cases  where  the  venereal 
matter,  like  a cold,  or  fever,  has  only  irritated  the 
glands  to  disease,  producing  in  them  scrofula,  to  which 
they  were  predisposed.  In  such  cases,  the  swellings 
commonly  arise  slowly,  give  but  little  pain,  and  seem 
ito  be  rather  hastened  in  their  progress,  if'mercury  is 
given  to  destroy  the  venereal  disposition.  Some  come 
to  suppuration  while  under  this  resolving  course ; and 
others,  which  probably  had  a venereal  taint  at  first, 
become  so  indolent  that  mercury  has  no  effect  upon 
them  ; and,  in  the  end,  they  get  well  of  themselves,  or 
by  other  means. — (P.  269.)  For  such  buboes,  Mr. 
Hunter  used  to  recommend  sea-bathing ; and,  in  case 
of  suppuration,  poultices  made  of  sea-water. 

Sir  A.  Cooper  observes,  that  the  predisposing  cause 
of  scrofula  is  congenital,  or  original  fault  of  constitu- 
tion. The  exciting  causes,  he  says,  are  whatever  tenda 
to  produce  or  increase  debility,  such  as  fever  from  dis- 
eases of  a specific  kind,  like  measles,  scarlet  fever,  and 
emalt-pox.  He  notices  the  greater  frequency  on  this 
account  of  scrofulous  cases  some  years  ago,  when  the 
advantages  of  vaccination  were  not  known  ; and  the 
importance  of  this  practice  to  society,  if  it  had  no  other 
recommendation.— (See  Lancet,  vol.  4,  p.  70.) 

In  the  words  of  a well  informed  Professor,  scrofula 
readily  forms  an  alliance  with  almost  every  morbid  af- 
fection, occurring  either  from  external  injury,  or  from 
internal  disease  ; it  modifies  the  appearance  of  other 
diseases,  and  seems  to  convert  them  gradttally  into  its 
own  nature.  Indeed,  there  are  few  of  the  local  in- 
flammatory affections  which  occur  in  this  country,  in 
which  the  symptoms  and  effects  of  these  affections, 
and  tlie  operation  of  the  food  and  remedies  employed 
for  their  cure,  are  not  more  or  less  modified  by  the  de- 
gree of  scrofulous  diathesis,  which  prevails  in  the  con- 
stitution of  those  who  are  affected  by  them.  The 


scrofulous  diathesis,  wherever  it  exists,  usually  givea 
more  or  less  of  a chronic  character  to  local  inflamma- 
tory affections.— ( P/toBisoTi’s  Lectures,  p.  131.) 

Sentiments  corresponding  to  some  of  those  already 
quoted  are  delivered  by  Dr.  Alison  ; “ The  facts,” 
says  he,  “ which  seem  most  decisive,  as  to  the  con- 
nexion of  the  scrofulous  habit  with  general  debilita- 
ting causes,  may  be  recapitulated  as  follows;—!.  The 
differences  in  the  symptoms  and  progress  of  inflamma- 
tion, when  scrofulous,  and  when  healthy,  appear  ma- 
nifestly to  indicate  in  the  former  case  a languid  state 
of  the  circulation,  particularly  in  the  capillary  vessels 
of  the  diseased  part.  2.  The  hereditary  disposition  to 
scrofula  is  chiefly  transmitted  from  parents,  and  is 
mostly  observed  in  children,  who  show  evident  marks 
of  constitutional  debility  in  other  respects.  3.  There 
is  no  state  of  the  body,  as  every  practitioner  knows, 
in  which  scrofulous  action  is  so  easily  excited,  as  the 
state  of  great  and  often  permanent  debility,  which  re- 
mains after  severe  febrile  disease,  continued  fever, 
small-pox,  measles,  scarlatina,  or  which  follows  the 
long-continued  use  of  mercury,  or  accompanies  ame- 
norrheea.  4.  The  season  at  which  scrofulous  diseases 
have  been  observed  to  prevail  most  in  this  climate,  is 
not  that  when  cold  weather  has  recently  set  in,  and  is 
most  productive  of  disease  in  general,  but  the  end  of 
the  winter  and  the  spring;  and  they  are  then  chiefly 
observed  in  those  young  persons  who  have  manifestly 
lost  strength  during  the  continuance  of  the  cold 
weather.” — {Alison,  in  Edin.  Med.  Chir.  Trans,  vol. 
J,p.381.) 

It  has  been  the  fashion  of  late  years  to  ascribe  the 
origin  of  a vast  number  of  diseases  to  disorder  of  the 
digestive  organs,  little  trouble  being  generally  taken  to 
consider,  with  any  impartiality,  whether  the  derange- 
ment of  those  organs  may  not  be  lather  the  common 
effect  than  the  common  cause  of  so  many  various  dis- 
eases. Numerous  circumstances  tend  to  perpetuate 
the  delusion  into  which  young  practitioners  are  falling 
upon  this  topic.  They  see  various  diseases,  attended 
with  dyspepsia,  flatulence,  loss  of  appetite,  costiveness, 
and  a torpid  state  of  the  bowels ; they  observe  that 
such  diseases  and  the  latter  complaints  of  the  aliment- 
ary canal  generally  diminish  together  ; that,  when  the 
functions  of  the  stomach  and  bowels  are  deranged, 
any  other  diseases  which  the  patient  may  be  labouring 
under,  either  grow  worse,  or  are  retarded  in  their 
amendment;  and,  lastly,  the  treatment  to  which  the 
theory  leads,  improves  the  health,  by  rectifying  the 
state  of  the  alimentary  canal ; and  the  sore,  tumour,  or 
other  complaint,  in  the  end,  with  the  additional  aid  of 
time,  nature,  and  other  favourable  circumstances,  gets 
well.  But,  however  simple,  safe,  and  beneficial  the 
practice  may  be,  and  plain  as  the  facts  are  which  lead 
to  it,  there  is  no  proof  that  the  other  disease  was  truly 
a consequence  of  the  disorder  of  the  digestive  organs. 
The  latter  symptom,  I believe,  is  very  frequently  an 
effect  mistaken  for  a cause,  and  perhaps  always  so  in 
relation  to  scrofula.  -Besides,  if  it  were  to  be  assumed 
(as  indeed  it  actually  is),  that  in  scrofula  “ there  always 
is  more  or  less  disorder  of  the  digestive  organs,  and 
primarily  of  no  other  important  function,"  I do  not 
see  that  we  advance  one  step  nearer  the  truth ; be- 
cause, as  the  same  cause  is  generally  assigned  by  gen- 
tlemen attached  to  this  theory,  for  a vast  number  of 
other  cases,  we  still  remain  in  the  dark  as  to  the  cir- 
cumstances which  make  so  many  complaints  of  dif- 
ferent kinds  spring  from  one  and  the  same  cause. 
These  circumstances,  though  buried  in  silence,  are  still 
the  mystery— still  the  secret,  wlfich  is  desired  ; and  if 
it  be  answered  that  the  eflfect  will  only  happen  in  par- 
ticular constitutions,  then  we  are  brought  back  at  once 
to  the  point  from  which  we  first  started,  viz.  that  scro- 
fula is  a disease  depending  upon  some  unknown  pecu- 
liarity of  constitution,  congenital  or  acquired,  and  ca- 
pable of  being  excited  into  action  by  various  causes,  as 
climate,  mode  of  living,  &c.  However,  lest  I may 
not  have  attached  sufficient  importance  to  the  doc- 
trine of  gastric  disorder  being  the  cause  of  sc.mfula,  I 
feel  pleasure  in  referring  for  the  arguments  in  its  sup- 
port, to  the  writings  of  Mr.  Abernethy,  Dr.  Carmichael, 
and  Mr.  Lloyd,  whose  sentiments  appear  highly  com- 
mendable as  far  as  they  tend  to  teach  sursieons  rather 
to  place  confidence  in  means  calculated  to  improve  the 
health  in  general,  as  the  most  likely  mode  of  benefit- 
ing scrofulous  patients,  than  to  encourage  foo^-h 
dreams  about  new  specifics  tor  the  distemper.  Tima 


SCROFULA. 


297 


far  I can  follov/  these  gentlemen  safely ; but  no  far- 
ther, except  as  a skeptic.  However,  perhaps  none  of 
the  believers  in  the  effect  of  disorder  of  the  digestive 
organs  mean  to  say,  that  such  disorder  is  any  tiling 
more  than  one  of  the  many  exciting  causes  of  scrofula ; 
and  with  this  qualification  their  theory  may  or  may 
not  be  correct.  It  is  the  doctrine  of  A li bert,  and  indeed 
of  nearly  all  writers  ; “ ce  sont  les  vices  de  la  puis- 
sance digestive,  qui  pr^parent  de  loin  les  scrofules. 
Rien  n’infiue  davantage  sur  leur  d^veloppemeni  que  la 
inauvaise  quality  des  aliniens,”  &c. — {JVosol.  J^Tatu- 
relle,  p.  449.)  “ Ajoutez  A.  cet  cause  le  s^jour  dans  les 
habitations  malsaines.”  But  every  ex^anation,  even 
of  exciting  causes,  remains  unsatisfactory,  as  long  as 
we  find  children  living  in  the  same  air,  under  the  same 
roof,  and  feeding  and  sleeping  together,  and  clothed 
also  exactly  alike,  yet  only  one  or  two  of  them  become 
scrofulous,  while  all  the  rest  continue  perfectly  free 
from  the  disease.  Here,  then,  we  are  again  compelled 
to  return  to  predisposition,  constitution,  diathesis,  and 
a congenital  tendency  to  the  complaint,  as  a solution 
of  the  difficulty.  In  short,  then,  respecting  the  etio- 
logy of  scrofula  little  is  known,  except  that  certain 
constitutions  probably  have  a congenital  disposition  to 
the  disease  - that  such  disposition  may  be  increased  or 
diminished  by  the  operation  of  climate,  mode  of  life, 
age,  &c. ; and  that  irritations  of  a thousand  kinds  may 
excite  the  disease  into  action,  when  the  system  is  pie- 
disposed  to  it,  by  inexplicable  causes.  That  climate 
has  great  influence  cannot  be  doubted,  when  it  is  re- 
flected, that  the  inhabitants  of  certain  countries,  in 
which  the  temperature  is  invariably  warm,  never  suffer 
from  scrofula.  It  is  noticed  by  Sir  A.  Cooper,  that  the 
occurrence  of  scrofula  is  much  promoted  by  climates,  in 
which  the  change  from  cold  to  heat,  and  from  heat  to 
moisture,  is  particularly  frequent,  as  is  the  case  in  this 
island.  But  though  cold  and  moist  climates  have  this 
effect,  he  remarks  that  persons  living  in  the  extremes 
of  heat  or  cold  are  not  affected.  The  disease,  he  says, 
is  even  arrested  by  cold  and  heat,  uncombined  with  a 
damp  atmosphere.  On  the  other  hand,  numerous 
children  who  come  from  the  East  or  West  Indies  to 
this  country  fall  a prey  to  scrofula.  He  has  also 
known  some  individuals  from  the  South  Sea  islands 
die  here  of  the  same  disease.— (Eawcet,  vol.  4,  p.  67, 
€8.)  The  fact  of  the  great  influence  of  climate  on  scro- 
fula is  equally  proved  by  the  effect  of  the  weather  and 
seasons,  for  it  is  a common  and  a true  remark,  that  in 
a mild  dry  atmosphere,  and  in  summer  time,  the  health 
of  scrofulous  persons  generally  improves,  and  what- 
ever local  complaints  they  may  have  get  better,  while 
on  the  contrary  their  disorder  in  winter  is  more  diffi- 
cult of  relief,  and  either  continues  stationary,  or  be- 
comes worse  again.  Hence,  as  Sir  A.  Cooper  has 
justly  remarked,  the  exact  value  of  any  proposed  re- 
medy for  scrofula  cannot  be  estimated,  without  refer- 
ence to  the  time  of  year  when  it  is  tried.  There  can 
also  be  no  doubt  that,  with  age,  the  disposition  to  scro- 
fula diminishes;  for  children  much  afflicted  while 
young,  frequently  get  quite  well  when  they  approach 
the  adult  state  ; and  if  a person  remain  perfectly  free 
from  every  mark  of  a scrofulous  conslilution  till  the 
age  of  twenty-five,  he  may  be  considered  as  nearly  out 
of  all  danger  of  the  disea.se. 

According  to  the  calculations  of  Dr.  Alison,  scrofu- 
lous diseases  are  much  more  frequent  in  the  inhabitants 
of  great  towns  than  in  the  agricultural  population  of 
any  climate.  This  seems  to  him  an  unquestionable 
fact,  and  one  that  confirms  the  truth  of  the  connexion 
of  scrofiilawith  debilitating  causes. — (See  Edinb.  Med. 
C/iir.  Trans,  vol.  1,  p.  383.) 

TREATMENT  OP  SCROFULA. 

“ For  the  cure  of  scrofula  (says  Cullen),  we  have  not 
yet  learned  any  practice  that  is  certainly  or  even  gene- 
rally successful.  The  remedy  which  seems  to  be  the 
most  successful,  and  which  our  practitioners  especially 
trust  to,  or  employ,  is  the  use  of  mineral  waters.  But, 
he  adds,  in  very  many  instances  of  the  use  of  these 
waters,  I have  not  been  well  satisfied  that  they  had 
shortened  the  duration  of  the  disease  more  than  had 
often  happened  when  no  such  remedy  had  been  ern 
ployed.  With  regard  to  the  choice  of  the  mineral 
waters  most  fit  for  the  purpose,  I cannot,  with  any 
confidence,  give  an  opinion.  Almost  all  kinds  of  mi- 
neral waters,  whether  chalybeate,  sulphureous,  or  sa- 
line, have  been  employed  for  the  cure  of  scrofula,  and 


seemingly  with  equal  success  and  reputation ; a cir- 
cumstance which  leads  me  to  think,  that  if  they  are 
ever  successful,  it  is  the  elementary  water  that  is  the 
chief  part  of  the  remedy.  Of  late,  sea-water  has  been 
especially  recommended,  and  employed  ; but  after  nu- 
merous trials,  1 cannot  yet  discover  its  superior  effi- 
cacy.”— {First  Lines  of  Physic,  vol.  4.)  On  the  sub- 
ject of  mineral  waters',  Dr.  Thomson  very  properly 
remarks,  that  they  are  now  usuaHy  employed  as  pur- 
gative and  tonic  remedies,  and  not  as  specifics.  In 
emplwying  them  it  is  often  difficult  to  distinguish  be- 
tween the  effects  which  they  in  reality  produce,  and 
those  which  are  to  be  attributed  to  the  slow  operation 
of  time,  the  season  of  the  year,  change  of  situation, 
alteration  in  the  mode  of  life,  or  exercise  in  the  open 
air. — {Lectures  on  Inflammation,  ^c.  p.  195.) 

• In  scrofulous  diseases,  Dr.  Fordyce  had  a high  opi- 
nion of  bark  ; and  he  endeavoured  to  prove,  that  in 
cases  of  tumefied  glands  attended  with  a feeble  habit 
dlid  a weak  circulation,  it  is  a most  efficacious  medi- 
cine, and  acts  as  a resolvent  and  discutient.  He  also 
brings  forward  a case  in  support  of  bark  being  a means 
of  cure  for  ophthalmia  strumosa. — (See  Mod.  Obt.  and 
Inq.  vol.  1,  p.  184.)  Dr.  Fothergill,  in  the  same  work, 
p.  303,  writes  in  favour  of  the  good  effects  of  bark  in. 
similar  cases ; small  doses  of  calomel  being  sometimes 
given  with  it. 

Dr.  Cullen  considered  the  efficacy  of  bark  in  .scrofula 
very  dubious  and  trivial. — {Phrst  Lines,  &rc.  vol.  4.) 

According  to  Mr.  Burns,  bark  has  been  frequently 
found  useful  m the  cure  of  scrofulous  inflammation, 
but  more  often  of  ulceration  than  tumefaction  of  the 
glands.  But,  says  he,  it  does  not  appear  to  possess,  by 
any  means,  that  certain  power  of  curing  scrofulous  af- 
feciions,  which  is  attributed  to  it  by  Dr.  Fothergill  and 
several  other  authors.  He  observes,  that  we  are  not  to 
suppose  it  will  infallibly  cure  .scrofulous  inflammation, 
or  ulceration  of  parts,  which,  even  when  affected  with 
simple  inflammation,  are  very  difficult  of  cure.  If  it 
be  difficult  to  cure  a simple  inflammation  or  ulceration 
of  a tendon,  cartilage,  or  bone,  we  must  not  be  disap- 
pointed if  even  a specific  remedy  for  scrofula  (were 
such  ever  discovered)  should  prove  ineffectual  in  pro- 
curing a speedy  restoration  to  health.  Mr.  Burns  con 
lends  that  bark  is  often  ineffectual,  because  improperly 
admini.stered.  Given  in  small  quantities,  once  or  twice 
a day,  it  may  prove  a stomachic,  and  increase,  like 
other  tonic  bitters,  the  power  of  the  stomach,  or  the 
functions  dependent  on  it : but  in  order  to  obtain  the 
benefits  of  the  specific  action  of  bark,  he  maintains 
that  it  should  be  given  in  In -ge  quantities,  for  several 
weeks,  with  a good  diet,  air,  and  proper  exercise. — ( On 
Inflammation,  vol.  2,  p.  Til.)  Dr.  Thomson  does  not 
believe  that  bark  or  iron  has  any  specific  virtue  in 
curing  scrofula;  but  he  admits  that  either  of  these 
medicines  may  sometimes  prove  useful  in  amending  the 
tone  of  the  digestive  organs,  when  given  after,  or  occa- 
sionally along  with,  a course  of  purgative  mineral 
waters. — {l.,e.ctures,p.  197.)  When  bark  is  prescribed, 
the  sulphate  of  quinine  is  one  of  the  best  fotmulai,  as 
lea.st  likely  to  disagree  with  the  stomach. 

As  far  as  I can  judge,  Mr.  White  has  with  much 
reason  recommended  paying  attention  to  such  circum- 
stances as  may  have  effect  in  preventing  the  disease, 
viz.  air,  cleanliness,  exercise,  and  diet.  He  mentions 
cold-bathing  among  the  preventives  of  struma,  and 
speaks  of  sea-bathing  as  being  the  best.  He  advises 
attention  also  to  be  paid  to  the  manner  of  clothing 
children,  keeping  them  more  covered  in  winter  than 
summer.  He  thought  a great  deal  of  sleep  prejudicial ; 
but  this  seems  only  conjecture. 

In  noticing  the  treatment  of  the  disease,  Mr.  White 
states,  that  “ the  general  idea  of  the  struma  is,  that  it 
is  a disease  of  debility  (a  doctrine  also  inculcated  by 
Sir  A.  Cooper) ; and,  tlierefore,  the  great  object  is  to  in- 
vigorate the  habit  by  every  possible  means  ; the  chief 
of  which  are  tonic  medicines  and  .sea  bathing.  Some 
are  of  opinion,  that  in  the  case  of  young  patients  this 
should  be  continued  during  the  summer  months,  every 
year,  to  the  age  of  fourteen  or  sixteen.  Many  recom- 
mend it  not  only  in  the  summer,  but  throughout  the 
year;  while  others  are  for  administering  alteratives, 
principally  the  alkaline  salts,  with  or  without  antimo- 
nials,  and  the  different  tonics,  durin't  the  winter ; and 
the  sea  water,  and  sea-bathing,  or  cold  bathing,  during 
the  sum'mer,  for  a continuance  of  tw'o  or  three  years 
from  the  commencement  of  the  disease;  with  this 


298 


SCROFULA. 


general  observation,  that  they  will  outgrow  the  com- 
plaint.” Mr.  White  mentions,  as  the  cliief  external 
means,  fomentations  and  poultices  of  sea-water.  With 
respect  to  regimen,  some  recommend  a milk  and  vege- 
table diet ; others  animal  food  and  fermented  liquors. 
Sir  A.  Cooper  in  particular,  who  regards  the  disease  as 
connected  with  congenital  debility,  strongly  recom- 
mends a nutritious  diet  of  animal  food,  in  preference  to 
one  of  vegetables. — {Lancet^  p.  71.) 

Mr.  White  maintains,  that  the  preceding  plans  of 
treatment  are  not  in  general  efficacious,  though  in 
some  instances  they  may  prove  useful.  “ In  early  af- 
fections of  the  lymphatic  glands  (says  this  gentleman), 
and  from  the  want  of  a pure  air  and  proper  exercise, 
where  children  are  delicate  and  irritable,  a change  of 
situation  to  the  seaside,  together  with  bathing,  when 
they  have  acquired  some  strength,  must  be  exceedingly 
proper ; and  in  gross  plethoric  subjects,  who  have 
diseased  lymphatics,  from  improper  feeding,  and  waj)t 
of  necessary  exercise,  a journey  to  the  seacoast  may 
be  very  useful,  particularly  if  the  salt  water  is  drank 
often,  and  in  a sufficient  quantity  to  become  purgative. 
This,  with  the  novelty  of  their  situation,  which  may 
naturally  produce  an  increase  of  exercise,  might  an- 
.«wer  every  expectation  ; but  these  are  the  kind  of  cases 
that  with  a very  little  attention  are  easily  cured.” — 

( White  on  the  Struma,  edit.  3,  p.  104.) 

The  conclusion  to  which  Mr.  White’s  remarks  upon 
this  part  of  the  subject  tend  is,  that  sea-bathing  only 
deserves  praise  as  a preventive,  and  in  the  early  stages 
of  the  disease.  He  particularly  condemns  cold-bathing 
for  poor,  weakly,  debilitated  children,  whose  thin  vi- 
sages, enlarged  bellies,  and  frequent  tickling  cough, 
sufficiently  indicate  diseased  viscera ; such  do  not  re- 
cover their  natural  warmth,  after  cold-bathing,  for 
hours,  and  their  subsequent  headache,  livid  lips,  and 
pale  countenance,  are  sufficient  marks  of  its  impro- 
priety.—(P.  107.) 

Dr.  Cullen  entertained  a very  favourable  opinion  of 
cnld-bathiiig,  since  he  affirms  that  he  had  seen  scrofu- 
lous diseases  more  benefited  by  it  than  any  other  re- 
medy.— ( First  Lines  of  Physic,  vol.  4.) 

“ Cold  bathing,  especially  cold  sea-bathing  (says  Mr. 
Russell)  is  a remedy  universally  employed  in  scrofula, 
and  I believe  with  great  advantage  in  many  cases ; for 
it  not  only  appears  to  improve  the  patient’s  general 
health  and  strength,  but  likewise  to  promote  the  de- 
tumescence of  enlarged  glands,  and  the  resolution  of  in- 
dolent swellings  in  the  joints,  even  after  t.hey  have  at- 
tained a considerable  size,  and  have  existed  fora  great 
length  of  time.  But  in  order  that  cold-bathing  may  be 
practised  with  safety  and  advantage,  the  constitution 
must  have  vigour  to  sustain  the  shock  of  immersion 
without  inconvenience.  If  the  immersion  be  succeeded 
by  a general  glow  over  the  surface  of  the  body,  and 
the  patient  feels  cheerful,  and  has  a keen  appetite,  we 
may  conclude  that  the  cold  bath  agrees  with  him  ; but 
if  he  shivers  on  coming  out  of  the  water,  continues 
chill,  and  becomes  drowsy,  we  may  be  assured  that 
the  practice  of  cold-bathing  does  no  good,  and  had 
better  be  omitted. 

“ In  estimating  thecomparative  merit  of  cold-bathing 
and  warm-bathing  in  the  cure  of  scrofiilous  complaints, 
my  own  experience,  together  with  the  result  of  different 
conversations  on  the  subject  with  some  of  the  most  ju- 
dicious practitioners  of  my  acquaintance,  would  lead 
me  to  bestow  much  more  commendation  on  the  effects 
of  w'arm-bathing.  I should  not  even  be  inclined  to 
circumscribe  the  practice  to  cases  of  emaciation  and 
debility,  since,  from  observation,  I am  fully  satisfied 
with  regard  to  the  beneficial  effects  of  the  w'arm  bath 
to  patients  of  plethoric  constitutions,  who  w'ere  ntuch 
affected  with  swelled  scrofulous  glands.  Several  of 
those  instances  occurred  in  young  wmmen,  about  the 
prime  of  life,  who  were  in  all  respects  healthy  and 
vigorous,  abating  the  swellings  of  the  glands  and  those 
symptoms  of  distress  which  were  connected  with  ful- 
ness of  blood. 

“The  sensation  of  the  warm  bath  is  exceedingly 
grateful  to  most  patients,  and  the  practice  is  universally 
safe.  It  may  be  employed  at  all  seasons  of  the  year, 
and  in  all  weather,  without  danger  or  inconvenience: 
the  risk  of  suffering  from  exposure  to  cold,  imme- 
diately after  immersion  in  the  warm  bath,  having  been 
much  magnified  by  prejudice.  There  is  not  even  any 
good  reason  to  believe  in  the  existence  of  such  a risk. 
The  precautions,  however,  which  are  emiiloyed  to  avert 


it,  are  perfectly  innocent ; and,  provided  they  do  not  im- 
pose any  unnecessary  and  incommoding  restraints  upon 
the  practice,  may  be  encour^ed,  so  far  as  to  relieve  the 
patient’s  mind  trom  uneasiness  and  groundless  appre- 
hensions. 

“ It  requires  many  weeks,  and  sometimes  several 
months,  to  ascertain  the  full  effects  of  warm-bathing 
in  relieving  scrofulous  complaints;  but  as  the  practice 
is  not  attended  with  any  inconveuiente,  nor  followed 
by  any  bad  consequence,  there  can  be  no  reason  to  in- 
termit the  course  till  the  trial  is  completely  satisfactory  ; 
and  I am  convinced  that  the  practice  of  warm-bathing 
in  cases  of  scrofula  will  be  more  universally  adopted 
after  the  knowledge  of  its  beneficial  effects  are  more 
widely  diffused. — (See  Russell's  Treatise  on  Scrofula.) 

Nothing  can  be  more  satisfactory  (says  Professor 
Thomson)  than  the  evidence  which  is  on  record  of  the 
efficacy  of  the  muriate  of  soda,  as  it  exists  in  sea-wa- 
ter. In  reading  this,  one  only  wmnders  how  so  effica- 
cious a remedy  should  ever  have  fallen  into  neglect. — 
(P.  196.)  In  a subsequent  passage,  however,  the  sn.-ne 
gentleman  evinces  only  a limited  confidence  in  this 
means  of  relief.  “Local  sea-bathing,  both  cold  and 
warm,  has  often  appeared  to  be  of  use  in  procuring  the 
resolution  of  scrofulous  sw'ellings.  The  temperature 
of  the  bath  must  always  be  varied  according  to  cir- 
cumstances, according  to  the  season  of  the  year,  the 
strength  and  habits  of  the  patient,  and  the  particular 
effect  which  the  bath  seems  to  produce.  It  is  at  all 
times  difficult  to  distinguish  between  the  effects  imme- 
diately arising  from  the  application  of  salt  water  to  the 
body,  and  those  which  arise  from  the  increased  warmth 
of  temperature  in  the  bathing  seasons  of  the  year  ; from 
the  exercise  which  patients  going  to  sea-bathing  gene- 
rally take  in  the  open  air;  from  the  change  of  situation 
and  amusements ; and,  among  the  pcwrer  classes,  from 
the  more  nourishing  diet  and  exemption  from  labour  in 
which  they  are  usually  permitted  to  indulge  during  their 
residing  at  sea-bathing  quarters.  It  is  not  improbable, 
that  those  living  on  the  seacoast,  w’ho  become  affected 
with  scrofula,  would,  for  similar  reasons,  derive  equal 
benefit  by  going  from  the  seacoast  to  reside  for  a time  in 
the  inie'rior  of  the  country.” — (See  Thomson's  Lec- 
tures, &-c.  p.  203, 204.)  A still  later  writer  declares  his 
belief,  that  cold  sea-bathing  has  no  specific  power  over 
the  disease. — (Lloyd  on  Scrofula,  p.  43.)  Yet  the  plain 
surgeon  in  search  of  practical  truths  will  not  care 
whether  any  plan  has  a specific  power  or  not  over  a 
complaint,  if  that  disorder  is  sometimes  relieved  hj'  it. 
And  that  this  is  the  fact  is  admitted  by  Mr.  Lloyd, 
when  he  says,  “ cold  sea-bathing,  however,  is  certainly 
useful,  when  judiciously  applied,”  &;c.  &c. — (P.  44.) 

With  regard  to  electricity,  Mr.  White  thinks  it  useful, 
when  from  length  of  time  the  enlarged  glands  have 
acquired  a degree  of  hardness  and  insensibility. 

Mr.  White,  after  enjoining  attention  to  air,  exercise, 
and  diet,  as  promotive  of  a recovery  as  well  as  a pre- 
ventive of  the  disease,  proceeds  to  explain  his  own 
practice.  The  first  external  symptoms,  such  as  swell- 
ings of  the  lips,  side  of  the  face,  and  of  glands  under 
the  chin  and  rouna  the  neck ; also  other  symptoms 
usually  considered  as  strumous,  viz.  roughness  of  the 
skin,  eruptions  on  the  back  of  the  hand  and  different 
parts  of  the  body,  redness  and  swelling  of  the  eyelids 
and  ey  es,  are  accompanied,  according  to  Mr.  White’s 
conceptions,  with  an  inflammatory  diathesis,  though 
seldom  such  as  to  require  bleeding.  Calontel  is  the 
medicine  which  this  gentleman  recommends  for  the 
removal  of  the  foregoing  complaints.  It  is  not  to  be 
given  in  such  quantities  as  to  render  it  a powerful 
evacuant,  either  by  the  intestines  or  any  other  way; 
but  in  small  doses  at  bedtime.  Thus,  says  Mr.  White, 
“ it  remains  longer  in  the  intestinal  canal,  a greater 
quantity  is  taken  into  the  habit,  and  the  patient  is  less 
susceptible  of  cold  than  when  taken  in  the  daytime. 
The  first  and  perhaps  the  second  dose  may  prove  pur- 
gative, which  is  in  general  a salutary  effect ; but  af- 
terward, the  same  quantity  will  seldom  do  more  than 
is  sufficient  to  keep  the  body  open ; and  should  it  fail 
of  answering  that  purpose,  I have  usually  recom- 
mended some  gentle  purgative  every  third  or  fourth 
morning,  according  to  circumstances.  If  there  should 
be  a prevailing  acidity,  a few  grains  of  the  sal  sodas, 
magnesia,  or  some,  testaceous  powder,  may  be  added 
to  the  medicine.  By  this  simple  method  (continues 
Mr.  White)  most  of  the  symptoms  before  mentioned 
will,  in  a short  lime,  disappear ; but  if  the  tumours 


SCROFULA. 


299 


87)ou1(1  continue  hard,  and  retain  their  figure  without 
dividing  into  smaller  ones,  we  may  derive  some  benefit 
from  external  applications,  particularly  the  steam  of 
warm  water.  I have  used  a variety  of  medicinal 
herbs  with  success;  bat  am  inclined  to  believe  that  the 
advantage  was  particularly  derived  from  warm  water, 
&.C.  At  other  times,  I have  stimulated  the  part  affected 
with  electricity,  insulating  the  patient,  and  drawing 
sparks  from  tlie  tumour,  until  a slight  degree  of  iiifiam- 
ination  was  excited.  After  the  application  of  the 
steam,  or  the  use  of  the  electrical  machine,  I liave 
sometimes  rubbed  a little  of  the  unguentum  mercuriale 
into  the  tumour  and  neighbouring  parts,  or  applied  the 
emplastrum  saponaceura  or  mercuriale  cum  ammo- 
riiaco  over  the  swelling,  or  a liniment  with  camphor,  ol. 
olivarum,  and  sp.  terebinth.”  Mr.  White  adds,  that  in 
such  cases,  if  the  tumours  should  suppurate  and  burst, 
the  parts  will,  in  most  instances,  heal  without  much 
trouble.  For  eruptions  on  the  head,  he  recommends 
applying  the  ung.  saturn.  album  camphoratum,  or  the 
cerat.  alb.  cum  hydrarg.  prajcip.  alb.  For  the  rough- 
ness of  the  skin,  which  is  generally  followed  by  erup- 
tions, he  also  advises  the  liquor  plumbi  acetatis  dilutus, 
aqua  calcis,  solutions  of  sal  tartar,  or  of  the  hydrarg. 
inur.,  as  outward  applications.  “This  last  fsays  Mr. 
White)  will  seldom  fail  to  check  the  progress  of  the 
complaint,  and,  dry  the  sores  ; and,  in  the  quantity  of 
ten  or  twelve  grains  to  a quart  of  warm  water,  the  use 
of  it  will  not  be  productive  of  any  pain.  If  the  erup- 
tion should  ulcerate,  and  require  any  unctuous  applica- 
tion to  prevent  the  adhesion  of  the  linen,  the  ointment 
feefore  mentioned  may  be  applied;  the  best  remedy 
will  be  warm-bathing,  and,  when  practicable,  the  sea- 
water claims  a preference.” — (P.  114.)  The  author 
next  mentions  his  having  occasionally  recommended 
the  vinum  antimoniale,  tartarum  emelicum,  decoctum 
lusitanicum,  decoctum  lignorum,  or  sarsaparillre  ; and 
that  he  sometimes  found  advantage  derived  from  arti- 
ficial drains.  We  need  not  detail  this  gentleman’s 
mode  of  treating  affections  of  the  eyelids,  as  notice  is 
taken  of  scrofulous  diseases  of  the  eye  and  eyelids  in 
the  articles  Ophthalmy  and  Psorophthalmy. 

For  the  cure  of  indurations  in  the  breast,  remaining 
after  mammary  abscesses,  Mr.  White  speaks  very 
highly  of  the  effects  of  the  steam  of  w'arm  water  ; and 
cautions  us  against  indiscriminately  employing  calomel, 
which  will  often  affect  the  mother  little,  but  the  child 
violently.  Mr.  White  mentions  his  employing  a small 
tin  machine,  large  enough  to  hold  a pitit  and  a half  or 
two  pints  of  boiling  water.  From  the  top  proceeded  a 
narrow  tube,  ten  or  twelve  inches  long,  through  w’hich 
the  steam  passed.  Near  its  end,  which  was  moveable 
and  curved,  was  a joint,  for  the  greater  convenience  of 
directing  the  steam  to  the  diseased  parts.  The  water 
was  easily  kept  boiling  by  means  of  a lamp  under  the 
machine.  Mr.  White  says  that  the  steam  should  be 
employed  tw'ice  or  thrice  a day,  and  a piece  of  flannel 
or  skin  afterward  applied.  The  body  should  also  be 
kept  open.  In  obstinate  neglected  cases,  mercurial 
preparations,  according  to  Mr.  White,  must  likewise 
be  given,  and  if  they  affect  the  child  much,  suckling 
should  be  suspended. — (P.  117,  118.)  For  chronic 
swellings  of  the  breast,  suspected  to  be  .scrofulous,  I 
would  here  particularly  recommend  a trial  of  iodine, 
which  should  be  used  both  externally  and  internally. 

— (See  Iodine.) 

When  the  glands  of  the  neck  or  other  parts  of  the 
body  tend  to  a state  of  suppuration,  it  is  very  slowly, 
the  skin  appearing  uniformly  thin  and  of  a deep-red 
colour,  and  the  tumour  seeming  flaccid.  In  such  cases, 
Mr.  White  recommends  the  use  of  the  lancet  or  caustic; 
for  if  no  artificial  opening  is  made,  it  will  be  a long 
time  before  the  skin  gives  way  ; and  when  it  does,  the 
ajierture  will  not  only  he  very  small,  but  often  unfa- 
vourable in  its  situation.  Mr.  White  adds,  that  the 
contents  will  often  be  more  like  mucus  than  pus,  or 
like  a mixture  of  both  ; and  the  discharge  will  continue 
for  a great  length  of  time  if  no  remedy  is  applied.  He 
found  a solution  of  gum  myrrhai  in  aqua  calcis,  used 
as  a lotion,  and  the  ceratum  sa[)onaceum,  or  some  si- 
milar outward  application,  the  best  method  of  treating 
this  symptom. 

We  need  not  describe  Mr.  White’s  practice  in  the 
treiflmentof  scrofulous  Joints,  as  the  subject  is  fully 
considered  in  the  article  .Joints.  It  appears,  however, 
that  he  confirms  the  efficacy  of  stimulating  aitplica- 
tion.s,  aii4  pressure  with  bandages,  when  the  fingers  and 


toes  are  affected  with  strumous  disease.— (P.  143.) 
What  may  be  done  in  these  cases  by  the  external  and 
internal  use  of  idione,  remains  to  be  proved  by  farther 
experience ; but  it  is  certainly  a medicine,  the  power 
of  which  in  scrofula  merits  the  fullest  investigation. 

Whoever  compares  the  practice  of  Mr.  White  in 
administering  calomel,,  occasional  purgatives,  the  de- 
coctum lusitanicum,  sarsajtarilla,  &c.,  with  the  blue 
pill,  sarsaparilla,  and  laxative  treatment  of  the  present 
day,  will  perceive  no  very  material  diflerence  between 
them,  especially  when  the  stress  which  Mr.  White  laid 
upon  attention  to  diet,  clothing,  &c.,  is  taken  into  the 
account.  Mr.  Lloyd,  who  has  detailed  Mr.  Aberne- 
thy’s  practice  in  scrofula,  lays  it  down  as  an  axiom, 
that  “ the  disease  is  only  to  be  cured  by  avoiding  all 
sources  of  irritation,  and  restoring  the  natural  and 
healthy  functions  of  the  digestive  organs.”— (P.  48.) 
By  sources  of  irritation,  Mr.  Lloyd  means  exciting 
causes : the  advice  is  therefore  excellent,  as  far  as  it 
can  be  followed,  or  such  causes  are  decidedly  known. 
The  restoration  of  the  functions  of  the  digestive  or- 
gans is  also  a thing  worth  aiming  at;  and  the  only 
difference  in  my  views  from  those  of  Mr.  Lloyd  is,  that 
as  I look  upon  the  disorder  of  the  digestive  organs  to  be 
in  general  only  a complication  or  effect  of  the  scrofu- 
lous disease,  ulcer,  abscess,  diseased  joint,  &c.,  and  not 
the  exciting  cause,  the  treatment,  when  beneficial,  be- 
comes so  only  on  the  principle  of  improving  the  ge- 
neral health,  by  the  removal  or  diminution  of  one  of 
the  most  hurtful  consequences  of  the  original  disease. 
It  is  hardly  necessary  to  inform  the  profession  that  the 
treatment  described  by  Mr.  Lloyd,  in  addition  to  the 
usual  advice  about  diet,  clothing,  the  avoidance  of 
damp  and  cold,  and  the  utility  of  good  air,  exercise, 
<fcc.,  consists  in  giving  the  patient  five  grains  of  the  pil. 
hydrarg.  every  night,  and  half  a pint  of  decoct,  sarsap. 
c.  twice  a day.  And  if,  at  a certain  hour  of  the  day, 
there  has  been  no  motion,  recourse  is  had  to  opening 
medicines.  This  plan  is  pursued  till  the  bowels  become 
regular;  and  then,  with  a view  of  preventing  a relapse 
of  the  bowels  into  their  former  state,  Mr.  Lloyd  con- 
tinues the  exhibition  of  alterative  doses  of  mercury 
for  an  indefinite  time,  the  preference  being  given  to  the 
compound  calomel  pill,  in  doses  of  five  grains  every 
night.  In  children,  the  practice  is  exactly  like  that  of 
Mr.  White,  viz.  small  doses  of  calomel  with  purgatives. 
When  acidity  prevails  in  the  stomach,  small  doses  of 
soda  are  commended;  and  when  the  stomach  is  weak, 
with  loss  of  appetite,  cinchona,  steel,  and  mineral 
acids.  A full  diet,  with  porter  and  wine,  is  disapproved 
of,  and,  as  already  stated,  not  much  confidence  is  placed 
in  sea-bathing. — {JJoyd  on  Scroftila,  p.  38.) 

Crawford,  Pinel,  and  others  tried  the  innrialed  ba- 
rytes in  scrofulous  cases. — {Med.  Communications,  vol. 

2.  JSTosogr.  Philosophique,  vol.  2,  p.  23d.)  It  has  the 
recommendation  of  the  celebrated  Hufeland.  Mr. 
Burns  says,  that  the  muriate  of  barytes  has  no  effect  on 
diseased  glands ; but  that  it  is  occasionally  serviceable 
in  scrofulous  ulceration ; though  he  adds  that  it  de- 
serves littie  dependence. — {Diss.  on  Infiam.  vol.  2,  p. 
372.)  This  gentleman  recommends  the  following  for- 
mula : 1}-..  Terrai  ponder,  salit.  chryst.  gr.  x.  Aq.  font, 
aq.  cassisB,  utriitsque  ^i’j-  Syrup,  aurent.  ^’j.  Half 
an  ounce  may  be  given  at  first,  twice  or  three  times  a 
day,  and  gradually  increased  to  such  quantity  as  the 
stomach  can  bear  without  sickness.  At  present,  few 
practitioners  have  any  faith  in  the  anti-scrofulous  vir- 
tues of  the  muriate  of  barytes;  and,  as  Dr.  Thomson 
remarks,  it  has  had  a much  shorter-lived  reputation 
than  sea-water  or  its  successor  the  muriate  of  lime. — 
(See  Lectures  on  Inflammation,  p.  196.) 

Fourcroy  proposed  the  muriate  of  lime;  but  its  effi- 
cacy is  very  doubtful  and  inconsiderabie.  “ Professor 
Thomson  (says  Mr.  Russell)  has  favoured  me  with  the 
following  observations  on  the  effects  of  muriate  of  lime. 
He  employed  muriate  of  lime  in  various  cases  of  scro- 
fula, without  having  derived  benefit  from  it  in  a single 
instance.  Some  patiehts,  indeed,  he  admits,  got  well 
while  under  a course  of  muriate  of  lime;  but  then  he 
had  no  reason  to  ascribe  the  cure  to  the  effect  of  the 
medicine.  In  other  cases  on  the  contrary,  the  muriate 
of  lime  produced  severe  sickness  and  suppression  at 
the  stomach,  and  the  patients  got  daily  worse  till  the 
muriate  of  lime  was  intermitted  and  other  medicines 
employed.  The  relief  experienced  from  the  intermis- 
sion of  the  muriate  of  lime,  left  no  douht  with  regard 
to  the  injurious  eflects  which  the  use  of  it  had  pro- 


300 


SCROFULA, 


duced ; and,  from  extensive  experience  and  accurate 
observation  on  the  subject,  Professor  Thomson  is  satis- 
fied that  muriate  of  lime  is  attended  with  prejudicial 
effects  in  many  ceises  of  scrofula.” — (See  Russeira 
Treatise  on  Scrofula.)  Since  the  publication  of  the 
earlier  editions  of  this  Dictionary,  I have  seen  the  mu- 
riate of  lime  given  in  several, cases  of  scrofula;  but 
without  any  beneficial  effect  on  the  disease.  How  long 
♦he  muriate  of  lime  will  be  permitted  to  enjoy  its  pre- 
sent fame.  Dr.  Thomson  will  not  venture  to  say  ; but 
frotn  what  he  has  seen  of  its  use,  he  imagines  its  repu- 
tation will  only  last  till  some  other  new  remedy  is  pro- 
posed by  those  who  are  still  sanguine  in  their  hopes  of 
discovering  a specific  for  scrofula. — (/^ectures,  (Src.  p. 
196.)  Iron,  given  either  alone  or  joined  with  the  fixed 
■or  volatile  alkali,  also  deserves  very  little  confidence. 
Burnt  sponge,  millepedes,  and  sulphate  of  potassa  have 
all  been  extensively  tried:  the  first  of  these  contains, 
as  is  now  well  known,  a proportion  of  iodine,  which  is 
unquestionably  a medicine  of  high  value  in  the  treat- 
ment of  scrofula. — (See  Iodine.) 

The  Mareschal  de  Rougeres  employed  a remedy, 
composed  of  iron  filings,  muriate  of  ammonia,  sub- 
carbonate of  potassa,  &c. — [Journ.  de  MM.  tom  40, 
p.  219.) 

Several  narcotics  have  been  tried,  such  as  opium, 
hj  oscyamus,  thesolanum  dulcamara,  &c. ; but,  though 
their  virtues  against  scrofula  have  been  sometimes 
cried  up  very  highly,  the  moderns  have  lost  all  faith  in 
them.  The  attention  of  the  public  to  the  effects  of 
cicuta,  in  cases  of  cancer  and  scrofula,  was  first  par- 
ticularly excited  by  the  accounts  of  its  virtues  pub- 
iished  by  Baron  Stork. 

Fothergill  also  praises  cicuta,  and  perhaps,  next  to 
iodine,  and  soda  joined  with  rhubarb  and  calumba,  it 
is  as  good  an  internal  medicine  as  can  be  tried;  but  it 
is  far  from  being  generally  efficacious.  It  is  highly  de- 
serving of  recommendation  for  irritable  scrofulous 
ulcers.  There  is  now  not  the  least  doubt,  however, 
that  the  statements  of  Baron  Stork  were  greatly  ex- 
aggerated. He  considered  cicuta  indicated,  whenever 
obstructions  and  tumours  existed ; and  under  this 
treatment,  he  says  that  he  found  the  swellings  melt 
away  like  ice.  What  i^  extraordinary,  every  sort  of 
tumour  yielded  to  cicuta.  But  (as  Dr.  Thomson  judi- 
ciously remarks)  universal  success  is  always  one  of 
the  most  suspicious  circumstances  w hich  can  be  men- 
tioned in  the  history  of  the  effects  produced  by  any 
new  remedy. — {Lectures,  Src.  p.  199.)  Dr.  Cullen  fre- 
quently employed  hemlock,  and  sometimes  found  it 
useful  in  discussing  obstinate  swellings  ; but,  he  says, 
it  also  frequently  disappointed  him,  and  he  never  saw 
it  dispose  scrofulous  ulcers  to  heal.  ^ 

With  regard  to  mercury,  we  have  already  rioVtced 
that  calomel  w^as  much  employed  by  Mr.  White. 
■Some  have  exhibited  the  sublimate,  others  the  acetate, 
of  mercury.  All  these  preparations  have  been  at  limes 
conjoined  with  cicuta,  antimony,  &c.  Calomel  is, 
perhaps,  the  best  mercurial  preparation  in  scrofulous 
■cases;  but  mercury,  given  internally  with  any  view  of 
exciting  salivation,  is  justly  deemed  hurtful  by  all  the 
best  practitioners.  As  an  alterative,  and  an  occasional 
purgative,  it  is  undoubtedly  a good  medicine  for 
strumous  patients.  Mercury  was  much  disa|)proved 
of  by  the  celebrated  Cullen  as  a medicine  for  scrofula. 
As  a distinguished  Professor  observes,  “From  the 
great  apparent  similarity  of  the  symptoms,  progress, 
and  seats  of  scrofula  to  those  of  syphilis,  and  from 
the  well  known  effects  of  mercnry  in  curing  syphilis, 
it  need  not  seem  strange,  that  medical  men  should 
have  been  a little  obstinate  in  their  attempts  to  obtain 
benefit  from  the  use  of  mercury  in  scrofula.  These 
expectations  are  in  general  abandoned,  and  mercury  is 
now  given  for  the  cure  of  scrofula  as  a purgative  only. 
A long-continued  or  improperly-administered  course 
of  this  medicine  has  often  been  known  to  aggravate  all 
the  symptoms  of  scrofula  ; and,  in  many  instances,  to 
excite  these  symptoms  in  persons  in  whom  they  did 
not  previously  exist.” — fSee  Thomson's  Lectures  on 
Inflammation,  p.l94,  195.) 

Mr.  Burns  thinks  the  nitrons  acid  has  some  effect  in 
promoting  the  suppuration  of  scrofulous  glands  and 
tumours,  and  disposing  ulcers  to  heal.  He  says,  two 
or  three  drachms  may  be  given  every  day  for  a fort- 
niaht:  but  if  in  this  time  it  should  do  no  good,  its  em- 
ployment ought  to  be  discontinued.  The  mineral 
acids,  diluted  with  water  (says  Professor  Thomson), 


are  often  used  with  views  similar  to  those  which  guide 
us  in  the  employment  of  tonic  remedies.  Their  me- 
dicinal powers  appear  to  be  nearly  the  same;  but  the 
nitric  acid  has  of  late  been  preferred,  particularly  in 
the  scrofulous  affections  which  are  sonretimes  induced 
by  the  action  of  mercury. — {Lectures,  S,  c.  p.  197.) 

The  pills  containing  carbonate  of  soda  (see  Pilulee), 
and  the  different  soda  waters  sold  at  the  shops,  have 
repute  for  their  good  effects  on  scrofuloi^  constitutions 
and  diseases.  A spirituous  infusion  oT  getitian,  into 
six  ounces  of  which  are  put  thirty-six  grains  of  the 
carbonate  of  soda,  or  the  same  quantity  of  the  car- 
bonate of  ammonia,  is  a medicine  highly  spoken  of  by 
Richerand  for  scrofulous  cases. — {M'osogr.  Chir.  t.  1, 
p.  184,  ed.  4.) 

Potassa,  in  large  doses,  with  mertyirial  frictions,  is 
the  practice  lately  extolled  by  Mr.  Farr ; but  it  appears 
to  me  that  mercury  and  potassa  had  been  repeatedly 
tried,  long  before  this  author  delivered  his  sentiments 
to  the  public ; and  that  such  practice  cannot  be  justly 
called  a method  for  the  eradication  of  this  disease. — 
(See  Farr  on  Scrofula,  8vo.  Lond.  1820.) 

According  to  Mr.  Burns,  eight  or  ten  drops  of  h^dro 
sulphuret  of  ammonia,  given  thrice  a day,  are  useful 
in  irritable  strumous  ulcers.  The  breathing  of  oxy- 
gen gas  has  been  proposed ; but  of  this  plan  I know 
nothing  from  experience ; and  as  it  now  makes  less 
noise  in  the  world  than  formerly,  I conclude  that  either 
its  usefulness  has  been  exaggerated,  or  the  difficulty 
of  the  practice  is  too  great  to  permit  its  extensive 
adoption. 

The  sentiments  of  Dr.  Cullen  are  decidedly  against 
antimony.  As  a modern  writer  observes,  no  great  de- 
pendence seems  ever  to  have  been  placed  in  the  use  of 
diaphoretic  medicines  for  the  cure  of  scrofula.  The 
different  preparations  of  antimony,  indeed,  have  been 
occasionally  administered;  but  chiefly  in  cutaneous 
affections,  supposed  to  be  of  a scrofulous  nature. 
Guaiacum,  sarsaparilla,  sassafras,  and  mezereon, 
singly,  and  in  combination,  have  all  been  supposed  to 
be  useful  in  the  cure  of  scrofula  ; but  they  are  now 
seldom  given  with  this  view,  except  in  cases  of  scro- 
fula combined  with  syphilis,  or  excited  by  the  too  free 
and  injurious  use  of  mercury. — {Thomson's  Lectures, 
Sre.p.m.) 

With  respect  to  Alibert’s  practice  among  the  vege- 
table bitters,  he  prefers  the  hop,  burdock,  gentian,  and 
bark.  He  seems  to  have  no  cotifidence  in  specifics, 
like  hemlock,  belladonna,  aconiturn,  &c.  Neither  does 
he  express  himself  favourably  of  alkaline  medicines, 
or  the  muriates  of  ammonia  and  barytes.  However, 
he  praises  the  good  effects  of  steel  medicines  on  en- 
larged glands.  He  affirms  that  he  has  seen  most  good 
derived  from  external  means;  aromatic  fumigations  in 
an  apparatus  prepared  by  the  chemist  Darcet.  What 
he  calls  scrofulous  eruptions,  he  covers  with  a strong 
solution  of  the  nitrate  of  silver.  Swelled  glands  he 
rubs  with  the  antimonial  ointment.  He  commends 
also  change  of  air,  and  the  avoidance  of  low,  damp 
places;,  and  speaks  favourably  of  sea-bathing,  sea- 
voyages,  sulphureous  mineral  waters,  and  particularly 
of  the  good  effects  derived  from  the  solar  warmth. — 
(See  JSTosol.  JtTat.  p.  449.) 

Sir  A.  Cooper,  in  his  account  of  the  treatment  of 
scrofula,  dwells  more  upon  the  good  effects  of  air,  e.x- 
ercise,  and  nourishment,  than  ujton  the  virtues  of 
physic.  He  asserts  that  there  is  no  specific  for  the  dis- 
ease. Medicines,  occasionally  given  for  the  improve- 
ment of  the  digestive  organs,  and  regulation  of  the 
secretions,  he  admits,  are  useful ; but  attention  to  air, 
exercise,  and  diet  he  considers  far  more  important. 
Sometimes  he  prescribes,  once  a week,  or  every  ten 
days,  two  grains  of  calomel  and  eight  of  rhubarb,  in 
order  to  restore  the  visceral  secretions.  A good  tonic 
medicine,  for  a short  time,  he  observes,  is  two  grains 
of  rhubarb,  and  from  three  to  five  of  the  carbonate  of 
iron.  Another,  he  says,  is  two  of  rhubarb,  six  of  dried 
subcarbonate  of  soda,  and  ten  of  calutnba,  taken  mixed 
with  sugar.  He  recommends  also  a few  grains  of  hy- 
drargyrns  cum  creta,  to  be  taken  in  the  infusion  of 
chamomile  flowers  at  bedtime;  or  the  oxymurias  hy- 
diargyri,  in  the  proportion  of  a grain  to  two  ounces  of 
tincture  of  bark,  of  which  a tea-spoonful  may  be  taken 
twice  a day  in  a glass  of  chamomile  infusion;  or, 
when  costivenoss  prevails,  the  tincture  of  rhubarb  may 
be  substituted  for  that  of  bark.  The  liquor  potassa'  is 
also  enumerated.  But  the  medicines  he  prefers  are 


SCROFULA. 


301 


iteel,  witli  rhubarb  and  calomel,  or  the  subcarbonate 
of  soda,  with  rhubarb  and  calumba. — {Lancet,  vol.  4, 

As  tonics  of  the  highest  merit,  the  sulphate  of  qui- 
nine, and  the  preparations  of  iodine,  should  also  be 
reinembeied. 

Tite  local  treatment  preferred  by  Mr.  White  has 
been  already  described.  I have  only  a few  words  to 
add  concerning  this  part  of  the  subject.  Dr.  Cullen 
slates,  that,  in  his  practice,  he  had  very  little  success  in 
discussing  incipient  scrofulous  tumours  by  topical  ap- 
plications; and  that  a solution  of  the  saccharum 
satuini,  though  sometimes  useful,  more  frequently 
failed.  Dr.  Cullen  found  the  aqua  ammonite  acet.  not 
more  successful.  “ Fomentations  of  every  kind  (says 
he)  have  been  frequently  found  to  do  harm ; and  poul- 
tices seem  only  to  hurry  on  a suppuration.  I am 
doubtful,  if  this  last  be  ever  practised  with  advantage; 
lor  scrofulous  tumours  sometimes  spontaneously  dis- 
appear, but  never  after  any  degree  of  inflammation 
lias  come  upon  them  ; and,  therefore,  poultices,  which 
commonly  induce  inflammation,  prevent  that  discus- 
sion of  tumours  which  might  otherwise  have  hap- 
pened.” Even  when  scrofulous  tumours  have  ad- 
vanced towards  suppuration,  Dr.  Cullen  thought,  that 
hastening  the  spontaneous  opening,  or  making  one  with 
a lancet,  was  hurtful. 

With  respect  to  ulcers.  Dr.  Cullen  remarks,  that 
escharotic  preparations  of  either  mercury  or  copper, 
have  been  sometimes  useful  in  bringing  on  a proper 
suppuration,  and  thereby  disposing  the  ulcers  to  heal ; 
but  they  have  seldom  succeeded,  and,  more  commonly, 
they  have  caused  the  ulcer  to  spread  more.  The 
escharotic  from  which  Cullen  saw  most  benefit  result, 
was  burnt  alum  mixed  with  some  mild  ointment. 
But  this  celebrated  writer  gives  the  preference  to  keep- 
ing the  sores  continually  covered  with  linen  wet  with 
cold  water  in  the  daytime,  and  some  ointment  or 
plaster  at  night.  He  usually  found  sea-water  loo  irri- 
tating, and  no  mineral  water  better  than  common 
water. — (First  Lines  of  tlie  Pract.  of  Physic,  vol.  4.) 

Formerly,  the  extirpation  of  scrofulous  tumours  was 
advised ; but  this  method  is  now  considered  as  being, 
for  the  most  part,  injudicious  and  unnecessary,  with 
the  exception  of  diseased  joints,  and  a few  other  parts, 
vvhich  frequently  require  being  amputated,  for  the  sake 
of  saving  the  patient’s  life.  Certainly  no  particular 
danger  (generally  speaking)  would  attend  cutting  out 
scrofulous  glands  and  tumours:  the  objections  to  the 
plan  are  founded  on  the  pain  of  the  operation;  on  the 
number  of  such  glands  frequently  diseased  ; on  their 
often  subsiding,  either  spontaneously  or  by  surgical 
treatment ; on  the  operation  doing  no  good  to  the  gene- 
ral affection  of  the  system,  &c.  When,  however,  a 
scrofulous  testicle,  breast,  or  joint,  seriously  impairs 
the  health,  and  endangers  life,  the  very  existence  of  the 
patient  demands  the  immediate  removal  of  the  dis- 
eased part.  Wiseman  relates,  that  he  was  in  the  habit 
of  cutting  out  scrofulous  glands  and  tumours  with 
great  success;  but,  for  reasons  already  alleged,  most 
of  the  moderns  think  such  operations  in  general  un- 
ad  vincible. 

Caustics  have  been  employed  for  the  same  purpose 
instead  of  the  knife;  but  as  they  effect  the  object  in 
view  less  certainly,  more  painfully  and  tediously,  and 
cause  extensive  ulcers,  they  are  disused  by  all  the  best 
surgeons  of  the  present  day. 

Some  autliors  have  advised  making  issues,  and  keep- 
ing them  open,  in  order  to  prevent  any  ill  effects  from 
tlie  healing  of  scrofulous  ulcers.  Issues  are  certainly 
quite  unnecessary  for  any  purpose  of  this  kind ; but 
they  are  eminently  useful  as  a part  of  the  local  treat- 
ment of  scrofulous  joints  and  abscesses,  as  we  have 
more  particularly  explained  in  the  articles  Joints, 
Lambar  Abscess,  and  P’ertebra. 

Mr.  Burns  notices,  that  issues  have  hitherto  been 
chiefly  used  in  diseases  of  the  bones  and  joints;  but 
lie  adds,  that  it  is  reasonable  to  suppose,  that  they 
ought  likewise  to  be  useful  in  the  cure  of  enlargements 
of  the  glands,  and  other  scrofulous  tumours,  if  inserted 
in  the  imnn-di  i'e  vicinity  of  the  part.  The  only  ob- 
j*-ction  to  their  use  is  the  scar  which  they  leave,  and 
whirfi,  in  certain  situations,  one  would  particularly 
wish  to  avoid.  When  the  tumour  is  thickly  covered 
with  the  integuments,  the  issue  m.ay  be  made  directly 
over  it,  and  kept  open  wiili  the  savine  ointment.  In 
other  cases,  a small  pea  issue  or  seton,  may  be  in- 


serted by  the  side  of  tlie  tumour.  This  method  would 
be  objectionable  for  scrofulous  glands  in  the  neck,  in 
consequence  of  the  scar;  but  it  might  be  employed 
when  the  mamma  is  diseased. — (Dissertations  on  In- 
flammation, vcl.  2.)  The  late  Mr.  Crowther  used  to 
apply  blisters  to  scrofulous  swellings,  and  maintain  a 
di.scharge  from  the  part.  And  a more  modern  practice 
is  that  of  producing  irritation  of  the  integuments,  co- 
vering tumours  and  abscesses,  by  means  of  the  tartar 
emetic  ointment. — (Alibert,  J^osol.  JTaturelle,  p.  449; 
Ooodlad  on  Diseases  of  the  Absorbents,  p.  1G2,  <S-c.) 
The  good  effects  of  iodine  upon  scrofulous  tumours, 
both  as  an  internal  medicine  and  local  application, 
seem  now  to  be  exciting  considerable  attention.  Cer- 
tain indolent  swellings  of  the  testicle  and  breast,  in 
particular,  yield  to  this  powerful  medicine. — (See 
Iodine.)  The  profession,  however,  are  still  in  want 
of  some  candid  and  accurate  reports  upon  tlie  subject, 
which  is  at  present  obscured  by  tlie  exaggerations 
always  attending  the  first  introduction  of  -a  medicine, 
supjiosed  to  have  power  over  any  disease  that  has  been 
found  so  little  under  the  control  of  physic  as  scrofula, 
I beg,  at  the  same  time,  the  attention  of  every  surgeon 
to  I he  strong  recommendations  with  which  iodine  has 
been  brought  into  notice,  and  to  its  great  medicinal 
powers,  as  already  verified  in  bronchocele. — (See 
Bronchocele  and  Iodine.) 

Preparations  of  lead;  cloths  dipped  in  cold  water, 
sea-water,  or  weak  vegetable  acids;  ether;  sea  salt 
mixed  with  bile;  the  linimentum  camphorte;  a mix- 
ture of  ether  and  the  linimentum  opiatum ; and  hem- 
lock poultices;  form  a long  list  of  applications,  which 
have  been  employed  for  scrofulous  tumours. 

According  to  Mr.  Burns,  moderate  pressure,  by 
means  of  adhesive  plaster,  conjoined  with  the  applica- 
tion of  cold  water,  is  one  of  the  best  plans  of  treating 
mild  scrofulous  ulcers,  when  their  situation  admits  of 
it.  In  other  cases,  he  recommends  applying  a powder, 
five  parts  of  which  consists  of  cerussa  acetala,  and  the 
sixth  of  burnt  alum.  A piece  of  dry  lint  is  next  to  be 
applied,  and  a compress,  with  such  a pressure  as  can 
be  used.  Benefit  occasionally  results  fiom  dipping  the 
compress  in  cold  water. 

The  ung.  zinci  is  a good  common  dressing,  when  it 
is  wished  not  to  interfere  much  with  the  progress  of 
the  ulcer.  The  urig.  liydrarg.  nitrat.  rub.  and  the  ung, 
hydrarg.  nitrat.  are  the  best  stimulating  ointments. 
Poultices  of  bread  and  sea-water  ; solutions  of  alum, 
sulphate  of  copper,  and  the  hydrarg.  mur. ; solutions 
of  the  nitrates  of  copper,  bismuth,  and  silver;  the  re- 
cent leaves  of  the  wood-sorrel  bruised  ; lint  dipped  in 
lemon-jurce,  or  vinegar  and  water;  a mixture  of  mer- 
curial ointment  and  ceraturn  saponis  (Scott  on  Chro- 
nic Inflammation,  &rc.)  ; are  among  the  applications  tty 
common  scrofulous  ulcers. 

For  irritable  sores,  diluted  hydrosulphuret  of  ammo- 
nia ; ointments  containing  opium  ; carrot  and  hemlock 
poifltices ; a solution  of  opium ; and  carbonic  acid  gas; 
are  commonly  recommended. 

The  following  are  Mr.  Russell’s  sentiments  respect- 
ing the  treatment  of  scrofulous  ulcers:  “Scrofulous 
complaints  in  general  do  not  agree  well  with  stimulant 
applications.  In  the  treatment  of  scrofulous  ulcers, 
under  the  ordinary  circumstances  of  complaint,  the 
simplest  and  mildest  dressings  answer  best.  When 
the  patients  are  using  a course  of  sea-bathing,  it 
is  usual  to  wash  the  sores  with  sea-water,  over  and 
above  the  momentary  application  of  the  sea-water 
during  the  immersion  of  the  whole  body.  Colei 
spring  water  is  likewise  a favourite  application  with 
many  practitioners;  and  from  much  observation,  it 
appears  that  the  operation  of  cold  is  well  suited  to- 
counteract  the  state  of  inflammation  which  accompa- 
nies scrofulous  sores.  Preparations  of  lead  are,  uporr 
the  whole,  very  convenient  and  useful  application.s, 
provided  the  solutions  be  used  in  a state  of  suffl  ient 
dilution  to  prevent  irritation.  Liquid  applications  are 
applied  by  means  of  wet  linen,  which  is  renewed 
whenever  ft  dries,  so  that  the  surface  of  the  sor  e may 
be  kept  constamly  moist,  when  under  this  course  of 
maiiagcment.  Upon  the  same  principle,  simple  oint- 
ment and  Goulard’s  cerate  furnish  the  best  dressing  in 
ordinary  cases. 

“Scrofulous  congestions  of  a solid  nature,  in  the 
more  external  parts  of  the  body,  are  little  adapted  to 
the  practice  of  local  bleeding,  unless  they  be  attended 
with  symptoms  of  inflainmatiou ; but  us  some  degree 


302 


SCR 


SCR 


of  inflammation  is,  in  general,  present  during  the  in- 
cipient stage,  it  may  be  prudent  to  employ  local  bleed- 
ing in  moderation  at  the  commencement  of  the  at- 
tack, although  there  may  be  no  indication  to  persist  in 
the  practice,  after  the  complaint  has  advanced  farther 
in  its  progress.  If,  however,  these  congestions  are 
more  of  an  indolent  nature,  unaccompanied  with  heat 
or  pain,  there  is  no  benefit  to  be  expected  from  the  local 
detraction  of  blood  ; warm  fomentations,  together  with 
the  use  of  stimulants,  and  a repetition  of  blisters,  are 
the  most  serviceable  class  of  remedies  : such  cases,  too, 
are  the  best  adapted  to  the  use  of  friction  as  a discu- 
tient.  Friction,  indeed,  has  long  been  employed  for 
this  purpose  ; but  of  late  years,  it  has  been  introduced 
to  an  extent,  and  with  an  effect,  far  beyond  the  expe- 
rience of  all  former  practice.  As  yet,  it  has  been  cir- 
cumscribed to  the  practice  of  a very  few  individuals, 
with  whom  it  is  said  to  have  performed  very  great 
cutes ; and  if,  upon  the  test  of  more  extensive  expe- 
rience, it  is  found  to  answer  its  present  high  charac- 
ter, I shall  consider  the  use  of  repeated  frictions  to  be 
one  of  the  most  valuable  improvements  which  have 
been  introduced  into  practice  in  modern  times.  The 
safety  and  simplicity  of  the  practice  recommend  it 
very  strongly  to  favour,  though  1 am  afraid  they  are 
the  very  circumstances  which  retard  its  adoption  by 
the  public  in  general.  I only  regret  that  I do  not  feel 
myself  entitled  to  give  a decided  opinion  upon  the  sub- 
ject from  ray  own  experience,  though  I have  known 
.some  instances  of  successful  cures ; but  the  reports  of 
success  are  so  numerous  and  so  well  supported,  that  I 
am  inclined  to  think  very  favourably  of  the  practice. 

“ There  is  no  substance  interposed  between  the  sur- 
face of  the  swelling  and  the  hand  of  the  person  who 
administers  the  friction,  excepting  a little  flour,  to  pre- 
vent the  abrasion  of  the  skin.  The  friction  is  applied 
regularly  two  or  three  hours  every  day,  with  great 
celerity,  the  hand  being  made  to  move  to  and  fro  one 
hundred  and  twenty  times  in  a minute,  and  the  course 
may  require  to  be  continued,  without  interruption,  for 
some  months.” — (See  Russell  on  Scrofula.)  Here  I 
would  again  recommend  to  the  notice  of  surgeons,  the 
external  use  of  iodine,  as  perhaps  possessing  more  eifi- 
cacy  than  simple  friction.— (See  Iodine.) 

I shall  not  enlarge  upon  this  endless  subject,  which 
still  stands  in  need  of  elucidation  as  much  as  any  dis- 
ease that  can  be  instanced.  The  scrofulous  affections 
of  the  joints  are  elsewhere  explained. — (See  Joints.) 
Bronckocele,  lodme,  Lumbar  Abscess.,  Spina  Bifida, 
and  Vertebra  are  other  articles  containing  matter  con- 
nected with  the  preceding  observations. 

The  reader  may  consult  Wiseman's  Chirurgical 
Treatises.  J.  Brown,  Adenockoiradelogia,  or  an  Ana- 
tomic-Chirurgical  Treatise  of  Glandules  and  Stru- 
mals,  or  King's  Evil  Swellings,  together  with  the 
Royal  Gift  of  Healing,  or  Cure  thereof  by  Contact,  or 
Imposition  of  Hands,  ire.  8vo.  Land.  1G84.  Wm. 
Clowes,  A right  frutefull  and  approved  Treatise, 
for  the  Artificial  Cure  of  the  Struma,  or  Evil,  cured  by 
Kings  and  Queens  of  England,  4to.  Lond.  1602.  Cul- 
len's First  Lines  of  the  Practice  of  Physic,  vol.  4. 
Feme  on  the  King's  Evil.  Cheyne  on  the  King's  Evil. 
R.  Russell,  A Dissertation  on  the  Use  of  Sea-  Water 
in  the  I^iseases  of  the  Glands,  ^-c.  8vo.  Lond.  17G9. 
B.  Bell's  Surgery,  vol.  5.  B.  Bell  on  Ulcers.  Tu- 
mour Strumosus  Colli  post  vomitorimn  imminutus, 
8vo.  ( Weikard,  Collect.  88.)  Kirkland's  Medical  Sur- 
gery, vol.  2.  J.  Mo^ey,  Essay  on  the  Mature  and 
Cure  of  Scrofulous  Disorders,  S,-c.,  new  edit.  8vo.  Lond. 
1778.  White  on  the  Struma,  edit.  2,  1794.  P.  l.,alo- 
nette,  Traiti  des  Scrofules,  Sc.,  Paris,  1780.  A.  G. 
Kortum's  Comment,  de  Vitio  Scrofuloso,  in  2 rols.  4to. 
Lerngovim,  1789.  R.  Hamilton,  Observations  on  Scro- 
fulous Affection,  Src.  8vo.  Lond.  1791.  Med.  Obs.  and 
Inq.  vol.  1.  S.  T.  Soemmering  de  Morbis  Vasorum 
Absorbentium  Corporis  Humani,  8vo.  Traj.  1795.  C. 
W.  Hufeland,  Ueber  die  Matur,  Src.  der  Skrophel- 
krankeit.  8vo.  .Tena,  1795.  Dissertations  on  Infiamma- 
tion,  by  John  Burns,  vol.  2.  M.  Underwood,  Treatise 
upon  Ulcers,  S'C.,  with  Hints  on  a successful  Method 
of  treating  some  Scrofulous  Tumours,  S-c.  8vo.  Lond. 
1785.  Crowther's  Obs.  on  the  Disease  of  the  Joints 
commonly  called  White  Swelling;  with  remarks  on 
Caries,  Mecrosis,  and  Scrofulous  Abscesses,  ^rc.,  edit. 
2,  1808.  A Treatise  on  Scrofula, by  James  Russell,  8va. 
Edinburgh,  1806.  J.ectures  on  Infiammation,  by  J. 
Thomson,  M,  D.  p.  130,  et  seq.  p.  155 — 191,  S'C.  Edinb. 


1813.  Wm.  Goodlad,  A Practical  Essay  on  the  Dis^ 
eases  of  the  Vessels  and  Glands  of  the  Absorbent 
System,  8vo.  Lond.  1814.  G.  Henning,  A Critical 
Inquiry  into  the  Pathology  of  Scrofula,  8vo.  Lond. 
1815.  Richerand,  Mosographie  Chir.  t.  1,  p.  165,  et 
seq.  edit.  4.  Delpech,  Precis  Elementaire  des  Maladies 
Chir.  t.  3,  p.  617,  <Src.  Paris,  1816.  Lassus,  Pathologic, 
Chir.  t.  2,  p.  383,  Src.  edit.  1809.  Callisen,  Systema  Chi- 
rurgiw  Hodiemw,  vol.  2,  p.  113,  Hofnia,  1800.  Boyer, 
Traiti  des  Maladies  Chir.  t.  2,  p.  414,  Src.  Paris,  1814. 
Ch.  Brown,  Treatise  on  Scrofulous  Diseases,  showing 
the  good  Effects  of  factitious  Airs,  8vo.  Lond.  1798. 
J.  Brandish,  Obs.  on  the  Use  of  Caustic  Alkali  in 
Scrofula,  and  other  Chronic  Diseases,  8co.  Lond.  1811. 
C.  Armstrong,  Essay  on  Scrofula,  in  which  an  Ac- 
count of  the  Effects  of  the  Carbonas  Ammoniw  is  sub- 
mitted to  the  Profession,8vo.  Lond.  1812.  W.  Lambe, 
Inquiry  into  the  Origin,  S'C.  of  Constitutional  Dis- 
orders, particularly  Scrofula,  Consumption,  Cancer, 
Src.  8vo.  Lond.  1805.  Also,  Additional  Reports  on  the 
Effects  of  a peculiar  Regimen  in  cases  of  Cancer, 
Scrofula,  S-c.  8vo.  Lond.  1815.  R.  Carmichael,  Essay 
on  the  Mature  and  Cure  of  Scrofula,  and  a Demon- 
stration of  its  Origin  from  Disorder  of  Digestive 
Organs,  8vo.  Dubl.  1810.  J.  Rabben,  De  Preecipuis 
Causis  Mali  Scrofulosi  ejusque  Remediis  efficacissi- 
mis  Commentatio,  ^‘imo.  Gott.  1817.  Alibert,  Mosolo- 
gie  Maturelle,  p.  4.48,  fol.  Paris,  1820.  Dirt,  des  Sci- 
ences Mid.  t.  50,  art.  Scrofules,  8vo.  Paris,  1821.  E. 
A.  Lloyd  on  the  Mature  and  the  Treatment  of  Scro- 
fula, 8vo.  Lond.  1821.  Dr.  Coindet's  Letter  on  the 
Administration  of  Iodine  in  Scrofula,  in  Joum.  of 
Science,  4-c.  vol.  12,  Jan.  1822.  Also,  his  Obs.  on  the 
Remarkable  Effects  of  Iodine  in  Brniichocele  and 
Scrofula  ; trans.  by  J.  R.  Johnson,  M.D.  Lond.  1821. 
Brera,  Saggio  Clinico  sulV  lodio,  *S'C-  8vo.  Padua,  1822. 
W.  Gibson,  Institutes,  &c.  of  Surgery,  vol.  1,  p.  249, 
<S-c.  8vo.  Philadelphia,  1824.  W.  P.  Alison,  in  Edinb. 
Med.  Chir.  Trans,  vol.  1,  Edinb.  1824.  A.  Manson  on 
the  Effects  of  Iodine,  8vo.  Lond.  1825.  J.  Scott  on 
Chronic  Inflammation,  8vo.  Lond.  1828.  T.  Buchanan 
on  a Mew  Mode  of  Treatment  for  Diseased  Joints, 
8vo.  Lond.  1828. 

SCROTOCE'LE.  (From  scrotum,  and  KyXy,  a tu- 
mour.) A rupture  or  hernia  in  the  scrotum. 

SCROTUM,  C.ANCER  OF.  ^Chimney-sweepers' 
Cancer.  The  Soot-wart.)  This  peculiar  disorder, 
which  commences  as  a wart-like  excrescence,  is  de- 
scribed by  Mr.  Pott,  as  always  mE»king  its  first  attack 
on,  and  its  first  appearance  in,  the  inferior  part  of  the 
scrotum ; where  it  produces  a superficial,  painful,  rag- 
ged, ill-looking  sore,  with  hard  and  rising  edges.  He 
never  saw  it  under  the  age  of  puberty.  Accord- 
ing to  Mr.  Earle’s  observations,  it  very  rarely  at- 
tacks persons  under  the  age  o'  thirty.  Most  of  the 
cases  seen  by  him,  were  in  individuals  between  the 
ages  of  thirty  and  forty.  He  has  seen  three  instances 
in  subjects  between  twenty  and  thirty  j but  only  one 
at  the  age  of  pubeity.  A single  case  is  mentioned  by 
Sir  J.  Earle,  which  happened  in  a child  under  eight 
years  of  age.  I have  seen  one  case  in  a boy  not 
inore  than  sixteen. — {Mrd.  Chir.  Trans,  vol.  12,  p.  299.) 

In  no  great  length  of  time,  it  pervades  the  skin  and 
membranes  of  the  scrotum,  and  seizes  the  testicle, 
which  it  enlarges,  hardens,  and  renders  truly  and  tho- 
roughly distempered  ; from  whence  it  makes  its  way 
up  the  spermatic  process  into  the  abdomen,  most  fre- 
quently indurating  and  sproiling  the  inguinal  glands: 
when  arrived  within  the  abdomen,  it  affects  some  of 
the  viscera,  and  then  very  soon  becomes  painfully  de- 
stnictive.— (Pori.) 

JVot  only  is  the  discharge  from  the  sore  very  fetid, 
but  the  perspiration  from  the  whole  body  has  a very 
peculiar  ammoniaral  smell. — {Earle,  in  Med.  Chir, 
Trans,  vol.  12,  p.  298.) 

“Other  people  besides  chimney  sweepers  (says  Pott) 
have  cancers  of  the  same  part ; and  so  have  others 
besides  lead-workers  the  Poictou  coMc,  and  the  conse- 
quent paralysis;  but  it  is  nevertheless  a disease  to 
which  they  are  peculiarly  liable  ; and  so  are  chimney- 
sweepers to  the  cancer  of  the  scrotum  and  testicles.” 

Workmen  exposed  to  the  fumes  of  arsenic,  are  said 
to  be  liable  to  a cancerous  disease  of  the  .scrotum,  re- 
sembling that  which  infests  chimney  sweepers.  This 
is  particularly  the  case  with  the  smelters  in  Cornwall. 
— (See  Paris's  Pharmacologia,  p.  89,  vol.  2,  ed.  5.)  If 
the  two  diseases  are  precisely  similar,  the  fact  is  parti- 


CR 


SEA 


303 


tiitnriy  iiileresiing  with  regard  to  the  cause  of  the  com- 
pjaint,  which  lias  been  referred  to  the  irritation  of  soot, 
and  this  alone,  in  a supposed  peculiar  condition  of 
constitution,  not  defined,  nor  indeed  at  all  understood. 

Mr.  Pott,  as  we  find,  describes  the  disease  as  always 
beginning  at  the  lower  part  of  the  scrotum  : but  there 
are  exceptions.  Sir  James  Earle  has  recorded  an  in- 
stance of  its  occurrence  on  the  wrist  of  a gardener,  who 
had  been  employed  in  distributing  soot  for  the  destruc- 
tion of  slugs;  and  some  cases  are  said  to  have  taken 
place  on  the  face. — {H.  Earle^  in  Med.  Chir.  Trans,  vol. 
12,  p.  297.)  One  circumstance  is  noticed  by  the  latter 
writer,  w'hich,  if  it  prove  generally  correct,  materially 
influences  the  prognosis  and  treatment:  he  says,  “ the 
inguinal  glands  are  often  enlarged,  but  they  will  gene- 
rally subside  on  the  removal  of  the  diseased  scrotum; 
clearly  proving  that  the  disease  is  not  commonly  com- 
municated in  the  course  of  the  absorbents.”~(F.  298.) 
He  knows  only  one  exception  to  this  statement;  a case 
where  a bubo  formed,  suppurated,  and  assumed  the 
same  characters  as  the  primary  affection  in  the  scrotum. 

If  there  be  any  chance  of  putting  a stop  to,  or  pre- 
venting this  mischief,  says  Mr.  Pott,  it  must  be  by  the 
immediate  removal  of  the  part  affected;  namely,  that 
part  of  the  scrotum  where  the  sore  is;  for  if  it  be  suf- 
fered to  remain  until  the  testicle  is  affected,  it  is  gene- 
rally too  late  even  for  castration.  “ I have  many  times 
in.ade  the  experiment ; but  though  the  sores,  after  such 
operation,  have  in  some  instances  healed  kindly,  and 
the  patients  have  gone  from  the  hospital  seemingly  well, 
yet  in  the  space  of  a few  months,  it  has  generally  hap- 
pened, that  they  have  returned  either  with  the  same 
disease  in  the  other  testicle  or  in  the  glands  of  the  groin, 
or  with  such  wan  complexions,  sucli  pale  leaden  coun- 
tenances, such  a total  loss  of  strength,  and  such  fre- 
quent and  acute  internal  pains,  as  have  sufficiently 
proved  a diseased  state  of  some  of  the  viscera,  and 
which  have  soon  been  followed  by  a painful  death.”— 
(Po«.) 

Mr.  Earl’s  experience  has  taught  him,  that  no  topical 
applications  nor  internal  medicines  have  the  slightest 
influence  over  the  disease.  The  scalpel,  he  says,  i.«  the 
only  resource,  and  it  may  be  employed  with  confidence 
provided  the  whole  of  the  diseased  mass  can  be  re- 
moved. Even  when  the  inguinal  glands  are  enlarged, 
he  inculcates  the  same  practice.  Also,  w'hen  the  testi- 
cle is  affected,  provided  the  spermatic  cord  is  sound,  he 
conceives,  that  it  is  right  to  give  the  patient  the  chance 
of  recovering;  and  notwithstanding  the  discouraging 
results  of  Mr.  Pott’s  operations  in  this  stage  of  the  dis- 
ease, he  has  known  the  attempt  succeed  in  two  cases,  in 
which  no  relapse  had  happened  several  years  after- 
ward.— (See  Pott's  Works,  vol.  3,  ed.  by  Earle.  Jilso, 
W . Simmons's  Obs.  on  Lithotomy,  to  which  are  added 
Ohs.  on  Chimney-sweepers'  Cancer,  8vo.  Manchester, 
1808.  H.  Earle  on  Chimney-sweepers'  Cancer,  in  Med. 
Chir.  Trans,  vol.  12,  p.  296,  <S-c.) 

SCROTUM,  Sarcomatous  Thickening  and  Enlarge- 
ment of.  The  investigations  of  Baron  Larrey  lead  ifim 
to  believe,  that  cases  of  enormous  growth  of  the  scro- 
tum areendemial  in  warm  countries,  or,  at  least,  that 
they  are  seldom  ob.served  in  cold  climates;  since  most 
of  the  examples  which  have  Iteen  seen  in  Europe  came 
from  Asia  and  Africa.  The  scrotal  tuiiiour  of  Dela- 
croix, formerly  minister  of  external  relations,  says  Lar- 
rey,  is  perhaps  the  only  well-authenticated  instance  of 
the  origin  of  such  a disease  in  our  own  climate  ; and 
it  was  also  much  smaller  than  the  instances  related 
in  the  Ephemerides  German,  for  the  year  1692,  in  (he 
Biirgica!  writings  of  Dionis,  in  the  9th  vol.  of  the  Bibli- 
othdque  de  M6(lecine,  and  those  which  Larrey  was 
surprised  to  meet  with  in  Egypt.  The  smallest  of 
these  latter,  after  they  had  attained  their  full  size, 
weighed  more  than  25  kilograms  (between  60  and  70 
poimd.s). 

Several  cases  of  this  curious  disc.ase  are  recorded  by 
other  writers,  particularly  by  Dr.  Cheston,  Dr.  Titley, 
and  the  celebrated  Sandifort.  I lately  saw,  in  Mr. 
Aberncthy’s  museum,  a considerable  fleshy  substance, 
which  was  a portion  of  diseased  scrotum. 

In  the  c.ases  which  Larrey  had  an  opportunity  of 
seeing  in  Egypt,  the  fleshy  mass,  into  which  the  scro- 
'utn  was  converted,  was  broad  below,  and  suspended 
from  the  pubes  by  a sort  of  pedicle.  “ Externally  fas 
Larrey  observes),  the  tumour  presents  rugosities  ofdif- 
fereiit  sizes,  separated  by  particular  lines,  or  sinuses,  to 
which  the  raucous  crypue  and  roots  of  the  hairs  cor- 


respond. Upon  a large  portion  of  ks  surface,  e.speci' 
ally  when  the  case  is  of  long  standing,  yellowish  scaly 
crusts  are  always  seen,  the  detachment  of  which  con- 
stantly leaves  so  many  small  herpetic  ulcers,  emitting 
an  ichorous  discharge.  Tlie  tumour  is  indolent  and 
hard  at  some  points,  but  softish  at  others.  It  may  be 
handled  and  pressed  in  different  directions,  without  the 
least  pain.  The  patiei  t is  only  incommoded  by  its 
weight,  and  the  impediment  which  it  causes  to  his 
walking  well.  Hence,  he  is  necessitated  to  employ  a 
suspensory  bandage.  In  consequence  of  the  situation 
of  the  urethra,  the  urine  dribbles  over  the  swelling; 
but  without  causing  any  excoriation.  In  most  of  the 
cases,  seen  by  Larrey,  the  spermatic  cord  and  testicles 
were  in  the  natural  state,  situated  at  the  sides  and  at 
the  root  of  the  swelling.  The  spermatic  vessels,  how- 
ever, w'ere  somewhat  enlarged  and  elongated.  All  the 
patients  were  likewise  more  or  less  affected  with  ele- 
phantiasis. 

Baron  Larrey  attempts  to  explain  the  causes  of  the 
complaint  in  Egypt^ut,  as  I think,  without  any  de- 
gree of  success.  As  the  affection  is  seldom  seen  in  cold 
countries,  climate  has  certainly  a chief  effect.  Employ- 
ments which  keep  persons  a good  deal  in  a sitting  pos- 
ture; the  loose  breeches  worn  by  the  Egyptians,  and 
the  consequently  pendulous  state  of  the  scrotum  ; dis- 
eases of  the  humours,  and  particularly  itchy  pustules, 
on  the  part,  an  ordinary  consequence  of  syphilis  in  that 
country;  bad  regimen ; abuse  of  veneiy;  and  the  im- 
moderate use  of  the  warm  bath ; are  merely  conjec- 
tures, which  will  not  bear  the  test  of  reasoning. 

The  enormous  magnitude  which  this  sort  of  disease 
may  attain  is  almost  incredible.  The  case  recorded  in 
the  Ephemerides  German,  weighed  about  a hundred 
kilograms, or  more  than  tv;o  hundred  weight.  Another, 
described  by  Larrey,  was  calculated  to  weigh  about  one 
hundred  and  twenty  pounds ; and  this  surgeon  likewise 
saw  in  Egypt  ten  or  twelve  more  instances,  nearly  as 
large,  and  all  of  the  same  character. 

A very  curious  example,  in  which  a similar  disease 
affected  the  labia  pudendi  in  a surprising  degree,  is  also 
detailed  by  Larrey.  The  woman  was  a native  of  Cairo. 

In  the  early  stage  of  the  disorder,  we  may  try  prepa- 
rations of  antimony  combined  with  sudorifics  ; driuKs 
acidulated  with  sulphuric  acid,  lotions  containing 
the  same  acid,,  or  the  oxyniuriate  of  mercury,  the 
oxyde  of  copper,  or  the  muriate  of  ammonia.  These 
means  are  to  be  assisted  by  a gradual,  uniform  com- 
pression of  the  whole  tumour.  In  one  case,  incisions, 
and  the  application  of  caustic,  proved  of  no  service, 
and  Larrey  very  properly  condemns  such  experiments. 

When  the  disease  resists  every  plan  tried  for  its  re- 
lief, and  its  increase  renders  the  patient’s  life  irksome 
and  wretched,  the  extirpation  of  the  tumour  with  a 
knife  becomes  proper.  In  this  proceeding,  the  chief 
skill  consists  in  doing  no  injury  to  the  spermatic  corda 
and  testicles,  which  are  generally  perfectly  sound.  As 
the  substance  of  the  swelling  is  not  furnished  with 
laige  vessels,  the  hemorrhage  need  not  be  feared.  Caro 
must  also  be  taken  not  to  injure  the  corpora  cavernosa 
penis,  and  the  urethra.  After  the  operation,  the  skin 
is  to  be  brought  over  the  exposed  testicles  as  much  as 
possible,  with  adhesive  plaster  and  a bandage. 

M.  Delonnes  successfully  removed  the  diseased  mass 
in  the  celebrated  case  of  the  French  minister  Delacroix, 
and  Larrey  perfornred  the  same  operation  with  success 
when  he  was  in  Egypt.  Dr.  Titley,  of  the  island  of 
St.  Christopher,  also  cut  away  such  a tumour,  which 
weighed  seventy  pounds,  and  the  patient,  who  was  a 
negro,  and  also  affected  with  elephantiasis,  speedily 
recovered. — (See  Med.  Chir.  Trans,  vol.  Q,p.  73,  <S-c.) 

It  is  probable  that  some  of  the  oases,  which  occur  in 
warm  countries,  are  analogous  to  the  elephantiasis ; 
but  I do  not  believe  that  the  scaly  incrustations  which 
are  represented  by  Larrey  as  occurring  in  the  case.-t 
which  he  saw  in  Egypt,  have  been  always  notici  d in 
the  instances  which  have  taken  place  in  colder  coun- 
tries. Nor,  indeed,  did  they  take  place  in  the  instance 
recorded  by  Dr.  Titley,  the  surface  of  the  tumour  hav- 
ing been  quite  smooth.— (/vttr?-cy,  Mim.  de  Chir.  MLli- 
taire,  t.  2,  p.  1 10,  et  see/.  Richerand,  JCosographic  Chir. 
t.  4,  ]>.  314,  Src.  edit.  4.  Dtlunnes's  Memoir.  Dr.  Ches- 
ton's Cnse,S,  c.  Med.  Chir.  Trans,  vol.  6.) 

SE.AKCHING.  The  operation  of  introducing  a me- 
tallic instrument,  through  the  urethra,  into  the  bladder^ 
for  the  purpose  of  ascertaining  whether  the  patient  ha» 
a Slone  or  not.— (See  Sounding.) 


304 


SIG 


SIG 


SETON.  A kind  of  issue,  usually  made  by  means 
of  a flar  needle,  from  lialf  an  inch  to  nearly  an  inch  in 
bieadih.  The  needle  is  commonly  a little  curved,  but 
if  straight,  it  would  be  better  calculated  lor  the  purpose. 
From  the  point  to  its  broadest  part  it  is  double-edged, 
and  behind  it  has  a transverse  eye,  through  wliich  a 
skein  of  thread,  or  silk,  of  exactly  the  same  breadth  as 
the  needle,  is  placed. 

A fold  of  skin  is  to  be  pinched  up  at  the  part  where 
the  seton  is  designed  to  be  made,  and  the  needle  is  to 
be  (rushed  through  it,  togetlrer  with  the  skein  of  thread, 
which  is  first  dipped  in  sweet  oil.  The  instrument  is 
not  to  be  introduced  too  low  irrto  the  base  of  the  fold, 
rtor  too  high  near  its  edge.  In  the  first  case,  the  nrus- 
cles  and  parts  which  ought  to  be  avoided  nright  be 
wouirded;  in  the  second,  the  interspace  between  the 
two  wounds  would  be  very  narrow,  aird  the  seton  soon 
make  its  way  through  it. 

When  ito  seton-needle  is  at  hand,  the  fold  of  the  skin 
may  be  purrctured  with  a lancet,  atrd  the  skein  of  thread 
irrtroduced  by  means  of  an  eye-^obe.  A seton  may 
be  applied  almost  to  any  part  of  the  surface  of  the 
body,  when  circumslaitces  require  it:  but  one  of  its 
operrings  should  always  be  made  lower  than  the  other, 
that  the  nratler  may  readily  flow  out.  The  skeitr  of 
thread  is  to  remain  untouched  for  a few  days  after  the 
operation,  until  the  suppuration  loosens  it.  Afterward 
the  part  of  the  thread  nearest  the  wound  is  to  be 
smeared  with  oil,  white  cerate,  or  any  digestive  oint- 
ment, and  drawn  under  the  fleshy  interspace  between 
the  two  wounds,  and  what  was  there  before  is  to  be 
cut  off.  The  seton  is  to  be  drawn  in  this  manner  once 
or  twice  a day,  according  as  the  quantity  of  matter  may 
require.  A new  skein  of  silk  or  thread  is  to  be  at- 
tached to  the  preceding  one  as  often  as  necessary. 
Care  is  to  be  taken  to  keep  the  thread  on  the  outside  of 
the  wound  well  covered,  a‘id  free  from  the  discharge, 
which  would  make  it  stiff  and  hard,  and  apt  to  occa- 
sion pain  and  bleeding  on  being  drawn  into  the  wound. 
If  the  discharge  should  be  deficient  in  quantity,  pow- 
dered cantharides  may  be  mixed  with  the  digestive 
ointment.  A neater  and  less  troublesome  kind  of  se- 
lon,  is  that  in  which  a thin,  smooth  slip  of  elastic  gum 
is  enjployed,  insiead  of  silk.  The  elastic  gum  tape  is 
generally  about  four  inches  long,  and  half  an  inch  wide : 
the  needle  for  conveying  it  through  the  integuments  has 
no  eye,  but  takes  hold  of  it  in  the  manner  of  a pair  of 
forceps.  This  kind  of  seton  has  the  recommendations 
of  being  less  pairiful  than  the  common  one,  more  clean- 
ly, and  does  not  require  the  repetition  of  the  disagree- 
able operation  of  changing  the  silk.  When  it  is  wished 
to  render  it  more  irritating,  the  elastic  gum  slip  may  be 
drawn  a little  out  of  either  opening,  and  smeared  with 
savine  ointment.  I feel  much  obliged  to  the  late  Sir 
Patrick  M‘Gregor,  for  reminding  me  of  this  improve- 
ment, which  is  derived  from  the  French. 

SHINGLES.  See  Herpes- 

SIGHT,  DEFECTS  OF.  There  are  persons  who, 
from  their  infancy,  are  incapable  of  distinguishing  one 
colour  from  another.  A man  who  was  affected  with 
this  infirmity,  could  not  distinguish  green  at  all.  Green 
and  red  appeared  to  him  the  same.  Yellow  and  blue 
he  could  discern  very  well.  With  regard  to  dark  red 
and  dark  bine,  he  frequently  made  mistakes.  In  other 
res()ects,  his  vision  was  sound  and  acute.  The  father 
of  this  patient  was  afflicted  with  the  same  infirmity. 
The  mother  and  one  sister  were  free  from  it.  Another 
sister  and  two  of  her  children  had  it.  The  patient  him- 
self had  two  children  who  did  not  labour  under  the  dis- 
order.—(See  PAfl.  Trans.  vol.^,part^.)  Another  sub- 
ject, whose  eyes  were  in  other  respects  healthy,  and 
whose  eyesight  was  sharp,  could  not  distinguish  a dark 
green  from  a dark  red. 

An  interesting  example  of  this  curious  imperfection 
of  vision  has  been  published  by  Dr.  Nicholl,  of  Cow- 
bridge. — (See  Med.  Chir.  Trans,  vol.  7,  p-  477,  A-c.) 
The  subject  was  a healthy  boy,  eleven  years  of  age, 
whose  eyes  were  gray,  with  a yellow  tinge  surround- 
ing the  pupil.  He  never  called  any  colour  green.  Dark 
bottled  green  he  called  brown.  He  could  distinguish 
light  yellow  ; but  darker  yellows  and  light  browns  he 
confounded  with  red.  Dark  brown  he  mistook  for 
black.  Pale  green  he  called  light  red  ; common  green 
he  termed  red.  Light  red  and  (unk  he  called  light  blue. 
Red  he  called  by  its  proper  name.  He  could  distin- 
guish blue,  both  dark  and  liglit.  On  the  mother’s  side, 
the  boy  had  some  relations  whose  sight  was  sitnilarly 


affected.  An  interesting  chapter  on  wltat  is  fermed 
coloured  vision  may  be  read  in  a modern  valuable 
work,  to  which  I have  great  pleasure  in  referrine. — (See 
Wardrop's  Essays  on  the  Morbid  Anatomy  of'the  Hu-' 
man  Eye.,  vol.  2,  p.  196,  8«o.  Lond.  1818.) 

Sometimes  objects  appear  to  the  eve  to  be  of  a differ 
mu  colour  from  what  they  really  are’  not  because  there 
is  any  thing  wrong  in  the  eye  itself,  but  in  consequence 
of  the  unclear  and  coloured  light  by  which  the  object 
is  illuminated.  Thus,  for  instance,  a bad  tallow  can- 
dle, which  emits  a yellow  flame,  makes  every  thing 
appear  yellow.  When  brandy  is  burning,  all  objects 
appear  blue.  In  short,  it  is  only  by  the  light  of  the  sun 
that  any  object  can  be  seen  in  its  clear,  natural  hue. 
In  certain  cases,  the  infirmity  is  owing  to  the  tianspa- 
rent  parts  and  humours  of  the  eye,  which  do  not  hap- 
pen to  be  of  a proper  colour.  Thus,  persons  liaving  the 
jaundice  in  a high  degree  see  all  things  yellow,  because 
the  transparent  parts  of  the  eye  are  of  that  colour. 
When,  in  consequence  of  external  violence  applied  to 
the  eye,  blood  is  effused,  and  the  aqueous  humour  ren-^ 
dered  red  by  this  fluid,  all  objects  seem  to  the  patient 
to  be  red  ; and  white,  when  the  aqueous  humour  has 
been  made  of  this  colour  by  the  couching  of  a milky 
cataract.  Sometimes  this  defect  in  vision  is  ascribable 
to  the  duration  of  an  impression.  When  one  has  sur- 
veyed a bright  coloured  object  a long  while,  as  for  ex- 
ample, a bright  red  or  yellow  wall,  on  which  the  sun 
shines,  that  colour  will  often  remain  a good  while  be- 
fore the  eyes,  although  one  may  not  be  looking  any 
more  at  an  object  of  this  hue.  There  are  some  eyes 
which  seem  much  disposed  to  retain  the  impression  of 
objects  which  are  not  very  bright-coloured ; but  such  a 
disposition  always  betrays  great  weakness  and  irrita- 
bility of  those  organs.  The  most  frequent  cause  of 
this  defect  in  vision,  is  an  irritation  operating  upon  the 
optic  nerves,  so  as  to  produce  the  irritability  in  them, 
which  alone  makes  objects  appear  of  one  colour.  The 
seat  of  such  irritation,  according  to  Richter,  is  also 
most  commonly  in  the  abdominal  viscera,  and  the  case 
denrands  evacuations,  tonics,  and  anodyne  medicines. 
But  the  disorder  may  also  originate  from  other  causes 
The  operation  of  bright-coloured  or  shining  objects 
upon  the  eye  sometimes  has,  for  a certain  time  after- 
ward, the  effect  of  making  objects  of  diverse  colours 
appear  to  be  moving  before  the  eyes.  In  extreme  ter- 
ror or  fright,  things  may  also  seem  to  have  a different 
colour  from  their  real  one.  The  same  often  happens 
in  fevers  attended  with  delirium.  A sudden  exposure 
of  the  head  to  cold,  at  a period  wiien  it  was  perspiring 
much,  in  one  instance,  caused  many-coloured  appear- 
ances before  the  eyes  ; but  the  disorder  subsided  in  a 
couple  of  days. — {Richter,  Anfangsgr.  der  IVundarin. 
b.3,p.  523.) 

Also,  a healthy  eye  sees  a distant  object  with  uncer- 
tainty and  error  in  a room  or  space,  the  extent,  length, 
and  breadth  of  which  are  uuk:'.own,  when  the  size  of 
the  object  itself  is  unascertained,  and  when  there  are 
few  or  no  other  objects  intervening  at  a smaller  dis- 
tance between  the  eye  and  the  thing  looked  at.  The 
more  numerous  the  objects  are  between  the  eye  and 
the  principal  thing  looked  at,  the  more  distant  it  is 
made  to  a[)pear ; the  fewer  they  are,  the  nearer  it 
seems  to  be.  In  a country  covered  with  snow,  and 
upon  the  sea,  very  distant  objects  appear  to  be  close. 
The  smaller  an  object  is  to  the  eye  in  relation  to  its 
known  magnitude,  the  farther  off  it  seems.  The  errors 
which  the  eye  makes,  in  regard  to  the  distance  of  ob- 
jects, also  lend  to  deceive.  But  there  are  certain  cases 
in  which  the  eye  is  aimost  entirely  incapable  of  judging 
of  the  distance  of  objects.  The  first  is,  when  the  object 
of  which  we  wish  to  ascertain  tiie  distance  is  looked  at 
with  only  one  eye.  Hence  all  one-eyed  persons,  and 
persons  affected  with  strabismus,  are  unable  to  judge 
well  of  the  real  distance  of  objects.  However,  they  are 
only  so  for  a certain  time;  and,  by  practice,  they  gra- 
dually acquire  the  faculty.  Even  when  two  eyes  are 
employed,  it  rtKiuires  some  exercise  in  order  to  enable 
them  to  jiidte  of  the  right  distance  of  objects.  Persons 
born  blind,  but  who  have  their  sieht  restored  in  both 
eyes  by  the  operation  for  the  cataract,  are  a long  while 
incapable  of  judging  of  distances,  and  only  obtain  this 
(lower  very  gradually.  Lastly,  this  infirmity  is  some- 
times owing  to  an  irritation  atfecting  the  oiitic  nerves, 
whereby  their  sensibility  is  so  altered,  that  distant  ob- 
jects make  the  impression  upon  them  of  near  ones. 
In  this  circumstance  all  objects  appear  to  the  patient 


sou 


305 


doser  than  they  really  are.  This  is  the  only  case 
which  admits  of  being  treated  as  a disease.  The  irri- 
tation producing  the  disorder  is  mostly  seated  in  the 
abdominal  viscera,  and  requires  evacuations,  and  such 
medicines  as  invigorate  the  nerves.  A suppression  of 
perspiration  is  alleged  to  be  sometimes  a cause.— 
{Richter^  Anfangsgr.  der  Wundarzn.  b.  3,  p.  525.) 

A sound  eye  likewise  does  not  always  judge  with 
accuracy  and  uniformity  of  the  magnitude  of  objects. 
This  may  arise  from  three  causes.  In  order  to  judge 
rightly  of  the  size  of  any  thing,  its  precise  distance 
must  be  known ; for  the  more  remote  it  is,  the  smaller 
will  it  seem  to  the  eye.  Hence,  any  conjecture  re- 
specting the  magnitude  of  an  object,  is  constantly  erro- 
neous, unless  the  distance  be  ascertained.  Size  is  in- 
variably something  relative.  A single  large  object, 
sirrrounded  by  many  small  ones,  always  appears  to  be 
larger  than  it  really  is ; et.vice  versd.  An  object  whose 
magnitude  is  known  seerhs  smaller  than  it  actually  is, 
w'hen  one  has  been  a little  previously  looking  at  an- 
other that  is  still  larger.  Lastly,  the  refraction  of  the 
rays  of  light  in  the  eye,  by  which  operation  an  object 
is  made  to  appear  large  or  small,  is  not  always  accom- 
plished in  the  same  degree,  as  the  eye  is  not  at  all  times 
equally  full  and  distended  with  its  humours.  Hence, 
at  one  time  the  same  object  will  appear  to  the  same 
eye,  and  at  the  same  distance,  larger ; at  another  time 
smaller.  Sometimes,  however,  the  eye  judges  so  er- 
roneously of  the  magnitude  of  objects,  that  there  is 
reason  for  regarding  the  case  as  an  infirmity  or  disease. 
It  is  for  the  most  part  owing  to  a defective  sensibility 
in  the  nerves,  caused  by  some  species  of  irritation  act- 
ing upon  the  eye,  and  generally  seated  in  the  gastric 
organs.  A man  to  whom  every  thing  seemed  one-half 
smaller  and  nearer  than  it  really  was,  was  cured  by 
means  of  an  emetic,  bark,  an  issue,  and  valerian. — 
(Leatm,  obs.  fascic.) 

Sometimes  to  the  eye,  under  circumstances  of  dis- 
ease, straight  lines  appear  serpentine ; perpendicular 
objects  sloping ; things  standing  upright,  to  be  inverted, 
Jfcc.  The  son  of  a distinguished  artist  began  when 
seven  years  old  to  learn  drawing  under  his  father,  who 
was  much  surprised  to  find  all  the  objects  which  the 
young  pupil  represented  drawn  upside  down.  It  was 
at  first  supposed,  that  the  child  might  be  practising  this 
inversion  of  objects  in  joke ; but  he  affirmed  that  the 
things  were  drawn  exactly  as  they  appeared  to  him, 
and  there  was  no  reason  to  doubt  his  word.  When- 
ever an  object  was  turned  before  he  took  a sketch  of  it, 
he  represented  it  in  the  natural  position,  showing  that 
the  sensation  received  by  the  eye  corresponded  perfectly 
with  the  inversion  formed  on  the  retina.  This  state  of 
vision  ceased  at  the  end  of  a year. — (See  Journ.  Uni- 
vers.  des  Scie7ices  jMed.  F6o.  1828.)  All  the  preceding 
cases  are  set  down  by  Richter  as  depending  upon  a 
wrong  sensibility  of  the  nerves,  occasioned  by  the  effect 
of  some  iiritation.  The  irritation,  he  says,  may  be  of 
many  kinds;  but  experience  proves  that  it  is  mostly 
seated  in  the  gastric  orirans.  These  defects  of  sight 
may  generally  be  cured  by  first  exhibiting  emetics  and 
purgatives,  and  afterward  having  recourse  to  reme- 
dies for  strengthening  the  nerves — bark,  oleum  ani 
male,  valerian,  issues,  &c.  One  mark  of  a very  weak 
and  irritable  eye  is,  when  objects,  after  being  looked 
at  a eood  while,  and  presenting  a right  appearance, 
begin  to  move,  swim  about,  mix  together,  and  at  length 
become  quite  undistinguishable.  This  principally 
happens  when  the  objects  regarded  are  small  and 
strongly  illuminated.  Here  such  remedies,  both  gene- 
ral and  topical,  as  have  the  effect  of  invigorating  the 
nerves  are  indicated.  However,  sometimes  the  in- 
firmity is  partly  owing  to  the  operation  of  some  species 
of  initation,  which  will  require  removal  ere  the  tonic 
medicines  and  applications  can  avail.  Indeed,  in  par- 
ticular cases,  the  dispersion  of  such  irritation  is  alone 
sufficient  to  accomplish  the  cure. 

Sometimes  all  objects  appear  to  the  eye  as  if  they 
were  in  a more  or  less  dense  mist.  This  defect  in 
vision  is  always  owing  either  to  some  slight  opacity  of 
one  of  the  humours  of  the  eye,  or  to  excessive  debility 
of  the  optic  nerves. — (See  Richter,  Anfangsgr.  der 
fVwidarzii.  b.  3,  p.  521,  S c.) 

SINUS.  A long,  narrow,  hollow  track,  leading 
from  some  abscess,  diseased  bone,  &c. 

SOUND.  An  instrument  which  surgeons  introduce 
through  the  urethra  into  the  bladder,  in  order  to  dis- 
cover whether  there  is  a stone  in  this  viscus  or  not. 
VoL.  U.-U 


SPI 

The  sound  is  made  of  highly-polished  steel,  that  it  may 
be  well  calculated  for  conveying  to  the  surgeon’s  fingers 
the  sensation  of  any  thing  against  which  its  end  may 
strike.  It  is  also  generally  rather  less  curved  than  a 
catheter,  so  that  its  e'xtremity  may  be  more  easily  in« 
dined  to  the  lower  part  of  the  bladder,  where  the  stone 
is  most  frequently  situated. 

SOUNDING.  Tne  operation  of  introducing  the 
foregoing  instrument. 

Sounds  are  generally  introduced  much  in  tlie  same 
way  as  catheters,  either  with  the  concavity  towards 
the  abdomen  or  the  convexity  ; in  which  last  method  it 
is  necessary,  as  soon  as  the  beak  of  the  sound  has  ar* 
rived  in  the  perinaum,  to  bring  the  handle  of  the  in* 
strument  downwards  by  a semicircular  movement  to 
the  right,  while  the  other  end  is  kept  as  much  fixed  as 
possible.  This  is  what  the  French  term  the  coup  ot 
tour  de  maltre;  a plan  that  is  often  followed  at  the- 
present  day,  though,  except  in  very  corpulent  subjects, 
it  has  no  particular  recommendation. 

When  a patient  is  to  be  sounded,  he  is  usually  put  Ift 
a posture  very  similar  to  that  adopted  in  the  lateral 
operation  for  the  stone,  with  the  exception  that  he  is 
not  bound  in  this  position,  as  there  is  sometimes  an  ad- 
vantage in  making  the  patient  stand  up,  in  order  that 
the  stone  may  come  in  contact  with  the  end  of  the 
sound.  The  instrument  having  been  introduced,  its 
extremity  is  to  be  turned  and  moved  in  every  direction, 
when,  if  there  be  a calculus,  its  presence  will  usually 
be  indicated  by  the  collision  against  the  beak  of  tlie 
sound. 

Stones  have  sometimes  been  found  in  the  bladder 
after  death,  although  they  could  never  be  discovered 
with  a sound  while  the  patient  was  alive,  suffering  all 
the  symptoms  of  the  complaint.  The  celebrated  French 
surgeon  La  Peyronie  Was  thus  circumstanced : he  was 
so  fully  convinced  of  there  being  a stone  in  his  bladder, 
notwithstanding  neither  he  nor  any  of  his  friends  could 
feel  it  witli  a sound,  that,  on  his  death-bed,  he  gave 
directions  for  ascertaining  the  fact.  Hence,  when 
the  usual  symptoms  of  a stone  in  the  bladder  continue, 
patients  should  be  searched  several  times  before  a posi- 
tive opinion  is  delivered  respecting  the  nature  of  the 
disease.  When,  during  the  operation  of  sounding,  all 
the  urine  has  escaped  from  the  bladder,  the  inner  sur- 
face of  this  viscus  comes  into  contact  with  the  end  of 
the  sound,  and  such  a sensation  may  be  communicated 
to  the  surgeon’s  fingers  as  leads  him  to  suspect  that  a 
fungus,  or  some  other  hardish  extraneous  substance  is 
contained  in  the  bladder.  In  such  cases  patients  have 
actually  been  cut  for  the  stone,  when  no  foreign  body 
whatever  was  present. — (See  Sabatier,  Medecine  Op^ 
ratoire,  t.  3,  p,  127, 128,  edit  2.  See  Lithotomy.) 

SPE'CULUM.  An  instrument  to  facilitate  the  ex- 
amination of  parts,  and  also  the  performance  of  opera- 
tions on  them  : tlius  we  have  specula  ani,  ocull,  auris, 
uteri,  &c. 

SPHA'CELUS.  (From  to  destroy.)  Sur- 

geons imply,  by  this  word,  complete  mortification, 
which  is  mostly  preceded  by  a stage  of  the  disorder, 
termed  gangrene.  See  Mortification. 

SPICA.  (From  andxvii  an  ear  of  corn.)  A name 
given  to  a kind  of  bandage,  in  consequence  of  its  turns 
being  thought  to  resemble  the  rows  of  an  ear  of  corn. 

In  order  to  apply  the  spica  bandage  to  the  shoulder, 
the  margins  of  the  axillce  must  first  be  protected  from 
the  effects  of  the  pressure,  by  means  of  soft  compresses, 
and  the  end  of  a common  roller  is  then  to  be  placetl 
under  the  armpit,  on  the  sound  side.  After  convey- 
ing the  bandage  backwards,  obliquely  over  the  scapul®, 
the  surgeon  is  to  bring  it  forwards  over  the  i.njured 
shoulder.  The  roller  is  next  to  descend  under  the  arm- 
pit, then  be  carried  upwards  again,  and  made  to  cross 
on  the  deltoid  muscle  It  is  now  to  be  carried  obliquely 
over  the  front  of  the  chest,  and  under  the  opposite  aim* 
pit,  where  the  end  of  it  is  to  be  pinned  or  stitched. 
The  bandage  is  next  to  pass  across  the  back,  over 
ftie  part  of  the  roller  previously  applied  in  this  situa- 
tion, and  is  to  he  conveyed  round  the  head  of  the  os 
brachii,  so  as  to  form  a turn  or  doloire  With  the  first 
circle  of  the  roller.  Three  or  four  doloires  or  turns, 
each  of  which  covers  about  one-third  of  the  preceding 
f)ne,  are  to  be  made,  and  then  the  upper  part  of  the 
arm  is  to  be  once  surrounded  with  a plain  circle  of  thi 
bandage.  This  last  circular  application  leaves  be- 
tween it  and  the  cross  previously  made,  a triangular, 
equilateral  space,  technically  named  by  writers 


306 


SPI 


SPI 


nis.  The  roller  is  now  to  be  carried  upwards  in  a spiral 
manner;  its  head  is  to  be  brought  to  the  opposite  arm- 
pit, and  the  application  oi'  the  whole  concludes  with  a 
few  turns  round  the  body.  The  bandage  is  to  be  fast- 
ened with  pins  at  the  place  where  it  commences. 

In  applying  the  spica  iiig-tiuiis,  the  end  of  the  roller 
is  to  be  placed  on  the  spine  of  the  os  ileum  of  the 
affected  side.  The  bandage  is  then  to  be  carried  ob- 
liquely over  the  groin,  and  under  the  perinaeum.  Then 
it  is  to  pass  over  the  back  of  the  thigh,  and  ne.xt  for- 
wards, so  as  to  cross  the  part  previously  applied  on  the 
front  of  the  groin.  The  application  is  continued  by 
carrying  the  roller  over  the  pubes,  over  the  opposite 
03  ileum,  and  next  round  the  body  above  the  buttocks. 
The  bandage  thus  returns  to  the  place  where  it  began. 
Its  application  is  completed  by  making  a few  turns 
like  the  preceding  ones,  and,  lastly,  a few  circles  round 
tlie  body. 

SPINA  BIFIDA,  (i,  e.  the  Cloven  Spine.)  Hydro- 
Rachitis.  A disease  attended  with  an  incomplete  state 
of  some  of  the  vertebrae,  and  a fluid  swelling,  which  is 
most  commonly  situated  over  the  lower  lumbar  ver- 
tebrae, sometimes  over  the  dorsal  and  cervical  ones, 
and,  in  some  instances,  over  the  os  sacrum.  The  same 
name  has  also  been  given  to  an  analogous  tumour, 
W'hich  sometimes  occurs  on  children’s  heads,  attended 
with  an  imperfect  ossification  of  a part  of  the  cranium. 
The  malformation  of  the  spine  seems  to  consist  in  a 
deficiency  of  one  or  more  of  the  spinous  processes. 
Sometimes,  indeed,  these  processes  are  wanting  the 
whole  length  of  the  vertebral  column,  as  was  seen  in 
the  case  reported  by  Fieliz. — (See  Richter's  Chir.  Bibl. 
b.  9,  p.  185.)  Sometimes  the  tumour  is  comjmsed  of 
two  distinct  cysts,  as  happened  in  the  case  recorded  by 
Mr.  Brewerton  (Edia.  Med.  and  Surg.  Journ.  vol.  17) ; 
but  this  is  uncommon. 

The  Arabians,  who  first  treated  of  this  disease,  erro- 
neously imputed  the  deficiency  of  one  or  more  of  the 
spinous  processes  to  the  tumour,  while  it  is  now  well 
known  that  the  incomplete  state  of  the  affected  ver- 
tebree  is  a congenital  malformation,  and  that  the  swell- 
ing is  only  an  effect.  In  fact,  the  tumour  generally  be- 
comes larger  and  larger  the  longer  it  continues.  The 
spina  bifida  may  be  regarded  as  an  affliction  only  met 
with  in  children  : few,  very  few,  live  to  the  adult  age 
with  this  incurable  affection.  Warner,  however,  has 
related  a case  in  which  the  patient  lived  till  he  was 
twenty. — (Cases  hi  Surgery,  p.  134,  edit.  4.)  I have  also 
seen,  under  the  care  of  Mr.  C.  Hutchison,  a young 
woman,  nineteen  years  of  age,  who  had  a spina  bifida, 
which  was  of  astonishing  size,  and  situated  at  the 
lower  part  of  the  vertebral  column.  One  curious  cir- 
cumstance in  the  case  was,  that  the  patient  used  to 
menstruate  through  a sore  in  the  thigh.  I conclude 
this  is  the  same  case  as  is  described  by  Mr.  Jukes  (see 
Med.  and  Phys.  Journ.  for  Feb.  1822),  and  who  states 
the  measurement  of  the  swelling  to  have  been  thirty 
inches  in  its  vertical  line.  The  urine  and  feces  used 
to  pass  involuntarily. 

As  I have  remarked,  the  swelling  is  most  frequently 
situated  towards  the  lower  part  of  the  spinal  canal, 
particularly  at  the  place  wheie  the  lumbar  vertebrae 
join  the  sacrum.  The  fluid  which  it  contains  resem- 
bles serum,  being  somewhat  more  liquid  than  the  white 
of  egg,  and,  like  the  latter,  frequently  coagulable.  It 
is  in  general  limpid  and  colourless  ; but,  occasionally, 
it  is  turbid  and  tinged  with  blood.  On  pressing  the 
tumour,  a fluctuation  is  very  perceptible,  and  a preter- 
natural space  may  also  be  felt  existing  between  some 
of  the  spinous  processes.  The  fluid  is  contained  in  a 
kind  of  cyst,  which  is  composed  of  the  continuation  of 
the  dura  mater  investing  the  spinal  canal,  and  is  for 
tlie  most  nart  closely  adherent  to  the  integuments. 

According  to  Morgagni,  spina  bifida  is  mostly  attended 
with  hydrocephalus,  and  the  enlargement  of  the  head 
has  been  known  to  undergo  a considerable  diminution 
after  the  casual  rupture  of  the  tumour  of  the  spine.— 
(De  Sed.  et  Cans.  Morb.  epist.  7,  art.  9.  Ephem.  Cur. 
JTat.  decad.  3,  art.  1,  decad.  2,  art.  2.)  The  fluid 
which  was  lodged  in  the  lateral  ventricles  and  third 
ventricle,  passed  into  the  fourth,  through  the  aquaduc- 
tus  Sylvii,  ruptured  the  calamus  scriptorius,  and  thus 
passed  into  the  spinal  canal. 

Spinte  bifidfe  usually  occur  on  the  lower  part  of  the 
spine ; but  they  occasionally  lake  place  on  the  cervical 
veru-biifi,  where  the  tumours  have  the  same  charac- 
teristic marks  as  those  near  the  sacrum.  Many  facts 


recorded  by  Ruysch,  in  his  Anatomical  Obstrvatianf 
confirm  the  preceding  account. 

The  present  affliction  is  one  of  a most  incurable  na' 
ture  ; for,  with  the  exception  of  one  case  mentioned  by 
Morgagni  (De  Sed.  et  Caus.  Morh.  epist.  12,  art.  9),  » 
second,  recorded  byKeilmann  (Prodr ovi.  Act.  Havn.  p^ 
136),  and  two  or  three  others  more  recently  published 
by  Sir  Astley  Cooper,  there  is  not,  I believe,  in  all  the 
records  of  medicine  or  surgery,  any  case  which  either 
got  well  of  itself,  or  was  benefited  by  any  mode  of 
treatment.  Opening  the  tumour  either  with  caustic» 
or  cutting  instruments,  has  generally  only  tended  to 
hasten  the  fatal  event  of  tl>e  disease.  Death  soon  fol- 
lows an  operation  of  this  kind,  and  sometimes  in- 
stantly. Tulpius  observes  on  this  subject ; quam  ca- 
lamitatum  si  quidem  reformides,  chirurge,  cave  sis 
improvide  aperias,  qnod  tarn  facili  occidit  hominem. — 

( Observ.  Med.) 

But,  wJiether  the  tumour  be  opened  or  not,  still  the 
disease  is  one  of  the  most  fatal  to  which  children  are 
exposed.  When  afflicted  with  it,  they  very  seldom- 
live  till  they  are  three  years  of  age  ; but  after  lingering 
several  months  from  their  birth,  suddenly  die.  It  has 
been  said,  that  children  with  spina  bifida  always  have 
their  legs  in  a paralytic  state.  However,  this  is  not 
true  ; for  one  of  the  largest  spina  bifida  I ever  saw  was 
under  my  friend  Mr.  Maul,  of  Bouthampton,  and  was 
unattended  with  any  weakness  of  the  legs.  Indeed, 
the  child  was,  to  all  appearance,  as  stout,  healthy,  and 
full  of  play  as  possible.  The  fatal  event,  however,, 
took  place  after  a time,  as  usual ; and  if  my  memory 
does  not  fail  me,  Mr.  Maul  noticed  that  a little  before 
death,  a remarkable  subsidence  of  the  swelling  occur- 
red, though  it  never  burst  externally.  Still  it  is  a fact, 
tliat  many  infants  with  spina  bifida,  have  paralytic 
legs,  and  can  neither  retain  their  feces  nor  urine. 

If  we  draw  our  own  inferences  from  the  cases  and 
remarks  offered  by  almost  every  writer  on  spina  bifida, 
we  must  regard  all  attempts  to  cure  the  disorder,  by 
making  any  kind  of  opening,  as  exceedingly  perilous,* 
if  not  positively  fatal.  It  is  to  be  observed,  at  the 
same  time,  that  some  practitioners  have  not  altogether 
abandoned  the  idea  of  devising  a mode  of  accomplish- 
ing a cure,  at  least  in  a few  instances.  Mr.  B.  Bell 
says,  that  if  the  tumour  proceed  from  disease  of  the 
spinal  marrow  or  its  membranes,  no  means  of  cure 
will  probably  ever  be  discovered.  But  if  the  deficiency 
in  the  spinous  processes  of  the  vertebrae,  with  which 
the  disease  is  always  accompanied,  be  not  an  effect  of 
the  complaint,  as  was  commonly  imagined,  and  if  the 
collection  of  fluid  take  place,  from  the  want  of  resist- 
ance in  the  dura  mater,  in  consequence  of  the  imper- 
fection of  the  bones,  Mr.  B.  Bell  questions  whether  it 
would  not  be  proper  to  tie  the  base  of  the  tumour  with 
a ligature,  not  merely  with  a view  of  removing  the 
swelling,  but  in  order  to  resist  the  propulsion  of  the 
cyst  farther  outwards.  Mr.  Bell  acknowledges  that  the 
event  of  this  practice  must  be  considered  as  very  du- 
bious ; but  expresses  his  wish  to  devise  any  plan  that 
would  afford  even  the  least  chance  of  success,  in  a case 
which  must  terminate  in  an  unfavourable  manner. 
Mr.  Bell  mentioned  the  design  of  putting  the  method  to 
a trial  on  the  first  opportunity,  and  after  the  detach- 
ment of  the  swelling  on  the  outside  of  the  ligature,  he 
intended  to  keep  a soft  compres.s  on  the  part  with  a 
proper  bandage.  I do  not  know  whether  this  gentle- 
man ever  put  the  above  scheme  in  |)iactice  ; but  sup- 
pose not.  It  is  properly  objected  to  by  the  author  of 
the  article  Spina  BiJidniwXhe  Encyclopedic  Mifthodique^ 
part.  Chir.,  because  the  disease  is  often  attended  with 
other  mischief  of  the  spinal  marrow  and  brain,  and 
the  base  of  the  swelling  is  almost  always  too  large  to 
admit  of  being  tied  at  all,  or  not  without  hazard  of 
dangerous  consequences. 

Richter  has  proposed  the  trial  of  two  caustic  issues 
at  a little  distance  from  the  swelling  ; hut  I am  not  ac- 
qtiainted  with  any  facts  in  favour  of  this  practice. 

Mr.  Abernethy  first  suggested  the  trial  of  a gentle 
degree  of  pressure  on  the  tumour  from  its  commence- 
ment, with  the  view  of  producing  absorption  of  the 
fluid,  and  preventing  the  distention  of  the  unsupp<)rted 
dura  mater.  Were  the  fluid  to  coniiime  to  increase, 
notwithstanding  such  pressure,  Mr.  Abernethy  thinks, 
that  as  death  would  be  inevitable  on  the  tumour  burst- 
ing. it  might  be  vindicahle  to  l»*t  out  the  fluid  by  means 
of  a puncture  tnade  with  a finely-cutting  instrument. 
The  wound  is  to  be  inimediutely  afterward  closed 


SPINA 

with  sticking-plaster,  and,  if  possible,  healed.  Another 
accumulation  is  then  to  be  prevented,  if  practicable, 
with  bandages  and  topical  applications.  Mr.  Aber- 
netliy  actually  made  the  experiment  of  a puncture  in 
one  hopeless  instance,  in  which,  indeed,  the  swelling 
had  previously  just  begun  to  burst.  The  puncture  was 
repeated  every  fourth  day  for  six  weeks,  during  which 
time  the  child’s  health  continued  unaffected.  The 
wounds  were  regularly  healed  ; but  the  plaster  having 
been  rubbed  off  one  of  the  punctures,  the  part  ulcer- 
ated, the  opening  could  not  be  healed,  the  discharge, 
from  having,  been  of  an  aqueous  quality,  became  pu‘ 
rulent,  and  death  ensued.  This  case  was  also  unfa- 
vourable for  the  trial  of  the  method,  as  the  integu- 
ments covering  the  tumour  were  diseased,  and  liad  no 
disposition  to  contract. 

The  annexed  case,  publislied  by  Sir  Astley  Cooper, 
will  serve  to  show  the  benefit  which  may  be  derived 
from  pressure. 

“James  Applebee,  Baldwin-street,  Old  street,  was 
born  on  the  19th  of  May,  1807,  and  his  mother,  imme- 
diately after  his  birth,  observed  a round  and  transpa- 
rent tumour  on  the  loins,  of  the  size  of  a large  walnut. 
On  the22dof  June,  1807,  the  child  was  brought  to  my 
bouse,  and  I found  that,  although  it  had  spina  bifida, 
the  head  was  not  unusually  large ; and  the  motion  of 
its  legs  were  perfect;  and  its  stools  and  urine  were 
discharged  naturally.  I applied  a roller  around  the 
child’s  waist,  so  as  to  compress  the  tumour,  being  in- 
duced to  do  so  from  considering  it  a species  of  hernia, 
and  that  the  deficiency  of  the  spine  might  be  compen- 
sated for  by  external  pressure.  The  pressure  made  by 
the  roller,  had  no  unpleasant  influence  on  its  volun- 
tary powers  ; its  stools  and  urine  continued  to  be  pro- 
perly discharged  ; but  the  mother  thought  that  the 
child  was  occasionally  convulsed.  At  the  end  of  a 
week,  a piece  of  plaster  of  Paris  somewhat  hollowed, 
and  that  hollow  partly  filled  with  a piece  of  loose  lint, 
was  placed  upon  the  surface  of  the  tumour;  a strap 
of  adhesive  plaster  was  applied  to  prevent  its  chang- 
ing its  situation  ; and  a roller  was  carried  around  the 
w'aist  to  bind  the  plaster  of  Paris  firmly  upon  the  back, 
ai.d  to  compress  the  tumour  as  much  as  the  child  could 
bear.  This  treatment  was  continued  until  the  month 
of  October,  during  which  time  the  tumour  was  exa- 
mined about  three  times  a week,  and  the  mother  re- 
ported that  the  child  was  occasionally  convulsed. 
When  the  child  was  five  months  old  a truss  was  ap- 
plied, similar  in  form  to  that  which  I sometimes  use 
for  umbilical  hernia  in  children,  and  this  has  been 
continued  ever  since.  At  the  age  of  fifteen  months, 
it  began  to  make  use  of  its  limbs  ; it  could  crawl  along  a 
passage  and  iiptwo  pair  of  stairs.  Ateighteen  months, 
by  some  accident,  the  truss  slipped  from  the  tumour, 
which  had  become  of  the  size  of  a small  orange,  and  the 
mother  observed,  when  it  was  reduced,  that  the  child 
appeared  in  some  degree  dull ; and  this  was  always 
the  case,  if  the  truss  was  left  off  for  a few  minutes, 
and  then  re-applied.  At  fifteen  months,  he  began  to 
talk  ; and  at  two  years  of  age,  he  could  walk  alone.  He 
now  goes  to  school,  runs,  jumps,  and  plays  about  as 
other  children.  His  powers  of  mind  do  not  ajipear  to 
differ  from  those  of  other  children.  His  memory  is 
retentive,  and  he  learns  with  facility.  He  had  the 
measles  and  small-pox  in  the  first  year,  and  the  hoop- 
ing-cough at  three  years.  His  head  previously  and 
stibsequently  to  the  bones  closing,  has  preserved  a due 
proportion  to  other  parts  of  the  body.  The  tumour  is 
kept  by  the  truss  entirely  within  the  channel  of  the 
spine  ; but  when  the  truss  is  removed,  it  soon  becomes 
of  the  size  of  half  a stnall  orange.  It  is  therefore  ne- 
cessary that  the  use  of  the  truss  should  be  contimted. 
When  the  truss  is  removed,  the  finger  can  be  readily 
pressed  through  the  tumour  into  the  channel  of  the 
spine.’’ — {Med.  Chir.  Trans,  vol.%  32.1,  &-c.) 

The  next  case,  also  published  by  Sif  Astley  Cooper, 
will  prove  that  spina  bifida  may  sometimes  be  treated 
on  another  plan,  so  as  to  accotnplish  a permanent  cure. 

“January  91st,  1809,  Mrs.  Little,  of  No.  27,  Lime- 
house  (’auseway,  brought  to  my  house  her  son,  aced 
ten  weeks,  who  was  the  subject  of  spina  bifida.  The 
tumour  was  situated  on  the  loins;  it  was  soft,  elastic, 
and  transparent,  and  its  size  about  as  large  as  a biiliaid 
hall  when  cut  In  half ; his  legs  were  perfectly  sensible, 
and  his  urine  and  feces  were  under  the  power  of  the 
will,&c.  Having  endeavoured  to  push  the  water  con- 
tained in  the  tumour  into  the  channel  of  the  spine,  and 


Bifida.  so? 

finding  that,  if  the  whole  was  returned,  the  pressure 
would  be  too  great  upon  the  brain  ; I thought  it  a fair 
opportunity  of  trying  what  would  be  the  effect  of  eva- 
cuating the  swelling  by  means  of  a very  fine- pointed  in- 
strument, and  by  subsequent  pressure  to  bring  it  into 
the  state  of  the  spina  bifida  in  Applebee’s  child.  I 
therefore  immediately  punctured  the  tumour  with  a 
needle,  and  drew  oft'  about  two  ounces  of  water.  On 
the  25tii  of  January,  finding  the  tuisour  as  large  as  be- 
fore it  had  been  punctured,  I opened  it  again,  and  in 
the  same  manner,  and  discharged  about  four  ounces  of 
fluid.  The  child  cried  when  the  fluid  was  evacuated, 
but  not  while  it  was  passing  off.  On  January  28th,  the 
tumour  was  as  large  as  at  first : I opened  it  again,  and 
discharged  the  fluid.  A roller  was  applied  over  the 
tumour  and  around  the  abdomen.  February  ist,  it  was 
again  pricked,  and  two  ounces  of  fluid  discharged. 
On  the  4th,  three  ounces  of  fluid  were  discharged.  On 
the  9th,  the  same  quantity  of  fluid  was  evacuated  as 
on  the  4th  ; but  instead  of  its  being  perfectly  clear  as  at 
first,  it  was  now  sanious,  and  it  had  been  gradually  be- 
coming so  in  the  three  former  operations.  On  the  13th, 
the  same  quantity  of  fluid  was  taken  away ; a flannel 
roller  was  applied  over  the  tumour  and  around  the  ab- 
domen ; a piece  of  pasteboard  was  placed  upon  the 
flannel  roller  over  the  tumour,  and  another  roller  over 
the  pasteboard  to  confine  it.  On  the  17th,  three  ounces 
of  fluid,  of  a more  limpid  kind,  were  discharged  ; the 
pasteboard  was  again  applied.  On  the  2tith,  the  sur- 
face of  the  tumour  inflamed;  the  fluid,  not  more  than 
half  its  former  quantity,  was  mixed  with  coagulable 
lymph,  and  the  child  suffering  considerable  constitu- 
tional irritation,  was  ordered  calomel  and  scammony, 
and  the  rollers  were  discontinued.  On  the  27lh,  the 
tumour  was  not  more  than  a quarter  of  its  former 
size  ; it  felt  solid  ; the  integuments  were  thickened, 
and  it  had  all  the  appearance  of  having  undergone  the 
adhesive  inflammation.  On  the  28lh,  it  was  still  more 
reduced  in  size,  and  felt  solid.  March  8th,  the  swelling 
was  very  much  lessened ; the  skin  over  it  thickened 
and  wrinkled  ; a roller  was  again  had  recourse  to;  a 
card  was  put  over  the  tumour,  and  a second  roller  was 
applied.  March  11th,  the  tumour  was  much  reduced ; 
the  skin  covering  it  was  a little  ulcerated.  On  the  15th, 
it  was  flat,  but  still  a little  ulcerated.  On  the  27th,  the 
effused  coagulable  lymph  was  considerably  reduced  in 
quantity,  and  of  a very  firm  consistence.  On  the  2d 
of  May,  tiothingmore  than  a loose  pendulous  bag  of  skin 
remained,  and  the  child  appearing  to  be  perfectly  well, 
the  bandage  was  soon  left  off.  On  December  the  18th, 
the  child  was  attacked  with  the  small-pox,  and  went 
well  through  the  disease.  The  skin  now  hangs  flaccid 
from  the  basis  of  the  sacrum  ; its  centre  is  drawn  to  the 
spine,  to  which  it  is  united,  and  thus  the  appearance  of 
a navel  is  produced  in  the  tumour  by  retraction  of  the 
skin.  The  pr’.cks  of  the  needles  are  very  obvious, 
forming  slight  indentations.” — (See  Med.  Chir.  Trans, 
vol.  2,  p.  326—329.) 

At  the  time  when  Sir  A.  Cooper  transmitted  this 
case  to  the  Medical  and  Chiriirgical  Society,  it  had 
been  under  his  observation  two  years  and  a half. 

The  first  of  the  preceding  observations  exemplifies 
the  palliative  treatment,  adopted  by  the  latter  gentle- 
man, and  consisting  of  the  application  of  pressure  in 
the  manner  of  a truss  for  hernia ; the  second  shows 
the  radical  mode  of  cure  by  puncturing  the  swelling 
from  time  to  time  with  a needle,  and  exciting  the  ad- 
hesive inflammation,  which,  with  the  assistance  of 
pressure,  stops  the  disease  altogether,  that  is  to  say,  in 
such  examples  as  admit  of  cure. 

Children  are  sometimes  born  with  tumours  analogous 
to  spina  bifida,  but  situated  on  the  head.  There  is  a 
deficiency  of  bon<  at  some  part  of  the  skull,  and 
through  the  opening  a sac,  cotnposed  of  the  dura  ma- 
ter, piotrtides  covered  only  by  the  integuments.  Mr. 
Earle  lately  met  with  such  a swelling  situated  upon  the 
occiput  of  a femal-  infant.  The  plan  of  repeatedly 
making  small  putictures  with  a common  needle, dis- 
charging the  fluid,  healing  np  the  punctures  and  apply- 
ing pressure,  was  tried,  and  followed  up  for  some  time, 
without  the  occurrence  of  any  unpleasant  symptoms. 
Even  ptincturcs  were  sometimes  made  with  an  ordi- 
nary lancet  ; yet  the  child  suffered  no  harm  from  the 
operation,  and  some  hopesof  a cure  were  indulged.  At 
length,  hrwvever,  ulceration  of  the  swelling  took  place, 
the  child  became  indisposed,  and  rapidly  sunk. — (See 
Med.  Chir.  Trans,  vol.  7,  p.'  427.)  Consult  Ruysehii 


308 


sn 


SPL 


Obs.  Anat.  Warner's  Cases  in  Surgery.  B.  Bell’s 
System  of  Surgery,  vol.  5.  Acrel,  in  Schwed.  Abhandl. 
X,  b.  p.  291,  &rc.  Murray,  Opusc.  2,  Mo.  5,  et  Med.  Bract. 
Bibl.  3,  p.  612.  Portal,  Oours  d'Anat.  Med.  t.  4,  p. 
66.  Lassus,  Patkologie  Chir.  1. 1,  p-  260,  et  seg.  edit. 

1809.  Abernethy's  Surgical  and  Physiological  Es- 
says, parts  1 and  3.  T.  f^.  Okes,  An  Account  of 
Spijia  Bifida,  with  remarks  on  the  Method  of  Treat- 
meht,  proposed  by  Mr.  Abernethy,  8vo.  Cambridge, 

1810.  Richter,  Anfangsgr.  der  Wundarzn.  b.  5,  kap. 
17.  Sir  A.  Cooper,  in  Med.  Chir.  Trans,  vol.  2,  p. 
322,  Src.  H.  Earle,  in  the  same  work,  vol.  7,  p.  427,  i,-c. 
Edinb.  Med.  and  Surgical  Joum.  Mo.  67.  J.  A.  Mur- 
ray, De  Spinm  Bifidce  ex  mala  Ossium  Conformatione. 
Initio,  Giitl.  1779.  Fleischmann  de  Vitiis  Congenitis 
circa  Tkoracem  et  Abdomen,  Erlang.  1810.  Otto,  in 
Seltenen  Beobacht.  Breslau,  1816.  PI.  Hayes,  inMew- 
Englnnd  Journ.  1817,  vul.  1,  Mo.  3,  Meuendorff,  De 
Spince  Bifida  Curatione  Radicali,  Lips.  1820. 

SPINA  VBNTOSA.  The  Arabian  writers  first  em- 
ployed this  term  to  express  a disease  in  which  matter 
formed  in  the  interior  of  a bone,  and  afterward  made 
its  way  outwards  beneath  the  skin.  Until  the  matter 
had  escaped  from  within  the  bone,  these  authors  de- 
scribe tlie  pain  as  being  incessant  and  intolerable  ; but 
that  after  tiie  pus  had  made  its  way  outwards  by  fistu- 
lous openings,  the  patient’s  suffering  underwent  a con- 
siderable diminution.  The  matter  sometimes  insinuated 
itself,  from  the  interior  of  the  bone,  into  the  cellular 
substance,  so  as  to  render  it  soft  and  flabby,  though  not 
always  attended  with  any  change  of  colour  in  the  skin. 
The  swelling  had  some  of  the  appearance  of  emphy- 
sema. To  express  this  state,  the  Arabians  added  the 
term  ventosa  to  that  of  spina,  which  was  employed, 
before  their  time,  to  express  the  nature  of  the  pain  at- 
teadant  on  the  disease. — (See  an  account  of  this  sub- 
ject in  the  Encyclopedic  Methodique,  part.  Chir.  art. 
Spina  Ventosa.) 

The  term  spina  ventosa  has,  since  the  time  of  the 
Arabian  writers,  been  used  by  many  to  signify  the 
disease  named  white  swelling,  and  they  might  also 
mean  by  it  a similar  affection,  though  the  contrary 
may  be  inferred  from  their  account  of  the  matter  pass- 
ing from  the  interior  of  the  bone  under  the  integuments, 
a thing,  which,  I believe,  never  yet  happened  in  any 
case  of  white  swelling.  Another,  and  perhaps  a deci- 
sive argument,  against  the  original  signification  of  the 
word  being  the  same  as  that  of  white  swelling  is,  that 
it  was  not  restricted  to  diseases  of  the  joints  and  heads 
of  the  bones ; but  was  also  applied  to  abscesses  which 
commenced  in  the  cavities  of  the  middle  portions  of 
the  long  bones,  where,  I need  hardly  observe,  white 
swellings  never  make  their  attack. 

For  these  reasons,  many  respectable  authors  have 
implied  by  the  term  spina  ventosa,  an  abscess  in  the  in- 
terior of  the  bone. — (See,  on  this  subject,  Laita's  Sys- 
tem of  Surgery,  vol.  1,  p.  165.)  Cases  of  this  latter 
kind,  I know,  are  infinitely  rare,  compared  with  that 
common  disorder  the  white  swelling ; and  I am  also 
certain,  from  the  descriptions  given  by  some  authors, 
that  their  cases  of  spina  ventosa  were  in  reality  in 
stances  of  necrosis.  But  that  abscesses  do  occur  and 
begin  in  the  interior  of  the  bones,  more  particularly  of 
those  of  young  persons,  I have  no  doubt  myself,  both 
from  two  or  three  cases  which  I remember  having  seen 
in  St.  Bartholomew’s  Hospital,  and  from  some  cases 
recorded  by  the  most  authentic  writers.  I can  hardly 
conceive  that  suppuration  can  take  place  to  any  extent 
within  a long  bone  without  being  followed  by  necrosis. 

Dr.  Cumin,  however,  whose  ingenious  arrangement 
of  diseases  of  bones  has  just  made  its  appearance,  saw 
a case  in  which,  though  matter  had  formed  within  ' 
one  of  the  bones  of  a diseased  finger,  and  was  in  a i 
state  of  decay,  it  was  certainly  not  affected  witli  ne-  ' 
erosis ; “ for  interstitial  absorption  seemed  to  be  going  | 
on  in  it  to  the  last,  and  no  line  of  separation  could  be  ! 
detected  between  the  diseased  parts  and  the  healthy  ( 
articulating  extremities.”— (See  Edin.  Med.  and  Surg.  i 
Journ.  Mo.  82.)  < 

J.  L.  Petit  relates,  that  a man  with  a tumour  on  the  1 
middle  of  the  tibia,  who  had  been  treated  by  him  as  a ] 
venereal  patient,  found,  a fortnight  afterward,  that  the  ! 
pains,  which  had  never  ceased,  now  began  to  grow  1 
more  violent.  The  patient  was  feverish,  his  legs  be-  i 
came  red  and  even  jiainful  externally.  An  incision 
was  made  in  the  situation  of  the  tumour,  with  a view  i 
of  letting  out  the  matter,  which  was  suspected  to  be  i 


s the  occasion  of  the  bad  symptoms,  and  to  have  insN 
!.  nuated  itself  under  the  periosteum.  The  incision  was 
;.  of  no  service,  and  two  days  afterward  the  trepan  was 
. applied,  by  which  means  a large  quantity  of  nratier 
. was  let  out.  The  medullary  part  of  the  bone  seemed 
- quite  annihilated,  and  the  cavity  almost  empty.  Peiil 
r made  three  other  perforations  with  the  trepan,  and  cut 
. away  the  intervening  pieces  of  bone.  The  actual  cau- 
, tery  w'as  also  used  several  times  to  destroy  the  caries, 

. and  the  patient  at  length  got  well.— ( TVaite  des  Mala- 
dies dcs  Os,  de  J.  L.  Petit.)  If  any  one  doubt  that 
abscesses  form  in  the  middle  of  the  long  bones,  I must 
request  him  to  consult  Mr.  Hey’s  Practical  Obs.  in 
• Surgery,  p.  22,  where  he  may  peruse  two  very  inte- 
resting cases  illustrative  of  what  Mr.  Hey  calls  Ab- 
scess in  the  Tibia  with  Caries. 

It  must  be  confessed,  however,  that  these  were  only 
cases  of  necrosis,  for  which  affTection  the  term  caries  is 
too  often  inaccurately  used.  Indeed,  it  would  appear 
from  the  observations  of  Dr.  Macartney,  that  a very 
small  suppuration  in  the  medulla  is  accompanied  with 
the  beginning  of  those  changes  of  the  periosteum  which 
attetid  necrosis. — (See  Mecrosis.) 

For  an  account  of  spina  ventosa,  in  the  sense  of 
white  swelling,  refer  to  Joints.  J.  Pandolphinus,  De 
Ventositatis  Spince  Savissimo  Morbo,  \2mo.  Mortb.  # 
1674.  A.  J.  van  der  Meer,  De  Spina  Ventosa,  Duisb.  * 
1729.  F.  L.  Augustin,  De  Spina  Ventosa  Ossium, 
icon.  4,  4to.  Halce,  1797.  F.  H.  Schuchardt,  Anno- 
tata  quadam  de  Spina  Ventosa,  cum  annexa  singulari 
hujus  Morbi  Observations,  \2mo.  Marburg.  1817. 

SPIRITUS  AMMONITE  COMPOSITUS.  Besides 
the  well-known  uses  of  this  medicine  internally  exhi- 
bited, its  vapours  are  occasionally  applied  to  the  eye 
in  some  cases  of  chronic  ophthalmy.  Scarpa  recom- 
mends a remedy  of  a similar  nature. 

SPLINTS.  Long  thin  pieces  of  wood  or  tin,  or 
strong  pasteboard,  employed  for  preventing  the  ends 
of  broken  bones  from  moving  so  as  to  interrupt  the 
process  by  which  fractures  unite.  They  are  some- 
times used  in  other  cases,  for  the  purpose  of  keeping 
the  joints  motionless,  particularly  in  some  kinds  of  dis- 
locations, wounds,  &c. 

In  simple  fractures  of  the  arm,  forearm,  or  even  of 
the  thigh  or  leg  in  young  infants,  it  matters  not  whe- 
ther the  splints  be  made  of  wood,  pasteboard,  or  tin- 
In  this  country,  surgeons  usually  keep  sets  of  splints 
made  expressly  for  the  leg.  These  are  of  different 
sizes,  excavated  and  shaped  to  the  part,  and  furnished 
below  with  apertures  for  the  projecting  malleoli. 
When  the  limb  is  laid  upon  its  outside,  the  foot  is  alsa 
usually  supported  and  kept  steady  by  the  under  splint 
extending  some  distance  towards  the  toes.  Very 
excellent  splints  for  the  legs  of  young  children  are 
made  of  strong  pasteboard,  accommodated  in  sh;-pe 
to  the  contour  of  the  limb.  Splints  for  the  thigh, 
arm,  and  forearm,  whether  made  of  tin  or  wood,, 
should  always  be  slightly  concave  on  the  side,  which 
is  to  be  applied  to  the  broken  limb.  They  should  like- 
wise be  made  as  thin  and  light  as  is  consistentAvith  the 
necessary  degrees  of  strength  for  preventing  the  broken 
bone  from  bending.  The  sets  of  splints  which  are  used 
for  fractured  legs  and  thiglis  in  England,  are  frequently 
furnished  with  straps  which  have  a great  many  smalt 
perforations  in  them  at  stated  distances,  and  can  thus 
be  easily  fastened  by  means  of  little  pegs  for  the  pur- 
pose. Tapes  are  also  sometimes  employed  ; but  they 
often  get  loose,  and  cannot  be  depended  upon  so  well 
as  leather  straps.  Pasteboard,  as  a material  for  splints, 
has  one  advantage,  viz.  when  wet  it  becomes  soft, 
and  admits  of  being  accurately  applied  to  every  point 
of  the  surface  of  the  limb  ; consequently,  as  soon  as  it 
dries  and  recovers  its  firmness  again,  it  retains  the 
exact  shape  of  the  part,  and  makes  every  where  equal 
pressure  on  it,  without  incommoding  the  patient.  • 
Pasteboard,  however,  is  hardly  strong  and  durable 
enouKh  for  many  fractures ; nor  will  it  answer  when 
there  is  a discharge,  nor  w'hen  the  surgeon  wishes  to 
employ  any  fluid  applications.  But  it  is  generally  al- 
lowed, that  no  substance  is  better  calculated  for  sup- 
porting the  fractured  lower  jaw ; for  it  is  perfectly 
strong  enough  for  this  particular  case,  and  if  wet  before 
being  applied,  it  forms,  when  dry,  a solid  covering  most 
accurately  corresponding  to  the  shape  of  the  jaw. 

Whatever  may  be  the  substance  of  which  splints 
are  made,  they  ought  always  to  be  at  least  as  long  as 
the  fractured  bone;  and  if  the  situatiou  of  the  limb 


STA 


STA 


309 


will  allow,  they  ought,  says  Boyer,  to  extend  its  whole 
length.  “ For  instance  (says  he),  for  simple  fractures 
of  the  thighs  of  very  young  children,  the  pasteboard 
splints  which  I employ,  reach  from  the  upper  part  of 
the  thigh,  to  the  lower  part  of  the  leg.  Generally 
speaking,  the  longer  splints  are,  the  better  they  fix  the 
limb,  and  keep  the  fracture  steady.” — {Boyer,  Traite 
des  Mai.  Chir.  t.  3,  p.  50.) 

The  number  of  splints  mustdepend  upon  their  breadth 
and  the  thickness  of  the  limb.  For  the  forearm  two  are 
sufficient ; for  the  upper  arm  and  thigh  four  are  often 
used  : and  for  the  leg  two,  and  sometimes  three. 

[ti  cases  of  fractured  thighs,  when  the  straight  posi- 
tion is  preferred,  the  external  splint  should  extend  from 
the  crista  of  the  ileum  to  some  little  distance  beyond 
the  sole  of  the  foot ; while  the  inner  one  should  reach 
from  the  upper  and  internal  part  of  the  thigh  also  be- 
yond the  sole  of  the  foot.  With  respect  to  the  ante- 
rior splint,  it  is  indifferent  whether  it  only  reaches  from 
the  groin  to  the  knee,  or  as  far  as  the  lower  part  of  the  leg. 

The  lateral  splints  for  a broken  leg  ought  to  be  suffi- 
ciently loi.g  to  embrace  the  knee  and  confine  the  mo- 
tions of  the  foot  and  ankle.  When  the  straight  pos- 
ture is  adopted,  a splint  is  frequently  laid  along  the 
front  of  the  leg,  from  the  patella  to  the  lower  part  of  the 
tibia.  None,  however,  can  ever  be  required  under  the 
linrb,  as  there  the  bedding  itself  more  conveniently  af- 
fords the  necessary  degree  of  support. 

Of  all  the  different  pieces  of  the  apparatus  for  the 
treatment  of  fractures,  the  splints  are  by  far  the  most 
important  and  essential.  Without  them,  indeed,  it 
would  be  in  vain  to  attempt  to  keep  the  extremities  of 
the  fracture  from  being  displaced. 

Assplintsaregenerally  composed  of  hard  materials,  the 
bad  effects  of  their  pressure  upon  the  skin  must  always 
be  counteracted  by  placing  a sufficient  quantity  of  tow, 
wool,  or  othersoft  substance,  between  them  and  the  limb. 

In  order  to  understand,  however,  the  principles 
which  should  guide  the  surgeon  in  the  choice  and  ap- 
plication of  splints,  many  remarks  offered  in  the  arti- 
cle Fracture  must  be  consulted. 

SPONGIA  PRiEPARATA.  {Prepared  Sponge; 
Sponge-tent.)  Formed  by  dipping  pieces  of  sponge  in 
hot  melted  emplastrum  ceraecompositum,  and  pressing 
them  between  two  iron  plates.  As  soon  as  cold,  the 
substance  thus  formed  may  be  cut  into  pieces  of  any 
shape.  It  was  formerly  much  used  for  dilating  small 
openings,  for  which  it  was  well  adapted,  a.s  when  the 
wax  melted,  the  elasticity  of  the  sponge  made  it  ex- 
pand and  distend  the  opening.  However,  the  best 
modern  surgeons  seldom  employ  it. 

SPONGIA  USTA.  {Burnt  Sponge.)  This  medi- 
cine, which  the  preparations  of  iodine  are  likely  to  su- 
persede, was  often  given  in  the  form  of  lozenges  in 
cases  of  bronchocele,  in  -which  particular  instances 
much  efficacy  was  imputed  to  allowing  ihe  lozenges  to 
dissolve  gradually  under  the  tongue.  Burnt  sponge  has 
also  been  exhibited  in  many  scrofulous  diseases,  and 
in  chronic  enlargements  of  the  prostate  gland.  The 
dose  is  from  a scruple  to  a drachm. 

STAFF.  An  instrument  of  considerable  import- 
ance in  the  operation  of  lithotomy,  being  in  fact  the 
director  for  the  gorget  or  knife.  It  is  made  of  steel, 
and  its  handle  is  generally  rough,  in  order  that  it  may 
be  more  securely  held.  As  it  is  intended  to  be  intro- 
duced through  the  urethra,  its  shape  ought  to  be  prin- 
cipally determined  by  the  natural  course  of  that  pas- 
sage. The  English  generally  employ  a staff,  the  cur- 
vature of  which  forms  the  segment  of  a larger  circle 
than  that  described  by  the  curvature  of  a staff  used  by 
the  French  practitioners. — (See  Roux,  Voyage  fait  d, 
Londres  en  1814,  ou  Parallile  de  la  Chirurgie  An- 
gloise,  &-C.  p.  319.)  In  other  words,  the  French  staff 
^urns  more  upwards  than  ours,  as  it  approaches  and 
enters  the  bladder.  There  may  be  some  advantage  in 
this  construction,  inasmuch  as  it  tends  to  make  the 
gorget  enter  in  the  direction  of  the  long  axis  of  the 
bladder  ; yet  a great  deal  more  seems  to  me  to  depend 
niK)n  the  position  in  which  the  staff  is  held,  than  upon 
its  shape.  Lithotomists  should  always  employ  as 
large  a staff  as  can  be  easily  introduced,  because  the 
operation  will  thereby  he  facilitated.  The  groove,  the 
most  important  part  of  the  staff,  is  of  course  situated 
upon  the  convexity  of  the  curved  part  of  the  instru- 
ment, or  upon  that  portion  which,  when  introduced, 
lies  in  the  membranous  part  of  the  urethra,  prostate 
gland,  and  the  bladder.  It  should  always  be  made 


very  broad  and  deep,  as  recommended  by  Langenbeck 
and  Marti neau. — (See  Lithotomy.)  The  termination 
of  the  groove,  at  the  end  of  the  instrument,  should  be 
closed  so  as  to  stop  the  farther  entrance  of  the  gorget, 

. and  prevent  the  beak  of  the  latter  instrument  from 
doing  mischief.  English  surgeons  have  been  justly 
censured  by  Desault  and  Sabatier,  for  neglecting  this 
essential  caution ; for  certainly  the  most  fatal  injury 
may  be  done  by  the  gorget  slipping  beyond  the  end  of 
the  staff. — (See  Lithotomy.)  For  my  own  part,  if  I 
am  more  sure  of  any  one  thing  in  surgery  than  another, 
it  is  this,  that  the  beak  of  a gorget  in  the  bladder  ought 
never  to  pass  out  of  or  beyond  the  groove  on  the  staff. 

STAPHYLOMA  (from  aratpvXil,  a grape,  from 
its  being  thought  to  resemble  a grape),  is  that  disease 
of  the  eyeball,  in  which  the  cornea  loses  its  natural 
transparency,  rises  above  the  level  of  the  eye,  and 
even  projects  beyond  the  eyelids,  in  the  form  of  an 
elongated,  whitish,  or  pearl-coloured  tumour,  which  is 
sometimes  smooth,  sometimes  uneven,  and,  according 
lo  Scarpa,  attended  with  total  loss  of  sight.  How- 
ever, staphyloma  is  either  partial  or  total;  that  is  to 
say,  it  affects  only  a part  or  the  whole  of  the  cornea  ; 
and  in  the  first  ;case,  if  tiiere  be  not  too  much  addi- 
tional injury  of  the  eye,  a degree  of  vision  may  yet  be 
left,  and  even  admit  of  farther  improvement.  The 
circumstance  of  Scarpa’s  observations  applying  only 
to  cases  in  which  the  eyesight  is  already  destroyed,  ac- 
counts for  some  important  differences  between  him 
and  other  writers,  who,  in  the  practice  which  they  ad- 
vise, refer  to  the  partial  staphyloma,  and  cases  in 
which  the  sight  is  not  quite  annihilated.  Scarpa  does 
not  mention  adhesion  of  the  iris  to  the  diseased  cor- 
nea, as  a part  of  the  definition  of  staphyloma  ; a point 
in  which  he  differs  both  from  Richter  and  Beer. — 
{Lehre  von  den  Augenkr.  b.  2,  p.  69.)  However, 
Scarpa  may  be  correct ; for  though,  as  Mr.  Wardrop 
remarks,  “ the  internal  surface  of  the  cornea  adheres 
to  the  iris  in  almost  every  case  of  staphyloma”  {Es- 
says on  the  Morbid  Anat.  of  the  Eye,  vol.  1,  p.  101), 
yet  as  it  does  not  invariably  do  so,  the  circumstance 
forms  no  essential  part  of  the  nature  of  the  disease. 
In  some  instances,  Mr.  Wardrop  has  seen  the  opacity 
confined  to  one  half  of  the  cornea,  generally  the  lower 
one. — {Vol.  cit.  p.  100.) 

Scarpa  observes,  that  infants  are  often  attacked  by 
this  disease  soon  after  their  birth,  and  mostly  in  con- 
sequence of  purulent  ophthalmy.  It  is  also  produced 
by  the  small-pox,  yet  never  during  its  eruption,  nor 
during  the  stage  of  suppuration,  but  when  the  pustules 
dry , and  even  after  the  detachment  of  the  variolous  scabs. 

In  a great  number  of  subjects,  says  Scarpa,  when 
staphyloma  has  attained  a certain  elevation  above  the 
cornea,  it  becomes  stationary,  or  only  increases  in  due 
proportion  to  the  rest  of  the  eye.  In  other  instances, 
the  small  tumour  of  the  cornea  enlarges  in  all  its  dimen- 
sions, and  in  such  a disproportion  to  the  restof  theeye, 
that  at  length  it  protrudes  considerably  between  the  eye- 
lids, to  the  great  molestation  and  deformity  of  the  patient. 

This  disease  is  justly  considered  as  one  of  the  most 
.serious  to  which  the  eyeball  is  subject ; for  to  the  total 
and  irremediable  loss  of  sight  that  it  occasions,  are 
added  all  the  evils  which  necessarily  result  from  the 
bulk  and  protuberance  of  the  staphyloma.  In  such 
circumstances,  the  continual  exposure  of  the  eyeball 
to  the  contact  of  the  air  and  particles  of  matter  sus- 
pended in  it ; the  friction  of  the  eyelashes  ; the  inces- 
sant flux  of  tears  down  the  subjacent  cheek  ; render 
the  eye  painful  and  inflamed  ; the  sound  one  is  af- 
fected by  sympathy,  and  the  diseased  one  at  length  ul- 
cerates, together  with  the  lower  eyelid  and  cheek  on 
which  it  presses. 

According  to  Richter  {Obs.  Chir.  fast.  2),  staphy- 
loma is  generally  formed  without  the  swelling  of  the 
cornea  being  preceded  by  any  of  those  moibific  dispo- 
sitions which  are  usually  considered  capable  of  weak- 
ening the  texture  and  elasticity  of  the  cornea  ; which, 
in  fact,  acquires  a much  greater  thickness  than  what 
it  has  in  its  natural  state,  and  conseqently  staphyloma, 
far  from  being  concave  within,  is  every  where  com- 
p.ict  and  solid  ; though  it  ought  to  be  quite  the  con- 
trary, if  the  tumour  were  occasioned,  as  Beer  yet  ap- 
pears to  believe,  by  an  immoderate  distention  opera- 
ting on  the  cornea  from  within  outwards  with  absorp- 
tion of  its  natural  texture. 

Scarpa  thinks  that  Richter  has  generalized  his  doc- 
trine too  much,  by  not  drawing  any  line  of  distinctioa 


310 


STAPHYLOMA.' 


between  the  staphyloma  of  recent  occurrence  in  in- 
fants and  that  of  adult  subjects,  in  whom  the  disease 
has  acquired  so  large  a volume,  as  to  protrude  con- 
siderably  beyond  the  eyelids.  He  agrees  with  Richter, 
that  the  recent  staphyloma  in  infants  is  quite  compact 
and  solid,  on  account  of  the  augmented  thickness  of 
the  cornea;  but  he  is  convinced  by  repeated  observa- 
tion, that,  in  this  very  same  staphyloma,  originally  quite 
solid  and  compact,  the  cornea  becomes  thinner,  or  at 
all  events  is  not  thicker  than  natural  after  the  disease 
has  existed  a series  of  years  in  adult  subjects,  and  in 
whom  the  swelling  of  the  cornea  has  attained  such  a 
size  as  to  protrude  between  the  eyelids.  The  tumour, 
he  observes,  is  not  solid  throughout,  except  in  regard 
to  its  containing,  in  its  amplffied  state,  the  iris,  the 
crystalline,  and  very  often,  also,  a portion  of  the  vi- 
treous humour. 

The  cornea  of  infants  in  its  natural  state  is  at  least 
twice  as  thick  and  pulpy  as  that  of  adults,  and  conse- 
quently the  anterior  chamber  of  the  aqueous  humour 
in  the  former  is  comparatively  so  contracted  to  what 
it  is  in  the  latter,  that  in  infants  at  the  breast  the  cor- 
nea may  be  considered  as  in  contact  with  the  iris. 

To  such  qualities  of  the  cornea,  in  children  of  len- 
der years,  and  to  the  natural  narrowness  of  the  ante- 
rior chamber  of  the  aqueous  humour,  Scarpa  imputes 
the  cause  why  ophthalmies  in  inlanis  so  often  produce 
opacity  and  thickening  of  this  membrane.  The  cornea 
swells,  becomes  preternaturally  thickened,  and  is  very 
soon  converted  into  a pointed,  whitish,  or  pearl-coloured 
tumour,  without  any  cavity  internally,  and  either  in 
perfect  contact  with,  or  adherent  to,  the  iris.  In  the 
course  of  years,  however,  this  disease  undergoes  new 
modifications.  For,  as  the  whole  eye  enlarges  with 
age,  the  iris  and  crystalline  lens,  from  causes  not  suffi- 
ciently understood,  abandon  their  natural  situation, 
and  are  propelled  forwards,  nearer  and  nearer  to  the 
cornea,  which  they  in  lime  distend  in  all  its  dimen- 
sions, so  as  to  make  it  project  beyond  the  eyelids,  at 
the  same  time  rendering  it  thinner  in  a ratio  to  its 
bulk  and  magnitude.  Scarpa  has  never  met  with  a 
voluminous  staphyloma,  projecting  beyond  the  eyelids 
in  adult  persons,  which  had  not  originally  made  its 
first  appearance  in  infancy  ; and  he  has  invariably 
found  that  the  thickness  and  density  of  the  cornea, 
both  in  the  living  and  dead  bodies  of  those  who  have 
been  affected  with  this  disease,  were  in  an  inverse 
ratio  to  the  eye.  In  inveterate  cases  of  staphyloma, 
forming  a large  protuberance  beyond  the  eyelids,  the 
iris  may  here  and  there  be  clearly  discerned  through 
the  diseased  cornea,  and  if  it  be  not  equally  manifest 
at  all  points  of  the  tumour,  it  is  because  the  conjunctiva 
externally  spread  over  the  cornea  forms,  in  conjunction 
with  its  varicose  vessels,  on  the  surface  of  the  tumour 
a stratum  of  matter  not  every  where  equally  dense  and 
opaque.  This  dense  stratum  of  the  conjunctiva  spread 
over  the  cornea  easily  causes  deception  in  a staphy- 
loma of  considerable  bulk.  The  more  the  tumour  in- 
creases, the  more  the  substance  of  the  cornea  seems  to 
become  dense  and  thickened ; while,  in  reality,  the 
contrary  happens.;  for  the  augmentation  in  the  density 
of  the  layer  of^!he  conjunctiva,  covering  the  cornea, 
only  partly  supplies  the  diminution  in  the  thickness  of 
the  latter  membrane.  In  staphyloma,  as  Mr.  Wardrop 
observes,  “ the  pupil  is  hid  according  to  the  situation 
and  degree  of  the  opacity  of  the  cornea  ; but,  in  most 
cases,  it  is  altogether  obliterated,  and  even  in  those 
where  a transparent  portion  of  the  cornea  is  opposite 
to  it,  the  vision  is  much  impaired  ; for,  as  the  eye  has 
lost  its  form  as  an  optical  instrument,  the  change  in 
its  refractive  power  must  render  objects  very  indis~ 
tinct." — {Morb.  Mnat.  of  the  Eye,  voL  1,  p.  101.) 

The  sclerotica  is  also  subject  to  staphyloma,  that  is, 
to  a partial  distention  and  prominence  of  its  anterior 
hemisphere  in  the  white  of  the  eye.  Scarpa  never  j 
met  with  any  tumour  or  prominence  on  the  front  sur-  | 
face  of  the  sclerotica,  corresponding  to  the  white  of  the 
eye ; but  in  the  dead  subject  he  has  met  with  two  e.x- 
ainples  of  staphyloma  in  the  posterior  hemisphere  of 
the  sclerotica.  According  to  Mr.  Travers,  in  the  sphe- 
roidal staphyloma  of  the  cornea,  the  sclerotica  some- 
times yields  so  much  as  greatly  to  increase  the  deformity. 
“This  happens  in  hydropic  and  other  degenerations  of 
the  humours.  It  also  frequently  becomes  attenuated  ; 
or  bulged,  near  its  junction  with  the  cornea,  in  the 
amaurosis  which  follows  inflammation  of  the  choroid. 
This  protrusion,  larger  or  smaller,  is  sometimes  cir- 


cumscribed, and  in  other  Instances  diffijsed  over  a large 
portion  of  the  ball.  It  is  often  seen  encircling  the 
cornea,  and  presenting  a sacculated  or  pouched  appear- 
ance. It  has  a bluish-gray  tint,”  ice.— {Synopsis  of 
the  Diseases  of  the  Eye,  p.  130.) 

When,  in  the  staphyloma  of  the  cornea,  this  part  is 
aflected  with  irremediable  opacity,  Scarpa  thinks  that 
if  the  disease  be  recent,  and  in  a cliild,  the  only  object 
must  be  to  hinder  the  increase  of  the  swelling  of  the 
cornea,  the  organization  of  which  is  already  destroyed. 
The  tumour  must  be  levelled  and  flattened  as  much 
as  possible ; and  when  the  swellirrg  of  the  cornea  is 
inveterate,  very  large,  and  prominent  beyond  the  eye- 
lids, it  is  to  be  diminished  by  surgical  means,  so  that  it 
may  return  within  the  orbit,  sufficiently  to  permit  the 
deformity  of  the  face  to  be  amended  by  the  application 
of  an  artificial  eye. 

• In  cases  of  recent  staphyloma,  Richter  used  to  make 
at  the  Irottom  of  the  tumour  of  the  cornea  an  artificial 
ulcer,  by  repeatedly  applying  the  argentifm  nitratum, 
or  the  oxygenated  muriate  of  antimony  (butter  of  anti- 
mony), and  to  keep  the  little  sore  open  by  the  conti- 
nued use  of  the  same  caustic,  with  the  view  of  eflecting 
a diminution  of  the  swelling  of  the  cornea.  In  this 
way  he  frequently  succeeded  in  lessening  staphyloma, 
and  in  one  particular  case,  he  even  restored  the  trans- 
parency of  the  cornea.  Ter  repetitd  operations,  quarto 
scilicet,  septimo  et  decimo  die,  ne  vestigium  quidem 
morbi  die  decimo-quarto  svperabat.  Obs.  Chir.  fasci- 
culus 2.  In  this  plan,  Mr.  Guthrie  conceives" that 
Richter  evidently  meant  that  the  small  ulcer  made 
with  the  caustic  should  penetrate  the  cornea ; and 
that  from  not  comprehending  this  particular,  Scarpa’s 
trials  of  the  method  were  unsuccessful. — (Operative 
Surgery  of  the  Eye,  p.  175  ) It  appears,  however, 
that  Richter  himself  never  intended  nor  attempted  any 
thing  more,  than  what  Scarpa  did  afterward;  for  he 
expressly  cautions  the  surgeon  not  to  let  the  caustic 
penetrate  through  the  cornea.  This  meaning,  indeed, 
admits  of  no  doubt:  in  his  chapter  on  staphyloma,  he 
refers  for  the  description  of  the  method  to  his  observa- 
tions on  leucoma  {Anfangsgr.  S-c.  b.  3,  p.  138,  139), 
<vhere  it  is  distinctly  slated,  “ immer  muss  man  wohl 
darauf  merken  dass  das  geschwiir  nich  zu  tief  in  die 
homhaut  eindrivgt,  und  dieselbe  ganz  und  gar  durch- 
frisst."  Richter  does  not  claim  the  proposal  as  one 
originally  made  by  himself,  but  mentions  it  as  a sug- 
gestion made  by  Giinz.— (Z)rss.  de  Staphylomate.) 

Though  Scarpa  frequently  attempted  to  cure  the 
recent  staphyloma  of  infants  by  the  above  method,  he 
never  met  with  such  success  as  could  be  at  all  com- 
pared with  Richter’s,  either  in  restoring  the  transpa- 
rency of  the  cornea,  or  accomplishing  a diminution  of 
the  volume  of  the  staphyloma.  Having  formed  with 
the  argentum  nitratum  a small  ulcer  at  the  bottom  of 
the  cornea,  and  kept  the  sore  open  thirty  days  and 
more,  he  failed  in  obtaining  any  benefit,  in  respect  to 
the  diminution,  much  less  the  opacity,  of  the  cornea,  in 
three  infants,  one  a year  and  a half  old,  and  the  two 
others  somewhat  more  than  three,  all  which  subjects 
had  been  recently  attacked  by  staphyloma  in  one  eye, 
in  consequence  of  the  small- po.x.  A violent  chemosis, 
in  a very  short  time,  produced  a staphyloma  in  the  eye 
of  a child  five  years  old.  Scarpa  made  an  ulcer  at  the 
bottom  of  the  cornea,  into  the  unorganized  swollen 
substance  of  which  he  introduced,  for  a little  depth, 
the  flat  part  of  a lancet.  'I’he  sore  was  kept  open  for 
five  weeks,  with  a solution  of  the  argentum  nitratum, 
and  the  staphyloma  became  somewhat  flatter,  so  as  to 
lose  the  acute  prominence  in  its  centre ; but  the  cornea 
continued,  as  before,  every  where  opaque.  Though 
Scarpa  emjtloyed  the  same  method  in  two  other  sub- 
jects, of  about  the  same  age  and  in  the  same  circum 
stances  ; though  he  kept  the  ulcer  open  fifty  days  ; he- 
was  never  able  to  effect  any  depression  or  diminution 
of  the  staphyloma ; and,  consequently,  the  pointed, 
pearl  coloured,  projecting  part  of  the  tumour  continued 
in  the  same  state  as  it  was  before.  The  conical  shajic 
which  the  cornea  assumes  in  this  disease,  he  observes, 
is  a characteristic  symptom,  by  which  a staphyloma 
may  be  distinguished  from  a leucoma,  with  total  opa- 
city of  the  cornea. 

if,  also,  in  the  course  of  farther  trials,  partial  benefit 
be  found  to  accrue  from  this  plan,  adopted  not  for  the 
purpose  of  re-estahlishimr  the  transparency  of  the  cor- 
nea, but  for  that  of  merely  checking  and  diminishing 
the  recent  staphyloma  in  infants,  still  Scarpa  is  of 


STAPHYLOMA. 


311 


opinion,  tlial  no  one  will  be  easily  persuaded  that  the 
aatne  treatment  can  ever  prove  of  the  least  service  in 
diminishing  the  size  of  the  large,  inveterate  siapliyloma 
III  adults;  in  other  words,  of  that  which  projects  be- 
yond the  eyelids  and  rests  on  the  cheek.  Under  these 
eircumstances,  he  believes  that  there  is  no  effectual 
means  of  restraining  the  progress  of  the  complaint, 
and  removing  the  deformity,  but  cutting  away  tlie 
Btaphyloiiia. 

Mr.  Guthrie  considers  Scarpa’s  application  of  Rich- 
ler’s  method  to  young  subjects  erroneous,  because  the 
thickness  of  the  cornea  in  them  prevents  the  caustic 
from  quickly  penetrating  the  anterior  chamber,  and 
Hconsiderable  inflaniniation  is  brought  on. — {^Operative 
Surgery  of  the  Eye,  p.  175.)  It  is  to  be  recollected, 
however,  that  Scar|«,  when  he  tried  Richter’s  plan, 
never  meant  the  caustic  to  penetrate  the  anterior 
chamber,  but  merely  to  form  and  keep  up  a sort  of 
Issue,  the  exact  principle  of  treatment  which  Richter 
himself  intended. 

Celsus  describes  two  modes  of  cure;  viz.  that  with 
a ligature,  and  the  removal  of  a portion  of  the  conical 
jnost- projecting  part  of  tlie  diseased  cornea. — f,Lib.  9, 
xap.  7.) 

Though,  says  Scarpa,  the  first  plan,  or  that  of  the 
ligature,  is  at  present  abandoned,  the  majority  of  sur- 
geons still  persevere  in  passing  a needle  and  ligature 
through  the  lower  part  of  the  staphyloma,  not  for  the 
purpose  of  tying  or  constricting  the  tumour,  it  is  true, 
but  of  making  a noose,  in  order  to  fix  the  eye  conveni- 
ently, when  the  staphyloma  is  to  be  cutoff  in  a circular 
manner.  This  use  of  a needle  and  ligature,  which,  I 
observe,  is  sanctioned  by  Mr.  Travers  {Synopsis,  c^c. 

285h  is  strongly  disapproved  of  by  Scarpa. 

With  regard  to  the  second  method  of  removing  the 
staphyloma,  or  that  of  excision,  Scarpa  thinks  that 
sufficient  attention  hasnotbeen  paid  to  the  directions 
of  Celsus,  that  this  operation  should  be  done  in  the 
centre  or  conical  point  of  the  tumour,  and  that  as 
much  of  this  part  of  the  staphyloma  ought  to  be  cut 
away  as  will  equal  a lentil  in  size  ; In  summd  parte 
gus  ad  lenticuloe  magnitudinem  exscindere.  Scarpa 
remarks,  that  the  great  importance  of  this  precept  can 
be  duly  appreciated  only  by  those  who  have  often 
had  occasion  to  compare  the  advantages  of  Celsus’s 
doctrine,  with  the  serious  inconveniences  which  result 
from  the  practice  of  cutting  away  the  staphyloma  cir- 
cularly at  its  base;  and  with  the  evils  produced  by  a 
semicircular  section,  comprehending  the  sclerotica,  in 
Woolhouse’s  manner,  always  followed  by  acute  in- 
flammation of  the  eyeball  and  eyelids,  violent  pains  in 
the  head,  restlessness,  spasms,  copious  and  sometimes 
gangrenous  suppurations  of  the  eye  and  eyelids. 

The  patient  being  seated,  Scarpa  directs  an  assistant 
to  support  his  head  properly;  then  taking  in  his  hand 
a knife,  similar  to  what  is  used  in  the  extraction  of  the 
cataract,  he  passes  the  instrument  completely  across 
the  staphyloma,  at  the  distance  of  one  line  and  a half, 
or  two  lines,  from  the  centre  or  apex  of  the  tumour, 
from  the  external  towards  the  internal  angle  of  the 
eye,  and,  by  passing  the  knife  forwards  in  the  same 
direction,  just  as  is  done  in  the  extraction  of  the  cata- 
ract, he  makes  a semicircular  incision  downwards,  in 
the  most  prominent  part  of  the  tumour.  Having  done 
this,  he  takes  hold  of  the  segment  of  the  staphyloma 
with  the  forceps,  and  turning  the  edge  of  the  knife 
upwards,  he  completes  the  circular  recision  of  the  apex 
of  the  tumour,  in  such  a way  that  the  detached  portion 
is  one,  two,  three,  or  four  lines  in  diameter,  according 
to  the  size  of  the  staphyloma.  As  a portion  of  the 
iris  adhering  to  the  cornea  from  the  very  commence- 
ment of  the  disease  is  commonly  included  in  this  sec- 
tion of  the  pointed  part  of  the  tumour,  no  sooner  is  the 
circular  division  of  the  apex  of  the  staphyloma  made, 
than  the  crystalline,  or  its  nucleus,  issues  from  the 
eye,  followed  by  a portion  of  the  vitreous  humour.  In 
consequence  of  this  evacuation,  the  eyeball  is  often  so 
diminished,  that  it  can  be  covered  by  the  eyelids,  to 
which  Scarpa  immediately  applies  a pledget  of  dry 
lint,  supiiorted  by  a retentive  bandage. 

When  the  eye  and  eyelids  beuin  to  be  painful,  in- 
flame, and  swell,  as  they  generally  do  on  the  fourth 
day,  I he  eye  is  to  lie  covered  with  a bread  and  milk 
pouliice.  When  things  proceed  in  a regular  manner, 
ihe  swellins  of  the  eyelids  subsides  about  the  seventh 
or  ninth  day,  and  purulent  matter  is  seen  on  the  poul- 
tice, blended  with  the  vitreous  humour.  'I’he  matter 


afterward  becomes  thick  and  whitish,  the  patient 
feels  great  relief,  and  the  eyeball  shrinks  and  sinks 
into  the  orbit. 

At  this  period,  on  gently  separating  the  eyelids,  the 
conjunctiva  is  found  swelled,  and  reddish,  and  the 
margin  of  the  wound  seems  like  a whitish  circle.  This 
is  usually  detached  on  the  twelfth  or  fourteenth  day 
after  the  operation,  when  the  edge  of  the  surface  from 
which  the  staphyloma  was  cut  becomes.red,  contracts, 
and  daily  ditninishes,  so  that  at  last  the  wound  is  en- 
tirely closed.  There  only  remains  in  the  centre  of  the 
cornea,  for  a few  days,  a small  fleshy  prominence, 
resembling  a little  reddish  papilla,  which,  after  being 
touched  a few  times  with  the  argentum  nitratum, 
contracts  ^ind  heals. 

So  far,  says  Scarpa,  are  alarming  symptoms  from 
following  this  operation,  that  in  a great  number  of 
cases  the  surgeon  is  even  obliged,  several  days  after- 
ward, to  stimulate  the  e3'e  on  which  it  ha.s  been  per- 
formed, in  order  to  make  it  inflame,  partly  by  leaving 
it  a long  while  uncovered  and  exposed  to  the  air,  partly 
by  enlarging  the  circular  reci?ion  made  in  the  centre  of 
the  stapliyloma,  of  which  another  circular  portion  half 
a line  broad  is  removed,  in  order  to  facilitate  the  more 
abundant  dischai^e  of  the  hurnonrs,  and  the  ingress  of 
air  into  the  cavities  of  the  eye  which  are  so  backward 
to  inflame.  As  soon  as  inflammation  has  invaded  the 
interior  of  the  eye,  and  suppuration  has  taken  place, 
the  rest  of  the  cure  regularly  follows  under  the  use  of 
topical  emollients,  and  is  soon  completed  with  all  pos- 
sible mildness. 

It  should  be  particularly  recollected,  that  Scarpa 
means  the  foregoing  practice  for  inveterate  cases  of 
staphyloma,  where  the  eyesight  is  totally  lost,  and  the 
projection  of  the  diseased  cornea  produces  serious  an- 
noyance. Under  other  circumstances  it  is  not  admis- 
sible. Among  others.  Dr.  Vetch  particularly  objects 
to  the  removal  of  the  apex  of  the  tumour,  as  desti  ac- 
tive of  all  chance  of  the  recovery  of  a degree  of  vision  ; 
a consideration,  however,  which  would  not  exist  in 
the  hopeless  cases  spoken  of  by  Scarpa.  Dr.  Vetch  also 
disapproves  of  letting  out  the  aqueous  humour  in  cases 
of  staphyloma,  as  an  endless  operation  from  which  no 
permanent  effect  takes  place,  the  humour  collecting 
again  in  a few  hours:  a sentiment  which  is  likewise 
expressed  by  Mr. Travers. — (See  Vetch  on  the  Diseases 
of  the  Eye,  p.  63 ; and  B.  Travers,  Synopsis,  Src.  p. 
^6.)  For  the  purpose  of  accomplishing  the  gradual 
diminution  of  the  tumour,  and  bringing  the  eye  into  a 
state  in  which  an  artificial  pupil  may  be  made,  Dr.  Vetch 
has  employed  caustic  (the  method  commended  both  by 
Richter  and  Beer),  and  the  introduction  of  a seton 
through  the  tumour.  Beer  confirms  the  statement  of 
Scarpa,  concerning  the  impossibility  of  restoring  the 
transparency  of  any  part  of  the  cornea  affected  with 
staphyloma.  For  the  relief  of  a partial  staphyloma, 
he  prefers  the  cautious  application  of  the  oxygenated 
muriate  of  antimony,  by  means  of  the  pointof  acamel- 
hair  brush,  while  the  eyelids  are  held  asunder.  The 
diseased  part  of  the  cornea  is  to  be  smeared  with  k 
until  a small  white  superficial  slough  is  formed,  when 
every  particle  of  the  caustic  must  be  immediately 
washed  out  of  the  eye  with  another  larger  camel-hair 
brush  dipped  in  water  or'milk.  The  application  is  not 
to  be  repeated,  until  the  subsequent  inflammation  has 
quite  subsided,  and  the  slough  been  thrown  off’.  Beer 
condemns  all  escharotic  salves,  because  their  action  ex- 
tends to  parts  which  should  be  left  unirritated. — {Lehre 
von  den  Jivgenkr.  b.  2,  p.  74.)  Mr.  Guthrie  regards 
the  treatment  with  caustic  as  only  applicable  to  cases 
in  adult  subjects,  where  the  disea.«<‘d  cornea  is  thin, 
and  the  sclerotica  nearly  or  quite  healthy.  7'he  knife, 
he  says,  is  requisite  in  young  or  old  individuals,  where 
the  staphyloma  is  evidently  thick  and  hard,  and  the 
front  of  the  eye  more  or  less  varicose — {Operative 
Surgery  of  the  Eye,  p.  174.)  In  this  last  condition,  in- 
dicated by  the  bluish,  leaden  apnearance  of  the  sclero- 
tica, which  sermis  to  be  penetrated  close  to  the  cornea 
by  many  tortuous  dark-red  vessels,  and  ac  ompanied 
in  a more  advanced  stage  by  a bulgiric  out  of  pariicular 
parts  in  the  same  situation,  he  says,  “ the  anterior  por- 
tion of  the  eye  ought  to  be  removed,  and  wiili  it  the 
vessels  which  are  in  a varicose  state.” — (P.  178.) 

Wenzel  and  numerous  other  writers  imply  by  slnphy- 
bma,  a protrusion  cf  a piece  of  the  iris  through  a wound 
nr  ulcer  of  the  eye. — (See  Iris,  Prolapses  of.) 

R.  Fr.  B.  iloeliler,  Dc  Stuphylomate,  Tubingae,  1748. 


312 


SUP 


SUL 

Scarpa  suUe  Malattie  degli  Occhi,  ed.  5.  G.  J.  Beer's 
Jinsic/it  der  Staphylomatosen  jMetamorphosen  dcs 
jiuges,  (S-c.  Wien,  1^5.  J\fachtrag  zur  Ansicht,  ^c. 
1806;  and  Lehre  von  den  Augenkr.  b.  2,  p.  69,  8co. 
Wien,  1817.  RicUer,  AnfangsgrUnde  der  Wundari- 
neykunst,  b.  3,  p.  153,  i c.  Gott.  1795.  Sabatier,  J\Ie- 
decine  Operatoire,  t,  2,p.  191,  ed.  2,1810.  James  War- 
drop,  Essays  on  the  Morbid  Anatomy  of  the  Human 
Eye,  vol.  1,  p.  99,  8vo.  Edinb.  1808.  B.  leavers, 
Synopsis  of  the  Diseases  of  the  Eye,  8vo.  Eond.  1820. 
J.  Vetch,  A Practical  Treatise  on  the  Diseases  of  the 
Eye,  8oo.  Land.  1821.  G.  J.  Guthrie,  Operative  Sur- 
gery of  the  Eye,  8vo.  Lond.  1823.  G.  Frick  on  Dis- 
eases of  the  Eye,  ed.  2,  by  Welbank,  p.  101,  8vo.  Lond. 
1826. 

STEATOM.'\.  (From  areap,  fat.)  A wen  or  en- 
cysted tumour  containing  fat. — (See  Tumours,  En- 
cysted.) 

STELLA,  or  STELLATED  BANDAGE.  A band- 
age, so  named  because  it  makes  a cross  or  star  on  the 
back.  It  is  u roller  applied  in  the  form  of  the  figure  8, 
BO  as  to  keep  back  the  shoulders.  It  is  often  employed 
in  cases  of  fractures  and  dislocations  of  the  clavicle 

STRA.MON1U.M.  A series  of  interesting  experi- 
ments were  detailed  in  illustration  of  the  properties  of 
Btrainonium  in  a Dissertation,  which  was  read  to  the 
Medical  Faculty  of  the  University  of  Pennsylvania,  on 
the  12th  of  May,  1797,  by  Dr.  Samuel  Cooper,  The  ex- 
periments No.  15  and  16  merit  particular  notice  in  this 
Dictionary,  as  being  perhaps  the  earliest  discovery  of' 
the  effect  of  the  local  application  of  powerful  narcotics 
in  dilating  the  pupil.  A drop  of  an  infusion  of  the 
powder  of  stramonium  was  let  fall  into  the  left  eye. 
In  half  an  hour  the  pupil  began  to  enlarge,  and  attained 
its  greatest  dimensions  about  twelve  hours  after  the 
experiment,  at  which  time  it  was  viewed  in  a consider- 
able light,  and  seemed  thrice  as  large  as  the  other.  It 
continued  dilated  two  days.  In  a strong  light  objects 
were  seen  more  distinctly  with  the  right  eye ; but  in  a 
weak  light  with  the  left.  Some  other  gentlemen,  how- 
ever, on  whom  the  experiment  was  tried,  experienced 
no  increased  power  of  seeing  in  the  dark.  A drop  of 
tlte  expressed  juice  dropped  into  the  eye  of  a cat,  soon 
converted  the  whole  of  the  coloured  part  of  the  eye  into 
pupil.-T-(See  Caldwell's  Medical  Theses,  p.  173,  8vo. 
Philadelphia,  1805.)  Stramonium  then  resembles  bel- 
ladonna and  hyoscyamus  in  its  action  upon  the  iris. 
It  has  been  exhibited  internally  in  epilepsy,  tic  doulou- 
reux, and  severe  chronic  pains,  and  used  in  poultices 
for  dispersing  indurations  of  the  breast,  and  in  oint- 
ments for  allaying  the  pain  of  piles.  The  doses  should 
at  first  be  only  gr.  ss.  of  the  e.xiract  twice  a day,  but 
they  may  be  gradually  increased  to  five  grains, 

[Stramonium  has  acquired  great  reputation  in  this 
country  in  the  treatment  of  tic  douloureux,  and  espe- 
cially in  rheumatism.  In  this  latter  disease  it  is  used 
externally  and  internally,  and  is  the  basis  of  very  many 
empirical  anti-rheumatics.  It  is  generally  preferred  in 
the  form  of  tincture  as  an  external  application,  though 
frequently  used  in  the  form  of  an  unguent,  prepared  by 
boiling  the  fresh  leaves  in  hog’s  lard. — Reese.] 

STRICTURE.  (From  stringo,  to  bind.)  A con- 
tracted state  of  some  part  of  a tube  or  duct. — (See  Ure- 
thra, Strictures  of;  (Esophagus,  .S'C-,  Rectum,  ^c.) 
Stricture  also  means,  in  cases  of  strangulated  hernia, 
the  narrowest  part  of  the  opening  or  passage  through 
which  the  bowels  protrude. — (See  Hernia.) 

STRU.MA.  (From  strwo,  to  heap  up.)  Scrofula  or 
gcropliula.  The  king’s  evil.— (See  Scrofula.) 

STYE.  A little  inflammatory  tumour  on  the  eyelid. 
^(See  Hordeolum.) 

SULPHURIC  ACID.  The  strong  sulphuric  acid  is 
used  as  a means  of  extricating  from  the  nitrate  of  pot- 
ash, or  muriate  of  soda,  certain  gases  for  the  pur^se 
of  purifying  the  air  of  sick  rooms  or  infected  places. 
A few  practitioners  have  also  sometimes  employed  it, 
blended  with  sixteen  times  its  weight  of  lard,  as  a local 
application  for  the  cure  of  scabies.  One  drachm  of  it, 
mixed  with  an  ounce  of  lard,  is  sometimes  rubbed  upon 
diseased  joints,  and  with  considerable  effect  when  the 
right  cases  are  selected. — (See  Joints.)  As  a caustic, 
this  acid  is  not  generally  eligible,  because  it  is  difficult 
to  limit  its  operation  exactly  to  the  parts  which  are  in- 
tended to  be  destroyed.  A few  years  ago,  a profwsal 
was  made  to  apply  it  along  the  outside  of  the  eyelid  in 
cases  of  trichiasis,  so  as  to  produce  a slough  and  sub- 
sequent ulcer,  the  cicatrization  of  which  would  draw 


out  the  inverted  tarsus.  Nay,  it  is  alleged  that  tbe  ap- 
plication sometimes  produces  an  instantaneous  amend- 
ment of  the  position  of  the  eyelid.  I have  seen  one 
example  in  which  the  experiment  was  tried ; but  whe- 
ther it  was  owing  to  the  acid  not  having  been  suffi- 
ciently applied  or  other  causes,  the  method  did  not  an- 
swer so  well  as  the  usual  plan  of  removing  a part  of 
the  integuments  w ilh  a cutting  instrument.  Sulphuric 
acid  has  also  been  employed  in  the  cure  of  ectropium. 
— (See  this  word.) 

Diluted  sulphuric  acid  is  frequently  employed  as  an 
ingredient  in  gargles.  It  is  also  commonly  exhibited 
with  a view  of  checking  passive  hemorrhages,  and  pro- 
fuse nocturnal  sweats  in  hectic  fever.  The  dose  is 
from  ten  to  thirty  drops. 

This  acid  in  the  diluted  form  has  been  tried  in  vene- 
real cases.  According  to  Mr.  Pearson,  when  a bad 
state  of  health  prohibits  the  introduction  of  mercury, 
the  case  has  not  yet  put  on  an  unequivocal  appearance, 
or  dyspeptic  symptoms,  attended  with  profuse  perspi- 
ration^ harass  the  patient,  it  is  a useful  remedy,  capa- 
ble of  giving  a temporary  check  to  the  progress  of  the 
disease.  He  says,  that  he  has  often  seen  it  arrest  the 
progress  of  venereal  ulcers  of  the  tonsils,  and  make 
venereal  eruptions  fade  and  nearly  disappear  ; but  that 
these  beneficial  effects  were  never  permanent.  At  the 
same  time  he  acknowledges  that  the  medicine  will 
confer  actual  and  durable  benefit  in  ulcers  of  the  penis, 
groin,  and  throat,  sometimes  remaining  stationary  after 
a mercurial  course.  He  has  likewise  found  this  acid 
very  efficient  when  mercury  acts  too  violently  upon  the 
mouth. — (See  Pearson's  Obs.  on  the  Effects  of  various 
Articles  in  the  Cure  of  Lues  Veiurea,  p.  189 — 191, 
ed.  2.) 

In  cases  of  poison  by  sulphuric  acid,  the  most  suc- 
cessful treatment  consists  in  making  the  patient  drink 
large  quantities  of  water,  in  which  calcined  magnesia 
is  suspended.  Should  this  last  n.edicine,  however, 
not  be  at  hand,  soap  blended  w’ith  w'ater  is  the  best 
substitute.  While  these  remedies  are  preparing,  co. 
pious  draughts  of  some  mucilaginous  beverage,  milk, 
or  even  of  common  water,  should  be  administered 
without  delay;  for  the  practitioner  should  ever  be 
mindful,  that  so  rapidly  does  sulphuric  acid  operate 
upon  the  texture  of  tbe  parts  with  which  it  comes  into 
contact,  that  all  chance  of  saving  the  patient  must  de- 
pend upon  the  quickness  with  which  the  means  to 
counteract  the  poison  are  applied.  After  the  acid  has 
been  diluted  and  neutralized,  local  and  general  bleed- 
ing, emollient  clysters,  and  mucilaginous  drinks  com 
stitute  the  best  remedies. — {OrfUa,  Traite  des  Poisons, 
(S-c.  vol.  I,  p 4.34,  ed.  2.) 

SUPPRESSION  OF  URINE.  See  Urine,  Reten- 
tion of. 

SUPPURATION.  A process  by  which  a peculiar 
fluid,  termed  pus,  is  formed  in  the  substance,  or  fioin 
the  surface  of  parts  of  the  body.  From  observations 
in  the  article  Inflammation  it  appears,  that  when  this 
last  affection  is  above  a certain  pitch,  it  sometimes  ter- 
minates in  suppuration. 

When  purulent  matter  accumulates  in  the  part  aL 
fected,  it  is  termed  an  abscess,  which  is  distinguished 
into  several  kinds — acute,  chronic,  venereal,  scrofu- 
Ions,  6rc. 

It  is  observed  by  Professor  Thomson,  that  the  tex- 
ture in  which  suppuration  seems  to  be  most  readily 
produced  by  a certain  degree  of  inflammation,  is  mu- 
cous membrane,  whether  this  lines  excretory  ducts  or 
canals,  or  covers  the  inner  surfaces  of  the  respiratory 
or  urinary  organs.  In  a few  hours  after  an  irritating 
cause  has  been  applied  to  these  surfaces,  the  physical 
and  chemical  qualities  of  the  fluid  which  they  secrete 
in  their  natural  state  are  chaneed.  From  being  a 
tough,  viscid  substance,  not  easily  miscible  with  wa- 
ter, the  mucus  of  the  nose  and  bronchia  becomes, 
during  an  attack  of  inflammation,  very  readily  miscible 
with  water,  of  a yellowish-white  colour,  and  fluid  con- 
sistence. If  in  this  state  tbe  secretion  from  these  mem- 
branes be  examined  with  the  microscope,  it  will  be 
found  to  contain  small  globules,  similar  to  those  which 
are  seen  in  the  blood  ; and  these  globules  are  found  to 
increase  in  number  in  proportion  to  the  degree  and 
continuance  of  the  inflammation.  We  have  examples 
of  the  production  of  this  pus,  or  at  least  of  a puriform 
fluid,  in  the  respiratory  organs  of  persons  affected  with 
catarrh,  and  in  the  urinary  organs  of  those  who  labour 
under  gonorrhoea.  In  the  progress  of  these  diseases  ws 


SUPPURATION. 


313 


«3n  generally  trac€  the  changes  which  take  place  by 
alow  but  sensible  degrees  in  the  nature  of  the  secretion, 
from  mucus  to  pus,  and  from  pus  back  again  to  the 
slate  of  mucus.  This  piiriform  discharge  from  mucous 
membranes  in  a state  of  inflammation  may  be  kept  up 
for  months  without  these  membranes  appearing  to  un- 
dergo any  other  morbid  changes  than  a slight  degree  of 
redness  and  swelling.  A loss  of  substance  or  ulcera- 
tion is  found  not  to  happen  oflener  than  in  one  case  out 
of  ten  examples  of  suppuration  from  mucous  mem- 
branes.— {On  Inflammation, p.  305,  306.) 

The  same  well-informed  writer  afterward  proceeds 
to  explain,  that  suppuration  may  be  readily  produced 
in  the  skin  or  cutaneous  texture,  by  whatever  excites 
inflammation  in  that  texture,  and  causes  a separation 
of  the  cuticle.  We  have  examples  of  this  fact  in 
blisters  from  cantharides,  and  in  vesications  of  the  cu- 
ticle from  superficial  burns.  If  the  cuticle  covering  a 
recent  blister  or  burn  be  removed,  and  the  cutis  ex- 
posed to  the  irritation  of  stimulating  substances,  pus 
will  soon  be  discharged  from  the  abraded  surface. 
Su^iuraiion  can  be  kept  up  in  cutaneous  texture  for 
an  indefinite  length  of  time,  as  we  see  done  every  day 
ill  the  management  of  perpetual  blisters.  Ulceration 
is  seldom  observed  in  these  cases,  and,  consequently, 
in  cutaneous  texture,  loss  of  substance  is  by  no  means 
necessary  for  the  production  of  pus. 

If  the  cutis  be  divided,  as  in  a wound,  or  a portion 
of  it  removed,  as  in  the  extirpation  of  tumours,  and 
either  the  air  or  any  other  external  body  be  permitted 
to  remain  in  contact  with  the  divided  surfaces,  the 
process  of  suppuration  is  speedily  induced  in  the  cel- 
lular texture  subjacent  to  the  skin.  After  the  hemor- 
rhage which  takes  place  from  the  small  vessels  has 
ceased,  an  oozing  of  a fluid,  at  first  resembling  serum, 
occurs,  which  is  gradually  changed  into  pus.  But  in 
this  case,  as  Dr.  Thomson  has  correctly  observed,  the 
surface  of  the  wound  is  previously  covered  with  a 
layer  of  coagulable  lymph,  which  is  penetrated  with 
blood-vessels,  and  gradually  raised  into  the  little  red 
eminences  termed  granulations. 

Appearances  similar,  though  slighter  in  degree,  says 
Dr.  Thomson,  are  observed  in  cutaneous  suppuration ; 
giving  probability  to  the  opinion  of  Sir  E.  Home,  that 
in  infiammation  a vascular  surface  is  produced  pre- 
viously to  the  formation  of  pus  in  a cellular  membrane, 
and  perhaps  also  in  cutaneous  texture.  Dr.  Thomson 
is  inclined  to  believe,  however,  that  no  new  vascular 
surface  is  generated  in  the  inflammation  of  mucous 
membrane.  Thus  we  see,  that  in  the  formation  of  pus 
in  mucous  membrane,  cutaneous  texture,  and  exposed 
cellular  substance,  no  ulceration,  no  breach  of  sub- 
stance occurs;  but  that,  on  the  contrary,  in  two  of 
these  textures,  the  cutaneous  and  cellular,  there  is  an 
addition  made  to  the  parts  by  the  exudation  of  coagu- 
lable lymph,  which  becomes  organized. — {Thomson, 
p.  305-308.) 

SYMPTOMS  or  SUPPURATION. 

When  matter  is  fully  formed  in  a tumour,  there  is  a 
remission  of  all  the  symptoms.  The  throbbing  pain, 
which  was  before  frequent,  now  goes  off,  and  the  pa- 
tient complains  of  a more  dull,  constant,  heavy  pain. 
A conical  eminence,  or  pointing,  as  it  is  termed,  takes 
place  at  some  part  of  the  tumour,  generally  near  its 
middle.  In  this  situation,  a whitish  or  yellowish  ap- 
pearance is  generally  observable,  instead  of  a deep  red, 
which  was  previously  apparent ; and  a fluctuation  of 
a fluid  underneath  may  be  discovered,  on  a careful  ex- 
amination with  the  fingers.  Sometimes,  indeed,  when 
an  ab.^cess  is  thickly  covered  with  muscles  and  other 
parts,  the  fluctuaiion  cannot  be  easily  distinguished, 
though,  from  other  concurring  circumstances,  hardly 
a doubt  can  be  entert  lined  of  there  being  even  a very 
considerable  collection  of  matter.  An  (edematous 
swelling  over  the  situation  of  deeply  situated  abscesses 
is  a symptom  which  often  occurs,  and  is  well  worthy 
the  attention  of  every  practical  surgeon. 

The  discovery  of  the  existence  of  deep  abscesses  is 
a circumstance  of  the  highest  importance  in  practice, 
and  one  which  greatly  involves  the  practitioner’s  re- 
putation. In  nt)  part  of  surgery  is  experience  in  former 
similar  cases  of  greater  use  to  him  than  in  the  present ; 
and  however  simple  it  may  appear,  yet  nothing,  it  is 
certain,  more  readily  distirigui.shes  a man  of  observa- 
tion and  extensive  practice,  than  his  being  able  easily 
lo  detect  collections  of  deep-seated  matter.  On  the 


contrary,  nothing  so  materially  injures  the  character 
and  professional  credit  of  a surgeon,  as  his  having  in 
such  cases  given  an  inaccurate  or  unjust  prognosis; 
for  generally,  in  disorders  of  this  kind,  the  nature  anti 
event  of  the  case  are  at  last  clearly  demonstrated  to 
all  concerned. 

Together  with  the  several  local  symptoms  of  the 
presence  of  pus  already  enumerated,  may  be  men- 
tioned the  frequent  shiverings  to  which  patients  are 
liable,  especially  on  the  first  formation  of  acute  ab- 
scesses. However,  these  rigors  seldom  occur  so  as  to 
be  distinctly  observed,  unless  the  collection  of  matter 
be  considerable,  or  situated  internally  in  some  of  the 
viscera. 

“ In  the  progress  of  the  fever  accompanying  acute 
inflammation  (says  Professor  Thomson),  rigors  or  cold 
shiverings  not  unfrequently  take  place,  which  recur  at 
irregular  intervals,  and  are  in  general  followed  by  a 
hot  fit,  and  slight  increase  of  the  febrile  symptoms. 
These  rigors  or  cold  shiverings  in  general  indicate, 
when  they  occur  in  the  progress  of  inflammatory  dis- 
eases, that  pus  either  is  formed,  or  is  about  to  be  so. 
In  inflammation  succeeding  lo  injuries  of  the  head, 
these  rigors  are  often  the  first  constitutional  symptoms 
which  give  alarm  to  the  well-informed  practitioner; 
for  they  are  generally,  though  not  always,  an  indica- 
tion that  inflammation  has  already  made  a dangerous 
if  not  fatal  progress.  These  rigors  also  accompany 
the  formation  of  pus  in  the  viscera  contained  within 
the  cavities  of  the  chest  and  belly ; and  are  often  the 
first  symptoms  which  inform  the  practitioner  that  his 
endeavours  to  procure  resolution  have  not  been  suc- 
cessful.”— (See  Thomson's  Lectures  on  Inflammation, 
p.  321.) 

Rigors,  as  Mr.  Hunter  remaikrd,  are  more  common 
at  the  commencement  of  spontaneous  inflammations, 
than  in  inflammations  from  external  injury.  They 
seldom  occur  in  the  suppurations  which  follow  opera- 
tions. 

According  to  Sir  A.  Cooper,  when  matter  is  formed 
upon  the  natural  surfaces  of  the  body  which  are  con- 
nected with  vital  organs,  much  irritation  and  disturb- 
ance lake  place  ; but  when  matter  is  produced  upon 
the  surface  of  a wound  in  a part  not  important  to  life, 
or  upon  parts  of  little  vital  importance,  then  its  form- 
ation is  often  unprcceded  by  irritative  fever. — (See 
Lectures,  c^c.  vol.  1,  p.  113.) 

The  constitutional  symptoms  which  attend  the  form- 
ation of  pus  in  the  progress  of  chronic  suppurations, 
are  generally  comprehended  under  the  name  of  hectic 
fever. — (See  Fevers.) 

The  pain  attending  what  Mr.  Hunter  termed  suppu- 
rative inflammation,  is  increased  at  the  time  when  the 
arteries  are  dilated,  and  this  gives  the  sensation  called 
throbbing,  in  which  every  one  can  count  his  own 
pulse,  by  merely  paying  attention  to  the  inflamed  part. 
Perhaps  this  last  symptom  is  one  of  the  best  character- 
istics of  this  species  of  inflammation.  When  the  in- 
flammation is  moving  from  the  adhesive  state  to  the 
suppurative,  the  pain  is  considerably  increased;  but 
when  suppuration  has  taken  place,  the  pain  in  some 
degree  subsides. 

The  redness  that  took  place  in  the  adhesive  stage  is 
now  increa.sed,  and  is  of  a pale  scarlet  colour.  The 
part  which  was  firm,  hard,  and  swelled  in  the  previous 
stage  of  the  inflammation,  now  becomes  still  more 
swelled,  in  consequence  of  the  greater  dilatation  of 
the  vessels,  and  the  greater  quantity  of  coagulating 
lymph  throw'n  oni.— {Hunter.) 

THEORY  OF  SUPPURATION. 

The  dissolution  of  the  livl  ig  solids  of  an  animal 
body  into  pus,  and  the  power  of  this  fluid  to  continue 
the  dissolution,  are  opinions  which  are  no  longer  en. 
tertained  by  any  well-informed  surgeons  of  the  present 
day  ; and  the  use  of  such  phrases  as  “ pus  corrodes," 
“it  is  acrid,"  &c.  exjiressions  which  imply  an  erro- 
neous way  of  thinking,  is  very  properly  almost  en- 
tirely di.scontinued  in  the  language  of  every  sensible 
medical  man.  If  these  notions  w’ere  true,  no  sore 
which  discharges  matter  could  be  exempted  from  a 
continual  dissolution.  Such  ideas  probably  arose  from 
the  circumstance  of  an  abscess  being  a hollow  cavity 
in  the  solids,  and  from  the  supposition  that  the  whole 
of  the  original  substance  of  that  cavity  w.as  now  the 
matter  whicJi  was  found  in  it.  This  was  a very  na- 
tural way  of  accounting  for  the  formation  of  pus  by 


314 


SUPPURATION. 


one  entirely  ignorant  of  the  moving  jniceg,  the  powers 
of  the  arteries,  and  what  takes  place  in  an  abscess 
after  it  is  opened.  The  know'ledge  of  these  three  sub- 
jects, abstracted  from  the  knowledge  of  the  abscess 
before  its  being  opened,  should  have  led  surgeons  to 
account  for  the  formation  of  pus  irom  tlie  iilood  by 
the  powers  of  the  arteries  alone.  According  to  tlie 
above  erroneous  principle,  abscesses  would  continue 
to  increase  after  being  opened  as  fast  as  belore.  Upon 
the  principle  of  tlie  solids  being  dissolved  into  pus  was 
founded  the  practice  of  bringing  ail  indurated  parts  to 
suppuration,  if  possible,  and  not  imiking  an  early 
opening.  This  was  done  for  the  purpose  of  giving 
lime  for  the  solids  to  melt  down  into  pus;  but  it  was 
apparently  forgotten,  that  abscesses  formed  matter 
after  they  were  opened,  and,  therefore,  the  parts  stood 
the  same  chance  of  dissolution  into  pus  as  before. 
Blinded  with  the  idea  chat  the  solids  entered  into  the 
compositioti  of  pus,  the  partisans  of  this  doctrine  could 
never  see  pus  flowing  frotn  any  ititernal  canal,  as  frotn 
the  urethra,  in  cases  of  gonon  hoja,  without  suppositig 
the  existence  of  an  ulcer  in  the  passage.  Such  senti- 
ments might  be  forgiven,  before  it  was  known  that 
these  surfaces  could,  and  generally  did,  form  pus, 
without  a breach  of  the  solids ; but  the  continuance  of 
this  way  of  thinking  now  is  not  mere  ignorance  but 
stupidity.  The  formation  of  pints  of  matter  in  the 
cavities  of  the  chest  and  abdomen,  without  any  breach 
in  the  solids,  could  not  have  been  overlooked  by  the 
most  zealous  advocates  for  the  doctrine  of  dissolution. 
The  moderns  have  been  still  more  ridiculous;  for, 
knowing  that  it  was  denied  that  the  solids  were  ever 
dissolved  into  pus,  and  that  there  was  not  a single 
proof  of  it,  they  have  been  busy  in  producing  what  to 
them  seemed  a proof.  They  have  been  putting  dead 
animal  matter  into  abscesses,  and  finding  that  it  was 
either  wholly  -or  in  part  dissolved,  they  therefore  at- 
tributed the  loss  to  its  being  turned  into  pus.  This, 
however,  was  putting  living  and  dead  animal  matter 
upon  the  same  footing,  which  is  a contradiction  in 
itself;  for  if  the  result  of  this  experiment  were  really 
what  they  supposed  it  to  be,  the  idea  of  living  parts 
being  dissolved  into  pus  must  be  abandoned,  because 
living  and  dead  animal  matter  can  never  be  considered 
in  the  same  light. 

It  might  have  been  remarked,  that  even  extraneous 
animal  matter  would  lie  in  abscesses  for  a considerable 
time  without  being  dissolved ; and  that  in  abscesses 
arising  either  from  violence  or  from  a species  of  ery 
sipelaious  inflammation,  there  were  often  sloughs  of 
the  cellular  membrane,  which  sloughs  would  come 
away  like  wet  low,  and,  therefore,  were  not  dissolved 
into  pus. — ( Hunter.) 

It  might  also  have  been  noticed,  that  in  abscesses  of 
tendinous  parts,  as  about  the  ankle,  a tendon  often 
mortified  and  sloughed  away,  and  that  the  sores  would 
not  heal  till  such  sloughs  w’ere  d(!tached ; but  though 
this  sepal  ation  was  sometimes  not  completed  for  seve- 
ral months,  yet  the  sloughs  were  at  last  thrown  oflT, 
and  not  converted  into  pus.  Pieces  of  dead  bone  often 
lie  soaking  in  matter  for  many  months,  without  being 
changed  into  pus;  and  although  bones  so  circum- 
stanced may  lose  a considerable  deal  of  their  sub 
stance,  a loss  which  some  might  impute  to  the  disso 
iution  of  the  bone  into  pus,  yet  such  waste  can  be 
accounted  for  on  the  principle  of  absorption.  'J’he  loss 
is  always  upon  that  surface  where  the  coniinuily  is 
broken  off,  and  it  is  a part  of  the  process  by  w hich  the 
exfoliation  of  a dead  piece  of  bone  is  accomplished. 
The  formation  of  pus  has  been  attributed  to  a kind  of 
fermentation,  in  which  both  the  solids  and  fluids  were 
concerned.  This  doctrine  is  easily  refuted  by  stating 
what  happens  in  internal  canals,  which  naturally  se- 
crete mucus,  but  frequently  form  pus  without  any  loss 
of  substance  or  any  previous  fermenting  process. 
Were  we  to  suppose  a fermentation  of  the  solids  and 
fluids  the  immediate  cause  of  the  production  of  pus, 
whence  could  the  solids  come  which  enter  into  the 
composition  of  discharges  from  the  urethral  for  the 
whole  penis  could  not  afford  matter  enough  to  form 
the  pus  which  is  discharged  in  a common  gonorrhoea. 
How  also  could  the  fermentation  of  the  solids  ever 
cease?  for  there  is  the  same  surface  secreting  its  mu- 
cus w henever  the  formation  of  pus  is  discontinued. 
It  may  be  asked,  likewise,  by  what  power  the  first 
particle  of  pus  in  an  abscess  or  on  a sore  i.**  formed, 
before  there  is  any  particle  existing  which  is  capable 


of  dissolving  the  solids?  An  abscess  may  be  station- 
ary for  months,  and  at  last  be  absorbed : what  becomes 
of  the  fermentation  all  the  while  the  collection  of 
matter  continues  stationary? 

Extravasated  blood  has  been  supposed  to  be  capable 
of  being  converted  into  pus.  We  find,  however,  that 
blood,  when  extravasated,  either  from  violence  or  a 
rupture  of  a vessel,  as  in  aneurism,  never  of  itself  be- 
comes pus;  nor  was  pus  ever  formed  in  these  cases, 
without  being  preceded  by  inflainination.  Botii  the 
blood  and  matter  are  also  found  together  in  the  same 
cavity,  under  such  circumstances.  If  the  blood  had 
coagulated,  which  it  seldom  does  in  cases  of  violence, 
it  would  be  found  still  coagulated;  and  if  it  had  not 
coagulated  the  pus  would  be  bloody. — {Hunter.) 

'I'he  modern  theory  of  suppuration  is,  that  the  mat- 
ter is  separated  from  the  blood  by  the  secreting  power 
of  tire  vessels  of  the  inflamed  part,  whicli  acquire  a 
new  mode  of  action. 

'J’hat  pus  is  formed  in  the  vessels  from  which  it  ex- 
udes, by  an  action  of  these  vessels  analogous  to  secre- 
tion, was,  so  far  as  I know  (says  Professor  Thomson), 
first  distinctly  suggested  by  Dr.  Simpson  of  St.  An- 
drew's, in  his  Dissertatiunes  de  Re  ^1/edrca,”  pub- 
lished in  the  year  1722.  An  opinion,  similar  to  that 
of  Dr.  Simpson’s,  suggested  itself,  about  the  year  1756, 
to  De  Haen,  from  the  consideration  of  what  takes 
place  in  some  cases  of  phthisis  pulrnonalis.  This  au- 
thor observed,  that  pus  was  often  expectorated  for  a 
great  length  of  time,  by  patients  affected  with  phthisis, 
in  whom,  after  death,  no  mark  of  ulceration  could  be 
perceived,  not  even  the  place  in  which  the  pus  had 
been  formed.  The  hypothesis  of  pus  being  a secretion 
was  afterward  more  fully  considered  by  Dr.  Morgan, 
of  Philadelphia,  in  his  inaugural  thesis  printed  at 
Edinburgh  in  1763,  entitled  " Puopuioses,  sivc  Tenta- 
men  Jiledicum  de  Paris  Confectione."  'I’he  belief  that 
pus  is  a secretion,  or  foimed  at  least  by  an  action  of 
the  vessels  analogous  to  secretion,  was  adopted  by  Mr. 
Hunter.  Indeed,  the  merit  of  the  original  sugge.stion 
of  this  hypothesis  has  been  ascribed  to  him,  though 
improperly.  Bi  uggman,  professor  of  botany  at  Leyden, 
has  maintained  the  same  doctrine  in  an  excellent  thesis 
“ De  Puogenia,"  published  in  1785 ; and  it  is  that 
which  is  now  very  generally  taught  all  over  Europe. — 
(See  Thomson's  Lectures  on  Inflammation,  p.316,  317.) 
With  respect  to  suppuration  from  exposed  surfaces, 
how'ever,  it  is  more  proper  to  say,  that  the  vessels  se- 
crete a fluid  which  becomes  pus:  for  Sir  Everard 
Home  has  proved  that  this  fluid  has  not  the  purulent 
appearance  when  first  secreted,  but  acquires  it  while  it 
remains  on  the  inflamed  surface,  and  does  not  acquire 
it  the  less  readily  when  removed  from  that  surface  in  a 
colourless  slate,  provided  its  proper  temperature  be 
pre.served,  and  it  be  kept  exposed  to  the  air,  which 
promotes  the  change. 

The  opinion  that  suppuration  is  a process  analo- 
gous to  glandular  secretion  was  at  first  hastily  rejected 
by  many,  who  were  swayed  by  the  fact  that  no  pus  is 
ever  found  blended  with  the  blood  in  the  circulating 
system.  By  this  mode  of  reasoning,  how-ever,  such 
thinkers  must  be  led  to  deny  the  universally-received 
and  undoubted  doctrine  that  the  bile  is  a secretion  ; and 
yet,  it  is  well  known  that  nothing  like  this  fluid  can  be 
delected  in  an  analy.ris  of  the  blood,  and,  indeed,  a 
very  small  quantity  would  be  sufficient  to  tinge  the 
whole  mass  of  circulating  blood  w'ith  a yellow  colour, 
the  same  as  we  see  in  cases  of  jaundice.  No  one 
would  wish  to  defend  the  idea  of  there  being  either 
pus  or  bile  actually  in  the  circulation;  but  only  the 
matter,  or  modifications  of  the  matter,  which,  by  the 
combinations,  or  whatever  changes  we  may  choose  to 
term  them,  produced  by  the  action  of  the  secreting 
vessels,  are  converted  into  one  of  the  particular  fluids 
in  question. 

Violence  done  to  parts  is  one  of  the  great  causes  of 
suppuration ; but  simple  violeisce  does  not  always 
occasion  it.  The  violence  mu.st  be  followed  by  some- 
thing that  prevents  the  cure  in  a more  simple  way, 
something  that  prevents  the  iiestoration  of  the  struc- 
ture, and  the  continuance  of  the  animal  functions  of 
the  part.  The  parts  must  be  kept  long  enough  in  that 
state  into  which  they  were  put  by  the  violence.  Or, 
what  is  somewhat  similar  to  this,  the  violence 
must  be  atteitded  with  death  in  a part,  as  in  many 
bruises,  all  mortifications,  and  all  sloughs,  in  con- 
sequence of  the  application  of  caustic,  which,  when 


SUPPURATION. 


315 


the  dead  parts  separate,  leave  internal  surfaces  exposed. 
— {Hunter.) 

As  every  injury,  or  effect  of  outward  violence  under 
the  above  circumstances,  is  more  or  less  exposed  to  the 
surrounding  air,  the  application  of  air  to  internal  sur- 
faces has  been  assigned  as  a cause  of  suppuration; 
hut  certainly  the  air  has  not  the  least  effect  on  parts, 
circumstanced  as  above,  for  a stimulus  would  arise 
from  a wound,  were  it  even  contained  in  a vacuum. 
In  circumscribed  abscesses,  the  air  cannot  possibly  get 
to  the  parts,  so  as  to  have  any  share  in  making  them 
suppurate. 

In  cases  of  emphysema,  when  the  air  is  diffused 
over  the  whole  body,  no  suppuration  is  the  conse- 
quence, unless  an  exposure  or  imperfection  of  some 
internal  surface  should  be  made,  for  the  purpose  of 
allowing  the  air  to  escape.  A stronger  proof  that  it 
is  not  tlie  admission  of  air  which  makes  parts  indame 
is,  that  the  cells  in  the  soft  parts  of  birds,  and  ni.any  of 
the  cells  and  canals  of  their  bones,  communicating 
tvith  the  lungs,  and  always  containing  air,  never  in- 
dame;  but  if  these  cells  are  exposed  in  an  unnatural 
way,  the  stimulus  of  imperfection  is  given,  these  ca- 
vities then  indanic,  and  their  surfaces  either  form  ad- 
hesions together,  or  produce  pus. — {Hunter.) 

When  the  interior  of  an  abscess  is  examined,  the 
cavity  which  contained  the  matter  is  observed  to  be 
lined  with  a smooth,  membrane  like  substance,  which 
is  of  a wliitish  ash  colour,  and  has  a strong  resem- 
blance to  eoagulatirig  lym|»h.  This  membrane-like  in- 
vestment has  been  termed  the  sac  or  cyst  of  the  ab- 
scess. It  seems  in  general  to  adhere  by  a vascular 
union  to  the  surrounding  cellular  membrane,  which  is 
itself  likewise  denser  in  texture,  and  more  vascular 
than  in  the  natural  state  { Thomson's  Lectures.,  p. 
310),  its  cells  being  closed  by  coagulating  lymph, 
effused  in  consequence  of  that  species  of  indammation 
which  Mr.  Hunter  teitned  the  adhesive.  Thus,  by  the 
formation  of  a cyst,  attd  the  effusion  of  coagulatitig 
lymph  in  the  cellular  substatice  aroutid  the  abscess,  the 
collection  of  matter  is  bounded  and  cannot  become 
diffused,  as  it  otherwise  would  do  in  the  commutii- 
cating  cavities  of  the  cellular  membrane,  like  the 
water  in  cedema. 

Something  like  this  diffusion  of  pus  seems  to  occur 
in  erysipelas  phlegmonoides.  “ But  in  this  case  (says 
Professor  Thomson),  the  vitality  of  greater  or  le.-s  por- 
tions of  the  cellular  substance  is  destroyed  ; the  dead- 
ened portions  are  converted  into  dirty,  whitish,  ash- 
coloured  sloughs;  and  it  becomes  extremely  dilficult  to 
say  whether  any  part  of  the  pus  contained  in  the 
deadened  cellular  membrane  has  been  formed  in  the 
cells  in  which  it  is  contained,  or  has  been  absorbed  into 
these  cells,  after  being  separated  from  the  parietes  of 
the  cavities  containing  the  sloughs  themselves.”  — 
(^Lectures,  d-c.  p.  310.) 

There  can  be  no  doubt  that,  after  an  abscess  has  re- 
ceived a membranous  lining  or  cyst,  the  secretion  of 
pus  is  continued  from  the  surface  of  the  latter  part  en- 
tirely. as  well  as  whatever  degree  of  absorption  of  the 
same  fluid  happens  to  be  going  on.  In  fact,  the  cysts 
must  be  both  secreting  and  absorbing  surfaces.  The 
circumstances  which  leave  no  doubt  of  this  point,  are 
the  frequent,  sudden,  or  gradual  removal  of  very  large 
manifest  collections  of  matter;  the  continual  changes 
X)ccurring  in  the  quantity  and  consistence  of  the  pus; 
and  the  speedy  filling  of  the  cavity  with  purulent  mat- 
ter again  after  the  first  contents  of  the  abscess  have 
been  discharged. 

Another  thing  which  is  yet  a subject  of  controversy 
is,  whether  suppuration  ever  happens  unpreceded  by 
inflammation?  Professor  Thomson,  of  Edinburgh, 
believes,  that  the  affirmative  opinion  on  this  point  was 
first  smruested  by  De  Haen,  of  Vienna;  but  he  thinks 
that  much  of  the  diflerence  of  sentiment  in  this  matter 
has  proceeded  from  the  vatiue  “notions  entertained 
with  regard  to  the  symptoms  which  necessarily  charac- 
terize the  slate  of  inflammation,  and  also  with  regard 
to  the  properties  by  which  pus  is  to  be  distinguished 
from  other  animal  fluids.  Accordingly,  in  almost  all 
the  examples  which  De  Haen  has  adduced  lo  prove  the 
formation  of  pus,  without  the  previmis  existence  of 
Inflammation,  he  has  himself  occasioti  to  retnark  the 
exudation  of  coagulating  lymph,  and  the  existence  of 
preternatural  adhesions;  phenomena,  which  we  now 
know  are  produced  by  that  st.ate  which  Mr.  Hunter 
tiiu  denominated  adhesive  inflammation.”  But  De 


Haen  uses  the  term  inflammation  to  express  that  state 
which  we  denominate  ulceration  or  ulcerative  absorp- 
tion; for  in  speaking  of  the  cases  of  suppuration 
which  he  has  adduced,  he  observes,  that  “ in  many  of 
them  no  previous  loss  or  consumption  of  substance 
could  be  perceived.”  An  observation  similar  to  this 
was  made  about  the  same  time,  or  perhaps  a little 
earlier,  by  Dr.  W.  Hunter,  and  an  account  given  of  it 
in  the  .second  vol.  of  the  London  Medical  Observations 
and  Inquiries. 

“Mr.  Hunter,  though  he  endeavours  to  establish  it  as 
ail  invariable  fact,  that  no  suppuration  takes  place 
whicli  is  not  preceded  by  inflammation,  is  of  opinion, 
that  collections  of  what  he  terms  extraneous  matter, 
something  like  pus,  may  form  in  various  parts  of  the 
body  without  the  previous  existence  of  inflammation 
in  the  parts  in  which  it  informed ; and  accordingly  you 
will  find,  at  page  300  of  his  Treatise  on  Inflammation, 
a chapter  entitled  ‘Of  Collections  of  Matter  without 
Inflammation.’  ” 

Professor  Thomson  doubts,  however,  “ whether 
these  collections  of  matter,  said  to  be  formed  without 
inflammation,  would  not  have  been  more  properly  de- 
nominated scrofulous  abscesses  or  chronic  suppura- 
tions. I am  disposed  to  believe  (says  he),  that  in 
whatever  texture  or  organ  of  the  body  scrofula  mani- 
fests itself,  there  inflammation  will  be  found  to  exist. 
The  phetiomena,  it  is  true,  of  inflammation,  both  local 
and  constitutional,  are  modified  by  the  existence  of  the 
scrofulous  diathesis;  but  they  are,  I believe,  always 
present  in  such  a degree  as  to  justify  us  in  giving  to 
them  the  name  of  inflammation,  and  in  classing  most, 
if  not  all  local  scrofulous  affections,  among  inflamma 
tnry  diseases.  When  the  indolent  swellings,  of  which 
Mr.  Hunter  speaks,  occur  near  to  the  surface  of  the 
body,  that  part  feels  warmer  than  usual,  as  may  be  felt  in 
white  swellings  o*"  the  joints.  The  swelling  also  is 
either  preceded  or  accompanied  with  some  degree  of 
pain,  though,  when  the  affection  is  internal,  the  patient 
may  not  always  be  very  accurate  with  regard  lo  the 
precise  state  of  this  pain.  When  cut  into,  the  parts 
also  affected  with  scrofulous  swellings  are  always  found 
more  vascular  than  usual  ; in  short,  all  the  symptoms 
occur  by  which  the  state  of  inflammation  is  charac- 
terized.”— (On  Inflammation,  p.313,  314.)  In  another 
place  Dr.  Thomson  admits,  that  the  matter  tvhich  is 
formed  in  chronic  suppurations  does  not  always  accu- 
rately resemble  that  which  is  formed  in  acute  ab- 
scesses : yet  he  contends,  that  it  is  so  analogous  both  in 
its  physical  and  chemical  characters,  as  well  as  in  the 
circumstances  in  which  it  is  produced,  that  he  can  see 
no  reason  why  it  should  not  be  called  pus  or  a puri- 
fnrm  fluid.— (P.  315.)  Sir  A.  Cooper  also  inculcates 
the  common  doctrine,  that  the  formation  of  matter  is 
preceded  by  inflammation,  which,  he  says,  in  healthy 
persons  is  active,  while  in  the  debilitated  and  scrofu- 
lous, it  is  often  very  slight,  and  the  pus  produced 
generally  less  perfect. 

Sometimes  there  is  even  such  a change  of  action 
that  the  products  entirely  differ,  being  in  scrofulous 
abscesses  serous  and  curd-like,  or  even  chalky. — (.Lec- 
tures, ^c.  vol.  l,p.  120.) 

QUAl.ITIES  OF  PUS. 

True  pus  has  certain  properties,  which,  when  taken 
singly,  may  belong  to  other  secretions,  but  which,  con- 
jointly, form  the  peculiar  character  of  this  fluid,  viz. 
globules  swimming  in  a fluid  which  is  coagulable  by  a 
solution  of  the  muriate  of  ammonia,  which  no  other 
animal  secretion  is,  and,  at  the  same  time,  a conse- 
quence of  inflammation.  This  fluid,  like  serum,  is 
coagulable  by  heat.  “ Pus  also  contains  abundance 
of  fibrin:  if  water  be  poured  upon  |tus  until  the  solid 
part,  which  remains  at  the  bottom  of  the  vessel,  be  en- 
tirely deprived  of  its  serum  and  globnle.s,  numerous 
portions  of  fibrin  are  found  remaining,  and  although 
not  exactly  of  the  same  size,  yet  they  have  a great 
uniformity  of  appearance.  Thus  pus  is  composed  of 
serum,  fibrin,  ami  globules;  and  (says  Sir  A.  Cooper) 
if  I were  lo  hazard  a theory  uptni  this  subject,  I should 
say  that  pus  was  composed  of  the  constituent  parts  of 
the  blood,  slit’hily  changed  in  their  character  by  inflam- 
mation."—(Lecture.?,  vol.  1,  p.  121.) 

'I’he  crrlonr  and  the  consistence  of  pus  are  the  two 
qualities  which  first  attract  the  tiotice  of  every  the 
most  superficial  rAtserver.  The  colour  arises  from  the 
largest  portion  of  this  fluid  being  composed  of  very 


316 


SUPPURATION, 


small  round  bodies,  much  resembling  the  globules  of 
cream.  The  fluid  in  which  the  globules  of  pus 
swim,  might  at  first  be  supposed  to  be  the  serum  of  the 
blood,  for  it  coagulates  witli  heat  like  the  latter  fluid. 
Pus  is  also  probably  mixed  with  a small  quantity  of 
coagulating  lymph;  as  it  partly  coagulates  after  it  is 
secreted.  However,  the  fluid  part  of  pus  is  found  to 
have  properties  which  serum  has  not.  There  being  a 
similarity  between  pus  and  milk,  experiments  have 
been  made  to  asterlaiii  whether  the  fluid  of  pus  couid 
be  coagulated  with  the  gastric  juice  of  animals:  but 
no  coagulation  could  be  effected  in  tliis  manner ; a so- 
lution of  muriate  of  ammonia  made  the  fluid  part  of 
pus  coagulate;  but  not  any  other  secretion  or  natural 
fluid;  and  hence  it  was  concluded,  that  whenever 
globules  were  found  swimming  in  a fluid  coagulable  by 
muriate  of  ammonia,  the  matter  was  to  be  considered 
as  pus. 

The  proportion  which  the  white  globules  bear  to 
the  other  parts  of  pus,  depends  on  the  health  of  the 
parts  producing  the  discharge.  When  the  globules  are 
very  abundant,  the  matter  is  thicker  and  whiter,  and  is 
called  healthy  pus ; the  meaning  of  which  is,  that  the 
solids  which  produced  it  are  in  good  health  ; for  these 
appearances  in  the  matter  are  no  more  than  the  result 
of  certain  salutary  processes  going  on  in  the  solids, 
the  effect  of  which  processes  is  to  produce  the  disposi- 
tion on  which  both  suppuration  and  granulation  de- 
pend.— (.Hunter.) 

Pus  is  specifically  heavier  than  water,  and  is  probably 
about  as  heavy  as  blood. 

Besides  the  above  properties,  pus  has  a sweetish, 
mawkish  taste,  very  different  from  that  of  most  other 
secretions  ; and  the  same  taste  takes  place,  whether  it 
is  pus  from  a sore,  or  an  irritated  inflamed  surface. 

Pus  has  a smell  in  some  degree  peculiar  to  itself ; 
but  this  differs  in  different  cases.  Some  diseases,  it  is 
said,  may  be  known  by  the  smell,  as,  for  instance,  a 
gonorrhcea. 

Pus  sinks  in  water;  mucus  floats.  Pus  communi- 
cates to  water  a uniformly  troubled  white  colour; 
mucus  gives  the  appearance  of  stringy  portions  floating 
in  it.  Mucus  is  said  to  be  more  readily  dissolved  by 
sulphuric  acid  than  pus  is.  It  has  also  been  asserted, 
that  if  water  he  added  to  such  solutions,  the  pus  is  pre- 
cipitated to  the  bottom  of  the  vessel ; while  the  mucus, 
instead  of  being  completely  precipitated,  forms  swim- 
ming flakes.  A solution  of  caustic  alkali  dissolves 
both  pus  and  mucus  ; but  when  water  is  added,  pus  is 
said  to  become  separated,  but  not  mucus. 

Though  solutions  in  chemical  menstrua  and  precipi- 
tations have  been  thought  a test  of  the  distinction 
between  these  two  fluids,  yet  the  method  has  been 
thought  absurd  aud  unphilosophical.  It  has  been  con- 
ceived that  all  animal  substances  whatever,  when  in 
solution  either  in  acids  or  alkalies,  ^'ould  be  in  the 
same  state,  and,  therefore,  that  the  precipitation  would 
be  the  same  in  alt.  Calcareous  earth,  when  dissolved 
in  muriatic  acid,  is  in  that  acid  in  the  same  state, 
whether  it  has  been  dissolved  from  chalk,  limestone, 
marble,  or  calcareous  spar  ; and  precipitations  from  all 
are  the  same.  Hence,  the  experiments  were  nrade  on 
organic  animal  matter,  such  as  muscle,  tendon,  carti- 
lage, liver,  and  brain  ; and  on  inorganic,  such  as  pus  and 
the  white  of  an  egg.  All  these  substances  were  dis- 
solved in  sulphuric  acid,  and  precipitated  with  potassa. 
Each  precipitation  was  examined  with  such  magnifiers 
as  plainly  showed  the  forms  of  the  precipitates,  all 
which  appeared  to  be  flaky  substances.  The  preci- 
pitate by  ammonia  had  exactly  the  same  appearance. 
The  same  appearances  were  seen,  when  the  above 
kinds  of  animal  matter  were  dissolved  by  caustic  po- 
tassa, and  precipitated  with  the  muriatic  acid.  A flaky 
substance,  void  of  any  regular  form,  composed  each 
precipitate.— (JTrtriter.)  For  additional  observations  on 
the  tests  of  pus,  and  an  account  of  those  suggested  by 
Dr.  Young  and  Grasmeyer,  see  the  First  Lines  of  the 
Practice  of  Surgery,  last  edition. 

Pus  does  not  irritate  the  particular  surface  which  se- 
cretes it,  though  it  may  be  very  irritating  to  any  other. 
Hence,  no  suppurating  surface  of  any  specific  kind 
can  be  kept  up  by  its  own  matter  : if  this  had  not  been 
the  case,  no  sore  of  a specific  quality,  or  producing 
matter  of  an  irritating  kind,  could  ever  have  been 
iinaled.  This  is  similar  to  every  other  secretion  of 
stimulating  fluids,  as  the  bile,  tea's?  &c.  which  fluids 
do  not  stimulate  their  own  glands  or  ducts,  but  are 


capable  of  stimulating  any  other  part  of  the  body.-  - 

(.Hunter.) 

Whenever  a real  disease  attacks  either  the  suppu- 
rating surface,  or  the  constitution,  the  production  of 
true  pus  ceases,  and  the  fluid  becomes  changed  in  some 
measure,  in  proportion  to  these  morbid  alterations.  In 
general,  it  becomes  fetid,  thinner,  and  more  transpa- 
rent, and  partakes  more  of  the  nature  of  the  blood,  as 
is  the  case  in  most  other  secretions  under  s.'inilar  cir- 
cumstatices.  Sanies  is  the  term  usually  applied  by 
surgeons  to  pus  in  this  degenerated  state.  This  un- 
healthy sort  of  matter  has  more  of  the  serum,  and  fre- 
quently more  of  the  coagulating  lymph  in  it,  and  less 
of  the  combination,  which  renders  it  coagulable  by  a 
solution  of  muriate  of  ammonia.  It  has  also  a greater 
proportion  of  the  extraneous  parts  of  the  blood,  which 
are  soluble  in  water,  such  as  salts  ; and  it  has  a greater 
tendency  than  true  pus  to  become  putrid.  Such  un- 
healthy matter  may  even  be  irritating  to  the  surface 
which  produces  it. 

The  secretion  of  matter  is  often  suspended  in  fevers : 
while  the  constitution  is  thus  disturbed,  a sore  will  fre- 
quently appear  almost  dried  up  ; but  on  the  subsidence 
of  the  fever,  its  surface  will  again  secrete  pus  in  abun- 
dance. This  is  a fact  which  every  young  dresser  must 
have  noticed.  A similar  check  to  the  secretion  of  pus 
is  also  produced  when  a sore,  or  the  parts  immediately 
around  it,  are  attacked  by  fresh  inflammation.  The 
diminished  quantity  of  pus  is  likewise  changed  in  its 
qualities,  as  it  becomes  a thin  ichor,  or  a red  fluid, 
composed  of  serum  and  red  particles. — (See  A.  Cooper's 
Lectures,  p.  123,  vul.  1.) 

The  discharge,  when  of  an  irritating  sort,  is  more 
stimulating  to  the  adjoining  parts  with  which  it  comes 
in  contact,  than  to  its  own  secreting  surface.  In  this 
manner  it  frequently  produces  excoriation  of  the  skin 
and  ulceration.  Tims  the  tears  excoriate  the  skin  of 
the  cheek,  in  consequence  of  the  quantity  of  salts  which 
they  contain.  From  this  effect,  matter  has  been  called 
corrosive,  a quality  which  it  has  not;  the  only  property 
which  it  possesses  being  that  of  irritating  the  parts 
which  it  touches  so  as  to  cause  their  absorption. — 
(.Hunter.) 

When  the  vessels  thus  lose  the  power  of  producing 
good  pus,  they  also  lose  more  or  less  the  power  of  form- 
ing granulations.  This  may  depend  on  some  devia- 
tion from  the  due  structure  and  action  which  such 
vessels  should  possess,  in  order  to  be  qualified  for  the 
performance  of  these  two  operations. 

Pus,  from  several  circumstances,  would  appear  in 
general  to  have  a greater  tendency  to  putrefaction  than 
the  natural  juices  have;  but,  perhaps,  this  is  not  the 
case  with  pure  pus,  which,  when  first  discharged  from 
an  abscess,  is  commonly  perfectly  sweet.  There  are, 
however,  some  exceptions  to  this ; but  these  depend  on 
circumstances  entirely  foreign  to  the  nature  of  pus 
itself.  Thus,  if  the  abscess  has  any  communication 
with  the  air  while  the  matter  is  confined  in  it;  or  if 
the  collection  has  been  so  near  the  colon,  or  rectum,  as 
to  have  been  infected  by  the  feces,  then  we  cannot 
wonder  that  the  matter  should  become  putrid.  When 
blood  is  blended  with  pus;  when  sloughs  are  mixed 
with  it ; when  the  parts  forming  the  seat  of  the  abscess 
are  in  a gangrenous  state  from  an  erysipelatous  affec- 
tion, the  matter  has  a greater  tendency  to  putrefy  than 
the  pure  pus  discharged  from  sound  abscesses  or  heal- 
ing sores.  Pure  matter,  though  easily  rendered  suscep- 
tible of  change  by  extraneous  additions,  is  in  its  own 
nature  tolerably  uniform  and  immutable.  It  appears  so 
unchangeable,  that  we  find  it  retained  in  an  abscess 
for  weeks,  without  having  undergone  any  alteration. 
These  qualities,  however,  only  belong  to  perfect  pus. 
If  a healthy  sore  inflames,  the  matter  now  produced 
from  it,  though  unmixed  with  extravasated  blood,  or 
dead  solids,  becomes  much  sooner  putrid,  and  much 
more  irritating  than  the  discharge  formed  before  this 
alteration  of  the  ulcer. — (Hunter.) 

In  the  preceding  paragraph  it  is  slated,  that  matter 
frequently  remains  unchanged  in  abscesses  for  weeks. 
This  expression  of  Hunter’s  is  not  strictly  correct ; for 
it  is  well  known,  that  the  surfaces  of  the  cavities  of 
abscesses  are  always  absorbing,  as  well  as  secreting 
ones  ; consequently,  there  must  be  a continual  muta- 
tion going  on  in  the  contained  matter. 

When  there  are  diseased  bones,  or  other  extraneous 
bodies,  excitimi  irritation,  sometimes  even  in  so  great  a 
degree  as  to  make  the  vessels  bleed,  and  often  wound 


SUPPURATION. 


317 


ihe  matter  is  always  found  to  be  very  offensive. 
'J'his  state  of  the  discharge  is  one  mark  of  a diseased 
bone. 

Tlie  discharge  of  an  unhealthy  sore  blackens  silver 
probes  and  preparations  of  lead.  This  effect  is  im- 
puted, by  Dr.  Crawford,  to  the  sulphuretted  hydrogen 
gas  generated  in  the  matter. — {Phil.  Trans,  vol.  80, 
year  1790,  p.  385.)  Farther  interesting  observations  on 
the  nature  of  pus  may  be  found  in  an  Essay  on  the  Dif- 
ferences between  Pus  and  Mucus,  by  Dr.  Darwin,  jun. ; 
also  in  Dr.  G.  Pearson’s  Paper  in  Philos.  Trans.  1811. 

USE  OF  PUS. 

By  some  it  is  supposed  to  carry  off  humours  from 
the  constitution.  Suppuration  is  sometimes  regarded 
as  a constitutional  disease  changed  into  a local  one, 
which  constitutional  malady  is  discharged,  or  thrown 
out  of  the  body,  either  in  the  form  of  pus  or  together 
with  this  fluid.  Critical  abscesses  have  been  thought 
to  be  cases  of  this  sort.  Suppuration  has  also  been 
imagined  to  carry  off  local  complaints  from  other  parts 
of  the  body,  on  the  old  principle  of  derivation  or  re- 
vulsion. For  this  reason  sores  or  issues  are  often 
made  in  sound  parts  before  other  sores  are  dried  up. 
Suppuration  is  sometimes  excited  with  a view  of 
making  parts,  such  as  indurated  swellings,  dissolve 
into  pus ; but  I have  endeavoured  to  show  that  no  dis- 
solution of  the  solids  is  concerned  in  the  production 
of  pus. 

A secretion  of  pus  is  looked  upon  as  a general  pre- 
vention of  many  or  of  all  the  causes  of  disease.  Hence, 
issues  are  made  to  keep  off"  universal  as  well  as  local 
diseases.  However,  the  use  of  pus  is  perhaps  unknown ; 
for  it  is  formed  most  perfectly  from  healthy  sores,  and 
in  healthy  constitutions ; and  large  discharges  from 
parts  not  very  essential  to  life  produce  very  little 
change  in  the  constitution,  and  as  little  upon  being 
heated  up,  whatever  some  may  suppose  to  the  contrary. 
—{Hunter.) 

This  is  certainly  the  case  witli  many  old  ulcers,  the 
suppuration  from  which  seems  to  have  little  or  no  ef- 
fect in  impairing  the  health.  Nor  is  there  any  real 
reason  to  be  afraid  of  healing  such  ulcers,  when  possi- 
ble, lest  a worse  disease  should  follow  from  the  stop- 
page of  a discharge  to  which  the  system  is  supposed  to 
be  so  habituated  that  the  continuance  of  it  must  be  es- 
sential to  health. 

Every  one  knows  that  when  there  is  no  interference 
of  art,  that  is,  when  the  surface  of  a sore  is  left  unco- 
vered, the  thin  part  of  the  matter  evaporates,  and  the 
thick  part  dries  ai.d  forms  a scab.  Nature,  therefore, 
seems  to  have  designed,  that  one  use  of  pus  should  be 
to  make  a cover,  or  protection  for  ulcerated  surfaces. 
But  I cannot  agree  with  what  has  been  asserted  {Hun- 
ter)., that  the  natural  healing  of  a sore  under  a scab 
takes  place  more  quickly  tlian  when  surgical  dressings 
are  employed. 

On  ulcers,  as  would  appear  from  modem  microscopi- 
cal observations,  “ the  coagulated  pus  is  rendered  tubu- 
lar by  the  extrication  of  its  carbonic  acid  gas,  and  these 
tubes,  o:  canals,  are  immediately  filled  with  red  blood, 
and  thus  connected  with  the  circulation.”  If  this 
point  were  established.  Sir  Everard  Home  conceives, 
that  there  would  then  be  little  difficulty  in  making  out 
the  succeeding  changes,  by  means  of  which  the  coagu- 
lated pus  afterward  becomes  organized. — {On  the 
Conoersion  of  Pus  into  GranulalioJis  or  new  Flesh,  in 
Phd.  Trans,  vol.  109,  p.  109,  Lond.  1819.)  These  state- 
ments are  curious,  and  ought  to  have  been  noticed  in 
the  article  Granulations,  to  which  they  more  immedi- 
ately relate.  I do  not  imagine,  however,  that  na- 
ture will  let  us  trace  much  farther  the  secrets  here  re- 
ferred to. 

Among  the  secondary  uses  of  suppuration  may  be 
mentioned,  opening  a communication  between  a disease 
and  the  external  surface  of  tlie  body  ; forming  a pas- 
sage for  the  exit  of  extraneous  bodies,  &c. 

TREATMENT  WHEN  SUPPURATION  MOST  TAKE  PLACE. 

In  cases  of  inflammation,  arising  from  accident,  but 
so  circumstanced  that  we  know  suppuration  cannot  be 
prevented,  the  indication  is  to  moderate  the  inflamma- 
tion, which,  if  the  powers  are  great,  and  the  injury 
done  considerable,  will  probably  be  very  violent.  If 
the  constitution  should  also  be  much  affected,  certain 
general  niean.s  are  proper,  such  as  bleeding,  purging, 
and  nauseating  medicines.  While  tlie  constitution  is. 


severely  disturbed,  suppuration  cannot  lake  place  in  the 
most  favotirable  manner.  In  these  cases,  also,  such 
medicines  as  produce  a gentle  perspiration  greatly  re- 
lieve the  patient;  for  instance,  the  pulv.  ipecac,  comp.; 
antimonials ; liq.  amnion,  acet. ; saline  draughts,  &.c. 
Opiates  may  produce  a temporary  diminution  of  action ; 
but  they  do  not  always  have  this  desirable  effect,  and 
in  some  constitutions  they  increase  the  general  irritabi- 
lity of  the  system,  and  seriously  aggravate  the  inflam 
matory  action. 

The  applications  to  inflammations  which  are  to  sup- 
purate and  form  an  abscess  commonly  used  are,  poul- 
tices and  fomentations.  These,  however,  appear  to 
be  applied  without  much  critical  exactness  or  discri- 
mination ; for  they  are  applied  before  suppuration  has 
taken  place,  and  when  this  event  is  not  desired ; and 
they  are  also  applied  after  suppuration  has  taken 
place.  With  respect  to  suppuration  itself,  abstracted 
from  all  otlier  considerations,  the  indication  cannot  be 
the  same  in  every  slate;  but  if  poultices  and  fomenta- 
tions are  found  to  be  of  real  service  in  the  two  stages 
of  the  disease,  there  must  be  something  common  to 
both  for  which  they  are  of  service,  independently  of 
simple  suppuration.  Poultices  are  useful  when  the 
inflammation  attacks  the  skin,  either  in  the  first  in- 
stance, or  after  an  abscess  has  approached  so  near  the 
skin  that  this  becomes  secondarily  affected.  This  benefit 
appears  to  arise  from  the  skin  being  kept  soft  and  moist. 
Such  is  the  use  of  a poultice  in  inflammation,  either 
before  or  after  suppuration,  until  the  abscess  is 
opened.  But  when  poultices  and  fomentations  are 
applied  to  inflamed  parts,  in  which  we  wish  to  avoid 
suppuration,  reason  and  principle  will  not  justify  the 
practice,  though  such  applications  may  be  proclaimed 
by  experience  to  be  very  proper. — {Hunter.) 

TREATMENT  AFTER  SUPPURATION  HAS  TAKEN  PLACE. 

When  suppuration  cannot  be  stopped  or  resolved,  it 
is  in  general  to  be  promoted. 

How  far  suppuration  can  be  usefully  promoted  by 
medicines  or  applications  is  questionable;  but  at- 
tempts are  generally  made,  and  for  this  purpose  sup- 
purating cataplasms  and  plasters,  composed  of  the 
warm  gums,  seeds,  &c.  were  formerly  much  recom- 
mended. Mr.  Hunter  doubted  whether  such  applica- 
tions had  any  considerable  effect  in  the  way  intended  ) 
.'or  if  they  were  put  on  a sore,  they  would  hardly  in 
crease  the  discharge  from  it,  and  perhaps  even  dimi- 
nish it.  However,  in  many  cases  in  which  the  parts 
are  indolent  and  hardly  admit  of  true  inflammation,  in 
consequence  of  which  a perfect  suppuration  cannot 
take  place,  stimulating  the  skin  brings  on  a more  sa- 
lutary, and,  of  course,  a quicker  inflammation.  Thus 
the  antimonial  ointment  and  blistering  the  skin  over 
chronic  swellings  and  abscesses,  are  sometimes  in- 
dicated. 

These  applications  have  been  found,  however,  to 
bring  the  matter  more  quickly  to  the  skin,  even  in 
the  most  rapid  suppurations.  T1iis  effect  has  been 
mistaken  for  an  increased  formation  of  pus ; but  this 
consequence  can  only  follow  in  cases  in  which  the 
inner  surface  of  the  abscess  is  within  the  influence  of 
the  skin.  The  accelerated  progress  of  the  matter  to- 
the  surface  of  the  body  arises  from  another  cause,  viz. 
the  promotion  of  ulceration  in  the  parts,  between  the 
collection  of  matter  and  the  cuticle. 

Emollient  poultices  are  commonly  applied  to  in- 
flamed parts,  when  suppuration  is  known  to  have 
taken  place.  These  can  have  no  effect  upon  suppura- 
tion, except  that  of  lessening  the  inflammation,  or 
rather,  making  theskin  more  easy.  'J'he  inflammatioiv 
must  have  reached  the  skin  before  poultices  can  have" 
much  effect,  for  they  can  only  affect  that  part.  The 
e.ase  of  the  patient,  however,  should  be  considered,  and 
we  find  that  fomentations  and  poultices  are  often  bene- 
ficial in  this  way.  By  keeping  the  cuticle  moist  and 
warm,  the  sensitive  operations  of  the  nerves  of  the 
parts  are  soothed.  On  the  contrary,  if  the  inflamed 
skin  is  allowed  to  dry,  the  inflammation  is  increased  ; 
and  as  suppuration  is  probably  not  checked  by  the  above 
treatment,  it  ought  to  be  pul  in  practice.  As  warmth 
excites  action,  the  fomentation  should  be  as  warm 
as  the  patient  can  bear  without  inconvenience.-— 
{Hunter.) 

“The  local  treatment  in  phlegmonous  absces-ses  (as 
Professor  Thomson  observes)  is  still  more  simple  than 
that  by  which  we  endeavour  to  procure  resolution.  Il 


318 


SUPPURATION. 


consists  almost  solely  in  the  application  of  a moderate 
degree  of  wariiiih  and  moisture  to  the  inflamed  part, 
either  by  means  of  fomentations  or  poultices.  'I'he 
manner  in  wliicli  these  means  act  in  promoting  suppu- 
ration is  unknown.  Independently  of  tiieir  tempera- 
ture. it  seems  very  doubtful  wiiether  fomentations  and 
poultices  have  any  power  of  promoting  suppuration  in 
the  parts  to  which  they  are  applied.  They  keep  the 
cuticle  moist  and  warm,  they  jiromote  perspiration, 
they  sooth  and  allay  pain  in  many  inflammations, 
ami  these  are  probably  the  only  immediate  effects 
which  they  produce.  I'he  rest  is  the  work  of  nature. 
In  suppurations  attended  by  very  severe  pain,  the  use 
of  warm  fomentations  is  often  found  to  afford  sin- 
gular relief;  not  only  by  their  effect  in  easing  pain, 
but  also  by  their  seeming  to  shorten  the  duration  of 
the  suppurative  stage.  In  the  cases  of  sup(iuraiion  in 
which  they  give  relief,  they  should  be  repeated  every 
fo  ur  or  six  hours.  The  most  common  way  of  eniplo}  - 
ing  them  is  by  w'ringing  linen  or  woollen  cloths  out  of 
warm  water,  and  applying  these  to  the  inflamed  pait, 
of  as  high  a temperature  as  the  feelings  of  the  patient 
can  bear.  Decoctions  of  herbs  were  formerly  much 
employed  in  the  way  of  embrocation,  and  were  then 
and  are  still,  by  many  practitioners,  supposed  to  possess 
peculiar  virtues  in  promoting  suppuration.  Whether 
embrocations  with  the  narcotic  herbs  might  not  in 
some  cases  be  beneficial,  by  producing  a sedative  effect 
in  allaying  pain,  I am  unable  to  say,  thoutth  I am  in- 
clined to  believe  that  even  they  act  chiefly  by  their 
warmth  and  moisture.  In  cases  where  you  find  it 
necessary  to  use  an  embrocation  with  heibs,  the  flow 
ers  of  chamomile  may  in  general  be  substituted  in  plate 
of  the  leaves  or  flowers  of  almost  every  other  plant. 
These  flowers  readily  imbibe  and  retain  moisture. 
They  are,  when  moist,  of  a soft  consistence,  and  can 
be  easily  moulded  to  the  figure  of  the  parts  to  which 
they  are  applied.” — {Thomson's  Lectures^  p.  333.) 
Oatmeal,  crum  of  bread,  and  especially  linseed  meal, 
are  the  ingredients  mostly  preferred  in  this  country  for 
emoliient  poultices.  When  bread  is  used,  it  is  gene- 
rally boiled  in  milk.  The  observations,  however, 
which  have  been  offered  on  poultices  in  another  place, 
are  here  equally  applicable.— (See  Inflammation.) 

or  THE  TIME  WHEN  ABSCESSES  SHOULD  BE  OPENED. 

As  abscesses,  wherever  formed,  must  increase  that 
part  of  the  cavity  which  is  next  to  the  skin  more 
quickly  than  the  bottom,  they  must  become,  in  some 
degree,  tapering  towards  the  latter  part,  with  their 
greatest  breadth  immediately  under  the  skin.  This 
shape  of  an  abscess,  when  allowed  to  take  place,  is  fa- 
vourable to  its  healing,  for  it  puts  the  bottom,  which  is 
the  seat  of  the  disease,  more  upon  a footing  with  the 
mouth  of  the  abscess  than  it  otherwise  could  be.  As 
the  bottom  or  part  where  the  abscess  began  is  more  or 
less  in  a diseased  state,  and  as  the  parts  between  the 
seat  of  the  abscess  and  the  external  surface  are  sound 
parts,  having  only  allowed  a passa^'e  for  the  pus,  they 
of  course  have  a stronger  disposition  to  heal  than  the 
bottom  has. 

To  keep  tlie  mouth  of  an  abscess  from  healing  be- 
fore its  bottom,  the  coll.  ction  of  matter  should  be  al- 
lowed to  break  of  itself;  for,  although  abscesses  in 
general  only  open  by  a small  orifice,  more  especially 
when  sound,  yet  in  such  cases  the  skin  over  the  gene- 
ral cavity  of  the  matter  is  so  thinned,  that  it  has  very 
little  tendency  to  heal,  and  often  ulcerates  and  makes 
a free  opening.  If  ihe  latter  event  should  not  sponta- 
neously occur,  it  may  now  be  more  easily  obtained  by 
the  interference  of  the  surgeon. 

Ahsce.sses  which  are  the  most  disposed  to  heal  fa- 
vourably, are  the  quickest  in  their  progress  to  the  skin, 
and  the  matter  comes  to  the  surface  almost  at  a 
|)oint ; the  swelling  is  not  so  conical  as  in  other  cases  ; 
and  when  it  bursts,  the  orifice  is  exceedingly  stnall. 
Oil  the  other  hand,  when  there  is  an  indolence  in  the 
progress  of  the  abscess,  the  collection  spreads  more,  or 
distends  the  surrounding  parts  in  a greater  deirree,  in 
consequence  of  their  not  being  so  firmly  tinited  by  in- 
flamtnatioii  in  the  one  as  they  are  in  the  other  instatice ; 
nor  will  ulceration  so  readily  take  the  lead,  and  the 
matter  will  come  to  the  skin  by  a broad  surface,  so  as 
to  thin  a large  portion  of  the  cutis. — {Hunter.) 

It  may  be  set  down  as  a general  axiom,  that  all 
phlegmonous  abscesses  should  be  allowed  to  break,  and 
not  be  opened  by  the  surgeon.  When  punctured  un- 


necessarily or  prematurely,  they  never  lieat  so  favtrtir^ 
ably  as  when  left  to  themselves. 

Particular  cases,  liowever,  should  be  opened  as  soon 
as  the  existence  of  matter  is  ascertained.  Abscesses 
sliould  only  be  allowed  to  burst  of  themselves,  when 
the  continement  of  the  matter  can  do  no  mischief.- 
Abscesses  in  the  abdomen  or  thorax,  under  the  cra- 
nium, near  the  eye,  or  in  joints,  should  be  mostly 
opened  very  soon.  When  suppuration  takes  place  be- 
neath ligamentous  expansions  or  aponeuroses,  which- 
invariably  retard  the  tirogress  of  the  matter  to  the  sur- 
face of  the  body,  an  early  opening  should  be  made.  If 
tJiis  be  not  done,  the  matter  spreads  to  a great  extentf 
separating  such  ligamentous  expansions  from  the  mus- 
cles, and  the  muscles  from  each  other,  and  as  the  pus 
cannot  get  to  the  surface  of  the  body,  the  length  of  the 
disorder  is  of  course  increased.  When  matter  is  so 
situated  as  to  be  liable  to  insinuate  itself  into  the  chest 
or  abdomen,  or  into  the  capsular  ligaments  of  the 
Joints,  it  is  highly  proper  to  prevent  this  extension 
of  mischief,  by  making  a timely  opening  into  the 
abscess. 

“ 'I'hose  .abscesses  ought  to  be  opened  early  (sayff 
Professor  Thomson)  that  are  situated  in  parts  through 
which  the  matter  is  liable  to  become  widely  diffused. 
This  is  particularly  the  case  with  abscesses  that  are 
situated  on  the  fore  part  of  the  neck  or  in  the  cavity 
of  the  axilla,  or  by  the  side  of  the  rectum.  When 
matter  is  formed  in  the  cavity  of  the  axilla,  if  it  does 
not  speedily  obtain  an  external  outlet,  it  is  very  liable 
to  pass  up  towards  the  clavicle  in  the  course  of  the 
axillary  plexus  of  nerves  and  vessels,  or  forwards  un- 
der the  pectoral  muscle.  I have  repeatedly  seen  axil- 
lary abscess  take  both  of  these  directions  at  the  samo 
time,  foiming  otie  of  the  most  painful  and  difficuli 
ctises  to  treat  which  occurs  in  the  management  of  ab- 
scesses.” Dr.  'riiornson  also  considers  an  early  open- 
ing proper  au,d  necessary,  when  the  matter  is  lodged, 
as  in  some  cases  of  whitlow,  in  the  sheaths  of  the  ten- 
dons ; wheti  matter  is  formed  under  the  periosteum , 
when  it  collects  under  fasciae  or  in  the  vicinity  of  large 
arteries,  joints,  or  the  greater  cavities  of  the  body  f 
and  also  when  Ihe  abscess  is  deep  seated. — (See  Thom- 
son's Lectures  on  Inflammation,  p.  336 — 338.) 

With  respect  to  making  an  early  opening  into  ab- 
scesses situated  near  large  arteries,  I am  not  aware 
that  any  danger  of  the  artery  ulcerating  in  conse- 
quence of  the  nearness  of  the  pus  really  exists.  There- 
fore, some  doubts  may  reasonably  be  entertained  of 
the  soundness  of  Professor  Thomson’s  advice  in  this 
particuliir  case,  as  the  general  rule  of  opening  abscesses 
near  large  blood  vessels  in  an  early  stage  of  the  dis- 
ease, would  be  objectionable  on  the  ground  of  the  prac- 
tice exposing  the  vessels  themselves  to  injury.  Indeed,, 
this  well-informed  writer  distinctly  mentions,  in  con- 
sidering the  subject  in  question,  ttuit  the  arteries  are 
not  very  susceptible  of  ulcerative  absorption. — {P.  337.) 

OF  THE  PLACE  WHERE  THE  OPENING  SHOULD 
BE  MADE. 

If  a free  opening  is  not  required,  or  making  one  isf 
not  practicable,  it  is  at  least  proper  to  make  whatever 
opening  can  be  made  in  a depeiidintr  situation.  By 
this  means  the  matter  will  more  retidily  escape,  and  all 
pressure  arising  from  the  confinement  or  lodgement  of 
pus  will  be  prevented.  A very  small  degree  of  pres- 
sure on  that  side  of  the  abscess  which  is  next  to  the 
skin  may  produce  ulceration  there;  and  although  such 
pressure  might  not,  in  many  cases,  be  so  great  as  to 
produce  ulceration  at  the  bottom  of  the  abscess,  yet  it 
might  be  sufficieiuly  great  to  prevent  granulations 
from  forming  on  that  side,  and  thereby  retard  the 
cure,  as  no  union  could  take  pltice  but  by  means  of 
granulations.  I'he  pressure  is  always  most,  and  re- 
tards the  formation  of  granulations  in  the  greatest  de- 
gree, at  the  most  depending  part  of  the  abscess.  Hence, 
if  no  opening  be  in.ade  in  this  sitnatron,  the  upper 
part  of  the  abscess  readily  heals  to  a small  point, 
which  becomes  a fistula. 

When  circumstances  forbid  making  an  opening  at 
themostdependkig  partof  an  abscess,  perhaps  nothing 
more  can  he  dmie,  than  to  evacuate  the  matter  as  often 
as  necessary,  and  gently  to  compress  the  sides  of  the 
abscess  together,  if  the  situation  of  the  case  admit  of 
the  practice. 

But  ab.scesses  are  not  always  to  be  opened  at  the 
most  depending  part.  The  distance  between  the  mat- 


SUPPURATION. 


319 


ter  and  the  skin  at  this  part  is  the  common  reason 
against  the  method.  If  an  abscess  is  rather  deeply  si- 
tuated, and  points  ill  a place  which  is  higher  than  w here 
the  collection  lies,  it  is  proper  to  make  the  opening 
where  the  conical  eminence,  or,  as  it  is  termed,  ihaj'oint- 
ivg,  appears.  Thus,  if  an  abscess  should  form  in  the 
centre  of  the  breast,  and  point  at  the  uppermost  part, 
which  is  often  the  case,  it  w ould  be  improper  to  cut 
through  the  lower  half  of  the  mamma,  in  order  to 
make  a passage  for  the  matter  in  that  direction.  If  an 
abscess  should  form  on  the  upper  part  of  the  foot,  it 
would  be  wrong  to  make  an  opening  through  the  sole 
of  the  foot  to  get  at  the  most  depending  part  of  the  ab- 
scess ; for  besides  cutting  such  a depth  of  sound  parts, 
a great  many  useful  ones  would  be  destroyed. 

When  the  abscess  does  not  point  in  a depending  si- 
tuation, as  in  the  instances  just  cited,  since  the  place 
where  the  matter  threatens  to  open  a passage  is  likely 
to  be  the  future  opening,  atid  this  situation  is  disadvan- 
tageous to  the  healing  of  fire  deep  part  of  the  abscess, 
it  is  generally  best  to  let  the  collection  of  matter  first 
burst  of  itself,  and  then  dilate  the  opening  as  freely  as 
necessary.  By  allowing  abscesses  to  burst  spontane- 
ously, the  opening  is  not  so  apt  to  heal  as  if  made 
by  art,  and,  therefore,  is  better  in  such  situations. — 
{Hunter.) 

In  most  cases,  it  is  more  advantageous  even  to  cut 
through  a certain  thickness  of  parts,  for  the  sake  of 
obtaining  a depending  opening,  than  to  make  an  open- 
ing w here  the  pointing  appears,  that  is,  w’heie  the  parts 
are  thinnest,  and  the  matter  nearest  the  surface.  This 
remark  is  highly  worthy  of  remembrance,  when  there 
is  no  doubt  of  the  existence  of  matter  at  the  depending 
place,  and  when  the  parts  to  be  divided  are  not  impor- 
tatit  ones.  Collections  of  matter  beneath  the  fas- 
cia; of  the  forearm  and  thigh  particularly  demand  at- 
tention to  this  direction,  as  they  commonly  point  where 
those  ligamentous  expansions  are  thinnest,  not  where  j 
the  matter  can  most  readily  escape. 

Abscesses  in  the  sheath  of  the  rectus  abdominis 
should  also  be  opened  in  a low  situation. 

DIFFERENT  METHODS  OF  OPENING  ABSCESSES. 

All  abscesses  will  naturally  burst  of  themselves,  un- 
less the  matter  be  absorbed,  and  in  general,  they  ought 
to  be  allowed  to  take  this  course.  There  are,  however, 
as  I have  already  explained,  particular  circumstances 
which  require  an  early  opening ; but,  when  the  skin 
over  the  abscess  is  very  thin,  it  is  not  of  so  much  con- 
sequence whether  the  case  be  permitted  to  burst  of  it- 
.^elf,  or  it  be  opened  by  the  surgeon. 

When  abscesses  are  large,  it  is  generally  necessary  to 
open  them  by  art,  whether  they  have  burst  of  them- 
selves or  not,  for  the  natural  opening  will  seldom  be 
sufficient  for  the  completion  of  a cure;  and  although, 
it  may  be  sufficient  for  the  free  discharge  of  the  matter, 
yet  these  abscesses  will  heal  much  more  readily  when 
a free  opening  is  made  ; for  the  thin  skin  over  the  ca- 
vity granulates  but  indifferently,  and  therefore  unites 
but  slowly  with  the  parts  underneath. — {Hunter.) 

Abscesses  may  be  opened  either  by  an  incision,  or  by 
making  an  eschar  with  caustic.  To  the  latter  plan,  how- 
ever, many  urge  strong  objections:  the  use  of  caustic 
is  not  usually  attended  with  any  advantage  which  may 
not  he  obtained  by  a sitiijtle  incision  ; upon  a tender  in- 
flamed |iart  it  gives  much  more  pain  ; it  is  more  slow  in 
its  effects ; attd  the  surgeon  can  never  direct  the  ope- 
ration of  the  caustic  so  accurately  as  to  destroy  exactly 
the  parts  which  he  wishes,  and  no  more.  If  the  eschar 
be  not  made  deep  enough,  the  lancet  must,  after  all,  be 
used.  Caustic  also  leaves,  after  its  application,  a dis 
agreeable  scar,  a consideration  of  some  importance  in 
opening  abscesses  about  the  female  neck  or  (ace.  To 
these  numerous  objections  we  have  to  add,  that  the  es- 
char is  very  frequently  ten  or  tw'elve  tedious  days  in 
becoming  detached. 

When  there  is  a redundance  of  skin,  or  when  there 
is  a good  deal  of  it  thinned,  however,  an  opening  made 
with  caustic  will  answer,  perhaps,  as  well  as  an  inci- 
sion. The  application  of  caustic  may  also  sometimes 
be  advantageously  resorted  to  when  there  is  a good  deal 
of  indolent  hardness  around  a small  abscess. 

The  calx  cum  pata.<f8a,  or  the  potassa  alone,  is  the 
best  caustic  for  opening  abscesses.  The  part  is  first  to 
be  covered  with  a piece  of  adhesive  plaster,  which  has 
a portion  cut  out  exactly  of  the  same  figure  and  size 
as  the  opening  intended  to  be  made  in  the  abscess. 


The  best  way  of  making  the  eschar  is  to  dip  the  end  of 
the  caustic  in  water,  and  to  rub  it  on  the  part  till  the 
skin  becomes  brown.  The  active  substance  is  then  to 
be  immediately  washed  oil’  with  some  wet  tow,  the 
plaster  is  to  be  removed,,  and  an  emollient  poultice  ap- 
plied. 

In  almost  all  cases,  it  is  better  to  use  the  lancet,  ot 
double-edged  bistoury.  Either  of  these  instruments 
opens  the  abscess  at  once,  and  with  less  pain  than  re-* 
suits  from  the  use  of  caustic;  it  occasions  no  loss  of 
substance,  consequently  a smaller  cicatrix;  and  by 
using  it  the  opening  may  be  made  in  the  most  advan- 
tageous direction,  and  of  the  exact  size  required. 

DRESSINGS  AFTER  OPENING  ABSCESSES. 

When  an  abscess  has  burst  of  itself,  and  it  is  unne- 
ces.sary  to  enlarge  the  opening,  the  only  thing  lequisite 
is  to  keep  the  surrounding  parts  clean.  The  continu- 
ation of  the  same  kind  of  poultice  which  was  before 
used  is,  perhaps,  as  good  a practice  as  atiy  ; and  when 
(he  tenderness  arising  from  the  inflammation  is  over, 
lint  and  a pledget  may  be  made  use  of,  instead  of  the 
poultice. 

But  an  abscess  opened  by  a cutting  instrument  is 
both  a wound  and  a sore,  and  partakes  more  of  the  na- 
ture of  a fresh  w ound  in  proportion  to  the  thickness  of 
the  parts  cut.  Hence,  it  is  necessary  that  something 
should  be  put  into  the  opciing  to  keep  it  from  healing 
by  the  first  intention.  If  it  is  lint,  it  should  be  dijiped 
in  some  salve,  which  will  answer  better  than  lint  alone, 
as  it  will  admit  of  being  taken  out  sooner.  This  i.s  ad- 
vantageous, because  such  sores  should  be  dressed  the 
next  day,  or,  at  latest,  on  the  second  day,  in  order  that 
the  pus  may  be  discharged  again.  When  the  cut  edges 
of  the  opening  have  suppurated,  which  will  be  iri  a 
few  days,  the  future  dressings  may  be  as  simple  as  pos- 
sible, for  nature  will  in  geneial  complete  the  cure. 

I If  the  abscess  has  been  opened  with  caustic,  and  the 
slough  has  either  beeti  cut  out  or  sepai  aled  o(  itself,  the 
case  is  to  be  regarded  altogether  as  a suppurating  sore, 
and  dressed  accordingly. 

Perhaps  dry  lint  is  as  good  a dressing  as  any,  till  the 
nature  of  the  sore  is  known.  If  it  should  be  of  a good 
kind,  the  same  dressing  may  be  continued  ; but  if  not, 
then  it  must  be  dressed  accordingly.  Parts  which  at 
first  appear  to  be  sound,  sometimes  assume  every  spe- 
cies of  disease,  whether  from  indolence,  from  irritabi- 
lity, from  scrofulous,  and  other  dispositions.  This  ten- 
dency to  disease  arises  in  some  cases  from  the  nature  of 
the  parts  affected,  as,  for  instance,  bone,  ligament,  &;c. 
— {Hunter.) 

[fJelpech,  Chirurgie  Clinique,  t.  2,  p.  353,  et  seq.  In 
the  article  Suppuration,  I have  explained  that  all  ab- 
scesses are  lined  by  a cyst,  which  is  the  organ  by  which 
the  pus  is  secreted  and  absorbed,  and  also  bounded. 
This  is  a subject,  on  which  Professor  Delpech  has  made 
some  correct  reflections.  In  all  cases,  he  observes, 
wherever  pus  is  formed  and  deposited,  whetlier  in 
what  is  improperly  called  a natural  cavity ; in  what 
trulydeserves  this  name ; in  some  unusual  space  formed 
in  the  substance  of  parts ; or  on  tbe  surface  of  a wound  ; 
in  every  instance,  a pseudo-membrane  is  found,  ami  in 
none  are  the  parenchyma  of  organs  and  the  natural 
surfaces  in  contact  with  the  purulent  matter.  Bichat 
had  noticed  the  presence  of  the  pseudo-membrane  on 
the  surface  of  a wound,  forming  the  layers  of  com- 
mon cellular  substance,  resisting  the  inflation  of  the 
part,  and  the  injection  of  fluids  into  it;  but,  according 
to  Delpech,  he  did  not  mark  the  constant  connexion  be- 
tween this  accidental  organization  and  the  formation  of 
pus.  In  every  exanqtle,  the  true  organ  by  which  pus 
is  generated  seems  to  Delpech  to  be  the  pseudo-mem- 
brane, which  has  a degree  of  organization  imparted  to 
it  by  the  suppurative  inflammation.  He  also  exjiiain.s 
that  it  is  not  till  ulcerated  surfaces  and  the  pleura  are 
covered  with  an  exudathtn  of  lymph,  that  pus  is  formed 
from  them,  and  that  when  the  matter  is  removed  the 
pseudo-membrane  is  seen.  Delpech  declares,  that  no 
collection  of  matter  is  ever  found  on  a serous  mem- 
brane, without  the  latter  being  completely  covered  by  a 
pseudo-membrane  of  more  or  less  thickness ; and  that, 
if  some  points  of  it  appear  naked,  or  only  coated  with 
a very  thin  layer,  as  frequently  hap|)ens,  we  always 
find  flakes  of  pseudo  membrane  in  the  fluid,  either  en- 
tirely or  partially  detached.  Another  doctrine,  much 
extended  by  Delpech  beyond  the  limits  usually  giveit 
to  it,  is,  that  whenever  the  suppurative  pseudo- mem- 


320 


SUR 


SUR 


brane  lakes  place,  it  is  followed  by  a slirinking  and 
contraction  of  the  libions  tissue,  wliich  it  produces  in 
the  progress  of  the  cure.  To  this  principle  he  even 
refers  the  diminution  and  alteration  in  the  shape  of  the 
chest  after  an  empyema,  that  has  been  cured,  and  not 
to  any  positive  changes,  the  result  of  the  dwindled  state 
of  the  lungs. — Prcf.] 

Consult  particularly  John  Hunter'^  Treatise  on  the 
Blood,  Inflammation,  and  Gun-shot  Wounds;  a work 
in  which  more  interesting  knowledge,  respecting  ab- 
scesses and  suppuration  is  contained,  than  in  any  other 
ever  published.  See  also  Traite  de  la  Suppuration  de 
F.  Ques7iay,  1749.  .7.  Orashuis,  A Diss.  on  Suppura- 
tion, 8vo.  Lond.  1752.  Various  parts  of  the  Memoires 
de  I'JIcademie  de  Chirurgie.  J.  B.  Boyer,  De  Suppu- 
ratione  et  Curatione  fnflammationis  per  Suppurationem 
tcrminandw.  Monsp.\l%&.  L' Encyclopedie  Methodi- 
qae,  Partie  Chirurgicale,  article  Abcis.  Dissertations 
on  Inflammation  by  John  Burns,  1800.  Sir  E.  Home's 
Dissertation  on  the  Properties  of  Pus,  1788;  and  his 
Pract.  Obs.  on  Ulcers,  Hd  edit.  1801.  James  Hendy, 
Essay  on  Glandular  Secretion,  containing  an  experi- 
mental, Inquiry  into  the  Formation  of  Pus,  Src.  8vo. 
Bond.  1775.  JV*.  Roumayne,  De  Puris  Generatione,  8vo. 
Edin.  1780.  C.  Darwin's  Experiments,  establishing  a 
criterion  between  mucilaginous  and  purulent  matter, 
^c.  Litchfield,  1780.  P.  Clare,  Essay  on  Abscesses, 
Bond.  1781.  Several  parts  of  Pott's  Chirurgical 
Works,  but  especially  his  Treatise  on  the  Fistula 
in  Ano.  T.  Brand,  Strictures  in  Vindication  of  some 
of  the  Doctrines  misrepresented  by  Mr.  Foot  in  his  two 
Pamphlets,  entitled,  ^^Observations  upon  the  JVew  Opi- 
nions of  J.  Hunter,  in  his  Treatise  on  the  Venereal,  in- 
cluding Mr.  Pott's  Plagiarisms,  and  Misinformation 
on  Pus,"  Src.  ito.  Bond.  1787.  Richter,  Anfangs- 
griinde  der  Wundarzneykunst,  b.  1,  kap.  2.  Dr.  J. 
Thomson' s Lectures  on  Inflammation,  p.  305,  S-c.  Edin. 
1813  ; a work  in  which  a profound  knowledge  of  medi- 
cal science,  and  of  surgery  in  particular,  is  everywhere 
conspicuous.  J.  F.  Crevecoeur,  De  Diagnosi  Puris  ; 
Jjongchamps,  1793.  Pearson's  Principles  of  Surgery, 
p.  34,  Src.  edit.  2.  Lassus,  Pathologic  Chir.  t.  l,p.  21, 
S c.  &c.  edit,  of  1809.  Seb.  J.  Brugmans,  De  Puoge- 
nia,  sive  Mediis  quibus  JTatura  utitur  in  creando  Pure, 
8vo.  Groningee,  1785.  Dr.  G.  Pearson's  Obs.  and  Ex- 
periments on  Pus,  in  he  Philosophical  Trans,  for  1811. 
C.  J.  M.  I^angenbeck,  Von  der  Bchandlung  der  Fistel- 
gange,  der  Schusscanale,  und  grosser  Eiter  absondem- 
dcr  H'ohlen.  in  fiteue  Bibl.  fur  die  Chirurgie,  12mo. 
Hanover,  1817.  Also  his  H'osnlogie  der  Chirurg, 
Krankheiten,  “iter  b.  Getting.  1823.  Gibson's  Insti- 
tutes, S’C.  of  Surgery,  vol.  1,  Philadelphia,  1824. 

SURGERY,  or  CHIRURGERY,  (from  x«P)  the 
hand,  and  epyov,  work),  has  been  sometimes  represented 
to  be  that  branch  of  medicine,  which  principally  effects 
the  cure  of  diseases  by  the  application  of  the  hand 
alone,  the  employment  of  instruments,  or  the  use  of 
topical  remedies. — {Encyclopedia  Methodique,  Partie 
Chir.  1. 1,  art.  Chirurgie.)  Such  definition,  however, 
conveys  but  a very  imperfect  idea  of  the  nature  of  this 
most  useful  profession,  and,  as  applied  to  the  present 
state  of  practice,  cannot  be  said  to  be  correct.  It  might 
indeed  be  applicable  to  that  short  unfavoured  period 
of  surgery,  some  centuries  ago,  when  its  practice  w’as 
denounced  by  the  Council  of  Tours,  as  unfit  for  the 
hands  of  priests  and  men  of  literature,  and  when  the 
surgeon  became  little  Itetter  than  a sort  of  professional 
servant  to  the  physician,  the  latter  alone  i^ot  only  hav- 
ing the  sole  privilege  of  prescribing  internal  medicines, 
but  even  that  of  judging  and  directing  when  surgical 
operations  should  be  performed.  Then  the  subordinate 
surgeon  was  only  called  upon  to  execute  with  his  knife, 
or  his  hand,  duties  which  the  more  exalted  physimn 
did  not  choose  to  undertake;  and,  in  fact,  he  visited  the 
patietit,  did  what  was  required  to  be  done,  and  took  his 
leave  of  the  case,  altogether  under  the  orders  of  his 
master.  In  modern  times,  however,  the  good  sense  cf 
mankind  has  discovered  that  surgery  is  deserving  of  an 
eminent  rank  among  such  arts  as  ought  to  be  culti- 
vated for  the  general  benefit  of  society  ; that  the  man 
who  is  not  himself  accustomed  to  the  performance  of 
operations  cannot  be  the  best  judge  of  their  safety  and 
necessity  ; and  that,  in  every  point  of  view,  the  surgi- 
cal practitioner  merits  as  much  favour  and  independ- 
ence in  the  exercise  of  his  profession,  as  he  whose  avo- 
cation is  confined  to  physic.  Hence,  the  surgeon  is  now 
exclusively  consulted  about  many  of  the  most  impor- , 


tant  diseases  to  wh  ich  the  human  body  is  liable.  Being 
no  longer  under  the  yoke  of  the  physician,  he  follow# 
the  dictates  of  his  own  judgment  and  knowledge;  he 
prescribes  whatever  medicines  the  case  may  demand^ 
internal  as  well  as  external ; and  under  the  encourage- 
ment of  an  enlightened  age,  he  sees  his  profession  daily 
becoming  more  scientific,  more  respected,  and  more  ex- 
tensively useful. 

Surgery,  as  Mr.  Lawrence  has  stated,  is  a branch  of 
that  science  and  art  which  have  diseases  for  their  ob- 
ject. This  science,  considered  generally,  embraces  the 
physical  history  of  man.  It  investigates  the  construe-' 
tion  of  the  human  body,  and  its  living  actions  ; it  in- 
quires into  the  purposes  executed  by  each  part,  and  into 
the  general  results  of  tneir  combined  exertions ; it  ob- 
serves the  human  organization  under  all  the  various 
modifications  impressed  on  it  by  surrounding  influences 
of  all  kinds;  and  it  draws  from  these  sources  the  rules 
for  preserving  health,  and  removing  disease.  The 
practical  application  of  these  rules  constitutes  the  art 
of  healing,  or  rather  of  treating  disease  (for,  in  many 
cases,  we  are  unable  to  heal,  and  do  not  even  attempt 
it) ; while  the  assemblage  of  facts  and  reasonings  on 
which  these  practical  proceedings  are  grounded  make 
up  the  science  of  medicine. 

By  some  writers,  physic  is  said  to  have  for  its  object 
the  treatment  of  internal,  surgery  that  of  external, 
diseases.  This  definition,  however  good  and  plausible 
it  may  at  first  appear,  can  only  be  received  with  nu- 
merous exceptions  in  regard  to  modern  practice : for 
instance,  the  psoas  abscess ; stone  in  the  bladder ; 
polypi  and  scirrhus  of  the  uterus;  stricture  of  the 
oesophagus ; an  extravasation  of  blood  within  the 
skull,  in  consequence  of  accidental  violence  ; are  uni- 
versally allowed  to  be  strictly  surgical  cases;  yet  no 
man  in  his  senses  would  call  these  disorders  external. 

As  Mr.  Lawrence  has  pertinently  observed,  “ Nature 
has  connected  the  outside  and  inside  so  closely,  that 
we  can  hardly  say  where  one  ends  and  the  other  begins. 
She  has  decreed  that  both  shall  obey  the  same  patho- 
logical laws ; and  has  subjected  them  to  such  powerful 
mutual  influences,  that  we  cannot  stir  a step  in  inves- 
tigating the  diseases  of  either,  without  reference  to  the 
other.  How  deep  would  the  domain  of  surgery  extend 
according  to  this  view  1 Half  an  inch  or  an  inch  ? 
The  entrance  of  the  various  mucous  membranes  pre- 
sents a series  of  puzzling  cases;  and  the  distribution 
of  diseases  in  these  situations,  between  the  two 
branches  of  the  profession,  is  quite  capricious.  How 
far  is  the  surgeon  to  be  trusted  ? He  is  allowed  to  take 
care  of  the  mouth.  Where  is  he  to  stop  ? At  the  en- 
trance of  the  fauces — in  the  pharynx — or  in  the  (Eso- 
phagus? Inflammation  and  ulceration  of  the  throat 
from  syphilis  belong  to  the  surgeon ; catarrhal  affection 
of  the  same  membrane  to  the  physician.  Polypus  anti 
ulceration  of  the  nasal  membrane  are  surgical ; coryza 
is  medical.  The  affections  of  the  bones  and  joints 
have  been  given  to  the  surgeon  ; yet  they  can  hardly 
be  called  external  parts.  In  hernia  and  aneurism, 
there  is  external  tumour ; but  it  is  produced  by  dis- 
placement or  disease  of  organs  that  are  quite  internal. 

“ When  we  look  to  the  nature  and  causes  of  disease, 
the  absurdity  of  the  distinctions  now  under  considera- 
tion is  still  more  apparent,  and  the  inseparable  con- 
nexion between  the  interior  and  exterior  of  our  frame 
more  obvious.  Internal  causes  produce  external  dis- 
ease, as  we  see  ifi  erysipelas,  carbuncle,  nettle  rash, 
gout,  (Edema  ; while  external  agencies  affect  inward 
parts,  as  in  catarrhal  rheumatic  afl'ections,  in  various 
inflammations  of  the  chest  and  abdomen.” 

Others  have  defined  surgery  to  be  the  mechanical 
part  of  physic,  “ quod  in  therapeia  mechanicum  but, 
althougli  this  has  obtained  the  assent  of  so  eminent  a 
modern  surgeon  as  Richerand  of  Paris  {Diet,  des 
Sciences  Mi‘dicales,  t.  5,  p.  85),  I believe  few  on  this 
side  of  the  water  Avill  be  of  his  opinion.  As  Mr.  J. 
Pearson  has  observed,  “ Many  people  have  imagined, 
that  when  a man  has  learned  the  art  of  dressing  sores, 
of  applying  bandages,  and  performing  operations  with 
a little  dexterity,  he  must  necessarily  be  an  accom- 
plished surgeon.  If  a conclusion  so  gross  and  fallacious 
had  been  confined  to  the  vulgar  and  illiterate,  the  pro- 
gress of  scientific  surgery  would  have  suffered  little 
interrtiption  : but  if  young  minds  are  dirtxited  to  these 
objects,  as  the  only  important  matters  upon  which  their 
faculties  are  to  be  exercised  ; if  the  gross  informations 
of  sense  constitute  the  sum  of  Uieir  knowledge ; liul« 


SURGERY. 


321 


more  can  be  expected  from  such  a mode  of  study  than 
eervile  imitation,  or  daring  empiricism.  Indeed,  some 
people  have  affected  to  oppose  surgery  as  an  art,  to 
medicine  as  a science  ; and  if  their  pretensions  were 
justly  founded,  the  former  would  certainly  be  degraded 
to  a mere  mechanical  occupation.  But  it  is  not  very 
easy  to  comprehend  the  grounds  of  such  a distinction. 
The  internal  and  external  parts  of  the  body  are  governed 
by  the  same  general  laws  during  a slate  of  health ; and 
if  an  internal  part  be  attacked  with  inflammation,  the 
appearances  and  effects  will  bear  a great  similarity  to 
the  same  disease  situated  externally ; nor  are  the  indi- 
cations of  cure,  in  general,  materially  different.  If  by 
science,  therefore,  be  meant  ‘ a knowledge  of  the  laws 
of  nature,’  he  who  knows  what  is  known  of  the  order 
and  method  of  nature,  in  the  production,  progress,  and 
termination  of  surgical  diseases,  merits  as  justly  the 
title  of  a scientifical  practitioner  as  the  well-educated 
physician.  The  practical  parts  of  physic  and  surgery 
are  very  frequently  disunited ; but  their  theory  and 
principles  are  indivisible,  since  they  truly  constitute 
one  and  the  same  science.” — (.Principles  of  Surgery, 
Preface.)  * 

As  a learned  Professor  notices,  the  limits  between 
Dhysic  and  surgery  are  not  very  precisely  marked,  and 
tlie  respective  functions  of  the  physician  and  surgeon, 
ong  as  those  names  have  existed,  are  still  but  very 
inaccurately  defined.  “ The  most  superficial  acquaint- 
ance with  the  symptoms,  progress,  and  termination  of 
the  various  morbid  affections  to  which  the  hunran  body 
is  liable,  must  be  sufficient  to  convince  every  unpre- 
judiced inquirer,  that  there  is  but  a slight  foundation, 
if  indeed  there  be  any,  for  this  distinction  in  the  nature 
of  the  diseases  which  these  practitioners  are  required 
to  treat,  or  in  the  modes  of  treatment  by  which  the 
diseases  themselves  may  be  cured  or  relieved.  Expe- 
rience has  long  shown  that  the  use  of  internal  remedies 
is  not  only  required  in  a large  proportion  of  the  diseases 
which  are  regarded  as  strictly  chirurgical,  but  also, 
that  there  are  few  diseases  which  come  under  the  care 
of  the  physician,  in  which  morbid  affections,  requiring 
the  manual  aid  or  practical  skill  of  the  surgeon,  do  not 
frequently  occur. 

“ The  treatment  of  febrile  and  internal  inflammatory 
diseases,  it  will  be  allowed,  belongs  exclusively  to  the 
province  of  the  physician,  wherever  the  distinction  be- 
tween physician  and  surgeon  has  been  introduced,  and 
is  rigidly  observed  ; yet,  in  some  species  of  fevers,  and 
in  all  internal  inflammatory  diseases,  blood-letting  is 
often  the  principal,  if  not  the  only  remedy  that  is  re- 
quired. But  this  is  an  operation,  however  urgent  the 
necessity  for  it  be,  which  from  engagement  the  physi- 
cian cannot,  and  from  the  fear  of  degrading  his  pro- 
vince of  the  profession  will  not,  perform.  Retention 
of  urine  not  unfrequently  takes  place  in  symptomatic 
febrile  diseases,  and  this  is  an  affection  which  does  not 
always  yield  to  the  use  of  internal  remedies  ; but  it  is 
an  affection  also,  from  the  painful  uneasiness  which  it 
immediately  excites,  as  well  as  from  the  danger  which 
it  threatens,  that  will  not  admit  of  delay.  When  in- 
ternal remedies,  therefore,  fail  in  relieving  the  patient, 
the  urine  must  be  speedily  drawn  off  by  means  of  a 
chirurgical  operation  ; otherwise  inflammation,  morti- 
fication, and  rupture  of  the  bladder  must  necessarily  en- 
sue. Febrile  and  internal  inflammatory  affections  termi- 
nate not  unfrequently  in  the  formation  of  fluids,  which 
it  is  necessary  to  let  out  by  a chirurgical  operation ; and 
abscesses,  fistulous  openings,  and  ulcers  are  formed, 
which  require  the  aid  of  the  surgeon.  In  patients, 
also,  affected  with  severe  febrile  diseases,  from  being 
long  fixed  down  to  their  beds  in  one  position,  some  of 
the  parts  of  the  body,  upon  which  they  rest,  occasion- 
ally acquire  a disposition  to  mortify,  larger  or  smaller 
portions  of  the  skin  and  subjacent  cellular  membrane 
becoming  dead,  separate  from  the  living  parts,  and 
sores  are  formed,  which  are  but  too  often  the  subject 
of  unavailing  chirurgical  practice.  To  employ,  in  the 
different  stages  of  this  species  of  mortification,  from  its 
first  commencement  to  the  complete  separation  of  the 
dead  parts,  and  the  formation  of  a new  skin,  the  ap- 
propriate external  apd  internal  remedies,  requires  a 
greater  share  of  chirurgical  skill  than  can  reasonably 
be  expected  in  those  who  make  a profession  solely  of 
physic.  Unhappy,  therefore,  must  be  the  lot  of  that 
atieiit,  who,  in  circumstances  similar  to  those  which 
have  described,  has  the  misfortune  to  have  for  his 
sole  medical  attendant  a physician  ignorant  of  surgery. 


“ But  (continues  Professor  Thomson)  if  a knowledge 
of  surgery  be  necessary  to  the  student  who  intends  to 
practise  physic,  the  knowledge  of  physic,  on  the  other 
hand,  is  no  less  necessary  to  him  who  intends  to  devote 
his  attention  exclusively  to  the  profession  of  surgery  ; 
for,  indeed,  there  are  few  chirurgical  diseases,  which 
are  not,  in  some  period  or  another  of  their  existence, 
accompanied  by  morbid  affections  of  the  same  nature 
with  those  which  fall  properly,  and  most  frequently, 
under  the  care  of  the  physician.  It  will  only  be  ne- 
cessary to  mention,  as  examples  of  these  affections, 
the  symptomatic  fever  which  attends  inflammation, 
whether  this  affection  has  been  induced  by  external 
injury,  or  has  occurred  spontaneously  in  the  body  from 
internal  disease  ; the  hectic  fever,  supervening  to  long- 
continued  processes  of  suppuration  ; the  febrile  state, 
and  other  morbid  affections,  which  are  sometimes 
brought  on  by  the  too  sudden  and  injudicious  use  of 
mercury;  bilious  fevers,  and  the  various  derangements 
of  the  digestive  organs,  which  are  sometimes  the  cause, 
and  at  other  times  the  consequence,  of  local  diseases ; 
the  nervous  affections,  such  as  apoplexy,  convulsions, 
paralysis,  and  mania,  which  arise  not  unfrequently 
from  injuries  of  the  head  ; and  locked  jaw,  or  tetanus, 
which,  in  warm  climates  particularly,  is  so  very  liable 
to  be  induced  by  punctured  wounds.  These  are  mor- 
bid affections,  the  proper  study  and  treatment  of  which, 
when  they  occur  without  local  injury,  are  supposed  to 
belong  to  the  physician,  rather  than  the  surgeon;  but 
occurring  very  frequently,  as  they  do  in  chirurgical 
diseases,  and  always  modifying  or  aggravating  the 
effects  of  these  diseases,  ignorance  of  their  nature, 
relations,  and  modes  of  cure,  is  not  only  inexcusable, 
but  highly  criminal  in  the  practitioner  who  ventures  to 
undertake  their  treatment.” — (Thomson's  Lectures  on 
Inflammation,  Introduction.  Also,  .7.  R.  C.  Bollman, 
Tentamen,  ostendens  Chirurgiam  a J\Iedicina  haud 
impune  separari,  12mo.  Rintel.  1803.) 

From  what  has  been  stated,  I think  it  very  certain 
that  there  never  can  be  a complete  and  scientific  divi- 
sion of  the  healing  art  into  physic  and  surgery ; and 
that  all  attempts  to  distinguish  the  numerous  diseases 
and  injuries  of  the  human  body  into  medical  and 
surgical  cases  must,  in  a great  measure,  be  decided  by 
custom  and  the  mutual  agreement  of  practitioners, 
rather  than  by  any  rules  or  principles  which  are  at  all 
consistent. 

Mr.  Lawrence  joins  all  the  most  judicious  practi- 
tioners in  believing,  that  the  line  of  demarcation  be- 
tween surgery  and  physic  cannot  be  easily  traced  ; 
and  he  considers  the  distinction  between  them  to  be 
a niere  matter  of  arbitrary  usage.  He  employs  the 
word  surgery  in  its  common  acceptation  ; understand- 
ing it  to  include,  1st,  Injuries  of  all  kinds ; 2dly,  The 
greater  part  of  external  and  local  complaints ; 3dly, 
Such  internal  affections  as  produce  changes  recog- 
nisable externally;  for  example,  alterations  of  figure, 
colour,  or  consistence ; 4thly,  All  cases  requiring  ex- 
ternal topical  treatment,  operations,  or  manual  pro- 
ceedings of  any  kind.  This  view  coincides  very  much 
with  the  catalogue  of  diseases  treated  of  in  the  present 
work  ; yet,  such  is  the  difficulty  of  separating  surgery 
from  physic  by  any  general  definitions,  that  every  man 
of  experience  will  immediately  recollect  various  excep- 
tions to  some  of  the  foregoing  principles  of  classification. 
Thus  ascites,  or  dropsy,  which  is  an  internal  disease 
productive  of  change  of  figure,  and  often  requiring  an 
operation,  is  usually  regarded  as  a medical  case. 

In  the  earliest  periods,  the  same  men  cultivated  the 
whole  field  of  medicine.  The  writings  of  Hippocrates, 
Galen,  Celsus,  Paulus  iEgineta,  Albucasis,  &c.  prove 
that  the  Greeks,  Romans,  and  Arabians  never  had  an 
idea  of  the  human  body  being  susceptible  of  only  two 
classes  of  diseases,  one  of  which  formed  the  province 
of  physic,  while  the  other  constituted  a separate  and  dis- 
tinct science,  called  surgery.  They  had  no  conception 
of  two  systems  of  pathology ; one  aiiplicable  to  the 
exterior,  the  other  to  the  interior  parts  of  the  body. 
They  knew,  as  well  as  the  best-informed  practitioners 
of  the  present  day,  that  though  each  organ  has  its  par- 
ticular function  to  perform,  its  office  is  not  independent 
of,  but  closely  connected  with  the  use  and  perfect  state 
of  other  organs.  Hence,  as  Mr.  Lawrence  has  noticed, 
the  expression  of  Hippocrates  is  perfectly  correct; 

I jab  or  unus ; consenticntia  omnia." 

The  numerous  individual  organs  which  make  up 
the  human  body,  although  various  in  structure  and 


322 


SURGERY. 


office,  are  all  intimately  connected  and  mutually  de- 
pendent. They  are  merely  subordinate  parts  of  one 
great  machine ; and  they  all  concur,  each  in  its  own 
way,  in  producing  one  general  result, — the  life  of  the 
individual.  All  the  leading  arrangements  are  calcu- 
lated to  give  a character  of  unity  to  the  organization 
and  living  actions  of  our  frame.  Inhere  is  a common 
source  of  nutrition  for  the  whole  body  ; a single  centre 
of  circulation  ; a common  place  of  union  for  all  sensa- 
tions and  volitions,  for  nervous  energy  of  whatever 
kind.  The  various  organs  are  not  only  intimately 
connected  by  the  share  which  they  severally  take  in 
executing  associated  and  mutually  dependent  functions, 
they  act  and  re  act  on  each  other,  often  very  power- 
fully, by  those  mysterious,  or  at  least  hitherto  unknown, 
influences  which  we  call  sympathies.  As  the  animal 
machine,  although  complicated  in  structure,  is  single  ; 
and  as  its  living  motions,  although  numerous  and  in- 
tricate, form  one  indivisible  series,  so  a similar  con- 
nexion runs  through  those  changes  of  structure  and 
functions,  which  constitute  disease.  Hence,  there  is 
one  anatomy  and  physiology ; and  there  can  be  only 
one  pathology. — {Lawrence.)  All  the  above-men- 
tioned ancient  writers  treat  successively  of  fevers, 
fractures,  wounds,  and  nervous  diseases ; and  none  of 
them  appear  to  have  supposed,  that  there  could  be  any 
disorders  which  really  deserved  to  be  called  external., 
and  others  internal.  Nor  was  it  until  the  middle  of 
the  twelfth  century,  when  the  clergy  w’ere  restrained 
from  undertaking  any  bloody  operation,  that  surgery 
was  rejected  from  the  universities,  under  the  empty 
pretext,  “ Ecclesia  abhorret  a sanguine,"  often  ex- 
pressed in  its  decrees,  as  Professor  Thomson  well  ob- 
serves, but  never  acted  upon,  except  in  this  instance, 
by  the  church  of  Rome.  It  is  to  this  epoch  that  we 
must  refer  the  artificial  separation  of  physic  from  sur- 
gery ; the  latter  being  abandoned  to  the  laity,  who  in 
those  ages  of  barbarism  were  totally  illiterate. 

It  is  an  observation  made  by  the  celebrated  Bichat, 
that  two  things  are  essentially  necessary  to  form  a 
great  surgeon  ; viz.  genius  and  experience.  One  traces 
for  him  the  way  ; the  other  rectifies  it ; both  recipro- 
cally assist  in  forming  him.  Without  experience  ge- 
nius would  be  unprofitably  fertile  ; without  genius  ex- 
perience would  only  be  a barren  advantage  to  him. — 
{(Euvres  Chir.  de  Desault,  par  Bichat,  t.  I,  Discours 
Prelim.)  Out  of  the  large  number  of  liospital  surgeons 
who  are  to  be  met  with  in  every  country  of  Europe, 
and  who  enjoy  ample  opportunities  of  profiting  by  the 
lessons  of  experience,  how  few  distinguish  themselves 
or  ever  contribute  a mite  to  the  improvement  of  their 
profession  ! Opportunity  without  talents  and  an  apt- 
ness to  take  advantage  of  it,  is  not  of  more  use  than 
light  to  a blind  man.  On  the  other  hand,  splendid 
abilities  without  experience  can  never  be  enough  to 
make  a consummate  surgeon,  any  more  than  a man 
with  the  greatest  genius  for  painting  can  excel  in  his 
particular  art,  without  having  examined  and  studied 
the  real  objects  which  he  wishes  to  delineate.  In  short, 
as  a sensible  writer  has  remarked,  “ Les  grands  chi- 
rurgiens  sont  aussi  rares,  quele  genie,  le  savoir,  et  les 
talens." — {Mem.  de  I’Acad.  de  Chir.  t.  1,  Pref.  p.  41, 
edit.  \2mo.) 

The  description  of  the  qualities  which  a surgeon 
ought  to  possess,  as  given  by  Celsus,  is  excellent  as  far 
it  goes.  A surgeon,  says  he,  should  be  young,  or  at 
any  rate  not  very  old ; his  hand  should  be  firm  and 
steady,  and  never  shake ; he  should  be  able  to  use  his 
left  hand  with  as  much  dexterity  as  his  right ; his  sight 
should  be  acute  and  clear ; his  mind  intrepid  and  piti- 
less, so  that  when  he  is  engaged  in  doing  any  thing  to  a 
patient  he  may  not  hurry,  nor  cut  less  than  he-ought, 
but  finish  the  operation  just  as  if  the  cries  of  the  patient 
made  no  impression  upon  him.— (.>3.  C.  CelsiMed.  Prcef. 
ad  lib.  7.) 

[The  following  judicious  discrimination  is  from  the 
pen  of  the  late  Professor  Godman,  and  does  honour  to 
his  head  and  heart. 

“ The  ditFerence  between  a surgeon  and  a mere  ope- 
rator may  be  estimated  by  contrasting  them.  The  sur- 
geon inquires  into  the  causes  and  removes  the  conse- 
quences of  constitutional  or  local  disease ; the  operator 
inquires  into  the  willingness  of  his  patient  to  submit, 
and  resorts  to  the  knife.  The  surgeon  relies  on  the 
restoration  of  the  healthy  actions  by  regimen  and  me- 
dicine ; the  operator  relies  on  himself,  and  cuts  off"  the 
diseased  part.  The  surgeon,  reflecting  on  the  comfort 


and  feelings  of  his  patient,  uniformly  endeavours  to 
save  him  from  pain  and  deformity ; the  operator  con- 
siders his  own  immediate  advantage  and  the  notoriety 
he  may  acquire,  regardless  of  otiier  considerations. 
The  surgeon  reluctantly  decides  on  the  employment  of 
instruments;  the  operator  delays  no  longer  than  to  give 
his  knife  a keen  edgq,  The  surgeon  is  governed  by 
the  jainciples  of  the  science  ; the  operator  most  gene- 
rally by  the  principle  of  interest ; one  is  distinguished 
by  the  numbers  he  has  saved  from  mutilation  and  re- 
stored to  usefulness;  the  other  by  the  number  of  crip- 
ples he  has  successfully  made.  The  surgeon  is  an 
honour  to  his  profession  and  a benefactor  of  mankind ; 
the  mere  operator  renders  the  profession  odious,  and  is 
one  of  the  greatest  curses  to  which  mankind,  anrong 
tlieir  manifold  miseries,  are  exposed.” — Reese.\ 

By  the  word  “ immisericors"  as  Richerand  has  ob- 
served {JVosogr.  Chir.  tom.  1,  p.  42,  Edit.  2),  Celsus 
did  not  mean  that  a surgeon  ouglil  to  be  quite  insen- 
sible to  pity;  but  that  during  the  performance  of  an 
operation  this  passion  should  not  influence  him,  as  all 
emotion  would  then  be  mere  weakness.  This  undis- 
turbed coolness,  which  is  still  more  rare  than  skill,  is 
the  most  valuable  quality  in  the  practice  of  surgery. 
Dexterity  may  be  acquired  by  exercise;  but  firmness  of 
mind  is  a gift  of  nature.  Haller,  to  whom  nature  was 
so  bountiful  in  other  respects,  was  denied  this  quality, 
as  he  candidly  confesses.  “ Although  (says  he)  I have 
taught  surgery  seventeen  years,  and  exhibited  the 'most 
difficult  operations  upou  the  dead  body,  I have  never 
ventured  to  apply  a cutting  instrument  to  a living  sub- 
ject, through  a fear  of  giving  loo  much  pain.” — {Bibl. 
Chir.  1775,  vol.  2.) 

Surgery  may  boast  of  having  had  an  origin  that  well 
deserves  to  be  called  noble ; for  the  earliest  practice  of 
it  arose  from  tlie  most  generous  sentiment  which  na- 
ture has  implanted  in  the  heart  of  man,  viz.  from  that 
sympathetic  benevolence  which  leads  us  to  pity  the 
misfortunes  and  sutferings  of  others,  and  inspires  us 
with  an  anxious  desire  to  alleviate  them.  He  who 
first  saw  his  fellow-creatures  suffer,  could  not  fail  to 
participate  in  tlie  pain,  and  endeavour  to  find  out  the 
means  of  aflording  relief.  Opportunities  of  exercising 
this  useful  inclination  were  never  wanting.  In  the 
first  ages  of  the  world,  man  in  his  destitute  state  was 
under  the  necessity  of  earning,  by  force  or  stratagem,  a 
subsistence  which  was  always  uncertain  ; and  in  the 
combats,  into  which  this  sort  of  life  drew  him,  he  fre- 
quently met  with  wounds  and  other  injuries.  Wher- 
ever the  chase  was  in  vogue  as  a means  of  livelihood  or 
amusement;  wherever  broils  and  contests  occasionally 
arose;  and  man  was  the  same  animal  he  now  is,  liable 
to  various  diseases  and  accidental  hurls ; there  must 
have  existed  a necessity  for  surgery : nor  can  there  be 
a doubt  that  the  origin  of  this  valuable  practice  is  as 
ancient  as  the  exposure  of  mankind  to  several  of  the 
same  kinds  of  itijuries  as  befall  the  human  race  at  the 
present  day.  At  length,  wars  became  more  fiequent 
and  extensive:  wounds  were  consequently  multiplied; 
and  the  necessity  for  surgical  assistance  was  increased, 
and  its  value  enhanced. 

Among  the  ancients,  the  profession  of  medicine  and 
surgery  constituted  a sacred  kind  of  occupation,  and 
the  practice  of  it  belonged  only  to  privileged  persons. 
.^Esculapius  was  the  son  of  Apollo.  In  the  armies,  the 
highest  princes  gloried  in  dressing  the  wounds  of  those 
who  had  fought  the  battles  of  their  country.  Among 
the  Grecians,  Podalirius,  Chiron,  and  Machaon  were 
not  only  distinguished  for  their  valour,  but  also  for  their 
skill  in  surgery,  as  we  learn  from  the  poem  of  the  im- 
mortal Homer.  The  value  which  was  placed  upon  the 
services  of  Machaon  by  the  Grecian  army,  may  well 
be  conceived  from  the  anxiety  which  it  evinced  to  have 
him  properly  taken  care  of  when  he  was  wounded  in 
the  shoulder  with  a dart.  “ O Nestor,  pride  of  Greece 
(cries  Idomeneus),  mount,  mount  upon  thy  chariot! 
and  let  Machaon  mount  w'ith  thee!  Hasten  with  him 
to  our  ships:  for  a warrior  who  knows,  as  he  does, 
how  to  relieve  pain  and  cure  wounds,  is  himself  worth 
a thousand  other  heroes.” — (See  Iliad,  lib.  xi.)  Hip- 
pocrates was  one  of  the  first  citizens  of  Greece;  he  no- 
bly refused  all  the  rich  offers  of  seteral  kines,  enemies 
of  his  country,  to  entice  him  into  their  service-;  and,  in 
particular,  he  disdained  to  accept  those  of  Xerxe^s, 
whom  he  regarded  as  a barbarian. 

It  is  in  the  immortal  poems  of  the  Iliad  and  Odys- 
sey, that  we  find  the  only  certain  traditions  respeaing 


SURGERY. 


323 


the  state  of  the  art  before  the  establishment  of  the  re- 
publics of  Greece,  and  even  until  the  time  of  the  Pelo- 
ponnesian war.  There  it  appears,  that  surgery  was  al- 
most entirely  confined  to  the  treatment  of  wounds,  and 
that  the  imaginary  power  of  enchantment  was  joined 
with  the  use  of  topical  applications. 

In  the  cures  recorded  in  the  sacred  writings  of  the 
Christian  religion,  the  intervention  of  a supernatural 
power  is  always  combined  with  what  is  within  the 
scope  of  human  possibility.  The  same  character 
evinces  itself  in  the  infancy  of  the  art  in  every  nation. 
The  priests  of  India,  the  physicians  of  China  and  Ja- 
pan, and  the  jugglers  of  the  savage  or  half  civilized 
tribes  of  the  old  and  new  continents,  constantly  asso- 
ciate with  drugs  and  manual  operations  certain  myste- 
rious practices,  upon  which  they  especially  rely  for  the 
cure  of  their  patients.  Such  was  also,  no  doubt,  the 
character  of  the  medicine  of  the  Egyptians  in  the  re- 
mote times,  previous  to  the  invention  of  the  alphabet, 
and  upon  which  so  very  little  light  is  now  thrown. 

It  is  curious,  however,  to  find,  from  some  late  ob- 
servations made  by  the  men  of  science  who  accompa- 
nied the  French  expedition  to  Egypt  in  1798,  that 
among  the  ruins  of  ancient  Thebes  there  are  docu- 
ments which  fully  prove  that  surgery,  in  the  early 
times  of  the  Egyptians,  had  made  a degree  of  progress, 
of  which  few  of  the  moderns  have  any  conception.  It 
is  noticed  by  Larrey,  that  when  the  celebrated  French 
General  Dessaix  had  driven  the  Mamelukes  beyond  the 
Cataracts  of  the  Nile,  the  Commission  of  Arts  had  an 
opportunity  of  visiting  the  monuments  of  the  famous 
Thebes,  and  the  renowned  temples  of  Tentyra,  Kar- 
nack,  Medynet  Abou,  and  Luxor,  the  remains  of  which 
still  display  their  ancient  magnificence.  It  is  upon  the 
ceilings  and  walls  of  these  temples  that  basso-relievos 
are  seen,  representing  limbs  that  had  been  cut  off  with 
instruments  very  analogous  to  those  which*  are  em- 
ployed at  the  present  day  for  amputations.  The  same 
instruments  are  again  observed  in  the  hieroglyphics, 
and  vestiges  of  other  surgical  operations  may  be  traced, 
proving  that,  in  these  remote  periods,  surgery  had  made 
some  considerable  progress. — (Larrey,  Mdmoires  de 
Chir.  Militaire,  t.  1,  p.  233 ; t.  2,  p.  223.) 

We  next  come  to  the  epoch  when,  by  the  union  and 
arrangement  of  scattered  facts,  the  science  truly  arose. 
Hippocrates,  born  in  the  island  of  Cos,  four  hundred 
and  sixty  years  before  the  common  era,  collected  the 
observations  of  his  predecessors,  added  the  results  of 
his  own  experience,  and  composed  his  first  treatises. 
In  the  hands  of  this  great  genius,  medicine  and  surgery 
did  not  make  equal  progress.  The  former  reached  a 
high  degree  of  glory.  Hippocrates  drew  up  the  history 
of  acute  diseases  in  so  masterly  a style,  that  twenty 
past  centuries  haVe  hardly  found  occasion  to  add  any 
thing  to  the  performance.  But  surgery  was  far  from 
attaining  the  same  degree  of  perfection.  The  religious 
veneration  for  the  asylums  of  the  dead,  and  the  impos- 
sibility of  dissecting  the  human  body,  formed  an  insur- 
mountable obstacle  to  the  study  of  anatomy.  An  im- 
perfect acquaintance  with  the  structure  of  animals,  re- 
puted to  bear  the  greatest  resemblance  to  man,  could 
only  furnish  venturesome  conjectures  or  false  infer- 
ences. These  circumscribed  notions  sufficed  for  the 
study  of  acute  diseases.  In  these  cases,  the  attentive 
observation  of  strongly  marked  symptoms,  and  the  idea 
of  the  operation  of  a salutary  principle,  derived  from 
remarking  the  regular  succession  of  such  symptoms, 
and  their  frequently  beneficial  termination,  enlightened 
the  physician  in  the  employment  of  curative  means; 
while  surgery,  deprived  of  the  assistance  of  anatomy, 
was  too  long  kept  back  in  an  infant  slate.  Whatever 
praises  may  have  been  bestowed  on  those  parts  of  the 
works  of  Hippocrates  particularly  relating  to  surgery, 
and  which  amount  to  six  in  number  (deofficina  medici  ; 
de  fracturis ; de  capitis  vulneribus ; de  articulis  vel 
luzatis ; de  ulceribus ; de  fistulis),  when  compared 
with  his  other  acknowledged  legitimate  writings,  they 
appear  only  as  the  rough  sketches  of  a picture  by  a 
great  master. 

Excepting  the  fragments  collected  or  cited  by  Galen, 
we  possess  no  work  written  by  any  of  the  succe.ssors  of 
Hippocrates  until  the  period  ofCelsus;  which  leaves  a 
barren  interval  of  almost  four  centuries.  In  this  space 
lived  Erasistratus,  as  well  as  Herophilus,  celebrated  for 
the  sects  which  they  established,  and  particularly  for 
having  been  the  first  who  studied  anatomy  qpon  the 
human  body» 


Celsus  lived  at  Rome  in  the  reigns  of  Augustus,  Ti- 
berius, and  Caligula.  He  appears  never  to  have  prac- 
tised the  healing  art,  on  which,  however,  he  has  written 
with  much  precision;  elegance,  and  perspicuity.  His 
work  is  the  more  precious,  inasmuch  as  it  is  the  only 
one  which  gives  us  information  with  regard  to  the 
progress  of  surgery  in  the  long  interval  between  Hip- 
pocrates and  himself.  The  last  four  bonks,  and  espe- 
cially the  seventh  and  eighth,  are  exclusively  allotted 
to  surgical  matter.  The  style  of  Celsus  is  so  elegant, 
that  he  has  generally  been  regarded  quite  as  the  Cicero 
of  medical  writers,  and  long  enjoyed  high  reputation 
in  the  schools.  His  surgery  was  entirely  that  of  the 
Greeks,  notwithstanding  he  wrote  at  Rome:  for,  in 
that  capital  of  the  world,  physic  was  then  professed 
only  by  persons  who  had  either  come  from.  Greece,  or 
had  received  instruction  in  the  celebrated  schools  of 
this  native  soil  of  all  the  arts  and  sciences. 

Let  us  pass  over  the  interval  which  separates  Celsus 
and  Galen.  This  latter  was  born  at  Pergamus  in  Asia 
Minor,  and  came  to  Rome  in  the  reign  of  the  Emperor 
Marcus  Aurelius,  where  he  practised  surgery  and  phy- 
sic about  the  year  165  of  the  Christian  era. — {Oaleni 
Opera  Omnia,  1521,  edit.  Aldi,  5 vols.  infol.)  These 
two  sciences  were  at  that  time  still  united,  or  rather 
the  possibility  of  completely  dividing  them  had  never 
been  conceived  ; and  though  some  writers  of  much  ear- 
lier date  speak  of  the  division  of  physic  into  dietetical, 
chirurgical,  and  pharmaceutical,  no  such  distinction 
was  followed  in  practice.  As  Galen  had  been  a surgeon, 
or  more  probably  a general  practitioner,  at  Perganjus,  he 
continued  the  same  profession  at  Rome;  but,  being 
soon  attracted  by  the  predominating  taste  of  the  age  in 
which  he  lived  to  studies  which  more  easily  accommo- 
date themselves  to  the  systems  and  dazzling  specula- 
tions of  philosophical  sects,  he  afterward  neglected 
surgery,  which  strictly  rejects  them.  His  writings 
prove,  however,  that  he  did  not  abandon  it  entirely. 
His  commentaries  on  the  treatise  of  Hippocrates,  De 
Officina  Medici,  and  his  essay  on  bandages,  and  the 
manner  of  applying  them,  show  that  he  was  well 
versed  even  in  the  minor  details  of  the  art.  Besides, 
it  is  known,  that  he  paid  great  attention  to  pharmacy; 
and  in  his  work  upon  antidotes,  chap.  13,  he  tells  us 
himself,  that  he  had  a drug  shop  in  the  Via  Sacra, 
which  fell  a sacrifice  to  the  flames  that  destroyed  the 
Temple  of  Peace  and  several  other  edifices  in  the  reign 
of  Commodus. 

To  Galen  succeeded  the  compiler  Oribasius,  Qiltius 
of  Amida,  a physician  who  lived  towards  the  close  of 
the  fifth  century,  Alexander  of  Tralles,  and  Paulus 
yEgineta,  so  called  from  the  place  of  his  birth,  though 
he  practised  at  Rome  and  Alexandria.  Paulus  col- 
lected into  one  work,  still  justly  esteemed,  all  the  im- 
provements which  had  been  made  in  surgery  down  to 
his  own  time.  He  concludes  the  series  of  Greek  and 
Roman  physicians,  and  may  be  looked  upon  as  the 
last  of  the  ancients,  unless  it  be  wished  to  let  the  Ara- 
bians have  a share  in  the  honours  of  antiquity.  “ He 
appears,”  says  Portal,  “ to  be  one  of  those  unfortunate 
writers  to  whom  posterity  has  not  done  justice.  It 
seems  as  if  he  had  been  decried  without  having  been 
read;  for  if  pains  had  been  taken  to  examine  his 
works,  he  would  neither  have  been  regarded  as  a mere 
copyist,  nor  been  called  the  ‘ ape  of  Galen,’  with  whom 
he  does  not  always  coincide.  Nay,  in  some  places,  he 
ventures  to  oppose  the  doctrines  of  Hippocrates.  He 
was  perfectly  acquainted  with  the  practice  of  the  an- 
cients ; and  when  he  agrees  with  or  differs  from  them, 
it  is  not  from  a spirit  of  contradiction,  but  because  the 
reasons  which  led  him  to  take  one  side  or  the  other 
appeared  to  him  well-founded.” — {Portal,  Hist,  de 
VAnat.  Src.  t.  1,  p.  123.)  All  now  agree,  that  surgery 
is  much  indebted  to  him. — (See  R.A.  Vogel,  De  Pauli 
ASgineta  Meritis  in  Medicinam  imprimisque  Chirur- 
giam,  4ta.  GStt.  1768.)  Afterward,  the  downfall  of 
surgery  followed  that  of  all  the  other  sciences,  and 
from  the  capture  of  Alexandria  by  the  Saracens  under 
Amrou,  Viceroy  of  Egypt,  in  641,  until  the  end  of  the 
tenth  century,  nothing'  prevailed  but  the  dark  clouds  of 
ignorance  and  barbarism.  The  Arabians,  who  be- 
came masters  of  a great  part  of  the  Roman  empire, 
dug  up  the  Greek  manuscripts  which  lay  buried  under 
the  ruins  of  the  libraries;  translated  them;  appropri- 
ated to  themselves  the  doctrines  which  they  contained ; 
impoverished  them  by  additions;  and  transmitted  to 
posterity  only  enormous  compilations.  In  a word, 


324 


SURGERY. 


such  are  the  treatises  of  Rhazes,  Hali- Abbas,  Avicenna, 
Averrhoes,  and  Albucasis,  the  most  celebrated  of  the 
Arabian  authors.  Inventors  of  a prodigious  number 
of  instruments  and  machines,  they  appear  to  have  cal- 
culated the  efficacy  of  surgery  by  the  richness  of  its 
arsenals,  and  to  have  been  more  anxious  to  inspire 
terror  than  confidence.  As  an  instance  of  the  cruelty 
of  their  methods,  I shall  merely  notice,  that  in  order 
to  stop  the  bleeding  after  amputation,  they  plunged  the 
stump  in  boiling  pitch. 

The  fate  of  medicine  was  not  more  fortunate.  In 
vain  the  school  of  Salernum,  founded  about  the  middle 
of  the  seventh  century,  made  some  attempts  to  revive 
its  splendour.  As  a modern  writer  observes,  medical 
science,  seated  on  the  same  benches  where  the  doctrine 
of  Aristotle  accommodated  to  religious  opinions,  was 
the  subject  of  endless  controversies,  imbibed,  as  it 
were,  by  contagion,  the  argumentative  and  sophistical 
mania,  and  became  enveloped  in  the  dark  hypotheses 
of  scholastic  absurdity. — {Richerand,  J^Tosogr.  Chir. 
1. 1,  ed.  2.) 

The  universal  ignorance  (continues  this  author), 
the  pretended  horror  of  blood,  the  dogma  of  a religion 
which  shed  it  in  torrents  for  useless  quarrels,  an  ex- 
clusive relish  for  the  subtleties  of  the  schools  and  spe- 
culative theories,  are  circumstances  farther  explaining 
the  profound  darkness  which  followed  these  empty 
labours.  About  the  middle  of  the  twelfth  century 
(1163),  the  Council  of  Tours  prohibited  the  clergy, 
who  then  shared  with  the  Jews  the  practice  of  medi- 
cine and  surgery  in  Christian  Europe,  from  under- 
taking any  bloody  operation.  It  is  to  this  epoch  that 
the  true  separation  of  medicine  from  surgery  must  be 
referred.  The  latter  was  abandoned  to  the  laity,  the 
generality  of  whom,  in  those  ages  of  barbarism,  were 
entirely  destitute  of  education.  The  priests,  however, 
still  retained  that  portion  of  the  art  which  abstained 
from  the  effusion  of  blood.  Roger  Rolandus,  Bruno, 
Gulielmiis  de  Salicetus,  Lanfranc,  Gordon,  and  Guy 
de  Chauliac  confined  themselves  to  commentaries  on 
the  Arabians;  and,  if  the  latter  author  be  excepted, 
they  all  disgraced  surgery  by  reducing  it  nearly  to  the 
mere  business  of  applying  ointments  and  plasters.  Guy 
de  Chauliac,  however,  the  last  of  the  Arabians,  is  to 
be  honourably  excluded  from  such  animadversion. 
His  work  written  at  Avignon,  in  1363,  in  the  pontifi- 
cate of  Urban  the  Fifth,  to  whom  he  was  physician, 
continued  to  be,  for  a long  while,  the  only  classical 
book  in  the  schools.  It  may  be  observed,  that  as  he 
imitated  in  every  respect  the  other  Arabian  physicians, 
and  like  them  thought  that  it  did  not  become  a priest 
to  deviate  from  the  austerity  of  his  profession,  he  has 
passed  over  in  silence  the  diseases  of  women. 

At  length,  Antonio  Beneveni,  a physician  of  Flo- 
rence, began  to  insist  upon  a truth  of  the  highest  im- 
portance to  the  extension  of  surgical  knowledge,  viz. 
that  the  compilations  of  the  ancients  and  Arabians 
ought  to  be  relinquished  for  the  observation  of  nature. 
— {De  abditis  Rerum  Causis,  Florent.  1507,  4te.)  A 
new  era  now  began.  The  moderns  were  convinced, 
that  by  treading  servilely  in  the  footsteps  of  their  pre- 
decessors, they  should  never  even  equal,  much  less 
surpass  them.  The  labours  of  Vesalius  also  gave 
birth  to  anatomy,  illuminated  by  which  science  sur- 
gery put  on  quite  a different  appearance  in  the  hands 
of  Atnbroise  Par6,  the  first  and  most  eminent  of  the 
ancient  French  surgeons.  For  the  credit  of  Italy, 
however,  it  should  be  recorded,  that  the  sensible  writ- 
ings published  in  that  country  prior  to  the  time  of 
Pard  had  the  greatest  influence  in  creating  a due  sense 
of  the  value  and  importance  of  surgery,  and  in  dis- 
posing men  of  talents  and  education  to  cultivate  it  as 
a liberal  profession. 

Obeying  the  dictates  of  his  genius,  Par6  either  com- 
pelled authority  to  yield  to  observation,  or  endea- 
voured to  reconcile  them.  However,  his  superior 
merit  soon  excited  the  ignorant,  the  jealous,  and  the 
malignant  against  him  ; he  became  the  object  of  a 
bitter  persecution;  and  his  discoveries  were  repre- 
sented as  a crime.  Although  he  was  the  restorer,  if 
not  the  inventor,  of  the  art  of  tying  the  blood-vessels, 
the  power  of  his  persecutors  compelled  him  to  make 
imperfect  extracts  from  Galen,  and  alter  his  text,  in 
order  to  rob  himself,  in  favour  of  the  ancients,  of  the 
glory  which  this  distinguished  improvement  deserved. 

Surgeon  of  King  Henry  the  Second,  Frapeis  the 
Second,  Charles  the  Ninth,  and  Henry  the  Third  of 


France,  Par6  practised  his  profession  in  various  places* 
followed  the  French  armies  into  Italy,  and  acquired 
such  esteem,  that  his  mere  presence  in  a besieged  town 
was  enough  to  reanimate  the  troops  employed  for  its 
defence.  In  the  execrable  night  of  St.  Bartholomew, 
his  reputation  saved  his  life.  As  he  was  of  the  re- 
formed religion,  he  would  not  have  escaped  the  mas- 
sacre, had  not  Charles  the  Ninth  himself  undertaken 
to  protect  him.  The  historians  of  those  days  {Mem. 
de  Sully)  have  preserved  the  remembrance  of  this  ex- 
ception, so  honourable  to  him  who  was  the  object  of 
it;  but  which  should  not  diminish  the  just  horror  which 
the  memory  of  the  most  weak  and  cruel  tyrant  must 
ever  inspire.  “ II  n’eu  voulut  jamais  sauver  aucun 
(says  Brantome)  sinon  maistre  Ambroise  Par«^.,  son 
premier  chirurgien,  et  le  premier  de  la  Chretiennete  ; 
el  I’envoya  querir  et  venir  le  soir  dans  sa  chambre  et 
garderobe,  lui  commandant  de  n’eu  bouger  ; et  disait 
qU’il  n’^tait  raisonnable  qu’un  qui  pouvait  servir  a 
tout  un  petit  monde,  fiit  ainsi  massaci6,” 

Ambroise  Pard  was  not  content,  like  his  predecet?- 
sors,  with  exercising  his  art  with  reputation ; he  did 
not  follow  the  example  of  the  Q.uatre-Maltres  of  Pi- 
tard,  so  justly  celebrated  for  having  composed  the  first 
statutes  of  the  College  of  Surgeons  at  Paris,  in  the 
reign  of  St.  Lewis,  whom  he  had  attended  in  his  ex- 
cursions to  the  Holy  Land ; and  of  several  other  sur- 
geons, the  fruits  of  whose  experience  were  lost  to  their 
successors ; he  transmitted  the  result  of  his  own  ex- 
perience in  a work  that  is  immortal, — (See  (Euvres 
d' Ambroise  Pare,  Conseiller  et  premier  Chirurgien  du 
Roi,  divisees  en  28  livres,  in  folio,  edit.  4to.  Paris, 
1535.) 

His  writings,  so  remarkable  for  the  variety  and  num- 
ber of  facts  in  them,  are  eminently  distinguished  from 
all  those  of  his  time,  inasmuch  as  the  ancients  are  not 
looked  dp  to  in  them  with  superstitious  blindness. 
Freed  from  the  yoke  of  authority,  he  submitted  every 
thing  to  the  test  of  observation,  and  acknowledged 
experience  alone  as  his  guide.  The  French  writers 
are  with  reason  proud  of  their  countryman  Par6  to 
this  day : they  allege,  that  he  must  ever  hold  among 
surgeons  the  same  place  that  Hippocrates  occupies 
among  physicians.  Nay,  they  add,  that  perhaps  none 
of  the  ancients  or  moderns  are  worthy  of  being  com- 
pared with  him. — {Richerand,  Mosogr.  Chirurg.  1. 1.) 

After  the  death  of  this  great  man,  surgery,  which 
owed  its  advancement  to  him,  continued  stationary, 
and  even  took  a retrograde  course.  This  circumstance 
is  altogether  ascribable  to  the  contemptible  state  into 
which  those  who  professed  the  art  fell,  after  being 
united  to  the  barbers  by  the  most  disgraceful  associ- 
ation. 

Pigrai,  the  successor  of  Ambroise  Par6,  was  far  from 
being  an  adequate  substitute  for  him.  A spiritless 
copier  of  his  master,  he  abridged  his  surgery  in  a Latin 
work,  where  the  unaffected  graces  of  the  original,  the 
sincerity,  and  the  ineffable  charm,  inseparable  from 
all  productions  of  genius,  entirely  disappeared  He 
received,  however,  equal  praise  from  his  contempora- 
ries ; doubtless,  because  he  filled  a high  situation : but, 
as  Richerand  remarks,  his  name,  which  is  to  day  al- 
most forgotten,  proves  sufficiently  that  dignities  do  not 
constitute  glory. 

Rousset  and  Guillemeau  distinguished  themselves, 
however,  in  the  art  of  midwifery ; 'while  Covillard, 
Cabrol,  and  Habicot  enriched  surgery  with  a great 
number  of  curious  observations. — (See  Ohs.  Chir. 
pleines  de  Remarques  curieuses,  Lyon,  1639,  in  8vo. 
Alphabet  Anatomique,  Geneve,  1602,  in  4to.  Semaine 
Anatomique ; Question  Chir.  sur  la  Bronchotomie, 
Paris,  1620,  in  8vo.) 

In  the  next  or  seventeenth  century,  a fresh  impulse 
produced  additional  improvements.  Then  appeared 
in  Italy  Caesar  Magatus,  who  simplified  the  treatment 
of  wounds  {De  Rard  Vulnerum  Medicatione,  libri  2, 
Venet,  1616,  in  folio);  Fabricius  ab  Aquapendente, 
even  less  praiseworthy  as  a surgeon  than  as  a physi- 
ologist {Opera  Chir.  Paris,  1613,  infol  ) ; and  Marcus 
Aurelius  Severinus,  that  restorer  of  active  surcery. — 
{De  Efficaci  Medicina,  libri  3,  Francofurt.  1613,  in 
folio.  De  recondita  Abscessuuyt:  Mature,  libri  7.  Me- 
opoli,  1632,  ill  4/0,  and  Trimembris  Chirnrgia,  S'C. 
Francofurt.  1653,  in  4to.)  Among  the  English  sur- 
geons flourished  Wiseman,  who  was  thePar6  of  Eng- 
land (see  Several  Chirurgical  Treatises,  Lond.  1676, 
infol.);  and  William  Harvey,  whose  discovery  of  the 


SURGERY. 


325 


circulation  of  the  blood  had  such  an  influence  over  the 
advancement  of  medical  science  in  general,  and  that 
of  surgery  in  particular,  that  he  must  be  classed 
among  the  principal  improvers  of  the  latter  profession. 
— (See  Exercitatio  Jhiatomica  de  Motu  Cordis  et  San- 
guinis in  Aninialibus.  Francofurti,  1653,  in  4to.)  In 
Germany,  Fabricius  Hildanus  {Obs.  et  Carationum, 
Centuriee  6, 2 vol.  in  ito,  1641),  who  was  far  superior, 
as  a surgeon,  to  the  Italian  Fabricius.  Scultetus,  so 
well  known  for  his  work  entitled  Armamentarium  Chi- 
rurgicum,  Ulmec,  1653,  in  folio ; Purmann  and  Solin- 
gen,  who  had  the  fault  of  being  too  partial  to  the  use 
of  numerous  complicated  instruments. — (See  Curses 
Obs.  Ckir,  Lipsiee,  1710,  in  Alo.  Manuals  Obs.  der 
Ckirurgim,  Amsterdam.,  1684,  in  4to.) 

Holland,  restored  to  liberty  by  the  generous  exertions 
of  its  inhabitants,  did  not  long  remain  a stranger  to 
the  improvement  of  surgery.  This  nation,  so  singular 
in  many  respects,  presents  us  with  one  particularity 
which  claims  the  notice  of  a medical  historian. 
Ruy.sch,  who  was  an  eminent  anatomist,  and  merits 
equal  celebrity  for  his  Obs.  Anatomico-Chirurgicarum 
Centuries,  Amstelodam.  1691,  in  4to.  carried  with  him 
to  the  grave  the  secret  of  his  admirable  injections. — 
(See  also  his  Thesaur.  Anat.  x.,in4to.  Adversariorum 
anatomicorum  inedico-chirurgicorum,  Decad.  3,  in  4to. 
Amstelodam.)  Roonhuysen  also  made  a secret  of  his 
lever,  which,  before  the  invention  of  the  forceps,  was 
the  only  resource  in  difficult  labours.  Raw,  who  suc- 
cessfully cut  fifteen  hundred  patients  for  the  stone, 
took  such  pains  to  conceal  his  manner  of  operating, 
that  Heister  and  Albinus,  his  two  most  distinguished 
pupils,  have  each  given  a different  explanation  of  it. 
Such  a disposition,  which  is  extremely  hurtfui  to  the 
advancement  of  medical  and  surgical  knowledge, 
would  materially  have  retarded  the'^rrogress  of  surgery 
in  Holland,  had  not  Camper,  in  the  following  century, 
effaced  the  imputation  by  the  great  number  of  his  dis- 
■ coveries,  and  his  zealous  desire  to  render  them  public. 

While  great  improvements  were  going  on  in  Italy, 
England,  and  Holland,  surgery  languished  in  a humi- 
liated state  in  France.  The  accoucheur  Mauriceau 
(Traits  des  Maladies  des  Femmes  grosses,  Paris, 
1668,  in  4to.),  Dionis  (Cours  d'  Operations  de  Chirur- 
gie,  Paris,  i707,8rjo.),  Saviard  (Mouveau  Recueild’Obs. 
Chir.  Paris,  1702,  in  ]2nro.),  and  Belloste  (Chirurgien 
d'Hdpital,  Paris,  1696,  in  8vo.)  were  tlie  only  French 
surgeons  of  note,  who  could  be  contrasted  with  so 
many  distinguished  men  of  other  nations.  Richerand 
observes,  that  the  splendid  days  of  Louis  the  Fourteenth 
were  in  an  iron  age  for  discouraged  surgery.  And  yet 
this  monarch  seems  to  have  been  personally  interested 
in  the  melioration  of  this  important  art;  for  he  was 
very  nearly  falling  a victim  to  a surgical  disease,  a 
fistula  in  ano,  and  was  not  cured  till  after  a great  num- 
ber of  blundering  operations  and  useless  experiments. 

Chronology  teaches  simply  the  history  of  dales.  In 
the  study  of  the  sciences,  the  only  method  of  impress- 
ing the  memory  with  facts  consists  in  connecting  the 
epoch  of  them  with  the  learned  men  by  whom  they 
have  been  illustrated.  But  the  greatest  surgeons  of  the 
eighteenth  century  have  not  altered  the  face  of  their 
profession,  although  they  have  powerfully  contributed 
to  its  advancement.  In  surgery,  as  an  author  has  re- 
marked, some  feeble  rays  always  precede  brilliant 
lights,  and  it  approaches  perfection  in  a very  gradual 
way.  In  the  last  century,  however,  among  the  dis- 
tinguished surgeons  of  France,  there  are  two  of'extra- 
ordinary  genius,  round  whom,  as  it  were,  all  the  others 
might  be  grouped  and  arranged,  and  whose  names  de- 
serve to  be  affixed  to  the  two  most  brilliant  epochs  of 
French  surgery.  These  are,  first,  J.  L.  Petit,  whose 
glory  was  shared  by  the  Academy  of  Surgery;  and, 
secondly,  the  celebrated  Desault. 

It  is  not  with  surgery  as  with  physic,  strictly  so 
called:  the  epochs  of  the  latter  are  distinguished  by 
hypotheses;  while  those  of  surgery  are  marked  by  dis- 
coveries. The  eminent  men  in  this  last  branch  of  the 
profession  have  not,  like  the  most  renowned  physi- 
cians, created  sects,  built  systems,  destroyed  those  of 
their  predecessors,  and  constructed  a new  edifice, 
which  in  its  turn  has  been  demolished  by  other  hands. 
All  of  them  have  been  satisfied  with  combating  ancient 
errors,  discovering  new  facts,  and  continuing  their  art, 
the  sphere  of  which  they  have  enlarged  by  their  dis- 
coveries, without  making  it  bend  under  the  yoke  of 
systems  which  it  would  have  ill  supported. 


The  eulogy  on  J.  L.  Petit,  delivered  in  the  midst  of  the 
Royal  Academy  of  Surgery,  of  which  he  was  one  of 
tire  first  and  most  distinguished  members,  represents 
him  as  blending  the  study  of  anatomy  with  his  amuse- 
ments when  a boy;  and  ardently  seeking  every  oppor- 
tunity to  increase  his  knowledge  by  observation.  He 
had  had  experience  endugh  to  publish  at  an  early  pe- 
riod of  his  life  his  Traits  sur  les  Maladies  des  Os, 
Paris,  1705,  in  \2mo. ; a work  which  for  a century 
was  esteemed  tlie  best  upon  the  subject.  His  success 
was  most  virulently  opposed  by  envious  critics;  and  it 
was  not  till  after  more  than  thirty  years  of  academical 
labours  and  extensive  practice  that  he  was  unani- 
mously chosen  the  head  of  his  associates.  Tliis  ac- 
knowledged superiority,  however,  was  the  more  flat- 
tering, as  the  honour  was  obtained  at  a period  when 
surgery  was  in  a flourishing  state  in  France,  and  when 
Petit  held  no  office  from  which  he  could  derive  any 
influence  unconnected  with  his  personal  merit.  While 
Mareschal,  La  Peyronie,  and  La  Martiniire  assured 
liim  of  the  royal  favour,  Q,uesnay,  Morand,  and  Louis, 
who  corrected  his  writings,  made  him  speak  a language 
which  does  honour  to  that  famous  collection  to  vyhich 
he  contributed  his  observations  (see  Memoires  et  Prix 
de  I'Academie  Royals  de  Chirurgie,  10  vols.  in  Ato.), 
and  in  which,  if  some  theoretical  explanations  be  put 
out  of  consideration,  nothing  Itas  lost  its  value  by  age. 
J.  L.  Petit  was  also  the  author  of  a “ Traits  des  Mala- 
dies Chirurgicales,  et  des  Operations  qui  leiir  convien- 
nent.  Ouvrage  Posthume a production  that  will 
always  stand  high  in  the  estimation  of  the  judicious 
surgeon. 

The  history  of  this  epoch,  so  glorious  for  the  pro- 
fession of  surgery,  is  completely  detailed  in  the  Me- 
moirs and  Prizes  of  the  Royal  Academy  of  Surgery ; 
a work  whicli  is  absolutely  indispensable,  and  the 
various  parts  of  which  cannot  be  too  often  considered. 
In  it  are  preserved  the  labours  of  Mareschal,  Q-uesnay, 
La  Peyronie,  Morand,  Petit,  De  la  Martinidre,  Le 
Dran,  Garengeol,  De  la  Faye,  Louis,  Verdier,  Foubert, 
Hevin,  Pibrac,  Fabre,  Le  (Cat,  Bordenave,  Sabatier, 
Puzos,  Levret,  and  several  other  practitioners,  who, 
though  less  famous,  contributed  by  their  exertions  and 
knowledge  to  form  this  useful  body  of  surgical  facts. 
Many  of  the  preceding  surgeons  also  distinguished 
themselves  by  other  productions,  which,  however,  I 
shall  not  here  enumerate,  as  they  are  quoted  in  many 
other  parts  of  this  work. 

To  the  foregoing  list  of  eminent  French  surgeons 
must  be  added  the  names  of  La  Motfe,  Matre-Jean, 
Goulard,  Daviel,  Ravaton,  Mejean,  Pouteau,  David, 
and  Frdre  Cosine. 

While  surgery  w'as  thus  advancing  in  France,  other 
nations  were  not  neglectful  of  it.  At  this  period  flou- 
rished, in  Great  Britain,  White,  Cheselden,  Douglas,  the 
two  Monros,  Sharp,  Cowper,  Warner,  Alanson,  Brom- 
field,  Pott,  Kirkland,  Hawkins,  Smellie,  and  the  two 
Hunters. 

White’s  Cases  in  Surgery,  1770;  Cheselden’s  Trea- 
tise on  the  High  Operation  for  the  Stone,  I^ondon,  1723, 
in  8wo.,  and  his  Treatise  on  the  Anatomy  of  the  Human 
Body;  Douglas’s  Tract,  entitled  Lithotomia  Dou- 
glassiana Sharp’s  Treatise  of  the  Operations,  and 
his  “ Critical  Inquiry  into  the  Present  State  of  Sur- 
geryMonro's  Works  by  his  son;  Warner's  Cases 
in  Surgery,  17.54,  and  his  Description  o^  the  Rye  and 
its  Diseases,  1775 ; Alanson' s Treatise  on  Amputa- 
tion; Pott's  Chirurgical  Works;  Kirkland's  Obs.  on 
Fractures,  1770;  his  Thoughts  on  Amputation,  1780; 
and  his  Medical  Surgery,  1783;  Smellie' s Midwifery; 
and  .John  Hunter  on  the  Blood,  Inflammation,  Src.; 
his  Treatises  on  the  Venereal  Disease,  Animal  Fwono- 
my,  the  Teeth,  and  all  the  papers  written  by  himself 
and  his  brother,  in  the  Phil.  Trans.  Med.  Obs.  and  In- 
quiries, and  Trans,  of  a Society  for  the  Improvement 
of  Med.  and  Chir.  Knowledge ; are  productions  which 
reflect  the  highest  credit  on  the  state  of  surgery  in 
England. 

But  of  all  these  eminent  men,  none  contributed  more 
powerfully  than  Mr.  Percival  Pott  to  the  improvement 
of  the  practice  of  surgery  in  England.  His  life,  in- 
deed, forma  a sort  of  epoch  in  the  history  of  the  pro- 
fession. Before  liis  inculcations  and  example  had 
produced  a desirable  change,  the  maxim  of  dolor  me- 
dicina  doloris,"  as  we  learn  from  Sir  Jamps  Earle,  re- 
mained unrefuted.  The  severe  treatment  of  the  old 
school,  in  the  operative  part  and  in  the  applications, 


326 


SURGERY. 


continued  in  force.  The  first  principles  of  surgery,  the 
natural  process  and  powers  of  healing,  were  either  not 
understood  or  not  attended  to ; painful  and  escharotic 
dressings  were  continually  employed ; and  the  actual 
cautery  was  in  such  frequent  use,  Uiat  at  the  times 
when  the  surgeons  visited  the  hospitals,  it  was  regu- 
larly heated  and  prepared  as  a part  of  the  necessary 
apparatus.  Where  shall  we  find  more  sensible  or 
more  truly  practicable  observations  on  the  treatment 
of  abscesses,  than  in  Pott’s  excellent  treatise  on  the 
fistula  in  ano  1 Where  shall  we  meet  with  better  re- 
marks on  the  local  treatment  of  gangrenous  parts,  than 
in  his  valuable  tract  on  the  mortification  of  the  toes 
and  feet?  What  author  abounds  with  so  many  just 
observations  on  the  injuries  of  the  head,  blended,  it  is 
true,  with  rather  too  great  a partiality  to  the  trepan, 
the  so  frequent  necessity  for  which  is  now  less  gene- 
rally acknowledged?  His  description  of  the  inflam- 
mation and  suppuration  of  the  dura  mater  and  of  the 
treatment  is  matchless.  The  account  which  he  has 
left  us  of  the  disease  of  the  vertebrae,  attended  with 
paralysis  of  the  limbs,  is  perhaps  his  most  original 
prod^iction.  His  celebrated  essay  on  fractures  was 
also  very  original,  and  has  had  in  this  country  con- 
siderable influence  over  the  treatment  of  these  inju- 
ries ; but  there  can  now  be  no  doubt  that  the  effects 
of  position  were  exaggerated  in  this  part  of  his 
writings,  and  that  surgeons  ought  still  to  make  every 
possible  exertion  to  render  their  apparatus  for  broken 
bones  more  effectual. — (See  Fractures.)  A more 
really  valuable  production  of  this  eminent  surgeon  is 
his  remarks  on  amputation.  The  necessity  for  that 
operation  in  certain  cases  is  there  convincingly  de- 
tailed ; and  the  most  advantJigeous  period  for  its  per- 
formance clearly  indicated.  The  urgency  for  its 
prompt  execution  after  particular  injuries  he  has  in- 
deed so  perfectly  explained,  that  the  late  inculcations 
on  the  subject  by  Larrey  and  several  other  modern 
surgeons  appear  to  be  in  a great  measure  anticipated; 
the  only  difference  being,  that  Pott’s  remarks  applied 
principally  to  compound  fractures,  while  Larrey’s  refer 
to  gun-shot  wounds.  All  these,  however,  are  cases  of 
accidental  violence,  and,  of  course,  should  be  treated 
upon  the  same  general  principles. 

A longer  comment  on  the  writings  and  improve- 
ments of  Percival  Pott  would  here  be  requisite  to  do 
him  every  degree  of  justice ; but  his  name,  advice,  and 
opinions  are  so  conspicuous  throughout  this  volume, 
that  I shall  be  excused  for  not  saying  any  thing  more  in 
the  present  place,  than  that  he  was  in  his  time  the  best 
practical  surgeon,  the  best  lecturer,  the  best  writer  on 
surgery,  the  best  operator  of  which  this  large  metro- 
polis could  boast. 

Another  character  of  still  greater  genius  and  origi- 
nality though  of  inferior  education,  was  the  ever  me- 
morable John  Hunter,  surgeon  to  St.  George’s  Hospital, 
who  was  at  once  eminent  as  a surgeon,  an  anatomist, 
a physiologist,  a naturalist,  and  a philosopher.  Indeed, 
he  was  the  greatest  man  that  ever  adorned  the  pro- 
fession, either  in  ancient  or  modern  times,  without 
making  any  exception  of  Hippocrates,  the  reputed 
father  of  physic,  Par4,  the  pride  of  the  French,  or 
Harvey,  the  still  greater  glory  of  England,  the  immor- 
tal discoverer  of  the  circulation  of  the  blood.  If  Pott 
materially  improved  many  parts  of  the  practice  of  sur- 
gery in  England,  and  evinced  himself  to  be  the  most 
skilful  operator  of  his  time,  John  Hunter  was  also  not 
less  importantly  employed  in  extending  the  boundaries 
of  physiological  knowledge,  and  in  the  investigation  ! 
of  human  and  particularly  comparative  anatomy. 
The  knowledge  which  he  derived  from  his  favourite 
studies  he  constantly  applied  to  the  improvement  of 
the  art  of  surgery,  and  he  omitted  no  opportunity  of 
examining  morbid  bodies,  whereby  he  collected  facts 
which  are  invaluable,  as  they  lend  to  explain  the  real 
causes  of  the  symptoms  of  numerous  diseases. 

In  the  practice  of  surgery,  whenever  operations 
proved  inadequate  to  their  intention,  filr.  Hunter 
always  investigated  w'ith  uncommon  zeal  the  causes 
of  ill  success,  and  in  this  way  he  detected  many  falla- 
cies as  well  as  made  some  important  discoveries  in  the 
healing  art.  He  a.scertained  the  cause  of  failure  com- 
mon to  all  the  operations  in  tise  for  the  radical  cure  of 
the  hydrocele,  and  was  enabled  to  propose  a mode  of 
operating  attended  with  invariable  success.  He  ascer- 
tained, by  e.xperiments  and  observations,  that  exposure 
to  atmospherical  air,  simply,  can  neither  produce  nor 


increase  inflammation.  He  discovered  in  the  blood  so 
many  phenomena  connected  with  life,  and  not  to  be 
referred  to  any  other  cause,  that  he  considered  it  alive 
in  its  fluid  state.  He  improved  the  operation  for  the 
fistula  lachrymalis,  by  removing  a circular  piece  of  the 
os  unguis  instead  of  breaking  it  down  with  the  point 
of  a trocar.  He  explained  better  than  any  of  his  pre- 
decessors all  the  highly  interesting  modern  doctrines 
relative  to  inflammation,  union  by  the  first  intention, 
suppuration, ulceration,  and  mortification.  His  writings 
also  throw  considerable  light  on  the  growth,  structure, 
and  diseases  of  the  teeth.  As  instances  of  his  opera- 
tive skill,  it  deserves  to  be  mentioned,  that  he  removed 
a tumour  from  the  side  of  the  head  and  neck  of  a pa- 
tient at  Sr.  George’s  Hospital,  as  large  as  the  head  to 
which  it  was  attached ; and  by  bringing  the  cut  edges 
of  the  skin  together,  the  whole  wound  was  nearly 
healed  by  the  first  intention.  He  likewise  dissected 
out  of  the  neck  a tumour  which  one  of  the  best  ope- 
rators in  this  country  had  declared,  rather  too  strongly, 
that  no  one  but  a fool  or  a madman  w'ould  meddle 
with;  and  the  patient  got  perfectly  well.  But,  per- 
haps, the  greatest  improvement  which  he  made  in  the 
practice  of  surgery,  was  his  invention  of  a new  mode 
of  performing  the  operation  for  the  popliteal  aneurism, 
by  taking  up  the  femoral  artery  on  the  anterior  part  of 
the  thigh  without  opening  the  tumour  in  the  ham. — 
(See  Trans,  of  a Society  for  the  Improvement  of  Med. 
and  Chir.  Knowledge.)  The  safely  and  efficacy  of  this 
method  of  operating  have  now  been  fully  established, 
and  the  plan  has  been  extended  to  all  operations  for 
the  cure  of  this  formidable  disease. — (See  .Aneurism.) 

According  to  Sir  Everard  Home,  Mr.  Hunter  was 
also  one  of  the  first  who  taught  that  the  excision  of  the 
bitten  part  was  the  only  sure  mode  of  preventing  hy- 
drophobia ; and  he  extended  the  time  during  which 
this  proceeding  might  be  reasonably  adopted,  beyond 
the  period  which  had  been  generally  specified. 

His  researches  into  the  nature  of  the  venereal  dis- 
ease, and  his  observations  on  the  treatment,  will  for 
ever  be  a lasting  monument  of  his  wonderful  powers 
of  reasoning  and  investigation.  If  he  left  some  points 
of  the  subject  doubtful  and  unsettled,  he  has  admi- 
rably succeeded  in  the  elucidation  of  others  ; and  his 
work  on  this  interesting  disorderis,  with  all  its  defects, 
the  best  which  is  extant. 

Even  the  language  and  mode  of  expression  of  this 
great  man  were  his  own  ; for  so  original  were  his  serj- 
timents  that  they  could  hardly  be  delineated  by  any 
ordinary  arrangement  of  words.  His  phrases  are  still 
adopted  in  all  the  medictil  schools  of  this  country,  and 
continue  to  modify  the  style  of  almost  every  profes- 
sional book.  Great  as  Mr.  Hunter’s  merit  as  a surgeon 
was,  it  was  still  greater  as  a comparative  anatomist 
and  physiologist.  The  museum  of  the  Royal  College 
of  Surgeons,  and  his  papers  in  the  Phil.  Trans.,  will 
for  ever  attest  his  greatness  in  these  characters. 

At  the  period  when  the  preceding  distinguished  men 
upheld  the  character  of  their  profession  in  Great 
Britain,  Lancisi,  Morgagni,  Molinelli,  Bertrandi,  Gu- 
attani,  Mascagni,  Matani,  Troja,  and  Moscaii,  were 
doing  the  same  thing  in  Ital}'.  Bertrandi’s  Treatise  on 
the  Operations  of  Surgery,  and  Troja’s  work  on  the 
Regeneration  of  Bones,  are  even  at  this  day  works  of 
the  highest  repute.  Of  late  years,  the  credit  of  the 
Italian  surgeons  has  been  honourably  maintained,  by 
Monteggia,  Scarpa,  Paletta,  Ouadri,  Assalini,  Morig(, 
and  others.  In  Holland  flourished  Albinus,  Deventer, 
Sandifort,  and  Camper;  and  in  Germany  and  the  north 
of  Europe,  the  immortal  Haller,  Heister,  well  known 
for  his  “ Institutiones  Chirurgim,”  Plainer,  Rcederer 
(Elementa  .drtis  Obstetriciw,  Goett.  1752.  Obs.  dt 
Partu  Laborioso,  decad.  11,  1756),  Stein,  Bilguer, 
Acrell,  Callisen  (Systema  Chirurgice  Hodiemce.,  2voU. 
8vo.),  Bratnbilla,  Theden  {Progris  ulterieurs  de  la  Chi- 
rurgiw),  Schmucker  {Vermischte  Chirurgische  Schrif- 
ten,  b.  3,  and  Chir.  JVahrnehmungen),  Richter  {Traiti 
des  Hernies,  2 vols.  8ro.  Bibl.  fur  die  Chirurgia ; jin- 
fangsgr.  der  Wundarzn.  7 b.  and  Obs.  Chirurgica- 
rum  Fasc).  Also  Arnemann,  Weidmann, Beer,  Soem- 
mering, Creutzenfeldt,  Hesselbach,  Hufeland,  Gracfe, 
Klein,  Rust,  Himly,  Langenbeck,  Walther,  J.  A. 
Schmidt,  G.  J.  Beer,  &c.  should  not  be  forgotten,  se- 
veral of  whom  are  still  pursuing  their  useful  and  ho- 
nourable career.  Be  it  also  recorded,  as  a part  of  the 
great  merit  of  the  Germans,  that  they  now  rank  among 
the  best  and  most  minute  anatomists;  that  they  are 


SURGERY. 


327 


lealous  cultivators  of  comparative  anatomy,  that 
their  industry  allows  no  improvement  in  medical  sci- 
ence, wherever  made,  to  escape  their  notice;  and  that 
surgery  is  greatly  indebted  to  them  for  the  best  descrip- 
tions of  the  diseases  of  the  eye. 

On  the  continent  the  Royal  Academy  of  Surgery  at 
Paris  was  long  considered  quite  as  the  solar  light  of 
this  branch  of  science.  Nothing,  indeed,  contributed 
so  materially  to  the  improvement  of  suigical  know- 
ledge as  this  establishment,  a noble  institution,  which, 
for  a long  while,  gave  our  neighbours  infinite  advan- 
tage over  us,  in  the  cultivation  of  this  most  useful  pro- 
fession. The  Frencli  Revolution,  which,  by  a fatal 
abuse,  involved  in  the  same  prohibition  both  useful 
and  pernicious  .societies,  did  not  spare  even  this  bene- 
ficial establishment,  in  which  emulation  and  talents 
had  been  so  long  united  for  the  benefit  of  mankind. 
The  various  dissertations  published  by  its  illustrious 
members  will  serve  as  a perpetual  .memorial  of  the 
spirit,  ability,  and  success  with  which  its  objects  were 
pursued ; and  centuries  hence  practitioners  will  reap 
from  the  pages  of  its  memoirs  the  most  valuable  in- 
formation. Although  the  Academy  was  deprived  of 
the  talents  of  Louis,  who  died  a short  time  before  its 
suppression,  it  yet  "had  at  this  period  several  members 
worthy  of  continuing  its  labours,  and  supporting  its 
reputation : Sabatier,  Desault,  who  may  be  regarded 
as  the  Pott  of  France,  Chopart,  Lassus,  Peyrilhe,  Du- 
bois, Percy,  Baudeloque,  Pelletan,  Sue,  &c. 

The  Academy  of  Surgery  in  France  was  succeeded 
by  what  is  named  the  Ecole  de  M^decine.  Desault, 
who  had  been  almost  a stranger  in  the  former,  became 
■quite  the  leading  character  in  the  tatter.  Several 
things  recommended  him  strongly  to  the  remembrance 
and  admiration  of  posterity ; the  exactness  and  method 
which  he  introduced  into  the  study  of  anatomy;  the 
ingenious  kinds  of  apparatus  which  he  invented  for  the 
treatment  of  fractures  ; a noble  ardour  in  his  profes- 
sion, which  he  knew  how  to  impart  to  all  his  pupils; 
his  clinical  lectures  upon  surgery,  which  were  the  first 
ever  delivered;  and  the  boldness  and  simplicity  of  his 
modes  of  operating.  Indeed,  such  was  his  genius, 
that  even  whf  n he  practised  only  methods  already  un- 
derstood, he  did  them  with  so  much  adroitness,  that  he 
rather  appeared  to  be  the  inventor  of  them.  From  the 
Ecole  de  M6decine  have  issued  Dupuytren,  Boyer,  Ri- 
cherand,  Dubois,  Lheritier,  Manoury,  Lallemant,  Petit 
de  Lyon,  Bichat,  Bedard,  Cloquet,  &c. 

Among  the  public  institutions  in  Europe  for  the  im- 
provement of  medical  and  surgical  knowledge,  the 
present  Medical  and  Chirurgical  Society  of  London 
certainly  stands  pre-eminent,  whether  the  reputation 
and  number  of  its  members,  the  importance  of  many 
of  the  papers  which  it  has  published,  or  the  extent  and 
value  of  its  library,  be  taken  as  the  criterion  of  the 
character  which  is  here  assigned  to  it.  Many  of  the 
facta  which  it  has  collected  and  published  are  of  con- 
siderable practical  importance,  especially  those  rela- 
ting to  the  subjects  of  aneurism,  hemorrhage,  the  dis- 
eases of  the  joints,  calculi  in  the  bladder,  and  that 
least  intelligible  of  all  diseases,  syphilis.  Its  library, 
which,  next  to  that  of  the  Royal  College  of  Surgeons, 
is  the  most  select,  valuable,  and  complete  collection  of 
medical  literature  in  Great  Britain,  more  especially 
with  reference  to  modern  works,  is  continually  receiv- 
ing additions,  both  by  large  purchases  at  home  and 
abroad,  and  by  the  numerous  donations  of  its  mem- 
bers and  others.  The  intercourse  and  correspondence 
which  such  a society  always  maintains  among  the  in- 
numerable scattered  members  of  the  profession,  can- 
not fail  to  be  attended  with  the  most  beneficial  effects 
upon  medical  science  in  general ; a generous  and  use- 
ful sort  of  emulation  is  thus  kept  alive;  the  spirit  of 
inquiry  is  kept  from  slumbering  ; and  every  individual 
who  ascertains  a new  fact  has  now  the  means  of  mak- 
ing it  known  to  the  world,  with  all  the  expedition 
which  its  importance  may  demand.  By  this  observa- 
tion I do  not  mean  that  it  will  always  appear  in  print 
directly  after  its  communication  to  the  society,  for  that 
is  a circumstance  which  must  necessarily  depend  upon 
there  being  or  not  a sufficient  quantity  of  interesting 
matter  in  the  Society’s  possession  to  form  an  additional 
part  to  its  Transactions  ; but  the  very  reading  of  the 
pa{)er  at  a public  meeting  gives  it  immediate  notoriety 
in  the  profession,  and  if  its  novelty  and  merit  be  great, 
it  «)on  excites  very  general  attention. 

The  researches  of  Bichat,  who  quitted  Surgery,  pow- 


erfully contributed  to  the  advancement  of  physiolo- 
gical science.  His  mind,  richly  stored  with  the  posi- 
tive facts  which  he  had  learned  in  the  study  of  sur- 
gery, conceived  no  less  a project  than  that  of  rebuild- 
ing the  whole  edifice  of  medicine.  Some  courses  of 
lectures  upon  the  materia  medica,  internal  clinical  me- 
dicine, and  morbid  anatomy,  announced  this  vast  de- 
sign, which  was  frustrated  by  a premature  death.  Bi- 
chat, as  a physiologist  and  man  of  very  original  genius, 
may  be  considered  as  the  John  Hunter  of  France ; but 
his  qualities  were  of  a different  cast,  and  hardly  admit 
of  comparison  with  those  of  Hunter,  whose  investiga- 
tions were  not  limited  to  man,  but  extended  to  the 
whole  chain  of  animated  beings.  Bichat  died  in  the 
midst  of  his  labours,  and,  in  dying,  his  greatest  regret 
was  that  of  not  having  completed  them.  His  exam- 
ple, says  Richerand,  proves  most  convincingly  what 
Boerhaave  always  inculcated,  and  every  man  of  expe- 
rience knows  how  indispensable  the  study  and  even 
<he  practice  of  surgery  are  to  him  who  would  wish  to 
be  a distinguished  and  successful  physician.— (JVoso^r. 
Chir.  t.  1,  p.  25.) 

In  the  course  of  the  last  thirty  years,  great  and  es- 
sential improvements  have  been  made  in  almost  every 
branch  of  surgery. 

Before  the  time  of  Mr.  Hunter,  our  ideas  of  the  ve- 
nereal disease  were  surrounded  with  absurdities;  and 
it  is  to  this  luminary  and  the  plain  facts  laid  before  the 
profession  by  the  late  Mr.  Rose,  that  we  are  in  an  emi- 
nent degree  indebted  for  the  increased  discrimination 
and  reason  which  now  prevail,  both  in  the  doctrines 
and  treatment  of  the  complaint.  It  must  be  confessed, 
however,  that  much  yet  remains  to  be  made  out,  re- 
specting the  nature  and  treatment  of  syphilitic  disor- 
ders. Need  I mention  a greater  proof  of  the  truth  of 
this  remark,  than  the  remarkable  change  of  practice 
in  some  of  the  principal  hospitals  in  London,  mercury 
being  now  exhibited  in  not  more  than  one  out  of  eight 
or  ten  cases,  for  which  this  medicine  a few  years  ago 
was  always  deemed  indispensable  ? Numerous  cases, 
having  all  the  characters  of  primary  venereal  sores, 
seem  also  now  to  be  curable  by  simple  dressings  and 
cleanliness;  and  the  necessity  for  violent  salivation,  in 
any  case,  begins  now  to  be  generally  disbelieved.  In 
short,  so  different  is  every  thing  from  what  it  used  to 
be,  that  many  surgeons  are  tempted  to  suppose  the 
nature  of  the  venereal  disease  totally  altered. — (See 
Venereal  Disease.) 

Strictures  in  the  urethra,  an  equally  common  and|dis- 
tressingdisease,  were  not  well  treated  ofbefore  Mr.  Hun- 
ter published  on  the  venereal  disease.  Until  his  time, 
we  were  unacquainted  with  a good  practical  method 
of  applying  caustic  within  the  urethra,  a method  which 
has  been  still  farther  perfected  with  the  armed  bougies, 
invented  by  Sir  Everard  Home.  The  latter  gentleman, 
indeed,  has  taken  a very  scientific  view  of  the  whole 
subject,  and  perhaps  his  only  error  is  that  of  not  having 
sufficiently  limited  his  favourite  plan  of  treatment. 

In  modern  times  hernial  diseases,  those  common  af- 
flictions in  every  country,  have  received  highly  inte- 
resting elucidations  from  the  labours  of  Pott,  Camper, 
Richter,  Sir  Astley  Cooper,  Hey,  Gimbernat,  Hessel- 
bach,  Scarpa,  Lawrence,  Langenlieck,  Cloquet,  &C. 

The  treatment  of  injuries  of  the  head  has  been  ma- 
terially improved  by  duesnay,  Le  Dran,  Pott,  Hill, 
Desault,  Dease,  Hey,  Abernethy,  and  Brodie. 

The  disease  of  the  vertebra;,  which  occasions  para- 
lysis of  the  limbs,  formerly  always  baffled  the  practi 
tioner;  but  the  method  proposed  by  Mr.  Pott  is  now 
frequently  productive  of  considerable  relief,  and  some- 
times of  a perfect  cure.  The  diseases  of  the  joints  in 
general  may  also  be  said  to  be  at  present  viewed  with 
much  more  discrimination  than  they  were  a very  few 
years  ago;  and  this  great  step  to  better  and  moresuccess- 
ful  practice  reflects  great  honour  on  Mr.  Brodie,  while  it 
keeps  up  a well-founded  hope  that  morbid  anatomy, 
the  study  which  has  of  late  banished  so  much  confu- 
sion from  this  part  of  surgery,  will  yet  be  the  means  of 
bringing  to  light  other  useful  facts  and  observations  re- 
lative to  the  patholo^  of  the  joints. 

In  the  time  of  Mr.  Pott,  few  patients  afflicted  with 
lumbar  abscesses  ever  recovered  ; for  soon  after  a free 
r)pening  had  been  made,  according  to  the  method  then 
in  vogue,  the  constitution  was  usually  seized  with  vio- 
lent irritative  fever,  which  hardly  admitted  of  any 
control.  Mr,  Abernethy  ascertained  that  much  of 
tl  is  risk  might  be  avoided  by  tnaking  only  a small 


328 


SURGERY. 


opening,  healing  it  by  the  first  intention,  after  the  mat- 
ter had  been  let  out,  and  then  repeating  the  same  plan 
from  time  to  time,  so  ps  to  prevent  the  cavity  of  the 
abscess  from  ever  being  distended,  and  give  it  the  op- 
portunity of  diminishing  by  a natural  process.  Of 
course  success  cannot  be  expected  to  attend  even  this 
treatment,  when  the  vertebrte  are  carious,  or  any  other 
serious  organic  disease  prevails. 

The  rarely-failing  plan  of  curing  hydroceles  by  means 
of  an  injection,  as  described  by  Sir  James  Earle,  may 
be  enumerated  as  one  of  the  most  decided  improve- 
ments in  modern  surgery  : at  least  no  doubt  is  enter- 
tained on  this  point  by  any  surgeon  of  eminence  in 
France,  the  British  dominions,  or  the  United  States. 

[This  is  the  first  mention  made  of  the  surgeons  of 
the  United  States  in  this  history  of  surgery,  and  it 
might  imply  that  in  this  country  the  radical  cure  of  hy- 
drocele is.  the  very  ultimatum  of  attainment  in  opera- 
tive surgery.  That  the  author  did  not  design  thus  to 
misrepresent  us,  is  clear  from  the  fact  that  he  hints  a^ 
Dr.  Mott’s  case  of  ligature  of  the  innominata,  and 
awards  him  the  meed  of  originality  in  amputating  the 
lower  jaw,  within  the  two  following  pages;  and  also 
from  the  respectful  notice  he  has  occasionally  given  to 
American  operations  in  ^his  Dictionary.  In  a pro- 
fessed history  of  operative  surgery,  however,  in  which 
the  distinguished  men  of  every  other  country  are 
named,  together  with  the  improvements  and  benefits 
they  conferred  upon  science  and  humanity,  one  would 
naturally  look  for  some  mention  of  the  names  at  least 
of  Drs.  Plwsick,  White,  Dudley,  Davidge,  Dorsey, 
Shippen,  Bard,  Post,  Mott,  Gibson,  Parish,  Barton, 
M'Clellan,  Stevens,  Warren,  Smith,  Jamieson,  and  a 
host  of  others  who  have  contributed  by  the  pen  and 
the  knife  to  elevate  this  department  of  the  profession, 
and  some  of  them  are  quite  as  distinguished  in  Ame- 
rica, as  thdse  of  whom  honourable  mention  is  made 
justly  are,  among  their  transatlantic  brethren.  This 
will  be  admitted,  unless  the  successful  ligature  of  the 
subclavian,  the  common  iliac,  internal  iliac,  and  that 
of  the  innominata,  the  amputation  of  the  hip-joint, 
and  upper  and  lower  jaw,  the  extirpation  of  the  pa- 
rotid gland,  the  exsection  of  the  clavicle,  and  the  cure 
of  aneurism  by  tying  on  the  distal  side  of  the  tumour, 
be  unworthy  of  record.  Some  of  these  operations 
have  never  been  attempted  in  Europe  until  our  sur- 
geons led  the  way,  and  by  these  and  other  splendid 
achievements  in  operative  surgery  demonstrated  their 
practicability  and  success. 

I may  be  allowed  to  express  the  hope  that  when 
the  author  shall  favour  the  profession  with  a still 
farther  improved  edition  of  his  Dictionary  so  highly 
appreciated  in  America,  he  will  provide  himself  with 
the  materials  so  accessible,  and  not  again  declare  with- 
out a brief  qualification,  that“./5ZI  the  boldest  opera- 
tions in  the  treatment  of  aneurismal  diseases  have  been 
devised  by  the  genius,  and  executed  by  the  spirit  and 
skill  of  British  surgeons."  I only  here  enter  a “ge- 
neral plea  of  demurrer,”  and  shall  scatter  my  “bill 
of  exceptions”  throughout  my  brief  notes  in  the  body 
of  the  present  edition. — Reese.] 

The  increasing  aversion  to  the  employment  of  the 
gorget  in  lithotomy,  the  many  distinguished  advocates 
for  the  use  of  better  instruments,  and,  above  all  things, 
the  clearer  exposition  of  the  right  principles  of  the  ope- 
ration now  made,  both  by  lecturers  and  authors,  I re- 
gard as  an  agreeable  indication  of  the  augmented 
degree  of  success  with  which  lithotomy  is  now  likely 
to  be  practised  in  every  fair  case  for  the  operation. 
The  necessity  for  the  same  frequent  performance  of 
lithotomy  which  prevailed  formerly,  must  not,  how 
ever,  be  now.  recognised  by  any  humane  or  judicious 
surgeon;  and  I entertain  a cheerful  hope  that  the  art 
of  pulverizing  calculi  in  the  bladder,  and  voiding  the 
fragments  through  the  urethra,  will  soon  attain  such 
perfection  as  shall  nearly  banish  the  dreadfully  painful 
and  frequently  fatal  practice  of  cutting  into  the  blad- 
der for  the  extraction  of  the  stone.  The  urethral  for- 
ceps recommended  by  Sir  A.  Cooper  for  removing  cal- 
culi through  the  urethra,  and  all  the  ingenious  inven- 
tions of  Dr.Civiale,  M.  Le  Roy,  and  Baron  Heurteloup, 
designed  to  reduce  the  stone  to  powder,  so  that  it  may 
be  voided  with  the  urine  through  the  urethra  (each 
plan  thus  superseding,  when  it  answers,  all  occasion 
for  lithotomy),  are  great  and  signal  improvements, 
which  entitle  their  inventors  to  a distinguished  rank 
among  those  men  of  genius  from  whose  labours  the 


present  and  future  generations  will  receive  inestimable 
benefit. 

The  diseases  of  the  eyes,  cases  to  w'hich  English 
surgeons  seemed  to  pay  much  less  attention  than  was 
bestowed  by  foreign  practitioners,  now  obtain  due  at- 
tention in  this  country.  Although  we  have  always 
had  what  are  called  oculists,  our  regular  surgeons  have 
generally  been  wonderfully  Ignorant  of  this  part  of 
their  profession,  and,  uninformed  on  the  subject,  they 
have  given  up  to  professed  oculists  and  quacks  one  of 
the  most  lucrative  and  agreeable  branches  of  practice. 
However,  the  able  writings  of  Daviel,  VVer.zel,  and 
Ware  begin  now  to  be  familiarly  known  to  practi- 
tioners; and  the  observations  of  Scarpa,  Richter, 
Beer,  Schmidt,  Himly,  Lawrence,  Frick,  Wardrop, 
Travers,  Saunders;  and  Guthrie  will  soon  have  im- 
mense effect  in  diffusing  in  the  profession  a due  know- 
ledge of  the  numerous  diseases  to  which  the  organs  of 
vision  are  liable.  As  likewise  the  hospital  surgeons 
of  London  long  and  grossly  neglected  the  study  of 
these  cases,  and  refused  to  have  any  thing  to  do  with 
them,  the.  public  at  length  saw  the  necessity  of  esta- 
blishing Eye  Infirmaries  in  London  and  other  large 
towns,  where  such  afflictions  might  be  more  atten- 
tively observed  and  relieved.  Sfflne  of  these  have 
now  become  excellent  schools,  in  which  the  rising  ge- 
neration of  surgeons  have  abundant  opportunities  of 
studying  the  nature  of  all  the  diseases  of  the  eyes,  and 
the  most  approved  methods  of  treatment. 

In  the  treatment  of  aneurismal  diseases,  English 
surgeons  have  much  to  be  proud  of.  All  the  boldest 
operations  in  this  branch  of  surgery  have  been  devised 
by  the  genius,  and  executed  by  the  spirit  and  skill  of 
British  surgeons.  Even  M.  Roux  himself  is  here  ob- 
liged to  confess  our  superiority.— (ParaZZ^Ze  de  la  Chi- 
rurgie  Angloise,  Src.  p.  249.)  The  carotid  artery,  the 
external  and  internal  iliac,  and  the  subclavian  have  all 
been  successfully  tied  by  surgeons  of  this  country. 
The  first  operation  in  which  the  external  iliac  was  tied, 
I was  a spectator  of : it  was  performed  by  Mr.  Aber 
nelhy  in  St.  Bartholomew’s  Hospital,  and  it  has  sub- 
sequently been  repeated  in  many  examples,  both  in  this 
country  and  others,  with  considerable  success.  I had 
also  the  honour  of  seeing  the  same  gentleman  tie  the 
carotid,  in  the  first  instance  of  that  operation  in  Eng- 
land. This  important  measure,  which  has  now  been 
frequently  practised  with  success,  constitutes  one  of 
the  great  improvements  in  the  operative  part  of  mo- 
dern surgery. 

In  the  article  Aneurism,  I have  cited  many  examples 
in  which  the  carotid  artery  has  been  successfully  tied; 
and  the  safety  and  propriety  of  the  operation  are  now 
generally  known  and  acknowledged.  Indeed,  so  little 
are  surgeons  now  afraid  of  the  ill  efiects  upon  the 
brain,  that  the  carotid  artery  has  been  lied  merely  for 
the  purpose  of  enabling  the  operator  to  take  away  a 
large  tumour,  including  the  whole  of  the  parotid  gland, 
from  the  side  of  the  neck,  without  risk  of  hemorrhage ; 
a mode  of  proceeding,  however,  which  ought  not  to  be 
encouraged  into  a common  practice. — (See  Med.  Chir. 
Trans,  vol.  7,  p.  112.)  The  example  of  skill,  judg- 
ment, and  boldness  set  by  the  surgeons  of  this  country 
has  not  been  lost  upon  foreign  practitioners.  In 
France,  in  Germany,  and  particularly  in  the  United 
Slates  of  America,  operations  for  aneurism  are  now 
familiarly  practised.  Indeed,  in  the  two  latter  coun- 
tries [first  in  America],  the  arteria  innominata  had 
been  lied  ; a proceeding  which,  though  it  was  origi- 
nally suggested  here,  [1]  I believe  has  not  yet  been 
ventured  upon  in  Great  Britain  : neither  may  it  be 
now  justifiable,  since  the  possibility  of  curing  aneu- 
rism on  the  plan  first  suggested  by  Brasdor,  and  of 
late  most  convincingly  illustrated  by  Wardrop,  leads  to 
a safer  expedient. — (See  .Aneurism.)  Mr.  Weiss’s 
aneurismal  needle,  for  the  conveyance  of  the  ligature 
under  very  deep  arteries  where  there  is  but  little  room, 
is  also  an  invention  likely  to  prove  of  very  material 
service  in  this  branch  of  surgery,  where  sometimes  the 
most  skilful  surgeons  have  either  been  quite  baffled  in 
their  endeavour  to  pass  the  ligature  under  the  vessel, 
or  have  detained  their  patient  so  long  in  the  operating 
room,  exposed  to  the  greatest  agony,  ere  the  business 
was  accomplished,  that  the  irritated  and  reduced  state 
of  the  constitution  seriously  le.-jsened  the  chance  of  a 
happy  issue.  Before  I quit  this  subject,  my  feelings 
call  upon  me  to  express  the  high  opinion  which  I en- 
tertain of  my  friend  Mr.  Hodgson’s  Treatise  on  tlie 


SURGERY. 


329 


Diseases  of  Arteries  and  Veins,  first  published  in  1815; 
a work  which  reflects  great  credit  on  Englislt  surgery, 
and  contains  practical  precepts  far  superior  to  those  of 
Scarpa.  A new  edition  of  it,  enriched  with  later  ob- 
servations, and  the  farther  e.\pt;rience  and  reflections 
of  tile  respected  author,  I am  happy  to  announce  as 
being  on  the  point  of  publication. 

In  the  modern  practiceof  surgery, a variety  of  old  preju- 
dices are  gradually  vanishing.  Peruvian  bark, not  many 
years  ago,  was  regarded  as  a sovereign  remedy  and 
specific  for  nearly  all  cases  of  gangrene ; and  in  these 
and  many  other  instances,  it  was  prescribed  without 
any  discrimination,  and  in  doses  beyond  all  modera- 
tion. But  the  false  idea  that  this  medicine  - has  any 
specific  effect  in  checking  mortification,  no  longer 
blinds  the  senses  of  the  ’most  superficial  practitioner. 
He  neither  believes  this  doctrine,  nor  the  still  more  ab- 
surd opinion,  that  strength  can  be  mysteriously  ex- 
tracted from  this  vegetable  substance,  and  communi- 
cated to  the  human  constitution  in  proportion  to  the 
quantity  which  can  be  made  to  remain  in  the  stomach. 

The  valuable  discoveries  recently  made  in  France, 
relative  to  quinine  and  cinchonine,  the  essential  parts 
of  Peruvian  bark,  comprised  in  a very  small  compass, 
will  lead  to  great  amendment  in  the  modes  of  pre- 
scribing this  medicine  in  every  case  where  it  may  de- 
serve trial. 

At  the  present  day,  the  subject  of  mortification  opens 
to  us  a point  for  investigation  of  the  first  rate  conse- 
quence. Every  surgeon  is  aware  that  when  a limb  is 
deeply  aflfected  with  mortification,  amputation  is  com- 
monly necessary.  This  is  generally  acknowledged ; but 
the  performance  of  the  operation  has,  since  the  time  of 
Mr.  Pott,  only  been  sanctioned  when  the  mortification 
has  manifestly  ceased  to  spread,  and  a line  of  separa- 
tion is  formed  between  the  dead  a>id  living  parts.  All 
other  instances  in  which  the  disorder  was  in  aspread- 
ing state,  were  left  to  their  fate.  It  is  true,  some  of  the 
old  surgeons  occasionally  ventured  to  deviate  frofti 
this  precept ; but  as  they  did  so  without  any  discrimi- 
nation or  knowledge  of  the  particular  examples  which 
ought  to  form  an  exception  to  the  general  rule,  their 
ill  success  cannot  constitute  a just  argutnent  against 
the  plan  of  amputating  earlier  in  a certain  description 
of  cases. 

Now,  if  modem  experience  prove  that  many  lives 
may  be  saved  by  a timely  performance  of  amputation, 
under  circumstances  in  which  it  has  until  lately  been 
generally  condemned,  it  must  be  allowed  that  the  es- 
tablished innovation  will  be  one  of  the  greatest  im- 
provements in  the  practice  of  the  present  lime. 

For  reviving  the  consideration  of  this  question,  and 
venturing  to  deviate  from  the  beaten  path,  the  world 
is  much  indebted  to  that  eminent  military  surgeon, 
Baron  Larrey.  How  different  his  doctrines  and  prac- 
tice are  from  those  usually  taught  in  the  schools,  the 
article  Mortification  will  sufficiently  prove. 

Connected  with  this  topic  is  Hospital  Gangrene^  a 
case  which  deserves  here  to  be  pointed  out,  as  having 
received  considerable  attention  of  late  years,  and  being 
much  better  treated  now  that  the  efficacy  of  the  solu- 
tion of  arsenic  and  strong  nitrous  acid,  has  been  so 
completely  proved  by  the  observations  of  Blackadder 
and  Welbank. 

In  the  treatment  of  ununited  fractures,  the  simple 
and  ingenious  practice  suggested  by  Dr.  Physick  of 
Philadelphia,  merits  particular  nfflice:  various  suc- 
cessful trials  have  been  made  of  it  in  this  country  and 
France  (see  Medico  Chir.  Trans,  vols.  5 and  7 ; and 
Boyer's  Traite  des  Maladies  Chir.)  as  well  as  in 
America,  and,  though  liable  to  failure,  it  is  yet  enti- 
tled to  be  regarded  as  a valuable  addition  to  the  plans 
hitherto  devised  for  these  cases,  which  too  often  render 
the  patient  a helpless  crippl'e  during  life. 

The  inestimable  treatise  of  Dr.  Jones  on  Hemor- 
rhage has  now  produced  quite  a revolution  in  all  the 
principles  by  which  the  surgeon  is  guided  in  ihe  em- 
ployment of  the  ligature  for  the  stoppage  of  bleeding, 
and  the  cure  of  aneurisms.  Instead  of  thick  clumsy 
cords,  small  firm  silks  or  threads  are  now  generally 
used  ; and  so  far  is  the  practitioner  from  being  fearful 
of  tying  arteries  too  tightly,  lest  the  ligature  cut  them, 
that  it  is  now  a particular  object  with  hiui  to  apply  the 
silk  or  thread  with  a certain  degree  of  force,  in  order 
that  the  inner  coat  of  the  vessel  may  be  divided.  If 
this  be  not  done,  the  effusion  of  coagulating  lymph 
within  tile  artery,  an  important  part  of  the  process  of 


obliteration,  cannot  be  expected  as  a matter  of  cer- 
tainty, and  secondary  hemorrhage  is  more  likely  to 
occur.  But  in  order  to  convey  an  adequate  idea  of  the 
beneficial  changes  whjch  Dr.  Jones’s  observations  are 
tending  to  produce  in  practice,  I have  been  carelul  in 
the  article  Hemorrhage,  to  give  a tolerably  full  ac- 
count of  the  results  of  all  his  interesting  experiments. 

Dr.  Veitch,  an  eminent  naval  surgeon,  deserves  here 
to  be  also  mentioned  with  particular  honour,  since  he 
is  probably  ilie  earliest  writer  that  laid  due  stress  on 
the  advantage  of  tying  the  arteries  with  very  small 
ligatures;  one  of  the  greatest  improvements  in  the 
treatment  of  wounds  and  in  operative  surgery.  “ My 
experience  and  reasoning  (says  he)  led  me  to  recom- 
mend a small  ligature ; and  its  nature  and  form  were 
not  left  to  conjecture,  but  clearly  laid  down  ; and  the 
introduction  of  this  practice  to  surgery  is,  I think,  un- 
questionably due  to  me.  Dr.  Jones  did  not  apply  his 
round  ligature  to  operations  on  the  human  body  ; and 
the  practiceof  using  the  small  single  ligature  was  not 
adopted  at  the  Edinburgh  Infirmary,  in  which  city  his 
experiments  were  made  until  the  appearance  of  the 
following  Essay  on  the  Ligature  of  Arteries,  which 
was  sent  to  the  editor  of  the  Edin.  Med.  and  Surgical 
Journal  in  1805,  but  was  not  published  until  the  1st  of 
April,  1806.” — (See  Obs.  on  the  Ligature,  <S-c.  Lond. 
1824.)  In  justice  to  Dr.  Jones  I should  mention  that 
his  book  was  published  in  1805. 

Besides  using  very  small,  firm,  round  threads,  in- 
stead of  large,  flat  tapes  or  cords,  as  was  the  custom  a 
few  years  ago,  some  modern  surgeons  have  suspected 
that  much  benefit  might  arise  from  cutting  off  both 
portions  of  the  ligature  close  to  the  knot  after  amputa- 
tion, the  removal  of  the  breast,  &.c.  No  one  has  in- 
sisted so  much  as  Mr.  Lawrence  upon  the  propriety  of 
examining  farther  the  merits  of  this  innovation.  If 
no  bad  eflects  result  from  leaving  so  small  a particle  of 
extraneous  substance  in  the  flesh,  as  the  little  bit 
of  silk  composing  the  knot  and  noose  on  the  ar- 
tery, the  practice  will  form  a considerable  improve- 
ment. The  wound  may  then  be  brought  together  at 
every  point ; the  quantity  of  extraneous  matter  in  the 
part  will  be  lessened  to  almost  nothing  ; the  danger  of 
convulsive  affections  will  be  reduced  in  proportion  as  a 
serious  cause  of  pain  and  irritation  is  diminished  ; and 
the  chance  of  accomplishing  perfect  union  by  the  first 
intention  will  be  materially  increased.  Mr.  Lawrence 
has  tried  the  plan  in  many  instances,  and  hitherto  his 
experience  has  not  found  any  ill  consequences  follow, 
while  it  has  proved  that  many  advantages  are  un- 
doubtedly the  result  of  it.  Mr.  Cross,  of  Norwich, 
however,  has  detailed  some  observations  which  are 
rather  against  the  practice,  and  it  is  certainly  far  from 
being  generally,  or  even  commonly,  adojited.  After 
amputation  it  was  practised  by  several  military  sur- 
geons in  the  late  war  ; and  although  they  probably  did 
not  employ  exactly  such  ligatures  as  this  mode  abso- 
lutely requires,  few  of  them  met  with  any  instances 
of  future  trouble  from  the  minute  bits  of  ligature  en- 
closed in  the  wound,  with  the  exception  of  Mr.  Guth- 
rie and  one  or  two  other  army  surgeons  of  my  ac- 
quaintance. However,  if  large  ligatures  be  used,  the 
practice  is  not  fairly  tried,  or  rather  the  practice  is  not 
tried  at  all;  because  the  great  principle  on  which  it 
answers,  is  the  very  small  atom  of  silk  composing  the 
extraneous  substance  left  in  the  wound,  when  such 
ligatures  as  Mr.  Lawrence  particularly  recommends 
are  employed.  Delpcch  and  Roux  have  also  some- 
times adopted  the  plan  of  removing  the  ends  of  the 
ligature  close  to  the  knot. — (See  Parallile  de  la  Chir. 
Angloise  avec  la  Chir.  Francoise,  p.  131.)  See  Am- 
putation, Aneurism,  Hemorrhage,  and  Ligature. 

Among  other  signal  improvements  in  modern  prac- 
tice, I must  not  forget  the  present  more  rational  me- 
thod of  dressing  the  wound,  after  the  majority  of  ca- 
pital operations,  with  light,  cooling  applications,  in- 
stead of  laying  on  the  part  a farrago  of  irritating 
pledgets  and  plasters,  and  a cumbersome  mass  of  lint, 
tow,  flannel,  and  other  bandages,  woollen  caps,  &c. 
The  fewer  the  adhesive  strips  are  the  better,  if  they 
only  hold  the  lips  of  the  wound  together.  This  is  all 
they  are  intended  to  do.  Whereas,  if  more  than  are 
necessary  for  this  purpose  be  employed,  they  do  harm 
by  heating  the  part  and  covering  the  wound  so  en- 
tirely as  to  prevent  the  issue  of  the  discharge.  Over 
the  adhesive  plasters,  let  the  surgeon  be  content  with 
placing  a simple  pledget  of  spermaceti  cerate  and  some 


330 


SURGERY. 


linen  wet  with  cold  water,  w-hich  will  often  avert  hurt- 
ful degrees  of  pain  and  inflammation  by  keeping  the 
parts  cool. 

Wars,  which  are  unfavourable  to  most  other  sci- 
'cnces,  are  rather  conducive  to  advances  in  surgery. 
The  many  new  and  interesting  observations  which 
Baron  Larrey  has  made  in  the  course  of  his  long  and 
extensive  military  experience,  are  a proof  of  the  fore- 
going remark.  Pitard,  almost  the  founder  of  surgery 
in  France,  was  a military  surgeon.  Ambroise  Par6 
and  Wisernan  collected  their  most  valuable  knowledge 
principally  in  the  service  of  the  army.  Mr.  Hunter 
himself  gained  much  of  his  practical  information  in 
the  same  line  of  life.  To  Baron  Larrey  surgeons  are 
indebted  for  many  highly  important  ob.servations  re- 
lating to  amputation  in  cases  of  gun-shot  wounds.  In 
particular,  he  has  adduced  a larger  and  more  convin- 
cing body  of  evidence  than  was  ever  before  collected, 
to  prove  that  in  gun-shot  injuries  the  operation  of  am- 
putation should  always  be  performed  without  the  least 
delay,  in  every  iifstance  in  which  such  operation  is 
judged  to  be  unavoidable  and  the  ultimate  preserva- 
tion of  the  limb  either  impossible  or  beyond  the  scope 
of  all  rational  probability.  He  has  established  the 
truth  of  this  mo.st  important  precept  in  military  sur- 
uery  by  innumerable  facts,  drawn  chiefly  from  his 
own  ample  experience,  and  partly  from  the  practice 
of  many  able  colleagues.  The  great  operations  of  the 
shoulder-joint  and  hip-joint  amputations  he  has  ex- 
ecuted with  success.  The  necessity  for  the  former, 
however,  he  proves  may  sometimes  be  superseded,  and 
the  limb  be  saved,  by  making  a suitable  incision  for 
the  extraction  of  the  splintered  portions  of  the  upper 
part  of  the  humerus.  This  method,  which  was  in 
many  instances  done  with  success  in  the  peninsular 
war,  and  has  been  also  repeatedly  performed  with  the 
same  result  by  Baron  Percy,  was,  I believe,  originally 
proposed  and  practised  by  Boucher. — (See  Mim.  de 
V Acad.de  Chir.t.%Ato.)  However,  it  was  first  more 
particularly  described,  and  even  practised,  by  Mr.  C. 
White  of  Manchester. — (See  his  Cases  in  Surgery.) 
Mr.  Morell  also  performed  it  successfully  in  the  York 
Hospital.— (See  Med.  Chir.  Trans,  vol.  1.) — See  Am- 
putation. 

Amputation  at  the  hip-joint,  performed  only  in  the 
most  dreadful  cases,  because  itself  the  most  dreadful 
operation  in  surgery,  Baron  Larrey  has  performed  five 
times,  and  twice  (I  believe)  with  success.  It  has  also 
now  been  done  by  Messrs.  Brownrigg  and  Guthrie,’*' 
Sir  Astley  Cooper,  Graefe,  Walther,  Delpech,  and 
others,  and  several  of  their  cases  terminated  in  the  re- 
covery of  the  patients.  As  must  be  the  case,  however, 
on  account  of  the  desperate  circumstances  under  which 
the  operation  is  performed,  and  the  severity  of  the  ope- 
ration itself,  the  examples  of  recovery  bear  only  a 
small  proportion  to  the  large  number  of  deaths  known  to 
have  fiillowed  amputation  at  the  hip  in  the  many  cases 
in  which  it  has  now  been  undertaken.  Yet  this  un- 
fortunate truth  should  not  be  exaggerated  into  a rea- 
son for  an  unqualified  condemnation  of  the  practice, 
which  is  adopted  as  the  only  means  aflTording  a chance 
of  saving  life.  But,  as  there  may  be  difficulty  in  de- 
ciding whether  the  patient  will  have  the  best  chance 
with  or  without  the  operation,  it  is  to  be  hoped  that 
no  surgeons  will  perform  it,  except  under  the  authority 
of  the  united  opinion  of  a board  or  consultation  of  the 
best-informed  practitioners,  whom  circumstances  will 
allow  to  assemble.  It  is  to  be  hoped,  likewise,  that* 
there  is  no  man  in  the  profession  so  destitute  of  honour 
and  principle,  as  to  aim  at  notoriety  through  the  me- 
dium of  this  terrible  operation,  and  court  the  oppor- 
tunity of  doing  it  merely  with  this  view,  instead  of 
being  compelled  to  undertake  it  ^ the  really  desperate 
circumstances  of  the  case.  If  there  be  such  an  indi- 
vidual in  existence,  his  scheme  of  wading  through 
blood  to  reputation,  now  that  the  novelty  of  the  ope- 
ration has  vanished,  would  have  but  little  chance  of 
success.  Be  it  also  recollected  by  the  profession,  that 
while  the  operation  itself  requires  only  ordinary  talents, 
the  business  of  avoiding  it,  and  of  discriminating  the 
exact  cases  in  which  it  should  be  done,  implies  an  ex- 
tensive acquaintance  with  the  principles  of  surgery. 


* Dr.  Mott  performed  this  operation  before  Sir  Astley 
Cooper,  and  with  success.  See  article  “ Amputation 
at  the  Hip- Joint,”  in  this  dictionary.— /ieese. 


ample  experience,  and  more  than  common  abilities  and 
judgment.  See  Amputation. 

In  military  surgery,  the  useful  innovation  of  ambu- 
lances or  light  caravans,  furnished  with  a proper  num- 
ber of  surgeons’  assistants  and  orderlies,  and  capable 
of  keeping  up  with  the  vanguard  if  requisite,  is  un- 
doubtedly the  best  means  of  affording  speedy  surei- 
cal  assistance  to  the  wounded  on  the  field  of  battle, 
and  ought  to  be  enumerated  as  an  arrangement  of 
great  consequence  in  military  surgery.  Barons  Percy 
and  Larrey  deserve  the  chief  praise  for  their  success- 
ful exertions  in  organizing  and  bringing  to  perfection 
so  indispensable  an  establishment.  The  account  of 
this  subject  well  deserves  perusal ; and  it  may  be  seen 
either  in  Larrey's  Mimoires  de  Chirurgie  Militaire, 
or  in  the  Diet,  des  Sciences  Medicates,  t.  4. 

Another  improvement  in  surgery,  of  an  humbler, 
but  not  less  useful  description  than  some  things  to 
which  I have  already  adverted,  is  the  elastic  gum 
seton,  which,  for  cleanliness  and  convenience,  is  far 
superior  to  what  has  generally  been  employed  by  prac- 
titioners. The  needle  for  it  and  the  slips  of  elastic 
gum  may  be  procured  of  Mr.  Weiss.  The  invention, 
I believe,  is  one  of  the  results  of  French  ingenuity. 

• The  excision  of  more  or  less  considerable  portions 
of  the  lower  jaw,  in  cases  of  irremediable  disease  of 
it,  is  a new  proceeding,  exemplifying  the  still-conti- 
nued progress  of  the  boldest  parts  of  operative  surgery. 
The  practice  also  merits  notice  on  another  account ; 
it  is  an  extension  of  the  most  effectual  part  of  surgery 
to  a class  of  miserable  and  hopeless  cases  first  devised 
and  executed,  I believe,  by  our  transatlantic  brethren 
in  the  United  States,  Dr.  Mott  having  been  the  means 
of  conferring  this  honour  upon  them.  Indeed,  it  ap- 
pears to  me  that  the  zeal  and  talent  with  which  the 
practice  of  surgery  is  now  cultivated  in  that  part  of 
the  world,  will  soon  render  it  a frequent  source  of  new 
and  useful  suggestions. 

The  last  illustration  which  I shall  quote  of  the  mo- 
dern advances  of  surgery,  is  the  discovery  of  various 
new  active  remedies  or  improved  forms  of  medicine, 
as  iodine,  morphine,  quinine,  and  cinchonine.  The 
first,  as  the  most  powerful  medicine  for  bronchocele. 
and  for  certain  chronic  enlargements  of  the  breast,  tea# 
tides,  glands,  and  joints,  supposed  to  be  of  a scrofulous 
nature,  is  a decidedly  valuable  addition  to  the  surgi- 
cal pharmacopoeia;  perhaps  the  most  valuable  one 
that  has  been  made  in  modem  times.  With  respect 
to  morphine,  if  experience  prove  that  it  possesses  all 
the  anodyne  qualities  of  opium  without  the  stimulat- 
ing ones,’  in  how  many  cases  and  circumstances  its 
exhibition  may  be  ventured  upon  where  the  practi- 
tioner would  be  fearful  of  the  common  preparations  of 
opium  ! As  for  quinine  and  cinchonine,  they  are 
considered  to  possess  all  the  essential  qualities  of  bark; 
and  as  the  doses  are  very  small,  they  admit  of  being 
prescribed,  when  the  more  bulky  preparations  of  it 
would  dangerously  disturb  both  the  stomach  and 
bowels. 

Let  me  not  conclude  this  article  without  offering  my 
sincere  congratulations  to  every  lover  of  surgical  sci- 
ence for  the  impulse  which  is  likely  to  be  given  to  it 
by  the  very  liberal  and  wise  regulations  lately  adopted 
by  the  Council  of  the  Royal  College  of  Surgeons  in 
London  ; regulations  which,  by  annihilating  all  mono- 
poly in  the  lecturing  department,  and  acknowledging 
schools  of  anatomy  and  surgery  wherever  competent 
ones  may  present  themselves,  will  give  genius  and 
talent  fair  play,  and  soon  demonstrate  that  medical 
science,  when  properly  cultivated,  will  flourish  in 
many  other  soils  and  atmosphere.s  than  those  of  Lon- 
don, Dublin,  Edinburgh,  Glasgow,  and  Aberdeen.  I 
also  anticipate  that  in  the  course  of  a very  short  time, 
we  shall  see  most  convincingly  exemplified  the  immor- 
tal truths,  that  the  same  science  will  always  make  the 
most  raifid  progress  when  freed  from  every  unnecessary 
restriction  ; and  that  the  larger  the  field  of  competition 
and  emulation  is  for  lecturers  and  hospital  surgeons, 
the  more  likely  are  we  to  see  among  them  men  of 
the  first-rale  merit.  Their  reputation,  as  it  ought  to 
do,  will  ensure  to  them  such  a class  as  will  handsomely 
reward  their  labour.  The  public  will  have  the  benefit 
of  the  valuable  doctrines  and  knowledL'e  imparted  by 
them  to  their  pupils,  the  rising  generation  of  practi- 
tioners to  whom  must  hereafter  be  confided  the  ardu- 
ous and  responsible  office  of  administering  medical  and 
surgical  aid  to  mankind.  As  for  other  teachers  of  in- 


SUT 


SUT 


331 


ferior  worth,  hitherto  kept  alive  by  the  artificial  sup- 
port of  great  hospitals,  and  pampered  by  the  unjust 
regulations  of  colleges,  they  will  quickly  find  (what  is 
truly  desirable)  their  proper  level.  If  henceforth  any 
principle  of  monopoly  is  to  be  endured  in  the  profes- 
sion, let  it  only  be  such  as  is  the  result  of  that  kind  of 
attraction  which  will  forever  belong  to  the  charm  of 
genius  and  the  splendour  of  superior  attainments;  and 
may  all  interference  that  would  lessen  the  influence 
of  this  meritorious  principle,  meet  with  eternal  re- 
sistance and  the  hatred  of  every  public-spirited  man  in 
the  profession. 

SUSPENSORY.  A bandage  for  supporting  the 
scrotum  ; a bag-truss.  Bandages  of  this  kind  are  now 
usually  sold  at  the  shops,  and  seldom  made  by  the  sur- 
geons themselves;  therefore  a particular  description 
of  them  is  not  essential  in  this  work.  In  cases  of 
hernia  humoraiis,  varicocele,  cirsocele,  some  parti- 
cular ruptures,  and  several  affections  of  the  testicle, 
and  spermatic  cord,  a suspensory  bandage, is  of  in- 
finite service. 

SUTURES.  (From  suo,  to  sew.)  A mode  of  uniting 
the  edges  of  a wound,  by  keeping  them  in  contact  with 
stitches. 

Mr.  Sharp  remarks,  that  “ when  a wound  is  recent, 
and  the  parts  of  it  are  divided  by  a sjiarp  instrument, 
without  any  farther  violence,  and  in  such  manner  that 
they  may  be  made  to  approach  each  other,  by  being 
returned  with  the  hands,  they  will,  if  held  in  close  con- 
tact for  sometime,  reunite  by  inosculation,  and  cement, 
like  one  branch  of  a tree  ingrafted  on  another.  To 
maintain  them  in  this  situation,  several  sorts  of  sutures 
have  been  invented  and  formerly  practised,  but  the 
number  of  them  has  of  late  been  very  much  reduced. 
Those  now  chiefly  described  are  the  interrupted.,  the 
glover's,  the  quilled,  the  twisted,  and  the  dry  sutures ; 
but  the  interrupted  and  twisted  are  almost  the  only 
useful  ones,  for  the  quilled  suture  is  never  preferable 
to  the  interrupted;  the  dry  suture  is  ridiculous  in 
terms,  since  it  is  only  a piece  of  plaster  applied  in  many 
different  ways  to  reunite  the  lips  of  the  wound;  and 
the  glover’s  or  uninterrupted  stitch,  which  is  recom- 
mended in  superficial  wounds  to  prevetit  the  deformity 
of  a scar,  does  rather,  by  the  frequency  of  stitches, 
occasion  it,  and  is  therefore  to  be  rejected,  in  favour 
of  a compress  and  sticking  plaster.” — {Oper.  of  Sur- 
gery.) The  twisted  suture  is  described  in  speaking 
of  the  hare-lip;  and  gastroraphe,  which  also  properly 
belongs  to  the  present  subject,  forms  a distinct  article 
in  this  dictionary. 

Interrupted  Suture. — The  wound  beingcleansed  from 
all  clots  of  blood,  and  its  lips  being  brought  evenly 
into  contact,  the  needle,  armed  with  a ligature,  is  to 
be  carefully  carried  from  without  inwards  to  the  bot- 
tom, and  so  on  from  within  outwards.  Care  must  be 
taken  to  make  the  puncture  far  enough  from  the  edge 
of  the  wound,  lest  the  ligature  should  tear  quite 
through  the  skin  and  flesh.  This  distance,  accord- 
ing to  Mr.  Sharp,  may  be  three  or  four-tenths  of  an 
inch.  The  other  stitches  required  are  only  repetitions 
of  the  same  process.  The  threads  having  been  all 
passed,  “you  are  in  general  to  begin  in  tying  them  in 
the  middle  of  the  wound;  though,  if  the  lips  be  held 
carefully  together,  it  will  not  be  of  great  consequence 
which  stitch  is  tied  first.” — ( Operations,  chap.  1.) 

Surgical  writers  in  general  state,  that  the  number  of 
stitches  must  in  a great  measure  depend  upon  the  ex- 
tent of  the  wound.  The  common  rule  is,  that  one 
suture  is  sufficient  for  every  inch  of  the  wound;  but 
that  in  some  instances  a stitch  must  be  more  frequently 
made,  particularly  when  a wound  gapes  very  much, 
in  consequence  of  a transverse  division  of  muscles. 
As  we  have  already  explained,  it  is  necessary  to  pierce 
the  skin  at  a sufficient  distance  from  the  sides  of  the 
wound,  lest  the  thread  should  cut  through  the  flesh  in 
a short  time : but  though  Mr.  Sharp  lays  down  the  ne- 
cessary distance  in  general,  as  three  or  four-tenths  of 
an  inch,  and  others  advise  the  needle  to  be  always  car- 
ried through  the  deepest  part  of  the  wound,  we  must 
receive  these  directions,  particularly  the  last,  as  subject 
to  numerous  exceptions.  When  a wound  is  very  deep, 
it  would  be  conspicuously  absurd,  and  even,  in  many 
instances  dangerous,  to  drive  the  needle  through  a vast 
thickness  of  parts.  Other  wounds  of  considerable 
length  might  not  be,  in  some  places,  four-tenths  of  an 
inch  deep ; though  it  is  true,  sutures  could  never  be 
requisite  at  such  points. 


The  needles  for  making  the  interrupted  suture  will 
pass  with  the  greatest  facility  when  their  shape  corres- 
ponds exactly  with  the  segment  of  a circle,  and  they 
should  always  form  a, track  of  sufficient  size  to  allow 
the  ligatures,  which  they  dratv  after  them,  to  pass 
through  the  flesh  with  the  utmost  ease. 

The  interrupted  suture  obviously  receives  its  name 
from  the  interspaces  between  the  stitches ; and  it  is  the 
one  most  frequently  employed.  Its  action  is  always 
to  be  assisted  and  supported,  either  with  the  uniting 
bandage  (see  Bandage),  or  with  strips  of  adhesive 
plaster,  compresses,  &c. 

(Quilled  Suture.  As  Mr.  John  Bell  has  observed ; 
“ When  the  wound  was  deep  among  the  muscular 
flesh,  the  old  surgeons  imagined,  that  so  large  a wound 
could  not  be  cornmanded  by  the  common  interrupted 
suture,  however  deep  the  stitches  might  be  driven 
among  the  flesh ; they  were,  besides,  fearful  of  using 
the  continued  (glover’s)  suture  in  deep  gashes,  lest  the 
wound  should  be  made  to  adhere  superficially  while 
it  was  still  open  within,  forming  perhaps  a suppura- 
tion or  deep  collection  of  matter.  They  believed,  that 
a deep  muscular  wound  could  not  be  safely  healed 
without  a degree  of  suppuration;  while  they  wished 
to  bring  it  together  at  the  bottom,  they  were  afraid  to 
close  it  very  exactly  at  the  mouth,  lest  the  matter 
should  be  collected  in  the  deeper  parts  of  the  wound: 
it  was  for  this  purpose  (says  Mr.  John  Bell)  that  they 
used  what  they  called  the  compound  or  quilled  suture. 
It  is  merely  the  interrupted  suture,  with  this  difference, 
that  the  ligatures  are  not  tied  over  the  face  of  the 
wound,  but  over  two  quills  or  rolls  of  plaster,  or  bou- 
gies, w^hich  are  laid  along  the  sides  of  the  wound.  In 
performing  this  suture,  we  make  first  two,  three,  or 
four  stitches  of  the  interrupted  suture  very  deep,  and 
then,  all  the  ligatures  being  put  in,  we  lay  two  bougies 
along  the  sides  of  the  wound;  then  slip  one  bougie 
into  the  loop  of  the  ligatures  on  one  side,  drawing  all 
the  ligatures  from  the  other  side  (Mr.  Bell  should 
rather  have  said  towards  the  other  side),  till  that  bou- 
gie is  firmly  braced  down.  Next  we  lay  the  other  bou- 
gie, and  make  the  knots  of  each  ligature  over  it,  and 
draw  it  also  pretty  firm ; and  thus  the  ligatures,  in 
form  of  an  arch,  go  deep  into  the  bottom  of  the  wound, 
and  hold  it  close,  while  the  bougies  or  quills  keep  the 
middle  of  the  wound,  and  lips  of  it,  pressed  together 
with  moderate  closeness,  and  prevent  any  strain  upon 
the  threads,  or  any  coarse  and  painful  tying  across  the 
face  of  the  wound.”  In  a note,  Mr.  J.  Bell  says  that 
Dionis  violently  reprobates  the  quilled  suture ; but  that 
De  la  Faye  (the  annotator  on  Dionis)  says,  it  is  good 
for  deep  muscular  wounds.  The  quilled  suture  is  now 
scarcely  ever  employed ; nor  has  it  any  advantages, 
except,  perhaps,  in  some  wounds  in  the  belly. — (See 
Principles  of  Surgery,  vol.  1,  p.  50  ) 

I think  the  reader  will  more  easily  comprehend  the 
manner  of  making  the  quilled  suture,  from  the  follow- 
ing simple  directions.  Take  as  many  needles  as 
stitches  intended  to  be  made,  arm  them  with  a double 
ligature,  or  one  capable  of  being  readily  split  into  two, 
introduce  the  ligatures  through  the  wound,  cut  off  the 
needles,  lay  a piece  of  bougie  along  one  side  of  the 
wound,  and  tie  the  ends  of  the  ligatures  over  it.  Next 
draw  the  other  extremities  of  the  ligatures,  so  as  to 
bring  the  first  piece  of  bougie  into  dose  contact  with 
the  flesh ; lay  the  second  piece  of  bougie  along  the 
opposite  side  of  the  wound,  and  tie  the  other  ends  of 
the  ligatures  over  it  with  sufficient  tightness. 

Glover's  Suture.  This  had  also  the  name  of  the 
continued  suture.  It  was  executed  by  introducing  the 
needle  first  into  one  lip  of  the  wound,  from  within 
outwards,  then  into  the  other  in  the  same  way  ; and 
in  this  manner  the  whole  track  of  the  wound  was 
sewed  up. 

The  glover’s  suture  has  long  been  rejected  by  all 
good  surgeons,  as  improper  to  be  employed  in  cases  of 
common  wounds.  It  was  not,  however,  till  very  lately 
that  this  suture  was  totally  abandoned  ; for  Mr.  Sharp, 
and  several  eminent  writers  since  his  time,  have  ad- 
vised its  adoption  in  woundsof  the  stomach  and  intes- 
tines. From  what  has  been  said  in  the  articles  Wounds 
of  the  .Abdomen  and  Hernia,  the  reader  will  perceive, 
that  even  in  such  particular  instances  the  glover’s  su- 
ture would  not  be  advisable ; so  that  it  may,  in  every 
point  of  view,  be  now  considered  as  totally  disused  in 
every  case  of  surgery  which  can  possibly  present  itself. 
When  we  remember  in  making  this  suture,  how  many 


332 


SUTURES. 


stitches  are  unavoidable ; how  unevenly,  and  in  what 
a puckered  .«tate,  the  suture  drags  the  edges  of  the  skin 
togetlier;  and  what  irritation  it  must  produce;  we  can 
no  longer  be  surprised  at  iu  now  being  never  practised 
on  tlie  living  subject-.  It  is  commonly  employed  for 
sewing  up  dead  bodies;  a purpose  for  wnichit  is  well- 
fitted  ; but  for  the  honour  of  surgery,  and  the  sake  of 
mankind,  it  is  to  be  hoped  that  it  will  never  again  be 
adopted  in  practice. 

False  or  Dry  Suture.  Modern  surgeons  commonly 
utiderstand,  by  this  expression,  nothing 'more  than  the 
plan  of  bringing  the  sides  of  a wound  together  by 
means  of  adhesive  plaster;  nor  did  Mr.  Sharp  attach 
any  other  meaning  to  the  phrase,  which  he  sets  down 
as  highly  ridiculous,  as  there  is  no  sewing  employed. 
For  the  following  remarks  I am  indebted  to  Mr.  Car- 
wardine,  of  Earls  Colne  Priory,  near  Halsted,  Essex. 
Alluding  to  what  was  stated  in  tiie  third  edition  of  this 
dictionary  concerning  the  dry  suture,  he  observes, 
“ You  do  not  appear  to  be  aware,  any  more  than  Mr. 
Sharp,  of  the  precise  mode  of  its  application,  or  why 
it  was  so  called.  Indeed,  it  is  a curious  circumstance 
how  this  method  of  dry  suture  should  have  been  so 
lost  as  not  to  be  described  by  any  modern  surgeons, 
who  laugh  at  the  very  term,  speaking  of  it  as  a niere 
application  of  a strip  of  adhesive  plaster.  In  the  su- 
tura  sicca, so  called  in  opposition  sutura cruenta^ 
where  blood  followed  the  needle,  some  adhesive  plaster 
was  spread  on  linen  having  a selvage.  A piece  of  this 
was  aitplied  along  each  side  of  the  wound  (the  sel- 
vages being  opposed  to  each  other),  and  then  drawn 
together  by  sewing  them  with  a common  needle,  with- 
out bloodshed.  Hence  the  term  sutura  sicca.  The 
dry  suture  was  used  in  all  wounds  of  the  face,  to  avoid 
scars.  You  will  find  it  thus  described  by  our  coun- 
tryman Thomas  Gale,  in  his  Enchiridion,  1563;  and 
also  by  A.  Par6,  who  gives  a figure  of  it  in  his  folio 
work,  1579.”  I feel  much  obliged  to  my  friend  Mr. 
Carwardine  for  this  explanation,  without  which  the 
expression  dry  suture  is  undoubtedly  absurd.  As  the 
common  way  of  dressing  wounds  with  sticking-plaster 
will  come  under  consideration  in  a future  part  of  this 
work  (see  fVounds),  I shall  not  here  detain  the  reader 
upon  that  topic. 

Sutures,  by  which  I mean  such  as  were  made  in  the 
flesh  with  a needle  and  ligature,  were  much  more  fre- 
quently employed  by  the  old  surgeons  than  they  are  by 
the  moderns.  The  best  practitioners  of  the  present 
day  never  resort  to  this  method  of  holding  the  sides  of 
a wound  in  contact,  except  in  cases  in  which  there  is 
a real  necessity  for  it,  and  other  modes  will  not  suffice. 

There  were,  indeed,  certain  instances  in  which  the 
employment  of  sutures  was  long  ago  forbidden.  Of 
this  kind  were  envenomed  wounds,  in  which  acci- 
dents the  destruction  of  the  poison  always  formed  a 
principal  indication  in  the  treatment.  Wounds,  ac- 
companied with  considerable  inflammation,  were  not 
deemed  proper  for  the  use  of  sutures,  as  the  stitches 
had  a tendency  to  increase  the  inflammatory  symp- 
toms. Also,  as  contused  wounds  necessarily  suppu- 
rated, and  consequently  could  not  he  united,  sutures 
were  not  recommended  for  them ; nor  were  they  judged 
expedient  for  wounds  attended  with  such  a loss  of 
substance  as  prevented  their  lips  from  being  placed  in 
contact.  Formerly,  wounds  penetrating  the  chest 
were  not  united  by  sutures;  nor  were  those  in  which 
large  blood-vessels  were  injured ; at  least  until  all  dan- 
ger of  hemorrhage  was  obviated  by  the  vessels  being 
tied. 

Dionis  believed,  with  several  other  authors,  that 
wounds  should  not  be  united  when  bones  were  ex- 
posed, on  account  of  the  exfoliations  which  might  be 
expected.  This  precept  is  no  longer  valid ; for  when 
bones  are  neither  altered  nor  diseased,  and  are  only 
simply  denuded  or  divided  with  a cutting  instrument, 
no  exfoliations  will  commonly  follow,  if  the  surgeon 
take  care  to  replace  the  fresh-cut  soft  parts,  so  as  to 
cover  the  exposed  portion  of  the  bone.  The  practica- 
bleness of  uniting  wounds  attended  with  the  division 
of  a bone,  is  confirmed  by  numerous  facts.  De  la 
Peyronie  communicated  to  the  French  Academy  of 
Surgery  a case  conclusive  on  this  point.  A man  was 
wounded  with  a cutting  instrument,  in  an  oblique  di- 
rection, on  the  external  and  middle  part  of  the  arm. 
The  bone  was  completely  cut  through,  together  with 
the  integuments  and  muscles,  in  such  a manner  that 
the  ann  only  hung  by  an  undivided  portion  of  the  skin, 


about  an  inch  wide,  under  which  were  the  large  ves- 
sels. De  la  Peyronie  tried  to  unite  the  parts,  being  con- 
vinced that  it  would  be  time  enough  to  amputate 
afterward,  if  the  case  should  require  it.  He  placed 
the  two  extremities  of  the  divided  bone  in  their  natu- 
ral situation,  made  several  sutures  for  promoting  the 
union  of  the  soft  parts,  and  applied  a bandage  to  the 
fracture.  In  this  bandage  there  were  slits  or  aper 
tures  over  the  wound,  to  allow  the  dressings  to  be  ap 
plied.  Spirit  of  wine,  containing  a little  muriate  of 
ammonia,  was  used  as  a topical  application ; and  the 
fore-arm  and  hand,  which  were  cold,  livid,  and  insensi- 
ble, were  also  fomented  with  the  same.  By  these 
means,  the  natural  warmth  was  restored,  and  the 
wound  was  dressed.  In  a week,  the  dressings  were 
removed  through  the  opening  in  the  bandage;  in  a 
fortnight  they  were  changed  a second  time,  and  the 
wound  seemed  disposed  to  heal.  On  the  eighteenth 
day,  the  healing  had  made  considerable  progress  ; the 
part  bad  a natural  appearance ; and  the  l^ating  of  the 
pulse  was  very  perceptible.  De  la  Peyronie  now  sub- 
stituted a common  roller  for  the  preceding  bandage, 
and  care  was  taken  to  change  the  dressings  every  ten 
days.  In  about  seven  weeks  all  applications  were  left 
oiF,  and  at  the  end  of  two  montlis  the  patient  was 
quite  well,  with  the  excejition  of  a little  numbness  in 
the  part.  This'case  is  one  of  the  most  important  in 
all  the  records  of  surgery;  for  it  displays,  in  a most 
striking  manner,  what  very  bad  wounds  it  is  the  duty 
of  the  surgeon  to  attempt  to  unite:  and,  above  all,  it 
exemplifies  the  propriety  of  attempting  to  save  many 
compound  fractures,  which,  judged  of  only  from  first 
appearances,  would  lead  almost  any  one  to  resort  to 
amputation.  In  such  cases,  when  the  divided  parts 
are  put  in  contact,  the  appearances  are  quite  altered. 

From  what  has  been  already  stated,  it  appears  that 
surgeons,  a considerable  time  back,  did  not  at  once 
sew  up  every  sort  of  wound ; though  the  considera- 
tions which  led  them  not  to  close  the  wound  were  er- 
roneous, as  may  perhaps  be  said  with  respect  to  the 
apprehension  of  bleeding  and  exfoliations.  The  best 
modern  practitioners  employ  sutures  much  less  fre- 
quently than  their  predecessors.  Pibrac’s  dissertation 
on  the  abuse  of  sutures,  inserted  in  the  third  volume 
of  the  Memoirs  of  the  Academy  of  Surgery,  has  had 
considerable  effect  in  producing  this  change,  and  I may 
safely  add,  this  improvement  in  practice.  That  ju- 
dicious and  enlightened  practitioner  opposed  the  me- 
thod of  uniting  wounds  by  means  of  sutures,  which 
he  contended  ought  never  to  be  adopted  in  practice, 
except  in  certain  cases,  in  which  it  was  absolutely  im- 
possible to  keep  the  sides  of  the  wound  in  contact,  by 
means  of  a suitable  posture,  and  the  aid  of  a method- 
ical bandage.  Such  circumstances  Pibrac  represents 
as  exceedingly  rare,  if  they  ever  occur  at  all.  He 
speaks  of  sutures  as  seldom  fulfilling  the  intention  of 
the  surgeon,  who,  in  the  majority  of  cases  in  which  he 
■employs  them,  finds  himself  necessitated  to  remove 
them,  before  they  have  accomplished  the  wished-for 
end.  Pibrac  believes  that  sutures  are  generally  more 
hurtful  than  conducive  to  the  union  of  wounds ; and 
that  when  they  succeed,  they  do  not  effect  a cure  more 
speedily  than  a proper  bandage.  He  cites  numerous 
cases  of  very  extensive  wounds  of  the  abdomen,  neck, 
&c.  for  the  cure  of  which  a bandage  proved  eflTectuHl, 
and  this  even  in  many  instances  in  w’hich  sutures  had 
previously  failed,  and  cut  their  way  through  the  flesh. 
Louis,  who  adopted  the  opinions  of  Pibrac,  published, 
in  the  fourth  volume  of  jifhn.  de  I' Acad.  Chirurgie,  a 
valuable  dissertation,  in  which  he  endeavours  to  prove, 
that  even  the  hare-lip  can  be  better  united  by  means 
of  the  uniting  bandage  than  with  sutures;  a case, 
however,  which  the  best  modem  surgeons  very  rightly 
agree  to  consider,  for  particular  reasons,  elsewhere 
noticed  (see  Hare-lip),  as  an  example  in  which  a su- 
ture is  advisable. 

As  far  as  I can  judge,  the  fair  statement  of  the  mat- 
ter is,  that  sutures  are  by  no  means  requisite  in  the 
generality  of  wounds;  but  that  there  are  particular 
cases  in  which  either  their  greater  convenience  or  su- 
perior efficacy  still  makes  them  approved.  Since  they 
cannot  be  practised  without  additional  wounds  being 
made,  and  pain  occasioned,  and  since  the  threads 
always  act  as  extraneous  bodies  in  the  parts,  exciting 
more  or  less  inflammation  and  suppuration  round 
them ; there  can  be  no  doubt  that  their  employment  is 
invariably  wrong,  whenever  the  sides  of  a wound  can 


SUT 


be  maintained  in  contact  by  less  irritating  means  with 
equal  steadiness  and  security.  For  what  is  it  which 
generally  counteracts  the  wishes  of  the  surgeon,  and 
renders  his  attempts  to  make  the  opposite  surfaces  of 
wounds  grow  together  unavailing  1 Is  not  the  general 
cause  too  high  a degree  of  inflammation,  which  neces- 
sarily ends  in  suppuration  ? Are  not  sutures  likely  to 
augment  inflammation,  both  by  the  additional  wounds 
of  the  needles,  and  the  still  more  pernicious  irritation 
of  the  threads,  which  always  act  as  foreign  bodies, 
sometimes  producing  not  merely  an  increase  of  inflam- 
mation and  suppuration  in  their  track,  but  frequently 
ulceration  or  sloughing  of  the  parts;  and  in  particular 
constitutions  an  extensive  erysipelatous  redness. 

In  consequence  of  the  ulcerative  process,  sutures 
very  often  cease  to  have  the  power  of  any  longer 
keeping  the  edges  of  wounds  in  contact;  as  the  ob- 
servations of  Pibrac,  and,  indeed,  what  every  man 
may  daily  remark  in  practice,  fully  testify;  and  the 
violent  inflammatory  symptoms  which  are  excited 
frequently  oblige  the  surgeon  to  cut  the  threads  and 
withdraw  them  altogether. 

But  even  admitting,  that,  by  the  general  adoption  of 
sutures,  some  wounds  would  be  united  which  could 
not  be  so  were  this  means  abandoned,  still  it  must  be 
allowed,  on  the  other  hand,  that  the  cause  of  other 
wounds  not  uniting  is  entirely  ascribable  to  the  irri- 
tation occasioned  by  the  sutures  themselves.  Hence, 
if  it  be  only  computed,  that  as  many  wounds  are  pre- 
vented from  uniting  by  the  irritation  of  sutures,  as 
other  wounds  which  are  united  by  their  means,  and 
could  be  united  by  no  other  methods,  we  must  still 
perceive,  that  mankind  would  be  no  suflTerers,  and  sur- 
gery undergo  no  deterioration,  were  sutures  altogether 
rejected  from  practice.  I believe,  however,  that  every 
man  who  has  had  opportunities  of  observation,  and 
has  made  use  of  them  with  an  unprejudiced  mind,  will 
feel  persuaded,  that  more  wounds  are  hindered  from 
uniting  by  sutures,  than  such  as  are  healed  by  them, 
and  could  not  be  united  by  other  means. 

But  prudent  practitioners  are  not  obliged  either  to 
condemn  or  praise  the  use  of  sutures  in  every  instance 
without  exception.  Men  of  independent  principles 
will  always  adopt  the  line  of  conduct  which  truth 
points  out  to  them  as  that  which  is  right;  nor  will  they 
obstinately  join  Pibrac  and  Louis,  in  contending  that 
sutures  are  always  improper  and  disadvantageous,  nor 
imitate  other  bigoted  persons  who  may  use  sutures  in 
every  kind  of  wound  whatever.  Perhaps  sutures  are  still 
rather  too  much  employed,  and,  in  all  probability,  will 
long  be  so.  It  will  be  difficult  entirely  to  eradicate  the 
prejudices  on  which  their  too  frequent  use  is  founded, 
as  long  as  what  may  be  called  the  teachers  of  surgery 
are  seen  holding  up  the  practice  for  imitation  in  every 
principal  hospital  in  the  kingdom.  Such  surgeons, 
however,  as  are  ready  to  imbibe  fair  and  candid 
sentiments  on  the  subject,  and  to  qualify  themselves 
for  practising  this  part  of  surgery  with  judgment, 
should  by  no  means  neglect  to  read  what  Pibrac  and 
Louis  have  written  on  the  subject.  I know  that  the 
latter  authors  are  a little  too  sanguine  in  their  repre- 
sentations; but  as  I have  already  remarked,  sutures 
are  still  rather  too  much  used,  and  something  is  yet 
necessary  for  the  abolition  of  a certain  unwarranted 
habit  of  having  recourse  to  them  without  real  neces- 
sity. Nothing  will  tend  to  produce  this  desirable 
change  sa  much  as  the  perusal  of  every  argument 
against  their  employment. 

I am  decidedly  of  opinion,  not  only  from  what  I have 
read,  but  what  I have  actually  seen,  that  the  sides  of 
the  generality  of  wounds  are  capable  of  being  effectu- 
ally kept  in  contact,  by  means  of  a proper  position  of 
the  part,  and  the  aid  of  strips  of  adhesive  plaster, 
compresses,  and  a bandage.  I believe  that  such  suc- 
cess can  be  obtained  with  every  advantage  which  can 
be  urged  in  favour  of  sutures  and  without  their  disad- 
vantages; such  as  greater  pain,  inflammation,  &c.  I 
even  think,  with  Louis,  that  the  hare-lip  might  in  gene- 
ral be  united  very  well  by  means  of  a bandage ; but 
still  I am  of  opinion,  that  the  twisted  suture  is  attended 
with  least  trouble,  is  most  suited  for  universal  practice, 
and  that  unless  such  pains  were  taken  as  many  prac- 
titioners would  not,  and  others  could  never  take,  the 
method  by  bandage  would  frequently  fail. 

I find  it  exceedingly  difficult  to  lay  down  any  fixed 
principles  for  the  guidance  of  the  surgeon,  in  re- 


SYP  333 

spect  to  when  he  ought  and  when  he  ought  not  to  use 

sutures. 

Perhaps  sutures  should  be  made  use  of  for  all  cuts 
and  wounds  which  occur  in  parts  of  the  body  subject 
to  an  unusual  degree  of 'motion,  such  as  would  be  apt 
to  derange  the  operation  of  bandages,  sticking-plaster, 
and  compresses.  Hence,  the  propriety  of  using  the 
twisted  suture  for  the  hare-lip. 

Sutures  are  probably,  for  the  most  part,  advan- 
tageous in  all  wounds  of  the  abdomen,  of  a certain 
leijgth,  and  attended  with  hazard  of  the  viscera 
making  a protrusion.  In  this  situation  the  continual 
motion  and  action  of  the  abdominal  muscles  in  re- 
spiration, besides  the  tendency  of  the  viscera  to  pro- 
trude, may  be  a reason  in  favour  of  the  use  of  sutures. 

When  two  fresh-cut  surfaces  positively  cannot  be 
brought  into  contact  by  sticking  plaster,  bandages,  the 
observance  of  a proper  posture,  &c.,  there  can  be  no 
doubt  of  the  advantages  of  using  sutures,  if  they  will 
answer  the  purpose.  Some  wounds  of  the  trachea, 
some  wounds  made  for  the  cure  of  certain  fistulous 
communications  between  the  vagina  and  bladder,  or 
others  for  the  curd  of  similar  affections  in  the  perinteum, 
afford  instances  of  cases  to  which  I allude. 

I observe  that  many  surgeons  in  this  metropolis  use 
sutures  for  bringing  the  sides  of  the  wound  together 
after  several  operations;  as  that  of  removing  a dis- 
eased breast,  castration,  and  operations  for  strangulated 
hernia. 

The  reason  for  using  sutures  in  the  scrotum,  I sup- 
pose, arises  from  the  difficulty  of  keeping  the  edges  of 
the  wound  in  contact,  owing  to  the  great  quantity  and 
looseness  of  the  part.  In  this  case,  I will  not  presume 
to  say  that  sutures  may  not  sometimes  be  really  ne- 
cessary, though  in  general  it  is  best  to  dispense  with 
them ; but  after  the  amputation  of  the  breast,  I have 
no  hesitation  in  pronouncing  their  employment  to  be 
always  wrong  and  injudicious. 

I shall  conclude  with  referring  to  what  Pibrac  and 
Louis  have  written  on  the  above  subjects,  in  Mem.  de 
I'jlcad.  de  Chir.  1.  3 and  4.  Sharp,  IJionis,  Gooch,  Le 
Dran,  Bertrandi,  Sabatier,  B.  Bell,  and  J.  Bell,  have 
all  treated  of  sutures.  See  also  C.  E.  Boeder,  Suturce 
Vulnerum ; Upsal,  1772. 

SYMPATHETIC  BUBO.  See  Bubo. 

SYNCH  YSIS.  (From  to  confound.)  The 

term  synehysis  sometimes  denotes  the  confusion  of  the 
humours  of  the  eye,  occasioned  by  blows,  and  attended 
with  a rupture  of  the  internal  membranes  and  cap- 
sules. Beer  understands  by  the  expression  a dissolu- 
tion of  the  vitreous  humour,  or  the  state  of  it  in  which 
its  consistence  is  entirely  destroyed. — (See  Lehre  von 
den  Adgenkr.  b.  2,  p.  257.) 

SYNECHIA.  The  case  in  which  the  iris  adheres  to 
the  cornea  is  termed  synechia  anterior ; that  in  which 
the  uvea  adheres  to  the  capsule  of  the  lens,  synechia 
posterior.  Beer  has  delivered  two  valuable  chapters 
on  these  subjects.  The  synechia  posteriorj  on  account 
of  the  frequent  delicacy  of  the  adhesions,  is  apt  not  to 
be  detected,  unless  the  eye  be  examined  with  particular 
care.  A magnifying-glass  should  be  used,  and  the 
pupil  be  first  dilated  with  hyoscyainus  or  belladonna. 
The  treatment,  as  far  as  the  prevention  and  removal 
of  such  adhesions  are  practicable,  strictly  belongs  to 
the  subject  of  iritis. — (See  Ophthalmy.)  With  the 
view  of  dispersing  them.  Beer  praises  the  good  effects 
of  applying  to  the  eye  itself  ointments  containing 
preparations  of  mercury,  or  a collyrium  hydrargyri 
oxymuriatis,  to  which  some  of  the  thebaic  tincture 
is  added.  As  an  inward  medicine,  he  says,  calomel 
is  the  most  effectual.  When  eye-salves  are  used. 
Beer  recommends  a little  of  the  extract  of  hyoscya- 
mus  to  be  mixed  with  them,  so  that  they  may  dilate 
the  pupil,  and  thus  suddenly  break  any  slight  threads 
of  lymph.— (i?.  2,  p.  58.)  For  additional  information 
on  the  synechia  posterior  and  anterior,  see  Lehre  von 
den  Augenkr.  b.  2,  p.  54,  and  p.  263.  Also  Beger,  De 
Synechia,  seu  preternaturali  Adhesions  Comece  cum 
hide.  Haller,  Disp.  Chir.  t.  1,  p.  435. 

SYNTHESIS.  (From  oruv,  together,  and  Oiaig,  po- 
sition, situation.)  A generic  term,  formerly  used  iu 
the  schools  of  surgery,  and  comprehending  every  ope- 
ration by  which  parts  that  had  been  divided  were 
reunited. 

SYPHILIS.  Lues  Venerea.  The  venereal  disease. 
— (See  Venereal  Disease ) 


[ 334  ] 


T 

TEN  TEN 


f|l  BANDAGE.  A bandage,  so  named  from  its 
dgure.  It  is  principally  used  for  supporting  the 
dressings  after  the  operation  for  the  cure  of  fistula  in 
ano,  in  diseases  of  the  perinfeum,  and  those  of  the 
groin,  anus,  &:c.  It  is  composed  of  two  longitudinal 
pieces  of  cloth,  of  greater  or  less  breadth,  according  to 
circumstances.  The  transverse  piece  of  cloth  serves 
to  go  round  the  body  above  the  hips ; the  perpendicular 
piece  is  sewed  at  one  of  its  ends  to  the  middle  of  the 
latter;  and,  in  general,  its  other  extremity  is  slit  into 
two  portions  or  tails,  about  six  or  eight  inches  long. 
The  perpendicular  piece  of  the  T bandage  applies 
itself  between  the  glulaei  muscles,  and  to  the  perinaeum ; 
while  its  two  ends,  just  described,  are  to  be  carried  be- 
tween the  thighs  and  the  pudenda  to  the  right  and  left, 
and  fastened  to  the  transverse  piece  surrounding  the 
body.  Besides  the  common  T bandage,  there  is  an- 
other one  named  double,  which  has  two  perpendicular 
pieces  sewed  to  the  transverse  one,  about  four  inches 
apart.  The  double  T bandage  is  said  to  be  more  par- 
ticularly applicable  after  lithotomy,  and  for  the  diseases 
of  the  perinseum ; because  one  may  make  the  two  per- 
pendicular pieces  cross  each  other  on  the  part  affected, 
and  leave  the  anus  uncovered;  an  advantage  which 
the  simple  T bandage  certainly  has  not.  The  T band- 
age may  be  used  in  some  other  ways,  which  have  been 
noticed  in  the  article  Bandage. 

TALPA.  (A  mole.)  A tumour  under  the  skin, 
compared  to  a mole  under  ilie  ground.  Such  is  the 
etymology.  Sometimes  it  means  an  encysted  tumour 
on  the  head. — (See  Atheroma,  and  Tumours,  Encysted.) 

TAPPING.  Sfee  Paracentesis. 

TARAXIS.  (From  rapdaao),  to  disturb.)  A slight 
inflammation  of  the  eye. 

TAXIS.  (From  rdo-cru,  to  put  in  order.)  The  opera- 
tion of  reducing  a hernia  with  the  hand. — (See  Hernia.) 

TENDONS,  RUPTURE  OF.  The  tendons  liable 
to  be  broken  by  the  violent  action  of  the  muscles  with 
which  they  are  connected,  are  the  tendo  achillis, 
that  of  tlie  extensor  muscles  of  the  leg,  and  the  tendon 
of  the  triceps  extensor  cubiti.  The  ancient  surgeons 
seem  not  to  have  been  well  acquainted  with  the  rup- 
ture of  the  tendo  achillis,  which  they  probably  might 
mistake  for  a sprain,  or  some  other  complaint.  In 
cases  in  which  this  part  had  been  cut,  they  recom- 
mended approximating  the  separated  portions,  and 
maintaining  them  in  contact  by  means  of  a suture. 

When  the  ruptured  tendo  achillis  was  afterward 
better  understood,  the  plan  just  mentioned  was  even 
adopled  in  this  case,  the  integuments  having  been 
previously  divided,  for  the  purpose  of  briiiging  the 
tendon  into  view.  But  there  is  no  necessity  for  having 
recourse  to  this  painful  proceeding. — {^Encyclopedic 
Methodique,partie  Chir.  t.  1,  p.  55.) 

The  superficial  situation  of  the  tendo  achillis  always 
renders  the  diagnosis  of  its  rupture  exceedingly  obvi- 
ous ; and  the  accident  can  only  become  at  all  dilflcult 
to  detect,  when  there  is  a considerable  degree  of  swell- 
ing, which  is  very  rare.  When  the  tendon  has  been 
cut,  the  division  of  the  skin  even  allows  the  accident 
to  be  seen.  When  it  has  been  ruptured,  the  patient 
hears  a sound,  like  that  of  the  smack  of  a whip,  at  the 
moment  of  the  occurrence.  In  whatever  way  it  has 
been  divided,  there  is  a sudden  incapacity,  or  at  least 
an  extreme  difficulty  either  of  standing  or  walking. 
Hence  the  patient  falls  down,  and  cannot  get  up  again. 
Besides  these  symptoms,  there  is  a very  palpable  de- 
pression between  the  ends  of  the  tendon,  which 
depression  is  increased  when  the  foot  is  bent;  and  di- 
minished, or  even  quite  removed,  when  the  foot  is 
extended. 

The  patient  can  spontaneously  bend  his  foot,  none 
of  the  flexor  muscles  being  interested.  The  power  of 
extending  the  foot  also  is  still  possible,  as  the  peroneei 
muscles,  the  tibialis  posticus,  and  long  flexors  of  the 
toes  (see  a case  reported  by  .7.  L.  Petit)  remain  per- 
fect, and  may  perform  this  motion.— (tEwnres  Chir. 
de  Desault,  par  Bichat,  p.  1.) 

The  indications  are,  to  bring  the  ends  of  the  divided 
part  together,  and  to  keep  them  so,  until  they  have  be- 


come firmly  united.  The  first  object  is  easily  fulfilled, 
by  putting  the  foot  in  a state  of  complete  extension  ; 
the  second,  namely,  that  of  keeping  the  ends  of  the 
tendon  in  contact,  is  more  difficult. 

In  order  to  have  a right  comprehension  of  the  indi- 
cations, we  should  consider  what  keeps  the  ends  of  the 
tendon  from  being  in  contact.  The  flexion  of  the  foot 
has  this  effect  on  the  lower  portion ; the  contraction  of 
the  gastrocnemius  and  solseus  on  the  upper  one.  The 
indications  then  are,  to  put  the  foot  in  an  unalterable 
state  of  extension,  and  to  counteract  the  action  of  the 
above  muscles. 

The  action  of  the  muscles  may  be  opposed  : — 1.  By 
keeping  these  powers  in  a continual  state  of  relaxation. 
For  this  purpose,  the  leg  must  be  kept  half-bent  upon 
the  thigh.  2.  By  applying  methodical  pressure  to  the 
muscles ; methodical,  because  it  is  to  operate  on  the 
fleshy  portion  of  the  muscles,  and  not  on  the  tendon, 
the  ends  of  which  being  depressed  by  it,  would  be  se- 
parated from  each  other,  and  instead  of  growing  to- 
gether, would  unite  to  the  adjacent  parts.  The  pres- 
sure should  also  operate  so  as  to  p.'-event  the  ends  of 
the  tendon  from  inclining  either  to  the  right  or  left. 

J.  L.  Petit  seems  entitled  to  the  honour  of  having  first 
devised  the  plan  of  treating  the  ruptured  or  divided 
tendo  achillis,  by  keeping  the  leg  and  foot  in  a parti, 
cular  posture,  with  the  aid  of  an  apparatus.  Seeing 
that  the  extension  of  the  foot  brought  the  ends  of  the 
tendon  into  contact,  it  occurred  to  him  that  such  exten- 
sion should  be  maintained  during  the  whole  of  fhe 
treatment,  in  order  to  bring  about  a permanent  union. 
This  aim  is,  in  fact,  the  common  basis  of  all  the 
numerous  methods  of  cure  which  have  been  since 
recommended. 

Dr.  Alexander  Monro,  primus,  happened  to  rupture 
his  tendo  achillis.  When  the  accident  took  place,  he 
heard  a loud  crack,  as  if  he  had  suddenly  broken  a nut 
with  his  heel,  and  he  experienced  a sensation  as  if  the 
heel  of  his  shoe  had  ntade  a hole  in  the  floor.  This 
sensation,  he  says,  has  also  been  observed  by  others, 
though  some  have  complained  of  a smart  stroke,  like 
what  would  be  produced  by  a stone  or  cane.  Imme- 
diately suspecting  what  had  happened,  the  doctor 
extended  his  left  foot,  in  which  the  occurrence  had 
taken  place,  as  strongly  as  he  could  with  his  right 
hand,  while  with  the  left  he  pressed  the  muscles  of  the 
calf  downwards,  so  as  to  bring  the  ends  of  the  broken 
tendon  as  near  together  as  possible.  In  this  position  he 
sat  until  two  surgeons  came  to  his  assistance.  They 
applied  compresses,  and  a bent  board  to  the  upper  part 
of  the  foot  and  fore  part  of  the  leg,  both  which  they 
kept  as  nearly  as  possible  in  a straight  line,  by  a tight 
bandage  made  with  a long  roller.  But  as  this  mode  of 
dressing  soon  became  very  uneasy,  it  was  changed  for 
the  following  one.  A foot-sock,  or  slipper,  was  made 
of  double-quilted  ticking,  from  the  heel  of  which  a 
belt  or  strap  projected,  of  sufficient  length  to  reach 
over  the  calf  of  the  leg.  A strong  piece  of  the  same 
materials  was  prepared  of  sufficient  breadth  to  sur- 
round the  calf,  and  this  was  fastened  with  lacings. 
On  the  back  part  of  this  was  a buckle,  through  which 
the  strap  of  the  foot-sock  was  passed,  so  that  the  foot 
could  be  extended,  and  the  calf  brought  down  at  plea- 
sure. The  leg  and  foot  were  wrapped  up  in  soft  flannel, 
fumigated  with  benzoin,  and  the  bandage  was  kept 
on  day  and  night,  the  belt  being  made  tighter  when 
the  doctor  was  about  to  go  to  sleep,  and  loosened  when 
he  was  awake  and  on  his  guard.  For  a fortnight 
he  did  not  move  his  foot  and  leg  at  all,  but  was  con- 
veyed in  a chair  on  castors  from  one  part  of  the  room 
to  another.  After  this,  he  began  to  move  the  ankle- 
joint,  but  in  such  a gentle  manner  as  not  to  give  any 
pain.  The  degree  of  motion  was  gradually  increased, 
as  the  tendon  became  capable  of  bearing  it,  care  being 
taken  to  stop  when  the  motion  began  to  create  uireasi- 
ness.  The  affected  limb  was  moved  in  this  way  for 
half  an  hour  at  a time.  In  a few  days  the  hollow 
between  the  separated  ends  of  the  tendon  became 
imperceptible,  though  the  part  continued  soft  much 
longer.  It  became,  however,  gradually  thicker  and 


TES 


TES 


335 


harder,  until  a knot  was  at  last  formed  in  »t,  appa- 
rently of  a cartilaginous  nature.  Though  this  was 
at  fii-st  as  large  as  middling  plum,  and  gradually  be- 
came softer  and  smaller,  yet  it  did  not  disappear  en- 
tirely. Having  occasion  to  go  out  six  weeks  after  the 
accident,  the  doctor  put  on  a pair  of  shoes  with  heels 
two  inches  high,  and  contrived  a steel  machine  to  keep 
his  foot  in  the  proper  position.  This  machine,  how- 
ever, he  afterward  changed  for  another,  made  of  the 
same  materials  as  the  former.  It  was  not  till  five 
months  after  the  accident,  that  he  thought  proper  to 
lay  aside  all  assistance,  and  to  put  the  strength  of  the 
tendon  to  a trial. — (.See  Monro's  Works,  p.  661.) 

Both  in  a wound  and  rupture  of  the  tendo  achillis, 
the  ancient  method  of  using  a suture  for  keeping  the 
ends  of  the  tendon  in  contact,  is  at  present  quite 
exploded,  and  position  of  the  limb  is  the  grand  agent 
by  which  the  cure  is  now  universally  accomplished. 
The  following  was  Desault’s  method,  which,  though 
it  was  expressly  designed  to  fill  all  the  above-men- 
tioned indications,  may  not  be  a more  valuable 
practical  plan  than  what  was  adopted  by  Dr.  Monro. 
After  the  ends  of  the  lejidon  had  been  brought  into 
contact,  by  moderate  flexion  of  the  knee  and  complete 
extension  of  the  foot,  Desault  used  to  fill  up  the  hollows 
on  each  side  of  the  tendon,  with  soft  lint  and  com- 
presses. The  roller  applied  to  the  limb  made  as  much 
pressure  on  these  compresses  as  on  the  tendon ; and 
hence  this  part  could  not  be  depressed  too  mucJi 
against  the  subjacent  parts.  Desault  next  took  a com- 
press, about  two  inches  broad,  and  long  enough  to 
reach  from  the  toes  to  the  middle  of  the  thigh,  and 
placed  it  tmder  the  foot,  over  the  back  of  the  leg  and 
lower  part  of  the  thigh.  He  then  began  to  apply  a few 
circles  of  a roller  round  the  end  of  the  foot,  so  as  to 
fix  the  lower  extremity  of  the  longitudinal  compress. 
After  covering  the  whole  foot  with  the  roller,  he  used 
to  make  the  bandage  describe  the  figure  of  8,  passing 
it  under  the  foot,  and  across  the  place  where  the  tendon 
was  ruptured ; and  the  method  was  finislied  by  en- 
circling the  limb  upwards,  with  the  roller,  as  far  as  the 
upper  end  of  the  longitudinal  compress. — (See  Monro's 
Works.  Encyclopedie  Mithodique,  article  Achille, 
Tendon  de ; and  Memoire  sur  la  Division  du  Tendon 
d'Achille,  in  CEuvrts  Chir.  de  Desault,  par  Bichat,  t. 
l,p.  306.) 

A rupture  of  the  tendon  of  the  extensor  muscles  of 
the  leg  would  require  nearly  the  same  kind  of  treat- 
ment as  a fracture  of  the  patella.  However,  pressure 
exactly  on  the  broken  part  of  the  tendon  should  be 
avoided  ; the  limb  should  be  kept  extended,  and  some- 
what raised  ; a bandage  might  be  put  round  the  thigh, 
and  antiphlogistic  treatment  be  at  first  adopted.  In 
the  course  of  two  or  three  weeks,  the  surgeon  should 
cause  the  joint  to  be  very  gently  moved,  vvithout  any 
muscular  exertion  on  the  part  of  the  patient  himself. 
When  the  tendon  of  the  triceps  extensor  cubiti  is  rup- 
tured, the  limb  is  to  be  kept  straight ; cold  applications 
are  to  be  used  for  a few  days ; and,  if  necessary,  strict 
antiphlogistic  treatment  pursued. 

TENT.  A roll  of  lint  for  dilating  openings,  si- 
nuses, &c. 

TEREBELLA.  (Dim.  of  terebra,  a perforating 
instrument.)  A trepan,  or  instrument  for  sawing  out 
circular  portions  of  the  skull.  A trephine. 

TEREBRA.  (From  ripio),  to  bore.)  A trepan,  or 
trephine.  Also  an  instrument  called  a perforator. 

TESTICLE,  DISEASES  OF.  For  an  account  of 
many  of  these  affections,  I must  refer  to  distinct  arti 
cles  in  this  Dictionary  ; for  instance,  Cirsocele,  Fun- 
pus  Hcematodes,  Hernia  Humoralis,  Hcematoccle, 
Hydrocele,  Src. 

Mr.  Pott  defines  sarcocele  to  be  a disease  of  the  body 
of  the  testicle,  and  as  the  term  implies,  it  consists,  in 
general,  in  such  an  alteration  made  in  the  structure  of 
that  organ  as  produces  a resemblance  to  a hard,  fleshy 
substance,  instead  of  that  fine,  soft,  vascular  texture 
which  it  naturally  presents.  “ Sarcocele  (says  Callisen) 
is  a name  applied  to  every  chronic  swelling  of  the  tes- 
ticle, attended  with  a total  or  partial  conversion  of  the 
pan  into  a heterogeneous  substance.” — (Sy sterna  Chi- 
rurpice  Hodierna,  pars  2,  p.  144.)  According  to  these 
definitions,  sarcocele  becomes  a term  admitting  of 
almost  general  application  to  morbid  affections  of  the 
tMticle,  since  most  of  them  are  attended  with  indura- 
tion and  swelling  of  the  part.  In  fact,  we  fitid  that  the 
old  writers,  and  a great  many  of  tlie  moderns,  call  all 


diseased  indurations  and  enlargements  of  the  testicle 
sarcoceles,  whether  the  disorder  be  a simple,  chronic, 
indolent  tumour,  unaccompanied  with  any  symptoms 
of  specific  disease  or  malignancy,  or  whether  it  be  a 
scrofulous,  or  what  is  -still  more  different  and  more 
serious,  a truly  scirrhous  disorder  of  the  organ.  Even 
the  fungus  heemaiodes  of  the  testicle  was,  until  lately, 
often  termed  sarcocele. 

That  this  vague  njethod  of  employing  the  word  sar- 
cocele can  be  attended  with  no  advantage,  but  on  the 
contrary  must  have  a tendency  to  destroy  all  useful 
discrimination,  is  a proposition  the  truth  of  which  is 
self-evident.  I am  well  aware  that  Mr.  Pott,  and 
many  late  writers,  set  out  with  an  idea  that  every  sar- 
cocele has  a propensity  to  change  into  scirrhus,  and 
actual  carcinoma,  and  therefore  the  latter  states  are 
considered  by  these  authors  only  as  stages  of  the  same 
disease.  Indeed,  it  is  nmstly  believed  that  a common 
indolent  sarcocele,  a simple  fleshy  enlargement  of  the 
testicle,  may  change  into  the  peculiar  malignant  dis- 
ease called  scirrhus,  or  cancer.  But  yet  it  is  by  no 
means  proved,  that  all  the  diseases  which  are  compre- 
hended under  the  name  of  sarcocele,  are  acconqianied 
with  a risk  of  their  assuming  the  nature  of  scirrhus 
and  cancer  ; for  nothing  can  be  more  certain,  than  that 
the  enlargenrent  of  the  testicle,  produced  by  fungus 
haematodes,  is  from  the  first  to  the  last  always  of  one 
character,  and  can  never  change  into  ordinary  scirrhus 
or  carcinoma.  Neither  do  indolent  scrofulous  swell- 
ings of  this  organ  ever  undergo  such  an  alteration  as 
deserves  the  epithets  of  scirrhous  and  cancerous.  In 
opposition  to  the  belief  of  Mr.  Hunter  (see  his  Treatise 
on  the  Venereal  Disease,  p.  59),  some  surgeons  still 
imagine,  that  there  is  really  one  kind  of  chronic  en- 
largement of  the  testicle  arising  from  a venereal  cause. 
— (Roux,  Parallile  de  la  Chirurgie  Angloise,  irc.p.  305. 
Richerand,  Mosographie  Chir.  t.  4,  p.  300,  edit.  4.)  Now 
this  also  has  asually  been  called  a sarcocele ; it  was  so 
named  by  Pott  himself ; and  if  there  be  such  a case,  no 
one  will  suppose  that  it,  or  any  other  form  of  lues  ve- 
nerea, is  capable  of  changing  into  a true  scirrhous  or 
cancerous  disease.  Perhaps,  therefore,  it  might  be 
more  consistent  and  advantageous  to  restrict  the  ap- 
pellation of  sarcocele  to  an  indolent  fleshy  enlargement 
of  the  testicle,  unaccompanied  with  any  present  symp- 
toms of  malignancy,  or  any  marks  of  its  being  the 
effect  of  a specific  disease ; and  as  soon  as  the  case 
evinces  another  character,  the  name  should  correspond 
with  the  particular  nature  of  the  disease. 

We  need  not  here  enter  into  a minute  account  of  the 
various  sarcomatous  diseases,  to  which  the  testicle  is 
subject ; for  they  have  no  pecidiarity  in  them,  except 
what  depends  upon  their  situation ; and  the  general 
characters  of  the  different  species  of  sarcoma  will  be 
considered  in  a future  article. — (See  Tumour.)  The 
testicle  is  especially  liable  to  three  kinds  of  sarcoma, 
which  have  been  named  by  Mr.  Abernethy,  the  com- 
mon vascular,  the  cystic,  and  the  medullary.  The  lat- 
ter case,  which  used  to  be  called  soft  cancer  of  the  testi- 
cle, is  described  in  this  work  under  the  name  of  Fun- 
gus Hcematodes.  Sometimes  the  testicle  is  converted 
into  a truly  scrofulous  mass.  It  is  increased  in  size, 
and,  when  cut  into,  a whitish  or  yellowish  coagulated 
matter  is  discovered,  mixed  with  pus.  The  complaint 
is  not  attended  with  so  much  pain  and  induration  as  a 
scirrhous  disorder  of  the  testicle;  nor  does  it  produce 
any  unfavourable  state  of  the  health. 

As  Dr.  Baillie  observes,  the  testicle  is  often  found  con- 
verted into  a hard  mass  of  a brownish  colour,  and  ge- 
nerally intersected  with  membranes.  Sometimes  there 
are  cells  in  the  tumour,  which  are  filled  with  a sanious 
fluid. — {Morbid  Anatomy,  Src.  p.  3.52,  353,  edit.  2 ) This 
is  the  truly  scirrhous  testicle,  which  is  attended  with 
great  hardness,  severe  pains  darting  along  the  sperma- 
tic cord  to  the  loins,  and  an  unequal  knotty  feel.  In 
general,  the  health  becomes  impaired.  To  use  Mr. 
Pott’s  words,  sometimes  the  fury  of  the  disease  brooks 
no  restraint;  but  making  its  way  through  all  the  mem- 
branes which  envelope  the  testicle,  it  either  produces  a 
large,  foul,  stinking,  phagedenic  ulcer,  with  hard  edges, 
or  it  thrusts  forth  a painful  gleeting  fungus,  subject  to 
frequent  hemorrhage. — (Pott's  Chirurgical  Works,  vol. 
2,  p.  390,  edit.  1808.)  These  latter  stales  of  the  disease 
are  denorninatt'd  cancer  of  the  testicle. 

Sooner  or  later,  the  scirrhous  induration  extends 
from  the  epididymis  upwards  along  the  spermatic  cord, 
even  within  the  abdominal  ring.  In  the  latter  circura- 


336 


TESTICLE. 


stance,  the  lymphatic  glands  in  the  groin  usually  be- 
come diseased ; and  this  extension  of  mischief,  together 
with  the  impossibility  of  removing  the  whole  of  the 
diseased  cord,  too  frequently  deprives  the  patient  of 
every  chance  of  getting  well. 

I have  already  stated,  that  some  of  the  most  simple 
sarcomatous  enlargements  of  the  testicle  are  capable  of 
assuming,  in  a very  sudden  manner,  a malignant  and 
cancerous  tendency ; and  that  soqietimes  the  scirrhous 
induration  of  th$  cord  makes  a rapid  progress  upwards, 
Hence,  that  surgeon  acts  with  prudence  who  recom- 
mends the  early  extirpation  of  every  testicle  which  is 
incurably  diseased,  and  so  deprived  of  its  original  or- 
ganization as  to  be  totally  unht  for  the  secretion  of  the 
semen. 

Chronic  enlargements  of  the  testicle  are  sometimes 
attended  with  an  accumulation  of  limpid  fluid  in  the 
tunica  vaginalis,  and  the  disease  is  then  termed  hydro- 
sarcocele,  an  appellation  first  employed  by  Fabricius  ab 
Aquapendenle. 

The  hardness  and  swelling  of  the  epididymis,  remain- 
ing after  an  acute  inflammation  of  the  testicle  (see 
Hernia  Humor alis)  do  not  constitute  a complaint  which 
surgical  authors  class  with  sarcocele;  fur  the  disease 
hardly  ever  increases  so  as  to  give  trouble. 

[As  it  is  obvious  that  Mr.  Cooper  intended  to  say 
something  of  the  nature  and  treatment  of  hernia  hu- 
moralis,  but  has  omitted  it  both  here  and  in  the  article 
itself,  I have  determined  to  supply  the  omission  in  this 
place. 

This  term,  hernia  humoralis,  is  applied  to  that  spe- 
cies of  swelled  testicle  which  arises  sympathetically 
upon  any  considerable  irritation  in  the  urethra,  whether 
excited  by  strictures,  injections,  bougies,  or  the  specific 
iriflaimnation  of  gonorrhcea.  The  generic  name  now 
given  to  it  by  modern  surgical  writers  is  orclniis,  from 
opxrj,  a testicle,  and  which  is  certainly  preferable,  as 
possessing  the  true  character  of  a definition,  according 
to  the  present  nomenclature. 

Orchitis  is  characterized  by  a painful  swelling  and 
inflatnination  of  the  testis  and  epididymis.  It  is  sud- 
den in  its  attack,  and  as  suddenly  disappears  under 
the  appropriate  treatment.  It  is  sometimes  very  vio- 
lent in  its  onset,  and  speedily  involves  the  whole  of  the 
spermatic  cord,  and  especially  the  vas  deferens,  and 
spermatic  veins,  which  often  become  varicose.  Some- 
times it  is  transferred  from  one  testis  to  the  other.  How- 
ever high  the  inflammation,  it  is  seldom  known  to 
suppurate,  and  never  if  proper  treatment  be  early 
adopted. 

The  disease  most  frequently  arises  from  previous 
gonorrhoea,  and  especially  when  the  discharge  has  been 
injudiciously  suppressed  by  astringent  or  saturnine  in- 
jections into  the  urethra.  When  the  tumef  action  conr- 
mences,  the  pain  and  burning  in  urinating  ceases,  and 
the  discharge  retires  altogether;  but  all  these  symptoms 
return  so  soon  as  the  inflammation  in  the  testicle  is  re- 
moved. Strangury,  to  an  alarming  extent,  sometimes 
accompanies  the  swelling  and  stopping  of  the  discharge, 
and  hence,  many  judicious  practitioners  invite  the  re- 
turn of  the  secretion  from  the  urethra,  thus  removing 
the  hernia  humoralis  more  speedily. 

Hernia  humoralis,  although  most  frequently  connected 
with  gonorrhoea,  may  arise,  as  already  intimated,  from 
strictures,  bougies,  or  any  other  irritation  in  the  ureth- 
ra, so  that  the  disease  cannot  be  considered  as  possess- 
ing a specific  character,  but  is  purely  syqipathetic ; 
hence,  buboes  of  the  same  character,  and  produced  in 
the  same  w'ay,  are  not  unfrequently  found  at  the  same 
time  in  the  inguinal  glands.  It  has  been  contended  by 
some  that  this  disease  is  not  seated  in  the  testis,  but  in 
the  epididymis,  and  they  therefore  object  to  its  being 
called  orchitis.  But  in  the  early  stage  of  the  disease,  a 
soft,  pulpy  enlargement  of  the  gland  itself  will  be  in- 
variably found,  though  the  epididymis,  at  the  base  of 
the  testis  will  be  found  soon  to  become  swollen,  and 
then  becomes  the  hardest  part  of  the  tumour. 

This  disease  is  often  mistaken  for  other  affections  of 
the  same  organ,  and  it  is  therefore  important  to  define 
the  diagnosis.  It  may  be  distinguished  from  hydrocele 
by  the  pain  it  inflicts,  especially  when  recent,  and 
when  chronic,  as  it  sometimes  is,  by  its  want  of  trans- 
parency, and  the  peculiar  hardness  of  the  epididymis. 
It  may  be  distinguished  from  sarcocele  by  its  small  in- 
crease of  weight  compared  with  the  enormous  size  it 
sometimes  acquires.  It  may  be  known  from  scirrhous 
cancer  or  scrofula,  by  these  diseases  being  slow  in  their 


progress,  while  this  comes  on  very  suddenly  and  very' 
soon  arrives  at  its  height.  These  diagnostics  should  n«)t 
be  lost  sight  of,  as  mistakes  very  often  occur  of  a most 
mischievous  kind,  and  of.  these  I have  known  many. 
The  difference  between  this  disease  and  any  species  of 
hernia  is  sufiiciently  obvious,  and  offer  an  adequate 
objection  to  its  name. 

The  treatment  of  this  disease,  although  the  peculiar 
province  of  the  physician,  is  often  submitted  to  the  sur- 
geon. It  consists  of  depletion,  either  by  venesection, 
leeches,  or,  what  some  prefer,  scarifications  to  the  scro- 
tum. Emetics  and  the  refrigerant  cathartics  may 
be  necessary,  and  are  often  judiciously  superadded,  A 
warm  fomentation  of  chamomile  flowers,  poppy,  or 
hops  will  be  found  preferable  to  the  cold  applications 
so  often  recommended,  and  especially  as  tliere  is  no 
fear  of  suppuration. — Reese-I 

I have  stated,  that  sarcoceles,  in  common  with  the 
generality  of  other  sarcomatous  tumours,  may  change 
into  distempers  which,  in  point  of  malignity  and  the 
manner  in  which  they  injure  the  health,  are  quite  as  bad 
as  cancer  itself.  It  is  said,  however,  that  sarcocele  of 
the  epididymis  rarely  becomes  malignant,  and  is  much 
more  easy  of  cure  than  the  same  disease  of  the  glan- 
dular portion  of  the  testicle;  but  both  parts  are  often 
diseased  together. 

Sarcoceles  sometintes  continue  for  years,  without 
undergoing  any  particular  change ; in  other  instances, 
they  increase  with  surprising  rapidity.  The  inconve- 
niences which  they  excite,  often  proceed.chiefly  from 
their  weight  and  magnitude : their  weight  occasions  an 
uneasy,  and  even  a painful  sensation  in  the  loins,  ('spe- 
cially when  the  patient  neglects  to  wear  a suspensory 
bandage,  or  a bag-truss,  for  the  support  of  the  part. 
Tire  danger  of  a sarcocele  arises  from  the  increase  and 
extension  of  the  hardness  up  the  spermatic  cord,  and 
from  the  change  of  the  tumour  from  its  indolent  state 
into  a painful,  ulcerated,  and  incurable  disease. 

A sarcocele  sometimes  bears  a resemblance  to  hydro 
cele  of  the  tunica  vaginalis.  It  may  have  the*  usual 
pyramidal  shape  of  the  latter  disease,  and,  like  it,  is  al- 
ways situated  at  the  lowerjend  of  the  spermatic  cord. 
The  chief  difference  between  the  two  cases  seems  to 
be,  that  the  sarcocele  is  hard,  while  the  hydrocele  has 
a soft,  yielding,  elastic  feel.  It  should  be  know'n,  how- 
ever, that  the  fungus  hsematodes  of  the  testicle  is  re- 
markable for  the  deceitful  feel  of  fluctuation  and  elas- 
ticity which  it  presents;  and  every  surgeon  ought  to 
be  aw’are,  that  a sarcocele  is  not  always  particularly 
hard,  and  that  hydroceles  are  sometimes  exceedingly 
indurated.  The  sarcocele,  indeed,  is  not  transparent; 
neither  is  the  hydrocele  in  certain  instances;  and  these 
are  cases  in  w hich  a mistake  may  easily  be  made.  Still, 
with  due  attention,  both  diseases  may  be  discriminated 
with  tolerable  precision.  The  sarcocele,  w hen  held  in 
the  surgeon’s  hand,  seems  heavier  than  the  hydrocele. 
Every  part  of  a diseased  testicle  is  seldom  equally  in- 
durated, so  that  the  sarcocele  is  usually  much  softer  in 
sotrre  places  than  others.  The  hydrocele  presents  the 
same  kind  of  feel  at  every  point,  except  behind,  where 
the  testicle  is  felt.  When,  in  the  case  of  hydrocele, 
pressure  is  made  in  this  latter  situation,  the  patient  ex- 
periences a much  more  acute  sensation  than  when 
the  pressure  is  n)ade  upon  any  other  part  of  the  tu- 
mour ; but,  in  the  example  of  sarcocele,  the  patient 
commonly  has  the  same  kind  of  feel,  let  the  pressure  be 
applied  to  any  part  of  the  swelling  whatsoever.  When 
the  upper  portion  of  the  s[)ermatic  cord  can  be  felt, 
and  it  seems  quite  hard  and  thickened,  the  surgeon  has 
reason  for  suspecting  the  case  to  be  a sarcocele.  Lastly, 
though  a hydrocele,  when  gently  handled,  may  seem 
very  hard,  yet,  on  being  more  strongly  compressed,  it 
will  generally  betray  a soft  elastic  feel,  which,  except- 
ing in  instances  of  fungus  haematodes,is  never  the  case 
with  an  indurated  sarcocele. 

It  has  been  already  explained,  that  a sarcocele  is 
sometimes  conjoined  with  a hydrocele,  which  case  is 
well  know’n  among  surgeons  by  the  appellation  of 
hydros arcocele.  As  the  diseased  testicle  is  then  sur- 
rounded with  fluid,  it  cannot  be  fell  and  examined  by 
the  fingers.  However,  when  an  unusual  degree  of 
hardness  is  perceptible  at  the  back  part  of  the  uimour, 
where  the  testicle  is  situated,  or  when  the  upper  por- 
tion of  the  spermatic  cord  is  found  to  be  quite  indu- 
rated, there  is  reason  for  suspecting  that  the  testicle  is 
diseased.  The  sarcocele,  also,  is  commonly  the  origi- 
nal and  principal  complaint,  the  hydrocele  not  occur- 


TESTICLE, 


337 


rmg  till  some  lime  after  the  enlargement  of  the  tes- 
ticle. 

In  some  unusual  cases,  the  substance  of  the  scrotum 
is  converted  into  an  indurated  mass,  whicli  occa.sion- 
alJy  attains  a vast  size,  and  presents  tiie  appearance 
of  an  enormous  sarcocele.  An  example  in  which 
the  tumour  weighed  701bs.  has  been  published  by  Dr. 
Titley. — (.See  Med.  Chir.  IVans.  vol.  6,  />.  73  ) — In  one 
case,  recorded  by  Dr.  Clieston,  a swelling  of  this  kind 
was  as  large  as  a child’s  head.  On  dissection  of  the 
parts,  the  testicle  and  tunica  vaginalis  were  found  to 
be  quite  free  from  disease.  The  tumour  proceeded  en- 
tirely from  an  induration  of  the  cellular  membrane, 
which  immediately  covers  the  external  surface  of 
the  vaginal  coat.  This  curious  disease  is  more  com- 
mon in  warm  climates,  and  several  instances  of  it 
were  met  with  in  Egypt  by  Baron  Larrey. — (See  M^m. 
de  Chir.  Militaire,  1.  2,p.  110,  et  seq.)  Mr.  E.  Tothill, 
lately  of  Staines,  showed  me  a case  in  wiiich  he  had 
removed  from  the  scrotum  a large  mass  of  fat,  contain- 
ing the  testes,  and  also  a hydrocele. 

The  operation  of  castration  is  the  most  certain  means 
of  relieving  the  patient  from  sarcocele.  This  measure, 
however,  is  not  invariably  practicable,  rtor  is  it  always 
necessary ; for  sometimes  the  induration  of  the  testicle 
admits  of  being  dispersed  by  the  judicious  employment 
of  internal  medicines  and  external  applications.  The 
hope  of  accomplishing  this  desirable  object  may  be  rea- 
sonably entertained,  when  the  swelling  is  not  very 
large,  when  it  has  not  existed  a considerable  time,  and 
when  it  is  not  attended  with  very  great  induration. 
Experience  has  proved,  that  some  kinds  of  sarcocele 
have  yielded  to  the  exhibition  of  emetics  {Warner., 
Pringle.,  and  Home.,  in  Chemical  Experiments) ; to  a 
decoction  of  ononis  spinos  {Bergius  Mat.  Med.  Rich- 
ter's Chir.  Bibl.  h.  7,  p.  605)  ; to  cicuta  and  bark 
{Warner)-,  to  mercurial  frictions  {Le  Dran,  B.  Bell, 
Richerand,  Delpech) ; to  the  external  use  of  the  liquor 
ammon.  acetatis,  and  camphorated  mercurial  ointment ; 
to  poultices  containing  opium  {Father gill,  in  Med.  Obs. 
and  Inq.  vol.  5) ; to  a lotion  made  of  a strong  decoction 
of  hemlock  ( Warner) ; to  the  steam  of  vinegar,  the  re- 
peated employment  of  leeches,  and  the  application  of 
cold,  &c.  It  also  behooves  me  particular  ly  to  mention, 
that  the  internal  and  external  use  of  the  preparations  of 
iodine  are  found  to  be  attended  with  strongly  marked 
efficacy  in  various  chronic  affections  of  the  testicle,  es- 
pecially those  reputed  to  be  scrofulous.  Many  facts  of 
this  kind  have  been  reported  to  me  by  my  profes- 
sional friends,  similar  ones  I have  witnessed  myself, 
and  they  are  well  worthy  of  being  remembered  in  prac- 
tice.—(See  Iodine.)  The  operation  of  all  these  means 
may  be  advantageously  promoted  by  the  continual  use 
of  a bag  truss,  the  observance,  as  much  as  possible,  of 
a horizontal  position,  attd  attention  to  a suitable  low 
diet. 

Mr.  Pott  believed,  that  the  man  who  has  the  misfor- 
tune to  be  afflicted  with  a sarcocele,  has  very  little 
chance  of  getting  rid  of  the  disease  by  any  plan,  except 
extirpation;  and  all  the  time  the  operation  is  deferred 
he  carries  about  him  a part,  not  only  useless,  but  bur- 
densome, atid  which  is  every  day  liable  to  become 
worse  and  unfit  for  such  an  operation.  Now,  although 
there  is  a great  deal  of  truth  in  this  opinion,  yet,  I con- 
ceive, it  is  rather  exaggerated,  and  that  it  would  tend  to 
authorize  the  practice  of  castration  to  an  extent  beyond 
all  necessity.  I certainly  think  with  Mr.  Pott,  that 
there  never  was  a sarcocele  cured,  where  the  organi- 
zation of  the  testicle  had  been  destroyed  by  disease,  or 
where  its  structure  had  sufibred  so  much  as  to  render 
it  incapable  of  the  office  for  which  it  is  destined.  But 
such  state  cannot  always  be  ktiown  by  inspection,  or 
manual  examination;  and  were  a surgeon  to  con- 
demn to  the  knife  every  testicle  which  he  finds  affected 
with  indolent  swelling  and  induration,  and  not  readily 
curable,  he  would  remove  many  which,  under  some 
of  the  above  plans  of  treatment,  might  be  perfectly 
cured.  That  there  are  some  chronic  enlargements  of 
the  testicle,  which  may  be  resolved,  is  a truth,  of  which 
experience  must  have  convinced  the  generality  of  sur- 
geons. 

The  scrofulous  induration,  and  several  other  swell- 
ings of  this  organ,  which  are  very  imperfectly  under- 
stood, may  sometimes  be  benefited,  and  even  entirely 
cured,  just  like  some  analogous  affections  of  the  breast. 
What  is  termed  the  venereal  sarcocele  (Mr.  Pott  allows) 
always  gives  way  to  a mercurial  course,  properly  con- 


ducted. The  diagnosis  of  this  case,  it  must  be  con- 
fessed, is  not  very  clearly  explained  by  surgical  writers, 
nor  was  its  reality  acknowledged  by  Mr.  Hunter.  Ac- 
cording to  Mr.  Pott,  it  is  seldom  an  early  symptom ; and 
he  does  not  remember.ever  to  have  seen  an  instance  in 
which  it  was  not  either  immediately  preceded  or  ac- 
companied by  some  other  appearances  plainly  vene- 
real. He  adds,  that  it  has  neither  the  inequality  nor 
darting  pains  of  scirrhus.  But  the  question  whether 
the  case  is  truly  syphilitic  or  not,  is  far  less  interesting 
than  the  question  whether  there  are  not  many  sarco- 
celes  which  may  be  diminished  and  cured  by  mercury  T 
The  affirmative  cannot  be  questioned.  I have  seen 
many  such  cases  myself,  and  there  are  numerous  ex- 
amples on  record.  A statement  of  several  has  been 
lately  published  by  Richerand. — {See  JVosographie  Chi- 
rurgicale,  t.  4,  p.  300,  et  seq.  edit.  4.)  The  authority 
of  Delpech  is  also  on  the  same  side. — {Precis  Eli- 
mentaire  des  Maladies  Reputies  Chir.  t.  3,  p.  564.) 

Indeed,  this  last  writer  maintains,  that  many  com- 
mon sarcoceles  and  scirrhi  of  the  testicle  are  so  much 
alike  in  their  symptoms,  that  the  difference  of  their  na- 
ture cannot  always  be  at  once  detected  by  the  practi- 
tioner. Hence,  although  I am  an  advocate  for  the  early 
performance  of  castration  in  cases  of  sarcocele,  when 
there  is  reason  to  suppose  the  disease  so  far  advanced 
that  the  organization  of  the  testicle  is  totally  destroyed ; 
or  where  internal  and  external  remedies  have  been 
tried  a certain  time  in  vain ; yet  these  sentirnents  do 
not  incline  me  to  recommend  the  operation  for  other 
examples,  in  which  the  disease  is  quite  recent,  and  no 
plan  of  treatment  whatsoever  has  been  fairly  tried.  I 
have  already  enumerated  various  plans  of  treatment, 
which  have  been  proved  by  experience  to  be  sometimes 
capable  of  affording  relief.  The  disease  of  the  testicle, 
whicli  is  usually  called  the  scrofulous  sarcocele,  like 
other  forms  of  scrofula,  often  gets  well  spontaneously 
after  a certain  time,  and  it  may  frequently  be  consi- 
derably benefited  by  administering  internally  the  co- 
nium  maculatum,  and  small  doses  of  the  submuriate 
of  mercury  ; lotions  of  sea-water,  or  poultices  of  sea- 
weeds, being  applied  to  the  scrotum.  The  good  effects 
of  iodine  in  such  cases,  I have  already  noticed.  Se- 
veral other  indolent  enlargements  of  the  testicle  yield 
to  frictions  with  camphorated  mercurial  ointment  on 
the  scrotum.  The  late  Mr.  Ramsden  thought  that 
some  sarcoceles  might  be  relieved  by  removing  with 
bougies  a supposed  morbid  irritability  of  the  urethra, 
with  which  his  theories  led  him  to  connect  the  origin 
of  the  complaint. — (See  Pract.  Obs.  on  Sclerocele,  ^c.) 
The  novelty  of  this  suggestion,  for  a time,  attracted 
considerable  notice ; but  the  interest  which  it  once  ex- 
cited has  now  died*  away ; a sufficient  proof,  to  my 
mind,  that  the  practice  inculcated  was  not  of  much 
value. 

From  the  preceding  observations,  it  may  be  inferred 
that  all  chronic  enlargements  of  the  testicle  are  not 
incurable ; but  that  we  ought  at  the  same  time  to  be 
duly  impre.ssed  with  the  expediency  of  not  wasting 
too  much  time  in  the  trial  of  means  which  are  not  to 
be  depended  upon,  and  which,  if  continued  immode- 
rately long,  might  allow  the  disease  to  advance  too 
far  to  be  capable  of  being  afterward  effectually  extir- 
pated. According  to  Mr.  Poit,  the  circumstances  in 
which  the  operation  of  castration  is  advisable  or  not 
are  of  two  kinds,  and  relate  either  to  the  genera!  habit 
of  the  patient,  and  the  disorders  and  indispositions  of 
some  of  the  viscera,  or  to  the  state  of  the  testicle  and 
spermatic  cord. 

A pale,  sallow  complexion,  in  those  who  used  to 
look  otherwise  ; a wan  countenance,  and  loss  of  appe- 
tite and  flesh,  without  any  acute  disorder  ; a fever  of 
the  hectic  kind;  and  frequent  pain  in  the  back  and 
bowels;  are,  in  those  who  are  afflicted  with  a scir 
rhous  testicle,  such  circumstances  as  would  induce  a 
suspicion  of  some  latent  mischief  in  some  of  the  vis- 
cera; in  which  case,  as  Mr.  Pott  truly  observes,  sue 
cess  from  the  mere  removal  of  the  tesficle  is  not  to  be 
expected.  They  whose  conslitutions  are  spoiled  by 
intemperance  previous  to  their  being  attacked  with 
this  diseasse,  who  have  hard  livers  and  anasarcous 
limbs,  he  says,  are  not  proper  subjects  for  such  an 
operation.  Hard  tumours  within  the  abdomen,  in  the 
regions  of  the  liver,  spleen,  kidneys,  or  mesentery,  im- 
plying a diseased  state  of  the  said  viscera,  are  very 
material  objections  to  the  removal  of  the  local  evil  in 
the  scrotum.  In  short,  whenever  there  are  manifest 


333 


TESTICLE. 


appearances  or  symptoms  of  a truly  diseased  state  of 
any  of  the  principal  viscera,  the  success  of  the  opera^ 
tion  becomes  very  doubtful. 

“ The  state  of  the  mere  testis  can  hardiy  ever  be  any 
objection  to  the  operation ; the  sole  consideration  is 
the  spermatic  cord : if  this  be  in  a natural  state  and 
free  from  disease,  the  operation  not  only  may,  but 
ought,  to  be  performed,  let  the  condition  of  the  testicle 
be  what  it  may  ; if  the  spermatic  cord  be  really  dis- 
eased, the  operation  ought  not  to  be  attempted.”  And 
Mr.  Pott  afterward  remarks,  “ When  the  spermatic 
vessels  are  not  only  turgid  and  full,  but  firm  and  hard ; 
when  the  membrane  which  invests  and  connects  them 
has  lost  its  natural  softness  and  cellular  texture,  and 
has  contracted  such  a state  and  such  adhesions  as  not 
only  greatly  to  exceed  its  natural  size,  but  to  become 
unequal,  knotty,  and  painful,  upon  being  handled; 
and  this  state  has  possessed  all  that  part  of  the  cord 
which  is  between  the  opening  in  the  oblique  muscle 
and  testicle;  no  prudent,  judicious,  or  humane  man 
will  attempt  the  operation ; because  he  will,  most  cer- 
tainly, not  only  do  no  good  to  his  patient,  but  will 
bring  on  such  symptoms  as  will  most  rapidly  as  well 
as  painfully  destroy  him. 

“ On  the  other  hand,”  says  Pott,  “ every  enlarge- 
ment of  the  spermatic  cord  is  not  of  this  kind,  nor 
by  any  means  sufficient  to  prohibit  or  prevent  the 
operation. 

“ These  alterations  or  enlargements  arise  from  two 
causes,  viz.  a varicose  dilatation  of  the  spermatic 
vein,  and  a collection  or  collections  of  fluid  in  the 
membrane  investing  and  enveloping  the  said  vessels.” 
Shortly  afterward  the  same  practical  wiiter  continues: 
” The  diseased  state  of  a truly  scirrhous  testicle,  its 
weight,  and  the  alteration  that  must  be  made  in  the 
due  and  proper  circulation  of  the  blood,  through  both 
it  and  the  vessels  from  which  it  is  dependent,  may  and 
do  concur  in  inducing  a varicose  dilatation  of  the  sper- 
matic vein,  without  producing  that  knotty,  morbid  al- 
teration and  hardness  which  forbid  our  attempts. 
Between  these,  a judicious  and  experienced  examiner 
will  generally  be  able  to  distinguish. 

“ In  the  former  (the  truly  diseased  state),  the  cord 
is  not  only  enlarged,  but  feels  unequally  hard  and 
knotty;  the  parts  of  which  it  is  composed  are  undis- 
linguishably  blended  together ; it  is  either  immedi- 
ately painful  to  the  touch,  or  becomes  so  soon  after  being 
examined ; the  patient  complains  of  frequent  pains 
shooting  up  through  his  groin  into  his  back  ; and  from 
the  diseased  state  of.  the  membrane  composing  the  tu- 
nica communis,  such  adhesions  and  connexions  are 
sometimes  contracted,  as  either  fix  the  process  in  the 
groin  or  render  it  difficult  to  get  flie  finger  and  thumb 
quite  round  it. 

“ In  the  other  (the  mere  varicose  distention),  the  ves- 
sels, though  considerably  enlarged  and  dilated,  are  ne- 
vertheless smooth,  soft,  and  compressible ; the  whole 
process  is  loose  and  free,  and  will  easily  permit  the  fin- 
gers of  an  examiner  to  go  quite  round  it,  and  to  distin- 
guish the  parts  of  which  it  is  composed ; it  is  not  pain- 
ful to  the  touch  ; nor  does  the  examination  of  it  pro- 
duce or  occasion  those  darting  pains  which  almost 
always  attend  handling  a process  malignantly  indu- 
rated.” 

Mr.  Pott  next  explains,  that  “ in  the  cellular  mem- 
brane leading  to  a diseased  testicle,  it  is  no  very  un- 
common thing  to  find  collections  of  extravasated  fluid. 
These,  as  they  add  considerably  to  the  bulk  and  appa- 
rent size  of  the  process,  make  the  complaint  appear 
more  terrible ; and,  as  I have  just  said,  less  likely  to 
admit  relief. 

“ When  the  extravasation  is  general  through  all  the 
cells  of  the  investing  membrane,  and  the  spermatic 
vessels  themselves  are  hardened,  knotty,  and  diseased, 
the  case  is  without  remedy ; for,  although  a puncture 
or  an  incision  will  undoubtedly  give  discharge  to  some 
or  even  the  greatest  part  of  the  fluid,  yet  this  extrava- 
sation is  so  small  and  so  insignificant  a circumstance 
of  the  disease,  and  the  parts  in  this  state  are  so  little 
capable  of  bearing  irritation,  that  an  attempt  of  this 
kind  must  be  ineffectual,  and  may  prove  mischievous. 

“But,  on  the  other  hand,  collections  of  water  are 
sometimes  made  in  the  same  membrane  from  an  ob- 
struction to  the  proper  circulation  through  the  nu- 
merous lymphatics  in  the  spermatic  process,  while  the 
vessels  themselves  are  really  not  diseased,  and  there- 
fore very  capable  of  permitting  the  operation.  In  this. 


case,  the  fluid  is  generally  in  one  cyst  or  bag,  like  to 
an  encysted  hydrocele,  and  the  spermatic  cord,  cyst  and 
all,  ate  easily  moveable  from  side  to  side ; contiary  to  the 
preceding  stale,  in  which  the  general  load  in  the  mem 
brane  fixes  the  whole  process,  and  renders  it  almost 
immoveable. 

“ A discharge  of  the  fluid  will,  in  this  case,  enable 
the  operator  to  examine  the  true  slate  of  the  process, 
and,  as  I have  twice  or  thrice  seen,  put  it  into  his 
power  to  free  his  patient  from  one  of  the  most  terrible 
calamities  which  can  befall  a man.” — (See  Pott  on  Hy- 
drocele, iSrC.) 

The  testicle  is  subject  to  a disease  often  called  soft 
cancer,  which,  though  of  a very  malignant  and  incu- 
rable nature,  is  different  from  the  true  cancer  already 
described.  It  has  been  particularly  noticed  by  Mr. 
Abernethy,  under  the  name  of  Medullary  Sarcoma. 
In  most  of  the  instances  which  this  gentleman  has 
seen,  the  tumour,  when  examined  after  removal,  ap- 
peared to  be  of  a whitish  colour,  resembling  on  a gene- 
ral and  distant  inspection  the  appearance  wf  the  brain, 
and  having  a pulpy  consistence.  He  nas  also  often 
seen  it  of  a brownish-red  appearance. 

This  disease  is  now  generally  considered  to  be  fun- 
gus haematodes.  If  there  are  any  differences,  they  con- 
sist in  the  parts  sloughing  out  and  then  healing,  instead 
of  a fungus  shooting  out,  and  continually  increasing 
in  size. — (See  Fungus  Hoematodes.) 

Dr.  Baillie  has  noticed  some  affections  in  which  the 
testicle  becomes  bony,  cartilaginous,  &.c. ; but  on 
these  it  is  not  necessary  for  me  to  dwell  in  this  Dic- 
tionary. The  preceding  observations  may  be  consi- 
dered as  relating  expressly  to  the  diseases  for  wliich 
castration  is  generally  performed. — (See  Castration.) 

Besides  the  fungus  which  arises  from  the  testicle  in 
the  advanced  stage  of  carcinoma,  and  the  bleeding 
fungous  growth  which  arises  from  this  organ  in  the 
ulcerated  state  of  fungus  hrematodes,  there  is  another 
superficial  fungous  excrescence,  to  which  the  testicle  is 
subject,  and  which  is  entirely  free  from  all  malig- 
nancy. The  disease  to  which  I refer  has  been  no- 
ticed by  Callisen,  under  the  name  of  lipoma  of  the 
testicle.  “Si  ex  superficie  albugineae  vel  ipsa  tunica 
vaginali  excrescentiae  surgunt,  totum  demum  testem 
involventes,  et  scirrhum  seu  fungum,  rnentientes, 
ipsius  famen  testis  substantia  parum  aut  vix  de  statu 
naiurali  aberrante ; malum  naturam  lipomalis  sequi- 
tur,  vix  unquam  in  scirrhum  et  carcinoma  abiens.” — 
(See  Systema  Chirurgice  Hodiernce,  vol.  2,  p.  145,  edit, 
1800.)  The  superficial  fungus,  or  lipoma  of  the  tes- 
ticle, was  noticed  in  an  early  edition  of  another  publi- 
cation ; and  described  as  “ a particular  affection  of 
the  testicle,  in  which  a fungus  grows  from  the  glan- 
dular substance  of  this  body,  and,  in  some  instances, 
from  the  surface  of  the  tunica  albuginea.  This  ex- 
crescence is  usually  preceded  oy  an  enlargement  of  the 
testicle,  in  consequence  of  a bruise  or  some  species  of 
external  violence.  A small  abscess  takes  place  and 
bursts,  and  from  the  ulcerated  opening  the  fungus  gra- 
dually protrudes.”  I then  proceeded  to  repieseiit  how 
unnecessary  and  improper  it  was  to  extirpate  the  tes- 
ticle on  account  of  this  affection,  if,  after  the  subsi 
dence  of  the  inflammation,  the  part  should  not  seem 
much  enlarged  and  indurated.  I recommended  the 
fungus  to  be  cut  off  or  else  destroyed  with  caustic ; and 
I founded  my  advice  on  a successful  attempt  of  the 
first  kind,  which  was  made  in  St.  Bartholomew’s  Hos- 
pital, by  Sir  James  Earle,  a little  while  before  my  book 
was  published.— (See  First  Lines  of  the  Practice  of 
Surgery,  p.  399.) 

An  interesting  little  paper  has  also  been  written  on 
the  subject  by  my  friend  Mr.  Lawrence,  who  has  fa- 
voured the  public  with  a more  particular  account,  and 
nine  cases  illustrative  of  the  causes,  symptoms,  and 
progress  of  the  disorder.  According  to  Mr.  Lawrence, 
the  patient  generally  assignssome  blow  or  other  injury 
as  the  cause  ofthe  complaint ; in  other  instances,  it  ori- 
ginates in  consequence  of  the  hernia  humoralis  from 
gonorrhoea,  ami  sometimes  appears  spontaneously.  A 
painful  swelling  of  the  gland,  parliculaily  character- 
ized by  its  hardness,  is  the  first  appearance  of  the  dis- 
ease. After  a certain  length  of  lime  the  scrotum, 
growing  gradually  thinner,  ulcerates;  but  the  opening 
which  is  thus  formed,  instead  of  discharging  matier, 
gives  issue  to  a firm  and  generally  insensible  fungus. 
The  surrounding  integuments  and  cellular  substance 
are  thickened  and  indurated  by  the  complaint,  so  that 


rET 


TET 


339 


there  appears  to  be  altogether  a considerable  mass  of 
disease.  The  pain  abates  and  the  swelling  subsides 
considerably,  when  the  scrotum  has  given  way.  In 
this  state  the  disorder  appears  very  indolent;  but  if  the 
fungus  be  destroyed  by  any  means,  the  integuments 
come  together,  and  a cicatrix  ensues,  which  is  insepa- 
rably connected  with  the  testicle.  Mr.  Lawrence  next 
informs  us,  that  if  the  part  be  examined  while  the 
fungus  still  remains,  the  excrescence  is  found  to  have 
its  origin  in  the  giandular  substance  of  the  testicle  it- 
self ; that  the  coats  of  the  part  are  destroyed  to  a cer- 
tain extent;  and  that  a protrusion  of  the  tubuli  .semi- 
niferi  takes  place  through  the  aperture  thus  formed. 
Mr.  Lawrence  says  he  has  often  ascertained  the  con- 
tinuity of  the  excrescences  with  the  pulpy  substance 
of  the  testicle,  of  which  more  or  less  remains  accord- 
ing to  the  difference  in  the  period  of  the  disorder.  The 
same  gentleman  thinks  that  the  glandular  part  of  the 
testicle  experiences  an  inflammatory  affection  in  the 
first  instance,  in  consequence  of  the  violence  inflicted 
on  it ; and  that  the  confinement  of  the  swollen  sub- 
stance, by  tJie  dense  and  unyielding  tunica  albuginea, 
sufficiently  explains  the  peculiar  hardness  of  the  tu- 
mour, and  the  pain  which  is  always  attendant  on  this 
stage  of  the  disorder.  The  absorption  of  the  coats  of 
the  testis  and  of  the  scrotum  obviates  the  tension  of 
the  parts,  and  thereby  restores  ease  to  the  patient  at 
the  same  time  that  the  fungus  makes  its  appearance 
externally. 

With  regard  to  the  treatment,  Mr.  Lawrence  is  of 
opinion,  that,  if  the  complaint  were  entirely  left  to  it- 
selt,  the  swelling  would  probably  subside,  the  fungus 
shrink,  and  a complete  cure  ensue  without  any  profes- 
sional assistance;  but,  he  adds,  that  the  disorder  is  so 
indolent  in  this  stage,  that  a spontaneous  cure  would 
not  be  accomplished  till  after  much  time.  He  says, 
that  the  excrescence  may  be  removed  with  a knife,  or, 
if  the  nature  of  its  attachment  permit,  with  a iigature, 
or  that  it  may  be  destroyed  with  escharotic  applications. 
Mr.  Lawrence  very  judiciously  gives  the  preference  to 
removing  the  tumour  to  a level  with  the  scrotum  by 
means  of  the  knife,  as  the  most  expeditious  and  effect- 
ual mode  of  treatment.  He  can  discern  no  ground 
whatever  for  proposing  castration  in  this  malady,  since 
in  no  part  of  its  progress,  nor  in  any  of  its  possible  con- 
sequences and  effects,  can  it  expose  the  patient  to  the 
slightest  risk. 

Mr.  Lawrence  also  mentions  the  possibility  of  there 
being  other  kinds  of  fungi,  which  may  be  met  with 
growing  from  the  testicle,  and  quotes  an  instance  in 
which  Dr.  Macartney  found  a fungus,  of  a firm  and  dense 
structure,  growing  from  the  tunica  albuginea,  while  all 
the  substance  of  the  testicle  itself  was  sound.  Dr. 
Macartney  was  so  kind  as  to  show  me  the  preparation, 
affording  a clear  specimen  of  the  second  kind  of  fun- 
gus. The  cases  drawn  up  by  Mr.  Lawrence  are,  in 
my  opinion,  highly  interesting,  and  may  be  read  in  the 
Edinb.  Med.  and  Sarg.  Journal  for  .Tidy.,  1808. 

I have  already  noticed,  that  Callisen  represents  the 
lipoma  as  sometimes  originating  from  the  surface  of 
the  tunica  vagitialis;  a kind  of  case  which  has  not  yet 
fallen  under  my  observation. 

In  the  preface  to  the  third  edition  of  this  Dictionary, 
p.  10,  I quoted  a case,  published  by  Dr.  H.  Weinhold, 
in  which  the  o|)eration  for  bubonocele  was  performed ; 
and  as  the  testicle  was  diseased,  the  surgeon  niade  a 
complete  division  of  the  spermatic  cord,  tied  the  sper- 
matic arteries,  and  then  left  the  testicle  in  its  natural 
situation.  After  a time,  the  absorbents  had  diminished 
the  part  to  a very  inconsiderable  little  tumour. — (See 
Journ.  der  Pract.  Heilkunde  von  C.  fV.  Hufeland  und 
K.  Himly,  1812.  Zehntes.  Stiick,  p.  112.)  This  case 
merits  attention,  and  ought  to  have  been  cited  in  the 
article  Castration,  because  it  is  the  first  instance,  1 be- 
lieve, in  which  such  practice  was  tried.  Subsequently 
the  following  work  has  been  published;  Mouvelie 
Methods  de  trailer  le  Sarcocele,  sans  avoir  recours  d 
V Extirpation  du  Testicule,  par  C.  Th.  Maunoir,  8vo. 
Gevive,  1820.”  The  new  plan  consists  in  dividing  and 
tying  the  spermatic  arteries,  and  leaving  the  rest  of  the 
cord  and  the  testis  undisturbed. 

TE'I'ANUS.  (From  rrlvu),  to  stretch.)  Tetanus  is 
defined  by  all  authors  to  be  a more  or  less  violent  and 
extensive  contraction  of  the  muscles  of  voluntary  mo- 
tion, attended  with  tension  and  rigidity  of  the  parts  af- 
fected. 

The  excessive  contraction  of  the  muscles  is  kept  up 

Y 2 


without  any  intervals  of  complete  relaxation  ; in  which 
respect  the  disorder  differs  from  ordinary  spasms  and 
convuisions,  where  the  contractions  and  relaxations 
alternate  in  rapid  succession.  In  tetanus,  the  powers 
of  sensation  and  intellect  also  remain  unimpaired,  in 
which  particularity  it  forms  a contrast  to  epilepsy. — 
{Rees'’s  Cyclopadia,  art.  Tetanus.) 

When  its  effects  are  confined  to  the  muscles  of  the 
jaw  or  throat,  it  is  called  trismus  or  locked-jaxc ; when 
all  the  body  is  affected  and  becomes  rigid,  but  re- 
tains its  ordinary  straightness,  the  case  is  named  te- 
tanus. When  the  body  is  bent  forwards,  the  disease  is 
termed  emprosthotonos ; and  opisthotonos,  when  the 
muscles  of  the  back  are  principally  affected. 

To  these  four  forms  some  writers  have  added  a fifth, 
which  they  denominate  pleurostkotonos,  and  which  is 
characterized  by  the  body  being  drawn  to  one  side.  It 
is  the  tetanus  lateralis  of  Sauvages. 

The  different  terms  which  are  applied  to  tetanic  af- 
fections do  not  imply  so  many  particular  diseases  ; but 
only  the  seat  and  various  degrees  of  one  and  the  same 
complaint. 

A far  more  important  division  of  tetanus  is  into  the 
acute  and  chronic,  according  to  its  greater  or  less  in- 
tensity. The  first  is  exceedingly  dangerous,  and  usually 
fatal  ; while  the  latter,  on  account  of  the  more  gradual 
progress  of  the  symptoms,  affords  more  opportunity  of 
being  successfully  treated.— (Larrey,  in  Mem.  de  Chi- 
rurgie  Militaire,  t.  1,  p.  235,  236.) 

Tetanus  may  also  be  distinguished  into  the  traumatic, 
or  that  arising  from  wounds,  being  the  case  with  w'hich 
surgeons  have  principally  to  deal ; and  into  the  idio- 
pathic, or  that  proceeding  from  a variety  of  other 
causes. 

Traumatic  tetanus  sometimes  comes  on  in  a sur- 
prisingly sudden  manner,  and  quickly  attains  its  most 
violent  degree.  The  most  rapidly  fatal  case  that  has 
ever  been  recorded  is  one  that  we  have  on  the  authority 
of  the  late  Professor  Robison,  of  Edinburgh.  It  oc- 
curred in  a negro,  who  scratched  his  thumb  with  a 
broken  china  plate,  and  died  of  tetanus  a quarter  of  an 
hour  after  this  slight  injury. — (See  Rees's  Cyclopcedia, 
art.  Tetanus.)  But  commonly  the  approaches  of  the 
disorder  are  more  gradual,  and  it  slowly  advances  to  its 
worst  stage.  In  this  sort  of  case  the  commencement 
of  the  disorder  is  announced  by  a sensation  of  stiffness 
about  the  neck  ; a symptom  which,  increasing  by  de- 
grees, renders  the  motion  of  the  head  difficult  and  pain- 
ful. In  proportion  as  the  rigidity  of  the  neck  becomes 
greater,  the  patient  experiences  about  the  root  of  the 
tongue  ail  uneasiness  which  soon  changes  into  a diffi- 
culty of  mastication  and  swallowing,  which  after  a 
time  become  totally  impossible.  The  attempt  at  deglu- 
tition is  attended  with  convulsive  efforts,  especially 
when  an  endeavour  is  made  to  swallow  liquids ; and 
so  great  is  the  distress  which  accompanies  these  con- 
vulsions, that  the  patient  becomes  very  reluctant  to 
renew  the  trials,  and  refuses  all  nourishment.  Some- 
times it  even  inspires  him  with  a dread  of  the  sight  of 
water,  and  a great  resemblance  to  hydrophobia  is  pro- 
duced. 

One  of  the  next  remarkable  symptoms  is  a very  se- 
vere pain  at  the  bottom  of  the  sternum,  darling  from 
this  point  backwards  to  the  .spine,  in  tiie  direction  of 
the  diaphragm.  As  soon  as  this  pain  commences,  the 
spasms  of  all  the  muscles  about  the  neck  become  ex- 
ceedingly violent,  and  the  head  is  drawn  backwards  or 
forwards,  according  as  the  contraction  of  the  extensor 
or  fiexor  muscles  happens  to  be  strongest ; but,  in  the 
majority  of  cases,  the  head  and  trunk  are  curved  back- 
wards {Boyer,  Traite  des  Mai.  Chir.  t.l,  p.  288),  and 
the  contractions  increasing  in  force,  the  body  is  fre- 
quently raised  in  the  form  of  a bow,  resting  upon  the 
head  and  feet  alone;  a slate  wliich  is  more  particularly 
denominated  opisthotonos. — (See  Rees's  Cyclopcedia, 
art.  Tetanus.)  At  the  same  time  the  muscles  which 
close  the  lower  jaw,  and  which  were  affected  with 
spasm  and  rigidity  in  the  very  beginning  of  the  disor- 
der, now  contract  with  great  power,  so  as  to  maintain 
the  lower  jaw-bone  Inseparably  applied  to  the  upper 
one.  The  last  state,  which  has  been  considered  as  a 
particular  affection  under  the  name  of  tn's/Hus,  or  the 
lockcd-jaw,  Boyer  conceives,  may  be  regarded  as  the 
pathognomonic  symptom  of  tetanus,  which  in  many 
instances  is  limited  to  such  an  affection  of  the  jaw. 

Tiie  muscles  affected  in  tetanic  cases  are  never  alto- 
gether relaxed  as  long  as  the  disease  continues;  but 


340 


TETANUS 


still  the)'  become  more  violently  contracted  in  the  fre- 
quent paroxysms  of  spasm,  which  always  attend  the 
complaint,  and  increase  as  it  advances. 

The  continuance  of  the  disease  is  marked  by  the  in- 
creasing spasm  of  the  diaphragm,  which  now  returns 
every  ten  or  fifteen  minutes,  and  is  instantly  succeeded 
by  a stronger  retraction  of  the  head  and  rigidity  of  the 
muscles  of  the  back,  and  even  of  those  of  the  lower  ex- 
trerriities.  The  abdominal  muscles  are  also  strongly  con- 
tracted, so  that  the  belly  feels  as  hard  and  tense  as  a 
board.  By  the  violence  of  the  contractions,  indeed,  the 
recti  muscles  have  been  known  to  be  lacerated,  as  I 
shall  relate  an  example  of  hereafter.  Sometimes  the 
spasm  and  tension  extend  only  to  the  muscles  on  one 
particular  side  of  the  body : the  tetanus  lateralis  of 
Sauvages,  and  the  pleurosthotonos  of  other  nosoh'gists. 

When  the  disease  reaches  its  most  violent  stage,  the 
flexor  muscles  of  the  head  and  trunk  contract  so  power- 
fully, that  they  counterbalance  the  force  of  the  exten- 
sors, and  hold  those  parts  in  a straight,  fixed,  immove- 
able position.  This  is  the  condition  to  which  the  ap- 
pellation of  tetanus  more  particularly  belongs.  The 
muscles  of  the  lower  extremities  become  rigid ; and 
even  the  arms,  which  till  now  were  little  affected,  also 
partake  of  the  general  spasm  and  stiffness,  with  the  ex- 
ception of  the  fingers,  which  often  retain  their  move- 
ableness to  the  last.  The  tongue  likewise  continues  a 
long  while  endued  with  the  power  of  voluntary  mo- 
tion ; but  at  length  the  violent  spasms  do  not  leave  it 
unaffected,  and  it  is  then  liable  to  be  forcibly  propelled 
between  the  teeth,  where  it  is  sometimes  dreadfully 
lacerated. 

In  the  extreme  period  of  the  disorder  all  the  muscles 
destined  for  voluntary  motion  are  affected;  among 
others  those  of  the  face;  the  forehead  is  drawn  up 
into  furrows ; the  eyes,  sometimes  distorted,  are  gene- 
rally fixed  and  motionless  in  their  sockets;  the  nose  is 
drawn  up  ; and  the  cheeks  are  retracted  towards  the 
ears;  so  that  the  features  undergo  a most  extraordinary 
change.  When  tetanus  arrives  at  this  stage,  and  the 
spasms  are  universal,  a violent  convulsion  usually  puts 
an  end  to  the  patient’s  misery. 

Wherever  the  muscular  contractions  are  situated  in 
cases  of  tetanus,  they  are  always  accompanied  with  the 
most  excruciating  pain.  They  sometimes  last,  without 
any  manifest  remission,  to  the  end  of  the  disorder ; but  in 
almost  all  cases  their  violence,  and  the  sufferings  excited 
by  them,  undergo  periodical  diminutions  every  minute 
or  two.  The  relaxation,  however,  is  never  such  as  to 
let  the  muscles  which  experience  it  yield  to  the  action  of 
their  antagonists;  and  it  is  in  nearly  all  cases  followed 
in  ten  or  twelve  minutes  by  a renewal  of  the  previous 
contractions  and  suffering.  The  recurrence  of  these 
aggravated  spasms  frequently  happens  without  any 
evident  cause ; but  it  is  often  determined  by  efforts 
%vhich  the  patient  makes  to  change  his  posture,  swal- 
low, speak,  &c. 

As  Dr.  Cullen  observes,  the  attacks  of  this  disease 
are  seldom  attended  with  any  fever  When  the  spasms 
are  genera!  and  violent,  the  pulse  is  contracted,  hurried, 
and  irregular,  and  the  respiration  is  affected  in  like 
manner  ; but  during  the  remission  both  the  pulse  and 
the  respiration  usually  return  to  their  natural  state. 
The  heat  of  the  body  is  commonly  not  increased ; fre- 
quently the  face  is  pale,  with  a cold  sweat  upon  it ; 
and  very  often  the  extremities  are  cold,  with  a cold 
sweat  over  the  whole  body.  When,  however,  the 
spasms  are  frequent  and  violent,  the  pulse  is  sometimes 
more  full  and  frequent  than  natural ; the  face  is  flushed, 
and  a warm  stveat  is  forced  out  over  the  whole  body. 

“ Although  fever  be  not  a constant  attendant  of  this 
disease,  especially  when  arising  from  a lesion  of 
nerves;  yet,  in  those  cases  proceeding  from  cold,  a 
fever  sometimes  has  supervened,  and  is  said  to  have 
been  attended  with  inflammatory  symptoms.  Blood 
has  often  been  drawn  in  this  disease;  but  it  never  ex- 
hibits any  inflammatory  crust ; and  all  accounts  seem 
to  agree,  that  the  blood  drawn  seems  to  be  of  a looser 
texture  than  ordinary,  and  that  it  does  not  coagulate  in 
the  usual  manner. 

" In  this  disease  the  head  is  seldom  affected  with  de- 
lirium or  even  confusion  of  thought,  till  the  last  stage 
of  it ; when,  by  the  repeated  shocks  of  a violent  dis- 
temper, every  function  of  the  system  is  greatly  disor- 
dered. 

“ It  is  no  less  extraordinary,  that  in  this  violent  dis- 
ease, the  natural  functions  are  not  either  immediately 


or  considerably  affected.  Vomitings  sometimes  appear 
early  in  the  disease,  but  commonly  they  are  not  conti- 
nued ; and  it  is  usual  enough  for  the  appetite  of  hunger 
to  remain  through  the  whole  course  of  the  disea^e; 
and  what  food  happens  to  be  taken  dowm  svems  to  be 
regularly  enough  digested.  The  excretnins  are  some- 
times affected,  but  not  always.  The  urine  is  sometimes 
suppressed,  or  is  voided  with  difficulty  and  pain  The 
belly  is  costive  ; but,  as  we  have  hardly  any  accounts, 
excepting  of  those  cases  in  which  opiates  have  been 
largely  employed,  it  is  uncertain  whether  the  costive- 
ness has  been  the  effect  of  the  opiates  or  of  the  disease. 
In  several  instances  of  this  disease,  a miliary  eruption 
has  appeared  upon  the  skin ; but  whether  this  be  a 
symptom  of  the  disease,  or  the  effect  of  a certain  treat- 
ment of  it,  is  undetermined.  In  the  mean  while,  it  has 
not  been  observed  to  denote  either  safety  or  danger,  or 
to  have  any  effect  in  changing  the  course  of  the  dis- 
temper.”— {First  Lines  of  Physic,  vol.  3.) 

According  to  Baron  Larrey,  the  opisthotonos  is  not 
so  often  observed  in  Egypt  as  the  emprosthotonos  ; and 
the  experience  of  this  gentleman  taught  him  that  the 
former  was  the  most  rapidly  fatal.  We  must  not 
adopt,  however,  his  curious  opinion,  that  the  violent 
extension  of  the  vertebrte  of  the  neck  and  the  manner 
in  which  the  head  is  thrown  back,  cause  strong  com 
pression  of  the  spinal  marrow,  and  a permanent  con- 
traction of  the  larynx  and  pharynx  {Mim.  de  Chirurgie 
JUilitaire,  t.  1,  p.  240),  since  this  sort  of  compression, 
if  it  did  not  at  once  destroy  the  patient,  would  at  any 
rate  paralyze  most  of  the  muscles,  and  instantly  stop 
their  extraordinary  contraction. 

I'his  experienced  writer  notices  how  much  the 
nerves  of  the  neck  and  throat  seem  generally  to  be 
affected  on  the  invasion  of  this  disease.  The  conse- 
quent contraction  of  the  muscles  of  these  parts  he 
says,  is  soon  attended  with  difficulty  of  deglutition  and 
respiration.  The  patients  then  experience,  if  not  a 
dread  of  liquids,  at  least  a great  aversion  to  them, 
which  often  prevents  the  administration  of  internal 
remedies ; and  if  the  wound  is  out  of  reach  of  the  in- 
terference of  art,  the  patient  is  doomed  to  undergo 
the  train  of  sufferings  attendant  on  this  cruel  and  ter- 
rible disorder.  Nothing  can  surmount  the  obstacles 
which  present  themselves  in  the  oesophagus.  The  in- 
troduction of  an  elastic  gum  catheter  into  this  canal, 
through  the  nostrils,  is  followed  by  convulsions  and 
suffocation.  “ I have  tried  this  means  (says  Larrey) 
on  the  person  of  M.  Navailh,  a surgeon  of  the  second 
class,  who  died  of  a locked-jaw,  brought  on  by  a 
wound  of  the  face,  accompanied  with  a comminuted 
fracture  of  the  bones  of  the  nose,  and  part  of  the  left 
orbit. 

“ In  the  examination  of  the  bodies  of  persons  dead 
of  tetanus,  I have  found  the  pharynx  and  oesophagus 
much  contracted,  and  their  internal  membrane  red, 
inflamed,  and  covered  with  a viscid  reddish  mucus. 

“ Hydrophobia,  hysteria,  and  several  other  nerv’ous 
diseases,  likewise  produce  their  chief  effects  upon  these 
organs,  and  the  result  appears  to  be  the  same.  Sol 
have  just  remarked,  when  tetanus  is  arrived  at  its 
worst  degree,  the  patients  have  a great  aversion  to 
liquids,  and  if  they  are  forced  to  swallow  them,  intme- 
diate  convulsions  are  excited.  This  circumstance  was 
particularly  observed  in  M.  Navailh.” — {Mem.de  Cki- 
rurgie  Militaire,  t.  \,p.  247,  248.) 

Sometimes  tetanic  affections  deviate  from  their  ordi- 
nary course  and  nature.  The  most  singular  of  these 
anomalies  is  recorded  by  Sir  Gilbert  Blane  : it  is  a case 
in  which  tetanus  prevailed  to  a very  considerable  ex- 
tent, without  any  degree  of  pain.  The  spasms  were 
accompanied  with  a tingling  sensation,  which  was 
even  rather  agreeable  than  'distressing.  The  case, 
however,  terminated  fatally  ; but  to  the  last,  no  pain 
was  experienced.  In  two  examples  mentioned  by  the 
same  author,  the  spasms  affected  only  the  side  of  the 
body  in  which  the  wound  was  situated. 

The  dissection  of  patients  who  have  died  of  tetanus 
has  thrown  no  light  upon  the  nature  of  this  fatal  dis- 
order. Sometimes  slight  effusions  are  found  within  the 
cranium  ; but  in  general,  no  morbid  appeaiance  what- 
ever can  be  detected  in  the  head.  There  is  always 
more  or  less  of  an  inflammatory  appearance  in  the 
oesophagus  and  in  the  villous  coat  of  the  stomach  about 
the  cardia.  But  those  who  are  conversant  with  dis- 
sections, must  be  well  aware  that  these  appearances 
are  common  to  a great  number  of  diseases,  and  are 


TETANUS. 


S41 


uniformly  met  with  in  every  case  of  rapid  or  violent 
death.  Besides  the  redness  and  increased  vascularity 
of  these  parts,  Baron  Larrey,  as  I have  already  stated, 
found  the  pharynx  and  oesophagus  much  contracted 
and  covered  with  a viscid  reddish  mucus.  He  also 
found  numerous  lumbrici  in  the  bowels  of  the  several 
patients  who  died. — (See  Mem.  de  Chir.  Militaire,  t. 
3,  p.  367.1  'J'his,  however,  could  only  be  an  accidental 
complication,  and  not  a cause.  In  several  cases,  Dr. 
M‘ Arthur  (imnd  the  intestines  much  inflamed  ; and 
in  two  of  them  a yellow  waxy  fluid,  of  a peculiar  offen- 
sive smell,  covered  their  internal  surface  ; but  whether 
the  inflammation  w'as  primary  or  only  a consequence 
of  the  pressure  of  the  abdominal  muscles,  w'hich  con- 
tract so  violently  in  this  disease,  he  is  unable  to  de- 
cide.— (See  Med.  Chtr.  Trans,  vol.  7,  p.  475 ; and 
Rees's  Cyclopaedia,  art.  Tetanus.) 

Dr.  Lionel  Chalmers,  of  Charleston,  South  Carolina, 
states,  that  when  the  disease  forms  very  quickly,  and 
invades  the  unfortunate  persons  with  the  whole  train 
of  its  mischievous  symptoms  in  a few  hours,  the  dan- 
ger is  proportioned  to  the  rapidity  of  the  attack,  and 
that  the  patients  thus  seized  generally  die  in  twenty- 
four,  thirty-six,  or  forty-eight  hours,  and  very  rarely 
survive  the  third  day.  But  when  the  disease  is  less 
acute,  few  are  lost  after  the  ninth  or  eleventh. — (See 
Med.  Obs.  and  Inq.  vol.  1,  p.  92,  93.) 

Frtim  the  valuable  report  of  Sir  James  Maegregor, 
it  appears  that  several  hundred  cases  of  tetanus  oc- 
curred in  our  army  during  the  late  campaigns  in  Spain 
and  Portugal.  The  disetise  was  observed  to  come  on 
at  uncertain  periods  after  the  receipt  of  the  local  injury  ; 
but  it  terminated  on  the  second,  third,  and  fourth  days, 
and  even  as  late  as  the  seventeenth  and  twentieth  day ; 
though  it  was  usually  not  protracted  beyond  the  eighth. 
— {.Med.  Chir.  Trans,  vol.  6,  p.  ?53.)  I had  a patient, 
how’ever,  who  lingered  in  the  military  hospital  at 
Oudenbosch  five  weeks  with  chronic  tetanus,  before 
he  died.  This  happened  in  the  year  1814,  soon  after 
the  assault  on  Bergen-op  Zoom,  where  the  patient  had 
been  wounded,  and  suffered  amputation  of  the  thigh. 

Although  tetanus  is  a disease  which  has  been  ob- 
served in  almost  all  parts  of  the  world,  experience 
proves  that  its  frequency  is  much  the  greatest  in  warm 
climates,  and  especially  in  the  hot  seasons  of  those 
climates.  It  is  also  more  common  in  marshy  situations 
and  countries  bordering  upon  the  sea,  than  in  places 
which  are  very  dry,  elevated,  and  at  a distance  from 
the  seacoast.  Every  class  of  individuals  is  exposed 
to  its  attacks  ; but  infants,  a few  days  after  their  birth, 
and  middle-aged  persons  are  said  to  be  oftener  affected 
than  older  subjects  or  others  in  the  youthful  period  of 
life.  The  male  sex  more  frequently  suffer  than  the 
female;  and  the  robust  and  vigorous  more  frequently 
than  the  weak. 

According  to  Dr.  Cullen  and  other  medical  writers, 
the  causes  of  tetanus  are  cold  and  moisture,  applied  to 
the  body  while  it  is  very  warm,  and  especially  the  sud- 
den vicissitudes  of  heat  and  cold.  Or  the  disease  is 
produced  by  punctures,  lacerations,  or  other  injuries. 
Cullen  admits,  however,  that  there  are  probably  some 
other  causes,  which  are  not  distinctly  known. 

Baron  Larrey  observed,  that  gun-shot  wounds  in  the 
course  of  the  nerves  atid  injuries  of  the  joints  often 
produced  tetanus  in  the  climate  of  Egypt,  particularly 
when  the  weather  or  temperature  passed  from  one 
extreme  to  the  other,  in  damp  situations,  and  in  those 
which  were  adjacent  to  the  Nile  or  the  sea.  What  he 
terms  dry  and  irritable  temperaments  were  the  most 
subject  to  the  disorder,  the  event  of  which  was  found 
to  be  almost  always  fatal.— (Larrey,  op.  et  loc.  cit.) 

Traumatic  tetanus  is  remarked  to  proceed  oftener 
from  wounds  of  the  extremities  than  from  similar  in- 
juries of  the  trunk,  head,  and  neck.  Sometimes  it 
originates  at  the  moment  of  the  accident,  as  in  the  in- 
stance mentioned  by  the  late  Professor  Robison  of 
Edinburgh  ; but  in  general  it  does  not  come  on  till  se- 
veral days  afterward,  sometimes  not  till  the  wound  is 
nearly  or  perfectly  healed,  and  free  from  all  pain  and 
uneasiness.  Wounds  of  every  description  may  give 
rise  to  tetanus,  and  in  warm  climates  very  trivial  in- 
juries produce  it.  Thu.s,  in  Egypt,  Larrey  had  one 
case,  which  proceeded  from  the  lodgement  of  a small 
piece  of  fi.sh-bone  in  one  of  the  sinuses  of  the  fauces. 
— {Mem.  de  Chir.  Militaire,  t.  1,  p.  254.)  In  co'der 
regions,  traumatic  tetanus  seldom  happens,  except 
from  contused,  punctured,  or  lacerated  wounds ; or 


wounds  of  the  ginglymoid  joints,  with  laceration  of  the 
tendons  and  ligaments ; compound  fractures  or  dislo- 
cations; deep  pricks  in  the  sole  of  the  foot;  and  espe- 
cially lacerations  or  ulcerations  of  the  fingers  and  toes. 
A partial  division  of  a nerve  has  been  suspected  as  a 
cause;  but  as  some  nerves  must  be  imperfectly  cut 
through  in  almost  every  wound,  and  yet  tetanus  does 
not  arise,  the  reality  of  this  cause  is  doubtful.  Besides, 
if  it  were  true,  the  cure  would  be  easily  effected,  by 
making  the  division  of  the  nerve  complete,  which  ex- 
perience contradicts.  Baron  Larrey,  however,  has 
recorded  a fact  which  favours  the  opinion,  as  I shall 
presently  notice ; and  a case  in  which  the  branch  of 
the  median  nerve  going  to  the  thumb  was  found 
partly  torn  through,  and  its  extremity  inflamed  and 
thickened,  has  been  related  by  Mr.  Liston. — {Ed.  Med. 
and  Surg.  Journ.  JVo.  79,  p.  292.)  The  inclusion  of 
the  nerves  in  ligatures  applied  to  arteries,  is  another 
alleged  cause  of  tetanus  ; but  as  this  fault  is  very  com- 
mon, and  tetanus  rather  rare  in  this  country,  while  it 
may  follow  all  sorts  of  wounds,  whether  from  accidents 
or  operations,  the  accuracy  of  this  opinion  may  also  be 
doubted.  In  support  of  it,  however,  there  are  some 
cases  and  observations  adduced  by  Larrey,  which  will 
be  quoted  in  the  sequel  of  this  article.— (See  t.  3 of  his 
Mem.  de  Chir.  Mil.)  At  the  same  time  I do  not  mean 
to  hint  that  the  nerves  are  not  sometimes  tied  in  tetanic 
cases,  or  that  the  practice  is  not  on  every  account  blame- 
able.  Amputation  and  castration  are  the  only  great 
surgical  operations  to  which  I have  seen  tetanus  suc- 
ceed ; though  it  may  follow  the  employment  of  the 
knife  on  less  severe  occasions.  In  St.  Bartholomew’s 
Hospital,  it  once  followed  the  operation  of  removing 
the  breast. 

In  warm  countries,  tetanus  is  an  ordinary  conse- 
quence of  all  kinds  of  wounds. 

There  cannot  be  a doubt  that  difference  of  climate 
makes  considerable  difference  in  the  degree  and  dan- 
ger of  tetanus.  Larrey  found  that  in  Egypt,  the  dis- 
ease was  more  intense,  and  bore  a greater  resemblance 
to  hydrophobia  than  in  the  colder  climate  of  Germany. 
In  both  these  countries  he  remarked  that,  when  the 
wounds  causing  tetanus  injured  nerves  situated  on 
the  fore  part  of  the  body,  emprosthotonos  was  occa- 
sioned; that  if  the  f sterior  nerves  were  hurt,  opis- 
thotonos followed ; and  that  when  the  wound  extended 
quite  through  a limb,  so  as  to  injure  equally  both  de- 
scriptions of  nerves,  complete  tetanus  ensued.  He 
noticed,  also,  that  the  disease  commonly  arose  from 
wounds  when  the  seasons  and  temperature  passed 
from  one  extreme  to  another.  Exposure  to  the  cold, 
damp,  nocturnal  air  he  found  particularly  conducive 
to  it. — (See  Mem.  de  Chir.  MUit.  t.  3,  p.  286.) 

In  the  late  campaigns  in  Spain  and  Portugal,  accord- 
ing to  the  report  of  Sir  James  Maegregor,  tetanus  oc- 
curred in  every  description  and  in  every  stage  of  wounds, 
from  the  slightest  to  the  ncosi  formidable : it  followed 
the  healthy  and  the  sloughing  ; the  incised  and  the  lace- 
rated; the  most  simple  and  the  most  complicated.  It 
occurred  at  uncertain  periods  ; but  it  was  remarked 
that,  if  it  did  not  commence  before  twenty-two  days 
from  the  date  of  the  wound,  the  patient  was  safe. — 
(See  Med.  Chir.  Trans,  vol.  6,  p.  453.)  In  Egypt,  as 
we  learn  from  Larrey,  the  latest  period  of  the  com- 
mencement of  tetanus  after  a wound,  was  from  the 
fifth  to  the  fifteenth  day. — {Mem.  de  Chir.  Militaire,  t. 
l,p.263.) 

It  is  observed  by  Dr.  Dickson,  that  as  the  acute  form 
of  tetanus  is  so  uniformly  fatal,  it  is  of  the  greatest 
consequence  to  attend  to  whatever  may  assist  in  de- 
tecting the  disease  early,  or  in  warding  it  off.  Riche- 
rand  states,  that  in  wounds  threatening  convulsions 
and  tetanus,  a persevering  extension  of  the  limbs  du- 
ring sleep  often  manifests  itself  before  any  aft'ection  of 
the  lower  jaw  ; and  we  should  naturally  pay  more  at- 
tention to  any  admonition  of  this  kind  in  punctured 
or  extensive  lacerated  wounds,  particularly  of  tendi- 
nous or  ligamentous  parts,  and  especially  in  injuries  of 
the  feet,  hands,  knee-joint,  back,  &c.  Some  prelusive 
indications  of  danger  may  often  be  derived  from  the 
increase  of  pain,  irritation,  restlessness,  nervous  twitch- 
ing.s,  pain  and  difficulty  in  deglutition,  or  in  turning 
the  head;  spasms  or  partial  rigidity  of  some  of  the 
voluntary  muscles;  pain  at  the  scrobiculis  cordis;  a 
su|>pre8sed  or  vitiated  slate  of  the  discharge,  &c.  which 
mark  the  slower  approaches  of  the  disease.  Larrey 
adduces  several  instances  of  tetanus,  in  which  the 


342 


TETANUS. 


wound  was  either  dry  or  afforded  only  a scanty  serous 
exudation,  and  where  the  symptoms  were  relieved  on 
suppuration  being  re-established ; and  Dr.  Reid  {Edinb. 
JHed.  and  Surgical  Journal  for  July,  1815)  remarks, 
that  on  removing  the  dressing,  the  wound  was  co- 
vered with  a darkish  unhealtliy-looking  matter,  and 
that  he  had  seen  this  change  the  forerunner  of  tetanus 
in  two  other  instances.  A torpor  of  the  intestines  has 
generally  been  observed  to  precede  as  well  as  accom- 
pany the  disease,  and  Boyer,  in  particular,  enumerates 
an  obstinate  constipation  among  the  predisposing 
causes. — ( Traitedes  JIal.  Chir.  1. 1,  p.  287.)  Mr.  Aber- 
nethy  also  informs  us,  that  in  four  cases  where  he  in- 
quired into  the  state  of  the  bowels,  the  evacuations 
were  not  like  feces;  and  he  proposes  as  a question,  in 
investigating  the  cause,  what  is  the  state  of  the  bowels 
between  the  infliction  of  the  injury  and  the  appear- 
ance of  this  dreadful  malady  1 — (jSbemethy's  Surgical 
Works,  vol.  1,  p.  104.)  Dr.  Parry  thinks  the  velocity 
of  the  circulation  a useful  criterion  of  the  danger  of 
the  disease,  and  observes,  that  if  the  pulse  be  not 
above  lOO  or  110,  by  the  fourth  or  fifth  day  the  patient 
almost  always  recovers;  but  that  if  it  be  quickened 
early,  the  disease  mostly  proves  fatal,  and  yet  there  are 
a fe%v  instances  of  recovery  where  the  pulse  has  risen 
to  120  on  the  first  day.  Baron  Larrey  remarks,  that 
when  the  perspiration  wdiich  so  often  attends  the  dis- 
ease is  symptomatic,  it  begins  upon  the  head  and  ex- 
tremities ; but  that  when  it  is  critical,  it  occurs  over 
the  chest  and  the  abdomen. — (Jlemoires  des  Chir. 
Militaire,  1. 1,  p.  256.)  It  must  be  confessed,  however, 
that  in  many  cases  perspiration  flows  very  freely,  with- 
out bringing  relief. — {Rees's  Cyclopedia,  art.  Tetanus.) 

1 next  proceed  to  consider  the  treatment  of  tetanus ; 
a subject  of  infinite  difficulty,  because  the  disease  fre- 
quently baffles  every  mode  of  practice,  and,  in  certain 
instances,  gets  well  under  the  employment  of  the  very 
same  remedies  which  decidedly  fail  in  other  similar 
cases  of  the  disorder.  Every  plan  has  occasionally 
succeeded,  and  every  plan  has  still  more  frequently 
miscarried.  The  great  difficulty,  therefore,  is  to  as- 
certain, among  numerous  discordant  accounts,  what 
practice  is  found  on  the  whole  to  be  attended  with  the 
least  ill-success?  For  in  the  present  state  of  our 
knowledge,  the  most  credulous  practitioner  will  not 
flatter  himself  with  the  supposition,  that  any  effectual 
remedy  for  tetanus  has  yet  been  discovered.  As,  how- 
ever, acute  tetanus  was  regarded  by  Hippocrates  and 
the  ancients  as  certainly  mortal,  and  it  does  not  al- 
W’ays  prove  so  in  modern  times,  it  seems  allowable  to 
conclude  that  the  recoveries  which  now  happen  must 
be  ascribed  to  improvements  in  practice.  This  reflec- 
tion should  lead  us  not  to  give  up  the  subject  as  hope- 
less ; but  to  redouble  our  exertions  for  the  discovery  of 
a more  successful  method  of  treatment,  and,  if  possible, 
of  some  new  medicine,  possessing  more  specific  power 
over  the  disorder. 

As  it  is  justly  observed  by  a well-informed  writer, 
when  we  reflect  upon  the  obscurity  which  involves 
both  the  ratio  symptomatum  and  the  proximate  cause 
of  tetanic  affections,  we  need  not  wmnder  that  the 
practice  in  these  disorders  should  still  be  entirely  em- 
pirical. The  indication  of  cure,  which  is  generally 
applicable  in  all  diseases,  namely,  the  removal  of  the 
exciting  causes,  has  but  little  place  in  a morbid  con- 
dition, which  is  the  consequence  of  causes  that  in 
general  have  ceased  to  act,  or  which  it  is  not  in  our 
power  either  to  remove  or  control.  In  those  cases, 
where  we  could  suppose  local  irritation  to  be  still  ope- 
rating, the  most  effectual  method  of  counteracting  its 
effects  on  the  system  would  obviously  be  to  intercept 
all  communication  between  the  seat  of  the  irritation 
and  the  sensorium.  If,  however,  the  disease  has  al- 
ready established  itself,  and  the  severe  symptoms  have 
come  on,  it  does  not  appear  that  this  would  succeed  in 
arresting  the  course  of  the  disorder.  Experience  has 
but  too  fully  proved,  that  the  amputation  of  the  limb, 
from  the  injury  of  which  the  tetanus  has  arisen,  will 
very  seldom  procure  ev’en  a mitigation  of  the  symp- 
toms, if  performed  after  a certain  period  from  their 
first  appearance, — {Rees's  Cyclopedia,  art.  Tetanus.) 
Baron  Larrey  has  been  the  greatest  modern  advocate 
for  the  performance  of  amputation  in  cases  where  te- 
tanus depends  upon  a wound  of  the  e.xtremities ; but 
the  facts  which  he  has  adduced  in  its  favour  are  not 
numerous,  and  he  limits  his  recommendation  of  the 
measures  chiefly  to  chronic  cases,  and  extends  it  to  no 


others,  except  on  the  very  first  accession  of  the  sjunp- 
toms. 

“ The  equally  unexpected  and  entire  success  (ob- 
serves Larrey)  obtained  by  the  amputation  of  the  in- 
jured limb,  in  the  person  of  an  officer  attacked  with 
chronic  tetanus,  leads  me  to  propose  the  question, 
whether,  in  this  disorder,  occasioned  by  a wound  of 
some  part  of  the  extremities,  it  would  not  be  better  to 
amputate  the  injured  limb  immediately  the  symptoms  of 
tetanus  commence,  rather  than  expect  from  the  re- 
sources of  nature,  and  from  very  uncertain  remedies, 
a cure  which  so  seldom  happens  ? 

“ If  tetanus  is  chronic,  as  is  sometimes  observed, 
amputation  may  be  done  at  every  period  of  the  dis- 
order, provided  a choice  be  made  of  the  lime  when 
there  is  an  intermission  of  the  symptoms.  The  ope- 
ration would  not  answer  so  well  in  acute  tetanus,  if 
the  disease  were  advanced,  and  the  muscles  to  be  di- 
vided were  strongly  contracted  and  rigid,  as  I have 
observed  at  the  siege  of  Acre  in  a soldier  who  was 
seized  with  tetanus,  in  consequence  of  a gun-shot 
wound  of  the  left  elbow.” — {Mem.  de  Chir.  Militaire, 
t.\,p.  262.) 

Larrey  did,  indeed,  try  amputation  in  a few  instances 
of  acute  tetanus.  In  the  case  last  cited,  the  symp- 
toms were  already  considerably  advanced,  when  the 
experiment  of  amputating  the  arm  was  made;  yet, 
says  he,  the  operation  was  followed  by  considerable 
ease.  The  symptoms  recurred,  however,  a few  hours 
afterward,  and  proved  fatal  on  the  third  day.  In  an- 
other example,  this  gentleman  repeated  the  experi- 
ment, though  acute  tetanus  had  begun.  The  opera- 
tion is  described  as  having  stopped  all  the  symptoms, 
as  it  were,  by  enchantment ; the  patient  even  passed 
twelve  hours  in  perfect  ease ; but,  being  exposed  to  the 
damp  cold  air,  the  disorder  returned,  and  carried  him 
off. — (See  Mem.  de  Chir.  Militaire,  t.  \,  p.  263 — 26q.) 
In  a case  of  acute  tetanus,  where  Mr.  Liston  ampu- 
tated the  wounded  hand,  the  opisthotonos  subsided  the 
following  day;  yet  the  case  ended  fatally,  and  ills  a 
question,  whether  the  degree  of  temporary  benefit 
which  was  obtained,  did  not  prt>ceed  from  other  reme- 
dies, tried  in  conjunction  with  the  operation? — (See 
Ed.  Med.  and  Surg.  Joum.  Mo.  79,  p.  293.) 

Larrey  records  some  cases  in  favour  of  amputation 
at  the  commencement  of  tetanus  from  wounds,  and 
especially  for  the  relief  of  the  disease  in  the  chronic 
form.  He  has  likewise  adduced  an  interesting  exam- 
ple, in  which  speedy  relief  and  a cure  followed  cutting 
off’  all  communication  between  the  nerves  of  the 
wounded  part  and  the  sensorium  by  a suitable  in- 
cision. 

In  this  place  I think  it  right  to  remind  the  reader, 
that  although  Baron  Larrey  once  or  twice  amputated 
when  acute  tetanus  had  somewhat  advanced,  he  does 
not  advise  the  practice;  and  ne  expressly  restricts  his 
sanction  of  amputation  to  chronic  or  quiie  incipient 
cases  of  tetanus,  and  to  a few  instances  in  which  the 
ginglymoid  joints  are  fractured,  accidents  which,  in- 
dependently of  tetanus,  would  generally  require  the 
operation.— (See  Mem.  de  Chir.  Mil.  t.  3.)  The  re- 
port of  Sir  James  Maegregor  fully  confirms  the  state- 
ment of  Larrey;  namely,  that  free  incisions  are  of 
little  avail  in  the  acute  and  fully-formed  disease,  and 
that  amputation  fails  in  the  same  kind  of  case.  After 
the  battle  of  Toulouse,  this  operation  was  extensively 
tried ; but  without  success.  The  French  are  also  said 
to  have  lost  an  immense  number  of  soldiers  from  te- 
tanus after  the  battle  of  Dresden,  when.  Sir  James 
infers,  that  the  practice  of  amputation  must  have  been 
fairly  tried.— (See  Med.  Chir.  Trans,  vol.  6,  p.  456.) 
We  have  seen,  however,  that  according  to  the  pre- 
cepts of  Larrey,  the  French  surgeons  would  only  have 
performed  the  operation  in  chronic  cases,  which  are 
not  the  most  frequent,  or  if  in  other  instances,  only  on 
the  very  first  accession  of  the  symptoms.  But  upon  the 
whole,  notwithstanding  the  partial  degree  of  success 
attending  Larrey’s  experiments,  I have  no  hesitation 
in  declaring  my  belief,  that  amputation  of  the  injured 
part,  in  cases  of  chronic  tetanus,  will  never  be  exten- 
sively adopted.  The  uncertain  efficacy  of  this  severe 
measure,  and  the  occasional  possibility  of  curing  this 
form  of  the  complaint  by  milder  plans,  will  for  ever 
constitute  insuperable  arguments  against  the  practice. 

Since  thethird  edition  of  thisDictionary  was  printed. 
Sir  Astley  Cooper  has  published  his  senttments  re- 
specting the  plan  of  amputating  in  cases  of  tetanus. 


TETANUS. 


343 


and  they  tend  to  confirm  the  opinion  which  I have 
always  given  upon  the  subject.  In  one  case  of  teta- 
nus, from  a compound  fracture  just  above  the  ankle, 
the  operation  seemed  to  precipitate  the  fatal  event.  In 
another  case,  the  finger  was  amputated  without  any 
good^  and  a third  case  is  referred  to,  in  which  the 
operation  also  failed  in  saving  the  patient’s  life.  In 
chronic  tetanus,  amputation  is  regarded  by  Sir  Astley 
Cooper  as  unjustifiable,  as  the  patient  often  recovers 
without  this  proceeding.  The  medicine  which  has 
appeared  to  this  gentleman  most  useful  in  such  cases, 
is  the  submuriate  of  mercury  joined  with  opium. — 
{Surgical  Essays^  part  2,  p.  190.) 

Mr.  Aberneihy,  in  his  lectures,  also  disapproves  of 
amputating  any  material  part  of  the  body  with  the 
view  of  relieving  tetanus,  unless  the  injury  require  the 
operation  on  other  grounds:  he  acknowledges,  how- 
ever, that  he  has  seen  tetanus  mitigated  by  the  prac- 
tice, though  the  patients  ultimately  fell  victims  to  the 
disease. 

On  the  subject  of  making  incisions  for  the  purpose 
of  separating  the  nerves  of  the  wounded  part  from  the 
sensorium,  Larrey  states,  that  they  should  be  practised 
before  inflammation  has  come  on ; for  if  this  has  made 
progress,  they  would  be  useless  and  even  dangerous. 
They  should  comprehend,  as  much  as  possible,  all  the 
nervous  filaments  and  membranous  parts;  bu^he  con- 
demns all  incisions  into  joints,  as  exasperating  the 
symptoms  of  tetanus,  instances  of  which  he  has  wit- 
nessed. The  Baron  has  recorded  some  convincing 
proofs  of  the  benefit  sometimes  arising  from  com- 
pletely dividing  the  trunk  of  the  injured  nerve.  In 
one  instance,  tetanic  symptoms  followed  an  injury  of 
the  supraorbitary  nerve,  but  were  immediately  stopped 
by  dividing  some  of  the  fibres  of  theoccipito-frontalis, 
and  the  nerves  and  vessels,  down  to  the  bone. 

On  the  principle  of  destroying  the  parts  which  are 
the  seat  of  the  local  irritation,  Larrey  also  frequently 
applied  the  actual  and  potential  cautery  to  the  wound. 
The  application  of  caustics,  says  he,  may  be  practised 
with  advantage  on  the  first  attack  of  the  symptoms, 
the  same  precept  being  observed  as  in  making  the  in- 
cisions. Bleeding,  if  necessary,  and  the  use  of  topical 
emollients  and  anodynes,  may  follow  these  operations; 
though  in  general  they  have  little  effect. — {Mdm.  de 
Chir.  Militaire^  f.  1,  p.  249.)  In  the  third  volume  of 
this  interesting  work,  p.  297,  Src.  are  several  cases  in 
which  the  cautery  was  employed  with  success.  We 
must  not  conclude,  however,  that  much  dependence 
ought  to  be  placed  in  the  use  of  the  cautery,  since 
Larrey  observes,  in  another  place,  “The  moxa  and 
actual  cautery,  recommended  by  the  Father  of  Medi- 
cine, have  been  equally  unavailing.  The  moxa  was 
employed  at  Jaffa  upon  three  wounded  men:  the  dis- 
ease notwithstanding  followed  its  usual  course,  and 
terminated  fatally. 

“ I have  cited  a striking  instance  of  the  inefficacy  of 
the  second  method,  in  a case  of  opisthotonos.” — {T.  1, 
p.  258.)  This  author  also  adduces  some  cases  which 
tend  to  support  the  opinion,  that  tetanus  occasionally 
proceeds  from  the  inclusion  of  a large  nerve  in  the  li- 
gature applied  to  an  artery.  The  son  of  General 
Darmagnac  died  of  tetanus  consequent  to  amputation, 
and  upon  examining  the  stump,  the  median  nerve  was 
found  included  in  the  ligature  with  the  artery,  and  its 
extremity  redd^h  and  swollen.— (Jl/.^»i.  de  Chir.  MU. 
t.  3,  p.  267  ) In  another  case,  Larrey  suspected  the 
tetanic  disorder  to  proceed  from  a principal  branch  of 
the  crural  nerve  being  tied  together  with  the  femoral 
artery,  and  he  cut  the  ligature;  but  the  relief  was  only 
partial  and  temporary.  The  cautery  was  therefore 
applied  deeply  to  the  whole  surface  of  the  stump.  A 
marked  amendment  took  place  a few  hours  afterward, 
and  the  patient  recovered.  A diaphoretic  mixture, 
with  camphor  and  opium,  was  also  exhibited. — (T.  3, 
;,.297.) 

Among  other  local  means  for  the  relief  of  tetanus, 
we  might  as  well  notice  the  employment  of  blisters  as 
near  as  possible  to  the  wound,  or  their  application,  or 
that  of  the  ointment  of  cantharides,  to  the  wound 
itself.  Almost  all  modern  writers  have  observed,  that 
tetanus  is  accompanied  at  its  commencement  and  in 
ite  progress  with  an  interruption  or  total  cessation  of 
suppuration  in  the  wound.  Hence,  the  indication  to 
e.vcite  this  process  again,  by  the  means  which  I have 
specified.  Larrey  seems  to  have  adopted  both  plans; 
but  he  particularly  applied  the  ointment  of  canthai  i- 


des to  the  wound  itself  in  an  early  stage  of  the  symp- 
toms, and  in  cases  where  there  not  only  was  a sup- 
pression of  the  discharge,  but  where  he  suspected  the 
nerves  of  the  wounded  part  had  suffered  from  ex- 
posure to  the  cold  dump  air,  on  the  detachment  of  the 
sloughs.  For  facts  in  favour  of  these  local  means,  the 
reader  must  refer  to  the  first  and  second  volumes  of 
the  Mimoires  de  Chirurgie  Militaire. 

It  appears  also  from  Larrey’s  experience  in  Egypt, 
that  poultices,  made  of  the  leaves  of  tobacco,  and  ap- 
plied to  the  wounds  of  persons  labouring  under  te- 
tanus, are  followed  by  no  advantageous  effect.  The 
alkalies  also  proved  of  no  service. — (T.  i,p-  257.) 

I shall  conclude  these  remarks  on  what  may  be 
called  the  local  treatment  of  tetanus,  with  mentioning, 
that  the  celebrated  Dr.  Rush  recommended  the  wound 
to  be  dilated  and  dressed  with  oil  of  turpentine  (see 
Trans,  of  the  American  Philos.  Society,  vol.  2) ; and 
that  some  of  our  naval  surgeons  have  used  tincture  of 
opium  as  a dressing. 

A great  degree  of  obscurity  prevails  respecting  the 
most  eligible  general  or  constitutional  plans  of  treating 
tetanus,  and  I am  afraid,  it  must  be  confessed,  that  our 
internal  remedies  cannot  be  more  depended  upon  than 
the  local  means  already  described.  This  opinion  is 
fully  confirmed  by  adverting  to  the  discouraging  fact, 
recorded  by  Sir  James  Macgregor,  viz.  that  out  of 
sever&l  hundreds  of  cases  which  occurred  in  the  British 
army  during  the  late  campaigns  in  Spain  and  Portugal, 
there  were  very  few  which  terminated  successfully,  or 
in  which  the  remedies  however  varied,  seemed  .to 
have  any  beneficial  influence  after  the  disease  had 
made  any  progress. — {Med.  Chir.  Tran^.  vol.  6,  p.  449.) 
The  possibility  of  doing  much  good  by  internal  medi- 
cines is  also  sometimes  totally  prevented  by  the  in- 
ability of  swallowing,  which  afflicts  the  patient.  In 
short,  the  present  state  of  our  knowledge,  respecting 
tetanus,  will  not  allow  us  to  indulge  much  hopes  of 
cure  from  any  means  yet  discovered,  except  in  the 
chronic  form  of  the  complaint;  the  instances  of  suc- 
cess in  the  treatment  of  acute  tetanus  being  by  no 
means  numerous,  and  not  the  result  of  any  determinate 
plan  of  treatment. 

Of  all  medicines,  opium  is  that  which  has  raised  the 
greatest  expectation,  and  been  the  most  extensively 
tried  in  cases  of  tetanus.  Indeed,  there  cannot  be  a 
doubt  that,  in  many  chronic,  mild  cases,  it  is  compe- 
tent to  effect  a cure.  But  for  this  purpose,  it  is  abso- 
lutely necessary  that  its  use  be  begun  from  the  earliest 
appearance  of  the  symptoms;  that  it  be  given  in  very 
large  doses ; and  that  the  doses  be  repeated  at  short  In- 
tervals, so  that  the  system  be  kept  constantly  under  the 
influence  of  the  remedy.  It  is,  indeed,  astonishing 
how  the  system,  when  labouring  under  a tetanic  dis- 
ease, will  resist  the  operation  of  this  and  other  reme- 
dies, which,  in  its  ordinary  state,  would  have  been 
more  than  sufficient  to  overpower  and  destroy  it. 
Patients  with  tetanus  will  bear,  with  impunity, 
quantities  of  opium  which  at  any  other  time  would 
have  been  certainly  fatal.  Instances  are  upon  record 
of  five,  ten,  and  even  twenty  grains,  being  taken  every 
two  or  three  hours,  for  many  days,  without  any  extra- 
ordinary narcotic  effects  being  produced  upon  the 
sensorium.  It  is  always  advisable,  however,  to  begin 
with  comparatively  moderate  doses,  such  as  forty  or 
sixty  drops  of  the  tincture  of  opium,  which  may  be 
repeated  at  intervals  of  three  or  four  hours,  and  in- 
creased at  each  repetition  until  some  sensible  effect  is 
produced  on  the  spasms.  It  seems  requisite  to  aug- 
ment the  dose  rapidly,  as  the  disease  presses  upon  us 
every  hour,  and  no  time  must  be  lost  while  there  is  yet 
a ciiance  of  controlling  its  fury.  I’lie  approaching 
closure  of  the  jaw,  and  difficulty  of  deglutition,  which 
may  increase  so  as  to  render  it  hardly  possible  to  intro 
duce  medicines  into  the  stomach,  are  additional  mo. 
tives  for  pushing  our  remedies  before  such  obstacles 
arise. — {Rees's  Cyclopcedia,  art.  Tetanus.)  I once 
supposed  it  possible  to  overcome  this  impediment  by 
introducing  a flexible  catheter  down  the  (E.sophagus 
from  one  of  the  nostrils;  but  the  attempt  to  do  this 
always  brings  on  a violent  paroxysm  of  spasms,  at- 
tended with  such  a sense  of  suffocation  that  it  cannot 
be  endured.  The  experience  of  my  friend,  the  rate 
Mr.  Cruttwell,  of  Bath,  and  that  of  Baron  Larrey,  have 
fully  proved,  that  no  assistance  can  be  derived,  in  these 
circumstances,  from  the  use  of  flexible  tubes.— (See 
Mem.  de  Chir.  Militaire,  t.  1,  p.  217.)  Sometimes^ 


344 


TETANUS. 


however,  the  obstacle  to  the  administration  of  medi- 
cines arising  from  the  closure  of  tlie  jaw,  is  prevented 
by  loss  of  some  of  the  incisor  teeth,  and,  in  a few  in- 
stances, Baron  Larrey  adopted  the  plan  of  extracting 
two  of  them.  This  would  be  useless,  however,  when 
deglutition  is  totally  hindered,  as  happened  in  one  in- 
stance recorded  by  the  latter  eminent  surgeon. — (Op. 
cit.  t.  3,  p.301.)  Clysters  are  the  only  resource  when 
the  spasm  of  the  fauces  cannot  be  overcome.  Iti  this 
way,  as  much  as  a drachm  of  the  extract  of  opium  has 
been  introduced  into  the  bowels  at  one  dose.  Opiate 
frictions  upon  the  jaws,  throat,  and  other  parts 
of  the  body,  have  been  practised.  Opiate  plasters 
have  also  been  applied  to  the  masseter  muscles,  and 
behind  the  ears.  This  external  use  of  opium,  however, 
can  only  be  regarded  as  a feeble  and  probably  useless 
method. 

A curious  fact,  noticed  by  Mr.  Abernethy  in  his  lec- 
tures, seems  to  offer  some  explanation  of  the  little  effect 
of  some  of  the  most  powerful  medicines  on  the  con- 
stitution in  tetanus;  on  opening  the  stomach  of  a pa- 
tient who  had  died  of  tetanus,  after  taking  large  doses 
of  opium,  thirty  drachms  of  this  substance  were  found 
undissolved  in  the  stomach.  Whether  morphine  will 
have  more  power  over  tetanus  than  the  common  pre- 
parations of  opium,  must  be  decided  by  farther  expe- 
rience; but  I confess  that  my  own  expectations  of  so 
desirable  a circumstance  are  not  very  sanguine. 

As  the  costiveness  always  produced  by  tetanus  is 
rendered  still  more  obstinate  by  opium,  laxative  medi- 
cines and  clysters  should  constantly  accompany  its  em- 
ployment. The  testimony  of  the  army  physicians,  as 
we  learn  from  the  report  of  Sir  James  Macgregor,  is 
highly  in  favour  of  a rigid  perseverance  in  the  use  of 
purgatives,  given  in  adequate  doses  to  produce  daily  a 
full  effect.  Dr.  Forbes  states,  that  a solution  of  sulphate 
of  magnesia  in  infusion  of  senna  was  found  to  an- 
swer better  than  any  other  purgative ; and  it  was  daily 
given  in  a sufficient  quantity  to  procure  a copious 
evacuation,  which  was  always  dark-coloured  and 
highly  offensive ; and  to  this  practice  he  chiefly  attri- 
butes, in  one  severe  case,  the  removal  of  the  disease. 
— {Med.  Chir.  Trans,  vol.  6,  p.  452.) 

A spasmodic  rigidity  of  the  muscles  being  the  most 
prominent  symptom  of  tetanus,  it  was  natural  for 
practitioners  to  try  the  efficacy  of  some  other  antispas- 
modic  medicines  besides  opium;  and  those  which 
have  been  principally  the  subject  of  experiment  are 
castoreum,  ether,  the  conium  maculatum,  musk,  cam- 
phor, and  latterly  the  digitalis.  In  many  cases,  opium 
and  camphor  have  been  exhibited  together.  Indeed, 
Larrey  asserts,  that  of  all  the  medicines  hitherto  pro- 
posed by  skilful  practitioners,  the  extract  of  opium 
combined  with  camphor,  and  the  nitrate  of  potassa, 
dissolved  in  a small  quantity  of  the  almond  emulsion, 
and  given  in  doses  more  or  less  strong,  produces  the 
most  favourable  effects,  since  patients,  who  have  an 
aversion  to  other  fluids,  take  with  pleasure  this  mix- 
ture, the  action  of  which  must  be  promoted  by  bleed- 
ing, if  necessary,  and  blisters,  under  the  circumstances 
which  have  been  specitied.— (See  Mem.  de  Chir.  Mili- 
taire,  t.  1,  p.  271.)  In  the  same  work,  several  cases 
are  detailed  which  were  benetited  by  such  treatment. 

Although  some  practitioners  have  thought  that  they 
saw  good  effects  result  from  musk,  yet  the  majority, 
who  have  made  trial  of  both  this  and  camphor  in  cases 
of  tetanus,  have  found  no  reason  to  recommend  these 
medicines.  One  hundred  and  fifty  grains  of  musk 
have  been  given  in  the  space  of  twelve  hours,  to  a 
young  girl,  thirteen  years  old,  affected  with  an  incipient 
tetanus;  but  no  salutary  effect  on  the  disorder  was 
produced. 

We  learn  also  from  Sir  James  Macgregor,  that  ether, 
camphor,  musk,  and  other  antispasmodics,  as  likewise 
the  alkalies,  were  tried  by  our  military  surgeons  in 
Spain,  and  found  unsuccessful. — {Medico- Chir.  Trans, 
vol.  6,  p.  458.) 

From  the  same  authority  we  find,  that  digitalis,  in 
large  doses,  was  tried  in  several  cases  in  the  Peninsula; 
and  that  it,  with  several  other  medicines  enumerated, 
failed  in  almost  every  case  of  acute  tetanus  which  oc- 
curred.— (P.  454.)  In  one  case  the  jaw  remained  fixed 
to  the  last,  and  the  patient  was  never  entirely  free  from 
spasms.— (P.  458.)  I am  not  acquainted  with  the  par- 
ticulars of  any  cases  in  which  belladonna  has  been 
given;  nor  whether  it  be  a remedy  worthy  of  farther 
trial. 


Analogy  has  also  led  to  the  employment  of  the  warm 
bath,  as  a plan  which  seemed  to  promise  great  benefit, 
by  producing  a relaxation  of  the  contracted  muscles. 
But,  notwithstanding  this  means  has  appeared,  in  a few 
instances,  to  occasion  some  liitle  relief,  particularly 
when  the  practitioner  has  been  content  with  mere 
fomentations,  it  generally  fails,  and  often  has  even  done 
mischief.  This  may  perhaps  be,  in  some  measure, 
ascribable  to  the  disturbance  and  motion  which  the 
patient  must  necessarily  undergo  in  order  to  get  into 
the  bath;  for  it  is  very  well  known,  that  every  exer- 
tion on  the  part  of  the  patient  is  very  apt  to  excite 
most  violent  paroxysms  of  spasm.  The  author  of  the 
article  Tetanus,  in  the  Encyclop4die  M^ihodique,  men- 
tions his  having  seen  the  warm  bath  do  harm,  in  two 
or  three  cases  in  which  it  was  expected  to  have  done 
good.  Though  numerous  wniters  have  recommended 
the  trial  of  the  plan,  it  would  be  difficult  to  trace,  in 
their  accounts,  any  facts  which  decidedly  show  that 
its  adoption  has  ever  been  followed  by  unequivocal 
benefit.  The  warm  bath  was  tried  in  Spain,  and  found 
to  produce  only  momentary  relief. — {Medico- Chir. 
Trans,  vol.  6,  p.  457.)  Dr.  Hillary,  who  practised  a 
long  while  in  the  w’arm  climate  of  America,  where 
tetanus  is  very  common,  disapproves  of  this  method 
of  treatinent.  He  observes,  that  although  the  use  of 
the  warm  bath  may  appear  to  be  very  rational,  and 
promise  to  be  useful,  he  always  found  it  much  less 
serviceable  than  emollient  and  antispasmodic  fomenta- 
tions ; and  he  also  mentions,  that  he  had  sometimes 
seen  patients  die  the  very  moment  when  they  came 
out  of  the  bath,  notwithstanding  they  had  not  been  in 
it  more  than  twenty  minutes,  the  temperature  of  the 
water  being  likewise  not  higher  than  29  or  30  of  Reau- 
mur’s thermometer. — (See  Hillary  on  the  Air  and 
Diseases  of  Barbadoes.) 

De  Haen  also  relates  a similar  fact  of  a patient  dying 
the  instant  he  was  taken  out  of  the  warm  bath. 

Hippocrates  was  an  advocate  for  the  apfdicalion  of 
cold  water  to  tetanic  patients.  The  advantages  of  the 
cold  bath  were  first  particularly  explained  by  Dr. 
Cochrane,  in  the  Edinb.  Medical  Commentaries ; and 
the  plan  has  subsequently  received  the  praises  of  Dr. 
Wright,  Dr.  Currie  of  Liverpool,  and  others.  Of  all 
the  remedies  which  have  been  employed  in  cases  of 
tetanus,  the  cold  bath  is  represented  by  some  authors 
as  that  which  has  been  attended  with  the  greatest  suc- 
cess. Dr.  Wright  published  in  the  Med.  Obs.  and  Ivq. 
vol.  6,  a paper  containing  a narrative  of  the  first  trials 
of  this  method,  which  were  all  successful.  The  plan 
is  said  to  be  preferred  throughout  the  West  Indies.  It 
consists  in  plunging  the  patient  in  cold  water,  and  in 
that  of  the  sea,  when  at  hand,  in  preference  to  any 
other,  or  else  in  throwing  from  a certain  height  several 
pails  of  cold  water  over  his  body.  After  this  has  been 
done,  he  is  to  be  very  carefully  dried  with  a towel,  an-* 
put  to  bed,  where  he  should  only  be  lightly  covered 
with  clothes,  and  take  twenty  or  thirty  drops  of  lauda- 
num. The  symptoms  usually  seem  to  give  way,  in  a 
certain  degree,  but  the  relief  which  the  patient  expe- 
riences is  not  of  long  duration,  and  it  is  necessary  to 
repeat  the  same  measures  at  the  end  of  three  or  four 
hours.  They  are  to  be  repeated  in  this  manner  until 
the  intervals  of  freedom  from  the  attacks  of  the  di^ 
order  increase  in  length.  This  desiri^le  event,  it  is 
said,  generally  soon  follows,  and  ends  in  a perfect  cure. 
Wine  and  bark  were  sometimes  conjoined  with  the 
foregoing  means,  and  seemed  to  co-operate  in  the  pro- 
duction of  the  good  effects.  Dr.  Wright  concludes  the 
account  with  the  following  remark,  sent  to  him  with  a 
case,  by  Mr.  Drummond,  of  Jamaica: — “I  am  of  opi- 
nion, that  opiates  and  the  cold  bath  will  answer  every 
intention  in  tetanus  and  such  like  diseases;  for  while 
the  opium  diminishes  the  irritability,  and  gives  a truce 
from  the  violent  symptoms,  the  cold  bath  produces  that 
wonderful  tonic  effect  so  observable  in  this  and  some 
other  cases.  Perhaps  the  bark,  joined  with  these, 
would  render  the  cure  more  certain.  May  we  not  then 
have  failed  in  many  cases,  by  using  opiates  alone  in 
large  doses,  or,  what  probably  is  worse,  with  the  warm 
bath  instead  of  the  coid  bath!  And  have  we  not  rea- 
son to  suspect,  that  the  increased  doses  of  opium, 
which  seemed  requisite  when  the  warm  hath  was  used, 
may  have  proved  pernicious  1” — {Vol.  6,  p.  161.) 

Our  army  surgeons  who  were  in  Spain,  are  said  to 
have  found  the  cold  bath  worse  than  useless  {Med. 
Chir.  TVans.  vol.  6,  p.  254) ; and  here  I beg  to  remark 


TETANUS. 


345 


particularly,  that  the  plan  seems  to  present  no  hope  of 
benefit  in  cases  of  tetanus  from  wounds,  however 
strong  the  evidence  is  of  us  utility  in  other  examples 
of  the  disease.  This  was  the  opinion  of  Hippocrates, 
and,  in  modern  times,  that  of  Dr.  Cullen,  Callisen,  &c. 
“ Immersio  subita  iierata  totins  corporis  in  aquaiii  fri- 
gidani  in  tetano  a causa  interna  mire  prodest,  in  letano 
a causa  externa  minor  em  effectum  praestat.”— (Sys  tewa 
ChirurgicB  Hodiernm^  part  1,  p.  169,  170,  edit.  1798.) 
On  the  subject  of  cold  eliusion  and  bathing,  there  are 
on  record  two  cases,  which  are  curious.  One  is  re- 
lated by  B.aron  Larrey.  It  was  an  instance  of  tetanus 
frotn  a gun-shot  wound.  The  cold  bath  was  used. 
The  first  two  trials  gave  the  patient  extreme  pain,  and 
no  amendment  followed.  The  sight  of  the  bath  the 
next  time  filled  him  with  an  invincible  dread  of  the 
water,  into  which  he  refused  to  be  put.  He  was  co- 
vered, however,  with  a blanket,  and  immersed.  The 
tetanic  stitfness  was  immediately  increased  and  dread- 
ful convulsions  excited.  It  became  necessary  to  re- 
move him  directly  from  the  bath,  and  put  him  to  bed. 
Deglutition  was  from  this  moment  utterly  impeded, 
and  the  contraction  of  the  muscles  carried  to  the  most 
violent  degree.  A tumour,  about  as  large  as  an  ega, 
suddenly  made  its  appearance  near  the  iinea  alba, 
below  the  navel.  After  deathj  this  was  found  to  be 
caused  by  a rupture  of  one  of  the  recti  muscles,  and  a 
consequent  extravasat-on  of  blood. — (See  Mem.  de 
Chir.  MU.  t.  3,  p.  ‘287 — 289.)  This  case  is  decidedly 
in  support  of  the  truth  of  the  sentiment  expressed  on 
this  subject  by  Hippocrates,  Cullen,  and  Callisen. 
The  next  is  not  so:  it  is  mentioned  by  Sir  .lames  Mac 
grigor,  that  in  the  march  of  the  guards  through  Gal- 
licia,  one  of  them  was  attacked  with  tetanus,  in  conse- 
quence of  a slight  wound  of  the  finger.  As  it  was 
impossible  to  think  of  leaving  the  man  in  the  wretched 
village  where  he  was  taken  ill,  he  was  carried  on  a 
bullock  car,  in  the  rear  of  the  battalion.  During  the 
first  part  of  the  day  he  was  drenched  with  rain,  the 
thermometer  standing  at  52°  ; but,  after  ascending  one 
of  the  highest  mountains  in  Gallicia,  the  patient  was 
in  a cold  of  30°;  and  he  was  exposed  from  six  in  the 
morning  to  ten  at  night,  when  he  was  found  half 
starved  to  death,  but  free  from  every  symptom  of  teta- 
nus.— (See  Msd.  Chir.  Trans,  vol.  6,  p.  450.) 

Mr.  Abemethy,  in  his  lectures,  expresses  his  convic- 
tion, that  in  tetanus  and  all  nervous  affections,  it  is  a 
most  material  point  to  operate  on  the  brain,  through 
the  medium  of  the  digestive  organs,  and  that  the  pro- 
duction of  secretions  from  the  alimentary  canal  has  a 
more  beneficial  effect  than  any  other  means.  He  par- 
ticularly commends  the  exhibition  of  calomel  and 
jalap,  mixed  with  treacle,  as  answering  better  than 
salts.  Where  much  difficulty  occurs  in  making  the 
patient  swallow  common  purgative  medicines,  I would 
strongly  recommend  to  the  recollection  of  practitioners, 
the  oleum  tiglii,  a drop  of  which,  blended  with  a little 
mucilage,  and  put  on  the  root  of  the  tongue,  will  ope- 
rate powerfully  on  the  bowels. 

Another  remedy  said  to  have  frequently  effected  a 
cure  in  tetanus  is  mercury.— (See  .Tourn.  de  Med.  p. 
45.)  Mercurial  frictions,  practised  so  as  to  bring  on  a 
quick  affection  of  the  mouth,  and  in  an  early  stage  of 
the  disorder,  are  preferred.  Others  contend,  that  it 
matters  not  whether  mercury  be  rubbed  into  the  body 
or  given  internally.  It  is  generally  allowed  that  opium 
may  be  advantageously  exhibited  at  the  same  time. 
This  practice  was  first  adopted  in  the  West  Indies 
(see  Edinb.  Physical  and  Literary  Essays,  vol.  3), 
where  it  succeeded  in  many  cases.  Whatever  benefit, 
however,  may  have  been  experienced  from  this  plan 
in  mild  cases,  it  completely  fails  in  the  acute  form  of 
the  disease.  Mercurial  frictions  appeared  to  Baron 
Larrey  to  aggravate  the  symptoms,  in  the  cases  where 
the  plan  was  tried  in  Egypt  de  Chir.  Mil.  t.  1, 

p.  257)  ; and  Dr.  Emery,  Mr.  Guthrie,  and  other  medi- 
cal officers  attached  to  our  army  in  the  Peninsula,  tried 
inunction  of  the  whole  body,  three  times  a day,  with 
strong  mercurial  ointment  in  unlimited  quantity,  with 
no  degree  of  success.  After  the  battle  of  Toulouse,  a 
fatal  case  even  occurred  in  a man  strongly  under  the 
Influence  of  mercury,  which  he  had  been  previously 
using  for  the  cure  of  the  itch. — {Sir  .7.  Maegrigor,  in 
Med.  Chir.  Trans,  vol.  6,  p.  454.)  The  submuriate  of 
mercury,  combined  with  ipecacuanha,  also  proved  in- 
efficacious in  acute  cases ; but  in  chronic  ones  it  proves 
serviceable  by  keeping  open  the  bowels. 


Another  method  of  treating  tetanus  is  that  of  admi- 
nistering the  most  powerful  tonics  and  stimulant.-;,  such 
as  wine,  brandy,  ether,  preparations  of  ammonia, 
bark,  cordials,  &c.  The  introduction  of  this  plan  was 
chiefly  owing  to  the  eminent  Dr.  Rush,  Professi.v  of 
Medicine  in  Philadelphia,  who  published  in  the  Trans, 
of  the  American  Philos.  St>ciety,  vol.  2,  a paper  entitled 
“ Obs.  on  the  Cause  and  Cure  of  Tetanus."  Dr.  Rush 
consideis  tetanus  as  a disease  essentially  connected 
with  debility,  and  he  recommends  for  it  the  exhibition 
of  the  preceding  class  of  remeoies.  He  pariiculmiy 
advises  the  liberal  use  of  wine  and  Peruvian  bark; 
and  as  we  have  already  stated,  when  tetanus  arises 
from  a wound,  he  directs  the  dilatation  of  it,  and  dress- 
ings with  oil  of  turpentine.  Considerable  success  is 
represented  as  having  attended  the  practice.  Several 
other  instances  of  success  are  also  recorded  by  Dr. 
Hosack. — (American  Medical  Repository,  'ool.  3 ) 

Di.  Elliotson,  considering  neuralgia,  paralysis,  agi- 
tans,  chorea,  and  tetanus  to  be  “ affection.-;  of  the 
nerves,  or  of  those  parts  of  the  brain  and  spinal  mar- 
row which  are  immediately  connected  with  them,” 
was  induced  to  try  the  effect  of  subcarbonate  of  iron 
in  three  examples  of  traumatic  tetanus,  in  consequence 
of. 'the  success  with  which  it  had  been  exhibited  in  the 
other  complaints  above  specified.  Cosiiveness  he  ob 
viated  by  giving  ^ij-  of  tho  ol.  terebinthins,  followed, 
when  requisite,  by  the  ol.  ricini.  The  subciirbonate 
of  iron  was  given  in  large  frequent  doses  of  3 ij  , and 
even  half  an  ounce,  every  two  hours.  It  was  mixed 
with  twice  its  quantity  of  treaide ; and  blended  with 
strong  beef-tea.  Two  of  the  cases  recovered  ; the 
third,  which  was  one  where  the  spasms  were  exces- 
sively violent,  and  the  pulse  140,  was  too  rapid  in  its 
progress  for  an  effectual  trial  of  the  remedy,  the  patient 
dying  the  day  after  the  commencement  of  the  plan. 
— (See  Med.  Chir.  Trans,  vol.  15,  p.  IGl,  4-c.)  As 
traumatic  tetatius  has  been  occasionally  cured  under  a 
variety  of  plans  of  treatment,  it  is  difficult  to  draw  any 
certain  inference  respecting  the  real  utility  of  the  sub- 
carbonate of  iron  in  this  disorder,  from  the  two  exam 
pies  of  recovery  published  by  Dr.  Elliotson. 

Nothing  is  a more  certain  proof  of  our  not  being 
acquainted  with  any  very  effectual  method  of  treating 
a disease  than  a multiplicity  of  remedies  which  are 
as  opposite  as  possible  in  their  effects.  We  have  seen 
that  the  celebrated  Dr.  Rush  conceived,  that  tetanus 
was  a disease  connected  with  debility ; and  he  has 
recorded  examples  in  which  it  was  successfully  treated  . 
by  tonics  and  stimulants.  Extraordinary,  however,  as 
if  may  appear,  many  practitioners  are  advocates  for 
venesection,  especially  in  the  early  stage  of  tetanus. 
Dr.  Dickson  thinks  that  in  a full  habit,  where  the 
wound  is  swelled,  inflamed,  and  painful,  venesection, 
with  free  purging  and  such  other  means  as  are  calcu- 
lated to  allay  the  general  and  local  irritation,  affords 
the  fairest  chance  of  averting  the  danger. — (See  Med. 
Chir.  Trans,  vol.  7,  part  2.)  Larrey  has  also  pub- 
lished several  cases  in  which  bleeding  had  a good 
effect.  We  are  informed  by  Sir  James  Maegrigor,  that 
in  our  military  hospitals  in  Spain  venesection  had  a 
fair  trial.  In  three  cases  at  St.  Andero,  detailed  by 
Mr.  Guthrie,  this  was  the  principal  remedy.  One  pa- 
tient with  tetanus,  from  a wound  of  the  back  part  of 
the  hand,  was  bled  nearly  ad  drliquium  several  times 
with  good  effect,  calomel  and  diaphoretics  being  also 
given,  and  he  recovered.  Another  patient  was  bled 
in  ihe  same  manner  with  such  amendment,  th<at  he 
suffered  but  little  from  spasm,  and  could  open  his 
mouth  very  well,  when  he  was  seized  with  diarrhoea, 
which,  in  his  debilitated  state,  carried  him  off.  In  the 
third  case,  which  was  one  of  acute  tetanus,  venesec- 
tion, pushed  to  the  utmost,  totally  failed.— (0/>.  cit. 
vol.  6,  p.  455,  456.) 

The  powerfully  relaxing  effects  of  tobacco  clysters, 
in  cases  of  hernia  and  enteritis,  have  suggested  a trial 
of  them  in  tetanus.  In  one  very  acute  case,  the  plan 
was  tried  by  Mr.  Earle,  but  it  only  afforded  a tempo- 
rary alleviation  of  ihe  spasms,  and  as  it  caused  severe 
agitation,  it  was  discontinued.  According  to  Sir  James 
Maegrigor,  tobacco  clysters  tried  in  the  advanced  stage 
of  the  disease  seemed  to  have  no  effect.  He  considers, 
however,  the  tobacco  fume  as  deserving  farther  trial. 

A remarkable  case  is  recorded  by  Dr.  Pnillips,  in 
which  the  jaw  suddenly  fell,  upon  the  exhibition  of  an 
enema.with  oil  of  turpentine.— (See  Med.  Chir.  Trana. 
uol.  6,  p.  65.) 


346 


THO 


THR 


According  to  Baron  Larrey,  frictions  with  oily  lini- 
ments, as  recommended  by  some  authors,  were  tried 
by  the  French  surgeons  at  Cairo;  but  they  produced 
no  change  in  the  state  of  the  disease.  We  learn  from 
the  same  authority,  that  the  application  of  blisters  to 
the  throat  also  failed  in  checking  the  symptoms. 

The  Barbadoes  tar,  mentioned  by  Cullen,  electricity, 
the  colchicum  autumnale,  or  meadow  saffron,  recom- 
mended by  Dufresnoy,  and  several  other  means  for- 
merly in  repute  for  their  virtues  in  cases  of  tetanus, 
have  now  been  fully  proved  by  experience  to  possess 
little  or  no  claim  to  this  character. 

[Perhaps  there  is  no  disease  which  has  been  treated 
by  so  great  a variety,  and  even  contrariety  of  remedies 
as  tetanus.  There  are  in  America  very  many  surgeons 
wlio  pursue  the  stimulating  plan  of  Dr.  Hush  ; among 
these  is  Professor  Hosack,  who  relies  upon  Madeira 
wine:  while  there  are  many  others  who  adopt  the 
opposite  theory,  and  not  only  bleed  unsparingly,  but 
combine  the  whole  antiphlogistic  battery;  and  instances 
of  their  success  are  reported,  quite  as  numerous  as 
those  of  the  opposite  theory  and  practice.  The  liberal 
use  of  mercury,  in  large  and  oft-repeated  doses,  has 
found  many  advocates,  and  many  cures  have  been  re- 
ported in  wliich  this  was  the  only  agent  employed. 

Of  late,  however,  the  treatment  of  this  disease  in 
this  country  has  very  much  changed,  and  extensive 
vesication,  especially  on  the  region  of  the  spine,  seems 
to  be  very  generally  relied  on,  and  with  singular  suc- 
cess. One  of  the  most  severe  cases  of  tetanus  I ever 
witnessed  arose  from  a gun  shot  wound,  a load  of  shot 
having  entered  the  back  and  petietrated  into  the  dorsal 
and  lumbar  vertebrie.  The  disease  speedily  assumed 
the  form  of  opisthotonos,  and  was  treated  by  the  appli- 
cation of  the  caustic  potash  to  the  spine,  from  the  cer- 
vical vertebrtE  to  the  sacrum.  About  an  inch  in  width 
of  the  skin  was  destroyed  all  the  way  down,  and  the 
only  internal  medicines  relied  upon  were,  prussic  acid 
in  large  doses,  atid  elaterium  as  a cathartic.  This  case 
and  its  successful  issue  was  reported  in  the  Medical 
Recorder  for  1825.  The  prussic  acid  was  given  at  the 
suggestion  of  my  friend  Professor  Pattison,  now  of  the 
London  University,  who  informed  me  that  he  had 
seen  it  of  great  value  in  the  treatment  of  every  form  of 
tetanus.  1 was  inclined  to  attribute  the  removal  of 
the  (lisea.se  to  the  effect  of  the  caustic  application,  as 
the  irritation  and  eschar  were  considerable,  and  relief 
almost  immediate.  Similar  re.sults  are  repmted  as 
having  followed  extensive  blisieiing  with  canlharides 
along  the  course  of  the  spinal  marrow,  and  this  prac- 
tice is  now  becoming  very  general  in  America.— Aecse.] 

Consult  Hippocrates  de  Murbis  Popularibus,  lib.  5 
et  7.  Cm'ius  Aurelianus  de  Morbis  acutis.  Med. 
Obs.  and  Tnq.  vol.  1,  p.  1 and  87  ; vol.  6,  p.  143.  Hil- 
lary on  the  Mr  and  Diseases  of  Barbadoes,  8vo.  1765. 
FAin.  Physical  and  Literary  Essays,  vol.  3.  Dr. 
Carter  in  Medical  Trans.  Dr.  Cochrane  in  Edin. 
Medical  Commentaries.  Cullen's  First  lAnes  of  the 
Practice  of  Physic,  vol.  3.  Rush's  Observations  on 
the  Cause  and  Cure  of  Tetanus,  in  vol.  2 of  the  Trans- 
actions of  the  American  Philosophical  Society.  Sir 
Gilbert  Rhine's  Observations  on  the  Diseases  of  Sea- 
men, edit.  3.  M.  Ward,  Facts  establishing  the  Efficacy 
of  the  Opiate  Friction  in  Spasmodic  and  Febrile  Dis- 
eases, Src.  8oo.  Manchester,  1809.^  Larrey,  Memoires 
de  Chir.  Militaire,  t.  1,  p.  235,  ire.;  t.  3,  p.  236,  Src. 
Callisen,  Systema  Chirurgice  Hodiernce,  pars  l,p.  16.5, 

5, -c.  Sir  .James  Maegrigor.  in  Med.  Chir.  Trans,  vol. 

6,  p.  449,  ^-c.  Dr.  Phillips's  Case  in  the  same  work 
and  volume,  p.  65.  Dr.  Dickson's  Observations  on 
Tetanus,  and  Dr.  Macarthur's  Letter  ih  vol.  7,  p.  448, 
Src.  of  the  same  book.  Trvka  de  Kriowiti.  de  Tetano 
Commentarius,  Vindob.  1777.  Richerand,  Mosogr. 
Chir.  t.2,p.  338,  (J-c.  edit.  4.  Edin.  Med.  and  Surgi- 
cal .Journal,  vol.  1,  p.  67 ; vol.  2,  p.  255 — 430  ; vol.  4,  p. 
45,  S-c.  Src.  Boyer,  Traite  des  Mai.  Chir.  t.  1,  p.  S®5, 
Sc.  Paris,  1814.  Rees's  Cyclopcedia,  art.  Tetanus. 
O.  H.  Parry,  Cases  of  Tetanus,  and  Rabies  Contagi- 
osa, Src.  8vo.  I.ond.  1814.  .John  Morrison,  a Treatise 
on  Tetanus,  8vu.  Mewry,  1816.  Robert  Reid  on  the 
Mature  and  Treatment  of  Tetanus  and  Hydrophobia, 
8vo.  Dublin,  1817.  Stewart,  in  Med.  Chir.  .Journ. ; 
oil  of  turpentine  tried.  Sir  Astley  Cooper,  Surgical 
Essays,  part  2,  p.  190.  Burmester,  in  Med.  Chir, 
Trans,  vol.  11.  EUiotson,  op.  cit.  vol.  15. 

thorax,  wounds  of.  See  Wounds  of  the 

Thorax. 


THROAT,  WOUNDS  OF.  Injuries  of  this  kind 
are  often  attended  with  considerable  danger,  on  ac- 
count of  the  great  number  of  important  parts  which 
are  interested  ; but  mere  cuts  of  the  integuments  of  the 
throat  and  neck  are  not  (generally  speaking)  dangerous 
cases,  and  do  not  materially  differ  from  common  in- 
cised wounds  of  the  skin  in  any  other  part  of  the  body. 
They  are  not  liable  to  be  followed  by  any  particular 
consequences,  and  require  the  same  kind  of  treatment 
as  cuts  in  general. — (See  Wounds — Incised  Wounds.) 

In  wounds  of  the  throat  and  neck,  however,  the 
larynx  and  trachea,  phaiynx  and  oesophagus,  the  trunk 
of  the  carotid  artery,  and  all  the  principal  branches  of 
the  external  carotid,  the  large  jugular  vein,  the  eighth 
pair  of  nerves,  and  the  recurient  nerve  are  all  exposed 
to  injury  ; some  much  more  so  than  others,  but  all  of 
them  being  occasionally  reached  by  the  edge  of  the 
knife  or  razor,  or  tlie  point  of  tlie  sword  or  other  in- 
struments. 

It  would  be  absurdity  to  offer  an  account  of  what  is 
to  be  done  in  cases  attended  with  some  part  of  the 
mischief  above  pointed  out ; for  no  patient  thus 
wounded,  would  ever  be  found  alive.  Wounds  of  the 
eighth  pair  of  nerves  are  generally  considered  fatal, 
though  some  doubts  begin  to  be  entertained  on  the 
point.  Indeed,  Klein  positively  states  that  such  an  in- 
jury is  not  fatal. — (See  Journ.  der  Chir.  b.  1,  p.  123, 
8vo.  Berlin,  18-0.)  However,  if  the  wound  of  one  of 
these  nerves  be  not  absolutely  fatal,  there  can  be  no 
doubt  of  its  being  highly  perilous,  and  that  it  should 
be  most  cautiously  avoided.  The  nerve,  as  is  well 
known,  proceeds  down  the  neck,  in  the  same  sheath  of 
cellular  substance  which  incimles  the  carotid  artery, 
and  lies  on  the  outside  of  this  vessel,  between  it  and 
the  internal  jugular  vein. 

Wounds  either  of  the  carotid  artery  or  internal  ju- 
gular vein  must  generally  prove  immediately  fatal,  in 
con.sequence  of  the  great  and  sudden  loss  of  blood. 
How'ever,  were  any  surgeon  on  the  spot  at  the  mo- 
ment, lie  should  instantly  secure  the  wounded  vessel. 
In  tying  the  carotid  one  caution  is  highly  necessary, 
viz.  always  to  be  sure  that  the  par  vagum  is  excluded 
liorn  the  ligature;  for  were  tliis  nerve  to  be  tied,  the 
mistake,  if  not  absolutely  mortal,  would  leave  but  a 
slight  possibility  of  recovery. 

If  the  mouth  of  the  vessel  could  not  be  at  once  se- 
cured, pressure  should  be  instantly  resorted  to,  for  the 
purpose  of  producing  a temporary  suppression  of  the 
hemorrhage.  The  surgeon  should  then  either  make 
the  necessary  enlargement  of  the  wound  in  the  integu- 
ments, w ith  a due  .and  constant  recollection  of  the  im- 
portant parts  near  the  place,  or  else,  in  the  case  of  the 
carotid  being  injured,  he  should  cut  down  to  this  ves- 
sel in  the  manner  explained  in  the  article  Aneurism. 

In  lacerated  wounds,  the  carotid  artery  may  be  in- 
jured, and  yet  the  patient  not  immediately  bleed  to 
death  ; for  it  is  the  nature  of  all  wounds  attended  with 
much  laceration  and  contusion  not  to  bleed  so  freely 
as  clean  cuts.  Mr.  Abernethy  has  related  a case  in 
which  the  carotid  and  all  the  chief  branches  of  it 
were  wounded  in  a man  who  was  gored  in  the  neck 
with  a cow's  horn  ; yet  death  did  not  directly  follow, 
and  there  was  time  to  have  recourse  to  the  ligature. 
Baron  Larrey  even  reports  one  or  two  cases  in  wliich 
the  bleeding  from  ihe  carotid,  injured  by  a gun-shot, 
was  permanently  stopped  by  pressure.— (See  Mem.  de 
Chir.  Mil.)  Dr.  Hennen  also  refers  to  another  in- 
stance of  a similar  nature. — (On  Military  Surgery, 
p.  106,  ed.  2.) 

Punctured  wounds  might  obviously  injure  either  the 
carotid  or  the  internal  jugular  vein,  without  the  pa- 
tient expiring  of  hemorrhage  at  once;  because  the 
smallness  of  the  wound  in  the  skin  might  hinder  the 
fatal  effusion  of  blond. 

How-ever,  frequently,  when  these  vessels  are  wounded, 
the  par  vagum  is  also  injured,  and  the  case  is  mortal, 
either  immediately  from  the  direct  effects  both  of  the 
injury  of  the  nerve  and  sudden  loss  of  blood,  or  very 
soon  afterward,  the  bleeding  being  of  a slower  and 
more  interrupted  kind;  which  circumstance  must  de 
pend  on  the  lacerated  nature  of  the  wound,  the  small 
size  of  the  opening  in  the  vessel,  or  of  that  in  the 
skin,  &c. 

Persons  who  attempt  suicide  by  cutting  their  throats, 
do  not  often  divide  the  carotid  artery,  on  account  of 
their  incision  being  made  too  high  up.  Where  the  ca- 
rotid arteries  emerge  from  the  chest,  they  are  situated 


THR 


THR 


347 


by  the  side  of  the  trachea,  and  even  a little  more  for- 
wards than  it.  However,  as  these  vessels  proceed  up 
the  neck,  they  become  more  laterally  situated  with  re 
spect  to  the  windpipe;  and  when  they  have  arrived  at 
the  upjrer  part  of  the  neck,  where  persons  who  aim  at 
suicide  almost  always  cut,  they  become  situated  more 
backwards  than  the  trachea,  inclining  towards  the 
angle  of  the  lower  jaw. 

The  aesophague  is  so  deeply  situated,  lying  close  to 
the  bodies  of  the  vertebrae  and  behind  the  trachea,  that 
it  is  not  often  concerned  in  any  incised  wounds,  which 
do  not  immediately  prove  fatal,  in  consequence  of  the 
division  of  other  important  parts.  Yet  numerous  cases 
are  recorded  in  which  the  oesophagus  is  said  to  have 
been  wounded ; and  what  is  usually  set  down  as  a cri- 
terion of  the  fact,  is  the  passage  of  victuals  through 
the  wound.  In  many  of  these  narrations,  the  writers 
seem  to  have  forgotten  that  wounds  made  above  the  os 
hyoides,  as  they  frequently  are,  may  enter  the  month, 
and  the  victuals  escape  through  the  cut,  without  the 
(esophagus  or  pharynx  being  at  all  concerned. 

However,  no  doubt  the  oesophagus  has  occasionally 
been  wounded,  together  with  the  trachea,  not  only 
without  the  patient  perishing  so  immediately  as  to  be 
incapable  of  receiving  any  succour,  but  without  every 
chance  of  recovery  being  destroyed.  Stabs  and  gun- 
shot wounds  may  injure  the  oesophagus,  and  leave  all 
other  important  parts  untouched.  Nay,  when  other 
parts  of  consequence  are  injured,  the  patient  is  some- 
times saved. — (See  Hennen's  Military  Surgery,  p.  363, 
ed.  2.) 

Even  where  the  oesophagus  is  known  to  be  wounded, 
its  deep  situation  would  prohibit  us  from  doing  any 
thing  to  the  breach  of  continuity  in  the  lube  itself. 
The  best  plan  would  be  to  have  recourse  to  antiphlo- 
gistic means,  and  to  introduce  a flexible  elastic  gum 
catheter,  from  one  of  the  nostrils  down  the  oesophagus, 
for  the  purpose  of  conveying  nourishment  and  medi- 
cines into  the  stomach,  without  any  risk  of  their  pass- 
ing out  at  the  wound.  An  instrument  of  this  kind 
will  lie  in  the  above  situation  for  any  length  of  time 
without  occasioning  much  inconvenience;  and  be- 
sides being  advantageous  for  injecting  nourishment 
and  medicines  down  the  passage,  and  keepiitg  them 
from  issuing  at  the  wound,  it  preverrts  all  necessity  for 
the  wounded  oesophagus  to  act,  and  become  disturbed, 
when  there  is  occasion  to  take  arty  kind  of  liquids, 
whether  in  the  way  of  medicine  or  food.  The  oirter 
wound  should  be  brought  together  and  treated  on 
common  principles. 

When  persons  cut  their  throats  as  I have  explained, 
they  do  not  often  divide  the  carotid  artery,  owiitg  to 
their  incision  being  usually  made  high  up  in  the  neck, 
where  this  vessel  has  attained  a very  backward  situa- 
tion. When  any  serious  hemorrhage  does  arise,  it  is 
sometimes  frcnn  the  lower  bratrches  of  the  liitgnal  ar- 
tery, but  most  frequently  from  the  superior  thyroideal 
arteries.  Such  arteries  may  occasion  a fatal  bleeding, 
which,  indeed,  would  more  frequently  be  the  event 
than  it  actually  is,  did  not  the  patient  often  faint,  in 
which  Slate  the  bleeding  spontaneously  ceases,  and 
gives  time  for  the  arrival  of  surgical  assistance. 

I need  hardly  tell  the  reader  that  these  arteries  are  to 
be  tied,  and  that  this  important  object  is  the  first  to 
which  the  surgeon  should  direct  his  attention.  The 
danger  of  bleeding  to  death  being  obviated  as  soon  as 
possible,  the  other  requisite  measures  may  be  more  de- 
liberately executed. 

With  respect  to  wounds  of  the  trachea,  the  same 
plan  of  conveying  forrd  and  medicines  into  the  sto- 
mach through  an  elastic  gum  catheter,  introduced 
from  one  of  the  nostrils  down  the  (Esophagus,  is  highly 
proper,  though  too  much  neglected  ; for  nothing  creates 
such  disturbarrce  of  the  wound  as  the  convulsive  ele- 
vation and  depression  of  the  larynx  and  trachea. 
Which  are  naturally  attendant  on  the  act  of  swal- 
lowing. 

When  the  trachea  is  cut,  the  patien*’s  power  of 
forming  the  voice  is  more  or  less  impaired,  in  conse- 
quence of  the  air  passing  into  and  out  oi  ’.he  lungs 
chiefly  through  the  wound.  Besides  air,  a consider- 
able quantity  of  the  natural  mucus  of  the  trachea  is 
also  continually  coming  out  of  the  wound. 

The  grand  means  of  accomplishing  the  union  of 
wounds  of  the  trachea,  are  a proper  position  of  ibe 
head,  and  a rieorous  observance  of  quietude.  B/ 
raising  the  patient’s  head  with  pillows,  and  keeping 


his  chin  close  to  his  breast,,  the  edge  of  the  wound  both 
in  the  skin  and  trachea,  are  placed  in  contact,  even 
without  any  other  assistance,  unless  the  division  of 
the  trachea  J)e  exceedingly  large.  It  is  proper,  how- 
ever, to  promote  the  'eflTeci  of  a suitable  position  with 
strips  of  sticking  plaster,  and  sometimes  with  a suture 
or  two.  But  the  necessity  for  sutures  must  depend  on 
the  extent  of  the  division  of  the  trachea;  for  unless 
most  of  the  circle  of  this  lube  be  cut,  and  position  be 
neglected,  the  wound  in  it  will  not  gape.  'J'he  stitches 
should  never  be  passed  through  the  lining  of  the  tra- 
chea, as  this  method  would  be  likely  to  make  it  in- 
flame, and  occasion  considerable  coughing  and  irrita- 
tion, attended  with  very  pernicious  efiects. 

Should  there  be  much  coughing,  apparently  arising 
from  irritation  and  inflammation  in  the  trachea,  bleed- 
ing is  proper,  if  other  considerations  do  not  forbid  it. 
The  spermaceti  mixture  with  opium  is  also  frequently 
of  great  service.  I never  saw  a wound  of  the  trachea 
unite  by  the  first  intention. 

[That  wounds  of  the  trachea  do  unite  by  the  first 
intention  would  seem  to  be  rendered  probable,  at  least, 
by  the  early  recovery  of  patients  after  the  operation  of 
broncholotny.  This  operation  is  now  very  frequently 
performed  in  this  country,  for  the  removal  of  foreign 
bodies  from  the  trachea  and  sometimes  for  trachitis  or 
croup.  Itideed  I have  known  it  resorted  to  dernierly 
in  phthisis  trachealis,  but  without  benefit.  The  fact 
however  is  sufficiently  established,  that  the  operation 
is  seldom  followed  by  any  troublesome  symptoms,  and 
the  trachea  does  unite  in  a very  few  days. 

In  this  operation  it  is  true  that  the  incision  is  often 
perpendicular  only,  and  the  crucial  incision  is  not  al- 
ways necessary,  while  in  wounds  of  the  throat  as  in 
attempted  suicides,  tne  trachea  is  generally  woundtd 
across  its  caliber  or  between  the  rings.  I remem- 
ber seeing  one  instance  in  which  a man  cut  his  throat 
with  a razrtr,  and  divided  the  trachea  entirely  across, 
and  yet  it  united  again  by  the  tieatment  recommended 
by  Mr.  Cooper,  and  in  a few  weeks  his  voice  and  respi 
ration  had  entirely  recovered.  We  should  always 
make  the  attempt  as  here  advised,  and  will  very  gene- 
rally be  successful. — Reese.] 

See  John  Bell  on  Wounds,  ed.  3.  Henven's  Mili- 
tary Surgery,  p.  356,  S/c.  ed.  2,  Qvo.  Edin.  1820. 
Among  othei  references  made  by  Dr.  Hennen,  the  fol- 
lowing seem  to  me  to  merit  particular  notice : — An  in- 
teresting case  of  wound  of  the  neck,  succeeaed  by  hemi- 
plegia, and  another  of  gun-shot  wound  of  the  throat, 
succeeded  by  paralysis  and  convulsions,  says  Dr.  Hen- 
nen, is  given  by  Forestus  in  his  Surgical  Observations. 
Another  with  loss  of  motion  in  the  arm,  from  a wound 
in  the  neck,  is  to  be  found  in  the  Edin.  Med.  Essays, 
rol.  1.  And  in  the  Med.  Commentaries,  by  Dr.  Dun- 
can, vol.  4,  p.  434,  and  vol.  8,  p.  356,  are  two  intc-esting 
cases.  Muremna,  in.  his  Med,  Chir.  Beobuchtuvgen, 
relates  a case  »f  removal  of*khe  thyroid  gland  by  a 
cannon-ball ; the  patient  survived  fourteen  days,  and 
died  of  dysentery.  Wounds  of  the  (Esophagus  often 
remain  open  for  indeterminate  periods,  as  is  exem.plifed 
in  a case  reported  by  Trioen,  in  his  Fasciculus  Obser- 
vationum,  Lugd  1745,  p.  40.  Mr.  Bruce  has  recorded 
an  interesting  case  of  wound  of  the  (E.'^ophagus,  in 
Med.  Chir.  .Journ.  vol.  1,  p.  369.  7 would  also  refer  to 

various  parts  of  Mem.  de  Chir.  Milit.  by  Baron  Jmr- 
rey ; and  7 homson's  Report  of  Ohs.  made  in  Mil. 
Hospitals  in  Belgium,  8t)o.  Edin.  1816. 

THROMBUS.  (From  SpbpSos,  coagulated  biood.) 
A clot  of  blood.  The  term  is  also  applied  to  a tuinour, 
formed  hy  a colleciion  of  extravasatecl  coagulated 
blood,  utnier  tiie  integuments  alter  bleeding.  When 
not  considerable  it  is  usually  called  an  eochymosis. — 
(See  this  word  and  Bleeding  ) 

A thrmnbus  after  bleeding  generally  arises  from  the 
opening  in  the  vein  not  corresponding  to  that  in  the 
skin.  The  patient’s  altering  the  posture  of  his  arm, 
while  the  blood  is  flowing  into  the  basin,  will  often 
cause  an  interruption  to  the  escape  of  the  fluid  from 
the  external  orifice  of  the  puncture  ; and  consequently 
it  insinuates  itself  into  the  cellular  substance  in  the 
vicinity  of  the  opening  in  the  vein.  In  |»roportion  as 
the  blood  issues  from  the  vessel,  it  is  effused  in  the  cel 
Inlar  membrane,  between  the  skin  and  fascia,  cover- 
ing the  muscles;  and  this  with  more  or  less  rapidity, 
and  in  a greater  or  less  quantity,  according  as  the 
edges  of  the  skin  more  or  less  impede  the  outwaid  es- 
cape of  the  fluid.  Sometimes,  also,  a thrombus  forms 


348 


THY 


THY 


after  venesection,  when  the  usual  dressings,  com- 1 
press,  and  bandage  have  been  put  over  the  puncture, 
and  tlie  patient  iiiiprudenily  makes  use  of  the  arm  on 
wliicli  the  operation  lias  been  done.  Tlii§  is  more  par- 
ticularly liable  to  happen  when  the  opening  in  the  vein 
has  been  made  large. 

When  the  extravasation  is  not  copious,  it  is  of  little 
importance,  for  the  tumour  generaliy  admits  of  being 
easily  resolved,  by  applying  linen  dipped  in  any  discu- 
tient  lotion.  If  the  swelling  be  more  extensive,  ap- 
plying to  it  a compress,vvet  with  a solution  of  common 
sea-salt,  is  deemed  an  efficacious  plan  of  promoting 
the  absorption  of  the  extravasated  blood.  Brandy  and 
a soliuioi:  of  ihe  muriate  of  ammonia  in  vinegar,  are 
likewise  eligible  applications. 

It  sometimes  happens  that  a thrombus  induces  in- 
flammation and  suppuration  of  the  edges  of  the  punc- 
ture. The  treatment  is  now  like  that  of  any  little  ab- 
scess: a common  linseed  poultice  may  be  applied,  and 
any  considerable  accumulation  of  matter  should  be 
prevented  by  making  an  opening  with  a lancet  in 
proper  time.  As  soon  as  tiie  inflammatory  symptoms 
have  ceased,  discutients  should  be  employed  again  for 
the  purpose  of  dispersing  the  remaining  clots  of  blood, 
and  surrounding  induration. 

When  the  quantity  of  blood  is  large,  many  authors 
recommend  opening  the  tumour  at  once;  and  despair- 
ing of  the  power  of  the  absorbents  to  remove  the  ex- 
travasation, they  direct  as  much  of  the  blood  as  pos- 
sible to  be  pressed  out  through  the  incision.  I believe, 
however,  that  making  an  opening  is  seldom  necessary, 
and  often  brings  on  inflammation  and  suppuration, 
when  they  might  be  avoided.  I have  never  seen  any 
case  in  which  this  practice  seemed  necessary,  though 
such  a case  may  be  conceived. 

THYROID  GLAND,  DISEASED.  See  Broncho- 
cele. 

THYROID  GLAND,  EXTIRPATION  OF.  That 
such  an  operation,  though  attended  with  great  diffi 
culties,  is  not  impracticable,  is  proved  by  the  following 
example 

On  the  20th  of  March,  1791,  a woman  presented  her- 
self for  admission  at  the  Hdtel  Dieu,  with  a tumour  of 
the  right  portion  of  the  thyroid  gland.  The  swelling 
was  two  inches  in  diameter,  round,  hard,  and  attached 
to  the  right  and  middle  pan  of  the  trachea,  and  it  pushed 
outwards  the  sterno  mastoideus  muscle.  Independ- 
ently of  its  being  sensibly  raised  by  each  pulsation  of 
the  arteries,  it  followed  the  motions  of  deglutition,  and 
in  a slight  degree  impeded  the  passage  of  solid  aliment. 
Desault  made  an  incision  through  the  middle  of  the  tu- 
mour, beginning  one  inch  above,  and  finishingone  inch 
below  the  swelling.  By  the  first  stroke  he  cut  down  as 
far  as  the  gland,  dividing  the  integuments,  the  platys- 
mamynides,  and  some  fibres  of  the  sterno  hyoidei  and 
sterno-thyroidei  musclH.  An  assistant,  with  the 
view  of  fixing  the  tumour,  drew  it  towards  the  inner 
edge  of  the  wound,  while  the  operator  detached  the 
swelling  from  the  sterno-mastoideus  muscle.  In  dis- 
secting the  cellular  substance  which  united  the  parts, 
two  small  arteries  were  divided,  which  were  secured 
with  ligatures.  The  outer  portion  of  the  tumour  being 
thus  disengaged,  the  inner  was  detached  in  the  same 
way.  The  tumour  was  then  drawn  outwards  by 
means  of  a hook,  that  it  might  be  separated  with  more 
ease  fiom  the  trachea.  In  the  course  of  this  dissection, 
the  branches  of  the  thyroid  arteries  were  successively 
tied  as  fast  as  they  were  divided.  The  assistant  who 
held  the  hook  pulled  the  gland  from  within  and  forwards, 
while  the  surgeon  finished  the  dissection  outwards 
and  from  above  downwards.  This  part  of  the  opera- 
tion was  most  d'fficult;  it  was  necessary  continually 
♦o  wipe  away  the  blood  with  a sponge,  which  neces- 
sarily prevented  the  parts  from  being  easily  distin- 
guished, and  obliged  tlie  surgeon  to  cut  but  a little  at  a 
time,  and  always  to  examine  well  with  his  finger  those 
parts  which  he  was  about  to  cut.  By  this  cautious  dis- 
section, the  superior  and  inferior  thyroid  arteries  were 
laid  bare,  and  afterward  tied  with  the  aid  of  a blunt 
crooked  needle.  They  were  then  transversely  divided, 
and  the  remaininc  part  of  the  tumour  detached  frem 
the  tracltea,  to  which  it  strongly  adhered.  The  wound 
resulting  from  this  operation  was  nearly  three  inches 
in  depth  ; outwardly  bounded  by  the  sterno-mastoideus 
muscle,  inwardly  by  the  trachea  and  cesophagus,  and 
posteriorly  by  the  carotid  artery  and  par  vagum,  which 
were  exposed  at  the  bottom  of  the  wound.  The  extir- 


pated tumour  was  five  inches  in  circumference;  and 
on  examination  was  found  to  differ  in  no  particular 
from  scirrhous  glands,  except  that  in  the  centre  tliere 
was  a cartilaginous  nucleu.s.  The  patient  left  the  hos- 
pital perfectly  well  the  thirty-fourth  day  after  the  ope- 
ration.— (See  Desault's  Parisian  Chir.  Joum.  vol.  2, 
p.  292.  296.) 

The  extirpation  of  the  thyroid  giand  is  an  operation 
extremely  difficult,  and  certainly  highly  dangerous, 
when  performed  by  an  ojierator  but  moderately  exer- 
cised in  the  practice  of  his  profession.  The  number 
and  size  of  the  arteries  divided,  the  proximity  of  the 
tracliea,  cesophagus,  jugular  vein,  and  carotid,  near 
which  the  knife  must  necessarily  pass,  are  the  princi- 
pal dangers  which  have  deterred  the  majority  of  prac- 
titioners from  performing  the  operation.  The  first 
time  that  Gooch  undertook  the  operation,  he  was  de- 
terred from  finishing  it  by  the  hemorrhage,  and  his  pa- 
tient died  on  the  eighth  day.  The  second,  time  he  suc- 
ceeded better,  but  was  incapable  of  securing  the  vessels  ; 
and  the  hemorrhage,  which  would  have  been  mortal, 
was  only  stopped  by  the  pressure  of  the  hands  of  as- 
sistants for  the  space  of  eight  days.— (GoocA’s  Med. 
and  Chir.  Obs.  p.  130.  Bell's  System  of  Surgery,  vol. 
5,  p.  525.  Richter's  Bibl.  t.  2,  p.  128.) 

Vogei  and  Theden  also  did  the  operation  with  suc- 
cess ; but  no  surgeon  who  has  attempted  this  bold  ope- 
ration has  signalized  himself  so  much  by  it  as  Dr. 
Hedenus,  of  Dresden,  who  has  removed  the  diseased 
thyroid  gland  in  six  instances  with  success.  His  rea- 
sons for  resorting  so  often  to  this  difficult  operation,  he 
says,  are:  1st,  because  he  has  seen  a patient  with  en- 
larged thyroid  gland,  for  which  the  seton  had  been 
employed,  seized  on  the  ninth  day  with  violent  teta- 
nus, which  proved  fatal  in  17  hours  ; 2dly,  because  he 
considers  setons  and  other  similar  means  unlikely  to  do 
good,  as  he  has  almost  always  found  portions  of  carti- 
lage or  bone  within  the  diseased  part.  In  one  of  his 
cases  the  gland  was  as  large  as  a skittle-bail ; it  covered 
the  whole  of  the  front  of  the  neck,  reaching  from  the 
os  hyoides  to  the  upper  part  of  the  sternum,  and  push- 
ing back  on  each  side  the  sterno-cieido-mastoideus  and 
adjacent  parts.  The  circumference  of  its  base  was  14 
inches,  and  its  transverse  diameter  seven.  It  had  afirm, 
tense,  heavy  feel.  The  skin  was  fuli  of  enlarged  veins: 
and  the  tumour  communicated  to  the  hand  a throbbing 
motion,  which  might  have  been  taken  for  that  of  an 
aneurismal  swelling. 

The  patient  was  laid  on  a mattress.  Dr.  Hedenus 
then  divided  the  skin  in  a longitudinal  direction,  from 
the  os  hyoides  to  the  top  of  the  sternum,  and  dissected 
and  turned  back  the  skin  and  platysma  myoides  on 
each  side  to  the  extent  of  two  inches.  The  sterno- 
hyoid and  sterno  thyroid  muscles  were  then  seen  firmly 
adherent  to  the  whole  tumour.  An  attempt  was  made 
10  separate  them  from  the  sw'elling  ; but  scarcely  had 
the  dissection  extended  a quarter  of  an  inch,  w'hen  a 
copious  stream  of  blood  proceeded  from  numerous 
small  arteries,  which  could  neither  be  tied,  on  account 
of  their  minuteness,  nor  stopped  with  styptics.  Hede- 
nus, therefore,  detennined  immediately  to  cut  through 
the  above-named  muscles  at  their  points  of  attachment 
above  and  below,  and  to  remove  the  intervening  por- 
tions with  the  tumour. 

Respecting  this  part  of  the  operation,  it  merits  parti- 
cular notice,  that,  after  tlie  cure,  the  motions  of  the  os 
hyoides  and  larynx,  and  the  functions  of  respiration, 
speech,  and  deglutition  all  remained  unimpaired; 
which  was  also  the  case  in  four  other  instances,  in 
w’hich  Hedenus  removed  portions  of  the  sterno-hyoidei 
and  sterno-thyroidei  muscles. 

Hedenus  next  separated  the  sw'elling  above  and  be- 
low, from  the  sterno  cleido-mastoid  and  omo-hyoid 
muscles,  and  also  from  the  jugular  vein  and  carotid 
arteries,  to  which  it  was  closely  adherent,  until  he  had 
freed  it  as  far  as  the  iioint  where  the  thyroid  arteries 
originate.  He  then  tied  all  the  superior  and  inferior 
thyroideal  arteries  close  to  the  tumour,  and,  on  account 
of  the  free  anastomoses,  applied  to  each  vessel  two  liga- 
tures, and  divided  it  in  the  interspace.  The  more 
deeply  the  dissection  now  reached,  the  more  hazard- 
ous did  the  operation  appear,  as  at  every  cut  of  four  or 
five  lines  he  was  obliged  to  tie  two  or  three  arteries, 
w'hich  W’as  done  with  great  difficulty.  After  most 
cautiously  dissecting  to  the  base  of  the  tumour,  w'hich 
was  firmly  attaclied  to  the  thyroid  cartilage,  and  the 
three  upper  rings  of  the  trachea,  he  met  with  so  many 


THY 


TIC 


349 


arteries,  for  the  most  part  as  large  as  the  radial  or  digi- 
tal, that  in  order  to  preve’it  farther  loss  of  blood,  he 
decided  to  lie  the  base  of  the  swelling,  and  then  cut 
away  the  tumour  above  the  ligatuie.  For  ibis  pur- 
pose he  used  a blunt-pointed  aneurisnial  needle,  armed 
with  two  four-threaded  ligatures.  This  was  passed 
through  the  middle  of  the  base,  while  the  tumour  was 
pulled  upwards  ; and  one  ligature  was  then  firmly  tied 
over  the  lower,  and  the  other  over  the  upper  half  of 
the  base.  For  the  sake  of  being  still  more  sure  ofcoin- 
nianding  the  hemorrhage,  Hedenus  also  applied  a third 
ligature  all  round  the  swelling,  and  he  then  extirpated 
the  diseased  gland,  without  any  bleeditig  from  the  part 
included  in  the  ligatures.  These  were  now  fastened  at 
the  sides  of  the  wound  with  adhesive  plaster.  The 
whole  surface  of  the  wound  was  sprinkled  with  pow- 
dered gum  arabic,  over  which  was  laid  agaric,  wet 
with  Theden’s  vulnerary  lotion.  These  applications 
having  been  covered  with  charpie,  the  lips  of  the 
wound  were  drawn  towards  each  other  with  adhesive 
plaster,  which  was  also  coveted  with  compresses  wet 
with  vinegar,  and  renewed  every  six  or  eight  minutes. 

It  is  quite  unnecessary  for  me  to  follow  the  narrative 
of  this  case  in  all  its  details.  The  patient,  between  the 
period  of  the  operation  and  that  of  his  cure,  suffered  a 
great  deal  of  indisposition,  which  at  first  chiefly  con- 
sisted of  difficult  deglutition,  severe  pain  all  over  the 
right  side  of  the  head,  imperfect  use  of  the  arm,  fre- 
quent cough,  and  hoarseness.  In  the  afternoon  blood 
began  to  flow  through  the  bandage,  and,  as  the  bleed- 
ing had  not  abated  after  an  hour’s  pressure  with  the 
hand,  the  dressings  were  removed,  and  the  blood  found 
to  proceed  not  from  any  particular  artery,  but  from  all 
the  wounded  surface.  I'he  wound  was  again  sprin- 
kled with  gnin  arabic,  which  was  covered  with  sponge 
and  a bandage  : two  surgeons  were  also  directed  to 
keep  up  pressure  with  their  hands.  The  day  after  the 
operation  the  febrile  symptoms  ran  high,  but  in  two 
days  subsided  again.  On  the  eighth  day  all  the  liga- 
tures came  away,  even  that  which  had  encircled  the 
tumour,  and  a large  quantity  of  fetid  matter  was  dis- 
charged. Soon  afterward  a considerable  bleeding 
arose,  which  however  was  stopped  with  sponge  and 
alum  powder.  On  the  16tli  day  another  serious  he- 
morrhage was  occasioned  by  a convulsive  cough,  and 
life  was  endangered  by  the  loss  of  not  less  than  two 
pounds  of  blood.  The  bleeding  which  came  from  the 
upper  angle  of  the  wound  was  stopped  by  means  of  a 
piece  of  spotige  dipped  in  rectified  spirit,  and  covering 
the  wound  and  indeed  the  whole  neck  with  compresses 
wet  with  vinegar,  pressure  being  also  kept  up  on  the 
sponge  with  the  hand.  The  dangerous  state  of  the  pa- 
tient may  be  conceived  when  it  is  known,  that  there 
was  now  a deadly  paleness  of  his  whole  body,  languid 
eyes,  dimness  of  vision,  loss  of  hearing  and  speech, 
and  extreme  prostration  of  the  vital  powers.  With  the 
aid  of  judicious  treatment,  however,  he  rallied,  and  in 
the  end  left  the  hospital  quite  cured. 

In  another  case  operated  upon  by  Hedenus,  the  diffi- 
culties were  even  greater,  owing  to  the  extension  of  a 
portion  of  the  right  lobe  of  the  thyroid  gland  as  far 
back  as  the  transverse  processes  of  the  cervical  verte- 
brae ; but,  after  the  thiid  day  from  the  operation,  the 
progress  to  recovery  was  not  ititerrupted  by  any  bleed- 
ings.— (See  Graefe's  Journ.  b.  2,  p.  237,  8rc.  or  the 
Quarterly  Journ.  of  Foreign  Med.  JTo.  19.) 

There  can  be  no  doubt,  that  the  method  adopted  by 
Hedenus  was  well  calculated  to  obviate  the  great 
source  of  immediate  danger,  viz.  the  bleeding.  As  long 
as  it  was  practicable  he  look  up  every  vessel  which  he 
exposed  or  divided ; and  when  this  plan  could  not  be  con- 
tinued, he  tied  the  base  of  the  tumour  ere  he  detached 
the  enlarced  gland  from  the  larynx.  This  tying  of  the 
base  of  the  swelling,  though  sometimes  practised  on 
other  occasions,  as  in  the  removal  of  diseased  axillaiy 
glands,  constitutes  the  chief  peculiarity  of  Hedenus’s 
method. 

A case  has  been  published  in  which  Klein  removed  a 
very  large  thyroid  gland.  The  patient,  a boy,  eleven 
years  ofage,  died  on  the  operating-table. — (See  Journ. 
der  Chir.  b.  1,  p.  120,  8vo.  Berlin.,  1820;  or  the  Quar- 
terly Journ.  of  Foreign  Medicine,  vol.  2,  p.  380.)  On 
the  whole,  I consider  that  the  piactice  of  tying  the  thy- 
roideal  arteries  is  generally  a safer  experiment  than  the 
removal  of  the  enlarged  gland  with  a knife. — (See 
B-ronchocele,  Med.  hit.  44,.,p.  363.)  But  now  that  the 
efficacy  of  the  preparations  of  iodine,  in  many  cases  of  i 


bronchocele  has  been  fully  proved,  it  is  to  be  hoped 
that  few  cases  will  present  themselves  in  which  either 
measure  will  be  absolutely  necessary. 

TIC  DOULOUREUX.  This  term  is  used  to  signify 
a disorder,  the  most  prominent  character  of  which  con- 
sists in  severe  attacks  of  pain,  affecting  the  nerves  of 
the  face;  most  frequently  the  filaments  of  that  branch 
of  the  fifth  pair  which  comes  out  of  the  infra  orbitary 
foramen  : but  sometimes  the  other  branches  of  the  fifth 
pair,  and  occasionally  the  numerous  filaments  of  the 
portio  dura  of  the  auditory  nerve,  which  are  distri- 
buted upon  the  face.  The  complaint  is  not  continual, 
but  occurs  in  violent  paroxysms,  which  vary  in  dura- 
tion in  different  instances.  It  is  the  trismus  dolorijicua 
of  Sauvages,  the  faciei  morbus  nervorum  crucians  of 
Dr.  S.  Fothergill ; and  of  that  order  of  diseases  which 
Professor  Chanssier  has  so  aptly  denominated  neural- 
gies  (from  vevpov,  a nerve,  and  aXyog,  pain) ; for  it 
should  be  known  that  many  other  parts  of  the  body 
are  subject  to  a similar  affection. 

The  first  excellent  description  of  tic  doulou,-eux  was 
published  in  the  year  1776,  by  the  late  Dr.  Fothergill. — 
(See  Med.  Obs.  and  Inq.  vol.  5.)  It  is  not  true,  how- 
ever, as  is  generally  stated,  that  he  was  the  first  author 
who  noticed  the  complaint.  This,  indeed,  is  so  far 
from  being  correct,  that  we  even  find  an  account  pf  au 
operation  done  long  ago  by  Louis,  for  the  relief  of  the 
disease  (see  Jfo.  36  de  la  Gazette  Salutaire,  1766) ; and 
this  identical  case  actually  became  a subject  of  hot  dis- 
pute between  the  physicians  and  surgeons  of  the 
French  metropolis. — (See  a Thesis,  entitled  “ Utrum 
in  pertinacibus  capitis  et  faciei  doloribus  aliquid  prod- 
esse  possit,  sectio  ramorum  nervi  quinii  parts  ? Pro- 
ponebal  Viellart,  1768,  conclusio  negutiva.") 

Tic  douloureux  conveniently  admits  of  being  di- 
vided into  four  species,  called  by  the  French  frontal, 
sub-orbitary,  and  maxillary  neuralgia,  and  the  neural- 
gia of  the  facial  nerve. 

In  the  frontal  neuralgia,  the  pain  usually  begins  in 
the  situation  of  the  snpra-orbitary  foramen,  extending 
at  first  along  the  branches  and  ramifications  of  the  fron- 
tal nerve,  distributed  to  ihe  soft  parts  upon  the  cranium, 
and  afterward  shooting  in  the  direction  of  the  trunk 
of  the  nerve  towards  the  bottom  of  the  orbit.  In  a 
more  advanced  stage,  the  conjunctiva  and  all  the  sur- 
face of  the  eye  pa.--ticipate  in  the  effects  of  the  disorder, 
and  become  affecled  with  chronic  inflammation,  which 
is  described  as  a particular  species  of  ophthalmy.  At 
lengih  the  pain  passes  beyond  the  distribution  of  the 
branches  of  the  frontal  nerve,  and  affects  all  the  cor- 
responding side  of  the  face  and  head.  It  seems  as  if 
it  extended  itself  to  the  facial,  sub-orbitary,  maxillary, 
and  even  to  the  temporal  and  occipital  nerves,  through 
the  communications  naturally  existing  between  the 
filaments  Of  all  those  organs  of  sensation.  Each  parox- 
ysm produces  a spasmodic  contraction  of  the  eyelids, 
and  a copious  effusion  of  tears. 

The  sub-orbitary  neuralgia  is  first  felt  about  the  sub- 
orliitary  foramen.  The  seat  is  probably  in  the  nerve 
of  this  name,  and  the  pain  extends  to  the  lower  eyelid, 
the  inner  canthus  of  the  eye,  the  muscles  about  the 
zygoma,  the  buccinator,  cheek  in  general,  ala  of  the 
nose,  and  the  upper  lip.  At  a later  period,  the  pain 
appears  to  extend  backwards  to®the  trunk  of  the  nerve, 
and  those  branches  which  are  given  off  in  its  passage 
through  the  sub-orbitary  canal.  Hence,  pains  are  then 
experienced  in  the  upper  teeth,  the  zygomatic  fossa, 
the  palate,  tongue,  and  within  the  cavity  of  the  nose. 
As  the  disorder  advances,  it  may  extend,  like  other 
neuralgiae  of  the  face,  to  all  the  same  side  of  the  head. 
Duringthe  paroxysms,  when  the  disease  is  fully  formed, 
an  abundant  salivation  usually  takes  place.  In  gene- 
ral, the  attendant  toothache  deceives  the  practitioner, 
who,  in  the  belief  that  the  pain  arises  from  another 
cause,  uselessly  extracts  several  of  the  teeth. 

The  tic  douloureux  of  the  lower  Jaw  or  maxillary  neu- 
ralgia, is  usually  first  felt  about  the  situation  of  the 
anterior  orifice  of  the  canalis  mentalis,  and  it  extends 
to  the  lower  lip,  chin,  neck,  teeth,  and  temple.  This 
form  of  the  complaint  is  more  uncommon  than  the 
preceding;  but  after  it  has  prevailed  some  time,  is 
equally  remarkable  for  its  intensity. 

With  respect  to  the  neuralgia  of  the  facial  nerve  or 
portio  dura  of  the  auditory  nerve,  it  is  a ca.se  which 
very  soon  cannot  easily  be  distinguished  from  the  other 
sjiecies  of  tic  douloureux.  The  pains  at  an  early  period 
are  no  longer  confined  to  the  passage  of  the  principal 


330 


TIC  DOULOUREUX. 


branches  of  this  nerve  between  the  parotid  gland  and 
ramus  of  the  jaw.  The  numerous  commmiicalions 
of  the  portio  dura  with  the  rest  of  the  nerves  of  the 
face  seem  to  facilitate  the  extension  of  the  disease,  so 
that  the  agony  is  soon  felt  over  the  whole  side  of  the 
head.  The  original  source  of  the  disorder  can  only  be 
detected  by  attentively  considering  the  progress  of  the 
complaint  in  all  its  stages.— (See  Delpcch,  Traite  des 
Maladies  reputees  Chirurg-icales,  t.  3,  sect.  7,  y.  214, 
4-c.) 

Tic  douloureux  may  be  known  from  rheumatism  by 
the  paroxysm  being  excited  by  the  slightest  touch,  by 
the  shortness  of  its  duration,  and  the  extreme  violence 
of  the  pain.  In  acute  rheumatism,  also,  there  is  fever, 
with  redness,  heat,  and  generally  some  degree  of  swell- 
ing; and  in  chronic  rheumatism  the  pain  is  obtuse, 
long  continued,  and  often  increased  at  night;  none  of 
which  symptoms  characterize  tic  douloureux. 

It  may  easily  be  distinguished  from  hemicrania  by 
the  pain  exactly  following  tlte  course  of  the  branches 
of  the  affected  nerve. 

It  is  known  from  the  toothache  by  the  comparative 
shortness  of  the  paroxyms;  the  quickness  of  their  sue 
cession;  the  intervals  of  entire  ease;  the  darling  of 
the  pain  in  the  track  of  the  particular  nerve  affected  , 
the  more  superheial  and  lancinating  kind  of  pain  ; and 
the  convulsive  twitchings  which  sometimes  accompany 
the  complaint. 

The  causes  of  tic  douloureux  may  be.  said  to  be  in 
general  unknown  ; but  there  are  a few  instances  re- 
corded. which  appear  to  be  the  consequence  of  external 
violence,  wounds,  contusions,  &c.  It  is  mentioned  in 
one  of  the  journals,  that  distant  irritations,  especially 
of  the  .splanchnic  neives,  often  produce  this  disease, 
and  that  Sir  H.  Halford  has  met  with  cases  where  the 
discharge  of  portions  of  diseased  bone,  even  from  a 
distant  part,  has  cured  the  complaint.— Chir. 
Remeic.,  Mo.  9,  vol.  3.)  The  difficulty  of  placing  im- 
plicit reliance  on  such  observations  depends  on  the 
fact,  that  di.sorders  frequently  exist  together  in  differ- 
ent parts,  without  having  any  kind  of  connexion  with 
each  other,  and  terminate  quite  as  independeiuly. 

A modern  writer  has  related  a very  curious  instance 
of  a resembling  disease  in  the  arm,  where  the  affection 
proceeded  fioin  the  lodgement  of  a small  hit  of  bullet 
in  the  radial  nerve. — {Devmark,  in  Med.  Chir.  Trans, 
vol.  4,  p.  48.)  Dr.  Parry  attributed  the  pain  to  increased 
vasculaiity  or  determination  of  blood  (perhaps  amount- 
ing to  inflammation)  to  the  neurilema  or  vascular 
membranous  envelope  of  the  nerves  affected. — {Ele- 
ments of  Pathology  and  Therapeutics.) 

Sir  A.  Cooper  states,  however,  in  his  lectures,  that 
the  nerves  in  this  disease  are  certainly  not  in  an  in- 
flamed state;  for  they  are  found  of  their  natural  colour, 
and  rather  diminished  than  enlaiged.  The  latter  fact 
was  ascertained  in  a dissection  made  by  Mr.  'I'liomas. 
An  occasional  thickening  of  the  nerve  is  mentioned  by 
Larrey,  Delpech,  <fec. ; but  whether  from  conjecture  or 
actual  observation  I am  uncettain. 

Stimulating  embrocations,  blisters,  caustic  issues, 
fomentations,  leeches,  friction  with  mercurial  ointment, 
lEdinb.  Med.  and  Sure.  Journ.  vol.  3),  electricity, 
opium  in  large  doses,  ^he  arsenical  solution,  and  a va- 
riety of  antispasmodtc  medicines,  are  the  principal 
means  which  have  been  tried  ; but  for  the  most  part, 
they  only  afford  partial  and  temporary  relief.  Lasserre 
has  reported  two  cases  which  were  cured  by  baik 
joined  with  opium  and  sulphuric  ether  ; and  two  other 
examples  which  yielded  to  pills  composed  of  the  ex- 
tract of  hyoscyamus,  valerian,  and  peroxide  of  zinc. — 
(.Tourn.  Unin.  des  Sciences  Mid.  Mo.  64,  Art.  14.)  Bel- 
ladonna has  often  been  tried  and  often  failed.  Two 
cases,  in  which  it  answered  in  doses  of  two  grains  and 
two  grains  and  a half,  were  lately  published  by  Mr. 
Thompson  of  Whitehaven. — (See  Lond.  Med.  Repo- 
sitory for  July,  1822.)  M.  Piedagnel  cured  a neuralgia 
of  the  infra  orbiiary  nerve,  with  the  sulphate  of  qni 
nine,  ten  grains  of  which  were  blended  with  equal 
portions  of  orange-flowor  water  and  syrup,  and  taken 
in  four  doses,  the  medicine  being  continued  afterward 
in  weaker  doses  for  a short  time.  M.  Dupr6  has  also 
published  various  observations  representing  the  sul- 
phate of  quinine  as  a very  powerful  remedy  for  neu- 
ralgia in  its  various  forms.  The  testimony  of  Dr. 
Rabey  is  also  in  favour  of  its  exhibition,  and  his  opinion 
Is  backed  by  two  cases  in  which  he  tried  the  medicine 
with  success. — (See  Magendic's  Journ.  de  Physiol. 


April,  1^2,  (S-c.)  An  example  of  violent  frontal  neu- 
ralgia yielded  to  pills,  containing  in  each  one-siXih 
of  a gr.  of  arsenious  acid  made  up  with  soap.  This 
case  was  the  consequence  of  an  injury  of  the  os  frontis. 
—{Journ.  Coniplim.  du  Diet,  des  Sciences  Mid.  Mo. 
48.)  From  some  facts  published  by  Dr.  Marcet,  the 
extract  of  stramonium  in  doses  of  one-eighth  and  one- 
half  a grain  thrice  a day,  seems  to  be  sometimes  capa- 
ble of  alleviating  the  distressing  agony  of  the  present 
disorder. — (See  Med.  Chir.  Trans.  vol.l,p.lb,  <S-c. ; 
also  Kirby's  Cases,  ^vo.  Lond.  1819.) 

In  1820,  Mr.  B.  Hutchinson  published  some  cases 
tending  to  prove  that  the  subcarbonate  of  iron,  in  doses 
of  3ij.  or  3j.  two  or  three  times  a day,  is  often  an 
excellent  remedy  for  tic  douloureux.  In  fact,  if  the 
sulphate  of  quinine  be  excepted,  this  medicine  at  pre- 
sent possesses  more  reputation  than  any  other  for  its- 
virtues  in  this  complaint.  It  is  also  highly  eommetided 
by  Sir  A.  Cooper  in  his  lectures.  Yet,  tor  the  follow- 
ing reasons,  a shrew  d critic  views  all  this  praise  v\  ilh 
distrust;  in  all  the  cases,  he  says,  the  iron  was  taken 
in  doses  of  3 j.  three  times  a day,  for  months.  Two 
months,  indeed,  often  elapsed  before  the  pain,  &c.  were 
more  than  slightly  relieved.  This,  he  observes,  is  in 
itself  almost  a proof  of  the  medicine  being  very  inert ; 
but  when  we  find  that  Mr.  Huchinson  conjoins  other 
treatment ; that  he  takes  off  inflammatory  action  ; that 
he  attends  to  the  abdominal  functions  and  to  the  diet, 
and  foi  bids  mercurials,  purgatives,  and  all  medicines 
likely  to  debilitate  the  nervous  system ; we  may  be 
allowed  to  doubt  the  sole  efficacy  of  the  iron  in  curing 
these  cases.  Sure  we  are,  that  the  majority  of  cases 
would  yield  in  less  time  to  the  plans  recommended  by 
Mr.  Aberneihy  for  restoring  the  health,  joined  with 
local  treatment,  calculated  to  relieve  the  inflammation 
which  in  most  cases,  he  says,  probably  affects  the 
nerves  themselves. — (See  Med.  Intelligencer  fur  1822, 
p.  472.)  The  latter  conjecture,  however,  is  rather  re- 
pugnant to  what  is  now  commonly  believed. 

The  strongest  fact  in  proof  of  the  real  efficacy  of  the 
subcarbonaie  of  iron,  is  mentioned  by  Dr.  Crawford : 
a severe  case  was  benefited  soon  after  its  exhibition  ; 
but  by  mistake,  the  carbonate  of  potass  was  then  given 
for  a few  days,  during  which  time  the  spasms  returned 
with  their  usual  violence  and  frequency:  but  when 
the  iron  was  given  again,  the  good  effects  formerly  ex- 
perienced irom  it  returned. — (See  Med.  and  Rhys. 
.Juum.for  Feb.  1823.) 

The  operation  of  dividing  the  trunk  of  the  affected 
nerve,  and  even  of  dissecting  out  a portion  of  it,  so  as 
to  prevent  all  chance  of  a relapse  from  the  reunion  of 
the  ends  of  the  nerve,  is  a plan  which  has  somelimes 
been  practised  with  permanent  benefit.  Thus,  any 
one  of  the  three  branches  of  the  tilth  pair  of  nerves 
may  be  divided  at  the  point  where  it  comes  out  upon 
the  face.  But  before  having  recourse  to  this  means, 
the  surgeon  should  be  sure  that  the  particular  nerve 
which  he  is  about  to  expose  and  divide  is  really  the 
principal  seat  of  the  disease  ; for  when  all  the  nerves 
of  the  face  generally  are  affected,  or  when  the  branches 
of  the  portio  dura  are  especially  concerned,  there  is 
little  hope  of  success.  In  fact,  it  must  be  confessed, 
that  the  operation  has  had  many  failures  and  relapses, 
either  from  the  cases  not  having  been  duly  discrimi- 
nated, or  from  the  neglect  to  remove  a portion  of  the 
exfiosed  nerve.  Richerand,  Delpech,  and  most  of  the 
leading  surgeons  in  France,  express  their  preference  to 
the  application  of  the  moxa  or  cautery,  which,  they 
say,  proves  more  frequently  successful  than  the  knife. 
This  should  be  done  directly  over  the  apertures  from 
which  the  nerves  emerge  on  the  forehead,  cheek,  or 
chin  ; and  Richerand  asserts,  that  by  such  treatment, 
the  pains  may  always  be  cured,  or  at  all  events  ren- 
dered supportable.— (JVo.-so.gv.  Chir.  t.  2,  p.  218,  edit. 
4.)  Delpech  also  affirms  tliat  the  section  of  the  nerve 
very  often  fails,  and  that  issues  and  the  repeated  use 
of  the  cautery  have  been  attended  with  the  greatest 
success. — (See  Precis  des  Mai.  Chir.  t.  3,p.  213  ) The 
disfigurement  of  the  countenance  by  burning  applica- 
tions must,  however,  be  very  objectionable  ; and  as  I 
think  there  is  no  irositive  evidence  of  the  superiority  of 
this  method  over  the  use  of  the  knife,  I consider  what 
Richerand  and  Delpech  have  stated  only  as  another 
instance  of  the  extreme  partiality  of  the  French  sur 
geons  to  the  moxa  and  cauterization.  Delpech  con 
fesses,  however,  that  when  the  pains  seem  to  be  the 
consequence  of  a ganglion  or  thickening  of  a part 


TIC 


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351 


of  a nerve,  the  excision  of  such  part  is  indispen- 
sable. Tliere  can  be  little  doubt  that  this  w'ould 
have  been  more  proper  than  amputation,  in  Mr.  Den- 
mark’s case,  to  which  I have  already  referred.  The 
theories  of  Dr.  Parry,  senior,  who  was  generally  in- 
clined to  refer  the  ertects  of  disease  to  increased  de- 
termination of  blood  to  the  parts  affected,  led  him  to 
believe  that  the  operation  of  cutting  the  nerve,  as 
performed  by  Dr.  Haighton  and  others,  did  good  rather 
by  the  division  of  the  artificial  branch  supplying  the 
affected  ramification  of  the  trigeminus  nerve,  than  by 
the  division  of  that,  ramification  itself. — {Parj  y,  Ele- 
ments of  Pathology,  ire.) 

There  have  been  many  examples  of  tic  douloureux, 
which,  after  resisting  all  attempts  to  cure  them,  have 
been  left  to  themselves,  and  after  a long  time,  spoiita- 
neously  subsided. — {Delpech,  Traite  dcs  Maladies 
Chir.  t.  3,  p.  212.  215.)  This  author  has  seen  the  ope- 
ration of  dividing  the  chief  branches  of  the  portio  dura, 
in  front  of  the  parotid  gland  undertaken,  and  even  a 
portion  of  the  soft  parts  cut  away ; but  without  any 
favourable  consequences. — (P.  218.) 

When  the  infra-orbifary  nerve  is  to  be  divided,  Sir 
A.  Cooper  recommends  it  to  be  done  a quarter  of  an 
inch  below  the  orbit.  The  supra  orbitary  nerve  should 
be  cut  through  just  where  it  passes  out  of  the  supra- 
orbiiary  foramen.  An  instance  in  which  this  measure 
produced  an  immediate  alteration  in  the  seat  of  the 
pain,  may  be  read  in  the  8th  No.  of  the  Quarterly  Jour- 
nal of  Foreign  Med. ; but  the  cure  was  not  complete 
till  the  integuments  had  been  divided  from  the  toot  of 
the  nose  to  the  temple.  The  method  of  dividing  the 
inferior  maxillary  nerve  advised  by  the  same  surgeon, 
is  to  cut  down  to  the  foramen  mentaleon  theinsideof  the 
lip  directly  under  the  bicuspid  tooth.  By  the  division 
of  this  nerve,  M.  Bouillaid  effectually  cured  one  very 
severe  case. — (Bee  hond.  Med.  Repository,  JVo.  79.) 

[ Dr.  Mott  has  adopted  the  practice  of  dividing  the 
nerve  in  almost  every  case  of  neuralgia,  where  it  is 
practicable.  He  has  repealed  this  operation  on  the  in- 
fra-obilary,  mental,  and  other  nerves  so  frequently  and 
with  so  great  success,  that  he  confidently  recommends 
it  to  his  pupils  and  patients.  He  sometimes  insulates 
a portion  of  the  nerve  by  repeated  incisions  through  it 
at  small  distances  from  each  other,  preferring  this  to 
the  removal  of  a portion  of  the  nerve,  as  recommended 
and  practised  by  others. 

My  own  experience  leads  me  to  believe  that  in  those 
cases,  in  which  the  division  of  the  nerve,  by  the  knife, 
the  insulation  or  removal  of  portions  of  it,  all  fail  of 
success,  that  we  have  a remedy  in  the  potass,  pur.  vel 
lapis  inferalis,  which  will  seldom,  if  ever,  fail.  I have 
several  times  cured  the  disease  in  its  worst  forhi  in  the 
pes  anserinus,  and  in  the  infra  orbitary  nerve,  by  ap- 
plying this  vegetable  caustic  until  it  tided  upon  the 
nerve.  Stramonium  and  the  tincture  of  iodine  have 
justly  obtained  reputation  as  internal  remedies  in  this 
disease. 

Professor  Hosack  has  published  among  his  medical 
essays  some  valuable  observations  on  tic  douloureux, 
in  which  he  contends  that  neuralgia  is  not  a local  affec- 
tion or  disease  of  a particular  nerve,  and  to  be  removed 
by  the  division  of  such  nerve;  but  a disease  dependent 
upon  the  whole  system,  and  oidy  to  be  counteracted  by 
remedies  addressed  to  the  peculiar  state  or  condition  of 
the  cotistitution. — Reese  ] 

I have  already  slated,  that  the  nerves  of  the  extremi- 
ties are  subject  to  affections  very  analogous  to  tic  dou- 
loureux. The  following  instance,  rela*ed  by  Mr.  Aber- 
nelhy,  will  be  found  interesting; — 

A lady  became  gradually  affected  with  a painful  state 
of  the  integuments  under,  and  adjoining  to,  the  inner 
edge  of  the  nail  of  the  ring-finger  of  the  left  hand.  No 
Injury  to  the  part  was  remembered,  which  could  have 
brought  on  this  disease.  'J'lie  pain  occurred  at  irregu- 
lar intervals,  and  was  extremely  severe  during  the  lime 
of  its  continuance,  which  was  for  a day  or  two,  when 
it  urually  abated.  Accidental  slight  injuries  always 
produced  great  pain,  and  frequently  brought  on  the  pa- 
roxysms, which,  however,  occasionally  occurred  spon- 
taneously, or  without  any  evident  exciting  cause.  In 
all  these  particulars,  the  disease  correctly  resembled  tic 
douloureux.  As  the  pain  increased,  the  disorder  seemed 
to  extend  up  the  nerves  of  the  arm.  After  the  patient 
had  endured  this  painful  affliction  for  seven  years,  she 
Bubmitled  to  have  theskin, which  was  theoriginal  seat  of 
the  disorder,  burnt  with  caustic.  This  application  gave 


her  intense  pain,  and,  on  the  healing  of  the  wound,  she 
found  her  sufferings  rather  augmented  than  diminished 
by  the  experiment.  After  four  years  more  of  suffering, 
she  consulted  Mr.  A-bernethy,  when  the  circumstances 
of  the  case  were  such  as  to  render  an  operaiion  indis- 
pensably necessary.  The  pain  of  the  part  was  intole- 
rable, and  it  extended  all  up  the  nerves  of  the  arm  ; and 
this  general  pain  was  so  constant  during  the  night  as  to 
deprive  the  patient  of  rest.  The  muscles  of  the  back 
of  the  neck  were  occasionally  affected  with  spasms. 
The  integuments  of  the  affected  arm  were  much  hotter 
than  those  of  the  opposite  arm,  and  sometimes  the  leii;- 
perature  was  so  increased  as  to  cause  a burning  sensa- 
tion in  them.  Under  these  circumstances,  Mr.  Aber- 
nethy  did  not  hesitate  to  divide  the  nerve  of  the  finger 
from  which  all  this  disorder  seemed  to  originate.  He 
laid  it  bare  by  a longitudinal  incision  of  about  three 
quarters  of  an  inch  in  length,  from  the  second  joint  of 
the  finger,  and  divided  it  oppo.-ile  to  that  joint,  by  a 
curved  sharp-pointed  bistoury,  which  was  conveyed 
under  it.  He  then  took  hold  of  the  nerve  with  a pair 
of  'forceps,  and  reflecting  it  downwards,  removed  a por- 
tion itj  half  an  inch  in  length,  so  that  the  possibility  of  a 
quick  re-union  might  be  prevented.  The  wiuind  was 
brought  together  with  sticking  plaster,  and  it  united 
by  adhesion  ; but  the  upper  part  of  the  wound,  oppo 
site  to  the  upper  end  of  the  nerves,  became  slightly  in- 
flarnmed  and  was  very  painful.  However,  in  the 
course  of  three  weeks,  the  appearance  of  inflammalion 
gradually  went  off.  After  the  operation,  Mr.  Aberne- 
thy  pinched  the  oiiginally  affected  integuments  sharply 
with  his  nails,  without  causing  any  sensation  ; but  if, 
in  so  doing,  he  moved  the  finger,  then  pain  was  felt. 

The  result  was,  that  nine  months  afier  the  operation, 
the  general  pains  in  the  nerves  had  become  very  trivial  • 
but  the  sensation  in  the  integuments  at  the  end  of 
the  finger  had  gradually  increa.«ed,  and  the  skin  had 
now  its  natural  sen.-ibility,  so  as  accurately  to  distin- 
guish the  tangible  properties  of  any  body  applied  to  it. 
If,  also,  the  originally  affected  part  was  slightly  com- 
pressed, painful  sensations,  resembling  those  which  for- 
merly occurred,  took  place. — {.Bbernethy' s Surgical 
Works,  vol.  2,  p.  203.)  In  a case  resembling  the  for 
mer,  but  the  consequence  of  a wound  of  the  finger,  Mr. 
Lawrence  also  cut  down  to  the  nerve  and  removed  a 
portion  of  it  with  permanent  success.  In  a case  of  se- 
vere  pain  in  the  thumb,  extending  up  the  arm  to  ho 
neck,  and  causing  a distortion  of  the  neck,  fits,  &c.,  Sir 
A.  Cooper  cut  down  upon  the  radial  nerve,  by  the  side 
of  the  flexor  carpi  radialis  longus,  and  cut  out  about 
five-eightbs  of  an  inch  of  it.  The  result  was  a com- 
plete cure.— (Lancet,  vol.  3,  p.  113.)  Fothergill's  Pa- 
per in  vol.  5,  of  the  Medical  Obs.  and  Inq.  Dr.  Haigh- 
ton's Obs.  in  the  Med.  Records  and  Researches.  Dar- 
win's Zoonornia.  jSberjiethy's  Surg.  Works,  vol.  2,  p. 
203,  Src.  Richerand,  JVosogr.  Chir.  t.  2,  p.  216,  ^c.  edit. 
4.  Dclpech,  Prdcis  dcs  Maladies  Chir.  t.  3,  p 206,  (S-c. 
Dr.  S.  Folhergill'.s  Systematic  Jiccount  of  Tic  Dou- 
loureux, 1804.  Med.  Chir.  Trans,  vol.  4,  p.  48  , vol.  7, 
P.5'75,  ^-c.  Kirby's  Cases, 8vo  J.,ovu  18\9.  B.  Hutch- 
inson, cases  of  Tic  Douloureux,  8vo.  1820.  Jilso  2d 
Cfiit.  1822.  Richmond,  in  Lond.  Med.  Phys.  Journ. 
Sept.  1821:  a case  in.  favour  of  subcarbonate  of  iron. 
Wadell,  in  Edinb.  Med.  .Tourn.  Mo.  32  ; case  to  the  same 
purport.  Lizars,  in  same  work,  Mo.69.  Carter's  case 
in  Med.  Repository,  Mo.  89.  Jj.  D.  Yeate' s Review  of  a 
severe  case  of  Mcuralgia,  iS-c.  with  observations,  1822. 
Dr.  Stewart  Crawford,  m Med.  and  Phys.  .Tourn.  Feb. 
1823.  Also,  T.  Thomson, in  the  same  Mo.;  and  ad- 
ditional cases  by  various  other  practitioners  in  theMos. 
for  Jlpril,  June,  and  September,  1823.  A.  Wilson,  in 
Edinb.  Med.  .Journ.  Mo.  75  : a case  cured  by  purgatives, 
followed  by  bark,  after  the  subcarbonate  of  iron  and  liq. 
arsenicalis  had  failed.  H.  Jeffries,  Meuralgia  of  the 
Median  Merve,  after  a bum  on  the  thumb,  cured  by  .snb- 
cn-bonate  of  iron.  See  Med.  and  Phys.  .Tourn.  May, 
1823.  T.  Taylor,  in  Edinb.  Med.  Journ.  Mo.  76;  car- 
bonate of  soda,  hemlock,  and  the  prussic  acid,  pre- 
scribed with  success. 

TINCTURA  CANTHARIDIS.  Sometimes  em- 
ployed  in  gleets,  and  incontinence  of  urine,  arising 
from  award  of  proper  action  in  the  sphincter  vesicfe 
muscle.  The  usual  dose  is  from  ten  to  forty  drop.a, 
twice  or  thrice  a day ; but  its  effects  should  be  carefully 
watched  ; for  it  is  apt  to  occasion  dangerous  inffanuna- 
lions  of  the  urinary  organs,  violent  stranguries,  and  re- 
tention of  urine.  It  is  occasionally  added  to  various 


352 


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TON 


liniments,  when  the  object  is  to  stimulate  the  skin  con- 
siderably and  rouse  the  action  of  the  nerves  and  absorb- 
ents, as  III  certain  cases  of  ptosis,  paralysis,  &c.  Dr. 
Anthony  Todd  Thomson  found  it  a useful  application 
in  the  moriilicatioa  of  the  extremities,  sometimes  liap- 
pening  without  any  apparent  cause;  and  also  to  frost- 
bitten parts. — {London  Dispensatory^  p.  658,  ed.  2.) 

[The  tincture  of  cantharides  has  long  been  in  use,  even 
internally,  but  its  value  as  a remedy  in  many  cases 
where  tonics  and  excitants  are  indicated,  has  but  re- 
cently become  well  established,  and  for  its  free  admi- 
nistration for  these  purposes  we  are  more  especially  in- 
debted to  lloberton  of  Edinburgh.  In  cases  of  long 
protracted  seminal  weakness,  in  gleet,  in  leucorrhcea, 
and  in  various  affections  of  the  bladder,  its  value  must 
not  be  overlooked.  Mr.  Roberton  has  given  us  his 
experience  that  it  may  be  deemed  almost  a specific  in 
leucorrhcea,  but  the  results  of  the  practice  of  our  Ame- 
rican physicians  do  not  coincide  with  those  of  this  in- 
trepid prescriber  in  this  disease.  And  when  we  consi- 
der the  various  causes  upon  which  leucorrhcea  may  de- 
pend, we  are  not  to  wonder  at  its  failure  in  so  embar- 
rassing a malady.  That  this  disorder  does,  however,  fre- 
quently yield  to  this  prescription,  we  have  many  cases 
to  prove.  It  is,  however,  especially  in  protracted  gleets, 
in  seminal  weakness,  and  in  im potency,  that  the  reme- 
dy is  found  most  available,  and  the  extent  to  which  it 
may  be  given  without  inducing  those  direful  effects 
which  some  have  attributed  to  it  deserves  to  be  recorded. 
The  usual  dose  to  begin  with  is  about  twenty  or  thirty 
drops  three  times  a day  ; this  quantity  may  be  gradually 
increased,  after  a few  days,  to  a diachm  three  times  a 
day,  and  often  to  the  extent  of  two  drachms,  as  often 
repeated.  It  has  been  administered  to  a much  larger 
amount,  and  with  perfect  safety,  in  the  hands  of  Pro- 
fessor Francis,  of  New-York,  by  whom  this  practice  to 
a great  extent  has  been  adopted.  It  is,  however,  to  be 
borne  in  mind,  that  the  beneficial  effects  of  the  ly  tta  are 
best  secured  by  persisting  for  a considerable  while  in 
the  use  of  the  remedy  in  moderate  doses,  rather  than 
by  excessively  large  ones.  “ In  no  instance,”  says  Dr. 
F.,  “have  I found  those  evils  to  ensue  from  its  use  which 
some  have  affirmed  to  be  a consequence  of  it,  and  I be- 
lieve that  I have  administered  it  more  fieely,  and  to  a 
greater  extent,  than  any  preset  iber  with  whom  I am 
acquainted.  In  seminal  weakness,  and  in  impotency, 
it  cannot  be  too  highly  prized.  In  some  cases  entire 
restoration  has  been  efiected  by  the  cauthai  ides,  in  con 
junction  with  other  tonics,  adapted  to  existing  circum- 
stances, vviihin  the  course  of  two  or  three  months;  in 
other  instances,  the  remedy  has  been  administered  for 
some  two  years  and  upwards,  m with  the  happiest  re- 
sults.”— Reese.'^ 

TINCTURA  FERRI  MURIATIS  has  sometimes 
been  exhibited  in  gleets  ; but  a more  important  use  was 
assigned  to  it  by  Mr.  Cline,  who  ordered  it  in  dysuria 
from  stricture^  in  the  dose  of  ten  drops  every  twenty  or 
thirty  minutes,  until  nausea  is  excited.  Where  chaly- 
beates  are  indicated,  this  preparation  is  one  much  ap- 
proved. 

“ Mr.  Justamond’s  liquid  for  external  use  in  cancers, 
and  which  the  original  inventor  called  his  panacea 
anticancrosa,  partook  considerably  of  the  nature  of  this 
tincture,  which,  indeed,  with  an  equal  quantity  of  spi- 
rit of  w ine,  was  sometimes  substiiutcd  for  it. 

“ Lastly,  it  is  remarkably  efficacious  in  destroying  ve- 
nereal or  other  warts,  either  used  alone  or  diluted  with 
a small  proportion  of  water.”— (P/tarrn.  Chir.) 

Tinctura  Iodine.  Take  of  alcohol,  7 dr.  52  gr. 
troy;  iodine,  gr.  39  1-3  troy:  dose,  10  drops  three 
times  a day  in  a little  sweetened  water;  used  in  bron- 
chocele  and  cases  of  scrofula. — (See  also  Iodink,  and 
Magen die's  Formulary^  2d  edit,  translated,  p.  35.  The 
dose  should  be  gradually  increased,  if  necessary,  to  25 
or  30  minims  thrice  a day. 

TINCTURA  'I’HEBAICA.  See  Vinum  Opii. 

TINEA  capitis!  See  Porrigo. 

TOBACCO  is  used  for  promoting  the  reduction  of 
strangulated  hernia,  either  in  the  form  of  a fluid  clys- 
ter, or  of  smoke,  which  latter  is  introduced  up  the  rec- 
tum by  means  of  an  apparatus.  Excepting  the  opera- 
tion, the  power  of  tobacco,  particularly  when  assisted 
by  the  topical  application  of  cold  to  liie  tumour,  is  most 
to  be  depended  upon  for  the  bringing  about  the  return 
of  the  protruded  viscera. — (See  Hernia  and  Rvema.) 
Tobacco  clysters  have  also  been  tried  with  advantace 
in  traumatic  tetanus  {O'Beime,  in  Dublin  Hospital 


Reports  ;)  and  Mr.  Earle  found  tobacco  clysters  very 
efficacious  in  certain  cases  of  retention  of  urine. — (See 
Tetanus,  and  Urine,  Retention  of.)  Consult  T.  Fow- 
ler, Medical  Reports  of  the  Effects  of  Tobacco,  8vo. 
Land.  1785.  JJ.  P.  Wilson,  an  Experimental  Essay 
on  the  Manner  in  which  Opium  and  Tobacco  act  on  the 
living  animal  Body,  8vo.  Edinb.  1795.  R.  Hamilton, 
De  J^icotiance  Viribus  in  Medicina,  &c.  8vo,  Edinb. 
1780. 

TONGUE,  DISEASES  OF.  This  part  is  subject  to 
various  diseases,  as  ulcers,  tumours,  and  such  enlarge- 
ments as  sometimes  cause  imminent  danger  of  suffo- 
cation. 

It  is  correctly  noticed  by  Mr.  Earle,  that,  when  any 
morbid  action  is  set  up  in  the  tongue,  many  things  con- 
tribute to  maintain  it.  “The  extreme  mobility  of  that 
organ  ; the  almost  continual  use  of  it  in  eating,  drink- 
ing, and  speaking ; the  contact  of  the  teeth,  which  are 
often  irregular  and  decayed ; are  quite  sufficient  to  in- 
terrupt any  efforts  to  restore  a healthy  action.  It  often 
happens,  too,  that  the  part  is  so  very  tender,  that  the 
patient  cannot  bear  to  cleanse  the  mouth  and  teeth, 
which  soon  become  incrusted ; and,  from  this  source 
alone,  the  complaint  will  be  greatly  aggravated,  and 
the  discharge  rendered  fetid  and  irritating.” — {Med. 
Chir.  Trans,  vol.  12,/».  283.)  The  matter  with  which 
the  teeth  become  incrusted  in  tliese  cases,  is  composed 
of  phosphate  of  lime  and  mucus  ; and  in  the  case  re- 
corded by  Palelta,  to  which  I shall  presently  refer,  the 
quantity  of  it  was  very  considerable. 

Carious  teeth,  with  points  and  inequalities,  producing 
continual  irritation,  are  the  mast  frequent  cause  of  ul- 
cerations of  the  tongue.  The  sores  thus  arising  often 
resist  every  kind  of  remedy,  and  ignorance  of  the  cause 
sometimes  leads  the  practitioner  to  consider  them  as  ir- 
remediable ; whereas,  a cure  may  easily  be  efiected  by 
extracting  the  carious  tooth,  or  simply  filing  off  its 
sharp  irregularities,  as  was  anciently  directed  by  Celsus. 

The  glandular  papillte,  situated  on  the  dorsum  of  the 
tongue,  have  a narrow  base,  and  a broad  termination 
or  head,  fike  a mushroom.  They  are  capable  of  be- 
coming considerably  enlarged,  so  as  to  form  preterna- 
tural tumours,  which  may  be  mistaken  for  cancerous 
excrescences. 

A young  man,  eighteen  years  of  age,  had  on  the  mid- 
dle of  his  tongue  a circumscribed  tumour  about  as 
large  as  a middle-sized  nutmeg.  Louis,  who  was  con- 
sulted, perceived  that  the  swelling  was  only  of  a fun- 
gous nature,  and  he  tied  its  base  with  a ligature,  with 
the  noose  of  which  he  contracted  the  diametei  of  the 
pedicle,  while  with  the  ends  he  kept  down  the  tongue. 
Then,  with  one  stroke  of  a pair  of  curved  scissors  he 
cut  off  the  tubercle.  Caustic  was  afterward  applied 
to  the  base  of  the  tumour,  and  the  patient  was  perfectly 
well  in  five  or  six  days. — {Sur  les  Maladies  de  la 
Langue,  in  Mim.  de  I'jicad.  de  Chir.  t.  5.)  Similar 
tubercles  are  mentioned  by  Morgagni. 

A peculiar  disease  of  the  tongue  was  met  with  in  a 
boy  by  Mr.  Earle.  Clusters  of  very  minute  semitrans- 
parent vesicles  pervaded  the  whole  thickness  of  the 
tongue,  occupying  nearly  one-half,  and  projecting  con- 
siderably both  above  and  below  that  organ.  The 
slightest  injury  caused  them  to  bleed  profusely,  and,  in 
some  places,  the  clusters  were  separated  by  deep  clefts, 
which  di>charged  a fetid,  irritating  sanies.  This  disease, 
which  had  resisted  various  plans  of  treatment,  both 
local  and  constitutional,  gradually  yielded  to  perfect 
quiet,  cleanliness,  large  doses  of  hyoscyamus,  which 
were  increased  to  3j.  of  the  extract  daily.”— (JWcef. 
Chir.  TVans,  vol.  12,  p.  285.) 

The  same  medicine,  he  says,  he  has  employed  with 
most  unequivocal  good  effect  in  many  cases  of  ragged, 
irritable  ulcers  of  the  tongue. 

The  tongue  is  occasionally  affected  with  a true  can- 
cerous disease  ; one  of  the  most  affiicting  cases  indeed 
which  can  possibly  happen,  as  maybe  conceived,  when 
it  is  known  that,  in  the  advanced  stage  of  the  disease, 
the  patient  can  hardly  take  his  food,  w’hich  must  be 
conveyed  over  the  tongue  by  some  means  or  another, 
before  it  can  be  swallowed,  while  he  is  obliged  to  write 
w’hatever  he  wishes  to  say. — (See  Home's  Proct.  Obs. 
on  Cancer,  p.  1 12.)  Cancer  of  the  tongue  seems  to  dif- 
fer from  other  carcinomatous  affections  in  frequency 
occurriin.'  in  youngish  subjects.  In  the  course  of  the 
disease,  the  glands  behind  the  jaw  and  in  the  neck  are 
sometimes  affected.  Louis  saw  a lady,  who  had  an 
ulcerated  cancerous  tubercle  on  the  left  edge  of  the 


TONGUE. 


353 


tongue.  The  little  swelling  was  circumscribed ; its  sire 
did  not  exceed  that  of  a filbert ; the  pains  were  lanci- 
nating; the  sore  had  penetrated  deeply;  and  its  tuber- 
culated  edges  were  affected  with  a scirrhous  hardness. 
Extirpation  of  the  disease  seemed  to  present  the  only 
chance  of  cure  ; but  the  patient  refused  to  accede  to 
any  thing  but  palliative  plans,  and  she  died  in  the  course 
of  a few  months. 

One  of  the  best  descriptions  of  cancer  of  the  tongue, 
is  that  lately  published  by  Mr.  Travers.  The  disease, 
he  says,  “ is  not  a smooth  and  firm  rounded  tubercle, 
such  as  is  often  met  with  in  this  organ,  but  an  irregu- 
lar rugged  knob  in  its  first  stage,  generally  situated  in 
the  anterior  third,  and  midway  between  the  raphd  and 
one  edge.  It  sometimes,  hut  seldom,  extends  across 
the  middle  line,  although  it  often  extends  alongside  of 
it.  The  hardness  is  unyielding,  inelastic,  and  the  mu- 
cous surface  puckered  and  rigid.  It  also  gives  to  the 
finger  and  thumb  of  the  surgeon  the  sensation  of  so- 
lidity, or  of  its  penetrating  the  entire  muscular  sub- 
stance, being  perceived  equally  on  either  surface. 
Sharp  shoots  of  pain  are  felt  through  the  side  of  the 
affected  organ,  towards  the  angle  of  the  jaw  and  ear. 
The  disease  tends  to  run  backwards  towards  the  base 
or  posterior  edge.  It  sometimes  acquires  great  bulk 
before  ulceration  takes  place,  so  as  to  project  the 
tongue  from  the  mouth.  In  this  state  a female  patient 
of  mine  was  seen  some  time  ago  in  St.  Thomas’s  Hos- 
pital, in  whom  the  permanent  projection  of  the  dis- 
eased organ , beyond  the  widely-distended  lips,  was  from 
three  to  four  inches.  Life  was  sustained  for  a time 
by  nutritive  injections.  The  ulceration  often  extends 
from  the  edge  of  the  tongue  to  the  membrane  of  the 
mouth  and  gums,  when  the  elevated  and  distended 
membrane  at  length  gives  way,  and  ulceration  is  rapid. 
The  surface  of  the  ulcer  is  very  uneven,  clean  and 
bright  granulations  appearing  in  parts,  and  in  others 
deep  and  sloughy  hollows.  The  darting  pain  is  very 
acute,  but  only  occasional.  There  is  a dull  aching  always 
present,  and  as  constant  a spitting  as  in  deep  saliva- 
tion. The  irritation  is  such  as  soon  impairs  the  powers 
of  life.  It  happens  to  strong  and  hitherto  healthy  per- 
sons, for  the  most  , part  males  from  the  age  of  forty 
onwards.  There  is  generally  an  evening  paroxysm  of 
pain ; and  the  nights  are  much  disturbed  by  the  secre- 
tion accumulating  in  the  throat,  and  exciting  cough. 
Often  the  patient  is  roused  by  a painful  compression 
of  the  tongue  falling  between  the  jaws.  The  leaden 
hue  of  the  countenance,  the  loss  of  flesh,  and  diffi- 
culty of  taking  food,  although  symptoms  of  the  ad- 
vanced stage  of  the  disease,  are  observed  long  before 
the  appetite  or  muscular  powers  fail  in  proportion. 
Frequent  moisture  with  mild  fluids,  as  tepid  milk  and 
water,  or  confectioners’  whey,  is  grateful  to  the  patient. 
Towards  the  fatal  termination  of  the  disease,  occa- 
sional profuse  hemorrhages  take  place  at  shortening 
intervals,  and  alarm  and  weaken  the  patient,  who  ul- 
timately dies  tabid  and  exhausted,  generally  with 
syniptonis  of  more  extensive  disease  of  the  mucous 
membrane  in  other  parts.” — {Travers.,  in  Med.  Chir. 
Trans,  vol.  15,  p.  245.) 

Forestus  makes  mention  of  four  women  who  were 
attacked  with  cancer  of  their  longues,  and  died  from 
the  ravages  of  the  disease  and  hemorrhage.  In  the 
writings  of  Hildanus,  there  is  a description  of  the 
origin  and  progress  of  a cancerous  tubercle  on  a young 
man’s  tongue,  whose  breath  was  intolerably  fetid,  and 
who  died  in  the  most  excruciating  pain.  The  same 
author  informs  us  of  another  case,  exhibiting  the  good 
effects  of  sedative  remedies  in  palliating  a cancerous 
ulcer  of  the  tongue,  and  the  fatal  consequences  of  an 
opposite  line  of  conduct. 

It  is  much  easier  to  cut  off  a portion  of  the  tongue, 
through  all  its  diameter,  than  to  remove  a cancerous 
ulceration  situated  at  one  of  its  edges. 

In  both  cases  there  is  a good  deal  of  difficulty  in 
fixing  the  part.  For  this  purpose,  Louis  recommended 
the  employment  of  forceps,  with  blades  terminating 
in  hook-like  extremities.  With  this  instrument,  the 
part  of  the  tongue  about  to  be  amputated  can  be  kept 
from  slipping  away. 

When  any  part  of  the  tongue  is  to  be  amputated, 
authors  very  properly  recommend  the  chief  vessels  to 
be  tied  if  possible ; but  when  this  cannot  be  accom- 
plished, they  advise  the  employment  of  astringent 
gargles,  such  as  a strong  solution  of  alum,  distilled 
vinegar,  or  diluted  sulphuric  acid.  When  these  me- 

^'OL.  II.-Z 


thods  fail,  the  continental  surgeons  recommend  the 
actual  cautery  as  the  only  resource.  When  only  a 
piece  of  the  tongue  is  cut  out,  in  the  shape  of  the  letter 
V,  the  best  mode  of  slopping  the  bleeding  is  to  bring 
the  sides  of  the  incision  together  with  a suture;  by 
which  means,  the  deformity  will  also  be  lessened,  and 
the  union  expedited,  as  is  exemplified  in  a case  re- 
corded by  Langenbeck. — (JVeite  Bibl.  b.  2,  p.  489.) 
Rather  than  suffer  a patient  to  die  of  hemorrhage,  if 
the  cautery  and  other  means  fail,  the  lingual  artery 
should  be  taken  up  where  it  passes  over  the  cornu  of 
the  os  hyoides.  Diseased  portions  of  the  tongue  admit 
of  removal  with  the  ligature.— (La  Motte,  Chirurgie, 
o6s.  208;  Godart,  in  Journ.  de  Med.  t.  13,  66;  Sir 

E.  Home,  Tract.  Obs.  on  Cancer,  p.  207 ; Inglis,  in 
Edin.  Med.  and  Surgical  Journ.  1803,  Mo.  l,p.  34.) 
Sir  E.  Home  generally  passed  a double  ligature  through 
the  centre  of  the  tongue  behind  the  diseased  portion, 
and  then  tied  the  threads  tightly  over  each  half  of  the 
organ,  so  as  to  make  all  the  part  in  front  of  the  con- 
striction slough  away. 

Mr.  Travers  is  of  opinion,  that  cancer  of  the  tongue 
only  admits  of  palliative  treatment.  He  has  seen  but 
one  case  in  which  the  ligature  or  knife  had  been  em- 
ployed, and  in  which  he  did  not  witness  or  hear  of  a 
recurrence  of  the  disease  before  a twelvemonth  had 
elapsed.  Excision  he  sets  down  as  hardly  safe,  when 
practicable  through  the  sound  parts.  The  actual  cau- 
tery and  the  lunar  caustic,  he  says,  decidedly  aggra- 
vate the  malady.  All  stimulant  applications,  myrrh, 
alum,  zinc,  copper,  and  even  borax,  he  has  found  to 
increase  the  pain  and  mischief.  The  carbonate  of 
iron,  and  alkaline  carbonates,  according  to  his  expe- 
rience, are  useless.  A wash  made  of  two  oz.  of  lime- 
water,  and  half  a drachm  of  calomel,  suspended  in  it 
by  means  of  mucilage,  he  deems  the  best  application. 
Opium,  locally  applied,  he  says,  rarely  has  an  ano- 
dyne effect ; and  he  represents  the  disease  as  not  being 
permanently  influenced  either  by  mercury,  steel,  arse- 
nic, iodine,  prussic  acid,  bark,  nr  any  other  medicine. 
— (See  Med.  Chir.  Trans,  vol.  15,  p.  247.) 

However,  very  malignant  ulcers  on  the  tongue  have 
sometimes  been  cured  without  the  removal  of  the 
part.  Sores  of  this  description  are  reported  to  have 
yielded  to  the  repeated  application  of  leeches  under 
the  tongue,  after  a vast  number  of  other  remedies  liad 
been  tried  in  vain.  In  the  Encyclopedic  Methodique, 
art.  Langue,  there  is  an  account  of  a very  alarming 
affection  of  the  tongue  (reputed  to  be  cancerous, 
though  this  may  be  doubted),  which  got  completely 
well  under  a very  simple  plan  of  treatment.  A woman, 
thirty-five  years  of  age,  subject  to  cutaneous  diseases 
and  ill-conditioned  ulcers,  complained,  for  seven  or 
eight  months,  of  little  swellings,  accompanied  with 
heat  and  pain,  which  made  their  appearance  on  the 
edge  and  towards  the  apex  of  the  tongue.  At  length, 
the  part  affected  began  to  swell,  grow  hard,  and  cause 
lancinating  pains.  Its  surface  became  irregular  and 
rough;  and  all  the  side  of  the  tongue  was  considerably 
swelled.  The  patient  could  not  put  her  tongue  out  of 
her  mouth,  nor  swallow  any  thing  except  liquids ; and 
her  breath  was  intolerably  fetid.  Various  sedative 
remedies  had  been  employed  without  success.  Cicuta 
had  been  used  as  a topical  application  ; it  had  been 
exhibited  internally  in  large  doses;  the  patient  had 
taken,  for  a long  while,  the  oxymuriate  of  mercury; 
but  nothing  proved  of  any  avail.  At  length,  the  pa- 
tient was  so  tired  of  trying  the  effect  of  medicines  and 
applications,  that  she  gave  them  up  entirely  ; and  con- 
tented herself  with  trying  the  experiment  of  keeping 
some  honey  continually  in  her  mouth.  As  this  method 
seemed  to  cive  her  some  ease,  she  was  prevailed  upon 
to  persist  in  it,  and  in  this  way  the  pains  were  gra- 
dually appeased ; the  swelling  was  diminished,  and 
at  the  end  of  two  or  three  months  she  was  quite  well, 
except  that  an  indurated  cicatrix  remained  on  the  part 
affected,  and  considerably  obstructed  the  extension  of 
the  tongue  on  that  side. 

On  this  case,  iiowever,  it  might  be  remarked,  that 
the  retardation  of  the  cure  seems  also  ascribable  to  the 
injury  of  the  health  produced  by  the  hemlock,  mercury, 
&c. ; and  that  the  amendment,  following  their  discon- 
tinuance, might  rather  have  arisen  from  the  conse- 
quent improvement  of  the  patient’s  healtii  than  from 
any  effect  of  the  honey. 

Some  inveterate  diseases  of  the  tongue  may  be 
cured  by  hemlock.  In  the  work  last  cited  is  mentioned 


354 


TON 


TON 


nn  instance  of  a very  unhealthy-looking  ulcer  near 
the  apex  of  tl)e  tongue,  attended  with  a considerable 
thickening  of  the  part,  and  of  some  duration,  which 
was  cured  by  giving  large  doses  of  cicuta.  But  of  all 
the  medicines  which  have  the  greatest  reputation  for 
their  beneficial  effects  upon  malignant  ulcers  of  the  lip 
and  tongue,  none  perhaps  is  deserving  of  so  much 
confidence  as  arsenic. — (See  C.  Lane's  case  of  ill-con- 
ditioned Ulcer  of  the  Tongue,  successfully  treated  by 
Arsenic,  Med.  Chir.  Trans,  vol.  8,  p.  201.)  Mr. 
Earle’s  report  of  the  favourable  effects  of  hyoscyamus, 

I have  already  noticed:  he  speaks  also  in  praise  of  the 
l>ulp  of  carrots  retained  on  the  ulcer,  and  frequently 
clianged. — ( Op.  cit.  vol.  12,  p.  286.) 

However,  notwithstanding  many  facts  of  this  kind 
on  record,  medicines  should  not  be  tried  too  long,  that 
is  to  say,  so  as  to  let  the  disease  attain  a condition  in 
which  it  will  no  longer  admit  of  being  cut  away. 
When  the  disease  makes  progress,  the  knife  should  be 
emjtloyed  before  it  is  too  late.  ’ 

The  whole  of  the  tongue  sometimes  inflames,  and. 
becomes  considerably  enlarged,  either  spontaneously 
and  without  any  apparent  cause,  or  in  consequence  of 
some  other  disease ; or  else  from  some  particular  irri- 
tation, such  as  that  of  mercury  or  some  poisonous 
substance.  Siegel,  who  was  at  Paris  about  the  middle 
of  the  17th  century,  saw  a patient  in  a salivation, 
whose  tongue  became  so  enormously  enlarged  that  the 
mouth  could  not  contain  it.  Pimprenelle,  an  eminent 
surgeon  of  that  time,  was  sent  for,  and,  finding  that  all 
trials  to  relieve  the  affection  were  in  vain,  amputated 
one-half  of  the  tongue  with  the  view  of  preventing 
its  mortification.  After  the  wound  had  healed,  it  is 
said  the  patient  could  articulate  very  well.  Louis, 
from  whom  this  fact  is  quoted,  justly  remarks,  that  the 
measure  resorted  to  by  Pimprenelle  was  an  exceedingly 
violent  one;  for  he  has  often  seen  urgent  symptoms 
occasioned,  during  a salivation,  by  a rapid  and  enor- 
mous swelling  of  the  tongue,  very  quickly  yield  to 
bleedings,  purgative  clysters,  change  of  air,  and  leaving 
off  mercury.  Two  or  three  facts  confirming  this 
statement  have  fallen  under  my  own  notice. 

Trincavellius  mentions  two  women  who  had  con- 
siderable enlargements  of  their  tongues.  One  of  these 
patients,  who  was  young,  had  been  rubbed  with  mer- 
curial ointment  on  her  head ; and  in  the  other,  who 
was  about  fifty  years  old,  the  complaint  arose  from  the 
small  pox.  The  excessive  swelling  of  the  tongue,  in 
both  these  instances,  terminated  in  resolution.  An- 
other case  of  ulceration,  enlargement,  and  protrusion 
of  the  tongue  is  recorded  by  Paletta,  who  recom- 
mended the  reduction  of  the  part  into  the  mouth, 
keeping  the  jaw  closed  with  a bandage,  and  the  fre- 
quent use  of  vinegar  and  alum  gargles.  The  result  is 
not  stated. — (See  Journ.  of  Foreign  Med.  Mo.  19, 
p.457.) 

When  the  urgency  is  such,  that  an  immediate  dimi- 
nution of  the  swelling  becomes  necessary  for  the  re- 
lief of  the  symptoms,  the  plan  of  making  one  or  two 
deep  incisions  along  the  tongue  is  strongly  recom- 
mended. See  the  cases  inserted  by  De  la  Malle,  in  the 
5lh  vol.  4to.  of  thd  Mein,  de  I' Acad,  de  Chirurgie,  and 
some  others,  related  by  Louis  in  the  paper  above  cited. 

A man,  recovering  from  a bad  fever,  was  suddenly 
attacked  with  a pain  in  his  tongue,  followed  by  a 
swelling  equally  large  and  rapid  in  its  formation.  In 
le-ss  than  five  hours  the  part  became  thrice  as  large  as 
it  is  in  its  natural  state;  and  in  this  space  of  time  De 
la  Malle,  who  had  been  consulted,  bled  the  patient 
successively  in  bis  arm,  neck,  and  foot.  The  man  felt 
very  acute  pain,  his  skin  was  excessively  hot,  his  face 
was  swelled,  his  pulse  was  hard  and  contracted,  and 
his  look  wild.  He  could  hardly  breathe:  the  tongue 
filled  all  the  cavity  of  the  mouth,  and  protruded  be- 
tween the  lips.  In  this  very  urgent  case,  the  mouth 
was  kept  a little  more  open  than  the  swelling  of  the 
tongue  actually  caused  it  to  be,  and  three  parallel  in- 
cisions were  made  along  this  organ;  one  along  its 
middle,  and  the  other  two  between  the  one  in  the  cen- 
tre and  the  edges  of  the  part  afl!ected.  The  cuts  ex- 
tended through  two-thirds  of  the  preternatural  swell- 
ing, and  had  all  the  good  effect  which  could  possibly 
he  desired.  There  was  a great  deal  of  hemorrhage, 
and  the  enlargement  of  the  tongue  subsided  so  much, 
that  an  hour  after  the  operation  the  patient  was  able 
to  speak.  The  next  day,  the  incisions  had  the  appear- 
ance of  being  only  superficial  scarifications,  and  the 


tongue  was  in  its  natural  state.  In  short,  the  incisions 
healed  in  a few  days,  with  the  use  of  a simple  gargle. 

De  la  Malle  quotes  several  other  cases,  all  of  which 
exhibit  the  success  which  he  met  with  from  this  prac- 
tice in  other  similar  cases.  He  quotes  also  the  testi- 
mony of  authors  antecedent  to  him,  who  have  recom- 
mended the  method ; and,  in  particular,  he  cites  Job  k 
Meckren,  who  adopted  this  practice  in  a case  where 
the  tongue,  together  with  the  tonsils  and  palate,  be- 
came spontaneously  affected  with  a sudden  and  dair- 
gerous  degree  of  swelling.  This  treatment  is  found  to 
answer  by  modern  practitioners. — (See  Joum.  Uni 
versel,  <^e.  June,  1823.) 

From  the  preceding  observations,  it  may  be  con- 
cluded, that  making  incisions  in  the  tongue  would 
have  saved  numerous  patients,  who  have  been  suffo- 
cated in  consequence  of  enormous  enlargements  of 
this  organ.  In  the  small-pox,  the  tongue  sometimes 
becomes  immensely  swelled  ; and  it  is  more  than  pro- 
bable, that,  in  many  instances,  the  employmeirt  of  the 
above  method  would  have  afforded  great  relief  to  pa- 
tients whom  the  disease  has  been  know'n  to  have  en- 
tirely bereaved  of  the  power  of  swallowing.  It  is  a 
curious  fact,  that  after  the  loss  of  very  considerable 
portiorrs,  or  even  what  may  be  called  the  whole  toirgue, 
patients  often  recover  the  power  of  speech,  mastication, 
and  deglutition. — {Louis,  in  Mem.  de  I'Acad.  de  Chir, 
f.  5 ; also,  J.  Rowland,  Aglossostomographie,  ou  De- 
scription d'une  Bouche  sans  Langne,laquelle  parle,  et 
fait  naturellemcnt  toutes  ses  aiitres  Fonctiovs.  12wro. 
Saumur,  1630.  J^ouis  surles  Maladies  de  la  Langve, 
Memoir es  de  V Acad,  de  Chir.  t.  5 : also,  the  Memoir  of 
De  la  Malle  in  the  same  volume.  Encyclopedic  M^- 
thodique,  partie  Chir.  art.  Langm.  Sir  Everard 
Home's  Tract.  Obs.  on  Cancer,  8co.  Land.  1805.  Lan- 
genbeck,  Meue  Bibl-  b.  2,  p.  487,  8vo.  Hanover,  1820. 
C.  /.awe  and  H.  Earle,  in  Med.  Chir.  Trans,  vols.  8 
and  12.  B.  Travers,  op.  cit.  vol.  15.) 

TONSILS.  The  tonsils,  like  all  other  parts  at  the 
back  of  the  mouth,  are  subject  to  different  kinds  of 
swelling  which  vary  as  much  in  their  nature  as  their 
consequences.  Some  are  rapid  in  their  progress,  and 
these  are  frequently  observed  to  affect  persons  of  what 
is  termed  a sanguineous  temperament.  They  are  also 
prone  to  attack  young  people,  and  such  as  labour  hard, 
and  they  have  all  the  essential  characters  of  inflam- 
mation. 

Other  swellings  of  the  tonsils  are  slower  in  their 
progress,  occur  in  damp  cold  weather,  and  in  indolervt 
and  what  the  old  physicians  used  to  call  phlegmatic 
constitutions. 

I.astly,  another  kind  of  enlargement  of  the  tonsils, 
which  is  usually  contagious,  readily  falls  into  a slough- 
ing, gangrenous  state,  sometimes  extends  to  the  neigh- 
bouring parts,  and  too  often  proves  fatal.  Hence,  the 
various  species  of  angina  Irave  been  named  by  some 
writers  inflammatory,  catarrhal,  and  gangrenous.  The 
first  two  kinds  frequently  terminate  in  resolution;  but 
sometimes  the  affected  tonsils  afterward  assume  a 
scirrhous  hardness,  and  obstruct  respiration  and  deghi- 
tition,  so  that  it  becomes  indispensably  necessary  either 
to  extirpate  them  with  the  ligature  or  knife. 

The  cutting  away  of  enlarged  tonsils  was  performed 
by  the  ancients  in  different  ways.  Sometimes,  w-ith 
their  fingers,  they  tore  the  membrane  covering  the 
tonsil,  and  then  pulled  this  part  out  of  the  situation 
which  it  occupies  between  the  pillars  of  the  velum 
pendulum  palati.  In  other  instances,  in  which  they 
experienced  too  much  resistance,  they  seized  the  dis- 
eased tonsil  with  a kind  of  hook,  and  then  cut  it  away 
with  a bistoury,  which  Paulus  ASgineta  informs  us, 
was  concave  on  the  side  towards  the  tongue. 

The  moderns,  who  for  a long  while  were  timid  in 
the  employment  of  both  these  methods,  adopted  plans 
of  a more  cruel  description.  The  actual  cautery  was 
proposed,  and  some  partial  success  which  followed  its 
use  at  once  established  its  reputation.  Caustics  were 
afterward  employed  instead  of  actual  fire;  but  the  in- 
convenience of  not  being  able  to  limit  their  action,  and 
the  hazard  of  their  falling  down  the  oesophagus,  soon 
caused  them  to  be  relinquished  by  all  rational  prac- 
titioners. Then  the  oiKuation  of  cutting  away  the 
tonsils  was  revived  ; and  it  was  performed,  sometimes 
ttt  the  manner  of  the  old  surgeons,  sometimes  with 
various  kinds  of  curved  scissors  or  knives.  Instead  of 
the  simple  tenaculum,  used  by  the  ancients,  a sort  of 
. double  one  came  into  fashion. 


TONSILS. 


355 


Bichat  describes  the  following  as  once  the  common 
plan ; the  surgeon  is  to  open  the  mouth  very  wide,  and 
depress  the  tongue  with  any  flat  instrument,  which  is 
to  be  held  by  an  assistant.  The  operator  is  then  to 
take  hold  of  the  diseased  tonsil  with  a tenaculum ; and 
with  a common  scalpel,  having  the  back  half  of  its 
blade  covered  with  rag,  he  now  removes  as  much  of 
tlie  tonsil  as  ought  to  be  taken  away.  In  common 
cases,  it  is  deemed  sufficient  to  cut  on  a level  with  the 
pillars  of  the  velum  pendulum  palati.  Any  other  por- 
tion, needing  removal,  should  next  be  taken  away. 
The  operation  being  finished,  the  patient  is  frequently 
to  wash  his  mouth  with  proper  gargles. 

The  preceding  method  was  long  adopted  by  Desault. 
However,  one  objection  is  urged  against  it,  viz.  that 
when  the  end  of  the  knife  is  conveyed  far  into  the 
mouth  it  may  do  mischief,  not  (as  has  been  alleged)  to 
the  internal  carotid  artery,  the  backward  situation  of 
W'hich  completely  keeps  it  out  of  all  danger  of  being 
wounded,  but  to  the  membranous  covering  of  the 
palate  in  a place  not  corresponding  to  the  tonsils.  De- 
sault thought  this  objection  was  the  more  forcible,  as 
when  the  hook  is  introduced  into  the  tonsil,  the  danger 
of  the  above  mischief  is  considerably  increased  by  a 
general  spasm,  which  seems  to  affect  every  part  of  the 
mouth.  Hence,  this  eminent  surgeon  used  to  employ, 
for  the  removal  of  diseased  tonsils,  an  instrument 
which  was  first  invented  for  dividing  cysts  of  the 
bladder.  It  consisted  of  a sharp-edged  blade,  which 
was  included  in  a silver  sheath.  The  latter  had  at  its 
extremity  a kind  of  notch,  in  which  the  gland  about  to 
be  extirpated  was  received.  The  rest  of  the  instru- 
ments were  similar  to  those  commonly  used.  Desault 
proceeded  as  follows: 

1.  The  patient  being  seated  on  a high  chair,  with  his 
head  supported  on  an  assistant’s  breast,  he  is  to  open 
his  mouth  very  wide,  and  the  lower  jaw  is  to  be  kept 
thus  depressed  by  some  solid  body  placed  between  the 
teeth,  and  held  there  by  an  assistant. 

2.  The  tongue  is  to  be  kepi  down  with  a broad 
spatula. 

3.  The  surgeon  is  next  to  take  hold  of  the  tonsil 
with  a double  hook,  with  which  he  is  to  raise  and  draw 
it  a little  towards  him.  He  is  tlien  to  take  the  above 
cystotome  and  put  the  tonsil  in  the  notch,  on  a level 
with  the  place  where  the  incision  is  intended  to  be* 
made. 

4.  When  the  portion  which  is  to  be  cut  off  is  engaged 
in  the  notch,  the  operator  is  to  draw  the  part  towards 
him  so  as  to  stretch  it,  and  press  the  instrument  against 
it  from  below  upwards.  The  blade  being  next  pushed 
across  the  notch,  the  necessary  section  is  accomi)lished. 
When  the  division  is  not  complete,  which  is  particu- 
larly liable  to  happen  when  the  diseased  gland  is  of  con- 
siderable magnitude,  the  blade  is  to  be  drawn  back,  and 
the  section  completed  by  applying  the  instrument  to 
the  wound  which  it  has  already  made.  Sometimes 
even  a third  application  may  possibly  become  requisite. 

5.  The  patient  is  to  be  directed  to  wash  his  mouth. 
Bichat  states,  that  this  plan  of  operating,  adopted  by 
Desault,  is  as  simple  and  easy  as  the  method  above  re- 
lated, with  the  advantage  of  being  safer.  Such  is  the 
consiruction  of  the  blade  of  the  instrument,  that  when 
it  slides  across  the  notch  it  presses  against,  and  steadily 
fixes,  the  parts  which  are  to  be  divided,  an  advantage 
which  neither  the  knife  nor  scissors  have,  under  the 
action  of  which  the  parts  are  quite  moveable.  Hence, 
there  is  difficulty  in  cutting  them.  When  the  intro- 
duction of  the  instrument  from  above  downwards  is 
difficult,  it  is  better  to  withdraw  it;  and  after  turning 
the  notch  in  the  opposite  direction,  pass  it  from  below 
upwards.  In  general,  however,  the  first  of  these  me- 
thods is  preferable,  because  the  gland,  when  half  cut 
through,  cannot  now  fall  back  and  obstruct  the  rima 
glottidis,  so  as  to  bring  on  danger  of  a sudden  suffoca- 
tion ; a circumstance  which  Wiseman  and  Moscati 
saw  happen.  With  the  view  of  preventing  this  occur- 
rence, Louis  recommended  the  common  scalpel  to  be 
used,  with  its  edge  directed  upwards,  as  has  been  ad- 
vised for  the  above  instrument;  which  latter  con- 
trivance, however,  being,  according  to  Bichat’s  account, 
more  easy  and  safe,  merits  the  preference.  Besides 
the  advantage  of  fixing  the  soft  parts  which  are  to  be 
cut,  it  has  that  of  not  contusing  them,  like  rm)st  other 
inslniments  of  this  nature,  as,  for  instance,  scissors; 
and  the  oblique  disposition  of  its  blade  enables  it  to 
divide  parts  in  the  manner  of  a saw. 


This  invention,  as  Bichat  allows,  is  certainly  in- 
creasing the  number  of  surgical  instruments;  a thing 
which  all  the  bes.t  modern  surgeons  endeavour  to 
avoid.  But  it  is  to  be  recollected,  that  this  instrument 
is  not  exclusively  applicable  to  any  particular  opera- 
tion. It  may  be  employed  for  cutting  away  the  tonsils 
and  uvula ; dividing  membranous  fra;na  in  the  rectum, 
vagina,  and  bladder;  amputating  fungous  excrescences, 
polypi  of  the  nose  (if  this  mode  of  extirpating  them 
were  preferred),  and  various  tumours  in  general, 
which  are  deeply  situated  in  different  cavities  of  the 
body,  where  instruments  introduced  unguardedly  might 
injure  parts  which  should  be  avoided,  or  where  the 
base  of  the  tumour  should  be  steadily  fixed,  when  its 
division  is  to  be  accomplished.  The  latter  object  can- 
not safely  be  effected  by  scissors.  When  the  base  of 
the  tumour  is  too  large  to  be  received  in  the  notch,  one 
part  is  first  to  be  divided,  and  then  another,  till  its 
whole  thickness  is  cut  through. 

In  England,  when  a diseased  tonsil  is  to  be  cut 
away,  surgeons  generally  prefer  a common  scalpel. 

As  a general  practice,  I consider  that  the  excision 
of  an  enlarged  tonsil  is  a better  practice  than  the  ex- 
tirpation of  it  with  a ligature,  which  also  sometimes 
answers  very  well,  and,  perhaps,  in  children  and  timid 
patients,  may  merit  the  preference.  The  chief  objec- 
tions to  the  ligature  are,  that  its  operation  is  rather 
tedious,  sometimes  productive  of  a great  deal  of  irrita- 
tion, and  on  the  whole  at  least  as  painful  as  the  knife. 

Moscati  having  once  adopted  this  plan,  very  severe 
pain  and  inflammation  ensued : the  difficulty  of  swal- 
lowing and  breathing  compelled  him  to  amputate  the 
tumour  at  the  place  where  the  ligature  was  applied, 
and  all  the  bad  symptoms  immediately  ceased.  Be- 
sides, when  the  ligature  is  used,  there  is  no  oozing  of 
blood  from  the  vessels,  a circumstance  which  tends  so 
much  to  diminish  the  inflammation.  The  base  of  the 
swelling  is  also  sometimes  broader  than  its  upper  part, 
and  does  not  admit  of  being  properly  surrounded  with 
a ligature.  And  when  it  has  a narrow  base,  it  can 
then  be  so  easily  removed  with  a scalpel,  or  with  De- 
sault’s instrument,  and  with  so  little  pain,  that  one  of 
the  last  modes  is  generally  preferable. 

The  ligature,  however,  has  had  its  advocates. 
Heister  recommends  it  in  certain  cases ; Sharp  praises 
it ; and  others  approve  its  use ; while  the  plans  of  em- 
ploying it  have  been  as  various  as  the  inventive  genius 
of  the  different  partisans  of  the  practice.  Some  make 
use  of  Levret’s  double  cannula,  which  is  furnished 
with  a silver  wire  noose,  in  which  the  tumour  is  to  be 
engaged.  By  twisting  the  instrument,  the  diseased 
part  becomes  constricted.  Some,  after  putting  the 
noose  of  a ligature  over  a kind  of  tenaculum,  take 
hold  of  the  tonsil,  push  the  ligature  over  the  enlarged 
gland,  which  they  tie,  without  having  any  means  of 
increasing  the  constriction  afterward.  Others  enjploy 
Belloque’s  instriiinent  for  putting  the  ligature  over  the 
tonsil.  Sir  A.  Cooper,  who  prefers  the  ligatuie  to  ex- 
cision, gives  to  an  eye-probe  the  requisite  curve,  and 
then  passes  the  ligature  with  it  behind  the  enlarged 
tonsil.  'I’he  probe  being  then  removed,  the  knot  is 
made  with  tonsil-irons,  if  the  fingers  are  not  long 
enough  for  the  purpose. 

Desault  employed  an  instrument  which  the  French 
call  un  serre-naud^  which  is  in  fact  nothing  more  than 
a long,  narrow,  round  piece  of  silver,  terminating  at 
one  end  in  a little  ring  or  hole,  and  at  the  other  in  a 
kind  of  groove  or  notch. 

1.  Tlie  patient  was  seated  on  a high  chair  with  his 
head  held  back  on  an  assistant’s  breast;  his  mouth 
was  opened  very  wide,  his  tongue  depressed,  and  the 
diseased  tonsil  taken  hold  of  with  a double  hook. 

2.  The  surgeon  took  the  serre-imud,  in  which  a liga- 
ture had  been  j)assed,  so  as  to  form  a noose.  ’I'lie 
noose  was  put  over  the  handle  of  the  hook,  which 
was  committed  to  the  charge  of  an  as.sistant,  and  the 
noose  then  pushed  over  the  tonsil,  so  as  to  etnbrace  it 
completely. 

3.  The  surgeon  now  drew  the  ligature  strongly  to- 
wards him,  and  pushed  forward  the  serre-nmnd]  so  as 
to  produce  the  requisite  constriction  of  the  tumour. 
In  general  the  ligature  was  not  made  very  tight  the 
first  day. 

4.  When  the  necessary  constriction  had  been  made, 
the  double  hook  was  withdrawn,  and  the  ligature 
twisted  round  the  notch  at  the  outward  end  of  the  in- 
strument. 


3S6 


TOU 


TOU 


5.  The  next  day  the  gland  became  unusually  large, 
in  consequence  of  the  impediment  to  the  return  of  the 
venous  blood.  The  ligature  was  unfastened  from  the 
notched  end  of  the  instrument,  and  drawn  more  out, 
so  as  to  increase  the  constriction,  after  which  it  was 
again  twisted  routrd  the  notch.  This  plan  was  followed 
up  till  the  tumour  was  detached,  which  usually  hap- 
pened on  the  fourth  or  fifth  day. 

The  late  Mr.  Chevalier  described  a particular  mode 
of  passing  and  securing  the  ligature.  He  passed  a flat 
spear-pointed  hook  behind  the  diseased  tonsil,  and  its 
point  was  then  pushed  forwards  so  as  to  perforate  it 
through  the  middle  of  its  base.  The  needle  was  then 
withdrawn,  an  eye-probe  very  much  curved,  and 
armed  with  a long  double  ligature,  was  then  readily 
passed  through  the  perforation  and  brought  out  at  the 
mouth,  the  ligature  divided,  and  one  portion  tied  round 
the  upper  half  of  the  tonsil  and  the  other  round  the 
lower.  “A  single  knot  being  first  made  upon  one  end 
of  the  thread,  the  end  so  knotted  is  to  be  brought  for- 
wards upon  the  other,  and  to  make  a single  noose  upon 
itself  including  the  other,  and  to  be  drawn  tight  upon 
it  close  to  the  first  knot.  The  free  end  of  the  thread  is 
then  to  be  passed”  through  a ring  at  the  end  of  an  in- 
strument for  the  purpose,  and  “ being  then  held  firm,  and 
the  ring  pushed  forwards  upon  the  knot,  the  loop  now 
formed  may  be  readily  tightened,  so  as  completely  to 
strangulate  the  diseased  part;  and  in  the  same  manner 
it  may  be  tightened  from  day  to  day,  till  the  part  is 
entirely  detached.” — (See  Med.  Chir.  Trans,  vol.  3, 
■p.  80,  (S  c.)  The  subject  is  more  intelligible  with  the 
plate. 

Sometimes,  in  angina,  the  tonsils  are  suddenly  at 
tacked  with  such  a degree  of  swelling,  that  respira- 
tion is  dangerously  obstructed.  This  case  is  analogous 
to  the  occasional  enormous  inflammatory  swelling  of 
the  tongue,  and  if  it  resist  venesection  and  leeches, 
the  most  prompt  mode  of  relief  is  that  of  making  se- 
veral deep  scarifications  with  a knife  in  the  part.  Many 
examples  confirming  the  good  effects  of  this  practice 
have  been  seen  by  Langenbeck. — (See  Meue  Bibl.  b. 
2,  p.  492,  &rc.) 

[fn  the  Medical  and  Physical  Journal  of  Philadel- 
phia, No.  1,  Dr.  Physick  has  given  a description  of  a 
method  of  removing  enlarged  tonsils  by  a double  can- 
nula and  iron  wire.  This  method  has  been  so  long 
before  the  profession,  that  it  is  unnecessary  to  describe 
it  here,  especially  as  removing  them  by  the  knife  is 
now  generally  preferred.  The  same  distinguished  sur- 
geon has  constructed  an  instrument  for  excision  of  the 
tonsils,  which  he  now  prefers  to  the  ligature.  It  is 
composed  of  two  steel  pieces,  attached  to  one  end  of 
each  is  a steel  ring ; between  the  two  is  a lancet- 
shaped  blade  moveable  on  two  screws  which  connect 
the  pieces.  The  tonsil  is  fixed  in  the  rings,  and  the 
blade  thrust  forwards  by  pressing  with  the  thumb  on  a 
button  at  the  extremity  of  the  handle,  when  it  will  be 
divided.  In  the  American  Medical  Recorder  for  1828, 
Dr.  Matthews,  of  Philadelphia,  has  described  another 
instrument  for  the  same  purpose.  Professor  Stevens, 
of  New- York,  has  described  in  the  N.  Y.  Med.  and 
Phys.  Journal  for  1828,  an  instrument  for  tlie  removal 
of  the  tonsils  by  a wire  ligature,  which  is  greatly  pre- 
ferable to  that  of  Dr.  Physick,  when  this  method  is 
adopted  instead  of  the  knife.  Dr.  Cox,  of  New-York, 
has  also  proposed  a method  of  excising  the  tonsils, 
which  seems  to  be  superior  to  either  of  the  numerous 
processes  which  have  been  published  by  way  of  im- 
provements in  this  operation.  A description  of  his 
instrument  may  be  found  in  the  N.  Y.  Med.  and  Phys. 
Journal  for  1829.— Reese.] 

TOPHUS.  A swelling  which  particularly  affects  a 
bone  or  the  periosteum.  See  Mode. 

TORTICOLLIS.  (From  torqueo,  to  twist ; and 
collim,  the  neck.)  The  wry-neck.  See  Wry  neck. 

TOURNIQ.UET.  {French.,  from  toumcr,  to  turn.) 
An  instrument  for  stopping  the  flow  of  blood  into  a 
limb,  until  some  requisite  operation  has  been  performed, 
or  a more  permanent  plan  of  checking  hemorrhage  has 
been  put  in  practice. 

The  old  surgeons  used  to  surround  the  limb  with  a 
band,  with  which  they  made  such  a degree  of  con- 
striction, that  the  circulation  was  quite  Bto{)ped.  They 
also  believed  that  the  pressure  of  the  band  was  advan- 
tageous in  benumbing  the  limb  and  moderating  the 
Iiain  of  operations. 

The  violent  pain  and  contusion,  however,  which 


such  a tourniquet  occasioned,  being  frequently  fol- 
lowed by  abscesses,  and  even  by  mortification,  sur- 
geons found  it  necessary  to  devise  some  other  method 
for  checking  hemorrhage.  The  application  of  the  cir 
cular  band  was  first  improved,  so  that  it  caused  less 
pain  and  less  mischief  to  the  skin.  The  limb  was  sur- 
rounded with  a very  thick  compress,  over  which  the 
band  was  placed.  Two  small  sticks  were  next  put 
under  the  band ; one  onl  the  inside,  the  other  on  the 
outside  of  the  limb  ; and  they  were  twisted  till  the  band 
was  rendered  sufficiently  tight.  It  is  in  ibis  manner, 
says  Dionis,  in  his  Traite  d'  Operations,  that  carriers 
tighten  the  cords  . which  fasten  the  bales  of  goods  in 
their  carts.  A French  surgeon  named  Morel,  is  said 
to  have  made  this  first  improvement  in  the  application 
of  tourniquets. 

J.  L.  Petit,  in  1718,  presented  to  the  Academy  of 
Sciences  a tourniquet  of  his  own  invention,  which 
was  much  more  perfect,  though  certainly  very  complex, 
when  compared  with  that  which  is  used  by  the  best 
modern  practitioners ; but  still  it  is  the  original  of  the 
latter,  and  both  are  constructed  on  the  same  principles. 
All  the  pieces  of  modern  tourniquets  are  connected 
together;  and,  instead  of  two  pieces  of  wood  used  by 
Petit,  there  is  a brass  bridge  which  is  capable  of  being 
elevated  or  depressed,  by  means  of  a screw  made  of 
the  same  metal.  Over  this  bridge  a very  strong  band 
proceeds,  and  by  passing  under  two  little  rollers  at 
each  end  of  the  bridge,  it  always  remains  connected 
with  the  instrument.  A convex  firm  pad  is  sewed  to 
the  band  and  put  immediately  over  the  artery  where 
the  instrument  is  applied.  There  are  no  cushions  for 
the  opposite  side  of  the  limb  under  the  screw ; but  a 
thick  piece  of  leather,  through  which  the  band  pro- 
ceeds in  two  places,  is  always  situated  under  the  lower 
surface  of  the  brass,  and  serves  to  prevent  any  bad 
effects  of  its  pressure.  It  is  usual  also  for  the  surgeon 
to  fold  some  rag  and  to  put  it  in  this  situation,  at 
the  time  of  applying  the  instrument.— (See  Hemor- 
rhage.) 

The  following  are  the  advantages  of  the  modern 
tourniquet,  fortned  on  the  principles  of  that  first  in- 
vented by  Petit ; 1.  It  compresses  the  lateral  parts 
of  the  limb  less  than  the  tourniquet  previously  in  use. 
2.  It  requires  the  aid  of  no  assistant  either  to  hold, 
tighten,  or  loosen  it.  3.  The  operator  is  able  of  him- 
self to  stop  the  flow  of  blood  in  the  artery,  by  means 
of  the  screw.  4.  When  there  is  any  danger  of  he- 
morrhage after  an  operation,  it  may  be  left  on  the 
limb,  and  in  case  of  bleeding,  the  patient,  if  no  one  be 
at  hand,  can  tighten  the  instrument  himself  as  much 
as  is  necessary.  5.  Its  constriction  produces  less  danger 
of  mortification,  because  it  does  not  altogether  stop  the 
flow  of  blood  through  the  collateral  arteries.  The  in- 
terruption of  the  circulation  in  parts  of  the  body  by 
the  tourniquet,  has  been  tried  as  a means  of  relieving 
diseases. — (See  O.  Kellie,  Obs.  on  the  Medical  Ef- 
fects of  Compression  by  the  Tourniquet,  8vo.  Edinb. 
1797.) 

[Dr.  Moore,  of  Massachusetts,  has  described,  in  the 
New-England  Journal,  a tourniquet  of  his  invention, 
which  is  very  generally  adopted  by  those  surgeons  in 
this  country  who  have  not  laid  aside  the  use  of  this 
instrument  in  their  amputations.  Many  of  the  most 
distinguished  American  surgeons  dispense  with  the 
tourniquet  altogether,  preferring  to  rely  upon  compres- 
sion made  on  the  principal  artery  of  the  limb  by  a 
competent  assistant.  It  is  certain  that  much  less  he- 
morrhage attends  an  amputation  than  when  any  modi- 
fication of  this  instrument  is  used,  and  in  very  many 
cases  the  success  of  the  operation  is  overthrown  by 
the  loss  of  blood. 

That  the  use  of  the  tourniquet  does  increase  the  he- 
morrhage will  be  apparent  to  any  who  ever  operate 
without  one,  and  although  the  bleeding  is  chiefly  from 
the  portion  of  the  limb  amputated,  yet  the  debility  in- 
duced is  not  the  less  on  this  ticcount.  On  the  first  ap- 
plication of  this  instrument  to  the  thigh,  for  example, 
the  compression  is  made  on  the  superficial  veins,  the 
return  of  the  blood  prevented,  and  the  morbid  state  of 
the  limb  often  favours  the  consequent  engorgement. 
As  the  instrument  is  screwed,  the  turgescence  of  the 
limb  below  the  point  at  which  the  compression  is  made 
continues  to  incrc<ase  until  the  circulation  is  eiopjred. 
No  sooner  is  the  incision  made,  than  a hemorrhage 
of  very  considerable  extent  takes  place,  and  the  assist- 
ant is  directed  to  tighten  the  instrument,  which  fails  to 


TRE 


TRE 


357 


suppress  it,  because  the  blood  flows  from  the  vessels  of 
the  limb  below  the  incision,  thus  unnaturally  distended. 
Every  operative  surgeon  must  have  suffered  inconve- 
nience, and  often  anxiety  from  this  source,  and  yet  few 
have  blamed  the  tourniquet,  which  is  the  true  cause 
of  the  mischief. 

I have  operated  myself,  and  witnessed  the  amputa- 
tion of  the  thigh  by  Dr.  Bushe  and  others,  where  the 
femora!  artery  was  suddenly  compressed  by  the  fin- 
gers of  an  assistant,  and  the  hemorrhage  was  always 
very  inconsiderable,  often  not  more  than  half  a pint 
during  the  whole  operation.  I believe  the  time  is  not 
very  remote  when  this  instrument  will  be  every  where 
abandoned,  except  where  the  surgeon  is  obliged  to  ope- 
rate without  an  assistant,  and  in  such  cases  the  incon- 
venience will  have  to  be  submitted  to  of  course. — 
Reese.] 

trachea.  Wounds  of.  See  Throat. 

TRACHEOTOMY.  (From  Tpaxaa,  the  windpipe, 
and  rifAvo),  to  cut.)  The  operation  of  cutting  an 
opening  into  the  windpipe  for  various  surgical  pur- 
poses. See  Bronchotomy. 

TREPAN.  (From  rpvTrdw,  to  perforate.)  Trepa- 
num;  Terebellum ; Modiolus.  A circular  saw,  by 
means  of  which  the  skull  is  perforated  in  the  opera- 
tion called  trepanning,  or  a circular  portion  of  any 
bone  may  be  sawed  out.  It  bears  a considerable  resem- 
blance to  the  well-known  instrument  named  a wimble, 
and  is  worked  in  the  same  manner.  Formerly  the  saw 
was  sometimes  made  of  a conical  shape  (see  Map- 
liston) ; but  this  construction  rendered  the  action  of 
the  instrument  difficult.  In  this  country  the  trepan  is 
now  superseded  by  the  instrument,  called  a trephine, 
which  has  a different  handle,  and  is  not  worked  in  the 
same  way.  On  the  continent,  however,  the  trepan  still 
has  the  preference. 

TREPHINE.  The  instrument  now  commonly  pre- 
ferred for  perforating  the  cranium,  for  purposes  which 
I shall  presently  explain.  It  consists  of  a simple  cylin- 
drical saw,  with  a handle  placed  transversely  like  tliat 
of  a gimlet ; and,  from  the  centre  of  the  circle,  which 
the  teeth  of  the  saw  describe,  a sharp  little  perforator 
projects,  named  the  centre-pin.  The  upper  part  of 
the  centre- pin  is  made  to  screw  in  a corresponding  hole 
at  the  inside  of  the  top  of  the  saw,  and  is  capable  of 
being  taken  out  or  put  in,  at  the  surgeon’s  option,  by 
means  of  a little  key  for  the  purpose.  Its  use  is  to  fix 
the  trephine  when  it  is  first  applied,  that  is,  before  the 
teeth  of  the  instrument  have  made  a sufficient  circular 
groove,  in  which  they  can  steadily  work.  When  this 
has  been  accomplislied,  the  centre-pin  must  always  be 
removed;  because  now  it  is  not  only  unnecessary,  but, 
if  left,  would  retard  the  progress  of  the  operation,  and 
inevitably  wound  the  dura  mater  and  brain,  when  the 
teeth  of  the  saw  had  cut  to  a certain  depth  through  the 
cranium.  My  trephines  have  their  centre  pins  con- 
trived to  slide  up  or  down,  and  to  be  fixed  in  either  posi- 
tion by  turning  a little  screw.  This  method,  seems  to 
me  both  ingenious  and  convenient. 

The  cylindrical  part  of  the  trephine  is  often  termed 
the  crown  of  the  instrument.  The  surgeon  should 
have  at  least  two  or  three  cylindrical  saws  of  various 
sizes ; for  it  is  always  a commendable  rule  never  to  saw 
away  any  more  of  the  cranium  than  is  absolutely  requi- 
site for  the  accomplishment  of  some  rational  object. 
There  is  no  occasion,  however,  for  having  more  than 
one  handle,  which  may  be  made  to  screw  on  any  of 
the  saws. 

Trephines  are  also  occasionally  applied  to  other 
bones,  besides  those  of  the  cranium.  In  the  articles 
.Sntrum,  Caries,  Exostosis,  Fractures  of  the  Sternum, 
Mecrosis,  Spina  Ventosa,  other  cases  are  mentioned 
in  which  the  employment  of  these  instruments  some- 
times becomes  proper. 

It  is  not  always  desirable  to  remove  a complete  cir- 
cular portion  of  the  cranium,  the  taking  away  of  a piece 
of  smaller  size,  and  of  a different  shape,  being  fre- 
quently much  more  advantageous.  Some  surgeons, 
who  object  to  removing  any  unnecessary  quantity  of 
the  cranium,  occasionally  employ  a trephine,  termi- 
nating only  in  a semicircular,  instead  of  a circular  saw, 
by  which  means  they  can  often  cut  across  the  base  of 
a depressed  portion  of  the  skull,  and  take  It  away, 
without  any  occasion  for  removing  also  a circular 
piece  of  bone.  An  instrument  of  the  latter  kind  may 
certainly  be  sometimes  useful. 

The  saws,  however,  which  Mr.  Hey  has  described, 


should  constantly  be  kept  in  every  case  of  trephining 
instruments.  This  practical  writer  remarks,  that  “ the 
purposes  for  which  any  portion  of  the  cranium  is  re- 
moved are,  to  enable  the  surgeon  to  extract  broken 
fragments  of  bone,  to  elevate  what  is  depressed,  and  to 
afford  a proper  issue  to  blood  or  matter  that  is  or  may 
be  confined,  &c. 

“ When  a broken  fragment  of  bone  is  driven  be- 
neath the  sound  contiguous  part  of  the  cranium,  it  fre- 
quently happens  that  the  extraction  cannot  be  executed 
without  removing  some  of  the  unbroken  part,  under 
which  the  fragment  is  depressed.  This  might  gene- 
rally be  effected  with  very  little  loss  of  sound  bone,  if 
a narrow  portion  of  that  which  lies  over  the  broken 
fragment  could  be  removed.  But  such  a portion  can- 
not be  removed  with  the  trephine.  This  instrument 
can  only  saw  out  a circular  piece.  And,  as  in  execut- 
ing this,  the  central  pin  of  the  saw  must  be  placed  upon 
the  uninjured  bone,  it  is  evident  that  a portion  of  the 
sound  bone,  greater  than  half  the  area  of  the  trephine, 
must  be  removed  at  every  operation.  When  the  broken 
and  depressed  fragment  is  large,  a repeated  application 
of  the  trephine  is  often  necessary,  and  a great  destruc- 
tion of  sound  hone  must  be  the  consequence. 

“ When  the  injury  consists  merely  of  a fissure  with 
depression,  a small  enlargement  of  the  fissure  would 
enable  the  surgeon  to  introduce  the  point  of  the  eleva- 
tor, so  as  to  raise  the  depressed  bone.  But  a small  en- 
largement of  the  fissure  cannot  be  made  with  the  tre 
phine.  When  it  is  necessary  to  apply  the  elevator ’to 
different  parts  of  the  depressed  bone,  a great  deal  of 
the  sound  cranium  must  be  removed,  where  a very  nar- 
row aperture  would  have  been  sufficient. 

“ The  same  reasoning  will  apply  to  the  case  of 
openings  made  for  the  purpose  of  giving  a discharge  to 
extravasated  blood  or  matter. 

“ If  a saw  could  be  contrived  which  might  be 
worked  with  safety  in  a straight  or  gently  curvilinear 
direction,  it  would  be  a great  acquisition  to  the  prac- 
tical surgeon.  Such  a saw  I can  now  with  confidence 
recommend,  after  a trial  of  twenty  years,  during  which 
time  I have  rarely  used  the  trephine  in  fractures  of  the 
skull.  Its  use  has  been  adopted  by  my  colleagues  at 
the  General  Infirmary  in  Leeds ; and  will  be  adopted, 
I hope,  by  every  surgeon  who  has  once  made  trial  of 
it.”  Mr.  Hey  next  informs  us,  that  the  instrument 
was  first  shown  to  him  by  Dr.  Cockell,  of  Pontefract ; 
but  that  there  is  a saw  formed  on  the  same  principle  in 
Scultetus’s  Armamentarium  Chirurgicum.  The  saws 
alluded  to  are  very  short  ones,  fixed  at  the  end  of  a 
longish  straight  handle;  their  edges  are  made  either 
straight  or  semicircular.  The  latter  construction  qua- 
lifies the  instrument  for  cutting  in  a curvilinear  direc- 
tion, which  is  often  proper.  The  edge  of  the  saw 
should  always  be  made  a little  thicker  than  the  rest  of 
the  blade,  by  which  means  it  will  work  in  the  groove 
which  is  cut  with  more  facility. 

Saws  made  on  the  principle  Just  described  are  also 
of  infinite  use  in  cutting  away  diseased  portions  of 
other  bones,  besides  the  skull,  exostoses,  &c.  In  necro- 
sis, when  a dead  part  of  a bone  is  quite  wedged  in  the 
substance  of  the  surrounding  new  bony  matter,  Mr. 
Hey’s  saws  may  ollen  be  advantageously  employed  for 
cutting  away  the  parts  which  mechanically  prevent 
the  detachment  of  the  dead  pieces.  The  saws  in- 
vented by  Mr.  Machell  and  Professor  Graefe  are  also 
highly  ingenious,  and  particularly  merit  attention, 
when  there  is  very  little  room  for  the  working  of  the 
instrument,  and  the  bone  to  be  cut  lies  deep.  They  are 
wheel-like  saws,  turned  by  machinery. 

Besides  treithines  of  various  sizes,  and  the  saws  Just 
now  noticed,  the  surgeon  should  al.so  take  care  to  have 
in  his  case  of  trephining  instruments  a little  brush  for 
occasionally  cleansing  away  the  jiarticles  of  bone  from 
the  teeth  of  the  saw  in  the  progress  of  the  operation ; a 
pair  of  forceps  for  extracting  the  round  piece  of  bone 
after  it  has  been  detached  by  the  saw  ; a lenticular  for 
removing  any  inequalities  which  may  present  them- 
selves round  the  sawed  edge  of  the  cranium  after  the 
circular  piece  is  taken  out ; a raspatory  for  the  same 
purpose,  and  also  for  scraping  the  bone  in  order  to  see 
whether  it  will  bleed,  which  is  a circumstance  in  some 
cases  very  important  to  be  attended  to  (see  J/ead,  In- 
juries of)-,  a largish  common  scalpel  for  dividing  the 
scalp,  &c. ; and  some  elevators  for  raising  depressed 
pieces  of  bone. 

The  common  elevator  is  now  generally  used  by  ail 


358 


TREPHINE, 


the  best  English  surgeons : but  several  others  have  been 
proposed,  as,  for  instance,  the  tripod  elevator ; and  an- 
other invented  by  J.  L.  Petit,  and  afterward  improved 
by  M.  Louis. 

Before  beginning  the  description  of  the  operation, 

I tliink  it  highly  proper  to  remind  the  reader  of  what 
has  been  so  forcibly  dwelt  upon  in  the  article  Head^ 
Injuries  of, — that  generally  the  removal  of  pressure  off' 
the  brain,  which  pressure  must  also  actually  occasion 
dangerous  symptoms,  can  form  the  only  true  and  vindi- 
cable  reason  for  employing  the  trephine,  or  sawing 
away  any  portion  of  the  skull.  There  are  very  few  ex- 
ceptions to  this  remark : it  may,  indeed,  be  now  and 
then  proper  to  saw  away  the  bony  edges  around  some 
fungous  excrescences  which  grow  from  the  dura  mater, 
and  make  their  way  outwards  by  occasioning  an  ab- 
sorption of  the  part  of  the  skull  immediately  over  them. 
— (See  Dura  Mater.)  It  may  also  be  sometimes  pro- 
per to  saw  out  diseased  portions  of  the  skull,  though  it 
must  be  confessed,  that  in  general  their  separation 
should  be  left  to  time  and  nature.  Loose  splinters 
should  always  be  removed,  and,  perhaps,  if  the  de- 
pressed portion  of  bone  be  denuded  in  a wound  of  the 
scalp,  a trial  to  raise  it  with  the  elevator  will  be  pro- 
per, even  though  urgent  symptoms  of  pressure  may 
not  exist.  In  such  a case.  Sir  A.  Cooper  sanctions  the 
appliQation  of  the  trephine  {Lectures,  vol.  1,  p.  343)  ; 
but  it  is  contrary  to  the  principle  which  I conceive 
ought  generally  here  to  be  our  guide. 

It  is  true  that  suppuration  of  the  dura  mater  may 
follow  in  such  a case ; but  I do  not  believe  that  tre- 
phining would  tend  to  prevent  it,  the  right  treat- 
ment consisting  in  antiphlogistic  measures ; and  that 
we  should  only  proceed  to  remove  bone  when 
the  symptoms  indicate  the  confinement  i of  matter 
under  it,  or  injurious  effects  from  the  continuance 
of  a depression  that  in  the  first  instance,  perhaps,  pro- 
duced no  unfavourable  symptoms.  On  this  point, 
however,  I deem  it  fair  to  mention,  that  Mr.  Brodie 
coincides  with  Sir  Astley  Cooper,  and  lays  down  the 
following  general  rule : that  if  the  depression  be  ex- 
posed in  consequence  of  a wound  of  the  scalp,  let  the 
surgeon  apply  the  trephine,  and  elevate  the  depression ; 
but  if  there  be  a depression  without  a wound  of  the 
scalp,  in  consequence  of  the  accident,  let  him  not  make 
such  a wound  by  an  operation.— (See  Med.  Chir. 
Trans,  vol.  14,  p.  403.) 

In  the  records  of  surgery  innumerable  facts  may  be 
consulted,  where  the  prudent  and  judicious  employ- 
ment of  the  trepan  has  effected  wonderful  cures,  and 
been  the  only  thing  by  which  the  patients’  lives  could 
possibly  have  been  saved.  The  benefit  which  the  ope- 
ration brings  about  is  also  sometimes  so  sudden  and 
astonishing,  that  in  no  instance  does  the  interposition 
of  the  surgical  art  display  itself  to  greater  advantage. 
The  immediate  restoration  of  sight  by  the  depression 
or  extraction  of  an  opaque  substance  from  the  eye,  is 
not  more  beautiful  and  striking  than  the  instantaneous 
communication  of  the  intellectual  faculties,  and  of  the 
powers  of  speech,  of  feeling,  &c.,  together  with  volun- 
tary motion,  to  a person  lying  in  an  apparently  lifeless  ‘ 
state  from  an  injury  of  the  head.  The  utility  of  the 
trepan  is  occasionally  manifested  even  in  this*degree. 
In  the  valuable  essay  of  Mr.  Abernethy  on  injuries  of 
the  head,  a case  may  be  seen  in  which  the  patient, 
who  had  been  in  a condition  almost  bereft  of  anima- 
tion, rose  up  and  spoke  the  instant  the  extravasated 
blood  was  removed  from  the  surface  of  the  brain  ; and 
among  the  wounded  at  the  battle  of  Waterloo,  there 
was  a soldier  of  the  44th  regiment,  whose  ca.se  is  of 
equal  interest.  He  had  been  struck  by  a musk(;t-ball 
on  the  right  parietal  bone,  which  was  exposed,  but  had 
no  appearance  of  being  fractured.  As,  however,  the 
symptoms  of  compression  were  urgent,  and  the  patient 
was  in  nearly  a lifeless  state,  I conceived  it  tight  to 
apply  the  trephine  to  the  part  on  which  the  violence 
had  acted.  I had  not  sawed  long  before  the  external 
table  came  away  in  the  hollow  of  the  trephine,  leav- 
ing the  inner  table  behind,  which  was  not  only  splin- 
tered, but  driven  at  one  point  more  than  half  an  inch 
into  the  membranes  and  substance  of  the  brain.  No 
sooner  were  the  fragments  taken  out  with  a pair  of 
forceps,  than  the  man  instantly  sat  up  in  his  bed, 
looked  around,  and  began  to  speak  with  the  utmost 
rationality.  It  is  a most  extraordinary  fact,  that  this 
patient  got  up  and  dres.sed  himself  the  same  day,  with- 
out leave  from  the  medical  officers,  and  never  had  a 


bad  symptom  afterward.  Immediately  the  operation 
was  finished  the  temporal  arteries  were  opened,  and 
some  purgative  medicines  exhibited. 

Mr.  Brodie  has  seen  a case  in  which  there  was  a 
fracture  with  distinct  depression  of  the  inner  table, 
while  there  was  a simple  fissure,  which  was  scarcely 
perceptible,  and  that  without  the  smallest  depression, 
of  the  outer  table.  He  also  adverts  to  the  example  re- 
corded by  Tulpius,  in  which  there  were  extensive  fis- 
sures of  the  inner  table,  although  the  outer  one  re- 
mained uninjured ; and  to  another,  mentioned  by  Pare, 
in  which,  while  the  outer  table  was  entire  the  inner 
table  was  broken  into  splinters,  some  of  which  were 
actually  driven  into  the  substance  of  the  brain.  In  all 
fractures  of  the  cranium  with  depression,  it  is  re- 
marked, that  the  inner  table  is  always  broken  to  a 
greater  extent  than  the  outer  one ; and  the  actual  de- 
pression greater  than  would  appear  from  the  mere  in- 
spection of  the  external  fracture.  These  circumstances 
are  imputed  to  the  greater  elasticity  of  the  outer  table, 
and  greater  brittleness  of  the  inner. — {Brodie,  in  Med. 
Chir.  Trans,  vol.  14,  p.  330.) 

In  a case  of  fungus  of  the  dura  mater,  with  diseased 
bone,  mentioned  by  Schmucker,  the  trepan  was  ap- 
plied eleven  times  in  less  than  a month,  and  the  ope- 
ration used  to  cause  so  little  indisposition,  that  the  pa- 
I tient  hardly  ever  required  to  go  to  bed  afterward,  and 
on  one  occasion  actually  went  to  market  an  hour  after 
its  performance. — ( Wahrnehmungen,  b.  1,  p.  456.) 

Let  not  the  young  surgeon,  however,  imbibe  from  a 
few  dazzling  examples  of  success  an  immoderate  soli- 
citude to  perform  the  operation  ; for  it  should  never  be 
undertaken  but  in  the  most  pressing  circumstances, 
and  when  the  symptoms  unequivocally  show  that  a 
dangerous  degree  of  pressure  on  the  brain  exists.  I 
recollect  an  unfortunate  example,  in  which  the  late 
Mr.  Ramsden,  of  St.  Bartholomew’s  Hospital,  ventured 
to  saw  out  a portion  of  the  frontal  bone  for  a mere  long- 
continued  pain  in  the  part ; the  patient  was  attacked 
with  inflammation  of  the  dura  mater,  and  perished  in 
three  or  four  days.  Two  analogous  cases  of  the  need- 
less use  of  the  trephine,  with  similarly  tragical  results, 
are  also  mentioned  by  Mr.  Brodie.— (See  Med.  Chir. 
Trans,  vol.  14,  p.  394.)  That  the  removal  of  bone 
creates  some  risk  of  a subsequent  ulceration  and 
sloughing  of  the  dura  mater,  and  protrusion  of  the 
brain,  is  now  a fact  universally  admitted.  We  may 
therefore  conclude  that  the  operation  is  not  itself  ex- 
empt from  danger ; and  it  is  certain,  that  it  ought  never 
to  be  resolved  on  without  deep  consideration.  “ Ora- 
vis  tamen  satis  est  operatio,  ut  nunguam,  nisi  indica- 
tiones  sufficientes  adsint,  institui  debet.'" — {Callisen, 
Syst.  Chir.  Hodiern.  tom.  1,  p.  658.) 

In  cases  of  injuries  of  the  head,  the  trepan  or  tre- 
phine is  never  necessary,  except  for  the  purpose  of  re- 
lieving the  brain  from  pressure.  Such  pressure  may  be 
caused  by  a depressed  portion  of  the  cranium,  or  it 
may  be  produced  by  an  extravasation  of  blood,  or  the 
lodgement  of  matter,  between  the  skull  and  the  dura 
mater.  The  chief  danger  of  concussion,  when  the  ac- 
cident is  not  directly  or  soon  fatal  from  the  disorgani- 
zation and  mischief  done  to  the  brain,  depends  upon 
the  consequent  inflammation  of  this  organ,  and  there- 
fore cannot  be  likely  to  be  benefited  by  the  tiepan.  If 
the  operation  become  proper  in  such  a case,  it  is  when 
an  abscess  has  formed  under  the  cranium,  and  when 
the  confined  matter  itself  creates  bad  .symptoms  by  its 
pressure  on  the  brain.  This  state  of  things,  however, 
cannot  come  on  till  after  the  inflammation  of  the  brain 
and  its  membranes  has  prevailed  a certain  time,  and 
it  is  always  accompanied  with  a detachment  of  the 
pericranium  and  a puffy  tumour  of  the  scalp;  or,  if 
there  be  a wound  of  the  latter  part  immediately  over 
the  abscess,  the  lips  of  the  injury  suddenly  acquire  an  un- 
favourable appearance  and  lose  their  vermilion  colour. 
The  patient  has  also  had  much  preceding  febrile  disor- 
der, pain  and  tension  over  the  whole  head,  redness  and 
turgescence  of  the  eyes,  and  generally  more  or  less  de- 
lirium. When  the  matter  is  forming  there  are  usually 
rigors,  and,  as  soon  as  it  is  formed,  the  patient  falls  into 
a comatose  stale,  and  paralytic  symptoms  show  them- 
selves. Here  the  urgency  for  the  prompt  application 
of  the  trephine  is  very  great,  and  the  patient’s  only 
chance  of  living  is  almost  essentially  connected  with 
the  immediate  performance  of  the  operation.  This 
important  case  has  been  particularly  dwelt  upon  in 
the  writings  of  Mr.  Pott. 


TREPHINE. 


In  the  article  Head,  Injuries  of,  I have  laid  down 
the  most  remarkable  symptoms  of  concussion  and 
compression  of  the  brain ; a subject  which  every  sur- 
geon should  study  with  earnest  attention  before  he 
ever  presumes  to  employ  the  trepan.  For  sometimes 
these  accidents  are  extremely  difficult  to  be  discrimi- 
nated ; sometimes  they  exist  together  in  the  same  in- 
dividual, a complication  which  is  peculiarly  embar- 
rassing; and,  in  every  instance,  where  the  symptoms 
are  those  of  concussion,  the  operation,  so  far  from  be- 
ing indicated,  would  be  a step  of  ail  others  the  most 
likely  to  do  harm,  by  increasing  the  irritation  and  in- 
Harnmation  of  the  brain  and  its  membranes.  A fall 
upon  the  b<ack  or  upon  the  head  occasions  a direct  con- 
cussion of  the  brain  ; and  the  shock,  not  being  mate- 
rially weakened  by  the  intervention  of  any  yielding 
elastic  structure,  is  the  more  dangerous.  When  a per- 
son has  fallen  from  a certain  height,  and  pitched  on 
his  head,  his  back,  the  buttocks,  the  knees,  or  even  the 
soles  of  the  feet ; when  he  has  been  instantly  deprived 
of  his  senses,  and  then  by  degrees  recovered  them  and 
come  to  himself  again ; the  fact  of  his  having  suffered 
concussion  of  the  brain  is  clear  and  indisputable. 
Concussion  has  likewise  taken  place,  though  in  a 
sligJiler  degree,  when  the  patient  has  been  only  stunned 
by  the  fall,  and  experienced  a sensation  of  sparks. 
But,  a multitude  of  degrees  separate  this  feeble  con- 
cussion from  that  in  which  the  substance  of  the  brain 
is  instantaneously  disorganized,  so  that  there  is  not 
the  possibility  of  recovery. 

The  symptoms  of  concussion  of  the  brain  are  at- 
tended with  coma,  and  the  compression  of  this  organ 
by  an  extravasation  is  also  accompanied  with  lethar- 
gic heaviness.  How  then  is  the  surgeon  to  ascertain 
whether  the  comatose  disorder  arises  from  one  or  the 
other  of  these  affections  1 

Here,  in  order  to  avoid  repetitions,  I beg  leave  to  re- 
fer to  the  observations  already  made  in  the  above- 
mentioned  article.  But  there  is  one  criterion  of  such 
importance,  that  it  may  prevent  innumerable  fatal  mis- 
takes, and,  indeed,  without  the  continual  recollection  of 
it  no  man  ought  to  interfere  with  this  dark  and  abstruse 
part  of  surgery.  On  this  account  I shall  mention  it 
here,  notwithstanding  it  has  been  already  noticed  else- 
where. If  the  patient  has  been  knocked  down  and 
stunned  directly  by  the  blow,  and  remain  in  a state  of' 
insensibility,  these  primary  symptoms  are  ascribable  to 
the  concussion.  On  the  contrary,  when  the  coma  and 
loss  of  sense  do  not  take  place  till  an  hour  or  two  after 
the  blow,  they  are  to  be  imputed  to  an  extrav.asation. 

The  shock  given  to  the  brain  by  concussion  must, 
like  every  other  impulse  communicated,  continue  to 
diminish  until  it  ceases  altogether.  If,  at  the  very 
time  of  the  blow,  the  shock  has  not  been  forcible 
enough  to  produce  alarming  symptoms,  such  symp- 
toms'will  not  afterward  come  on  when  their  cause  is 
weakened.  Hence  the  reason  why  compression  can 
be  distinguished  from  concussion  of  the  brain,  when 
there  has  been  an  interval  of  sense  between  the  re- 
ceipt of  the  blow  and  the  occurrence  of  the  bad  symp- 
toms. But  the  distinction  of  the  symptoms  into  pri- 
mary and  consecutive  cannot  be  made  when  concus- 
sion and  e.xtravdsation  exist  together. 

Having  made  these  few  remarks  on  concussion  and 
compression  of  the  brain,  remarks  which  seemed  ne- 
cessary before  I entered  into  a description  of  tlie  ope- 
ration of  the  trepan,  I shall  next  premise  some  ob- 
fiervations  relative  to  contusions  and  fractures  of  the 
skull,  cases  on  which  the  most  erroneous  opiidons 
have  been  entertained.  It  is  true,  that  I have  in  an- 
other place  (see  Head,  Injuries  of,)  considered  the  sub- 
ject ; but  it  may  he  better  to  recapitulate  certain  points 
here,  because  they  have  such  immediate  connexion 
with  the  .'ipplication  of  the  trephine. 

Contusions  of  the  head  not  nnfrequently  occasion  a 
small  kind  of  tumour,  which  is  soft  in  the  centre,  but 
hard  and  resisting  at  the  circumference,  especially 
when  the  violence  has  been  considerable.  Now  the 
ease  with  which  the  centre  or  seat  of  the  extravasated 
fluid  admits  of  being  depressed,  while  the  circumfe- 
rence remains  hard  and  elevated,  is  extremely  apt  to 
give  rise  to  the  belief,  that  a fracture  with  dejiression 
has  happened.  The  true  nature  of  this  .accident  was 
first  clearly  explained  by  J.  L.  Petit,  and  since  his 
time,  the  proper  cautions  not  to  fall  into  a mistake  con- 
cerning it  have  been  laid  down  by  the  generality  of 
surgical  writers. 


359- 

Often  nothing  is  more  obscure,  than  the  diagnosis  c.  t 
fractures  of  the  cranium  : their  existence  indeed  can 
only  be  made  out  with  certainty  when  they  can  be  felt 
or  seen.  Thus  a fracture  of  the  skull,  attended  with 
a wound  of  the  scalp  and  exposure  of  the  bone,  shows 
itself  in  the  form  of  a fissure  more  or  less  wide  and 
extensive,  and  taking  various  directions.  The  acci- 
dent may  also  be  known  by  the  touch  even  when  the 
soft  parts  continue  entire,  particularly  if  the  fracture 
is  accompanied  with  splinters,  or  the  edges  of  the  fis- 
sure are  materially  separated.  When  there  are  many 
splinters,  entirely  detached,  a crepitus  will  likewise 
serve  to  explain  the  nature  of  the  accident;  but,  un- 
assisted by  these  symptoms,  imparted  to  him  by  the 
sight,  the  hearing,  or  the  touch,  the  practitioner  can- 
not at  once  offer  a decided  opinion  as  to  whether  a 
fracture  exists  or  not. 

In  order  to  procure  more  positive  information, 
would  it  be  right  and  judicious  to  make  several  inci- 
sions and  uncover  the  bone?  But  here  the  surgeon 
would  be  embarrassed  in  the  very  commencement  of 
his  proceedings;  for  how  would  he  be  able  to  judge 
where  the  knife  should  be  applied?  Why  also  should 
he  resort  to  a useless  and  painful  operation,  which 
(to  say  the  best  of  it)  would  only  render  the  patient’s 
cure  more  distant? 

The  symptoms  indicating  compression  of  the  brain 
can  alone  justify  an  examination  of  the  fracture 
These  symptoms  also  must  be  urgent  and  alarming; 
for  when  they  prevail  in  a slight  degree,  bleeding  and 
evacuations  promise  more  benefit  than  any  operation 
on  tlie  skull ; and  consequently  all  examination  of  tlie 
part  supposed  to  be  broken  must  be  unnecessary. 

Even  when  the  cranium  has  been  denuded,  so  that 
the  sight  can  convey  due  information  respecting  the 
solution  of  continuity  in  the  bone,  care  must  be  taken 
not  to  be  deceived  by  a suture,  or  by  tlie  groove  of  a 
vessel.  In  cases  of  doubt,  a modern  surgical  author 
advises  us  to  scrape  the  outside  of  the  bone ; and  he 
tells  us,  that  if  after  the  removal  of  the  external  scale 
the  fissure  yet  appear,  and  a thread  of  blood  be  seen 
at  its  outer  pait,  no  doubt  exists  of  its  being  a leal  fis- 
sure. As,  however,  making  this  examination  can 
answer  no  purpose,  except  with  a view  to  determine 
the  place  where  the  trepan  should  be  applied,  I can- 
not recommend  the  plan,  excejit  where  the  symptoms 
are  such  as  to  render  this  inlbrmation  desirable.  On 
the  contrary,  it  appears  to  me,  that  all  examinations 
of  the  bone,  m.ade  seemingly  from  mere  curiosity,  and 
without  any  true  surgical  object,  should  be  deprecated 
as  rash  and  hurtful. 

The  danger  of  fractures  of  the  skull  does  not  depend 
upon  the  simple  solution  of  continuity:  it  bears  alto- 
gether a relation  to  the  concussion  and  compression  of 
the  brain,  with  which  the  injury  of  the  bone  may  be 
complicated.  The  pressure  caused  by  depressed  splin- 
ters of  bone  is  less  alarming,  inasmuch  as  the  cause 
of  the  compression  is  easy  of  removal.  The  pressure 
of  extravasated  fluid  is  far  more  serious,  in  conse- 
quence of  the  difficulty  of  ascertaining  positively  its 
existence  and  precise  situation. 

Its  seat  is  sometimes  between  the  skull  and  the  dura 
mater,  which  is  detached  from  the  bone.  More  fre- 
quently it  occurs  either  between  the  dura  mater  and 
tunica  arachnoides,  in  the  substance  of  the  brain,  or 
else  in  the  ventricles.  'J'he  quantity  of  extravasated 
fluid  is  generally  less  in  those  extravasations  which 
are  situated  between  the  dura  mater  and  the  skull, 
unless  they  lie  in  the  course  of  the  middle  meningeal 
artery,  when  they  are  frequently  very  copious.  The 
extravasations  which  are  formed  in  the  substance  of 
the  brain  itself  are  not  only  more  considerable,  but 
also,  .as  they  mostly  depend  ujion  concussion,  are  more 
alarming,  than  effusions  on  the  surface  of  the  dura 
mater.  It  is  indeed  extremely  difficult,  if  not  impos- 
sible, to  a.scertain  the  situation  of  the  extravasated 
fluid.  In  such  cases,  the  trepan  is  likewise  of  no  use; 
while  concussion,  when  so  violent  as  to  produce  in- 
ternal extravasation,  is  invariably  fatal.  In  extrava- 
sations between  the  dura  mater  and  the  skull,  which 
are  almost  the  only  cases  of  the  kind  to  which  sur- 
gery can  administer  relief,  when  the  eflused  fluid  lies 
under  a part  of  the  skull  accessible  to  the  trepan,  the 
extravasated  fluid  is  generally,  except  in  the  instance 
just  now  specilied,  small  in  quantity.  'J'he  danger, 
however,  is  not  the  less:  ten  or  twelve  drops  of  fluid 
are  sometimes  enough  to  produce  a fatal  comprension. 


360 


TREPHINE. 


When  the  extravasation  has  happened  in  the  sub- 
stance of  the  brain,  the  compression  is  far  more  peril- 
ous : in  short,  it  may  be  said  to  prove,  with  very  few 
exceptions,  certainly  mortal. 

The  lethargy,  the  degrees  of  which  increase  from 
mere  drowsiness  into  the  most  perfect  coma  ; and  the 
paralysis  of  tlie  opposite  side  of  the  body  to  the  seat 
of  the  extravasation ; are  the  most  common  syiniitoins 
of  this  accident.  Having  explained  elsewhere  (see 
Heady  Injuries  of,)  some  other  symptoms,  such  as 
stertorous  respiration,  dilated  pupils,  &c.,  which  usually 
indicate  pressure  on  the  brain,  it  is  unnecessary  here 
to  dwell  upon  them.  The  subsequent  increase  of  the 
coma  and  paralytic  affections,  and  the  gradual  aug- 
mentation of  their  intensity,  serve  to  render  these 
symptoms  distinguishable  from  others  which  are  sud- 
denly brought  on  by  concussion.  But  there  are  in- 
stances, as  every  man  of  experience  knows,  in  which 
concussion  ruptures  the  blood-vessels,  and  produces 
an  extravasation  of  blood.  In  this  circumstance,  it  is 
obvious  that  the  symptoms  of  compression  are  blended 
with  those  of  concussion.  The  symptoms  proceeding 
from  the  latter  cause  always  diminish  in  proportion  to 
the  time  which  has  elapsed  from  the  moment  of  the 
injury ; while  those  of  compression  succeed,  and,  on 
the  contrary,  increase  in  intensity,  in  proportion  as  the 
quantity  of  extravasated  fluid  becomes  more  consider- 
able. Notwithstanding  these  distinctions,  however, 
it  must  be  acknowledged,  that  there  are  many  cases  in 
which  the  surgeon  is  obliged  to  remain  in  doubt  with 
regard  to  the  particular  cause  of  the  symptoms.  This 
indecision  is  the  more  enrbarrassing,  because  the  ope- 
ration of  the  trepan  is  necessary  in  cases  of  extrava- 
sation, but  useless  in  those  of  concussion.  Even  when 
extravasation  is  known  to  exist,  the  practitioner  re- 
quires more  information;  for  he  ought  to  know  the 
precise  situation  of  the  effused  fluid.  It  is  true,  in- 
deed, that  paralysis  of  one  side  of  the  body  generally 
indicates  the  pressure  to  be  upon  the  opposite  hemi- 
sphere of  the  brain.  But  what  surgeon  would  venture 
to  follow  the  practice  advised  by  Van  Swieten,  and 
apply  to  the  suspected  side  of  the  head  three  crowns 
of  the  trepan!  Possibly,  not  one  of  fhem  might  fall 
on  the  situation  of  the  extravasated  fluid.  When  the 
skull  is  broken,  the  extravasation  is  almost  always  on 
the  same  side  as  the  fracture.  When  it  is  the  effect 
of  concussion,  or  when  the  breach  of  continuity  in 
the  skull  is  what  is  termed  a counter-fissure,  the  effu- 
sion is  generally  on  the  side  of  the  head  most  remote 
from  the  blow.  If  the  pressure  is  caused  by  a de- 
tachment of  the  internal  table  of  the  skull,  the  nature 
of  the  case  cannot  be  ascertained  before  the  operation 
of  the  trepan  has  been  performed  on  the  part  of  the 
skull  upon  which  the  violence  has  acted.  When  there 
are  two  extravasations,  one  depending  upon  a fracture, 
and  situated  immediately  under  it,  between  the  dura 
mater  and  the  skull;  the  other  arising  from  concus- 
sion, and  situated  at  some  point  directly  opposite, 
either  between  the  dura  mater  and  tunica  arachnoides, 
or  within  the  substance  of  the  brain  itself:  paralysis 
may  occur  on  the  same  side  as  the  fracture;  and 
hence  it  may  be  inferred,  that  the  palsy  does  not  al- 
ways take  place  on  the  side  opposite  to  the  extravasa- 
tion. But,  says  Richerand,  an  examination  of  the  body 
quickly  proves  that  the  case  does  not  deviate  from  the 
common  rule.  The  extravasation  produced  by  con- 
cussion being  almost  invariably  more  considerable 
than  that  caused  by  a fracture,  accounts  for  the  ex- 
tension of  the  palsy  to  the  same  side  of  the  body. 
Sometimes  the  side  which  is  not  paralytic  is  aflected 
with  convulsions,  the  pulse  is  full  and  hard,  and  the 
respiration  stertorous;  in  short,  the  symptoms  are 
analogous  to  those  caused  by  apoplexy. 

The  following  observations  and  advice  fully  accord 
with  the  doctrines  which  I have  always  inculcated  in 
my  writings  upon  this  part  of  surgery,  and  they  also 
agree  with  the  practice  which  was  so  successfully 
adopted  by  me  in  the  case  of  the  soldier  of  the  44th 
regiment,  wounded  at  the  battle  of  Waterloo,  as  al- 
ready mentioned : it  is  therefore  with  much  pleasure 
that  I quote  the  authority  of  Mr.  Brodie  on  a point 
about  which  practitioners  have  been  so  much  per- 
plexed: “Blood  (says  Mr.  Brodie)  is  seldom  poured 
out  in  any  considerable  quantity  between  the  dura 
mater  and  the  bone,  except  in  consequence  of  a lace- 
ration of  the  middle  meningeal  artery,  or  one  of  its 
principal  branches;  and  it  is  very  rare  for  this  accident 


to  occur,  except  as  a consequence  of  fracture.  If, 
therefore,  we  find  the  patient  lying  in  a state  of  stupor, 
and  on  examining  the  head  we  discover  a fracture 
with  or  without  depression,  extending  in  the  direction 
of  the  middle  meningeal  artery,  although  the  existence 
of  an  extravasation  on  the  surface  of  the  dura  mater 
is  not  thereby  reduced  to  an  absolute  certainty,  it  is 
rendered  highly  probable,  and  the  surgeon,  under  these 
circumstances,  would  neglect  his  duty  if  he  omitted 
to  apply  the  trephine;  and  where  no  fracture  is  dis- 
coverable, yet  if  there  is  other  evideiir.e  of  the  injury 
haying  fallen  on  that  part  of  the  cranium  in  which  the 
middle  meningeal  artery  is  situated,  the  use  of  the  tre- 
phine may  be  resorted  to  on  speculation,  rather  than 
that  the  patient  should  be  left  to  die  without  an  attempt 
being  made  for  his  preservation.  I cannot,  indeed, 
adduce  any  particular  experience  of  my  own  in  favour 
of  what  is  here  recommended;  but  I conceive,  that 
the  instances  which  have  been  recorded,  in  which  the 
middle  meningeal  artery  has  been  ruptured  without 
any  fracture  of  the  bone,  and  the  known  fact  that 
there  is  sometimes  a fracture  of  the  inner  table  of  the 
skull,  while  there  is  none  of  the  outer  table,  suffi- 
ciently justify  such  an  experiment  in  desperate  cases.” 
— {Brodie,  in  Med.  Chir.  Trans,  vol.  14,  p.  385.) 

With  the  foregoing  exception,  in  which,  indeed,  a 
ground  for  suspecting  the  seat  of  the  effused  blood 
rests  upon  the  knowledge  of  the  exact  part  on  which 
the  violence  has  operated,  the  evacuating  plan,  recom- 
mended for  the  treatment  of  concussion  (see  Head, 
Injuries  of),  is  all  that  can  be  done  when  every  thing 
is  uncertain  relative  to  the  situation  of  the  extravasa- 
tion. It  is  all  that  can  be  done  in  those  frequent  in- 
stances where  the  effusion  has  taken  place  in  the  sub- 
stance of  the  brain,  so  that  it  cannot  possibly  be  voided. 
The  trepan  then  is  indicated  only  when  there  is  an 
extravasation  between  the  dura  mater  and  the  bone, 
the  fracture  being  situated  at  a part  of  the  skull  ac- 
cessible to  instruments,  and  not  at  the  base.  We  shall 
not  here  dwell  upon  the  doubtful  example,  where  the 
fluid  lies  between  the  dura  mater  and  the  arachnoides. 
I believe  that  the  operation  should  be  limited  to  a 
small  number  of  cases,  in  which  not  only  the  existence 
and  situation  of  the  pressure  are  known,  or  may  be 
suspected  on  the  ground  above  explained,  but  in  which 
the  symptoms  arising  from  this  cause  are  urgent  and 
dangerous,  and  the  pressure  can  be  removed  by  no 
other  means. 

Desault  in  the  last  years  of  his  practice  abandoned 
the  operation  of  the  trepan  altogether,  its  ill  success  at 
the  Hdtel-Dieu  having  become  notorious.  Surgeons 
of  the  present  day  trephine  with  more  caution  and 
discrimination,  and  sometimes  with  striking  success. 

When  the  case  is  a simple  fissure,  the  trepan  ought 
to  be  applied  upon  the  solution  of  continuity,  if  the 
symptoms  indicate  a dangerous  degree  of  pressure  on 
the  brain. 

When  the  detached  portions  of  bone  are  depressed, 
so  as  to  compress  the  brain,  the  operation  is  still  requi- 
site if  they  cannot  be  elevated  by  other  means.  But 
Richerand  maintains,  that  a positive  indication  for 
trepanning  is  not  frequent,  either  because  it  is  difficult 
to  judge  of  the  existence  and  situation  of  extravasa- 
tions, or  because  extravasated  fluids  readily  escape 
through  the  interspaces  of  the  fragments,  when  there 
is  a splintered  fracture.  Such  facility  is  also  increased 
when  one  of  the  portions  of  broken  bone  is  totally  de- 
tached, so  that  it  can  be  removed,  leaving  an  aperture 
equivalent  to  what  would  be  produced  by  the  applica- 
tion of  the  trepan. 

When  the  operation  is  determined  on,  the  head 
should  be  shaved  ; indeed,  this  is  often  done  immedi- 
ately the  surgeon  is  called,  in  order  that  he  may  have 
a better  opportunity  of  seeing  wiiat  parts  of  the  scalp 
have  been  struck  ; for  it  is  in  such  situations  that  he 
has  most  reason  to  apprehend  fractures  of  the  bone,  or 
extravasations  beneath  it.  If,  however,  the  violence 
has  occasioned  a large  wound  or  laceration  of  the 
scalp,  the  practitioner,  knowing  where  the  force  has 
been  applied,  is  frequently  content  with  having  a little 
of  the  hair  shaved  off  the  parts  surrounding  the  injury. 
,411  that  need  be  said  on  this  subject  is,  that  it  is  always 
better  to  have  enough  of  the  hair  taken  away,  to  afford 
the  surgeon  an  uninterrupted  opportunity  of  e.xamining 
the  scalp  freely,  and  doing  whatever  may  be  necessary. 
The  loss  of  a little  hair  is  of  very  little  consequence, 
while  the  concealment  of  the  seat  of  a depressed 


TREPHINE. 


361 


fracture,  or  extravasation,  might  lead  to  fatal  conse- 
quences. 

When  the  propriety  and  necessity  of  trephining  are 
fully  indicated,  provided  the  wound  or  laceration  of 
tlie  scalp  should  not  have  exposed  a sufficient  surface 
of  the  bone  for  the  application  of  the  crown  of  the 
trephine,  an  adequate  dilatation  of  such  wound  ought 
immediately  to  be  made.  If,  in  the  situation  of  the 
blow,  there  should  only  be  a contusion,  or  a lump,  un- 
attended with  any  wound,  a division  of  this  part  of 
the  scalp  is  to  be  made  by  carrying  the  knife  quite 
down  to  the  bone.  In  those  cases  in  which  the  swell- 
ing occasioned  by  the  violence  i.s  considerable,  and 
attended  with  the  sensation  of  a crepitus ; as  well  as 
in  oUier  instances,  in  which  there  is  only  a contusion, 
under  which  a fracture  and  displaced  pieces  of  bone 
may  be  felt;  the  scalp  must  be  divided  in  the  same 
manner,  only  with  greater  caution,  lest  the  point  of 
the  knife  should  insinuate  itself  through  the  fracture, 
and  do  mischief  to  the  dura  mater  and  brain. 

Authors  recommend  the  shape  of  the  incision  to  be 
different,  according  to  the  kind  of  fracture  and  the  parts 
of  the  head  on  which  the  violence  has  operated.  When 
the  whole  extent  of  the  Injury  can  be  brought  into  view, 
by  means  of  an  incision  having  the  form  of  the  letter 
T,  the  surgeon  should  be  content  with  such  a division  ; 
but  if  this  be  not  sufficient,  he  may  give  it  a crucial 
shape.  When  the  trephine  is  to  be  applied  to  the 
squamous  part  of  the  temporal  bone,  we  are  recom- 
mended to  make  the  incision  as  much  as  possible  in 
the  shape  of  the  letter  V,  the  branches  of  which  are  to 
be  upwards,  and  the  angle  downwards,  in  order  that 
as  little  as  possible  of  the  temporal  muscle  may  be  cut, 
and  that  the  division  of  its  fibres  may  be  avoided  as 
far  as  it  is  in  our  power. 

Having  divided  the  scalp,  the  next  object  is  to  reflect 
it ; but  no  man  would  be  warranted  in  cutting  any  part 
of  it  away,  although  such  practice  is  advised  by  Pott. 
The  purposes  of  the  operation  do  not  require  any  re- 
moval of  this  kind ; and  the  method  would  leave  a 
wound  which  would  be  long  in  healing,  and  when 
healed,  never  exempt  from  deformity.  In  short,  the 
reflected  flaps  of  the  scalp  are  capable  of  adhering  to 
the  parts  on  which  they  are  laid  after  the  operation, 
and  consequently  ought  never  to  be  wantonly  cut 
away. 

The  scalp  being  reflected,  authors  next  advise  us  to 
scrape  away  the  pericranium,  either  with  the  knife  or 
the  raspatory.  Perhaps  this  measure  may  be  consi- 
dered as  one  which  does  neither  much  harm  nor  much 
good.  The  design  is  to  facilitate  the  application  of  the 
trephine  to  the  bone.  However,  the  teeth  of  a proper 
instrument,  in  good  order,  will  not  be  impeded  by  the 
slender  periosteum ; and  scraping  this  membrane  away 
from  parts  of  the  skull  which  are  not  to  be  removed 
may  conduce  to  exfoliations. 

Sometimes  the  bleeding  from  branches  of  the  tem- 
poral or  occipital  artery  is  so  copious,  that  the  bone 
cannot  be  very  conveniently  perforated  before  the 
hemorrhaae  is  suppressed.  If  it  be  prudent  to  wait  a 
little,  and  the  case  (as  it  generally  does)  should  be  likely 
to  be  benefited  by  the  evacuation  of  blood,  it  is  as  well 
to  let  the  bleeding  continue  for  a certain  time.  The 
surgeon  may  then  just  direct  an  assistant  to  put  the 
and  of  one  of  his  fingers  on  the  mouth  of  the  vessel, 
and  proceed  in  the  operation.  In  some  cases,  the  bleed- 
ing might  be  so  troublesome  that  it  would  be  better  to 
tie  the  artery  at  once. 

All  parts  of  the  cranium  do  not  admit  of  being  tre- 
phined with  equal  convenience  and  safety.  It  has 
usually  been  set  down  by  surgical  authors,  that  the 
trephine  cannot  be  applied  below  the  transverse  ridge 
of  the  os  occipitis.  There  are  some  cases,  however, 
which  prove  that  such  an  operation  may  be  safely 
done,  and  thdt  we  ought  not,  in  urgent  circumstances, 
to  be  afraid  of  dividing  the  trapezius  and  complexus 
muscles,  in  order  to  be  enabled  to  apply  the  trephine  to 
the  bone. — (See  Hutchison's  Case  in  Med.  Chir. 
Trans,  vol.  2,  p.  104,  dj-c.) 

The  majority  of  writers  also  forbid  the  application 
of  the  trephine  to  the  frontal  sinuses,  in  consequence 
of  the  indeterminate  depth  of  these  cavities,  and  the 
apprehension  of  incurable  fistulte.  However,  Larrey 
has  deviated  from  this  precept  in  several  instances ; 
and  his  practice  confirms  the  statement  of  Mr.  C.  Bell, 
that  by  oprming  the  frontal  sinus  with  a large  trephine, 
and  then  using  a small  one,  the  internal  parietes  of  this 


cavity  may  be  trephined  with  perfect  safety,  and  no 
risk  of  injuring  the  dura  mater  with  the  saw. — (See 
Larrey's  Mem.  de  Chirurgie  Militaire,  t.  2,  p.  136 — 
138,  t.  4.) 

Writers  also  caution  us  not  to  apply  the  trephine  to 
the  anterior  inferior  angle  of  the  parietal  bone,  in  con- 
sequence of  the  middle  artery  of  the  dura  mater  lying 
under  it,  generally  in  a groove  of  the  bone,  and  occa- 
sionally in  a canal  in  its  very  substance.  In  the  latter 
circumstance,  this  portion  of  the  parietal  bone  could 
not  possibly  be  taken  away,  without  wounding  the 
vessel.  However,  notwithstanding  this  advice,  which 
has  been  unthinkingly  handed  down  by  one  writer  to 
another,  from  generation  to  generation,  I very  much 
question  the  soundness  of  the  doctrine.  We  undoubt- 
edly ought  to  avoid  trephining  this  part  of  the  cranium 
when  we  can  prudently  do  so.  But  the  causes  de- 
manding this  operation  are  always  so  urgent,  that  the 
patient’s  sole  chance  of  existence  depends  on  their 
quick  removal.  Hence,  were  there  pressure  on  the 
brain,  either  from  a depressed  portion  of  bone,  from 
blood,  or  matter,  and  such  pressure  could  not  be  re- 
moved without  trephining  the  •anterior  inferior  angle 
of  the  parietal  bone,  what  operator  would  be  afraid  of 
doing  so?  Besides,  the  fear  of  the  hemorrhage  has 
been  very  unfounded  ; for  the  lodgement  of  the  artery 
in  a bony  furrow  or  canal,  which  authors  have  pointed 
out  as  rendering  the  suppression  of  the  hemorrhage 
more  difficult,  is  a mere  visionary  idea,  as  it  is  well 
known  that  a little  plug  of  lint,  pushed  into  the  orifice 
of  a vessel  so  situated,  will  always  stop  the  bleeding, 
with  as  much  certainty  and  ease  as  can  possibly  be 
imagined. 

The  foregoing  suggestion  was  made  in  the  early  edi- 
tions of  my  works,  and  I now  see  the  safety  of  the 
practice  has  been  confirmed.  “ I have  also  applied 
the  trepan  (says  Larrey)  over  the  track  of  the  spheno- 
spinous  artery,  at  the  inferior  anierior  angle  of  the 
parietal  bone.  The  artery  was  divided  ; but  I stopped 
the  hemorrhage  almost  immediately,  by  applying  an 
iron  probe  red-ffiot.” — {Mdm.  de  Chir.  Militaire,  t.  2, 
p.  138.) 

Writers,  until  very  lately,  also  prohibited  us  from 
trephining  over  any  of  the  sutures,  and  especially  over 
the  sagittal  suture,  beneath  which  the  longitudinal 
sinus  is  situated.  The  fetfr  of  the  dura  mater  being 
injured,  and  of  this  vessel  being  wounded,  was  the 
reason  for  the  advice.  With  regard  to  the  sutures  in 
general,  the  trephine  may  be  applied  to  them  as  well 
as  to  any  other  part ; and  as  for  the  sagittal  suture, 
many  facts  confirm  the  propriety  of  not  being  deterred 
even  by  it,  though  situated  immediately  over  the  longi- 
tudinal sinus.  It  is  to  be  remembered,  also,  that  the 
dura  mater,  in  cases  of  extravasated  blood  and  matter 
beneath  the  cranium,  is  detached  by  the  intervention 
of  such  fluids  from  the  inner  table. 

By  means  of  a perforation  practised  over  the  sagittal 
suture,  Garengeot  successfully  elevated  a portion  of 
bone  which  pressed  upon  the  longitudinal  sinus,  and 
made  the  patient  quite  comatose.  The  depressed  piece 
of  the  cranium  could  not  have  been  so  advantageously 
raised,  had  the  trepan  been  applied  in  any  other  situa- 
tion. But  a still  stronger  argument  in  favour  of  this 
practice,  when  the  case  at  all  requires  it,  is  the  fact 
that  wounds  of  the  longitudinal  sinus,  and  the  hemor- 
rhage resulting  from  them,  are  not  attended  with  any 
serious  danger.  Sharp  mentions  his  having  twice  seen 
a bleeding  of  this  kind.  Another  instance  is  also  re- 
corded in  Warner’s  Cases.  A child  received  a wound 
on  its  forehead  ; the  two  parietal  bones  were  fractured, 
and  a portion  of  each  was  depressed  on  the  dura  mater. 
The  child  lived  a month  without  any  operation  being 
done  ; but  at  the  end  of  this  time  Warner  applied  the 
trepan.  He  found  a splinter  of  bone  sticking  in  such  a 
way  into  the  longitudinal  sinus,  that  it  could  not  easily 
be  got  out ; consequently  he  enlarged  with  a lancet  the 
opening  in  which  the  splinter  was  entangled.  The 
hemorrhage,  which  was  copious,  was  easilysuppre.'ssed 
by  the  application  of  a little  dry  lint,  and  the  child  was 
relieved,  though  it  died  at  the  end  of  two  months,  after 
suffering  a variety  of  symptoms  which  had  no  con- 
nexion with  the  wound  of  the  sinus,  the  opening  of 
which  soon  healed.  The  fourth  case,  related  by  Mar- 
chetti.s,  also  proves  that  wounds  of  the  longitudinal 
sinus  are  not  fatal.  Pott  and  Callisen  have  since  re- 
ported other  facts,  tending  to  the  same  conclusion. — 
(See  Syst.  Chir.  Hodiernae,  pars  1,  p.  659,  edit.  1798.) 


362 


TREPHINE. 


Whenever  a depressed  fracture  can  be  elevated  to 
its  proper  level  without  applying  the  trephine,  ajid 
with  the  mere  aid  of  a pair  of  forceps  or  an  elevator, 
trephining  should  never  be  performed,  unless  there  be 
strong  reason  to  apprehend  that  blood,  or  matter,  lodged 
OH  the  surface  of  the  dura  mater,  contributes  to  the 
production  of  the  bad  symptoms,  and  cannot  otherwise 
be  discharged. 

Tlie  scalp  having  been  divided,  if  necessary,  and  the 
pericranium  scraped  from  the  surface  of  the  bone,  ac- 
cording to  the  common  precepts  and  practice,  the  next 
thing  is  the  application  of  the  crown  of  the  trephine. 

The  surgeon  is  first  to  make  a little  impression  with 
the  point  of  the  centre- pin,  for  the  purpose  of  marking 
the  place  where  it  will  work,  when  the  crown  of  the 
trephine  is  applied  in  the  proper  situation  ; for  where 
such  impression  is  made,  the  operator  must  make  a 
small  hole  with  a perforator,  in  order  to  fix  the  point 
of  the  centre-pin,  on  which  the  crown  of  the  instru- 
ment turns  backwards  and  forwards,  as  on  an  axis, 
during  the  first  stage  of  the  operation.  Mr.  Savigny’s 
centre-pins  make  a perforation,  without  need  of  any 
particular  instrument  for  the  purpose,  and  in  this  re- 
spect are  advantageous. 

The  point  of  the  centre-piii  having  been  fixed,  the 
trephine  is  to  be  turned  by  regular  semicircular  mo- 
tions, alternately  to  the  right  and  left,  which  object  is 
effected  by  steady  pronations  and  supinations  of  the 
operator’s  hand.  The  teeth  of  the  saw  having  made 
a manifest  circular  groove,  in  which  they  can  steadily 
work,  the  centre-pin  becomes  useless,  and  as  it  would, 
if  not  withdrawn  or  removed,  certainly  injure  the 
dura  mater  and  brain,  by  reason  of  its  projecting  far- 
ther than  any  other  part  of  the  instrument,  it  would  be 
an  unpardonable  blunder  to  let  it  remain  after  a proper 
circular  groove  had  been  formed  by  the  teeth  of  the 
saw. 

The  beginning  of  the  sawing  may  be  executed  boldly 
and  quickly;  for  the  operator  runs  no  hazard  of  doing 
mischief.  It  is  necessary  occasionally,  with  the  view 
of  facilitating  the  action  of  the  instrument,  to  clean 
away  the  particles  of  bony  matter  with  a little  brush, 
usually  kept  for  the  purpose  in  every  box  of  trephining 
instruments.  Were  this  plan  neglected,  the  action  of 
the  cylindrical  saw  would  be  very  much  clogged. 

The  operator,  however,  must  increase  his  caution, 
when  the  sawing  has  made  greater  progress ; for  were 
he  to  be  too  bold,  he  might  sometimes  lacerate  the 
membranes  of  the  brain  with  the  teeth  of  the  instru- 
ment, particularly  as  the  thickness  of  the  cranium  is 
subject  to  infinite  variety,  both  in  different  parts  of  the 
same  head  and  in  different  subjects.  Let  the  surgeon, 
therefore,  never  forget  to  examine  frequently,  with  the 
point  of  a quill,  whether  any  part  of  the  circular 
groove  is  cut  through  or  nearly  so ; for  when  this  is  the 
case,  the  instrument  must  only  be  worked  in  such  a 
way  as  to  make  pressure  upon,  and  cut,  the  part  of  the 
circle  wliich  yet  remains  to  be  divided.  In  some  few 
cases,  it  is  said,  that  tiie  surgeon  can  distinctly  feel 
when  the  teeth  of  the  saw  reach  the  diploe  or  medul- 
lary structure  between  the  two  tables  of  the  cranium  ; 
and  some  writers  have  rashly  directed  us  to  saw  with 
boldness  till  the  sensation  of  this  occurrence  is  com- 
municated to  our  hand  and  fingers.  However,  I be- 
lieve, this  possibility  of  discriminating  the  arriv’al  of 
the  teeth  of  the  saw  at  the  diploe  is  so  uncommon  and 
so  fallacious,  that  it  should  never  be  expected  or  relied 
on.  Nor  ought  the  surgeon  to  saw  with  incautious 
force  and  rapidity,  till  he  sees  the  teeth  of  the  trephine 
bloody,  which  appearance  has  been  set  down  as  an- 
other criterion  of  their  having  reached  the  diploe.  I 
have  already  stated,  that  a great  many  skulls  have 
hardly  any  space  between  several  parts  of  the  two 
tables.  This  is  particularly  often  the  case  in  old 
persons. 

A prudent  man  will  always  prefer  exerting  a little 
force  for  the  purpose  of  breaking  some  of  the  bony 
connexion,  retaining  tlie  circular  piece  of  bone,  to 
running  any  hazard  of  injuring  the  dura  mater  by 
sawing  too  deeply.  After  a certain  time,  therefore,  it 
is  better  to  lay  down  the  trephine,  and  endeavour  to 
elevate  the  portion  of  bone,  with  the  aid  of  a pair  of 
forceps  constructed  for  the  purpose,  and  kept  in  most 
cases  of  trephining  instruments,  or  else  by  means  of 
an  elevator,  which  is  still  more  calculated  for  the 
purpose. 

When  the  circular  piece  of  bone  has  been  taken  out, 


and  the  edges  of  the  perforation  are  unequal  and  splin- 
tered, the  irregularities  are  to  be  cut  off  with  the  len- 
ticular knife.  When  there  is  extravasated  blood  un- 
derneath the  opening  which  has  been  made,  it  some- 
times spontaneously  makes  its  escape,  and  if  it  should 
not  do  so,  the  surgeon  must  remove  it  himself.  If  one 
perforation  of  Uie  skull  should  not  suffice  for  letting 
out  the  blood,  as  much  more  of  the  cranium  ought  to 
be  removed  with  the  trephine  as  circumstances  may 
require;  there  being  no  comparison  between  the  dan- 
ger of  repeating  the  application  of  the  instrument,  and 
that  of  leaving  a quantity  of  undischarged,  compress- 
ing fluid,  on  the  surface  of  the  brain.  Certainly,  many 
facts  on  record  evince,  that  the  dura  mater  may  be 
very  extensively  uncovered  without  dangerous  conse- 
quences. Sarrau  saw  a whole  parietal  bone  exfoliate, 
in  consequence  of  a blow  on  the  head.  Blegny  relates 
a sitnilar  case;  and  Saviard  makes  mention  of  a 
woman  who  had  lost  the  upper  part  of  the  os  fronlis, 
both  the  parietal  bones,  and  a large  portion  of  the  os 
occipitis,  all  of  which  had  come  away  at  the  same 
time;  yet  she  recovered.  Vaugion,  however,  who 
seems  also  to  relate  this  identical  case,  describes  the 
exfoliation  as  not  being  quite  so  extensive. 

I am  of  opinion,  notwithstanding  these  facts,  that 
exposing  a large  part  of  the  dura  mater  with  tlie  tre- 
phine is  by  no  means  an  operation  exempt  from  serious 
danger.  And  what  I conceive  confirms  this  statement, 
is  my  having  known  instances,  in  which  persons  who 
had  been  rashly  advised  to  submit  to  being  trephined, 
for  the  cure  of  violent  pains  in  the  head,  &c.,  died  in 
consequence  of  the  operation.  I make  this  observa- 
tion, well  aware  of  the  successful  instance  of  the 
practice  recorded  by  Schmucker. — {Wahrnehm.  b.  1, 
p.  434.) 

However,  I perfectly  coincide  with  writers  who 
direct  the  removal  of  as  much  bone  as  is  necessary  in 
order  to  be  able  to  remove  the  whole  of  the  pressure 
from  the  surface  of  the  dura  mater. 

The  application  of  the  trephine,  in  cases  of  large 
extravasations,  must  in  particular  be  made  several 
times,  when  the  situation  of  the  fluid  does  not  favour 
its  escape.  But  in  this  circumstance,  Sabatier  says, 
that  we  should  not  make  numerous  perforations  all 
along  the  extent  of  the  extravasation;  but  only  a 
counter-opening,  as  is  done  on  the  soft  parts.  This 
author  expresses  his  surprise  at  there  not  being  on  re- 
cord many  examples  of  counter-openings  made  in  the 
cranium,  since  analogy  demonstrates  their  utility.  I 
cannot  help  remarking  on  this  part  of  the  subject,  that 
one  very  obvious  objection  to  making  openings  of  this 
kind  in  the  cranium,  is  the  impossibility  of  knowing, 
with  certainty,  whether  blood  lies  under  any  particular 
part  of  the  skull ; whereas,  in  abscesses  of  the  soft 
parts,  the  surgeon  feels  the  fluctuation  of  the  matter, 
and  knows  that  his  counter-opening  will  be  made  in 
the  cavity  containing  it.  One  may  sometimes  have 
occasion  to  make  more  than  one  perforation,  in  order 
to  discharge  blood  extravasated  beneath  the  skull,  when 
the  blow  has  happened  near  a suture,. to  which  the 
dura  mater  continues  adherent;  for  a single  opening, 
made  only  on  one  side  of  the  suture,  might  only  give 
vent  to  a part  of  the  extravasation. 

When  the  trephine  is  applied,  on  account  of  a frac- 
ture with  depression,  Mr.  Brodie  considers  the  removal 
of  a small  portion  of  bone  as  generally  sufficient;  but 
when  the  case  is  an  extravasation  of  blood  on  the  sur- 
face of  the  dura  mater,  he  recommends  a freer  removal 
of  the  skull.  He  was  led  to  adopt  this  rule  by  having 
seen  a case,  in  which,  after  two  triangular  portions  of 
bone  had  been  taken  away  with  a straight  saw,  and  a 
large  quantity  of  blood  discharged,  to  the  great  relief 
of  the  patient,  suppuration  afterward  took  place  on 
the  surface  of  the  dura  mater,  wherever  this  membrane 
had  been  separated  by  the  extravasation  from  the 
bone.  The  matter  was  hindered  by  the  granulations 
from  escaping  by  the  aperture  already  made,  and, 
though  another  portion  of  bone  was  removed,  the 
practice  was  too  late  to  save  the  nian’s  life. — (See 
Med.  Chir.  Travs.  vol.  14,  p.  387.)  Whether  an  ex- 
tensive removal  of  the  cranium  ought  to  be  generally 
made  in  anticipation  of  suppuration  of  the  dura  mater 
in  such  a easel  whether  such  a me,asure  might  not 
rather  tend  to  make  the  event  more  likely  to  happen  ? 
and  whether  the  practice  which  Mr.  Brodie  .actually 
adopted  might  not  have  be  en  the  best,  though,  in  the 
instance  brought  forward,  unsuccessful  ? are  questions, 


TREPHINE.  363 


I think,  on  which  the  most  judicious  surgeons  may  en- 
tertain differences  of  opinion.  As  my  principles  lead 
me  to  disapprove  of  the  old  custom  of  trephining  for 
the  purpose  of  preventing  inflammation  and  suppura- 
tion of  the  dura  mater,  they  would  incline  me  to  be 
content  with  rigorous  antiphlogistic  treatment,  and 
discharging  the  confined  matter  as  soon  as  the  ill  effects 
of  its  pressure  began  to  show  themselves. 

If  we  should  not  find  blood  lodged  under  the  cra- 
nium, but  the  dura  mater  should  seem  elevated,  tense, 
dark-coloured,  forming  a prominent  fluctuating  tu- 
mour outwards,  it  may  be  cautiously  opened  with  a 
lancet  or  bistoury,  with  a view  of  letting  out  any  col- 
lection of  blood  underneath.  In  the  article  Head^  In- 
juries of,  I have  stated  the  result  of  Mr.  Abernethy’s 
experience,  in  regard  to  the  operation  of  opening  the 
dura  mater.  This  gentleman  found,  that  the  method 
never  eflectually  discharged  all  the  blood,  but  only  the 
serous  part  of  it.  The  evacuation  of  any  of  the  com- 
pressing fluid  must,  however,  be  desirable;  and  if  the 
surgeon  cannot  do  more,  yet  he  has  fulfilled  his  pro- 
fessional duty. 

Although  Mr.Brodie  admits,  that  wounds  of  the  dura 
mater  are  attended  with  great  danger,  he  approves  of 
the  practice  here  recommended  (see  Med.  Chir.  Trans, 
vol.  14,  p.  389),  and  supports  his  opinion  by  reference 
to  an  interesting  case  under  the  late  Mr.  Chevalier. 
This  gentleman  was  called  to  a child,  a year  and  a half 
old,  which  had  received  a severe  blow  on  the  head,  and 
lay  insensible  and  convulsed.  There  was  no  wound 
of  the  scalp;  but  the  fontanel  appeared  somewhat  ele- 
vated. It  was  therefore  exposed  by  an  incision,  and 
raised  so  as  to  uncover  the  subjacent  dura  mater,  be- 
neath w^hich  the  purple  colour  of  extravasated  blood 
w’as  plainly  discernible.  A puncture  having  been  made 
with  a lancet,  three  or  four  ounces  of  blood  issued  out 
with  considerable  force;  the  symptoms  were  imme- 
diately relieved,  and  the  child  recovered.— (See  Med. 
Phys.  Journ.  vol.  8,  p.  505.)  An  example,  furnishine 
an  equally  convincing  proof  of  the  practice  here  ad- 
vised, is  also  adduced  by  Mr.  Brodie  from  the  practice 
of  my  friend  and  neighbour,  Mr.  Ogle.  * 

The  utility  of  trephining  is  not  limited  to  discharging 
extravasated  blood  or  matter  lodged  underneath  the 
skull.  This  operation  frequently  enables  us  to  elevate 
depressed  portions  of  bone.  The  latter  object  can  often 
be  accomplished  by  merely  making  one  perforation. 
Sometimes  several  perforations  are  requisite  to  be 
made  near  each  other.  Authors  even  state,  that  it 
may  also  become  necessary  to  remove  the  intervening 
portions  of  bone  with  a pair  of  cutting  forceps.  The 
depressed  part  may  then  be  easily  raised  by  means  of 
an  elevator.  Occasionally,  indeed,  I may  say,  very 
often,  the  best  practice  is  to  remove  the  depressed  por- 
tion entirely,  when  its  total  separation  from  the  rest 
of  the  skull  can  be  accomplished  by  cutting  across  the 
base  of  the  depressed  piece. 

According  to  some  writers,  if,  after  dividing  the  dura 
mater,  the  surface  of  the  brain  appears  smooth  and 
flabby,  with  a fluctuation,  we  may  conclude  there  is 
an  abscess  in  its  substance ; and  these  authors,  more 
enterprising  with  their  pens,  it  is  to  be  hoped,  than 
with  their  scalpels,  sanction  the  method  of  carrying 
the  point  of  the  bistoury  to  the  depth  of  an  inch,  if 
circumstances  render  so  deep  a puncture  necessary. 
“But,”  says  Richerand,  “prudence  forbids  us  to  go 
farther.  Cutting  the  surface  of  the  brain  causes  no 
pain,  and  it  produces  less  danger  than  one  might  ap- 
prehend ; experience  and  observation  prove  (in  oppo- 
sition to  phrenological  theories),  that  the  essential 
parts  of  this  organ  are  situated  near  its  base,  and  that 
its  surface  may  be  removed  without  danger  or  pain." 
— (Jfosogr.  Chir.  t.  2,  p.  301,  e<Z.  3.) 

A case,  in  which  Dupuytren  plunged  a bistcxiry  to 
the  depth  of  more  than  an  inch  into  the  brain,  and 
thus  let  otit  an  ounce  and  a half  of  pus,  is  recorded  in 
a valuable  periodical  work.— (.^ce  .Journ.  of  Foreign 
Med.  JSTo.  18,  p.  298.)  Some  temporary  amendment 
followed  ; but  the  case  had  a fatal  termination. 

After  the  operation  of  trephining,  the  divided  scalp 
is  to  be  placed  as  nearly  as  possible  in  its  natural  situa- 
tion, and  lightly  dressed  with  a simple  pledget  of  any 
common  unirritating  ointment.  In  applying  the  dress- 
ings, the  surgeon  should  invariably  keep  in  view  these 
objects;  namely,  to  let  whatever  is  put  on  the  wound 
be  as  light  as  possible,  not  apt  to  make  pressure  on  the 
brain,  and  of  a nature  which  cannot  excite  irritation. 


All  stimulants  are  to  be  strictly  avoided ; nor  will  any 
bandage  be  better  than  an  ordinary  night-cap  of  suffi- 
cient size  to  be  put  on  with  facility.  It  may  be  secured 
wiih  bits  of  tape,  which  are  to  be  tied  under  the  jaw 

The  practitioner  should  not  now  conceive  that  he 
has  done  all  that  he  ought  to  do.  Let  him  remember 
the  urgent  necessity  of  keeping  off,  or  diminishing,  the 
inflammation  of  the  dura  mater  and  brain,  which  is 
still  to  be  feared.  Let  him  bleed  the  patient  largely 
and  repeatedly;  exhibit  saline  purges,  clysters,  and 
antimonials;  and  if  the  symptoms  continue,  let  him 
apply  a blister  to  some  part  of  the  head.  I shall  avoid, 
however,  any  repetitions  on  this  subject,  by  referring 
to  Head,  Injuries  of. 

The  aperture  in  the  skull  usually  becomes  closed 
with  soft  granulations,  which  slowly  acquire  a hard 
consistence.  While  the  cicatrix  is  soft,  it  should  be 
protected  from  external  injury  with  a thin  piece  of  horn 
or  metal.  Exfoliations  from  the  margin  of  the  per- 
foration sometimes  retard  the  healing  of  the  wound; 
but  now  that  the  practice  of  dressing  with  drying 
spirituous  applications  has  been  exploded,  and  the  re- 
moval of  any  part  of  the  scalp  is  condemned  by  all  the 
best  surgeons,  these  unpleasant  consequences  are  ren- 
dered much  less  frequent  than  in  former  days. 

The  reader  may  find -an  account  of  the  operation  of 
trepanning  or  trephining  in  every  system  of  surgery ; 
but  he  should  particularly  consult  the  writings  of 
Sharp,  Le  Dran,  Dionis,  Bertrandi,  Pott,  Sabatier, 
Schmucker,  Richter,  Dease,  Abernethy,  Desault,  Cal 
lisen,  Richerand,  C.  Bell,  and  seveial  parts  of  the 
Mem.  dc  VAcad.  de  Chirurgie.  Also,  B.  C.  Brodie  on 
Injuries  of  the  Brain,  in  Med.  Chir.  Trans,  vol.  I4-. 

[This  article  on  the  trephine  contains  perhajis  the 
most  valuable  practical  information  any  where  to  be 
found  in  our  language.  The  excellent  diagnosis  be- 
tween concussion  and  compression,  and  the  valuable 
arguments  against  the  indiscriminate  use  of  the  tre- 
phine, and  in  favour  of  large  and  repeated  venesection, 
cannot  be  too  familiarly  known  nor  too  highly  estima- 
ted, especially  by  the  young  surgeon. 

It  is  a high  source  of  gratification  to  be  able  to  record, 
that  in  this  country,  the  trephine  is  now  much  more 
seldom  used  than  formerly.  But  a few  years  ago,  on 
a man  being  stunned  by  a blow  or  a fall,  to  any  consi- 
derable extent,  almost  any  neighbouring  physician 
would  apply  the  trephine  without  hesitation,  and  the 
facility  with  which  this  operation  can  be  performed, 
offers  no  small  temptation  to  the  mere  operator,  espe- 
cially as  there  is  seldom  any  risk  of  life,  and  always 
a gain  in  reputation  among  the  multitude.  It  is  now 
very  generally  viewed  as  it  ought  to  be,  as  a dernier 
resort  in  such  cases,  and  the  use  of  it  is  not  counte- 
nanced, unless  the  symptoms  of  compression  by  de- 
pressed bone,  or  extravasated  blood,  are  altogether  un- 
equivocal ; and  a consultation  with  the  best  surgeons  is 
always  premised. 

I have  seen  scores  of  persons,  who  would  have  for- 
merly been  trephined,  without  even  a “ trial  by  jury,” 
recovered  from  coma,  paralysis,  and  convulsions,  justly 
attributable  to  compression  on  the  brain,  by  very  large 
and  copious  bleedings,  aided  by  cathartics  and  stimu- 
lating frictions  and  cataplasms  to  the  extremities. 

Still,  however,  there  will  be  a sufficiency  of  instances, 
imperiously  requiring  the  use  of  the  trephine,  to  render 
it  necessary  that  every  practitioner  should  be  conver- 
sant with  the  instrument,  and  all  the  circumstances 
connected  with  its  use.  Indeed,  some  of  the  most  de- 
plorable cases  to  which  surgical  assistance  is  ever  ren- 
dered, are  occasionally  met  with  among  the  examples 
in  which  the  trephine  becomes  indispensable. 

In  the  year  1819,  I assisted  Dr.  Henry  Wm.Ducachet, 
then  a practitioner  in  the  city  of  Baltimore,  in  the  per- 
formance of  this  operation  on  a woman  who  had  re- 
ceived several  blows  on  the  head  with  an  axe,  from  a 
brutal  husband.  We  could  discover  no  depression  of 
bone,  and  yet  the  coma,  stertor,  hemiplegia,  and  other 
evidences  of  compression,  resisted  all  our  depletion, 
and  on  the  third  day  after  the  violence,  we  deter- 
mined to  apply  the  trephine,  being  sustained  by  judi- 
cious counsel  in  our  opinion,  that  there  must  be  exten- 
sive extravasation  of  blood  beneath  the  cranium.  On 
removing  the  circular  piece  of  bone,  with  the  largest 
crown  of  the  instrument,  a coagulum  was  found  ex- 
tending over  the  left  hemisphere  of  the  brain,  exterior 
to  the  dura  mater.  This  being  removed,  and  only 
a mitigation  of  the  symptoms  following,  the  obvi- 


364 


TRI 


TRl 


ous  distention  of  the  dura  mater  itself,  pointed  out 
the  existence  of  still  more  extended  mischief.  We 
therefore  divided  the  dura  mater  with  a piobe-pointed 
bistoury,  for  the  space  of  half  an  inch,  when  coagulated 
blood  to  an  immense  extent  forced  itself  through  the 
opening.  After  washing  out  the  cavity  by  warm  wa- 
ter thrown  in  with  the  syringe,  we  were  delighted  to 
find  the  entire  removal  of  the  symptoms  instantane- 
ously result.  Our  patient  spoke  for  the  first  time,  asked 
for  water,  seemed  as  though  awoke  from  an  ordinary 
sleep,  the  stertor  ceased,  the  dilatation  of  the  pupil  and 
liemiplegia  were  removed,  and  the  most  sanguine  liopes 
were  entertained  of  her  recovery. 

I shall  never  forget  the  painf  ul  acuteness  of  our  dis- 
appointment, when  in  a few  hours  we  found  all  these 
dangerous  symptoms  return  in  a still  more  aggravated 
form,  discovering  to  us  the  mortifying  truth,  that  though 
the  operation  had  succeeded,  yet  our  patient  would  die ; 
for  although  we  had  removed  the  coagula,  we  could 
not  stop  the  bleeding  vessel. 

On  the  post  mortem  examination,  the  temporal  bone 
was  found  fractured,  and  a spicula  of  bone  had  pierced 
the  meningeal  artery,  which  had  not  ceased  to  pour  out 
its  blood,  and  hence,  coagula  were  found  to  fill  the  whole 
space  of  the  hemi-cranium,  above  and  below  the  dura 
mater.  I have  preserved  the  skull  in  my  cabinet  of 
morbid  preparations,  and  the  point  at  which  the  frac- 
ture of  the  internal  table  pierced  the  great  artery  of  the 
dura  mater,  is  distinctly  visible  in  the  depression  which 
marks  its  course,  which  is  in  this  case  deeper  than  or- 
dinary. It  was  exhibited  on  the  trial  of  the  mur- 
derer, and  was  highly  important  in  a medico-legal  point 
pf  view,  since  it  fully  satisfied  the  court,  counsel,  and 
jury,  that  her  death  was  occasioned  by  the  blows,  and 
that  the  injury  was  altogether  irreparable.  This  was 
■clear,  from  the  fact  that  the  only  blows  which  had 
wounded  the  scalp  were  on  the  top  of  the  head,  and  on 
the  middle  of  the  os  parietalis.  The  fracture  and 
consequent  rupture  of  the  vessel  was  low  down  in  the 
temple,  where  no  external  wound  was  found,  and  two 
inches  from  the  point  at  which  the  trephine  was  ap- 
plied, guided  as  it  was  by  the  external  injury. 

Since  that  time,  I have  applied  the  trephine  and 
Hey’s  saw  for  the  removal  of  a large  portion  of  the 
frontal  bone,  which  had  become  carious  from  syphilis, 
involving  nearly  the  whole  forehead.  The  extensive 
suppuration  which  had  entered  the  frontal  sinus,  and 
even  passed  into  the  cavity  of  the  skull,  rendered  this 
operation  necessary,  in  the  opinion  of  the  consultation ; 
the  man  having  become  idiotic  from  the  disturbance  of 
the  cerebrum,  and  being  a burden  to  liimself  and  fa- 
mily, from  frequent  epilepsy. 

I applied  the  crown  of  the  instrument  four  times,  re- 
moving all  the  diseased  portion  of  the  bone,  and  only 
once  entering  through  the  skull,  the  caries  being  in  the 
other  parts  confined  to  the  external  table,  and  the  diploe 
filled  with  a fetid  pus  which  had  not  sufficient  egress, 
and  by  consequence  was  involving  the  bone  still  more 
extensively  in  the  specific  morbid  action.  A large  num- 
ber of  smaller  pieces  of  the  cranium  were  removed 
with  Hey’s  saw,  and  by  the  forceps.  A very  consider- 
able quantity  of  pus  was  found  upon  the  dura  ma- 
ter, at  the  point  at  which  the  caries  had  entered  the 
cavity,  which  was  discharged  through  the  opening 
made  by  the  trephine,  and  the  cavity  of  the  head 
washed  out  with  warm  water.  Notwithstanding  the 
specific  character  of  the  disease,  the  almost  hopeless 
extent  to  which  it  had  progressed,  and  the  extreme  ema- 
ciation which  had  been  superinduced  by  neglect  and 
mismanagement,  this  patient  entirely  recovered,  and  has 
ever  since  the  time  of  the  operation  (1822)  been  ac-  ' 
tively  employed  as  a mechanic;  never  having  had  epi- 
lepsy since,  nor  any  intellectual  deficiency,  although 
this  had  become  apparent  for  months  before.  I saw  ! 
him  when  last  in  Baltimore  in  perfect  health.  i 

In  the  JV’ew-  York  Med.  and  Phys.  Journal,  vol.  5,p.  I 
79,  will  be  found  a report  of  a singular  case  of  epilepsy  I 
arising  from  depression  of  bone,  cured  by  trephining. 

It  was  performed  by  my  friend  Dr.  David  L.  Rogers,  I 
of  this  city. — Reese.]  ( 

TRICHIASIS  (derived  from  the  hair)  denotes  ( 
a faulty  inclination  of  the  eyelashes  inwards  against  i 
the  globe  of  the  eye.  According  to  Scarpa,  the  disease  i 
presents  itself  under  two  distinct  forms : the  first  is,  : 
where  the  cilia  are  turned  inwards,  without  the  natn-  i 
ral  position  and  direction  of  the  tarsus  being  at  all  \ 
changed ; the  second  consists  in  a tnorbid  inclination  < 


t of  the  tarsus  inwards  {Entropium),  and  consequently 
I of  the  eyelash  towards  the  eyeball  ( Trichiasis). 

Tiie  first  form  of  this  disease  is  said,  both  by  Beer 
and  Scarpa,  to  be  uncommon,  nor  has  it  come  under  the 
I observation  of  the  latter  writer  more  than  once,  and, 
in  this  instance,  only  some  of  the  hairs  had  changed 
their  direction.  On  this  point,  however,  Mr.  Travers 
is  completely  at  variance  with  the  foregoing  authors,  as 
he  describes  an  inversion  of  the  cilia  as  frequently  ex- 
ing  independent  of  entropeon. — (Synopsis,  p.  232.) 
The  second  species  or  form  of  trichiasis,  or  that  which 
c'onsists  in  a folding  inwards  of  the  tarsus  and  cilia  at 
the  same  time,  is  the  case  which  is  commonly  met  with 
in  practice.  It  may  be  either  complete,  affecting  the 
whole  of  the  tarsus,  or  incomplete,  occupying  only  a cer- 
tain portion  of  the  edge  of  the  eyelid,  most  frequently 
near  the  external  angle  of  the  eye.  Sometimes,  the  dis- 
ease is  confined  to  one  eyelid ; at  other  times  it  affects 
both ; and  occasionally  the  patient  is  afflicted  with  it  in 
both  eyes. 

Some  writers,  among  whom  is  Beer  (Lehre  von  den 
Jlugenkr.  b.  2,  p.  118),  admit  a case,  which  they  call 
distichiasis,  and  which  they  suppose  to  be  produced 
by  a double  and  unusual  row  of  hairs.  But,  accord- 
ing to  Scarpa,  this  third  species  is  only  imaginary,  and 
the  reason  of  this  subdivision  sdemsto  have  arisen  from 
not  recollecting  what  was  long  ago  remarked  by  Wins- 
low and  Albinus,  that  although  the  roots  of  the  cilia 
appear  to  be  disposed  in  one  line  only,  they  form  two, 
three,  and  in  the  upper  eyelid  even  four  rows  of  hairs, 
unequally  situated,  and,  as  it  were,  confused.  When- 
ever, therefore,  in  consequence  of  disease,  a certain 
number  of  hairs  are  separated  from  each  other  in  a 
contrary  direction  and  disorderly  manner,  the  eyelash 
will  appear  to  be  composed  of  a new  and  unusual  row 
of  them,  while,  in  fact,  there  is  no  change,  either  with 
respect  to  their  number,  or  natural  implantation. 

It  is  not  an  easy  matter  to  determine  precisely,  says 
Scarpa,  what  are  the  causes  which  sometimes  make 
a few  of  the  hairs  deviate  from  their  natural  direction, 
while  the  tarsus  continues  in  its  right  position.  They 
are  commonly  referred  to  cicatrices  in  consequence  of 
previous  ulceration,  whereby  the  cilia  fall  off,  and  those 
which  are  growing  are  hindered  from  taking  their  pro- 
per direction.  There  must,  however,  be  other  causes 
sometimes  concerned ; for,  in  the  case  seen  by  Scarpa, 
two  or  three  hairs  were  turned  inwards  against  the 
eyeball,  although  there  had  been  no  preceding  ul- 
ceration nor  cicatrices  of  any  part  of  the  tarsus.  In- 
deed, Scarpa  is  inclined  to  believe,  that  the  small  ulcers 
and  scars  which  are  sometimes  formed  upon  the  inter- 
nal margin  of  the  tarsus,  are  more  likely  to  cause  the 
second  form  of  the  disease,  or  the  inversion  of  the  edge 
of  the  eyelid,  and,  consequently,  of  the  cilia  towards 
the  globe  of  the  eye.  As  these  ulcers,  when  neglected, 
destroy  the  internal  membrane  of  the  eyelids  near  the 
tarsus,  it  necessarily  follows,  that  in  proportion  as  they 
heal  and  diminish,  they  draw  along  with  them  and 
turn  inwards  the  tarsus  and  hairs  inserted  into  it.  And 
since  they  do  not  always  occupy  the  whole  extent  of 
the  internal  margin  of  the  eyelid,  but  are  sometimes 
confined  to  a few  lines  in  the  middle  or  extremity  near 
the  external  angle  of  the  eyelid,  so,  after  the  cicatrices 
are  formed,  the  whole  of  the  hairs  are  not  invariably 
turned  inwards,  but  only  a certain  number  of  them, 
which  correspond  to  the  extent  of  the  ulcers  previ- 
ously situated  along  the  internal  edge  of  the  tarsus. 
Indeed,  in  every  case  of  imperfect  trichiasis  from  a 
cicatrix  of  the  inner  margin  of  the  eyelid,  the  tarsus 
and  cilia  are  every  where  in  their  natural  situation, 
except  opposite  the  part  where  the  ulcers  formerly  ex- 
isted. Also,  if  the  eyelid  be  everted,  its  internal  mem- 
brane, near  that  part  of  the  margin  corresponding  to  the 
seat  of  the  trichiasis,  will  be  found  pale,  rigid,  and  hard- 
ened, the  inversion  of  the  cartilaginous  border  and  of 
the  cilia  being  plainly  the  effect  of  the  contraction  of 
the  cicatrized  point. 

Chronic  ophthalmies  of  long  continuance  sometimes 
bring  on  the  complaint,  in  consequence  of  the  skin 
of  the  eyelids  being  kept  for  a long  time  in  a state  of 
di.stention  and  oedema,  terminating  in  a considerable 
relaxation  of  it.  And,  according  to  Beer,  the  too  long 
continued  use  of  emollient  poultices  may  have  the 
same  effect.— (Dc/trc,  4-c.  b.  %p.  113.)  The  cartilagi- 
nous margin  of  the  eyelid  then  loses  the  proper  sup- 
port of  the  integuments,  inclines  towards  the  eyeball, 
and  afterward  turns  inwards,  drawing  the  eyelashes 


TRICHIASIS. 


365 


along  with  it  in  the  same  improper  direction.  Long- 
continued  puiiform  dischargp.s  from  the  ciliary  glands 
likewise  spoil  the  shape  and  consistence  of  the  cartilage 
of  the  eyelid,  and  therefore  not  unfrequenily  occasion 
trichiasis.  Scarpa  doubts  whether  a spasmodic  contrac- 
tion of  the  orbicularis  palpebrarum  muscle  can  ever  be 
a cause  of  the  disease. 

The  annoyance  which  must  necessarily  result  from 
the  hairs  perpetually  pressing  upon  the  cornea  and 
white  of  the  eye,  as  Scarpa  observes,  may  be  easily 
imagined.  The  evil  is  rendered  still  greater  by  the 
hairs  which  are  turned  inwards  becoming  much  longer 
and  thicker  than  those  which  retain  their  natural  di- 
rection. And  although  the  trichiasis  be  confined  to 
one  eye,  both  the  eyes  usually  sutfer  from  the  effects  of 
the  disease.  Indeed,  generally,  the  eye  on  the  sound 
side  cannot  be  moved  without  occasioning  pain  in  that 
which  is  e.vposed  to  the  irritation  and  friction  of  the 
inffecled  hairs.  In  almost  all  cases,  both  the  eyes  are 
very  irritable,  and  incapable  of  bearing  the  light.  As, 
in  cases  of  incomplete  trichiasis,  the  patient  retains 
some  little  power  of  opening  the  eyelids  for  the  purpose 
of  seeing,  and  that  most  frequently  towards  the  inter- 
nal angle  of  the  eye,  the  head  and  neck  are  often  in- 
clined in  an  awkward  manner,  so  that  in  children  a 
distortion  of  the  neck  and  shoulders  is  at  last  produced, 
wliich  cannot  be  rectified  without  difficulty,  even  after 
the  trichiasis  is  cured.  Unfortunately,  also  children 
are  impatient  of  the  uneasiness  arising  from  the  in- 
flected hairs,  and,  therefore,  are  continually  rubbing 
the  eyelids,  whereby  all  the  ill  effects  of  the  complaint 
are  much  increased. 

The  cure  of  the  second  species  of  trichiasis,  or  that 
which  is  commonly  met  with  in  practice,  is  accomplished 
by  artificially  everting  the  eyelid,  and  fixing  it  perma- 
nently in  its  natural  position,  together  with  the  eye- 
lashes which  irritate  the  globe  of  the  eye.  According  to 
Professor  Scarpa,  this  indication  is  perfectly  fulfilled 
by  the  excision  of  a piece  of  the  skin  close  to  the  edge 
of  the  eyelid,  of  such  a breadth  and  extent  that,  when 
the  cicatrix  is  formed,  the  tarsus  and  margin  of  the  eye- 
lid may  be  turned  outwards,  and  sufficiently  separated 
from  the  eyeball,  the  cicatrix  of  the  integuments  afford- 
ing a point  of  support  fully  adequate  to  keep  the  parts 
in  their  natural  position  and  direction.  Scarpa  believes 
that  very  few  modern  surgeons,  with  a view  to  the  ra- 
dical cure  of  this  disease,  now  place  any  confidence 
either  in  plucking  out  the  inverted  eyelashes,  bending 
them  outwards,  and  retaining  them  so  by  means  of  ad- 
hesive plaster ; or  in  plucking  them  out,  and  destroying 
their  roots  with  caustic:  much  less  in  extirpating  the 
edge  of  the  eyelid  along  with  the  hairs,  or  dividing  the 
orbicularis  muscle  on  the  internal  surface  of  the  eye- 
lid, under  an  idea  that  the  disease  is  sometimes  pro- 
duced by  a spasmodic  contraction  of  it. 

The  following  is  the  mode  of  proceeding  recommend- 
ed by  Scarpa.  The  patiant  being  seated  in  a chair,  if 
an  adult,  or,  if  a child,  laid  upon  a table,  with  the  head 
raised,  and  firmly  held  by  an  assistant,  who  must  stand 
behind  the  patient,  the  surgeon  is  to  jmsh  outwards,  with 
the  end  of  a probe,  the  hairs  which  irritate  the  eye. 
Then,  with  a pair  of  dissecting  forceps,  or  the  ends  of 
his  fore-finger  and  thumb,  he  should  lift  up  a fold  of  the 
skin  of  the  eyelid,  taking  great  care  that  the  piece  which 
is  taken  hold  of  corresponds  exactly  to  the  middle  of 
the  whole  extent  of  the  trichiasis ; for  sometimes  the 
whole,  sometimes  a half,  and,  in  other  instances,  only 
a third  of  the  extent  of  the  tarsus  is  inverted.  The  sur- 
geon, with  his  left  hand,  must  raise  the  fold  of  the  skin 
more  or  less,  according  as  the  relaxation  of  the  inte- 
guments, and  the  inversion  of  the  tarsus,  are  more 
or  less  considerable.  The  reason  of  this  is  evident,  viz. 
the  greater  the  quantity  of  skin  is  which  is  raised,  the 
greater  is  the  quantity  which  will  be  cut  away.  Sup- 
posing the  patient  to  be  an  adult,  as  soon  as  the  fold  of 
skin  has  been  raised  in  a certain  degree,  the  surgeon 
must  request  him  to  open  his  eye  ; and  if  in  this  act 
the  tarsus  and  eyelashes  resume  their  natural  place  and 
direction,  the  portion  of  skin  already  raised  will  be  suf- 
ficient for  the  purpose.  When  the  integuments  are  ele- 
vated by  means  of  a pair  of  dissecting  forceps,  and  care 
is  taken  to  lay  hold  of  the  skin  precisely  at  the  middle 
point  of  the  whole  extent  of  the  trichia.sis,  it  necessa- 
rily follows,  that  the  consequent  section  of  the  skin  will 
form  an  oval,  and  that  the  greatest  width  of  the  wound 
will  correspond  exactly,  or  nearly  so,  to  the  middle  of 
the  eyelid,  and  its  narrowest  parts  to  the  angles,  or  com- 


missures of  the  same.  This  contributes  very  materi- 
ally to  make  the  cicatrix  correspond  to  the  natural 
fold  of  the  eyelid,  and  hinder  the  origin  of  the  disease 
of  an  opposite  nature  to  the  one  about  to  be  reme- 
died, towards  the  angles  of  the  eye,  viz.  a turning  out 
of  the  commissures  of  the  eyelids. — (See  Ectropium.) 

Besides  this  caution,  relative  to  the  situation  and 
figure  of  the  fold  of  the  integuments  to  be  cut  off,  the 
surgeon  must  be  careful  that  the  division  of  the  skin 
be  made  very  near  tlie  inverted  tarsus.  Were  this  cir- 
cumstance neglected,  the  operator  might  have  the  mor- 
tification of  finding,  after  the  wound  is  healed,  that 
altJiough  the  eyelid  is  shortened,  on  the  whole,  from 
the  eyebrow  to  the  place  of  the  recision,  yet  it  is  not 
equally  so  at  the  space  which  is  between  the  edge  of 
the  eyelid  and  the  cicatrix  of  the  skin.  Hence,  the  tar- 
sus would  not  be  turned  outwards  sufficiently  to  keep 
the  eyelashes  from  rubbing  against  the  eye. 

The  surgeon,  holding  up  the  fold  of  skin  by  means  of 
the  forceps  in  his  left  hand,  is,  with  a pair  of  probe- 
pointed,  sharp-curved  scissors,  to  cut  olT  the  whole  of 
the  duplicature,  being  first  sure  that  one  of  the  blades 
of  the  instrument  is  applied  close  to  the  edge  of  the 
eyelid.  If  the  eyelids  should  be  affected,  the  same  ope 
ration  must  immediately  be  done  upon  both  of  them, 
with  such  caution,  and  in  such  proportion,  as  the  ex- 
tent of  the  disease,  and  the  degree  of  inversion  of  each 
eyelid  may  require. 

Scarpa  next  dissuades  us  from  employing  any  suture 
to  unite  the  wound,  and  represents  that  it  will  be  suffi- 
cient to  keep  the  eyebrow  as  much  downwards  as  pos- 
sible, if  the  operation  has  been  done  on  the  upper  eye- 
lid, or  if  on  the  lower,  to  support  it  against  the  inferior 
arch  of  the  orbit,  by  pressing  it  from  below  upwards, 
so  as  to  keep  the  edges  of  the  wound  from  becoming  se- 
parated. Then  the  lips  of  the  wound  are  to  be  brought 
exactly  together  by  means  of  adhesive  plaster,  which 
should  extend  from  the  superior  arch  of  the  orbit  to  the 
zygoma;  and  the  maintenance  of  this  state  of  the 
wound  will  be  still  more  securely  effected,  by  placing 
two  compresses,  one  on  the  eyebrow,  and  another  on 
the  zygoma,  together  with  a bandage.  On  the  other 
hand,  Langenbeck  disapproves  of  the  omission  of  su- 
tures, by  which  he  finds  that  the  wound  may  be  both 
more  accurately  and  expeditiously  united.  Indeed,  he 
expresses  himself  generally  in  favour  of  sutures,  where 
the  wounded  part  is  liable  to  be  disturbed  by  th 
continual  action  of  muscles.— (ATewe  Bibl.  b.  1,  p.  415, 
ij-c.  12mo.  Hanover,  1818.)  Langenbeck,  however, 
takes  care  to  withdraw  the  ligatures  in  about  twelve,  or 
at  most  twenty-four,  hours,  as  their  longer  continu- 
ance would  produce  suppuration.  Beer  also  particu- 
larly insists  upon  the  utility  of  bringing  the  edges  of 
the  incision  together  with  a suture  ; and  both  he  and 
Langenbeck  employ  forceps,  the  ends  of  which  have 
transverse  pieces,  calculated  to  take  better  hold  of  the 
slip  of  skin  to  be  removed. — {Lehre,  Src.  b.  2,  //.  114.) 

On  taking  off  the  first  dressings  the  third  day  after  the 
operation,  the  surgeon  will  find,  says  Scarpa,  that  the 
patient  can  open  his  eye  with  ease,  and  that  the  inverted 
tarsus  and  eyelashes  have  resumed  their  natural  posi- 
tion and  direction.  In  the  partial  or  incomplete  trichi- 
asis, or  that  which  only  occupies  a half  or  a third  of 
the  whole  length  of  the  tarsus,  and  in  subjects  who 
have  had  the  skin  of  the  eyelids  very  loose,  Scarpa  has 
often  found  the  wound  perfectly  united  on  removing 
the  first  dressing. 

When,  however,  only  a part  of  the  incision  has  healed, 
while  the  rest  seems  disposed  to  heal  by  suppuration 
and  granulation,  the  surgeon  is  to  cover  the  wound 
with  a small  piece  of  lint,  spread  with  the  unguentum 
ceruss® ; and  if  the  sore  should  become  flabby,  it  must 
be  occasionally  touched  with  the  argentum  nitratum, 
until  the  cure  is  finished. 

With  regard  to  the  first  form  of  this  disease,  or  tliat 
in  which  the  eyelashes  project  against  the  eyeball, 
without  the  natural  position  of  the  tarsus  being  at  all 
altered  (a  case  which  is  fortunately  rare),  the  accom- 
plishment of  a cure  is  very  difficult,  since  neither  the 
pulling  out  of  the  hairs,  nor  burning  the  sil nation  of 
their  mots,  are  means  at  all  to  be  depended  upon  for 
producing  a com[)lete  cure  of  the  disorder ; and  turning 
the  tarsus  out  of  its  natural  position  would  make  the 
patient  liable  to  an  irremediable  dropping  of  the  tears 
over  the  cheek,  attended  with  a chronic  thickening  of 
the  lining  of  the  eyelid.  It  has  only  been  in  youngish 
individuals,  that  Beer  has  ever  seen  the  repeated  and 


366 


TRICHIASIS. 


careful  extraction  of  the  cilia  effect  a radical  cure. 
— (See  Lehre  von  den  Augenkr.  b.  2,  p.  121.)  In  the 
instance  of  this  form  of  the  disease  which  Scarpa  met 
with,  only  two  or  three  of  the  eyelashes  inclined  against 
the  eyeball.  He  found,  on  turning  the  eyelid  a little 
out,  opposite  to  the  situation  of  the  faulty  hairs,  that  he 
could  not,  indeed,  completely  put  them  in  their  natural 
position ; but  he  saw  that  he  could  thus  remove  them 
so  far  from  the  cornea,  that  they  would  not  rub  against 
it,  without  altering  the  position  of  the  eyelids  so  much 
as  to  occasion  a perpetual  discharge  of  the  tears  over 
the  cheek.  And  as,  in  the  patient  alluded  to,  the  skin 
about  the  eyelid  was  very  tense,  Scarpa  made  an  inci- 
sion with  the  back  of  the  lancet,  near  the  tarsus,  three 
lines  long,  and  took  away  a small  piece  of  skin  of  the 
same  length,  but  very  little  more  than  one  line  broad. 
When  the  cut  healed,  the  operation  was  found  to  an- 
swer as  well  as  the  nature  of  the  case  would  allow, 
though  the  cure  was  not  complete. 

The  trichiasis  being  cured,  something  more  always 
remains  to  be  done,  for  the  purpose  of  correcting  the 
cause  of  the  disease,  as  well  as  curing  the  disorder  of 
the  eye,  occasioned  by  the  previous  friction  and  irrita- 
tion of  the  inverted  hairs.  The  usual  indications  are 
to  restore  the  tone  of  the  vessels  of  the  conjunctiva,  to 
lessen  the  swelled  Meibomian  glands,  and  obviate  opa- 
city of  the  cornea. 

According  to  Mr.  Guthrie,  when  chronic  inflamma- 
tion prevails,  and  there  is  a commencing,  but  incom- 
plete general  inversion  of  the  cilia,  the  cure  of  the 
inflammation  will  restore  the  conjunctiva  to  its  natural 
state,  and  the  cilia  to  their  original  direction,  without 
any  especial  means  being  employed  for  the  cure  of  the 
beginning  inversion  ; but,  when  these  changes  proceed 
too  slowly,  the  sulphuric  acid,  recommended  by  Hel- 
ling, of  Berlin,  and  Guadri,  of  Naples,  should  be  ap- 
plied, and  will  always  be  found  effectual.  Indeed,  in 
cases  where  the  incurvation  of  the  cartilage  is  slight, 
and  the  contraction  of  the  angles  moderate,  Mr.  Guth- 
rie says,  that  such  treatment  will  render  another  opera- 
tion unnecessary.  Guadri  applies  the  acid  as  follows  : 
1st.  A small  quantity  of  concentrated  sulphuric  acid  is 
to  be  applied,  by  means  of  a piece  of  smooth  solid  wood, 
to  the  centre  of  the  affected  part  of  the  lid,  and  rubbed 
along  on  an  oval  space,  a little  exceeding  in  length  the 
part  on  which  the  inverted  hairs  are  situated,  and 
from  three  to  four  or  six  lines  in  width,  according  to 
the  inveteracy  of  the  disease.  The  part  ought  to  be 
wiped  dry,  after  the  acid  has  been  applied  about  ten 
seconds,  in  order  to  prevent  any  of  it  from  getting  into 
the  eye.  2d.  The  application  of  the  acid  is  now  to  be 
repeated,  care  being  taken  that  it  approach  the  edge  of 
the  eyelid,  and  touch  the  parts  immediately  over  the 
inverted  eyelashes ; and  it  is  to  be  continued,  or  re- 
peated, a third  or  a fourth  lime,  until  the  contraction  of 
the  parts  draws  the  hair  from  within  outwards,  or  to 
their  natural  situation  ; when  the  operation  is  com- 
pleted, and  the  part  ought  to  be  again  perfectly  dried. 
The  attachment  of  the  cilia  to  the  forehead  by  means 
of  pieces  of  silk  and  adhesive  plaster,  as  practised  by 
Guadri,  Mr.  Guthrie  very  properly  rejects  as  incon- 
venient and  unnecessary. — {^Operative  Surgery  of  the 
Eye,p.  30.)  Instead  of  sulphuric  acid,  Del pech  applies 
the  actual  cautery. 

Some  new  methods  of  performing  the  operation  for 
the  cure  of  trichiasis  have  been  proposed  by  Mr. 
Crampton,  Mr.  Saunders,  Dr.  .Taeger,  Schreger,  and 
Mr.  Guthrie.  With  respect  to  that  of  Mr.  Saunders, 
however,  its  novelty  is  denied  by  Graefe,  who  states 
that  the  practice  is  as  old  as  the  time  of  .^Eiius. 

The  following  is  the  account  which  Mr.  Crampton 
gives  of  his  plan,  which  he  tried  in  one  instance  with 
complete  success.  “ Let  the  eyelid  be  well  turned  out- 
wards by  an  assistant ; let  the  operator  then,  with  a 
lancet,  divide  the  broad  margin  of  the  tarsus  completely 
through,  by  two  perpendicular  incisions,  one  on  each 
side  of  the  inverted  hair  or  hairs  ; let  him  then,  by  a 
transverse  section  of  theconjiinctivaofthe eyelid,  unite 
the  extremities  of  the  perpendicular  incisions.  The 
portion  of  cartilage,  contained  within  the  incisions, 
can  then,  if  inverted,  with  ea.se  be  restored  to  its  ori- 
ginal situation,  and  retained  there  hy  small  strips  of 
adhesive  plaster,  or,  perhaps,  what  is  better,  by  a sus- 
pensoriuin  palpebrae,  adapted  to  the  length  of  the  por- 
tion of  the  tarsus  which  it  is  intended  to  sustain, 
should  one  or  two  hairs  be  displaced  without  inversion 
of  the  tarsus.” — (Essay  on  the  Entrupeon,  p.  55.) 


Mr.  Travers  informs  us,  that,  in  cases  of  a circum- 
scribed inversion,  “ produced  by  cicatrix  from  burn  or 
wound,”  he  has  found  Mr.  Crampton’s  method  an 
effectual  remedy.  It  is  added,  that  the  complete  divi- 
sion of  the  conjunctiva  and  tarsal  cartilage,  including 
the  inverted  portion,  and  parallel  to  its  border,  with 
the  aid  of  sticking  plaster,  sometimes  proved  sufficient. 
Mr.  Travers  also  sees  no  objection  to  the  entire  remo- 
val of  that  portion  of  the  tarsal  edge,  which  is  incorri- 
gibly inverted  from  such  a cause,  especially  when  com- 
bined with  a preternatural  growth  of  cilia  from  the 
Meibomian  border  of  the  tarsus. — (Synopsis,  <^c.  p. 
356.)  In  one  inveterate  case,  which  was  not  effectu- 
ally relieved  by  the  frequent  extraction  of  the  cilia, 
cauterizing  the  edge  of  the  tarsus,  the  excision  of  a 
slip  of  skin,  and  smearing  the  eyelid  with  concentrated 
sulphuric  acid,  as  proposed  by  Helling  (Hufeland's 
Journ.  St.  4,  p.  115),  Schreger,  with  a pair  of  curved 
scissors,  cut  out  a triangular  piece  of  the  cartilage  of 
the  eyelid  at  the  place  where  the  cilia  were  most  trou- 
blesome. The  great  benefit  derived  from  the  operation 
then  led  the  same  practitioner  to  suggest  the  removal  of 
the  whole  of  the  inverted  edge  of  the  tarsus,  towards 
the  inner  canthus,  where  some  irritation  was  yet  main- 
tained. The  plan  though  followed  by  severe  pain, 
appears  to  have  succeeded. — (Chir.  Versiiche,  b.  2,  p. 
253.) 

Mr.  Saunders  entertained  a favourable  opinion  of 
Mr.  Cramplon’s  operation  for  the  cure  of  the  disease 
in  its  early  stage;  but  he  contended,  that  such  a vi- 
cious bending  of  the  tarsus  inwards  was  often  the  con- 
sequence of  repeated  ophthalmy,  attended  with  ulcer- 
ation of  the  conjunctiva  and.inside  of  the  eyelid,  so  that 
every  endeavour  to  rectify  the  wrong  position  of  the 
tarsus,  and  restore  its  original  direction,  would  be 
fruitless.  Hence,  he  believed  that  its  excision  was  de- 
cidedly indicated ; an  operation  which  is  said  to  be 
followed  by  no  pain  nor  uneasiness,  and  which  is  sure 
in  its  effect.  No  particular  shortening  of  the  eyelid 
ensues  ;*  the  deformity  is  materially  lessened  ; and, 
unless  the  cornea  be  already  too  opaque,  perfect  vision 
is  re-established.  Mr.  Saunders  directs  a piece  of  thin 
horn,  or  a plate  of  silver,  having  a curvature  corres- 
ponding to  that  of  the  eyelid,  to  be  introduced  under 
this  part,  with  its  concavity  towards  the  eyeball.  On 
this  instrument,  the  eyelid  is  to  be  stretched.  An  inci- 
sion is  to  be  made  through  the  integuments  and  orbi- 
cularis palpebrarum,  down  to  the  tarsus,  immediately 
behind  the  roots  of  the  cilia.  The  cut  should  extend 
from  the  punctum  lachryrnale  to  the  external  angle. 
The  exterior  surface  of  the  tarsus  is  then  to  be  dissect- 
ed, until  the  orbital  margin  is  exposed,  when  the  con- 
junctiva is  to  be  cut  through  directly  by  the  side  of  the 
tarsus,  which  must  now  be  disengaged  at  each  extre- 
mity. The  punctum  lachryrnale  must  be  left  uninjured. 
The  operation  is  described  as  being  simple,  and  if  any 
embarrassment  arises,  it  is  from  the  hemorrhage  of  the 
ciliary  artery,  the  blood  sometimes  obscuring  the  punc- 
tum lachryrnale,  just  when  the  operator  is  about  to 
divide  the  tarsus  by  the  side  of  it.  No  dressings  are 
required,  it  being  merely  necessary  to  keep  the  eye 
covered  for  a few  days.  The  skin  will  continue  to  be 
elevated.  Just  as  the  perfect  eyelid  was;  and,  though 
less  completely,  yet  enough  to  leave  the  pupil  clear, 
when  the  eye  is  moderately  directed  upwards.  In  all 
the  cases  in  which  Mr.  Saunders  operated,  a fungus 
grew  from  the  wound.  He  recommends  the  excres- 
cence to  be  destroyed  with  caustic  or  the  knife. 

Respecting  this  operation,  I shall  merely  observe 
that  it  is  more  severe  than  that  advised  by  Scarpa,  and 
even  than  the  method  of  Schreger,  and  must  leave 
greater  disfigurement.  Unless,  therefore,  the  latter 
methods  prove  ineffectual,  I should  consider  the  practice 
unjustifiable.  Mr.  Guthrie  has  seen  three  persons,  on 
whom  this  operation  had  been  performed,  and  on  two 
of  them  hy  Mr.  Saunders  himself:  in  all,  the  defor- 
mity was  considerable,  and  the  relief  only  partial. — 
(Operative  Surgery  of  the  Eye,  p.  25.)  Nor  is  Schre- 
ger’s  method  allowable,  except  in  cases  which  resist 
the  milder  plan,  sanctioned  by  Beer  and  Scarpa. 

Mr.  Guthrie  recommends  the  following  operation, 
as  adequate  to  the  cure  of  the  worst  ctises.  A small 
narrow  knife,  or  one  blade  of  a blunt-pointed  scissors, 
is  to  be  introduced  close  to  the  external  angle,  and  a 
perpendicular  incision  made,  from  a quarter  to  half  an 
inch  in  extent,  or  of  sufficient  length  to  render  the  eye- 
lid quite  free.  Another  incision  is  then  to  be  made, 


TRl 


In  a similar  way,  at  the  inner  angle,  without  including 
the  punctum  lachryniale.  “ The  length  to  which  the 
perpendicular  incisions  at  both  angles  ought  to  extend 
must  now  be  decided  upon  by  the  appearance  of  the 
part ; they  must  be  continued,  if  necessary,  by  repeated 
touches  with  the  scissors,  until  that  part  of  the  eye- 
lid containing  the  tarsal  cartilage  is  perfectly  free, 
and  is  evidently  not  acted  upon  by  the  fibres  of  the 
orbicularis  muscle.”  The  part  included  in  the  inci- 
sions is  now  to  be  completely  everted,  and  retained  by 
the  fore-finger  of  the  operator’s  left  hand  against  the 
patient’s  brow;  when,  if  any  lateral  attachment  be 
observed,  confining  the  lid,  it  is  to  be  divided.  “On 
letting  the  eyeball  fall  on  the  eye,  the  edge  of  the  tar- 
sus and  the  hairs  will  frequently  appear  in  the  natural 
situation,  in  consequence  of  the  relaxation  of  the  an- 
gles which  bound  them  down  ; but  if  the  tarsal  carti- 
lage has  become  altered  in  its  curvature,  this  will  be 
immediately  perceived  ; it  will  turn  inwards  at  its 
ciliary  edge,  and  be  completely  bent  at  its  extremities, 
more  especially  at  the  inner  one,  where  it  is  more  pow- 
erfully acted  upon  by  the  ciliaris  muscle.  On  desiring 
the  patient  to  raise  the  lid,  he  readily  attempts  it,  but 
the  action  of  the  levator,  in  such  cases  of  vicious  cur- 
vature, causes  the  cartilage  to  resume  its  situation  ; 
and  on  examination  the  curve  will  be  observed  to  be 
so  permanently  vicious,  for  about  an  eighth  of  an  inch 
at  each  extremity,  and  especially  at  the  inner,  tiiat  it 
cannot  be  induced  to  resume  its  actual  situation. 
When  this  is  the  case,  the  cartilage  is  to  be  divided 
exactly  at  the  place  where  it  is  bent  in  its  length,  and 
in  a direction  at  a right  angle  with  the  perpendicular 
incision ; the  portion  thus  slit  is  only  connected  with 
the  common  integuments  of  the  eyelid ; and  although 
this  incision  scarcely  exceeds  one,  and  never  two, 
eighths  of  an  inch,  at  both  extremities,  and  in  general 
is  only  necessary  at  the  inner,  it  enables  the  surgeon  to 
renmve  the  altered  curvature  of  the  part.”  The  next 
proceeding  in  Mr.  Guthrie’s  operation  consists  in  cut- 
ting away  a fold  of  skin  from  the  part  of  the  eyelid 
between  the  incisions.  Three  or  four  ligatures  are  then 
to  be  introduced,  and  the  divided  parts,  from  which 
the  fold  has  been  removed,  are  to  be  brought  together 
by  the  ligatures,  each  of  which  is  to  be  twisted  and  fast- 
ened to  the  forehead  with  several  short  strips  of  stick- 
ing plaster.  The  fold  of  skin  should  be  raised  regularly 
with  the  finprs,  and  as  near  as  possible  to  the  margin 
of  the  eyelid.  It  may  then  be  taken  hold  of  with 
Beer’s  forceps,  the  grasping  pieces  of  which  are  trans- 
verse, slightly  curved,  and  shut  with  a spring.  1'he 
skin  thus  taken  hold  of,  which  need  not  be  large,  may 
now  be  cut  away  with  a large  pair  of  curved  or  straight 
scissors.  The  ligatures  are  first  inserted  at  each  angle, 
and  when  the  vicious  curvature  is  considerable,  Mr. 
Guthrie  not  only  passes  them  through  the  skin,  but 
takes  care  to  make  the  internal  one  include,  at  its  lower 
part,  the  ovter  edge  of  the  margin  of  the  eyelid.  The 
ligatures,  thus  placed,  are  to  be  equally  drawn  up  on 
the  forehead,  until  the  eyelid  is  completely  everted, 
when  they  are  to  be  fastened  in  the  manner  above 
specified.  In  order  to  prevent  union  by  the  first  inten- 
tion, and  make  the  granulating  process  necessary,  the 
edges  are  slightly  touched  with  the  sulphate  of  copper. 
The  eye  and  eyelids  are  now  to  be  carefully  cleansed  ; 
a piece  of  lint,  spread  with  the  ung.  cetacei,  is  to  be 
placed  upon  them  ; a small  compress  under  the  edge  of 
the  orbit;  and  a retaining  bandage  over  the  whole. 
The  next  morning  the  bandage  and  lint  are  to  be 
removed,  the  eye  fomented  and  cleansed,  and  the  dress- 
ings replaced.  On  the  second  day,  great  care  must  be 
taken  that  the  ligatures  keep  the  lid  sufficiently  raised  ; 
and  if  any  union  has  taken  place  by  adhesion  at  the 
angles  of  the  incisions,  it  must  be  broken  through  with 
the  probe.  On  the  third  day,  the  plasters  on  the  fore- 
head should  generally  be  changed.  The  ligatures  them- 
selves must  be  supported  by  straps  of  plaster,  placed 
vertically  between  them  ; and  the  edges  of  the  incisions 
should  he  touched  again  with  the  sulphate  of  copper, 
or  separated  with  a probe.  In  a few  days  more, 
the  ligatures  cut  their  way  out;  and  by  the  time 
the  parts  are  healed,  the  eyelid  will  havu  resumed 
its  natural  situation. — (.Operative  Surgery  of  the  Kye, 
p.  31,  See.)  Operations  on  the  same  principle  are 
also  recommended  by  Mr.  Guthrie  for  the  lower 
eyelid. 

When  a stirgeon  chooses  to  try  the  foregoing  opera- 
tion, he  ought  to  be  certain  that  the  cartilage  of  the 


TRO  367 

tarsus  is  so  altered  in  its  shape  as  not  to  afford  much 
chance  of  effectual  relief  from  milder  plans. 

Inversion  of  the  lower  eyelid  is  much  less  common 
than  that  of  the  upper  one.  The  late  Mr.  Saunders 
never  saw  this  disease  arise  from  the  same  causes 
which  induce  it  in  the  upper  eyelid,  though  he  acknow- 
ledges the  possibility  of  such  a case.  However,  he 
met  with  several  instances  of  the  affection  in  conse- 
quence of  encysted  tumours,  which,  as  they  increased, 
carried  the  orbital  edge  of  the  tarsus  outwards,  and  in 
the  same  proportion  inclined  the  ciliary  edge  towards 
the  globe  of  the  eye. 

An  inversion  of  the  inferior  palpebra  is  sometimes 
produced  by  inflammation  and  swelling  of  that  part  of 
the  conjunctiva  which  connects  the  eyelid  with  the 
eyeball.  In  cases  of  ophthalmy  this  membrane  often 
forms  between  the  latter  parts  a distinct  fold,  which  is 
situated  just  on  the  inside  of  the  orbital  edge  of  the 
tarsus,  and  pushes  it  outwards ; while  the  contraction 
of  the  orbicularis  muscle  turns  the  ciliary  edge  in- 
wards, and  inclines  it  between  the  swelling  of  the  con- 
junctiva and  the  eye.  In  this  particular  case,  Mr. 
Saunders  assures  us  that  replacitig  the  eyelid  in  the 
early  stage  of  the  disease,  and  maintaining  it  so  until 
the  ophthalmy  has  been  lessened  by  proper  means, 
will  be  found  effectual.  But  when  the  conjunctiva  is 
much  thickened  and  itidurated,  Mr.  Saunders  recom- 
mends cutting  such  diseased  part  of  it  away,  and  the 
application  of  compresses  to  keep  the  orbital  margin 
of  the  tarsus  inwards. — (See  also  Travers's  Synopsis, 
p.  234  and  355.) 

Albinus  has  recorded  a species  of  trichiasis,  which 
originated  from  the  growth  and  inversion  of  one  of 
the  hairs  upon  the  caruncula  lachrymalis.  The  plan 
of  relief  consisted  in  plucking  out  the  irritating  hair  ; 
but  it  is  not  mentioned  whether  it  grew  again. 

.7.  Scultetus,  Trichiasis  Mmiranda,  sive  Morbus 
Pilaris  Mirabilis,  l^mo.  JVorib.  1658.  Scarpa  sulle 
Principali  Malattie  degli  Occhi.  R.  Crampton,  Essay 
on  the  Entropeon,  Lond.  1805.  Saunders's  Obs.  on  se- 
veral practical  Points  relative  to  the  Diseases  of  the 
Eye,  ed.  3.  Richter's  Anfangsgrunde  der  Wundarz- 
neykunst,  b.  3.  G.  J.  Beer,  Lehre  von  den  Avgenkranky 
heiten,  b.  2,  p.  Ill — 117,  Wein,  1817.  Schreger, 
Chirurgische  Versiiche,  b.  2.  JVeue  Methode  die  Tri- 
chiasis zu  Operiren,  p.  253,  8vo.  JSTurnberg,  1818.  B. 
Travers,  Synopsis  of  the  Diseases  of  the  Eye,  p, 
232—354,  <J-c.  8vo.  Lond.  1820.  Jaeger,  Diss.  sistens 
Diagnosin  et  Curam  Radicalem  Trichiasis,  Distichia- 
sis,  necnon  Entropii.  Vienna.  This  method  is  said  by 
Mr.  Guthrie  to  be  similar  to  that  proposed  by  Saun- 
ders. G.  J.  Guthrie,  Operative  Surgery  of  the  Eye, 
dvo.  Lond.  1823.  Delpech,  Clinique  de  Chirurgie,t.2; 
4to.  1828. 

TRISMUS.  (From  rpt^w,  to  gnash  the  teeth.;  The 
locked  jaw.  See  Tetanus. 

TROCHAR,  or  Trocar.  (From  the  French,  trois- 
quart,  three-fourths,  from  its  point  being  of  a trian- 
gular form.)  An  instrument  used  for  dischargirig 
aqueous  fluids,  and  now  and  then  matter  from  differ- 
ent cavities  in  the  body,  particularly  those  of  the  preri- 
toneum,  and  tunica  vaginalis,  in  cases  of  ascites  and 
hydrocele.  Trocars  are  also  employed  for  tapping  the 
bladder,  dropsical  ovaries,  &c. 

A trocar  consists  of  a perforator  or  slilet,  and  of  a 
cannula,  which  is  so  adapted  to  the  first  piece  of  the 
instrument,  that  when  the  puncture  is  made,  they  both 
enter  the  wound  together  with  perfect  ease,  after 
which,  the  stilet  being  withdrawn,  the  cannula  re- 
mains in  the  wound,  and  gives  a ready  passage  for  the 
fluid  outwards. 

Such  are  the  uses  of  a trocar,  and  the  principles  on 
which  it  should  be  constructed.  It  would  be  unneces- 
sary in  this  work  to  detail  every  little  particularity  in 
the  instrument.  I shall  merely  observe,  that  the  trian- 
gular-pointed trocars  seem  to  retain  the  greatest  share 
of  approbation ; for,  although  those  of  a flat  lancet- 
pointed  shape  enter  parts  with  more  ease,  their  can- 
nula; are  not  large  enough  for  the  ready  escapie  of  fluids 
which  are  at  all  thick,  gelatinous,  or  blended  with  hy- 
datids, and  flaky  substances. 

The  trocar  for  puncturing  the  bladder  from  the  rec- 
tum should  be  longer  than  a common  trocar  and  of  a 
curved  form  ; but,  as  Mr.  Carpue  has  explained,  it 
should  not  be  passed  too  high  up  the  rectum,  lest  the 
peritoneum  be  wounded. 

Surgeons  ought  always  to  have  at  least  three  trocars; 


368 


TRU 


TRU 


one  of  full  size,  another  of  middling  width,  and  a third 
of  small  dimensions.  In  cases  of  hydrocele,  the  latter 
is  often  preferable. 

TRUSS.  ( Troiisse,  French.)  Bracherium.  A band- 
age or  apparatus  for  keeping  a hernia  reduced.  A 
truss  which  fulfils  its  intention  properly  should  com- 
press the  neck  of  the  hernial  sac  and  the  ring,  or  exter- 
nal opening  of  the  hernia,  in  such  a manner,  that  a 
protrusion  of  any  of  the  contents  of  the  abdomen  will 
be  prevented  with  complete  security.  Hence,  it  is  the 
indispensable  quality  of  a good  truss  first  to  make  ef- 
fectual and  eq»ial  pressure  on  the  parts  indicated,  with- 
out causing  pain  or  inconvenience  to  the  patient ; se- 
condly, not  easily  to  slip  out  of  its  right  situation,  in 
the  varying  motions  and  positions  of  the  body. 

Trusses  are  either  of  an  elastic  or  non-elastic  kind. 
The  latter  are  composed  of  leather,  fustian,  dimity,  or 
similar  materials.  These  cannot  be  at  all  depended 
on,  and  should  therefore  be  entirely  banished  from 
surgery.  Since  (as  Mr.  Lawrence  has  remarked)  the 
size  of  the  abdomen  varies  according  to  the  different 
states  of  the  viscera  and  to  the  motions  of  its  parie- 
tes  in  respiration,  a non-elastic  bandage  must  vary 
constantly  in  its  degree  of  tightness,  and  keep  up  either 
too  great  or  too  little  pressure.  The  omentum  or  in- 
testine easily  slips  out  when  the  opening  is  not  exactly 
closed,  and  the  patient  who  wears  such  a bandage 
must  be  in  a state  of  constant  insecurity.  Those  who 
lead  an  active  life,  or  are  obliged  to  use  laborious  ex- 
ertions, will  be  more  particularly  exposed  to  risk.  If 
the  patient,  after  experiencing  these  defects,  endea- 
vours to  remedy  them  by  drawing  the  bandage  tighter, 
he  may  confine  the  viscera,  but  he  produces  other  in- 
conveniences. The  increased  pressure  injures  the 
spermatic  cord,  and  may  affect  the  testicle  ; the  integu- 
ments become  red,  painful,  and  excoriated : and  the 
bandage  must  be  entirely  laid  aside  until  the  parts 
have  recovered.  Richter  has  often  seen  painful  tume- 
faction of  the  testicle,  hydrocele,  and  even  cirsocele, 
produced  from  this  cause,  and  entirely  dissipated  by 
the  employment  of  a proper  truss. — ( TraiU  des  Htr- 
nies,  p.  24.)  He  also  saw  the  pad  of  a non-elastic 
bandage  excite  in  the  region  of  the  abdominal  ring  a 
considerable  inflammation,  which  terminated  after  a 
few  days  in  suppuration.  The  hernia  never  appeared 
again  after  the  cure  of  the  abscess.  The  inflamma- 
tion had  extended  to  the  neck  of  the  sac  and  oblite- 
rated that  part. — {On  Ruptures,  ed.  3,  p.  69,  70.)  The 
spring  is  a very  essential  part  of  every  elastic  truss, 
and  it  consists  of  a flat  long  piece  of  steel,  which  is 
adapted  to  the  side  of  the  body  on  which  the  hernia 
is  situated.  It  is  not  a great  many  years  since  the 
spring  used  to  be  made  of  common  iron,  and  Arnaud 
and  Richter  express  their  preference  to  a mixture  of 
malleable  iron  and  steel,  so  that  the  instrument  may 
be  moulded  by  the  hand  to  any  particular  shape ; but, 
as  Mr.  Lawrence  well  observes,  a truss  which  admits 
of  such  management  must  be  more  or  less  liable  to 
the  objections  which  apply  to  inelastic  bandages,  and 
the  only  material  which  possesses  the  requisite  quali- 
ties of  firmness  and  elasticity,  is  well-tempered  steel. 
The  front  part  of  the  steel  spring  has  an  expanded 
form,  and  when  the  truss  is  properly  applied,  ought  to 
be  situated  over  the  mouth  of  the  hernial  sac.  The 
spring  of  a truss  has  commonly  been  a semicircle, 
with  the  posterior  end  resting  on  the  spine.  Camper 
proposed  to  carry  it  round  to  the  anteiior  superior 
spine  of  the  ileum  on  the  sound  side  ; a plan  of  which 
Scarpa  highly  approves.  Trusses  of  this  form  fit  with 
a degree  of  steadiness,  which  cannot  be  given  to 
others  by  tightening  the  strap.  They  keep  up  the  rup- 
ture better  than  even  a stronger  spring  of  the  com- 
mon kind.  Under  the  back  surface  of  the  anterior 
end  of  the  spring  is  placed  the  pad,  which  should  be 
adapted  in  shape  and  size  to  the  passage  which  is  in- 
tended to  be  shut  up.  The  steel  spring  is  usually  co- 
vered with  leather,  is  lined  with  soft  materials,  and 
after  being  put  on  the  patient,  is  fastened  in  its  situa- 
tion by  means  of  a strap,  which  extends  from  the  two 
ends  of  the  spring  round  that  side  of  the  body  on 
which  the  hernia  is  not  situated.  Hare-skin,  with  the 
fur  outwards,  is  sometimes  considered  the  best  cover- 
ing for  preserving  the  spring  from  the  ill  effects  of  per- 
spiration. 

When  it  is  necessary  to  make  strong  compression, 
as  in  large  old  ruptures  and  in  persons  who  cannot 
avoid  labour  and  exercise,  the  elastic  spring  should  be 


made  accordingly  thicker  and  broader.  But  an  object 
of  the  first-rate'  importance  is  to  make  the  spring  press 
equally  upon  every  point  of  the  body  which  it  touches. 
This  is  what  demands  the  earnest  attention  both  of  the 
surgeon  and  the  instrument- maker,  especially  as  the  hips 
of  some  individuals  are  flat  and  narrow,  while  those 
of  other  persons  are  broad  and  prominent.  A tliick, 
flexible,  metallic  wire,  accurately  applied  round  the 
pelvis,  will  serve  to  take  the  measure  and  proper 
shape  of  the  spring,  which  may  afterward  be  altered  a 
little  if  found  necessary.  The  wire,  however,  should 
be  somewhat  longer,  on  account  of  the  length  of  the 
spring. 

The  springs  of  trusses  intended  for  children  and  per- 
sons who  do  not  undergo  much  labour  and  exertion, 
need  not  be  made  so  strong  as  those  designed  for  hard- 
working, active  people. 

The  idea  that  children  cannot  wear  steel  trusses  is 
as  erroneous  as  it  is  dangerous  in  its  practical  conse- 
quences ; a point  on  which  Mr.  Pott  has  strongly  in- 
sisted. 

Trusses  are  sometimes  fabricated  with  a pad  move- 
able  on  the  spring  instead  of  being  riveted  to  it.  This 
may  be  inclined  upwards  or  downwards  according  to 
the  form  of  the  abdomen ; and  it  is  retained  at  the  de- 
sired point  by  a spring  fitting  into  the  teeth  of  a rack. 
In  others,  the  plate  contains  a screw,  by  which  the 
cushion  is  pushed  farther  inwards,  or  allowed  to  recede 
at  pleasure.  Although  there  cannot  be  a doubt  that 
some  of  these  inventions  possess  considerable  merit, 
and  are  in  certain  instances  superiorly  useful,  it  must 
be  confessed  that  in  general  their  utility  is  not  so  much 
greater  than  that  of  common  pads,  as  to  make  amends 
for  the  want  of  simplicity  and  the  increase  of  expense. 
I should  be  sorry,  however,  to  say  any  thing  that  would 
unfairly  discourage  all  such  ingenious  endeavours  to 
improve  an  instrument  so  difficult  to  bring  to  perfection 
as  a truss ; especially  as  I believe  there  are  particular 
cases  in  which  pads  with  racks,  screws,  springs,  &c. 
may  be  employed  with  great  advantage. 

Notwithstanding  every  care,  sometimes  even  elastic 
trusses  cannot  be  hindered  from  slipping  away  from 
the  part  which  they  are  designed  to  compress.  Some- 
times they  slip  downwards,  which  in  fat  subjects  ia 
generally  caused  by  the  projection  of  the  abdomen. 
Occasionally,  the  fault  consists  in  the  instrument  be- 
coming displaced  in  the  direction  upwards,  which 
mostly  happens  in  thin  persons,  and  is  produced  by 
the  flatness  of  the  abdomen.  In  the  first  case,  the  dis- 
placement is  to  be  prevented  by  the  use  of  an  elastic 
scapulary ; in  the  second,  the  slipping  of  the  pad  up- 
wards is  to  be  prevented  by  the  employment  of  a 
thigh  strap. 

When  a patient  is  afflicted  with  a rupture  on  each 
side,  the  two  protrusions  may  be  very  well  kept  up  by 
means  of  a single  truss  made  with  two  pads,  which 
are  joined  together  at  the  exact  distance  of  the  rings 
from  each  other  by  a piece  of  steel,  applied  over  the 
convexity  of  the  symphysis  of  the  pubes,  and  propor- 
tioned in  length  to  the  space  between  the  two  open- 
ings through  which  the  viscera  descend.  In  such 
cases,  however,  it  is  absolutely  necessary  to  have  tlie 
spring  stronger  than  if  there  were  only  one  rupture. 
The  truss  should  also  be  put  on  that  side  of  the  body 
upon  w’hich  the  hernia  most  difficult  to  retain  is  situ- 
ated. Some  practitioners,  however,  give  the  prefer- 
ence to  the  use  of  two  single  trusses  joined  together  in 
front  and  behind  with  suitable  strap.s. 

With  respect  to  tlie  application  and  use  of  trusses, 
the  following  instructions  seem  to  merit  attention. 

1.  A truss  should  never  be  first  applied,  or  changed, 
except  when  the  patient  is  in  the  horizontal  posture, 
and  it  is  known  with  certainty  that  all  the  contents  of 
the  rupture  are  completely  reduced. 

2.  The  first  applications  of  a truss  should  always  be 
made  under  the  superintendence  of  the  surgeon  him- 
self; and  care  should  be  taken  to  put  on  the  instru- 
ment in  such  a manner  that  the  lower  third  of  the  pad 
will  compress  the  neck  of  the  hernial  sac  against  the 
os  pubis,  while  the  upper  portion  will  compress  the 
abdominal  ring.  The  surgeon  should  also  make  the 
patient  acquainted  with  the  right  manner  of  applying 
the  truss;  the  principles  on  which  it  keeps  up  the 
bow'els,  and  affords  a chance  of  a radical  cure;  the 
requisite  cautions  to  be  observed,  &c.  When  a patient 
first  begins  to  wear  a truss,  he  should  be  particularly 
careful  not  to  be  guilty  of  anv  imprudent,  exertions, 


TRU 


TUM 


369 


and  it  behooves  him  to  observe  most  attentively,  that 
the  instrument  does  not  slip  from  its  proper  situation. 
It  will  also  be  necessary  for  him  to  pay  attention  to 
the  instrument  being  neither  too  tight  nor  too  loose. 

3.  Tlie  patient  ought  to  be  provided  with  at  least 
two  trusses,  which  should  be  changed  every  morning 
in  bed.  In  order  to  save  the  truss,  especially  in  fat 
persons  wiio  perspire  a great  deal,  it  is  a good  plan  to 
lay  a soft  piece  of  calico  under  the  pad. 

4.  An  uneasiness  about  the  ring,  which  always  gives 
rise  to  a suspicion  that  a portion  of  intestine  or  omen- 
tum is  protruded,  makes  it  proper  to  take  off  the  truss, 
carefully  examine  the  parts,  and  reduce  them  if  they 
have  descended. 

5.  When  the  skin  is  excoriated  by  the  truss,  the  part 
may  be  cured  by  sprinkling  upon  it  the  powder  of  ace- 
tate of  lead,  fullers’  earth,  lapis  calaminaris,  &c.,  or 
bathing  the  part  with  an  astringent  lotion.  It  will 
also  be  right  to  protect  the  excoriated  place  with  a 
piece  of  linen  put  under  the  truss. 

6.  When  the  pressure  of  the  truss  excites  affections 
and  swellings  of  the  spermatic  cord  and  testicle,  either 
the  thigh-strap  must  be  relaxed  or  the  lower  part  of 
the  pad  made  less  prominent.  And  when  strong  pres- 
sure is  absolutely  necessary  to  keep  the  hernia  reduced, 
the  pad  should  have  an  excavation  in  it  over  the  sper- 
matic cord.  Whoever  wears  a truss  should  be  careful 
to  employ  it  day  and  night  without  interruption,  so 
that  there  may  be  no  opportunity  for  the  hernia  to  pro- 
trude again.  If,  under  the  employment  of  a truss,  the 
rupture  once  descends  again,  either  a strangulation 
happens  from  the  narrowness  of  the  neck  of  the  sac, 
or  at  all  events,  the  hope  of  a radical  cure,  which  may 
have  been  entertained  for  years  and  months,  is  de- 
stroyed in  a moment;  for  experience  has  put  it  beyond 
all  doubt,  that  by  the  continual  unremitted  use  of  a 
truss,  and  the  steady  retention  of  the  contents  of  the 
hernia,  the  neck  of  the  hernial  sac  and  the  ring  may 
be  gradually  lessened  in  diameter,  until  they  are  en- 
tirely closed,  and  a radical  cure  of  the  rupture  effected. 
This  is  more  frequently  observed  in  young  subjects, 
seldom  in  adults,  and  scarcely  ever  ih  persons  of  ad- 
vanced years.  But  trusses  must  be  worn  a long  while ; 
nor  should  the  patient  venture  to  lay  aside  their  use 
till  after  many  cautious  attempts;  beginning  the  expe- 
riment at  first  only  in  the  night-time,  and  not  making 
it  in  the  day  till  after  a considerable  period  from  the 
time  when  he  first  thinks  himself  safe.  The  longer 
and  more  attentively  a truss  is  worn,  the  greater  is  the 
hope  of  a radical  cure.— (CaWtsen,  Syst.  Chir.  Hod. 
t.2.) 

In  the  last  edition  of  the  First  Lines  of  the  Practice 
of  Surgery^  the  truss  for  navel  ruptures,  which  was 
devised  by  Mr.  England,  and  latterly  preferred  by  Mr. 
Hey,  is  described ; and  in  the  article  Hernia  an  ac- 
count is  given  of  the  truss  for  umbilical  hernia,  in- 
vented by  Mr.  Marrison,  of  Leeds,  and  described  by  Mr. 
Hey.  In  the  same  part  of  this  Dictionary  nmy  also  be 
found  some  observations  relative  to  the  place  against 
which  the  pressure  of  the  pads  of  trusses  should  be 
directed  in  cases  of  inguinal  hernia,  in  conformity  to 
Sir  A.  Cooper’s  description  of  the  situation  at  which 
the  parts  first  protrude  from  the  abdomen. 

[The  truss  of  Salmon,  Ody,  & Co.,  of  London,  for- 
merly obtained  a preference  in  this  country,  amid  the 
multitude  of  modifications  to  which  this  instrument 
has  been  subjected.  And,  indeed,  very  little  was 
taught  or  known  among  surgeons  in  reference  to  this 
instrument,  its  construction  and  application  being  in- 
trusted for  the  most  part  to  the  mechanic  and  to  the 
patient,  until  within  a few  years. 

Our  profession  is  very  largely  indebted  to  Dr.  Amos 
G.  Hull,  of  New- York,  for  the  valuable  service  he  has 
rendered  the  cause  of  humanity  as  well  as  the  science 
of  surgery,  by  the  indefatigable  labours,  and  perse- 
vering ingenuity  which  he  has  devoted  to  this  interest- 
ing department  of  cliirurgery.  After  experiencing  in 
his  own  practice  the  defects  of  the  various  kinds  of 
trusses  ordinarily  employed,  and  suffering  the  inconve- 
niences of  w'hich  surgeons  and  patients  have  so  long 
complained,  he  was  induced  to  attempt  the  construc- 
tion of  an  instrument,  which  should  fulfil  the  surgical 
indications  in  the  treatment  of  reducible  hernia;  an 
object  which  seemed  to  have  been  overlooked  by  pre- 
vious inventors,  and  to  accomplish  which  a knowledge 
of  the  anatomy  of  the  parts,  and  the  mechanical  ope- 
ration of  the  truss  was  alike  indispensable.  J 

VoL.  II.-A  a 


Dr.  Hull  brought  to  this  subject  a mechanical  genius 
of  more  than  ordinary  acuteness,  and  at  the  same  time 
an  intimate  and  accurate  knowledge  of  the  intricate 
subject  of  hernia  itself,  and  succeeded  in  constructing 
an  instrument  which  is  not  only  applicable  to  every 
species  of  rupture  to  which  a truss  is  adapted ; but^  in 
recent  cases,  and  young  children,  is  fully  adequate  to 
effect  a radical  cure,  as  proved  by  experience  and  at- 
tested by  the  leading  surgeons  of  the  present  day. 

I shall  not  describe  the  improvements  and  modifica- 
tions to  which  Dr.  Hull  subjected  his  invention  before 
it  arrived  to  its  present  degree  of  perfection,  nor  speak 
of  the  difficulties  he  has  encountered  in  introducing  it 
into  general  use,  and  acquiring  for  it  an  almost  uni- 
versal preference.  He  has,  however,  at  once  an  apo- 
logy and  justification  for  his  having  patented  the  in- 
strument, thus  deviating  from  what  is  considered  ordi- 
narily professional,  in  the  fact,  that  base  and  servile 
imitations  of  his  instrument  would  otherwise  have 
deprived  the  profession  and  the  world  of  the  improve- 
ment itself,  by  bringing  it  into  disrepute.  This  has 
already  been  a subject  of  painful  interest  to  Dr.  Hull 
and  his  professional  friends,  apart  from  its  manifest 
injustice  to  the  inventor.  Numerous  innovations  and 
modifications  have  been  resorted  to  with  a view  of 
appropriating  the  surgical  principles  embraced  in  the 
instrument  of  Dr.  Hull,  by  those  who  construct  their 
trusses  of  inferior  materials,  and  otherwise  defeat  the 
utility  and  success  of  the  invention. 

Dr.  Hull  claims  for  himself  the  merit  of  accomplish- 
ing the  true  indications  in  the  surgical  treatment  of 
reducible  hernia,  by  the  four  following  distinctive  pe- 
culiarities embraced  in  his  truss,  viz. 

1st.  The  concave  internal  surface  of  the  rupture 
pad,  from  its  pressure  being  greatest  at  the  circumfe- 
rence, tends  constantly  to  approximate  the  hernial  pari- 
etes,  affording  them  rest  and  mechanical  support. 

2d.  The  combined  hinge  and  pivot  mode  of  con- 
nexion between  the  spring  and  pad,  by  means  of  a 
tenon  and  mortice  so  constructed  as  to  preserve  a 
double  hinge  and  limited  joint  acting  in  every  direction, 
thereby  securing  the  uniform  pressure  of  the  spring  on 
the  pad,  and  sustaining  the  same  nice  coaptation  of 
the  pad  and  rupture  opening,  as  well  under  the  varied 
ordinary  muscular  actions  as  when  the  body  is  in  a 
recumbent  posture. 

3d.  The  graduating  power  and  fixture  of  the  pad  to 
the  spring,  rendering,  as  will  be  readily  perceived,  the 
condition  of  the  pad  perfectly  controllable, -even  to 
nameless  minuteness.  Also  resulting  from  this  me- 
chanism is  the  advantage  of  accommodating  a large 
truss  to  a small  person ; hence  the  facility  of  sup- 
plying, without  disappointment,  persons  at  a distance. 

4th.  The  double  inguinal  truss  being  simply  the  ad- 
dition of  another  pad  attached  to  a short  elastic  me- 
tallic plate  ; this  plate  with  its  pad  move  on  the  main 
spring  by  the  same  power  of  adjustment  and  fixture 
as  the  first  pad,  the  pressure  of  the  pads  being  gradu- 
ated at  pleasure  by  an  intervening  cork  wedge. 

In  the  article  Hernia  I have  hinted  at  the  import- 
ance of  a concave  rupture  pad,  instead  of  a convex 
one,  so  universal  and  once  thought  indispensable.  It 
is  no  marvel  that  so  few  radical  cures  were  ever  known 
by  the  truss,  when  the  convex  pad  of  the  itistrument 
was  fitted  to  the  mouth  of  the  rupture,  thus  enlarging 
the  hernial  opening.  By  this  instrument,  the  elevated 
circular  margin  of  the  concave  pad  is  made  to  approx- 
imate the  sides  of  the  hernial  opening,  closes  the  aper- 
ture, and  hence  resulls  in  a permanent  cure  of  the  dis- 
ease. I have  known  many  instances  of  radical  cures 
by  this  instrument,  and  in  some  of  them  the  truss  has 
been  laid  aside  for  several  years  without  the  smallest 
return  of  the  disease.  It  is  to  the  interest  of  the  pro- 
fession universally  to  become  acquainted  with  this  in- 
strument, and  to  profit  by  its  superiority. — Reese.] 

TUMOUR.  A swelling.  In  considering  all  the  va- 
rious tumours  and  indurations  which  occur  in  inflam- 
mation and  disease,  no  doubt,  the  processes  by  which 
they  are  formed  must  be  attended  with  considerable 
diversity.  Yet,  as  Dr.  Armstrong  has  remarked,  the 
general  principles  of  morbid  changes  of  structure  may 
admit  of  being  reduced  to  a small  number.  Thus, 
says  he,  if  we  take  the  acknowledged  products  of  in- 
flammation, and  to  them  add  tubercle,  scirrhus,  fun- 
gus, and  melanosis,  we  have  at  once  a bird’s-eye  view 
of  the  most  important  changes  which  occur  in  the 
solids. — (See  Morbid  Anatomy  of  the  Bowels,  Sre.p  1.) 


370 


TUMOUR. 


In  the  present  article,  I intend  only  to  treat  of  what 
are  usually  called  sarcomatous  and  encysted  tumours. 
Mr.  Abernethy  thinks,  that  the  manner  in  which  tu- 
mours are  formed  is  best  illustrated  by  those  which 
hang  pendulous  from  the  membranous  lining  of  differ- 
ent cavities  This  gentleman  adverts  to  an  example 
noticed  by  Mr.  Hunter,  in  which,  on  the  cavity  of  the 
abdomen  being  .opened,  there  appeared  lying  upon  the 
peritoneum  a small  portion  of  red  blood  recently  co- 
agulated. This,  on  examination,  was  found  to  be  con- 
nected with  the  surface  upon  which  it  had  been  de- 
posited, by  means  of  an  attachment  half  an  inch  long, 
and  this  neck  had  been  formed  before  the  coaguluni 
had  lost  its  red  colour. — (See  Trans,  for  the  Improve- 
ment of  Med.  and  Chir.  Knowledge,  vol.  1,  p.  231.) 
Mr.  Abernethy  observes,  that  if  vessels  had  shot 
through  the  slender  neck,  and  organized  the  clot  of 
blood,  this  would  then  have  become  a living  part;  it 
miglit  have  grown  to  an  indefinite  magnitude,  and  its 
nature  and  progress  would  probably  have  depended  on 
the  organization  which  it  had  assumed.  He  mentions 
his  possession  of  a pendulous  tumour  found  growing 
from  the  surface  of  the  peritoneum,  and  which  was 
undoubtedly  formed  in  the  same  manner  as  the  tumour 
noticed  by  Mr.  Hunter,  viz.  by  vessels  shooting  into  a 
piece  of  extravasated  blood  or  lymph,  and  rendering 
it  a living  organized  substance.  Tumours  in  every 
situation,  and  of  every  description,  are  probably 
formed  in  the  same  way.  The  coagulating  lymph 
being  effused,  either  accidentally  or  in  consequence  of' 
disease,  is  afterward  converted  into  a living  part,  by 
the  growth  of  the  adjacent  vessels  and  nerves  into  it. 
Mr.  Abernethy  remarks,  that  when  th%  deposited  sub- 
stance has  its  attachment  by  a single  thread,  all  its  vas- 
cular supply  must  proceed  through  that  part;  but  in 
other  cases,  the  vessels  shoot  into  it  irregularly  at  va- 
rious parts  of  its  surface.  Thus  an  unorganized  con- 
crete becomes  a living  tumour,  which  has  at  first  no 
perceptible  peculiarity  as  to  its  nature.  Although  its 
supply  of  blood  is  furnished  by  the  vessels  of  the  sur- 
rounding parts,  it  seems  to  live  and  grow  by  its  own 
independent  powers,  while  its  future  structure  seems 
to  depend  on  the  operation  of  its  own  vessels.  Mr. 
Abernethy  conceives,  that  the  altered  structure  of  an 
enlarged  gland  affords  no  contradiction  to  the  above 
account,  as  in  this  latter  case  the  substance  of  the 
gland  is  the  matrix,  in  which  the  matter  forming  the 
tumour  or  enlargement  is  deposited.  The  structure  of 
a tumour,  he  observes,  is  sometimes  like  that  of  the 
parts  near  which  it  grows.  Such  as  are  pendulous  in 
joints  are  cartilaginous  or  osseous.  Fatty  tumours 
frequently  form  in  the  midst  of  the  adipose  substance, 
and  he  has  seen  some  tumours  growing  from  the 
palate  which  had  a slender  attachment,  and  resembled 
the  palate  in  structure. 

However,  this  resemblance  of  the  structure  of  a tu- 
mour to  that  of  the  neighbouring  parts  is  not  always 
observable.  I have  in  my  own  possession  a com- 
pletely cartilaginous  tumour,  which  I found  in  the 
midst  of  the  fat  near  the  kidneys.  The  pendulous 
portion  of^fat  growing  from  the  peritoneum,  and  men- 
tioned by  Mr.  Abernethy,  serves  as  another  instance 
of  the  fact;  and  one  might  add,  that  every  polypus 
which  we  meet  with  bears  no  resemblance  in  structure 
to  the  neighbouring  parts.  He  has  seen  bony  tumours 
which  were  unconnected  with  bone  or  the  periosteum, 
and  he  observes,  that  the  structure  of  a tumour  is  in 
general  unlike  that  of  the  part  in  which  it  is  produced. 

When  the  coagulable  part  of  the  blood  is  effused, 
and  the  absorbents  do  not  take  it  away,  the  surround- 
ing blood-vessels  are  supposed  to  grow  into  it,  and  con- 
vert it  into  a vascular  tumour.  The  effusion  of  the 
coagulable  part  of  the  blood  may  be  the  effect  of  acci- 
dent, or  of  a common  inflammatory  process,  or  it  may 
be  the  consequence  of  some  diseased  action  of  the 
surrounding  vessels,  which  diseased  action  may  in- 
fluence the  organization  and  growth  of  the  tumour. 

In  the  former  cases,  the  parts  surrounding  the  tu- 
mour may  be  considered  simply  as  the  sources  from 
which  it  derives  its  nutriment,  while  it  grows  appa- 
rently by  its  own  inherent  powers,  and  its  organiza- 
tion depends  upon  actions  beiiun  and  existinc  in  itself. 
If  such  a tumour  be  removed,  the  surrounding  parts, 
being  sound,  soon  heal,  and  a complete  cure  ensues. 
But  if  a tumour  be  removed,  whose  existence  depends 
on  the  disease  of  the  surrounding  parts  which  are 
still  left,  and  this  disease  be  not  altered  by  the  stimulus 


of  the  operation,  no  benefit  is  obtained.  These  parts 
again  produce  a diseased  substance,  which  has  gene- 
rally the  appearance  of  fungus,  and,  in  consequence 
of  being  irritated  by  the  injury  of  the  operation,  the 
disease  is  in  general  increased  by  the  means  which  were 
designed  for  its  cure.  It  appears,  therefore,  that  in 
some  cases  of  tumours,  the  newly-formed  part  alone 
requires  removal,  while  in  others  the  surrounding  sub- 
stance must  be  taken  away,  or  a radical  cure  cannot 
be  effacted.—iMernethy's  Surg.  Obs.  1804.)  This 
gentleman  conceives,  that  the  irritation  of  the  tumour 
itself,  when  once  the  swelling  has  been  produced,  keeps 
up  an  increased  action  in  the  surrounding  vessels,  so 
as  to  become  a sufficient  cause  of  the  disease  continu- 
ing to  grow  larger.  As  the  tumour  becomes  of  greater 
magnitude,  it  condenses  the  surrounding  cellular  sub- 
stance, and  thus  makes  for  itself  a sort  of  capsule. 
The  close  or  loose  manner  in  which  tumours  become 
connected  with  the  surrounding  parts,  seems  to  depend 
very  much  on  the  degree  of  irritation  and  inflamma- 
tion excited  in  the  circumjacent  parts.  When  a tu- 
mour has  been  at  all  tender,  painful,  and  inflamed,  it 
is  generally  found  intimately  adherent  to  all  the  neigh- 
bouring parts.  Mr.  Abernethy  also  believes,  that  the 
increased  irritation  which  a tumour  creates,  when  it 
has  exceeded  a certain  size,  may  explain  why  some 
tumours,  which  are  at  first  slow  in  their  progress,  af- 
terward begin  to  grow  with  great  rapidity. 

The  process  by  which  tumours  are  formed  is  com- 
monly thought  to  be  attended  with  an  increased  action 
of  the  vessels  which  supply  them  with  blood.  It  is 
supposed,  in  short,  to  be  the  same  kind  of  process 
which  forms  all  the  thickenings  and  indurations,  which 
under  various  circumstances  occur  in  different  parts 
of  the  human  body.  It  has  sometimes  been  named 
chronic  inflammation,  to  distinguish  it  from  that  which 
is  more  quick  in  the  production  of  certain  effects,  and 
is  often  attended  with  a manifest  throbbing  in  the  part 
affected.  This  subject  of  chronic  or  passive  inflam- 
mation is  one  about  which  very  little  certain  is  known ; 
and  even  the  name  itself  has  commonly  been  admitted 
only  on  the  supposition,  that  some  kind  of  increased 
action  exists  in  the  vessels,  though  of  a slower  and  less 
evident  kind  than  what  prevails  in  acute  inflam- 
mation. According  to  Dr.  Wilson  Philip,  the  differ- 
ence between  jvhat  is  called  active  and  passive  inflam- 
mation, seems  to  depend  upon  “the  degree  in  which 
the  arteries  supplying  the  vis  d tergo  to  the  debilitated 
vessels  are  excited.” — {Laws  of  Vie  Vital  Functions, 
p.  282,  edit.  2.)  If  this  position  be  satisfactorily  esta- 
blished, one  important  step  will  be  made  to  a know- 
ledge of  the  differences  between  acute  and  chronic 
inflammation,  but  much  would  yet  remain  for  expla- 
nation, before  our  ideas  of  the  latter  process  would  be 
at  all  complete. 

In  a work  of  considerable  merit,  Dr.  Baron,  of  Glou- 
cester, offers  many  considerations  against  the  -correct- 
ness of  the  ordinary  doctrines  respecting  the  formation 
of  tubercles  and  tumours.  By  tubercles,  he  means 
disorganizations  composed  of  one  cyst,  “ whatever  be 
its  magnitude,  or  the  nature  of  its  contents;”  and  by 
tumours,  he  would  understand  “morbid  structures, 
Uiat  appear  to  be  composed  of  more  than  one  tubercle.” 
— (On  Tuberculated  .Accretions  of  Serous  Membranes, 
Sec.  p.  213.)  From  certain  appearances  traced  in  dis- 
sections, Dr.  Baron  infers,  that  all  tubercles,  wherever 
situated  and  of  whatever  substance  composed,  were  at 
their  commencement  small  vesicular  bodies,  with  fluid 
contents  ; hydatids,  as  he  endeavours  to  prove.  “ It  is 
impossible  to  say  how  minute  they  may  have  been  at 
their  origin,  or  how  large  tliey  may  grow  before  their 
transformations  begin  ; nor  are  we  acquainted  with 
the  circumstances  which  occasion  sucli  transforma- 
tions.” To  these  changes  in  hydatids  (according  to 
this  writer),.certain  tubercles  owe  their  existence,  and 
“ on  the  size,  relative  position,  and  structure  of  the 
tubercles,  which  are  so  formed,  depend  the  characters 
of  many  of  the  most  formidable  disorganizations  to 
which  the  human  body  is  exposed.” — (P.  215.)  A 
single  hydatid,  when  it  is  transformed  (says  Dr.  Baron), 
will  give  rise  to  one  tubercle.  “It  may  be  pendulous, 
or  imbedded  in  any  soft  part,  or  it  may  be  found  be- 
tween the  layers  of  membranes,  and  wherever  the  te.\- 
tures  are  of  such  a nature  as  to  admit  of  its  grow'lh. 
It  may  be  so  small  as  to  be  scarcely  visible,  or  it  may 
acquire  a very  great  magnitude.  Single  tubercles  are 
often  seen  in  a viscus,  while  all  the  rest  of  the  organ  is 


TUMOUR. 


371 


free  from  disease,  and  its  functions  are  performed  in 
an  uninterrupted  manner.  But  it  is  evident  that  the 
same  state  of  the  system  (whatever  tliat  may  be) 
which  calls  one  tubercle  into  existence,  may  generate 
an  indefinite  number.  They  may  be  diffused  through 
the  vvliole  of  a viscus,  leaving  nothing  of  its  original 
texture,  or  they  may  occupy  any  proportion  of  it,  or 
extend  to  the  contiguous  parts,  and  involve  them  in 
the  same  form  of  disease.” — (P.  216.)  When  hydatids, 
growing  in  clu.sters  and  hanging  within  cavities,  be- 
come changed  into  tubercles.  Dr.  Baron  conceives  that 
the  morbid  appearances  must  of  course  correspond,  in 
some  degree,  with  the  original  distribution  of  the  parts. 
He  has  seen  tubercles  attached  in  this  form  to  the  cho- 
roid plexus,  to  the  valves  of  the  heart,  to  the  fimbriated 
extremities  of  the  Fallopian  tubes,  and  to  the  omentum 
and  convolutions  of  the  bowels.  In  the  latter  instance 
they  were  very  minute,  the  largest  not  being  bigger 
than  the  head  of  a pin,  and  their  number  defied  all 
calculation. 

“Other  varieties  in  the  arrangement  of  the  element- 
ary parts  of  morbid  growths  will  of  course  cause  cor- 
responding varieties  in  their  appearance.  Thus,  when 
hydatids  are  enclosed  the  one  within  the  other^  and  are 
transmuted  into  solid  substances,  a section  of  these 
substances  will  exhibit  a series  of  concentric  laminw." 

Another  variety  pointed  out  by  Dr.  Baron  is,  “ when 
an  immense  number  of  very  small  tubercles  are  gene- 
rated in  juxtaposition,  and  unite  together.  Wherever 
such  an  event  occurs,  the  original  texture  of  the  part  is 
entirely  lost,  and  a mass  of  varying  degrees  of  density 
and  firmness  formed.  In  the  earlier  stages  of  its 
growth,  a granulated  appearance  may  be  distinctly 
traced  ; but  in  process  of  time  this  disappears,  the  con- 
solidation becomes  more  complete,  and  substances  of 
a gristly,  or  cartilaginous,  or  scirrhous  texture  maybe 
found.  I have  traced  (says  Dr.  Baron)  the  whole  of 
these  gradations  in  the  liver,  the  lungs,  the  pleura,  the 
omentum,  the  peritoneum,  and  in  tumours  in  other 
parts.”— (P.  219.) 

“ Sometimes  small  hydatids  grow  from  the  outer  or 
inner  surface  of  large  ones,  or  float  within  them.  I 
have  seen  (says  Dr.  Baron),  from  a source  of  this  kind, 
the  uterus  and  its  appendages  converted  into  an  enor- 
mous misshapen  mass,  tubercles  of  the  size  of  the  fist 
growing  ft-om  it,  while  these  again  were  surmounted 
by  smaller  ones  in  many  gradations.  Some  had  glairy 
contents,  others  were  in  a state  of  scirrhosiiy,  and 
others  were  but  little  changed,  having  thin  delicate 
cysts,  and  containing  a transparent  fluid. 

“But  perhaps  (remarks  Dr.  Baron)  the  most  import- 
ant variety  of  all  is,  when  tubercles,  originally  distinct 
from  each  other,  approximate  as  they  increase  in  size, 
ultimately  unite,  and  form  tumours,  which  have  re- 
ceived different  designations,  according  to  the  predo- 
minant character  of  their  contents  and  internal  struc- 
ture. It  was  chiefly  to  elucidate  this  part  of  the  subject, 
that  I made  the  distinction  between  the  words  tumour 
and  tubercle,”  &-c.— (P.  219.)  By  thus  adverting  to 
the  primitive  arrangement,  number,  size,  &c.  of  hyda- 
tids, and  their  subsequent  mutations.  Dr.  Baron  tries 
to  account  for  the  varieties  of  encysted  and  sarcoma- 
tous tumours,  fungus  haematodes,  tuberculated  sar- 
coma, scirrhous  swellings,  &;c.  &c.  The  late  Dr. 
Adams,  as  is  well  known,  referred  cancer  to  the  living 
state,  growth,  and  multiplication  of  the  hydatid. — {On 
the  Cancerous  Breast,  p.  77.)  In  order  to  account  for 
the  various  appearances  of  the  disease,  he  has  divided 
hydatids  into  a number  of  species,  as  lymphatica,  cru- 
enta,  and  carcinomatosa,  and  suspects  that  there  may 
be  others.  These,  he  affirms,  are  lodged  in  different 
cavities,  or  enclosed  in  a fungus,  which  is  occasioned 
by  any  individual  or  numbers,  stimulating  the  sur- 
rounding parts  to  generate  it,  for  the  purpose  of 
dividing  the  dead  from  the  living.  This  fungus  is  a 
nidus,  formed  altogether  for  the  protection  of  another 
generation  ; by  means  of  it,  the  living  families  are  se- 
parated from  the  dead,  and  their  preservation  is 
secured.  They  die,  he  says,  without  otherwise  aflljct- 
ing  the  body  in  which  they  existed  but  by  their  local 
etimirtus,  and  he  declares  that  his  object  is  to  prove  the 
‘animalcular  existence  of  carcinoma.  Now,  according 
to  Dr.  Baron,  this  main  position  is  the  fundamental 
error  of  Dr.  Adams’s  book  ; for  “ in  no  rational  nor 
legiiiniate  point  of  view  may  cancer  be  said  to  have 
an  animalcular  existence ; because  admitting,  for  the 
Bake  of  argument,  that  hydatids  are  animalcules,  it 

A a2 


has,  I trust,  been  shown  (says  Dr.  Baron)  that  it  is  to 
the  loss  of  the  hydalical  character  altogether,  and  the 
transformations  of  these  bodies,  that  the  morbid  ap- 
pearances in  this  'and  many  other  diseases,  are  to  be 
referred." — (P.  276.) 

Although  I consider  the  evidence  and  remarks  which 
Dr.  Baron  has  adduced  in  support  of  his  opinions  in 
many  respects  interesting,  the  facts  brought  forward 
do  not  appear  to  me  to  justify  the  conclusion,  that  the 
formation  of  tubercles  and  tumours  originally  depends 
upon  hydatids  and  their  transformation.  That  hyda 
tids  are  sometimes  found  within  diseased  structures, 
and  that  cells,  cysts,  granulated  and  tuberculated  ap- 
pearances are  often  noticed  in  tumours  of  diflerent 
kinds,  are  facts  universally  received.  But  the  pre- 
sence of  hydaiids  in  the  unchanged  state  is  oidy  an 
occasional  circumstance  ; whereas,  if  they  were  gene- 
rally a cause  of  tumours  by  undergoing  some  unex- 
plained transfornnition,  it  is  impossible  to  suppose, 
that  some  of  them  at  least  would  not  be  more  com- 
monly found  in  a distinct,  unaltered  form  within  or 
around  all  swellings  imagined  to  proceed  from  clusters 
of  them.  As  the  growth  of  tumours  formed  on  these 
principles  could  not,  I imagine,  be  accounted  for  with- 
out supposing  a continual  multiplication  and  transform- 
ation of  hydatids,  either  within  or  around  the  swell- 
ings, one  would  expect  that  some  visible  hydaiids, 
previously  to  their  transfiguration,  would  certainly 
be  apparent  on  minutely  examining  the  interior  and 
the  circumference  of  the  diseased  structure.  Yet  I am 
not  aware  that  such  fact  has  been  proved  to  be  gene- 
rally the  case,  either  by  the  aid  of  the  scalpel  or  the 
microscope.  The  observation  of  cavities,  cells,  and 
tuberculated  appearances  in  some  kinds  of  tumours,  is 
no  proof  that  such  modifications  of  structure  are  trans- 
formed hydatids.  Besides,  if  my  limits  would  allow 
me  to  consider  this  topic  farther,  many  reasons  might 
be  urged  against  the  hydatid  doctrine,  arising  from  the 
consideration  of  the  changes  evident  in  the  blood-ves- 
sels supplying  parts  in  which  a considerable  tumour  is 
situated.  Thus  we  often  see  the  trunks  of  the  arteries 
running  towards  such  parts,  doubled  in  size,  as  is  no- 
ticed with  respect  to  the  carotid  in  the  natural  growth 
of  the  stag’s  horn,  and  indicating,  at  least,  that  the  form 
ation  and  increase  of  swellings  are  effected  through 
the  medium  of  the  blood-vessels.  The  sudden  effect 
of  tying  the  arteries  by  which  a tumour  is  supplied 
with  blood,  would  also  be  difficult  to  explain,  if  the 
growth  of  the  swelling  really  depended  upon  some  un- 
defined transformation  of  hydatids. 

It  seems  to  be  generally  admitted,  that  the  growth  of 
all  tumours  may  be  retarded,  and  that  sometimes  they 
may  even  be  diminished  by  means  of  topical  bleeding 
with  leeches,  and  keeping  the  parts  in  a continually 
cool  state  by  the  incessant  application  of  cold  sedative 
washes.  Afterward,  when  the  increased  action  of  the 
vessels  seems  checked,  and  the  tumour  ceases  to  en- 
large, discutients  are  indicated,  such  as  frictions  with 
mercurial  ointment,  pressure,  electricity,  rubefacient 
plasters,  solutions  of  salts,  blisters,  and  issues.  Very 
few  sarcomatous  or  encysted  tumours,  liowever,  are 
ever  completely  removed  by  these  local  means.  The 
swelling,  on  the  contrary,  generally  increases,  notwitli- 
standing  them  ; and  the  irritation  of  the  disease  by  sti- 
mulants is  not  altogether  unattended  with  danger  of 
the  affection  becoming  changed  by  them  into  very 
malignant  and  dangerous  cases,  sometimes  to  all  ap- 
pearances cancerous.  The  most  advisable  plan  is  to 
recommend  the  removal  of  sarcomatous  tumours  with 
the  knife,  while  they  are  small  and  in  an  incipient 
state  ; for  thus  they  are  got  rid  of  by  an  operation 
which  is  certainly  trivial,  compared  with  what  might 
afterward  become  requisite,  if  the  disease  were  allowed 
to  proceed,  and  attain  an  enormous  magnitude. 

Tumoub.s,  sarcomatous.  These  have  been  so 
named  from  their  firm,  fleshy  feel.  They  are  of  many 
kinds,  some  of  which  are  simple,  while  others  are 
complicated,  with  a malignant  tendency.  Mr.  Aber- 
nethy  has  attempted  to  form  a classification  of  sarco- 
matous tumours,  for  the  different  species  of  which  he 
has  proposed  names,  deduced  from  the  structure  which 
they  exhibit  on  dissection.  This  gentleman  has  named 
the  kind  of  swellings  which  he  first  consider.s.  Common 
Vascular  or  Organized  Sarcoma.  Under  this  title 
Mr.  Abernethy  includes  all  those  tumours  which  ap- 
pear to  be  composed  of  the  gelatinous  part  of  the  blood, 
rendered  more  or  less  vascular  by  the  growth  of  vessels 


372 


TUMOUR, 


through  it.  The  vessels  which  pervade  this  substance 
are,  in  different  instances,  either  larger  or  smaller,  and 
more  or  less  numerous ; being  distributed  in  their  usual 
arborescent  manner,  without  any  describable  peculiar- 
ity of  arrangement.  Perhaps  all  the  varieties  of  sar- 
comatous tumours  are  at  first  of  this  nature.  The 
structure  under  consideration  is  met  with,  not  only  in 
distinct  tumours,  but  also  in  the  testis,  mamma,  and 
absorbent  glands.  When  a common  vascular  or  organ- 
ized sarcoma  has  attained  a certain  magnitude,  the 
veins  of  the  skin  seem  remarkably  large,  and  their 
winditrg  course  under  the  integuments  excites  notice. 
This  kind  of  sarcoma  is  not  at  all  tender,  so  that  it 
may  be  freely  handled,  and  also  electrified,  without 
giving  pain.  The  tumour  sometimes  grows  to  such  a 
size  that  the  skin  bursts,  the  substance  of  the  swelling 
sloughs  out,  and  the  disease  is  got  rid  of.  However, 
this  mode  of  cure  is  attended  with  such  terrible  local 
appearances,  and  so  much  fever,  &c.,  that  the  removal 
of  the  disease  with  the  knife  is  to  be  preferred.  The 
enormous  mass  of  44^  pounds  weight,  involving  the 
penis,  testes,  and  scrotum,  and  lately  removed  by  Mr. 
Liston,  together  with  those  organs  (see  Edinb.  Med. 
and  Surg.  Journ.  ’JVb.  77),  was  probably  the  kind  of 
tumour  which  Mr.  Abernethy  would  call  a common 
vascular  sarcoma.  Other  similar  cases  are  noticed  in 
another  place.  See  Scrotum. 

[Delpech.,  Chirurgie  Clinique,  t.  2,  Alo.  1828.  Pro- 
fessor Delpech  gives  an  account  of  a patient  aged  35,  a 
native  of  Perpignan,  whose  scrotum  was  converted 
into  an  enormous  mass  weighing  sixty  French  pounds, 
in  which  the  penis,  the  spermatic  cords,  and  the  testi- 
cles were  completely  buried.  Such  a disease  is  much 
more  frequently  met  with  in  hot  than  in  temperate 
climates,  as  explained  in  the  article  Scrotum  of  this 
Dictionary,  where  a notice  of  some  other  remarkable 
instances  of  it  will  be  found.  The  swelling  described 
by  Delpech  was  nearly  pyriform,  flattened  transversely, 
divided  at  its  lower  front  part  into  three  principal 
lobes,  and  reached  downwards  below  the  calf  of  tire 
leg.  Behind,  it  formed  a vast  projection,  and  it  was 
attached  to  the  perinaeum  and  hypogastric  region  by  a 
neck  or  pedicle,  that  occupied  the  whole  space  com- 
prised between  the  pubes,  the  two  groins,  and  the  anus. 
The  circumference  of  the  pedicle*  at  its  narrowest 
part  was  eighteen  French  inches.  The  patient  could 
neither  walk  nor  stand,  without  much  difficulty.  Al- 
though the  organs  of  generation  were  buried  in  the 
manner  thus  specified,  erections  and  seminal  emissions 
occasionally  took  place.  Some  parts  of  the  integu- 
ments were  tuberculated  ; and  in  the  anterior  lobe  of 
swelling,  which  was  like  a cauliflower  excrescence, 
there  was  a transverse  fissure,  at  the  bottom  of  which 
was  a deep  sinus,  running  upwards  and  rather  to  the 
left : such  was  the  state  of  the  prepuce  and  passage 
through  which  the  urine  was  discharged.  For  the 
particulars  of  the  operation  by  which  this  enormous 
mass  was  removed,  so  as  to  leave  two  lateral  flaps  of 
sound  skin  for  covering  the  testicles,  I must  refer  to 
the  above  work.  The  extent  of  the  wound  may  be 
conceived,  when  it  is  stated  that  the  external  pudendal 
artery,  the  artery  of  the  septum  scroti,  the  dorsal  arte- 
ries of  the  penis,  the  transverse  artery  of  the  perinaeum, 
the  right  and  left  arteries  of  the  bulb,  and  several 
branches  of  the  inferior  hemorrhoidal,  required  liga- 
tures, the  ends  of  which  M.  Delpech  cut  off,  in  order 
that  the  quantity  of  extraneous  substance  in  the  wound 
might  be  lessened.  Owing  to  the  prodigious  elonga- 
tion of  the  spermatic  cords,  it  was  necessary  to  arrange 
them  after  the  operation  in  a tortuous  form,  and  some 
difficulty  was  experienced  in  fixing  the  testicles  in  their 
proper  situation.  The  wound  was  completely  cured 
in  about  tw-o  months;  and  the  patient  returned  to  Per- 
pignan, where  in  the  course  of  a few  weeks  he  became 
indisposed  and  died.  On  opening  the  body,  a very 
large  abscess  was  detected  in  the  liver.  Must  this  be 
regarded  as  a consequence  of  the  extensive  wound 
inflicted  in  the  operation,  or  as  the  result  of  the  pa- 
tient’s excesses  after  the  wound  had  healed?  If  the 
former  view  be  adopted,  it  is  another  confirmation  of 
the  frequency  of  visceral  inflammations  and  suppura- 
tions after  severe  local  injuries  or  great  operations ; a 
subject  on  which  much  interesting  matter  may  be  col- 
lected in  the  Memoirs  of  the  Royal  dicademy  of  Sur- 
gery, and  in  the  papers  of  Messrs.  Rose  and  Arnott  in 
the  Medico-Ckir.  Trans,  of  London. 

With  regard  to  the  nature  of  the  tumour,  Delpech 


contends  that  it  presented  an  example  of  true  elephan- 
tiasis of  the  scrotum  ; a point  on  which  many  practi- 
tioners will  disagree  with  him.  The  following  cir- 
cumstances relative  to  the  structure  and  composition 
of  the  swelling  are  noticed.  The  skin  of  its  anterior 
part  was  not  less  than  three  inches  thick  ; and  the 
inequalities  observable  upon  every  portion  of  it  were 
here  greatest.  Notwithstanding  the  discolorations 
which  the  skin  exhibited  in  places,  where  it  was  most 
deeply  affected,  the  incisions  in  it  bled  very  little  ; few 
vessels  of  considerable  size  were  met  with,  and  not  a 
single  varicose  vein.  The  cellular  tissue  was  mani- 
festly every  where  distended,  its  lamellae  were  length- 
ened, and  included  very  large  cells ; most  of  them  were 
semi-opaque  and  of  a white  pear  colour,  which  change 
is  ascribed  by  Desault  to  an  inflammatory  process  that 
had  thickened  them.  The  areolae  of  this  tissue,  besides 
being  very  dense,  contained  a serosity,  a part  of  which 
flowed  out  in  the  operation,  while  the  rest,  in  conse- 
quence of  its  greater  consistence,  did  not  escape  from 
the  cells,  though  they  were  opened.  Both  contained 
a large  proportion  of  albumen,  and  were  coagulated  by 
heat  or  acids.  Blood-vessels  were  seen  ramifying  in 
this  tissue ; but  they  were  not  numerous,  and  only  of 
small  size.  The  lymphatics  were  plainly  discernible 
in  great  numbers  and  of  considerable  diameter.  In 
front  of  the  spermatic  cord  some  fat  was  found,  the 
only  situation  in  which  it  presented  itself;  and  here  its 
accumulation  made  Delpech  suspect,  for  a little  while, 
that  there  was  an  omental  hernia,  with  a very  thin 
transparent  sac.  The  cremaster  seemed  to  have  pre- 
served the  spermatic  cord  completely  from  the  disease. 

To  the  preceding  history.  Professor  Delpech  has  an- 
nexed the  case  of  what  he  terms  an  elephantiasis  of 
the  female  sexual  organs,  removed  by  Dr.  Talrich,  of 
Perpignan.  The  disease,  which  originated  just  below 
the  mons  veneris,  hung  down  as  low  as  three  inches 
above  her  knees,  and,  unless  it  was  pushed  towards 
the  navel,  rendered  the  evacuation  of  the  urine  diffi- 
cult. It  involved  the  labia,  especially  the  right  one; 
and  the  clitoris,  which  was  considerably  elongated  by 
the  weight  of  the  swelling,  was  concealed  under  its 
root.  I do  not  adopt  the  view  taken  by  Delpech  of  the 
character  of  this  swelling,  wliich  he  contends  was  that 
of  elephantiasis.  Whoever  will  compare  the  descrip- 
tion of  the  disease  with  the  history  of  elephantiasis 
(see  Oood’s  Study  of  Medicine,  vol.  3,  p.  423,  ed.  3),  will 
see  few  points  of  resemblance  between  them. — Pre/.] 
[Tumours  of  a steatomatous  nature  often  occur  from 
the  inner  surface  and  from  the  outside  of  the  .uterus. 
Several  remarkable  specimens  of  this  sort  are  in  the 
collection  of  Professor  Francis,  of  New-York.  The  par- 
ticularsof  two  cases  which  fell  under  the  observation  of 
Dr.  F.,  and  occurred  in  the  practice  of  Professor  Mott, 
are  given  in  Dr.  Francis’s  third  revised  edition  of  Den- 
man’s Midwifery,  New-York,  1829.  In  one  of  these 
cases,  upon  examination,  the  tumour  was  found  to  be 
of  a fleshy  nature,  and  of  a fibrous  vascular  structure. 
It  was  almost  wholly  one  solid  mass.  It  grew  by  a 
peduncular  attachment  from  the  fundus  of  the  womb. 
According  to  evidence  taken  at  the  time  of  examina- 
tion, the  tumour  and  its  excrescences  weighed  rather 
more  than  one  hundred  pounds.  The  extent  of  tlie 
abdomen  of  the  patient  before  the  removal  of  the  tu- 
mour measured  four  feet  eight  inches  and  a half.  In 
the  other  instance,  a number  of  tumours  were  found 
attached  to  the  external  surface  of  the  uterus  and  its 
appendages.  These  tumours  and  the  diseased  uterus 
weighed  thirty-two  pounds  four  ounces.  Other  re- 
markable cases  of  this  nature  are  stated  in  Francis’s 
Denman.  In  one  the  external  tumour  was  nearly  the 
size  of  the  head  of  a foetus  at  seven  months.  In  two 
other  instances  they  were  about  two  inches  in  circum- 
ference. These  tumours  occasionally  create  much 
constitutional  uneasiness  and  false  signs  of  pregnancy. 
But  much  depends  upon  the  portion  of  the  uterus  from 
which  they  grow. — Reese.] 

The  second  kind  of  sarcomatous  tumour  noticed  In 
Mr.  Abernethy’s  classification,  is  the  .Adipose  Sarcoma. 
Every  one  at  all  in  the  habit  of  seeing  surgical  disease, 
must  know  that  fatty  tumours  are  e.xceedinely  com- 
mon. blr.  Abernethy  believes  that  these  swellings  are 
formed  in  the  same  manner  as  others,  viz.  in  the  first 
instance  they  were  coagulable  lymph,  rendered  vas- 
cular by  the  growth  of  vessels  into  it,  and  that  their 
future  structure  depended  on  the  particular  power  and 
action  of  the  vessels.  According  to  Sir  Astley  Cooper, 


TUMOUR. 


373 


“ they  are  not  composed  of  fatty  matter  only,  but  the 
adipose  membrane  is  increased,  and  their  structure  is 
similar,  only  somewhat  more  compact,  to  that  of  the 
fatty  membrane  in  other  parts  of  the  body.” — {Med. 
Chir.  Trans,  vol.  11,  p.  440.)  This  fact  is  very  much 
against  the  doctrine  which  ascribes  the  origin  of  tu- 
mours to  hydatids  and  their  transformation.  Adipose 
sarcomatous  tumours  always  have  a thin  capsule, 
formed  by  the  simple  condensation  of  the  surrounding 
cellular  substance.  It  adheres  very  slightly  to  the 
swellings,  and  chiefly  by  means  of  vessels  which  pass 
through  this  membranous  covering  in  order  to  enter 
the  tumour.  As  Mr.  Abernethy  has  accurately  de- 
scribed, the  vessels  are  so  small,  and  the  connexion  so 
slight,  that  in  removing  the  tumour  no  dissection  is  re- 
quisite, as  the  operator  may  easily  put  his  fingers 
between  the  swelling  and  its  capsule,  so  as  to  break  the 
little  vascular  connexions,  and  entirely  detach  the  dis- 
ease. Some  individuals  seem  to  have  a disposition  to 
the  formation  of  fatty  tumours  upon  various  parts  of 
their  bodies;  a memorable  example  of  which  is  re- 
corded in  the  Revue  Medicate.  The  patient  was  a 
young  woman,  aged  18,  whose  constitution  was  not  in 
any  way  remarkable.  Although  very  lean,  and  of  the 
middle  stature,  she  weighed  169  French  pounds.  Be- 
tween her  shoulders  were  two  tumours,  eight  inches 
long  and  three  broad.  A third,  of  less  size,  was  situ- 
ated near  the  right  armpit.  A fourth  arose  from  the  in- 
ferior angle  of  the  shoulder-blade,  and  was  15  inches 
long  and  six  broad.  A fifth,  lower  down,  was  six 
inches  long  and  five  broad.  The  sixth,  which  was 
larger  than  a man’s  head,  was  situated  upon  the  right 
hip.  The  seventh,  a small  one,  was  below  the  right 
trochanter  major.  The  eighth,  a prodigious  one,  arose 
from  the  left  hypochondrium,  and  hung  down  as  low 
as  the  middle  of  the  calf  of  the  leg,  being  two  feet 
long  and  three  feet  one  inch  in  circumference  at  its 
base.  All  these  tumours  were  of  a fatty  nature,  soft, 
uneven,  and  quite  unconnected  with  internal  organs  or 
the  muscles. — (See  Q^uarterly  Journ.  of  Foreign  Me- 
dicine, vol.  4,  p.  618.) 

The  substance  of  adipose  tumours  is  never  furnished 
with  very  large  blood-vessels,  and  the  fear  of  hemor- 
rhage, which  frequently  deters  surgeons  from  ope- 
rating, is  quite  unfounded.  It  is  an  undoubted  fact, 
that  there  is  no  species  of  tumour  that  can  be  removed 
with  so  much  celerity,  with  such  apparent  dexterity, 
or  with  such  complete  security  against  future  conse- 
quences as  those  of  an  adipose  nature.  However, 
now  and  then,  when  the  tumour  has  been  sometimes 
in  an  inflammatory  .state,  the  capsule  becomes  thick- 
ened, and  intimately  adherent  to  the  surface  of  the 
swelling,  so  that  the  separation  of  the  disease  is  more 
difficult,  and  requires  the  knife  to  be  more  freely  em- 
ployed. The  tumour  also  sometimes  becomes,  after 
inflammation,  closely  adherent  to  the  contiguous  parts. 
Adipose  tumours  often  acquire  an  enormous  magni- 
tude. Indeed,  there  can  be  no  doubt  of  the  fact  stated 
by  Sir  Astley  Cooper,  that  they  acquire  a greater  mag- 
nitude than  any  other  swelling  ever  reaches.  Mr. 
Abernethy  relates  an  example  of  one,  removed  by  Mr. 
Cline,  which  weighed  between  141bs.  and  151bs.,  and 
which  I saw  myself  previously  to  the  operation.  Sir 
Astley  Cooper  also  mentions  the  successful  extirpation 
of  several  adipose  tumours  of  immense  size;  one 
weighing  141b.  lOoz.  removed  by  himself;  and  another 
weighing  22lbs.  removed  from  a lady’s  thigh  by  Mr. 
Copeland.  But  a still  more  remarkable  case  is  one,  in 
which  Sir  Astley  Cooper  lately  removed  a fatty  swell- 
ing, which  weighed,  independently  of  the  blood  in  it, 
37Ibs.  lOoz.,  and  was  situated  on  the  abdomen  of  a 
man  aged  57. — (See  Med.  Chir.  Trans,  vol.  11,  p.440.) 
In  the  case  above  quoted  from  the  Revue  Medicate, 
and  recorded  by  M.  Dagorn,  of  Morlaix,  the  largest  of 
the  swellings  weighed,  after  its  removal,  46  French 
pounds. — (See  Quartcrlry  .Town,  of  Foreign  Med.  vol. 
4,  p.  618.)  Although  it  is  true,  that  when  adipose 
swellings  attain  an  enormous  bulk,  the  immense  size 
of  the  wound  requisite  for  their  removal  must  be 
dangerous,  and  is  a strong  argument  in  favour  of 
having  recourse  to  the  operation  at  an  earlier  period, 
yet  it  is  equally  true,  that  large  fatty  swellings  may  be 
taken  out  with  a greater  prospect  of*  success  than  any 
other  kind  of  tumour  of  equal  size. 

The  next  species  of  sarcoma,  noticed  in  Mr.  Aber- 
nethy’s  classification,  is  what  he  names  pancreatic, 
from  the  resemblance  of  its  structure  to  that  of  the 


pancreas.  This  kind  of  disease,  it  is  remarked,  is  oc- 
casionally formed  in  the  cellular  substance ; but  more 
frequently  in  the  female  breast,  on  that  side  of  the 
nipple  which  is  next  to  the  arm.  When  a pancreatic 
sarcoma  is  indolent,  and  increases  slowly,  the  sur- 
rounding parts  and  the  glands  in  the  axilla  are  not 
affected.  But  some  of 'these  swellings  deviate  from 
their  common  character,  and  become  of  a very  irrita- 
ble nature,  occasioning  severe  and  lancinating  pain, 
and  producing  an  inflammatory  state  of  the  skin 
covering  them,  so  that  it  becomes  adherent  to  their 
surface.  The  absorbents  leading  to  the  axilla  are  also 
irritated,  and  the  glands  enlarged.  Pancreatic  sarcoma 
does  not  grow  to  a very  large  size ; but  when  its  pro- 
gress is  unrestrained,  the  pain  attendant  on  the  dis- 
ease becomes  lancinating,  and  so  severe  as  to  make 
the  patients  feverish,  and  lose  their  health  and  strength. 
Mr.  Abernethy  remarks,  that  when  the  axillary  glands 
become  affected,  one  generally  swells  at  first,  and  is 
extremely  tender  and  painful ; but  afterward  the  pain 
abates,  and  the  part  remains  indurated.  Another  is 
then  affected,  and  runs  through  the  same  course. 

To  another  species  of  sarcoma,  Mr.  Abernethy  ap- 
plies the  epithet  mastoid  or  mammary,  from  the  re- 
semblance which  this  gentleman  conceives  its  struc- 
ture bears  to  that  of  the  mammary  gland.  This  kind 
of  disease,  Mr.  Abernethy  says,  he  has  not  often  seen. 
In  the  example  which  he  met  with,  the  tumour  was 
about  as  large  as  an  orange,  and  situated  on  a woman’s 
thigh.  The  swelling  was  removed  by  an  operation; 
but  the  wound  afterward  degenerated  into  a malignant 
ulcer,  attended  with  considerable  induration  of  the 
surrounding  parts,  and  the  woman  died  of  the  disease 
in  two  months.  Mr.  Abernethy  conceives,  that  the 
whole  of  the  morbid  part  had  been  cut  away,  but  that 
the  contiguous  parts  had  a disposition  to  disease, 
which  was  irritated  by  the  operation,  and  that  if  the 
nature  of  the  case  could  have  been  known  beforehand, 
it  would  have  been  right  to  have  made  a freer  removal 
of  the  substance  surrounding  the  tumour. 

Mr.  Abernethy  places  the  imastoid  sarcoma  between 
such  sarcomatous  swellings  as  are  attended  with  no 
malignity,  and  the  following  ones  which  have  this 
quality  in  a very  destructive  degree. 

The  tuberculated  sarcoma  is  composed  of  a great 
many  small,  firm,  roundish  tumours  of  diflTerent  sizes 
and  colours,  connected  together  by  cellular  substance. 
Some  of  the  tubercles  are  as  large  as  a pea ; others 
equal  a horsebean  in  size ; most  of  them  are  of  a 
brownish-red  colour;  but  some  are  yellowish.  Mr. 
Abernethy  mentions  his  having  seen  this  species  of 
sarcoma  chiefly  in  the  lymphatic  glands  of  the  neck. 
The  disease  proceeds  to  ulceration ; becomes  a painful 
and  incurable  sore ; and  ultimately  occasions  death. 

Another  kind  of  sarcoma,  mentioned  in  Mr.  Aber- 
nethy’s  classification  of  tumours,  is  distinguished  by 
the  epithet  medullary,  from  its  having  the  appearance 
of  the  medullary  matter  of  the  brain.  It  appears  to 
be  an  exceedingly  malignant  disease ; communicates  to 
the  lymphatic  glands  a similar  distemper ; ulcerates 
and  sloughs,  and  at  last  proves  fatal.  It  is  particularly 
apt  to  make  its  attack  on  the  testis,  and  is  treated  of  in 
other  parts  of  this  book. — (See  Fungus  Hcematodes, 
and  Testicle,  Diseases  of.) 

Mr.  Abernethy  includes  also  in  his  classification 
carcinomatous  sarcoma. — (See  Cancer.) 

I must  refer  to  another  article  {Mamma,  Removal 
of),  for  an  account  of  the  plan  of  removing  sarcoma- 
tous tumours. 

Besides  many  operations  which  have  of  late  years 
been  performed,  and  are  remarkable  on  account  of  the 
great  size  of  the  swellings  removed,  others  still  more 
interesting  claim  attention,  on  account  of  the  nature 
and  situation  of  the  parts  extirpated.  On  the  excision 
of  the  thyroid  gland  I need  not  here  dwell,  as  it  is  else- 
where noticed  (see  Thyroid  Gland) ; but  I feel  called 
upon  to  mention  some  other  very  bold  operations,  exe- 
cuted within  the  last  few  years.  The  first  is  that  per- 
fVirmed  by  Mr.  Goodlad,  of  Bury,  in  Lancashire.  The 
case  was  an  immense  tumour,  situated  on  the  left  side 
of  the  face  and  neck,  and  the  base  of  which  was.about 
twenty-eight  inches  in  circumference.  The  disease 
extended  from  the  external  canthus  of  the  eye  above 
to  within  three  quarters  of  an  inch  of  the  clavicle 
below,  and  some  idea  of  the  depth  of  its  attachments 
may  be  conceived,  when  it  is  known  that  the  whole 
parotid  gland  was  involved  in  it.  For  the  purpose  of 


374 


TUMOUR. 


obviating  all  danger  of  hemorrhage,  Mr.  Goodlad  began 
with  tying  the  carotid  artery.  The  nature  of  the  ope- 
ration will  be  best  understood  by  adverting  to  the  ap- 
pearances afterward  presented  by  the  wound.  “ The 
whole  sterno-inastoid  muscle  was  e.\posed,  and  its 
fibres  dissected  clean,  except  about  half  an  incJi  from 
its  insertion  into  the  clavicle.  The  w’ound  extended 
backwards  from  behind  the  mastoid  process  to  the 
trachea  anteriorly,  but  became  narrower  in  the  direc- 
tion of  the  muscle  at  the  lower  part  of  the  neck.  The 
sub-maxillary  gland  was  exposed,  and  about  one-fifth 
of  its  substance  not  appearing  healthy  was  removed. 
The  digastric  and  the  greater  portion  of  the  mylo- 
hyoideus  were  exposed.  The  ramus  of  the  jaw  was 
only  covered  by  periosteum,  except  where  covered  by 
the  masseter  muscle,  part  of  which  not  appearing 
healthy  was  dissected  away.  The  whole  of  the  con- 
dyloid process  of  that  bone  was  laid  bare  in  the  same 
manner,  and  behind  it  the  pterygoid  muscles  were  also 
exposed.  The  membrane  of  the  cheek  was  only  co- 
vered by  a cellular  substance  which  did  not  appear 
healthy;  but  sufficient  skin  was  saved  to  cover  the 
zygoma.  The  parotid  gland  was  entirely  removed-.” 
This  enormous  wound  healed  in  ten  weeks  ; but  un- 
fortunately the  cure  W'as  not  permanent;  the  disease 
returned,  and  fifteen  months  after  the  operation  the 
poor  woman  died.— (See  Med.  Chir.  Trans,  vol.  7,  p. 
112,  (S-c.  vol.  8,  p.  582.) 

Respecting  the  foregoing  severe  operation,  many  sur- 
geons may  be  inclined  to  doubt  the  propriety  of  tying 
the  carotid  artery  as  a preparatory  step,  and,  indeed,  it 
is  positively  condemned  in  an  anonymous  note  attached 
to  the  above  case;  simple  temporary  pressure  on  the 
exposed  vessel  being  represented  as  preferable.  It  ap- 
pears to  me,  however,  that  Mr.  Goodlad’s  method  was 
justifiable,  and  on  the  whole  the  best,  because  the  ap- 
plication of  the  ligature  to  the  carotid  not  only  re- 
moved the  dangers  of  hemorrhage  during  the  operation, 
but  obviated  them  afterward,  and  no  doubt  lessened 
the  necessity  for  a prodigious  number  of  ligatures  for 
vessels  which  would  otherwise  have  poured  out  a pro- 
fuse quantity  of  blood. 

Nay,  the  hemorrhage  is  so  profuse  from  the  main 
branches  of  the  external  carotid,  and  mere  pressure  so 
uncertain  of  always  commanding  the  flow  of  blood, 
that  the  patient  may  actually  die  from  sudden  loss  of 
blood,  as  nearly  happened  in  another  very  interesting 
case  of  removal  of  a large  tumour  involving  also  the 
parotid  gland,  and  connected  with  the  transverse  pro- 
cess of  the  atlas,  the  basis  of  the  skull,  the  meatus  au- 
ditorius,  mastoid  process,  and  angle  of  the  jaw.  The 
operator,  Mr.  Carmichael,  in  order  to  complete  the  dis- 
section, was  obliged  to  divide  the  trunk  of  the  facial 
artery;  “ Instantly  (says  he)  an  alarming  gush  of 
blood,  wiiich  evidently  came  from  a large  vessel,  fol- 
lowed the  division ; and  the  danger  appeared  the  more 
imminent  as  the  pressure.,  which  Mr.  Todd  applied  with 
all  the  force  he  could  exert  upon  the  carotid  trunk,  was 
actually  incapable  of  repressing  the  torrent.  There 
was  not  a moment  to  be  lost.  Mr.  Colies  plunged  a 
dry  sponge  to  the  bottom  of  the  wound,  and  firmly 
pressed  on  the  bleeding  vessel,  while  I made  a horizon- 
tal section  of  the  tumour,  till  I arrived  at  the  cavities 
occupied  by  the  sponge,  with  the  view  of  exposing  as 
quickly  as  possible  the  mouth  of  the  bleeding  vessel. 
This  was  accomplished  in  sufficient  time  to  save  the 
patient’s  life.”  Mr.  Carmichael,  at  the  conclusion  of 
the  history,  remarks,  that  if  he  were  called  upon  to 
perform  such  an  operation  again,  he  would,  in  the  first 
instance,  pass  a ligature  under  the  carotid  trunk, 
-ichich  might  be  tightened  or  not  as  occasion  should  re- 
quire. The  case  here  spoken  of  liad  a successful  ter- 
mination. One  remarkable  consequence  was  a para- 
lysis of  one  side  of  the  face,  brought  on  by  the  division 
of  the  trunk  of  the  portio  dura  in  the  operation. — 
(See  Trans,  of  the  King's  and  Queen's  College  of  Phy- 
sicians, vol.  2,  p.  101,  dtvo.  JJuhlin,  1818.) 

The  next  instance  which  I shall  notice  of  the  re- 
moval of  an  enormously  enlarged  parotid  gland,  is  that 
recorded  by  Klein,  the  eminent  operating  surgeon  at 
Stuttgard.  The  patient  was  a woman  of  seventy, 
and  the  swelling  extended  from  the  ear  to  the  shoulder. 
In  the  operation,  all  the  branches  of  the  facial  nerve 
were  divided  ; a piece  of  the  masseter  was  left  hanging ; 
the  external  carotid  artery  and  par  vagum  were  left 
quite  bare;  the  dissected  sterno-mastoid  lay  on  one 
side ; and  the  temporal,  external  maxillary,  and  auri- 


cular arteries  wei  e of  course  divided  along  with  seve- 
ral arteries  of  the  neck;  yet  the  largest  of  these  being 
tied,  the  bleeding  was  very  inconsiderable.  The  event 
was  so  successlul,  that  at  the  beginning  of  the  third 
week  the  wound  was  entirely  healed. 

The  same  distinguished  surgeon  also  removed  a fatty 
tumour,  extending  from  the  buttock  to  the  ham,  and 
measuring  three  feet  one  inch  in  length,  and  two  feet 
six  inches  in  circumference.  Klein  undertook  its  re- 
moval on  the  supposition  that  it  was  an  encysted 
tumour  lying  above  the  fascia  lata  ; but  it  turned  out 
to  be  asteatoma  coming  from  beneath  it,  and  reaching 
to  the  thigh  bone,  and  in  every  direction  among  the 
muscles,  nerves,  and  blood-vessels  of  the  thigh.  At 
length,  partly  with  the  fingers  and  partly  with  the 
knife,  the  fatty  mass  was  separated  from  all  its  impor- 
tant connexions.  Several  vessels  were  tied,  and 
among  them  the  profunda  femoris.  However,  not 
more  thau  a pound  of  blood  was  lost.  I'he  tumour, 
after  its  removal,  weighed  twenty-seven  pounds  and 
three-quarters.  The  patient,  a woman  44  years  of 
age,  went  on  very  well  for  eight  days;  but  on  the 
ninth,  she  was  constantly  complaining  of  uneasiness 
in  the  foot  of  the  affected  limb ; her  pulse  became 
weak  and  intermitting;  and  she  sunk  in  the  most  un- 
expected manner. — (See  Journ.  fiir  Chirurgie  He- 
rausgegeben  von  D.  L.  Oraefe  und  D.  P.  F.  fValther, 
b.  1,  p.  106,  >S'C.  8ae.  Berlin,  1820  ; or  Quarterly  Jour- 
nal of  Foreign  Medicine,,  6rc.  vol.  2,  p.  373,  4 c.) 

In  the  autumn  of  1823,  M.  Bedard  removed  the 
whole  of  the  parotid  gland,  which  is  described  as  be- 
ing in  a truly  scirrhous  state : the  disease,  however, 
returned,  and  the  patient  ultimately  died  of  it.  Two 
curved  incisions  were  made  so  as  completely  to  en- 
circle the  tumour.  The  portion  of  it  situated  on  the 
masseter  was  first  detached.  Then  an  endeavour  was 
made  to  separate  the  tumour  from  below  upwards; 
but  a continuation  of  it  was  found  reaching  a great 
depth  backwards  and  under  the  pterygoideus  internus. 
In  order  to  avoid  a hemorrhage,  which  it  would  have 
been  difficult  to  stop  in  the  operation,  M.  Bedard  now 
determined  to  cut  into  the  substance  of  the  swelling, 
at  the  point  where  the  deep  production  went  off  from 
it,  and,  dissecting  from  below  upwards,  he  removed 
the  mass  ; and,  together  with  it,  the  lower  half  of  the 
cartilage  of  the  meatus  auditorius  externus,  which 
participated  in  the  disease.  Numerous  arteries  being 
now  tied,  Bedard  proceeded  to  the  extirpation  of  the 
remainder  of  the  tumour.  A part  of  the  front  and 
inner  surface  of  the  mastoid  muscle  found  diseased 
W'as  cut  away.  Nearly  the  whole  of  the  elongation 
behind  the  jaw  had  been  cautiously  dissected  out, 
when  a large  jet  of  arterial  blood  indicated  that  either 
the  external  carotid  or  one  of  its  branches  close  to  its 
origin  was  divided.  M.  Bedard  placed  his  left  fore- 
finger on  the  point  from  which  the  blood  issued,  and  a 
double  ligature  was  applied,  one  portion  of  it  above, 
the  other  below,  the  lateral  opening  in  the  carotid. 
The  artery  was  now  held  forwards  and  a little  raised, 
while  the  rest  of  the  parotid  was  dissected  out.  Only 
one  small  continuation  of  the  tumour,  situated  just  in 
front  of  the  cervical  vertebras,  was  left,  on  account  of 
its  nearness  to  the  internal  jugular  vein ; and  it  was 
tied.  In  the  wound,  the  masseter  was  seen  cleanly 
dissected.  The  branches  of  the  seventh  pair  of  nerves 
had  been  removed  with  the  tumour ; the  labial  artery, 
denuded  but  not  wounded,  was  seen  pulsating  in  front 
of  the  lower  part  of  the  masseter.  The  posterior  part 
of  the  wound  exhibited  the  mastoid  process  and  the 
sterno-cleido-mastoid  muscle.  Internally,  the  styloid 
process,  the  external  carotid  tied  with  two  ligatures, 
the  stylo-hyoideus,  digastriens,  and,  rather  lower  down, 
the  small  part  of  the  tumour  that  was  lied,  formed  the 
bottom  of  the  wound  which  opened  into  the  meatus 
auditorius  externus.  The  following  inferences  are  de- 
duced from  the  case;  First,  The  reality  of  scirrhus  of 
the  salivary  glands  is  confirmed.  Secondly,  The  pos- 
sibility of  removing  the  parotid  demonstrated.  Thirdly, 
Hemorrhage  from  a wound  of  the  carotid  in  the  ope- 
ration may  be  stopped  by  ligature;  bur  the  attempt  to 
remove  by  the  first  incisions  that  portion  of  the  disease 
which  is  wedged  behind  the  jaw,  is  dangerous,  as 
opening  the  carotid  might  then  prove  fatal ; whereas, 
if  the  largest  portion  of  the  tumour  be  first  removed, 
and  then  the  test  cautiously  and  slowly,  tne  carotid, 
if  now  wounded,  may  be  more  easily  secured,  be- 
cause the  mass  which  lay  over  it  has  been  taken 


TUMOUR. 


375 


away.  Fourthly,  The  erysipelas  and  delirium,  by 
which  the  patient  was  afterward  attacked,  are  com- 
mon after  operations  on  the  face,  and  the  return  of 
cancerous  disease  but  too  frequent,  even  when  com- 
pletely extirpated.  Fifthly,  The  paralysis  of  the  mus- 
cles of  the  face  which  took  place,  is  explained  by  the 
division  of  the  branches  of  the  seventh  pair  of  nerves. 
— (See  Archives  Gin.  de  Med.  Janvier,  1824.) 

A question  may  be  entertained  whether,  in  some 
morbid  enlargements  of  the  parotid  gland,  and  parts 
extending  deeply  about  the  throat,  it  v/ould  not  some- 
times be  better  to  be  content  with  simply  tying  the  ca- 
rotid artery,  and  trying  whether  stopping  this  large 
supply  of  blood  to  the  diseased  parts  would  not  be 
followed  by  an  absorption  of  the  tumour  ? Some  facts 
appertaining  to  this  question  are  noticed  in  the  article 
Aneurism,  where  the  aneurism  by  anastomosis  falls 
under  consideration.  It  will  there  be  seen,  that  the 
result  of  this  experiment  is  not  sure  of  permanently 
Repressing  the  growth  of  a tumour  of  this  last  kind, 
even  when  it  has  this  eflect  at  first.  This  uncertainty 
will,  no  doubt,  incline  many  practitioners  to  prefer  the 
bold  method  of  extirpation.  Yet  others  will  perceive 
that  such  an  operation,  notwithstanding  its  success  in 
a few  examples,  is  dreadfully  severe,  and  must  of  it- 
self in  the  generality  of  cases  have  fatal  consequences. 
They  will  also  be  encouraged,  in  any  similar  instance, 
to  try  the  effect  of  the  ligature,  by  the  cure  which  Sir 
A.  Cooper  accomplished,  of  an  enormous  cutaneous 
enlargement  of  the  lower  extremity,  by  tying  the  artery 
in  the  groin.  Indeed,  I am  sure,  that  as  the  improve- 
ments in  modern  surgery  advance,  the  plan  of  curing 
tumours  by  cutting  off  their  main  supply  of  blood, 
will  be  much  more  extensively  adopted  than  has 
hitherto  been  the  case.  In  this  way  the  surgeon  may 
attempt  the  dispersion  of  many  tumours  which  could 
not  be  meddled  with  in  any  other  manner,  and  which, 
if  left  to  themselves,  must  have  a fatal  termination. 
With  respect  to  aneurism  by  anastomosis,  the  plan 
adopted  by  Mr.  White,  Mr.  Lawrence,  and  Mr.  Brodie, 
of  extirpating  it  by  a ligature  applied  round  its  base, 
is  sometimes  preferable  to  the  use  of  the  knife,  which 
may  bring  on  a perilous  degree  of  hemorrhage. 

Tumours,  encysted.  These,  which  are  commonly 
named  wens,  consist  of  a cyst  which  is  filled  with  dif- 
ferent substances.  When -the  contained  matter  is 
fatty,  it  is  termed  a sleatoma;  when  somewhat  like 
honey,  meliceris ; when  like  pap,  atheroma.  These 
are  the  three  species  into  which  writers  usually  divide 
encysted  tumours.  However,  some  of  these  swellings 
do  not  conform  to  either  of  the  above  distinctions,  as 
their  contents  are  subject  to  very  great  variety  indeed, 
and  are  occasionally  of  an  earthy,  bony,  or  horny  na- 
ture. Some  encysted  tumours  of  the  latter  description 
occasionally  burst,  and  assume  the  appearance  of 
horns,  by  the  gradual  projection  of  the  matter  secreted 
within  their  cysts.— (See  Sir  Everard  Home's  Obs.  on 
the  Growth  of  Horny  Excrescences,  in  Phil.  Trans, 
for  1701.)  In  the  year  1824  I attended  with  Mr. 
Drew,  of  Gower-street,  a medical  gentleman,  from 
whose  hip  I removed  a swelling  of  this  nature,  which 
had  become  very  troublesome  in  consequence  of  its 
pressure  making  the  parts  around  its  base  inflame.  It 
had  been  cut  off  many  years  ago  by  another  surgeon, 
but  grew  again.  At  present  (1829),  there  is  no  appear- 
ance of  its  reproduction,  against  which  I guarded  by 
carrying  the  incisions  very  deeply.  I saw  an  excres- 
cence of  this  kind  removed  some  years  ago  from  the 
scrotum  of  a man  in  St.  Bartholomew’s  Hospital.  Sir 
James  Earle  performed  the  operation,  and,  if  I am  not 
mistaken,  the  preparation  of  the  disease  is  now  in  the 
museum  of  that  institution.  But  still  more  remark- 
able specimens  of  such  excrescences  are  preserved  in 
the  Anatomical  Museum  of  St.  Thomas’s  Hospital; 
one  in  particular,  which  resembles  a ram’s  horn  in 
shape,  and  w'as  removed  from  a gardener’s  head  at 
Kingston,  by  Dr.  Roots.  A farther  account  of  the 
case  is  given  in  Rees’s  Cyclopaidia,  article  Homy  Ex- 
crescence. 

I suppose  every  body  in  London  has  now  seen  in  the 
British  Museum  the  horn  deposited  there  as  a curio- 
sity, and  which,  with  another  of  the  same  size,  grew 
upon  the  head  of  a human  subject.  What  is  equally 
curious,  hairs  are  not  unfrequently  found  growing  in 
the  cavities  of  encysted  tumours  {Delpech,  Precis  des 
Mai.  Chir.  t.  3,  p.  412)  ; and  even  teeth,  more  or  less 
Verfeclly  formed,  have  been  strangely  met  with  in  the 


same  situations.  An  interesting  specimett  of  the  latter 
occurrence,  in  a double  encysted  tumour  in  the  orbit, 
was  published  some  time  ago  by  my  friend  Mr. 
Barnes,  of  Exeter.— (See  Med.  Chir.  Trans,  vol.  4, 
p.  316.) 

It  is  observed  by  Sir  Astley  Cooper,  that  it  is  when 
encysted  tumours  are  situated  upon  the  temple  and 
near  the  eyebrows  and  other  hairy  parts,  that  they 
sometimes  contain  hairs;  these  “ have  no  bulbs  nor 
canal,  and  differ  therefore  from  those  which  are  pro- 
duced on  surfaces  of  the  body  which  naturally  form 
hair.”  In  sheep,  the  cysts  sometimes  contain  wool. — 
{Surg-ical  Essays,  part  2,  p.  233.)  The  manner  in 
which  these  horny  excrescences  are  produced  is  stated 
to  be  as  follows  ; “ The  horn  begins  to  grow  from  the 
open  surface  of  the  cyst ; at  first  it  is  soft,  but  soon 
acquires  considerable  hardness;  at  first  it  is  pliant,  but 
after  a few  weeks  it  assumes  the  character  of  horn.” — 

( Tol.  cit.  p.  235 ; see  also  Home,  in  Phil.  Trans,  for  1791.) 

Encysted  tumours  are  generally  of  a roundish  shape, 
and  are  more  elastic  than  fleshy  swellings.  However, 
the  latter  circumstance  depends  very  much  upon  the 
nature  of  their  contents  and  the  thickness  of  their 
cysts.  As  far  as  my  observation  extends,  encysted  tu- 
mours form  more  frequently  on  the  head  than  any 
other  part ; but  they  are  very  frequently  met  with  in 
all  situations  under  the  integuments,  and  sometimes  in 
deeper  places.  Encysted  tumours  are  also  very  often 
seen  on  the  eyelids. 

According  to  Sir  Astley  Cooper,  they  are  in  general 
nearly  globular,  and  when  seated  on  the  head  feel  very 
firm,  but  upon  the  face  they  are  attended  with  a fluc- 
tuation more  or  less  obscure.  The  skin  covering  them 
is  generally  uninflamed ; but  it  is  now  and  then 
streaked  with  blood-vessels  which  are  larger  than 
those  of  the  surrounding  integuments.  “ In  the  centre 
of  the  tumour  on  the  skin,  it  often  happens  that  in  its 
early  state,  a black  or  dark-coloured  spot  may  be  seen, 
which  sometimes  continues  through  the  whole  course  or 
the  disease.  In  general,  they  are  unattended  with 
pain,  are  never  in  themselves  dangerous,  and  only  re- 
quire removal  from  the  parts  in  which  they  occur,  and 
the  unseemly  appearance  they  produce.  They  move 
readily  within  the  cellular  membrane  if  they  are  free 
from  inflammation,  but  the  skin  in  general  does  not 
easily  move  over  them.” — {Surgical  Essays,  part  2,  p. 
230.)  The  greatest  number  of  encysted  tumours 
which  this  experienced  surgeon  has  met  with  in  the  same 
individual  was  sixteen,  situated  upon  the  head  ; and 
he  has  seen  nine  in  another  patient,  as  many  as  which 
number  on  one  person  I have  seen  myself.  Four,  five, 
and  six,  as  Sir  Astley  remarks,  are  not  uncommon.  The 
largest  which  he  has  ever  seen  was  equal  in  size  to  an 
ordinary  cocoa-nut,  and  grew  upon  the  head ; but  in 
general  they  are  not  more  than  one  or  two  inches  in 
diameter.  He  considers  them  in  some  degree  heredi- 
tary, as  he  has  often  heard  a patient  observe,  “ I have 
several  swellings  upon  my  head,  and  my  father  (or  my 
mother)  had  several.”  They  also  frequently  occur  in 
several  of  the  same  family. — (P.  231.) 

According  to  Sir  Astley  Cooper,  when  encysted  tu- 
mours are  dissected,  some  part  of  their  surface  is  found 
firmly  adhering  to  the  skin,  while  other  parts  are  con- 
nected to  it  merely  by  the  cellular  membrane.  The  cyst 
icselfis  imbedded  more  or  less  deeply  in  the  cellular  mem- 
brane, and  its  thickness  is  different  in  different  parts  of 
the  body.  On  the  face  or  near  the  outer  canthus  the  cyst 
is  very  thin ; but  on  the  back  it  is  much  thicker,  and  on 
the  head  it  is  so  thick  and  firm  that  it  retains  its  form  after 
the  discharge  of  its  contents,  and  is  so  elastic  that  after 
being  compressed  it  readily  expands  again  to  its  for- 
mer size.  Within  the  cyst.  Sir  Astley  Cooper  remarks, 
there  is  a lining  of  cuticle  which  adheres  to  its  inte- 
rior, and  several  desquamations  of  the  same  sub- 
stance are  formed  within  the  first  lining.  If  the  vessels 
ofthe  cyst  are  injected,  they  are  found  to  be  numerous, 
but  of  small  size.  The  cysts  are  occasionally  met  with 
in  an  ossified  state. — {Surgical  Essays,  part  2,  p.  232, 
233.)  It  is  the  opinion  of  Sir  Astley  Cooper,  that  en- 
cysted tumours  arise  from  the  enlargement  of  the  fol- 
licles or  glandular  pores,  in  consequence  of  the  ob- 
struction of  their  orifice, — (P,  236.)  If  this  sentiment 
were  correct,  the  fact  would  furnish  another  consider- 
ation against  the  view  taken  of  the  formation  of  tu- 
mours by  Dr.  Baron.  There  are  some  reasons,  how- 
ever, which  render  the  adoption  of  Sir  Astley’s  expla- 
nation difficult ; for  if  encysted  tumours  were  only 


376 


TUMOUR. 


enlarged  follicles,  they  would  not  be  found  so  far  from 
the  skin  as  they  frequently  are ; as,  for  instance,  within 
the  orbit,  between  the  peritoneum  and  abdominal 
muscles,  and  in  other  situations  yet  farther  from  the 
surface  of  the  body  ; and  the  collections  of  sebaceous 
matter  which  are  so  often  noticed,  as  this  gentleman 
observes,  in  the  follicles  of  the  skin  of  the  nose,  and 
may  be  pressed  from  them  in  the  form  of  worms, 
would,  if  the  cause  assigned  were  true,  make  encysted 
swellings  on  the  nose  itself  exceedingly  common  ; yet 
this  part  is  not  so  often  the  seat  of  such  tumours  as 
other  parts  of  the  face.  As  far  also  as  my  observa- 
tions extend,  pressure  cannot  be  said  to  have  any 
share  in  giving  rise  to  the  formation  of  encysted  tu- 
mours, because  I have  seen  them  chiefly  in  situations 
where  this  kind  of  cause  could  not  be  suspected;  as, 
for  instance,  on  the  face  and  about  the  vertex,  and  not 
particularly  round  that  part  of  the  head  which  is  com- 
pressed by  the  hat.  If  also  encysted  swellings  were 
owing  to  obstruction  of  the  cutaneous  pores  with  seba- 
ceous matter,  I apprehend  few  persons  would  escape 
the  disease.  The  cure  in  the  early  stage  would  also  be 
as  easily  elfected  by  the  timely  removal  of  the  alleged 
obstruction,  as  the  cure  of  the  little  tender  points  on 
the  nose,  really  caused  by  the  lodgement  of  the  seba- 
ceous matter  in  the  cutaneous  pores.  This  does  not 
appear  to  me  to  be  consonant  to  general  experience. 
How  the  formation  of  steatomatous encysted  swellings 
is  to  be  thus  accounted  for,  I cannot  at  all  conceive. 
And,  lastly,  it  is  to  be  noticed,  that  the  little  swellings  on 
the  nose,  arising  in  the  way  described,  are,  when  they 
occur,  frequently  attended  with  soreness,  from  which 
true  encysted  tumours,  at  least  in  the  early  stage,  are 
completely  free.  These  and  other  reflections  lead  me 
to  believe,  that  the  origin  of  encysted  swellings  cannot 
be  satisfactorily  explained  upon  the  principles  sug- 
gested by  the  above  distinguished  practitioner.  At 
the  same  lime  I ought  to  thank  him  for  his  kindness  in 
showing  me  two  cases,  in  which  the  fact  of  there  be- 
ing an  opening  in  the  ekin,  communicating  with  the 
cavity  of  the  swelling,  and  giving  occasional  exit  to  its 
contents,  was  completely  manifest ; but  whether  such 
opening  actually  were,  or  ever  had  been,  the  orifice  of 
a sebaceous  gland  of  the  skin,  is  a point  which  I can- 
not undertake  to  determine.  However,  as  all  Sir  A. 
Cooper’s  opinions  on  surgical  questions  are  deservedly 
valuable,  I subjoin  the  advice  which  he  has  given, 
founded  upon  the  preceding  doctrine.  If  the  follicle 
can  be  seen  only  as  a black  spot  filled  with  hardened 
sebaceous  matter,  he  recommends  a probe  to  be  passed 
into  it,  and  the  sebaceous  matter  to  be  pressed  out  of 
the  tumour,  which  is  done  with  little  inconvenience. 
But  if  the  contents  cannot  be  pressed  out  without  such 
violence  as  w'ould  create  inflammation,  he  says  that 
the  best  plan  is  to  make  the  opening  larger.  Other 
surgeons  have  tried  to  cure  encysted  tumours  by 
pricking  them  with  needles  and  squeezing  out  their 
contents ; by  opening  them  more  freely,  and  filling 
them  with  lint  or  charpie  {Delpech,  Clinique  de  Chi- 
rur^ie ; t.  2,  1828) ; or  by  applying  stimulating  and 
discutient  applications  to  them.  However,  some  of 
these  plans  mostly  fail,  and  the  others  sometimes  con- 
vert the  case  into  a terrible  disease,  in  which  a fright- 
ful fungus  shoots  out  from  the  inside  of  the  cyst,  at- 
tended with  immense  pain  and  irritation,  and  often 
proving  fatal. — (See  Jibernethy's  Surgical  Observa- 
tions, 1804,  p.  94.) 

' Similar  dangerous  fungous  diseases  may  also  arise, 
whenever  the  surgeon,  in  cutting  out  encysted  tumours, 
leaves  any  part  of  the  cyst  behind. 

The  most  advisable  method,  I believe,  is,  to  have  re- 
course to  the  knife,  before  an  encysted  tumour  has  at- 
tained any  considerable  size.  However,  if  it  is  large 
at  the  time  of  the  operation  being  done,  a portion  of 
the  skin  must  be  taken  away  with  the  swelling,  in  the 
manner  described  in  the  article  Mamma,  Removal  of. 
Tlie  chief  piece  of  dexterity  in  the  operation  consists 
in  detaching  all  the  outside  of  the  cyst  from  its  sur- 
rounding connexions  without  wounding  it.  Thus  the 
operator  takes  the  part  out  in  an  entire  state,  and  is 
sure  that  none  of  the  cyst  remains  behind.  When  the 
cyst  is  opened,  some  of  the  contents  escape,  it  collapses, 
and  the  dissection  is  rendered  more  tedious  and  diffi- 
cult. 

Such  is  the  common  opinion,  which  has  always  ap- 
peared to  me  correct.  However,  Sir  .^stley  Cooper 
states,  that  Uie  best  manner  of  doing  the  operation  is,  to 


make  an  incision  into  the  swelling,  and  then  to  press 
the  sides  of  the  skin  together,  by  which  means  the 
cyst  may  be  easily  detached  and  removed.  If  the  at- 
tempt be  made  to  extract  the  tumour  whole,  “ the  dis- 
section is  most  tedious,  and,  before  it  is  completed,  the 
cyst  is  either  cut  or  burst.  So  many  incisions,  and  so 
much  pain,  may  be  readily  prevented  by  opening  it 
freely  by  one  incision,  raising  its  edge  between  the  for- 
ceps,” and  dissecting  it  from  its  adhesions  to  the  sur- 
rounding membrane. — {Surgical  Essays,  part  2,  p. 
240.)  When  the  swelling  is  in  the  scalp.  Sir  Asiley 
directs  an  incision  to  be  made  through  its  centre,  from 
one  side  to  the  other,  when  its  contents,  which  in  this 
situation  are  very  solid,  are  immediately  discharged  in 
a mass  of  the  same  shape  as  the  tumour.  The  cyst 
being  raised  with  a tenaculum,  may  then  be  easily  se- 
parated. 

When  the  foregoing  difficulties  are  likely  to  be  en- 
countered, a late  writer  suggests  the  plan  of  first  open- 
ing the  cyst,  washing  out  its  contents,  and  then  inject- 
ing into  it  a thin  mixture  of  sulphate  of  lime,  whicfl 
will  immediately  harden,  and  facilitate  the  excision  of 
the  cyst. — {M^Ohie,  in  Ed.  Med.  Journ.  Mo.  76.) 
This  proposal,  though  ingenious,  is  perhaps  not  likely 
to  , be  adopted,  because  the  operation,  which  is  gene- 
rally easy  enough  without  it,  would  thus  be  rendered 
long  and  complex. 

With  respect  to  encysted  tumours  of  the  eyelids,  the 
atheroma  and  meliceris  are  said  by  Beer  to  form  only 
upon  the  upper  eyelid,  on  the  side  towards  the, temple, 
while  he  has  always  found  the  steatoma  to  be  seated 
either  in  the  vicinity  of  one  of  the  eyelids,  or  sometimes 
over  the  lachrymal  sac.  The  atheroma  and  meliceris, 
he  says,  usually  lie  in  the  loose  cellular  substance  di- 
rectly under  the  skin  of  the  eyelid,  though  sometimes 
more  deeply  under  the  orbicularis  muscle,  or  even 
quite  underneath  the  levator  palpebrae  superioris,  upon 
the  convex  surface  of  the  tarsal  cartilage,  to  which  the 
swelling  is  then  generally  so  firmly  adherent,  that  it  is 
impossible  to  remove  this  part  of  the  cyst.  Encysted 
tumours  of  the  upper  eyelid  are  commonly  so  move- 
able, that  they  can  be  pushed  above  the  superciliary 
ridge  of  the  os  frontis;  which  is  regarded  by  Beer  as 
a very  favourable  circumstance  in  the  operation. 
Though  the  atheroma  and  meliceris  of  the  upper  eye- 
lid occasionally  become  as  large  as  a pigeon’s  egg. 
Beer  has  never  known  a steatoma,  in  the  vicinity  of 
the  eyelids,  exceed  the  size  of  a hazel-nut.  Encysted 
tumours  of  the  upper  eyelid  itself  sometimes  appear 
moveable,  though  they  may  be  at  the  same  time  closely 
adherent  to  the  cartilage.  Hence,  Beer  recommends 
moving  the  tumour  about  for  a few  days  before  the 
operation,  and  trying  to  push  it  above  the  superciliary 
ridge;  and,  if  this  cannot  be  done,  the  circumstance 
will  prove,  that  the  swelling  is  connected  with  the  car- 
tilage, or  at  least  is  under  the  orb'icular  muscle,  and  the 
mode  of  operating  regulated  accordingly.  With  the 
yellow  pappy  substance,  found  in  the  cysts  of  athero- 
matous tumours  of  the  eyelids,  fine  short  hairs,  scarcely 
one  line  in  length,  are  frequently  blended.  Sometimes, 
as  Beer  remarks,  the  whole  inside  of  the  cyst  is  co- 
vered with  these  little  short  hairs,  which  may  all  be 
washed  out,  and  are  destitute  of  bulbs : a fact  also  no- 
ticed by  Sir  Astley  Cooper.  It  merits  attention,  how- 
ever, that  in  tumours  of  the  meliceris  kind,  formed 
upon  the  eyelid.  Beer  never  met  with  hairs. — {Lehre 
von  den  .^ugenkr.  b.  2,  p.  607 — 609.)  He  remarks, 
that  when  encysted  swellings  of  the  eyelid  are  let  alone, 
be  has  never  known  them  produce  any  injury  to  the  eye 
itself,  except  in  the  hindrance  to  the  opening  of  it, 
when  they  are  large.  On  the  other  hand,  if  they  be 
unskilfully  removed,  or  lashly  attacked  with  caustic, 
various  ill  consequences  may  ensue;  as,  for  instance, 
fistula;  of  the  lachrymal  gland,  entropium  from  a 
shrinking  of  the  tarsal  cartilage,  ectropium  from  de- 
struction of  the  skin,  and  the  hare-eye  from  an  actual 
shortening  of  the  upper  eyelid.  In  consequence  of 
the  inflammation  caused  by  escharotics,  Heer  has  more 
than  once  found  the  integuments  so  adherent  to  the  tu- 
mour, that  in  the  operation  the  removal  of  a consider- 
able piece  of  them  was  unavoidable.  But,  says  he, 
when  swellings  of  this  nature  are  properly  treated  in 
good  time,  they  may  be  removed  without  leaving  any 
vestige  behind,  excepting  a trivial  scar.  Professor 
Beer  joins  all  the  best  modern  surgeons  in  considering 
the  entire  removal  of  the  sac,  and  the  reunion  of  the 
wound  by  tlie  first  intention,  as  Uie  safest  and  most 


TUMOUR. 


377 


effectual  method  of  curing  encysted  tumours  of  the 
eyelids.  He  admits,  however,  that  the  hinder  portion 
of  the  cysts  of  some  swellings  of  this  nature  upon  the 
upper  eyelid  cannot  be  dissected  out,  because  it  may 
be  so  closely  adherent  to  the  cartilage,  that  its  excision 
would  injure  the  latter  part  too  much,  and  produce 
either  an  incurable  entropium,  or  an  irremediable 
shortening  of  the  eyelid.  But  steatomatous  tumours 
near  the  eyelids  may  almost  always  be  completely  dis* 
sected  out,  the  only  exceptions  being  cases  in  which  the 
swellings  happen  to  be  situated  between  the  lachrymal 
sac  and  the  orbicular  muscle,  and  so  intimately  con- 
nected with  the  first  of  these  parts,  that  the  back  por- 
tion of  the  cyst  could  not  be  cut  away  without  per- 
manently destroying  the  functions  of  the  excreting 
parts  of  the  lachrymal  organs.  However,  when  the 
swelling  is  not  too  strongly  attached  to  the  cartilage  of 
the  eyelid.  Beer  sanctions  the  removal  of  the  whole  of  the 
cyst.  He  particularly  insists  upon  the  utility  of  mov- 
ing the  tumour  a good  deal  about  daily,  for  a few  days 
before  the  operation,  so  as  to  loosen  its  connexions, 
and  enable  the  surgeon  to  push  it  over  the  edge  of  the 
orbit,  where  it  may  be  steadily  fixed  during  its  removal. 
— (if.  2,  p.  612.)  Excepting  a few  instances  in  which 
the  skin  was  diseased,  and  firmly  adherent  to  the  cyst. 
Beer  has  never  found  it  necessary,  in  the  excision  of 
encysted  swellings  of  the  eyelids,  to  remove  any  por- 
tion of  the  integuments ; and  he  has  cut  away  some 
tumours  of  this  kind  which  were  as  large  as  a pigeon’s 
or  hen’s  egg.  The  incision  through  the  skin,  he  says, 
should  be  longer  than  the  tumour,  so  as  to  facilitate  the 
extraction  of  the  distended  cyst.— (i?.  2,  p.  613.) 
When  it  is  not  advisable,  for  reasons  above  slated,  to 
attempt  to  dissect  out  every  particle  of  the  cyst.  Beer 
fills  the  cavity  with  lint,  lets  the  wound  suppurate,  and, 
if  this  plan  is  not  sufficient,  he  applies  stimulants  and 
caustic.  It  is  noticed  by  Sir  Asiley  Cooper,  that  en- 
cysted tumours  at  the  outer  canthus  are  often  difficult 
of  removal,  on  account  of  their  extending  into  the  or- 
bit, and  being  adherent  to  the  periosteum. — {Surgical 
Essays,  part  2,  p.  241.)  Professor  Scarpa  has  strongly 
recommended  making  the  incision  for  the  extraction 
of  encysted  swellings  of  the  palpebrae  on  the  inside  of 
these  parts.  But,  as  Mr.  Travers  correctly  remarks, 
the  swellings  are  often  situated  superficially,  and 
loosely  connected  with  the  tarsus;  iti  which  case,  the 
operation  should  be  done  on  the  outside  of  the  eyelid. 
The  latter  writer  admits,  however,  that  the  cyst  is 
often  formed  between  the  cartilage  and  the  ligamentary 
membrane  which  covers  it ; and,  in  his  opinion,  it  is 
only  when  an  intricate  adhesion  subsists,  and  the  ap- 
pearance of  a white  circumscribed  indentation  is  seen 
upon  the  everted  tarsus,  that  the  excision  should  be 
performed  on  the  inside  of  the  eyelid  by  dividing  the 
cartilage. — {Synopsis  of  the  Diseases  of  the  Eye,  p. 
357.) 

I shall  conclude  the  subject  of  tumours  with  a few 
observations,  delivered  by  Sir  Astley  Cooper  and  Pro- 
fessor Langenbeck.  “ The  removal  of  encysted  tu- 
mours (the  first  gentleman  observes)  is  not  entirely 
unattended  with  danger.  I have  seen  three  instances 
of  severe  erysipelatous  inflammation  succeed  the  ope- 
ration of  removing  these  swellings  upon  the  head, 
and  I believe  it  is  owing  to  the  tendon  of  the  occipito- 
frontalis being  wounded  in  the  attempt  to  dissect  them 
out  whole.” — {Surgical  Essays,  part  2,  p.  241.) 

In  the  extirpation  of  tumours  about  the  neck,  Lan- 
genbeck adopts  the  following  rules : he  makes  a free 
division  of  the  integuments,  and  dissects  the  muscles 
from  the  tumour  which  lie  over  it,  but  he  avoids  cut- 
ting through  or  injuring  them  ; in  this  manner  the 
swelling  is  rendered  more  moveable.  By  the  situation 
of  the  muscles,  he  is  then  enabled  to  know  the  place 
of  the  chief  blood-vessels;  and,  on  this  account,  he 
particularly  advises  young  surgeons  to  study  myology 
with  the  greatest  care.  As  Langenbeck  remarks,  it  is 
indeed  an  important  advantage,  after  a muscle  is  ex- 
posed, to  know  what  vessels  lie  at  its  edges  or  under- 
neath it.  Thus,  the  sartorius  is  a sure  guide  to  the 
crural  artery,  and  the  sterno-cleido-mastoideus  to  the 
carotid.  A surgeon  wfio  knows  correctly  the  anatomy 
of  the  parts  will  not  be  in  danger  of  wounding  un- 
intentionally any  large  vessel.  When  the  surface  of 
the  tumour  has  been  cleared,  but  the  base  of  it  is  yet 
firmly  attached,  Langenbeck  commences  the  separa- 
tion on  the  side  which  presents  the  least  risk,  that  is 
where  the  least  considerable  blood-vessels  are,  and 


thence  he  proceeds  by  degrees  towards  the  most  ha- 
zardous side.  In  favour  of  this  method,  he  offers  the 
following  considerations  : if,  by  chance,  an  artery  re- 
quiring a ligature  should  be  cut,  it  can  now  be  more 
easily  secured,  as  the  base  of  the  tumour  is  already 
partly  detached.  The  loosened  swelling  may  also  be 
drawn  away  from  the  large  vessels  with  the  hand  or  a 
tenaculum.  Langenbeck  never  introduces  the  knife 
deeply  when  there  are  large  blood-vessels  there,  but 
pulls  the  swelling  outwards,  and  then  divides  the  cellu- 
lar substance  thus  stretched,  which  is  situated  upon 
the  already  exposed  portion  of  the  tumour.  In  this 
manner  the  swelling  can  always  be  drawn  more  and 
more  away  from  the  vessels,  until  at  last  there  is  no 
danger  of  wounding  them.  By  attending  to  these 
principles,  Langenbeck  has  succeeded  in  removing 
many  very  large  tumours  from  the  neck,  where  nearly 
all  the  muscles  of  that  part  were  exposed  by  the  dis- 
section, and  the  carotid  denuded.  After  one  of  these 
operations,  not  only  the  styloid  process  could  be  felt, 
but  all  the  muscles  originating  from  it  could  be  dis- 
tinctly seen. — {Bibl.  fiir  die  Chir.  b.^p.  312,  ire.  VHmo. 
Obttingen,  1808.)  C.  O.  Steutzel,  De  Steatomatibus  in 
Principio  Jiort<B  repertis  et  Cysticis  in  Genere  excres- 
centibus.  Wittersb.  1723.  J.  J.  Plenck,  J^ovum  Sys- 
tema  Tumorum,  quo  hi  morbi  in  sua  genera  et  species 
rediguntur.  Pars  prior.  12wo.  Viennm,  1767.  Wm. 
Ogle,  Letter  concerning  the  Cure  of  encysted  and  other 
kmds  of  Tumours  without  the  Knife,  8vo.  Land.  1754. 
Abernethy' s Surgical  Works.  Ph.  Tr.  W allher,  iiber 
die  angebohrnen  Fetthautgeschwulsten  und  andere 
Bildungsf ebler.  fol.  Landshut,  18li.  J.P.  Weidmann, 
Annotatio  de  Steatomatibus,  Ato.  Maguntiaci,  1817. 
W.  Hey,  Practical  Obs.  in  Surgery,  p.  517,  ed.  2,  800. 
Land.  1810.  Allan  Burns,  Surgical  Anatomy  of  the 
Head  and  JVeck,  8vo.  Edin.  1811 : this  work  contains 
much  valuable  information  respecting  the  extirpation 
of  swellings  about  the  neck.  Schreger,  Chirurgische 
Versiiche,  b.  1,  p.  297;  Ueber  Lipoma  und  Extirpatio 
derselben.  8vo.  J^iirnberg,  1811.  John  Baron,  An  In- 
quiry, illustrating  the  JCature  of  Tuberculated  Accre- 
tions of  Serous  Membranes,  and  the  Origin  of  Tuber- 
cles and  Tumours  in  different  Textures  of  the  Body, 
800.  Land.  1819.  Also,  Illustrations  of  the  Inquiry, 
Src.  8vo.  Land.  1822.  Sir  Astley  Cooper,  Surgical 
Essays,  part  2 ; and  Med.  Chir.  Trans,  vol.  2.  C.  J. 
M.  Langenbeck,  Bibl.fiir  die  Chir.  b.  2,  p.  312.  Oiitt. 
1808.  Also,  Geschichte  einer  grossen  Speckgeschwulst 
welcher  mit  dem  Unlerkiefer  so  fest  zusammenhing, 
dass  die  Trennung  mit  der  Sage  verrichtet  werden 
muste.  Jfeue  Bibl.  b.  1,  p.  295,  12mo.  Hanover,  1817. 

B.  H.  Jacobsen  de  Tumoribus  Cysticis,  Ato.  Jence,  1792. 

C.  G.  Ludwig,  Monita  de  exscindendis  Tumoribus 
Tunica  incliisis.  Ato.  Lips.  1758.  B.  Liston,  Cases 
of  Large  Tumours  in  the  Scrotum  and  Labium,  re- 
moved by  Operation:  see  Edin.  Med.  Journ.  JVo.  77. 
Armstrong's  Morbid  Anatomy  of  the  Bowels,  Liver, 
Src.  Ato.  1828.  B.  Travers  on  the  local  diseases,  termed 
malignant ; in  Med.  Chir.  Trans,  vol.  15. 

[Delpech  has  published,  in  the  second  volume  of  his 
Chirurgie  Clinique,  numerous  cases  of  what  the  French 
call  cysts  (kystes),  including,  besides  the  ordinary 
encysted  tumours  of  surgical  writers,  hydrocele,  dropsy 
of  the  ovary,  and  certairr  collections  of  fluid,  that  would 
rather  be  classed  by  us  with  chronic  or  scrofulous 
abscesses.  His  first  case,  which  consisted  of  a very 
large  collection  of  imperfect  nratter  and  serous  fluid, 
in  the  neck  of  a female,  was  one  of  this  latter  descrip- 
tion, though,  on  account  of  the  matter  being  contained 
in  a pouch,  the  disease  nright  certainly  be  called  a cyst, 
or  an  encysted  swelling.  His  treatment  of  this  first 
form  of  cysts,  the  »ero-mucous,  as  he  names  them, 
consists  in  opening  them,  discharging  their  contents, 
and  then  producing  inflammation  and  suppuration  of 
their  whole  extent  by  filling  them  with  charpie,  and 
persisting  in  this  method  until  their  cavities  are  obli- 
terated. An  enormous  encysted  tumour,  which  had 
been  increasitig  in  the  orbit  for  twenty-one  years,  attend- 
ed with  displacement  of  the  eye,  immense  enlarge- 
ment of  the  orbit,  and  other  deformity,  was  successfully 
treated  on  the  same  principle.  Also,  in  another  patient, 
a smaller  cyst,  containing  three  ounces  of  yellowish 
limpid  fluid,  and  causing  a protrusion  of  the  eye,  was 
cured  in  a similar  way.  According  to  Delpech,  the 
treatment  ofencysted  swellings  should  depend  upon  the 
diversified  texture  of  their  cysts.  Some  cysts  are  thin 
and  transparent,  often  contain  hairs,  inserted  into  them 


378 


TUMOUR. 


obliquely,  and  hold  a limpid,  slightly  viscid  fluid.  These 
Delpech  calls  serous  or  sero-mucous  cysts;  and  he 
says  that  they  admit  of  cure  by  the  foregoing  plan. 
Another  kind  of  cyst  has  more  consistence,  is  thicker, 
rather  opaque,  and  composed  of  two  layers  ; the  inner 
one  fleecy,  the  outer  partaking  of  the  appearances  of 
horny  tissues.  Hairs  are  frequently  inserted  into  its 
cavity  obliquely,  and  the  matter  which  it  contains  is 
a white  or  yellowish  sort  of  pulp,  compared  to  pap, 
honey,  or  suet.  Hence  the  terms  atheroma,  meliceris, 
and  steatoma.  Such  cysts  Delpech  would  name 
horny.  A third  class  of  cysts  presents  a lamellated 
structure,  or  a series  of  strata,  with  a cavity  of  mode- 
rate size.  The  external  strata  have  a flbrous  appear- 
ance ; the  middle  and  internal  have  less  and  less  con- 
sistence, and  exhibit  the  characters  of  albumen,  or 
what  is  called  coagulable  lymph,  or  pseudo-niem- 
branes.  To  Delpech  it  is  clear,  that  the  whole  is  de- 
rived from  the  same  origin,  and  that  this  substance,  as 
seen  in  the  different  strata,  has  various  degrees  of  or- 
ganization. Such  cysts  he  calls  albuminous ; they  ge- 
nerally contain  a moderate  quantity  of  gelatinous  matter. 
Other  cysts  exhibit  an  assemblage  of  cellular  and 
fibrous  tissues;  they  are  disposed  to  acquire  much 
greater  dimensions  than  the  rest,  and  their  contents  are 
subject  to  greater  variety.  For  the  most  part,  how- 
ever, the  fluid  in  them  is  a mixture  of  serum  and  albu- 
men; sometimes  it  is  brownish,  and  more  or  less 
viscid;  and,  in  a few  rare  instances,  it  is  gelatinous, or 
composed  of  albumen  nearly  pure,  either  liquid  or  con- 
crete. Frequently,  in  the  substance  of  their  parietes, 
layers  of  osseous  matter  are  noticed,  and  sometimes 
calcareous  deposites  in  their  cavity.  Delpech  calls  these 
cysts  fibrous.  They  are  mostly  developed  in  the  ova- 
ries, where  they  frequently  grow  to  such  a size,  that 
they  fill  the  whole  of  the  abdomen,  and,  according  to 
his  statement,  are  occasionally  combined  with  carci- 
nomatous disease. 

The  horny  cysts  do  not  admit,  as  the  sero-mucous 
ones  do,  of  having  their  cavity  gradually  obliterated  by 
the  effect  of  inflammation.  When  treated  on  this  prin- 
ciple, they  sometimes  assume  the  appearances  of  can- 
cer. Such  appearances  Delpech  has  found  to  be  con- 
stantly rendered  worse  by  the  cautery  ; but,  if  extir- 
pated or  amputated,  he  never  knew  the  disease  to  be 
followed,  either  directly  or  remotely,  by  any  carcino- 
matous mischief  in  other  parts.  This  seems  to  the 
learned  professor  a satisfactory  proof,  that  the  fungous 
painful  disease,  into  which  a cyst,  when  improperly 
irritated,  is  sometimes  converted,  is  not  true  carcinoma ; 
a point  which,  I believe,  has  long  been  admitted  by 
every  Judicious  surgeon  in  this  country.  In  operating 
upon  horny  cysts,  I observe  that  Delpech,  like  Sir 
Astley  Cooper,  lays  them  open,  squeezes  out  their  con- 
tents, and  then  takes  hold  of  their  inside  with  a pair  of 
forceps,  and  extracts  them  ; their  loose  connexion  with 
the  surrounding  cellular  substance  rendering  this  pro- 
cess easy.  As  Delpech  had  only  had  opportunities  of 
seeing  albuminous  cysts  in  the  practice  of  others,  who 
adopted  the  plan  of  extirpating  them,  he  refrains  from 
entering  into  the  consideration  of  their  treatment. 
However,  of  ovarial  cysts,  which  are  most  commonly, 
but  not  always,  of  the  kind  he  calls  fibrous,  he  offers 
many  cases  accompanied  by  observations.  In  one  of 
his  dissections,  a sero-mucous  and  a horny  cyst  were 
both  found  connected  with  the  ovary  : a case  which 
he  deems  exceedingly  rare.  He  affirms,  that  the  cure 
of  an  ovarial  cyst  has  never  been  observed,  whether  as 
the  work  of  nature  or  art ; and  nothing  can  be  cited, 
that  would  justify  any  comparison  with  the  spontane- 
ous or  artificial  terminations  of  the  sero-mucous  and 
horny  cysts.  From  the  cases  and  dissections  of  ovarial 
cysts  which  he  records,  he  deduces,  among  other 
inferences,  the  following;  1.  They  are  the  product  of 
a particular  and  accidental  organization,  and  by  no 
means  of  the  gradual  dilatation  of  the  natural  vesicles  of 
the  ovary.  2.  Observation  has  not  yet  sufficiently 
proved,  whether,  under  favourable  circumstances,  this 
or  any  other  kind  of  cyst  of  the  ovary  is  ever  formed 
alone,  unaccompanied  by  any  other  change  of  this 
organ.  3.  Most  frequently,  cancer  is  at  the  same  time 
developed,  ma.sses  of  this  nature  existing  either  upon 
or  between  the  layers  of  the  cyst.  Here  I must  observe, 
that  the  sarcomatous  substances  so  commonly  attend- 
ing ovarial  cysts  are  not  usually  regarded  by  British 
Burgeons  as  truly  carcinomatous ; nor  can  I discover, 
that  Delpech  brings  any  proof  of  the  correctness  of  this 


part  of  his  observations.  The  question  is  also  a mate* 
rial  one,  inasmuch  as  it  has  great  influence  on  the  prac- 
tical point,  whether  paracentesis  and  other  active  mea- 
sures should  be  undertaken  or  not  1 4.  The  statement, 
that  there  are  always  several  cysts,  does  not  agree  with 
Dr.  Baillie’s  account  of  the  whole  ovary  being  some- 
times converted  into  a capsule.— ( Works,  by  Wardrop, 
vol.  2,  p.  315.)  In  their  structure  they  are  alike, 
though  their  parietes  may  differ  in  thickness ; but  the 
nature  of  the  matter  which  one  cyst  contains  may  be 
very  different  from  what  is  included  in  another,  inde- 
pendently of  the  effectof  any  incidental  inflammation. 
This  remark  coincides  with  what  Dr.  Baillie  has  said 
on  the  same  point.  5.  Only  one  cyst  attains  a vast 
magnitude,  so  as  to  fill  the  cavity  of  the  abdomen ; and 
though  the  others  increase,  they  do  not  exceed  a mid- 
dling size.  6.  The  parietes  of  the  cysts  do  not  become 
thin  in  proportion  to  their  distention ; but,  on  the  con- 
trary, grow  thicker.  7.  The  cysts  communicate  with 
one  another  only  accidentally.  This  disposition  is 
sometimes  remarked  after  paracentesis,  or  some  other 
surgical  proceeding  calculated  to  produce  an  inflamma' 
tion  of  some  duration  in  the  morbid  mass ; but  Del- 
pech thinks  that  we  have  no  ground  for  presuming 
that  it  ever  happens  spontaneously,  and  from  the  mere 
effect  of  distention  or  ulceration  ; an  opinion  which,  I 
conceive,  requires  farther  confirmation.  8.  For  the 
most  part,  the  origin  of  the  disease  is  quite  clandestine ; 
the  swelling  being  the  only  thing  at  first  taken  notice 
of.  If  pains  are  sometimes  experienced  in  the  situa- 
tion of  the  ovary,  or  in  that  of  the  uterus,  it  is  not  till 
the  tumour  has  made  a considerable  progress  and  has 
been  of  long  standing.  Such  pains  are  always  exceed- 
ingly vague,  and  only  manifested  by  some  sympathetic 
ailment ; and  it  may  be  doubted  whether  they  may  not 
rather  depend  upon  distention  than  organic  disease. 
At  all  events,  nothing  justifies  the  suspicion  of  their 
dependence  upon  inflammation.  9.  Inflammation 
sometinjes  originates  spontaneously  in  an  ovary  con- 
taining cysts ; but  more  frequently,  its  cause  is  active 
injudicious  treatment.  Hence  arise  particular  symp- 
toms, readily  distinguished  from  such  as  belong  to  the 
organic  disease.  Dissections  evince  that  the  inflam- 
mation leads  to  adeposite  of  different  quantities  of  con- 
crete albuminous  matter  or  pus  in  only  some  of  the 
cysts.  And  Delpech  believes  that  the  inflammatory 
process  does  not  readily  establish  itself;  nor  easily 
spread  to  the  whole  mass  of  an  ovaiy  in  this  state. 
10.  An  ovarial  cyst  may  enlarge  in  such  a degree  that 
the  whole  abdomen  is  filled  by  it.  When  the  surround- 
ing peritoneum  inflames,  the  cyst  may  become  adhe- 
rent to  all  the  viscera  and  to  the  parietes  of  the  belly. 
Under  these  circumstances,  its  strength  is  augmented 
by  the  support  of  all  the  circumjacent  parts ; and  if 
inflammation  be  kept  off,  and  the  accompanying  scir- 
rhous substances  should  not  increase,  the  disease  may 
remain  stationary  for  many  years.  11.  The  cyst  may 
burst  and  some  of  its  contents  pass  into  the  peritoneum, 
where  a dangerous  inflammation  may  be  the  conse- 
quence. Several  examples  of  this  occurrence  are 
recorded  by  Delpech.  12.  The  accident  can  hardly  be 
recognised  with  certainty  by  the  symptoms ; but  it  is 
to  be  apprehended,  when  the  tumour  augments  rapidly, 
attended  with  acute  fixed  pain.  13.  Here  the  proper 
treatment  will  depend  upon  the  consequences  of  the 
rupture.  When  absorption  of  the  extravasated  fluid 
ensues,  the  surgeon  will  be  prudent  not  to  interfere 
much ; but  if  this  desirable  event  should  not  take 
place,  Delpech  recommends  paracentesis  to  be  per- 
formed on  the  opposite  side.  14.  As  no  treatment  is 
known  that  will  cure  the  organic  disease  of  the  ovary, 
and  active  medicines  create  serious  irritation  in  the 
abdominal  viscera,  which  Delpech  describes  as  pecu- 
liarly irritable  in  this  disorder,  he  lays  it  down  as  a 
fundamental  rule  in  practice,  that  they  ought  not  to  be 
employed.  15.  As  puncturing  the  tumour  when  a 
fluctuation  is  evident  creates  a risk  of  bringing  on  peri- 
tonitis, or  such  hemorrhage  as  cannot  be  commanded, 
the  operation  should  never  be  done  for  the  first  time, 
unless  the  cyst  be  about  to  give  way.  Delpech  advises 
the  puncture  to  be  generally  made  at  the  side  of  the 
hy  pogastrium,  corresponding  to  the  diseased  ovary.  If, 
however,  the  fluctuation  should  be  plain  at  the  bottom 
of  the  vagina,  and  the  tumour  should  not  quit  this  place 
in  the  dift'erent  altitudes  of  the  patient,  he  considerB 
that  this  is  the  most  advantageous  situation  fur  the 
puncture.  If  the  cyst  should  form  a projection  at  the 


TUMOUR. 


379 


n«vel  as  sometimes  happens,  this  part  should  be  se- 
lected. 16.  A puncture  may  be  undertaken  with  more 
confidence,  when  one  has  been  previously  made  with- 
out ill  consequences^  provided  care  be  taken  to  make 
the  opening  precisely  in  the  situation  of  the  former. 
17.  In  these  last  cases,  if  the  patient’s  strength  be  not 
too  much  reduced,  Delpech  sanctions  the  attempt  to 
establish  an  artificial  fistula  by  leaving  in  the  puncture 
an  elastic  gum  catheter ; but  if  inflammation  come  on, 
the  scheme  is  to  be  renounced.  18.  Le  Dran’s  opera- 
tion of  making  a free  incision  into  the  cyst  (See  Para- 
centesis) is  condemned,  as  likely  to  excite  peritonitis?, 
and  aggravate  what  Delpech  calls  (as  I think  without 
foundation)  the  cancerous  masses  around  the  cyst. 
These  consequences  he  thinks  the  more  likely  to  fol- 
low, as  experience  proves,  that  such  treatment  produces 
an  extensive  mortification  of  the  cyst.  19.  An 
inflammaiion  of  the  large  cavity  of  the  cyst,  he  con- 
ceives, is  sometimes  the  cause  of  death,  even  without 
peritonitis.  20.  Every  thing  that  is  known  respecting 
ovarial  cysts,  proves  to  Delpech,  that  they  are  incapa- 
ble of  undergoing  the  kind  of  diminution  which  takes 
place  in  the  sero  mucous  ones  ; that  when  punctured 
and  kept  open,  whether  they  inflame  or  not,  they  sub- 
side, and  are  thrown  into  folds,  but  still  retain  their 
cavity,  and  the  property  of  secreting  the  same  fluid  as 
heretofore;  that  when  the  puncture  closes,  the  cyst 
fills  and  expands  again,  sometimes  with  an  unusual  de- 
gree of  pain  in  consequence  of  the  adhesions  formed  in 
its  empty  state  ; that  the  punctured  part  then  generally 
re-opens  spontaneously  ; that  the  inflammation  caused 
by  opening  the  cyst  with  a bistoury  is  not  more  effect- 
ual in  bringing  on  adhesive  inflammation,  than 
what  follows  either  a simple  puncture,  or  this  plan  suc- 
ceeded by  that  of  keeping  up  a fistulous  aperture  ; that 
the  practice  of  an  incision,  and  its  consequent  perils, 
have  most  frequently  only  terminated  in  the  formation 
of  such  an  opening ; that,  in  a few  rare  examples,  in 
which  the  operation  produced  a complete  obliteration 
of  the  cavity,  the  whole  cyst  was  destroyed  by  gan- 
grene. 21.  The  project  of  treating  an  ovarial  cyst 
like  a hydrocele  is  strongly  disapproved  of  by  Delpech, 
with  whose  opinion  the  observation  of  some  attempts 
of  this  kind  leads  me  fully  to  coincide. — (See  Paracen- 
tesis.) 

It  appears  to  me,  that  notwithstanding  the  possi- 
bility of  the  accident,  Delpech  overrates  the  danger  of 
internal  hemorrhage  from  puncturing  an  ovarial  cyst; 
and  that  he  ought  to  have  admitted  the  severe  indis- 
position, the  oppression  of  breathing,  the  retention  of 
urine,  and  other  urgent  symptoms,  often  produced  by 
the  great  pressure  of  the  swelling,  as  circumstances 
reridering  the  operation  indispensable  for  the  present 
relief  of  the  patient.  The  reader  may  usefully  com- 
pare what  has  been  here  said  with  that  part  of  the 
article  Paracentesis  which  treats  of  ovarial  dropsy. — 
Pref.] 

[An  Account  of  some  of  the  most  important  Dis- 
eases peculiar  to  Women,  8uo.  Lond.  1829.  By  Robert 
Oooch,  j¥.  D.  In  the  fourth  chapter  of  this  valuable 
and  practical  work,  the  reader  will  find  many  inte- 
resting remarks  on  polypi  of  the  uterus.  The  disease, 
he  observes,  is  commonly  mistaken  for  a long  time  for 
profuse  menstruation  ; the  patient,  instead  of  menstru- 
ating regularly  and  moderately,  has  frequent  and  pro- 
fuse hemorrhages  from  the  uterus,  and  in  the  intervals 
a pale  discharge.  These  gradually  drain  her  circula- 
tion and  injure  her  health,  until  she  acquires  the  deadly 
paleness,  and  suffers  the  complaints,  which  are  the 
ordinary  effects  of  deficiency  of  blood.  The  absence 
of  pain  from  the  utenis  or  pelvis  (for  there  is  often 
none,  and  never  that  degree  which  attends  the  malig- 
nant diseases  of  this  organ)  prevents  all  suspicion 
that  the  hemorrhages  depend  on  a disease  of  structure. 
Tonics  and  astringents  are  given  in  various  forms;  one 
practitioner  is  consulted  after  another;  till,  at  length, 
the  uterus  is  examined,  and  a polypus  is  discovered. 
In  ascertaining  the  nature  of  the  tumour,  for  the  pur- 
pose of  determining  the  propriety  of  removing  it  by 
an  operation.  Dr.  Gooch  considers  the  mode  of  its  at- 
tachment as  one  of  the  chief  guides;  and,  in  this 
respect,  what  is  true  of  polypus  of  the  fundus  is  not  so 
of  polypus  of  the  neck  and  orifice.  In  polypus  of  the 
fundus,  the  stalk  is  completely  encircled  by  the  neck 
of  the  uterus,  and  if  the  finger  can  be  introduced  into 
the  orifice,  it  passes  easily  round  between  the  stalk 
and  the  encircling  neck.  In  polypus  of  llte  neck,  the 


finger  cannot  be  passed  quite  round  the  stalk : it  may 
be  passed  partly  round  it ; but  it  is  stopped  when  it 
comes  to  that  point  at  which  it  is  attached  to  the  neck. 
In  polypus  of  the  edge  of  the  orifice,,  the  stalk  does 
not  enter  the  orifice,.but  grows  from  the  edge  of  it,  and 
is  not  encircled  by  it.  With  respect  to  the  structure  of 
polypi,  Dr.  Gooch  describes  them,  when  cut  open,  as  pre- 
senting a hard  whitish  substance  intersected  by  mem- 
branous partitions;  but,  he  adds,  that  they  are  some- 
times of  a much  softer  and  looser  consistence,  and  some- 
times have  considerable  cavities  in  them.  I’heir  ex- 
ternal covering  is  the  mucous  membrane  of  the  uterus. 
Tlieir  size  differs  greatly  in  different  cases.  Dr.  Gooch 
has  removed  several  which  were  as  large  as  the  head 
of  a new-born  child.  They  are  commonly  of  a much 
more  moderate  size;  and  he  has  known  several  cases 
in  which  frequent  hemorrhages  were  occasioned  by  a 
polypus  not  larger  than  a filbert,  attached  just  within 
the  cavity  of  the  neck  of  the  uterus. 

According  to  Dr.  Gooch,  a polypus  of  the  fundus 
uteri  sometimes  passes  through  the  orifice  of  the  womb 
gradually  and  insensibly;  sometimes  suddenly,  during 
the  action  of  the  bowels.  He  has  known  several  in- 
stances, in  which  patients,  after  this  action,  were  sud- 
denly seized  with  retention  of  urine,  and,  on  examina- 
tion, a polypus  was  found  in  the  vagina,  compressing 
the  urethra. 

Another  valuable  observation  made  by  Dr.  Gooch 
is,  that  the  bleeding  comes  from  the  tumour  and  not 
from  the  uterus  itself;  for  “ as  soon  as  a ligature  is 
applied,  and  tightened  round  the  stalk,  the  hemorrhage 
from  that  time  ceases,  although  it  may  be  several  days 
before  the  tumour  comes  away.”  He  notices  the 
opinion  of  M.  Levret,  that  a polypus  does  not  bleed 
while  it  remains  within  the  uterus;  but  that  after  its 
expulsion  into  the  vagina,  the  orifice  of  the  uterus,  by 
compressing  its  stalk,  impedes  the  return  of  blood  in 
its  veins,  which  consequently  burst  and  bleed  pro- 
fusely. The  incorrectness  of  the  first  part  of  this 
statement  he  convincingly  proves. 

The  tumours  which  are  likely  to  be  mistaken  for  po- 
lypi, are,  1st,  the  prolapsed  uterus ; 2dly,  the  inverted 
uterus ; 3dly,  malignant  excrescences  from  the  uterus. 
In  a prolapsus,  besides  the  distinctions  usually  noticed, 
Dr.  Gooch  adverts  to  the  sensibility  of  the  tumour  as  a 
criterion ; a polypus  being  insensible,  so  that  if  pricked 
or  scratched  the  patient  does  not  feel  it.  With  regard 
to  inversion,  when  this  is  only  partial,  that  is  when 
only  the  fundus  descends  through  the  os  tincae  into  the 
vagina,  and  the  patient  has  survived  for  many  months, 
the  tumour  feels  exactly  like  a polypus  of  the  fundus. 
Here  the  distinguishing  circumstances  are  its  sensi- 
bility, and  the  time  of  its  first  appearance,  which  must 
have  been  immediately  after  delivery. 

When  there  is  doubt,  whether  the  case  is  a polypus 
or  a malignant  excrescence,  Dr.  Gooch  recommends 
the  application  of  a ligature,  if  the  swelling  has  a 
stalk  which  can  be  tied  without  any  danger  of  includ- 
ing the  neck  or  fundus  of  the  uterus.  According  to 
his  experience,  the  plan  succeeds  in  an  immense  pro- 
portion of  cases;  and  he  has  known  it  succeed  in  se- 
veral, attended  with  a cauliflower  roughness  of  the 
tumour.  Even  if  the  excrescence  should  return,  the 
patient,  he  says,  would  not  be  worse  ofF  than  she  was 
previously. 

This  excellent  physician  strongly  enjoins  the  con- 
stant observance  of  the  practical  rule  commended  by 
all  men  of  good  judgment  and  experience;  namely, 
that  whenever  hemorrhages  from  the  uterus  resist  the 
ordinary  means,  the  nature  of  the  case  should  be  cer- 
tified by  manual  examination. 

For  the  extir[)ation  of  polypi.  Dr.  Gooch  prefers  two 
tubes,  resembling  those  described  and  engraved  in 
Richter’s  Elements  of  Surgery,  and  my  First  Lines  of 
the  Practice  of  Surgery;  but  they  are  straight  instead 
of  being  curved,  which  last  shape  he  finds  very  incon- 
venient. The  danger  of  including  the  uterus  in  the 
ligature,  he  thinks,  may  always  be  avoided  by  the  fol- 
lowing rules.  1.  Itistead  of  aiming  at  passing  the  liga- 
ture as  high  as  po.ssible  on  the  stalk,  it  is  to  be  passed 
as  low  as  possible,  care  being  taken,  however,  to  pass 
it  over  the  body  of  the  tumour.  He  knows  by  expe- 
rience, that  the  portion  of  stalk  left  above  the  ligature 
will  not  grow  again,  but,  like  the  remnant  of  umbilical 
cord,  dies  and  falls  away.  2.  When  the  stalk  grows 
from  the  cervix,  the  os  uteri,  if  it  can  he  felt,  will  best 
denote  where  the  neck  ends  and  the  stalk  begins.  The 


380 


ULC 


ULC 


ligature  ought  to  be  applied  a little  below  the  orifice ; 
but  if  this  cannot  be  felt,  the  next  best  guide  is  the  or- 
dinary length  of  the  projecting  part  of  the  neck,  that 
is,  about  two- thirds  of  an  inch.  When  the  polypus  is 
very  large,  and  the  vagina  closely  contracted,  it  is  dif- 
ficult, or  impossible,  to  reach  the  stalk  and  the  cervix 
60  as  to  make  an  accurate  measurement,  and  the  first 
rule  only  is  practicable.  3.  To  attend  to  the  sensations 
of  the.  patient  when  the  ligature  is  tightened;  for  if  it 
give  much  pain,  a part  of  the  uterus  is  most  probably 
included. 

When  a polypus  grows  from  the  neck  or  lip  of  the 
uterus,  it  sometimes  occasions  merely  an  obstinate  and 
profuse  leucorrhoea.  A case  is  related  by  Dr.  Gooch 
exemplifying  this  fact,  and  the  great  liability  of  dis- 
eases of  the  uterus  to  be  mistaken,  unless  a manual 
examination  be  instituted. 

Women  who  have  a polypus,  especially  one  growing 
from  the  neck  or  lip  of  the  uterus,  sometimes  become 


pregnant.  Of  this  Dr.  Gooch  has  known  two  in- 
stances. In  one,  the  tumour  was  discovered  in  the 
fifth  month  of  pregnancy,  and  was  removed  by  liga- 
ture. The  pregnancy  went  on  to  the  ninth  month, 
when  the  patient  was  safely  delivered.  In  the  other  case 
it  was  not  discovered  till  the  commencement  of  labour, 
and  it  occasioned  death  a few  hours  after  delivery. 

After  relating  many  important  cases,  and  adding 
some  valuable  reflections  on  the  excrescences  likely  to 
be  mistaken  for  polypi.  Dr.  Gooch  concludes  with  this 
remark,  well  deserving  of  recollection,  namely,  that 
“ where  we  see  one  case  of  cauliflower  excrescence, 
we  see  ten  or  even  twenty  of  common  polypus,  and 
fifty  of  carcinoma  or  malignant  ulcer  of  the  uterus.” 
Every  medical  man  should  study  Dr.  Gooch’s  work 
most  attentively,  for  it  abounds  in  sterling  practical 
information. — Pref.] 

TYMPANUM.  For  an  account  of  its  diseases,  see 
Ear. 


u 


TTLCERATION  is  the  process  by  which  sores  or 
ulcers  are  produced  in  animal  bodies.  In  this 
operation,  the  lymphatics  appear  to  be  at  least  as  ac- 
tive as  the  blood-vessels.  An  ulcer  is  a chasm,  formed 
on  the  surface  of  the  body  by  the  removal  of  parts  back 
into  the  system  by  the  action  of  the  absorbents.  At 
first,  it  may  be  difficult  to  conceive  how  a part  of  the 
body  can  be  removed  by  itself;  but  there  is  not  more 
difficulty  in  conceiving  this,  than  how  the  body  can 
form  itself.  Both  facts  are  equally  well  confirmed. 
When  it  becomes  necessary  that  some  whole  living 
parts  should  be  removed,  it  is  evident,  says  Mr.  Hunter, 
that  nature,  in  order  to  effect  this  object,  must  not  only 
tonfer  a new  activity  on  the  absorbents,  but  must  throw 
the  part  to  be  absorbed  into  a state  which  yields  to  this 
operation.  The  absorption  of  whole  parts  in  disease 
arises  from  five  causes:  pressure;  irritation  of  stimu- 
lating substances;  weakness;  inutility  of  parts;  death 
of  them. — {Hunter  on  Infiarumation,  £rc,  p.  44^ — 446.) 

Ulceration  takes  place  much  more  readily  in  the  cel- 
lular and  adipose  substance,  than  in  muscles,  tendons, 
ligaments,  nerves,  and  blood-vessels.  Hence,  in  the 
progress  of  pus  to  the  surface  of  the  body,  ulceration 
often  takes  a circuitous  course  for  the  purpose  of  bring- 
ing the  matter  to  the  skin.  The  skin  itself,  also,  being 
highly  orgatiized,  considerably  retards  the  bursting  of 
abscesses.  On  the  same  account,  when  ulceration  is 
spreading,  the  edges  of  the  skin  hang  over  the  ulcerated 
surface. — {Hunter,  p.  447 — 449.)  Parts  at  a consider- 
able distance  from  the  source  of  the  circulation  are  ge- 
nerally more  disposed  to  ulcerate,  than  others  situated 
nearer  to  the  heart:  hence,  one  reason  of  the  greater 
number  of  ulcers  on  the  lower  extremities,  than  on  the 
arms. 

New-formed  parts,  such  as  cicatrices,  callus,  and  all 
adventitious  new  matter,  like  tumours,  readily  admit 
of  being  absorbed.  Thus,  in  Lord  Anson’s  voyage, 
when  the  crew  of  the  ship  began  to  sufier  from  great 
privations,  fatigue,  the  scurvy,  &c.,  it  was  remarked, 
that  such  men  as  had  had  ulcers  and  broken  bones  for- 
merly, became  again  disabled  by  their  old  sores  breaking 
out  afresh,  and  the  callus  of  their  old  fractures  being  re- 
moved. The  adventitious  matter  is  even  more  prone 
to  be  absorbed  than  that  which  is  a substitute  for  the 
old.  Mr.  Hunter  explained  this  circumstance  on  the 
principle  of  weakness. 

When  ulceration  takes  place  in  consequence  of  the 
death  of  an  external  part,  it  occurs  first  on  the  outer 
edge,  between  the  dead  and  living  substance. 

A tumour,  when  it  makes  equal  pressure  in  every 
direction  around,  will  only  make  its  way  in  an  exter- 
nal course,  because  what  Mr.  Hunter  termed  interstitial 
absorption  happens  in  no  other  direction. — {P.  449.) 

The  parts  situated  between  an  abscess,  or  any  extra- 
neous substance,  and  the  nearest  surface,  are  those 
which  are  most  susceptible  of  ulceration.  This  is  one 
of  the  most  curious  phenoniena  connected  with  the  pro- 
cess under  consideration.  It  shows  that  there  is  a prin- 
ciple in  the  human  body  by  which  parts  are  always 
prone  to  free  themselves  from  disease.  Slight  pressure 


from  without  will  often  produce  a thickening  of  parts, 
and  hence,  Mr.  Hunter  remarks,  there  even  appears  to 
be  a corresponding  backwardness  to  admit  disease. — 
{P.  449.)  Both  these  facts,  he  observes,  are  shown  in 
the  case  of  fistula  lachrymalis;  for,  though  the  matter 
is  nearest  the  cavity  of  the  nose,  still  it  makes  its 
way  externally,  by  means  of  ulceration,  while  the 
Schneiderian  membrane  even  becomes  thickened,  so  as 
to  become  a barrier  against  the  progress  of  the  disease 
inward.— (P.  451.) 

Not  unfrequently,  as  Sir  A.  Cooper  has  remarked, 
matter  forms  behind  the  sternum,  close  to  the  pleura 
and  pericardium,  which  membranes  are  extremely 
thin.  From  the  proximity  of  these  membranes,  it  might 
be  expected,  that  the  matter  would  generally  open  into 
the  pleura,  and,  by  discharging  itself  into  the  cavity  of 
the  chest,  destroy  life.  Instead  of  this  result,  however, 
the  pleura  undergoes  no  other  alteration  than  that  of 
becoming  thickened ; and  while  it  is  acquiring  this  ad- 
dition of  substance,  the  process  of  absorption  is  going 
on  in  the  inner  part  of  the  sternum,  an  aperture  is 
formed  through  it,  and  the  matter  is  voided  externally. 
The  same  fact  is  exemplified  in  abscesses  between 
the  peritoneum  and  abdominal  muscles.  Abscesses 
of  the  liver,  however,  generally  burst  into  the  sto- 
mach or  bowels,  which  are  nearer  to  them  than  the 
skin,  and  afford  also  a passage  for  their  evacuation. — 
{Lectures,  vol.  1,  p.  132.) 

There  is  one  difference  between  the  advancement  of 
an  encysted  tumour  to  the  surface  of  the  body,  and  the 
progress  of  an  abscess  in  the  same  direction,  viz.  that 
the  former  does  not  excite  ulceration  of  the  cyst,  but  an 
interstitial  absorption  of  the  sound  parts,  between  the 
cyst  and  skin,  till  the  cyst  and  external  skin  come  into 
contact,  at  which  period  inflammation  takes  place,  and 
absorption  becomes  accelerated  into  ulceration.  In 
an  abscess,  the  progressive  ulceration  begins  in  the  cyst, 
at  the  same  time  that  the  interstitial  absorption  in  the 
sound  part  covering  the  matter  is  going  on. — {P.  452 — 
457.) 

The  action  of  progressive  absorption  is  to  remove 
surfaces  contiguous  to  irritating  causes,  which  Mr, 
Hunter  referred  to  pressure,  irritation,  and  weakness. 
In  cases  of  tumours,  pressure  becomes  a cause.  The 
buttocks  and  hips  of  persons  who  lie  long  on  their  backs 
often  ulcerate.  The  heels  of  many  patients  with  frac- 
tures, w ho  lie  for  agreat while  in  the  same  position,  are 
apt  to  ulcerate.  In  the  latter  instances,  Mr.  Hunter  con- 
ceived, that  ulceration  is  a substitute  for  mortification, 
and  is,  at  the  same  time,  a proof  of  a certain  degree  of 
strength;  for,  if  the  patient’s  constitution  were  very 
weak,  the  same  parts  w'ould  mortify. — {P.  453.)  That 
pressure  is  a frequent  cause  of  ulceration,  is  also 
evinced  by  the  occasional  effects  of  chains  on  prison- 
ers, and  harness  on  horses. 

That  irritating  substances  produce  ulceration,  needs 
no  illustration. 

Progressive  absorption  may  occur  either  with  or 
without  suppuration.  VVe  have  instances  of  the  lat- 
ter in  cases  of  extraneous  bodies,  which  travel  about 


ULC 


ULC 


381 


the  body,  without  producing  irritation  enough  to  give 
rise  to  the  secretion  of  pus.  In  the  progress  of  aneu- 
risms of  the  aorta,  and  of  fungous  tumours  of  the  dura 
mater  to  the  surface,  the  same  fact  is  also  illustrated. 
—{P.  455.) 

Absorption  with  suppuration,  in  other  words,  ulcer- 
ation, either  happens  in  consequence  of  suppuration 
already  begun,  in  which  event  the  pus  acts  as  pressure ; 
or  else  absorption  attacks  external  surfaces  from  parti- 
cular irritations,  or  weakness,  in  which  case  suppura- 
tion must  follow. — (P.  456.) 

The  production  of  ulceration  requires  much  greater 
pressure  from  without  than  from  within.  The  process 
is  always  disposed  to  take  place  more  quickly  when 
near  the  surface  of  the  body ; and  its  progress  becomes 
accelerated  in  proportion  as  it  arrives  near  the  skin. 

The  adhesive  inflammation  precedes  the  suppurative, 
and  prevents  the  pus  from  becoming  diffused  as  soon  as 
it  is  secreted  ; and  when  the  cyst  afterward  ulcerates, 
in  order  to  let  the  matter  approach  the  skin,  the  adhe- 
Hve  inflammation  still  continues  to  go  before  the  ulcer- 
ative process,  and  thus  prevents  the  matter  from  insinu- 
ating itself  into  the  interstices  of  the  cellular  substance. 
— (P.  457.) 

I’he  pain  of  ulceration  is,  in  some  degree,  propor- 
tioned to  its  quickness.  When  ulceration  begins  on  a 
surface,  or  takes  place  for  the  purpose  of  bringing  mat- 
ter to  the  skin,  the  pain  is  always  considerable.  When 
ulceration  takes  place,  in  order  to  separate  a dead  part, 
as  in  sloughing,  exfoliations,  &c.,  there  is  seldom  any 
particular  pain. — (P.  459.) 

The  ulcerating  sore  always  exhibits  little  cavities, 
while  the  edge  of  the  skin  is  scalloped,  and  thin,  at  the 
same  time  turning  a little  out,  and  overhanging,  more 
or  less,  the  ulcerated  surface.  The  face  of  the  sore  ap- 
pears foul,  and  the  discharge  is  very  thin. 

When  ulceration  stops,  the  edges  of  the  skin  become 
regular,  smooth,  a little  rounded,  or  turned  in,  and  of  a 
purple  colour,  covered  with  a semi-transparent  white. 
— {Hunter  on  Inflammation^  ire.  p.  460.) 

The  reader,  desirous  of  farther  information,  should 
particularly  consult  this  last  publication,  and  Thomaon 
on  Inflammation.,  p ■ 349,  ire. 

ULCERS.  Surgeons  usually  define  an  ulcer  to  be 
a solution  of  continuity  in  any  of  the  soft  parts  of 
the  body,  attended  with  a secretion  of  pus,  or  some 
kind  of  discharge.  “A  granulating  surface,  secreting 
matter,”  has  been  proposed  as  a definition  {A.  Cooper, 
Lectures,  Sre.p.  182),  which  is  very  applicable  when 
ulcers  have  formed  gr,anulations,  but  cannot  include 
case,  in  which  the  effects  of  ulceration  are  extending, 
and  the  granulating  process  has  not  yet  commenced. 

In  the  present  part  of  this  Dictionary,  there  will  not 
be  occasion  to  speak  of  several  kinds  of  sores,  which 
have  been  treated  of  in  other  articles. — (See  Cancer, 
Cancrum  Oris,  Chilblain,  Fistula,  Hospital  Gan- 
grene, Lupus,  Ozeena,  Scrofula,  Sinus,  and  Venereal 
Disease.) 

Ulcers  are  divided  into  local  and  constitutional.  As 
Professor  Thomson  has  well  observed,  however,  it  is 
only  within  certain  limits  that  this  distinction  is  well 
founded ; for  an  ulcer,  which  is  at  first  completely 
local,  may  in  time  affect  the  system  so  as  to  become 
constitutional;  and  ulcers,  which  derive  their  origin 
from  some  general  affection  of  the  system,  may  remain 
after  the  removal  of  the  constitutional  disorder  by 
which  they  were  originally  produced. — {Lectures  on 
Inflammation,  p.  427.) 

“ Ulcers  (says  Dr.  Thomson)  have  usually  been  dis- 
tinguished from  each  other  by  the  causes  by  which 
they  are  induced,  by  the  symptoms  which  they  exhibit, 
and  by  the  parts  of  the  body  in  which  they  occur. 
The  want  of  a disposition  to  heal  in  a suppurating 
surface  may  depend  upon  some  specific  action  in  the 
cause  from  which  it  proceeds,  upon  something  peculiar 
in  the  constitution  of  the  patient  in  whom  it  exists,  or 
merely  upon  an  improper  mode  of  management:  and 
hence  the  distinction  that  has  long  been  made  of  ill- 
conditioned  sores  or  ulcers,  into  those  which  are  spe- 
cific in  their  nature,  and  into  those  which  are  simple. 

“ Specific  sores  or  ulcers  may  be  occasioned  by  spe- 
cific poisons,  or  by  particular  diathesis.  The  sores  or 
ulcers,  which  arise  from  specific  poisons,  may  be  either 
local,  that  is,  confined,  like  a primary  syphilitic  ulcer, 
to  one  spot ; or  constitutional,  that  is,  liable  to  occur 
in  any  part,  texture,  or  organ,  such  as  secondary  syphi- 
litic ulcers.  Of  diatheses  predisposing  to  ulcers  we 


have  examples  in  the  scrofulous,  scorbutic,  and  arthri- 
tic diatheses,  and  also  in  the  syphiloid  diathesis,  or  that 
which  arises  not  unfrequently  in  those  who  have  had 
syphilis,  from  the  too  free  and  injudicious  use  of  mer- 
cury. 

“ Every  ulcer,  strictly  speaking,  is  of  a local  nature ; 
but  there  are  ulcers  which,  though  necessarily  local 
in  their  appearance,  are  connected  with,  or  dependent 
upon,  diseases  which  affect  the  general  system.  These 
ulcers  ought  to  be  regarded  as  modifications  of,  or 
forms  in  which  the  diseases  appear,  with  which  they 
are  connected.  Considered  in  this  light,  it  is  obvious 
that  specific  ulcers  can  be  treated  of  with  propriety 
only  under  the  head  of  the  diseases  to  which  they  re- 
spectively belong. 

“We  call  those  ulcers  simple  which  do  not  appear 
to  proceed  from  any  specific  disease  or  morbid  diathesis 
existing  in  the  constitution  of  those  in  whom  they  take 
place.  They  are  usually  solitary  occurrences,  and  the 
consequences  of  accidental  injuries  and  improper 
modes  of  management.  They  may  occur  in  every 
part  of  the  body,  but  they  appear  most  frequently  upon 
the  lower  extremities.” 

Professor  Thomson  afterward  remarks,  that  “the 
appearances  which  different  ulcers  exhibit,  seem,  at 
first  view,  to  afford  an  excellent  foundation  for  distinc- 
tions among  them,  and  so  they  undoubtedly  do  in  many 
respects.” 

“ But  (says  he)  it  is  to  be  regretted,  that  the  charac- 
ters upon  which  the  distinctions  of  ulcers,  as  well  as 
of  many  other  local  diseases,  are  founded,  are  neither 
very  uniform  in  their  appearance,  nor  very  easily  dis- 
tinguishable from  one  another.  Not  only  are  the  local 
appearances  which  present  themselves  in  simple  ulcers 
liable  to  great  variations  in  the  different  stages  of  the 
same  individual  affection,  but  they  are  often  appa- 
rently the  same  with,  or  at  least  not  easily  distinguisha- 
ble from,  those  which  occur  in  specific  diseases,  and 
which  require  for  their  cure  peculiar  modes  of  treat- 
ment. It  is  this  circumstance  which  renders  it  so  ne- 
cessary for  us,  in  endeavouring  to  distinguish  and  to 
cure  ulcers,  to  avail  ourselves  of  all  the  information 
which  we  can  procure  from  the  history  of  the  ulcer, 
from  the  nature  of  the  exciting  cause  by  which  it  has 
been  induced,  and  from  the  effects  of  the  remedies 
which  have  been  employed,  as  well  as  from  the  par- 
ticular appearances  which  the  ulcer  itself  exhibits.” 

In  noticing  another  ground  of  distinction  among 
ulcers,  or  that  derived  from  the  parts  in  which  they 
occur.  Dr.  Thomson  observes,  that  “ every  texture  and 
organ  of  the  body  possesses  physical  and  vital  quali- 
ties peculiar  to  itself;  and  these  qualities  must  neces- 
sarily modify  the  appearances  which  each  texture  and 
organ  respectively  exhibits  in  the  state  of  disease. 
Specific  diseases  render  some  parts  more  liable  than 
others  to  atacks  of  ulceration.  Thus  secondary  sy- 
philis appears  most  frequently  in  the  throat ; scurvy  in 
the  gums;  cancer  in  the  lower  lip;  and  lupous  and 
scrofulous  ulcerations  in  the  upper  lip  or  in  the  nose. 
Cancer  seldom  or  never  appears  primarily  in  the  upper 
lip;  but  syphilis,  when  it  attacks  this  part,  puts  on 
many  of  the  appearances  of  cancer ;”  a fact  which 
Dr.  Thomson  says,  he  first  learned  from  Mr.  Pearson. 
— (On  Inflammation,  p.4i27 — 430.) 

In  the  valuable  treatise  on  ulcers  published  by  Sir 
Everard  Home,  these  complaints  are  divided  into  six 
principal  kinds,  viz.: 

1.  Ulcers  in  parts  which  have  sufficient  strength  to 
carry  on  the  actions  necessary  for  their  recovery. 

2.  Ulcers  in  parts  which  are  too  weak  for  that 
purpose. 

3.  Ulcers  in  parts  whose  actions  are  too  violent  to 
form  healthy  granulations,  whether  this  arise  from  the 
state  of  the  parts  or  of  the  constitution. 

4.  Ulcers  in  parts  whose  actions  are  too  indolent, 

whether  this  arise  from  the  state  of  the  parts  or  of  the 
constitution.  " 

5.  Ulcers  in  parts  which  have  acquired  some  spe- 
cific action,  either  from  a diseased  state  of  the  parts  or 
of  the  constitution. 

6.  Ulcers  in  parts  which  are  preveifted  from  healing 

by  a varicose  state  of  the  superficpal  veins  of  the 
upper  part  of  the  limb.  1 

Although  I have  chosen,  in  the  subsequent  columns, 
to  adopt  this  nomenclature,  I am  perfectly  aware  of 
its  being  on  some  accounts  objectionable,  but  especially 
because  it  assumes  hypotheses,  the  truth  of  which  can 


382 


ULCERS. 


never  be  established  nor  proved.  This  is  one  of  the 
considerations  which  have  induced  Professor  Thomson 
lo  prefer  the  old  names. — ( Op.  cit.  p.  435 — 438.) 


porting  the  muscles  and  skin,  which  are  often  in  a 
flabby  slate  from  the  unexercised  state  of  the  limb, 
and  in  defending  the  newly-formed  parts. 


or  ULCERS  IN  PARTS  WHICH  HAVE  SUFFICIENT 

STRENGTH  TO  CARRV  ON  THE  ACTIONS  NECESSARY 

FOR  THEIR  recovery:  SIMPLE  PURULENT,  OR 

HEALTHY  ULCERS. 

In  this  species  of  ulcer,  the  pus  is  of  a white  colour, 
thick  consistence,  and  readily  separates  from  the  sur- 
face of  the  sore,  and  when  diluted  and  examined  in  a 
microscope,  is  found  to  be  made  up  of  small  globules, 
swimming  in  a transparent  fluid.  The  granulations 
are  small,  florid,  and  pointed  at  the  top.  As  scon  as 
they  have  risen  to  the  level  of  the  surrounding  skin, 
those  next  to  the  old  skin  become  smooth,  and  are  co- 
vered with  a thin,  semi-transparent  film,  which  after- 
ward becomes  opaque  and  forms  cuticle. 

In  the  treatment,  it  is  only  necessary  to  keep  the 
surface  clean,  and  prevent  the  natural  processes  from 
being  interrupted.  Sir  E.  Home  observes,  that  this  is 
in  general  best  done  by  the  application  of  dry  lint,  for 
the  purpose  of  absorbing  and  retaining  the  matter, 
which  serves  as  a soft  covering  for  the  granulations, 
and  by  putting  over  the  lint  a pledget  of  any  simple 
ointment,  in  order  to  hinder  the  matter  from  evapo- 
rating, by  which  means  the  dressings  will  not  become 
adherent,  and  may  be  easily  taken  ofl^  as  often  as 
requisite. 

Although  healthy  ulcers  require  no  medicated  applica- 
tion to  be  made  to  them,  the  dressings  must  be  such  as 
do  not  disagree  with  the  granulations  or  surrounding 
skin. 

In  some  patients,  a roller,  applied  with  moderate 
tightness,  with  a view  of  retaining  the  dressings,  will 
cause  uneasiness,  and  make  the  ulcer  lose  its  healthy 
appearance.  Sir  E.  Home  has  seen  several  cases  of 
this  kind,  in  which  the  proper  appearance  of  the  sore 
returned  as  soon  as  the  bandage  was  discontinued. 

In  some  patients,  ointment  irritates  and  inflames  the 
neighbouring  skin  ; and  certain  superficial  ulcers  will 
not  heal  w'hile  kept  in  a moist  state,  and  unexposed  to 
the  air;  but  heal  when  allowed  lo  become  dry  and  co- 
vered with  a scab. 

These  particularities  are  referred  by  the  preceding 
author  to  constitutional  causes,  and  not  disease ; for  the 
ulcers  heal  as  soon  as  the  particular  things  which  dis- 
agree with  them  are  discontinued.  These  peculiarities 
in  certain  healthy  sores  may  also  attend  others  of  a 
diflTerent  description,  and  should  always  be  discrimi- 
nated from  the  effects  of  disease. 

1.  Applications  in  the  form  of  vapour,  and  fomenta- 
tions, should  never  be  employed,  as  they  render  the 
texture  of  the  granulations  looser,  and  diminish  the 
disposition  lo  form  skin. 

2.  With  respect  to  fluid  applications.  Sir  E.  Home 
also  very  properly  condemns  poultices,  as  well  as  fo- 
mentations. He  speaks  of  alcohol  as  being  an  appli- 
cation which  promotes  the  formation  of  a scab,  when 
this  mode  of  cure  is  chosen. 

3.  In  regard  to  ointments,  their  only  use,  in  cases  of 
healthy  ulcers,  is  to  keep  the  matter  from  evaporating. 
The  most  simple  ointments  are  the  best  for  the  pur- 
pose ; particularly  the  one  comiiosed  of  white  wax  and 
olive  oil. 

Sir  E.  Home  observes,  that  the  great  objections  to  the 
common  simple  ointments  are,  that  they  sometimes  dis- 
agree with  the  skin,  even  when  recent  and  free  from 
all  rancidity.  When  they  have  acquired  the  latter 
quality,  they  still  more  frequently  create  a greater  de- 
gree of  irritation. 

4.  With  respect  to  applications  in  the  form  of  pow- 
der, Sir  E.  Home  remartcs,  that  when  it  is  desirable  to 
form  a scab  on  the  ulcer  any  inert  powder  may  be 
sprinkled  on  the  sore ; but  ht  prefers  dry  lint.  Nothine 
should  touch  the  powder  or  Vnt ; and  to  prevent  this 
circumstance,  Sir  E.  Home  recommends  applying  a 
little  bolster  on  each  side  of  the  sore,  and  over  them  a 
roller,  which  will  go  from  one  boVsier  to  the  other  in 
the  manner  of.  a bridge. 

For  healthy  ulcers,  dry  lint  is  to  be  regarded  as  being 
upon  the  whole  the  most  eligible  application.  When 
the  sore  does  not  secrete  pus  enough  in  twenty-four 
hours  to  moisten  the  lint,  the  dressings  are  to  be 
changed  only  every  other  day. 

When  a moderately  tight  bandage  is  not  forbidden 
by  constitutional  peculiarities,  it  is  useful  both  in  sup- 


ULCERS  IN  PARTS  WHICH  ARE  TOO  WEAK  TO  CARRY 

ON  THE  ACTIONS  NECESSARY  FOR  THEIR  RECOVERY. 

This  is  the  second  of  the  classes  into  which  Sir  Eve- 
rard  Home  has  divided  ulcers  in  general. 

The  granulations  of  these  sores  are  larger,  more 
round  on  their  external  surface,  and  of  a less  compact 
texture,  than  those  formed  on  ulcers  in  healthy  parts. 
Sir  E.  Home  has  also  noticed  their  semi-transparent 
appearance.  When  they  have  filled  up  the  cavity  of 
an  ulcer  to  a level  with  the  surface  of  the  body,  they 
do  not  readily  form  skin,  but,  rising  up  in  a still  higher 
manner,  often  lose  altogether  the  power  of  producing 
new  cutis.  When  the  parts  are  still  weaker,  the  gra- 
nulations sometimes  continue  gradually  to  fill  up  the 
hollow  of  the  ulcer,  and  then,  all  on  a sudden,  are 
suddenly  absorbed,  so  as  to  leave  the  sore  as  deep  as  it 
was  before. 

Ulcers  may  be  weak  from  the  first,  or  become  so  in 
the  progress  of  the  case.  Even  granulations  of  the 
most  healthy  kind,  if  they  are  not  skinned  over  in  a 
certain  time,  gradually  lose  their  primitive  strength. 

Sores  on  the  legs  are  greatly  under  the  influence  of 
all  natural  peculiarities  of  the  constitution,  and  every 
thing  w’hich  affects  the  health.  When  the  constitu- 
tion becomes  in  the  least  weaker  or  stronger,  the  ap- 
pearance of  the  granulations  becomes  changed  accord- 
ingly, and  this  effect  of  constitutional  weakness  or 
strength,  on  ulcers,  is  greater  in  proportion  as  the  sores 
are  farther  from  the  source  of  the  circulation. 

While  the  constitution  is  undergoing  any  kind  of 
disturbance,  the  healing  of  an  ulcer  is  suspended. 
Mental  anxiety  is  very  apt  to  retard  cicatrization. 

Such  effects  of  the  constitutional  kind  on  ulcers  are 
greater  in  weak  and  delicate  persons  than  in  the  strong 
and  robust.  Change  of  weather  has  considerable  in- 
fluence over  the  healing  of  sores.  Sir  E.  Home  men- 
tions, in  proof  of  this  fact,  that  when  there  were  seve- 
ral hiindrpHs  of  ulcers  in  the  Naval  Hospital  at  Ply- 
mouth, in  1778,  every  time  the  weather  changed  from 
a dry  to  a moist  state,  the  ulcers  universally  assumed 
an  unhealthy  appearance;  but  put  on  a better  aspect 
when  the  weather  became  dry  again. 

In  the  treatment  of  this  kind  of  ulcer,  tonics  are  to 
be  exhibited,  particularly  bark  and  steel,  and  every 
thing  which  disagrees  with  the  constitution  is  to  be 
avoided.  Wine  and  cordial  medicines  are  also  usu- 
ally prescribed.  Porter,  however,  is  deemed  better 
than  wine  for  working  people. 

Sir  E.  Home  observes,  that  the  first  object  in  the 
local  part  of  the  treatment,  is  to  keep  the  granulations 
from  rising  above  the  edge  of  the  surrounding  skin. 
This  gentleman  (in  my  opinion)  very  judiciously  re- 
presents the  greater  propriety  of  preventing  the  granu- 
lations from~ever  becoming  too  high  by  the  employ- 
ment of  proper  applications,  than  following  the  com- 
mon plan  of  destroying  the  high  granulations  with  es- 
charotics,  after  they  have  risen  to  an  improper  height. 
There  cannot  be  the  smallest  doubt,  that  if  the  gra- 
nulations could  always  be  prevented  from  rising  up 
too  much,  the  patient  would  suffer  a great  deal  less 
pain. 

Instead  of  applying  to  the  surface  of  the  ulcers  now 
under  consideration  lunar  caustic,  blue  vitriol,  or  red 
precipitate.  Sir  E.  Home  prefers  mixing  these  escha- 
rotics  with  other  substances,  so  as  to  render  them  only 
strong  stimulants,  and  using  them  in  this  latter  form. 
He  conceives  that  when  the  high  granulations  are  de- 
stroyed with  escharotiCB,  the  disposition  of  the  sur- 
face underneath  to  reproduce  them  is  increased,  but 
that  this  is  not  the  case  when  the  luxuriant  parts  are 
only  stimulated  so  as  to  become  absorbed.  He  believes 
that  when  animal  substances  grow  with  great  rapidity, 
they  are,  like  vegetable  ones,  weaker  than  when  pro- 
duced in  a slower  manner.  Hence  he  is  of  opinion, 
that  the  growth  of  granulations  ought  to  be  checked 
in  the  early  stage  of  their  formation,  by  some  resist- 
ance which  they  are  just  able  to  overcome ; under 
which  circumstances  they  derive  strength  from  the  li- 
mited increase  of  action  which  they  are  obliged  to 
undergo. 

On  the  same  principle,  according  lo  Sir  E.  Home, 
the  pressure  of  light  bandages  is  advantageous,  and 
ulcers  which  heal  while  the  patient  is  walking  about, 


ULCERS.  383 


are  not  so  apt  to  break  out  again  as  others  healed  while 
the  parts  are  in  a state  of  perfect  rest. 

In  the  treatment  of  these  ulcers,  when  the  granula- 
tions have  come  to  a proper  height,  and  do  not  form  a 
thin,  semi-transparent  pellicle  upon  their  surface,  they 
are  to  be  considered  as  weak  parts  and  treated  accord- 
ingly. In  this  circumstance,  when  no  particularity  of 
constitution  forbids.  Sir  E.  Home  recommends  pres- 
sure made  with  a thin  piece  of  lead  over  the  dressings, 
and  supported  with  a tight  bandage. 

Among  the  impediments  to  the  healing  process.  Sir 
A.  Cooper  notices  the  languid  state  of  a sore,  denoted 
by  the  glassy,  semi-transparent  appearance  of  the  gra- 
nulations already  described.  The  dressings  enume- 
rated by  him  for  the  improvement  of  an  ulcer  in  this 
condition  are,  the  ung.  hydr.  nitrico-oxydi,  which,  how- 
ever, is  said  to  produce  a thickening  of  the  cuticle  at 
the  edge  of  the  sore,  preventing  the  growth  of  the  gra- 
nulations at  that  part,  and  requiring  the  application  of 
the  ung.  hydr.  fort,  for  its  correction  ; a lotion  of  the 
sulphate  of  zinc,  two  grains  to  one  ounce  of  water ; a 
sokition  of  the  sulphate  of  copper,  one  grain  to  an 
ounce  of  water ; and  a solution  of  one  grain  of  oxy- 
muriate  of  mercury  in  an  ounce  of  lime-water.  A 
roller  is  to  be  applied,  the  diet  is  to  be  nutritious, 
and  the  patient  to  take  exercise.— (Z-ectures,  vol.  1, 

187.) 

OF  APPLICATIONS  TO  ULCERS  ATTENDED  WITH  WEAK- 
NESS. 

Although  Strictly  we  have  no  topical  applications 
which  can  directly  communicate  strength  to  granula- 
tions, there  are  certainly  some  which  prevent  the  gra- 
nulations from  exhausting  themselves  by  luxuriant 
growth,  and  stimulate  them  to  draw  more  blood  from 
the  arteries,  which  effects,  as  Sir  E.  Home  remarks, 
render  such  granulations  stronger. 

1.  This  gentleman  very  properly  condemns  as  appli- 
cations to  weak  ulcers,  all  relaxing  fomentations  com- 
monly employed ; and  recommends,  instead  of  them, 
the  use  of  spirits  of  wine  and  the  decoction  of  poppies 
in  equal  proportions,  not,  however,  to  be  applied  hot. 

2.  With  regard  to  moist  applications,  the  same  gen- 
tleman expresses  his  disapprobation  of  poultices ; and 
mentions  a weak  solution  of  the  argentum  nitratum, 
as  the  most  eligible  application  in  an  aqueous  form. 

3.  On  the  subject  of  powdered  substances  as  appli- 
cations to  weak  ulcers,  Sir  E.  Home  says  he  has  often 
tried  bark  and  the  lapis  calaminaris,  without  perceiv- 
ing that  the  former  had  any  power  of  strengthening 
granulations,  or  the  latter  any  virtue  in  disposing  them 
to  form  new  skin ; properties  commonly  imputed  to 
these  applications. 

Sir  E.  Home  entertains  no  better  opinion  of  plaster 
of  Paris  or  powdered  chalk,  employed  with  the  view 
of  promoting  the  formation  of  skin.  Powdered  car- 
bon he  speaks  of  as  being  more  adapted  to  irritable 
than  weak  ulcers.  He  praises  powdered  rhubarb  as 
particularly  applicable  to  the  latter  kind  of  ulcer,  be- 
cause it  represses  the  luxuriant  growth  of  the  granu- 
lations, renders  them  small  and  compact,  and  disposes 
them  to  form  skin.  When,  however,  the  granulations 
have  risen  above  the  level  of  the  skin,  it  is  not  power- 
ful enough  to  reduce  them.  When  the  rhubarb  is  too 
stimulating,  it  is  to  be  mixed  with  a fourth  part  of  crude 
opium  in  powder. 

A piece  of  lint,  a little  less  than  the  sore,  is  always 
to  be  put  over  the  powder,  and  covered  with  a pledget 
of  simple  ointment. 

4.  Ointments,  according  to  Sir  E.  Home,  are  parti- 
cularly apt  to  disagree  with  weak  ulcers.  When  other 
applications  fail,  however,  greasy  ones  may  be  tried, 
and  the  above  gentleman  gives  a preference  to  the 
ung.  hydrarg.  nilrat.,  mixed  with  hog’s  lard,  in  the 
proportion  of  one  to  five,  or  else  to  common  cerate, 
blended  with  a small  quantity  of  the  hydrarg.  nitrat. 
ruber. 

OF  ULCERS  IN  PARTS  WHOSE  ACTIONS  ARE  TOO  VIO- 
LENT TO  FORM  HEALTHY  GRANULATIONS,  EITHER 

FROM  THE  state  OF  THE  PARTS,  OR  THE  CONSTI- 
TUTION : IRRITABLE,  GANGRENOUS,  OR  SLOUGHING 

ULCERS. 

There  are  three  states  of  the  constitution  influencing 
the  nature  of  ulcers : an  irritable  state,  in  which  all 
the  actions  of  the  animal  economy  are  more  rapid 
than  in  health ; an  indolent  state,  in  which  they  are 


unusually  languid ; and,  lastly,  a diseased  state,  by 
which  they  are  aflfected. 

An  irritable  and  an  indolent  ulcer  cannot  in  general 
be  distinguished  from  each  other  by  mere  appearances, 
though  they  may  be  so  in  a few  instances.  Sir.  E. 
Home  informs  us,  that  the  disposition  of  an  ulcer,  like 
the  disposition  of  a constitution,  can  only  be  accu- 
rately ascertained  by  determining  the  actions  which 
arise  from  the  different  impressions  made  upon  it. 

The  following  appearances,  he  says,  at  once  show 
the  ulcer  to  be  of  an  irritable  kind.  The  margin  of 
the  surrounding  skin  being  jagged,  and  terminating  in 
an  edge  which  is  sharp  and  undermined.  The  bottom 
of  the  ulcer  being  made  up  of  concavities  of  different 
sizes.  There  being  no  distinct  appearance  of  granu- 
lations, but  a whitish  spongy  substance  covered  with  a 
thin  ichorous  discharge.  Every  thing  that  touches  the 
surface  gives  pain,  and  very  commonly  makes  it  bleed. 
The  discharge  is  altered  from  common  pus  to  a thin 
fluid,  in  proportion  to  the  degree  of  irritability  com- 
municated to  the  sore  by  constitutional  causes.  In 
general,  the  pain  of  an  irritable  sore  gradually  becomes 
less.  When  it  is  not  constant,  but  comes  on  in  parox- 
ysms chiefly  in  the  evening,  or  night-time,  with  great 
violence,  convulsive  motions  of  the  limb  are  apt  to 
occur,  and  extend  to  various  other  parts.  Sir  E.  Home 
refers  this  symptom  to  irritation  communicated  along 
the  course  of  the  nerves,  and  producing  an  action  in 
them,  attended  with  a violent  contraction  of  the  mus- 
cles which  they  supply. 

When  the  above-mentioned  signs  of  an  irritable 
ulcer  are  not  present,  we  must  form  a judgment  of  the 
nature  of  the  sore  from  listening  to  the  history  of  the 
case,  the  effects  of  various  applications,  &c.  When 
this  kind  of  information  cannot  be  obtained,  Sir  E. 
Home  recommends  the  treatment  to  begin  on  the  sup- 
position of  the  ulcer  being  of  an  irritable  nature. 

The  gangrenous  or  sloughing  ulcer  is  frequently 
only  one  stage  of  the  irritable  one,  and  is  therefore  fre- 
quently met  with  in  persons  whose  constitutions  have 
been  hurt  by  intemperance.  It  occurs  also,  as  Sir  A. 
Cooper  has  related,  among  persons  emaciated  and  re- 
duced by  extreme  want.  The  surface  of  the  sore  is 
dry,  its  edges  have  a livid  appearance,  with  small  vesi- 
cles on  them,  and  the  patient  suffers  much  from  irrita- 
tive fever. 

When  an  ulcer  occurs  just  over  the  malleolus  ex- 
lernus,  it  is  generally  of  an  irritable  kind,  in  conse- 
quence of  the  nature  of  the  part  on  which  it  is  situ- 
ated, quite  independently  of  any  constitutional  or  local 
disposition  to  irritability.  Sir  E.  Home  conceives  that 
the  periosteum,  which  here  lies  immediately  under  the 
skin,  becomes  the  seat  of  the  ulcer,  is  the  cause  of  its 
being  very  difficult  to  heal,  and  gives  it  the  Irritable 
appearance.  The  fact  that  sores  situated  on  the  liga- 
ment of  the  patella,  and  over  the  periosteum  of  the 
anterior  surface  of  the  tibia,  assume  a similar  appear- 
ance, and  are  equally  difficult  to  heal,  made  him  more 
confirmed  in  his  sentiment. 

As  internal  medicines  in  these  cases.  Sir  A.  Cooper 
praises  calomel  and  opium ; one  grain  and  a half  of 
the  former,  and  one  of  the  latter,  morning  and  eve- 
ning. By  some  practitioners,  the  compound  decoction 
of  sarsaparilla  seems  also  to  be  regarded  as  a good 
medicine  for  lessening  constitutional  irritability.— (Z.ec- 
tures,  Sec.  vol.  195.) 

In  treating  ulcers  in  general,  the  surgeon  will  find  it 
advantageous  to  be  acquainted  with  the  effects  of  a 
great  many  external  applications ; for  very  few  cases 
will  continue  to  heal  beyond  a certain  time,  without 
some  alteration  in  the  treatment.  The  necessity  of 
changing  the  applications  after  they  have  been  con- 
tinued for  a certain  time,  is  strikingly  illustrated  by 
the  fact,  that  leaving  off  a powerful  application  and 
employing  one  which  at  first  would  have  had  no  ef- 
fect, often  does  a great  deal  of  service.  When  the 
change  is  made  to  a medicine  of  powers  equal  to  those 
of  the  previous  one,  the  benefit  will  be  more  lasting 
than  in  the  preceding  circumstance. 

OF  APPLICATIONS  TO  IRRITABLE  ULCERS. 

1.  Sir  E.  Home  recommends  applications  in  the 
form  of  vapour,  as  being  particularly  useful  by  their 
quality  of  allaying  irritation  and  soothing  pain. 

The  steam  of  warm  water  is  productive  of  benefitin 
this  way,  though  seldom  used  by  itself.  Its  good  effects 
are  increased  when  it  is  mixed  with  spirits. 


384 


ULCERS. 


Sir  E.  Horae  speaks  also  in  favour  of  the  benefit  de- 
rived from  fomentations  containing  opium ; such  as  the 
tincture  of  opium  sprinkled  on  flannel,  wrung  out  of 
warm  water ; or  the  application  of  flannels  wet  with  a 
warm  solution  of  the  extract  of  opium,  or  with  a de- 
coction of  poppy-heads.  A decoction  of  chamomile 
flowers,  the  tops  of  wormwood,  or  hemlock  leaves 
may  also  be  employed  for  the  same  purpose. 

Sir  E.  Home  points  out  particular  irritable  ulcers, 
however,  which  are  rendered  more  painful  by  warm 
applications ; and  he  states  that  the  sores  alluded  to 
are  generally  attended  with  a mottled  purple  discolo- 
ration of  the  limb,  for  some  way  from  them,  and  a 
coldness  of  the  lower  part  of  the  leg,  and  that  they  are 
often  disposed  to  mortify,  which  event  is  promoted  by 
warmth. 

2.  As  for  moist  applications,  the  poultice  made  of 
linseed  meal  is  the  most  simple,  and  most  easily  made ; 
and,  as  it  does  not  necessarily  require  any  addition 
of  oil,  is  to  be  preferred  when  this  disagrees  with  the 
sore. 

Sir  E.  Home  does  not  say  much  in  favour  of  the 
use  of  the  liquor  plumbi  acetatis,  in  poultices ; for, 
though  he  allows  that  it  often  answers  very  well,  he 
adds  that  it  also  frequently  disagrees  with  the  ulcer, 
and,  if  long  used,  is  apt  to  bring  on  the  lead-colic. 

A decoction  of  poppy-heads  is  said  to  be  a very  good 
liquor  for  making  poultices. 

The  carrot-poultice  is  also  found  to  agree  with  a 
great  many  irritable  sores.  I sometimes  add  to  it  the 
opium  lotion. 

The  great  objection  to  poultices  in  these  cases,  being 
the  weight  of  such  applications,  the  limb  should  al- 
ways, if  possible,  rest  upon  the  poultice,  and  not  the 
poultice  upon  the  limb. 

If  poultices  be  employed,  their  use  is  to  be  continued 
as  long  as  the  granulations  are  small,  and  the  ulcer  is 
rapidly  diminishing  in  size,  and  this  even  till  the  cica- 
trization is  complete.  When  the  granulations  become 
large  and  loose  in  their  texture,  poultices  should  be 
left  off. 

When  the  weight  of  poultices  prohibits  their  use, 
Sir  E.  Home  advises  the  trial  of  lint,  dipped  in  one  of 
the  following  lotions,  and  covered  with  a pledget  of 
some  simple  ointment:  a solution  of  the  extract  of 
opium  ; a decoction  of  poppies  ; the  tincture  of  opium  ; 
a decoction  of  cicuta  ; the  liquor  plumbi  acetatis  dilu- 
tus  ; or  a weak  solution  of  the  argentum  nitratum. 

3.  Powdered  applications  are  generally  too  stimu- 
lating for  irritable  ulcers.  C.arbon  has  been  found 
useful ; so  has  powdered  extract  of  opium  mixed  with 
an  equal  quantity  of  carbon  or  linseed  flour.  How- 
ever, opium  occasionally  affects  the  constitution,  in 
consequence  of  absorption,  and  it  has  been  known 
to  excite  violent  inflammation,  ending  in  mortification. 

4.  Ointments  are  not  often  proper  applications  for 
irritable  ulcers,  as  they  are  always  more  or  less  rancid, 
and  generally  disagree  with  the  skin. 

According  to  Sir  A.  Cooper,  however,  the  following 
ointment  agrees  well  with  such  cases : R.  Ung.  cetacei, 
ung.  hydr.  nit.  a a 5 ss.  Pulv.  opii3j.  M— {.Lectures^ 
vol.  1,  p.  194.) 

Sir  E.  Home  mentions  cream  as  being  a very  useful 
application,  particularly  in  cases  in  which  warmth  is 
found  to  do  harm.  As  a substitute  for  it  he  recom- 
mends an  ointment  composed  of  hog’s  lard,  purified 
by  being  repeatedly  washed  in  spring  water,  and  then 
mixed  with  a small  quantity  of  white  wax  and  rose- 
water. 

The  observations  made  respecting  solutions  of  lead 
apply  to  the  unguentum  cerussae  acetat®. 

5.  The  pressure  of  bandages  is  generally  hurtful  to 
irritable  sores,  though  a slight  degree  of  it  proves  ser- 
viceable to  certain  ulcers  which  are  somewhat  less 
irritable  and  arise  from  weakness. 

When  the  ulcer  is  gangrenoiis  or  sloughing,  the  best 
application  is  the  nitric  acid  lotion  (50  drops  of  the 
acid  to  a quart  of  water).  Lint  is  to  be  dipped  in  it, 
laid  over  the  sore,  and  then  covered  with  a piece  of 
oiled  silk,  so  as  to  keep  it  wet  several  hours.  The  re- 
cumbent posture  is  to  be  observed. — {Sir  A.  Cooper, 
Lectures,  ^c.  vol.  1,  p.  191.)  This  gentleman  also 
gives  internally,  three  times  a day,  twenty  drops  of  the 
tincture  of  opium,  and  10  gr.  of  carbonate  of  ammonia, 
with  an  ounce  and  a half  of  camphor  mixture,  and  a 
little  of  the  compound  tinct.  of  cardamom  seeds.  Here 
the  exhibition  of  morphine  might  be  advantageous. 


OF  ULCERS  IN  PARTS  WHOSE  ACTIONS  ARE  TOO  IVVO 

LENT  TO  FORM  HEALTHY  GRANULATIONS,  WHETHER 

THIS  INDOLENCE  ARISES  FROM  THE  STATE  OF  THE 

PARTS,  OR  OF  THE  CONSTITUTION  ; THE  CALLOUS 

ULCERS  OF  SEVERAL  WRITERS. 

The  indolent  ulcer  forms  in  its  appearance  a com 
plete  contrast  to  the  irritable  one.  The  edges  of  the 
surrounding  skin  are  thick,  prominent,  smooth,  and 
rounded.  The  surface  of  the  granulations  is  smooth 
and  glossy.  The  pus,  instead  of  being  of  a perfect 
kind,  is  thin  and  watery,  being  composed  of  a mixture 
of  pus  and  coagulating  lymph.  The  lymph  consists  of 
flakes,  which  cannot  be  easily  separated  from  the 
surface  of  the  sore.  The  bottom  of  the  ulcer  forms 
quite  a level,  or  nearly  so,  and,  as  Sir  E.  Home  very 
accurately  remarks,  the  general  aspect  conveys  an  idea 
that  a portion  of  the  skin  and  parts  underneath  has 
been  removed,  without  the  exposed  surface  having  be- 
gun any  new  action  to  fill  up  the  cavity. 

When,  however,  the  indolence  of  the  ulcer  is  not 
so  strongly  marked,  the  sore  does  not  correspond  to  the 
preceding  description,  but  resembles  in  appearance  the 
ulcer,  which  possesses  an  inferior  degree  of  irritability, 
and  can  only  be  discriminated  from  it  by  receiving  no 
benefit  from  soothing  applications. 

The  odd  circumstance  of  some  indolent  sores  having 
the  appearance  of  irritable  ones  is,  in  some  degree,  ex- 
plained by  ulcers  always  being  influenced  by  change? 
in  the  constitution,  and  accidental  circumstances  af- 
fecting the  parts. 

Most  of  the  ulcers  seen  in  the  London  hospitals  are 
of  the  indolent  kind.  An  indolent  disposition  in  an 
ulcer  may  proceed  altogether  from  the  long  existence 
of  the  disease ; and  hence.  Sir  E.  Home  very  justly 
observes,  it  is  immaterial  whether  at  first  it  were 
healthy,  weak,  or  irritable ; for,  if  not  cured  within  a 
certain  lime,  it  becomes  indolent,  with  the  exception  of 
a few  of  the  irritable  kind,  which  never  change  their 
nature. 

Indolent  sores  do  form  granulations ; but  these,  eveiy 
now  and  then,  are  all  on  a sudden  absorbed,  and,  in 
the  course  of  fbur-and-twenty  hours,  the  sore  becomes 
as  much  increased  in  size  as  it  had  been  diminished  in 
as  many  days  or  weeks.  This  absorption  of  the  gra- 
nulations arises  principally  from  their  not  being  of  a 
healthy  kind  ; but  the  event  is  promoted  by  changes  in 
the  iveather,  anxiety,  fatigue,  &c. 

The  object  in  the  treatment  of  indolent  ulcers  is  not 
simply  to  produce  a cure,  but  to  render  such  cure  as 
permanent  as  possible.  This  can  only  be  accomplished 
by  altering  the  disposition  of  the  granulations,  and 
rendering  them  strong  enough  to  stand  their  ground 
after  the  ulcer  is  filled  up. 

When  an  ulcer  which  has  existed  six  months  is 
dressed  with  poultices  for  a week,  the  granulations  at 
the  end  of  this  time  will  partly  have  filled  up  the  hol- 
low of  the  sore,  but  they  will  present  a large,  loose, 
and  glossy  appearance.  Should  the  poultice  be  now 
discontinued,  and  some  proper  stimulating  application 
used  for  another  week,  the  granulations  will  be  found, 
at  the  expiration  of  this  time,  to  have  become  smaller, 
more  compact,  redder,  and  free  from  the  glossy  ap- 
pearance. The  ulcer,  w'hen  healed  by  the  latter  appli- 
cation, will  not  be  so  likely  to  break  out  again,  as 
when  healed  with  large,  loose,  flabby,  glossy  granu- 
lations. 

Sir  E.  Home  states,  that  the  number  of  indolent 
sores  which  healed  under  the  use  of  stimulating  ap- 
plications, and  do  not  break  out  again,  compared  with 
similar  cases  treated  with  mild  dressings,  are  as  four 
to  one. 

APPLICATIONS  TO  INDOLENT  ULCERS. 

1.  Medicines  in  the  form  of  vapour  cannot  heal  in- 
dolent sores  so  as  to  accomplish  a lasting  cure.  It  is 
only  when  these  ulcers  assume  a foul  appearance,  and 
are  in  a temporary  state  of  irritation,  that  such  appli- 
cations can  be  advantageously  employed. 

In  general,  patients  on  their  first  admission  into  hos- 
pitals with  sore  legs,  have  their  ulcers  in  a temporary 
state  of  irritation  from  neglect,  exercise,  excesses,  &c. 
Hence,  it  is  commonly  found  advantageous  for  the  first 
few  days  or  even  a week,  to  have  recourse  to  poultices 
and  fomentations. 

I believe  that  any  common  fomentation,  w'hether  of 
chamomile,  poppy-heads,  or  mere  warm  water,  an- 
swers equally  well.  The  lime  for  using  it  is  while  a 


ULCERS, 


385 


fresh  poultice  is  preparingj  and  this  latter  application 
should  be  changed  twice  a day. 

2.  Moist  applications,  such  as  poultices,  are  to  be 
employed  wlien  fomentations  are  proper,  and  they 
may  be  made  of  bread,  oatmeal,  or  linseed. 

Sir  E.  Home  describes  a species  of  indolent  ulcers 
which  occur  in  patients  of  debilitated  constitutions, 
which  put  on  a sphacelated  a{)pearance  without  any 
apparent  cause,  even  after  they  have  made  some  pro- 
gress towards  a cure,  and  in  this  way  spread  to  a very 
large  size.  Some  of  these  ulcers,  if  judged  of  from 
their  appearances,  would  be  ranked  as  irritable  ones ; 
but,  as  soothing  applications  do  not  agree  with  them, 
they  are  not  to  be  classed  with  the  latter  kind  of  sores. 
They  are  said  to  occur  particularly  in  seamen  and 
soldiers  who  have  been  long  at  sea,  and  have  been 
termed  scorbutic  ulcers.  Sir  E.  Home  represents  them, 
however,  as  not  being  necessarily  connected  with  the 
scurvy,  and  being  often  met  with  in  patients  who  have 
not  been  on  the  sea.  He  states  that  they  are  not  of  ne-  ‘ 
cessity  joined  with  any  specific  disease  ; but  are  com- 
mon to  all  kinds  of  patients  whose  constitutions  have 
been  impaired,  either  by  salt  provisions,  warm  cli- 
mates, or  drinking. 

f’rom  .some  trials,  first  made  by  Dr.  Harness,  and  af- 
terward by  Sir  E.  Home,  it  appears  that  these  parti- 
cular ulcers,  when  in  a sphacelated  state,  are  benefited 
by  employing  the  gastric  juice  of  ruminating  animals 
as  an  external  application.  It  makes  the  sloughs  fall 
off,  and  the  sore  assume  a better  appearance.  Some 
pain  follow^  oii  its  being  first  applied,  and  it  is  to  be 
regarded  as‘a  Emulating  application. 

SirE.  Home- mentions,  that  in  the  West  Indies, such 
ulcers  are  advantageously  dressed  with  the  fresh  root 
of  the  cassada,  grated  into  a pulp.  Lime-juice  has 
also  been  found  a useful  application,  and  solutions 
of  the  sulphate  of  copper  and  alum  have  been  recom- 
mended. 

When  indolent  ukers  are  not  attended  with  certain 
peculiarities,  a solution  of  the  argentum  nitratum  is 
one  of  the  best  of  the  watery  applications.  It  stimu- 
lates the  granulations,  and  makes  them  put  on  a more 
healthy  appearance,  and  its  strength  may  be  increased 
according  to  circumstances.  An  ulcer  which  at  first  can- 
not bear  this  solution  above  a certain  strength  without 
pain,  and  without  the  granulations  being  absorbed,  be- 
comes able,  after  the  application  has  been  used  about 
ten  days  or  a fortnight,  to  bear  it  twice  as  strong  with- 
out such  effects  being  produced  ; a proof  of  the  granu- 
lations hayipg  acquired  strength. 

The  tincture  of  myrrh  is  often  employed  as  an  ap- 
plication to  Qlcers.  Hunczowsky  has  praised 

a decoction  of  the  v?alnut-tree  leaves,  and  soft  covering 
of  the  walnut  for  tlie  same  purpose. — {Acta  Acad. 
Med.  Oiir.  Vindob.  t.  1,  1788.)  Sir  E.  Home  gives 
his  testimony  in  favour  of  both  the  latter  dressings. 

Diluted  sulphuric  acid  and  the  expressed  juice  of 
the  pod  of  different  species  of  pepper  in  a recent  state, 
are  mentioned  by  Sir  E.  Home  as  having  been  used  as 
apf)lications  to  indolent  ulcers:  the  latter  in  the  West 
Indies. 

This  gentleman  recommends  also  a scruple  of  ni- 
trous acid,  mixed  with  eight  ounces  of  water,  as  a very 
useful  medicine  for  externa!  use.  The  strength  must 
be  increased  or  diminished  according  to  circumstances. 
Sir  E.  Home  has  found  that  this  application  promotes, 
in  a very  uncommon  manner,  the  progress  of  the  cure. 

The  first  application  .qf  diluted  nitrous  acid  gives  a 
good  deal  of  pain,  vvl/ich  lasts  about  half  an  hour  and 
then  goes  off. 

When  an  indolent  ulcer  heals  with  the  diluted  ni- 
trous acid,  the  process  of  skinning  is  accomplished 
with  more  rapidity  than  when  other  applications  are 
employed  ; and  the  new  skin  is  said  to  be  more  coin- 
l)letely  formed.  The  acid  coagulates  the  pus  as  soon 
as  it  is  secreted. 

Sir  E.  Home  states,  that  several  patients  who  had 
ulcers  dressed  with  the  diluted  nitrous  acid,  were  al- 
lowed to  walk  about  without  finding  the  progress  of 
the  cure  retarded,  although  no  bandage  to  support  the 
limb  was  made  use  of.  The  same  surgeon  informs  us, 
also,  that  in  ulcers  of  the  leg,  attended  with  an  expo- 
sure of  a piece  of  bone,  which  retards  the  cure,  be- 
cause it  does  not  exfoliate  and  come  away,  the  appli- 
cation of  diluted  nitrous  acid  to  the  bone  removes  the 
earthy  part,  and  excites  the  absorbents  to  act  upon  the 
remaining  animal  portion. 

VoL.  II.-B  b 


3.  The  only  application  in  the  form  of  powder 
adapted  to  indolent  ulcers  is,  according  to  Sir  E.  Home, 
the  hydrargyrus  nilratus  ruber.  It  may  be  occasion- 
ally used  for  ulcers  of  the  most  indolent  kind. 

4.  Ointments  are  represented  as  being  particularly 
good  applications  for  indolent  sores. 

The  idea  of  the  air  having  bad  effects  on  sores  which 
are  exposed  to  it,  is  now  disbelieved.  That  air  has  no 
irritating  property  of  this  kind  is  proved  by  the  fact, 
that  when  the  abdomen  of  an  animal  is  filled  with  it, 
no  inflammation  is  excited.  When  the  cellular  mem- 
brane is  loaded  with  it,  in  cases  of  emphysema,  the 
parts  do  not  afterward  inflame.  Nor  do  ulcers  in  the 
throat,  as  Sir  E.  Home  justly  remarks,  heal  less  fa- 
vourably than  others,  although  they  are  of  necessity 
always  exposed  to  the  air. 

Whatever  ill  eflects  arise  may  probably  be  explained 
by  the  consequences  of  evaporation,  which  converts 
the  soft  pus  into  a scab.  The  granulations  are,  in  all 
probability,  most  favourably  circumstanced  when  they 
are  covered  with  their  own  matter,  W’hich  sltould  only 
be  now  and  then  removed,  in  order  that  such  applica- 
tions may  be  made  as  will  stimulate  them  to  secrete  a 
more  perfect  pus.  From  what  has  been  just  stated, 
it  must  be  obvious  tli.at  indolent  ulcers  should  not  bo 
frequently  dressed,  and  that  if  they  are  so,  and  the 
dressings  are  stimulating,  the  practice  will  do  harm. 
Changing  the  dressings  once  in  twenty-four  hours  is 
deemed  quite  sufficient,  unless  the  quantity  of  matter 
be  very  great,  which  seldom  happens. 

One  part  of  the  unguentum  hydrargyri  nitrati, 
mi.xed  with  three  of  hog’s  lard,  is  one  of  the  best  ap- 
plications. Its  strength,  however,  must  be  gradually 
increased. 

The  unguentum  hydrargyri  nitrati  has  the  effect  of 
quickly  removing  the  thickness  of  the  edges  of  indo- 
lent ulcers,  and  the  surrounding  dark-red  colour  of  the 
skin.  It  seems  also  to  have  particularly  great  power 
in  making  the  granulations  become  small  and  healthy, 
and  of  course  the  ulcer  less  likely  to  break  out  again. 

With  some  ulcers,  however,  this  ointment  is  found 
to  disagree. 

The  ceratum  resinne  and  the  unguentum  elemi,  mixed 
W'ith  the  balsam  of  turpentine,- or  that  of  copaiba,  are 
other  common  applications  to  indolent  sores.  Sir  E. 
Horne  states,  that  the  resins  and  turpentines  are  not  so 
powerful  as  the  acids  and  metallic  salts,  in  giving  the 
granulations  a healthy  appearance,  and  a disposition 
to  resist  absorption. 

Cases  attended  with  a degree  of  indolent  thickening 
are  most  likely  to  be  improved  by  camphorated  oint- 
ments. 

In  numerous  cases,  the  applications,  whatever  they 
are,  soon  lose  their  effect,  and  others  should  then  be 
substituted  for  them.  The  past  and  present  states  of 
the  sore  are  always  to  be  considered.  Although  the 
ulcer  may  be  in  its  nature  indolent,  it  is  liable  to  tem- 
porary changes  from  constitutional  causes,  and  hence, 
a temporary  alteration  in  the  treatment  becomes  pro- 
per. 

5.  Bandages  are  undoubtedly  of  essential  service  in 
healing  many  kinds  of  ulcers  ; but  their  efficacy  is  so 
great  in  curing  numerous  indolent  sores,  that  they  are 
sometimes  considered  the  principal  means  of  cure. 
Among  modern  advocates  for  rollers,  the  late  Mr. 
Whately  was  one  of  the  most  zealous.  While  this 
gentleman  acknowledged  that  the  efficacy  of  •pressure 
in  counteracting  the  effects  of  the  dependent  posture 
was  known  to  Wiseman,  w'lio  recommendt'd  the  use 
of  the  laced  stocking  for  this  purpose,  he  conceived 
that  the  effects  of  pressure  in  the  cure  of  ulcers  on  the 
extremities,  previously  to  the  appearance  of  Dr.  Un- 
derwood’s treatise,  were  not  duly  insisted  upon  by  sur- 
gical writers.  However,  he  confessed,  that  there 
alw'ays  had  been  practitioners  w ho  w'ere  acquainted 
with  the  importance  of  this  mode  of  treatment,  and 
adopted  it  in  their  practice.  He  has  criticised  the  work 
of  Sir  Evqrard  Home,  in  which  it  is  remarked,  that 
the  effect  of  pressure  is  not  much  relied  upon  for  the 
cure  of  the.se  complaints.  Indeed,  says  Mr.  Whately, 
it  is  stated  in  that  book,  not  only  that  no  bensfit  is  de- 
rived from  compression  in  several  species  of  these  ulcers, 
but  that  many  ulcers  are  rendered  worse,  more  painful, 
and  more  unhealthy  in  iheir  appearance  by  its  use; 
truths  which  it  would  be  impossible  for  Mr.  Whately 
to  refute.  They  are,  I conceive,  admitted  by  himself, 
when  he  ol>serves,  that  there  are  certain  conditions  of 


386 


ULCERS. 


an  ulcer  which  will  not  bear  compression.  Whether 
Sir  Everard  Home  has  not  given  a sufficiently  favour- 
able account  of  the  effects  of  pressure  in  the  cure  of 
ulcers  of  the  leg,  I will  not  presume  to  determine  ; per- 
haps he  may  not  have  insisted  so  much  upon  this 
treatment  as  it  deserves;  but  1 can  find  no  fault  with 
him  for  speaking  of  it  as  frequently  injurious,  because 
the  fact  is  notorious. 

In  the  cases  published  in  Mr.  Whately’s  essay  very 
little  variety  of  dressing  was  used  ; pressure  being  the 
principal  means  of  cure,  with  some  exceptions  parti- 
cularly specified  in  the  work. 

“ I cannot  doubt  (says  Mr.  Whately)  that  the  practice 
here  recommended  must  in  the  end  prevail,  notwith- 
standing it  has  this  great  obstacle  to  contend  with,  that 
surgeons  must  condescend,  for  the  most  part,  to  apply 
the  bandages  with  their  own  hands.  The  clumsy  and 
ineffectual  manner  in  w’hich  this  business  is  too  fre- 
quently done  can  never  be  expected  to  produce  the  de- 
sired effect.  I Eun  certain,  that  if  the  necessary  pains 
be  taken,  according  to  the  directions  here  laid  down, 
such  effects  will  uniformly  follow  as  must  convince  the 
unprejudiced  mind,  that  to  have  recourse  to  the  opera- 
tion of  tying  varicose  veins,  and  the  application  of  a 
great  variety  of  remedies  can  be  very  rarely^  most 
probably  never ^ necessary.” 

With  respect  to  Mr.  Baynton’s  mode  of  treatment, 
while  Mr.  Whately  regards  it  as  a confirmation  of  the 
principles  insisted  upon  in  his  own  tract,  he  considers 
the  plan  of  making  the  pressure  with  adhesive  plaster 
inconvenient,  and  on  several  accounts  objectionable. 
In  every  case  related  by  Mr.  Baynton  he  is  sure  that 
the  proper  application  of  compresses  and  flannel  roll- 
ers would  have  produced  similar  good  effects.  The 
instances  of  success  by  this  method,  after  the  supposed 
failure  by  the  roller,  he  attributes  to  the  pressure  made 
by  the  plasters  having  been  applied  with  Mr.  Baynidn’s 
own  hands,  w'hereas  that  with  the  roller  was  probably 
so  made,  that  the  effect  intended  by  it  could  not  possi- 
bly be  obtained.  No  surgeon,  he  observes,  who  will 
not  be  at  the  trouble  of  applying  the  roller  and  com- 
resses  himself,  can  be  a judge  of  what  may  be  effected 
y the  proper  management  of  them. 

The  following  is  the  calamine  cerate  which  Mr. 
Whately  has  usually  employed: 

BL.  Axung.  porcin.  depur.  lib.  iij. 

Empl.  plumbi.  lib.  iss. 

Lap.  calam.  praep.  ap.  lib.  j.  M. 

To  this  formula  (says  IMr.  Whately)  I shall  add 
another  for  making  a cerate,  which  nearly  resembles 
the  unguentum  tripharmicum  of  the  old  Dispensatory, 
but  being  less  oily,  it  makes  a much  more  adhesive 
plaster.  It  should  be  spread  on  rag  or  silk  as  an  exter- 
nal coveriitg  to  the  dressing  on  lint,  where  a tow  plas- 
ter cannot  be  conveniently  used ; as  in  wounds  of  the 
face  or  hands,  a bubo,  or  any  other-  sore  where  an  ex- 
ternal plaster  cannot  be  readily  retained  in  its  situation 
by  a bandaee.  This  plaster  is  likewise  so  mild,  that 
it  never  irritates  the  skin.  T have  found  it  also  a very 
useful  plaster  in  fractures.  The  following  is  the  for- 
mula: 

ft.  Empl.  plumbi.  lib.  j. 

Axnng.  porcin.  depur.  unc.  vj. 

Aceti  unc.  iv.  M.” 

With  respect  to  the  proper  method  of  applying  the 
roller  and  compresses,  Mr.  Whately  offers  the  follow- 
ing remarks : j 

“ The  best  width  for  a flannel  roller,  designed  for 
those  who  have  slender  legs,  is  three  inches : but  for 
those  whose  legs  are  of  a large  size,  they  should  always 
be  three  inches  and  a half  in  width.  They  must  there- 
fore be  at  first  torn  a little  wider,  that  they  may  be 
of  their  proper  width  when  repeatedly  washed.  It 
will  likewise  be  found,  that  rollers  made  of  fine,  soft, 
and  open  flannel  will  answer  much  better  than  those 
made  of  coarse  hard  flannel. 

For  those  who  have  full-sized  legs,  the  length  of 
six  yards  is  but  just  sufficient  to  answer  all  the  pur- 
poses intended  by  a roller;  but  in  those  who  have  very 
small  legs  five  yards  is  a sufficient  length.  Care  should 
be  taken  that  the  rollers  be  washed  in  very  hot  water, 
and  they  should  he  hung  up  to  dry  immediately  on  be- 
ing washed.  If  these  precautions  be  not  attended  to, 
repeated  washingof  them  will,  in  some  kindsof  flannel, 
make  them  as  narrow  as  tape,  by  which  they  will  be 
rendered  almost  useless. 

In  applying  a roller,  the  first  circle  should  be  made 


round  the  lowest  part  of  the  ankle,  as  near  as  possible 
to  the  heel;  the  second  should  be  fonnod  from  thence 
round  the  foot;  the  third  sliould  be  passed  again  round 
the  foot  quite  to  the  toes.  The  roller  should  then  be 
passed  from  the  foot  round  the  ankle  and  instep  a se- 
cond time,  to  make  the  fourth  circle.  In  doing  this,  it 
should  be  brought  nearer  (but  not  over;  the  point  of 
the  heel,  than  it  was  at  the  first  time  of  going  round 
this  part.  The  fifth  circle  should  pass  over  the  ankle 
again,  and  not  more  than  half  an  inch  higher  up  the  leg 
than  the  fourth  circle.  The  sixth,  seventh,  eighth,  and 
ninth  circles  should  ascend  spirally  along  the  small 
of  the  leg,  at  the  exact  distance  of  three-fourths  of  an 
inch  from  each  other.  Having  proceeded  thus  far  up 
the  leg,  we  may  begin  to  increase  the  distances  of  the 
circles  from  each  other  ; they  may  succeed  each  other 
upwards  to  the  knee  at  the  distance  of  from  one  to  two 
inches,  according  to  the  size  and  shape  of  the  leg.  At 
that  part  where  the  calf  of  the  leg  commences,  it  is 
generally  necessary  to  let  the  upper  edge  of  the  roller 
be  once,  twice,  or  thrice  turned  dowmwards  for  about 
half  the  circumference  of  the  leg,  in  order  to  make  the 
roller  lie  smooth  between  the  middle  of  the  calf  and 
the  small  of  the  leg.  When  the  roller  has  been  thus 
applied  as  far  as  the  knee,  there  will  be  a portion  of  it 
to  spare,  of  perhaps  a yard  in  lengtli ; this  remainder 
should  be  brought  down  by  spiral  windings  at  greater 
distances  from  each  other  than  those  wffiich  w'ere 
made  on  the  ascent  of  the  roller.  The  windings 
should  in  general  be  completed  in  the  small  of  the  leg, 
wherfe  the  roller  should  be  pinned. 

In  many  cases  it  is  necessary  to  apply  the  roller 
over  the  keel.  It  should  be  brought  as  low  as  possible 
round  the  ankle,  as  in  the  former  description.  From 
thence  the  second  circle  of  the  roller  should  pass  from 
the  instep  over  one  side  of  the  heel,  and  be  brought 
over  the  other  side  of  the  heel  to  the  instep  again. 
The  third  circle  should  be  passed  round  the  ankle  a se- 
cond time,  but  still  nearer  to  the  heel  than  the  first 
circle  was.  The  roller  should  after  this  be  brought  back 
to  the  foot,  and  passed  round  it  to  make  the  fourth  cir- 
cle. A fifth  circle  should  be  again  made  (though  it  ia 
not  in  all  ca.ses  absolutely  necessary)  round  the  foot  to 
the  toes.  To  make  the  sixth  circle,  the  roller  should 
be  brought  back,  and  passed  round  the  ankle  again. 
The  seventh,  eighth,  ninth,  tenth,  and  eleventh  circles 
should  ascend  spirally  at  the  exact  distance  of  three- 
fourths  of  an  inch  from  each  other;  these  distances 
commencing  at  the  sixth  circle.  The  roller  should  then 
be  carried  to  the  knee  and  be  brought  down  again  to 
the  small  of  the  leg,  as  described  in  the  former  instruc- 
tion. 

In  applying  the  compresses,  it  is  necessary  in 
every  instance  to  put  them  on  one  by  one,  and  not  all 
in  a mass,  though  they  be  of  a proper  size  and  number. 
They  should  be  crossed  in  diflerent  directions;  the 
largest  of  them  should  in  no  case  be  longer  than  just 
to  meet  on  the  opposite  side  of  the  leg  to  which  they 
are  applied.  I have  in  many  instances  seen  the  com- 
presses applied  by  the  patients  of  such  a length  as  to 
go  round  the  leg  like  a roller,  and  be  fastened  together 
with  pins.  This  method  generally  wrinkles  and  blis- 
ters the  skin,  and  by  no  means  answers  the  purpose  of 
making  a compression  on  the  part  where  it  is  most 
w'anted.  I never  suffer  a pin  to  be  used  in  the  com- 
presses. If  the  same  compresses  in  any  case  be  ap- 
plied tw'o  days  together,  they  should  alw  ays  be  turned 
on  the  contrary  side  at  each  reapplication,  in  order  to 
prevent  wrinkles  on  the  skin.” — (See  Practical  Obs.  on 
the  Cure  of  Wounds  and  Ulcers  on  the  Legs  without 
rest,  by  T.  Whately,  1799.) 

6.  I shall  next  introduce  an  account  of  Mr.  Bayn- 
ton’s plan  of  curing  old  ulcers  of  the  leg,  by  means  of 
adhesive  plaster.  Were  I to  say,  that  any  particular 
method  of  dressing  such  sores  is  entitled  to  superior 
praise,  I should  certainly  decide  in  favour  of  this  gen- 
tleman’s practice.  I have  seen  it  most  succe-ssful 
myself,  and  I hear  it  highly  spoken  of  by  numerous 
professional  friend.s,  in  whose  unprejudiced  judgment 
I place  much  reliance. 

Mr.  Baynton  acquaints  us,  that  the  means  proposed 
by  him  will  be  found,  in  most  instances,  sufficient  to 
accomplish  cures  in  the  worst  cases  without  pain  or 
confinement.  After  having  lieen  repeatedly  disap- 
pointed in  the  cure  of  old  ulcers,  he  determined  to  bring 
their  edges  nearer  together  by  means  of  slips  of  adhe- 
sive plaster.  To  this  he  w as  chiefly  led  from  having 


ULCERS. 


387 


ftequenlly  observed,  that  the  probability  of  an  ulcer 
continuing  sound  depended  much  on  the  size  of  the 
cicatrix  whioh  remained  after  the  cure  appeared  to  be 
accomplished;  and  from  well  knowing  that  the  true 
skirt  was  a much  more  substantial  support  and  defence, 
as  well  as  a better  covering  than  the  frail  one,  which 
is  obtained  by  the  assistance  of  art.  But  when  he  had 
recourse  to  the  adhesive  plaster,  with  a view  to  lessen 
the  probability  of  those  ulcers  breaking  out  again,  he 
little  expected  that  an  application  so  simple  would 
prove  the  easiest,  most  efficacious,  and  most  agreeable 
means  of  treating  ulcers. 

Although  the  first  cases  in  which  Mr.  Baynton  tried 
this  practice  were  of  an  unfavourable  nature,  yet  he 
had  soon  the  satisfaction  to  perceive  that  it  occasioned 
very  little  pain,  and  materially  accelerated  the  Cure, 
while  the  size  of  the  cicatrices  was  much  less  than  it 
would  have  been,  had  the  cures  been  obtained  by  any 
of  the  common  methods. 

At  first,  however,  the  success  was  not  quite  perfect; 
as,  in  many  instances,  he  was  not  able  to  remove  the 
slips  of  plaster,  without  removing  some  portion  of  the 
adjacent  skin,  which,  by  occasioning  a new  wound, 
proved  a disagreeable  circumstance  in  a part  so  dis- 
posed to  inflame  and  ulcerate  as  that  in  the  vicinity  of 
an  old  sore.  He  therefore  endeavoured  to  obviate  that 
inconvenience  by  keeping  the  plasters  and  bandages 
well  moistened  with  spring  water  for  some  time  before 
they  were  removed  from  the  limb.  He  had  soon  the 
satisfaction  to  observe,  that  the  inconvenience  was  not 
only  prevented,  but  that  every  succeeding  case  justified 
the  confidence  he  now  began  to  place  in  the  remedy. 
He  also  discovered  that  moistening  the  bandages  was 
attended  with  advantages  which  he  did  not  expect; 
for  while  the  parts  were  wet  and  cool,  the  patients 
were  much  more  comfortable,  and  the  surrounding  in- 
flammation was  sooner  removed. 

By  the  mode  of  treatment  here  recommended,  Mr. 
Baynton  found  that  the  discharge  was  lessened,  the 
offensive  smell  removed,  and  the  pain  abated  in  a very 
short  time.  But  besides  these  advantages,  he  also 
found  that  the  callous  edges  were  in  a few  days  level 
with  the  surface  of  the  sore;  that  the  growth  of  fun- 
gus was  prevented,  and  the  necessity  of  applying  pain- 
ful escharotics  much  lessened,  if  not  entirely  done 
away.  Mr.  Baynton  gives  the  following  description  of 
his  method. 

“The  parts  should  be  first  cleared  of  the  hair,  some- 
times found  in  considerable  quantities  upon  the  legs,  by 
means  of  a razor,  that  none  of  the  discharges,  by  being 
retained,  may  become  acrid,  and  inflame  the  skin,  and 
that  the  dressings  may  be  removed  with  ease  at  each 
time  of  their  renewal,  which,  in  some  cases  where  the 
discharges  are  very  profuse,  and  the  ulcers  very  irrita- 
ble, may,  perhaps,  be  necessary  twice  in  the  twenty- 
four  hours,  but  w'hich  I have,  in  every  instance,  been 
only  under  the  necessity  of  performing  once  in  that 
space  of  time. 

The  plaster  should  be  prepared  by  slowly  melting, 
in  an  iron  ladle,  a sufficient  quantity  of  litharge  plaster, 
or  diachylon,  which,  if  too  brittle  when  cold  to  adhere, 
may  be  rendered  adhesive  by  melting  half  a drachm  of 
resin  with  every  ounce  of  the  plaster;  when  melted,  it 
should  be  stirred  till  it  begins  to  cool,  and  then  spread 
thinly  upon  slips  of  smooth  porous  calico,  of  a conve- 
nient length  and  breadth,  by  sweeping  it  quickly  from 
the  end  held  by  the  left  hand  of  the  person  who  spreads 
it,  to  the  other,  held  firmly  by  another  person,  with  the 
common  elastic  spatula  used  by  apothecaries;  the  un- 
even edges  must  be  taken  off,  and  the  pieces  cut  into 
slips  about  tw'o  inches  in  breadth,  and  of  a length  that 
will,  after  being  passed  round  the  limb,  leave  an  end  of 
about  four  or  five  inches.  The  middle  of  the  piece  so 
prepared  is  to  be  applied  to  the  sound  part  of  the  limb, 
opposite  to  the  inferior  part  of  the  ulcer,  so  that  the 
lower  edge  of  the  plaster  may  be  placed  about  an  inch 
below  the  lower  edge  of  the  sore,  and  the  ends  drawn 
over  the  ulcer  with  as  much  gradual  extension  as  the 
patient  can  well  bear;  other  slips  are  to  be  secured  in 
the  same  way,  each  above  and  in  contact  with  the 
other,  until  the  whole  surface  of  the  sore  and  the  limb 
Is  completely  covered,  at  least  one  inch  below,  and  two 
or  three  above,  the  diseased  part. 

The  whole  of  the  leg  should  then  be  equally  de- 
fended with  pieces  of  soft  calico,  three  or  firur  times 
doubled,  and  a bandage  of  the  same,  abmit  three  inches 
in  breadth,  and  four  or  five  yards  in  length,  or  rather  as 

B b2 


much  as  will  be  sufficient  to  support  the  limb  from  the 
toes  to  the  knee,  should  be  applied  as  smoothly  as  can 
be  possibly  performed  by  the  surgeon,  and  with  as  much 
firmness  as  can  be  born  by  the  patient.  It  is  to  be  first 
passed  round  the  leg,  at  the  ankle  joint,  then  as 
many  times  round  the  foot  as  will  cover  and  support 
every  part  of  it,  except  the  toes,  and  afterward  up  the 
limb  till  it  reaches  the  knee,  observing  that  each  turn  of 
the  bandage  should  have  its  lower  edge  so  placed  as  to 
be  about  an  inch  above  the  lower  edge  of  the  fold  be* 
low  it. 

If  the  parts  be  much  inflamed,  or  the  discharge  very 
profuse,  they  should  be  well  moistened,  and  kept  cool 
with  cold  spring-water,  poured  upon  them  as  often  as 
the  heat  may  indicate  to  be  necessary,  or,  perhaps,  at 
least  once  every  hour.  The  patient  may  take  what 
exercise  he  pleases,  and  it  will  be  always  found,  that 
an  alleviation  of  his  pain  and  the  promotion  of  his  cure 
will  follow  as  its  consequence,  though  under  other 
modes  of  treating  the  disease,  it  aggravates  the  pain 
and  prevents  the  cure. 

These  means,  when  it  can  be  made  convenient, 
should  be  applied  soon  after  rising  in  the  morning,  as 
the  legs  of  persons  affected  with  this  disease  are  then 
found  most  free  from  tumefaction,  and  the  advantages 
will  be  greater  than  when  they  are  applied  to  limbs  in  a 
swollen  state.  But  at  whatever  time  the  applications 
be  made,  or  in  whatever  condition  the  parts  be  found,  I 
believe  it  will  always  happen,  that  cures  may  be  ob- 
tained by  these  means  alone,  except  in  one  species  of 
the  disease,  which  seldom  occurs,  but  that  will  hereaf- 
ter be  described.  The  first  application  will  sometimes 
occasion  pain.  Which,  however,  subsides  in  a short  time, 
and  is  felt  less  sensibly  at  every  succeeding  dressing. 
The  force  with  which  the  ends  are  drawn  over  the 
limb  must  then  be  gradually  increased,  and  when  the 
parts  are  restored  to  their  natural  state  of  ease  and 
sensibility,  which  will  soon  happen,  as  much  may  be 
applied  as  the  calico  will  bear,  or  the  surgeon  can 
exert ; especially  if  the  limb  be  in  that  enlarged  and 
compressible  state  which  has  been  denominated  the 
scorbutic,  or  if  the  edges  of  the  wound  be  widely  sepa 
rated  from  each  other.” 

Mr.  Baynton  afterward  takes  notice  of  the  breaking 
of  the  skin  near  the  ulcers ; a circumstance  which 
sometimes  proved  troublesome,  and  arose  partly  from 
the  mechanical  effect  of  the  adhesive  plasters,  and  partly 
from  the  irritating  quality  of  the  plaster.  Mr.  Baynton, 
however,  only  considers  such  sores  of  serious  con- 
sequence when  they  are  situated  over  the  tendon  of 
Achilles,  in  which  situation  they  are  sometimes  seve 
ral  weeks  in  getting  well.  This  gentleman  recommends, 
with  a view  of  preventing  these  ulcers,  a small  shred 
of  soft  leather  to  be  put  under  the  adhesive  plaster. 

Mr.  Baynton  next  adds,  “that cures  will  be  generally 
obtained  without  difficulty,  by  the  mere  application  of 
the  slips  and  bandage ; but  when  the  parts  are  much  in- 
flamed, and  the  secretions  great,  or  the  season  hot,  the 
frequent  application  of  cold  Water  will  be  found  a valu- 
able auxiliary,  and  may  be  alwmys  safely  had  recourse 
to,  where  the  heat  of  the  part  is  greater  than  is  natural, 
and  the  body  free  from  perspiration.” — {_See  ^ descrip- 
tive Account  of  a new  Method  of  treating  old  Ulcers  of 
the  Legs,  edit.  2, 1799.) 

One  circumstance,  strongly  in  favour  of  the  advan- 
tages of  the  foregoing  mode  of  treatment,  deserves  par- 
ticular notice  : when  M.  Roux  visited  the  London  hos- 
pitals a few  years  ago,  he  had  for  the  first  time  an  op- 
portunity of  seeing  this  practice,  which  had  never  been 
tried  in  France.  The  plan  appeared  to  him  so  differ- 
ent from  every  thing  which  he  had  been  accustomed 
to  see  in  his  own  country,  w'here  ulcers  were  almost 
always  treated  by  rest  in  a iiorizontal  posture,  and 
emollient  applications,  that  he  left  London  somewhat 
prejudiced  acainst  the  new  metliod.  Subsequently  to 
his  return  to  Paris,  however,  he  has  given  it  a fair  trial, 
and  experience  has  now  entirely  changed  his  opinion, 
as  he  has  had  the  candour  to  acknowledge. — (See 
latimi  d'un  Voyage  fait  d Londres  en  18M;  ou  Pa- 
rallele  de  la  Chirurgie  Angloise  avec  la  Chirurgie 
Francoise,  par  P.  J.  Roux,  p.  150.) 

OF  UI.CKRS  ATTENDED  WITH  SOME  SPECIFIC  DISEASED 

ACTION,  EITHER  CONSTITUTIONAL  OR  LOCAL. 

1.  Ulcers  which  yield  to  Mercury, 

Here  we  shall  exclude  from  consideration  venereal 
ulcers,  as  tins  subject  is  treated  of  in  the  article  Vene- 


388 


ULCERS. 


real  Disease.  At  present  we  shall  only  notice  such 
sores  as  are  produced  by  other  diseases  of  the  general 
system,  or  of  the  parts,  and  are  capable  of  being  cured 
by  mercury. 

Perhaps  there  is  no  greater  source  of  error  in  the 
whole  practice  of  surgery,  than  the  supposition  that  a 
sore,  when  it  yields  to  mercury,  must  be  of  a syphilitic 
nature.  Surgeons,  however,  who  run  into  this  absurd- 
ity, can  hardly  be  imagined  to  be  unaware,  that  so  po- 
tent a medicine  must  have  effects  on  numerous  diseases 
of  very  different  descriptions.  Sir  E.  Home  accurately 
remarks,  that  many  ulcers,  unconnected  with  the  ve- 
nereal disease,  which  receive  no  benefit  from  other  me- 
dicines, heal  under  a mercurial  course,  or  yield  to  mer- 
curial applications.  In  some  ca.ses,  the  ulcer  remains 
in  the  same  state  while  mercury  is  used;  but  begins  to 
look  better  as  soon  as  the  medicine  is  discontinued,  in 
consequence  of  the  beneficial  change  produced  in  the 
system  by  the  mercurial  course.  In  these  cases,  mercu- 
rial frictions  are  the  best,  because  they  occasion  least 
impairment  of  the  constitution,  in  consequence  of  the 
stomach  continuing  undisturbed,  and  capable  of  digest- 
ing well. 

Another  description  of  ulcers,  noticed  by  Sir  E.  Home, 
as  deriving  benefit  from  mercury,  occur  on  the  instep 
and  foot,  have  a very  thickened  edge,  and  are  attended 
with  a diseased  state  of  the  surrounding  skin,  so  as  to 
bear  some  resemblance  to  elephantiasis.  They  are  fre- 
quently observed  affecting  servants  who  live  in  opulent 
families,  in  an  indolent  and  luxurious  way.  Sir.  E. 
Home  states,  that  fumigations  with  hydrargyrus  sul- 
phuratus  ruber  heal  these  ulcers,  and  resolve  in  a great 
degree  the  swelling  of  the  surrounding  parts.  In  some 
instances,  an  ointment  of  calomel  and  hog’s  lard ; in 
others,  the  camphorated  weak  mercurial  ointment  is 
the  best  application. 

Many  diseased  ulcers,  particularly  those  of  a super- 
ficial kind,  with  a thickened  edge,  may  be  healed,  when 
they  are  dressed  with  a solution  of  one  grain  of  the  hy- 
drargyrus muriatus,  in  an  ounce  of  water,  contaitiing 
a little  spirit. 

2.  Ulcers  curable  by  Hemlock. 

Sir  E.  Home  places  more  reliance  on  hemlock  as  an 
external  than  an  internal  remedy  for  ulcers.  The  ul- 
cers which  usually  receive  benefit  from  hemlock  appli- 
cations, look  like  those  of  an  irritable  sort ; but  the  sur- 
rounding parts  are  thickened,  in  consequence  of  some 
diseased  action.  Such  sores  occur  near  the.  ankle; 
which  joint  is  at  the  same  time  enlarged.  Sometimes, 
but  not  so  often,  they  take  place  over  the  ligaments  of 
the  knee.  On  account  of  their  situation,  and  the  swel- 
ling of  the  joint,  they  may  be  suspected  to  be  scrofu- 
lous, though  they  are  more  sensible  than  strumous  ul- 
cers usually  are.  The  sores  just  described  are  rendered 
less  painful,  their  diseased  disposition  is  checked,  and 
the  sw'elling  of  the  joint  diminished,  by  hemlock.  Se- 
veral irritable  scrofulous  ulcers  are  also  particularly 
benefited  by  this  medicine. 

Sir  E.  Home  gives  the  preference  to  hemlock  poul- 
tices, unless  their  weight  should  be  objectionable,  in 
which  case  he  advises  lint  to  be  dipped  in  a decoction 
of  the  herb,  and  put  on  the  sore. 

Sometimes  an  ointment  is  made  with  the  inspissated 
juice  or  extract. 

3.  Ulcers  curable  by  Salt  Water, 

Sir  E.  Home  takes  notice  of  other  specific  ulcers, 
which  yield  to  this  ai)plication,  after  resisting  other  re- 
medies. Poultices  made  with  .sea-water,  are  often  em- 
ployed ; but  this  gentleman  seems  to  prefer  keeping  the 
part  immersed  in  the  water  in  a tepid  state,  about  a 
quarter  of  an  hour,  twice  a day. 

When  sea-w'ater  poultices  bring  out  pimples,  in  cases 
of  scrofulous  ulcers  on  the  legs  and  feet.  Sir  E.  Home 
informs  u.s,  that  this  disagreeable  circumstance  may  be 
obviated  by  diluting  such  water  with  an  equal  quantity 
of  a decoction  of  poppies.  After  a time,  the  salt  wa- 
ter may  be  tried  by  itself  again.  While  each  fresh 
poultice  is  preparing,  the  part  should  also  be  immersed 
in  such  water  warmed. 

When  there  is  a tendency  to  anasarca,  or  when  there 
is  an  unusual  coldness  in  the  limb,  unattended  with  any 
propensity  to  mortification,  tepid  salt  water  may  be 
used  with  infinite  advantage. 

4.  Ulcers  curable  by  the  Jlrfrevtum  J^itratum. 

Sir  E.  Home  notices,  under  this  head,  uu  ulcer,  which 


does  not  penetrate  more  deeply  than  lh§  cutis:  but 
spreads  in  all  directions,  producing  ulceration  on  the 
surface  of  the  skin,  andqDfien  extending  nearly  through 
its  whole  thickness.  The  part  first  affected  heals,  while 
the  skin  beyond  it  is  in  a state  of  ulceration. 

Of  this  description  are,  a leprous  eruption,  mostly 
seen  in  men  impressed  in  Ireland ; a disease  of  the  skin 
induced  by  buboes,  which  have  continued  a great  while 
after  the  venereal  virus  has  been  destroyed ; and  the 
ring-worm. 

All  these  diseases  are  most  easily  cured  by  applying 
to  them  a solution  of  the  argentum  nitratum. 

The  leprous  eruption  is  communicated  by  contact, 
and  makes  its  appearance  in  the  form  of  a bile.  This 
is  converted  into  an  ulcer,  which  discharges  a fetid 
fluid,  by  which  the  surrounding  skin  is  excoriated,  and 
the  ulceration  is  extended  over  a large  surface.  The 
pain  is  most  severe,  and  the  discharge  greatest,  in  hot 
weather.  The  parts  first  diseased  heal,  while  others 
are  becoming  ulcerated,  and  the  disease  is  always  ren- 
dered worse  by  spirituous  liquors,  salt  provisions,  and 
catching  cold. 

Sir  E.  Home  remarks,  that  the  disease  in  the  skin 
produced  by  the  effects  of  very  irritable  buboes,  in 
constitutions  broken  down  by  mercury,  is  attended 
with  ulceration  of  a ntore  violent,  deep,  and  painful 
kind  than  the  foregoing  distemper.  The  progress  of 
this  disoider  is,  in  other  respects,  very  similar  to  that 
of  the  leprous  eruption. 

Although  the  ring-worm  only  occurs  in  the  form  of 
an  ulcer  in  warm  climates,  a mild  species  of  the  affec- 
tion takes  place  in  summer-time  in  this  country.  I< 
seems  to  be  infectious ; though  it  often  occurs  without 
infection.  It  commences  with  an  efflorescence,  which 
is  attended  with  very  trivial  sw'elling,  and  spread* 
from  a central  point.  The  circumference  of  the  efflo- 
rescence becomes  raised  into  a welt,  while  the  rest 
assumes  a scurfy  appearance.  The  welt  becomes  co- 
vered wdth  a scab,  which  falls  off  and  leaves  an 
ulcerated  ring,  in  general  not  more  than  a quarter  of 
an  inch  wide.  The  outer  margin  of  this  ring  con- 
tinues to  ulcerate,  while  the  inner  one  heals,  so  that 
the  circle  becomes  larger  and  larger.  The  discharge 
consists  of  a thin,  acrid  fluid,  which  seems  to  have  a 
great  share  in  making  the  disease  spread. 

For  all  the  lliree  preceding  diseases,  a solution  of 
the  argentum  nitratum  is  strongly  recommended  by 
Sir  E.  Home. 

5.  Ulcers  which  yield  to  Arsenic. 

The  sores  which  come  under  the  definition  of  noli 
me  tc.vgere  or  lupus,  derive  great  benefit  from  this 
powerful  remedy.  Sir  E.  Home  observes,  that  they  are 
nearly  allied  to  cancer,  differing  from  it  in  not  con- 
taminating the  neighbouring  parts  by  absorption,  and 
only  spreading  by  immediate  contact. 

From  some  cases  which  fell  under  Sir  E.  Home’s 
observation,  he  discovered  that  arsenic  was  not  only 
efficacious  as  an  external,  but  also  as  an  internal  re- 
medy. I shall  not  unnecessarily  enlarge  upon  this 
subject  in  the  present  place,  as  the  reader  may  refer  to 
the  articles  Arsenic,  Cancer,  Lupus,  Hospital  Gan- 
grene, &c.,  for  additional  information  relative  to  the 
uses  of  this  mineral  in, the  practice  of  surgery. 

Sir  E.  Home  is  an  advocate  for  its  employment,  both 
internally  and  externally,  for  ulcers  of  untoward  ap- 
pearance on  the  legs.  The  fungated  ulcer  is  particu- 
larly i)ointed  out  by  this  gentleman  as  being  benefited 
by  arsenic.  This  ulcer  occurs  on  the  calf  of  the  leg, 
and  on  the  sole  of  the  foot.  From  its  surface,  a fungus 
shoots  out,  which  is  entirely  different  from  common 
granulations.  The  new’-formed  substance  is  radiated 
in  its  structure,  the  bottom  of  the  ulcer  being  the  cen- 
tral point,  and  the  external  surface,  wdiich  is  continu- 
ally increasing,  the  circumference.  The  substance  of 
this  fungus  is  very  tender,  and  readily  bleeds.  The 
first  stage  of  the  disease  sometimes  has  the  appearance 
of  a scrofulous  affection  of  the  metatarsal  bones ; but 
the  parts  seem  more  enlarged,  and  when  the  skin 
ulcerates,  a fungus  shoots  out  and  betrays  the  nature 
of  the  case. 

One  species  of  the  fungated  ulcer  is  capable  of  con- 
taminating the  lymphatic  glands;  the  other  is  not  so. 
The  first  is  represented  by  Sir  E.  Home  as  being  in- 
curable by  arsenic  or  any  other  known  medicine. 

I'lie  second  yields  to  this  remedy.  Sir  E.  Home  uses 
a satin  aied  suiutiou,  made  by  boiling  while  arsenic  ia 


ULCERS. 


389 


water  for  several  hours,  in  a sand  heat.  He  gives  from 
three  to  ten  drops  internally;  and  for  outward  use, 
dilutes  a drachm  with  two  pints  of  water,  making  it 
afterward  gradually  stronger  and  stronger  till  it  is  of 
double  strength.  The  application  may  either  be  made 
in  the  form  of  a poultice,  or  of  lint  dipped  in  the  lotion. 

The  best  and  safest  preparation  of  arsenic,  both  for 
internal  and  external  use,  is  the  kali  arsenicatum. 
The  mode  of  employing  it  may  be  learned  by  turning 
to  the  articles  Arsenic^  Cancer,  Potassa,  Lupus,  &lc. 

6.  Ulcers  attended  with  Varicose  Veins. 

A certain  kind  of  ulcer  is  very  apt  to  occur  on  the 
inside  of  the  leg,  and  is  equally  difficult  to  cure,  and 
liable  to  break  out  again.  It  has  the  look  of  a mild, 
indolent  sore;  but  the  branches  and  trunk  of  the  vena 
*aphena  are  enlarged,  and  this  varix  of  the  veins  keeps 
the  ulcer  from  healing.  The  sore  is  seldom  deep, 
usually  spreads  along  the  surface,  and  has  an  oval 
shape,  the  ends  of  which  are  vertically  situated. 
There  is  a pain  affecting  the  limb  rather  deeply,  ex- 
tending up  in  the  course  of  the  veins,  and  exasperated 
by  keeping  the  leg  a long  while  in  an  erect  posture^ 

This  is  a kind  of  ulcer  which  derives  immense  be- 
nefit from  a tight  roller,  applied  from  the  toes  to  the 
knee,  although  the  direct  operation  of  the  pressure  of 
the  bandage  on  the  sore  is  itself  productive  of  no  par- 
ticular good. 

Sir  E.  Home  found,  however,  that  many  patients 
could  not  bear  laced  stockings,  or  tight  bandages,  and 
that  others  received  no  relief  from  them.  He  repre- 
sents, that  in  consequence  of  the  size  of  the  vena  sa- 
phena, and  its  numberless  convolutions,  the  return  of 
blood  from  the  smaller  branches  is  so  impeded  as  to 
retard  the  circulation  in  the  smaller  arteries,  and  to  in- 
terfere with  their  action  in  forming  healthy  granula- 
tions. The  coats  and  valves  of  the  veins  also  become 
thickened,  so  that  the  latter  parts  (the  valves)  do  not 
do  their  office  of  supporting  the  weight  of  the  column 
of  blood. 

These  reflections  induced  him  to  think,  that  some 
benefit  might  be  obtained  from  applying  a ligature 
round  the  vena  saphena  where  this-vessel  passes  over 
the  knee-joint,  so  as  to  take  off  a part  of  the  pressure 
of  the  column  of  blood.  The  following  way  of  per- 
forming the  operation  was  recommended : “ As  the 
veins  are  only  turgid  in  the  erect  posture,  the  operation 
should  be  performed  while  the  patient  is  standing ; and 
if  placed  upon  a table,  on  which  there  is  a chair,  the 
back  of  the  chair  will  serve  him  to  rest  upon  ; and  he 
will  have  the  knee-joint  at  a very  convenient  height 
for  the  surgeon.  The  leg  to  be  operated  upon  must 
stand  with  the  inner  ankle  facing  the  light,  which  will 
expose  very  advantageously  the  enlarged  vena  saphena 
passing  over  the  knee-joint.  While  the  patient  is  in 
this  posture,  if  a fold  of  the  skin,  which  is  very  loose 
at  this  part,  is  pinched  up  transversely,  and  kept  in  that 
position  by  the  finger  and  thumb  of  the  surgeon  on  one 
side,  and  of  an  assistant  on  the  other,  this  fold  maybe 
divided  by  a pointed  scalpel,  pushed  through  with  the 
back  of  the  knife  towards  the  limb  to  prevent  the  vein 
being  wounded  ; much  in  the  same  way  as  the  skin  is 
divided  in  making  an  issue.  This  will  expose  the 
vein  sufficiently;  but  there  is  commonly  a thin  mem- 
branous fascia  confining  it  in  its  situation;  and  when 
that  is  met  with,  the  vein  had  better  be  laterally  dise  n 
gaged  by  the  point  of  the  knife.  This  is  most  expe- 
ditiously done  by  laying  hold  of  the  fascia  with  a pair 
of  dissecting  forceps,  and  dividing  it;  for  it  is  difficult 
to  cut  upon  parts  which  give  little  resistance,  and  there 
is  a risk  of  wounding  the  vein.  After  this,  a silver 
crooked  needle,  with  the  point  rounded  off,  will  readily 
force  its  way  through  the  cellular  membrane  con- 
nected with  the  vein,  without  any  danger  of  wounding 
the  vessel,  and  carry  a ligature  round  it.  This  part,  or, 
indeed,  what  may  be  considered  as  the  whole  of  the 
operation  being  finished,  the  patient  had  better  be  put 
to  bed,  so  as  to  allow  the  vein  to  be  in  its  easiest  state 
before  the  ligature  is  tied,  and  then  a knot  is  to  be 
made  upon  the  vein ; this  gives  some  pain  ; but  it  is  by 
no  means  severe.  The  edges  of  the  wound  in  the 
skin  are  now  to  he  brought  together  by  sticking  plaster, 
except  where  the  ligature  passes  out,  and  a compress 
and  bandaL'e  applied,  so  as  to  keep  up  a moderate  de- 
gree of  pressure  on  the  veins,  both  above  and  below 
the  part  included  in  the  ligature.” — (Horne,  On  Ulcers, 
p.  296,  ed.  2.) 


As  a general  practice,  I never  entertained  any  doubt 
about  the  preference  which  ought  to  be  given  to  band- 
ages. Indeed,  the  risk  attending  the  plan  of  tying 
and  dividing  large  veins  has  now  been  displayed  in  so 
many  fatal  examples,,that  I begin  to  think,  that,  in  a 
few  years  more,  such  operations  will  only  be  men- 
tioned as  things  which  ought  not  to  be  done.  Sir  A. 
Cooper,  indeed,  has  already  entered  his  protest  against 
them,  and  mentions  several  cases  in  which  the  experi- 
ment had  a fatal  result. — (Lectures,  4-c.  vol.  1,  p.205.) 

It  appears  that  A.  Par6  proposed  and  performed  an 
operation  similar  to  that  described  by  Sir  E.  Home. — 
( The  Works  of  A.  Pare,  translated  by  Johnson ; folio, 
p.  319.)  An  account  of  Mr.  Brodie’s  operation  for  the 
cure  of  varicose  veins,  and  some  additional  remarks 
on  the  treatment  of  ulcers  accompanied  with  varices, 
will  be  found  in  a subsequent  article.  See  Varicose 
Veins.  A description  of  what  has  sometimes  been 
called  the  hospital  sore,  is  given  under  the  head  of 
Hospital  Gangrene. 

7.  Ulcers  from  irritation  of  the  Hails. 

Sometimes  portions  of  (he  nails  grow  against,  or 
even  into  the  flesh  of  the  fingers  or  toes,  a fungus 
arises  there,  and,  notwithstanding  the  repealed  appli- 
cation of  caustic,  the  disease  returns,  and  the  patient 
continues  in  a state  of  considerable  pain  and  seriously 
disabled.  The  treatment  recommended  by  Sir  A. 
Cooper  consists  in  paring  the  nail  till  it  is  as  thin  as  it 
can  be  made  without  the  production  of  bleeding:  its 
edge  is  then  to  be  raised,  and  a small  bit  of  lint  placed 
between  it  and  the  sore.  When,  however,  the  irrita- 
tion is  so  great,  that  even  the  application  of  lint  cannot 
be  endured,  he  slits  up  the  nail  and  turns  it  back  with 
forceps,  or  even  removes  it. — (Lectures,  Sec.  p.  200, 
vol.  1.)  A common  plan  is  to  apply  Plunket’s  caustic, 
a strong  solution  of  nitrate  of  silver,  the  liquor  arse- 
nicalis,  or  a blister,  so  as  to  produce  a separation  of  the 
offending  part  of  the  nail ; but  such  treatment  is  some- 
times tedious.  According  to  Mr.  Wardrop,  the  shape 
of  the  nail  is  not  really  altered,  and  the  chief  point  in 
the  treatment  is,  not  to  cut  away  any  of  it,  but  to  re- 
duce the  swelling  of  the  soft  parts  which  press  against 
the  nail,  and  he  has  generally  found  that  the  applica- 
tion of  lunar  caustic  destroys  the  painful  and  irritable 
ulcerated  surface,  while  it  promotes  the  absorption  of 
the  thickened  parts. — (See  Med.  Chir.  Trans,  vol.  5,p. 
131,  .S-r.) 

I shall  conclude  this  article  with  a brief  notice  of 
Mr.  Stafford’s  new  method  of  treating  deep  excavated 
ulcers.  It  consists  in  pouring  into  the  excavation 
melted  wax  of  an  extremely  adhesive  quality,  and  just 
of  that  temperature  which  it  has  when  it  is  on  the 
point  of  cooling,  and  when  it  will  immediately  become 
solid  in  the  ulcer.  In  this  manner  the  under  surface  of 
the  wax,  when  cold,  comes  into  close  contact  with  the 
general  surface  of  the  sore,  and  the  whole  excavation 
is  filled  by  it.  The  ulcer  having  been  cleaned  with 
dry  lint,  a brush  is  then  to  be  dipped  in  the  melted 
wax,  which  is  to  be  allowed  to  drop  from  it  into  the 
sore.  After  the  wax  has  become  solid,  it  is  to  be  re- 
tained in  its  place  with  a strip  or  two  of  adhesive 
plaster.  This  inode  of  dre.ssing  is  to  be  renewed  on 
the  third  day.  The  presence  of  the  mass  of  wax 
seems  to  have  the  effi'Ct  of  exciting  the  growth  of 
healthy  granulations.  The  wax  used  by  Mr.  Stafford 
consists  of  four  parts  of  white  wax,  and  of  one  of 
Venice  turpentine.  The  cases  to  which  he  conceives 
this  treatment  adapted  are,  “ the  open  and  excavated 
bubo;  ulcers  of  the  legs;  indolent  scrofulous  sores; 
excavations  in  the  flesh  in  consequence  of  sloughing 
phagedoena ; ulcers  situated  over  large  arteries ; sinuses 
and  fistulous  passages  that  have  been  laid  open;  the 
sores  left  by  extensive  burns ; broken  chilblains;  and, 
in  short,  those  of  any  depth,  from  whatever  cause  they 
may  arise.”  He  also  speaks  of  Its  utility  in  cancerous 
ulcers. — (See  Stafford's  Rssay  upon  the  Treatment  of 
the  Deep  and  Excavated  Ulcer,  See.  Land.  1829.)  As 
I have  never  tried  this  simple  method,  it  is  imjiossible 
for  me  to  offer  any  jiositive  opinion  on  its  merits.  Mr. 
Stafford’s  accounts  of  it  are  very  flattering;  and  it  is 
to  be  hoped  that  other  practitioners  may  find  it  as  effi- 
cacious a.s  he  seems  to  have  done  in  so  many  ulcers, 
and  these  of  characters  so  very  diirerent. 

Consult  Michael  Underwood' s Treatise  on  Ulcers  of 
the  I^egs,  S'c.  8vo.  Loud.  1783,  and  Surgical  Tracts  : 
3d  ed.  1799.  B.  Dell,  A Treatise  on  the  Theory  and 


390 


UNG 


UNG 


Management  of  Ulcers^  i^c.  new  ed.  8vo.  n91 ; and  his 
System  of  Surgery.  J.  Merk,  De  Curationibus  Ul- 
eerum  difficilium  prcesertim  in  Cruribus  Obviorum.  ^to. 
Ooett.  1776.  Baynton's  Descriptive  Account  of  a 
Mew  Method  of  Treating  Old  Ulcers  of  the  Legs., 
1799,  ed.  2,  Bristol,  1799.  Whately's  Practical 
Observations  on  the  Cure  of  Wounds  and  Ulcers  on 
the  Legs,  without  Rest,  800.  Lond.  1799.  Practical 
Obs.  on  the  Treatment  of  Ulcers  on  the  Legs,  to  which 
are  added  some  Observations  on  Varicose  Veins  and 
Piles,  by  Sir  Everard  Hume,  ed.  2,  1801.  Principles 
of  Surgery,  by  John  Bell,  vol.  J,  1801.  Hunter  on  the 
Blood,  Inflammation,  «S-c.  C.  Curtis,  An  Account  of 
the  Diseases  of  India,  &rc.  with  Observations  on  Ulcers 
and  the  Hospital  Sores  of  that  Country,  ^c.  8vo.  Edin. 
1807.  B.  Brodie  on  the  Treatment  of  Varicose  Veins 
of  the  Legs,  in  Med.  Chir.  Trans,  vol.  1,  p.  195,  4-c. 
Roux,  Voyage  fait  a.  Londres  en  1814,  ou  Parallele  de 
la  Chirurgie  Angloise  avec  la  Chirurgie  Francoise,  p. 
142,  A-c.  Paris,  1815.  Dr.  John  Thomson's  Lectures 
on  Inflammation,  p.  423,  S-c.  Edin.  1813.  Dr.  Dewar 
on  the  Treatment  of  Sinuous  Ulcers,  in  Med.  Chir. 
Trans,  vol.  7,  p.  482,  Arc.  Sir  A.  Cooper's  Lectures, 
vol.  1,  1824.  Gibson's  Institutes  of  Surgery,  vol.  i, 
Philadelphia,  1824.  The  stages  of  several  cutaneous 
affections  attended  with  ulceration,  have  been  excel- 
lently described  by  Dr.  Bateman  in  his  valuable  Sy- 
nopsis of  Cutaneous  Diseases.  Essay  upon  the  Treat- 
ment of  the  Deep  and  Excavated  Ulcer,  by  R.  A.  Stafr 
ford,  8vo.  Iwnd.  1829. 

UNGUENTUM  ACID!  SULPHURICI.— 5c.  Acidi 
Bulphurici  3j.  Adipis  Siiillae  praparatje  |j. — These 
are  to  be  well  mixed  together  in  a glass  mortar. 

This  ointment  has  been  used  by  Dr.  Duncan,  of 
Edinburgh,  for  curing  the  itch.  It  has  the  character 
also  of  being  efficacious  in  the  reduction  of  some  chro- 
nic swellings  of  the  joints;  and  when  mixed  with  a 
good  deal  of  camphor,  it  was  rubbed  upon  the  tumour 
in  cases  of  bronchocele,  by  Mr.  Naylor,  of  Gloucester, 
with  considerable  effect. 

As  the  sulphuric  acid  is  particularly  destructive  of 
vegetable  substances,  the  parts  to  which  this  ointment 
is  applied,  should  always  be  covered  with  flannel  in- 
stead of  linen. 

UNGUENTUM  ANTIMONII  TARTARIZ  ATI.— 
R.  Antim.  Tart.  3j.  Ung.  Cetacei  ^j-M’sce.  The 
antimonial  ointment,  frequently  used  for  e.xciting  irri- 
tation of  the  skin,  with  the  view  of  relieving  diseases 
in  the  vicinity  of  the  irritated  part,  as  is  exemplified  in 
the  treatment  of  some  diseases  of  the  eyes  and  joints, 
and  a variety  of  indolent  swellings. 

UNGUENTUMCETACEL— R.Cetacei  3 vj.  Cera 
Albae  3 ij.  Olei,  Olivce  uiicias  tres.  These  are  to  be 
melted  upon  a slow  fire,  and  then  briskly  stirred  till 
eold. — This  ointment,  spread  on  lint,  serves  as  a simple 
dressing  for  wounds,  ulcers,  &c. 

UNGUENTUM  CERvE  CUM  ACETO.— R.  Cerae 
Albae  | iv.  Olei  OlivjB  Sbj.  Aceti  Distillati  5 U-  The 
vinegar  is  to  be  gradually  mixed  with  the  first  two  in- 
gredients after  these  have  been  melted  together.  Dr. 
Cheston  recommends  this  ointment  for  superficial  ex- 
coriations, cutaneous  eruptions,  &cc. 

UNGUENTUM  CON  II.— R.  Foliorum  Conii  re- 
centiiim.  Adipis  Suill®  praeparatan,  sing.  ^iv.  The 
hemlock  is  to  be  bruised  in  a marble  mortar,  after 
which  the  lard  is  to  be  added,  and  the  two  ingredients 
thoroughly  incorporated  by  beating.  They  are  then  to 
be  gently  melted  oyer  the  fire,  and  after  being  strained 
through  a cloth,  and  the  fibrous  part  of  the  hemlock 
well  pressed,  the  ointment  is  to  be  stirred  till  quite  cold. 
To  cancerous  or  scrofulous  sores  this  ointment  may 
be  applied  with  a prospect  of  advantage. — {Pharm. 
Chirurg.) 

The  Pharmacopceia  of  St.  Bartholomew’s  Hospital 
directs  the  unguentum  conii,  vel  cicutae,  to  he  made  as 
follows; — R.  Foliorum  Cicuiar  Ibj.  Adipis  Suill® 
Ibiss.  Boil  the  leaves  in  the  melted  hog’s  lard  until 
they  become  crisp.  Then  strain  the  ointment.  A si- 
milar ointment  might  be  more  conveniently  made, 
by  mixing  the  extracturn  conii  w'ith  any  common  salve. 

UNGUENTUM  DIGITALIS— R.  Foliorum  Digi- 
talis Purpurea;  recentium.  Adipis  Suillae  preparata*, 
sing.  5>v-  'I’his  ointment  may  be  made  in  the  same 
manner  as  the  unguentum  conii,  and  tried  in  the  same 

UNGUENTUM  ELEMI  COMPOSITUM. R. 

Eleiui  Ihj.  Terebiuthinap  3 xi.  Sevi  Ovilli  prteparali 


Ibij.  Olei  OlivsB  jij.  Melt  the  elemiwith  the  suef; 
remove  them  from  the  fire,  and  mix  them  immediately 
with  the  turpentine  and  oil.  Then  strain  the  mixture. 
— Sometimes  employed  for  dressing  ulcers  which  stand 
in  need  of  stimitlating  applications. 

UNGUENTUM  GALLiE  CAMPHORATUM  -R. 
Gallarum  Pulveris  Subtilissimi  3 ij.  Camphoras  3 ss. 
Adipis  SuilltE  preparat®  | ij.  Misce. — This  is  a very 
good  application  to  piles,  after  their  ifjrfafhmatory 
state  has  been  diminished  by  the  liq.  plumbi  acet.  dilut., 
bleeding,  aperient  medicines,  and  leeches. 

UNGUENTUM  HELLEBORI  ALBI.— R.  Helle- 
bori  Albi  Pulv.  5j-  Adipis  Suillae  prapparat®  3 iv. 
Olei  Limonis  3ss.  Misce. — This  ointment  will  cure 
the  itch,  and  several  other  cutaneous  diseases. 

UNGUENTUM  HYDRARGYRI  FORTIUS.— R. 
Hydrargyri  purificati  Ibij.  Adipis  Suill®  preparat® 
Sxxiij.  Sevi  Ovilli  pr®parati  5j-  First  rub  the  quick- 
silver with  the  suet,  and  a little  of  the  hog’s  lard,  until 
the  globules  disappear;  then  add  the  remainder  of  th^ 
lard,  and  make  an  ointment.— This  is  the  commoE 
strong  mercurial  ointment.  Of  its  uses  we  need  say 
nothing  in  this  place.  See  Mercury. 

UNGUENTUM  HYDRARGYRI  CAMPIIOEA- 
TUM.— R.  Unguenli  Hydrargyri  5j.  Camphor®  3 ss. 
Misce. — This  is  often  recommended  to  be  rubbed  on 
thickened,  indurated  parts,  with  the  view  of  exciting 
the  action  of  the  absorbents.  Rubbed  along  the  course 
of  the  urethra,  it  is  very  serviceable  in  diminishing  and 
removing  chordee. 

UNGUENTUM  HYDRARGYRI  MITIUS.— R. 
Unguenti  Hydrargyri  fort.  ibj.  Adipis  Suill®  pr®pa- 
rat®  ibij.  Misce. — ^The  weaker  mercurial  ointment  is 
often  rubbed  on  indurated,  thickened  parts  and  tumours, 
when  the  object  is  merely  to  promote  their  absorption  ; 
and  it  is  not  advisable  to  employ  the  unguentum  hy- 
drargvri  fort,  lest  a salivation  should  be  induced. 

UNGUENTUM  HYDRARGA^RI  NTTRATIS.— 
R.  Hydrarg.  Purificati  Ij.  Acidi  Nitrosi  5 U-  Adipis 
pr.®parat®  | vj.  Olei  Oliv®  | iv.  Dissolve  the  quick- 
silver in  the  nitrous  acid;  and  while  the  solution  is  yet 
hot,  mix  with  it  the  oil  and  hog’s  lard,  previously 
melted,  but  beginning  to  concrete  by  being  exposed  to 
the  air.  This  ointment  is  a celebrated  application  to 
the  inside  of  the  eyelids  in  cases  of  chronic  ophthalmy, 
and  also  to  specks  on  the  cornea.  When  blended  with 
a little  olive  oil,  it  also  forms  a very  eligible  stimula- 
ting dressing  for  numerous  kinds  of  sores.  It  is  parti- 
cularly efficacious  in  curing  tinea  capitis  and  many 
other  cutaneous  diseases. 

UNGUENTUM  HYDRARGYRI  NTTRICO-OX- 
YDI.— R.  Hydrargyri  nitrico-oxydi  |j.  Cer®  Alb® 
I ij.  Adipis  prapar.  5 vj.  Misce.— This  is  a common 
stimulating  application  to  indolent  ulcers  and  sores  in 
general. 

UNGUENTUM  HYDRARGYRI  PEAICIPITATI 
ALBI.— R.  Hydrarg.  Piacip.  Albi  3j.  Adipis  pr®. 
parat®  | iss.  Misce.  A useful  application  in  certain 
cases  of  porrigo,  and  some  other  cutaneous  diseases. 
See  Porrigo. 

[There  is  scarcely  to  be  found  among  the  whole  class 
of  unguents  so  valuable  a means  of  relief  as  that 
which  is  afforded  by  the  white  precipitate  ointment  in 
cases  of  venereal  ulcers.  The  formula  may  he  ung. 
simpl.  5 j.  cum  pifficip.  alb.  3 ij.  M.  Thedressings  may  be 
renewed  two  or  three  times  a day.  The  excess  of  dis- 
charge created  is  no  less  remarkable  than  the  altera- 
tion effected  in  the  part  itself.  I have  more  freely  ap- 
plied this  unguent  to  venereal  ulcers  in  different  parts 
of  the  body  than  any  other  prescription;  when  the 
disease  has  been  of  comparatively  short  existence,  and 
when  the  constitution  has  laboured  under  the  infirmity 
for  months  and  even  vears. — Reese.'] 

UNGUE.\TU5I  lODlNAE.  See  Iodine. 

UNGUENTUM  lAQ.  PLUMBI  ACETATIS.—R 
Liquori.s  Plumbi  Acemtis  r v.  Adipis  Suilla-  ibj.  Cer® 
Alb®  |iv.  Melt  the  ingredients  together,  and  continue 
to  stir  them  till  cold. — This  ointment  is  employed  wii'h 
great  advantage  as  a simple  dressing.  According  to 
Mr.  Dunn,  of  Scarhorotigh,  it  Is  much  improveti  by 
pouring  the  liquefied  mixture  before  the  lend  has  been 
added  to  it  into  cold  water.  It  is  then  to  be  rubbed  in 
a mortar  or  on  a glab,  with  the  liq.  plumbi  acet.  The 
water  occasions  a fine  white  cloudy  precipitation, 
which  gives  to  the  composition  a better  appear- 
ance. 

UNGUENTUM  OPHTHALMICUM.— R.  Adipis 


URE 


URE 


391 


Suillae  preparat®  S ss.  Tuti®  prsparat®,  Bol.  Armen, 
sing.  3 ij.  Prscip.  Hydrarg.  Albi.  3j.  Misce. — Janin’s 
celebrated  ophthalmic  ointment. 

UNGUENTUM  OXYGENATUM,  vel  ACIDI  NI- 
TROSI. — R.  Axungi®  Suill®  lecentis  non  sals®  uncias 
sexdecim.  Lent  calore  in  vase  vitreo  leute  liquefactis 
aut  couiinua  agitatione  instillentur  Acidi  Nitrici  unci® 
duffi.  Massa  igiii  exponalur,  donee  ebullire  coepit;  tunc 
ab  igne  removeatur,  frigefactaque  sevetur. 

In  this  process  the  nitric  acid  is  decomposed,  the  ni- 
trous gas  escaping,  and  the  oxygen  cotnbining  with  the 
lard.  This  ointment  was  particularly  recommended 
by  Alyon,  as  an  application  to  venereal  and  herpetic 
ulcers.  Its  virtues  are  said  to  vary  considerably,  ac- 
cording to  the  strength  of  the  acid  employed,  and  it  is 
not  generally  deemed  so  efficacious  as  the  ointment  of 
nitrate  of  mercury. 

UNGUENTUM  PICIS.— R.  Picis,  Sevi  Ovilli  pr®- 
paraii,  sing.  Ibss.  Melt  and  then  strain  them. 

UNGUENTUM  PICIS  COMPOSITUxM.— R.  Un- 
guenti  Picis,  Unguenti  Pluinbi  Superacetatis  sing.  ibss. 
Misce. 

The  two  preceding  ointments  are  applicable  to  cases 
of  tinea  capitis,  and  some  eruptive  complaints.  Also 
to  some  kinds  of  irritable  ulcers. 

UNGUENTUM  PICIS  CUM  SULPHURE.— R. 
Unguenti  Picis,  Unguenti  Sulphnris,  sing.  | iv.  Misce. 
— This  is  one  of  the  most  common,  and,  I believe, 
the  most  efficacious  apniications  for  curing  porrigo. 

UNGUENTUM  PLUMBI  SUPERACETATIS.— 
Be.  Plumbi  Superacetatis  3 ij.  Cer®  Alb®  3 ij.  Olei 
ibss.  The  superacetate  of  lead,  previously  powdered, 
is  to  be  triturated  with  part  of  the  olive  oil.  The 
melted  wax  and  rest  of  the  oil  are  then  to  be  added. 
This  is  a good  dressing  for  cases  requiring  a mild  as- 
tringent application. 

UNGUENTUM  RESINeE.— R.  Resin®  Flav®, 
Cer®  Flav®  sing.  Ibj.  Olei  Oliv®  Ibj.  Melt  the  resin 
and  wax  with  a slow  fire ; then  add  the  oil,  and  strain 
the  mixture  while  hot. — This  is  a common  applica- 
tion to  ulcers  which  stand  in  need  of  being  gently 
stimulated. 

UNGUENTUM  SAMBUCI. — R.  Florum  Sambuci, 
Adipis  Suill®,  singulorum  Ibj.  The  hog’s  lard  being 
melted,  boil  the  elder  flowers  in  it  till  they  become 
crisp,  then  strain  the  mixture. 

UNGUENTUM  SULPHURIS.— R.  Adipis  Suill® 
Ibss.  Florum  Sulphuris  5 iv.  Misce. 

UNGUENTUM  TUTI^..— R.  Tuti®  prsparat®, 
Unguenti  Cetacei  q.  s.  Misce. — Used  for  smearing  the 
borders  and  inside  of  the  eyelids  in  cases  of  chronic 
ophthalmy,  &c. 

UNGUENl’UM  TUTI.E  COMPOSITUM. R. 

Tuti®  pr®paralffi,  Lapidis  Calaminaris  pr®parati, 
sing.  3 vj.  C.amphor®  3 ij.  Unguenti  Sambuci  Ibj. 
Misce. 

This  formula  is  contained  in  the  Pharmacopoeia  of 
St.  Bartholomew’s  Hospital.  It  is  occasionally  ap- 
plied to  the  inside  of.  the  eyelids,  piles,  ulcerations,  ex- 
coriations, &c. 

UNGUENTUM  ZINCI.— R.  Zinci  oxydi  5j.  Adi- 
pis pr®par.  5 vj.  Misce. — An  astringent  application  in 
very  common  use. 

UNGUIS.  (A  nail.)  Some  surgical  authors  apply 
this  term  to  a collection  of  pus,  or  matter  in  the  eye, 
when  the  abscess  appears,  through  the  cornea,  to  be 
shaped  like  a finger  nail. 

UNION  BY  THE  FIRST  INTENTION.— When 
the  opposite  surfaces  of  a wound  are  brought  into  con- 
tact and  grow  together  at  once  without  suppurating, 
union  by  the  first  intention  is  said  to  take  place.  When 
wounds  heal  by  suppurating,  granulating,  &c.  they  are 
sometimes  surgically  described  as  getting  well  by  the 
second  intention.  See  Wounds. 

URETHRA,  DESTRUC'J’ION  OF  PART  OF  THE. 
— The  attempts  to  complete  the  canal  by  operations 
performed  on  the  Taliacotian  principles,  will  be  no- 
ticed in  the  article  Urinary  Fistula. 

URETHRA,  STRICTURES  OF.— A stricture  of 
the  urethia,  as  a modern  writer  observes,  “consists  of 
some  morbid  alteration  of  action  or  of  structure,  by 
which  a part  of  the  canal  is  rendered  narrower  than 
the  re.st.” — ( Wilson  on  the  Male  Urinary  and  Genital 
Organs,  p.  361.)  According  to  .Mr.  John  Hunter,  most 
olwirnctinns  to  the  passage  of  the  urine,  if  not  all,  are 
attended  with  nearly  the  same  symptoms.  Few  per 
sons  take  notice  of  the  first  syiiiptoms  of  a stricture, 


till  they  have  either  become  violent,  or  other  inconve- 
niences have  been  the  consequence.  A patient  may 
have  a considerable  stricture,  yet  be  unconscious  that 
his  urine  does  not  come  away  freely  ; and,  in  conse- 
quence of  a stricture,  .there  may  even  be  a tendency  to 
inflammation  and  suppuration  in  the  perin®um,  while 
he  feels  no  obstruction  to  the  passage  of  his  urine,  and 
does  not  suspect  that  he  has  any  other  complaint. 

Three  kinds  of  strictures  are  described ; viz.  the  per- 
manent stricture,  which  arises  from  an  alteration  in  the 
structure  of  the  part  of  the  urethra ; the  mixed,  con- 
sisting of  a permanent  stricture  and  a spasm ; and  the 
spasmodic. 

It  is  observed  by  a modern  writer,  that  the  spasmodic 
stricture  arises  from  the  whole  or  a part  of  the  canal  of 
the  urethra  being  so  highly  irritable,  that  the  slightest  sti- 
mulus will  cause  it  to  contract  and  occasion  the  stream 
of  urine  to  be  suddenly  obstructed.  Spasmodic  stric- 
tures he  considers  as  being  often  the  result  of  faulty  di- 
gestion. He  has  known  a spasmodic  stricture  follow 
the  eating  of  high-seasoned  and  indigestible  food,  or  the 
drinking  of  acidulous  liquors ; and  he  asserts,  that  the 
spasmodic  state  of  the  urethra  will  cease  if  the  irrita- 
ting substance  in  the  alimentary  canal  be  carried  off,  or 
the  acid  neutralized.  When  general  irritability  exists, 
he  believes  that  spasmodic  affection  of  the  urethra  may 
be  brought  on  by  urine  of  an  irritating  quality,  or  any 
other  local  stimulation  of  the  urethra,  as  by  a bougie, 
&c. — (See  Stafford  on  Strictures  in  the  Urethra,  &fC. 
p.  3.) 

Whether  the  urethra  be  a truly  muscular  canal,  and 
whether  a variety  of  circumstances,  remarkable  in  its 
healthy  and  diseased  state,  can  be  accounted  for  by  its 
elasticity,  the  action  of  the  muscles  in  the  perinffium, 
and  other  principles,  without  supposing  the  canal  to  be 
itself  muscular,  are  questions  on  which  different  opi- 
nions are  entertained.  However,  the  generality  of  mo- 
dern practitioners  in  this  country  incline  to  that  view 
of  the  subject  which  refers- the  property  of  muscular- 
ity either  to  the  membrane  of  the  urethra  itself,  or  to 
the  substance  immediately  surrounding  it.  The  latter 
has  been  alleged  to  be  the  real  case.  “From  Mr. 
Bauer’s  examination  (says  Sir  Everard  Home)  we  find 
that  the  human  urethra  is  made  up  of  two  parts,  an  in- 
ternal membrane,  and  an  external  muscular  covering. 
The  internal  membrane  is  exceedingly  thin,  and  no 
fibres  are  met  with  that  can  give  it  the  power  of  con- 
traction. When  it  is  put  on  the  stretch  in  a transverse 
direction,  the  circumference  of  the  canal  is  no  ways  in- 
creased ; but  when  stretched  longitudinally,  a small  de- 
gree of  elongation  is  produced.  When  a transverse 
section  of  the  urethra  is  made,  while  in  a collapsed 
state,  the  internal  membrane  is  found  thrown  into  folds, 
pressed  together  by  the  surrounding  parts.’’  It  is  af- 
terward explained,  that  “ the  muscular  covering  by 
which  the  membrane  is  surrounded,  or  enclosed,  is 
made  up  of  fasciculi  of  very  short  fibres,  which  ap- 
pear to  be  interwoven  together  and  to  be  connected 
by  their  origins  and  insertions  with  one  another. 
They  all  have  a longitudinal  direction.  There  is  a 
greater  thickness  ’of  this  muscular  structure  upon  the 
upper  than  the  under  surface  of  the  urethia,  which 
is  still  more  evident  as  it  approaches  nearer  to  the 
external  orifice.  The  fasciculi  are  united  together 
by  an  elastic  substance  of  the  consistence  of  mucus. 
Immediately  beyond  the  muscular  portion  of  the 
urethra,  is  the  cellular  structure  of  the  corpus  spon- 
giosum.” 

Formerly,  “ it  was  believed,  that  either  the  lining  of 
the  urethra  was  composed  of  circular  fibres,  possessed 
of  a power  of  contraction,  or  that  it  was  immediately 
surrounded  by  such  fibres  ; and,  therefore,  that  the  dis- 
ease commonly  known  by  the  name  of  a stricture  in 
the  urethra  was  produced  by  a contraction  of  some  of 
these  circular  fibres ; and  that  permanent  stricture  was 
a term  a[)plied  to  these  parts,  when,  in  conse<iuence  of 
inflammation,  they  became  confined  to  that  particular 
state.  We  now  find  that  the  lining  of  the  urethra  is 
never  met  with  in  a contracted  state,  but  is  thrown  into 
folds  by  the  action  of  the  elastic  ligamentous  covering 
of  the  corpus  spongiosum,  and  the  swell  of  the  longi- 
tudinal mnscnldr  (ibres  within  it;  and  when  these  fibres 
have,  by  acting  through  their  whole  length,  reduced  the 
urethra  to  its  shortest  state,  the  pressure  upon  the  in- 
ternal membrane  is  so  great  that  there  is  not  room  for 
the  urine  to  pass,  till  these  fibres  ore  relaxed  by  elon- 
gating the  whole  canal. 


392 


URETHRA. 


A spasmodic  stricture  is  in  reality  a contraction  of 
a small  portion  of  the  longitudinal  muscular  fibres, 
while  the  rest  are  relaxed ; and  as  this  may  take  place 
either  all  around,  or  upon  anyone  side,  it  explains  what 
is  met  with  in  practice,  and  could  not  before  be  satis- 
factorily accounted  for;  the  mark,  or  impression  of  a 
stricture  sometimes  forming  a circular  depression  upon 
the  bougie  ; at  other  times,  only  on  one  side. 

A permanent  stricture  is  that  contraction  of  the  ca- 
nal which  takes  place  in  consequence  of  coagulable 
lymph  being  ezuded  between  the  fasciculi  of  muscular 
fibres,  and  upon  the  internal  membrane,  in  different 
quantities,  according  to  circumstances ; and,  in  the 
same  proportion,  diminishing  the  passage  for  tlie  urine 
at  that  part,  or  completely  closing  it  up.”— (Sir  £ne- 
rard  Home  in  Phil.  Trans.  1820,  and  Tract.  Obs.  on 
Strictures,  vol.  3,  p.  26,  ij-c.  Svo.  Aond.  1821.) 

For  a particular  detail  of  the  arguments  and  remarks 
urged  against  the  doctrine  of  the  urethra  being  a tube, 
capable  of  having  its  diameter  suddenly  lessened  at 
every  point  by  tlie  contraction  of  muscular  fibres,  I 
must  refer  to  the  writings  of  Mr.  C.  Bell  and  Mr.  Shaw, 
whose  statements,  indeed,  have  been  noticed  in  my  in- 
troductory work.— (See  First  Lines  of  the  Practice  of 
Surgery,  p.  595,  cd.  5.) 

In  all  obstructions  of  the  urethra,  the  stream  of  water 
becomes  small  in  proportion  to  the  stoppage  ; but  though 
this  symptom  is  probably  the  first,  it  is  not  always  ob- 
served by  the  patient. 

According  to  Sir  A.  Cooper,  the  earliest  symptom  of 
a stricture  is  the  retention  of  a few  drops  of  urine  in 
the  urethra,  after  the  patient  has  made  water,  which 
drops  soon  escape,  and  slightly  wet  the  linen,  while 
another  small  quantity  of  urine  collected  between  the 
neck  of  the  bladder  and  the  stiicture,  may  be  expelled 
by  pressure  on  the  lower  side  of  the  urethra.  This  in- 
ability of  completely  emptying  the  urethra,  however,  is 
observed  in  the  generality  of  persons  after  a certain 
Hge,  and  even  in  youngish  individuals  who  have  led  ir- 
regular lives : much  stress,  therefore,  cannot  be  laid 
upon  this  circumstance  alone.  The  next  thing  noticed, 
he  says,  is  an  irritable  state  of  the  bladder,  evinced  by 
the  patient  not  being  able  to  sleep  so  long  as  usual,  with- 
out discharging  his  urine.  As  the  disease  increases, 
the  stream  of  urine  is  forked,  spiral,  or  scattered;  and, 
in  a more  advanced  stage,  the  water  is  often  voided 
only  by  drops,  especially  when  the  urethra  is  under  the 
influence  of  cold,  irritation,  or  the  effects  of  intempe- 
rance. When  the  stream  of  urine  is  thus  altered,  or 
broken,  Mr.  Hunter  recommends  the  passage  to  be  ex- 
amined with  a bougie  ; and,  and  if  one  of  a common 
size  can  be  readily  introduced,  the  difficulty  of  voiding 
the  urine  is  likely  to  depend  on  a diseased  enlargement 
of  the  prostate  gland,  which  should  be  examined. — 
(See  Prostate  Gland.) 

The  spasmodic  stricture  may  be  known  by  its  being 
only  of  temporary  duration.  This  kind  of  case,  and 
more  particularly  the  permanent  stricture,  are  gene- 
rally attended  with  a gleet.  The  latter  complaint  is  of- 
ten suspected  to  be  the  only  one,  until  all  efforts  to  pro- 
duce a cure  are  found  to  be  fruitless. 

In  diseases  of  the  urethra,  and  also  of  the  prostate 
gland  and  bladder,  there  is  commonly  an  uneasiness 
about  the  perirueuin,  anus,  and  lower  part  of  the  abdo- 
men.— {Hunter.) 

The  first  progress  of  the  contraction  is  generally  very 
slow  ; but  when  once  it  has  so  far  increased,  that  the 
longitudinal  fibres  are  not  wholly  relaxed  by  the  force 
of  the  urine,  its  subsequent  advances  are  more  rapid, 
and  new  symptoms  are  perceived.  The  urine  is  voided 
more  frequently,  does  not  pass  without  a considerable 
effort,  attended  with  pain  ; and  a straining  setisation 
continues  after  the  bladder  is  emptied.  If  the  patient 
accidentally  catch  cold,  drink  a glass  of  spirituous 
liquor,  acid  beverage,  or  punch,  commit  an  excess  in 
drinking  wine,  or  remove  quickly  from  a warm  to  a 
cold  temperature,  the  urine  will,  perhaps,  pass  only  in 
drops,  or  be  entirely  obstructed.  These  causes  induce, 
in  the  longitudinal  fibres  at  the  contracted  part,  a spas- 
modic aciion  by  which  it  is  closed.  Cold,  externally 
applied  to  the  body,  has  so  great  an  effect  upon  a spas- 
modic stricture,  that  a patient,  who  can  make  water 
without  the  smallest  difficulty  in  a warm  room,  is  often 
quite  unable  to  void  a drop,  on  makinii  the  attempt  in 
the  open  air.  However,  on  returning  to  a warm  room, 
and  sitting  down  .a  little  while,  ho  becomes  able  again 
to  expel  ins  urine.  The  symptoms  of  a stricture  are 


more  frequent  in  persons  who  lead  a sedentary  life 
than  in  others  whose  pursuits  are  active. 

Strictures  in  the  urethra  being  attended  with  a dis- 
charge and  pain  in  making  water,  especially  after  any 
excess,  are  frequently  regarded  and  treated  as  a gonor- 
rlima.  These  two  symptoms  often  come  on  a few 
hours  after  connexion  with  women ; the  degree  of  in- 
flammation is  very  slight ; the  discharge  is  the  first  symp 
tom,  and  is  more  violent  at  the  commencement  than  at 
any  other  period.  Tire  inflammation  subsides  in  a few 
days,  leaving  only  the  discharge,  which  also  frequently 
disappears  in  five  or  six  days,  whether  any  means  be 
employed  or  not  for  its  removal. — (Home.) 

What  renders  a stricture  particularly  apt  to  be  mi.s 
taken  for  a gonorrhcea  is,  that  in  both  diseases,  the  pain 
in  making  water  is  experienced  about  an  inch  and  a 
half  from  the  orifice  of  the  glans  penis. 

In  consequence  of  the  natural  sympathy  between  the 
urethra  and  testicles,  the  latter  organs  are  apt  to  swell 
in  cases  of  stricture ; and  as  there  is  also  a discharge, 
the  disease  is  often  mistaken  for  a common  hernia  hu- 
moralis  from  gonorrhcea,  and  a treatment  on  very 
wrong  principles  is  instituted. 

In  a more  advanced  stage,  the  part  of  the  urethra, 
which  is  the  seat  of  stricture,  is  always  much  narrower 
than  the  rest  of  the  canal.  The  stricture  is  permanent, 
being  combined  with  a thickening  of  structure,  wher^ 
by  the  diameter  of  the  diseased  part  of  the  passage  is 
lessened.  However,  the  diameter  of  the  aflfected  por- 
tion of  the  canal  even  now  varies,  according  as  the 
spasm  and  projection  of  the  longitudinal  fibres,  and  the 
spasmodic  aciion  of  the  muscles  about  the  perinaeum, 
and  the  etfects  of  inflammation,  contribute  more  or  less 
to  a temporary  increase  of  the  obstruction.  In  the  lan- 
guage of  Sir  Everard  Home,  the  case  is  now  both  a 
permanent  stricture  and  a spasmodic  one ; permanent, 
because  the  diseased  part  of  the  urethra  is  always  nar- 
rower than  the  re«tof  this  passage;  and  spasmodic, in- 
asmuch as  the  stricture  may  be  rendered  still  more  con- 
tracted by  spasm  affecting  the  muscular  structure, 
adjoining  the  disease.  In  the  contracted  state,  the 
passage  is  closer!  up  ; in  the  relaxed,  the  urine  can  pass 
through  it  in  a small  stream. 

In  old  cases  of  stricture,  the  muscular  coat  of  the 
bladder  becomes  thickened  and  stronger  than  natural, 
in  consequence  of  more  force  being  necessary  to  pro- 
pel the  urine  through  the  obstructed  part.  The  blad- 
der, in  this  thickened  state,  does  not  admit  of  the  usual 
dilatation,  so  that  the  patient  is  obliged  to  make  water 
very  frequently,  and  he  is  unable  to  pass  the  whole 
night  without  making  this  evacuation  once  or  twice. — 
(Home) 

A noctunial  emission  of  the  semen  is  another  very 
common  symptom  of  a stricture;  and  some  patients 
seem  to  have  no  othej-  complaint  attendant  on  the  dis- 
ease of  the  urethra. 

A periodical  discharge  is  sometimes  brought  on  by 
cold,  or  other  occasional  causes.  When  the  inflamma- 
tion extends  to  the  bladder,  the  frequency  of  making 
water  is  considerably  increased,  and  the  urine  very 
turbid.  It  is  voided  for  twelve  or  twenty-four  hours, 
once  or  even  twice  every  hour;  and,  when  allowed  to 
stand,  it  deposites  a substance  in  the  form  of  powder, 
consisting  of  coagulable  lymph.  This  is  the  slightest 
kind  of  attack. 

Sometimes  the  bladder  is  inflamed  in  a greater  de- 
gree, and  secretes  pus,  which  is  di.«cbarged  with  the 
urine.  In  a still  more  violent  attack,  the  discharge  is 
sindlar  to  the  white  of  an  egg,  and  iiarticularly  adhe- 
sive, being,  according  to  Sir  Everard  Home,  the  vitiated 
secretion  of  the  prostate  gland.  When  the  inflamma- 
tion of  the  bladder  becomes  still  worse,  the  affection 
sometimes  extends  to  the  peritoneum,  and  tlie  patient 
dies. 

As  strictures  of  longstanding  alwaj’s  impede  the  pas- 
sage of  the  urine,  the  bladder  acts  v itii  augmented 
force  to  overcome  the  resistance.  In  this  m:inner,  the 
stricture  is  kept  in  a continual  slate  of  irrilaiioti, 
and  the  obstruction  becomes  more  and  more  consi- 
derable. 

In  a few  cases,  indeed,  the  diseased  part  of  the  ureth- 
ra is  rendered  quite  impervious;  and  the  paiiimt's  life 
is  preserved  by  the  urethra  ulcertiiitig  at  some  point 
wiihin  the  obikniction,  and  fistulous  openitigs  taking 
place  in  the  pcrina'iim.— (Pee  Fi.-^tulw  in  Perina-o.) 

As  Sir  A.  Cooper  has  correctly  observed,  piles  are 
sometimes  a consequence  of  strictures;  and  the  efforts 


URETHRA.  393 


made  to  expel  the  urine,  are  occasionally  a cause  of 
the  direct  or  internal  inguinal  hernia. 

Strictures  are  frequently  attended  with  constitutional 
symptoms,  one  of  which  is  a complete  paroxysm  of 
fever.  The  cold  fit  is  very  severe;  this  is  followed  by 
a iiot  fit,  and  then  a profuse  perspiration.  During  the 
rigor  nausea  and  vomiting  generally  occur,  and  at  this 
period  the  patient  has  occasion  to  make  water  fre- 
quently, seldom  experiencing  at  the  same  time  any 
strangury.  When  the  fit  is  tolerably  complete,  the  pa- 
tient suffers  in  general  only  one ; in  the  opposite  cir- 
cumstance two  ; but  a greater  number  rarely  happens. 
Such  febrile  paroxysms  are  most  frequent  in  warm 
countries ; but  do  every  now  and  then  take  place  in 
this  climate,  particularly  in  consequence  of  exposure 
to  cold,  excesses,  and  the  introduction  both  of  common 
and  armed  bougies.  They  are  also  said,  by  Sir  A. 
Cooper,  to  be  common  in  that  stage  of  the  disease 
in  which  the  urine  is  blended  with  pus. 

According  to  the  principles  of  Sir  Everard  Home,  the 
longitudinal  muscular  fibres  on  the  outside  of  the  mem- 
brane of  the  urethra  are  liable  to  a spasmodic  contrac- 
tion, in  which  state  their  swell  lessens  the  diameter  of 
the  passage,  and  they  are  incapable  of  becoming  re- 
laxed again  until  the  spasm  is  removed.  This  spas- 
modic stricture  is  only  a wrong  action  of  these  longi- 
tudinal fibres;  and,  if  the  parts  could  be  examined  in 
their  relaxed  state,  there  would  be  no  appearance  of 
disease. 

When  the  contraction  is  not  considerable,  it  appears, 
on  examination  after  death,  to  be  merely  a narrowing 
of  the  urethra;  but  a permanent  stricture,  in  a more 
advanced  state,  usually  consists  of  a ridge,  which 
forms  a projection  in  the  passage. — {Home.)  The  lat- 
ter form  of  the  disease  is  now  described  by  the  gene- 
rality of  modern  writers  as  the  effect  of  chronic  in- 
flammation.— (C.  Bell.,  Boyer,  Sir  A.  Cooper,  Src.) 

Mr.  Hunter  informs  us,  that  the  disease  generally 
occupies  no  great  length  of  the  passage  ; at  least,  that 
this  was  the  case  in  most  of  the  instances  which  he 
examined.  In  these  cases,  the  contraction  was  not 
broader  than  if  it  had  been  produced  by  surrounding 
the  urethra  with  a piece  of  packthread  ; and  in  many 
it  had  a good  deal  of  the  appearance  which  one  may 
fancy  such  a cause  would  produce.  He  had  seen, 
however,  the  urethra  contracted  for  more  than  an  inch 
in  length,  owing  to  its  coats  or  internal  membrane  be- 
ing irregularly  thickened,  and  forming  a winding  ca- 
nal. I lately  saw  a man  in  the  King’s  Betich  prison, 
whose  urethra  was  completely  obliterated  from  the 
glans  to  the  perinteum,  where  a fistula  was  situated, 
out  of  which  he  voided  his  urine.  Besides  these  forms 
of  stricture.  Sir  A.  Cooper  used  to  show  in  his  lectures 
a kitid  of  stricture  produced  by  the  extension  of  a 
membranous  band  across  the  passage. 

According  to  Mr.  Stafford,  the  contractions  which 
occupy  a considerable  extent  of  the  passage  are  gene- 
rally extremely  irregular;  and  their  structure  resembles 
that  of  cartilage,  being  indurated  and  totigh.  In  these 
cases,  which  are  usually  of  long  standing,  the  mem- 
brane likewise  partakes  of  the  change,  being  firmer 
and  thicker  than  natural. — {On  Strictures,  Src.p.  II.) 

A stricture  does  not  always  arise  from  an  equal 
contraction  of  the  urethra  all  round ; for  in  some  in- 
stances, the  contraction  is  only  on  one  side;  a fact 
which  appears  to  me  to.  be  better  accounted  for  by  the 
consideration  of  the  longitudinal  arrangement  of  the 
muscular  fibres  in  packets  on  the  outside  of  the  mem- 
brane of  the  urethra,  than  the  circular  kind  of  stricture 
only  occupying  as  small  an  extent  of  the  passage  as 
the  constriction  which  would  arise  from  the  application 
of  a piece  of  packthread  round  it.  The  contraction  of 
one  side  of  the  canal  only  throws  the  passage  to  the 
opposite  side,  which  often  renders  the  introduction  of  a 
bougie  difficult.  The  contracted  part  is  whiter  than 
the  rest  of  the  urethra,  and  is  harder  in  its  consistence. 
In  some  cases  tliere  are  several  strictures.  Mr.  Hunter 
saw  half  a dozen  in  one  urethra,  and  he  observes,  tlmt 
a stricture  is  frequently  attended  with  small  tightnesses 
in  other  parts  of  the  passage.  According  to  the  same 
authority,  every  part  of  the  tirethra  is  not  equally 
subject  to  strictures,  the  bulbous  portion  being  much 
the  most  subject  to  them.  A stricture  is  sometimes 
situated  on  this  side  of  the  bulb,  hut  very  sehlorn  be- 
yond it,  that  is,  nearer  the  bladder.  Mr.  Hunter  never 
saw  a stricture  in  that  part  of  the  uiethra  which 
passes  through  the  prostate  gland ; and  the  bulb,  be- 


sides being  the  most  frequent  seat  of  this  disease,  is 
also  subject  to  it  in  its  worst  forms. 

Sir  Everard  Home  njeasured  the  length  of  the  ure- 
thra in  different  subjects,  and  examined  the  diameters 
of  the  several  parts  -of  the  passage.  Strictures,  ac- 
cording to  this  gentleman,  occur  most  commonly  just 
behind  the  bulb  of  the  urethra,  the  distance  from  the 
external  orifice  being  6^  or  7 inches.  The  situation 
next  in  the  order  of  frequency  is  about  4|  inches  from 
the  orifice  of  the  glans.  The  disease  does  also  occur 
at  3§  inches,  and  sometimes  almost  close  to  the  exter- 
nal orifice.  The  two  parts  of  the  urethra  most  fre- 
quently affected  with  strictures  are  naturally  the  nar- 
rowest. Sometimes  the  very  orifice  of  the  urethra  is 
contracted,  and  the  circumstance  often  leads  to  an  er- 
roneous supposition,  that  the  whole  canal  is  naturally 
formed  of  the  same  size.  In  cases  of  strictures  the 
prepuce  alsrj  is  observed  to  be  particularly  often  affected 
with  a natural  phyraosis. 

In  almost  all  the  cases  which  Sir  E.  Home  met  with 
there  was  one  stricture  about  seven  inches  from  the 
external  orifice,  whether  there  were  any  others  or  not. 

We  have  seen  that  Mr.  Hunter  and  Sir  E.  Home  do 
not  agree  respecting  the  most  frequent  place  of  stric- 
tures. Sir  A.  Cooper  also  partly  differs  from  both 
these  authorities ; for,  though  he  coincides  with  Mr. 
Hunter,  in  setting  down  the  most  common  situation  to 
be  in  front  of  the  bulb,  just  where  this  part  joins  the 
corpus  spongiosum,  yet  he  varies  from  both  in  repre- 
senting strictures  in  the  membranous  and  prostatic 
portions  of  the  urethra  as  next  in  order  of  frequency. 
Here,  however,  he  may  comprehend  the  variations  in 
the  course  of  the  urethra,  and  the  obstruction  to  the 
passage  of  the  urine  attending  disease  of  the  prostate 
gland , cases  generally  considered  as  a separate  subject. 

Among  the  consequences  of  the  disease  which  are 
found  on  dissection  are,  first,  in  very  bad  cases,  a great 
dilatation  of  the  urethra  behind  the  stricture ; secondly, 
a considerable  thickening  of  the  coats  of  the  bladder, 
as  already  mentioned;  thirdly,  enlargement  of  the 
ureters,  an  effect  of  their  being  distended  with  urine 
during  the  retentions  common  in  the  advanced  stages 
of  the  disease;  fourthly,  the  kidneys  are  often  dis- 
eased, their  glandular  structure  behig  sometimes  en- 
tirely destroyed,  and  the  rest  of  them  enormously  di- 
lated ; a mode  in  which  the  case  may  prdve  fatal. 
The  prostate  gland  is  frequently  enlarged  ; abscesses 
are  occasionally  found  in  it,  with  fistulce  leading  from 
them  to  the  perinteum  or  parts  around,  and  its  natural 
ducts  are  often  considerably  dilated. — (See  Stafford  on 
Strictures,  Src.  p.  41,  ed.  2.) 

The  portion  of  the  urethra  between  the  stricture  and 
the  bladder  is  generally  more  or  less  inflamed ; and 
ulceration  of  it  much  disposed  to  take  place,  and  to 
lead  to  abscesses  and  fistulse  in  the  perinasum. 

With  respect  to  the  causes  of  strictures,  some  writers 
have  imputed  the  disorder  to  the  effects  of  gonorrhtea, 
and  often  to  the  method  of  cure.  Mr.  Hunter  enter- 
tained strong  doubts,  how'ever,  whether  strictures 
commonly  or  ever  proceeded  from  those  causes ; 
though  he  acknowledges,  that  since  most  men  have 
had  gonorrhoea,  a refutation  of  the  opinion  is  very 
difficult.  He  w'as  led  to  think,  that  strictures  did  not 
commonly  arise  from  such  causes,  by  reflecting  that 
they  are  common  to  most  passages  in  the  human  body. 
They  often  take  jdace  in  the  oesophagtis;  the  intes- 
tines, particularly  the  rectum  ; the  anus;  the  prepuce, 
so  as  to  produce  phymosis  ; and  in  the  lachrymal  duct, 
so  as  to  occasion  a fistula  lachrymalis.  Strictures 
sometimes  take  place  when  there  have  been  no  pre- 
vious venereal  complaints.  Mr.  Hunter  saw  an  in- 
stance of  this  kind  in  a ^’oung  man,  nineteen  years  of 
age,  who  had  had  the  complaint  for  eight  years,  and 
which  therefore  began  when  he  was  only  eleven  years 
old.  He  was  of  a weak  scrofulous  habit.  Mr.  Hunter 
had  also  seen  a stricture  in  a boy  only  four  years  old, 
and  a fistula  in  perin.'co  in  consequence  of  it.  Stric- 
tures, he  says,  happen  as  frecpiently  in  persons  who 
have  had  gonorrheea  in  a slight  degree  as  in  others 
who  have  had  it  in  a severe  form. 

However,  it  must  not  be  dissembled,  that  many  very 
judicious  and  experienced  men  still  regard  Mr.  Hunter’s 
conclusions  on  this  question  as  erroneous,  and  Sir  A. 
Cooper  in  particular  differs  from  him  so  much  as  to 
say,  that  he  considers  gonorrhoea  in  ninety-nine  cases 
out  of  a hundred  to  be  the  cause  of  strictures.  At  the 
same  time,  he  admits  the  possibility  of  thei;  origin 


394 


URETHRA. 


from  other  causes,  and  mentions  a case  which  he  saw 
himself,  and  which  arose  from  an  injury  received  by  a 
child  as  it  was  riditig  on  horseback.  Delpech  also  de- 
scribes strictures  as  a very  frequent  consequence  of 
gonorrhoea;  and  lie  is  a zealous  advocate  for  cubebs 
and  copaiba  in  this  last  disorder,  because  his  observa- 
tions lead  him  to  believe,  that,  by  shortening  its  dura- 
tion, they  materially  lessen  the  chance  of  strictures. — 
{Clinique  de  Chir.  p.  271.) 

It  is  not  an  uncommon  belief,  that  strictures  arise 
from  the  use  of  astringent  injections  in  the  treatment 
of  the  gonorrhoea.  Sir  Everard  Home  is  of  this  senti- 
ment, and  so  was  the  late  Mr.  Wilson.— (On  the  Male 
Genital  and  Urinary  Organs^  p.  370.)  The  latter 
gentleman,  however,  mentions  some  circumstances 
calculated  to  raise  doubts  on  this  point,  especially  the 
fact,  that  while  injections  rarely  enter  far  into  tlie 
urethra,  the  most  common  seat  of  a stricture  is  where 
the  membranous  part  of  the  canal  joins  the  bulh.  Mr. 
Hunter  himself  deemed  the  opinion  founded  on  preju- 
dice, and  slates  that  he  had  seen  as  many  strictures 
after  gonorrlHsa,  which  had  been  cured  without  injec- 
tions, as  after  cases  which  had  been  treated  with  these 
latter  applications. 

He  rejected  also  the  old  doctrine,  that  strictures  are 
a consequence  of  ulcers  in  the  urethra;  for,  ulcers 
hardly  ever  occur  in  this  passage,  except  when  there 
are  strictures ; and  it  is  now  generally  admitted,  that 
in  gonorrhoea  there  are  no  sores  in  the  urethra.  Stric- 
tures are  sometimes  produced  by  external  violence, 
though  the  passage  would  appear  to  be  capable  of 
frequently  bearing  considerable  wounds  and  other  in- 
juries without  this  consequence.  Thus,  strictures  are 
not  common  from  lithotomy,  and  in  a modern  work 
we  read  the  case  of  a serious  gun-shot  wound  of  the 
urethra,  where  no  stricture  ensued. — (See  Annuaire 
Med.  Chir.  des  Hdpitaux  de  Paris,  ito.  1819.) 

According  to  a well  informed  modern  writer,  stric- 
tures are  mostly  preceded  by  a state  of  the  passage, 
called  an  irritable  urethra,  which  has  great  share  in 
bringing  them  on.  The  morbid  sensibility  by  which  it 
is  chiefly  characterized  may  affect  the  whole  passage, 
or  only  part  of  it,  in  which  last  case  the  prostatic  portion 
is  almost  always  that  which  is  affected.  In  cases  of  ir- 
ritable urethra,  the  size  of  the  stream  of  urine  varies 
remarkably  at  different  times,  the  variation  being,  it  is 
said,  much  greater  than  in  examples  of  stricture. — (See 
Macilwain' s Treatise,  p.  9,  d-c.)  There  can  be  no 
doubt  that  what  this  gentleman  has  so  well  described 
as  the  irritable  urethra,  is  the  same  case  which  some 
other  writers  denominate  spasmodic  stricture. 

SPASMODIC  STRICTURES,  OR  IRRITABLE  URETHRA. 

These  cases  should  be  treated  by  removing  the  cause, 
and,  if  they  depend  upon  disordered  digestion,  as  is 
sometimes  alleged,  whatever  gives  rise  to  this  slate 
must  be  avoided  or  removed.  If,  says  Mr.  Stafford, 
the  spasmodic  stricture  depend  upon  the  extreme  irri- 
tability of  the  urethra,  occasioned  by  a morbid  irrita- 
bility of  the  stomach,  and  produced  by  some  irritating 
cause  in  that  organ,  we  should  remove  the  offending 
matter,  or  neutralize  its  effects;  we  may  also  exhibit 
opium,  camphor,  and  other  antispasmodics,  or  employ 
fomentations.  If  the  urine  be  of  too  stimulating  a 
quality,  mucilaginotrs  drinks  and  alkalies  may  be  pre- 
scribed. The  diet  should  be  plain,  and  medicines  given 
to  promote  digestion  and  the  excretions.  Whenever 
the  evacuation  of  urine  is  attended  w'ilh  much  pain, 
spasm,  and  a diminution  of  the  stream,  leeches  should 
be  applied  to  the  perinaeum,  the  patient  put  into  the 
warm  bath,  and  aperients  given.  These  remedies  are 
to  be  repeated  at  least  twice  a week  or  ofiener,  ac- 
cording to  circumstances.  When  the  pain  and  irrita- 
tion in  the  urethra  have  subsided,  and  not  sooner,  a 
bougie  may  be  introduced  to  ascertain  the  state  of  the 
passage.  If  the  instrument  give  much  pain,  and  be 
quite  resisted  by  spasm,  it  is  to  be  concluded,  that  the 
inflammation  of  the  urethra  is  not  subdued,  and  the 
antiphlogistic  soothing  means,  leeches,  low  diet,  foment- 
ations, opium,  hyosciamus,  cotiium,  subcarbonate  of 
potash,  opiate  clysters,  and  purgative  medicines,  must 
be  continued.  Afterward,  that  is  to  say,  when  the 
inflammation  has  been  quite  subdued,  the  morbid  irri- 
tability of  the  urethra  may  be  removed  by  the  gentle 
and  occa.sional  employment  of  bougies  or  catheters. — 
(See  Stafford  on  Strictures,  p.  42,  tS-c.) 


TREATMENT  OF  STRICTURES  WITH  COMMON  BOU- 
GIES, ON  THE  PRINCIPLE  OF  DILATATION. 

The  cure  of  strictures  may  be  accomplished  either 
by  a dilatation  of  the  contracted  part,  or  a destruction 
of  it  by  ulceration  or  escharotics.  To  these  methods 
are  to  be  added,  first,  the  plan  of  forcing  a passage 
through  the  stricture  with  a conical  sound,  as  practised 
by  Uie  French  surgeons  when  they  cannot  otherwise 
get  through  the  stricture,  and  the  symptoms  are  ur- 
gent.—(See  J.  Cross, Sketches  of  the  Medical  Schools  of 
Paris,  8vo.  Land.  1815,  p.  Ill  ; and  First  Lines  of  the 
Practice  of  Surgery,  ed.  5.)  Secondly,  the  melliod  of 
cutting  down  to  obliterated  portions  of  the  urethra, 
and  attempting  to  cure  tlie  obstruction  by  the  removal 
of  the  diseased  parts,  tracing  the  continuation  of  the 
passage,  and  trying  to  heal  the  wound  over  a catheter. 
Both  these  practices  are  attended  with  such  difficulties 
and  dangers,  as  should  make  a prudent  surgeon  reluc- 
tant to  adopt  them,  except  under  the  most  urgent  cir- 
cumstances, in  which  every  milder  method  fails.  Third- 
ly, the  practice  of  perforating  strictures  with  a sharp 
instrument  introduced  from  the  orifice  of  the  urethra. 
The  dilatation  is  accomplished  by  means  of  bougies, 
catheters,  and  dilators;  but  Mr.  Hunter  considered 
that  a cure  effected  on  this  principle  was  seldom  or 
never  more  than  temporary.  The  removal  of  stric- 
tures by  ulceration  may  also  be  eflfected  with  bougies  ; 
their  destruction  is  accomplished  with  caustic  or 
armed  bougies. 

The  cure  by  dilatation  is  principally  mechanical 
when  effected  by  bougies,  the  powers  of  which  are 
generally  those  of  a wedge.  However,  Mr.  Hunter 
conceived  that  their  ultimate  eflfect  was  not  always  so 
simple  as  that  of  a wedge  upon  inanimate  matter  ; for 
pressure  makes  living  parts  either  adapt  themselves  to 
their  new  position,  or  else  recede  by  ulceration.  Bou- 
gies, of  course,  either  dilate  strictures,  or  make  them 
ulcerate. 

The  disease  has  generally  made  considerable  pro- 
gress before  surgical  assistance  is  required ; and  the 
stricture  may  be  so  advanced,  that  a small  bougie 
cannot  be  made  to  pass  without  a great  deal  of  trou- 
ble. If  the  end  of  a small  bougie,  let  it  be  ever  so 
small,  can  be  introduced  through  the  stricture,  the 
cure  is  then  in  our  power.  However,  a small  bougie 
frequently  cannot  pass  in  the  first  instance,  and  even 
not  after  repeated  trials. 

Often  when  the  stricture  is  very  considerable,  a 
great  deal  of  trouble  is  given  by  occasional  spasms, 
which  either  resist  the  introduction  of  a bougie  altoge- 
ther, or  only  allow  a very  small  one  to  pass.  At  other 
periods,  however,  a larger  one  may  be  introduced.  In 
these  circumstances,  Mr.  Hunter  sometimes  made  the 
point  of  the  bougie  enter,  by  rubbing  the  outside  of  the 
perinaeum  with  the  finger  of  one  hand,  while  he  pushed 
the  bougie  on  with  the  other.  He  also  frequently  suc- 
ceeded by  letting  the  bougie  remain  a little  while  close 
to  the  stricture,  and  then  pushing  it  on.  Sometimes 
the  spasm  may  be  taken  off"  by  dipping  the  glans  penis 
in  cold  w’aler. 

Although,  in  cases  of  pemianent  strictures,  the  bou- 
gie may  not  pass  at  first,  yet,  after  repeated  trials,  it 
will  every  now  and  then  find  its  way.  In  this  man- 
ner, future  attempts  become  more  certain  and  easy. 

However,  the  success  of  the  subsequent  trials  to 
introduce  a bougie,  does  not  always  depend  on  the  in- 
strument having  been  once  or  twice  passed.  Sonte- 
times  it  can  be  introduced  to-day,  but  not  to  morrow ; 
and  in  this  stale  the  case  may  continue  for  weeks, 
notwithstanding  every  trial  which  can  be  made.  But, 
according  to  Mr.  Hunter,  the  introduction  ofthe  bougie 
generally  becomes  gradually  less  difficult. 

According  to  Delpech,  when  the  stricture  is  not  very 
close,  and  permits  the  urine  to  flow  out  in  a moderate 
jet,  a fine  gum  elastic  bougie  steadily  pushed  on,  while 
the  urethra  is  rendered  tense  by  the  penis  being  drawn 
forwards,  will  pass  as  far  as  the  bladder  after  some 
little  difficulty,  at  the  contracted  point  of  the  canal.  If 
there  exist  at  the  same  lime  a sliglit  swelling  of  the 
sides  of  the  passage,  the  instrument  may  not  h.ave  con- 
sistence enough  to  overcome  the  obstacle,  which  may 
be  in  other  resjtecfs  only  moderate.  In  this  circum- 
stance, Delpech  reconuTtends  the  use  of  a hollow  but 
fine  bougie,  containing  a whalebone  stilet,  whereby 
the  necessary  snpiileness  and  consistence  of  the  instru- 
ment will  be  united.  But,  he  observes,  the  swelling  of 
the  parictes  of  the  canal  is  nut  always  uniform; 


URETHRA. 


395 


hence,  deviations  in  the  course  of  the  passage.  Also, 
he  says,  though  ulcerations  in  it  are  very  uncommon, 
yet  they  do  occur ; and  tlieir  cicatrices  are  sometimes 
accompanied  with  deformity : hence,  unusual  peculiari- 
ties in  the  s hape  of  the  canal  in  the  situation  of  the 
stricture.  Possibly,  by  various  examinations  made 
with  a bougie,  the  principal  difficulty  to  its  introduc- 
tion may  be  found  to  lie  especially  on  one  particular 
side  of  the  passage,  so  that  a determinate  inclination 
of  the  end  of  the  bougie  would  elude  the  impediment. 
In  such  a case,  Delpech  has  found  great  advantage  in 
the  use  of  fine  flexible  catheters,  or  hollow  bougies, 
containing  a small  leaden  stilet;  the  end  of  an  instru- 
ment of  this  kind  being  capable  of  receiving  and  retain- 
ing a slight  bend  purposely  given  to  it,  and  by  means 
of  which  the  obstacle  at  the  contracted  point  of  the 
canal  is  avoided,  and  the  catheter  or  bougie  passes 
into  the  bladder.  Delpech  then  adverts  to  other  exam- 
ples, in  which  the  stricture  is  such  that  no  bougie  can 
penetrate  it.  If  the  stricture  and  attendant  swelling 
be  then  of  small  extent,  he  first  employs  catgut  bougies 
of  greater  or  less  fineness,  softening  their  ends  by 
biting  them,  and  letting  the  saliva  penetrate  them,  so 
as  to  give  them  the  form  of  a small,  very  supple  pencil. 
When  the  catgut  (as  often  happens  in  such  a case) 
passes  beyond  the  obstruction,  Delpech  fastens  it  to 
the  penis,  keeps  the  patient  perfectly  quiet,  apd 
changes  the  dilating  substance  every  two  hours,  in- 
creasing its  diameter  every  time.  Immediately  there 
is  room  enough  for  the  admission  of  a small  bougie 
(which  should  be  before  the  end  of  the  day),  he  em- 
ploys the  latter,  and  relinquishes  the  catgut.  A catgut 
bougie,  he  says,  ought  to  be  changed  thus  frequently, 
because  the  moisture  of  the  passage  makes  it  swell, 
and  untwists  it  in  an  irregular  manner,  so  that  knots 
are  liable  to  be  formed  and  render  its  extraction  very 
difficult  and  painful,  attended  sometimes  with  an 
actual  laceration.  The  catgut  may  even  break,  when 
it  has  been  left  in  the  passage  too  long  and  the  surgeon 
attempts  to  withdraw  it.  What  remains  behind  may 
then  glide  into  the  bladder,  and  become  the  nucleus  of 
a calculus. — {Delpech^  Clinique  de  Chir.  p.  273.) 

When  the  passage  is  very  small,  it  is  not  easy  to 
know  whether  the  bougie  "has  entered  the  stricture  or 
not ; for  bougies  as  slender  as  those  which  must  be  at 
first  employed,  bend  so  readily,  that  the  surgeon  is  apt 
to  fancy  that  they  are  passing  along  the  urethra,  while 
they  are  only  bending.  Mr.  Hunter  advises  the  surgeon 
first  to  make  himself  acquainted  with  the  situation  of: 
the  stricture,  fay  means  of  a common-sized  bougie ; and 
then  to  take  a smaller  one,  and  when  its  point  arrives 
at  the  stricture,  the  instrument  is  to  be  gently  pushed 
forwards,  but  only  for  a short  time.  If  the  bougie  has 
passed  farther  into  the  penis,  the  surgeon  may  know 
how  far  it  has  entered  the  stricture,  by  taking  the 
pressure  off  the  bougie;  for  if  it  recoil^  he  may  be  sure 
that  it  has  not  passed  ; at  least,  has  not  passed  far,  but 
only  bent.  On  the  contrary,  if  it  remain  fixed  and  do 
not  recoil,  it  has  certainly  entered  the  stricture. 

However,  the  preceding  remarks  are  said  not  to  be 
so  applicable  when  a very  fine  bougie  is  employed, 
which  may  become  bent  without  our  being  aware  of 
the  circumstance. 

For  very  close  strictures,  catgut  bougies,  or  the 
smallest  elastic  gum  catheters,  are  sometimes  the  most 
successful  instruments  to  begin  with  ; the  latter  I can 
recommend  from  repeated  experience. 

A bougie  may  frequently  be  introduced  a little  way, 
for  instance,  only  one-tenth  of  an  inch,  and  then  it 
bends,  and  cannot  be  pushed  farther.  To  determine 
whether  this  is  the  case,  Mr.  Hunter  says  it  is  neces- 
sary to  withdraw  the  bougie  and  examine  its  end.  If 
the  end  be  blunted,  we  may  be  sure  that  the  bougie 
lias  not  entered  at  all  ; but  if  it  be  flattened  for  an  eighth 
or  tenth  of  an  inch,  be  grooved,  or  have  its  outer 
waxen  coat  pushed  up  to  that  extent,  or  if  there  be  a 
circular  impression  made  upon  the  bougie,  or  only  a 
dent  on  one  side  made  by  the  stricture,  we  may  be 
sure  that  the  instrument  has  passed  as  far  as  these 
appearances  extend.  It  then  becomes  necessary  to 
introduce  another  of  exactly  the  same  size,  and  in  the 
same  manner,  and  to  let  it  remain  as  long  as  the  patient 
can  bear  it  or  convenience  will  allow.  By  repetitions 
of  this  plan  the  stricture  will  be  overcome. 

When  wax  bougies  are  employed.  Sir  A.  Cooper  in 
hU  lectures  recommends  the  surgeon  always  to  give 


them  the  natural  curvature  of  the  passage  before  their 
introduction.  He  also  approves  of  the  plan  of  warm- 
ing the  bougie  first  used,  so  that  it  may  be  soft  enough 
to  receive  the  impression  of  the  stricture,  and  show  its 
form  and  situation.  After  the  first  bougie  is  with- 
drawn, he  directs  one  of  rather  larger  size  to  be  intro- 
duced, and  as  soon  as  this  is  taken  out,  another  of  still 
larger  size  to  be  introduced.  On  repeating  the  opera- 
tion, two  bougies  are  again  introduced ; the  first 
being  of  the  same  size  as  that  last  used,  and  the  second 
of  an  increased  diameter.  By  continuing  this  method, 
he  assures  us  that  strictures  may  be  more  speedily 
cured  than  in  the  ordinary  mode.  He  does  not  con- 
sider it  necessary  to  let  the  bougie  remain  any  length 
of  time  in  the  urethra. 

Mr.  Hunter  remarks,  that  the  time  which  each  bou- 
gie ought  to  remain  in  the  passage  must  be  determined 
by  the  feelings  of  the  patient;  for,  if  possible,  no  pain 
should  ever  be  given.  If  the  patient  should  experience 
very  acute  pain  when  the  bougie  is  passing,  it  ought 
not  to  be  left  in  the  urethra  above  five,  or  at  most  ten 
minutes,  or  not  so  long  if  the  pain  be  exceedingly 
severe.  Each  time  of  application  should  afterward 
be  lengthened  so  gradually  as  to  be  imperceptible  to 
the  feelings  of  the  patient  and  the  irritability  of  the 
parts.  Mr.  Hunter  affirms  that  he  has  known  many 
patients  who  could  not  hear  a bougie  to  remain  in  the 
passage  ten,  or  even  five  minutes,  till  after  several  days, 
and  even  weeks,  but  who  in  time  were  able  to  wear 
the  instrument  for  hours,  and  this  at  last  without  any 
difficulty.  The  best  time  for  keeping  a bougie  in  the 
urethra  is  when  the  patient  has  least  to  do  ; or  in  the 
morning  while  he  is  in  bed,  if  he  can  introduce  the  in- 
strument himself. 

The  bougie  should  be  increased  in  size  according  to 
the  facility  with  which  the  stricture  becomes  dilated, 
and  the  ease  with  which  the  patient  bears  the  dilata- 
tion. If  the  parts  are  very  firm  or  irritable,  the  in- 
crease of  the  size  of  the  bougie  should  be  slow,  so  as 
to  allow  them  to  become  gradually  adapted  to  the  aug- 
mented size  of  the  instrument.  But  if  the  sensibility 
of  the  parts  will  allow,  the  increase  of  the  size  of  the 
bougie  may  be  somewhat  quicker,  but  never  more 
sudden  than  the  patient  can  easily  bear.  The  surgeon 
must  continue  to  increase  the  size  of  the  bougie  till  one 
of  large  size  can  freely  pass ; nor  should  the  use  of  this 
be  discontinued  till  after  three  weeks  or  a month,  in 
order  that  the  dilated  part  may  have  time  to  become 
habituated  to  its  new  position,  and  lose  its  disposition 
to  contract  again.  However,  Mr.  Hunter  believed  that 
the  permanency  of  a cure,  effected  on  the  principle  of 
dilatation,  could  seldom  be  depended  upon.  I am  de- 
cidedly of  opinion  with  Sir  A.  Cooper,  that  no  bougies 
should  ever  be  used  which  are  larger  than  those  now 
usually  numbered  14. 

With  respeetto  dilators,  as  they  are  called,  I shall  here 
merely  observe  that  their  use  is  far  from  being  much 
approved  by  the  best  modern  surgeons,  and  their  em- 
ployment is  impossible,  except  when  the  stricture  will 
permit  the  entrance  of  a bougie,  or  other  instrument 
of  small  size;  in  which  event  the  dilator  is  deemed 
unnecessary,  because  the  other  instrument  will  operate 
with  greater  facility  and  certainty. — (See  Macihoaiu 
on  Strictures.) 

At  the  present  day,  many  surgeons  prefer  bougies 
composed  of  metal,  flexible  enough  to  allow  their  cur- 
vature to  be  adapted  to  the  bend  of  the  urethra,  yet 
sufficiently  firm  to  retain  the  figure  given  them  while 
they  are  employed.  These  instruments  do  not  seem  to 
me  eligible  in  the  commencement  of  the  treatment, 
unless  made  with  a conical  point.  Others  use  iron 
sounds,  which,  in  cases  where  it  Ls  necessary  to  have 
an  instrument  possessing  more  firmness  than  a wax 
bougie,  and  having  a point  more  unchangeably  turned 
upwards  than  that  of  the  latter  instrument,  may  have 
advantages.  Sir  A.  Cooper  commonly  uses  what  he 
calls  a silver  bougie,  shaped  like  a catheter,  but  conical 
towards  the  point,  and  gradually  increasing  in  breadth 
for  some  distance  from  it.  The  situation,  form,  and 
size  of  the  stricture  having  been  first  ascertained  with 
a wax  bougie,  the  silver  one  is  introduced,  the  point  of 
which  is  passed  into  the  strictute,  and  dilates  it  more 
and  more  the  farther  it  enters.  When  this  instrument 
is  not  at  hand,  a silver  catheter  may  be  used  instead  of 
it.  Respecting  the  shape  of  catheters  and  instruments 
in  iioueral  for  the  urethra,  an  observation  has  been 


396 


URETHRA. 


made  by  Mr.  Stanley,  which  merits  great  attention ; 
viz.  that  according  to  the  natural  course  of  the  ure- 
thra, as  indicated  by  careful  dissection,  the  part  of 
them  corresponding  to  the  curve  of  the  urethra  under 
the  arch  of  the  pubes  should  form  a considerable  seg- 
ment of  a circle,  about  one  and  a half  or  two  inches  in 
diameter,  and  the  remainder  be  perfectly  straight.— 
(See  Macilwain  on  Strictures.)  For  all  ordinary 
cases,  I consider  a common  wax,  or  flexible  metallic 
bougie,  the  safest  and  best  instrument ; one  with  which 
the  surgeon  is  less  apt  to  exert  unwarrantable  force, 
so  as  to  occasion  a dangerous  degree  of  irritation,  or, 
what  is  worse,  a false  passage;  but,  in  obstinate  or 
urgent  cases,  other  means  are  certainly  proper,  and, 
among  them,  the  conical  silver  bougie  or  sound, 

CURE  OF  STRICTURES  BY  ULCERATION. 

This  is  also  accomplished  by  means  of  a bougie,  or 
metallic  instrument,  and  the  plan  may  be  tried  both 
when  they  can  or  cannot  be  kitroduced  through  the 
stricture.  In  the  first  instance,  the  method  is  less  pro- 
per, because  the  stricture  admits  of  being  dilated. 

In  order  to  cure  a stricture  by  making  it  ulcerate,  the 
bougie  is  to  be  introduced  as  far  through  the  contracted 
part  as  possible,  and  the  size  of  the  instrument  is  to  be 
augmented  as  fast  as  the  sensations  of  the  patient  can 
well  bear.  In  this  manner  ulceration  will  be  produced 
in  the  part  which  is  pressed  ; and  Mr.  Hunter  remarks, 
that  the  cure  will  be  more  lasting,  because  more  of  the 
stricture  is  destroyed  than  when  the  parts  are  simply 
dilated.  This  eminent  surgeon  notices,  however,  that 
few  patients  will  submit  to  this  practice,  and  that  few, 
indeed,  would  be  able  to  bear  it,  since  it  is  apt  to  bring 
on  violent  spasms  in  the  part,  attended  wiUi  a very 
troublesome  retention  of  urine. 

If  the  smallest  bougie  cannot  be  made  to  pass  a 
stricture,  by  using  some  degree  of  force,  dilatation  be- 
comes impracticable ; and  as  the  stricture  must  be  de- 
stroyed, something  else  must  be  tried.  In  many  cases, 
says  Mr.  Hunter,  it  may  be  proper  to  get  rid  of  the 
stricture  by  making  it  ulcerate.  Bougies,  intended  to 
excite  ulceration,  need  not  be  so  small  as  in  the  fore- 
going cases,  as  they  are  not  designed  to  be  passed 
through  the  stricture;  and  in  consequence  of  being  of 
middling  size,  they  may  be  more  surely  applied  to  the 
parts  causing  the  obstruction.  The  force  applied  to  a 
bougie,  in  this  case,  should  not  be  great ; for  a stricture 
is  the  hardest  part  of  the  urethra  ; and  if  a bougie  is 
forcibly  pushed  on,  it.s  end  may  slip  off  the  stricture 
before  ulceration  has  commenced,  and  make  a false 
passage  for  itself  in  the  corpus  spongiosum  urethree. 

In  trying  to  cure  strictures  by  ulceration,  the  utmost 
attention  must  be  paid  ; and  if  the  patient  does  not 
make  water  better,  notwithstanding  the  bougie  ’passes 
farther,  the  surgeon  may  be' sure  that  he  is  forcing  a 
false  passage. 

When  the  stricture  has  so  far  yielded  as  to  allow  a 
small  bougie  to  be  introduced,  the  treatment  is  then  to 
be  conducted  on  the  principle  of  dilatation. 

The  attempt  to  remove  strictures  by  exciting  ulcera- 
tion of  them  is  at  the  present  day  almost  abandoned, 
or  only  used  when  the  stricture  absolutely  will  not 
admit  of  other  methods.  The  chief  reasons  against 
the  practice  are,  the  risk  of  forming  a false  passage, 
and  its  extreme  tediousness. 

Mr.  Hunter  observes,  that  whenever  a bougie  of  a 
tolerable  size  passes  with  ease,  and  the  parts  and  the 
patient  have  become  accustomed  to  it,  the  surgeon 
need  no  longer  attend  for  the  purpose  of  introducing  it. 
The  patient  may  now  be  allow'ed  to  introduce  bougies 
himself;  and  when  he  can  do  this  with  ease,  the  busi- 
ness may  be  trusted  to  him,  as  he  can  make  use  of  the 
instruments  at  the  most  convenient  times,  so  that  they 
may  be  more  frequently  and  longer  applied.  In  the 
mean  while,  the  surgeon  should  only  pay  occasional 
visits.  Mr.  Hunter  adds,  that  this  practice  of  the  pa- 
tient, under  the  surgeon’s  eye,  by  which  means  the 
former  learns  the  art  of  introducing  bougies,  is  the 
more  necessary,  since  strictures  are  diseases  which 
commonly  recur ; and,  therefore,  no  man  w'ho  has  ever 
had  a stricture,  and  is  cured  of  it,  should  rely  on  the 
cure  as  lasting;  but  should  always  be  prepared  for  a 
return,  and  keep  some  bougies  in  his  possession.  He 
should  not  go  a journey,  even  of  a w'eek,  without 
them ; and  the  niimber  should  be  according  to  the  time 
wltich  he  is  absent,  and  the  place  to  w'hich  he  is  going ; 


for,  in  many  parts  of  the  world,  he  cannot  be  supplied 
with  them. 

To  prevent  the  inconvenience  of  a bougie  slipping 
out,  or  the  mischief  of  its  gliding  into  the  urethra,  a 
soft  cotton  thread  must  be  tied  round  that  end  of  the 
bougie  which  is  out  of  the  urethra,  and  then  round  the 
root  of  the  glans.  This  last  part  of  the  thread  should 
be  very  loose.  The  redundant  part  of  the  bougie  re- 
maining out  of  the  urethra  surgeons  usually  clip  off. 

In  many  examples,  in  which  a stricture  is  accom- 
panied with  excessive  irritability  in  the  urethra,  much 
pain,  and  a tendency  to  frequent  retentions  of  urine, 
when  a common  bougie  is  employed,  it  becomes  ad- 
visable to  alter  the  plan  of  treatment,  and  use  either 
flexible  metallic  or  elastic  gum  catheters : but  to  elastic 
gum  bougies,  which  always  tend  to  a straight  form, 
and  therefore  do  not  adapt  themselves  to  the  natural 
course  of  the  urethra,  I have  a strong  objection  founded 
on  experience.  Desault  commonly  cured  all  strictures 
by  Jhe  skilful  employment  of  flexible  gum  catheters, 
which  his  patients  were  directed  to  wear  a certain 
length  of  time  every  day.  These  last  instruments  pro- 
duce less  pain  and  irritation  than  any  kind  of  bougie, 
more  especially  w'hen  the  wires  are  withdrawn : and 
were  I to  be  myself  afflicted  with  strictures,  I should 
feel  strongly  disposed  to  attempt  their  removal  by  the 
use  of  elastic  gum  catheters,  which  are  unquestionably 
the  mildest  and  least  painful  means  of  cure.  I have 
seen  cases,  however,  in  which  the  flexible  metallic 
bougie  seemed  to  cause  much  less  irritation  than  any 
other  kind  of  bougie ; but,  in  general,  those  made  of 
elastic  gum  give  the  least  pain.  Metallic  instruments 
possess  the  advantage  of  retaining  the  exact  curvature 
of  the  passage  better  than  others  ; and,  as  I have  ob- 
served, they  enable  the  surgeon  to  employ  more  force, 
and  this  w’ith  more  precision  than  can  be  done  with  a 
w’ax  bougie.  In  ordinary  cases,  I believe  the  best  plan 
is  to  begin  with  wax  bougies,  or  elastic  gum  catheters, 
which  may  be  employed  of  very  small  size,  and  are 
therefore  more  likely  to  pass  the  stricture.  But  as 
soon  as  this  has  been  somewhat  dilated,  and  it  will 
admit  an  instrument  of  increased  diameter,  the  surgeon 
may  commence  the  use  of  metallic  bougies  or  sounds, 
which  are  to  be  gradually  augmented  in  size  in  pro- 
portion as  the  stricture  yields. 

CURE  OF  STRICTURES  WITH  THE  ARGENTUM 
NITRATUM. 

Wi.?eman  mentions  the  plan  of  curing  strictures  or 
caruncles,  as  they  were  once  called,  by  means  of 
caustic.  Fr.  Roncalli  also  described  a method  of  ap 
plying  the  lapis  infernalis  to  strictures,  in  a work  pub- 
lished early  in  the  last  century;  and  this  is  the  more 
worthy  of  being  mentioned,  because  the  instrument 
used  by  him  for  the  purpose  is  very  much  like  what 
was  subsequently  proposed  by  Mr.  Hunter. — {Exerci- 
tatio  agens  novmn  Methodum  eMirpandi  Carunculas 
et  cur andi  Fistulas  Urethra;  Brixia, 'i'i'20.) 

About  the  year  1752,  Mr.  Hunter  attended  a chimney- 
sweeper who  had  a stiicture.  Not  finding  that  any 
benefit  was  derived  from  the  use  of  common  bougies, 
for  a space  of  six  months,  he  conceived,  that  the  stric 
ture  might  be  destroyed  with  escharotics,  and  the  first 
attempt  which  he  made  was  with  red  precipitate.  He 
put  some  salve  on  the  end  of  a bougie,  and  then  dipped 
it  in  the  powder.  The  bougie,  in  this  state,  was  passed 
down  to  the  stricture ; but  it  brought  on  considerable 
inflammation  all  along  the  passage.  He  then  intro- 
duced a silver  cannula  down  to  the  stricture,  and  acain 
passed  the  bougie  with  precipitate  through  the  tube. 
As  the  patient,  however,  did  not  make  water  any 
better,  and  the  smallest  bougie  could  not  be  introduced 
through  the  stricture,  it  was  suspected  that  the  pre- 
cipitate had  not  sufficient  power  to  destroy  the  obstruc- 
tion. Mr.  Hunter  was  induced,  therefore,  to  fasten  a 
small  piece  of  the  argentum  nitratum  on  the  end  of  a 
piece  of  w'ire,  with  sealing-wax,  and  introduce  the 
caustic  through  the  cannula  to  the  stricture.  After 
having  made  the  application  three  times,  at  intervals 
of  two  days,  he  found  that  the  man  voided  his  urine 
much  more  freely,  and  on  applying  the  caustic  a fourth 
time,  the  cannula  went  through  the  stricture.  A 
bougie  was  introduced  for  a little  while  afterward, 
and  the  man  completely  recovered. 

Having  experienced  this  success,  Mr.  Hunter  tried  to 
invent  an  instrument  belter  suited  to  the  pur|K)Be  than 
the  above  contrivance  ; and  one  was  devised,  although 


URETHRA. 


397 


he  acknowledges  that  it  was  not  perfectly  adapted  to 
strictures  in  every  situation  in  tlie  urethra.  He  re- 
jiiarks,  that  the  caustic  should  be  prevented  from  hurt- 
ing the  unaffected  part  of  the  urethra,  by  introducing 
the  active  substance  through  a cannula  down  to  tlie 
stricture ; and  that  it  should  be  capable  of  protruding  a 
little  beyond  the  end  of  the  cannula,  by  which  means 
it  will  only  act  upon  the  stricture.  The  caustic  should 
be  fixed  in  a small  portcrayon,  and  it  is  necessary  to 
have  a piece  of  silver  of  the  length  of  the  cannula, 
with  a ring  at  one  end  and  a button  at  tlie  other,  of  the 
same  diameter  as  the  cannula.  Tlie  button  forms  a 
kind  of  plug,  which  should  project  beyond  the  end  of 
the  cannula  in  the  uretlira,  so  as  to  make  a rounder 
end;  or,  as  Mr.  Hunter  says,  the  portcrayon  may  be 
formed  with  this  button  at  its  other  end.  The  cannula, 
with  the  button,  is  to  be  passed  into  the  urethra,  and 
when  it  reaches  the  stricture,  the  silver  plug  should  be 
withdrawn,  and  the  portcrayon  with  the  caustic  intro- 
duced in  its  place ; or  if  the  plug  and  portcrayon  are 
on  the  same  instrument,  then  it  is  only  necessary  to 
withdraw  the  plug  and  introduce  the  portcrayon  with 
the  caustic.  The  plug,  besides  giving  a smooth  rounded 
end  to  the  cannula,  answers  another  good  purpose,  by 
preventing  the  tube  from  being  tilled  with  the  mucus 
of  the  urethra  when  the  instrument  is  passing  inwards, 
which  mucus  would  be  collected  in  the  end  of  the  can- 
nula, dissolve  the  caustic  too  soon,  and  hinder  its  ap- 
plication to  the  stricture. 

When  the  stricture  was  beyond  the  straight  part  of 
the  urethra,  Mr.  Hunter  owned  that  it  was  difficult  to 
apply  caustic  to  the  disease  through  a cannula. 

A better  mode  of  applying  lunar  caustic  to  strictures 
was  afterward  suggested  by  Hunter,  and  introduced 
into  practice  by  Sir  E.  Home.  This  gentleman  directs 
us  to  take  a bougie  of  the  size  that  can  be  readily 
passed  down  to  the  stricture,  and  to  insert  a small  piece 
of  lunar  caustic  into  the  end  of  it,  letting  the  caustic  be 
even  with  the  surface,  but  surrounded  every  where 
laterally  by  the  substance  of  the  bougie.  This  should 
be  done  some  little  time  before  it  is  required  to  be  used  ; 
for  the  materials  of  which  the  bougie  is  composed  be- 
come warm  and  soft  by  being  handled  in  inserting  the 
caustic ; and,  therefore,  the  hold  which  the  bougie  has 
of  the  caustic  is  rendered  more  secure  after  the  wax 
has  been  allowed  to  cool  and  harden.  The  bougie 
thus  prepared  is  to  be  oiled  and  made  ready  for  use; 
but  before  passing  it,  a common  bougie  of  the  same 
size  is  to  be  introduced  down  to  the  stricture  in  order 
to  clear  the  canal,  and  to  measure  the  exact  distance 
of  the  stricture  from  the  orifice  of  the  urethra.  This 
distance  being  marked  upon  the  armed  bougie,  it  is  to 
be  passed  down  to  the  stricture  as  soon  as  the  other  is 
withdrawn.  The  caustic,  in  its  passage,  is  scarcely 
allowed  to  come  into  contact  with  any  part  of  the 
membrane,  because  the  point  of  the  bougie,  of  which 
the  argentum  nitratnm  forms  the  central  part,  always 
moves  in  the  middle  line  of  the  canal ; and,  indeed,  the 
quickness  with  which  it  is  conveyed  to  the  stricture, 
prevents  any  injury  of  the  membrane  lining  the  pas- 
sage when  the  caustic  accidentally  touches  it. 

In  this  mode,  the  caustic  is  passed  down  with  little 
or  no  irritation  to  the  lining  of  the  urethra;  it  is  ap- 
plied in  the  most  advantageous  manner  to  the  stric- 
ture, and  can  be  retained  in  that  situation  sufficiently 
long  to  produce  the  desired  effect. 

The  reasons  urged  in  favour  of  the  employment  of 
bougies  armed  with  the  lunar  caustic  are,  that  a per- 
manent cure  is  effected,  which  common  bougies  can- 
not accomplish ; that  the  pain  arising  from  the  applica- 
tion of  the  argentum  nitratum  to  the  stricture  is  very 
inconsiderable;  and  that  neither  irritation  nor  inflam- 
mation i.s  found  to  ensue.  The  meaning  of  these  re- 
marks, however,  is  to  be  received  as  a general  one, 
liable  to  exceptions.  Indeed,  Sir  E.  Horne  himself  ac- 
knowledges that  some  inconveniences  occ<asionally 
follow  the  use  of  armed  bougies.  He  remarks,  how- 
ever, that  “ whatever,  a priori^  might  be  supposed  to 
be  the  effrtcls  of  so  violent  an  ap[)licaiion  to  a mem- 
brane so  sensible  and  irritable  as  the  urethra,  and  I 
w ill  admit  that  it  is  very  natural  to  conceive  they 
would  be  very  severe,  the  result  of  experience,  the 
only  thing  to  be  relied  on,  evinces  the  contrary.  Tfte 
pain  that  is  brought  on  is  by  no  means  violent;  and 
neither  irritation  nor  inflammation  is  found  to  take 
[ilace. 

That  cases  do  occur  in  which  strictures  have  pro- 


duced so  much  mischief,  and  rendered  so  great  an  ex- 
tent of  the  canal  diseased,  that  the  use  of  the  caustic 
has  proved  unsuccessful,  is  certainly  true  ; and  several 
of  these  cases  have  fallen  within  my  own  knowledge, 
^ut  when  it  is  slated  that  none,  even  of  these,  were 
made  worse  by  its  use ; that  no  bad  consequences  at- 
tend it ; and  that  no  other  mode,  at  present  known,  is 
equally  efficacious ; any  occasional  want  of  success 
cannot  be  considered  as  an  objection  to  this  mode  of 
practice. 

But  if  the  apprehension  of  violent  effects  from 
the  caustic,  however  ill-founded,  cannot  be  removed, 
let  the  alternative  be  considered;  namely,  the  only 
operation  previously  in  use,  where  a stricture  cannot 
be  dilated  by  the  bougie. 

In  those  cases,  we  are  obliged  to  have  recourse  to 
means  certainly  more  severe  and  violent,  laying  open 
with  a knife  the  diseased  urethra,  and  passing  tiirough 
the  divided  parts  a flexible  gum  catheter  into  the  blad- 
der. This  1 have  done  myself,  and  have  frequently 
seen  performed  by  Mr.  Hunter,  and  it  always  suc- 
ceeded ; neither  bringing  on  so  much  inflammation  as 
was  expected,  nor  being  attended  with  any  symptoms 
of  irritation. 

This  practice  has  by  other  surgeons  been  carried 
still  fartlier  ; the  portion  of  diseased  urethra  has  been 
dissected  out  and  entirely  removed  ; nor  has  so  severe 
an  operation  always  brought  on  untoward  symptonis  ; 
and  patients  have  recovered. 

If  the  membrane  of  the  urethra,  when  diseased,  is 
capable  of  suffering  so  much  injury  without  any  con- 
sequent symptoms  of  irritation,  it  cannot  be  doubted, 
that  it  will  bear  with  impunity  to  be  touched  in  a 
very  partial  manner,  several  different  times,  with  lunar 
caustic.” 

Sir  Everard  afterward  proceeds ; “ Having  met  with 
a number  of  facts  from  which  a general  principle  ap- 
pears to  be  established,  that  the  irritable  state  of  a 
stricture  is  kept  up,  and  even  increased,  by  the  use  of 
the  bougie,  but  lessened  and  entirely  destroyed  by  the 
application  of  lunar  caustic,  I am  desirous  to  commu- 
nicate my  observations  upon  these  facts,  and  to  recom- 
mend the  use  of  the  caustic  in  many  cases  of  irritable 
stricture,  in  preference  to  the  bougie. 

As  the  use  of  the  caustic  upon  this  principle  is,  I 
believe,  entirely  new,  and  is  contrary  to  every  notion 
that  has  been  formed  upon  the  subject,  it  will  require 
something  more  than  general  assertion  to  gain  even  the 
attention  of  many  of  my  readers,  still  more  their  be- 
lief : I sliall  therefore  detail  the  circumstances  as  they 
occurred,  by  which  I conceive  the  propriety  of  this 
practice  to  be  established  ; and  afterward  make  some 
observations  upon  the  principle  on  wbicli  it  depends. 

My  connexion  in  practice  with  Mr.  Hunter  af- 
forded me  opportunities  of  attending  to  cases  of  stric- 
ture in  all  tlieir  different  stages ; many  of  them 
brought  on  during  a long  residence  in  India,  attended 
with  great  irritability,  and  exceedingly  difficult  of 
cure. 

One  case  of  this  kind  admitted  the  passing  of  3 
small  bougie ; but,  in  the  course  of  three  years,  very 
little  was  gained  by  a steady  perseverance  in  the  use- 
of  that  instrument,  either  in  dilating  the  canal  or  pal- 
liating the  symptoms  of  stricture : this  made  me  look 
upon  the  bougie  as  less  efficacious  tlian  I liad  always 
been  taught  to  believe  it.  I was  willing,  however,  to 
consider  this  as  an  uncommon  case,  depending  more 
on  the  peculiarities  of  the  patient’s  constitution  than 
on  the  nature  of  the  disease;  but  1 found,  on  a parti- 
cul.ar  inquiry,  that  several  other  gentlemen  from  India 
were  under  circumstances  nearly  similar  ; the  bougie 
only  prevetilLiig  the  increase  of  the  stricture,  but  being 
unable  to  dilate  it  beyond  a certain  size;  and  when  it 
was  left  otf,  the  stricture  in  less  than  two  months  re- 
turned to  its  former  state  of  contraction. 

In  August,  1794,  a gentleman  consulted  me  for 
some  symptoms  which  had  been  considered  as  indi- 
cating tlie  presence  of  gonorrhoea  ; but  as  they  did  not 
yield  to  the  common  treatment  in  the  usual  time,  be 
was  induced  to  take  my  advice  respecting  the  nature 
of  his  complaint.  In  the  necessary  inquiry  to  obtain  a 
perfect  history  of  the  case,  among  other  tilings  it  was 
stated,  that  nineteen  years  before,  tiu  re  was  a stricture 
which  became  very  trouble.some,  and  that  Mr.  Hunter, 
by  the  desire  of  the  patient,  bad  applied  the  caustic,  by 
which  the  stricture  was  removed,  and  it  never  after- 
ward returned.  He  said  that  he  was  one  of  the  first 


398 


URETHRA. 


persons  on  whom  the  caustic  had  been  used.  From 
this  account  1 was  naturally  led  to  believe  that  the 
stricture  liad  gradually  returned,  and  was  now  in- 
creased so  iiiucli  as  to  produce  the  present  symptoms  ; 
a discharge  being  almost  always  a symptom  of  stric- 
ture, when  it  is  much  contracted  ; but,  upon  examin- 
ing the  canal,  a bougie  of  full  size  passed  into  the  blad- 
der without  the  smallest  impediment.  1 therefore  took 
up  the  case  as  an  inflammation  in  the  urethra;  and 
large  doses  of  the  balsam  of  copaiba,  given  internally, 
elfected  a cure. 

The  circumstance  of  a stricture  having  been  re- 
moved nineteen  years  before  and  not  returning,  made 
a strong  impression  on  my  mind  ; and  made  me  desi- 
rous to  ascertain  whether  this  practice  could  be  em- 
ployed in  cases  of  stricture  in  general,  and  the  cme 
produced  by  it  equally  perinanent.  A short  time  after- 
ward, I had  an  opportunity  of  trying  it  in  the  following 
case. 

A captain  in  the  East  India  Company’s  service, 
in  September,  179|,  ai)plied  to  me  for  assistance.  His 
complaints  were  great  irritation  in  the  urethra  and 
bladder,  constant  desire  to  make  water,  and  an  ina- 
bility to  void  it,  except  in  very  small  quantities.  These 
symptoms  had  been  at  first  supposed  to  arise  from  go- 
norrhoea, afterward  rendered  more  severe  by  catching 
cold;  but,  not  yielding  to  the  usual  remedies  for  go- 
norrhtEa,  they  were  investigated  more  minutely,  and 
a stricture  w'as  discovered  in  the  urethra.  The  mode 
of  treatment  was  now  changed,  and  the  bougie  em- 
ployed ; but  its  use  aggravated  all  the  symptoms,  and 
brought  on  so  great  a degree  of  irritability  in  the  blad- 
der and  urethra,  that  there  was  an  alarm  for  the  pa- 
tient’s life,  which  was  the  reason  for  applying  for  my 
assistance. 

Besides  the  local  symptoms,  this  patient  had  those 
of  quick  pulse,  white  tongue,  hot  and  dry  skin,  toss 
of  appetite,  and  total  want  of  sleep,  with  frequent  at- 
tacks of  spasm  in  the  bladder  and  urethra.  A very 
small  flexible  gum  catheter  was  passed,  and  the  water 
drawn  off,  in  quantity  about  a pint,  which  gave  him 
great  relief  ; this  was  repeated  morning  and  evening, 
to  keep  the  bladder  in  as  easy  a state  as  possible ; but 
in  other  respects  he  continued  much  the  same. 

As  the  present  symptoiits  were  brought  on  by  the 
use  of  the  bougie,  little  good  was  to  be  expected  from 
that  instrument ; and  where  the  urethra  had  been  so 
easily  irritated,  and  was  disposed  to  continue  in  that 
slate,  there  was  no  prospect  of  the  use  of  the  bougie 
afterward  effecting  a cure.  These  circumstances  I 
explained  to  the  patient;  and  mentioned,  in  proof  of 
my  opinion,  the  case  in  which  so  little  had  been  ef- 
fected in  three  years. 

I then  proposed  to  him  a trial  of  the  caustic,  with 
a view  to  deaden  the  edge  of  the  stricture,  as  the  only 
probable  means  of  effecting  a cure.  The  degree  of  ir- 
ritation was  already  great : I was,  however,  led  to  be- 
lieve that  the  application  of  the  caustic  was  not  likely  to 
increase  it;  since,  by  destroying  the  irritable  part,  it 
might  lessen,  and  even  remove,  the  spasmodic  affec- 
tion ; but  if,  contrary  to  my  expectation,  the  irribation 
continued,  we  still  should  be  able  to  draw  off  the 
water,  as  the  slough  formed  by  the  caustic  would  pre- 
vent the  edge  of  the  stricture  from  acting  and  obstruct- 
ing the  instrument. 

The  application  of  the  caustic  was,  upon  these 
grounds,  determined  on  ; and  it  was  applied  in  the  fol- 
lowing manner. 

I passed  a common  bougie,  nearly  the  size  of  the 
canal,  down  to  the  stricture,  to  ascertain  its  exact  situ- 
ation, and  to  make  the  can.al  of  the  urethra  as  open  as 
possible.  The  distance  w.as  then  marked  upon  a bou- 
gie armed  with  caustic,  of  the  same  size,  which  was 
conveyed  down  as  quickly  as  the  nature  of  the  opera- 
tion vvould  admit.  It  was  retained  upon  the  stricture 
with  a slight  degree  of  pressure:  at  first  there  was  no 
pain  from  the  caustic,  but  a soreness  from  pressure;  in 
less  than  a minute  a change  was  felt  in  the  sensation 
of  the  part ; it  was  at  first  a heat,  succeeded  by  the 
burning  pain  peculiar  to  caustic;  as  soon  as  this  was 
distinctly  felt,  the  bougie  and  caustic  were  withdrawn, 
having  remained  in  the  urethra  about  a minute  alto- 
gether. The  soreness,  he  said,  was  entirely  local,  by 
no  means  severe,  w<as  tinaccompanied  by  irritation 
along  the  canal,  and  he  thought  the  uneasiness  in  the 
bladder  diminished  by  it.  He  described  the  pain  as 
resembling  very  exactly  the  first  symptoms  of  gonor- 


rhoea. This  sensation  lasted  half  an  hour  after  with- 
drawing the  bougie. 

The  caustic  was  applied  about  one  o’clock  in  the 
forenoon,  and  he  passed  the  day  more  free  from  irri- 
tation than  he  had  been  since  the  beginning  of  the  at- 
tack, which  had  lasted  six  days.  In  the  evening,  the 
water  was  drawn  off  with  more  ease  than  the  night 
before.  He  passed  a tolerable  night,  and  the  next  day- 
continued  free  from  irritation.  On  the  third  day,  the 
caustic  was  again  applied  in  the  forenoon  ; the  painful 
sensation  was  less  than  on  the  former  application, 
lasted  a shorter  time,  and  in  an  hour  after  the  armed 
bougie  was  withdrawn,  he  made  water  freely  for  the 
first  time  since  the  commencement  of  his  indisposition. 
He  said  the  irritation  in  the  bladder  was  removed,  and 
he  felt  very  well ; his  appetite  returned,  he  slept  very 
well,  and  continued  to  void  his  urine  with  ease. 

In  this  state,  nothing  was  done  till  the  fifth  day, 
leaving  always  a day  between  the  applications  of  the 
caustic. 

On  this  day  a common-sized  bougie  went  readily 
into  the  bladder;  it  was  immediately  withdrawn,  and 
the  cure  was  considered  as  complete ; no  bougie  was 
afterward  passed,  lest  it  might  bring  back  an  irritation 
upon  the  passage.  I met  this  gentleman  twelve 
months  afterward,  and  he  assured  me  he  Itad  con- 
tinued perfectly  well ; and  I have  since  learned  that, 
in  three  years,  there  has  been  no  return. 

P’rom  the  result  of  this  case,  I was  encouraged  to 
hope  tiiat  the  caustic  might  be  applied  to  strictures  in 
the  urethra  with  more  confidence  than  I had  hitherto 
believed,  since  it  evidently  did  not  bring  on  or  increase 
the  general  irritation,  but,  on  the  contrary,  seemed  to 
allay  it.” 

The  foregoing  case,  together  with  another  which  Sir 
E.  Home  has  related,  convinced  this  gentleman  that  he 
had  discovered  an  effectual  mode  of  treating  such 
strictures  as  do  not  admit  of  being  relieved  by  thecom- 
mon  bougie.  Hence,  he  adopted  the  use  of  armed  bou- 
gies as  a general  practice ; but  he  has  not  concealed 
the  circumstances  under  which  the  method  does  not 
prove  successful.  Sir  Everard  informs  us,  that  “ in 
some  constitutions,  where  the  patients  have  resided 
long  in  warm  climates,  every  time  the  caustic  is  ap- 
plied to  a stricture,  a regular  paroxysm  of  fever,  called 
by  the  patient  an  ague,  takes  place ; and  this  has  been 
so  violent  as  to  render  it  impossible  to  pursue  this  mode 
of  practice.  Of  this  I have  met  with  two  instances. 
I consider  this  disposition  to  fever  as  the  effect  of  cli- 
mate, and  not  of  any  natural  peculiarity  of  constitu- 
tion ; for  the  brother  of  one  of  these  patients  laboured 
under  the  same  disease,  but  as  he  had  not  been  in 
warm  climates  it  was  removed  by  the  caustic,  without 
his  experiencing  such  attacks.” 

In  gouty  constitutions,  attacks  of  the  gout  have  in 
two  instances  brought  on  spasmodic  constrictions, 
after  the  stricture  had  been  removed  by  caustic.  This, 
however,  cannot  be  called  a failure  of  the  caustic.  It 
only  shows  that  gout  can  eff'ect  strictures  and  repro- 
duce them. 

In  some  patients  the  strictures  are  so  obdiu-ate, 
that  the  use  of  the  caustic  is  necessary  to  be  continued 
for  a longer  time  than  the  parts  can  bear  its  application, 
or  even  that  of  the  bougie  passing  along  the  urethra  ; 
irritation  therefore  comes  on  and  stops  the  progress  of 
the  cure,  and  when  the  same  means  are  resorted  to 
again,  the  same  thing  takes  place.  The  cases  of  failure 
of  this  kind  that  I have  met  with,  some  of  which  may 
yet  ultimately  be  cured  if  the  patients  will  take  the 
necessary  steps  for  that  purpose,  amount  in  all  to  six. 

In  some  patients,  the  stricture  is  readily  removed 
by  the  caustic,  hut  in  a few  weeks  contracts  again. 
The  stricture  being  wholly  spasmodic,  the  caustic,  by 
taking  off’  the  spasm,  is  allowed  to  pass  through,  and 
cannot  completely  destroy  the  stricture.  Of  this  kind 
I have  met  with  one  instance,  which  1 must  consider  as 
a failure,  as  I have  hitherto  been  unable  to  get  the 
better  of  it. 

In  those  cases,  where  the  caustic  gradually  re- 
moves the  stricture,  and  brings  the  urethra  to  a size 
that  allows  the  patient  to  make  water  perfectly  well, 
if  there  is  any  return,  it  is  not  to  be  attributed  to  the 
failure  of  the  caustic,  but  to  the  want  of  proper  ma- 
nagement, either  from  the  caustic  being  too  small  or  its 
use  left  off  too  soon  ; hut  all  such  cases  are,  I believe, 
within  the  power  of  being  cured  by  the  caustic,  if  it* 
use  is  recurred  to  when  that  is  found  necessary.” 


URETHRA. 


399 


The  power  of  caustic,  however,  to  effect  a more 
lasting  cure  than  other  methods,  begins  now  to  be  very 
generally  disbelieved.  I have  known  myself  several 
patients  whose  disease  returned  after  they  had  been 
apparently  cured  with  armed  bougies.  Indeed,  the 
necessity  of  occasionally  passing  a common  bougie  is 
as  great  after  this  treatment  as  after  others  ; an  impor- 
tant fact,  which  Baron  Boyer  insists  upon,  on  account 
of  the  many  relapses  with  which  he  is  acquainted. — 
{MaL.  Chir.  t.  9,  p.  227.)  Delpech  also  assures  us,  that 
he  has  had.  abundant  opportunity  of  learning  the  incu- 
rable nature  of  strictures;  they  only  admit,  he  says,  of 
temporary  relief,  and  have  an  invincible  tendency 
gradually  to  return.  He  declares  that  this  is  constantly 
the  case,  whatever  treatment  may  have  been  adopted. 
It  would  be  abusing  the  credulity  of  patients  and  me- 
dical men,  and  insulting  truth  to  pretend  the  contrary. 
— (See  Chirurgie  Clinique,  1. 1,  p.  2T3.) 

For  the  generality  of  strictures  in  the  urethra,  which 
do  not  occupy  more  extent  of  the  canal  than  if  caused 
by  a piece  of  packthread  being  tied  round  it,  bougies 
armed  with  lunar  caustic  answer  very  well;  and  so  1 
believe  do  common  bougies,  to  which  the  preference, 
as  1 believe,  ought  to  be  given.  For  cases,  also,  in 
which  the  urethra  is  diminished  in  diameter,  for  an 
inch  or  more,  common  bougies  must  be  most  advanta- 
geous ; that  is  to  say,  when  they  can  be  introduced 
through  the  stricture,  so  as  to  cure  it  on  the  principle 
of  dilatation. 

Whether  in  certain  cases,  where  no  progress  can  be 
made  with  common  bougies,  it  is  better  to  try  caustic, 
or  attempt  to  force  the  obstruction  with  a sound,  is  a 
question  on  which  there  is  a great  deal  of  difference  of 
opinion.  “ The  practice  of  pressing  firm  bougies,  or 
metallic  instruments,  so  as  to  force  the  stricture,  or  to 
produce  an  ulceration  of  it  (says  a modern  writer),  so 
frequently  has  been  found  to  form  false  jrassages,  fis- 
tulae,  and  gangrene,  that  I need  here  make  no  farther 
observation  on  the  practice  or  its  consequences.  All 
the  advantages  that  can  be  gained  by  pressure,  tearing 
through  the  stricture,  or  producing  ulceration  of  it, 
may  be  obtained  by  a careful  and  judicious  use  of  the 
caustic,  which  will  be  found  on  the  whole  a safer  ap- 
plication, and  will  be  attended  with  less  inflammation 
and  pain.” — (^IVilson  on  the  Male  Urinary  and  Geni- 
tal Organs,  p.  383.)  This  gentleman  is  not,  however, 
an  advocate  for  the  caustic  in  every  case.  “ I consider 
it,”  says  he,  “ the  safest  practice  in  cases  which  will 
not  yield  to  the  introduction  of  bougies,  and  which 
require  a portion  of  the  stricture  to  be  destroyed  ; but 
the  .symptoms  which  sometimes  attend  its  use,  and  the 
injury  which  may  be  done  by  its  improper  application, 
should  confine  it  to  those  cases.” — (P.  385.) 

Sir  A.  Cooper,  in  his  lectures,  states  his  opinion,  that 
caustic  bougies  ought  never  to  be  employed,  except 
where  the  stricture  is  accompanied  with  fistula  in 
perinteo,  and  the  fistula  is  behind  the  stricture ; in 
which  c!ise  there  can  be  no  risk  of  a retention  of  urine 
being  produced  by  the  caustic.  In  France,  caustic 
bougies  have  never  had  many  advocates ; under  par- 
ticular circumstances,  however,  their  employment  is 
sanctioned  by  Delpech.  He  says  that  the  swelling  of 
the  parietes  of  the  urethra,  in  the  situation  of  the 
stricture,  may  bring  them  into  so  close  contact,  that  no 
bougies  nor  catgut  will  pass,  and  the  diiliculty  may  be 
still  farther  increased  by  some  slight  deformity  of  the 
same  point  of  the  passage.  Such,  he  remarks,  are  the 
cases  in  which  he  has  found  bougies  armed,  with 
nitrate  of  silver  of  great  service.  His  plan,  however, 
is  only  to  remove  with  caustic  the  impediment  to  the 
I«ssage  of  a small  bougie  ; and  as  soon  as  this  can  he 
introduced,  he  discontinues  the  caustic,  and  practises 
simple  dilatation. — {Chir.  Clinique,  t.  \,p.  275.) 

The  following  are  some  of  the  general  directions 
given  by  Sir  E.  Iloine,  how  to  apply  lunar  c(justic  to 
strictures. 

“ 'J’lie  distance  of  the  stricture  from  the  external  ori- 
fice is  to  be  measured,  and  the  canal  cleared  by  passing 
a common  bougie  fully  as  large  as  that  which  is 
armed.  The  armed  bougie,  with  the  distance  marked 
upon  it,  is  then  to  be  introduced  and  applied  to  the 
stricture : when  it  is  brought  in  contact  with  the  ob- 
struction, it  is  to  be  steadily  retained  there,  with  a 
moderate  degree  of  pressure  at  first,  and  less  as  it  is 
longer  continued,  since  the  bougie  becomes  soft  by 
remaining  in  the  urethra,  and  readily  bends  if  the 
pressure  is  too  great.  The  time  it  is  to  remain  depends 
a great  deal  u{>on  the  sensations  of  the  patient,  and  the 


length  of  time  the  parts  have  been  diseased  ; but  on 
the  first  trial  it  should  be  less  than  a minute,  as  it  then 
commonly  gives  greater  pain  than  on  any  subsequent 
application.  The  pain  produced  by  the  caustic  is  not 
felt  so  immediately  as  it  would  be  natural  to  expect; 
the  first  sensation  arises  from  the  pressure  of  the  bou- 
gie on  the  stricture ; a little  afterward,  there  is  the 
feeling  of  heat  in  the  parts;  and  lastly,  that  of  pain. 

As  soon  as  the  caustic  begins  to  act,  the  surgeon 
who  makes  the  application  is  made  sensible  of  it  by 
the  smaller  arteries  of  the  parts  beating  with  unusual 
violence,  which  is  very  distinctly  felt  by  tlie  finger  and 
thumb  that  grasp  the  penis. 

The  pain  that  is  brought  on  by  the  caustic  lasts  for 
some  time  after  it  is  withdrawn  ; butthis  period  differs 
in  almost  every  patient,  being  sometimes  extended  to 
half  an  hour,  and  sometimes  only  a few  minutes. 

The  kind  of  pain  is  heat  and  soreness,  which  is  not 
severe,  not  being  accompanied  with  the  peculiar  irrita- 
tion upon  so  many  occasions  experienced  by  patients 
who  have  strictures ; an  irritation  that  cannot  be 
described,  which  is  most  insupportable,  and  is  loo  often 
brought  on  by  dilating  strictures  with  the  bougie.”  In 
the  vol.  from  which  the  above  directions  are  taken.  Sir 
E.  Home  recommends  the  patient  to  make  water  as 
soon  as  the  armed  bougie  is  withdrawn  ; but  in  a sub 
sequent  vol.  he  explains  his  change  of  opinion  upon  this 
point;  “I  not  only  have  no  wish  that  the  patient 
should  make  water  immediately  after  the  application, 
but  would  rather  that  it  be  retained  some  time.” — {On 
Strictures,  vol.  3,/».51,  8vo.  Lond.  1821.) 

“It  happens  not  tinfrequently,”  he  says,  “that  at 
the  first  time  of  making  water,  some  blood  passes 
along  with  it.  This  is  rather  favourable  • as,  when 
the  parts  bleed,  the  stricture  usually  proves  to  be  so  far 
destroyed,  that  at  the  next  trial  the  bougie  passes- 
through  it.  Every  other  day  appears  in  general  to  be 
as  often  as  it  is  prudent  to  apply  the  caustic.  I have, 
however,  done  it  every  day  in  very  obstinate  cases 
where  the  parts  are  less  sensible,  without  any  detri- 
ment.” 

In  his  third  volume,  he  states  that  he  now  rarely 
passes  the  bougie  oftener  than  every  third  day,  and 
never  when  the  pain  from  the  last  application  has 
not  entirely  gone  off.  He  also  never  continues  any 
one  application  beyond  the  time  when  the  pain  begins 
to  extend  farther  than  the  spot  to  which  the  armed 
bougie  is  applied. — {Vol.  3,^.  51.) 

The  bottgie  which  is  passed  down  to  prepare  the 
way  for  the  caustic  and  measure  the  distance  of  the 
armed  bougie,  must  be  made  of  sort  materials,  that  it 
may  readily  receive  an  impression  from  the  part  against 
which  it  is  pressed ; and  its  colour  should  be  light,  so 
as  to  admit  of  those  impressions  being  more  distinctly 
seen.  With  the  assistance  of  such  bougies,  the  sur- 
geon can  discover  the  size  and  shape  of  the  orifice  of 
the  stricture,  ascertain  with  accuracy  the  progress  of 
the  caustic  upon  it,  see  w'hether  it  is  on  one  side  of  the 
canal  or  equally  all  round,  and  apply  the  caustic 
accordingly. 

“ When  the  soft  bougie  passes  through  the  stricture, 
by  leaving  it  in  the  canal  a few  minutes,  it  can  be 
known  whether  the  stricture  is  completely  destroyed 
or  only  relaxed  ; in  the  last  case,  there  is  an  impression 
on  the  side  of  the  bougie.” — {Home  on  Slricturesy 
vol.  1.) 

I think  the  advice  given  by  Delpech,  not  to  let  the 
end  of  the  caustic  be  covered  with  any  greasy  sub- 
stance, is  good  ; for  certainly  its  action  would  thus  be 
lessened,  or  even  defeated.  At  first  he  applies  the 
caustic  half  a minute,  and  afterward  a minute,  if  the 
patient’s  feelings  will  permit.  The  application  is 
repeated  every  two  or  three  days,  and  before  each 
time  the  passage  is  examined  with  a small  bougie, 
which,  if  it  can  be  insinuated  through  the  stricture,  is 
used  instead  of  that  armed  with  lunar  caustic. — {Chir. 
Clinique,p.  276.)  Delpech  regards  caustic  as  an  ap- 
plication liable  to  be  attended  with  serious  conse- 
quences and  unfit  for  practice,  in  cases  where  either 
several  points  of  the  canal  would  need  its  repeated  use, 
or  where  the  stricture  is  accompanied  with  an  exten- 
sive firm  thickening  of  parts,  including  the  parietes  of 
the  canal  and  all  the  perinseum.  In  tlie  first  case,  on 
discovering  a second  stricture,  he  has  recourse  without 
delay  to  the  plan  of  forcing  the  obstruction  with  a 
conical  sound  if  a catgut  bougie  cannot  be  passed. 
Many  of  Sir  E.  Home’s  cases,  however,  were  of  this 
description,  and  yet  successfully  treated  with  caustic.^ 


400 


URETHRA. 


From  time  to  time  proposals  have  been  made  to  per- 
forate very  bad,  extensive,  and  unyielding  strictures 
with  a pointed  or  cutting  instrument,  applied  through 
a tube.  In  cases  of  permanent  stricture,  where  the 
part  is  irregularly  thickened,  and  so  indurated  as  to 
resemble  cartilage,  and  the  canal  so  contracted  that  it 
is  either  quite  impermeable,  or  will  only  admit  a bou- 
gie of  the  smallest  size,  Mr.  Stafford  disapproves  of 
attempting  the  cure  either  by  exciting  ulceration,  or  by 
forcing  a passage  through  the  stricture  with  a conical 
sound,  or  by  the  use  of  caustic,  or  by  cutting  down  to 
the  obstruction  through  the  perinaeum.  Of  course, 
when  a small  bougie  can  be  introduced  through  the 
stricture,  several  of  these  plans  must  be  quite  unne- 
cessary; because  the  best  treatment  can  be  successfully 
continued  on  the  principle  of  dilatation,  unless  it  be 
argued  that  the  cartilaginous  induration  of  thestiicture 
will  defeat  the  method  ; a point  on  which  much  doubt 
may  be  entertained.  Instead  of  these  plans,  and  espe- 
cially in  preference  to  the  employment  of  armed  bou- 
gies, Mr.  Stafford  recommends  the  use  of  what  he  calls 
the  lanceted  stilet,  with  which  he  divides  the  stric- 
ture. For  this  purpose,  he  has  invented  two  instru- 
ments ; one  for  the  division  of  permanent  strictures, 
which  yet  admit  of  a small  bougie  or  wire  being 
passed  through  them,  the  other  for  the  division  of 
those  strictures  which  are  impervious.  The  instru- 
ment for  the  latter  cases  he  calls  the  double  lanceted 
stilet;  it  consists  of  a round  silver  graduated  sheath, 
open  at  both  ends,  of  the  size  of  catheter  No.  10,  but 
with  rather  a less  curve,  and  furnished  with  a stilet 
which  is  also  hollow,  and  open  at  both  ends.  At  one 
end  of  the  stilet  are  two  oblong  lancets ; and  at  the 
other  a handle  resembling  a button.  When  the  instru- 
ment is  complete,  the  stilet  fits  into  the  sheath;  so 
that,  by  pushing  the  handle,  the  lancets  will  project 
from  the  extremity  of  the  tube,  and  by  drawing  it  back 
they  will  recede  again.  The  instrument  is  passed  over 
a wire  down  to  the  stricture,  and  the  lancets  are  thrust 
forwards  on  each  side  of  it,  by  which  means  the  con- 
traction is  made  as  large  as  the  natural  size  of  the 
urethra.  The  armed  stilet,  for  the  division  of  imper- 
vious strictures,  resembles  that  which  has  first  been 
described,  excepting  Uiat  the  stilet  is  solid  and  fur- 
nished with  only  one  lancet.  The  exact  distance  of 
the  stricture  from  the  .orifice  of  the  urethra  having 
been  first  ascertained,  the  smallest  catheter  capable  of 
containing  a wire  is  to  be  introduced  into  the  bladder. 
The  wire,  which  is  double  the  length  of  the  catheter, 
and  blunted  at  one  end  so  that  it  may  not  injure  the 
bladder,  is  then  pushed  forwards,  and  the  catheter  gra- 
dually withdrawn.  The  armed  catheter  is  then  passed 
over  the  wire  until  its  point  rests  against  the  stricture, 
when  the  handle  of  the  stilet  is  to  be  gently  and  gra- 
dually pressed.  As  soon  as  any  impression  is  made, 
the  lancets  should  be  allowed  to  retire  into  their 
sheaths,  and  the  blunt  point  of  the  instrument  be  urged 
forw'ards.  If  it  should  not  pass  on,  the  laiKets  may  be 
made  to  project  again.  After  the  stricture  has  been 
divided,  the  armed  catheter  should  be  withdrawn,  and 
one  of  elastic  gum  introduced.  Mr.  Stafford  recom- 
mends this  to  be  kept  in  for  a day  or  two,  in  order  to 
prevent  the  union  of  the  divided  parts,  and  the  possi- 
bility of  extravasation  of  urine.  After  its  removal,  a 
bougie  is  to  be  passed  twice  a week,  or  oftener,  accord- 
ing to  circumstances.  The  other  kind  of  stilet  for 
impervious  strictures  is  to  be  used  in  the  same  manner, 
except  that  it  is  not  passed  over  a wire. — (See  Stafford 
on  Strictures,  p.  71,  .S'C.)  This  gentleman  adduces 
many  examples  of  the  success  of  the  foregoing  treat- 
ment, and  he  states  that,  with  moderate  care  and  skill, 
there  will  be  no  risk  of  m.aking  a false  passage.  Nei- 
ther do  his  accounts  mention  any  troublesome  degree 
of  hemorrhage  as  being  the  result  of  the  method.  On 
the  whole,  I consider  the  practice  may  be  useful  in 
certain  cases  of  impervious  stricture;  but  that,  in 
other  instances,  the  milder  plan  of  dilating  the  obstruc- 
tion should  be  first  tried. 

CURE  OF  STRICTURES  WITH  THE  POTASSA  FUSA. 

Mr.  Whately  argues,  that  strictures  are  not  merely 
contracted  fibres  of  the  \irethra,  but  really  diseased 
portions  of  the  membrane  lining  that  canal,  with  a 
continued  disposition  to  increased  contraction.  Hence, 
he  conceives  that  a remedy,  calculated  both  to  remove 
the  diseased  affection  and  to  dilate  the  contracted  part, 
might  perfectly  cure  the  complaint,  without  putting 


the  patient  to  the  inconvenience  of  wearing  a bougie. 
Such  a remedy,  he  says,  is  caustic,  when  judiciously 
used ; but,  instead  of  lunar  caustic,  he  recommends 
the  potassa  fusa,  which,  he  says,  when  used  in  the 
manner,  and  with  the  precautions  about  to  be  descril)ed, 
will  be  found  to  possess  singular  efficacy.  Of  its 
safety  he  is  also  as  well  convinced  as  of  its  efficacy. 

However,  if  the  potassa  fusa  be  applied  while  the 
parts  are  in  a highly  inflamed  or  irritable  state,  or  (as 
Mr.  Whately  expresses  himself)  tending  to  gangrene ; 
if  the  habit  be  bad,  and  the  patient  very  far  advanced 
in  years,  the  most  mischievous  effects  may  be  expected 
from  the  application ; and  the  use  of  any  kind  of 
caustic,  under  such  circumstances,  for  strictures  in  the 
urethra,  is  censured  as  dangerous  in  the  extreme. 

Mr.  Whately  represents,  that  if  the  patient  be 
affected  with  fever,  or  any  other  acute  disease ; if  lie 
be  much  indisposed  from  any  cause ; if,  in  particular, 
he  have  a gonorrhoea,  attended  with  much  inflammation 
and  irritation  in  the  urethra ; if  the  prepuce,  glans,  or 
any  other  part  of  the  penis,  or  the  parts  adjoining  to  it, 
be  swelled  and  inflamed ; if  the  urethra,  and  especially 
the  strictured  part  of  it,  be  so  irritable  as  not  to  bear 
the  touch  of  a bougie ; the  use  of  the  caustic  is  for  the 
present  forbidden.  Mr.  Whately  also  enjoins  great 
caution  in  applying  this  remedy  to  peisons  advanced 
in  3'ears.  Even  when  no  objections  of  the  above  kind 
exist,  the  caustic  should  not  be  resorted  to  in  the  first 
instance.  In  every  case  of  stricture,  before  venturing 
to  employ  the  caustic,  we  ought  to  be  able  to  pass  into 
the  bladder  a.bougie  of  at  least  a size  larger  than  one 
of  the  finest  sort.  This  is  necessary,  both  to  let  the 
caustic  be  applied  to  the  whole  surface  of  the  stricture, 
and  to  relieve  a retention  of  urine,  should  it  occur 
during  tire  use  of  the  caustic. 

When  a bougie  of  the  preceding  description  can  be 
introduced,  without  occasioning  pain,  faintness,  or 
great  dejection  of  spirits,  the  use  of  caustic  may  com 
mence  immediately,  provided  none  of  the  above-de- 
scribed objections  erist. 

When  the  urethra  is  very  irritable,  Mr.  Whately 
recommends  a common  bougie  to  be  introduced  every 
day,  and  kept  in  the  urethra ; at  first,  for  a few  minutes 
only ; but,  by  degrees,  for  a longer  time ; till  the  irrita- 
bility of  the  parts  has  been  sufficiently  lessened. 

When  the  urethra  is  rendered  so  impervious  by  a 
stricture,  that  a small  bougie  cannot  be  passed  into  the 
bladder,  which  viscus  is  also  in  a painful  inflamed 
state,  Mr.  Whately  asserts,  that  caustic,  in  any  form 
or  quantity,  must  not  be  immediately  employed ; but 
that  the  stricture  should  be  first  rendered  capable  of 
allowing  a bougie  a little  larger  than  one  of  the  finest 
size  to  be  introduced  into  the  bladder.  When  this  is 
done,  the  urine  is  more  freely  evacuated,  and  the  con- 
sequent irritation  and  inflammation  of  the  bladder 
lessened,  if  not  removed,  together'with  the  danger  of  a 
retention  of  urine.  Caustic  may  then  be  advan 
tageously  conveyed  into  the  centre  of  the  stricture. 

Mr.  VVhately  considers  the  practice  of  at  once 
thrusting  down,  in  this  sort  of  case,  an  armed  bougie 
considerably  larger  than  the  narrowest  part  of  the 
contracted  canal,  as  most  dangerous,  and  horridly 
painful.  For,  says  this  gentleman,  it  frequently  hap- 
pens, that  nearly  the  whole  of  the  tirethra  anterior  to 
the  bulb  is  so  much  contracted  by  numerous  and 
uncommonly  rigid  strictures,  that  it  is  impossible,  by 
any  art  whatever,  to  dilate  the  passage  to  its  natural 
size.  If,  therefore,  the  canal,  while  in  such  a state,  be 
rudely  torn  open  by  a large  caustic  bougie,  hemorrhage, 
pain,  dangerous  suppressions  of  urine,  inflammation, 
mortification,  and  death  itself,  must  sometimes  inevi- 
tably ensue, — even  before  the  caustic  can  be  applied  to 
the  principal  seat  of  the  disease.  In  cases  like  the 
one  just  mentioned,  the  first  step,  preparatory  to  the 
use  of  the  caustic,  should  be,  according  to  Mr. 
Whately,  to  dilate  the  strictured  part  of  the  urethra  ; 
for  which  purpose,  he  advises  the  slow  and  gentle 
introduction  of  a fine  bougie,  with  its  point  inclined  to 
the  lower  side  of  the  canal,  in  order  to  avoid  the  large 
lacunae,  situated  on  its  upper  part.  When  the  surgeon, 
by  steady  perseverance  and  dexterity,  has  succeeded 
in  getting  a fine  bougie  through  the  worst  stricture  into 
the  bladder,  the  instrument  should  be  worn,  for  a few 
hours  every  day  till  the  passage  is  sufficiently  dilated 
to  admit  a larger  one. 

Mr.  Whately,  after  explaining  that  caustic  potas.«a 
ought  not  to  be  applied  to  strictures  of  the  urethra  till 


URETHRA. 


401 


a bougie  of  a proper  size  can  be  passed  into  the 
bladder ; poititiiig  out  the  methods  to  be  taken,  before 
applying  this  caustic ; and  enumerating  certain  cases 
and  circumstances  in  which  its  employment  is  inter- 
dicted ; next  proceeds  to  describe  the  mode  of  practice 
which  it  is  the  particular  object  of  his  book  to  recom- 
mend. 

For  the  purpose  of  arming  a bougie,  Mr.  Whately 
advises  us  to  put  a small  quantity  of  caustic  potassa 
upon  a piece  of  strong  paper,  and  to  break  the  bit  of 
caustic  with  a hammer  into  small  pieces  of  about  the 
size  of  large  and  small  pins’  heads.  In  doing  this,  care 
should  be  taken  not  to  reduce  it  to  powder.  Thus 
broken,  it  should  be  kept  for  use  in  a phial,  closed  with 
a ground  stopper.  The  bougie  should  have  a proper 
degree  of  curvature  given  to  it,  by  drawing  it  several 
times  between  the  finger  and  thumb  of  the  left  hand. 

Mr.  Whately  next  acquaints  us,  that  before  the 
caustic  is  inserted  into  the  bougie,  it  is  necessary  to 
ascertain  the  exact  distance  of  llie  stricture  (to  which 
the  caustic  is  to  be  applied)  from  the  extremity  of  the 
penis.  For  this  purjrose,  the  bougie,  which  should  be 
just  large  enough  to  enter  the  stricture  with  some  degree 
of  tightness,  ought  to  be  gently  introduced  into  the 
urethra;  and  when  its  poiiit  stops  at  the  stricture, 
which  it  almost  always  does  before  it  will  enter  it,  a 
notch  is  to  be  made  with  the  finger-nail,  on  the  upper 
or  curved  portion  of  the  bougie,  on  the  outside  of  the 
urethra,  exactly  half  an  inch  from  the  extremity  of  the 
penis.  When  the  bougie  is  withdrawn,  a small  hole, 
about  the  sixteenth  part  of  an  inch  deep,  should  be 
made  at  the  extremity  of  its  rounded  end.  A large 
blanket-pin,  two  inches  and  a half  in  length,  with  the 
head  struck  off,  will  answer  tiie  purpose;  the  hole 
being  made  with  the  point  of  the  pin.  The  extremity 
of  the  bougie  should  then  be  made  perfectly  smooth 
with  the  finger  and  thumb,  taking  care  that,  in  doing 
this,  the  hole  in  its  centre  be  not  closed.  Some  of  the 
broken  caustic  should  then  he  put  on  a piece  of  writing 
paper,  and  a piece  less  in  size  than  the  smallest  pin’s 
head  should  be  selected  ; tbe  particle,  indeed,  says  Mr. 
Whately,  cannot  be  too  small  for  the  first  application. 
Let  this  be  inserted  into  the  hole  of  the  bougie  with  a 
pocket-knife,  spatula,  or  some  such  instrument;  and 
pushed  into  it  with  the  blunt  end  of  the  pin,  so  as  to 
make  the  caustic  sink  a very  little  below  the  margin  of 
the  hole.  To  prevent  the  potassa  fusa  from  coming 
out,  the  hole  should  then  be  contracted  a little  with  the 
finger,  and  the  reftiainiiig  vacancy  in  it  is  to  be  filled 
with  hog’s  lard,  ^’his  last  substance  (continues  Mr. 
Whately)  will  prevent  the  caustic  from  acting  on  the 
sound  part  of  the  urethra,  as  the  bougie  passes  to  the 
stricture.  When  the  bougie  is  quite  prepared,  let  it  be 
first  oiled,  and  immediately  afterward  introduced,  by 
a very  getiile  motion,  with  the  curvature  upwards,  as 
far  as  the  anterior  part  of  the  stricture,  upon  which  the 
caustic  is  to  be  applied.  In  doing  this,  the  end  of  the 
bougie,  held  by  the  finger  and  thumb,  should  be  a good 
deal  inclined  towards  the  abdomen,  on  the  first  intro- 
duction of  the  instrument,  in  order  to  preserve  its 
curvature.  After  it  has  passed  about  five  inches,  this 
end  should  be  gradually  brought  downward.?,  as  the 
bougie  passes  on,  till  it  forms  a right  angle  with  the 
body.  The  bougie  is  known  to  have  arrived  at  the 
stricture  by  the  resistance  made  to  its  progress. 

As  soon  as  the  bougie  has  reached  the  anterior  part 
of  the  stricture,  it  should  rest  there  for  a few  seconds, 
that  the  caustic  may  begin  to  dissolve.  It  should  then 
be  pushed  very  gently  forwards  about  one-eighth  of  an 
inch  ; after  which,  there  should  be  another  pairse  for 
a second  or  two.  The  bougie  should  then  be  carried 
forwards  in  the  same  gentle  manner,  till  it  has  got 
throirgh  the  stricture.  The  sense  of  feeling  will  gene- 
rally inform  the  operator  when  the  point  of  the  bougie 
has  proceeded  so  far  ; but  the  notch  in  the  bougie  is  to 
be  an  additional  guide,  by  becoming  very  near  the 
orifice  of  the  urethra,  when  the  end  of  the  instrument 
has  just  got  through  the  stricture. 

The  bougie  should  now  be  immediately  withdrawn 
by  a very  gentle  motion  to  the  part,  at  which  it  was 
first  made  to  rest  awhile.  1'hen  it  should  be  very 
slowly  passed  through  the  stricture  a second  time  ; but 
without  letting  the  bougie  stop  in  its  passage.  If  the 
patient  coinplain  of  pain,  or  be  faint,  the  bougie  should 
be  itnmediately  withdrawn  ; but  if  these  effects  are 
not  produced,  we  may  repeat  the  operation  of  passing 
and  withdrawing  the  bougie  tluough  tl»e  stricture 

VoL.  II.— C c 


once  or  twice  move  before  we  finish  the  operation, 
which  will  take  up,  in  the  whole,  about  two  minutes. 

The  first  application  of  the  potassa  fusa,  in  this 
manner,  gives,  according  to  Mr.  Whately’s  account, 
a very  little  pain.  A slight  scalding  in  making  water, 
and  a trifling  discharge,  during  tlie  first  day  or  two, 
however,  are  commonly  produced. 

At  the  end  of  seven  days,  tlie  application  of  the 
caustic  is  to  be  repeated  in  the  same  manner.  When 
the  first  application  has  enlarged  the  aperture  of  the 
stricture,  which  maybe  known  bypassing  a bougie 
through  it  of  the  same  size  as  that  by  which  the 
caustic  was  conveyed,  the  bougie  used  in  the  second 
operation  should  be  a size  larger  than  the  one  used  in 
the  first ; but  it  must  not  be  too  large  to  pass  through 
the  stricture.  If  the  patient  had  no  pain  on  the  first 
application,  the  bit  of  potassa  fusa  Si^y  also  be  trivially 
larger.  At  the  end  of  seven  days  more,  the  armed 
bougie  should  be  introduced  a third  time.  At  this  and 
all  future  applications,  the  bougie  should  be  increased 
in  size  fn  proportion  as  the  aperture  in  the  stricture 
becomes  dilated.  The  quantity  of  caustic,  however 
is  never  to  be  increased  in  a ratio  to  the  size  of  the 
bougie.  In  no  cases  whatever  does  Mr.  Whateiy 
apply  more  of  tlie  potassa  fusa  at  a time,  than  a piece 
about  tlie  size  of  a common  pin’s  head.  Twelve  bits 
of  the  largest  size  which  this  gentleman  ever  uses 
weigh  one  grain. 

When  there  are  several  strictures,  the  potassa  fusa 
should  be  generally  applied  to  only  one  at  a time. 

An  interval  of  seven  days  Is  what  Mr.  Whately 
generally  allows  to  elapse  between  the  applications  of 
the  caustic.  The  rule,  however,  may  now  and  then 
be  deviated  from ; but  the  potassa  fusa  ought  never  to 
be  reapplied  till  the  action  of  the  last  application  has 
completely  ceased.  In  a few  instances  the  interval 
may  only  be  five  days;  in  some  others  it  may  be  eight, 
nine,  or  even  a longer  space. 

In  the  above  method  of  using  the  potassa  fusa, 
Mr.  Whately  represents,  that  this  substance  is  equally 
difiTiised  over  every  part  of  the  strlctured  surface,  and 
only  abrades  the  membrane  of  the  stricture  witixout 
producing  a slough.  The  degree  of  this  abrasion,  he 
says,  may  be  increased  or  lessened,  as  circumstance.? 
dictate,  by  paying  attention  to  the  quantity  of  the 
caustic. 

The  foregoing  account  will  convey  an  adequate  idea 
of  Mr.  Whately's  method,  in  which  I never  saw  any 
recommendation  but  that  of  novelty.  To  abrade  with- 
out destroying  is  rather  too  nice  a distinction  for  a 
practical  man,  doing  business,  as  it  were,  in  the  dark. 
Nor  can  I conceive,  that  a liquid  caustic  (for  so  it  is 
represented  as  becoming)  can  be  applied  with  the  ac- 
curacy  to  strictures  wliich  Mr.  Whately  seems  to  sup- 
pose happens.  This,  however,  is  merely  my  own  sen- 
timent, and  I do  not  wish  to  conceal,  that  there  are  yet 
a few  surgeons  who  believe,  that  Mr.  Whately’s  plan 
is  the  most  eligible  for  all  cases  in  which  the  stricture 
is  irritable  or  far  advanced.— (See  Hoteskip's  Pract. 
Obs.  on  the  Urinary  Organs^  p.  207.)  On  the  other 
hand,  I know  some  very  eminent  surgeons,  who  for- 
merly took  up  this  practice  with  great  zeal,  and  now 
have  entirely  abandoned  it.  I consider  it  myself  the 
worst  and  most  random  mode  of  applying  caustic  to 
strictures,  and  more  likely  to  act  on  the  sound  than  the 
diseased  portion  of  the  urethra.  Sir  A.  Cooper  is  de- 
cidedly averse  to  the  use  of  caustic  alkali,  which,  he 
says,  is  much  too  soluble,  and  calculated  to  produce  a 
great  deal  of  inflammation  by  running  over  an  exten- 
sive surface.  In  this  advice  I fully  concur. 

Upon  the  whole  I may  safely  declare,  that  caustic 
bougies  of  every  kind  are  now  much  less  frequently 
used  by  the  best  sirrgeons  in  London  than  they  were 
aboirt  twenty  years  ago.  Several  distinguished  prac- 
titioners, who  to  rny  knowledge  were  then  accustomed 
to  recommend  and  employ  tliem,  have  at  present  re- 
turned either  to  lire  use  of  comrnoti  bougies,  or  those 
made  of  rnel.al  or  elastic  gnin,  to  which,  afier  many 
comiiarative  trials,  I acknowledge  a general,  but  not  a 
universal  preference  seems  to  me  to  be  due.  We  iearn 
from  M.  Roux,  that  caustic  bougies  never  had  many 
advocates  in  France;  and  the  inquiries  which  he  made 
when  lie  was  in  London,  authorized  him  to  announce 
to  Ills  conntiymen  after  his  return,  that  such  instrii- 
inents  were  not  more  in  general  favour  here  than  they 
were  at  Paris. — (.See  Voyage  fait  d Londres  en  1814, 
OH  ParalUle  do  la  Chirurgie  ^ngloise,  d-c-  p,  31.''.) 


402 


URETHRA. 


Cases  of  stricture,  where  the  disease  is  far  advanced, 
of  long  standing,  and  attended  w ith  such  obstruction 
that  no  kind  of  common  boogie  can  be  introduced,  ap- 
pear to  me  to  be  examples  in  which  perforation  on 
Mr.  Stafford’s  plan  may  be  justifiable.  Instead  of 
this,  however,  some  surgeons  would  prefer  the  em- 
ployment of  a common  bougie,  or  a conical  sound 
made  of  iron,  silver,  or  plaiina,  with  sufficient  force  to 
make  iu  way  through  the  stricture  by  laceration.  If 
the  stricture  occupy  a considerable  length  of  the  pas- 
sage, I believe  a passage  through  it  must  sometimes  be 
attempted  on  the  principle  of  exciting  ulceration,  and 
that  fur  tliis  purpose  a sound  or  metallic  catheter  should 
be  employed.  An  interesting  case  of  cartilaginous 
stricture  and  fistulae  in  perinajo  is  recorded  by  Delpech, 
where  a false  pa.ssage  was  made  with  a lunar  caustic 
bougie,  which  actupdiy  pierced  the  rectum ; two  days 
after  this  accident  the  stricture  was  forced  with  a coni- 
cal sound,  which  fortunately  eluded  the  false  passage 
and  entered  the  bladder.  An  abscess  in  the  perinaeum 
followed,  but  the  case  ended  well  under  the  use  of 
elastic  gum  catheters. — {Chir.  Clin.  p.  280.)  When 
the  treatment  of  strictures  brings  on  severe  shiverings, 
followed  by  febrile  symptoms,  opiuitt  is  the  best  medi- 
cine to  be  given,  and  the  introduction  of  instruments 
into  the  passage  should  be  suspended.  When  hemor- 
rhage from  the  urethra  is  occasioned  by  the  use  of 
bougies  or  other  instruments,  cold  evaporating  lou  ^iis 
to  the  perinaeum,  or  the  cold  bath  itself,  is  the  most 
effectual  way  of  suppressing  it.  In  one  case,  men- 
tioned by  air  A.  Cooper  in  his  lectures,  be  was  under 
tlte  necessity  of  dividing  the  aitery  of  the  bulb;  a 
measure  which  completely  succeeded. 

[So  numerous  have  been  the  failures  of  surgical 
treatment  in  strictures  of  the  urethra,  that  many  sur- 
geons have  considered  a severe  stricture,  and  especially 
a series  of  strictures  in  this  canal,  the  most  incurable 
and  unmanageable  of  surgical  diseases.  The  great 
number  of  strictures  foutid  in  the  incurable  wards  of 
our  hospitals,  alms-houses,  and  infirmaries  have  long 
rendered  this  affection  an  opprobrium  chirurgite.  The 
most  skilful  will  often  do  mischief  with  the  armed 
bougie,  and,  if  they  by  caution  avoid  this,  still  their 
failure  will  often  be  a painful  source  of  mortification. 

Professor  Jameson,  of  Baltimore,  has  introduced  an 
operation  by  which  he  has  succeeded  in  curing  a large 
number  of  obstinate  cases;  and  although  he  only  ad- 
vises and  performs  this  operation  in  the  worst  instances 
of  severe,  long-continued,  and  complicated  stricture, 
the  proportion  of  cutes  has  been  greater  than  is  ordi- 
narily found  in  the  practice  of  any  surgeon  who  treats 
ail  kinds  of  cases  indiscriminately  by  any  of  the  former 
methods. 

In  the  Amer.  Med.  Recorder  for  1824,  Dr.  Jameson 
has  published  an  essay  on  stricture  of  the  urethra,  in 
which  he  reports  a number  of  cases,  with  their  treat- 
ment and  results.  Several  of  these  cases  came  under 
my  own  notice ; and  during  my  former  residence  in 
Baltimore,  I witnessed  his  operation  several  times,  and 
had  an  opportunity  of  seeing  his  success,  and  the  en- 
tire removal  of  the  disease. 

This  operation  consists  in  opening  the  urethra 
through  the  perinseuin,  and  introducing  a flexible  ca- 
theter through  the  penis  into  the  bladder,  which  is 
suffered  to  remain  until  the  wound  in  the  urethra  is 
united. 

The  patient  is  tied  as  for  lithotomy,  and  a sound  in- 
troduced as  far  as  it  can  be  passed,  which  serves  as  a 
guide,  if  it  can  be  introduced  as  far  as  the  bulb.  An 
incision  is  now  made  throughthe  perinaeum,  and  theure- 
thra  laid  open.  In  bad  cases  he  advises  to  divide  the 
triangular  ligament  both  above  and  below  the  urethra. 
The  fore-finger  is  then  to  be  introduced  through  the  re- 
mainder of  the  stricture.  When  it  is  necessary  to  di- 
vide the  muscles  surrounding  the  membranous  part  of 
the  urethra,  a director  is  first  introduced,  and  the  inci- 
sion made  with  a scalpel  or  bistoury,  when  the  finger 
may  be  passed  into  the  bladder.  A flexible  catheter  is 
now  passea  through  the  penis  into  the  bladder,  and  the 
wound  is  placed  in  the  most  favourable  circumstances 
to  tmite. 

'I’hough  this  operation  is  as  severe,  and  even  some- 
times more  difficult 'han  lithotomy,  Dr.  J.’s  experience 
has  shown  that  it  is  seldom  attended  with  danger. 
The  only  cases  in  which  this  operation  would  be  ad- 
vi.sable  are  those  in  which  no  sound  or  staff  can  be 
pas-sed  into  the  bladder,  and  herein  consists  the  diffi- 


culty of  the  operation.  It  is  a means,  however,  which 
has  afforded  relief  in  cases  which  had  otherwise  been 
abandotied  as  hopeless — Reese.] 

A Treatise  on  the  V tnereal  Disease,  by  John 
Hunter,  2d  edit.  Practical  Obs.  on  the  Treatment  of 
Strictures  in  the  Urethra  and  (Esophagus,  by  Sir  Eve- 
rard  Home,  in  3 vols.  8vo.  Eond.  An  improved  Me~ 
thod  of  treating  Strictures  in  the  Urethra,  by  Thomas 
Whately,  edit.  2, 1806.  M.  W.  Andrews's  Obs.  on  the 
Application  of  Lunar  Caustic  to  Strictures  in  the  Ure- 
thra and  (Esophagus,  Svo,  Land.  1807.  T.  Lux- 
more's  Practical  Observations  on  Strictures,  (S-c.  8co. 
Land.  1809.  Huwship's  Practical  Obs.  on  the  Diseases 
of  the  Urinary  Organs,  8uo.  Lond.  1816.  Soemmer- 
rivg  Abhandlung  iiber  die  schnell  und  langsum  tbdt- 
lichen  Krankkeiten  der  Harnbluse  und  Harnrohre  bey 
Mdnnern  im  hohen  Alter,  ito.  Frankf.  1809.  Letters 
concerning  the  Diseases  of  the  Urethra,  by  C.  Bell, 
1810;  subsequently  republished  with  additions  by  Mr. 
Shaw.  James  Wilson,  Lectures  on  the  Structure  and 
Physiology  of  the  Male  Urinary  and  Genital  Organs, 
and  their  Diseases,  8vo.  Lond.  1821.  James  Arnott, 
A Treatise  on  Stricture  of  the  Urethra,  8vo.  I.ond. 
1819.  An  account  of  this  gentleman's  dilator,  and  his 
method  of  treatment  is  given  in  the  First  Lines  of  the 
Practice  of  Surgery,  edit.  4.  .7.  Cross,  Sketches  of  the 

Medical  Schools  of  Paris,  p.  Ill,  <^c.  8oo.  Lond.  1815. 
Boyer,  Traite  des  Mai.  Chir.  t.  9,  Paris,  1S34.  J. 
Howship  on  Diseases  of  the  Urinary  Organs,  8no. 
Lond.  1823.  O.  Macilwain,  On  Stricture  of  the  Ure- 
thra, 8vo.  Lond.  1824 : a very  useful  manual.  Del- 
pech, Chirurgie  Clinique  de  Montpellier,  1. 1,  4£o.  Paris, 
1823.  R.  A.  Stafford,  On  Strictures  of  the  Urethra,  ed. 
2,  8vo.  Lond.  1829. 

URETHRA,  FALSE  PASSAGE  IN.  One  of  the 
worst  consequences  of  using  catheters  and  bougies  in 
an  improper  manner,  is  the  rupture  of  the  urethra,  or 
the  formation  of  a false  passage  by  ulceration.  With 
bougies  this  accident  is  generally  occasioned  by  trials 
to  excite  ulceration  by  the  application  of  the  end  of  the 
bougie  to  the  stricture,  when  this  instrument  cannot  be 
passed  through  it.  When  once  the  new  passage  has 
been  formed,  whenever  the  bougie  is  introduced  it 
cannot  be  hindered  from  going  into  the  false  track,  and 
its  action  on  the  stricture  is  altogether  frustrated. 

In  this  kind  of  case,  Mr.  Hunter  has  advised  the  fol- 
lowing operation  to  be  practised.  Pass  a staff  or  any 
such  instrument  into  the  urethra  as  far  as  it  will  go^ 
which  will  probably  be  to  the  bottom  of  the  new  pas- 
sage, and  this,  we  may  be  certain,  is  beyond  the  stric- 
ture. Feel  for  the  end  of  the  instrument  externally, 
and  cut  upon  it,  making  the  wound  about  an  inch  long, 
if  the  disease  be  before  the  scrotum;  and  an  inch  and 
a half,  or  more,  if  in  the  perinajum.  If  the  new  pas- 
sage be  between  the  urethra  and  body  of  the  penis, 
you  will  most  probably  get  into  the  sound  urethia  be- 
fore you  come  to  the  instrument  or  new  passage.  If 
so,  introduce  a probe  into  the  urethia  through  the 
wound,  and  pass  it  towards  the  glans  penis,  or,  ia 
other  words,  towards  the  stricture.  When  it  meets 
with  an  obstruction,  this  must  be  the  stricture,  whicli 
is  now  to  be  got  through,  and  afterward  dilated.  To 
complete  the  operation,  withdraw  the  pirobe,  and,  in- 
stead of  it,  introduce  a hollow  cannula  forwards  to  the 
stricture.  Then  introduce  another  cannula  from  the 
glans  downwards,  till  the  two  tubes  are  opposite  each 
other,  having  the  stricture  between  them.  An  assist- 
ant is  now  to  take  hold  of  the  urethra  on  the  outside 
with  his  finger  and  thumb  just  where  the  two  cannulas- 
meet,  in  order  to  keep  them  in  their  pilaces.  Through 
the  upper  cannula  next  introduce  a jiiercing  instrument, 
wliich  is  to  jierforate  the  stricture,  and  enter  the  lower 
cannula.  The  piercing  instrument  is  now  to  be  with- 
drawn, and  a bougie  introduced  through  the  first  can- 
nula and  stricture  into  the  second  cannula.  The 
tubes  are  to  be  withdrawn,  and  the  end  of  the  bougie 
in  the  wound  directed  into  the  bladder,  tlrrough  the 
farther  portion  of  the  urethra.  It  may  also  be  neces- 
sary to  lay  the  whole  of  the  false  passage  open,  in 
order  to  make  it  heal ; for,  otherwise,  it  might  still  ob- 
struct the  future  passage  of  bougies  into  the  proper 
canal. 

When  the  new  passage  is  between  the  skin  and  ure- 
thra, the  surgeon  must  extend  his  incision  more  deeply, 
for  the  pnirposc  of  finding  out  ihe  natuial  passage. 
Then  he  is  to  proceed  as  almve  explained. 

The  longer  the  first  bougie  is  allowed  to  remain  bk 


URI 


URI 


403 


the  canal,  the  more  readily  will  the  second  pass.  The 
bougies  must  be  gradually  increased  in  size,  and  used 
till  tlie  wound  is  healed.  The  only  improvement 
which  seems  proper  to  be  made  in  this  plan,  is  to  em- 
ploy flexible  gum  catheters,  which  might  be  worn 
longer  than  common  bougies,  as  the  patient  could  void 
his  urine  through  them. 

It  appears,  from  the  observations  of  Mr.  Stafford, 
that  if  a false  passage  be  made,  leading  from  one  pan 
of  the  urethra  to  another,  and  the  urine  pass  through 
the  new  channel,  it  becomes  lined  by  a kind  of  mem- 
brane, resembling  that  of  the  natural  canal.— (On 
Strictures,  p.  39,  ed.  %) 

URINARY  ABSCESSES.  Extravasations  of  urine 
may  be  in  Riree  difterent  states.  This  fluid  may  be 
collected  in  a particular  pouch  ; it  tnay  be  widely  dif- 
fused in  the  cellular  membrane;  or,  lastly,  it  may  pre- 
sent itself  in  a purulent  form,  after  having  excited  in- 
flammation and  suppuration  in  the  parts  among  which 
it  is  situated.  This  case  is  termed  a urinary  abscess. 

Such  extravasations  of  urine  always  imply  a rup- 
ture, either  in  the  kidneys  or  ureters,  the  bladder  or  the 
urethra.  'J'he  solution  of  continuity  may  be  produced 
by  a variety  of  causes.  It  is  most  frequently  the  ef- 
fect of  a forcible  distention  of  these  passages  in  conse- 
quence of  a retention  of  urine.  The  bursting  of  phleg- 
monous abscesses  into  the  same  passages  may  occasion 
the  breach.  It  may  also  be  produced  by  the  penetration 
of  the  parts  with  a sword  or  other  foreign  body : there 
are  likewise  examples  of  eft'usion  of  urine  from  the  dis- 
placement of  the  cannula  of  the  trocar  after  the  ope- 
ration of  puncturing  the  bladder.  Others  are  caused  by 
false  passages  in  the  urethra,  or  by  violent  contusions 
of  the  perinajum,  attended  with  laceration  of  the  urethra. 

In  Desault’s  Surgical  Works  {t.  3)  it  is  observed, 
that  the  ravages  which  extravasated  urine  makes  are 
usually  greater  and  more  extensive  when  it  enters  the 
cellular  membrane,  than  when  it  is  confined  in  a parti- 
cular cyst.  The  mischief  is  also  less  when  the  excre- 
tory passage  is  free,  llian  when  it  is  closed  by  any  ob- 
stacle, as  in  cases  of  retention.  The  more  or  less  loose 
texture  of  the  parts  in  which  such  eiTusions  happen, 
likewise  makes  a considerable  difference  in  their  pro- 
gress and  formation.  When  the  pelvis  or  infundibu- 
lum of  the  kidney,  or  the  upper  part  of  the  ureter 
gives  way,  the  urine  is  commonly  effused  in  the  loins 
and  the  fossse  iliacre,  betw'een  the  peritoneum  and  the 
adjacent  parts.  When  the  lower  part  of  the  ureter  or 
the  bladder  near  its  lower  portion  gives  way,  the  ex- 
travasation is  generally  included  within  the  pelvis. 

But  when  the  rupture  occurs  in  the  anterior  parietes 
of  the  bladder  near  its  upper  part,  and  especially 
when  it  takes  place  at  a time  when  this  organ  is  ex- 
tremely distended  and  dilated,  the  urine  becomes  ef- 
fused behind  and  above  the  pubes,  sometimes  ascends 
to  the  epigastric  region,  between  the  peritoneum  and 
the  abdominal  muscles,  and,  after  having  followed  the 
course  of  the  spermatic  vessel.s,  it  often  makes  its  exit 
at  the  rittg,  and  is  extravasated  in  the  groins  and  scro- 
tum. If  the  rupture  has  happened  in  the  urethra,  the 
most  common  situation  of  the  effusion  Is  in  the  pei  i- 
nteum  and  scrotum.  The  extravasation  frequently 
extends  to  the  penis  and  upper  part  of  the  thighs,  and 
even  sometimes  propagates  itself  under  the  skin  of  the 
abdomen  up  to  the  hypochondria  and  sides  of  the  chest. 

There  is  no  fluid  the  extrava.«ation  of  which  is  so 
fatal  as  that  of  the  urine.  If  it  is  not  promptly  dis- 
charged, it  soon  excites  suppuration  and  sloughing  of 
lire  cellular  membrarre,  a gattgrenorts  inflammation  of 
the  skirt,  and  almost  always  a mortification  of  the  parts 
anrottg  which  it  flows. 

While  the  exuavasation  of  urine  is  confined  to  the 
interior  of  the  [relvis,  and  lumbar  and  iliac  regions, 
without  manifesting  itself  externally,  there  is  no  cer- 
tain sign  of  its  existence.  The  circumstances  which 
iitay  be  recollected,  however,  Joined  with  the  symp- 
toms which  the  jraiient  coutplains  of,  may  lead  to  a 
suspicion  of  the  extravasation.  Thus,  when,  in  con- 
sequence of  a relemion  of  uritte  in  the  ureters  or  blad- 
der, the  patient  has  suddenly  experienced  great  relief, 
without  any  of  the  urine  having  been  discharged  the 
natural  way;  when  he  has  at  the  same  instant  felt  a 
kind  o*'  pricking  in  the  loiirs  or  pelvis;  when  to  the 
ease,  which  lasted  otrly  a few  horrrs,  symplonrs  more 
severe  than  the  former  ones  have  succeeded  (such  as 
violent  fever,  hiccough,  vomiliirg,  &c.),  an  internal 
extravasation  is  to  be  suspected. 


As  soon  as  the  extravasation  is  apparent  externally, 
the  case  is  announced  by  symptoms  which  hardly  ever 
deceive.  The  preceding  retention  of  urine ; the  sud- 
den appearance  of  the  swelling  caused  by  this  fluid ; 
the  rapid  progress  of  (he  tumour ; the  kind  of  crepita- 
tion perceptible  in  it,  like  that  which  occurs  in  emphy- 
sema ; the  shining  tension  and  oedema  of  the  skin ; 
the  diminution  of  such  symptotns  as  depended  en- 
tirely upon  the  retention  ; are  the  first  changes  which 
are  observable  when  the  extravasation  is  somewhat 
considerable. 

If  the  patient  is  not  speedily  assisted  and  the  urine 
continues  to  be  extravasated,  the  tumtmr  spreads  more 
and  more;  the  skin  assumes  a red  violet  colour  ; gan- 
grenous eschars  are  formed,  the  separation  of  which 
gives  issue  to  a very  fetid  sanies,  in  which  the  smell  of 
mine  is  readily  distinguishable.  Portions  of  dead  cel- 
lular membrane  are  presently  discharged  together  with 
the  sanies;  the  ulcer  grows  larger;  and  the  dressings 
are  continually  wet  with  the  urine. 

When  one  of  the  ureters  has  given  way,  and  a uri- 
nary abscess  is  formed  in  the  loins,  the  aid  to  be  de- 
rived from  surgery  is  limited  to  making  an  opening  in 
the  extravasation  as  soon  as  it  can  be  felt  externally. 
It  is  then  not  in  the  power  of  art  to  re-establish  the 
natuial  course  of  the  urine,  or  to  hinder  this  fluid 
from  passing  through  the  wound  and  rendering  it  fis- 
tulous. However,  there  are  some  circumstances  in 
which  a radical  cure  may  be  attempted.  For  exam- 
ple, if  the  abscess  were  produced  by  a calculus  lodged 
in  ihe  infundibulum  or  ureter,  and  it  could  be  felt  and 
taken  hold  of  with  a pair  of  forceps  introduced  into 
the  opening,  the  extraction  of  the  foreign,  body  might 
promote  the  healing  of  the  ulcer,  by  rendering  the  na- 
tural channel  for  the  urine  Iree. 

When  the  opening  by  which  the  urine  has  become 
extravasated  exists  in  the  bladder  or  urethra,  one  indi- 
cation that  does  not  present  itself  in  the  foregoing 
case  may  be  fulfilled,  viz.  the  urine  may  be  drawn  off 
by  means  of  a catheter  passed  into  the  bladder  and 
kept  there.  By  this  means  we  not  only  immediately 
stop  the  progress  of  the  extravasation,  but  attack  the 
very  cause  of  the  malady,  by  removing  the  obstacles 
which  oppose  the  natural  course  of  the  urine.  The 
introduction  of  the  catheter  then  becomes  a matter  of 
the  most  urgent  necessity.  This  operation  is  often  at- 
tended will!  the  greatest  difficulties.  Besides  the  ordi- 
nary obstruction  of  the  canal,  we  have  also  to  sur- 
mount the  obstacles  which  the  urinary  swellings  situ- 
ated in  the  course  of  the  urethra  create  to  the  passage 
of  the  instrument.  When  these  tumours  are  consider- 
able, they  ought  to  be  ojrened  before  the  catheter  is 
employed.  The  subsidence  of  the  swellings  would 
render  catheterism  more  easy.  Besides,  Desault  was 
assured,  by  daily  experience,  that  with  a little  skill,  ex- 
ercise, and  patience,  the  catheter  might  always  be  got 
into  the  bladder.  If,  however,  the  thing  could  not  be 
done,  ought  we  to  puncture  the  bladder,  or  have  re- 
course to  the  operation  of  cutting  into  the  dilated 
portion  of  the  urethra  between  the  stricture  and  the 
bladder  1 

Desault  was  an  advocate  for  neither  of  these  pro- 
ceedings : he  thought  it  was  a more  simple  and  benefi- 
cial practice  merely  to  make  an  external  opening  in 
the  collection  of  effused  urine.  This  measure  would 
both  afford  an  outlet  for  the  urine,  and  arrest  the  ex- 
tension of  the  extravasation.  Besides,  such  an  open- 
ing is  often  indispensably  requisite  for  the  purpose  of 
putting  a stop  to  the  symptoms  depending  upon  the  ef- 
fusion and  stagnation  of  the  urine.  But  if  the  cathe- 
ter can  be  introduced,  there  may  be  cashes  in  which  an 
opening  would  not  only  be  useless  but  hurtful ; for  in- 
stance, when  the  swelling  caused  by  Ihe  urine  is  of 
little  extent,  or  when  it  is  situated  in  the  thickness  of 
the  parietes  of  the  passage,  or  along  its  track,  it  al- 
most always  admits  of  dispersion  by  the  simple  em- 
ployment of  the  catheter.  But  it  seldom  happens  that 
this  swelling,  however  small,  ends  in  resolution ; it  al- 
most always  suppurates;  yet,  as  it  breaks  into  the 
urethra,  the  matter  escajres  between  this  canal  and  the 
catheter,  and  renders  the  making  of  an  external  open- 
ing needless.  Experience  teaches  us,  also,  ti>at  wlien 
the  tumour  is  situated  in  the  scrotum,  or  Iretween  the 
root  of  the  penis  and  the  symphysis  pubis,  even  after 
the  healing  of  the  incisions  made  in  these  situa'ions,  a 
fistula  will  often  remaiti,  which  is  very  difficult  of 
cure.  With  the  exception  of  these  particular  cases, 


C c2 


URI 


404  URI 

Desault  was  an  advocate  for  opening  all  urinary  ab- 
scesses. 

Ill  uiy  own  practice,  1 have  never  e.tperienced  much  dif- 
ficulty in  healing  fistulas  in  the  perinaeum,  after  the  re- 
moval of  tlie  obstruction  in  the  urethra ; and  my  usual 
plan,  whellier  the  effusion  of  urine  be  consklerable  or 
not,  is  always  first  to  make  a puncture  or  incision  in 
the  swelling,  so  as  to  obviate  the  risk  of  its  increase, 
and  then  to  have  immediate  recourse  to  the  catheter. 

The  manner  of  opening  such  collections  varies  ac- 
cording as  the  urine  may  be  in  one  cavity  or  widely 
effused  in  the  cellular  membrane.  In  the  first  case,  a 
simple  incision  the  whole  length  of  the  cavity  will  suf- 
fice tor  empiying  and  healing  it.  In  the  second,  if  the 
e-ttravasation  is  extensive,  the  incisions  must  be  mul- 
tiplied. It  would  be  absurd  to  spare  the  parts ; for  all 
those  with  which  the  urine  has  come  into  contact  sel- 
dom escape  mortification.  The  incisions  which  are 
made  hardly  ever  have  the  effect  of  saving  them  ; but 
by  accelerating  the  discharge  of  putrid  sanies  and  stag- 
nant urine,  they  prevent  mischief  which  would  origi- 
nate from  a lariher  lodgement.  At  all  events,  when  the 
operation  is  at  ali  delayed,  rtie  destruction  of  all  the 
parts  in  contact  with  this  irriiating  fluid  is  inevitable. 
The  approach  of  mortification  is  indicated  by  the  cre- 
pitation under  the  bistoury,  resembling  the  kind  of 
noise  produced  by  tearing  parchment.  'The  extent  and 
depth  of  the  incisions  must  be  pioportioned  to  those  of 
the  abscess.  When  the  extravasation  occupies  the 
scrotum,  long  deep  scarifications  should  be  made  in 
that  part,  as  well  as  in  the  skin  of  the  penis,  and  in 
every  place  where  the  urine  is  effused. 

Practitioners  unaccustomed  tosee  such  diseases  would 
be  alarmed  at  the  extent  of  the  sore  produced  by  the 
separation  of  the  eschars.  Sometimes  the  whole  scro- 
tum, ski».  of  the  penis,  and  that  of  the  groins,  peri- 
njEum,  and  upper  part  of  the  thigh,  mortify,  and  the 
naked  testicles  hang  by  the  spermatic  cords  in  the 
midst  of  this  enormous  ulcer.  It  is  hardly  conceivable 
how  cicatrization  could  take  place  over  the  exposed 
testicles ; but  the  resources  of  nature  are  unlimited. 
She  unites  the  testicles  and  the  cords  to  the  subjacent 
parts,  and  drawing  the  skin  from  the  circumference  to 
the  centre  of  the  ulcer,  she  covers  these  organs  again, 
and  furnishes  them  with  a sort  of  new  scrotum.  This 
statement  is  founded  upon  numerous  cases  in  which 
nature  alw'ays  followed  this  course.  The  cicatrization 
of  the  ulcer  is  even  more  expeditious  than  might  be 
apprehended,  considering  its  extent.  In  all  this  busi- 
ness, what  does  art  do  7 If  the  introduction  of  the 
catheter  is  excepted,  which,  indeed,  is  absolutely  ne- 
cessary for  the  radical  cure,  her  assistance  is  very 
limited,  and  almost  nothing,  in  the  generality  of  in- 
stances ; for  when  patients  are  not  exhausted  by  the 
tediousness  of  the  disorder,  when  they  are  of  a good 
constitution  and  in  tlie  prime  of  life,  they  get  well  as 
quickly  and  certainly  with  the  aid  of  a good  diet  and 
simple  dressings  a.s  when  they  take  internal  medi- 
cines and  use  a multiplicity  of  compound  topical  ap- 
plications. The  practice  of  Desault,  at  the  Hotel- 
Dieu,  consisted  in  applying  emollient  poultices  until 
the  sloughs  were  detached.  The  ulcer  w'as  then  some- 
times dressed  with  pledgets  charged  with  styrax;  but 
frequently  mere  diy  lint  was  used,  and  continued  till 
the  cure  was  competed.  If  any  complication  occur- 
red in  the  course  of  the  treatment,  suitable  remedies 
w'ere  prescribed  for  it.  Thus,  when  prostration  of 
strength  and  tendency  to  sloughing  existed,  bark,  cor- 
dials, and  antiseptics  were  ordered.  But,  in  every 
case,  the  catheter  is  the  essential  means  of  cure; 
without  it  the  rt‘eatment  is  almost  always  imperfect, 
and  the  ulcer  will  not  heal  without  leaving  several  uri- 
nary fistulte. — (See  CEuvres  Chir.  de  Desault,  par  Bi- 
chat,  t.  3,  p.  277—287.) 

URINARY  C.ALCULI.  A true  explanation  of  the 
nature  of  urinary  calculi  was  quite  impossible,  before 
chemistry  had  made  considerable  progress,  and  the 
methods  of  analysis  had  advanced  a great  way  to- 
wards perfection  : and,  as  w ill  appear  in  the  course  of 
this  article,  all  the  valuable  knowledge  which  now  ex- 
ists upon  this  subject  is  in  reality  the  fruit  of  modern 
investigations.  It  is  to  be  regretted,  however,  that  our 
information  on  many  points  is  far  from  being  settled 
or  complete,  as  any  impartial  and  judicious  reader 
may  soon  convince  himself  by  a reference  to  the  able 
and  scientific  views  lately  taken  by  Dr.  Prout,  of  va- 
rioua  questions  relative  to  the  formation  of  gravel  and 


calculi,  and  the  treatment  of  such  cases  in  all  their  va- 
rieties.— (See  Jin  Inquiry  into  the  J^Tature  and  Treat* 
meut  of  Gravel  and  Calculus,  and  other  Diseases  cun* 
nected  with  a deranged  Operation  of  the  Urinary  Or- 
gans, 6vo.  Bond,  l&l.) 

Mechanical  deposiles  from  the  urine  are  divided  by 
Dr.  Prout  into  three  classes.  1.  Pulverulent  or  amor- 
phous sediments.  2.  Crystalline  sediments,  usually 
denominated  gravel.  3.  Solid  concretions  or  calculi, 
formed  by  the  aggregation  of  these  sediments. 

Pulverulent  or  Amorphous  Sediments  are  described 
by  Dr.  Prout  as  almost  always  existing  in  a slate  of  so- 
lution in  the  urine  before  it  is  discharged,  and  even 
afterward  until  it  begins  to  cool,  when  they  are  deito- 
sited  in  the  state  of  a fine  powder,  the  panicles  of 
which  do  not  appear  to  be  crystalline.  Their  colour  is 
for  the  most  part  brown  or  yellow,  and,  generally 
speaking,  they  consist  of  two  species  of  neutral  saline 
compounds ; viz.  the  lithaies  of  ammonia,  soda,  and 
lime,  tinged  more  or  less  with  the  colouring  principle 
of  the  urine,  and  with  the  purpurates  of  the  same 
bases,  and  constituting  what  are  usually  denominated 
pink  and  lateritious  sediments;  and,  secondly,  the 
earthy  phosphates,  namely,  the  phosphate  of  lime,  and 
the  triple  phosphate  of  magnesia  and  ammonia,  con- 
stituting for  the  most  part  .sediments  nearly  white.  The 
two  species  of  sediments  are  frequently  mixed  to- 
gether; though  the  liihates  generally  prevail. 

Crystalline  Sediments,  or  Gravel,  are  commonly 
voided  in  the  form  of  minute  angular  grains  or  crys- 
tals, composed,  1.  Of  lithic  acid,  nearly  pure ; 2.  Of 
triple  phosphate  of  magnesia  and  ammonia ; and,  3. 
Of  oxalate  of  lime.  The  crystals  of  lithic  acid,  w hich 
are  by  far  the  most  frequent,  are  always  more  or  les» 
of  a red  colour.  Those  composed  of  the  triple  phos- 
phate of  magnesia  and  ammonia  are  nearly  white; 
while  others,  composed  of  the  oxalate  of  lime,  which 
are  extremely  rare,  are  of  a dark,  blackish  green  co- 
lour. It  is  farther  remarked  by  Dr.  Prout,  that  these 
different  varieties  of  crystalline  deposiles  are  never 
voided  together,  though  they  not  unfrequently  occur 
with  amorphous  sediments. — {Prout,  op.  cit.  p.  79,  <S-c.) 

Solid  Concretions,  or  Urinary  Calculi,  arising  from 
the  precipitation  and  consolidation  of  the  urinary  sedi- 
ments, may  be  formed  in  any  of  the  cavities  to  which 
the  urine  has  access;  and  hence  they  are  met  with  ii> 
the  kidneys,  ureters,  bladder,  and  urethra.  Their  va- 
rious appearances  and  chemical  properties  will  be  pr^ 
sently  described.  Most  of  them  are  believed  to  be  ori- 
ginally produced  in  the  kidneys,  from  which  they  af- 
terw  ard  descend  with  the  twine.  To  this  statement, 
however,  the  cases  in  which  calculi  are  formed  upon 
foreign  bodies  introduced  into  ih6  bladder  through  the 
urethra,  an  accidental  wound,  or  some  ulcerated  com- 
munication between  the  intestines  and  the  Madder,  are 
manifest  exceptions.  In  the  centre  of  urinary  calculi, 
bullets,  splinters  of  bone,  pieces  of  bougies,  and  wood, 
pins,  needles,  nuts,  &c.  are  frequently  observed ; and 
it  would  appear  that  a very  minute  substance  is  ca- 
pable of  becoming  a nucleus  ; a mere  clot  of  blood,  or  a 
little  bit  of  chaff,  if  not  soon  voided,  being  sufficient  to 
lead  to  the  formation  of  a stone  in  the  bladder.  The 
lithic  acid  itself  is  a common  nucleus,  even  where  the 
whole  calculus  is  not  of  the  same  material. 

That  many  urinary  calculi  are  originally  produced 
in  the  kidney,  is  certain  ; first,  from  the  severe  pain 
w'hich  the  passage  of  such  foreign  bodies  down  the 
ureter  always  excites;  and,  secondly,  from  their  being 
often  discovered  in  the  infundibula  and  pelvis  of  that 
viscus  after  death.  This  last  fact  is  well  illustrated  in 
the  first  plate  of  Dr.  Marcet’s  interesting  “ Essay  on  the 
Chemical  History  and  Medical  Treatment  of  Calcu- 
lous Disorders,"  8vo.  1817.  The  engraving  is  taken 
from  a preparation  in  the  Museum  of  Guy’s  Hospital. 
In  this  instance,  there  were  several  calculi  closely 
pressed  against  each  other  ; but,  in  another  example, 
drawn  from  a sjiecimen  in  Mr.  Abernethy’s  museum, 
the  renal  concretion  was  composed  of  a single  ma*** 
w hich  represented  a complete  cast  of  the  pelvis,  and 
part  of  the  infundibula  of  the  kidney.  In  this  form 
of  the  disease,  the  kidney  loses  at  last  all  vestiges  of  ita 
natural  structure,  and  is  converted  into  a kind  of  cyst 
filled  with  the  e.xtraneous  substance.  When  so  com- 
plete an  alteration  of  the  structure  takes  place,  the  se- 
cretion of  urine  must  of  course  be  entirely  carried  on 
by  the  other  kidney.  However,  in  some  instances,  the 
inconvenience  thus  produced  is  so  alight,  Utat  it  almoa* 


URINARY  CALCULI. 


405 


escapes  notice ; and  sometimes  even  both  kidneys  are 
diseased  in  a very  great  degree,  and  yet  liCe  is  preserved 
for  a considerable  time. — {Op.  cit.p.  3,4.) 

Calculi  are  sometimes  found  in  the  ureters,  especi- 
ally at  the  upper  part;  but  it  is  not  supposed,  that  they 
are  originally  formed  there  ; an  event  not  likely  to  hap- 
pen, uidess  there  were  some  cause  retarding  the  descent 
of  the  urine  through  those  tubes.  The  common  belief 
is,  that  all  calculi  found  in  the  ureter,  are  first  produced 
in  the  infutidibula,  and  pelvis  of  tlie  kidney,  from  which 
tliey  afterward  descend  wiih  the  urine. 

The  generality  of  calculi,  however,  which  leave  the 
kidney  are  of  small  size,  and,  consequently,  after  a 
time,  and  exciting  some  pain  and  inconvenience,  they 
usually  pass  into  the  cavity  of  the  bladder.  Indeed,  as 
Dr.  Marcet  remarks,  the  bladder  is  the  most  frequent 
seat  of  calculi : not  only  because  all  urinary  concre- 
tions, or  their  nuclei,  formed  in  the  kidneys,  tend  to  fall 
into  that  organ;  but,  also,  because  a stone  may  be,  and 
probably  often  is,  originally  formed  in  the  bladder  it- 
self. 

Renal  concretions  vary  considerably  in  their  number, 
size,  and  shape.  In  some  cases,  a single  small  calculus 
has  been  found  occupying  one  of  the  foregoing  situa- 
tions; while,  in  other  instances,  an  innumerable  col- 
lection of  calculous  substances  are  observed  filling  the 
whole  of  the  cavity  of  the  pelvrs  and  infundibula  of 
the  kidney,  distending  its  parietes,  and  even  obstruct- 
ing the  passage  of  the  urine  out  of  this  viscus,  which 
is  converted  into  a sort  of  membranous  cyst.  Lastly, 
a single  stone  in  the  kidney  may  acquire  a very  large 
size  there;  or  a great  number  of  small  calculi,  in  the 
same  situation,  may  become  cemented  together,  so  as 
to  form  one  mass  of  enormous  dimensions,  and  the 
«hape  of  which  invariably  corresponds  to  the  space  in 
which  it  is,  as  it  were,  moulded.  Hence,  renal  cal- 
culi often  present  a variety  of  odd,  irregular  figures, 
resembling  those  commonly  observed  in  specimens  of 
coral. 

Great  disorder  of  the  stomach,  frequent  vomiting, 
and  great  irritability  of  the  bladder  are  common  ef- 
fects of  a calculus  in  the  kidney.  Sir  A.  Cooper  met 
with  a case  in  which  the  chief  pain  was  at  the  anterior 
superior  .spinous  process  of  the  ileum. 

It  has  been  already  remarked,  that  urinary  concretions 
of  large  .«ize  very  often  exist  in  the  kidney,  without 
their  presence  being  indicated  by  any  external  circum- 
stances, or  attended  with  any  symptoms,  sufficiently 
unequivocal  to  constitute  a ground  for  suspecting  the 
importance  of  their  cause.  On  the  other  hand,  it  is  very 
usual  for  renal  calculi,  of  middling  dimensions,  to  ex- 
cite serious  and  alarming  complaints.  Tlie  reason  of 
this  difference  becomes  obvious,  when  it  is  recollected, 
that  smallish  concretions  are  readily  carried  with  the 
urine  into  the  ureter,  and  become  fixed  in  the  narrow 
portion  of  the  tube.  But  very  large  calculi  can  be  con- 
tained only  in  the  upper  part  of  this  canal,  where  its 
parietes  are  more  yielding,  and  the  space  in  them  more 
capacious. 

Calculi  of  middling  size,  in  their  passage  through  the 
ureter,  cause,  at  first,  a feeling  of  heaviness,  or  an  in- 
determinate sense  of  uneasiness,  and  an  obtuse  pain  in 
the  region  of  the  corresponding  kidney.  These  com- 
plaints occur  at  intervals  of  greater  or  less  duration. 
At  length,  the  pain  grows  more  urgent  and  annoying, 
attended  with  flatulence,  heart  burn,  frequent  vomit- 
ing, painful  retraction  of  the  testicle,  and  sometimes 
acute  fever.  As  Sir  A.  Cooper  has  remarked,  in  his 
lectures,  it  is  at  the  period,  when  the  calculus  is  pass- 
ing over  the  lumbar  plexus,  that  a great  deal  of  pain  is 
felt  in  the  groin  and  in  the  course.of  the  anterior  crural 
nerve,  just  as  the  spasmodic  contraction  of  the  cre- 
master arises  at  the  time  when  the  calculus  is  descend- 
ing over  the  spermatic  plexus.  The  patient  makes 
water  frequently,  and  in  small  quantities  at  a time  ; 
and  the  urine  is  high-coloured  and  bloody.  The  patient 
cannot  sit  upright,  his  body  being  bent  forwards  to- 
wards the  affected  side.  These  symptoms  may  have 
more  or  less  duration,  and  then  suddenly  cease.  They 
may  also  subside  and  recur  several  times  at  intervals  of 
some  days.  In  the  latter  case,  the  pain  is  felt  at  each 
attack  to  be  situated  lower  in  the  track  of  the  ureter. 
Lastly,  when  the  symptrrms  have  entirely  di.sappeared, 
the  urine  is  more  abundant,  not  so  high  coloured,  and 
easily  discharged,  the  stream  sometimes  bringing  out 
with  it  the  urinary  concretion,  after  its  entrance  into 
the  bladder. 


Suppuration  of  the  kidney,  and  an  abcess  in  the  lum- 
bar region,  in  consequence  of  renal  calculi,  are  not 
very  cornnron  events.  However,  these  are  the  only 
cases  of  the  kind  in  which  the  interposition  of  sur- 
gery can  be  useful.  ' By  adverting  to  previous  circum- 
stances, and  irregularity  of  the  pain  about  the  kidney, 
the  practitioner  may  suspect  the  nature  of  a phlegmo- 
noustumuor  in  the  situation  of  this  viscus.  Whatever 
may  be  his  conjectures,  however,  he  must  carefully  ab- 
stain from  the  use  of  his  lancet  until  purulent  matter 
is  plainly  under  the  integuments.  He  may  then  safely 
make  an  opening,  from  which  urine  and  pus  will  be 
discharged,  and  through  which  the  calculi  themselves 
may  sometimes  be  felt  and  extracted.  If  they  cannot 
be  readily  touched  with  a probe,  let  not  the  surgeon 
rashly  conceive  that  l.*e  is  justified  in  endeavouring  to 
discover  them  with  his  knife.  Their  situation  may  be 
such  as  to  baffle  all  his  endeavours,  and  the  operation 
itself  might  cause  a most  dangerous  hemorrhage,  and 
other  fatal  mischief.  The  opening  of  an  abscess  of  tiie 
kidney  may  remain  a long  while  fistulous,  and  indeed 
warrant  the  conclusion,  that  the  healing  is  prevented 
by  the  presence  of  some  extraneous  substances  ; but  a 
prudent  practitioner  will  never  think  of  performing  any 
operation  for  their  extraction,  unless  they  can  be  dis- 
tinctly felt,  and  nature  has  brought  them  tolerably  neat 
to  the  surface. — (See  JVephrotomy.)  Sir  A.  Cooper,  in 
his  lectures,  mentions  a singular  case,  in  which  Mr. 
Cline  was  able  plainly  to  feel,  in  a very  thin  patient,  a 
calculous  situated  in  the  kidney.  He  adverts  also  to 
another  example,  in  which  a great  deal  of  purulent 
matter  had  been  voided  from  the  bowels  before  death, 
and,  on  opening  the  body,  a calculus  was  found  lodged 
in  the  ureter,  between  which  tube  and  the  colon  an 
open  communication  existed,  through  which  the  abscess 
of  the  kidney  had  discharged  itself  into  the  intestines. 
In  one  particular  case,  related  by  the  same  experienced 
surgeon,  a calculus,  fixed  in  the  ureter,  gave  rise  to  a 
renal  abscess,  which  burst  into  the  cavity  of  the  abdo- 
men, and  the  patient’s  death  quickly  followed. 

Urinary  calculi,  which  form  upon  foreign  bodies  ac- 
cidentally introduced  into  the  bladder,  and  acting  as 
nuclei,  are  always  single,  utdess  the  number  of  foreign 
bodies  themselves  happen  to  be  greater.  It  is  curious 
also  to  find,  from  the  observations  of  Mr.  Murray  Forbes 
(On  Gravel  and  Gout,  p l^,  8i:o.  Lon.  1793)  and  Dr. 
Marcet,  that,  in  such  instances,  the  deposition,  most 
frequently,  if  not  always,  consists  of  the  earthy  pnos- 
phates,  and  especially  of  the  fusible  calculus.  Thus, 
in  the  collection  of  Mr.  R.  Smith  of  Bristol,  there  is  a 
pin,  a piece  of  bougie,  and  four  pieces  of  stick,  coated 
with  fusible  matter. — (See  Med.  Chir.  Trans,  vol.  11, 
p.  11.)  But  when  calculi  originate  from  a particular 
diathesis,  there  may  be  many  of  them  lodged  in  the  blad- 
der  at  the  same  time.  Several  distinct  nuclei  may  de- 
scend successively  from  the  kidneys,  and  each  may  in- 
crease in  a separate  manner.  Sometimes,  however, 
calculi  in  the  bladder,  which  are  at  first  distinct  and  un- 
connected, become  afterward  cemented  together,  so  as 
to  make  only  one  mass. 

The  magnitude  of  calculi  in  the  bladder  is  generally 
in  an  inverse  ratio  to  their  number.  Some  hundreds 
have  been  found  in  one  bladder ; but  they  were  not 
larger  than  a pea.  One  very  remarkable  instance  has 
lately  been  recorded,  in  which  398  calculi,  from  the  size 
of  a pea  to  that  of  an  olive,  were  found  in  the  bladder 
after  death.  By  analysis,  they  were  found  to  consist 
of  phosphate  of  lime,  phosphate  of  magnesia,  and  uric 
acid. — {Mag.  der  Jiuslavdischen  Literatur,  Hamb.Jan. 
Feb.  1822  ; and  Journ.  of  Foreign  Med.  Mo.  15.)  It  is 
observed  by  Sir  Astley  Cooper,  that  when  a great  num- 
ber of  calculi  are  found  in  the  bladder,  the  circum- 
stance is  generally  attended  with  an  enlargement  of 
the  prostate  giand,  directly  behind  which  a sacculus 
is  formed.  In  cases  of  diseased  prnsiategland,  the  blad- 
der can  seldom  be  completely  emptied  ; and  this  partial 
stagnation  of  the  urine  in  the  sac  here  alluded  to,  is 
supposed  to  facilitate  the  production  of  calculi.  From 
their  number  and  collision  against  each  other,  their  sur- 
faces are  generally  smooth,  and  their  shape  is  common- 
ly roundish. — (See  Med.  Chir.  Trans,  vol.  11,  p.  359, 
and  art  Prostate  Gland.)  Other  calculi  have  been 
met  with  of  so  large  a size,  that  they  were  more  than 
six  inches  in  diameter.  In  Fourcroy’s  museum,  atid  in 
that  of  the  Ecole  de  Mddecine,  at  Paris,  may  be  seen 
some  calculi  which  filled  the  whole  cavity  of  the  blad- 
der; and  in  the  Phil.  Trans,  for  1809,  the  late  Sir 


406 


URINARY  CALCULI. 


James  Earle  described  an  enormous  stone,  which  he 
extracted  after  death  from  the  bladder  of  the  late  Sir 
David  Ogilvie,  wlio  had  been  unsuccessfully  cut  for 
it.  This  calculus,  which  was  of  the  fusible  kind, 
weighed  foriy-lbur  ounces,  and  was  of  an  oval  shape, 
its  long  axis  measuring  sixteen  inches,  and  the  shorter 
fourteen.  The  ave.^age  size  of  vesical  calculi  may  be 
compared  with  that  of  a chestnut,  walnut,  or  a small 
hen  s egg.  Their  size  depends  very  much  upon  their 
composition,  the  largest  being  of  the  fusible  kind. 
Their  weight  differs  from  a few  grains  to  upwards  of 
fifty  ounces;  but  on  an  average,  it  is  from  two  to  six 
ounces.  Their  weight  is  not  always  proportioned  to 
their  size;  for  substances  of  different  qualities  enter 
into  their  composition,  and  diversify  their  heaviness. 

I’he  urinary  salts,  in  calculous  patients,  are  not  con- 
tinually precipitated  in  the  same  quantities:  in  some 
cases,  indeed,  the  process  appears  to  be  even  suspended 
for  a considerable  time.  Hence,  a stone  of  middling 
size  already  formed,  may  inci  ease  but  very  slowly  ; and 
it  has  actually  happened,  that  a calculus,  which  could 
be  plainly  felt  with  a sound,  has  remained  more  than 
ten  years  in  the  bladder,  and  yet,  after  all  this  time, 
been  only  of  a moderate  size. 

According  to  Dr.  Marcet,  the  form  of  urinary  calculi 
is  mostly  spheroidal,  sometimes  egg-shaped,  but  often 
flattened  on  twosideslike  an  almond. — (P.50.)  Some- 
times the  calculous  matter  which  descends  from  the 
kidneys  is  in  the  form  of  minute  spherical  grains, 
which  have  a singular  tendency  to  unite  either  to  each 
other,  or  to  calculi  already  lodged  in  the  bladder. 

When  there  are  several  loose  calculi  in  the  bladder 
together,  they  seldom  lie  long  in  contact  with  each 
other,  while  their  size  is  diminutive,  but  are  incessantly 
changing  their  situation  as  the  patient  moves  about,  or 
alters  the  position  of  his  body.  Hence,  their  increase 
is  at  first  regular  and  uniform  ; but  when  they  have  at- 
tained a more  considerable  size,  or  by  their  numbers 
compose  a large  mass,  their  relative  situation  is  more 
permanent,  and  many  of  their  surfaces  being  in  this 
manner  usually  covered,  no  longer  receive  any  addi- 
tional depositions.  Every  other  part  of  these  calculi, 
however,  goes  on  increasing.  It  is  thus  that  stones, 
with  surfaces  corresponding  to  those  of  other  stones,  are 
produced,  and  which  are  aptly  denominated  by  the 
French  writers  pierres  d faceltes.” 

Dr.  Marcet  has  likewise  taken  notice  of  the  angular 
shape  of  certain  calculi,  and  remarked  the  rare  occur- 
rence of  their  being  sometimes  almost  cubic.  His  work 
contains  the  engraving  of  a species  of  calculus,  which 
somew'hat  resembles  a pear,  with  a circular  protuber- 
ance at  its  broader  end,  apparently  moulded  in  the  neck 
of  the  bladder. 

The  same  intelligent  writer  has  also  particularly  con- 
sidered the  variety  in  the  colours  and  surfaces  of  cal- 
ciili,  which  often  afford  indications  of  their  chemical 
nature.  “ When  they  have  a brownish  or  fawn  co- 
lour, somew  hat  like  mahogany  wmod,  with  a smooth, 
though  sometimes  finely  tuberculated  surface,  they  al- 
most always  consist  of  lithic  acid.  When  cut  open 
they  appear  to  be  formed  of  concentric  layers,  some- 
times homogeneous,  sometimes  alternating  with  other 
substances.  The  colour,  hov/ever,  cannot  be  consi- 
dered as  acertain  criterion,  since  other  kinds  of  calculi 
may  often  be  coloured  in  the  bladder,  in  a similar  man- 
ner, by  bloody  mucus,  or  other  vitiated  secretions. 

When  calculi  are  white,  or  grayish-white,  they 
always  consist  of  earthy  phosphates.  'J’his  is  particu- 
larly the  case  with  the  species  called  fusible.  And 
when  they  are  dark  brown,  or  almost  black,  hard  in 
their  texture,  and  covered  with  tubercles  or  protube- 
rances, they  are  generally  of  the  species  which  has 
been  distinguished  by  the  name  of  mulberry^  and  con- 
sist of  oxalate  of  lime. 

Calculi  have  sometimes  an  uneven,  crystalline 
surface,  studded  with  shining,  transparent  particles. 
This  appearance  always  denotes  the  presence  of  the 
ammoniaco-magnesian  phosphate.” — {Marcet^  p.  52.) 

A large  calculus,  especially  when  it  has  a rough. 
Irregular  surface,  produces  a great  deal  of  irritation  of 
the  bladder,  which  contracts  more  closely  round  it. 
The  contact,  however,  js  remarked  to  be  particularly 
exact  at  the  transverse  line,  which  extends  between 
the  terminations  of  the  two  ureters  in  the  bladder ; a 
part  of  this  organ  which  generally  becomes  more 
thickened  than  the  rest.  Sometimes,  indeed,  the  ca- 
vity of  the  bladder  is  nearly  effaced,  and  the  urine  can 


be  retained  only  a very  short  time,  or,  if  it  be  not  eva- 
cuated, it  spreads  uniformly  round  the  calculus,  espe- 
cially above  and  below  the  above-described  transverse 
projection,  which  is  less  yielding  than  other  parts  of 
this  organ.  Hence,  the  surface  of  the  stone,  towards 
the  orifices  of  the  ureters,  does  not  enlarge  so  fast  as 
the  other  sides  of  it,  and  a circular  groove  is  proiiuced, 
giving  the  foreign  body  the  shape  of  a calabash. 
Such  calculi  are  generally  very  large,  and  sontetimes 
even  of  enormous  size.  In  the  latter  circumstance, 
the  foreign  body  fills  the  cavity  of  the  bladder  so  com- 
pletely, that  there  is  no  space  left  for  the  lodgement  of 
the  urine  there,  which  fluid  then  generally  passes  along 
a sort  of  groove,  situated  in  a line  reaching  from  the 
lower  termination  of  the  ureter  to  the  neck  of  the 
bladder.  This  state  is  of  course  accompanied  with  a 
complete  incontinence. 

Urinary  calculi  are  not  always  loose  and  moveable 
in  the  cavity  of  the  bladder;  being  sometimes  fixed  in 
various  ways  to  certain  points  of  the  circumference  of 
this  organ;  a subject  which  has  been  noticed  in  the 
article  Lithotomy. 

When  the  bladder  protrudes  from  the  alidomen  so  as 
to  form  a hernia,  a stone  is  occasionally  situated  in  the 
displaced  portion  of  it.  This  circumstance  has  the 
same  effect  as  the  encysted  state  of  a calculus ; for  t.he 
foreign  body  is  thereby  fixed,  and  it  cannot  be  propelled 
towards  the  neck  of  the  bladder  at  the  period  when  the 
urine  is  discharged.  Also,  in  cases  of  prolapsus  uteri, 
when  the  bladder  is  drawn  downwaids,  a stone  has 
sometimes  been  found  lodged  at  the  lowest  part  of  it. 
The  possibility  of  the  complication  of  a calculus  with 
such  displacements  of  the  bladder,  ought  to  be  well  re- 
membered, since,  if  the  nature  of  the  case  be  detected, 
its  treatment  becomes  materially  simplified. 

The  symptoms  of  a stone  in  the  bladder  have  been 
detailed  in  the  article /Jt/wtomy,  and  iherefoie  need 
not  here  be  repeated.  They  are  all  so  equivocal,  and 
bear  so  great  a resemblance  to  the  effects  of  several 
other  disorders,  that  they  cannot  be  depended  upon, 
and  consequently  no  well-in ft)rnied  surgeon  will  ven- 
ture to  pronounce  positively  that  there  is  a calculus  in 
the  bladder,  unless  he  can  distinctly  feel  it  with  a 
sound. — (See  Lithotomy  and  Sounding.)  As  for  the 
operation,  if  the  surgeon  cannot  plainly  feel  the  cal- 
culus immediately  before  he  commences  the  incisions, 
it  ought  to  be  postponed. 

Notwithstanding  tlie  laudable  zeal  with  which  va- 
rious distinguished  physicians  and  surgeons  of  the 
present  day  liave  applied  themselves  to  the  considera- 
tion of  the  causes  of  urinary  calculi,  the  subject  is  yet 
in  great  obscurity.  The  conjectures  which  have  been 
started,  respecting  the  influence  of  particular  kinds  of 
food,  drink,  air,  and  habits  of  life,  are  all  of  them 
liabie  to  such  objections  as  throw  considerable  doubts 
on  their  correctness,  and  scmeiimes  amount  to  a do 
elded  refutation  of  them. 

If  a foreign  body  be  inttodneed  into  a cavity  to 
which  the  urine  has  access,  whatever  may  be  the  na- 
ture of  the  immersed  substance,  if  always  becomes 
after  a lime  inernsted  with  calculous  matter,  tboiigb  it 
undergoes  no  chemical  clninge  in  its  compo.sition.  In 
such  cases,  it  is  found  (see  Forbes  on  Gravel  and  Govt, 
Svo.  J.ovd.  1723;  and  Marcet  on  the  Chemical  Hist.^ 
SfC.  of  Calculous  Disorders,  Bvo.  Lend.  1817)  that  the 
concretion  mostly,  if  not  always,  consists  of  the  eat  thy 
phosphates.  Mere  the  operation  of  any  paiticular 
diathesis  is  beyond  all  suspicion,  because  the  foreign 
body  which  lornis  the  nucleus  would  lead  to  the  pro- 
duction of  a calculus  in  all  descriptions  of  patients. 

There  are  some  countries,  where  patients  with  calculi 
are  tolerably  miinerons;  and  other  parts  of  the  world, 
where  the  disease  is  rare,  or  never  met  with  ; and  yet 
the  difference  cannot  always  be  accounted  for  by  any 
geographical  circumstance,  which  is  constant,  or  any 
definable  peculiarity  of  constitution,  climate,  diet,  or 
mode  of  life.  One  fact,  however,  I believe,  is  certain, 
viz.  the  uniform  rarity  of  the  disease  in  very  hot  coun- 
tries. In  tropical  climates,  urinary  calculi  are  almost 
unknown,  and.  as  Dr.  Marcet  observes,  the  testimony 
of  Dr.  Scott  on  tills  jioint,  who  long  resided  in  India, 
must  be  considered  valuable.  Dr.  Scott  affirms,  that, 
between  the  tropics,  be  never  met  with  a single  in- 
stance of  the  formation  of  a stone  in  the  urinary 
bladder,  although  he  knew  of  some  cases  which  had 
been  imported  and  were  not  cured  by  climate. — (See 
Marcet  on  the  Chemical  History  and  Med.  Treatment 


URINARY  CALCULI. 


407 


of  Calculous  Disorders^  chap.  2,  Qvo.  Land.  1817.)  Yet, 
as  calculi  fiequetitly  form  on  various  nuclei,  bullets, 
pieces  of  bougies,  &c.,  I conceive,  that  even  in  India, 
calculi  will  some  day  or  another  be  found  to  originate 
from  this  cause,  though  not  perhaps  from  diathesis. 

Urinary  calculi  are  said  also  to  be  very  uncommon 
in  Spain  and  Africa,  though  patients  with  gravel  are 
numerous  in  Majorca,  w hich  lies  between  them. — {Ma- 
gendie,  Recherches  sar  les  Causes,  iS-c.  de  la  Gravelle, 
p.  31, 8vo.  Paris,  1818.)  The  usual  belief  is,  that  cal- 
culi are  most  frequent  in  damp,  cold  countries,  like 
England  and  Holland,  but  that  iti  such  other  parts  of 
the  world  as  are  either  very  Jiot  or  cold,  the  disease  is 
j-aie.  However,  in  every  estimate  of  this  kind,  the 
number  of  the  inhabitants  of  the  countries  or  districts 
in  question,  is  always  an  essential  thing  for  considera- 
tion, because  the  proportion  of  stone- patients,  in  a 
given  number  of  individuals,  is  invariably  rather 
small ; and,  therefore,  in  referring  to  the  rarity  of  such 
patients  in  very  cold  countries,  it  is  to  be  considered, 
whether  ihe  fact  may  not  be,  in  some  measure,  as- 
cribable  to  the  fewness  of  the  inhabitants.  The  stale 
of  medicine  and  surgery,  in  the  countries  from  which 
the  uiformation  is  transmitted,  is  likewise  another 
thing  for  contemplation,  inasmuch  as  patients  are  not 
likely  to  be  reported  as  sutfering  from  or  dying  of  stone, 
where  the  nature  of  diseases  is  not  scientifically  ob- 
served, morbid  anatomy  is  uncultivated,  and  the  ope- 
ration of  sounding  never  attempted.  However,  as  our 
East  India  native  regiments  are  furnished  with  excel- 
lent surgeons,  I consider  it  well  proved,  that  in  those 
regiments  the  disease  is  uncommon,  for  otherwise  the 
statement  would  no  doubt  have  been  contradicted  by 
them.  The  fact  seems,  therefore,  well  established,  in 
relation  to  the  East  Indies.  At  the  same  time,  the 
age's  of  the  individuals  to  whom  any  calculation  ap- 
plies, is  aUvays  to  be  taken  into  considerati{)n  before 
any  inference  be  drawn  respecting  the  cause  of  the 
rarity  of  calculi ; because,  if  the  disease  be  rare  among 
soldiers  in  India,  it  is  also  rare  among  soldiers  in 
Europe,  and  therefore  climate  would  not  explain  the 
fact  in  both  parts  of  the  world.  But,  probably,  the 
recollection  that  common  soldiers  are  neither  children, 
nor  men  above  the  middle  period  of  life,  and  that  the 
first  formation  of  stone  in  youths,  adults,  and  middle 
aged  persons,  is  uncommon,  unless  some  extraneous  | 
substance  happen  to  enter  the  bladder  and  form  the 
nucleus,  may  furnish  a reason  for  the  infrequency  of 
the  disease  among  .soldiers,  applicable  perhaps  to  such 
individuals  in  every  country.  And  that  the  children 
of  soldiers,  like  those  of  other  persons,  are  not  exempt 
from  the  disease,  I know  very  well,  having  had  occa- 
sion myself  to  operate  upon  a patient  of  this  kind 
during  my  service  with  the  army. 

The  preceding  consideration  also  of  the  general  age 
of  sailors  in  the  royal  navy,  and  of  the  little  chance 
there  must  be  of  a boy  w ith  stone,  being  sent  to  sea,  or 
of  any  sailor  being  admitted  on  board  of  a king’s  ship 
with  that  disorder,  unless  it  be  wilfully  concealed  by 
the  man  himself,  furnish  to  my  mind  a better  explana- 
tion of  the  cause  of  so  few'  cases  of  stone  having  been 
met  with  among  seafaring  persons,  than  any  of  the 
references  to  the  habits  or  mode  of  life  of  a sailor 
made  by  Mr.  C.  Hutchison  in  his  ingenious  paper. — 
(See  JHed.  Chir.  Trans,  vol.  9,  p.  443,  A-c.)  From  this 
gentleman’s  account  it  seems,  that  out  of  86,000  pa- 
tients admitted  into  the  naval  hospitals  at  Haslar, 
Plymouth,  and  Deal,  in  the  space  of  sixteen  years, 
there  have  only  been  eight  calculous  cases,  or  one  in 
10,7.70  patients.  Two  of  these  cases  were  boys,  about 
fourteen  years  of  age,  “ who  had  laboured  under  symp- 
toms of  stone  fur  some  years  previously  to  their  ad- 
mission into  the  service,  and  into  which  they  had  re- 
cently entered  expressly  for  the  purpose  of  deriving  be- 
nefit from  our  magnificent  institutions ; one  was  a 
marine  who  had  been  at  sea  a few  months  only;  three 
were  adult  seamen,  and  the  seventh  a marine;  but 
their  length  of  service  afloat  could  not  be  at  all  ascer- 
tained: the  eighth  and  last  case  w'as  a warrant-officer, 
advanced  in  years,  who  had  been  serving  in  ordinary, 
that  is,  in  a ship  in  harbour,  for  a considerable  time 
preyiou.sly  to  the  operation.”  Subsequently  to  the 
period  embraced  by  the  returns,  collected  by  Mr.  C. 
Hutchison,  a boy  has  also  been  operated  upon  in 
Haslar  Hospital.— (Fol.  cit.  p.  449.)  Mr.  R.  Smith,  of 
Bristol,  has  published  an  interesting  statistical  inquiry 
into  the  frequency  of  stone  in  the  bladder,  in  Great 


Britain  and  Ireland,  though  stiictly  it  is  a comparative 
estimate  of  the  number  of  operations  for  stone  in  dif- 
lerent  parts  of  the  kingdom  in  given  spaces  of  lime, 
and  not  of  the  number  of  calculous  patients. — (See 
Med.  Chir.  Trans,  vol.  11.)  As  far  as  I can  judge 
from  the  facts  stated  in  Mr.  Smith's  paper,  andJrom 
what  I know  about  the  average  number  of  operations 
for  Slone  in  London,  not  more  than  180  can  be  fairly 
reckonrrd  as  the  annual  total  in  Great  Britain  and  Ire- 
land, which  is  about  1 for  each  100,000  gf  the  popula- 
tion, taken  at  18,000,000.  Now,  if  this  fact  be  recol- 
lected, in  computing  the  rarity  of  stone  operations  in 
the  navy,  and  the  other  circumstances  of  there  being 
few  children  and  old  men  in  that  service,  and  of  every 
man  being  examined  by  a surgeon,  as  to  the  state  of 
his  health,  befote  he  is  entered,  I think  the  reason  of 
the  infrequency  of  stone  in  the  navy  will  be  tolerably 
clear.  How'ever,  as  sailors  live  partly  in  very  hot  and 
partly  in  very  cold  climates,  even  if  they  were  of  tlie 
ages  most  subject  to  calculi,  they  may  perhaps  be 
rather  less  disposed  to  the  complaint  than  individuals 
of  the  same  periods  of  life  constantly  resident  in  Eng- 
land. In  the  cold  country  of  Sweden,  urinary  calculi 
are  said  to  be  unfiequent  {Richerand,  JVosogr.  Chir.  t. 
3,  p.  528,  ed.  4) ; and  as  surgery  is  there  highly  culti- 
vated, the  uncontradicted  statement  weighs  considera- 
bly in  favour  of  the  truth  of  the  general  belief  in  the 
rarity  of  this  disorder  in  very  cold  countries.  But  as 
I have  already  said,  the  number  of  inhabitants  to 
which  any  particular  evidence  on  this  point  relates,  is 
an  essential  inquiry,  before  a safe  inference  can  be 
drawn. 

It  is  perfectly  well  ascertained,  that  the  greater  num- 
ber of  urinary  calculi  are  composed  chiefly  of  lithic  or 
uric  acid,  which  is  naturally  contained  either  in  a free 
or  combined  state  in  the  urine  of  man,  and  all  other 
animals  which  consume  a great  deal  of  food  abounding 
in  azote,  as  flesh  of  every  kind,  fish,  shell-fish,  eggs, 
<fcc.  Whenever  the  urine  will  redden  the  tincture  of 
turnsol,  Magendie  infers,  with  the  generality  of  che- 
mists, that  it  contains  lithic  acid,  the  proportion  of 
which.  Ire  says,  varies  according  to  the  quantity  of 
substances  abounding  in  azote  taken  as  food.  And 
Magendie  farther  observes,  that  when  animals  live 
altogether  on  flesh,  their  urine  is  full  of  uric  acid,  and 
[ even  may  be  entirely  composed  of  it,  as  is  proved  with 
respect  to  birds,  by  the  experiments  both  of  Dr.  Wol- 
laston and Vauquelin.  Here Magendiecannotrnean  free 
uric  acid,  but  this  acid  in  a state  of  combination  ; for,  as 
Dr.  Prout  has  observed,  there  is  no  instance  known  in 
which  lithic  or  uric  acid  is  secreted  in  a pure  state; 
birds,  serpents,  &c.  always  secrete  it  in  combination 
with  ammonia ; in  the  gouty  chalk-stone  it  is  secreted 
in  combination  with  soda.— (Ore  the  Mature,  <S-c.  of 
Gravel  and  Calculus,  p.l3.)  On  the  contrary,  if  ani- 
mals live  on  veuetables,  as  is  the  case  with  the  herbi- 
vorous class,  Mapndie  states,  that  there  is  no  appear- 
ance of  lithic  acid  in  their  urine.  In  a series  of  ex- 
■ iieriments,  communicated  by  Mage'ndie  to  the  Academy 
of  Sciences  in  1816,  this  distinguished  physiologist  ex- 
em|»lified,  that  if  a carnivorous  animal  be  deprived  of 
all  nutriment  containing  azote,  and  be  fed  with  sugar, 
gum,  oil,  and  other  substances  considered  to  be  nutri- 
tions, and  having  no  azote  in  their  composition,  the 
urine,  in  three  or  four  weeks,  will  contain  no  lithic 
acid. — (See  Mem.  sur  les  Proprietis  nutritives  des  Sub- 
stances, qui  ne  conticnv.ent  pas  d'aiote.  Paris,  1817.) 
A dog,  allowed  only  sugar  at;d  distilled  water,  soon 
began  to  grow  lean  and  died  apparently  starved  on  the 
32d  day  from  the  commencement  of  his  diet.  The  in- 
ference which  Magendie  draws  from  his  experiments, 
and  from  some  cases  which  he  has  detailed,  is,  that  the 
quantity  of  uric  acid  in  the  urine,  and,  of  course,  the 
tendency  to  gravel  and  calculous  disorders,  depend 
very  much  upon  the  kind  of  food.  However,  he  takes 
into  consideration  the  relative  proportion  of  the  uric 
acid  to  the  urine  itself;  because,  if  this  be  also  abun- 
dant, the  liability  to  calculi  is  counteracted.  It  would 
appear  also,  from  his  observations,  that  the  urine  not 
only  becomes  impregnated  with  a great  proportion  of 
uric  acid  in  animals  which  eat  a large  quantity  of 
flesh,  but  is  also  scanty;  and  that,  on  the  other  hand,  a 
vegetable  diet  always  promotes  the  secretion  of  a larire 
quantity  of  fluid  from  the  kidneys,  as  well  as  checks 
the  formation  of  the  acid  in  question  Mairendie  is 
also  disposed  to  believe,  that  the  rarity  of  calculi  in 
hot  climates  may  be  partly  traced  to  the  kind  of  food 


408 


URINARY  CALCULI. 


employed.  In  fact,  it  is  well  known,  that  in  a con- 
siderable part  of  Asia  many  millions  of  the  inhabitants 
never  eat  flesh.  But  though  this  circumstance  must 
be  allowed  to  have  full  weight  with  respect  to  the  sects 
which  religioufsly  decline  animal  food,  the  influence  of 
climate  cannot  be  rejected,  because  calculi  are  rare  in 
all  hot  countries,  whether  meat  be  freely  eaten  or  not. 
At  the  same  time,  the  tenor  of  this  gentleman’s  rea- 
soning may  be  true,  that,  .setting  out  of  the  question 
ihe  influence  of  climate,  a vegetable  diet  tends  to  pre- 
vent the  fornaation  of  lithic  acid  calculi,  while  eating 
large  quantities  of  such  food  as  contains  a great  deal 
of  .azote  has  the  opposite  effect. 

However,  Magendie  himself  is  not  so  partial  to  his 
theory,  as  not  to  confess  that  it  is  liable  to  objections ; 
fbr,  says  he,  individuals  are  met  with  every  day,  who, 
from  their  age,  manner  of  living,  and  habits,  appear  to 
be  subjected  to  every  condition  calculated  to  produce 
the  gravel,  and  yet  they  remain  free  from  it.  Hence 
he  infers  that  there  must  be  some  unknown  causes 
which  sometimes  keep  the  uric  acid  dissolved,  even 
where  its  quantity  in  the  urine  is  copious.  On  the 
other  hand,  he  admits  that  certain  persons  are  met 
with,  whose  regimen  and  mode  of  life  ought  to  exempt 
them  from  gravel,  and  still  they  are  afflicted.  In  proof 
of  this  fact,  he  adverts  to  the  poor  inhabitants  of  a 
district  in  Sussex,  mentioned  bj’  Dr.  Scudamore  ( On 
the  Kature  and  Cure  of  Gout,  S-c.  8?jo.  Lond.  J817), 
who  live  almost  entirely  on  vegetable  matter  and  hard 
beer,  and  many  of  whom  are  much  troubled  with  gra- 
vel. Magendie  might  also  have  recollected,  that  some 
birds,  which  live  entirely  on  vegetable  matter,  as  se- 
veral singing-birds  kept  in  cages,  void  a good  deal  of 
the  lithate  of  ammonia.  Magendie  refers  to  examples 
of  gravel  being  always  produced  in  certain  individuals 
after  any  unusual  exertion,  and  in  other  apparently 
healthy  subjects,  after  any  difficulty  of  digestion,  flatu- 
lence, the  eating  of  salad,  raw  fruit,  &c.  With  re- 
gard to  the  dyspepsia,  frequently  attendant  on  calcu- 
lous disorders  and  other  chronic  diseases,  Magendie 
sets  down  the  complaints  of  the  stomach  and  of  the 
urinary  organs,  as  probably  only  two  effects  of  the 
same  cause,  and  not  mutually  productive  of  each 
other. — (See  Recherches,  Src.  sur  les  Causes,  4-c.  de  la 
Gravelle,  8vo.  Paris,  1818.) 

It  should  be  observed,  that  Magendie’s  observations 
are  meant  to  apply  only  to  cases  of  gravel,  and  where 
the  substance  voided  is  lithic  acid.  And  as  for  other 
instances  in  which  the  calculous  matter  is  formed  of 
phosphate  of  lime,  oxalate  of  lime,  cystic  oxyde,  <fcc. 
he  deems  the  causes  entirely  unknown.  One  thing  is 
certain,  that  Magendie’s  theory  will  not  account  for 
the  origin  of  calculi,  unless  a predisposition  to  the  dis- 
ease from  other  unknown  or  conjectured  causes,  be 
taken  as  a matter  of  fact.  Indeed,  this  admission  he 
makes  himself ; and  he  enumerates  various  circum- 
stances conducive  to  gravel,  besides  a diet  of  food 
abounding  in  azote;  as  advanced  age;  a sedentary 
life,  and  hard  study,;  long  retention  of  the  urine  in  the. 
bladder ; strong  wines  and  liquors.  In  fact,  without 
the  predisposition  arising  from  unknown  causes  and 
particular  periods  of  life,  a meat  diet  will  not  render 
the  occurrence  of  calculi  frequent,  as  is  exemplified  in 
sailors  who  eat  a great  deal  of  salt  beef  and  pork. 
And,  on  the  contrary,  that  the  eating  of  little  or  no 
animal  food  will  not  alwa}’s  prevent  the  formation  of 
calculi,  when  there  is  tendency  to  it  from  time  of  life, 
diathesis,  or  other  causes,  is  sufficiently  proved  by 
the  frequency  of  the  disease  in  infants,  in  whose  food 
there  is  a much  smaller  proportion  of  meat  and  azotic 
substances  than  in  the  usual  diet  of  an  adult. 

With  respect  to  amorphous  sediments,  the  circum- 
stances which  Dr.  Prout  has  observed  to  produce  a 
lithic  acid  diathesis  in  persons  subject  to  slight  dys- 
pepsia, but  in  other  respects  healthy,  are,  1.  Simple 
errors  in  diet;  2.  Unusual  or  unnatuml  exercise,  either 
bodily  or  mental,  particuFarly  after  eating,  and  the 
want  of  proper  exercise  at  all  other  times;  3.  Debili- 
tating circumstances. — {On  Gravel,  Calculus,  Sre.  p. 
113.)  An  unusually  heavy  meal,  especially  of  animal 
food,  or  bread,  he  says,  is  invariably  followed  by  a 
deposition  of  the  lithate  of  ammonia  from  the  urine. 
Heavy  unfermented  bread,  and  compact,  hard-boiled, 
fat  dumplings  or  puddings,  he  finds  particularly  apt  to 
produce  such  an  effect. 

Crystallized  sediments  or  gravel,  consisting  of  nearly 
pure  lithic  acid,  Dr.  Prout  ascribes  to  a ftee  acid  being 


sometimes  generated  in  the  kidneys,  and,  combining 
with  the  ammonia  with  which  the  lithic  acid  is  pre- 
viously united,  so  as  to  precipitate  the  latter  in  a pure 
crystallized  state.  According  to  the  investigations  of 
Dr.  Prout,  the  precipitating  acid  is  not  constantly  the 
same,  though  generally  the  phosphoric,  and  sometimes 
the  sulphuric. — {P.  127,  J28.) 

The  same  intelligent  writer  represents  the  circum- 
stances which  promote  the  formation  of  uruiary  sedi- 
ments in  general,  as  being  either  natural  or  acquired. 
“ With  respect  to  those  of  the  first  description  (says 
he),  it  fannot,  I think,  be  doubted,  that  certain  indi- 
viduals'are  much  more  liable  to  these  sediments  than 
others.  This  tendency  is  not  unfrequenily  inherited  : 
thu.«,  I know  a family,  where  the  grandfather  and  fa- 
ther have  actually  lithic  calculi  in  the  bladder;  and 
where  the  grandson,  a youth  of  twelve  or  thirteen 
years  of  age,  has  a very  strong  tendency  to  the  same 
disease;  his  urine  depositing  frequently  very  large 
quantities  of  lithic  acid,  both  in  the  form  of  amorphous 
and  crystalline  sediments.  On  the  other  hand,  the 
disposition  to  generate  these  sediments  in  excess  is, 
like  gout,  or  rather  simultaneously  with  gout,  but  too 
frequently  acquired  by  indolent  habits,  and  excess  in 
eating  and  drinking.  Most  frequently,  however,  the 
tendency  to  these  diseases  is  connected  with  some  un- 
known causes,  peculiar  to  certain  districts  or  coun- 
tries ; as,  for  examjde,  the  district  of  which  Norwich 
may  be  considered  the  centre ; in  which  more  calcu- 
lous cases  occur  than  in  the  whole  of  Ireland  or  Scot- 
land. In  such  instances,  the  water,  diet,  temperaturs, 
&c.  of  the  district,  has  been  each  accused  in  its  turn, 
of  being  the  exciting  cause  ; but  (says  Dr.  Prout),  the 
circumstance,  I believe,  still  remains  unexplained.  I 
have,  in  one  or  two  instances,  seen  a fit  of  lithic  gra- 
vel inditced  in  the  predisposed  by  sitting  on  a damp, 
cold  seat  for  some  Irours.  Sometimes  also  a tendency 
to  lithic  calculus  is  evidently  connected  with  local  in- 
jury, or  disease  of  the  kidney.” — (P.  133.) 

The  difficulty  of  tracing  the  causes  of  the  formation 
of  calculi,  is  rather  increased  than  lessened  by  tha  fact, 
that  except  when  the  urinary  organs  are  much  dis- 
eased, the  patient  may  appear  to  in  perfect  health. 
Indeed,  persons  of  the  strongest  constitutions  are  often 
troubled  with  the  stone,  quite  independently  of  the 
entrance  of  any  foreign  body,  as  a nucleus,  into  the 
bladder ; and  it  is  now  universally  admitted,  that  lithic 
acid  itself  constitutes  by  far  the  most  common  nu- 
cleus, even  when  other  calculous  matter  is  deposited 
round  it. — (See  Prout  on  Gravel,  p.  95.)  It  is  some- 
times conjectured  that  the  female  is  less  liable  than 
the  male  sex  to  calculi;  but  whether  this  is  the  fact,  or 
whether  the  circumstance  can  be  satisfactorily  ex- 
plained on  another  principle,  viz.  the  facility  with 
which  any  calculi  of  moderate  size  are  generally 
discharged  through  the  shoit  and  capacious  meatus 
urinarius,  are  questions  perhaps  not  yet  completely 
settled. 

Infants  and  children  to  the  age  of  twelve  or  four- 
teen are  very  liable  to  stone.  However,  it  is  asserted  by 
Delpech,  that  at  this  period  of  life  relapses  are  unfre- 
quent ; that  is  to  say,  an  entirely  fresh  stone  is  hardly 
ever  formed  again;  and,  if  a return  of  the  complaint 
happens,  the  quickness  of  its  recurrence,  and  an  atten- 
tive examination  of  the  calculus,  will  mostly  prove, 
either  that  the  second  stone  has  formed  round  a fragment 
of  the  first  left  behind,  or  that  it  existed  when  the  former 
one  was  taken  out,  but  was  not  discovered.  I am  not 
inclined  myself  to  put  much  faith  in  this  statement, 
because  it  is  hardly  credible  that  the  calculous  dia- 
thesis of  childhood  can  be  at  all  diminished  by  the  cir- 
cumstance of  there  having  already  been  one  calculus, 
and  of  ihe  patient  having  had  the  bladder  opened  for 
its  removal. 

Dr.  Marcet  thinks  that  the  disorder  is  frequent  only 
among  the  children  of  the  poor  classes;  and  that  in 
those  of  the  higher  ranks,  or  even  of  the  lowest  classes, 
provided  they  are  well  fed,  the  same  frequency  is  not 
observed.  ‘‘  In  the  Foundling  Hospital,  for  instance, 
within  the  last  27  years,  during  which  1151  children 
have  been  admitted,  only  three  cases  of  stone  have  oc- 
curred, all  of  which  were  among  children  while  at 
nurse  in  the  country.  And,  in  the  Military  Asylum  at 
Chelsea,  which  contains  about  1250  children,  and  into 
which  upwards  of  6000  of  them  hav»  been  already  ad- 
mitted, no  more  than  one  single  case  of  stone  has 
occurred.” — (See  Marcet's  Essay  on  Calculous  Dis^ 


urinary  calculi, 


409 


orders,  p.  36.)  However,  supposing  that  the  foregoing 
statement  refers  to  operations  for  stone,  and  that  tiie 
average  number  of  operations  for  tiie  population  of 
Great  Britain  and  Ireland,  is  annually  about  one  for 
each  100,000  inhabitants,  the  inference  drawn  by  Dr. 
Marcet,  which  also  does  not  agree  with  later  statis- 
tical reports,  cannot  be  received,  because,  in  the  total 
number  of  children  specihed  as  having  been  admitted 
into  the  above  charities,  even  when  every  allowance  is 
made  for  the  time  comprised  it:  the  calculation,  the  pro- 
portion of  operations  is  far  beyond  the  average,  with  re- 
ference to  the  population  ingeneral.  And  thatstonecases 
are  more  numerous  in  the  children  of  the  poor  than  in 
those  of  the  higher  classes,  is  a fact  wliich  perhaps  may 
be  explained  by  the  recollection  that  the  mass  of  the  po- 
pulation consists  of  the  poor  and  laborious  classes. 


In  the  period  of  life  between  the  age  of  twelve  or 
fourteen,  and  that  of  forty,  the  liability  to  stone  in  the 
bladder  is  much  less  than  in  infancy,  childhood,  or  old 
age.  And,  no  doubt,  many  of  the  cases  which  do  pre- 
sent themselves  in  adults  or  middle-aged  individuals, 
either  began  at  an  earlier  period  of  life,  or  are  owing  to 
some  extraneous  nucleus. 

According  to  Delpe.ch,  in  old  men  who  are  particu- 
larly subject  to  calculi,  the  disposition  to  the  return  of 
the  disease  always  continues  during  life  ; and  hence 
in  them  lelapses  are  frequent. — {Precis  des  Mai.  Chir. 
t.2,p.  193,<i'c.) 

The  following  table,  collected  by  Dr.  Prout,  ex- 
hibits the  proportion  of  stone  cases  before  and  after 
puberty,  and  of  their  occurrence  in  the  different 
sexes : 


Consisting  of 

Bristol. 

Leeds. 

Norwich. 

Total. 

Males. 

Females. 

14  years  and  under. 

178 

96 

2.35 

509 

Above  14  years. 

177 

101 

271 

549 

355 

, 197 

506 

1014 

44 

Thus,  nearly  one-half  of  the  tehole  number  of  stone 
cases  occur  before  the  completion  of  the  14<A  year  ; and 
it  appears  also  from  Mr.  Smith’s  valuable  reports,  that 
there  is  an  evident  increase  in  the  number  of  cases, 
about  the  age  of  forty  years. — (See  Prout  on  Gravel, 
Src.  p.  210 ; and  R.  Smith,  in  Med.  Chir.  Trans,  vol.  10.) 

Dr.  Marcet  has  estimated  the  comparative  frequency 
of  the  disease  in  various  countries,  and  in  the  different 
stations  of  life,  and  tried  to  ascertain  whether  its  fre- 
quency be  influenced  by  varieties  of  climate,  or  situa- 
tion, or  by  (leculiarities  in  our  habits  and  occupations. 
He  instituted  inquiries  at  all  the  great  hospitals  of  the 
metropolis,  in  the  hope  of  getting  at  some  useful 


records  concerning  the  vast  number  of  patients  on 
whom  lithotomy  had  been  performed  in  those  esta- 
blishments. In  London,  he  found  it  impossible  to  ob- 
tain ail  the  particulars  of  such  cases,  as  no  entry  of 
them  had  been  preserved.  The  Norwich  Hospital, 
however,  afforded  him  some  details  which  are  interest- 
ing. All  the  calculi  which  have  been  extracted  in  that 
hospital  for  44  years,  viz.  from  1772  to  1816,  and 
which  amount  to  506,  have  been  carefully  preserved, 
with  the  circumstances  annexed  to  each  stone,  and  the 
event  of  the  operation  distinctly  recorded.  Dr.  Marcet 
has  given  the  results  of  these  records  in  the  following 
table: 


Number  of  Operations. 

Deaths. 

Children 
under  14. 

Adults. 

Total. 

Children 

Adults. 

Total. 

Males, 

227 

251 

478 

12 

56 

68 

Females, 

8 

20 

28 

1 

1 

2 

235 

271 

506 

13 

57 

70 

It  appears,  says  Dr.  Marcet,  frotn  the  above  table, 
that  the  .mean  annual  number  of  cases  of  lithotomy  in 
the  Norwich  Hospital  during  44  years,  has  been  11^,  or 
23  in  every  two  years ; and  that  the  total  number  of 
fatal  cases  in  the  506  operations,  is  70,  or  1 in  1\,  or  4 
in  29.  The  proportion  of  females  wlio  have  umler- 
gone  the  operation  is  to  that  of  males  as  58  to  1000,  or 
about  1 to  17 ; that  the  mortality  from  the  operation 
in  children  was  only  about  1 in  18,  while  in  adults  it 
was  4 in  19,  or  nearly  quadruple. 

\ccording  to  Mr.  Smith,  the  nmrlality  from  litho- 
tomy at  the  Bristol  Infirmary,  has  been  in  the  follow- 
in,j  proportions : 


Age. 

10  vears  of  age  and  under, 

Bjwween  10  and  20 

20  30  

30 40  

40  50  

50  60  

60  70  

70  80  


Rate  of  Mortality. 
1 in  4i 
1 5 

1 7 

1 5 

1 ^ 

1 4| 

1 

1 2 


Mean  at  all  ages,  1 in  4^ 


from  1767 

to  1777 

Cases  of 
Litlmtomy. 
24,  of  which 

died 

2 

1777 

1787 

62 

8 

1787 

1797 

23 

3 

1797 

1807 

42 

7 

1807 

1817 

46 

8 • 

Mean  at  all  ages,  1 in  7 4-5 


The  preceding  table  is  also  fro.m  Mr.  Smith’s  paper, 
and  refer.s  to  the  Leeds  Hospital.— (See  Med.  Chir. 
TVans.  vol.  10.) 

In  the  Norfolk  Infirmary,  the  mortality  has  been 
much  less  in  childien  than  adults.  But  at  St.  Bar- 
tholomew’s, the  proportion  of  death  in  children  during 
the  20  years  that  I frequently  attended  operations  for 
stone  there  was  very  tireat.  In  the  Bristol  Infirmary, 
the  risk  in  children  seems  to  have  been  about  equal  to 
what  it  has  been  in  adults.  In  all  calculations  of  this 
kind,  however,  it  is  to  be  recollected,  ilmt  as  operations 
for  the  stone  are  done  not  only  by  surgeons  of  various 
degrees  of  skill,  hut  in  different  ways,  and  even  with 
instruments  of  great  diversity,  such  computations  do 
not  give  the  fair  average  of  any  one  method  of  ope 
rating. 

Now',  where  the  patients  are  equally  favourable, 
but  the  results  of  any  given  number  of  operations  on 
them  are  considerably  different,  the  skill  of  the  sur- 
geons, the  particular  methods  of  operating  pursued, 
the  kinds  of  instruments  used,  the  general  liealthiness 
of  the  hospital  itself,  and  the  treatment  after  the 
patients  are  put  to  bed,  are  consid'uations  by  which 
questions  apparently  inexplicable  might  sometimes  be 
solved. 

From  the  year  1772  to  1816,  the  Norwich  Hospital 
received  18,859  patients  of  all  kinds,  making  an  ave- 
rage of  428  annual  admissions;  and  Dr.  Marcet  ob- 
serves, that  the  proportion  of  506  operations  of  litho- 
tomy out  of  18,859  patients,  which  corresponds  to 
about  1 in  38,  exceeds  in  an  astonishing  degree  that 
obtained  from  any  of  the  other  public  institutions, 
whose  records  he  examined. 

Next  to  the  records  of  the  Norwich  Hospital,  Dr. 
Marcet  derived  the  most  distinct  information  of  this 


410 


URINARY  CALCULI. 


kind  from  Clieselden,  who  mentions  in  his  work  on 
anatomy,  that  during  the  course  of  his  public  practice 
in  St.  Tlioinas’s  Hospital,  a period  ot  about  20  years, 
he  had  perfonned  the  operation  of  the  stone  213  tiuies, 
and  lost  only  20  patients.  This  was  about  2 cases  in  21, 
which  is  much  less  than  the  common  average. 

In  St.  Thomas’s  Hospital,  during  ten  years,  the  ope- 
ration of  lithotomy  had  been  done  on  an  average  11 
times  in  each  two  years;  and  one  case  of  stone  had 
occurred  in  each  528  patients  admitted. 

In  St.  Barllioloniew’s,  lithotomy  was  performed  56 
times  in  the  years  1812,  18J3,  1814,  1815,  and  1816. 
The  annual  average  about  11,  or  1 in  each  340  patients 
of  all  descriptions. 

In  Guy’s  Hospital,  lithotomy  had  been  performed  on 
an  average  about  9 or  10  limes  annually,  during  the 
space  of  20  or  30  years.  The  proportion  of  calculous 
patients  there  was  also  estimated  by  Dr.  Marcet  as  1 
ill  about  300  cases  of  all  kinds. 

Dr.  Marcet’s  inquiries  inclined  him  to  think  that,  on 
the  whole,  Iilh<Homy  in  the  London  hospitals  for  some 
years  has  been  gradually  becoming  less  frequent;  and 
this,  he  conceives,  may  be  owing  partly  to  a real  reduc- 
tion in  the  frequency  of  the  stone,  from  some  alteration 
in  the  diet  or  habits  of  the  people  ; pai  *!y  to  the  use  of 
appropriate  medicines;  and  partly  to  the  circumstance 
of  calculous  patients  not  resorting  so  exclu^ively  as  was 
formerly  the  case  to  the  great  London  hospitals  for  the 
operation. 

In  the  Royal  Infirmary  at  Edinburgh,  the  average 
number  of  stone  cases  annually,  during  the  six  years 
preceding  the  period  of  Dr.  Marcel’s  publication,  is 
said  not  to  have  exceeded  2,  although  about  2000  pa- 
tients had  been  admitted  there  every  year. 

Dr.  Marcet  was  informed  by  M.  Koux,  that  in  La 
Charitd  at  Paris,  ten  or  twelve  cases  of  stone  occur 
every  year  out  of  about  2600  patients,  and  that  the 
proportion  of  deaths  from  the  operation  there  is  1 in 
5 or  6. 

With  respect  to  the  Hdpital  des  Enfans  Malades,  in 
the  same  city.  Dr.  Marcet  states,  on  the  authority  of 
Dr.  Biett,  that  about  6 cases  of  stone  are  received  every 
year  into  that  establishment,  where  about  3000  chil- 
dren of  both  sexes  are  annually  admitted.  There  have 
been  only  3 cases  in  females,  and,  what  is  remarkable, 
only  2 deaths  from  the  operation  in  the  course  of  the 
last  seven  years. 

Dr.  Marcet  has  been  acquainted  that  lithotomy  is 
comparatively  rare  at  Vienna  ; not  on  account  of  the 
want  of  good  surgeons,  or  the  unlrequent  occurrence  of 
stone  cases  in  that  part  of  the  continent,  but  in  conse- 
quence of  the  little  attention  paid  to  this  disease  by  the 
most  eminent  surgeons  of  the  Austrian  capital. 

At  Geneva,  says  Dr.  Marcet,  in  a population  of 
30,000,  lithotomy  has  been  performed  only  thirteen 
times  in  the  last  twenty  years,  though  good  surgeons 
are  never  wanting  in  that  town  to  perform  the  opera 
iion  whenever  an  opportunity  presents  itself.  Out  of 
these  thirteen  patients,  seven  were  not  stiictly  Gene- 
vese, though  belonging  to  the  neighbouring  districts, 
and  one  w'as  an  Englishman ; so  that  the  disease 
Would,  at  first  sight,  appear  to  be  a rare  occurrence  at 
tteneva.  But,  continues  Dr.  Marcet,  if  the  smallness 
«/  the  Genevese  yo]iulatioji  he  taken  into  accounts  t.his 
proportion  of  calculous  cases  may  not  fall  very  short 
of  that  observed  in  other  places.  At  Lyons,  a popu- 
lous town  not  more  than  eighty  miles  distant  from 
Geneva,  the  disease  is  stated  to  be  rather  frequent. 

With  regard  to  the  chemical  nature  of  urinary  cal- 
culi, there  was  nothing  known  until  1776,  when  Scheele 
published  on  the  subject  in  the  Stockholm  Transac- 
tions. He  there  stated,  that  all  the  urinary  calculi 
which  he  had  examined  consisted  of  a peculiar  con- 
crete substance,  now  well  known  by  the  name  of  lithic 
or  uric  acid,  which  he  also  showed  was  soluble  iti 
alkaline  lixivia.  Scheele  farther  discovered  that  the 
Tiihic  matter  was  in  some  degree  capable  of  being  dis- 
solved in  cold  water;  that  this  solution  possessed  acid 
properties,  and  in  particular  that  of  reddening  litmus ; 
that  it  was  acted  upon  in  a peculiar  manner  when 
boiled  in  nitric  acid;  and,  lastly,  that  human  urine 
always  contained  this  substance  in  greater  or  less 
quantity,  and  often  let  it  separate  in  the  form  of  a 
brick-coloured  sediment  by  the  mere  effect  of  cooling. 

The  discovery  made  by  Scheele  was  confirmed  by 
Bergmann  and  Morveau,  and  the  investigation  of  the 
subject  was  afterward  prosecuted  by  others  with  re- 


doubled ardour.  As  Professor  Murray  observes,  expe. 
rimenls  continued  to  be  repeated  and  diversified  on 
these  concretions  and  bn  their  solvents.  At  length,  it 
was  fully  ascertained  that  there  existed  others,  besides 
those  composed  of  uric  acid  ; and  latterly,  our  know- 
ledge of  them  has  been  much  extended  by  the  re- 
searches of  Pearson,  Wollaston,  Fourcroy,  and  Vau- 
quelin.  Several  important  facts  have  also  been  esta- 
blished by  the  talents  and  industry  of  some  other 
distinguished  men,  viz,.  Dr.  Henry,  of  Manchester; 
Professor  Brande,  of  the  Royal  Institution  of  London  ; 
Dr.  .Marcet,  late  of  Guy’s  Hospital ; and  Dr.  Piout,  of 
London.  'I'he  facts  and  considerations  of  the  latter 
writer  render  it  probable,  however,  that  the  common 
opinion  of  pure  lithic  acid  being  contained  in  the  urine 
is  not  exactly  correct;  but  that  this  acid  “in  healthy 
urine  exists  in  a stale  of  combination  with  ammonia, 
and  that  in  reality  this  fluid  contains  no  uncombined 
acid  at  all.” — (On  the  Ji'ature,  <J-c.  of  Gravel  and  Cal- 
culus, c.  13.) 

The  credit  which  is  due  to  Dr.  Wollaston  for  his 
valuable  and  original  discoveries  respecting  urinary 
calculi  is  very  considerable ; a truth,  which  I have 
particular  pleasure  in  recording  here,  since  his  merits 
have  not  been  fairly  appreciated  by  the  French  che- 
mists. Indeed,  as  Dr.  Marcet  observes,  it  is  the  more 
desirable  that  his  claims  should  be  placed  in  the  clearest 
point  of  view,  as  the  late  celebrated  M.  Fourcroy, 
both  in  his  “ Systdmedes  Connoissances  Chimiques,” 
and  in  his  various  papers  on  this  pariicular  subject,  has 
in  a most  unaccountable  manner  overlooked  Dr.  Wol- 
laston’s labours,  and,  in  describing  results  exactly 
similar  to  those  previously  (.btained  and  published  by 
the  English  chemist,  has  claimed  them  as  his  own  dis- 
coveries. Yet  Dr.  Wollaston’s  paper  was  printed  in 
our  Philosophical  Transactions  two  years  before 
Fourcroy  published  his  Memoir  in  the  “Annales  de 
Chimie,”  and  three  years  before  he  gave  to  the  world 
his  “ Syst^me  des  Connoissances  Chimiques ;”  and  he 
discussed  in  these  works  a paper  of  Dr.  Pearson  on  the 
lithic  acid,  published  in  a volume  of  the  Philosophical 
Transactions  (for  1798)  subsequent  to  that  which  con- 
tained the  account  of  Dr.  Wollaston’s  discoveries  ! — 
(See  Marcel's  Essay  on  Calculous  Disorders,  p.  60. 
Also  Murray's  Syst.  of  Chem.  vul.  4,  p.  636,  edit,  of 
1809.) 

It  would  appear,  then,  that  Scheele  first  discovered 
the  nature  of  those  urinary  calculi  which  consist  of 
lithic  acid,  but  that  Dr.  Wollaston  first  asceitained  the 
nature  ofsevetal  other  kinds,  some  of  which  have  also 
been  described  at  a later  |teriod  by  Fourcroy  and  Vau- 
qut'lin.  On  the  whole,  tlieie  are  five  species  of  con- 
cretions. whose  chemical  properties  were  first  |)ointed 
out  by  Dr.  Wollaston,  and  no  less  than  four  belong  to 
the  urinary  organs.  These  are,  1st,  Gouty  concretions. 
2dly,  The  fusible  calculus.  3dly,  The  mulberry  cal- 
culus. 4thly,  The  calculus  of  the  prostate  gland. 
5lhly,  Tne  cystic  oxide,  discovered  in  1810. 

1.  Lithic  Jlcid  Calculus.  Dr.  Proul  believes,  that  at 
least  two-thirds  of  the  whole  number  of  calculi  origi- 
nate from  lithic  acid  ; for,  as  it  forms  by  far  the  most 
common  nucleus,  round  which  other  calculous  matter 
is  subsequently  deposited,  if  such  nuclei  had  not  been 
formed  and  detained,  two  persons  at  least  out  of  three 
w ho  suffer  from  stone,  would  never  have  been  trou- 
bled with  the  disorder — (On  Gravel,  Calculus,  ij-c. 
p.  95.) 

Lithic  acid  forms  a hard,  inodorous  concretion,  of  a 
yellowish  or  brown  colour,  similar  to  lliat  of  wood 
of  various  shades.  According  to  Professor  Murray, 
calculi  of  this  kind  are  in  fine,  close  layers,  fibioiis  or 
radiated,  and  generally  smooth  on  their  surface,  though 
sometimes  a little  rough.  They  are  rather  brittle,  ai.d 
have  a specific  gravity  varying’  from  1.276  to  1.786,  but 
usually  about  1.500.  One  part  of  lithic  acid  i.-  said  to 
dissolve  in  1720  parts  of  cold  water,  and  1150  parts  of 
boiling  water  {Marcet,  p.  65);  and  this  solution  turns 
vegetable  blues  to  a red  colour.  VV'hen  it  has  been  dis- 
solved in  boiling  water,  small  yellowish  crystals  are  dc- 
IKtsited  as  the  fluid  becomes  cold.  Lithic  acid  calculi 
blacken,  but  are  not  melted  by  the  blow  pipe,  tmif.ing 
a peculiar  animal  smell,  and  gradually  evaporating, 
until  a small  quantity  of  white  ash  remains,  which  is 
alkaline.  Hy  distillation,  they  yield  ammonia  and  pru.-- 
sic  acid.  They  are  soluble,  in  the  cold,  in  a solution  of 
pure  potassa  or  soda,  and  from  the  solution  a precipi- 
tate of  a fine  w hite  powder  is  thrown  down  by  the  acid. 


URINARY  CALCULI 


411 


Lime-water  likewise  dissolves  them,  but  more  spar- 
ingly. According  to  Sclieele,  they  remain  unchanged 
in  solutiojis  of  the  alkaline  carbonates;  a siatenient 
which  agrees  with  that  of  Dr.  Prout,  who  accounts  for 
the  e^eci  said  to  be  produced  by  the  alkaline  carbonates 
upon  calculi  in  the  hiadder  by  their  property  of  dissofv- 
ing  the  lithate  of  ammonia. — {Egan,  in  Trana,^  of  Irish, 
Jlcad.  1805.  Front,  On  Gravel,  ^c.  p.  84.)  I'hey  are 
not  much  acted  upon  by  ammonia.  They  are  not  so- 
luble either  in  the  muriatic  or  sulphuric  acid ; though 
they  are  so  in  the  nitric  when  assisted  by  heat,  and  the 
residue  of  this  solution,  when  evaporated  to  dryness, 
assumes  a remarkably  bright  pink  colour,  which  disap- 
pears on  adding  either  an  acid  or  an  alkali.  In  many 
of  these  calculi,  the  lithic  acid  is  nearly  pure  ; in  others 
there  is  an  intermixture  of  other  ingredients,  particu- 
larly of  phosphate  of  lime,  and  jihosphate  of  ammonia 
and  magnesia ; and  in  almost  all  of  them,  there  is  a 
portion  of  animal  matter  which  occasions  the  smell 
when  they  are  burnt,  and  the  loss  in  their  analysis. — 
(See  Murray's  Chemistry,  vol.  4,  p.  640  ; and  Marcet's 
Essay  on  the  Chein.  and  Med.  Hist,  of  Calculous  Dis- 
orders, Svo.  Lund.  1817.) 

A great  quantity  of  uric  acid  is  formed  in  gouty  con- 
stitutions, and  deposited  in  the  joints  or  soft  pa«:s  in 
the  state  of  lithate  of  ammonia.  Sir  Everard  Horne 
removed  a tumour  weighing  four  ounces  from  the  heel 
of  a gentleman,  a maiiyr  to  the  gout;  and  when  ana- 
lyzed by  Professor  Braude,  it  was  f ound  to  be  principally 
composed  of  uric  acid. — {On  Strictures,  vol.  3,  p.  313.) 

2.  Lithate  of  .Mmmunia  Calculus,  according  to  Dr. 
Prout,  is  generally  of  the  colour  of  clay.  Its  surface  is 
sometimes  smontli ; sometimes  tuberculated.  It  is  com- 
posed of  concentric  layers,  and  its  fracture  resembles 
that  of  compact  limestone.  It  is  generally  of  small 
size,  and  rather  unqommon  ; but  the  lithate  of  ammo- 
nia very  frequently  occurs,  mixed  with  lithic  acid,  form- 
ing a mixed  variety  of  calculus.  Under  the  flame  of 
the  blow-pipe,  it  usually  decrepitates  strongly.  It  is 
much  more  soluble  in  water  than  the  lithic  acid  calcu- 
lus ; atid  always  gives  otf  a strong  smell  of  ammonia 
on  being  heated  with  caustic  potash.  The  lithate  of 
ammonia  is  also  readily  soluble  in  the  alkaline  subcar- 
bonates, which  pure  lithic  acid  is  nut. — {Prout,  On  Gra- 
vel, iS^c.  p.  83.) 

3.  Bone  Earth,  Phosphate  of  Lime  Calculus.  The 
resence  of  phosphate  of  lime  in  urinary  calculi  had 
een  mentioned  by  Bergmann  and  others,  when  Dr. 

Wollaston  first  ascertained  that  some  calculi  are  en- 
tirely composed  of  it.  From  the  inve.stigations  of  Dr. 
Wollaston,  it  appears  that  this  substance  sometimes, 
though  rarely,  composes  the  entire  calculus,  but  that  in 
general  it  is  mixed  with  other  ingredients,  particularly 
with  uric  acid  and  phosphate  of  magnesia  and  ammo- 
nia. In  the  first  case,  the  calculus  is  described  as  be- 
ing of  a pale-brown  colour,  and  so  smooth  as  to  appear 
polished.  When  sawed  through  it  is  found  very  regu- 
larly laminated,  and  the  laminae,  in  general,  adhere  so 
slightly  to  each  other,  as  to  separate  with  ease  into  con- 
centric crusts.  It  dissolves  entirely,  though  slow’ly,  in 
muriatic  or  nitric  acid.  E.xposeti  to  the  flame  of  the  blow- 
pipe, it  is  at  first  slightly  charred,  but  soo^/  becomes  per- 
fectly white,  retaining  its  form,  until  urged  with  the  ut- 
most heat  from  a common  blow- pipe,  when  it  may  be 
completely  fused.  It  appeais  to  be  more  fusible  than  the 
phosphate  of  lime,  which  (onus  the  basis  of  bone; 
a circumstance  which  Dr.  Wollaston  ascribes  to  the 
latter  containing  a larger  quantity  of  lime. — {Phil. 
Trans.  1797.) 

4.  IViple  Phosphate  of  Magnesia  and  Ammonia  Cal- 
culus. The  existence  of  this  calculus  in  the  intestines 
of  animals  wa.«  first  pointed  out  by  Fourcroy  ; but  its 
beitit!  a constituent  part  of  some  urinary  calculi  of  the 
human  subject  was  originally  discovered  by  Dr.  Wol- 
laston.—(PAtZ.  'Trans.  1797.)  According  to  Dr.  Prout, 
this  species  of  calculus  is  always  nearly  white  ; its  sur- 
face is  commonly  uneven,  and  covered  with  minute 
shining  crystals.  Its  texture  is  not  laminated,  atid  it  is 
easily  broken  and  reduced  to  powder.  In  some  tare 
instances,  however,  it  is  hard  and  compact,  and  when 
broken,  exhibits  a crystalline  texture,  and  is  more 
or  less  transparent.  Calculi  composed  entirely  of  the 
phosphate  of  magnesia  and  ammonia  are  rare,  but 
specimens  in  which  they  constitute  the  predominant 
ingredient  are  by  no  means  tinc’oinmon. — {Prout,  p. 
86.)  When  the  blow-pipe  is  applied,  an  ammoniacal 
■meil  is  perceived,  the  fragment  diminishes  in  size,  and 


if  the  heat  be  strongly  urged,  it  ultimately  undergoes 
an  imperfect  fusion,  being  reduced  to  the  state  of  phos- 
phate of  magnesia. — (P.  69.)  Dr.  Wollaston  describes 
tlie  (brm  of  the  crystals  of  this  salt  as  being  a short  tri- 
lateral prism,  having  one  angle  a right  angle,  and  the 
other  two  equal,  terminated  by  a pyramid  of  three  or 
six  sides.  I hese  crystals,  as  Dr.  Marcethas  explained 
are  but  very  sparingly  soluble  in  water,  but  very  rea- 
dily in  most,  if  not  all  the  acids,  and  on  precipitation, 
tiiey  reassume  the  crystalline  form.  From  the  solu- 
tions of  these  crystals  in  muriatic  acid,  .«al  ammoniac 
may  be  obtained  by  sublimation.  Solutions  of  caustic 
alkalies  disengage  ammonia  from  the  triple  salt,  the  al- 
kali combining  with  a portion  of  the  phosphoric  acid. 
One  fact,  of  great  importance,  respecting  this  species  of 
calculus  is  mentioned  by  Sir  A.  Cooper  in  his  lectures ; 
viz.  that  it  is  particularly  liable  to  be  reproduced  after 
lithotomy,  and  therefore,  until  the  patient’s  diathesis 
has  been  corrected  by  medical  treatment,  he  cautions 
surgeons  not  to  perform  the  operation.  In  cases  of  this 
description,  he  says,  a substtince  like  mortar  is  dis- 
charged ftom  the  bladder,  and  the  urine  is  very  fetid. 

5.  Fusible  Calculus.  Mr.  Tennant  first  discovered 
that  this  substance  was  different  from  the  lithic  acid, 
and  that,  when  urged  by  the  blow  pipe,  instead  of  be- 
ing nearly  consumed,  a large  part  of  it  melted  into  a 
white  vitreous  globule.  The  nature  of  the  fusible  cal- 
culus was  afterward  more  fully  investigated  and  ex- 
plained by  Dr.  Wollaston. — {Phil.  Trans.  1797.)  Ac- 
cording to  the  excellent  description  lately  given  of  this 
calculus  by  Dr.  Marcet,  it  is  commonly  whiter  and 
more  friable  than  any  other  species.  It  sometimes  re- 
sembles a mass  of  chalk,  leaving  a white  dust  on  the 
fingers,  and  separates  easily  into  layers,  or  laminag,  the 
interstices  of  which  are  often  studded  with  s[)aikling 
crystals  of  the  triple  phosphate.  At  other  times,  it  ap- 
pears in  the  form  of  a spongy  and  very  friable  whitish 
mass,  in  which  the  laminated  structure  is  not  obvious. 
Calculi  of  this  kind  often  acquire  a very  large  size,  and 
they  are  apt  to  mould  themselves  in  the  contracted  ca- 
vity of  the  bladder,assumingapeculiarityofform  which 
Dr.  Marcet  has  never  observed  in  any  of  the  other  spe- 
cies of  calculi,  and  which  consists  in  the  stone  termi- 
nating, at  its  broader  end,  in  a kind  or  peduncle,  corres- 
ponding to  the  neck  of  the  bladder.  The  chemical 
coniposiiioii  of  the  fusible  calculus  is  a mixture  of  the 
triple  phosphate  of  magnesia  and  ammonia,  and  of  the 
phosphate  of  time.  The.«e  two  salts,  which,  when  se- 
parate, are  infusible,  or  nearly  so,  when  mixed  together 
and  urged  by  the  blow-pipe,  easily  run  into  a vitreous 
globule.  The  composition  of  this  substance,  says  Dr. 
Marcet,  may  be  shown  in  various  ways.  Titus,  if  it 
be  pulverizrd,  and  acetic  acid  poured  upon  it,  the  triple 
crystals  will  be  readily  dissolved,  wiiile  the  phosphate 
of  lime  will  scarcely  be  acted  upon;  after  which  the 
muriatic  acid  will  readily  dissolve  the  latter  phosphate, 
leaving  a small  residue,  consisting  of  lithic  acid,  a por- 
tion of  which  is  always  found  mixed  with  the  fusinie 
calculus. 

If  is  also  remaiked  by  Dr.  Marcet,  that  many  of  the 
calculi  which  form  round  extraneous  bodies  in  the 
bladder  are  of  the  fusible  kind.  And  the  calculous 
matter  sometimes  deposited  between  the  prepuce  and 
glans  is  found  to  be  of  the  same  nature. 

6 Mulberry  Calculus,  or  Oxalate  of  Lime,  is  mostly 
of  a dark  brown  colour,  its  interior  being  often  gray. 
Its  sui  face  is  usually  uneven,  presenting  tubercles  more 
or  less  prominent,  frequently  rounded,  sometimes 
pointed,  and  either  tough  or  polished.  It  is  very  hard, 
difficult  to  saw,  and  appears  to  consist  of  successive 
unequal  layers;  excepting  the  few  stones  which  con- 
tain a proportion  of  silica,  it  is  the  heaviest  of  the  uri- 
nary coiicretions.  Thoi.-gh  this  calculus  has  been 
named  mulberry,  from  its  resemblance  to  that  fruit,  yet 
as  Dr.  Marcet  has  observed,  there  are  many  concre- 
tions of  this  class,  wivrjt,  far  from  having  the  mulberry 
a|>pearance,  are  rem»'’kably  smooth  and  pale-coloured, 
as  may  be  seen  in  plate  8,  fig.  6,  of  that  eentleman’s 
essay.  According  to  Mr.  Braude,  persons  vvlnr  have 
voided  this  species  of  calculus,  are  much  less  liable  to 
to  a return  of  the  complaint,  than  other  patients  who 
discharge  lithic  caIc.uli.--(PArZ.  'Trans.  1808.) 

With  regard  to  chemical  characters  (says  Professor 
Murray),  it  is  less  aflected  by  the  application  of  the 
usual  reacenls  lhaii  any  other  calculus.  'I'he  pure  al- 
kaline solutions  have  no  eflecl  upon  it,  and  the  acids 
dissolve  it  with  great  difficulty.  When  it  is  reduced, 


412 


URINARY  CALCULI. 


however,  to  fine  powder,  both  muriatic  and  nitric  acid 
dissolve  it  slowly.  The  solutions  of  the  alkaline  car- 
bonates decompose  it,  as  Fourcroy  and  Vauquelin  have 
observed;  and  this  affords  us  the  easiest  method  of 
analyzing  it.  TJie  calculus  in  powder  being  digested 
in  the  solution,  carbonate  of  lime  i&sorrn  formed,  which 
remains  insoluble,  and  is  easily  distinguished  by  the 
effervescence  produced  by  the  addition  of  weak  acetic 
acid,  while  there  is  obtained  in  solution  the  compound 
of  cxalic  acid  with  the  alkali  of  the  alkaline  carbo 
nate.  From  this  the  oxalic  acid  may  be  piecipitated 
by  the  acetate  of  lead  or  of  barytes;  and  this  oxalate, 
thus  formed,  may  be  afterward  decomposed  by  sul- 
phuric acid.  Another  method  of  analyzing  this  cal- 
culus is  by  exposure  to  heat ; its  acid  is  decomposed, 
and  by  raising  the  heat  sufficiently,  pure  lime  is  ob- 
Xnined,  amounting  to  about  a third  of  the  weight  of 
the  calculus.  According  to  Fourcroy  and  Vauquelin, 
the  oxalate  of  lime  calculus  contains  more  animal  mat- 
ter than  any  other.  This  animal  matter  appeared  to 
them  to  be  a mixture  of  albumen  and  ur^e.  The  com- 
position of  a calculus  of  this  species,  analyzed  by  Mr. 
Brande,  was  oxalate  of  lime,  65  grains  ; uric  acid,  16 
grains;  phosphate  of  lime,  13  grains;  animal  matter, 
4 grains. 

7.  The  Cystic  Oxide  Calculus  is  small,  and  very 
rare.  It  was  first  described  by  Dr.  Wollaston.— (PAi7. 
Trans,  for  1810.)  In  external  appearance,  it  bears  a 
greater  resemblance  to  the  triple  phosphate  of  magne 
sia  than  any  other  sort  of  calculus.  However,  it  is  more 
compact,  and  does  not  consist  of  distinct  lammas,  but 
appears  as  one  mass  confusedly  crystallized  tlnongh- 
out  its  substance.  It  has  a yellowish  semi-transpa- 
rency, and  a peculiar  glistening  lustre.  Under  the 
blow-pi  pe,  itgives  asingularly  fetid  smell,  quite  different 
from  that  of  lithic  acid,  or  the  smell  of  prussic  acid. 
In  consequence  of  the  readiness  with  which  this  spe- 
cies of  calculus  unites  both  with  acids  and  alkalies,  in 
common  with  other  oxides,  and  the  fact  of  its  also  con- 
taining oxygen  (as  is  proved  by  the  formation  of  car- 
bonic acid  by  distillation),  Dr.  Wollaston  named  it  an 
oxide,  and  the  terra  cystic  was  added  from  its  having 
been  originally  found  only  in  the  bladder  in  two  exam- 
ples. Dr.  Marcet,  however,  has  subsequently  met  with 
no  less  than  three  instances  of  calculi  formed  of 
cystic  oxide,  all  of  which  were  unquestionably  of 
renal  origin. 

8.  Alternating  Calculus.  Lithic  strata  frequently 
alternate  with  layers  of  oxalate  of  lime  or  with  the 
phosphates.  Sometimes  also  the  mulberry  alternates 
with  the  phosphates,  and  in  a few  instances,  three  or 
.even  four  species  of  calculi  occur  in  the  same  stone, 
disposed  in  distinct  concentric  laminae.  On  the  com- 
parative frequency  of  these  and  other  varieties  of  cal- 
culi, Dr.  Prout’s  work  contains  valuable  informa-lion. 

9.  Compound  Calculi,  with  their  Ingredients  inti- 
mately mixed.  Under  this  title.  Dr.  Marcet  compre- 
hends certain  calculi  which  have  no  characteristic 
feature  by  which  they  can  be  considered  as  distinctly 
belonging  to  any  of  the  other  classes.  He  observes, 
•that  they  may  sometimes  be  recognised  by  their  more 
or  less  irregular  figure,  and  their  le.ss  determinate  co- 
lour ; by  their  being  less  distinctly,  if  at  all  divisible 
Into  strata ; and  by  tb^ir  often  possessing  a considerable 
hardness.  By  cnea.ical  analysis,  confused  results  are 
.f)btained. — (See  Essay  on  the  Chem.  and  Med.  Hist,  of 
Calculous  Disorders,  p.  90.) 

10.  Calculi  of  the  Prostate  Gland.  The  composi- 
tion of  these  calculi  is  said  to  have  been  first  explained 
by  Dr.  Wollaston. — (See  Phil.  Trans,  for  1797.)  They 
all  consist  of  phosphate  of  lime,  the  earth  not  being 
redundant  as  in  bone.s.  Their  size  varies  from  that  of 
a pin’s  head  to  that  of  a hazel-nut.  Their  form  is 
more  or  less  spheroidal ; and  they  are  of  a yellowish- 
brown  colour, 

Fourcroy  has  described  a species  of  urinary  calculus, 
which  is  characterized  by  beinireom posed  of  the  urate 
or  lithate  of  ammonia.  Dr.  Wollaston,  Mr.  Brande, 
and  Dr.  Marcet  dib  not,  however,  satisfactorily  ascer- 
tain the  presence  of  th's  substance  in  any  of  the  con- 
cretions which  they  examined.  As  also  urea  and  the 
triple  phosphate,  both  of  which  afford  ammonia,  are 
frequently  present  in  lithic  calculi,  it  is  conjectured 
that  these  circumstances  may  have  given  rise  to  the 
analytical  results,  from  which  the  existence  of  urate 
of  ammonia  has  been  inferred.— (Brande,  in  Phil. 
Trans.  1808.  Marcel's  Essay,  p.  93.) 


The  recent  investigations  of  Dr,  Prout,  however,  tend 
to  establish  the  reality  of  Uie  lithate  of  ammonia  cal- 
culus. 

Dr.  Marcet  met  with  two  specimens  of  urinary  cal- 
culi, entirely  different  from  any  whicn  have  hitherto 
been  nuticed.  One  of  these  he  proposes  to  name 
xanthic  oxide,  from  l^avOdg,  yellow,  because  one  of  its 
most  characteristic  properties  is  that  of  forming  a 
lemon-coloured  comptmnd,  when  acted  upon  by  nitric 
acid.  The  chemical  properties  of  the  other  new  cal- 
culus, mentioned  by  Dr.  Marcet,  correspond  to  those 
of  fibrine,  and  lie  theiefore  suggests  the  propriety  of 
distinguishing  it  by  Ihe  term  fibrinous.  For  a parti- 
cular description  of  these  new  substances,  1 must  refer 
to  this  gentleman’s  Essay. 

11.  Carbonate  of  Lime  Calculus.  This  substance 
is  not  enumerated  by  Dr.  Marcet,  as  entering  in  the 
composition  of  urinary  calculi.  But  according  to  Mr. 
R.  Smith,  there  can  be  no  doubt  of  tlie  fact.  Dr.  W. 
H.  Gilby,  of  Clifton,  be  says,  detected  it  decidedly  in 
four  instances.  “ A notice  of  it  will  be  found  in  Mr. 
Tilloch’s  Journ.  for  1817,  vol.  49,  p.  188,  in  the  account 
of  a curious  calculus,  given  to  me  by  Mr.  G.  M.  Bur- 
roughs, of  Clifion  ; the  nucleus  of  which  is  a common 
cinder,  an  inch  and  a half  loTTg,  and  one  broad.  Since 
the  publication  of  that  paper  (continues  Mr.  Smiih), 
Mr.  H.  Sully,  of  Wivelisconibe,  sent  me  three  oddl)- 
shaped  calculi,  which  he  removed  from  a lad,  together 
with  15  pea  sized  ones  previously  voided  by  the  ure- 
thra, which  are  entirely  carbonate  of  lime,  held  to- 
gether by  animal  mucus.” — (See  Med.  Chir  Trans, 
vol.  11,  p.  14.)  Dr.  Prout  has  also  seen  some  small 
calculi,  conqiosed  almost  entirely  of  carbonate  of  lime. 
— (0«  Gravel,  ire.  p.  89.) 

Dr.  Prout  has  investigated,  with  considerable  talent, 
the  comparative  prevalency  of  the  different  forms  of 
urinary  deposiies,  and  the  order  of  their  succession. 
His  data  are  taken  from  the  examinations  made  by  Pro- 
fessor Brande,  of  the  calculi  in  the  Hunterian  Collec- 
tion ; by  Dr.  Marcet,  of  those  at  Norwich  and  Guy’s 
Hospital ; by  Dr.  Henry,  of  those  at  Manchester  ; and 
by  Mr.  Smith,  of  others  preserved  at  the  Bristol  Infirm- 
ary. The  w'hole  numher  of  calculi  e.xamined  was 
823;  of  these,  294  were  classed  under  the  tiame  of 
lithic  acid,  98  of  which  were  nearly  pure;  151  were 
mixed  with  a little  of  the  oxalate  of  lime  ; and  45  with 
a little  of  the  phosphates.  113  consisted  of  oxalate  of 
lime.  Three  were  of  cystic  oxide;  202  were  phos- 
phates ; of  which  16  were  nearly  pure  ; 84  mixed  with 
a small  proportion  of  lithic  acid ; 8 consisted  of 
phosphate  of  lime  nearly  pure;  3 of  triple  phos- 
phate nearly  pure ; and  91  of  the  fusible  or  mixed 
calculi.  186  were  alternating  calculi,  or  those  whose 
laminae  varied,  but  consisted  of  lithic  acid,  oxalate  of 
lime,  and  phosphates  : of  these,  15  consisted  of  lithic 
acid  and  oxalate  of  lime,  the  first  being  in  the  greatest 
proportion;  40  of  the  oxalate  of  lime  in  the  greatest 
proportion,  and  lithic  acid  in  the  least;  51  of  the  lithic 
acid  and  the  phosphates  ; 49  of  the  oxalate  of  lime, 
and  the  phosphates ; 12  of  the  oxalate  of  lime,  lithic 
acid,  and  the  phosphates;  1 of  fusible  and  lithic; 
2 of  fusible  and  oxalate  of  lime;  and  16,  Ihe  compo- 
sition of  whilh  was  not  mentioned. 

Of  compound  calculi  whose  compositions  W’as  not 
specified,  there  w'ere25. — (See  W.  Prout' s Inquiry  into 
the  Mature,  ire.  of  Gravel  and  Calculus,  p.  94.) 

The  proportion  of  lithic  acid  calculi  is  somewhat 
more  than  one-third  of  the  whole  number.  But  as 
this  acid  is  the  common  nucleus,  round  which  other 
calculous  matter  is  deposited,  Dr.  Prout  computes  the 
proportion  of  calculi  originating  from  it,  to  be  at  least 
two-thirds  of  the  whole  number.  According  to  the 
experiments  of  the  same  physician,  the  red  crystalline 
calculus  is  composed  of  nearly  pure  lithic  acid  ; and 
the  earthy,  amorphous  one  consists  of  lithic  acid,  more 
or  less  ammonia,  generally  a little  of  the  phosphates, 
and  sometimes  a small  portion  of  the  oxalate  of  lime. 
The  lighter  the  colour,  ihe  greater  in  general  the  pro- 
portion of  lithate  of  ammonia  and  the  phosphates. — 
-(P.97.) 

Oxalate  of  lime  calculi  form  one-seventh  of  the 
whole  number,  without  any  regularity,  liow'ever,  in 
different  museums. 

Cystic  oxide  calculi  are  so  rare,  that  the  proportion 
found  was  only  one-in  274. 

Calculi  composed  of  the  phosphates  made  about  one- 
fourth  of  the  whole  number. 


URINARY 

Mumativg  calculi  amounted  to  between  one-fourth 
and  one-fiflli ; but  Dr.  Proiil  offers  good  reasons  for  be- 
lieving that  the  data,  from  w inch  the  estimate  is  drawn, 
cannot  be  depended  upon.  For  additional  information 
on  this  branch  of  the  subject,  I must  refer  to  Dr.  Prout’s 
valuable  work. 

Tiie  st<»ne  being  a severe  affliction,  and  the  operation 
extremely  hazardous  and  painful,  a variety  of  experi- 
ments have  been  instituted  for  the  purpose  of  disco- 
vering a solvent  for  urinary  calculi.  Hitherto,  how- 
ever, all  the  remedies  and  plans  which  have  been 
tried,  have  been  attended  with  very  limited,  and  by  no 
means  unequivocal,  success,  notwithstanding  many 
persons  may  have  been  deceived  into  a contrary  opi- 
nion. 

The  dissolution  of  stones  in  the  bladder  has  been  at- 
tempted by  liihontriptic  medicines.,  as  they  are  termed, 
and  by  fluids  injected  into  this  viscus.  At  the  present 
day,  practitioners  direct  their  endeavours  very  much  to 
the  correction  of  those  particular  diatheses  or  states 
of  the  constitution  on  which  the  formation  of  various 
calculi  depend ; and  more  confidence  seems  to  be 
placed  in  this  aim,  than  in  any  schemes  for  the  dissolu- 
tion of  urinary  concretions.  It  is  certain  that,  in  the 
latter  project,  many  difficulties  present  themselves ; and 
among  these,  some  of  the  most  serious  are,  the  great 
variety  in  the  composition  of  calculi;  the  impossibility 
of  knowing  the  exact  ingredients  of  a stone  while 
it  is  concealed  in  the  bladder,  though  many  useful  sug- 
gestions for  assisting  the  judgment  on  this  point  have 
been  recently  offered  by  Dr.  Prout:  and,  lastly,  if  the 
right  solvent  were  ascertained,  as  calculated  upon 
chemical  principles  applied  to  urinary  concretions  out 
of  the  body,  it  is  obvious,  that  any  medicines  taken  by 
the  mouth  are  liable  to  so  many  changes  in  the  ali- 
mentary canal,  and  in  the  lymphatic  and  vascular  sys- 
tem, that  it  must  be  exceedintrly  difficult  to  get  them  in 
an  unaltered  state  and  effective  quantity  info  the  blad- 
der ; while,  if  this  were  pos>ible  (as  it  is  in  the  way 
of  injection  through  a catheter),  the  bladder  itself 
might  be  incapable  of  bearing  tlie  application,  and  the 
patient  lose  his  life  in  the  experiment. 

As  Dr.  Prout  well  observes,  a calculus  in  the  bladder 
may  be  considered  a substance  placed  in  a solution  of 
various  principles  in  a certain  quantity  of  water.  If 
any  of  the  more  insoluble  of  these  priticiples  exist  in 
this  solution  in  a state  of  supersaturation,  the  calculus 
will  aff  »rd  a nucleus,  round  which  the  excess  will  be 
dei>osited.  But  if  none  exist  in  a state  of  excess,  of 
course  none  can  be  deposited,  and  the  calculus  will  not 
increase  in  bulk. 

Whoever  studies  the  chemical  properties  of  the 
urine,  says  Dr.  Marcet,  will  learn  that  “if  any  alkali 
(a  few  drops  of  ammonia,  for  instance)  be  added  to 
recent  urine,  a white  cloud  appears,  and  a sediment, 
consisting  of  {)hosphate  of  lime,  with  some  ammoni- 
aco-magnesian  pho.sphate,  subsides,  in  the  proportion 
of  about  two  graitis  of  the  precipitate  from  four  ounces 
of  urine.  Lime-water  produces  a precipitate  of  a si 
milar  kind,  which  is  still  more  copious;  for  the  lime, 
ill  combining  with  the  e.xcess  of  phosphoric,  and  per- 
haps, also,  of  lactic  acid,  not  only  precipitates  the 
phosphate  of  lime,  which  these  acids  held  in  solution, 
but  it  decomposes  the  other  phosphates,  thus  generating 
an  additional  quantity  of  the  phosphate  of  lime,  which 
is  also  depitsited. 

“ If,  on  the  contrary  (observes  the  same  author),  a 
small  quantity  of  any  acid,  either  the  phosphoric,  the 
muriatic,  or,  indeed,  even  common  vinegar,  be  added 
to  recent  healthy  urine,  and  the  mixture  be  allowed  to 
stand  for  one  or  two  days,  small  reddish  crystalline 
particles  of  lithic  acid  will  be  gradually  deposited  on 
the  inner  surface  of  the  vessel. 

It  is  on  these  two  general  facts,  that  our  princijiles 
of  chemical  treatment  ultimately  rest.  Whenever  the 
lithic  secretion  predominates,  the  alkalies  are  the  ap- 
propriate remedies;  and  the  acids,  particularly  the 
muriatic,  are  the  airents  to  be  resorted  to,  when  tlie  cal- 
careous or  magnesian  salts  prevail  in  the  deposite.’’ — 
(F.  147,  148.) 

The  alkalies  taken  into  the  stomach  certainly  reach 
the  urinary  passage.s  through  the  medium  of  the  circu- 
lation ; and  it  is  also  strongly  suspected  that  the  acids 
likewise  do  so,  though  Ihis  circumstance  is  still  a ques 
tion.  Unfortunately,  ihe  quantity  of  either  alkalies  or 
acids  which  thus  mixes  with  the  urine  is  so  small,  that 
no  impression  is  made  upon  calculi  of  magnitude. 


CALCULI.  413 

The  experience  of  Dr.  Marcet,  Dr.  Prout,  and  others^ 
however,  has  clearly  ascertained  that  such  medicines 
are  often  capable  of  checking  a tendency  to  the  forma- 
tion of  stone,  and  eometimes  of  bringing  on  a calculous 
deposite  depending  upon  the  altered  state  of  the  sys- 
tem. Indeed,  Dr.  Marcet  expresses  his  decided  opinion, 
that  even  supposing  not  an  atom  of  alkali  or  acid  ever 
reached  the  bladder,  still  it  would  not  be  unreasonable 
to  expect  that  these  remedies  may  respectively  produce 
the  desired  changes  during  the  first  stages  of  assimila- 
tion ; in  one  case,  by  neutralizing  any  morbid  excess 
of  acid  in  the  primai  viae  ; and  in  the  other,  by  check- 
ing a tendency  to  alkalescence  or  otherwise  disturbing 
those  affinities,  which,  in  the  subsequent  processes  of 
assimilation  and  secretion,  give  rise  to  calculous  affec- 
tions.— (P.  153.) 

When  muriatic  acid  is  prescribed,  from  5 to  25  drops 
may  be  given  two  or  three  times  a day,  diluted  with  a 
sufficient  quantity  of  water. 

The  best  way  of  taking  the  alkalies  is  by  drinking 
soda  water  as  a common  beverage.  It  is  asserted, 
however,  on  the  authority  of  Sir  G.  Blane  that,  when 
the  alkalies  are  combined  with  citric  acid,  as  in  the  or- 
dinary saline  draught,  they  also  have  the  effect  of  de- 
priving the  urine  of  iis  acid  properties. 

Dr.  Marcet,  wilh  every  appearance  of  probability, 
refers  to  carbonic  acid  itself  no  solvent  power ; and  he 
does  not  even  adopt  Mr.  Braude’s  opinion,  that  this 
acid  passes  into  the  urine,  when  patients  drink  fluids 
impregnated  with  it. 

But  it  may  be  inquired,  if  no  known  internal  medicine 
will  dissolve  a stone  already  formed,  what  is  the  good  of 
merely  altering  the  diathesis  a.id  checking  the  increase 
of  the  calculus,  as  lithotomy  must  still  be  necessary? 
The  reasons  for  persevering  in  the  aim  of  correcting 
any  particular  state  of  the  system  and  the  urinary  se- 
cretion, on  which  state  the  increase  of  a calculus  de- 
pends, are  very  important ; for  it  is  found,  that  though 
medicines  may  be  quite  incapable  of  dissolving  a cal- 
culus, they  relieve  a great  deal  of  the  distress  and  suf- 
fering apparently  the  effect  of  the  diathesis  itself,  as 
will  be  presently  noticed,  and  sometimes  afford  such 
ease,  that  the  operation  may  be  postponed  until  the 
health  is  improved,  or,  in  a very  old  subject,  even  be 
dispensed  with  altogether,  'iiie  aim  is  also  of  high 
importance,  with  the  view  of  preventing  relapses. 

As  the  lithic  acid  diathesis  seems  ^be  concerned  in 
the  production  of  about  two-thirds  or  the  whole  num- 
ber of  the  urinary  calculi,  the  correction  of  it  has 
been  a chief  aim  among  modern  practitioners.  For 
this  purpose,  Magendie,  whose  experimcuits  tend  to 
prove,  that  the  lithic  acid  diathesis  may  be  lessened  andi 
removed  by  abstinence  from  animal  food,  and  other 
nutriments  abounding  in  azote,  founds  his  practice 
very  much  upon  this  alleged  fact.  His  indicatkms, 
however,  are  four  in  number,  viz.  1.  To  lessen  the 
quantity  of  uric  acid  produced  by  the  kidneys;  2.  To 
augment  the  secretion  of  urine;  a maxim  which  leads 
him  to  consider  cutaneous  perspiration  injurious;  a 
statement  which  I think  must  be  rejected,  considering 
the  rarity  of  calculi  in  hot  climates,  independently  of 
the  sentiments  of  Dr.  Wilson  Philip,  that  the  precipr 
tating  acid  (if  such  be  the  cause)  is  thrown  off  by  the’ 
skin,  and  consequently  that  ensuring  a due  perfornrance 
of  the  cutaneous  functions  must,  in  these  cases,  be  be-' 
neficial. — (See  Medical  Trans,  of  the  College  of  Phy- 
sicians, vol.  6.)  3.  To  prevent  the  lithic  acid  from  as- 
suming a solid  form  by  saturating  it.  4.  When  graveP 
and  calculi  are  formed,  to  promote  their  discharge  anrf 
attempt  their  dissolution. — {Recherches,  ire.  sur  la 
Oravellc,  p.  42.) 

For  correcting  the  lithic  acid  diathesis.  Dr.  Prout 
particularly  enjoins  the  avoidance  of  errors  in  diet, 
exercise,  &c.  The  error  of  quantity  of  food  he  deems 
worse  than  the  error  of  quality.  Patients,  he  says, 
should  abstain  altogether  from  things  which  manifestly 
disagree  with  them,  and  which  must  be  unwholesome 
to  all;  such  as  heavy  unfermented  bread,  hard  boiled 
and  fat  puddings,  salted  and  dried  meats,  acescent 
fruits,  and  (if  the  digestive  organs  be  debilitated)  soups 
of  every  kind.  In  general  also  wine,  and  fiaiticularly 
those  of  an  acescent  quality  should  be  avoided.  The 
wearing  of  flannel,  the  preserving  a regular  state  of 
the  bowels,  and  Ihe  occasional  use  of  alterative  medi- 
cines are  likewise  commended.— (Pro«r,  On  Gravelf 
i-c.  p.  135.) 

According  to  the  same  author,  the  treatment  of  calcu- 


414 


URINARY  CALCULI. 


loua  affections  is  either  of  a local  or  general  description. 
Tlie  local  treatment  is  nearly  tlie  same  in  all  the  sjie- 
cies;  the  general  treatment  will  depend  upon  the  na- 
ture of  the  calculous  diathesis. 

What  Dr.  Prout  calls  ihe  local  treatment  consists 
chiefly  in  prescribing  hyoscyamus  and  opium,  either 
alone  or  combined  with  uva  ursi.  The  hyoscyamiii!, 
he  says,  is  generally  preferable  in  the  lithic  acid  dia- 
thesis, and  opium  in  the  phosphatic.  He  also  recom- 
mends the  use  of  opium  in  the  form  of  injection  and 
embrocation,  and  especially  in  that  of  a suppository. 
The  warm  bath,  fomentations,  and  sitting  over  hot 
water  are  spoken  of  as  other  mentis  of  relief. 

According  to  the  observations  of  the  same  well- 
informed  writer,  the  distressing  symptoms  produced  by 
lithic  acid  calculi  have  a very  constant  relation  to  the 
severity  of  the  diathesis  present;  a circumstance 
which,  he  says,  is  also  more  or  less  true  with  respect 
to  all  the  other  kinds  of  calculi;  that  is  to  say,  in  pro- 
portion as  the  urine  is  unnatural,  and  loaded  with  gravel 
and  amorphous  sediments,  in  the  same  proportion  are 
the  patient’s  sufferings.  Hence,  our  first  object  should 
be  to  restore  the  uiine  to  its  natural  state.  The  first 
means  to  be  recommended  in  ordinary  cases  is  usually  a 
dose  of  calomel  and  antimonial  powder,  the  Plummer's 
pill,  or  some  other  alterative  purgative  taken  at  night, 
to  be  followed  up  the  next  morning  by  an  alkaline  , 
diuretic  purgative,  composed,  for  example,  of  Rochelle 
salts  and  magnesia  or  subcarbonale  of  soda  ; during 
the  day  a strong  infusion  of  uva  ursi,  combined  with 
hyoscyamus  and  the  liquor  potassa?,  may  be  taken. 
These  means  are  to  be  uersisted  in  for  a greater  or  less 
time,  according  to  the  circumstances,  and  till  the  urine 
begins  to  be  natural ; they  may  then  be  gradually  left 
off  or  varied  as  occasion  may  require;  and  under  this 
plan  it  will  be  found,  that,  in  the  majority  of  cases,  nut 
only  the  urine  will  assume  Us  natural  state,  hut  most 
or  all  the  distressing  symptoms  of  calculus  in  the 
bladder  will  he  very  much  diminished,  and  in  many  in- 
stances disappear.  It  is  obvious,  also,  that  while  the 
urine  is  in  its  natural  state,  the  calculus  cannot  in- 
crease in  size. 

“ After  the  diathesis  is  once  fairly  broken  by  these 
means,  it  may  in  general  be  easily  prevented  from  re- 
curring, by  attention  to  the  diet  and  other  circum- 
stances, formerly  mentioned  as  inducing  this  diathesis, 
and  by  the  occasional  use  of  medicines;  and  the  pa- 
tient will  scarcely  know  that  he  has  a calculus  in  the 
bladder,  at  least  Irom  the  pain  that  it  gives  him.  I state 
this  with  confidence,  but,  at  the  same  time,  I wish  to 
be  under.«lor)d  to  mean,  that  the  freedom  from  pain, 
depend  in  no  inconsiderable  degree  upon  the  size 
of  the  calculus,  its  smoothness,  upon  the  exercise  a 
patient  is  obliged  to  take,  &c.,  all  of  which  are  pre- 
sumed to  be  favourable;  for  it  must  be  sufficiently  ob- 
vious, that  a foreign  substance  in  the  bladder  cannot 
be  prevented  from  acting  mechanically,  and  from  oc- 
casionally producing  bloody  urine,  or  a temporary 
stojipage  of  the  discharge  of  tliat  secretion  from  the 
bladder,  and  similar  symptoms,  if  the  patient  is  obliged 
to  take  severe  exercise.” — (Prout,  On  Gravel,  S,'c.  p. 
202—204.) 

At  the  beginning  of  the  eighteenth  century  lime  and 
the  alkalies  were  known  to  be  frequently  jiroductive 
of  relief  in  cases  of  stone;  and  in  particnhir  the  nos- 
trum of  a Mrs.  Steevens,  the  active  ingredients  of 
which  were  calcined  egg-shells  and  snap,  acquired  such 
celebrity  for  the  cures  which  rt  effected,  that  much 
anxiety  was  expressed  that  her  formula  should  be 
made  public.  The  consequence  was,  that  in  the  year 
1739  parliament  appointed  a committee  of  22  respect- 
able men  to  investigate  the  merits  of  the  remedy  in 
question,  and,  on  their  very  favourable  report,  the  se- 
cret was  purchased  for  the  sum  of  SflOOZ.  These  pro- 
cecdincs  natnrally  interested  our  neighbours,  and  in 
the  years  1740  and  1741,  Morand  communicated  to  the 
Academy  of  Sciences  two  memoirs,  in  which  are  re- 
ported numerous  cases  where  the  new  remedy  was 
tried,  and  mostly  with  success;  the  greater  number  of 
the  patients  being  desciibed  as  either  benefited  or  ac- 
tually cured. 

In  many  instances,  stones,  which  had  been  unques- 
tionably felt,  were  no  longer  to  he  discovered  ; and,  as 
the  same  persons  were  examined  by  surgeons  of  the 
greatest  skill  and  eminence  both  before  and  after  the 
exhibition  of  the  medicines,  it  is  no  wonder  that  the 
conclusion  was  drawn,  that  the  stones  had  been  really 


dissolved.  From  the  cessation  of  this  success,  how- 
ever, and  from  its  now  being  known  that  stones  occa- 
sionally become  lodged  in  a kind  of  cyst,  on  the  out- 
side ot  the  general  cavity  of  the  bladder,  so  as  to  cause 
no  lotiger  any  material  suffering,  surgeons  of  the  pre- 
sent day  are  inclined  to  suspect  that  this  must  have 
happened  in  Mrs.  Steevens’s  cases.  This  was  certainly 
what  happened  to  one  of  the  persons  on  whom  tire 
above  medicine  was  tried,  as  Dr.  W.  Hunter  informs 
us.  It  is  evident  that  a stone  so  situated  would  not  in 
general  produce  a great  deal  of  irritation,  nor  admit  of 
being  felt  with  a sound ; though,  as  I have  stated  in 
the  article  Lithotomy,  there  have  been  a few  excep- 
tions to  this  observation. 

Mrs.  Steevens  first  gave  calcined  egg-shells  alone; 
but,  finding  costiveness  produced,  she  added  soap.  In 
time  she  rendered  her  process  iiune  complicated,  add- 
ing snails  burnt  to  blackness,  a decoction  of  chamomile 
flowers,  parsley,  sweet  fennel,  and  the  greater  burdock. 

That  in  the  lithic  acid  diathesis  the  carbrmates  of 
soda  and  potassa  taken  in  large  doses  have  the  effect 
of  passing  into  the  urine,  and  saturating  the  redundant 
lithic  acid  iti  the  unhealthy  state  of  that  fluid,  is  a fact 
decidedly  proved.  If  there  were  any  doubt  yet  remain- 
ing upon  this  point,  it  would  be  immediately  removed 
by  the  perusal  of  the  case  of  the  celebrated  Mascagni, 

I as  detailed  by  himself. — (See  J\Iem.  della  Soc.  Jtal. 
lf?04.)  This  eminent  anatomist,  being  much  afflicted 
with  gravel,  derived  benefit  from  drinking  the  aqua 
alcalina  mtphitica,  or  Seltzer  water ; but  conceiving 
that  more  good  might  result  from  a trial  of  carbonate 
of  potash,  he  took  at  first  half  adrachm  of  thissubstance 
in  the  morning,  and  as  much  in  the  evening,  dissolved 
in  ten  ounces  of  water.  The  second  day  the  dose  was 
augmented  to  two  drachms,  and  on  the  third  to  three, 
which  quantity,  dissolved  in  20  ounces  of  water,  was 
continued  for  ten  days.  “ Before  taking  the  carbonate 
of  potash  (says  Mascagni),  my  urine  was  very  acid, 
and  immediately  reddened  litmus  paper ; as  soon  as 
the  medicine  was  begun,  I made  the  same  experiment 
with  the  urine  then  voided,  and  found  the  intensity  of 
the  colour  of  the  paper  less.  The  second  day  the  paper 
was  very  little  altered,  and  on  the  third  the  urine  did 
not  redden  it  at  all.  The  acid  in  my  urine,  therefore, 
was  saturated,  and,  at  the  same  time,  the  pain  in  my 
loins  diminished,  and  no  more  gravel  was  voided  with 
my  urine.  Afterward  the  pain  ceased  entirely,  the 
urine  became  clearer,  and  I perceived  that  it  contained 
an  excess  of  potash.”  Being  attacked  again  at  a sub- 
sequent period  with  the  gravel,  Mascagni  adopted  the 
same  treatment,  and  experieticed  equal  benefit  from  if. 

In  the  lithic  acid  diathesis,  the  liquor  potassae  has 
sometimes  been  thought  to  have  more  efficacy  than  the 
carbonate. 

Sir  E.  Htime  and  Mr.  Hatchet  first  suggested  the  uti- 
lity of  giving  magnesia  in  cases  of  stone;  and  the  pro- 
posal was  communicated  to  the  public  by  Mr.  Brande 
(Phil.  Trans.  1810).  As  Dr.  Marcet  observes,  magne- 
sia is  often  found  advantageous  in  long- protracted 
cases,  in  which  the  constant  use  of  the  snbcarbonaled 
or  caustic  alkalies  would  itijnre  the  stomach.  But  he 
properly  remarks,  that  if  magnesia  is  sometimes  bene 
ficial,  it  has  of  late  years  often  tione  harm.  For,  as 
this  earth  is  the  base  of  one  of  the  most  common  spe- 
cies of  calculi,  viz.  that  containing  the  phosphate  of 
ammonia  and  magnesia,  there  is  nearly  an  even  chance 
when  magnesiti  is  prescribed,  without  any  previous 
knowledge  of  the  nature  of  the  calculus,  that  it  w ill 
prove  injurious.  Magnesia  also,  when  long  and  pro- 
fusely administered,  sometimes  fortns  large  masses  in 
the  intestinal  canal,  causing  serious  distress,  and  even 
fatal  consequences. 

According  to  Dr.  Prout,  purgatives  will  sometime.'i 
stop  calculous  depositions,  especially  in  children  ; and 
Dr.  Henry,  of  Manchester,  has  observed,  that  a quack 
medicif.e,  composed  of  turpentine  anrl  opium,  will  oc- 
casionally (irotince  a plentiful  discharge  of  lithic  acid 
from  Ihe  bladder. 

On  the  whole,  I believe,  reason  and  experience  will 
allow  us  to  consider  lime-water,  soap,  ncidnions  soda 
water,  the  caibonate  of  potassa,  the  liquor  potass®, 
and  inagtiesia  only  as  palliative  remedies,  by  which 
the  pain  of  the  disorder  may  sometimes  be  diminished, 
and  the  urinary  secretion  improved,  it  being  more  ra- 
tional to  impute  the  few  supposed  instances  of  greater 
success  to  the  calculi  becoming  encysted. 

As  medicines  taken  into  the  stomach  will  not  di»- 


URl 


URI 


415 


solve  urinary  calculi,  solvent  injections  have  been  In- 
troduced tlirough  a catheter  directly  into  the  bladder. 
Fourcroy  and  Vauquelin  ascertained  that  a solution 
of  potassa  or  soda,  not  too  strong  to  be  swallowed, 
softens  and  dissolves  small  calculi  composed  of  the  uric 
acid  and  urate  of  ammonia  when  they  are  left  in  the 
liquid  a few  days.  They  proved,  that  a beverage 
merely  acidulated  with  nitric  or  muriatic  acid  dissolves, 
with  still  greater  quickness,  calculi  formed  of  the  phos- 
phate of  lime,  and  of  the  triple  phosphate  of  ammonia 
and  magnesia.  Tliey  also  ascertained  that  calculi 
composed  of  the  oxalate  of  lime,  which  are  the  most 
difficult  of  solution,  may  be  softened,  and  almost  quite 
dissolved,  in  nitric  acid  gieatly  diluted,  provided  they 
are  kept  in  the  mixture  a sufficient  time. 

Liquids  are  then  known  which  will  dissolve  calculi 
of  various  compositions;  but,  as  I have  already  hinted, 
much  difficulty  occurs  in  employing  them  effectually 
in  practice.  For,  although  they  can  be  easily  injected 
into  the  bladder,  this  organ  is  so  extremely  tender  and 
irritable,  that  the  action  of  such  liquids  upon  it,  as 
would  be  requisite  for  dissolving  a stone,  would  pro- 
duce sufferings  which  no  man  could  endure,  and  tiie 
most  dangerous  and  fatal  effects  on  the  bladder  itself. 
Another  objection  to  this  practice  also  arises  from  the 
surgeon  never  knowing  what  the  exact  composiiion  of 
a calculus  i.s  before  this  body  is  extracted,  and  his  con- 
sequent inability  to  determine  what  solvent  ought  to  be 
tried. 

Until  the  complete  .success  of  lithontriptics  is  esta- 
blished, therefore,  the  operation  of  lithotomy,  severe 
and  hazardous  as  it  is,  must  continue  an  indispensable 
practice,  wherever  the  patient’s  sufferitigs  are  great, 
and  the  calculus  too  large  to  be  voided  or  extracted 
through  the  urethra,  or  the  circumstances  such  as  to 
prevent  the  successful  application  of  the  litliotrilic  in- 
siruments  devised  by  M.  Le  Roy  D’Etiolles,  Dr.  Civiale, 
and  Baron  Heurteloup,  and  which  are  calculated  to 
reduce  the  calculus  to  powder  or  small  particles,  so 
that  it  may  be  discharged  with  the  urine. — (See  Lithon- 
triptor.)  The  great  success,  iiowever,  that  has  attend- 
ed this  practice  in  France,  justities  a confident  hope 
that  it  will  soon  have  the  effect  of  materially  diminish- 
ing the  number  of  operations  in  Englaiid  as  well  as  in 
other  countries.  Children  are  conceived  not  to  be 
favourable  subjects  for  it,  on  account  of  the  small 
diameter  of  their  urethra  and  their  unmanageableness. 
It  is  also  alleged,  that  as  lithotomy  is  very  successful 
upon  youns;  subjects,  lithotritic  attempts  are  not  re- 
quisite. Doubts  may  be  entertained,  however,  of  the 
soundness  of  these  views;  for  cases  are  on  record, 
where  the  stone  was  most  effectually  crushed,  and 
voided  from  children.  Though  iu  them  the  urethra  is 
narrow,  still  it  may  be  gradually  dilated,  and  its  short- 
ness in  some  measure  compensates  for  its  little  diame- 
ter. If  also  it  be  generally  the  fact  that  children  hear 
lithotomy  more  safely  than  adults,  it  is  far  from  being 
true  that  such  is  the  great  success  of  the  operation  on 
them,  that  the  application  of  litln  tritic  plans  to  them 
is  scarcely  a desideratum.  Sometimes  very  old  sub- 
jects are  so  reduced  by  the  long  continued  irritation 
and  e.xcrnciating  agony  of  stone,  that  it  is  argued  that 
their  situation  will  not  admit  of  delay,  and  that  litho- 
tomy should  here  be  preferred  as  the  quickest  means 
of  relief.  In  defence  of  this  view  of  the  subject,  it  is 
also  urged,  that  in  many  old  persons  the  bladder  con- 
tracts so  feebly,  that  if  the  calculus  were  crushed  or 
ground  to  powder,  they  would  not  be  able  to  expel  the 
fragments  or  panicles.  No  doubt  the  lithotritic  art,  at 
least  in  its  present  state,  must  have  restrictions  ; but  it 
is  rational  to  believe,  that  it  is  yet  susceptible  of  im- 
provement, and  that  as  this  lakes  place,  the  number 
of  cases  to  which  it  will  become  applicable  w'ill  con- 
siderably increase.  As  things  are,  I regard  it  as  an  in- 
vention of  the  higliest  importance  to  mankind,  and 
reflecting  immortal  honour  on  the  several  ingenious 
men  by  whose  industry  and  talents  it  has  been  made 
capable  of  doing  what  it  has  already  done.  In  the 
early  stage,  befiire  calculi  have  exceeded  a certain 
size,  if  they  cannot  be  expelled  with  the  urine,  they 
may  sometimes  be  taken  out  by  means  of  the  uretin  al 
forceps  invented  by  Mr.  Wti-s,  of  the  Strand  : this  in- 
slniment  is  shaped  like  a sound,  but  its  end,  after  in- 
tiodiiciion  into  the  bladder,  admits  of  being  opened 
and  made  to  grasp  the  calculus,  which  is  then  to  be 
drawn  through  the  urethra.  The  urine  is  first  to  be 
discharged  through  a callieter.— (See  an  Account  of  a 


Case,  in  which  numerous  Calculi  were  extracted  witlf 
out  cutting  Instruments,  by  Sir  A.  Cooper,  in  Med. 
Chir.  Trans,  vol.  11,  p.  249.  Also,  Lithotomy.) 

Consult  T.  Lobb,  a Treatise  on  Dissolvents  of  the 
Stone,  8vo.  Lond.  1739,  Stephen  Hales,  Experiments 
and  Observations  on  Mrs.  Steevens's  Medicines,  8oo. 
Lond.  1741.  Morand.  in  Mem.  de  I' Acad,  des  Sciences^ 
1740  and  1741.  J.  Rutty,  Mew  Experiments  on  Juannor 
Steevens's  Medicines,  8vo.  Lond.  1742.  R.  Whytt,  an 
Essay  on  the  Virtues  of  Lime-water  and  Soap,  in  the 
Cure  of  Stone,  8vo.  Edinb.  1761.  D.  Hartley,  a View 
of  the  present  Evidence  fur  and  against  Mrs.  Stee- 
veTus's  Medicine,  dvo.  Lond.  1739;  and  Supplement, 
1740.  JV.  Hulnie,  A safe  and  easy  Remedy  for  the 
Slone,  ^c.  4lo.  Lond.  1778.  Wm.  butler.  Method  of 
Cure  for  the  Stone,  chiefly  by  injections,  12mo.  Edinb. 
1754.  B.  Langrish,  Physical  Experiments  upon 
Brutes,  in  order  to  discover  a safe  Method  of  dis- 
solving Stones  in  the  Bladder  by  Injections,  8vo.  Loud. 
1746.  J.  .Jurin,  Effects  of  Soap-ley,  taken  internally 
for  the  Stone,  2d  ed.  with  an  Appendix,  12we.  Lond. 
1745.  J.F.  Schreiber,  De  Medicamenlo  d J.  Steevens, 
contra  Calculum,  divulgato  inefficaci  et  noxio,  (ibtt. 
1744.  Murray  Forbes,  A Treatise  upon  Gravel  and 
Oont,  with  an  Examination  of  Dr.  Austin's  Theory 
of  Stone,  an  Inquiry  into  the  Operation  of  Solvents,  tfc. 
8vo.  Lond.  1793.  W.  Austin,  a T realise  on  the  Origin 
and  component  Parts  of  the  Stone,  d'C.  8vo.  Lond.  1791. 
T.  Beddoes  on  the  Mature  and  Cure  of  Calculus,  Src. 
8vo.  Lond.  1793.  J.  S.  Dorsey,  an  Essay  on  the  Li- 
thonlriptic  Virtues  of  the  Gastric  Liquor,  8vo.  Phila- 
delphia, 1802.  ,M.  Oirardi,  De  Uva  Ursma,  ejus  qiie 

et  Aquee  Calcis  Vi  lilhontriptica,  (S-c.  Patav.  1764. 
Scheele,  ill  Stockholm  Trans.  Fourcroy,  in  Systime  des 
Connoissances  Chimiques.  Wollaston,  Pearson,  and 
Brande,  in  Phil.  Trans,  and  Journal  of  Science  and 
Arts,  vols.  6 and  8,  ^c.  A.  Marcet  on  the  Chemical 
History  and  Medical  Treatment  of  Calculous  Disor- 
ders, 8vo.  Lond.  1817 ; a work  full  of  valuable  informa- 
tion. Wilson  Philip,  in  Med.  Trans,  vol.  6.  Dr. 
Henry,  in  Med.  Chir.  Trans,  vol.  10.  C.  Scudamore  cn 
Gout,  d^c.  ed.  3.  F.  Magendie,  Recherches  Physiolo- 
giques  et  Medicales  sur  les  Causes,  &c.  de  la  Oravelle, 
8vo.  Paris,  1818.  Ph.v.  Walthcr  ueberdie  Harnsteine, 
in  Journ.  fiir  Chir.  b.  1,  Berlin,  1820.  A.  Copland 
Hutchison  on  the  Comparative  Infrequency  of  Urinary: 
Calculi  among  Seafaring  People,  vid.  Med.  Chir. 
Trans,  vol.  9.  R.  Smith,  A Statistical  Inquiry  into  the 
Frequency  of  Stone  in  the  Bladder,  in  Great  Britain 
and  Ireland,  vid.  Med.  Chir.  Trans,  vol.  11.  W.  Prout, 
An  Inquiry  into  the  Mature  and  Treatment  of  Gravel, 
Calculus,  (S-c%  8vo.  Lond.  1821 : a work  abounding  in 
original  valuable  observations.  J.  Wilson  on  ike 
Structure  and  Physiology  of  the  Male  Urinary  and 
Genital  Organ.'i,  and  the  Mature  and  Treatment  of 
their  Diseases,  8vo.  Lond.  1821 ; this  publication  con- 
tains an  excellent  summary  of  the  latest  observations 
on  the  subject.  J.  P.  Frank  on  Urinary  Calculi,  see 
.Tonrn.  of  Foreign  Med.  Mo.  19. 

URINARY  FISTUL.^.  By  a urinary  flstula  is 
implied  a deep,  narrow  ulcer  which  leads  into  some  of 
the  urinary  passages.  If,  however,  as  is  alleged,  the 
fistula  after  a time  becomes  lined  by  a kind  of  mem- 
brane resembling  a rnneons  membrane  (see  Stafford  on 
Strictures,  p.  39,  ed.  2),  it  is  not  strictly  correct  to  de- 
scribe the  whole  fistula  as  an  ulcer,  though  its  orifice 
may  really  have  this  character.  The  application  of 
this  name  to  sinuses,  whicli  do  not  communicate  with 
these  passages,  but  only  terminate  near  some  point  of 
their  course,  appears  to  me  rather  absurd.  One  of  the 
chief  circumstances  tending  to  evince  that  a sinus  ha» 
no  communication  with  the  urethra  is,  that  no  urine 
has  ever  escaped  through  the  opening;  for,  with  re- 
spect to  the  judgment  formed  from  the  impo.ssibility  of 
making  a probe  touch  a catheter  in  the  passage,  it 
must  be  exceedingly  fallacious,  because  the  winding 
course  of  the  sinus  or  the  small  size  of  its  commnni 
cation  witli  the  urethra,  may  prevent  the  inslruinenls 
from  touching  each  other. 

According  to  Desault,  the  indications  in  the  treat- 
ment of  such  a case  deoend  upon  the  nature  of  its  coni'- 
plicaiions.  Wlien  tlie  sinuses  are  kept  up  by  a sepa- 
ration of  the  scrotum  from  the  parietes  of  the  uretlna, 
Desault  recommends  exact  compression  to  he  made 
over  the  part,  which  method,  he  says,  is  sometimes 
siifpcietii  to  accouiplish  a cure.  When  this  plan  fails, 
he  stales,  that  the  healing  of  the  sinus  may  be  pro* 


416 


URINARY  FISTULiE. 


moled  by  practising  an  incision  on  one  side  of  the  scro- 
tum, and  carrying  it  as  far  as  the  denuded  portion  of 
the  urethra.  When  sinuses  exist,  and  they  depend 
upon  the  smallness  of  tlie  opening,  or  its  unfavourable 
situation  for  the  discharge  of  the  matter,  the  aperture 
should  be  enlarged  by  making  an  incision  into  the 
main  collection  of  pus.  When  there  are  callosities, 
which  resist  cataplasms  and  the  most  active  re- 
solvents, Desault  advises  us  to  introduce  into  the  fistula 
trochees  of  minium,  for  the  purpose  of  destroying  tlie 
indurated  parts;  a plan  that  has  long  been  relinquished. 
When  the  bones  are  diseased,  exfoliation  must  be 
awaited  ; and,  in  every  instance,  the  treatment  should 
vary  according  to  the  cause  upon  which  the  fistula 
depends. 

Fistulae  communicating  with  the  urethra,  but  having 
no  external  opening,  are  sometimes  produced  in  con- 
sequence of  the  bursting  of  an  abscess  into  this  canal ; 
the  ulceration  from  a retention  of  urine;  a false  pas- 
sage ; and  the  healing  of  the  external  part  of  the  wound 
made  in  lithotomy  while  the  internal  part  is  not  united. 

In  these  cases,  there  is  a discharge  of  pus  from  the 
urethra  before,  and  sometimes  after,  the  issue  of  the 
urine ; and  one  may  feel,  in  the  course  of  the  urethra, 
a tumour  which  increases  while  the  patient  is  making 
water,  and  afterward  disapi>ears  on  pressure,  attended 
with  a fresh  discharge  from  the  penis  of  a mixture  of 
pus  and  urine. 

These  internal  urinary  hstulae  cannot  be  cured  ex- 
cept by  preventing  the  urine  from  passing  into  them 
and  lodging  there.  The  catheters  employed  should  be 
neither  too  large  nor  too  small.  If  too  large,  they 
would  exactly  fill  the  canal,  and  the  pus  and  urine  con- 
tained in  the  fistulas  could  not  be  discharged.  If  too 
small,  the  urine  would  insinuate  itself  between  them 
and  the  sides  of  the  urethra  and  enter  the  fistulae. 
Their  use  must  be  continued  till  the  ulcer  is  entirely 
healed. 

The  most  frequent  urinary  fistulte  are  those  which 
are  termed  complete.  Their  origin  may  be  in  the 
Ureters,  bladder,  or  urethra.  Those  which  arise  in  the 
ureters  sometimes  terminate  in  the  colon,  and  the  urine 
is  discharged  per  anum  mixed  with  the  feces.  But 
most  commonly  they  make  their  appearance  externall}', 
either  in  the  lumbar  or  inguinal  regions.  Those  which 
communicate  with  the  bladder,  have  also  different 
terminations.  When  they  proceed  from  the  upper  and 
interior  part  of  this  organ,  they  ordinarily  pierce  the 
parietes  of  the  abdomen  above  the  pubes  and  towards 
the  navel.  They  also  sometimes  terminate  in  the 
groins.  When  they  originate  in  the  posterior  parietes 
of  the  bladder,  they  sometimes  tend  into  the  cavity  of 
the  abdomen,  where  they  almost  always  prove  mortal; 
and  sometimes  into  the  intestinesj  if  there  should  be 
adhesions  between  these  and  ihe  bladder,  so  as  to 
favour  this  communication.  When  the  opening  in  the 
bladder  is  near  the  bottom  of  this  viscus,  the  fistula 
sometimes  terminates  in  the  rectum  of  the  male  and 
the  vagina  of  the  female  subject;  but  most  frequently 
it  ends  in  the  perinseum  in  both  sexes.  With  regard  to 
the  fistula?,  which  originate  in  the  urethra,  they  usually 
open  externally  in  the  perinaeum,  the  scrotum,  or  the 
penis,  and  sometimes  also  in  the  rectum.  It  is  not  un- 
common to  see  the  external  opening  of  tliese  fistulte  at 
a great  distance  from  the  ititernal  one,  and  to  find  it 
in  the  middle  and  even  the  low(!r  part  of  the  thighs,  the 
groins,  parietes  of  the  abdomen,  and  as  high  as  the 
sides  of  the  chest.  Oflen  there  is  only  one  opening  in 
the  urethra,  while  there  are  several  situated  externally, 
more  or  less  distant  from  one  another. 

Most  of  these  fistulte  are  the  consequences  of  a re- 
tention of  urine,  and  owing  to  the  same  causes  as  the 
diseases  of  which  they  are  a symptom.  Those  which 
communicpte  with  the  rectum,  in  the  male  subject, 
sometimes  depend  upon  this  intestine  having  been 
wounded  in  the  operation  of  littiotomy;  and  those 
which  open  into  the  vagina  are  often  the  effect  of  a 
violent  contusion,  caused  by  the  head  of  the  child  in 
difficult  labours,  or  of  ulceration  produced  by  pessaries 
which  are  too  large,  and  the  margins  of  whiclt  are  too 
sharp  and  irreitular.  Carcinoma  of  the  rectum  and 
vagina  also  give  rise  to  fistulce,  by  extending  into  the 
bladder. 

The  discharge  of  urine  from  the  external  orifice  of 
the  fistula  is  an  unequivocal  proof  of  its  communica- 
tion with  the  urinary  passages:  when  the  fistula  is 
narrow,  and  there  is  no  obstruction  in  the  urethra,  the 


urine  sometimes  escapes  more  readily  the  latter  way 
than  through  the  fistula.  It  may  also  be  difficult,  or 
even  impossible,  to  find  out  the  internal  oiince  of  the 
fistula  with  a probe.  When  the  fistula  communicates 
with  the  rectum  or  vagina,  a staff  introduced  through 
the  urethra  may  sometimes  be  felt  in  those  parts. 

When  fistulce  of  the  bladder  or  urethra  are  the  con- 
sequences of  a retention  of  urine,  produced  by  stric- 
tures which  still  exist,  or  have  even  increased  since 
the  formation  of  the  fistulte,  the  circumstance  may 
render  the  introduction  of  the  catheter  difficult.  In 
this  sort  of  case,  if  ihe  catheter  cannot  be  passed,  the 
surgeon  must  endeavour  to  remove  the  stricture  with 
bougies  or  other  instruments,  on  the  principles  ex- 
plained in  the  article  Urethra.,  Strictures  of.  “ In 
general  (as  Sir  Everard  Home  observes),  where  fistulte 
lake  place  in  perimeo,  in  consequence  of  a stricture, 
the  removal  of  the  stricture  is  sufficient  to  give  the 
fistula  a disposition  to  heal.  There  are,  however, 
cases  which  require  more  being  done  for  that  purpose, 
and  simply  laying  them  open  is  not  sufficient.” — (See 
Fistulte  in  Perinteo.)  Under  such  circumstances  he 
finds  tne  actual  cautery  the  surest  means  of  making 
the  part  heal.  In  one  case,  he  passed  a bougie  into  the 
urethra,  ar-d  seared  the  edge  of  the  fistula  with  a hot 
wire,  introduced  as  far  as  to  touch  the  bougie.  In  an- 
other instance,  a full-sized  silver  sound  was  passed 
into  the  bladder,  and,  the  direction  of  the  fistula  having 
been  ascertained  with  a probe,  a female  steel  sound 
was  fieated  to  redness,  and  “ at  the  moment  at  which 
it  passed  from  a red  to  a black  heat,  it  was  hurried 
down  through  the  fistula  (about  two  inches  and  a hall) 
to  the  sound  in  the  urethra.”  In  both  these  cases  a 
cure  was  effected. — {Home  on  Strictures,  vol.  3,  p.  262, 
•S-c.)  According  to  my  experience,  at  least  nine  urinary 
fistulae  out  of  ten  are  the  consequences  of  strictures  in 
the  urethra. 

When  fistulae  terminate  in  the  lower  part  of  the 
bladder,  Desault  advises  the  utmost  care  to  be  taken  to 
prevent  the  catheter  from  being  stopped  up,  and  to 
hinder  the  instrument  from  becoming  displaced,  or 
slipping  out  of  the  bladder;  for  which  last  purpose, 
thecalhetei  bracelet,  described  by  Sir  E.  Home,  seems 
well  calculated.  However,  when  the  fistula  commu- 
nicates with  the  urethra,  Desault  believes,  that  no  ad 
vantage  would  be  derived  from  keeping  the  catheter 
open.  In  both  cases,  he  recommends  us  to  continue 
the  catheter,  not  only  until  the  fistula  is  cured,  but  also 
until  the  obstacles,  which  hinder  the  urine  from  passing 
the  natural  way,  are  removed. 

Fistulae  of  the  bladder,  communicating  with  the 
vagina,  and  produced  by  difficult  labours,  are  alinnst 
always  attended  with  loss  of  substance.  The  forcible 
contusion,  occasioned  by  the  child’s  head  on  the  anterior 
parietes  of  Ihe  vagina  and  bottom  of  the  bladder,  gives 
rise  to  the  formation  of  sloughs,  the  separation  of  v\'hich 
sometimes  leaves  apertures  large  enough  to  admit  the 
finger,  and  hence  I he  difficulty  of  the  cure.  In  treating 
such  fistulaB,  there  are  two  indications  tobe  fulfilled : Isl, 
to  hinder  Ihe  urine  from  passing  into  the  vagina  ; 2dly, 
to  keep  the  edges  of  the  division  as  closely  as  possible 
together,  so  as  to  give  them  an  opportunity  of  uniting. 

In  women,  the  introduction  of  the  catheter  is  easy  ; 
but  the  in.-^trument  is  more  difficult  to  be  fixed,  than  in 
men.  Desault  contends,  however,  that  it  i.s  very  es- 
sential to  have  it  so  fixed  in  the  bladder,  that  the  urine 
may  escape.  He  found,  that  the  only  effectual  plan 
was  to  fasten  the  catheter  to  a point,  that  always 
retained  the  same  position,  with  respect  to  the  meatus 
urinariiis.  He  used  a kind  of  machine,  made  after  the 
maimer  of  a truss,  the  circle  of  which  wa.s  long 
enough  to  embrace  the  upper  part  of  tiie  pelvis,  and 
had  in  its  middle  an  oval  plate,  intended  to  be  placed 
upon  the  pubes.  In  the  centre  of  this  plate  was  a 
groove,  to  which  a piece  of  silver  was  fitted,  curved  so 
that  one  of  its  end.s,  with  an  aperture  in  it,  came  over 
the  vulva,  on  a level  with  the  meatus  urinariiis.  'I’his 
piece  of  silver  admitted  of  being  fastened  to  the  plate 
with  a screw.  After  the  catheter  had  been  introduced 
and  arranged  in  the  bladder,  so  that  its  beak  and  eyes 
were  situated  at  the  lowest  part  of  this  viscus,  the  end 
of  the  instrument  was  put  through  the  aperture  of  the 
piece  of  silver,  which  slided  into  the  groove  of  the 
plate,  and  it  was  afterward  fixed  in  the  way  already 
explained.  By  means  of  this  machine,  the  catheter 
was  securely  fixed,  without  incommoding  the  patient, 
even  when  she  was  walking 


URl 


URI 


417 


In  these  last  cases,  large  catheters,  with  full-sized 
apertures,  should  be  employed,  so  that  the  urine  may 
more  readily  escape  through  tl»e  instrument,  than  fall 
into  the  vagina.  In  the  early  part  of  tlie  treatment,  the 
catheters  should  also  be  left  constantly  open. 

In  order  to  keep  the  edges  of  the  division  as  near 
together  as  possible,  Desault  introduced  into  the  vagina 
a soft  kind  of  pessary,  large  enough  to  fill  the  vagina, 
without  distending  it.  By  this  means,  the  form  of  the 
fistula  was  changed  from  round  to  oval,  which  is  the 
most  favourable  to  its  reunion ; and  the  advantage 
was  gained  of  closing  the  fistula,  and  hindering  the 
urine  from  falling  into  the  vagina.  The  efficacy  of  the 
catheter,  when  properly  fixed,  has  lately  been  illus- 
trated in  an  interesting  case,  published  by  Dr.  Cumin, 
of  Glasgow,  who  considers  the  introduction  of  the 
pessary  into  the  vagina  useless  and  objectionable.— (See 
Edin.  Med.  Journ.  JVb.  78,  p.  62 — 64.) 

When  the  rectum  is  wounded  in  lithotomy,  Desault 
advised  dividing  the  parts,  comprehended  between  the 
wound  of  the  operation,  the  opening  in  the  rectum, 
and  the  margin  of  the  anus.  That  such  an  operation 
may  become  necessary  in  some  instances,  I will  not 
say ; but,  it  can  never  be  proper,  until  it  is  seen  whether 
the  wound  of  the  rectum  will  not  heal  up  favourably, 
without  such  treatment.  I have  seen  two  cases,  in 
which  the  rectum  was  cut  in  lithotomy,  yet  no  fistula 
ensued ; and  other  similar  facts  have  been  mentioned 
to  me  by  professional  friends.  The  success,  also,  with 
which  the  wound  has  generally  been  healed  after  litho- 
tomy, done  through  the  rectum,  is  another  fact  tending 
to  prove  that  the  inconveniences  of  a wound  of  the 
latter  bowel  in  the  operation  have  been  rather  exag- 
gerated. 

In  a case  of  urinary  fistula,  communicating  with 
the  rectum,  and  which  could  not  be  healed  with  the 
catheter.  Sir  A.  Cooper  introduced  a catheter  into  the 
bladder,  and  his  finger  into  the  rectum,  and  then  made 
an  incision,  as  in  the  operation  for  the  stone,  in  the 
left  side  of  the  raphe,  until  he  felt  the  staff  through  the 
bulb.  He  then  directed  a double-edged  knife  across 
the  perinaeum,  between  the  prostate  gland  and  the 
rectum,  with  the  intention  of  dividing  the  fistulous 
communication  between  the  urethra  and  the  bowel.  A 
piece  of  lint  was  introduced  into  the  wound,  and  a 
poultice  applied.  When  the  lint  was  removed,  the 
urine  was  found  to  lake  its  course  through  the  opening 
in  perinaeo;  the  aperture  in  the  rectum  gradually 
healed  ; and  that  in  the  perinaeum  quickly  closed  ; the 
urine  being  all  now  discharged  in  the  natural  way. — (./9. 
Cooper,  Surgical  Essays, part  1,  p.  215.) 

As  the  same  gentleman  has  observed,  apertures  in 
the  urethra,  attended  with  loss  of  substance,  are  ex- 
tremely difficult  to  heal.  He  relates  a case,  where  the 
urethra  had  sloughed  at  the  junction  of  the  scrotu.m 
with  the  penis  ; the  opening  healed  at  its  margin,  but  a 
large  fistulous  orifice  still  remained.  Bougies,  the  plans 
of  excoriating  the  edges  of  the  opening  with  blistering 
plaster,  and  even  paring  them  off,  and  bringing  the 
fresh-cut  surfaces  together  with  the  twisted  suture, 
had  all  been  tried  in  vain.  In  this  example,  a cure 
was  effected  by  applying  the  nitrous  acid  to  the  edge  of 
the  fistulous  orifice,  and  to  the  skin,  three-quarters  of 
an  inch  around  it,  the  principle  on  which  Sir  A. 
Cooper  rested  his  hopes  of  success  being  the  con- 
traction of  the  skin  in  cicatrization.  The  first  appli- 
cation having  produced  considerable  amendment,  the 
plan  was  repeated  several  limes  in  the  course  of  about 
nine  months,  at  the  end  of  which  time,  the  fistula  was 
closed.  He  is  of  opinion,  that  such  practice  will  only 
succeed  in  cases  where  the  skin  is  very  loose,  and  the 
scrotum  forms  a part  of  the  fistulous  orifice.  If  the 
skin  be  much  confined,  he  suggests  raising  a piece  of 
skin  from  the  scrotum,  paring  off  the  edges  of  the 
fistulous  orifice,  and  removing  the  skin  to  a small 
extent  around  it.  The  skin  thus  raised  is  to  be  turned 
half  round,  so  that  its  raw  surface  may  be  applied  to 
the  opening,  and  unite.  An  elastic  catheter  is  first  to 
be  introduced.  In  the  successful  operation  of  this 
kind,  which  was  actually  done,  the  flap  was  held  by 
four  sutures ; and  small  slips  of  adhesive  plaster,  and 
a bandage  to  support  the  scrotum,  were  employed.  In 
the  course  of  the  treatment,  pressure  was  found  neces- 
sary to  prevent  the  occasional  passage  of  urine  through 
the  wound. — {A.  Cooper,  Surgical  Essays,  part  2,  p. 
221,  Src. 

Mr.  Earle  met  with  a case,  in  which  the  integuments 

VoL.  II.— D d 


in  the  petinseum,  and  above  an  inch  of  the  canal  of  the 
urethra,  had  sloughed  away,  in  consequence  of  external 
violence.  At  the  man’s  entrance  into  St.  Bartho- 
lomew’s Hospital,  a large  smooth  cicatrix  occupied  the 
place  of  the  urethra,  no  vestige  of  which  remained  in 
that  part.  The  integuments  on  the  right  side  had  suf- 
fered less  extensively  than  those  on  the  left ; so  that 
when  the  catheter  was  introduced,  that  portion  of  the 
instrument,  which  passed  over  the  cicatrix,  could  be 
about  half  covered,  by  drawing  the  skin  and  healed 
part  from  the  right,  towards  the  opposite  side.  The 
treatment  was  therefore  begun  by  confining  the  knees 
together  over  a pillow,  and  applying  a kind  of  truss, 
which  kept  the  skin  constantly  pressed  towards  the 
left  side.  While  these  measures  were  going  on,  the 
opportunity  was  taken  of  dilating  the  anterior  portion 
of  the  urethra  with  bougies.  Afterward  the  following 
operation,  which  I had  the  pleasure  of  seeing,  was  per- 
formed: a portion  of  the  integuments  was  removed, 
about  an  inch  and  a half  long,  and  one-third  of  an  inch 
in  width,  on  the  left  side  of  the  cicatrix.  The  groove, 
thus  formed,  was  intended  for  the  reception  of  the 
edge  of  the  skin  to  be  detached  from  the  opposite  side. 
An  incision  was  then  made  across  the  perinseum,  above 
and  below,  so  as  to  pare  away  the  callous  edges  of  the 
urethra.  The  skin  was  next  dissected  off  from  a 
portion  of  integument  on  the  right  side  of  the  perinaeum, 
about  an  inch  and  a half  in  length,  and  half  an  inch 
broad,  leaving  a smooth  space  of  rather  more  than  an 
inch  between  the  cut  surfaces.  The  integuments,  on 
the  right  side,  were  now  dissected  up,  turned  over  a 
catheter,  and  brought  in  contact  with  the  opposite 
groove.  The  detached  portion  of  cicatrix  bled  little 
during  the  operation ; and  before  it  could  be  applied  to 
the  groove,  its  edge  had  so  livid  an  appearance,  as  to 
create  an  apprehension  that  it  must  perish.  Two 
sutures  were  employed  to  assist  in  retaining  it  in  the 
desired  position,  and  some  straps  of  adhesive  plaster, 
and  a bandage,  completed  the  dressings.  The  day 
after  the  operation,  it  was  evident,  that  some  urine  had 
escaped  by  the  side  of  the  catheter ; and,  on  the  third 
day,  when  the  dressings  were  removed,  it  was  found, 
that  the  portion  of  flesh  which  had  been  deprived  of 
skin  had  sloughed,  but  that  a sufficient  quantity  had 
united,  above  and  below,  to  form  a canal,  open  at  one 
side,  and  large  enough  to  include  the  whole  catheter. 
After  the  parts  had  healed,  some  urine  could  be  made 
to  pass  through  the  urethra,  when  pressure  was  applied 
to  the  left  side  of  the  remaining  fistula.  Various 
attempts  were  afterward  made  to  excoriate  its  edges, 
and  unite  them,  but  without  success. 

A second  operation  was  therefore  done  in  the  summer 
of  1820,  and  integuments  were  now  borrowed  from  the 
opposite  side  to  that  from  which  they  had  been  taken 
in  the  first  operation.  “ A deep  groove  was  made  on 
the  right  side,  the  surface  was  denuded  of  its  cutis  to 
some  extent,  a considerable  portion  of  integument  was 
then  detached  from  the  left  side,  and,  in  order  to  obtain 
healthy  skin  (says  Mr.  Earle),  I encroached  a little  on 
the  thigh,  and  laid  bare  the  edge  of  the  fascia  lata. 
Instead  of  passing  any  ligature  through  the  detached 
portion,  the  old  quill-suture  was  employed,  which  was 
passed  from  the  two  outer  cut  surfaces.  A pad  of  ad- 
hesive plaster  was  interposed  between  the  ligatures  and 
the  flap  of  skin.”  The  catheter  was  not  left  in  the 
urethra,  but  introduced  about  three  times  in  24  hours. 
By  this  operation,  much  more  was  gained,  and  about 
two-thirds  of  the  deficient  part  of  the  canal  were  re- 
stored : but  still  a small  aperture  remained  at  the  upper 
part.  This  opening  could  not  be  closed  by  touching  it 
with  escharotics,  and,  consequently,  a third  operation 
on  a smaller  scale  was  done,  which  so  nearly  com- 
pleted the  cure,  as  to  leave  only  an  orifice  large  enough 
to  admit  a bristle,  and  this  opening  subsequently 
closed,  and  the  patient  remained  quite  well  in  March, 
1821.— (See  Phil.  Trans,  for  1821.) 

Here  we  see  the  same  art,  by  which  new  noses  and 
under  lips  are  formed,  extending  itself  to  cases,  where 
it  may  be  the  means  of  extricating  some  individuals 
from  a state  in  which  life  is  hardly  desirable.  The 
surgeon  of  judgment,  however,  will  never  forget,  that 
such  an  operation  is  only  indicated  where  the  fistula 
is  large,  the  urethra  free  from  obstruction,  and  bougies 
and  the  catheter  ins\ifficient. 

URINE,  INCONTINENCE  OF.  This  complaint 
is  quite  the  reverse  of  retention  of  urine;  for,  as  in 
the  latter  affection,  the  urine  is  continually  flowing 


418 


URINE,  INCONTINENCE  OF. 


into  the  bladder,  without  the  patient  having  the  power 
to  expel  it ; so,  in  the  former,  it  flows  out,  without  the 
patient  being  able  to  retain  it. 

According  to  Desault,  children  are  particularly  liable 
to  the  disorder ; adults  are  less  frequently  afilicted  with 
it ; and  persons  of  advanced  years  appear  to  be  still 
less  liable  to  it.  The  last  observation  may  seem  an 
error  to  such  practitioners  as  have  met  with  numerous 
examples,  where  patients  advanced  in  years  were 
incapable  of  retaining  their  urine.  The  fact  is,  that 
the  overflow  of  this  fluid,  or,  in  other  words,  its  drib- , 
bling  away  through  the  urethra,  in  some  cases  of' 
retention,  of  which  it  is  only  a symptom,  has  been  too 
commonly  confounded  with  an  incontinence  of  urine, 
though  the  cases  are  as  different  in  their  nature  as 
possible,  and  require  very  opposite  modes  of  tieatment. 
Jji  retentions  1 depending  upon  weakness  and  paralysis 
of  the  bladder^  the  involuntary  dribbling  of  theurine  is 
generally  only  an  effect  of  the  other  disease,  and  they 
prevail  together.  The  distended  bladder  reacts  upon 
the  urine,  and  forces  some  of  it  out  of  the  urethra, 
until  the  resistance  of  the  sphincter  and  of  the  urethra 
are  precisely  equal  to  the  expelling  power.  Sometimes 
the  urine  even  dribbles  away  incessantly,  as  is  found  to 
happen  when  the  action  of  the  bladder  is  entirely 
destroyed ; for,  being  then  constantly  full,  it  cannot 
hold  any  more  of  the  urine  descending  to  it  through 
the  ureters,  unless  as  much  be  voided  through  the 
urethra  as  is  received  from  the  kidneys,  and  as  unre- 
mittingly as  the  addition  from  the  latter  organs  con- 
tinues to  be  made.  Such  a case  rather  belongs  to  the 
anicle,  Urine^  Retentiop,  of,  than  the  present  subject. 

It  is  correctly  remarked  by  Desault,  that  the  causes 
of  an  incontinence  of  urine,  strictly  so  called,  are  the 
very  reverse  of  those  of  a retention.  The  latter  case 
happens  whenever  the  action  of  the  bladder  is  weak- 
ened, and  the  resistance  in  the  urethra  increased.  On 
the  contrary,  an  incontinence  originates  either  from  the 
expelling  power  of  the  bladder  being  augmented,  while 
the  resistance  in  the  urethra  is  not  proportionately  in- 
creased, or  from  the  resistance  being  lessened  while 
the  expelling  force  continues  the  same.  On  these 
principles,  Desault  thought  it  easy  to  explain  why  the 
disorder  should  be  most  common  in  children  ; and  one 
reason  which  he  gives  for  the  circumstance  is,  that  in 
childhood  there  is  more  irritability  than  at  any  other 
period  of  life.  The  expulsion  of  the  urine,  he  observes, 
is  entirely  effected  by  muscular  action,  while  the  re- 
sistance is  merely  owing  to  the  sphincter  vesicas,  the 
ievatores  ani,  and  perhaps  to  a few  other  inconsiderable 
fasciculi  of  muscular  fibres;  for  the  different  curva- 
tures of  the  urethra  and  the  contractile  power  of  this 
tube  itself,  he  thought,  could  make  only  a feeble  resist- 
ance to  the  discharge  of  the  urine.  An  incontinence 
happens  in  children,  because  the  bladder  contracts  so 
suddenly  and  forcibly  that  its  contents  are  voided 
almost  before  these  young  subjects  are  aware  of  the 
occasion  to  make  water,  and  without  their  being  able 
to  restrain  the  evacuation.  There  are  also  many  chil- 
dren who,  from  indolence  or  carelessness,  do  not  make 
water  immediately  the  first  calls  of  nature  invite  them, 
and  who  afterward,  being  urgently  pressed,  wet  their 
clothes.  In  other  young  subjects,  the  sensation  which 
makes  the  bladder  contract  and  accompanies  the  expul- 
sion of  the  urine  is  so  slight,  that  the  function  is  per- 
formed without  any  formal  act  of  the  will,  without 
even  exciting  an  impression  sufficiently  strong  to  dis- 
turb sleep.  This  is  the  case  with  such  children  as  are 
troubled  only  with  an  incontinence  of  urine  in  the 
night-time.  Increasing  years,  by  diminishing  the  irri- 
tability of  the  bladder  and  making  man  more  attentive 
to  his  necessities,  usually  bring  about  a cure  of  the  in- 
firmity, which  seldom  continues  till  the  patient  has 
attained  the  adult  state. 

It  was  not,  however,  the  doctrine  of  Desault,  that  no 
period  of  life  excepting  childhood  is  subject  to  incon- 
tinence of  urine.  On  the  contrary,  he  admits  that 
other  ages  are  subject  to  it;  but  then  it  depends  almost 
always  upon  a want  of  resistance  to  the  escape  of  the 
urine.  Thus,  it  may  be  occasioned  by  weakness,  or 
paralysis  of  the  sphincter  vesicae,  or  Ievatores  ani ; 
sometimes  also  by  a forcible  dilatation  of  the  urethra, 
and  loss  of  its  elasticity,  and  (as  Desault  might  have 
added)  its  muscular  power  of  contraction,  since  the 
microscopical  observations  of  Mr.  Bauer  tend  to  con- 
firm the  existence  of  muscular  fibres  on  the  outside  of 
the  membrane  of  the  canal,  though,  as  is  elsewhere 


mentioned,  their  arrangement  and  mode  of  action  are 
now  represented  to  be  quite  different  from  what  was 
formerly  supposed.— JPee  Urethra,  Strictures  of  the.) 

A calculus,  a fungus,  or  any  other  extraneous  body 
of  an  irregular  shape,  may  lodge  in  the  neck  of  the 
bladder,  but,  not  accurately  filling  it,  may  allow  the 
urine  to  escape  at  the  sides  ; or  there  may  even  be  in 
the  calculus  grooves  through  which  the  urine  may  pass 
into  the  urethra. 

A violent  contusion,  or  forcible  distention  of  the 
sphincter,  is  often  followed  by  an  incontinence  of 
urine.  Formerly,  the  complaint  used  to  be  very  com- 
mon after  the  mode  of  lithotomy  called  the  apparatus 
major,  and  it  is  even  at  present  not  an  unusual  conse- 
quence of  the  extraction  of  calculi  from  females,  either 
by  dilatation  or  division  of  the  meatus  urinarius  and 
neck  of  the  bladder. 

Women,  after  difficult  labours,  and  in  whom  the 
child’s  head  has  seriously  contused  and  weakened  the 
neck  of  the  bladder,  are  also  subject  to  a species  of 
incontinence  of  urine  ; which,  however,  is  in  general 
experienced  only  when  they  laugh,  or  make  exertions. 

Incontinence  of  urine  is  stated  by  many  writers  to 
be  an  attendant  on  palsy  and  apoplexy.  Here  they 
mistake  what  the  French  surgeons  aptly  call  the 
“ retention  d'urine  avec  regorgement,"  for  an  inconti- 
nence. In  such  cases,  the  involuntary  discharge  of 
urine  has  been  referred  to  paralysis  of  the  sphincter  of 
the  bladder ; but,  it  is  forgotten  that  the  bladder  itself 
also  participates  in  the  paralytic  affection ; for  the 
sphincter  not  being  a particular  muscle,  but  only  a fas- 
ciculus of  fleshy  fibres,  formed,  as  Desault  observes, 
by  the  junction  of  those  which  compose  the  inner  layer 
of  the  muscular  coat  of  the  bladder,  it  can  only  be 
weakened  in  the  same  degree  and  at  the  same  time  as 
the  rest  of  this  organ.  Besides,  says  Desault,  it  is 
proved,  and  all  physiologists  admit  the  fact,  that  the 
action  of  the  bladder  is  absolutely  necessary  for  the 
expulsion  of  the  urine,  and  that  when  this  organ  cannot 
act,  a retention  always  ensues.  Although  much  less 
danger  attends  an  incontinence  than  a retention  of 
urine,  the  infirmity  is  a serious  affliction  ; for,  as  the 
patient’s  clothes  are  continually  wet  with  a fluid  that 
readily  putrefies,  the  stench  which  he  carries  about 
with  him  is  offensive  to  himself  and  every  body  who 
approaches  him. 

In  children,  the  disorder  usually  gets  well  of  itself,  as 
they  grow  up  and  acquire  strength.  When  they  wet 
their  beds  really  from  idleness  and  carelessness,  mode- 
rate chastisement  may  be  proper,  inasmuch  as  the  fear 
of  correction  will  make  them  pay  more  attention  to  the 
earliest  call  to  make  water.  However,  it  has  always 
been  my  own  belief  that  this  doctrine  is  carried  to  an 
unjustifiable  extent,  particularly  in  schools,  and  been 
a pretext  for  the  most  absurd  kind  of  severity.  Nor  is 
it  doubted  by  any  man  who  understands  the  subject, 
that  in  almost  all  cases  the  disorder  is  a true  infirmity 
arising  from  the  causes  already  indicated,  and  not 
from  indolence;  the  supposed  crime  taking  place,  in 
fact,  when  the  child  is  asleep  and  unconscious  of  what 
is  happening. 

If  excessive  irritability  and  constitutional  weakness 
be  the  cause  of  incontinence  of  urine,  and  a very 
small  quantity  of  urine  forces  the  bladder  to  contract, 
the  resistance  of  the  urethra  being  involuntarily  over- 
come, an  endeavour  should  be  made  to  lessen  such  irri- 
tability by  the  use  of  the  warm  or  cold  bath,  sea-bathing, 
tonics,  chalybeates,  good  air,  &c.  And  in  order  to  pre- 
vent the  accident  from  taking  place  in  the  night-time, 
the  child  should  not  take  any  drink  for  some  time 
before  being  put  to  bed,  the  bladder  should  be  always 
emptied  before  sleep,  and,  if  necessary,  the  child  ought 
to  be  taken  up  in  the  night  for  the  same  purpose. 

If  the  infirmity  arises  from  a want  of  action  in  the 
parts,  causing  the  resistance  in  the  urethra,  tonics  may 
be  externally  and  internally  employed.  However, 
when  the  disorder  has  been  of  long  standing,  Desault 
found  that  they  rarely  succeeded. 

Palliative  means  are  then  the  only  resource ; viz. 
instruments  calculated  either  to  compress  the  urethra 
and  Intercept  the  passage  of  the  urine,  or  to  receive 
the  fluid  immediately  it  is  voided.  The  first  of  these 
plans  is  more  difficult  to  accomplish  in  women  than 
men;  but  it  may  be  executed  by  means  of  an  elastic 
hoop  which  goes  round  the  pelvis,  and  from  the  middle 
of  wlxich,  in  front,  a curved  elastic  piece  of  steel 
descends,  and  terminates  in  a small  compress,  which  is 


419 


URINE,  RETENTION  OF. 


contrived  to  cover  accurately  the  meatus  urinarius.—  ; 
(See  (Euv.  Chir.  de  Desault, par  Bichat,  t.3,p.  95,  iS'c.) 

Large  blisters  applied  over  tli0  os  sacrum  have  often 
cured  an  incontinence  of  urine,  both  when  the  com- 
plaint seemingly  arose  from  the  excessive  irritability  of 
the  bladder,  and  from  paralysis  and  loss  of  tone  in  this 
organ  and  the  parts,  which  naturally  resist  the  expul- 
sion of  the  urine  from  it ; the  case  being,  in  fact,  a 
retention  “ par  regorgement,”  or,  as  one  might  call  it 
in  plain  English,  a retention  combined  with  inconti- 
nence of  urine. — {See  J\Ied.  Obs.andinq.)  As  in  some 
of  these  cases  the  blisters  removed  also  a paralysis  of 
the  lower  extremities,  they  might  have  furnished  a hint 
to  the  j)ractice  of  making  issues  for  the  relief  of  the 
palsy  of  the  legs,  connected  with  diseased  vertebrte. 
Cantharides  have  also  been  given  inwardly  with  suc- 
cess.— (See  Juurn.  de  Med.  t.  55,  p.  72 ; and  Howship 
on  Diseases  of  the  Urinary  Organs,  p.  205.) 

URINE,  RETENTION  OF.  It  is  observed  by  the 
experienced  Mr.  Hey,  that  a retention  of  urine  in  the 
bladder,  when  the  natural  efforts  are  incapable  of 
affording  relief,  is  in  male  subjects  a disease  of  great 
urgency  and  danger.  Persons  advanced  in  years  are 
moresubjeci  to  this  com  plaint  than  the  young  or  middle 
aged.  It  is  often  brougiit  on  by  an  incautious  resist- 
ance to  the  calls  of  nature,  and,  if  not  speedily  relieved, 
generally  excites  some  degree  of  fever. 

The  distinction,  says  Mr.  Hey,  which  has  sometimes 
been  made  between  a suppression  and  retention  of 
urine,  is  practical  and  judicious.  The  former  most 
properly  points  out  a defect  in  the  secretion  of  the 
kidneys ; the  latter,  an  inability  of  expelling  the  urine 
when  secreted. 

The  retention  of  urine  is  an  inability,  whether  total 
or  partial,  of  expelling  by  the  natural  efforts  the  urine 
contained  in  the  bladder.  The  characteristic  symptom 
of  this  disease,  previous  to  the  introduction  of  the 
catheter,  is  a distention  of  the  bladder  (to  be  perceived 
by  an  examination  of  the  hypogastrium),  after  the 
patient  has  discharged  all  the  urine  which  he  is  capable 
of  expelling. 

As  this  complaint  may  subsist  when  the  flow  of  urine 
from  the  bladder  is  by  no  means  totally  suppressed, 
great  caution  is  required  to  avoid  mistakes. 

Violent  efforts  to  make  water  are  often  excited  at 
intervals,  and  during  these  strainings  small  quantities 
of  urine  are  expelled.  Such  a case  may  be  mistaken 
for  strangury. 

At  other  times  a morbid  retention  of  urine  subsists, 
when  the  patient  can  make  water  in  a stream,  and 
discharge  a quantity  equal  to  that  which  is  commonly 
discharged  by  a person  in  health.  Under  this  circum- 
stance, Mr.  Hey  has  known  the  pain  in  the  hypogas- 
trium and  distention  of  the  bladder  continue  till  the 
patient  was  relieved  by  the  catheter. 

And,  lastly,  it  sometimes  happens  that  when  the 
bladder  has  suffered  its  utmost  distention,  the  urine 
runs  off  by  the  urethra  as  fast  as  it  is  brought  into  the 
bladder  by  the  ureters.  Mr.  Hey  has  repeatedly  known 
this  circumstance  cause  a serious  misapprehension  of 
the  true  nature  of  the  disease. 

In  formitjg  a correct  judgment  of  all  these  cases,  it 
is  very  necessary  to  recollect  the  important  division  of 
retentions  of  urine  into  the  complete  and  incomplete 
forms;  a distinction  which  will  at  once-put  the  sur- 
geon on  his  guard  against  a variety  of  errors. 

In  every  case  of  retention  of  urine  which  the  late 
Mr.  Hey  had  attended,  the  disease  could  be  ascertained 
by  an  examination  of  the  hypogastrium  taken  in  con- 
nexion with  the  other  symptoms.  The  distended 
bladder  forms  there  a hard  and  circumscribed  tumour, 
giving  pain  to  the  patient  when  pres.=ed  with  the  hand. 
Some  obscurity  may  arise  upon  the  examination  of  a 
very  corpulent  person ; but,  in  all  doubtful  cases,  the 
catheter  should  be  introduced. 

Mr.  Hey  has  not  adverted  to  the  swelling  in  the 
rectum  or  vagina,  nor  to  cases  of  contracted  bladder, 
where,  of  cour.se,  the  information  derived  in  ordinary 
instances  from  the  tumour  above  the  pubes  cannot  be 
had ; but,  in  other  respects,  his  observations  on  the 
diagnosis  are  practical  and  correct.  He  had  seen  only 
a few  cases  of  ischuria  renalis,  or  complete  suppres- 
sion of  the  secretion  of  urine.  The  disease  proved 
fatal  in  all  his  patients  except  one,  in  whom  it  was 
brought  on  by  tlie  effect  of  lead  taken  into  the  body  by 
working  in  a pottery.  It  subsisted  three  days  during  a 
violent  attack  of  the  colica  pictonuin,  and  was  then 

Dd2 


removed,  together  with  the  original  disease.  Mr.  Hey 
found  no  difficulty  in  distinguishing  this  disorder  in  any 
of  the  cases  from  the  ischuria  vesicalis ; though,  for 
the  satisfaction  of  some  of  his  patients,  he  introduced 
the  catheter. — {Pract,  Obs.  in  Hur.  p.  374,  (S-c.) 

Retention  of  urine  may  be  the  effect  of  a great  many 
different  causes ; as  paralysis  of  the  bladder ; inflani- 
niation  of  its  neck  ; the  presence  of  foreign  bodies  in 
it ; pressure  made  on  its  cervix  by  the  gravid  uterus ; 
enlargement  of  the  prostate  gland ; strictures  in  the 
urethra,  &c. 

Every  case  of  retention  of  urine  demands  prompt 
assistance;  but  when  the  disorder  presents  itself  in  its 
complete  form,  the  mischief  of  delay  is  of  the  most 
serious  nature  ; for  if  the  bladder  remain  preternatu- 
rally  distended,  it  not  only  loses  its  contractile  power, 
but  is  quickly  attacked  w'iih  inflammation  and  slough- 
ing. At  length  some  proint  of  it  bursts,  and  the  urine  is 
extravasated  in  the  cellular  membrane  of  the  pelvis ; 
spreading  behind  the  peritoneum  as  far  up  as  the  loins, 
and,  in  other  directions,  into  the  perinaeum,  scrotum, 
and  the  integuments  of  the  penis,  and  upper  part  of  the 
thighs.  The  common  result  then  of  the  rupture  of 
the  bladder  and  the  efl'usion  of  its  contents,  is  the 
speedy  death  of  the  patient,  from  the  effects  of  this 
irritating  fluid  upon  all  the  parts  with  which  it  comes 
in  contact,  among  which  effects  is  inflammation  of  the 
peritoneum  and  bowels.  It  appears  also  from  the  ob- 
servations both  of  Desault  and  Sir  Everard  Home,  that 
a complete  retention  of  urine,  after  a time,  has  the  ef- 
fect of  putting  a mechanical  stoppage  to  the  farther 
secretion  of  this  fluid  in  the  kidneys  ; a circumstance 
which  sometimes  has  a principal  share  in  producing 
death,  particularly  when  this  event  happens  before  the 
urine  becomes  extravasated. 

In  all  cases  of  retention  of  urine,  the  indications  are 
sufficiently  manifest,  viz.  1st.  To  adopt  such  treatment 
as  seems  best  calculated  to  procure  a discharge  of  the 
urine  through  the  natural  passage,  which  object  is  per- 
formed sometimes  by  means  of  fomentations,  the 
warm  bath,  bleeding,  opium,  and  other  medicines  ; 
sometin)es  by  the  removal  of  mechanical  obstacles  to 
the  flow  of  the  urine ; but  more  frequently  by  the  use 
of  the  catheter  than  any  other  means.  When  all  these 
plans  fail,  it  then  becomes  necessary  to  puncture  the 
bladder.  2dly.  The  second  indication,  or  that  which 
presents  itself  after  the  immediate  dangers  of  the  dis- 
tention of  the  bladder,  are  thus  guarded  against,  is,  to 
remove  whatever  disease,  or  other  circumstance,  con- 
stitutes the  still  existing  impediment  to  the  natural  ex- 
pulsion of  the  urine. 

With  respect  to  the  fit  manner  and  time  of  employ 
ing  the  several  means  for  fulfilling  the  above  indica- 
tions, and  the  selection  which  should  be  made  of  them, 
these  are  important  considerations,  which  vary  in  dif- 
ferent cases,  and  actually  cannot  be  understood  with- 
out due  reference  to  the  causes  and  circumstances  of 
each  individual  case.  Some  of  this  subject  belongs 
also  to  other  parts  of  this  work,  to  which,  in  order 
to  avoid  the  necessity  of  repetition  I here  refer. — (See 
Catheter;  Bladder,  Puncture  of;  Prostate  Oland, 
Diseases  of ; Urethra,  Strictures  of,  Src.) 

With  respect  to  catheters,  we  shall  find  that  some 
cases  require  the  urine  to  be  drawn  off  two  or  three 
times  a day,  and  the  instrument  to  be  taken  out  after 
each  evacuation  ; while  in  other  instances  it  is  prudent 
to  keep  the  tube  continually  introduced.  Here  one 
general  caution  may  be  conveniently  offered,  which  is, 
never  to  let  a silver  catheter  remain  in  the  passage 
more  than  a week  or  ten  days  without  taking  it  out 
and  cleaning  it;  for  if  this  be  not  done,  the  instrument 
becomes  coated  with  deposites  from  the  urine,  so  as  af- 
terward not  to  adnjit  of  being  withdrawn  through  the 
urethra  without  great  suffering  and  irritation.  The 
eye  in  the  beak  is  also  apt  to  become  completely 
blocked  up;  and  sometimes  the  pressure  which  the  ca- 
theter makes  on  the  part  of  the  urethra,  corresponding 
to  the  root  of  the  penis,  in  ffont  of  the  scrotum,  causes 
in  this  situation  Inflammation,  followed  by  a slough  as 
large  as  a crown  piece,  and  an  opening  formed  by  the 
loss  of  substance  is  left,  which  may  even  continue  fis- 
tulous during  the  patient’s  life.  These  remarks  par- 
ticularly apply  to  metallic  catheters ; but  such  as  are 
supposed  to  be  made  of  elastic  gum,  especially  those 
ordinarily  met  with  in  the  shops,  are  apt  to  spoil  and 
become  blocked  up  with  mucus,  if  not  taken  out  and 
cleaned  or  changed  every  five  or  six  days.  However, 


420 


URINE,  RETENTION  OF. 


as  I have  mentioned  in  the  article  Prostate  Oland, 
Diseases  of,  Mr.  Weiss  has  succeeded  in  constructing 
elastic  catheters  which  may  be  retained  more  than  a 
fortnight  in  the  urethra  without  becoming  obstructed, 
besides  having  the  advantage  of  always  retaining  a 
due  curve. 

1.  Of  the  Retention  of  Urine,  to  which  persons  of  ad- 
vanced age  are  liable. — This  disorder  is  so  common 
in  elderly  persons,  that  it  is  generally  allowed  to  be  one 
of  the  grievances  to  which  their  period  of  life  is  par- 
ticularly exposed.  In  them  the  bladder  is  less  irritable 
than  in  younger  subjects,  and  hence  it  is  not  so  soon 
stimulated  by  the  presence  of  the  urine.  In  fact,  it  is 
not  until  a painful  sensation  arises  from  the  distention 
of  the  coats  of  the  bladder,  that  |he  patient  is  aware 
of  the  occasion  to  discharge  the  urine.  The  bladder 
then  contracts ; but  still  would  not  be  able  to  expel  its 
contents  were  it  not  for  the  powerful  action  of  the  ab- 
dominal muscles.  Nor  is  the  expulsion  of  the  urine 
even  now  complete ; since  the  bladder  no  longer  re- 
tains the  power  of  etfacing  the  whole  of  its  cavity. 
On  the  contrary,  after  each  evacuation,  some  urine  is 
still  left  undischarged,  and  already  constitutes  an  in- 
cipient retention.  The  quantity  daily  augments,  and 
at  length  not  more  than  half  the  fluid  contained  in  the 
bladder  is  voided  at  each  evacuation. 

The  complaint  particularly  attacks  old  subjects  of  a 
plethoric  state  of  body,  and  of  sedentary  and  studious 
habits.  It  also  especially  afflicts  those  who,  from  care- 
lessness or  indolence,  do  not  take  time  enough  to  expel 
the  last  drops  of  urine ; and  others,  who  are  accus- 
tomed to  discharge  their  urine  into  a pot,  as  they  lie  in 
bed,  instead  of  rising  for  the  purpose. 

In  these  cases,  the  urethra  and  neighbouring  parts 
seem  to  be  free  from  every  disease  capable  of  prevent- 
ing the  issue  of  the  urine;  which  has  always  come 
away  freely  and  in  a full  stream,  although  it  could  not 
be  discharged  with  the  same  force  nor  to  the  same  dis- 
tance as  formerly.  At  length,  instead  of  describing 
an  arch  as  it  flows  out,  it  falls  down  perpendicularly 
between  the  legs.  Towards  the  close  of  the  evacua- 
tion, the  patient  is  also  not  sensible  of  the  final  con- 
tractile effort  of  the  bladder,  of  which  he  used  to  be 
conscious  in  his  younger  days.  When  he  is  about  to 
make  water,  he  is  obliged  to  wait  some  time  before  the 
evacuation  commences;  and  as  the  disorder  increases, 
he  cannot  make  water  without  considerable  efforts ; the 
quantity  of  urine  voided  each  time  manifestly  de- 
creases ; the  desire  to  empty  the  bladder  becomes  more 
and  more  frequent;  and  lastly,  the  urine  only  comes 
away  by  drops  and  an  incontinence  succeeds  a retention. 

In  this  state,  the  patient’s  sufferings  are  not  very 
great.  The  tumour  formed  by  the  bladder  above  the 
pubes  is  indolent,  and  if  it  be  pressed  upon  with  some 
force,  a certain  quantity  of  urine  is  discharged  from 
the  urethra. 

The  retention  of  urine  arising  from  old  age  is  seldom 
complete : the  urine,  after  having  filled  and  distended 
the  bladder,  dribbles  oqt  of  the  urethra,  so  that  the 
patient  voids  as  much  of  this  fluid  in  a given  time  as 
he  does  in  a state  of  health.  Nor  is  this  species  of  re- 
tention of  urine  commonly  attended  with  very  urgent 
symptoms.  It  does  not  occasion,  like  complete  reten- 
tion, a suppression  of  the  urinary  secretion  in  the  kid- 
neys ; and  as  the  urine  escapes  through  the  urethra 
after  the  bladder  is  distended  to  a certain  degree,  the 
disorder  is  less  apt  to  produce  a rupture  of  this  organ, 
and  dangerous  extravasations  of  the  urine.  The  swell- 
ing of  the  bladder  then  continues,  without  any  particu- 
lar suffering,  except  a sense  of  weight  about  the  pubes 
and  perinaeum.  These  circumstances  have  often  led 
to  serious  mistakes,  and  the  disease  has  been  set  down 
as  an  abscess  or  dropsy. 

The  indications  are,  to  evacuate  the  urine  and  re- 
store the  tone  of  the  bladder.  When  the  retention  is 
incipient,  the  proper  action  of  the  bladder  will  some- 
times return  after  cold  applications  are  made  to  the 
hypogastric  region  or  thighs,  and  the  patient  goes  from 
a warm  into  a cool  place  in  order  to  make  water. 

The  patient  must  also  be  strictly  careful  to  make  water 
immediately  the  least  inclination  to  do  so  is  felt ; for  if 
this  precaution  be  neglected,  the  bladdergrows  more  and 
more  inert ; the  desire  to  make  water  subsides ; and  the 
retention,  which  at  first  consisted  of  only  a few  drops, 
very  soon  becomes  complete.  It  would  then  be  in 
vain,  as  Desault  observes,  to  try  the  expedients  above 
recommended  No  stimulus  will  now  make  the  blad- 


der contract  sufficiently  to  expel  the  whole  of  the  urine, 
and  the  catheter  is  the  only  thing  by  which  this  fluid  can 
be  discharged.  This  artificial  mode  of  evacuation,  how- 
ever, only  affords  temporary  relief;  for,  as  the  bladder  is 
slow  in  recovering  its  tone,  a relapse  would  be  inevitable 
if  the  employment  of  the  catheter  were  not  conlinned. 
Hence  this  instrument  must  either  be  left  in  the  blad- 
der or  introduced  as  often  as  the  patient  has  occasion 
to  make  water.  When  a skilful  surgeon  is  constantly 
at  hand,  or  when  the  patient  knows  how  to  pass  the 
catheter  himself,  Desault  thinks  it  better  to  introduce 
the  instrument  only  when  the  bladder  is  to  be  emptied, 
by  which  means  the  inconvenience  arising  from  the 
continual  presence  of  a foreign  body  will  be  avoided. 

In  this  case,  either  a silver  catheter  or  an  elastic  gum 
one  may  be  used  with  equal  advantage  ; but  if  the  in- 
strument is  to  be  kept  in  the  bladder,  one  made  of  elas- 
tic gum  and  provided  with  a curved  stilet  is  to  be  pre- 
ferred. As  in  old  subjects  the  urethra  is  flaccid,  a 
large  catheter  is  generally  found  to  enter  more  easily 
than  one  of  smaller  diameter. 

As  the  treatment  must  be  continued  for  a long  while, 
and  the  bladder  seldom  perfectly  regains  its  tone  in  old 
age,  the  patient  should  be  instructed  how  to  introduce 
the  catheter  himself,  and  he  is  to  pass  it  whenever  he 
wants  to  make  water.  After  a certain  time,  however, 
he  may  try  if  he  can  empty  the  bladder  without  tl\i3 
instrument.  When  he  'finds  that  he  can  expel  the 
urine,  he  should  assure  himself,  by  means  of  the  cathe- 
ter, that  the  last  drops  of  this  fluid  are  duly  voided. 
Should  they  not  be  so,  he  must  persevere  in  the  use  of 
the  instrument. 

In  this  sort  of  retention  of  urine,  it  has  been  pro- 
posed to  throw  into  the  bladder  astringent  injections; 
Desault  tried  them  ; but  he  does  not  give  a favourable 
report  of  the  practice. 

Warm  balsamic  diuretic  medicines,  cold  bathing, 
and  liniments  containing  the  tincture  cantharidurn, 
have  likewise  been  praised ; but,  according  to  Desault, 
these  means  frequently  prove  hurtful  to  persons  of  ad- 
vanced years,  and  are  seldom  useful.  He  restricted 
his  own  practice  to  the  use  of  the  catheter,  which, 
when  skilfully  employed,  often  restored  the  tone  of  the 
bladder,  and,  when  it  failed,  other  means  also  were  in- 
effectual. A blister  over  the  sacrum  may  deserve  a trial. 

Passing  over  the  cases  of  retention  of  urine,  referred 
by  Desault  to  the  effects  of  intemperance  with  women, 
and  the  immoderate  use  of  diuretic  drinks ; cases 
which  considerably  resemble,  in  their  nature  and  treat- 
ment, the  retention  from  the  weakened  state  of  the 
bladder  in  elderly  persons ; I proceed  to  another  ex- 
ample of  the  disorder,  still  more  interesting  to  the 
practical  surgeon. 

2.  Retention  of  Urine  from  an  Jiffection  of  the 
JVemes  of  the  Bladder. — These  nerves  may  be  affected 
either  at  their  origin,  or  in  the  course  of  their  distribu- 
tion. Injuries  of  the  brain  are  seldom  followed  by  a 
retention  of  urine;  but  the  complaint  often  accompa- 
nies those  of  the  spinal  marrow.  A concussion  of 
this  medullary  substance  from  blows  or  falls  upon  the 
vertebral  column  ; the  injury  which  it  suffers  in  frac- 
tures and  dislocations  of  the  vertebrae,  or  from  a vio- 
lent strain  of  the  back ; its  compression  by  blood,  pu- 
rulent matter,  or  other  fluid  effused  in  the  vertebral 
canal,  and  the  effects  which  a caries  of  the  spine  has 
upon  it ; may  all  operate  as  so  many  causes  of  a reten- 
tion of  urine.  This  form  of  the  complaint  may  also 
be  the  consequence  of  tumours  situated  in  the  track 
of  the  nerves,  which  are  distributed  to  the  bladder. 
Whether  the  retention  of  urine,  common  in  typhus 
fever,  arises  from  an  affection  of  the  nerves  of  the  blad- 
der, or  from  the  general  debility  extending  itself  to  the 
expelling  powers,  may  be  a question;  but  the  liability 
of  patients  in  fevers  to  this  disorder  should  never  be 
out  of  the  practitioner’s  recollection. 

When  a retention  of  urine  arises  from  injury  or  dis- 
ease of  the  spinal  marrow,  an  insensibility  and  weak- 
ness of  the  lower  extremities  are  almost  always  con- 
comitant symptoms.  The  patients  suffer  very  little; 
most  of  them  are  ignorant  of  their  condition  ; and  do 
not  complain  of  any  thing  being  wrong  in  the  functions 
of  the  urinary  organs.  The  surgeon,  aware  that  a re- 
tention of  urine  is  common  in  these  cases,  should  exa-  * 
mine  whether  there  is  any  interruption  of  the  evacua- 
tion, either  by  feeling  the  state  of  the  abdomen  just 
above  the  pubes,  or  by  introducing  a et  theter. 

As'this  species  of  retention  o£  urine  is  only  symptom- 


URINE,  RETENTION  OF.  421 


atic,  and  not  dependent  upon  any  previous  defect  in 
the  bladder,  it  is  not  in  itself  alarming ; but,  with  re- 
ference to  its  cause,,  it  is  exceedingly  dangerous.  Af- 
fections of  the  spine  complicated  with  injury  of  the  spi- 
nal marrow,  are  often  fatal.  By  means  of  a catheter, 
it  is  always  easy  to  relieve  the  inconveniences  arising 
from  the  bladder  not  contracting,  and  thus  fulfil  the 
only  indication  which  this  sort  of  retention  of  urine 
presents ; viz.  the  evacuation  of  the  urine.  But  this 
proceeding  is  merely  palliative;  and  the  bladder  will 
not  recover  its  contractile  power  until  the  causes  of  its 
weakness  are  remcv>.'ed.  The  last  then  is  the  main  ob- 
ject in  the  treatment,  which  must  vary  according  to  the 
nature  and  extent  of  the  disorder. 

The  consideration  in  detail  of  all  the  means  which 
may  be  requisite  for  the  relief  of  the  different  accidents 
and  diseases  of  the  spine,  belongs  toother  parts  of  this 
work. — (See  Dislocations  and  Fractures  of  the  Verte- 
bra; Vertebra,  Diseases  of.)  In  shocks  and  concus- 
sions of  the  spinal  marrow,  Desault  had  a high  opinion 
of  the  benefit  resulting  from  cupping.  This  was  done 
on,  or  near  the  part  of  the  back,  which  had  been  struck, 
and  the  number  of  scarifications  was  proportioned  to 
the  strength  of  the  patient.  The  plan  was  sometimes 
repeated  the  same  day,  and  for  several  days  in  succes- 
sion; and  when  the  patient  could  not  bear  the  loss  of 
more  blood,  dry  cupping  was  employed,  which,  in  this 
country  would  be  deemed  less  efficacious  than  stimulat- 
ing liniments  or  blisters.  In  diseases  of  the  spine,  De- 
sault also  preferred  the  moxa  to  caustic  issues. 

3.  Retention  of  Urine  from  Distention  of  the  Blad- 
der.— Desault  thought  that  this  form  of  the  disorder 
might  very  properly  be  called  secondary,  because  it  is 
invariably  preceded  by  a primary  retention.  Of  course 
its  remote  causes  are  all  those  circumstances  which 
may  bring  on  the  other  forms  of  the  complaint;  but  its 
immediate  cause  depends  altogether  upon  the  weakness 
and  loss  of  irritability  in  the  bladder,  occasioned  by  the 
immoderate  distention  of  its  coats.  The  disorder  fre- 
quently occurs  in  persons,  who  from  bashfulness,  indo- 
lence, or  intense  occupation,  neglect  to  make  water 
when  they  first  have  a desire ; or  who  cannot  for  a time 
empty  the  bladder  in  consequence  of  some  temporary 
obstruction  in  the  urethra.  Although  the  impediment 
to  the  escape  of  the  urine  no  longer  exists,  and  the  blad- 
der is  in  other  respects  sound,  yet  as  this  organ  has  been 
weakened  by  the  excessive  distention  of  its  coats,  it 
cannot  now  contract  sufficiently  to  obliterate  the  whole 
of  its  cavity,  and  expel  the  last  portion  of  urine. 

The  indication  is  simple;  for  there  is  not  here,  as  in 
other  retentions  of  urine,  another  disease  to  be  reme- 
died. The  catheter,  when  left  in  the  bladder,  generally 
proves  adequate  to  the  restoration  of  the  tone  of  this 
viscus.  I do  not  conceive,  however,  that  English  sur- 
geons will  place  any  confidence  in  warm  diuretics, 
which  were  commended  by  Desault,  though  they  may 
join  him  in  the  approval  of  a tonic  plan  of  treatment 
in  general.  When  the  urine  flows  from  the  catheter  in 
a rapid  stream,  and  is  projected  to  sotne  distance,  and 
when  it  also  passes  out,  between  the  catheter  and  the 
urethra,  it  is  a sign  that  the  bladder  has  regained  its 
power  of  contraction,  and  that  it  can  empty  itself  with- 
out the  aid  of  the  instrument.  In  this  circumstance, 
the  catheter  is  to  be  discontinued,  and  the  patient  may 
gradually  resume  his  usual  mode  of  life.  But  when 
the  urine  is  discharged  only  in  a slow  stream,  the  cathe- 
ter cannot  be  laid  aside,  without  the  bladder  becoming 
distended  again,  and  losing  whatever  degree  of  tone  it 
may  have  recovered. 

The  time  which  the  bladder  takes  to  regain  its  power 
of  contracting,  varies  considerable  in  different  cases. 
When  the  disease  is  accidental  and  sudden,  it  frequently 
goes  off  in  a few  days.  When  it  has  come  on  in  a slow 
manner,  it  usually  lasts  about  six  weeks.  However, 
the  cure  is  not  to  be  despaired  of,  if  the  paralytic  af- 
fection of  the  bladder  should  continue  much  longer. 
Sabatier  says,  that  he  has  seen  patients  wear  a catheter 
upwaids  of  ninety  days,  and  yet  ultimately  get  complete- 
ly well.  When  there  is  reason  for  believing  that  the 
urine  will  come  away  of  iiself,  the  use  of  the  cfitheter 
may  be  discontinued.  When  the  patient  makes  water 
very  slowly;  when  he  is  obliged  to  make  frequent  at- 
•teinpts  ; and  when  he  feels  a sense  of  weight  about  the 
neck  of  the  bladder ; this  organ  has  not  completely  re- 
covered its  tone,  and  the  employment  of  the  catheter  is 
still  necessary.  When  the  patient  could  make  water 
tolerably  well  in  the  day,  but  not  during  the  rest  of  the 


twenty-four  hours,  Sabatier  often  saw  benefit  arise  from 
the  catheter  being  worn  only  in  the  night-time. 

When  three  or  four  months  elapse,  without  amend- 
ment, Sabatier  states  his  conviction,  that  the  tone  of 
the  bladder  is  lost  for  ever.  In  this  unfortunate  case, 
the  patient  may  continue  the  flexible  catheter,  which 
he  should  be  taught  to  introduce  himself,  as  often  as 
necessary. — (See  De  la  Midecine  Operatoire,  t.  2.) 

Among  the  means  deserving  of  trial,  when  the  con- 
tractile power  of  the  bladder  does  not  return  with  the 
use  of  the  catheter,  I have  to  mention  the  tincture  of 
cantharides  ; bark ; the  sulphate  of  quinine ; steel  me- 
dicines ; blisters  applied  to  the  sacrum,  and  kept  open 
with  thesavine  ointment ; and  cold  washes  to  the  hypo- 
gastric region. 

In  all  cases  where  the  incapacity  of  the  bladder  to 
contract,  whether  from  weakness  or  paralysis,  is  the 
cause  of  retention,  and  where,  though  the  bladder  con- 
tinues distended,  a certain  quantity  of  urine  is  voided 
daily,  niistakes  are  particularly  liable  to  be  made.  Thus, 
besides  the  chance  of  the  disease  being  mistaken  for  an 
abscess,  which,  as  Colot  slates,  was  not  uncommon  in 
his  time,  other  errors  may  take  place.  Sabatier  was 
consulted  about  a lady  who  had  been  advised  to  repair 
to  some  distant  mineral  waters,  with  the  view  of  dis- 
persing a tumour,  which  remained  after  a difficult  la- 
bour, and  was  supposed  to  be  in  the  uterus  itself. 
However,  the  swelling  turned  out  to  be  only  a retention 
of  urine,  as  it  disappeared  as  soon  as  the  catheter  was 
introduced.  Here  no  suspicion  had  been  entertained 
of  the  real  nature  of  the  case,  because  the  patient  had 
voided  her  urine  without  any  apparent  difficulty,  and 
in  reasonable  quantity,  for  the  five  or  six  weeks  dur- 
ing which  the  swelling  existed. 

In  a thesis  by  Murray,  a case  is  recorded  in  which 
the  swelling  of  the  bladder  was  so  considerable,  that  it 
was  mistaken  for  dropsy.  The  abdomen  of  a delicate 
woman  began  to  enlarge  without  any  particular  pain, 
and  the  cause  was  at  first  supposed  to  be  pregnancy. 
Thi.'  idea, however,  was  removed  by  theenlargementin- 
creasing  too  rapidly,  attended  with  a great  deal  of  ana- 
sarca of  the  lower  extremities,  arms,  and  face.  The 
patient  was  now  considered  to  be  dropsical ; and  a sur- 
geon was  sent  for  to  tap  the  abdomen.  The  fluctuatioti 
in  the  belly  was  quite  evident.  Fortunately,  before 
the  operation  was  done,  a trial  of  diuretic  medicines 
was  determined  upon ; and  while  this  plan  was  going 
on,  the  patient  was  attacked  with  a total  retention  of 
urine  for  three  days ; a symptom  which  she  had  not 
previously  suffered.  It  was  now  judged  prudent  to 
pass  a catheter  before  the  trocar  was  employed.  Eigh- 
teen pints  of  urine  were  drawn  off,  and  the  swelling  of 
the  abdomen  subsided.  The  next  day  twelve  more 
pints  of  urine  were  drawn  off.  The  anasarca,  which 
was  entirely  Symptomatic,  disappeared.  The  appli- 
cation of  cold  water  re-established  the  tone  of  the 
bladder,  so  that  when  three  pints  of  urine  had  been 
drawn  off  by  means  of  the  catheter,  the  patient  herself 
could  spontaneously  expel  three  or  four  others,  with  the 
aid  of  pressure  on  the  hypogastric  region. 

The  retention  of  urine  caused  by  weakness  or  pa- 
ralysis of  the  bladder,  and  the  swelling  above  the  pubes, 
may  continue  a long  while  without  any  inconvenience 
excepting  a sense  of  weight  about  the  hypogastric  re- 
gion, and  frequent  inclination  to  make  water.  Saba- 
tier has  known  patients  labour  under  the  complaint 
more  than  six  months. 

4.  Retention  of  Urine  from  Inflammation  of  the 
Bladder. — According  to  Desault,  writers  have  ascribed 
different  effects  to  an  inflammation  of  the  neck  of  the 
bladder,  and  to  the  same  affection  of  the  body  of  this 
viscus.  They  have  in  fact  regarded  the  first  case  as  a 
cause  of  retention ; and  the  last  as  a cause  of  inconti- 
nence of  urine.  An  inflamed,  highly  sensible  bladder, 
instead  of  being  weakened,  has  been  supposed  to  ac- 
quire an  increase  of  energy,  and  to  contract  with 
greater  vigour.  But  if  there  had  not  been  retentions  of 
urine,  which  could  be  referred  to  nothing  but  inflam- 
mation of  the  bladder,  still  analogy  might  have  unde- 
ceived us;  for  an  inflamed  muscle  is  never  found  dis- 
posed to  contract,  and  if  it  be  compelled  to  act,  its  ac- 
tion is  always  feeble. 

Plethoric,  bilious  subjects  are  said  to  be  particularly 
liable  to  this  species  of  retention.  It  is  also  frequently 
occasioned  by  the  abuse  of  wine,  or  other  spirituous 
liquors,  heating  diuretic  drinks,  or  the  external  or  in- 
ternal employment  of  cantharides.  This  form  of  tho 


422 


URINE,  RETENTION  OF 


complaint  makes  its  attack  suddenly,  and  may  be  known 
by  the  frequent  desire  to  make  water  ; the  acute  pain 
in  the  region  of  the  bladder;  pain,  which  is  increased 
by  the  etforts  to  make  water,  and  which  shoots  up  to 
the  loins  and  along  the  urethra  to  the  end  of  the  glans 
by  the  frequency  and  hardness  of  the  pulse,  and  other 
symptoms  of  fever;  by  the  aggravation  of  the  pain 
when  the  hypogastric  region  is  pressed ; by  the  easy 
passage  of  a catheter  into  the  bladder;  by  the  acute 
pain  w’hich  is  excited  by  the  instrument  touching  the 
inside  of  this  organ ; and  by  the  red,  inflammatory  co- 
lour of  the  urine. 

In  this  case  the  most  prompt  assistance  is  necessary. 
The  urine,  which  is  a source  of  additional  irritation, 
should  be  drawn  off.  The  catheter  should  be  introduced 
with  great  gentleness,  and  merely  far  enough  to  let  its 
eye  pass  beyond  the  neck  of  the  bladder. 

The  inflammation  itself  is  to  be  counteracted  by  the 
most  powerful  antiphlogistic  remedies,  large  and  re- 
peated venesections;  the  application  of, leeches  to  the 
perinceum  and  hypogastric  regions  ; the  warm  batb , 
clysters;  fomentations  on  the  abdomen  ; and  cold  mu- 
cilaginous beverages.  When  the  inflammation  ex- 
tends to  the  other  abdominal  viscera,  attended  with  hic- 
cough and  vomiting,  and  continues  beyond  the  sixth 
day,  the  patient’s  life  is  in  extreme  danger. 

5.  Retention  of  Urine  from  Hernia  of  the  Bladder. — 
An  inability  to  discharge  the  urine  is  a symptom  gene- 
rally attending  hernia  of  the  bladder.  But  the  weak- 
ness of  this  organ  is  not  always  the  sole  cause  of  the 
infirmity ; for  the  urethra  itself  makes  greater  resist- 
ance than  natural  to  the  issue  of  the  urine.  As  the 
neck  of  the  bladder  is  drawn  out  of  its  right  position 
by  the  portion  of  this  organ  which  actually  piotrudes, 
the  beginning  of  the  urethra  also  undergoes  an  elon- 
gation, and  a change  of  its  curvature,  by  being  pressed 
towards  the  symphysis  of  the  pubes,  and  its  diameter 
is  likewise  diminished.  The  urine  may  also  be  de- 
tained in  the  pouch  composing  the  hernia,  in  conse- 
quence of  the  communication  between  this  and  the 
rest  of  the  bladder  being  too  small,  or  indirect,  or  per- 
haps from  the  hernial  portion  not  being  compressed  by 
the  action  of  the  abdominal  muscles,  or  capable  of  any 
contraction  itself.  However,  the  rest  of  this  organ, 
within  the  pelvis,  can  itself  rarely  expel  the  last  drops 
of  the  urine.  Its  complete  contraction  cannot  be  ac- 
complished without  great  difficulty;  and,  in  the  end,  it 
almost  invariably  follows,  that  the  urine  is  retained 
both  in  the  protruded  and  unprotruded  portions. 

When  a retention,  arising  from  a hernia  of  the  blad- 
der, is  complete,  and  occurs  in  both  parts  of  this  organ, 
there  is  in  addition  to  the  symptoms  common  to  other 
retentions  produced  by  w-eaknessof  the  bladder,  a more 
or  less  considerable  swelling  in  the  situation  of  the  her- 
nia. Tire  tumour  is  unattended  with  any  change  of 
the  colour  of  the  skin ; is  not  very  tender ; and  it  pre- 
sents a feeling  of  fluctuation  sometimes  obscure,  some- 
times very  distinct..  When  the  swelling  is  pressed 
upon,  the  desire  to  make  water  is  excited  or  increased, 
and  occasionally  a few  drops  escape  from  the  urethra. 
As  soon  as  the  urine  has  been  drawn  off  with  a cathe- 
ter, and  the  patient  is  put  in  a posture  in  which  the  pro- 
truded portion  of  the  bladder  is  higher  than  the  rest  of 
this  organ  within  the  pelvis,  the  tumour  subsides,  and  it 
is  some  time  before  it  becomes  large  again. 

When  the  hernia  is  recent,  and  the  protruded  portion 
of  the  bladder  small  and  reducible,  the  part  ought  to  be 
returned  and  kept  up  with  a truss.  When  the  part  is 
adherent  and  irreducible,  the  swelling  ought  to  be  emp- 
tied by  pressure  and  supported  with  a suspensory  band- 
age. If  the  hernia  could  in  this  manner  be  made  to 
return  gradually  into  the  abdominal  ring,  a truss  would 
afterward  be  requisite.  Proposals  have  been  made  to 
endeavour  to  excite  adhesive  inflammation  in  the  ca- 
vity of  the  protruded  part  of  the  bladder  by  compres- 
sion gradually  increased,  and  thus  obliterate  the  pouch 
in  which  the  urine  lodges.  Although  Desault  thought 
the  attempt  cautiously  made  justifiable,  he  deemed  the 
re.sult  very  uncertain. 

Were  the  retention  of  urine  accompanied  with  a 
strangulated  state  of  the  protruded  bladder,  and  the 
contents  could  not  be  pressed  into  the  other  part  of 
this  organ,  a puncture  of  the  swelling  with  a trocar 
has  been  advised.  But  if  there  were  an  enterocele 
also  present,  as  often  happens,  this  operation  would  be 
attended  with  risk  of  injuring  the  intestine.  Hence, 
Desault  preferred  opening  the  tumour  by  a careful  in- 


cision, and  he  even  approved  of  cutting  away  the  pro-' 
truded  cyst,  if  the  communication  between  it  and  the 
rest  of  the  bladder  wete  obliterated. 

6.  Retention  of  Urine  caused  by  displacement  of  the 
Viscera  of  the  Pelvis. — The  displacements  here  signi- 
fied are,  a retroversion,  prolapsus,  and  inversion  of  the 
uterus,  and  a prolapsus  of.the  vagina  or  rectum.  When 
the  intimate  connexions  of  the  bladder  with  the  uterus 
and  vagina  in  the  female,  and  with  the  rectum  in  the 
male  subject  are  considered,  it  is  obvious,  that  the  latter 
parts  cannot  be  displaced,  without  drawing  along  with 
them  the  bladder;  and  that,  in  this  state,  whatever 
may  be  its  contractile  power,  it  cannot  contract  so  per- 
fectly as  to  expel  the  whole  of  the  urine.  To  this  de- 
ficient action  of  the  bladder  is  necessarily  joined  an 
increase  of  resistance  on  the  part  of  the  urethra;  for 
the  beainning  of  this  canal  being  drawn  by  the  blad- 
der, changes  its  accustomed  direction,  and  such  alter- 
ation cannot  be  made  without  the  sides  of  the  tube 
being  pressed  together.  Thus  the  retroverted  uterus 
draws  the  os  tincae  above  the  pubes,  and  the  posterior 
part  of  the  bladder  is  displaced,  which,  in  its  turn, 
draws  along  with  it  the  commencement  of  the  ure- 
thra, pulls  it  upwards,  and  increases  the  curvature 
which  this  canal  describes  under  the  symphysis  of  tlie 
pubes,  against  which  it  is  forcibly  applied. 

In  a prolapsus  or  inversion  of  the  womb,  vagina, 
and  rectum,  the  back  part  of  the  bladder,  instead  of 
being  drawn  upwards  and  forw'ards,  is  pulled  down- 
wards and  backwards,  and  the  curvature  of  the  ure- 
thra is  totally  altered.  Below'  the  pubes,  the  bladder 
forms  a convexity,  and  not  a large  concavity,  as  in  the 
instance  of  a retroversion  of  the  womb.  This  posi- 
tion of  the  parts  should  always  be  recollected  in  pass- 
ing the  catheter,  as  it  shows  what  curvature  and  di- 
rection should  be  given  to  the  instrument,  in  order  to 
facilitate  its  introduction. 

These  retentions  of  urine  are  not  often  followed  by 
any  very  bad  consequences.  It  is  generally  sufficient 
to  rectify  the  wrong  position  of  the  bladder,  and  the 
commencement  of  the  urethra,  by  the  reduction  of  the 
displaced  viscera ; and  a cure  is  then  a matter  of  course, 
unless  the  excessive  distention  should  have  induced 
considerable  weakness  of  the  bladder,  in  which  event, 
recourse  must  be  had  to  the  means  previously  recom- 
mended for  this  state  of  the  organ.  The  reduction  of 
the  viscera  generally  forms  the  first  indication,  and  the 
manner  of  accomplishing  it  is  described  under  the  head 
of  Uterus.  When  the  reduction  is  not  immediately 
practicable,  or  when  it  fails  to  remove  at  once  the  re- 
tention of  urine,  the  catheter  is  to  be  used.  Frequently, 
when  the  urine  has  been  drawn  off,  the  reduction  be- 
comes more  easy ; but  sometimes  the  altered  direction 
of  the  urethra  renders  the  introduction  of  the  catlieter 
difficult;  nor  will  the  instrument  pass,  unless  it  be  ac- 
commodated to  the  preternatural  state  of  that  canal. 
Thus,  in  the  retroversion  of  the  uterus,  a catheter,  very 
much  curved,  answers  better  than  one  nearly  straight, 
like  that  commonly  used  for  females. 

A curved  catheter,  says  Desault,  only  answers  in 
CEises  of  prolapsus  uteri,  &c. ; but  with  this  difference, 
that  in  a retroversion,  the  concavity  of  the  instrument 
must  be  turned  towards  the  pubes,  but  in  the  prolapsus, 
towards  the  anus.  Sometimes,  the  catheter  will  not 
pass  unless  it  be  rotated,  as  it  were ; and  sometimes 
when  a silver  catheter  cannot  in  any  manner  be  intro- 
duced, an  elastic  one  will  readily  enter. 

Were  every  effort  to  reduce  the  viscera  and  pass  a ca- 
theter unavailing,  and  the  hazard  of  the  bladder  giving 
way  urgent,  the  surgeon  wotild  be  called  upon  to  let  out 
the  urine  with  a trocar.— (See  Bladder.,  Puncture  of.) 

7.  Retention  of  Urine  from  the  pressure  of  the  Ute- 
rus or  Vagina  on  the  J^eck  of  the  Bladder Besides 

the  distention  of  the  uterus  and  vagina  in  pregnancy 
and  parturition  (which  cases  I mean  to  pass  over  as 
belonging  more  properly  to  midwifery),  there  are  other 
conditions  of  these  organs  which  may  give  rise  to  a 
retention  of  urhie.  Thus  it  sometimes  arises  from  the 
presence  of  various  kinds  of  tumours  or  collections  of 
blood,  or  other  fluid  in  the  uterus  or  ovary  ; or  the  dis- 
tention of  the  vagina  with  the  menses,  pessaries,  &c. 

In  such  cases,  the  retention  of  urine  being  only 
symptomatic,  the  prognosis  must  depend  upon  the  na- 
ture of  the  cause,  of  which  the  interruption  of  the  uri- 
nary evacuation  is  only  an  effect.  The  latter  complaint 
is  here  not  very  dangerous,  because  its  inconvenience 
may  be  obviated  by  means  of  the  catlteler.  But  when 


423 


URINE.  RETENTION  OF. 


the  cause  of  the  retention  of  urine  is  easily  removed, 
and  the  tone  of  the  bladder  is  not  impaired,  even  the 
catheter  is  not  always  necessary,  as  when  the  com- 
plaint is  induced  by  a pessary  or  collection  of  blood  in 
the  vagina.  In  other  examples,  in  which  the  cause  of 
the  difficulty  of  making  water  cannot  be  immediately 
obviated,  as  in  cases  of  tumours,  the  catheter  must  be 
employed.  In  scirrhous  and  cancerous  diseases  of  the 
uterus  also,  this  instrument  is  the  only  means  of  re- 
lieving the  retention  of  urine,  as  nature  and  art  can  do 
little  lor  the  removal  of  the  cause.  It  ou^t  to  be 
known,  however,  that  as  these  last  diseases  increase, 
an  incontinence  often  succeeds  to  a retention  of  urine, 
in  consequence  of  ulceration  taking  place  between  the 
upper  surface  of  the  vagina  and  the  lower  part  of  the 
bladder. 

8.  Retention  of  Urine  from  Pressure  of  the  Rectum 
upon  the  J^eck  of  the  Bladder— Ahsces&es  in  the  vi- 
cinity of  this  intestine  ; hemorrhoidal  tumours  ; alvine 
concretions ; and  the  scirrho-contracted  state  of  the 
gut,  &c.,  may  bring  on  a retention  of  the  urine  by 
pressure  on  the  neck  of  the  bladder.  The  irritation 
also,  existing  in  these  cases,  may  tend  to  produce  the 
complaint  by  e.\citing  a spasmodic  contraction  of  the 
adjacent  part  of  the  urethra.  Here  the  relief  of  the 
retention  of  urine  is  to  be  effected  by  removing  or 
curing  the  other  disorder  which  operates  as  its  cause. 
If  this  cannot  be  immediately  accomplished,  the  ca- 
theter must  be  used,  though,  in  several  instances,  it 
will  be  better  to  avoid  even  the  irritation  of  the  cathe- 
ter, and  try  the  effects  of  bleeding,  the  warm  bath,  and 
opium,  which  will  frequently  enable  the  patient  to 
make  water.  The  last  means,  however,  will  not  suf- 
fice, when  the  cause  of  the  retention  is  likely  to  con- 
tinue a long  time. 

9.  Retention  of  Urine  from  foreign  Bodies  in  the 
Bladder.— Wlihonx  slopping  to  consider  the  uncommon 
kinds  of  retention  produced  by  carcinoma,  fungous 
diseases,  and  hydatids  in  the  bladder,  let  us  pass  on  to 
the  case  in  which  the  urine  is  obstructed  by  a calculus 
at  the  neck  of  the  bladder.  Here  the  patient,  by  alter- 
ing his  position,  frequently  changes  the  situation  of  the 
stone,  and  is  immediately  able  to  make  water  again. 
However,  this  expedient  will  only  procure  relief  while 
the  calculus  is  loose  in  the  cavity  of  the  bladder ; for, 
after  it  has  become  fixed  in  the  commencement  of  the 
urethra,  it  must  either  be  pushed  back  with  a catheter, 
taken  hold  of  and  brought  out  with  the  urethra-for- 
ceps used  by  Sir  A.  Cooper,  broken  or  pulverized  by 
lithotrillc  instruments,  or  extracted  by  a kind  of  ope- 
ration, resembling  the  apparatus  minor.— (See  Litho- 
tomy.) 

’ Many  instances  of  various  kinds  of  worms  in  the 
bladder  are  upon  record.  On  this  subject,  an  interest- 
ing paper  was  published  a few  years  ago  by  my  friend 
Mr.  Lawrence,  who  met  with  an  example,  in  which  an 
undescribed  species  of  worms  was  abundantly  voided 
from  the  bladder.  “ The  origin  of  those  animals  (says 
Mr.  Lawrence)  which  inhabit  the  internal  parts  of 
living  bodies,  is  involved  in  much  obscurity.  Although 
the  intestinal  worms  appear  manifestly,  from  their  pe- 
culiar form,  consistence,  and  organs,  to  be  particularly 
designed  for  those  situations  in  which  they. are  found; 
although  they  have  generative  organs,  and  no  similar 
animals  are  known  to  exist  out  of  living  bodies,  yet  it 
has  been  generally  conceived,  that  the  germs  frorn 
which  they  spring  enter  from  the  mouth.  The  pro- 
duction of  hydatids  in  various  parts  of  the  body,  can- 
not, however,  be  accounted  for  on  such  a supposition  ; 
neither  can  we  very  easily  conceive  that  ova  should 
enter  from  without  into  the  urinary  organs.”  The 
following  facr^,  also  stated  by  Goeze  (as  Mr.  Lawrence 
observes),  entirely  overturn  this  opinion.  Professor 
Brendel,  of  GSttingen,  found  ascarides  in  the  rectum 
of  an  immature  embryo.  Blumenbach  discovered 
teniae  in  the  intestinal  canal  of  young  dogs  a few 
hours  after  birth,  &c. — {Versuch  einer  JsTaturgeschichte 
der  Eingeweidewiirmer,  p.  55.)  The  case  which  Mr. 
Lawrence  has  recorded,  exhibits  an  unquestionable 
instance  of  peculiar  and  undescribed  worms,  voided 
from  the  urinary  passages.  This  gentleman  says,  that 
he  knows  of  no  other  case  in  which  a distinct  species 
of  worm  has  been  clearly  proved  to  come  from  the 
bladder.  Most  of  the  cases  published  were  instances 
of  common  intestinal  round  worms,  which  sometimes 
perforate  the  intestines  and  are  discharged  by  ab- 
iBcesses,  or  get  into  the  bladder  after  the  formation  of 


adhesions  between  this  organ  and  the  bowels.  In  other 
instances,  coagula  of  blood,  mucus,  or  portions  of  the 
mucous  coat  of  the  bladder,  have  been  mistaken  for 
worms;  and  as  Mr. Lawrence  farther  observes,  some 
of  the  descriptions  can  apply  only  to  larvte  of  insects. 
Two  specimens  of  this  last  sort,  he  has  seen  himself, 
which  were  sent  from  the  country  as  worms  voided 
from  tlie  bladder. — (See  Medico- Chir.  Trans,  vol.  2,  p, 
382,  A-c.) 

In  whatever  way  these  animals  get  into  the  bladder, 
a retention  of  urine  may  be  produced,  either  when 
they  are  numerous,  or  when  there  is  only  one  present, 
but  large  enough  to  obstruct  the  vesical  orifice  of  the 
urethra.  In  the  very  curious  example  related  by  Mr. 
Lawrence,  the  passage  of  the  urine  was  obstructed, 
and  the  use  of  the  catheter  continually  necessary. 
The  oil  of  turpentine  was  given  internally,  with  some 
appearance  of  benefit  at  first ; but  it  afterward  brought 
on  febrile  symptoms  and  erysipelas,  and  its  exhibition 
could  not  be  kept  up.  It  was  then  injected  into  the 
bladder  with  an  equal  part  of  water.  This  rather  ac- 
celerated the  discharge  of  the  worms  ; but  they  came 
away  at  times,  whether  the  injection  was  used  or  not ; 
and  as  this  means  produced  the  erysipelatous  indispo- 
sition again,  it  was  left  off.  Olive  oil  was  afterward 
injected  : the  irritation  after  it  was  less,  and  the  fits  of 
pain  about  the  bladder  less  violent.  It  was  calculated 
at  the  time  when  Mr.  Lawrence  was  writing  the  par- 
ticulars of  the  case,  that  from  800  to  1000  worms  had 
been  discharged.  For  a detail  of  the  symptoms,  and  a 
particular  description  of  the  worms  themselves,  I must 
refer  to  the  above-mentioned  publication. 

According  to  theobservationsof  Desault,  a retention 
of  urine  is  frequently  occasioned  by  coagula  of  blood 
in  the  bladder.  The  blood  is  said  sometimes  to  come 
from  the  kidneys,  sometimes  from  the  bladder,  and 
sometimes  it  even  regurgitates  from  the  urethra.  While 
fluid,  it  may  be  expelled  with  the  urine;  but  when  co- 
agulated, it  is  no  longer  capable  of  being  discharged. 
It  is  the  blood  whicii  passes  into  the  bladder  after 
wound.s,  or  the  operation  of  lithotomy,  that  is  most 
disposed  to  coagulate.  If  the  clots  were  too  large  to 
pass  through  a catheter,  the  best  plan  would  be  to  inject 
into  the  bladder  lukewarm  water,  for  the  purple  of 
loosening  and  dissolving  them.  An  instance  ot  re- 
tention of  urine  from  a large  quantity  of  coagulated 
blood  in  the  bladder  is  related  in  the  2d  vol.  of  the  Me- 
dical Gazette,  p.  255.  The  injection  of  warm  water, 
and  the  use  of  a very  long  catheter,  succeeded  in  pro- 
curing the  discharge  of  the  urine. 

A retention  of  urine  has  sometimes  arisen  from  the 
entrance  of  a piece  of  bougie  into  the  bladder.  Even 
whole  bougies,  which  had  not  been  properly  secured, 
have  been  known  to  glide  into  the  cavity  of  that  organ. 
As  Desault  observes,  the  urethra  appears  to  posse.ss  a 
kind  of  anti  peristal  tic  action,  by  which  it  tends  to  draw 
into  the  bladder  whatever  substances  it  includes;  for, 
says  he,  it  is  constantly  noticed,  that  when  these  sub- 
stances are  once  within  the  urethra,  if  they  be  not  ex- 
pelled by  the  urine,  they  always  advance  towards  the 
bladder ; a circumstance  which  cannot  be  accounted 
for  by  their  weight. 

The  insinuation  of  foreign  bodies  into  the  bladder  is 
a serious  occurrence  both  for  the  patient  and  surgeon. 
The  former  cannot  avoid  the  consequence,  which  will 
sooner  or  later  originate  from  the  extraneous  substance, 
except  by  submitting  to  a dangerous  and  painful  ope- 
ration ; the  latter  will  be  accused  of  being  the  author 
of  all  the  evil,  and  will  find  it  difficult  to  exculpate 
himself.  In  order  to  obviate  the  necessity  of  cutting 
into  the  bladder  in  such  cases,  Desault  proposed  the  use 
of  small  spring-forceps  passed  into  the  bladder  through 
a cannula  ; but,  although  the  Instrument  seemed  to  an- 
swer on  the  dead  subject,  no  instances  of  its  doing  so 
on  living  patients  are  on  record.  Were  any  instru- 
ment likely  to  succeed,  I think  it  would  be  the  urethra- 
forceps,  shaped  like  a sound,  employed  by  Sir  A. 
Cooper  for  the  extraction  of  small  calculi  from  the 
bladder,  or  the  forceps  used  in  lithotrity.— (See  LitAon- 
triptor,  Lithotomy,  and  Urinary  Calculi.) 

10.  Retention  of  Urine  from  Inflammation  of  the 
Urethra.— \n  order  to  comprehend  the  mechanism  of 
this  case,  it  is  necessary  to  remember  that  inflamma 
(ion  never  exists  without  swelling,  and  that  every  tu- 
mefaction of  the  lining  of  the  urethra  must  necessarily 
les.sen  its  diameter  Inflammation  of  the  urethra  is 
most  commonly  produced  by  the  external  application. 


424 


URINE,  RETENTION  OF. 


or  Internal  exhibition,  of  lyttce,  by  gonorrhoea,  the  un- 
skilful use  of  the  catheter,  the  employment  of  stimu- 
lating injections,  bougies,  &c.  Together  with  the  les- 
sening of  the  canal  by  the  effect  of  swelling,  there  can 
also  be  no  doubt,  that  in  many  of  these  instances  a 
spasmodic  contraction  of  the  urethra  and  neck  of  the 
bladder  also  contributes  to  the  retention  of  urine.  Al- 
though Desault  believed,  that  inflamed  parts,  endued 
with  a contractile  power,  were  not  disposed  to  contract 
in  that  state,  yet  it  should  be  recollected,  that,  even  ad- 
mitting this  to  be  true,  the  whole  length  of  the  urethra 
is  seldom  inflamed,  and  a part  of  it  may  therefore  be 
affected  with  a spasmodic  action,  without  the  theory 
espoused  by  Desault  being  at  all  implicated.  The  ef- 
fects of  opium,  tobacco,  and  other  antispasmodics 
often  evinced  in  immediately  relieving  these  kinds  of 
retention  of  urine,  seem  indeed  to  leave  no  doubt  re- 
specting the  existence  of  more  or  less  spasm  in  the 
passage.  Whatever  may  be  the  cause  of  inflammation 
of  the  urethra,  the  diagnosis  is  free  from  all  obscurity. 
Besides  the  general  symptoms  of  inflammation,  the 
patient  complains  of  a scalding  sensation  in  the  pas- 
sage ; he  experiences  a great  deal  of  smarting,  which 
is  sometimes  insupportable  when  he  makes  water ; the 
penis  becomes  in  some  degree  swollen,  and  more  ten- 
der; and  a very  little  pressure  on  the  urethra  gives 
acute  pain.  In  the  mean  time,  the  stream  of  urine  be- 
comes lessened ; and  at  length  this  fluid  can  only  be 
voided  in  a very  narrow  current,  or  only  by  drops,  and 
often  not  at  all. 

The  disorder  is  to  be  treated  on  antiphlogistic  prin- 
ciples. Diluting,  cooling,  mucilaginous  beverages, 
venesection,  leeches  to  the  perinseum,  the  warm  bath, 
opium,  particularly  in  the  form  of  clysters,  and  foment- 
ations, are  the  means  which  usually  give  relief.  When 
inflammation  exists  in  the  urethra,  it  is  always  desira- 
ble to  avoid  as  long  as  possible  the  employment  of  ca- 
theters, which  create  irritation,  and  of  course  increase 
the  cause  of  the  retention.  It  is  particularly  in  cases 
of  this  description,  and  in  the  retentions  of  urine  aris- 
ing from  strictures,  that  Mr.  Earle  has  suggested  the 
use  of  tobacco  in  the  form  of  clysters ; a method  de- 
serving adoption  when  the  means  above  enumerated 
are  unavailing,  and  it  is  preferable  to  the  catheter,  be- 
cau^  it  does  not  cause  any  increase  of  irritation  and 
inflammation  in  the  urethra.— (See  Med.  Ghir.  Trans, 
vol.  6,  p.  82,  4-c.) 

11.  Retention  of  Urine  from  Laceration  of  the  Ure- 
thra.— The  urethra  is  sometimes,  ruptured  by  vio- 
lent contusions  on  the  perinsum,  and  the  rough  and 
unskilful  use  of  bougies  and  catheters.  The  conse- 
quences usually  are  an  extravasation  of  urine  in  the 
cellular  membrane  of  the  scrotum  and  penis,  a consi- 
derable dark-coloured  swelling  of  these  parts  often  fol- 
lowed by  sloughing,  and  retention  of  urine.  The  treat- 
ment consists  in  introducing  an  elastic  gum  catheter 
into  the  bladder  witli  as  little  delay  as  possible,  and 
keeping  it  there  until  the  breach  in  the  canal  is  re- 
paired. At  the  same  time,  the  evils  threatened  by  the 
effusion  of  the  urine  are  to  be  averted  as  much  as  pos- 
sible, by  making  two  or  three  free  incisions  in  a de- 
pending part  of  the  swelling,  and  the  employment  of 
fomentations  and  antiphlogistic  remedies. 

12.  Retention  of  Urine  from  Tumours  situated  in 
the  Perinceum,  Scrotum,  or  Penis. — A retention  of 
urine  has  been  known  to  arise  from  phlegmonous 
swellings  and  abscesses,  extravasations  of  blood,  and 
urinary  tumours  and  calculi  formed  in  the  perinteura 
and  scrotum ; also  from  the  pressure  of  a sarcocele, 
hydrocele,  a very  large  scrotal  hernia,  an  aneurism  of 
the  corpus  cavernosum,  a ligature  on  the  penis,  &c. 

Tlie  radical  cure  of  all  such  retentions  of  urine  can 
only  be  accomplished  by  curing  the  disease  on  which 
they  are  dependent.  However,  until  the  cause  can  be 
obviated,  the  urine  must  be  drawn  off"  with  a catheter. 
Elastic  gum  catheters  usually  enter  more  easily  than 
those  made  of  silver,  as  by  their  flexibility  thfey  accom- 
modate themselves  better  to  any  deviation  of  the  ure- 
thra from  its  ordinary  direction.  Desault  particularly 
recommended  a catlieter  of  middling  size  to  be  selected, 
and  introduced  armed  with  its  siilet  until  it  stops  in 
the  canal ; when  he  advised  withdrawing  the  stilel  for 
about  an  inch,  in  order  to  leave  the  beak  of  the  instru- 
ment quite  free,  so  that  it  might  follow  the  curve  of 
the  urethra.  Then  the  tube  and  the  stilet  were  pushed 
farther  into  the  canal,  care  being  taken,  however,  to 
keep  the  stilet  drawn  back  seme  distance  from  the  ex- 


tremity of  the  instrument.  By  these  precautions,  say* 
Desault,  the  catheter  may  always  be  got  into  the  blad- 
der. should  the  introduction  prove  neither  painful 
nor  difficult,  Desault  thought  it  better  net  to  annoy  the 
patient  by  making  him  continually  wear  the  instru- 
ment. 

13.  Retention  of  Urine  from  Disease  of  the  Prostate 
Gland.— When  the  swelling  of  the  prostate  glapd  is  of 
an  inflammatory  kind,  the  retention  of  urine  makes  its 
appearance  with  the  same  kind  of  symptoms  as  attend 
inflammation  about  the  neck  of  the  bladder. 

Here  similar  treatment  to  that  commonly  adopted  for 
the  retention  of  urine  produced  in  the  latter  case  is  in- 
dicated; particularly  bleeding,  fomentations,  the  warm 
bath,  opening  medicines,  anodyne  clysters,  the  tinctura 
ferri  muriati,  and,  in  very  obstinate  urgent  cases,  an 
enema  of  tobacco.  If  these  means  fail,  the  surgeon 
may  gently  endeavour  to  introduce  an  clastic  gum  ca- 
theter. 

The  Symptoms  of  the  retention  of  urine,  caused  by 
chronic  enlargement  of  the  prostate  gland,  and  the  rea- 
son of  the  impediment  to  the  discharge  of  that  fluid 
in  such  a case,  are  explained  in  another  part  of  this 
work. — (See  Prostate  Oland.)  From  the  remarks 
there  introduced,  it  appears,  that  when  the  regular 
evacuation  of  the  urine  begins  to  be  impeded,  the  ca- 
theter becomes  indispensable,  though  the  surgeon  will 
often  be  foiled  in  his  endeavour  to  draw  off  the  urine 
with  it,  unless  he  be  duly  acquainted  with  the  morbid 
ciianges  produced  in  the  parts.  And,  as  Sabatier  long 
ago  very  correctly  observed,  the  urine  may  not  be  dis- 
charged, though  the  instrument  enter  a considerable 
way,  either  because  its  beak  becomes  entangled  in  the 
prostate  gland,  or  between  a swollen  portion  of  this 
gland  arid  the  neck  of  the  bladder,  and  does  not  reach 
the  urine.  Hence,  he  recommended  the  employment 
of  a catheter  with  a very  long  beak,  which  should  also 
be  bent  considerably  upwards.  When,  however,  all 
efforts  to  pass  a catheter  fail,  the  only  resources  are  to 
force  a passage  with  a conical  catheter,  or  to  puncture 
the  bladder  above  the  pubes.  I believe  that  the  latter 
proceeding  is  scarcely  ever  necessary  in  this  particular 
form  of  retention  of  urine,  as,  with  moderate  skill,  an 
instrument  may  almost  always  be  passed  by  the  ure- 
thra. Such  is  also  the  opinion  of  Sir  Astley  Cooper. — 
Catheter,  Bladder,  Puncture  of .) 

14.  Of  the  Retention  of  Urine  produced  by  Strictures 
in  the  Urethra.— From  the  account  which  is  given  of 
strictures  in  another  part  of  this  Dictionary  (.see  Ure- 
thra, Strictures  of),  it  appears  that  almost  every  stric- 
ture, bad  as  it  may  be,  is  capable  of  being  rendered  still 
worse,  and  the  morbid  part  of  the  urethra  more  imper- 
vious, by  a spasmodic  affection.  Going  out  of  a warm 
into  a cold  situation,  drinking,  and  other  kinds  of  in- 
temperance, will  often  bring  on  an  irritable  state  of 
the  canal,  attended  with  a spasmodic  action  of  the 
strictured  part,  an  increased  difliculty  of  voiding  the 
urine,  and  even  a total  retention  of  this  fluid.  The 
patient  makes  repeated  efforts  to  relieve  himself,  but 
hardly  a drop  of  urine  is  discharged.  In  the  mean 
while,  the  bladder  becomes  filled,  and  ascends  above 
the  pubes,  the  abdomen  grows  tense  and  painful,  fever 
comes  on,  the  countenance  looks  red,  the  brain  be- 
comes affected,  and  circumstances  assume  an  ex- 
tremely urgent  appearance. 

In  this  case  antiphlogistic  means  should  be  adopted 
without  delay.  The  patient  ought  to  be  bled,  if  no- 
thing in  his  constitution  and  age  prohibit  this  evacua- 
tion, which  it  may  even  be  proper  to  repeal.  He  should 
also  be  put  into  the  warm  bath,  and  fomentations 
should  be  continually  applied  to  the  hypogastric  re- 
gion. Slightly  diuretic  beverages  may  be  prescribed, 
and  leeches  put  on  the  perinseum.  The  principal 
means,  however,  from  which  the  greatest  benefit  may 
be  expected,  is  a liberal  dose  of  the  tinctura  opii,  toge- 
ther with  an  anodyne  clyster.  This  is  also  another 
example  for  which  Mr.  Earle  has  particularly  recom- 
mended the  exhibition  of  tobacco  in  the  form  of  a 
clyster,  and  he  has  related  a case  in  illustration  of  the 
efficacy  of  the  plan. — (See  Medico- Chir.  Trans,  vol.  6, 
p.  88.)  The  tinctura  ferri  muriati,  which,  according  to 
Mr.  Cline,  has  a specific  effect  in  overcoming  spasm 
of  the  urethra,  seems  also  worthy  of  ti  ial.  Indeed,  it 
should  always  be  tried  before  tobacco,  wliich,  being 
sometimes  violent  in  its  effects,  ought  perhaps  to  be 
the  last  resource  in  the  way  of  medicities.  When  such 
measures  fail  in  enabling  the  patient  to  empty  Ids 


UTE 


UTE 


425 


bladder,  and  this  viscus  is  becoming  more  and  more  dis- 
tended, an  immediate  attempt  should  be  made  to  intro- 
duce a small  flexible  elastic  gum  catheter  through  the 
stricture  or  strictures  into  the  bladder,  which  object 
ma>'  be  frequently  accomplished,  when  due  care,  per- 
severance, and  gentleness  are  not  neglected. 

Sometimes,  when  a small  flexible  catlieter  cannot  be 
i.'itroduced,  a fine  bougie  admits  of  being  passed  into 
the  bladder,  and,  on  being  withdrawn,  the  urine  fol- 
lows, and  is  discharged. 

When  all  the  preceding  plans  prove  unavailing,  and 
the  danger  arising  from  the  retention  of  urine  conti- 
nues to  increase,  either  the  stricture  must  be  perforated 
with  a stilet  made  for  the  purpose,  forced  with  the 
conical  sound  (see  Catheter),  an  incision  practised  be- 
hind the  obstruction,  or  the  bladder  punctured.  The 
cannula  of  the  trocar  should  then  be  left  in  the  wound 
till  tire  strictures  are  either  cured,  or,  at  least,  till  the 
urine  resumes  its  natural  C/Ourse. 

15.  Retention  of  Urine  from  the  Lodgement  of  fo- 
reign Bodies  in  the  Urethra. — That  such  accident 
must  obstruct  the  discharge  of  urine,  is  too  plain  to 
need  any  particular  ex[ilanation.  Calculi  are  the  most 
common  substances  which  bring  on  this  kind  of  case, 
but  articles  introduced  into  the  urethra  from  without, 
such  as  bougies,  large  pins,  &c.,  are  occasionally  lodged 
in  the  passage;  and  1 once  extracted  from  a man’s 
urethra  a long  black  pin,  with  which  he  had  been  ex- 
amining the  passage.  The  head  of  it  was  towards  the 
periniEum,  and  the  point  about  two  inches  from  the 
orifice  of  the  glans.  I passed  the  point  through  the 
lower  surface  of  the  urethra,  and  then  taking  hold  of 
it,  drew  it  farther  out,  turned  the  head  towards  the 
glans,  from  Uie  orifice  of  which  it  was  then  easily  re- 
moved. When  substances  like  calculi  lodge,  oily  in- 
jections are  sometimes  tried,  with  the  view  of  render- 
ing the  passage  more  slippery,  and  occasionally  the 
dilatation  of  the  canal  with  bougies  and  catheters, 
followed  by  a very  forcible  expulsion  of  the  urine,  has 
answered.  The  ancients  sometimes  tried  the  efiect  of 
suction.  When  the  foreign  body  is  closely  embraced 
by  the  urethra,  and  it  cannot  be  pushed  forwards  by  the 
fingers,  Desault  recommends  endeavouring  to  extract 
it  with  the  forceps  invented  for  the  purpose  by  Mr. 
Hunter,  and  which  are  contained  in  a cannula;  or  the 
urethra-forceps  spoken  of  in  the  articles  Lithotomy  and 
Urinary  Calculi  might  be  employed.  When,  how- 
ever, the  foreign  body  is  loo  large  to  be  taken  out  in 
this  manner,  it  must  be  extracted  by  an  incision.  If 
an  elastic  catheter  be  now  kept  in  the  urethra,  so  as  to 
prevent  the  urine  from  coming  into  contact  with  the 
cut  part,  the  wound  will  heal  very  well.  Some  time 
ago  there  was  published  a case  of  calculqs  in  the  ure- 
thra, attended  with  dysury,  where  almost  instantane- 
ous relief  was  obtained  from  the  exhibition  of  a tobacco 
clyster.  The  patient  soon  felt  a strong  desire  to  void 
his  urine,  and  “ upon  making  the  attempt,  a large  cal- 
culus came  rolling  along  the  urethra,  with  complete 
relief  of  all  his  complaints.” — (See  Edinb.  Med.  and 
Surgical  Journal,  vol.  12,  p.  373.) 

M.  Colot,  TVaiU  de  V Operation  de  la  Taille, 
avec  des  Obs.  sur  la  Formation  de  la  Pierre,  et  les 
Suppressions  de  V Urine,  Sfc.  V2mo.  Paris,  1727.  Sa- 
batier, de  la  Mcdecine  Operatoire,  t.  2.  C B.  Trye, 
Remarks  on  Morbid  Retentions  of  Urine,  2d  edit.  8vo. 
Gloucester,  1784.  Pfey's  Practical  Obs.  in  Surgery, 
ed.  3.  Schreger,  Chirurgische  Versiiche,  p.  187,  (J-c. 
der  Ischuria  Calculosa,  8i?o.  Miirnberg,  1811.  De- 
sault's Parisian  Chirurgical  Journal.  S.  T.  Soem- 
mering, Mhandlung  iiber  die  schnell  und  langsam 
todtlichen  Krankheiten  der  Hamblase  und  Harnrohre 
bey  Mdnnem  in  hohen  MterrAto.  Frank.  1809.  Richter, 
Jinfangsgriinde  der  Wundarzneykunst,  b.  6,  p.  210, 
Src.  (Euvres  Chir.  de  Desault,  par  Bichat,  t.  3.  De- 
sault et  Chopart,  Traitt  des  Maladies  des  Foies 
Urinaires,  8vo.  1796.  Mauche,  Mouvelles  Recherches 
sur  les  Retentions  d' Urine  par  Retrecissement  de 
V Uritre,  et  par  Paralysie  de  la  Vessie,  6rc.  8vo.  Paris, 
1806.  Home's  Practical  Obs.  on  the  Treatment  of 
Strictures,  Src.  3 vols.;  and  on  Diseases  of  the  Pros- 
tate Gland,  2 vols.  8»o.  Lond.  1811 — 1818.  H.  Earle, 
in  Medico-Chir.  Trans,  vol.  6,  p.  82,  <S-c.  J.  Howship 
on  Diseases  of  the  Urinary  Organs,  8vo.  Lond.  11^3. 

UTERUS,  INVERSION  OF.  This  case  may  either 
be  complete  or  incomplete.  When  it  is  incomplete, 
only  the  fundus  of  the  uterus  passes  through  the  os 
tincse.  When  the  inversion  is  complete,  the  uterus 


becomes  entirely  turned  inside  out,  passing  through 
the  opening  in  its  cervix,  dragging  along  with  it  a part 
of  the  vagina,  and  descending  more  or  less  far  down, 
sometimes  even  between  the  patient’s  thighs. 

The  inversion  of  the  uterus  mostly  arises  from  the 
manner  in  which  the  placenta  is  extracted  after  deli- 
very. Immediately  after  parturition  the  uterus  is  not 
yet  contracted,  and'ils  cervix  is  in  a widened  state. 
When  things  are  thus  disposed,  the  uterus  may  easily 
follow  the  after-birth,  which  is  attached  to  it,  and  thus 
become  inverted.  The  event  is  particularly  liable  to 
happen  ; 1st,  When  a premature  attempt  is  made  to 
extract  the  placenta.  2dly,  When  the  funis  is  pulled 
outwards,  without  due  care  being  taken  to  support  the 
uterus  with  the  fingers  of  the  left  hand.  3dly,  When 
the  operator  draws  out  the  after-birth  too  roughly  and 
violently.  Though  the  placenta  is  sometimes  so  adhe- 
rent that  its  extraction  is  difficult,  and  a risk  must  be 
encountered  of  dragging  down  the  uterus  with  it,  this 
disagreeable  accident  may  generally  be  avoided  by 
performing  the  necessary  separation  of  the  parts  with 
the  fingers  introduced  into  the  cavity  of  the  uteius. 

The  inversion  following  delivery  does  not  always 
proceed  from  unskilfulness;  but  sometimes  happens, 
notwithstanding  every  precaution,  either  because  the 
patients  themselves  make  too  violent  efl'orts,  or  because 
the  uterus  is  enlarged  and  heavy ; or  else  in  conse- 
quence of  some  predisposition,  some  unusual  laxity  of 
the  organ,  which  can  neither  be  foreseen  nor  prevented. 
Ruysch  saw  an  inversion  of  the  uterus  take  place  after 
the  expulsion  of  the  placenta,  although  delivery  had 
occurred  in  the  most  favourable  way. 

Mr.  Windsor  believes  that  when  the  uterus  and  va- 
gina are  in  a relaxed  state,  and  the  female  has  been, 
subject  to  prolapsus  uteri,  there  is  a greater  disposi- 
tion to  the  occurrence  of  inversion  at  the  time  of 
labour  than  when  such  condition  of  the  parts  does  not 
exist. — {Med.  Chir.  Trans,  vol.  10,  jj.  360.) 

A tendency  to  the  accident  is  very  common  in 
women  who  have  once  been  afflicted  with  it.  Amand 
mentions  a woman  who  had  an  inversion  of  the  uterus 
after  her  first  delivery,  but  the  part  was  reduced.  She 
was  attended  by  Amand  again  in  her  next  confine- 
ment, and  another  inversion  of  uterus,  quite  as  bad  as 
the  first,  would  have  happened,  had  he  not,  on  per- 
ceiving the  disposition  to  the  accident,  introduced  his 
finger  into  the  cavity  of  the  uterus,  and  separated  the 
placenta  from  its  attachments,  before  making  any 
attempt  to  extract  it. 

Besides  causes  connected  with  parturition,  there  are 
others  of  a different  nature.  Ruysch,  Maiiriceau,  and 
Lamotte  supposed  an  inversion  of  the  uterus  could 
only  happen  at  the  time  when  the  placenta  was  ex- 
tracted, or  a little  while  afterward.  The  accident 
seemed  to  them  impossible  at  any  other  period,  both 
on  account  of  the  thickness  of  the  uterus,  and  the 
smallness  of  the  os  tincae.  However,  many  facts  prove 
that  the  case  may  also  depend  on  internal  causes,  and 
affect  women  who  have  never  had  children  as  well  as 
others  who  have  had  them.  Thus,  polypi  of  the  uterus 
may  bring  on  inversion  of  the  part.  As  their  pedicle 
is  attached  to  the  fundus  of  the  uterus,  they  may 
easily  drag  it  downwards  when  its  texture  is  lax  and 
soft,  particularly  as  the  operation  of  their  weight  is 
continual. — (See  Denman's  Plates  of  a Polypus,  with 
an  Inversion  of  the  Uterus,  fol.  1801.)  Uterine  he- 
morrhages may  also  be  corjducive  to  the  accident,  both 
because  they  relax  the  texture  of  the  uterus,  and 
because  they  are  usually  attended  with  acute  pain, 
which  makes  the  diaphragm  and  abdominal  muscles 
act  upon  the  uterus  with  all  their  power. 

Levret  speaks  of  a case  of  inversion  of  the  uterus, 
where  the  displacement  was  not  noticed  until  five  years 
after  delivery.  In  this  example,  it  is  conjectured  that 
the  very  gradual  and  slow  formation  of  the  disease 
must  have  been  the  reason  of  its  not  having  attracted 
earlier  attention.— (Z)ict.  des  Sciences  Mid.  t.  23,  p. 
288.  Also,  Baudelocque,  in  Brogniard,  Bulletin  des 
Sciences,  2,  n.  1.) 

When  an  inversion  of  the  uterus  takes  place  after 
delivery,  there  are  certain  symptoms  by  which  it  may 
easily  be  known.  The  uterus,  in  its  natural  situation, 
thickened  and  swelled  as  it  is  at  this  period,  presents 
itself  in  the  hypogastric  region  in  the  form  of  a round 
circumscribed  tumour  ; but  when  it  has  fallen  down- 
wards and  become  inverted,  a vacancy  is  felt  in  the 
situation  which  it  ought  to  occupy.  When  the  inver 


426 


Ul’ERUS,  INVERSION  OF. 


sion  is  incomplete,  an  examination  with  the  fingers 
detects  in  the  vagina  a tumour  shaped  like  the  segment 
of  a sphere,  having  a smooth  surface,  and  surrounded 
by  the  cervix  uteri  as  by  a kind  of  collar,  round  which 
the  finger  may  easily  be  passed,  either  between  it  and 
the  uterus,  or  between  it  and  the  vagina.  When  the 
inversion  is  complete,  which  case  is  more  rare  than  the 
preceding,  a tumour  may  be  felt  in  the  vagina,  from 
which  it  sometimes  even  protrudes,  apt  to  bleed,  of  an 
irregularly  round  shape,  hanging  by  a neck,  the  lower 
partofwhich  is  surrounded  by  the  above  circular,  thick, 
fieshy  substance,  consisting  of  the  os  uteri  itself.  The 
slightest  touch  makes  the  swelling  bleed.  The  part 
has  a red  colour,  which,  however,  generally  diminishes 
in  proportion  to  the  duration  of  the  displacement.  In 
time,  indeed,  its  surface  becomes  less  sensible  to  exter- 
nal impressions,  and  only  bleeds  at  the  menstrual 
periods  ; the  blood  oozing  from  every  point  of  the 
swelling,  and  not  issuing  from  a single  aperture  at 
the  lower  part  of  the  tumour,  as  in  cases  of  prolapsus 
uteri. 

In  the  incomplete  inversion,  patients  feel  acute  pain 
in  the  groins  and  kidneys,  an  oppressive  sense  of  hea- 
viness in  the  hypogastric  region,  and  a tenesmus ; 
which,  compelling  them  to  make  violent  efforts,  forces 
the  uterus  farther  down,  and  sometimes  produces  a 
total  inversion  of  it.  Besides  these  symptoms,  more 
or  less  copious  hemorrhages  also  occur.  When  the 
inversion  is  complete,  the  pain  is  more  acute,  the  loss 
of  blood  more  considerable,  and  the  patient  often 
affected  with  peculiar  weakness,  followed  by  cold 
sweats,  convulsions,  and  delirium. 

In  both  forms  of  the  disease,  if  the  reduction  be  not 
almost  immediately  effected,  fatal  consequences  fre- 
quently ensue,  either  very  soon  after  the  accident, 
from  the  violence  of  the  hemorrhage,  or  at  a more  or 
less  remote  period,  partly  from  repeated  losses  of 
blood,  and  partly  from  the  constitutional  irritation  and 
disturbance  incessantly  kept  up. 

Happily,  as  Mr.  Windsor  observes,  the  accident  ad- 
mits of  remedy,  if  an  intelligent  person  be  present  to 
teplace  the  uterus ; for,  if  this  be  done  immediately, 
and  the  hand  of  the  accoucheur  be  retained  in  the 
cavity  of  this  organ  until  it  has  contracted,  and  the 
patient  be  afterward  confined  to  the  recumbent  pos- 
ture, she  will  generally  do  w ell.  An  unsettled  point 
appears  to  be,  whether  the  placenta,  if  still  remaining, 
should  be  extracted  before  or  after  the  reduction.  Mr. 
Windsor,  who  appears  inclined  to  prefer  the  latter 
method,  refers  to  two  examples,  in  which  each  plan 
was  followed  by  a recovery. — (See  Med.  Chir.  Trans, 
vol.  10, p.  360.) 

And  in  all  cases,  as  the  same  author  remarks,  the 
accoucheur,  after  the  expulsion  of  the  placenta,  should 
assure  himself  by  manual  examination  that  the  os 
internum  is  free,  while  an  endeavour  is  made  to  feel 
the  uterus  with  the  hand  placed  upon  the  abdomen. 
“ In  consequence  of  the  neglect  of  this  practice,”  says 
Mr.  Windsor,  “ it  is  to  be  feared  that  many  lives  have 
been  lost ; the  true  cause  of  the  succeeding  hemorrhage 
not  being  ascertained  till  too  late,  as  happened  in  the 
fatal  case  that  occurred  to  a midwife  here  (Manches- 
ter) last  w'inter.”  Some  women  perish  at  once,  or 
within  a few  hours ; and  when  they  live  longer,  the 
reduction  is  exceedingly  difficult,  because  the  uterus 
and  its  cervix  are  becoming  more  and  more  con- 
tracted. 

In  the  reduction,  Sabatier  regards  the  interposition 
of  linen  between  the  hands  and  the  uterus  as  unneces- 
sary, and  even  disadvantageous ; because  it  prevents 
the  practitioner  from  having  the  assistance  of  a correct 
feel  of  the  part.  The  trial  should  be  continued  as  long 
as  the  patient’s  strength  will  allow.  However,  if  the 
tumour  were  in  an  inflamed  state,  it  would  be  prudent 
to  put  the  patient  in  the  warm  bath,  use  emollient 
applications,  and  exhibit  anodyne  and  laxative  medi- 
cines, &c. 

When  the  reduction  cannot  be  accomplished,  many 
patients  die ; while  others  survive,  subject  to  an  op- 
pressive sense  of  weight  and  frequent  hemorrhages, 
which  bring  on  great  emaciation.  Sabatier  attended 
two  patients  who  had  had  an  inversion  of  the  uterus 
six  months,  and  yet  they  were  able  to  go  about  their 
family  affairs.  The  same  author  had  heard  of  other 
women  who  had  been  afflicted  with  an  inversion  of 
the  uterus  several  years. 

If  the  redaction  cannot  be  performed,  and  the  patient 


survive  the  immediate  effects  of  the  injury,  “ some 
degree  of  inflammatory  symptoms,  accompanied  with 
fever,  ensues.  The  abdomen  becomes  full,  tender  to 
the  touch,  and,  at  its  lower  part,  sometimes  rather 
hard.  There  is  cosliveness  of  the  bowels,  and  some- 
times retention  of  urine,  requiring  for  a time  the  use 
of  the  catheter.  By  the  use  of  fomentations,  enemata, 
laxatives,  and  an  antiphlogistic  regimen,  the  symptoms 
abate,  the  power  of  expelling  the  urine,  especially  if 
the  uterus  is  first  raised  a little  in  the  vagina,  is  re- 
gained, and  the  patient  gradually  recovers  the  full 
power  of  this  function.  Afterward,  she  becomes  able 
to  walk  about,  suckles  her  infant,  and  perhaps  enjoys 
apparently  even  a tolerable  state  of  health ; yet  the 
sanguineous  discharges  generally  after  a time  return 
profusely,  and  her  pale  countenance  and  emaciated 
appearance  indicate  the  greatest  debility. 

About  the  time  when  she  relinquishes  the  office  of 
suckling,  the  menses  return  more  regularly,  the  dis- 
charges of  blood  are  very  considerable  in  quantity,  or 
of  long  duration,  the  mucous  discharges  are  generally 
copious  at  other  times,  and  the  constitution  begins  to 
sink  under  the  reiterated  losses  it  sustains.  The  pulse 
becomes  frequent,  the  appetite  is  impaired,  a cough, 
with  hectic  symptoms,  sometimes  occurs,  and  the  pa- 
tient is  quite  unable  to  pursue  her  usual  domestic 
duties.  In  this  state,  palliative  means,  as  the  use  of 
astringent  and  other  remedies,  become  inadequate  to 
check  the  exhausted  progress  of  the  complaint,  and  the 
unfortunate  sufferer  must  soon  perish  unless  some 
decisive  means  be  devised  for  her  relief.  In  this  pain- 
ful extremity,  the  extirpation  of  the  uterus  itself  has 
been  proposed  as  the  most  efficient  means  of  relief ; 
and,  formidable  as  the  operation  at  first  view  seems,  it 
is  known  to  have  been  already  performed  with  suc- 
cess.”— ( Windsor^  in  Med.  Chir.  Trans,  vol.  10,  p. 
361—363.) 

One  of  the  most  afflicting  consequences  of  an  inver- 
sion of  the  uterus  is  so  considerable  an  inflammation 
of  the  part,  as  to  induce  a danger  of  its  mortifying.  In 
this  circumstance,  the  extirpation  of  the  uterus  has 
been  also  suggested,  and  even  practised  ; an  operation 
that  has  had  but  little  success,  the  majority  of  patients 
on  whom  it  has  been  practised  under  such  circum- 
stances having  died. 

The  practice  of  extirpating  the  inverted  uterus 
through  apprehension  of  the  part  mortifying,  cannot  be 
too  strongly  reprobated  ; for,  unless  mortification  has 
really  happened,  the  uterus  may  possibly  be  brought  into 
a state  again  in  which  the  inconveniences  arising  from 
its  inversion  would  be  very  supportable,  and  the  opera- 
tion altogether  avoided.  Even  supposing  mortification 
were  to  take  place,  the  indication  would  be  to  appease 
the  bad  symptoms,  and  promote  the  separation  of  the 
sloughs  by  suitable  applications,  without  doing  any 
injury  to  the  living  parts.  One  example,  in  which  the 
latter  practice  was  successfully  adopted,  is  recorded  by 
Rousset.  That  the  extirpation  of  the  uterus,  when 
this  organ  is  completely  or  incompletely  inverted, 
totally  irreducible,  and  attended  with  the  sufferings 
and  reduced  health  so  well  described  by  Mr.  Windsor, 
may  sometimes  be  advisable,  cannot  now  be  doubted. 
The  unequivocal  examples  on  record  of  the  removal 
of  the  cancerous  uterus  by  Osiander,  Dupuytren,  Lan- 
genbeck,  and  others,  and  the  cases  published  by  Mr 
Newnham,  Mr.  Windsor,  and  Dr.  C.  Johnson  i,Dublin 
Hospital  Reports, vol.3),  where  the  inverted  and  irre- 
ducible uterus  was  successfully  extirpated,  furnish  suf- 
ficient evidence  in  favour  of  the  practice,  without 
referring  to  numerous  other  cases  reported  on  older 
authorities,  the  correctness  of  some  of  which  may  be 
questionable. 

In  fact,  polypi,  growing  from  the  uterus,  frequently 
attain  so  considerable  a size,  that  they  protrude  out  of 
the  vagina,  and  are  occasionally  mistaken  for  the 
uterus  itself.  The  surgeon  extirpates  the  tumour  with 
a ligature;  the  operation  does  not  undeceive  him 
about  the  nature  of  the  part;  his  patient  has  a 
favourable  recovery ; and  the  case  is  published  as  an 
instance  of  the  successful  extirpation  of  the  uterus 
itself.  . 

Although  it  is  easy  to  distinguish  the  inversion  of  the 
uterus  which  happens  soon  after  delivery,  it  is  not  so 
to  make  out  the  nature  of  such  cases  as  happen  in 
other  circumstances,  notwithstanding  the  presence  of 
the  same  kind  of  symptoms.  As  cases  of  the  latter 
kind  are  uncommon,  and,  consequently,  not  expected, 


UTE 


UTE 


427 


mistakes  are  the  more  liable  to  be  made.  A polypus 
has  often  been  mistaken  for  an  inversion  of  the  uterus ; 
but  it  should  be  recollected,  that  the  upper  part  of  a 
polypus  is  always  narrow,  and  the  tumour,  which  is 
not  very  sensible,  is  irreducible ; whereas,  the  uterus, 
in  a state  of  incomplete  inversion,  forms  a semi- 
spherical  swelling,  sometimes  a little  oblong,  but  always 
broader  above  than  below.  It  is  very  sensible,  and 
may  generally  be  reduced.  And  when  the  inversion 
is  complete,  the  tumour  has  a greater  resemblance  to  a 
polypus,  inasmuch  as  it  seems  to  have  a pedicle,  but, 
the  impossibility  of  introducing  a probe  far  at  the  cir- 
cumference of  such  pedicle,  as  can  be  done  in  cases 
of  polypi,  will  generally  serve  at  once  as  a criterion  of 
the  nature  of  the  disease. 

The  greatest  obscurity  in  the  diagnosis  is  said  to 
prevail  when  the  inversion  is  partial  and  chronic,  be- 
cause the  os  uteri  then  encircles  the  summit  of  the 
tumour,  just  as  it  does  a polypus,  and,  in  both  cases,  the 
finger  will  pass  all  around  between  the  parts. — (See 
J^ewnhavVs  Essay  on  Inversio  Uteri,  with  a History 
of  the  successful  Extirpation  of  that  Organ,  p.  82,8vo. 
Eond.  1818.)  However,  as  I do  not  believe,  with  this 
gentleman,  that  the  neck  of  a polypus  is  frequently  as 
large,  and  sometimes  larger  than  its  inferior  portion,  I 
should  yet  expect,  that  the  difference  in  the  form  of  the 
two  swellings  perceptible  on  manual  examination 
would  here  be  an  important  criterion.  In  general, 
also,  the  fact,  that  inversion  of  the  uterus  first  happens 
at  or  soon  after  delivery,  is  a consideration  that  would 
tend  to  a right  discrimination  of  the  cases,  inasmuch  as 
the  first  protrusion  of  a polypus  directly  after  delivery 
is  rare,  and  when  it  does  happen  under  these  circum- 
stances, is  probably  always  complete,  and  not  partial. 

Reduction  is  the  only  plan,  whether  the  case  has 
arisen  from  the  weight  of  a polypus,  or  from  uterine 
hemorrhage.  However,  this  proceeding  is  generally 
useless,  when  the  disease  oiiginates  from  obesity.  In 
the  latter  case,  as  the  cause  still  continues  in  full  force, 
the  uterus  is  soon  displaced  again,  and  a pessary  is  the 
only  means  to  which  the  patient  can  resort. 

Having  delivered  many  additional  observations  on 
the  subject  of  inversion  of  the  womb,  in  the  second 
vol.  of  the  First  Lines  of  Surgery,  ed.  4,  I shall  here 
conclude  with  referring  to  some  works,  in  which  the 
reader  will  find  valuable  instruction  on  the  subject. 
F.  B.  Wachter  de  Prolapsu  et  inversione  Uteri,  Halce, 
1745.  Act.  JVaturw  Cur.,  vol.  6,  obs.  107,  uterus  feli- 
citer  extirpatus.  J^Tauche,  Des  Maladies  de  V Uterus, 
8vo.  Paris,  1816.  Osiander,  JVeue  Denkwurdigkeiten, 
1 b.p.  307.  Sabatier,  Midecine  Opiratoire,  t.  2.  Diet, 
des  Sciences  Mifd.  t.  ^,p.  287.  W.  Mewnham  on  the 
Symptoms,  Causes,  and  Treatment  of  Inversio  Uteri, 
with  a History  of  the  successful  Extirpation  of  that 
Organ,  during  the  Chronic  Stage  of  the  Disease,  8vo. 
Lond.  1818.  J.  Windsor,  Obs.  on  Inversion  of  the 
Uterus,  with  a Case  of  successful  Extirpation  of  that 
Organ,  Med.  Chir.  Trans,  vol.  10, p.  358,  <^c.  Denman's 
Plates  of  a Polypus,  with  an  Inversion  of  the  Uterus, 
1801.  Dr.  Baillie's  Series  of  Engravings,  (S-c.,  fasc. 
9,  tab.  5.  Cleghorn,  in  Med.  Communications,  vol.  2 : 
a chronic  case.  E.  B.  Herzog  dc  Inversione  Uteri,  4to. 
Wirceb.  1817. 

UTERUS,  POLYPI  OF.  (See  Polypus.) 

UTERUS,  PROLAPSUS  OF.  The  womb,  situated 
in  the  upper  and  middle  part  of  the  pelvis,  is  but  im- 
perfectly secured  in  its  natural  place  by  means  of  its 
broad  and  round  ligaments ; hence,  it  sometimes  de- 
scends into  the  lesser  cavity  of  the  pelvis,  so  as  to  pass 
more  or  less  down  the  vagina,  or  even  protrude  beyond 
the  labia.  The  first  case  is  the  mcomplete;  the  second, 
the  complete  prolapsus  uteri. 

In  the  first  form  of  the  disease,  where  the  uterus  has 
not  passed  down  so  low  as  to  protrude  externally,  some 
of  the  complaints  which  the  patient  experiences 
depend  upon  the  pressure  of  the  displaced  viscus  upon 
the  parts  unaccustomed  to  it,  particularly  the  bladder 
and  rectum  ; while  other  inconveniences  arise  from  the 
tension  of  the  ligaments,  destined  to  retain  the  organ 
in  its  natural  position.  These  last  grievances  are 
chiefly  a sense  of  heaviness  in  the  pelvis,  and  a drag- 
ging pain  in  the  loins ; symptoms  which  are  aggra- 
vated when  the  patient  sits  up,  or  walks  about,  but 
diminish  when  she  remains  in  bed,  though,  as  the 
disease  when  neglected  scarcely  ever  fails  to  grow 
worse,  they  rarely  subside  altogether.  However,  such 
amendment  actually  sometimes  happens,  in  conse- 


quence of  the  parts  becoming  gradually  habituated  to 
their  change  of  situation.  When  the  disease  comes 
on  with  great  suddenness,  the  symptoms  are  remarked 
to  be  much  more  severe  than  when  it  takes  place 
slowly : in  the  first  case,  long-continued  syncope,  pain 
over  the  whole  abdomen,  tenesmus,  uterine  hemor- 
rhage, inflammation  of  the  peritoneum,  and  severe 
febrtle  symptoms  may  be  excited. 

With  regard  to  the  effects,  caused  by  the  pressure  of 
the  tumour  on  the  bladder  and  rectum,  they  consist  o'f 
more  or  less  difficulty  in  voiding  the  urine  and  feces. 
Tlie  dysury  and  constipation  increase  in  proportion  us 
the  patient  continues  in  an  upright  posture,  and  the 
uterus  descends  nearer  to  the  inferior  orifice  of  the 
vagina.  Sometimes  the  irritation  brings  on  a conside- 
rable mucous  discharge,  which,  when  the  patient 
suffets  little  other  inconvenience  from  the  prolapsus,  is 
apt  to  be  mistaken  for  fluor  albus  or  gonorrhoea. 

A woman  nmy  become  pregnant,  notwithstanding 
an  incomplete  prolapsus  of  the  womb.  The  displace- 
ment may  even  take  place  at  a more  or  less  advanced 
period  of  gestation  {Portal  des  Accouchemens),  while, 
in  other  still  more  uncommon  instances,  the  prolapsus 
has  been  remarked  to  disappear,  when  the  period  of 
labour  drew  near.  Cases  exemplifying  both  these 
facts,  are 'related  by  Loder  {Journ.  fur  die  Chir.  b.  2, 
p.  13),  by  Saviard.  Porttri  {Mem.  de  I'Acad.  de  Chir.  t. 
3.),  in  the  Journ.  de  M6decine,  t.  45,  and  by  Chopart 
{Traile  des  Maladies  des  Voies  Urinaires).  A pro- 
lapsus uteri  may  also  happen  during  parturition. 
— {Oarin,  Jour,  de  Med.  continue,  t.  4,  p.  265 ; Ducreuz, 
Mem.  de  I'Acad.  de  Chir.  t.  8,  p.  393.) 

When,  in  the  course  of  time,  a prolapsus  uteri 
changes  from  the  incomplete  to  the  complete  state,  all 
the  inconveniences  depending  upon  the  pressure  of  the 
part  upon  the  rectum  and  bladder,  subside ; that  is  to 
say,  the  feces  and  urine  are  now  freely  voided.  But, 
on  the  other  hand,  the  symptoms  arising  from  the 
stretching  of  the  peritoneum  become  considerably 
worse.  The  uterus  drags  down  with  it  the  vagina, 
which  becomes  doubled  on  itself ; and  a part  of  the 
bladder,  connected  with  the  upper  part  of  the  latter  tube, 
is  also  drawn  down.  Some  of  the  abdominal  viscera 
may  even  fall  into  the  cul-de-sac,  formed  by  the  vagina, 
and  considerably  increase  the  size  of  the  tumour.  The 
swelling,  protruding  between  the  thighs,  is  of  an 
oblong,  nearly  cylindrical  form,  and  terminates  below 
in  a narrow  extremity,  in  which  a transverse  opening, 
the  os  tincee,  may  be  discerned,  from  which  the  menses 
are  discharged  at  the  periods  prescribed  by  nature. 
However,  the  cylindrical  shape  of  the  tumour  may  lead 
to  mistakes,  for  the  vagina,  being  doubled  on  itself,  and 
exposed  to  the  effects  of  the  air,  sometimes  looks  like 
skin.  Hence,  women  thus  afflicted  have  occasionally 
been  supposed  to  be  hermaphrodites,  the  tumour  being 
mistaken  for  a penis.  Such  a case  is  recorded  by 
Saviard. 

The  patient  is  generally  troubled  with  tenesmus,  and 
sometimes  feels  acute  pain  in  the  tumour  itself,  which  is 
subject  to  inflame  and  ulcerate,  in  consequence  of  its 
depending  posture,  the  friction  to  which  it  is  exposed, 
and  the  irritation  of  the  urine. 

The  direction  both  of  the  bladder  and  urethra 
becomes  horizontal,  so  that  the  urine  is  thrown  for- 
wards, or  even  upwards,  in  which  latter  case  it  wets 
the  abdomen.  Frequently  the  bladder  cannot  be  emp- 
tied without  the  assistance  of  the  catheter ; and  some 
times  the  displaced  uterus  becomes  affected  with 
inflammation  and  swelling.  In  many  cases,  there  are 
profuse  hemorrhages.  However,  some  women  jecome 
so  habituated  to  the  disease,  that  thejl  hardly  seem  to 
experience  any  annoyance  from  it ; whenever  tiey  are 
in  an  erect  posture,  and  walk  about,  the  wonib  falls 
down,  bringing  with  it  the  vagina ; and  as  soon  as  they 
lie  down  on  their  backs,  the  parts  as  readily  return  into 
their  natural  position  again. 

The  incomplete  prolapsus  is  alone  subject  to  any  ob- 
scurity, which,  however,  may  be  dispelled  by  manual 
examination.  In  this,  however,  some  precautions  are 
necessary.  For  instance,  as  the  womb  generally  re 
turns  into  its  natural  situation  when  the  patient  lies 
down,  the  examination  should  always  be  made  as  she 
is  standing  up.  For  the  same  reason,  if  she  is  in  the 
habit  of  lying  long  in  bed,  the  morning  is  not  the  best 
period  of  the  day  for  the  examination.  The  practi- 
tioner may  also  be  deceived,  if  he  examine  the  parts 
when  the  rectum  and  bladder  are  distended  with  their 


438 


UTERUS,  PROLAPSUS  OF. 


contents,  in  which  state  the  uterus  may  be  hindered 
from  descending  as  low  as  at  other  periods. 

If  attention  be  paid  to  these  circumstances,  an  in- 
complete prolapsus  may  always  be  distinguished 
without  risk  of  error.  However,  the  records  of  sur- 
gery prove,  that  the  case  has  sometimes  been  mistaken 
by  the  inexperienced  or  ignorant  fin-  a polypus,  and 
the  part  extirpated  under  this  supposition.  So  serious 
a blunder  will  be  avoided,  if  care  be  taken  to  remember, 
that  polypi  are  generally  softer,  and  less  sensible,  than 
the  uterus  ; that,  in  a case  of  prolapsus,  the  os  tincse  is 
situated  at  the  lower  part  of  the  swelling ; and  that  if 
by  chance  any  resembling  aperture  should  be  met  with 
upon  the  corresponding  portion  of  a polypus,  the  pro- 
lapsus may  still  be  known  by  the  greater  depth  to 
which  a probe  will  enter  such  opening.  A polypus  of 
the  uterus,  I believe,  is  always  broadest  at  that  ex- 
tremity which  is  nearest  the  vulva  ; but  the  woutb,  in 
a state  of  incomplete  prolapsus,  forms  a tumour  which 
is  narrower  below  thati  above.  With  very  few  excep- 
tions, the  womb  is  likewise  reducible,  and  the  patient 
directly  afterward  feels  great  relief ; whereas  a polypus 
cannot  be  pushed  back,  and  the  attempt,  instead  of 
giving  relief,  only  increases  the  patient’s  sufferings. 

In  a complete  prolapsus,  no  doubt  can  ever  prevail 
about  the  real  nature  of  the  case,  for  whatever  uncer- 
tainty the  feel  of  the  parts  may  create,  none  can  ever 
remain  when  the  swelling  is  distinctly  visible. 

Although  Mauriceau,  Saviard,  and  Monro  have  re- 
corded instances  of  prolapsus  uteri  in  maidens,  such 
cases  are  exceedingly  rare.  The  disease  is  hardly  ever 
met  with,  except  in  women  who  have  had  children, 
and  generally  in  those  who  have  borne  a great  many. 
This  particularity  is  ascribed  by  writers  to  the  elon- 
gation of  the  ligaments  of  the  uterus  in  women,  in 
whom  this  organ  has  been  repeatedly  gravid.  The 
same  consideration  may  also  account  for  the  frequency 
of  prolapsus  uteri  during  the  first  months  subsequent 
to  parturition,  especially  as  the  womb  remains  for  some 
time  after  labour  more  enlarged  and  heavy  than  na- 
tural. The  disease  is  more  common  in  thin  than  fat 
women,  and  is  said  often  to  take  place  in  females  when 
they  suddenly  change  from  a fat  to  a very  emaciated 
state.  The  displacement  is  facilitated  by  a capacious 
vagina,  by  a great  width  of  the  lesser  cavity  of  the 
pelvis,  and  the  effects  of  tedious  and  profuse  attacks 
-of  fiuoralbus.  Prolapsus  uteri  has  also  been  brought 
on  by  violent  concussions  of  the  body ; the  protracted 
efforts  of  vomiting,  coughing,  or  crying,  hard  labour, 
and  lifting  or  carrying  heavy  burdens.  In  what  has  been 
stated,  one  may  discern  the  reason,  why  the  affliction 
is  so  frequent  among  the  lower  classes  of  society,  and 
why  women,  for  a certain  time  after  parturition,  should 
avoid  an  erect  posture,  and  every  kind  of  exertion.  In 
the  treatment  of  pfolapsus  uteri,  there  are  two  indi- 
cations : the  first  is  to  reduce  the  part ; and  the  second 
is  to  keep  it  from  falling  down  again. 

In  the  incomplete  prolapsus,  the  first  indication  is 
very  easy  of  accomplishment;  and,  indeed,  when  the 
patient  is  placed  on  her  back  with  her  pelvis  raised 
somewhat  higher  than  her  chest,  the  uterus  often  re- 
turns of  itself  into  its  natural  situation  again.  At  all 
events,  the  reduction  may  be  immediately  effected  by 
pushing  the  uterus  up  into  the  pelvis  with  the  fingers. 

More  difficulty  generally  attends  the  reduction  of  a 
complete  prolapsus.  Here  the  same  posture  is  to  be 
chosen  as  in  the  former  case;  but  the  legs  and  thighs 
should  be  bent.  The  rectum  should  also  be  first  emptied 
with  clysters.  Sometimes,  indeed,  every  attempt  at 
reduction  fails,  notwithstanding  the  adoption  of  the 
most  vigorous  measures,  the  use  of  the  warm  bath, 
purgatives,  venesection,  low  diet,  fomentations,  &c. 
Occasionally,  the  part  is  returned  after  a great  deal  of 
trouble;  but  owing  to  the  long- altered  state  of  parts, 
the  reduction  brings  on  worse  symptoms  than  resulted 
from  the  continuance  of  the  prolapsus.  Such  a case 
is  recorded  by  Richter. — {Bibl.  der  Chir.  1.  3,  p.  141.) 
The  patient’s  sufferings  were  so  much  increased  by 
the  reduction,  and  so  obstinate  a constipation  came 
on,  that  it  became  absolutely  necessary  to  let  the  ute- 
rus descend  again.  In  any  irreducible  case,  all  that 
can  be  done  is  to  support  the  swelling  and  prevent  its 
increase  with  a suspensory  bandage,  and  draw  off  the 
urine  with  a catheter  whenever  requisite.  In  these 
cases,  the  altered  course  of  the  meatus  urinarius  is  to 
be  remembered,  and  the  catheter  directed  horizontally 
towards  the  tectum. 


When  the  displaced  uterus  is  inflamed  and  consider- 
ably swelled,  the  attempt  at  reduction  should  be  pre- 
ceded by  antiphlogistic  remedies,  the  patient  should  be 
kept  in  bed,  be  put  on  a low  regimen,  be  bled,  take 
purgative  medicines,  use  the  warm  bath,  and  drink 
diluent  beverages,  while  emollient  applications  are 
made  to  the  part  itself.  This  plan  of  ireatmeni  has 
often  been  attended  with  complete  success  in  cases  of 
prolapsus  uteri  of  long  standing  and  considerable  size. 
Ruysch  disapproved  of  making  any  attempt  to  reduce 
the  uterus  while  it  w-as  inflamed  and  swelled.  He  also 
thought  that  the  operation  should  be  postponed  when 
the  uterus  was  in  an  ulcerated  state.  However,  Saba- 
tier rightly  observes,  that  as  this  complication  is  only 
accidental,  and  merely  arises  from  the  friction  to  which 
the  tumour  is  exposed,  and  the  irritation  of  the  urine, 
the  plan  of  immediately  replacing  the  part  cannot  be 
attended  with  any  danger.  On  the  contrary,  since  the 
cause  which  produces  and  keeps  up  the  ulceration 
will  cease  as  soon  as  the  reduction  is  accomplished, 
the  sores  will  heal  after  the  uterus  is  put  into  its  natu- 
ral situation  again. 

When  a prolapsus  uteri  occurs  in  the  early  stage  of 
pregnancy,  this  state  should  not  let  the  practitioner 
neglect  to  reduce  the  part.  Several  instances  are  re- 
corded, in  which  the  reduction  was  successfully  accom- 
plished in  pregnant  women  ; and  one  case  of  this  kind 
is  reported  by  Giraud. — {Journ.  de  Mededne,  t.  45.} 
When  pregnancy  is  far  advanced,  or  the  disease  is  of 
long  standing,  the  reduction  is  difficult.  Perhaps,  says 
Sabatier,  it  may  be  more  prudent,  in  these  circum- 
stances, to  let  the  uterus  continue  protruded  than  to 
disturb  the  mother  and  foetus  with  reiterated  attempts 
to  reduce  the  part.  The  uterus,  however,  should  not 
be  left  to  itself;  but  be  well  supported  with  a suitable 
bandage,  and  the  patient  kept  in  bed.  When  the  pro- 
lapsus uteri  occurs  at  the  period  of  delivery,  every  at 
tempt  at  reduction  is  both  useless  and  dangerous.  In 
this  case,  the  delivery  of  the  foetus  should  be  expedited 
by  gradually  dilating  the  os  tincse,  which,  at  the 
same  time,  should  be  carefully  supported.  'Phe  ex- 
traction of  the  placenta  also  requires  a great  deal  of 
caution,  and  it  should  be  accomplished  by  introducing 
one  hand  into  the  uterus,  with  the  palm  turned  away 
from  the  cavity  of  this  viscus  towards  the  outside  of 
the  placenta,  which  is  to  be  gradually  separated  from 
its  edges  towards  its  centre. 

In  cases  of  complete  prolapsus  uteri,  Ruysch  was  an 
advocate  for  leaving  the  expulsion  of  the  foetus,  if 
alive,  to  be  effected  by  nature  ; and  the  same  writer 
advises  us  to  be  content  with  supporting  the  os  tincae. 
But  when  the  child  is  dead,  he  recommends  extracting 
it  with  o.ie  hand,  while  the  uterus  is  supported  with 
the  other.  Sabatier,  however,  entertains  different  sen- 
timents. The  expulsion  of  the  child,  he  says,  is  not 
less  the  effect  of  the  contraction  of  the  diaphragm  and 
abdominal  muscles,  than  of  the  womb  itself.  Hence, 
when  either  of  these  agents  fails  to  co-operate,  the  de- 
livery becomes  either  very  difficult  or  impossible. 
This  is  exactly  what  happens  in  the  present  case ; for 
the  uterus  having  fallen  down,  cannot  be  compressed 
by  the  diaphragm  and  abdominal  muscles.  Nor  can 
Sabatier  discern  the  reason  why  Ruysch  should  recom- 
mend the  line  of  conduct  to  differ,  according  to  the 
different  state  of  the  child.  This  is  quite  passive  in 
parturition,  and  contributes  not  in  the  least  to  its  own 
expulsion. 

The  second  indication,  or  that  of  keeping  the  uterus 
reduced,  demands  the  employment  of  astringent  injec- 
tions and  pessaries. 

The  uterus  in  a state  of  prolapsus,  is  sometimes  also 
affected  with  scirrhus  and  cancer.  A case  of  this  de- 
scription was  met  with  by  Ruysch ; and,  very  recently, 
a woman  whose  uterus  was  cancerous,  and  in  a state 
of  complete  prolapsus,  without  any  inversion,  was  at- 
tended by  Langenbeck,  who  succeeded  in  removing 
the  diseased  organ  with  a knife,  and  the  patient  re- 
covered. According  to  this  author’s  description,  after 
the  vagina  had  been  separated  from  the  uterus,  the 
latter  organ  was  detached  from  the  peritoneum  with- 
out the  latter  membrane  being  opened,  a small  portion 
of  the  fundus  uteri  being  left,  however,  as  it  appeared 
quite  sound.  The  bleeding  was  very  profuse,  and  re- 
quired the  use  of  the  needle  and  ligatures.  The  ova- 
ries and  divided  ligamenta  rotunda,  were  found  con- 
nected with  the  removed  portion  of  the  uterus. — (Bibl. 
J’iir  die  Chir.  b.  1,  p.  551, 12me.  JJanover,  1818.  Sa- 


UTE 


UTE 


429 


viard,  Observ.  Ohir.  Vimo.  Paris,  1702.  J.  O.  Preund, 
J)e  novo  Artijicio  curandi  Procidentiam  Uteri,  Fran- 
co/. ad  Viadn.  1710.  hevret,  in  Journ.  de  Med.  t.  40, 
et  Obs.  suj^  la  Cure  radicale  des  ylusicurs  Polypes,  <S-c. 
Morgagni  de  Sedibus  et  Causis  Morborum,  epist.  45. 
Kalinus  de  Uteri  Delapsu,  Suppressionis  Urince,  et 
sabsequentis  Mortis  Causa,  Oedani,  1732.  White,  in 
Med.  Obs.  and  Inq.  vol.  2.  Shaw,  in  Mem.  of  the 
Medical  Society  of  London,  vol.  1.  Portal,  Cours 
de  VAnatomie  Med.  t.  5,p.  538,  et  Mim.  de  I'Acnd.  de 
Chir.  t.  3.  Sabatier,  in  Mem.  de  I' Acad,  de  Chir.  t.  3,  p. 
361,  and  Midecine  Operatoire,  t.  2.  Ducreux,  in  Mem.  de 
VAcad.  de  Chir.  t.  8,p.  493.  Osiander,Annalen,  b.  1,  p, 
175.  Diet  des  Sciences  Med.  t.23,  art.  Hysteroptose.) 

UTERUS,  RETROVERSION  OF,  is  said  to  hap- 
pen when  its  fundus  falls  downwards  and  backwards, 
between  the  rectum  and  the  posterior  part  of  the  va- 
gina, while  its  cervix  inclines  upwards  towards  the 
symphysis  pubis.  The  ancients  are  thought  to  have 
had  some  imperfect  notions  of  this  case,  and  in  proof 
of  this  opinion,  certain  passages  are  referred  to  in 
CEtius  (Tetrab.  4,  Serm.  4,  c.  77),  Mercurialis,  Mer- 
catus,  and  others. — (See  Diet,  des  Sciences  Med.  t.  23, 
p.  273.)  Be  this  as  it  may,  it  is  generally  confessed, 
that  the  subject  had  fallen  into  oblivion  when  Dr. 
Wm.  Hunter  called  the  attention  of  his  pupils  to  the 
subject  in  1754,  and  afterward  drew  up  an  interesting 
paper  concerning  it. — {Med.  Obs.  and  Inquiries,  vol.  4, 
8vo.  Lond.  1771.)  Subsequently  the  knowledge  of  the 
subject  has  been  extended  by  the  observations  of  Wlze- 
zeck  {De  Utero  retroflexo,  Prag.  1777),  the  remarks 
of  Richter  {Chir.  Bibl.  b.  5,p.  521,  and  b.  9,  p.  182), 
and  those  of  Wall  {Diss.  de  Uteri  Retrover sione, 
Hal.  1782),  and  by  the  memoir  of  Desgranges,  to 
which  the  prize  of  the  Royal  Academy  of  Surgery  at 
Paris  was  adjudged,  in  the  year  1785.  According  to 
Sabatier,  retroversion  of  the  womb  was  a case  men- 
tioned by  Gregoire  in  his  private  lectures  on  midwifery 
at  Paris. 

Walter  Wall,  an  English  surgeon,  who  had  attended 
Gregofcre,  suspected  that  he  had  met  with  a retroversio 
uteri  in  a woman,  some  months  advanced  in  preg- 
nancy, and  he  called  in  Dr.  Hunter,  in  order  that  he 
might  have  the  benefit  of  his  advice.  However,  she  was 
attacked  with  an  obstinate  constipation,  and  retention  of 
urine,  and  died  in  about  a week.  A large  tumour  was 
found  occupying  the  whole  of  the  pelvis,  and  pushing  the 
vagina  against  the  os  pubis.  It  had  been  found  im- 
practicable to  push  the  swelling  back  inta  the  abdo- 
men, although  the  patient  had  been  put  on  her  knees 
and  elbows,  while  one  hand  had  been  introduced  into 
the  vagina,  and  two  fingers  of  the  other  hand  into  the 
rectum.  Great  curio.sity  existed  about  what  informa- 
tion would  be  afforded  by  dissection.  On  opening  the 
body,  the  bladder,  which  was  exceedingly  full  of  urine, 
filled  almost  the  whole  anterior  part  of  the  abdomen, 
in  the  same  manner  as  the  uterus  does  in  the  last 
month  of  pregnancy.  When  it  had  been  emptied,  that 
part  of  it  in  wliich  the  ureters  terminate,  and  which  is 
connected  with  the  vagina  and  cervix  uteri,  was  found 
raised  up  as  high  as  the  upper  aperture  of  the  pelvis, 
by  a large  tumour,  which  filled  the  whole  cavity  of  the 
pelvis,  and  was  found  to  be  the  uterus  A catheter, 
when  passed  into  the  vagina,  could  be  made  to  lift  up 
the  latter  viscus  and  the  upper  part  of  the  tumour. 
This  portion  of  the  swelling  on  which  the  bladder  lay, 
consisted  of  the  cervix  uteri,  while  the  fundus  of  this 
organ  was  situated  downwards  towards  the  os  coccy- 
gis  and  an<u8.  The  uterus  was  so  large  that  it  could 
not  be  taken  out  of  the  pelvis  before  the  symphysis 
pubis  was  divided,  and  the  two  ossa  innominata  were 
pulled  asunder.  It  was  found  impossible  to  assign  any 
cause  for  the  displacement  of  the  uterus,  as  the  patient 
had  been  making  no  exertion,  and  had  met  with  no 
fall,  though  she  is  said  to  have  been  frightened  at  some- 
thing just  before  the  complaint  commsneed. 

Dr.  Hunter,  struck  with  the  singular  nature  of  the 
case,  thought  it  deserving  of  the  auention  of  medical 
men,  and  he  made  it  the  subject  of  a lecture,  which  he 
delivered  in  1754,  He  was  afterward  consulted  by  se- 
veral persons  who  were  afflicted  with  retroversio  uteri ; 
but  not  in  so  acute  a way  as  in  the  above  instance. 
All  the  patients  were  in  the  third  month  of  pregnancy, 
and  first  suffered  a difficulty  of  making  water,  suc- 
ceeded by  retention  of  urine,  and  afterward  by  tenes- 
mus and  constipation.  Dr.  Hunter  always  emptied 
the  bladder  and  rectum  by  mean9..of  a catheter  and 


clysters,  which  measures  sometimes  effected  a cure, 
the  uterus  spontaneously  resuming  its  natural  posi- 
tion. In  every  instance  tiie  accident  disappeared  when 
pregnancy  was  more  advanced,  and  the  uterus  had  ac- 
quired larger  dimensions.  In  some  cases,  in  which 
Dr.  Hunter  was  consulted  too  late,  the  trials  to  empty 
the  bladder  and  replace  the  uterus  proved  fruitless,  and 
the  women  died.  Dr.  Hunter  was  so  firmly  convinced 
of  the  impossibility  of  saving  patients  circumstanced 
in  the  above  manner,  unless  extraordinary  means  were 
resorted  to,  that  he  thought  that  an  endeavour  should 
be  made  to  diminish  the  size  of  the  uterus,  by  intro- 
ducing a trocar  into  the  body  of  this  viscus  through  the 
posterior  parietes  of  the  vagina,  so  as  to  let  out  the 
water  of  the  amnios,  the  relative  quantity  of  which  is 
known  to  be  greater  in  the  early  than  in  the  advanced 
stage  of  pregnancy. — (See  Jourcl,  in  Bulletin  de  la 
Faculte  de  M6d.  p.  173,  an  1812.) 

Such  a puncture  might  certainly  be  the  means  of 
bringing  the  uterus  back  into  its  natural  position  ; but 
not  without  considerable  danger  of  abortion  being  pro- 
duced. No  risk  of  this  kind  would  be  encountered  by 
puncturing  the  bladder  above  the  pubes.  In  this  man- 
ner, a free  passage  would  be  afforded  for  the  escape  of 
the  urine,  and  the  reduction  of  the  uterus  might  then 
be  effected.  The  suggestion  of  puncturing  the  uterus, 
I believe,  has  never  been  put  in  practice,  and  my 
opinion  coincides  with  that  of  Mr.  Weir,  who  thinks 
that  it  never  will.  A more  justifiable  mode  of  dis- 
charging the  fluid  would  be  by  opening  the  membranes 
through  the  os  tincae,  if  such  evacuation  were  deemed 
prudent. — {Glasgow  Med.  Journ.  vol.  1,;>.268.) 

Mr.  Lynn,  a surgeon  in  Suffolk,  knew  an  instance 
of  the  bladder  bursting,  and  the  urine  becoming  fatally 
extravasated  in  the  abdomen,  in  a case  of  retroversion 
of  the  uterus,  in  consequence  of  the  patient’s  refusal 
to  submit  to  paracentesis  of  the  bladder. 

Retroversio  uteri  does  not  often  happen,  except  in 
the  third  or  fourth  month  of  pregnancy,  and  in  women 
whose  pelvis  is  very  wide  while  the  brim  is  much  con- 
tracted. If  the  uterus,  in  a pelvis  of  this  conforma- 
tion, be  pushed  back  by  a distended  bladder  and  pressed 
against  the  sacrum,  while  the  soft  pans  yield,  it  be- 
comes, as  it  were,  wedged,  and  is  incapable  of  changing 
its  position,  m this  immoveable  state  it  presses  upon 
the  surrounding  parts,  and  these  upon  it,  so  that  a 
very  serious  train  of  bad  symptoms  is  the  conse- 
quence. 

It  must  not  be  supposed,  however,  that  retroversion 
of  the  womb  occurs  only  in  pregnant  women.  Sweig- 
hauser  and  Schmidt  had  even  seen  it  more  frequently 
inr  unimpregnated  females. — (See  Richter's  Chir.  Bibl. 
b.  5,  p.  132  ; b.  9,;?.  310.)  As  Mr.  Weir  has  remarked, 
pregnancy  is  not  always  necessary  for  the  production 
of  this  affection,  although  he  conceives  that  the  womb 
must  be  in  a certain  degree  enlarged,  either  by  preg- 
nancy or  disease;  before  it  can  become  retroverted. 
“Desault,”  he  observes,  “ relates  an  instance  produced 
by  a polypus,  and  I have  seen  a case,  where  there  was 
chronic  enlargement  of  the  uterus,  but  no  impregnation. 
Mr.  C.  Bell  mentions  a fatal  case  of  obstruction  of 
urine,  as  having  occurred  in  the  practice  of  Mr.  Clieyne, 
where,  on  examination  of  the  body  after  death,  the 
womb  was  found  enlarged  by  disease,  which  had  pro- 
duced the  same  effect  as  if  enlarged  from  pregnancy; 
for  its  fundus  had  fallen  into  the  hollow  of  the  sacrum, 
and  had  formed  adhesions  to  the  rectum,  while  the  os 
uteri,  pressing  upon  the  urethra,  caused  the  obstruc- 
tion. Mr.  Pearson  {Obs.  on  Cancerous  Complaints,  p. 
113)  mentions  a case  of  retroversion  where  the  womb 
was  enlarged  from  cancer.  The  patient,  with  a view 
of  curing  the  cancerous  affection,  adhered  most  rigidly 
to  a diet  composed  of  liquids  only,  and,  in  the  course 
of  four  weeks,  the  severe  pains  were  completely  re- 
moved, the  uterus  reduced  in  size,  and  restored  to  its 
natural  position.  Dr.  Burns  mentions  that  retroversion 
may  take  place  “ whenever  the  womb  is  enlarged  to  a 
certain  degree  by  disease.” 

“ Retroversion  may  also  occur  a short  time  after  de- 
livery, when  the  uterus  is  of  that  size  which  predis- 
poses it  for  being  thrown  out  of  its  true  situation.” 
Mr.  Weir  also  adverts  to  a case,  reported  to  him,  in 
which  a retroversion  happened  two  days  after  delivery. 
The  same  occurrence  is  noticed  by  Calliscn,  and  most 
of  the  cases  recorded  by  Dr.  Merriman  are  of  this  de- 
scription.— (See  Ola.ogow  Med.  .Journ.  vol.  1,  p.  262.) 
It  is  questionable  whether  the  uterus  in  a {terfectly 


430 


UTE 


tJVA 


healthy  state  can  ever  become  retroverted.  Dr.  Denman 
was  of  opinion,  that  the  case  is  possible ; but  this  is  con- 
trary to  what  is  usually  believed,  and  requires  the  con- 
firmation of  facts.  One  of  Mr.  Weir’s  cases  happened 
in  a female  48  years  of  age,  just  after  the  catamenia 
had  permanently  ceased ; and  Dr.  Merriman  has  known 
of  similar  examples.  At  this  crisis,  the  circumstance 
of  the  uterus  being  apt  to  enlarge  and  grow  heavy, 
may  explain  the  reason  of  its  displacement. — (See 
Glasgow  Med.  Journ.  vol.  1,  p.  265.) 

The  first  care  of  a practitioner,  consulted  in  a case 
of  retroversio  uteri,  should  be  to  empty  the  bladder  and 
large  intestines,  and  to  relax  the  parts  by  every  possible 
means.  Then  he  should  immediately  proceed  to  re- 
duce the  uterus  by  placing  the  patient  in  a suitable 
posture,  and  making  methodical  pressure  in  the  rectum 
and  vagina.  Shoula  he  be  so  fortunate  as  to  succeed, 
the  patient  is  to  be  confined  in  bed,  her  bowels  are  to 
be  kept  open,  and  she  is  to  be  advised  always  to  obey 
the  calls  of  nature  the  first  moment  she  is  conscious  of 
them. 

She  is  also  to  be  enjoined  to  avoid  all  kinds  of  ex- 
ertion, and  wait  till  the  gradual  enlargement  of  the 
uterus  removes  the  possibility  of  its  descending  into 
the  pelvis. — {Sabatier,  Medecine  Operatoire,  t.  2.) 

Some  practitioners,  of  considerable  eminence,  rather 
discourage  the  manual  interference  to  reduce  the 
uterus,  believing  that  drawing  off  the  urine  will  gene- 
rally render  such  interference  unnecessary. — {Croft, 
in  Lond.  Med.  Journ.  vol.  9,  p.  53.  Denman's  Mid 
wifery,^to.Lond.\Q0\.  Burns's  Midwifery.  S.Mer 
riman  on  Retroversioii  of  the  Womb,  Svo.  Lond.  1810.) 

This  difference  of  practice  arose  from  the  different 
views  taken  of  the  cause  of  the  displacement  of  the 
womb.  Dr.  Hunter  believed,  that  the  retroversion  was 
the  cause  of  the  retention  of  urine,  and  of  all  the  other 
symptoms.  On  the  contrary.  Dr.  Denman  argued,  that 
the  retention  of  urine  was  the  first  symptom,  and  that 
the  consequent  enlargement  of  the  bladder  raised  the 
neck  and  mouth  of  the  womb,  and  caused  the  fundus 
to  fall  backwards;  in  which  position  its  pressure  on 
the  urethra  and  rectum  kept  up  the  retention  of  urine, 
tenesmus,  difficulty  of  emptying  the  bowels,  &c. 

In  one  case,  under  Mr.  Weir,  although  the  urine  was 
repeatedly  drawn  off  by  means  of  a catheter,  with 
some  difficulty,  the  uterus  could  not  be  reduced  until 
an  assistant  pushed  its  fundus  upwards,  with  his  hand 
passed  into  the  rectum;  while  Mr.  Weir  himself  cau- 
tiously drew  down  the  mouth  of  the  womb.  Abortion 
followed ; but  the  patient  recovered. 

I have  adverted  to  the  case  where  Dr.  Hunter  could - 
not  succeed  in  the  reduction ; and  where,  after  death, 
the  uterus  was  so  fixed  in  the  hollow  of  the  sacrum, 
that  it  could  pot  be  replaced  until  the  symphysis  of  the 
pubes  had  been  divided.  But,  as  Mr.  Weir  remarks, 
the  reduction  may  in  general  be  easily  accomplished 
when  attempted  early;  and  although  it  has  been  as- 
serted, that  forcible  attempts  will  be  very  apt  to  pro- 
duce abortion,  or  even  worse  consequences,  he  is  not 
aware  of  any  case  on  record,  where  bad  efects  were 
fairly  attributable  to  the  manual  efforts.  Abortion  has, 
no  doubt,  occurred  ; but  this,  he  argues,  was  the  con- 
sequence of  the  disease,  or  deemed  absolutely  neces- 
sary to  effect  the  reduction.  He  admits  that  violent 
and  unnecessary  attempts  are  not  justifiable;  but  he 
contends,  that  if  the  retroversion  be  complete,  and 
dangerous  symptoms  be  present,  the  uterus  must  be 
replaced  at  every  risk.  Our  efforts,  he  thinks,  should 
be-  in  proportion  to  the  difficulty  to  be  overcome.  He 
is  aware,  that  cases  have  occurred  in  which  the  uterus 
could  not  be  moved.  Besides  the  case  quoted  above 
f^rom  Dr.  Hunter,  where  the  fundus  of  the  womb  could 
not  be  got  out  of  the  sacrum  even  in  the  dead  subject, 
until  the  symphysis  of  the  pubes  had  been  divided,  he 
states,  that  the  same  thing  happened  in  a patient  who 
had  been  under  Dr.  Perfect  {Perfect's  Cases  in  Mid- 
wifery, vol.  1,  p.  394);  and  in  a singular  case,  related 
by  Mr.  White,  of  Paisley  {Med.  Communications,  vol. 
20),  many  attempts  to  replace  the  womb  were  made  in 
vain.  Here,  however,  the  uterus  was  enlarged  from 
disease  as  well  as  one  of  the  ovaries.  The  patient  re- 
covered after  much  danger,  and  the  bursting  of  an  ab- 
scess of  the  ovary  into  the  rectum.  “The  advocates 
for  non-interference  have  asserted  (says  Mr.  Weir), 
that  the  catheter  can,  in  general,  be  easily  introduced  ; 
and  that  the  distention  of  the  bladder,  which  is  the 
cause  of  the  retroversion,  being  thus  removed,  all 


chance  of  danger  is  obviated ; and  one  author  men-r 
tions,  that  no  case  will  ever  occur  where  the  ufine 
cannot  be  drawn  off.  Now,  the  cases  already  referred 
to  clearly  show,  that,  in  general,  there  will  be  more  or 
less  difficulty  in  introducing  the  catheter ; and  there 
are  some  on  record,  where  it  was  found  impossible. 
In  Dr,  Cheston’s  {Med.  Commun.  vol.  2,  p.  96),  Mr. 
Lynn’s  {Med.  Obs.  and  Inq.  vol.  4),  Dr.  Squire’s  {Med. 
Review,  1801),  M.  Baudelocque’s  {L'Art  des  Accouch- 
mens,  sect.  253),  Doeverius’s  Case  {Merriman  on  Re- 
troversion^p.  12),  Mr.  Combe’s  {Med.  Comment,  vol.  5), 
and  Dr.Perfect’s  {Cases,  vol.  \,p.  394),  the  urine  could 
not  be  drawn  off.  In  the  first,  the  bladder  was  punc- 
tured above  the  pubes;  and  in  four  the  bladder  burst. 

Mr,  Weir,  as  I conceive,  with  great  reason,  doubts 
the  correctness  of  the  doctrine,  that  the  distention  of 
the  bladder  is  the  first  cause  of  the  retroversion. 
When  this  takes  place,  a full  slate  of  the  bladder  may 
certainly  tend  to  increase  it,  and  to  prevent  the  reduc- 
tion of  the  uterus.  He  considers  Dr.  Hunter’s  opinion 
as  most  correct;  namely,  tliat  some  degree  of  displace- 
ment first  occurs,  and  that  this  brings  on  the  retention. 
He  adverts  to  cases  in  which  the  urine  was  regularly 
drawn  off  for  several  weeks,  and  the  distention  of  the 
bladder  removed,  yet  the  uterus  did  not  rise.  In  Dr. 
Bell’s  case  {Med.  Trans,  vol.  8),  the  urine  was  drawn 
off  regularly ; but  the  uterus  continued  retroverted,  and 
was  the  remote  cause  of  an  inflammatory  affection  of 
the  abdomen,  which  proved  fatal.  Sir  A.  Cooper  has 
also  referred  to  one  of  Dr.  Marcet’s  patients,  from 
whom  the  urine  was  discharged  regularly;  yet  the 
consequence  of  allowing  the  womb  to  remain  retro- 
verted was  the  death  of  both  mother  and  child.  An- 
other example  is  also  cited  {Mew-York  Med.  Reposi- 
tory, vol.  40),  where  the  urine  was  never  obstructed  at 
all,  and  where  the  retroversion  continued  for  some 
months  till  the  woman  died. — (See  Weir,  in  Glasgow 
Med.  Journ.  vol.  1 ) 

[Ut£rus,  inversion,  prolapsus,  and  retrover- 
sion or  THE.  These  disorders,  as  well  , as  rupture  of 
the  womb,  which  is  not  at  all  noticed,  might  have  been 
treated  of  at  length  by  our  author,  inasmuch  as  they 
exercise  a vast  influence  on  the  female  economy,  and 
are  the  fruitful  source  of  many  serious  affections;  but 
they  are,  doubtless  on  account  of  their  more  close  con- 
nexion with  another  department  of  the  profession,  dis- 
missed in  the  manner  we  see  in  the  text.  The  reader 
will  find  some  mo.st  interesting  observations  on  dis- 
placements of  the  womb,  and  on  the  sequela  of  those 
disorders,  in  the  admirable  work  of  Charles  Mansfield 
Clark,  entitled,  “ Observations  on  the  Diseases  of 
Females  attended  with  Discharges,”  and  also  in  the 
System  of  Midwifery  and  on  Female  Diseases,  by  the 
distinguished  Professor  Dewees,  of  Philadelphia.  See 
also  Ramsbottorn’s  Midwifery,  and  the  edition  of 
Denman’s  Midwifery,  with  notes  and  emendations,  by 
Professor  Francis,  of  New- York,  third  edition,  1829. 
A valuable  paper  on  rupture  of  the  uterus,  by  Professor 
James,  may  be  seen  in  the  New-York  Medical  Reposi- 
tory, vol.  7,  and  a judicious  essay  on  the  same  subject, 
by  Dr.  Church,  in  the  American  Medical  Review,  vol. 
3.  In  this  last  paper  Dr.  Church  satisfactorily  shows,, 
that  too  great  discrepancy  exists  in  the  writings  of  the 
best  writers  on  the  pathological  signs  of  this  lamentable 
accident. — Reese."] 

See  Lynn,  W.  Hunter,  Oarthshore,  Bird,  and 
Hooper,  in  Med.  Obs.  and  Inq.  vols.  4, 5,  and  6.  dies- 
ton  and  Cleghorn,  in  Med.  Communications,  vol.  2. 
John  Clarke,  Practical  Essays  on  the  Management  of 
Pregnancy  and  Labour,  Lond.  1793.  Murray,  in 
Uteri  Retroversionem  Animadversiones,  Upsal,  1797. 
Denman's  Introduction  to  Midwifery,  Lond.  1801.  8. 
Merriman  on  Retroversion  of  the  Womb,  ire.  8vo. 
Lond.  1810.  John,  De  Utero  Retroverso,  Jen.  1787. 
Desgranges,  in  Journ.  de  Mid.  t.  66,  p.  85.  Klein, 
Chir.  Bemerkungen,  p.  235.  Baudelocque  sur  le  Ren- 
versement  de  la  Matricc,  ire.  Paris,  1803.  Cockell, 
Essay  on  Retroversion  of  the  Uterus,  I.ond.  1785. 
Richter,  Chir.  Bibl.  b.  4,  p.  61 — 70,  235 — 555;  6.5,  p. 
132-548 ; 6.  7,  p.  292  ; 6. 8,  p.  715 ; 6.  9,  p.  182 ; 6.  11, 
;>.310— 328;  6. 12,  p.  45—50;  and  two  Cases  of  Retro- 
versio Uteri,  with  Remarks,  in  Glasgow  Med.  .lourn. 
vol.  1,  p.  262,  ire.  This  last  paper  is  full  of  practical 
information,  and  merits  careful  perusal. 

UVA  URSI,  which  was  first  brought  into  notice  by 
De  Haen,  was  once  considered  a powerful  remedy  in 
I calculus;  but,  though  its  virtue  in  lessening  the  irrita- 


VAG 


VAG 


431 


tion  of  the  bladder  is  still  acknowledged,  its  claim  to 
utility  on  any  other  principle  is  quite  rejected.  Dr. 
Austin  recommended  it  for  lessening  tlie  irritability  of 
the  bladder,  and  diminishing  the  secretion  of  diseased 
mucus,  which,  he  supposed,  greatly  contributed  to  the 
augmentation  of  the  stone. 

Mr.  B.  Bell  also  strongly  recommended  it  in  gonor- 
rhoea, where  the  irritability  of  the  bladder  was  excited 
in  a high  degree,  and  where  the  urine  was  loaded  with 
viscid  matter.  In  these  cases,  he  directed  a scruple  or 
half  a drachm  of  the  powder  three  times  a day. 

Dr.  Saunders  used  to  order  three  drachms  of  uva 
ursi  to  be  macerated  in  a pint  of  hot  water,  and  two 
or  three  ounces  of  the  strained  liquor  to  be  given  three 
times  a day.— (PAarm.  Chirurg.) 


UVULA,  AMPUTATION  OP.  The  uvula  is  sub 
ject  to  several  kinds  of  enlargement,  in  which  it  be- 
comes both  longer  and  more  bulky  than  natural,  or  is 
simply  lengthened.  In  consequence  o'f  such  changes, 
it  becomes  troublesome  in  deglutition  and  speaking, 
and  causes  a disagreeable  tickling  at  the  root  of  the 
tongue,  frequent  retchings,  and  an  annoying  cough. 

When  things  have  attained  this  state,  medicines  are 
often  ineffectual,  and  the  only  plan  of  relief  consists  in 
amputating  a portion  of  the  uvula  with  a pair  of  scis- 
sors. I lately  amputated  a gentleman’s  uvula,  on  ac- 
count of  an  obstinate  and  deep  ulceration,  extending 
nearly  through  its  root  and  producing  a lateral  dis- 
placement of  the  part,  attended  with  a considerable 
degree  of  irritation  and  annoyance. 


V 


■^AGINA  IMPERFORATE.  Female  infants  are 

• often  born  with  different  imperforations  of  the 
vagina.  Sometimes  this  passage  is  not  completely  shut 
up,  the  usual  evacuations  happen  in  an  uninterrupted 
manner,  and  it  is  a considerable  time  before  the  mal- 
formation is  discovered.  Some  females  are  even  stated 
to  have  become  pregnant,  notwithstanding  such  ob- 
struction ; and  in  these  cases,  the  membrane,  which 
shut  up  a part  of  the  mouth  of  the  vagina,  was  either 
torn  by  the  effects  of  labour,  or  divided  as  much  as 
was  necessary  for  delivery. 

Two  membranes,  one  placed  beyond  the  other,  and 
obstructing  the  vagina,  have  also  been  found.  That 
which  is  commonly  met  with,  is  only  the  hymen, 
thicker  and  stronger  than  natural.  Ruysch  describes 
the  case  of  a woman,  who  had  been  in  labour  three 
days,  and  could  not  be  delivered.  The  head  presented 
itself,  but  was  prevented  from  coming  out  by  the 
hymen,  which  shut  up  the  vagina,  and  was  very 
tense.  Ruysch  made  an  incision  into  the  membrane  ; 
but  to  no  purpose,  since  there  was  another  membrane 
of  a thicker  texture,  situated  more  deeply  in  the  passage. 
As  soon  as  this  second  membrane  had  been  divided, 
the  child  was  expelled,  and  the  case  ended  well. 

When  the  vagina  is  completely  imperforate,  and  the 
time  of  the  menses  commences,  many  complaints  occur 
which  afflict  the  patient  with  more  severity,  in  pro- 
portion as  the  blood  accumulates  in  the  passage,  and 
they  may  even  lead  to  a fatal  termination,  when  the 
cause  is  not  understood  or  not  detected  till  it  is  too  late. 
These  complaints  are  very  similar  to  those  of  preg- 
nancy ; for  instance,  rumblirig  noises  in  the  bowels, 
loss  of  appetite,  nausea,  vomiting,  enlargement  of  the 
mammae,  spasms,  convulsions,  swelling  of  the  abdo- 
men, &;c.  Hence,  girls  in  this  situation,  have  often 
been  supposed  to  be  pregnant,  although  they  were  not 
in  a state  even  to  become  so ; and  some  young  women 
have  been  known  to  die  after  dreadful  sufferings. 

When  the  malformation  consists  altogether  in  the 
orifice  of  the  vagina  being  shut  up  by  a membrane, 
the  patient  may  be  easily  relieved  by  a crucial  incision 
or  a single  cut,  the  edges  of  which  are  kept  apart  by  a 
tent  of  suitable  shape  and  size.  Instances  of  the  suc- 
cess of  such  an  operation  are  to  be  found  in  numerous 
writers-  Fabricius  ab  Aquapendente  informs  us  that  a 
female  child  was  born  with  a membrane,  which  com- 
pletely shut  up  the  vagina.  The  girl  experienced  no 
inconvenience  from  it  till  she  was  about  thirteen,  when 
the  period  of  her  menses  began.  As  the  blood  was  re- 
tained, she  became  afflicted  with  severe  pains  in  the 
loins,  the  lower  part  of  the  abdomen,  and  about  the 
upper  part  of  the  thighs.  She  was  supposed  to  be  at- 
tacked with  sciatica,  and  treated  accordingly.  Medi- 
cines were  prescribed  which  did  no  good ; and,  at 
length,  she  became  hectic,  and  reduced  to  a complete 
stale  of  marasmus,  in  which  she  passed  restless  nights, 
lost  her  appetite,  and  was  delirious.  A painful,  very 
elastic  tumour  afterward  presented  itself  in  that  part 
of  the  abdomen,  which  corresponds  to  the  uterus. 
The  pains  were  aggravated  every  month,  at  the  period 
when  the  patient  ought  to  have  menstruated.  She 
was  in  a dying  condition,  when  Fabricius  ab  Aqiia- 
pendente  was  consulted,  who,  after  ascertaining  the 
real  nature  of  the  case,  performed  the  requisite  opera- 


tion. A prodigious  quantity  of  black  putrid  blood  v/as 
discharged  from  the  vagina;  the  bad  symptoms  gradu- 
ally subsided,  and  the  patient  recovered. — (See  also  J. 
C.  Loder,  Obs.  Imperforationis  VagincB,  leone  illus- 
trata,  4to.  JencEi  1800 ; and  numerous  other  cases  on 
record.) 

When  the  malformation  is  produced  by  an  extensive 
concretion  of  the  sides  of  this  passage  to  each  other, 
the  cure  is  sometimes  difficult.  The  result  of  the  ope- 
ration is  doubtful,  because  it  is  impossible  to  reach  the 
confined  menstrual  fluid,  without  cutting  through  a 
considerable  thickness  of  parts,  in  doing  which  there 
is  .some  danger  of  wounding  the  rectum  or  bladder.  A 
lady,  twenty-four  years  of  age,  after  having  tried  for 
eight  years  such  remedies  as  seemed  best  calculated 
for  exciting  the  menstrual  discharge,  became  affected 
with  a large  hard  swelling  of  the  abdomen,  and  a kind 
of  herpetic  affection  round,  the  body  near  the  navel. 
At  length  it  was  discovered,  that  the  imperforation  of 
the  vagina  was  the  sole  cause  of  all  the  bad  symptoms 
which  the  patient  had  long  endured.  An  incision 
was  made,  which  enabled  the  operator  to  introduce  his 
finger  into  a large  cavity,  and  which  gave  vent  to  a 
considerable  quantity  of  blood,  (t  was  thought  that 
an  opening  had  been  made  into  the  vagina ; but  the 
palient  having  died  three  days  afterward,  it  was  seen 
that  a mistake  had  been  made,  as  the  cavity  in  which 
the  finger  had  been  introduced  was  that  of  the  blad- 
der. The  vagina  was  closed  below  by  a substance, 
one  inch  in  diameter,  and  half  an  inch  thick.  The 
upper  part  of  this  passage,  the  uterus,  and  the  Fallo- 
pian tubes  were  exceedingly  enlarged,  and  filled  with  a 
dark-brown  sanious  fluid.  A similar  fluid  was  found 
extravasated  in  the  abdomen,  through  a rupture,  which 
had  taken  place  in  the  Fallopian  tube.  The  ovaries 
were  in  the  natural  state.  De  Haen,  who  has  related 
this  case  in  the  sixth  part  of  his  work,  entitled  Ratio 
Medendiy  was  of  opinion,  that  in  order  to  avoid  open- 
ing the  rectum  or  bladder,  only  one  oblique  cut  should 
be  made  in  the  membrane  which  stops  up  the  vagina, 
just  as  was  advised  by  M6eckren. — {Sabatier  dc  la 
Medecine  Operatoire,  t.  1.) 

VAGINA,  PROLAPSUS  OR  INVERSION  OF. 
According  to  Sabatier  and  Levret,  the  lining  of  the 
vagina  is  alone  displaced ; but  Richter,  Chelius,  and 
other  writers  describe  the  vagina  as  liable  to  two  kinds 
of  prolapsus ; in  one,  all  its  tunics  are  included  in  the 
protrusion  ; in  the  other,  only  its  relaxed  lining.  It  is 
only  in  thislast  case,  that  the  uterus  may  not  he  involved 
in  the  prolapsus. — {Chelius,  Handb.  der  Chir.  b.  1,  p. 
771.) 

Occasionally,  a prolapsus  of  a very  limited  portion 
of  the  vagina  is  observed.  This  case  is  generally  the 
consequence  of  an  uncommon  sort  of  rupture,  termed 
the  vaginal  hernia  (see  Hernia)  ; but  it  should  also  be 
known  that,  in  some  cases  of  dropsy,  a circumscribed 
protrusion  of  the  vagina  in  the  form  of  a cyst  or  pouch, 
filled  with  fluid,  is  sometimes  noticed. 

When  the  prolapsus  vaginae  is  recent,  the  part  may 
be  easily  reduced  and  kept  up  with  a pessary.  The 
use  of  astringent  lotions  will  then  tend  to  prevent  a 
relapse.  But  when  the  case  has  been  of  long  standing, 
it  is  neither  easy  to  effect  the  reduction  nor  to  prevent 
a recurrence  of  the  disorder.  Softening,  relaxing  re- 


432 


VAR 


VAR 


medies,  in  this  circumsta  ce,  are  recomraenddd,  and 
the  patient  should,  in  particular,  confine  herself  to  her 
bed,  and  wear  a T bandage,  which  should  be  made  to 
press  upon  and  support  a piece  of  sponge  in  the  orifice 
of  the  vagina. 

It  is  reasonable  to  expect  that,  after  a prolapsus 
vaginse  has  continued  a long  while,  the  reduction  must 
be  difficult;  because  the  vagina  in  this  state  becomes 
affected  with  swelling  and  induration.  According  to 
the  reports  of  Hoin  and  Levret,  a large  protrusion  of 
this  kind,  ten  inches  in  length,  was  so  diminished  by 
keeping  the  patient  invariably  confined  in  bed  upon 
her  back,  that  in  the  course  of  a month,  the  rest  of  the 
tumour  admitted  of  being  reduced.  Indeed,  as  Rich- 
ter observes,  there  can  be  little  doubt  that  the  treat- 
ment which  has  been  advised  by  some  authors  for  the 
diminution  of  very  old,  enormous,  omental  ruptures, 
would  here  be  equally  applicable ; viz.  long  confine- 
ment. in  bed  upon  the  back,  with  the  buttocks  some- 
what elevated ; unremitting  well-directed  external 
pressure ; a very  low  diet ; and  repeated  mercurial 
purges. 

During  pregnancy,  a prolapsus  of  the  whole  sub- 
stance of  the  vagina  may  cause  much  embarrassment 
and  even  danger.  In  one  case  of  this  description, 
where  the  protrusion  was  five  inches  in  length,  it  be- 
came necessary  to  turn  the  child,  and  the  displaced 
vagina  was  lacerated.  The  woman,  however,  reco- 
vered.— {Pietsck,  Journal  de  Mdd.  t.  34.)  In  another 
instance,  where  the  prolapsus  became,  at  each  return 
of  the  labour-pains,  as  large  as  a man’s  head,  the 
practitioner  succeeded  in  holding  the  parts  back,  while 
delivery  was  effected  with  the  aid  of  the  forceps. — (See 
Loder's  Journ.  b.  1,  p.  490.)  When  this  is  impracti- 
cable, it  is  necessary,  according  to  Richter,  to  make  an 
incision  through  both  sides  of  the  prolapsus ; a mea- 
sure, says  he,  to  which  the  practitioner  may  the  more 
readily  make  up  his  mind,  inasmuch  as  the  parts  have, 
in  some  cases,  been  lacerated  without  any  ill  conse- 
quences. 

A prolapsus  of  the  inner  membrane  of  the  vagina 
while  small  and  recent,  might  perhaps  be  removed  by 
astringent  applications.  When,  however,  it  is  of  long 
standing,  indurated,  and  of  large  size,  much  expecta- 
tion of  success  from  this  treatment  cannot  be  enter- 
tained. Richter  sees  no  reason  why,  in  such  a case,  j 
the  superfluous  rela.xed  part  should  not  be  cut  away, 
especially  if  the  disease  be  accompanied  with  ulcer- 
ation and  other  serious  complaints.  As  he  observes, 
there  can  be  no  doubt  that  a prolapsus  of  the  inner 
membrane  of  the  vagina,  when  limited  to  one  part  of 
this  canal,  may  always  be  safely  extirpated,  either 
with  a knife  or  a ligature. — {Anfangsgr.  der  Wun- 
darzn.  h.  7,  chap.^\  J.  C.  Loder,  Progr.  1 — 3.  De 
VagincR  Uteri  Procidentia  ; Jen.  1781.  M.  J.  Chelius, 
Ilandb.  der  Chir.  b.  1,  p.  770,  Heidelb.  1826.) 

VARICOCE'LE.  (From  varix,  a distended  vein, 
and  Kr/Xri,  a tumour.)  Many  writers  mean  by  the  term 
varicocele,  a varicose  enlargement  of  the  spermatic 
veins,  which  latter  affection  I have,  with  Celsus  and 
Pott,  treated  of  under  the  name  of  Cirsocele. 

Pott  remarks,  that  the  varicocele  (which  is  an  en- 
largement and  distention  of  the  blood-vessels  of  the 
scrotum)  is  very  seldom  an  original  disease,  independ- 
ent of  any  other,  and  when  it  is,  that  it  is  hardi'y  an 
object  of  surgery.  The  original  disease  is  what  en- 
gages our  attention,  and  not  this  simple  effect  of  it.— 
{Pott's  Chirurgical  Works,  vol.  2.) 

VARICOSE  VEINS.  T he  term  waWx  is  applied  by 
surgeons  to  the  permanently  dilated  state  of  a vein,  at- 
tended with  an  accumulation  of  dark-coloured  blood, 
the  circulation  of  which  is  materially  retarded  in  the 
affected  vessel.  When  veins  are  varicose,  they  are 
not  only  dilated,  they  are  also  evidently  elongated; 
for,  besides  being  irregular,  and  in  several  places  stud- 
ded with  Knots,  they  rnake  a variety  of  windings,  and, 
coiling  themselves,  form  actual  tumours. 

Varices  are  most  commonly  observed  in  the  lower 
extremities,  reachina  sometimes  even  as  far  up  as  the 
abdomen.  They  have,  however,  been  noticed  in  the 
upper  extremities,  and  it  is  probable  that  the  whole 
venous  system  is  susceptible  of  the  affection.  As  a 
well  informed  writer  observes,  “ the  great  venous  trunk 
sometimes  becomes  varicose.  When  the  disease  is 
situated  near  the  heart,  it  is  attended  with  pulsation, 
which  renders  it  liable  to  be  mistaken  for  aneurism. 
Morgagni  observed,  that  the’jugular  veins  were  occa- 


sionally very  much  dilated,  and  possessed  a pulsation 
— {Letter  8,  art.  9, 10, 11.)  He  also  relates  a case  in 
which  the  vena  azygos,  for  the  length  of  a span,  was  so 
much  dilated  that  it  might  be  compared  with  the  vena 
cava.  The  patient  died  suddenly  in  consequence  of 
the  rupture  of  this  varix  into  the  right  side  of  the 
chest. — {Letter  26,  art.  29.)  A similar  case  is  related 
by  Portal,  who  also  mentions  an  instance  in  which  the 
right  subclavian  vein  was  excessively  dilated  and  burst 
into  the  chest. — {Cours  d'Anatomie  Medicate,  tom.  3,  p. 
354.  373.)  Mr.  Cline  described  in  his  lectures  the  case 
of  a woman,  who  had  a large  pulsating  tumour  in  her 
neck,  which  burst  and  proved  fatal  by  hemorrhage.  A 
sac  proceeded  from  the  internal  jugular  vein;  the 
carotid  artery  was  lodged  in  a groove  at  the  posterior 
part  of  this  sac.  The  veins  of  the  upper  extremity 
very  rarely  become  varicose.  Excepting  cases  of 
aneurismal  varix,  the  only  instance  of  this  disease 
with  which  I am  acquainted,  is  mentioned  by  Petit.— 
( Traits  des  Maladies  Chir.  tom.  2,  />.49.)  In  this  case, 
a varix  was  situated  at  the  bend  of  the  arm : the  pa- 
tient was  so  fat  that  no  other  vein  could  be  found  for 
the  purpose  of  venesection,  which  operation  Petit  re- 
peatedly performed  by  puncturing  this  varix.  The  su- 
perficial epigastric  veins  sometimes  become  varicose, 
but  the  most  frequent  seats  of  this  disease  are  the  venae 
saphenae,  the  spermatic  and  hemorrhoidal  veins.” — 
(See  Hodgson's  Treatise  on  the  Diseases  of  Arteries 
and  Veins,  p.  538,  539.)  The  deep-seated  veins  of  the 
extremities  seldom  become  varicose.  The  disease 
rarely  occurs  before  the  adult  period  of  life,  and  its 
progress  is  extremely  slow.  It  is  very  frequently  re- 
marked in  pregnant  women,  who  have  passed  a certain 
age  ; but  it  is  particularly  unusual  for  it  to  happen  in 
young  women,  even  during  a series  of  repeated  preg- 
nancies. Surgeons  have  not  hitherto  made  out  any 
very  precise  information  respecting  the  kinds  of  con- 
stitution which  promote  the  occurrence  of  a varicose 
enlargement  of  the  veins.  Norhasitbeen  well  proved 
that  the  disease  often  proceeds  from  swellings  of  the 
abdominal  viscera,  or  any  other  species  of  tumour  ca- 
pable of  mechanically  obstructing  the  venous  circula- 
tion. (Jne  or  more  veins  of  the  same  limb  are  at  first 
most  commonly  affected  with  a slight  degree  of  dila- 
lation,  without  pain  or  any  sensation  of  uneasiness. 
This  beginning  change  ordinarily  advances  with  great 
slowness,  except  in  cases  where  it  accompanies  preg- 
nancy, in  which  circumstance  one  or  both  the  lower 
extremities,  as  early  as  the  first  months,  are  frequently 
seen  covered  with  largely  dilated  veins,  or  even  with 
tumours  formed  by  an  assemblage  of  varices.  The 
veins  gradually  become  more  and  more  distended, 
lengthened,  coiled  up,  and  tortuous.  The  patient  then 
begins  to  complain  of  a sense  of  heaviness,  numbness, 
and  sometimes  of  very  acute  wandering  pain  through 
the  whole  of  the  affected  limb.  In  a more  advanced 
age,  in  proportion  as  the  varices  increase,  and  especi- 
ally when  the  dilated  veins  actually  form  tumours,  the 
limb  swells  and  becomes  more  or  less  oedematous,  ac- 
cording to  the  extent  of  the  disease,  and  the  time  which 
it  has  existed.  Delpech  thinks,  however,  that  the 
oedema  in  this  case  is  not  such  as  to  justify  the  conclu- 
sion, that  the  increased  size  of  the  veins,  and  the  way 
in  which  they  distend  the  integuments,  produce  a me- 
chanical interruption  of  the  function  of  the  absorbent 
system.  For,  says  he,  enormous  varices  are  some- 
times, though  not  often,  met  with,  which  are  not  at- 
tended with  any  swelling  of  the  cellular  sub.«tance; 
and  cases  are  still  more  frequently  seen  in  which  there 
is  a considerable  degree  of  oedema,  while  the  varices 
are  scarcely  remarkable.  When  the'Iatter  have  pre- 
vailed a long  while,  and  made  mucJi  progress,  the 
coats  of  the  affected  veins  are  not  unfrequently  thick- 
ened, swelled,  and  indurated,  forming  a sort  of  half- 
canal or  solid  tube.  As  Mr.  Hodgson  remarks,  “ the 
blood  occasionally  deposites  strings  of  coagulum  in  va- 
ricose veins  ; when  this  is  the  case,  the  vessel  is  inca- 
pable of  being  emptied  by  pressure,  and  is  firm  to  the 
touch.  The  deposition  does  not  in  general  fill  the 
vessel,  but  by  diminishing  its  caliber,  it  retards  the 
flow  of  blood,  and  causes  the  dilatation  to  increase  in 
the  inferior  portion  of  the  vein,  and  in  the  branches 
which  open  into  it.”— (On  the  Diseases  of  Arteries 
and  Veins,  p.  541.)  This  gentleman  has  seen  four 
cases,  in  which  the  coagulum  accumulated  to  such  an 
extent,  that  the  canals  of  the  dilated  vessels  were  obli 
. terated,  and  a spontaneous  cure  was  the  consequence 


VARICOSE  VEINS, 


433 


The  excessive  distention  of  the  coats  of  a superficial 
vein  produces  an  inflammatory  irritation,  at  first  in  the 
a^oining  cellular  membrane,  and  afterward  in  the  in- 
teguments. These  textures  become  at  first  connected 
together  by  the  adhesive  inflammation ; and  if  the 
distention  continue  to  operate,  they  mtfy  at  length 
ulcerate  and  burst,  and  hemorrhage  be  the  consequence. 
In  such  cases,  th#  eflfusion  of  blood  is  sometimes  con- 
siderable; but,  says  Delpech,  we  have  no  example  of 
its  having  proved  dangerous.  The  syncope  following 
it,  or  a moderate  compression,  suffices  for  its  stoppage. 
A more  common  occurrence  than  bleeding  is  the  coagu- 
lation of  the.  blood  in  the  cavity  of  a varicose  vein. 
The  vessel  then  becomes  hard  and  incompressible,  and 
it  loses  that  elastic  yielding  softness  which  renders  it 
capable  of  being  diminished  by  gentle  pressure.  If  the 
parts  be  already  inflamed,  Delpech  conceives  that  the 
clot  in  the  diseased  vein  may  act  as  an  extraneous 
body,  and  bring  on  ulceration  by  the  effects  of  which 
it  is  at  last  brought  into  view.  In  this  sort  of  case,  it 
is  extremely  uncommon  for  hemorrhage  to  occur ; for, 
in  general,  the  vessel  is  already  obliterated  by  the  pre- 
ceding inflammation.  But  the  ulcer  itself  is  very  diffi- 
cult to  heal,  and  may  be  kept  up  a long  while  by  the 
(Edematous  swelling  of  the  limb.  Varices,  or  rather 
the  oedema,  which  is  the  consecytence  of  them,  have 
the  same  effect  upon  every  other  species  of  ulcer,  and 
even  upon  the  most  simple  solution  of  continuity. 
While  the  swelling  of  the  limb  cannot  be  dispersed  ; 
while  the  edges  of  a solution  of  continuity  are  kept 
asunder  by  the  tense  state  of  the  skin  ; and  while  the 
divided  parts  are  irritated  by  this  painful  tension ; 
every  thing  is  unfavourable  to  cicatrization.  Thus  we 
see  the  most  simple  wounds,  which  have  been  allowed 
to  suppurate,  and  ulcers,  which  should  have  healed 
rapidly,  continue  uncured  a great  many  years,  merely 
because  the  limbs  on  which  they  are  situated  are  af- 
fected with  an  oedematous  swelling,  the  consequence 
of  varices.  Such  is  the  condition  of  things  ia  the 
case  which  has  been  improperly  named  the  varicose 
■ulcer. — {.Delpech.,  Precis  des  Maladies  Chir,  t.  3,  sect. 
8,  art.  3.) 

In  the  investigation  of  the  causes  of  varices,  it  is 
usual  to  dwell  very  much  upon  the  mechanical  ob- 
structions which  may  affect  the  circulation  of  the 
blood  in  the  veins.  Surgeons  have  thought  themselves 
justified  in  regarding  this  as  the  only  cause,  because  a 
circular  moderate  compression  incontestably  retards 
the  course  of  the  blood  in  these  vessels,  and  produces 
a temporary  dilatation  of  them.  The  opinion  seems 
also  to  derive  confirmation  from  the  knotty  appear- 
ance of  varicose  veins ; a circumstance  which  has  been 
accounted  for  by  supposing  that  the  distention  is  great- 
est in  the  situation  of  the  valves.  Lastly,  the  idea  is 
farther  supported  by  the  well-known  fact  of  the  fre- 
quent occurrence  of  varices  during  the  state  of  pieg- 
nancy.  But  it  has  not  been  remembered  that  the  use 
of  garters,  for  example,  is  extremely  common,  yet  va- 
rices of  the  legs  are  infinitely  less  frequent ; that  very 
large  varices  are  met  with  in  persons  who  have  never 
employed  any  kinds  of  ligatures,  to  which  the  origin 
of  the  complaint  can  be  imputed;  that  when  the  dila- 
tation of  the  veins  extends  to  the  thighs  and  parietes 
of  the  abdomen,  no  causes  of  this  description  even  ad- 
mit of  suspicion : that  varicose  veins  are  observable 
round  several  kinds  of  tumours,  especially  scirrhi, 
when  there  is  no  possibility  of  pointing  out  any  mecha- 
nical obstruction  to  the  circulation  of  the  blood ; that 
varices  sometimes  make  their  appearance  at  the  com- 
mencement of  pregnancy,  and  long  before  the  enlarge- 
ment of  the  womb  can  impede  the  free  return  of  the 
blood  through  the  veins  in  the  pelvis ; that  nothing  is 
more  unusual  than  a varicose  dilatation  of  the  veins 
of  the  lower  extremities  in  consequence  of  swellings 
of  the  abdominal  viscera ; and,  lastly,  it  has  been  for- 
gotten, that  the  knots  of  the  dilated  veins  are  far  too 
numerous  to  admit  of  being  ascribed  to  the  resistance 
of  the  valves.  It  cannot  be  denied,  that  pressure  ap- 
plied in  the  track  of  the  vessels  tends  to  promote  their 
dilatation;  but  it  can  neither  be  considered  as  the  only 
cause,  nor  as  the  principal  one.  The  foregoing  ob- 
servations, made  by  Delpech,  render  it  probable,  that 
some  unknown  general  cause  is  concerned  in  produc- 
ing varices,  the  formation  of  which  may  also  be  faci- 
litated by  the  impediments  to  the  free  return  of  the 
blood  occasioned  by  certain  attitudes  and  particular 
articles  of  clothing. 

VoL.  II.-E  e 


Mr.  Hodgson  conceives  it  probable,  that,  in  some  in- 
stances, the  valves  are  ruptured  in  consequence  of 
muscular  exertions  or  external  violence,  in  which  cases 
the  pressure  of  the  column  of  blood  is  the  first  cause 
of  the  dilatation  of  the  veins.  Sometimes  also  the  dis- 
ease appears  to  arise  from  preternatural  weakness  in 
the  coats  of  the  veins,  as  iit  those  instances  in  which, 
without  any  evident  cause,  it  exists  in  various  parts  of 
the  same  person. — {Treatise  on  the  Diseases  of  Arte- 
ries and  Veins,  p.  537.) 

Experience  proves,  says  Delpech,  that  there  is  no 
certain  mode  of  curing  varices,  strictly  so  called, 
which  he  thinks  cannot  be  wondered  at,  since  the  na- 
ture and  causesof  the  disease  are  completely  unknown. 
The  same  source  of  knowledge,  however,  also  proves 
that  the  increase  in  the  dilatation  of  varicose  veins  may 
be  retarded,  and  that  the  oedematous  swelling  attend- 
ant on  the  complaint  may  be  beneficially  opposed  by 
methodical  and  permanent  compression.  When  the 
wliole  of  a limb  affected  with  varices  is  subjected  to 
this  last  mode  of  treatment,  the  dilated  veins  subside, 
the  circulation  is  more  regularly  performed,  and  the 
oedema  and  pain  cease.  There  is  not  (says  Delpech) 
any  belter  method  of  healing  the  solutions  of  continuity 
in  the  soft  parts,  produced  or  kept  up  by  the  varicose 
state  of  the  limb  and  its  consequences.  But  sometimes, 
as  soon  as  the  compression  is  discontinued,  the  varices 
make  their  appearance  again,  the  pain  recurs,  the  oede- 
ma returns,  and  the  ulcers  which  were  healed  break 
out  afresh. 

Inflammation  of  the  integuments  covering  a varix 
or  varicose  tumour  cannot  invariably  be  prevented  by 
compression,  nor  will  this  treatment  always  succeed 
even  in  removing  the  intolerable  pain  which  some- 
times attends  numerous  clusters  of  varicose  veins.  In 
the  first  case,  rest  and  relaxing  applications  will  often 
succeed ; and  in  the  second,  the  topical  use  of  seda- 
tives frequently  gives  relief.  It  has  been  proposed  to 
puncture  and  empty  varicose  veins;  but  if  a tempo- 
rary emptiness  and  relaxation  of  these  vessels  were  to 
remove  the  pain  for  a time,  things  would  fall  into  the 
old  state  again  in  the  course  of  a few  days.  If  the 
plan  were  adopted,  it  would  be  necessary  to  nrake  a 
very  free  opening  in  the  dilated  vein,  and  extract  the 
coagulum.  The  vessel  would  then  need  no  ligature 
above  and  below  the  opening,  for  the  slightest  com- 
pression would  afterward  stop  the  bleeding,  and  the 
vessel  be  obliterated  by  the  subsequent  inflammation. 
Graefe’s  plan,  indeed,  consists  in  making  an  incision 
two  inches  long  through  the  integuments  and  coats 
of  the  largest  knotty  part  of  the  vein,  stopping  the 
bleeding  by  pressure  with  the  finger,  filling  the  ex- 
posed cavity  of  the  vein  with  lint,  and  then  applying 
a compress  and  roller.  When  the  varices  are  confined 
to  the  leg,  one  incision  of  this  kind  is  set  down  by 
Graefe  as  sufficient;  when  they  reach  to  the  middle  of 
the  thigh,  he  practises  one  incision  above  the  ankle, 
and  a second  a little  above  the  knee;  and,  if  the  whole 
of  the  thigh  be  afiected,  he  makes  a third  incision  in 
the  upper  part  of  the  limb.  A bandage  and  cold  lo- 
tions are  to  be  applied  for  a few  days.  The  result  is, 
that  an  inflammation  follows,  which  spreads  from  the 
large  varicose  veins  to  the  surrounding  ones  in  a suffi- 
cient degree  to  bring  about  th-eir  subsidence. — (See 
Graefe' s Preface  to  the  German  Transl.  of  C.  Bell's 
Surffery.)  Chelius  deems  this  plan  of  treatment  pre- 
ferable to  that  of  exposing  the  venous  trunk  and  in- 
juring its  coats. — {Handb.  der  Chirurffie,  b.  l,p.  888.) 

We  learn  from  Celsus  that  the  ancients  were  accus- 
tomed to  remove  varices  by  excision,  or  destroy  them 
with  the  cautery. — {De  lie  Medica,  lib.  7,  cap.  3.) 
When  the  vein  was  much  convoluted,  extirpation 
with  the  knife  was  preferred  ; but,  in  other  cases,  the 
dilated  vessel  was  exposed  by  an  incision,  and  then 
cauterized.  Petit,  Boyer,  and  many  British  surgeons 
have  also  sometimes  cut  out  clusters  of  varico.se  veins. 

Dplpech  remarks,  that  the  extirpation  of  tumours 
composed  of  numerous  varices  has  been  practised, 
either  for  the  purpose  of  removing  the  pain  in  the  situ- 
ation of  the  disease,  or  other  inconveniences.  This 
operation  has  been  successfully  performed;  but  it  ap- 
[lears  not  to  have  constantly  had  the  elfect  of  prevent- 
ing the  formation  of  new  varices,  and  it  has  sometimes 
proved  tedious,  difficult,  and  severely  painful  in  its  exe- 
cution. In  fact,  an  erroneous  judgment  must  neces- 
sarily be  formed  of  the  extent  of  these  swellings,  when 
they  are  judged  of  only  from  the  appearance  which  they 


434 


VARICOSE  VEINS. 


present  under  the  skin.  Varices  are  not  always  con- 
fined to  the  superficial  veins,  and;  when  they  extend 
deeply,  the  operation  must  be  ineffectual.  The  opi- 
nion of  Delpech  is,  that  it  should  never  be  undertaken, 
unless  the  disease  be  accompanied  with  perilous  symp- 
toms, or  the  patient  nearly  deprived  of  the  use  of  his 
limb. 

It  has  been  thought,  that  one  of  the  established  prin- 
ciples in  the  treatment  of  aneurisms  might  be  advan- 
tageously extended  to  the  cure  of  varicose  veins.  By 
tying  the  principal  venous  trunk  above  the  point  to 
whicli  the  varicose  affection  reaches,  it  is  said,  that 
llie  course  of  the  blood  in  the  morbid  vessels  may  be 
totally  stopped,  the  column  of  this  fluid  made  to  coagu- 
late, and  the  consequent  obliteration  of  the  vessels 
themselves  accomplished. 

The  practice  of  tying  veins  for  the  cure  of  varices 
appears  to  have  been  employed  in  the  days  of  Part  and 
Dionis  (Cours  d'  Operations  de  Chirurgie,  p.  QIQ),  who 
accurately  describe  the  operation  of  tying  and  dividing 
the  vein  between  the  two  ligatures.  Sit:  Everard 
Home  has  related  many  cases  of  varicose  veins  in  the 
leg,  some  of  them  accompanied  with  tedious  ulcers, 
which,  after  the  vena  saphena  major  had  been  tied 
as  it  passes  over  the  inside  of  the  knee,  were  readily 
healed,  and  the  dilatation  of  the  veins  of  the  leg  re- 
lieved. 

This  practice  has  sometimes  answered,  .but  it  has 
also  had  its  failures. 

Among  other  evils,  an  inflammation  of  the  tied 
vein  has  been  observed  extending  very  far  in  the 
vessel,  and  succeeded  by  great  constitutional  disorder, 
symptoms  very  analogous  to  those  of  typhus  fever  and 
death.  Sir  A.  Cooper  in  his  lectures  strongly  depre- 
cates it ; he  says  that  he  has  seen  it  twice  prove  fatal 
in  the  borough  hospitals,  and  refers  to  at  least  a 
dozen  other  examples  which  had  a similar  end.  In 
some  of  these  cases,  previously  to  their  termina- 
tion, abscesses  form  in  the  direction  of  the  vessel 
either  below  or  above  the  ligature ; in  others,  such 
collections  of  matter  are  not  observed.— (See  7>-a- 
vers  on  Wounds  and  Ligatures  of  Veins.  Surgical 
Essaysy  part  1,  p.  216,  and  Oldknow  in  Edinb.  Med. 
and  Surg.  Journ.  vol.  5 ; R.  Carmichael,  in  Trans,  of 
the  King's  and  Queen's  College  of  Physicians,  vol.  2, 
p.  345,  <^c.)  Indeed,  the  dangers  arising  from  an  in- 
flammation of  the  internal  coat  of  the  veins  are  now 
generally  acknowledged,  and  every  endeavour  should 
be  made  to  avoid  them.  A case  which  happened  in 
Guy’s  Hospital  in  1816  fully  proves  them  ; the  femoral 
vein  happened  to  be  pricked  in  an  operation  for  aneu- 
rism, and  a ligature  was  applied  round  the  aperture. 
Inflammation  of  its  internal  coat  took  place,  extending 
up  into  the  vena  cava,  and  the  patient  is  supposed  to 
have  died  of  the  indisposition  resulting  from  it. — (See 
Travers's  Surgical  Essays,  part  1,  p.  222.)  The 
opinion  of  Mr.  Arnott  on  this  point  will  be  noticed  in 
the  ensuing  article.  Veins. 

Hence  arises  one  of  the  most  weighty  objections  to 
the  practice  of  tying  the  trunks  of  varicose  veins,  with 
the  view  of  curing  their  morbid  dilatation,  and  its 
effects  upon  the  limb. 

As  Mr.  Brodie  observes,  it  seems  to  be  now  esta- 
blished by  the  experience  of  modem  surgeons,  that  a 
mechanical  injury  inflicted  on  the  trunk  of  one  of  the 
larger  veins  is  liable  to  be  followed  by  inflammation  of 
its  internal  membrane,  and  a fever  of  a very  serious 
nature;  and  the  occasional  occurrence  of  these  symp- 
toms after  the  ligature,  or  even  the  simple  division  of 
the  vena  saphena,  has  made  surgeons  less  confident 
than  formerly  of  the  propriety  of  attempting  such  ope- 
rations for  the  relief  of  a varicose  state  of  that  vessel 
in  the  leg.  Certain  reflections,  however,  induced  Mr. 
Brodie  to  think  that  the  same  ill  effects  would  not 
follow  a similar  operation  performed  on  the  branches 
themselves.  “ Where  the  whole  of  the  veins  of  the 
leg  are  in  a state  of  morbid  dilatation,  and  the  distress 
produced  by  the  disease  is  not  referred  to  any  parti- 
cular part,  there  seem  to  be  no  reasonable  expectations 
of  benefit  except  from  the  uniform  pressure  of  a well 
applied  bandage.  But,  not  unfrequently,  we  find  an 
ulcer  which  is  irritable  and  difficult  to  heal  on  account 
of  its  connexion  with  some  varicose  vessels ; or,  with- 
out being  accompanied  by  an  ulcer,  there  is  a varix  in 
one  part  of  the  leg,  painful,  and  perhaps  liable  to  bleed, 
while  the  veins  in  other  parts  are  nearly  in  a natural 
Slate,  or,  at  any  rate,  are  i ot  the  source  of  particular 


uneasiness.  In  some  of  these  cases,  I formerly  applied 
the  caustic  potash,  so  as  to  make  a slough  of  the  skin 
and  veins  beneath  it ; but  I found  the  relief  which  the 
patient  experienced  from  the  cure  of  the  varix,  to 
afford  but  an  inadequate  compensation  for  the  pain  to 
which  he  was  subjected  by  the  use  of  the  caustic,  and 
the  inconvenience  arising  from  the  tedious  healing  of 
the  ulcer,  which  remained  after  the  reparation  of  the 
slough. 

In  other  cases,  I made  an  incision  with  a scalpel 
through  the  varix  'and  skin  over  it.  This  destroyed 
the  varix  as  completely  as  it  was  destroyed  by  the 
caustic,  and  I found  it  to  be  preferable  to  the  use  of  the 
caustic,  as  the  operation  occasioned  less'pain,  and  as, 
in  consequence  of  there  being  no  loss  of  substance,  the 
wound  was  cicatrized  in  a much  shorter  space  of  time. 
I employed  the  operation,  such  as  I have  described  it, 
with  advantage  in  several  instances  ; but  some  months 
ago  I made  an  improvement  in  the  method  of  per- 
forming it,  by  which  it  is  much  simplified;  rendered 
less  formidable  not  only  in  appearance,  but  also  in 
reality ; and  followed  by  an  equally  certain,  but  more 
speedy  cure. 

It  is  evident  (says  Mr.  Brodie)  that  the  extensive 
division  of  the  skin  over  a varix  can  be  attended  with 
no  advantage.  On  the  contrary,  there  must  be  a dis- 
advantage in  it,  as  a’  certain  time  will  necessarily  be 
required  for  the  cicatrization  of  the  external  wound. 
The  improvement  to  which  I allude  consists  in  this ; 
the  varicose  vessels  are  completely  divided,  while  the 
skin  over  them  is  preserved  entire,  with  the  exception 
of  a moderate  puncture  which  is  necessary  for  the 
introduction  of  the  instrument  with  which  the  incision 
of  the  veins  is  effected.  Thus  the  wound  of  the  inter- 
nal parts  is  placed  under  the  most  favourable  circum- 
stances for  being  healed,  and  the  patient  avoids  the 
more  tedious  process,  which  is  necessary  for  the  cica- 
trization of'a  wound  in  the  skin  above. 

For  this  operation  I have  generally  employed  a 
narrow,  sharp-pointed  bistoury,  slightly  curved,  with 
its  cutting  edge  on  the  convex  side.  Having  ascer- 
tained the  precise  situation  of  the  vein,  or  cluster  of 
veins,  from  which  the  distress  of  the  patient  appears 
principally  to  arise,  I introduce  the  point  of  the  bistoury 
through  the  skin  on  one  side  of  the  varix,  and  pass 
it  on  between  the  skin  and  the  vein  with  one  of  the 
flat  surfaces  turned  forwards  and  the  other  backwards, 
until  it  reaches  the  opposite  side.  I then  turn  the  cut- 
ting edge  of  the  bistouiy  backwards,  and,  in  withdraw- 
ing the  instrument,  the  division  of  the  varix  is  effected. 
The  patient  experiences  pain,  which  is  occasionally 
severe,  but  subsides  in  the  course  of  a short  time. 
There  is  always  hemorrhage,  which  would  be  often 
profuse,  if  neglected,  but  which  is  readily  stopped  by  a 
moderate  pressure  made  by  means  of  a compress  and 
bandage  carefully  applied.” 

Mr.  Brodie  particularly  enjoins  the  necessity  of  keep- 
ing the  patient  quietly  in  bed  for  four  or  five  days  after 
the  operation,  and  removing  the  bandage  and  first 
dressings  with  ihe  utmost  care  and  gentleness.  He 
also  cautions  surgeons  not  to  make  the  incision  more 
deep  than  absolutely  necessary.  Inflammation  of  the 
coats  of  the  veins  has  not  occurred  in  any  of  the  cases 
in  which  Mr.  Brodie  has  adopted  this  method  of  treat- 
ment. This  gentleman  wishes  it  to  be  understood, 
however,  that  he  does  not  recommend  the  practice 
indiscriminately,  but  with  a due  attention  to  the  cir- 
cumstances of  each  individual  case.  “ The  cases  for 
which  it  is  fitted  are  not  those  in  which  the  veins  of 
the  leg  generally  are  varicose,  or  in  which  the  patient 
has  little  or  no  inconvenience  from  the  complaint;  but 
those  in  which  there  is  considerable  pain  referred  to  a 
particular  varix,  or  in  which  hemorrhage  is  liable  to 
take  place  from  the  giving  way  of  the  dilated  vessels, 
or  in  which-  they  occasion  an  irritable  and  obstinate 
varicose  ulcer.”— (See  Med.  Chir.  Trans,  vol.  7,  p. 
195,  et  seq.) 

On  the  subject  of  cutting  through  veins  affected  with 
varix,  it  is  proper  to  observe,  that  even  this  plan  has 
been  known  to  bring  on  severe  and  fatal  symptoms. 
Cases  confirming  this  fact  are  recorded  in  a valuable 
modern  work,  which  should  be  in  the  hands  of  every 
practical  suigeon.-  (See  Hodgson's  Treatise  on  the 
Diseases  of  Arterits  and  Veins,  p.555,  et  seq.)  It  is 
but  justice  to  stale,  however,  that  in  these  examples 
Mr.  Brodie’s  manner  of  doing  the  operation  was  not 
adopted.  On  the  contrary,  his  method,  as  far  as  I have 


VEI 


yel  heard,  receives  very  general  approbation.  Some 
eases  and  observations  highly  in  favour  of  it  are  de- 
tailed by  Mr.  Carmichael. — (See  Trans,  of  the  King's 
and  Queen's  College  of  Physicians,  vol,  2,  p.  369,  6,-c.) 

Cases  of  spontaneous  varix  in  the  veins  of  the  arm 
are  rarely  observed.  When  these  vessels  become 
varicose,  it  is  almost  always  in  consequence  of  a com- 
munication being  formed,  in  the  operation  of  venesec- 
tion, between  the  brachial  artery  and  one  of  the  veins 
at  the  bend  of  the  arm.  The  superficial  veins  in  this 
situation  then  become  more  or  less  dilated  by  the  im- 
pulse of  the  stream  of  arterial  blood  which  is  thrown 
into  them.  There  is,  however,  a good  deal  of  ditFerence 
between  these  accidental  varices  actually  induced  by  a 
mechanical  cause,  and  those  which  originate  sponta- 
neously, or  from  causes  not  very  clearly  understood. 
The  former  never  acquire  the  size  which  the  latter 
often  attain;  they  never  exceed  a certain  magnitude, 
whether  pressure  be  employed  or  not ; they  never  form 
tumours  composed  of  an  assemblage  of  varicose  veins  ; 
they  are  never  filled  with  tough  coagula  of  blood  ; their 
coats  are  never  thickened,  nor  constitute  the  solid 
half  obliterated  canal  remarked  in  the  other  species  of 
varices  ; the  skin  which  covers  them  is  not  disposed  to 
inflame  and  ulcerate  ; they  are  not  subject  to  occa- 
sional hemorrhage;  and  the  limb  is  not  affected  with 
any  oedematous  swelling. — {Delpech,  Traite  des  Ma- 
ladies Chir.  t.  3,  p.  261.)  These  circumstances  render 
it  evident  that  here  all  surgical  interference  would  be 
unnecessary. 

See  Aneurism,  where  the  aneurismal  varix  is 
described ; Cirsocele,  where  the  varix  of  the  spermatic 
cord  is  treated  of;  Hemorrhoids,  where  the  diseased 
and  enlarged  veins  of  the  rectum  are  considered  ; Va- 
ricocele, where  those  of  the  scrotum  are  noticed. 

VARIX.  (From  aarms,  unequal.)  The  term 
is  applied  to  a kind  of  knotty,  unequal,  dark-coloured 
swelling,  arising  from  a morbid  dilatation  of  veins. — 
(See  Varicose  Veins.) 

VEINS,  DISEASES  OF.  To  the  observations  and 
references  made  in  the  preceding  article  {Varicose 
Veins),  I here  annex  a few  remarks  on  the  principal 
diseases  of  the  venous  system,  in  order  to  render  what 
has  been  already  stated  in  other  parts  of  tlie  work 
more  complete. 

It  is  observed  by  Mr.  Hodgson,  that  “the  veins  are 
liable  to  all  those  morbid  changes  which  are  common 
to  soft  parts  in  general ; but  the  membranous  lining  of 
these  vessels  is  peculiarly  susceptible  of  inflammation. 
When  a vein  is  wounded,  the  inflammation,  which  is 
the  effect  of  the  injury,  sometimes  extends  along  the 
lining  of  the  vessel  into  the  principal  venous  trunks, 
and  in  some  instances  even  to  the  membrane  which 
lines  the  cavities  of  the  heart. — (See  Bleeding.)  'phs 
inflammation  sometimes  produces  an  effusion  of  co- 
agulating lymph,  by  which  the  opposite  sides  of  the 
vein  are  united,  so  as  to  obliterate  the  tube ; in  this 
manner,  a great  extent  of  the  vessel  is  occasionally 
converted  into  a solid  cord.  In  some  instances,  the 
secretion  of  pus  into  the  cavity  of  the  vessel  is  the 
consequence  of  inflammation  of  the  membranous 
lining  of  a vein.  Under  these  circumstances,  the 
matter  is  either  mixed  with  the  circulating  blood,  or, 
the  inflammation  having  produced  adhesion  of  the 
sides  of  the  vessel  at  certain  intervals,  boundaries  are 
formed  to  the  collection  of  pus,  which  in  this  man- 
tier  form  a chain  of  abscesses  in  the  course  of  the 

V6SS6i. 

When  the  inflammation  of  veins  is  not  very  exten- 
sive, its  symptoms  are  the  same  as  those  of  local 
inflammation  in  general ; but  when  the  inflammation 
extends  into  the  principal  venous  trunks,  and  pus  is 
secreted  into  the  vessel,  it  is  accompanied  with  a high 
degree  of  constitutional  irritation,  and  with  symptoms 
which  bear  a striking  resemblance  to  those  of  typhus 
fever.” — (Ora  the  Diseases  of  Arteries  and  Veins,  p. 
511,  512.) 

The  observations  of  Mr.  Arnott  tend  to  show,  that 
the  points  at  which  the  inflammatory  changes  in  the 
coats  of  veins  usually  terminate,  are  determined  by  the 
passage  of  a current  of  blood.  Thus,  when  a trunk  is 
concerned,  the  boundary  is  the  entrance  of  a branch  ; 
and  when  a branch  is  concerned,  the  boundary  is  the 
junction  of  this  with  the  trunk. — (See  Med.  Chir. 
Trans,  vol.  15,  p.  47.)  It  is  not  meant,  however,  that 
the  inflammation  necessarily  stops  where  a current  of 
blood  interferes,  but  that,  at  the  point  where  the  in- 

£e2 


VEI  435 

flammation  does  cease,  the  vein  affected  either  sends 
off  a branch  or  terminates  in  a venous  trunk. 

JBesides  the  example  of  inflammation  of  femoral  and 
other  large  veins,  brought  on  by  a ligature  round  a 
small  aperture  accidentally  made  in  the  femoial  vein 
in  the  operation  for  popliteal  aneurism,  as  mentioned 
in  a foregoing  e.xi\e\e  {Varicose  Veins),  Mr.  Travers 
reports  another  case,  in  which  a fatal  inflammation  of 
the  femoral  and  external  iliac  veins,  with  marks  of 
diffused  inflammation  up  to  the  right  auricle,  was  appa- 
rently caused  by  the  application  of  .q  ligature  to  the 
mouth  of  the  femoral  vein,  after  an  amputation. — {Sur- 
gical Essays,  p.  227.)  And  the  same  catastrophe 
would  appear  to  be  occasionally  the  result  of  venous 
inflammation  after  amputation,  even  where  the  femo- 
ral vein  is  not  tied. — (See  Carmichael,  in  Trans,  of 
King's  and  Queen's  College  of  Physicians,  vol.  2,  p. 
365.)  In  short,  Mr.  Travers’s  observations,  as  well  as 
those  of  Mr.  Hodgson  and  Mr.  Carmichael,  tend  to 
prove  “ that  the  inflammation  of  the  interior  tunic  of  a 
vein  sometimes  follows  a puncture,  sometimes  a divi- 
sion, a ligature  encircling  the  tube,  or  including  only  a 
part  of  it,  or  arises  spontaneously  from  an  inflamed 
surface,  of  which  the  vein  forms  a part.” — (P.  2.38.) 
Mr.  Carmichael  relates  an  instance,  in  which  the  ap- 
pearances after  death  seemed  to  evince  that  the  patient 
died,  subsequently  to  an  operation  for  femoral  aneu- 
rism, of  inflammation  and  suppuration  within  the 
femoral  vein,  and  extending  both  down  the  sai)hena 
and  upwards  through  the  common  iliac  vein.  The 
femoral  vein  had  been  pricked  in  the  operation,  but 
not  tied. — {Trans,  of  the  King's  and  Queen's  College 
of  Physicians,  Ireland,  vol.  %p.  350,  ^-c.)  In  order  to 
avoid  the  danger  of  wounding  the  femoral  vein  above 
the  edge  of  the  sartorius,  Mr.  Carmichael  recommends 
“introducing  the  needle  on  the  pubal  side  of  the 
artery”  (;?.357);  a direction  which  I have  noticed  in 
the  article  ./2raeMr«srra.  With  respect  to  the  danger  of 
tying  a large  vein.  Sir  A.  Cooper  is  so  convinced  of  it, 
that  he  says  in  his  lectures,  that  if  he  were  the  subject 
of  operation,  he  would  rather  let  his  femoral  artery  be 
tied  tlian  the  vena  saphena  major. 

M.  Ribes  has  published  one  example,  in  which  an 
inflammation  of  the  veins  of  the  arm  arose  from  a gan- 
grenous chilblain  of  the  hand,  and  after  death,  marks 
of  inflammation  were  traced  into  the  superior  vena 
cava  and  right  auricle  and  ventricle.  He  also  relates  a 
case  of  mortification  of  the  foot  and  leg,  and  a conse- 
quent inflammation  of  the  vena  saphena,  where  ap- 
pearances of  inflammation  were  also  discovered  in  the 
right  auricle  and  ventricle,  and  in  the  inferior  vena 
cava. — {Revue  Med.  Juillet,  1825.)  According  to  the 
researches  of  Mr.  Arnott,  the  extension  of  inflamma- 
tion to  the  venae  cavae  and  heart  in  phlebitis,  is  a very 
unusual  occurrence,  and  cannot,  therefore,  be  consi- 
dered as  the  cause  of  death.  The  suggestion,  he  ob- 
serves, which  was  made  by  Mr.  Hunter,  has  been 
adopted  without  examination.  The  facts  which  Mr. 
Arnott  has  adduced,  tend  to  prove  that  there  are  con- 
siderable differences  in  the  extent  of  vein  occupied  by 
inflammation  in  fatal  cases  of  phlebitis.  “Sometimes 
the  disease  has  spread  into  several  or  most  of  the  veins 
of  a limb  from  that  primarily  affected ; at  others,  it 
has  not  proceeded  beyond  the  vessel  in  which  it  origi- 
nally appeared.  This  last  circumstance,  together  with 
that  of  the  fatal  consequences  sometimes  ensuing  from 
inflammation,  limited  to  a few  inches  only  of  a vein, 
justifies  the  inference  that  the  dangerous  consequences 
from  phlebitis  bear  no  direct  relation  to  the  extent  of 
the  vein  which  is  inflamed.” — {Med.  Chir.  Trans,  vol. 
15,  p.  44.)  In  bis  inquiry  into  the  nature  of  the  con 
nexion  between  the  primary  and  secondary  affections 
in  this  disease,  Mr.  Arnott  takes  up  the  question,  whe- 
ther the  latter  depend  upon  the  secretion  of  pus  by 
the  inflamed  vein,  and  its  entrance  into  the  circula- 
tion? This  leads  him  to  inquire  into  the  contents 
of  the  inflamed  veins.  In  several  of  the  cases  which 
he  has  collected,  in  which  “an  open  wound  existed 
in  the  vein,  pus  was  discharged  from  it  during  life. 
While  in  14  cases  out  of  19,  pus,  or  pus  in  conjunction 
with  lymph,  was  present  in  the  vessels  after  death. 

In  two  instances  no  mention  is  made  of  pus,  the  con- 
tents of  the  veins  being  described  in  the  one,  as  ‘ ad- 
hesive matter ;’  in  the  other,  where  the  vena  cava 
was  concerned,  as  ‘ flakes  of  lymph.’  In  one  ease  oidy 
(Mr.  Hodgson’s),  where  the  inflammation  occurred  in 
a vein  previously  diseased,  or  in  a vein  the  branches 


VEN 


436  VEI 

of  which  at  least  were  varicose,  neither  pus  nor  lymph 
was  found  in  the  vessel. 

It  results  from  tliis  statement  (says  Mr.  Arnott),  that 
although  pus  is  present  in  the  veins  in  the  great  major- 
ity of  fatal  cases  of  phlebitis,  and  that  although  it  ap- 
j)«ars,  from  the  character  of  the  general  symptoms,  and 
the  effects  produced  upon  animals  by  the  injection  of  a 
similar  fluid  into  their  vessels,  that  the  passage  of  pus 
into  the  circulation  is  probably  the  principal,  yet  the 
circumstances  do  not  justify  us  in  regarding  it  as  the 
sole  cause  of  the  secondary  affection.  In  addition  to 
tlie  presumed  absence  of  pus  in  two  instances,  and  to  its 
declared  absence  in  a third,  it  may  be  remarked  that  the 
early  appearance  of  the  symptoms  in  some  cases 
seems  scarcely  to  correspond  with  the  time  usually  re- 
quired for  the  production  of  pus,  as  in  one  which  oc- 
curred to  Mr.  Freer  {Hodgson  on  Dis.  of  Art.j).  551), 
where  they  came  on  suddenly,  four  hours  after  lipture 
of  the  saphena.  If,  then,  the  constitutional  afiection 
in  phlebitis  is  to  be  explained  by  the  introduction  of  a 
fluid  into  the  circulation  which  contaminates  the  blood 
and  operates  as  a poison,  this  property  must  be  attri- 
buted to  inflammatory  secretions  generally  from  the 
vein,  although  not  purulent.” — (See  Mod.  Chir.  Trans, 
vol.  15,  p.  45.) 

The  careful  investigations  of  Mr.  Arnott  prove  that 
the  secondary  aflection  in  phlebitis  commonly  begins 
in  from  two  to  ten  or  twelve  days  after  the  receipt  of 
the  injury  which  has  made  the  vein  inflame.  The  fol- 
lowing are  described  as  the  symptoms : great  restless- 
ness and  anxiety,  prostration  of  strength,  and  depres- 
sion of  spirits,  sense  of  weight  at  the  prsecordia,  fre- 
quent sighing  or  rather  mourning,  with  paroxysms  of 
oppressed  and  hurried  breathing,  the  patient  being  at 
the  same  time  unable  to  refer  his  suflerings  to  any  si)e- 
cific  source.  The  common  symptoms  of.fever  are  pre- 
sent, the  pulse  is  rapid,  reaching  sometimes  to  130  or 
140  in  a minute,  but  is  in  other  respects  extremely  va- 
riable. There  is  often  sickness,  with  violent  vomiting, 
especially  of  bilious  matter.  Frequent  and  severe  ri- 
gors almost  invariably  occur.  The  general  irritability 
and  deep  an.viety  of  countenance  increase;  the  man- 
ner is  quick ; and  the  look  occasionally  wild  and  dis- 
tracted. When  left  to  himself  the  patifflit  is  apt  to 
mutter  incoherently  ; but  on  being  directly  addressed, 
becomes  clear  and  collected.  The  features  are  shrunk, 
and  the  skin  of  the  whole  body  assumes  a sallow  or 
yellow  colour : under  symptoms  of  increasing  debility, 
and  at  a time  when  the  local  affection  may  appear  to 
be  in  a great  degree  subsiding,  secondary  inflammation 
of  violent  character,  and  quickly  terminating  in  effu- 
sion of  pus  or  lymph,  very  frequently  takes  place  in  si- 
tuations remote  from  the  origitial  injury ; the  cellular 
substance,  the  joints,  and  the  eye  have  been  affected ; 
but  it  is  more  particularly  under  a rapidly  developed 
attack  of  inflammation  of  the  viscera  of  the  chest,  that 
the  fatal  issue  usually  occurs.  Whether  this  is  ob- 
served  or  not,  death  is  always  preceded  by  symptoms 
of  extreme  exhaustion,  a rapid,  feeble  pulse,  dry,  brown, 
or  black  tongue,  teeth  and  lips  covered  with  sordes,  hag- 
gard countenance,  low  delirium,  &c. — {Arnott^  in  Med. 
Chir.  Trans,  vol.  15,  p.  52.) 

This  gentleman  considers  the  resemblance  of  the  se- 
condary affection  in  phlebitis  to  the  diseases  arising 
from  the  inoculation  of  a morbid  poison,  as  particularly 
striking;  and  the  conclusion  to  which  his  facts  and 
arguments  bring  him  is,  that  death,  in  cases  of  phlebi- 
.tis,  does  not  take  place  from  the  inflammation  extend- 
ing to  the  heart,  but  that  the  entrance  of  pus  or  even  of 
some  other  product  of  inflammation,  from  the  inflamed 
part  of  the  vein  into  the  circulation,  is  the  source  of  the 
alarming  and  fatal  indisposition. — (Op.  cit.p.  61.) 

The  formation  of  abscesses  in  the  liver,  joints,  lungs, 
&c.  after  injuries  of  the  head,  parturition,  great  surgi- 
cal operations,  and  suppurating  wounds  (see  Velpeau, 
in  Revue  Med.  .Tain,  Juillet,  et  Dec.  1826;  Mai,  1827; 
Rose,  in  Med.  Chir.  Trans,  vol.  14),  is  also  referred  by 
Mr.  Arnott  to  inflammation  of  the  veins  of  the  part 
inimarily  affected,  and  the  entrance  of  pus  into  the  cir- 
culation ; and  (says  he)  it  becomes  a question,  whether 
the  occurrence  of  phlebitis  and  the  passage  of  pus  from 
an  inflamed  vein  into  the  circulation,  are  not  sufficient 
of  themselves  to  account  for  the  secondary  affections 
of  wounds,  without  its  being  necessaiy  to  re.sorl  to  an 
absorption  of  the  same  fluid  from  their  suppurating  sur- 
faces.—(See  Med.  Chir.  Trans,  vol.  15,  p.  68 — 122,  <S-c.) 

The  researches  of  Mr.  Arnott  on  this  interesting  sub- 


ject certainly  reflect  great  credit  upon  his  industry  and 
judgment;  and  if  they  do  not  akogether  free  particu- 
lar points  from  doubt,  they  certainly  present  the  moat 
rational  views  of  them,  which  have  hitherto  been 
given. 

Inflammation  frequently  produces  a thickening  of 
the  coats  of  the  veins,  as  well  as  adhesion  of  their  sides 
and  obliteration  of  their  cavities.  Indeed,  in  some  in- 
stances, these  vessels  have  been  found  to  resemble  ar- 
teries in  the.  thickness  of  their  coats,  and  in  retaining 
a circular  'form  when  cut  across. — {Hodgson,  op.  cit, 
p.  513.) 

Ulceration  sometimes  extends  to  the  coats  of  veins, 
and  by  exposing  their  cavities  gives  rise  to  hemorrhage. 
In  certain  examples,  it  commences  in  the  membranous 
lining,  and  destroys  the  other  coats.  In  general,  how- 
ever, the  adhesive  inflammation  precedes  the  ulcera- 
tive, and  by  obliterating  the  cavities  of  these  vessels, 
prevents  the  occurrence  of  hemorrhage.  When  spha- 
celation takes  place  in  the  vicinity  of  veins,  their  cavities, 
like  those  of  arteries  under  similar  circumstances,  are 
filled  with  extensive  plugs  of  coagulum,  which  prevent 
hemorrhage  upon  the  separation  of  the  mortified  part. 

Veins  are  sometimes  rtiplured  without  any  previous 
morbid  alteration  in  their  structure,  and  the  accident 
may  be  induced  by  muscular  exertions,  external  vio- 
lence, the  sudden  effects  of  the  cold  bath,  &c. 

Although  a deposition  of  calcareous  matter  almost 
invariably  takes  place  in  the  arteries  of  persons  ad- 
vanced in  life,  it  is  an  extremely  rare  occurrence  in  the 
coats  of  veins. 

Loose  calculi  have  been  found  in  the  cavities  of 
veins  ; and  tumours  sometimes  grow  from  their  lining. 
In  a case  of  scirrhous  pylorus,  Mr.  Hodgson  found 
a tumour  larger  than  a hazel  nut,  growing  from  the 
lining  of  the  splenic  vein,  and  resembling  in  its  ap- 
pearance and  consistence  the  disease  which  existed  sA 
the  pylorus. — {P.  524.) 

The  venous,  like  the  arterial,  system  appears  to  be 
capable  of  carrying  on  a collateral  circulation,  when 
any  part  of  it  is  impervious.  Even  after  the  oblitera- 
tion of  the  vena  cava  inferior,  the  blood  has  been 
known  to  be  conveyed  with  facility  to  the  heart  through 
the  lumbar  veins  and  vena  azygos.  In  the  case  re- 
corded by  Dr.  Baillie  ( Trans,  for  the  Improvement  of 
Medical  and  Chir.  Knowledge,  vol.  1,  p.  127),  it  is  re- 
markable, that  the  vena  inferior  was  obliterated  at  the 
point  where  the  venae  cavae  hepaticae  opened  into  it,  so 
that  not  only  the  blood  from  the  lower  extremities,  but 
also  that  from  the  liver,  must  have  passed  through  col- 
lateral channels  to  the  heart. 

Want  of  room  having  prevented  me  from  introduc- 
ing farther  observations  on  the  diseases  of  veins,  I must 
refer  to  the  following  works  for  adaitional  information. 
J.  Hunter,  in  Trans,  for  the  Improvement  of  Med.  and 
Chir.  Knowledge,  vol.  J,  1793.  Abernethy's  Works, 
vol.  2.  J.  Hodgson,  on  the  Diseases  of  Arteries  and 
V eins.  Longuet,  Dis.  sur  V Inflammation  des  Veines, 
Paris,  1815.  B.  Travers,  in  Surgical  Essays,  part  1, 
8uo.  Land.  1818.  F.  A.  B.  Puchelt,  Das  Venensystem 
in  Seinen  Krankhaften  Verhdltnissen,  8uo.  Leipz.  1818. 
R.  Carmichael,  in  Trans,  of  the  Association  of  Fel- 
lows, Src.  of  the  Kind's  and  Queen's  College  of  Physi- 
cians in  Ireland,  vol.  2,  8uo.  Dublin,  1818.  J.  M.  Ar- 
noU,  A Pathological  Inquiry  into  the  Secondary  Ef- 
fects of  Inflammation  of  Veins,  in  Med.  Chir.  Trans, 
vol.  15. 

LA  valuable  paper  on  the  “ Surgical  Anatomy  of  the 
Veins,”  by  Professor  Annan,  of  Wasbington  Medical 
College,  Baltimore,  will  be  found  in  the  Maryland  Me- 
dical Recorder,  vol.  1,  No.  2.  I regret  that  my  limits 
preclude  me  from  inserting  even  a portion  of  it,  as  it 
contains  much  valuable  matter  of  a practical  kind,  and 
on  a subject  too  much  overlooked  by  surgical  writers. 
— Reese.} 

VENEREAL  DISEASE.  {Lues  Venerea.  Mor- 
bus Oallicus.  Syphilis.)  About  the  year  1494,  or  1495, 
the  venereal  disease  is  said  to  have  made  its  first  aj)- 
pearance  in  Europe.  Some  writers  believe,  that  it  ori- 
ginally broke  out  at  the  siege  of  Naples;  but  most  of 
them  suppose  that,  as  Columbus  returned  from  his  first 
expedition  to  the  West  Indies,  on  March  13lh,  1493,  his 
followers  brought  the  disorder  with  them  from  the  new 
to  the  old  world.  Other  authors,  however,  among 
whom  are  Mr.  Beckett  (PM.  Trans.  vols.’iO  and  21), 
Mr.  B.  Bell,  and  Dr.  Swediaur,  maintain  the  opinion, 
that  the  venereal  disease  was  well  known  upon  the 


VENEREAL  DISEASE. 


437 


old  continent,  and  that  it  prevailed  niong  the  Jews, 
Greeks,  and  Romans,  and  their  descendants,  long  before 
the  discovery  of  America.  Another  doctrine,  not  en- 
tirely destitute  of  ingenious  arguments,  and  even  con- 
taining many  valuable  truths,  is,  that  the  venereal  dis- 
ease, as  it.is  considered  in  modern  times,  has  no  real  ex- 
istence as  a distinct  affection,  arising  from  any  parti- 
cular virus,  but  is  a name  given  to  an  assemblage  of 
disorders  of  different  kinds,  to  which  the  human  race 
have  always  been  subjected  from  time  immemorial. — 
(See  a tract  entitled  Sur  la  J^fon-exintence  de  la  Ma- 
ladic  Venerienne^"  Svo.  Paris,  1811.)  One  writer  of 
high  reputation  believes,  that  though  syphilis  was 
brought  to  Europe  by  tiie  followers  of  Columbus,  there 
existed  previously  to  that  event  throughout  the  old  con- 
tinent venereal  disorders,  both  local  and  constitutional, 
which  strongly  resembled  the  newly-imported  disease, 
and  were  for  more  than  three  centuries  confounded  with 
it. — (R.  Carmichael  on  Venereal  Diseases,  p.  33,  8vo. 
I.ond.  1825,  ed.  2.)  My  friend  Mr.  Bacot  has  be- 
stowed great  pains  on  an  examination  of  all  the  pas- 
sages in  old  works,  affording  any  ground  for  the  opinion 
that  syphilis  existed  in  ancient  times:  he  finds  in  them 
allusions  to  many  local  complaints  of  the  genitals, 
warts,  discharges,  ulcers,  pustules,  &:c.,  sometimes 
clearly  ascribed  to  impure  coition,  but  no  distinct  re- 
ference to  any  constitutional  symptoms.  “Surely,” 
says  he,  “ I may  be  allowed  to  say,  that  if  there  is  any 
historical  fact  that  can  be  said  to  be  proved,  it  is  that 
of  the  origin  of  syphilis  being  referable  to  the  latter 
years  of  the  fifteenth  century ; for,  I cannot  under- 
stand otherwise,  why,  at  that  precise  period,  we  all  at 
once  hear  of  ulcers  on  the  parts  of  generation  in  both 
sexes,  followed  speedily  by  excruciating  nocturnal  pains, 
by  corroding  ulcers  over  the  whole  .body,  by  afiections 
of  the  throat  and  nose,  and  very  frequently  by  death  ; 
w hen  not  one  word  that  can  be  construed  into  any  si- 
milar affection  is  to  be  met  with  distinctly  stated  by 
any  writer  before  that  period.”— (-f.  Bacot,  in  Med. 
Gazette,  vol.  2,  p.  JOO.)  But  while  this  writer  will  not 
admit  the  truth  of  the  existence  of  the  venereal  disease' 
in  times  of  antiquity,  he  allows  that  a disorder  resem- 
bling gonorrhoBa  has  been  known  from  the  remotest 
periods  of  history. 

Although  many  considerations  lead  me  to  coincide 
with  Hunter,  Sprengel,  Pearson,  and  Bacot,  in  reject- 
ing the  common  history  of  syphilis  as  fabulous,  I mean 
that  account  which  refers  its  origin  to  America,  or  tlie 
French  army  in  Italy,  it  does  not  appear  to  me  that 
any  utility  would  be  likely  to  result  from  agitating 
this  question  in  modern  times,  because,  if  it  be  true,  as 
the  most  candid  and  intelligent  surgeons  of  the  present 
day  generally  acknowledge,  that  they  cannot  precisely 
define  what  the  venereal  disease  is,  nor  alwmys  point 
out  the  exact  circumstances  in  which  it  differs  from 
some  other  anomalous  complaints,  even  when  the  cases 
are  before  their  eyes,  how  can  such  discrimination  be 
attempted  from  a mere  review  of  old  descriptions,  not 
accompanied  with  the  advantage  of  a view  of  the 
living  patients  themselves  ? But  as  far  as  the  nature 
of  the  venereal  disease  has  been  unravelled,  and  it  is 
allowable  to  judge  from  such  comparisons,  I may  be 
permitted  to  remark,  that,  in  degree  of  severity,  acute- 
ness of  symptoms,  rapidity  of  propagation,  and  extent 
and  quickness  of  fatality,  no  forms  of  disease,  now 
ever  conjectured  to  be  venereal,  bear  the  least  resem- 
blance to  the  destructive  malady  with  which  the  army 
before  Naples  was  afflicted  at  the  close  of  the  fifteenth 
century  : nor  will  any  ignorance  of  the  uses  of  mer- 
cury, as  will  be  presently  noticed,  explain  differences 
so  strongly  marked.  With  reference  to  the  contagious 
disorder  which  scourged  a great  part  of  Europe  at  the 
close  of  the  fifteenth  century,  there  is  a decree  of  the 
parliament  of  Paris,  dated  1496,  in  which  the  disease 
is  mentioned  to  have  been  then  prevalent  in  that  city 
two  years:  consequently  it  was  known  there  in  1494: 
yet  the  conquest  of  Naples  by  Charles  the  VIII.  was 
not  effected  till  1495.  It  is  clear,  therefore,  that  the 
disease  here  alluded  to,  could  not  have  been  derived 
from  America.  It  appears  to  have  been  communicated 
from  one  person  to  another  by  the  mere  touch,  resi- 
dence in  the  same  chamber,  &c. ; and,  in  fact,  unless 
some  other  mode  of  propagation  besides  coition  be 
snpprrsed,  its  extension  throughout  Europe  in  two 
years,  would  imply  a depravity  of  manners  (piite  ex- 
traordinary, and  beyond  all  credibility.  Another  fact 
is,  that  whatever  the  disorder  might  be,  it  was  not  of 


longcomtuuance;  and  Guicciardini,  the  historian,  who 
wrote  a few  years  after  its  breaking  out,  assures  us,  that 
it  had  already  become  much  mi'.der,  and  undergone 
of  itself,  a change  into  kinds  different  from  the  first. 

The  venereal  disease  is  supposed  to  arise  from  a spe- 
cific morbid  poison,  which,  when  applied  to  the  human 
body,  has  the  power  of  propagating  or  multiplying  it- 
self, and  is  capable  of  acting  both  locally  and  consti- 
tutionally, 

Mr.  Hunter  was  of  opinion,  that  the  effects  produced 
by  the  poison  arise  from  its  peculiar  or  specific  irrita- 
tion, joined  with  the  aptness  of  the  living  principle  to 
be  irritated  by  such  a cause,  and  the  parts  so  irritated 
acting  accordingly.  Hence  he  considered  that  the  ve- 
nereal virus  irritated  the  living  parts  in  a manner  pe- 
culiar to  itself,  and  produced  an  inflammation  peculiar 
to  that  irritation,  from  which  a matter  is  produced  pe- 
culiar to  the  inflammation. 

The  venereal  poison  is  capable  of  affecting  the  hu- 
man body  in  two  different  ways  ; locally,  that  is,  in 
those  parts  only  to  which  it  is  first  applied  ; and  consti 
tutionally,  that  is,  in  consequence  of  its  absorption. 

In  whatever  manner  the  venereal  disease  was  first 
produced,  it  began,  says  Mr.  Hunter,  in  the  human 
race,  as  no  other  animal  .seems  capable  of  being  af- 
fected by  it.  He  conceives  also,  that  the  parts  of  gene- 
ration were  those  first  affected ; for  if  the  disease  had 
taken  place  on  any  other  part,  it  would  not  have  gone 
farther  than  the  person  in  whom  it  first  arose.  On 
the  contrary,  if  the  disease,  in  the  first  instance  of 
its  formation,  be  presumed  to  have  attacked  the  parts 
of  generation,  where  the  only  natural  connexion  takes 
place  between  one  human  being  and  another,  except 
that  between  tlie  mother  and  child,  it  was  in  the  most 
favourable  situation  for  being  propagated ; and  Mr. 
Hunter  infers,  also,  that  the  first  effects  of  the  disease 
must  have  been  local,  in  consequence  of  the  fact,  now 
well  established,  that  none  of  the  constitutional  effects 
are  communicable  to  other  persons,  that  is  to  say,  in- 
fectious. 

Thus,  the  numberless  cases  of  the  venereal  disease, 
afflicting  generation  after  generation,  and  obsetvable 
in  all  the  known  parts  of  the  world,  are  supposed  to 
be  originally  derived  from  tlie  amours  of  some  unfor- 
tunate individual,  in  whom  the  poison  was  firstformed, 
from  causes  beyond  the  reach  of  human  investigation. 
But  that  any  statement  of  this  kind  is  more  valuable 
than  unsupported  conjecture,  is  a proposition  to  which 
my  mind  is  not  prejiared  to  assent,  particularly  when 
it  is  considered,  that  sores  on  the  genitals,  giving  rise 
to  such  constitutional  symptoms  as  puzzle  the  iiiost 
discerning  practitioners,  are  often  of  a very  diversified 
character,  so  as  hardly  to  admit  of  reference  to  one 
common  origin.  And,  as  I have  already  hinted,  every 
modern  speculation  about  the  origin  of  the  distemper, 
promises  but  little  instruction  or  success,  because  the 
question  relates  to  a disease,  the  diagnosis  of  which 
is  still  very  unsettled,  and  the  complete  definition  of 
which  has  hitherto  baffled  men  of  the  greatest  genius 
and  experience. 

According  to  Mr.  Hunter,  the  venereal  poison  is 
commonly  in  the  form  of  pus,  or  some  other  secretion. 
In  most  cases  it  excites  an  inflammation  which  (to  use 
the  same  author’s  language)  is  attended  witli  a specific 
mode  of  action,  different  from  all  other  actions  attend- 
ing inflammation,  and  accounting  for  the  specific  qua- 
lity in  the  matter. 

The  formation  of  matter,  though  a general,  is  not  a 
constant,  attendant  on  this  disease;  for  inflammation 
produced  by  the  venereal  poison,  sometimes  does  not 
terminate  in  suppuration.  But  if  Mr.  Hunter’s  senti- 
ments are  correct,  it  is  the  matter  produced,  whether 
with  or  without  inflammation,  which  alone  contains 
the  poison.  Hence,  a person  having  the  venereal  irri- 
tation in  any  form  not  attended  with  a discharge,  can- 
not communicate  the  disease  to  another.  In  proof  of 
this  doctrine  he  states,  that  though  married  men  often 
contract  the  disease,  and  continue  to  cohabit  with  their 
wives,  even  for  weeks,  yet,  in  the  whole  of  his  prac- 
tice, he  never  once  found  that  the  complaint  was  com- 
municated thunder  such  circumstances,  except  wlien 
connexion  had  been  continued  after  the  appearance  of 
the  discharge. 

The  late  Mr.  Hey,  of  Leeds,  however,  gave  it  as  his 
opinion,  that  a man  might  communicate  lues  venerea 
after  all  the  symptoms  of  the  disease  had  been  re- 
moved, and  he  was  apparently  in  perfect  health. — (Seo 


438 


VENEREAL  DISEASE. 


Med.  Chir.  Trans,  vol.  7,  p.  547.)  This  seniiment  is 
not  only  repugnant  to  the  authority  of  Mr.  Hunter,  but 
to  common  observation  and  all  sound  reasoning.  The 
very  case  which  Mr.  Hey  adduced  in  proof  of  the  oc- 
currence, is  decidedly  inadequate  to  the  purpose,  in 
consequence  of  the  impossibility  of  trusting  to  the  ac- 
counts which  patients,  under  circumstances  involving 
their  honour,  are  apt  to  give  of  themselves.  In  the 
case  recited  by  him,  the  patient  might  have  had  some 
venereal  affection  at  the  period  of,  or  subsequently  to, 
his  marriage;  and  yet  his  feelings,  and  a sense  of  the 
disgrace  of  infecting  a virtuous  woman,  might  have 
compelled  him  to  conceal  the  real  truth  from  his  sur- 
geon. Again,  it  is  to  be  remembered,  that  the  lady  her- 
self might  have  deviated  from  the  path  of  chastity, 
and  exposed  herself  to  infection  ; and,  if  she  had  done 
so,  she  would  have  informed  neither  her  husband  nor 
Mr.  Hey.  I confess  that  it  is  at  all  times  painful  to 
suspect  the  veracity  of  individuals  whose  situations  in 
life  are  respectable ; but  whenever  an  occurrence  takes 
place  decidedly  contrary  to  the  evidence  of  general 
experience,  every  possibility  is  to  be  recollected,  in 
order  to  avoid  the  necessity  of  admitting  doctrines  not 
founded  upon  truth. 

Mr.  Hey,  with  much  more  reason,  joins  in  the  belief 
of  the  possibility  of  the  venereal  disease  being  com- 
municated to  the  foetus  in  ulero,  though  in  what 
manner  the  infection  is  transmitted,  is  a question  not 
yet  elucidated.  A universal  desquamation  of  the  cu- 
ticle ; a hoarse,  squeaking  voice ; copper-coloured 
blatches ; a scaly  eruption  upon  the  chin ; an  unna- 
tural redness  of  the  anus ; are  the  common  symp- 
toms which  he  sets  down  as  proofs  of  syphilis  in  very 
young  infants.  As  these  complaints  yield  to  small 
doses  of  the  submuriate  of  mercury,  or  the  hydrargy- 
riis  cum  creta,  and  either  the  nurse  or  parent  has  had 
some  venereal  or  syphiloid  disease  at  no  very  distant 
period,  the  cases  are  often  regarded  as  decided  speci- 
mens of  one  of  these  disorders. 

The  venereal  poison  would  appear  to  be  very  irre- 
gular in  its  effects,  different  persons  being  variously  af- 
fected by  it;  and  hence,  probably,  one  cause  of  a great 
deal  of  the  uncertainty  yet  prevailing  about  its  distin- 
guishing characters.  Thus,  as  Mr.  Hunter  mentions, 
two  men  sometimes  have  connexion  with  the  same 
woman ; both  catch  the  disease  ; but  one  may  have 
very  severe,  the  other  exceedingly  mild  symptoms. 
He  knew  of  an  instance,  in  which  one  man  gave  the 
disease  to  different  women,  some  of  whom  had  it  with 
great  severity,  while  the  others  suffered  but  slightly.  On 
the  same  point  I find  an  interesting  statement,  made 
by  Dr.  Hennen,  in  his  Report  of  Observations  on  Sy- 
philis in  the  Military  Hospitals  in  Scotland: — “We 
have  had  (says  he)  frequent  opportunities  of  remark- 
ing two  or  more  sores  of  different  kinds,  existing  at  the 
same  time:  an  irregularly-shaped,  diffused  sore;  an 
elevated  sore,  covered  with  a light-coloured  slough,  as 
if  a bit  of  chamois  leather  had  been  stuck  on  by  some 
tenacious  substance ; a groove  or  streak  along  the 
glans,  as  if  made  by  a scraping  instrument,  filled  with 
purulent  matter;  and  the  true  ana  perfect  chancre,  ac- 
cording to  Mr.  Hunter’s  definition  ; or  the  true  syphi- 
litic ulcer,  according  to  Mr.  Carmichael.  This  last 
has,  in  some  cases,  occupied  the  glans;  in  some  the 
prepuce  ; while  the  sores  of  another  description  have 
been  on  the  same  part  close  beside  it,  or  on  another 
part  at  a distance.  Three  of  these  cases  I particularly 
selected  for  examination  and  public  demonstration,  at 
the  C.'istle  Hospital ; in  one,  the  Hunterian  chancre 
was  on  the  glans,  and  a sore  without  any  hardness  on 
the  prepuce  ; in  another,  it  was  on  the  prepuce,  and  a 
simple  ulcer  on  the  glans ; in  the  third,  a most  perfect 
specimen  of  Hunterian  chancre  occupied  the  internal 
prepuce  close  to  the  corona  glandis ; and,  at  about  half 
an  inch  from  it,  nearer  the  frasnum,  but  farther  from 
the  glans,  was  an  elevated  ulcer.  In  all  these  cases, 
the  Hunterian  chancre  healed  (without  mercury)  seve- 
ral days  before  the  others. 

“ Soldiers  (says  Dr.  Hennen)  are  gregarious  in  their 
amours,  and  we  have  frequently  several  men  at  the 
same  time  in  hospital  infected  by  the  same  woman, 
with  whom  they  have  had  connexion  in  very  rapid 
succession ; some  of  them  have  had  one  kind  of  sore, 
some  another,  and  some  both. — {Principles  of  Military 
Surgery,  ed.  2,  p.  525.)  But  if  these  facts,  which 
agree  with  my  own  observations,  be  rather  adverse  to 
the  theory  of  a plurality  of  venereal  poisons  (see  Car- 


michael's Essays  on  the  Venereal  Disease,  ^c.j,  they 
still  leave  difficulties  which  cannot  be  entirely  solved 
by  reference  to  peculiarities  of  constitution  and  differ- 
ent states  of  the  health,  because  no  explanation  on  thia 
principle  would  account  for  a man  having,  at  the  same 
time,  upon  the  penis,  two  or  three  different  kinds  of 
ulcers,  apparently  excited  by  one  cause.  Neither  will 
any  difference  of  texture  afford  the  needed  explana- 
tion, though  the  utmost  latitude  be  given  to  the  doc- 
trine, that  the  appearance  and  progress  of  sores  are 
considerably  modified  by  the  nature  of  the  parts.  It 
is  only  necessary  to  consider  the  above  passage  from 
Dr.  Hennen’s  work,  to  perceive  that  the  particular  tex- 
ture, whether  prepuce,  skin,  glans,  or  corona  glandis, 
does  not  always  communicate  to  sores  one  invariable 
character,  even  when  they  arise,  as  the  evidence  would 
dispose  one  to  suppose,  as  nearly  as  possible  under  the 
same  circumstances,  and  from  the  same  source  of  in- 
fection. 

But  though  in  such  examples  no  data  with  which  I 
am  acquainted  lead  to  any  safe  inference,  respecting 
the  exact  cause  of  the  diversity  of  effect  produced  in 
different  persons,  and  evert  on  different  parts  of  the 
same  individual  by  one  kind  of  virus,  not  a doubt  can 
be  entertained,  that  generally  climate  and  constitution 
have  vast  influence  over  the  venereal  disease.  In  all 
warm  countries,  the  disorder,  as  far  as  regards  the  na- 
tives, and  those  who  have  been  long  settled  there,  is 
not  only  much  milder  in  its  symptoms,  but  much  more 
easy  of  cure.  In  the  West  Indies,  the  Brazils,  &c.,  it 
has  for  a long  period  of  time  been  very  commonly 
cured  by  means  of  sarsaparilla,  guaiacum,  mezereon, 
&c.,  without  a grain  of  mercury.  It  is  alleged,  how- 
ever, that  this  mildness  of  syphilitic  complaints,  and 
their  facility  of  cure  in  warm  climates,  do  not  extend 
to  strangers  recently  arrived  there,  who  are  said  even 
to  suffer  more  from  the  virulence  of  the  disease  than 
in  their  native  climate.  In  Portugal,  during  the  late 
war,  the  dreadful  ravages  of  the  venereal  disease 
among  the  British  soldiers,  and  its  comparatively 
milder  phenomena  among  the  inhabitants  of  the  coun- 
try, were  particularly  noticed.  “ In  the  British  army 
(says  Dr.  Fergusson),  it  is  probable  that  more  men  have 
sustained  the  most  melancholy  of  all  mutilations, 
during  the  four  years  that  it  has  been  in  Portugal, 
through  the  disease,  than  the  registers  of  all  the  hos- 
pitals in  England  could  produce  for  the  last  century; 
while  venereal  ulceration  has  not  only  been  more  in- 
tractable to  the  operation  of  mercury  than  under  simi- 
lar circumstances  at  home,  but  the  constitution,  while 
strongly  under  the  influence  of  the  remedy,  has  become 
affected  with  the  secondary  symptoms  in  a proportion 
that  could  not  have  been  expected.  With  the  natives, 
on  the  contrary,  the  disease  is  very  mild  ; curable,  for 
the  most  part,  by  topical  treatment  alone,  or  wearing 
itself  out  when  received  into  the  constitution,  after 
running  a certain  course,  not  always  a very  destruc— ' 
tive  one,  without  the  use  of  any  adequate  mercurial 
remedy,  &c.  The  bulk  of  the  people,  and  of  all  the 
military  at  the  hospitals,  even  though  a general  order 
has  been  given  out  enjoining  the  use  of  mercury,  cure 
themselves  or  get  cured  by  other  means.  I have  now 
been  upwards  of  two  years  at  the  head  of  their  hos- 
pital department,  and  I can  declare,  that  it  never  oc- 
curred to  me  among  all  the  venereal  patients  whom  in 
that  time  I have  seen  pass  through  the  hospitals,  to 
meet  a single  one  under  the  influence  of  mercury,  ex- 
cepting those  cases  wherein  I myself  have  personally 
superintended  its  administration.  They  go  out  cured 
by  topical  remedies  alone ; and  I have  lived  long 
enough  among  them  to  ascertain  that  their  return  to 
hospital  under  such  circumstances  for  secondary  symp- 
toms, is  far  from  being  a universal  or  even  a frequent 
occurrence.” — {Fergusson,  in  Med.  and  Chir.  'Trans, 
vol.  4,  p.  1, 2.) 

The  inference  at  which  Dr.  Fergusson  arrives  is, 
that,  in  Portugal,  the  disease  is  exhausted,  and  has  lost 
much  of  its  virulence,  in  the  same  manner  as  the  na- 
tural small-pox,  unresisted  by  inoculation,  appears  to 
have  changed,  in  the  same  country,  into  a very  mild 
disease,  which  does  well  under  any  mode  of  treatment. 

“Yet  (says  Dr.  Fergusson)  I have  no  doubt,  that  were 
this  mild  di.sease,  or  tire  mildest  that  was  ever  produced 
from  the  improved  inoculation  of  England,  communi- 
cated to  a tribe  of  Indians,  or  to  a plantation  of  ne- 
groes, or  any  other  class  of  people  who  had  never  be- 
fore known  the  small-pox,  it  would  desolate  with  all 


VENEREAL  DISEASE, 


439 


ttte  fury  of  pestilence,  destroying  wherever  it  could 
find  victims,  and  never  ceasing  until  it  had  destroyed 
the  whole  ” And,  on  the  same  principles.  Dr.  Fergus- 
son  attempts  to  explain  the  severe  effects  of  the  inocu- 
lation of  the  exhausted  syphilitic  virus  of  Portugal 
into  the  constitution  of  the  British  or  other  stranger, 
and  the  impo-ssibility  of  curing  the  disease  by  the  same 
treatment  which  answers  for  the  natives  themselves. — 
i^Med.  Chir.  Trans,  vol.  4,  p.  7.  10.)  On  the  other 
hand,  Mr.  Guthrie  does  not  admit,  that  the  disease 
which  the  troops  contracted  in  Portugal  was  more  vio- 
lent than  the  same  complaint  in  England ; or  rather,  he 
admits  the  fact,  but  gives  a different  explanation  of  it 
from  that  of  Dr.  Fergusson ; and  refers  the  severe  effect 
of  the  disease  upon  the  soldiers  in  Portugal  to  the  ope- 
ration of  the  climate  upon  their  northern  constitutions, 
and  their  irregularity  and  intemperance,  vices  to  which 
the  natives  are  not  addicted. — (See  Med.  Chir.  Trans, 
vol.  8,  p.  56S.) 

The  opinion,  that  the  venereal  disease  was  continu- 
ally changing  in  its  nature,  and  that,  in  the  end,  it 
would  entirely  cease,  is  one  that  has  been  brought  for- 
ward at  various  periods  ever  since  its  supposed  im- 
portation into  Europe.  Von  Hutten  would  lead  us  to 
suppose,  that  its  original  violeilce  did  not  last  more  than 
about  seven  years  from  the  assumed  period  of  its 
birth ; “ qui  nunc  vagatur  fmditate  tolerabilior  qui 
nunc  grassatur  viz  Mius  generis  esse  putetur."  J. 
Benedictus  also  writes ; “ tempore  isto,non  reperiuntur 
gallicantes  cum  tarn  scevis  accidentibus  sicut  apparue- 
runt  ante  aliquot  annos. — (7?e  Morb.  Oallico,  cap.  3, 
anno  1508.)  The  idea  that  syphilis  would  at  some  pe- 
riod be  extinguished,  is  as  ancient  as  the  times  of  Fra- 
castorius : 

Cum  fata  dabunt  laientibus  annis 

Tempus  erit,  cum  nocte  atra  sopita  jacebit  interritu 
data. 

From  the  testimony  of  these  and  other  writers,  espe- 
cially that  of  A.  T.  Petronius  {lib.  1,  cap.  3)  and  B. 
Tomitani  {lib.  2),  no  doubt  can  be  entertained,  that  the 
severe,  rapidly  spreading,  and  frequently  fatal  disease, 
which  broke  out  in  Italy  at  the  close  of  the  fifteenth 
century,  did  not  continue  many  years  with  its  original 
violence,  but  changed  so  much  as  even  to  justify  the 
opinion,  defended  by  many  able  men,  that  it  was  a 
totally  different  disorder  from  any  complaint  now  re- 
puted to  be  venereal.  And  the  historical  fact  of  the 
gradual  change  in  the  nature  of  the  disease  which 
broke  out  in  the  French  army  before  Naples,  at  the 
close  of  the  fifteenth  century,  might  be  taken  as  an 
argument  against  its  having  been  syphilis,  by  those 
who  will  not  admit  that  the  latter  disease  has  under- 
gone any  alteration  of  character.  Among  the  moderns, 
Peyrilhe  has  denied  the  correctness  of  the  doctrine, 
that  the  nature  of  the  venereal  disease  is  changed : he 
treats  of  two  sorts  of  change  or  degeneration,  as  it  was 
termed;  one  general ; the  other  particular.  He  denies 
the  first,  and  maintains  that  the  venereal  disease  is  as 
destructive  now  as  in  past  times.  As  for  the  degene- 
ration of  the  poison  in  an  individual,  he  admits  it : 
“ perhaps  (says  he)  spontaneous  cures  will  be  doubted : 
numerous  facts  attest  them  to  those  who  know  how  to 
see,  and  we  have  tried  to  demonstrate  them  to  others. 
For  our  own  part,  we  cannot  doubt  that  the  venereal 
poison  becomes  weaker  and  weaker  in  the  infected 
person,  becomes  milder,  and,  as  it  gets  older,  loses  its 
principal  character,  its  property  of  communicating  the 
disease.” — (See  Remide  Mouveau,  ire.  Montp.  1786.) 

It  has  been  a contested  question,  whether  the  vene- 
real disease  and  gonorrhoea  arise  from  the  same  poison  1 
Mr.  Hunter  acknowledges,  that  the  opinion  of  their 
originating  from  two  distinct  poisons  seems  to  have 
some  foundation,  when  the  difference  in  the  symptoms 
and  method  of  cure  is  considered.  But  he  asserts,  that 
if  this  question  be  taken  up  upon  other  grounds,  and 
experiments  be  made,  the  result  of  which  can  be  safely 
depended  upon,  this  notion  will  be  found  to  be  errone- 
ous. 4s  the  arguments  of  Mr.  Hunter,  in  support  of 
the  doctrine,  that  both  diseases  are  produced  by  the 
same  virus,  are  noticed  in  the  article  Oonorrhcea,  I 
shall  not  here  repeat  them. 

On  the  other  hand,  Mr.  B.  Bell  relates  some  experi- 
ments, from  which  the  conclusion  is  made,  that  the 
jwisons  of  the  venereal  disease  and  gonorrhoea  are  en- 
tirely different  and  distinct. 

Matter  was  taken  upon  the  point  of  a probe  from  a 


chancre  on  the  glans  penis,  before  any  application  was 
made  to  it,  and  completely  introduced  into  the  urethra. 
For  the  first  eight  days,  the  gentleman  who  made  this 
experiment  felt  no  kind  of  uneasiness;  but  about  this 
period  he  was  attacked  with  pain  in  making  water. 
On  dilating  the  urethra  as  much  as  possible,  nearly  the 
whole  of  a large  chancre  was  discovered,  and  in  a few 
days  a bubo  formed  in  each  groin.  No  discharge  took 
place  from  the  urethra  during  the  whole  course  of  the 
disease ; but  another  chancre  was  soon  perceived  in 
the  opposite  side  of  the  urethra,  and  red  precipitate 
was  applied  to  it  as  well  as  to  the  other,  by  means  of  a 
probe  previously  moistened  for  the  purpose.  Mercurial 
ointment  was  at  the  same  time  rubbed  on  the  outside 
of  each  thigh,  by  which  a profuse  salivation  was  ex- 
cited, The  buboes,  which,  till  then,  had  continued  to 
increase,  became  stationary,  and  at  last  disappeared 
entirely;  the  chancres  became  clean,  and,  by  a due 
continuance  of  mercury,  a complete  cure  was  at  last 
obtained.  If  this  case,  and  another  to  which  I shall 
presently  advert,  could  be  entirely  depended  upon, 
they  would  tend  to  disprove  the  part  of  Mr.  Hunter’s 
theory,  accounting  for  the  different  effects  of  the  same 
poison  by  its  application  in  the  case  of  chancre  to  a 
non-secreting  surface  covered  with  cuticle,  and  that  of 
gonorrhoea  to  a secreting  mucous  membrane.  How- 
ever this  may  be,  I have  never  seen  a chancre  within 
the  urethra. 

The  next  experiment  was  made  with  the  matter  of 
gonorrhoea,  a portion  of  which  was  introduced  be- 
tween the  prepuce  and  glans,  and  allowed  to  remain 
there  without  being  disturbed.  In  the  course  of  the 
second  day,  a slight  degree  of  inffammation  was  pro- 
duced, succeeded  by  a discharge  of  matter,  which,  in 
the  course  of  two  or  three  days,  disappeared. 

The  same  experiment  was  repeated ; but  no  chancre 
ever  ensued  from  it. 

Two  medical  students  were  anxious  to  ascertain  the 
point  in  question ; and  with  this  view  they  made  the 
following  experiments,  at  a time  when  neither  of  them 
had  ever  laboured  under  either  gonorrhoea  or  syphilis, 
and  both  in  these  and  in  the  preceding  experiments,  the 
matter  of  infection  was  taken  from  patients  w'ho  had 
never  made  use  of  mercury. 

A small  dossil  of  lint,  soaked  in  the  matter  of  go- 
norrhoea, was  by  each  of  them  inserted  between  the 
prepuce  and  the  glans,  and  allowed  to  remain  on  the 
same  spot  for  the  space  of  twenty-four  hours.  From 
this  it  was  expected  that  chancres  would  be  produced ; 
but  in  one  a very  severe  degree  of  inflammation  en- 
sued over  the  whole  glans  and  praeputium,  giving  all 
the  appearance  of  what  is  usually  termed  gonorrhoea 
spuria.  A considerable  quantity  of  fetid  matter  was 
discharged  from  the  surface  of  the  inflamed  parts,  and 
for  several  days  there  was  reason  to  fear  that  an  ope- 
ration would  be  necessary  for  the  removal  of  a para- 
phymosis.  By  the  use  of  saturnine  poultices,  laxatives, 
and  low  diet,  however,  the  inflammation  abated,  the 
discharge  ceased,  no  chancre  took  place,  and  the  case 
got  entirely  well.  In  the  other  gentleman,  says  Mr.  B. 
Bell,  the  external  inflammation  was  slight,  but  in  con- 
sequence of  the  matter  finding  access  to  the  urethra, 
he  was  attacked,  on  the  second  day,  with  a severe 
gonorrhoea,  with  which  he  was  troubled  for  more  than 
a year. 

The  next  experiment  was  made  by  the  friend  of  the 
latter  student:  he  inserted  the  matter  of  gonorrhoea, 
with  a lancet,  beneath  the  skin  of  the  praiputium,  and 
likewise  into  the  substance  of  the  glans;  but,  although 
this  was  repeated  three  dilferent  times,  no  chancres 
ensued.  A slight  degree  of  inflammation  was  excited ; 
but  it  soon  disappeared,  without  any  thing  being  done 
for  it.  His  last  experiment  was  attended  with  more 
serious  consequences.  The  matter  of  a chancre  was 
inserted  on  the  point  of  a probe  to  the  depth  of  a 
quarter  of  an  inch  or  more,  in  the  urethra.  No  symp- 
toms of  gonorrhoea  ensued ; but,  in  the  course  of  five 
or  six  days,  a painful  inflammatory  chancre  was  per- 
ceived on  the  spot  to  which  the  matter  was  applied. 
To  this  succeeded  a bubo,  which  ended  in  suppuration, 
notwithstanding  the  immediate  application  of  mercury ; 
and  the  sore  that  was  produced  proved  both  painful 
and  tedious.  Ulcers  were  at  last  perceived  in  the 
throat,  nor  was  a cure  obtained  till  a very  large  quan- 
titv  of  mercury  had  been  given,  and  tlie  patient  kept 
in  close  confinement  for  thirteen  weeks. — ( On  Gonor- 
rhoea Virulenta  and  Lues  Venerea^  vol.  1,  ed.  2,  p.  438, 


440 


VENEREAL  DISEASE. 


4-c.)  Mr.  Evans,  it  appears,  has  also  several  times 
inoculated  with  the  matter  of  gonorrhoea,  but,  in  every 
ease,  it  failed  to  produce  any  effect. — (O/r  Ulceration 
of  the  Genital  Organs,  p.  81,  800.  Land.  1819.) 

Some  other  facts  on  record,  however,  tend  rather  to 
support  Mr.  Hunter’s  inference,  if  any  conclusion  can 
be  ventured  upon  without  the  aid  of  the  most  minute 
details.  Thus  Vigaroux  mentions  an  instance  in 
which  six  young  Frenchmen  had  connexion  with  the 
same  woman,  one  after  the  other.  The  first  and  fourth, 
in  the  order  of  connexion,  had  chancres  and  buboes, 
the  second  and  third  gonorrhoea,  the  fifth  chancre,  and 
the  sixth  bubo. — {(Euvres  de  Chir.  Pratique;  Montp. 
1812,  p.  8.)  And  Dr.  Hennen,  who  refers  to  this  case, 
mentions  a similar  one,  in  which  the  first  person  es- 
caped, the  second  had  true  chancres  and  elevated  sores, 
and  the  third  gonorrhoea.  The  connexion  took  place 
within  an  hour. — {Military  Surgery,  edit.  2,  p.  526.) 
These  facts  would  indeed  be  much  more  interesting,  if 
the  disease  with  which  the  women  were  affected  had 
been  ascertained,  and  one  could  securely  calculate 
upon  the  men  not  having  exposed  themselves  within  a 
given  time  to  any  other  sources  of  infection.  In  short, 
without  a perfect  history  and  description  of  cases  of 
this  kind,  from  their  beginning  to  their  end,  no  light  is 
thrown  by  them  on  the  question  about  the  venereal 
and  gonorrhoeal  poisons.  Nor  does  Dr.  Hennen  quote 
them  with  this  view ; but  for  the  purpose  of  exempli- 
fying the  variety  of  efiects  produced  on  difterent  indi- 
viduals apparently  by  the  same  infection  ; though  the 
same  consideration  which  prevents  any  certain  infer- 
ence from  such  observations,  in  regard  to  the  identity 
of  the  venereal  and  gonorrhoeal  poisons,  seems  also  to 
interfere  with  the  other  conclusion.  In  the  experi- 
ments detailed  both  by  Hunter  and  B.  Bell,  there  is 
also  one  point  assumed  by  both  parties,  though  it  is 
far  from  being  determined,  viz.  that  the  matter  dis- 
charged from  the  urethra  is  always  of  one  kind, 
in  respect  to  its  infectious  principle,  whatever  this  may 
be,  and  that  the  secretion  from  every  chancre  contains 
one,  and  only  one,  species  of  infectious  matter.  From 
the  candid  and  very  practical  work  of  Mr.  Evans,  it 
would  appear  that  some  ulcerations  on  the  penis,  such 
as  would  usually  be  called  chancres,  though  they  have 
of  late  years  been  sometimes  named  elevated  ulcers, 
arise  from  an  altered  secretion,  without  any  breach  of 
surface,  or  discernible  disease  in  the  female  organs. 
The  same  gentleman  was  also  frequently  present  at  the 
examinations  of  the  public  women  in  Valenciennes, 
and  always  surprised  at  tlie  small  portion  of  disease 
to  be  found  among  them ; “ At  one  which  I attended 
(says  he),  no  less  than  200  women  of  the  lowest  de- 
scription, and,  of  course,  the  most  frequented  by  sol- 
diers, were  examined,  and  not  one  case  of  disease  was 
found  among  them : nevertheless  the  military  hospi- 
tals had,  and  continued  to  have,  their  usual  number  of 
venereal  cases  (ulcerations). 

At  an  inspection  I have  since  attended,  where  100 
women  were  examined,  only  two  were  found  with  ul- 
c.erations:  I noticed  several  with  increased  secretions, 
and  one  with  purulent  discharge,  hut  these  were  taken 
no  notice  of  by  the  attending  surgeons,  as  they  did  not 
come  sufficiently  under  the  nead  of  virulent  gonor- 
rhosa. 

That  the  two  women  above  mentioned  as  having 
ulcers,  infected  the  whole  of  the  men  diseased  in  gar- 
rison, during  the  preceding  fifteen  days,  no  one  can  for 
a moment  admit  even  as  likely  ; but  1>  it  be  allowed 
that  an  altered  secretion  be  sufficient  for  the  produc- 
tion of  this  disease  (the  ulcus  elevatum),  we  shall  at 
once  have  an  explanation  of  how  it  happened  that  the 
military  hospitals  continued  to  have  their  usual  num- 
ber of  venereal  cases,  &;c.” — {Evans  on  Ulcerations 
of  the  Genital  Organs,  p.  72,  73,  <S*c.)  From  the  in- 
vestigations of  the  same  author, 'the  ulcus  elevatum  is 
Ihe  most  frequent  of  all  the  sores  met  with  on  the  ge- 
nitals, and  besides  being  excited  by  diseased  secretions 
and  gonorrhceal  matter,  is  capable  of  being  transferred 
by  inoculation,  and  even  of  originating  spontaneously. 
— (P.  67—81,  Src.) 

Lagneau  admits  that  gonorrhoea  may  not  always 
proceed  from  the  same  poison  as  the  venereal  disease  ; 
but  he  believes  that  in  the  greater  number  of  instances, 
the  virus  is  of  the  same  quality.  He  is  led  to  this 
opinion  by  the  consideration  of  several  women  having 
been  infected  by  the  same  man  with  both  complaints, 
and  of  the  two  diseases  having  been  communicated 


to  several  men  who  had  cohabited  with  one  woman, 
and  as  is  presumed  with  her  alone,  at  least  inasmuch 
as  may  relate  to  the  possibility  of  any  other  infection 
weakening  the  conclusion  attempted  to  be  drawn  from 
the  case ; a point  which  has  only  been  assumed,  and  by 
no  means  ascertained.  However,  be  this  and  other  simi- 
lar narrations  true  or  not,  in  every  particular,  I agree 
with  Mr.  Guthrie  in  believing  that  the  evidence  ad- 
duced on  the  point  under  consideration,  justifies  the 
opinion  “ that  ulcers  will  arise  on  the  penis  front  the 
matter  of  gonorrhoea;  that  gonorrhoea  will  in  its  turn 
be  caused  by  the  matter  of  these  same  ulcers ; and 
that  both  occur  in  consequence  of  promiscuous  or  un- 
cleanly intercourse.  That  many  of  the  ulcers  pro- 
duced in  this  manner  will  occasionally  assume  every 
character  of  chancre,  and  cannot  be  distinguished  from 
it,  I am  perfectly  satisfied  of  from  repeated  observa- 
tion ; but  I am  equally  certain,  that  a gonorrhoea  in 
men,  with  the  worst  appearances  and  symptoms,  can, 
and  often  does  arise  from  irritating  causes  common  to 
parts  free  from  any  specific  disease  or  poison,  is  not 
distinguishable  from  one  that  has  arisen  from  promis- 
cuous intercourse,  and  that  both  complaints  are  cu- 
rable in  the  same  way,  and  without  mercury.”  On 
the  question,  whether  gonorrhoea  or  the  ulcers  result- 
ing from  the  matter  of  gonorrhoea,  can  produce  con- 
stitutional symptoms,  Mr.  Guthrie  believes  that  they 
generally  do  not,  although  he  does  not  affirm  that  they 
cannot  under  particular  circumstances  of  constitution  ; 
and  he  is  farther  of  opinion,  that  if  such  symptoms 
ever  really  arise,  they  become  serious  only  in  conse- 
quence of  the  exhibition  of  mercury. — (See  Med.  Chir. 
Trans,  vol.  8,  p.  554.)  Delpech  considers  the  possi- 
bility of  a general  infection  from  the  effect  of  w'hat 
he  terms  a syphilitic  gonorrhoea,  completely  proved  ; 
though  he  admits  that  there  are  numerous  instances  in 
which  this  consequence  does  not  happen.  He  owns 
that  the  distinction  of  one  class  of  cases  from  the  other 
is,  d priori,  extremely  difficult,  and  most  frequently 
quite  impossible.  Yet,  widely  dissenting  from  esta- 
blished modern  practice,  he  inclines  to  ancient  maxims, 
and  considers  it  prudent  to  destroy  the  first  effect  of  the 
infection  without  delay,  his  aim  being  to  shorten  the 
duration  of  the  discharge  with  cubebs,  or  copaiba, 
and  then  to  introduce  mercury  into  the  system  through 
the  same  channel  as  conveys  the  virus  into  it,  by  rub- 
bing the  ointment  on  the  integuments  of  the  penis. — 
{Chir.  Clinique,  p.  292.) 

From  what  has  been  already  observed,  it  must  be 
evident,  that  one  of  the  greatest  obstacles  to  our  arri- 
val at  a satisfactory  knowledge  of  the  nature  of  lues 
venerea,  is  the  fact,  that  under  this  denomination, 
many  various  diseases  are  comprised  and  confounded, 
and  the  particular  distinctions  of  each  of  which  are 
not  yet  sufficiently  made  out  to  enable  surgeons,  to 
form  a well-founded  and  practical  classification  of 
them,  satisfactory  to  every  impartial  observer,  and 
agreeing  with  general  experience.  But  though  such 
progress  has  not  yet  been  made,  the  attention  of  mo- 
dern practitioners,  and  especially  that  of  John  Hunter, 
Mr.  Abernethy,  and  Mr.  Carmichael,  has  been  directed 
to  the  subject.  In  fact,  notwithstanding  some  myste- 
rious circumstances  in  particular  syphilitic  cases  may 
not  admit  of  complete  and  satisfactoiy  explanation  by 
the  doctrine  of  a plurality  of  poisons,  no  intelligent 
surgeons,  I believe,  now  suppose  that  the  diseases  fre- 
quently communicated  by  sexual  intercourse  always 
proceed  from  one  peculiar  poison.  As  Mr.  Rose  has 
observed,  long  before  syphilis  is  supposed  to  have  com- 
menced its  career  in  the  world,  some  of  these  diseases 
were  frequently  met  with,  and  Mr.  Pearson  thinks  that 
in  addition  to  those  formerly  known,  new  forms  of 
disease  have  occasionally  arisen,  “ which  are  suc- 
ceeded by  a regular  series  of  symptoms  nearly  resem- 
bling the  progress  of  lues  venerea.” — {Obs.  on  the  Ef- 
fects of  various  Articles  of  the  Materia  Medica  in  the 
Cure  of  Lues  Venerea,  2d  ed.  Introd.  p.  53  ; and  Rose 
in  Med.  Chir.  Trans,  vol.  8,  p.  418.)  Mr.  Hunter  also, 
in  the  seventh  chapter  of  his  Treatise  on  the  Venereal 
Disease,  speaks  of  many  examples  of  new-formed  dis- 
eases, arising  from  peculiar  poisons,  quite  different,  he 
supposes,  from  every  other  virus  previously  known,  or 
judged  of  by  its  effects.  But  though  Mr.  Rose  appears 
to  join  in  the  belief  of  a plurality  of  poisons,  he  is  very 
far  from  considering  it  settled,  how  far  the  variety  in 
the  symptoms  of  venereal  cases  is  to  be  attributed  to 
difierent  poisons,  or  how  far  the  symptoms  of  the  same 


VENEREAL  DISEASE. 


441 


poison  may  be  modified  and  altered  by  constitution, 
climate,  and  Jiabits  of  life.  He  remarks,  that  we  sel- 
dom have  an  opportunity  of  tracing  difterent  cases  to 
the  same  source  of  infection,  and  of  comparing  their 
progress  with  each  other. — {Vol.  cit.  p.  419.)  And  I 
may  add,  tiiat  as  far  as  observations  of  this  nature 
have  been  made,  and  can  be  trusted,  they  rather  tend 
to  prove,  as  already  noticed  in  the  foregoing  columns, 
that  difterent  individuals,  when  infected  nearly  at  the 
same  time  and  by  the  same  woman,  are  very  far  from 
having  any  uniformity  in  their  complaints;  some  hav- 
ing one  kind  of  sore,  some  another,  and  others  claps, 
&c.  And  the  tenor  of  the  remarks  made  likewise  by 
Mr.  Evans,  as  far  as  he  has  yet  entered  into  the  sub- 
ject, lead  equally  to  the  conclusion,  that  one  primary 
complaint,  when  it  produces  another,  does  not  always 
occasion  one  resembling  itself.  Thus,  the  ulcus  eleva- 
tum  on  the  penis,  though  capable  of  being  communi- 
cated by  inoculation,  appeared  sometimes  to  be  the  ef- 
fect of  one  kind  of  infection,  sometimes  of  another, 
and  sometimes  even  to  have  a spontaneous  origin. 
Who  shall  unravel  all  these  intricacies  I know  not, 
whether  he  bring  to  his  assistance  plurality  of  poisons, 
or  states  of  the  parts  and  constitution,  climate,  neglect, 
intemperance,  wrong  treatment,  or  any  other  circum- 
stance, which  can  possibly  be  conceived  to  have  influ- 
ence over  the  appearances,  progress,  and  consequences 
of  the  disease.  Nay,  it  would  appear  from  some  of 
the  curious  and  perplexing  histories  mentioned  in  the 
preceding  pages,  that  one  kind  of  primary  complaint 
in  an  individual  may  impart  toother  persons  primary 
complaints  of  a different  nature,  so  that  even  the  hope 
of  elucidating  parts  of  this  abstruse  subject,  hy  advert- 
ing to  a plurality  of  infections,  and  a vigilant  observa- 
tion of  their  characteristic  effects,  meets  with  discou- 
ragement almost  at  its  very  birth ; and  though  the 
doctrine  of  several  kinds  of  poisons  being  concerned 
in  the  production  of  syphilis  and  syphiloid  diseases 
still  maintains  its  ground,  an  absolute  proof  of  its  cor- 
rectness can  hardly  be  said  to  have  been  yet  afforded ; 
nor  indeed  could  it  be  obtained,  unless  the  inoculation 
of  healthy  individuals  with  the  matter  of  the  differ- 
ent forms  of  disease  were  justifiable  for  the  elucida- 
tion of  the  question.  And,  as  this  is  not  the  case,  I 
think,  with  Mr.  Carmichael,  that  it  might  be  a benefit 
to  society  if  criminals  were  sometimes  permitted  to 
commute  a heavier  punishment  by  submitting  to  such 
experiments,  without  which  the  inquiry  into  the  reality, 
number,  nature,  and  effects  of  the  morbid  poisons 
under  consideration,  can  perhaps  never  be  brought  to 
a satisfactory  termination.  “I  am  perfectly  aware 
(says  Mr.  Carmichael)  how  much  the  state  of  the  hu- 
man constitution  will  modify  local  diseases,  and  am 
willing  to  attribute  to  a certain  extent,  the  great  va- 
riety of  appearances  we  witness  daily  in  venereal 
complaints,  to  this  cause  alone.  But  we  observe  that 
many  of  those  primary  ulcers  evince,  from  their  very 
commencement,  such  peculiar  and  distinct  characters, 
that  it  would  be  quite  an  absurdity  to  believe  that  the 
virus  is  always  the  same,  and  the  variety  of  characters 
dependent  alone  upon  constitution.  Thus,  nothing 
can  be  more  opposite,  from  the  commencement,  than 
the  common  chancre,  with  its  hardened  base,  like  a 
piece  of  cartilage  under  the  skin,  and  the  sloughing 
ulcer.  The  first  is  slow  and  chronic ; the  latter  begins 
with  a mortified  spot,  extends  by  alternate  sloughing 
and  phagedenic  ulceration,  and  makes  more  progress 
in  three  days,  than  the  former  in  as  many  weeks. 

The  phagedenic  ulcer  is  equally  distinct  from 
chancre,  as  it  does  not  evince  at  any  period  a hardened 
base,  but  gradually  creeps  from  one  part  to  another  of 
the  penis,  leaving  those  parts  to  heal  which  in  the  first 
instance  it  attacked;  so  that  when  the  disease  has  ex- 
isted for  some  months,  the  glans  is  seen  to  exhibit  its 
entire  surface  furrowed  over  with  ulcerations  and  ci- 
catrices. 

There  is  a raised  ulcer,  also,  with  elevated  edges, 
approaching  the  nature  of  the  phagedenic  ulcer,  yet 
whose  characters  are  sufficiently  distinct  to  be  considered 
as  a separate  species.  But  the  most  common  venereal 
primary  ulceration  presents  such  various  appearances 
in  different  individuals,  that,  until  a more  exact  know- 
ledge is  obtained,  it  is  better  described  by  its  negative 
than  its  positive  qualities,  and  it  may  be  designated  an 
ulcer  without  induration,  raised  edges,  or  phagedenic 
surface. 

If  (continues  Mr.  Carmichael)  the  plurality  of  vene- 


real poisons  is  supported  by  the  variety  of  primary 
ulcers,  it  is  equally  so  by  the  multiplicity  of  constitu- 
tional eruptions.  A primary  ulcer,  which  was  not 
phagedenic  or  sloughing  at  first,  may  afterward,  like 
any  other  ulcer,  become  so  by  irritation,  neglect,  or 
inflammation.  But  I do  not  conceive  that  we  have 
grounds  for  supposing  that  the  state  of  the  constitution 
can  so  modify  morbid  poisons,  as  to  cause  the  same 
virus  to  produce  in  one  person  the  chronic  scaly  lepra 
and  psoriasis,  and  to  assume  in  another  a decided  pus- 
tular form,  each  pustule  spreading  rapidly  into  a deep 
ulcer.” — {On  the  Symptoms  and  specific  Distinctions 
of  Venereal  Diseases,  p.  6,  <i-c.  8vo.  Load.  1818.) 

The  same  gentleman,  in  his  Essays  on  this  subject, 
published  some  years  previously  to  the  above  date,  gives 
his  reasons  for  believing  that  certain  primary  appear- 
ances are  followed  by  a corresponding  train  of  consti- 
tutional symptoms.  1st,  That  the  syphilitic  chancre 
gives  rise  to  scaly  eruptions,  lepra,  and  psoriasis,  an 
excavated  ulcer  of  the  tonsils,  and  pains  and  nodes  of 
the  bones.  2dly,  That  the  ulcer,  without  induration, 
raised  edges,  or  phagedenic  surface,  gonorrhoea  viru- 
lenta,  an  excoriation  of  the  glans  and  prepuce,  are 
followed  by  a papular  eruption,  which  ends  in  desqua- 
mation, pains  in  the  joints  resembling  those  of  rheu- 
matism, soreness  of  the  fauces,  and  frequently  swell- 
ing of  the  lymphatic  glands  of  the  neck,  but  without 
any  nodes  of  the  bones.  3dly,  That  the  ulcer  with 
elevated  edges,  in  the  few  instances  in  which  it  was 
traced  by  Mr.  Carmichael  to  its  constitutional  symp- 
toms, was  followed  by  a pustular  eruption,  which  ter- 
minated in  mild  ulcers,  pains  in  the  joints,  and  ulcers 
in  the  throat,  but  no  appearance  of  nodes.  4thly, 
That  the  phagedenic  and  sloughing  ulcers  are  generally 
attended  with  constitutional  symptoms  of  peculiar 
obstinacy  and  malignity;  viz.  pustular  spots  and  tu- 
bercles, which  form  ulcers,  generally  spreading  with 
a phagedenic  edge,  and  healing  from  the  centre.  Ex- 
tensive ulceration  of  the  fauces,  particularly  of  the 
back  of  the  phayrnx,  obstinate  pains  of  the  knees  and 
other  joints,  while  nodes  are  frequently  present,  and 
the  bones  of  the  nose  are  occasionally  affected. — (See 
Carmichael's  Essays,  and  his  Obs.  on  the  Symptoms, 
i^-c.  of  Ven.  Diseases,  p.  9.) 

The  observations  of  other  modern  writers  seem 
generally  to  coincide  with  those  of  Mr.  Carmichael 
respecting  the  great  variety  of  character  in  primary 
venereal  sores,  and  partly  also  with  regard  to  the  hypo- 
thesis of  various  kinds  of  poisons  or  infectious  matter. 
But  on  some  other  great  questions  immediately  con- 
nected with  these  points,  little  similarity  of  opinion 
prevails  between  him  and  other  gentlemen,  who  have 
laudably  and  impartially  entered  into  the  disquisition. 
And,  in  the  first  place,  without  adverting  again  to  cer- 
tain statements  already  premised,  which  render  it  pro- 
bable that  differences  of  the  virus,  or,  at  all  events, 
differences  in  the  forms  of  the  primary  complaints  in 
the  contaminating  individuals,  would  not  always  ex- 
plain the  reason  of  the  diversified  appearances  and 
nature  of  the  primary  forms  of  disease  in  the  contami- 
nated,  I shall  lay  before  the  reader  other  evidence 
having  an  immediate  relation  to  Mr.  Carmichael’s 
sentiment,  that  each  kind  of  primary  venereal  sore  is 
followed  by  a peculiar  and  corresponding  train  of  con- 
stitutional symptoms.  In  the  cases  recited  by  Mr. 
Rose,  “ most  of  the  papular  eruptions  followed  ulcers 
which  were  not  very  deep,  and  which  healed  without 
much  difficulty.  Several  of  them  had  a thickened,  but 
not  a particularly  indurated  margin.  This  corresponds 
with  the  observations  of  Mr.  Carmichael: — I could 
not,  however,  discover  any  decidedly  uniform  character 
in  such  sores ; and  the  16th  case  I should  have  consi- 
dered as  a well-marked  instance  of  chancre.” — [Med. 
Chir.  Trans,  vol.  8,  p.  In  another  place,  it  is 

stated  that  the  ajipearances  of  sores  can  seldom  be 
relied  on  in  parts  of  such  vascular  structure,  and  in 
the  midst  of  sebaceous  glands. — (P.  419.)  With  respect 
to  tlie  phagedenic  ulcer,  Mr.  Rose  expresses  his  belief 
that  it  is  rarely  followed  by  secondary  symptoms, 
though  he  inclines  to  the  opinion  that  it  arises  from  the 
application  of  slhme  morbific  matter,  acknowledging, 
however,  the  great  difficulty  of  deciding  “ whether  the 
great  degree  of  erethismus,  excited  by  the  local  affec- 
tion, should  be  attributed  to  any  peculiarity  in  that 
matter,  or  is  owing  to  the  peculiar  state  of  the  constitu- 
tion.”— {Med.  Chir.  Trans,  vol.  8,  p.  372.)  And  he 
then  refers  to  the  case  reported  by  Ur.  Fergusson,  where 


442 


VENEREAL  DISEASE. 


“ the  infection  was  communicated  by  an  opera  dancer 
at  Lisbon,  apparently  in  perfect  health,  who  continued 
on  the  stage  lor  several  months  afterward,  occasion- 
ally infecting  others,  without  any  thing  extraordinary, 
as  far  as  he  could  learn,  in  the  nature  of  the  symp- 
toms.”— {Op.  cit.  vol.  4,  p.  12.)  And, on  the  same  sub- 
ject, Mr.  Guthrie  does  not  think  “ that  Mr.  Carmichael’s 
opinion,  as  to  the  secondary  symptoms  peculiar  to  the 
phagedenic  and  sloughing  ulcer,  receives  any  support 
from  what  occurred  to  the  troops  in  Portugal ; because 
it  did  not  appear  that  either  of  them,  following  sex- 
ual intercourse,  were  dependent  on  the  cause  which 
produced  the  ulcer.  Where  many  men  have  had 
iatercourae  with  the  same  woman  (and  with  no 
others  1),  they  have  not  all  had  the  same  complaint, 
although  one  of  the  ulcers  so  originating  has  become 
phagedenic  or  sloughed;  neither  has  the  same  woman 
herself  sulFered  from  this  distemper ; indeed,  the  na- 
ture of  an  ulcer  of  either  kind  must,  after  a short  time, 
elfectually  prevent  any  intercourse;  and  we  often  find 
that  their  peculiar  characters  only  appear  after  the 
ulcer  has  existed  for  several  days.  I firmly  believe, 
also,  that  in  the  greater  number  of  cases  of  sloughing 
ulcer,  where  mercury  is  not  given.,  no  secondary  symp- 
toms would  appear } and  in  those  cases  in  which  they 
did  appear,  I apprehend  they  would  be  equally  depend- 
ent on  the  state  of  the  constitution,  as  to  the  mode  of 
cure  and  their  destructive  characters.  In  other  words, 
my  observations  lead  me  to  conclude  that  these  ulcers 
do  not  depend  upon  a specific  poison,  but  on  the  state  of 
the  constitution  under  particular  excitement;  and  that 
when  secondary  symptoms  occur,  they  are  not  depend- 
ent on  the  state  of  the  ulcer ; although  I am  ready  to 
admit,  that  in  a constitution  where  an  ulcer  will  readily 
become  phagedenic,  the  secondary  symptoms,  when 
they  occur,  may  be  diflTerent  to  a certain  extent  from 
those  that  follow  more  simple  ulcers  in  a healthier 
habit  of  body.” — {Guthrie,  in  Med.  Chir. Trans,  vol.  8, 

564.)  My  observations  lead  me  to  believe,  with 

r.  Guthrie,  that  primary  sloughing  ulcers  do  not 
depend  upon  any  peculiar  poison;  and  I am  also  dis- 
posed to  join  him  in  the  opinion,  that  when  hurtful 
local  treatment  is  out  of  the  question,  they  are  chiefly 
owing  to  the  state  of  the  constitution.  According  to 
my  experience,  all  kinds  of  ulcers  on  the  genitals  may, 
from  particularity  of  constitution,  impairment  of 
health,  and  sometimes  from  the  pernicious  effects  of 
the  immoderate  and  indiscriminate  employment  of 
mercury,  assume  in  their  progress  a sloughing  disposi- 
tion, and  even  have  it  from  their  very  commencement. 
Mr.  Rose  mentions  a case,  in  which  a healthy  young 
man  was  affected  with  a sloughing  sore  on  the  penis,  in 
consequence  of  a suspicious  connexion.  It  was  not 
attended  with  any  constitutional  disturbance,  and 
yielded  readily  to  mercury.  The  same  patient,  twice 
afterward,  at  a very  considerable  interval,  had  a fresh 
infection,  and  the  sores  each  time  had  precisely  the 
same  character  as  the  first.  This,  says  Mr.  Rose,  is  no 
uncommon  occurrence,  and  it  is  not  probable  that  the 
sloughing  and  appearance  of  the  sores  arose  from  the 
peculiarity  of  the  poison.— (.4fed.  Chir.  Trans,  vol.  8, 
p.  420.)  And  another  intelligent  and  experienced  sur- 
geon, who  has  particularly  attended  to  this  investiga- 
tion, declares  his  conviction  that  “ many  *varieties  of 
sore,  independently  of  the  sloughy  chancre  mentioned 
by  Mr.  Carmichael,  lead  to  constitutional  symptoms, 
differing  in  no  respect  from  those  he  has  described,  and 
admitting  of  the  same  mode  of  cure.”  Nor  does  he 
believe,  with  Mr.  Carmichael,  that  only  one  particular 
species  of  sore  is  capable  of  producing  the  true  second- 
ary symptoms  of  lues. — {J.  Bacot,  On  Syphilis,  p.  51.) 

From  these  observations,!  think  we  may  safely  infer, 
tlial  with  respect  to  the  sloughing  ulcer,  it  neither 
arises  from  the  application  of  any  one  specific  poison 
to  the  part,  nor  is  it  connected  with  any  regular  train  of 
secondary  symptoms. 

Dr.  Hennen  assures  us,  that  he  has  frequently  had 
occasion  to  observe  that  eruptions  of  the  same  nature 
and  character  have  succeeded  to  the  foul,  indurated, 
excavated  ulcer,  and  to  the  simple  excoriation.  “ In 
fifteen  cases  of  eruptions,  unacconfpanied  by  any 
other  symptom-s,  which  succeeded  the  Hunterian  sore, 
six  were  tubercular,  five  exatithematous,  two  pustular, 
one  tubercular  and  scaly,  and  one  tubercular  and  vesi- 
cular. 

In  four  cases  following  the  same  sore,  but  in  which 
the  eruptions  were  complicated  with  sore  throat,  two 


were  tubercular,  one  was  tuoercular  and  scaly,  and 
one  was  tubercular  and  exanthematous. 

In  twelve  cases  following  the  non  Hunterian  sore, 
and  in  which  eruptions  were  the  only  symptoms,  six 
were  pustular,  three  were  exanthematous,  and  one 
was  tubercular  and  scaly. 

In  seven  cases  where  the  eruption  was  accompanied 
with  sore  throat,  three  were  exanthematous,  two  were 
tubercular,  one  was  papular,  scaly,  and  tubercular, 
and  one  was  pustular  and  tubercular.”  Dr.  Hennen 
also  recites  an  instance,  in  which  a Hunterian  chancre 
was,  at  the  distance  of  ten  weeks,  succeeded  by  a 
papular  eruption,  which,  in  the  course  of  a month, 
was  removed  by  low  diet,  purgatives,  and  the  decoction 
of^sarsaparilla.  In  two  months  afterward,  an  erup- 
tion of  a similar  nature  appeared  without  any  fresh 
infection.  This  was  treated  with  mercury,  which 
was  administered  five  weeks,  so  as  to  excite  a mode- 
rate salivation.  Under  this  treatment  the  eruption 
faded,  having  during  its  progress  assumed  the  appear- 
ance of  vesicles  and  pustules,  and  at  length  falling  off 
in  amber-coloured  scales  with  livid  bases.  Notwith- 
standing this  mercurial  course,  the  patient  was  a third 
time  admitted,  ten  weeks  afterward  (without  any 
intervening  primary  affection),  with  a pustular  erup- 
tion, which  was  finally  cured  without  mercury,  and 
the  pustules  falling  off  in  squamulae.  In  another 
month,  without  any  fresh  infection,  he  was  a fourth 
time  taken  into  hospital  with  a very  thickly  dispersed 
pustular  eruption,  somewhat  different  from  the  former, 
the  pustules  being  more  numerous,  smaller,  and  acumi- 
nated. They  yielded  to  non-mercurial  treatment. 
During  ail  these  attacks,  there  was  aphthous  sore 
throat,  and  occasional  flying  pains  in  the  joints.  The 
inference  drawn  from  this  case  is,  that  even  a full  and 
judiciously  conducted  mercurial  course  does  not  pre- 
vent the  reappearance  oUvenereal  eruptions,  and  that 
they  assume  at  difterent  times  different  characters,  not- 
withstanding the  interruption  they  receive  in  their 
natural  progress  by  the  use  of  that  remedy. — {On  Mili- 
tary Surgery,  ed.  2,p.  528—530.)  After  these  accounts,  I 
can  have  no  hesitation  in  coming  to  another  conclusion, 
which  is,  that  with  the  exception  of  the  partial  confirma- 
tion of  Mr.  Carmichael’s  doctrine  by  Mr.  Rose,  as  far  as 
relates  to  the  frequency  of  papular  eruptions  after 
superficial  primary  ulcers,  the  regular  connexion  of  par- 
ticular forms,  of  secondary  symptoms  with  any  given 
descriptions  of  primary  sores,  is  so  far  from  being  sup- 
ported by  the  testimony  of  other  observers,  that  one 
kind  of  primary  ulcer  may  lead  in  the  same  patient  to 
eruptions  of  several  different  sorts,  either  existing  toge- 
ther on  various  parts  of  the  body,  or  breaking  out  in 
succession ; and  no  regular  connexion  can  be  traced  be- 
tween any  one  species  of  primary  sore  and  any  deter- 
minate class  of  secondary  symptoms.  These  truths,  I 
believe,  must  be  admitted,  disadvantageous  as  they  are 
to  the  prospect  of  bringing  the  diagnosis  of  syphilis  to 
a final  settlement,  so  as  to  enable  the  writer  to  describe 
the  disease  with  accuracy,  and  the  practitioner  to 
recognise  and  treat  it  with  certainty.  The  first  essen- 
tial step  to  the  elucidation  of  this  subject,  however,  is 
undoubtedly  the  subversion  of  every  doctrine  relative 
to  it,  which  is  repugnant  to  general  experience.  The 
same  facts  which  may  render  it  necessary  for  Mr. 
Carmichael  to  retract  some  of  his  inferences,  and 
which  have  now  been  established  beyond  all  doubt  or 
possibility  of  successful  contradiction  by  the  very  im- 
partial, disinterested,  and  extensive  investigations 
made  in  the  army  hospitals,  would  have  obliged  even 
Hunter  himself,  had  he  been  alive,  to  confess  the  mis- 
taken views  which  he  sometimes  took  of  the  nature  of 
the  venereal  disease. 

With  respect  to  Mr.  Carmichael’s  theory,  Mr.  Bacot 
has  brought  forwards  several  arguments  against  it. 
“ Mr.  Carmichael  (he  says)  gives  us  an  example  of  a 
phagedenic  sore,  followed  by  those  appearances  which 
should  attach  to  the  raised  ulcer ; he  admits  that  the 
papular  and  pustular  diseases  are  sometimes  mixed ; 
in  some  of  his  phagedenic  cases  we  find  that  that  cha- 
racter has  been  given  to  the  ulcer  by  the  action  of  mer- 
cury ; in  still  more  of  them  the  original  character  of 
the  sore  is  not  preserved  throughout,  so  that  the  form 
of  secondary  symptoms,  which  ought  to  succeed  to  the 
classification,  is  very  difficult  to  divine ; in  short,  he 
frequently  departs  from  his  own  arrangement  His 
description  of  a phagedenic  ulcer  includes,  unless  I am 
much  mistaken,  two  very  distinct  kinds  of  sore ; and, 


VENEREAL  DISEASE, 


443 


in  more  than  one  instance,  a phagedenic  surface  and 
elevated  edges  are  united  in  the  same  description  of 
ulcer.  Nay,  more ; lie  tells  us,  that  occasional  difficulty 
is  encountered  in  distinguishing  the  pliagedenic  ulcer 
from  the  other  primary  ulcers.  It  displays,  however, 
its  character  of  phagedena  so  early,  that,  he  thinks,  it 
cannot  often  be  confounded  with  an  ulcer  that  becomes 
phagedenic  from  irritation  ; and,  he  adds,  that  neglect, 
local  irritation,  and  even  constitutional  iiritability  will 
cause  any  ulcer  to  become  phagedenic.  What  then 
should  prevent  me  from  assuming,  that  an  early  irrita- 
tion may  produce  an  early  change  in  the  character  of 
the  sore"?  And  then  what  becomes  of  the  phagedenic 
ulcer,  and  its  appropriate,  consecutive,  constitutional 
symptoms?” — (J.  Bacot,  in  Med.  Gazette,  vol.  2,  p. 
422.)  Notwithstanding  this  reasoning,  however,  if  it 
were  proved  that  the  primary  phagedenic  ulcer,  not 
made  so  by  irritation,  neglect,  &c.  always,  or  even 
generally,  were  followed  by  one  kind  of  secondary 
symptoms  and  not  by  others,  Mr.  Carmichael’s  re- 
searches would  have  c'^ntributed  much  to  enlighten 
this  obscure  subject.  As  I do  not  believe,  that  sores, 
which  are  originally  phagedenic,  necessarily  depend 
upon  any  one  peculiar  virus,  of  course  ntuch  difficulty 
presents  itself  to  my  mind  in  the  adoption  of  this  part 
of  Mr.  Carmichael’s  views. 

In  a very  ingenious  paper  by  Mr.  Welbank  I find 
several  observations  well  deserving  the  attention  of 
the  practical  surgeon.  Among  other  things,  he  sug- 
gests a plan  of  investigating  venereal  diseases,  which,  if 
carefully  followed  up,  might  throw  considerable  light  on 
their  diagnosis.  “ Instead  of  recording  with  laboured 
minuteness  the  resemblance  or  dissimilarity, confessedly 
sometimes  fallacious,  of  primary  sores,  of  eruptions, 
or  of  other  really  or  seemingly  consecutive  diseases  in 
the  cases  of  different  individuals,  we  should  (says  he) 
faithfully  chronicle  the  diversity  of  disease  existing  at 
the  same  time  in  the  same  person.  We  should  note, 
for  instance,  the  various  character  and  progress  of  a 
phagedenic  sore,  as  it  attacks  different  tissues,  or  the 
phenomena  of  several  of  these  sores,  when  they  have 
occurred  at  the  same  time,  in  different  situations,  from 
the  same  infection.  Let  us  also  record  the  multiform 
secondary  effects  of  the  same  disease,  contemporaneous 
in  their  appearance  or  coexistent  in  the  same  system, 
and  various  as  they  are  manifested  in  absorbents,  mu- 
cous membrane,  skin,  cellular  tissue,  fibrous  membrane, 
or  in  the  bones.  From  repeated  observation  of  collec- 
tive phenomena,  we  shall  soon  arrive  at  the  inference, 
that  many  affections,  often  noticed  in  conjunction,  but 
various  in  their  apparent  characters,  are  in  reality  the 
constant  result  of  one  or  other  distinct  stimulus,  acting 
upon  a diversity  of  organization.  By  a patient  and 
unbiassed  prosecution  of  this  mode  of  inquiry,  we 
cannot  fail  soon  to  acquire  diagnostic  data,  which  will 
enable  us  to  solve  some  of  the  most  difficult  problems 
in  the  distinction  of  venereal  complaints.” — (Med.  Chir. 
Trans,  vol.  13,  p.  566.)  Mr.  Welbank’s  experience 
leads  him  to  admit  the  general  truth  of  Mr.  Carmi- 
chael’s opinions,  of  which  he  recommends  a farther 
patient  investigation.  He  also  endeavours  to  obviate 
some  of  the  difficulties  which  occur  in  their  adoption. 

“ Were  it  granted  (he  observes)  that  syphilis  had 
arisen  in  the  same  individual,  together  with  the  vene- 
rolic  ulcer,  under  the  same  circumstances  of  infection, 
rather  than  reason  generally  from  such  an  exception, 
or  adopt  so  unphilosophical  a conclusion,  as  that  one 
and  the  same  cause,  acting  under  precisely  the  same 
circumstances,  could  produce  effects  so  distinctly  dif- 
ferent as  venerola  and  chancre  ; the  one  disease  being 
directly  amenable  to  mercury,  and  the  other  often  ex- 
asperated by  its  use ; it  would  be  safer  to  suppose,  that 
the  Vitus  of  syphilis  had  coexisted  in  the  infected  per- 
son.” He  refers  to  various  instances  of  sores  result- 
ing from  connexion  with  women  apparently  healthy  ; 
venerola,  phagedena,  &c.  A point  noticed  by  him  as 
not  sufficiently  adverted  to  in  considering  the  multipli- 
city of  disease,  apparently  arising  from  the  same  infec- 
tion, is  the  disposition  which  may  exist  in  different  or 
the  same  individuals  to  spontaneous  morbid  affections 
of  the  genitals,  and  consequcntiy  not  unlikely  to  suc- 
ceed the  mere  local  excitement  of  sexual  intercourse. 
Among  these  he  si»ecifie3  the  psoriasis  pr.-eputii  and 
scrotalis,  in  which  may  frequently  be  observed  distinct 
spots  of  a brownish  tint  and  elevated.  These,  lie  says, 
are  often  scaly,  and  with  them  may  exist  similar  spots 
about  the  scalp  and  upper  extremities.  In  some  in- 


stances, erythematous  and  aphthous  inflammations  of 
the  tonsils,  fauces,  and  mouth  take  place,  and  some- 
times repeated  discharges  (rom  the  urethra,  generally 
of  short  duration.  Mr.  Welbank  considers  one  source 
of  the  great  variety  in  the  effects  of  morbid  poisons  to 
be  the  various  degree  of  power,  which  is  ascertained 
by  direct  experiments  to  be  proportionate  to  the  tem- 
porary activity  of  the  disease  from  wliich  the  conta- 
gious matter  is  taken.  On  this  various  degree  of  viru- 
lence, he  conceives,  the  circumstance  may  depend, 
whether  an  eruption  in  the  same  texture  of  tlie  skin 
snail  be  papular,  vesicular,  or  pustular,  ora  phagedenic 
sore  be  deep  or  superficial,  stationary  or  disposed  to 
extend  its  ravages.  Another  source  of  complexity  in 
the  multiform  phenomena  of  the  same  poison  lies,  ac- 
cording to  Mr.  Welbank,  in  many  adventitious  circum- 
stances influencing  the  character  of  primary  venereal 
sores  by  their  stimulant  or  sedative  effect.  Tire  occa- 
sional coexistence  of  distinct  primary  diseases,  he  sets 
down  as  the  possible  origin  of  much  complexity  in  the 
secondary  phenomena. — (See  Med.  Chir.  Trans,  vol. 
13,  p.  578,  Sec.)  Many  of  these  circumstances  are  of 
course  only  suggested  as  possibilities,  to  which  farther 
attention  should  be  directed. 

Among  other  doctrines,  Mr.  Hunter  inculcates,  that 
“ the  venereal  matter,  when  taken  into  the  constitution, 
produces  an  irritation  which  is  capable  of  being  conti- 
nued, independent  of  a continuance  of  absorption,  and 
the  constitution  has  no  power  of  relief ; therefore  a lues 
venerea  continues  to  increase."  The  same  criterion 
was  proposed  by  Mr.  Abernethy,  who  states,  that  the 
“constitutional  symptoms  of  the  venereal  disease  are 
generally  progressive,  and  never  disappear,  unless  me- 
dicine be  employed.” — (Surgical  Observations,  p. 
137.)  And  notwithstanding  some  dissent  may  be 
traced  in  both  old  and  modern  writers,  from  the  belief 
that  mercury  was  absolutely  essential  to  the  cure  of 
the  venereal  disease,  and  an  opposite  conclusion 
might  easily  have  been  drawn  from  the  whole  history 
of  this  subject,  including  the  practice  of  former  and 
present  times,  the  contrary  hypothesis  was  that  always 
taught  in  all  the  great  medical  schools  of  this  coun- 
try, even  down  to  so  late  a period  as  fifteen  years 
ago.  But  the  error  no  longer  prevails;  and  no  facts 
are  more  completely  established,  than  that  mercury, 
however  useful  it  may  frequently  be  in  the  treatment 
of  the  venereal  disease,  is  not  absolutely  necessary  for 
the  cure  either  of  the  primary  or  secondary  symptoms ; 
and  that  the  disease,  so  far  from  always  growing 
worse  unless  mercury  be  administered,  ultimately  gets 
well  without  the  aid  of  this  or  any  other  medicine. 
If  any  man  yet  doubt  the  general  truth  of  this  state- 
ment, let  him  impartially  consider  the  many  facts  and 
arguments  brought  forwards  in  proof  of  it  in  the  anony- 
mous tract  “ Sur  la  non-existence  de  la  Maladie  Veni- 
rienne,"  and  in  the  writings  of  Dr.  Fergusson,  Mr. 
Rose,  Dr.  Hennen,  Dr.  Thomson,  Mr.  Guthrie,  Mr. 
Bacot,  and  other  modern  practitioners.  Perilhe,  as  I 
have  already  noticed,  distinctly  admitted  the  frequency 
of  spontaneous  cures,  and  so  does  Delpech.  “ Ob- 
servation seems  to  prove  (says  he),  that  there  are  some 
individuals,  in  whom  the  lymphatic  system  appears  to 
be  endued  with  the  fortunate  property  of  extinguishing 
the  syphilitic  principle,  so  that  merely  primary  symp- 
toms occur.” — (Chir.  Chimique,  1. 1,  p.  341.)  In  short, 
if  there  be  such  a skeptic  now  living  in  this  country, 
let  him  peruse  the  returns  made  by  the  surgeons  of  the 
whole  British  army,  documents  which  will  be  noticed 
in  the  sequel  of  this  article;  let  him  consider  the  evi- 
dence of  the  surgeons  of  other  countries,  especially 
that  of  Cullerier,  who  annually  demonstrates  to  his 
class  of  pupils  the  cure  of  venereal  ulcers  without  mer- 
cury; and  the  testimony  and  practice  of  the  German 
surgeons  who  were  attached,  during  the  war,  to  regi- 
ments of  their  countrymen  in  the  British  service.  The 
fact  is  therefore  indisputable,  that  the  venereal  disease, 
in  all  its  ordinary  and  diversified  forms,  is  capable  of 
a spontaneous  cure,  and,  consequently,  that  the  ques- 
tion, whether  the  disease  is  syphilitic  or  not,  can  never 
be  determined  by  the  circumstance  of  the  complaint 
yielding,  and  being  permanently  cured,  without  the  aid 
of  mercury.  Yet,  as  Mr.  Rose  has  observed,  the  suppo- 
sition, that  syphilis  did  not  admit  of  a natural  cure, 
and  that  mercury  was  the  only  remedy  that  had  the 
pow'er  of  destroying  its  virus,  was  of  late  so  much  re- 
lied upon,  that  where  a disease  had  been  cured  without 
the  use  of  that  medicine,  and  did  not  afterward  return, 


444 


VENEREAL  DISEASE. 


such  fact  alone,  whatever  might  have  been  the  symp- 
toms, was  regarded  as  sufficient  proof  that  it  was  not 
a case  of  syjrhilis.  And,  as  the  same  writer  very  judi- 
ciously remarks,  the  refutation  of  these  notions  is  of  con- 
siderable importance,  “ not  so  much  in  reference  to  the 
treatment  of  syphilis,  under  common  circumstances, 
for  the  strikingly  good  effects  of  mercury  will  proba- 
bly not  render  it  advisable  in  general  to  give  up  the  use 
of  that  remedy,  but  from  the  change  it  will  produce  in 
our  views  of  the  diagnosis  of  the  disease.  The  dis- 
tinction which  has  engaged  such  a share  of  attention 
of  late  years,  and  which  is  evidently  so  important  be- 
tween syphilis  and  syphiloid  diseases,  has  been  made  to 
depend  so  much  on  the  former  admitting  of  no  cure, 
except  by  mercury,  that,  if  this  principle  should  be 
found  to  be  erroneous,  the  difficulties  which  liave  at 
tended  it  will  in  a great  measure  be  explained.” — 
{Med.  Chir.  Trans,  vol.  8,  p.  350,  351.)  That  it  is  er- 
roneous, will  appear  more  clearly  when  the  treatment 
of  syphilis  falls  under  consideration. 

Excluding  from  present  attention  works  of  ancient 
date,  it  is  curious  to  find  how  very  near  several  writers, 
within  the  last  twenty  or  thirty  years,  arrived  at  the 
same  point  to  which  recent  investigations  have  led. 
Thus  Mr.  B.  Bell  observes,  that  “ a chancre  might  fre- 
quently be  cured  with  external  applications  alone,  and 
as  we  know  from  experience  that  the  virus  is  not  al- 
ways absorbed,  the  cure  would  in  a few  instances 
rove  permanent ; but  as  we  can  never  with  certainty 
now  whether  this  would  happen  or  not,  while,  in  a 
great  proportion  of  cases,  there  would  be  reason  to 
think  that  absorption  would  take  place,  w’e  ought  not 
in  any  case  to  trust  toil.” — (On  Gonorrhoea  Virulenta, 
drc.  vol.  2,  ed.  2,  p.  325,  8vo.  Edinb.  1797.)  And,  in 
some  reflections  upon  a case  of  doubtful  nature.  Dr. 
Clutterbuck  long  ago  remarked ; “ Supposing  even  that 
the  diseased  appearances  had  after  a time  got  well  of: 
themselves,  / should  deem  even  this  no  absolute  proofs 
of  their  not  being  of  a venereal  nature.  I have  seen 
cases  which  induce  me  to  believe,  that  the  venereal 
disease,  in  some  of  its  stages  and  in  certain  circum- 
stances, may  get  well  without  mercury  or  any  other 
remedy.  But  this  is  contrary  to  the  doctrine  of  Mr. 
Hunter,  who  supposed  that  venereal  actions  go  on  in- 
creasing, without  any  tendency  to  wear  themselves  out. 
That  lues  venerea  is  much  modified  by  climate  and 
other  circumstances  is  generally  allowed;  that  it  has 
been  cured  by  other  means  than  mercury,  we  have 
also  very  sufficient  evidence  in  the  older  writers  on  the 
subject;  not  to  mention  the  late  successful  trials  with 
acids  and  other  substances.  Many  of  the  appearances 
on  the  skin  go  off  spontaneously.  When  purple  spots 
appear  on  the  skin  (Mr.  Hunter  observes,  p.  319),  giv- 
ing it  a mottled  appearance  in  this  disease,  many  of 
the  spots  disappear,  while  others  continue  and  in- 
crease.”— {H.  Clutterbuck,  Remarks  on  some  of  the  Opi- 
nions of  the  late  Mr.  John  Hunter,  p.  27,  8vo.  Lond. 
1799.)  If  Dr.  Clutterbuck  had  advanced  one  step  far- 
ther, and  declared  that  the  venereal  disease  might  be 
cured  without  mercury  or  any  other  remedy  in  all.  or 
nearly  all,  its  forms,  and  not  merely  in  some  of  them, 
he  would  actually  have  anticipated  the  most  import- 
ant fact,  recently  established  chiefly  by  the  meritorious 
labours  of  the  army  surgeons,  whose  opportunities  of 
going  through  the  investigation  were  better  on  several 
accounts  than  those  of  private  practitioners,  who  gene- 
rally soon  lose  sight  of  their  patients,  and  never  have 
them  sufficiently  under  their  control  and  observation 
to  render  a full  perseverance  in  any  method  a matter 
of  certainty.  At  all  events.  Dr.  Clutterbuck  may 
justly  claim  the  merit  of  having  distinctly  marked  the 
fact,  that  the  circumstance  of  a disease  giving  way, 
and  being  cured  without  mercury,  is  no  proof  that  the 
case  is  not  venereal. 

One  of  the  most  ingenious  theories  ever  devised  for 
explaining  all  the  perplexities  and  irregularities  of 
syphilis,  is  unquestionably  that  of  the  late  Mr.  Hunter ; 
for  it  accommodated  itself  almost  to  every  thing,  and 
every  believer  in  it  fancied  he  could  account  satisfac- 
torily for  many  puzzling  occurrences,  which  admitted 
of  no  good  explanation  on  other  principles.  Mr.  Hunter 
inculcated,  that  the  parts  contaminated  by  the  absorp- 
tion of  the  venereal  poison,  do  not  immediately  begin 
to  be  palpably  diseased,  but  only  acquire  a disposition 
to  take  on  the  venereal  action.  He  farther  believed, 
that  when  this  disposition  was  once  formed  in  a part, 
it  necessarily  changed  into  action,  or  manifest  disease. 


at  some  future  period.  That  mercury  can  cure  the 
disease,  when  positively  formed,  but  not  the  disposition 
to  it.  That  although  mercury  cannot  destroy  the  dis- 
position already  contracted,  yet  that  it  can  prevent  it 
from  being  formed  at  all.  That  the  disposition  never 
becomes  the  real  disease,  or,  in  Mr.  Hunter’s  language, 
goes  into  action  during  the  use  of  mercury.  That  the 
action,  having  once  taken  place,  always  increases,  never 
wearing  itself  out.  That  parts  once  cured  never  be- 
come again  contaminated  from  the  same  stock  of 
infection.  And  that  the  matter  of  secondary  ulcers, 
or  those  which  break  out  in  consequence  of  absorption, 
is  not  infectious.  What  Mr.  Hunter  meant  by  the 
terra  disposition,  I think  is  better  explained,  than  the 
grounds  for  the  adoption  of  the  theories  connected  with 
it:  viz.  the  presumption  of  its  being  formed  in  ali  the 
parts,  capable  of  contamination ; llie  certainty  of  its 
future  change  into  actual  disease;  the  impossibility  of 
curing  it  by  mercury,  previously  to  such  change  ; but 
the  possibility  of  preventing  its  formation  at  all  by  the 
timely  use  of  that  remedy.  ...u 
Dr.  Clutterbuck  has  well  observed,  that  the  only 
foundation  for  all  these  hypotheses,  connected  with 
the  phrase  disposition,  is  the  fact  that  secondary  symp- 
toms sometimes  arise,  notwithstanding  a full  use  of 
mercury.  If,  says  this  gentleman,  we  were  to  suppose, 
with  Mr.  Hunter,  that  all  the  parts  which  are  suscep- 
tible, become  at  once  contaminated,  and  mercury  has 
no  influence  over  tfiem  in  this  state,  the  constitution 
should  become  affected  in  almost  all  cases  ; for  absorp- 
tion probably  always  precedes  the  application  of 
remedies.  Either,  therefore,  mercury  does  prevent  the 
future  action,  or  a more  frequent  absence  of  suscepti- 
bility to  the  disease  must  be  supposed,  than  there  are 
grounds  for  imagining. — {Remarks  on  the  Opinions  of 
Mr.  Hunter,  p.  9 — 12.)  But  surgeons  of  the  present 
day,  enlightened  by  many  new  facts  unequivocally  de- 
termined since  Mr.  Hunter’s  time,  know  very  well, 
that  a disposition  to  the  disease  is  in  many  instances 
not  produced  at  all,  even  though  the  matter  of  a chancre 
be  supposed  to  be  absorbed  ; since  in  a large  proportion 
of  cases  of  chancres,  which  had  all  the  characteristic 
appearances  of  such  ulcers,  according  to  Mr.  Hunter’s 
own  description,  no  secondary  symptoms  followed, 
though  the  patients  were  treated  and  cured  without 
any  mercury.  Yet,  if  Mr.  Hunter’s  theory  were  true, 
the  disposition  must  have  been  produced,  the  action  or 
disease  itself,  in  the  form  of  secondary  symptoms,  must 
have  ensued,  sooner  or  later,  and  no  cure  could  have 
been  ultimately  effected  without  mercury.  Fortu- 
nately for  mankind,  unsound  as  some  of  the  theories 
seem,  which  are  attached  by  Mr.  H unter  to  the  sup- 
posed disposition  of  the  venereal  disease,  or  its  latent 
form,  there  was  one  piece  of  advice  given  by  him, 
which  may  be  said  to  have  had  a beneficial  effect  in 
practice,  though  founded  upon  these  very  doctrines ; 
and  it  was  this;  “ that  we  should  push  our  medicine 
no  farther  than  the  cure  of  the  visible  effects  of  the 
poison,  and  allow  whatever  parts  may  be  contaminated 
to  come  into  action  afterward.” — {On  the  Venereal 
Disease,  p.'iM.)  This  maxim,  I know',  has  been  re- 
garded by  some  admirers  of  long  salivations,  as  the 
cause  of  many  relapses  and  imperfect  cures ; but  when 
I advert  to  the  dreadful  mischief  which  formerly 
attended  protracted  courses  of  mercury  for  latent  and 
imaginary  complaints,  my  mind  regrets  that  Mr. 
Hunter  himself  should  not  have  strictly  adhered  in 
practice  to  llis  own  principle,  from  which  he  undoubt- 
edly deviated  with  his  patients,  and  even  in  certain 
other  parts  of  his  writings.  However,  the  effect  has 
been  to  discourage  long  courses  of  mercury ; and  per- 
haps in  this  way  the  world  has  been  benefited  by  the 
counsel,  though  not  rigorously  adopted  by  him  who 
gave  it.  Confessing  my  own  inability  to  reconcile  the 
various  theories  about  the  nature  and  effects  of  the 
venereal  poison,  to  many  facts  which  are  disclosed  in 
practice,  I shall  now  proceed  to  offer  a few  remarks  on 
each  of  the  primary  and  secondary  symptoms. 

Chancres. — The  penis,  as  Mr.  Hunter  has  observed, 
which  in  men  is  the  common  seat  of  a chancre,  is, 
like  every  other  part  of  the  body,  liable  to  diseases  of 
the  ulcerative  kind,  and,  on  some  accounts,  is  rather 
more  so  than  other  parts.  When  attention  is  not  paid 
to  cleanliness,  e.xcoriations  or  superficial  ulcers  often 
originate.  The  genitals,  also,  like  almost  every  other 
part  that  has  been  injured,  when  once  they  have  suffered 
from  the  venereal  disease,  are  very  liable  to  ulcerate 


VENEREAL  DISEASE. 


445 


again.  Since,  therefore,  the  penis  is  not  exempted  from 
common  diseases,  every  judgment  of  the  nature  of 
ulcers  upon  it,  as  Mr.  Hunter  truly  remarks,  should  be 
formed  with  great  attention,  particularly  as  all  diseases 
upon  this  part  are  suspected  to  be  venereal.  But  for  a 
particular  description  of  the  many  ordinary  complaints 
which  are  apt  to  occur  on  the  genitals,  either  preceded 
or  unpreceded  by  sexual  intercourse,  I refer  to  Mr. 
Evans’s  treatise. — (See  Pathological  and  Practical  Re- 
marks on  Ulcerations  of  the  Oenital  Organs,  8»o. 
Land.  1819.)  From  the  facts  already  mentioned  in 
this  article,  however,  it  would  appear,  that  primary 
syphilitic  ulcers,  or  chancres,  by  which  I imply  sores 
capable  of  giving  rise  to  the  secondary  symptoms  of 
the  venereal  disease,  have  no  determinate  external 
character,  are  extremely  diversified  in  their  appearance, 
and  absolutely  cannot  be  distinguished  by  their  mere 
look  from  sores  which  are  of  a common  or,  at  least, 
a very  different  nature.  This  is  another  important 
fact,  for  which  every  man  in  the  profession  who  seeks 
only  truth,  and  the  expulsion  of  errors  from  the  doc- 
trines of  surgery,  must  feel  obliged  to  the  army 
surgeons.  Nor  is  their  merit  lessened  by  the  consider- 
ation, that  the  detection  of  mistake  on  this  point,  like 
the  discovery  of  the  error  concerning  the  invariable 
progress  of  the  venereal  disease  from  bad  to  worse, 
unless  medicine  be  given,  has  taken  place  in  opposition 
to  the  tenets  of  Mr.  Hunter. — “ Venereal  ulcers  (says 
he)  commonly  have  one  character,  which,  however,  is 
not  entirely  peculiar  to  them ; for  many  sores  that  have 
no  disposition  to  heal  {which  is  the  case  with  a chancre) 
have  so  far  the  same  character.  A chancre  has  com- 
monly a thickened  base,  and,  although  in  some  Uie 
common  inflammation  spreads  much  farther,  yet  the 
specific  is  confined  to  this  base.” — (P.  215.)  And 
elsewhere,  he  observes,  a chancre  first  begitis  with  an 
itching  in  the  part.  When  the  inflammation  is  on  the 
glans  penis,  a small  pimple,  full  of  matter,  generally 
arises,  without  much  hardness,  or  seeming  inflam- 
mation, and  with  very  little  tumefaction  ; for  the  glans 
penis  is  not  so  apt  to  swell  in  consequence  of'  inflam- 
mation as  many  other  parts  are,  especially  the  prepuce, 
hlr.  Hunter  also  explains,  that  chancres  situated  on  the 
glans  are  not  attended  with  so  much  pain  and  incon- 
venience as  sores  of  this  nature  on  the  prepuce. 
When  chancres  occur  on  the  fra;num,  or  particularly 
on  the  prepuce,  a much  more  considerable  degree  of 
inflammation  soon  follows,  attended  with  effects  more 
extensive  and  visible.  These  latter  parts,  being  com- 
posed of  very  loose  cellular  membrane,  afford  a ready 
passage  for  the  extravasated  fluids.  The  itching  is 
gradually  converted  into  pain : in  some  cases,  the 
surface  of  the  prepuce  is  excoriated,  and  afterward 
ulcerates ; while  in  other  examples  a small  pimple  or 
abscess  appears  on  the  glans,  and  then  turns  into  an 
ulcer.  The  parts  become  affected  with  a thickening, 
which  at  first,  while  of  the  true  venereal  kind,  is  very 
circumscribed,  not  diffusing  itself,  as  Mr.  Hunter  ob- 
serves, gradyally  and  imperceptibly  into  the  surrounding 
parts;  but  terminating  rather  abruptly.  Its  base  is 
hard,  and  the  edges  a little  prominent.  When  it  begins 
on  the  frcenum,  or  near  it,  that  part  is  very  commonly 
wholly  destroyed,  or  a hole  is  often  made  through  it  by 
ulceration.  Mr.  Hunter  thought  it  better  in  general, 
under  the  latter  circumstance,  to  divide  the  part  at  once. 

When  the  venereal  matter  is  applied  to  the  body  of 
the  penis,  or  front  of  the  scrotum,  where  the  cuticle  is 
thicker  than  that  of  the  glans  penis  and  prepuce,  the 
chancre  generally  makes  its  appearance  in  the  form  of 
a pimple,  which  commonly  forms  a scab,  in  conse- 
quence of  evaporation.  The  first  scab  is  generally 
rubbed  off ; after  which,  a second  still  larger  one  is 
produced. 

When  the  disease  is  more  advanced,  it  is  often 
attended  with  inflammation  peculiar  to  the  habit,  be- 
coming in  many  instances  more  diffused,  and  often 
producing  phymosis  and  paraphymosis.  However, 
says  Mr.  Hunter,  there  is  yet  a hardness  around  the 
sores,  which  is  peculiar  to  such  as  are  caused  by  the 
venereal  virus,  particularly  those  on  the  prepuce. 

Mr.  Carmichael,  also,  in  his  arrangement  of  primary 
ulcers  on  the  penis,  considers  the  true  chancre  as  being 
particularly  distinguished  by  its  hardened  base,  which 
he  compares  to  a piece  of  cartilage  under  the  skin.  It 
is  to  be  observed,  however,  that,  by  the  true  chancre, 
or  primary  syphilitic  ulcer,  he  does  not  signify  that  it  is 
tlie  only  sore  from  which  secondary  symptoms  may 


arise ; but  his  observations  lead  him  to  regard  it  as  the 
cause  of  such  constitutional  effects  as  belong  to  what 
he  deems  the  true  form  of  syphilis,  or  that  in  which 
the  use  of  mercury  is;  the  most  decidedly  indicated.  It 
would  give  me  sincere  pleasure  to  find  any  agreement 
on  this  part  of  the  subject  among  other  observers. 
The  reader,  indeed,  must  already  know',  tjiat  the  hard- 
ened base,  which  both  Hunter  and  Carmichael  have 
regarded  as  a distinguishing  character  of  a true  chancre, 
is  not  found  to  be  so  by  other  gentlemen,  w'ho  have 
most  impartially  investigated  this  point.  Thus  Dr. 
Hennen  observes,  “ We  are  not  in  possession  of  the 
knowledge  of  any  invariable  characteristic  symptoms, 
by  which  to  discriminate  the  real  nature  of  the  primary 
sore,  and  we  are  equally  at  a loss  in  many  of  the  se- 
condary symptoms.  I am  well  aware,  that  some  prac- 
titioners have  assumed  to  themselves  the  possession  of 
a ‘tactus  eruditus,’ by  which  they  can  at  once  distin- 
guish h chancre,  or  a venereal  ulcer,  or  eruption,  in 
which  mercury  is  indispensable,  from  one  of  a different 
nature ; but  I have  seen  too  many  instances  of  self- 
deception  to  give  them  all  the  credit  that  they  lay  claim 
to.  It  would  be  by  no  nieans  difficult  to  show,  that  the 
high  round  edge,  the  scooped  or  excavated  sore,  the 
preceding  pimple,  the  loss  of  substance,  the  hardened 
base  and  edge,  whether  circumscribed  or  diffused,  and 
the  tenaciously  adhesive  discharge  of  a very  fetid  odour, 
are  all  observable  in  certain  states  and  varieties  of 
sores,  unconnected  with  a venereal  origin.  The  hard- 
ened edge  and  base,  particularly,  can  be  produced  arti- 
ficially by  the  application  of  escharotics  to  the  glans  or 
penis  of  a sound  person,  and  if  any  ulceration  or  warty 
excrescence  previously  exists  on  these  parts,  this  effect 
is  still  more  easily  produced.” — (On  Military  Surgery, 
ed.  2,  p.  517.)  Now,  if  it  be  asked,  whether  the  chancre 
with  a hardened  base  and  prominent  edge  is  distin- 
guished by  its  not  admitting  of  cure  without  mercury, 
and  by  any  regularity  or  peculiarity  in  the  nature  of 
secondary  symptoms,  when  they  originate  from  such 
an  ulcer?  modern  experience  denies  the  validity  of 
both  these  criteria.  If  Mr.  Rose’s  excellent  paper  be 
consulted,  the  reader  will  see  that  this  gentleman  has 
certainly  cured,  without  the  aid  of  mercury,  ulcers 
which  had  a decidedly  marked  induration  of  the  mar- 
gins and  bases,  by  which  the  syphilitic  chancre,  ac- 
cording to  Mr.  Carmichael,  is  easily  distinguished. — 
{Med.  Chir.  Trans,  vol.  8,  p.  421,  ^c.;  also,  Guthrie, 
vol.  cit.  p.  576.)  And  as  for  the  other  points,  sufficient 
evidence  has  already  been  detailed  in  the  foregoing 
columns  to  satisfy  any  impartial  mind,  that,  as  far  as 
the  eye  can  teach  us,  no  kind  of  primary  sore  has  yet 
been  satisfactorily  proved  to  be  the  cause  of  only  one 
set  of  peculiar  constitutional  symptoms  ; but  on  the 
contrary,  that  a great  variety  of  appearances  in  the 
skin,  throat,  &c.  may  follow  sores  which,  as  far  as 
external  characters  are  concerned,  seem  exactly  alike. 
The  only  partial  exception  to  this  remark  is,  the  great 
frequency  of  papular  eruptions  after  superficial  sores: 
a point  on  which  both  Mr.  Carmichael  and  Mr.  Rose 
agree,  though  the  latter  gentleman  does  not  represent 
even  this  conne-xion  as  constant.  Mr.  Hunter  computed 
that  claps  appear  more  frequently  than  chancres,  in  the 
proportion  of  four  or  five  to  one : I am  not  prepared  to 
offer  any  opinion  on  this  calculation,  in  reference  either 
to  chancres  as  defined  by  that  interesting  writer,  or 
under  the  more  comprehensive  view  of  them  to  which 
the  results  of  modern  investigations  would  lead.  One 
intelligent  writer,  however,  has  observed,  that  present 
experience  docs  not  justify  Mr.  Hunter’s  conclusion 
respecting  the  infrequency  of  chancre  compared  with 
gonorrhoea. — (.7.  Bacot,  Obs.  on  Syphilis,  p.  54.)  Yet, 
in  Dublin,  if  Mr.  Carmichael’s  statement  be  correct, 
the  frequency  of  gonorrhoea,  as  compared  with  that  of 
what  is  sometimes  termed  the  true  vetiereal  chancre, 
must  be  so  great  as  to  defy  all  computation  ; for  he  in- 
forms us,  that  since  the  descriptions  of  the  success  of 
the  non-mercurial  practice  fell  into  his  hands,  he  has 
been  anxious  to  a.scertain,  by  personal  observation, 
whether  true  syphilitic  chancres  did  really  admit  of 
being  cured  without  mercury  ; but,  says  he,  “ this  dis- 
ease, as  described  by  Hunter,  has  diminished  in  so  ex- 
traorditiary  a degree  in  this  country,  that,  strange  to 
say,  I have  from  that  period  met  with  only  one  case 
of  true  chancre.” — ( Observations  on  the  Symptoms, 
Sec.  of  Venereal  Diseases,  p.  14.)  As  this  chancre  re- 
mained stationary  a month,  it  was  thought  proper  to 
emoloy  mercurial  frictions,  and  it  then  soon  healed, 


446 


VENEREAL  DISEASE. 


leaving  a callosity  which  continued  two  months  longer. 
However,  after  the  above  passage  was  written,  Mr. 
Carmichael  met  with  two  cases  of  “ well-marked 
chancre,”  each  of  which  was  attended  with  psorias 
syphilitica,  scaly  from  its  commencement.  No  mercury 
was  given.  For  five  weeks  the  disease  gained  ground ; 
but  in  the  end,  both  cases  were  cured,  merely  by  the 
administration  of  sarsaparilla.  The  following  obser- 
vations, contained  in  the  appendix  to  Mr.  Carmichael’s 
work,  do  him  infinite  credit : “ Although  (says  he) 
these  two  cases  cannot  fail  to  make  a due  impression, 
yet,  if  they  stood  alone,  their  evidence  could  not  be 
deemed  sufficient  to  establish  a belief,  that  true  syphilis, 
like  the  papular  disease,  is  capable  of  yielding  to  the 
powers  of  the  constitution  or  to  remedies  in  which 
mercury  does  not  form  an  ingredient.  But  this  defi- 
ciency seems  to  be  in  a great  measure  supplied  by  the 
testimony  of  Mr.  Rose,  Dr.  Hennen,  and  other  equally 
intelligent  surgeons,  who  had  the  advant^e  of  serving 
with  our  army  on  the  continent ; and  if,  in  the  pre- 
ceding pages,  I appear  to  be  skeptical,  with  respect  to 
the  accuracy  of  their  obsei  vations,  and  doubted  that  it 
was  true  chancre  and  true  syphilitic  eruption  which 
yielded  to  their  prescriptions  unaided  by  mercury,  these 
two  cases  have  satisfied  me,  that  every  attention  is 
due  to  the  exactness  and  discernment  of  these  respect- 
able individuals;  and  if  I hesitated  until  I saw  with 
my  own  eyes,  and  judged  with  my  own  understanding, 
I claim  for  my  own  observations  no  larger  a measure 
of  faith  from  others.”  And  he  afterward  adds,  “ In 
thus  relinquishing  my  opinion  that  true  syphilis  differs 
from  other  venereal  complaints  by  always  requiring 
mercury  for  its  cure,  it  is  necessary  to  reduce  the  doc- 
trine I hold  to  this  proposition ; that,  with  respect  to 
the  use  of  that  medicine,  it  differs  froirr  them  only  in 
not  being  injured,  but  decidedly  benefited  by  it  in  all 
its  symptoms  and  stages. — (P.  218,  219.) 

According  to  Mr.  Hunter,  there  are  three  ways  in 
which  chancres  may  be  produced  : first,  by  the  poison 
being  inserted  into  a wound;  secondly,  by  being  applied 
to  a non-secreting  surface ; and  thirdly,  by  being  applied 
to  a common  sore.  A wound,  it  seems,  is  much  more 
readily  infected  than  a sore.  To  whichever  of  these 
three  different  surfaces  the  pus  is  applied,  it  produces 
its  specific  inflammation  and  ulceration,  attended  with 
a secretion  of  pus.  The  matter  produced  in  conse- 
quence of  these  difterent  modes  of  application,  he 
says,  partakes  of  the  same  nature  as  the  matter  which 
was  applied  ; because,  he  observes,  the  irritations  are 
alike.  How  the  alleged  examples  of  very  difterent 
primary  sores  being  sometimes  communicated  by  the 
application  of  the  matter  of  chancre,  are  to  be  recon- 
ciled with  the  Hunterian  doctrines,  it  is  difficult  to 
suggest,  unless  Mr.  Carmichael’s  observation  about  the 
present  excessive  rarity  of  the  true  syphilitic  chancre 
can  furnish  the  explanation.  However,  as  far  as  I 
can  believe  my  own  eyes  and  judgment,  I now  see  in 
London  the  same  forms  of  chancre  which  used  to  pre- 
vail during  my  apprenticeship  at  St.  Bartholomew’s 
Hospital,  more  than  twenty  years  ago.  And  if  any 
difference  can  be  particularized,  it  is  only  that  which 
depends  upon  their  being  less  rarely  converted  into 
worse  diseases  than  mere  syphilitic  ulceration,  by  the 
dreadful  effects  of  immoderate  courses  of  mercury. 

With  respect  to  the  three  modes  in  which  Mr.  Hun- 
ter speaks  of  the  venereal  poison  being  applied  and 
taking  effect,  I know  not  why  he  should  have  alto- 
gether excluded  secreting  surfaces  ; for  of  this  nature 
(as  a late  writer  remarks)  are  the  glans  penis  and  co- 
rona glandis  (Bacot  on  Syphilis,  p.  55) ; and  of  a si- 
milar kind  are  the  insides  of  the  labia,  the  surfaces  of 
the  nymphjE,  &c.,  where  sores  are  common  enough. 
Whatever  may  be  the  truth  of  the  impossibility  of  the 
formation  of  chancres  within  the  urethra,  the  latter 
considerations  certainly  tend  to  prove  that  the  secret- 
ing nature  of  its  membrane  is  not  the  only  reason  for 
the  alleged  fact. 

i I shall  not  here  detain  the  reader  with  descriptions 
of  the  primary  ulcer  with  elevated  edges,  the  phage- 
denic, and  the  sloughing  chancre.  Such  descriptions  I 
have  imbodied  in  the  last  edition  of  the  First  Lines 
of  Surgery,  with  the  sentiments  of  Mr.  Carmichael 
respecting  the  train  of  constitutional  symptoms,  ap- 
pertaining, as  he  believes,  to  each  form  of  ulcer.  It  is 
an  interesting  disquisition  ; but  as  far  as  my  observa- 
tions and  inquiries  go,  it  has  not  yet  reached  any  degree 
of  certainty  or  precision  ; and,  as  I have  already  e.v 


plained,  the  reports  published  by  other  gentlemen  en- 
gaged in  this  investigation,  do  not  by  any  means  con- 
firm the  much-desired  intelligence,  that  such  progress- 
lias  been  made  in  the  knowledge  of  all  the  diversified 
symptoms  of  the  venereal  disease,  that  its  varieties  can 
now  be  classed,  both  in  regard  to  the  primary  ulcers 
and  the  secondary  symptoms  connected  with  each  de- 
scription of  chancre. 

I firmly  believe,  that  with  respect  to  all  the  appear- 
ances of  this  disease,  both  in  its  primary  and  secondary 
forms,  a vast  deal  depends  upon  constitution,  inde- 
pendently of  the  nature  of  the  virus.  And  I adopt 
this  opinion,  at  the  same  time  that  many  reflections 
already  hinted  at  in  this  article  lead  me  to  join  in  the 
belief,  that  syphilitic  diseases  may  depend  upon  a va- 
riety of  poisons,  whereby  some  of  the  perplexity  of 
these  cases  may  be  explained. 

The  local  or  immediate  eftects  of  the  venereal  dis- 
ease are  seldom  wholly  specific ; but  are  usually  at- 
tended both  with  the  specific  and  constitutional  in- 
flammation. Hence,  Mr.  Hunter  advises  particular  at- 
tention to  be  paid  to  the  manner  in  which  a chancre 
first  appears,  and  to  its  progress.  If  the  inflammation 
spreads  in  a quick  and  considerable  way,  the  constitu- 
tion must  be  more  disposed  to  inflammation  than  na- 
tural. When  the  pain  is  severe,  Mr.  Hunter  remarks, 
there  is  a strong  disposition  to  irritation.  Chancres 
also,  sometimes,  soon  begin  to  slough,  there  being  a 
strong  tendency  to  mortification.  Here  he  probably 
adverts  to  what  are  now  usually  called  phagedenic 
sores,  and  frequently  believed  to  differ  from  the  truly  ve- 
nereal chancre. 

It  is  also  observed  by  Mr.  Hunter,  that  when  there  is 
a considerable  loss  of  substance,  either  from  sloughing 
or  ulceration,  a profuse  bleeding  is  no  uncommon  cir- 
cumstance, more  especially  when  the  ulcer  is  on  the 
glans.  The  adhesive  inflammation  does  not  appear  to 
take  place  sufficiently  to  unite  the  veins  of  this  part  of 
the  penis,  so  as  to  prevent  their  cavity  from  being  ex- 
posed, and  the  blood  escapes  from  the  corpus  spongi- 
osum urethrae.  The  ulcers  or  sloughs  often  extend  as 
deeply  as  the  corpus  cavernosum  penis,  and  similar 
bleedings  are  the  consequence. 

With  respect  to  chancres  in  women,  the  labia  and 
nymphae,  like  the  glans  penis  in  men,  are  subject  to 
ulceration,  and  the  ulcerations  are  generally  more  nu- 
merous in  females  than  males,  in  consequence  of  the 
surface  on  which  the  sores  are  liable  to  form  being 
much  larger.  As  Mr.  Hunter  observes,  chancres  are 
occasionally  situated  on  the  edge  of  the  labia;  some- 
times on  the  outside  of  these  parts ; and  even  on  the 
periiiffium.  When  the  sores  are  formed  on  the  inside 
of  the  labia  or  nymphae,  they  can  never  dry  or  scab ; 
but  when  they  are  externally  situated,  the  matter  may 
dry  on  them,  and  produce  a scab,  just  as  happens  with 
respect  to  chancres  situated  on  the  scrotum  or  body  of 
the  penis. 

Mr.  lymter  remarks,  that  tlie  venereal  matter  from 
these  sores  is  apt  to  run  down  the  perinaeum  to  the  anus, 
and  excoriate  the  parts,  especially  about  the  anus, 
where  the  skin  is  thin,  and  where  chancres  may  be 
thus  occasioned. 

Chancres  have  been  noticed  in  the  vagina  ; but  Mr. 
Hunter  suspected  that  they  were  not  original  ones,  but 
that  they  had  spread  to  this  situation  from  the  inside 
of  the  labia. 

Before  any  of  the  virus  has  been  taken  up  by  the 
absorbents  and  conveyed  into  the  circulation,  a chancre 
is  entirely  a local  affection.  From  the  Hunterian  doc- 
trines, however,  it  would  appear,  that  absorption  must 
generally  soon  follow  the  occurrence  of  the  sore ; and 
all  the.  modefn  opinions  concerning  the  nature  of  ul- 
ceration itself,  would  lead  to  the  same  inference. 
When  no  secondary  symptoms  take  place  after  the 
cure  of  chancre  without  mercury,  I believe  few  sur- 
geons of  the  present  day  would  attempt  to  account  for 
the  fact  by  the  hypothesis  of  the  matter  not  having 
been  absorbed  ; and  this  observation  is  made,  with 
every  disposition  on  my  part  to  express  my  assent  to 
the  truth  of  another  circumstance,  viz.  that  some  per- 
sons appear  much  more  susceptible  of  the  effects  of 
the  venereal  disease  than  other  individuals.  It  is  re- 
marked by  Mr.  Hunter,  that  the  interval  between  the 
application  of  the  poison,  and  its  effects  upon  the  parts, 
is  uncertain ; but  that,  on  the  whole,  a chancre  is 
longer  in  appearing  than  a gonorrhoea.  However,  the 
nature  of  the  parts  affected  makes  some  difference 


VENEREAL  DISEASE, 


447 


When  a chancre  occurs  on  the  fra?num  or  at  the  ter- 
mination of  the  prepuce  in  the  glans,  the  disease  in 
general  comes  on  earlier ; these  parts  being  more  easily 
affected  than  either  the  glans  penis,  common  skin  of 
this  organ,  or  the  scrotum.  He  adds,  that  in  some 
cases  in  which  both  the  glans  and  prepuce  were  con- 
taminated from  the  same  application  of  the  poison, 
the  chancre  made  its  appearance  earlier  on  the  latter 
part.  Mr.  Hunter  knew  of  some  instances  in  which 
chancres  appeared  twenty -four  hours  after  the  appli- 
cation of  the  matter ; and  others,  in  which  an  interval 
of  seven  weeks,  and  even  two  months  elapsed,  be- 
tween the  time  of  contamination  and  that  when  the 
chancre  commenced.  However,  here,  as  in  almost  all 
other  statements  about  this  perple.xing  subject,  we 
never  know  with  certainty  that  the  writer  has  sufficient 
grounds  for  the  assumed  fact,  that  it  is  only  one  kind 
of  poison  which  is  spoken  of. 

It  was  one  of  Mr.  Hunter’s  opinions,  that  the  ulcer- 
ation arising  from  venereal  inflammation  generally,  if 
not  always,  continues  till  cured  by  art ; and  his  theo- 
retical reason  for  this  circumstance  was,  that,  as  the 
inflammation  in  the  chancre  spreads,  it  is  always  at- 
tacking new  ground,  so  as  to  produce  a succession  of 
irritations,  and  hinder  the  disease  from  curing  itself. 

It  was,  no  doubt,  the  foregoing  opinion  of  Mr.  Hun- 
ter, which  formed  the  authority  for  the  position  which 
was  always  forcibly  insisted  upon  in  the  surgical  lec- 
tures of  Mr.  Abernethy,  which  I attended  many  years 
ago,  viz.  that  all  truly  venereal  complaints,  when  not 
counteracted  by  remedies,  invariably  grow  progres- 
sively worse,  which  is  not  the  case  with  pseudo  syphi- 
litic  diseases.  But  modern  experience  apprizes  us  that 
this  doctrine  is  far  from  being  correct.  As  I have  no- 
ticed in  the  foregoing  pages.  Dr.  Fergusson  assures  us 
that,  in  Portugal,  the  disease  in  its  primary  state  among 
the  natives  is  curable  without  mercury,  and  by  simple 
topical  treatment ; that  the  antisyphilitic  woods,  com- 
bined with  sudorifics,  are  an  adequate  remedy  for  con- 
stitutional symptoms;  and  that  the  virulence  of  the 
disease  has  there  been  so  much  mitigated,  that,  after 
running  a certain  course  (commonly  a mild  one) 
through  the  respective  orders  of  parts,  accorfling  to 
the  known  laws  of  its  progress,  it  exhausts  itself  and 
ceases  spontaneously. — (See  Med.  and  Chir.  Trans, 
vol.  4,  p.  2—5.)  In  the  third  edition  of  the  First  Lines 
of  the  Practice  of  Surgery.,  it  was  sufficiently  proved, 
from  several  conclusions  drawn  from  the  writings  of 
Mr.  Pearson  {Obs.  on  the  Effects  of  various  Articles  in 
the  Cure  of  Lues  Venerea),  that  venereal  sores  might 
be  benefited,  and  even  healed,  under  the  use  of  several 
inert  insignificant  medicines.  And,  as  I have  previ- 
ously explained  the  possibility  of  curing  chancres  and 
other  venereal  complaints  without  mercury,  was  long 
since  remarked  by  Dr.  Clutterbuck,  who  thence  very 
justly  inferred,  that  the  healing  of  a sore  without  this 
remedy,  was  no  test  that  it  was  not  venereal. — (See 
Remarks  on  the  Opinions  of  the  late  John  Hunter, 
1799.) 

But  although  the  whole  history  of  the  venereal  dis- 
ease, and  of  the  various  articles  of  the  materia  medica, 
if  carefully  reflected  upon,  must  have  led  to  the  same 
conclusion,  the  truth  was  never  placed  in  such  a view 
as  to  command  the  general  belief  of  all  the  most  ex- 
perienced surgeons  in  this  and  other  countries  of  Eu- 
rope. I do  not  mean  to  say  that,  the  truth  was  not 
seer)  and  remarked  by  several  of  the  older  writers ; 
for,  that  it  was  so,  any  man  may  convince  himself 
by  referring  to  several  works  quoted  in  the  course  of 
this  article.  But  it  is  to  be  understood,  all  indeci- 
sion could  never  be  renounced  as  long  as  prejudices 
interfered  with  the  only  rational  plan  which  could 
be  adopted,  with  a view  of  bringing  the  question 
to  a final  settlement;  I mean  experiments  on  a large 
and  impartial  scale,  open  to  the  observation  of  nume- 
rous judges,  yet  under  such  control,  as  ensured  the  ri- 
gorous trial  of  the  practice.  Nor  could  such  investiga- 
tion be  so  well  made  by  any  class  of  practitioners  as 
the  army  surgeons,  whose  patients  are  numerous, 
obliged  to  follow  strictly  the  treatment  prescribed, 
without  any  power  of  going  from  hospital  to  hospital, 
or  from  one  surgeon  to  another,  as  caprice  may  dictate, 
or  of  eluding  the  observation  of  the  medical  attendants 
after  a seeming  recovery.  And  here  I must  take  the  op- 
portunity of  stating,  that  as  far  as  my  judgment  ex- 
tends, the  most  important  and  cautious  document  yet 
extant,  on  the  tvvo  questions  of  the  possibility  and  ex- 


pediency of  curing  the  venereal  disease  without  mer- 
cury, is  the  paper  of  Mr.  Rose.  For  let  it  not  be  pre- 
sumed, that  because  the  army  surgeons  find  the  vene- 
real disease  curable  without  mercury,  they  mean  to  re- 
commend the  total  abandonment  of  that  remedy  for 
the  distemper,  any  more  than  they  would  argue  that 
possibility  and  expediency  are  synonymous  terms.  At 
the  time  when  Mr.  Rose  published  his  observations,  he 
had  tried  the  non-mercurial  treatment  in  the  Cold- 
stream regiment  of  guards,  during  a year  atid  three- 
quarters,  and  had  thus  succeeded  in  curing  all  the  ul- 
cers on  the  parts  of  generation,  which  he  met  with  in 
that  period,  together  with  the  constitutional  symptoms 
to  which  they  gave  rise.  “I  may  not  be  warranted  in 
asserting  (says  this  gentleman),  that  many  of  these 
were  venereal ; but  urfdoubtedly  a considerable  number 
of  them  had  all  the  appearances  of  primary  sores,  pro- 
duced by  the  venereal  virus,  and  arose  under  circum- 
statices  where  there  had  been  at  least  a possibility  of 
that  virus  having  been  applied.  Admitting  that  there 
is  nothing  so  characteristic  in  a chancre  as  to  furnish 
incontrovertible  proof  of  its  nature,  it  will  yet  be  al- 
lowed, that  there  are  many  symptoms  common  to  such 
sores,  although  not  entirely  peculiar  to  them,  and  when- 
ever these  are  met  with,  there  are  strong  grounds  to 
suspect  that  they  are  the  effects  of  the  syphilitic  virus. 
In  a sore,  for  instance,  appearing  shortly  after  suspi- 
cious connexion,  where  there  is  loss  of  substance,  a 
want  of  disposition  to  granulate  and  an  indurated  mar- 
gin and  base,  there  is  certainly  a probability  of  that 
poison  being  present.  Among  a number  of  cases  of 
such  a description,  taken  indiscriminately,  the  proba- 
bility of  some  being  venereal  is  materially  increased, 
and  must  at  last  approach  nearly  to  a certainty.  On 
this  principle,  some  of  the  sores  here  referred  to  must 
have  been  venereal.  They  were  also  seen  by  different 
surgeons,  on  whose  judgment  I would  rely,  who  agreed 
in  considering  many  of  them  as  well-marked  cases  of 
true  chancre.” — {Rose,  in  Med.  Chir.  Trans,  vol.  8,  p. 
357,  Sec.)  The  men  thus  treated  were  examined  al- 
most every  week  for  a considerable  time  after  their  ap- 
parent cure,  “ both  that  the  first  approach  of  constitu- 
tional symptoms  might  be  observed,  and  that  any  de- 
ception from  an  underhand  use  of  mercury  might  be 
guarded  against.” — (P.  359.)  Sixty  cases  of  ulcers  on 
the  penis  were  also  cured  by  Mr.  Dease  in  the  York 
Hospital,  by  means  of  simple  dressings,  the  only  gene- 
ral remedy  being  occasional  purgatives.  The  practice 
was  likewise  extensively  tried  by  Mr.  Whymper  and 
Mr.  Good,  surgeons  of  the  Guards,  with  the  same  kind 
of  success.  In  Mr.  Rose’s  practice,  all  idea  of  speci- 
fic remedies  was  entirely  laid  aside.  The  patients  were 
usually  confined  to  their  beds,  and  such  local  applica- 
tions were  employed  as  the  appearances  of  the  sores 
seemed  to  indicate.  Aperient  medicines,  antimony, 
bark,  vitriolic  acid,  and  occasionally  sarsaparilla  were 
administered. — (P.  363.)  “ Upon  an  average  (says 

Mr.  Rose),  one  out  of  every  three  of  the  sores  thus 
treated,  was  followed  by  some  form  or  other  of  consti- 
tutional affection  : this  was  in  most  instances  mild  and 
sometimes  so  slight  that  it  would  have  escaped  notice, 
if  it  had  not  been  carefully  sought  for.  The  constitu- 
tional symptoms  were  evidently  not  such  as  could  be 
regarded  as  venereal,  if  we  give  credit  to  the  com- 
monly received  ideas  on  the  subject.  Caries  of  the 
bones,  and  some  of  the  least  equivocal  symptoms,  did 
not  occur.  In  no  instance  was  there  that  uniform  pro- 
gress, with  unrelenting  fury,  from  one  order  of  symp- 
toms and  parts  affected  to  another,  which  is  consi- 
dered as  an  essential  characteristic  of  true  syphilis.” 
— {Med.  Chir.  Trans,  vol.  8,  p.  422.)  The  constitu 
tional  symptoms  also  yielded,  without  the  aid  of  mer- 
cury; and  frequently  primary  sores,  corresponding  to 
what  had  been  called  the  true  chancre,  with  indurated 
base,  were  cured  in  this  manner,  yet  were  followed  by 
no  secondary  symptoms.  We  are  also  informed,  that 
“ several  cases  occurred  of  a cluster  of  ill-conditioned 
sores  over  the  whole  inner  surface  of  the  prepuce  ; and 
behind  the  corona  glandis;  and  also  of  a circle  of 
small  irritable  sores,  situated  on  the  thickened  and  con- 
tracted ring  at  the  extreme  margin  of  tl**  prepuce. 
These  occasionally  produced  buboes.”  JTone  of  the 
sores  of  this  description,  met  with  by  Mr.  Rose,  were 
followed  by  any  constitutional  affection. — ( Vol.  cit.  p, 
370.)  He  bears  testimony  to  the  ill  effects  of  mer- 
cury and  stimulants  in  cases  of  phagedenic  ulcers,  and 
confirms  a not  uncommon  opinion,  that  they  are  sel- 


448 


VENEREAL  DISEASE 


dom  followed  by  secondary  symptoms,  which  opinion 
should  be  qualified  witli  the  condition  mentioned  by 
lilr.  Guthrie  {Med.  Chir.  'Trans,  vol.  8,p.  565),  that  no 
luercurv  be  given.  Lastly,  as  I have  already  staled, 
Mr.  Rose  observed,  that  most  of  the  ca^es  of  papular 
eruptions  followed  ulcers,  which  were  not  very  deep, 
and  healed  without  much  difficulty. — (P.  399.) 

Although  the  fact  of  the  possibility  of  curing  every 
kind  of  ulcer  on  the  genitals  without  mercury  has  been 
fully  confirmed  by  the  statements  of  Mr.  Guthrie  {.Med. 
Chir.  Trans,  vol.  8,  p.  558  and  576),  Dr.  J.  Thomson 
{Edin.  Med.  and  Surg.  Journ.  for  January.,  1818),  Dr. 
Hennen  ( Op.  cit.  Mos.  54  and  55,  and  Principles  of  Mi- 
litary Surgery,  ed.  2),  Mr.  Bacot  (On  Syphilis,  p.  26, 
4'c.),  and  many  other  careful  observers;  and,  although 
it  is  of  great  importance  in  relation  to  the  removal  of 
an  erroneous  doctrine  concerning  the  diagnosis ; yet 
the  expediency  of  the  practice  must  evidently  be  deter- 
mined by  other  considerations,  tlie  principal  of  which 
are  the  comparative  quickness  of  the  cures  effected 
with  and  without  mercury;  the  comparative  severity 
and  frequency  of  secondary  symptoms ; and  the  gene- 
rally acknowledged  fact,  that  a syphilitic  primary  sore 
is  liot  indicated  w ith  any  degree  of  certainty  by  its 
mere  external  character,  or  indeed  any  other  criterion 
hitherto  discovered. 

Respecting  the  comparative  quickness  of  the  cures 
of  chancres,  or  repul^  chancres,  without  the  aid  of 
mercury,  much  disagreement  prevails  in  the  different 
reports,  even  those  collected  by  the  same  individuals, 
whose  statements  must  therefore  be  deemed  perfectly 
impartial,  though  inconclusive. — (See  Hennen's  .Mili- 
tary Surgery,  ed.  2,  p.  536,  iS-c.)  Some  ot  Mr.  Rose's 
best  marked  cases  of  chancre,  that  is  to  say,  such  as 
were  distinguished  by  the  indurated  base  and  circum- 
ference, healed  in  a verj-  short  time.  But  even  respect- 
ins  these,  or  any  other  kinds  of  chancre,  no  regularity 
on  this  point  can  be  found.  Mr.  Guthrie  observes, 
if  the  ulcers  were  not  without  any  marked  appear- 
ance, and  did  not  amend  in  'the  first  fortnight  or  three 
w’eeks,  they  generally  remained  for  five  or  seven  weeks 
longer;  and  the  only  difference  in  this  respect  between 
them  and  the  raised  ulcer  of  the  prepuce  was,  that  this 
often  remained  for  a longer  period,  and  that  ulcers, 
possessing  the  true  character  of  chancre,  required  in 
general  a still  longer  period  for  their  cure,  that  is,  from 
six,  eight,  to  ten,  and  in  one  case,  even  twenty-six 
wrecks,  healing  up  and  ulcerating  again  on  a hardened 
base.  Those  that  required  the  greatest  length  of  time 
had  nothing  particular  in  their  appearance  that  would 
lead  us  to  distinguish  them  from  others  of  the  same 
kind  which  were  healed  in  a shorter  time.”— (A/ed. 
Chir.  Trans,  vol.  8,  p.  538.)  The  same  writer  after- 
ward expresses  his  belief,  that  almost  all  the  pro- 
tracted cases  would  have  been  cured  in  one-half  or  even 
one-third  of  the  time,  if  a moderate  course  of  mercury 
had  been  resorted  to. 

In  relation  to  the  question  before  us,  one  of  the  most 
important  documents  which  I have  met  with,  is  an  of- 
ficial circular,  signed  by  Sir  James  M'Grigor  and  Sir 
Wm.  Franklin,  from  which  it  appears  that  in  1940 
cases  of  primary  venereal  ulceiations  on  the  penis, 
cured  without  mercury,  between  December,  1816,  and 
December,  1818  (including  not  only  the  more  simple 
sores,  but  also  a regular  proportion  of  those  with  the 
most  marked  characters  of  syphilitic  chancre),  the 
average  period  taken  up  by  the  treatment  when  bubo 
did  not  exist,  was  21  days ; with  bu'oo,  45  days.— (See 
Hennen^  .Military  Surgery,  ed.  2,  p.  545.)  And  it  far- 
ther appears,  that  during  the  period  above  specified, 
2827  chancres,  a more  considerable  proportion  of  which 
were  probably  Hunterian  chancres,  were  treated  with 
mercury,  and  that  the  average  period  required  for  the 
cure  when  there  was  no  bubo,  was  33  days ; with 
bubo,  50.  As  far,  therefore,  as  a judgment  can  be 
formed  from  this  official  estimate,  and  no  calculation 
is  ever  likely  to  be  furnished  on  a larger  or  more  im- 
partial scaled  the  evidence  tends  to  prove,  that  primary 
sores  may  generally  be  cured  rather  sooner  without 
than  with  the  administration  of  mercury.  But  as 
practitioi  •rs  are  not  obliged  to  restrict  themselves 
either  to  the  mercurial  or  non-mercurial  practice,  I am 
of  opinion  that  the  total  rejection  of  mercury  is  by  no 
means  justified  by  any  facts  yet  before  the  public,  con- 
cerning the  time  requisite  for  the  cure  on  either  plan; 
because,  as  it  is  universally  admitted  that  some  cases 
are  very  tedious  unless  mercurj’  be  given,  neither  rea- 


son nor  experience  will  sanction  the  exclusive  adoptkni 
of  only  one  mode  of  practice,  whether  the  backward- 
ness to  heal  exist  or  not.  On  the  contrary,  as  far  as 
the  consideration  of  time  has  weight,  prudence  and 
common  sense  teach  us  to  diversify  the  treatment  ac- 
cording to  circumstances.  But  it  may  be  inquired, 
since  the  backward  disposition  of  a sore  to  heal  can- 
not be  known  at  first  by  its  mere  appearance,  should 
the  treamient  begin  with  mercury  or  not  1 Now,  ab 
though  late  writers  dw’ell  very  much  on  tlie  impossi- 
bility of  judging  of  the  nature  of  a sore  by  its  look 
alone,  qne  fact  is  certain,  that  some  ulcers  on  the  penis 
have  a clean  appearance  from  their  very  commence- 
ment ; some  cases  are  simple  excoriations  ; and  others, 
though  ill-conditioned,  are  so  small,  that  a fair  chance 
offers  itself  of  destroying  every  part  of  the  disease 
with  caustic.  In  all  such  cases,  1 should  never  com- 
mence w ith  mercury.  With  respect  to  phagedenic  and 
sloughing  chancres,  repeated  experience  has  convinced 
me,  that  they  are  cases  in  the  first  stage  of  w hich,  at 
aU  events,  mercury  should  always  be  avoided ; and 
I believe,  with  Mr.  Guthrie,  that  when  this  is  strictly 
done,  secondary  symptoms  are  rare.  One  sore  of  this 
kind  wtis  long  ago  pointed  out  by  Mr.  Pearson,  as  not 
requiring  mercury,  and  the  attention  of  surgeons  has 
been  of  late  particularly  directed  to  it  by  Mr.  Bacot. 
“ It  is  characterized  by  a great  derangement  of  the  ge- 
neral health,  by  a high  state  of  inflammation  of  the 
part,  by  great  focal  pain,  and  proceeds  rapidly  to  the 
destruction  of  the  parts.  The  situation  of  this  sore  is 
most  commonly  in  the  angle  between  the  prepuce  and 
glans  penis;  and  those  of  a full  habit  of  body,  the 
young  and  the  vigorous,  are  most  liable  to  its  attack. 
The  most  prompt  and  vigorous  antiphlogistic  means 
are  necessary  to  arrest  the  progress  of  this  sore  ; and 
the  blood  taken  away  in  these  cases  presents  the  usual 
inflammatory  appearances,  frequently  in  a very  high 
degree.  The  exhibition  of  mercury  in  this  species  of 
sore  is  highly  mischievous,  and  productive  of  the 
worst  consequences  ; nor  does  it  often  happen  that  se- 
condary symptoms  succeed,  &c. — {On  Syphilis,  p.  57.) 
Here,  according  to  Mr.  Pearson’s  observations,  made 
many  years  ago,  mercury  is  not  perhaps  necessary  for 
the  security  of  the  constitution ; but  I conceive  it 
might  be  more  correct  to  say  tliat  the  safety  of  the 
constitution  actually  requires  that  mercury  should 
be  strictly  avoided,  because  there  is  some  ground  for 
believing  that,  in  these  instances,  it  is  not  only  in 
jurious  to  the  local  disease,  but  conducive  to  second- 
ary symptoms.  However,  if  the  latter  symptoms 
should  arise,  notwithstanding  mercury  has  not  been 
administered  during  the  cure  of  the  ulcer,  alterative 
doses  of  that  medicine  may  still  be  useful,  as  Mr.  Car- 
michael observes,  when  the  disease  is  in  the  w ane,  but 
not  until  then,  previously  to  which  period,  the  best  in- 
ternal remedies  are  antimonials,  sarsaparill^  guaiacum, 
compound  pow  der  of  ipecacuanha,  arseniate  of  kali, 
the  nitrous  acid,  and  nitro-muriatic  bath. — (See  Obs. 
on  the  Symptoms,  Src.  of  the  Venereal  Disease,  p.  209.) 

With  respect  to  chancres  with  a hardened  base  and 
margin,  it  certainly  appears  that  many  of  them  have 
healed  tolerably  fast  without  mercury ; but  a large 
proportion  of  them  were  tedious  when  that  medicine 
was  not  employed. — (See  three  cases  recorded  in  the 
work  last  quoted.)  It  may  be  thought,  however,  that 
the  official  document  circulated  by  Sir  James  M'Gri- 
gor  and  Sir  William  Franklin,  tends  to  prove  that,  at 
ail  events,  these  sores  heal  sooner  without  than  with 
mercury’.  But  this  conclusion  seems  hardly  allowable, 
because,  as  these  faithful  and  impartial  reporters  have 
sensibly  remarked,  the  2827  sores  treated  with  mer- 
cury may  be  fairly  presumed  to  have  partaken  of  the 
character  of  Hunter's  chancre  in  a greater  proportion 
than  the  1940  primary  sores  treated  without  mercury. 
— (See  Hennen's  .Military  Surgery,  p.  545.)  Conse- 
quently, though  the  sores  treated  with  mercury  seem, 
on  the  average,  to  have  healed  more  slowly  than  others 
treated  without  it,  yet  it  is  to  be  taken  into  Uie  account, 
that  a larger  number  of  the  first  cases  were  ulcers  with 
a hardened  base  and  margin,  and  that  if  they  had  not 
had  the  mercurial  treatment  extended  to  them,  it  is 
possible  their  complete  cure  might  generally  have  been 
still  more  tedious.  .As  the  evidence  now  stands,  there- 
fore, I conceive  it  right  to  employ  mercury  with  mode- 
ration, for  all  sores  on  the  penis  having  the  characters 
of  the  Hunterian  chancre,  and  appearing  aAer  a sus- 
picious connexion. 


VENEREAL  DISEASE. 


449 


A consideiation,  however,  which  ought  to  have 
greater  influence  than  the  slowness  or  quickness  of 
the  cure  of  primary  sores  with  and  without  mercury, 
is  the  question,  whether,  upon  the  average,  secondary 
symptoms  are  more  frequent  after  the  non-mercurial 
practice  than  the  other?  On  this  most  interesting 
point  the  reports  vary,  as  indeed  they  do  on  almost 
every  matter  in  the  investigation,  excepting  the  facts 
of  the  possibility  of  curing  all  forms  of  the  venereal 
disease  without  mercury,  the  great  rarity  of  any  affec- 
tion of  the  bones,  and  the  general  mildness  of  the  se- 
condary symptoms,  when  that  medicine  is  not  em- 
ployed. On  all  these  points  the  testimonies  are  strong 
and  convincing.  But  white  Mr.  Rose  found  secondary 
symptoms  take  place  in  one-third  of  his  cases  treated 
without  mercury  {Med.  Chir.  Trans,  vol.  8,  p.  422), 
the  proportion  in  the  York  and  some  other  hospitals, 
was  only  about  one-tenth. — {VoL  cit.  p.  559.)  In 
the  1940  cases  of  primary  sores  on  the  penis,  treated 
without  mercury  in  the  army  hospitals,  between  De- 
cember, 1816,  and  December,  1818,  there  were  only  96 
instances  of  secondary  symptoms  of  different  sorts,  or 
not  more  than  one-twentieth.  But  the  proportion  of 
cases  of  secondary  symptoms  in  the  cases  of  primary 
ulcers  treated  with  mercury  was  still  smaller,  and  this 
in  an  important  degree,  being  only  51  out  of  2827 
casej,  or  about  one-fifty-fiflh.  Were  it  not  necessary 
to  make  a considerable  allowance  for  the  probable  cir- 
cumstance of  the  Hunterian  chancre  prevailing  most 
in  the  cases  treated  with  mercury,  a point  admitted  by 
Sir  James  M'Grigor  and  Dr.  Franklin,  we  should  here 
have  a powerful  and  decisive  evidence  in  favour  of 
the  general  superiority  of  mercury  for  the  prevention 
of  secondary  symptoms.  Nor  am  I certain  that  the 
conclusion  can  be  much  weakened  by  the  probability 
of  the  difference  here  alluded  to,  because  from  the 
evidence  of  late  brought  to  light  respecting  the  nature 
of  the  class  of  diseases  which  go  under  the  name  of 
syphilis,  we  have  no  right  to  infer  that  what  has  been 
called  the  true  or  Hunterian  chancre  is  more  disposed 
than  some  other  primary  sores  to  occasion  secondary 
symptoms.  Indeed,  Mr.  Guthrie  declares,  in  the  cases 
referred  to  in  his  paper,  that  when  mercury  was  not 
used,  these  symptoms  more  frequently  followed  the 
raised  ulcer  of  the  prepuce,  than  the  true  character- 
istic chancre  of  syphilis  affecting  the  glans  penis. — 
{Mid.  Ckir.  Trans,  vol.  8,  p.  577.)  On  the  whole,  as 
the  reports  now  stand,  and  as  far  as  I can  judge  from 
cases  which  I have  seen  myself,  the  secondary  symp- 
toms are  more  frequent  when  primary  ulcers  are  pro- 
misctiously  treated  without  mercury.  But  it  by  no 
means  follows  from  this  fact,  that  the  way  to  have  the 
smallest  possible  number  of  cases  of  secondary  symp- 
toms is  to  employ  mercury  in  all  instances  of  sores  on 
the  genitals.  This  both  reason  and  experience  contra- 
dict, inasmuch  as  mercury  given  in  cases  which  do  not 
require  it  for  the  security  of  the  constitution,  is  fre- 
quently itself  a source  of  cutaneous  diseases,  sore 
tliroats,  and  nodes,  which,  without  its  baneful  influ- 
ence, would  never  have  occurred.  The  prudent  course 
seems  here  to  be  to  exercise  our  judgment  and  discre- 
tion, and  to  be  guided,  in  some  measure,  by  the  appear- 
ance and  progress  of  the  sore,  according  to  principles 
already  suggested  ; for  though  the  look  of  a sore  may 
not,  in  the  present  state  of  our  knowledge,  always  en- 
able us  to  form  a certain  inference  respecting  the  risk 
of  secondary  symptoms  if  mercury  be  omitted,  it  can- 
not be  said  that  the  danger  would  be  positively  obvi- 
ated by  having  recourse  at  once  to  mercury  in  every 
kind  of  primary  sore;  and  notwithstanding  every 
thing  which  has  been  lately  published,  I still  flatter 
myself,  that  surgeons,  accustomed  to  see  much  of  ve- 
nereal cases,  can  yet  distinguish  excoriations,  herpes 
of  the  prepuce,  biles,  simple  healthy  sores,  and  some 
other  common  aliments  (see  Evans  on  Ulcerations  of 
the  Oenital  Organs,  8vo.  Land.  1819),  from  ulcers,  by 
which  the  constitution  is  liable  to  be  affected.  Until 
farther  data  exist,  I cannot  venture  to  lay  down  other 
directions  about  the  treatment  of  primary  sores.  It  is 
with  pleasure,  however,  that  I subjoin  the  advice  of 
other  gentlemen,  whose  sentiments  and  talents  deserve 
respect,  though  their  opinions  may  not  exactly  agree 
with  ray  own.  In  every  primary  ulcer  (says  Dr. 
Hennen),  I would  give  up  the  idea  of  using  mercury  at 
first,  treating  it  as  if  it  were  a simple  ulceration,  by 
cleanliness,  rest,  and  abstinence,  and  applying  to  it  the 
most  simple  and  mildest  dressings.  If  the  sore  did  not 
VoL.  II.— F f 


put  on  a healing  appearance  in  a reasonable  time,  the 
extent  of  which  must  depend  upon  the  circumstances 
of  the  patient,  I should  make  use  of  more  active  dress- 
ings. But  if,  beyond  all  calculation,  it  remained  open, 

I should  certainly  not  sacrifice  every  consideration  to  a 
dislike  of  mercury,  knowing  how  many  persons  have 
been  seriously  benefited  by  a judicious  and  mild  ad- 
ministra,tion  of  that  remedy.” — (On  Military  Surgery^ 
edit.  2,  p.  518.)  When  primary  ulcers  resist  common 
means  a certain  time,  Mr.  Bacot  would  also  have  re- 
course to  mercury. — (On  Syphilis,  p.  69.)  Like  me, 
however,  the  latter  author  does  not  approve  of  inva- 
riably postponing  that  remedy  until  the  latter  criterion, 
viz.  the  backwardness  of  the  sore  to  be  healed  by  other 
methods,  is  afforded. 

Whenever  the  employment  of  mercury  in  this  work  is 
recommended,  I am  very  far  from  wishing  to  be  thought 
an  advocate  for  pushing  that  medicine,  as  the  phrase 
is.  On  the  contrary,  experience  has  fully  convinced 
me,  that  in  no  forms  of  chancre,  nor  in  any  other  stages 
of  the  venereal  disease,  is  it  proper  to  exhibit  mercury 
in  the  unmerciful  quantity,  and  for  the  prodigious 
length  of  time,  which  custom,  ignorance,  and  preju* 
dice  used  to  sanction  in  former  days.  Violent  sali- 
vations, at  all  events,  ought  to  be  for  ever  exploded. 

When  I was  an  articled  student  at  St.  Barlholo- 
mew’s  Hospital,  most  of  the  venereal  patients  in  that 
establishment  were  seen  with  their  ulcerated  tongues 
hanging  out  of  their  mouths  ; their  faces  prodigiously 
swelled ; and  their  saliva  flowing  out  in  streams.  The 
wards  were  not  sufficiently  ventilated,  and  the  stench 
was  so  great  that  the  places  well  deserved  the  ap- 
pellation of  foul.  Yet,  notwithstanding  mercury  was 
thus  pushed  (as  the  favourite  expression  was),  it  was 
then  common  to  see  many  patients  suffer  the  most  dread- 
ful m utilations,  in  consequence  of  sloughing  ulcers  of  the 
penis;  many  unfortunate  individuals,  whose  noses 
and  palates  were  lost ; and  others  who  were  afflicted 
with  nodes  and  dreadful  phagedenic  sores. 

Happily,  at  the  present  day,  this  attachment  to  vio- 
lent salivations  no  longer  prevails ; simple  excoriations 
and  common  ulcers  are  more  attentively  discriminated ; 
and,  even  in  what  are  reputed  to  be  true  syphilitic 
chancres,  mercury  is  seldom  given,  except  in  very  mo- 
derate doses,  or  such  quantities  as  only  gently  affect 
the  gums  and  salivary  glands.  The  surgeon,  now  no 
longer  blinded  with  the  continual  fear  of  the  rapid  and 
furious  progress  of  syphilis  when  not  duly  resisted  by 
mercury,  avoids  the  very  mode  of  practice  which  was 
itself  the  cause  of  all  the  aggravated  forms  of  the  dis- 
ease. The  consequence  is,  that  very  bad  instances  of 
the  ravages  of  lues  venerea  are  now  hardly  ever  ob- 
served, except  from  the  neglect  and  intemperance  of  pa- 
tients themselves  ; and  the  few  aggravated  cases  which 
are  met  with,  even  in  hospitals,  are  generally  in  that 
state  previously  to  their  admission.  Another  benefit 
also  resulting  from  modern  investigations,  which  prove 
that  chancres,  and  all  other  varieties  of  the  venereal 
disease,  do  not  absolutely  require  mercury  for  their 
cure,  is  the  safety  with  w’hich  it  is  now  known  that 
the  use  of  such  medicine  may  be  postponed,  where 
the  patient’s  present  state  of  health  would  not  well 
bear  its  exhibition.  And  I know  that  an  ignorance  of 
this  fact  formerly  caused  the  death  of  many  poor  sufferers. 

The  greater  present  mildness  of  syphilitic  diseases 
in  England,  I ascribe  chiefly  to  the  more  judicious 
treatment  now  adopted,  and  not  to  any  change  or  mo- 
dification in  the  nature  of  the  disorder.  There  are 
others,  however,  who  may  think  as  Mr.  Fergusson  does 
with  regard  to  syphilis  in  Portugal,  that  the  disease  has 
exhausted  a great  deal  of  its  virulence  from  long  con- 
tinuance among  us.  But  before  we  are  altogether  jus- 
tified in  drawing  such  a conclusion,  we  must  forget  all 
the  bad  practice  which  prevailed  in  former  days,  and 
which,  in  my  opinion,  is  sufficient  to  account  for  the 
more  severe  forms  in  which  syphilis  then  presented  it- 
self ; though  not  for  the  ravages  of  that  acute,  quickly 
spreading,  and  fatal  disorder  which  broke  out  in  the 
French  army  at  Naples,  at  the  close  of  the  15th  cen- 
tury. According  to  my  own  judgment,  this  was  de- 
cidedly a very  different  disease  from  any  venereal  ma- 
ladies with  which  we  are  now  acquainted;  too  differ- 
ent indeed  to  be  accounted  for  either  by  any  sponta- 
neous alteration  of  its  own,  or  by  any  improvements 
in  practice. 

According  to  Mr.  Hunter’s  ideas,  the  most  simple 
method  of  treating  a cliancrc  is  to  extirpate  it  with 


450 


VENEREAL  DISEASE. 


caustic  or  the  knife,  whereby  it  is  reduced  to  the  slate 
of  a common  sore  or  wound,  and  heals  up  as  such. 
However,  he  sanctions  this  practice  only  on  the  first 
appearance  of  the  chancre,  when  the  surrounding 
parts  are  not  yet  contaminated  ; for  he  says  it  is  abso- 
lutely necessary  to  remove  the  whole  of  the  diseased 
part,  and  this  object  is  exceedingly  difficult  of  accom- 
plishment when  the  disease  has  spread  considerably. 
When  the  chancre  is  situated  on  the  glans  penis,  he 
thought  touching  the  sore  with  the  lunar  caustic  pre- 
ferable to  cutting  it  away,  because  the  hemorrhage 
from  the  cells  of  the  glands  would  be  considerable  after 
the  use  of  the  knife. 

The  caustic  should  be  pointed  at  the  end,  like  a pen- 
cil, in  order  that  it  may  only  touch  such  parts  as  are 
really  diseased  ; and  its  application  should  be  repeated 
till  the  surface  of  the  sore,  after  the  separation  of  the 
last  sloughs,  assumes  a red  and  healthy  appearance, 
when  it  will  heal  like  any  other  sore  made  with  caustic. 

When  the  sore  is  on  the  prepuce,  or  the  common 
skin  of  the  penis,  and  in  an  inoipient  state,  the  same 
practice  may  be  adopted  with  success.  When  the 
chancre  is  large,  however,  it  cannot  be  destroyed  with 
the  argentum  nitratum,  which  does  not  extirpate  the 
increasing  sore  deeply  enough.  In  such  cases,  Mr. 
Hunter  thought  that  the  potassa  cum  calce  might  an- 
swer better.  When  the  caustic  could  not  be  conve- 
niently employed,  this  author  sometimes  recommended 
the  excision  of  chancres,  a plan  which  he  had  adopted 
himself,  and  the  part  afterward  healed  with  common 
dressings.  However,  says  he,  as  our  knowledge  of  the 
extent  of  the  disease  is  not  always  certain,  and  as 
this  uncertainty  increases  with  the  size  of  the  chancre, 
the  cure  must  be  in  some  measure  promoted  by  proper 
dressings,  and  it  will  be  prudent  to  dress  the  sore  with 
mercurial  ointment.  When  a chancre  is  destroyed 
almost  immediately  on  its  first  appearance,  Mr.  Hunter 
believes  that  there  is  little  danger  of  the  constitution 
being  infected,  as  it  is  reasonable  to  conclude  that  there 
has  not  been  time  for  absorption  to  take  place.  How- 
ever, on  account  of  the  impossibility  of  being  certain 
on  this  point,  he  recommends  mercury  to  be  given 
from  motives  of  prudence,  the  quantity  of  which  me- 
dicine, he  says,  should  be  proportioned  to  the  duration 
and  progress  of  the  sore.  When  the  chancre  is  large, 
Mr.  Hunter  deems  mercury  absolutely  necessary  ; and 
he  conceives  that  very  little  good  is  to  be  done  by  the 
extirpation. 

Among  modern  advocates  for  the  application  of 
caustic  to  chancres,  Delpech  is  one  of  the  most  zealous, 
and  the  nitrate  of  mercury  is  that  which  he  commonly 
employs  ; he  abstains  from  the  practice,  however,  when 
much  inflammation  is  present. — (Chir.  Clinique^  t.  1.) 

With  respect  to  dressings  for  chancres,  Mr.  Hunter 
seems  to  have  placed  a good  deal  of  confidence  in  those 
which  contain  mercury  ; but  I do  not  believe  that  the 
same  attachment  to  them  prevails  now  which  existed 
twenty  years  ago.  And  the  established  fact  of  mercury 
not  being  absolutely  necessary  in  any  way  for  the  cure 
of  different  venereal  sores,  must  have  the  effect  of 
removing  some  prejudices  on  this  part  of  the  subject. 
As  common  mercurial  ointment  is  always  more  or  less 
rancid,  I have  found  it  in  many  cases  a bad  kind  of 
dressing,  and  now  seldom  apply  it  to  ulcerated  sur- 
faces. In  ordinary  cases,  I believe  astringent  lotions, 
made  with  the  sulphate  of  copper,  acetate  of  lead, 
alum,  &c.  answer  the  best.  Some  chancres  are  indo- 
lent and  require  stimulants,  like  the  hydrargyri  nitrico- 
o.xydum  blended  with  ointment,  the  unguentum  hy- 
drargyi  nitrati  more  or  less  weakened,  or  a solution 
of  the  nitrate  of  silver.  Mr.  Hunter,  always  partial, 
even  in  cases  of  indolent  chancres,  to  mercurial  dress- 
ings, expresses  his  preference  to  a salve  containing 
calomel,  as  being  more  active  than  common  mercurial 
ointment.  In  phagedenic  and  sloughing  chancres,  the 
carrot  and  fermenting  poultices,  solutions  of  the  ex- 
tracts of  hemlock  and  opium ; but  particularly  bread 
and  water  poultices  with  opium,  and  lotions  of  the 
arseniate  of  potassa,  containing  arsetiic,or  nitrous  acid, 
and  nitrate  of  silver,  merit  trial. 

In  general,  Mr.  Hunter  was  an  advocate  for  changing 
the  dressings  very  often,  because  the  matter  separates 
them  from  the  sore,  so  as  to  diminish  their  effect.  He 
states,  that  changing  the  applications  thrice  a day  will 
not  be  found  too  often,  particularly  when  they  are  in 
the  form  of  an  ointment. 

When  the  venereal  nature  of  a chancre  is  removed, 


the  sore  frequently  becomes  stationary ; in  which  cSiC, 
Mr.  Hunter  observes,  that  new  dispositions  have  beert 
acquired,  and  the  quantity  of  disease  in  the  part  has 
been  increased.  When  chancres  are  only  stationary, 
Mr.  Hunter  says,  they  may  often  be  cured  by  touching 
them  slightly  with  the  lunar  caustic. 

In  these  cases,  no  cicatrization  seems  possible  till  the 
contaminated  surface,  or  the  new  flesh  which  grows 
on  that  surface,  has  either  been  destroyed  or  altered. 
When  sores  are  situated  under  the  prepuce,  where 
they  are  concealed  by  a phymosis,  some  emollient  or 
gently  astringent  lotion  should  frequently  be  injected 
under  the  foreskin,  so  as  to  wash  out  any  matter  which 
might  otherwise  lodge  there  and  cause  additional  ini- 
tation. 

Contrary  to  the  doctrines  which  the  facts  of  modern 
experience  have  now  fully  established,  xMr.  Hunter 
believed  that  mercury  should  be  given  in  every  case  of 
chancre^  however  slight,  and  even  when  it  has  been 
destroyed  by  caustic,  or  other  means,  on  its  very  first 
appearance.  The  remedy^  he  says,  should  be  continued 
^for  some  time  after  the  chancre  has  healed,  in  order  to 
hinder  the  venereal  disposition  from  forming.  Here 
we  find  even  Hunter  himself  falling  into  some  incon- 
sistencies ; for,  in  other  parts  of  his  work,  he  seems  to 
approve  of  the  principle  of  giving  mercury  otdy  when 
actual  and  visible  disease  exists,  because  it  cannot 
cure  the  disposition  to  it  even  if  it  exists.  Now,  as  the 
chancre  is  cured,  no  farther  absorption  of  the  virus 
from  it  is  possible ; and  whatever  disposition  to  the 
disease  can  arise  from  absorption  n)ust  have  alretidy 
been  formed,  and  therefore  cannot  be  prevented ; and 
though,  according  to  Mr.  Hunter’s  own  theory,  the 
virus  has  been  long  ago  expelled  from  the  system  toge- 
ther with  some  of  the  excretions,  mercury  is  recom- 
mended with  the  view  of  protecting  the  constitution. 

However,  if  Mr.  Hunter’s  explanations  are  not  alto- 
gether satisfactory  on  this  part  of  the  subject,  I believe 
the  fault  is  in  his  theory ; because,  in  cases  where  mer- 
cury is  deemed  advisable,  general  experience  appears 
to  sanction  the  practice  of  continuing  its  use  for  some 
time  after  the  chancre  is  perfectly  healed.  Yet  many 
exceptions  to  this  rule  present  themselves ; for,  if  a 
chancre  is  large  and  very  long  in  healing,  its  syphilitic 
character  is  generally  extinct  a good  while  before 
cicatrization  is  completed,  and  perseverance  in  mer- 
cury, under  these  circumstances,  would  be  both  an 
absurd  and  a dangerous  practice. 

Hence,  in  a great  measure,  the  cause  of  the  numerous 
instances  of  the  mercurial  disease,  as  Hr.  Mathias  has 
named  it,  and  which  in  former  days  did  far  more  mis- 
chief than  syphilis  itself. — (See  An  Inquiry  into  the 
History  and  J^ature  of  the  Disease  produced  in  th» 
Human  Constitution  by  the  Use  of  Mercury,  2d  ed.  8vo. 
Lond.  1816.)  This  part  of  the  subject  is  noticed  by  Mr. 
Hunter,  who  states  that,  in  very  large  chancres,  it  may 
not  always  be  necessary  to  continue  either  the  external 
or  internal  administration  of  mercury  till  the  sore  is 
healed;  for  the  venereal  action  is  just  as  soon  de- 
stroyed in  a large  chancre  as  it  is  in  a small  one,  since 
every  part  of  the  sore  is  equally  affected  by  the  medr 
cine,'  and  of  course  cured  with  equal  expedition.  But 
in  regard  to  cicatrization,  circumstances  are  different, 
because  a large  sore  is  longer  than  a small  one  in  be- 
coming covered  with  skin.  Hence,  according  to  Mr. 
Hunter,  a large  chancre  may  be  deprived  of  its  vene- 
real action  long  before  it  has  healed ; while,  on  tlie 
other  hand,  a small  one  may  heal  before  the  syphilitic 
affection  has  been  destroyed.  In  the  latter  case,  he 
represents  it  as  most  prudent,  both  on  account  of  the 
chancre  and  constitution,  to  continue  the  employment  of 
mercury  a little  while  after  the  sore  is  heated  ; advice 
which,  as  I have  already  stated,  is  at  variance  with 
certain  parts  of  his  own  theory,  however  well  justified 
it  may  be  by  experience. 

As  Mr.  Hunter  has  explained,  chancres,  both  in  men 
and  women,  often  acquire  during  the  treatment  new 
dispositions,  which  are  of  various  kinds,  some  retard- 
ing the  cure  and  leaving  the  parts  in  an  indolent  thick- 
ened state  after  the  cure  is  accomplished.  In  other 
instances,  a new  disposition  arises,  which  utterly  pre- 
vents the  parts  from  healing,  and  often  produces  a 
much  worse  disease  than  that  from  which  it  originated. 
Such  new  dispositions  may  lead  to  the  growth  of 
tumours.  They  are  more  frequent  in  men  than  wo- 
men, and  generally  occur  only  when  the  inflammation 
has  been  violent  from  some  peculiarity  of  the  parts  o* 


VENEREAL  DISEASE. 


451 


Constitution.  They  have  sometimes  been  considered 
as  cancerous. 

Among  tlie  diseases  in  question,  Mr.  Hunter  notices 
those  continued  and  often  increased  inflammations, 
suppurations,  and  ulcerations,  which  become  diffused 
through  the  whole  prepuce,  and  also  along  the  common 
skin  of  the  penis,  which  becomes  of  a purple  hue,  at- 
tended with  such  a general  thickening  of  the  cellular 
membrane  as  makes  the  whole  organ  appear  considera- 
bly enlarged.  The  same  writer  observes,  that  the  ul- 
ceration on  the  inside  of  the  prepuce  will  sometimes  in- 
crease, and  run  between  theskin  and  the  body  of  the  pe- 
nis, and  eat  holes  through  different  places  till  the  whole 
is  reduced  to  a number  of  ragged  sores.  The  glans 
often  shares  the  same  fate,  till  more  or  less  of  it  is  gone. 
Frequently,  the  urethra  in  this  situation  is  wholly  de- 
stroyed by  ulceration,  and  the  urine  is  discharged  some 
way  farther  back.  The  ulceration,  if  unchecked,  at 
length  destroys  all  the  parts.  In  this  acute  case,  prompt 
relief  is  demanded;  but  often  the  proper  mode  of 
treatment  cannot  be  at  once  determined,  owing  to  our 
ignorance  with  respect  to  the  exact  nature  of  the  pecu- 
liar cause  of  the  disease.  Mr.  Hunter  states,  that  the 
decoction  of  sarsaparilla  is  often  of  service  when  given 
in  large  quantities,  and  that  the  extract  of  hemlock 
and  sea-bathing  are  sometimes  capable  of  effecting  a 
cure.  According  to  my  own  experience,  the  omission 
of  mercury  is  here  the  most  essential  point. 

Sometimes,  after  a chancre  has  healed,  the  cicatrix 
breaks  out  again,  and  puts  on  the  appearances  of  the 
preceding  sore.  Occasionally  similar  diseases  break 
out  in  different  places  from  that  of  the  cicatrix.  Mr. 
Hunter  believes  that  they  differ  from  a chancre  in  ge- 
nerally not  spreading  so  fast,  nor  so  far ; in  not  being 
so  painful,  nor  so  much  inflamed  ; in  not  having  such 
hard  bases  as  venereal  sores  have  ; and  in  not  produc- 
ing buboes.  This  writer  is  of  opinion  that  they  are 
not  venereal,  and  he  states  that  they  are  very  apt  to 
recur. 

Mr.  Hunter  does  not  specify  any  particular  mode  of 
cure  for  all  these  cases  ; but  he  mentions  one  instance 
which  seemed  to  be  cured  by  giving  forty  drops  of  the 
liquor  potass®,  every  evening  and  morning,  in  a basin 
of  broth ; and  he  adverts  to  another  case,  which  was 
permanently  cured  by  sea-bathing. 

In  some  instances,  after  a chancre  has  healed,  the 
parts,  as  Mr.  Hunter  remarks,  do  not  ulcerate,  but 
appear  to  become  thickened  and  indurated.  Both  the 
glans  and  prepuce  seem  to  swell,  so  as  to  form  on  the 
end  of  the  penis  a tumour  or  excrescence  shaped  very 
much  like  a cauliflower,  and,  when  cut  into,  showing 
radii  running  from  its  base  or  origin  towards  the  exter- 
nal surface.  It  is  extremely  indolent,  and  not  always 
a consequence  of  the  venereal  disease  ; for  Mr.  Hunter 
has  seen  it  arise  spontaneously. 

No  medicine  seems  to  be  at  all  likely  to  cure  the 
disease ; the  only  successful  means  is  to  amputate  a 
considerable  part  of  the  penis,  and  then  to  keep  a 
proper  catheter  introduced  in  the  urethra. 

Another  disposition,  induced  by  the  previous  occur- 
rence of  chancres,  is  that  to  excrescences,  or  cutaneous 
tumours,  called  warts.  These  are  frequently  considered, 
not  simply  as  a consequence  of  the  venereal  poison,  but 
ns  possessed  of  its  specific  disposition ; and  therefore, 
says  Mr.  Hunter,  surgeons  have  recourse  to  mercury  for 
Ihe  cure  of  them ; and  it  is  said  that  such  treatment 
often  removes  them.  This  eminent  practitioner  never 
saw  mercury  produce  this  effect,  although  the  medicine 
was  given  in  sufficient  quantity  to  cure  recent  chancres 
and  a lues  venerea  in  the  same  person.— (See  Wart.) 

Mr.  Hunter  takes  notice  of  sloughs  which  occur  in 
the  tonsils  from  the  effect  of  mercury  on  the  throat,  and 
are  apt  to  be  mistaken  for  venereal  complaints.  He 
also  mentions,  that  sometimes  when  the  original  chan- 
cre has  been  doing  well  and  been  nearly  healed,  he  has 
seen  new  sores  break  out  on  the  prepuce  near  the  first, 
and  assume  all  the  appearance  of  chancres. 

When,  in  the  treatment  of  chancres,  a bubo  arises, 
while  the  constitution  is  under  the  influence  of  a suffi- 
cient quantity  of  mercury  to  cure  such  sores,  which 
medicine  has  also  been  rubbed  into  the  lower  extre- 
mity on  the  same  side  as  the  bubo,  Mr.  Hunter  sus- 
pects that  the  swelling  in  the  groin  is  not  venereal,  but 
is  produced  by  the  mercury.  In  these  cases,  he  always 
preferred  conveying  mercury  into  the  system  in  some 
other  manner. 

W ith  respect  to  the  treatment  of  chancres  in  women, 

Ffil 


since  it  is  difficult  to  keep  dressings  on  the  parts,  Mr. 
Hunter  advises  the  sores  to  be  frequently  washed  with 
some  mercurial  solution,  and  speaks  of  one  made  with 
oxymuriate  of  mercury  as  being  perhaps  the  best,  since 
it  will  act  as  a specific  and  stimulant  also  when  this  is 
requisite.  When  the  chancres,  however,  are  irritable, 
they  are  to  be  treated  in  the  same  manner  as  similar 
complaints  in  men.  Wlien  the  sores  extend  into  the 
vagina,  this  passage  must  be  kept  fiom  becoming  con- 
stricted or  closed,  by  the  introduction  of  lint. 

Sometimes,  after  a chancre  and  all  venereal  disease 
are  cured,  the  prepuce  continues  thickened  and  elon- 
gated, so  that  the  glans  cannot  be  uncovered  ; perhaps 
the  case  is  often  without  remedy.  Mr.  Hunter,  how- 
ever, very  properly  recommends  trying  every  possible 
means ; and  he  informs  us,  that  the  steam  of  warm 
water,  hemlock  fomentations,  and  cinnabar  fumiga- 
tions are  frequently  of  singular  service. 

When  the  thickening  and  enlargement  of  the  pre- 
puce cannot  be  removed  by  applications,  all  the  por- 
tion anterior  to  the  glans  penis  may  be  cut  away.— 
(See  Phymosis.) 

Bubo. — The  immediate  consequence  of  a chancre, 
which  is  called  a bubo,  and  also  the  remote  effects  im- 
plied by  the  constitutional  or  secondary  symptoms^  arise 
from  the  absorption  of  recent  venereal  matter  from 
some  surface  where  it  has  either  been  applied  or  formed. 

We  are  already  aware  that  Mr.  Hunter  believed  the 
matter  of  gonorrhoea  to  be  capable  of  comrnunicating 
the  venereal  disease.  Hence,  he  explains  in  the  fol- 
lowing terms,  the  three  ways  in  which  he  thought  a 
bubo  might  arise  in  consequence  of  absorption.  He 
observes,  that  the  first  and  most  simple  manner  is  when 
the  matter,  either  of  a gonorrhoea  or  chancre,  has  only 
been  applied  to  some  sound  surface,  without  having 
produced  any  local  effect  on  the  part ; but  has  been  ab- 
sorbed immediately  after  its  application.  Mr.  Hunter 
affirms,  that  he  has  seen  instances  of  this  kind,  though 
he  confcsses  that  they  are  very  rare,  and  that  in  most 
cases,  apparently  of  this  nature,  a small  chancre  may 
be  found  to  have  existed. 

The  second  mode  of  absorption,  or  that  taking  place 
in  a gonorrhoea,  Mr.  Hunter  represents  as  more  fre- 
quent. That  secondary  symptoms  do  occasionally  fol- 
low gonorrhoea  is  now  commonly  admitted,  though 
whether  they  differ  essentially  from  those  which  follow 
true  chancres,  is  a point  not  yet  completlely  settled. 
Delpech  describes  them  as  of  the  same  nature  {Chir, 
Clinique,  t.  1)  ; but  his  facility  of  belief  in  the  multi- 
plied effects  of  syphilis  and  gonorrhoea  is  almost  un- 
bounded. On  a point  of  this  kind,  therefore,  I should 
not  attach  much  importance  to  his  opinion.  However, 
as  far  as  Mr.  Carmichael’s  experience  goes,  there  is  a 
difference,  a part  of  which  consists  in  the  eruption  be- 
ing of  the  papular  kind,  as  it  is  also  after  many  instances 
of  simple  primary  ulcers— (See  Obs.  on  the  Symptoms, 
Src.  of  Venereal  Diseases,  8vo.  lA>nd.  1818.) 

The  third  mode  is  the  absorption  of  matter  from  an 
ulcer,  which  may  either  be  a chancre  or  a bubo.  This 
mode  is  by  far  the  most  common,  and  it  proves,  with 
many  other  circumstances,  that  a sore  or  ulcer  is  the 
most  favourable  for  absorption.  Mr.  Hunter  believed, 
that  absorption  was  more  apt  to  take  place  from  sores 
on  the  prepuce,  than  tho.se  on  the  glans. 

A fourth  mode  of  absorption  is  from  a wound ; a 
case  which,  according  to  Delpech,  is  almost  constantly 
followed  by  an  eruption  on  the  face,  soon  extending 
all  over  the  body,  and  very  quickly  followed  by  sore 
throftt,  periostoses,  atid  pains  in  the  bones.  In  siiort, 
his  idea  is,  that  when  the  poison  is  absorbed  from  a 
wound,  especially  one  that  has  not  suppurated,  its  ope- 
ration is  peculiarly  rapid  and  violent. — {CJiir.  Clinique, 
t.  I,p.  334.) 

Mr.  Hunter  notices,  that  what  is  now  commonly  un- 
derstood by  a bubo  is  a swelling  taking  place  in  the 
absorbing  system,  especially  in  the  glands,  and  arising 
from  the  absorption  of  some  poison,  or  other  irritating 
matter.  When  such  swellings  take  place  in  the  groin, 
they  are  called  buboes,  whether  they  proceed  from  ab- 
sorption  or  not. 

Mr.  Hunter  regards  every  abscess  in  the  absorbing 
system  as  a bubo,  whether  in  the  vessels  or  the  glands, 
when  it  originates  from  the  absorption  of  venereal 
matter. 

The  matter  is  taken  up  by  the  absorbent  vessels,  and 
is  conveyed  by  them  into  the  circulation.  In  its  pas- 
sage through  these  vessels  it  often  affects  them  with 


452 


VENEREAL  DISEASE. 


the  specific  inflammation.  The  consequence  is  the 
formation  of  buboes,  which  are  venereal  inflamma- 
tions or  abscesses  of  tlie  lympliatie  glands  or  vessels. 
The  sores  resulting  from  their  being  opened,  or  spon- 
taneously bursting,  au0  exactly  similar  to  a chancre  in 
their  nature  and  effects,  the  only  difference  being  in 
regard  to  size.  As  the  lymphatic  vessels  and  glands 
are  irritated  by  the  specific  matter  before  it  has  un- 
dergone any  change  in  its  passage,  the  inflammation 
produced  and  the  matter  secreted  partake  of  the  spe- 
cific quality. 

Inflammation  of  the  absorbent  vessels  themselves  is 
not  nearly  so  frequent  as  that  of  the  glands.  In  men  such 
inflammations,  in  consequence  of  chancres  upon  the 
glans  or  prepuce,  generally  appear  like  a cord,  leading 
along  the  back  of  the  penis  from  the  sores.  Sometimes 
the  absorbents  inflame  in  consequence  of  the  thickening 
and  excoriation  of  the  prepuce  in  gonorrhoea.  The  in- 
durated lymphatics  often  terminate  insensibly  near  the 
root  of  the  penis,  or  near  the  pubes;  while,  in  other 
instances,  they  extend  farther  to  a lymphatic  gland  in 
the  groin.  Mr.  Hunter  believed,  that  this  affection  of 
the  absorbent  vessels  is  truly  venereal.  The  formation 
of  a hard  cord,  he  conceived,  arose  from  a thickening 
of  the  coats  of  the  absorbents,  and  from  an  extravasa- 
tion of  coagulable  lymph  on  their  inner  surface. 

A cord  of  the  above  kind  often  suppurates,  sometimes 
in  more  places  than  one,  so  as  to  form  one,  two,  or  three 
buboes,  or  small  abscesses,  in  the  body  of  the  penis. 

Inflammation  much  more  frequently  afiects  the  ab- 
sorbent glands  than  the  vessels.  The  structure  of  the 
former  parts  appears  to  consist  of  the  ramifications  and 
reunion  of  the  absorbent  vessels.  From  this  structure, 
observes  Mr.  Hunter,  we  may  reasonably  suppose,  that 
the  fluid  absorbed  is  in  some  measure  detained  in  the 
glands,  and  thus  has  a greater  opportunity  of  communi- 
cating the  disease  to  them  than  to  the  distinct  vessels. 

Swellings  of  the  absorbent  glands  may  originate 
from  other  diseases,  and  should  be  carefully  discrimi- 
nated from  those  which  arise  from  the  venereal  poison. 
With  this  view,  Mr.  Hunter  advises  us  first  to  inquire 
into  the  cause,  in  order  to  ascertain  whether  there  is  any 
venereal  complaint  at  some  greater  distance  from  the 
heart,  such  as  chancres  on  the  penis,  or  any  preceding 
disease  in  this  situation.  He  recommends  us  to  inquire 
whether  any  mercurial  ointment  has  been  at  all  ap- 
plied to  the  leg  and  thigh  on  the  diseased  side ; for 
mercury,  applied  to  those  parts  for  the  cure  of  a chan- 
cre, will  sometimes  cause  glandular  enlargements, 
which  are  occasionally  mistaken  for  venereal  buboes. 
This  irritation  of  the  inguinal  glands  by  the  mechani- 
cal action  of  mercurial  ointment,  has  also  been  parti- 
cularly noticed  by  Professor  Assalini,  who  states  that 
he  has  had  frequent  opportunities  of  convincing  him- 
self of  the  fact. — (See  Manuale  di  Chirurgia^  p.  67.) 
Mr.  Hunter  reminds  us  to  observe  whether  there  has 
been  any  preceding  disease  in  the  constitution,  such  as 
a cold,  fever,  &c.  The  quick  or  slow  progress  of  the 
swelling  is  likewise  to  be  marked,  and  the  tumour  must 
be  distinguished  from  femoral  hernia,  lumbar  ab- 
scesses, and  aneurisms  of  the  crural  artery.  In  parti- 
cular cases  it  would  appear,  that  some  time  elapses  be- 
fore the  venereal  matter  produces  its  effects  on  the  ab- 
sorbent glands  after  its  absorption.  Mr.  Hunter  notices, 
that  sometimes,  at  least,  six  days  transpire  first;  a 
circumstance  which  can  only  be  known  by  the  chancres 
Laving  healed  six  days  before  the  bubo  began  to  ap- 
pear. However,  as  the  last  matter  of  a chancre  is 
probably  not  venereal,  he  infers,  that  in  cases  of  this 
kind  absorption  must  have  taken  place  earlier  than 
other  considerations  would  lead  one  to  suppose.  Ac- 
cording to  Mr.  Hunter,  in  general,  only  the  glands 
nearest  to  the  seat  of  absorption  are  attacked.  Thus, 
when  the  matter  is  taken  up  from  the  penis  in  men, 
the  inguinal  glands  are  affected  ; and,  when  from  the 
vulva  in  women,  those  glands  swell  which  are  situated 
between  the  labium  and  thigh,  and  the  round  ligaments. 

It  was  one  of  Mr.  Hunter’s  opinions,  that  only  one 
gland  at  a time  is  commonly  affected  by  the  absorption 
of  venereal  matter.  If  this  sentiment  be  correct,  the 
circumstance  may  be  considered  as  a kind  of  criterion 
between  venereal  and  other  buboes.  The  second  order 
of  lymphatic  vessels  and  glands  are  never  affected; 
as,  for  instance,  those  along  the  iliac  vessels  or  back. 
Mr.  Hunter  informs  us,  that  he  also  observed,  that 
when  the  disease  was  contracted  by  a sore  or  cut  upon 
the  fteger,  the  bubo  occurred  a little  above  the  bend  of 


the  arm,  by  the  side  of  the  biceps  muscle,  and  no  swefl- 
ing  of  this  sort  formed  in  the  armpit.  However,  he 
had  heard  of  a few  rare  cases  in  which  a swelling  ii» 
the  axilla  was  also  produced. 

When  buboes  arise  from  a venereal  disease  on  the 
penis,  they  are  situated  in  the  glands  of  the  groin^ 
When  a bubo  arises  from  a gonorrhuea,  either  groin 
may  be  attacked.  But  when  the  disease  originates 
from  a chancre,  the  bubo  most  frequently  takes  place 
in  the  nearest  groin. 

The  situation  of  the  absorbent  glands,  however,  is 
not  always  exactly  the  same,  and  the  course  of  the 
lymphatics  therefore  is  subject  to  some  variety.  Hence, 
Mr.  Hunter  has  seen  a venereal  bubo  produced  by  a 
chancre  on  the  penis,  situated  a considerable  way  down 
the  thigh ; he  has  also  often  seen  buboes  as  high  as  the 
lower  part  of  the  belly,  before  Poupart’s  ligament ; and 
sometimes  near  the  pubes.  At  the  present  day,  swell- 
ings of  the  femoral  glands  are  rarely  considered  to  be 
venereal. 

1 am  now  (Nov.  1829)  attending  a gentleman  who 
had  a small  sore  on  the  penis,  followed  by  a bubo  in 
each  groin ; one  of  them  restricted  to  the  femoral  glands, 
the  other  to  the  inguinal.  The  sore  was  nearly  well 
when  he  applied  to  me,  and  T desired  him,  for  the  sake 
of  security,  to  continue  the  blue  pill  and  aperient  me- 
dicines a little  while  longer.  The  ulcer  healed;  but 
the  buboes  remained  indolent  and  stationary  for  nearly 
a month  afterward,  notwithstanding  frictions  with 
camphorated  mercurial  ointment,  the  application  of 
soap  and  mercurial  plasters,  and  the  use  of  the  com- 
pound calomel  pill,  with  the  decoct,  sarsap.  c.  At 
length,  the  bubo  in  the  femoral  glands  suppurated.  I 
punctured  it,  and  a thin  fluid  was  discharged,  together 
with  flakes  of  a substance  like  wet  paper.  The  swell- 
ing underwent  some  diminution,  yet  did  not  get  com- 
pletely well,  and  emitted,  from  tiirre  to  time,  the  same 
kind  of  discharge  which  it  did  at  first.  The  other 
bubo,  however,  was  partially  resolved  without  suppu- 
rating at  all ; and,  at  the  end  of  about  two  months,  as 
the  patient  had  merely  two  chronic  indurations  in  the 
groins,  he  left  town  for  the  seaside,  in  the  hope  that 
they  would  undergo  a farther  diminution  there.  In 
two  or  three  weeks,  or  more,  instead  of  being  cured, 
he  returned  to  me  with  an  abscess  in  the  groin,  which 
had  previously  suppurated,  and  a phagedenic  ulceration, 
as  large  as  a shilling,  in  the  other  groin,  with  its  bot- 
tom and  edges  all  covered  with  white  pulpy  sloughs. 
He  had  at  the  same  time  a sore  throat,  and  an  eruption 
of  about  fifteen  spots  on  the  face,  resembling  small  biles, 
with  a conical  sloughy  elevated  point  on  each  of  them. 
There  was  also  a circular  spot,  of  large  size,  on  one  of 
the  arms,  with  a dark-coloured  slough  in  its  centre. 
The  patient  suffered  severely  from  wandering  pains  in 
his  limbs,  head,  and  even  different  parts  of  his  trunk, 
and  complained  much  of  loss  of  rest,  and  debility. 
He  now  tried  in  succession  the  nitrous  acid,  with 
compound  decoction  of  sarsaparilla,  and  the  sulphate 
of  quinine;  the  liquor  arsenicalis;  the  conium  united 
with  calomel ; the  sulphuric  acid  ; the  oxymuriate  of 
mercury  ; and  various  other  alterative  and  tonic  reme- 
dies; but  hitherto  the  only  amendment  has  been  that  of 
the  groins.  His  throat  and  the  ulcer  on  his  arm  are  much 
worse,  and  so  is  his  general  health.  During  the  last 
fortnight  he  has  been  at  Leamington,  where  he  is  at- 
tended by  Mr.  John  Pritchard,  who  has  sent  me  a very 
unfavourable  account  of  the  present  state  of  the  case. 
In  thi.s  example,  the  occurrence  of  a sloughy  surface  or 
point  in  every  appearance  which  presented  itself  led 
me  to  regard  the  disorder  as  a specimen  of  what  has 
been  termed  the  phagedenic  venereal  disease ; and  the 
circumstance  of  one  of  the  buboes  being  confined  to 
the  femoral  glands  also  inclined  me  to  the  belief,  that 
the  case  was  not  one  of  true  syphilis.  Yet,  hitherto  no 
alterative  plans  of  treatment  have  answ'ered ; and  it  re- 
mains to  be  seen  whether  the  freer  use  of  mercury, 
mercurial  fumigations  of  the  throat,  tonics,  and  a gene- 
rous diet,  and  confinement  to  the  house,  to  which  the 
patient  has  not  yet  submitted,  will  bring  about  a cure. 

The  seat  of  absorption  is  more  extensive  in  the  fe- 
male sex,  and  the  course  of  some  of  the  absorbents  is 
also  different.  Hence,  buboes  in  women  may  occur  in 
three  situations,  tw'o  of  which  are  totally  different  from 
those  in  men. 

When  chancres  are  situated  forwards  near  the  mea- 
tus urinarius,  nymphse,  clitoris,  labia,  or  mons  veneris, 
the  absorbed  matter  is  generally  conveyed  along  one  or 


VENEREAL  DISEASE. 


453 


fcoth  of  the  round  ligaments ; and  the  buboes  are  formed 
in  those  ligaments,  just  before  they  enter  the  abdomen. 
Mr.  Hunter  suspected  such  buboes  not  to  be  glandular 
ones,  but  only  inflamed  absorbents. 

When  chancres  are  situated  far  back,  near  or  on  the 
peritiaeum,  the  absorbed  matter  is  carried  forwards  along 
the  angle  between  the  labium  and  the  thigh,  to  the 

lands  in  the  groin,  and  often,  in  this  course,  small 

uboes  are  formed  in  the  absorbents,  similar  to  those 
abscesses  which  occur  on  the  penis  in  men. 

When  the  effects  of  the  poison  do  not  rest  here,  a 
bubo  in  the  groin  may  be  occasioned  in  the  same  man- 
ner as  in  men. 

Owing  to  the  difficulty  of  being  sure  that  women 
are  quite  free  from  infection,  it  is  often  more  difficult 
to  decide  in  them  than  in  men  whether  a bubo  is  vene- 
real or  not.  In  men  who  have  had  no  local  complaint, 
the  bubo  can  only  be  venereal  when  direct  absorption 
from  the  surface  of  the  skin  has  taken  place. 

A bubo,  says  Mr.  Hunter,  commonly  begins  with  a 
sense  of  pain,  which  leads  the  patient  to  examine  the 
part,  where  a small  hard  tumour  is  to  be  felt.  This 
increases  like  every  other  inflammation  that  has  a 
tendency  to  suppuration,  and  unless  checked,  pus 
forms,  and  ulceration  follows,  the  matter  making  its 
way  to  the  skin  very  fast. 

The  above  celebrated  writer  remarks,  however,  that 
some  cases  are  slow  in  their  progress.  This  circum- 
stance he  imputes  either  to  the  inflammatory  process 
being  kept  back  by  mercury  or  other  means,  or  to  its 
being  retarded  by  a scrofulous  tendency. 

The  inflammation,  he  says,  is  at  first  confined  to  the 
gland,  which  may  be  moved  about  in  the  cellular  mem- 
brane ; but  when  the  part  has  enlarged,  or  when  the 
inflammation  and  suppuration  are  more  advanced,  the 
surrounding  parts  become  more  inflamed,  and  the  tu- 
mour is  more  diffused.  Some  buboes  become  compli- 
cated with  an  erysipelatous  and  oedematous  affection, 
by  which  they  are  rendered  more  diflTused  and  less  dis- 
posed to  suppurate. 

Mr.  Hunter  allows,  that  to  distinguish  with  certainty 
the  true  venereal  bubo  from  other  swellings  of  the 
glands  in  the  groin  may  be  very  difficult.  He  represents 
the  true  venereal  bubo,  in  consequence  of  a chancre, 
as  being  most  commonly  confined  to  one  gland.  It 
preserves  its  specific  distance  till  suppuration  has  taken 
place,  and  then  becomes  more  diffused.  It  is  rapid  in 
its  progress  from  inflammation  to  suppuration  and  ul- 
ceration. The  suppuration  is  commonly  large,  consi- 
dering the  size  of  the  gland,  and  there  is  only  one  ab- 
scess. The  pain  is  very  acute,  and  the  inflamed  part 
of  the  skin  is  of  a florid  red  colour. 

Mr.  Hunter  describes  such  buboes  as  arise  without 
any  visible  cause,  as  being  of  two  kinds.  One  sort 
inflame  and  suppurate  briskly.  These  he  always  sus- 
pected to  be  venereal,  although  he  allows  there  was  no 
proof  of  it,  and  only  a presumption  deduced  from  the 
quick  progress  of  the  disease. 

The  second  kind  are  generally  preceded  and  attended 
with  slight  fever  or  the  common  symptoms  of  a cold, 
and  they  are,  for  the  most  part,  indolent  and  slow  in 
their  progress.  If  they  are  quicker  than  ordinary,  they 
become  more  diffused  than  venereal  buboes,  and  they 
are  often  not  confined  to  one  gland.  When  very  slow, 
they  give  but  little  sensation  ; but,  when  quicker,  the 
sensation  is  more  acute,  though  not  so  much  so  as  in 
venereal  cases.  They  usually  do  not  suppurate,  and 
often  become  stationary.  When  they  do  suppurate,  it 
is  in  a slow  manner,  and  frequently  in  more  glands 
than  one,  while  the  inflammation  is  more  diffused  and 
not  considerable,  in  relation  to  the  swelling.  The  mat- 
ter makes  its  way  to  the  skin  slowly,  and  the  part  af- 
fected is  of  a more  purple  colour.  Sometimes  the  ab 
scesses  are  very  large,  yet  not  painful. 

In  considering  whether  the  swellings  of  the  inguinal 
glands  are  or  are  not  venereal,  the  first  thing  to  be  at- 
tended to  is,  whether  or  not  there  are  any  venereal 
complaints.  If  there  are  none,  Mr.  Hunter  observes, 
that  there  is  a strong  presumptive  proof  that  the  swell- 
ings are  not  venereal.  When  the  swelling  is  only  in 
one  gland,  very  slow  in  its  progress,  and  gives  but  little 
or  no  pain,  it  is  probably  merely  scrofulous.  How- 
ever, when  the  swelling  is  considerable,  diffused,  and 
attended  with  some  inflammation  and  pain,  the  consti- 
tution is  most  probably  affected  with  slight  fever,  the 
symptoms  of  which  are,  lassitude,  loss  of  appetite, 
want  of  sleep,  small  quick  pulse,  and  an  appearance 


of  approaching  hectic.  Such  swellings  are  long  in 
getting  well,  and  do  not  seem  to  be  affected  by  mercury, 
even  when  promptly  applied. 

Mr.  Hunter  mentions  hi.s  having  seen  the  above  af- 
fection of  the  groiii,  together  with  the  constitutional 
indisposition,  take  place  where  there  were  chancres ; 
and  he  w’as  puzzled  to  determine,  whetlrer  the  di.sease 
in  the  groin  was  sympathetic  from  derangement  of  the 
constitution,  or  whether  it  arose  from  the  absorption  of 
matter.  He  had  long  suspected  that  there  was  a mixed 
case,  and  was  at  last  certain  that  such  a case  might 
prevail.  He  had  seen  instances,  in  which  the  venereal 
matter,  like  a cold  or  fever,  only  irritated  the  glands 
to  disease,  producing  in  them  scrofula,  to  which  they 
were  disposed. 

In  such  cases,  says  Mr.  Hunter,  the  swellings  com- 
monly arise  slowly,  give  but  little  pain,  and  if  mercury 
be  given  to  destroy  tlie  venereal  disposition,  their  pro- 
gres,s  is  accelerated.  Some  suppurate  while  under 
this  resolving  course ; and  others,  which  probably  had 
a venereal  taint  at  first,  become  so  indolent,  that  mer- 
cury has  no  effect  upon  them,  and,  in  the  end,  they 
either  get  well  of  themselves  or  by  other  means. 

According  to  Mr.  Hunter,  buboes  are  local  complaints. 

When  a bubo  is  judged  to  be  venereal,  and  only  in 
an  in^amed  state,  an  attempt  is  to  be  made  to  resolve 
the  swelling.  The  propriety  of  the  attempt,  however, 
depends  on  the  progress  which  the  disease  has  made. 
If  the  bubo  be  very  large,  and  suppuration  appears  to 
be  near  at  hand,  resolution  is  not  likely  to  be  effected. 
When  suppuration  has  already  taken  place,  Mr.  Hunter 
much  doubted  the  probability  of  any  success  attending 
the  endeavour,  which  now  may  only  retard  the  suppu- 
ration and  protract  the  cure. 

The  resolution  of  these  inflammations,  says  Mr. 
Hunter,  depends  principally  on  mercury,  and  almost 
absolutely  on  the  quantity  which  can  be  made  to  pass 
through  them.  When  suppuration  has  taken  place^ 
the  cure  also  depends  on  the  same  circumstances. 
Hence,  he  recommended  the  mercury  to  be  applied  to 
such  surfaces  as  allow  the  remedy,  when  absorbed,  to 
pass  through  the  diseased  gland.  In  this  manner  he 
conceived  that  the  disease  in  the  groin  might  be  sub- 
dued, and  that  the  constitution  would  be  less  likely  to 
be  contaminated.  At  the  same  time,  he  admitted  that 
the  situation  of  many  buboes  is  such,  as  not  to  have 
much  surface  for  absorption  beyond  them ; for  instance, 
the  buboes  on  the  body  of  the  penis,  arising  from  chan- 
cres on  the  glans  or  prepuce.  This  principle  has  been 
much  insisted  upon  by  Delpech  in  his  late  work.— 
(Chir.  Clinique,  t.  1,  p.  301.) 

As  venereal  buboes  are,  in  effect,  a consequence  of 
chancres  or  venereal  sores,  and  glandular  swellings  in 
the  groin  may  take  place  from  other  kinds  of  sores  or 
local  irritations,  and  even  from  various  constitutional 
causes,  while  modern  surgeons  profess  their  incapacity 
always  to  pronounce  the  character  either  of  a primary 
sore  or  a bubo  by  its  first  appearance  and  progress,  it 
is  evident  that  the  same  difficulties  present  themselves 
here  as  in  cases  of  primary  sores,  respecting  the  prin- 
ciples by  which  the  treatment  should  be  guided.  It  is 
likewise  to  be  remembered,  that  buboes,  when  sup- 
posed to  be  decidedly  syphilitic,  are  not,  as  Mr.  Hun- 
ter imagined,  absolutely  incurable  without  mercury. 
The  firm  confidence,  also,  which  Mr.  Hunter  had,  and 
Delpech  still  has,  in  the  doctrine  of  the  benefit  derived 
from  the  practice  of  rubbing  mercury  into  surfaces 
from  which  it  would  be  conveyed  directly  to  the  dis- 
eased glands,  so  as  boflr  to  resolve  the  swelling  and 
preserve  the  constitution,  is  not  now  regarded  as  an 
unquestionable  subiect.  As  Mr.  Racot  has  judiciously 
remarked,  there  is  some  inconsistency  in  Mr.  Hunter’s 
own  statements  upon  this  point;  for  in  one  place  he 
affirms,  that  mercury,  applied  to  the  legs  and  thighs  for 
the  cure  of  a chancre,  will  sometimes  cause,  instead  of 
dispersing,  a bubo. — (P.  404.)  And  Mr.  Bacot  believes 
himself,  that  mercury  as  frequently  promotes  the  sup- 
puration of  buboes  as  their  dispersion. — (On  Syphilis, 
p.  74.)  And  respecting  the  practice  of  trying  to  make 
the  mercury  pass  through  the  diseased  glands,  Mr.  Hun- 
ter rather  contradicts  himself  in  another  page,  where 
he  confesses  his  own  doubts  of  its  utility  in  suppurated 
buboes.  However,  he  admits  that  mercury  alone  is 
not  always  capable  of  effecting  the  cure  of  such  bu- 
boes as  are  deemed  venereal ; and  when  the  inflam- 
mation  rises  very  high,  he  approves  of  bleeding,  purg- 
ing, and  fomentations.  When  the  inflammation  is 


454 


VENEREAL  DISEASE. 


erysipelatous,  he  has  a high  opinion  of  bark ; and 
when  it  is  scrofulous,  he  praises  hemlock  and  poultices 
made  with  sea- water.  He  was  also  aware  of  the  fact 
of  emetics  sometimes  occasioning  the  absorption  of  the 
matter  of  buboes,  after  it  is  distinctly  formed. 

If  there  is  generally  great  difficulty  in  pronouncing 
nt  first  the  nature  of  a primary  sore,  as  to  the  question 
of  its  being  syphilitic  or  not,  the  same  difficulty  must 
occur  with  resp  ct  to  judging  of  the  glandular  swellings 
excited  by  it : and  on  this  account,  and  from  the  en- 
couraging circumstances  that  all  buboes  may  be  cured 
without  mercury,  and  that  the  course  of  the  venereal 
disease,  unresisted  by  that  mineral,  is  not  so  terrible 
and  incurable  as  used  to  be  supposed,  some  surgeons,  in- 
stead of  having  immediate  recourse  to  mercury,  prefer 
a little  delay,  in  order  to  see  whether  the  swelling  will 
subside  or  not  under  the  use  of  common  antiphlogistic 
means.  Thus  Dr.  Hennen  disapproves  of  using  mer- 
cury immediately  a bubo  presents  itself ; and  he  states, 
that  the  same  principle#  which  guide  him  in  the  primary 
ulcers,  would  have  the  same,  if  not  greater,  force  in 
the  case  of  buboes.  “ In  their  irritable  state  (says  he) 
I consider  mercury  jiltogether  inadmissible.” — ( On  Mi- 
litary Surgery,  ed.  2,  p.  513.) 

Although  the  correctness  of  some  of  the  principles 
by  which  Mr.  Hunter  regulated  his  practice  in  buboes 
must  now  be  questionable,  inasmuch  as  he  calcu- 
lates too  much  on  the  absolute  necessity  for  mercury, 
and  on  the  usefulness  of  making  it  pass  through  the 
diseased  glands,  I conceive  that  some  of  his  directions 
are  yet  too  important  to  be  excluded  from  this  work. 
He  says,  the  quantity  of  mercury  nece.ssary  for  the 
recolution  of  a bubo,  must  be  proportioned  to  the  ob- 
stinacy of  the  complaint ; but  that  care  must  be  taken 
Tiot  to  extend  the  employment  of  the  medicine  so  far  as 
to  produce  certain  effects  on  the  constitution.  When 
the  bubo  is  in  a situation  which  admits  of  a large 
quantity  of  mercury  being  rubbed  in,  so  as  to  pass 
through  the  swelling,  and  when  the  complaint  readily 
yields  to  the  use  of  half  a drachm  of  mercurial  oint- 
ment every  night,  the  mouth  not  becoming  sore,  or,  at 
most,  only  tender,  Mr.  Hunter  thinks  it  sufficient  to 
pursue  this  course  till  the  gland  is  reduced  to  its  na- 
tural size.  In  this  manner,  the  constitution  will  pro- 
bably be  safe,  provided  the  chancre  which  may  have 
caused  the  bubo  heal  at  the  same  time.  When  the 
mouth  is  not  affected  in  six  or  eight  days,  and  the  gland 
does  not  readily  resolve,  then  two  scruples  or  a drachm 
may  be  applied  every  night;  and,  continues  Mr.  Hun- 
ter, if  there  should  still  be  no  amendment,  even  more 
must  be  rubbed  in.  In  short  (says  he),  if  the  reduc- 
tion is  obstinate,  the  mercury  must  be  pushed  as  far 
as  can  be  done  withovt  a salivation. 

When  tliere  is  a bubo  on  each  side,  so  much  mercury 
cannot  be  made  to  pass  through  each,  as  the  constitu- 
tion in  general  will  not  bear  this  method.  However, 
Mr.  Hunter  sanctions  the  plan  of  minding  the  soreness 
of  the  mouth  less  in  this  kind  of  case;  though  he  adds, 
that  it  is  better  to  let  the  buboes  proceed  to  suppuration, 
than  to  load  the  system  with  too  much  mercury. 

When  the  situation  of  buboes  will  not  allow  an  ade- 
quate quantity  of  absorbed  mercury  to  pass  through 
them,  the  frictions  must  be  continued  in  order  to  affect 
the  constitution;  but  according  to  Mr, Hunter,  in  this 
case,  more  mercury  will  be  requisite,  than  when  the 
remedy  can  be  made  to  pass  directly  through  the 
diseased  gland ; an  assertion  which  may  now  be 
doubted. 

Many  buboes  remain  without  either  coming  to  reso- 
lution or  suppuration  : and,  notwithstanding  every  at- 
tempt to  promote  these  changes,  the  glands  become 
hard  and  scirrhous.  Mr.  Hunter  corjieivcd,  that  these 
cases  are  eitlier  scrofulous  at  first,  or  become  so  as  soon 
us  the  venereal  disposition  is  removed.  He  advises  the 
use  of  hemlock,  sea-water,  poultices,  and  oeu-bathine. 

According  to  a modern  surgeon  of  judgment  and  con- 
eiderable  experience,  when  buboes  are  iuachronie,  sta- 
tionary state,  the  application  of  blisters  to  the  swehing 
is  attended  with  the  most  beneficial  effects.  And  he 
rightly  observes,  that  when  such  tumours  are  extremely 
hard  and  indolent,  it  is  more  advantageous  to  let  the 
patient  have  the  benefit  of  the  open  air,  exercise,  and 
bis  accustomed  mode  of  living,  than  to  confine  him  in 
an  hospital.-.— C.yJ.'fsaZfin',  in  Manuald  di  Chirurgin,  p. 
64;  Milano,  1812.)  Stimulatint'  the  skin  with  the  an- 
timonial  ointment  is  also  sometimes  a good  practice. 

The  suppuratioji  of  buboes  frequently  cannot  be  pre- 


vented by  any  known  moans.  They  are  then  to  be 
treated  in  some  respects  like  any  other  abscess.  Before 
opening  buboes,  Mr.  Hunter  conceived  it  advantage- 
ous to  let  the  skill  become  as  thin  as  possible,  because 
a large  opening  w'ould  then  be  unnecessary,  and  no 
measures  requisite  for  keeping  the  skin  from  closing, 
before  the  bottom  of  the  sore  had  healed. 

Mr.  Hunter  was  doubtful,  whether  the  application 
of  mercury  should  be  continued  through  the  whole  sup- 
puration. He  was  inclined  to  continue  it;  but  in  a 
smaller  quantity. 

There  has  been  much  dispute  whether  a bubo  should 
be  opened  or  allowed  to  burst  of  itself,  and  whether 
the  opening  should  be  made  with  a cutting  instrument 
or  caustic.  On  this  subject  Mr.  Hunter  remarks,  that 
there  is  no  peculiarity  in  a venereal  abscess,  to  make 
one  practice  more  eligible  than  another.  The  surgeon, 
he  says,  should  be  guMed  in  some  degree  by  the  patient. 
Some  patients  are  afraid  of  caustic  ; others,  of  cutting 
instruments.  But  when  the  surgeon  has  the  choice, 
Mr.  Hunter  expresses  a preference  to  opening  the  bubo 
with  a lancet,  in  which  method  no  skin  is  lost.  But  he 
observes,  that  when  a bubo  is  very  large,  and  there 
will  be  a great  deal  of  loose  skin  after  the  discharge  of 
the  matter,  he  thinks  that  caustic  may  perhaps  be 
better,  as  it  will  destroy  some  of  the  redundant  skin, 
and  occasion  less  inflammation  than  what  is  caused  by 
an  incision.  The  potassa  cum  calce  is  the  caustic  com- 
monly employed. 

After  the  bubo  has  been  opened,  surgeons  usually 
poultice  it  as  long  as  the  discharge  and  inflammation 
are  considerable,  and  then  they  employ  dressings,  which 
must  be  of  a quality  adapted  to  circumstances.  In  the 
mean  while,  mercury  is  continued,  both  to  make  the 
bubo  heal,  and  prevent  the  bad  effects,  which  might 
otherwise  arise  from  the  matter  being  continually  ab- 
sorbed. 

The  mercurial  course  is  to  be  pursued  till  the  sore  is 
no  longer  venereal.  But  in  general,  since  this  point  is 
difficult  to  ascertain,  Mr.  Hunter  advises  the  continu- 
ance of  mercury  till  the  part  has  healed,  and  even 
somewhat  longer,  if  the  bubo  has  healed  very  quickly , 
for  the  constitution  is  apt  to  become  contaminated. 
However,  he  did  not  approve  of  this  long  use  of  mer- 
cury in  all  cases ; because  buboes  often  assume,  besides 
the  venereal,  other  dispositions,  which  mercury  cannot 
cure,  and  will  even  exasperate. 

Sometimes  the  sores,  when  they  are  losing,  or  en- 
tirely deprived  of  the  venereal  disposition,  become 
changed  into  ulcers  of  another  kind,  and  most  proba- 
bly of  various  kinds.  How  far  it  is  a disease  arising 
from  a venereal  taint,  and  the  effects  of  a mercurial 
course  jointly,  says  Mr.  Hunter,  is  not  certain.  He 
suspected,  however,  that  the  nature  of  the  part  or 
constitution  had  a principal  share  in  the  case;  and,  I 
believe,  few  surgeons  of  the  present  time  entertain  any 
doubt  of  the  abuse  of  mercury  being  a very  frequent 
cause,  independently  of  any  other  circumstance. — (See 
Mathias  on  the  Mercurial  Disease,  ed.  8.) 

Mr.  Hunter  observes,  that  such  diseases  make  the  cure 
of  the  venereal  affection  much  more  uncertain,  because 
when  the  sore  becomes  stationary,  or  the  mercury  be- 
gins to  disagree,  we  are  ready  to  suspect  that  the  virus 
is  gone ; but  this  (he  supposes)  is  not  always  the  case. 
He  had  seen  some  buboes  exceedingly  painful  and  ten- 
der to  almost  every  thing  that  touched  them,  and  the 
more  mild  the  dressings  were,  the  more  painful  the 
parts  became. 

In  some  instances  the  skin  alone  becomes  diseased. 
The  ulceration  spreads  to  the  surrounding  integuments, 
while  a new  skin  forms  in  the  centre,  and  keeps  pace 
with  the  ulceration,  so  that  an  irregular  sore,  w hich  Mr. 
Hunter  compares  with  a worm-eaten  groove,  is  formed 
all  round.  It  appears  only  to  have  the  power  of  con- 
taminating the  parts  which  have  not  yet  been  affected ; 
and  those  which  have,  readily  heal.  According  to  the 
same  author,  when  buboes  become  stationary,  and  aie 
little  inclined  to  spread,  attended  with  a sinus  or  two, 
hemlock,  joined  with  bark,  is  the  medicine  most  fre- 
I quently  serviceable.  It  is  to  be  used  both  externally 
and  internally.  Mr.  Hunter  also  speaks  favour- 
bly  of  sarsaparilla,  sea-bathina,  and  seawater  poul- 
tices. He  states,  that  at  the  Lock  Hospital,  gold-refi- 
ners’ water  has  been  found  a useful  application  ; and 
that,  in  some  cases,  benefit  has  arisen  from  drinking 
large  (mantities  of  orange  juice,  and  fiom  the  use  ot 
niezercon. 


VENEREAL  DISEASE. 


455 


Lues  Venerea. — Surgeons  imply,  that  a lues  venerea 
has  taken  place,  when  the  venereal  virus  has  been  ab- 
• sorbed  into  the  circulation.  Mr.  Hunter  does  not  think 
the  epithet  constitutional  strictly  proper  in  its  applica- 
tion to  this  form  of  the  venereal  disease.  By  constitu- 
tional disease,  he  observes,  he  should  understand  that 
in  which  every  part  of  the  body  is  acting  in  one  way, 
as  in  fevers  of  all  kinds  ; but  the  venereal  poison  seems 
to  be  only  diffused  through  the  circulating  fluids,  and, 
as  it  were,  to  force  certain  parts  of  the  body  to  assume 
the  venereal  action,  which  action  is  perfectly  local. 
To  use  Mr.  Hunter’s  phrase,  it  takes  place  in  different 
parts  in  a regular  succession  of  susceptibilities.  Only 
a few  parts  are  acting  at  the  same  time  ; and  a person 
may  be  constitutionally  affected  in  this  way,  and  yet 
almost  every  function  may  be  perfect. 

The  venereal  poi-son  is  generally  conveyed  into  the 
system  from  a chancre.  It  may  also,  according  to  Mr. 
Hunter’s  doctrine,  be  absorbed  from  a gonorrhoea. 
There  is  likewise  a possibility  of  its  getting  into  the  cir- 
culation from  the  surface  of  the  body,  without  any  previ- 
ous ulceration.  According  to  his  doctrine,  it  may  beab- 
sorbed  from  common  ulcers,  without  necessarily  render- 
ing them  venereal ; and  it  may  be  taken  up  from  wounds, 
in  which  cases  it  generally  first  causes  ulceration. 

Venereal  Ulcers. — In  consequence  of  the  blood  being 
contaminated  with  real  venereal  pus,  it  might  be  ex- 
pected that  the  local  effects  thus  ()roduced  would  be 
similar  in  their  nature  to  those  producing  them.  Mr. 
Hunter  believed  that  this  is  not  the  case.  He  notices, 
that  the  local  effects  from  a constitutional  contamina- 
tion are  all  of  one  kind,  viz.  ulcers,  let  the  effects 
make  their  appearance  on  any  surface  whatever,  either 
the  throat  or  commonskin.  But  Mr.  Hunter  conceived, 
that  if  the  matter,  when  in  the  constitution,  were  to 
act  upon  the  same  specific  principles  as  that  which  is 
externally  applied,  a gonorrhoea  would  arise  when  it 
affected  a canal,  and  only  sores  or  chancres  when  it  at- 
tacked other  surfaces. 

Mr.  Hunter  found,  that  even  the  sores  which  are 
caused  in  the  throat  are  very  different  from  chancres. 
He  says  that  the  true  chancre  produces  considerable  in- 
flammation, often  attended  with  a great  deal  of  pain, 
and  quickly  followed  by  suppuration.  But  the  local 
effects  arising  from  the  virus  in  the  constitution,  are 
Blow  in  their  progress,  attended  with  little  inflammation, 
and  are  seldom  or  never  painful,  except  in  particular 
parts.  However,  Mr.  Hunter  allows  that  this  sluggish- 
ness in  the  effects  of  the  poison,  depends  on  the  nature 
of  the  parts  diseased  ; and  he  owns,  that  when  the  ton- 
sils, uvula,  or  nose  are  affected,  the  progress  of  the 
morbid  mischief  is  rapid,  and  bears  a greater  resem- 
blance to  a chancre  than  when  it  occurs  on  the  skin. 
Even  in  those  parts,  Mr.  Hunter  thought,  that  the  ul- 
cers were  attenderl  with  less  inflammation  than  chan- 
cres which  were  spreading  with  equal  celerity. 

Before  the  time  of  Mr.  Hunter,  the  matter  secreted 
by  sores  w'hich  arise  from  a constitutional  infection, 
was  always  considered  to  be  of  a poisonous  quality, 
like  the  matter  of  a chancre.  At  first,  one  would  ex- 
pect that  this  must  actually  be  the  case,  because  vene- 
real matter  is  the  cause,  and  mercury  cures  chancres, 
and  also  ulcers  proceeding  from  a lues  venerea.  Mr. 
Hunter  remarks,  however,  that  the  latter  circum- 
stance is  not  a decisive  proof,  since  mercury  is  capable 
of  curing  many  diseases  besides  the  venereal.  He  also 
takes  notice,  that  when  pus  is  absorbed  from  a chan- 
cre, it  generally  produces  a bubo;  but  that  a bubo  is 
never  occasioned  by  the  absorption  of  matter  from  a 
venereal  sore  arising  from  the  virus  diffused  in  the 
circulation.  For  instance,  when  there  is  a venereal 
ulcer  in  the  throat,  no  buboes  occur  in  the  glands  of  the 
neck;  when  there  are  syphilitic  sores  on  the  arms,  or 
even  suppurating  nodes  of  the  ulna,  no  swellings  form 
in  the  glands  of  the  armpit,  although  these  complaints 
occur  when  fresh  venereal  matter  is  applied  lo  a com- 
mon sore  on  the  arm,  hand,  or  fingers.  No  swelling  is 
produced  in  the  groin  in  consequence  of  nodes,  or 
blotclies  on  the  legs  and  thighs. 

Some  very  important  experiments  are  related  in  Mr. 
Hunter’s  Treatise  on  the  Venereal  Disease^  in  order  lo 
prove  that  the  matter  from  a gonorrhoea,  or  chancre,  is 
capable  of  affeciiiig  a man  locally,  who  is  already  la- 
bouring under  a lues  venerea,  and  that  the  matter  from 
secondary  syphilitic  sores  has  not  the  same  power. 
The  particulars,  however,  are  too  long  lobe  inserted  in 
this  book. 


Parts  most  susceptible  of  the  Lues  Venerea^  See.— 
Some  parts  of  the  body  seem  to  be  much  less  susceptible 
of  lues  venerea  than  others;  indeed,  Mr  Hunter  ob- 
serves, that,  as  far  as  our  knowledge  extends,  certain 
parts  cannot  be  affe'eted  at  all.  The  brain,  heart,  sto- 
mach, liver,  kidneys,  and  several  other  viscera,  have 
never  been  known  to  be  attacked  by  syphilis. 

The  first  order  of  parts,  or  those  which  become  af- 
fected in  the  early  stage  of  lues  venerea,  are,  the  skin, 
tonsils,  nose,  throat,  inside  of  the  mouth,  and  some- 
times the  tongue. 

The  second  order  of  parts,  or  those  which  are  affected 
at  a later  period,  are,  the  periosteum,  fasciae,  and  bones. 

Mr.  Hunter  conceived,  that  one  great  reason  for  the 
superficial  parts  of  the  body  suffering  the  effects  of  the 
lues  venerea  sooner  than  the  deep-seated  ones,  depends 
on  the  former  being  more  exposed  to  external  cold.  He 
remaiked,  that  even  the  second  order  of  parts  do  not 
all  become  diseased  at  the  same  time,  nor  every  where 
at  once.  But,  on  the  contrary,  such  as  are  nearest 
the  external  surface  of  the  body  are  first  diseased, 
as,  for  instance,  the  periosteum,  bones  of  the  head,  the 
tibia,  ulna,  bones  of  the  nose,  &;c.  Neither  does  the 
disease  affect  these  bones  equally  on  all  sides  ; but  first 
on  that  side  which  is  next  to  the  external  surface.  It 
was  Mr.  Hunter’s  belief,  however,  that  the  susceptibi- 
lity of  particular  bones  did  not  altogether  depend  upon 
their  nearness  to  the  skin  ; but  upon  this  circumstance 
and  their  hardness  together. 

The  foregoing  account  by  no  means  agrees  with  the 
results  of  modern  inquiries  into  the  nature  of  the  vene- 
real disease ; for  unless  mercury  be  given,  it  appears  that 
the  bones  are  very  seldom  affected  by  it.  Thus,  in  the 
cases  which  were  treated  by  Mr.  Rose  without  mercury, 
he  observes,  that  “the  constitutional  symptoms  were 
evidently  not  such  as  could  be  regarded  as  venereal,  if 
we  give  credit  to  the  commonly  received  ideas  on  the 
subject.  Caries  of  the  bones,  and  some  of  the  least 
equivocal  symptoms,  did  not  occur.  In  no  instance 
was  there  that  uniform  progress,  with  unrelenting  fury, 
from  one  order  of  symptoms  and  parts  affected  to 
another,  which  is  considered  as  an  essential  character- 
istic of  true  syphilis.” — {Med.  Chir.  Trans,  vol.  8,  p. 
423.)  We  learn  also  from  Mr.  Guthrie,  that  the  bones 
were  not  affected  in  any  of  the  cases  cured  entirely 
without  mercury  in  the  York  Hospital,  though  there 
were  several  other  cases  admitted,  “ in  which  a few 
mercurial  pills  had  been  taken,  and  the  mouth  not  af- 
fected, and  in  which  the  primary  symptoms  were  fol- 
lowed by  eruptions,  both  papular  and  scaly,  by  ulcers  in 
the  threat,  by  nodes,  and,  in  one  case,  by  inflammation 
of  the  periosteum  covering  the  bones,  and  ulceration  of 
the  septum  nasi,  although  mercury  was  resorted  to  for 
its  cure."— {Vol.  cit.  p.  560.)  The  late  Sir  Patrick 
M'Gregor,  however,  informed  me  of  one  or  two  cases, 
in  which  a node  took  pace,  though  no  mercury  had  been 
used.  The  occurrence,  at  all  events,  seems  to  be  rare. 

In  the  examples  treated  without  mercury,  under  the 
superintendence  of  Dr.  Hennen,  this  gentleman  did  not 
see  “ a single  case  in  which  the  bones  of  the  nose  were 
affected;  some  cases  of  periostitis,  and  of  pains  and 
swellings  of  the  bones  of  the  cranium  and  extremities, 
were  met  with  ; but,  except  in  two,  he  never  remarked 
any  nodes  which  could  be  regarded  as  unequivocally 
syphilitic."  One  of  those  yielded  to  blisters  and  sar- 
saparilla; the  other,  after  resisting  guaiacum  and  su- 
dorifics,  was  dispersed  by  mercury.— ( Ore  Military 
Surgery,  ed.  2,  p.  581.)  Dr.  Henneii’s  statement  on 
this  subject  would  have  been  more  satisfactory,  had  it 
comprised  his  opinion  of  the  characters  of  an  une- 
quivocally syphilitic  node.  On  the  whole,  it  appears 
tolerably  certain  that  mercury,  especially  when  em- 
ployed unmercifully,  and  even  when  employed  in  mo- 
deration, and  the  patient  exposes  liimself  to  damp  and^ 
cold,  tends  to  promote  the  frequency  of  nodes,  as  a 
sequel  of  the  venereal  disease ; though  as  the  long  and 
abundant  use  of  the  same  mineral  does  not  cause  the 
same  consequence  after  other  complaints,  and  venereal 
ulcers,  treated  altogether  without  mercury,  rarely  lead 
to  nodes,  it  would  seem  .as  if  these  swellings  were  the 
product  of  the  combined  .action  of  syphilis  and  mer- 
cury together.  The  infrequency  of  nodes  in  the  strictly 
non-mercurial  practice,  is  one  of  the  most  important 
facts  yet  established  in  it.s  favour,  and  it  is  curious  to 
find,  from  some  quotations  made  by  Dr.  Hennen,  that 
it  was  w'ell  known  in  former  days.  Fallopius,  in  his 
90th  chap.  iJe  Ossium  Corriiptione,  speaking  of  the 


456 


VENEREAL  DISEASE. 


loss  of  the  bones  of  the  nose  and  palate,  says,  “Et 
sciatis  quod  non  in  omni  inveterato  gallico  hoc  fit,  sed 
tantum  in  illis,  in  quibus  inunctio  facta  cst  cum  hy- 
drargyro."  And  Fernelius,  in  speaking  of  the  in- 
jurious effects  of  mercury,  observes,  “ Recidiva  raro 
similis  est  radici  neque  iisdeni  symptomatis  exercet, 
ged  fere  distillatione,  arthritide  tophis,  vel  ossium 
carie.” — {^phrodisiacus,  vol.  3,  p.  146.)  And  Palma- 
rius,  in  considering  the  affection  of  the  bones,  as  Dr. 
Hennen  has  noticed,  uses  the  following  remarkable 
words : “ Sed  hoc  iis  dunlaxat  contingit,  qui  olim  a lue 
venerea  hydrargyrosi  vinditati  putarenlur,  non  qui  de- 
coclo  guaiacino  et  alexipharmaco  curati  fuissent.”— 
(De  Morb.  Contagiosis,  cap.  7,  lib.  2,  p.  124 ; Parisiis, 
1578.)  Dr.  Hennen  expresses  his  own  conviction,  in 
which  I entirely  agree,  that  the  carious  affections  of 
the  bones  which  are  so  common  in  persons  treated  by 
long  mercurial  courses,  proceed,  not  from  the  disease, 
but  from  the  remedy  rapidly  and  irregularly  thrown  in 
while  periostitis  exists : and  he  has  not  seen  a single 
case  of  carious  bone  in  the  military  hospitals  since  the 
non-mercurial  treatment  was  adopted,  except  where 
mercury  had  formerly  been  used. — (Ora  Military  Sur- 
gery, ed.  2,  p.  505,  506.) 

Nor  will  the  results  of  modern  experience  and  in- 
quiries, made  on  a very  extensive  and  impartial  scale, 
allow  us  to  consider  the  venereal  disease  as  regularly 
and  unavoidably  leading  to  any  secondary  symptoms, 
even  though  no  medicine  at  all  be  employed  for  their 
prevention.  This  is  fully  exemplified  in  the  official 
reports  of  the  army  hospitals.  The  particulars  of 
5000  cases,  spoken  of  by  Sir  James  M'Grigor  and  Sir 
W.  Franklin,  lead  to  the  opinion,  that  “ the  fre- 
quency or  rarity  of  secondary  symptoms  would  seem 
to  depend  on  circumstances  not  yet  sufficiently  under- 
stood or  explained,  although  the  following  fact  would 
tend  to  the  belief,  that  either  the  constitutions  of  the 
men,  or  the  mode  of  conducting  the  treatment  without 
mercury,  are  the  causes  that  possess  the  greatest  in- 
fluence in  their  production.  In  one  regiment,  four 
secondary  cases  out  of  24,  treated  without  mercury, 
supervened.”  In  another  regiment,  68  cases  were 
treated  without  mercury,  ail  bearing  marks  of  the  true 
venereal  disease  (and  28  of  them  especially  selected  for 
their  decided  characters  of  chancre),  yet  no  secondary 
symptoms  of  any  kind  had  taken  place  fifteen  months 
after  the  treatment  had  ceased.  The  same  document, 
founded  on  the  above  large  number  of  cases,  confirms 
another  fact,  that  no  peculiar  secondary  symptoms 
follow  peculiar  primary  symptoms ; a conclusion  which 
is  directly  adverse  to  Mr.  Carmichael’s  opinions,  of 
which  I have  taken  more  notice  in  another  work. — 
(See  First  Lines  of  the  Practice  of  Surgery,  ed.  5.) 

According  to  Mr.  Hunter,  the  titne  necessary  for  the 
appearance  or  production  of  the  local  effects  in  parts 
most  susceptible  of  the  disease,  after  the  virus  has 
passed  into  the  constitution,  is  generally  about  six 
weeks ; but  in  many  cases  the  period  is  much  longer ; 
while  in  other  instances  it  is  shorter.  Sometimes  the 
local  effects  make  their  appearance  within  a fortnight 
after  the  possibility  of  absorption. 

The  effects  on  other  parts  of  the  body  which  are  less 
susceptible  of  the  venereal  irritation,  or  slower  in  their 
action,  says  Mr.  Hunter,  are  much  later  in  making 
their  appearance.  And  when  the  first  and  second 
order  of  parts  are  both  contaminated,  the  effects  gene- 
rally do  not  begin  to  appear  in  the  latter  till  after  a 
considerable  time,  and  sometimes  not  till  those  affect- 
ing the  former  parts  have  been  cured. 

Mr.  Hunter,  however,  refers  to  instances  in  which 
the  periosteum  or  bone  was  affected  before  any  of  the 
first  order  of  parts;  but  he  was  uncertain  whether  the 
skin  or  throat  would  afterward  have  become  diseased, 
as  the  disorder  was  not  allowed  to  go  on. 

According  to  Delpech,  the  principal  morbid  effects 
produced  on  the  bones  by  syphilis,  are  periostoses,  ex- 
ostoses, and  necrosis.  As  for  caries,  which  has  been 
commonlv  set  down  as  a consequence  of  the  disease, 
he  says,  tliat  authors  have  generally  mistaken  necrosis 
for  it ; and  that  the  pretended  examples  of  caries  of 
the  bones  of  the  nose  and  palate  are  in  fact  more  or 
less  extensive  denudations  and  mortifications  of  the 
maxillary  and  turbinated  bones,  the  septum  nasi,  &c. 
— (See  Chir.  Clin.  t.  1,  p.  355.) 

Venereal  Eruptions. — The  whole  tenor  of  various 
facts,  specified  in  the  foregoing  columns,  tends  to 
piove  that  what  is  usually  called  the  venereal  disease, 


is  in  reality  several  diseases  modified  also  by  constitu- 
tion, climate,  regimen,  and  mode  of  treatment.  And 
hence,  perhaps,  the  chief  source  of  all  the  perplexity 
and  uncertainty  which  are  yet  so  manifest,  as  fully  to 
justify  the  doubt  sometimes  entertained,  whether  any 
disease,  corresponding  to  the  foimer  notions  of  syphi- 
lis, really  exists.  ^Were  any  proof  of  the  truth  of  this 
reflection  needed,*  in  addition  to  the  many  other  proofs 
of  it  already  premised,  the  subject  of  venereal  erup- 
tions would  at  once  furnish  it;  for  here  no  kind  of  re- 
gularity can  be  traced,  neither  in  the  appearances  on 
the  skin  abstractedly  considered,  nor  in  the  connexion 
between  certain  kinds  of  primary  ulcers  and  particular 
forms  of  cutaneous  disease.  Nay,  as  I have  noticed 
in  the  preceding  pages,  sometimes,  in  consequence  of 
a primary  venereal  sore,  difierent  kinds  of  eruptions 
form  together  or  successively  on  one  individual ; and, 
as  far  as  one  can  judge  by  the  eye,  exactly  the  same 
kind  of  chancre  may  produce  very  different  eruptions 
in  different  persons,  even  though  treated  on  precisely 
the  same  plan.  These  circumstances  are  truly  con- 
fusing. In  Mr.  Rose’s  paper,  however,  there  is  a par- 
tial confirmation  of  one  part  of  Mr.  Carmichael’s 
theory,  viz.  the  frequency  of  papular  eruptions  after 
simple  primary  ulcers,  or  superficial  sores,  which  rea- 
dily heal.  According  to  the  latter  gentleman,  this  form 
of  eruption  may  also  follow  gonorrhoea,  and  is  gene- 
rally preceded  by  fever,  and  ends  in  desquamation, 
Whatever  may  be  the  degree  of  truth  respecting  the 
relation  between  this  kind  of  eruption  and  the  alleged 
primary  complaints,  the  practice  recommended  by  Mr. 
Carmichael  for  such  cases  is  judicious.  General 
blood-letting  is  recommended  when  there  is  fever,  and 
the  medicines  praised  are  antimonials  and  sarsaparilla. 
Afterward,  when  the  fever  subsides,  and  the  eruption 
desquamates,  an  alterative  course  of  antimony  and 
calomel,  it  is  said,  will  accelerate  the  cure,  though  not 
absolutely  necessary.  In  cases  of  venereal  pustular 
eruptions,  supposed  by  Mr.  Carmichael  to  be  most  fre- 
quent after  chancres  with  elevated  edges,  without  in- 
duration, blood-letting  is  also  advised  during  the  febrile 
stage,  followed  by  antimonials,  sarsaparilla,  guaiacum, 
tar-ointment,  baths  of  sulphurated  potassa,  or  the  nitro- 
muriatic  bath ; and  after  the  pustules  have  terminated 
in  scaly  blotches,  alterative  doses  of  mercury,  con- 
joined with  sarsaparilla  or  guaiacum.  An  eruption 
of  tubercles,  or  spots  of  a pustular  tendency,  or  of 
both  intermixed,  preceded  by  fever,  and  terminating  in 
ulcers  covered  with  thick  crusts,  complaints  which 
Mr.  Carmichael  considers  a sequel  rather  of  the  phage- 
denic than  other  chancres,  he  treats  at  first  by  blood- 
letting, followed  by  antimonials,  sarsaparilla,  guaia- 
cum, compound  powder  of  ipecacuanha,  arseniate  of 
potassa,  nitrous  acid,  and  nitro-muriatic  bath.  Mer- 
cury is  said  to  be  hurtful  except  in  the  last  stage.  To 
scaly  blotches,  which  he  conceives  to  be  a sequel  of 
the  true  chancre  or  callous  ulcer,  he  applies  the  same 
local  treatment  as  to  pustular  eruptions,  and  he  deems 
the  question,  whether  sarsaparilla  and  guaiacum 
might  here  be  substituted  for  mercury,  yet  unsettled. — 
(See  Obs.  on  the  Symptoms,  &-c.  of  Venereal  Diseases, 
S7jnopsis,  p.  205,  &c.)  The  investigations  made  in  the 
military  hospitals  decidedly  prove,  that  all  kinds  of 
eruptions,  supposed  to  be  venereal,  may  be  cured  with- 
out mercury  ; but,  I believe,  the  great  and  superior  use- 
fulness of  moderate  quantities  of  mercury,  for  the  re- 
moval of  the  scaly,  copper-coloured  blotches,  is  still 
generally  acknowledged.  But  even  in  these  cases  of 
copper-coloured  spots,  Mr.  Bacot’s  advice  may  be  good, 
viz.  when  the  general  health  is  much  deranged,  the 
tongue  loaded  and  furred,  and  the  appetite  gone,  to 
defer  mercury  “ until,  by  proper  evacuations  and  atten- 
tion to  the  general  health,”  the  patient  has  had  the 
benefit  of  a delay,  “ which  will,  in  many  instances, 
render  all  farther  medical  treatment  unnecessary.  It 
is  undoubtedly  true,  that  whatever  plan  be  pursued, 
these  eruptive  symptoms  will  eventually  disappear; 
still,  where  they  continue  to  linger  for  a long  time,  and 
are  attended  with  their  usual  accompaniments  of  great 
languor,  debility,  and  disturbed  rest,  I neither  know, 
nor  can  I understand,  the  advantage  of  delaying  that 
remedy  which  repeated  experience  has  taught  me  to 
rely  upon,”  &c. — (Bacoton  S7jphilis,p.  99.)  Although 
Mr.  Carmichael’s  practice  seems  good,  his  theory  about 
the  connexion  of  certain  sores  with  particular  erup- 
tions and  other  peculiar  secondary  symptoms,  appears 
to  be  nearly  refuted  by  the  late  investigations  nrade  in 


VENEREAL  DISEASE. 


457 


the  military  hospitals.  To  some  facts  relating  to  this 
question  I have  already  adverted. 

There  is  as  little  certainty  about  the  essential  cha- 
racters of  syphilitic  eruptions,  as  about  the  test  of 
every  other  symptom  of  the  venereal  disease  or  rather 
diseases.  While  Mr.  Hunter  describes  the  eruption  as 
generally  occurring  over  the  whole  body,  Dr.  Bateman 
states,  that  syphilitic  affections  of  the  skin  commonly 
make  their  first  appearance  on  the  face,  where  they  are 
usually  copious,  and  on  the  hands  and  wrists. — (^Pract. 
Synopsis  of  Cutaneous  Diseases,  p.332,  ed.  3.)  Tlieir 
colour,  he  says,  is  in  general  less  livid  than  that  of  or- 
dinary eruptions,  being  of  a brownish-red  of  different 
shades ; but  that  this  is  not  universal ; for  some  of  the 
syphilitic  ecthyinata  have  a bright  red  base  in  the  be- 
ginning. Exposure  to  cold  accelerates  their  progress 
and  increases  their  extent ; while,  on  the  other  hand, 
warmth  retards  and  ameliorates  them. — (P.  333.)  Ac- 
cording to  Hunter,  the  discolorations  make  the  skin 
appear  mottled,  and  many  of  the  eruptions  disappear, 
while  others  continue  and  increase  with  the  disease. 

In  other  cases,  the  eruption  comes  on  in  distinct 
blotches,  which  are  often  not  observed  till  the  scurf  has 
begun  to  form.  At  other  times,  the  eruption  assumes 
the  appearance  of  small  distinct  inflammations,  con- 
taining matter  and  resembling  pimples,  not  being,  how- 
ever, so  pyramidal  nor  so  red  at  the  base.  Mr.  Hunter 
also  observes,  that  venereal  blotches,  on  their  first 
coming  out,  are  often  attended  with  inflammation, 
which  gives  them  a degree  of  transparency  which  is 
generally  greater  in  the  summer  than  the  winter,  espe- 
cially if  the  patient  be  kept  warm.  In  a little  time, 
this  inflammation  disappears,  and  the  cuticle  peels  off 
in  the  form  of  a scurf.  The  latter  occurrence  often 
misleads  the  patient  and  the  surgeon,  who  look  upon 
this  dying  away  of  the  inflammation  as  a decay  of  the 
disease,  till  a succession  of  scurfs  undeceives  them. 

The  parts  affected  next  begin  to  form  a copper- 
coloured,  dry,  inelastic  cuticle,  called  a scurf  or  scale. 
This  is  thrown  off  and  new  ones  are  formed,  which 
spread  to  the  breadth  of  a sixpence  or  shilling;  but 
seldom  more  extensively,  at  least  for  a considerable 
time.  In  the  mean  while,  every  succeeding  scale  be- 
comes thicker  and  thicker  till  at  last  it  becomes  a com- 
mon scab.  Then  the  disposition  for  the  formation  of 
the  matter  takes  place  in  the  cutis  underneath,  and  a 
true  ulcer  is  produced,  which  commonly  spreads, 
although  in  a slow  way. 

When  the  affected  part  of  the  skin  is  opposed  by 
another  portion  of  skin,  which  keeps  it  in  some  degree 
more  moist,  as  between  the  nates,  about  the  arms,  be- 
tween the  scrotum  and  the  thigh,  iti  the  angle  between 
the  two  thighs,  on  the  red  part  of  the  lip,  or  in  the  arm- 
pits,  the  eruptions,  instead  of  being  attended  with 
scurfs  and  scabs,  are  accompanied  with  an  elevation 
of  the  skin,  which  is  swollen  with  exlravasaied  lymph 
into  a white,  soft,  moist,  flat  surface,  which  discharges 
a white  matter. — {Hunter.) 

Sir  Anthony  Carlisle  has  pointed  out  what  he  terms 
an  herpetic  abrasion  of  the  cuticle  on  the  breast  or 
abdomen,  having  the  appearance  of  venereal  blotches. 
He  states  that  it  is  less  deep  in  the  skin;  that  it  has 
less  of  an  inflammatory  base  ; and  that  it  is  not  so  dis- 
tinctly circumscribed  as  the  true  venereal  blotch.  It 
never  forms  a purulent  crust;  but  is  simply  a furfura- 
ceous  scaling  of  the  cuticle.  This  form  of  disease 
seems  to  him  to  be  produced  by  a disordered  stomach 
and  liver. — (See  Lond.  Med.  Reposit.vol.  7,  p.  92.) 

A venereal  eruption  often  attacks  that  part  of  the 
fingers  on  which  the  nail  is  formed.  Here  the  disease 
renders  the  surface  red,  which  is  seen  shining  through 
the  nail;  and  if  allowed  to  continue,  a separation  of 
the  nail  takes  place. 

When  surfaces  of  the  body  covered  with  hair  are 
attacked,  the  hair  separates,  and  cannot  be  reproduced 
as  long  as  the  disease  lasts. 

Mr.  Welbank  describes  the  true  syphilitic  eruption, 
as  consisting  of  firm  and  slightly  elevated  spots,  from 
which  pellicles  or  scales  are  from  the  commencement 
successively  detached.  These  spots  are  thick  about 
the  scalp,  chin,  forehead,  and  upper  and  inner  part  of 
the  thighs.  Where  there  is  hair,  they  frequently  form 
slightly  elevated  crusts  of  a pale  colour.  On  the  palms 
of  the  hands,  or  soles  of  the  feet,  they  are  charac- 
terized by  a thick,  honeycomb  desquamation  of  the 
dense  cuticle.  They  are  more  disposed  to  superficial 
ulceration,  when  confluent,  or  situated  between  opposed 


and  secreting  surfaces,  as  the  angles  of  the  mouth, 
scrotum,  and  thigh,  &c. — (See  Med.  Chir,  Trans,  vol. 
13,/>.  569.) 

It  must  be  allowed,  that  it  is  frequently  very  difficult 
to  say,  whether  an  eruption  is  syphilitic  or  not,  and  an 
opinion  should  rather  be  formed  from  the  history  of 
the  case  than  from  any  particular  appearance  of  the 
eruption  itself.  As  Dr.  Bateman  has  remarked,  the 
cutaneous  eruptions,  which  are  the  result  of  the  vene- 
real poison,  are  often  the  source  of  considerable  embar- 
rassment to  the  practitioner.  They  assume  such  a 
variety  of  forms,  that  they  bid  defiance  to  any  arrange- 
ment founded  upon  their  external  character;  and,  in 
fact,  they  possess  no  common  or  exclusive  marks,  by 
which  their  nature  and  origin  are  indicated.  There  is, 
perhaps,  no  order  of  cutaneous  appearances,  and 
scarcely  any  genus  or  species  of  the  chronic  eruptions, 
which  these  secondary  symptoms  of  syphilis  do  not 
occasionally  resemble.  Dr.  Bateman  admits,  however, 
that,  in  many  cases,  there  is  a difference,  which  a prac- 
tised eye  will  recognise,  between  the  ordinary  diseases 
of  the  skin  and  the  syphilitic  eruptions,  to  which  the 
same  generic  appellation  might  be  given.  This,  says 
he,  is  often  observable  in  the  shade  of  colour,  in  the 
situation  occupied  by  the  eruption,  in  the  mode  of  its 
distribution,  and  in  the  general  complexion  of  the  pa- 
tient. Hence,  to  a person  conversant  with  those  ordi- 
nary diseases,  a degree  of  anomaly  in  these  respects 
will  immediately  excite  a suspicion,  which  will  lead 
him  to  investigate  the'  history  of  the  progress  of  such 
an  eruption,  and  of  its  concomitant  symptoms.— (See 
Bateman's  Practical  Synopsis  of  Cutaneous  Diseases, 
p.  331,  332,  edit.  3.) 

Dr.  Hennen  does  not  pretend  to  be  able  to  discri- 
minate the  true  syphilitic  eruptions  from  others,  and, 
indeed,  by  what  criterion  they  are  to  be  known,  I am 
myself  entirely  puzzled  to  comprehend,  after  the  nu- 
merous facts  so  fully  established  by  recent  experimental 
inquiries.  Dr.  Hennen  generally  approves  of  deferring 
the  use  of  mercury  at  first,  in  order  to  see  whether 
these  cutaneous  affections  will  yield  to  other  means; 
" but  (says  he)  I should  not  very  long  postpone  the  em- 
ploymentof  the  mildest  mercurial  alteratives,  aided  by 
warm  bathing  and  sudorifics.” — ( On  Military  Surgery, 
ed.  2,  p.  518.) 

Venereal  Disease  of  the  Throat,  Mouth,  and  Tongue. 
—In  the  throat,  tonsils,  and  inside  of  the  mouth,  the 
disease  is  said  by  Mr.  Hunter  generally  to  make  its 
appearance  at  once  in  the  form  of  an  ulcer,  without 
much  previous  tumefaction.  Consequently,  the  tonsils 
are  not  much  enlarged. 

A venereal  ulcer  in  the  throat  was  supposed,  by  the 
same  author,  to  be  in  general  tolerably  well  marked, 
though  he  confesses,  that  it  may  not  in  every  instance 
be  distinguished  from  an  ulcer  of  a different  nature. 
Several  diseases  of  the  throat,  he  remarks,  do  not  pro- 
duce ulceration  on  the  surface.  One  is  common 
inflammation  of  the  tonsils.  The  inflamed  place  often 
suppurates  in  the  centre,  so  as  to  form  an  abscess, 
which  bursts  by  a small  opening  ; but  never  looks  like 
an  ulcer  that  has  begun  superficially,  like  a true  vene- 
real sore.  The  case  is  always  attended  with  too  much 
inflammation,  pain,  and  tumefaction  of  the  parts  to  be 
venereal.  Also,  when  it  suppurates  and  bursts,  it  sub- 
sides directly,  and  it  is  generally  attended  with  other 
inflammatory  symptoms  in  the  constitution. 

Mr.  Hunter  then  notices  an  indolent  tumefaction  of 
the  tonsils,  peculiar  to  many  persons,  whose  constitu- 
tions are  disposed  to  scrofula.  The  complaint  produces 
a thickness  in  the  speech.  Sometimes  coagulable 
lymph  is  thrown  out  on  the  surface  of  the  parts 
affected,  and  occasions  appearances  which  are  by  some 
called  ulcers  ; by  some,  sloughs ; and  by  others,  putrid 
sore  throats.  The  case  is  attended  with  too  much 
swelling  to  be  venereal,  and.  with  a little  care,  it  may 
easily  be  distinguished  from  an  ulcer  or  loss  of  sub- 
stance. However,  when  this  difference  is  not  obvious 
at  first  sight,  it  is  proper  to  endeavour  to  remove  some 
of  the  lymph,  and,  if  the  surface  of  the  tonsil  under- 
neath should  appear  to  be  free  from  ulceration,  we  may 
conclude  with  certainty  that  the  disease  is  not  venereal. 
Mr.  Hunter  states,  that  he  has  seen  a chink  filled  with 
coagulable  lymph,  so  as  to  appear  very  much  like  an 
ulcer  ; but,  on  removing  that  substance,  the  tonsil  un- 
derneath was  found  perfectly  sound.  He  adds,  that  he 
has  seen  cases  of  a swelled  tonsil  having  a slough  in 
its  centre,  which  slough,  before  its  detachment,  looked 


VENEREAL  DISEASE. 


4sa 

very  like  a foul  ulcer.  The  stage  of  tlie  complaint,  he 
says,  is  even  more  puzzling  when  the  slough  has  come 
out ; for  then  the  disease  has  most  of  the  characters  of 
the  venereal  ulcer.  Whenever  he  met  with  the  disease 
in  its  first  stage,  he  always  treated  it  as  if  it  had  been 
of  the  nature  of  erysipelas,  or  a carbuncle.  When  the 
complaint  is  in  its  second  stage,  without  any  preceding 
local  symptoms,  he  recommends  the  practitioner  to 
suspend  his  judgment,  and  to  wait  a little,  in  order  to 
see  how  far  nature  is  able  to  relieve  itself.  If  there 
sltould  have  been  any  preceding  fever,  the  case  is  still 
less  likely  to  be  venereal.  Jlr.  Hunter  informs  us,  that 
he  has  seen  a sore  throat  of  this  kind  mistaken  for  a 
venereal  case,  and  mercury  given  until  it  affected  the 
mouth,  when  the  medicine  brought  on  a mortification 
of  all  the  parts  concerned  in  the  first  disease. 

Another  complaint  of  these  parts,  which  Mr.  Hunter 
represents  as  being  often  taken  for  a venereal  one,  is 
an  ulcerous  excoriation,  which  runs  along  their  surface, 
becoming  very  broad  and  sometimes  foul,  having  a 
regular  termination,  but  never  going  deeply  into  the 
substance  of  the  parts,  as  Mr.  Hunter  believes  the  ve- 
nereal ulcer  does.  No  part  of  the  inside  of  the  mouth 
is  exempt  from  this  ulcerous  excoriation ; but,  according 
to  Mr.  Hunter,  the  disease  most  frequently  occurs  about 
the  root  of  the  uvula,  and  spreads  forwards  along  the 
palatum  molle.  He  remarks,  that  the  complaint  is  evi- 
dently not  venereal,  since  it  does  not  yield  to  mercury. 
He  has  seen  these  ulcerous  excoriations  continue  for 
weeks,  without  undergoing  any  change,  and  a true 
venereal  ulcer  make  its  appearance  on  the  surface  of 
the  excoriated  part.  He  says  that  such  excoriations 
were  cured  by  bark,  after  the  end  of  the  mercurial 
course,  by  which  the  syphilitic  sore  was  cured. 

This  author  describes  the  tiue  venereal  ulcer  in  the 
throat,  as  a fair  loss  of  substance, part  being  dug  out, 
as  it  were,  from  the  body  of  the  tonsil:  it  has  a deter- 
minate edge,  and  rs  commonly  very  foul,  having  thick 
white  matter,  like  a slough,  adhering  to  it,  and  not  ad- 
mitting of  being  washed  away. 

According  to  the  experience  of  one  late  writer,  the 
ulceration  of  the  tonsil  is  attended  with  little  pain  at 
first,  and  excavates  the  part  deeply,  and  often  in  a tri- 
angular form,  as  if  the  tonsil  were  split.  It  slowly 
acquires  a smooth  bluffy  surface. — {Welbank,  in  Med. 
Chir.  Trans,  vol.  13,  p.  569.) 

Here,  however,  as  in  most  other  supposed  forms  of 
syphilis,  some  test  is  wanting,  by  which  the  case  may 
be  certainly  distinguished  from  other  diseases  of  the 
throat  presenting  similar  appearances : for,  as  Mr.  Rose 
has  very  truly  remarked,  “ the  excavated  ulcer  of  the 
tonsils,  as  described  by  Mr.  Hunter,  is  not,  as  Mr.  Car- 
michael seems  to  think,  a peculiar  symptom  of  the 
presence  of  the  syphilitic  virus.  I have  repeatedly 
seen  it,  as  well  as  the  scaly  blotch,  in  cases  where  mer- 
cury had  been  freely  employed  for  the  primary  sores, 
and  in  which  I considered  the  virus  as  eradicated,  and 
both  have  disappeared  under  the  use  of  sarsaparilla.” 
—{Med.  Chir.  Trans,  vol.  8,  p.  421.)  In  a recent  work, 
Mr.  Carmichael  himself  acknowledges  the  justice  of 
the  preceding  observation,  and  owns  that  since  the  pub- 
lication of  his  Essays,  he  has  often  noticed  the  exca- 
vated ulcer  of  the  tonsils,  either  attending  the  primary 
phagedenic  ulcer  or  the  train  of  constitutional  symp- 
toms which  arise  from  it. — ( On  the  Symptoms,  iS-c.  of 
Venereal  Diseases,  p.  17.)  In  affections  of  the  throat, 
Dr.  Hennen  states,  that  he  “ would  be  more  guarded 
than  in  any  others  in  the  employment  of  mercury, 
until  all  inflammatory  disposition  was  removed.” 
Afterward  he  has  seen  them  yield,  “ as  if  by  magic,  so 
soon  as  the  local  effects  of  mercury  on  the  parts  within 
the  mouth  became  obvious.”  But,  when  mercury  was 
given  earlier,  he  has  seen  a vast  number  of  instances 
in  which  irremediable  mischief  was  done. — {On  Mili- 
tary Surgery,  ed.  2,  p.  518.) 

According  to  Hunter,  lues  venerea  sometimes  pro- 
duces a thickening  and  hardening  of  the  tongue,  but 
frequently  ulceration,  as  in  other  parts  of  the  mouth. 
He  describes  venereal  sores  on  the  tongue  as  generally 
more  painful  than  those  on  the  skin  ; but  less  so  than 
common  sore  throats  from  inflamed  tonsils.  They 
oblige  the  patient  to  speak  thick,  as  if  his  tongue  were 
too  large  for  his  month,  with  a small  degree  of  snuffling. 

Mr.  Hunter  doubted  the  reality  of  a venereal  oph- 
thalmy  ; but,  that  one  form  of  iritis  is  of  this  nature,  is 
at  present  a fact  universally  admitted.  Sec  the  subject 
of  iritis,  in  the  article  Ophthabny. 


Symptoms  of  the  second  stage  of  Lues  Venerea.— The 
periosteum,  fasciae,  tendons,  ligaments,  and  bones  are 
tlie  parts  which  Mr.  Hunter  enumerates  as  liable  to  be 
affected  in  the  second  stage  of  lues  venerea.  This  ob- 
servation in  its  full  extent,  however,  seems  to  be  ren- 
dered rather  questionable  ; for  it  would  appear  from 
the  evidence  both  of  ancient  and  modern  writers,  that 
true  nodes  or  venereal  swellings  of  the  bones,  andpar- 
ticularly  caries,  rarely  take  place  from  .syphilis,  unless 
mercury  be  employed.  It  is  an  observation  of  Mr. 
Hunter’s,  that  we  cannot  always  know  with  certainty 
what  parts  may  become  affected  in  this  stage  of  the 
disease.  He  says  he  has  known  the  distemper  produce 
a total  deafness,  sometimes  followed  by  suppuration, 
and  great  pain  in  the  ear  and  side  of  the  head.  I have 
already  explained,  that  it  was  one  of  this  gentleman’s 
doctrines,  that  the  second  order  of  parts  was  generally 
deep  seated.  When  these  become  irritated  by  the 
poison,  he  observes,  that  the  progress  of  the  disease  is 
more  gradual  than  in  the  first  order  of  parts.  It  as- 
sumes very  much  the  character  of  scrofulous  swellings, 
or  chronic  rheumatism  ; only  it  affects  the  joints  less 
frequently  than  the  latter  affection  does.  A swelling 
sometimes  makes  its  appearance  on  a bone,  when 
there  has  been  no  possible  means  of  catching  the  infec- 
tion for  many  months;  and,  in  consequence  of  the 
little  pain  experienced,  the  tumour  may  be  of  consider- 
able size  before  it  is  noticed.  Sometimes  a great  deal 
of  pain  is  felt;  but  no  swelling  conies  on  till  after  a 
long  while.  According  to  Mr.  Hunter,  these  remarks 
are  also  applicable  to  swellings  of  the  tendons  and 
fasciae.  As  tumours  of  this  kind  only  increase  by  slow 
degrees,  they  are  not  attended  with  symptoms  of  much 
inflammation.  When  they  attack  the  periosteum,  they 
seem  like  an  enlargement  of  the  bone  itself,  in  conse- 
quence of  being  very  firm,  and  closely  connected  with 
the  latter  part.  Mr.  Hunter  also  farther  observes,  that, 
in  these  advanced  stages  of  the  disease,  the  inflam- 
mation can  hardly  get  beyond  the  adhesive  kind,  in 
which  state  it  continues  to  become  worse  and  worse, 
and  when  matter  is  formed  it  is  not  true  pus,  but  of  a 
slimy  description.  Some  nodes,  he  says,  both  of  the 
tendons  and  bones,  last  for  years,  before  they  form  any 
matter  at  all.  These  cases  he  considered  as  not  being 
certainly  venereal,  though  commonly  considered  as 
such.  Mr.  Hunterfbund  itdifficult  to  explain  the  reason, 
why,  when  lues  venerea  attacks  the  bones,  or  the  peri- 
osteum, the  pain  should  sometimes  be  considerable,  and 
sometimes  very  trivial.  Venereal  pains  in  the  bones 
are  described  by  Mr.  Hunter  as  being  of  a periodical 
kind,  generally  most  severe  in  the  night-time. 

At  the  present  day,  when  naany  cases  formerly  sup- 
posed to  be  syphilitic  are  treated  without  any  mercury, 
and  even  those  which  are  reputed  to  be  venereal  are 
cured  by  much  smaller  doses  of  that  medicine  than 
were  given  in  Mr.  Hunter’s  time,  nodes  have  become 
much  less  frequent;  and  I have  already,  in  a previous 
part  of  this  article,  expressed  my  decided  belief  in  the 
justness  of  the  opinion  given  by  Fallopius  and  others, 
that  a disposition  to  nodes  is  often  occasioned  by  the 
abuse  of  mercury. 

Treatment  of  Lues  Venerea. — In  Mr.  Hunter’s  opi- 
nion, the  first  order  of  parts,  or  those  which  are  most 
susceptible  of  being  affected  in  lues  venerea,  are  also 
the  most  easy  of  cure  ; while  the  second  order  of  parts 
takes  more  lime  to  be  remedied. 

In  the  class  of  complaints  arising  in  the  second  stage 
of  the  lues  venerea,  Mr.  Hunter  believed  that  it  was 
unnecessary  to  continue  the  employment  of  mercury 
till  all  the  swelling  had  disappeared.  For  it  is  ob- 
served by  this  distinguished  writer,  that,  since  these 
local  comphiints  cannot  contaminate  the  constitution 
by  reabsorption,  and  since  the  venereal  disposition 
and  action  from  the  copstitution  can  be  cured  while 
the  local  effects  siill  remain,  and  this  even  when  the 
tumefaction,  forming  nodes  on  the  bones,  fascite,  &.c. 
has  proceeded  to  suppuration,  there  can  be  no  occasion 
for  continuing  the  course  after  the  venereal  action  has 
been  destroyed.  Whatever  may  be  hereafter  decided 
concerning  the  superiority  of  mercury  as  a remedy  for 
many  secondary  symptoms,  one  thing  appears  already 
well  made  out,  viz.  that  it  should  always  be  employed 
with  moderation,  lest  it  produce  worse  effects  and 
more  terrible  diseases  than  those  which  it  is  designed 
to  relieve.  For  an  account  of  the  various  ways  of 
exhibiting  it,  I must  refer  to  the  article  Mercury. 
Delpech  adopts  the  notion,  that  tJie  primary  symptoms 


VENEREAL  DISEASE. 


459 


«f  the  venereal  disease  are  most  successfully  treated 
by  introducing  mercury  into  the  system  from  the  sur- 
face of  the  body,  and,  if  possible,  partly  through  the 
same  set  of  absorbents  as  first  took  up  the  virus  ; for 
the  cure  of  secondary  symptoms  he  prefers  the  blue 
pill.— (CA»r.  Clin.  t.  1.) 

To  the  following  ingenious  reasoning  on  the  opera- 
tion of  mercury,  and  the  principles  by  which  its  admi- 
nistration should  be  regulated,  surgeons  of  the  present 
day  will  not  give  more  credit  than  facts  warrant;  be- 
cause some  of  Mr.  Hunter’s  opinions  are  manifestly 
influenced  by  the  supposition  that  mercury  is  abso- 
lutely necessary  for  the  cure  of  the  venereal  dis- 
ease. 

In  curing  the  lues  venerea,  mercury  can  only  have 
two  modes  of  action  ; one  on  the  poison,  the  other  on 
the  constitution.  If,  says  Mr.  Hunter,  mercury  acted 
on  the  poison  only,  one  might  conceive  it  did  so,  either 
by  destroying  its  qualities,  by  decomposing  it,  or  else 
by  attracting  it,  and  carrying  it  out  of  the  circulation. 
If  mercury  acted  in  the  first  of  these  ways,  one  would 
e.xpect  that  the  cure  would  depend  on  the  quantity  of 
the  medicine  taken  into  the  system.  If  it  acted  in  the 
second  manner,  one  would  infer  that  the  progress  of 
the  cure  would  be  proportionate  to  the  quantity  of 
evacuation.  But,  observes  Mr.  Hunter,  if  it  act  upon 
the  principle  of  destroying  the  diseased  action  of  the 
living  parts,  and  of  counteracting  the  venereal  irrita- 
tion by  producing  one  of  a different  kind,  then  neither 
quantity  alone  nor  evacuations  will  avail  much.  He 
states,  that  the  quickness  of  the  cure  depends  on  quan- 
tity joined  with  visible  effects.  How'ever,  it  is  added, 
that  although  the  effects  which  mercury  has  upon  the 
venereal  disease,  are  in  some  degree  proportioned  to  the 
local  effects  of  the  medicine  on  some  of  the  glands  or 
particular  parts  of  the  body,  as  the  mouth,  skin,  kidneys, 
and  intestines,  yet  such  effects  are  not  altogether  pro- 
portioned to  these  other  circumstances.  When  mer- 
cury disagrees  with  the  constitution,  so  as  to  produce 
great  irritability  and  hectic  symptoms,  this  action  of 
irritation,  as  Mr.  Hunter  explains,  is  not  a counter- 
irritation to  the  venereal  disease. 

It  was  also  noticed  by  the  same  author,  that  the 
effects  of  mercury  on  lues  venerea  are  always  in  pro- 
portion to  the  quantity  of  the  remedy  exhibited  in  a 
given  time,  and  the  susceptibility  of  the  constitution  to 
the  mercurial  irritation.  He  says  that  these  circum- 
stances require  the  most  minute  attention,  and  that,  in 
order  to  obtain  the  greatest  action  of  mercury  with 
safely,  and  in  the  most  effectual  manner,  the  medicine 
must  be  given  till  it  produces  effects  somewhere. 
However,  it  must  not  be  exhibited  too  quickly,  in 
order  that  a sufficient  quantity  may  be  given  before 
we  are  obliged  to  stop,  in  consequence  of  the  effects. 
Mr.  Hunter  thinks  that  when  the  local  effects  are  pro- 
duced too  quickly,  they  prevent  a sufficient  quantity 
of  the  remedy  from  being  taken  into  the  system  to 
counteract  the  venereal  irritation  at  large. 

Mr.  Hunter  mentions  his  having  seen  some  onses  in 
which  mercury  acted  very  readily  locally,  and  yet  the 
constitution  was  hardly  affected  by  it,  for  the  disease 
would  not  give  way.  He  states  that  he  has  met  with 
other  cases,  in  which  the  mere  quantity  of  mercury 
did  not  answer,  till  it  was  given  so  quickly  as  to  affect 
the  constitution  in  such  a manner  as  to  produce  local 
irritation,  and,  consequently,  sensible  evacuations. 
This,  he  observes,  is  a proof  that  the  local  effects  of 
mercury  are  often  the  sign  of  its  specific  effects  on  the 
constitution  at  large,  and  it  shows  that  the  susceptibility 
of  the  diseased  parts  to  be  affected  by  the  niedicine  is 
in  proportion  to  its  effects  on  the  mouth.  Its  effects, 
he  contends,  are  not  to  be  imputed  to  evacuation,  but 
to  its  irritation.  Hence  he  inculcates,  that  mercury 
should  be  given,  if  possible,  in  such  a manner  as  to 
produce  sensible  effects  upon  some  parts  of  the  body, 
and  in  the  Largest  quantity  that  can  be  given  to  pro- 
duce these  effects  within  certain  bounds.  Mr.  Hunter 
also  reuiark.s,  that  these  sensible  effects  should  be  the 
means  of  determining  how  far  the  medicine  may  be 
pushed,  so  as  to  have  the  greatest  effect  on  the  disease 
without  endangering  the  constitution.  The  practice 
must  vary  according  to  circumstances ; and  if  the  dis- 
ease be  in  a violent  degree,  less  regard  must  be  had  to 
the  constitution,  and  mercury  must  be  thrown  into  the 
system  in  larger  quantities  ; a very  dangerous  precept, 
as  far  as  1 can  judge  from  many  cases  in  which  I have 
seeti  it  acted  upon. 


Mr.  Hunter  likewise  acquaints  us,  that  when  the 
disease  is  in  the  first  order  of  parts,  a smaller  quantity 
of  mercury  is  necessary  than  when  the  second  order  of 
the  parts  is  affected  and  the  disease  has  been  of  long 
standing:  its  first  appearances  alone  being  cured,  and 
the  venereal  disposition  still  remaining  in  the  secondary 
parts.  For  the  purpose  of  curing  the  venereal  disease, 
whether  in  the  form  of  chancre,  bubo,  or  lues  venerea, 
Mr.  Hunter  was  of  opinion  that  probably  the  same 
quantity  of  mercury  is  necessary.  He  represents  that 
one  sore  requires  as  much  mercury  as  fifty  sores  in  the 
same  person,  and  a small  sore  as  much  as  a large  one. 
He  thought  that  the  only  difference,  if  there  is  any, 
must  depend  upon  the  nature  of  the  parts  affected,  Uiat 
is,  on  their  being  naturally  active  or  indolent.  He 
conceived,  however,  that,  on  the  w'hole,  recent  vene- 
real complaints  are  generally  more  difficult  to  cure  than 
the  symptoms  of  lues  venerea,  and  that  this  may  make 
a difference  in  regard  to  the  quantity  of  mercury 
necessary. 

Having  now  delivered  the  principal  general  instruc- 
tions relative  to  the  exhibition  of  mercury  in  the  treat- 
ment of  the  venereal  disease,  as  given  by  Mr.  Hunter, 
I must  not  quit  this  subject  without  remarking  that 
even  this  emitient  surgeon  appears  on  the  whole  too 
partial  to  the  long  use  of  mercury,  and  sometimes  to 
the  introduction  of  immoderate  quantities  of  it  into 
the  system.  In  general,  however,  his  observations 
tend  to  condemn  all  violent  salivations.  It  is  to  be 
recollected  that,  in  his  days,  nobody  had  a suspicion 
that  truly  syphilitic  sores  (if  this  expression  be  allow- 
able, while  they  cannot  be  defined  nor  distinguished  by 
their  appearances)  would  in  the  end  spontaneously 
heal ; and  he  himself  had  no  dependence  upon  any 
medicine  except  mercury  for  the  cure  of  the  true  vene- 
real disease.  But  modern  experience  evinces  that  the 
disorder  seldom  now  presents  itself  in  forms  so  bad 
and  intractable  as  formerly ; that  it  is  even  capable  of 
spontaneously  ceasing : and  that  we  hardly  ever  see 
cases  in  W'hich  it  is  requisite  to  give  mercury,  except 
in  very  moderate  quantities.  Indeed,  such  is  the 
change,  that  many  surgeons  suspect  that  the  very  na- 
ture of  the  disease  must  have  undergone  a nraterial 
alteration  or  modification.  In  England,  in  my  opinion, 
every  thing  is  to  be  referred  to  the  improved  manner  of 
employing  mercury  only  in  moderate  doses,  and  never 
pushing  its  exhibition  till  the  constitution  is  so  impaired 
that  indescribable  forms  of  diseases  ensue,  W'hich  are 
sometimes  the  compound  effect  of  mercury  and  syphilis 
together ; and,  in  other  instances,  of  that  description 
which  surgeons  now  frequently  call  syphiloid  ox  pseudo- 
syphilitic.,  not  depending  upon  the  venereal  poison  at 
all,  but  upon  a state  of  the  system,  which  mercury  is 
known  to  aggravate  in  the  w’orst  degree.  For  addi- 
tional information  concerning  internal  remedies  for  the 
venereal  disease,  see  Mercury,  Guaiacum,  Meiercon, 
Muriatic  Acid,  Mitrous  Acid,  iiarsaparilla,  Sulphuric 
Acid,  (S'e. 

With  respect  to  the  local  treatment  of  the  symptoms 
of  lues  venerea,  Mr.  Hunter  thought  that  none  would 
in  general  be  necessary,  since  the  constitutional  treat- 
ment would  commonly  effect  a cure.  However,  he 
admits  that  sometimes  the  local  effects  will  not  give 
way,  and  the  parts  remain  swollen  in  an  indolent,  inac- 
tive state,  even  after  there  is  every  reason  to  believe 
that  the  constitution  is  perfectly  cuied.  In  such  cases, 
he  recommends  assisting  the  constitutional  treatment 
by  local  applications  of  mercury  to  the  part,  either  in 
the  form  of  a plaster  or  ointment.  The  latter  apfdica- 
tion,  he  says,  is  the  best.  When  these  are  not  sufficient, 
he  advises  an  attempt  to  be  made  to  excite  inflamma- 
tion of  another  kind.  He  says,  he  has  seen  a venereal 
node,  which  gave  excruciating  pain,  cured  by  merely 
making  cm  incision  down  to  the  hone  the  whole  length  of 
the  node.  The  pain  ceased,  the  swelling  decreased, 
and  the  sore  healed  up  kindly,  without  the  assistance 
of  ® grain  of  mercury.  He  mentions  that  blisters 
have  been  applied  to  nodes  with  success,  removing  the 
pain  and  taking  away  the  swelling. 

With  regard  to  these  last  cases,  I may  add  that,  for 
many  years  past,  the  idea  of  completely  dispersing 
nodes  by  mercury  has  been  entirely  abandoned  by 
many  of  the  best  practitioners;  and  at  present,  long 
protracted  mercurial  courses  for  the  cure  of  such  swell- 
ings are  totally  relin()uished.  When  small,  moderate 
quantities  of  mercury  have  had  their  full  effect,  a blister 
is  applied  over  the  swelling,  and  kept  open;  under 


460 


VENEREAL  DISEASE. 


which  plan  the  tumour  generally  subsides,  as  far  as  its 
nature  will  allow. 

Diseases  resembling  the  Venereal.  Pseudo-syphi- 
lis.— Sores  on  the  glans  penis,  prepuce,  &.C.,  in  the  Ibrm 
of  chancres,  as  Mr.  Hunter  notices,  may  and  do  arise 
without  any  venereal  infection ; and  sometimes  they 
are  a consequence  of  former  venereal  sores  which 
have  been  cured. 

The  symptoms  produced  by  the  venereal  poison  in 
the  constitution,  are  such  as  are  common  to  many 
other  diseases.  For  instance,  Mr.  Hunter  remarks, 
that  blotches  on  the  skin  are  common  to  what  is  called 
a scorbutic  habit;  pains  are  common  to  rheumatism  ; 
swellings  of  the  bones,  periosteum,  fasciae,  &c.  to  many 
bad  habits,  perhaps,  of  the  scrofulous  and  rheumatic 
kind.  Thus,  says  he,  most  of  the  symptoms  of  the  vene- 
real disease,  in  all  its  forms,  are  to  be  found  in  many 
other  diseases.  Hence,  the  original  cause,  and  many 
leading  circumstances,  such  as  dates,  effects  of  the  dis- 
order upon  others,  from  connexion,  when  only  local,  the 
previous  andpresent  symptoms,  Sec.  must  be  considered, 
before  we  can  determine  absolutely  what  the  disease 
truly  is.  All  the  circumstances  and  symptoms  taken 
together  may  be  such  as  will  attend  no  other  disease. 
However,  Mr.  Hunter  confesses  that,  with  all  our 
knowledge,  and  with  all  the  application  of  that  know- 
ledge to  suspicious  symptoms  of  this  disease,  we  are 
often  mistaken,  calling  distempers  venereal  which  are 
not  so,  and  sometimes  supposing  really  syphilitic  affec- 
tions to  be  of  another  nature. 

Mr.  Hunter  takes  notice  that,  in  some  constitutions, 
rheumatism,  in  many  of  its  symptoms,  resembles  the 
lues  venerea.  The  nocturnal  pains,  swelling  of  the 
tendons,  ligaments,  and  periosteum,  and  pains  in  those 
swellings,  are  symptoms  both  of  the  rheumatism  and 
also  of  the  venereal  disease,  when  it  attacks  such 
parts.  Mr.  Hunter,  however,  did  not  know  that  he 
had  ever  seen  the  lues  venerea  attack  the  joints,  though 
many  rheumatic  complaints  of  such  parts  are  cured  by 
mercury,  and  therefore  supposed  to  be  venereal. 

Mercury,  given  without  caution,  often  produces  the 
same  symptoms  as  rheumatism.  Such  complaints 
Mr.  Hunter  had  seen  mistaken  for  venereal  ones,  and 
mercury  continued.  He  explains  that  some  diseases 
not  only  resemble  the  venereal  in  appearance,  but  in 
the  mode  of  contamination,  proving  themselves  to  be 
poisons  by  affecting  the  part  of  contact ; then  producing 
immediate  consequences  similar  to  buboes ; and  also 
remote  consequences  similar  to  the  lues  venerea. 

Mr.  Hunter  observes,  that  it  is  nearly  as  dangerous 
in  some  constitutions  to  give  mercury  when  the  dis- 
ease is  not  venereal,  as  to  omit  it  in  other  cases  which 
are  really  syphilitic;  and,  had  he  been  acquainted 
with  recent  investigations,  he  would  undoubtedly 
have  gone  farther,  and  declared  that  it  is  in  reality  far 
more  dangerous.  Many  of  the  constitutions  which 
put  on  some  of  the  venereal  symptoms  when  the  dis- 
ease is  not  really  present,  he  says,  are  those  with 
which  mercury  seldom  agrees,  and  commonly  does 
harm.  He  had  seen  mercury  which  was  exhibited  for 
a supposed  venereal  ulcer  of  the  tonsils,  produce  a 
mortification  of  those  glands,  and  the  patient  was 
nearly  destroyed.  No  doubt  this  was  an  example  of 
what  Mr.  Carmichael  would  call  the  phagedenic  ve- 
nereal disease. 

Mr.  Abernethy,  in  his  Surgical  Observations,  1804, 
has  treated  at  some  length  of  diseases  resembling  sy- 
philis, and  has  adduced  several  very  interesting  cases, 
which  I advise  every  surgical  practitioner  to  read  with 
the  greatest  attention,  as  they  confirm  the  views  of  the 
subject  lately  so  fully  established. 

“ A gentleman  (says  he)  thought  that  he  had  infected 
a slight  cut  on  his  hand  (which  was  situated  in  front  of, 
and  just  below,  the  little  finger)  with  the  discharge  from 
a bubo  in  the  groin,  that  he  had  occasion  to  open.  The 
wound  fretted  out  into  a sore  about  the  size  of  a six- 
pence, which  he  showed  me,  and  which  I affirmed  had 
not  the  thickened  edge  and  base,  and  other  characters 
of  a venereal  chancre.  I therefore  recommended  him 
to  try  the  effect  of  local  means,  and  not  to  use  mercury. 

In  about  a month,  the  sore,  which  had  spread  a lit- 
tle, became  contracted  in  its  dimensions,  and  assumed 
a healing  appearance.  At  this  time,  pain  was  felt  ex- 
tending up  the  arm,  and  suddenly  a considerable  tumour 
rose  over  the  absorbing  vessels,  which  proceed  along 
the  inner  edge  of  the  biceps  muscle.  This  tumour  be- 
came nearly  as  big  as  a small  orange.  As  the  original 


sore  seemed  now  disposed  to  heal,  and  as  there  was  no 
surrounding  induration,  I could  not  believe  it  venereal, 
and  therefore  recommended  him  still  to  abstain  from 
mercury,  and  apply  leeches  and  linen  moistened  in  the 
aq.  litharg.  acet.  comp,  to  the  tumour  formed  over  the 
inflemed  absorbents.  For  it  seemed  to  me  that  if  the 
venereal  poison  had  been  imbibed  from  the  sore,  it 
would  have  passed.on  to  one  of  the  axillary  glands, 
and  would  have  caused  induration  and  inflammation 
to  take  place  there  more  slowly  than  had  occurred  on 
the  present  occasion. 

Under  this  treatment  the  tumour  was  discussed, 
and  the  sore  at  the  same  thne  healed.  About  three 
weeks  afterward  the  patient  called  on  me,  and  said 
that  there  were  venereal  ulcers  in  his  throat ; and  in 
each  tonsil  there  was  an  ulcer  deeply  excavated,  with 
irregular  edges,  and  with  a surface  covered  by  adher- 
ing matter;  ulcers,  in  short,  which  every  surgeon  who 
depends  on  his  sight  as  his  guide,  would  have  pro- 
nounced to  be  venereal.  Shortly  after,  also,  some  cop- 
per-coloured eruptions  appeared  on  his  face  and  breast. 
He  showed  his  disease  to  several  surgeons,  on  whose 
opinion  he  relied,  who,  without  hesitation,  affirmed 
that  they  were  venereal,  and  that  the  mercurial  course 
had  been  improperly  delayed. 

While  the  patient  was  looking  out  for  lodgings,  in 
order  that  he  might  go  jhrough  the  mercurial  process, 
a circumscribed  thickening  and  elevation  of  the  peri- 
cranium, covering  the  frontal  bone,  appeared  : it  was 
of  the  circumference  of  a half-crown  piece  ; and  was, 
in  short,  what  every  surgeon  who  is  guided  only  by 
his  sight  and  touch,  would,  without  hesitation,  have 
called  a fair  corona  veneris.  I now  told  the  patient 
that  I was  more  inclined  to  believe  his  disease  was  not 
syphilitic,  from  the  sudden  and  simultaneous  occur- 
rence of  this  node  with  the  sore  throat,  &c.  Other 
surgeons  thought  differently ; and  I believe  this  very 
sensible  and  amiable  young  man  imagined  that  his 
health  would  become  a sacrifice  if  he  any  longer  at- 
tended to  my  opinion.  He  was  preparing  to  submit  to 
a mercurial  course,  when  very  important  conceri>8 
called  him  instantly  into  the  country.  He  went  with 
great  reluctance,  taking  with  him  mercurial  ointment, 
&c. ; and  after  a fortnight  I received  a letter  from  him, 
saying  that  he  found  his  complaints  benefited  by  his 
journey,  that  business  had  prevented  him  from  begin- 
ning the  use  of  mercury  for  a few  days,  that  he  now 
found  it  was  unnecessary,  for  his  symptoms  had  almost 
disappeared ; and  shortly  afterward  he  became  perfectly 
well.” 

Mr.  Abernethy  considers  this  case  as  the  most  une- 
quivocal instance  extant  of  a disease  which  could  not 
by  appearance  be  distinguished  by  surgeons  of  the 
greatest  experience  from  syphilis,  and  which,  however, 
was  undoubtedly  of  a different  nature  (that  is  to  say, 
it  was  of  a different  nature  according  to  certain  cri- 
teria then  generally  believed,  but  which  recent  inves- 
tigations have  proved  to  be  destitute  of  foundation). 
All  the  tests  here  alluded  to  having  been  spoken  of 
in  the  foregoing  columns,  I shall  not  here  repeat  them. 

Some  years  ago  the  nitric  acid  was  introduced  as  a 
remedy  for  syphilis. — (See  JiTitrous  Acid.)  To  the  po- 
sition of  its  efficacy  being  as  great  in  venereal  cases  as 
was  first  alleged,  many  surgeons  have  not  acceded, 
though,  as  a sensible  writer  has  observed,  it  has  cer- 
tainly been  allowed,  with  some  other  medicines,  to 
ren)ain  in  a kind  of  copartnership  with  mercury,  and 
admitted  to  be  useful  in  venereal  cases  under  certain 
circumstances.  A great  deal  of  this  want  of  agree- 
ment on  the  effects  of  remedies  in  syphilitic  cases,  is 
now  explained  by  the  imperfection  of  the  diagnosis, 
and  the  important  fact  that  the  disease  may  generally 
be  cured  in  time  without  any  medicines  whatsoever, 
though  this  time  is  sometimes  long.  Dr.  Scott,  who 
first  suggested  the  use  of  nitrous  acid,  has  attempted 
to  account  for  its  alleged  occasional  failures  by  observ- 
ing, that  the  acid  wliich  he  employed  was  not  pure 
nitric  acid,  but  an  impure  acid,  containing  an  admix- 
ture of  muriatic  acid.  He  therefore,  some  time  ago, 
recommended  the  use  of  a compound  acid,  containing 
three  parts  of  nitric  acid,  and  one  of  muriatic,  which 
he  administered  internally,  and  also  applied  externally, 
largely  diluted  as  a bath,  until  the  gums  were  affected 
and  ptyalism  produced;  and  he  conceived  every  trial 
as  quite  inconclusive,  unless  these  constitutional  effects 
occurred. 

“The  acid  that  I have  used  of  late  (says  Dr.  Scott) 


VENEREAL  DISEASE. 


461 


is  the  nitro-muriatic ; and  it  is  formed  by  mixing  to- 
gether  equal  parts  of  the  nitrous  or  nitric  acid  and 
muriatic  acid.  If  these  acids  be  in  the  state  of  con- 
centration that  they  usually  possess  in  the  shops,  and 
if  the  quantities  be  considerable,  a great  volume  of 
gas  is  developed  on  their  coming  into  contact,  which 
taints  every  part  of  a house,  is  extremely  hurtful  to 
the  lungs,  and  disagreeable  to  the  smell.  To  avoid 
this  inconvenience,  I put  a quantity  of  water,  at  least 
equal  in  bulk  to  both  the  acids,  into  a bottle,  and  I add 
the  acids  to  it  separately.  This  method  does  not  only 
prevent  the  unpleasant  odour,  but  it  tends  to  retain  the 
chlorine,  on  which  its  effects  depend.  It  is  well 
known,  that  the  nitro-muriatic  acid  acts  very  readily 
on  the  metals  and  earth ; nothing,  therefore,  but  glass 
or  extremely  well-glazed  vessels  of  porcelain,  should 
be  used  to  contain  it.  Wooden  tubs  for  bathing  an- 
swer very  well,  and  they  should  always  be  made  as 
small  as  possible,  compatible  with  their  holding  the 
body,  or  the  limbs  that  we  wish  to  expose  to  the  bath. 
From  their  being  small  we  save  acid,  and  are  able  to 
heat  the  bath  with  ease.  In  India,  I have  often  ex- 
posed the  whole  body  below  the  head  to  this  bath ; but 
here  I have  been  satisfied,  in  general,  with  keeping  the 
legs  and  feet  exposed  to  it.  In  order  to  warm  the  bath 
after  the  first  time,  I have  commonly  made  a third  or  a 
fourth  part  of  it  be  thrown  away,  and  the  loss  re- 
placed by  boiling  water  and  a proportional  quantity  of 
acid.  To  save  the  expenditure  of  acid,  I have  occa- 
sionally warmed  a portion  of  the  bath  in  porcelain 
ves-sels,  placed  near  the  fire,  but  I fear  this  may  dimi- 
nish its  effects. 

It  is  no  easy  matter  (continues  Dr.  Scott)  to  give 
directions  with  regard  to  the  degree  of  acidity  of  the 
bath.  I have  commonly  made  it  about  as  strong  as 
very  weak  vinegar,  trusting  to  the  taste  alone.  The 
strength  should  be  regulated  by  the  degree  of  irrita- 
bility of  the  patient’s  skin.  I may  say,  that  although 
I like  to  know  that  it  is  strong  enough  to  prick  the  skin 
a very  little,  after  being  exposed  to  it  from  fifteen  to 
thirty  minutes,  yet  I believe  that  even  such  an  effect 
as  this  is  unnecessary. 

The  lime  too  of  remaining  in  the  bath  in  order  to 
produce  the  greatest  effect,  is  a matter  of  doubt.  I 
have  kept  the  legs  and  feet  exposed  to  it  for  half  an 
hour  or  more ; but  with  more  delicate  people,  not  above 
one-half  or  one-third  of  that  time.  I have  repeated 
these  baths  daily,  or  even  twice  or  thrice  a day.” — 
(See  Med.  Chir.  Trans,  vol.  8,  p.  181.)  Dr.  Scott  adds, 
that  the  mere  sponging  the  skin  with  nitro-muriatic 
acid  sufficiently  diluted  with  water,  gives  rise  to  the 
very  same  effects  as  bathing,  and  is  more  easily 
adopted.  Fifteen  or  twenty  minutes  may  be  employed 
in  the  sponging,  though  a much  less  time  produces 
very  material  effects. 

Dr.  Scott  has  found  the  nitro-muriatic  acid  particu- 
larly useful  even  in  this  country,  in  that  description  of 
syphilis  which  is  termed  pseudo  syphilis ; and  he  at- 
ttibutes  the  beneficial  effects  to  the  chlorine,  which  is 
loosely  combined  in  this  compound. — (See  Journal  of 
Science  and  the  Arts,  vol.  1,  p.  205 — 211;  Land.  Med. 
Reposit.  vol.  l,p.  50  ] and  Med.  and  Chir.  Trans,  vol. 
8,  p.  173,  ct  seq.) 

The  only  important  conclusion  which  I venture  to 
draw  from  Dr.  Scott’s  observations  is,  a confirmation 
of  the  fact  of  the  generally  curable  nature  of  syphilitic 
diseases  without  the  aid  of  mercury.  And  I farther 
believe,  that  though  the  nitro-muriatic  bath  may  some- 
times be  useful,  the  surest  way  of  bringing  it  into  dis- 
credit is,  to  represent  it  as  applicable  to  all  forms  of  sy- 
philis, for  which  neither  this  remedy  nor  even  mercury 
itself  will  ever  suffice.  The  muriate  of  gold  has  been 
much  cotntnended  of  late  years ; but  after  the  facts 
detailed  in  this  article,  the  alleged  merit  of  new  reme- 
dies must  be  received  with  suspicion,  and  in  particu- 
lar the  idea  of  their  specific  powers  rejected. 

[The  preceding  article  is  an  elaborate  and,  upon  the 
whole,  an  able  exposition  of  the  present  slate  of  our 
knowledge  of  the  venereal  disease,  though  in  the  exist- 
ing condition  of  conflicting  opinions  concerning  the 
identity  of  the  poison  capable  of  inducing  such  a 
variety  of  results  as  are  to  be  observed  in  syphilitic 
affections,  we  are  yet  left  in  doubt  as  to  some  of  the 
most  important  principles  which  ought  to  govern  us  in 
our  treatment  of  specific  disorders  of  the  genital  sys- 
tem. To  Mr.  Carmichael  the  profession  is  in  an  es- 
pecial manner  indebted  for  much  interesting  matter  on 


the  subject,  and  the  facts  which  the  more  recent  occur- 
rence of  the  disease  among  the  peninsular  army  has 
furnished  us,  are  also  to  be  cherished  as  of  great  prac- 
tical utility. — (See  Hennen,  Fergusson,  Outhrxe,  ^c.) 

The  writers  on  mercury,  and  on  syphilitic  com- 
plaints, who  have  appeared  in  the  United  States,  de- 
serve also  to  be  studied  with  some  care,  inasmuch  as 
not  a few  of  them,  from  ample  opportunities,  have  set 
forth  many  interesting  views  on  these  intricate  ques- 
tions.— (See  Rousseau  in  Philadelphia  Medical  Mu- 
seum, vol.  4.  Holyoke,  in  Mew-  York  Medical  Repos, 
vol.  1.  See  in  do.  vol.  4.  Rush,  in  do.  vol.  5.  Ogden, 
in  do.  vol.  5.  Harris,  in  Morth  Amer.  Med.  Journal, 
vol.  1.  Warren's  View  of  Mercurial  Practice,  in 
Mass.  Med.  Communications.  Francis's  Dissertation 
on  Mercury.  Chapman's  Therapeutics,  <S-c.) 

Medical  observers  of  the  present  day  seem  to  place 
less  confidence  in  the  authoritative  opinions  of  Mr. 
Hunter  than  formerly,  and  his  doctrine  of  the  identity 
of  the  poison  of  gonorrhoea  and  syphilis,  of  his  infal- 
lible diagnostics  of  chancre,  and,  farther,  his  precept 
of  the  necessity  of  excessive  salivation,  have  probably 
few  advocates  in  America.  Moreover,  the  latest  inves- 
tigations by  British  and  continental  writers  seem  to 
have  removed  the  little  of  partiality  that  was  cherished 
until  recently  in  behalf  of  these  Hunterian  principles. 

That  gonorrhoea  and  syphilis  originate  from  dis- 
tinct poisons,  and  that  moderate  salivation  only,  or  the 
merely  subjecting  the  system  to  the  influence  of  mer- 
cury, is  all  that  is  necessary,  is,  perhaps,  maintained 
by  nine-tenths  of  the  intelligent  prescribers  of  this 
country;  and  the  sweeping  anathemas  of  Mr.  John 
Pearson,  of  the  London  Lock  Hospital,  in  relation  ta 
the  inefficiency  of  the  corrosive  sublimate,  have  been 
disproved  innumerable  limes  by  most  decided  clinical 
illustration.  I shall  here  insert  an  extract  from  an  ela- 
borate essay  on  mercury,  by  my  friend  Prof.  Francis, 
written  some  time  since,  when  the  advocates  for  the 
corrosive  sublimate  were  not  so  numerous  as  at  present. 
The  entire  paper  may  be  seen  in  Hosack's  and  Fran- 
cis's American  Med.  and  Philosophical  Register,  vols. 
3 and  4.  To  the  interrogatory,  what  are  the  changes 
effected  in  the  system  by  the  influence  of  mercury? 
Dr.  F.  observes,  “ Little  is  indeed  known  concerning 
the  peculiar  nature  of  the  virus  of  specific  diseases;  the 
action  which  takes  place  upon  the  application  of  the 
smallest  particle  of  morbific  matter  to  the  human  body, 
and  the  process  by  which  it  generates  disease,  con- 
verting a local  into  a general  disorder,  and  thus  pro- 
ducing an  altered  and  vitiated  state  of  the  whole  sys' 
tern,  it  must  be  admitted,  are  neither  very  obvious  to 
the  senses,  nor  very  clear  to  the  reasoning  powers  of 
man.  The  effects  themselves,  however,  have  been 
long  and  familiarly  known,  and,  from  duly  considering 
these,  a rational  theory  may,  perhaps,  be  formed  of  the 
manner  in  which  they  are  produced. 

That  the  poison  of  specific  diseases,  as  that  of  lues 
venerea,  small  pox,  &c.,  diffuses  itself  through  the 
whole  constitution,  and  assimilates  into  its  own  nature 
the  general  mass  of  circulating  fluids,  seems  to  be  most 
consonant  to  all  that  is  understood  of  their  peculiar 
character.  Upon  the  introduction  of  a particle  of  va- 
riolous matter  into  the  system,  an  inflanunaloiy  aciioiip 
of  the  part  into  which  it  is  inserted  is  excited  ; by  whiclt 
action  new  morbific  matter  of  the  same  nature  is  ge^ 
nerated.  This  process  may  be  carried  on  to  a greater 
or  less  extent,  in  a longer  or  shorter  lime,  in  different) 
persons,  before  the  specific  material  enters  the  absorb^ 
ents  ; and  hence  local  inflammation  is  in  some  cases 
considerably  advanced  before  the  system  becomes  af- 
fected, while  in  others  the  eruptive  symptoms  super- 
vene when  it  appears  to  have  made  very  little  pro- 
gress. 3’he  morbid  poison,  modified  in  its  action  by  its 
degree  of  acrimony,  the  condition  of  the  part,  and  ha- 
bit of  body,  is  taken  up  by  the  absorbents,  and  enters 
the  blood-vessels,  whence  it  is  received  into  the  general 
circulation,  and  produces  its  peculiar  effects  upon  the 
constitution.  The  fluids  themselves  are  therefore  ne- 
cessarily first  affected,  and,  as  a consequence  of  their 
morbid  condition,  the  solids  themselves  next  become 
vitiated.  Hence  the  multiplication  of  the  matter  of 
variolous  contagion  in  inoculated  small  pox ; and 
hence,  on  the  same  principle,  the  general  ion  of  morbific 
matter  from  a similar  action,  arising  from  the  intro- 
duction of  the  other  specific  contagions.  By  the  intro- 
duction of  a specific  morbid  matter  into  the  body,  its 
condition  is  changed  from  a healthy  to  a diseased  state, 


462 


VENEREAL  DISEASE. 


the  local  is  converted  into  a general  disorder ; the  fluids, 
and  ultimately  the  solids,  become  aflected,  and,  ac- 
cording to  the  peculiar  virus  introduced,  the  whole 
constitution  partakes  in  a greater  or  less  degree  of  its 
peculiar  nature,  whether  it  be  small-pox,  lues  venerea, 
measles,  <Scc.”  'I'he  theory  of  Mr.  Hunter,  that  mer- 
cury induces  its  salutary  changes,  by  creating  a new 
specitic  action,  and  that  thus  it  destroys  the  specific  dis- 
order lues  venerea,  in  conformity  to  the  law  that  no  two 
specific  actions  can  exist  at  the  same  time,  is  shown 
by  Dr.  F.  to  be  untenable  and  unsatisfactory,  from  the 
well-known  fact,  that  it  often  happens  that  two  specific 
diseases  prevail  siiiiultaneously  in  the  human  constitu- 
tion; as  we  find  recorded  in  the  cases  of  Pearson,  Jen- 
ner,  Haygarth,  and  others  in  tlie  small-pox,  and  by 
other  authors  on  various  diseases  of  an  acknowledged 
specific  character. 

But  the  theory  of  Mr.  Hunter  is  attempted  to  be 
overthrown  by  other  facts  concerning  the  changes  in- 
duced by  morbid  action,  for  which  [ must  refer  the 
reader  to  the  essay  of  Dr.  F. — {Jimer.  Med.  and  Phil. 
Register^  vol.  4,  p.  488 — 492.) 

In  relation  to  the  curative  action  of  mercury  in  the 
treatment  of  lues  venerea,  he  remarks,  “ The  action 
of  mercury,  though  primary  on  the  nervous  system,  is 
communicated  to  every  fibre  of  the  body,  and  produces 
a degree  of  restlessness,  anxiety,  and  debility.  When 
taken  into  the  system,  it  manifests  itself  by  a quick- 
ened circulation,  gives  the  blood  the  disposition  to  show 
the  bufty  coat  when  drawn,  renders  the  pulse  frequent 
and  harder,  increases  the  respiration,  excites  the  tem- 
perature of  the  body,  occasions  a whitish  fur  on  the 
tongue,  and  other  symptoms  of  general  inflammatory 
action,  its  effects  upon  the  secretions  are  still  more 
apparent,  producing  a preternatural  flow  of  saliva,  an 
increased  action  of  the  mucous  vessels  of  the  trachea, 
lungs,  digestive  organs,  chylopo?etic  viscera,  and  whole 
intestinal  canal.  It  excites  a copious  discharge  of 
urine,  and  in  the  smallest  quantity  operates  on  the  skin. 
In  its  extensive  influence  on  the  body,  it  produces  an 
increased  action  of  the  absorbent  vessels.  These  may 
be  considered  the  more  ordinary  effects  of  mercury, 
when  its  action  is  not  particularly  modified  by  the 
morbid  condition  of  the  constitution.”  Dr.  F.,  there- 
fore, concludes,  that  from  the  very  general  stimulant 
operation  of  mercury  in  promoting  the  excretions  of 
the  whole  system  depends  its  curative  action.  We 
farther  conclude  from  these  views,  that  from  those  pre- 
parations of  mercury  which  are  best  calculated  to  se- 
cure this  general  action,  our  most  approved  means  of 
relief  are  to  be  drawn  ; and  hence  the  corrosive  subli- 
mate and  the  blue  pills  are  to  be  preferred  as  possess- 
ing this  character.  We  are  still  farther  strengthened 
in  this  view  by  observing  the  effects  of  climate  on  the 
venereal  disease,  and  are  enabled  also  better  to  appre- 
ciate the  valuable  facts  furnished  us  by  Mr.  Carmi- 
chael. Accordingly,  the  preposterous  practice  of  Mr. 
Howard,  and  of  the  older  writers,  who  advocate  pro- 
fuse salivation  long  continued,  and  say  that  the  hu- 
mours ought  to  '•'■JlovD  like  a river,"  will  find  few  or  no 
advocates  in  the  present  enlightened  state  of  know- 
ledge. Indeed,  it  seems  to  be  well  established,  that 
where  salivation  is  early  excited  by  a loo  free  use  of 
mercury,  our  chances  of  a prompt  and  efficacious  cure 
are  actually  lessened,  and  somelinies  entirely  cut  off. 

There  is  another  circumstance  connected  with  the 
action  and  effects  of  mercury  on  the  human  constitu- 
tion, which,  though  it  does  not  strictly  come  under  our 
consideration  here,  may  nevertheless  be  mentioned. 

1 allude  to  a peculiarity  in  the  influence  which  a mer- 
curial salivation  produces,  involving  a point  of  inteiest 
in  juridical  medicine  as  well  as  in  practice.  It  seems 
to  be  well  established  on  practical  authority,  that  sali- 
vation, having  been  arrested,  after  an  interval  of  weeks, 
nay  months,  may  be  renewed  by  the  slightest  doses  of 
mercury.  Bromfield  and  Howard,  of  the  Lock  Hospi- 
tal, give  us  facts  of  this  sort.  Mead  mentions  a case 
where  the  interval  was  six  months,  and  Hamilton,  of 
Edinburgh,  relates  a case  of  a like  nature.  In  his  lec- 
tures on  forensic  medicine.  Dr.  Francis  informs  me  he 
has  recorded  two  instances  of  a similar  sort  in  bis  own 
practice,  in  which  a few  grains  of  mercury  renewed  a 
salivation  which  had  been  suspended  for  several  weeks 
in  one  case,  and  in  the  other  for  more  than  four  months. 
The  inference  to  be  deduced  from  occurrences  of  this 
nature  renders  it  necessary  for  us  always  to  institute  the 
inquiry,  whether  the  patient  about  to  submit  to  mer- 


cury for  the  cure  of  venereal  disorder  has  or  has  not 
been  previously  under  the  operation  of  salivation,  lest 
ptyalism  unexpectedly  occur,  and  thus  protract  or  de- 
feat our  curative  indications.  The  action  of  mercury, 
to  prove  satisfactory  in  syphilis,  ought  to  be  directed 
on  a constitution  properly  prepared  for  the  purpose; 
the  powers  of  the  system  often  require  to  be  renovaitd 
by  tonics  belore  we  commence  with  this  active  agent. 
Hence  we  shall  find  that  bark  or  other  tonics  will 
often  be  indicated  before  commencing  with  minerals  in 
constitutions  impaired  by  intemperance  and  other 
causes.  Dr.  F.  informs  me,  that  in  some  instances  Ire 
has  given  as  a suitable  preparative  charcoal  or  quinine, 
especially  in  cases  of  long-protracted  syphilis,  where 
mercury  had  been  previously  mal-administered. 

The  muriate  of  gold  has  not  been  attended  w'ith  that 
success  in  the  treatment  of  syphilis  in  this  country, 
which  might  have  been  expected  from  the  reports  of 
its  efficacy  abroad.  In  my  own  practice  in  Baltimore, 
and  in  this  city,  it  has  proved  inefficient;  and,  in  those 
cases  where  scrofula  was  combined  with  lues,  I was 
compelled  wholly  to  abandon  the  gold,  and  administer 
the  corrosive  sublimate  occasionally  conjoined  with 
cicuta.  The  learned  Dr.  Mitchill,  however,  affirms  of 
the  practice  of  the  New-York  Hospital,  in  which  insti- 
tution he  introduced  the  method  of  Chrestein  in  1811, 
that  that  article  was  capable  of  effecting  salutary  re- 
sults. “ Without  presuming  to  affirm,”  says  he,  in  his 
letter  to  Dr.  Dyckman  {Edin.  Dispensatory,  Jimer.  ed. 
of  1818),  ” that  it  is  capable  of  eradicating  the  distem- 
per in  every  instance,  my  opinion  upon  the  whole  is, 
that  the  muriate  of  gold  will  effect  all  that  is  achieved 
by  muriate  of  quicksilver.”  Still  more  recently,  Neil 
has  endeavoured  to  substantiate  the  claims  of  auriferous 
preparations  as  adequate  to  the  cure  of  venereal  dis- 
eases ; and  this  author  of  1823  is  almost  as  enthusiastic 
in  his  praises  of  gold  as  an  anti-venereal  remedy,  as 
was  Salmon  of  lb99,  w'hen  he  pronounced  it  capable 
of  radically  driving  all  noxious  humours  and  matters 
out  of  the  human  body,  elephantiasis  and  the  French 
pox,  because  it  purified  the  blood,  and  strengthened  the 
marrow  of  the  bones.  I feel  assured,  however,  if  the 
testimony  of  American  physicians  and  surgeons  was 
impartially  examined  into,  that  their  decision  would  co- 
incide with  that  of  the  Academy  of  Paris,  who,  with  the 
venerable  Percy  at  their  head,  have  reported  unfavour- 
ably on  the  subject,  and  declared  the  remedial  powers 
of  this  favourite  remedy  with  some  to  be  exaggerated 
and  equivocal. — (See  farther  American  Med.  Rev.  vol. 
1,  article  by  Dr.  Eberle.)  For  a detail  of  experiments 
with  the  muriate  of  platina  in  syphilis,  by  Cullerier,  I 
must  refer  to  the  Diet,  des  Sciences  Med.  art.  Platine, 
1820.  I am  not  aware  that  this  article  has  ever  been 
used  by  American  physicians. 

Our  author  has  made  reference  to  the  excellent 
paper  of  the  late  Mr.  Hey,  in  the  Medico-Chirurg. 
Trans,  of  London,  vol.  7.  That  paper  is  a valuabfe 
contribution  to  our  stock  of  knowledge  on  venereal 
diseases.  Mr-  Hey  is  one  of  the  eminent  authorities 
who  support  the  opinion,  that  the  venereal  disorder  is 
capable  of  affecting  the  fetus  in  utero,  nor  do  the  dis- 
cussions of  Mr.  John  Pearson  lessen  our  confidence  in 
what  the  venerable  Hey  has  advanced — (See  Pcar- 
son's  Life  of  Hey.)  That  cases  of  this  kind  occa- 
sionally occur  under  the  observation  of  the  medical 
practitioners  cannot  be  denied ; I have  repeatedly  seen 
the  disease  thus  imparted.  Mahon  seems  to  have 
given  no  proofs  sufficient  on  this  head  ; several  cases 
of  this  nature  are  also  furnished  us  by  Professor  Hosack 
in  his  Medical  Essays,  vol.  2 ; and  I might  also  set 
forth  in  some  detail  those  given  by  Professor  Francis  in 
his  revised  edition  of  Dr.  Denman’s  Midwifery.  “ I 
have  had  under  my  own  care,”  says  Dr.  F.,  “six 
cases  of  the  venereal  disease  communicated  to  the 
fetus  in  utero ; two  of  these  cases  occurred  where  the 
genital  S3'stem  appeared  in  a perfectly  sound  state;  in 
another  there  were  ulcers  of  the  labiae,  and  constitu- 
tional disease.  In  two  the  disease  was  apparent  im- 
mediately after  birth,  and  in  one  four  months  had 
elapsed  before  the  disease  manifested  itself  distinctly.” 
Cases  thus  contracted  are  doubtless  best  treated  by  the 
internal  use  of  the  corrosive  sublimate,  and  to  the 
newly-born  infant  we  can  most  conveniently  give  the 
solution.  See  also  Dyckman,  On  the  Pathology  of 
the  Human  Fluids,  who  contends  that  an  infect^ 
nurse  by  lactation  may  communicate  lues  venerea.  A 
valuable  paper  embracing  cases  illustrative  of  the  pr*>- 


VENEREAL  DISEASE. 


463 


per  use  of  mercury  in  venereal  complaints  by  Dr.  Dar- 
rach  has  recently  appeared  in  theJVo?  tA  Amer.  Medical 
and  Surgical  Journal^  vol.  7. — Reese.'] 

J.  de  VigOy  De  Arte  Ckirurgica,  fol.  Lugd.  1518. 

Montesaurus^  De  Dispositiombus,  quas  vulgo 
Mai  Franios  appellant^  1497.  Micol.  Massa  de  Morbo 
Gallico,  liber  4to.  F'enet.  1532,  et  1536,  auctior,  1563. 
JV*/c.  DeoniceruSy  Liber  de  Epidemia  quam  Itali  mor- 
bum  Gallicurn,  Oalli  vero  JVeapolitanum  vacant,  fol. 
PavicBy  1506.  Oabr.  Fallopius  de  Morbo  Gallico,  ito. 
Patav,  1563.  JV7c.  de  Blegnpy  Zodiacus  Medico- Oal- 
licusy  Ato.  Oenevai,  1680.  Hieron.  Fracastoriusy  Sy- 
philis Poema;  et  Tractatus  de  Syphilide;  Verona, 
1530.  Also,  De  Covtagione  et  Contagiosis  Morbis, 
Venet.  1546.  Casp.  Torella,  Tractatus  cum  Consiliis 
contra  Pudendagram,  Romm,  1497.  Also,  Dialogue 
de  Dolore  et  de  Ulceribus  in  Pudendagra ; Romm, 
1500.  Ant.  Francantianus  de  Morbo  Gallico,  8uo. 
Patav.  1563.  Jul.  Palmarius,  De  Morbis  Contagiosis, 
4to.  Paris,  1578.  Ouil.  Rondelctius  de  Morbo  Gallico, 
1576.  J.  Femelius,  Universa  Medicina,  Ato.  Venet. 
1564,  p.  584.  593,  Src.  Ulrich  von  Hutten  de  Morbo 
Gallico,  Mogunt.  1531.  R.  Rostinio,  Trattato  di  Mai. 
Francese,  12/tto.  Venet.  1556.  Al.  Luisinus,  Aphrodi- 
siacus,  Venet.  1566,  et  in  2 tom.  fol.  Lugd.  Bat.  1728  ; 
one  of  the  most  valuable  collections  of  the  works  of 
ancient  writers  on  Syphilis.  Diaz  de  Isla,  Tratado 
contra  las  Bubas,  1527.  Wm.  Clowes,  a new  and  ap- 
proved Treatise,  concerning  the  Cure  of  the  French 
Pockes,  by  the  Unctions,  8vo.  Land.  1575 ; said  to  be 
the  earliest  English  book  on  Syphilis.  J.  Astrnc  de 
Morbis  Venereis ; Lutet.  Paris,  1740.  Le  Blond, 
Obs.  sur  la  Fiivre  Jaune,  chap.  A.  I.,eo  Africanus,  De- 
scriptio  Africm,  1. 1,  p.86.  The  last  two  authors  men- 
tion the  fact  of  the  Venereal  Disease  getting  well 
spontaneously  in  hot  climates.  Dav.  Abercromby, 
Tuta  ac  efficax  Luis  Venerem,  smpe  absque  Mercurio, 
ac  semper  absque  Salivatione  Mercuriali,  Curandm 
Methodus,  Land.  \2mo.  1684.  J.  Sintelaer,  The 
Scourge  of  Venus  and  Mercury,  represented  in  a 
Treatise  on  the  Venereal  Disease,  giving  a succinct 
Account  of  that  dreadful  Distemper,  and  the  fatal 
Consequences  arising  from  Mercurial  Cures,  Src.,  with 
the  true  Way  of  curing  the  Mercurial  Pox,  found  to 
be  more  dangerous  than  Pox  itself,  Lond.  1709.  Mor- 
gagni de  Sedibus,  Src.  Morborum.  John  Douglas, 
Dissertation  on  the  Venereal  Disease,  wherein  a Me- 
thod of  curing  all  the  Stages  of  that  Distemper  will  be 
communicated  without  the  help  of  amj  Mercurial 
Drenches,  Vomits,  or  Fumigations,  Src.,  and,  above 
all,  a Salivation  in  all  Cases  will  be  avoided,  8vo. 
Lond.  1737.  Ludolff,  Demonstratio,  quod  atrocissimm 
Luis  Venerem  symptomata  non  sint  affectus  Morbi, 
sed  Curm  Mercurialibus  Institutm,  Erf.  1747.  C^ 
Willoughby,  The  Practice  of  Salivation  shown  to  be 
of  no  Use,  Lond.  1723.  J.  Profily,  An  Easy  and  Ex- 
act Method  of  Curing  the  Venereal  Disease,  Src. ; to 
which  are  added  Experiments  publicly  made  of  an  ef- 
fectual Method  of  Cure  without  Salivation  or  Con  fine- 
ment,8vo.  Lond.  1748.  Wm.  Bromfield,  Account  of  the 
English  Might-Shade,  Src.  and  Observ.  on  the  Use  of 
Corrosive  Sublimate,  Sarsaparilla,  and  Mercury. 
Also,  of  the  Cure  by  the  Secretion  of  Urine,  8vo.  I.,ond. 
1759.  M.  de  Jansen,  Tableau  des  Maladies  Veneri- 
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12/710.  Paris,  1759.  Gataker  on  Venereal  Complaints, 
1754.  C.  Hales,  Salivation  not  necessary  for  the  Cure 
of  Venereal  Diseases, Svo.  Lond.  1764  and  1772.  Dan. 
Turner,  Aphrodisiacus,  containing  a Summary  of  the 
ancient  Writers  on  the  Venereal  Disease,  Svo.  Lond. 
1738.  Wm.  Becket,  History  and  Antiquity  of  the  Ve- 
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sive  de  Lue  Venerea,  induas  Partes  divisus  ; quorum 
vna  continet  ejus  vestigia  in  veterum  auctorum  monu- 
menta  obvia;  altera,,  quos  Aloysius  Luisinus  temeri 
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des  Maux  Veneriens,  fol.  Paris,  1773.  Christ.  Gir- 
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8oo.  QQtt.  1788.  H:  Clutterbuck  on  some  of  the  Opi- 
nions of  the  late  John  Hunter,  <S'C.  Svo.  Lond.  1799. 
S.  Chapman,  a Treatise  on  the  Venereal  Disease,  be- 
ing chiefly  designed  as  an  Abridgment  of  Dr.  As- 
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ments, with  regard  to  the  Use  of  Sarsaparilla,  Meze- 
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Method  of  Cure,  8oo.  Lond.  1770.  W.  Dense  on  the 
different  Methods  of  treating  the  Venereal  Disease, 
Svo.  Dublin,  1783.  P.  Clare,  A new  Method  of  curing 
Lues  Venerea  by  the  Introduction  of  Mercury  through 
the  Orifices  of  the  absorbent  Vessels  on  the  Inside  of 
the  Mouth,  2d  ed.  Lond.  1780.  Jesse  Foote,  Obs.  on 
the  Mew  Opinions  of  John  Hunter,  Svo.  Lond.  1786, 
1787;  also,  Complete  Treatise  on  the  Venereal  Disease, 
Svo.  Lond.  C.  B.  Trye,  a Review  of  Jesse  Foote’s 
Obs.  on  the  Mew  Opinions  of  '^Hunter,  Svo.  Lond. 
1787.  B.  Bell,  Treatise  on  Gonorrhma  Virulenta,  and 
Lues  Venerea,  ed.  3.  Lalouette,  Mouvelle  Mithode  de 
trailer  les  Maladies  Venkriennes  par  la  Fumigation, 
drc.  Paris,  1776.  John  Hunter,  A Treatise  on  the  Ve- 
nereal Disease,  ed.  2d ; or  with  Dr.  Adams’s  Com- 
mentary. S.  Sawrey,  An  Inquiry  into  some  of  the  Ef- 
fects of  the  Venereal  Poison,  Svo.  Lond.  1802.  Jos. 
Adams  on  Morbid  Poisons,  ed.  2.  J.  Pearson  on  the 
Effects  of  various  Articles  of  the  Materia  Medica,  in 
the  cure  of  Lues  Venerea,  ed.  2,  Svo.  Lond.  1807.  J. 
Abernethy,  on  Diseases  resembling  Syphilis,  in  Sur- 
gical Observations,  Svo.  J^ond.  1804.  P.  A.  O.  Ma- 
hon, Recherches  sur  la  Maladie  Syphilitique,  1804.  F. 
H.  Martens  et  Tilesius,  Tableaux  des  Syrnpt&mes  de  la 
Maladie  Vinirienne,  dessinis  d’apris  Mature,  Ato. 
Leipz.  1804.  F.  Swediaur,  Traite  Complet  sur  les 
Symptdmes,  Femmes  enceintes,  les  Enfans  nouveaux- 
nis,  Src.  Src.  des  Maladies  Syphilitiques,  2 tomes,  Imt 
ed.  Paris,  1804.  Fergusson,  Obs.  on  the  Venereal  Dis- 
ease in  Portugal,  as  affecting  the  Constitutions  of  the 
British  Soldiers  and  Motives,  in  Med.  Chir.  Trans, 
vol.  A.  Wm.  Hey,  on  the  Effects  of  the  Venereal  Dis- 
ease on  the  Foetus  in  Utero,  op.  cit.  vol.  7,  p.  541,  <J-c. 
Wm.  Blair,  Essay  on  the  Venereal  Disease,  and  the 
Effects  of  Mitrous  Acid,  and  other  analogous  Reme- 
dies, lately  proposed  as  Substitutes  for  Mercury,  Svo. 
Lond.  1808.  T.  Beddoes,  a Collection  of  Testimonies, 
respecting  the  Treatment  of  the  Venereal  Disease,  by 
Mitrous  Acid,  Svo.  Lond.  1799.  Alyon,  Essai  sur  les 
ProprieUs  Medicinales  de  V Oxygine,  et  sur  V Applica- 
tion de  ce  Principe  dans  les  Maladies  VenMcnnes, 
Src.  Svo.  Paris,  an  7.  C.  Platt,  An  Inquiry  into  the 
Efficacy  of  Oxygen  in  the  Cure  of  Syphilis,  Svo.  Lond. 
1802.  Berlin,  Traiti  de  la  Maladie  Vdniirjenne  chez 
les  Enfans  nouveaux-nes,  les  Femmes  enceintes,  et  les 
Mourrices,  Src.  Svo.  Paris,  1810.  O.  Rees,  a Treatise 
on  the  Primary  Symptoms  of  Lues  Venerea;  with  a 
concise,  critical,  and  chronological  Account  of  all  the 
English  Writers  on  this  Subject,  Svo.  Lond.  1802.  J. 
Rollo,  Cases  of  Diabetes,  with  the  Results  of  the  Trials 
of  certain  Acids,  and  other  Substances,  Svo.  Lond. 
1806.  Lagneau,  Exposb  des  Symptdmes  de  la  Mala- 
die Vdnirienne,  Ame  ed.  Svo.  Paris,  1816.  Bateman’' s 
Synopsis,  ed.  5.  H.  Scott,  on  the  internal  and  external 
Use  of  the  Mitro-muriatic  Acid,  in  Med.  Chir.  Trans, 
vol.  8,  p.  173  ; also,  in  .Tourn.  of  Science  and  the  Arts, 
vol.  1,  p.  205,  Src.  Schweigger,  on  the  Cure  of  Syphilis 
by  Abstinence,  vid.  Huf eland  and  Harle’s  Journ.  A. 
Carlisle,  on  the  present  unsettled  State  of  Opinion 
about  the  Venereal  Disease,  vid.  Lond.  Med.  Reposit. 
vol.  1,  p.  89.  R.  Carmichael,  Essays  on  the  Venereal 
Diseases,  which  have  been  confounded  with  Syphilis, 
S-c.  Ato.  1814;  also,  Obs.  on  the  Symptoms  and  specific 
Distinctions  of  Venereal  Diseases,  >^c.  Svo.  Lond. 
1818 ; and  an  Essay  on  Venereal  Diseases,  and  the 
Uses  and  Abuses  of  Mercury,  ed.  2,  I.ond.  1825.  T. 
Rose,  Obs.  on  the  Treatment  of  Syphilis,  with  an  Ac- 
count of  several  Cases,  in  which  a Cure  was  effected 
without  the  Use  of  Mercury,  in  Med.  Chir.  Trans,  vol. 
8.  G.  J.  Guthrie,  on  the  Treatment  of  the  Venereal 
Disease  without  Mercury,  vol.  cit.  A.  Mathias,  the 
Mercurial  Disease,  ed.  3,  Svo.  Lund.  1816.  ./.  Thom- 
son and  J.  Hennen,  in  Edin.  Med.  and  Surgical 
.Tourn.  vol.  14  ; also,  J.  Hennen,  in  Principles  of  Mi- 
litary Surgery,  edit.  2,  Svo.  Edin.  1820.  J.  Bacot, 
Obs.  on  Sijphilis,  principally  with  reference  to  the  Use 


464 


VER 


VER 


of  Mercury,  8vo.  Land.  1821“,  and  Essays  on  Syphilis, 
in  Med.  Gazette,  vul.  2,  8vo.  L,ond.  1828.  James 
Evans,  Pathological  and  Practical  Remarks  on  Ulcer- 
ations of  the  Genital  Organs,  8vo.  Lond.  1819.  F. 
G.  Sarfass,  De  Methodis  atque  Medicamentis  antisy- 
philiticis,  ito.  Berol.  1816.  Anonym,  sur  la  Mon-ex- 
istence de  la  Maladie  Venerienne,  &rc.  Suo.  Paris, 
1811.  Delpech,  Chir.  Clinique,  t.  1,  4io.  1823.  R. 
Welbank,  on  the  Mecessity  and  Method  of  farther  in- 
vestigating the  Distinctions  between  Syphilis  and 
other  Varieties  of  Venereal  Disease,  in  Med.  Chir. 
Trans,  vol.  13,  8oo.  Lond.  1827.  Dr.  JV.  Barbantini, 
Del.  Contagio  Venereo  Trattato,  vol.  4,  8vo.  Lucca, 
1820,  1821.  Professor  Barbantini  was  so  kind  as  to 
send  me  a copy  of  this  work,  which  abounds  in  valuable 
historical  information,  and  good  practical  observa- 
tions; the  result  of  his  own  experience.  J-  M.  Titley, 
on  Dis.  of  the  Genitals,  ^c.  1829. 

VENESECTION.  (From  vena,  a vein,  and  sectio, 
a division.)  The  operation  of  opening  a vein.  Phle- 
botomy. See  Bleeding. 

VERRU'CA.  A wart.  See  Wart. 

VERTEBRA,  DISEASE  OF.  The  case  here  to  be 
considered  is  a disease  of  the  spine,  sometimes  origi- 
nating in  an  ulceration  of  the  intervertebral  cartilages, 
sometimes  in  a morbid  condition  of  the  cancellous 
structure  of  the  bodies  of  the  vertebrse  {^Brodie  on 
Diseases  of  the  Joints,  p.  259),  followed  bv  a more  or 
less  complete  loss  of  the  power  of  using  the  legs. 

Formerly,  the  affection  of  the  limbs  was  generally 
called  a palsy,  and  treated  as  a paralytic  affection ; to 
which  it  is  in  almost  every  respect  perfectly  unlike. 

In  the  true  paralysis  (says  Mr.  Pott),  from  whatever 
cause,  the  muscles  of  the  affected  limb  are  soft,  flabby, 
unresisting,  and  incapable  of  being  put  into  even  a 
tonic  state;  the  limb  itself  may  be  placed  in  almost  .any 
position  or  posture;  if  it  be  lifted  up,  and  then  let  go,  it 
falls  down,  and  it  is  not  in  the  power  of  the  patient  to 
prevent,  or  even  to  retard,  its  fal I ; the  joints  are  perfectly 
and  easily  moveable  in  any  direction;  if  the  affection 
be  of  the  lower  limbs,  neither  hips,  knees,  nor  ankles 
have  any  degree  of  rigidity  or  stiffness,  but  permit  the 
limb  to  be  turned  or  twisted  in  almost  any  manner. 

In  the  present  case,  the  muscles  are  indeed  lessened, 
but  they  are  rigid,  and  always  at  least  in  a tonic  state, 
by  which  the  knees  and  ankles  acquire  a stiffness,  not 
very  easy  to  overcome.  By  means  of  this  stiffness, 
mixed  with  a kind  of  spasm,  the  legs  of  the  patient  are 
either  constantly  kept  stretched  out  straight,  in  which 
case  considerable  force  is  required  to  bend  the  knees,  or 
they  are,  by  the  action  of  the  stronger  muscles,  drawn 
across  each  other  in  such  manner  as  to  require  as  much 
to  separate  them.  When  the  leg  is  in  a straight  posi- 
tion, the  extensor  muscles  act  so  powerfully  as  to  re- 
quire a considerable  degree  of  force  to  bend  the  joints 
of  the  knees  ; and  when  they  have  been  bent,  the  legs 
are  immediately  and  strongly  drawn  up  with  the  heels 
towards  the  buttocks.  By  the  rigidity  of  the  ankle 
joints,  joined  to  the  spasmodic  action  of  the  grastroc- 
nemii  muscles,  the  patient’s  toes  are  pointed  down- 
wards in  such  manner  as  to  render  it  impossible  for  him 
to  put  his  foot  flat  to  the  ground  ; which  makes  one  of 
the  decisive  characteristics  of  the  distemper. 

The  majority  of  those  who  labour  under  this  disease 
are  infants  or  young  children : adults  are  by  no  means 
exempt  from  it;  but  Mr.  Pott  never  saw  it  at  an  age 
beyond  forty;  and  Mr.  Baynton  never  met  with  more 
than  three  instances  which  approached  that  period  of 
life. — ( On  Diseases  of  the  Spine,  p.  4.) 

In  one  case,  however,  recited  by  Mr.  Brodie,  the 
patient  was  forty-five  years  old  (On  Diseases  of 
Joints,  p.  268) ; and  I have  now  a patient  who  cannot 
be  younger.  By  Pott,  Baynton,  and  several  other  wri- 
ters, a belief  is  entertained  that  the  disease  is  most  in- 
clined to  happen  in  scrofulous  subjects,  in  which  opi- 
nion I am  also  disposed  to  join.  There  can  also  be  no 
doubt  of  the  fact  stated  by  Mr.  Pott,  that  it  most  fre- 
quently happens  in  weak  and  delicate  children. 

According  to  Mr.  Pott,  if  the  patient  be  a child, 
the  account  most  frequently  given  is,  that  for  some 
time  previous  to  the  incapacity  of  using  its  limbs,  it  had 
been  observed  to  be  languid,  listless,  and  very  soon 
tired  ; that  it  was  unwilling  to  move  much  or  briskly ; 
that  it  had  been  observed  frequently  to  trip  and  stum- 
ble, although  no  impediment  lay  in  its  way  ; that  when 
it  moved  hastily,  or  unguardedly,  its  legs  would  cross 
each  other  involuntarily,  by  which  it  was  often  and 


suddenly  thrown  down ; that  if  it  endeavoured  to  stand 
still  and  upright,  unsupported  by  anoiher  person,  its 
knees  would  totter  and  bend  under  it;  that  it  could  not, 
with  any  degree  of  precision  or  certainty,  steadily  di- 
rect either  of  its  feet  to  any  particular  point,  but  that 
in  attempting  so  to  do,  they  would  be  suddenly  and  in- 
voluntarily brought  across  each  other;  that  soon  after 
this  it  complained  of  frequent  pains  and  twitchings  in 
its  thighs,  particularly  when  in  bed,  and  of  an  uneasy 
sensation  at  the  pit  of  the  stomach ; that  when  it  sal  on 
a chair  or  a stool,  its  legs  were  aln)Ost  always  found 
across  each  other,  and  drawn  up  under  the  seat ; and 
that,  in  a little  lime  after  these  particulars  had  been  ob- 
served, it  totally  lost  the  power  of  walking. 

The  same  author  observes,  that  if  the  incurvation  be 
of  the  neck,  and  to  a considerable  degree,  by  affecting 
several  vertebraj,  the  child  finds  it  inconvenient  and 
painful  to  support  its  own  head,  and  is  always  desirous 
of  laying  it  on  a table  or  pillow,  or  any  thing  to  take 
off  the  weight.  If  the  affection  be  of  the  dorsal  ver- 
tebrae, it  is  soon  attended  with  loss  of  appetite,  hard 
dry  cough,  laborious  respiration,  quick  pulse,  and  dis- 
position to  hectic. 

Mr.  Pott  stales  that  an  adult,  in  a case  where  no 
violence  has  been  committed  or  received,  will  tell  you 
that  his  first  intimation  was  a sense  of  weakness  in 
his  backbone,  accompanied  with  what  he  will  call  a 
heavy,  dull  kind  of  pain,  attended  with  such  a lassi- 
tude as  rendered  a small  degree  of  exercise  fatiguing ; 
that  this  was  soon  followed  by  an  unusual  sense  of 
coldness  in  his  thighs,  not  accountable  for  from  the 
weather,  and  a palpable  diminution  of  their  sensibility ; 
that  in  a little  time  more  his  limbs  were  frequently 
convulsed  by  involuntary  twitchings,  particularly 
troublesome  in  the  night ; that,  soon  after  this,  he  not 
only  became  incapable  of  walking,  but  that  his  power 
either  of  retaining  or  discharging  his  urine  and  feces 
was  considerably  impaired,  and  his  penis  became  inca- 
pable of  erection. 

The  adult  also  finds  all  the  offices  of  his  digestive 
and  respiratory  organs  much  affected,  and  complains 
constantly  of  pain  and  tightness  at  the  stomach. 

The  true  cause  of  the  disease  is  a morbid  state  of  the 
spine,  and  of  some  of  the  parts  connected  with  it; 
which  distempered  state  of  parts  will,  upon  careful 
inquiry,  be  always  found  to  have  preceded  the  defor- 
mity some  length  of  time.  In  infants,  this  is  the  sole 
cause,  and  external  violence  has  nothing  to  do  with  it. 
“In  the  adult  (says  Mr.  Pott),  I will  not  assert  that 
external  mischief  is  always  and  totally  out  of  the  ques- 
tion ; but  I will  venture  to  affirm  what  is  equal,  as  far 
as  regards  the  true  nature  of  the  case,  which  is,  that 
although  accident  and  violence  may  in  some  few  in- 
stances be  allowed  to  have  contributed  to  its  more 
immediate  appearance,  yet  the  part  in  which  it  shows 
itself  must  have  been  previously  in  a morbid  state,  and 
thereby  predisposed  for  the  production  of  it.  I do  not 
by  this  mean  to  say  that  a violent  exertion  cannot 
injure  the  spine,  nor  produce  a paralytic  complaint; 
that  would  be  to  say  more  than  I know : but  I will 
venture  to  assert,  that  no  degree  of  violence  whatever 
is  capable  of  producing  such  an  appearance  as  I am 
now  speaking  of,  unless  the  bodies  of  the  vertebrae 
were  by  previous  distemper  disposed  to  give  way;  and 
that  no  supposable  dislocation,  caused  by  mere  violence 
done  to  the  bones  of  the  back,  which  bones  were  before 
the  receipt  of  the  injury  in  a sound  state,  can  possibly 
be  attended  with  the  peculiar  symptoms  of  a curved 
spine.” 

For  some  observations  connected  with  this  point,  I 
refer  the  reader  to  C.  Bell’s  Surgical  Observations, 
vol.  1. 

Mr.  Brodie  agrees  with  Mr.  Pott  and  other  writers 
on  the  fact  that  the  actual  curvature  must  be  preceded 
by  a disease  of  the  parts,  unaccompanied  with  any 
visible  deformity,  and  “ cannot  take  place  until  the 
caries  has  made  considerable  progress.”  In  the  early 
stage  of  the  case,  therefore,  when,  as  Mr.  Brodie  justly 
observes,  the  diagnosis  is  of  the  most  importance,  no 
information  can  be  obtained  from  the  appearance  of  the 
spine  itself,  the  shape  of  which  is  yet  unchanged  ; and 
frequently  the  symptoms,  which  do  take  place  early, 
are  not  unequivocal.  They  are,  according  to  this 
writer,  “ a pain,  and  some  degree  of  tenderness  in  that 
part  of  the  spine  where  the  disease  has  begun ; a sense 
of  constriction  of  the  chest;  an  uneasy  feeling  at  the 
pit  of  the  stomach  and  of  the  whole  abdomen ; a dis- 


VERTEBR-®,  DISEASE  OF. 


4GB 


larbed  state  of  the  functions  of  the  alimentary  canal 
and  of  the  urinary  bladder;  a sense  of  weakness  and 
aching,  and  occasional  cramps  of  the  muscles  of  the 
extreiiiiiies.”  But,  as  Mr.  Brodie  confesses,  very  simi- 
lar symptoms  may  arise  from  other  causes,  and  some- 
times no  particular  complaints  are  made  previously  to 
the  actual  discovery  of  the  curvature. — (Ora  Diseases 
of  Joints.)  p.  279,080.) 

[ have  already  mentioned  Mr.  Brodie’s  opinion  de- 
duced from  dissection,  that  in  many  instances  caries  of 
the  spine  has  its  origin  in  an  ulceration  of  the  interver- 
tebral cartilages,  beginning  in  their  centre,  and  extend- 
ing to  their  circumference,  and  afterward  affecting  the 
bodies  of  the  contiguous  veriebr® ; but  that,  in  other 
cases,  the  disease  has  its  origin  in  the  bodies  of  the 
vertebra)  themselves,  which  are  liable  to  the  same  pecu- 
liar disease  of  the  cancellous  structure,  which  is 
noticed  in  the  afticulating  extremities  of  other  bones. — 
{Brodie,  on  Diseases  of  Joints,  p. 267.)  This  gentleman 
suspects  that  the  disease,  which  begins  in  the  cancellous 
structure  of  the  vertebrae,  is  more  immediately  followed 
by  suppuration  than  that  which  commences  in  the 
intervertebral  cartilages;  and  that  the  first  form  of  the 
disease  seldom  occasions  so  extensive  a destruction  of 
the  vertebrae  as  the  last.  “ But  (says  Mr.  Brodie) 
farther  than  this,  nothing  which  I have  hitherto  ob- 
served enables  me  to  point  out  any  circumstances  in 
which  the  symptoms  of  these  different  diseases  differ.” 
— (P.  276.)  Respecting  another  statement,  that  when 
the  lumbar  vertebrse  are  alone  affected,  the  symptoms 
dependent  on  pressure  or  irritation  of  the  spinal  mar- 
row are  absent,  I cannot  say  that  it  accords  with  several 
cases  which  have  fallen  under  my  own  notice  ; that  is 
to  say,  if  the  affection  of  the  lower  limbs  is  to  be  re- 
ceived as  a lest  of  such  irritation  or  pressure. 

According  to  Mr.  Pott,  the  true  curvature  is  invaria- 
bly uniform,  in  being  from  within  outwards ; but  it 
varies  in  situation,  in  extent,  and  in  degree ; it  affects 
the  neck,  the  back,  or  the  loins ; it  comprehends  one 
vertebrae  only,  or  two,  or  more;  and  as  few  or  more 
are  affected,'  or  as  these  are  more  or  less  morbid, 
and  consequently  give  way  more  or  less,  the  curve 
must  be  different. 

In  these  cases,  as  Mr.  Brodie  remarks,  “ the  distortion 
of  the  spine  is  usually  of  a peculiar  kind,  and  such  as 
nothing  can  produce  except  the  destruction  of  the  bodies 
of  one  or  more  vertebrae.  The  spine  is  bent  forwards, 
so  as  to  form  an  angle  posterioily ; and  although  the 
destruction  of  the  vertebrae  may  be  the  same,  it  is  more 
obvious  in  some  parts  of  the  spine  than  it  is  in  others. 
For  example,  the  spinous  processes  in  the  middle  of  the 
back  being  long,  and  projecting  downwards,  the  eleva- 
tion of  one  of  these  must  occasion  a greater  prominence 
than  that  of  one  of  the  spinous  processes  of  the  neck, 
which  are  short,  and  stand  directly  backwards. 

Curvature  of  the  spine,  in  the  direction  forwards, 
may  arise  from  other  causes,  as  a weak  condition  of 
the  muscles,  or  a rickety  affection  of  the  bones.  In 
general,  in  such  cases,  the  curvature  occupies  the  whole 
spine,  which  assumes  the  form  of  a segment  of  a 
circle.  At  other  times,  however,  it  occupies  only  a 
portion  of  the  spine,  usually  that  w’hich  is  formed  by 
the  superior  lumbar  and  inferior  dorsal  vertebrae.”  But 
here,  a.s  Mr.  Brodie  has  found,  the  curvature  is  always 
gradual,  and  never  angular;  a circumstance  by  which 
it  is  distinguishable  from  the  curvature  produced  by 
caries.  The  cases,  however,  he  thinks  have  often 
been  confounded,  and  some  speedy  and  complete  cures 
of  carious  spine  on  record,  he  infers,  must  have  been 
cases  of  an  entirely  different  nature. — (Ora  Diseases  of 
Joints,  p.  282,  <S-c.;  and  Earle,  in  Edinb.  Med.  Journ. 
Jan.  1815.) 

“ Lateral  curvatures  of  the  spine  are  alleged  gene- 
rally to  incline  to  the  right  side;  and  the  fact  is 
referred  (with  what  correctness  I know  not)  to  the 
undue  power  which  is  acquired  by  the  more  general 
use  of  the  right  arm,  and  of  other  muscles  in  the  per- 
formance of  the  voluntary  actions.” — {Baynton,  onDis- 
cascs  of  the  Spine,  p.i3.)  It  is  admitted,  however,  that 
exceptions  are  met  with,  and  that  the  lateral  curvature 
sometimes  tends  to  the  left,  and  occasionally  resembles 
the  letter  S reversed.  On  this  subject  I have  also 
another  rare  exception  to  specify,  which  is  explained 
by  Mr.  Brodie,  viz.  that  though  lateral  distortions  of  the 
spine  generally  arise  from  causes  indeiiendenl  of  caries, 
a slight  degree  of  lateral  curvature  is  in  some  instances 
produced  by  the  bodies  of  the  vertebra)  having  been  I 

VoL  II.— G g 


destroyed  on  one  side  by  caries,  in  a greater  degree 
than  on  the  other. — {Brodie,  on. Joints,  p.  284.) 

In  general,  the  lower  limbs  alone  usually  feel  the 
effect.  Mr.  Pott,  however,  has  seen  two  cases,  in  one 
of  which  the  arms  only  were  affected,  in  the  other  both 
legs  and  arms.  Mr.  Ford  showed  him  a lad  who  had 
lost  the  use  of  both  arms  and  legs  from  a curvature. 
An  account  of  two  similar  examples  was  also  commu- 
nicated to  Mr.  Pott  by  Mr.  Parke  of  Liverpool. 

Mr.  Brodie  has  never  known  the  paralysis  affect  the 
muscles  of  the  arms,  when  the  disease  was  at  the 
lower  or  middle  part  of  the  spine ; but  he  agrees  with 
Mr.  Copeland,  that  the  symptoms  are  not  always  con- 
fined to  parts  below  the  disease,  and  that  it  is  not  un 
common  for  pains  in  the  upper  extremities  to  accom- 
pany the  paralytic  affection  of  the  legs  and  thighs. — 
{Brodie,  p.  285.  Copeland,  Obs.  on  Diseased  Spine, 
^e.) 

Very  soon  after  the  curvature,  some  patients  are 
rendered  totally  and  absolutely  incapable,  not  only  of 
walking,  but  of  using  their  legs  in  any  manner : others 
can  make  shift  to  move  about  with  the  help  of  crutches, 
or  by  grasping  their  thighs  just  above  the  knees  with 
both  hands.  Some  can  sit  in  an  armed  chair  without 
much  trouble  or  fatigue  ; others  cannot  sit  up  with  any 
help.  Some  retain  such  a degree  of  power  of  using 
their  legs,  as  to  be  able  to  shift  their  posture  when  in 
bed ; others  have  no  such  power,  and  are  obliged  to 
be  moved  upon  all  occasions. 

I have  been  present  at  the  dissection  of  persons  who 
died  of  lumbar  abscesses,  and  who,  while  they  lived, 
never  suffered  the  peculiar  loss  of  the  use  of  the  lower 
extremities,  so  well  described  by  Mr.  Pott,  though  the 
vertebrte  were  found  to  be  diseased.  However,  in 
other  instances  of  such  abscesses,  attended  with  caries 
of  the  spine,  the  legs  are  deprived  of  their  power.  But 
whether  the  difference  is  to  be  explained  by  the  consi- 
deration that,  in  some  cases,  the  disease  of  the  bone 
may  be  secondary,  and  the  abscess  itself  the  primary 
complaint,  I cannot  determine.  At  all  events,  suppu- 
ration is  frequently  only  an  effect,  the  curvature  exist- 
ing long  before  the  abscess ; and,  in  such  cases,  the  legs 
are  affected.  Some  lime  ago,  Mr.  Dunn,  of  Scar- 
borough, consulted  me  about  a case,  in  which  the  latter 
facts  were  exemplified.  Mr.  Brodie’s  opinion  that  sup- 
puration takes  place  at  an  earlier  period,  in  cases 
where  the  disease  begins  in  the  cancellous  structure  of 
the  bones,  has  been  already  noticed.  In  having  a ten- 
dency to  excite  suppuration,  and  in  producing  the 
weakness  of  the  lower  extremities,  the  present  disease 
of  the  spine  appears  to  be  materially  diflerent  from 
the  absorption  of  the  vertebrte,  sometimes  caused  by 
the  pressure  of  aneurisms  and  other  tumours. — {Hodg- 
son on  Diseases  of  Arteries,  Src.  p.  80.) 

Mr.  Pott  observes,  when  a child  appears  to  be  what 
the  common  peojile  call  naturally  weakly,  whatever 
complaints  it  may  have  are  supposed  to  be  caused 
by  its  weak  state,  and  it  is  generally  believed  that  time 
and  common  care  will  remove  them  ; but  when  a cur- 
vature has  made  its  appearance,  all  these  marks  of  ill 
health,  such  as  laborious  respiration,  hard  cough, 
quick  pulse,  hectical  heat  and  flushing,  pain  and  tight- 
ness of  the  stamach,  &c.,  are  more  attentively  regarded 
and  set  to  the  account  of  the  deformity  consequent  to 
the  curve,  more  especially  if  the  curvature  be  of  the 
dorsal  vertebrae,  in  which  case  the  deformity  is  always 
greatest ; but  whoever  will  carefully  attend  to  all  the 
circumstances  of  this  disorder,  will  be  convinced  that 
most,  if  not  all  the  complaints  of  children  labouring 
under  this  infirmity,  precede  the  curvature;  and  that 
a morbid  state  of  the  spine,  and  of  the  parts  connected 
with  it,  is  the  original  and  primary  cause  of  both. 

Among  many  other  reasons  for  thinking  that  an 
effect  was  misiaken  for  a cause  Mr.  Pott  enumerates 
the  following ; 

1.  “That  he  did  not  remember  ever  to  have  seen 
this  useless  state  of  the  limbs  from  a mere  malformation 
of  the  spine,  however  crooked  such  malformation 
might  have  made  it. 

2.  That  none  of  those  deviations  from  right  shape 
which  growing  girls  are  so  liable  to,  however  great  the 
deformity  might  be,  was  ever  attended  with  this 
effect.” 

With  respect  to  the  treatment  of  diseased  spine,  I 
think  bne  principle  laid  down  by  Mr.  Pott  must  receive 
approbation ; viz.  that  the  primary  and  sole  cause  of 
all  the  symptoms  is  a distempered  .state  of  the  parts, 


466 


VERTEBRAE, 

composing  or  in  immediate  connexion  with  the  spine, 
tending  to,  and  most  frequently  ending  in,  a caries  of 
the  vertebrcB.  Hence,  says  he,  all  the  ills,  whether 
general  or  local,  apparent  or  concealed  ; tlie  ill  health 
of  the  patient,  and  in  time  the  curvature.  As  the 
disease  does  not  originate  in  the  limbs,  no  application 
to  them  can  be  of  any  use,  and  the  great  indication 
must  be  to  stop  the  progress  of  the  disease  in  the 
artected  part  of  the  spine. 

The  first  suggestion  of  the  probability  that  issues 
might  prove  serviceable  in  this  disease,  appears  to 
have  been  made  to  Mr.  Pott  by  Dr.  Cameron,  of  Wor- 
cester, who  told  him  that,  having  remarked  in  Hippo- 
crates, an  account  of  paralysis  of  the  lower  limbs 
cured  by  an  abscess  in  the  back,  he  had,  in  a case  of 
useless  limbs,  attended  with  a curvature  of  the  spine, 
endeavoured  to  imitate  this  act  of  nature,  by  exciting 
a purulent  discharge,  and  that  it  had  proved  very  be- 
neficial ; which  was  confirmed  to  Mr.  Pott  by  Mr.  Jef- 
freys, of  Worcester,  who  had  made  the  experiment 
with  the  same  success. 

The  practice  which  Pott  recommends  consists 
merely  in  procuring  a large  discharge  of  matter  from 
the  integuments  on  each  side  of  the  distempered  bones, 
forming  the  curvature,  and  in  maintaining  such  dis- 
charge until  the  patient  shall  have  recovered  his  health 
and  the  use  of  his  limbs.  They  who  are  little  con- 
versant with  matters  of  this  sort  (says  Rlr.  Pott)  will 
suppose  the  means  very  inadequate  to  the  proposed 
end ; but  they  who  have  been  experimentally  ac- 
quainted with  the  very  wonderful  effects  of  purulent 
drains,  made  from  the  immediate  neighbourhood  of 
diseases,  will  not  be  so  much  surprised  at  this  parti- 
cular one ; and  will  immediately  see  how  such  kind  of 
discharge,  made  and  continued  from  the  distempered 
part,  checks  the  farther  progress  of  the  caries,  gives 
nature  an  opportunity  of  exerting  her  own  powers  of 
throwing  off  the  diseased  parts,  and  of  producing  a 
union  of  the  bones  (now  rendered  sound),  and  thereby 
establishing  a cure. 

Mr.  Pott  considers  it  a matter  of  very  little  impor- 
tance towards  the  cure,  by  w'hat  means  the  discharge 
be  procured,  provided  it  be  large,  that  it  come  from  a 
sufficient  depth,  and  that  it  be  continued  for  a sufficient 
length  of  time.  He  tried  setons,  issues  by  incision, 
and  issues  by  caustic,  and  found  the  last  in  general  pre- 
ferable, being  least  painful,  most  cleanly,  most  easily 
manageable,  and  capable  of  being  longest  continued. 

The  caustics,  he  observes,  should  be  applied  on 
each  side  of  the  curvature,  in  such  a manner  as  to 
leave  the  portion  of  skin  covering  the  spinal  pro- 
ces.ses  of  the  protruding  bones  entire  and  unhurt,  and 
so  large,  that  the  sores,  upon  the  separation  of  the  es- 
chars, may  easily  hold  each  three  or  four  peas,  in  the 
case  of  the  smallest  curvature ; but  in  large  curves,  at 
least  as  many  more. 

The  issues  which  modern  surgeons  usually  make 
for  the  relief  of  the  symptoms  arising  from  diseased 
vertebrse,  are  larger  than  such  as  Mr.  Pott  himself  was 
in  the  habit  of  forming.  They  now  commonly  prefer 
making  an  issue  on  each  side  of  the  spinous  processes, 
about  three  or  four  inches  long,  and  half  an  inch  broad. 

The  size  of  the  issue  intended  to  be  made  being  de- 
termined, the  place  where  it  is  to  be  made  should  be 
accurately  marked  out  with  ink.  All  the  skin  imme- 
diately around  should  then  be  covered  with  adhesive 
plaster,  in  order  that  it  may  be  protected  from  the  ac- 
tion of  the  caustic.  Let  the  surgeon  next  take  a piece 
of  caustic  potassa  or  of  potassa  cum  calce,  and  wrap  a 
little  tow  round  one  end  of  it,  so  that  he  may  take 
hold  of  it  w'ith  safety  and  convenience.  The  other 
end  of  the  caustic  should  then  be  moistened  a little, 
and  rubbed  very  quickly  on  the  portion  of  the  integu- 
ments which  is  to  be  converted  into  an  eschar.  The 
caustic  is  to  be  rubbed  in  this  manner,  till  the  part 
turns  of  a dull  brown  colour,  when  the  caustic  should 
be  carefully  w'ashed  off  with  a little  wet  tow,  and  a 
poultice  applied. 

As  soon  as  the  eschars  admit  of  being  removed,  a 
row  of  peas  or  beans,  connected  together  with  thread, 
should  be  laid  on  the  sore,  and  confined  there  with 
sticking  plaster.  A compress,  containing  a piece  of 
pasteboard  or  sheet  lead,  is  then  to  be  bound  over  the 
peas  or  beans  with  a roller.  In  consequence  of  the 
continued  pressure,  the  peas  or  beans  soon  form  little 
hollows  for  themselves,  in  which  they  should  he  regu- 
larly placed  every  day.  When  the  pressure  is  not  duly 


DISEASE  OF. 

maintained,  the  granulations  qre  apt  to  rise  so  high, 
that  the  peas  cannot  be  well  kept  on  the  part.  In  this 
circumstance,  the  surgeon  must  try  to  repress  the  high 
surface  of  the  sore  by  sprinkling  on  it  a little  savine 
powder  and  subacetute  of  copper,  mixed  together  in 
equal  proportions.  When  this  plan  is  unavailing,  the 
reapplication  of  the  caustic  becomes  indispensable. 

VVhatever  time  may  be  requisite  to  restore  the  health 
as  well  as  the  use  of  the  limbs,  Mr.  Pott  thinks  that  the 
issues  should  be  kept  open  until  these  objects  are  com- 
pletely fulfilled ; and  even  longer,  especially  in  grow- 
ing children.  He  owns,  that  nothing  can  be  more  un- 
certain than  the  time  required  for  the  cure.  He  has 
seen  it  perfected  in  two  or  three  months  ; and  he  has 
known  it  require  two  years  ; two-thirds  of  which  lime 
passed,  before  there  was  any  visible  amendment. 

After  the  discharge  has  been  made  some  time,  the 
patient  is  found  to  be  belter  in  all  general  respects,  and, 
if  of  age  to  distinguish,  will  acknowledge  that  he  feels 
himself  to  be  belter  in  health  ; he  begins  to  recover  his 
appetite,  gets  refreshing  sleep,  and  has  a more  quiet  and 
less  hectical  pulse  ; but  the  relief  which  he  feels  above 
all  others,  is  from  having  got  rid  of  that  distressing 
sensation  of  tightness  about  the  stomach ; in  a little 
time  more,  a degree  of  warmth  and  a sensibility  are 
felt  in  the  thighs,  w'hich  they  had  been  strangers  to  for 
sometime;  and  generally  much  about  the  same  time, 
the  pow'er  of  retaining  and  discharging  the  uritie  and 
feces  begins  to  be  in  some  degree  exerted. 

The  first  return  of  the  power  of  motion  in  the 
limbs,  says  Mr.  Pott,  is  rather  disagreeable ; the  mo- 
tions being  involuntary,  and  of  the  spasmodic  kind, 
principally  in  the  night;  and  generally  attended  with  a 
sense  of  pain  in  all  the  muscles  concerned. 

At  this  point  of  amendment,  if  it  may  be  so  called,  it 
is  no  uncommon  thing,  especially  in  bad  cases,  for 
the  patient  to  stand  some  lime  without  making  any 
farther  progress ; this,  in  adults,  occasions  impatience, 
and  in  parents,  despair:  but  in  the  milder  kind  of 
case,  the  power  of  voluntary  motion  generally  soon 
follows  the  involuntary. 

The  knees  and  ankles  by  degrees  lose  their  stiff- 
ness, and  the  relaxation  of  the  latter  enables  the  patient 
to  set  his  feet  flat  upon  the  ground,  the  certain  mark 
that  the  power  of  walking  will  soon  follow  ; but  those 
joints,  having  lost  their  rigidity,  become  exceedingly 
weak,  and  are  not  for  some  time  capable  of  serving  the 
purpose  of  progression. 

An  attentive  examination  of  the  morbid  appear- 
ances, and  their  effects  in  different  subjects,  led  Mr. 
Pott  to  conclude,  amons:  other  things,  that  the  disease 
W'hich  produces  these  effects  on  the  spine  and  the  parts 
in  its  vicinity,  is  what  is  in  general  called  scrofula. 

That  ulceration  or  caries  of  the  bodies  of  the  verte- 
brse  affected,  is  the  common  morbid  change,,  and  not 
enlargement. 

That  when  the  attack  is  made  upon  the  dorsal  ver- 
tebrae, the  sternum  and  ribs,  for  want  of  proper  sup- 
port, necessarily  give  way,  and  deformity,  additional 
to  the  curve,  is  produced. 

That  this  kind  of  caries  is  always  confined  to  the 
bodies  of  the  vertebrae,  seldom  or  never  affecting  the 
articular  processes.  Two  cases  were  seen  by  Pott,  in 
which  the  bodies  of  the  vertebrse  were  completely  de- 
tached from  their  processes,  so  as  to  leave  the  mem- 
brane of  the  spinal  marrow  perfectly  bare. 

That  without  this  destruction  of  the  bodies  of  the 
vertebrae,  there  can  be  no  curvature  of  the  kind  here 
treated  of ; or,  in  other  words,  that  erosion  is  the  sine 
qua  non  of  this  disease  ; that  although  there  can  be  no 
true  curve  without  caries,  yet  there  is,  and  that  not  uii- 
frequently,  caries  w'ilhout  curve. 

That  the  caries  with  curvature  and  useless  limbs  is 
most  frequently  of  the  cervical  or  dorsal  vertebrae,  the 
caries  without  curve  of  the  lumbal;  though  this  is  by 
no  means  constant  or  necessary. 

That  in  the  case  of  carious  spine,  without  curvature, 
it  most  frequently  happens  that  internal  abscesses  and 
collections  of  matter  are  formed,  which  matter  makes 
its  way  outwards,  and  appears  in  the  hip,  groin,  or 
thigh;  or,  being  detained  within  the  body,  destroys  the 
patient : the  real  and  immediate  cause  of  whose  death 
is  seldom  known  or  even  rightly  guessed  at,  unless  the 
dead  body  be  examined. 

That  what  are  commonly  called  lumbal  and  psoas 
abscesses  are  not  unfrequenlly  produced  in  this  man- 
ner, and,  therefore,  when  we  use  these  terms,  we  should 


46T 


VERTEBRA,  DISEASE  OF. 


be  understood  to  mean  only  a description  of  the  course 
which  such  matter  has  pursued  in  its  way  outwards  or 
the  place  vvliere  it  makes  its  appearance  externally, 
the  terms  really  meaning  nothing  more,  nor  conveying 
any  precise  idea  of  the  nature,  seat,  or  origin  of  a dis- 
temper subject  to  great  variety,  and  from  wliich  va- 
riety its  very  different  symptoms  and  events  in  different 
subjects  can  alone  be  accounted  for. 

That,  contrary  to  the  general  opinion,  a caries  of  the 
spine  is  more  frequently  a cause  than  an  effect  of 
tliese  abscesses. 

That  the  true  curvature  of  the  spine,  from  within 
outwards,  of  which  the  paralytic  or  useless  state  of  the 
lower  limbs  is  a too  frequent  consequence,  is  itself  but 
07ie  effect  of  a distempered  spine ; such  case  being 
always  attended  with  a number  of  complaints  which 
arise  from  tire  same  cause:  the  generally  received 
opinion,  therefore,  that  all  the  attending  symptoms 
arederived  from  thecurvature, considered  abstractedly, 
is  by  no  means  founded  in  truth,  and  may  be  productive 
of  very  erroneous  conduct. 

That  when  two  or  more  vertebrae  are  affected,  form- 
ing a large  curve,  however  perfect  the  success  of  the 
treatment  may  be  with  regard  to  the  restoration  of 
health  and  limbs,  yet  the  curvature  will  and  must 
remain,  in  consequence  of  the  union  of  the  bones 
with  each  other. 

That  the  useless  state  of  the  limbs  is  by  no  means  a 
consequence  of  the  altered  figure  of  the  spine  or  of 
the  disposition  of  the  bones  with  regard  to  each  other, 
but  merely  of  the  caries:  of  this  truth  there  needs  no 
other  proof  than  what  may  be  drawn  from  the  cure  of 
a large  and  extensive  curvature,  in  which  three  or 
more  vertebrae  were  concerned  ; in  this  the  deformity 
always  remains  unaltered  and  unalterable,  notwith- 
standing the  patient  recovers  both  health  and  limbs. 

Pott  contends,  that  a morbid  state  of  the  parts  pre- 
vious to  deformity,  caries,  or  curve,  must  be  allowed. 
All  the  general  complaints  of  persons  afflicted  with 
this  disorder,  he  says,  will,  upon  careful  inquiry,  be 
found  to  have  preceded  any  degree  of  deformity,  to 
liave  increased  as  the  curve  became  apparent,  and  to 
have  decreased  as  the  means  used  for  relief  took  place : 
the  pain  and  tightness  about  the  stomach,  the  indiges- 
tion, the  want  of  appetite,  the  disturbed  sleep,  &c.  &c. 
gradually  disappear,  and  the  marks  of  returning  health 
become  observable,  before  the  limbs  recover  the  smallest 
degree  of  their  power  of  moving. 

On  the  other  hand,  it  is  admitted  to  be  as  true,  that 
when,  from  extent  or  degree  or  inveteracy  of  the  caries, 
the  issues  are  found  to  be  unequal  to  the  wished-for 
effect,  the  general  complaints  receive  no  amendment; 
but  increase  until  the  patient  sinks  under  them. 

If  all  this  be  true,  says  Mr.  Pott,  and  it  be  found  that 
the  issues  are  capable  of  effecting  a perfect  cure,  even 
after  a caries  has  taken  place,  and  that  to  a consider- 
able degree,  is  it  not  reasonable  to  conclude  that  the 
same  means,  made  use  of  in  due  time,  might  prove  a 
preventive  1 

Eesides  the  forms  of  disease  of  the  spine  treated  of 
in  this  article,  the  observations  of  Mr.  Wilson  prove, 
that  the  distemper  may  sometimes  begin  within  the 
theca  vertebralis,  and  thence  extend  to  the  bones.  He 
also  demonstrated  at  the  College  of  Surgeons,  scrofu- 
lous tumours  in  the  spinal  marrow.  • Such  diseases 
would  create  a loss  of  power  in  the  parts  below  them, 
without  any  curvature  of  the  spine. — {Lectures  on  the 
Skeleton,  Sec.  p-  397.) 

In  France,  the  same  indication  is  followed  as  that  on 
which  Mr.  Pott  lays  stress,  viz.,  to  endeavour  to  arrest 
the  disease  of  the  spine  by  means  applied  in  the  vici- 
nity of  the  morbid  parts.  But  instead  of  employing 
caustic  issues,  the  moxa  is  used,  and  sometimes  re- 
peated cupping  near  the  affected  hones ; both  which 
means  were  particularly  recommended  by  Desault. 

Another  practice  which  yet  has  partisans,  though  it 
was  strongly  disapproved  of  by  Pott,  is  that  of  sup- 
porting the  spine  with  machinery.  Perhaps  the  latter 
author  may  have  carried  his  objections  to  this  method 
beyond  all  reason,  and  with  the  exception  of  Dr.  Har- 
rison (see  J.ond.  Med.  and  Physical  Journ.  J^ov.  1820), 
I believe  no  modern  practitioner  now  ever  advises  it 
on  the  supposition  of  there  being  any  dislocation ; an 
error  which  formerly  prevailed.  As  Mr.  Brodie  ob- 
serves, certainly  no  machines  ought  ever  to  be  em- 
ployed for  the  purpose  of  elongating  the  spine  and  cor- 
recting the  deformity  ; but  if  they  be  used  simply  to 

Gg2 


take  off  the  weight  of  the  head,  chest,  and  upper  ex- 
tremities, from  the  diseased  pan  of  the  spine,  they  may 
sometimes  be  of  service.  The  late  Sir  James  Earle 
had  a very  favourable  opinion  of  their  utility.  1 be- 
lieve, with  Mr.  Brodie,  that  they  ought  never  In  the 
first  instance  to  supersede  the  constant  tnaintenance  of 
the  horizontal  position  ; but  that  they  may  be  advan- 
tageous, when  circumstances  make  it  desirable,  that 
the  patient  should  begin  to  sit  up  a part  of  the  day.— 
{On  Diseases  qf  the  Joint,  p.  291.) 

From  Mr.  Pott’s  own  account,  it  will  be  seen,  that  he 
never  pretended  that  issues  kept  open  in  the  vicinity 
of  the  disease  were  a sure  means  of  relief ; and  a late 
eminent  surgeon  has  actually  referred  the  good  which 
Pott  thought  accrued  from  them,  to  the  long  observance 
of  the  horizontal  posture.  IMr.  Baynton,  the  gentleman 
to  whom  I allude,  also  mentions  that  M.  David  is  the 
only  writer  who  has  suggested  that  rest  would  effect 
the  cure  of  diseases  of  the  spine.  On  this  point,  how- 
ever, Mr.  Baynton  was  entirely  mistaken,  as,  about 
eighteen  years  ago,  Loder  wrote  some  remarks,  par- 
ticularly directed  to  the  object  of  recommending  quie- 
tude in  the  present  disease,  as  the  best  means  of  pro- 
moting anchylosis.— (See  Med.  Chir.  Beobachtungenqp., 
251,  Sve.  Weimar,  1794.) 

Now,  although  I fully  concur  in  the  propriety  of 
keeping  the  patient  asquiet  as  possible  in  the  recumbent 
position,  inasmuch  as  motion  must  be  hurtful  to  the 
diseased  part  of  tlie  spine,  it  does  not  follow,  because 
this  admission  is  made,  that  issues  should  be  rejected, 
and  that  rest  must  do  every  thing.  In  one  part  of  Mr. 
Baynton’s  reasoning,  an  error  prevails,  which  I shall 
here  notice,  as  it  seems  greatly  to  have  influenced  his 
opinions;  and,  as  far  as  1 know,  it  has  not  been  re- 
marked by  the  critical  examiners  of  that  gentleman’s 
book.  The  mistake  is  in  supposing  that  the  process, 
by  which  the  diseased  part  of  the  sjtine  is  to  be  restored 
and  united,  should  be  conducted  exactly  on  the  same 
principles  as  the  union  of  bones  free  from  disease.  In 
fact,  there  is  an  arlditional  indication,  which  is,  to  stop 
the  progress  of  the  disease,  for  which  purpose  expe- 
rience proves  that  issues,  aided  by  rest,  are  the  means 
affording  the  best  chances  of  success.  I have  attended 
several  children  myself,  who,  from  the  effect  of  issues, 
recovered  the  use  of  their  lower  extremities,  even 
though  they  could  not  be  kept  constantly  at  rest.  I 
must  also  give  my  testimony  to  the  truth  of  Mr.  Brodie’s 
statement,  that  many  patients  are  benefited  almost 
immediately  the  issues  are  made,  or  uniformly  find 
themselves  better  after  each  application  of  the  caustic. 
— {On  Diseases  of  Joints,  p.  282.)  In  some  cases, 
however,  caustic  issues  fail  to  afford  relief;  and  when 
they  are  of  no  use,  rest  in  the  horizontal  posture,  below 
ground,  I believe,  must  soon  be  the  patient’s  doom. 
Whether  the  occasional  failure  of  issues  is  to  be 
ascribed  to  tiie  advanced  progress  which  the  disease  has 
made,  or  to  its  having  begun  in  the  cancellous  structure 
of  the  vertebrte,  as  suggested  by  Mr.  Brodie,  future  ob- 
servation must  decide.^ 

I have  now  under  my  care  a patient,  who  lost  the 
faculty  of  sensation  in  one  leg,  and  yet  retained  in  it 
the  power  of  motion  ; while  the  other  leg  was  deprived 
of  motion,  but  not  of  feeling.  By  blistering  the  loins 
and  sacrum,  and  giving  tonics  and  aperient  medicines, 
I have  so  far  succeeded  in  curing  the  patient,  that  he 
can  walk  about  his  room,  and  the  power  of  feeling,  in 
the  limb  that  was  deprived  of  it,  is  restored.  Cases  of 
this  description  tend  to  confirm  the  new  and  interesting 
doctrine  of  the  double  roots  of  the  spinal  nerves. 

Consult  Pott's  Chirurgical  Works,  vol.  3.  G.  Gehb^ 
Select  Cases  of  the  Disorder  commonly  termed  Paralysis 
of  the  Lower  Extremities,  Bvo.  Land.  1782.  C.  H. 
Wilkinson,  Essays  on  Distortion  of  the  Spine,  S,-c.Qvo. 
Lond.  1798.  Loder,  Med.  Chir.  Beobachtungen,  b.  1, 
p.  247,  (S-c.  8vo.  Weimar,  1794.  .7.  C.  Frank,  Oratio  de 

Vertebralis  Columna;  in  Mnrhis  Dignitute,  Pavia, 
1791.  C.  Van  Roy,  De  Scolinsi,Ato.  Lugd.  \11A.  Sir 
J.  Earle,  Observations  on  the  Cure  of  Carved  Spine; 
in  which  the.  effect  of  Mechanical  Assistance  is  consi- 
dered, 8no.  Jwnd.  1803.  Bcrgamaschi,  Osservazioni 
sulla  Tnflammazione  dello  Spinnle  Medollo  e delle  sue 
Membrane,  Ato.  Pav.  1810.  T.  Baynton,  An  Account 
of  a Successful  Method  of  Treating  Diseases  of  the 
Spine,  8vn.  Bristol,  1813.  /{.  Earle,  in  Ed  in.  Med.  and 

Surg.  .Tourn.  far  January,  1815.  ./.  L.  Choulant, 

Dccas  Pelviurn  Spinarnmqae  Deformatarum,  Ato.  Lips. 
1818.  G.  Malsch,  De  nova  Machina  Oraefiana  Distor- 


468 


WHl 


WHI 


tiones  Spine  Dorsi  ad  Saiiandas,  necnon  Disquisitio 
IJeformitatum  istarum,  4fo.  Berol,  1818.  Abercrombie, 
in  Edin.  Med.  and  Surg.  Journ.  for  January,  1818. 
Kapelar,  in  Annuaire  Med.  Chir.  des  Hdpitaux  de 
Paris,  t.  \,p.  390, 4to.  Paris,  1819.  T.  Copeland,  Ubs. 
on  the  Symptoms  and  Treatment  of  Diseased  Spine,  8vo. 
B.  C.  Brodie,  Pathological  and  Surgical  Observations 
on  the  Joints,  p.  257,  <S-c.  Qvo.  Bond.  1818.  James 
Wilson,  Lectures  on  the  Structure  and  Physiology  of 
the  Skeleton,  and  on  the  Diseases  of  the  Bones  and 
Joints,  p.  395, 8co.  Land.  1820.  W.  T.  Ward,  Distor- 
tions of  the  Spine,  Chest,  and  Limbs,  8vo.  Bond.  1822. 
J.  Shaw,  on  the  JTature  and  Treatment  of  Distortions 


to  which  the  Spine  and  Bones  of  the  Chest  are  subjectf 
Src-  8vo.  Bond.  1823.  J.  Boyle  on  Moza  and  Spinal 
Diseases,  8vo.  Bond.  1825. 

VINEGAR.  See  Acetic  Acid. 

VINUM  OPII.  Take  of  extract  of  opium 
cinnamon  bark  bruised,  cloves  bruised,  of  each  3j.; 
wine  a pint.  Macerate  for  eight  days,  and  filter.  The 
thebaic  tincture,  or  liquid  laudanum  of  Sydenham.  In 
surgery,  it  is  often  preferred  to  the  common  tincture  of 
opium,  as  an  application  to  the  eye. 

VIPER,  BITE  OF.  See  Wounds. 

VOLVULUS.  (From  volvo,  to  roll  up.)  See  Intus- 
susception. 


w 


ART.  Mr.  Hunter  observes,  that  a wart  appears 
* “ to  be  an  excrescence  from  the  cutis,  or  a tumour 
formed  upon  it,  by  which  means  it  becomes  covered 
with  a cuticle,  which  is  either  strong  or  hard,  or  thin 
and  soft,  just  as  the  cuticle  is  that  covers  the  parts  from 
which  the  excrescence  arises.  Warts  are  radiated  from 
their  basis  to  their  circumference.  The  surface  of  the 
radii  appears  to  be  pointed,  or  granulated,  like  the  sur- 
face of  healthy  granulations,  with  the  e.xception  of 
being  harder  and  rising  higher.  The  surface  on  which 
a wart  is  formed  seems  only  to  be  capable  of  producing 
one;  for  the  surrounding  and  connecting  surface  does 
not  throw  out  a similar  substance.  Thus,  when  a wart 
has  once  begun  to  grow,  it  rises  higher  and  higher 
without  becoming  larger  at  its  basis.  Such  excrescences 
seem  to  have  within  themselves  the  power  of  growing ; 
for,  as  Hunter  remarks,  after  they  have  risen  above  the 
surface  of  the  skin,  on  which  their  basis  cannot  grow 
larger,  they  swell  out  into  a round  thick  substance, 
which  becomes  rougher  and  rougher. 

In  consequence  of  this  structure,  warts  are  liable  to 
be  hurt  by  bodies  rubbing  against  them,  and  from  such 
a cause  they  often  bleed  very  profusely,  and  are  ren- 
dered sore  and  painful. — (On  the  Venereal  Disease,  p. 
250,  edit.  2.) 

As  warts  are  adventitious  substances,  and  not  any 
part  of  the  original  structure  of  the  body,  their  powers 
of  life  are  weak.  Hence,  when  stimulated  they  gene- 
rally become  smaller,  and  at  length  altogether  disap- 
pear or  drop  oft’. 

On  this  principle  warts  may  frequently  be  cured  by 
the  application  of  the  tinctura  ferri  muriati,  sulphate 
of  copper,  or  a powder  composed  of  the  powders  of 
savine  leaves  and  the  subacetate ‘of  copper,  in  equal 
proportions. 

However,  the  employment  of  stronger  escharotics, 
like  the  nitrate  of  silver  or  the  cr)ncentrated  acetic 
acid  ; the  removal  of  such  excrescences  with  a knife 
or  pair  of  scissors ; or  tying  their  necks  with  a ligature ; 
are  plans  frequently  pre-ferred,  because  the  cure  is 
sooner  accomplished. 

The  last  two  methods  are  eligriile  when  the  wart  has 
a narrow  neck  ; but  after  the  removal  of  the  excres- 
cence, it  is  still  proper  totouch  the  root  with  the  caustic 
or  the  acetic  acid;  for  unless  the  whole  be  completely 
destroyed,  the  wart  will  inevitably  grow  again. 

Warts  on  the  pudenda  and  about  the  anus,  scarcely 
ever  withstand  the  effect  of  the  powder  of  savine,  and 
subacetate  of  copper,  though  they  will  sometimes  resist 
a course  of  mercury  adequate  to  cure  lues  venerea ; a 
consideration  which  led  Mr.  Hunter  to  believe  them  not 
to  be  syphilitic.  In  this  opinion,  I believe  all  the  best 
surgeons  of  the  present  day  concur. 

WHITLOW.  ( Panaris,  Onychia,  Panaritium,  Pa- 
ronychia.) A whitlow  is  an  inflammation  at  the  end 
of  one  of  the  fingers  or  thumb,  exceedingly  painful,  and 
very  much  disposed  to  suppurate.  The  toes  are  also 
sometimes  the  seat  of  the  disease. 

Writers  usually  divide  whitlows  into  four  kinds.  In 
the  first  or  mildest,  a vesicle  filled  with  matter  com- 
monly arises  near  the  root  or  side  of  the  nail,  after  a 
superficial  inflammation  of  trivial  extent.  The  matter 
is  situated  immediately  under  the  cuticle.  Sometimes 
the  abscess  takes  place  under  the  nail,  in  which  case 
the  pain  is  severe,  and  not  (infrequently  shoots  uowards 
as  far  as  the  external  condyle. 


The  second  kind  of  whitlow  is  chiefly  situated  in  the 
cellular  substance  under  the  cutis,  and  for  the  most 
part  occurs  at  the  very  end  of  the  finger.  In  this  case 
the  inflammatory  symptoms,  especially  the  pain,  are 
far  more  violent  than  in  other  conwnon  inflammations 
of  not  greater  extent.  However,  although  the  pain  is 
thus  severe,  it  does  not  in  general  extend  far  from  the 
part  affected.  Writers  usually  impute  the  violence  of 
the  pain,  and  the  considerable  degree  of  inflammation 
attending  the  complaint,  to  the  hard  and  unyielding 
nature  of  the  skin  on  the  finger.  To  the  same  cause 
they  also  ascribe  the  difficulty  of  perceiving  any  fluc- 
tuation, after  matter  is  formed  ; and  the  slowness  with 
which  the  pus  makes  its  way  outwards. 

The  third  kind  of  whitlow  is  distinguishable  from 
the  otheis  by  the  following  circumstances.  With  the 
most  excruciating  pain,  there  is  little  swelling  in  the 
affected  finger,  but  a vast  deal  in  the  hand,  particularly 
about  the  wrist,  and  over  the  whole  forearm.  The 
pain  extends  to  the  hand,  wrist,  elbow,  and  even  the 
shoulder.  When  suppuration  takes  place,  a fluctuation 
can  never  be  felt  in  the  finger,  though  it  may  often  be 
distinctly  perceived  in  the  hand,  at  the  wrist,  or  even 
somewhere  in  the  forearm.  The  case  is  frequently 
accompanied  with  considerable  fever.  The  disease  is 
seated  in  the  tendons  and  their  sheaths,  and  the  power 
of  moving  the  fingers,  and  even  the  w’hole  hand,  is  lost. 

Authors  describe  the  fourth  kind  of  whitlow,  as 
arising  principally  from  an  inflammation  of  the  perios- 
teum. The  case  is  attended  with  one  peculiarity, 
which  is,  that  however  violent  the  pain  may  be,  k 
never  extends  to  the  hand  and  forearm,  nor  is  there 
any  external  swelling  of  the  affected  finger.  Suppu- 
ration generally  follows  very  soon,  the  usual  conse- 
quence of  which  is  a caries,  or  rather  a necrosis  of  tire 
subjacent  finger-bones. 

Whklows  commonly  begin  on  the  inside  of  the 
fingers ; but  they  do  occasionally  commence  on  the 
back  of  these  parts,  and  even  on  that  of  the  hand. 
Though  pain  about  the  wrist  is  usually  the  effect  of 
inflammation  in  the  finger,  Acrel  mentions  a case  in 
which  the  disorder  was  altogether  coitfined  to  the  hand 
itself. — ( Vorfdlhe,  b.2,  p.  191.) 

Mr.  Wardrop  has  favoured  the  public  with  an  ac- 
count of  a particular  species  of  whitlow,  which,  from; 
its  nralignant  character,  he  has  denominated  the  onychia 
maligna.  “ The  commencement  of  this  disease  is 
marked  by  a degree  of  swelling,  of  a deep  red  colour, 
in  the  soft  parts  at  the  root  of  the  nail.  An  oozing  of 
a thin  ichor  afterward  takes  place  at  the  cleft  fm  med 
between  the  root  of  the  nail  and  soft  parts,  and  at  last 
the  soft  parts  begin  to  ulcerate.  The  ulcer  appears  on 
the  circular  edge  of  the  soft  parts  at  the  root  of  the 
nail;  it  is  accompanied  with  a good  deal  of  swelling, 
and  the  skin,  particularly  that  which  is  adjacent  to  the 
ulcer,  has  a deep  purple  colour.  'The  appearance  of 
the  ulcer  is  very  unhealthy,  the  edges  being  thin  and 
acute,  and  its  surface  covered  with  a dull  yellow  or 
brown-coloured  lymph,  and  attended  with  an  ichorous 
and  very  fetid  discharge.  The  growth  of  the  nail  is 
interrupted,  it  loses  its  natural  colour,  and  at  some 
places  appears  to  have  but  little  connexion  with  the 
soft  parts.  In  this  state  (says  Mr.  Wardrop)  I have 
seen  the  disease  continue  for  several  years,  so  that  the 
toe  or  finger  became  a deformed  bulbous  mass.  The 
pain  is  sometimes  very  acute ; but  the  disease  is  more 


WHITLOW. 


469 


■commonly  indolent,  and  accompanied  with  little  un- 
easiness. This  disease  affects  both  the  toes  and  the 
fingers.  I have  only  observed  it  on  the  great  toe,  and 
more  frequently  on  the  thumb  than  any  of  the  fingers. 
It  occurs,  too,  chiefly  in  young  people ; but  I have  also 
seen  adults  affected  with  it.” — (^fVardrop,  in  Med.  Chir. 
Trans,  vol.  5,  p.  135,  136.) 

The  causes  of  whitlows  are  generally  of  a local  na- 
ture. Writers  enumerate  the  following  as  the  most 
common:  a contusion;  suddenly  warming  the  finger 
when  it  is  exceedingly  cold;  pricks  with  needles  or 
other  sharp  instruments  ; and  the  insinuation  of  irri- 
tating matter  into  scratches  on  the  finger.  A surgeon, 
in  operating  for  a fistula  in  ano,  has  been  known  to  cut 
his  finger,  and  have,  in  consequence  of  the  accident,  a 
very  severe  and  dangerous  kind  of  whitlow.  Richter 
also  mentions  a person,  who  had  a most  obstinate 
whitlow,  in  consequence  of  a slight  wound  on  the  fin- 
ger, in  examining  the  head  of  a horse  that  had  the 
glanders.  Sometimes  the  cause  of  a whitlow  depends 
on  a splinter  or  thorn  which  continues  lodged  in  the 
part.  Very  often  no  particular  cause  whatever  can  be 
assigned  for  the  complaint. 

The  first  case,  which  occurs  about  the  root  of  the 
rail,  ought  to  be  opened  as  soon  as  possible.  When 
this  plan  is  not  adopted,  the  matter  is  apt  to  penetrate 
more  deeply,  reach  the  root  of  the  nail,  and  occasion 
a loss  of  this  part.  When  an  effectual  opening  is  not 
made,  the  matter  collects  again.  In  general,  a detach- 
ment of  the  cuticle  takes  place  as  far  as  the  abscess 
extends.  When  the  inflammation  has  been  very  vio- 
lent, and  the  matter  has  made  its  way  as  far  as  the 
loot  of  the  nail,  the  nail  itself  is  in  general  gradually 
detached,  while  the  denuded  portion  of  the  root  of  the 
nail  acts  on  the  sore  as  a foreign  body,  and  hinders  it 
from  healing.  Hence,  the  surgeon  should  repeatedly 
cut  away  as  much  of  the  lower  edge  of  the  nail  as  he 
can,  and  insinuate  a little  soft  lint  between  the  margin 
of  the  nail  and  the  sore,  in  order  to  keep  the  latter 
from  being  irritated  by  the  former.  In  proportion  as 
the  old  nail  gradually  separates  a new  one  makes  its 
appearance. 

When  matter  lies  under  the  nail,  an  opening  should 
be  made  through  the  part  as  speedily  as  possible  for  the 
discharge  of  the  abscess.  In  order  to  perform  this 
operation,  Richter  advises  the  surgeon  to  scrape  the 
nail  with  a piece  of  glass  till  it  is  as  thin  as  it  can  well 
be,  when  it  maybe  cut  through  with  a bistoury. 

In  the  second  species  of  whitlow,  suppuration  may 
sometimes  be  prevented,  and  the  inflammation  be  re- 
solved by  the  timely  employment  of  proper  means. 
When  the  pain  is  violent,  and  acute  fever  prevails,  it 
may  be  advisable  to  bleed  the  patient.  In  a few  se- 
vere cases,  the  application  of  three  or  four  leeches  to 
the  affected  finger  has  been  known  to  procure  prompt 
relief. — (Schmucker.)  Theden  thinks,  that  applying  a 
roller  round  the  finger,  hand,  and  arm,  and  frequently 
•Vetting  the  first  two  parts  with  a lotion,  are  the  most 
certain  means  of  resolving  the  inflammation.  Plainer 
advises  the  finger  to  be  for  some  time  immersed  in 
water  as  warm  as  the  patient  can  bear.  Some  recom- 
mend the  external  use  of  camphorated  spirit,  or  the 
linimentum  ammonisE ; while  others  advise  the  affected 
finger  to  be  plunged  in  a warm  solution  of  soap,  or  an 
alkaline  lotion.  When  the  whitlow  is  occasioned  by 
a prick,  particular  care  must  be  taken  that  no  extrane- 
ous substance  remain  in  the  puncture. 

When  the  symptoms  do  not  abate  by  the  fourth  day, 
Richter  recommends  an  opening  to  be  made.  Even 
when  no  fluctuation  is  discovered  he  approves  oSu' 
making  a crucial  incision  in  the  seat  of  the  pain,  and 
he  states,  that  although  no  matter  may  be  discharged, 
the  patient  always  derives  infinite  relief  from  the  ope- 
ration. The  benefit,  he  says,  may  either  be  imputed 
to  the  bleeding  or  to  the  divi.sion  of  the  hard  tense 
skin,  which  compresses  the  subjacent  inflamed  parts. 
Sometimes  the  collection  of  matter  can  be  plainly  felt, 
and,  in  this  case,  there  can  be  no  hesitation  about  the 
plar^  where  the  opening  should  be  made.  However, 
it  may  be  proper  to  remark,  that  the  opening  should 
always  be  made  sufficiently  large.  When  the  surgeon 
makes  a small  puncture  it  soon  closes  again,  and  a re- 
petition of  the  operation  becomes  necessary.  When 
opening  the  abscess  is  delayed,  the  theca  of  the  flexor 
tendons  easily  becoities  affected,  or  the  matter  may 
spread  to  a considerable  extent  under  the  akin.  Some- 
times it  makes  its  way  through  the  cutis  by  ulceration. 


and  raises  up  the  cuticle.  In  this  case,  as  soon  as  the 
cuticle  has  been  opened,  a director  should  be  introduced 
into  the  aperture  in  the  skin,  and  the  latter  opening  be 
enlarged  with  a bistoury. 

The  third  species  of  whitlow  seldom  affects  the  last 
phalanx  of  the  fingers;  but  generally  the  second  or 
third.  In  this  case,  Richter  enjoins  us  never  to  defer 
making  an  opening  longer  than  the  third  day.  If  we 
wait  till  suppuration  happens,  we  shall  wait  till  the 
tendons  are  destroyed  and  the  use  of  the  finger  is  lost. 
In  the  case  under  consideration,  the  matter  is  always 
of  bad  quality  and  very  small  in  quantity.  A fluctua- 
tion in  the  finger  can  seldom  be  felt.  However,  in  a 
few  instances,  the  matter  is  perceptible  at  the  extremity 
of  the  finger  or  about  the  finger-joints ; but  more  often 
in  the  palm  of  the  hand,  or  near  the  wrist.  In  these 
circumstances  the  tendons  are  in  general  already  de- 
stroyed, and  a stiffness  of  the  finger  and  hand  is  to  be 
apprehended.  When  the  complaint  is  the  consequence 
of  a puncture,  the  best  plan,  according  to  Richter,  is  at 
once  to  enlarge  the  wound ; for,  in  tliis  sort  of  case,  all 
other  methods  are  unavailing.  It  is  not  enough,  how- 
ever, to  cut  through  the  skin;  the  tendinous  theca 
itself  must  be  laid  open. 

When  a collection  of  matter  forms  towards  the 
wrist,  attended  with  violent  pain  in  that  situation,  an 
opening  must  also  be  made  there.  If  an  opening 
should  have  already  been  made  in  the  hand,  a probe 
may  be  introduced  into  the  wound,  and  another  aper- 
ture made  in  an  eligible  situation  by  cutting  on  the 
end  of  the  instrument.  In  the  same  way  Richter  ad- 
vises an  opening  to  be  made  in  any  part  of  the  fore- 
arm, where  great  pain,  or  the  symptoms  of  suppura- 
tion may  indicate  its  propriety. 

In  the  fourth  kind  of  whitlow,  early  incisions  made 
down  to  the  bone  are  the  most  certain  means  of  ob- 
viating the  danger.  When  such  incisions  are  not  made 
early  enough,  suppuration  takes  place,  and  the  bone 
perishes.  The  cut  is  to  be  made  in  the  place  where 
the  pain  is  most  severe.  When  the  first  phblanx  is 
affected,  the  incision  may  be  made  in  front  of  the  fin- 
ger, but  when  the  second  or  third  is  the  seat  of  the 
complaint,  the  opening  should  be  made  on  one  side. 
However,  in  order  that  the  opening  may  be  useful,  it 
is  absolutely  necessary  to  make  it  down  to  the  bone. 
When  the  incision  is  delayed  too  long,  a small  quan- 
tity of  unhealthy  matter  is  usually  detected,  and  the 
bone  is  found  in  the  state  of  necrosis.  As  an  exfolia- 
tion can  hardly  be  expected  in  this  situation,  it  is  best 
to  remove  at  once  the  diseased  piece  of  bone.  When 
the  last  phalanx  alone  is  affected,  the  finger  retains  its 
form,  with  the  exception  of  its  end  being  a little  shorter 
and  flatter.  When  the  disease,  however,  is  situated 
in  the  third  phalanx,  Richter  thinks  it  better  to  am- 
putate the  finger  than  remove  the  diseased  bone,  as  the 
finger,  if  left,  would  always  remain  stiff  and  unser- 
viceable.— (See  Anfangsgr.  der  Wundarzneykunst, 
vol.  7.) 

With  regard  to  the  treatment  of  the  species  of  wliit- 
low  named  by  Mr.  Wardrop  onychia  maligna,  all  local 
applications  have  in  many  instances  proved  quite  in- 
effectual, and  the  part  been  amputated.  The  only  local 
treatment  which  Mr.  Wardro[)  has  ever  seen  relieve 
this  complaint  has  been  the  evulsion  of  the  nail,  and 
afterward  the  occasional  application  of  escharotics  to 
the  ulcerated  surface.  I have  myself  seen  a similar 
plan  occasionally  succeed,  and  the  applications  which 
appeared  to  answer  best  were  arsenical  lotions,  Plun- 
ket’s  caustic,  or  a very  strong  sohiiion  of  the  nitrate 
of  silver.  Nothing,  however,  will  avail,  till  the  nail  is 
removed,  and  its  total  separation  sometimes  takes  up  a 
good  deal  of  time,  unless  the  patient  submit  to  the 
great  pain  of  having  it  cut  away. 

In  four  cases  of  the  onychia  maligna,  Mr.  Wardrop 
tried  with  success  the  exhibition  of  mercury.  It  was 
given  in  small  doses  at  first,  and  afterward  increased, 
so  as  to  affect  the  gums  in  about  twelve  or  fourteen 
days.  When  the  system  was  in  this  state,  the  sores  in 
general  soon  assumed  a healing  appearance,  and  the 
bulbous  swelling  gradually  disappeared. — (See  Med- 
Chir.  Trans,  vol.  5,  p.  138.) 

[Dr.  .1.  B.  Whitridge,  of  Charleston,  S.  C.,  informs 
me,  that  in  cases  of  whitlow,  when  by  neglect  or  mal 
treatment  the  bone  becomes  carious,  he  has  frequently 
preserved  the  member  by  a timely  removal  of  the  dis- 
eased bone.  Persons  much  in  the  habit  of  using  the 
pen,  and  others  whose  livelihood  depeiwls  on  their  re- 


470 


WOU 


WOU 


taining  the  use  of  the  thumb  and  fore  finger,  are  the 
subjects  to  whom  this  operation  is  sometimes  signally 
beneficial.  Dr.  W.  has  several  limes  removed  the  bone 
of  the  first  phalanx,  and  twice  that  of  the  second, 
and  still  preserved  sutficient  flexibility  of  the  member 
to  use  it  with  tolerable  dexterity.  The  other  fingers, 
under  similar  circumstances,  may  be  amputated  with- 
out materially  interfering  with  ordinary  manipulations. 

This  disease  is  so  often  neglected  or  mismanaged  by 
timid  practitioners,  that  in  the  cases  alluded  to,  it  is 
often  important  to  be  possessed  of  a remedial  means 
at  once  so  professional  and  so  humane. — Reese.'[ 

WOUNDS.  A great  deal  of  the  subject  of  wounds 
has  been  already  considered  in  the  articles  Gun-shot 
Wounds;  Head,  Injuries  of;  Hemorrhage-,  Hydro- 
phobia; Parotid  Duct ; Sutures;  Tetanus;  Throat ;S,-c. 

A wound  may  be  defined  to  be  a recent  solution  of 
continuity  in  the  soft  parts,  suddenly  occasioned  by 
external  causes,  and  generally  attended  at  first  with 
hemorrhage. 

Wounds  in  general  are  subject  to  considerable  variety 
in  their  nature,  degree  of  danger,  facility  of  cure,  and 
the  consequences  which  are  to  be  apprehended  from 
them.  Some  wounds  are  quite  trivial,  not  extending 
more  deeply  than  the  skin  and  cellular  membrane; 
while  others  are  very  serious  and  dazigerous,  penetrat- 
ing the  muscles,  tendons,  large  blood-vessels,  and  nerves 
of  importance.  There  are  also  certain  wounds  which 
are  not  confined  to  the  soft  parts,  but  injure  even  the 
bones;  such  are  many  sabre-cuts,  which  frequently 
separate  at  once  both  a portion  of  the  scalp  and  the 
subjacent  part  of  the  skull.  Many  wounds  of  the  head, 
chest,  and  abdomen  injure  the  organs  contained  in 
those  cavities.  In  short,  the  vaiieties  and  the  degree 
of  danger  attending  wounds  in  general,  depend  very 
much  upon  some  of  the  following  circumstances : the 
e.xtent  of  the  injury;  the  kind  of  instrument  with 
which  it  has  been  inflicted;  the  violence  which  the 
fibres  qf  the  part  have  suffered,  in  addition  to  their 
division ; the  size  and  importance  of  the  blood-vessels 
and  nerves  which  happen  to  be  injured  ; the  nature  of 
the  wounded  part,  in  respect  to  its  general  power  of 
healing  favourably  or  not ; whether  the  operations  of 
the  system  at  large,  and  life  itself,  can  be  well  sup- 
ported or  not,  while  the  functions  of  the  wounded  part 
are  disturbed,  interrupted,  or  suspended  by  the  acci- 
dent; the  youth  or  old  age  of  the  patient;  the  good- 
ness or  badness  of  his  constitution ; and  the  opportu- 
nities which  there  may  be  of  administering  proper  sur- 
gical aid  and  assistance  of  every  kind. 

All  wounds  of  considerable  size  or  depth,  not  pro- 
ducing immediate  death,  are  followed  by  more  or  less 
disturbance  of  the  whole  constitution;  by  a fever, 
which,  on  account  of  its  being  an  effect  of  the  local 
injury,  is  sometimes  called  symptomatic ; and  some- 
times sympathetic,  in  consequence  of  its  being,  as  it 
were,  the  sympathy  of  the  whole  animal  economy 
with  the  wounded  part.  It  is  likewise  frequently 
named  inflammatory  fever,  as  being  a constant  attend- 
ant on  severe  inflammation.  A description  of  it  will 
be  found  in  another  part  of  this  work. — (See  Fevers.) 

Wounds,  especially  those  of  the  fingers  and  toes, 
and  other  tendinous  parts,  are  occasionally  productive 
of  another  form  of  constitutional  disturbance,  affecting 
in  a violent  degree  the  muscular  system,  and  well 
known  by  the  name  of  locked-jaw.  Of  this  I have 
fully  treated  in  another  article. — (See  Tetanus.) 

Profusely  suppurating  wounds,  the  cure  of  which  is 
retarded  by  any  incidental  circumstances,  invariably 
bring  on  great  debility,  and  a particular  disturbance  of 
the  sanguiferous,  secreting,  digestive,  nervous,  and 
other  systems,  known  by  the  name  of  hectic  fever,  of 
which  I have  also  delivered  an  account. — (See  Fevers.) 

Another  complication  of  wounds,  often  met  with  in 
crowded  military  hospitals,  is  a peculiar  species  of 
mortification,  frequently  supposed  to  be  contagious; 
and  already  described  in  the  article  Hospital  Gan- 
grene. 

Besides  these  consequences  of  wounds,  it  is  my  duty 
to  mention  another  very  common  one,  which  seems  to 
be  intimately  connected  with  the  patient’s  temperament 
or  habit  of  body.  I here  allude  to  erysipelas,  which 
may  be  excited  by  a wound,  in^iead  of  healthy  phleg- 
monous inflammation. — (See  Erysipelas.) 

I may  as  well  here  also  briefly  advert  to  another  com- 
plication of  wounds;  namely,  toiheforniation  of  absces- 
ses in  the  liver,  lungs,  around  the  joints,  or  in  other  im- 


portant organs,  sfttiated  at  a considerable  distance  from 
the  wounded  part.  These  occasional  suppurations  in 
the  liver  and  lungs,  after  injuries  of  the  head,  have  been 
known  to  surgeons  for  the  last  sixty  or  seventy  j ears. 
They  have  been  noticed  by  Le  Dran,  Schmucker,  and 
Klein ; and  they  have  again  been  recently  brought  un- 
der consideration  by  Mr.  Rose  and  Mr.  Arnott.— -(See 
Med.  Chir.  Trans,  vols.  14  and  15.)  The  latter  writer 
conjectures,  that  they  may  depend  upon  the  absorption 
of  some  specific  matter  from  the  wounded  part,  and,  as 
I have  elsewhere  detailed  (see  Veins),  he  imputes  tlie 
fatal  symptoms  of  phlebitis,  in  which  similar  abscesses 
are  frequently  found  in  the  viscera,  or  around  tlie  joints, 
to  the  same  cause,  and  not  to  the  extension  of  the  in- 
flammation along  the  lining  of  tlie  vein  to  the  veiite 
cavte,  and  even  the  heart. 

Wounds  are  distinguished  by  surgical  writers  into 
several  kinds  ; viz.  incised,  punctw-ed,  contused,  lace- 
rated, poisoned,  and  gun-shot  loounds.  They  also  make 
another  equally  important  division  into  TVotmds^of  the 
Head,  Thorax,  Abdomen,  ire. 

Of  gun-shot  wounds,  and  wounds  of  the  head,  an  ac- 
count has  already  been  given. — (See  Gun-shot  Wounds, 
and  Head,  Injuries  of.)  The  other  cases  I shall  now 
proceed  to  consider. 

Incised  Wounds. — As  a general  observation,  it  may 
be  slated  that,  caeteris  paribus,  a wound  which  is  made 
with  a sharp  cutting  instrument,  which  is,  in  short,  a 
mere  incision,  is  attended  with  less  hazard  of  danger- 
ous consequences  than  any  other  kind  of  wound 
whatever.  The  fibres  have  only  been  simply  divided  ; 
they  have  suffered  no  contusion  nor  laceration ; con- 
sequently, they  are  less  likely  to  inflame  severely,  or  to 
suppurate,  or  slough;  and  they  commonly  admit  of 
being  united  again  in  a very  expeditious  manner. 

Generally,  simple  incised  wounds  bleed  more  freely 
than  contused  and  lacerated  ones,  which  at  first  some- 
times scarcely  pour  out  any  blood  at  all,  although  con- 
siderable blood-vessels  may  be  injured.  But  this  cir- 
cumstance, apparently  diminishing  the  danger  of  con- 
tused and  lacerated  wounds,  is  deceitful,  and  serves  ra- 
ther to  render  the  case  in  reality  more  perilous,  by  in- 
ducing the  inexperienced  practitioner  to  be  off'  his 
guard  against  hemorrhage.  Thus,  in  gun-shot  wounds, 
it  often  happens,  that  on  their  first  occurrence  the  bleed- 
ing is  trivial ; but  the  side  of  some  large  artery  having 
suffered  great  violence  at  the  time  of  the  accident,  it 
may  ulcerate  or  slough,  a week  or  ten  days  afterward, 
and  an  alarming,  and  even  fatal,  effusion  of  blood  be 
the  result. 

In  cases  of  simple  incised  wounds,  the  bleeding, 
which  at  once  takes  place  from  all  the  divided  vessels, 
is  a source  of  very  useful  information  to  the  surgeon, 
inasmuch  as  it  enables  him  to  judge  what  danger  is  to 
be  apprehended  from  the  hemorrhage,  whether  the  cut 
vessels  are  large  enough  to  demand  the  ligature,  or,  on 
the  contrary,  whether  they  are  such  as  will  cease  to 
bleed  either  by  slight  pressure  or  of  their  own  accord. 

In  a recent  simple  incised  wound,  there  are  three  ob- 
jects which  the  surgeon  should  endeavour  to  accom- 
plish without  the  least  delay.  The  first,  and  that  which 
requires  his  immediate  interference,  is  the  bleeding, 
which  must  be  checked.  The  second  is  the  removal 
of  all  extraneous  matter  from  the  surface  of  the  wound. 
Tlie  third  is  the  reunion  of  the  opposite  sides  of  tire 
injury. 

When  the  divided  vessels  are  not  above  a certain 
size,  the  bleeding  soon  spontaneously  ceases,  and  no 
surgical  measures  need  be  taken  on  this  particular  ac- 
count. When  the  wounded  vessels  are  even  somewhat 
larger,  and  their  situation  is  favourable  for  compres- 
sion with  a bandage,  it  is  often  advisable  to  close  the 
wound  and  apply  compresses  and  a roller,  rather  than 
have  recourse  to  ligatures,  which  always  create  a cer- 
tain degree  of  irritation  and  suppuration.  However, 
thoiich  I have  made  this  observation,  I should  be  ex- 
ceedingly sorry  to  appear  at  all  against  the  general  pre- 
ference to  ligatures,  whenever  the  wounded  arteries 
are  above  a ce4aain  magnitude.  In  this  circumstance, 
tying  the  bleeding  vessels  is  the  only  safe  mode  of  pro- 
ceeding. When  the  aitery  is  of  considerable  size,  and 
its  mouth  can  be  readily  seen,  the  most  proper  instru- 
ment for  taking  hold  of  it  is  a pair  of  forceps,  lii  ap- 
plying the  ligature,  the  surgeon  must  take  care  to  pull 
its  ends  in  such  a manner  that  the  noose  will  not  rise 
above  the  mouth  of  the  vessel,  and  for  the  purpose  of 
altering  the  direction  of  the  force  employed  in  lighten 


WOUNDS. 


471 


hJg  the  ligature,  the  ends  of  the  thunsbs  are  generally 
made  use  of.  The  tenaculum  is  coiiunonly  employed 
for  taking  up  arteries,  which  are  not  large  and  distinct. 

Fine  ligatures,  of  sufficient  strength,  are  at  present 
often  applied,  as  well  to  large  as  small  vessels  ; an  ini- 
provemenl,  to  the  establishment  of  which  the  experi- 
ments of  Dr.  Jones,  and  the  writings  of  Dr.  Veitch,  ma- 
terially contributed.  One  half  of  each  ligature  should 
always  be  cut  off  before  the  wound  is  closed,  and  there 
are  some  surgeons  who  prefer  the  method  of  cutting  off 
all  the  ligature,  except  what  forms  the  noose  imme- 
diately round  the  artery. — (Z>e/j>ecA,  Mini,  sur  la  Pour- 
riture  d'  U^pital,  29 ; Lawrence,  in  Med.  Chir,  Trans, 
vol.  6,  p.  156.}  To  the  latter  plan,  however,  a few  sur- 
geons have  adduced  objections,  particularly  Mr.  Gitthrie, 
who  only  admits  the  utility  of  it  in  cases  where  the 
wound  will  not  unite  by  the  first  intention  (On  Gun- 
shot fVounds,  p.  94),  and  Mr.  Cross,  of  Norwich. — 
(See  the  London  Medical  Repository,  vol.  7,  p.  353.) 
The  experiments  of  Mr.  Cross  tend  to  the  following 
conclusions ; 

First,  If  the  wounds  do  not  unite  by  the  first  inten- 
tion, tire  ligatures  may  escape  with  the  discharge,  with- 
out any  inconvenience. 

Secondly,  If  common  ligatures  of  twine  are  cut  short, 
the  wound  may  unite  over  them,  and  they  may  be 
found  in  abscesses  after  an  interval  of  many  weeks. 

Thirdly,  If  the  finest  dentist’s  silk  be  employed  in 
the  same  way,  and  the  wound  unite  over  it,  the  ligature 
may  be  detached  from  the  vessel,  and  remain  buried  in 
an  abscess,  where  it  will  be  found  at  different  periods, 
from  one  to  seven  months;  and  this  may  happen, 
whether  the  ve.ssel  be  firmly  compressed  with  a single 
ligature  or  divided  between  two  ligatures,  so  as  to  imi- 
tate the  circumstances  under  which  vessels  are  tied  af- 
ter operations. 

Fourthly,  If  Indian  silk,  fine  as  hair,  be  put  round  a 
vessel,  so  as  to  diminish  its  diameter,  or  to  effect  its  obli- 
teration by  just  compressing  its  sides  together,  it  may 
remain  in  this  situation,  without  exciting  abscess,  or 
producing  any  inconvenience.  The  ligature  may  be 
thus  applied  to  compress  an  artery  for  the  cure  of  aneu- 
rism ; but  not  to  secure  vessels  divided  in  operations. 
If  a thin  ligature  be  drawn  sufficiently  tight  upon  a ves- 
sel on  the  face  of  a stump  to  be  secure,  Mr.  Cross  is 
persuaded,  that  the  extremity  of  the  vessel  which  be- 
comes insulated,  as  it  were,  must  die.— -'(See  London 
Med.  Reposit.  vol.  7,  p.  363.)  It  deserves  attention 
that  the  preceding  inferences  are  chiefly  founded  on 
experiments  made  upon  asses  and  dogs.  For  farther 
observations,  see  .Aneurism,  Hemorrhage,  Ligature, 
Surgery,  Urc. 

The  bleeding  having  been  suppressed,  the  next  object 
is  to  remove  any  extraneous  matter,  such  as  dirt,  bits 
of  glass,  clots  of  blood,  &c.,  from  the  surface  of  the 
wound.  Were  this  circumstance  neglected,  the  plan 
of  uniting  the  opposite  sides  of  the  cut  by  the  adhesive 
inflammation,  or  by  what  is  more  frequently  termed, 
union  by  the  first  intention,  would  in  general  be  frus- 
uated. 

As  soon  as  attention  has  been  paid  to  the  foregoing 
indications,  the  surgeon  must  put  the  lips  of  the  wound 
in  contact,  and  take  measures  for  keeping  them  in  this 
slate  until  they  have  grown  firmly  together.  The  sides 
of  incised  wounds  are  kept  in  a state  of  apposition  by 
means  of  adhesive  plaster,  a proper  position,  the  pres- 
sure of  a roller,  and,  in  a few  particular  instances,  by 
the  employment  of  sutures. 

With  respect  to  sutures,  as  they  create  pain,  irrita- 
tion, and  some  degree  of  suppuration,  they  ought  ne- 
ver to  be  employed  Svhen  the  parts  can  be  kept  in 
contact  without  them.  However,  certain  cases  require 
them,  and  it  is  admitted  by  many  experienced  surgeons 
that  in  sabre-wounds  of  the  ears,  eyelids,  nose,  and 
lips,  it  is  proper  to  use  them. — (See  .Assalini's  Ma- 
nuale  di  Chir.  Parte  Seconda,  p.  10.)  An  account  of  the 
several  kinds  of  sutures,  with  remarks  on  their  em- 
ployment, will  be  found  in  the  article  Sutures. 

'I'he  best  and  most  common  method  of  keeping  the 
surfaces  of  divided  parts  in  contact  is  by  means  of 
strips  of  adhesive  plaster.  When  they  are  to  be  aft- 
plied,  the  surgeon  should  put  the  wounded  limb  or  parts 
in  the  position  which  is  most  favourable  to  bringing  the 
lips  of  the  wound  together.  With  this  view,  a posi- 
tion should  generally  be  chosen  which  relaxes  the  skin 
and  subjacent  iniisole.s.  An  assistant  should  then  jilace 
Uie  edges  of  the  wound  as  evenly  together  as  jiossible, 


and  hold  them  in  this  state  until  the  surgeon  has  se- 
cured them  in  this  condition  by  strips  of  adhesive  plas- 
ter, applied  across  the  line  of  the  wound.  In  general,  it 
is  deemed  advisable  tojeave  a small  interspace  of  about 
a quarter  of  an  inch  between  each  two  strips  of  plaster, 
by  which  means  the  matter  cannot  be  confined  in  case 
of  suppuration.  Over  these  first  strips,  lint  is  to  be  ap- 
plied, and  kept  in  its  place  with  other  pieces  of  adhe- 
sive plaster.  Then,  if  necessary,  a pledget  and  com- 
presses are  to  be  put  on  the  part,  and,  lastly,  the  band- 
age or  roller  is  to  be  applied. 

In  this  manner  the  fresh-cut  surfaces  are  brought  into 
contact ; and  to  preserve  them  quietly  in  this  state,  is 
the  next  great  aim  which  the  surgeon  should  have  in 
view.  The  wounded  part  should  be  laid  in  the  pos- 
ture which  was  found  the  most  favourable  for  approx- 
imating the  sides  of  the  cut  at  the  time  of  applying  the 
dressings,  and  the  patient  should  be  directed  to  keep  the 
part  in  a perfectly  quiet  state. 

When  attention  is  paid  to  these  circumstances,  it  of- 
ten happens,  that  the  two  opposite  surfaces  of  the 
wound  grow  logetiier  again  in  the  course  of  forty-eight 
hours,  without  any  degree  of  suppuration.  The  pro- 
cess by  which  this  desirable  event  is  accomplished  is 
well  known  among  surgeons  by  the  name  of  union  by 
the  first  intention.  Besides  the  advantage  of  the  cure 
being  effected  in  this  way  wdth  the  greatest  expedition 
possible,  there  is  still  another  thing  much  in  favour  of 
constantly  promoting  this  method  of  healing  wounds, 
which  is,  that  the  scar  is  much  less  than  after  any  other 
mode  of  cicatrization,  and  the  part  is  covered  with  ori- 
ginal skin,  which  is  always  much  stronger  than  any 
which  can  be  formed  as  a substitute  for  it. 

It  is  wonderful  with  what  celerity  union  by  the  first 
intention  takes  place  under  favourable  circumstances. 
In  the  course  of  three  days,  the  large  wound,  made  in 
the  operation  of  amputation,  is  frequently  all  healed, 
except  just  where  the  ligatures  are  situated. 

When  the  two  sides  of  the  wound  have  been  brought 
together,  before  the  oozing  of  blood  has  entirely  ceased, 
Mr.  Hunter  conceives,  that  blood  itself  becomes  the 
first  bond  of  union  ; but,  on  this  point.  Professor  Thom- 
son of  Edinburgh,  entertains  a doubt ; and  all  practi- 
cal surgeons  agree,  that  the  lodgement  of  blood  on  the 
surface  of  a wound  is  more  likely  to  prevent,  than  pro- 
mote, the  union  of  the  parts.  In  all  common  instances, 
what  Mr.  Hunter  calls  the  adhesive  inflammation  takes 
place.  In  this  process,  coagulating  lymph  either  issues 
from  the  half-closed  mouths  of  the  vessels,  or  from  the 
surface  of  the  opened  cells  of  the  cellular  substance. 
This  becomes  the  first  uniting  medium,  and  very  soon 
afterward,  in  some  inexplicable  manner,  a vascular  in- 
tercourse is  established  between  the  opposite  sides  of 
the  wound. 

The  power  which  parts  of  the  animal  body  have  of 
thus  growing  together,  is  strikingly  evinced  by  the  pos- 
sibility of  removing  a part  of  one  body  and  then  unit- 
ing it  to  some  part  of  another.  In  this  latter  case,  there 
can  be  no  assistance  given  to  the  union  on  one  side, 
since  the  detached  part,  as  Mr.  Hunter  observes,  can 
hardly  do  more  than  just  preserve  its  own  living  prin- 
ciple and  accept  of  union.  In  this  way,  says  the  same 
writer,  the  spurs  of  the  young  cock  can  be  made  to 
grow  on  its  comb,  or  on  that  of  another  cock ; and 
its  testicles,  after  having  been  removed,  may  be  made 
to  unite  to  the  inside  of  any  cavity  of  an  animal. 

Every  one  initiated  in  surgery  has  heard  of  the  feats 
of  Taliacotius,  Garengeot,  and  others,  who  are  said  to 
have  succeeded  in  effecting  the  union  of  parts,  which 
were  completely  severed  from  the  body.  Several 
other  not  less  extraordinary  performances  by  modern 
surgeons  are  recorded. — (See  Obs.  on  Adhesion,  with 
two  Cases  demonstrative  of  the  Power  of  Mature  to  re- 
unite Parts  which  have  been  by  accident  totally  sepa- 
rated from  the  animal  System,  by  JVm.  Balfour,  8vo. 
Edinb.  1814.)  Indeed,  the  well-known  practice  of 
transplanting  the  teeth,  the  experiments  of  Duhamel 
and  Hunter,  and  the  number  and  respectable  character 
of  the  testimonies  upon  this  subject,  fully  convince  me 
of  the  oecasional  success  which  may  attend  the  endea- 
vour to  bring  about  such  a union.  Experience  also 
fully  proves  the  frequent  success  of  an  endeavour  to 
unite  a part,  which  retains  only  the  slight  connexion  of 
a small  piece  of  flesh,  or  even  a few  fibres.  My  friend, 
Mr.  Lawrence,  attended  a case  which  illustrates  the 
truth  of  this  statement.  A man  on  the  top  of  a stage 
coach  was  carried  utider  a gateway  which  did  not  leave 


472 


WOUNDS. 


sufficient  room  for  him  to  pass  without  injury,  and  his 
head  was  so  nrach  wounded  that  one  of  his  ears  was 
entirely  separated,  with  the  e^cception  of  an  attach- 
ment by  a trivial  piece  of  integuments.  Mr.  Lawrence 
assented  to  the  man’s  wish  of  not  having  the  separa- 
tion completed,  and  fixed  the  part  in  its  situation  with  a 
few  sutures.  The  consequence  was,  that  the  ear  soon 
united  again,  and  the  patient  escaped  all  disfigurement. 
Of  the  knowledge  of  the  disposition  of  living  cut  sur- 
faces to  grow  together  with  considerable  expedition, 
surgeons,  both  of  ancient  and  modern  times,  have 
availed  themselves,  not  only  in  the  treatment  of  acci- 
dental wounds,  but  also  in  the  removal  of  deformity,  as 
exemplified  in  the  cure  of  fissures  in  the  palate  or  lips 
(see  Hare-lip),  but  most  particularly  in  the  curious  and 
interesting  ariof  forming  newundeiiips  and  noses,  and 
closing  large  deficiences  in  the  urethra  with  flaps  of 
flesh,  raised  from  the  adjacent  parts,  shaped  according 
to  circumstances,  and  laid  directly  down  upon  a fresh 
cut  surface  purpoStely  prepared,  where  it  is  steadily  con- 
fined for  a certain  time  with  sutures,  or  simple  adhe- 
sive plaster,  and  pressure,  as  the  nature  of  the  case 
may  indicate.  Nay,  sometimes,  the  flesh  for  the  form- 
ation of  the  organ  to  be  restored  has  even  been  taken 
from  a distant  part,  as,  for  instance,  from  the  arm  for 
the  restoration  of  parts  of  the  face.  When  this  was 
done,  the  limb  was  confined  in  close  contact  with  the 
raw  surface  formed  on  the  face,  until  a union  between 
them  had  been  effected ; a division  was  now  performed 
with  the  scalpel,  and  the  opportunity  taken  to  shape 
the  portion  of  the  limb,  which  was  to  be  left  behind, 
according  as  the  part  to  be  restored  might  be  the  ear, 
nose,  or  lip.  At  the  present  day,  the  flesh  is  usually 
taken  from  the  adjacent  parts;  a connexion  of  the  flap 
with  the  rest  of  the  body  is  retained,  so  as  to  ensure 
some  circulation  of  blood  in  it,  and  it  is  turned  into  any 
position  which  the  circumstances  may  demand.— (See 
Oaspar  Taliacotius,  Ckirurgia  JSTova  de  J^arium,  j^u- 
riurrif  Labiorumque  Defectu,  per  institionem  cutis  ex 
humero  sarciendo,  irc.  feo.  Franco/.  1598.  J.  C.  Car- 
pue,  an  .Account  of  two  successful  Operations  for  re- 
storing a lost  J^ose  from  the  Integuments  of  the  Fore- 
head, 4to.  Lond.  1816.  Giuseppe  Baronio,  Degli  In- 
nesti  Animali,  Svo.  Milan.  C.  F.  Graefe,  De  Rhino- 
plastice,  sive  .Srte  curtum  Masum  ad  Vivum  restitu- 
endi,  commentatio,  qudprisca  illius  ratio  iterum  expe- 
rimentis  illustratur  novisque  methodis  ad  maorem  per- 
fectionem  perduciter,  4to.  Berol.  1818.  Sir  jI.  Cooper 
on  Unnatural  Jlpertures  in  the  Urethra;  Surgical 
Essays,  part  2.  H.  Earle  on  the  Re-establishment  of 
a Canal  in  the  place  of  a portion  of  the  Urethra,  in 
Phil.  Trans,  for  1821.  A Case  of  restored  Mose,  by 
A.  C.  Hutchison.  A Case  of  artificial  Anus  cured  by 
O.  F.  Collier,  in  Med.  and  Physical  Journ.  for  June, 
1820.  Delpech,  Chir.  Clin.  t.  2,  Paris,  1828.) 

Mr.  John  Bell  describes  the  process  of  adhesion  to 
be  this;  either  the  arteries  of  the  opposite  surfaces 
inosculate  mouth  to  mouth,  or  rather  each  cut  surface 
throws  out  a gluten;  the  gluten  fills  up  the  interme- 
diate space  ; into  that  gluten  the  lesser  arteries  of  each 
cut  surlace  extend  themselves  ; and  it  is  thus,  perhaps, 
by  the  generation  of  a new  intermediate  substance, 
that  the  continuity  and  entireness  of  the  part  are  so 
quickly  restored.  If  any  one  point  fail  to  adhere, 
there  the  wound  must  run  into  suppuration;  because, 
says  Mr.  J.  Bell,  at  that  point  there  is  a separation  of 
parts,  which  is  equivalent  to  a loss  of  substarice. 

The  same  writer  observes,  that  there  are,  no  doubt, 
accidents  both  of  the  constitution  and  the  wound 
which  will  prevent  adhesion.  If  the  patient  be  of  a 
bad  habit  of  body ; if  he  be  lying  in  a foul  hospital,  in 
the  midst  of  putrid  sores,  and  breathing  a contagious 
air : if  he  be  ill  of  a fever,  or  flux,  or  any  general  disease ; 
then  the  properties  of  the  body  being  less  perfect,  the 
wound  will  not  adhere.  Mr.  J.  Bell  also  notices,  that 
ifthe  wound  be  foul,  made  with  a poisoned  weapon,  or 
left  with  foreign  bodies  lodged  in  it ; or  if  a consider- 
able quantity  of  blood  be  poured  out  into  the  cavity  of 
the  wound,  or  if  there  be  a wounded  lymphatic,  or  a 
wounded  salivary  duct,  a wounded  intestine,  or  a 
bleeding  artery  or  vein,  the  immediate  adhesion  of  the 
whole  of  the  wound  may  be  prevented.  However,  I 
cannot  help  remarking,  that  though  Mr.  John  Bell,  in 
im  it ation  of  most  surgical  writers,  sets  down  the  wound 
of  a lymphatic  as  preventive  of  the  union  of  wounds, 
I cannot  say  that  I ever  saw  such  an  effect  imputable 
to  the  cause  just  mentioned.  Also,  when  an  artery  or 


vein  is  cut  and  requires  to  be  tied,  the  adhesion  of  the 
wound  would  be  prevented  only  just  where  the  liga 
ture  lies,  and  at  no  other  point. 

There  is  no  wound,  observes  Mr.  John  Bell,  in  which 
we  may  not  try  with  perfect  safety  to  procure  this  ad- 
hesion : for  nothing  can  agree  better  with  one  surface 
of  the  wound  than  the  opposite  one,  which  has  been 
just  separated  from  it.  They  may  immediately  adhere 
together,  and  even  if  they  should  not  do  so,  no  harm  is 
done,  and  the  wound  will  yet  suppurate  as  favourably 
as  if  it  had  been  roughly  dressed  with  dry  caddis,  or 
some  vulnerary  balsam,  or  acrid  ointment.  If  one 
part  should  suppurate  while  one-half  adheres,  then, 
says  Mr.  John  Bell,  one-half  of  our  business  is  done. 
In  short,  this  simple  duty  of  immediately  closing  a 
wound  is  both  natural  and  saJe.— {Discourses  on  the 
Mature  and  Cure  of  Wounds,  vol.  1.) 

Upon  this  interesting  topic  of  the  advantages  of 
union  by  the  first  intention,  the  most  enlightened  sur- 
geons of  all  Europe  now  begin  to  entertain  only  one 
opinion.  The  practice  is  generally  adopted,  both  in 
the  treatment  of  accidental  cuts  and  in  that  of  wounds 
resulting  from  surgical  operations.  Thus  Assalini,  one 
of  the  best  modern  surgeons  in  Italy,  begins  his  Manual 
of  Surgery  with  the  following  axiom  : “Wounds  and 
injuries  of  the  soft  parts  produced  by  cutting  instru- 
ments, from  the  trifling  wound  of  a vein,  made  for  the 
purpose  of  discharging  a few  ounces  of  blood,  to  the 
incision  in  the  uterus  for  the  extraction  of  the  foetus, 
inclusively,  should  all  be  united  by  the  first  intention.” 
— (See  Manuals  di  Chirurgia;  Discorso  Primo.  Mi- 
lano, 1812.) 

British  surgeons  have,  indeed,  been  accused  by  M. 
Roux  of  indiscriminate  partiality  to  the  plan  of  uniting 
all  incised  wounds  by  the  first  intention ; and  his  coun 
tryman  Baron  Larrey  has  wished  the  method  to  be 
discontinued  after  amputation,  in  order  (as  he  says)  to 
lessen  the  chance  of  tetanus.  But  the  exceptions  which 
these  surgeons  desire  to  make  are  few ; and  few  as 
they  are,  they  are  not  likely  to  be  established,  since 
several  of  the  circumstances  alleged  as  reasons  for 
limiting  so  beneficial  a practice  are  hypothetical,  and 
far  from  being  clearly  proved. — (See  Roux,  Mtnoire  et 
Obs.surla  Reunion  immediate  de  la  Plaie,  apris  I'Am 
putation  circulaire  des  Membres,  9vo.  Paris,  1814. 
Larrey,  Mim.  de  Chir.  Mil.  t.  4,8vo.  1812—1817.) 

Sometimes  the  attempt  to  procure  union  by  the  first 
intention  fails,  even  in  cases  of  incised  wounds ; but  in 
this  circumstance,  no  harm  arises  from  the  kind  of 
practice  that  has  been  followed.  The  case,  in  fact, 
now  falls  into  nearly  the  same  state  as  would  have 
occurred  had  no  attempt  at  union  been  made  at  all. 
The  patient  has  taken  the  chance  of  a quicker  mode 
of  cure  ; but  he  has  not  been  successful,  and  he  must 
now  be  cured  by  a process  which,  on  account  of  its 
slowness,  he  at  first  wished  to  avoid.  It  is  to  be  ob- 
served, also,  that  union  by  the  first  intention,  if  not 
spoiled  by  sutures,  rarely  fails  so  completely  that  there 
is  not  a partial  adhesion  of  some  points  of  the  wound. 
Tlie  moment  when  we  observe  pain,  inflammation, 
and  swelling  of  the  wound,  a separation  or  gaping  of 
its  lips,  the  stitches  tense  (when  these  have  been  used), 
and  the  points  where  the  stitches  pass  particularly  in- 
flamed, Mr.  John  Bell  advises  us  to  undo  the  bandages, 
draw  out  the  sutures,  and  take  away  every  thing  act- 
ing like  a stricture  on  the  wound.  These  prudent 
measures,  he  observes,  may  abate  fhe  rising  inflamma- 
tion, and  prevent  the  total  separation  of  the  skin,  while 
an  endeavour  may  still  be  nrade  to  keep  the  edges  of 
the  wound  tolerably  near  each  other  by  the  more  gentle 
operation  of  sticking  plasters. 

However,  when  the  inflammation  rises  still  higher, 
and  it  is  evident  that  a total  separation  of  the  sides  of 
the  wound  cannot  be  avoided,  Mr.  John  Bell  wisely 
recommends  leaving  the  parts  quite  loose,  and  apply- 
ing a large  soft  poultice  ; for,  says  he,  should  you  in 
this  critical  juncture  persist  in  keeping  the  parts  toge- 
ther with  sutures,  the  inflammation,  in  the  foim  of 
erysipelas,  would  extend  over  the  w'hole  limb,  attended 
with  a fetid  and  bloody  suppuration.  After  the  wound 
has  been  brotight  into  a favourable  state,  another  at- 
tempt may  be  made  to  bring  the  edges  near  earh  other, 
not  with  sutures,  but  strips  of  adhesive  plaster,  oi  the 
gentle  application  of  a bandage. 

Mr.  John  Bell  concludes  with  remarking  that  the 
suppuration,  production  of  granulations,  and  all  that 
follows,  are  the  work  of  nature.  'I'he  only  thing  that 


WOUNDS. 


473 


the  surgeon  ean  usefully  do  is  to  take  care  of  the 
health.  When  the  wound  does  not  suppurate  favour- 
ably, the  discharge  generally  becomes  profuse,  thin, 
and  gleety.  This  state  is  to  be  amended  by  bark,  wine, 
rich  diet,  and  good  air. 

I shall  conclude  this  subject  of  union  by  the  first  in- 
tention, with  an  extract  from  the  writings  of  Mr.  Hun- 
ter, who  observes,  that 

“ It  is  with  a view  to  this  principle  of  union,  that  it 
has  been  recommended  to  bring  the  sides  (or  lips)  of 
wounds  together ; but  as  the  natural  elasticity  of  the 
parts  makes  them  recede,  it  has  been  found  necessary 
to  employ  art  for  that  purpose.  This  necessity  first 
suggested  the  practice  of  sewing  wounds,  and  after- 
ward gave  rise  to  various  inventions  in  order  to  answer 
this  end,  such  as  bandages,  sticking  plasters,  and  liga- 
tures. Among  these,  the  bandage  commonly  called 
the  uniting  bandage  is  preferable  to  all  the  rest,  where 
it  can  be  employed ; but  its  application  is  very  con- 
fined, from  being  only  adapted  to  parts  where  a roller 
can  be  used.  A piece  of  sticking  plaster,  which  has 
been  called  the  dry  suture,  is  more  general  in  its  appli- 
cation than  the  uniting  bandage,  and  is  therefore  pre- 
ferable to  it  on  many  occasions. 

I can  hardly  suppose  (says  Mr.  Hunter)  a wound  in 
any  situation  where  it  may  not  be  applied,  excepting 
penetrating  wounds,  where  we  wish  the  inner  portion 
of  the  wound  to  be  closed  equally  with  the  outer,  as  in 
the  case  of  hare-lip.  But  even  in  such  wounds,  if  the 
parts  are  thick  and  the  wound  not  large,  the  sides  will 
seldom  recede  so  far  as  to  make  any  other  means  neces- 
sary. The  dry  suture  has  an  advantage  over  stitches 
by  bringing  a larger  surface  of  the  wound  together,  by 
not  inflaming  the  parts  to  which  it  is  applied,  and  by 
neither  producing  in  them  suppuration  nor  ulceration, 
which  stitches  always  do.  When  parts,  therefore,  can 
be  brought  together,  and  especially  where  some  force 
is  required  for  that  purpose,  from  the  skin  not  being  in 
large  quantity,  the  sticking  plaster  is  certainly  the  best 
application.  This  happens  frequently  to  be  the  case 
after  the  removal  of  tumours  in  amputation,  or  where 
the  sides  of  the  wound  are  only  to  be  brought  together 
at  one  end,  as  in  the  hare-lip  ; and  I think  the  difference 
between  Mr.  Sharp’s  cross-stitch  after  amputation  as 
recommended  in  his  Critical  Inquiry,  and  Mr.  Alanson’s 
practice,  shows  strongly  the  superiority  of  the  sticking 
plaster  (or  dry  suture).  In  those  parts  of  the  body 
where  the  skin  recedes  more  than  in  others,  this  treat- 
ment becomes  most  necessary  ; and  as  the  scalp  proba- 
bly recedes  as  little  as  any,  it  is  therefore  seldom 
necessary  to  apply  any  thing  in  wounds  of  that  part ; 
the  practice  will  certainly  answer  best  in  superficial 
wounds,  because  the  bottom  is  in  these  more  within  its 
influence. 

The  sticking  plasters  should  be  laid  on  in  strips, 
and  these  should  be  at  small  distances  from  each  other, 
viz.  about  a quarter  of  an  inch  at  most,  if  the  part 
requires  close  confinement ; but  when  it  does  not,  they 
may  be  at  greater  distances.  This  precaution  becomes 
more  necessary  if  the  bleeding  is  not  quite  stopped; 
there  should  be  passages  left  for  the  exit  of  blood,  as 
its  accumulation  might  prevent  the  union,  though  this 
does  not  always  happen.  If  any  extraneous  body, 
such  as  a ligature,  should  have  been  left  in  the  wound, 
suppuration  will  take  place,  and  the  matter  should  be 
allowed  to  vent  at  some  of  those  o{)enirig9  or  spaces 
betw’een  the  slijrs  of  plaster.  I have  known  a very 
considerable  abscess  formed  in  consequence  of  this 
precaution  being  neglected,  by  which  the  whole  of  the 
recently  united  parts  have  been  separated. 

The  interrupted  suture,  which  has  generally  been 
recommended  in  large  wounds,  is  still  in  use,  but  sel- 
dom proves  equal  to  the  intention.  This  we  may 
reckon  to  be  the  only  one  that  deserves  the  name  of 
suture ; it  was  formerly  used,  but  is  now  in  a great  mea- 
sure laid  aside  in  practice,  not  from  the  impropriety 
of  uniting  parts  by  this  process,  but  from  the  ineffect- 
ual mode  of  attempting  it.  In  what  manner  better 
methods  could  be  contrived,  I have  not  been  able  to 
suggest.  It  is  to  be  understood  that  the  above  methods 
of  bringing  wounded  parts  together  in  order  to  unite 
them,  are  only  to  be  put  in  practice  in  such  cases  as 
will  admit  of  it;  for  if  there  was  a method  known, 
which,  in  all  cases,  would  bring  the  wounded  surfaces 
into  contact,  it  would  in  maftiy  instances  be  improper, 
as  some  wounds  are  attended  with  contusion,  by  which 
iJic  [larts  have  been  more  or  less  deadened ; in  such 


cases,  as  was  formerly  observed,  union  cannot  take 
place  according  to  our  first  principle,  and  therefore  it 
is  improper  to  attempt  it. 

In  many  wounds  which  are  not  attended  with  con- 
tusion, when  we  either  know  or  suspect  that  extra- 
neous bodies  have  been  introduced  info  the  wound, 
union  by  the  first  intention  should  not  be  attempted, 
but  they  should  be  allowed  to  suppurate,  in  order  that 
the  extraneous  matter  may  be  expelled.  Wounds 
which  are  attended  with  laceration,  although  free 
from  contusion,  cannot  always  be  united  by  the  first 
intention  ; because  it  must  frequently  be  impossible  to 
bring  the  external  parts  or  skin  so  much  in  contact  as 
to  prevent  that  inflammation  w hich  is  naturally  pro- 
duced by  exposure.  But  even  in  cases  of  simple  lace- 
ration, wliere  the  external  influence  is  but  slight,  or 
can  be  prevented  (as  we  observed  in  treating  of  the 
compound  fracture),  we  find  that  union  by  the  first  in- 
tention often  takes  place;  the  blood  which  fills  up  the 
interstices  of  the  lacerated  parts,  having  prevented  the 
stimulus  of  imperfection  in  them  and  prevented  sup- 
puration, may  afterward  be  absorbed. 

Many  operations  may  be  so  performed  as  to  admit 
of  parts  uniting  by  the  first  intention  ; but  the  prac- 
tice should  be  adopted  with  great  circumspection:  the 
mode  of  operating  with  that  view  should  in  all  cases 
bo  a secondary,  and  not  a first  consideration,  which  it 
has  unluckily  been  too  often  among  surgeons.  In 
cases  of  cancer,  it  is  a most  dangerous  attempt  at  re- 
finement in  surgery. 

In  the  union  of  wounded  parts  by  the  first  intention, 
it  is  hardly  or  never  possible  to  bring  them  so  close  to- 
gether at  the  exposed  edges  as  to  unite  them  perfectly 
by  these  means ; such  edges  are  therefore  obliged  to 
take  another  method  of  healing.  If  kept  moist,  they 
will  inflame  as  deep  between  the  cut  surfaces  as  the 
blood  fails  in  the  union,  and  there  suppurate  and  gra- 
nulate ; but  if  the  blood  be  allowed  to  dry  and  form 
a scab  between  and  along  the  cut  edges,  then  inflam- 
mation and  suppuration  of  those  edges  will  be  pre- 
vented, and  this  will  complete  the  union,  as  will  be  de- 
scribed by-and-by. 

As  those  effects  of  accidental  injury  which  can  be 
cured  by  the  first  intention  call  up  none  of  the  powers 
of  the  constitution  to  assist  in  the  reparation,  it  is  not 
the  least  affected  or  disturbed  by  them ; the  parts  are 
united  by  the  extravasated  blood  alone,  which  was 
thrown  out  by  the  injury,  either  from  the  divided  ves- 
sels or  in  consequence  of  inflammation,  without  a 
single  action  taking  place  even  in  the  part  itself,  except 
the  closing  or  inosculation  of  the  vessels ; for  the  floW’ 
ing  of  the  blood  is  to  be  considered  as  entirely  me- 
chanical. Even  in  cases  where  a small  degree  of  in- 
flammation comes  on,  it  is  merely  a local  action,  and 
so  inconsiderable  that  the  constitution  is  not  affected  by 
it ; because  it  is  an  operation  to  which  the  powers  be- 
longing to  the  parts  themselves  are  fully  equal.  The 
inflammation  may  produce  a small  degree  of  pain,  hut 
the  operation  of  union  gives  no  sensation  of  any  kind 
whatever.” — {Hunter  on  the  Bloody  Injlamrnation,  and 
Oun-shot  Wounds.) 

Contused  and  Lacerated  Wounds. Lacerated 

wounds  are  those  in  which  the  fibres,  instead  of  being 
divided  by  a cutting  instrument,  have  been  torn  asun- 
der by  some  violence  capable  of  overcoming  their 
force  of  adhesion.  The  edges  of  such  wounds,  in- 
stead of  being  straight  and  regular,  are  jagged  or  un- 
equal. 

The  term  contused  is  applied  to  wounds  occasioned 
by  some  blunt  instrument  or  surface,  which  has  vio- 
lently struck  a part  of  the  body. 

These  two  species  of  wounds  greatly  resemble  each 
other,  and  as  they  require  nearly  the  same  kind  of 
treatment,  writers  usually  treat  of  them  together. 

Ijacerated  and  contused  wounds  differ  from  simple 
incised  ones  in  appearing,  at  first  view,  much  less 
alarming  than  the  latter,  while,  in  reality,  they  are  in- 
finitely more  dangerous.  In  simple  cut  wounds,  the 
retraction  of  the  parts  and  hemorrhage  are  much  more 
considerable  than  in  a lacerated  wound  of  the  same 
size.  However,  notwilhstanding  these  circumstances, 
they  commonly  admit  of  being  In'aled  with  far  greater 
ease.  It  is  worthy  of  particular  notice,  that  lacerated 
and  contused  wounds  are  not  in  general  attended  with 
any  serious  effusion  of  blood,  even  though  large  blood- 
vessels may  be  injured.  I say  in  general,  because,  in 
the  year  1813,  I saw  a soldier  whose  death  was  occa- 


474 


WOUNDS. 


Bioned  by  a sudden  effusion  of  a very  large  quantity  of 
blood  from  the  internal  jugular  vein,  which  vessel  had 
been  injured  by  a musket-ball,  that  first  entered  the  in- 
teguments behind  the  mastoid  process,  and  passed 
obliquely  downwards  and  forwards  towards  the  ster- 
num. The  blood  did  not  issue  e.xternaliy  ; but  formed 
between  the  integuments  and  the  trachea  a large  dark- 
coloured  swelling,  which  produced  almost  immediate 
suffocation.  At  the  memorable  siege  of  Saragossa, 
Professor  Assalini  saw  a surgeon,  whose  left  carotid 
artery  had  been  injured  by  a inusket-ball,  perish  of  he- 
morrhage in  a few  seconds. — (See  Assalini' s Manuale 
di  Chirurgia^  p.  32,  Milano^  1812.) 

In  most  cases,  however,  there  is  at  first  no  hemor- 
rhage of  consequence,  from  lacerated  or  contused 
wounds,  and  it  is  a circumstance  that  often  leads  inex- 
perienced practitioners  to  commit  great  mistakes,  by 
inducing  them  to  promise  too  much  in  the  prognosis 
which  they  make.  Surgeons  versed  in  practice,  how- 
ever, do  not  allow  themselves  to  be  deceived  by  the  ab- 
sence of  hemorrhage,  and  in  proportion  as  there  is 
little  bleeding,  they  apprehend  that  the  violence  done 
to  the  fibres  and  vessels  has  been  considerable.  What 
is  it,  but  the  contused  and  lacerated  nature  of  the 
wound,  that  prevents  hemorrhage  from  the  umbilical 
arteries,  when  animals  divide  the  navel-string  with 
their  teeth?  Whole  liinbs  have  frequently  been  lorn 
from  the  body  without  any  hemorrhage  of  consequence 
taking  place. 

In  the  Phil.  Trans.  Cheselden  has  recorded  a very 
remarkable  case,  in  which  a man’s  arm  was  suddenly 
torn  from  his  body.  Samuel  Wood,  a miller,  had 
round  his  arm  a rope,  which  got  entangled  with  the 
wheel  of  the  mill.  He  was  lifted  off  the  ground,  and 
then  stopped  by  a beam,  which  prevented  his  trunk 
from  passing  farther;  at  this  instant  the  wheel,  which 
was  moving  with  immense  force,  completely  tore  and 
carried  away  his  arm  and  scapula  from  his  body.  The 
appearance  of  a wound  occasioned  in  this  manner 
must  of  course  be  horrible,  and  the  first  idea  thence 
arising,  must  naturally  be  tliat  the  patient  cannot  pos- 
sibly survive.  Samuel  Wood,  however,  escaped  with 
his  life.  The  limb  had  been  torn  off  with  such  velo- 
city that  he  was  unaware  of  the  accident  till  he  saw 
liis  arm  moving  round  on  the  wheel.  He  immediately 
descended  by  a narrow  ladder  from  the  mill,  and  even 
walked  some  paces,  with  a view  of  seeking  assistance. 
He  now  fell  down  from  weakness.  The  persons  who 
first  came  to  his  assistance,  covered  the  wound  with 
powdered  sugar.  A surgeon,  v.’ho  afterward  arrived, 
observing  that  there  was  no  hemorrhage,  was  content 
w'ith  bringing  down  the  skin,  which  was  very  loose, 
so  as  to  make  it  cover  the  surface  of  the  wound.  For  ‘ 
this  purpose,  he  used  two  cross-stitches.  The  patient 
was  conveyed  the  next  day  to  St.  Thomas’s  Hospital, 
and  put  under  the  care  of  Mr.  Fern.  This  practi- 
tioner employed  the  usual  means  for  preventing  the 
bad  symptoms  most  to  be  expected  in  this  sort  of  case. 
The  first  dressings  came  away  without  any  bleeding; 
no  alarming  consequences  ensued ; and  the  patient  in 
lv\'o  months  completely  recovered. 

When  the  arm  was  examined,  it  was  found  that  the 
muscles  inserted  into  the  scapula  were  torn  tlirough 
near  their  insertions ; while  other  muscles,  arising 
from  this  bone,  were  carried  away  with  it.  The  skin 
covering  the  scapula  had  remained  in  its  natural  situa- 
tion, and  seemed  as  if  it  had  been  divided  precisely  at 
the  insertion  of  the  deltoid  muscle. 

In  La  Motte’s  Traite  des  Accouchemens  may  be 
found  an  account  of  a little  boy,  who,  while  playing 
near  the  wheel  of  a mill,  got  his  hand,  forearm,  and 
arm  successively  entangled  in  the  machinery,  and  the 
limb  was  violently  torn  away  at  the  shoulder-joint,  in 
consequence  of  the  lad’s  body  not  being  able  to  pass  in 
the  direction  in  which  the  arm  was  drawn.  The 
bleeding  was  so  trivial,  that  it  was  stopped  with  a little 
lint,  and  the  boy  very  soon  recovered. 

In  the  fifth  vol.  of  the  FAinb.  Med.  Commentaries^ 
may  also  be  perused  the  history  of  a child  three  years 
and  a half  old,  whose  arm  was  torn  off  by  the  wheel 
of  a mill.  Mr.  Carmichael,  who  saw  the  child  about 
an  hour  after  the  accident,  found  it  almost  in  a dying 
state,  with  cold  extremities,  small  faltering  pulse,  and 
all  the  riuht  side  of  the  body  convulsed.  However, 
there  wa.s  hardly  any  bleeding.  The  arm  w.as  broken 
about  an  inch  and  a iialf  above  the  elbow  ; the  slump 
hadadieadful  appearance;  allllie  soft  parts  were  in 


a contused  and  lacerated  state,  and  the  humerus  was 
laid  bare  as  high  as  the  articulation,  which  was  itself 
ex[)osed.  The  skin  and  muscles  were  lacerated  to  a 
much  greater  extent,  and  in  different  directions.  The 
remainder  of  the  humerus  was  removed  from  the 
shoulder-joint  by  amputation,  only  as  much  skin  and 
muscle  being  left  as  was  sufficient  to  cover  Uie  wound. 
In  two  months  the  child  was  well. 

In  the  Mim.  de  VAcad.  de  Chir.  t.  2,  is  an  account 
of  a leg  being  torn  away  at  the  knee-joint  by  a cart- 
wheel. The  patient  was  a boy,  about  nine  or  ten 
years  of  age.  This  accident,  like  the  foregoing  ones, 
was  accompanied  with  no  hemorrhage.  The  lower 
portion  of  the  os  femoris,  vi'hich  was  exposed,  was  am- 
putated, together  with  such  portion  of  the  soft  parts  as 
was  in  a contused  and  lacerated  slats.  The  patient 
experienced  a perfect  recovery. 

The  preceding  cases  strikingly  confirm  the  observa- 
tion which  I have  already  made,  in  regard  to  the  little 
bleeding  which  usually  arises  from  contused  and  lace- 
rated wounds. 

In  these  instances,  the  pain  is  also  in  an  inverse  ratio 
to  the  cause  of  the  accident;  it  is  generally  very  se- 
vere, when  the  wound  is  only  moderately  contused ; 
and,  on  the  other  hand,  when  there  has  been  so  violent 
a degree  of  contusion,  as  at  once  to  destroy  the  organi- 
zation of  the  part,  the  patient  suffers  scarcely  any  pain 
at  all. 

When  the  bruised  fibres  have  not  been  injured 
above  a certain  degree,  the  part  suppurates  ; but  such 
portions  of  the  wound  as  have  suffered  greater  vio- 
lence inevitably  die,  and  are  cast  off  in  the  form  of 
sloughs.  Granulations  are  afterward  formed,  and  the 
breach  of  continuity  is  repaired  by  the  process  of  cica- 
trization.— (See  this  word.) 

When  a still  greater  degree  of  violence  has  been 
done,  and  especially  when  arteries  of  a certain  magni- 
tude have  been  injured,  a mortification  is  coo  frequently 
the  consequence.  However,  if  the  constitution  be 
good,  and  the  mischief  not  too  extensive,  the  case  may 
still  end  well.  But,  in  other  instances,  the  event  is 
alarmingly  dubious;  for  the  mischief  is  then  not  limited 
to  the  wounded  parts,  which  have  suffered  the  greatest 
degree  of  contusion,  but  too  frequently  extends  over 
such  parts  as  were  not  at  all  interested  by  the  wound 
itself. 

The  mortification  arising  directly  from  the  impaired 
organization  of  parts  is  not  what  is  the  most  alarming 
circumstance.  A still  more  dangerous  kind  of  morti- 
fication is  that  which  is  apt  to  oiiginate  from  the  vio- 
lent inflammation  produced  by  the  accident.  This 
consequence  demands  the  utmost  attention  on  the  part 
of  the  surgeon,  who  must  let  no  useful  means  be  ne- 
glected, with  the  view  of  diminishing  the  inflammation 
before  it  has  attained  too  high  a degree,  and  very  dan- 
gerous symptoms  have  commenced.  In  the  first  in- 
stance, he  should  not  be  afraid  of  letting  the  wound 
bleed  a little,  if  it  should  be  disposed  to  do  so.  The 
edges  of  the  wound  should  then  be  gently  drawn  to- 
wards each  other,  with  a few  strips  of  sticking  plaster, 
so  as  to  lessen  the  extent  of  the  exposed  surface  ; but 
no  sutures  are  proper.  Indeed,  the  plan  of  diminishing 
the  exposed  surface  of  a contused  wound  with  strips 
of  adhesive  plaster  is  not  invariably  right ; because 
their  application  creates  a hurtful  degree  of  irritation. 
The  method  is  chiefly  advisable,  when  there  is  a laige 
loose  flap  of  skin,  which  can  be  conveniently  brought 
over  the  wound.  In  other  cases,  it  is  best  to  leave  the 
parts  free,  uncompressed,  and  unconfined  with  any  ad- 
hesive plaster,  because,  if  it  were  applied,  its  irritation 
would  do  harm,  and  could  not  possibly  procure  any 
union  of  the  parts.  Under  the  most  favourable  cir- 
cumstances, hardly  any  part  of  the  wound  can  be  e.x- 
pected  to  unite  by  the  first  intention  ; the  whole  or  the 
greater  part  of  it  will  necessarily  suppurate  after  the 
detachment  of  the  sloughs.  The  surface  will  then 
granulate,  new  skin  will  be  formed,  and  the  part  heal, 
just  like  a common  wound.  Perhaps,  until  the  sloughs 
separate,  the  best  application  is  a soft  iroultice,  which 
should  be  put  on  cold,  lest  it  bring  on  loo  great  an 
oozing  of  blood. 

Nothing,  indeed,  is  so  proper  for  checking  any  ten- 
dency to  hemorrhage  as  cold  applications,  which  are 
also  the  most  effectual  in  preventing  and  diminishing 
the  great  degree  of  inflartimation,  which  is  one  of  the 
most  dangerous  consequences  of  this  descnptiou  of 
wonnd.s. 


WOUNDS.  475 


No  surgical  writer,  I think,  has  given  more  rational 
advice  respecting  contused  wounds  than  that  published 
by  Professor  Assalini.  In  general,  says  he,  the  treat- 
ment of  contused  wounds,  whether  they  be  simple  and 
slight,  or  complicated  and  severe,  requires  the  active 
employment  of  debilitating  means  in  order  to  prevent 
intlammation.  Cold  water  and  ice,  and  general  and 
topical  bleeding,  are  the  things  usually  resorted  to  with 
success.  Vulnerary  lotions,  camphorated  spirit,  and 
other  spirituous  applications  are  improper;  and  if 
their  pernicious  effects  are  not  always, very  evident,  it 
is  only  because  the  contused  injuries  have  been  trifling, 
and  in  their  nature  perfectly  easy  of  cure.  In  these 
cases,  as  well  as  in  those  of  extravasations  and  gland- 
ular swellings,  Assalini  gives  a preference  to  cold  ap- 
plications. Tire  internal  remedies  and  regimen  (says 
he)  should  also  be  adapted  to  the  condition  of  the  pa- 
tient. A cannon-ball,  at  the  end  of  its  course,  may 
cmne  into  contact  with  a limb  and  fracture  the  bones, 
while  the  integuments  have  the  appearance  of  being 
uninjured.  Such  cases  are  often  attended  with  dread- 
ful mischief  in  the  soft  parts  around  the  bone,  which 
generally  sphacelate.  This  is  an  accident  for  which 
immediate  amputation  is  mostly  indispensable  (see 
Gun-shot  wounds)  -,  but  if  any  thing  be  capable  of  pre- 
venting inflammation  and  gangrene,  it  is  an  active  de- 
bilitating plan  of  treatment,  assisted  with  cold  appli- 
catiotis  to  the  injured  part.  In  such  cases,  the  internal 
and  external  use  of  stimulants  is  approved  of  by  many 
surgeons.  But  Assalini  prefers  considering  the  stale  of 
the  injured  limb  just  like  what  it  is  when  affected  with 
frost;  and  he  thinks  that  the  employment  of  stimulants 
will  necessarily  produce  the  same  effect  as  caloric  pre- 
maturely applied  to  parts  deadened  with  cold.  On  the 
contrary,  from  the  outward  employment  of  ice  and 
cold  lotions  in  these  cases,  and  in  contused  injuries  in 
general  he  has  seen  the  greatest  benefit  derived. 

Assalini  conceives  that  reason  will  be  found  to  sup- 
port this  piactice.  The  operation  of  cold,  he  says, 
retards  the  course  of  the  blood,  which,  meeting  with 
only  damaged  vessels,  augments  the  extravasation  as 
it  continues  to  flow.  By  lessening  the  temperature  of 
the  part,  eold  applications  likewise  diminish  the  dan- 
ger of  inflammation  and  Sphacelus,  at  the  same  lime 
that  they  have  the  good  effect  of  rendering  the  suppu- 
ration which  must  ensue  less  profuse  than  it  would  be, 
were  not  the  extravasation  of  blood  and  violence  of 
the  inflammation  lessened  by  such  applications,  and  a 
lowering  plan  of  treatment. 

Why,  says  Assalini,  should  not  this  method,  which 
is  so  generally  adopted  to  prevent  the  effects  of  concus- 
sion of  the  brain  after  blows  on  the  head,  be  for  ana- 
logous reasons  employed  in  examples  of  extravasation 
and  commotion  in  other  parts  of  the  body  1 — {Manuals 
di  Chirurgia,  Parte  Prima,p.  17.)  Cold  applications, 
however,  in  cases  of  contused  wounds  are  chiefly  to  be 
preferred  for  the  first  day  or  two,  in  order  to  check  the 
increase  of  extravasation  and  inflammation.  After 
this  period,  I give  a decided  preference  to  an  emollient 
linseed  poultice,  which  will  be  found  the  most  easy 
dressing  during  those  processes  by  which  the  sloughs 
are  detached,  the  surface  of  the  wound  cleansed,  and 
the  origin  of  granulations  established.  When  these 
changes  have  happened,  the  remaining  sore  is  to  be 
treated  on  the  same  principles  as  ulcers  in  general. — 
(See  Ulcer.) 

Punctured  Wounds. — A punctured  wound  signifies 
one  made  with  a narrow-pointed  instrument,  the  ex- 
ternal orifice  of  the  injury  being  small  and  contracted, 
instead  of  being  of  a size  proportionate  to  its  depth. 
A wound  produced  by  the  thrust  of  a sword  or  bayonet 
affords  us  an  example  of  a punctured  wound. 

Wounds  of  this  decriplion  are  in  general  infinitely 
more  dangerous  than  cuts,  notwithstanding  the  latter 
have  the  appearance  of  being  by  far  the  most  exten- 
sive. In  cases  of  stabs,  the  greatest  degree  of  danger 
always  depends  on  the  injury  and  rough  violence 
which  the  fibres  have  suffered,  in  addition  to  their 
mere  division.  Many  of  the  disagreeable  consequences 
are  also  to  be  imputed  to  the  considerable  depth  to 
which  these  wounds  extend,  whereby  important  parts 
and  organs  are  frequently  injured.  Sometimes  the 
treatment  is  rendered  perplexing  by  the  difficulty  of 
removing  extraneous  substances,  as,  for  instance,  a 
piece  of  the  weapon  which  has  been  left  in  the  wound. 
Lastly,  fcxiMjrience  proves  that  punctured  wounds  and 
stabs  arc  particularly  liable  to  be  followed  by  a gretii 


deal  of  inflammation,  fever,  deep-seated  abscesses, 
sinuses,  &c. 

A strange  notion  seems  to  pervade  the  writings  of 
many  systematic  authors,  that  all  the  danger  and  dis- 
agreeable consequences  of  punctured  wounds  depend 
entirely  upon  the  narrowness  of  their  orifice.s,  so  that 
suitable  applications  cannot  be  introduced  to  their  bot- 
tom. Hence,  it  is  absurdly  recommended  to  dilate  the 
opening  of  every  stab,  with  the  view,  as  is  generally 
added,  of  converting  the  accident  into  a simple  incised 
wound.  Some  of  these  writers  are  advocates  for 
making  the  dilatation  with  a cutting  instrument,  while 
others,  with  equal  absurdity,  propose  to  enlarge  the 
opening  with  tents. 

Certain  authors  regard  a punctured  wound  as  a re- 
cent sinus,  and,  in  order  to  make  the  inner  surfaces 
unite,  they  recommend  exciting  a degree  of  inflamma- 
tion in  them,  either  by  means  of  setons  or  injections. 

In  the  earliest  edition  of  The  First  Lines  of  the 
Practice  of  Surgery,  I took  particular  pains  to  expo.se 
the  folly  and  errors  which  prevail  in  most  writings  on 
this  part  of  practice.  In  the  above  work  I have  re- 
marked, that  if  the  notion  were  true,  that  an  import- 
ant punctured  wound,  such  as  the  stab  of  a bayonet, 
could  be  actually  changed  into  a wound  partaking  of 
the  mild  nature  of  an  incision,  by  the  mere  enlarge- 
ment of  its  orifice,  the  corresponding  practice  would 
certainly  be  highly  commendable,  however  painful. 
But  the  fact  is  otherwise : the  rough  violence  done  to 
the  fibres  of  the  body  by  the  generality  of  stabs  is 
little  likely  to  be  suddenly  removed  by  an  enlargement 
of  the  wound.  Nor  can  the  distance  to  which  a 
punctured  wound  frequently  penetrates,  and  the  num- 
ber and  nature  of  the  parts  injured  by  it,  be  at  all  altered 
by  such  a proceeding.  These,  which  are  the  grand 
causes  of  danger,  and  of  the  collections  of  matter  that 
often  take  place  in  the  cases  under  consideration,  must 
exist,  whether  the  mouth  and  canal  of  the  wound  be 
enlarged  or  not.  The  time  when  incisions  are  proper 
is,  when  there  are  foreign  bodies  to  be  removed,  ab- 
scesses to  be  opened,  or  sinuses  to  be  divided.  To 
make  painful  incisions  sooner  than  they  can  answer 
any  end,  is  both  injudicious  and  hurtful.  They  are 
sometimes  rendered  quite  unnecessary,  by  the  union  of 
the  wound  throughout  its  whole  extent  without  any 
suppuration  at  all. 

Making  a free  incision  in  the  early  stage  of  these 
cases  undoubtedly  seems  a reasonable  method  of  pre- 
venting the  formation  of  sinuses,  by  preventing  the 
confinement  of  matter;  and  were  sinuses  an  inevitable 
consequence  of  all  punctured  wounds,  for  which  no 
incisions  had  been  practised  at  the  moment  of  their 
occurrence,  it  would  undoubtedly  be  unpardonable  to 
omit  them.  Fair,  however,  as  this  reason  may  appear, 
it  is  only  superficially  plausible,  and  a small  degree  of 
reflection  soon  discovers  its  want  of  real  solidity. 
Under  what  circumstances  do  sinuses  form  ? IJo  they 
not  form  only  w'here  there  is  some  cause  existing  to 
prevent  the  healing  of  an  abscess  7 This  cause  may 
either  be  the  indirect  way  in  which  the  abscess  com- 
municates  with  the  external  opening,  so  that  the  pus 
cannot  readily  escape ; or  it  may  be  the  presence  of 
some  foreign  body  or  carious  bone  ; or,  lastly,  it  may 
be  an  indisposition  of  the  inner  surface  of  the  abscess 
to  form  granulations,  arising  from  its  long  duration, 
but  removable  by  laying  the  cyst  completely  open  to 
the  influence  of  the  air.  Thus  it  becomes  manifest, 
that  the  occurrence  of  suppuration  in  punctured  wounds 
is  followed  by  sinuses  only  when  the  surgeon  neglecis 
to  procure  a free  issue  for  the  matter  after  its  accu- 
mulation, or  when  he  neglects  to  remove  any  extrane- 
ous bodies.  But  as  dilating  the  wound  at  first  can 
only  tend  to  augment  the  inflammation  and  render  the 
suppuration  more  extensive,  it  ought  never  to  be  prac- 
tised in  these  cases;,  excc[)t  for  the  direct  objects  of  giv- 
ing free  exit  to  matter  already  collected,  and  of  being 
able  to  remove  extraneous  bodies  palpably  lodged.  I 
shall  once  more  repeat,  that  it  is  an  erroneous  idea  to 
suppose  the  narrowness  of  punctured  wounds  so  jirin- 
cipal  a cause  of  the  bad  symptoms  with  which  they 
are  often  attended,  that  the  treatment  ought  invariably 
to  aim  at  its  removal. 

Recent  punctured  wounds  have  absurdly  had  the 
same  plan  of  treatment  applied  to  them  as  oid  and  cal- 
lous fistula;.  Setons  and  stimulatifig  injections,  which, 
in  the  latter  ca.ses,  sometimes  act  beneficially,  by  ex- 
citing such  inflammation  as  is  productive  of  the  effusion 


476 


WOUNDS. 


of  coagTiIating  lymph,  and  of  the  granulating  process, 
never  prove  serviceable  when  the  indication  is  to  mo- 
derate an  inflammation  which  is  too  apt  to  rise  to  an 
improper  height.  The  counter-opening  that  must  be 
•formed  in  adopting  the  use  of  a seton  is  also  an  objec- 
■‘tion.  However,  what  good  can  possibly  arise  from  a 
seton  in  these  cases  1 Will  it  promote  the  discharge 
of  foreign  bodies,  if  any  are  present?  By  occupying 
the  external  openings  of  the  wound,  will  it  not  be  more 
likely  to  prevent  it?  In  fact,  wilt  it  not  itself  act  with 
all  the  inconveniences  and  irritation  of  an  extraneous 
substance  in  tlie  wound?  Is  it  a likely  means  of  di- 
minishing the  immoderate  pain,  swelling,  and  exten- 
sive suppuration  so  often  attending  punctured  wounds  ? 
It  will  undoubtedly  prevent  the  external  openings  from 
healing  too  soon ; but  cannot  this  object  be  effected  in 
a better  way?  If  the  surgeon  observe  to  insinuate  a 
piece  of  lint  into  the  sinus,  and  pass  a probe  through 
its  track  once  a day,  the  danger  of  its  closing  too  soon 
will  be  removed. 

The  practice  of  enlarging  punctured  wounds  by  in- 
cisions, and  of  introducing  setons,  is  often  forbidden  by 
the  particular  situation  of  these  injuries. 

In  the  first  stage  of  a punctured  wound,  the  indica- 
tion is  to  guard  against  the  attack  of  violent  inflamma- 
tion. When  no  considerable  quantity  of  blood  has 
been  lost,  general  and  topical  bleeding  should  be  prac- 
tised. In  short,  the  antiphlogistic  plan  is  to  be  followed. 
As  no  man  can  pronounce  whether  such  a wound  will 
unite  or  not,  and  as  no  harm  can  result  from  the  at- 
tempt, the  orifice  ought  to  be  closed,  and  covered  with 
simple  dressings.  In  such  cases,  cold  applications  are 
also  highly  commendable.  Whether  gentle  compres- 
sion might  be  made  to  promote  the  adhesive  inflam- 
mation or  not  may  be  doubtful : I confess  that  I should 
not  have  any  reliance  upon  its  usefulness.  Perfect 
quietude  is  to  be  observed.  When  the  pain  is  severe, 
opium  is  to  be  administered. 

Sometimes,  under  this  treatment,  the  surgeon  is 
agreeably  surprised  to  find  the  consequent  inflammation 
mild,  and  the  wound  speedily  united  by  the  first  inten- 
tion. “ Numerous  are  the  examples  of  wounds,  which 
penetrate  the  large  cavities,  being  healed  by  the  first 
intention,  that  is,  without  any  suppuration.  Even 
wounds  of  the  chest  itself,  with  injury  of  the  lungs 
(continues  an  experienced  military  surgeon  and  profes- 
sor). ought  to  be  united  by  the  first  intention.” — {As- 
salini,  in  Jilanuale  di  Ckirurgia,  parte  seconda,  p.  13.) 
More  frequently,  how'ever,  in  cases  of  deep  stabs  the 
pain  is  intolerable ; and  the  inflammatory  .symptoms 
run  so  high  as  to  leave  no  hope  of  avoiding  suppura- 
tion. In  this  condition,  an  emollient  poultice  is  the 
best  local  application ; and  when  the  matter  is  formed, 
the  treatment  is  like  that  of  abscesses  in  general.— 
(See  Suppuration.) 

Poisoned  Wounds:  Bite  of  the  Viper. — If  wee.xclude 
from  present  consideration  the  bites  of  mad  dogs,  and 
other  rabid  animals,  which  subject  is  fully  treated  of 
in  the  article  Hydrophobia.,  wounds  of  this  description 
are  not  very  common  in  this  kingdom.  In  dissections, 
pricks  of  the  hand  sometimes  occur,  and  they  are,  in 
reality,  a species  of  poisoned  wound,  frequently  causing 
considerable  pain  and  irritation  in  the  course  of  the 
absorbents;  swelling  and  suppuration  of  the  lymphatic 
glands  of  the  arm  or  axilla;  and  severe  fever  and  con- 
stitutional irritation.  An  instance  of  the  fatal  conse- 
quences of  such  an  injury  must  still  be  fresh  in  the  re- 
■collection  of  the  profession ; and  some  others  of  yet 
more  recent  date  have  taken  place  in  this  metropolis. 
— (See  London  Medical  Repository,  vol.  7,  p.  288.) 

In  many  instances,  however,  surgeons  wound  their 
fingers  in  dissecting  bodies,  and  no  particular  ill  con- 
sequences ensue.  The  healthy  and  robust  are  said  to 
suffer  less  frequently  after  such  accidents  than  persons 
whose  constitutions  have  been  weakened  by  hard  study, 
excesses,  pleasure,  or  previous  disease.  It  is  remarked, 
also,  that  pricks  of  the  fingers,  met  with  in  opening  the 
bodies  of  persons  who  have  died  of  contagious  dis- 
eases, and  where  a virus  or  infectious  matter  might  be 
expected  to  exist  in  such  bodies,  do  not  communicate 
the  iiffeclion.  Doubtless  (observes  Richerand)  the  ac- 
tivity of  certain  animal  poisons,  from  which  the  ve- 
nereal and  .several  other  diseases  arise,  is  extinguished 
with  life. — (Mosographie  Chir.  t.  1,  p.  102,  103,  ed.  4.) 
This  is  a point,  liowever,  that  does  not  seem  to  me  by 
any  means  established  ; and  that  the  small  pox  can  be 
cuminunicaled  from  a corpse  to  a person  who  does  not 


even  touch  the  body,  v.ras  exemplified  the  spring  of 
1829  in  the  cases  of  two  students  at  St.  Bartholomew’s, 
one  of  whom  was  my  own  nephew.  The  disease  was 
caught  by  merely  attending  a lecture  in  the  anatomical 
theatre,  where  the  body  of  a black,  who  had  died  of 
confluent  small  pox,  was  produced. 

With  regard  to  the  treatment  of  the  pricks  of  dis- 
secting scalpels,  the  surgeons  of  the  continent  recom- 
mend the  immediate  cauterization  of  the  little  wounds 
with  a grain  of  caustic  potassa,  or  the  liquid  muriate 
of  ammonia.  Tonic  remedies,  particularly  wine,  are 
prescribed,  and  great  attention  paid  to  emptying  the 
bowels. 

[Dr.  Godman,  late  Professor  of  Anatomy  in  Rutgers 
Medical  College,  has  related  a most  interesting  case  of 
dissection  wound,  which  terminated  fatally  in  the  per- 
son of  Adrian  A.  Kissam,  a student  of  medicine,  who 
received  a wound,  about  one-third  of  an  inch  in 
length,  across  the  fleshy  part  of  the  last  joint  of  his 
left  middle  finger,  which  bled  freely.  He  died  on  llie 
6th  day  after  the  injury. — (See  Amor.  Journal  of 
Med.  and  Phys.  Science,  vol.  1.) — Reese.] 

The  stings  of  bees,  wasps,  and  hornets  are  also  poi- 
soned wounds,  though  they  are  seldom  important 
enough  to  require  the  assistance  of  a surgeon.  The 
hornet  is  not  found  in  Scotland ; but  it  is  an  inhabitant 
of  several  of  the  woods  in  England.  Its  sting,  which 
is  more  painful  than  that  of  a bee  or  wasp,  is  not,  how- 
ever, often  the  occasion  of  any  serious  consequences. 
The  stings  of  all  these  insects  are  attended  with  a 
sharp  pain  in  the  part,  very  quickly  succeeded  by  an 
inflammatory  swelling,  which,  after  a short  time,  ge- 
nerally subsides  of  itself.  When  the  eye  is  stung,  as 
sometimes  has  happened,  the  effects  may  be  very  se- 
vere, as  is  elsewhere  noticed. — (See  Ophthalmy.)  It 
has  been  lately  observed,  that  the  pain  of  the  stings  of 
venomous  insects,  like  the  bee,  depends  less  upon  the 
introduction  of  the  sting  into  the  part  than  upon  that 
of  the  venomous  fluid.  The  experiments  of  Professor 
Dumeril  tend  to  prove,  that  when  the  little  poison- 
bladder,  situated  at  the  base  of  the  sting,  has  been  cut 
off,  a wound  with  the  sting  then  produces  no  pain. 
The  poison  flows  from  the  vesicle  through  the  sting  at 
the  instant  when  this  passes  into  the  flesh.  ’The  exact 
nature  of  the  venomous  fluid  is  not  known.  When 
applied  to  mucous  surfaces,  or  even  to  the  surface  of 
the  conjunctiva  of  the  eye,  it  causes  no  disagreeable 
sensation ; but  when  it  is  introduced  into  the  skin  by 
means  of  a needle,  it  immediately  excites  very  acute 
pain. 

Oil,  honey,  spirit  of  wine,  the  juice  of  the  plantain, 
and  a variety  of  other  local  applications,  have  been 
extolled  as  specifics  for  tlie  relief  of  the  stings  of  insects. 
Modern  experience,  however,  does  not  sanction  their 
claim  to  this  character.  In  fact,  none  of  these  appli- 
cations either  neutralize  the  poison  or  appease  with 
superior  efficacy  the  pain  of  the  sting. 

These  cases  should  all  be  treated  on  common  anti- 
phlogistic principles,  and  the  most  rational  plan  is  to 
extract  the  sting,  taking  care,  in  the  first  in.stance,  to 
cut  off  the  little  poison-vesicle  with  scissors,  lest  in  the 
attempts  to  withdraw  the  sting,  more  of  the  virus  be 
compressed  into  the  part.  The  stung  part  should  then 
be  immersed  for  a time  in  ice-cold  water,  and  after- 
ward covered  with  linen  wet  with  the  liquor  plumbi 
acetatis  dilutus.  Were  the  inflammation  to  exceed  tlte 
usual  degree,  leeches  and  aperient  medicines  would  be 
proper.  In  short,  as  there  is  no  specific  for  the  cure  of 
these  cases,  they  are  to  be  treated  with  common  anti- 
phlogistic means. 

With  regard  to  the  bites  of  serpents,  tho.se  inflicted 
by  the  rattlesnake  of  America,  and  the  cobra  di  Cu- 
pello  of  the  East  Indies,  are  the  most  speedily  mortal. 
Indeed,  this  is  so  much  the  case,  that  sometimes  there 
is  scarcely  an  opportunity  of  trying  any  remedies ; and 
even  when  tlie  patient  is  not  destroyed  thus  rapidly, 
there  is  such  general  disorder  of  the  nervous  systen’i, 
with  repeated  faintings  and  sickness,  that  medicines 
cannot  well  be  retained  in  the  stomach,  at  least  for 
some  time. 

Mr.  Catesby,  in  the  Preface  to  his  Natural  History 
of  Carolina,  informs  us,  that  the  Indians,  who,  by  their 
constant  wanderings  in  the  woods,  are  liable  to  be  bit 
by  snakes,  know,  ns  soon  as  they  receive  the  injury, 
whether  it  will  prove  mortal  or  not.  If  it  be  on  any 
part  at  a distance  from  large  blood-vessels,  or  where 
the  circulation  is  not  vigorous,  they  apply  their  reme- 


WOUNDS. 


477 


dies ; but  if  any  vein  of  considerable  magnitude  be 
hurt,  they  quietly  resign  themselves  to  their  fate, 
Knowing  that  nothing  can  then  be  of  service.  Among 
the  remedies  on  which  they  chiefly  depend,  are  senega 
root,  ammonia,  and,  particularly,  strong  doses  of  arse- 
nic, as  will  be  presently  noticed  again. 

If  we  put  out  of  consideration  animals  affected  with 
rabies,  the  viper  inflicts  the  worst  poisoned  wound 
ever  met  with  in  these  islands.  In  fact,  it  is  an  ani- 
mal that  inserts  into  the  part  which  it  bites  a poison 
capable  of  exciting  very  serious  consequences.  Tlie 
jaws  of  the  viper  are  furnished  with  teeth,  two  of 
which  in  the  upper  jaw  are  very  different  from  the 
rest.  These,  which  are  about  three  lines  long,  are 
covered,  for  about  two-thirds  of  their  length,  with  a 
membranous  coat  or  sheath,  are  of  a curved  shape, 
and  articulated  with  the  jaw-bone.  When  the  animal 
is  tranquil,  and  its  mouth  shut,  they  lie  down  with 
their  points  turned  backwards  ; but  they  instantly  pro- 
ject Arrwards  when  it  is  irritated  and  about  to  bite. 
In  them  are  canals  which  terminate  by  a very  narrow 
fissure,  on  their  convex  sides,  a little  way  from  their 
points.  The  rest  of  these  fangs  is  very  hard  and  solid ; 
and  the  canal  is  usually  filled  with  a transparent,  yel- 
lowish fluid,  the  poison  of  the  viper. 

This  venomous  fluid  is  secreted  by  two  glands,  or 
rather  by  two  clusters  of  glands,  one  on  each  side  of 
the  head,  placed  on  the  front  of  the  forehead,  directly 
behind  the  eyeball,  under  the  muscle  which  serves  to 
depress  the  upper-jaw.  Thus  the  muscle  cannot  act 
without  pressing  upon  them,  and  promoting  the  secre- 
tion of  the  fluid  which  they  are  destined  to  prepare. 
A little  bag  or  vesicle,  connected  to  the  base  of  the  first 
bone  of  the  upper-jaw,  as  well  as  to  the  end  of  the  se- 
cond, covers  also  the  roots  of  the  curved  fangs,  and 
forms  a receptacle  for  the  venom. 

The  viper  is  chiefly  found  in  hilly,  stony,  and  woody 
districts,  and  seldom  in  flat  or  marshy  places.  It  is  not 
its  nature  to  attack  man,  or  large  animals,  except  when 
provoked.  Its  venom  is  only  employed  for  the  destruc- 
tion of  smaller  animals,  such  as  mice,  frogs,  &c., 
which  are  usua\ly  swallowed  whole,  and  to  the  diges- 
tion of  which  the  venomous  secretion  is  by  some 
writers  supposed  to  contribute.  When,  however,  a 
viper  is  pursued,  trod  upon,  taken  hold  of,  or  hurt,  it 
immediately  bites,  and,  were  it  only  on  account  of  the 
shape  of  the  fangs,  the  wound  might  be  attended  with 
very  unpleasant  effects;  but  it  is  certain  of  being  so, 
by  reason  of  the  species  of  inoculation  which  compli- 
cates it,  and  of  which  the  mechanism  is  as  follows: 

When  a viper  is  about  to  bite,  it  opens  its  mouth 
very  wide.  The  two  curved  fangs,  which  had  pre- 
viously lain  flat  down  in  the  cavity  of  the  membrane 
attached  to  their  base,  now  project  and  become  perpen- 
dicular to  the  lower-jaw.  When  the  bite  takes  place, 
the  poison  is  propelled  through  the  fangs  by  the  con- 
traction of  the  muscles  and  the  closure  of  the  mouth, 
and  is  injected  inlo  the  wound  with  a force  propor- 
tioned to  its  accidental  quantity  at  the  time,  and  the 
vigour  of  the  animal. 

The  bite  of  a viper  is  quickly  followed  by^severe 
effects,  some  of  which  are  local  and  the  others  general ; 
but  it  is  with  the  former  that  the  disorder  invariably 
commences.  At  the  instant  of  the  bite,  the  bitten  part 
is  seized  with  an  acute  pain  which  rapidly  shoots  over 
the  whole  limb,  and  even  affects  tlie  viscera  and  in- 
ternal organs.  Soon  afterward,  the  wounded  part 
swells  and  reddens.  Sometimes  the  tumefaction  is 
confined  to  the  circumference  of  the  injury;  but  most 
frequently  it  spreads  extensively,  quickly  affecting 
every  part  of  the  limb,  and  even  the  trunk  itself.  A 
saiiious  fluid  is  often  discharged  from  the  wound, 
around  which  phlycten.-e  arise  similar  to  those  of  a 
burn.  After  a short  time,  however,  the  pain  abates 
considerably;  the  inflammatory  tension  changes  into  a 
doughy  or  oedemaious  softness;  the  part  grows  cold; 
and  tire  skin  exhibits  large  livid  spots  like  those  of 
gangrene.  The  general  symptoms  also  come  on  with 
celerity;  the  patient  is  troubled  with  anxiety,  prostra- 
tion of  strength,  difficulty  of  breathing,  and  cold  pro- 
fuse sweats.  Vomiting  frequently  occurs,  and  some- 
times copious  bilious  evacuations  from  the  bowels. 
These  symptoms  are  almost  constantly  attended  with 
a universal  yellowness  and  excruciating  pain  about 
the  navel. 

The  effects  occur  in  the  same  way  in  nearly  all  sub- 
jects, with  some  differences  depending  upon  the  par- 


ticular irritability  and  constitution  of  the  patient;  the 
high  or  low  temperature  of  the  atmosphere;  the  greater 
or  less  anger  of  the  viper;  the  number  of  its  bites, 
the  size  of  the  reptile  itself ; the  depth  to  which  the 
fangs  have  penetrated ; and  whether  the  bitten  part 
happens  to  be  one  of  great  sensibility,  or  was  naked  or 
not,  at  the  time  of  the  accident.  In  general,  weak, 
pusillanimous  persons,  of  bad  constitutions  and  loaded 
stomachs,  suffer  more  sudden  and  alarming  ill  conse- 
quences than  strong,  healthy  subjects  who  view  the 
danger  without  fear.  Several  bites  are,  of  course, 
more  dangerous  than  a single  one ; and,  lastly,  it  has 
been  remarked,  that  the  venom  of  the  viper  is  more 
active  in  summer  than  the  spring. 

A year  or  two  ago,  however,  the  newspapers  re- 
corded the  death  of  a servant,  from  the  inadvertent  ap- 
plication of  the  poison  to  a scratch  on  his  hand,  as  he 
was  examining  the  fangs  and  venomous  organs  of  a 
viper  perfectly  torpid  in  the  winter  season. 

Severe,  however,  as  the  effects  of  the  bite  of  a viper 
may  be,  they  are  far  from  being  so  perilous  as  they  are 
commonly  supposed  to  be.  Indeed,  the  injury  rarely 
proves  fatal  to  an  adult,  even  when  inflicted  by  a viper 
in  the  middle  of  summer,  the  period  when  the  animal  is 
most  active  and  vigorous.  Exceptions  to  this  common 
belief,  however,  are  upon  record.  Thus,  in  the  year 
1816,  a woman  in  France,  aged  sixty-four,  was  bit  on 
the  thigh  by  a viper,  and  died  in  thirty-seven  hours, 
notwithstanding  the  internal  use  of  the  liquor  ammo- 
nia?, and  the  enlargement  of  the  wound  and  cauteriza- 
tion of  it  with  this  fluid.  In  this  case,  it  is  to  be  ob- 
served, that  an  hour  elapsed  before  any  thing  was  done. 
— (See  Annales  du  Cercle  Midicale,  t.  I,  p.  44,  Sao. 
Paris,  1820.) 

Fontana,  therefore,  was  not  exactly  correct  in  con- 
cluding, that  the  bite  of  an  ordinary  viper  will  not  prove 
fatal  to  a full-grown  person,  nor  even  to  a large  dog, 
though  it  does  so  to  smaller  animals.  Five  bites  from 
three  strong  and  healthy  vipers  were  not  able  to  kill  a 
dog  weighing  sixty  pounds ; and  as  this  dog  was  little 
more  than  a third  part  of  the  weight  of  an  ordinary 
man,  Fontana  supposed  that  a single  bite  could  never 
be  fatal  to  an  adult.  He  says,  that  he  had  seen  a 
dozen  cases  himself,  and  had  heard  of  fifty  more,  only 
two  of  which  ended  fatally.  Concerning  one  of  these 
cases  he  could  get  no  information ; the  other  patient 
perished  of  gangrene  twenty  days  after  the  bite.  The 
mortification  began  three  days  after  the  accident,  the 
bitten  place  having  been  deeply  scarified  almost  as 
soon  as  the  injury  was  received.  Fontana  believes, 
that  much  of  the  faintness,  &c.  which  ensues  upon  the 
bite  of  a viper,  is  the  mere  effect  of  terror.  “Upon  a 
person  being  bit  (says  he),  the  fear  of  its  proving  fatal 
terrifies  himself  and  the  whole  family.  From  the  per- 
suasion of  the  disease  being  mortal,  and  that  not  a 
moment  is  to  be  lost,  they  apply  violent  or  hurtful  re- 
medies. The  fear  increases  the  complaint.  I have 
known  a person  that  was  imperceptibly  bit  in  the 
hands  or  feet,  and  who,  after  seeing  the  blood,  and  ob- 
serving a viper  near  him,  suddenly  fainted  away ; one, 
in  particular,  continued  in  a swoon  for  upwards  of  art 
hour,  until  he  was  accidentally  obser.ved  and  recovered 
out  of  it  by  being  suddenly  drenched  in  cold  water. 
We  know  that  death  itself  may  be  brought  on  by  vio- 
lent affections  of  the  mind,  without  any  internal  dis^ 
ease.  Why  may  not  people  who  are  bit  die  from  a 
disease  produced  entirely  by  fear,  and  who  would  not 
otherwise  have  died  from  any  complaint  produced  by 
the  venom?’’  Although  it  must  be  owned  that  Fon- 
tana bestowed  a great  deal  of  attention  upon  this  sub- 
ject, the  above  reasoning  is  hypothetical  and  inconclu- 
sive, If  it  were  to  be  granted,  that  some  very  timid, 
delicate,  or  nervous  people  die  from  feiir  alone,  it  could 
not  be  admitted,  that  the  generality  of  people  bit  by 
snakes  perish  also  from  the  violent  effect  of  mental 
alarm. 

Whenever  the  patient  dies,  the  catastrophe  is  always- 
ascribable  to  the  quantity  of  venom  inserted  in  the 
wound  ; the  number  of  bites  : their  situation  near  im- 
portant organs ; and  the  neglect  of  proper  means  of 
relief.  In  ordinary  cases  of  a single  bite  upon  the  ex- 
tremities, the  patients  would  get  well  even  without  any 
assistance  ; but  the  symptoms  would  probably  be  more 
severe  and  the  cure  slower. 

From  .some  facts  recorded  by  Sir  Everard  Home, 
and  observations  made  on  the  operation  of  the  poisons 
of  the  black-spottcd  snake  of  St.  Lucia,  the  cobra  di 


478 


WOUNDS, 


Capello,  and  the  rattlesnake,  it  appears,  that,  the 
effects  of  the  bite  of  a snake  vary  according  to  the  in- 
tensity of  the  poison.  When  the  poison  is  very  active, 
tlie  local  irritation  is  so  sudden  and  so  violent,  and  its 
effects  on  the  general  system  are  so  great,  that  death 
soon  lakes  place.  When  the  body  is  afterward  in- 
spected, the  only  alteration  of  structure  met  with  is 
in  the  parts  close  to  the  bite,  where  the  cellular  mem- 
brane is  completely  destroyed,  and  the  neighbouring 
muscles  very  considerably  inflamed.  When  the  poison 
is  less  intense,  the  shock  to  the  general  system  does  not 
prove  fatal,  [t  brings  on  a slight  degree  of  delirium, 
and  the  pain  in  the  part  bitten  is  venj  severe;  in  about 
half  an  hour,  swelling  takes  place  from  an  effusion 
of  scrum  in  the  cellular  membrane,  which  continues  to 
increase,  with  greater  or  less  rapidity,  for  about  twelve 
hours,  exlending  during  that  period  into  the  neighbour- 
hood of  the  bile.  The  blood  ceases  to  flow  in  the  small 
vessels  of  the  swollen  parts ; the  skin  over  them  be- 
comes quite  cold;  the  action  of  the  heart  is  so  weak 
that  the  pulse  is  scarcely  perceptible,  and  the  stomach  is 
so  irritable  that  nothing  is  retained  by  it.  In  about 
sixty  hours,  these  symptoms  go  off;  inflammation  and 
suppuration  take  place  in  the  injured  parts ; and  when 
the  abscess  formed  is  very  great,  it  proves  fatal.  When 
the  bite  has  been  in  the  flnger,  that  part  has  immedi- 
ately mortified.  When  death  has  taken  place  under 
such  circumstances,  the  absorbent  vessels  and  their 
glands  have  undergone  no  change  similar  to  the  effects 
of  morbid  poisons,  nor  has  any  part  lost  its  natural  ap- 
pearance, except  those  immediately  connected  with 
the  abscess.  In  those  patients  who  recover  with  diffi- 
culty from  the  bite,  the  symptoms  produced  by  it  go 
off  more  readily  and  more  completely  than  those  pro- 
duced by  a morbid  poison,  which  has  been  received 
into  the  system.” — {Sir  E.  Home,  Case  of  a Man  who 
died  in  consequence  of  the  Bite  of  a Rattlesnake,  in 
Phil.  Trans.  1810.) 

[There  is  scarcely  to  be  found  a more  interesting 
case  of  its  kind  than  that  recorded  by  Sir  Everard 
Home,  as  quoted  by  our  author,  and  the  history  of  So- 
per deserves  to  be  studied  with  all  the  minuteness 
which  Sir  Everard  has  given  to  it.  Mr.  Home  men- 
tions that  the  intellectual  powers  of  the  patient  were 
materially  affected.  This  is  an  occasional  circum- 
stance only  in  cases  of  poisoning  from  venomous  ani- 
mals. Such  appears  to  have  been  the  fact  in  the  case 
of  a young  man,  Mr.  A.,  of  New-York,  who  was  in 
1812  seriously  bitten  in  the  arm  by  a rattlesnake,  that 
liad  been  kept  in  confinement  for  a public  show.  The 
action  of  the  poison,  according  to  Dr.  Francis,  began  to 
manifest  its  effects  as  in  the  instance  of  Soper  (Home’s 
case),  within  the  first  half  hour,  and  its  local  changes, 
such  as  great  swelling,  pain,  &c.,were  also  similar. 
But  in  the  case  of  A.  the  mind  preserved  its  wonted 
functions  throughout  his  whole  illness.  When  the 
bite  is  inflicted  in  a large  vein,  its  effects  seem  to  be 
more  immediate  and  its  fatality  more  certain  than 
under  other  circumstances. — (See  Francis  on  Med.  Ju- 
risprud.  JSTew-York  Med.  and  Phys.  Journal,  vol.  2.) — 
Reese.'] 

Numerous  remedies  for  the  bites  of  common  vipers 
have  obtained  celebrity.  According  to  certain  writers, 
each  of  these  remedies  has  effected  wonderful  cures; 
and  yet,  as  Boyer  well  remarks,  every  one  of  them 
has  been  in  its  turn  relinquished  for  another,  the  sole 
recommendation  of  which  has  frequently  consisted  in 
its  novelty.  Any  of  these  boasted  medicines,  though 
of  opposite  qualities,  cured  or  at  least  seemed  to  cure 
the  patients,  and  the  partisans  of  each  considered  he 
had  a right  to  extol  his  own  remedy  as  a specific, 
when  the  patient  to  whom  he  administered  it  was 
seen  to  recover  perfectly,  after  suffering  a train  of  se- 
vere symptoms.  But  the  reason  of  this  pretended 
efficacy  becomes  obvious,  when  one  knows  that  the 
bite  of  a viper  is  of  itself  rarely  mortal  to  the  human 
subject,  and  that  the  severity  of  the  symptoms  mate- 
rially depends  upon  the  quantity  of  the  venom  in  the 
wound. — {Boyer,  Tra'iU  des  Maladies  Chir.  t.  I,  p. 
428.) 

The  treatment  of  the  bite  of  a viper  is  divided  into 
local  and  general  meansi 

The  local  treatment  has  for  its  principal  object  the 
destruction  of  the  venom,  the  prevention  of  its  en- 
trance into  the  vessels,  or  the  removal  of  it  from  the 
wound. 

Of  scarifying  the  wound,  I shall  only  say  that  it 


promises  no  utility,  if  it  be  practised  with  view  of  Icf^ 
Utig  sucj)  dressings  be  applied  as  are  extolled  as  speci- 
fics; forvvenow  know  that  no  local  application  is  enii- 
lied  to  this  character.  Fontana  was  an  advocate  for 
applying  a ligature  round  the  limb,  in  order  to  check  the 
ingress  of  the  venom  into  the  circulation  ; and  he 
thought  that  he  had  seen  much  good  result  from  this 
practice.  Sir  Everard  Home  is  also  of  opinion,  that 
“ the  only  rational  local  treatment  to  prevent  the  se- 
condary mischief,  is  making  ligatures  above  the  tume- 
fied part,  to  compress  the  cellular  membrane,  and  set 
bounds  to  the  swelling,  which  only  spreads  in  the  loose 
parts  under  the  skin,  and  scarifying  freely  the  parts 
already  swollen,  that  the  effused  serum  may  escape,  and 
the  matter  be  discharged  as  soon  as  it  is  formed.  Jn- 
gatures  (he  says)  are  employed  in  America,  but  with  a 
different  view,  viz.  to  prevent  the  poison  being  ab- 
sorbed into  the  system.”— (TAi7.  Trans,  for  ISlff,  p.  87.) 
At  all  events,  if  compression  be  employed,  it  should  be 
so  regulated  as  not  to  create  any  risk  of  gangrenous 
mischief  by  its  interruption  of  the  circulation.  With 
respect  to  scarification  of  poisoned  wounds,  the  inves- 
tigations of  Dr.  Barry  lead  him  to  entertain  a different 
view  of  them  from  that  adopted  by  the  foregoing  wri- 
ter, as  will  be  presently  noticed. 

Suction  of  the  wound  has  been  proposed,  and  seems 
now  to  be  supported  both  by  reason  and  experience,  as 
I shall  presently  explain  in  noticing  the  valuable  re- 
searches of  Dr.  Barry. 

One  of  the  most  certain  methods  of  removing  the 
virus  consists  in  the  excision  of  the  bitten  part.  This 
operation,  however,  would  hardly  be  proper,  unless 
done  immediately  after  the  injury,  before  much  in- 
flammation had  come  on.  It  is  likewise  a practice  to 
which  many  patients  would  not  assent,  and  even  some 
surgeons  might  deem  the  proceeding  too  severe  in  rela- 
tion to  the  bite  of  the  viper  of  this  country.  The  bite 
might  also  be  inconveniently  situated  for  the  excision 
of  the  parts.  Excision,  as  Dr.  Barry  observes,  carr 
only  be  of  use  in  proportion  to  its  extent.  If  it  reach 
beyond  the  poison  it  will  certainly  save,  but  not  other- 
wise ; and  owing  to  the  wider  mouths  of  the  vessels 
being  now  exposed  to  the  atmospheric  pressure,  the 
particles  of  poison  beyond  the  boundary  of  the  excision, 
will  pass  with  increased  rapidity  to  the  heart.— (Car- 
ry’s/Icsear'cAes,  ij-c.y.  159.) 

Another  plan  more  commonly  preferred  is  that  of 
destroying  the  envenomed  part  with  caustic  or  the  ac- 
tual cautery.  When  this  is  done  in  time,  it  is  said 
that  the  poison  will  be  prevented  from  extending  its 
irritation  over  the  system.  The  caustic  and  cautery,  it 
is  conjectured,  may  also  have  the  effect  of  chemically 
destroying  the  venom  itself,  while  they  tend  to  hinder 
its  passage  into  the  circulation,  inasmuch  as  they  de- 
.stroy  the  neighbouring  absorbent  vessels.  The  caustic 
which  Fontana  preferred  was  potassa.  But,  as  Boyer 
sensibly  remarks,  every  caustic  of  equal  strength  must 
infallibly  have  the  same  effect,  as  itgmode  of  operating 
is  that  of  destroying  the  point  of  irritation,  viz.,  the 
seat  of  the  venom.  In  France,  liquid  caustics  are  pre- 
ferred, the  fluid  muriate  of  antimony,  the  liquor  am* 
monitef  or  the  sulphuric  or  nitric  acid,  because  their 
action  is  quicker,  and  they  more  certainly  penetrate  to 
the  bottom  of  the  wound.— (Tra«le  des  Mai.  Chir.  t.  1, 
p.  429.)  Either  of  these  liquids  may  be  applied  by 
means  of  a slender-pointed  bit  of  wood,  which  is  to  be 
dipped  in  it,  and  then  introduced  into  the  punctures 
made  by  the  fangs  of  the  reptile.  The  piece  of  wood 
should  be  withdrawn,  wet  once  more,  and  applied 
again.  If  a drop  of  the  caustic  can  be  inserted,  so 
much  the  better.  When  the  bite  is  very  narrow  and 
deep,  the  caustic  cannot  well  be  introduced  before  the 
mouth  of  the  wound  is  somewhat  enlarged  with  a 
lancet.  A little  bit  of  lint  may  then  be  wet  in  one  of 
the  above  fluids,  and  be  pressed  deeply  into  the  wound. 
The  actual  and  potential  cautery,  like  excision,  will 
only  succeed,  when  their  action  extends  beyond  the 
limits  of  the  poison. 

After  the  caustic  has  produced  an  eschar,  the  best 
application  is  an  emollient  poultice. 

It  is  not,  however,  every  bite  of  a viper  that  requires 
local  treatment,  even  of  this  degree  of  severity.  When 
the  wound  is  superficial  ; the  viper  beimndied  with 
cold  ; its  poison  considerably  exhausted  by  its  having 
previously  bitten  other  animals;  the  swelling  inconsi- 
derable; and  the  patient  neither  affected  with  prostra- 
tion of  strength  nor  pain  about  the  ptatcordia;  a few 


WOUNDS. 


479 


drops  of  ammonia  may  be  introduced  into  the  wound, 
and  a small  compress  wet  with  the  same  fluid  applied. 
Formerly,  olive  oil  was  considered,  in  England,  one  of 
the  best  applications  for  the  bites  of  snakes,  and  its 
virtues  were  afterward  extolled  in  France  by  Pou- 
teau  ; but,  saj's  Boyer,  it  possesses  no  specific  efficacy, 
as  the  experiments  of  Hunaud  andGeoflroi  have  deci- 
dedly proved. — {Traite  des  Mai.  Chir.  t.  1,  p.  431.) 
Suction  of  poisoned  wounds,  and  especially  of  that  oc- 
casioned by  venomous  snakes,  is  an  ancient  proposal, 
and  one,  the  principle  of  which  has  been  rendered  ex- 
ceedingly important  by  the  e-Xperiments  and  researches 
of  Dr.  Barry.  Several  dogs  and  rabbits  were  bitten  by 
vipers  To  the  bites  of  some.  Dr.  Barry  applied  the 
cupping-glass;  to  the  bites  of  others  nothing-,  and  all 
file  animals  abandoned  did  not  ultimately  perish ; yet 
when  the  cupping-glass  was  applied  for  half  an  hour  to 
such  as  had  been  bitten  by  one,  two,  and  sometimes 
three  vipers,  they  suffered  no  symptom  whatever  of 
constitutional  poisoning,  while  those  which  were  left 
to  nature  were  invariably  attacked  with  convulsions 
and  stupor,  and  the  dogs  with  vomiting. — (See  Exp. 
Researches  on  the  Injluence  of  Atmospheric  Pressure 
upon  the  Blood  in  the  Veins,  <S-c.  p.  121,  8vo.  Land. 
1826.)  From  the  experiments  detailed  in  this  work, 
Dr.  Barry  deduces  the  following  inferences  in  relation 
to  our  present  subject.  First,  That  neither  sound  nor 
wounded  parts  of  the  surface  of  a living  animal  can 
absorb,  when  placed  under  a vacuum.  Secondly, 
That  the  application  of  the  vacuum  by  means  of  a pis- 
ton cu[)ping-glass,  placed  over  the  points  of  contact  of 
the  absorbing  surface,  and  the  poison,  which  is  in  the 
act  (jf  being  absorbed,  arrests  or  njitigates  the  symp- 
toms caused  by  the  poison. — (Exp.  JVo.4.)  Thirdly, 
That  the  application  of  a cupping-glass  for  half  an 
hour  deprives  the  vessels  of  the  part  over  which  it  is 
applied  of  their  absorbent  faculty,  for  an  hour  or  two 
after  the  removal  of  theglass.— (£zp.  JVo.5.)  Fourthly, 
That  the  pressure  of  the  air  forces  into  the  vacuum, 
even  through  the  skin,  a portion  of  the  matter  intro- 
duced into  the  cellular  tissue  by  injection,  that  is,  if 
the  skin  of  the  animal  be  not  too  dense,  as  in  the  dog. 
— (Exp.  Mo.  16 — 20.  Barry,  op.  cit.  p.  134.)  Another 
important  remark  made  by  this  author  is,  that  when 
the  soft  parts  about  a wound,  however  minute,  are 
forced  into  the  vacuum  of  a cupping-glass,  the  point 
which  offers  the  least  resistance  to  the  exit  of  the 
fluids  contained  in  these  parts  is  the  little  wound  it- 
self But  if  scarifications  have  been  made  round  it, 
this  is  no  longer  the  case.  “ Therefore,  the  balance 
between  the  vacuum  within  the  glass  and  the  pressure 
without,  wilt  tend  to  be  established  by  a discharge  from 
the  scarifications,  and  not  from  the  original  wound. 
Hence,  the  probability  of  the  poison  being  forced  out 
of  the  wound,  and  the  vessels  around  it,  will  be  dimi- 
nished in  proportion  to  the  magnitude  of  the  scarifica- 
tions. If  these  scarifications  extend  beyond  the  area 
of  the  vacuum,  the  contents  of  the  vessels  thus  divided 
will  cease  to  be  influenced  by  it,  and,  therefore,  what- 
ever portion  of  the  poison  may  have  passed  beyond  the 
point  of  division,  will  be  carried  to  the  heart  just  as 
if  no  vacuum  had  been  applied.” — (Op.  cit.  p.  158.) 
According  to  Dr.  Barry,  if  actual  or  potential  cauteries 
are  used,  and  any  portion  of  the  poison  remain  beyond 
the  depth  to  which  their  action  may  extend,  the  appli- 
cation of  the  vacuum  will  be  perfectly  useless,  because 
the  openings  through  which  the  poison  might  have 
been  pressed  out,  are  sealed  up.  He  thinks  that  the 
ligature,  recommended  by  Celsns  to  be  placed  between 
the  wound  and  the  heart,  but  not  so  tightly  as  to  de- 
prive the  limb  of  sensation,  should,  with  simple  ablu- 
tion of  the  part,  and  protecting  it  from  the  contact  of 
air,  be  the  only  rentedial  measures  ever  sufiered  to 
precede  the  application  of  the  vacuum  ; and  even  these, 
only  when  a cupping-glass  or  suction  by  the  mouth 
cannot  be  immedialely  cotnmanded. 

It  is  farther  remarked  by  Dr.  Barry,  that  when  the 
cupping-gl.ass  has  been  applied  for  an  hour  to  the  poi- 
soned part  previously  to  excision,  the  contents  of  all 
the  vessels  will  have  acquired  a retrograde  direction  ; 
and  from  not  being  permitted  to  flow  fre«;ly  into  the 
vacuum,  a perfect  stagtiaiion  of  the  fluids  is  esta- 
blished. Hence,  the  loss  of  the  absorbing  faculty  of 
the  cupped  surface. — (Exp.  5 and  7.)  Thus,  says  lie, 
by  allowing  the  first  cupping  to  precede  the  excision  of 
the  part,  not  oidy  is  there  a greater  quantity  of  the 
I oison  removed,  but  the  danger  of  a more  rapid  ab- 


sorption is  avoided  ; while  the  certainly  of  extracting 
a still  farther  portion,  or  perhaps  the  whole  of  what 
may  have  remained,  constitutes  an  additional  and  im- 
portant advantage  to  be  obtained  by  the  second  cup- 
ping. The  advantage  of  the  actual  cautery,  after 
excision  and  the  second  cupping,  depends  upon  its  her- 
metically closing  the  mouths  of  the  small  vessels,  and 
rendering  their  tubes  for  a certain  extent  incompres- 
sible. Their  absorbing  powers  are  therefore  suspended, 
because,  as  Dr.  Barry  argues,  the  pressure  of  the  at- 
mosphere can  neither  force  any  thing  into  them,  nor 
compress  them  upon  their  own  contents. — (See  Barry's 
Researches  on  the  Injiuenee  of  Atmospheric  Pressure 
upon  the  Blood  in  the  Veins,  ^-c.  p.  157,  158.)  These 
observations  relate  to  poisoned  wounds  in  general,  and 
more  especially  to  the  treatment  of  hydrophobia,  and 
of  other  cases  where  the  symptoms  resulting  from  the 
poi.son  are  of  an  exceedingly  dangerous  and  rapid 
description. 

With  respect  to  the  general  treatment  of  the  bite  of  a 
viper  or  of  any  other  venomous  snake,  if  we  exclude 
emetics,  of  which  Dr.  Mead  had  a high  opinion  when 
the  patient  was  much  jaundiced,  the  favourite  medi- 
cines are  cordials,  ammonia,  and  arsenic.  The  ancients 
employed  theriaca,  mithridates,  salt,  and  the  carbonate 
of  ammonia.  Of  all  stimulants,  however,  the  liquor 
animonice  is  that  which  now  obtains  the  greatest  confi- 
dence, or  else  the  eau  de  luce,  which  only  differs  from 
the  fluid  ammonia  in  containing  a small  quantity  of 
the  oleum  succinatum.  In  France,  this  remedy  is  even 
at  the  present  time  regarded  as  having  the  best  claim 
to  the  title  of  a specific  for  the  bite  of  a viper. — (B  oyer, 
op.  cit.) 

In  France,  Bernard  de  Jussieu  first  tried  ammonia 
in  the  year  1747  (see  Hist,  de  VAcad.  des  Sciences, 
1747) ; since  which  time  it  has  been  extensively  em- 
ployed for  the  cure  of  the  bites  of  vipers,  both  as  an 
internal  and  external  remedy.  It  had,  however,  been 
highly  praised  by  Dr.  Mead  at  a mucheailier  period. 

A few  drops  of  the  remedy  are  to  be  exhibited  every 
two  hours;  but  as  it  is  very  powerful,  it  must  always 
be  diluted  with  tea,  or  some  other  drink,  or  the  mis- 
tura  camphorae.  The  dose,  however,  must  depend 
upon  the  age  and  constitution  of  the  [)atient,  and  the 
intensity  of  the  symptoms.  Four  or  five  drops  suffice 
for  a person  of  weak,  delicate,  irritable  habit ; but 
twelve  or  fifteen  may  be  given  to  stronger  subjects, 
when  the  symptoms  are  violent.  With  ammonia,  some 
practitioners  order  wine. 

In  St.  George’s  Hospital,  the  man  who  was  bit  by 
the  rattlesnake  kept  for  exhibition  took  aperient  medi 
cines,  the  liquor  ammonitE,  ether,  the  spiritus  ammo- 
niae,  comp,  opium,  and  other  stimulants;  but  without 
any  apparent  benefit.  The  disease  followed  that 
course  which  Sir  E.  Home  has  described  as  usual 
when  the  shock  on  the  system  is  not  directly  fatal, 
and  the  mischief  in  the  arm  ultimately  produced  the 
man’s  death.— (See  Phil.  Trans.  1810.) 

From  the  following  passage  in  relation  to  the  bites 
of  snakes  in  general,  it  seems  that  Sir  Everard  Home 
in  1810  had  no  confidence  in  any  medicines  which  had 
then  been  duly  tried.  “ The  violent  effects  which  the 
poison  produces  on  the  part  bitten,  and  on  the  general 
system,  and  the  sliortness  of  their  duration,  where  they 
do  not  terminate  fatally  (says  he),  have  frequently 
induced  the  belief  that  the  recovery  depended  on  the 
medicines  employed  : and  in  the  East  Indies,  eau  de 
luce  is  considered  as  a specific. 

There  does  not  appear  to  be  any  foundation  for  such 
an  opinion;  for  when  the  poison  is  so  intense  as  to 
give  a sufficient  shock  to  the  constitution,  death  imme- 
diately takes  place;  and  where  the  poison  produces  a 
loctil  injury  of  sufficient  extent,  the  patient  also  dies, 
while  all  slighter  cases  recover.  The  effect  of  the 
poison  on  the  constitution  is  so  immediate,  and  the 
irritability  of  the  stomach  so  great,  that  there  is  no 
opportunity  of  exhibiting  medicines  till  it  has  fairly 
taken  place,  and  then  there  is  little  chance  of  beneficial 
effects  being  produced.”— (6'ir  E.  Home,  in  Phil. 
'J’rnns.  1810.) 

Fontana  also  had  little  faith  in  reputed  antidotes; 
but  it  is  to  he  noticed,  that  his  observations  refer  only 
to  the  bites  of  vipers.  “ In  no  country  (says  he) 
through  which  I passed,  could  I ever  find  any  two 
people  or  [jersons  bit  by  the  viper,  either  in  the  moun- 
tains or  valleys,  that  used  the  same  remedies.  Some 
used  theriaca  alone,  either  externally  or  internally 


480 


WOUNDS. 


applied ; others,  common  oil ; a tliird  set  used  stimu- 
lants, such  as  the  strongest  spirituous  liquors ; while 
others,  oii  the  contrary,  tried  every  different  kind  of 
sedative.  In  short,  there  is  hardly  any  active  kind  of 
medicine  that  has  not  been  tried  as  a cure  in  this  dis- 
ease ; while  at  the  same  time  it  is  certain,  that,  under 
all  the  varieties  of  application,  none  of  the  patients 
died.’’  Hence,  Fontana  concluded  that  none  of  the 
remedies  had  any  efiect  in  curing  the  disease. 

Later  observations,  however,  tend  to  raise  our 
hopes,  that  a medicine  is  now  known  which  really 
seems  to  possess  considerable  efficacy  against  the  bite 
even  of  a very  formidable  kind  of  snake.  From  some 
facts  recorded  in  Dr.  Russell’s  History  of  Indian  Ser- 
pents, on  the  authorities  of  Mr.  Duffin  and  Mr.  Ram- 
say, it  appears  that  the  Tanjore  pill,  of  which  arsenic 
is  the  chief  ingredient,  is  e.xhibited  with  considerable 
success  in  India  after  the  bites  of  venomous  serpents. 
This  information  led  Mr.  Chevalier  to  propose  the  fair 
trial  of  arsenic. 

Mr.  Ireland,  surgeon  to  the  60th  regiment,  had  for- 
merly heard  Mr.  Chevalier  recommend  the  trial  of 
arsenic,  and  he  was  resolved  to  make  the  experiment 
whenever  an  opportunity  offered.  On  his  arrival  in 
the  island  of  St.  Lucia,  he  was  informed  that  att  officer 
and  several  men  belonging  to  the  68th  regiment  had 
died  from  the  bites  of  serpents,  supposed  to  be  the 
coluber  carinatus  of  Linnaeus. 

The  reader  will  find  some  interesting  account  of  the 
serpent  here  alluded  to,  in  a tract  which  I have  lately 
read,  entitled  Monogrwphie  du  Trigonocephale  des 
Antilles,  ou  Grand  Vipire  Fer-de-Lance  de  la  Marti- 
nique,par  A.  Moreau  des  Jonnes,8vo.  Paris,  1816. 

Mr.  Ireland  also  learned  that  every  thing  had  been 
tried  by  the  attending  medical  men  to  no  purpose,  as 
all  the  patients  had  died,  some  in  six,  and  others  in 
about  twelve  hours  from  their  receiving  the  wound. 

A case,  however,  soon  came  under  Mr.  Ireland’s 
own  observations,  and  as  nothing  that  had  been  done 
before  seemed  to  have  been  of  any  service,  he  was  de- 
termined to  give  arsenic  a full  trial. 

“Jacob  Course,  a soldier  in  the  York  light  infantry 
volunteers,  was  bitten  in  the  left  hand,  and  the  middle 
finger  was  so  much  lacerated,  that  I found  it  necessary 
to  amputate  it  immediately  at  the  joint  with  the  meta- 
carpal bone. 

I first  saw  him  about  ten  minutes  after  he  had  re- 
ceived the  wound,  and  found  him  in  a torpid,  senseless 
state  ; the  hand,  arm,  and  breast  of  the  same  side  were 
much  swelled,  mottled,  and  of  a dark  purple  and  livid 
colour.  He  was  vomiting,  and  appeared  as  if  much 
intoxicated.  Pulse  quick  and  hard : he  felt  little  or  no 
pain  during  the  operation. 

The  w'ound  being  dressed  and  the  patient  put  to  bed, 

I ordered  a cathartic  clyster,  and  the  following  medi- 
cine to  be  taken  immediately.  Liquor,  arsenic  3 ij. 
Tinct.  opii  gt.  x.  Aq.  menth.  pip.  5iss;  which  was 
added  to  halfan  ounce  of  lime-juice,  and  as  it  produced 
a slight  effervescence,  it  was  given  in  that  state.  This 
remained  on  his  stomach,  and  was  repeated  every  half 
hour  for  four  successive  hours.  In  the  mean  time,  the 
parts  were  frequently  fomented  with  common  foment- 
ations, and  rubbed  with  a liniment  composed  of  Ol. 
terebinth,  jss..  Liquor,  ammon.  ^ss.,  and  01.  oliv. 

3 iss.  The  cathartic  clyster  was  repeated  twice,  when 
the  patient  began  to  be  purged,  and  the  arsenical  me- 
dicine was  now  discontinued.  He  had  become  more 
sensible  when  touched,  and  from  that  time  he  gradually 
recovered  his  faculties ; he  took  some  nourishment, 
and  had  several  hours’  sleep. 

'Phe  next  day  he  appeared  very  weak  and  fatigued  ; 
the  fomentation  and  liniment  were  repeated.  The 
swelling  diminished  gradually ; the  natural  colour  and 
feeling  returned,  and  by  proper  dressings  to  the  wound, 
and  attention  to  the  stale  of  his  bowels,  he  soon  reco- 
vered and  returned  to  his  duty.” 

Mr.  Ireland  recites  about  four  other  examples,  in 
which  arsenic  was  exhibited  with  similar  success. 

It  deserves  particular  notice,  that  the  liquor  arseni- 
calis  employed  by  3Ir.  Ireland  was  prepared  according 
to  Dr.  Fowler's  prescription,  which  directs  sixty-four 
grains  of  arsenic  and  as  many  of  the  fi.xed  vegetable 
alkali  to  he  dissolved  in  a sand  heat,  and  the  solution 
to  be  made  an  exact  pint,  so  that  two  drachms  contain 
ene  grain  of  arsenic  in  solution. — (See  Med.  Chir. 
Trans,  vol.  2,  p.  393,  drc.)  Whatever  may  be  the  con- 
eiitutional  treatment  of  poisoned  wounds,  the  local 


management  of  them  on  their  first  occurrence,  accord* 
ing  to  the  principles  explained  by  Dr.  Barry,  and 
already  noticed  in  this  article,  should  never  be  ne 
glected,  as  it  is  certainly  most  deserving  of  confidence. 
It  operates  as  a preventive  of  symptoms,  which,  after 
they  have  come  on,  sometimes  prove  fatal.  In  hydro- 
phobia this  is  too  often  proved. 

[A  singular  case  of  poisoned  wound  from  the  bite  of 
a rattlesnake  occurred  some  years  since,  under  the 
observation  of  Dr.  S.  T.  Barstow,  of  Wilkesbarre, 
Pennsylvania,  and  in  some  respects  is  perfectly  ano- 
malous. 

A lady  in  the  fourth  or  fifth  month  of  her  pregnancy 
was  bitten  by  a rattlesnake,  but  under  the  appropriate 
treatment  she  at  length  recovered  from  the  symptoms 
usually  consequent  upon  such  wounds.  At  the  full 
period  of  gestation,  she  was  safely  delivered  of  a fine, 
heallhy-looking  child  ; but  immediately  on  its  being 
applied  to  the  breast  and  allowing  it  to  suck,  the  child 
assumed  the  peculiar  hues  of  the  rattlesnake,  swelled 
exceedingly,  and  soon  died.  She  then  procured  a 
puppy  to  relieve  her  breasts,  which  died  in  two  days  of 
the  same  symptoms.  A lamb  was  then  tried  ; and  in 
succession,  one  puppy  and  three  lambs  shared  the 
same  fate.  Another  puppy  was  then  procured,  which 
escaped  with  its  life,  but  exhibited  some  of  the  symp- 
toiiis  which  had  been  fatal  to  its  predecessors.  The 
lady  remained  all  this  time  without  any  symptom  of 
disease,  and  had  as  rapid  a convalescence  from  partu- 
rition as  is  usually  observed. 

The  poison  seems  to  have  been  excreted  by  the  pro- 
cess of  lactation ; for  the  second  year  afterward  she 
had  another  child,  and  though  she  applied  it  to  lier 
breasts,  not  without  fearful  forebodings,  yet  no  evil 
consequences  resulted. 

The  obscurity  in  which  the  action  of  poisons  on  the 
human  constitution  is  involved,  is  in  nowise  lessened 
when  we  consider  that  testimony  of  the  most  satisfac- 
tory sort  shows  that  hydrophobia  may  be  generated  by 
heat,  and  that  the  disea.se  may  sometimes  occur  spon- 
taneously. According  to  M.  Unaniel,  in  1807,  in  the 
village  of  Sea,  forty-two  persons  died,  after  having 
been  bitten  by  mad  dogs;  and  on  the  north  coast, 
hydrophobia  occurred  in  several  individuals  without 
bile. — (See  Journal  des  Progres,  quoted  in  Morth  Am. 
Med.  and  Surg.  Journ.  vol.  6.)  The  causes  which  may 
induce  spontaneous  hydrophobia  are  violent  emotions 
of  the  mind,  sorrow,  fear,  rage,  fright,  the  want  of 
food,  &c.  Drs.  Hosack  and  Francis  enjoyed  a singular 
opportunity  of  witnessing  a case  of  hydrophobia,  aris- 
ing in  a young  man,  aged  thirteen  years,  independent 
of  the  bite  of  a rabid  animal.  He  had  been  severely 
treated  by  his  guardian  or  overseer  for  some  imaginary 
offence;  the  want  of  food  and  clothing  at  an  inclement 
season  of  the  year  could  alone  be  looked  upon  as  tlie 
exciting  cause  of  his  complaint.  The  symptoms  of  his 
disorder  throughout  were  similar  to  those  arising  from 
madness  induced  by  the  bite  of  a rabid  animal. — {JVew- 
York  Med.  and  Phys.  Journ.  vol.  2.)  A curious  paper 
on  the  various  means  employed  for  the  cure  of  hydro- 
phobia by  Dr.  Mease,  may  be  seen  in  the  Philad.  Med. 
Museum ; and  though  I have  no  confidence  in  the 
remedy,  I must  refer  to  Dr.  Ramsay’s  paper  in  the 
Medical  Repository  of  New-York,  concerning  the  value 
of  the  volatile  alkali  in  such  cases. — (See  farther 
Thacher  on  Hydrophobia.) — Reese.] 

IVoundsofthe  Thorax. — The  thorax  is  a cavity  of 
an  irregularly  oval  figure,  bounded  in  front  by  the 
sternum,  laterally  by  the  ribs,  posteriorly  by  the  verte- 
bra; of  the  back,  above  by  the  clavicles,  and  below  by 
the  diaphragm,  a very  powerful  muscle,  which  forms  a 
kind  of  partition  between  the  cavity  of  the  thorax  and 
that  of  the  abdomen. 

The  diaphragm  is  not  stretched  across  in  a straight 
direction  from  one  side  of  the  chest  to  the  other;  but, 
on  the  contrary,  descends  much  farther  in  some  places 
than  in  others.  If  the  cavity  of  the  thorax  be  opened 
by  a transverse  section,  about  the  middle  of  the 
sternum,  the  diaphragm  appears,  on  examination,  to 
be  very  prominent  and  convex  towards  its  centre,  while 
it  sinks  downward  at  its  edges,  towards  all  the  points 
to  which  the  muscle  is  attached.  At  its  anterior  and 
most  elevated  part,  it  is  fi.xed  to  the  ensifonn  cartilage, 
whence,  descending  obliquely  to  the  right  and  left,  it  is 
inserted  on  both  sides  into  the  seventh  rib,  all  the  lower 
ribs,  and  lastly  into  the  lower  dorsal  vertebra;.  Ac- 
cording to  this  description,  it  is  obvious  that  the  cavity 


WOUNDS. 


481 


of  the  thorax  has  much  greater  depth  and  capacity 
behind  than  in  front;  a circumstance  which  surgeons 
ought  to  be  well  aware  of,  or  else  they  will  be  liable  to 
give  most  erroneous  opinions  concerning  wounds  of 
the  chest.  For  instance,  a practitioner  deficient  in 
anatomical  knowledge  might  imagine,  that  a weapon 
pushed  from  above  downwards  into  the  front  of  the 
chest  could  never  reach  the  lungs,  after  having  pene- 
trated the  cavity  of  the  abdomen.  It  is  a fact,  how- 
ever, that  no  instrument  could  pass  in  this  direction, 
even  some  inches  below  the  highest  part  of  the  abdo- 
men, without  entering  the  chest. 

The  whole  cavity  of  the  thorax  is  lined  with  a mem- 
brane named  the  pleura,  which  is  every  where  adherent 
to  the  bones  which  form  the  parietes  of  this  cavity, 
and  to  the  diaphragm.  Each  side  of  the  thorax  has  a 
distinct  pleura.  The  two  membranes  meet  in  the 
middle  of  the  chest,  and  extend  from  the  sternum  to 
the  vertebrae.  In  this  manner,  two  cavities  are  formed, 
which  have  no  sort  of  communication  with  each  other. 
By  the  two  pleurae  touching  and  lying  against  each 
other,  a middle  partition  is  formed,  called  the  medias- 
tinum. These  two  membranes  are  intimately  adherent 
to  each  other  in  front,  the  whole  length  of  the  sternum  ; 
but  behind,  where  they  approach  the  vertebrae,  they 
separate  from  each  other,  so  as  to  leave  room  for  the 
aorta,  oesophagus,  &c.  The  heart,  enclosed  in  the 
pericardium,  occupies  a considerable  space  on  the  left 
of  the  mediastinum,  and  all  the  rest  of  the  chest  is 
filled  with  the  lungs,  except  behind,  where  the  large 
blood-vessels,  nerves,  thoracic  duct,  and  oesophagus 
are  situated.  In  the  perfectly  healthy  state,  the  lungs 
do  not  adhere  to  the  pleura ; but  in  the  majority  of' 
subjects,  at  least  in  this  climate,  who  are  examined 
after  death,  such  adhesions  are  found  in  a greater  or 
less  degree.  The  disease  may  probably  be  occasioned 
by  very  slight  inflammation ; and  as  the  surface  of  the 
lungs  IS  naturally  destined  to  be  always  in  close  con- 
tact with  the  pleura,  and  patients  are  frequently  not 
suspected  to  have  any  thing  wrong  in  the  thorax,  this 
morbid  change  being  often  accidentally  discovered  after 
death,  in  looking  for  something  else,  it  may  be  con- 
cluded that  it  does  not  produce  any  serious  effects. 

The  thorax  is  subject  to  all  kinds  of  wounds;  but 
their  importance  particularly  depends  on  their  depth. 
Those  which  do  not  reach  beyond  the  integuments,  do 
not  differ  from  common  wounds,  and  when  properly 
treated  are  seldom  followed  by  any  bad  consequences. 
On  the  contrary,  those  which  penetrate  the  cavity  of 
the  pleura,  even  by  the  slightest  opening,  may  give  rise 
to  alarming  symptoms.  Lastly,  wounds  injuring  any 
of  the  thoracic  viscera  are  always  to  be  considered  as 
placing  the  patient  in  a state  of  considerable  danger. 

From  what  has  been  said,  it  appears  that  wounds  of 
the  thorax  are  very  properly  divisible  into  three  kinds ; 
viz.  1,  such  as  affect  only  the  skin  and  muscles , 2, 
such  as  enter  the  cavity  of  the  chest,  but  injure  none 
of  the  viscera ; 3,  others  which  injure  the  lungs  or 
some  other  viscus. 

Superficial  Wounds  of  the  Thorax. — Immediately  a 
surgeon  is  called  to  a recent  wound  of  the  chest,  his  first 
care  should  be  to  ascertain  whether  the  weapon  has 
penetrated  the  pleura  or  not.  In  order  to  form  a judg- 
ment on  this  circumstance,  surgical  writers  recommend, 
1.  Placing  the  w’ounded  person  in  the  same  posture  in 
which  he  was  when  he  received  the  wound,  and  then 
carefully  examining,  with  the  finger  or  probe,  the  direc- 
tion and  depth  of  the  stab.  2.  The  examination,  if 
possible,  of  the  weapon,  so  as  to  see  how  much  of  it  is 
stained  with  blood.  3.  The  injection  of  fluid  into  the 
wound,  and  attention  to  whether  it  regurgitates  imme- 
diately or  lodges  in  the  part.  4.  The  colour  and  quan- 
tity of  the  blood  discharged  from  the  wound  are  to  be 
noticed,  and  whethei  any  is  coughed  up.  5.  We  are 
to  examine,  whether  air  escapes  from  the  wound  in 
respiration,  and  whether  there  is  any  emphysema.  6. 
Lastly,  the  state  of  the  pulse  and  breathing  must  be 
considered. 

In  wounds  of  the  chest,  however,  surgeons  should 
not  be  too  officious  with  their  probes,  merely  for  the 
sake  of  gratifying  their  curiosity,  or  appearing  to  be 
doing  something.  No  judicious  surgeon  can  doubt  that 
authors  have  dwelt  too  much  on  the  subject  of  probing 
wounds  of  the  abdomen  and  thorax  ; for  they  would 
really  lead  their  readers  to  believe,  that  until  the  wound 
has  been  traced  with  the  finger  or  probe  to  its  very 
bottom  and  termination,  surgeons  are  not  qualified  to 

Vor..  U.— H h 


institute  any  mode  of  treatment.  The  only  advantage 
of  knowing  that  a wound  penetrates  the  chest  is,  that 
the  practitioner  immediately  feels  himself  justified  in 
having  recourse  to  bleeding  and  other  antiphlogistic 
means,  with  the  view  of  preventing  inflammation  of 
the  pleura  and  lungs,  which  affection,  if  not  controlled 
in  time,  often  proves  fatal.  However,  there  can  be 
little  doubt,  that  if  the  nature  and  depth  of  the  wound 
cannot  be  readily  detected  with  the  eye,  the  finger  or  a 
probe,  or  by  the  discharge  of  air  or  blood,  it  is  much 
safer  to  bleed  the  patient  than  to  put  him  to  useless  pain 
with  the  probe,  and  waste  opportunities  of  doing  good 
which  too  frequently  can  never  be  recalled.  In  short, 
generally  speaking,  it  is  better  and  more  advantageous 
for  all  patients,  that  some  of  them  should  lose  blood, 
perhaps  unnecessarily,  than  that  any  of  them  should 
die  in  consequence  of  the  evacuation  being  omitted  or 
delayed. 

Almost  all  writers,  who  have  taken  pains  to  direct 
how  wounds  of  the  thorax  should  be  probed,  conclude 
with  remarking,  that  however  advantageous  a know- 
ledge of  the  direction  and  depth  of  the  wound  maybe, 
much  harm  has  frequently  been  done  by  pushing  the 
attempts  to  gain  such  information  too  far.  It  is,  per- 
haps of  greater  importance  to  learn  by  some  kind  of 
examination,  the  extent  of  a wound,  which  does  not 
reach  beyond  the  integuments  or  intercostals,  than  to 
know  whether  the  wound  extends  into  the  cavity  of 
the  chest.  For  even  when  the  pleura  is  found  to  be 
divided,  if  the  wound  be  attended  with  no  urgent 
symptoms,  the  information  is  of  no  practical  use,  if  we 
make  it  a rule  to  adopt,  without  the  least  delay,  a strict 
antiphlogistic  plan  of  treatment  in  all  cases,  in  which 
there  is  any  suspicion  or  chance  of  the  parts  within 
the  chest  being  wounded  and  likely  to  inflame.  Be- 
sides, frequently  the  symptoms  are  more  urgent  and 
alarming  than  they  could  be,  were  only  parts  on  the 
outside  of  the  thorax  injured  ; and  under  such  circum- 
stances, it  is  manifest  that  a probe  cannot  be  necessary 
for  discovering  that  the  wound  extends  into  the  chest. 

With  respect  to  the  injection  of  lukewarm  water, 
or  any  other  fluid,  and  the  circumstance  of  its  regurgi- 
tation as  a criterion  of  the  wound  being  only  super- 
ficial, the  plan  is  more  objectionable  than  the  employ- 
ment of  a probe;  for  if  the  liquid  be  propelled  with 
force,  it  may  be  injected  into  the  cellular  substance, 
and  seem  to  be  passing  through  the  track  of  the  wound 
into  the  chest,  while,  in  reality,  not  a drop  does  so. 
Besides,  is  it  a warrantable  proceeding  to  try  to  insi- 
nuate any  quantity  or  kind  of  liquid  whatever  between 
the  pleura  and  lungs,  into  a situation  in  which  it  must 
necessarily  obstruct  the  important  function  of  respira- 
tion, and  cause  serious  inconvenience? 

When  air  issues  from  the  wound  in  expiration,  there 
is  ground  for  suspecting  that  the  lungs  are  wounded. 
But  I believe  that  such  authors  as  represent  this  cir- 
cumstance as  an  infallible  criterion  of  the  nature  of 
the  accident,  labour  under  a mistake  ; for  when  there 
is  simply  an  opening  in  the  chest,  without  any  injury 
of  the  lungs  whatever,  the  same  symptom  may  occur. 
The  air  which  is  discharged  through  the  wound  in 
expiration  has  previously  entered  the  bag  of  the  pleura 
through  the  same  wound  in  inspiration.  In  order  to 
remove  all  doubt,  the  patient  may  be  requested  to 
expire  as  strongly  as  he  can,  so  as  to  force  out  whatever 
air  may  have  accumulated  in  the  chest.  At  the  end  of 
each  expiration  of  this  kind,  care  must  be  taken  to 
bring  the  skin  closely  over  the  orifice  of  the  wound, 
and  to  keep  it  thus  applied  during  each  following 
inspiration,  for  the  purpose  of  preventing  the  external 
air  from  entering.  In  this  way,  if  there  be  no  wound 
of  the  lungs,  all  the  air  will  soon  be  expelled  ; but  if  it 
still  continues  to  be  discharged  in  expiration,  the  lungs 
must  be  wounded. 

Sometimes  an  emphysematous  swelling  takes  place 
round  wounds  of  the  thorax,  in  consequence  of  a quan- 
tity of  air  diffusing  itself  in  the  cellular  substance.  In 
wounds  which  are  straight  and  ample  this  symptom  is 
very  uncommon,  but  in  cases  of  narrow  oblique  stabs, 
and  where  the  lungs  are  wounded  by  the  points  of 
broken  ribs,  it  is  by  no  means  unfrequent.— (See  Em- 
physema.) When  a considerable  quantity  of  blood 
flows  from  the  wound,  there  is  reason  for  conjecturing 
not  only  that  the  weapon  htts  penetrated  the  cavity  of 
the  thorax,  but  that  some  of  the  thoracic  viscera  are 
injured.  Excepting  the  intercostal  arteries,  which  run 
along  the  edges  of  the  lower  ribs,  and  the  trunks  of  the 


482 


WOUNDS. 


thoracic  arteries,  all  the  other  vessels  on  the  outside  of 
the  chest  are  very  inconsiderable.  The  effects  of  com- 
pression will  indicate  whether  the  blood  escapes  from 
an  artery  on  the  outside  of  the  cavity  of  the  pleura ; 
and  sometimes  the  situation  and  direction  of  a wound 
at  once  denotes  that  the  hemorrhage  cannot  proceed 
from  the  trunks  of  the  thoracic  arteries. 

Even  the  appearance  of  the  blood  which  comes 
from  the  wound  may  lead  to  some  conjectures  con- 
cerning the  depth  of  the  injury.  The  blood  which 
flows  from  wounds  of  the  lungs  is  of  a brighter  scarlet 
colour,  and  more  frothy  than  that  which  is  discharged 
from  the  vessels  of  any  other  part. 

There  can  be  no  doubt  of  the  lungs  being  wounded, 
when  the  patient  is  observed  to  spit  up  blood  ; but  the 
absence  of  this  symptom  is  not  a positive  proof  of  their 
being  untouched,  though  unquestionably  a very  im- 
portant circumstance  in  the  diagnosis,  and,  generally 
speaking,  a correct  criterion  of  the  lungs  having  escaped 
injury.  At  all  events,  when  no  blood  is  spit  or  coughed 
up,  the  lungs  can  never  be  deeply  penetrated. 

The  state  of  the  pulse  and  that  of  respiration,  ought 
to  be  particularly  attended  to  by  the  practitioner. 
Neither  one  nor  the  other  seems  altered,  at  least  at  first, 
v/hen  wounds  do  not  reach  more  deeply  than  the  in- 
teguments: but  those  which  penetrate  the  cavity  of 
the  thorax,  and  especially  such  as  injurb  the  viscera, 
may  frequently  be  distinguished  from  the  very  first 
moment  of  their  occurrence,  by  their  effects  on  the  san- 
guiferous system,  and  the  function  of  respiration. 
When  the  lungs  are  wounded  at  a point  where  they 
adhere  to  the  pleura,  no  air  can  be  effused  in  the  thorax, 
and  the  functions  of  those  organs  may  on  this  account 
suffer  less  disturbance  than  would  be  the  consequence 
of  an  equal  degree  of  injury  at  some  other  unadherent 
portion  of  the  lungs.  Experience  proves,  that  when 
either  air  or  blood  insinuates  itself  between  the  lungs 
and  the  pleura,  the  lungs  become  immediately  op- 
pressed, the  breathing  is  attended  with  great  difficurry, 
the  pulse  is  weak,  contracted,  and  intermittent. 

Wounds  of  the  integuments  and  muscles  of  the 
thorax  are  not  attended  with  any  particular  danger; 
they  heal  with  the  same  readiness,  and  by  the  same 
means,  as  common  superficial  wounds  in  any  other 
part  of  the  body. 

When  the  case  is  a punctured  or  a gun-shot  wound, 
some  writers  are  advocates  for  laying  open  the  track 
of  the  injury  from  one  end  to  the  other,  if  its  course 
should  not  be  too  e.\tensive,  and  they  then  recommend 
dressing  the  cavity  down  to  its  bottom.  When  the 
track  of  the  wound  was  too  extensive,  a seton  was 
sometimes  introduced.  The  aim  of  such  exploded 
practices  was  to  prevent  the  outer  part  of  the  wound 
from  healing  too  soon,  and  thus  give  time  for  the  whole 
of  it  to  heal  in  an  equal  degree.  When  a seton  was 
used,  the  thickness  of  the  skin  was  gradually  dimi- 
nished, and  after  the  whole  of  it  had  been  removed,  a 
slight  compression  was  kept  up  for  a few  days,  with 
the  view  of  completing  the  cure. 

The  French  surgeons  have  the  discredit  of  having 
brought  setons  into  fashion  in  this  branch  of  surgery ; 
and  1 am  particularly  glad  that  a late  writer  has  well 
exposed  the  absurdity  of  the  pracUce.  “ We  find  (says 
Mr.  John  Bell)  the  history  of  it  to  be  plainly  this  ; that 
as  Guy  de  Chauliac,  ParJft,  and  all  the  older  surgeons, 
did  not  know  how  to  dilategun-shot  wounds,  they  found 
these  same  setons  useful  in  bringing  the  eschar  sooner 
away,  and  in  preserving  an  open  wound  ; and  as  they 
believed  the  wounds  to  be  poisoned,  they  took  the  op- 
portunity of  conducting,  by  these  setons,  whatever 
acrid  medicines  might,  according  to  the  prevailing  doc- 
trines of  that  time,  have  any  chance  of  correcting  the 
poison.”  Mr.  J.  Bell  notices,  how  surprising  it  is  to  see 
the  cruelty  and  perseverance  with  which  some  modern 
practitioners,  particularly  French,  draw  these  cords 
through  wounded  limbs ; and  when  the  roughness  of 
such  a cord,  or  the  acrimony  of  the  drugs  conveyed  by 
it,  produces  a copious  suppuration,  these  men  are  de- 
lighted with  such  proof  of  their  success.  The  setons 
have  been  introduced  by  the  French  surgeons,  across 
the  thickest  parts  of  the  limbs,  along  the  whole  length 
of  the  forearm,  and  at  the  same  time  frequently  through 
the  wrist  joint.  The  setons  have  also  been  covered 
with  stimulating  applications.  Profuse  suppurations 
and  dreadful  swellings,  of  course,  ensued  ; still,  as  Mr. 
J.  Bell  has  remarked,  these  cruelties  were  continued 
till  the  wound  healed  almost  in  spite  of  the  pain ; or 


till  the  coming  on  of  very  dreadful  pain,  great  suppu- 
rations, convulsions,  &cc.  made  the  surgeon  discontinue 
the  method,  or  even  amputate  the  limb.  The'  French 
have  become  so  familiarized  to  setons,  that  they  do  not 
restrict  their  use  to  flesh  wounds  ; they  pass  them  quite 
across  the  thorax,  across  the  abdomen,  and  even 
through  wounds  of  the  knee-joint. 

When  we  wish  to  excite  inflammation  in  the  cavity 
of  the  tunica  vaginalis,  for  the  purpose  of  radically 
curing  a hydrocele,  vve  either  pass  a seton  through  the 
part ; lay  it  open  with  an  extensive  incision  ; cram  a 
tent  into  it;  or  inject  some  irritating  fluid  into  it. 
While  the  animal  machine  continues  the  same,  says 
Mr.  John  Bell,  the  same  stimuli  will  produce  the  same 
eftects,  and  a seton,  injection,  or  long  tent,  if  they  pro- 
duce pain  or  inflammation  in  the  scrotum,  will  not  be 
easy  in  the  chest ; and  unless  we  can  use  them  in  the 
.chest,  with  the  same  intentions  with  which  we  use 
them  in  the  hydrocele,  in  other  words,  unless  we  are 
justified  in  inflaming  the  chest  and  causing  an  adhesion 
of  all  the  parts,  we  cannot  use  them  with  any  con- 
sistency or  good  sense. 

With  regard  to  the  cases  which  the  French  adduce 
in  confirmation  of  the  good  effects  of  their  plans,  I am 
entirely  of  opinion  with  Mr.  J.  Bell,  that  the  facts  only 
prove,  that  the  patients  recovered  in  spite  of  the  setons. 
“It  is  like  (adds  this  author)  what  happened  to  a sur- 
geon who  was  dabbling  in  the  thorax  with  a piece  of 
caustic,  which  fell  directly  into  the  cavity  of  the  chest, 
w'here  it.  caused  very  large  suppurations,  and  yet  the 
patient  was  saved.  The  patient  recovered  in  spite  of 
the  caustic,  just  as  M.  Guerin’s  patient,  and  many 
other  poor  unhappy  souls,  who  lived  in  spite  of  the  se- 
tons. One  would  think  that  people  took  a pleasure  in 
passing  setons  across  the  eyeball,  the  chest,  the  knee- 
joint,  &c.  merely  to  make  fools  stare,  when  the  busi- 
ness might  be  as  effectually  done  with  an  abscess  lancet.” 

Mr.  John  Bell,  in  his  usual  lively  style,  makes  the  em- 
ployment of  tents,  in  wounds  of  the  chest,  seem  equally 
ridiculous  and  improper.  Indeed,  he  says,  he  knows  of 
no  occasion  in  all  surgery  in  which  tents  can  be  useful, 
except  in  the  single  one  of  a narrow  opening  which  we 
desire  to  dilate,  in  order  to  get  at  the  bottom  of  the 
wound  ; and  where,  either  on  account  of  some  great  ar- 
tery, or  the  fearful  temper  of  our  patient,  we  dare  not 
use  the  knife. — (See  J.  Bell  on  Wounds.  Discourse  2, 
vol.  2.) 

Having  hitherto  been  engaged  rather  in  pointing  out 
what  ought  not  to  be  done,  than  what  ought,  I shall  next 
make  some  remarks  on  the  line  of  conduct  which 
should  be  adopted  in  cases  of  wounds  of  the  parietes 
of  the  chest. 

When  the  wound  is  a common  cut,  the  sides  of  the 
division  are  to  be  brought  into  contact,  and  maintained 
in  this  position  with  strips  of  adhesive  plaster,  com- 
presses, and  a bandage,  until  they  have  grown  together. 
If  the  surgeon  take  care  to  relax  such  muscles  as  hap- 
pen to  be  cut,  or  to  be  situated  immediately  under  the 
wound  of  the  integuments,  there  will  rarely  be  any 
need  of  sutures. 

As  cut  wounds  seldom  or  never  penetrate  the  chest, 
and  there  is  generally  no  reason  why  they  should  not 
unite  by  the  first  intention  without  being  followed  by 
extensive  inflammation  and  abscesses,  antiphlogistic 
means  should  be  employed  with  moderation.  Bleeding 
will  not  often  be  requisite.  The  grand  objects  are  to 
keep  the  patient  in  a quiet  state,  on  rather  a low  diet, 
and  to  hinder  him  from  taking  wine,  porter,  spirits,  or 
any  other  stimulating  beverages. 

If  the  wound,  instead  of  healing  favourably,  should 
inflame,  the  treatment  must  be  regulated  by  the  princi- 
ples laid  down  in  the  article  Inflammation.  If  it  sup- 
purate over  its  whole  surface,  but  without  a great  deal 
of  surrounding  sw'elling  and  inflammation,  one  or  tw'o 
strips  of  sticking  plaster  may  still  be  used  with  advan- 
tage ; for  in  this  w'ay  the  cavity,  which  must  now  be 
filled  up  by  granulations,  will  be  rendered  much  smaller 
than  it  otherwise  would  be.  Some  very  soft  lint  may 
be  laid  in  the  cavity  of  the  wound,  which  the  sticking 
plaster  does  not  entirely  remove,  and  over  the  whole  a 
pledget  of  some  mild,  unirritating  ointment.  No  pres- 
sure is  now  proper,  until  the  inflammation  diminishes  ; 
and  if  the  discharge  should  be  profuse,  or  the  surround- 
ing inflammation  considerable,  the  best  application 
would  be  an  emollient  poultice.  In  this  state  of  things 
the  patient  should  also  be  bled,  and  leeches  be  applied 
near  the  inflamed  parts. 


WOUNDS. 


483 


When  the  case  is  a stab  or  punctured  wound,  the  fibres 
of  the  divided  parts  are  not  simply  cut,  tliey  are  also 
considerably  stretched,  bruised,  and  otherwise  injured. 
Hence,  generally,  they  will  not  admit  of  being  united  so 
readily  as  the  sides  of  a clean  incision,  made  with  a 
sharp  instrument.  However,  the  possibility  of  uniting 
the  opposite  sides  of  punctured  wounds  must  depend 
very  much  on  the  shape  of  the  weapon,  and  the  sud- 
denness, roughness,  and  violence  with  which  it  was 
driven  into  the  part.  A prick  with  a needle  is  a punc- 
tured wound  ; so  is  that  often  made  by  surgeons  with 
their  lancets ; yet  these  injuries  do  not  frequently  bring 
on  violent  inflammation  and  abscesses,  as  other 
wounds  frequently  do  which  are  inflicted  with  bayo- 
nets and  pikes. 

Let  us  suppose  a man  to  have  received  the  thrust  of 
a bayonet,  which  has  run  into  the  skin  and  muscles 
covering  one  side  of  the  thorax:  what  plan  can  the 
surgeon  follow  with  the  greatest  advantage  to  his 
patient  'I 

Instead  of  laying  open  the  whole  track  of  such  a 
wound  with  a knife,  as  is  barbarously  recommended 
in  many  of  the  works  on  surgery  ; instead  of  drawing 
a seton  through  its  whole  course,  or  of  cramming  into 
the  part  a hard  irritating  tent;  the  practitioner  should 
take  whatever  chance  there  may  be  of  uniting  the 
wound  without  suppuration.  For  this  purpose,  he 
should  recollect  that  the  great  degree  of  violence  done 
to  the  parts  in  punctured  wounds  is  the  reason  why 
they  are  so  apt  to  inflame  and  suppurate.  Hence,  the 
expected  inflammation  is  to  be  counteracted  in  the  very 
first  instance  ; and  immediately  the  wound  is  dressed, 
the  patient  should  be  freely  bled,  and  take  some  saline 
purgative  medicines.  With  regard  to  the  dressings,  the 
orifice  of  the  wound  may  be  lightly  closed  with  stick- 
ing plaster,  or  covered  with  any  mild  superficial  appli- 
cations. Over  and  around  these  the  surgeon  may  ap- 
ply linen,  kept  continually  wet  with  cold  water  or  the 
liquor  plumbi  acetaiis  dilutus.  As,  however,  many 
patients  have  a strong  dislike  to  cold  applications  to  any 
wounds  upon  their  bodies,  it  is  often  necessary  to  dis- 
pense with  this  practice.  The  dressings  are  to  be  re- 
tained with  a roller ; but  it  is  not  to  be  tight,  as  pres- 
sure is  more  likely  to  do  harm  than  good.  Thus,  the 
inflammation  of  the  wound  will  be  moderated ; the  ex- 
travasation of  blood  prevented  ; the  chance  of  union 
by  the  first  intention  taken ; and  all  painful  operations 
avoided.  And  nothing  is  more  certain  than  the  fact, 
that  if  antiphlogistic  means  be  strictly  employed,  many 
stabs  heal  without  abscesses,  or  any  very  severe  symp- 
toms, when  no  hope  could  be  entertained  of  their  doing 
BO  under  other  treatment.  But  if  suppuration,  should 
happen,  and  a collection  of  matter  take  place,  would 
the  patient  sufier  more  or  be  put  into  greater  danger  by 
having  a proper  depending  opening  of  just  sufficient 
size,  now  made  into  the  abscess  in  an  eligible  place, 
than  if  he  had  submitted  to  have  the  formidable  ope- 
ration of  laying  open  the  whole  extent  of  a stab  per- 
formed in  the  first  instance  1 In  short,  will  he  suffer 
half  so  much,  be  half  so  long  in  getting  well,  or  have 
to  encounter  half  the  danger?  With  all  this  advan- 
tage, he  will  have  taken  a certain  chance  which  attends 
all  these  cases  of  the  wound  becoming  united  by  what 
is  called  the  first  intention;  that  is  to  say,  without  any 
suppuration.  I need  not  enlarge  upon  this  subject,  but 
refer  the  reader  to  what  has  been  said  in  the  preceding 
columns  on  the  subject  of  Punctured  Wounds.,  and  to 
the  treatment  of  abscesses,  in  the  article  Suppuration. 
Gun-shot  wounds  merely  injuring  the  parietes  of  the 
chest  are  to  be  treated  according  to  principles  elsewhere 
explained. — (See  Oun-shot  Wounds.) 

Of  Wounds  penetrating  the  Cavity  of  the  Thorax. — 
Penetrating  wounds  of  the  chest  are  always  dangerous, 
and  claim  the  utmost  attention  of  the  practitioner.  I 
shall  first  treat  of  such  wounds  as  enter  the  cavity  of 
thorax,  but  without  injuring  the  viscera. 

In  the  healthy  state,  the  lungs  so  completely  fill  the 
thorax,  that,  both  in  inspiration  and  expiration,  they  are 
always  in  close  contact  with  the  pleura;  and  whenever 
air,  blood,  or  any  other  matter  insinuates  itself  between 
the  pleura  costalis  and  pleura  pulmonalis,  more  or  less 
oppression  and  difficulty  of  breathing  immediately  take 
place.  In  all  wounds  attended  with  a division  of  the 
pleura  costalis,  and  occurring  in  a situation  where  there 
happens  to  be  no  adhesion  between  this  membrane  and 
the  lungs,  some  of  the  external  air,  or  a small  quantity 
of  blood,  or  both,  can  hardly  fail  to  get  into  the  cavity 


of  the  thorax.  If  one  of  the  intercostal  arteries  be 
wounded,  and  the  external  orifice  be  very  narrow, 
the  blood  furnished  by  this  vessel  may  pass  itito  the 
chest,  and  immediately  produce  oppression  of  the 
breathing,  and  other'  symptoms  of  pressure  on  the 
lungs.  Of  what  is  to  be  done  in  this  case,  I shall  pre- 
sently speak. 

When  a wound  is  known  to  have  entered  the  pleura, 
and  there  is  no  symptom  leading  to  a suspicion  that  the 
lungs  or  any  large  vessel  is  wounded,  the  injury  is  to  be 
dressed  according  to  common  principles,  and  the  nmre 
superficially  the  better.  Authors  also  usually  direct  us, 
just  before  we  close  the  opening,  to  tell  the  patient  to 
make  a deep  inspiration,  for  the  purpose  of  expelling 
as  much  of  the  air  as  possible  which  may  have  passed 
into  the  cavity  of  the  pleura.  At  the  end  of  such  in- 
spiration, the  edges  of  the  wound  in  the  skin  are  to  be 
brought  together  and  kept  so  with  slicking  plaster, 
compresses,  and  a roller.  The  other  indications  are  to 
prevent  inflammation  of  the  pleura  and  lungs,  by  rigo- 
rous antiphlogistic  remedies,  particularly  bleeding, 
which  should  be  copious,  and  repeated  as  circumstances 
may  require. 

Penetrating  wounds  of  the  chest  maybe  complicated 
with  some  of  the  following  circumstances ; 1.  Foreign 
bodies.  2.  Injury  of  one  of  the  intercostal  arteries. 
3.  Protrusion  of  a portion  of  the  lungs.  4.  Emphyse- 
ma. 5.  Extravasation  of  blood  in  the  thorax. 

1.  Almost  all  these  wounds  occasion  pain  and  diffi- 
culty of  breathing.  Many  of  them  are  also  follow'ed 
by  an  emphysematous  swelling  around  the  wound ; the 
patient  flrequently  coughs  up  blood ; and  after  having 
had  for  some  lime  a small,  contracted,  irregular  pulse, 
with  a pallid  countenance  and  cold  extremities,  he  is 
too  often  seized  with  severe  febrile  symptoms,  the  ef- 
fect of  inflammation  of  the  lungs  and  parts  within  the 
chest.  These  symptoms  should  be  counteracted  by  bleed- 
ing, a very  low  regimen,  opening  saline  medicines,  the 
use  of  leeches,  or  cupping,  and  the  strict  observance  of 
quietude.  If  such  indisposition  should  continue  longer 
than  a few  days  without  diminution,  writers  inform  us 
that  there  is  ground  for  suspecting  that  they  depend 
upon  the  presence  of  some  foreign  body.  However,  it 
may  be  doubted  whether  Sabatier’s  advice,  immediately 
to  make  search  after  the  extraneous  substance,  is  proper, 
under  these  circumstances.  For  my  own  part,  I cannot 
think  the  symptoms  above  related  by  any  means  unequi- 
vocal, and  even  were  they  so,  the  practice  vrould  still  be 
questionable. — (See  Medecine  Opiratoire,  t.  2,  p.  244.) 

Sabatier  has  quoted  the  two  following  cases,  for  the 
purpose  of  showing  what  may  be  attempted  in  these 
cases.  “A  man,  twenty-seven  years  of  age,  was 
struck  very  violently  with  a knife  on  the  outer  part  of 
the  fourth  true  rib.  Simple  dressings  w'ere  applied  for 
the  first  few’  days ; but  a considerable  coughing  and 
spitting  of  blood  ensuing,  M.  Gerard  was  consulted, 
who  found  that  the  symptoms  depended  on  the  pre- 
sence of  a piece  of  the  knife,  which  had  pierced  the 
rib  and  was  projecting  some  w’ay  into  the  thorax.  So 
little  of  the  foreign  body  was  on  the  outside  of  the  rib, 
and  it  was  so  fixed  in  the  bone,  that  it  could  neither  be 
extracted  with  any  kind  of  forceps,  nor  even  moved  in 
the  least  with  a leaden  mallet,  &c.  Although  the  only 
expedient  seemed  now  to  be  that  of  sawing  or  cutting 
out  a portion  of  the  rib,  Gerard  conceived  that  an  at- 
tempt might  first  be  made  to  extract  the  foreign  body 
by  pushing  it  from  within  outwards.  Far  this  purpose, 
having  put  a steel  thimble  on  his  inder  finger,  he  intro- 
duced it  into  the  cavity  of  the  thorax,  and  thus  suc- 
ceeded in  pushing  out  the  piece  of  the  knife. 

A spicula  of  the  bone  was  aferward  felt;  but  it  was 
too  firmly  connected  w'ith  tj^  rest  of  the  rib  to  admit 
of  being  completely  taken  out.  Gerard  was  absurd 
enough  to  surround  the  nhole  rib  at  the  splintered  part 
with  a ligature.  To  thrse  ingenious  proceedings,  as  the 
French  term  them,  vas  imputed,  not  only  the  cessation 
of  all  the  bad  syn>»)l«'ns,  but  a speedy  recovery.— (See 
La  Faye's  JVrtes  to  the  TraiU  des  Operations  de 

^An  officer  was  shot  in  the  left  side  of  the  chest.  The 
ball  entered  about  where  the  bone  and  cartilage  of  the 
sevent*  true  rib  unite,  and  came  out  in  the  situation  of 
tlie  angle  of  the  same  bone,  which  was  broken  in  two 
p|.ices.  The  posterior  part  of  the  first  false  rib  was 
also  broken.  Incisions  were  made  which  enabled  the 
surgeon  to  take  away  several  splinters  of  bone,  and  fa- 
cilitated (that  mischievous  French  practice)  the  Intro- 


484 


WOUNDS, 


duction  of  a seton.  Soft  mild  dressings  were  applied. 
The  patient  was  bled  twenty-six  limes,  with  the  view 
of  relieving  the  fever,  difficulty  of  breathing,  and  spit- 
ting of  blood.  On  the  fifth  day,  suppuration  commenced 
and  the  seton  could  be  easily  drawn.  In  about  a fort- 
night, the  patient’s  sufferings  considerably  abated,  and 
he  passed  some  of  the  ensuing  days  in  a tolerably  easy 
state.  Circumstances,  however,  made  it  necessary  to 
remove  him  to  another  place,  and  on  the  twenty-fourth 
day  he  had  a bad  night  ; febrile  symptoms  came  on ; 
and  the  discharge  was  not  of  its  usual  consistence.  He 
was  bled  twice  more,  and  his  critical  state  led  the  sur- 
geon to  examine  the  wounds  again.  On  passing  a fin- 
ger into  the  posterior  wound,  a foreign  body  was  felt 
and  easily  extracted.  It  was  apiece  of  the  patient's  coat. 
A spicula  of  bone  was  also  felt  more  deeply  lodged, 
which  required  the  wound  to  be  dilated.  Partial  relief 
followed  the  removal  of  these  extraneous  substances. 

On  the  thirtieth  day  the  bad  symptoms  recurred,  two 
more  bleedings  were  practised,  and,  as  fears  were  en- 
tertained that  the  seton  was  doing  harm.,  it  was  sup- 
pressed. The  patient  now  first  made  complaint  of 
feeling  something  which  pricked  him  in  a deep  situa- 
tion, between  the  two  openings  of  the  wound.  It  was 
therefore  determined  to  divide  all  the  parts  intervening 
between  the  two  orifices,  and  occupying  an  extent  of 
seven  or  eight  inches.  Guerin  cut  the  parts  between 
the  two  ribs  from  within  outwards,  under  the  guidance 
of  his  finger  introduced  into  the  posterior  wound,  care 
being  taken  not  to  cut  near  the  lower  edge  of  the  up- 
per rib.  In  this  way,  the  whole  track  of  the  ball  was 
laid  open,  and  in  the  middle  of  it  a very  sharp  splinter 
was  found,  projecting  into  the  substance  of  the  lungs. 
It  was  removed,  and  the  wound  dressed  with  simple  ap- 
plications. From  this  day  all  the  bad  symptoms  ceased. 
— ( Obs.  de  Oner  in  in  Metn.  de  VAcad.  de  Chir.  t.  2,  \to.) 

Blr.  John  Bell  has  taken  notice  of  the  preceding 
case ; he  observes,  that  some  of  Guerin’s  steps  were 
bold  and  good,  as  well  as  successful ; but  that  the  em- 
ployment of  the  seton  was  wrong.  The  example 
teaches  us  several  important  circumstances:  1.  The 
propriety  of  making  very  free  dilatations  for  the  ex- 
traction of  splinters  of  bone.  2.  The  utility  of  repeated 
copious  bleedings,  which,  in  the  above  case,  indeed, 
had  the  greatest  effect  both  in  preventing  such  hemor- 
rhage in  the  chest,  as  would  probably  have  produced 
suffocation,  and  also  in  averting  a degree  of  pulmonary 
inflammation,  which  would  have  proved  fatal. 

Mr.  John  Bell  judiciously  condemns  the  seton : “ Had 
M.  Guerin  (says  he)  been  asked  what  good  it  was  to 
do,  it  would  have  been  difficult  for  him  to  have  in- 
vented even  a plausible  apology  for  the  practice,  which, 
if  it  was  not  doing  good,  could  not  fail  to  do  harm. 
Was  this  seton  necessary  for  keeping  the  wound  open  ? 
No,  surely,  for  the  wound  could  not  have  closed  while 
it  was  irritated  and  kept  in  suppuration  by  splinters 
of  bone,  and  a piece  of  cloth  within  the  breast.  Was 
it  to  draw  the  piece  of  cloth  out  7 Surely,  in  the  course 
of  twenty  days,  a piece  of  cloth  would  have  had  some 
chance,  at  least,  of  being  floated  towards  the  wound, 
either  by  the  natural  flux  of  the  matter,  or  by  the  help 
of  a mild  injection.  Was  it  useful  in  supporting  the 
discharge?  This  would  have  been  a sore  question  for 
M.  Guerin;  for  it  supported  the  suppuration  only  by 
inflaming  the  chest ; and  where  inflammation  of  the 
chest,  or  high  cough,  or  bloody  expectoration,  or  a 
profuse  discharge  were  the  chief  dangers,  a great  seton 
could  hardly  be  a comfortable  inmate  in  the  breast. 
I think  one  might  very  boldly  promise  to  produce 
bloody  expectoration  and  terrible  cough,  profuse  sup- 
purations, and  oppressV)n  to  any  degree,  by  drawing 
such  a cord  across  a souti-i  thorax.” 

Mr.  John  Bell  ne.xt  censu-.es  M.  Guerin  for  not  hav- 
ing discovered  the  pricking  ,iiece  of  bone  before  the 
thirty-eighth  day  ; a disadyanttj?e  which  he  partly  as- 
cribes to  the  seton,  the  pain  of  dtsvving  which  across 
the  chest  deadened  every  less  fain,  and,  conse- 
quently, the  patient  could  not  feel  the  trifling  pricking 
of  the  bone,  till  his  greater  sufferings  hom  the  seton 
were  allayed.  “ In  short  (says  Mr.  Johr.  Bell),  M. 
Guerin  passes  a great  strap  of  coarse  linen  across  the 
cavity  of  the  chest,  and  when  it  causes  inflammation, 
he  thinks  to  subdue  it  by  bleeding;  when  M.  Gaerin 
continued  for  thirty  days  drawing  a coarse  seton  through 
the  breast  every  morning,  and  bleeding  for  the  cough 
every  night,  what  did  he  do,  but  raise  inflammation 
with  his  left  hand,  to  show  how  well  he  could  cure  it 


with  his  right.”— (See  John  Bell,  On  Wounds,  vol  2, 
p.  36—38.) 

The  liability  of  wounds  of  the  chest  to  be  compli- 
cated with  the  lodgement  of  foreign  bodies,  is  a cir- 
cumstance of  which  the  practitioner  should  ever  be 
mindful.  “ In  the  examination  of  the  bodies  of  sol- 
diers who  have  died  from  these  injuries  (says  Dr. 
Hennen),  I have  frequently  found  pieces  of  wadding 
or  clothes,  spiculae  of  bone,  and  balls,  and,  in  one  case, 
some  charpie  used  as  a dressing;  either  loose  in  va- 
rious parts  of  the  lungs,  or  lying  in  sacs,  which  the  ex- 
ertions of  the  constitution  to  free  itself  had  thrown 
round  them  by  the  medium  of  the  coagulating  lymph. 
In  the  more  fortunate  few  who  have  recovered,  these 
matters  have  been  discharged  from  the  wounds,  or  ex- 
tracted from  them  by  the  surgeon.  In  some  lucky 
cases,  they  have  been  ejected  by  the  convulsive  efforts 
to  cough,  which  their  irritation  has  occasioned.” — 
{On  Military  Surgery,  ed.  2,  p.  367.)  For  an  account 
of  the  dexterity  with  which  Larrey  has  sometimes 
traced  balls  in  the  chest,  and  extracted  them  by  bold 
operations,  I must  refer  to  his  valuable  writings. — 
(See  Mdm.  de  Chir.  Mil.  t.  4,  p.  250,  <!^c.)  Balls  have 
sometimes  lodged  and  remained  encysted  in  the  lungs 
for  upwards  of  twenty  years,  without  the  health  being 
at  all  disturbed  by  their  presence. — (See  Percy,  Ma- 
nuel, (S-c.  p.  125 ; Boyer,  Traite  des  Mai.  Chir.  t-  7,  p. 
310,  (S-c.) 

2.  When  one  of  the  intercostal  arteries  is  wounded 
by  a narrow  oblique  stab,  the  accident  cannot  at  first 
be  known.  In  this  case,  the  blood  commonly  makes 
its  way  into  the  cavity  of  the  chest,  where  it  causes  a 
more  or  less  considerable  extravasation.  But  when 
the  wound  is  ample  and  direct,  the  effused  blood, 
which  has  all  the  characters  of  arterial  blood,  leaves  no 
doubt  concerning  the  injury  of  an  intercostal  artery. 
However,  if  any  uncertainty  prevail,  it  may  easily  be 
dispelled  by  introducing  a finger  into  the  wound,  and 
making  pressure  with  it  on  the  lower  edge  of  the  rib, 
which  corresponds  to  the  vessel  suspected  to  be  injured. 

Gerard  ‘proposed  to  stop  hemorrhage  from  the  inter- 
costal artery  by  means  of  a ligature.  His  plan  was  to 
enlarge  the  external  wound  as  far  as  the  upper  edge  of 
the  rib,  corresponding  to  the  wounded  intercostal  ar- 
tery, and  then  to  introduce  into  the  chest  a common 
curved  needle,  armed  with  a ligature,  to  which  was 
attached  a dossil  of  lint.  The  needle  was  passed  be- 
hind the  rib,  rather  higher  than  the  superior  edge  of 
the  bone.  The  point  of  the  instrument  was  then 
pushed  from  within  outwards,  and  brought  out  through 
the  external  wound  together  with  the  ligature.  When 
the  dossil  had  come  into  contact  with  the  artery,  the 
two  ends  of  the  ligature  were  tied  over  a thick  com- 
press, placed  on  the  outside  of  the  rib.  In  this  man- 
ner, the  bone  was  surrounded  with  the  ligature,  and 
the  artery  compressed. 

Goulard,  of  Montpellier,  having  found  difficulty  in 
passing  a common  needle,  whose  shape  little  corres- 
ponded to  the  track  through  which  it  had  to  pass,  be- 
ing curved  towards  its  point,  and  straight  towards  the 
eye,  invented  one  expressly  for  this  operation.  He  also 
objected  to  the  commpn  bent  needles,  as  be  conceived 
that  they  might  wound  the  lungs  with  their  sharp 
points  and  edges.  Goulard’s  needle  formed  three- 
fourths  of  a circle,  and  was  fixed  on  a iong  handle, 
which  facilitated  its  introduction.  The  eye,  in  which 
the  ligature  was  put,  was  situated  near  the  point, 
which  was  a little  blunted,  and  the  ligature  lay  in  a 
groove  in  the  convexity  of  the  instrument.  When  the 
needle  had  passed  through  the  intercostal  muscles, 
and  its  point  had  made  its  appearance  over  the  rib, 
which  was  above  the  artery,  the  ligature  was  untied, 
and  held,  while  the  needle  was  withdrawn  at  the  place 
where  it  had  entered.  The  ligature  was  then  tied,  as 
in  Gerard’s  method. 

It  was  afterward  thought,  that  compression  might 
answer  better  than  the  foregoing  use  of  the  ligature. 
Lottery,  professor  of  anatomy  in  the  university  of  Tu- 
rin, constructed  for  this  purpose  a steel  plate,  which  is 
described  and  engraved  in  the  second  volume,  4to.  of 
the  Mimoires  de  VAcad.  de  Chir.  This  plate  was  nar- 
row at  one  end,  broad  at  the  other,  and  curved  in  two 
directions  at  its  narrow  part,  where  there  were  some 
holes,  by  means  of  which  a compress  for  the  artery  w'as 
fastened  on  the  instrument.  The  broad  end  of  the  plate 
had  two  long  parallel  slits,  through  which  a riband 
was  passed,  witli  which  the  instrument  was  secured. 


WOUNDS, 


485 


When  the  wound  corresponding  to  the  intercostal 
artery  was  sufficiently  extensive  in  the  transverse  di- 
rection, the  narrow,  bent  end  of  the  instrument  was  so 
introduced,  that  the  lower  edge  of  the  rib  above  was 
placed  in  the  concavity  of  the  curvature,  while  the 
compress  acted  on  the  edge  of  the  bone,  and,  of  course, 
on  the  artery.  The  rest  of  the  instrument  applied  it- 
self to  the  side  of  the  thorax,  in  which  situation  it  was 
fastened.  When  the  wound  was  not  ample  enough,  a 
sufficient  dilatation  of  it  was  first  made  for  the  intro- 
duction of  the  instrument. 

Q,uesnay  employed  a piece  of  ivory,  which  he  co- 
vered with  lint,  &;c.  and  introduced  within  the  chest. 
Tlie  instrument  was  then  drawn  from  within  outwards 
by  means  of  a riband,  and  thus  the  necessary  com- 
pression was  produced. 

Ciuesnay’s  plan  is  somewhat  like  that  invented  by 
Li6ttery.  But  to  have  introduced  the  compress  en- 
tirely into  the  thorax,  together  with  the  ivory,  which 
was  the  basis  of  it,  and  then  to  have  drawn  the  con- 
trivance from  within  outwards,  as  was  probably  in- 
tended, a very  large  wound  would  have  been  indis- 
pensable. This  was  also  one  of  the  many  strong  ob- 
jections to  L6ttery’s  instrument,  which,  in  fact,  could 
only  be  employed  when  there  was  a free  and  ample 
opening. 

Belloque,  seeing  the  inefficacy  of  all  the  compressing 
means  used  before  his  time,  and  their  inconveniences, 
invented  an  instrument,  which,  he  says,  is  calculated 
for  making  proper  pressure,  and  following  the  motion 
of  the  ribs  without  hindering  the  escape  of  extravasated 
blood.  The  machine  is  engraved  and  described  in  2 t. 
of  Mem.  de  VAcad.  de  Chir.  Ato.  It  is  composed  of  two 
plates,  which  are  wadded,  and  capable  of  being  brought 
towards  eqch  other  by  means  of  a screw.  This  in- 
strument, as  Sabatier  observes,  may  indeed  answer ; 
but  it  is  complicated  and  awkward,  and  its  utility  is 
founded  on  the  supposition  of  the  wound  being  larger 
than  wounds  are  which  are  made  with  common  wea- 
pons. 

Justly  averse  to  any  unnecessary  multiplication  of 
surgical  instruments,  modern  practitioners  reject  all 
particular  contrivances  for  stopping  hemorrhage  from 
the  intercostal  arteries.  Indeed,  as  the  accident  is 
very  rare,  it  is  probable,  that  if  the  best  instrument 
possible  were  devised  it  would  hardly  ever  be  at  hand 
when  required. 

A common  dossil  of  lint  (says  Sabatier),  fastened  to 
a strong  ligature,  and  introduced  between  the  two  ribs, 
or  even  quite  into  the  chest,  and  then  drawn  from 
within  outwards  like  Q.uesnay’s  compress,  would  fulfil 
every  desirable  purpose.  The  external  wound  should 
then  be  covered  with  simple  dressings,  and  a bandage 
applied  round  the  body.  The  patient  should  be  freely 
and  repeatedly  bled,  and  treated  on  the  most  rigorous 
antiphlogistic  plan. 

Professor  Assalini  joins  all  the  best  modern  surgeons 
in  reprobating  the  introduction  of  the  preceding  con- 
trivances and  extraneous  substances  into  the  chest,  in 
order  to  stop  hemorrhage  from  the  intercostal  artery. 
All  these  methods,  he  remarks,  are  calculated  to  excite 
a dangerous  degree  of  inflammation  in  the  chest. 
Hence,  he  prefers  simply  cutting  the  artery  across,  so 
as  to  allow  it  to  retract,  and,  if  this  plan  fail,  he  re- 
commends the  wound  to  be  closed.  Should  the  blood 
find  its  way  into  the  chest,  it  is  true,  the  consequences 
will  be  serious,  but  not  fatal ; and  if  the  symptoms  re- 
quire it,  the  ojjeration  of  empyema  may  afterward  be 
done.  A small  quantity  of  effused  blood,  however, 
may  be  absorbed,  and  no  such  proceeding  be  requisite. 
— {Manuale  di  Chirurgia,  p.  58,  59.) 

Dr.  Hennen  conceives,  that  whenever  the  tenacu- 
lum can  be  used  for  an  injured  intercostal  artery,  the 
practice  should  be  adopted.  He  states,  that  cases  are 
reported  in  which  the  vessel  was  thus  secured  ; but  that 
he  has  never  seen  the  method  adopted  himself.  “ Un- 
fortunately (says  he),  we  but  too  often  are  disappointed 
in  finding  the  source  of  the  hemorrhage,  and  here  ju- 
dicious pressure  is  our  only  resource.  In  some  very 
Blight  cases,  I have  used  the  graduated  compress  with 
success  ; but,  if  the  sloughing  is  extensive,  nothing  but 
the  finger  of  an  assistant,  relieved  as  often  as  occasion 
may  require,  atsd  pressure  direct  upon  a compress 
placed  along  the  course  of  the  ves.sel,  or  so  disposed  as 
to  operate  upon  its  bleeding  orifice,  will  be  of  any  avail.” 
— {Military  Surgery.,  ed.  2,  p.  377.) 

3.  The  protrusion  of  a portion  of  the  lungs,  in  con- 


sequence of  wounds  penetrating  the  cliest,  is  a very 
unusual  case ; but  there  are  some  instances  recorded 
by  writers,  and  one  case  I attended  myself  after  the 
battle  of  Waterloo.  Schenckius  relates  an  example 
taken  from  Rolandus-.  The  latter  was  called  to  a man 
who  had  been  wounded  in  the  thorax  six  days  before. 
A portion  of  the  lung  protruded,  in  a state  of  mortifi- 
cation. Rolandus  extirpated  it,  and  the  patient  soon 
recovered. 

Tulpius  has  recorded  a similar  fact.  A man  received 
an  extensive  wound  just  below  his  left  nipple.  His 
naturally  gay  disposition,  however,  led  him  to  neglect 
the  injury  : and  on  the  third  day,  a piece  of  the  lungs, 
three  inches  in  length,  protruded.  The  patient  went 
to  Amsterdam,  whence  he  was  distant  two  days’ 
journey,  for  the  purpose  of  receiving  succour  in  one  of 
the  hospitalsof  that  city.  The  protruded  piece  of  lung, 
which  was  already  mortifying,  was  tied,  and  cut  off 
with  scissors.  It  weighed  three  ounces.  The  wound 
healed  in  a fortnight,  and  the  patient  experienced  no 
complaint  afterward,  except  a slight  cough,  with 
which  he  was  occasionally  troubled.  He  survived  the 
accident  six  years,  leading  a wandering,  drunken  life. 
After  death,  nothing  particular  was  observed  in  the 
thorax,  except  that  the  lungs  Itad  become  adherent  to 
the^llip-a,  in  the  situation  of  the  wound.  Hildanus 
relsBeTanother  case.  A man  was  wounded  with  a 
knife  between  the  fifth  and  sixth  ribs,  near  the  ster- 
num. As  a piece  of  lung  protruded  at  the  opening  and 
was  of  a livid  colour,  it  was  extirpated  with  the  actual 
cautery.  The  wound  was  then  dilated,  and  the  ribs 
kept  apart  with  a wooden  wedge,  under  which  plan 
the  portion  of  lung  girt  by  the  opening  shrunk 
within  the  chest.  The  patient  was  soon  completely 
well. 

A fourth  example  of  a protrusion  of  a piece  of  lung 
through  a wound  in  the  thorax,  is  among  the  cases 
recorded  by  Ruysch.  The  servant  of  a seafaring  man 
was  wounded  in  the  anterior  and  inferior  part  of  the 
chest,  and  was  immediately  attended  by  a surgeon, 
who  mistook  the  protruded  piece  of  lung  for  a portion 
of  omentum,  and  applied  a tight  ligature  round  it. 
Ruysch,  w'ho  was  consulted,  soon  detected  the  mistake 
which  had  been  made ; but  he  delivered  his  opinion 
that  the  wound  would  heal  very  well,  as  soon  as  the 
tied  piece  of  lung  was  detached.  The  event  justified 
his  prognosis,  and  the  patient  recovered. 

When  the  protruded  portion  of  lung  is  sound,  the 
reduction  ought  to  be  made  without  the  least  delay. 
It  should  be  done  on  the  same  principles  as  those  on 
which  protruded  pieces  of  intestine,  or  omentum,  are 
reduced. — (See  Wounds  of  the  Abdomen.)  A recur- 
rence of  the  accident  is  to  be  prevented  by  closing  the 
wound,  and  placing  a compress  over  it.  But  when  the 
piece  of  lung  is  already  in  a mortified  state  in  conse- 
quence of  the  constriction  which  it  has  suffered,  or 
when  its  large  size  prevents  reduction,  Sabatier  is  of 
opinion  that  the  only  resource  is  to  extirpate  the  part, 
after  applying  a ligature  round  its  base.  If  the  latter 
step  were  not  taken,  a dangerous  hemorrhage  might 
follow,  or  even  an  extravasation  in  the  thorax. — 
{Medecine  Operatoire,  tome  2,  p.  SIZA.)  However,  the 
practice  recommended  by  Sabatier  appears  question- 
able in  the  instance  of  mortification,  because  the  dead 
part  will  naturally  be  thrown  off  by  a spontaneous  pro- 
cess; and  when  the  wound  is  too  small  to  allow  the 
part  to  be  returned,  its  dilatation  might  be  more  ad- 
visable than  the  removal  of  a consideiable  portion,  or 
even  any,  of  the  lung. 

After  the  battle  of  Waterloo,  I had  a patient  with  a 
protrusion  of  a piece  of  lung,  four  or  five  inches  in 
length.  The  part  was  much  bruised,  and  could  not  be 
easily  reduced.  I therefore  applied  a ligature  round 
its  base,  and  cut  it  off'.  Previously,  however,  I made 
an  incision  in  it,  in  order  to  ascertain  whether  it  would 
bleed  freely,  which  being  the  case,  induced  me  to  use 
a ligature.  I was  afterward  informed  by  my  friend, 
Mr.  Collier,  that  the  man  died. 

4.  Emphysema  is  another  symptom  with  which 
penetrating  wounds  of  the  chest  are  frequently  com- 
plicated, especially  when  they  are  small  and  indirect. 
When  such  wounds  are  small,  and  not  straight  in  their 
course;  when  their  track  is  rendered  impervious,  either 
by  change  in  the  situation  of  the  muscles,  the  swelling 
of  the  parts,  clots  of  blood,  or  any  extraneous  sub- 
stances ; air  may  insinuate  itself  into  the  cellular  sub- 
stance, so  as  to  cause  a great  deal  of  tumour  and  dia-, 


486 


WOUNDS. 


tention.  Emphysema  is  easily  distinguishable  by  the 
tumefaction  of  the  part  affected,  without  any  pain,  or 
change  of  colour  in  the  skin,  and  by  the  crepitation 
which  is  perceptible  on  pressing  the  air  from  one  part 
of  the  cellular  substance  into  another.  Emphysema 
may  take  place  where  the  lungs  are  not  wounded;  but 
in  this  case  it  can  never  be  of  much  extent.  Here  the 
emphysematous  swelling  is  caused  by  the  air  which 
insinuates  itself  into  the  carvity  of  the  thorax  through 
the  wound,  during  the  first  inspirations  which  follow 
the  accident,  and  the  same  air  is  expelled  in  the  subse- 
quent acts  of  expiration.  But  when  the  lungs  are 
wounded,  the  emphysema  arises  from  the  escape  of  air 
from  those  organs  during  inspiration,  first  into  the 
cavity  of  the  thorax,  and  thence,  through  the  inner 
opening  of  the  external  wound,  into  the  cellular  sub- 
stance. 

I should  have  deemed  it  unnecessary  to  have  said 
any  thing  in  this  part  of  the  work  on  the  present  sub- 
ject, and  have  contented  myself  with  referring  to  the 
article  Emphysema,  were  not  the  cause  of  this  symp- 
tom rather  perplexing,  and  did  I not  hope  that  the 
following  extract  from  Sir  A.  Halliday’s  publication 
will  tend  to  facilitate  the  comprehension  of  these  cases. 
This  gentleman  mentions  the  following  circumstances, 
under  which  air  may  escape  from  the  lungs,  or^tehy- 
sema  arise. 

1st.  “ An  injury  or  disease  of  the  pleura  pulmonalis, 
causing  a wound  or  ulceration  of  that  membrane,  and 
thus  allowing  the  air  to  escape  from  the  lungs,  as  in 
oblique  external  wounds,  where  the  outer  opening  and 
that  of  the  pleura  costalis  have  healed,  or  closed  up, 
and  in  ulcers  of  the  surface  of  the  lungs. 

2dly.  That  pleura  pulmonalis  and  pleura  costalis 
may  be  wounded  or  ulcerated,  when  there  is  no  exter- 
nal opening,  as  when  the  ends  of  fractured  ribs  pene- 
trate through  both  into  the  substance  of  the  lungs ; and 
it  is  from  this  accident,  &c.  that  emphysema  most  com- 
ntonly  takes  place. 

3dly.  The  common  integuments  of  the  parietes  of 
the  chest,  the  intercostal  muscles,  and  the  pleura  cos- 
talis may  be  wounded,  while  the  pleura  pulmonalis 
and  the  lungs  remain  uninjured ; so  that  the  air  ad- 
mitted from  without  and  collected  in  the  cavity  of  the 
thorax,  may  be  pressed  into  the  cellular  membrane,  so 
as  to  occasion  emphysema.” 

The  same  writer  remarks,  “ that  the  lungs  in  the 
thorax  have  often,  and  not  inaptly,  been  compared  to  a 
bladder  in  a close  pair  of  bellows  ; but  if  we  suppose 
the  bellows  to  be  divided  into  two  compartments,  and 
each  of  these  to  contain  a bladder,  which  mutually 
communicate  with  each  other  and  with  the  external 
air,  by  means  of  a tube,  which  is  exactly  adapted  to 
the  nozzle  of  the  bellows,  and  which  admits  the  air 
only  into  the  cavity  of  the  bladders,  and  not  into  the 
space  between  the  bladders  and  bellows,  we  shall  then 
have  a perfect  representation  of  the  mechanical  struc- 
ture of  the  thorax.  The  bellows  will  represent  the 
thorax,  divided  in  the  middle  by  the  mediastinum  ; the 
bladders  will  represent  the  lungs  of  the  right  and  left 
sides;  and  the  tube  which  communicates  with  the 
bladders  and  with  the  external  air,  will  represent  the 
trachea.  The  only  thing  which  is  wanting  to  render 
this  mechanical  representation  perfect  is,  that  the 
bladders  should  exactly  fill  the  bellows,  so  as  to  leave 
no  air  between  them  and  the  bellows.” 

It  is  explained  by  Sir  A.  Halliday,  that  when  the 
handle  of  the  bellows  is  lifted  up,  the  bladders  become 
filled  by  the  external  air,  which  rushes  in  through  the 
tube  which  communicates  with  both  of  them.  When 
the  handle  is  depressed,  the  air  is  expelled  again.  In 
the  like  manner,  the  lungs  are  filled  with  air,  and  emp- 
tied again  when  the  capacity  of  the  chest  is  enlarged 
by  the  inspiratory  muscles,  and  then  diminished  by  the 
expiratory  ones. 

When  emphy.sema  arises  from  a wound  or  ulcera- 
tion of  the  pleura  pulmonalis,  on  one  side  of  the  thorax, 
the  case  is  nearly  the  same  as  if  an  opening  were  made 
in  one  of  the  bladders,  which  opening  would  form  a 
communication,  as  the  same  gentleman  observes,  with 
the  bellows  and  bladder  on  one  side.  If  this  should 
happen  while  the  handle  of  the  bellows  is  depressed, 
no  sooner  is  the  handle  raised,  than  air  rushes  into  the 
space  between  the  bladder  and  bellows;  and  on  keeping 
up  the  handle  a little  while,  the  bladder  will  become 
quite  collapsed,  and  the  place  which  it  occupied,  while 
distended,  will  now  be  occupied  by  the  air.  “ If  now 


(says  Sir  A.  Halliday)  we  attempt  to  force  out  the  air 
by  depressing  the  handle  of  the  bellows,  we  shall  find 
that  this  cannot  be  done;  for  there  is  no  direct  com- 
munication between  the  bellows  and  the  external  air ; 
and  as  the  effused  air  presses  equally  on  all  parts  of 
the  collapsed  bladder,  it  cannot  escape  through  it.” 

When  the  thorax  is  expanded  in  inspiration,  the 
pressure  is  taken  off  the  surface  of  the  wounded  lung, 
and  the  air  which  now  enters  this  organ,  instead  of 
distending  its  cells,  passes  through  its  wound  into  the 
space  between  the  pleura  pulmonalis  and  pleura  cos- 
talis. The  lung  will,  indeed,  be  partially  expanded, 
as  long  as  inspiration  on  that  side  goes  on  ; the  more 
so,  the  smaller  its  wound  is.  At  every  expiration, 
however,  when  the  thorax  is  diminished,  the  effused 
air  will  be  compressed  against  the  wounded  lung;  but 
none  of  the  air  which  has  escaped  can  re-enter  the 
lung  again  ; “ because  (as  the  preceding  writer  accu- 
rately remarks)  the  whole  of  the  air  contained  in  the 
lung  must  be  forced  out,  and  then  the  pressure  (of  the 
air)  against  every  part  of  the  collapsed  lung  being 
equal,  will  prevent  its  separating  any  part,  so  as  to 
make  a passage  for  itself  into  the  trachea.”  Thus 
fresh  air  accumulates  at  every  inspiration  in  the  space 
between  the  pleuree,  while  none  can  escape  from  the 
same  situation  during  expiration  ; and  the  quantity 
accumulated  will  at  last  equal  that  which  is  received 
into  the  other  lung  during  the  most  powerful  inspira- 
tion. 

When  the  pleura  pulmonalis  and  pleura  costalis  are 
both  wounded,  the  same  effusion  of  air  between  them 
continues  from  the  above-mentioned  causes,  till  the 
lung  collapses.  When  an  attempt  is  now  made  to 
ex[tire,  the  injured  side  of  the  thorax  must  continue 
distended,  notwithstanding  every  effort  of  the  patient. 
In  this  expiratory  act,  however,  if  the  capacity  of  the 
thorax  be  diminished,  and  the  air  compressed,  a part  of 
it  finds  its  way  through  the  wound  in  the  pleura  cos- 
talis, into  the  common  cellular  substance  of  the  parietes 
of  the  chest. 

The  passage  of  air  into  the  cavity  of  the  thorax 
during  the  inspiration  is,  as  Sir  A.  Halliday  observes, 
now  more  easy  than  the  return  of  that  already  effused 
in  the  cellular  membrane;  and,  consequently,  the swft- 
cutaneous  emphysema  continues  to  increase  with  a 
rapidity  which  is  remarkable,  as  long  as  the  patient 
lives. 

To  explain  the  origin  of  emphysema  in  cases  of 
wounds  which  only  enter  the  chest  and  do  not  injure 
the  lungs  at  all,  this  writer  has  recourse  to  the  simile 
of  the  bellows  and  bladders.  Were  an  opening  made 
into  the  bellows  without  injuring  the  contained  blad- 
ders, and  the  access  of  air  by  this  opening  more  free 
than  that  by  the  nozzle,  communicating  with  the 
cavity  of  the  bladder,  more  air  would  enter  by  the 
opening  than  by  the  pipe,  on  the  handle  being  raised ; 
so  that  the  bladder  would  not  rise  as  usual,  when  no 
opening  in  the  side  of  the  bellows  existed.  If  the  latter 
opening  be  smaller  than  that  of  the  pipe,  the  bladder 
will  only  be  partially  filled;  and  on  depressing  the 
handle  of  the  bellows,  tbe  air  contained  in  the  bladder, 
and  that  between  the  bladder  and  the  bellows,  will  be 
expelled  in  the  same  proportion  to  each  other  as  that 
in  which  they  were  formerly  filled.  This  process 
would  continue  to  go  on  in  the  same  way,  did  not  the 
bladder  naturally  collapse  more  and  more  from  its 
gravitation.  Let  us  now  stop  the  mouth  of  the  pipe, 
while  the  handle  of  the  bellows  is  raised,  and  the 
bladder  partially  filled.  On  trying  next  to  depress  the 
handle,  it  results  that,  as  no  air  can  escape  from  the 
pipe,  the  air  contained  between  the  bladder  and  the 
bellows  must  be  first  evacuated,  while  that  contained 
in  the  bladder  of  the  sound  side  will  be  forced  into  the 
bladder  on  the  injured  side,  and  either  distend  it,  so  as 
to  rupture  it,  or  cause  it  to  protrude. 

Hence,  in  the  case  of  a wound  penetrating  the  chest 
without  injuring  the  lungs,  if  the  air  can  enter  more 
freely  by  the  wound  than  by  the  trachea,  more  of  it 
will  enter,  in  the  act  of  inspiration,  into  the  cavity  of 
the  thorax  than  into  the  lungs.  On  tbe  contrary,  when 
the  opening  of  the  wound  is  not  so  large  as  that  of  the 
trachea,  less  air  will  enter  the  thorax  than  the  lungs. 

In  the  expiration,  the  air  will  be  forced  from  the  two 
different  situations  in  proportion  to  the  quantity  which 
enters  each  of  them  in  inspiration,  and  no  air  at  all 
would  accumulate  in  the  thorax,  did  not  the  lungs 
always  tend  to  collapse  from  their  gravitation.  Should, 


WOUNDS. 


487 


however,  the  patient,  in  making  an  effort  to  expire, 
contract  the  glottis,  the  air  contained  in  the  lungs  of 
the  sound  side  may  be  propelled  into  the  bronchia  and 
air-cells  of  the  lungs,  on  the  same  side  as  the  wound, 
so  as  to  distend  them,  and  even  make  them  protrude 
at  the  wound. 

Dr.  Halliduy  remarks,  that  such  a protrusion  often 
happens  when  wounds  are  made  in  dogs,  and  has  been 
erroneously  adduced  as  an  argument  against  the  col- 
lapse of  the  lungs,  when  an  opening  is  made  into  the 
thorax  of  the  human  subject. — (See  Obs.  on  Emphy- 
sema^ by  Sir  A.  Halliday,  1807.) 

For  informtKion  concerning  the  treatment  of  this 
affection,  see  Emphysema. 

5.  I have  already  noticed,  that  wounds  of  the  thorax 
may  injure  one  of  the  intercostal  arteries,  and  when 
the  blood  cannot  flow  outwards  it  may  be  extravasated 
in  the  chest.  The  same  consequence  may  follow 
wounds  of  the  pulmonary  vessels,  those  of  the  heart, 
or  of  the  heart  itself.  And  here  I may  take  the  oppor- 
tunity of  remarking,  that  sometimes  wounds  of  the 
heart  do  not  prove  instantaneously  fatal.  A case,  in 
which  a bayonet  passed  through  the  colon,  stomach, 
diaphragm,  part  of  the  lungs,  and  the  right  ventricle 
of  the  heart,  and  yet  the  patient  lived  nine  hours  after 
the  receipt  of  the  injury,  is  recorded  by  Dr.  Babington. 
— (See  Med.  Records  and  Researches,  Eond.  1798 ; also., 
a case  by  Chastenet,  in  Journ.  de  Med.  Mil.  t.  2.)  In 
almost  all  cases,  however,  such  injuries  prove  instantly 
fatal ; and  the  same  remark  will  extend  to  cases  of  he- 
morrhage from  vessels  above  a certain  size,  but  when 
they  are  less  considerable,  the  patient  may  live  for  a 
greater  or  less  time  and  receive  the  aid  of  surgery. 

[Though  wounds  of  the  heart  are  deemed  necessa- 
rily fatal,  they  do  not  always  immediately  prove  so. 
Our  medical  records  contain  various  cases  in  proof  of 
this:  very  recently  a case  of  murder  came  before  the 
Criminal  Court  of  New-York,  in  which  the  medical 
witnesses  in  behalf  of  the  people  affirmed,  that  the  de- 
ceased, as  proved  upon  the  examination  of  the  body, 
had  received  the  fatal  wound  in  the  left  ventricle  of 
the  heart;  yet  the  sufferer  survived  nearly  three-quar- 
ters of  an  hour  after  the  occurrence. — Reese.] 

The  following  are  the  symptoms  which  denote  an 
extravasation  of  blood  in  the  thorax.  The  patient 
feels  great  oppression,  and  such  uneasiness  as  will  not 
let  him  long  continue  in  one  position.  Unless  he  bend 
his  body  very  much  forwards,  in  which  position  the 
diaphragm  is  relaxed,  and  not  so  much  dragged  by  the 
weight  of  the  extravasated  fluid,  he  feels  great  diffi- 
culty in  standing  or  sitting  up.  When  the  thighs  are 
bent,  the  patient  can  lie  with  tolerable  ease  on  his 
back ; he  is  also  not  averse  to  lying  on  the  side  on 
which  the  wound  is  situated  ; but  he  cannot  place  him- 
self on  the  opposite  side  without  feeling  very  acute 
pain  in  the  situation  of  the  mediastinum. 

His  respiration  is  short,  frequent,  and  interrupted  by 
sighs;  his  veins  become  empty ; a cadaverous  paleness 
spreads  over  his  countenance;  his  extremities  become 
cold  ; a viscid  perspiration  covers  his  neck  and  temples ; 
his  teeth  chatter ; his  pulse  becomes  weak  ; and  if,  as 
most  frequently  happens,  the  lungs  are  wounded,  he 
spits  up  frothy  blood,  and  air  issues  from  the  wound. 

Though  one  might  suppose  the  above  class  of  symp- 
toms always  attendant  on  a considerable  effusion  of 
blood  in  the  thorax,  this»is  not  the  case.  Wounded 
persons  have  been  known  to  die  of  such  an  extravasa- 
tion whose  respiration  was  tolerably  free,  and  who  did 
not  complain  of  suffering  more  inconvenience  in  one 
posture  than  another.  Sabatier  says,  that  several 
facts  of  this  kind  have  fallen  under  his  own  observa- 
tion. Other  wounded  persons  also,  who  suffered  most 
of  the  complaints  ascribable  to  extravasation  of  blood 
in  the  thorax,  have  been  cured  by  ordinary  means. 
Mery  gives  an  account  of  a young  man,  wounded  in 
the  anterior  and  superior  part  of  the  chest,  about  two 
o’clock  in  the  morning,  who  had  such  difficulty  of 
breathing  and  fever  five  hours  afterward,  that  an  ex- 
travasation was  supposed  to  exist,  and  Mery  was 
thinking  of  making  an  opening  for  its  evacuation.  A 
tumour  near  the  great  pectoral  muscle,  presenting  nei- 
ther the  feel  of  fluctuation,  nor  that  of  emphy-sema, 
made  him  suspend  his  decision.  The  tumour  was  dis- 
persed by  bleeding,  and  the  application  of  compre.sses 
dipped  in  a mixture  of  spirit  of  wine  and  water. 

However,  even  the  as.semblage  of  the  above  symp- 
toms did  not  deceive  Petit.  Having  been  requested  to 


assist  at  an  operation  which  was  about  to  be  done  on  a 
wounded  man,  about  whose  armpit,  pectoralis  major, 
and  latiasiinus  dorsi  muscles,  a prodigious  emphyse- 
matous swelling  had  taken  place  ; whose  respiration 
was  painful  and  difficult ; and  who  spit  up  frothy 
blood ; Petit  gave  it  as  his  opinion,  that  it  was  unne- 
cessary to  make  an  opening  into  the  chest.  He  thought 
it  would  be  sufficient  to  enlarge  the  wound,  which  was 
at  a little  distance  from  the  armpit,  near  the  edge  of 
the  latissimus  dorsi,  so  as  to  give  vent  to  the  effused 
air.  This  advice  was  followed,  the  emphysema  soon 
dispersed,  and  the  patient  recovered. 

The  equivocal  nature  of  the  symptoms  of  extrava- 
sations of  blood  in  the  thorax,  has  induced  practitioners 
to  pay  the  most  scrupulous  attention  to  every  circum- 
stance attendant  on  these  cases.  In  several  instances, 
Valentin  remarked,  that  an  ecchymosis  occurred  at  the 
angle  of  the  false  ribs,  and  spread  towards  the  loins. 
The  ecchymosis  is  described  as  being  of  a clear  purple 
colour,  like  the  spots  which  sometimes  foim  on  the  ab- 
domen a little  while  after  death.  In  a case,  in  which 
most  of  the  symptoms  of  extravasation  were  combined 
with  the  above  sort  of  ecchymosis,  Valentin  advised  a 
counter-opening  to  be  made.  The  advice  was  over- 
ruled and  the  patient  soon  afterward  died  : more  than 
six  pints  of  blood  were  found  extravasated  in  the  thorax. 

Sabatier  remarks,  that  we  cannot  too  highly  applaud 
the  zeal  of  those  practitioners  who  endeavour  to  dispel 
the  doubts  which  still  prevail  in  several  parts  of  sur- 
gery. At  the  same  time,  he  thinks  that  all  who  take 
interest  in  the  improvement  of  this  science  should  en- 
deavour to  ascertain  the  truth  of  any  new  observations 
which  are  oflered.  Hence,  he  deems  it  proper  to  relate 
a case  which  wqs  communicated  to  him  by  M.  Sauce- 
rotte  (the  father),  an  eminent  military  surgeon,  and 
which  shows,  that  the  ecchymosis  observed  by  Va- 
lentin is,  at  least,  not  invariably  attendant  on  extrava- 
sations of  blood  in  the  chest.  A light- horseman,  who 
had  received  a thrust  with  a sabre  in  the  right  side  of 
the  thorax,  above  the  tendon  of  the  pectoralis  major, 
appeared  to  be  going  on  very  well  ior  the  first  four 
days  after  the  accident.  On  the  fifth,  he  complained 
of  difficulty  of  breathing,  uneasiness,  and  an  inability 
of  lying  on  the  left  side,  without  aggravating  his  com- 
plaints. He  complained  of  a great  deal  of  pain  in  the 
region  of  the  liver,  and  at  the  top  of  the  shoulder. 
His  pulse  was  small  and  contracted,  and  rather  hard 
than  weak.  The  right  side  of  the  chest  seemed  larger 
than  the  left.  On  the  eighth  and  ninth  days  the  symp- 
toms became  more  urgent,  and  the  patient  found  no 
ease  except  in  leaning  on  his  right  side,  and  supporting 
himself  on  a chair  placed  across  his  bed.  This  assem- 
blage of  symptoms  indicated  an  extravasation  of  blood 
in  the  right  cavity  of  the  thorax ; but  as  the  ecchymo- 
sis which  Valentin  has  described,  was  not  apparent, 
doubts  were  entertained  about  the  real  nature  of  the 
case.  When  a counter-opening  was  made  on  the  dead 
body,  a pint  of  putrid  blood  flowed  out. 

When  the  surgeon  feels  assured  that  an  extravasa- 
tion of  blood  in  the  thorax  has  really  occurred,  and  the 
symptoms  are  very  urgent,  the  discharge  of  the  con- 
fined fluid  appears  to  promise  benefit.  However,  be- 
fore the  operation  is  done,  the  revived  state  of  the 
pulse,  the  return  of  warmth  in  the  extremities,  and  the 
cessation  of  great  faintness,  ought  to  denote,  that  the 
hemorrhage  no  longer  continues  from  the  vessels;  for, 
if  this  be  not  the  case,  a fresh  quantity  of  blood  must 
soon  be  extravasated  again,  and  the  patient  die  ex- 
hausted. 

Authors  mention  five  methods  of  discharging  blood 
from  the  thorax;  viz.  1st,  By  placing  the  patient  in  a 
posture  which  favours  the  escape  of  the  blood ; 2dly, 
By  introducing  a syringe  for  the  purpose  of  sucking  it 
out,  or  a mere  cannula  through  which  it  is  to  flow; 
3dly,  By  enlarging  the  wound ; 4thly,  By  employing 
injections ; 5thly,  By  making  an  opening  in  a depend- 
ing part  of  the  thorax. 

1.  SSuccess  cannot  be  expected  from  merely  placing 
the  patient  in  a posture  which  is  favourable  to  the 
escape  of  the  extravasated  blood,  except  when  the 
wound  is  situated  at  the  inferior  part  of  the  chest,  and 
is  large  and  direct  in  its  course.  Par^  successfully 
adopted  this  method  in  the  case  of  a soldier,  who  was 
stabbed  in  three  places  with  a sword,  one  of  the  wounds, 
which  entered  the  chest,  being  situated  under  the  right 
nijiple.  The  man  was  first  dressed  by  a surgeon,  who 
made  several  sutures.  The  patient  was  soon  afterward 


488 


WOUNDS. 


attacked  with  considerable  difficulty  of  breathing, 
fever,  coughing,  spitting  of  blood,  and  acute  pain  in 
the  side.  Pare,  who  was  consulted  the  next  day,  sus- 
pected that  an  extravasation  had  happened ; conse- 
quently he  cut  out  the  sutures,  and  placed  the  patient 
in  a position  in  which  his  feet  were  much  more  raised 
than  the  head.  Par6  also  recommended  him  to  hold 
his  breath,  and  then  introduced  his  finger  into  the 
wound,  in  order  to  take  away  some  clots  of  blood 
which  appeared  at  its  orifice.  By  these  steps  the  dis- 
charge of  seven  or  eight  ounces  of  fetid,  coagulated 
blood  was  effected. 

2.  The  idea  of  drawing  out  of  the  thorax  extrava- 
sated  blood  with  a syringe,  is  rather  ancient.  The 
pipes  of  all  syringes  for  this  purpose  should  have  blunt 
ends,  lest  they  injure  the  lungs.  Mere'  tubes,  contain- 
ing a stilet,  have  also  been  frequently  employed.  Scul- 
tetus  relates  a case,  in  which  an  instrument  of  the 
latter  sort  was  successfully  employed.  A"o  syringe  or 
any  suction  with  the  mouth  was  requisite ; it  was  found 
necessary  merely  to  introduce  the  tube,  and  then  with- 
draw the  siilet. 

Lamotte  used  only  a simple  cannula,  which  he  intro- 
duced into  the  centre  of  the  extravasation.  Then 
having  placed  the  patient  in  what  he  conceived  to  be 
the  most  favourable  posture,  and  requested  him  to  hold 
his  breath,  he  drew  off  the  collection  of  fluid.  His 
cases,  numbered  216,  217,  218,  show  the  success  which 
attended  this  method.  Although  it  might  also  have 
answered  very  well  in  case  219,  Lamotte  saw  that  the 
high  situation  of  the  wound  would  not  have  allowed 
all  the  blood  to  be  discharged,  and  therefore  he  made  a 
counter-opening.  Thus  the  thorax  was  completely 
emptied,  and  a recovery  ensued.  When  a cannula  is 
employed,  authors  recommend  it  to  be  introduced  every 
day,  till  the  bad  symptoms  cease  and  no  more  fluid 
escapes  through  the  cavity  of  the  instrument.  After 
having  given  vent  to  blood,  it  allows  a bloody  serous 
fluid  to  escape,  and  at  a later  period  pus,  which  be- 
comes of  a thicker  and  thicker  consistence  the  nearer 
the  patient  is  to  a recovery. 

3.  The  cases  in  which  a wound,  complicated  with  an 
extravasation  in  the  chest,  should  be  dilated,  are  those 
in  which  the  situation  of  the  opening  is  favourable  to 
the  escape  of  the  blood.  The  operation  is  performed 
with  a curved  bistoury  and  a director.  The  integu- 
ments and  external  muscles  are  to  be  divided  in  a per- 
pendicular direction,  and  the  intercostal  muscles  in  a 
line  parallel  to  the  ribs.  Care  is  also  to  be  taken  not 
to  cut  too  near  the  lower  edge  of  the  upper  rib,  lest  the 
intercostal  artery  1^  wounded.  Dionis  practised  such 
an  operation  on  a soldier  who  was  wounded  at  Befort, 
in  1703,  with  a sword,  below  the  right  nipple,  whereby 
a direct  opening  was  made  into  the  thorax.  When  the 
extravasated  fluid  had  been  let  out,  Dionis  made  the 
patient  lie  on  the  wounded  side  during  the  night,  and 
in  proportion  as  the  blood  continued  to  be  thus  eva- 
cuated the  breathing  became  free  from  oppression. 

4.  The  methods  above  explained  may  be  of  use  when 
the  Wood  retains  its  natural  state  of  fluidity;  but  when 
it  is  coagulated,  as  often  happens,  they  can  be  of  no 
avail.  In  this  circumstance,  most  authors  direct  a 
proper  opening  to  be  made,  and  tepid  water  then  to  be 
thrown  into  the  chest,  with  the  view  of  loosening  and 
dissolving  the  coagula  and  washing  them  out  of  the 
wound.  The  French  writers,  even  the  modern  ones 
{Sabatier),  most  absurdly  recommend  the  injection  of 
various  detergent  vulnerary  decoctions,  and  of  solu- 
tions of  honey  of  roses,  soap,  salt,  &c.  What  idea 
these  authors  can  entertain  of  the  great  tendency  to 
inflammation  of  the  lungs  and  pleura,  or  what  good 
they  can  expect  from  such  applications,  is  difficult  of 
conception.  I am  firmly  convinced,  that  the  meanest 
scribbler  on  surgery,  in  this  country,  would  be  ashamed 
of  offering  such  advice. 

5.  When  the  wound  is  narrow,  and  situated  at  the 
upper  part  of  the  chest,  the  extravasated  blood  cannot 
be  discharged,  unless  a counter-opening  be  made  at  the 
lower  part  of  this  cavity.  The  best  place  for  making 
the  opening,  and  the  proper  manner  of  executing  the 
ope!  ation,  are  described  under  the  head  of  Paracentesis. 
As  soon  as  the  opening  has  been  made,  the  blood  flows 
out.  Its  discharge  is  then  to  be  promoted  by  such  a 
posture  as  will  render  the  opening  depending. 

The  old  surgeons,  who  had  much  more  fear  than 
the  moderns  of  letting  the  opening  heal  up,  sometimes 
employed  tents  for  the  purpose  of  preventing  this 


event,  until  all  danger  of  another  collection  of  blood 
or  matter  seemed  to  be  over.  However,  as  in  these 
cases  tents  are  apt  to  bring  on  inflammation  of  the 
pleura  and  lungs,  hinder  the  escape  of  whatever  fluid 
is  contained  in  the  chest,  and  cause  great  irritation, 
pain,  and  even  exfoliations  from  the  ribs,  their  use  is 
now  relinquished. 

As  large  tents  had  the  effect  of  hindering  the  dis- 
charge of  blood  or  matter  from  the  cavity  of  the  chest, 
some  of  the  old  French  surgeons  employed  a kind  of 
wick;  but  in  the  present  state  of  surgery,  I do  not 
consider  that  it  would  be  at  all  edifying  to  enter  into  a 
comparison  of  these  contrivances.  If  any  means  be 
ever  requisite  for  keeping  the  opening  from  closing, 
there  cannot  be  a better  thing  for  the  purpose  than  a 
short  cannula,  with  a rim  to  keep  it  from  slipping  into 
the  thorax,  and  two  little  rings  for  confining  it  in  its 
situation  with  a riband.  This  should  only  just  enter 
deeply  enough  to  have  its  inner  orifice  on  a level  or  a 
very  little  farther  inwards  than  the  pleura  costalis,  so 
that  it  may  not  irritate  the  lungs. 

When  the  patient  has  been  dressed,  he  is  to  be  kept 
in  bed,  with  his  head  and  chest  somewhat  elevated, 
and  his  thighs  bent,  in  which  position  the  breathing 
will  be  least  oppressed.  It  is  usual  also  to  recommend 
him  to  lie,  as  much  as  possible,  on  the  side  on  which 
the  operation  has  been  done.  He  is  to  keep  himself  in 
as  quiet  a condition  as  he  can.  He  is  to  be  put  on 
very  low  diet,  and,  if  his  strength  allows,  he  is  to  be 
bled  from  the  arm,  and  this  evacuation  must  be  re- 
peated, with  other  antiphlogistic  means,  as  often  as  the 
urgency  of  the  fever  and  inflammatory  symptoms  in- 
dicate, and  the  strength  allows.  Bleeding  from  the 
arm,  besides  counteracting  inflammation  in  the  chest, 
which  is  a principal  source  of  danger,  does  good  by 
lessening  the  force  of  the  circulation  in  the  wounded 
vessels,  and  thus  diminishing  the  tendency  to  internal 
hemorrhage. 

The  old  practice  of  keeping  wounds  of  the  chest 
open  is  now  nearly  exploded  ; but  if  it  ever  be  advis- 
able, particular  caution  must  be  used  not  to  let  the 
tents  and  pieces  of  the  dressings  glide  into  the  cavity 
of  the  pleura.  Tulpius  speaks  of  a Danish  gentleman 
who  had  been  under  a careless  surgeon  on  account  of 
a wound  in  the  thorax,  and  who  coughed  up,  six 
months  afterward,  a large  tent  A similar  fact  is  re- 
corded by  Hildanus.  A man  was  stabbed  in  the  right 
side  of  the  chest  near  the  axilla,  between  the  second 
and  third  ribs.  For  a fortnight,  a great  deal  of  blood 
was  discharged  both  from  the  wound  and  the  mouth. 
The  wound  healed ; but  the  patient  continued  to  be 
afflicted  with  considerable  difficulty  of  breathing,  an 
incessant  cough,  and  to  spit  up  a greenish  fetid  matter. 
Three  months  afterward  he  coughed  up  two  tents 
w'hich  had  slipped  into  the  cavity  of  the  thorax. 

A relaxation  of  the  antiphlogistic  regimen  must  be 
made  with  very  great  circumspection.  Too  much 
nourishment,  talking  too  frequently,  and  any  exertion 
are  circumstances  which  may  induce  a renewal  of  the 
hemorrhage  and  extravasation.  Vesalius  saw  an  ac- 
cident of  this  nature  happen  a fortnight  after  the 
wound,  and  eleven  days  after  the  operation  for  em- 
pyema. A soldier,  who  had  been  stabbed  in  two 
places  with  a sword  above  the  right  nipple,  was  at- 
tacked with  fever,  difficulty  of  breathing,  restlessness, 
and  acute  pain  at  the  bottom  of  the  chest.  These 
symptoms  induced  Vesalius  to  infer,  that  an  extrava- 
sation had  taken  place;  but  he  was  afraid  of  making 
an  opening  in  the  chest,  for  fear  the  hemorrhage  should 
still  continue  from  the  wounded  vessels.  How’ever,  as 
the  patient  remained  in  the  same  state  the  fourth  day 
after  the  receipt  of  the  wounds,  and  he  still  had 
strength  enough,  Vesalius  undertook  the  operation,  by 
which  a considerable  quantity  of  extravasated  blood 
was  discharged.  The  patient  felt  great  relief  at  the 
instant.  The  oozing  of  blood  continued  for  a few 
days,  after  which  a favourable  suppuration  took  place 
in  all  the  three  wounds,  and  the  case  was  expected  to 
end  well.  But  the  patient  having  regained  his  strength 
and  taken  too  much  food,  the  recurrence  of  hemor- 
rhage caused  his  death.  Lombard  saw  a soldier  die 
instantaneously  of  internal  hemorrhage,  brought  on  by 
throwing  a bowl  at  some  nine-iiins,  two  months  after 
he  had  been  cured  of  a wound  of  the  lungs. 

When  the  edges  of  a penetrating  wound  of  the  chest 
are  to  be  brought  together,  writers  state,  that  the  pa- 
tient should  be  requested  to  make  a strong  inspiration 


WOUNDS. 


489 


with  the  wound  closed,  and  then  a long,  slow  expira- 
tion with  it  open,  and  so  on,  till  as  much  of  the  air  is 
discharged  from  the  thorax  as  possible,  and  then  the 
wound  is  to  be  accurately  closed  with  sticking  plaster. 
From  what  has  been  observed,  however,  in  the  article 
Emphysema,  it  will  appear,  that  when  there  is  a direct 
opening  into  the  thorax,  so  as  to  admit  the  external  air, 
the  lungs  on  one  side  collapse,  and  remain  so  till  the 
wound  is  healed  and  the  air  absorbed.  When  one  of 
these  organs  is  wounded,  a collapsed  state  is,  indeed, 
the  best  condition  in  which  it  can  possibly  be  for  a 
certain  time,  that  is,  till  the  breach  of  continuity  in  it  is 
healed.  Schemes  for  making  the  lung  expand  by  ex- 
hausting the  air  from  the  cavity  of  the  pleura  may  be 
amusing  on  paper,  but,  I apprehend,  they  will  never  be 
of  real  use  in  practice. 

Fistuls  sometimes  continue  a long  while  after 
wounds  of  the  thorax.  Platner  mentions  an  instance 
in  which  there  was  a fistulous  opening,  out  of  which 
the  air  rushed  with  sufficient  force  to  blow  out  a candle. 
The  patient  lived  a long  while  in  this  state  without 
suffering  any  particular  inconvenience. 

Another  occasional  consequence  of  a wound  of  the 
chest  is  a hernia  of  the  lungs,  an  affection  of  which 
Sabatier  met  with  an  example.  A soldier,  thirty  years 
of  age,  was  wounded  with  a bayonet  in  the  right  side 
of  the  chest,  between  the  middle  part  of  the  fifth  and 
sixth  true  ribs.  The  wound  healed  ; but  as  the  inter- 
costal muscles  had  been  divided  to  a great  extent,  and 
could  not  be  approximated  with  precision,  an  empty 
space  was  left  under  the  integuments,  which  allowed  a 
piece  of  the  lungs,  as  large  as  a walnut,  to  protrude 
between  the  ribs.  The  swelling  enlarged  at  the  time 
of  inspiration,  and  grew  smaller  when  expiration  took 
place,  occasioning  merely  a slight  pain  without  any 
oppression  in  the  chest. 

Though  so  much  has  been  written  on  the  subject  of 
discharging  blood  from  the  chest  in  cases  of  extrava- 
sation within  that  cavityj  the  operation  is  very  rare. 
During  the  last  thirty  years,  I have  never  heard  of  its 
being  done  by  any  of  the  surgeons  in  London.  In  mi- 
litary surgery,  however,  the  practice  is  occasionally 
exemplified. — {Larrey,  Mem.  de  Chir.  Mil.  t.2,p.  158, 
^c.)  No  doubt,  the  true  reason  of  the  operation  being 
uncommon  is  the  obscurity  in  the  diagnosis,  the  symp- 
toms being  all  of  an  equivocal  nature.  Even  Larrey, 
generally  so  partial  to  operations,  recommends  the  im- 
mediate closure  of  all  wounds  of  the  chest,  excepting 
such  as  are  complicated  with  injury  of  the  intercostal 
artery,  because  (says  he),  unless  very  considerable  ves- 
sels of  the  lungs  are  injured  (in  which  case  nothing 
can  be  of  any  use),  either  no  extravasation,  or  only  a 
trivial  one  happens,  which,  under  the  employment  of 
rigorous  antiphlogistic  treatment,  may  be  dispersed  by 
absorption.— <P.  127.)  Respecting  the  general  pro- 
priety of  closing  all  wounds  of  the  chest,  I entirely 
concur  with  Larrey,  Pelletan,  Boyer,  and  Dr.  Hennen. 
— ( On  Military  Surgery,  ed.  2,  p.  373.) 

Consult  Sabatier,  De  la  Midecine  Opiratoire,  t.  2. 
Joum.  de  Mid.  Militaire,  7 tomes.  Schmucker,  Wahr- 
nehmungen,  2 b.  Berlin,  1774 — 1789.  J.  Bell,  on  the 
Mature  and  Cure  of  Wounds,  ed.  3.  D.  ./.  Darrey, 
Mim.  de  Chir.  Militaire,  8tJo.  Paris  181SJ — 1817,  m va- 
rious places.  John  Hennen,  Principles  of  Military 
Surgery,  ed.  2,  8«o.  Edinb.  1820.  Wm.  Maiden,  an 
Account  of  a Case  of  Recovery  after  an  extraordinary 
Accident,  4to.  Lond.  1812.  The  injury  here  referred  to 
is  one  of  the  most  extraordinary  on  record ; the  shaft 
of  the  gig  having  been  drivenwith  the  greatest  violence 
between  the  sternum  and  lungs.  Sir  A.  Halliday,  in 
Edinb.  Med.  and  Surg.  .Tourn.  vol.  11,  p.  140 ; a reco- 
very from  a gun-shot  injury,  in  which  a great  part  of 
the  shoulder  was  carried  away,  and  the  lungs  and  peri- 
cardium were  exposed  : to  the  authenticity  of  this  case 
lean  bear  witness  myself,  having  been  at  the  field  hos- 
pital, when  the  soldier  arrived  from  the  trenches,  near 
Antwerp. 

Wounds  of  the  Abdomen. — Here  one  of  the  chief 
causes  of  danger  is  the  tendency  of  the  peritoneum  to 
inffame.  Every  penetrating  wound  of  the  belly  is  apt 
to  excite  this  inflammation,  which  too  often  extends 
itseif  over  all  the  viscera,  and  terminates  in  the  death 
of  the  patient. 

There  are  (says  Mr.  John  Bell)  a thousand  occasions 
on  which  the  delicacy  of  the  peritoneum  may  be  ob- 
served. The  wound  of  the  small  sword  and  the  stab 


of  the  stiletto,  explain  to  us  how  quickly  the  perito- 
neum and  all  its  contained  bowelk  inflame  from  the 
most  minute  wound,  although  the  injury  be  almost  too 
small  to  be  visible  on  the  outside  and  scarcely  within  ; 
for  often,  upon  dissection,  no  intestines  are  discovered 
wounded,  and  no  feces  have  escaped  into  the  abdomen. 
In  subjects  who  die  after  lithotomy,  we  find  the  cavity 
of  the  peritoneum  yniversally  inflamed.  The  opera- 
tion of  the  CaKsarean  section  is  fatal,  not  from  any  loss 
of  blood,  for  there  is  little  bleeding ; nor  from  the  parts 
being  exposed  to  the  air,  for  patients  also  die  in  whom 
the  womb  bursts  and  where  the  air  has  no  possible  op- 
portunity of  insinuating  itself ; but  the  case  proves  fatal 
from  the  inflammation,  which  is  always  disposed  to 
originate  from  wounds  of  the  peritoneum,  small  as  well 
as  great. — (Discourses  on  the  Mature  and  Cure  of 
Wounds,  p.  310,  edit.  3 ) 

But  although  there  can  be  no  doubt  that  the  wound, 
abstractedly  considered,  is  the  most  frequent  occasion 
of  this  dreadful  inflammation  ; yet  it  sometimes  hap- 
pens that  the  inflammatory  consequences  must  be  as- 
cribed to  another  kind  of  cause.  If  an  intestine  be 
wounded,  its  contents  may,  under  certain  circum- 
stances, be  effused  in  the  abdomen  ; if  the  liver,  spleen, 
kidney,  or  any  large  vessel  be  injured,  blood  may  be 
poured  out  among  the  viscera ; if  the  gall-bladder  be 
wounded,  bile  may  be  effused  ; and  if  the  bladder  be 
pierced,  the  urine  may  escape  into  the  abdomen.  Now 
all  these  fluids  are  extraneous  substances,  with  respect 
to  the  surfaces  with  which  they  often  come  into  con- 
tact, and  as  such  they  give  rise  to  inflammation  of  the 
peritoneum  and  viscera. 

Wounds  of  the  belly  are  divided,  by  almost  all  wri- 
ters, into  such  as  penetrate  the  cavity  of  the  abdomen, 
and  into  others  which  only  interest  the  skin  and  mus- 
cles. 

The  former  differ  very  much  in  their  nature  and  de- 
gree of  danger,  according  as  they  do  or  do  not  injure 
parts  of  importance  contained  in  the  peritoneum.  The 
latter  are  not  remarkably  different  from  the  generality 
of  other  superficial  wounds.  The  chief  indications 
are  to  lower  inflammation  and  to  prevent  collections 
of  matter.  A few  particularities,  however,  in  the 
treatment  of  superficial  wounds  of  the  abdomen  merit 
attention. 

Superficial  Wounds.— The  most  ancient  ^surgeons, 
and  their  successors  down  to  the  present  day,  have  re- 
corded, tliat  wounds  of  tendinous  parts  frequently  give 
rise  to  very  unpleasant  consequences.  Almost  the 
whole  front  of  the  abdomen  is  covered  with  tendinous 
expansions,  and,  on  this  account,  it  is  not  unusual  to 
see  punctured  wounds  in  this  situation  followed  by 
extensive  inflammation  and  the  formation  of  abscesses. 
At  the  same  time,  the  patient  is  affected  with  a great 
deal  of  inflammatory  fever.  He  suffers  acute  pain, 
sickness,  hiccough,  and  considerable  disturbance  of  the 
nervous  system. — (Callisen,  Syst.  Chirurg.  Hodiernce, 
vol.  1,  p.  698.  Hafnice,  1798.) 

When  the  tension  and  swelling  of  the  abdomen 
abate,  shiverings  sometimes  occur,  and  indicate  the  oc- 
currence of  suppuration.  The  matter  sometimes  ac- 
cumulates in  the  tendinous  sheath  of  the  rectus  mus- 
cle, and  when  the  collection  in  this  situation  remains 
undiscovered  until  a pointing  appears,  no  sooner  does 
the  abscess  burst,  or  it  is  opened,  than  an  extraordinary 
quantity  of  matter  is  discharged.  The  surgeon  should 
carefully  remember  the  nature  of  this  kind  of  case,  as 
there  is  frequently  not  sufficient  alteration  in  the  ap- 
pearance of  the  integuments  to  denote  either  the  exist- 
ence or  the  extent  of  the  suppuration. 

Such  an  abscess  forms  one  remarkable  exception  to 
the  excellent  general  rule  of  allowing  acute  phlegmo- 
nous abscesses  to  burst  of  their  own  accord.  In  the 
present  instance,  there  is  an  aponeurotic  expansion  in- 
tervening between  the  abscess  and  the  skin,  and  no- 
thing retards  the  natural  progressof  the  matter  to  the  sur- 
face of  the  body  so  powerfully  as  the  interposition  of 
a tendinous  fascia.  But  even  in  this  circumstance  the 
propensity  of  pus  to  make  its  way  outwards  is  often 
seen  to  have  immense  influence.  Though  there  is  only 
a thin  membrane  (viz.  the  peritoneum)  between  matter 
so  situated  and  the  cavity  of  the  abdomen,  the  abscess, 
after  a time,  mostly  points  externally. 

The  proper  treatment  of  this  case  is  to  prevent  the 
surprising  accumulation  of  matter,  and  rapid  increase 
of  mischief,  by  making  a depending  opening,  some- 


490 


WOUNDS. 


times  at  the  very  lowest  part  of  the  sheath  of  the  rectus 
muscle,  and  this,  as  soon  as  the  lodgement  of  matter  is 
clearly  ascertained. 

If  ever  there  be  a case  in  which  it  is  advantageous 
and  justifiable  to  make  an  early  dilatation  of  a punc- 
tured wound,  in  order  to  prevent  the  above-described 
ill  consequences,  it  is  unquestionably  the  present  one. 
Such  practice,  indeed,  is  particularly  recommended 
by  Callisen,  in  addition  to  the  strictest  antiphlogistic 
means. — (See  Syst.  Chir.  Hodiernce,  vol.  1,  p.  698,  edit. 
1798.) 

Sometimes  the  matter  is  formed  between  the  exter- 
nal and  internal  oblique  muscles,  and  spreads  to  a great 
extent.  The  pus  may  even  insinuate  itself  into  the 
abdomen,  and  the  case  end  fatally.  Such  an  example 
is  recorded  by  Dr.  Crowther,  of  Wakefield.  In  this 
instance,  however,  the  disease  proceeded  from  a con- 
tusion, not  a wound. — (See  Edinb.  Med.  and  iSurgical 
Journal^  vol.  2,  p.  129.) 

Superficial  wounds  of  the  abdomen  are  to  be  treated 
on  the  same  principles  as  similar  wounds  in  other  si- 
tuations. The  indications  are  to  prevent  inflammation 
by  alt  possible  means,  and  if  suppuration  should  be  in- 
evitable, to  let  out  the  matter  by  a dejiending  opening  as 
soon  as  the  abscess  is  known  to  exist.  The  inflamma- 
tion is  to  be  checked  by  general  and  topical  bleeding, 
low  diet,  emollient  clysters,  diluent  beverages,  quie- 
tude, opening  medicines,  cold  applications  or  fomenta- 
tions, and  the  mildest  and  most  simple  dressings. — (See 
Jnflainviation.) 

Whenever  the  abdominal  muscles  are  wounded,  they 
should  be  relaxed,  and  the  patient  kept  quiet  in  bed. 
A very  important  point  in  the  treatment  of  wounds  of 
the  parietes  of  the  abdomen,  is  to  afford  a degree  of 
support  to  the  wounded  parts,  so  that  the  pressure  of 
the  viscera  may  be  resisted.  The  sides  of  the  abdo- 
men are  almost  wholly  composed  of  soft  parts,  which 
easily  yield.  No  part  of  the  front  or  sides  of  the  abdo- 
men is  supported  by  a bony  structure,  and  as  the  vis- 
cera are,  for  the  most  part,  more  or  less  moveable,  and 
closely  compressed  by  the  abdominal  muscles  and  dia- 
phragm, they  are  liable  to  protrude  whenever  the  resist- 
ance of  the  containing  parts  is  not  sufficiently  power- 
ful. Hence,  all  wounds  of  the  abdomen,  especially 
those  in  which  both  the  integuments  and  muscles  have 
been  cut,  demand  strict  attention  to  the  precaution  of 
supporting  the  wounded  part,  and  this,  though  the  perito- 
neum itself  should  not  happen  to  be  divided.  The  pa- 
tient ought  to  keep  as  much  as  possible  in  a horizontal 
position,  and  suitable  compresses  and  bandages  should 
be  applied  And,  in  order  to  guard  against  herniae,  the 
parts  should  be  supported  in  this  way  a considerable 
time  after  the  wound  is  healed. 

The  peritoneum  being  connected  by  means  of  cellu- 
lar substance  with  the  inner  surface  of  the  abdominal 
muscles  there  is  always  some  risk  of  the  inflammation 
of  these  parts  extending  to  that  membrane.  The  dan- 
ger must  be  averted  by  the  rigorous  employment  of  an- 
tiphlogistic treatment.  What  renders  the  event  still 
more  dangerous  is,  that  when  one  point  of  the  perito- 
neum is  affected,  the  inflammation  usually  spreads  with 
immense  rapidity  over  its  whole  extent,  and  too  often 
proves  fatal. 

As  superficial  wounds  of  the  abdomen  are  to  be 
treated  on  the  general  principles  applicable  to  all  re- 
sembling wounds  in  other  situations,  it  is  hardly  neces- 
sary to  state,  that  union  by  the  first  intention,  if  possi- 
ble, is  always  to  be  attempted. 

Of  Wounds  penetrating  the  Cavity  of  the  Abdomen. 
— The  first  thing  which  the  surgeon  is  generally  anx- 
ious to  know,  when  he  is  called  to  a wound  of  the  belly, 
is,  whether  the  wound  penetrates  the  cavity  of  the  ab- 
domen, and  whether  any  of  the  viscera  are  injured. 

When  the  wound  is  extensive,  and  the  bowels  pro- 
trude, the  first  part  of  the  question  is  at  once  decided. 
But  when  the  wound  is  narrow,  and  the  viscera  do  not 
protrude,  it  is  more  difficult  to  know  whether  the  ca- 
vity of  the  abdomen  is  penetrated  or  not.  An  opinion, 
however,  may  be  formed,  by  carefully  examining  the 
wouiid  with  a finger  or  a probe ; by  observing,  if  pos- 
sible, how  much  of  the  weapon  is  stained  with  blood  ; 
considering  the  direction  in  which  it  was  pushed;  the 
quantity  of  blood  lost,  the  state  of  the  pulse,  and 
whether  any  bile,  feces,  or  other  fluids,  known  to  be 
naturally  contained  in  some  of  the  abdominal  viscera, 
have  been  discharged  from  the  orifice  of  the  injury. 

I When  the  wound  is  sufficiently  large  to  admit  the 


finger,  a surgeon  can  always  learn  whether  the  injury 
extends  into  the  abdomen,  because  the  smooth  lining  of 
that  cavity,  and  the  contained  how'els,  may  be  easily 
felt.  There  is  one  chance  of  deception,  however,  aris- 
ing from  the  possibility  of  mistaking  the  inside  of  the 
sheath  of  the  rectus  muscle  for  the  cavity  of  the  peri- 
toneum ; and  when  the  examination  is  made  with  a 
probe,  particular  caution  should  be  used  in  forming  a 
judgment  of  the  nature  of  the  case;  for  the  parts  are 
so  soft  and  yielding,  that  a very  little  force  will  make 
the  instrument  pass  a considerable  way  inwards.  Every 
examination  of  this  kind  should  always  be  undertaken, 
if  possible,  when  the  patient  is  exactly  in  the  same  po- 
sition in  which  he  was  at  the  time  of  receiving  the 
wound.  Formerly,  injections  were  sometimes  em- 
ployed as  tests  of  the  penetration  of  the  cavity  of  the 
abdomen.  This  absurd  experiment  is  now  very  rightly 
exploded.  It  is  well  known  to  the  moderns,  that  the 
space,  termed  the  cavity  of  the  abdomen,  is  in  fact 
completely  filled  with  the  various  viscera,  and  that  in 
gener  al,  an  injected  fluid  would  not  so  easily  find  its 
way  into  the  bag  of  the  peritoneum,  as  an  unreflecting 
person  might  suppose.  And  if  it  were  propelled  with 
much  force,  it  would  be  quite  as  likely  to  insinuate  it- 
self into  the  cellular  substance  of  the  parietes  of 
the  abdomen  or  perhaps  into  the  sheath  of  the  rectus 
muscle.  The  least  tortuosity  of  the  woirnd,  or  a piece 
of  bowel,  or  omentum,  laying  against  the  internal  ori- 
i fice  of  the  injur  y,  wmuld  also  completely  prevent  arr  in- 
i jection  from  passing  into  the  abdomen. 

Wheir  a cortsiderable  quantity  of  blood  issues  from  a 
wound  of  the  abdomen,  we  may  pronounce,  almost  with 
certainty,  that  sonre  large  vessel  within  its  cavity  is  in- 
jured. Excepting  the  epigastric  artery,  which  runs  on 
the  forepart  of  the  abdomen,  along  the  inrrer  surface  of 
the  rectus  muscles,  no  large  vessel  is  distributed  to  the 
muscles  aird  integuments.  At  the  same  time,  it  is  de- 
serving of  particular  notice,  that  a large  artery  may  be 
opened  in  the  abdomen,  and  not  a drop  of  blood  be 
discharged  from  the  wound. 

In  such  cases,  the  consequent  symptoms  qtrickly  lead 
to  a suspicion  of  what  has  happened.  The  patient 
complains  of  extreme  debility  and  faintness;  his  pulse 
falters;  he  has  cold  sweats ; and  if  the  bleeding  should 
not  speedily  cease,  these  symptoms  are  soon  followed 
by  death. 

Sometimes  the  extension  of  the  wound  into  the  ca- 
vity of  the  abdomen  is  from  the  first  quite  manifest, 
being  indicated  by  the  escape  of  chyle,  bilious  matter, 
feces,  or  other  fluids.  The  vomiting  up  of  a consider- 
able quantity,  of  blood,  or  its  discharge  by  stool,  affords 
also  the  same  information.  The  urine,  however,  may 
flow  from  a wound  which  does  not  actually  penetrate 
the  abdomen  ; for  the  kidneys,  ureter,  and  bladder  may 
be  said  to  be  out  of  the  abdomen,  because  they  are  re- 
ally outside  of  the  cavity  of  the  peritoneum. 

When  none  of  the  above  symptoms  occur;  when 
neither  the  finger  nor  the  probe  can  be  introduced; 
when  none  of  the  fluids  known  to  be  contained  in  the 
various  receptacles  in  the  abdomen  are  discharged  from 
the  wound  ; when  the  pulse  remains  natural,  and  the 
pain  is  not  excessive,  there  is  reason  to  hope  that  the 
wound  has  not  injured  parts  of  greater  consequence 
than  the  integuments  and  muscles. — {Encyclopedie  Md- 
thodique,  partie  Chir.  art.  Abdomen.) 

I have  now  taken  a survey  of  the  criteria  commonly 
noticed  by  writers  for  the  purpose  of  enabling  surgeons 
to  discriminate  a wound  which  penetrates  the  abdomen 
from  one  which  is  more  superficial.  My  next  duty  is 
to  warn  the  practitioner,  that  too  much  solicitude  to 
determine  this  point  is  very  frequently  productive  of 
serious  harm.  It  may  be  set  down  as  an  axiom  in  sur- 
gery, that  in  general.,  whenever  the  probing  of  a wound 
is  not  rendered  absolutely  necessary  by  some  particular 
object  in  view,  it  may  be  judiciously  omitted.  A nar- 
row oblique  wound  may  enter  the  cavity  of  the  abdo- 
men without  there  being  any  particular  method  of  as- 
certaining whether  it  has  done  so  or  not.  However, 
this  w'ant  of  positive  information  is  of  no  practical 
importance;  for  when  there  are  no  urgent  symptoms 
evincing  the  nature  of  the  case,  the  treatment  ought 
obviously  to  resemble  that  of  a simple  wound;  and 
whether  the  wound  be  deep  orsupeificial,  antiphlogistic 
remedies  are  indicated. 

The  edges  of  a wound  penetrating  the  abdomen,  but 
unattended  with  injury  of  the  viscera,  are  to  be  brought 
together  with  sticking  plaster,  iii  the  same  way  as  com- 


WOUNDS. 


491 


mon  wounds.  Suturos  are  not  generally  necessary. 
Numerous  cases  may  he  found  in  the  records  of  sur- 
gery, proving  that  wounds  of  the  abdomen  may  be  ea- 
sily united  without  sutures,  provided  the  surgeon  lake 
care  to  avail  himself  of  the  assistance  which  may  be 
derived  from  a suitable  position  and  a proper  bandage. 
But  such  cases  are  less  decisive  than  relations  of  the 
Ca;sarean  operation,  the  extensive  wound  of  which  ad- 
mits of  being  healed  by  the  same  simple  means.  It  is 
not  my  intention  to  assert,  that  in  the  majority  of  these 
examples,  sutures  were  altogether  dispensed  with  ; but 
the  ligatures  frequently  cut  their  way  through  the  skin 
and  muscles,  and  the  application  of  others  was  impos- 
sible, either  on  account  of  the  particular  state  of  the 
case,  or  the  patient’s  aversion  to  them.  Still  the  union 
of  such  wounds  was  accomplished.  A bandage  made 
on  the  same  plan  as  that  with  eighteen  tails,  would  be 
extremely  convenient  for  longitudinal  wounds  of  the 
abdomen. — (See  Pibrac,  in  Mem.  de  VAcad.  de  €hir.  U 
3,  4£o.) 

In  the  treatment  of  wounds  of  the  abdomen  sutures 
may  generally  be  relinquished,  not  only  without  harm, 
but  with  benefit ; for  their  employment  is  sometimes 
the  cause  of  bad  symptoms.  In  one  instance,  the  hic- 
cough and  vomiting  could  not  be  appeased  by  any 
remedy  which  was  tried.  On  the  fourth  day,  the 
wound  was  inflamed  and  painful,  and  it  was  judged 
proper  to  cut  away  two  sutures,  and  employ  only  simple 
dressings,  with  the  view  of  diminishing  the  pain  and 
swelling.  The  symptoms  quickly  abated,  and  in  a week 
were  entirely  cured,  the  wound  healing  up  very  well. 
— {Op.  cit.) 

However,  there  are  circumstances  in  which  it  would 
be  impossible  to  dispense  with  sutures.  If,  for  instance, 
the  belly  were  torn  open  from  one  side  to  the  other  by 
a bullock’s  horn  ; or  if  it  were  extensively  divided  with 
the  tusks  of  a wild  boar,  a stag’s  horn,  a razor,  &;c.,  and 
the  inflated  intestines  could  not  be  kept  from  protruding, 
some  stitches  would  be  absolutely  necessary  ; but  even 
then,  they  should  be  as  few  as  possible. — {Sabatier, 
Medecine  Opiratoire,  t.  \,p.  214,  edit.2.) 

“ Our  good  old  surgeon  Wiseman  (observes  Mr.  John 
Beil)  has  said  with  great  simplicity,  as  a great  many 
have  said  after  him,  ‘ it  frequently  happeneth,  that  a 
oword  passeth  through  the  body  without  wounding 
any  considerable  part.’  He  means  that  a rapier  or  ball 
often  passes  quite  across  the  belly,  in  at  the  navel,  and 
out  at  the  back,  and  that  without  one  bad  sign  the  pa- 
tient recovers,  and,  as  has  very  often  happened,  walks 
abroad  in  good  health,  in  eight  days;  which  speedy 
cure  has  been  supposed  to  imply  a simple  wound,  in 
which  all  the  bowels  have  escaped.  But  we  see  now, 
how  this  is  to  be  explained;  for  we  know  that  in  a 
thrust  across  the  abdomen,  six  turns  of  intestine  may 
be  wounded, — each  wound  may  adhere;  adhesion,  we 
know,  is  begun  in  a few  hours,  and  is  perfected  in  a few 
days ; and  when  it  is  perfect,  all  danger  of  inflam- 
mation is  over  ; and  when  the  danger  of  inflammation 
is  over,  the  patient  may  walk  abroad;  so  that  we  may 
do  just  as  old  Wiseman  did  in  the  case  here  alluded 
to  (P.  98,  the  case  of  a man  who  was  wounded  across 
the  belly,  and  well  and  abroad  in  seven  days),  ‘ bleed 
him,  and  advise  him  to  keep  his  bed  and  be  quiet.’  In 
short,  a man,  thus  wounded,  if  he  be  kept  low,  has  his 
chance  of  escaping  by  an  adhesion  of  the  internal 
wounds.” — {Discourses  on  the  Mature  and  Cure  of 
fVounds,p.  329,  330,  edit.  3.) 

The  truth  of  these  observations  is  well  illustrated  in 
a case  mentioned  by  Dr.  Hennen,  in  which  a soldier 
recovered,  whose  abdomen  was  pierced  with  a ramrod, 
which  stuck  so  fast  in  the  vertebra;,  that  some  force  was 
required  to  disengage  it. — {On  Military  Surgery,  p. 
4(^2,  ed.  2.) 

When  a man  is  stabbed  or  shot  in  the  belly,  and 
none  of  the  bowels  protrude,  the  wisest  plan  is  to  keep 
the  patient  as  quiet  as  possible,  have  recourse  to  copious 
and  repealed  bleeding,  prescribe  anodynes,  and  the 
lowest  fluid  diet,  and  apply  light  superficial  unirritating 
dressings.  In  the  event  of  severe  pain  and  swelling  of 
the  belly  coming  on,  leeches,  fomentations,  the  warm 
bath,  and  emollient  poultices  will  be  necessary,  and 
nothing  will  now  avail  except  the  most  rigorous  etn- 
ployment  of  antiphlogistic  remedies.  As  Dr.  Hennen 
(Tbserves,  the  best  means  of  emptying  the  bowels  are 
oleaginous  clysters,  and  if  any  internal  mcdicitie  be 
given  as  a purgative,  itshould  be  of  the  mildest  nature. 
— {On  Military  Surgery,  p.  \V(2,ed.‘.i.)  Castor  oil  is 


perhaps  the  best ; but,  on  the  whole,  for  some  few  days 
I would  hardly  venture  beyond  the  use  of  clysters  for 
procuring  evacuations  from  the  bowels. 

Suppuration  in  the  Abdomen,  in  consequence  of 
Wounds. — Abscesses  within  the  bag  of  the  peritoneum 
are  far  from  being  common.  As  a late  writer  well 
observes,  the  containing  and  contained  parts  of  tlie 
abdomen  present  to  each  other  a uniform  and  con- 
tinuous surface  of  membrane.  This  membrane  is  of 
tire  serous  class,  and  the  species  of  inflammation  to 
which  it  is  especially  subject  is  that  which  has  been 
denominated  the  adhesive.  The  membrane  lining  the 
intestinal  canal  is  of  the  mucous  class,  and  the  ulcer- 
ative inflammation  is  the  species  to  which  this  class  is 
liable.  This  beneficent  provision  is  an  irresistible  evi- 
dence of  the  operation  of  a salutary  principle  in  disease. 
If  the  inflamed  peritoneum  had  run  directly  into  sup- 
puration, ulceration  of  surrounding  parts  would  have 
been  required  for  an  outlet;  and  if  the  internal  surface 
of  the  irritated  bowel  had  tended  to  form  adhesions, 
the  canal  would  have  been  in  constant  danger  of  obli- 
teration.—(7Vaaers  on  Injuries  of  the  Intestines,  ^c. 

p.  10.) 

That  collections  of  matter,  however,  do  sometimes 
take  place  in  the  cavity  of  the  abdomen,  in  conse- 
quence of  wounds,  is  a fact  of  which  there  are  loo 
many  proofs  on  record,  for  the  possibility  of  the  case 
to  be  doubted.  At  this  moment,  be  it  sufficient  to  refer 
to  two  examples  of  the  occurrence,  as  related  by  Mr, 
B.  Bell. — {System  of  Surgery,  vol.  6,  p.  256.) 

If  the  abscess  were  in  any  other  part  of  the  body, 
and  did  not  readily  point,  the  wisest  practice  would 
undoubtedly  be  to  make  an  opening  sufficient  for  the 
evacuation  of  the  matter.  But  suppuration  in  the  ab- 
domen can  seldom  be  known  with  certainty  in  an  early 
stage  of  the  case  ; for  the  abscess  is  so  deep,  that  no 
fluctuation  nor  swelling  is  perceptible,  until  the  quantity 
of  pus  is  considerable.  Nor  would  it  be  judicious  to 
expose  the  patient  to  the  hazard  which  might  arise 
from  making  an  opening  into  the  abdomen,  merely  for 
the  sake  of  discharging  a small  quantity  of  matter. 

Many  writers  impute  much  of  the  danger  of  wounds 
of  the  abdomen  to  the  entrance  of  air  into  the  cavity 
of  the  peritoneum.  In  inculcating  such  opinions, 
however,  they  betray  an  inaccuracy  of  observation, 
which  a very  little  reflection  would  have  set  right. 
Too  much  stress  has  long  been  laid  on  the  introduction 
of  air  into  the  abdomen,  as  being  a cause  of  inflam- 
mation. The  fact  is,  the  cavity  of  the  belly  is  always 
so  completely  occupied  by  the  several  viscera,  that  the 
whole  inner  surface  of  the  peritoneum  is  invariably  in 
close  contact  with  them,  and  therefore  air  cannot  easily 
diffuse  itself  from  the  wound,  throughout  the  abdomen. 
After  tapping,  in  dropsical  cases,  inflammation  seldom 
arises,  though  here  the  air  has  quite  as  good  an  oppor- 
tunity of  entering  the  abdomen  as  in  any  case  of 
wound.  The  peritoneum  in  animals  has  been  inflated 
without  any  inflammation  being  excited.  In  cases  of 
tympanitis,  the  peritoneum  is  distended  with  air,  and 
yet  both  this  membrane  and  the  bowels  are  quite  unin- 
flamed. In  the  human  .subject,  it  seems  probable,  that 
if  a wound  were  made  in  a vacuum,  the  breach  of 
continuity  itself  would  bean  adequate  cause  of  inflam- 
mation. It  may  also  be  remarked,  that  collections  of 
matter  in  the  abdomen  are  almost  always  com- 
pletely circumscribed,  and  separated  from  the  general 
cavity  of  the  peritoneum,  by  the  adhesion  of  the 
viscera  to  each  other,  and  to  the  inside  of  the  perito- 
neum. • 

I am  of  opinion,  that  no  surgical  writer  has  suc- 
ceeded so  well  as  Mr.  John  Bell  in  exposing  the  absurd 
ajiprehensions,  not  uncommonly  entertained  by  practi- 
tioners, respecting  the  entrance  of  air  into  the  abdomen 
and  other  cavities  of  the  body.  He  inquires;  1st, 
Whether  air  can  really  get  into  the  cavity  of  the  ab- 
domen 1 and,  2dly,  Whether,  if  it  were  there,  it  would 
produce  the  dreadful  effects  ascribed  to  it? 

Upon  the  first  question,  his  arguments  run  thus: — 
“ Suppose  a wound  of  an  inch  in  length  ; — suppose  the 
bowel  to  have  sunk,  in  some  strange  way,  into  the 
pelvis,  for  example,  so  as  to  have  left  a mere  vacuum ; 
what  should  happen  with  the  flexible  parietes  of  th« 
abdomen  ? Should  they  stand  rigid,  while  the  air 
rushed  into  the  cavity  to  fill  it  ? No,  surely.  But,  on 
the  contrary,  the  walls  of  the  abdomen  w'ould  fall  to- 
gether, and  the  pre.ssure  of  the  outward  air,  far  from 
making  the  air  rush  in  by  the  outward  wound,  would 


492 


WOUNDS. 


at  once  lay  the  belly  flat  and  close  the  wound.  But 
since  the  walls  of  the  abdomen  are  not  flaccid,  nor  the 
cavity  empty,  but  the  abdomen  full,  and  the  flat  muscles 
which  cover  it  acting  strongly,  the  effect  must  be  much 
more  particular ; for  the  moment  that  the  belly  is 
wounded,  the  action  of  the  muscles  would  force  out 
part  of  the  bowels;  the  continuance  of  that  action  is 
necessary  to  respiration  ; the  respiration  continues  as 
regular  after  the  wound  as  before;  and  the  continual 
pressure  of  the  abdominal  muscles  and  the  diaphragm 
against  all  the  viscera  of  the  abdomen,  prevents  the 
access  of  air  so  effectually,  that  though  we  should  hold 
such  a wound  open  with  our  fingers,  no  air  could  jrass 
into  the  abdomen,  farther  than  to  that  piece  of  gut 
which  is  first  touched  with  the  finger,  when  we  thrust 
it  into  the  abdomen.  Nothing  is  absolutely  exposed  to 
the  air,  except  that  piece  of  intestine  which  is  without 
the  abdomen,  or  that  which  we  see  when  we  expose  a 
small  piece  of  the  bowels,  by  holding  aside  the  lips  of 
the  wound.  The  pressing  forward  of  that  piece,  and 
the  protrusion  of  a portion  of  the  gut,  proportioned 
always  to  the  size  of  the  wound ; the  pressure  from 
behind,  keeping  that  piece  protruded,  so  that  it  is  with 
difficulty  we  can  push  it  back  with  our  finger;  this 
incessant  pressure  in  all  directions  is  an  absolute  se- 
curity against  the  access  of  air.  The  intestine  comes 
out,  not  like  water  out  of  a bottle,  the  place  of  which 
must  be  supplied  by  air  entering  into  the  bottle,  in  pro- 
portion as  ilie  water  comes  out ; but  the  gut  is  pushed 
down  by  the  action  of  the  muscular  walls  of  the  ab- 
domen, and  that  action  follows  the  intestine,  and 
keeps  it  down,  and  prevents  all  access  of  the  air,  whe- 
ther the  gut  continue  thus  protruding,  or  whether  it  be 
reduced ; for  if  it  be  reduced,  the  walls  of  the  abdomen 
yield,  allowing  it  to  be  thrust  back,  but  admitting  no 
air.  Those  who  want  to  know  the  effect  of  air,  dif- 
fused within  the  cavity  of  the  abdomen,  must  make 
other  experiments  than  merely  cutting  open  pigs’ 
bellies; — they  must  give  us  a fair  case,  without  this 
unnecessary  wound.  We  will  not  allow  them  to  say, 
when  they  cut  open  the  belly  of  any  creature  with  a 
long  incision,  that  the  inflammation  arises  from  the 
air;  much  less  shall  we  allow  them  to  say,  when  they 
open  the  belly  with  a smaller  incision,  that  by  that 
little  incision  the  air  gets  into  the  abdomen,  and  that 
all  the  bowels  are  exposed  to  the  air.” — {Discourses  on 
the  J^ature  of  Wounds,  p.  343.  384.) 

In  adverting  to  the  question,  whether  air  is  so  irri- 
tating to  the  cavities  of  the  body  as  many  have  sup- 
posed, Mr.  John  Bell  criticises  with  much  spirit  and 
success  the  opinions  published  on  this  subject,  by  Dr. 
A.  Monro,  in  his  account  of  the  burste  mucosae,  as  the 
annexed  quotations  will  show.  “That  the  vulgar 
should  believe  the  first  superficial  impression  that 
strikes  them,  of  air  hurting  a wound  or  sore,  is  by  no 
means  surprising ; but  it  is  not  natural  that  men  bred 
to  philosophy  should  allow  so  strange  an  assertion  as 
this  without  some  kind  of  proof.  That  the  air  which 
we  breathe,  and  which  we  feel  upon  the  surface  so 
bland  and  delightful,  should  have  so  oppo.site  a relation 
to  the  internal  parts,  that  it  should  there  be  a stimulus 
more  acrid  and  more  dangerous  than  the  urine,  is  not 
to  be  believed  upon  slight  grounds.  I do  affirm  (says 
Mr.  John  Bell)  that  it  remains  to  be  proved,  that  this 
fluid,  which  seems  so  bland  and  pleasant  to  all  our 
senses,  and  to  the  outward  surface,  is  yet  a horrible 
stimulus,  when  admitted,  as  a celebrated  author 
grandly  expresses  it,  ‘ into  the  deep  recesses  of  our 
body.’  ” — {Monro's  Bursa  Mucosa.) 

With  how  much  reason  Mr.  John  Bell  objects,  that 
this  doctrine  is  unfounded,  will  be  manifest  to  every 
man  of  any  discernment  or  impartiality. 

“ The  air,  for  instance,  escapes  from  the  lungs,  in  a 
fractured  rib,  and  first  goes  abroad  into  the  thorax ; 
then  into  the  cellular  substance;  then  the  emphyse- 
matous tumour  appears;  but  often  without  any  scari- 
fications, with  very  little  care  and  assistance  on  our 
part,  the  air  is  absorbed,  the  tumour  disappears,  and 
without  inflammation  of  the  chest,  or  any  particular 
danger,  the  man  gets  well.  Here  then  is  the  air,  within 
the  cavity  of  a shut  sac,  filling  the  thorax,  and  op- 
pressing the  lungs,  without  any  dangerous  inflamma- 
tion ensuing. 

That  the  air  may  be  pushed  under  the  cellular  sub- 
stance over  all  the  body,  without  causing  inflammation, 
is  very  plain  from  the  more  desperate  cases  of  em- 
physema, where  the  patients,  after  living  eight  or  ten 


days,  have  died,  not  from  inflammation,  but  from  op- 
pression merely,  the  body  being  so  crammed  with  air, 
that  even  the  eyeballs  have,  upon  dissection,  been 
found  as  tense  as  blown  bladders.  We  have  also  many 
ludicrous  cases  of  this  kind,  which  prove  this  to  our 
perfect  satisfaction.  Soldiers  and  sailors  sometimes 
touch  the  scrotum  with  a lancet,  introduce  a blow-pipe, 
and  blow  it  up  to  an  enormous  size,  imitating  herniae, 
by  which  they  hope  to  escape  from  the  service.  The 
old  story  of  a man  who  was  so  wicked  as  to  make  a 
hole  in  liis  child’s  head,  and  blow  it  up,  that  he  might 
show  the  child  in  the  streets  of  Paris  for  a monster,  is 
well  authenticated ; and  I have  little  doubt,  that  a 
fellow,  who  knew  how  to  do  this,  would  blow  it  up 
every  morning,  and  squeeze  it  out  when  he  put  the 
child  to  bed  at  night.  Some  villanous  butchers,  having 
a grudge  at  a soldier,  found  him  lying  drunk  under  a 
hedge : they  made  a little  hole  in  his  neck,  and  blew 
him  up  till  he  was  like  a bladder,  or,  as  Dr.  Hunter  de- 
scribes the  disease  of  emphysema,  like  a stuffed  skin." 
— (P.  388,  389.) 

After  many  other  pertinent  observations,  blended 
with  appropriate  satire  on  the  extravagant  notions  pro- 
fessed by  Monro,  on  the  bad  effects  of  the  air,  in  litho- 
tomy, operations  for  hernia  and  hydrocele,  the  Caesa- 
rean section,  &c.,  Mr.  John  Bell  most  justly  holds  up 
to  ridicule  the  proposition  of  Dr.  Aitken,  to  perform 
this  last  operation  under  the  cover  of  a warm  bath,  in 
order  to  exclude  the  air.  “ This,  though  it  may  seem 
to  be  a scurvy  piece  of  wit,  was  really  proposed  in 
sober  serious  earnest.  But  (adds  Mr.  John  Bell)  the 
admission  of  atmospheric  air,  as  a stimulus,  when 
compared  with  the  great  incisions  of  lithotomy,  of 
hernia,  of  hydrocele,  of  Caesarean  section,  of  the 
trepan,  is  no  more  than  the  drop  of  the  bucket  to  the 
waters  of  the  ocean.  And  it  is  just  as  poor  logic  to 
say,  that  after  such  desperate  operations,  these  cavities 
are  inflamed  by  the  admission  of  air,  as  it  would  be  to 
say  (as  Monro  did),  that  when  a man  is  run  through 
the  pericardium  with  a red  hot  poker,  that  the  heart 
and  pericardium  are  inflamed  by  the  admission  of  the 
air.”— (P.  347,  edit.  3.) 

Enough,  I conceive,  has  been  said  to  dispel  all  the 
idle  fear  and  prejudices  which  have  prevailed  con- 
cerning the  bad  effects  of  the  air  in  wounds  of  the 
abdomen,  as  well  as  several  other  cases.  When  so  . 
justly  eminent  a man  as  Dr.  Alexander  Monro,  senior, 
was  disturbed  by  such  apprehensions,  itis  not  wonder- 
ful that  many  a poor  ordinary  member  of  the  profession 
should  have  been  terrified  nearly  out  of  his  wits  upon 
the  subject;  and  for  quieting  this  alarm,  and  exposing 
its  absurdities,  I really  think  Mr.  John  Bell  deserving 
of  particular  praise. 

In  general,  in  all  cases  of  wounds  of  the  abdomen, 
it  is  an  excellent  rule  never  to  be  officious  about  ah- 
scesses  which  may  take  place,  nor  to  exhibit  partiality 
to  such  experiments  as  have  been  devised  for  learning 
precisely  what  bowel  is  wounded.  It  is  quite  time 
enough  to  interfere  when  the  urgency  of  the  symptoms 
confirms  any  suspicions  which  may  be  entertained. 
A great  deal  of  harm  is  frequently  done  bj'  handling  and 
disturbing  the  wounded  parts  more  than  is  necessary, 
and  it  is  well  known,  that  wounds  at  first  attended 
with  alarming  symptoms  frequently  have  a favourable 
termination.  Swords,  balls,  and  other  weapons  some- 
times pass  completely  through  the  body  without  the 
patient  suffering  afterward  any  threatening  symptom, 
or  indeed  any  effects  which,  abstractedly  considered, 
would  authorize  the  inference  that  the  viscera  had 
been  at  all  injured.  Severe  inflammations  may  not 
end  in  suppuration,  and  when  pus  is  formed  it  is  some- 
times absorbed  again.  Nothing  then  indicates  the  ne- 
cessity for  the  discharge  of  purulent  matter  in  the  ab- 
domen, unless  the  fluctuation  and  situation  of  the  ab- 
scess be  very  distinct,  and  the  quantity  and  pressure 
of  the  matter  clearly  productive  of  inconveniences. 
Under  these  circumstances,  the  surgeon  shrjuld  make  a 
cautious  puncture  with  a lancet. 

Protrusion  of  the  Viscera. — The  omentum  and 
small  intestines  are  the  parts  most  liable  to  protrusion  ; 
but  in  large  wounds  the  great  intestines,  the  stomach, 
and  even  the  liver  and  spleen  may  project  through  the 
opening.  The  general  symptoms  indicating  a protru- 
sion of  the  parts  are  sufficiently  obvious ; but  it  de- 
serves attention,  that  in  fat  subjects  the  adipose 
membrane  may  project  from  the  wound,  and  put  on 
somewhat  of  the  appearance  of  omentum.  The  apo- 


WOUNDS. 


493 


cial  symptoms  are  to  be  collected  from  a knowledge  of 
the  natural  situation  of  the  parts,  and  reflecting  what 
region  of  the  abdomen  is  wounded. — {Callisen,  Syst. 
Chir.  Hodiernm,  t.  1,  702  and  703,  edit.  1798.) 

From  penetrating  wounds  considerable  portions  of 
the  bowels  or  omentum  sometimes  protrude;  and 
though  those  viscera  may  not  have  received  injury, 
yet  their  being  displaced  is  sometimes  productive  of 
fatal  consequences. 

The  best  mode  of  preventing  such  mischief,  is  to  re- 
turn the  viscera  into  the  cavity  of  the  abdomen  as 
speedily  as  possible.  Almost  all  authors  recommend 
fomenting  the  displaced  parts,  previously  to  the  at- 
tempt at  reduction;  but  in  giving  this  advice,  they 
seem  to  forget,  that  while  time  is  lost  in  this  prepara- 
tory measure,  the  protruded  bowels  suffer  much  more 
liarm  from  exposure,  that  is  to  say,  from  the  very  cir- 
cumstance of  their  being  out  of  their  natural  situation, 
than  they  can  possibly  receive  good  from  any  applica- 
tion made  to  them.  No  kind  of  fomentation  can  be 
half  so  beneficial  as  the  natural  warmth  and  moisture 
of  the  cavity  of  the  abdomen.  In  order  to  facilitate 
the  return  of  a protruded  piece  of  intestine  or  omentum, 
the  abdominal  muscles  should  be  relaxed  by  placing 
the  patient  in  a suitable  posture,  and  the  large  intes- 
tines emptied  with  a clyster.  In  mentioning  the  last 
measure,  it  is  not  meant,  that  the  surgeon  should  de- 
lay the  attempt  to  reduce  the  part  until  the  clyster  has 
operated.  No,  this  means  is  only  enumerated  as  one 
that  may  become  serviceable  in  case  the  surgeon  can- 
not immediately  accomplish  the  object  in  view. — The 
mesentery  ought  always  to  be  reduced  before  the  intes- 
tine; the  intestine  before  the  omentum;  but  the  last 
protruded  portion  of  each  of  these  parts  ought  to  be 
the  first  reduced. 

It  is  only  when  the  intestine  and  omentum  are  free 
from  gangrene  and  mortification,  that  they  are  inva- 
riably to  be  returned  into  the  cavity  of  the  belly  with- 
out hesitation.  Also,  when  the  protruded  parts  are 
covered  with  sand,  dust,  or  other  extraneous  matter, 
they  should  be  tenderly  washed  with  a little  tepid 
water. 

For  the  reduction  of  the  parts,  the  fore-fingers  are 
the  most  convenient,  and  it  is  a rule  to  keep  the  por- 
tion first  returned  from  protruding  again  by  one  finger, 
tmtil  it  has  been  followed  by  another  portion  introduced 
by  the  other  finger.  The  second  piece  is  to  be  kept  up 
in  the  same  way  by  the  finger  used  to.  return  it ; and 
so  on,  till  the  displaced  parts  have  all  been  put  into 
their  natural  situation. 

In  attempting  to  reduce  a piece  of  protruded  intes- 
tine, the  patient  should  be  placed  in  the  most  favour- 
able posture ; the  head  and  chest  should  be  elevated, 
and  the  pelvis  raised  with  pillows.  Nothing  can  be 
more  absurd  than  the  advice  to  put  the  thorax  rather 
lower  than  the  pelvis,  in  order  that  the  weight  of  the 
viscera  may  tend  to  draw  inwards  the  protruded  parts. 
This  is  another  erroneous  idea,  arising  from  the  ridi- 
culous supposition,  that  a great  part  of  the  abdomen  is 
actually  an  empty  cavity.  The  relaxation  of  the  ab- 
dominal muscles  is  a much  more  rational  and  useful 
object.  Wtien  this  is  properly  attended  to,  the  above 
directions  are  observed,  and  the  wound  is  not  exceed- 
ingly small,  in  relation  to  the  bulk  of  the  protruded 
viscera,  the  parts  may  generally  be  reduced.  But  in 
addition  to  what  has  been  already  stated,  it  is  neces- 
sary to  remark,  that  the  pressure  should  be  made  in  a 
straight  direction  into  the  abdomen ; for  when  made 
obliquely  towards  the  edges  of  the  w.ound,  the  parts 
are  liable  to  suffer  contusion  without  being  reduced, 
and  even  to  glide  between  the  layers  of  the  abdominal 
muscles,  and  become  strangulated.  When  the  wound 
is  in  the  front  of  the  abdomen,  pressure  made  in  this 
unskilful  way  may  force  the  viscera  into  the  sheath  of 
the  rectus  muscle,  and  cause  the  same  perilous  symp- 
toms as  arise  from  an  incarcerated  hernia.— (See  Her- 
nia.) 

When  the  reduction  seems  complete,  the  surgeon 
should  assure  himself  of  it,  by  introducing  his  finger 
into  the  cavity  of  the  abdomen,  so  as  to  feel  that  the 
parts  are  all  actually  reduced,  and  suffer  no  constriction 
between  the  edges  of  the  wound  and  the  viscera  in  the 
abdomen. 

A difficulty  of  reduction  may  arise  from  the  pro- 
truded intestines  being  distended  with  feces  or  air.  In 
this  circumstance,  the  contents  of  the  gut  may  fre- 
quently be  fnade  to  pass  by  degrees  into  that  portioi! 


of  the  intestinal  canal  which  is  within  the  abdomen. 
In  order  to  accomplish  this  purpose,  the  surgeon  must 
press  the  contents  of  the  bowel  towards  the  wound, 
and  if  he  succeeds,  in  emptying  the  part,  he  will  com- 
monly experience  equal  success  in  his  next  attemp*  *o 
replace  it  in  the  abdomen. 

Sometimes,  in  cases  of  narrow  stabs,  considerable 
pieces  of  intestine  protrude,  and  cannot  be  reduced 
without  doing  imprudent  violence  to  the  bowel.  Under 
these  circumstances,  the  dilatation  of  the  wound  is  in- 
dispensable. However,  when  the  reduction  seems  al- 
most a matter  of  impossibility,  on  account  of  the 
smallness  of  the  wound,  if  the  surgeon  be  careful  to 
relax  the  abdominal  muscles,  draw  a little  more  intes- 
tine out  of  the  wound,  and  gently  press  the  contents  of 
the  bowel  through  the  constriction  in  the  abdomen,  he 
will  frequently  succeed  in  reducing  the  parts  without 
using  the  knife. 

When  such  operation  is  unavoidable,  the  dilatation 
should  be  made  in  a direction  which  will  not  endanger 
ihe  epigastric  artery,  and,  if  possible,  in  the  same  line 
as  the  muscular  fibres. 

We  are  also  advised  to  make  the  incision  upwards 
rather  than  downwards,  when  it  can  be  done  with 
equal  convenience,  because  it  is  supposed  the  first  di- 
rection will  be  followed  by  less  danger  of  hernia. — 
{Sabatier,  M^decine  Operatoire,  t.  1,  p.  220,  ed.  2.  Cal- 
lisen,  Syst.  Chir.  Hod.  t.  1,  p.  705.)  If,  however,  the 
upper  angle  of  the  wound  correspond  to  the  direction 
of  the  suspensory  ligament  of  the  liver,  writers  advise 
making  the  dilatation  at  the  lower  angle,  in  order  to 
incur  no  risk  of  hemorrhage  from  the  umbilical  vein. 
In  the  adult  this  vessel  is  generally  obliterated,  and 
turned  into  a ligamentous  substance;  though  it  would 
appear  that,  in  a few  instances,  it  remains  pervious  to 
the  navel.  Hildanus  saw  a young  man  die  instantly  in 
consequence  of  a stab  in  the  belly  between  the  false 
ribs  and  the  umbilicus,  and  on  opening  the  body,  he 
found  blood  effused  from  a wound  of  the  umbilical  vein. 
It  has  been  feared  also,  that  cutting  the  suspensory 
ligament  of  the  liver  might  give  rise  to  such  a displace- 
ment of  that  viscus  as  would  interrupt  the  freedom  of 
respiration,  or  obstruct  the  circulation  of  the  blood  in 
the  vena  cava.  But  the  apprehension  is  unfounded ; 
for  Riolan  found  this  ligament  ruptured  and  retracted 
towards  the  liver  in  a nimble  ADthiopian  female  dancer, 
whose  respiration  had  not  suffered  any  particular  dis- 
turbance during  her  lifetime. — {Sabatier,  Med.  Opera- 
toire,  t.  1,  p.  220,  221,  ed.  2.) 

The  incision  should  never  be  larger  than  absolutely 
requisite,  as  hernia  is  much  disposed  to  occur. wherever 
the  peritoneum  has  been  divided.  The  operation  may 
be  done  with  a curved  bistoury  and  a director,  much 
in  the  same  way  as  is  done  in  cases  of  strangulated 
ruptures. — (See  Hernia.) 

After  the  battle  of  Waterloo  many  cases  presented 
themselves  in  which  the  bov/els  and  omentum  pro- 
truded, and  in  several  of  these  examples  the  reduction 
could  not  be  effected  before  the  wounds  had  been  en- 
larged. So  tightly  also  were  the  parts  girt,  that  the 
operation  was  sometimes  far  from  being  easy. 

Instead  of  enlarging  wounds  of  the  abdomen,  it  has 
been  proposed  to  let  out  the  air  from  the  protruded  in- 
testines, by  making  small  punctures  with  a needle,  so 
as  to  lessen  their  volume  sufficiently  to  make  them  re- 
ducible. The  suggestion  first  originated  with  Pare, 
who  declares,  that  he  had  practised  the  method  with 
success.  Rousset,  his  contemporary,  also  informs  us, 
that  the  plan  was  adopted  by  another  surgeon,  in  an  in- 
stance where  the  epigastric  region  was  wounded,  and 
a large  portion  of  the  intestines  protruded  in  a strangu- 
lated state.  Peter  Lowe,  an  English  surgeon,  likewise 
assures  us,  that  he  frequently  adopted  the  practice 
when  other  means  failed.  Garengeot,  Sharp,  and 
Van  Swieten  are  all  advocates  for  Part’s  proposal; 
but  they  recommend  Ihe  employment  of  a round  nee- 
dle, which  will  merely  separate  the  fibres  of  the  intes- 
tinal canal  without  cutting  them,  as  a fiat,  triangular, 
sharp-edged  needle  would  unavoidably  do.  These 
last  writers,  however,  only  sanction  the  practice  when 
the  q\iantity  of  protruded  intestine  is  great,  and  the 
bowel  is  so  enormously  distended  with  air,  that  it 
would  be  impossible  to  reduce  the  part,  though  the 
wound  were  enlarged,  and  every  thing  else  put  in 
practice  likely  to  bring  about  the  reduction.  But,  as 
Sabatier  remarks,  the  puirctures  must  be  entirely  use- 
less, if  made  with  a fine  needle,  since  they  wili  be  iin- 


494 


WOUNDS. 


mediately  stopped  up  with  mucous  secretion,  with 
which  the  bowel  is  constantly  covered ; and  if  the 
punctures  are  made  with  a broad  triangular  needle, 
or  a very  large  round  one,  as  Desault  and  Chopart  ad- 
vise, they  must  be  highly  dangerous,  inasmuch  as  they 
are  likely  to  give  rise  to  inflammation,  and  even  to 
extravasation  within  the  abdomen. — (M^decine  Ope- 
ratoire,  t.  l,p.  10.) 

That  small  punctures  In  the  bowel  would  not  an- 
sw'er  the  purpose,  but  be  obstructed  by  the  villous  or 
mucous  coat,  is  a fact  which  has  been  for  a long  time 
well  known  to  surgeons.  Callisen,  among  others, 
has  particularly  noticed  it:  “ acu  puncturae  enim  flati- 
bus  exitum  parare  nequeunt,  siquidem  tunica  villosa 
foraminula  obstrait,”  &.c. — (Syst.  Chir.  Hod.  t.  2,  p. 
704.) 

It  was  the  circumstance  of  small  punctures  being 
unavailing,  that  led  Desault  and  Chopart  to  recommend 
the  use  of  a large  round  needle,  “ pour  que  I'ouver- 
ture  ne  soil  point  bouchie  par  les  mucositis  dont  les 
intestins  sont  enduits."  But  they  were  also  aware  of 
the  danger  of  employing  such  an  instrument,  since  they 
give  us  directions  how  to  proceed,  in  order  to  prevent 
extravasation  and  inflammation;  “ On  privitndra 
V ipanchement  des  matiires  star  cor  ales  enpassant,  avant 
de  riduire  I'intestin^  une  anse  de  Jil  dans  la  portion  de 
mesentire  qui  repond  d la  piqure  pour  la  fixer  contre 
les  bords  de  la  plaie  exterieure,  et  Von  comkattra  par 
les  remedes  generaux  Vinflammation  que  cet  piqure 
peut  attirer." — {Traitd  des  Maladies  Chirurg.  t.  2,  p. 
135.)  Ricberand  is  still  an  advocate  for  puncturing 
the  bowel,  for  which  operation  he  boldly  recommends 
a small  hydrocele  trocar. — {Mosogr.  Clin.  t.  3,  p.  336, 
ed.  4.) 

Mr.  Travers,  one  of  the  latest  and  best  writers  upon 
this  subject,  most  properly  joins  in  the  condemnation 
of  the  plan  of  pricking  ine  protruded  bowels.  “Blan- 
card  and  others  protested  against  this  practice,  on  the 
very  sulficient  ground  of  its  inefficacy.  La  Faye  very 
truly  says,  it  is  a useless  as  well  as  dangerous  practice ; 
for  the  opening  made  by  a round  needle  cannot  give 
issue  to  the  contained  air.^’  Mr.  Travers  then  cites 
two  cases,  showing  that  even  small  stabs  in  a bowel 
will  not  prevent  its  becoming  distended  with  air. 

“A  man  was  brought  to  St.  Thomas’s  Hospital  on 
Saturday,  the  30th  of  June  last  (1311),  who  had  been 
stabbed  in  the  direction  of  the  epigastric  artery,  on  the 
left  side  of  the  abdomen,  by  a case-knife.  He  died  in 
eighteen  hours,  apparently  from  the  sudden  and  copious 
hemorrhage  which  had  taken  place  within  the  belly. 
About  half  a yard  of  ileon  was  protruded.  The  gut 
was  highly  discoloured,  and  so  much  distended,  not- 
withstanding it  was  pierced  in  three  places,  that  the 
wound  of  the  integuments  required  to  be  freely  dilated 
before  it  could  be  returned.  The  apertures  were^  in 
fact.,  obliterated  by  the  mucous  coat." 

“ It  appeared  upon  the  trial  of  Captain  Sutherland 
(Ann.  Reg.  June,  1809)  for  the  murder  of  his  cabin- 
boy,  that  the  intestines  had  been  extensively  protruded 
through  a wound  near  the  left  groin,  and  had  lain 
exposed  for  four  or  five  hours ; that  the  dirk  had 
pierced  through  one  fold  of  intestine,  and  entered 
another  ; that  the  wound  of  intestine  was  half  an  inch 
long ; that  the  reduction  could  not  be  accomplished 
until  the  parietal  wound  was  dilated;  aiTd  that  the 
intestine  was  then  returned,  and  the  integuments 
sewed  up.” — {^Travers,  On  Injuries  of  the  Intestines, 
p.  174.  176.) 

With  respect  to  this  last  case,  however,  I must  ob- 
serve, that  it  does  not  satisfactorily  prove  what  the 
author  intends,  namely,  that  the  bowel  was  distended 
with  air,  though  there  was  a wound  in  it  half  an  inch 
long ; for  the  evidence  does  not  inform  us  that  the 
difficulty  of  reduction  was  owing  to  this  cause.  1 have 
seen  a very  small  portion  of  omentum  protrude  through 
a wound,  and  bafile  all  endeavours  to  reduce  it  for 
nearly  an  hour.  The  first  case  adduced  by  Mr.  Tra- 
vers, however,  is  more  explicit  and  interesting;  and 
we  are  to  infer  from  it,  and  the  observations  of  Haller, 
Callisen,  &c.,  that  the  punctures  made  in  an  intestine 
are  not  closed  by  mucus,  as  Sabatier  and  Desault 
have  a.sserted,  but  by  the  mucous  coat  itself. 

As  the  above  expedient  has  been  recommended  by 
writers  of  some  weight,  I thought  that  the  subject 
should  not  be  passed  over  in  silence,  and  without  a 
caution  to  the  reader  never  to  put  any  confidence  in 
the  method.  The  plan  does  not  facilitate  the  business 


of  the  operator  ; there  is  not  even  tliis  solitary  reason 
in  favour  of  the  practice ; and  though  it  may  have  an- 
swered when  large  needles  were  used,  and  some 
patients  so  treated  may  have  recovered,  every  person 
who  has  the  least  knowledge  of  the  animal  economy 
will  easily  comprehend  how  even  the  smallest  opening, 
made  in  parts  so  irritable  and  prone  to  inflammation 
as  the  bowels,  must  be  attended  with  greater  danger 
than  would  result  from  enlarging  a wound  of  the  skin 
and  muscles.  Besides,  the  air  may  frequently  be 
pressed  out  of  the  intestine  in  a safer  way,  as  I have 
already  described. 

A wound  of  the  abdomen,  attended  with  one  of  the 
most  considerable  protrusions  of  the  viscera  that  I 
have  ever  read  of,  is  recorded  by  Mr.  Hague,  surgeon 
at  Ripon : — “ August  30th,  1808  (says  this  gentleman), 
I went  to  Norton  Mills,  about  four  miles  from  hence, 
to  see  John  Brown,  aet.  12  years,  who  had  received  a 
w'ound  in  the  abdomen  from  a pair  of  wool-shears. 
On  my  arrival,  which  was  little  more  than  an  hour 
after  the  accident,  I found  the  poor  lad  in  a very  dis- 
tressing situation ; the  great  arch  of  the  stomacli,  and- 
the  whole  of  the  intestinal  canal  (duodenum  excepted) 
contained  within  the  abdomen,  having  protruded 
through  the  wound.  The  incision  was  on  the  left  side 
of  the  body,  commencing  at  about  two  inches  below 
the  scrobiculis  cordis,  and  extending  in  a straight  line 
near  four  inches  in  length,  distant  from  the  navel  two 
inches,  and  he  w’as  quite  sensible,  and  had  vomited  so 
as  to  empty  the  stomach.  Very  little  blood  was  lost. 
I immediately  proceeded  very  carefully  to  examine 
the  protruded  viscera,  none  of  which  were  wounded, 
and  reduced  them  as  quickly  as  possible,  beginning 
with  the  stomach,  and  following  the  regular  course  of 
the  intestines;  in  the  latter  portion  of  which  I dis- 
tinctly felt  feces  of  rather  firm  consistence.  He  com- 
plained of  some  pain  during  the  reduction,  though  not 
much,  and  expressed  great  relief  when  the  parts  w’ere 
completely  returned.  I now  desired  an  assistant  to 
lay  the  palm  of  his  hand  over  the  wound,  and  make 
some  pressure  upon  it;  for  I found  that  without  this 
the  parts  would  soon  have  protruded  again  by  the 
action  of  respiration,  which  was  oppressed  and  la- 
borious. I brought  the  sides  of  the  wound  together  by 
five  sutures,  beginning  from  above  downwards,  and 
passed  the  needle  on  each  side,  quite  through  the  inte- 
guments with  the  peritoneum,  &c.  The  wound  was 
also  dressed  with  adhesive  plaster,  and  covered  with  a 
bandage.” — (Vide  Edinburgh  Medical  and  Surgical 
Journal,  vol.  5,  p.  129,  iS'C.) 

This  case  is  interesting;  for  notwithstanding  so  un- 
limited a protrusion  of  the  viscera,  and  the  circumstance 
of  the  parts  being  left  unreduced  for  more  than  an 
hour,  a recovery  ensued,  under  the  judicious  employ- 
ment of  bleeding,  purging,  anodynes,  &c. 

In  La  Caserne  de  St.  Elizabeth,  at  Brussels,  after 
the  battle  of  Waterloo,  the  number  of  protrusions  of 
the  viscera  which  fell  under  my  notice  was  much 
more  considerable  than  w hat  I previously  had  any 
idea  of  ever  meeting  with.  I well  remember,  in  my 
own  part  of  the  hospital,  two  protrusions  of  a large 
portion  of  the  stomach,  three  of  the  bladder,  and  ten 
or  twelve  of  the  mesentery,  omentum,  or  intestines. 

Whether  a suture  should  be  used  when  the  protruded 
intestine  is  w’ounded,  is  a subject  which  will  ^ noticed 
in  considering  wounds  of  the  intestines. 

Some  of  the  exposed  intestine  may  have  mortified 
before  the  arrival  of  surgical  assistance.  In  cases  of 
wounds,  this  event  is  rare ; but  in  those  of  strangulated 
hernite,  it  is  not  uncommon.  The  treatment  is  ex- 
plained in  the  article  Hernia. 

When  the  protruded  intestine  is  in  a state  of  inflam- 
mation, its  immediate  reduction  is,  beyond  all  dispute, 
the  means  most  likely  to  set  every  thing  right.  Even 
when  the  inflammation  is  considerable,  the  timely 
reduction  of  the  displaced  part,  and  the  employment  of 
antiphlogistic  means,  will  often  prevent  gangrenous 
mischief.  The  dull,  brown,  dark-red  colour  of  the 
intestine  may  induce  the  practitioner  to  suppose,  either 
that  the  part  is  already  mortified,  or  must  inevitably 
become  so ; and  consequently,  he  may  delay  returning 
it  into  its  natural  situation.  But  notwithstanding  this 
suspicious  colour  of  the  intestine,  its  firmness  will 
evince  that  it  is  not  in  a state  of  gangrene.  The  ulti- 
mate recovery  of  a portion  of  intestine  so  circum- 
stanced is  always  a matter  of  uncertainty ; but  the 
propriety  of  speedily  replacing  the  part  in  its  natural 


WOUNDS. 


495 


situation  is  a thing  most  certain.  “ Partes  egressae 
sanse  (observes  Callisen)  citissime  sunt  repoiiend®, 
neque  obstat  mutatio  coloris  nativi  in  rubruni  subfus- 
cum.” — (Syst.  Chir.  Hod.  t.  1,  p.  703,  edit.  1798.)  In 
case  the  bowel  mortify  after  its  reduction,  all  hopes  of 
the  preservation  of  life  are  not  to  be  abandoned ; as  I 
have  noticed  in  the  articles  ./2wms,  artificial,  and  Hernia, 
in  which  last  part  of  the  book,  many  things  necessary 
to  be  known  concerning  the  mode  of  reducing  protruded 
omentum  will  also  be  found. 

When  a piece  of  intestine  cannot  be  reduced,  granu- 
lations and  new  skin  sometimes  grow  over  it,  and  a 
cure  follows,  as  the  experience  of  Callisen  confirms. — 
( Op.  cit.  p.  706.) 

The  protruded  viscera  having  been  reduced,  the 
next  object  is  to  retain  them  in  the  abdomen  until  the 
wound  is  completely  healed.  When  the  wound  is 
small,  this  is  a matter  of  no  difficulty:  for  it  is  enough 
to  put  the  patient  in  a position  which  will  relax  the 
fibres  of  the  wounded  muscles,  while  the  edges  of  the 
wound  are  maintained  in  contact  with  sticking  plaster, 
anti  supported  by  a compress  and  bandage.  Costive- 
ness is  to  be  removed  by  the  mildest  purgatives,  such 
as  the  oleum  ricini,  or  by  laxative  clysters,  which  are 
still  preferable.  But  in  cases  of  extensive  wounds, 
even  when  the  treatment  is  conducted  with  all  possible 
judgment,  it  is  occasionally  difficult,  and  even  impos- 
sible, to  hinder  the  protrusion  of  the  bowels  by  common 
dressings  and  a bandage.  In  this  circumstance,  the 
edges  of  the  wound  must  be  sewed  together. — (See 
G astro-raphe.)  In  modern  times,  however,  sutures 
are  much  more  seldom  employed  than  formerly;  and 
in  the  above  article,  some  remarks  are  offered,  proving 
that  the  generality  of  wounds  of  the  abdomen  do  not 
require  the  practice. 

When  the  omentum  protrudes,  and  is  strangulated 
by  the  narrowness  of  the  opening,  it  soon  contracts 
adhesions  to  it,  unless  speedily  reduced.  Should  such 
connexion  be  already  formed  when  the  surgeon  is  first 
consulted,  we  are  advised  to  cut  off  the  portion  which 
exceeds  the  level  of  the  integuments,  and  to  leave  the 
rest  in  the  wound.  The  latter  will  block  up  the  open- 
ing, and  have  the  good  effect  of  preventing  hernia.— 
(Richerand,  JSTosogr.  Chir.  t.  3,  p.  339,  edit.  4.)  When 
the  protruded  omentum  is  sound  and  free  from  adhe- 
sions, it  ought  to  be  reduced  without  delay.  But  when 
the  protrusion  m large,  and  there  is  reason  to  fear, 
from  the  vomiting  and  the  pains  shooting  from  the 
wound  to  the  epigastric  region,  that  the  stomach  is 
dragged,  the  displaced  part  must  be  made  free,  and,  if 
sound,  reduced.  Should  it  be  in  a mortified  state,  the 
dead  part  must  be  previously  cut  away,  and  any  ves- 
sels which  bleed  tied  separately  with  a piece  of  fine 
thread  or  silk,  both  ends  of  which  may  either  be  cut  off 
close  to  the  knot,  and  the  part  then  reduced ; or  one 
end  of  the  silk  may  be  left  out  of  the  wound,  and  the 
other  cut  away.  Practitioners  who  apprehend  ill  effects 
from  leaving  within  the  abdomen  so  small  a particle  of 
extraneous  matter  as  the  little  knot  of  fine  thread,  will 
prefer  the  last  method,  and  withdraw  the  ligature  alto- 
gether as  soon  as  it  becomes  loose. 

Extravasation  in  the  Abdomen. — Wounds  of  the 
abdomen  may  be  complicated  with  extravasations  of 
blood,  chyle,  excrement,  bile,  or  urine.  None  of  these 
complications,  however,  are  half  so  frequent  as  an 
inexperienced  practitioner  would  apprehend.  The  em- 
ployment of  the  phrase  cavity  of  the  abdomen  has 
paved  the  way  to  much  erroneous  supposition  upon 
this  subject,  and  has  induced  many  absurd  notions, 
which  even  the  sensible  observations  long  ago  published 
by  J.  L.  Petit  have  scarcely  yet  dispelled. 

As  a modern  writer  has  observed,  “There  is  not 
truly  any  cavity  in  the  human  body,  but  all  the  hollow 
bowels  are  filled  with  their  contents,  all  the  cavities 
filled  with  their  hollow  bowels,  and  the  whole  is 
equally  and  fairly  pressed.  Thus,  in  the  abdomen,  all 
the  viscera  are  moved  by  the  diaphragm  and  the  abdo- 
minal muscles  upwards  and  downwards,  with  an  equa- 
ble continual  pressure,  which  has  no  interval ; and 
one  would  be  apt  to  add,  the  intestines  have  no  repose, 
being  kept  thus  in  continual  motion ; but  though  the 
action  of  the  diaphragm  and  the  reaction  of  the  abdo- 
minal muscles  are  alternate,  the  pressure  is  continual ; 
the  motion  which  it  produces  is  like  that  which  the 
bowels  have  when  we  move  forwards  in  w«alking, 
liaving  a motion  with  respect  to  space,  but  none  with 
regard  to  each  other,  or  to  the  part  of  the  belly  which 


covers  them.  The  whole  mass  of  the  bowels  is  alter- 
nately pressed,  to  use  a coarse  illustration,  as  if  between 
two  broad  boards,  which  keep  each  turn  of  intestine  in 
its  right  place,  while  the  whole  mass  is  regularly 
moved.  When  thebowels  are  forced  down  by  the  dia- 
phragm, the  abdominal  muscles  recede;  when  the 
bowels  are  pushed  back  again,  it  is  the  reaction  of  the 
abdominal  muscles  that  forces  them  back  and  follows 
them.  There  is  never  an  instant  of  interruption  of  this 
pressure  ; never  a moment  in  which  the  bowels  do  not 
press  against  the  peritoneum ; nor  is  there  the  smallest 
reason  to  doubt  that  the  same  points  in  each  are  con- 
tinually opposed.  We  see  that  the  intestines  do  not 
move,  or,  at  least,  do  not  need  to  move,  in  performing 
their  functions  ; for  in  hernia,  where  large  turns  of  in- 
testines are  cut  off  by  gangrene,  the  remaining  part  of 
the  same  intestines  is  closely  fixed  to  the  groin,  and  yet 
the  bowels  are  easy  and  their  functions  regular.  We 
find  the  bowels  regular,  when  they  lie  out  of  the  belly 
in  hernia,  as  when  a certain  turn  of  intestine  lies  in 
the  scrotum,  or  thigh,  or  in  a hernia  of  the  navel ; and 
where  yet  they  are  so  absolutely  fixed,  that  the  piece 
of  intestine  is  marked  by  the  straightness  of  the  rings. 
We  find  a person,  after  a wound  of  the  intestine, 
having  free  stools  for  many  days  ; and  what  is  it  that 
prevents  the  feces  from  escaping,  but  merely  this  regu- 
lar and  universal  pressure!  We  find  a person,  on  the 
fourth  or  fifth  day,  with  feces  coming  from  the  wound ! 
a proof,  surely,  that  the  wound  of  the  intestine  is  still 
opposite,  or  neatly  opposite,  to  the  external  wound. 
We  find  the  same  patient  recovering  without  one  bad 
sign.'  What  better  proof  than  this  could  we  desire, 
that  none  of  the  feces  have  exuded  into  the  abdo- 
men? 

If,  in  a wound  of  the  stomach,  the  food  could  get 
easily  out  by  that  wound,  the  stomach  would  unload 
itself  that  way,  there  would  be  no  vomiting,  the  patient 
must  die ; but  so  regular  and  continual  is  this  pressure, 
that  the  instant  a man  is  wounded  in  the  stomach  he 
vomits ; he  continues  vomiting  for  many  days,  while 
not  one  particle  escapes  into  the  cavity  of  the  abdomen. 
The  outward  wound  is  commonly  opposite  to  that  of 
the  stomach,  and,  by  that  passage,  some  part  of  the 
food  comes  out ; but  when  any  accident  removes  the 
inward  wound  of  the  stomach  from  the  outward 
wound,  the  abdominal  muscles  press  upon  the  stomach, 
and  follow  it  so  closely,  that  if  there  be  not  a mere 
laceration  extremely  wide,  this  pressure  closes  the  hole, 
keeps  the  food  in,  enables  the  patient  to  vomit,  and  not 
a particle  even  of  jellies  or  soups  is  ever  lost,  or  goes 
out  into  the  cavity  of  the  belly. 

How  (proceeds  Mr.  J.  Bell),  without  this  universal 
and  continual  pressure,  could  the  viscera  be  supported  ? 
Could  its  ligaments,  as  we  call  them,  support  the 
weight  of  the  liver  ? Or  what  could  support  the  weight 
of  the  stomach  when  filled?  Could  the  mesentery  or 
omentum  support  the  intestines ; or  could  its  own  liga- 
ments, as  we  still  name  them,  support  the  womb? 
How,  without  this  uniform  pressure,  could  these  vis- 
cera fail  to  give  way  and  burst?  How  could  the  cir- 
culation of  the  abdomen  go  on  ? How  could  the  liver 
and  spleen,  so  turgid  as  they  are  with  blood,  fail  to 
burst  ? Or  what  possibly  could  support  the  loose  veins 
and  arteries  of  the  abdomen,  since  many  of  them,  e.  g. 
the  splenic  vein,  is  (are)  two  feet  in  length,  is  (are)  of 
the  diameter  of  the  thumb,  and  has  (have)  no  other 
than  the  common  pellucid  and  delicate  coats  of  the 
veins?  How  could  the  viscera  of  the  abdomen  bear 
shocks  and  falls,  if  not  supported  by  the  universal 
pressure  of  surrounding  parts  ? In  short,  the  accident 
of  hernia  being  forced  out  by  any  blow  upon  the  belly, 
or  by  any  sudden  strain,  explains  to  us  how  perfectly 
full  the  abdomen  is,  and  how  ill  it  is  able  to  bear  any 
pressure,  even  from  its  own  muscles,  without  some 
point  yielding,  and  some  one  of  its  bowels  being  thrown 
out.  And  the  sickness  and  faintness  which  imme- 
diately follow  the  drawing  off  of  the  waters  of  a 
dropsy,  explain  to  us  what  are  the  consequences  of 
such  pressure  being  even  for  a moment  relaxed.  But, 
perhaps,  one  of  the  strongest  proofs  is  this,  that  the 
principle  must  be  acknowledged,  in  order  to  explain 
what  happens  daily  in  wounds ; for  though  in  theory 
we  should  be  inclined  to  make  this  distinction,  that  the 
hernia  or  abscess  of  the  inte.stines  will  adhere  and  be 
safe,  but  that  wounded  intestines,  not  having  time  to 
adhere,  will  become  flaccid,  as  we  see  them  do  in  dis- 
sections, and  so,  falling  away  from  the  external  wound, 


496 


WOUNDS. 


will  pour  out  their  feces  into  the  abdomen  and  prove 
fatal;  though  we  should  settle  this  as  a fair  and  good 
distinction  in  the  theory,  we  find  that  it  will  never  an- 
swer in  practice.  Soldiers  recover  daily  from  the  most 
desperate  wounds;  and  the  most  likely  reasons  that 
we  can  assign  for  it  are  the  fulness  of  the  abdomen; 
the  universal,  equable,  and  gentle  pressure;  and  the 
active  disposition  of  the  peritoneum,  ready  to  inflame 
with  the  slightest  touch.  The  wounded  intestine  is,  by 
the  universal  pressure,  kept  close  to  the  external 
wound,  and  the  peritoneum  and  the  intestine  are 
erjually  inclined  to  adhere.  In  a few  hours  that  ad- 
hesion is  begun,  which  is  to  save  the  patient’s  life,  and 
the  lips  of  the  wounded  intestine  are  glued  to  the  lips 
of  the  external  wound.  Thus  is  the  side  of  the  intes- 
tine united  to  the  inner  surface  of  the  abdomen;  and, 
though  the  gut  casts  out  its  feces  while  the  wound  is 
open  ; though  it  often  casts  them  out  more  freely  while 
the  first  inflammation  Icists;  yet  the  feces  resume  their 
regular  course  whenever  the  wound  is  disposed  to 
close.” — {John  Bell's  Discourses  on  Wounds,  p.  323. 
327,  ed.  3.) 

The  foregoing  extract,  though  drawn  up  in  a careless 
style,  contains  such  observations  as  are  well  calculated 
to  make  the  reader  understand,  that  the  abdomen  is  in 
reality  not  a cavity,  but  a compact  mass  of  containing 
and  contained  parts;  that  the  close  manner  in  which 
the  various  surfaces  are  constantly  in  contact  most 
powerfully  opposes  extravasations;  and  that,  in  fact,  it 
often  entirely  prevents  them.  The  passage  cited  im- 
presses us  with  the  utility  of  that  quick  propensity  to 
the  adhesive  inflammation  which  prevails  throughout 
every  peritoneal  surface,  and  which  not  only  often  has 
the  efiect  of  permanently  hindering  effusion  of  the  con- 
tents of  the  viscera,  by  agglutinating  the  parts  together, 
but  which,  even  when  an  extravasation  has  happened, 
beneficially  confines  the  eifused  blood  in  one  mass,  and 
surrounds  it  with  such  adhesions  of  the  parts  to  each 
other  as  are  rapid  in  their  formation  and  effectual  for 
the  purposes  of  limiting  the  extent  of  the  effusion,  and 
preventing  the  irritation  of  the  extravasated  matter 
from  affecting  the  rest  of  the  abdomen. 

It  is  to  Petit  that  surgeons  are  indebted  for  more  cor- 
rect modes  of  thinking  upon  the  foregoing  subject;  and 
it  is  with  great  pleasure  that  I here  refer  to  his  valua- 
ble observations. — (See  jMim.  de  VAcad.  de  Chir.) 

But  notwithstanding  the  reciprocal  pressure  of  the 
containing  and  contained  parts  against  each  other,  and 
the  useful  effect  of  the  quickly-arising  adhesive  in- 
flammation, in  all  penetrating  wounds  of  the  belly, 
complicated  with  injuries  of  the  viscera,  we  are  not  to 
suppose,  that  extravasation  never  happens ; but  only 
that  it  is  much  less  frequent  than  has  been  commonly 
supposed.  Mr.  Travers,  with  much  laudable  industry, 
has  endeavoured  to  trace,  more  minutely  than  any  pre- 
ceding writer,  the  particular  circumstances  under 
which  effusions  in  the  abdomen  are  likely  or  unlikely 
to  happen.  “ It  being  admitted  (says  he)  that  there  are 
cases  in  which  effusion  does  take  place,  it  is  easy  to 
conceive  circumstances  which  must  considerably  in- 
fluence this  event.  If,  for  example,  the  stomach  and 
bowels  be  in  a state  of  emptiness,  the  nausea  which 
follows  the  injury  will  maintain  that  state.  If  the  ex- 
tent of  the  wound  be  considerable,  the  matter  will 
more  readily  pass  through  the  wound  than  along  the 
canal.  A wound  of  the  same  dimensions  in  the  small 
and  large  intestines  will  more  readily  evacuate  the 
former  than  the  latter,  because  it  bears  a larger  pro- 
portion to  the  caliber.  Incised  and  punctured  wounds 
admit  of  the  adhesion  of  the  cut  edges  or  the  eversion 
of  the  internal  coat  of  the  gut,  so  as  to  be  in  many 
instances  actually  obliterated ; whereas,  lacerated  or 
ulcerated  openings  do  not  admit  of  these  salutary  pro- 
cesses. Again,  in  a transverse  section  of  the  bowel, 
contraction  of  the  circular  fibre  closes  the  wound; 
whereas,  in  a longitudinal  section,  the  contraction  of 
this  fibre  enlarges  it.  Such  (says  Mr.  Travers)  are  the 
circumstances  which  combined,  in  a greater  or  less  de- 
gree, increase  or  diminish  the  tendency  to  effusion.” — 
(On  Injuries  of  Intestines,  (S-c.  p.  13,  14.) 

After  the  details  of  some  experiments  and  cases,  the 
preceding  author  makes,  among  other  conclusions,  the 
following: 

1.  That  eff’usion  is  not  an  ordinary  consequence  of 
penetrating  wounds. 

2.  That  if  tlie  gut  be  full  and  the  wound  extensive, 
the  surrounding  pressure  is  overcome  by  the  natural 


action  of  the  bowel  tending  to  the  expulsion  of  it# 
contents. 

3.  That  if  food  has  not  recently  been  taken,  and  the 
wound  amounts  to  a division  of  the  gut,  or  nearly  so, 
the  eversion  and  contraction  of  the  orifice  of  the  tube 
prevent  eflfusion. 

4.  That  if  the  canal  be  empty  at  the  time  of  the 
wound,  no  subsequent  state  of  the  bowel  will  cause 
eff’usion,  because  the  supervening  inflammation  agglu- 
tinates the  surrounding  surfaces  and  forms  a circum- 
scribed sac;  nor  can  eff’usion  take  place  from  a bowel 
at  the  moment  full,  provided  it  retain  a certain  portion 
of  its  cylinder  entire,  the  wound  not  amounting  nearly 
to  a semi-division  of  the  tube,  for  then  the  eversion 
and  contraction  are  too  partial  to  prevent  an  extrava- 
sation. 

5.  That  when,  however,  air  has  escaped  from  the 
bowel,  or  blood  has  been  extravasated  in  quantity 
within  the  abdomen  at  the  time  of  the  injury,  the  re- 
sistance made  to  eff’usion  will  be  less  effectual,  although 
the  parietal  pressure  is  the  same,  as  such  fluids  will 
yield  more  readily  than  the  solids  naturally  in  contact. 
—(P.25,  26.  100.) 

6.  That  though  extravasation  is  not  common  in  pe- 
netrating wounds,  it  follows  more  generally  in  cases 
where  the  bowel  is  ruptured  by  blows  or  falls  upon  the 
belly,  while  the  integuments  continue  unwounded. — 
(P.  36.) 

7.  That  when  the  bowels  are  perforated  by  ulcera- 
tion, there  is  more  tendency  to  effusion  than  in  cases 
of  wounds.— (P.  38,  ire.) 

Mr.  Travers  attempts  to  explain  the  reason  of  the 
greater  tendency  to  effusion  in  cases  of  intestine  burst 
by  violence  than  in  those  of  ulceration,  “by  the 
diflTerence  in  the  nature  of  the  injury  which  the  bowel 
sustains  when  perforated  by  a sword  or  bullet,  as  in  one 
case,  or  burst  or  ulcerated,  in  the  other.  A rupture  by 
concussion  could  only  take  place  under  a distended 
state  of  the  bow'el,  a condition  most  favourable  to 
effusion,  and  from  the  te.xture  of  the  part,  a rupture 
so  produced  would  seldom  be  of  limited  extent.  The 
process  of  ulceration,  by  which  an  aperture  is  formed, 
commences  in  the  internal  coat  of  the  bowel,  which 
has  always  incurred  a more  extensive  lesion  than  the 
peritoneal  covering.  The  puncture  or  cut  is  merely  a 
solution  of  continuity  in  a point  or  line;  the  ulcerated 
wound  is  an  actual  loss  of  substance.  The  consequence 
Af  this  difference  is,  that  while  the  former,  if  small,  is 
glued  up  by  the  eff’usion  from  the  cut  vessels,  or,  if 
large,  is  nearly  obliterated  by  the  full  eversion  of  the 
villous  coat,  the  latter  is  a permanent  orifice.” — ( P.  46.) 

How  much  Mr.  Travers  and  Mr.  John  Bell  differ  in 
opinion  upon  these  latter  points,  will  appear  from  the 
following  passage:  after  adverting  to  the  adhesion, 
which  takes  place  between  the  viscera  and  the  perito- 
neum, under  a variety  of  circumstances  attending  dis- 
ease, Mr.  John  Bell  observes,  “ This  it  is  which  makes 
the  chief  difference,  in  point  of  danger,  between  an 
ulcerated  and  a wounded  intestine;  for,  in  a wound, 
there  is,  as  we  should  suppose,  no  time  for  adhesion, 
nothing  to  keep  the  parts  in  contact,  no  cause  by  which 
the  adhesion  might  be  produced.  But  in  an  ulcer 
there  is  a slow  disease,  tedious  inflammation,  adhesion 
first,  and  abscess  and  bursting  afterward;  sometimes  a 
fistula  remains  discharging  feces,  and  sometimes  there 
is  a perfect  cure.  If  a nut-shell,  a large  coin,  a bone, 
or  any  dangerous  thing  be  swallowed,  it  stops  in  the 
stomach,  causing  swelling  and  dreadful  pain : at  last  a 
hard,  firm  tumour  appears,  and  then  it  suppurates, 
bursts,  the  bowel  opens,  the  food  is  discharged  at  every 
meal,  till  the  fistula  gradually  lessens  and  heals  at  last. 
But  where  the  stomach  is  cut  with  a broad  wound  of 
a sabre,  the  blood  from  the  wounded  epiploic  vessels, 
or  the  food  itself,  too  often  pours  out  into  the  abdomen, 
and  the  patient  dies,  &c.” — (Discourses  on  Wounds,  p. 
321,  ed.  3.)  The  author  afterward  proceeds  to  explain 
how,  in  cases  of  penetrating  wounds,  the  compact 
state  of  the  containing  and  contained  parts,  and  the 
incessant  and  equable  pressure  which  the  viscera  sus- 
tain, frequently  hinder  effusion. 

Which  of  these  gentlemen  is  most  correct  I cannot 
presume  to  determine ; and  whether  Mr.  Travers’s 
cases  are  deviations  from  what  is  most  common,  can 
only  be  decided  by  a comparative  examination  of  a 
greater  numberof  facts.  When  the  intestines  ulcerate, 
and  thus  rid  themselves  of  foreign  bodies,  the  general 
tenor  of  the  cases  on  record  undoubtedly  affords  us 


WOUNDS. 


497 


little  reason  to  be  apprehensive  of  extravasation.  Yet, 
with  respect  to  ulceration  of  the  intestines  from  other 
causes,  circumstances  may  be  very  different.  And  it 
is  but  justice  to  state,  that  Mr.  Travers’s  opinions  have 
received  some  confirmation  from  an  interesting  case, 
published  by  Dr.  J.  Crampton,  of  Dublin.  It  is  an  in- 
stance of  rupture  of  the  stomach,  and  fatal  effusion  of 
its  contents  into  the  cavity  of  the  abdomen.  The  pa- 
tient was  a young  lady,  aged  29.  She  was  suddenly 
taken  ill  with  spasm  in  her  stomach,  and  other  severe 
symptoms,  and  died  in  about  twelve  hours.  “On 
opening  the  abdomen,  the  stomach  was  observed  to  be 
pale,  flaccid,  and  empty.  Its  contents,  among  which 
were  recognised  oatmeal  and  castor-oil,  had  escaped 
into  the  cavity  of  the  abdomen  through  a round  aper- 
ture situated  on  its  anterior  surface  at  the  union  of  the 
cardiac  and  pyloric  portions.  This  perforation  of  the 
stomach  was  perfectly  circular,  about  the  size  of  a pea, 
and  appeared  to  be  the  result  of  an  ulcer  on  the  mu- 
cous surface,  which  had  gradually  penetrated  the  other 
coats.  This  ulcer  was  hollow  and  circular,  nearly  the 
size  of  a shilling,  and  had  the  appearance  as  if  it  had 
been  made  with  caustic,  with  the  orifice  in  its  centre.” 
— (j7.  Crampton^  Med.  Chir,  Trans,  vol.  8,  p.  230.)  To 
the'  preceding,  Mr.  Travers  has  annexed  some  addi- 
tional facts:  one  is  an  example  of  a rapidly  fatal  effu- 
sion of  the  intestinal  contents  through  an  ulcerated 
opening  about  a finger’s  breadth  below  the  pylorus. 
The  foramen  had  a peritoneal  margin,  and  proved  to 
be  the  centre  of  an  irregular  superficial  ulcer  of  the 
mucous  coat.  Another  case  is  that  of  a similar  ulcera- 
tion of  the  small  intestines,  and  fatal  extravasation  of 
their  contents.  In  another  example,  a circular  aper- 
ture of  the  peritoneum,  large  enough  to  admit  a crow’s 
quill,  was  found  after  death  at  the  junction  of  the  duo- 
denum and  stomach.  It  also  was  the  centre  of  an 
ulcer  that  had  destroyed  the  villous  and  muscular  coats 
of  the  bowel  to  the  extent  of  half  an  inch.  For  many 
other  ingenious  observations,  I must  refer  the  reader  to 
Mr.  Travers’s  paper,  who  concludes  with  remarking, 
that  the  chief  diagnostic  symptoms  of  these  hopeless 
cases  appear  to  be : 

1.  Sudden,  most  acute,  and  unremitting  pain,  radi- 
ating from  the  scrobiculus  cordis  or  the  navel,  to  the 
circumference  of  the  trunk,  and  even  to  the  limbs.'  A 
peculiar  pain,  the  intensity  of  which,  like  that  of  par- 
turition, absorbs  the  whole  mind  of  the  patient,  who, 
within  an  hour  from  the  enjoyment  of  perfect  health, 
expresses  his  serious  and  decided  conviction,  that  if  the 
pain  be  not  speedily  alleviated  he  must  die. 

2.  Coeval  with  the  attack  of  pain,  remarkable  rigid- 
ity and  hardness  of  the  belly,  from  a fixed  and  spastic 
contraction  of  the  abdominal  muscles. 

3.  A natural  pulse  for  some  hours,  until  the  symp- 
toms are  merged  in  those  of  acute  peritonitis  and  its 
fatal  termination  in  the  adhesive  stage. — {Med.  Chir. 
Trans,  vol.  8,  p.  231,  et  seq.) 

Blood  is  more  frequently  extravasated  in  the  abdo- 
men than  any  other  fluid,  but  it  does  not  always  take 
place,  unless  the  wounded  vessels  be  above  a certain 
magnitude.  The  compact  state  of  the  abdominal  vis- 
cera in  regard  to  each  other  and  their  action  on  each 
other,  oppose  this  effect.  The  action  alluded  to,  which 
depends  on  the  abdominal  muscles  and  diaphragm,  is 
rendered  very  manifest  by  what  happens,  in  conse- 
quence of  operations  for  hernias,  attended  with  altera- 
tion of  the  intestines  or  omentum.  If  these  viscera 
burst  or  suppurate,  after  being  reduced,  the  matter 
which  escapes  from  them  or  the  pus  which  they  se- 
crete is  not  lost  in  the  abdomen;  but  is  propelled  to- 
wards the  wound  in  the  skin,  and  there  makes  its  exit. 
The  intestinal  matter  effused  from  a mortified  bowel 
has  been  known  to  remain  lodged  the  whole  interval, 
between  one  time  of  dressing  the  wound  and  another, 
in  consequence  of  the  surgeon  stopping  up  the  external 
wound  with  a large  tent.  When  the  above-mentioned 
action  or  pressure  of  the  muscles  is  not  sufficient  to 
keep  the  blood  from  making  its  escape  from  the  ves- 
sels, still  it  may  hinder  it  from  becoming  diffused 
among  the  convolutions  of  the  viscera,  and  thus  the 
extravasation  is  confined  in  one  mass.  The  blood  ef- 
fused and  accumulated  in  this  way,  is  commonly 
lodged  at  the  inferior  and  anterior  part  of  the  abdomen, 
above  the  lateral  part  of  the  pubes,  and  by  the  side  of 
one  of  the  recti  muscles.  Tho  weight  of  the  blood 
may  propel  it  into  this  situation,  or  perhaps  there  may 
be  less  resistance  in  this  direction  than  in  others.  In 

Vol.  II.-I  i 


opening  the  bodies  of  persons  who  have  died  with  such 
extravasations,  things  may  put  on  a difierent  aspect, 
and  the  blood  seem  to  be  promiscuously  extravasated 
over  every  part  of  the  abdomen.'  But  when  such  bo- 
dies are  examined'vvilh  care,  it  w'ill  be  found  that  the 
blood  does  not  insinuate  itself  among  the  viscera  till 
the  moment  when  the  abdomen  is  opened,  and  the 
mass  previously  lies  in  a kind  of  pouch.  This  pouch 
is  frequently  circumscribed  and  bounded  by  thick 
membranes,  especially  when  the  extravasation  has 
been  of  some  standing.— (SaJatrer,  M<^dccine  Opira~ 
toire,  t.  1,  p.  28 — 30.) 

Every  practical  surgeon  should  remember  well,  that 
all  the  abdominal  viscera  closely  touch  either  each 
other  or  the  inner  surface  of  the  peritoneum.  This  is 
one  grand  reasori  why  extravasations  are  seldom  ex- 
tensively diffused  ; but  commonly  lie  in  one  mass,  as 
Petit,  Sabatier,  and  all  the  best  moderns  have  noticed. 
The  pressure  of  the  elastic  bowels,  diaphragm,  and 
abdominal  muscles,  not  only  frequently  presents  an  ob- 
stacle to  the  difl'usion  of  extravasated  matter,  but  often 
serves  to  propel  it  towards  the  mouth  of  the  wound. 
The  records  of  surgery  furnish  numerous  instances  in 
which  persons  have  been  stabbed  through  the  body, 
without  fatal  consequences,  and  sometimes  without 
the  symptoms  being  even  severe.  In  Mr.  Travers’s 
publication  many  cases  exemplifying  this  observation 
are  quoted  from  a variety  of  sources ; Fab.  Hildan. 
Obs.  Chirurg,  cent.  5,  obs.  74.  CEuvres  de  Pare,  lio. 
10,  cAap.  35.  Wiseman's  Surgery,  p.  371.  La  Matte's 
Traite  Complet  de  Chirurgie,  <S-c.  i^c.  In  such  cases 
the  bowels  have  been  supposed  to  have  eluded  the 
point  of  the  weapon,  and  perhaps  in  a fhw  instancea 
this  may  actually  have  been  the  fact ; but  in  the  gene- 
rality of  such  examples,  the  bowels  must  have  been 
punctured,  and  the  extravasation  of  intestinal  matter 
prevented  by  the  pressure  of  the  viscera  against  each 
other. 

The  pouch  or  cyst  in  which  the  extravasated  blood 
or  matter  lies,  as  mentioned  by  Sabatier,  is  formed  by 
the  same  process  which  circumscribes  the  matter  of 
abscesses. — (See  Suppuration.)  It  is,  in  short,  the  ad- 
hesive inflammation.  All  the  surfaces  in  contact  with 
each  other,  and  surrounding  the  extravasation  and 
track  of  the  wound,  generally  soon  become  so  inti- 
mately connected  together  by  the  adhesive  inflamma- 
tion, that  the  place  in  v.'hich  the  extravasation  is  lodged, 
is  a cavity  entirely  destitute  of  all  communication 
with  the  cavity  of  the  peritoneum.  The  track  of  the 
wound  leads  to  the  seat  of  the  effused  fluid,  but  has 
no  distinct  opening  into  the  general  cavity  of  the  ab- 
domen. The  rapidity  with  which  the  above  adhesion* 
frequently  form  is  almost  incredible. 

It  should  be  known,  however,  that  extravasations 
are  occasionally  diffused  in  various  degrees  among  the 
viscera,  owing  to  the  patient  being  subjected  to  a great 
deal  of  motion  or  affected  with  violent  spasmodic  con- 
tractions of  the  intestines.  Urine  and  bile  are  also 
generally  dispersed  to  a great  extent.  As  for  blood,  its 
disposition  to  coagulate  must  often  tend  both  to  stop 
farther  hemorrhage  and  confine  the  extravasation  in 
one  mass. 

Symptoms  and  Treatment  of  Extravasations  in  the 
Abdomen.  1.  Blood. — Wounds  of  the  spleen  and  of 
very  large  veins  and  arteries  in  the  abdomen,  almost 
always  soon  prove  fatal  from  internal  hemorrhage. 
The  blood  generally  makes  its  way  downwards,  and 
accumulates  at  the  inferior  part  of  the  abdomen,  unless 
the  presence  of  adhesions  happen  to  oppose  the  de- 
scent of  the  fluid  to  the  most  depending  situation. 
The  belly  swells,  and  a fluctuation  is  perceptible. 
The  patient  grows  pale,  loses  his  strength,  is  affected 
with  syncope,  and  his  pulse  becomes  weak  and  in 
scarcely  distinguishable.  In  short,  the  symptoms 
usually  attendant  on  profuse  hemorrhage  are  observ- 
able. As  the  viscera  and  vessels  in  the  abdomen  are 
compressed  on  all  sides  by  the  surrounding  parts,  the 
blood  cannot  be  effused  without  overcoming  a certain 
degree  of  resistance;  and  unless  a vessel  of  the  first 
magnitude,  like  the  aorta,  the  vena  cava,  or  one  of  their 
principal  branches  has  been  wounded,  the  blood  es- 
capes from  the  vessel  slowly,  and  several  days  elapse 
before  any  considerable  quantity  accumulates. 

In  these  cases,  the  symptoms  which,  perhaps,  had 
disappeared  under  the  employment  of  bleeding  and 
anodyne  medicines,  now  recur.  A soft  fluctuating  tu- 
mour may  be  felt  at  the  lower  part  of  tlie  abdomen; 


498 


WOUNDS. 


sometimes  on  the  right  side;  sometimes  on  the  left; 
but  occasionally  on  both  sides.  The  pressure  made  by 
the  effused  blood  on  the  urinary  bladder,  excites  dis- 
tressing inclinations  to  make  water ; while  the  pres- 
sure which  the  sigmoid  flexure  of  the  colon  suffers  is 
the  cause  of  obstinate  constipation.  In  the  mean  time, 
as  the  quantity  of  extravasated  blood  increases,  the 
peritoneum  inflames.  The  pulse  grows  weaker,  debi- 
lity ensues;  the  countenance  becomes  moistened  with 
cold  perspirations  ; and  according  to  some  writers,  un- 
less the  surgeon  practise  an  incision  for  tlie  discharge 
of  the  fluid,  the  patient  falls  a victim  to  the  accident. 

In  the  year  1733,  Vacher  adopted  this  treatment  with 
success.  Petit  afterward  tried  the  same  plan,  though 
it  did  not  answer  (as  is  alleged)  in  consequence  of  the 
inflammation  having  advanced  too  far  before  the  ope- 
ration was  performed.  Long  before  the  time  of  Va- 
cher and  Petit,  a successful  instance  of  similar  practice 
was  recorded  by  Cabrole,  in  a work  which  this  autlior 
published  under  the  title  of  ’AX^a/Jr/Tov  avaToynKov,  id 
est,  Anatomes  Elenchus  accuratissimus,  omnes  humuni 
Corporis  Partes  ed  qua  solent  secari  Methodo,  delineans. 
Accessdre  Osteologia,  Observationesque  Medicis  ac 
Chirurgicis  perutiles,  Genevae,  1604.  The  method  pur- 
sued by  Vacher  was  therefore  not  so  new  as  Petit  inta- 
gined. 

Indeed,  when  the  symptoms  leave  no  doubt  of  tltere 
being  a large  quantity  of  blood  extravasated  in  the 
abdomen ; when  the  patient’s  complaints  are  of  a very 
serious  nature,  and  are  evidently  owing  to  the  irrita- 
tion and  pressure  of  the  blood  on  the  surrounding  vis- 
cera ; and  when  a local  swelling  denotes  the  steat  of 
the  extravasation,  there  cannot  be  two  opinions  about 
the  propriety  of  making  an  incision  for  its  evacuation. 

Surgeons  should  recollect,  however,  that  if  no  open- 
ing be  made,  a small  extravasation  of  blood  may  not 
produce  any  considerable  irritation.  On  the  contrary, 
when  the  cyst  including  the  blood  is  opened,  the  air 
then  has  access,  atid  that  part  of  the  fluid  which  cannot 
be  discharged  putrefies,  and  becomes  so  irritating  as  to 
be  a true  cause  of  inflammation.  The  bad  symptoms 
are  also  sometimes  chiefly  owing  to  the  injury  done  to 
parts  within  the  abdomen,  and  still  more  commonly  to 
inflammation  within  that  cavity,  arising  rather  from 
the  wound  than  from  the  presence  of  effused  blood. 
On  the  whole,  I am  disposed  to  join  a late  writer  in  the 
belief,  that  the  practice  of  discharging  extravasated 
blood  from  the  abdomen  can  rarely  be  advisable. — (See 
Hennen'e  Mil.  Surgery^  p.  412,  ed.  2.) 

2.  Chyle  and  Feces.—These  are  not  so  easily  extra- 
vasated in  the  abdomen  as  blood,  because  they  do  not 
require  so  much  resistance  on  the  outside  of  the  sto- 
mach and  intestines  to  make  them  continue  their  na- 
tural route  through  the  alimentary  canal,  as  blood  re- 
quires to  keep  it  in  the  vessels.  However,  when  the 
wound  is  large,  and  the  bowel  distended  at  the  moment 
of  the  injury,  or  when,  as  Mr.  Travers  has  explained, 
air  is  extravasated  or  blood  effused  in  the  abdomen, 
which  fluids  are  incapable  of  making  effectual  resist- 
ance to  the  escape  of  the  intestinal  matter,  the  latter 
may  be  effused. — (See  An  Inquiry  into  the  Proeess  of 
AT ature  in  repairing  Injuries  of  the  Intestines,  Src.  p. 
26.)  Nothing  is  a better  proof  of  the  difficulty  with 
which  chyle  and  feces  are  extravasated,  than  the  ope- 
ration of  an  emetic,  when  the  stomach  is  wounded  and 
full  of  aliment.  In  this  instance,  if  the  resistance  to 
the  extravasation  of  the  contents  of  the  stomach  were 
not  considerable,  they  would  be  effused  in  the  abdomen 
instead  of  being  vomited  up.  A peculiarity  in  wounds 
of  the  stomach  and  intestines  is,  that  the  opening 
which  allows  their  contents  to  escape,  may  also  allow 
them  to  return  into  the  wounded  viscus. 

Extravasation  of  intestinal  matter  in  the  abdomen 
is  attended  with  severe  febrile  symptoms;  considerable 
pain  and  swelling  of  the  belly  ; convulsive  startings  ; 
and  hiccough  and  vomiting,  with  which  the  patients 
are  generally  attacked  the  day  after  the  receipt  of  the 
wound. — (Sabatier,  Med.  Operatoire,  t.  1,  p.  34.) 

In  these  cases,  only  general  means  can  be  employed; 
venesection,  leeches,  fomentations,  low  diet,  perfect 
rest,  anodynes,  &c.  All  solid  food  must  be  strictly 
prohibited.  If  pre.ssure  can  be  borne  without  incon- 
venience, as  is  sometimes  the  case  in  the  early  stage, 
the  close  state  of  the  viscera  may  be  increased  by  the 
application  of  a bandage  round  the  body. 

If  the  symptoms  are  not  speedily  assuaged,  the  in - 
flaran)ation  spreads  over  the  whole  cavity  of  tiie  abdo- 


men, gangrenous  mischief  takes  place,  and  the  patient* 
die  in  the  course  of  a few  days. 

3.  Bile. — Bile,  on  account  of  its  great  fluidity,  is 
more  apt  to  be  widely  extravasated  in  the  abdomen 
than  either  blood  or  the  contents  of  the  stomach  and 
intestines.  However,  on  account  of  the  small  size  of 
the  gall-bladder,  and  its  deep  guarded  situation,  between 
the  concave  surface  of  the  liver  and  upper  part  of  the 
transverse  arch  of  the  colon,  wounds  of  it  are  uncom- 
mon. 

Sabatier  informs  us,  that  he  has  only  been  able  to 
find  one  example  on  record.  This  case  was  communi- 
cated to  the  Royal  Society  of  London,  by  Dr.  Stewart. 
—{Mo.  414,  p.  341.  AbHdgm.  vol.  7,  p.  571,  572.)  A 
wound  penetrated  the  cavity  of  the  abdomen,  and  en- 
tered the  fundus  of  the  gall  bladder,  without  doing  any 
material  injury  to  the  adjacent  parts.  The  abdomen 
was  immediately  distended,  as  if  the  patient  had  been 
afflicted  with  an  ascites,  or  tympanitis;  nor  did  the 
swelling  either  increase  or  diminish,  till  the  patient’s 
death,  which  happened  in  a week. 

Though  there  was  a great  deal  of  tension,  there  was 
no  rumbling  noise  in  the  abdomen.  No  stools  and 
very  little  urine  were  discharged,  notwithstanding 
purgatives  and  clysters  and  a good  deal  of  liquid  nbu- 
rishment  were  given.  Anodynes  failed  to  procure  one 
instant  of  sound  sleep,  and  the  patient  was  incessantly 
in  a most  restless  state.  There  was  tio  apj)earance  of 
fever,  and  the  pulse  was  always  natural  till  the  last 
day  of  the  patient’s  life,  when  it  became  intermittent. 
After  death,  the  intestines  were  found  much  distended, 
the  gall-bladder  quite  empty,  and  a large  quantity  of 
bile  extravasated. 

Sabatier  had  an  opportunity  of  noticing  the  syiep- 
toms  of  an  extravasation  of  bile,  in  consequence  of  a 
wound  of  the  gall-bladder.  The  patient’s  abdomen 
swelled  very  quickly,  his  respiration  became  difficult, 
and  he  soon  afterward  complained  of  tension  and  pain 
in  the  right  hypochondrium.  His  pulse  was  small, 
frequent,  and  contracted ; his  extremities  were  cold, 
and  his  countenance  very  pale.  The  bleedings  which 
were  practised  the  first  day  gave  him  a little  relief ; 
but  the  tension  of  the  abdomen  and  the  difficulty  of 
breathing  still  continued.  A third  bleeding  threw  the 
patient  into  the  lowest  state  of  weakness,  and  he 
vomited  up  a greenish  matter.  On  the  third  day,  the 
lower  part  of  the  belly  was  observed  to  be  more  pro- 
minent, and  there  was  no  doubt  of  an  extravasation, 
Sabatier  introduced  a trocar,  and  gave  vent  to  a green, 
blackish  fluid,  which  had  no  smell,  and  was  pure  bile, 
that  had  escaped  from  the  wound  of  the  gall-bladder. 
After  the  operation,  the  patient  grew  weaker  and 
weaker,  and  died  in  a few  hours.  On  opening  the 
body,  a large  quantity  of  yellow  bile  was  found  be- 
tween the  peritoneum  and  intestines ; but  it  had  not 
insinuated  itself  among  the  convolutions  of  the  viscera. 
A thick  gluten  connected  the  bowels  together,  and  they 
were  prodigiously  distended.  The  gall-bladder  was 
shrivelled,  and  almost  empty.  Towards  its  fundus, 
there  was  a wound  about  a line  and  a half  long,  cor- 
responding to  a similar  wound  in  the  peritoneum.  The 
wound  which  had  occurred  at  the  middle  and  lower 
part  of  the  right  hypochondrium,  between  the  third 
and  fourth  false  ribs,  had  glided  from  behind  forwards, 
and  from  above  downwards,  between  the  cartilages  of 
the  ribs,  until  it  reached  the  fundus  of  the  gall- 
bladder. 

Sabatier  takes  notice  that  tlie  symptoms  of  the  two’ 
cases,  which  have  just  now  been  related,  were  very 
similar.  Both  the  patients  were  affected  with  an  ex- 
ceedingly tense  swelling  of  the  belly,  unattended  with 
pain  or  borborygmus,  and  they  were  both  obstinately 
constipated.  Their  pulse  was  extremely  weak  the 
latter  days  of  their  indisposition,  and  they  were  afflicted 
with  hiccough,  nausea,  and  vomiting. 

Sabatier  seems  to  think  one  thing  certain,  viz.  that 
wounds  of  the  gall-bladder,  attended  with  effusion  of 
bile,  are  absolutely  mortal,  and  that  no  operation  can 
be  of  any  avail. — (Mcdecine  Operatoire,  t.  1,  p.  34 — 
37.) 

A contrary  inference,  however,  may  be  drawn  fiom 
a case  detailed  by  Paroisse,  in  which  a bullet  had 
lodged  in  the  gall-bladder  two  years. — (Opnseules  de 
Chir.  p.  255.)  The  recovery  published  by  Mr.  Fryer, 
of  Stamford,  tends  also  to  prove  that  every  effusion  of 
bile  is  not  unavoidably  fatal.  A boy,  about  thirteen 
years  old,  received  a violent  blow  from  one  of  the 


WOUNDS. 


499 


fehaftsof  a cart,  on  the  region  of  the  liver.  The  injury 
was  succeeded  by  pain,  frequent  vomiting  of  bilious 
matter,  great  sinking,  coldness  of  the  extremities,  and 
ii  weak,  small,  fluttering  pulse.  The  belly  was  fo- 
mented, and  purging  clysters  thrown  up.  On  the  third 
day,  symptoms  of  inflammation  began,  attended  with 
considerable  pain  about  the  liver,  great  tension  and 
soreness  of  the  abdomen,  and  frequent  vomiting.  The 
pulse  was  quick,  small,  and  weak ; the  skin  hot  and 
dry  ; the  tongue  much  furred ; the  urine  high-coloured  ; 
and  there  was  some  difficulty  of  breathing,  and  great 
thirst.  Eight  ounces  of  blood  were  taken  away,  the 
fomentations  continued,  and  a few  grains  of  calomel 
were  directed  to  be  given  every  four  hours,  until  the 
bowels  were  properly  opened.  Afterward,  the  effer- 
vescing mixture,  with  ten  drops  of  laudanum,  was  ex- 
hibited every  four  hours. 

On  the  following  day  the  patient  had  some  motions, 
and  was  much  better ; but,  as  his  sickness  continued, 
he  was  ordered  a grain  of  opium  every  four  hours. 
About  a week  afterward,  he  complained  of  a great 
increase  of  pain,  which  was  somewhat  relieved  by  a 
blister.  He  was  now  completely  jaundiced,  and  his 
stools  were  white,  but  the  tension,  pain,  and  sickness 
Were  abated. 

Two  days  afterward,  a fluctuation  was  perceived 
in  the  abdomen,  which,  in  aTiother  week,  became  con- 
siderably distended  with  fluid.  The  patient  now  did 
not  complain  of  much  pain,  but  appeared  to  be  sinking 
fast ; a puncture  was  made  in  the  swelling,  and  thir- 
teen pints  of  what  appeared  to  be  pure  bile  were  eva- 
cuated. The  bowels  then  soon  became  regular,  and 
the  appetite  good.  In  twelve  days,  the  operation  was 
repeated,  and  fifteen  pints  of  the  same  bilious  fluid 
were  drawn  off.  Nine  days  afterward,  another  punc- 
ture was  made,  and  thirteen  pints  more  let  out:  and 
six  were  discharged  in  another  fortnight.  From  this 
period  the  boy  went  on  well,  and  perfectly  recovered 
under  the  use  of  light  tonic  medicines. — (See  Med. 
Chir.  Trans,  vol.  5,  p.  330.) 

A previous  accidental  adhesion  of  the  gall-bladder  to 
the  peritoneum  might  also  prevent  the  extravasation 
of  bile  and  its  dangerous  effects. — {Callisen,  Syst. 
Chir.  Hodiernm,  t.  1,  p.  718.) 

According  to  Dr.  Hennen,  a deep  wound  of  the  liver 
is  as  fatal  as  if  the  heart  itself  was  engaged.  The 
slighter  injuries  are  recoverable.  He  states  that  the 
usual  symptoms  of  a wound  of  the  liver  are  yellow- 
ness of  the  skin  and  urine,  derangement  of  the  ali- 
mentary canal,  and  great  and  distressing  itching  of  the 
skin.  The  discharge  from  the  wound  is  generally 
yellow  and  glutinous,  though  sometimes  either  serous, 
or  like  unmixed  bile. — (On  Military  Surgery,  ed.  2,  p. 
429.)  For  some  other  interesting  observations  on 
wounds  of  the  liver,  I have  great  pleasure  in  referring 
to  the  latter  work. — (See  also  Wedekind  de  Vulnere 
Hepatis  curato,  Jence,  1735 ; and  Thomson's  Report  of 
Ohs.  made  in  the  Military  Hospitals  in  Belgium,  8ve. 
1816.) 

4.  Urine. — Urine  being  of  a very  fluid  natuie,  miy, 
like  the  bile,  be  extensively  diffiised  in  the  abdomen, 
when  the  bladder  is  wounded  at  any  part  connected 
with  the  peritoneum.  If  in  this  kind  of  ca^  the  urine 
be  not  drawn  off  with  a catheter,  so  as  to  prevent  its 
extravasation,  the  patient  soon  perishes.  IMany  in- 
stances are  recorded  of  the  bladder  being  injured  even 
by  gun  shot  wounds,  which  were  not  mortal. 

Wounds  of  the  bladder  are  attended  with  a discharge 
of  bloody  urine  and  difficulty  of  making  water.  They 
are  always  dangerous  cases,  both  on  account  of  the 
risk  of  the  effusion  of  so  irritating  a fluid  in  the  abdo- 
men, and  of  the  chance  of  extravasation  in  the  cellular 
membrane.  Under  proper  treatment,  however,  they 
often  admit  of  cure. — (See  Gun-shot  Wounds.)  If  pos- 
sible, the  effused  fluid  should  be  discharged  by  a de- 
pending posture,  or  suitable  punctures,  or  incisions, 
and  the  recurrence  of  extravasation  prevented  by  the 
introduction  of  a catheter,  which  is  to  be  left  in  the 
urethra.  The  patient  must  also  be  allowed  little 
drink.  As  for  the  tension  and  pain  of  the  belly,  the 
common  attendants  of  a wounded  bladder,  they  may 
be  greatly  relieved  by  the  use  of  the  warm  bath 
{Callisen,  t.  1,  p.  719),  or  rather  fomentations,  which 
would  not  require  the  patient  to  be  moved  ; bleeding, 
low  diet,  and  other  antiphlogistic  means,  not  being 
omitted. 

Wounds  of  the  Stomach. — As  Dr.  Hennen  has  ob- 

Ii2 


served,  these  cases  are  extremely  dangerous,  thougli 
not  always  mortal.  “ Baron  Percy  calculates,  that  of 
twenty  cases,  four  or  five  only  have  escaped  ; this, 
however,  is  a most  favourable  average.”  Two  cures 
of  the  wounds  of  the  stomach  are  reported  by  Dr. 
Thomson  — ( Obs.  made  in  the  Military  Hospitals  in 
Belgium,  S,-c.)  With  respect  to  the  chances  of  reco- 
very, Dr.  Hennen  justly  remarks,  that  the  histories  of 
the  Eohemiati,  Prussian  (Z).  Beckher  de  Cultrivoro 
Prussiaco,  12mo.  Lugd.  1638),  and  English  “Cultri- 
vores,”  in  some  of  whom  the  knives  have  been  cut 
out,  and  in  others  discharged  spontanet)Usly  through 
the  coats  of  the  stomach  and  parietes  of  the  abdo- 
men, are  very  encouraging.  In  France,  a silver  fork 
was  lately  extracted  from  a young  man’s  stomach, 
by  Mr.  Renaud,  of  Romans,  in  the  department  of  the 
Drdme,  who  performed  gastrotorny  for  the  purpose 
with  complete  success. — (See  Quarterly  Journ.  of  For. 
Med.  JVo.  18,  p.  301.)  Hevin  has  collected  many  in- 
stances of  recovery,  both  from  incised  and  gun  shot 
wounds  of  the  stomach. — {Mem.  de  VAcad.  de  Chir. 
t.  1.)  But  according  to  Dr.  Hennen,  Ploucquet,  in  the 
articles  “ Ventriculus”  and  “ Pantophagi,”  has  brought 
together  the  largest  number  of  cases.  Dr.  Hennen  also 
refers  to  Lowthorpe's  Abridgment  of  the  Phil.  Trans, 
vol.  6,p.  192,  for  instances,  in  which  the  stomach  of  a 
horse  was  wounded  and  sewed  up,  and  the  same  prac- 
tice extended  to  the  human  subject  with  success.  It 
appears,  also,  from  the  Annales  de  Littirature,  Src. 
t.  2,  by  Khiyskens,  from  Schlichting’s  Traumatologia, 
and  the  Bulletin  de  la  Faculte,  (S-c.  t.  5,  p.  386,  that 
wounds  of  the  human  stomach  have  been  stitched  with 
success,  in  various  cases  of  recent  date. — (See  Hennen' s 
Military  Surgery,  ed.  2,  p.  438.)  As  the  latter  author 
observes,  wounds  of  the  stomach  not  unfrequenlly  be* 
come  fistulous,  and  remain  open.  In  a case  recorded 
by  Richerand,  the  fistula  continued  open  nine  years; 
and  in  another  instance,  related  by  Ettmuller,ten  years. 
— {De  Vulnere  Ventriculi  Programma,  Lip.  1730.) 
And  Wencker  has  detailed  a case,  in  which  the  open- 
ing continued  twenty-seven  years. — (See  Halleri  Dis- 
sert. Chir.  vol.  5,  art.  19.)  For  farther  infortnation 
connected  with  this  subject,  the  reader  may  also  con- 
sult Jungen  de  Lethalitate  Vulnerum  Ventriculi, 
Helmst.  1751 ; and  Jjudov.  Horn,  de  Ventriculi  Rup- 
tura,  8vo.  Berol.  1817.  Also,  Med.  Chir.  Journ.  vol.  .5, 
p.  72. 

Wounds  of  the  Intestines. — The  vomiting  of  blood, 
or  discharge  of  it  by  stool ; the  escape  of  fetid  air  or  of 
intestinal  matter  from  the  mouth  of  the  wound;  an 
empty,  collapsed  state  of  a portion  of  bowel,  protruded 
at  the  opening  in  the  skin,  are  the  common  symptoms 
attending  a wound  of  this  kind.  When  the  wound  is 
situated  in  the  protruded  portion,  it  is  obvious  to  the 
surgeon’s  eye ; but  when  it  affects  a part  of  the  intesti- 
nal canal  within  the  abdomen,  the  nature  of  the  case 
can  be  known  only  by  a consideration  of  other  .sytnp- 
toms.  In  addition  to  such  as  I have  already  described, 
there  are  some  others  wdiich  ordinarily  accompany 
wounds  of  the  bowels;  as,  for  instance,  oppression 
about  the  precordia,  acute  or  griping  pain  in  the  belly, 
cold  sweats,  syncope,  &c.  But  unless  the  wounded 
intestine  protrude,  there  is  no  practical  good  in  know- 
ing whether  the  bowel  is  injured  or  not;  since,  if  it  be 
in  the  abdomen,  the  treatment  otight  not  to  be  mate- 
rially different  from  that  of  a simple  penetrating  wound 
of  the  belly,  unattended  with  a wound  of  any  of  the 
viscera.  Large  wounds  of  the  small  intestines,  parti- 
cularly of  the  duodenum  and  jejunum,  are  attended 
with  acute  fever,  anxiety,  paleness  of  the  countenance, 
syncope,  cold  perspirations,  a small,  intermitting,  tre- 
mulous pulse,  and  they  frequently  prove  fatal.  Injuries 
of  the  small  intcstiiyes  are  also  more  often  than  those 
of  the  laige  ones  followed  by  extravasation.  A total 
divisioti  of  the  upper  part  of  the  intestinal  canal, 
towards  the  pylorus,  will  deprive  the  body  of  the  nou- 
rishment requisite  for  its  support.  If  the  chyle  e.scape 
from  the  wound,  the  patient  will  die  of  a slow  maras- 
mus; and  if  it  become  extravasated,  it  will  be  likely  to 
e.xcite  such  irritation  as  will  prove  fatal.  7’ he  escape 
of  excrement  or  of  fetid  air  from  the  wound,  indicatea 
an  injury  of  one  ofthe  large  inu^stines.  In  these  cast's, 
the  symptoms  are  generally  mihler,  and  the  ptissage  of 
the  intestinal  contents  outwards,  through  the  wound, 
more  easy,  on  account  of  the  bowel  being  le.ss  move- 
able. For  the  same  reason,  the  wounded  intestine 
more  re.'tdily  contracts  an  adhesion  to  tlie  adjacent 


500 


WOUNDS. 


parts.— (Caiijsen,  Syst.  Oururgi<B  HodiernoB,  t.  1,  p. 
717.) 

A wounded  intestine  is  said  to  present  some  par- 
ticular appearances,  to  which  the  generality  of  writers 
have  paid  no  attention : “ If  a gut  be  punctured,  the 
elasticity  of  the  peritoneum,  and  the  contraction  of 
the  muscular  fibres,  open  the  wound,  and  the  villous 
or  mucous  coat  forms  a sort  of  hernial  protrusion  and 
obliterates  the  aperture  If  an  incised  wound  be 
made,  the  edges  are  drawn  asunder,  and  averted  so 
that  the  mucous  coat  is  elevated  in  the  form  of  a 
fleshy  lip.  If  the  section  be  transverse,  the  lip  is 
broad  and  bulbous,  and  acquires  tumefaction  and  red- 
ness from  the  contraction  of  the  circular  fibres  behind 
it,  which  produces,  relatively  to  the  everted  portion, 
the  appearance  of  a cervi.x.  If  the  incision  be  ac- 
cording to  the  length  of  the  cylinder,  the  lip  is  narrow, 
and  the  contraction  of  the  adjacent  longitudinal  fibres, 
resisting  that  of  the  circular  fibres,  gives  the  orifice  an 
oval  form.  This  eversion  and  contraction  are  produced 
by  that  series  of  motions  which  constitutes  the  peri- 
staltic action  of  the  intestines.” — {Travers  on  Injuries 
of  tke  Intestines,  p.  85.) 

According  to  this  gentleman,  some  of  these  appear- 
ances were  described  by  Haller,  in  Element.  Physiol, 
lib.  24,  sect.  2 ; and  Opera  Minora,  t.  1,  sect.  15. 

Having  witnessed  the  facility  with  which  consider- 
able injuries  of  the  intestinal  tube  were  repaired,  Mr. 
Travers  was  desirous  of  ascertaining  more  fully  the 
powers  of  nature  in  the  process  of  spontaneous  repa- 
ration, and  of  determining  under  how  great  a degree 
of  injury  it  would  commence,  as  well  as  the  mode  of 
its  accomplishment.  For  these  purposes,  he  divided 
the  small  intestine  of  several  dogs  as  far  as  the  mesen- 
tery. All  these  animals  died,  in  consequence  of  the 
intestinal  matter  being  extravasated,  if  they  had  been 
lately  fed,  or  if  they  had  been  fasting,  in  consequence 
of  inflammation,  attended  with  a separation  of  the 
ends  of  the  divided  bowel,  eversion  of  the  mucous  coat, 
and  obliteration  of  the  cavity,  partly  by  this  eversion, 
and  partly  by  a plug  of  coagulated  chyle. 

In  one  particular  instance,  in  which  Mr.  Travers 
made  a division  of  the  bowel,  half  through  its  diameter, 
a sort  of  pouch  was  formed  round  the  injured  intestine. 
“ A pouch,  resembling  somewhat  the  diverticulum  in 
these  animals,  was  formed  opposite  to  the  external 
wound  on  the  side  of  the  parietes,  by  the  lining  perito- 
neum, on  the  other  side,  by  the  mesentery  of  the  injured 
intestine,  that  intestine  itself,  and  an  adjacent  fold, 
which  had  contracted  with  it  a close  adhesion.  The 
pouch  thus  formed  and  insulated  included  the  opposed 
sections  of  the  gut,  and  had  received  its  contents,  &c. 
The  tube  at  the  orifices  was  narrowed  by  the  half 
eversion,  but  offered  no  impediment  to  the  passage  of 
fluids.” — {P.  96.)  Whether,  under  these  circum- 
stances, the  functions  of  the  alimentary  canal  could 
have  been  continued,  Mr.  Travers  professes  himself 
incapable  of  deciding.  Among  the  inferences  which 
this  gentleman  has  drawn  from  the  experiments  de- 
tailed in  his  publication,  the  tendency  of  the  two  por- 
tions of  a divided  bowel  to  recede  from  each  other, 
instead  of  coalescing  to  repair  the  injury,  merits  notice, 
inasmuch  as  it  tends  to  show,  that  the  only  means  of 
spontaneous  reparation  consist  in  the  formation  of  an 
adventitious  canal,  by  the  encircling  bowels  and  their 
appendages.  The  everted  mucous  coat,  which  is  the 
part  opposed  to  the  surrounding  peiitoneum,  is  also 
indisposed  to  the  adhesive  inflammation. 

When,  however,  the  wound  of  the  intestine  is 
smaller,  the  obstacles  to  reparation  are  not  absolutely 
insurmountable.  Here  retraction  is  prevented,  and  the 
processes  of  eversion  and  contraction  modified  by  the 
limited  extent  of  the  injury.  If,  therefore,  the  adhesive 
inflammation  unite  the  contiguous  surfaces,  effusion 
will  be  prevented,  and  the  animal  escape  immediate 
destruction.  But  union  can  only  take  place  through 
the  medium  of  the  surrounding  parts. 

According  to  Mr.  Travers,  it  is  the  retraction  imme- 
diately following  the  wound  that  is  a chief  obstacle  to 
the  reparation  of  the  injury  ; for  if  the  division  be  per- 
formed in  such  a way  as  to  prevent  retraction,  the  ca- 
nal will  be  restored  in  so  short  a time  as  but  slightly  to 
interrupt  the  digestive  function.  In  confirmation  of 
this  statement,  a ligature  was  tightly  applied  round  the 
duodenum  of  a dog,  which  became  ill,  but  entirely  re- 
covered, and  was  killed.  “ A liirature,  fastened  around 
the  intestine,  divides  the  interior  coats  of  the  gut,  in 


this  effect  resembling  the  operation  of  a ligature  upon 
an  artery.  The  peritoneal  tunic  alone  maintains  its 
integrity.  The  inflammation  which  the  ligature  in- 
duces on  either  side  of  it  is  terminated  by  the  depo- 
sition of  a coat  of  lymph,  which  is  exterior  to  the  liga- 
ture, and  quickly  becomes  organized.  When  the  liga- 
ture, thus  enclosed,  is  liberated  by  the  ulcerative  pro- 
cess, it  falls  of  necessity  into  the  canal,  and  passes  off 
with  its  contents.” — {P.  103,  104.) 

It  appears  also  from  Mr.  Travers’s  experiments  and 
observations,  that  longitudinal  wounds  of  the  bowels 
are  more  easily  repaired  than  such  as  are  transverse. 
In  a dog,  a longitudinal  wound  of  the  extent  of  an  inch 
and  a half  was  repaired  by  the  adhesive  inflammation. 
Here  the  process  of  eversion  is  very  limited  ; the  aper- 
ture bears  a smaller  proportion  to  the  cylinder  of  the 
bowel ; and  the  entire  longitudinal  fibres  resist  the  ac- 
tion of  the  circular,  which  are  divided,  and  can  only 
slightly  lessen  the  area  of  the  canal. — [P.  108.) 

We  come  now  to  the  consideration  of  the  treatment 
of  wounds  of  the  intestines  ; a subject  in  which  much 
difference  of  opinion  has  prevailed;  principally,  how- 
ever, concerning  the  circumstances  in  which  sutures 
are  necessary,  and  the  most  advantageous  way  of  ap- 
plying them. 

When  the  wounded  bowel  lies  within  the  cavity  of 
the  abdomen,  no  surgeon  of  the  present  day  would 
have  the  rashness  to  think  of  attempting  to  expose  the 
injured  intestine,  for  the  purpose  of  sewing  up  the 
breach  of  continuity  in  it.  In  fact,  the  surgeon  seldom 
knows  at  first  what  has  happened  ; and  when  the  na- 
ture of  the  case  is  afterward  manifested,  by  the  dis- 
charge of  blood  per  anum,  an  extravasation  of  intes- 
tinal matter,  &c.,  it  would  be  impossible  to  get  at  the 
injured  part  of  the  bowel,  not  only  because  its  exact 
situation  is  unknown,  but  more  particularly  on  account 
of  the  adhesions,  which  are  always  formed  with  sur- 
prising rapidity.  But  even  if  the  surgeon  knew  to  a 
certainty,  in  the  first  instance,  that  one  of  the  bowels 
was  wounded,  and  the  precise  situation  of  the  injury, 
no  suture  could  be  applied  without  considerably  en- 
larging the  external  wound,  drawing  the  wounded  in- 
testine out  of  the  cavity  of  the  abdomen,  and  handling 
and  disturbing  all  the  adjacent  viscera.  Nothing  would 
be  more  likely  than  such  proceedings  to  render  the 
accident,  which  might  originally  be  curable,  unavoid- 
ably fatal.  I entirely  agree  upon  this  point  with  Mr. 
John  Bell,  who  say.?,  “ When  there  is  a wounded  in- 
testine, which  we  are  warned  of  only  by  the  passing 
out  of  the  feces,  we  must  not  pretend  to  search  for  it, 
nor  put  in  our  finger,  nor  expect  to  sew  it  to  the  wound  ; 
but  we  may  trust  that  the  universal  pressure,  which 
prevents  great  effusion  of  blood,  and  collects  the  blood 
into  one  place,  that  very  pressure  which  always  causes 
the  wounded  bowel  and  no  other  to  protrude,  will  make 
the  two  wounds,  the  outward  wound  and  the  inward 
wound,  of  the  intestine,  oppose  each  other,  point  to 
point;  and  if  all  be  kept  there  quiet,  though  but  for 
one  day,  so  lively  is  the  tendency  to  inflame,  that  the 
adhesion  will  be  begun  which  is  to  save  the  patient’s 
life.” — {Discourses  on  Wounds,  p.  361,  edit.  3.) 

When  the  extravasation  and  other  symptoms,  a few 
days  after  the  accident,  show  the  nature  of  the  case,  a 
suture  can  be  of  no  use  whatever,  as  the  adhesive  in- 
flammation has  already  fixed  the  part  in  its  situation, 
and  the  space  in  which  the  extravasation  lies  is  com- 
pletely separated  from  the  general  cavity  of  the  abdo- 
men, by  the  surrounding  adhesions. 

When  the  bowel  does  not  protrude,  and  the  opening 
in  it  is  situated  closely  behind  the  wound  in  the  perito- 
neum, a suture  is  not  requisite ; for  the  contents  of  the 
gut,  not  passing  onward,  will  be  discharged  from  the 
outer  wound,  and  not  be  diffused  among  the  viscera,  if 
care  be  taken  to  keep  the  external  wound  open.  There 
is  no  danger  of  the  wounded  bow'el  changing  its  situa- 
tion, and  becoming  distant  from  the  wound  in  the  peri- 
toneum, for  the  situation  which  it  now  occupies  is  its 
natural  one.  Nothing  but  violent  motion  or  exertions 
could  cause  so  unfavourable  an  occurrence,  and  these 
should  always  be  avoided.  The  adhesions  which  lake 
place  in  the  course  of  a day  or  two  at  length  render  it 
impossible  for  the  bowel  to  shift  its  situation. 

Things,  however,  are  far  different  when  the  wounded 
part  of  the  bowel  happens  to  protrude.  Here  we  have 
the  authority  of  all  writers  in  sanction  of  the  employ- 
ment of  a suture.  No  enlargement  of  the  outer  wound 
is  requisite  to  enable  the  practitioner  to  adopt  sucU 


WOUNDS. 


501 


practice ; there  is  no  disturbance  of  tlie  adjacent  parts ; 
there  is  no  doubt  concerning  the  actual  existence  of 
the  injury;  no  difficulty  in  immediately  finding  out  its 
situation. 

But  though  authors  are  so  generally  agreed  about  the 
propriety  of  using  a suture  in  the  case  of  a wounded 
and  protruded  bowel,  they  differ  exceedingly,  both  as 
to  the  right  object  of  the  method,  and  the  most  advan- 
tageous mode  of  sewing  the  injured  part  of  the  intes- 
tine. Some  have  little  apprehension  of  extravasation, 
advise  only  one  stitch  to  be  made,  and  use  the  ligature 
chiefly  with  the  view  of  contining  the  injured  bowel 
near  the  external  wound,  so  that  in  the  event  of  an  ex- 
travasation, the  etfused  matter  may  find  its  way  out- 
wards. Other  writers  wish  to  remove  the  possibility  of 
extravasation,  by  applying  numerous  stitches,  and 
attach  little  importance  to  the  plan  of  using  the  liga- 
ture principally  for  the  purpose  of  keeping  the  intestine 
near  the  superficial  wound. 

When  the  wound  of  a bowel  is  so  small  that  it  is 
closed  by  the  protrusion  of  the  villous  coat,  the  appli- 
cation of  a suture  must  evidently  be  altogether  need- 
less ; and  since  the  ligature  would  not  fail  to  cause  irri- 
tation, as  an  extraneous  substance,  the  employment  of 
it  ought  unquestionably  to  he  dispensed  with. 

Supposing,  however,  the  breach  in  the  intestine  to  be 
.small,  yet  sufficient  to  let  the  feces  escape,  what  method 
ought  to  be  adopted  1 The  following  practice  seems 
rational.  As  Sir  Astley  Cooper  was  operating  on  a 
strangulated  hernia,  at  Guy’s  Hospital,  an  aperture, 
giving  issue  to  the  intestinal  contents,  was  discovered 
in  a portion  of  the  sound  bowel,  just  when  the  part 
was  about  to  be  reduced.  The  operator,  including  the 
aperture  in  his  forceps,  caused  a fine  silk  ligature  to  be 
carried  beneath  the  point  of  the  instrument,  firmly  tied 
upon  the  gut,  and  the  ends  cut  otT  close  to  the  intestine. 
The  part  was  then  replaced,  and  the  patient  did  well. 
Mr.  Travers,  who  has  related  this  fact,  approves  of  the 
plan  of  cutting  away  the  extremities  of  the  ligature, 
instead  of  leaving  them  hanging  out  of  the  external 
wound.  It  appears  that  when  the  first  practice  is  fol- 
lowed, the  remnant  always  makes  its  way  into  the 
intestine,  and  is  discharged  with  the  stools,  without 
any  inconvenience.  But  when  the  long  ends  are  drawn 
through  the  outer  wound,  and  left  in  it,  they  materially 
retard  the  process  of  healing. — ( On  Injuries  of  the  In- 
testines, ire.  p.  112,  113  ) 

Let  us  now  inquire  what  ought  to  be  the  conduct  of 
a surgeon,  should  he  be  called  to  a patient  whose 
bowel  is  divided  through  its  whole  cylinder,  and  pro- 
truded out  of  the  external  wound. 

Various  have  been  the  schemes  and  proposals  for 
the  treatment  of  this  sort  of  accident ; and  since  expe- 
rience has  furnished  few  practitioners  with  an  oppor- 
tunity of  seeing  such  a case  in  the  human  subject,  a 
variety  of  experiments  have  been  made  on  animals,  in 
order  to  determine  what  treatment  would  be  the  most 
successful.  Ramdohr,  indeed,  is  stated  by  Moebius  to 
have  had  occasion  to  try  on  the  human  subject  a plan, 
of  which  a vast  deal  has  been  said  and  written.  He 
cut  off  a large  part  of  a mortified  intestine,  and  joined 
the  two  sound  ends  together  by  inserting  the  upper 
within  the  lower  one,  and  fixing  them  in  this  position 
with  a suture,  the  ligature  being  also  employed  to  keep 
them  at  the  same  time  near  the  external  wound.  The 
patient  recovered,  and  the  feces  continued  to  jrass  en- 
tirely by  the  rectum  in  the  natural  way. — (See  Halleri 
Disput.  Anat.  vol.  6,  Obs.  Med.  Miscellan.  18.) 

About  a year  after  the  operation  the  patient  died, 
when  the  anatomical  preparation  of  the  parts  was  sent 
to  Ramdohr  by  Heister.  They  were  preserved  in  spirit 
of  wine,  and  exhibited,  according  to  the  latter  author, 
a union  of  the  two  ends  of  the  bowel  together,  and 
their  consolidation  with  a part  of  the  abdomen.  Now 
it  has  been  questioned  by  a late  writer,  whether  the 
union  here  spoken  of  ever  really  happened.  When 
the  upper  end  of  the  bowel  is  introduced  into  the  lower, 
the  external  surface  of  the  former  is  put  in  contact  with 
the  inner  one  of  the  latter ; a serous  membrane  is  placed 
in  contact  with  a mucous  one.  These  heterogenous 
structures,  he  alleges,  are  not  disposed  to  unite.  The 
mucous  membrane,  when  inflann-d,  more  readily  se- 
cretes a kind  of  mucus,  which  would  be  an  invincible 
obstacle  to  adhesion.  He  thinks  it  theiefitre  more  than 
probable,  that,  in  the  case  related  by  Heister,  the  inva- 
gination was  maintained  by  the  union  of  the  intestine 
with  the  corresponding  part  of  the  abdominal  parietes. 


Several  experiments  on  living  animals  have  convinced 
him,  that  this  happens,  and  that  the  mucous  membrane 
will  not  unite  with  the  external  peritoneal  coat.  This 
impossibility  of  producing  an  immediate  union  between 
the  mucous  and  serous  membranes  may  of  course  be 
urged  as  an  objection  to  Ramdohr’s  practice. — {Riche- 
rand,  Mosographie,  Chir.  t.  3,  p.  344,  345,  edit.  4.) 
Another  equally  strong  objection  is,  that  the  upper  end 
of  the  bowel  cannot  be  put  into  the  lower  one,  unless 
it  be  separated  from  a part  of  the  mesentery.  Here 
the  division  of  the  mesenteric  arteries  may  cause  a 
dangerous  bleeding.  In  vain  did  Boyer  tie  seven  or 
eight  of  these  vessels  : his  patient  died  with  an  extra- 
vasation in  the  abdomen.— (i?rcAera7td,  t.  3,  p.  343, 
edit.  4.) 

Moebius  attempted  to  repeat  Ramdohr’s  operation 
upon  a dog;  but  he  could  not  succeed  in  insinuating 
the  upper  part  of  the  divided  bowel  into  the  lower  one, 
on  account  of  the  contraction  of  the  two  ends  of  the 
intestinal  tube  and  the  smallness  of  the  canal.  Moe- 
bius, therefore,  was  obliged  to  be  content  with  merely 
bringing  the  ends  of  the  bowel  together  with  a suture: 
the  animal  soon  afterward  died  of  an  extravasation  of 
the  feces. 

Dr.  Smith,  of  Philadelphia,  also  tried  to  repeat  Ram- 
dohr’s method,  but  could  not  succeed.  He  divided  the 
intestine  of  a dog  transversely,  and  having  inserted  a 
piece  of  candle  into  that  portion  of  the  bowel  which 
was  supposed  to  be  uppermost,  he  endeavoured  to  in- 
troduce the  superior  within  the  inferior  ; but  the  ends 
became  .so  inverted  that  it  was  found  utterly  impossible 
to  succeed.  The  scheme  was  therefore  given  up,  and 
only  one  stitch  made,  the  ligature  being  then  attached 
to  the  external  wound  in  the  manner  advised  by  Mr 
John  Bell.  The  dog  died,  and  on  examination  there 
was  found  a considerable  quantity  of  feces  and  water 
in  the  abdominal  cavity. 

Two  more  trials  were  made  of  Mr.  John  Bell’s  plan 
by  Dr.  Smith,  on  the  intestines  of  dogs:  in  both  in- 
stances the  animals  died,  the  intestines  being  much  in- 
flamed, and  feces  effused  in  the  abdomen.— (See  Dr. 
Smith's  Thesis.) 

Mr.  Travers  likewise  tried  the  same  experiment. 
“ I divided  the  small  intestine  of  a dog  which  had  been 
for  some  hours  fasting,  and  carried  a fine  stitch  through 
the  everted  edges  at  the  point  opposite  to  their  con- 
nexion with  the  mesentery.  The  gut  was  then  allowed 
to  slip  back  and  the  wound  was  closed.  The  animal 
survived  only  a few  hours. — Examination.  The  peri- 
toneum appeared  highly  inflamed.  Adhesions  were 
formed  among  the  neighbouring  folds,  and  lymph  was 
deposited  in  masses  upon  the  sides  of  the  wounded  gut. 
This  presented  two  large  circular  orifices.  Among  the 
viscera  were  found  a quantity  of  bilious  fluid  and 
some  extraneous  substances,  and  a worm  was  depend- 
ing from  one  of  the  apertures.  By  the  artificial  con- 
nexion of  the  edges  iti  a single  point  of  their  circum- 
ference, and  their  natural  connexion  at  the  mesentery, 
they  could  recede  only  in  the  intervals,  and  here  they 
had  receded  to  the  utmost.”  In  another  experiment, 
Mr.  Travers  increased  the  number  of  points  of  contact, 
by  placing  three  single  stitches  upon  a divided  intestine, 
cutting  away  the  threads  and  returning  the  gut.  The 
animal  died  on  the  second  day. — Examination.  Simi- 
lar marks  of  inflammation  presented  themselves.  The 
omentum  was  partially  wrapped  about  the  wound ; 
but  one  of  the  spaces  between  the  sutures  was  unco- 
vered, and  from  this  the  intestinal  fluids  had  escaped. 
On  cautiously  raising  the  adhering  omentum,  the  re- 
maining stitches  came  into  view.  Here  again  the  re- 
traction was  considerable,  and  the  intervening  elliptical 
aperture  proportionably  large.  On  the  side  next  to  the 
peritoneum,  however,  the  edges  were  in  contact  and 
adhered  so  as  to  unite  the  sections  at  an  angle. 

From  such  experiments,  the  conclusion  drawn  by 
Mr.  Travers  is,  that  apposition,  at  a point  or  points,  is, 
as  re.spects  effusion,  more  disadvantageous  than  no 
apposition  at  all;  for  it  admits  of  retraction  and  pre- 
vents contraction,  so  that  each  stitch  becomes  the  ex- 
tremity of  an  aperture,  the  area  of  which  is  deter- 
mined by  the  distance  of  the  stitches. — {P.  116.  119.) 
This  gentlcttian,  therefore,  maintains,  that  the  ab.<iolute 
contact  of  the  everted,  surf  aces  of  a.  divided  intestine,  in 
their  entire  eircurnference,  is  requisite  to  secure  the  ani- 
mal from  the  danger  of  abdominal  effusion. — (P.  121.) 
The  S|)ecie8of  suture  employed  (says  Mr.  Tiavers)  is 
of  secondary  importance,  if  it  secures  this  contact. — 


502 


WOUNDS. 


(P.  134.)  And  among  oilier  observations,  I find 
“ wounds  amounting  to  a direct  division  of  the  canal 
are  irreparable,  and  therefore  invariably  fatal.” — 
(P.  133.) 

These  inferences  do  not  appear  to  me  satisfactorily 
established.  We  are  told,  that  apposition  at  a point 
or  points  is,  as  respects  effusion,  more  disadvantageous 
than  no  apposition  at  all,  and  that  the  absolute  contact 
of  the  divided  surfaces,  in  their  entire  circumference, 
IS  requisite  to  secure  the  animal  from  the  danger  of 
abdominal  effusion.  The  foundation  of  these  unqua- 
lified conclusions  is  five  experiments  made  on  dogs;  in 
four  of  which  experiments,  the  divided  bowel  was 
brought  together  with  one  stitch,  on  Mr.  John  Bell’s 
plan,  while,  in  another,  three  stitches  were  made;  and 
yet,  in  all  these  instances,  the  animals  died  with  the  con- 
tents of  the  bowels  effused.  So  far  the  inferences 
seem  established.  Unfortunately  for  their  stability, 
however,  Mr,  Travers  immediately  afterward  proceeds 
to  relate  other  experiments,  instituted  by  Sir  Astley 
Cooper,  Dr.  Thomson,  and  Dr.  Smith,  which,  though 
Mr.  Travers  seems  unaware  of  the  fact,  tend  most 
completely  to  overturn  the  conclusions  which  he  had 
been  previously  making. 

“ Sir  A.  Cooper  repeated  the  e.xperiments  of  Du- 
verger,  who  had  succeeded  in  uniting  by  suture  the 
divided  intestine  of  a dog,  including  in  it  a portion  of 
the  trachea  of  a calf.  In  place  of  the  uninterrupted 
suture,  three  distinct  stitches  weie  inserted.  On  the 
sixteenth  day  the  animal  was  killed,  and  the  union  was 
complete.”— (P.  123.) 

Here  are  two  facts,  proving  that  a wounded  intestine 
niay  be  united,  though  the  suture  was  not  such  as  to 
maintain  the  divided  surfaces  in  contact  in  the  whole 
of  their  circumference. 

Sir  Astley  Cooper  then  made  the  experiment,  with- 
out including  the  foreign  substance.  'J'he  animal  re- 
covered, being  a third  fact  tending  to  prove,  that  the 
ab.solute  contact  of  every  point  of  the  ends  of  the  di- 
vided bowel  is  not  essential  to  the  cure. — (See  j3. 
Cooper  on  Inguinal  and  Congenital  Hernia^  chap.  2.) 

After  dividing  the  small  intestine  of  a dog.  Dr.  John 
Thomson,  of  Edinburgh,  applied  five  interrupted 
stitches,  at  equal  intervals,  the  ends  of  the  ligatures 
were  cut  off,  and  the  external  wound  was  closed  with 
a suture.  This  animal  did  not  die  of  the  operation, 
and  when  he  was  afterward  Jtilled,  it  appeared  that 
the  threads  had  made  their  way  into  the  interior  of  the 
intestinal  canal.  Dr.  Thomson  repeated  this  experi- 
ment, and  did  not  kill  the  animal  till  six  weeks  after- 
ward, when  the  same  tendency  of  ligatures  to  pass 
into  the  bowels  and  be  thus  discharged  was  exemplified. 

These  last  two  cases  make  five  in  proof  that  the  ab- 
solute contact  of  every  part  of  the  ends  of  a divided 
bowel  is  not  essential  to  prevent  effusion,  or  the  con- 
sequences of  the  wound  from  proving  fatal ; and  seve- 
ral other  experiments  were  made  by  Dr.  Smith,  of 
Philadelphia,  who  employed  four  stitches  with  similar 
success. 

As  far  then  as  the  majority  of  such  facts  ought  to 
have  weight,  we  are  bound  to  receive  the  conclusions 
of  Mr.  Travers  as  incorrect  and  unestablished.  I am 
only  surprised  that  Mr.  Travers  himself,  who  has  cited 
the  particulars  of  all  these  last  experiments,  did  not 
perceive  that  they  struck  directly  at  his  own  inferences. 
They  are  not  only  irresistible  arguments  against  Mr. 
Travers’s  conclusion,  that  the  union  of  a divided  bowel 
requires  the  contact  of  the  cut  extremities  in  their 
entire  circumference;  but  they  are  a plain  denial  of 
another  position,  advanced  by  this  author,  viz.  that 
wounds  amounting  to  a direct  division  of  the  canal 
are  irreparable,  and  therefore  invariably  fatal. 

With  respect  to  the  species  of  suture  being  of  se- 
condary importance,  provided  it  secure  the  complete 
contact  of  every  part  of  the  everted  ends  of  the  di- 
vided bowel,  I regret  that  Mr.  Travers  has  omitted  to 
institute  experiments,  in  order  to  prove  that  any  such 
suture  can  be  practised,  and  if  he  has  the  ingenuity  to 
apply  it,  whether  the  result  would  be  for  or  against  the 
conclusions  which  hehasformed.  The  fact  of  the  sutures 
always  making  their  way  into  the  cavity  of  the  bowel, 
and  being  thus  got  rid  of,  appears  to  me  highly  inte- 
resting, since  it  shows  the  safety  of  cutting  away  the 
ends,  instead  of  leaving  them  hanging  out  of  the  ex- 
ternal wound,  so  as  to  create  the  usual  irritation  and 
inconveniences  of  extraneous  substances.  It  seems 
that  Mr.  Benjamin  Bell  first  recommended  cutting  the 


ends  of  the  ligatures  away,  and  reducing  the  bowel  tn 
this  state  into  the  abdomen,  as  he  says,  a considerable 
part  of  the  remainder  of  the  ligature  will  fall  into  the 
cavity  of  the  gut. — {System  of  Surgery,  vol.  2,  p.  12S, 
ed.  7.)  We  have  seen  that  the  experiments  of  Dr. 
Thomson  confirm  the  observation,  and  those  instituted 
by  Mr.  Travers  tend  to  the  same  conclusion. 

According  to  the  latter  writer,  the  following  is  the 
process  by  which  a divided  intestine  is  healed  when 
sutures  are  employed.  “ It  commences  with  the  agglu- 
tination of  the  contiguous  mucous  surfaces,  probably 
by  the  exudation  of  a fluid  similar  to  that  which  glues 
together  the  sides  of  a recent  flesh  wound  when  sup- 
ported in  contact.  The  adhesive  inflammation  super- 
venes and  binds  down  the  everted  edges  of  the  peri- 
toneal coal,  from  the  whole  circumference  of  which  a 
layer  of  coagulable  lymph  is  effused,  so  as  to  envelope 
the  wounded  bowel.  The  action  of  the  longitudinal 
fibres,  being  opposed  to  the  artificial  connexion,  the 
sections  mutually  recede,  as  the  sutures  loosen  by  the 
process  of  ulcerative  absorption.  During  this  time, 
the  lymph  deposited  becomes  organized,  by  which  far- 
ther retraction  is  prevented,  and  the  original  cylinder, 
with  the  threads  attached  to  it,  is  encompassed  by  the 
new  tunic. 

The  gut  ulcerates  at  the  point  of  the  ligatures,  and 
these  fall  into  its  canal.  The  fissures  left  by  the  liga- 
tures are  gradually  healed  up;  but  the  opposed  villous 
surfaces,  so  far  as  my  observation  goes,  neither  adhere 
nor  become  consolidated  by  granulation,  so  that  the 
interstice  making  the  division  internally,  is  probably 
never  obliterated.” — {Travers  on  Injuries  of  the  Intes- 
tines, Src.  p.  128.) 

Notwithstanding  I have  carefully  read  all  the  argu- 
ments adduced  by  Mr.  Travers  in  favour  of  stitching  a 
divided  bowel  at  as  many  points  as  possible,  I still  re- 
main unconvinced  of  the  advantage  of  such  practice, 
for  reasons  already  suggested.  If  a case  were  to  pre- 
sent itself  to  me,  in  which  a bowel,  partly  cut  through, 
protruded,  I should  apply  only  a single  suture,  made 
with  a small  sewing-needle  and  a piece  of  fine  silk. 
If  the  bowel  were  completely  cut  across,  I should  have 
no  objection  to  attach  its  ends  together  by  means  of  two 
or  three  stitches  of  the  same  kind.  I coincide  with 
Mr.  Travers,  respecting  the  advantage  of  cutting  off 
the  ends  of  the  ligature  instead  of  leaving  them  in  the 
wound,  its  I believe  he  is  right  in  regard  to  the  little 
chance  there  is  of  the  injured  intestine  receding  far 
from  the  wound;  and  if  the  ends  of  the  ligature  are 
then  of  no  use  in  keeping  the  bowel  in  this  position, 
they  must  be  objectionable  as  extraneous  substances. 

As  confirming  some  of  the  foregoing  observations,  I 
would  refer  to  the  valuable  writings  of  Scarpa  and 
those  of  Dr.  Hennen,  The  remarks  of  the  former,  to 
which  I allude,  being  contained  in  the  last  edition  of 
the  First  Lines  of  Surgery,  need  not  be  repeated, 
“ The  older  practitioners  (says  Dr.  Hennen)  were  very 
much  averse  from  leaving  any  thing  to  nature  in  cases 
of  abdominal  injuries,  although  their  universal  em- 
ployment of  sutures  ought  to  have  convinced  them 
how  much  she  could  bear  with  impunity;  for  there  can 
be  very  little  doubt  that  their  uniform  performance  of 
the  operation  of  gastroraphe  was  at  least  superfluous, 
if  not  positively  hurtful.  In  the  course  of  a very  ex- 
tensive practice,  two  cases  only  have  come  under  my 
notice,  where  it  was  required  to  a wounded  intestine, 
though  frequently  it  may  be  needed  for  injuries  to  the 
parietes.”— (Ore  Military  Surgery,  ed.  2,  p.  411.) 

When  the  protruded  intestine  is  mortified,  which 
must  be  a very  rare  occurrence  in  cases  of  wounds,  the 
treatment  should  be  the  same  as  that  of  a mortified 
enterocele.— (See  Hernia.) 

As  Dr.  Hennen  observes,  in  the  treatment  of 
wounds  of  the  abdomen,  the  violence  of  symptoms  is 
to  be  combated  more  by  general  means  than  by  any 
of  the  mechanical  aids  of  surgery.  The  search  for 
extraneous  bodies,  unless  superficially  situated,  or  they 
can  be  felt  with  a probe,  is  entirely  out  of  the  question. 
“ Enlargement  or  contraction  of  the  wound,  as  the 
case  may  require,  for  returning  protruded  intestine,  se- 
curing the  intestine  itself,  and  promoting  the  adhesion 
of  the  parts,  is  all  that  the  surgeon  must  do  in  the  way 
of  operation  ; and  even  in  this  the  less  he  interferes  the 
better.” — (Ore  Military  Surgery,  ed.  2,  p.  401.) 

The  principal  indication  is  to  prevent  a dangerous 
degree  of  inflammation.  Hence  bleeding  and  the  anti- 
phlogistic treatment  ate  highly  indispensable.  Let  not 


WOUNDS. 


503 


the  surgeon  be  deterred  from  such  practice  by  the  ap- 
parent debility  of  the  patient,  his  small,  concentrated 
pulse,  and  the  coldness  of  his  extremities  ; symptoms 
common  in  acute  inflammation  of  the  bowels,  and,  in 
fact,  themselves  indicating  the  propriety  of  repeated 
venesection.  Wounds  of  the  small  intestines  aie  at- 
tended with  more  dangerous  symptoms  than  those  of 
the  large  ones.  All  flatulent,  stimulating,  and  solid 
food  is  to  be  prohibited.  The  bowels  are  to  be  daily 
emptied  with  clysters,  by  which  means  no  matter  will 
be  suffered  to  accumulate  in  the  intestinal  canal,  so  as 
to  create  irritation  and  dtetention. 

When  excrementitious  matter  is  discharged  from  the 
outer  wound,  it  is  highly  necessary  to  clean  and  dress 
the  part  very  frequently.  Gentle  pressure  should  also 
be  made  with  the  fingers,  at  the  circumference  of  the 
wound,  at  each  time  of  applying  the  dressings,  for  the 
j)urpose  of  promoting  the  escape  of  any  extravasated 
matter.  For  the  same  reason  the  patient  should  al- 
ways lie,  if  convenient,  in  a posture  that  will  render 
the  external  opening  depending. 

After  a day  or  two  the  surgeon  need  not  be  afraid  of 
letting  the  outer  wound  heal  up;  for  the  adhesive  in- 
flammation all  around  the  course  of  the  wound  will 
now  prevent  any  extravasated  matter  from  becoming 
diffused  among  the  viscera.  If  the  case  should  end 
well,  the  intestine  generally  undergoes  a dinfinution  in 
its  diameter  at  the  place  where  the  wound  was  situated. 
When  this  contraction  is  considerable,  the  patient  oc- 
casionally experiences  colic  pains  at  the  part,  especially 
after  eating  such  food  as  tends  to  produce  flatulence. 
As  these  pams  usually  go  entirely  off  after  a certain 
lime,  and  no  inconvenience  whatsoever  remains,  the 
intestine  may  possibly  regain  its  wonted  capacity 
again.  A more  considerable  constriction  of  the  above 
sort  has  been  known  to  occasion  a fatal  miserere.  Even 
the  intestine  itself  has  been  known  to  burst  in  this  situa- 
tion, afie*"  -ts  contents  had  accumulated  behind  the  con- 
tracted part.  Patients,  who  have  recovered  from 
wounds  in  the  intestines,  should  ever  afterw'ard  be  par- 
ticularly careful  not  to  swallow  any  hard  substances, 
or  indigestible  flatulent  food.  On  this  subject  the  writ- 
ings of  Scarpa  are  particularly  interesting. 

In  some  instances  intestinal  matter  continues  to  be 
discharged  from  the  outer  wound,  either  in  part  or  en- 
tirely, so  that  either  a fistula  or  an  artificial  anus  is  the 
consequence.  A fistula  is  more  apt  to  follow  when 
an  intestine  has  been  injured  by  a ball,  has  been  quite 
cut  through,  or  has  mortified.  But  numerous  cases 
prove  that  this  is  not  invariably  the  consequence,  and 
that  a perfect  cure  has  frequently  followed  each  of 
these  occurrences. — (See  jliius,  Artificial.) 

When  an  intestine  is  completely  cut  through,  and  the 
lower  portion  of  the  canal  lies  inaccessibly  concealed 
in  the  abdomen,  writers  insist  upon  the  necessity  of 
promoting  the  formation  of  an  artificial  anus.  In  this 
particular  case  they  recommend  fixing  the  extremity  of 
the  intestine  with  a fine  suture  to  the  edges  of  the  outer 
wound.  In  order  to  distinguish  the  upper  end  of  the 
intestine  from  the  lower,  the  proposal  is  sometimes 
made  to  give  the  patient  a little  milk,  and  to  observe 
whether  the  fluid,  after  a time,  issues  from  the  mouth  of 
the  protruded  gut.  In  the  mean  while  fomentations  are 
employed.  If  the  upper  end  of  the  intestine  be  in  the 
abdomen,  these  speculative  authors  even  deem  it  justi- 
fiable, when  the  accident  is  quite  recent,  to  dilate  the 
outer  wound,  search  for  the  hidden  continuation  of  the 
bowel,  and  then  sew  the  two  ends  together. 

Practical  surgeons,  I believe,  are  right  in  attaching 
little  value  to  such  directions.  “ Indeed  (says  a mo- 
dern writer),  the  surgical  world  have  long  since  dis- 
missed their  fears  about  the  intestine  falling  inwards, 
and  about  the  difficulties  of  distinguishing  between  the 
right  and  the  wrong  end  of  it.  The  apprehensions  of 
abdominal  effusions  are  now  all  pretty  well  subdued. 
The  occurrence  is  extremely  rare,  and  when  it  does 
happen,  we  leave  the  poor  wretch  to  die  in  peace, 
without  searching  after  effused  fluids,  the  nature  of 
which  cannot  be  known,  or,  if  known,  the  information 
cannot,  in  the  most  remote  degree,  lead  to  recovery. 

I have  tiever  witnessed  a case  where  any  possible 
good  effects  could  follow  the  paracentesis;  for  perito- 
nitis, in  its  most  exquisite  form,  has  always  preceded 
the  symptoms,  which  would  lead  to  the  performance 
of  that  operation.” — {Hennen  on  Military  Surgery, 
ed.  2,p.  411.) 

Jnsome  instances  musket-balls  pass  into  the  abdo- 


men, lodge  there  a considerable  time,  and  are  then 
voided  through  the  intestinal  canal ; wliile  in  other  ex- 
amples they  become  encysted,  and  continue  lodged  the 
rest  of  the  patient’s  life,  without  producing  much,  or 
indeed  any  inconvenience. 

Contusions  and  other  Injuries  of  the  Abdomen. — A 
violent  contusion  of  the  abdomen  may  injure  the  con- 
tained viscera,  without  the  occurrence  of  any  external 
wound.  It  was  in  this  way  that  the  liver  or  gall- 
bladder was  ruptured  in  the  boy  inentiotied  by  Mr. 
Fryer  (Jl/ed.  Chir.  Trans,  vol.  4) ; and  that  the  vena 
cava  was  lacerated  in  the  case  which  fell  under  the 
observation  of  Richerand,  where  a cart-wheel  passed 
over  a child’s  belly. — (JVosographie  Chir.  t.  3,  p.  353.) 
In  other  instances  the  miscliief  is  done  to  the  intes- 
tines ; and  still  more  frequently  the  viscera,  as  well  as 
the  parietes  of  the  abdomen,  have  only  suffered  a more 
or  less  forcible  contusion.  The  efiects  of  such  violence 
are  inflammation  of  the  injured  bowels,  and  their  ad- 
hesion to  the  itiside  of  the  peritoneum.  Thus,  the 
stomach  and  intestines,  the  liver,  and  the  gall-bladder, 
when  inflamed  from  a blow  upon  the  front  of  the  belly, 
contract  adhesions  to  the  corresponding  portion  of  the 
parietes,  which  has  been  also  bruised,  and  is  itself  in- 
flanied.  When  such  inflammations  suppurate  (and, 
according  to  Richerand,  it  is  their  most  usual  course), 
on  opening  the  abscess,  the  pus  is  found  blended  with 
the  matter  which  the  viscera  contain  or  secrete.  Thus 
the  alimentary  matter,  and  even  intestinal  worms,  have 
been  discharged  with  the  pus  on  opening  certain  ab- 
scesses which  communicated  with  the  cavity  of  the 
stomach  or  bowels;  and  bile  has  been  found  blended 
with  the  matter  of  abscesses  in  the  right  hypochon- 
drium. 

When,  in  consequence  of  a blow  upon  the  anterior 
part  of  the  belly,  the  patient  experiences  in  the  situa- 
tion of  the  injury  a deeply-seated  pain  ; when  a tu- 
mour forms,  and  the  symptoms  indicate  violence  done 
to  some  of  the  adjacent  viscera,  the  inflammation  is  to 
be  opposed  by  every  possible  antiphlogistic  means. 
But  when,  notwithstanding  such  treatment,  the  swell- 
ing increases  and  suppurates,  the  abscess  is  not  to  be 
opened  until  it  is  perfectly  mature.  The  inflammatory, 
symptoms,  which  precede  its  formation,  indicate  theit 
there  is  an  adhesion  between  the  injured  organ  and 
the  parietes  of  the  abdomen.  Without  this  adhesion, 
opening  the  abscess  would  be  attended  with  more  ris 
because  the  pus  or  other  matter  might  become  extra- 
vasated in  the  cavity  of  the  peritoneum.  For  the 
same  reason,  in  the  examples  of  tumours  caused  by 
bile  in  the  gall-bladder,  J.  L.  Petit  recommends  defer- 
ring the  operation  of  opening  them,  until  the  inflam- 
matory symptoms  evince  that  an  adhesion  has  taken 
place  between  the  fundus  of  the  gall-bladder  and  the 
corresponding  point  of  the  parietes  of  the  abdomen. 

An  adhesion  of  the  abdominal  viscera  to  the  inner 
surface  of  the  peritoneum  may  be  induced  by  other 
causes  besides  the  action  of  contusing  bodies.  A knife, 
a fork,  a shoemaker’s  awl,  a needle,  and  other  extra- 
neous substances  incapable  of  passing  throughout  the 
alimentary  canal,  have  been  known  to  irritate  the 
stomach  or  bowel,  and  to  bring  on  adhesion  of  them  to 
the  parietes  of  the  abdomen,  where  a tumour  has 
formed,  which,  on  being  opened,  has  discharg'ed  the 
foreign  body.  The  records  of  surgery  abound  in  facts 
of  this  kind.  A fistula  succeeds  the  opening  of  the 
abscess,  the  alimentary  matter  escapes,  and,  if  the 
aperture  admit  not  of  being  healed  by  methodical.com- 
pression,  the  intestinal  canal  between  the  fistula  and 
the  anus  contracts  ; nrnst  of  the  contents  of  the  bowels 
pass  out  at  the  preternatural  openingj  and  the  patient 
falls  into  a state  of  marasmus,  the  more  quickly  fatal, 
the  nearer  the  injury  of  the  intestinal  carral  is  to  the 
stomach. 

A long-continued  pressure  on  the  epigastric  region 
may  cause  an  adhesion  of  the  stomach  to  the  perito- 
neum, and  suppuration  taking  place  at  the  part,  a fis- 
tula, communicating  with  the  cavity  of  that  organ 
may  be  formed,  and  allow  the  victuals  to  escape  ex- 
ternally.— (See  Richerand,  Physiologic,  t.  I,  Chymtfi~ 
cation:  iN'osographie  Chirurgie,  t.  3,  p.  353 — 356, 
edit.  4.) 

1 shall  conclude  with  repealing,  that  in  the  generality 
of  injuries  of  the  abdomen  from  external  violence, 
whether  wounds  or  cotitusions,  the  principal  danger 
depends  upon  inflammation  of  the  peritonenm.  In 
the  treatment,  therefore  the  most  necessary  thing  is  to 


504 


WOU 


WRY 


prevent  and  oppose  tliia  perilous  affection.  Copious 
and  repeated  venesection,  the  application  of  leeches, 
mild  aperient  clysters,  a low  fluid  diet,  perfect  rest,  fo- 
mentations, and  the  warm  bath  are  among  the  most 
effectual  antiphlogistic  remedies  which,  in  such  cases, 
are  entitled  to  praise  and  confidence. 

For  information  on  wounds  of  the  abdomen,  see 
Flajani,  Oaservaziuni,  Src.  t.  3.  Malaval,  Quastio, 
4fc.  an  tenuium  intestinorum  vulnus  letkale?  Paris, 
1734.  JVencker,  Virginis  per  viginti  septem  annos 
ventriculam  perforatum  habentis  Historia  et  Sectio, 
Argent.  1743.  Haller,  Diss.  Ckir.  5—19.  Callis^'s 
Systema  Chirur.  Hodiernce,  t.  1,  p.  697,  Src.  ed.  1798, 
Hafnice.  Richerand,  JVosogr.  Chir.  t.  3,  p.  327,  (J-c. 
ed.  4.  Med.  Chir.  Trans,  vol.  4,  p.  330.  J.  Cramp- 
ton's  Case  of  Rupture  of  the  Stomach  and  Escape  of 
Its  Contents,  Src.  with  Obs.  by  B.  Travers,  in  Med. 
and  Chir.  Trans,  vol.  8.  p.  228,  ^i'C.  Richter,  Anfangs- 
griinde  der  Wundarzneykunst,  b.  5,  kap.  1.  Dis- 
courses on  the  Mature  a?id  Cure  of  Wounds,  by  John 
Bell,  ed.  3.  L.  Mannoni,  De  Similium  Partium  hu- 
manum  Corpus  ennstitutentium  Regenerations.  Me- 
diolani,  1782.  Encyclopedic  Methodique,  partie  Chir. 
art.  Abdomen  et  Intestine.  Dr.  Smith's  Inaugural 
Thesis.  B.  'Travers,  An  Inquiry  into  the  Process  of 
Mature,  in  repairing  Injuries  of  the  Intestines,  8vo. 
1812.  J.  Hunter,  On  Gun-shot  Wounds.  Sir  A. 
Cooper's  Work  on  Inguinal  and  Congenital  Hernia, 
chap.%  fol.  1804.  Sabatier,  Medecine  Operatoire,  t.  1. 
Petit,  Essai  sur  les  Epanchemens,  et  Suite  de  I'Essai 
sur  les  Epanchemens,  in  Mem.  de  V Acad,  de  Chir. 

For  inlormation  on  wounds  in  general,  see  Cces. 
Magatus,  De  Rara  Medicatione  Vnlnerum,  seude  Vul- 
neribus  raro  tractandis,  fol.  Ven.  1616.  A.  Read,  his 
ZDorks,  containing,  1.  Dectures  on  Tumours  and  Ulcers. 
2.  A Treatise  of  the  First  Part  of  Chirurgery,  which 
teacheth  the  Reunition  of  the  parts  of  the  Body  dis- 
jointed, and  the  methodical  Doctrine  of  Wounds,  &-c. 
ed.  2,  8vo.  Land.  1650.  Werner,  De  Vulneribus  abso- 
lute et  per  accidens  Irthalibus,  Regiorn.  1650.  J.  Bohn, 
De  Renunciatione  Vnlnerum  ; sen  Vulnerum  jMha- 
Itum  Examen.  12mo.  Lips.  1689.  P.  Ammannus, 
Praxis  Tulnerum  lethnlium,  &c.  12mo.  Francof.  1690. 
J.  Colbatch,  Mew  Light  of  Surgery,  showing  a more 
safe  and  speedy  Way  of  curing  Wounds  than  has  hi- 
therto been  practised,  12mo.  Lond.  1695.  Ph.  Conr. 
Fabricius,  Programma  quo  Causa  Infrequentice  Vul- 
nerum lethalium,  pros  minus  lethiferi  sexfabrica  Cor- 
pus humani  anatomica,  et  Situ  Partium  prcecipue  eru- 
untur,  Helmstad.  1753.  John  Hunter,  A 'Treatise  on 
the  Blood,  Inflammation,  Src.  John  Bell's  Principles 
of  Surgery,  and  his  Discourses  on  Wounds.  W, 
Balfour,  Observations  on  Adhesion,  with  two  Cases, 
demonstrative  of  the  Powers  of  Mature  to  reunite 
Parts  which  have  been  totally  separated  from  the  ani- 
mal System,  8vo.  Ediiu  1814,  Larrey,  Memoires  de 
Chirurgie  Militairc.  Memoires  et  Prix  de  V Academic 
Roy  ale  de  Chirurgie.  Sabatier,  Medecine  Operatoire. 
Assalini,  Manuals  di  Chirurgia ; Milano,  1812.  Riche- 
rand, Mosogr.  Chir.  ed.  4.  Boyer,  Traiti  des  Maladies 
Chir.  1. 1.  Delpech,  Precis  des  Maladies  Reputees  Chi- 
rurgicales,  t.  1,  Schmucker,  Wahrnehmungen  und 
Chirurgische  Schriften.  Lombard,  Instruction  Som- 
maire  sur  I'Art  des  Pansemens,  8vo.  Strasbourg,  1797. 
Also,  Clinique  Chirurg.  relative  aux  Plaies,  8vo.  Strasb. 
an  6.  Guthrie,  On  Gun-shot  Wounds,  edit.  2.  Jones,  On 
Hemorrhage.  Schreger,  Chirurgische  Versuche,  b.2,p. 
260,  &-C.  8vo.  Murnberg,  1818.  Thomson's  Lectures 
on  Inflammation,  8vo.  1813;  and  his  Report  and  Obs. 
made  in  the  Military  Hospitals  in,  Belyiam,  8vo.  1816. 
J.  Hennen's  Military  Surgery,  ed.  2,  8vo.  Edin.  1820 ; 
and  the  various  works  cited  in  the  course  of  this  article, 
and  at  the  conclusion  of  that  on  Gxin-shot  Wounds. 

For  information  on  poisoned  wounds,  consult  F.  Redt, 
Osservazioni  inlorno  alle  Vipere,  Firenze,  1664.  M. 
Chants,  Moi'.velles  Krp^rienecs  Sur  la  Vipire,  4to. 
Paris,  1669.  Also,  A Reply  to  Redi's  Letter  concern- 
ing Vipers,  12/ne.  Lond.  1673.  Stanford  Wolferstan, 
Inquiry  into  the  Causes  of  Diseases  in  general,  See. 
Also  of  the  Venom  of  Vipers,  12wo,  I^ond.  1692.  A. 
Moureau  de  .Tonnes,  Monographic  du  'Trigonocephale 
des  .Antilles  on  Grand  Vipere  Fcr  de  Lance  de  la  Mar- 
tinique, Par.  8oo.  3816.  A.  Vater  et  F.  Gensler,  de 
Antidoto  Movo  adnersus  Viperarum  Morsum,  preesen- 
tissimo  in  Anglia  hand  itn  pridem  detecto  ; Wittemb. 
1736.  (Haller,  Disp.  ad  Morb.  6,  .593.)  .7.  E.  Bertin 

et  J.  F-  C.  Morand,  Thesis,  in  h<ec  verba,  ergo  sped- 


ficum  VipercB  Morsus  Antidotum  Alkali  Volatile,  in 
Haller's  Disp.  ad  Morb.  6,  611.  Paris,  1749.  Cates- 
by's  Hist,  of  Carolina.  Mead  on  Poisons.  Fontana 
on  the  Venom  of  the  Viper.  Acrel  de  Morsura  Ser- 
pentum,  4to.  Upsal,  1762.  Russel  on  Indian  Serpents. 
Ireland,  in  Med.  Chir.  'Trans,  vol.  2.  Sir  E.  Home,  in 
Phil.  'Trans.  1810.  David  Barry,  Exp.  Researches  on 
the  Influence  of  Atmospheric  pressure  on  the  Blood 
in  the  V tins,  Src.  and  on  the  Prevention  and  Cure  of 
the  Symptoms  caused  by  the  Bites  of  Rabid  or  Venom- 
ous Animals;  8vo.  Lond.  1826. 

WRY-NECK.  (Caput  Obstipum ; Torticollis.)  An 
involuntary  and  fi,\ed  inclinaFion  of  the  head  towards 
one  of  the  shoulders  ; a disorder  not  spoken  of  by  the' 
ancients.  It  should  not  be  confounded  with  a mere 
rheumatic  tension  and  stiffness  of  the  neck,  nor  with 
the  faulty  position  of  the  head  arising  from  deformity 
of  the  cervical  vertebrae. 

Tulpius,  about  the  middle  of  the  seventeenth  century, 
recorded  the  cureof  a boy  twelve  years  old,  who,  from 
his  earliest  infancy,  had  had  his  head  drawn  down  to- 
wards his  left  shoulder  by  a contraction  of  the  scalenus 
muscle.  Fomentations  were  applied  in  vain.  The 
head  could  not  be  brought  into  the  right  posture,  even 
with  the  aid  of  steel  collars.  A consultation  was 
therefore  held,  in  which  it  was  decided  to  put  the  boy 
under  the  care  of  Minnius,  a surgeon  who  had  per- 
formed several  operations  with  success  in  similar  cases. 
A large  eschar  was  first  made  with  caustic  ; and  the 
muscle  which  drew  the  head  to  one  side  was  then 
divided  with  a knife.  Tulpius,  who  lias  left  a very 
confused  account  of  the  operation,  observes,  that  it 
was  performed  with  great  slowness  and  circumspec- 
tion, for  fear  of  wounding  the  carotid  artery  and  jugu- 
lar vein.  However,  he  offers  one  good  piece  of  advice, 
which  is,  not  to  make  any  preliminary  application  of 
caustic,  as  it  only  causes  useless  pain,  and  cannot  be 
of  any  service.  He  also  recommends  the  operation 
not  to  be  done  little  by  little  at  repeated  times ; and  says 
that  the  surgeon  should  make  a complete  division  of 
the  muscle  at  once,  with  the  necessary  degree  of  cau- 
tion. 

Job  d Meeckren  also  treats  of  the  operation  for  the 
cure  of  a wry-neck.  He  states  that  he  had  seen  it 
performed  on  a boy  fourteen  years  old.  The  tendon  of 
the  sterno-cleido-mastoideus  muscle  was  skilfully  di- 
vided with  one  stroke  of  a sharp  pair  of  scissors,  by  a 
surgeon  named  Flurianus,  and  as  soon  as  the  incision 
had  been  made,  the  head  resumed  its  right  position. — 
(Obs.  Med.  Chir.  c.  33.)  Mr.  S.  Sharp  believed  that 
the  wry-neck  mostly  arose  from  a contraction  of  the 
sterno-cleido-mastoideus  muscle,  which  he  proposed 
the  division  of,  whenever  the  disorder  seemed  to  pro- 
ceed from  this  kind  of  cause.  However,  he  made  an 
exception  of  cases  in  which  the  disorder  had  existed  a 
considerable  time  or  from  infancy.  He  remarks,  that 
if  the  cervical  vertebrae  have  grown  in  a distorted  di- 
rection,  the  position  of  the  head  cannot  be  rectified. 
With  these  restrictions,  the  following  is  the  operation 
which  he  recommends:  a transverse  incision  is  to  be 
made  through  the  skin  and  fat,  of  a size  somewhat  more 
extensive  than  the  breadth  of  the  muscle,  and  about 
one-third  of  its  length  from  the  clavicle.  A probed 
razor  is  then  to  be  passed  underneath  the  muscle  and 
to  be  drawn  out,  so  as  to  make  the  requisite  division 
of  the  part.  After  the  incision  has  been  made,  Mr, 
Sharp  recommends  the  wound  to  be  filled  with  dry  lint, 
and  to  be  always  dressed  in  a way  best  calculated  to 
keep  the  extremities  of  the  muscle  from  growing  to- 
gether again.  For  this  purpose,  he  directs  the  cut  ends 
to  be  separated  from  each  other  as  much  as  possible, 
with  the  assistance  of  a bandage  to  support  the  head 
durin^tjje  whole  time  of  the  cure,  which  he  says  will 
generally  be  about  <t  month.— ( Ow  the  Operations  of 
Surgery,  chap.  35.) 

According  to  Mr.  Sharp’s  account,  this  operation 
ought  to  be  common.  However,  if  attention  be  paid 
to  the  nature  and  causes  of  the  disease,  and  to  the  difi- 
ferences  resulting  from  whether  the  disorder  be  recent  or 
of  long  standing;  constant  or  periodical;  idiopathic 
or  sympathetic;  dependent  on  spasm  or  merely  on 
paralysis  of  the  antagonist  muscles  : and,  lastly,  if  it 
be  recollected  that  the  affection  may  be  produced  by 
other  muscles  besides  the  sterno  cleido-mtistoidens ; it 
will  appear  that  cases  in  which  the  foregoing  operation 
can  be  judiciously  undertaken  are  not  frcqiient. 

With  regard  to  the  manner  in  which  Mr.  Sharp  ope- 


WRY-NECK. 


505 


rated,  Mr.  B.  Bell  conceived  that  it  was  attended  with 
hazard  of  wounding  the  large  blood-vessels.  But 
though  it  seems  to  me  better  to  use  a probe-pointed 
bistoury  and  a director  than  the  kind  of  razor  which 
Mr.  Sharp  employed,  I do  not  coincide  with  Mr.  B.  Bell 
in  thinking  that  the  latter  surgeon’s  plan  was  at  all  ob- 
jectionable on  the  score  of  danger  in  respect  to  wound- 
ing the  vessels.  Some  practitioners  may  even  think 
Mr.  B.  Bell’s  method  most  likely  to  injure  the  large 
vessels ; for  he  advises  the  operator  to  cut  the  muscle 
from  withoutgradually  inwards,  as  deeply  as  necessary. 

Perhaps  the  most  prudent  method  of  operating,  is  to 
divide  the  clavicular  portion  of  the  contracted  muscle 
near  the  clavicle,  and  even  to  cut  out  a sufficient  piece 
to  remove  all  chance  of  the  two  ends  uniting  again. 
This  step  would  weaken  the  muscle  considerably,  and 
perhaps  might  answer  every  purpose.  It  might  easily 
be  accomplished  by  means  of  a dii*tector  and  curved 
bistoury,  after  making  the  requisite  division  of  the 
skin  with  a common  scalpel.  Were  this  proceeding  to 
produce  only  partial  amendment,  the  sternal  portion 
of  the  muscle  might  afterward  be  divided.  A director 
should  be  passed  under  it,  and  the  division  made  with 
a probe-pointed  curved  knife.  In  operating  on  a fe 
male  patient,  it  might  be  advisable,  with  the  view  of 
avoiding  a large  scar,  to  make  only  a puncture,  and 
pass  the  knife  flatly  against  and  close  behind  the  ster- 
nal portion  of  the  muscle,  the  posterior  part  of  which 
could  be  divided  by  then  turning  the  edge  of  the  instru- 
ment forwards.  In  this  manner,  Dupuytren  operated 
successfully  in  one  instance. — (See  Quarterly  Journ. 
of  Foreign  Med.  Mo.  20,  p.  623.) 

Any  cause  destroying  the  equilibrium  between  the 
Bterno-cleido  mastoidei  muscles,  will  produce  a wry- 
neck. Thus,  when  one  of  them  is  affected  with  spasm, 
and  acts  more  forcibly  than  the  other,  it  draws  the 
head  towards  the  shoulder  of  its  own  side ; but  when 
one  sterno-cleido-mastoideus  is  paralytic,  while  the 
other  retains  only  its  natural  power,  the  balance  of  ac- 
tion is  equally  destroyed,  and  the  sound  muscle  inclines 
the  head  towards  the  nearest  shoulder.  In  paralytic 
cases,  electricity  {Phil.  Trane,  vol.  68,  p.  97  ; Oilby  in 
London  Med.  Journ.  vol.  4,  1790),  blisters,  stimulating 
liniments,  the  shower-bath,  sea-bathing,  issues,  setons, 
the  application  of  moxa,  and  attention  to  the  health  in 
general,  are  the  means  affording  the  best  chances  of 
relief. 

Although  the  wry-neck  sometimes  depends  on  the 
state  of  the  sterno-cleido-mastoidei  muscles,  it  is  fre- 
quently owing  to  a shortening  of  the  integuments. 
Louis  often  successfully  divided  contractions  of  the 
ekin,  which  had  kept  the  head  drawn  to  one  side  for 
many  years,  and  had  been  occasioned  by  burns.  Some 
of  these  contractions,  he  says,  might  easily  have  been 
mistaken  for  a part  of  the  sterno-cleido-mastoideus 
itself 

Mr.  Gooch  relates  a case  of  wry-neck,  which  was 
caused  by  a contraction  of  the  platysma  myoides  mus- 
cle. The  patient  was  a young  gentleman  fourteen 
years  of  age,  who  had  always  enjoyed  very  good  health 
in  every  other  respect.  For  several  months  his  head 
had  been  strongly  drawn  to  one  side  by  a constant 
contraction  of  the  platisma  myoides  muscle,  which 
w’as  exceedingly  rigid,  especially  about  its  insertion  at 
the  basis  of  the  jaw ; and  from  the  angle  of  the  os 
maxillare  inferius  to  the  chin,  the  skin  presented  an 
appearance  like  that  of  the  cicatrix  of  a burn.  The 
same  side  of  the  face,  quite  from  the  point  of  the  chin, 
was  much  shrunk  and  distorted  by  the  contraction  of 
the  muscle;  and  the  corner  of  the  mouth  in  particular 
was  so  drawm  to  one  side  and  downward.s  when  the 
patient  turned  his  head,  that  a vast  deal  of  deformity 
was  the  consequence.  From  the  inferior  part  of  the 
eyebrow,  at  the  internal  angle  of  the  eye  to  near  the 
top  of  the  head,  there  was  a kind  of  furrow  upon  the 
skin  about  half  an  inch  hroad,  with  a shining,  polished 
appearance,  like  the  cicatrix  of  a wound,  and  destitute 
of  hair,  which  had  fallen  off.  From  the  corner  of  the 
eye  downwards,  there  was  the  same  kind  of  appear- 
ance in  a less  degree.  The  patient  was  subjected  to 
repeated  attacks  of  spasms,  which  began  at  the  inser- 
tion of  the  muscle,  and  terminated  at  the  eye,  attended 
with  a great  deal  of  pain.  The  ear,  and  also  the  tem- 
poral and  frontal  muscles,  were  sometimes  affected  in 
a similar  manner.  The  parts  in  the  course  of  the  in- 
sertion of  the  muscle  into  the  jaw-bone,  were  consi- 
derably thickened,  without  being  in  the  least  inflamed 


externally,  and  when  touched,  but  not  stretched,  they 
were  little  painful.  The  subjacent  muscles  did  not 
seem  at  all  affected. 

It  appears  from  the  account  given  by  Mr.  Gooch, 
that  in  the  treatment  of  this  affection,  every  known 
means  had  been  tried,  by  the  advice  of  the  most  emi- 
nent practitioners  ; but  without  effect.  Mr.  Gooch  de- 
termined to  try  what  benefit  would  be  produced  by  the 
division  of  the  muscle.  He  first  divided  the  integu- 
ments a little  below  the  jaw,  and  thus  exposed  the 
whole  breadth  of  the  platisma  myoides  muscle,  the 
fibres  of  which  seemed  to  be  in  a state  of  violent  ex- 
tension, especially  when  the  patient’s  head  was  in- 
clined towards  the  opposite  side.  Mr.  Gooch  then 
divided  the  muscle  completely  across,  by  a very  careful 
dissection,  until  the  fasciae  of  the  subjacent  muscles 
were  exposed.  The  patient  was  then  directed  to  turn 
his  head  towards  the  opposite  side,  and  Mr.  Gooch  had 
the  satisfaction  of  observing,  that  the  patient  could 
perform  this  motion  without  the  face  and  corner  of  the 
mouth  being  affected,  as  they  used  previously  to  be. 
The  wound  was  treated  in  the  ordinary  way,  and  no 
particular  symptoms  arose.  As  soon  as  the  inflam- 
mation had  subsided,  the  patient  was  directed  fre- 
quently to  move  his  head  about,  in  order  to  prevent 
any  kind  of  stiffness  which  might  ensue  from  the  con- 
traction of  the  muscular  fibres,  and  the  inelasticity  of 
the  cicatrix. 

The  patient  was  perfectly  relieved  by  the  foregoing 
operation,  and  had  no  return  of  the  painful  spasms,  to 
which  he  had  been  previously  subject.  The  side  of  his 
face,  however,  never  recovered  its  proper  degree  of 
plumpness. — {Chir.  Works  of  B.  Gooch,  vol.%  p.  I.) 

I have  lately  seen  an  elderly  gentleman,  who  is 
afflicted  with  a wry-neck,  for  which  several  of  the  most 
eminent  surgeons  have  been  consulted  ; but  they  have 
not  advised  an  operation,  nor  have  any  of  their  pre- 
scriptions been  of  service.  The  case  is  complicated 
with  a constant  tremulous  motion  of  the  head,  and 
great  weakness  and  unsteadiness  of  the  upper  extre- 
mities, so  that  the  patient  cannot  put  a glass  or  cup  to 
his  mouth,  without  using  both  hands  for  the  purpose. 

Whenever  an  attempt  is  made  to  cure  a wry-neck, 
by  dividing  any  of  the  muscles,  or  merely  the  integu- 
ments, it  becomes  necessary  to  take  some  measures  for 
keeping  the  head  in  a proper  position,  during  the  treat- 
ment of  the  wound  ; lest,  in  consequence  of  the  head 
inclining  in  the  direction  in  which  it  .was  before  the 
operation,  the  divided  parts  should  grow  together  again, 
and  bring  the  patient  into  the  same  condition  in  which 
he  was  before  any  thing  had  been  done.  With  a view 
of  preventing  this  unpleasant  circumstance,  Mr.  Sharp 
recommends  filling  the  wound  with  lint,  and  making  it 
suppurate.  Mr.  B.  Bell,  on  the  other  hand,  advises  the 
employment  of  a proper  machine  for  keei>ing  the  head 
in  a due  position.  Some  writers  think  the  use  of  a 
bandase  sufficient  for  the  purpose.  In  Dupuytren’s 
ca.=e,  the  cut  edges  of  the  muscle  were  kept  asunder  by 
depressing  the  clavicle,  and  inclining  ifie  head  to  the 
opposite  side.  The  first  object  was  fulfilled  by  binding 
the  hand  on  the  same  side  as  the  operation  firmly  to 
the  foot,  the  knee  being  bent ; the  last,  by  means  of  a 
roller  applied  round  the  head,  and  under  the  axilla  of 
the  opposite  side. — (See  Quarterly  Journ.  of  Foreign 
Med.  Mo.  20,  p.  623.)  Sometimes,  the  removal  of  a 
small  portion  of  the  affected  muscle  may  be  necessary 
in  the  operation. 

Boyer  met  with  a paralysis  of  the  extensor  muscles 
of  the  head,  attended  with  a constant  approximation 
of  the  skin  to  the  sternum.  The  disease  resisted  every 
plan  of  treatment,  and  an  apparatus  for  supporting  tlie 
head  was  the  only  thing  found  of  any  use.— (See 
Traili  dcs  Mai.  Chir.  t.  7,  p.  61,  8vo.  Paris,  1821.) 
Sharp's  Treatise  on  the  Operations  of  Surgery,  chap. 
35.  Blasius,  Obs.  Med.  Bar.  p.  2,  Mo.  1 ; cure  effected 
by  operation.  Mauchart,  De  Capite  Obstipo,  Tub. 
17.37.  Chirurgical  Works  of  B.  Gooch,  vol.  2,  p.  81. 
B.  Bell's  System  of  Surgery.  Roonhuysen,  Ileylcuren, 
p.  1,  JVo.  22  and  33;  successful  operation.  Encyclo- 
pidie  Methodique,  partie  Chirurgicale,  t.  2,  art.  Tor- 
ticollis. Joh.  Christ.  Gottfr.  Jorg.  iiber  die  Verr- 
kriimmungen  des  Mensehlichen  Kdrpcrs,  und  eine 
ratiovelle  und  sichcre  Jleilart  derselbcn ; J.cipzig, 
1810.  The  ingenious  apparatus  recommended  by  this 
author  is  described  and  engraved  in  the  “ First  Lines 
of  the  Practice  of  Surgery,”  ed.  5.  Baron  Boyer, 
Train  des  Mai.  Chir.  t.  7,  p.  48,  »^-c.  8vo.  Paris,  1821 


(506  ) 


Z 


ZIN 

ZINC.  The  preparations  of  this  metal  are  of  con- 
siderable use  in  surgery.  With  respect  to  the 
sulphate  of  zinc,  it  may  be  said  to  be  generally  the  best 
emetic  in  cases  where  it  is  desirable  to  empty  the  sto- 
mach without  the  least  delay,  as  in  cases  of  poison ; for 
which  purpose,  the  common  dose  is  3j.  “ As  an  ex- 
ternal application,  this  salt  dissolved  in  rose-water,  in 
the  propoition  of  gr.  iss.  to  5 j.  of  rose-water,  forms  an 
excellent  collyrium  in  the  latter  stage  of  ophthalmia, 
after  the  inflammatory  action  has  subsided;  it  is  a 
good  injection  in  a similar  stage  of  gonorrhoea,  and  a 
lotion  in  some  kinds  of  superficial  inflammations.  Of 
double  strength,  this  solution  is  the  best  application 


ZIN 

that  can  be  used  in  scrofulous  tumours,  after  they 
have  suppurated,  and  the  abscess  has  been  discharged.” 
— (j1.  T.  Thomson,  London  Dispensatory,  ed.  2,  p. 
559.)  A gargle  of  sulphate  of  zinc  is  often  advisable 
for  ulcerations  of  the  mouth,  tongue,  or  throat. 
R.  Zinci  sulphatis  3j.  Aq.  rosae  5vij.  Oxymellis 
5j.  M.  ft.  gargarisma  frequenter  utendum.  The 
unguentum  zinci,  composed  of  an  ounce  of  the  oxide 
of  zinc,  and  six  ounces  of  prepared  lard,  is  a useful, 
astringent,  mildl)r  stimulant  application  ; and  is  fre- 
quently employed  in  various  cutaneous  diseases,  ring- 
worm, sore  nipples,  and  chronic  inflammation  of  the 
conjunctiva  of  the  eyelids. 


THE  END. 


4- 


(507  ) 


SUPPLEMEJVTARY  APPEJVDIX 

BY  THE  AMERICAN  EDITOR. 


Several  accidental  omissions  having  occurred  during  the  progress  of  this 
edition  through  the  press,  and  other  articles  having  been  mislaid  or  overlooked 
until  too  late  to  introduce  them  under  the  respective  subjects  to  which  they 
refer,  I have  concluded  to  insert  some  of  them  in  this  supplementary  Appendix, 
which  it  is  proposed  to  enlarge  in  each  succeeding  edition,  as  the  progress  and 
improvement  of  the  science  may  require. 


ANEURISM. 

Under  this  head,  I have  introduced  the  only  instance 
of  the  ligature  of  the  internal  iliac  for  the  cure  of  glutsal 
aneurism  ever  performed  in  this  country,  as  communi- 
cated by  Dr.  S.  Pomeroy  White,  of  Hudson,  N.  Y.,  and 
it  is  there  stated  to  be  the  fourth  instance  in  which  this 
operation  has  ever  been  attempted.  I find  by  a late 
number  of  the  London  Gazette,  that  Dr.  Thompson,  of 
Barbadoes,  has  since  performed  this  difficult  operation, 
but  without  success,  as  would  seem  from  the  fact  that 
a preparation  of  the  parts  has  been  sent  to  Sir  A. 
Cooper,  and  is  now  in  the  museum  at  Guy’s  Hospital. 
So  that  this  artery  has  now  been  tied  five  times : twice 
in  the  West  Indies,  once  in  Russia,  once  in  Great  Bri- 
tain, and  once  in  the  United  States. 

Dr.  Stevens,  of  St.  Croix,  was  the  first  to  attempt 
this  hazardous  operation,  as  may  be  seen  by  a reference 
to  the  article  in  this  Dictionary.  This  case  occurred  in 
1812,  and  was  completely  successful.  The  patient 
lived  ten  years  after  the  operation,  and  dying  in  1822  of 
some  other  disease,  an  opportunity  was  afforded  of  ex- 
amining the  parts.  The  preparation  was  sent  to 
London  to  remove  the  skepticism  of  those  who  perse- 
vered in  declaring  the  operation  impossible.  Still, 
however,  a few  distinguished  men  doubted  the  reports 
of  the  several  cases,  and  Mr,  Lawrence  in  his  lectures 
still  questioned  the  possibility  of  tying  the  internal 
iliac,  and  alluded  to  only  one  case  in  which  it  was  said 
to  have  been  performed. — (See  London  Med.  Gazette, 
No.  128.) 

During  the  present  year  Dr.  Stevens  visited  London, 
in  the  suite  of  the  governor-general  of  the  Danish  West 
India  islands ; and  having  his  attention  called  to  the 
skepticism  of  Mr.  Lawrence,  he  immediately  sent  the 
preparation,  which  had  been  in  London  unnoticed  for  se- 
veral years,  to  the  Royal  College  of  Surgeons,  where,  in 
the  presence  of  Mr.  Lawrence,  a minute  examination 
was  made  to  the  entire  satisfaction  of  all  present.  It 
appeared,  however,  that  the  aneurism  was  not  in  the 
glutaeal  artery,  as  had  been  supposed,  but  in  the  great 
ischiatic ; and  Dr.  Stevens  suggests,  that  this  is  pro- 
bably the  seat  of  the  disease  in  many  instances  of  what 
has  been  called  glutaeal  aneurism. 

Sir  Astley  Cooper  has  given  a conclusive  certificate, 
after  having  minutely  examined  Dr.  Stevens’s  prepara- 
tion, which  is  also  published  in  the  Gazette,  declaring 
himself  perfectly  satisfied  of  the  existence  of  the  aneu- 
rism, and  the  complete  obliteration  of  the  internal  iliac. 
For  although  this  preparation  has  been  in  spirits  eight 
years,  “ it  still  exhibits  the  internal  iliac  converted  into 
an  impervious  chord  where  the  ligature  was  applied, 
and  shows  very  distinctly  the  remains  of  the  aneu- 
rismal  swelling  in  the  ischiatic  artery.” 

CALCULI. 

A highly  interesting  case  has  lately  fhllen  under  my 
own  observation,  in  which  upwards  of  a hundred  calculi 
have  passed  at  different  periods  through  the  urethra, 
varying  in  size  from  that  of  the  head  of  a pin  to  that  of 
a large-sized  grain  of  coffee.  Seventy-three  of  these 
calculi  are  now  in  my  possession ; and  as  the  patient 
is  under  my  personal  observation,  and  more  are  passing 
«very  w'eek,  I can  vouch  for  the  facts  here  recorded, 


and  shall  report  to  the  profession  the  progress  and  the 
result  of  the  case  in  one  of  our  periodicals. 

The  colour  of  these  calculi  is  a yellowish  brown, 
very  smooth  on  their  surface,  and  for  the  most  part 
have  a concavity  on  one  side,  and  a convexity  on  the 
other ; which,  with  some  pains,  may  be  accurately  fitted 
one  to  the  other,  in  the  same  order  and  relation  in  which 
they  may  be  supposed  to  lie  when  in  situ. 

These  calculi  resemble  very  much  those  lithic  con- 
cretions which  are  so  often  discharged  from  the  bladder, 
and  are  liable  to  be  mistaken  for  these.  On  analysis, 
however,  they  are  found  to  contain  only  phosphate  of 
lime,  without  a particle  of  lithic  acid  or  ammonia.  The 
valuable  paper  of  Dr.  Wollaston,  in  the  Philosophical 
Transactions  for  1797,  furnishes  us  with  this  test,  by 
which  to  distinguish  the  calculi  of  the  prostate  gland 
from  those  of  the  bladder  and  kidneys ; and  by  this  and 
other  criteria,  there  can  be  little  doubt  but  the  concre- 
tions in  this  case  have  existed  in  the  prostate  gland ; 
whence,  so  fast  as  they  are  dislodged,  they  get  back 
into  the  bladder,  or  forward  into  the  urethra,  and  then 
pass  off  with  the  urine. 

The  history  of  this  case  is  highly  important,  and  from 
the  patient  I collect  the  following  facts.  He  had  been 
of  a hale,  vigerous  constitution,  without  any  symp- 
toms of  this  affection,  until  about  four  years  since, 
when  he  was  61  years  of  age.  He  was  then  attacked 
suddenly  by  a suppression  of  urine ; frequent  inclina- 
tion, but  no  ability,  to  empty  the  bladder ; pain  so  ex- 
cruciating, as  to  disable  him  from  his  work  and  from 
walking.  He  at  first  resorted  to  Harlem  oil,  and  by 
the  advice  of  his  physician,  drank  mucilaginous  teas  of 
various  kinds  made  of  rain-water ; the  disease  being 
supposed  to  have  originated  from  the  pump- water  here- 
tofore used.  Soon  after  this  excruciating  torture  came 
on,  while  drinking  gin  to  a great  extent,  with  the  hope 
of  finding  relief  by  this  means,  he  observed  for  the  first 
time,  that  whenever  the  urine  flowed,  small  calcareous 
concretions  of  a yellowish  colour,  of  the  shape  and  size 
of  radish-seeds,  passed  through  the  urethra.  Having 
collected  a tea-spoonful  of  these  little  stones,  he  sub- 
mitted them  to  a physician  for  examination ; by  whom 
he  was  sent  to  a distinguished  surgeon  in  this  city  that 
he  might  undergo  the  operation  of  sounding.  The 
sound  having  been  introduced,  and  the  presence  of 
calculi  having  been  detected,  he  was  told  that  the  ope- 
ration of  lithotomy  could  alone  afford  him  any  relief. 

From  his  advanced  age,  he  declined  to  submit  to  the 
operation,  and  gave  himself  up  to  a lingering  death. 
As,  however,  no  relief  was  obtained  from  the  diluents 
or  diuretics  which  he  had  been  so  long  using,  and  as 
he  began  to  feel  that  the  gin  was  doing  positive  injury, 
he  resolved  to  discontinue  the  use  of  them  all,  and 
begin  to  drink  pump-water,  fVom  which  he  had  been 
deprived  by  medical  advice,  and  then,  as  he  expresses 
it,  “ trust  in  the  Lord  for  life  or  death.” 

In  about  three  weeks  from  the  time  in  which  he  thus 
gave  up  all  medical  treatment  and  drank  ft-eely  of  cold 
pump- water,  he  observed  a small  stone  to  drop  into  the 
urinal,  and  in  a few  days  another ; each  affbrding  him 
some  relief.  Since  that  time,  which  is  now  a little 
more  than  eighteen  months,  he  has  passed  all  these, 
and  many  more  which  have  not  been  preserved.  He 


508 


SUPPLEMENTARY  APPENDIX. 


say-3  that  one  passes  every /oar  or  five  days,  and  some- 
times two  at  once ; and  he  is  conscious  of  the  passage 
of  each,  although  the  pain  is  very  slight.  Since  these 
calculi  have  been  passing,  he  has  been  rapidly  recover- 
ing his  health  and  bodily  strength ; and  from  a spec- 
tacle of  emaciation,  he  is  now  a strong,  robust  man, 
and  at  his  age  has  extraordinary  health.  He  has  now 
no  difficulty  in  passing  his  urine,  except  sometimes 
when  a momentarj-  interruption  occurs  to  the  stream, 
by  one  of  the  stones  passing  into  the  urethra ; when  it 
is  soon  forced  out  \vith  very  little  inconvenience. 

He  is  impressed  with  the  belief  that  these  are  frag- 
ments of  a large  calculus  in  his  bladder,  which  was 
felt  by  the  sound  ; and  that  since  he  ceased  to  trust  in 
human  power,  it  has  been  miraculously  broken,  and 
that  he  is  now  convalescent  by  supernatural  agency. 
He  is  perfectly  happy  under  this  conviction : and  the 
propriety  of  dissuading  him  from  this  view  of  the 
subject,  or  convincing  him  that  natural  causes  will 
account  for  the  comfort  he  enjoys,  is  exceedingly  ques- 
tionable. 

But  while  we  leave  the  patient  himself  undisturbed 
in  the  enjoyment  of  his  faith,  the  medical  philosopher 
cannot  fail  to  discover  in  the  progress  of  this  case,  as 
narrated  by  the  patient,  and  in  the  results  of  which  he 
IS  now  in  possession,  details  presenting  some  most  im- 
portant and  interesting  features,  which  may  be  im- 
proved for  practical  purposes. 

That  these  calcareous  deposites  have  never  been  larger 
than  they  now  are  is  clear  from  their  smooth  surface, 
and  from  their  peculiar  organization.  That  they  did 
not  originate  in  the  bladder  or  kidneys  may  be  deduced 
from  the  fact  already  named,  that  they  do  not  contain 
an  atom  of  the  lithic  acid.  And  that  they  could  exist 
at  all  in  the  bladder  in  this  quantity  for  any  length  of 
lime  is  improbable,  from  the  fact  that  so  soon  as  one  of 
them  gets  into  the  bladder,  it  produces  uneasiness  until 
it  is  discharged,  w'hen  the  relief  seems  to  be  entire. 

The  probability  is  that  when  he  was  sounded  by  the 
surgeon,  one  or  more  of  these  calculi  had  passed  into 
the  bladder  from  the  prostate  gland  in  which  they  were 
imbedded,  either  in  the  enlarged  cells  of  the  gland,  or 
encysted,  as  they  are  sometimes  found.  These  were 
felt  by  the  sound ; and  as  the  rest  produce  ulceration, 
they  pass  one  or  two  at  a tim.e  into  the  bladder,  and  so 
out  through  the  urethra. 

Had  this  patient  submitted  to  the  operation  of  litho- 
tomy, and  the  calculi  been  removed,  it  will  be  readily 
perceived  that  no  permanent  or  satisfactorj-  relief  would 
have  been  obtained  ; for  to  remove  them  from  the  body 
of  the  prostate  is  altogether  impracticable.  It  is  highly 
probable,  therefore,  that  his  refusal  to  submit  to  the 
operation  has  saved  his  life,  although  any  surgeon  would 
be  liable  to  give  the  same  opinion  under  similar  cir- 
cumstances. May  we  not  safely  presume,  that  many 
of  the  failures  occurring  in  lithotomy  occur  under 
similar  circumstances,  the  calculi  originating  in  the 
prostate,  and  thence  finding  their  way  perpetually  into 
the  bladder  1 

In  Marcet’s  valuable  Essay  on  CalculoiLS  Disorders, 
much  information  on  this  subject  w'ill  be  found,  toge- 
ther with  a plate  ver>'  accurately  representing  these  cal- 
culi of  the  prostate  gland.  He  states,  that  the  svTnp- 
toms  are  often  mistaken  for  stone  in  the  bladder;*  and 
if  any  of  these  calculi  be  discharged,  their  appearance 
is  so  similar  to  that  of  lithic  concretions,  that  unless 
their  chemical  nature  be  ascertained,  they  will  almost 
infallibly  be  mistaken  for  that  species  of  calculus.  He 
also  records  an  instance  of  an  error  of  the  opposite  kind, 
in  the  case  of  a foreign  minister ; w'ho,  w'hile  attended 
by  one  of  the  most  eminent  surgeons  in  London,  passed 
a number  of  small  brownish  concretions,  which  were 
mistaken  for  calculi  of  the  prostate,  and  the  treatment 
was  for  some  time  conducted  oil  that  supposition.  But 
upon  subjecting  these  calculi  to  chemical  analysis,  he 
found  them  to  consist  of  pure  lithic  acid ; and  upon  an 
appropriate  treatment  being  adopted,  the  complaint 
soon  entirely  disappeared. 

Distinct  from  this  affection,  and  requiring  different 
treatment,  a case  may  be  mentioned  which  often  occurs, 
in  which  the  calculus,  although  formed  in  the  kidney 
or  bladder,  becomes  lodged  in  Ihe  prostate,  in  attempt- 
ing to  pass  through  the  urethra.  Sir  Astley  Cooper 
lias  recorded  a case  of  this  description,  in  which,  upon 
attempting  to  introduce  the  catheter,  he  felt  a grating 
sensation  at  the  neck  of  the  bladder  ; and  on  introduc- 
ing the  finger  into  the  rectum,  calculi  could  be  felt 


moving  in  a cyst  within  the  prostate,  and  a distinct 
clashing  could  be  heard  as  their  surfaces  were  pressed 
together.  It  was  proposed  that  a small  incision  should 
be  made  through  the  rectum  into  the  prostate,  for  the 
purpose  of  extracting  the  calculi ; but  the  patient  would 
not  consent.  This  gentleman  died  a few  years  after- 
ward, when  the  prostate  was  found  to  contain  a 
number  of  calculi ; and  this  was  also  the'case  with 
his  kidneys,  from  which  these  concretions  had  doubt- 
less descended,  and  were  arrested  in  their  course. 

CURVATURE  OF  THE  SPINE. 

Dr.  J.  K.  Mitchell,  one  of  the  physicians  of  the  Penn- 
sylvania Alms-house,  has  favoured  the  profession  with 
some  excellent  observations  of  a practice  character  in 
this  embarrassing  and  too  often  fatal  complaint. — (See 
North  American  Med.  and  Surg.  Joum.  vol.  1.) 

CUTANEOUS  DISEASES. 

I had  purposed  to  have  given  a summary  view  of  the 
most  approved  method  of  treatment  in  that  obstinate 
class  of  disorders,  included  under  the  denomination  of 
diseases  of  the  skin.  This  service  has  in  part  been 
performed  by  the  author  of  this  Dictionary.  The  most 
valuable  work  which  has  recently  appeared  on  this 
subject  is  that  by  Cazenave  and  Schendel,  8vo.  Pbilad. 
1829.  This  work  may  be  justly  considered  as  possess- 
ing superior  claims  to  either  Bateman  or  Plumbe,  and, 
restricted  as  I am,  I must  refer  to  their  valuable  publi 
cation  for  much  that  is  new  and  important. 

GANGR^NOPSIS. 

In  the  American  Medical  Recorder  for  July,  1827, 
Dr.  Jackson,  of  Northumberland,  has  pubUshed  a paper 
containing  a number  of  cases,  with  remarks  on  a dis- 
ease of  children,  which  he  proposes  to  call  gangramop- 
sis  ; and  in  the  American  Joum.  of  the  Med.  and  Phys. 
Sciences,  vol.  5,  Dr.  Webber  has  furnished  a detail  of 
several  interesting  cases  of  this  gangrenous  erosion  of 
the  cheek.  Dr.  W.  has  had  the  opportunity  of  witness- 
ing four  instances  in  the  course  of  two  or  three  years; 
three  of  the  milder  kind,  and  one  of  the  most  severe 
form,  answering  to  the  nomer  of  Bums.  Case  4 being 
the  most  minutely  drawn  up,  I shall  here  insert,  as  a 
suitable  appendage  to  my  article  on  caries  of  the  jaws 
of  children.  “This  case  occurred  in  September,  1828, 
in  a little  girl  10  years  old.  It  ensued  upon  typhus,  in 
w'hich  diarrhma  had  been  a troublesome  symptom. 
About  the  fourteenth  day,  when  the  fever  was  appa- 
rently beginning  to  abate,  she  complained  of  a feeling 
of  soreness  and  pain  in  the  left  cheek,  not  far  from  the 
angle  of  the  mouth.  The  part  was  slightly  swollen, 
somewhat  hard,  and  reddish,  like  the  commencement  of 
a bile.  Volatile  liniment  with  laudanum  was  applied, 
and  the  redness  disappeared,  though  the  swelling  con- 
tinued, being,  however,  less  hard  and  rather  more  dif- 
fuse. A day  or  twm  after  aphthae  appeared  in  the  mouth 
and  fauces,  for  which  a gargle  of  diluted  muriatic  acid 
w’as  employed.  She  complained,  however,  of  the  cheeks 
being  hotter  and  sorer,  and  the  swelling  had  evidently 
increased.  On  the  inside  of  the  cheek  it  protruded  in  a 
ridge  between  the  teeth.  Lead-water  was  used  exter- 
nally as  a constant  application,  in  addition  to  the  occa- 
sional use  of  the  liniment  above  mentioned,  and  the 
inside  of  the  mouth  was  frequently  touched  with  honey, 
acidulated  with  muratic  acid ; small  quantities  of  wiiie 
were  given,  and  one-fourth  of  a grain  of  sulphate  of 
quinine  thrice  a day ; also  small  doses  of  Dover's  pow- 
der to  regulate  the  bowels,  still  rather  too  loose,  and  to 
procure  sufficient  rest.  The  cheek,  nevertheless,  con- 
tinued to  swell,  and  the  breath  became  very  fetid.  The 
aphthae  disappeared  in  a day  or  two;  but  upon  the 
most  prominent  part  of  the  internal  swelling  of  the 
cheek  was  a kind  of  flabby  pustule  or  blister  seem- 
ingly beneath  the  whole  thickness  of  the  internal  inte- 
gument, which  over  the  swelling  was  opaque,  and  of  a 
dirty  w'hite  colour.  This  broke  the  same  evening,  dis- 
charging a small  quantity  of  fetid  fluid,  and  leaving  a 
sloughing  appearance  of  its  membranous  covering.  It 
was  repeatedly  touched  during  the  night  and  the  fol- 
lowing day  with  a strong  preparation  of  muriatic  acid 
and  honey,  sufficiently  strong  to  corrugate  the  slough- 
ing membrane,  and  make  it  settle  down  below  the  level 
of  the  surrounding  parts.  This  it  was  hoped  would 
put  a check  to  the  diseased  action,  and  cause  the  slough 
to  separate.  Notwithstanding  it  continued  to  increase 
! during  the  subsequent  night ; and  on  the  next  morning 


SUPPLEMENTARY  APPENDIX. 


509 


had  nearly  reached  the  angle  of  the  mouth,  which  looked 
dusky,  and  approached  to  a state  of  gangrene. 

An  eminent  practitioner  from  a distance  met  me  in 
consultation  this  morning,  and  advised  carrot  and  fer- 
menting poultices  with  charcoal  over  the  cheek,  a small 
blister  externally  over  the  angle  of  the  mouth,  and  one 
on  the  inside  of  the  cheek,  of  a size  sufficient  to  cover 
the  slough  and  the  surrounding  sound  edges,  while  the 
internal  remedies  were  continued  in  increased  doses. 
The  disease,  however,  proceeded  with  redoubled  ra- 
pidity. Gangrene  in  undistinguished  blackness  passed 
in  a few  hours  across  the  external  blister,  and  at  the 
same  time  came  through  the  cheek,  opposite  to  the 
point  on  the  inside  first  attacked.  In  spite  of  the  assi- 
duous application  of  the  poultices,  these  spots  spread  so 
as  to  coalesce  in  the  course  of  the  night,  and  by  the 
next  morning  involved  most  of  the  unattacked  portion 
of  the  cheek.  The  case  was  now  deemed  hopeless,  and 
dissolution  was  soon  expected.  The  fetor  being  ex- 
cessive, with  a view  to  lessen  it  the  part  was  covered 
with  a cloth  wet  with  a solution  of  the  chloride  of  lime 
(bleaching  powder).  This  lessened  the  rapid  spread- 
ing of  the  gangrene  so  much,  that  for  hours  it  seemed 
almost  entirely  stationary,  but  did  not  become  wholly 
60,  though  it  progressed  very  slowly  till  it  had  covered 
the  whole  of  the  swelling  existing  at  the  commence- 
ment, reaching  almost  to  the  lower  eyelid,  over  the 
membranous  part  of  the  nose  of  the  same  side,  the 
septum,  two-thirds  of  the  lips,  and  half  of  the  chin, 
including  all  the  cheek  down  to  below  the  under  edge 
of  the  lower  jaw,  and  backwards  nearly  to  the  ear. 
The  parts  were  completely  sphacelated,  and  had  nearly 
separated  : when,  at  the  expiration  of  twelve  days  from 
the  first  appearance  of  danger,  the  little  patient  died. 
All  the  peculiar  symptoms  of  the  fever  had  entirely 
subsided  long  before  her  death.” 

I have  had  several  opportunities  of  witnessing  this 
frightful  disease ; but  in  all  the  cases  I saw,  it  could 
be  traced  to  the  injudicious  use  of  merci^.  In  two  of 
them  the  whole  cheek  sloughed  off,  leaving  the  carious 
bones  and  the  internal  structure  ofthe  throat  exposed, 
before  they  terminated  fatally. 

PTYALISM. 

Dr,  Fahnestock  has  published  a paper  in  the  Amer. 
Joum.  of  Med.  and  Phys.  Sciences,  vol  5,  on  the  effi- 
cacy of  the  rhus  glabrum  as  a remedy  for  ptyalism. 
He  observes,  that  the  medications  in  use  intended  to 
check  inordinate  and  protracted  salivations  are  all  of  a 
highly  stimulating,  afitringent,  and  often  corrosive 
nature,  such  as  borax,  myrrh,  alum,  nitric  acid,  &c., 
which  seldom  fail  to  aggravate  the  sufferings,  and 
create  deeper-seated  irritations.  Having  seen  very 
alarming  ahd  even  fatal  effects  from  salivation,  and  the 
remedies  employed  to  control  it,  his  attention  was 
directed  to  the  use  of  the  gentle  astringents,  such  as 
common  tea,  «fec. ; and  finding  much  advantage  from 
these,  the  experiments  were  extended  to  articles  still 
milder,  as  the  elm,  sassafras,  and  sumach ; from  the 
latter  of  which  he  has  derived  peculiar  benefit,  and 
continues  to  use  it  with  uniform  and  unparalleled  suc- 
cess. An  infusion  of  the  inner  bark  of  the  root  of  the 
rhus  glabrum  is  a very  mild,  mucilaginous  refrigerant ; 
moderately  astringent,  cooling  and  soothing  to  the 
irritated  surface  of  the  mouth  and'throat,  and  can  be 
applied  at  any  stage,  and  even  to  children.  It  acts  by 
allaying  and  obstructing  excitement,  sheathing  the  de- 
licate surfaces,  and  healing  abrasions. 

It  is  highly  important,  however,  to  distinguish  the 
several  species  of  rhus,  and  particularly  the  vernix, 
which  resembles  the  glabrum  very  closely,  but  is  very 
poisonous. — (See  Barton's  Essay  towards  a Materia 
Medi,ca  of  the  United  States.) 

TRACHEOTOMY. 

Since  the  note  inserted  under  the  head  of  broncho- 
lomy  was  prepared,  I have  had  occasion  to  perform  this 
operation  upon  a child  nine  years  old,  who  was  near  suf- 
focation from  the  presence  of  a tamarind  seed  in  the  tra- 
chea. The  oedema,  and  other  diagnostic  symptoms,  fully 
satisfied  me  of  the  presence  of  the  foreign  body ; but  on 
opening  the  trachea,  its  presence  could  not  be  detected. 
Tlie  opening  was  enlarged,  and  suffered  to  remain  open 
half  an  hour,  but  nothing  could  be  seen  or  felt  of  the 
eeed,  although  the  alarming  symptoms  subsided,  and 
the  most  sati.sfactory  relief  was  obtained.  I felt  as- 
sured that  the  foreign  body  was  lodged  below  the  inci- 


sion, perhaps  at  or  near  the  bronchial  bifurcation,  and 
did  not  despair  of  yet  accomplishing  its  removal.  An 
obstinate  cough  continued,  with  irritative  fever,  for 
several  days,  when  a small  portion  ofthe  seed  came  up 
by  expectoration.  But  it  was  not  until  three  weeks 
had  elapsed  that  the  main  body  of  the  tamarind  seed 
came  up  during  a paroxysm  ol'  coughing,  and  the  little 
patient  is  now  convalescent. 

In  this  case,  although  the  operation  did  not  immedi* 
ately  accomplish  the  object  to  which  it  was  directed, 
yet  there  can  be  no  doubt  that  it  preserved  the  life  of 
the  patient;  for  at  the  time  of  its  performance,  the 
child  could  have  survived  but  a short  time.  The  de- 
cided improvement  in  the  respiration  which  supervened 
upon  the  operation,  and  the  absence  of  every  bad  symp- 
tom said  to  be  apprehended  after  bronchotomy,  satisfied 
us  fully  of  the  safety  and  utility  of  opening  the  trachea 
in  dangerous  cases  of  trachitis  from  any  cause.  For 
although  the  opening  was  made  of  a crucial  form, 
first  by  dividing  the  cartilage  between  the  rings,  and 
then  by  a longitudinal  incision  half  an  inch  in  length, 
yet,  after  leaving  it  open  half  an  hour,  it  was  closed 
by  adhesive  plaster,  and  in  less  than  a week  had  en- 
tirely united ; the  air  only  escaping  at  the  opening,  at 
intervals,  during  the  first  few  hours. 

TUMOURS. 

Under  this  head  I am  permitted  to  add  a highly  in- 
teresting case  of  tumour  in  the  neck,  in  which  the 
operation  for  its  removal  was  performed  by  Professor 
Alden  March,  of  Albany,  N.  Y.  And  although  this 
operation  was  unsuccessful,  yet  the  cause  of  its  failure 
was  apparent,  and  ought  to  be  known  to  the  profession, 
that  it  may  be  avoided  in  future  surgical  wounds,  in 
which  the  neck  is  to  be  involved.  This  operation  was 
performed  in  August  last,  and  the  patient  died  on  the 
table,  from  the  introduction  of  the  air  into  the  cavity  of 
the  heart,  through  the  external  jugular. 

The  tumour  was  as  large  as  a pint  bowl,  occupying 
the  left  side  of  the  neck,  somewhat  egg-shai)ed,  having 
its  largest  extremity  turned  upwards,  encroaching  on 
the  lobe  of  the  ear,  so  as  to  project  it  considerably,  and 
inferiorly  extending  nearly  to  the  clavicle. 

The  following  is  the  report  furnished  of  the  operation 
from  notes  taken  at  the  time ; 

The  first  incision  was  commenced  under  the  lobe  of 
the  ear,  and,  pursuing  a curvilinear  direction,  termi- 
nated at  the  sternal  extremity  of  the  clavicle.  A second 
incision  was  commenced  in  the  line,  and  within  an  inch 
ofthe  top  of  the  former,  and  extending  downwards  in 
an  opposite  direction,  terminating  within  an  inch  and  a 
half  of  the  sternum.  A third  was  commenced  upon 
the  base  of  the  jaw,  at  an  inch  distant  from  the  chin, 
and  carried  backwards  and  upwards,  so  as  to  form  an 
angle  with  the  top  of  the  first,  and  terminating  at  the 
posterior  and  superior  portion  of  the  mastoid  process  of 
the  temporal  bone. 

The  anterior  flap  was  raised  and  turned  over  the 
larynx,  which  exposed  the  cervical  fascia,  inasmuch  as 
the  muscular  fibres  ofthe  platysma-myoides  were  obli- 
terated. The  fascia  was  divided  over  the  anterior 
margin  of  the  sterno-hyoideus  muscle  to  the  extent  of 
nearly  two  inches,  which  exposed  the  muscular  fibres 
of  the  omo-hyoideus.  In  the  angle  formed  by  these 
and  the  lower  and  anterior  portion  of  the  mastoid 
muscle,  the  carotid  artery  was  exposed  and  secured 
with  two  ligatures. 

The  next  step  of  the  operation  was  to  separate  the 
upper  part  of  the  tumour  from  the  base  of  the  jaw,  the 
submaxillary  and  parotid  glands,  both  of  which  were 
found  to  be  in  a perfectly  natural  ami  healthy  state.  At 
the  point  where  the  labial  or  fascial  artery  passes  through 
the  submaxillary  gland,  it  was  divided  or  a large  branch 
of  iL  It  bled  quite  freely,  although  the  common  caro- 
tid had  jtist  been  secured.  This  branch  must  have 
derived  its  blood  from  the  internal  carotid  of  the  oppo- 
site side,  by  the  way  of  the  circle  of  Willis,  by  the 
vertebral,  or  by  the  superior  thyroidal  of  the  opposite 
side,  or  perhaps  from  these  several  sources.  This  and 
the  carotid  were  the  only  arteries  which  were  secured 
by  ligatures. 

The  next  step  in  the  operation  was  to  dissect  tho 
posterior  flap  from  the  surface  of  the  tumour,  when  it 
was  found  that  the  muscular  fibres  ofthe  sterno-cleido- 
mastoideus  were  completely  obliterated  over  the  centre 
of  the  tumour,  or  reduced  to  a mere  tendinous  fascia. 
The  dissection  was  then  directed  to  detaching  the  tu- 


510 


SUPPLEMENTARY  APPENDIX. 


mour  from  above  and  below,  of  course  avoiding  the 
chief  branches  of  the  carotid,  as  well  as  the  trunk,  the 
pneumogastric  nerve,  and  the  great  internal  jugular. 
At  this  period  of  the  dissection  the  tumour  became 
loose,  and  an  immediate  and  successful  completion  of 
the  operation  was  confidently  anticipated.  But  while 
cautiously  dissecting  at  the  lower  part  of  the  attach- 
ments of  the  tumour,  the  external  jugular  vein  was 
divided  very  near  the  point  at  which  it  unites  with  the 
internal  jugular.  At  this  moment  a phenomenon  oc- 
curred which  was  most  alarming.  It  was  the  noise  of 
a strange  rushing  of  air,  as  though  the  trachea  or 
cavity  of  the  thora.x  had  been  cut  into,  and  seemed  to 
threaten  the  instant  dissolution  of  the  patient ; a noise 
resembling  the  sudden  pouring  a liquid  from  a junk- 
bottle.  The  patient  was  instantly  seized  with  tremors 
and  convulsions,  became  pulseless,  the  lips  livid, 
frothed  at  the  mouth,  and  the  pupils  dilated  to  the 
greatest  possible  extent.  The  moment  the  occurrence 
happened,  the  finger  was  placed  on  the  mouth  of  the 
wounded  vein ; and  the  operation  being  suspended,  the 
patient  seemed  to  revive  from  the  effects  of  diffusible 
stimuli,  and  partially  roused.  The  operation  w'as  then 
resumed,  and  very  soon  comideted.  The  patient,  how- 
ever, expired  without  a struggle,  before  he  could  be 
removed  from  the  operating  table. 

That  this  patient  died  by  the  introduction  of  air  into 
the  cavity  of  the  heart  there  can  be  little  doubt,  and 
this  candid  narration  of  the  facts  should  teach  us  the 
imminent  danger  of  opening  veins  in  the  vicinity  of  the 
heart ; and  the  knowledge  of  this  dangerunay  save  many 
lives,  which  might  otherwise  be  lost  by  a similar  casu- 
alty. It  is  unfortunate  that  the  case  reported  by  M. 
Dupuytren,  of  a similar  operation  wth  the  like  result, 
has  not  been  noticed  in  our  standard  works,  else  still 
greater  caution  might  have  been  used  in  this  case.  Dr. 
March  informs  me,  that  Professor  Stevens,  of  this  city, 
had  well  nigh  lost  a patient  from  the  same  cause,  while 
operating  on  the  neck;  and  Professor  Mott  had  to 
abandon  an  operation  in  consequence  of  this  occur- 
rence, the  convulsions  were  so  alarming.  This  pa- 
tient, however,  as  well  as  that  of  Professor  Stevens, 
recovered. 

Dr.  March,  the  operator  in  the  unfortunate  case  here 
detailed,  has  since  tried  some  experiments  on  inferior 
animals ; and  among  others,  he  introduced  a blow-pipe 
into  the  jugular  of  a cat,  and  a single  puff  of  the  breath 
resulted  in  convulsions  and  death ; and  on  dissection, 
the  right  side  of  the  heart  and  larger  veins  were  found 
filled  with  air.  His  experiments  on  this  subject  may 
be  of  the  highest  practical  importance ; and  the  expla- 
nation of  the  remarkable  phenomena  which  followed 
the  wounding  of  the  vein  in  this  and  other  cases,  is  a 
physiological  problem,  the  solution  of  which,  if  accom- 
plished, will  be  of  the  deepest  interest  to  the  profession 
and  to  humanity. 

.ANTRUM. 

In  the  article  under  this  head,  I inadvertently  omitted 
to  record  a new  and  difficult  operation  performed  for 
the  removal  of  a fungus  from  that  cavity,  by  Dr.  A.  H. 
Stevens,  Professor  of  Surgery  in  the  University  of 
New-York.  The  details  of  the  case  are  included  in 
Dr.  Stirling’s  Appendix  to  Velpeau’s  Surgical  Anatomy, 
recently  published.  It  is  the  more  important  I should 
Introduce  it  here,  since  in  another  part  of  this  work  I 
have  attributed  to  Dr.  Rogers  the  merit  of  having  first 
operated  in  this  country  for  the  removal  of  the  upper 
jaw.  Dr.  R.’s  operation  was  performed,  it  will  be 
perceived,  in  May,  1824,  while  that  oi  Dr.  Stevens  was 
in  August,  1823.  I was  led  into  this  error,  as  respects 
the  date,  by  the  circumstance  that  the  latter  operation 
was  not  published  until  the  present  year,  the  doctor 
having  withheld  the  report  of  the  case  from  the  public 
from  motives  of  delicacy  to  the  patient  and  his  friends, 
lest  the  individual  should  be  identified,  and  the  extent 
of  the  mutilation  known. 

The  tumour  in  this  case  occupied  the  whole  antrum, 
arising  by  a broad  base  from  its  lower  portion,  and  oc- 


casioned a great  deformity  in  the  cheek,  and  protruded 
into  the  mouth. 

For  the  full  account  of  this  superior  operation,  I 
must  refer  to  the  work  just  mentioned.  It  will  be  suf- 
ficient here  to  state,  that  a great  portion  of  the  anterior 
and  inferior  portions  of  the  os  maxillare  superius  were 
removed  without  dhnding  the  cheek,  by  drawing  up  the 
commissure  of  the  lips,  and  dissecting  the  upper  lip 
from  the  bone  to  xvithin  a line  of  the  infra-orbital 
foramen.  And  the  peculiar  merit  of  the  operation  is  in 
the  manner  of  dividing  the  bone  by  a flexible  elastic 
saw,  made  of  clock-spring,  instead  of  the  use  of  the 
mallet,  chisel,  and  gouges,  and  the  still  more  painful 
and  equivocal  operation  with  the  actual  cautery’. 

This  patient  is  now  living  in  perfect  health,  and  the 
cavity  in  the  cheek  which  followed  the  operation  has 
been  filled  by  an  artificial  jaw  made  of  ivory,  having 
teeth  attached  to  it ; and  the  articulation  and  degluti- 
tion are  so  perfectly  retained,  that  only  a few  friends 
are  aware  of  the  nature  of  the  operation  to  which  he 
has  submitted. 

This  entire  triumph  of  our  art  over  so  horrible  a disease 
is  alike  honourable  to  Dr.  Stevens  and  the  profession. 

LIGATURE  OF  THE  INTERNAL  JUGULAR 
VEIN. 

The  follo\ving  operation  is  likewise  original  with 
Professor  Stevens,  and  has  not  before  been  published. 

“ The  question  of  the  possibility  of  tying  the  internal 
jugular  vein  in  operations  for  the  extirpation  of  tu- 
mours in  the  neck  is  one  to  which  the  attention  of  sur- 
geons must  have  often  been  directed  with  great  anx- 
iety. The  records  of  our  art  do  not  furnish,  to  my 
knowledge,  any  case  in  which  this  operation  has  been 
attempted.  That  which  I am  about  to  relate  establishes 
the  important  fact  that  it  may  be  tied  with  safety. 

A man  of  middle  age  came  under  my  care  in  the 
New-York  Hospital  during  the  last  winter  (1830),  with 
an  extensive  flattened  tumour  under  the  sterno-mastoid 
muscle,  formed  of  the  chain  of  lymphatic  glands  which 
accompanies  the  great  vessels  on  the  left  side  of  the 
neck,  in  a state  of  great  enlargement.  It  had  been  the 
subject  of  a previous  unsuccessful  operation,  a.id  v’as 
then  alarmingly  obstructing  the  powers  of  deglutition 
and  respiration.  In  the  course  of  my  operation  for  the 
removal  of  this  tumour,  after  it  had  been  detached, 
except  at  its  inner  and  posterior  edge,  I drew  the  tu- 
mour outwards  and  forwards,  and  divided  a vein  of 
considerable  size,  passing  horizontally  outwards,  near 
its  junction  with  the  internal  jugular.  Half  an  ounce 
of  venous  blood  escaped,  and  in  an  instant  afteiward  a 
peculiar  sound  was  heard,  like  that  occasioned  by 
drawing  into  a syringe  the  last  portions  of  water  from 
a basin.  It  was  a moment  of  intense  anxiety,  for  the 
fate  of  Dupuytren’s  patient  was  fresh  in  my  recollec- 
tion. I immediately  placed  my  finger  on  the  aperture 
in  the  vessel,  seized  the  pulse  with  the  other  hand,  and 
watched  the  patient’s  countenance.  All  seemed  well, 
and  the  patient’s  reply  to  my  interrogatory  confirmed 
these  favourable  indications.  After  a moment’s  delibe- 
ration, I determined  to  pass  a ligature  around  the  inter- 
nal jugular,  below  and  above  the  junction  of  the 
wounded  branch.  It  was  accordingly  separated  from 
the  par  vagum  and  carotid  with  the  blunt  point  of  an 
eyed  probe,  armed  with  a double  ligature;  one  of 
which  was  secured  below  and  the  other  above  the 
wounded  vessel.  The  operation,  of  which  little  re- 
mained to  be  done,  was  then  completed.  The  man 
suffered  from  cough  and  difficult  respiration  betw’een 
the  fourth  and  seventh  days  after  the  operation,  for 
which  he  was  tw’ice  bled  and  took  saline  purgatives. 
The  ligatures  came  away  on  the  fourteenth  day,  and  the 
case  went  on  without  any  peculiarities. 

If  the  par  vagum  can  be  divided  on  one  side  without 
endangering  life,  a question,  I believe,  not  yet  settled 
by  positive  experiment,  the  proposition  will  be  esta- 
blished, that  many  tumours  in  the  side  of  the  neck  (the 
removal  of  which  is  now  deemed  impracticable)  may 
be  successfully  extirpated.” 


THE  END. 


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